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NEW  YORK  MEDICAL  JOURNAL, 


INCORPORATING  THE 

PHILADELPHIA. MEDICAL  JOURNAL 

AND  THE 

MEDICAL  NEWS. 


A   WEEKLY   REVIEW   OF  MEDICINE. 


EDITED  BY 

FRANK  P.  FOSTER,  M.  D. 

ASSOCIATE  EDITOR, 

John  M.  Swan,  M.  D., 

Philadelphia. 

Assistant  Editors  : 
FREDERICK  T.  HANEMAN,  M.  D., 
CHARLES  F.  BOLDUAN,  M.  D.,  ANDREW  F.  CURRIER,  M.  D., 

SAiMUEL  M.  BRICKNER,  M.  D.,  MATTHIAS  LANCKTON  FOSTER,  M.  D., 

De  SAXTOS  SAXE.  M.  D. 

VOLUME  LXXXIX, 

JANUARY  TO  JUNE,  1909,  INCLUSIVE. 


NEW  YORK: 
A.  R.  ELLIOTT  PUBLISHING  CO., 
1909. 


Copyright,  1909, 
By  A.  R.  ELLIOTT  PUBLISHING  CO. 


LIbT  OF  CONTRIBUTORS  TO  VOLUME  LXXXIX. 


Those  whose  names  are  marked  with  an  asterisk  have  contributed  editorial  articles. 


Abbott,  Alexander  C,  M.  D.,  Philadel- 
phia. 

Adami,  J.  George,  A.  M.,  INl.  D.,  F.  R. 

S.,  Montreal,  Canada. 
Allvn,  Her.max  B..  M.  D.,  Philadelphia. 
Andeksox,  a.  AL,  M.  D. 
*Ar.mstroxg,  Samuel  T.,  M.  D. 
AsHMEAD,  Albert  S.,  M.  D. 
Attix,  J.  C,  M.  S.,  D.  D.  S.,  Al.  D., 

Philadelphia. 
BAfTisr,  H.  L..  M.  D.,  Ivy  Depot,  Va. 
Barclay,  \V.  F.,  AI.  D..  Pittsburgh,  Pa. 

*  Barrows,  C.  Clifford,  A1.  D. 
Bartholow,  Paul,  AI.  D. 
Basch,  Sev.mour,  AL  D. 
Bassler  Axthonv,  A1.  D. 
Bauer,  F.  AL,  AL  D. 

Baum,  Joseph,  AL  D. 

Beardslev,  E.  J.  G..  AL  D.,  L.  R.  C.  P. 

(Lond.).  Philadelphia. 
Beck,  Carl,  AL  D. 
Beck,  E.mil  G.,  AL  D..  Chicago. 
*Bexedict,  a.  'L.,  AL  D..  Buffalo. 
Bexja.min,  a.  E.,  AL  D.,  Alinneapolis. 
Berxsteix.  E.  P.,  AL  D. 
Berry,  John  AL,  AL  D.,  Troy,  N.  Y. 

*  Billings,  John  S.,  Jr.,  AL  D. 
Blackwell,  H.  B..  AL  D. 

BoGGS,  Rusell  H.,  AL  D..  Pittsburgh, 
Pa. 

Boldt.  H.  J.,  AL  D. 

BoxNAR,  JoHx  D.,  AL  D.,  Buffalo.  . 

Bopp,  Walter  F.,  AI.  D. 

Br-\t)dock,  Charles  S.,  Jr.,  Ph.  G.,  M. 
D.,  Haddonfield,  N.  J. 

Bradley,  William  N.,  M.  D.,  Philadel- 
phia. 

Brady,  William,  AL  D.,  Elmira.  N.  Y. 
Branth,  Johx  Herman,  AL  D. 
Braude,  AL,  AL  D.,  Chicago. 
Br-M'.  A.vron,  AL  D.,  Philadelphia. 
*Brickxer,  Samuel  AL,  A.  AL,  AI.  D. 
Brixkerhoff,  Nelsox  AL,  AI.  D.,  Phila- 
delphia. 

Browx,  Arthur  Erwix,  Sc.  D..  Phila- 
delphia. 

Brow.v.  Isaac  W.,  AI.  D..  Philadelphia. 

Bryaxt.  Joseph  D.,  AL  D., 

Bryant,  W.  Sohier,  A.  AL,  AI.  D. 

Bull,  Charles  Stedmax,  A.  AL.  AI.  D. 

*Burtexshaw,  James  Hawley,  AI.  D. 

Butler,  William  J.,  AL  D.,  Chicago. 

Calhoun,  F.  Phinizy",  A.  B.,  M.  D.,  At- 
lanta. Ga. 

Carlisle,  Robert  J.,  AI.  D. 

Carr,  W.  p.,  AL  D.,  Washington,  D.  C. 

Carrixgtox,  p.  AL,  AI.  D..  U.  S.  Public 
Health  and  Alarine  Hospital  Service. 

Carsox,  Hamptox  L.,  Esq.,  Philadel- 
phia. 

Castelli,  E.,  AL  D. 

Church,  C.  Herbert.  AI.  D.,  Newark, 
N.  J. 

Clark,  Franklin  C,  AI.  D.,  Providence, 
R.  I. 

Clary,  W.  A.,  Jr.,  AI.  D..  Alemphis. 
Term. 

Clay.  T.  A,.  AL  D.,  Paterson,  X.  J. 
Cleborxe,  Alan  Bellingh.\m,  AI.  D., 

Savannah,  Ga. 
Clothier,  Joseph  V.,  AI.  D..  Philadel 

phia. 

Cobb,  J.  O.,  AI.  D..  Surgeon,  United 
States  Public  Health  and  Alarine  Hos- 
pital Service. 

Coleman,  Warren,  AL  D. 

Cooke.  Charles  O.,  A.  AL,  AI.  D..  Prov- 
idence, R.  I. 

Cornwall,  Edward,  E.,  AL  D.,  Brook 
lyn. 

*Crandall.  Floy'd  AL,  AI.  D. 
Crispin.  Antonio  AL,  AL  D. 
Croftan,  Alfred  C,  AL  D.,  Chicago. 


Crothers,  Bronson,  A.  B.,  Boston. 
*CuMSTOX,   Ch.\rles   Greene,   AI.  D., 
Boston. 

*Currier,   Andrew  F.,  AL  D.,  Alount 

Yernon,  N.  Y. 
Dalaxd,  Judsox,  AL  D.,  Pliiladelphia. 
D.\xziGER,  Erxst,  AL  D. 
Davisox,  Robert  E.,  AI.  D.,  Pittsburgh, 

Pa. 

De.wer,  Johx  B.,  AI.  D.,  LL.  D.,  Phila- 
delphia. 

De  Bar,  George  O.  B.,  AL  D.,  Eugene, 
Ore. 

*Delavan,  D.  Bryson,  M.  D. 

Di  Rocco,  Joseph,  AI.  D. 

DiTMAX,  NORMAX  E.,  AI.  D.,  Ph.  D. 

Dow,  Edmund  L.,  M.  D., 

Drennax,  Jexnie  G.,  AL  D..  C.  AL. 
Kmgston,  Canada. 

Drum.  J.  H..  AI.  D.,  Syracuse,  N.  Y. 

DuFFiELD,  Warren  L..  AI.  D..  Brooklyn. 

Earp,  Samuel  E.,  AL  S..  AI.  D.,  Indian- 
apolis. 

Edgar,  J.  Clifton,  AI.  D. 

Egbert,  J.  Hobart,  A.  AL,  AI.  D.,  Willi- 
mantic,  Conn. 

Einhorn,  AIax,  AI.  D. 

EiSENBERG,  A.  D.,  AL  D.,  Brooklyn. 

Elliott,  Arthur  R.,  AI.  D.,  Chicago. 

Elliott,  Edw.jird  Everett,  Chicago. 

*Elliott,  George,  AL  D.,  Toronto,  Can- 
ada. 

Ellis,  Aller  G..  AL  D.,  Philadelphia. 
Erdmaxx,  Johx  F.,  AI.  D. 
Fairchild,  D.  S.,  AL  D.,  Des  Aloines,  la. 
Faught,  Fraxcis  Ashley,  AI.  D.,  Phil- 
adelphia. 

Faulkxer,  Richard  B.,  AI.  D.,  Pitts- 
burgh, Pa. 

Files,  Charles  O..  A.  AL,  AI.  D.,  Port- 
land, Ale. 

Fischer,  Hermann,  AI.  D. 

I-"ischer.  L(juis,  AI.  D. 

FiSKE,  James  Porter,  AL  D. 

Folkes,  H.  AL,  AI.  D.,  Biloxi,  Aliss. 

Fordyce,  John  A.,  AI.  D. 

*Foster,  Fr.\nk  p.,  AL  D. 

Foster,  George  B..  Jr.,  AI.  D.,  Pliiladel- 
phia. 

*Foster,  AIatthias  Lanckton,  AL  D. 

Foulkes,  Sara  E.,  AI.  D.,  Trenton.  X.  J. 

Pricks,  L.  D.,  AI.  D.,  U.  S.  Public 
Health  and  Alarine  Hospital  Service. 

*Fridexberg,  Percy,  AL  D. 

Fried,  G.  A..  AI.  D. 

Gerhard,  C.  H.,  AI.  D.,  Philadelphia. 

Gilbride,  Johx  J..  A.  B..  AI.  D..  Phila- 
delphia. 

GoEPP,  R.  AIax,  AI.  D.,  Philadelphia. 
GoFFE,  J.  Riddle,  AL  D. 
Gordox.  Alfred,  AI.  D..  Philadelphia. 
Grace,  Ralph,  AL  D. 
Graham,  George  A..  AI.  D.,  Kansas  City, 
AIo. 

Graham,  St.  J.  B.,  AI.  D.,  Ellijay,  Ga. 

Graxt,  Sir  James,  K.  C.  AI.  G..  F.  R. 
C.  P.,  Lond.,  Ottawa,  Canada. 

Greexe,  Robert  Holmes,  A.  AL,  AI.  D. 

Gruexixg,  Emil,  AL  D. 

Halliday',  Charles  H.,  AL  D.,  Beau- 
tort,  S.  C. 

"Haxemax,  Frederick  T.,  AI.  D. 

Harbridge.  D.  Forest.  AI.  D.,  Philadel- 
ohia. 

Hare.  Hobart  Amory,  AI.  D.,  Phila- 
delphia. 

Harris.  William  L.,  AI.  D.,  Providence. 
R.  I. 

Harrower,  Henry  R.,  M.  D.,  Chicago. 
Haskell.    Charles    Nahum,    AL  D., 

Bridgeport,  Conn. 
Hays,  Harold  AL,  A.  AL.  AL  D. 
Hays,  Walter  E.,  AL  D. 


Heiser,  Victor  G.,  AL  D.,  Alanila,  P.  I. 
Hekzig,  Arthur  J.,  AL  D. 
HiKST,  John  Cooke,  AI.  D.,  Philadel- 
phia. 

HoFER,  Cl.^rexce  a.,  AI.  D.,  Philadel- 
phia. 

H(;gax,  Austix,  AI.  D.,  Jolinstown,  N.  Y. 

"Howard,  Tasker,  AI.  D.,  Brooklyn. 

Huhner,  AIax,  AI.  D. 

Hunt,  Charles  J.,  AL  D.,  Philadelphia. 

*=HuxT,  Reid,  AI.  D.,  Ph.  D.,  U.  S.  Pub- 
lic Health  and  Alarine  Hospital  Ser- 
vice. 

*J.\CKsoN,  George  Thomas,  AI.  D. 
*Jelliffe,  Smith  Ely',  A.  AL,  AI.  D., 
Ph.  D. 

Je.nkixs,  Xorburxe  B.,  AI.  D. 
Johxston,  James  C,  AI.  D. 

JUDD,  ASPINWALL,  AI.  D. 

Karpas,  AloRRis  J.,  AI.  D. 

*Keenan,  Thomas  J. 

Keller.  AIorris  J.,  AL  D. 

Keller,  William  L.,  AI.  D.,  Aledical 
Corps  of  the  United  States  Armv. 

Kexxedy,  J.  W.,  AL  D.,  Philadelphia. 

Keowx,  JTames  a.,  AL  D..  Lynn,  Mass. 

KiRKPATRicK,  A1urr.\y'  B.,  Jr.,  AL  D., 
Trenton,  N.  J. 

KivLix,  C.  F.,  M.  D..  Troy,  X.  Y. 

Klotz,  J.  E.,  AL  D.,  Lanark,  Canada. 

K.XbPF,  S.  Adolphus,  AI.  D. 

KxoTT,  Johx,  A.  AL,  AI.  D.,  Ch.  B.,  and 
D.  P.  H.  (Univ.  Dub.)  ;  AI.  R.  C.  P. 
I. :  AI.  R.  I.  A.,  etc.,  Dublin,  Ireland. 

KxowLES,  Fraxk  Crozer,  AI.  D.,  Phila- 
delphia. 

Kr.^uss,  Frederick,  AI.  D.,  Philadelphia. 
L.VMPERT,  AI.  A.,  AI.  D..  Brooklyn. 
*L.\xrMAX,  A.  J.,  AI.  D.,  London. 
Landry',  Adriax  a.,  AL  D.,  Plaquemine, 
U. 

Laxge,  Sidney,  AL  D.,  Cincinnati,  Ohio. 

Lawson,  George  B.,  A.  AL,  AL  D.,  Roan- 
oke, Va. 

Leary,  Timothy,  AI.  D.,  Boston. 

Ledbetter  Robert  E..  AI.  D.,  Xorfolk, 
\^a. 

Lederer,  William  J.,  D.  D.  S. 
L"Exgle,  Edward  AL,  AI.  D..  Philadel- 
phia. 

Le  Roy.  Berx.\rd  R..  AI.  D.,  Athens,  O. 
Leshure,  Johx,  AI.  D. 
Lo.M.\x,  Eugexe  W.,  AI.  D.,  Bluefield, 
W.  Va. 

Longenecker,  G.  W.,  AI.  D.,  Elsmore, 
Kans. 

Lydstox.  Fraxk,  AI.  D.,  Chicago. 
AIcCormick,  William  S.,  AI.  D.,  Phila- 
delphia. 

AIcCoY,  George  W.,  AI.  D.,  U.  S.  Public 
Health  and  Alarine  Hospital  Service. 

AIcAIurray,  T.  E.,  AL  D.,  Wilkinsburg, 
Pa. 

AIcAluRTRv,  Ch.\rles  Wood,  AL  D. 

AIcAIurtry.  Lewis  S.,  A.  AL,  AL  D., 
Louisville,  Ky. 

AIcRae,  Floyd  W.,  AL  D.,  Atlanta,  Ga. 

AIcWiLLiAMS,  Clarence  A.,  AI.  D. 

*AIacKee,  George  AL,  AL  D. 

AIackixxey',  William  H.,  AI.  D.,  Phila- 
delphia. 

AIacWhinnie,  a.  Morgan,  AL  D.,  Seat- 
tle, Wash. 

AIakuen,  G.  Hudson,  AI.  D.,  Philadel- 
phia. 

AIarchisio.  Alexander,  AI.  D. 
AI.\rkley',  p.  H.,  M.  D.,  Camden,  X.  J. 
AIay,  James  V.,  M.   D.,  Binghamton, 
N.  Y. 

*AIayo,  Caswell  A.,  Ph.  G. 
AIeeker.  Harold  Df.nman.  AI.  D. 
AIiller.  George  L,  AL  D.,  Brooklyn. 
AIiLLiCAN,  Kenneth  W.,  AL  D.,  Chicago. 


IV 


INDEX  TO  VOLUME  LXXXIX. 


Mitchell,  O.  W.  H.,  M.  D.,  Columbia, 
.Mo. 

Moore,  J.  L'i  tle,  M.  U.,  Toledo,  Ohio. 
Morris,  Robert  T.,  M.  D. 
MoKRow,  Prince  A.,  A.  M.,  M.  D. 
Morse,  John  Lovett,  A.  M.,  M.  D.,  Bos- 
ton. 

MosKowiTZ,  Samuel,  D. 

Nascher,  J.  L.,  M.  D. 

Newton,  Richard  Cole,  M.  D.,  Mont- 

clair,  N.  J. 
NicoLL,  Alexander,  M.  D. 
Noble,  Charles  P.,  M.  D.,  Philadelphia. 
Ogilvy,  Charles.  M.  D. 
Palier,  E.,  M.  D. 

Palmer,  W.  H.,  M.  D..  Providence,  R.  I. 
P.vNOFF,    Charles    Edward,    M.  D., 
Brooklyn. 

Parrish,  Henry,  M.  D.,  Philadelphia. 
Peckham,  F.  E.,  M.  D.,  Providence,  R.  I. 
Pedersen,  James,  M.  D. 
Perkins,  Charles  E.,  M.  D. 
Peters,  W.  H.,  M.  D.,  Providence,  R.  I. 
*PiFFARD,  Henry  G.,  A.  M.,  M.  D., 
LL.  D. 

PiTFiELD.  Robert  L..  M.  D.,  Philadelphia. 
Polak,  John  Osborne,  M.  Sc.,  M.  D., 
Brooklyn. 

PoRCHER,  W.  Peyre,  M.  D..  Charlestor^, 
S.  C. 

Porter,  P.  Brynberg,  M.  D. 

Pr.vtt,  J.  a.,  M.  D.,  Aurora,  111. 

Prince,  A.  E.,  M.  D.,  Spring-field,  111. 

Proescher,  Frederick,  M.  D.,  Pitts- 
burgh, Pa. 

Prout,  J.  S.,  M.  D.,  Brooklyn. 

Rectenwald,  J.  J.,  M.  D.,  Pittsurgh, 
Pa. 

♦Richard,      Lieutenant  Colonel 

Charles,     Medical     Corps,  United 

States  Army. 
Riesman,  David,  M.  D.,  Philadelphia. 
RoBARTS,  Heber,  M.  D.,  St.  Louis,  Mo. 
Robinson,  A.  R.,  M.  B.,  L.  R.  C.  P.,  and 

S.,  Edin. 
Robinson,  Be\-erley,  M.  D. 
Robinson,  B\t«on,  B.  S.,  M.  D.,  Chicago. 
Robinson,  W.  F.,  M.  D.,  Palm  Beach, 

Fla. 

Rose,  A.,  M.  D. 

RosENBERGER,  Randle  C,  M.  D.,  Phila- 
delphia. 
Rosen  HECK,  Charles,  M.  D. 


RucKER,  S.  T.,  AI.  D.,  Memphis,  Tenn. 
Run  VON,  F.  J.,  M.  D.,  Clarksville,  Tenn. 
Ryan,  W.  J.,  M.  D.,  East  Mauch  Chunk, 
Pa. 

Sajous,  Charles  E.  de  AL,  M.  D.,  Phil- 
adelphia. 

*Salmon,  Thomas  W.,  M.  D.,  U.  S. 
Public  Health  and  Marine  Hospital 
Service. 

'Sa.xe,  De  Santos,  ]\I.  D. 

ScHA.MBERG,  J.\Y  Frank,  M.  D.,  Phila- 
delphia. 

Schurmann,  Edward  A.,  AI.  D.,  Phila- 
delphia. 

Schwartz,  Hans  J.,  M.  D. 

*Shaffer,  Newton  M.,  M.  D. 

Sheddan,  L..  M.  D.,  Knoxville,  Tenn. 

*Shively,  Henry  L.,  AI.  D.,  LL.  D. 

Shoemaker,  Harlan.  A.  B.,  M.  D.,  Phil- 
adelphia. 

Shoe.maker,  John  V.,  i\l.  D.,  LL.  D., 
Philadelphia. 

Sichler,  E.  H.,  M.  D.,  Detroit,  Mich. 

SiGLER,  C.  L.,  M.  D.,  Pinckney,  Mich. 

Silkworth,  W.  Duncan,  M.  D. 

Sill,  E.  Mather,  M.  D. 

Singer,  David  A.,  A.  B.,  M.  D. 

S:vtiTH,  E.  Franklin,  M.  D. 

Smith,  F.  H.,  M.  D.,  Lewisburg,  W.  Va. 

Smith,  S.  MacCuen.  M.  D.,  Philadel- 
phia. 

Smith,  Thomas  A.,  M.  D. 

Soule,  Robert  E.,  .-V.  B..  M.  D. 

SouLES,  S.  G.,  AI.  D.,  Stanbridge  East, 
Quebec  Canada. 

Steinhardt,  Irving  D.,  M.  D. 

Stuart,  A.  F.,  M.  D.,  Portland.  iMe. 

Summers,  John  E.,  M.  D..  Omaha,  Neb. 

Super,  Charles  W.,  Ph.  D.,  LL.  D., 
Athens,  Ohio. 

Sutton.  R.  T.,  M.  D..  Kansas  Cit)%  Mo. 

*SwAN,  John  M.,  M.  D.,  Philadelphia. 

Sweeny,  Gilliford  B..  M.  D..  Pitts- 
burgh, Pa. 

Talmage,  John  B.,  M.  D. 

Talmey,  Max,  M.  D. 

Tatchell,  W.  Arthur,  M.  R.  C.  S. 
CEng.).  L.  R.  C.  p.  (Lond.),  Hankow, 
Central  China. 

Tay'lor,  Arthur  N. 

♦Taylor,  Henry  Ling.  M.  D. 

Teah,  Theodore  Emil,  M.  D.,  Renovo, 
Pa. 


Tho.mpso.v,  Francis  A.,  M.  D.,  Milwau- 
kee. Wis. 

Thomson.  W.  Hanna,  M.  D.,  LL.  D. 
Todd,  John  B.,  ;M.  D.,  Syracuse,  N.  Y. 
Torrance,  Gaston,  j\I.  D.,  Birmingham, 
Ala. 

TousEY",  Sinclair,  M.  D. 

Tri.mble,  William  B.,  M.  D. 

TuRCK,  Raymond  Custer,  M.  D.,  Jack- 
sonville, Fla. 

Twitchell,  George  B.,  M.  D..  Cincin- 
nati. 

Uhle,  Alexander  A.,  M.  D.,  Fniladel- 
phia. 

Vander  Veer,  Albert,  M.  D.,  LL.  D., 

Albany,  N.  Y. 
Van  Sweringen,  B.,  M.  D.,  Fort  Wayne, 

Ind 

Voorhees,  Irving  \\'ilson,  M.  S.,  M.  D. 
W.\inwright,  John  W.,  M.  D. 
Wandless,  H.  W.,  M.  D. 
Warren,  D.  E.,  M.  D.,  Passaic.  N.  J. 
Warren,  J.  N.,  M.  D.,  Sioux  City,  Iowa. 
Watson,  J.  J.,  M.  D..  Columbia,  S.  C. 
Weber,  Leonard,  M.  D. 
Weil,  Henry,  M.  D. 
Welch,  William  M.,  M.  D.,  Philadel- 
phia. 

Welker.  William  H..  A.  C,  Ph.  D. 
*Wheeler.  Cl.'\ude  L.,  a.  B.,  M.  D., 
Brooklyn. 

White,  Francis  W.,  M.  D.,  Philadel- 
phia. 

*Whitehouse,  H.  H.,  M.  D. 
Whitford,  William.  Chicago. 
Wile,  Ira  S..  M.  S.,  M.  D. 
Wiley.  Harvey  W.,  M.  D.,  Washington, 
D.  C. 

*WiLLi.\MS.  Tom  A.,  M.  B.,  C.  M.,  Edin., 

Wasnington,  D.  C. 
Wilson,  Gordon,  M.  D.,  Baltimore. 
Wiseman,  Joseph  R.,  M.  D.,  Syracuse, 

N.  Y. 

Wolbarst,  a.  L.,  M.  D. 

Woodruff.  Major  Charles  E..  Medical 
Corps  of  the  L'nited  States  Army. 

Wright.  Barton  Lisle,  Surgeon,  Medi- 
cal Corps,  U.  S.  Navy. 

Wright,  Jonathan,  !M.  D. 

Young.  A.  A.,  M.  D.,  Newark,  X.  Y. 

Zavatt.  Josefa,  M.  D.,  Philadelphia. 

Zemp,  E.  R.,  B.  S.,  M.  D.,  Knoxville. 
Tenn. 


LIST  OF  ILLUSTRATIONS  IN  VOLUME  LXXXIX. 


Page 

Acidimeter.    One  Illustration   24 

Adenoids.    Three  Illustrations   26" 

Anthropology.    Three  Illustrations   1030 

Autointoxication.    Four  Charts   1303 

Autoprotective  Mechanism  of  Human  Body.    Two  Illus- 
trations   433 

Bismuth  Poisoning.    Five  Illustrations  18-20 

Blood  Pressure  and  Life  Insurance.   Three  Illustrations.  1040 

Bull,  Dr.  William  T.    Portrait   448 

Cardiodilator.    One  Illustration   1077 

Cutaneous    Cyst    Formations.      Twenty  -  two  Illustra- 
tions  1125-1133 

Deficient  Oxidation  and  Nephritis.  Three  Illustrations..  1093 
Economic  Housing  of  Consumptives.  Four  Illustrations  727 
Electricity  in  Genitourinary  Diseases.    Four  Illustrations  1038 

Flagellation  of  Leucocytes.    One  Illustration   1 133 

Flat  Foot.    Six  Illustrations   734 

Fracture  of  Neck  of  Femur.    Four  Illustrations  22-23 

Fracture  of  Patellae.    Two  Illustrations   852 

French  Medical  Science  During  the  Middle  Ages   978 

Gonorrluea  in  the  Male.    Six  Illustrations  217-218 

Hays's  Pharyngoscope.    One  Illustration   §23 

Hospital  of  the  University  of  Pennsylvania,  New  Build- 
ings of   858 

Hypernephroma  and  Cancer.    Three  Illustrations   I'ss 

Hystcrosalpingostf)my.    Two  Illustrations   H93 

Ingrowing  Toe  Nail.    Two  Illustrations   388 


Page 

Intraabdominal   Injection  of  O.xygen.     Three  Ilfustra- 

tions    741 

Lacerations  of  the  Cervix  Uteri.    Two  Illustrations   153 

Marine  Hospital  Sanatorium  for  Tuberculosis  at  Fort 

Stanton,  N.  M.    Seven  Illustrations  417-424 

Mercury  in  the  Treatment  of  Tuberculosis.    Three  Illus- 
trations   1180 

Moro  Tuberculin  Reaction.    Three  Illustrations   1034 

Myocarditis  in  Children.    Two  Charts   1295 

Nephritis    and    Deficient    Oxidation.     Three  Illustra- 
tions  1138-1139 

New  Frontal  Sinus  Punch.    One  Illustration   461 

Painful  Heels.    Four  Illustrations   626 

Pellagra.    Three  Illustrations  938-939 

Radical  Cure  of  Hernia.    Four  Illustrations.   528 

Serum  Diagnosis  of  Syphilis.    Two  Illustrations   208 

Sound,  a  New.    Three  Illustrations   1240 

Spirochaeta  Lymphatica.    Thirteen  Illustrations   852 

Thoracic  Aneurysm.    Three  Illustrations   4^4 

Tonsil  Forceps    305 

Ureteral  Calculi.    Three  Illustrations..   1 190 

Uretcrorenal  Decalogue.    Six  Illustrations   5.'° 

Uterine  Dilator.   Two  Half  Tones.   628 

\'esicovaginal  Fistula.    Five  Illustrations   I57 

X  Ray  Examination  of  CEsophagus.    Five  Illustrations.  160-164 
X  Rav  Treatment  of  Internal  Structures.    Two  Illustra- 
tion's   622 

X  Ravs  in  Thoracic  Lesions.    Twelve  Illustrations  942-947 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  The  Medical  News 

A  Weekly  Review  of  Medicine,  Established  1S4J. 


Yo\..  LXXXIX.  Xo.  I. 


XEW  YORK.  JAXUARY  2.  1909. 


A\'iioLE  Xo.  1570. 


{Briainal  Commanitations. 


THE  RESPONSIBILITY  OF  THE  FAMILY  PHYSI- 
CIAN  TOWARD  TUBERCULOSIS.* 

By  S.  Adolphus  Knopf,  M.  D., 
New  York. 

Professor  of  Phtbisiotherapy  at  the  New  York  Postgraduate  Medical 
School   and   Hos  ital;   Associate   Director   of   the   Clinic  for 
Pulmonary  Diseases  of  the  Health  Department;  Visit- 
ing Physician  to  the   Riverside   Sanatorium  for 
Consumptives  of  the  City  of  New  York,  etc. 

The  treatment  of  the  subject  assigned  to  me  in 
the  few  minu^es  I  shall  have  at  my  disposal  must, 
of  necessity,  be  incomplete,  and  I  trust  that  this 
audience  of  teachers  of  medicine,  of  practising  phy- 
sicians of  to-day  and  of  to-morrow,  will  bear  with 
me  if  I  do  not  succeed  in  covering  the  ground  as 
fully  as  the  importance  of  the  subject  demands.  To 
me  there  is  no  more  vital  factor  among  all  those  ap- 
pertaining to  the  solution  of  the  tuberculosis  prob- 
lem than  the  responsibility  which  rests  upon  the 
family  physician  or  general  practitioner. 

Of  the  vast  importance  of  the  early  recognition  of 
tuberculosis  you  have  already  heard,  and  you  a'! 
know  that  it  is  the  family  practitioner  who  has  the 
greatest  opportunities  for  making  an  earlv  diagnosis. 
To  do  this  he  should  not  wait  until  the  patient 
coughs,  becomes  emaciated,  has  an  evening  rise  of 
temperature,  or  a  fall  below  normal  in  the  morning, 
becomes  irritated  or  tires  easily,  or  has  a  hsemop- 
tysis.  To  my  mind  it  is  not  only  the  privilege  of 
the  family  physician,  but  it  is  his  sacred  duty,  to 
examine  the  chests  of  all  the  members  of  the  familv 
in  which  he  practises.  This  should  be  done  not  onlv 
occasionally  or  sporadically,  but  periodically :  that 
is  to  say,  every  three  or  four  months.  If  there  is  a 
tuberculosis  he  is  thus  sure  to  discover  it  in  time. 

\Miat  is  his  duty  then?  Immediately  to  inform 
the  patient,  if  he  is  an  adult,  and  also  the  rest  of 
the  family,  of  the  condition  found.  To  hide  from 
the  intelligent  adult  the  fact  that  he  is  tuberculous 
or  that  a  member  of  his  family  is  afflicted  with  the 
disease,  in  the  light  of  our  modern  knowledge,  is  an 
absolute  wrong,  or  perhaps  it  may  even  be  said,  a 
criminal  neglect.  That  the  family  physician  will 
use  the  utmost  tact  in  revealing  such  a  condition  to 
the  patient  or  to  the  friends  of  the  patient  is  a 
matter  self  understood.  What  we  know  to-day  of 
the  curability  of  an  early  tuberculosis  makes  the 
task  all  the  more  easy.    One  can  inspire  the  patients 


.\ddress  delivered  at  the  Museum  of  Natural  Ilistorv  before  the 
mass  meeting  of  medical  students  on  the  occasion  of  the  Inter- 
national Tuberculosis  Exhibition  in  New  York  citv,  December  S 
1908,  Professor  Edward  G.  Janeway,  M.  D.,  LL.  D'.,  presiding. 

Copyright, 


and  friends  with  absolute  hope  for  recovery  when  in 
the  presence  of  an  early  tuberculosis. 

It  has  been  my  practice,  in  order  to  overcome  the 
shock  whicli  the  revelation  of  the  presence  of  the 
disease  at  times  produces  in  the  patient,  to  tell  him, 
"be  grateful  for  this  early  discovery  of  a  curable 
condition,  which,  when  cured,  will  leave  you  a 
stronger  and  more  vigorous  man  than  you  ever 
were  before." 

AMiether  you  should  then  at  once  institute  the 
hygienic  and  dietetic  treatment  at  home,  or  send 
the  patient  away,  will  depend  on  the  circumstances 
of  the  family,  upon  the  patient's  character  and  pos- 
sible peculiarities.  Whether  he  remains  at  home 
for  good  or  only  for  a  few  days  until  accommoda- 
tions in  a  sanatorium  or  health  resort  can  be  found, 
it  is  your  duty  at  once  to  institute  all  the  prophv- 
lactic  measures  to  prevent  the  infection  of  others 
or  the  reinfection  of  the  patient. 

Where  compulsory  or  even  only  voluntar\-  noti- 
fication is  required,  notify  the  health  authorities  of 
the  existence  of  the  case.  You  know  that  they  will 
not  interfere  when  you  assume  the  responsibility  for 
the  necessary  preventive  measures. 

Xot  all  of  you  will  be  family  physicians  right 
away,  and  there  are  a  great  many  families  who  have 
no  physicians,  and  you  will  probably  often  be  called 
into  a  family  only  because  the  case  exists  and  the 
early  s\mptoms  frightened  the  people  sufficiently  to 
make  them  seek  medical  aid.  In  such  instances  it 
is  your  duty  to  act  as  if  you  were  the  family  phvsi- 
cian.  I  know  it  will  be  a  delicate  task  for  you  to 
insist  upon  the  examination  of  all  the  members  of 
the  faniily,  for  since  you  cannot  afford  to  do  this  in 
e\-ery  instance  for  nothing,  small  minds  will  inter- 
pret your  desire  to  do  your  duty  as  a  scheme  to 
niake  money.  Avoid  this  suspicion  by  ir.erelv  tell- 
ing these  families  that  you  presume  that  thev  have 
a  tamil\-  physician  and  that  you  would  urge  them  to 
call  on  him  for  the  examination  of  all  the  members 
of  the  family. 

\\'hen  you  are  called  into  the  homes  of  the  well 
to  do  to  see  a  patient  in  the  latter  stages  of  the  dis- 
ease, should  you  advise  a  change  of  climate?  Yes, 
if  the  patient  wishes  it.  Xo.  if  he  does  not  wish  it. 
In  the  latter  instance  make  him  comfortable,  relieve 
his  suffering,  prolong  his  life  as  best  vou  can.  and 
let  him  end  his  days  peacefully  amid  his  famih-  and 
friends. 

Should  you  send  a  patient  with  little  or  no  means, 
in  a  curable  stage  of  the  disease,  to  a  faraway  cli- 
mate, in  the  hope  that  in  a  few  v>eeks  he  may  find 
light  employment  there,  when  this  patient  is  in  need 
of  rest  and  care?   Xo.  .a  thousand  times  no.  Unless 

1909,  by  A.  R.  Elliott  Publishing  Company. 


2 


KNOPF:  PHYSICIAN'S  RESPONSIBILITY  IN  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


you  are  absolutely  certain  that  he  will  be  able  to 
work  in  a  few  weeks  or  find  work  that  will  permit 
him  to  complete  his  cure,  you  have  no  right  to  send 
him  away.  Not  unless  he  is  provided  with  funds 
sufficient  at  least  to  last  him  for  a  year,  with  or 
without  work,  and  also  for  treatment  during  that 
time,  should  the  patient  be  sent  to  any  distant  cli- 
mate. By  getting  rid  of  a  patient  without  this  pro- 
vision you  wrong  yourself,  you  wrong  your  fellow 
citizens  in  Colorado,  New  Mexico,  or  elsewhere,  by 
placing  an  undesired  burden  upon  their  community, 
and,  above  all,  you  wrong  your  patient  by  depriving 
him  of  a  reasonably  good  chance  to  get  well  in  or 
near  the  home  where  he  must  live  and  labor  after  his 
restoration  to  health.  Here  his  chances  of  staying 
cured  are  certainly  not  so  bad,  though  the  time 
taken  to  cure  him  may  have  been  a  little  longer  than 
anticipated. 

Your  responsibility  is  perhaps  greatest  when  you 
are  taking  care  of  a  tuberculous  parent  who  has 
children  and  must  be  treated  at  home.  If  he  is  well 
to  do,  the  task  is  not  so  difficult.  You  can  isolate 
film  in  a  well  lighted,  well  aired,  and  sunny  room. 
You  can  make  him  sleep  on  the  veranda  or  in  a 
\\indow  tent,  \ou  can  assign  a  nurse  to  look  after 
him,  one  to  whom  you  entrust  the  carrying  out  of  all 
the  preventive  and  hygienic  measures.  The  children 
of  the  patient  you  will  instruct  in  elementary  hygi- 
ene, you  will  see  that  they  are  properly  clad  and 
properly  fed.  You  will  develop  their  chests  by  ap- 
propriate respiratory  exercises  and  calisthenics.  In 
other  words,  you  will  try  to  render  them  imtriune 
against  possible  infection  and  to  overcome  a  possible 
inherited  predisposition"  which  is  nothing  more  and 
nothing  less  than  a  physiological  poverty. 

If  you  fear,  nevertheless,  that  the  habitus  phthi- 
sictis,  so  well  described  by  that  great  physician 
of  antiquity,  Hippocrates,  has  developed  or  is  de- 
veloping in  any  one  of  these  children,  you  will 
insist  that  the  future  career  of  this  boy  or  girl 
will  be  such  a  one  as  to  exclude,  as  far  as  pos- 
sible, the  development  of  tuberculosis.  You  will 
not  send  this  child  to  school  before  the  eighth 
year,  and  if  circumstances  permit,  you  will  not 
send  him  to  the  public  school  at  all,  but  have  him 
taught  privately  or  sent  to  an  open  air  school. 
This  is  easy  with  the  well  to  do,  but  how  different 
and  how  difficult  is  it  in  the  homes  of  the  poor ! 
When  because  of  lack  of  hospital  or  sanatorium 
facilities  the'  poor  consumptive  must  be  treated  at 
home,  how  to  isolate  him,  how  to  prevent  infection, 
and  particularly  the  drop  infection,  so  dangerous  in 
our  crowded  .tenements,  will  tax  all  your  ingenuity. 
Tlie  children  of  the  poor  will  not  be  able  to  receive 
private  instructions  at  home,  and  few  communities 
are  as  yet  blessed  with  public  open  air  schools.  The 
choice  of  a  future  career  for  the  boy  or  girl  of  a 
consumptive  father  or  mother  has  a  great  bearing 
on  the  possibility  whether  or  not  he  or  she  shall 
become  a  victim  of  the  disease.  The  son  of  a  con- 
sumptive printer,  stone  cutter,  weaver,  or  tailor 
should  not  follow  in  the  footsteps  of  his  father,  nor 
should  a  daughter  of  a  consumptive  seamstress  be- 
come likewise  a  seamstress.  To  prevent,  if  possible, 
that  the  children  of  the  consumptive  poor  as  well  as 
of  the  consumptive  rich  shall  choose  a  career  by 
which  they  are  endangered  to  fall  victim  to  the  dis- 


ease with  which  their  parent  was  afflicted  is  the  duty 
of  every  family  physician  or  general  practitioner. 

I  would  consider  it  a  violation  of  my  duty  as  a 
teacher  did  I  not  speak  here  of  the  delicate  subject 
of  marriage  of  the  tuberculous  and  the  possible  pro- 
creation of  a  tuberculous  race.  There,  exist  in  some 
States  laws  which  prevent  the  marriage  of  tuber- 
culous individuals.  With  all  due  respect  and  admi- 
ration for  those  brave  legislators  who  enacted  this 
law,  and  while  I  would  not  wish  to  underestimate 
the  educational  value  of  such  legislation,  I  can  tell 
them,  however,  that  when  tuberculous  persons  want 
to  be  married,  they  do  not  care  for  the  law  of  one 
State  when  it  is  possible  for  them  to  be  married  in 
another. 

I  have  more  than  once  in  my  life  told  consump- 
tives not  to  marry.  They  did  it  all  the  same  in  a 
good  many  instances.  Should  they  have  children, 
particularly  when  the  woman  is  the  invalid  and  when 
she  has  passed  the  incipient  stage?  Decidedly  no! 
A  pregnancy  in  a  tuberculous  woman  will  almost 
always  aggravate  the  condition,  though  this  aggra- 
vation may  only  show  itself  after  childbirth.  What 
can  we  do?  The  emptying  of  the  uterus,  if  done 
with  skilled  hands  and  after  due  consultation  with 
acknowledged  experts,  may  be  justified  in  some  in- 
stances in  order  to  save  the  mother's  life ;  but  pre- 
vention is  better,  and  I  am  willing  to  acknowledge 
that  I  favor  it.  I  am  willing  to  assume  the  responsi- 
bility before  the  law  of  man  and  before  my  creator 
for  every  time  I  have  counselled  the  tuberculous  to 
cease  procreating  children.  The  issue  of  such  pa- 
rentage means,  in  the  majority  of  cases,  an  early 
death  of  the  mother,  or  a  child  with  a  hereditary 
predisposition  and  a  constant  exposure  to  postnatal 
infection,  or  both. 

There  is  but  one  more  phase  of  my  subject  which 
I  must  touch  in  conclusion.  It  is  treatment.  This 
must  never  be  confined  to  the  specialist  alone.  The 
general  practitioner,  the  family  physician,  should 
know  how,  must  know  how  to  treat ;  should  treat 
and  must  treat  tuberculous  patients.  It  is  his  duty 
to  inform  himself  of  all  that  is  new  and  good  and 
old  and  good  in  the  treatment  of  tuberculosis,  and 
it  is  his  duty  to  apply  it.  Without  being  a  culinary 
artist,  he  should  know  how  to  direct  the  dietetic 
treatment.  Without  being  a  mechanical  genius,  he 
should  know  how  to  rig  up  some  sort  of  device  to 
assure  the  patient  the  greatest  amount  of  pure  and 
fresh  air.  He  should  know  what  drugs  to  give  them 
and  what  not  to  give  them.  Last  but  not  least,  he 
should  know  how  to  inspire  his  patient  with  confi- 
dence. He  should  be  firm  when  firmness  is  needed, 
but  always  kind.  He  should  look  upon  the  patient 
not  as  a  case  but  as  an  individual  in  need  of  sympa- 
thy and  help. 

We  hear  much  in  these  days  of  the  Emmanuel 
movement,  of  the  wonderful  cures  its  promoters 
have  accomplished,  not  only  in  nervous  and  mental 
diseases,  but  also  in  tuberculosis.  They  report 
eighty  per  cent,  of  cures  of  pulmonary  tuberculosis, 
comprising  all  the  stages  of  the  disease.  It  was  re- 
cently my  privilege  to  meet  the  great  leaders  of  the 
Emmanuel  Church  movement,  the  two  doctors  of 
divinity,  Worcester  and  McComb.  and  the  two  doc- 
tors of  medicine,  Coriat  and  Pratt.  While  I  have 
never  for  a  moment  doubted  the  accuracy  of  their 


January  2,  1909. J 


CUMSTON:  BENJAMIN  FRANKLIN. 


3 


so  unusually  favorable  statistics  of  cures,  I  was  in- 
terested to  find  out  why  it  was  possible  for  these 
men  to  obtain  and  to  do  what  to  the  best  of  my 
knowledge  has  never  been  attained  or  done  before. 
I  did  not  inquire  how  they  cured  the  habitual  drunk- 
ard, the  hysteric,  the  mentally  depressed,  or  those 
afflicted  with  functional  disorders,  but  I  did  want 
to  learn  all  I  could  about  their  phthisiotherapy.  In 
the  true  spirit  of  humanity  and  of  brotherly  love, 
they  made  no  secrets  to  me  of  their  methods,  and 
I  gladly  impart  them  to  you.  The  eighty  per  cent, 
of  cures  which  I  mentioned  relate  to  twenty-eight 
cases  of  pulmonary  tuberculosis  in  various  stages 
of  the  disease.  These  patients  have  been  treated  for 
two  long  years  in  classes  in  or  near  their  homes  after 
the  most  improved  hygienic  and  dietetic  treatment 
with  rest  in  the  open  air,  constant  supervision  by 
nurses  under  the  direction  of  an  experienced 
phthisiotherapeutist. 

Thus  far  for  the  medical  treatment  and  their 
patints'  physical  comfort ;  but  now  listen  to  the 
secret.  Without  imposing  their  religious  conviction, 
the  doctors  of  divinity  went  among  these  patients 
and,  assisted  by  friendly  visitors,  inspired  them  with 
hope  and  comfort,  talked  to  thiem  of  home,  children, 
wives,  and  husbands.  Then  the  friendly  visitors 
looked  after  the  wives  or  children,  mothers  or  sis- 
ters in  the  home.  In  all  instances  when  the  bread- 
winner was  the  invalid,  these  good  women  took  it 
upon  themselves  to  see  that  there  was  nothing  want- 
ing in  that  home  that  was  without  a  breadwinner. 
In  other  words,-  the  invalids  and  their  famiHes  were 
taken  care  of  by  the  Emmanuel  Church  people  for 
two  years.  Perhaps  never  before  in  their  lives  had 
these  individuals  so  much  peace  of  mind,  happiness, 
and  contentment  as  when  lying  on  their  reclining 
chairs  taking  the  rest  cure  in  the  open  air  and  think- 
ing of  their  well  provided  family,  their  prospective 
recovery,  and  having  at  the  same  time  the  assurance 
given  to  them  that  employment  would  be  provided 
when  they  were  again  able  to  work.  And  all  this 
without  being  away  from  home.  The  element 
of  homesickness,  so  distressing  to  many  sanato- 
rium patients,  did  not  exist.  Herein  lies  the  suc- 
cess of  the  Emmanual  Church  movement  as  far 
as  tuberculosis  is  concerned.  Will  it  be  necessary 
for  us,  in  order  to  cure  tuberculosis,  to  imitate 
the  Emmanuel  Church  movement  in  all  its  details, 
and  will  we  not  be  able  to  obtain  sitnilar  success 
without  calling  in  the  brethren  of  the  church  ?  You 
have  already  heard  me  say  how  greatly  I  respect 
and  admire  the  work  done  by  the  Emmanuel 
Church,  but  this  will  not  prevent  me  from  telling 
you,  and  here  I  address  myself  particularly  to  you, 
my  young  fellow  students,  be  not  discouraged.  As 
family  practitioners,  as  citizens,  as  coworkers  in 
the  antituberculosis  movements  in  the  homes  to 
which  you  may  return  after  you  will  have  com- 
pleted your  studies  here,  you  can  interest  phil- 
anthropists, noble  hearted  men  and  women  inside 
and  outside  of  the  church,  to  help  you.  If  you  find 
a  congenial  clergyman  who,  remaining  in  his  sphere 
of  comforting  the  soul,  is  wilHng  to  help  you,  by  all 
means  welcome  him  and  work  together.  However, 
I  do  not  think  this  absolutely  necessary,  and  it  is 
of  no  great  import  whether  you  or  he  will  get  the 
means  together  to  enable  you  to  treat  your  con- 


sumptive poor  for  two  years  and  to  provide  for  their 
families  for  the  same  space  of  time.  . 

If  I  were  to  make  a  suggestion,  I  would  venture 
to  advise  those  of  you  who  intend  to  interest  them- 
selves in  the  treatment  of  the  consumptive  poor  to 
follow  the  example  of  our  brethren  in  Germany. 
They  presented  the  cause  to  the  women  of  Germany, 
who  responded  in  various  sections  by  organizing 
themselves  for  the  purpose  of  giving  systematic  and 
practical  help  to  families  whose  breadwinners  are 
incapacitated  by  tuberculosis.  I  refer  here  parti- 
cularly to  the  society  known  in  Germany  as  Patriot- 
ischc  Frauen  von  Charlottenburg  (Patriotic  Women 
of  Charlottenburg).  This  organization  works  under 
the  auspices  of  the  German  Red  Cross  Society. 

Think  what  a  useful  field  of  labor  this  would  be 
for  our  own  Red  Cross  Associations  in  time  of 
peace.^  They  could  thus  help  to  combat  an  enemy 
far  more  terrible,  far  more  murderous,  far  more 
costly  than  the  mightiest  army  of  the  mightiest 
nation.  A  work  more  patriotic  and  more  helpful 
toward  the  solution  of  the  tuberculosis  problem  it 
would  be  difficult  to  conceive.  A  movement  of  this 
kind  would  by  no  means  exclude  the  collaboration 
of  the  doctors  of  divinity  or  sisters  of  charity.  There 
is  a  second  organization  working  for  the  same  pur- 
pose, called  German  Lay  Sisters  of  Charity.  But 
whoever  works  with  you,  be  they  patriotic  women, 
mothers,  wives,  sisters,  or  sweethearts,  whether  you 
work  with  or  without  the  clergy,  if  you  have  the 
means  necessary  to  spare  the  patient  anguish,  anx- 
iety, and  sorrow,  and  give  him  the  best  in  phthisio- 
therapy as  long  as  he  needs  it,  I  have  no  doubt  that 
your  results  will  equal  those  of  the  Emmanuel 
Church. 

However,  to  attain  these  results  you  must  have 
not  only  the  material  means  but  a  complete  knowl- 
edge of  phthisotherapy,  must  have  coworkers  not 
only  of  material  wealth  but  of  wealth  of  heart  and 
mind,  and  above  all  you  yourself  must  be  a  picture 
of  perfect  health,  and  inspiration  of  hope,  an  ex- 
ample of  good  cheer,  of  genuine  sympathy,  and  of 
complete  devotion.  In  short,  you  must  indeed  be 
a  physician  in  the  higher  sense  of  the  word,  a  healer 
of  the  body  or  the  mind  diseased,  a  friend  and 
counsellor  of  the  soul  in  need. 

16  West  Ninety-fifth  Street. 


BENJAMIN  FRANKLIN  FROM  THE  MEDICAL 
VIEWPOINT. 

By  Charles  Greene  Cumston,  M.  D., 
Boston, 

Member  of  the  Medical  Historical  Society  of  France,  etc.,  etc. 

Benjamin  Franklin  is,  without  doubt,  one  of  the 
most  original  and  sympathetic  figures  that  is  to  be 
found  in  the  history  of  science.  He  not  only  applied 
his  genius  to  the  study  of  physics  and  political  econ- 
omy, but  he  was  one  of  the  first  to  apply  electricity 
to  medicine.  He  also  undertook  remarkable  experi- 
ments on  subjects  of  physiology.  And  lastly,  we 
have  his  little  work  on  smallpox  and  his  dialogue  on 
gout. 

In  a  work  entitled:  "Some  Account  of  the  Penn^ 

'See  New  York  Medical  Journal,  November  28,  1908:  The  Red 
Cross  in  the  Antituberculosis  War. 


4 


CUMSrON:  BEXJAMIN  FRANKLIN. 


[New  York 
Medical  Jolrxal. 


syhvnia  Hospital;  from  its  first  Rise  to  the  begin- 
ning of  the  P  if  til  Month,  called  May  IJ34.  Phila- 
delphia: Printed  by  B.  Franklin,  and  D.  Hall. 
MDCCLH' ."  we  find  Franklin  on  the  list  of  con- 
tributors, the  sum  he  gave  being  twenty-five  pounds, 
while  "on  the  7th  of  May,  1752,  there  was  a  new- 
Choice  of  Directors,  and  a  Treasurer."  There  were 
twelve  managers  elected,  among  whom  we  find 
Franklin.  All  this  goes  to  show  that  this  versatile 
man  was  interested  in,  and  gave  much  thought  to, 
medicine. 

It  has  consequently  appeared  to  me  that  it  is  not 
without  interest  to  study  these  various  intellectual 
manifestations  in  a  man  that  is  so  greatly  a  genius, 
l)ut  before  entering  into  the  medical  side  proper,  it 
seems  essential  to  devote  a  little  space  to  Franklin's 
life. 

Franklin  was  born  in  Boston  on  January  6,  1706. 
being  the  last  son  of  a  numeroiis  family.  His  pa- 
rents originated  from  Northamptonshire,  England, 
and  the  family  had  had  in  possession  for  at  least 
three  hundred  }ears  a  small  farm  to  which  was 
added  the  products  of  a  forge.  For  many  years  back 
they  had  embraced  the  reformed  religion,  and  for 
this  reason  at  dift'erent  times,  had  undergone  much 
persecution.  Franklin  had  sixteen  brothers  and 
sisters,  these  being  the  result  of  .two  marriages.  His 
father,  Josias  Franklin,  came  to  America  about  1685. 
at  this  time  having  seven  children  by  his  first  wife, 
while  ten  children  resulted  from  his  second  mar- 
riage with  Abiah  Folger,  Benjamin  being  the  last 
on  the  list  of  the  pledges  of  marriage. 

While  all  his  brotlters  had  been  placed  in  dift'er- 
ent hands  in  order  to  learn  various  trades,  Benjamin, 
at  the  age  of  eight,  was  sent  to  college  as  his  father 
destined  him  for  the  Church.  He,  however,  re- 
mained there  hardly  a  year,  because  on  account  of 
the  family  expenses,  his  father  was  unable  to  con- 
tinue tlie  pay  for  his  education,  and  he  therefore 
sent  him  to  a  school  kept  by  an  excellent  teacher,  in 
order  to  learn  writing  and  arithmetic.  At  the  age 
of  ten,  his  father  brought  him  back  so  that  he  might 
help  him  in  a  new  trade,  that  of  manufacturing 
candles  and  soap,  as  the  business  of  a  dyer  which  Iil- 
had  followed  up  to  that  time  was  not  sufficientl\- 
lucrative,  lienjamin  was  far  from  happy  in  his  new 
surroundings.  He  had  always  been  attracted  by  a 
sailor's  life,  and  at  an  early  age  he  could  swim  and 
steer  a  boat.  His  father  wished  at  all  cost  to  deter 
him  from  going  to  sea,  so  he  frequently  took  him  tn 
watch  masons,  carpenters,  etc.,  work,  thus  hoping  to 
discover  his  son's  tastes  and  keep  him  on  land. 

'i"he  taste  of  reading  at  this  time  developed  in 
Franklin,  and  he  had  soon  read  all  the  books  in  the 
small  library  of  his  father  which  was  composed  prin- 
cipally of  works  on  theology,  and  he  said  later  in 
his  life  that  he  greatly  regretted  not  to  have  had 
access  to  other  bonks  at  this  time.  Soon  afterwards, 
however,  he  obtained  a  translation  of  Plutarch  that 
he  diligently  read  and  he  always  considered  that  he 
hatl  thus  employed  his  time  to  advantage.  The 
Essay  on  Projects  by  Foe  had  also  considerable  in- 
fluence over  him. 

This  disposition  at  last  determined  his  father  to 
nipke  a  i)rinter  of  him,  although  he  had  alreadv  an- 
other son  in  this  profession.  Franklin's  oldest 
hrotluT  had  set  up  business  in  Boston  in  1717,  and 


owned  his  press  and  type.  A  contract  of  appren- 
ticeship was  concluded  between  the  two  brothers, 
which  bound  Benjamin  until  the  age  of  twenty-one 
years.  At  the  time  the  contract  was  made  he  was 
twelve  years  old.  It' was  understood  that,  he  would 
only  receive  wages  as  a  workman  during  the  last 
year  of  his  apprenticeship. 

I'Vanklin  macle  rapid  progress  and  soon  made  him- 
self useful.  Numerous  excellent  works  came  to  his 
hands,  lent  him  by  apprentices  at  bookshops  with 
whom  he  was  acquainted.  A  man  of  much  mind,  by 
name  Mathew  Adams,  who  was  possessed  of  a  very 
fine  collection  of  books  placed  them  at  his  disposal. 
His  reading  at  last  gave  him  the  idea  of  himself  try- 
ing to  write  some  works.  He  composed  two  ballads 
which  were  most  successful  and  greatly  flattered  his 
vanity,  but  his  father  was  sensible  enough  to  point 
out  to  him  the  ridiculousness  of  these  productions. 
According  to  Franklin  himself  they  were  miserable 
compositions  and  he  w^as  grateful  to  his  father  for 
makmg  him  escape  from  being  a  bad  poet,  the  most 
useless  individual  of  all  creation.  During  the  rest 
of  his  life  he  was  contented  w'ith  expressing  him- 
self in  prose. 

At  aliout  this  time  he  became  intimate  with  a 
young  man  named  Collins,  and  as  they  were  both 
given  to  controversy,  they  had  frequent  discussions 
which  for  them  was  an  agreeable  war  of  words,  the 
fruit  of  their  first  readings.  How-ever,  Franklin 
soon  corrected  himself  in  this  respect. 

What  is  of  extreme  interest  is  to  see  how  from 
each  happening,  whether  small  or  great,  in  his 
life.  Franklin  knew  how  to  deduct  some  practical 
teaching,  which  he  was  able  later  on  in  life  to 
apply.  A  great  controversy  on  the  education  of 
women  arose  between  Collins  and  himself,  but 
Franklin's  father  pointed  out  to  the  young  printer 
that  although  he  might  carry  in  reason  and  ortho- 
graphy, his  adversary  was  superior  in  the  elegance 
of  his  language  and  the  choice  of  expression.  Frank- 
lin saw  the  justice  of  these  criticisms  and  resolved 
to  acquire  that  which  he  was  wanting  in. 

An  odd  volume  of  The  Spectator  fell  to  him  and 
he  read  and  reread  it  and  finally  decided  to  adopt  the 
style  therein  contained.  From  tiine  to  time  he  se- 
lected pieces  from  which  he  made  short  extracts, 
then  laid  them  aside  and  after  a  few  days  en- 
deavored to  recomposc  them.  He  thus  discovered 
his  faults  and  was  able  to  correct  them. 

At  the  age  of  sixteen  he  by  chance  read  a  work  by 
Tyron,  in  which  the  author  recommended  a  vege- 
table diet.  Franklin  wished  to  try  it.  but  as  he  was 
boarding  with  his  brother  and  the  other  apprentices 
with  people  in  the  neighborhood,  this  singular  re- 
gime became  rather  difficult.  He  projwsed  to  his 
brother  to  ,give  him  each  week  only  the  half  of  what 
he  paid  for  his  board  and  this  demand  being  ac- 
cepted. Franklin  who  was  always  desirous  of  ac- 
quiring books  was,  able  to  still  save  one-half  of  the 
money  given  him. 

-After  a  frugal  repast,  usually  composed  of  bread 
and  fruit,  he  employed  for  study  the  time  which  re- 
mained until  his  brother  and  employes  returned  for 
work.  It  was  at  this  time  that  he  assimilated 
Cocke's  Treatise  on  .  Irithinetic.  a  work  on  naviga- 
tion by  Seller  and  Stuniy.  Locke  On  the  I'nder- 
slanding.  The  .  Irt  of  Thinking  by  the  Messieurs  of 


January  2,  1909.] 


CCMSTOX 


BENJAMIN  FRANKLIN. 


5 


the  Port-Royal,  and  Xenophon's  work  entitled 
"Memorable  Things  of  Socrates."  The  Greek  phil- 
osopher's way  of  reasoning  and  discussing  struck 
him  forcibly,  and  renouncing  possible  arguments,  he 
tried  to  limit  himself  to  interrogation. 

In  his  Autobiography  Franklin  says  that,  'from 
reading  Shaftesbury  and  Collins,  made  a  doubter,  as 
I  already  was  in  many  jwints  of  our  religious  doc- 
trines, I  found  this  method  the  safest  for  myself 
and  very  embarrassing  to  those  against  whom  I  used 
it ;  therefore,  I  took  delight  in  it,  practised  it  con- 
tinually, and  grew  very  artful  and  expert  in  draw- 
ing people  even  of  superior  knowledge  into  con- 
cessions, the  consequence  of  which  they  did  not 
foresee,  entangling  them  in  difficulties  out  of  which 
they  could  not  extricate  themselves,  and  so  obtain- 
ing victories  that  neither  myself  nor  my  cause  al- 
ways deserved." 

But  these  very  triumphs  showed  him  the  empti- 
ness of  his  method,  and  little  by  little  he  abandoned 
it,  only  retaining  the  habit  of  always  expressing 
himself  witli  modesty.  He  having  found  that  the 
end  of  all  conversation  was  to  instruct  or  be  in- 
structed, or  to  please  or  persuade  intelligent  men  or 
those  having  good  intentions,  weakened  the  power 
that  they  have  of  doing  good  by  taking  a  decisive 
and  cutting  tone,  which  rarely  fails  in  displeasing 
and  tends  to  contradiction. 

In  1720  his  brother  began  to  publish  a  paper 
called  The  Nezc  England  Coiirant.  It  appears  that 
this  was  the  second  newspaper  published  in 
America,  and  "curious  to  see  what  effect  an  article 
from  his  own  pen  might  produce,  he  wrote  one  an- 
onymously and  sent  it  to  the  paper.  It  was  great 
pleasure  to  him  to  find  that  it  was  approved  by  cer- 
tain intelligent  men,  likewise  their  curiosity  to  find 
the  real  author,  only  naming  those  people  who  were 
enjoying  a  certain  reputation  of  knowledge  and  wit. 
Encouraged  by  other  articles  that  he  wrote,  these 
having  obtained  the  same  approval,  he  finally  let  his 
brother  into  the  secret,  but  it  appears  that  the  latter 
was  not  very  content. 

Franklin's  brother  was  very  violent  and  frequent- 
ly beat  him,  and  it  is  perhaps  this  hard  and  tyranni- 
cal treatment  that  made  him  all  his  life  preserve  a 
hatred  against  arbitrary  power.  For  this  reason 
Franklin  was  most  desirous  of  abridging  his  appren- 
ticeship. The  opportunity  occurred  in  a  most  unex- 
pected way.  A  political  article  of  certain  violence 
having  appeared  in  the  journal,  his  brother  was  ar- 
rested and  sent  to  jail  for  a  month  because  he  re- 
fused to  expose  the  author's  name.  During  his  stay 
in  jail,  inflamed  with  resentment  and  having  charge 
of  the  direction  of  the  journal.  Franklin  was  hardy 
enough  to  publish  numerous  sarcastic  items  relative 
to  the  government. 

When  his  brother  was  liberated  he  was  prohibited 
from  continuing  the  printing  of  the  journal  under 
his  name,  so  that  it  was  concluded  that  the  best 
means  to  resort  to  was  to  publish  the  paper  in  the 
future  under  the  name  of  Benjamin  Franklin.  It 
was  decided  that  the  older  brother  should  publicly 
give  over  the  patent  of  apprenticeship  to  the  younger, 
but  in  a  secret  clause  Benjamin  signed  a  second 
contract  which  again  bound  him  to  his  brother. 

A  quarrel  arose  between  them  and  Benjamin,  be- 
ing indignant  of  the  violences  he  was  subjected  to, 


resolved  to  profit  by  the  situation.  He  made  good 
the  annulment  of  his  first  contract,  supposing  that 
his  brother  would  not  produce  the  second,  which  in 
reality  he  did.  Quite  thrown  over  by  this  action, 
his  brother  also  discredited  him  to  such  an  extent  in 
Boston  that  Franklin  could  find  no  work  there,  and 
then,  again,  the  affair  of  the  paper  had  rendered  hiin 
suspicious  to  the  government.  His  indiscreet  talk 
on  religion  placed  him  in  a  very  bad  way  as  both  an 
atheist  and  infidel.  Even  his  own  father  considered 
him  in  the  wrong,  and  so  he  determined  to  leave 
Boston  surreptitiously  and  go  to  Xew  York.  His 
friend  Collins  helped  him  in  his  flight,  and  in  order 
to  make  a  little  money  Franklin  sold  his  books  and 
then  set  sail. 

On  arriving  at  Xew  York,  Franklin,  who  was  at 
this  time  seventeen  years  of  age,  was  without  hardh' 
any  money  and  no  introductions.  However,  an  old 
printer  by  name  Bradford,  who  had  established 
the  first  printing  house  in  Pennsylvania,  proposed 
that  Franklin  should  go  to  Philadelphia,  where  his 
son  might  find  employment  for  him.  The  trip  was 
fruitful  in  accidents ;  the  sea  was  rough,  and,  as  the 
yoimg  man  had  gone  thirty  hours  without  eating,  he 
was  taken  w"ith  a  high  fever.  He  had  read  that  cold 
water  taken  in  large  quantity  was  a  remedy  against 
this  affection,  and,  carrying  out  this  treatment,  it 
was  followed  by  an  abimdant  perspiration  during 
the  greater  part  of  the  night,  and  in  the  morning  he 
was  cured.  Franklin  continued  his  trip  on  foot  and 
then  in  a  boat,  which  he  rowed  himself.  He  arrived 
at  Philadelphia  much  the  worse  for  wear,  almost  dy- 
ing from  want  of  sleep  and  hunger,  and  with  only  a 
dollar  and  a  shilling  in  his  pocket,  which  he  gave  the 
boatman  for  his  passage. 

Sir  \\'illiam  Keith,  who  was  at  this  time  governor 
of  the  province,  interested  himself  in  him  and  of- 
fered him  the  superintendency  of  a  printing  estab- 
lishment that  he  wished  to  establish  on  his  own  ac- 
count, and  proposed  to  Franklin  that  he  should  go  to 
England  for  the  necessary  materials.  He,  however, 
first  returned  to  Boston,  where  he  was  badly  received 
both  by  his  brother  and  his  father,  who  would  give 
him  no  help,  and  he  embarked  with  letters  of  intro- 
duction that  the  Governor  had  given  him. 

Franklin  arrived  at  London  on  December  24.  1724, 
and  he  then  learned  that  Keith  did  not  merit  the  con- 
fidence that  he  had  inspired.  Isolated  and  without 
any  friends  and  little  money.  Franklin  began  to  work 
at  a  printing  shop,  where  he  worked  on  the  setting  up 
of  a  treatise  by  W'oUaston  on  Natural  Religion,  and 
still  imbued  with  ideas  of  scepticism,  which  he  was 
soon  to  relinquish,  he  gave  vent  to  them  in  disserta- 
tion on  liberty  and  necessity,  pleasure,  and  hardship. 

After  a  sojourn  of  eighteen  months  in  London,  a 
merchant  who  was  about  to  leave  for  America  pro- 
posed to  take  him  as  clerk,  and  Franklin  accepted 
this  with  great  joy.  Upon  h.is  return,  however,  he 
met  with  a  great  disappointment,  because,  before 
leaving  America,  he  had  almost  become  engaged  to 
a  Miss  Read,  whom  he  tenderly  loved.  Upon  his 
return  he  found  her  married  and  unhappy. 

At  this  time  he  established  himself  in  business  in 
Philadelphia  with  a  friend  by  the  name  of  Meredith, 
who  furnished  the  necessary  funds,  and,  encouraged 
by  the  feeling  of  ownership,  he  adopted  a  wiser  and 
more  laborious  life.    A  certain  number  of  learned 


6 


CUMSTON:  BENJAMIN  FRANKLIN. 


[New  York 
Medical  Journal. 


persons  assembled  at  his  house  once  a  week  to  dis- 
cuss morals,  politics,  and  physics. 

He  soon  became  the  exclusive  proprietor  of  his 
press,  and  fortune  finally  smiled  upon  him.  In  1730 
he  married  his  old  love.  Miss  Read,  who  had  become 
free,  having  been  abandoned  by  her  husband,  and 
she  proved  for  him  a  tender  and  faithful  companion. 

His  public  life  dates  from  this  time,  and,  realizing 
how  useful  books  had  been  to  him,  he  established  a 
library,  and  in  1732  commenced  the  publication  of 
his  Poor  Richard's  Ahuanac,  in  which  the  wisest 
advice  is  given  with  an  originality  of  expression 
which  renders  it  easy  to  understand  and  quite  im- 
possible to  forget.  He  created  a  fire  insurance  com- 
pany, invented  the  Pennsylvania  fireplace,  and  taught 
the  people  to  pave  the  streets  and  light  them  at  night. 

Of  his  famous  experiments  with  electricity,  his 
various  important  political  missions  in  England,  be- 
ing so  well  known,  I  need  not  refer  to  them  here.  I 
would  merely  point  out  that  during  his  stay  in  Eng- 
land, on  several  occasions,  he  came  in  contact  with 
most  eminent  men  and  entered  into  relationship  with 
the  most  distinguished  scientists.  In  the  summer  of 
1759  he  visited  Scotland  and  there  entered  into  rela- 
tionship with  David  Hume,  Robertson,  Fergusson, 
and  several  other  well  known  men.  He  was  also 
made  a  member  of  the  Royal  Society.  Franklin 
shows  a  great  predilection  for  the  people  of  letters 
of  Edinburgh,  and  it  would  appear  that  Scotland 
was,  to  a  certain  extent,  his  intellectual  country. 

I  shall  now  devote  a  little  space  to  Franklin's  stay  in 
France,  which  was  from  1776  to  1785,  because  it  was 
here  that  he  contracted  many  friends  among  the  emi- 
nent scientists  of  the  day.  On  account  of  his  personal 
celebrity  he  was  chosen  ambassador  to  France 
after  the  war,  while  by  reason  of  his  discoveries  he 
had,  in  1772,  been  elected  a  foreign  associate  of  the 
Academy  of  Science  of  France,  which  brought  him 
in  relationship  with  the  most  distinguished  members 
of  this  noted  company.  One  of  them,  the  Due  de  la 
Rochefoucauld,  whom  he  had  known  in  London  in 
1769,  had  kept  up  a  very  continued  and  intimate 
correspondence  with  him.  Consequently,  upon  his 
arrival  at  Paris,  Franklin  was  at  once  introduced  to 
those  holding  the  highest  social  rank  in  Parisian  so- 
ciety. His  reserve  and  patient  firmness  were  great- 
ly admired,  likewise  his  solid  judgment  and  delicate, 
ingenious  mind.  His  noble  features,  rendered  still 
more  venerable  by  his  long  white  hair,  made  him 
loved  by  all: 

As  soon  as  he  arrived  he  conformed  in  his  ways 
to  the  then  existing  fortune  of  his  own  country.  AH 
the  art  of  his  politics  consisted  in  forming  for  him  a 
great  personal  consideration  which  he  could  make 
reflect  on  his  country,  and  instead  of  the  embassy 
upholding  the  ambassador,  it  was  Franklin  who  up- 
held the  embassy.  The  success  that  he  had  hoped 
for  soon  came,  and  soon  public  enthusiasm  was  at 
its  height,  while  the  departure  of  M.  de  la  Fayette, 
which  was  the  result,  rendered  it  more  startling  and 
general.  Finally,  the  court,  irresistibly  forced  by 
public  opinion,  concluded  the  treaty  of  alliance  in 
1778  with  the  United  States,  which  was  then  recog- 
nized as  an  independent  power.  Sweden  and  Prus- 
sia followed  this  example  and  signed  treaties  of 
friendship  and  commerce  througli   the  hands  of 


Franklin.  This  end  having  been  attained,  and  thus 
having  assured  the  supreme  work  of  the  independ- 
ence of  this  country,  Franklin  remained  in  France 
as  minister  plenipotentiary.  He  then  resided  at 
Passy,  in  an  agreeable  retreat,  where  he  could  en- 
joy a  commerce  with  science  and  the  pleasures  of 
friendship.  He  preferably  sought  the  company  of 
scientists  and  philosophers,  and  as  he  was  endowed 
with  a  very  searching  mind,  particularly  the  things 
of  nature,  and  endowed  with  scientific  truth,  he  be- 
came very  intimate  with  a  number  of  eminent  physi- 
cians of  his  time. 

The  Royal  Society  of  Medicine  had  been  founded 
in  1776,  and  from  its  commencement  had  among  its 
members  most  illustrious  men,  such  as  A.  L.  de 
Jussieu,  Daubenton,  Vicq  d'Azyr,  and  as  foreign  as- 
sociates, Heberden  and  Priestley,  only  to  mention 
a  few  of  the  principal  ones. 

Franklin,  who  was  at  that  time  president  of  the 
Philadelphia  Society,  member  of  the  Royal  Society 
of  England,  and  the  Royal  Academy  of  Science  of 
Paris,  was  the  first  foreign  associate  nominated  by 
this  company. 

In  the  transactions  of  the  Royal  Society  of  Medi- 
cine of  Paris  will  be  found  evidence  of  his  collabo- 
ration. In  1776  he  presented  before  it  a  work  by 
Dr.  Perkins,  of  Boston,  entitled  On  the  Nature  and 
Origin  of  Epidemic  Catarrhal  Fevers.  Among  the 
members  of  this  society  was  Dr.  Barbeu  du  Bourg, 
with  whom  Franklin  was  very  intimate,  and  on  ac- 
count of  this  intimacy  the  latter  made,  in  1783,  a 
French  translation  of  Franklin's  works.  A  physi- 
cian little  known  at  this  time,  Marat  by  name,  pre- 
sented Franklin  with  a  work  on  physics  which  he 
had  written,  and  the  contact  of  these  two  personali- 
ties, so  different  from  each  other,  is  singularly  sug- 
gestive. 

The  therapeutic  methods  of  Mesmer  were  at  this 
time  in  great  vogue.  His  partisans  and  adversaries 
gave  themselves  up  to  heated  discussions,  and  finally 
a  commission  was  nominated  to  examine  into  his 
doctrine  and  experiments.  The  Academy  of  Science 
nominated  Franklin  as  one  of  the  commissioners,  and 
other  members  belonging  to  this  same  body  who 
were  appointed  were  Bailly,  Lavoisier,  Leroy,  and 
de  Bary.  Five  other  commissioners  were  appointed 
by  the  Faculty  of  Medicine,  namely,  Poissonnier, 
Caille,  Mauduyt,  Audry,  and  Laurent  de  Jussieu. 

The  report  of  this  commission,  which  was  ap- 
pointed on  [March  12,  1784,  appeared  on  the  nth  of 
August  of  the  same  year.  The  commissioners  asked 
the  following  questions  of  Deslon,  who  was  Mes- 
mer's  principal  student  and  representative:  (i)  To 
demonstrate  the  existence  of  animal  magnetism  ;  (2) 
to  communicate  his  knowledge  on  this  discovery  ;  (3) 
to  demonstrate  its  utility  in  the  cure  of  diseases.  The 
commission,  after  having  observed  what  took  place 
at  Deslon's,  were  not  at  all  convinced  of  the  exist- 
ence of  the  fluid  and  decided  to  experiment  them- 
selves. The  members  magnetized  themselves  on 
several  occasions  without  any  result.  They  then  took 
seven  patients  who  were  magnetized  at  Franklin's 
home  at  Passy.  Only  three  of  them  appeared  to  be 
influenced.  An  entire  series  of  experiments  were 
organized,  resulting  negatively.  The  following  is 
the  conclusion  of  the  report  submitted  by  the  com- 


January  2,  1909.] 


CUMSTON:  BENJAMIN  FRANKLIN. 


7 


mission,  and  should  be  consulted  at  the  present  time 
by  those  who  are  interested  in  this  subject  of  hypno- 
tism and  diseases  of  the  nervous  system : 

Les  Comniissaires,  ayant  reconnu  que  le  fluide  mag- 
netique  animal  ne  peut  etre  perqu  par  aucun  de  nos  sens, 
qu  i!  n'a  eu  aucune  influence,  ni  sur  eux-memes,  ni  sur 
les  malades  qu'ils  lui  ont  soumis,  s  etant  assure  que  les 
pressions  et  les  attouchements  occasionnent  des  change - 
ments  rarement  favorables  dans  I'economie  animale,  et  des 
ebranlements  toujours  facheux  dans  I'imagination ;  ayant 
enfin  demontre,  par  des  experiences  deceisives,  que  I'imag- 
ination, sans  magnetisme,  produit  des  convulsions,  et  que 
le  magnetisme  sans  I'imagination  ne  produit  rien,  ils  ont 
conclu,  d'une  voix  unanime,  que  rien  ne  prouve  I'existence 
du  fluide  magnetique  animal,  que  ce  fluide,  sans  existence 
est  par  consequent  sans  utilite ;  que  les  violents  effets  qu'on 
observe  au  traitement  public  appartiennent  a  I'attouchement, 
a  rimagination  mise  en  action,  et  a  cette  imitation  machin- 
ale  qui  nous  porte  malgre  nous  a  repeter  ce  qui  frappe  nos 
sens.  Et  en  meme  temps,  ils  se  croient  obliges  d'aj outer, 
comme  une  observation  importante,  que  les  attouchements, 
Taction  repetee  de  I'imagination,  pour  nroduire  des  crises, 
peuvent  etre  nuisibles,  a  cause  de  cette  imitation  dont  la 
nature  semble  nous  avoir  fait  une  loi ;  et  que  par  conse- 
quent, tout  traitement  public  ou  les  moyens  du  magnetisme 
sont  employes,  ne  peut  avoir  a  la  longue  que  de  effets 
funestes. 

There  existed  at  this  time  at  Auteuil  a  ntimber  of 
distinguished  men,  who  had  formed  a  club,  which 
has  remained  celebrated,  under  the  name  of  the  So- 
ciete  d'Auteuil,  of  which  Madame  Helvetius  was  the 
central  figure.  The  family  of  Helvetius  established 
itself  in  France  during  the  reign  of  Louis  XIV,  when 
Jean  Adrien  Helvetius,  a  physician  of  Holland,  came 
there.  He  is  particularly  well  known  in  medicine 
for  his  studies  on  the  use  of  ipecac  in  dysentery.  His 
son,  Jean  Claude  Helvetius,  had  cured  Louis  XV 
when  a  child  of  a  very  serious  malady,  and  for  this 
reason  he  had  been  admitted  into  the  medical  corps 
of  the  young  king  by  the  Regent,  and  later  on  he 
was  appointed  counsellor  of  state,  general  inspector 
of  the  military  hospitals  of  Flanders,  and  first  physi- 
cian to  Queen-  jNIarie  Leczinska.  The  son  of  Jean 
Claude,  who  had  become  fermier  general  at  the  age 
of  twenty-three  years,  spent  the  300,000  francs 
which  represented  his  salary  in  all  kinds  of  enter- 
tainment for  men  of  letters,  and  very  magnificently 
treated  the  most  renowned  among  them.  He  re- 
signed his  position  in  1750  in  order  to  give  himself 
up  entirely  to  study.  The  most  celebrated  of  his 
works  is  entitled  De  I'Esprit,  which  was  published 
in  1758,  was  condemned  by  the  Sorbonne  and  Par- 
liament, burnt  by  the  executioner,  and  the  author, 
after  having  publicly  retracted  this  writing,  with- 
drew himself  to  the  court  of  Frederick  and  later  re- 
tired to  the  court  of  England. 

His  wife  survived  him  for  thirty  years,  and  her 
house  was  the  rendezvous  of  men  such  as  Condillac, 
d'Holbach.  Turgot,  Jefferson,  Champfort.  Abbe, 
]\Iorellet,  Cabanis,  Destutt  de  Tracy,  F.  Didot,  and 
Gallois.  It  is  not  at  all  doubtful  that  Franklin,  in 
his  intimacy  with  these  personages  at  Passy,  influ- 
enced many  eminent  men,  who  later  on  took  part  in 
the  great  revolutionary  movement,  and  that  he  con- 
tributed in  inspiring  them  with  conscience  and  bold- 
ness. It  is  also  quite  certain  that  he  had  a  most 
happy  influence  over  physicians  of  merit,  and  only 
to  mention  one,  namely,  his  friend  Cabanis.  who  has 
left  us  the  following  appreciation  of  Franklin's  char- 
acter : 

Ce  qui  distingue  particulierement  son  esprit,  c'est  la  rec- 
titude, la  siiiiplicite,  la  sagacite.    II  s'etait  fait  de  bonne 


heure  I'habitude  de  voir  les  objects  sous  leurs  vrais  rap- 
ports; il  ocartait  toujours  soigneusement  tout  ce  qui  pou- 
vait  ou  les  denaturer  ou  les  obscurcir ;  ce  n'etait  pas  a  des 
choses  extraordinaires  ou  brillantes  qu'il  aimait  a  s'attacher. 
II  ne  faisait  pas  que  de  celles  qui  sont  d'une  application 
directe;  il  cherchait  a  les  ramener  aux  terms  les  plus  sim- 
ples et  les  plus  usuels ;  et  s'il  presentait  habituellement  sa 
pensee  d'une  maniere  ingenieuse  et  piquante,  il  semblait 
que  ce  iut  seulement  pour  la  rendre  plus  facile  a  saisir, 
et  la  mettre  a  la  portee  des  esprits  les  plus  communs. 
Aucun  homme.  du  reste,  n'a  jamais  vu  plus  promptement 
et  plus  surement  tout  le  parti  qu'il  y  avait  a  tirer  d'une 
idee  qu'on  lui  presentait,  d'un  fait  qui  s'ofFrait  a  lui.  Dans 
ce  que  vous  lui  disiez  au  hasard,  il  voyait  I'explication  ou 
le  lieu  d'une  foule  d'observations  isolees ;  dans  la  plus 
petite  experience,  il  voyait  les  lois  generales  de  la  physique, 
et  ce  qui  nous  passe  chaque  jour  sous  les  yeux,  sans  attirer 
le  moins  du  monde  notre  attention,  lui  fournissait  souvent 
I'idee  des  inventions  les  plus  utiles. 

II  avait  lu  beaucoup,  mais  il  n'etait  pas  ce  qu'on  appele 
erudit,  et  dans  la  physique  meme,  il  avait  plus  invente 
qu'appris,  Sa  memoire  ne  retenait  de  chaque  livre  que  ce 
dont  il  esperait  faire  usage ;  mais  c'etait  pour  toujours. 

II  n'avait  rien  oublie  de  ce  qu'il  avait  recueilli  d'interes- 
sant,  pendant  le  cours  d'une  longue  vie,  dans  le  commerce 
des  hommes.  Les  observations  ou  les  anecdotes  qui  s'y  rap- 
portaient,  toujours  presentes  a  sa  memoire,  formaient  pour 
lui  une  espece  de  science  et  de  morale  pratique,  dont  il 
trouvait  sans  cesse  a  faire  I'application  dans  sa  conduite 
journaliere,  ou  qui,  repandue  a  chaque  instant  dans  sa  con- 
versation, la  rendait  egalement  altachante  et  profitante. 

II  ne  faut  pas  croire  au  reste  que  la  justesse  de  son  es- 
prit rendit  sa  philosophie  triste  et  serieuse.  Jamais  per- 
sonne  ne  fut  plus  enjoue.  n'aime  plus  a  jouir  de  la  vie.  II 
meprisait  egalement  cette  pedantesque  ou  niinutieuse  rec- 
titude que  certains  esprits  veulent  porter  dans  les  choses 
et  dans  les  idees  usuelles,  et  cette  morale  grandeuse  qui 
jette  un  voile  funeste  sur  I'existence.  II  m'ettait  la  mau- 
vaise  humeur  au  rang  des  vices. 

Sir  Humphrey  Davy  was  also  one  of  his  intimate 
friends,  and  he  has  expressed  himself  most  enthusi- 
astically of  Franklin,  pointing  out  his  most  singular 
method  of  induction,  which  guided  him  in  all  his  re- 
searches, and  how,  by  small  means,  he  established 
great  truths. 

The  return  of  Franklin  to  the  LTnited  States  was  a 
great  triumph  for  him.  He  again  took  his  place  at 
the  Assembly  and  was  elected  president  twice,  but  in 
1788  he  gave  up  everything  on  account  of  his  age 
and  his  infirmities.  In  the  public  assemblies  he  had 
a  manner  of  com'porting  himself  which  was  quite 
personal ;  he  did  not  discourse,  but  reasoned,  and 
he  endeavored  not  by  great  oratory,  but  by  a  sudden 
and  well  placed  word,  to  strike  home,  and  this  com- 
prised his  entire  rhetoric.  Appointed  to  request  the 
English  minister  to  cease  sending  European  crimi- 
nals to  the  Colonies,  the  minister  pointed  out  to  him 
the  necessity  of  purging  England  of  them,  to  which 
Franklin  replied,  "What  would  you  say,  if,  for  the 
same  reason,  we  sent  rattlesnakes  to  you?" 

When  once  he  had  given  up  his  active  work  he  still 
had  sufficient  strength  to  found  some  very  useful  in- 
stitutions, among  which  we  may  mention  the  Society 
for  the  Abolition  of  Commerce  of  Slaves.  His  last 
years  were  passed  among  his  family  and  friends,  but 
he  was  continually  occupied  in  the  accomplishment 
of  viseful  things.  He  did  not  fear  death,  and  often 
spoke  of  it,  considering  it  somewhat  like  sleep,  quite 
as  natural  and  necessary  to  the  human  constitution 
as  ordinary  sleep.  He  was  fearfully  tormented  by 
gout,  and  the  last  few  months  of  his  life  he  was 
obliged  to  keep  his  bed,  and  resort  to  large  doses  of 
opium  to  calm  the  pain.  Through  all  this  suffering 
he,  however,  retained  his  quiet  gaiety,  and  died 
April  17.  1790,  at  the  ripe  age  of  eighty-five  years. 


8 


CCMSTON:  BENJAMIN  FRANKLIN. 


[New  York 
Medical  Joukxal. 


On  June  nth  of  the  same  year,  A'lirabeau  an- 
nounced to  the  Assemblee  Constituante,  the  death  of 
Franklin,  which  up  to  that  time  had  not  been  made 
known  in  France : 

Franklin  csl  mort !  II  est  retourne  au  sein  de  la  Divinite. 
Le  genie  qui  afranchit  I'Amerique,  et  versa  sur  I'Europe 
des  torrents  de  lumiercs,  le  sage  que  les  deux  Mondes  re- 
clament,  I'homme  que  se  disputent  I'historie  des  sciences  et 
I'historie  des  empires  tenait  sans  doute  un  rang  eleve  dans 
I'espece  humaine.  Assez  longtemps  les  cabinets  politiques 
ont  notilie  la  mort  de  ceux  qui  ne  furent  grands  que  dans 
leur  eloge  funebre :  assez  longtemps  I'etiquette  des  cours 
a  proclame  des  deuils  hypocrites ;  les  nations  ne  doivent 
porter  que  le  deuil  de  leurs  bienfaiteurs  :  les  representants 
lies  nations  ne  doivent  recommander  a  leur  hommage  que 
les  heros  de  I'humanite. 

Le  Congres  a  ordonne,  dans  les  quartorze  Etats  de  la 
Confederation,  un  deuil  de  deux  mois  pour  la  mort  de 
Franklin,  et  I'Amerique  acquitte  en  ce  moment  ce  tribut  de 
\-eneration  pour  I'un  des  peres  de  sa  constitution. 

Ne  serait-il  pas  digne  de  nous,  Messieurs,  de  nous  unir  a 
cet  acte  religieux,  de  participer  a  cet  hommage  rendu  a  la 
face  de  I'univers,  et  aux  droits  de  I'homme  et  au  philosophc 
qui  a  le  plus  contribue  a  en  propager  la  conquete  sur  la 
terre  ? 

L'Antiquite  eut  eleve  des  autels  a  ce  puissant  genie  qui 
au  profit  des  mortels,  embrassant  dans  sa  pensee  le  ciel  et 
la  terre,  sut  dompter  la  foudre  et  les  tyrans.  L'Europe 
eclairee  et  libre  doit  du  moins  un  temoignage  de  souvenirs 
et  de  regrets  a  I'un  des  plus  grands  hommes  qui  aient  jamais 
servi  la  philosophic  et  la  liberte.  Je  propose  qu'  il  soit 
decrete  que  I'Assemblee  Nationale  portera,  pendant  trois 
jours,  le  deuil  Benjamin  Franklin. 

This  proposition  was  unanimously  adopted. 

In  his  will  Franklin  left  to  George  Washington 
his  walking  stick,  made  of  wild  apple,  which  he  al- 
ways took  with  him  in  his  walks,  while  the  follow- 
ing is  the  epitaph  written  by  him  in  1728: 

THE  BODY 
OF 

BENJAMIN  FRANKLIN 
PRINTER 

(Like  the  cover  of  an  old  book,  its  contents  torn 
out  and  stript  of  its  lettering  and  gilding) 
Lies  here,  food  for  worms, 
For  it  will  (as  he  believed)  appear  once  more 
In  a  new  and  more  elegant  edition 
Revised  and  corrected 
by 

The  Author. 

We  will  now  take  up  the  scientific  correspondence 
of  Franklin,  and  although  many  more  letters  could 
l>e  given,  I  shall  only  reproduce  a  few  among  many, 
that  arc  of  interest  medically,  as  they  will  serve  my 
purpo.se  of  proving  his  knowledge  of  medicine. 

Franklin  had,  apparently,  from  the  following  let- 
ter written  to  Sir  John  Pringle,  employed  electricity 
in  cases  of  paralysis. 

December  21,  1757. 

Sir — In  compliance  with  your  request,  I  send  you  the 
following  account  of  what  I  can  at  present  recollect  relat- 
ing to  the  effects  of  electricity  in  paralytic  cases  which  have 
fallen  under  my  observation. 

Some  years  since,  when  the  newspapers  made  mention  of 
great  cures  performed  in  Italy  and  Germany  by  means  of 
electricity,  a  number  of  paralytics  were  brought  to  me  from 
different  parts  of  Pennsylvania,  and  the  neighboring  pro- 
vinces, to  be  electrized,  which  I  did  for  them  at  their  re- 
quest. My  method  was  to  place  the  patient  first  in  a  chair, 
on  an  electric  stool,  and  draw  a  number  of  large,  strong 
sparks  from  all  parts  of  the  affected  limb  or  side.  Then  I 
fully  charged  two  six  gallon  glass  jars,  each  of  which  had 
about  three  square  feet  of  surface  coated:  and  I  sent  the 
united  shock  of  these  through  the  affected  limb  or  limbs, 
repeating  the  stroke  commonly  three  times  each  day.  The 
first  thing  observed  was  an  immediate  greater  sensible 


warmth  in  the  lame  limbs  that  had  received  the  stroke  than 
in  the  others :  and  the  next  morning  the  patients  usually 
related  that  they  had  in  the  night  felt  a  pricking  sensation 
in  the  flesh  of  the  paralytic  limbs ;  and  would  sometimes 
show  a  number  of  small  red  spots  which  they  supposetl 
were  occasioned  by  those  prickings.  The  limbs,  too,  were 
found  more  capable  of  voluntary  motion,  and  seemed  to  re- 
ceive strength.  A  man,  for  instance,  who  could  not  the  first 
day  lift  the  lame  hand  from  off  his  knee,  would  the  next  day 
raise  it  four  or  five  inches;  the  third  day,  higher;  and  on 
the  fifth  day  was  able,  but  with  a  feeble,  languid  motion  to 
take  off  his  h»t.  These  appearances  gave  great  spirit  to 
the  patients,  and  made  them  hope  ?.  perfect  cure ;  but  I  do 
not  remember  that  I  ever  saw  any  amendment  after  the 
fifth  day ;  which  the  patients  perceiving,  and  finding  the 
shocks  pretty  severe,  they  became  discouraged,  went  home, 
and  in  a  short  time  relapsed ;  so  that  I  never  knew  any  ad- 
vantage from  electricity  in  palsies,  that  was  permanent,  and 
how  far  the  apparent,  temporary  advantage  might  arise 
from  the  exercise  in  the  patient's  journey,  and  coming  daily 
to  my  house,  or  from  the  spirits  given  by  the  hope  of  suc- 
cess, enabling  ihem  to  exert  more  strength  in  moving  their 
limbs,  I  will  not  pretend  to  say. 

Perhaps  some  permanent  advantage  might  have  been  ob- 
tained if  the  electric  shocks  had  been  accompanied  with 
proper  medicine  and  regimen,  under  the  direction  of  a  skill- 
ful physician.  It  may  be,  too,  that  a  few  great  shocks,  as 
given  in  ir.y  method,  may  not  be  so  proper  as  many  sma'l 
ones ;  since  by  the  account  from  Scotland  of  a  case  in  which 
two  hundred  shocks  from  a  phial  were  given  daily,  it  seems 
that  a  perfect  cure  has  been  made.  As  to  any  uncommon 
strength  supposed  to  be  in  the  machine  used  in  that  case,  1 
imagine  it  could  have  no  share  in  the  effect  produced ;  since 
the  strength  of  the  shock  from  the  charged  glass  is  in  pro- 
portion to  the  quantity  of  surface  of  the  glass  coated ;  so 
that  my  shocks  from  those  large  jars  must  have  been  much 
greater  than  any  that  could  be  received  from  a  phial  held 
in  the  hand. 

I  am,  with  great  respect.  Sir, 

Your  most  obedient  servant, 

B.  Franklin. 

The  following  letter  is  in  reply  to  Dr.  Perkins,  of 
Boston,  who  had  asked  Franklin  for  the  number  of 
patients  that  had  died  from  inoculation  in  Philadel- 
phia, at  the  instance  of  Dr.  Douglass,  who  intended 
to  write  something  on  smallpox. 

Philadelphia,  13  August.  1752. 

Sir — I  received  your  favor  of  the  3d  instant.  Some  time 
last  winter  I  procured  from  one  of  our  physicians  an  ac- 
count of  the  number  of  persons  inoculated  during  the  five 
visitations  of  the  smallpox  we  have  had  in  twenty-two 
years ;  which  account  I  sent  to  Mr.  W.  V.,  of  your  town, 
and  have  no  copy.  If  I  remember  rightly,  the  number  e.K- 
ceeded  eight  hundred,  and  the  deaths  were  hut  four.  1 
suppose  Mr.  V.  will  show  you  the  account,  if  he  ever  re- 
ceived it.  These  four  were  all  that  our  doctors  allow  to 
have  died  of  the  smallpox  by  inoculation,  though  I  think 
there  were  two  more  of  the  inoculated  who  died  of  the  dis- 
temper;  but  the  eruptions  appearing  soon  after  the  opera- 
tion, it  is  supposed  they  had  taken  the  infection  before  in 
the  common  way. 

I  shall  be  glad  to  see  what  Dr.  Douglass  may  \yritc  on 
the  subject.  I  have  a  French  piece  printed  at  Paris,  1724, 
entitled.  Observations  sur  la  Saigncc  du  pird.et  sur  Ja  Pur- 
gation, au  commencement  dc  la  Petit  Verole.  et  Raisons  de 
double  contre  I'lnocuJation.  A  letter  of  the  Doctor's  is 
mentioned  in  it.  If  he  or  you  have  it  not,  and  desire  to  see 
it.  T  will  send  it.  Please  to  favor  me  with  the  particulars 
of  your  purging  method,  to  prevent  the  secondary  fever, 
&c.,  &c.  Sir,  yours,  &c., 

B.  Fr.\nki.in. 

As  will  be  seen  T  have  merely  given  that  part  of  the 
above  letter  which  pertains  to  smallpox.  The  French 
work  referred  to  was  written  by  the  famous  Dr. 
Hecquet.  one  of  the  medical  celebrities  of  Paris  at 
this  time. 

The  following  letter  written  to  Iiis  parents  shows 
that  Franklin  was  well  versed  in  at  least  one  uro- 
logical  subject,  namely  that  of  calculus. 


January  2,  1909.] 


CUMSTON:  BENJAMIN  FRANKLIN. 


9 


Philadelphia,  6  September,  1/44. 

Honored  Father  and  Mother — I  apprehend  I  am  too 
bu!)\-  in  prescribing  and  meddling  in  tiie  doctor's  sphere, 
when  any  of  you  complain  of  ails  in  your  letters.  But  as  1 
always  employ  a  physician  myself  when  any  disorder  arises 
in  my  family,  and  submit  implicitly  to  his  orders  in  every- 
thing, so  1  hope  you  consider  my  advice,  when  I  give  any, 
only  as  a  mark  of  good  will,  and  put  no  more  of  it  in  prac- 
tice than  happens  to  agree  with  what  your  doctor  directs. 

Your  notion  of  the  use  of  strong  lye  I  suppose  may  have 
a  good  deal  in  it.  The  salt  of  tartar,  or  salt  of  wormwood, 
frequently  prescribed  for  cuttmg,  opening,  and  cleansing,  is 
nothing  more  than  the  salt  of  lye  procured  by  evaporation. 
jNIrs.  Stevens's  medicine  for  the  stone  and  gravel,  the  secret 
of  which  was  lately  purchased  at  a  great  price  by  the  Par- 
liament, has  for  its  principal  ingredient  salt,  which  Boer- 
haave  calls  the  most  universal  remedy.  The  same  salt  in- 
timately mixed  with  oil  of  turpentine,  which  you  also  men- 
tioned, makes  the  sapo  philosophorum,  wonderfully  ex- 
tolled by  some  chemists  for  like  purposes.  It  is  highly 
probable,  as  your  doctor  says,  that  medicines  are  much 
altered  in  passing  between  the  stomach  and  bladder ;  but 
such  salts  seem  well  fitted  in  their  nature  to  pass  with  the 
least  alteration  of  almost  anything  we  know ;  and,  if  they 
will  not  dissolve  gravel  and  stone,  yet  I  am  half  persuaded 
that  a  moderate  use  of  them  may  go  a  great  ways  towards 
preventing  these  disorders,  as  they  assist  a  weaker  diges- 
tion in  the  stomach  and  powerfully  dissolve  crudities,  such 
as  those  which  I  have  frequently  experienced.  As  to  honey 
and  molasses,  I  did  not  mention  them  merely  as  openers 
and  looseners,  but  also  from  conjecture  that,  as  they  are 
heavier  in  themselves  than  our  common  drink,  they  might 
when  dissolved  in  our  bodies  increase  the  gravity  of  our 
fluids,  the  urine  in  particular,  and  by  that  means  keep 
separate  and  suspended  therein  those  particles  which,  when 
unused,  form  gravel,  etc. 

I  will  inquire  after  the  herb  you  mention.  We  have  a 
botanist  here,  an  intimate  friend  of  mine,  who  knows  all 
the  plants  in  the -country.  He  would  be  glad  of  the  cor- 
respondence of  some  gentlemen  of  the  same  taste  with  you, 
and  has  twice,  through  my  hands,  sent  specimens  of  the 
famous  Chinese  ginseng  found  here  to  persons  who  desired 
it  in  Boston,  neither  of  whom  has  had  the  civility  to  write 
him  a  word  in  answer,  or  even  to  acknowledge  the  receipt 
of  it,  of  which  please  to  give  a  hint  to  brother  John. 

We  have  had  a  very  healthy  summer  and  a  fine  harvest , 
the  country  is  filled  with  bread ;  but  as  trade  declines  since 
the  war  began,  I  know  not  what  our  farmers  will  do  for  a 
market.    I  am  your  affectionate  and  dutiful  son, 

B.  Franklin. 

The  several  letters  written  to  Cadwallader  Golden, 
in  which  Franklin  relates  his  experiments  on  the  cir- 
culation and  respiration,  I  shall  merely  mention  here 
as  being  of  considerable  interest  medically,  but 
space  forbids  their  reproduction,  and  I  will  now  re- 
produce a  paper  by  Franklin  entitled:  A  Conjecture 
as  to  the  Cause  of  the  Heat  of  the  Blood  in  Health, 
and  of  the  Cold  and  Hot  Fits  of  some  Fevers.  This 
piece  was  found  in  Franklin's  handwriting-  among 
the  papers  of  Cadwallader  Colden  by  Sparks,  who 
remarks  that  its  date  is  uncertain,  but  was  probably 
written  before  the  year  1750. 

The  parts  of  fluids  are  so  smooth,  and  roll  among  one 
another  with  so  little  friction,  that  they  will  not  by  any 
(  niechanical)  agitation  grow  warmer.  A  phial  half  full  of 
water  shook  with  violence  and  long  continued,  the  water 
neither  heats  itself  nor  warms  the  phial.  Therefore  the 
blood  does  not  acquire  its  heat  either  from  the  motion  and 
friction  of  its  own  parts,  or  its  friction  against  the  sides 
of  its  vessels. 

But  the  parts  of  solids,  by  reason  of  their  closer  adhesion, 
can  not  move  among  themselves  without  friction,  and  that 
produces  heat.  Thus,  bend  a  plummet  to  and  fro,  and,  in 
the  place  of  bending,  it  shall  soon  grow  hot.  Friction  on 
any  part  of  our  flesh  heats  it.  Clapping  of  the  hands  warms 
them.    Exercise  warms  the  whole  body. 

The  heart  is  a  thick  muscle,  continually  contracting  and 
dilating  nearly  eighty  times  in  a  minute.  By  this  motion 
there  must  be  a  constant  interfrication  of  its  constituent 
solid  parts.   That  friction  must  produce  heat,  and  that  heal 


must  consequently  be  continually  communicated  to  the  per- 
fluent  blood. 

To  this  may  he  added,  that  every  propulsion  of  the  blood 
by  the  contraction  of  the  heart  distends  the  arteries,  which 
contract  again  in  the  intermission ;  and  this  distension  and 
contraction  of  the  arteries  may  occasion  heat  in  them,  which 
they  must  likewise  communicate  to  the  blood  that  flows 
through  them. 

That  these  causes  of  the  heat  of  the  blood  are  sufficient 
to  produce  the  effect,  may  appear  probable,  if  we  consider 
that  a  fluid  once  warm  requires  no  more  heat  to  be  applied 
to  it  in  any  part  of  time  to  keep  it  warm  than  what  it  shall 
lose  in  an  equal  part  of  time.  A  smaller  force  will  keep 
a  pendulum  going,  than  what  lirst  set  it  in  motion. 

The  blood,  thus  warmed  in  the  heart  carries  warmth 
with  it  to  the  very  extremities  of  the  body,  and  communi- 
cates to  them ;  but,  as  by  this  means  its  heat  is  gradually 
diminished,  it  is  returned  again  to  the  heart  by  the  veins 
for  a  fresh  calefection. 

The  blood  communicates  its  heat,  not  only  to  the  solids 
of  our  body,  but  to  our  clothes  and  to  a  portion  of  the 
circumambient  air.  Every  breath  though  drawn  in  cold 
is  expired  warm ;  and  every  particle  of  the  materia  perspir- 
abilis  carries  off  with  it  a  portion  of  heat. 

While  the  blood  retains  a  due  fluidity,  it  passes  freely 
through  the  minutest  vessels,  and  communicates  a  proper 
warmth  to  the  extremities  of  the  body.  But  when,  by  any 
means  it  becomes  so  viscid  as  not  to  be  capable  of  passing 
those  minute  vessels,  the  extremities,  as  the  blood  can  bring 
no  more  heat  to  them,  grow  cold. 

The  same  viscidity  in  the  blood  and  juices  checks  or 
stops  the  perspiration,  by  clogging  the  perspiratory  duct, 
or,  perhaps,  by  not  admitting  the  perspirable  parts  to  sep- 
arate. Paper  wet  with  size  and  water  will  not  dry  so  soon 
as  if  wet  with  water  only. 

A  vessel  of  hot  water,  if  the  vapor  can  freely  pass  from 
it,  soon  cools.  If  there  be  just  fire  enough  under  it  to  add 
continually  the  heat  it  loses  it  retains  the  same  degree.  If 
the  vessel  be  closed,  so  that  the  vapor  may  be  retained, 
there  will  from  the  same  fire  be  a  continual  accession  of 
heat  to  the  water,  till  it  rises  to  a  great  degree.  Or,  if 
no  fire  be  under  it,  it  \w\\\  retain  the  heat  it  first  had  for  a 
long  time.  I  have  experienced  that  a  bottle  of  hot  water 
stopped,  and  put  in  my  bed  at  night,  has  retained  so  much 
lieat,  seven  or  eight  hours,  that  I  could  not  in  the  morning 
bear  my  foot  against  it,  without  some  of  the  bedclothes  in- 
tervening. 

During  the  cold  fit,  then,  perspiration  being  stopped, 
great  part  of  the  heat  of  the  blood,  that  used  to  be  dissi- 
pated is  confined  and  retained  in  the  body ;  the  heart  con- 
tinues its  motion,  and  creates  a  constant  accession  to  that 
heat ;  the  inw  ard  parts  grow  very  hot,  and,  by  contact  with 
extremities,  communicate  that  heat  to  them.  The  glue  of 
the  blood  is  by  this  heat  dissolved,  and  the  blood  after- 
wards flows  freely  as  before  the  disorder. 

We  now  come  to  the  dialogue  between  Franklin 
and  the  Gout,  which  was  written  by  him  during  one 
of  his  stays  at  Passy,  and  as  it  is  a  little  gem  of  both 
hygiene  and  treatment  of  this  afifection,  I  will  repro- 
duce it  in  full : 

Midnight,  October  22.  1780. 

Franklin — Eh  !  oh  !  eh  !  What  have  I  done  to  merit  these 
cruel  sufferings  ? 

Gout — Many  things :  You  have  ate  and  drunk  too  freely 
and  too  much  indulged  those  legs  of  yours  in  their  indo- 
lence. 

Franklin — Who  is  it  that  accuses  me? 
Gout — It  IS  I,  even  I,  the  Gout. 
*  Franklin — What?    My  enemy  in  person? 
Gout — No.  not  your  enemy. 

Franklin — I  repeat  it — my  enemy ;  for  you  would  not 
only  torment  my  body  to  death,  but  ruin  my  good  name : 
you  reproach  me  as  a  glutton  and  a  tippler ;  now  all  the 
world,  that  knows  me,  will  allow  that  I  am  neither  the  one 
nor  the  other. 

Gout —  The  world  may  think  as  it  pleases;  it  is  always 
very  complacent  to  itself  and  sometimes  to  its  friends;  but 
T  very  well  know  that  the  quantity  of  meat  and  drinV 
proper  for  a  man  who  takes  a  reasonable  degree  of  exer- 
cise would  be  too  much  for  another  who  never  takes  any. 

Franklin — I  take — eh  !  oh  ! — as  much  exercise — eh  ! — as  I 


lO 


CUMSTON:  BENJAMIN  FRANKLIN. 


[New  York 
Medical  Journal. 


can,  Madam  Gout.  You  know  my  sedentary  state,  and  on 
that  account  it  would  seem.  Madam  Gout,  as  if  you  might 
spare  me  a  little,  seeing  it  is  not  altogether  my  fault. 

Gout — Not  a  jot;  your  rhetoric  and  your  politeness  are 
thrown  away ;  your  apology  avails  nothing.  If  your  situa- 
tion in  life  is  a  sedentary  one,  your  amusements,  your  recrea- 
tions, at  least  should  be  active.  You  ought  to  walk  or  ride, 
or  if  the  weather  prevents  that,  play  at  billiards.  While 
the  mornings  are  long  and  you  have  leisure  to  go  abroad, 
what  do  you  do?  Why,  instead  of  gaining  an  appetite  for 
breakfast  by  salutary  exercise,  you  amuse  yourself  with 
books,  pamphlets,  or  newspapers  which  commonly  are  not 
worth  reading.  Yet  you  eat  an  inordinate  breakfast — four 
dishes  of  tea  with  cream  and  one  or  two  buttered  toasts, 
with  slices  of  hung  beef,  which,  I  fancy,  are  not  things  the 
most  easily  digested.  Immediately  afterward  you  sit  down 
to  write  at  your  desk  or  converse  with  persons  who  apply 
to  you  on  business.  Thus  the  time  passes  till  one  without 
any  kind  of  bodily  exercise,  but  all  this  I  could  pardon,  in 
regard,  as  you  say,  to  your  sedentary  condition.  But  what 
is  your  practice  after  dinner?  Walking  in  the  beautiful 
gardens  of  those  friends  v/ith  whom  you  have  dined  would 
be  the  choice  of  a  man  of  sense ;  yours  is  to  be  fixed  down 
to  chess,  where  you  are  found  engaged  for  two  or  three 
hours.  This  is  your  perpetual  recreation,  which  is 
the  least  eligible  of  any  for  a  sedentary  man,  because,  in- 
stead of  accelerating  the  motion  of  the  fluids  the  rigid 
attention  it  requires  helps  to  retard  the  circulation 
and  obstruct  internal  secretions.  Wrapt  in  the  specula- 
tions of  this  wretched  game  you  destroy  your  con- 
stitution. What  can  be  expected  from  such  a  course  of 
living  but  a  body  replete  with  stagnant  humors,  ready  to 
fall  a  prey  to  all  kinds  of  dangerous  maladies,  if  I,  the 
Gout,  did  not  occasionally  bring  you  relief  by  agitating 
those  humors  and  so  purifying  or  dissipating  them?  If  it 
was  in  some  nook  or  alley  in  Paris,  deprived  of  walks,  that 
you  played  a  while  at  chess  after  dinner,  this  might  be  ex- 
cusable ;  but  the  same  taste  prevails  with  you  in  Passy, 
Auteuil,  Montmartre,  or  Sanoy — places  where  there  are  the 
finest  gardens  and  walks,  a  pure  air,  beautiful  women,  and 
most  agreeable  and  instructive  conversation;  all  of  which 
you  might  enjoy  by  frequenting  the  walks.  But  these  are 
rejected  for  this  abominable  game  of  chess.  Fie  then,  Mr. 
Franklin!  But  amid  my  instructions* I  had  almost  forgot 
my  wholesome  corrections,  so  take  that  twinge — ^and  that ! 

Franklin — Oh  !  eh  !  oh  !  oh-h  !  As  much  instruction  as 
you  please,  Madam  Gout,  and  as  many  reproaches ;  but 
pray,  madam,  a  truce  with  your  corrections ! 

Gout — No,  sir,  no.  I  will  not  abate  a  particle  of  what 
is  so  much  for  your  good ;  therefore  

Franklin — Oh  !  eh-h-h  !  It  is  not  fair  to  say  I  take  no 
exercise,  when  I  do  very  often,  going  out  to  dine  and  re- 
turning in  my  carriage. 

Gout — That,  of  all  imaginable  exercises,  is  the  most  slight 
and  insignificant,  if  you  allude  to  the  motion  of  a  carriage  sus 
pended  on  springs.  By  observing  the  degree  of  heat  obtained 
by  different  kinds  of  motion,  we  may  form  an  estimate  of  the 
quantity  of  exercise  given  by  each.  Thus,  for  example,  if 
you  turn  out  to  walk  in  winter  with  cold  feet,  in  an  hour's 
time  you  will  be  in  a  glow  all  over ;  ride  on  horseback,  the 
same  effect  will  scarcely  be  perceived  by  four  hours'  round 
trotting;  but  if  you  loll  in  a  carriage,  such  as  you  have 
mentioned,  you  may  travel  all  day,  and  gladly  enter  the  last 
inn  to  warm  your  feet  by  the  fire.  Flatter  yourself,  then, 
no  longer  that  half  an  hour's  airing  in  your  carriage  de- 
serves the  name  of  exercise.  Providence  has  appointed 
few  to  roll  in  carriages,  while  he  has  given  to  all  a  pair  of 
legs,  which  are  machines  infinitely  more  commodious  and 
serviceable.  Be  grateful,  then,  and  make  a  proper  use  of 
yours.  Would  you  know  how  they  forward  the  circulation 
of  your  fluids  in  the  very  action  of  transporting  you  from 
place  to  place,  observe,  when  you  walk,  that  all  your  weight 
is  alternately  thrown  from  one  leg  to  the  other;  this  oc- 
casions a  great  pressure  on  the  vessels  of  the  foot  and  re- 
pels their  contents ;  when  relieved,  by  the  weight  of  being 
thrown  on  the  other  foot,  the  vessels  of  the  first  are  al- 
lowed to  replenish,  and  by  a  return  of  this  weight  this 
repulsion  again  succeeds;  thus  accelerating  the  circulation 
of  the  blood.  The  heat  produced  in  any  given  time  de- 
pends on  the  degree  of  this  acceleration ;  the  fluids  are 
shaken,  the  humors  alternated,  the  secretions  facilitated, 
and  all  goes  well ;  the  checks  are  ruddy  and  health  is  es- 
tablished. Behold  your  fair  friend  at  Auteuil,  a  lady  who 
received  from  bounteous  nature  more  really  useful  science 


than  half  a  dozen  such  pretenders  to  philosophy  as  you 
have  been  able  to  extract  from  all  your  books.  When  she 
honors  you  with  a  visit  it  is  on  foot.  She  walks  all  hours 
of  the  day  and  leaves  indolence  and  its  concomitant  mala- 
dies to  be  endured  by  her  horses.  In  this  see  at  once  the 
preservative  of  her  health  and  personal  charms.  But  when 
you  go  to  Auteuil  you  must  have  your  carriage,  though  it 
is  no  further  from  Passy  to  Auteuil  than  from  Auteuil  to 
Passy. 

Franklin — Your  reasonings  grow  very  tiresome. 

Gout — I  stand  corrected.  I  will  be  silent  and  continue 
my  office ;  take  that,  and  that. 

Franklin — Oh  !  oh  !    Talk  on,  I  pray  you  I 

Gout — No,  no.  I  have  a  good  number  of  twinges  for 
you  tonight,  and  you  may  be  sure  of  some  more  tomorrow. 

Franklin — What,  with  such  a  fever !  I  shall  go  distract- 
ed.   Oh !  eh  !    Can  no  one  bear  it  for  me  ? 

Gout — Ask  that  of  your  horses;  they  have  served  vou 
faithfully. 

Franklin — How  can  you  so  cruelly  sport  with  my  tor- 
ments ? 

Gout — Sport!  I  am  very  serious.  I  have  here  a  list  of 
offenses  against  your  own  health  distinctly  written,  and  can 
justify  every  stroke  inflicted  on  you. 

Franklin — Read  it  then. 

Gout — It  is  too  long  a  detail,  but  I  will  briefly  mention 
some  particulars. 

Franklin — Proceed.    I  am  all  attention. 

Gout — Do  you  remember  how  often  you  have  promised 
yourself  the  following  morning  a  walk  in  the  Grove  of 
Boulogne,  in  the  Garden  of  de  la  Muette,  or  in  your  own 
garden,  and  have  violated  your  promise,  alleging  at ,  one 
time  it  was  too  cold,  at  another  too  warm,  too  windy,  too 
moist,  or  whatever  you  please,  when  in  truth  it  was  to 
nothing  but  your  inseparable  love  of  ease  ? 

Franklin — That,  I  confess,  may  have  happened  occasion- 
ally, probably  ten  times  in  a  year. 

Gout — Your  confession  is  very  far  short  of  the  truth; 
the  gross  amount  is  one  hundred  and  ninety-nine  times. 

Franklin — Is  it  possible? 

Gout — So  possible  that  it  is  fact;  you  may  rely  on  the 
accuracy  of  my  statement.  You  know  M.  Brillon's  gardens 
and  what  fine  walks  they  contain ;  you  know  the  handsome 
flight  of  one  hundred  steps  which  lead  from  the  terrace 
above  to  the  lawn  below.  You  have  been  in  the  practice 
of  visiting  this  amiable  family  twice  a  week  after  dinner, 
and  it  is  a  maxim  of  your  own  that  "a  man  may  take  as 
much  e.xercise  in  walking  a  mile,  up  and  down  stairs,  as  in 
ten  on  level  ground."  What  an  opportunity  was  here  for 
you  have  had  exercise  in  both  those  ways !  Did  you  em- 
brace it  and  how  often? 

Franklin — I  cannot  immediately  answer  that  question. 

Gout — I  will  do  it  for  you.    Not  once. 

Franklin — Not  once? 

Gout — Even  so.  During  the  summer  you  went  there  at 
si.x  o'clock.  You  found  the  charming  lady,  with  her  lovely 
children  and  friends,  eager  to  walk  with  you  and  entertain 
you  with  their  agreeable  conversation  ;  and  w  hat  has  been 
your  choice?  Why,  to  sit  on  the  terrace,  satisfy  yourself 
with  the  fine  prospect,  and  passing  your  eye  over  the  beau- 
ties of  the  garden  below,  without  taking  one  step  to  de- 
scend and  walk  about  in  them.  On  the  contrary,  you  call 
for  tea  and  the  chess  board;  and  lo!  you  are  occupied  in 
your  seat  till  nine  o'clock,  and  that  besides  two  hours'  play 
after  dinner ;  and  then,  instead  of  walking  home,  which 
would  have  disturbed  you  a  little,  you  step  into  your  car- 
riage. How  absurd  to  suppose  that  all  this  carelessness  can 
be  reconcilable  with  health  without  my  interposition ! 

Franklin — I  am  convinced  now  of  the  justice  of  Poor 
Richard's  remark  that  "Our  debts  and  our  sins  are  always 
greater  than  we  think  for." 

Gout — So  it  is.  You  philosophers  are  sages  in  your  max- 
ims and  fools  in  your  conduct. 

Franklin — But  do  you  charge  among  my  crimes  that  I 
return  in  the  carriage  from  M.  Brillon's? 

Gout — Certainly ;  for  having  been  seated  all  the  while, 
you  cannot  object  the  fatigue  of  the  day,  and  cannot  want, 
therefore,  the  relief  of  a  carriage. 

Franklin — What,  then,  would  you  have  me  do  with  my 
carriage  ? 

Gout — Burn  it  if  you  choose;  you  would  at  least  get  heat 
out  of  it  once  in  this  way:  or,  if  you  dislike  that  proposal, 
here's  another  for  you :  Observe  the  poor  peasants  who 
work  in  the  vineyards  and  grounds  about  the  villages  of 


January  2,  1909.] 


CUMSrON:  BENJAMIN  FRANKLIN. 


II 


Passy,  Auteuil,  Chaillot,  &c. ;  you  may  find  every  day 
among  these  deserving  creatures  four  or  five  old  men  and 
women,  bent  and  perhaps  crippled  by  weight  of  years  and 
too  long  and  too  great  labor.  After  a  most  fatiguing  day 
these  people  have  to  trudge  a  mile  or  two  to  their  smoky 
huts.  Order  your  coachman  to  set  them  down.  This  is  an 
act  that  will  be  good  for  your  soul ;  and  at  the  same  time 
after  your  visit  to  the  Brillons,  if  you  return  on  foot,  that 
will  be  good  for  your  body. 

Franklin — Ah  !  How  tiresome  you  are  ! 

Gout — Well,  then,  to  my  office;  it  should  not  be  forgot- 
ten that  I  am  your  physician.   There  ! 

Franklin — Oh-h-h  !    What  a  devil  of  a  physician  ! 

Gout — How  ungrateful  you  are  to  say  so !  Is  it  not  I 
who,  in  the  character  of  your  physician,  have  saved  you 
from  the  palsy,  dropsy,  and  apoplexy,  one  or  other  of  which 
would  have  done  for  you  long  ago  but  for  me? 

Franklin — I  submit  and  thank  you  for  the  past,  but  en- 
treat the  discontinuance  of  your  visits  for  the  future ;  for 
in  my  mind  one  had  better  die  than  be  cured  so  dolefully. 
Permit  me  just  to  hint  that  I  have  also  not  been  unfriendly 
to  you.  I  never  feed  a  physician  or  quack  of  any  kind  to 
enter  the  list  against  you ;  if,  then,  you  do  not  leave  me  to 
my  repose,  it  may  be  said  you  are  ungrateful,  too. 

Gout — I  can  scarcely  acknowledge  that  as  an  objection. 
As  to  quacks,  I  despise  them ;  they  may  kill  you,  indeed, 
but  cannot  injure  me.  And  as  to  regular  physicians,  they 
are  at  last  convinced  that  the  gout,  in  such  a  subject  as 
you  are,  is  no  disease,  but  a  remedy;  and  wherefore  cure 
a  remedy?    But  to  our  business;  there! 

Franklin — Oh !  oh !  for  heaven's  sake  leave  me,  and  I 
promise  faithfully  nevermore  to  play  at  chess,  but  to  take 
exercise  daily  and  live  temperately. 

Gout — I  know  you  too  well.  You  promise  fair,  but  after 
a  few  months  of  good  health  you  will  return  to  your  old 
habits ;  your  fine  promises  will  be  forgotten  like  the 
forms  of  the  last  year's  clouds.  Let  us,  then,  finish  the  ac- 
count, and  I  will  go.  But  I  leave  you  with  an  assurance 
of  visiting  you  again  at  a  proper  time  and  place ;  for  my 
object  is  your  good,  and  you  are  sensible  now  that  I  am 
your  real  friend. 

In  closing,  I  will  refer  to  Franklin's  Plain  In- 
structions for  Inoculation,  a  rare  little  work,  which 
was  written  because  he  felt  assured,  as  he  states  in 
the  introduction,  that  the  practice  of  inoculation 
"would  be  much  more  general  among  the  English  on 
the  Continent  of  America,  and  of  course  many  lives 
would  be  saved,  if  all  who  are  desirous  of  being  in- 
oculated could  easily  be  furnished  with  the  means  of 
having  it  done."  The  Instructions  comprise  seven 
and  a  half  large  pages  and  indicate  the  necessary 
preparations  to  be  made,  the  season  of  the  year 
proper  for  inoculation,  the  age  and  constitution  of 
the  patient,  the  technique  of  inoculation,  and  the 
after  treatment  of  the  case.  To  these  pages  I  would 
refer  the  reader  desirous  of  learning  more  of  the 
method  of  inoculation  employed  in  those  days,  but  I 
will  here  transcribe  in  toto  the  introductory  letter  to 
this  work,  because,  as  will  be  seen,  it  is  an  historical 
document  of  considerable  importance  relative  to 
smallpox.  The  exact  title  of  the  work  is  as  follows : 
Some  account  of  the  Success  of  Inoculation  for  the 
small-Pox  ill  England  and  America.  Together  zinth 
Plain  Instructions,  By  which  any  Person  may  he  en- 
abled to  perform  the  Operation,  and  conduct  the 
Patient  through  the  Distemper.  London:  Printed 
by  W.  Strahan.  M,DCC,LIX. 

London,  Feb.  j6.  1759. 
Having  been  desired  by  my  greatly  esteemed  friend,  Dr. 
William  Haberden^  F.  R.  S.,  one  of  the  principal  Physi- 
cians of  the  city,  to  communicate  what  account  I  had  of 
the  success  of  Inoculation  in  Boston,  New  England,  I 
some  time  since  wrote  and  sent  to  him  the  following  paper, 
viz. : 

About  1753  or  54.  the  Small-pox  made  its  appearance  in 
Boston,  New  England.    It  had  not  spread  in  the  town  for 


many  years  before,  so  that  there  were  a  great  number  of 
the  inhabitants  to  have  it.  At  first,  endeavours  were  used 
\o  prevent  its  spreading,  'oy  removing  the  sick,  or  guarding 
the  houses  in  which  they  were;  and  with  the  same  view 
Inoculation  was  forbidden ;  but  when  it  was  found  that 
these  endeavours  were  fruitless,  the  distemper  breaking  out 
in  different  quarters  of  the  town,  and  increasing.  Inocula- 
tion was  permitted. 

Upon  this,  all  that  inclined  to  Inoculation  for  themselves 
or  families  hurried  into  it  precipitately,  fearing  the  infec- 
tion might  otherwise  be  taken  in  the  common  way ;  the 
numbers  inoculated  in  every  neighborhood  spread  the  in- 
fection likewise  more  speedily  among  those  who  did  not 
chuse  Inoculation ;  so  that  in  a  few  months  the  distemper 
went  thro'  the  town,  and  was  extinct ;  and  the  trade  of  the 
town  suffered  only  a  short  interruption,  compar'd  with 
what  had  been  usual  in  former  limes,  the  country  people 
during  the  seasons  of  that  sickness  fearing  all  intercourse 
with  the  town. 

As  the  practice  of  Inoculation  always  divided  people  into 
two  parties,  some  contending  warmly  for  it,  and  others  as 
strongly  against  it;  the  latter  asserting  that  the  advantages 
pretended  were  imaginary,  and  that  the  Surgeons,  from 
views  of  interest,  conceal'd  or  diminish'd  the  number  of 
those  who  died  of  the  Small-pox  in  the  common  way:  It 
was  resolved  by  the  Magistrates  of  the  town,  to  cause  a 
strict  and  impartial  enquiry  to  be  made  by  the  Constables 
of  each  ward,  who  were  to  give  in  their  returns  upon  oath ; 
and  that  the  enquiry  might  be  made  more  strictly  and  im- 
partially, some  of  the  partisans  for  and  against  the  practice 
were  join'd  as  assistants  to  the  officers,  and  accompany'd 
them  in  their  progress  through  the  wards  from  house  to 
house.  Their  several  returns  being  received  and  summ'd 
up  together,  the  numbers  turn'd  out  as  follows : 

Had  the  sinnll-  Received  the  dis- 

pox  in  the  temper  by 

common  way.  Of  these  died.        inoculation.  Of  these  died. 

Whites.   Blacks.  Whites.   Blacks.   Whites.   Blacks.   Whites.  Blacks. 

5.059        485  -152            62         1,974        159  23  7 

It  appeared  by  this  account  that  the  deaths  of  persons 
inoculated  were  more  in  proportion  at  this  time  than  had 
been  formerly  observed,  being  something  more  than  one  in 
a  hundred.  The  favourers  of  Inoculation,  however,  would 
not  allow  that  this  was  owing  to  any  error  in  the  former 
accounts,  but  rather  to  the  Inoculating  at  this  time  many 
unfit  subjects,  partly  through  the  impatience  of  people  who 
would  not  wait  the  necessary  preparation,  lest  they  should 
take  it  in  the  common  way ;  and  partly  from  the  impor- 
tunity of  parents  prevailing  with  the  Surgeons  against  their 
judgment  and  advice  to  inoculate  weak  children,  labouring 
under  other  disorders;  because  the  "parents  could  not  im- 
mediately remove  them  out  of  the  way  of  the  distemper, 
and  thought  they  would  at  least  stand  a  better  chance  by 
being  inoculated,  than  in  taking  the  infection,  as  they  would 
probably  do,  in  the  common  way.  The  Surgeons  and  Phy- 
sicians were  also  suddenly  oppress"d  with  the  great  hurry 
of  business,  which  so  hasty  and  general  an  Inoculation  and 
spreading  of  the  distemper  in  the  common  way  must  oc- 
casion, and  probably  could  not  so  particularly  attend  to  the 
circumstances  of  the  patients  offered  for  Inoculation. 

Inoculation  was  first  practiced  in  Boston  by  Dr.  Boyle- 
stone  in  1720.  It  was  not  used  before  in  any  part  of  Amer- 
ica and  not  in  Philadelphia  till  1730.  Some  years  since,  an 
enquiry  was  made  in  Philadelphia  of  the  several  Surgeons 
and  Physicians  who  had  practic'd  Inoculation,  what  num- 
bers had  been  by  each  inoculated,  and  what  was  the  suc- 
cess. The  result  of  this  enquiry  was.  that  upwards  of  800 
(I  forget  the  exact  number"),  had  been  inoculated  at  differ- 
ent times,  and  that  only  four  of  them  had  died.  If  this  ac- 
count was  true,  as  I  believe  it  was,  the  reason  of  greater 
success  there  than  had  been  found  in  Boston,  where  the 
general  loss  by  Inoculation  used  to  be  estimated  at  about 
one  in  100,  may  probably  be  from  this  circumstance ;  that 
in  Boston  they  always  keep  the  distemper  out  as  long  as 
they  can,  so  that  when  it  comes  it' finds  a  greater  number 
of  adult  subjects  than  in  Philadelphia,  where  since  1730  it 
has  gone  through  the  town  once  in  four  or  five  years,  so 
that  the  greatest  number  of  subjects  for  Inoculation  must 
be  under  that  age. 

Notwithstanding  the  now  uncontroverted  success  by  In- 
oculation, it  does  not  seem  to  make  that  progress  among 
common  people  in  America  which  at  first  was  expected. 
Scruples  of  conscience  weigh  with  many,  concerning  the 


12  THOMSON:  ASIATIC  CHOLERA. 


LAWFULNESS  of  the  practice :  and  if  one  parent  or  near 
relative  is  against  it,  the  other  does  not  chuse  to  inoculate 
a  child  without  free  consent  of  all  parties,  lest  in  case  of  a 
disastrous  event,  perpetual  blame  should  follow.  These 
SCRUPLES  of  a  SENSIBLE  CLERGY  may  in  time  remove.  The 
EXPENSE  of  having  the  operation  performed  by  a  Surgeon 
weighs  with  others,  for  that  has  been  pretty  high  in  some 
parts  of  America  ;  and  where  a  common  tradesman  or 
artificer  has  a  number  in  his  family  who  have  the  distem- 
per it  amounts  to  more  money  than  he  can  well  spare. 
Many  of  these,  rather  than  own  the  true  motive  for  de- 
clining Inoculation,  join  with  the  scrupulous  in  the  cry 
AGAINST  IT,  and  influence  others.  A  small  Pamphlet  wrote 
in  plain  language  by  some  skilful  Physician  and  publish'd, 
directing  what  preparations  of  the  body  should  be  used 
before  Inoculation  of  children,  what  precautions  to  avoid 
giving  the  infection  at  the  same  time  in  the  common  way, 
and  how  the  operation  is  to  be  performed,  the  incisions 
dress'd,  the  patient  treated,  and  on  the  appearance  of  what 
symptoms  a  Physician  is  to  be  called,  etc.,  might  by  en- 
couraging parents  to  inoculate  their  own  children  be  a 
means  of  removing  that  objection  of  the  expence,  render 
the  practice  much  more  general,  and  thereby  save  the  lives 
of  thousand's. 

The  Doctor,  after  perusing  and  considering  the  above, 
humanely  took  the  trouble  {tho'  his  .extensive  practice  af- 
fords him  scarce  any  time  to  spare)  of  writing  the  follow- 
ing Plain  Instructions,^  and  generously  at  his  oivn  private 
expense  printed  a  very  large  impression  of  them,  which 
ivas  put  into  my  hands  to  be  distributed  gratis  in  America. 
Not  aiming  at  the  praise  which,  however,  is  justly  due  to 
such  disinterested  benevolence,  he  has  omitted  his  name  ; 
but  as  I  thought  the  adz'ice  of  a  nameless  Physician  might 
possibly  on  that  account  be  less  regarded  I  have  zvithout 
his  knowledge  here  divulg'd  it.  And  I  have  prefix'd  to  his 
fmall  but  valuable  ivork  these  pages,  containing  the  facts 
thai  give  rise  to  it  because  Facts  generally  have,  as  indeed 
they  ought  to  have,  great  zveight  in  persuading  to  the  prac- 
tice they  favour.  To  these  I  may  also  add  an  account  I 
have  been  favoured  with  by  Dr.  Archer,  physician  to  the 
Small-pox  Hospital  here,  vis.: 

There  have  been  inoculated  at  this  hospital  since  its  first 
institution,  this  day,  December  31,  1758,  1,601  Persons.  Of 
which  number  6  died. 

Patients  who  had  the  Small-pox  in'  the  common  way  in 
this  Hospital,  to  the  same  day,  3856.  Of  which  number 
have  died  1,002. 

By  this  account  it  appears,  that  in  the  zvay  of  Inoculation 
there  has  died  but  one  patient  in  267,  zvhereas  in  the  com- 
mon ivay  there  has  died  more  than  one  in  four.  The 
mortality  indeed  in  the  latter  case  appears  to  have  been 
greater  than  usual  {one  in  seven,  when  the  distemper  is 
not  very  favourable ,  being  as  reckon  d  the  common  loss 
in  towns  by  the  Small-pox,  all  ages  and  ranks  taken  to- 
gether), but  these  patients  were  niostlT;  adults,  and  were 
received,  it  is  said,  into  the  Hospital,  after  great  irregular- 
ities had  been  commiftd.  By  the  Boston  account  it  ap- 
pears that,  Whites  and  Blacks  taken  together,  but  about 
one  in  eleven  died  in  the  common  way,  and  the  distemper 
then  7fas  therefore  reckon' d  uncommonly  favourable.  I 
have  also  obtained  from  the  Foundling  Hospital  (where  all 
the  children  admitted  that  have  not  had  the  Small-pox  are 
inoculated  at  the  age  of  Ave  years)  an  account  to  this  time 
of  the  success  of  that  practice  there,  which  stands  thus,  viz: 

Inoculated,  boys  162;  girls,  176;  in  all,  338.  Of  these 
died  in  Inoculation,  2 ;  and  the  death  of  one  of  those  two 
cases  was  occasioned  by  a  worm  fever. 

On  the  whole,  if  the  chance  were  only  as  two  to  one  in 
favour  of  the  practice  among  children,  would  it  not  be 
sufficient  to  induce  a  tender  parent  to  lay  hold  of  the  ad- 
vantage? But  luhen  it  is  so  much  greater  as  it  appe^irs 
to  be  by  these  account?,  (in  some  even  as  thirty  to  one) 
surely  parent?,  ivill  no  longer  refuse  to  accept  and  thank- 
fully use  a  discovery  God  in  his  mercy  has  been  pleased  to 
bless  mankind  zvith;  wliereby  some  check  may  noiv  be  put 
to  the  ravages  that  cruel  disease  has  been  accustomed 
to  make,  and  the  human  species  be  again  suffered  to  in- 
crease as  it  did  before  the  .Small-pox  made  its  appearance. 
This  increase  has  indeed  been  more  obstructed  by  that  dis- 

'To  make  the  plainer  and  more  generally  intelligible,  the  Doctor 
purposely  avoided  as  much  as  possible  the  medical  terms  and  ex- 
pressions used  by  Physicians  in  their  writings. 


[New  York 
Medical  Journal. 

temper  than  is  usually  imagin'd:  For  the  loss  of  one  in  ten 
thereby  is  not  nearly  the  loss  of  so  many  persons,  but  the 
accmnulated  loss  of  all  the  children  and  children's  children 
the  deceased  might  have  had,  multiplied  by  successive  gen- 
erations. B.  Franklin, 

of  Philadelphia. 

871  Beacon  Street. 


ASIATIC  CHOLERA 

And  its  Lessons  hozu  Infectious  Diseases  Should  Be 
Classified.* 
By  W.  Hanna  Thomson,  M.  D.,  LL.  D., 
New  York. 

There  is  no  disease  which  illustrates  more  than 
does  Asiatic  cholera  the  wonderful  progress  made  in 
our  generation  by  the  medical  profession  in  the 
knowledge  of  the  infections .  But  it  also  must 
be  admitted  that  nothing  so  illustrates  the  short- 
comings of  the  profession  in  acquainting  the  pub- 
lic, by  a  proper  terminology,  as  the  distinction  be- 
tween the  three  great  classes  of  infectious  diseases. 
Instead  of  that,  we  find  both  individual  members 
of  the  profession  and  official  bodies  confounding 
in  a  highly  injurious  degree  the  terms  used  to  dis- 
tinguish one  class  of  infectious  diseases  from  an- 
other. Due  to  this  confusion,  an  uncertainty  pre- 
vails widely  in  the  minds  of  the  public  on  this 
subject,  with  the  result  that  panics,  most  costly 
to  the  community  and  disgraceful  to  our  civiliza- 
tion, have  repeatedly  occurred  even  within  recent 
years.  The  history  of  the  epidemics  of  Asiatic 
cholera  strikingly  illustrates  this  truth.  In  the  year 
1855,  the  officials  of  the  Massachusetts  State  Board 
of  Health  issued  a  statement  intended  to  reassure  the 
public,  about  the  nature  of  Asiatic  cholera,  which 
then  threatened  to  become  epidemic.  In  this  state- 
ment they  strongly  insisted  that  Asiatic  cholera  was 
not  at  all  a  contagious  disease,  but  was  due  to  a 
miasm  pervading  the  atmosphere.  Both  these  state- 
ments were  mischievous  errors,  because  it  was  then 
understood  that  in  denying  that  Asiatic  cholera  was 
contagious  it  was  also  intended  to  deny  that  it  was 
communicable  from  person  to  person.  Whereas  the 
truth  is  that  this  disease,  without  being  properly 
contagious,  and  hence  no  one  need  run  away  from 
a  cholera  patient,  nevertheless  is  a  highly  communi- 
cable disease,  in  that  no  case  of  cholera  occurs  with- 
out having  contracted  it  from  a  previous  case  of 
cholera.  We  now  know  that  the  second  statement 
was  equally  erroneous.  There  is  no  miasm  ;  for  even 
the  disease  called  by  its  ancient  name,  malaria  or 
"bad  air,"  we  now  know  is  an  infection  caused  solely 
through  a  hypodermic  injection  by  a  mosquito.  The 
whole  conc<?ption  of  a  deadly  miasm  arising  from 
swamps  and  unhealthy  localities,  which  has  for  ages 
weighed  upon  the  medical  mind,  is  a  mistake,  and 
therefore  there  arc  no  unhealthy  localities  or  un- 
healthy climates  as  such,  but  only  regions  infected 
by  a  certain  variety  of  mosquito,  and  which  medical 
science  therefore  knows  now  how  to  disinfect  and 
render  as  healthy  as  any  other  climates. 

Had  the  Massachusetts  State  Board  of  Health  only 
perused  the  reports  published  by  the  government  of 

*Paper  read  at  the  meeting  of  the  Medical  Association  of  the 
Greater  City  of  New  York,  November  16,  1908. 


January  2,  1909.  J 


THOMSON:  ASIATIC  CHOLERA. 


13 


Denmark  on  the  epidemic  of  cholera  in  that  king- 
dom ni  tne  }ear  1653,  they  would  at  once  havt 
known,  as  the  profession  ever  since  has  known,  that 
cholera  does  spread  from  person  to  person,  and 
spreads  in  no  other  way,  and  is  never  disseminated 
through  the  atmosphere,  'i  his  was  proved  by  the 
Danisn  government  issuing  directions  to  all  physi- 
cians practising  in  country  districts  in  Denmark,  to 
report  the  first  case  of  cholera  occurring  in  their 
rural  neighborhood,  then  the  second,  and  third,  and 
fourth,  up  to  the  fifth  case.  When  these  reports 
were  collected  it  was  shown  that  the  case  of  each 
second,  third,  and  fourth  patient  could  in  some  way 
be  traced  as  having  had  some  communication  with 
the  first  patient,  although  in  one  instance,  a  laun- 
dress who  had  washed  the  clothes  of  a  cholera  pa- 
tient was  taken  sick,  who  never  saw  the  patient,  and 
lived  ten  miles  from  him. 

'1  his  leads  me  to  say  that  this  fact  affords  a 
valuable  illustration  how  country  practitioners  may 
greatlv  assist  their  profession  by  systematic  observa- 
tions on  the  epidemic  prevalence  of  certain  infec- 
tions, when  occurring  in  isolated  rural  communities. 
When  I  was  president  of  the  Academy  of  Medicine 
I  was  asked  to  see  in  consultation  a  case  of  polio- 
myelitis in  a  schoolboy  on  a  farm  in  Dutchess. 
County.  I  then  learned  that  a  schoolmate  of  his 
who  sat  next  him  in  the  schoolroom  was  taken  with 
the  disease  a  week  before  he  was,  and  died  in  five 
days.  I  was  also  told  that  a  young  lady  living  three 
miles  away  from  his  country  house  was  dying  from 
some  cerebral  trouble.  I  was  driven  to  her  house 
and  found  her  comatose,  with  a  history  of  cerebro- 
spinal meningitis.  On  further  questioning  I  learned 
that  she  was  a  cousin  of  this  first  patient  mentioned ; 
that  that  boy  had  passed  the  night  on  a  visit  to  her 
house  three  nights  before  she  was  taken  sick.  My 
two  medical  friends  whom  I  met  in  consultation 
then  told  me  that  an  epidemic  of  meningitis  and 
myelitis  had  been  prevailing  some  ten  weeks  in  their 
neighborhood.  I  tried  strongly  to  recommend  that 
their  local  medical  society  should  at  once  take  up 
the  investigation  of  this  epidemic,  after  the  fashion 
of  the  Danish  physicians  mentioned  about  cholera, 
to  note  whether  any  kind  of  communication  had  oc- 
curred between  the  different  cases  before  they  devel- 
oped. I  told  them  that  only  men  in  their  position 
could  give  satisfactory  observations  on  such  infec- 
tions, compared  to  us  who  practised  in  large  cities. 
In  Xew  York  everybody,, sooner  or  later,  comes  in 
very  close  contact  with  his  fellow  citizens,  and  dur- 
ing the  rush  hours  at  the  Brooklyn  Bridge,  or  on 
our  trolley  cars,  all  one  can  do  sometimes  is  to  pre- 
vent being  telescoped  by  somebody  either  before  or 
behind  him.  How  infectious  diseases  are  therefore 
spread  in  cities  is  impossible  to  determine,  whereas 
only  a  little  trouble  would  be  sufificient  to  give  valu- 
able information  on  such  a  subject  in  a  country  dis- 
trict, where  everv  one  knows  every  one  else.  I 
ofYered  to  have  the  report  published  by  the  New 
York  Acadmy  of  Medicine,  but  no  such  report  was 
forthcoming.  Year  before  last  we  had  just  such  an 
epidemic  prevail  in  this  city,  but  it  was  impossible 
then  to  settle  just  how  its  victims  were  infected. 

But  to  return  to  the  subiect  of  a  popular  classifi- 
cation, with  the  corresponding  terms  to  be  used  for 
the  guidance  of  the  public,  I  should  recommend  a 
short  statement  adopted  by  some  authoritative  med- 


ical society,  defining  the  three  classes  of  infeciious 
diseases,  as  follows : 

The  term  "'infectious"  should  include  every  dis- 
ease caused  by  the  entrance  into  and  subsequent 
multiplication  in  the  body  of  its  own  specific  micro- 
organism. This  term,  therefore,  ought  to  cover 
them  all,  from  smallpox  to  tuberculosis  and  malariaL 
infectious  diseases  are  divisible  into  three  classes. 
First  class,  that  in  which  the  disease  is  communi- 
cated from  the  sick  to  the  healthy  directly,  and  in 
which  mere  proximity  to  the  sick  with  them  is 
enough  to  endanger  those. who  are  susceptible  to  the 
disease.  To  this  class  only  should  the  term  "con- 
tagious" be  applied.  The  chief  members  of  this 
class  are  smallpox,  scarlet  fever,  measles,  diphtheria, 
influenza,  whooping"  cough,  mumps,  and  typhus 
fever.  Though  the  term  contagious  implies  their 
spread  by  personal  contact,  it  is  doubtful  if  this  actu- 
ally occurs  except  in  syphilis  and  gonorrhoea,  but  the 
term  "'simple  proximity"  fully  sufifices  to  designate 
their  nature. 

As  all  the  infectious  diseases  are  accidental,  and 
the  body  by  no  process  of  its  own,  normal  or  ab- 
normal, can  give  rise  to  them,  any  more  than  a  field 
spontaneously  generates  what  grows  in  it,  therefore 
all  these  diseases  should  be  prevented  like  any  other 
accidents.  The  only  method  for  prophylaxis  of  a 
contagious  disease  is  by  quarantine  or  the  segrega- 
tion of  those  sick  with  them. 

To  the  second  class  belong  those  diseases  which 
are  communicated  from  the  sick  to  the  healthy,  not 
directly,  but  indirectly  through  some  intermediate 
carrier.  Prophylaxis  or  prevention  of  them,  there- 
fore, is  secured  by  discovering  what  the  intermediate 
carrier  is,  and  then  destroying  the  infecting  agent 
on  or  in  them.  These  diseases  not  being  contgious. 
can  be  attended  by  their  friends,  nurses,  and  physi- 
cians without  any  danger  of  their  contracting  the 
infection.  The  chief  members  of  this  class  are  Asi- 
atic cholera,  typhoid  fever,  and  tuberculosis. 

The  third  class  comprises  those  diseases  that  are 
communicated  only  by  inoculation,  through  some 
puncture,  or  wound,  or  equivalent  lesion  of  the  skin 
or  mucous  membrane,  and  therefore  they  are  not 
dangerous  to  bystanders,  as  the  contagious  diseases 
are.  It  is  in  this  third  class  that  the  greatest  triumphs 
of  preventive  medicine  have  been  secured.  They  con- 
stitute the  entire  class  of  malarial  infections  by  the 
bite  of  the  mosquito,  also  yellow  fever  by  the  same 
means,  also  other  very  fatal  maladies,  as  the  sleep- 
ing sickness  of  Africa,  caused  by  the  bite  of  the 
tsetze  fly,  and  the  no  less  fatal  kala  azar  of  the  East 
Indies,  which  is  produced  by  the  bites  of  bedbugs, 
and  finally  the  bubonic  plague,  which  is  propagated 
to  human  beings  by  the  bites  of  fleas  which  have 
bitten  rats  infected  by  the  plague  bacillus.  Much 
the  most  important  members  of  this  class  are  those 
pyrogenic  organisms  which  become  inoculated  into 
the  blood  during  surgical  operations,  or  by  the 
uterus  after  delivery.  Tetanus  and  hydrophobia  also 
belong  to  this  class. 

Now,  I  do  not  assert  that  this  classification  covers 
every  means  by  which  infection  can  occur.  Any  in- 
fection mieht  be  communicated  by  intravenous  injec- 
tion ;  smallpox  and  scarlet  fever  can  be  carried  bv 
letter:  but  these  are  not  the  usual  methods  by  which 
they  spread,  and  hence  it  is  not  necessarv  to  confuse 
the  public  with  such  details.    On  the  other  hand,  it 


14 


THOMSON:  ASIATIC  CHOLERA. 


[New  York 
Medical  Journal. 


is  especially  of  the  second  class  or  those  which  are 
propagated  by  intermediate  carriers,  that  the  public 
need  to  be  fully  informed  as  to  their  nature.  We 
cannot  expect  the  cooperation  of  the  community  in 
our  efforts  to  get  rid  of  tuberculosis,  or  to  diminish 
the  prevalence  of  typhoid  fever  without  the  public 
becoming  so  well  informed  on  these  very  points  that 
they  will  then  see  the  reasonableness  of  supporting 
the  preventive  measures  recommended  by  the  med- 
ical profession.  This  is  well  illustrated  by  the  history 
of  the  last  visit  of  Asiatic  cholera  to  the  port  of 
New  York,  when  it  came  to  us  by  steamers  from  the 
highly  infected  port  of  Hamburg,  in  the  summer  of 
.1892.  Its  approach  was  heralded  in  the  newspapers 
all  over  the  country,  and  accordingly,  very  soon 
upon  the  first  news  of  an  infected  ship  entering  New 
York  harbor,  a  widespread  business  panic  took  place 
which  very  seriously  affected  the  commerce  of  the 
city  of  New  York.  As  more  vessels  arrived,  the 
authorities  attempted  to  have  the  passengers  of  the 
infected  ships  landed  at  places  on  the  southern  shore 
of  Long  Island.  Armed  mobs  were  quickly  collected 
among  the  inhabitants  of  those  localities  to  prevent 
by  force  any  persons  sick  with  cholera  being  landed, 
and  no  one  was  allowed  to  leave  the  ships.  Mean- 
time, it  had  not  occurred  to  any  one  to  account  for 
the  fact  that  it  was  the  steerage  passengers  on  those 
ships  which  were  seriously  affected,  while  not  a 
single  case  occurred  among  the  saloon  passengers, 
although  they  paced  the  deck  right  over  them.  At 
the  same  time,  it  w"as  reported  to  the  Academy  of 
Medicine  that  some  Italian  laborers  who  had  diar- 
rhoea had  escaped  from  these  ships,  and  who  were 
employed  by  a  contractor  on  the  Harlem  railroad, 
where,  in  the  town  of  Bedford,  they  were  huddled 
in  cabins  with  the  water  closets  draining  into  a 
brook  which  discharged  into  the  Croton  river.  The 
Academy  of  Medicine  at  once  conferred  with  the 
board  of  health,  how  to  prevent  the  contamination 
of  the  Croton  water  by  this  means,  and  they  were 
met  with  a  statement  that  the  city  officials  proposed 
to  buy  a  strip  of  300  yards  in  width  on  both  banks 
of  the  Croton  river  and  disinfect  these  strips,  so 
that  the  Croton  should  not  be  contaminated.  This 
real  estate  speculation  did  not  commend  itself  to  the 
academy,  and  a  committee  was  appointed,  of  which 
I  was  chairman,  to  go  to  Albany  and  to  demonstrate 
to  the  Senate  Committee  on  Cities  that  this  plan 
would  not  $ufifice  at  all  to  shield  the  city  against  the 
infection. 

As  I  began,  in  my  remarks  to  the  senate  com- 
mittee, to  refer  to  the  extensive  experience  with  this 
disease  in  English  cities,  the  chairman  of  the  senate 
committee  roared  out :  "We  do  not  want  anything 
English  here !  God  Almighty  Himself  contaminates 
the  Croton  when  he  sends  his  rain !"  As  it  was 
plain  to  our  committee  that  we  might  as  well  ad- 
dress a  bench  of  Mohammedan  muftis  as  this  body 
of  senators,  we  withdrew.  In  the  next  morning's 
papers,  the  Academy  published  to  the  panic  stricken 
city  a  statement  showing  what  a  danger  to  public 
health  politicians  can  be  in  such  emergencies. 

We  cited,  at  the  time,  what  I  was  not  allowed  to 
show  to  our  senators,  the  official  reports  that  had 
been  sent  to  me  hy  the  Hamburg  authorities.  The 
latter,  when  they  found  that  one  side  of  a  street  had 
many  cases  of  cholera,  if  it  was  supplied  by  water 
from  the  Elbe,  while  the  opposite  side  of  the  same 


street,  which  had  a  different  water  supply,  did  not 
have  a  case,  at  once  ordered  scientific  engineers  to 
construct  great  sand  filters  to  purify  the  Elbe  water. 
On  the  completion  of  these  filtering  plants  cholera 
ceased,  but  not  until  ships  infected  with  it  had  al- 
ready started  for  New  York.  The  authorities, 
alarmed  by  the  newspapers,  asked  for  another  con- 
ference with  our  committee,  promising  to  adopt  any 
bill  that  the  Academy  would  draft.  But  when  the 
Academy  proposed  that  a  faltering  plant  for  the 
Croton  should  be  constructed  by  experts  chosen 
from  the  American  Institute  of  Engineers,  instead 
of  by  the  City  Board  of  Public  Works,  the  city 
officials  were  much  incensed.  As  the  cholera  scare 
meantime  had  died  out.  New  York  city  to  this  day 
continues  to  drink  unfiltered  Croton  water,  with 
the  result  that  thousands  die  here  from  typhoid 
fever,  which,  like  cholera,  is  a  water  borne  disease, 
and  which  every  year  becomes  more  rife  as  the 
Croton  runs  low.  Philadelphia  also  has  its  yearly 
epidemics  of  typhoid,  which  the  medical  profession 
there  has  protested  might  be  obviated  by  filtering 
the  Schuylkill  waters.  So  it  might,  but  for  the  poli- 
ticians making  a  job  of  the  construction  of  the  filter 
works,  so  that  they  get  the  money  out  of  it  but  leave 
the  typhoid  germs  in.  The  drainage  of  Connecticut 
towns  also  infects  the  oyster  beds  of  Long  Island 
Sound,  and  I  have  been  called  in  consultation  to 
patients  at  our  most  fashionable  hotels,  ill  with 
typhoid  from  their  habit  of  eating  raw  oysters  for 
their  first  course  at  dinner. 

A  striking  illustration  of  how  a  knowledge  of  the 
methods  of  propagation  of  a  member  of  the  third, 
or  intermediately  carried  infections,  may  be  used 
to  arrest  its  prevalence,  is  furnished  in  the  case  of 
Asiatic  cholera.  The  present  generation  hardly 
knows  how  the  dread  spectre  of  this  epidemic  once 
made  all  the  western  nations  tremble  when  the  news 
came  that  it  had  started  afresh  on  its  travels  from 
its  native  India.  The  British  government  had  dis- 
covered there  that  its  chief  outbursts  coincided  with 
the  great  Hindu  pilgrimage,  which  occurred  once  in 
twelve  years,  to  Hardwar,  on  the  Ganges.  How 
cholera  might  abound  on  such  an  occasion  is  well 
shown  bv  the  description  of  Dr.  Simpson,  the  able 
health  officer  of  Calcutta. 

At  this  pilgrimage,  which  is  also  held  as  a  fair,  from 
Soo.ooo  to  1,000.000  Hindus  collect  to  drink  the  holy  waters 
of  their  sacred  Ganges,  and  to  bathe  in  the  great  tank  con- 
structed at  the  riverside.  From  April  8  to  April  12,  1891. 
it  presented  the  spectacle  of  a  seething  mass  of  humanity 
in  constant  motion  through  the  pool  at  the  rate  of 
400  to  500  per  minute.  Now,  it  can  easily  be  imagined 
that  a  few  cases  of  cholera  introduced  into  such  a  multi- 
tude would  easily  induce  not  only  an  outbreak  of  cholera 
there  and  then,  but  by  the  returning  pilgrims  would  be  car- 
ried far  and  wide.  Thus  a  sanitary  commissioner  says  of 
previous  Hardwar  gatherings  that  very  little  remains  on 
record,  but  that  little  is  a  record  of  disease  and  death.  So 
grave  was  the  outlook  that  the  question  of  prohibiting  the 
pilgrimage  in  1891  was  seriously  discussed,  and  many  offi- 
cials of  great  experience  reported  that  the  most  complete 
sanitary  arrangements  would  be  powerless  to  prevent  the 
spread  of  cholera  if  the  fair  were  held. 

As  this  prohibition  might  entail  the  dancer  of  a  general 
insurrection,  the  British  government  decided  to  hand  the 
management  over  to  the  Indian  Medical  Staff.  The  latter, 
now  knowing  just  how  cholera  infects,  and  that,  without 
being  taken  in  food  or  drink,  it  cannot  travel  six  inches.  • 
allowed  the  fair  to  be  held.  They  promptly  removed  to 
appointed  tents  every  case  of  the  disease  in  this  Asiatic 
crowd  as  soon  as  reported.  All  discharges  from  the  pa- 
tients were  quickly  disinfected,  with  the  result  that  the 


January  2,  1909.] 


RIESMAX:  ADDRESS  TO  NURSES. 


15 


cholera  was  stamped  out  as  effectually  as  a  fire  can  be 
extinguished  if  taken  just  at  its  beginning. 

What  a  gain  it  is  to  humanity  that  the  civihzed 
world  now  knows  that  tuberculosis  is  not -conta- 
gious! Not  many  years  ago  the  New  York  City 
Board  of  Health  announced  that  tuberculosis,  being 
an  infectious  disease,  was  therefore  contagious.  The 
board  was  promptly  called  to  account  for  this  out- 
rageous statement.  Every  one  knows  what  a  con- 
tagious disease  is  smallpox.  Because  of  its  being 
contagious,  the  patient's  nearest  and  dearest  friends 
should  keep  away  from  him.  Hence,  after  this  offi- 
cial pronouncement,  many  a  poor  consumptive  was 
needlessly  discharged  by  his  employer  as  a  danger 
to  all  his  fellow  workmen,  whereas  thousands  of 
consumptives  never  infect  the  members  of  their  .own 
families.  A  few  simple  precautions,  w^hich  would 
be  utterly  useless  against  a  really  contagious  disease, 
would  effectively  remove  the  danger  from  him. 
Now  that  it  is  widely  known  that  tuberculosis  al- 
ways has  to  be  carried  by  something  outside  of  the 
patient,  attention  is  directed,  not  to  the  patient  so 
much  as  to  the  carrier  of  the  infection,  and  the  pub- 
lic, learning  this  fact,  is  willing  intelligently  to  join 
as  never  before  in  the  crusade  against  it,  until  we 
may  hope  that  ere  long  tuberculosis  will  become  as 
uncommon  as  leprosy. 

23  West  Forty-sevexth  Street. 

ADDRESS  TO  NURSES, 
Delivered  at  the  Graduation  of  Nurses,  Polyclinic  Hospital 
Training  School,  November  11.  igo8. 

By  David  Riesmax,  M.  D., 
Philadelphia. 

The  history  of  nursing  is  the  history  of  all  revo- 
lutionary movements.  The  pioneers  idealized,  or 
rather  overidealized,  the  cause  they  were  engaged 
in.  Those  who  took  up  the  work  in  the  middle  of 
the  last  century  felt  a  sentimental  elevation  of  spirit 
quite  akin  to  that  which  possessed  the  knights  and 
ladies  in  the  age  of  chivalry,  the  newness  of  the  call- 
ing, and  the  fact  that  many  of  those  who  entered  it 
did  not  have  to  work  for  a  living,  having  encom- 
passed it  with  a  halo  of  sentiment  that  could  not  long 
endure.  The  reaction  came,  and  with  it  a  purely  com- 
mercial view  of  the  profession  of  the  nurse,  from 
which  we  are  now  happily  beginning  to  emerge. 
There  is  unquestionably  a  drift  toward  a  riper  and 
nobler  conception,  in  wWch  the  ideal  of  work,  not 
wages,  is  dominant;  the  feeling  that  each  woman 
must  work  out  her  salvation  for  herself,  with  her 
own  hands,  with  her  own  brains,  in  the  field  best 
suited  to  her  talents,  whether  it  be  in  the  home  or 
in  the  world  at  large.  This  feeling  has  energized 
woman's  latent  powers,  and  in  the  case  of  your  pro- 
fession has  given  it  a  tremendous  force. 

Daily  the  nurse's  calling  is  increasing  in  impor- 
tance and  in  scope.  Training  schools  are  multiply- 
ing in  the  larger  cities :  and  in  smaller  tow' ns,  the 
building  of  hospitals,  a  thing  virtually  impossible 
were  it  not  for  the  nurses  filling  the  important  posi- 
tions, is  going  on  apace.  In  many  of  these  smaller 
new  institutions,  the  appointments  of  which  are 
often  of  the  best,  training  schools  are  also  being 
established. 

There  is  now,  too,  a  greater  use  of  nurses  by  pri- 


vate families.  Even  within  my  recollection  there 
was  a  period  when  it  was  difficult  to  persuade  a 
family  in  moderate  circumstances  to  have  a  trained 
nurse.  A  few  days  ago  I  had  such  an  experience — 
a  middle  aged  woman  had  been  taken  ill,  not 
seriously,  yet  I  thought  it  would  be  best  to  have  a 
nurse  to  watch  her.  The  members  of  the  family 
were  opposed  to  it.  "We  don't  believe  in  trained 
nurses ;  they  make  so  much  bother,  and  are  but  lit- 
tle help."  I  waited  for  a  few  days,  then  I  insisted 
again,  and  carried  my  point.  The  nurse  came,  with 
the  result  that  on  two  occasions  when  the  patient 
wanted  to  discharge  her,  thinking  she  could  get 
along  without  a  nurse,  the  family  begged  me  to 
persuade  the  patient  to  keep  her.  This  is  not  an  un- 
common occurrence. 

In  the  sociological  field  the  scope  of  nursing  has 
widened  enormously — slum  nursing,  district  nurs- 
ing, nursing  in  public  schools — what  a  magnificent 
field !  In  the  home  the  nurse  has,  however,  not  fully 
reached  the  measure  of  her  possibilities ;  she  is  not 
yet  all  that  she  should  be.  She  is  still  in  many  in- 
stances merely  a  nurse,  a  machine,  instead  of,  in  the 
Emersonian  sense,  woman  nursing.  To  achieve 
that  ideal  she  must  expand,  not  only  along  technical 
lines — and  here  I  want  to  take  issue  with  those  who 
advocate  a  shortening  of  the  curriculum — but  also 
along  general  cultural  lines.  With  regard  to  tech- 
nical education,  I  want  to  urge  you  not  to  stop  study 
with  graduation ;  do  not  stand  still ;  read  your  text- 
books and  your  notes  frequently ;  from  time  to  time, 
as  new  editions  of  textbooks  come  out,  try  to  get 
them ;  and  then,  to  keep  more  fully  abreast  of  the 
advances  in  your  profession  and  in  touch  with  your 
sister  nurses,  read  systematically  a  nursing  journal. 
Nurses  after  their  graduation  live  too  much  indi- 
vidual lives,  and  often  care  but  little  for  the  gen- 
eral good  of  their  calling  or  whether  the  position  of 
their  profession  is  bettered  or  not,  just  so  long  as 
they  have  steady  employment.  This  is  a  narrow 
spirit  that  does  harm  to  the  nurse  herself  and  de- 
tracts from  the  strength  and  influence  of  the  cause 
she  represents. 

I  believe  in  organization — less  perhaps  for  offense 
and  defense  than  for  the  purpose  of  intellectual  ad- 
vancement and  the  furthering  of  an  esprit  dc  corps. 
I  should  like  to  see  nurses'"  societies  established" 
somewhat  on  the  lines  of  our  scientific  medical  socie- 
ties, composed  of  the  graduates  of  all  reputable 
training  schools,  at  which  papers  would  be  read  per- 
taining to  nursing,  or  to  medical  subjects  in  so  far  as 
they  are  of  interest  to  the  nursing  profession.  In  a 
general  way,  such  meetings  should  further  both  tech- 
nical and  cultural  advancement.  The  nurse,  with  her 
varied  experiences  in  the  home  and  in  the  wards 
of  the  hospital,  has  so  much  of  interest  and  of  value 
to  tell  that  the  opportunity  should  be  given  her  to  do 
so.  How  much  the  younger  nurses  would  profit 
by  listening  to  those  who  have  been  in  practice  for 
many  years  and  are  living  lives  of  intense  activity! 
This  is  rather  a  pet  idea  of  mine,  and  I  hope  you 
will  think  it  over.  Medicine,  the  most  progressive  of 
all  sciences,  discovers  something  new  every  day.  I  am 
afraid,  however,  that  for  the  majority  of  nurses  all 
the  new  things  coming  after  graduation  remain  un- 
known. That  is  not  right ;  that  is  not  as  it  should 
be;  it  is  a  sad  anticlimax  to  a  three  years'  course 


I 

i6 


BECK:   BISMUTH  POISONING. 


[New  York 
Meuical  Journal. 


of  ardent  study.  The  nurses"  society  is  the  place  for 
learning  about  these  new  things.  From  time  to 
time  a  doctor  might  be  invited  to  read  a  paper ;  but 
for  the  most  part  the  nurses'  contributions  should 
make  up  the  programme  of  the  meetings.  The 
society  should  possess  a  library,  or,  if  that  is  im- 
possible for  pecuniary  reasons,  arrangements  should 
be  made  with  the  trustees  of  public  libraries  for  the 
establishment  of  a  special  nurses'  library  with  text- 
books and  nursing  journals. 

I  stated  a  little  while  ago  that  the  nurse  had  not 
fully  realized  the  importance  of  her  mission  in  the 
home.  I  want  you  to  be  not  only  nurses,  not  only 
ministers  of  health  for  the  sick,  but  apostles  of  hy- 
giene to  the  well,  for  in  this  capacity  you  can  be  of 
the  greatest  help  to  the  physician  in  the  spreading  of 
the  principles  of  preventive  medicine.  There  are 
many,  many  lines  of  the  best  kind  of  missionary 
work  for  you.  Take  vaccination,  for  example — - 
you  will  be  astonished  when  you  go  out  to  find 
how  strong  is  the  prejudice  against  it;  and  yet 
there  has  never  been  a  discovery  that  has  done  more 
good  to  mankind.  Vaccination  is  a  sure  preventive 
of  smallpox,  and  nothing  in  the  whole  range  of 
medicine  compares  with  it.  I  have  not  time,  nor  is 
this  the  place,  to  s'o  into  the  objections  raised 
against  it ;  but  taken  all  together  they  have  no 
weight. 

Another  idea  I  desire  you  to  combat  in  your  mis- 
sionary vv-ork  is  the  idea  that  all  children  must  have 
children's  diseases,  measles,  chickenpox,  whooping 
cough,  scarlet  fever,  and  that  if  one  child  in  the 
household  is  afflicted,  the  best  thing  to  do  is  to  ex- 
pose them  all,  so  that  all  the  trouble  may  come  about 
the  same  time  and  the  doctor's  bill  be  lessened  by 
reason  of  wholesale  service.  It  is  not  necessary  for 
children  to  have  all  the  diseases  of  childhood,  and 
bv  sheltering  them  in  a  sensible  manner  they  n:ay 
escape  some  of  them ;  one  can  never  tell,  even  the 
mildest  is  at  times  fatal  or  leaves  after  effects  that 
cause  lifelong  suffering  and  regret. 

Another  idea,  the  spreading  of  which  among  the 
])eople  would  be  of  benefit,  is  the  love  of  fresh  air. 
You  must  support  us  in  our  crusade  in  this  field  to 
the  best  of  your  ability ;  the  people  must  be  told  that 
.fresh  air,  whether  itjjc  night  air  or  day  air,  is  not 
harmful ;  that  the  sleeping  room  windows  should  i;e 
wide  open  at  all  seasons  :  and  that  stuffy  houses  do 
more  harm  than  winter  snows  or  autumn  rains. 
Gradually  the  knowledge  is  growing  among  the  lait\- 
that  colds  are  contagious  and  that  ordinary  sore 
throat  may  be  communicated  :  but  acquaintance  with 
this  indul)itablc  fact  is  not  as  widespread  as  it 
should  be.  Mere,  too,  you  can  do  a  little  preach- 
ing ;  but  be  careful  not  to  impress  upon  the  laity 
such  a  fear  of  contagion,  such  a  dread  of  germs,  as 
to  make  life  miserable. 

And  then  the  great  subject  of  diet,  how  little  it 
is  understood !  I  am  afraid  the  blame  falls  some- 
what upon  us  physicians ;  yet  you  have  learned  a 
few  things  about  this  in  your  three  years'  course, 
and  can  liclp  in  diffusing  your  knowledge  among 
the  f)eople.  Under  the  iicad  of  diet  I  would  include 
the  drinking  of  water.  Make  it  known  to  all  that 
watiM-  is  f)ne  of  the  best  things  of  the  earth  taken 
at  tlie  right  time  and  in  the  right  quantities;  that 
it  promotes  health  and  lessens  the  need  for  drugs. 


These  things  that  I  have  been  telling  you  are  im- 
portant, and  you  must  ever  keep  them  before  you. 
There  .is  only  one  thing  more  that  I  have  to  say  and 
that  goes  deejDer,  goes  nearer  to  the  root  of  things — 
it  is  that  the  one  really  great  thing  in  life  is  zvork. 
That  is  the  ideal  with  which  you  must  start  out. 
Carlyle  says :  "It  is  the  grandest  cure  for  all  the 
maladies  and  miseries  that  ever  beset  mankind- 
honest  work,  which  you  intend  getting  done.  The 
most  unhappy  of  all  men  is  the  man  who  cannot  tell 
what  he  is  going  to  do,  who  has  got  no  work  cut  out 
for  him  in  the  world.  Work  is  life,  and  to  have 
one's  work  cut  out  for  him  and  to  do  it  is  to  live." 
Just  think,  then,  how  fortunate  you  are  in  having  a 
purpose  and  the  capability  to  carry  it  out.  I  want 
you' to  go  from  here  glorifying  work.  I  care  but 
little  whether  in  beginning  to  practice  your  pro- 
fession you  think  it  is  the  grandest  in  the  world ;  it 
does  not  matter ;  indeed  you  need  not  think  about  it 
at  all  if  only  you  have  the  impetus  within  you  to 
work.  The  real  truth,  after  all,  is  not  that  you  are 
working  in  nursing  because  it  is  the  grandest  pro- 
fession, but  that  because  of  work  in  it  it  becomes 
the  grandest  profession.  Moreover,  you  must  re- 
member you  help  to  cure,  not  only  because  you 
are  nurses,  but  because  you  are  women.  Renan. 
whose  love  for  his  sister  gave  him  a  profound  lui- 
derstanding  of  the  female  sex,  eloquently  says : 
"Who  wovild  dare  to  assert  that  in  many  cases, 
certain  injuries  always  excepted,  the  touch  of  a 
gentle  and  beautiful  woman  is  not  worth  all  the 
resources  of  pharmacy?  Cure  is  eft'ected  by  the 
mere  pleasure  of  seeing  her.  She  gives  what  she 
can,  a  smile,  a  hope,  and  it  is  not  in  vain." 


TOXIC  EFFECTS  FROM  BISMUTH  SUBXITRATE, 
With  Reports  of  Cases  to  Date. 
By  Emil  G.  Beck,  'M.  D., 
Chicago, 

Surgeon  to  the  North  Chicago  Hospital. 

Toxic  effects  from  the  use  of  bismuth  subnitrate 
in  medicine  and  surgery  are  so  rare  that,  until  re- 
cently, physicians  have  regarded  its  administration 
as  perfectly  harmless.  Schuler  ( i )  and  von  Bar- 
deleben  (2)  have  pronounced  its  action  as  nontoxic, 
the  latter  having  treated  one  hundred  cases  of  ex- 
tensive burns  by  dusting  with  bismuth  subnitrate, 
and  observed  no  unpleasant  symptoms  therefrom. 
Professor  Muhlig  (3)  administered  20  grammes 
daily  for  a  prolonged  period  without  producing  any 
poisonous  effect. 

It  was,  therefore,  not  surprising  when  radiogra- 
phers began  to  use  bismuth  subnitrate  for  the  ])ur- 
pose  of  obtaining  radiographs  of  the  stoniach  and 
intestines,  that  they  had  no  hesitancy  in  administer- 
ing large  doses,  and  boasted  of  the  safety  with 
which  as  much  as  forty  grammes  in  one  dose  could 
be  administered.  The  subject  of  bismuth  poisoning 
came  into  comparative  revival  only  within  the  past 
two  years,  when  radiographers  began  to  employ  the 
drug  more  extensively. 

Cases  of  poisoning  resulting  from  the  administra-^ 
tion  of  bismuth  subnitrate  have  been  reported  as 
earlv  as  tjc)^,  but  these  were,  thought  to  be  due  to 
the  ini]nirities  in  the  drug,  such  as  arsenic,  etc.  The 


January'  ji,  1909.  J 


BECK:   BISMUTH  POISONING. 


17 


first  authentic  report  of  bismuth  poisoning  was 
made  by  Theodor  Kocher  (4)  in  1882,  who  ob- 
served that  the  insoluble  bismuth  preparation,  when 
applied  to  large  wound  surfaces,  is  capable  of  yield- 
ing so  much  bismuth  to  absorption  as  to  produce 
poisonous  ef¥ects,  characterized  by  acute  stomatitis, 
black  discoloration  of  the  mucous  membrane,  usual- 
ly beginning  at  the  border  of  the  teeth,  but  later 
spreading  over  the  whole  mouth,  followed  by  intes- 
tinal catarrh,  pain,  and  diarrhoea,  and  in  severe 
cases,  desquamative  nephritis. 

Similar  cases  were  reported  by  Professor  Peter- 
son (5).  Thereafter  the  literature  on  the  subject 
remained  silent  until  1901,  when  Professor  Muhlig 
(3)  reported  the  following  two  cases: 

Case  I.- — A  man,  twenty-six  years  of  age,  received  a  burn  on 
both  arms,  hand,  and  neck,  the  same  were  dressed  with  oil  for 
three  days  and  the  pure  bismuth  subnitrate  applied.  Two 
weeks  later  a  black  border  around  the  teeth  appeared,  and 
within  five  more  days  the  whole  mouth  and  uvula  were 
greyish  blue  and  slightly  ulcerated.  Urine  remained  nor- 
mal, digestion  normal.  Recovery  took  place  after  wounds 
were  curetted  and  freed  from  bismuth. 

Case  II. — A  man,  thirty-four  years  old,  was  burned  on  both 
legs,  Treatment  same  as  in  Case  I.  Twelve  days  after  first 
bismuth  dressing  symptoms  identical  with  those  in  Case  I 
appeared.  Urine  and  stool  remained  normal.  The  curet- 
tage of  the  wounds  resulted  in  prompt  remission  of  the 
symptoms.  The  bismuth  used  in  these  cases  was  free  from 
impurities. 

A  similar  case  was  reported  by  Dressman  (6). 

Case  III. — A  man,  thirty  years  old,  received  a  burn  of  third 
degree.  Five  days  later  a  ten  per  cent,  bismuth  salve  was 
applied.  Three  weeks  later  a  black  sediment  was  discov- 
ered in  the  ruine.  A  severe  stomatitis  with  deglutition 
pains  followed.  A  bluish  green  border  around  his  teeth 
was  noticed,  and  the  mouth  resembled  the  condition  which 
exists  after  eating  huckleberries.  After  the  bismuth  dress- 
ings were  stopped  the  symptoms  abated,  but  even  six 
months  later  there  were  blue  marks  around  the  teeth. 

Wordan,  Sailer,  Pancoast,  and  Davis  (7)  reported 
two  cases,  in  which  sixty  and  120  grammes  were 
administered  in  one  dose.  In  both  cases  the  char- 
acteristic symptoms  of  bismuth  poisoning  developed 
and  both  patients  recovered. 

The  first  fatal  case,  directly  traceable  to  the  ad- 
ministration of  bismuth  subnitrate  for  diagnostic 
purposes,  is  reported  by  Bennecke  and  Hoff- 
man (8). 

Case  IV. — A  three  weeks'  old_child,  suffering  from  en- 
teritis, weak  and  emaciated.  A  mixture  of  three  grammes 
of  bismuth  subnitrate  in  100  c.c.  of  buttermilk  was  admin- 
istered by  stomach,  in  order  to  diagnosticate  a  pyloric  sten- 
osis by  rontgenograph.  Twelve  hours  later  cyanosis  devel- 
oped, collapse  followed,  and  the  child  died  three  hours  later. 
Post  mortem  examination  revealed  bismuth  in  the  bowel, 
and  small  quantities  in  the  liver  and  blood.  Methremoglo- 
bircem.ia  was  present. 

From  the  same  clinic  another  similar  case  was  re- 
ported by  Bohme  (9). 

Ca.se  V. — A  child,  one  and  a  half  years  old,  markedly 
rachitic,  artificially  fed  and  marasmic,  received  a  few 
grammes  of  bismuth  subnitrate  by  stomach  for  radio- 
graphic purpose.  Stomach  was  washed  and  no  symptoms 
of  poisoning  appeared.  Two  days  later  a  few  grammes 
of  bismuth  subnitrate  were  injected  by  the  rectum  for  the 
same  purpose,  and  again  the  bismuth  was  washed  out. 
Three  hours  later  the  child  was  suddenly  seized  with  pain, 
cried,  became  cyanotic,  pale,  skin  cool,  pulse  small,  and 
died  in  twenty  to  thirty  minutes. 

Section  :  Distinct  mcthsemoglobinsemia,  all  mucous  mem- 
branes were  brownish  discolored,  marked  rachitis,  dilation 
of  the  stomach,  with  stenosis  of  pylorus.  Colon  contained 
large  quantities  of  black  and  white  bismuth. 


Professor  Hefter  suggested  that  death  might; 
have  been  caused  by  nitrate  poisoning.  The  blood 
and  pericardial  fluids  were  tested,  and  in  both 
nitrites  were  found.  Bismuth  could  not  be  detected 
in  the  liver  or  blood.  These  chemical  findings 
threw  new  light  on  both  cases  and  prompted  Dr. 
Bohme  to  determine  the  true  cause  of  bismuth  sub- 
nitrate poisoning.  The  results  of  his  experiments 
were  as  follows: 

A  number  of  pure  cultures  of  the  Bacterium  coli  were 
found  to  liberate  nitrites  in  every  case,  when  added  to 
bouillon  to  whicli  some  bismuth  subnitrate  was  added.  The 
controls  of  bouillon,  treated  the  same  way  but  without  the 
addition  of  bismuth,  remained  free  from  nitrites.  This  ex- 
periment was  repeated  by  using  a  solution  of  children's 
stool  instead  of  pure  cultures,  and  in  every  instance  the  for- 
mation of  nitrites  was  marked,  while  the  same  experiments 
with  stools  from  grown  persons  showed  nitrites  absent  in 
forty  per  cent.,  slight  in  thirty-five  per  cent.,  and  marked  in 
only  twenty-five  per  cent,  of  the  cases.  The  ingestion  of 
food  seemed  to  have  no  influence  in  regard  to  nitrite  for- 
mation, as  some  of  the  adults  received  a  milk  diet. 

The  next  question  Bohme  determined  was 
whether  the  formation  of  nitrites  would  occur  in 
feeding  lower  animals  with  bismuth  subnitrate. 
Cats  and  rabbits  were  used  for  experiments,  and 
after  finding  their  stools  and  urine  free  from  nitric 
acid,  they  were  given  from  three  to  five  grammes 
of  bismuth  subnitrate  in  milk.  Nitrates  appeared 
in  the  urine  after  a  few  hours  and  did  not  cease  to 
be  eliminated  from  the  kidney  for  twenty-four 
hours.  Reaction  to  nitrites  was  absent  in  the  rab- 
bit and  only  faintly  marked  in  the  cats. 

To  prove  that  children's  fasces  mixed  with  bismuth 
subnitrate  would  liberate  nitrites  in  the  bowel  of  the 
rabbit,  Bohme  injected  a  inixture  of  five  grammes 
of  each  into  a  part  of  the  bowel,  by  first  ligating  the 
loop.  Nitrates  and  nitrites  were  found  in  the  urine, 
but  ,not  in  the  blood  taken  from  the  hearts  of  the 
animals.  In  the  faeces  of  the  ligated  part  of  the 
bowel  a  large  quantity  of  nitrates  and  nitrites  was 
found.  In  trying  larger  quantities  by  the  same 
method,  and  testing  the  urine  hourly,  the  quantity  of 
nitrates  and  nitrites  increased,  but  not  enough  was 
absorbed  to  cause  metha;moglobinaemia. 

By  these  experiments  Bohme  proved  by  test  tube 
and  animal  experiments  that  the  fasces  of  children 
when  in  contact  with  bismuth  subnitrate  will  liber- 
ate nitrites,  which  are  quickly  absorbed  from  the 
intestine  and  found  in  the  urine.  While  methsemo- 
globinsemia  was  not  caused  by  the  absorption,  it 
must  be  assumed  that  the  absorption  of  larger 
quantities  would  produce  methaemoglobinaemia.  Ex- 
periinents  proved  this  to  be  a  fact. 

CoUishon  (10)  reports  two  cases  of  accidental 
nitrite  poisoning  in  which  sodium  nitrite  instead 
of  the  sodium  nitrate  was  given.  The  symptoms 
were  cyanosis,  extreme  weakness,  and  a  greyish 
blue  discoloration  of  the  mucous  membrane  and  the 
tongue.  The  symtoms  were  so  severe  as  to  produce 
collapse,  but  cleared  up  after  the  drug  was  discon- 
tinued. Binz  (11)  injected  dogs  with  small  doses 
of  sodium  nitrite,  causing  their  death  in  a  few  hours, 
with  symptoms  of  gastroenteritis  and  methaemoglo- 
binaemia. 

Harnack  (12)  killed  a  cat  by  administering  five 
grammes  of  sodium  nitrite  within  five  minutes. 
Methaemoglobin?cmia  was  present. 


BECK:  BISMUTH  POISONING. 


[New  York 
ilEDiCAL  Journal. 


Fig.   I. — Lung  abscess.     Case  CLXVII.     Child  six  years  old. 
Bismuth  paste  injected  at  point  A,  cavity  B. 

Routenberg  (13)  reported  a  case  in  which  a 
methaemoglobinaemia  with  the  usual  symptoms  of 
nitrite  poisoning  folfowed  the  rectal  injection  of 
fifty  grammes  of  bismuth  subnitrate  in  400  c.c.  of 
oil  of  sesame,  and  while  the  author  ascribes  the  poi- 
soning to  the  contamination  of  the  oil,  the  analogy 
with  other  similar  cases  leads  one  to  suspect  that 
it  was  a  case  of  nitrite  poisoning. 

A  recent  report  of  a  fatal  nitrite  poisoning  due 
to  bismuth  subnitrate  is  published  by  Novak  and 
Gutig  (14). 

Case  VI. — A  man,  forty-four  years  of  age,  who,  a  year  after 
a  retrocolic  gastroenterostomy,  sufYered  from  symptoms  of 
obstruction,  received  in  July,  1908,  a  rectal  injection  of  four 
tablespoonfuls  of  bismuth  subnitrate  suspended  in  two  litres 
of  water,  to  test  the  function  of  the  anastomosis.  Soon  after 
the  X  ray  examination,  the  bowels  were  washed  out.  After  a 
restless  night  the  nurse  noticed  a  discoloration  of  the  pa- 
tient's skin.  This  condition  was  not  discovered  until  nine  and 
a  half  hours  after  injection,  and  it  was  assumed  that  it  could 
have  been  detected  much  sooner  by  daylight.  Gradually 
the  patient  became  greyish  green,  mucous  membranes 
cyanotic,  temperature  40°  C,  pulse  96.  Patient  did  not 
respond  to  treatment  and  had  stertorous  breathing.  Flush- 
ing of  bowels  and  administration  of  oxygen  had  no  effect. 
Venesection  revealed  the  blood  to  be  of  chocolate  color, 
due  to  methremoglobinsmia.  Patient  died  eighteen  hours 
after  rectal  injection  of  bismuth  subnitrate.  Spectroscopic 
examination  of  blood  of  a  few  hours  after  death  showed 
that  blood  became  normal,  brown  color  having  changed  to 
red.  Two  days  later  the  post  mortem  examination  revealed 
that  the  methxmoglobinfEmia,  which  was  positive  before 
death,  had  now  disappeared  and  blood  resumed  a  normal 
color. 

This  case  also  gave  further  impetus  to  investiga- 
tion. "The  administration  of  100  grammes  of  bis- 
muth subnitrate  by  mouth,  then  by  rectum,  and 
through  a  fistula  into  the  small  and  large  bowels  of 
dogs  and  rabbits,  failed  to  produce  any  symptoms 
of  poisoning,  while  in  cats  much  smaller  quantities 
(twenty  grammes)  would  cause  death  in  ten  hours. 


.Seven  hours  after  ingestion  of  this  quantity  the  cat 
vomited,  her  mucous  membranes  became  bluish 
grey,  blood  assumed  a  chocolate  color,  and  spectro- 
scope revealed  the  methsemoglobin  stripe  in  the 
red." 

This  proves  that  certain  animals  are  susceptible 
to  nitrite  poisoning,  while  others  are  not.  It  is  not 
yet  fully  determined  to  which  class  the  human  be- 
longs. 

It  has  been  proved  that  nitrites,  when  formed  in 
the  bowel,  may  be  neutralized.  By  adding  iodine 
nitrate  to  the  faeces  containing  nitrites,  the  latter  will 
disappear  in  two  to  three  days.  Maasen  proved  that 
certain  bacteria  in  the  bowel  convert  the  nitrites  into 
ammonia  or  into  nitrogen.  It  is  likely  that  the  bis- 
muth subnitrate  ingested  always  causes  a  liberation 
of  small  quantities  of  nitrites,  which  are  either  ab- 
sorbed, and  owing  to  the  small  amount  cause  no 
toxic  symptoms,  or  are  changed  in  the  intestine  into 
ammonia  or  nitrogen. 

When,  however,  large  quantities  of  bismuth  sub- 
nitrate are  given,  and  the  liberation  of  nitrites  is 
abundant  and  cannot  be  neutralized  quickly,  so  that 
large  quantities  of  nitrites  are  absorbed,  typical 
sypmtoms  of  nitrite  poisoning  will  appear.  Alco- 
hols and  glycerin  accelerate  the  formation  of  nitrites 
in  the  intestines.  This  suggests  to  us  a  practical 
point,  namely :  When  we  encounter  a  case  of  nitrite 
poisoning,  to  withhold  alcoholics  and  glycerin  from 
ingestion  and  administer  some  form  of  iodine. 

From  these  experiments  and  reports  of  fatal  cases 
we  must  conclude  that  the  poisonous  effects  of  the 
bismuth  subnitrate  were  not  due  to  the  absorption 
of  the  metallic  bismuth,  but  to  the  absorption  of 
nitrites,  which  caused  the  methsemoglobin  to  pre- 
cipitate in  the  blood.  The  methaemoglobinsemia  ap- 
pears to  be  the  factor  producing  most  of  the  clin- 


Fic.  2. — Lung  abscess.    Case  CLXVIL    Radiograpli  two  months 
later  showing  absorption  of  paste. 


January  2,  1909.] 


BECK:   BISMUTH  POISONING. 


19 


ical  symptoms,  the  cyanosis,  dyspnoea,  diarrhoea,  and 
cramps.  They  indicate  that  the  sudden  change  in 
the  blood  impairs  the  internal  or  tissue  respiration, 
and  the  patients  succumb  with  symptoms  of  suf¥oca- 
tion. 

It  appears  that  the  intestine,  and  especially  the 
sigmoid  and  the  rectum,  are  the  laboratories  for  the 
liberation  of  nitrites.  The  bacteria  in  this  part  of 
the  intestinal  tract  evidently  are  the  nitrite  splitting 
factors,  whereas,  those  in  the  stomach  and  small  in- 
testine allow  the  bismuth  subnitrate  to  pass  into  the 
large  intestine  without  liberation  of  any  quantities 
of  nitrites. 

This  probably  accounts  for  the  fact  that  in 
Novak's  and  Gutig's  experiments  the  small  intestine 
was  usually  found  empty,  while  in  the  large  in- 
testine was  found  bismuth  subnitrate.  The  animals 
appeared  perfectly  well  for  several  hours,  but  as 
soon  as  the  symptoms  of  poisoning  appeared,  the  in- 
tensity progressed  rapidly,  causing  death  very 
quickly. 

The  fatal  cases  thus  far  reported  were  all  suf- 
fering from  intestinal  diseases,  especially  diarrhoea 
or  constipation,  which  suggests  that  the  intestinal 
putrefaction  accelerated  the  nitrite  formation  and 
rapid  poisoning. 

During  the  past  two  years  the  author  (15)  has 
employed  bismuth  subnitrate  quite  extensively  in  the 
treatment  of  empyema,  sinus  and  abscess  cavities, 
l)y  injecting  a  mixture  containing  thirty-three  per 
cent,  bismutli  subnitrate  incorporated  in  petrolatum 
into  the  cavities.  The  question  as  to  what  became 
of  the  bismuth  paste  after  the  injection  arose.  A 
study  of  the  subject  revealed  the  facts  that  if  the 
paste  did  not  discharge  from  the  sinus  soon  after 
injection,  but  was  retained,  it  became  encapsulated 
and  absorbed.  In  nonresilient  cavities,  such  as  bone 
■cavities,  the  mass  was  generally  penetrated  from  all 
sides  by  fibroblasts,  and  gradually  replaced  by  con- 
nective tissue,  while  in  collapsable  cavities,  such  as 
the  pleura,  the  expanding  lung  gradually  replaced 
the  slowly  absorbing  bismuth  paste.  This  could  be 
confirmed  by  taking  radiographs  of  the  regions  so 
injected  at  certain  intervals  (Figs,  i  and  2). 

This,  then,  proves  that  the  bismuth  paste  is  ab- 
sorbed, and  the  question  arises :  How  is  the  bismuth 
-excreted,  and  is  its  absorption  harmful  ?  These  two 
problems  are  now  being  investigated,  but  as  the  in- 
vestigation is  not  completed,  I  shall,  in  this  paper, 
bring  forth  only  practical  and  conclusive  facts,  and 
defer  the  publication  of  the  theoretical  aspect  until 
the  data  obtained  will  warrant  definite  conclusions. 

Harnack  (16)  states  that  bismuth  subnitrate  is 
slowly  absorbed  and  slowly  eliminated.  OrfiUa 
found  bismuth  subnitrate  in  the  liver.  M.  M.  Ber- 
geret  (17)  states  that  bismuth  subnitrate  is  found 
in  the  urine,  in  the  serous  exudates,  a  few  hours 
after  administration,  and  in  rabbits  the  administra- 
tion of  a  few  grains  could  be  detected  in  the  spleen, 
muscles,  and  blood.  Professor  E.  S.  Wood  (18) 
has  detected  bismuth  in  the  urine  four  weeks  after 
administration,  proving  its  slow  absorption.  We 
may,  therefore,  conclude  that  the  bismuth  is  slow- 
ly absorbed  and  slowly  eliminated. 

Before  attempting  to  answer  the  second  ques- 
tion. Is  the  absorption  harmful?  we  must  decide 
Avhether  the  harmful  effects  noted  in  the  cases  re- 


Fic.   3. — Empyema  pleurse.     Case  XXIX.     720  grammes  of  paste 
injected,  but  not  allowed  to  be  absorbed. 

ported  are  due  to  the  absorption  of  the  liberated 
nitrites  or  of  the  bismuth  itself.  By  comparing  the 
symptoms  of  the  two  cases  reported  by  Collishon, 
which  were  caused  by  a  sodium  nitrite  overdose,  with 
those  of  other  authors,  caused  by  the  administration 
of  bismuth  subnitrate,  one  can  hardly  doubt  that  the 
source  of  poisoning  is  identical,  and  that  the  nitrites 
are  the  factors  which  are  responsible  for  the  sudden 
and  violent  attacks  of  poisoning.  This  fact  is  sup- 
ported by  the  experiments  of  Bohme,  and  Novak 
and  Gutig. 

In  my  experience  with  the  injection  of  bismuth 
petrolatum  into  sinus  and  abscess  cavities,  I  have 
not  encountered  any  case  in  which  the  train  of  symp- 
toms would  correspond  to  that  of  an  acute  nitrite 
poisoning,  so  graphically  described  by  the  various 
authors  who  have  met  with  these  cases.  In  many 
patients  I  have  noticed  a  slight  lividity  of  the  mu- 
cous membranes  and  skin,  a  bluish  border  at  the 
margin  of  the  teeth,  otherwise  the  conditions  were 
perfectly  normal.  In  one  patient  I  noted  a  distinct 
ulceration  in  the  mouth,  which  was  characteristic 
of  the  bismuth  absorption  as  Kocher  describes  it. 
It  disappeared  in  a  few  days.  In  another  patient 
with  an  empyema  pleurae,  in  whom  I  injected  into 
the  pleural  cavity  720  grammes  of  thirty-three  per- 
cent, bismuth  paste,  which  was  retained  there  for 
six  weeks,  when  a  desquamative  nephritis  devel- 
oped, there  appeared  albuminuria,  rapid  loss  of  pre- 
viously gained  weight,  and  the  blue  border  around 
the  teeth  (Fig.  3).  As  soon  as  the  bismuth  paste 
was  withdrawn  by  means  of  injecting  olive  oil  and 
then  applying  a  specially  devised  suction  pump,  all 
the  symptoms  disappeared,  and  the  patient  regained 
his  weight  in  a  few  weeks. 

I  further  desire  to  put  on  record  a  case  referred 


20 


BECK:   BISMUTH  POISONING. 


[New  Vokk 
Medical  Journal. 


FtG.  4. — Photomicrograph,  section  about  4  micra  thick.     Some  liver 
cells  loaded  with  bismuth.     Magnification   1,000  diam. 

to  me  by  Dr.  Roberts,  in  which  the  bismuth  injec- 
tions had  caused  severe  bismuth  intoxication,  and 
after  same  abated  the  patient  died. 

Case  VII. — Mr.  R.,  a  lawyer,  fifty-seven  years  old,  for 
many  years  an  invalid,  had  a  tuberculosis  of  his  hip  since 
1896,  and  after  extensive  operations  retained  several  sinuses 
which  discharged  large  quantities  of  foul  pus.  In  March 
liis  sinuses  had  been  injected  by  the  house  physician  twenty 
times  in  a  period  of  sixty  days  with  a  thirty-three  per  cent, 
bismuth  petrolatum  paste,  the  total  amount  representing 
about  400  grammes  of  pure  bismuth  subnitrate.  While  his 
general  condition  improved  at  first,  and  his  sinuses  healed, 
all  signs  of  typical  bismuth  intoxication  gradually  developed, 
as  described  by  Kocher.  The  mucous  mem- 
brane of  the  mouth  and  gums  became  bluish 
black,  with  ulcerations,  teeth  became  loose 
and  lips  oedematous.  He  experienced  great 
thirst,  diarrhoea,  and  had  desquamative 
nephritis.  The  symptoms  gradually  abated, 
and  he  became  well  enough  to  resume  his 
work  as  an  attorney,  and  for  two  months 
was  active  in  his  vocation.  A  radiograph 
taken  of  his  pelvis  demonstrates  that 
there  .were  only  small  quantities  of  bismuth 
within  the  tissues,  but  they  appeared  to  be 
disseminated  through  the  entire  pelvis. 

August  I,  1908,  he  fell,  injured  his  wrist, 
and  a  large  abscess  formed,  which  was  op- 
erated on  by  Dr.  V.  Verity.  A  large  area 
of  necrosis  followed.  From  this  time  his 
temperature  varied  from  99°  to  101.5°  C. 
He  lost  in  strength,  his  urine  was  loaded 
with  casts  and  albumin;  his  heart  became 
weaker,  and  irregular,  and  he  died  August 
16,  1908. 

Post  mortem  examination,  made  by  Dr.  A. 
Gelirmann  and  myself,  showed  findings  a? 
reported  in  the  following: 

Subject  is  an  old  man,  rather  poorly 
nourished  Right  leg  shows  some  shorten- 
ing. (Finding  in  region  of  right  hip  by  Dr. 
Beck.) 

.\bdominal  cavity :  A  small  amount  of 
fluid  present.  No  adhesions  or  evidences 
of  tumors  or  inflammatory  exudates. 

Liver:  About  normal  in  size,  dark  brown- 
ish in  color.  Section  fails  to  show  any  no- 
ticeable changes. 

Spleen :  Normal  in  size,  but  unusually 
dark,  quite  soft. 

Pancreas:  Negative. 


Intestines :  Somewhat  distended  with  gas  but  otherwise 
negative. 

Vermiform  appendix:  Negative. 

Mucous  membrane  of  intestines  shows  dark  color,  very 
marked. 

Kidneys :  About  normal  in  size.  External  surface  of 
Doth  shows  some  evidence  of  beginning  contraction  aS  the 
capsule  is  irregularly  depressed.  Sections  show  both  kid- 
neys to  be  of  dark  color  with  the  cortical  markings  not  as 
distinct  as  in  a  normal  organ. 

Pelvis  and  Ureters :  Free.  On  the  right  side  in  the  pelvis 
the  retroperitoneal  tissue  appears  gelatinous,  but  more  con- 
sistent of  a  whitish  glistening  appearance,  as  though  filled 
with  a  foreign  substance. 

Chest :  Pericardium  negative.  Heart  about  the  size  of 
subject's  fist.  Heart  muscle  rather  softer  than  normal. 
Valves  negative  and  coronary  arteries  negative. 

Lungs :  Few  adhesions  about  apices  on  both  sides.  Some 
hypostasis  on  both  sides.    Otherwise  negative. 

Inspection  of  bones  of  thorax  and  spine  as  far  as  possible 
fails  to  show  fractures,  tumors,  or  inflammatory  changes. 

Head  not  posted. 

The  microscopical  examination  of  the  tissues  from  the 
liver,  spleen,  kidney,  heart  muscle,  and  intestine,  and  the 
chemical  analysis  of  tissues  were  made  by  Dr.  Maximilian 
Herzog,  and  his  report  is  as  follows : 

Liver:  The  liver  parenchyma  cells  in  general  do  not 
show  r.ny  marked  pathological  changes.  Some  cloudy 
swelling  is  noticeable  here  and  there,  but  the  process  is  not 
at  all  extensive,  but  on  the  contrary,  quite  limited.  There 
is  very  little  fatty  infiltration  and  fatty  degeneration  seen. 
Quite  a  number  of  parenchyma  cells  show  bile  granules  in 
their  paraplasm.  Whether  the  latter  also  contain  here  and 
there  bismuth  is  a  question  which  cannot  be  definitely  de- 
cided, since  we  do  not  know  of  any  microchemical  reaction 
for  bismuth.  However,  it  appears  that  we  find  frequently 
in  liver  cells  granules  darker  than  the  bile  granules,  and 
that  they  are  bismuth  granules.  The  latter  can  first  be 
seen  distinctly  and  beyond  doubt  in  the  intralobular  capil- 
laries. Here  we  see  the  dark  granules  in  the  lumen  of  the 
small  vessels  and  crowded  in  fusiform  cells,  probably  the 
star  cells  of  Kuppfer.  In  the  interlobular  veins  (the  ter- 
minal branches  of  the  portal  vein)  bismuth  is  present  to  a 
large  extent ;  it  is  found  in  the  vascular  endothelium  and 


KiG.  5. —  Photomicrogra|ih,  section  of  liver  about  4  micra  thick. 
In  the  centre  an  interlobular  vein,  to  the  right  and  above 
a  suhlobular  vein.  The  intima  of  both  lined  with  bismuth. 
Magnification,    210  diam. 


January  2,  1909. J 


BECK:   BISMUTH  POISONING. 


21 


deposited  in  the  torm  of  fine  granules  on  the  free  surface 
of  the  mcima.  Occasionally  one  sees  in  the  interlobular  con- 
nective tissue  a  vessel,  apparently  a  sublobular  vein  (the 
terminal  branch  of  the  hepatic  vein),  which  likewise  con- 
tains bismuth.  But  this  point  is  not  clear  beyond  doubt, 
as  is  the  presence  of  bismuth  in  the  portal  system.  Bile 
capillaries  containing  bismuth  can  be  distinguished  here 
and  there  between  the  liver  cells ;  bismuth  is  also  occasion- 
ally found  in  the  small  interlobular  bile  ducts,  but  the 
biliary  ducts  and  capillaries  are  generally  collapsed  and 
empty  (Figs.  2,  4,  5). 

Kidneys :  The  renal  tissue  shows  chronic  interstitial 
changes  with  hyaline  degeneration  of  a  considerable  num- 
ber of  glomeruli.  A  few  of  the  degenerated  hyaline 
spheres  contain  lime  salts.  Some  tubules  contain  hyaline 
casts,  besides  here  and  there  the  tubular  epithelia  show 
marked  cloudy  swelling.  There  is  no  bismuth  present  in 
the  renal  sections. 

Spleen :  There  is  some  thickening  of  the  capsule  and  of 
the  trabecule  noticeable.  The  pulp  spaces  are  not  very  dis- 
tmct,  well  crowded  with  erythrocytes  and  leucocytes.  The 
Malpighian  bodies  are  not  well  defined.  Some  bismuth  is 
present  in  the  shape  of  amorphous  granules  and  denser 
masses  in    the  pulp  spaces. 

Myocardium :  Striation  is  not  very  distinct,  there  is  here 
and  there  a  fine  vacuolation,  also  occasionally  some  cells 
which  show  the  pigmentation  of  brown  atrophy.  But  these 
pathological  changes  are  very  moderate  in  degree.  On  the 
whole,  the  myocardium  is  fairly  normal.  A  few  subperi- 
cardial  round  cells  foci  are  present. 

Intestinal  Tissue :  Nothing  except  a  very  few  thick,  ir- 
regular sections  were  accessible  for  examination.  These 
show  an  extensive  infiltration  of  the  mucosa  with  bis- 
muth. The  lymphoid  tissue  likewise  shows  bismuth,  and 
much  of  the  latter  is  found  in  the  veins  of  the  submucosa. 

Chemical  Examination — i.  Heart  muscle:  A  faint  trace 
of  bismuth. 

2.  Spleen  (very  small  piece)  :  Distinct  reaction  for  bis- 
muth. 

3.  Liver :  Contained  0.13  per  cent,  of  bismuth  oxide  (bis- 
muth 2,  oxide  3).  The  tissue  was  pressed  fairly  dry  be- 
tween filter  paper.  Weight  =  2.292  grammes;  total  ash 
weight  =  0.030  grammes,  in  which  bismuth  2,  oxide  3  = 
0.003  grammes. 

From  the  above  incomplete  microscopical  examination 
it  might  appear  that  the  bismuth  was  first  absorbed  into 
the  lymphatics,  that  it  was  transported  to  and  excreted 
into  the  intestines.  However,  much  was  reabsorbed  by  the 
portal  circulation  and  transported  to  the  liver,  to  be  there 
excreted  into  the  bile  passages.  There  is  no  evidence  that 
any  of  the  bismuth  was  excreted  by  the  kidneys. 

The  above  case  does  not  present  the  typical  symp- 
toms of  an  acute  nitrite  poisoning,  such  as  collapse, 
cyanosis,  etc.,  and  while  the  absorption  of  the  metal 
bismuth  is  proved  by  microscopical  examination  and 
chemical  analysis,  the  question  still  remains  as  to 
whether  the  absorption  and  presence  of  metallic 
bismuth  in  the  tissues  was  a  cause  of  death.  The 
pathological  changes  in  his  liver,  spleen,  and  heart 
muscle,  do  not  indicate  that  a  severe  destructive 
process,  which  would  interfere  with  function  was 
going  on.  The  interstitial  nephritis  was  probably 
not  due  to  the  bismuth  absorption,  since  the  renal 
tissue  was  free  from  deposits  of  the  metal  and  such 
pathological  conditions  could  be  expected  in  an  old 
man  who  has  for  years  suflfered  from  a  chronic  sup- 
purative disease.  Dr.  Verity  reports  to  me  that  the 
patient  was  treated  by  him  ten  years  ago  for  chronic 
nephritis. 

The  discussion  to-night  should  decide  whether 
this  case  should  go  into  literature,  classed  as  a  fatal 
case  from  bismuth  intoxication,  or  a  case  recovering 
from  the  effects  of  bismuth  absorption,  death  being 
only  accidental  and  due  to  other  causes. 

Conclusions :  i — Bismuth  subnitrate  administered 
by  stomach,  in  small  doses,  is  harmless. 

2 — In  the  presence  of  certain  bacteria  in  the  faeces 


of  children  bismuth  subnitrate  will  liberate  nitrites, 
which  will  be  absorbed  by  the  intestines  and  elim- 
inated by  the  kidneys,  and  if  the  production  is  faster 
than  the  elimination,  methsemoglobinsemia  will  re- 
sult. 

3 —  In  large  doses  by  mouth  it  is  liable  to  pro- 
duce an  acute  nitrite  poisoning,  characterized  by 
cyanosis,  collapse,  methasmoglobinsemia,  and  may 
terminate  fatally. 

4 —  Rectal  injection  of  small  doses  of  bismuth  sub- 
nitrate may  cause  nitrite  poisoning  much  quicker 
and  more  severe  than  when  administered  by  mouth. 

5 —  Children  are  more  susceptible  to  nitrite  poi- 
soning due  to  administration  of  bismuth  subnitrate. 

6 —  Persons  suffering  with  intestinal  putrefaction 
are  very  susceptible  to  nitrite  poisoning  when  bis- 
muth subnitrate  is  injected  into  the  bowels. 

7 —  The  bismuth  injected  into  these  sinuses,  and 
encapsulated,  will  be  gradually  absorbed,  and  may 
be  found  in  the  liver,  spleen,  muscles,  and  intestines. 

8 —  Characteristic  symptoms  of  black  borders  of 
gums,  ulcerations  of  mucous  membranes,  diarrhoea, 
desquamative  nephritis  may  appear  several  weeks 
following  the  injection  of  the  paste. 

9 —  After  the  injection  of  large  quantities  of  the 
bismuth  paste  into  suppurating  sinuses,  mild  symp- 
toms of  nitrite  intoxication  may  appear. 

10 —  ^The  acute  nitrite  poisoning  is  to  be  regarded 
as  a  distinctly  separate  affection  from  the  more 
chronic  bismuth  absorption. 

11 —  Radiographers  should  employ  some  other 
preparation  of  bismuth  than  the  nitrate,  and  refrain 
from  injections  of  subnitrate  into  the  bowels,  espe- 
cially if  intestinal  putrefaction  is  present. 

Since  writing  the  above  article  a  report  has  ap- 
peared in  the  Centralblatt  fur  Chirurgie,  October 
31,  1908,  No.  44,  by  Dr.  H.  Eggenberger  from  the 
Clinic  of  Professor  Wilms,  of  Basel,  of  a  fatal  case 
of  bismuth  intoxication  subsequent  to  the  injection 
of  a  sinus  following  a  psoas  abscess  in  a  child,  seven 
years  old.  Thirty  grammes  of  the  paste  were  in- 
jected and  retained  for  six  weeks.  A  stomatitis 
developed,  resembling  mercurial  intoxication,  pulse 
rose  to  130,  and  a  picture  of  toxic  cortex,  such  as 
is  often  observed  in  uraemia,  developed.  The  ab- 
scess cavity  was  evacuated,  but  the  child  died  a 
few  days  later. 

Autopsy  revealed  only  hyperaemia  condition  of 
the  central  nervous  system,  no  apparent  anatomical 
changes.  Small  haemorrhagic  spots  were  observed 
in  the  mucous  membranes  of  the  stomach.  The  in- 
testinal follicles  were  red  and  swollen,  and  on  the 
valvula  Bauhini,  a  greenish  brown  ulceration,  2  to 
3  cm.  in  circumference  was  found. 

References. 

1.  Schuler.    Zeitschrift  fiir  Chirurgie,  1885. 

2.  Von  Bardeleben.  Deutsche  medicinische  Wochen- 
schrift,  1901,  No.  23,  p.  544. 

3.  Muhlig.  Munchener  medizinische  Wochenschrift, 
1901,  No.  15,  p.  592. 

4.  Theodor  Kocher.  Volkmann's  Klinische  Vortr'dge, 
1882,  p.  224. 

5.  Peterson.  Deutsche  medizinische  Wochenschrifi, 
June  20,  1883. 

6.  Dressman.  Munchener  medizinische  Wochenschrift, 
T901,  No.  6,  p.  238. 

7.  Davis.  University  of  Pennsylvania  Medical  Bulletin, 
1906. 


SOULE:  FRACTURE  OF  NECK  OF  FEMUR. 


LAew  Vork 
Medical  Journal. 


8.  Bennecke  and  Hoffman.  Miinchener  medizinische 
Wochcnschrift,  1906,  No.  19. 

9.  Bohme.  Archiv  fur  experimentelle  Pathologic  und 
Pharmakologie,  p.  441,  1907. 

10.  Collishon.  Deutsche  medizinische  Wochenschrifi, 
No.  41,  1889. 

11.  Binz.  Archiv  fiir  experimentelle  Pathologic  una 
Pharmakologie,  xiii. 

12.  Harnack.    Ibid,  1908,  p.  246. 

13.  Routenberg.  Berliner  kUnische  Wochcnschrift,  1906, 
No.  43,  p.  1397. 

14.  Novak  and  Giitig.  Berliner  klinische  Wochcnschrift, 
1908,  No.  .39,  p.  1764. 

15.  Beck.   Illinois  Medical  Journal,  April  and  July,  1908. 

16.  Harnack.    Arzneilchre,  1883,  p.  383. 

17.  Bergeret.    Journal  de  I'anatomic ,  1873,  p.  242. 

18.  Wood.  Transactions  of  the  American  Neurological 
Association,  1883,  p.  23. 

173  L.^KE  View  Avenue. 


METHOD  OF  TREATMENT   OF  FRACTURE  OF 
THE  NECK  OF  THE  FEMUR. 

By  Robert  E.  Soule,  A.  B.,  M.  D., 
New  York, 

Attending  Surgeon  to  the  New  York  Orthopaedic  Dispensary  and 
Hospital;  Surgeon  in  Chief  to  the  New  Jersey  Orthopaedic 
Hospital  and  Dispensary,  Orange,  N.  J. 

Consideration  of  the  procedures  adopted  in  meth- 
ods of  treatment  of  fracture  of  the  femoral  neck, 
particularly  of  the  difificulties  to  be  overcome  in  con- 
trolling the  accurate  apposition  of  the  fragments 
when  replaced  (viz..  the  necessary  skilfulness  of 
assistants  during  the  replacement  and  application  of 
the  plaster  of  Paris  dressing,  the  inability  to  ob- 
serve the  position  at  all  times  during  treatment,  to- 
gether with  the  hot,  clumsy,  and  unsanitary  dress- 
ing of  the  plaster  of  Paris),  has  led  me  to  adopt  the 
following  method,  which  has  in  the  single  instance 
used  by  me  given  a  most  satisfactory  result,  as 
shown  by  radiographs,  function  and  actual  meas- 
urements. 

The  case  in  question  was  a  boy,  J.  K.,  five  years  old,  who 
was  brought  to  me  July  31,  1907,  with  the  diagnosis  of 
tuberculous  disease  of  the  right  hip  joint. 

From  the  history  I  learned  the  child  had  a  fall  four  days 
previously,  since  which  time  he  had  been  unable  to  walk, 
owing  to  extreme  pain  and  deformity.  This  was  evident  at 
the  time  of  my  examination.  Inspection  showed  the  right 
thigh  abducted,  externally  rotated,  and  flexed  35° ;  at- 
tempted manipulation  elicited  pain,  acute  spasm  of  thigh 
groups  of  muscles,  and  crepitation. 

To  make  a  more  thorougii  examination  the  patient  was 
anaesthetized,  when  the  muscle  spasm  relaxed  and  defor- 
mity lessened.  Manipulation  developed  false  arc  of  motion 
and  distinct  crepitation,  and  traction  produced  equality  in 
length  of  limbs. 

With  the  patient  still  under  the  anaesthetic  a  set  of 
swansdown  adhesive  traction  straps  was  applied  to  limb, 
as  shown  in  Fi?;ure  i,  in  such  a  manner  that  the  force  of 
the  pull  was  e(|ually  distributed  about  the  thigh,  thus  re- 
lieving the  strain  upon  the  structure  of  the  knee  joint,  a 
very  important  consideration.  This  dressing  was  protected 
from  loosening  by  applying  a  spiral  muslin  bandage  over  it, 
beginning  at  the  ankle. 

The  limb  being  dressed  and  the  deformity  overcome,  the 
limb  was  held  in  position  by  an  assistant  making  traction  in 
15°  to  20°  abduction  and  slight  flexion,  while  the  Taylor 
extension  hip  splint  was  applied,  as  seen  in  accompanying 
Figure  2. 

The  illustration  of  the  brace  used  is  more  de- 


scriptive than  words,  as  is  also  the  photograph 
showing  the  patient  with  brace  applied,  without  the 
spiral  muslin  bandage  and  secondary  application  of 
adhesive  support.  The  chief  advantage  lies  in  the 
accuracy  of  the  extension  by  means  of  the  key 
when  turned  in  the  lock,  causing  the  grooved  rod 
to  slide  downward  in  the  sheath,  procuring  accu- 
rate position  of  the  limb. 

W  ith  the  traction  adhesive  straps  buckled  to  the 
straps  attached  to  the  foot  piece  of  the  brace  and 
counter  pressure  obtained  by  soft  padded  perineal 
straps  attached  by  buckles  to  the  hip  band  of  the 
brace  anteriorly  and  posteriorly,  so  that  their  pres- 


FiG.  I. — Showing  patient  with  apparatus  applied  without  the  encir- 
cling adhesive  strapping  of  thigh. 


.sure  on  the  perinseum  is  just  external  to  the  tuber 
ischii.  the  detail  of  the  application  of  the  brace  is 
complete. 

To  overcome  any  tendency  to  external  rotation  of  thigh 
and  dropping  backward  of  the  lower  fragment,  adhesive 
straps  were  applied,  encircling  the  leg  and  including  the 
shaft  of  the  brace  as  high  up  as  the  perinaeum  would 
permit. 

The  child  was  then  placed  on  a  hard  mattressed  bed  with 
board  between  spring  and  mattress  to  maintain  a  level  sur- 
face. There  was  no  weight  and  pulley,  and  raising  of  the 
foot  of  the  bed  to  prevent  patient  from  slipping  down 
lov/ard  the  footboard  as  is  the  case  with  the  Buck's  exten- 
'^ion.  and  no  other  restraint  to  prevent  the  patient  from 
being  turned  and  handled  freely  in  his  apparatus  for  the 
purpose  of  bathing,  etc.,  no  heavy,  hot.  and  unsanitary 


January  2,  ig-^g.J 


SOULE:  FRACTURE  OF  NECK  OF  FEMUR. 


23 


plaster  of  Paris  dressing,  but  a  simple,  comparatively  com- 
fortable, sanitary,  and  accurately  fixing  appliance. 

In  the  fifth  week  the  patient  was  allowed  up  in  a  semi- 


reclining  position.  At  the  end  of  the  fifth  week  the  brace 
was  removed  and  the  patient  was  examined.  Union  seemed 
firm  and  motion  free,  the  splint  was  reapplied,  and  the  child 


Fig.  3. — X  ray  showing  limb  restoied.     Arrow  denoting  point  of 
fracture. 


was  allowed  to  stand  and  walk  about.  The  seventh  week  the 
brace  was  removed  and  the  child  allowed  to  walk.  Limbs 
were  equal  in  length,  there  was  no  deformity,  and  arcs  of 
motion  were  nearly  equal  to  those  of  left  thigh.  Patient 
was  discharged  and  not  seen  again  until  March  17,  1908, 
when  X  ray  photographs  were  taken  with  all  apparatus  re- 
moved and  limb  restored.    (Fig.  3  and  Fig.  4.) 

From  this  result  the  method  as  described  would 
seem  to  me  to  be  a  feasible  one  to  adopt  and  one  by 
which  the  most  satisfactory  result  can  be  obtained. 

The  thigh  and  pelvis  thus  held  and  maintained 
throughout  repair  constantly  accessible  to  observa- 
tion, examination,  and  measurements,  would  seem 
to  me  to  present  the  least  chance  for  malposition, 


Fig.  4. — Photograph  of  patient  after  apparatus  was  removed'. 

and  did  in  my  case  restore  the  limb  to  an  equal' 
length,  normal  arc  of  motion,  with  no  limp,  no  de- 
formity save  a  slight  thickening  of  the  neck  due  to- 
callous  formation  as  shown  in  the  radiograph,  from 
which  it  also  appears  there  is  a  good  angle  of  neck 
to  shaft  of  femur. 

The  extension  hip  splint  with  coaptation  splint 
has  already  been  successfully  used  in  fracture  in 
the  continuity  of  the  shaft  of' the  femur,  but  I  have 
not  found  any  instance  where  this  method  was 
adopted  in  fracture  of  the  neck. 

601  Lexington  Avenue. 


24 


NARROWER:  ACI DIMETER.— BRAV :  DISCOLORATIOM  OF  CONJUNCTIVA.      LNew  Vork 

'  IMedical  Jouknau 


A  NEW  INSTRUMENT  FOR  THE  ESTIMATION 
OF  THE  URINARY  ACIDITY. 

By  Henry  R.  Harrower,  M.  D., 
Chicago. 

In  an  attempt  to  simplify  the  technique  of  the 
various  laboratory  estimations,  which  should  be 
rnuch  more  frequently  made  by  every  general  prac- 
tician, I  have  for  some  time  been  working  with  a 
very  simple  little  instrument  which  I  have  found 
useful  in  the  estimation  of  the  urinary  acidity. 

It  is  not  intended  to  supplant  the  very  necessary 
graduated  buret  employed  by  workers  in  the  larger 
clinical  laboratories,  but  to  provide  the  wherewithal 
for  the  busy  man  to  perform  this  important  test  in 
daily  routine.  The  idea  was  gained  from 
a  very  handy  little  tube  invented  by 
Gunzberg  for  the  estimation  of  the  acid- 
ity of  the  gastric  juice. 

The  acidimeter  which  I  'have  designed 
consists  of  a  glass  tube  so  graduated  that 
lo  c.c.  is  the  first  measuring  point.  From 
this  upward  the  tube  is  graduated  in 
fifths  of  a  degree  to  ioo°,  each  degree 
representing  the  amount  of  decinorma! 
sodium  hydroxide  solution  required  to 
neutralize  lOO  c.c.  of  urine. 

The  method  of  using  the  acidimeter  is 


70°-f 
60°-f 
50°-f 

30°^ 
10°^ 


'10 

CjR- 


as  follows :  The  tube  is  filled  with  the 
specimen  of  urine  to  be  tested,  until  the 
lower  edge  of  the  meniscus  is  just  on  the 
10  c.c.  mark.  Two  drops  of  phenolph- 
thalein  indicator  solution  are  added,  and 
then  with  an  ordinary  medicine  dropper 
decinormal  sodium  hydroxide  solution  is 
slowly  added,  inverting  the  tube  after 
each  addition,  until  the  color  of  the  fluid 
has  been  changed  from  a  yellow  to  a  light 
rose  pink.  The  acidity  in  degrees  is  now 
read  of?  on  the  tube  at  the  level  of  the 
fluid.  The  normal  urinary  acidity  of  a 
mixed  twenty-four  hour  specimen  should 
be  between  30  and  40  degrees. 

If  the  urine  is  alkaline  in  reaction  and 
it  is  desired  to  estimate  the  degree  of  al- 
kalinity, decinormal  hydrochloric  or  ox- 
alic acid  solution  must  be  used  in  place 
of  the  sodium  hydroxide,  the  pink  color 
present  being  just  discharged  by  the  acid. 
The  advantages  of  this  instrument  are : 
I.  Facility  of  handling,  it  can  be  car- 
ried in  the  pocket  or  bag  and  is  not 
easily  broken  as  is  the  burette.  No  stand  is  re- 
quired. 

2.  Accuracy  of  results,  the  graduations  being  just 
the  same  as  in  the  standard  delivery  buret. 

3.  Price,  the  first  cost  is  considerably  less  than 
that  of  a  buret,  and  as  the  acidimeter  is  far  less 
liable  to  breakage  the  eventual  cost  is  very  much 
less. 

easily  broken  as  is  the  burette.  No  stand  is  re- 
tendant,  or  his  wife  may  be  quickly  taught  its  rapid 
and  accurate  use. 

I  believe  that  this  instrument  will  simplify  the 
present  laboratory  facilities  of  the  medical  man, 
thus  increasing  his  diagnostic  capabilities  and  hiy 
professional  success. 

2806  North  Paulina  Street. 


Acidimeter. 


A  CASE  OF  BLUEISH  DISCOLORATION  OF  THE 
CONJUNCTIVA  FROM  AN  INDELIBLE  PENCIL. 

By  Aaeon  Brav,  M.  D., 
Philadelphia. 

Miss  A.  H.,  age  nineteen,  bookkeeper,  consulted  me  Octo- 
ber 30th,  10  a.  m.,  and  gave  the  following  history :  "While 
sharpening  my  indelible  lead  pencil  a  piece  of  the  lead 
struck  my  eye,  which  began  to  smart  somewhat.  I  tried  to 
rub  my  eye  in  the  endeavor  to  remove  the  foreign  sub- 
stance when  I  noticed  a  discoloration  on  my  finger.  I  hur- 
ried to  the  looking  glass  and  found  my  eye  a  purple  blue. 
I  have  no  actual  pain,  but  a  stinging  sensation." 

On  examination  I  found  the  right  eye  perfectly  normal. 
Left  eye  cornea  and  pupil  normal,  no  foreign  bodv  notice- 
able, a  small  laceration  of  the  conjunctiva  of  the  lower  lid, 
and  both  the  conjunctiva  of  the  lower  lid  as  well  as  the 
bulbar  conjunctiva  up  to  the  lower  corneoscleral  margin 
was  a  dark  purple,  blue  mass.  The  patient  was  very  anx- 
ious for  information.  She  wanted  to  know  the  prognosis 
as  to  its  ultimate  disappearance,  and  how  long  it  would 
take  for  the  disappearance  of  the  discoloration.  I  confess 
I  was  at  a  loss  to  prognosticate  the  exact  amount  of  time 
necessary  for  the  absorption  of  the  stain.  I  felt,  however,, 
sure  that  the  vascularity  of  the  conjunctiva  would  eventu- 
ally restore  the  eye  to  its  normal  color.  And  at  the  same 
time,  considerino-  the  fact  that  I  had  a  laceration  of  the 
conjunctiva  and  the  possible  reaction  of  the  then  to  me 
unknown  substance  of  the  indelible  pencil  with  the  albumin- 
ates of  the  tissues,  it  was  not  surprising  that  I  felt  it  a  duty 
on  my  part  to  my  patient,  whose  anxiety  can  easily  be 
imagined,  to  consult  a  reliable  chemist  on  the  subject.  1 
consequentlj'  called  the  chief  chemist  of  the  Mulford  Chem- 
ical Company  to  the  telephone  and  inquired  of  him  as  tO' 
the  chemistry  of  the  indelible  pencil  and  its  possible  reac- 
tion with  the  albuminates  of  the  tissues  to  form  an  insol- 
uble salt.  After  half  an  hour  research  in  the  laboratory, 
the  answer  was  that  the  indelible  pencil  contained  the  ani 
line  dyes,  that  it  had  no  special  reaction  on  the  tissues,  and 
that  no  insoluble  salt  would  form  with  the  albuminates  of 
the  tissues.  As  to  the  time  of  its  complete  absorption,  this 
would  depend  upon  the  vascularity  of  the  part  and  the 
quantity  of  the  dye.  Needless  to  say  that  I  was  very  grate- 
ful to  him  for  the  information,  and  my  thanks  are  due  to 
the  house  for  the  readiness  to  serve  the  profession.  After 
this  information  I  was  able  to  give  full  assurance  to  my 
patient,  who,  being  an  intelligent  girl,  highly  appreciated 
my  investigation  in  her  behalf.  I  prescribed  an  alkaline 
wash,  ten  grains  of  sodium  biborate  to  the  ounce  of  water, 
to  bathe  the  eye  several  times,  and  asked  my  patient  to  see 
me  to-morrow. 

During  the  afternoon  I  had  a  chance  to  see  many  of  the 
physicians  and  ophthalmologists,  neither  of  whom  had  had 
the  opportunity  to  observe  such  a  case;  in  fact,  one  was  of 
the  opinion  that  it  would  take  a  long  time  for  the  ab- 
sorption. 

Next  morning  my  patient  came  back  and  not  a  trace  of 
any  stain  could  be  noticed ;  the  eye  was  slightly  irritated, 
and  the  conjunctiva  somewhat  lacerated.  She  told  me  that 
she  watched  the  eye  very  closely,  and  that  by  six  p.  m.  the 
discoloration  entirely  disappeared.  To  use  her  language, 
absorption  was  so  rapid  that  she  could  see  the  process 
going  on.  It  required  eight  hours  for  the  complete  disap- 
pearance of  the  stain. 

This  case  may  not  be  of  great  importance  to  the 
profession,  yet  the  physician  who  will  happen  to 
be  in  the  same  embarrassing  position  that  I  have 
been  after  reading  this  will  find  the  value  of  this 
report  and  appreciate  my  effort  in  placing  this  case 
on  record.  Indelible  pencils  are  used  very  exten- 
sively, and  the  occurrence  may  puzzle  any  of  my 
professional  colleagues,  so  that  this  report  is  intend- 
ed tc  ;av:  them  the  embarrassment. 

917  Spruce  Street. 


janiiary  2,  1909. J 


JUDD:  ENLARGED  THYREOID. 


25 


FURTHER  REPORTS  OF  TREATMENT  OF  EN- 
LARGED THYREOID. 
By  Means  of  the  X  Ray  and  High  Frequency  Currents. 

Bv  ASPINWALL  JUDD,  M.  D., 

New  York, 

Adjunct  Professor  of  Surgery  and  Radiologist,   New  York  Post- 
graduate Medical   School  and  Hospital. 

In  1905  to  1906  I  made  a  preliminary  report  in 
the  Medical  Record  of  eight  cases  of  enlarged  thy- 
reoid treated  in  our  clinic  at  the  Postgraduate  Hos- 
pital and  in  my  own  private  work.  These  patients 
had  been  under  treatment  for  a  sufficient  length  of 
.time  to  make  it  seem  probable  that  the  results  ob- 
tained were  not  merely  transient  or  the  result  simply 
of  a  remission  of  symptoms,  which  so  often  occurs 
in  this  class  of  cases.  A  review  of  these  cases  up 
to  the  present  writing,  together  with  a  report  of  six 
additional  cases,  may  prove  somewhat  instructive. 

Such  a  mass  of  data  from  other  observers  has  ac- 
cumulated since  my  last  reports  as  to  make  it  a  mat- 
ter now,  of  surety,  that,  with  the  exception  of  opera- 
tive interference  and  perhaps  of  the  Roger  serum, 
the  X  ray  and  high  frequency  currents  of¥er  the  best 
means  of  alleviation  or  cure  in  this  ver^  distressing 
disease.  The  percentage  of  cure  or  very  decided 
improvement,  four  patients  cured  and  two  improved 
in  our  first  series,,  and  of  three  cured  and  one  im- 
proved in  our  second  list,  makes  the  statistics  on  this 
treatment,  so  far  as  we  have  been  able  to  ascertain, 
better  than  that  of  any  other  means  at  our  com- 
mand. 

In  observing  the  reactions  caused  by  our  treat- 
ment we  have  come  to  roughly  divide  our  cases  into 
three  classes :  First,  those  in  which  a  true  hyper- 
plasia of  the  gland  existed,  either  with  or  without 
exophthalmus,  and  these  cases  have  been  the  ones 
that  have  reacted  most  kindly  to  treatment ;  second- 
ly, those  in  which  the  struma  or  fibrous  elements  of 
the  gland  were  greatly  in  excess.  On  these  the 
treatment  has  had  little  effect  beyond  producing 
an  increase  in  the  fibrous  elements.  The  third  class 
of  cases  were  those  with  large  colloid  deposit. 
These  cases  have  been  little  or  not  at  all  affected. 

The  physiological  action  of  the  x  ray  upon  gland- 
ular tissue  is  to  produce  at  first  a  stimulation,  in- 
creased activity,  and  proliferation;  secondly,  by 
overstimulation,  a  fatty  necrosis  and  death  of  the 
cell  elements,  together  with  an  obliterating  endarte- 
ritis by  destruction  of  the  intima  of  the  smaller 
bloodvessels,  and  consequently  a  deprivation  in 
great  measure  of  nourishment  to  the  gland.  Upon 
connective  tissue,  however,  its  effect  is  to  produce 
an  exaggeration  of  the  adult  type  of  connective  tis- 
sue, with  a  disappearance  of  the  cell  elements  and 
an  increase  in  the  number  and  size  of  the  fibres.  The 
second  effect  of  obliterating  endarteritis  also  occurs 
in  this  type  of  tissue  to  a  more  limited  extent. 

To  return  to  our  first  series  of  cases.  Of  the 
cured  patients,  three  have  remained  in  perfect  health 
to  the  present  time.  Two  of  our  patients  have  re- 
lapsed, but  further  treatment  has  once  more  proved 
effectual. 

Of  our  second  series  of  cases,  two  patients  dis- 
continued treatment  after  three  months,  unim- 
proved.    One  patient,  a  case  of  extreme  severity, 


with  dilated  heart,  very  rapid  pulse,  and  greatly  en- 
larged thyreoid,  is  still  under  treatment  at  the  end 
of  six  months,  somewhat  improved  as  to  pulse,  gen- 
eral nervous  symptoms,  and  size  of  gland.  How 
much  of  this  improvement  is  due  to  rest  in  bed  and 
medication  it  is  impossible  to  determine.  One  pa- 
tient, after  eight  months'  treatment,  is  so  far  im- 
proved as  to  tempt  me  to  include  the  case  as  a  cure, 
were  it  not  that  I  have  frequently  seen  a  recurrence 
of  symptoms  after  cessation  of  treatment  after  a 
considerable  interval  of  time.  In  this  case,  which 
was  accompanied  by  exopthalmus,  no  change  has 
occurred  in  the  eyes.  The  pulse,  which  ranged  from 
120  to  150  at  the  beginning  of  treatment,  now  aver- 
ages between  80  and  90.  The  neck  measurement 
has  diminished  nearly  two  inches  in  circumference. 
The  nervous  symptoms  have  entirely  disappeared. 
The  patient  considers  herself  well,  and  complains 
somewhat  of  our  insistence  upon  her  continued 
treatment. 

C.'\SE  V. — This  was  a  case  of  beginning  enlargement  in 
a  young  girl  of  fourteen,  and  was  coincident  with  the 
beginning  of  menstrual  history.  There  was  no  exoph- 
thalmus in  this  case.  The  gland  was  of  the  true  hyperplas- 
tic type,  the  pulse  no,  the  heart  apparently  otherwise  nor- 
mal, and  there  were  no  nervous  symptoms.  Two  treat- 
ments a  week,  for  fifteen  minutes,  for  five  months,  were 
suflicient  to  produce  a  disappearance  of  symptoms.  It  is 
in  this  class  of  cases  that  the  x  ray  and  high  frequency  cur- 
rents have  proved  particularly  valuable. 

Case  VI. — This  was  a  boy,  fifteen  years  of  age,  with  a 
tremendously,  symmetrically  enlarged  gland,  both  right  and 
left  lobes  and  isthmus  participating  in  the  swelling.  The 
gland  was  firm  and  hard  in  parts,  and  elastic,  almost  fluc- 
tuatmg,  in  others.  There  was  no  exophthalmus,  no  history 
of  nervous  symptoms,  no  rapidity  of  pulse ;  but,  on  the 
other  hand,  the  boy  was  dull,  apathetic,  with  heavy  features, 
and,  in  short,  with  beginning  symptoms  of  myxoedema.  His 
history  was  that  of  a  normal  child  up  to  about  fifteen 
months  previous  to  his  appearance  in  our  clinic. .  My  diag- 
nosis was  that  of  a  fibrous  gland,  with  possibly  cysts  filled 
with  colloid  material.  At  the  suggestion  of  the  physician 
of  the  medical  clinic,  who  referred  him  to  me,  however, 
and  where  medical  treatment  had  been  tried,  I  subjected 
him  to  X  ray  treatment  for  nearly  three  months.  The  gland 
continued  to  increase  in  size,  the  symptoms  of  myxoedema 
increased  also,  and  I  finally  operated  upon  him,  removing 
practically  the  entire  thyreoid  gland.  Upon  exposing  the 
same,  I  found  my  diagnosis  was  correct.  After  the  opera- 
tion, the  boy  was  fed  upon  thyreoid  extract,  with  a  con- 
siderable amelioration  of  the  symptoms,  but  finally  suc- 
cumbed at  the  end  of  six  weeks. 

Our  method  of  treatment  has  differed  somewhat 
from  that  used  by  most  x  ray  workers.  I  have 
found  that  a  very  high  tube,  that  is,  one  rich  in  pen- 
etrating X  rays,  placed  at  a  distance  of  nine  inches 
from  the  patient,  the  tube  focused  upon  the  gland 
and  the  other  parts  well  protected  with  lead  foil,  has 
given  the  best  results.  The  treatment  is  usually 
maintained  for  fifteen  minutes  twice  a  week,  and  up 
to  the  present  time  without  even  symptoms  of 
erythema.  A  slight  browning  of  the  skin  usually 
results,  however.  In  cases  where  the  tachycardia 
is  extreme,  it  has  been  our  custom,  in  addition  to 
the  x  ray,  to  use  the  high  frequency,  Tesla  current, 
applied  by  means  of  a  glass  electrode  over  the  cer- 
vical sympathetic  on  both  sides  of  the  neck.  The 
effect  of  this  current,  as  noted  by  other  observers, 
as  well  as  by  myself,  is  distinctly  sedative,  both  as 
to  the  heart  action  and  the  general  nervous  system, 
the  pulse  rate  falling  from  10  to  20  possibly  before 
the  cessation  of  the  treatment,  which  is  continued. 


26 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


as  a  rule,  for  five  minutes  on  each  side.  This 
diminution  in  the  pulse  rate  persists  for  from  a  few 
hours  to  forty-eight  hours,  gradually  increasing  in 
length  as  the  treatment  goes  on.  Whether  the  ef- 
fect of  this  current  is  simply  that  of  a  general  seda- 
tive in  which  the  heart  partakes,  or  whether  it  is 
due  to  a  specific  action  upon  the  cervical  sympa- 
thetic, I  am,  as  yet,  unable  to  determine.  When  ap- 
plied to  other  parts  of  the  body  its  gentle  sedative 
action  is  quite  as  marked.  Indeed,  it  is  not  tmcom- 
mon  to  find  our  patients,  when  treated  for  whatever 
cause,  drowsv  to  the  point  of  somnolence,  and,  in- 
deed, even  sleeping  quietly,  if  in  a  reclining  posi- 
tion, at  the  end  of  the  treatment;  but  I  have  not 
found  such  marked  eflFect  in  lowering  the  pulse  rate 
as  when  applied  over  the  cervical  sympathetic. 

It  has  been  my  fortune  during  the  past  three 
years  to  operate  in  four  cases  of  enlarged  thyreoid 
treated  by  myself  or  other  men  by  the  x  ray.  One 
I  have  mentioned  before.  Two  other  cases  were 
treated  by  the  ray  with  the  result  of  rather  increas- 
ing the  size  of  the  gland.  Pathological  examina- 
tion of  the  specimens  in  these  two  cases  showed  a 
great  increase  in  the  fibrous  element  and  a  des- 
quamation and  partial  obliteration  of  the  acini.  The 
fourth  patient,  in  whom  improvement  had  been  very 
considerable  from  the  treatment,  but  in  whom  a  re- 
lapse had  occurred,  showed  a  gland,  hyperplastic  in 
character,  with  the  cells  in  many  of  the  acini  ob- 
literated and  with  small  necrotic  areas  and  a  cer- 
tain amount  of  obliterating  endarteritis.  I  am  still 
convinced  that  our  choice  of  procedure  in  enlarged 
thyreoid  is  an  operatiorf  for  the  removal  of  a  por- 
tion, at  least,  of  the  gland,  and  in  these  days  of 
bloodless  operation,  with  its  consequent  immunity 
from  thyreoid  poisoning,  and  keeping  in  view 
Kocher's  admonition  to  operate  before  dilatation  of 
the  heart  has  taken  place,  operation  offers  us  the 
best  means  at  our  command  for  the  relief  of  this 
disease. 

Where  we  have  an  enlarged  gland  due  to  increase 
of  fibrous  or  colloid  elements,  accompanied  by 
pressure  symptoms  or  deformity,  of  course,  an  op- 
eration is  indicated,  the  x  ray  having  either  no  ef- 
fect, or  of  merely  increasing  the  fibrous  elements, 
and,  consequently,  the  size  of  the  tumor.  In  that 
class  of  cases,  however,  in  which  dilatation  of  the 
heart  has  already  supervened  or  in  which  we  are 
unable  to  obtain  the  patient's  consent  to  an  opera- 
tion, the  X  ray  offers  us  in  a  sufficient  number  of 
cases,  either  relief  or  cure,  to  be  given,  at  least,  a 
trial. 

137  West  Sixty-ninth  Street. 

 ^  

Death  Rate  From  Tuberculosis.— R.  W.  Philip 
gives  the  following  table  in  the  Boston  Medical  and 
Surgical  Journal  of  the  death  rate  from  pulmonary 
tuberculosis  per  10,000  of  population  in  the  principal 
towns  of  Scotland : 


1897.  1901.  1906. 

Glasgow    20.3  18.5  15.6 

Dundee    22.3  17.2  16.9 

Aberdeen    16.7  13.9  12.2 

Leith    21.2  19.2  12.7 

Paisley    17.8  16.6  12.8 

Greenock   20.7  14.8  13.2 

Perth    22.1  16.1  17.9 


(0ur  ^tnhxs'  §\msnm. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXI. — How  do  you  treat  chronic  eczema?  (^Closed 
December  15,  IQ08.) 

LXXXIl. — How  do  you  treat  chronic  lead  poisoningt 
{Answers  due  not  later  than  January  15,  igog.) 

LXXXIII. — How  do  you  treat  acute  dysentery?  (An- 
swers due  not  later  than  February  15,  igog.) 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  required)  that  the  answers  be  short;  if  practica- 
ble, no  one  answer  to  contain  more  than  six  hundred 
words. 

All  persons  will  be  entitled  to  compete  for  the  prise, 
zvhether  subscribers  or  not.  This  prize  zvill  not  be  awarded 
to  any  one  person  more  than  once  within  one  year.  Every 
answer  must  be  accompanied  by  the  writer's  full  name  and 
address,  both  of  which  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal. 
Our  readers  are'  asked  to  suggest  topics  for  discussion. 

The  prize  of  $25  for  the  best  essay  submitted  in  ansiver 
to  question  LXXX  has  been  awarded  to  Dr.  Paul  F.  Ela, 
of  East  Douglass,  Mass.,  whose  article  appeared  on  page- 
1225  of  the  previous  volume. 


PRIZE  QUESTION  LXXX. 
THE  TREATMENT  OF  ASPHYXIA  NEONATORUM. 

{Continued  from  Lxxxviii,  p.  1228.) 

Dr.  Theodore  Emil  Teah,  of  Renovo,  Penn.,  says: 

By  asphyxia  neonatorum  is  meant  that  condition' 
of  the  new  born  where  there  is  a  deficiency  of  res- 
piration. Any  condition  that  exists  which  will  act 
as  an  obstacle  to  the  blood  supply  of  the  new  born,, 
thereby  cutting  off  its  supply  of  oxygen,  will  brings 
about  this  condition. 

Asphyxia  neonatorum  is  usually  divided  into  two- 
classes:  1st,  Asphyxia  livida,  that  condition  in  which; 
there  is  an  accumulation  of  carbon  dioxide  in  the 
blood,  yet  circulation  and  reflexes  persist.  2d,  As- 
phyxia pallida,  an  advanced  stage  of  the  former 
characterized  by  a  weakness  of  the  heart,  a  slow- 
ness of  pulsation,  and  an  abolition  of  reflexes.  In 
this  last  condition  the  prognosis  is  very  unfavorable. 
The  prognosis  of  asphyxia  neonatorum  in  general 
depends  upon  the  heart  action,  for  as  long  as  the 
heart  continues  to  act  there  may  be  some  hope  for 
resuscitation.  This  will  suffice  for  the  aetiology^ 
symptomatology,  and  prognosis  of  the  subject. 

For  the  prophylaxis  of  asphyxia  neonatorum  it 
will  be  well  to  avoid  any  malposition  of  the  uterus 
before  labor  and  to  correct  the  same  if  possible,  the 
correction  of  any  position  which  threatens  impac- 
tion, speedy  relief  of  spastic  rigidity  of  the  cervix, 
acceleration  by  manual  compression,  preservation  of 
the  bag  of  waters,  and  lastly  to  avoid  any  abuse  or 
the  over  indulgence  in  the  use  of  chloroform. 

The  curative  treatment  consists  of  the  following 
steps :  In  case  the  diagnosis  of  intra  partum  as- 
phyxia is  made  immediate  delivery  should  be  our 
course,  the  choice  of  which  in  most  cases  will  be  by 
the  use  of  forceps.  If  after  the  expulsion  of  the 
child  marked  cyanosis  is  present  the  cord  should  be 
divided  at  once  and  allowed  to  bleed  until  about  an 
ounce  of  blood  has  escaped.   In  case  the  child  should 


January  2,  1909. J 


OUR  READERS'  DISCUSSIUNi,. 


27 


present  a  condition  of  asphyxia  pallida  it  would  be 
best  to  cover  the  infant  with  hot  flannels  and  wait 
for  the  cessation  of  pulsation  of  the  cord. 

Where  delivery  has  taken  place  and  asphyxia 
neonatorum  is  present  it  is  our  duty  first  to  remove 
any  foreign  substances  or  particles  from  the  respira- 
tory passages,  and  this  is  usually  accomplished  by 
inverting  the  infant  in  the  following  manner:  With 
the  left  hand  grasp  the  feet  of  the  child  and  invert, 
the  little  finger  of  the  right  hand  is  wrapped  with 
gauze  and  the  mouth  and  throat  swabbed  out,  there- 
by removing  any  foreign  substance.  However,  the 
cleansing  of  the  mouth  and  nasal  passages  should  be 
performed  upon  immediate  delivery  of  the  head.  In 
cases  of  obstruction  of  the  larynx  as  the  result  of 
tumefaction  of  the  muscles  of  the  neck  or  the  result 
of  mechanical  interference  to  the  passage  of  air, 
catheterization  of  the  larynx  and  inflation  of  the 
lungs  are  advisable.  The  best  method  of  applying 
this  form  of  artificial  respiration  is  with  a  No.  6  soft 
rubber  catheter  cut  at  the  end  and  a  pipette  inserted 
in  the  catheter  so  that  the  bulbous  portion  catches  the 
aspirated  fluids.  The  catheter  is  then  gently  passed 
and  inflation  practised.  The  application  of  the  fol- 
lowing reflex  stimuli  applied  after  the  cleansing  of 
the  respiratory  tract  usually  suffices :  Blowing  in  the 
face  of  the  infant,  slapping  the  buttocks,  sprinkling 
or  the  immersion  in  hot  or  cold  water,  being  used 
alternately,  the  dropping  of  alcohol,  ether,  cold  or 
warm  water  on  an  exposed  chest  from  some  height. 
Dilatation  of  the  anus  with  the  finger  or  traction 
upon  the  tongue  may  now  be  tried  when  the  others 
fail. 

If  the  application  of  external  stimuli  fails  to  have 
the  desired  result  the  several  methods  of  artificial 
respiration  may  be  used :  Mouth  to  mouth  insuffla- 
tion; a  soft  pillow  should  be  placed  under  the  in- 
fant's neck,  the  head  having  been  well  extended,  a 
piece  of  gauze  or  soft  towel  placed  over  its  mouth, 
the  physician  then  takes  a  deep  breath  and  blows  the 
first  part  of  the  expired  air  into  the  infant's  mouth, 
the  head  is  then  flexed  and  the  chest  compressed. 
This  is  practised  many  times  until  this  seems  of  no 
avail,  when  the  Schultze  method  should  be  tried : 
The  infant  is  wrapped  in  a  towel  to  protect  it  from 
being  chilled,  and  turned  upon  its  back ;  it  is  grasped 
by  the  shoulders,  the  open  hand  having  been  slipped 
beneath  the  head,  the  last  three  fingers  remain  ex- 
tended in  contact  with  the  back  while  each  index 
finger  is  inserted  into  an  axilla.  The  child  so  held 
is  allowed  to  swing  feet  down,  and  so  suspended  it 
is  now  swung  over  the  operator's  shoulder.  This 
swinging  motion  is  practised  fifteen  or  twenty  times. 
The  infant  then  immersed  in  warm  water  for  a  few 
seconds  to  raise  its  temperature  and  the  movements 
tried  again. 

Sylvester's  method  of  artificial  respiration  is  im- 
practicable as  a  result  of  weakness  to  the  muscles  of 
the  chest,  but  Marshall  Hall's  method  of  suspending 
the  infant  in  a  towel,  then  rolling  it  from  side  to 
side  so  suspended,  may  prove  useful  at  times.  After 
all  the  methods  have  failed  I  always  consider  the 
case  hopeless. 

The  after  treatment  of  asphyxia  neonatorum 
should  also  be  taken  into  consideration.  After  re- 
viving an  infant  deeply  asphyxiated  it  will  more 
than  likely  die  within  forty-eight  hours  after  birth ; 
however,  it  should  be  carefully  watched  in  order  to 


detect  the  most  feeble  heart  action  and  any  evidence 
of  feeble  respiration  or  intracranial  disturbance. 
Routinially  I  give  to  such  infants  five  drops  of 
spiritus  frumenti  and  one  drop  of  tincture  of  digi- 
talis in  a  little  hot  water  every  four  hours,  keeping 
the  infant  surrounded  in  cotton  wool  and  the  appli- 
cation of  hot  water  bags  or  bottles  as  the  case 
requires. 

Dr.  Saro  E.  Foiilks,  of  Trenton,  N.  J.,  observes: 

The  normal  child  should  make  efforts  at  respira- 
tion shortly  after  it  emerges  from  the  vulva.  If 
this  does  not  occur  the  mouth  should  be  cleansed 
with  sterile  gauze,  the  child  grasped  by  the  feet  and 
with  body  hanging  down  slapped  vigorously  with 
the  palm  of  the  hand.  If  success'  does  not  follow, 
cut  the  cord  and  immerse  the  body  in  a  hot  bath, 
about  io8°,  alternating  with  a  cold  one.  Care  should 
be  exercised  to  keep  the  head  above  water  and  well 
supported,  and  circulation  encouraged  by  rubbing 
the  skin  of  the  limbs  and  trunk  briskly  all  the  while. 

Counter  irritation  plays  an  important  part  in  re- 
suscitation and  may  be  easily  practised  while  the 
child  is  in  the  bath.  Compresses  wrung  out  of  hot 
water  alternating  with  cold  ones,  placed  over  the 
sternum  or  direct  rubbing  of  the  abdomen  and  chest 
with  a  lump  of  ice,  or  a  few  drops  of  alcohol  or 
ether  allowed  to  fall  upon  the  chest  from  a  height 
has  often  proved  useful  in  its  quick  results.  A  few 
drops  of  aromatic  spirit  of  ammonia  upon  a  piece 
of  absorbent  cotton  may  irritate  the  nasal  mucous 
membrane  to  such  an  extent  that  respiration  not  only 
begins,  but  movements  of  the  whole  body  are  re- 
flexly  instituted.  In  some  cases  the  asphyxia  persists 
and  other  measures  are  necessary.  If  there  is  any 
suspicion  that  the  bronchial  tubes  contain  foreign 
matter  a  small  elastic  No.  9  French  catheter  should 
be  introduced  and  the  material  removed  by  suction. 

One  of  the  most  efficient  means  of  resuscitation 
and  one  which  if  practised  early  often  results  favor- 
ably is  the  forcible  expansion  of  the  lungs  with  air 
by  means  of  the  mouth  to  mouth  method.  The  air 
should  be  propelled  by  no  greater  force  than  can  be 
exerted  by  the  cheeks  of  the  operator,  thus  avoiding 
rupture  of  the  alveoli  with  resulting  emphysema.  To 
be  sure,  much  of  the  air  enters  the  stomach,  but 
enough  traverses  the  tubes  to  expand  to  some  extent 
the  lungs  and  a  gasping  breath  followed  by  weak 
but  certain  respirations  often  results  when  all  other 
methods  have  failed.  The  efficiency  of  this  method 
may  be  increased  by  first  introducing  a  catheter  into 
the  larynx  and  forcing  the  air  through  this.  Too 
much  stress  cannot  be  laid  upon  the  early  and  per- 
sistent use  of  this  procedure. 

If  still  the  child  seems  lifeless,  wrap  it  carefully 
in  blankets,  surround  the  body  with  heat  in  some 
form  and  apply  Laborde's  method  of  resuscitation. 
This  consists  briefly  of  the  following :  Lay  the  child 
upon  a  table  or  chair,  allowing  the  head  to  overhang 
the  edge.  Grasp  the  tip  of  the  tongue  with  a  piece 
of  gauze  and  draw  it  as  far  forward  as  possible,  then 
allow  it  to  recede.  Do  this  ten  to  twenty  times  per 
minute  at  regular  intervals.  If  no  results  follow 
after  a  few  tractions  the  case  may  practically  be  con- 
sidered hopeless. 

One  very  efficient  means  of  forcing  air  into  the 
lungs  is  that  of  Schultze,  which  in  a  few  words  is 
as  follows  :  The  operator  grasps  the  shoulders  of  the 


28 


CORRESPONDENCE. 


INew  VoRr. 
Medical  Journal. 


child,  applies  his  index  fingers  under  the  axilla  and 
his  thumbs  over  the  thorax,  at  the  same  time  press- 
ing the  palms  of  the  other  fingers  to  the  back  while 
the  head  is  held  firmly  by  the  balls  of  the  thumbs. 
He  first  allows  the  child  to  hang  down,  then  carries 
it  slowly  over  his  head,  allowing  the  body  to  flex 
upon  itself  and  the  legs  fall  toward  the  face,  then 
gradually  brings  it  back  to  its  original  position.  Re- 
peat this  eight  to  ten  times  per  minute.  After 
swinging  a  few  times  try  again  the  hot  and  cold 
tubbing.  Though  so  efficient  that  air  may  be  heard 
to  enter  the  lungs  of  a  dead  child,  this  method  has 
many  opponents,  as  fracture  of  bones  of  the  thorax 
or  rupture  of  internal  viscera  has  been  known  to 
occur.  This  procedure  would  of  course  never  be 
used  in  the  pallid  variety  of  asphyxia. 

Byrd's  modification  has  gained  of  late  considerable 
favor.  The  swinging  is  done  away  with ;  simply  rest 
the  back  of  the  child  upon  the  palms  of  the  opera- 
tor's hands,  with  thumbs  pointing  upward.  Ap- 
proximate the  hands  and  bring  the  child's  head  and 
feet  closely  together.  This  compression  of  the 
thorax  causes  expiration  and  the  reverse  inspiration. 

In  obstinate  cases  beneficial  results  sometimes  fol- 
low hypodermic  injections  of  a  few  drops  of  whiskey 
or  ether  or  a  minute  fraction  of  strychnine.  If  pos- 
sible a  faradic  battery  may  be  used.  This  has  found 
favor  in  the  sight  of  many.  One  pole  should  be 
placed  above  the  clavicle,  the  other  at  the  edge  of 
the  ribs  at  the  right  side. 

In  the  livid  variety  blood  letting  has  been  recom- 
mended, but  as  a  rule  this  is  unnecessary,  as  warm 
bathing  and  brisk  rubbing  relieves  the  internal  or- 
gans by  attraction  to  the  skin. 

When  asphyxia  is  due  to  depressed  fracture  of  the 
skull,  elevation  of  the  fragments  should  be  under- 
taken only  by  a  competent  operator  and  when  the 
heart  beats  strongly  though  slowly. 

With  all  the  methods  use  perseverance.  Efforts 
should  be  persevered  in  as  long  as  the  heart  con- 
tinues to  beat  and  even  if  it  does  not  one  after 
another  method  should  be  tried  in  hopes  of  some  re- 
sult, as  success  is  not  unusual  after  trials  lasting  an 
hour  or  more. 

After  deep  asphyxia  watch  the  child  carefully  for 
several  days  and  keep  well  covered  and  in  an  even 
temperature,  supplying  artificial  heat  in  some  form 
to  its  body  whenever  needful.  If  too  weak  to  take 
the  breast  a  little  colostrum  or  milk  should  be  coaxed 
out  and  the  baby  fed  by  means  of  a  dropper.  Avoid 
handling  as  much  as  possible  and  keep  perfectly 
quiet  on  a  pillow. 

(To  be  continued.) 
 <$>  


LETTER  FROM  LONDON. 
The  King's  Hospital  Fund. — The  Barnato  Bequest. — An 
Alleged  New  Cure  for  Cancer. — The  Revision  of  the 
Pharmacopeia. — The  Medical  Curriculum. 

I^NDON,  December  15.  igo8. 
The  King's  Hospital  Fund  held  its  annual  meet- 
ing yesterday  at  Marlborough  House  for  the  pur- 
pose of  awarding  grants  to  the  hospitals  and  other 
institutions  for  the  present  year.  The  Prince  of 
Wales,  who  is  the  president,  took  the  chair,  and 
there  was  a  very  large  and  influential  gathering 


present.  The  Prince  directed  attention  in  particular 
to  the  valuable  work  which  is  being  done  in  improv- 
ing the  administration  of  the  various  hospitals  and 
convalescent  homes  and  coordinating  them  by  amal- 
gamation or  otherwise,  so  as  to  equip  the  metropolis 
with  agencies  for  the  relief  of  the  sick  poor  in  ac- 
cordance with  a  carefully  considered  scheme.  Hith- 
erto the  provision  has  been  to  some  extent  hap- 
hazard. Some  districts  have  been  well  provided, 
while  in  others  there  has  been  inadequate  accom- 
modation or  equipment  or  both.  The  fund  is  acting 
in  the  interest  of  all  who  subscribe  to  the  main- 
tenance of  hospitals  and  convalescent  homes,  so  as 
to  obtain  the  best  value  for  the  money  available.  It 
is  the  fairy  godmother  of  these  institutions,  advising 
as  occasion  requires,  insisting  on  efficient  and  eco- 
nomical administration,  and  checking  overlapping. 
This  year  the  amount  available  for  distribution 
reaches  the  handsome  total  of  £140,000,  an  amount 
larger  by  £19,000  than  that  available  in  1907.  In 
their  donations  the  Council  of  the  Fund  are  giving 
greater  attention  to  convalescent  homes  and  to  coun- 
try sanatoria  for  the  care  of  tuberculous  patients. 
Among  the  largest  grants  are  £12,000  to  the  London 
Hospital  and  £8,000  to  Kings  College  Hospital,  in- 
cluding £5,000  toward  the  removal  fund.  The  build- 
ing of  this  hospital  at  its  new  site  in  Denmark  Hill 
has  now  been  begun.  Guy's  Hospital  gets  £7,500, 
and  most  of  the  other  large  hospitals  get  sums  vary- 
ing from  £2,000  to  £5,000.  Among  the  smaller  hos- 
pitals, the  West  London  gets  £4,500  and  the  Ealing 
Cottage  Hospital  £2,000,  a  remarkably  large  dona- 
tion for  a  cottage  hospital.  The  London  Hospital 
will  also  obtain  a  large  sum  of  money  as  the  result 
of  its  quinquennial  appeal.  Up  to  the  present  time 
the  sum  of  £70,000  has  been  obtained,  which,  though 
large,  is  less  than  was  expected. 

Another  windfall  to  hospital  charities  is  the  be- 
quest of  the  late  Henry  Isaacs  Barnato,  who  left  a 
quarter  of  a  million  sterling  to  found  a  hospital  or 
other  charitable  institution  in  memory  of  his  brother, 
Barney  Barnato,  and  his  nephew,  Woolf  Joel.  The 
trustees  have  absolute  discretion  as  to  the  apphca- 
tion  of  the  fund  and  the  fullest  powers  as  to  the 
equipment,  endowment,  and  management  of  the 
institution.  It  is  suggested  that  an  institution  be 
established  for  some  specific  purpose,  such  as  for 
the  treatment  of  tuberculous  disease  in  childhood, 
for  which  there  is  at  present  very  inadequate  provi- 
sion. It  is  thought,  however,  that  the  money  will 
be  u.sed  in  establishing  a  large  Jewish  hospital, 
which  will  make  special  provision  for  the  treatment 
of  poor  Jewish  patients.  For  such  an  institution 
there  appears  to  be  a  decided  want,  notwithstanding 
the  existence  of  the  London  Hospital,  in  the  crowd- 
ed Jewish  neighborhood  of  the  East  End. 

The  Daily  Telegraph  has  given  publicity  to  an 
alleged  new  cure  for  cancer  introduced  by  Professor 
Octave  Laurent,  of  Belgium.  The  treatment  con- 
sists in  the  injection  of  a  concentrated  solution  of 
formol  directly  into  the  diseased  part.  The  "cure" 
is,  however,  not  new  at  all.  At  the  Cancer  Hospital. 
Brompton,  this  remedy  has  been  thoroughly  tried, 
with  negative  results,  and  not  only  formol.  but 
numerous  other  compounds  and  derivatives,  none  of 
which  have  proved  to  be  in  any  true  sense  a  "cure" 
for  cancer.    The  action  of  formol  is  simply  that  of 


January  2,  1909  ] 


THERAPEUTICAL  NOTES. 


29 


a  powerful  caustic,  and  it  may  be  able  to  destroy  a 
small  cancer  in  its  beginning,  but  it  is  obvious  that 
this  can  be  done  with  much  more  certainty  and  pre- 
cision by  the  surgeon's  knife,  and  there  will  be  less 
likelihood  of  recurrence  after  operative  treatment  in 
the  early  stages. 

The  news  thus  given  widespread  publicity  will 
only  raise  false  hopes  in  the  minds  of  the  poor  suf- 
ferers, and  the  feeling  is  that  such  publications  in 
the  lay  press  cannot  be  too  strongly  condemned. 

There  is  no  doubt  that  modern  therapeutics  is 
largely  indebted  to  commercial  enterprise,  and  the 
Therapeutic  Committee  of  the  British  Medical  Asso- 
ciation tacitly  acknowledges  this  in  its  recommenda- 
tions for  the  revision  of  the  British  Pharmacopma. 
The  addition  of  about  fifteen  new  remedies  is  sug- 
gested. Among  them  are  chloralamide,  veronal, 
guaiacol,  a  solution  of  formaldehyde,  antidiphthe- 
ritic  serum,  and  a  "preparation  possessing  the  prop- 
erties of  the  suprarenal  gland."  There  are  also  sev- 
eral recommendations  for  deletions,  and  they  include 
applications  which  in  former  times  were  very  famil- 
iar, such  as  emplastrum,  calefaciens,  an  old  fash- 
ioned, mild  counterirritant.  Cerium  oxalate  is  stated 
not  to  possess  the  specific  action  attributed  to  it,  and 
caffeine  citrate  is  objected  to  because  it  is  unstable 
and  is  decomposed  when  dissolved  in  more  than 
three  parts  of  water.  The  omission  of  spiritus  vini 
gallici  is  suggested  on  the  ground  that  it  is  very 
rarely  prescribed  as  such  and  requires  no  official 
description.  For  the  rest,  however,  a  large  propor- 
tion of  the  deletions  relate  to  what  were  regarded 
at  one  time  as  pharmaceutical  elegancies,  such  as 
cherry  laurel  water,  carraway  water,  elder  flower 
water,  fennel  water,  and  the  like. 

The  Education  Committee  of  the  General  Medical 
Council  have  been  considering  the  question  of  the 
retardation  of  medical  students  in  passing  their  ex- 
aminations. It  was  brought  out  that  the  average 
time  taken  in  obtaining  a  diploma  was  seven  years 
in  England,  six  years  in  Ireland,  and  five  years  and 
a  half  in  Scotland.  Only  a  small  minority  of  stu- 
dents are  able  to  obtain  a  registrable  qualification 
in  the  minimum  period  of  five  years.  It  has  been 
shown  that  the  delay  is  due  to  the  failure  of  the 
student  to  pass  his  examinations  at  the  proper  time, 
and  a  further  point  brought  out  was  that,  in  many 
instances  the  greater  part  of  the  delay  occurred  in 
the  early  period  of  study,  that  is,  in  the  period  de- 
voted to  chemistry,  physics,  and  biology,  and  then 
in  anatomy  and  physiology.  There  was  a  brief  dis- 
cussion by  the  council  as  to  the  practical  conclusions 
to  be  drawn  from  these  data,  and  the  remedies  sug- 
gested for  this  state  of  afiFairs.  It  was  suggested 
that  the  preliminary  subjects,  chemistry,  physics,  and 
biology,  should  be  completed  before  the  student  be- 
gan his  medical  curriculum,  and  this  suggestion  met 
with  some  support.  Another  point  discussed  was 
the  question  of  devoting  the  fifth  year  entirely  to 
clinical  work,  as  it  was  suggested  that  this  was  en- 
croached upon  by  the  student  doing  work  at  this 
period  which  ought  to  have  been  completed  earlier. 
No  steps,  however,  have  yet  been  taken  by  the 
council  in  the  matter,  and  the  probability  is  that  there 
will  not  be  any  alterations  in  the  medical  curriculum 
for  the  present  at  any  rate. 


1  ^erapfutital  Jotfs. 


Liniment  for  Sciatica. — -The  following  is  rubbed 
into  the  painful  parts  night  and  morning  (Yzeta, 
Journal  de  medecine  de  Paris,  November  21,  1908)  : 


I*    Olive  oil  5y.iii; 

Oil  of  turpentine,   Biiss; 

Ammonia  water,   3x; 

Tincture  of  cantharides,  3iv. 

M. 

Haemoptysis  Treated  by  Adrenalin. — Adrenalin 


in  combination  with  calcium  chloride  and  adminis- 
tered internally  is  employed  by  Dr.  Pronchinski 
(Gazeta  lekarska,  July  25,  1908)  in  the  treatment 
of  haemoptysis.  The  mixture  is  said  to  be  more 
effective  than  either  ergotine,  gelatin,  or  opiates.  It 


is  prescribed  as  follows : 

R    Calcium  chloride  3v; 

Solution  of  adrenalin  (one  per  cent)  TH,  xlv  ; 

Distilled  water  5vii. 


M.  et  Sig. :  One  tablespoonful  every  two  hours. 

For  Gastrodynia. — A  correspondent  of  The  Pre- 
scriber  says  the  following  prescription  has  been  given 
successfully  in  cases  of  gastrodynia  in  tipplers  and 


in  similar  gastric  troubles  : 

R    Heavy  magnesium  oxide,  Jss; 

Bismuth  subnitrate,  .3ii ; 

Gallic  acid,   3iss;. 

Aromatic  powder,  Sj.i 

Peppermint  oil,   gtt.  xii. 


M.  et.  Sig. :  A  teaspoonful  in  a  little  water  every  morn- 
ing. 

Iodine  as  an  Antidote  to  Carbolic  Acid  Poison- 
ing.— A  diluted  tincture  of  iodine  has  been  used 
with  good  results  as  an  application  to  the  skin  to 
counteract  the  corrosive  action  of  carbolic  acid.  It 
has  also  been  recommended  for  internal  use  as  an 
antidote  against  poisoning  by  the  acid  (J.  Alaberly: 
Repertoire  de  phannacie;  through  L'Union  pharma- 
ceutique,  November,  1908).  Tincture  of  iodine  neu- 
tralizes the  corrosive  action  of  the  acid  on  the  mu- 
cous membranes  of  the  mouth  and  oesophagus,  over- 
comes the  poisonous  symptoms,  and  is  said  to  pre- 
vent lesions  of  the  stomach  and  intestines  by  the 
probable  formation  of  a  nontoxic  phenol  iodide.  The 
author  regards  the  action  of  tincture  of  iodine  in 
cases  of  carbolic  acid  poisoning  as  superior  to  that 
of  the  alkali  sulphates. 

Sodium  Nucleinate  in  Acute  Infections. — Laine 

publishes  {The  Therapeutic  Gazette,  November, 
1908)  reports  of  ten  cases  of  infectious  disease  in 
which  injections  of  sodium  nucleinate  were  used 
with  good  results.  Among  the  cases  reported  were 
several  of  purulent  i>eritonitis  following  appendic- 
ular inflammation,  pyosalpinx,  epiploitis  following 
an  operation  for  hernia,  and  phlebitis.  The  best  re- 
sults were  obtained  by  one  or  two  massive  doses 
(five  grains)  once  or  twice  a  day.  The  injections 
must  be  given  deep  in  the  muscles,  as  the  one  ob- 
jection to  their  use  is  that  they  are  somewhat  pain- 
ful. The  beneficial  results  seem  to  be  caused  by  the 
production  of  an  artificial  hyperleucocytosis.  It  is 
noted  by  the  author  that  the  sodium  nucleinate  is  a 
combination  of  nucleinic  acid,  derived  from  fish  or 
the  flesh  of  animals  (not  yeast),  with  soda. 


30 


EDITORIAL  ARTICLES. 


[New  York 
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and  The  Medical  News. 

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NEW  YORK,  SATURDAY,  JANUARY  2,  1909. 


RESUSCITATION  AFTER  APPARENT 
DEATH. 

Death  upon  the  operating  table  is  not  a  common 
occurrence,  but  when  it  does  happen  it  is  of  grievous 
importance.  The  patient  submits  to  an  operation  in 
the  hope  that  some  pathological  process  will  be  over- 
come ;  his  family  spend  the  time  in  anxious  waiting 
for  the  result,  which  they  hope  will  prolong  the  life 
of  one  of  their  number ;  the  surgeon  undertakes  the 
manipulation,  not,  as  many  people  profess  to  believe, 
because  he  is  anxious  for  an  opportunity  to  try  his 
operative  skill,  but  because  he  hopes  to  be  the  means 
of  the  realization  of  these  hopes  on  the  part  of  his 
patient  and  his  patient's  family.  It  is  demoralizing, 
then,  for  the  surgeon  to  have  to  announce  to  the 
family  that  the  patient  has  died  on  the  table.  It  is 
demoralizing  to  all  connected  with  the  operation.  It 
was  in  the  line  of  pure  philanthropy,  therefore,  that, 
in  his  Miitter  Lecture  on  Surgical  Pathology,  deliv- 
ered at  the  College  of  Physicians  of  Philadelphia  on 
Friday  evening,  December  nth.  Dr.  George  W. 
Crile,  professor  of  clinical  surgery  in  the  Western 
Reserve  University,  described  his  method  of  resus- 
citating individuals  apparently  dead. 

The  patient  is  placed  in  the  prone  posture  and 
rapid  rhythmical  pressure  is  made  on  the  lower  por- 
tion of  the  chest,  which  produces  artificial  respira- 
tion and,  to  a  certain  extent,  artificial  circulation. 
A  cannula  is  rapidly  inserted  into  any  artery  and  di- 
rected toward  the  heart.  To  this  a  rubber  tube  and 
funnel  arc  attached  and  sterile  normal  salt  solution 


or  Locke's  solution  or  Ringer's  solution  is  poured 
into  the  vessel.  Other  fluids  may  be  used,  even  to 
tap  water,  but  the  solutions  mentioned  are  prefera- 
ble. When  about  a  quart  of  fluid  has  passed  into  the 
bloodvessels,  fifteen  to  thirty  minims  of  a  one  to  one 
thousand  adrenalin  solution  are  injected  into  the  ves- 
sel by  inserting  the  needle  of  the  hypodermic  syringe 
through  the  rubber  tubing  close  to  the  cannula. 
Synchronously  with  this  injection  the  rhythmical 
pressure  on  the  chest  is  brought  to  its  maximum,  so 
that  the  adrenalin  solution  shall  reach  the  heart 
promptly.  When  the  pressure  within  the  coronary 
arteries  reaches  thirty  to  forty  millimetres  of  mer- 
cury the  heart  will  begin  to  beat.  The  cannula  is 
then  withdrawn.  The  saline  solution  is  used  for 
the  purpose  of  filling  the  arteries  so  that  the  adrena- 
lin solution  will  reach  the  heart  promptly.  If,  how- 
ever, there  has  been  much  haemorrhage,  the  saline 
solution  fills  the  depleted  vessels,  giving  them  a  fluid 
to  circulate.  Such  a  technique  must  be  applied 
promptly  in  order  to  be  of  service ;  the  operating 
room  staff  must  be  so  trained  that  the  materials  and 
instruments  may  be  produced  within  two  minutes 
after  the  cessation  of  respiration  or  of  the  heart  beat. 

Dr,  Crile  has  applied  his  method  to  a  number  of 
patients  who  have  apparently  died  after  accidents 
such  as  drowning,  shock  by  live  wires,  etc.,  and  he 
finds  that  the  human  heart  responds  to  the  treatment 
more  readily  than  the  hearts  of  experimental  ani- 
mals. One  patient  so  treated  recovered  permanent- 
ly. The  method  does  not  destroy  the  chance  of  per- 
manent recovery  of  the  patient.  It  does  prevent 
operative  death  on  the  table,  and  allows  the  fatal 
termination  to  come  after  the  return  of  the  patient 
to  his  bed,  a  much  less  distressing  circumstance. 
It  is,  in  Dr.  Crile's  opinion,  the  best  method  of  re- 
suscitation, excepting  the  direct  transfusion  of  blood, 
and  including  the  administration  of  stimulants,  oxy- 
gen, electricity,  and  cardiac  massage.  Direct  trans- 
fusion of  blood  is  considered  to  be  a  specific  remedy 
in  haemorrhage  and  shock. 


SURGICAL  AN/EMI  A  AND 
RESUSCITATION. 

The  method  described  by  Dr.  Crile  in  his  Miitter 
Lecture  is  based  on  careful  experimental  work.  We 
see  in  the  results  of  the  experiments  performed  by 
Dr.  Crile  a  benefit  to  the  human  family,  as  we  have 
indicated  in  the  preceding  article.  Dr.  Crile  says 
that  death  is  relative  or  definitive.  In  relative 
death  some  of  the  functions  of  the  body  are  sus- 
pended, but  others  are  still  present  and  active. 
Relative  death  admits  of  resuscitation  for  varying 
periods  after  the  occurrence  of  complete  anaemia. 
Resuscitation  of  dead  tissues  may  be  accomplished 


January  2,  1909.] 


EDITORIAL  ARTICLES. 


31 


locally  or  for  the  entire  economy.  As  an  example 
of  the  former,  the  prevention  of  local  death  of  tis- 
sue following  the  relief  of  pressure  on  the  aflfected 
parts  may  be  mentioned. 

The  death  of  the  entire  organism  is  usually  due 
to  anaemia  of  the  brain.  In  thirty-three  per  cent,  of 
cases  of  neck  operations  cerebral  embolism  follows 
ligation  of  the  common  or  internal  carotid  artery 
from  the  loosening  of  the  clot  in  the  ligated  vessel. 
As  operations  on  the  neck  are  usually  performed 
for  the  relief  of  carcinoma,  studies  were  under- 
taken to  determine  whether  this  condition  could  not 
be  prevented.  It  was  found  that  if  the  carcinoma 
had  not  invaded  the  wall  of  the  artery,  ligature  was 
not  necessary.  If,  on  the  other  hand,  the  carcinoma 
had  invaded  the  wall  of  the  artery,  ligature  gave 
but  temporary  relief,  and  it  was  advisable  not  to 
run  the  risk  of  cerebral  embolus  in  addition  to  the 
surely  fatal  extension  of  the  carcinoma.  Conse- 
quently, Crile  adopts  the  method  of  closing  the 
common  carotid  artery  in  operations  upon  the  neck 
by  a  screw  clamp,  and  after  the  dissection  has 
reached  the  deeper  tissues  he  transfers  the  clamp  to 
the  external  carotid  artery.  At  first  he  employed 
simultaneous  closure  of  both  common  carotid  arte- 
ries, but  this  method  was  found  to  involve  too  great 
a  danger  of  "complete  cerebral  anaemia  from  the  dis- 
turbance of  the  intracranial  circulation.  In  cases 
of  anaemia  of  the  brain  due  to  an  increase  of  intra- 
cranial pressure  the  only  method  of  resuscitation  is 
prompt  operative  decompression. 

In  the  resuscitation  of  the  individual  as  a  whole 
many  methods  have  been  advocated.  Massage  of 
che  heart  rarely  resuscitates  an  animal.  Cardiac 
massage  with  artificial  respiration  and  the  head 
■down  position  produces  occasional  resuscitation. 
These  methods,  with  the  intravenous  injection  of 
normal  saline  solution,  result  in  more  resuscita- 
tions. The  addition  of  adrenalin  solution  gives  the 
very  best  results  in  resuscitation,  particularly  when 
the  apparent  death  has  been  due  to  respiratory  fail- 
ure. It  has  been  found  that  adrenalin  will  increase 
the  blood  pressure  in  the  coronary  arteries,  particu- 
larly when  it  is  introduced  into  the  arterial  system 
toward  the  heart.  When  introduced  into  the  venous 
circulation,  adrenalin  spends  its  action  on  the  veins 
and  on  the  vessels  of  the  lungs  before  it  reaches 
the  left  ventricle  and  the  coronary  arteries.  When 
a  cannula  directed  toward  the  heart  is  tied  into  the 
femoral  artery  of  a  dog  apparently  dead  from  the 
action  of  ether,  and  then  artificial  respiration  and 
the  injection  of  normal  salt  solution  and  adrenalin 
are  employed,  the  blood  pressure  in  the  coronary 
arteries  rises  in  a  few  seconds,  and  the  heart  be- 
gins to  beat  vigorously  in  about  forty-five  seconds 
as  a  rule.    Twenty  animals  that  had  been  apparent- 


ly killed  by  chloroform  were  resuscitated  at  periods 
varying  from  three  to  fourteen  minutes.  If  resus- 
citation is  done  in  less  than  five  minutes  after  the 
cessation  of  the  heart  beat,  the  recovery  is  rapid  and 
free  from  after  eflfects.  In  animals  that  have  been 
resuscitated  and  then  die  Marchi's  method  shows 
degeneration  of  fibre  tracts,  and  Nissl's  method 
shows  chromolytic  changes  in  the  brain  and  the 
spinal  cord. 


OFFICIAL  MEDICAL  JOURNALISM. 

Dr.  James  Peter  Warbasse  has  retired  from  the 
editorial  management  of  the  New  York  State  Jour- 
nal of  Medicine,  which  is  the  oflficial  publication  of 
the  ]\Iedical  Society  of  the  State  of  New  York,  and 
his  graceful  valedictory  appears  as  an  editorial  in 
the  December  issue  of  that  journal.  He  further  con- 
tributes to  the  same  number  a  formal  article  entitled 
State  Journalism  in  Particular,  with  Especial  Refer- 
ence to  the  Nezu  York  State  Journal  of  Medicine, 
In  connection  with  that  journal  Dr.  Warbasse  has 
had  sufficient  editorial  experience  to  give  great 
weight  to  what  he  says  on  the  subject  of  official 
journals  of  medicine,  and  we  may  add  that  undci 
his  guidance  the  journal  from  which  he  now  re- 
tires has  been  free  from  the  censoriousness  that 
some  journals  of  its  class  have  thought  fit  to  indulge 
in.  We  regret  his  withdrawal  from  the  editorial 
fraternity. 

Dr.  Warbasse  points  out  some  of  the  disadvan- 
tages to  which  official  journals  are  apt  to  be  subject- 
ed. Among  them  he  clearly  has  clique  rule  in  mind, 
though  he  does  not  use  the  term,  and  he  thoroughly 
appreciates  the  shifting  policy  that  cliques  impose ; 
the  clique  of  to-day,  he  implies,  may  blow  hot,  and 
the  clique  of  to-morrow  may  blow  cold.  "A  very 
few  members  run  things,"  he  says,  "but  now  and 
then  a  revulsion  takes  place  upon  some  special  prov- 
ocation, and  the  policy  is  changed  by  the  whole  or- 
ganization voting  to  upset  the  plans  of  the  minor- 
ity." Therefore,  he  contends,  an  individual  should 
dominate  the  policy  of  the  journal,  and  that  individ- 
ual should  be  the  editor.  The  editor,  he  insists, 
should  be  the  editor  in  every  sense  of  the  word, 
though  "a  corps  of  figure  heads,  collaborators,  and 
assistants  do  no  harm,  provided  the  actual  editorial 
responsibility  is  vested  in  one  individual."  "1  have 
no  hesitancy  in  predicting,"  he  adds,  "that  State 
journals  which  are  edited  by  committees  will  always 
lack  bowels." 

Dr.  Warbasse  feels,  as  we  all  do,  that  the  ideal 
medical  journal  should  contain  no  advertisements  of 
any  kind,  but  he  realizes  the  virtual  impossibility  of 
attaining  to  that  eminence  of  virtue  if  the  journal  is 
to  any  extent  dependent  for  its  commercial  success 


32 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journai,. 


on  other  sources  of  income  than  what  is  derived 
from  its  subscribers,  and  that  he  thinks  that  as  a 
rule  it  must  be  so  dependent  we  may  gather  from 
the  following  passage:  "The  old  and  substantial 
medical  journals  in  this  country,  which  are  the  re- 
positories of  the  best  medical  thought,  are  under  the 
business  control  of  well  established  business  houses. 
Such  a  condition  makes  for  permanence.  Here  the 
success  of  the  publication  is  the  aim.  A  fixed  policy 
prevails,  even  though  the  personnel  of  the  controlling 
power  changes.  But  with  publications  controlled  by 
societies  there  is  a  lack  of  fixedness  of  policy."  "If 
advertisements  are  to  be  accepted,"  says  Dr.  War- 
basse,  "the  strictest  supervision  over  their  quality 
should  be  exercised,  leaning  always  to  the  side  of 
strictness  rather  than  laxity  toward  enterprises  which 
have  wares  to  vend  to  the  medical  profession." 

Dr.  Warbasse  recognizes  that  it  is  not  the  purvey- 
ors of  pharmaceuticals  alone  who  make  extravagant 
and  misleading  statements  in  advertisements.  For 
example,  he  tells  us  that  the  journal  from  which  he 
is  now  retiring,  as  well  as  the  Journal  of  the  Amer- 
ican Medical  Association,  "carries  the  advertise- 
ment of  a  publishing  house  advertising  a  work  as 
being  written  by  'the  world's  most  eminent  authori- 
ties.' "  He  tells  us  that  he  has  carefully  scrutinized 
this  list  of  authors,  and_  finds  that,  while  many  of 
them  are  eminent  medical  men,  the  list  is  not  by 
any  means  made  up  of  "the  world's  most  eminent 
authorities."  He  instances  two  other  advertise- 
ments in  which  false  statements  are  made,  in  one 
concerning  the  beauty  of  a  beach,  and  in  the  other 
concerning  the  "unexcelled  laboratory  facilities"  of 
a  certain  medical  college,  which  facilities,  he  says, 
are  "excelled  by  several  other  colleges  within  its 
own  city."  These  instances  are  sufficient  to  show 
the  difficulty  of  avoiding  objectionable  advertise- 
ments. 


THE  CAMPAIGN  AGAINST  OPHTHALMIA 
NEONATORUM. 

On  June  26,  1895,  a  law  was  enacted  by  the  legis- 
lature of  the  Commonwealth  of  Pennsylvania  which 
was  intended  to  prevent  blindness  from  lack  of  care 
of  the  new  born  infant.  This  law  provides  that  any 
midwife,  nurse,  or  other  person  having  the  care  of 
an  infant  the  eye  or  eyes  of  which  become  inflamed, 
swollen,  or  reddened  at  any  time  within  two  weeks 
after  birth  shall  report  this  fact  to  the.  health  officer 
or  to  a  legally  qualified  practitioner  of  medicine, 
whose  duty  it  shall  be  to  notify  the  persons  in 
charge  of  the  infant  of  the  danger  of  blindness  and 
inform  such  persons  of  the  proper  method  of  treat- 
ment. Health  officers  are  also  required  under  the 
act  to  furnish  a  copy  of  the  law  to  all  persons  known 


to  them  to  act  as  midwives  or  nurses.  The  penalty 
for  failure  to  comply  with  the  provisions  of  the  act 
is  a  fine  not  to  exceed  $200,  or  imprisonment  not  to 
exceed  thirty  days,  or  both. 

Hitherto  no  attempt  seems  to  have  been  made  to 
enforce  this  law,  but  we  are  glad  to  learn  that  Dr. 
Samuel  G.  Dixon,  health  commissioner  of  the  Com- 
monwealth of  Pennsylvania,  has  only  this  week  noti- 
fied 10,000  physicians  in  the  State  of  the  existence 
of  the  law  and  of  the  fact  that  it  is  to  be  strictly 
enforced.  Each  of  the  730  township  health  officers 
in  the  State  has  also  received  this  notification  and 
instructions  as  to  their  duties.  The  health  officers 
are  required  to  urge  the  family  to  secure  the  services 
of  a  competent  physician  if  none  has  been  engaged. 
Meanwhile  the  nurse  or  person  in  charge  is  to  be 
instructed  to  bathe  the  lids  of  the  child's  eyes  with 
a  solution  of  two  teaspoonfuls  of  boric  acid  and  half 
a  teaspoonful  of  table  salt  in  a  pint  of  boiled  water, 
the  solution  to  be  kept  in  a  covered  jar  which  has 
previously  been  boiled.  The  nurse  must  also  be  in- 
structed to  instil  a  few  drops  of  this  solution  into 
the  eye  three  times  a  day.  This  treatment  is  to  be 
followed  only  pending  the  arrival  of  the  physician. 

More  than  one  third  of  the  persons  admitted  into 
the  Pennsylvania  School  for  the  Blind  during  the 
past  eight  years  owe  their  affliction  to  ophthalmia 
neonatorum,  but  it  is  to  be  expected  that  the  medical 
profession  and  the  health  officers  of  the  State  will 
give  their  cordial  support  to  Dr.  Dixon  in  his  efforts 
to  enforce  this  law,  and  consequently  we  can  look 
forward  with  confidence  to  a  marked  diminution  of 
blindness  from  this  cause.  The  need  for  such  vig- 
orous measures  has  long  been  realized  by  the  med- 
ical profession,  and  it  is  to  be  hoped  that  the  excel- 
lent example  set  by  the  health  commissioner  of  the 
State  of  Pennsylvania  will  be  followed  by  officials  in 
other  States  where  such  laws  have  been  enacted  but 
not  enforced,  and  that  similar  laws  will  be  enacted 
and  enforced  throughout  the  United  States. 


A  TRIBUTE  TO  DR.  TRUDEAU. 

In  commemoration  of  his  sixtieth  birthday,  several 
of  the  pupils  of  Dr.  Edward  L.  Trudeau,  of  Saranac 
Lake,  N.  Y.,  gave  a  dinner  to  him  on  December  19th 
and  presented  him  with  two  handsomely  bound  vol- 
umes of  their  reprinted  articles,  entitled  collectively 
Studies  in  Tuberculosis.  The  actual  birthday  fell 
on  October  5th,  but  for  various  reasons,  one  of 
which  was  connected  with  the  International  Con- 
gress on  Tuberculosis,  the  presentation  was  post- 
poned to  the  date  first  mentioned.  The  authors 
whose  writings  formed  the  collection  were  A.  H. 
Allen,  E.  R.  Baldwin.  Lawrason  Brown,  N.  M.  Car- 
ter, Irwin  H.  Hance.  H.  McL.  Kinghorn.  P.  A.  Le- 


January  2,  1909.  J 


OBITUARY.— NEWS  ITEMS. 


33 


vene.  E.  J.  S.  Lupton.  J.  L.  Xichols.  E.  G.  Pope, 
J.  W.  Price,  D.  C.  Twichell.  and  J.  A.  Wilder.  The 
volumes  form  a  most  appropriate  tribute  to  the  dis- 
tinguished founder  of  the  Adirondack  Cottage  Sani- 
tarium, one  of  our  best  known  and  most  respected 
phthisiologists,  a  man  still  at  the  height  of  his  in- 
tellectual powers. 


THE  OFFICE  OF  COROXER. 
According  to  the  newspaper  reports,  a  coroner 
holding  an  inquisition  in  the  borough  of  The  Bronx 
recently  conducted  himself  toward  a  gentleman  and 
his  wife  who  were  witnesses  in  the  case  in  such  a 
manner  as  to  call  forth  protests  from  several  per- 
sons who  were  present.  Whatever  may  have  been 
the  coroner's  reasons  for  treating  these  witnesses 
with  severity,  the  aflfair  seems  likely  to  make  on 
the  public  mind  an  impression  favorable  to  the 
abolition  of  the  office  of  coroner — an  impression 
which  has  been  that  of  most  members  of  the  med- 
ical profession  for  many  years. 


A  MEDICAL  STRIKE. 
We  learn  from  the  Progres  medical  for  December 
19th  that  all  the  candidates  for  appointment  as  ex- 
ternes  to  the  Marseilles  hospitals  recently  refused  to 
appear  before  the  examining  board,  for  the  reason 
that  it  had  been  decided  to  discontinue  the  monthly 
stipend  of  twenty-five  francs  (about  $5).  There- 
upon the  provision  for  payment  was  restored  and 
another  examination  ordered.  Though  peace  ap- 
pears to  have  been  accomplished,  the  incident,  ac- 
cording to  our  contemporary,  has  inspired  the  stu- 
dents with  the  laudable  idea  of  founding  an  incor- 
porated association  of  medical  students.  Truly  they 
do  many  things  well  in  France. 

 <^  

^bituarg. 


RICHARD  A.  F.  PENROSE,  M.  D.,  LLD., 
of  Philadelphia. 
Dr.  Richard  Alexander  FuUerton  Penrose  died  of 
pneum.onia.  at  his  residence,  on  Saturday,  December 
26th.  He  was  born  in  Carlisle,  Pa.,  on  ]\Iarch  24, 
1827.  He  was  graduated  from  Dickinson  College,  in 
the  class  of  1846,  and  from  the  Medical  Department 
of  the  University  of  Pennsylvania  in  1849.  After  a 
term  spent  as  resident  physician  in  the  Pennsylvania 
Hospital,  he  started  in  the  practice  of  medicine  in 
Philadelphia,  with  the  medical  activities  of  which 
city  he  has  been  connected  ever  since.  During  the 
period  of  the  civil  war  he  was  one  of  the  surgeons 
at  the  Government  Hospital  at  Satterlee's  Heights,- 
West  Philadelphia.  In  1854  he  delivered  a  course 
i  f  lectures  on  the  diseases  of  women  and  children  in 
the  Philadelphia  Hospital,  and  he  was  appointed 
professor  of  obstetrics  and  diseases  of  women  and 


children  in  the  University  of  Pennsylvania  in  1863. 
He  was  made  emeritus  professor  upon  his  retire- 
ment from  active  service  as  professor  in  1889.  Dr. 
Penrose  was  one  of  the  founders  of  the  Children's 
Hospital  in  Philadelphia,  of  the  Hospital  of  the  Uni- 
versity of  Pennsylvania,  and  of  the  Gynecean  Hos- 
pital. "  He  was  a  fellow  of  the  College  of  Physicians 
and  a  member  of  the  Philadelphia  County  Aledical 
Society,  of  the  Medical  Society  of  the  State  of  Penn- 
sylvania, of  the  American  ]\ledical  Association,  of 
the  Academy  of  Natural  Sciences  of  Philadelphia, 
and  of  the  American  Philosophical  Society. 


Ilttos  |tfms. 


A  Medical  Reserve  Corps  for  the  Navy  has  been 
recommended  by  the  Surgeon  General  of  the  Nav_v,  and  the 
recommendation  has  been  approved  by  the  Secretary  of  the 
Navy.  The  corps  is  to  be  recruited  and  organized  along 
the  same  lines  as  the  ^Medical  Reserve  Corps  of  the  Army. 

The  Philadelphia  Academy  of  Medicine  was  chartered 
on  Thursday,  December  24th.  The  officers  are :  President, 
Dr.  G.  Harlan  Wells ;  vice-president,  Dr.  Leon  T.  Ash- 
craft;  secretarv,  Dr.  Ralph  Bernstein;  and  treasurer,  Dr. 
J.  W.  Frank. 

The  Cleveland  Medical  Library  Association  held  its 
annual  meeting  recently  and  elected  the  following  officers 
for  1909 :  President,  Dr.  H.  G.  Sherman ;  vice-president. 
Dr.  D.  H.  Beckwith ;  treasurer.  Dr.  W.  E.  Brunner ;  secre- 
tary, Dr.  H.  E.  Fanford. 

A  Presentation  to  Dr.  Roswell  Park. — A  silver  ser- 
vice was  presented  to  Dr.  Park  by  the  senior  class  of  the 
Medical  Department  of  the  University  of  Buffalo,  on  the 
twenty-fifth  anniversary  of  his  accepting  the  chair  of  sur- 
gery in  the  institution. 

Isolation  Hospitals  at  Army  Posts. — The  isolation 
hospital,  recently  established  at  Fort  Myer,  Va.,  has  proved 
so  satisfactory  that  a  similar  one  is  soon  to  be  erected  at 
Fort  Slocum,  N.  Y.  Tlie  policy  of  establishing  hospitals 
for  contagious  diseases  at  Army  posts  will  be  further  ex- 
tended. 

Gifts  to  the  Union  Hospital,  Fall  River.  Mass. — .An- 
nouncement is  made  that  Sirs.  Elizabeth  R.  Stevens,  of 
Swansea,  has  made  a  Christmas  gift  of  $50,000  to  this  hos- 
pital, and  that  the  heirs  cf  the  estate  of  Miss  Elizabeth  M. 
Borden  have  given  $ro.ooo  to  the  hospital,  to  endow  five 
beds  for  crippled  children. 

Contagious  Diseases  in  Chicago. — During  the  week 
ending  December  19,  1908,  there  were  744  cases  of  con- 
tagious diseases  reported  to  the  Department  of  Health,  as 
follows :  Diphtheria,  201  cases :  scarlet  fever,  199  cases ; 
measles,  99  cases ;  chickenpox,  46  cases ;  pneumonia,  17 
cases;  whooping  cough.  12  cases;  tuberculosis,  61  cases; 
minor  diseases.  26  cases. 

A  Reception  to  Dr.  Moschcowitz. — The  Hartfor<i, 
Conn.,  Medical  Society  gave  a  reception  to  Dr.  Alexis  V. 
Moschcowitz,  of  New  York,  who  was  the  guest  of  honor  at 
the  regular  meeting  of  the  Surgical  Section  of  this  society 
on  Monday  evening,  December  28th.  After  the  reception 
Dr.  Moschcowitz  delivered  an  address  on  Personal  Obser- 
vations upon  Ureteral  Calculi. 

Riot  of  Medical  Students  in  Paris. — Two  thousand 
students  of  the  Faculty  of  Medicine  of  tbe  University  of 
Paris  engaged  in  a  riot  in  the  college  building  on  December 
2ist,  as  a  protest  against  the  action  of  the  faculty  in  making 
out  two  kinds  of  diplomas,  designating  first  and  second 
class  graduates.  The  students  say  that  this  stamps  them 
as  first  and  second  class  doctors. 

Lectures  to  Mothers  at  the  Babies'  Hospital,  New 
York.— A  course  of  lectures  on  how  to  care  for  the  baby 
is  being  given  free  to  young  mothers  at  the  Babies'  Hospi- 
tal, Fifty-fifth  Street  and  Lexington  Avenue,  on  Monday 
mornings.  Dr.  Josephine  Hemenway,  the  resident  physician 
pf  the  hospital ;  Miss  Mary  .\.  Smith,  the  superintendent, 
and  Miss  Judson,  the  assistant  superintendent,  are  alternat- 
ing in  giving  these  talks.  The  subiects  chosen  include  artifi- 
cial feeding,  nursery  hygiene,  contagious  diseases,  emergen- 
cies, the  nursing  baby,  and  the  feeding  of  older  children. 


34 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


The  Seaman  Prize  Awarded  to  Major  Mason. — The 

Military  Institution  of  the  United  States  has  awarded  the 
Seaman  First  Prize  for  1908,  amounting  to  $100,  to  Major 
Charles  F.  Mason,  of  the  Medical  Corps  of  the  United 
States  Army,  for  his  essay  on  The  Medical  Department  of 
the  United  States  Army:  Upon  What  Lines  should  its 
Much  Needed  Reorganization  be  Instituted? 

Dietitians  Wanted  at  Bellevue.— Ten  dietitians  are 
wanted  by  Bellevue  and  Allied  Hospitals  and  the  Department 
of  Public  Charities.  On  January  22d  the  Municipal  Civil 
Service  Commission  will  examine  candidates  to  fill  these 
positions.  Candidates  must  have  had  two  years'  experience 
in  an  approved  school  of  domestic  science,  or  its  equivalent. 
The  salaries  paid  are  from  $720  to  $1,500  a  year. 

The  Mortality  of  Connecticut. — During  the  month  of 
November,  1908,  there  were  reported  to  the  Connecticut 
State  Board  of  Health  1,138  deaths  from  164  towns,  cor- 
responding to  an  annual  death  rate  of  13. i  in  a  thousand 
population.  Of  the  total  number  of  deaths  reported  185 
were  of  children  under  one  year  of  age,  and  92  of  children 
between  one  and  five  years  of  age.  Thirty-three  towns 
were  reported  as  having  no  deaths  in  November. 

Philadelphia  County  Medical  Society. — The  Central 
Branch  of  this  society  held  a  meeting  on  Wednesday  even- 
ing, December  23d.  The  programme  consisted  of  the  ex- 
hibition of  patients,  the  presentation  of  specimens,  and  the 
following  papers :  Gastrointestinal  Disturbances  due  to  Ar- 
teriosclerosis, by  Dr.  John  J.  Gilbride;  A  Medical  Library 
for  the  Philadelphia  County  Medical  Society,  by  Dr.  James 
M.  Anders ;  Operating  upon  the  Cranial  Vault,  by  Dr.  H. 
C.  Masland. 

The  Herter  Lectures  will  be  delivered  by  Dr.  J.  B. 
Leathes,  of  London,  at  the  Carnegie  Laboratory  of  the 
University  and  Bellevue  Hospital  Medical  College,  New 
York,  beginning  Monday,  January  4th,  at  4  o'clock  in  the 
afternoon,  and  continuing  daily  throughout  the  week  at  the 
same  hour.  There  will  be  six  lectures  in  the  course,  and 
the  subject  will  be  The  Metabolism  of  the  Nonnitrogenous 
Substances  in  the  Animal  Body.  All  who  are  interested  are 
cordially  invited  to  attend. 

Bacteriologist  Wanted  by  the  New  York  Health  De- 
partment.— The  Municipal  Civil  Service  Commission 
will  hold  an  examination  on  January  25th  to  fill  the  position 
of  bacteriologist  to  the  Health  Department  of  the  City  of 
New  York.  Both  men  and  women  may  take  the  examina- 
tion. Candidates  must  have  taken  a  course  in  bacteriology 
in  some  medical  college  of  recognized  standing,  and  must 
have  had  practical  experience  in  a  reputable  bacteriological 
laboratory.    The  salary  is  $1,200  a  year. 

Tuberculosis  to  be  Reported  as  an  Infectious  Disease 
in  Pasadena. — The  mayor  and  council  of  Pasadena,  Cal., 
recently  passed  resolutions  recommending  a  more  rigid  en- 
forcement of  the  ordinance  requiring  the  reporting  of  all  cases 
of  infectious  diseases,  including  tuberculosis.  They  have  also 
appropriated  a  generous  sum  to  provide  for  the  fumigation, 
at  the  city's  expense,  of  all  rooms  and  houses  in  which  these 
diseases  have  occurred.  The  movement  is  receiving  the 
unanimous  support  of  the  health  officer  of  the  city  and  the 
members  of  the  Pasadena  Medical  Society. 

Vital  Statistics  of  Minneapolis. — The  report  of  the 
Department  of  Health  of  the  city  of  Minneapolis  shows 
that  during  the  month  223  deaths  were  reported  to  the  de- 
partment, which  corresponds  to  an  annual  death  rate  of 
7.68  in  a  thousand  population.  The  annual  death  rate  for 
the  year  1907  was  8.56  in  a  thousand  population.  The  total 
number  of  deaths  of  children  under  five  years  of  age  was 
37,  and  of  these  26  were  less  than  one  year  of  age.  There 
were  26  '^till  births,  17  males  and  9  females.  The  births  for 
the  month  nnmhored  387,211  males  and  176  females.  Three 
hundred  and  fortv-six  marriages  were  reported. 

The  Medical  Society  of  the  County  of  Erie,  N.  Y.— 
The  eighty-seventh  annual  meeting  of  this  society  was  held 
in  Buffalo  on  December  21st.  Officers  were  elected  as  fol- 
lows :  President,  Dr.  Charles  A.  Wall ;  first  vice-president. 
Dr.  Grovcr  W.  Wonde ;  second  vice-president,  Dr.  Bernard 
Cohen :  secretary.  Dr.  Franklin  C.  Gram ;  treasurer.  Dr. 
Albert  T.  Lytic :  censors,  Dr.  John  H.  Grant,  Dr:  De  Lan- 
ccy  Rochester ;  Dr.  F.  F.  Fronczak,  Dr.  Walter  D.  Greene, 
and  Dr.  George  L.  Brown  ;  chairman  of  the  committee  on 
legislation.  Dr.  F.  Park  Lewis ,  chairman  of  the  committee 
on  public  health,  Dr.  Ernest  Wende;  chairman  of  the  com- 
mittee on  membership.  Dr.  Thomas  H.  Burke.  Many 
interesting  papers  were  read,  and  Dr.  Roswcll  Park  ex- 
hibited a  new  electrical  machine  for  the  treatment  of  can- 
cer which  he  had  purchased  in  Germany. 


Guarding  Against  Ophthalmia  Neonatorum  in  Penn- 
sylvania.— Dr.  Samuel  G.  Dixon,  health  commissioner 
of  the  Commonwealth  of  Pennsylvania,  has  notified  the 
health  officers  and  the  physicians  of  the  State  that  the  law 
enacted  on  June  26,  1895,  for  the  prevention  of  blindness, 
which  has  heretofore  been  ignored,  will  hereafter  be  rigidly 
enforced.  This  law  requires  that  all  nurses  or  other  per- 
sons having  charge  of  infants  shall  notify  the  local  health 
authorities  whenever  an  infant  in  their  care  develops 
inflammation,  swelling,  or  redness  of  the  eyes  or  eyelids, 
and  imposes  on  the  health  officer  the  duty  of  seeing  that 
such  infants  receive  proper  attention. 

Medical  Missionaries  to  Make  a  Special  Study  of 
Tropical  Medicine.— It  has  been  recommended  by  the 
Medical  Missionary  Association  of  China  that  medical  mis- 
sionary candidates  be  required  to  show  evidence  that  they 
have  made  a  special  study  of  tropical  diseases.  A  practi- 
cal course  in  tropical  medicine  for  each  candidate  would  be 
preferred  by  the  board,  but  if  this  should  prove  to  be  im- 
practicable, candidates  should  at  least  be  required  to  attend 
a  course  of  lectures  on  the  subject  and  be  thoroughly 
trained  in  practical  bacteriology  and  microscopic  methods. 
It  is  also  recommended  that  medical  missionaries,  while  on 
furlough,  be  allowed  time  for  postgraduate  studies,  and,  if 
necessary,  the  requisite  fees  be  paid. 

A  Department  of  Preventive  Medicine  at  Columbia. — 
President  Butler  has  appointed  a  committee  composed  of 
twelve  eminent  scientists  and  economists  to  formulate  plans 
for  the  establishment  of  a  school  of  preventive  medicine  in 
connection  with  Columbia  University.  In  this  school  men 
will  be  trained  for  the  positions  of  health  officer  and  sani- 
tary inspector.  The  members  of  the  committee  are  as  fol- 
lows: Norman  E.  Ditman,  M.  D.,  chairman;  Samuel  W. 
Lambert,  M.  D. ;  Philip  H.  Hiss,  M.  D. ;  M.  Allen  Starr, 
M.  D. ;  Frederick  S.  Lee,  Ph.  D. ;  Edward  T.  Devine,  Ph. 
D. ;  Livingston  Farrand,  M.  D. ;  E.  R.  A.  Seligman.  Ph.  D. ; 
Gary  N.  Calkins,  Ph.  D. ;  WilHam  H.  Burr.  C.  E. ;  Dean 
Goetz,  and  Rudolph  Tombo,  Jr.,  Ph.  D. 
Infectious  Disease  in  New  York: 

M^e  arc  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  follozinng  statistics  of  new 
cases  and  deaths  reported  for  the  two  zveeks  ending  De- 
cember 26,  igo8: 

I  Dec.  19  ,    ,  Dec.  26  , 

Cases.    DeEths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    418         185         384  135 

Diphtheria    376  {i  393  37 

Measles    352  13         369  12 

Scarlet  fever    282  15         28 1  17 

Smallpox   

Varicella    199  ..  204 

Typhoid   fever    60  10  41  2 

Whooping  cough    30  5  28  3 

Cerebrospinal  meningitis    6  4  5  4 

Totals   1.723         263       1.705  210 

A  Complimentary  Dinner  to  Dr.  Spratling. — On  the 

evening  of  December  22d  the  faculty  of  the  College  of 
Physicians  and  Surgeons,  Baltimore,  gave  a  dinner  at  the 
Maryland  Club  in  honor  of  Dr.  William  P.  Spratling.  Pro- 
fessor William  Simon  acted  as  toastmaster,  and  among  the 
invited  guests  who  responded  to  toasts  were  President  Ira 
Remsen,  of  the  Johns  Hopkins  University ;  Professor  Wil- 
liam H.  Welch,  Professor  John  M.  Thomas,  and  Professor 
Llewellys  F.  Barker,  of  the  Johns  Hopkins  Medical  School ; 
and  Dr.  Charles  F.  Bevan,  dean,  Dr.  John  W.  Chambers, 
and  Dr.  Harry  Friedenwald,  of  the  College  of  Physicians 
and  Surgeons.  Covers  were  laid  for  fifty-four.  Dr.  Sprat- 
ling, who  was  formerly  medical  superintendent  of  the  Craig 
Colony  for  Epileptics,  Sonyea,  N.  Y.,  now  occupies  the 
chair  of  neurology  at  the  College  of  Physicians  and 
Surgeons. 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  January  9,  1909: 

Mo.N'D.w,  January  jth. — Pliiladclphia  .Academy  of  Surgery; 
Biological  and  Microscopical  Section,  Academy  of  Nat- 
ural Sciences;  West  Philadelphia  Medical  Association; 
Northwestern  Medical  Society. 

TuESD.w,  January  jih. — Academy  of  Natural  Sciences; 
Philadelphia  Medical  Examiners'  Association ;  Wills 
Hospital  Ophthalmic  Society. 

Wei)Nesd.\v,  January  6th. — College  of  Physicians. 

Thursday,  January  yih. — Obstetrical  Society;  Germantown 
Branch,  Philadelphia  County  Medical  Society;  South- 
wark  Medical  Society ;  Section  Meeting,  Franklin  In- 
stitute ;  Delaware  Valley  Ornithological  Club. 

Frid.w,  January  8th. — Northern  Medical  Association. 


January  2,  1909.] 


NEWS  ITEMS. 


35 


The  Mortality  of  Chicago. — The  total  number  of 
deaths  reported  to  the  Department  of  HeaUh  during  the 
week  ending-  December  19,  1908,  was  580,  as  compared  with 
537  for  the  preceding  week  and  592  for  the  corresponding 
period  in  1907.  The  annual  death  rate  in  a  thousand  popu- 
lation was  13.95,  as  against  a  death  rate  of  14.65  in  the  cor- 
responding period  in  1907.  Of  the  total  number  of  deaths 
162  were  of  children  under  five  years  of  age,  and  of  these 
118  were  under  one  year  of  age.  The  principal  causes  of 
death  were:  Apoplexy,  16  deaths;  Bright's  disease,  36 
deaths;  bronchitis,  20  deaths;  consumption,  50  deaths;  can- 
cer, 35  deaths;  convulsions,  i  death;  diphtheria,  23  deaths; 
heart  diseases,  60  deaths ;  influenza,  3  deaths ;  intestinal 
diseases,  acute,  34  deaths ;  measles,  3  deaths ;  nervous  dis- 
eases, 12  deaths ;  pneumonia,  90  deaths ;  scarlet  fever,  12 
deaths;  suicide,  12  deaths;  typhoid  fever,  12  deaths;  vio- 
lence, 35  deaths ;  whooping  cough,  i  death ;  all  other  causes, 
125  deaths. 

The  International  Medical  Congress  at  Budapest. — 

The  chairman  of  the  American  Committee,  Dr.  John  H. 
Musser,  of  Philadelphia,  announces  that  arrangements  for 
the  transportation  of  the  American  party,  who  will  attend 
this  congress,  have  been  placed  in  the  hands  of  Thomas 
Cook  &  Sons.  All  the  necessary  plans  have  been  perfected, 
and  a  very  low  round  trip  rate,  including  all  expenses,  will 
shortly  be  announced.  Some  rooms  have  already  been  re- 
served in  the  best  hotels  in  Budapest,  but  in  order  to  secure 
a  sufficient  number  of  rooms  it  will  be  necessary  for  the 
committee  to  know  at  an  early  date  the  approximate  num- 
ber who  intend  joining  the  party.  All  communications  in 
regard  to  transportation  and  hotel  accommodations  should 
be  addressed  to  Dr.  Charles  Wood  Fassett,  St.  Joseph,  Mo., 
and  communications  relating  to  the  scientific  programme 
or  to  membership  should  be  addressed  to  Dr.  John  H.  Mus- 
ser, 1927  Chestnut  Street,  Philadelphia. 

American  Laryngological,  Rhinological,  and  Otolog- 
ical  Society. — The  Eastern  Branch  of  this  organization 
will  hold  a  meeting  at  the  College  of  Physicians,  Philadel- 
phia, on  Saturday,  January  9th.  Members  of  the  medical 
profession  are  cordially  invited  to  attend.  Tliere  will  be 
two  sessions,  one  in  the  morning  at  10  o'clock,  and  the 
other  in  the  afternoon  at  2  130  o'clock,  at  both  of  which  pa- 
pers will  be  read  by  well  known  specialists  in  these  three 
branches,  and  there  will  be  the  usual  presentation  of  pa- 
tients, exhibition  of  specimens,  demonstration  of  surgical 
instruments,  etc.  The  programme  is  an  exceptionally  good 
one,  and  the  meeting  will  probably  be  both  interesting  and 
instructive.  Dr.  Francis  R.  Packard,  chairman  of  the  East- 
ern Section  of  the  society,  will  entertain  the  visiting  mem- 
bers at  luncheon  at  the  University  Club  on  the  day  of  the 
meeting,  and  a  dinner  will  be  served  at  the  club  in  the 
evening  to  the  visiting  members  by  the  Philadelphia  mem- 
bers of  the  society. 

Personal. — Dr.  Archibald  Church  has  resigned  as  edi- 
tor of  the  Chicago  Medical  Recorder. 

Dr.  E.  B.  Gieason,  for  many  years  professor  of  clinical 
otology  in  the  Medicochirurgical  College,  Philadelphia,  has 
been  elected  to  the  major  faculty  of  the  institution. 

Dr.  Charles  E.  North,  formerly  with  the  Lederle  Labor- 
atories, has  established  an  office  in  the  Times  Building, 
New  York,  where  lie  will  engage  in  private  practice. 

Dr.  F.  X.  Dercum,  professor  of  neurology  and  mental 
diseases  at  the  Jefferson  Medical  College,  Philadelphia,  has 
been  elected  to  membership  in  the  Sociefe  de  neurologie ,  of 
Paris.  The  only  other  American  member  of  this  society- 
is  Dr.  Charles  L.  Dana,  of  New  York. 

Dr.  H.  V.  Wiirdemann  and  Dr.  A.  M.  MacWhinnie,  for- 
merly of  Milwaukee,  Wis.,  have  opened  offices  in  the  White 
Building,  corner  of  Fourth  Avenue  and  Union  Street.  Seat- 
tle, Wash.  Their  practice  will  be  limited  to  the  eye,  ear, 
nose,  and  throat. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing December  19,  1908,  the  following  cases  of  transmissible 
diseases  were  reported  to  the  Bureau  of  Health  of  Phila- 
delphia :  Typhoid  fever.  30  cases,  5  deaths ;  scarlet  fever, 
67  cases,  2  deaths :  chickenpox,  91  cases,  o  deaths ;  diph- 
theria, III  cases.  17  deaths;  cerebrospinal  meningitis,  2 
cases,  2  deaths ;  measles.  80  cases,  i  death ;  whooping 
cough,  8  cases,  4  deaths;  tuberculosis  of  the  lungs.  115 
cases,  55  deaths :  pneumonia,  109  cases,  74  deaths ;  erysipe- 
las, 4  cases,  0  deaths ;  puerperal  fever,  i  case,  2  deaths ; 


mumps,  II  cases,  o  deaths;  cancer,  21  cases,  25  deaths; 
trachoma,  i  case,  o  deaths.  The  following  deaths  were  re- 
ported from  other  transmissible  diseases :  Tuberculosis, 
other  than  tuberculosis  of  the  lungs,  5  deaths;  diarrhoea 
and  enteritis,  under  two  years  of  age,  12  deaths.  The  total 
deaths  numbered  464,  in  an  estimated  population  of  i,S32,- 
738,  corresponding  to  an  annual  death  rate  of  15.70  in  a 
thousand  population.  The  total  infant  mortality  was  106; 
88  under  one  year  of  age,  and  18  between  one  and  two  years 
of  age.  There  were  45  still  births ;  22  males,  and  23  fe- 
males.   The  total  precipitation  was  0.38  inch. 

The  Pelgado  Memorial  Building  of  the  Charity  Hos- 
pital, New  Orleans,  was  dedicated  and  formally  opened 
with  imposing  ceremonies  on  Saturday  afternoon,  Decem- 
ber 19th.  This  building,  which  was  erected  with  funds 
donated  by  Mr.  Isaac  Delgado,  in  memory  of  his  uncle  and 
aunt,  Samuel  and  Virginia  Delgado,  is  to  be  devoted  to  the 
treatment  of  surgical  and  gynaecological  cases.  It  is  a  hand- 
some five  story  structure,  strictly  modern  both  in  its  con- 
structive features  and  in  its  equipment.  The  exterior  de- 
sign is  an  adaptation  of  the  French  Renaissance,  with  light 
grey  brick  and  white  terra  cotta.  Dr.  Ernest  S.  Lewis, 
vice-president  of  the  board  of  administrators  of  the  Charity 
Hospital,  presided,  and  delivered  the  introductory  address. 
Addresses  were  also  delivered  by  the  Hon.  Jared  Y.  Sand- 
ers, governor  of  the  State  of  Louisiana ;  the  Hon.  Martin 
Behrman,  mayor  of  New  Orleans ;  and  Dr.  L.  G.  Le  Beuf. 
A  tribute  to  the  memory  of  Samuel  and  Virginia  Delgado, 
by  a  near  friend,  was  read,  for  the  author,  by  Dr.  Rudolph 
Matas.  The  benediction  was  pronounced  by  Dr.  Beverley 
Warner. 

The  International  Tuberculosis  Exhibit. — ^Since  the 
opening  of  this  exhibit  in  the  American  Museum  of  Natural 
History,  on  November  30,  1908,  nearly  half  a  million  people 
have  visited  it.  When  it  was  first  suggested  by  the  Com- 
mittee on  the  Prevention  of  Tuberculosis  of  the  Charity 
Organization  Society  that  the  exhibit  be  brought  from 
Washington  to  New  York,  it  was  hoped  that  the  number 
of  spectators  would  reach  100,000,  and  the  record  breaking 
attendance  has  greatly  encouraged  all  engaged  in  the  fight 
against  tuberculosis,  for  it  is  a  definite  manifestation  that 
the  people  are  aroused.  Tuberculosis  can  be  diminished  or 
stamped  out  only  as  the  people  are  taught  how  to  guard 
themselves  against  it,  and  how  to  prevent  its  spread. 
The  list  of  speakers  at  the  meetings  held  in  connection 
with  the  exhibit  embraces  the  names  of  many  em- 
inent men,  and  in  addition  to  the  general  meetings  there 
have  been  a  New  York  State  Day,  a  New  Jersey  Day,  a 
Rhode  Island  Day,  and  two  Labor  Days.  There  have  also 
been  many  special  meetings  of  social  workers,  public  school 
teachers,  medical  students,  and  domestic  science  workers. 
The  exhibit  closes  on  January  15th,  when  it  will  be  taken 
in  its  entirety  to  Philadelphia. 

Society  Meetings  for  the  Coming  Week: 

Monday,  January  4th. — German  Medical  Society  of  the 
City  of  New  York ;  Utica,  N.  Y.,  Medical  Library 
Association ;  Niagara  Falls,  N.  Y.,  Academy  of  Medi- 
cine ;  Practitioners'  Club,  Newark,  N.  J. ;  Hartford, 
Conn.,  Medical  Society. 

Tuesday,  January  5th. — New  York  Academy  of  Medicine 
(Section  in  Dermatology)  ;  New  York  Neurological 
Society  (annual)  ;  Buffalo  Academy  of  Medicine  (Sec- 
tion in  Surgery)  ;  Ogdensburgh,  N.  Y.,  Medical  Asso- 
ciation ;  Syracuse,  N.  Y.,  Academy  of  Medicine ;  Hud- 
son County,  N.  J.,  Medical  Association  (Jersey  City)  ; 
Medical  Association  of  Troy  and  Vicinity  (annual)  ; 
Hornellsville,  N.  Y.,  Medical  and  Surgical  Association; 
Long  Island,  N.  Y.,  Medical  Society ;  Bridgeport, 
Conn.,  Medical  Association. 

Wednesday.  January  6th. — Psychiatrical  Society  of  New 
York ;  Society  of  Alumni  of  Bellevue  Hospital,  New 
York ;  Harlem  Medical  Association,  New  York ;  El- 
mira,  N.  Y.,  Academy  of  Medicine. 

Thursday,  January  7th. — New  York  .Academy  of  Medi- 
cine :  Dansville.  N.  Y..  Medical  Association. 

pRmAY,  January  8th. — New  York  Academy  of  Medicine 
(Section  in  Otolog>')  ;  New  York  Society  of  Derma- 
tology and  Genitourinary  Surgery ;  Eastern  Medical 
Society  of  the  City  of  New  York;  Saratoga  Springs, 
N.  Y.,  Medical  Society. 

Saturday,  January  gth. — Therapeutic  Club,  New  York. 


t 


36 


PITH  01'  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


|)it^  ol  iurrent  f  ittratnrt. 

BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

December  24,  igo8. 

1.  Tuberculosis  of  the  Larynx, 

By  Albert  C.  Getchell. 

2.  Report  of  a  Case  of  Chronic  Gout,  with  Observations 

on  Gout  in  General,  By  Daniel  E.  Keefe. 

3.  Observations  on  Epilepsy  (Concluded), 

By  Everett  Flood. 

I.  Tuberculosis  of  the  Larynx. — Get:hell  says 
that  the  treatment  of  the  tuberculous  larynx  is 
primarily  the  treatment  of  the  patient  and  second- 
arily the  treatment  of  the  larynx.  It  is  not  neces- 
sary nowadays  to  speak  in  detail  of  the  treatment 
of  tuberculosis.  Tuberculous  involvement  of  the 
larynx  is  a  part  of  a  more  or  less  general  tuber- 
culosis, usually,  however,  limited  to  the  lungs.  The 
same  measures  that  will  cure  the  pulmonary  lesion 
will  cure  the  laryngeal.  Aside  from  the  elements 
of  fresh  air,  good  food,  and  judicious  medical 
supervision,  the  author  emphasizes  rest  in  the  local 
treatment  of  laryngeal  tuberculosis.  Talking  and 
coughing  are  the  two  activities  that  keep  the  laryn.x 
in  motion,  and.  therefore,  are  to  be  considered  pri- 
marily in  treatment.  The  tuost  remarkable  result 
he  has -ever  seen  in  treatment  of  tuberculous  laryn- 
gitis has  come  from  rest  alone.  Cough  is  not  neces- 
sarily an  accompaniment  of  laryngitis,  tuberculous 
or  simple.  It  is  seldom  a  symptom  of  laryngitis 
alone,  but  rather  of  tracheal  inflammation  and  dis- 
eased conditions  lower  down.  If,  however,  it  per- 
sists when  there  is  tubei^culous  disease  in  the  larynx, 
it  must  be  controlled  by  rest,  open  air,  soothing  in- 
halations, suggestion,  but  if  by  no  other  means,  by 
opium  if  necessary.  Tracheal  catarrh  is  a  not  in- 
frequent cause  of  cough  in  tuberculous  persons.  An 
excellent  treatment  for  this  is  intratracheal  injec- 
tions of  guaiacol  and  menthol  in  olive  oil :  Guaiacol, 
gr.  20;  menthol,  gr.  40;  olive  oil,  ,5i.  In  addition 
to  these  general  measures  more  definite  ones  may 
be  employed,  according  to  the  state  of  the  disease. 
For  purposes  of  treatment  the  author  classifies  the 
cases:  i.  Moderate  involvement  of  the  larynx  with 
active  inflammation,  either  with  or  without  ulcera- 
tion, the  pulmonary  lesions  being  active,  with  con- 
stitutional symptoms  such  as  fever,  etc.  2.  More 
localized  areas  of  disease  in  the  larynx,  either  of  in- 
filtration or  ulceration,  without  active  inflammation 
of  the  surrounding  tissues,  the  pulmonary  lesion  be- 
ing inactive  and  there  being  no  marked  constitu- 
tional symptoms.  3.  Marked  and  extensive  involve- 
ment of  the  larynx,  either  with  or  without  ulcera- 
tion, particularly  involvement  of  the  arytenoids  v.ith 
gray  infiltration,  and  of  the  epiglottis,  either  with 
or  without  active  pulmonary  disease.  Cases  of  the 
first  class  need,  primarily,  treatment  of  the  patient, 
and,  secondarily,  treatment  of  the  larynx.  Th'ey 
.should  be  placed  under  the  best  hygienic  conditions, 
if  possiI)le  in  a  sanatorium,  where  they  will  have 
constant  medical  supervision.  Complete  silence 
should  be  enjc)ined  and  cough  controlled.  If  they 
arc  strong  enougli,  the  larvnx  may  be  treated  sev- 
eral times  daily  with  antiseptic  cleansing  sprays, 
like  Dobcll's  solution,  which  may  be  followed  by 
sootliing  sprays  or  inhalations,  such  as  menthol  and 
guaiacol  in  a  bland  oil.  As  the  acute  inflammation 
subsides,  astringent  and  antiseptic  sprays  should  be 


added  to  the  treatment  or  these  agents  may  be  ap- 
plied with  a  brush.  For  the  ulcerations,  in  cases  of 
this  type,  the  author  uses  lactic  acid  or  iodoform. 
Cases  of  the  second  class  need  more  active  treat- 
inent.  If  there  is  catarrh,  the  cleansing  spray 
should  be  used.  For  ulcerations,  without  doubt  the 
best  agent  is  lactic  acid.  The  application  of  the 
acid  should  be  preceded  by  sprays  to  w^ash  as  clean 
as  possible  the  surface  of  the  ulcers.  If  the  physi- 
cian has  acquired  sufficient  skill,  and  the  larynx  is 
roomy  enough  to  allow  definite  work,  the  ulcers 
may  be  curetted  previous  to  the  use  of  the  lactic 
acid.  For  the  destruction  of  localized  areas  of  in- 
filtration, the  best  and  most  reliable  agent  is  the 
electric  cautery.  Cases  of  the  third  class  we  can- 
not hope  to  cure,  only  to  relieve.  The  pressing 
symptoms  which  call  for  relief  are  pain  and  diffi- 
culty of  breathing.  Here  again  Dobell's  solu.ion  is 
of  great  use^  dissolving  and  removing  the  sticky 
mucus.  For  the  pain  orthoform  in  powder  form 
may  be  used.  Sooner  or  later  cocaine  or  morphine 
must  be  used,  in  order  that  the  patient  may  not  only 
be  relieved  of  pain,  but  that  he  may  take  food. 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 

December  26,  igo8. 

1.  Yellow  Fever  and  the  Mosquito,  By  J.  H.  White. 

2.  Mosquito  Destruction  in  the  Tropics.    Occurrence  and 

Habits  of  Anopheles ;  Breeding  Places ;  Methods  of 
Destruction;  Conditions  that  Favor  Anophele  Prop- 
•  agation ;  Results  of  Antimalarial  Work, 

By  J.  A.  Le  Prince. 

3.  Clinical  and  Medicolegal  Significance  of  Slight  Trauma 

to  Joints,  By  Sidney  Lange. 

4.  The  Registration  of  Vital  Statistics, 

By  Cres.sy  L.  Wilbur. 

5.  Use  of  Digitalis  in  Pneumonia, 

By  Thomas  F.  Reillv. 

6.  Hemorrhagic  Diseases  of  the  Newborn, 

By  Henry  Enos  Tulev. 

I,  2.  Mosquito  Extermination.  —  W  hite  con- 
cludes that  we  should  insist  upon  the  three  points : 
I.  Destroy  within  our  own  borders  all  disease  bearing 
mosquitoes.  2.  P^ollow  the  advice  of  Surgeon  General' 
Wyman  given  in  1895  in  his  letter  to  the  Secretary  of 
the  Treasury  strongly  urging  that  Havana  and  all 
other  then  existing  danger  points  be  compelled  to 
clean  themselves.  3.  Educate  all  our  young  physicians 
as  profoundly  as  we  can  in  entomology  and  in  tropical 
medicine,  remembering  that  it  is  no  small  part  of 
the  duty  of  the  physician  to  educate  his  people  in 
sanitation. — Prince  observes  that  in  the  north  the 
following  conditions  favor  extermination:  i.  The 
breeding  sea  .son  is  short.  2.  There  is  a  period  of 
drought  in  the  middle  of  that  season.  3.  Growth  of 
aquatic  vegetation,  alg;e,  and  grass  is  relativelv 
slower.  4.  Frequent  cleaning  of  open  ditches  is  not 
so  necessary  as  in  southern  climates.  5.  The  rain- 
fall is  not  heavy — relatively  long  periods  occur  be- 
tween rains,  hence  the  number  of  breeding  areas  is 
relatively  small.  6.  The  breeding  places  arc  more- 
accessible  and  easier  to  locate.  In  the  tropical  and 
semitropical  countries  the  destruction  of  mosqui- 
toes is  more  difficult.  The  author  mentions  among 
the  reasons  the  following :  The  ovidepositing  con- 
tinues e'lch  month  throughout  the  year.  During  the 
rainy  season  the  periods  between  rains  are  .short. 
The  open  drainage  ditches  in  the  tropics  could  be- 
come a  veritable  Mecca  for  anopheles.  In  order  to 
keep  a  ditch  of  low  grade  or  a  .stream  perfectly  free 
from  vegetable  growth  and  alg.-e.  so  that  the  fish 


January  2,  igc.g.] 


PITH  OF  CURRENT  LITERATURE. 


37 


may  have  access  to  all  parts  of  it,  it  would  be  neces- 
sary carefully  and  properly  to  clean  out  such  a  ditch 
or  stream  about  every  ten  days.  There  have  been 
installed  in  the  Canal  Zone  considerable  tile  drain- 
age during  the  past  year  and  the  results  of  such 
work  were  exceedingly  satisfactory.  The  malarial 
situation  in  1907  was  a  vast  improvement  over  that 
of  1906.  So  far  this  year,  aside  from  light  cases  at  the 
local  sick  camps,  the  percentage  of  employees  sent  to 
the  hospitals  with  malaria  averages  about  seventy- 
five  per  cent,  less  than  during  January  to  April,  in- 
clusive, of  last  year.  This  is  for  the  territory  be- 
tween La  Boca,  on  the  Pacific  side,  and  Gatun, 
where  the  locks  are  to  be  built.  This  territory  is 
fortv-two  miles  long  and  Gatun  is  about  six  miles 
from  the  Caribbean  Sea.  At  the  end  of  April,  1908, 
the  lowest  weekly  sick  rate  was  reached.  During 
the  week  ending  May  2  only  one  malarial  patient 
was  sent  to  the  hospital  for  each  1,000  employees 
at  work. 

4.  The  Registration  of  Vital  Statistics. — Wil- 
bur gives  the  following  as  essential  requirements 
for  registration  of  deaths:  i.  Deaths  must  be 
recorded  immediately  after  their  occurrence.  2.  Cer- 
tificates of  death  of  standard  form  should  be  used. 
3.  Burial  or  removal  permits  are  essential  to  the 
enforcement  of  the  law.  .4.  Efficient  local  registrars 
are  necessary.  5.  The  responsibility  for  reporting 
deaths  to  the  local  registrar  should  be  placed  on  the 
undertaker  or  other  person  having  charge  of  the 
disposition  of  the  body.  6.  The  central  registration 
office  should  have  full  control  of  the  local  machinery, 
and  its  rules  should  have  the  eft'ect  of  law.  7.  The 
transmission  and  preservation  of  returns  should  be 
provided  for.  8.  Penalties  should  be  provided  and 
enforced.  Essential  requirements  for  registration  of 
births:  i.  Births  must  be  recorded  immediately 
after  their  occurrence.  2.  Certificates  of  birth  of 
standard  form  should  be  required.  3.  Some  check 
is  necessary  to  secure  enforcement  of  the  law.  4. 
Efficient  local  registrars  are  necessary.  5.  The  re- 
sponsibility for  reporting  births  to  the  local  registrar 
should  be  placed  upon  the  attending  physician  or 
midwife,  and  upon  the  parents  if  no  physician  or 
midwife  was  in  attendance.  6.  The  central  regis- 
tration office  should  have  full  control  of  the  local 
machinery,  and  its  rules  should  have  the  effect  of 
law.  7.  The  transmission  aiid  preservation  of  re- 
turns should  be  provided  for.  8.  Penalties  should 
be  provided  and  enforced.  Our  State  boards  of 
health  should  be  strengthened  when  weak,  and  they 
should  have  ample  provisions  for  the  necessary  cost 
of  registration  of  vital  statistics — which  is  not  ex- 
cessive-— when  this  duty  is  imposed  on  them.  They 
should  obtain  the  best  ability  possible  to  direct  the 
registration  work,  and  should  support  it  firmly  in 
the  fearless,  but  imiform  and  equitable,  enforcement 
of  the  law.  If  they  cannot  obtain  money  for  this 
purpose  or  command  executive  ability,  they  should 
retire  from  the  field  and  seek  to  build  up  a  bureau 
of  vital  statistics  in  some  more  favored  department 
of  the  government.  But  it  will  usually  be  possible 
to  secure  the  necessary  means,  and  care  should  be 
taken  that  thev  are  devoted  to  the  fundamental  re- 
quirement of  better  vital  statistics  rather  than  di- 
verted to  more  attractive  but  less  essential  lines  of 
work.  If  vital  statistics  are  in  fact,  and  not  as  a 
mere  theory,  the  foundation  of  sanitation,  then  one 


should  insist  on  a  good  foundation  before  attem])t- 
ing  much  of  a  superstructure. 

6.  Haemorrhagic  Diseases  of  the  Newborn. — 
Tuley  gives  a  good  resume  of  the  treatment  in  such 
conditions  :  Kophk  suggests  the  cold  coil ;  ergotin, 
14  to  ^  grain  subcutaneously ;  Henoch  suggests  one 
drop  of  liquor  ferri  sesquichloridi  in  barley  water, 
every  hour;  Williams  suggests  gallic  acid,  gr.  i, 
every  three  hours,  oil  of  turpentine,  tti  i,  in  mucilage 
every  hour;  extract  of  krameria,  grains  2,  every  two 
or  three  hours,  or  an  injection  into  the  bowel  of  an 
infusion  4  to  5  ounces,  and  calcium  chloride  to  in- 
crease the  coagulability  of  the  blood.  Weil,  of  Paris, 
experimented  in  patients  with  hfemophilia,  in  whom 
he  w^as  able  to  control  the  tendency  to  bleed  for  a 
certain  time  with  the  injections  of  fresh  serum.  He 
states  that  the  "sera  of  man,  the  rabbit,  horse,  and  , 
cattle  have  been  found  equally  efficacious,  although 
in  vitro,  the  action  of  the  human  serum  is  more  evi- 
dent in  correcting  the  disorder."  He  injects  30  c.c. 
under  the  skin,  and  suggests  the  use  of  diphtheritic 
serum,  if  fresh. 

MEDICAL  RECORD. 

December  26,  1908. 

1.  Tuberculosis  among  the  Jews,     By  Maurice  Fishberg. 

2.  Italian  Immigration  and  Insanity, 

By  Albert  Warren  Ferris. 

3.  The  Opiate  Habit,  By  William  F.  Waugh. 

4.  Early  Diagnosis  of  Gastric  Carcinoma, 

By  Anthony  Bassler. 

5.  System  and  the  Doctor,        By  Leonard  K.  Hirshbekg. 

6.  I'ansinnsitis  Dextra  with  Paralysis  of  the  Right  Vocal 

Cord,  By  Irving  Wilson  Voorhees. 

7.  The   Prevention   of   H.Temorrhage   during  Operations 

upon  the  Nose  and  Throat, 

By  Henry  Hubbard  Pelton. 

I.  Tuberculosis  among  the  Jews. — Fishberg 
observes  that  the  eft'ects  of  the  thorough  urbaniza- 
tion of  the  Jews  are  manifesting  themselves  in  mnnv 
other  ways.  It  has  been  observed  by  many  physi- 
cians that  even  when  infected  by  the  tubercle  bacilli 
the  prognosis  is  more  favorable  in  the  Jew  than  in 
other  people.  The  course  of  the  disease  is  slower. 
He  has  seen  very  few  cases  of  tuberculosis  of  the 
fulminant  or  galloping  type  among  several  thousand 
cases  of  consumption  in  Jews.  Acute  miliary  tu- 
berculosis is'  very  rare  indeed  among  them.  The 
cases  in  which  the  victim  is  stricken  with  high 
fever,  rapid  extension  of  the  disease  with  cavity 
formation  within  a  few  weeks  or  months  are  also 
rare.  But  cases  of  the  extreme  chronic  type,  run- 
ning on  for  years  and  still  permitting  the  victim  to 
make  himself  useful  at  soine  easy  occupation,  are 
common ;  more  so  than  among  other  people  of  the 
same  social  status.  To  a  certain  extent  this  is  also 
due  to  the  infrequency  of  alcoholics  among  them, 
but  this  alone  does  not  explain  the  condition.  It 
appears  that  thoroughly  urbanized  humanity  does 
not  off^er  a  goOd  soil  for  the  growth  and  develop- 
ment of  the  tubercle  bacilli,  while  the  inhabitant  of 
the  open  plain,  and  less  so  the  peasant  or  farmer  in 
modern  European  and  American  villages,  ofifers  a 
virgin  soil  for  these  parasites.  This  is  the  onlv 
reasonable  way  to  explain  the  high  rates  of  morbid- 
ity and  mortality  from  tuberculosis  of  the  rural 
dwellers  who  emigrate  to  cities.  Being  more  pre- 
disposed to  infection  they  also  more  often  supplv 
cases  of  the  acute  fulminant  or  galloping  type,  as 
well  as  acute  miliarv  tuberculosis.    There  are  indi- 


38 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Jourkai„ 


cations  that  this  advantage  of  the  Jews  is  not  per- 
manent. It  appears  that  in  eastern  Europe  tuber- 
culosis has  been  on  the  increase  during  recent  years, 
and  the  same  has  been  reported  from  London.  In 
New  York  city  the  number  of  applicants  to  the 
United  Hebrew  Charities  who  suffer  from  tuber- 
culosis has  exceeded  i,ooo  during  1907,  while  six 
years  ago  only  one  half  that  number  applied.  The 
total  number  of  applications  for  relief  has  not  in- 
creased materially  during  these  years.  It  seems 
that,  adapted  as  they  are  to  indoor  life,  they  still 
cannot  resist  infection  when  their  economic  condi- 
tions become  very  unfavorable. 

3.  The  Opiate  Habit. — Waugh  says  that  the 
treatment  should  consist  in  elimination.  We  must 
rid  our  patient  of  his  stored  toxines,  must  disembar- 
rass his  system  of  the  excess,  and  reduce  his  manu- 
facture of  new  toxines  to  that  point  at  which  he 
will  need  no  opiate  inhibition  to  make  him  comfort- 
able. If  elimination  is  thus  established  he  will  find 
the  need  for  opiate  lessening  with  each  discharge  of 
excretory  material,  and  it  will  be  merely  a  matter  of 
time  when  he  will  need  none.  Empty  the  impacted 
colon,  loosen  the  masses  of  toxines  stored  in  the 
liver,  keep  the  renal  action  up  to  its  highest  level  of 
efficacy,  incite  the  skin  to  aid  in  throwing  off  the 
toxic  products  whenever  there  is  evidence  of  their 
active  presence  in  the  blood.  Meanwhile,  give  a 
nonnitrogenous  diet,  and  keep  the  patient  at  rest  as 
absolutely  as  circumstances  permit.  The  means  to  be 
employed  to  secure  these  ends  vary  with  each  case, 
and  the  physician  who.  treats  such  maladies  must 
be  qualified  to  fit  his  treatment  to  the  varying  indi- 
cations that  are  present.  But  time  must  be  allowed 
for  the  altered  conditions  to  be  established,  for  the 
patient  to  learn  to  live  without  drugs,  for  the  vari- 
ous organs  to  accustom  themselves  to  functionate  in- 
dependently of  drug  control.  It  is  not  too  much  to 
exact  a  year's  absolute  rest,  of  real  playtime,  after 
the  cessation  of  the  habit.  During  this  period  the 
metabolism  is  apt  to  fall  into  arrears,  and  toxines 
tend  to  accumulate.  One  of  the  most  significant 
symptoms  of  this  period  is  a  subnormal  temperature. 
Another,  usually  accompanying  it,  is  respiratory  op- 
pression. These  demand  instant  action,  in  emptying 
the  bowels,  unloading  the  liver,  and  stimulating  all 
the  vital  functions  by  the  use  of  that  priceless  vital- 
izer,  strychnine.  Calomel,  emetine,  pilocarpine, 
strychnine,  juglandin,  and  salines  should  be  always 
at  the  patient's  disposal,  and  he  himself  should  be 
carefully  instructed  in  their  application,  so  that  he 
may  be  independent  of  the  chance  practitioner,  who 
may  be  of  the  sort  who  look  on  "suffering  as  an  in- 
dication for  morphine."  With  a  year  of  rest,  prop- 
erly so  called,  there  is  no  reason  for  any  cured  pa- 
tient relapsing. 

BRITISH  MEDICAL  JOURNAL. 
December  5,  190S. 

1.  The  Use  and  Abuse  of  the  Curette, 

By  G.  E.  Herman. 

2.  Remarks  on  Pregnancy  Complicated  by  Fibromyomata 

of  the  Uterus.  A  Record  of  Ten  Cases  Treated  by 
Laparotomy,  By  F.  W.  N.  Haultain. 

3.  Puerperal  Eclampsia,  By  J.  Lytle. 

4.  A  Contribution  to  the  Physiology  of  the  Falloppian 

Tube,  By  J.  T.  Shirlaw. 

5.  A  Case  of  Uterine  Arteriosclerosis,       By  J.  Pearse. 

6.  Axis  Traction  Forceps,  By  J.  R.  Purdy. 

7.  Some  of  the  Effects  of  Excessive  Smoking. 

By  J.  D.  Mann. 


8.  Notes  of  a  Case  of  Osteitis  Deformans, 

By  S.  White. 

9.  Note  upon  a  Case  of  Cancer   of   the   Right  Breast 

"Cured"  by  the  Cardigan  "Cancer  Curers."  The 
Aftermath:  A  Danger  Signal  to  the  Public, 

By  J.  L.  Thomas. 
10.    Syphillis  Communicated  by  Industrial  Implements, 

By  S.  Snell. 

1.  The  Uterine  Curette. — Herman  discusses 
the  use  and  abuse  of  curetting  in  diseases  of  the 
uterus.  There  are  three  reasons  which  are  too 
widely  accepted  at  the  present  time.  These  are: — i. 
Curetting  merely  because  the  patient  is  anaesthetised 
for  some  other  operation,  the  curetting  being  ap- 
parently supposed  to  be  in  some  way  beneficial  to  a 
healthy  uterus.  2.  Curetting  a  uterus  which  has 
been  infected  with  pathogenic  microbes,  with  the 
idea  that  it  is  possible  to  scrape  away  the  whole  of 
the  infected  tissue.  3.  Curetting  neurasthenic  pa- 
tients for  pain,  without  excessive  haemorrhage,  the 
pain  being  supposed  to  be  due  to  endometritis 
brought  about  by  variations  in  the  shape  and  size  of 
the  uterus,  all  these  changes  never  having  been 
shown  to  be  pathological.  The  real  use  of  the  cu- 
rette or  scraper  is  to  remove  new  growths,  either  as 
a  treatment  or  for  diagnosis.  In  a  case  of  haemor- 
rhage severe  enough  to  weaken  the  patient,  where 
bimanual  examination  reveals  nothing,  the  proper 
treatment  is  to  dilate  the  cervix  and  explore  the 
uterine  cavity  with  the  finger.  If  nothing  can  be 
felt  which  can  be  removed  with  a  forceps,  the  en- 
dometrium should  be  scraped  and  the  scrapings  ex- 
amined. The  haemorrhage  may  be  due  to  overgrowth 
— so  called  "hyperplastic  endometritis"  although 
there  is  no  inflammation.  The  morbid  change  is 
an  adenomatous  growth,  the  endometrium  coming 
away  in  soft,  gelatinous  looking  flakes.  Sometimes  a 
small  polypus  or  polypi  exist  in  the  uterine  cavity — 
"fungous,"  "nelous,"  or  "polypoid"  endometritis. 
It  is  not  common  and  occurs  mostly  in  women  near 
the  climacteric.  Sometiines  one  scraping  will  stop 
the  hasmmorhage  and  cure  the  patient.  If  it  recurs, 
hysterectomy  should  be  performed.  The  scraper  is 
useful  in  some  illnesses  following  pregnancy — 
haemorrhages  due  to  abortion,  oncoming  abortion^ 
etc.  In  conclusion  emphasis  is  laid  on  the  statement 
that  curetting  the  uterus  is  not  a  remedy  for  pain. 

2.  Pregnancy  and  Fibromyomata. — Haultain 
reports  ten  cases  of  pregnancy  complicated  by  fibro- 
myomata, and  treated  by  laparotomy  with  two 
deaths.  The  complication  is  not  a  frequent  one. 
The  induction  of  abortion  is  to  be  entirely  depre- 
cated and  should  never  be  resorted  to,  the  dangers 
of  abortion  being  very  great,  and  it  being  almost 
certain  that  the  woman  will  have  to  undergo  fur- 
ther treatment  by  myomectomy  or  hysterectomy. 
Myomectomy,  when  practicable,  is  the  ideal  treat- 
ment, but  it  is  unfortunately  unsuitable  in  most 
cases  because  of  the  multiplicity  of  the  growths, 
their  degenerations,  and  sessile  character.  Statistics 
also  show  it  to  be  more  dangerous  than  hysterec- 
tomy. During  pregnancy  hysterectomy  is  more 
easily  performed  than  usual,  because  of  the  softness 
of  the  surrounding  tissues  and  the  laxity  of  the  peri- 
tonaeum. The  author's  conclusions  are: — I.  Fi- 
broids tend  toward  sterility.  2.  The  association  of 
pregnancy  with  fibroids  in  themselves  sufficient  to 
give  rise  to  symptoms  is  ah  extremely  anxious  com- 
plication.   3.    Treatment  in  all  cases  should  be  ex- 


January  2,  1909.] 


FITH  OF  CURRENT  LITERATURE. 


39 


pectant,  but  on  complications  arising  myomectomy 
or  hysterectomy  should  be  adopted. 

3.  Puerperal  Eclampsia. — Lytle  defines  puer- 
peral eclampsia  as  a  form  of  epileptiform  convul- 
sions occurring  during  the  latter  months  of  preg- 
nancy or  during  the  after  parturition,  and  caused 
primarily  by  the  effects  of  the  pregnancy  on  the  or- 
ganism. The  predisposing  causes  are  acute  and 
chronic  diseases  of  the  kidney,  especially  pregnancy 
kidney,  obstructed  delivery,  a  neurotic  tempera- 
ment,' old  and  very  young  women,  long  retention 
of  the  excretions,  multiple  pregnancy,  and  illegiti- 
macy. The  first  symptom,  and  the  one  general- 
ly overlooked,  is  the  presence  of  albumin  in  the 
urine.  Diminution  of  the  excretion  of  urea  is  also 
important,  other  symptoms  being  headache,  vertigo, 
drowsiness,  depression,  and  epigastric  pain.  (Edema 
of  the  feet  and  eyelids  may  be  present.  The  symp- 
toms of  the  actual  attack  generally  occur  about 
the  eighth  month,  and  resemble  an  ordinary  attack 
of  epilepsy,  except  that  there  is  no  aura,  and  that 
there  is  a  preliminary  stage  of  convulsive  move- 
ments of  the  head  and  face.  Then  follow  in  suc- 
cession the  stages  of  tonic  and  clonic  convulsions, 
succeeded  in  turn  by  stupor  or  coma,  the  tempera- 
ture generally  rising.  Eclampsia  has  to  be  distin- 
guished from  epilepsy,  hysteria,  alcoholic  coma,  and 
convulsions,  and  the  convulsions  of  cerebral  and 
meningeal  disease.  The  principal  complications  are 
cardiac  failure,  oedema  of  the  lungs,  cerebral  haemor- 
rhage, and  septic  inhalation  pneumonia.  The  prog- 
nosis for  the  mother  is  very  grave,  the  average  mor- 
tality being  about  twenty  per  cent.  The  prognosis 
is  improved  by  the  death  of  the  foetus.  The  gravity 
of  the  prognosis  depends  upon  the  number  and  se- 
verity of  the  fits,  the  length  of  the  coma,  the  quantity 
of  urine  passed,  and  the  amount  of  albumin  it  con- 
tains, the  temperature,  and  the  condition  of  the 
heart  and  lungs.  Attacks  during  pregnancy  or 
labor  are  more  dangerous  than  those  occurring  after 
labor.  The  foetal  mortality  is  about  fifty  per  cent. 
The  principal  objects  of  treatment  are  tO'  control  the 
fits,  to  eliminate  the  toxines  from  the  blood,  and  to 
empty  the  uterus.  To  control  the  fits  the  principal 
drugs  used  are  the  vascular  depressants  such  as 
veratrum  viride,  and  the  narcotics  such  as  chloro- 
form, chloral,  and  morphine.  Pilocarpine  and  nitro- 
glycerin have  also  been  recommended.  The  elim- 
inative  treatment  consists  in  removing  the  toxic  sub- 
stances from  the  blood  by  the  bowels  and  the  skin, 
and  reestablishing  the  action  of  the  kidneys — hy- 
dragogue  purgatives,  diaphoretics,  and  diuretics  be- 
ing indicated.  The  writer  is  strongly  in  favor  of 
emptying  the  uterus  by  operative  treatment.  If  the 
patient  is  in  labor  and  progressing  favorably,  con- 
trolling the  attack  by  morphine  may  be  all  that  is 
required.    If  the  os  is  dilated  forceps  may  be  used. 

7.  Excessive  Smoking.- — Mann  discusses  the 
ef¥ects  of  excessive  smoking,  and  divides  them  into 
two  stages — one  group  in  which  no  recognizable 
organic  changes  have  been  produced,  the  other  where 
such  changes  are  in  progress.  In  the  first  group, 
various  functional  disorders  manifest  themselves, 
palpitation  of  the  heart,  which  is  worse  at  night,  fail- 
ure of  vision,  etc.  The  alterations  in  vision  afiford 
the  most  convincing  diagnostic  indication  of  chronic 
nicotine  pyoisoning.    The  visual  field  is  sometimes 


concentrically  contracted ;  but  of  much  greater  im- 
jjortance  is  the  presence  of  a  scotoma  for  red  or 
green,  either  partial  or  complete.  In  the  second 
group,  the  organic  disorders  caused  by  excessive 
smoking,  are  included  arteriosclerosis,  angina  pec- 
toris, degeneration  of  the  myocardium,  and  other 
circulatory  disorders.  Dysbasia  angiosclerotica  (in- 
termittent limp)  is  very  frequently  due  to  nicotine 
poisoning. 

LANCET. 

December  5,  1908. 

1.  The  Latent  Persistence  and  the  Reactivation  of  Patho- 

genic Bacteria  in  the  Body  (Horace  Dobell  Lec- 
ture), By  L.  S.  Dudgeon. 

2.  Further  Notes  on  the  Treatment  of  Syphilis  by  Arylar- 

sonates,  By  F.  J.  Lambkin. 

3.  The  Common    Cold :    Its    Pathology  and  Treatment. 

With  Especial  Reference  to  Vaccine  Therapy  {Con- 
cluded), By  R.  W.  Allen. 

4.  Prophylaxis  in  Acidosis  Following  Anaesthesia, 

By  F.  H.  Wallace  and  E.  Gillespie. 

5.  A  Case  of  Aneurysm  of  the  Anterior  Cerebral  Artery, 

By  A.  S.  MacNalty. 

6.  A  Note  on  the  Bacterial  Contamination  of  Milk  as 

Illustrating  the  Connection  between  Flies  and  Epi- 
demic Diarrhoea,  By  J.  T.  C.  Nash. 

7.  A  Case  of  Traumatic  Exophthalmos, 

By  D.  Ranken. 

8.  Extension  of  a  Pleural  Effusion  toward  the  Sound 

Side  in  a  Still  Born  Child  Corresponding  to  Grocco's 
Paravertebral  Triangle, 

By  R.  D.  Keith  and  A.  Keith. 

9.  Motoring  Notes,  By  C.  T.  W.  Hirsch. 

I.  Persistence  of  Bacteria  in  the  Body. — Dud- 
geon discusses  the  existence  of  the  more  important 
pathogenic  bacteria  in  normal  tissues,  and  their  per- 
sistence in  the  body  subsequent  to  some  infective 
lesion.  It  is  now  being  recognized  that  pathogenic 
bacteria  may  persist  in  the  tissues  for  varying  peri- 
ods without  causing  any  ill  health  in  the  patient  in 
whose  tissues  they  occur,  but  at  any  period  they 
may  leave  their  host  to  infect  others,  or  may,  from 
some  unknown  reason,  excite  inflammatory  changes 
in  the  tissues  in  which  they  have  been  living  in  an 
inactive  state.  The  Staphylococcus  epidermidis 
albus  is  a  normal  inhabitant  of  the  human  skin,  and 
after  operations  is  liable  to  give  rise  to  infections 
of  more  or  less  severity.  It  is  one  of  the  most  im- 
portant organisms  in  peritoneal  infections.  It  is 
probably  identical  with  the  Micrococcus  neoformans, 
which  occurs  so  frequently  in  malignant  growths. 
The  pneumococcus  was  first  discovered  as  the  result 
of  the  examination  of  the  saliva  of  a  normal  person. 
It  is  very  common  in  the  saliva,  in  the  normal  nose, 
and  in  the  tonsillar  crypts.  The  gonococcus  may 
remain  in  the  tissues  for  indefinite  periods  without 
producing  ill  efifects.  Diphtheria  bacilli  are  capable 
of  retaining  their  virulence  for  long  periods  in  the 
throats  of  infected  persons  without  giving  rise  to 
any  abnormal  condition  of  the  throat.  The  Bacillus 
proteus  persists  in  the  urine  for  indefinite  periods 
and  causes  attacks  of  so  called  alkaline  cystitis.  In 
some  cases  of  cerebral  abscess  it  is  the  only  organ- 
ism which  can  be  cultivated  from  the  piis.  The 
colon  bacillus  is  a  normal  inhabitant  of  the  intestinal 
tract ;  on  the  other  hand,  it  is  the  most  constant 
organism  met  with  in  the  bacteriology  of  appen- 
dicitis and  peritonitis.  Many  surgeons  have  cases  of 
appendicular  inflammation  vaccinated  with  this  or- 
ganism previous  to  operation.  The  urinary  tract  may 
be  infected  with  the  colon  bacillus  without  any  in- 


40 


PITH  OF  CURRENT  LITERATURE. 


[Ne.v  York 
Medical  Journal. 


flammatory  condition  being  given  rise  to  and  with- 
out any  symptoms.  The  persistence  of  typhoid 
bacilH  in  the  gallbladers  of  so  called  "typhoid  car- 
riers" need  only  be  mentioned.  Organisms  of  the 
typhoid  paratyphoid  group,  which  are  capable  of 
giving  rise  to  serious  epidemics,  may  practically  live 
as  saprophytes  in  our  tissues,  with  or  without  occa- 
sional periods  of  activity,  or  be  discharged  from  our 
bodies  and  thus  be  the  source  of  acute  infection  in 
a  fresh  host. 

3.  The  Common  Cold. — Allen  sums  up  his  con- 
clusions as  follows  ;  i.  There  are  at  least  five  organ- 
isms capable  of  the  production  of  an  attack  of  acute 
nasal  catarrh,  viz.:  (i)  The  bacillus  of  influenza; 
(2)  the  Bacillus  scpticus;  (3)  the  bacillus  of  Fried- 
lander ;  (4)  the  Micrococcus  catarrlialis;  and  (5) 
the  Micrococcus  paratetragenus.  2.  These  may  be 
present  in  the  nasopharyngeal  space  in  a  certain 
percentage  of  cases  which  exhibit  no  pathological 
features ;  increase  of  virulence  and  lowered  resist- 
ance of  the  tissues  may  light  them  up  into  activity. 
In  other  cases  the  infection  is  one  from  without. 
3.  Each  organism  produces  its  own  type  of  cold, 
and  a  differential  diagnosis  of  the  organism  is  pos- 
sible from  a  consideration  of  the  clinical  features  ; 
this  is  more  difficult  should  the  infection  be  a  mul- 
tiple one.  4.  This  distinctive  diagnosis  is  of  con- 
siderable value  both  in  prognosis  and  in  treatment. 

5.  Chronic  nasal  catarrh  is  probably  always  due  to 
infection  by  the  bacillus  of  Friedlander,  unless  the 
Eustachian  tube  and  middle  ear  be  involved  by  the 
Micrococcus  catarrlialis ;  chronic  tracheal  catarrh 
to  infection  by  the  Micrococcus  catarrlialis  or 
Micrococcus  paratetragenus,  to  which  secondary  in- 
fection by  staphylococci,  streptococci,  pneumococci, 
and  other  pathogenic  organisms  may  be  superadded. 

6.  For  infection  local  defect  of  opsonin  and  for  cure 
local  increase  of  opsonin  are  probably  necessary 
conditions.  7.  By  means  of  the  injection  of  the 
corresponding  bacterial  vaccines  an  attack  of  an 
acute  cold  due  to  any  given  organism  or  organisms 
can  be  considerably  shortened  and  complications  be 
probably  prevented.  8.  In  a  similar  manner  chronic 
infections  may  be  cured.  9.  By  injection  of  the 
vaccines  of  the  several  organisms  in  appropriate 
doses  and  at  appropriate  intervals,  considerable  if 
not  complete  immunity  against  future  attacks  of 
acute  cold  may  be  secured.  In  those  who  are  very 
susceptible  and  fall  victims  to  every  epidemic  th  u 
may  occur,  the  best  procedure  probably  is  systemati  • 
immunisation  every  four  to  six  months  against  all 
the  cold  organisms  and  special  immunisation  against 
the  particular  organism  or  organisms  which  may  be 
responsible  for  the  appearance  of  subsequent  epi- 
<lemics  against  which  protection  is  desired. 

LA  PRESSE  MEDICALE 

October  3J,  1908. 

1.  Search  for  tlie  Meningococcus  in  the  Nasal  Fossa, 

By  DoPTER  and  Koch. 

2.  Lumbar  Anrcsthcsia  by  Means  of  Stovaine  and  Strych- 

nine Combined,  By  R.  Rom  me. 

I.  The  Meningococcus  in  the  Nasal  Fossa. — 
Dopter  and  Koch  come  to  the  following  conclu- 
sions: The  search  for  the  meningococcus  should  be 
niarlc  not  only  in  the  nasal  fossa,  but  also  in  the 
riiinf)i)harynx,  which  is  its  chosen  habitat,  not  only 
in  persons  with  meningitis,  but  also  in  those  who 


carry  the  germs.  The  direct  microscopical  exam- 
ination of  the  mucus  from  the  nasopharynx  does  not 
suffice  for  the  identification  of  the  meningococcus, 
because  numerous  species  of  germs  which  resemble 
this,  but  are  entirely  different,  can  be  found  in  both 
patients  and  normal  persons  either  alone  or  asso- 
ciated with  the  meningococcus.  The  morphological 
aspect  of  a  single  one  of  these  germs  isolated  by 
culture  from  the  mucus  of  the  rhinopharynx  is  like- 
wise incapable  of  making  the  distinction.  Study  of 
the  pathogenic  power  cannot  be  relied  upon.  Two 
simultaneous  tests  enable  us  to  arrive  at  an  exact 
diagnosis,  the  fermentation  of  sugar  and  the  agglu- 
tination by  a  specific  serum. 

November  4,  190S. 

1.  The  Decalcifying  Regime  in  Atheroma  of  the  Arteries. 

By  Maurice  Loeper  and  Xavier  Gouraud. 

2.  Symptomatology  of  the  Supraspinous  Fossa,  the  Zone 

of  Alarm  in  Tuberculosis,      By  Stephen  Chauvet. 

1.  Decalcifying  Regime  in  Atheroma. — Loeper 
and  Gouraud  say  that  it  is  necessary  to  distinguish 
between  the  preventive  and  the  curative  inedications 
in  the  treatment  of  persons  threatened  with  athe- 
roma and  of  others  already  atheromatous.  Preven- 
tive medication  consists  of  the  establishment  of  a 
regime  destitute  so  far  as  possible  of  calcareous 
salts,  and  of  a  therapeusis  which  facilitates  elimina- 
tion, both  urinary  and  intestinal.  Curative  medica- 
tion, which  is  infinitely  less  efficacious  and  more 
dangerous,  does  not  consist  of  the  administration  of 
acids  and  of  the  iodides  in  large  doses  because  these 
substances  mobilize  and  transport  the  fixed  lime  of 
the  bones  and  cartilages  into  the  soft  tissues,  the  cal- 
careous coefficient  of  which  they  increase.  It  is 
much  better  to  give  sodium  bicarbonate,  as  this  is 
able  to  remove  the  lime  from  the  soft  tissues  with- 
out attacking  the  fixed  lime  in  the  bony  and  car- 
tilaginous tissues. 

2.  Symptomatology  of  the  Supraspinous  Fossa. 
— Chauvet  declares  that  the  supraspinous  fossa  fur- 
nishes a  little  zone  in  which  one  is  apt  to  find  the 
first  physical  signs  of  tuberculosis.  The  prognosis 
of  this  disease  is  dependent  undeniably  on  the  earli- 
ness  of  the  diagnosis,  and  therefore  this  region  as- 
sumes the  value  of  a  true  zone  of  alarm.  At  a  more 
advanced  period  of  the  disease  this  region  is  the  one 
in  which  the  physical  signs  indicative  of  the  pul- 
monary lesions  are  to  be  heard  most  clearly. 

LA  SEMAINE   MEDICALE,  ' 
November  4,  1908. 

1.  Should  Extrauterine  Pregnancy  be  Operated  on  during 

Shock?  By  Professor  R.  de  Bovi.';. 

2.  Ts   the   Antitryptic   Power  of   Serum   of  Diagnostic 

Value?  By  L.  Ambard. 

1.  Operation  for  Extrauterine  Pregnancy. — 

De  Bovis  presents  the  arguments  urged  for  and 
against  immediate  operation,  but  fails  to  decide  the 
question.  Over  a  third  of  the  many  references  are 
to  American  surgeons  and  their  writings. 

2.  Diagnostic  Power  of  Antitryptic  Serum. — 
Ambard  says  that  we  are  brought  to  consider  the 
augmentation  of  the  antitryptic  power  of  the  serum 
as  a  consequence  of  pancreatic  hypersecretion,  and 
it  is  conceivable,  if  the  facts  finally  confirm  this  in- 
terpretation, that  we  have  in  this  sign  a  relatively 
simple  means  of  diagnosis  of  a  modification  of  the 
pancreatic  secretion. 


January  2,  1909.) 


PITH  OF  CURRENT  LITERATURE. 


41 


BERLINER  KLINISCHE   WOCH ENSCH Rl FT 

XoTCiiibcr  790^. 

1.  When  and  in  What  Wav  Should  Retrodeviations  of  the 

Uterus  be  Treated?  By  P.  Str.\ssmann. 

2.  The  Physiological  Signification  of  the  Prostate, 

By  C.  PosNER. 

3.  Contributions  to  the  Theory  and  Practice  of  Wasser- 

mann's  Syphilis  Reaction. 

By  Hans  Sachs  and  Pietro  Rondoni. 

4.  Turgosphygmography  and  Finger  Plethysmograpliy, 

By  F.  Fleischer. 

5.  The  Light  Treatment  of  Lupus,     By  Max  Piorkowski. 

6.  Treatment  of  Pulmonary  Tuberculosis  on  the  Coast  of 

the  North  Sea,  By  C.  M.  Mol. 

7.  Studies  Concerning  the  Relations  between  Human  Tu- 

berculosis and  Tubercle  Bacilli  and  the  Tuberculosis 
and  Tubercle  Bacilli  of  Cattle  (Continued), 

By  Johannes  Fibiger  and  C.  O.  Jensen. 

1.  Retrodeviations  of  the  Uterus. — Strassmann 
reconimends  as  a  prophylaxis  against  retrodeviations 
of  the  uterus  that  the  pelvic  organs  of  girls  should 
be  regularly  evacuated,  particularly  just  before  and 
after  menstruation.  He  also  recommends  early  in- 
tervention when  a  retrodeviation  has  taken  place,  and 
describes  a  number  of  the  operations  that  are  per- 
formed for  the  purpose  of  correcting  such  faults. 

2.  The  Prostate. — Posner  says  that  from  one 
point  of  view  the  prostate  may  be  looked  upon  as  a 
rudimentary  organ  which  perhaps  had  a  higher  func- 
tion in  the  lower  animals  than  it  has  to-day  in  man. 

4.  Turgosphygmography  and  Finger  Plethys- 
mography.— Fleischer  describes  an  instrument  by 
means  of  which  can  be  studied  not  only  the  rhythm 
of  the  pulse,  but  at  the  same  time  the  form  of  the 
pulse,  the  blood  pressure,  and  the  dependence  of  both 
upon  each  other,  and  another  made  for  the  purpose 
of  studying  the  pulse  through  the  vessels  of  the 

•  finger. 

5.  Light  Treatment  of  Lupus. — Piorkowski 
reports  some  excellent  results  obtained  by  means  of 
the  treatment  of  lupus  with  the  Finsen  light. 

7.  Relations  between  Human  Tuberculosis  and 
that  of  Cattle. — Fibiger  and  Jensen  have  shown 
tluis  far  that  in  the  twenty-seven  cases  studied  ba- 
cilli virulent  for  cattle  were  found  only  in  those  cases 
in  which  the  localization  of  the  disease,  and  in  some 
cases  the  history,  favored  the  theory  that  the  tuber- 
ctilosis  in  that  patient  was  produced  through  infec- 
tion from  cattle,  and  that  where  the  history  pointed 
to  infection  through  human  beings  the  bacilli  found 
exhibited  no  greater  virulence  for  cattle  than  that 
I'sually  met  with  in  pure  cultures  of  the  human  ba- 
cilli. Hence  the  demonstration  of  bacilli  virulent  for 
cittle  in  cases  of  human  tuberculosis  would  indicate 
tliat  in  such  cases  the  tuberculosis  came  from  infec- 
tion from  cattle.  This  appears  to  confirm  the  find- 
ings of  Theobald  Smith,  of  the  English  commission. 

MUNCHENER  MEDIZINISCHE  WOCH  ENSCH  Rl  FT. 
November  s,  igo8. 

1.  Studies  Concerning  Variola, 

By  von  Pkowazek  and  de  Beaurepaire. 

2.  Concerning  the  Influence  of  Scarlet  Red  upon  Tumors 

in  ^lice.  By  Werner. 

3.  Nervous  Disturbances  of  the  Upper  Extremity  in  Ar- 

teriosclerosis (Dyscinesis  and  Paresthesia  Intermit- 
tens), By  Wandel. 

4.  -Mbuminurica  Proyocati\a  Orthostatica,        By  Bruck. 

5.  The  Importance  and  Specificity  of  Complement  Binding 

Antibodies  in  Tuberculosis  and  their  Relations  to  the 
Processes  of  Healing,  By  Engel  and  Bauer. 

6.  Oironic  Pneumothora.x,  By  Bittorf. 

7.  Our  Knowledge  of  Cirrhosis  of  the  Liver,    fey  Meyer. 

8.  Foreign  Bodies  in  the  (Esophagus,  By  AcH. 


9.    Treatment  of  Hypospadia  Penoscrotalis  in  Adults, 

ByMoHR. 

10.  ^F^tiology  of  Kohler's  Disease  of  Bones,  By  Dobisch. 
ir.  History  of  Appendicular  Inflammation,  By  Boss. 

12.  Obituary  of  Friedrich  Bezold,  By  Denker. 

2.  Influence  of  Scarlet  Red  upon  Tumors  in 
Mice. — Werner  finds  that  concentrated  solutions 
of  scarlet  red  in  oil  increases  the  growth  of  car- 
cinomata  in  mice,  while  the  same  in  fifty  per  cent, 
alcohol  causes  destruction  of  the  tumors,  showing 
that  the  combination  with  the  coloring  matter  dis- 
plays a  much  greater  cytotoxic  action  than  plain  al- 
cohol of  the  same  strength.  The  proliferation 
caused  by  the  scarlet  oil  is  not  due  to  chemotatic  in- 
fluence, but  to  an  irritation  of  the  cells,  as  is  shown 
by  the  effect  of  the  intratumoral  injections. 

3.  Nervous  Disturbances  of  the  Upper  Ex- 
tremity in  Arteriosclerosis. — Wandel  analyzes  a 
considerable  number  of  cases  of  arteriosclerosis  that 
have  come  under  his  observation,  and  finds  nervous 
disturbances  of  the  upper  extremity,  in  the  form  of 
dyscinesis  and  parsesthesia  intermittens,  to  be  pres- 
ent very  frequently.  In  regard  to  aetiology  he  does 
not  find  that  alcoholism,  nicotinism,  lead  poisoning, 
syphilis,  diabetes,  or  frequent  infections  played  any 
noteworthy  part  in  his  cases.  Age  alone  was  a  com- 
mon factor. 

5.  Complement  Binding  Antibodies  in  Tuber- 
culosis.— Engel  and  Bauer  state  that  hitherto  too 
small  doses  of  tuberculin  have  been  used  in  the 
treatment  of  tuberculosis.  They  say  that  thera- 
peutical injections  cause  a  moderate  rise  of  teinper- 
attire,  that  this  can  be  overcoine  by  repeated  injec- 
tions of  the  same  amount,  and  that  then  larger 
quantities  can  be  given,  even  as  high  as  20  c.c.  in 
divided  doses  and  in  dififerent  parts  of  the  body. 

6.  Chronic  Pneumothorax. —  Bittorf  reports  a 
case  of  chronic  pneumothorax  in  which  the  cause 
was  a  pulmonary  embolus. 

ANNALS  OF  SURGERY. 
December,  igo8. 

1.  Invagination  of  Meckel's  Diverticulum,  By  H.  T.  Gray. 

2.  Peritonitis  in  Children  from  Unknown  Sites  of  Infec- 

tion, By  C.  N.  DowD. 

3.  Diffuse  Septic  Peritonitis  due  to  Appendicitis, 

By  R.  H.  Fowlek. 

4.  The  Interlocking  Suture,  By  R.  C.  Turck. 

5.  Primary  Sarcoma  of  the  Peritonseum,    By  J.  M.  Eldek. 

6.  Gunshot  Wound  of  Abdomen  complicated  with  Preg- 

nancy, By  H.  M.  Lee. 

7.  Appendicular  Inflammation  and  Tetany, 

By  C.  H.  Goodrich. 

8.  Harrington's  Operation  of  Intraperitoneal  Cystotomy, 

By  C.  L.  ScuDDEK. 

g.'  Simultaneous  Ligation  of  both  External  Iliac  Arteries 
for  Secondary  H.-emorrhage, 

By  A.  V.  MoscHcowiTz. 

10.  A  Further  Report  of  the  Operative  Treatment  of  Acute 

Gonorrhceal  Epididymitis.  By  F.  R.  Hagner. 

11.  Finger  Enucleation  of  the  Tonsil,  By  F.  S.  Matthews. 

12.  Blastomycosis  of  the  Spine, 

By  G.  E.  Brewer  and  F.  C.  Wood. 

13.  Arteriovenous  Anastomosis  for  Gangrene, 

By  J.  C.  Hubbard. 

14.  A  Modification  of  the  Gritti  Amputation, 

By  J.  M.  Wainwright. 

15.  Skin  Grafting  of  the  Heel,  By  C.  J.  H.xbhegger. 

16.  Some  Deformities  of  the  Hand,  By  E.  Aldex. 

17.  Fracture  of  the  Os  Magnum,         By  A.  H.  Harrigan. 

2.  Peritonitis  in  Children  from  Unknown  Sites 
of  Infection.  —  Dowd  thinks  that  children  are 
more  likely  than  adults  to  have  rapidly  spreading, 
insidious  forms  of  peritonitis  since  they  are  less 


42 


PITH  OF  CURRENT  LITERATURE. 


likely  to  encapsulate  the  inflammation.  They  are 
also  less  likely  to  be  constipated  during  the  disease, 
and  are  less  susceptible  to  tympanitis,  always  an  im- 
portant symptom  in  making  a  diagnosis.  There  are 
frequently  associated  cerebral  symptoms  which  may 
confound  the  distinction  between  cerebral  and  ab- 
dominal disease.  Furthermore,  since  pulmonary  in- 
flammation is  often  accompanied  by  abdominal  pain 
and  rigidity  a  child  with  beginning  pneumonia  may 
be  thought  to  have  appendicular  inflammation.  Chil- 
dren frequently  suffer  with  pneumococcus  periton- 
itis, general  gonococcus  peritonitis,  and  tuberculous 
peritonitis.  Three  cases  of  peritonitis  due  to  strep- 
tococcus infection  are  reported.  This  form  spreads 
with  great  virulence,  is  not  easily  diagnosticated, 
and  is  not  associated  with  any  discoverable  site  of 
infection.  It  is  supposed  that  infection  usually 
takes  place  by  the  passage  of  the  germs  through 
the  intestinal  wall. 

3.  Diffuse  Septic  Peritonitis  due  to  Appendic- 
ular Inflammation. — Fowler  reaches  the  following 
conclusions:  i.  We  must  look  for  a  lowering  of  the 
high  mortality  rate  in  early  operation,  rather  than  in 
further  development  in  mechanical  intervention.  2. 
Postural  drainage  must  be  instituted  early.  This  is 
of  greater  aid  in  preventing  septic  material  from 
reaching  the  diaphragmatic  peritonaeum  than  in  pre- 
venting further  absorption  after  this  area  has  been 
involved.  3.  Peritoneal  lavage  dilutes  septic  mate- 
rial, and  when  practised  should  be  continued  until 
the  cavity  is  partially  closed.  4.  Drainage  should  be 
used  in  all  these  cases.  The  ideal  method  in  women 
is  by  means  of  a  large  rubber  tube  through  a  pos- 
terior vaginal  incision.  In  cases  which  are  not 
drained  frequently  pus  pockets  and  superficial 
wound  infections  develop.  5.  Ochsner's  treatment 
should  be  instituted  after  operation,  and  Murphy's 
proctoclysis  practised.  6.  The  abdomen  should  be 
opened  by  a  small  incision  over  McBurney's  point, 
the  primary  focus  quickly  dealt  with,  evisceration 
avoided,  and  the  greatest  gentleness  shown  in  hand- 
ling the  tissues. 

II.  Finger  Enucleation  of  the  Tonsils. — ^Mat- 
thews  enumerates  the  following  advantage  for  fin- 
ger enucleation  of  the  tonsils:  i.  Whole  tonsils  are 
removed,  a  tonsillectomy.  2.  The  anaesthesia  is  pri- 
mary and  of  short  duration.  3.  The  operation  re- 
quires only  a  few  minutes,  even  when  adenectomy 
is  added.  4;  The  armamentarium  is  simple  and 
cheap,  only  three  instruments  being  required,  a 
mouth  gag,  a  Mackenzie  tonsillotome,  and  an  ade- 
noid curette.  5.  Only  one  assistant  is  needed,  either 
a  physician  or  nurse,  the  operator  giving  the  anaes- 
thetic himself  in  the  latter  case.  6.  Skill  in  remov- 
ing the  tonsils  with  the  finger  is  easily  acquired.  7. 
As  the  operation  is  done  entirely  by  the  aid  of  touch 
the  presence  of  blood  and  nuicus  in  tlie  throat  do 
not  cause  difficulty.  8.  Convalescence  is  not  longer 
nor  more  painful  than  after  tonsillotomy.  9.  The 
operation  is  quick,  safe,  simple,  and  thorough. 

AMERICAN  JOURNAL  OF  OBSTETRICS. 

December,  jgoS. 

1.  A  Hemolytic  Test  for  Malignant  Tumors, 

By  C;.  W.  Crile. 

2.  The  Omentuir.  as  a  Factor  in  Abdominal  Surgery, 

By  C.  C.  NoRRiS. 

3.  The  Treatment  of  Post  Partum  Haemorrhage, 

By  J.  C.  Edgar. 


[New  York 
Medical  Journal. 

4.  The  Treatment  of  Accidental  Haemorrhage  and  Pla- 

centa Praevia,  By  G.  L.  Brodhead. 

5.  Cystocele,  By  I.  S.  Stone. 

6.  Injuries  to  the  Bladder  during  Hernia  Operations, 

By  R.  E.  Skeel. 

7.  Report  of  a  Case  of  Gastric  Tetany,  Operation,  and 

Recovery,      By  J.  Y.  Brown  and  W.  Engelbach. 

8.  Treatment  of  Typhoid  Fever  Perforation, 

By  J.  D.  S.  Davis. 

9.  Cancer  of  the  Cervix  Uteri  in  Pregnancy, 

By  I.  S.  Stone. 

10.  The  Anatomical  Basis  for  successful  Repair  of  the 

Female  Pelvic  Outlet,  By  I.  S.  Haynes. 

11.  The  Intraabdominal  Route  for  the  Removal  of  Calculi 

from  the  Pelvic  Portion  of  the  Female  Ureter, 

By  D.  Bissell. 

12.  Some   Old   Fallacies   in    Retroversion    Surgery  Re- 

vived, By  A.  GoLDSPOHN. 

13.  Repair  Rather  than  Removal  of  the  Generative  Organs 

of  Women,  By  J.  E.  Cannaday. 

1.  A  Haemolytic  Test  for  Malignant  Tumors. 

— Crile  states  that  when  haemoglobin  escapes  from 
the  red  corpuscles  and  is  free  in  the  urine  and  other 
secretions  it  stains  all  the  tissues,  causes  a  brilliant 
jaundice,  the  process  being  known  as  haemolysis 
and  the  agents  which  cause  it  haemolysins.  The 
latter  may  be  organic  or  inorganic.  In  200  cases 
of  individuals  without  malignant  tumors  or  infec- 
tion there  was  no  haemolysis  resulting  from  suit- 
able experimentation.  In  146  proved  cases  of  malig- 
nant tumors  haemolysis  was  observed  in  eighty-four 
per  cent.  The  negative  tests  were  mostly  in  late 
inoperable  cases.  Positive  tests  in  the  absence  of 
cancer  were  observed  in  chronic  suppuration,  certain 
fevers,  and  syphilis.  In  all  cases  heat  destroyed  the 
haemolysis.  In  all  cases  haemolysis  disappeared  with- 
in three  weeks  after  the  apparent  removal  of  all  of 
the  cancerous  tissue.  It  is  concluded  that  haemoly- 
sis is  organic  because  it  is  thermolabile,  and  that  its 
origin  is  in  the  growth  itself  because  it  disappears 
after  the  removal  of  the  tumor.  The  test  is  not  re- 
garded as  diagnostic,  but  as  important  evidence  of 
malignancy.  No  positive  conclusion  can  as  yet  be 
formed. 

2.  The  Omentum  as  a  Factor  in  Abdominal 
Surgery. — Norris  states  that  the  omentum  must 
now  be  regarded  as  a  highly  specialized  organ,  very 
important  from  a  surgical  standpoint.  One  of  its 
chief  functions  is  to  pour  out  leucocytes  and  thus 
combat  peritoneal  infection.  It  is  rich  in  bloodves- 
sels, especially  in  its  upper  portions,  which  when 
stimulated  or  irritated  rapidly  pour  out  the  protect- 
ing leucocytes.  It  also  abounds  in  lymphatics  from 
which  the  peritoneal  fluid, is  chiefly  poured  out,  this 
fluid  washing  through  the  peritoneal  cavity  and  be- 
ing finally  absorbed  through  the  diaphragm.  The 
author  does  not  find  that  the  omentum  has  any  power 
of  motion,  its  changes  in  location  being  due  to  peris- 
talsis of  the  intestine  and  to  changes  in  abdominal 
pressure.  Its  function  in  walling  off  pus  and  in  clos- 
ing injured  portions  of  the  bowel  is  very  important. 
Omental  adhesions  should  not  be  indiscriminately 
broken,  but  .should  be  ligated  and  cut  if  possible. 
The  omentum  is  rarely  the  seat  of  tumor  or  other 
disease,  with  the  exception  of  secondary  inflamma- 
tion. Torsion  has  been  reported  in  about  sixty  cases 
and  is  readily  amenable  to  operation.  A  very  large 
omentum  may  cause  trouble  by  dragging  on  the 
stomach  and  colon. 

8.  Treatment  of  Typhoid  Fever  Perforation. 
— Davis  gives  the  following  conclusions:  1.  Tyj)hoid 


January  2,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


43 


fever  is  a  surgical  disease.  2.  About  five  per  cent, 
of  such  cases  perforate.  3.  Nearly  all  patients  of  per- 
forating cases  die  when  left  to  nature.  4.  A  large  per- 
centage may  be  sated  by  operative  interference.  5. 
Incision  should  be  large  enough  for  expeditious 
work,  preferably  through  the  right  rectus  fascia.  6. 
Lavage  with  hot  saline  is  essential,  especially  if  fxcal 
extravasation  has  taken  place.  7.  Abdominal  closure 
without  drainage  may  be  adopted  if  there  is  perfect 
toilet  of  the  peritonaeum.  8.  Treatment  by  Fowler's 
position  is  important  to  confine  bacteria  and  septic 
material  to  the  lower  abdomen.  9.  One  should  en- 
deavor to  destroy  or  obstruct  bacterial  growth  in 
the  tissues  and  blood,  as  by  antistreptococcus  serum 
and  unguentum  Crede.  10.  Elimination  should  be 
secured  by  hypodermic  salt  solution  for  failing  heart, 
and  by  proctoclysis  until  sepsis  is  overcome.  11. 
Supportive  treatment  may  consist  in  transfusion  of 
salt  solution  or  blood,  with  strychnine  and  digitalis, 
also  spartein  in  large  doses  for  heart  and  general 
stimulation,  morphine  for  rest,  and  the  control  of 
shock ;  nourishment  should  be  given  as  soon  as  pos- 
sible. 

 ^  

|rot«Mngs  of  ^ociftus. 


AMERICAN   ASSOCIATION   OF  OBSTETRICIANS 
AND  GYNECOLOGISTS. 

Tzveufy-first  Attfiiial  Meeting,  held  in  Baltimore,  Septem- 

.  ber  22,  23,  and  24,  igo8. 
The  President,  Dr.  E.  Gustav  Zinke,  of  Cincinnati,  in  the 
Chair. 

Arteriosclerosis  of  the  Uterus. — Dr.  Charles 
Rees,  of  Charleston,  S.  C,  pointed  out  that  (i) 
sclerotic  changes  in  the  arterial  supply  to  the  uterus 
were  probably  of  greater  frequency  than  had  gener- 
ally been  observed;  that  (2)  a  pathological  change 
might  take  place  in  the  uterus  independently  of  gen- 
eral arteriosclerosis;  that  (3)  by  the  frequent  physio- 
logical changes  to  which  the  uterine  blood  supply 
was  subjected,  and  the  resistance  offered,  sclerotic 
changes  were  favored ;  that  (4)  sclerosis  and  even 
changes  advanced  to  atheroma  with  calcareous  de- 
posits in  the  arterial  walls  of  the  uterine  arteries 
were  found  localized  in  the  uterus ;  that  ( 5 )  these 
changes  occurred  in  the  vast  majority  of  childbear- 
ing  women  about  the  menopause  ;  that  (6)  arterio- 
sclerosis of  the  uterus  might  be  the  cause  of  alarm- 
ing hjemorrhages  which  were  uncontrollable  by  any 
of  the  ordinary  measures,  and  hysterectomy  was 
necessary  to  save  life;  and  that  (7)  haemorrhages 
caused  by  arteriosclerosis  of  the  uterus  usually  came 
on  at  a  cancer  period  of  a  woman's  life  and  could 
not  be  distinguished  by  any  other  means  than  hys- 
terectomy and  microscopical  examination. 

He  emphasized  the  following  facts:  i.  That  a 
diagnosis  of  arteriosclerosis  of  the  uterus  was  dififi- 
cult  to  make,  and  could  be  made  only  where  it  was 
possible  to  exclude  every  other  cause  of  hjemorrhage 
from  the  uterus,  by  microscopical  examination  of 
scrapings  from  the  uterus  in  which  sclerosed  capil- 
laries were  found,  or  finally  from  sections  of  such  a 
uterus  after  its  removal.  2.  That  arteriosclerosis,  as 
a  definite  cause  of  haemorrhage,  appearing  in  women 
between  the  ages  of  forty  and  fifty  and  among  those 


who  had  borne  children,  was  of  greater  importance 
than  had  generally  been  determined.  3.  That  in  a 
fair  proportion  of  cases  the  haemorrhages  from  the 
uterus  were  in  themselves  sufficient  to  endanger  the 
life  of  a  woman  and  could  be  made  to  yield  only  to 
hysterectomy.  4.  That,  with  the  uncertainty  of  di- 
agnosis even  after  examinations  of  a  section  from 
the  cervix  and  scrapings  from  the  uterus,  which 
showed  no  evidence  of  malignancy  in  women  who 
between  the  ages  of  forty  and  fifty  had  borne  chil- 
dren, and  suffered  with  frequently  recurring  haemor- 
rhages, hysterectomy  was  justified. 

Dr.  C.  C.  Frederick,  of  Buffalo,  said  he  had  seen 
several  cases  in  the  past  two  years  of  persistent  bleed- 
ing in  which  there  was  no  great  enlargement  of  the 
uterus,  and  there  was  no  evidence  of  any  fibroid 
growth,  and  no  evidence  from  the  scrapings  of  any 
degenerative  changes  in  the  uterus  indicative  of  can- 
cer. Repeated  curetting  failed  to  control  the  haem- 
orrhage. In  these  cases  he  had  done  vaginal  hyster- 
ectomy, and  had  advised  that  the  operation  be  done 
by  the  clamp  method.  The  operation  might  be  done 
through  the  abdomen,  but  preferably  through  the 
vagina,  as  it  was  a  much  easier  and  shorter  opera- 
tion by  this  route.  There  was  also  less  shock.  When 
the  uterus  was  not  enlarged,  he  advised  always  that 
the  operation  be  done  through  the  vagina  with  the 
clamp. 

Dr.  Hugo  O.  Pantzer,  of  Indianapolis,  said  that 
the  localized  occurrence  of  sclerosis  of  the  uterine 
arteries  was  described  by  Mrchow  in  connection  with 
the  case  of  a  woman  who  had  had  but  one  preg- 
nancy, and  involution  was  followed  by  the  usual 
changes.  The  frequency  of  this  afifection  was  much 
greater  than  was  commonly  believed,  and  there  was 
no  doubt  that  many  of  these  patients  could  be  re- 
lieved by  operation.  He  recalled  one  patient  who 
would  not  submit  to  operation,  and  after  profuse 
haemorrhages  she  got  well.  In  operating  he  invari- 
ably preferred  the  abdominal  route,  but  not  by  the 
clamp  method. 

Dr.  Frederick  Blume,  of  Pittsburgh,  confirmed 
what  Dr.  Frederick  said  with  reference  to  the  re- 
moval of  the  uterus  in  these  cases  through  the  va- 
gina. He  had  operated  in  three  cases  of  arterio- 
sclerosis of  the  uterus  by  the  vaginal  route  and  the 
clamp  method  in  the  last  two  years. 

Dr.  John  A.  Lyons,  of  Chicago,  reported  a  case 
of  arteriosclerosis  of  the  uterus  in  which  hysterec- 
tomy had  been  recommended  by  others,  but  he  suc- 
ceeded in  relieving  the  patient  by  electricity,  using 
forty  milliamperes  for  from  five  to  ten  minutes  at  a 
time,  the  duration  of  the  treatment  extending  over  a 
month  or  more,  at  the  end  of  which  time  the  haem- 
orrhage ceased. 

Dr.  Charles  G.  Cumstox,  of  Boston,  said  that 
some  years  ago  he  read  a  paper  entitled  Haemor- 
rhagic  Aletritis,  and  in  it  he  gave  the  pathological 
findings,  which  were  chiefly  arteriosclerosis  of  the 
small  vessels  of  the  uterine  parenchyma,  also  consid- 
erable sclerosis  of  the  uterus.  He  advised  and  prac- 
tised at  the  time  vaginal  hysterectomy,  but  was  vig- 
orously opposed  as  being  too  radical.  Since  that  time 
he  had  had  several  cases  in  which  he  found  the  ute- 
rus somewhat  enlarged,  movable,  with  apparently  no 
lesion  in  the  annexa,  and  had  operated  purely  for 
uncontrollable  haemorrhage.  Repeated  curetting  was 


44 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


insufificient.  If  the  uterine  li?emorrhage  continued 
in  these  cases  after  regeneration  of  the  endometrium, 
he  beheved  the  proper  procedure  was  to  perform 
vaginal,  and  not  abdominal,  hysterectomy. 

Dr.  Albert  Goldspohn,  of  Chicago,  called  atten- 
tion to  the  difificulty  of  making  a  diagnosis  in  cases 
of  arteriosclerosis  of  the  uterus ;  consequently,  there 
was  danger  of  treating  some  cases  under  a  mistaken 
diagnosis.  Actual  cases  of  arteriosclerosis  of  the 
uterus  should  be  treated  by  hysterectomy,  and  noth- 
ing else.  In  connection  with  the  vaginal  operation 
he  highly  recommended  the  use  of  the  Downes  elec- 
tric angeiotribe  or  clamp. 

Hysteria  as  the  Surgeon  Sees  it. — Dr.  ApMok- 
GA.\  \'a.\ck,  of  Louisville,  related  a  number  of  in- 
teresting clinical  instances  of  hysteria  stimulating 
grave  organic  lesions.  He  spoke  of  the  methods  of 
cure  which  he  attributed  to  the  power  of  suggestion 
and  an  attitude  of  command  as  the  controlling  ele- 
ments in  vanquishing  the  obsession  of  the  victims. 
He  suggested  the  necessity  of  alertness  to  avoid  mis- 
diagnosis, and  attributed  his  quick  and  certain  suc- 
cess in  the  diagnosis  and  treatment  of  some  of  these 
cases  to  that  alertness  bred  of  the  rivalry  in  diagno- 
sis which  came  within  his  fortunate  experience  early 
in  his  medical  career. 

Dr.  Herman  E.  Hayd,  of  Buffalo,  emphasized 
the  difficulty  attending  a  correct  diagnosis  in  cases 
of  hysteria.  Every  one  had  seen  patients  who  had 
been  sadly  neglected,  and  who  had  been  treated  for 
all  kinds  of  hysterical  symptoms,  when  there  was 
really  not  only  one  pathological  condition  at  the  bot- 
tom of  them,  but  various  pnthological  conditions, 
making  the  case  extremely  complex ;  therefore,  the 
reason  why  so  many  of  these  neurasthenic,  hysteri- 
cal, and  neurotic  women  were  not  cured  was  not 
that  they  had  not  received  good  surgery,  but  that 
they  had  not  had  enough  good  surger\ . 

Dr.  CuMSTON  had  found  that  the  quickest  way  to 
make  hysterical  patients  walk,  who  thought  they  had 
hip  joint  disease,  was  to  mention  in  their  presence 
that  high  amputation  was  the  proper  thing,  and  in  a 
case  he  recalled  the  patient  was  able  to  walk  in  a 
short  time  afterward.  He  related  the  case  of  a  wo- 
man who  was  supposed  to  have  had  hip  joint  dis- 
ease, such  a  diagnosis  having  been  made  by  an  or- 
thopaedic surgeon.  A  pelvic  examination  disclosed 
hydrosalpinx,  and  upon  its  removal  the  hip  joint 
symptoms  disappeared. 

Dr.  John  A.  Lyons,  of  Chicago,  took  issue  with 
Dr.  Hayd  in  the  statement  that  there  was  always  a 
marked  pathology  in  these  hysterical  patients,  and 
supported  the  views  advanced  by  the  author  of  the 
paper.  He  believed  that  in  many  instances  the  hys- 
teria could  be  relieved  by  suggestion,  and  cited  at 
length  a  case  that  came  under  his  own  observation 
in  support  of  it. 

Dr.  Roland  E.  Skkel,  of  Cleveland,  said  the  wel- 
fare of  the  medical  profession  and  its  patients  de- 
pended on  recognizing  the  fact  that  there  were  two 
factors  in  many  cases,  namely,  that  while  there  might 
be  minor  pathology,  it  was  only  recognized  by  the 
patients  themselves  by  reason  of  overexcitable  and 
oversensitive  nerves,  and  that  physicians  really  over- 
looked these  two  factors.  These  minor  pathological 
conditions  could  be  found  if  they  were  sought  for, 
and  inasnnich  as  there  was  no  perfect  human  body, 
even  if  a  pathological  condition  was  removed  it 


would  only  cure  a  limited  number  of  patients.  He 
referred  to  the  many  reflex  troubles  that  might  arise 
from  minor  pathological  conditions,  and  reported 
cases. 

Comparative  Merits  of  Abdominal  Coeliotomy 
and  Colpotomy  in  the  Treatment  of  Intrapelvic 
Abscess. — Dr.  W.  S.  Smith,  of  Baltimore,  read  a 
paper  on  this  subject.  He  said  that  if  one  consid- 
ered the  improvements  that  had  been  made  in  sur- 
gical technique,  together  with  the  striking  results 
obtained  in  purulent  cases  by  the  Fowler  postural 
treatment  and  the  Murphy  irrigation,  the  mortality 
plea  lost  much  of  its  force.  Recent  experience  in 
this  connection  on  the  part  of  the  author  had  been 
instructive  and  satisfactory.  In  the  last  no  lapa- 
rotomies which  he  had  done  there  had  been  no  mor- 
tality. Of  this  number,  fifty-three  were  performed 
for  pus  in  the  pelvis.  Drainage  was  indicated  and 
used  in  ten  instances,  and  the  Fowler-Murphy  treat- 
ment was  resorted  to  twice.  During  the  same  period 
of  time  there  had  been  but  ten  colpotomies,  and  two 
of  these  were  followed  by  the  abdominal  operation. 

Dr.  Charles  L.  Bonifield,  of  Cincinnati,  said 
that  vaginal  incision  was  of  great  importance  in  se- 
lected cases,  and  the  earlier  one  could  get  at  pus  be- 
hind the  uterus  and  drain  it,  the  less  damage  there 
would  be  done  to  the  uterine  appendages,  and  the 
more  hope  there  was  of  curing  these  patients  with- 
out a  radical  operation.  Under  the  most  favorab  e 
circumstances  it  was  the  exception  rather  than  the 
rule  that  these  patients  were  cured  by  this  simple 
procedure.  To  deal  with  these  cases  by  the  vaginal 
route  if  the  temperature  had  become  normal,  and  the 
patient  was  in  a  condition  to  withstand  a  radical  op- 
eration, was  to  attack  the  disease  in  an  awkward 
and  inefficient  way.  The  mortality  from  operations 
for  pus  in  the  pelvis  depended  very  greatly  on  when 
the  operation  was  done.  One  should  avoid  abdom- 
inal .section  for  the  removal  of  suppurating  appen- 
dages while  the  patient  had  elevation  of  tempera- 
ture. Personally,  he  had  almost  completely  given 
up  conservative  surgery  in  cases  of  inflammatory 
disease  of  the  appendages.  Conservative  surgery  as 
regarded  the  tubes  was  more  frequentl\-  successful 
than  that  with  regard  to  the  ovaries.  In  cases  in 
which  he  had  left  part  of  an  ovary,  the  patients  usu- 
ally returned  for  a  subsequent  operation. 

Dr.  Goldspohn  said  that  vaginal  drainage  was 
permissible  in  acute  pelvic  conditions,  and  the  cajes 
amenable  to  this  operation  were  those  in  which  the 
focus  of  pus  was  located  in  the  pelvic  cellular  tissue 
— a  parametritis.  Where  the  primary  focus  of  in- 
flammation was  not  intraperitoneal  or  intratubal,  but 
was  in  the  pelvic  cellular  tissue,  great  relief  was  af- 
forded or  even  a  cure  sometimes  effc;:ted  by  vagin-il 
drainage.  Intraperitoneal  suppurative  conditions 
were  not  usually  benefited  very  nnich  by  vaginal 
drainage,  but  more  radical  measures  were  needed. 

Dr.  C.  C.  Frederick,  of  Buffalo,  said  that  in  pel- 
vic abscess  he  preferred  the  vaginal  route  for  drain- 
age, and  then,  if  neces.sary,  a  more  radical  operation 
could  be  done  at  a  later  time. 

Dr.  1)LU.\IE  said  he  had  resorted  to  vaginal  inci- 
sion and  drainage  in  the  cases  under  discussion,  and 
later,  if  the  patient  returned,  he  performed  an  ab- 
dominal operation.  Where  the  uterus  was  veritably 
riddled  with  .small  abscesses,  even  though  one  re- 
moved the  uterus,  the  j^atient  was  usually  so  general- 


January  2,  i<)^g.]' 


PROCEEDINGS  OF  SOCIETIES. 


45 


ly  infected  that  an  operation  was  likely  to  be  fol- 
lowed by  an  unfavorable  result. 

Dr.  Joseph  A.  Hall,  of  Cincinnati,  said  that  many 
pelvic  abscesses  were  the  result  of  tuberculosis,  and 
many  of  these  abscesses  were  caused  by  the  gono- 
coccus.  \'aginal  section  accomplished  much  good 
in  some  of  these  cases,  but  in  others  more  radical 
operative  measures  were  indicated. 

Dr.  LouLs  Frank,  of  Louisville,  said  there  could 
be  no  question  as  to  the  advisability  of  vaginal  in- 
cision and  drainage  in  acute  pus  collections  as  a 
temporary  expedient.  His  experience,  however,  was 
that  in  some  cases  in  which  it  was  done  abdominal 
section  was  required  later.  In  one  case  there  was  a 
pus  collection  between  the  bladder  and  uterus  in 
which  the  fever  continued  unduly  high  after  vaginal 
colpotomv.  Cases  of  infection  of  the  tubes  and 
broad  ligament  which  did  not  subside  after  opening 
the  abscesses  yielded  only  to  extirpation  of  the  tube 
and  the  removal  of  the  broad  ligament. 

Dr.  Joseph  H.  Branham,  of  Baltimore,  called  at- 
tention to  the  virulence  of  infection,  saying  that  in 
some  cases  it  was  slight,  while  in  others  it  was  great. 
As  there  was  this  great  difference,  the  treatment 
should  vary  in  different  cases. 

Dr.  Smith  said  he  had  not  been  convinced  of  the 
importance  of  removing  a  healthy  tube,  even  though 
the  infection  was  of  gonorrhoeal  origin.  He  thought 
that  a  thorough  curetting  of  the  uterus  and  careful 
exsection  of  the  diseased  tube  would  result  in  a  per- 
manent cure,  and  there  was  seldom  any  necessity 
for  taking  oiit  a  healthy  tube  even  in  gonorrhoeal 
cases. 

A  Simple,  Certain,  and  Universally  Applicable 
Method  of  Preventing  the  Serious  Accident  of 
Leaving  a  Sponge  in  the  Abdomen. — Dr.  H.  S. 

Crossex,  of  St.  Louis,  said  that  security  against 
this  fatal  accident  was  counted  one  of  the  unsolved 
problems  of  abdominal  surgery.  Practically  all 
authorities  stated  that  there  was  no  guarantee 
against  its  occurrence,  even  in  routine  hospital  work, 
and  with  all  the  rules  of  cooperation  and  the  cum- 
bersome apparatus  devised  to  prevent  it.  The  fail- 
ure of  the  preventive  methods  in  general  use  was 
due  to  their  dependence  on  sustained  attention  con- 
cerning the  sponges,  which  attention  cpuld  not  be 
given  by  the  operator,  it  being  required  elsewhere. 
A  method  to  be  effective  under  all  circumstances 
must  be  practically  automatic,  must  be  applicable  in 
emergency  work  in  the  country  as  well  as  in  hospital 
work,  and  should  be  fairly  convenient.  Such  was 
the  method  he  had  used  during  the  past  two  years. 
It  insured  the  removal  of  all  gauze  without  partic- 
ular attention  on  the  part  of  any  one.  It  consisted 
in  the  elimination  of  all  detached  pads  and  sponges 
and  the  utilization  of  ten  yard  gauze  strips,  each 
strip  packed  in  a  convenient  bag  in  such  a  way  that 
it  might  be  drawn  out  a  little  at  a  time,  as  was 
needed. 

Mobility  of  the  Patient  after  Laparotomy. — Dr. 

Walter  B.  Chase,  of  Brooklyn,  contributed  a  paper 
on  this  subject  in  which  he  stated  that  (i)  the  early 
dictum  of  the  rigid  immobility  of  the  patient  after 
laparotoni)— yet  too  much  in  vogue — was  wrong  in 
principle  and  injurious  in  practice;  (2)  limited  mo- 
bility of  the  patient,  active  or  passive,  within  rational 
limitations,  was  admissible  and  desirable  whenever 
the  comfort  and  advantage  of  the  patient  were  there- 


by promoted;  (3)  the  cardinal  prerequisites  to 
prompt  healing  of  wounds  were  perfect  coaptation, 
■perfect  rest,  and  freedom  from  infection;  (4)  the 
sitting  up  of  the  patient  in  bed  or  out  of  bed  the  day 
after  the  operation,  being  around  the  ward  the  fol- 
lowing day,  and  leaving  the  hospital  for  ordinary 
exercise  at  the  end  of  a  week,  were  not  compatible 
with  sound  surgical  procedure,  even  though,  in  indi- 
vidual instances,  satisfactory  recovery  had  followed ; 
(5)  by  ignoring  the  pathological  conditions  present, 
the  burden  of  proof  that  the  phlebitis  was  not  due 
to  infection,  or  that  the  mischief  attending  throm- 
bosis and  embolism  was  not  a  result  of  too  early 
mobility  of  the  patient,  rested  with  the  advocates  of 
the  new  departure. 

Dr.  Goi-DSPOHX  said  it  was  wrong  to  encourage 
patients  to  get  up  on  the  second  or  third  day  after 
laparotomy,  as  it  was  necessary  to  wait  until  cica- 
trization was  fairly  complete,  and  this  did  not  occur 
in  less  than  about  ten  days. 

Dr.  Daniel  H.  Craig,  of  Boston,  stated  that  the 
mobility  of  a  patient  after  operation  had  a  relation- 
ship to  the  postoperative  complications  of  phlebitis 
and  thrombosis,  and  he  believed  that  early  mobility 
of  patients  lessened  the  lial)ility  to  these  complica- 
tions. 

Extrauterine  Pregnancy. — Dr.  Havd  classified 
his  cases  according  to  their  clinical  manifestations : 
I ,  The  tragic,  or  cataclysmic,  class,  where  there  was 
free  haemorrhage  going  on  into  the  peritoneal  cavity, 
with  no  tendency  to  localization.  Here  an  imme- 
diate abdominal  operation  was  recommended.  2, 
The  cases  where  a  small  rupture  had  taken  place 
and  where  htematocelc  more  or  less  circumscribed 
developed.  In  this  class  vaginal  incision  and  drain- 
age was  advised  if  the  pregnancy  was  not  advanced 
beyond  the  sixth  week  or  if  the  blood  clot  had  not 
become  too  firmly  organized.  3,  Those  cases  w^hich 
had  gone  on  to  the  second  and  on  to  the  fourth  or 
fifth  month,  when  rupture  took  place,  but  the  foetal 
product  continued  to  grow  on  account  of  the  new 
attachment  it  made.  4.  Those  cases  which  had  gone 
on  to  the  development  of  a  pelvic  abscess  with 
broken  down  foetal  products  in  the  mass.  5,  Those 
cases  -A'hich  had  gone  on  to  term  and  the  patients 
were  delivered  by  operation  when  the  child  was 
viable,  or  where  the  child  had  died  and  undergone 
mummification  or  calcification  as  a  lithopjedion. 

Advanced  Ectopic  Gestation,  with  Living 
Child,  with  Reports  of  Three  Cases. — Dr.  X.  O. 
Werder,  of  Pittsburgh,  read  a  paper  with  this  title, 
in  which  he  said  that  all  these  cases  began  as  tubal 
pregnancy.  The  time  of  rupture  could  be  estimated 
from  the  history  of  every  case.  In  the  first  case  it 
occurred  at  about  the  end  of  the  second  month  ;  in 
the  second  case  it  apparently  occurred  unusually 
late,  about  the  middle  of  the  fourth  month ;  and  in 
the  third  case  severe  cramps  about  six  weeks  after 
the  last  menstrual  period  indicated  that  rupture  took 
place  at  that  time,  although  the  complication  with 
normal  pregnancy  and  a  subsequent  abortion  caused 
the  symptoms  to  be  rather  mixed  and  consequently 
.  less  definite  than  in  the  previous  cases.  In  none 
of  the  cases  was  the  diagnosis  attended  with  great 
difificulty.  In  the  advanced  form  of  extrauterine 
pregnancy  the  only  other  condition  with  which  it 
might  be  confounded  was  normal  uterine  pregnancy. 
Mistakes  in  diagnosis  were  less  likely  to  occur  than 


46 


LETTERS  TO  THE  EDITOR.— BOOK  NOTICES. 


[New  York 
Medical  Journal. 


in  the  earlier  forms  of  ectopic  gestation,  although 
even  the  latter  cases  were  not  usually  difficult  to 
recognize. 

Having  in  the  prophylactic  instrumental  com- 
pression of  the  abdominal  aorta  a  safe  and  reliable 
means  of  preventing  the  dreaded  placental  haemor- 
rhage, which  had  really  been  the  principal  stumbling 
block  in  the  surgical  treatment  of  advanced  ectopic 
gestation,  there  seemed  to  be  no  longer  any  just 
ground  for  other  than  a  radical  operation  in  this 
condition,  consisting  in  the  complete  extirpation  of 
the  gestation  sac  with  the  living  placenta,  an  opera- 
tion which  in  his  opinion  was  the  only  proper  and 
correct  surgical  procedure  for  these  cases. 

{To  be  concluded.) 
 ^  

fetters  to  \\t  ibttor. 


THE  L\TRODUCTION  OF  BRANDY  INTO  GREECE 
THROUGH  PHYSICIANS. 

New  York,  December  7,  jgo8. 

To  the  Editor: 

In  an  article  on  Alcoholismos  bj^'Dr.  A.  Bethan- 
opoulos,  published  in  the  monthly  medical  rruriw?, 
November,  igo8,  is  given  the  following  interesting 
statement : 

Twenty-seven  years  ago  brandy  was  almost  un- 
known among  the  Greek  people ;  according  to  Pro- 
fessor Baphan,  it  came  into  use  through  physicians 
in  the  following  way:  When  in  the  year  1881  Ath- 
ens was  visited  by  a  severe  epidemic  of  abdominal 
typhus  {xDikiaxoi;  ruifixf),  in  English  called  ty- 
phoid fever,  the  physicians  of  that  time  prescribed 
abundantly  cognac  for  the  patients,  and  from  this 
time  this  liquor  became  known  among  the  common 
people  in  Athens  and  throughout  Greece.  Manu- 
facturers of  beverages  devoted  themselves  now  to 
the  production  of  cognac,  an  industry  which  before 
had  been  of  very  limited  extent,  because  cognac  was 
consumed  by  very  few.  Now  it  is  very  popular 
throughout  Greece;  next  to  it  comes  masticha  (re- 
sembling absinthe),  and  in  the  third  line  beer. 

The  Greek  physicians  have  to  combat  with  all 
their  might  the  idea  that  brandy  is  good  in  malaria, 
during  pregnancy,  in  bellyache,  and  as  a  general 
prophylactic  against  all  sorts  of  ailments.  They 
have  to  impress  the  common  people  with  the  experi- 
ence of  the  physicians  of  antiquity.    In  the  excellent 

periodical    "  'I'uyiaTpuij   y.a\    Asufio/.oytxij   'ETTcdsw/tKfii;  " 

of  my  esteemed  friend.  Dr.  Blabianos,  the  editor  has 
written  numerous  articles  against  the  Megaira  of 
the  human  race,  alcoholism.  A.  Rose. 

 ^  

iflfflk  |[oti«5. 

[IVe  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 

Lectures  on  Principles  of  Surgery.  By  Stuart  McGuire, 
M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical 
Surgery,  University  College  of  Medicine,  Richmond,  Va. 
Baltimore :  Southern  Medical  Publishing  Company,  1908. 
Pp.  480.    (Price,  $4.) 

This  is  a  condensed  exposition  of  the  surgery  of 
the  present  day  in  its  general  aspects — that  is  to  say. 


without  special  attention  to  the  particular  parts  of 
the  body  affected  by  diseases  or  injuries  which  may 
require  surgical  treatment.  Dr.  McGuire  presents  a 
very  satisfactory  summary  of  contemporary  views 
without  insisting  on  any  peculiar  tenets  of  his  own, 
and  he  does  it  in  clear  and  often  graphic  terms.  We 
must  commend  the  book  especially  to  students  and 
young  practitioners. 

Hygiene  for  Nurses.  By  Isabel  McIsaac,  Author  of  Pri- 
mary Nursing  Technique,  Graduate  of  the  Illinois  School 
for  Nurses,  etc.    New  York :  The  Macmillan  Company, 

1908.  Pp.  xiv-208.    (Price,  $1.) 

The  author  states  in  her  preface  for  teachers  that 
the  object  of  this  book  is  to  secure  for  the  young 
nurse  a  textbook  on  hygiene  which  shall  be  prac- 
tical and  within  the  range  of  her  daily  \vork,  as  the 
standard  works  embrace  an  immense  amovmt  of 
information  entirely  beyond  the  comprehension  of 
the  young  pupil. 

The  book  is  a  very  good  compilation  on  this  sub- 
ject, thorough  and  scientific.  But  where  will  this 
lead  to?  Is  it  really  necessary  for  a  young  nurse, 
studying  in  her  first  year,  to  acquire  such  an  amount 
of  knowledge?  It  is  absolutely  unnecessary  ballast 
for  the  average  nurse.  If  she  wishes  to  educate 
herself  for  a  special  duty,  say  as  a  district  w'orker 
visiting  the  homes  of  out  patients  of  dispensaries, 
she  may  be  called  upon  to  have  some  knowledge  on 
this  matter.  But  otherwise  she  should  not  be  over- 
educated  ;  it  is  certainly  not  in  the  province  of  a 
nurse,  a  Pfiegerin,  whose  plain  duty  it  is  to  nurse 
the  sick,  under  the  guidance  and  supervision  of  a 
physician,  to  be  an  authority  on  hygiene.  But,  as 
we  have  said,  the  book  is  a  very  good  compendium 
on  hygiene,  good  enough  for  ihe  medical  student  in 
his  first  year. 

Die  krankhaftcn  Erscheinungen  dcs  Gcschlechtssinnes. 
Von  Dr.  Georg  Merzbach,  Arzt  fiir  Haut-und  Harn- 
leiden  in  Berlin.     Wien  und  Leipzig:  Alfred  Holder, 

1909.  Pp.  viii-470. 

The  author  has,  with  great  industry,  compiled  a 
book  on  the  diseased  condition  of  the  sexual  sense, 
on  which  subject  there  have  lately  appeared  quite  a 
number  of  textbooks.  The  book  can  be  w^ell  recom- 
inended,  not  only  to  the  specialist,  but  also  to  the 
general  practitioner,  as  it  avoids  any  unnecessary 
detail,  is  scientifically  written,  and  is  not  expensive. 
It  will  not  appeal  to  the  layman  as  much  as  other 
books  of  its  kind,  as  the  author  has  omitted  the  em- 
bellishing additions  in  which  some  of  his  colleagues 
have  chosen  to  indulge. 

Consumption,  How  to  Prevent  it  and  How  to  Live  with  it. 
Its  Nature,  its  Causes,  its  Prevention,  and  the  Mode  of 
Life,  Climate,  Exercise,  Food,  Clothing  Necessary  for  its 
Cure.  By  N.  S.  D.wis.  A.  M.,  M.  D.,  Professor  of  Prin- 
ciples and  Practice  of  Medicine,  Northwestern  University 
Medical  School ;  Physician  to  Mercy  and  Wesley  Hos- 
pitals, etc.  Second  Edition,  Thoroughly  Revised.  Phila- 
delphia :  F.  A.  Davis  Company,  1908.    Pp.  viii-168. 

When  this  book  appeared  for  the  first  time,  in 
1891 — it  has  been  printed  several  times,  but  not  re- 
vised until  this  second  edition — the  education  of  the 
j)ublic  in  regard  to  tuberculosis  had  hardly  begun. 
How  vastly  different  to-day,  when  many  are  well 
acquainted  with  the  prevention  and  treatment  of 
consumption.  The  book  is  specially  written  for  the 
layman,  and  will  thus  be  of  benefit  to  the  tuber- 
culous patient. 


January  z,  1909.] 


BOOK  NOTICES. 


47 


Textbook  of  Nervous  Diseases  and  Psychiatry.  For  the 
Use  of  Students  and  Practitioners  of  Medicine.  By 
Charles  L.  Dana,  A.  M.,  M.  D.,  LL.  D.,  Professor  of 
Nervous  Diseases  in  Cornell  University  Medical  College, 
etc.  Seventh  Edition.  Illustrated  by  Two  Hundred  and 
Sixty-one  Engravings  and  Three  Plates  in  Black  and 
Colors.  New  York:  William  Wood  &  Ca,  1908.  Pp. 
xii-782.    (Price.  $5.) 

We  are  glad  to  see  another  edition  of  this  excel- 
lent work,  and  we  have  no  doubt  that  many  more 
editions  will  be  called  for.  Dr.  Dana  writes  with 
remarkable  lucidity ;  there  is  never  any  uncertainty 
as  to  his  meaning.  That  quality  it  is,  we  think, 
that,  in  addition  to  the  sound  teaching  in  the  book, 
has  led  to  its  becoming  a  favorite  with  the  pro- 
fession. 

The  new  matter  in  this  edition  is  chiefly  to  be 
fotmd  in  the  sections  on  the  histology  of  the  neurone 
and  on  the  anatomy  and  physiology  of  the  brain. 
The  author  has  discarded  the  term  phrenasthenia 
in  favor  of  psychasthenia.  We  would  particularly 
commend  his  remarks  about  alcohol  (page  27). 
From  the  mechanical  point  of  view,  the  book  is 
very  handsome. 

Surgery  of  the  Ureter.  An  Historical  Review  (1585-1905). 
By  Benjamin  Merrill  Ricketts,  Ph.  B.,  M.  D.,  LL.  D. 
Cincinnati  (Printed  for  the  Author)  :  1908.    Pp.  244. 

This  is  a  reprint  of  the  series  of  articles  on  the 
surgery  of  the  ureter,  its  history  and  bibliography, 
published  as  a  serial  in  the  St.  Louis  Medical  Re- 
view. Dr.  Ricketts  deserves  much  credit  for  having 
unselfishly  undertaken  the  laborious  task  of  compil- 
ing the  extensive  bibliography  of  the  ureter  which 
he  furnishes  with  these  articles.  This  bibliography 
will  prove  of  great  value  for  reference  to  all  those 
who  in  the  future  may  be  engaged  in  literary  or  sci- 
entific research  on  the  ureters.  In  general  appear- 
ance and  makeup  this  little  volume  is  similar  to  the 
author's  Surgery  of  the  Prostate,  etc.,  1904.  It  is 
to  be  regretted  that  the  typography  of  the  biblio- 
graphical reference  has  not  undergone  more  careful 
revision,  especially  in  the  spelling  of  foreign  quota- 
tions, and  that  more  tmiformity  has  not  been  main- 
tained in  the  abbreviations,  etc. 

Estimation  of  the  Renal  Function  in  Urinary  Surgery.  By 
J.  W.  Thomson  Walker,  M.  B..  C.  M.  (Edin.),  F.  R.  C. 
S.,  Hunterian  Professor  of  Surgery  and  Pathology, 
Royal  College  of  Surgeons  of  England  (1907)  ;  Surgeon 
in  Charge  of  Out  Patients  at  the  Northwest  London  Hos- 
pital, etc.  With  2  Colored  and  7  Black  and  White  Plates, 
34  Figures  in  the  Text,  and  32  Charts.  London :  Cassell 
&  Company,  Limited,  1908.    Pp.  xiv-273. 

This  monograph  is  the  first  in  the  English  lan- 
guage, so  far  as  we  know,  devoted  exclusively  to  the 
functional  estimation  of  the  kidneys.  The  methods 
of  renal  functional  diagnosis,  which  first  came  to  be 
recognized  when  von  Koranyi,  of  Budapesth,  ap- 
plied cryoscopy  to  the  clinical  examination  of  the 
urine,  have  passed  through  the  stages  of  doubt  and 
darkness  tmtil  now  certain  well  understood  princi- 
ples have  been  evolved  out  of  a  mass  of  clinical  and 
experimental  data,  including  much  conflicting  testi- 
mony. Dr.  Walker's  treatise  presents  a  very  satis- 
factory summary  of  the  present  status  of  functional 
renal  diagnosis,  and  deals  systematically  with  the 
theory,  technique,  and  clinical  significance  of  the 
variotis  tests  that  have  been  employed  in  this  field  of 
work.  Chapters  upon  the  physiology  of  the  kidney, 
upon  the  method  of  urine  analysis,  as  applied  to 


functional  diagnosis,  upon  methods  of  catheterizing 
the  ureters,  etc.,  find  their  proper  place  among  the 
other  sections  of  the  book.  Some  attention  is  also 
given  to  the  '"separators"  of  Luys,  Cathelin,  and 
others,  but  the  author  has  found  the  catheterizing 
cystoscope  more  satisfactory  and  more  trustworthy. 
This  is  the  status  of  the  question  at  present,  as  shown 
in  the  published  opinions  of  the  majority  of  sur- 
geons who  have  used  both  classes  of  instruments. 

A  good  description  is  given  of  the  technique  of 
ureteral  catheterism  with  the  indirect  instruments  of 
Albarran,  Nitze,  and  Casper,  but  not  a  word  is  said 
of  the  direct  instruments  so  much  in  vogue  in  this 
coimtry  and  so  successfully  used  by  many  of  our 
surgeons.  Dr.  Walker  discusses  briefly  the  merits 
and  fallacies  of  each  of  the  various  functional  diag- 
nostic methods.  Personally,  he  tises  the  methylene 
blue  test,  with  the  phloridzin  test  for  confirmation  (p. 
255).  He  lays  no  stress  on  the  indigo-carmin  test, 
which  to-day  has  come  to  be  recognized  both  in 
Germany  and  in  this  country  as  the  most  efficient 
and  most  trustworthy  of  the  tests  employed  in  this 
field  of  diagnosis.  In  his  experience  (p.  241)  the 
indigo-carmin  method  has  no  advantages  over  the 
methylene  blue  test.  A  table  of  fatal  cases  of  uni- 
lateral nephrectomy  published  within  recent  years  is 
appended  to  the  book. 

Chronischer  Magenkatarrh  (Gastritis  chronica).  Von  Hof- 
rat  Dr.  Friedrich  Cramer.  Mit  4  Kunstdruck  Tafeln. 
Miinchen  :  J.  F.  Lehmann,  1908.     Pp.  iv-i68. 

Dr.  Cramer's  subject  in  the  postgraduate  medical 
course  in  ^Munich  treats  of  the  diseases  of  the  stom- 
ach and  intestines.  During  the  winter  of  1907  to 
1908  he  spoke  in  seven  lectures  on  chronic  gastritis, 
and  they  now  appear  in  book  form. 

It  is  a  carefully  prepared  book,  in  contrast  with 
many  books  of  its  kind,  which  only  treat  of  the  sub- 
ject in  general  terms  without  giving  exact  data. 
Such  is  so  often  the  case,  especially  with  prescrip- 
tions, where  we  read,  prescribe  bismuth  or  bella- 
donna or  strychnine,  etc.,  not  mentioning  the  proper 
ingredients  of  the  prescription.  Our  author  prop- 
erly avoids  this  favilty  compilation  :  he  gives  a  good 
and  full  list  of  practical  prescriptions.  He  also  has 
compiled  a  valuable  table  showing  the  distinctive 
diagnosis  between  chronic  gastritis,  ulcer  of  the 
stomach,  and  cancer  of  the  stomach ;  and  another 
table  giving  the  diet  for  gastritic  patients,  with  rules 
how  to  eat  and  how  to  prepare  the  food. 

It  is  interesting  to  note  that  Dr.  Cramer  finds  that 
acid  gastritis  is  more  frequent  than  subacid  or  an- 
acid  gastritis,  while  it  is  usually  accepted  that 
chronic  gastritis  is  subacid. 

BOOKS,   PAMPHLETS,   ETC.,  RECEIVED. 

Die  atonische  und  die  spastische  Obstipation.  Ihre  Dif- 
ferentialdiagnose  und  Behandlung.  Von  Privatdozent  Dr. 
Gustav  Singer.  Primararzt  am  k.  k.  Krankenhause  "Rudolf- 
Stiftung"  in  Wien.  Mit  zwei  Abbildungen.  Halle  a.  S. : 
Carl  Alarhold,  iQog.    Pp.  46. 

Transactions  of  the  Tenth  Annual  Meeting  of  the  Amer- 
ican Proctologic  Society,  held  at  Chicago,  111.,  June  i  and  2, 
1908.    Pp.  146. 

Lehrbuch  der  physiologischen  Chemie  in  zweiunddreissig 
Vorlesungen.  Von  Emil  Abderhalden.  o.  Professor  der 
Physiologic  an  der  kgl.  tierarztlichen  Hochschule,  Berlin. 
Zweite,  vollstandig  umgearbeitete  und  erweiterte  Auflage. 
Mit  19  Figuren.  Berlin  und  Wien :  Urban  &  Schwarzen- 
berg,  1909.    Pp.  vii-984. 


48 


OJ-'J-'JCIAL  XEirS.— BIRTHS,  MARRIAGES  AXD  DEATHS. 


LNew  York 
Medical  Journal. 


Cat;uact  Extraction.  By  H.  Herbert,  F.  R.  C.  S.,  late 
Lieutenant  Colonel,  I.  M.  S.,  Professor  of  Ophthalmic 
Medicine  and  Surgery,  Grant  Medical  College,  and  m 
charge  of  the  Sir  Cowasjee  Jehangir  Ophthalmic  Hospital, 
Bombay.    New  York:  William  Wood  &  Co.,  1908.    Pp.  391. 

Studies  in  Paranoia.  Periodic  Paranoia  and  the  Origin 
of  Paranoid  Delusions.  By  Dr.  Nikolaus  Gierlich,  Wies- 
baden. Contributions  to  the  Study  of  Paranoia.  By  Dr. 
M.  Friedniann,  Mannheim.  Translated  and  edited  by  Smith 
Ely  Jellifife,  M.  D.  New  York:  The  Journal  of  Nervous 
and  Mental  Disease  Publishing  Company,  1908.    Pp.  iv-77. 

Modern  Medicine.  Its  Theory  and  Practice.  In  Original 
Contributions  by  American  and  Foreign  Authors.  Edited 
by  William  Osier,  M.  D.,  Regius  Professor  of  Medicine  in 
Oxford  University,  England,  etc.  Assisted  by  Thomas 
McCrae,  M.  D.,  Associate  Professor  of  Medicine  and  Clin- 
ical Therapeutics  in  the  Johns  Hopkins  University,  Balti- 
more, etc.  Volume  V.  Diseases  of  the  Alimentary  Tract. 
Illustrated.  Philadelphia  and  New  York;  Lea  &  Febiger, 
igo8.    Pp.  viii-903. 

The  Doctor  in  Art.  Twenty-five  Reproductions  of  World- 
famous  Masterpieces.  Edited,  with  Authentic  Text,  by 
Charles  Wells  RIoulton.  Buftalo :  The  Douglass  Publish- 
ijig  Company,  1908.    Pp.  25. 

Traite  de  I'arterio-sclerose.  Par  le  Docteur  O.  Josue, 
medecin  des  hopiteaux  de  Paris.  Preface  de  M.  le  Pro- 
fesseur  Roger,  professeur  a  la  faculte  de  medecine  de 
Paris.  Avec  20  figures  noires  et  coloriees.  Paris  :  Librairie 
J.  B.  Bailliere  et  Fils,  1909.  Pp.  xii-404. 

Jahresbericht  fiber  die  Fortschritte  in  der  Lehre  von  den 
pathogenen  Mikroorganismen  umfassend  Bakterien,  Pilze 
und  Protozoen.  Unter  Mitwirkung  von  Fachgenossen  bear- 
beitet  und  herausgegeben  von  Dr.  med.  P.  Von  Baumgar- 
ten,  o.  o.  Professor  der  Patliologie  an  der  Universitat 
Tubingen,  und  Dr.  med.  F.  Tangl,  o.  6.  Professor  der  allge- 
meincn  und  experimentellen  Pathologic  an  der  Universitat 
Budapest.  Zweiundzwanzigster  Jahrgang,  1906.  Leip^^ig: 
S.  Hirzel,  1908.    Pp.  xii-964. 


Public    Health   and    Marine    Hospital  Service 
Health  Reports: 

The  following  cases  of  siiialll>ox ,  yclUnc  fever,  cholera 
und  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  xveek  ending  December  25,  igo8: 


Cases.  Deaths. 


Smallpox — United  States. 

Places. 

California- — San  Diego  County ...  Nov.   1-30   11 

California — San  Francisco  Nov.    --nec.    3   7 

Indiana — ElUiart  Dec.   6-12   i 

Indiana — l.a  Fayette  Dec.   8- 14   5 

Kansas — Kansas  City  Dec.    1.^19   2 

Texas — San  Antonio  Dec.   6-i_'   i 

Utah — Salt  Lake  City  Nov.   1-30   36 

Wisconsin — La  Crosse  Dec.   6-12   2 

Wisconsin — Milwaukee  Dec.   22-28   3 

Smallpox — Foreign. 

Algeria — -Mge-rs  Nov.  1-30  

Brazil — I'ahia  Nov.  7-14   51 

Brazil — Pernambnco  Oct.  15-31  

Brazil — W\o  dc  Janeiro  Nov.  9-15  311 

Canada — Kingston  Nov.  23-29   2 

India — Homhay  Nov.  18-24  

Mexico — Vera  Cruz  Dec.   6-12   i 

Peru — Lima  Nov.   15-21   1 

Russia — Moscow  Nov.  22-28   9 

Spain — Valencia  Nov.  22-28   3 

Turkey — Constantinople  Nov.  28-Dec.  6  

Cholera — Fo  reign . 

Japan — Fuoko  ken  Sept.    15-25   49 

Japan — Oita  ken  Jan.   i-Nov.   15   7 

Jajian — Saga  ken  To   Nov.    15   2 

Japan — Tsushima  Oct.    20-31  .  70 

Korea — General  Oct.  21-Nov.   15   31 

Philippine  Island.s — Manila  Oct.    25-31   45  - 

Yellow  Feier — Foreign. 

Mexico— Mcrida  Nov.  29- Dec.  5   3 

Mexico — Vera  Cruz  Nov.  29-Dcc.  5   4 

Mexico — Zumpich  Nov.  1-30   2 

Plague  — Foreign. 

Brazil — Pcrnambuco  Oct.  1-30  

Chile — Inuitpu-  Nov.   i-8   1 

China — Ilongkong  Nov.  1-7   i 

Ecuador — Cruayaquil  Nov.  22-28  

Peru — Lima  Nov.  5-11   S 


24 
141 


Army  Intelligence: 

Official  list  of  changes  in   the  stations  and  duties  of 

officers  serving  in  the  Medical  Corps  of  the  United  States 

Army  for  the  iveeft  ending  December  26,  1908: 

Appel,  a.  H.,  Lieutenant  Colonel,  Medical  Corps.  Ordered 
to  Fort  Robinson,  Nebr.,  for  general  court  martial 
duty,  January  6,  1909. 

Carter,  E.  C,  Lieutenant  Colonel,  Medical  Corps.  Ordered 
to  Fort  Robinson,  Nebr.,  for  general  court  martial 
duty,  January  6,  1909. 

Ebert,  R.  G.,  Lieutenant  Colonel  Medical  Corps.  Ordered 
to  Fort  Robinson,  Nebr.,  for  general  court  martial 
duty,  January  6,  1909. 

Field,  P.  C.,  Captain,  Medical  Corps.  Granted  leave  of  ab- 
sence for  fourteen  days. 

Greenle.'^f,  H.  S.,  Captain,  JVIedical  Corps.  Granted  sick 
leave  of  absence  to  January  22,  1909. 

La  Garde.  L.  A.,  Lieutenant  Colonel,  Medical  Corps.  Or- 
dered to  Fort  Robinson,  Nebr.,  for  general  court  mar- 
tial duty,  January  6,  1909. 

Lamson,  T.,  Captain,  Medical  Corps.  Relieved  from  duly 
at  Fort  Bliss,  Texas,  and  ordered  to  Columbus  Bar- 
racks, Ohio,  for  duty. 

Leech,  W.  F.,  First  Lieutenant,  Medical  Reserve  Corps. 
Honorably  discharged  from  the  service  of  the  United 
States. 

Peck,  L.   B.,  First  Lieutenant,  Medicp.l  Reserve  Corps. 

Granted  leave  of  absence  for  ten  days. 
Richardson,   G.   H.,   First   Lieutenant,   ^ledical  Reserve 

Corps.    Relieved  from  duty  at  the  Presidio  of  San 

Francisco,  Cal.,  and  ordered  to  sail  January  5,  1909,  for 

duty  in  the  Philippines  Division. 

Navy  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of 
officers  serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  meek  ending  December  26.  igo8: 
Brook.s,  F.  H.,  Assistant  Surgeon.     Detached  from  the 
Franklin  and  ordered  to  the  naval  recruiting  station, 
Baltimore,  Md. 
Huffman,  O.  V.,  Assistant  Surgeon.    Ordered  to  the  naval 
medical  school  hospital,  Washington,  D.  C,  for  treat- 
ment and  observation. 
Mayers,  G.  M.,  Passed  Assistant  Surgeon.    Detached  from 
the  naval  recruiting  station,  Baltimore,  Md.,  and  or- 
dered to  the  naval  medical  school  hospital.  Washins;- 
ton,  D.  C,  for  treatment  and  observation. 
Thompson,  F.  W.,  Acting  Assistant  Surgeon.    Ordered  t'l 
the  naval  hospital,  New  'S'ork,  N.  Y. 


§irt^s,  parriages,  ani  f  eat^s. 


Married. 

Barney — Melville. — In  Fort  McHenry,  Maryland,  o;t 
Wednesday,  December  i6th.  Lieutenant  Frederick  M.  Bar- 
ney, Medical  Reserve  Corps,  United  States  Army,  and  Miss 
Isabelle  D.  Melville. 

Campbell — Stover. — In  Marine  City,  Michigan,  on  Thurs- 
day, Decejnber  17th,  Dr.  J.  F".  Campbell  and  Miss  Maud 
Stover. 

RoBP-iNoviTz — Bernstein. — In  New  York,  on  \\''cdnesday, 
December  30th,  Dr.  Samuel  Robbinovitz  and  Miss  Anna 
Bernstein. 

Died. 

Ali.en. — In  Washington,  D.  C,  on  Friday,  December 
25tli,  Dr.  Charles  Allen,  aged  seventy-three  years. 

Caldwell. — In  Little  Sioux,  Iowa,  on  Sunday,  December 
13th,  Dr.  S.  A.  Caldwell. 

Clark. — In  Westi'ield,  Massachusetts,  on  Sunday,  De- 
cember 20th.  Dr.  James  Sanniel  Clark,  aged  fifty-four 
years. 

Goodrich. — In  Vernon,  Connecticut,  on  Simday,  Decem- 
ber 20th,  Dr.  Alfred  Russell  Goodrich,  aged  ninety  years, 

Maxcv. — In  Washineton,  D.  C,  on  Friday,  December 
25th,  Dr.  Frederick  E.  Maxcy,  aged  thirty-five  years. 

Patton. — In  Chicago,  on  Tuesday,  December  T5th,  Dr. 
Henry  J.  Patton,  aged  sixty-nine  years. 

RirH.\Knso\, —  In  Slurgiss,  Michigan,  on  Friday.  Decem- 
ber 251)1.  Dr.  T.  S.  Richardson. 

Volkman. — In  West  Baltimore,  Maryland,  on  Fin  da; . 
December  18th,  Dr.  .August  F.  \''oIkmaiL 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  The  Medical  News 

A  Weekly  Review  of  Medicine,  Established  1S4J, 


Vol.  LXXXIX.  Xo.  2. 


XEW  YORK.  JAXUARY  9,  1909. 


Whole  Xo.  1571 


(Original  Communitatiflns. 


THEORIES  AND  PROBLEMS  OF  HEREDITY. 
Bv  Jonathan  Wright,  M.  D., 

New  York. 
/.   The  Fundamental  Theories. 

A  survey  of  the  fields  of  research  in  the  physical 
sciences  and  in  biology  can  not  fail  to  reveal  the 
tendency  to  reduce  all  vital  processes  to  a  mechani- 
cal formula.  Whether  life  is  springing  into  ex- 
istence now  or  whether  it  first  did  so  millions  of 
years  ago,  it  is,  or  was,  in  the  first  instance  a  process 
of  higher  molecular  synthesis  from  lower  molecular 
aggregates,  and  the  question  of  date  is  unimportant. 
The  fundamental  question  is  how  HiLxley's  speck 
of  protoplasm  floating  on  the  surface  of  the  tepid 
waters  came  to  be  imbued  with  what  we  are  pleased 
to  call  life.  Was  it  there  in  obedience  to  a  special 
mandate  aside  from  other  things  called  inorganic, 
or  did  it  arise  in  the  course  of  evolution  in  obedience 
to  the  laws  which  govern  other  matter? 

The  final  mystery  is  a  mystery  for  us  all.  but  it  is 
of  the  utmost  importance  whether  we  are  to  be 
allowed  to  place  it  at  the  beginning  of  life,  or  only 
at  the  beginning  of  all  things.  There  is  really  no 
reason  why  we  should  not  fill  in  the  gaps  in  our 
knowledge  in  many  places  with  it,  since  we  meet  the 
Unknowable,  in  Spencer's  language,  at  the  start. 
This  inherent  possibility  must  always  be  admitted  at 
every  stage  of  inquiry,  and  the  scorn  heaped  upon 
those  who  turn  to  it  in  despair  is  entirelv  unphilo- 
sophical.  The  laws  of  evolution  have  been  sug- 
gested by  Boussinesq  for  the  birth  of  the  universe, 
and  they  have  been  applied  by  Lockyer  to  the  birth 
of  the  chemical  elements.'  We  can  not  avoid  trying 
to  apply  them  to  the  birth  of  protoplasm  any  more 
than  we  can  avoid  formulating  them  from  the  his- 
tory of  its  development,  ^\'hether  the  attempt  will 
be  successful  or  not  none  can  tell. 

The  laws  of  the  evolution  of  protoplasm  are  the 
laws  of  heredity,  and  any  theon-  of  the  nature  of 
heredity  must  depend  upon  the  point  at  which  we 
admit  the  intrusion  of  a  metaphysical  principle. 
The  postulate  of  life  as  being  the  function  alone  of 
the  cell  as  a  whole  and  not  of  its  parts  involves  the 
assumption  that  here  is  the  point  of  entrance  of  the 
metaphysical  principle,  or  else  it  involves  the  admis- 
sion that  this  line  is  an  artificial  one.  one  for  conven- 
ience of  taxonomy  only.  Unless  we  do  admit  such  a 
line  as  a  real  one.  then  we  can  scarcely  escape  the 
conclusion  that  the  heredity  of  matter,  the  evolution 
of  matter,  hands  over  its  acquisitions  from  the  in- 

^Jnerganic  Evolution,  1904. 


organic  to  the  organic.  Dr.  Bastian  has  long  as- 
serted that  he  has  demonstrated'  the  birth  of  life  in 
his  test  tubes,  and  recently  Professor  Dunbar'  has  so 
far  confirmed  many  of  Bastian's  observations  on 
heterogcnesis  as  to  see  bacteria  born  anew  in  algse. 
I  have  stated'  the  reasons  of  an  a  priori  nature  which 
make  scepticism  unavoidable  in  the  face  of  such 
demonstraticns.  and  they  are  to  be  indirectly  infer- 
red from  the  observations  of  Prowazek."  He  found 
that  certain  alga;  when  thoroughly  crushed  have  the 
power  of  regeneration,  through  which  algce  are 
again  formed  out  of  the  mass  of  disorganized  pro- 
toplasm, provided  the  mass  contains  a  proper  rela- 
tive amount  of  nuclei.  A  membrane  is  formed 
around  the  balls  of  matter  and  the  mass  advances 
to  the  formation  of  a  typical  alga  thread.  Thus  all 
our  biological  knowledge  constrains  us  to  believe  that 
a  living  cell  has  a  long  ancestry  of  processes  behind 
it.  by  which  it  is  controlled  :  and  we  are  unable  to 
believe  the  assertions  of  P>astian  and  of  Dunbar  that 
a  heterogcnesis  so  complete  as  they  report  can  take 
place.  If  it  is  true  that  algae,  when  crushed,  by  vir- 
tue of  the  power  inherent  in  their  nuclei,  can  re- 
generate new  algae  by  a  process  with  which. the  ex- 
periments of  Loeb  have  made  us  familiar,  we  must 
conclude  that  their  heredity,  their  life,  is  contained 
in  bits  smaller  than  cells,  so  chemicallv  constituted 
that  they  start  the  membrane  formation  which  is 
the  first  step  in  the  development  of  a  new  being. 
That  such  a  chemical  constitution  may  be  so 
altered  as  to  account  for  the  change  of  algal  matter 
into  a  bacterium  is  not  incredible.  It  simply  seems 
improbable. 

These  observations  are  entirely  ignored  bv  the 
biological  world.  In  spite  of  mv  own  scepticism.  I 
can  not  but  recognize  that  they  might  well  rank 
among  the  best  of  demonstrable  facts  were  they 
reconcilable  with  familiar  current  biological  theo- 
ries. It  is  but  an  instance  of  the  failure  of  "facts" 
to  convince.  They  are  ranked,  I  suppose,  in  the 
orthodox  biological  mind  as  mistaken  observations. 
In  spite  of  much  nonsense  written  and  uttered  about 
the  supreme  value  of  experiment  and  observation, 
we  know  from  actual  experience  that  our  five  senses 
are  as  liable  to  mistake  as  our  powers  of  deductive 
reasoning,  and  when  we  outrage  a  system  of  belief 
only  based  on  the  latter  and' supported  by  authority, 
observed  "facts"  knock  at  the  gates  of  our  mental 
storehouses  in  vain.  Such  a  statement  finds  ample 
illustration  in  the  literature  of  the  theories  of  hered- 
ity.    A  "fact"  observed  is  in  itself  not  half  as  liable 

"Or.  H.  Charlton  Bastian.     Tltc  Evoiution  of  Life,  1907. 
^Ztir  Frage  dcr  Steliung  dcr  Baktcrien,  etc.,  1907. 
^Medical  Record,  August  17.  1907. 

^Bin!oeisrlies  Centralblatt.    1907.   xxiii.   p.    737      Reference:  Bio- 
physikalisehes  Centralblatt,  iii,  parts  7  and  8,  January,  190S. 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


50 


I i- RIGHT:  THEORIES  AND  PROBLEMS  Of  HEREDITY. 


[Ne\v  York 
Medical  Journal. 


to  be  a  reality  when  it  conforms  to  some  well  ac- 
cepted orthodox  belief  as  when  it  does  not.  The  or- 
thodox observer,  from  his  own  unconscious  prepos- 
sessions, is  much  more  apt  to  be  deceived,  because 
he  is  aware  that  his  statement  will  be  free  from  a 
searching  and  more  or  less  supercilious  criticism, 
and  it  will  not  be  so  liable  to  pass  into  oblivion  as  if 
it  had  not  accepted  belief  to  lean  on.  The  orthodox 
observer  is  much  more  apt  to  be  a  careless  observer 
than  the  heretic. 

In  practice  there  is  no  safe  criterion  of  truth.  In 
practice  theory  and  observation  go  hand  in  hand, 
in  experimental  work  not  less  so.  Let  the  medical 
man  then  not  scof¥  at  the  biogenic  theories,  much 
less  at  the  theories  of  heredity.  Neither  experi- 
ment nor  observation  nor  practice  can  do  without 
them.  It  is  when  theory  is  erected  into  a  dogma, 
it  is  when  men  of  science,  building  theories,  take 
themselves  and  their  theories  too  seriously,  that 
harin  is  done.  When  Weismann  declares  that  his 
determinants  are  something  real  and  tangible"  his 
theory  becomes  dogma  and  ceases  to  be  a  helpful 
working  hypothesis.  In  defense  of  Weismann's 
theory,  which  must  be  considered  quite  aside  from 
the  practical  point  at  issue,  the  transmissibility 
of  acquired  characters,  as  much  and  only  as  much 
can  be  said  of  many  other  theories.  Does  the 
theory  help  us  to  arrange  our  ideas  in  their  proper 
sequence  ?  There  can  be  no  denial  that  to  some 
it  has  been  helpful,  and  no  one  should  be  readier 
to  admit  it  than  he  to  whom  no  such  benefit  has 
accrued  if  he  realizes  that  mental  processes  vary 
widely.  Its  chief  merit,  its  chief  help  to  all,  how- 
ever, has  arisen  from  the  enormous  discussion 
that  has  raged  around  it.  The  vast  stimulus  such 
a  widely  discussed  explanation  of  a  phenomenon 
as  yet  inexplicable  has  given  to  research,  to  ob- 
servation, to  imagination  and  reflection  is  beyond 
all  dispute.  As  for  Weismann  himself,  we  must  all 
bear  testimony,  not  only  to  his  all  but  unfailing 
courtesy  hut  to  his  mastery  in  dialectics,  to  his  clear- 
ness in  exposition  and,  above  all,  to  his  honesty. 
When  his  followers  become  so  infatuated  with  his 
theory  that  they  place  it  alongside  of  the  atomic 
theory,  when  in  their  ardor  of  advocacy  they  igp.ore 
evidence  on  one  side  which  they  accept  on  the  otixr, 
when  they  discredit  earnest  endeavor  by  sneering 
at  the  efforts  of  fellow  workers,  this  theory  becomes 
a  stumbling  block  in  the  path  of  progress  and  a  bone 
of  discord  between  individuals  of  a  class  of  men 
who  should  continually  disagree  yet  continually  live 
together  in  harmony.  .\s  ignorance,  in  the  words 
of  Gregory,  is  the  mother  of  devotion,  so  is  rever- 
ence the  wet  nurse  of  error. 

It  having  become  apparent  in  the  course  of  cy to- 
logical  study  that  life  and  heredity  are  inherent  in 
smaller  entities  than  any  visible  parts  of  the  :ell, 
all  sorts  of  names  have  been  given  to  them.  It 
has  not  been  the  peculiarity  of  the  system  of  \\'eis- 
mann  that  one  grade  of  these  submicroscopic  di- 
vision- is  called  a  determinant  and  endowed  with 
the  mystery  it  is  .supposed  to  explain.  Biogens, 
biophors.  ids.  gemmules,  physiological  units,  deter- 
minants, are  helpful  in  the  economies  of  svntax,  hut 

*yortrage  iiber  die  Desceiidenslchre ,  second  edition.  1904,  i,  p.  301. 
It  may  be  well  to  quote  liis  o«_n  words:  "In  diescm  .illgcnieineni 
Pinn  sind  Dctcrminantcn  de*  K.-ims  niclits  liypotlietlschcs.  sondern 
(twas  tat^.irlilichcs.  chen«o  siclicr  als  ob  wir  sie  mit  iinsrren  Aiigen 
jfcsehcn  imd  ihre  Entwickclting  vi-rfolgt  hiitteti." 


in  no  way  explain  how  form  and  function  are 
handed  down  from  one  living  being  to  its  offspring. 
Professor  Thomson',  a  devout  follower  of  Weis- 
mann, refers  to  the  old  joke  of  the  horologeity  of 
the  clock  which  he  turns  upon  the  critics  of  his 
leader,  but  the  most  shining  marjc  for  it  in  biologi- 
cal lore  would  seem  to  be  Weismann's  determinants. 
Since  the  discovery  of  the  chromosomes  of  the  nu- 
cleus, and  since  especially  the  evidence  has  been  in- 
sistent that  they  are  intimately  associated  with  the 
functions  of  the  germ  cells,  the  conceptions  of  mate- 
rial units  as  the  bearers  of  heredity,  and  conse- 
quently Weismann's  formulae  have  been  very  popu- 
lar with  the  builders  of  theories  of  heredity.  The 
mosaic  conception  of  heredity,  formulated  in  the 
laws  of  Mendel,  has  still  further  added  to  the 
strength  of  Weismannism.  But  how  can  material 
units  stand  for  immaterial  forces?  The  bird's  wing 
stands  as  the  emblem  of  flight,  but  it  is  very  far 
from  explaining-  the  physical  processes  whereby  it 
keeps  itself  in  the  air.  The  chromatin  granule  in 
the  nucleus  contains  no  material  subdivision,  we  may 
be  sure,  which  does  any  more.  The  comprehension 
of  the  principles  of  aviation  like  that  of  the  princi- 
ples of  heredity  receives  but  slight  assistance  from 
the  contemplation  of  such  symbols. 

The  physicochemical  process  whereby  in  natural 
heritable  immunity  the  phagocyte  engulfs  the  bac- 
terium is  a  matter  of  the  index  of  the  electrodyna- 
mic  surface  tension  of  each.  Its  variation  is  a  char- 
acter of  living  things  which  is  heritable.  How  are 
we  to  figure  to  ourselves  the  heredity  here  involved 
by  means  of  material  units?  It  is  the  dynamics  of 
the  cell,  not  the  phosphorous  nor  the  calcium  nor 
the  oxygen  of  the  two  living  things  which  is  here 
concerned.  It  is  the  force  that  arranges  their  mole- 
cules and  atoms. 

I  have  tried,  chiefly  by  citations  from  the  litera- 
ture of  biology,  to  show  that  biologists  are  begin- 
ning to  look  upon  the  figures  of  mitosis  as  the  paths 
of  force*;  and  the  advance  of  this  concept  must 
necessarily  wreck  the  bioblastic  value  of  a  material 
unit  as  a  symbol,  much  more  its  acceptation  as  a 
reality.  We  can  not  thus  resolve  a  mystery  into 
chemical  elements.  We  can  not  thus  crystallize  and 
materialize  it,  make  it  into  something  we  can  stahi 
and  see,  even  by  ultra  microscopy.  We  can  do  this 
no  more  than  we  can  grasp  the  sunbeam,  or  taste 
it,  or  smell  it. 

Weismann  is  forced  to  admit  that  his  determin- 
ants which  guide  the  course  of  evolution  must  be 
endowed  with  some  vital  property  aside  from  the 
physiocochemical  forces  with  which  we  are  famil- 
iar.' So  plain  is  this  metaphysical  element  that 
Poulton,  one  of  Weismann's  followers,  gives  it  an 
ancient  theological  twist  by  his  interpretation  that 
"no  characters  except  those  predetermined  in  the 
germ  are  available  for  evolution." 

Dividing  things  into  vague  infinitesimals  and 
then  calling  them  hiophors  or  determinants  is  a  more 
complex  but  not  a  more  satisfactory  solution  than 
frankly  vitalistic  theories,  when  we  are  compelled 
in  the  end  to  affix  the  mystery  to  the  infinitesimals. 

''Heredity.    .\.  F.  Thomson.  1008. 

'The  Physical  Processes  of  Imnuinity.  Keiv  York  Medical  Jciir- 
i:nl.  February  16.  March  9  and  23.  .\\ir\\  6  and  -r.  1007.  The 
Mechanicobiological  Standponit  in  Medical  Problem...  .Vr:c  Yorl: 
Medical  Journal.  October  10.  and  November  7.  1008. 

'Loco  citato,  i,  p.  305 ;  ii.  p.       it  scq. 


Tamiary  9.  looo.  I 


WRIGHT:   THEORIES  AND  PROBLEMS  OF  HEREDITY. 


51 


We  go  around  in  a  circle  to-day  with  such  logo- 
machy quite  as  nnich  as  Bichat  did  a  hundred  years 
ago,  when  he  defined  life  as  "the  totality  of  the 
forces  which  resist  death."  The  neovitalists  may 
say  with  Bergson "  that  life  creeps  into  material  phe- 
nomena, adopting  their  laws,  but  at  the  same  time 
turning  them  aside  from  what  would  otherwise  be 
their  result,  and  I  have  reterred  to  some  mvestiga- 
tions  of  IMoore  and  Roaf"  which  seem  to  show  that 
the  currents  back  and  forth  through  cellular  mem- 
branes do  not.  in  certain  instances  at  least,  obey  the 
laws  of  osmosis  with  which  we  are  familiar  outside 
of  a  living  environment ;  yet  we  must  look  upon 
such  things  rather  as  evidence  of  oin^  ignorance  than 
of  the  intrusion  of  a  metaphysical  principle.  The 
dominants  and  the  entelechies  of  Reinke"  and  of 
Driesch'^  have  the  advantage  of  simplicity  in  their 
application  over  the  determinants  of  Weismann,  be- 
cause they  are  universal  rather  than  specific  cries 
for  help.  I  know  of  little  objection  to  them  since 
the  neovitalists  keep  on  working  at  the  problems 
with  as  much  vim  as  others.  They  refuse  any  teleo- 
logical  significance  to  these  terms,  as  I  understand 
it,  but  they  insist  on  their  metaphysical  nature.  While 
neovitalism  excludes  the  claim  of  a  directive  force 
in  the  interest  of  or  for  the  good  of  living  things, 
I  presume  it  is  to  be  regarded  as  the  intrusion  of 
that  mystery  at  the  origin  of  all  things  which  we 
all  recognize.  I  know  no  reason  why  it  should  not 
intervene  in  cosmic  law  of  the  living  or  the  dead, 
but  I  quite  agree  with  the  feeling  generally  ex- 
pressed that  the  logical  sequence  of  an  admission 
that  it  does  iiitrude  is  nihilism  in  science  and  an 
obstacle  to  all  progress.  I  do  not  attempt  to  deny, 
as  Haeckel  does,  that  there  is  a  metaphysical  basis 
back  of  all  things.  I  see  no  escape  from  the  con- 
clusion that  there  is,  and  it  may  be  behind  many 
things  to  elucidate  which  science  is  patiently  work- 
ing. Mystery  is  everywhere.  Insoluble  mystery  is 
doubtless  somewhere.  I  know  no  reason  why  simi- 
lar organs  should  be  reproduced  from  parts  which 
have  embryogenticall}^  no  connection  with  the  parts 
producing  the  organs  in  the  first  place.  I  know  no 
reason  why  the  eve  of  the  crab  should  resemble  that 
of  the  ox.  A\'ithout  the  invention  of  a  teleological 
vitalism  I  do  not  see  clearly  how  the  specific  re- 
semblance has  emerged  from  such  a  distinct  separa- 
tion in  phylogeny  and  in  environment.  I  only  know 
that  the  admission  that  these  things  can  not  be  ex- 
plained on  the  same  principles  as  an  electric  motor 
would  be  fatal  to  the  curiosity  which  prompts  me 
to  seek  the  explanation.  T  know  it  is  true,  as  Rey 
remarks'*  that  "every  day  diminishes  the  interval 
which  separates  the  biological  processes  from  the 
processes  of  inorganic  matter."  Tt  is  a  fact  of  his- 
torical experience  that  the  lines  of  separation  have 
one  after  another  disappeared  before  the  revelations 
of  cosmic  law.  "Every  time  a  man  of  science  studies 
a  biological  phenomenon  he  either  establishes  its 
direct  dependence  upon  physical  phenomena  or  he 
shows  a  remarkable  analogy  between  the  realm 
of  the  inorganic  and  that  of  the  organic."  \Miile 
these  words  may  not  be  literallv  true,  thev  are  suf- 
ficiently  near  to  being  so  to  make  us  look  askance 

"Bergson.  L'E^  olution  creatrice,  p.  102. 
'^^Biochemical  Journal,  January  22,  1908. 

Weh  ah  That. 
^'Der  Vitalisinus  als  Geschichte  uitd  ats  Leiire. 
'*La  Philcsof'hic  modcrne,  1908. 


at  any  theory  which  rests  directly  or  indirectly  upon 
metaphysical  principles. 

Confronted  by  these  fundamental  difficulties  in 
entertaining  any  formula  for  the  ultimate  nature  of 
life  and  heredity,  it  is  no  wonder  our  observations 
of  fact  have  outstripped  our  hypotheses.  The  ad- 
vance of  our  knowledge  of  vital  processes  which  has 
taken  place  in  the  last  twenty  years  would  render 
the  most  satisfactory  theory  of  heredity  of  another 
generation  insufficient  in  its  application.  Our  knowl- 
edge of  cellular  anatomy,  and  above  all  of  cellular 
physiology,  has  in  the  last  two  decades  enormously 
increased.  Not  only  have  discoveries  and  observa- 
tions piled  up,  but  the  inevitable  influence  of  the 
changes  wrought  in  other  scientific  fields  causes  us 
to  look  at  problems  in  biology  from  a  standpoint 
influenced  by  them.  To  medical  men  it  is  important 
in  the  last  degree  what  their  understanding  i  f  that 
standpoint  is. 

In  medicine  many  problems  are  pressing  for  solu- 
tion which  involve  a  comprehension  of  the  funda- 
mental principles  of  heredity.  They  enter  directly 
and  indirectly  into  our  discussion  of  the  relative 
importance  of  the  different  factors  in  the  causation 
of  tuberculosis.  Upon  this  depends  the  plan  of 
campaign,  whatever  may  be  its  direction  now.  which 
ultimately  will  restilt  in  its  prevention.  Intimately 
bound  up  with  them  is  the  search  for  the  cause 
of  cancer.  No  proper  comprehension  can  be  at- 
tained of  many  phenomena  of  phx  siology  and  em- 
bryology until  we  see  less  frequently  before  us  a  sole 
refuge  in  vitalism.  The  history  of  the  rise  of  com- 
municable diseases  will  receive  from  and  will  cast 
upon  the  study  of  heredity  much  light.  It  is  im- 
possible in  a  few  lines,  and  perhaps  unnecessary,  to 
enumerate  the  directions  in  which  medical  progress 
has  been  halted  for  the  want  of  a  more  satiffactory 
understanding  of  the  nature  of  heredity. 

The  study  of  microscopic  and  inframicroscopic 
processes  has  created  a  demand  that  to  them  shall 
be  applied  the  same  law  of  heredity  as  to  the  macro- 
cosm, and  coeval  advances  in  physics  and  chemistry 
demand  that  this  law  shall  conform  to  discoveries 
and  tendencies  which  are  noted  in  those  field^. 

Heredity  must  be  conceived  as  governing  the  be- 
havior of  the  cells  of  the  metazoa  quite  as  much  as 
the  behavior  of  the  individual.  A  little  before  the 
publication,  at  least  in  this  country,  of  the  first  form 
of  Weismann's  theory,  Roux  made  an  attempt  to 
apply  the  new  doctrine  of  evolution,  the  survival  of 
the  fittest  among  individuals  in  the  struggle  for  ex- 
istence, to  the  problems  of  the  growth  and  config- 
uration of  the  tissues.  His  lack  of  success  and  that 
of  Weismann's  addendum  of  germinal  selection  to 
satisfy  histologists  has  resulted  in  a  justifiable  drift 
toward  neovitalism.  As  Poulton'^  admits,  Huxley, 
from  his  experience  as  an  histologist.  devout  de- 
fender a  oiitrance  of  Darwinism  as  he  was.  could 
not  entirely  reconcile  himself  to  the  view  that  na- 
tural selection  was  the  sole  explanation  of  the  dis- 
tinction and  survival  of  form  and  function.  This  in- 
sufficiency to  explain  the  problems  of  histologv  has 
also  been  noted  in  the  study  of  paleontology,  and 
Professor  Osborn  has  well  said  there  is  some  factor 
in  Evolution  which  has  not  been  recognized  by  the 
neo-Darwinians,  though  he  refrains  from  the  at- 

"Essays  on  Evolution,  1908. 


52 


WRIGHT:  THEORIES  AND  PROBLEMS  OE  HEREDITY. 


(New  York 
Medical  Journal. 


tempt  to  identify  it.  I  do  not  mean  at  this  point  to 
enter  into  the  question  of  the  transmission  of  ac- 
quired cliaracters,  hut  I  must  hroach  the  suhject 
enough  to  point  out  that  at  the  very  heginning  of  it 
we  are  confronted  with  the  question  which  has 
never  been  sufficiently  discussed, — what  is  a  "char- 
acter"? XoL, — 'what  is  an  acquisition? — that  has 
been  vohniiinously  discussed, — but  what  is  a  "char- 
acter" innate  or  acquired?  It  is  not  only  a  man's 
nose  which  forms  a  characteristic  of  his  face,  but 
a  superabundance  of  cartilage  which  forms  a  char- 
acter of  the  nose.  The  superabundance  of  cells 
forms  a  characteristic  of  the  cartilage.  It  is  the 
intracellular  arrangement  of  the  molecules,  nay  in 
all  probability  the  intramolecular  stereoscopic  ar- 
rangement which  needs  a  determinant  in  every  cell. 
Jn  fact  there  seems  no  point  short  of  atoms,  further 
down  at  least  than  most  biologists  assert  is  the  limit 
of  life,  which  does  not  feel  the  need  of  determinants 
in  Weismann's  theory.  W'e  should  have  to  have  as 
many  determinants  as  cells  or  parts  of  cells  to  ac- 
count for  all  kinds  of  variations  of  characters.  This 
need  for  an  infinite  number  of  infinitesimal  deter- 
minants rests  on  no  specious  pleading  or  captious 
criticism.  We  need  them  in  immunity  to  take  care 
of  the  "complements."  There  is  all  the  more  need 
for  them  now  it  is  pointed  out  that  immunity  from 
and  susceptibility  to  disease  obeys  Mendel's  law  of 
mosaic  inheritance  in  the  rust  of  wheat,  a  fungus 
disease.  Determinants  of  a  chemical  or  physical  ar- 
rangement of  molecules  which  lie  at  the  foundation 
of  some  of  the  most  striking  characteristics  of  living 
beings  are  a  little  hard  to  furnish  in  quantities  to 
supply  the  demand. 

The  drift  toward  neovitalism  swings  around  the 
ve.xing  i)roblems  of  regeneration  and  repair  and  of 
physiological  form'"  or  the  so  called  histonal  selec- 
tion. Rou.x  and  Weismann"  speak  of  a  "functional 
irritation."  but  this  has  no  ultimate  meaning,  allays 
in  no  way  the  curiosity  of  the  histologist,  who  sees 
functionless  vagaries  arise,  such  as  a  bony  cyst  of 
the  middle  turljinate"  or  the  hypertrophy  of  a  faucial 
tonsil.' '  They  are  but  the  local  persistence  of  growth 
beyond  physiological  needs  due  to  the  hypernutrition 
of  inflammation,  but  in  the  functionless  growths 
why  docs  the  polyblast  in  one  place  make  a  bony 
cyst,  in  another  an  ecchondrosis,  in  another  an  en- 
larged tonsil?  Neo-Darwinism  does  not  return  as 
satisfactory  an  answer  as  the  neovitalism  of  Dricsch. 
\\'eismann  -admits  this  insufficiency  of  Roux's 
theory  of  the  battle  of  the  parts  and  yet  he  advances 
the  same  arguments  for  his  germinal  selection  so 
far  as  I  can  .see.  The  germinal  selection  of  deter- 
minants endowed  with  vitalistic  attributes  is  no  more 
satisfying  than  the  fornuila  of  Driesch  :  "The  pros- 
pective fate  of  a  cell  is  a  function  of  its  position." 
Indisposed  as  T  am  to  accept  the  cntclcchy  of 
Driesch,  it  is  more  imiucdiately  applicable  to  many 
of  the  problems  of  histogenesis  than  the  theory  of 
Koux.  Roux  in  his  theory  of  the  battle  of  the  parts 
attem|)tcd  to  show  natural  selection  at  work  in  build- 
ing up  the  architectural  structure  of  the  bony  skele- 
ton, and  his  followers  and  co-workers  evinced  much 
entlnisiasni  for  it,  and  years  ago  they  published 

'•.Mbrecht.  Frankfurter  Zeitschrift  fur  Pathologic,  ii.  part  i, 
"Weismann.    VortrSgc  fiber  die  Deseeiidenzlehrc,  Second  Edition, 

i,    p.  20I. 

"WriRht.  Awvirnn  Joiniml  of  the  Mcilical  Sciences.  May,  1907. 
"A'car  York  Medical  Joiinuil,     .\iikiisI  S.  igtfi. 


much  in  support  of  the  idea ;  but  on  the  whole  it  has 
not  found  the  response  among  histologists  which 
might  be  expected  from  such  a  pronouncement  had 
it  easily  observed  facts  for  a  basis.  Plausibility  and 
a  coincidence  with  the  general  law  of  natural  selec- 
tion should  ere  this  have  incited  the  myriad  of 
workers  with  the  microscope  to  build  a  stately  edi- 
fice for  the  support  of  the  theory  in  the  general  and 
broader  field  of  biology.  Such  has  not  been  the 
case.  The  absence  of  such  a  response  in  histolog)', 
when  heaven  and  earth  have  been  searched  for  facts 
in  support  of  Weismannism,  is  significant. 

The  beasts  and  birds  and  men  themselves  are 
falling  all  around  us  and  we  see  the  fittest  survive, 
but  we  see  no  polyblast  perish  because  it  is  not  fit 
to  shape  a  bone.  Every  physiological  act  so  far  as 
we  can  see  seems  to  be  done  with  a  wonderful 
economy,  quite  a  contrast  to  the  wasteful  method 
of  natural  selection  which  macroscopically  we  see 
about  us  everywhere.'"  Has  this  come  about,  is  it 
still  coming  about  by  individual  selection  ?  The 
mind  recoils  before  the  suggestion.  The  stupendous 
slaughter  necessary  to  keep  the  cellular  and  sub- 
cellular processes  of  man  in  proper  working  condi- 
tion, while  evidently  at  work  in  the  forging  of  im- 
munity, would  seem  entirely  inadequate  to  weed  out 
the  possible  harmful  variations  of  microscopic  proto- 
plasm were  they  as  frequent  as  unfit  individuals.  I 
am  aware  that  we  are  asked  to  believe  that  the  meta- 
zoan  economy  was  built  up  as  a  result  of  protozoan 
waste,  but  the  constant  trimming  of  the  microcosm 
is  not  apparent  while  the  lopping  off  process  in  the 
macrocosm  meets  us  at  every  turn.  Tt  is  natural 
then  for  the  zoologist  to  find  in  neo-Darwinism  a 
completeness  of  satisfaction  which  is  not  vouch- 
safed to  the  histologist.  Lamarckians  of  the  old 
school  were  taunted  with  their  lack  of  success  in 
producing  a  race  of  bobtailed  dogs  or  mice  or 
sheep,  by  persistently  docking  their  ancestors,  just 
as  Darwinism  was  taunted  with  the  declaration 
that  natural  selection  might  be  the  explanation  of 
the  death  of  species  but  not  of  the  origin  of  species. 
The  changes  have  been  rung  on  these  themes  as 
they  have  on  the  recession  of  unused  parts  and  it 
seems  almost  useless  to  try  to  say  anything  new  ofi 
the  subject ;  yet  the  projection  of  molecular  physics 
into  the  arena  of  the  discussion  of  the  nature  of  life 
processes  having  become  more  frequent  and  in- 
sistent of  late,  there  may  be  some  aspects  of  even 
these  tbi-eadbarc  subjects  deserving  of  consideration. 

Panmixia  and  germinal  selection  have  been  of- 
fered as  an  explanation  for  the  recession  of  unused 
parts.  That  is  the  determinants  not  receiving  nu- 
trition whicii  they  attract  when  in  use  are  weakened, 
and  cede  their  place  in  the  struggle  to  those  better 
fed  by  virtue  of  active  function,  and  so  man's  ap- 
pendix vcrmiformis  or  the  whale's  legs  are  organs 
tending  to  disappear. 

1  larking  back  to  our  example  of  molecular  ar- 
rangement for  the  character  of  man's  immunity  to 
bacteria  or  of  wlicat  to  rust,  viewing  the  process  in 
the  germ  plasm  as  a  shifting  of  the  .stereoscopic 
structure  of  the  living  molecule,  wc  find  ourselves 
at  a  standpoint  where  it  is  not  a  loss  but  a  shift  of 

""It  may  be  urged,  of  course,  tliat  our  concern  ahout  the  waste 
is  entirely  anthropomorphic.  The  susceptible  man  who  perishes  is 
food  for  the  worms  at  le.nst.  Hut  eliminating  the  word  waste,  the 
piiint  which  I  wish  to  make  is  that  the  cellular  selecHon  is  not  the 
obvious  phtnomcnoii  to  histologists  which  individual  selection  is  to 
zoologists. 


January  g,  1909.] 


WILLIAMS:  HYSTERIA. 


53 


determinants,  if  we  must  use  Weismann's  symbol, 
which  forms  our  conception  of  the  change.  Remem- 
bering that  it  is  the  process  and  not  the  material 
unit  which  is  the  manifestation  of  the  mystery  of 
heredity,  the  mechanical  conception  of  life  figures 
without  difficulty  such  a  shift  of  molecules  as  to 
drop  a  valence  for  another  molecule,  somewhat  in 
the  fashion  which  Adami  imagined  in  an  application 
of  the  concepts  of  Ehrlich  to  the  problems  of  hered- 
ity. This  specific  manifestation  of  force,  this  at- 
traction or  repulsion  is  easily  converted  into  other 
manifestations  of  energy,  but  how  are  we  to  get  rid 
of  the  determinant  when  necessary?  Only  by  the 
mysterious  process  of  its  becoming  latent.  How  are 
we  to  figure  that  for  a  material  unit  ?  In  what  nook 
are  we  to  tuck  away  the  latent  determinant  of  a 
characteristic?  It  is  something  real,  according  to 
\A'eismann,  and  therefore  must  have  a  real  nook  to 
retire  to.  Such  determinants  as  obey  the  law  of 
Mendel  are  in  need  of  these  nooks,  it  is  plain,  and 
the  same  is  no  less  true  for  those  which  do  not. 

Individual  selection  not  sufficing,  since  unused 
parts  are  often  harmless,  germinal  selection  invented 
by  Weismann  seems  to  require  the  intervention  of 
the  effects  of  use  and  disuse  in  the  germ  plasm 
which  is  denied  to  the  soma  for  purposes  of  trans- 
mission. Cutting  of  dogs'  tails  has  produced  no 
effect  on  the  germ  plasm.  A  dog  can't  use  a  tail 
he  has  lost,  but  the  tail  reappears  in  his  son.  Hence 
disuse  has  no  effect  on  the  germ  plasm.  The  wag- 
ging of  a  dog's  tail  has  no  survival  value,  yet  the 
dog's  tail  persists.  Hence  the  use  of  it  in  wagging 
saves  it  from  the  fate  of  the  whale's  legs.  I  do 
npt  see  why  all  this  sort  of  reasoning  is  not  on  a 
par  of  puerility. 

It  all  receives  its  answer  in  the  phrase  of  Jen- 
nings's conclusion  from  direct  observations:  "In  or- 
der that  it  may  be  inherited  a  characteristic  must  be 
tlie  result  of  such  a  modification  of  the  mother  cell 
as  will  cause  it  to  behave  in  a  certain  way  at  re- 
production. It  makes  no  difference  whether  the 
mother  cell  in  question  is  a  germ  cell  in  a  metazoan 
or  a  differentiated  protozoan.'"'  We  may  suppose 
that  modification  of  the  mother  cell  to  be  such  a 
shifting  of  the  structure  of  the  molecule  as  neither 
destroys  it  nor  interferes  with  that  mysterious 
power  of  handing  on  its  own  attractions  and  re- 
pulsions, but  we  must  not  flatter  ourselves  with  the 
idea  that  such  a  conception  explains  the  mystery  of 
heredity.  Such  a  shift  may  make  large  somatic 
changes  (mutations)  or  small  somatic  changes  (in- 
dividual variations).  The  shift  may  be  persistent 
or  it  may  slide  back  again,  but  whatever  it  does, 
it  depends  on  the  environment  and  not  on  some 
mysterious  vital  force. 

It  is  small  matter  what  may  be  the  personal  views 
of  one  so  foreign  in  his  activities  to  this  war  of 
theories,  but  as  for  myself.  I  prefer  to  lean  on  the 
perilous  support  of  analogies  found  in  so  called  in- 
animate matter  involving  the  assumption,  decried 
by  Professor  Thomson,  that  no  hard  and  fast  line 
between  it  and  life  exists.  You  may  call  it  panthe- 
ism or  gross  materialism,  as  you  like,  but  I  fail  to 
see  how  any  other  attitude  is  possible  in  biological 
pursuits. 

The  oldest  analogy,  the  most  frequently  drawn 

■-'Heredity.  Variation  and  Evolution  in  Protozoa.  Journal  of 
Experimental  Zoology,  June,  1908. 


parallel  is  that  between  crystallization  and  vital  or- 
ganization. When  the  angles  of  a  crystal  are 
broken,  it  has  been  shown  that  it  repairs  itself  by 
intussusception  as  the  crab  does  for  its  claw  when 
it  loses  it. 

Sir  Oliver  Lodge  says:  "Solid  substances  store 
up  in  their  structure  any  previous  arrangement  of 

their  molecules  The  properties  of  all 

fluids,  whether  liquids  or  gases,  depend  upon  their 
state  at  the  moment  and  upon  nothing  else ;  not  at  all 
upon  how  they  reached  that  state,  or  upon  what  has 
happened  to  them  in  past  time."  Now  between  these 
states  of  matter,  the  one  all  but  rigid,  unmoving,  and 
the  one  of  fluidity  unable  to  receive  and  store  up  the 
past  impressions,  we  have  the  colloid  state  involving 
fluidity  and  the  ability  to  store  up  past  experience. 
It  has  been  shown  that  this  state  of  matter  is  one 
of  minute  subdivisions,^  between  which  in  a  fluid 
menstruum  there  is  "an  interplay  of  electro- 
magnetic forces ;  but  no  explanation  exists  of  how 
matter  in  this  state  of  electro-dynamic  suspension 
stores  up  the  impressions  of  past  experience.  Yet 
the  colloids  of  protoplasm  do  this  and  the  colloids 
of  the  metals  are  said  to  do  it.  It  has  been  in- 
sisted that  a  bar  of  iron  once  struck  by  the  sledge 
of  the  blacksmith  never  returns  to  its  pristine 
molecular  condition.  That  blow  forms  part  of  the 
heredity  of  that  bit  of  iron  as  long  as  it  lasts.  The 
reactions  of  a  metallic  colloid  are  also  said  to  depend 
on  its  past  experience.  I  can  not  but  believe  that 
finally  it  will  be  shown  that  the  colloid  of  the  germ 
cell  obeys  the  same  law.  Jennings"  declares  that, 
for  the  somatic  cells  at  least,  the  physiological  states 
into  which  they  are  thrown  by  vital  processes  de- 
termine the  character  of  their  reaction  to  stimuli. 
The  colloid  state  of  the  living  cell  thus  shows  its 
affinity  with  the  colloid  state  of  the  metals. 

In  the  references  I  have  made  in  former  articles 
to  the  pulsating  molecule  supposed  to  explain  some 
of  the  phenomena  exhibited  by  the  benzol  group  of 
compounds,  we  find  another  analogv  with  the  oscil- 
lating equilibrium  of  life. 

Yet  identifying  vital  processes  with  inorganic 
proces.ses,  even  admitting  they  are  all  identical, 
which  is  far  from  having  been  proved,  the  heredity 
of  living  matter  has  been  in  no  way  explained, 

44  West  Forty-ninth  Street. 


THE  PRESENT  STATUS  OF  HYSTERIA.* 

By  'Jom  a.  Willi.ams.  M.  B.,  C.  M.  (Edin.), 
Wasliington,  D.  C. 

Since  hysteria  cannot  be  demonstrated  histologic- 
ally, rigorous  clinical  observation  is  needed  for  its 
elucidation  ;  for  with  whatever  good  faith  one  ob- 
serves, psychological  hypotheses  or  theoretical  in- 
terpretations are  very  apt,  if  not  to  influence  the 
observations,  at  least  to  cause  undue  weight  to  be 
attached  to  some,  and  others  to  be  minimized. 

To  this  question,  the  most  authoritative  contribu- 
tion ever  presented  is  that  now  afforded  by  the  dis- 
cussion at  the  Paris  Neurological  Society.  The 
report  which  led  to  it  was  asked  for  so  long  ago  as 
1901  when  Dupre  was  charged  to  make  it  after 

--Bfliazior  of  the  Lower  Organisms,  1906. 

*Read  before  the  Washington  Society  of  Mental  and  Nervous 
Disease,  November  19,  1908. 


54 


WILLIAMS:  HYSTERIA. 


[New  York 
Medical  TournaL- 


Babinski  had  promulgated  his  definition,  then  so 
novel,  astonishing,  and  at  seeming  variance  with 
the  facts  of  hysteria. 

The  immensity  of  the  task  and  the  uncertainty 
of  the  facts  upon  which  reliance  had  to  be  placed 
postponed  the  report  until  this  year.  During  all 
this  time,  the  facts  were  being  sifted,  more  especial- 
ly in  Paris,  with  that  critical  acumen,  logical  hon- 
esty and  clear  insight  so  characteristic  of  the  French 
intelligence,  until  it  was  felt  that  poorly  observed 
cases  and  ill  digested  theories  could  no  longer  cloud 
the  issue  by  their  preponderance. 

To  systematize  the  discussion,  it  was  taken  under 
eight  different  heads,  which  were  considered  separ- 
ately and  in  order.  They  were  placed  in  the  form 
of  questions  to  be  decided  by  discussion  and  vote 
of  the  members  present. 

The  first  question  was :  J'Among  the  phenomena 
usually  included  in  hysteria,  is  there  a  special  group 
of  symptoms  which  can  be  exactly  reproduced  by 
suggestion  and  which  can  disappear  under  the  in- 
fluence solely  of  suggestion  or  persuasion :  In  par- 
ticular, certain  kinds  of  convulsive  fits,  paralyses, 
contractures,  anjpsthesise,  hyperassthesire ;  of  modi- 
fications of  the  special  senses  and  of  difficulties  of 
speech ;  as  well  as  certain  respiratory,  digestive,  and 
other  troubles."  This  question  has  been  discussed 
in  the  Paris  Neurological  Society,  principally  at  the 
/  instigation  of  Babinski,  during  the  past  six  years. 
Hence  little  further  talk  was  required  before  the 
ciuestion  was  answered  unanimously  in  the  affirma- 
tive. Even  Raymond,  whose  ideas  concerning  hys- 
teria are  those  which  have  been  characteristic  of  the 
Salpetriere  since  the  days  of  Charcot,  acceded,  let- 
ting it  be  clearly  understood,  however,  that  he  spoke 
of  certain  cases  and  not  of  all.  Souques  reported 
a  case  of  a  young  peasant  girl  of  sixteen,  who  came 
to  consult  him,  being  subject  to  crises  dc  ncrfs.  The 
examination  showed  neither  contraction  of  the  vis- 
ual field  nor  anaesthesia.  She  was  admitted  into  the 
hospital  and  shortly  afterwards  she  showed  signs 
of  hcmianassthesia  of  sensitivosensorial  type  with 
bilateral  and  concentric  contraction  of  the  visual 
field.  During  the  interval  there  had  been  several 
examinations  made  avcc  rccherches  des  stigmatcs. 
Souques  said :  "I  think  that  the  hysterical  symptoms, 
particularly  hemiansesthesia,  are  the  result  of  an 
unconscious  suggestion,  the  more  often  of  medical 
origin."  Brissaud  also  cited  a  case  of  a  man  who 
met  with, an  accident  while  at  work.  No  hemian- 
jesthesia  was  declared  immediately  after  the  acci- 
dent, but  later,  on  the  occasion  of  an  assessment,  he 
presented  a  hemianresthesia.  Dupinet,  who  accom- 
panied the  patient,  had  been  present  at  the  produc- 
tion of  this  hemian?esthesia,  which  was  called  forth 
by  another  expert.  Dejerine.  Raymond,  and  Pitres, 
although  they  believed  that  this  is  often  the  case,  do 
not  admit  it  in  certain  cases  where  it  does  not  appear 
to  them  possible  to  incriminate  a  previous  exam- 
ination performed  by  the  doctor.  They  think  that 
sometimes  suggestion  plays  no  part  in  the  origin  of 
the  hysterical  stigmata  and  that  they  may  appear 
spontaneously. 

2.  The  second  question  was  as  follows:  "If  one 
admits  the  existence  of  a  group  of  characteristic 
symptoms,  is  it  not  necessary  to  give  these  symp- 
toms a  name?   The  term  of  pithiathism  having  been 


proposed,  should  it  be  kept?"  (The  word  pithiatisni 
was  first  proposed  by  Babinski ;  as  from  its  deriva- 
tion it  seemed  a  more  suitable  term  to  designate  the 
troubles  defined  by  hysterical  than  the  old  word 
with  its  numerous  erroneous  connotations.) 

This  second  question  was  postponed  to  the  end 
of  the  discussion,  as  it  concerned  terminology. 

3.  The  third  question  concerned  the  genesis  of 
hysterical  symptoms ;  and  it  is  of  the  greatest  prac- 
tical importance.  The  writer  has  elsewhere  dis- 
cussed this  matter  very  fully.'  It  was  as  follows : 
"(a)  Are  not  the  so  called  hysterical  stigmata  (sen- 
sitivosensorial hemianaesthesia,  contraction  of  the 
visual  field,  monocular  polyopia,  dyschromatopsia, 
loss  of  pharyngeal  reflex,  hysterogenetic  zones,  etc.) 
the  result  of  an  unconscious  suggestion,  usuall)'  of 
medical  origin?  (b)  Is  it  not  possible  to  admit  that 
sometimes  suggestion  plays  no  part  in  originating 
the  stigmata,  and  that  they  may  develop  spontane- 
ously under  an  unknown  influence?" 

Both  Raymond  and  Dejerine  firmly  believe  that 
cases  occur  where  undoubted  hysterical  symptoms 
arise  without  any  possible  suggestive  influence. 
They,  however,  are  speaking  here  merely  of  direct 
medical  or  other  suggestion.  They  do  not  consider 
the  possibility  of  a  suggestion  induced  by  their  own 
examination  of  the  patient.  Babinski  once  more  in- 
sisted upon  his  method  of  avoiding  suggestion  in  ex- 
amining the  sensibility.  The  "writer  has  described 
this  in  a  recent  communication,'  and  both  Ballet  and 
Scuques  declare  that  nowadays,  taking  these  precau- 
tions, they  never  find  the  stigmata  in  hysterics  who 
have  not  been  previously  medically  examined.  Bris- 
saud cited  still  another  instance  of  traumatic  neurosis 
in  which  hemianaesthesia  occurred  under  the  eyes,  so 
to  speak,  of  the  medical  adviser. 

There  is,  however,  another  cause  for  the  hemi- 
anassthetic  type  being  more  common  than  other  dis- 
tributions of  sensory  abnormality :  It  is  that  even 
ignorant  peasants  have  seen  hemiplegics  and  that  in 
proportion  to  that  ignorance,  they  are  astonished 
that  a  paralysed  limb  can  feel,  paralysis  and  loss  of 
sensibility  appearing  to  them  necessary  concomit- 
ants. The  picture  of  hemiplegia  is  latent  in  their 
minds,  the  idea  of  disability  due  to  injury  connotes 
to  them  the  absence  of  sensibility  in  the  injured 
limb. 

Raymond,  however,  believes  that  this  susceptibil- 
ity to  anaesthesia  is  something  special  to  hysteria. 
It  seems  very  evident  that  the  special  predilection 
is  one  towarcls  suggestibilit\ ,  this  being  the  cause  of 
the  anaesthesia,  ascertainable  in  the  vast  majority 
of  cases  in  proportion  to  the  technical  skill  used  for 
its  elucidation.  The  position  does  not  differ  from 
that  formerly  occupied  by  the  finding  of  Koch's 
bacillus  in  tuberculosis  and  Eberth's  bacillus  in  the 
blood  of  enteric  cases.  The  proportion  found  cor- 
responds to  skill  in  technique.  Another  factor  was 
remarked  by  Meige,  who  pointed  out  that  the  ex- 
aminer usually  pricks  the  left  side  of  the  patient 
first,  because  this  was  opposite  the  right  hand  hold- 
ing the  pin ;  and  as  Pitres  had  to  confess,  asks 
the  patient  ''Do  you  feel?":  this  in  itself  coutains 
a  suggestion  that  he  may  not  feel,  besides  being  sub- 
ject to  the  fallacy  of  the  patient's  iniscomprchen- 

'^Intcrnational  Clinics.  October,  1Q08. 

•To  appear  in  the  Aiiicricaii  Journal  of  the  Medical  Sciences. 


January  9.  sgog.] 


WILLIAMS:  HYSTERIA. 


55 


sion  in  believing  tliat  the  question  concerns  only 
pain,  which  need  by  no  means  be  caused  by  every 
pin  prick  as  may  be  verified  on  any  normal  person. 

A  most  pertinent  remark  was  that  of  1  homas 
when  he  pointed  out  that  one  usually  compares  arm 
w  ith  arm  and  leg  with  leg,  and  very  rarely  arm  with 
leg  and  leg  with  arm ;  hence  the  commonness  of 
unilaterality  and  the  rarity  of  paralaterality  in  the 
distribution  of  hysterical  symptoms. 

As  it  is  impossible  to  prove  a  universal  negative, 
question  (bj  is  necessarily  insoluble,  logically 
speaking,  more  especially  as  such  symptoms  are  fre- 
quently consciously  simulated,  and  that  the  dif- 
ference between  conscious  and  unconscious  simula- 
tion is  moral  and  not  medical ;  each  of  them,  how- 
ever, is  equally  derivable  from  suggestion,  autoch- 
thonous or  not.  I  have  discussed  hyterical  mani- 
festations with  country  physicians  in  England  and 
America,  and  have  been  much  struck  by  the  num- 
ber of  instances  in  w-hich  they  have  unmasked  sim- 
ulation, and  have  been  successful  in  curing  their 
patients  on  the  old  fashioned  plan  of  treating  them 
as  moral  delinquents  rather  than  as  sic^c  people. 
They  direct  the  conduct  of  their  patients  into  nor- 
mal channels  by  reinforcing  their  weak  or  perverted 
will  through  the  unpleasantness  entailed  by  the 
medical  treatment,  instead  of  fostering  the  pleasing 
novelty,  notoriety,  sympathy,  and  interest  which  the 
patient  excites  in  the  less  sceptical  and  more  indul- 
gent. 

The  majority  of  the  society  decided  then  that  one 
finds  medical  suggestion  at  the  root  of  a  vast  ma- 
jority of  hysterical  symptoms  in  proportion  as  one 
seeks  it  with  more  intelligence  and  care,  and  that 
it  is  of  course  impossible  to  deny  it  even  in  most 
of  these  cases  where  it  is  not  elicited. 

(4)  The  fourth  question  is  as  follows: — 
"Have  suggestion  and  persuasion  any  action  upon 
(a)  the  tendon  reflexes,  (b)  the  skin  reflexes,  (c) 
the  pupil  reflexes,  (d)  the  circulatory  and  trophic 
functions  (dermographia,  urticaria,  cedema,  erup- 
tions, haemorrhages,  ulcers,  gangrene,  (e)  the  se- 
cretory functions  (urine,  sweat,  saliva),  (f)  the 
temperature  (fever)?" 

Everyone  agrees  that  suggestion  has  no  power 
over  the  tendon  reflexes,  as  they  are  beyond  voluntary 
control ;  but  the  skin  reflexes  are  more  or  less  modi- 
fied by  the  will,  and  it  is  very  probable  that  they 
react  through  the  cortex.'  Hence,  they  may  be 
amenable  to  suggestion.  It  is  very  easy  by  a  little 
practice  to  inhibit  the  false  pharyngeal  reflex,  i.  e. 
the  drawing  back  of  the  patient :  but  one  cannot  in- 
hibit the  true  faucial  reflex,  which  consists  of  the 
retraction  of  the  soft  palate  and  its  pillars.  The 
plantar  reflex  is  absent  in  at  least  ten  per  cent,  of 
people.  A  person  can  inhibit  reactions  to  tickling, 
of  which  that  of  the  fascia  lata  is  one.  Of  course, 
any  of  these  reflexes  can  be  more  or  less  simulated 
or  suppressed  intentionally ;  but  even  then  the  re- 
production is  incomlpete,  often  exaggerated  or  ill 
timed,  and  can  be  distinguished  from  the  true  reflex 
by  a  discriminating  observer  with  a  little  finesse. 

It  must  not  be  forgotten  that  many  intoxicated 
states  which  paralyse  the  neurones  which  govern 
the  reflexes  also  necessarily  interfere  with  the 
psyche,  and  give  rise  among  other  symptoms  to 

^\'an  GehuchteTi,  La  Neurone.  1904. 


many  of  hysterical  type.  This  by  no  means  means 
the  modification  of  reflexes  by  the  hysterical  symp- 
toms ;  both  are  effects  of  a  common  cause ;  either 
may  occur  independently  in  accordance  with  the  pre- 
ponderance of  the  intoxication  upon  one  or  other 
part  of  the  nervous  system. 

These  remarks  also  apply  to  pupil  reactions  in 
dementia  prjecox,  with  its  crowd  of  hysterical  man- 
ifestations ;  for  every  one  nowadays  agrees  that  sug- 
gestion cannot  modify  the  reflex  of  the  pupils.  As 
to  the  contracted  visual  field,  and  the  dyscroma- 
topsia  the  examination  to  be  valid  must  be  made 
with  the  same  illumination,  by"  the  same  method, 
and  with  colors  of  the  same  intensity  and  tone ;  be- 
sides which  it  must  be  recollected  that  the  position 
at  which  a  color  can  be  distinguished  clearly  is  not 
an  exact  point,  but  shades  oft"  gradually.  It  is 
certain  that  with  these  precautions  an  honest  ob- 
server does  not  find  contracted  visual  fields  de- 
rived from  suggestion. 

Xo  member  could  affirm  that  he  had  ever  by  sug- 
gestion provoked  dermatographia,  urticaria,  oedema, 
ulcerations,  etc.,  though  both  Pitres  and  Brissaud 
believed  that  they  had  in  the  past  seen  cases  which 
seemed  like  hysterical  swelling  of  the  breast.  It  is 
necessary  here  to  take  account  of  the  niytlwinanic 
character  of  so  many  suggestible  patients.  Their 
trickeries  are  almost  beyond  belief,  e.  g..  that  of  the 
man  who  confessed  to  concealing  a  hypodermic 
syringe  in  his  rectum ;  and  this  was  not  all,  for 
in  a  moment  of  exasperation,  an  evacuation  revealed 
two.  IMedicolegal  work  reveals  to  the  critical  doc- 
tor prodigies  of  simulation,  and  the  literature  teems 
with  such  cases.  The  exsanguine  character  of  a 
wound  is  however  believed  by  Dupre  to  be  a  true 
index  of  the  anaesthesia  of  psychic  causation ;  but 
every  one  agreed  that  suggestion  had  no  influence 
over  it.  An  explanation  of  these  difficulties  may  be 
found  in  the  fact  that  many  hysterical  mythomanias 
are  often  mere  episodes  in  a  dementia  prsecox  or  in- 
toxication psychosis  syndrome  during  which  there 
are  always  vasomotor  modifications,  which  inaeed 
may  originate  the  idea  of  anaesthesia.  Pascal 
strikingly  demonstrates  these  facts.* 

As  to  hysterical  fever,  none  of  the  observations 
hitherto  published  are  beyond  criticism  as  regards 
the  precautions  taken  to  eliminate  on  the  one  hand 
deception,  and  on  the  other  intercurrent  disease.  It 
is  certain  that  no  one  has  succeeded  experimentally 
in  producing  fever  by  suggestion. 

The  fifth  question  was  as  follows: — 'Tn  admitting 
that  neither  suggestion  nor  persuasion  have  any 
influence  upon  the  above  named  phenomena  (see 
fourth  question)  does  there  not  exist  a  connection 
between  these  phenomena  and  the  symptoms  noted 
in  paragraph  i  ;  and  is  the  connection  one  of  cau- 
sality, of  interdependence,  of  association,  or  of 
simple  coincidence  ? 

Some  members  were  under  the  impression  that 
they  had  observed  facts  indicating  causality  be- 
tween these  phenomena,  especially  as  regards  the 
vasom.otor.  though  most  believed  it  was  one  of 
simple  coincidence,  and  Babinski  urged  the  import- 
ance of  eliminating  trickery. 

Question  six  began  in  a  discussion  as  to  the  mean- 

*Les  ictus  dans  la  demence  nrecose;  forme  prodromale  neuras- 
thenic de  la  demence  precoce  {L'Encephale,  1907). 


56 


WILLIAMS:  HYSTERIA. 


[New  York 
Medical  Jour.val. 


ing  of  the  word  suggestion.  Dejerine  pointed  out 
that  all  the  acts  of  our  life  are  influenced  by  sug- 
gestion. Even  the  most  cogent  reasoning  for  an 
opinion  only  convinces  through  the  hearer's  faith 
in  the  superiority  of  the  reasoner.  It  must  be  ad- 
mitted that  this,  to  a  large  extent,  is  true,  as  Bern- 
heim  has  long  insisted.  Even  education,  or  cultiva- 
tion of  the  intelligence,  fails  to  prevent  the  sug- 
gestibility of  susceptible  individuals,  or  in  matters 
to  which  the  subject  has  not  applied  his  learning. 
Oliver  Wendell  Holmes  long  ago  pointed  out  in  the 
Poet  at  the  Breakfast  Table  that  a  scientific  man's 
opinion  was  of  value  only  in  his  branch ;  although 
his  reasoning,  in  common  with  that  of  every  one, 
might  be  respected  when  applied  to  any  branch  of 
learning  provided  it  was  cogent  and  based  upon 
accurately  observed  facts.  Power  of  accurate  ob- 
servation in  a  laboratory  does  not  in  itself  fit  its 
possessor  for  valid  reasoning  or  synthetic  insight. 
That  the  opinions  of  a  man  of  science  regarding  the- 
ology or  politics,  for  instance,  are  often  dictated, 
not  by  the  scientific  habits  he  has  recently  acquired, 
but  by  the  suggestions  given  him  in  youthful  im- 
pressions and  habits,  is  well  known  to  every  stu- 
dent of  mental  failure. 

On  the  contrary,  Babinski  believes  that  the  term 
suggestion  should  always  imply  a  pejorative  idea, 
that  is  to  say,  correspond  to  our  use  of  the  word 
insinuation;  and  that  to  the  notion  of  making  an- 
other person  accept  an  idea  that  is  reasonable  the 
name  persuasion  should  be  given.  This  distinc- 
tion between  the  words  seems  to  the  writer  unsound 
both  in  psychology  and  logic  as  well  as  being  less 
practical  than  the  distinction  he  proposes,  which  de- 
pends not  upon  the  truth  or  validity  of  the  idea  im- 
posed but  upon  the  manner  of  its  acceptance  by  the 
subject.  There  is  no  means  of  ascertaining  truth 
and  validity;  we  have  to  judge  it  by  a  consensus  of 
opinion.  Fundamental  truths  accepted  by  people 
are  simply  those  to  which  they  feel  themselves  in- 
capable of  bringing  the  criticism  of  experience,  but 
on  which,  nevertheless,  all  their  acts  are  founded  ; 
so  much  so  that  they  would  think  their  individuality 
was  different  did  they  believe  otherwise.  For  in- 
stance belief  in  personal  devils  made  the  possessed 
of  the  Middle  Age?  behave  in  a  devilish  man- 
ner. Nowadays,  belief  in  spinal  commotion  pro- 
duces psychic  paralysis  of  the  limbs ;  belief  in  a 
delicate  stomach  creates  a  false  gastropathy.  After 
being  cured  of  dyspepsia  by  a  slow  removal  of  her 
erroneous  belief  one  of  Dejerine's  patients  said :  "I 
don't  feel  myself  at  all,  it  is  like  another  person." 
When  a  hysterotraumatic  patient  who  had  main- 
tained a  digital  contracture  for  five  years  reacted 
by  an  attack  of  nerves  when  a  gentle  attempt  was 
made  to  relax  his  fingers,  Brissaud  pertinently  re- 
marked "His  contracture  is  his  life."  The  most 
credulous  person  may  conform  to  an  opinion,  and 
thus  come  to  hold  ideas  judged  reasonable,  though 
he  has  never  shown  the  least  critical  power  or  capa- 
city for  judgment ;  in  other  words  he  may  be  the 
mcst  suggestible  of  men  with  the  most  reasonable 
of  ideas :  hence  there  is  no  discordance  between  sug- 
gestibility and  apparent  reasonableness  in  thought 
and  action. 

On  the  other  hand,  a  person  of  the  most  pains- 
taking criticality  may  have  a  knowledge  of  facts 


not  generally  known  or  be  unaware  of  an  incident 
well  known  to  his  neighbors,  which  may  cause  him 
to  profoundly  dissent  from  recognized  standards, 
and  to  appear  utterly  imreasonable.  His  unreason- 
able ideas,  however,  are  based  upon  a  capacity  for 
independent  judgment,  and  not  upon  suggestibility 
by  the  environment.  It  is  the  process  which  would 
be  called  persuasion  did  it  derive  from  another  per- 
son, hence  there  is  no  disaccord  between  unreason- 
able ideas  and  susceptibility  to  persuasion,  we  must 
therefore  conclude  that  the  distinction  between  sug- 
gestion and  persuasion  does  not  depend  upon  the 
result. 

For  instance  the  indisposition  of  the  man  who 
became  ill  on  account  of  the  reiteration  of  his 
friends  vv'hc  for  a  joke  plotted  against  him  is  an  ex- 
ample of  pejorative  suggesticn;  but  must  we  not 
call  meliorative  the  suggestion  which  induces  a 
child  to  get  up  and  continue  to  walk  although  he 
has  fallen  and  hurt  himself  because  he  is  made  to 
believe  by  certain  distractions  that  he  is  very  little 
hurt?  The  medical  literature  teems  with  cases  of 
psychotherapy  by  meliorative  suggestion  similar  in 
principle  to  the  preceding  example. 

Our  daily  life  furnishes  numerous  examples  of 
meliorative  persuasion,  even  though  the  majority 
of  men  arc  not  rationalists.  For  example :  When 
a  person  resolves  to  sleep  with  the  windows  open 
after  havmg  learned  that  a  consumptive  takes  less 
catarrh,  suffers  less  from  the  cold,  and  enjoys  bet- 
ter health  on  account  of  living  in  the  open  air— it 
being  taken  for  granted  that  he  understands  the 
physical  properties  of  the  atmosphere,  which  make 
the  access  of  a  sufficient  quantity  of  oxygen  impos- 
sible without  a  draught  more  or  less  severe.  It  is 
right  to  say  that  he  makes  his  decision  because  of 
persuasion. 

As  for  perjorative  persuasion,  the  best  examples 
are  the  eccentrics,  who  for  lack  of  education  can- 
not see  the  defects  in  the  bizarre  ideas  they  have 
adopted  after  a  long  ])eriod  of  reflection  upon  the 
facts.  Were  they  suggestible,  such  eccentric  ideas 
would  be  substituted  with  great  facility  by  any  new 
idea;  but  it  is  not  so.  The  persons  who  do  change 
their  idea.s  so  easily  are  merely  the  imitators  of  ec- 
centricity ;  and  these  are  no  more  truly  eccentric 
than  are  truly  decadent  the  followers  of  the  cult  of 
decadence.  One  cannot  judge  the  psychology  of  a 
class  by  a  study  of  its  camp  followers. 

If  suggestion  cannot  be  distinguished  from  per- 
suasion by  results,  it  follows  that  its  difference  de- 
pends upon  the  process ;  but  before  examining  this 
it  is  necessary  to  eliminate  those  properties  pos- 
ses.sed  in  common  in  both  suggestion  and  persua- 
sion. For  example :  The  act  of  substituting  a  new- 
ly imposed  idea  for  an  antecedent  belief  belongs 
both  to  suggestion  and  persuasion ;  in  either,  the 
subject  may  make  an  effort  to  oppose  the  incoming 
idea.  Here  it  is  possible  to  make  a  distinction  re- 
garding the  criticism  used  by  the  subject;  but  any 
difference  depends  fundamentally  upon  the  number 
of  facts  he  valued  in  order  to  resist  persuasion  as 
against  suggestion.  In  the  latter,  there  is  a  mere 
brute  resistance  against  the  imposing. 

When  this  opposition  is  overcome  by  stating  that 
it  vanish,  and  also  when  it  is  overcome  by  stratagem 
or  by  surprise  it  is  equally  so  by  suggestion.  This 


January  9,  ipoq.  I 


II' IL I.IAMS :  H  YSTERIA . 


57 


suggestion  is  indirect  when  the  opposition  of  the 
subject  is  disposed  of  through  turning  its  tlanks,  so 
to  speak,  while  the  subject  is  occupied  with  some  ir- 
relevant matter.  The  suggestion  is  direct  when  a 
mere  affirmation  suffices  to  destroy  an  adverse  idea. 

Xow,  on  the  contrary,  an  idea  is  imposed  by  per- 
suasion in  virtue  of  the  fact  that  the  subject  reaches 
the  new  conviction  while  all  the  time  fully  aware 
of  the  w-hole  process,  practically  speaking,  which 
takes  place  in  the  minds  both  of  himself  and  his  per- 
suader. An  orthodox  believer  in  the  cosmogony  of 
the  book  of  Genesis  who  becomes  convinced  of  the 
truth  of  the  Darwinian  theory  of  natural  selection 
bv  reading  books  of  Christian  apologetics  must  have 
become  so  by  persuasion,  contrary  suggestion  being 
put  aside.  l"he  distinction  then  is  one  of  aware- 
ness of  the  subject.  The  popular  mind  has  grasped 
this  distinction  in  the  current  notion  voiced  by  the 
saying :  "I  don't  know  how  I  was  tempted  to  do 
that,  the  man  hypnotized  me." 

From  these  considerations  it  follows  that  there  is 
a  fundamental  distinction  between  suggestion  and 
persuasion,  and  this  consists  of  the  subject's  entire 
unconsciousness,  the  absence  of  realization  of  the 
manner  in  which  a  new  idea  has  been  imposed  upon 
him  during  suggestion.  Sometimes  he  is  even  ig- 
norant of  having  received  anything  new.  Per- 
suasion on  the  other  hand  appeals  to  the  individ- 
ual's own  power  of  reflection  and  this  makes  him 
aware  of  the  whole  process  of  reasoning  by  which 
he  becomes  convinced.  A  false  conclusion  derived 
from  persuasion  is  false  not  in  virtue  of  incorrect 
reasoning  but  by  error  in  the  premises.  The  folic 
raisoniiantc  of  the  paranoiac  furnishes  another 
striking  example  of  autopersuasion. 

Suggestibility  is  annihilated  by  scepticism,  the 
habit  of  suspension  of  judgment,  doubt.  These, 
however,  connote  persuadability  unless  carried  to 
the  pathological  degree  of  folie  de  doute.  The 
victim  of  this  form  of  psychasthenia  may  be  per- 
suaded but  not  convinced.  The  lack  of  conviction, 
however,  is  merely  one  of  the  manifestations  of  the 
diminished  feeling  for  reality  which  is  so  prominent 
a  symptom  of  these  patients.  They  are  altogether 
unamenable  to  suggestion,  which  is  impossible  with- 
out a  feeling  of  entire  certainty,  a  certainty  so  great 
as  to  impel  its  victim  to  acts  and  beliefs  which  may 
be  entirely  irrational. 

Suggestibility  is  diminished  and  persuadability 
fostered  by  rational  education  :  and  during  the  pro- 
gress of  this,  the  same  individual  may  exhibit  both 
reaction?  according  to  the  intellectual  habit  aroused 
by  the  various  stimuli  employed.  The  rational  psy- 
chotherapy of  hysteria  includes  a  reeducative  pro- 
cedure of  this  type.  At  the  conclusion  of  the  course 
the  patient  is  no  longer  suggestible,  and  cannot 
therefore  be  termed  a  hvsteric. 

For  the  purposes  of  the  discussion,  the  members 
accepted  the  use  cf  the  word  advanced  by  Babinski. 
Dupre,  from  his  experience  in  the  police  infirmary, 
believed  that  suggestibility  was  seen,  outside  hys- 
teria, as  defined  in  paragraph  one,  in  the  debiles, 
demented,  descqnilibrcs.  and  in  the  dreamlike  states 
of  delirium.  He  attached  importance  to  the  inter- 
connection of  imitation,  of  mental  confusion  in  psy- 
chopathic individuals  as  seen  in  cases  of  delire  a 


deux,  religious  manias,  tobacco  smoking,  sexual  per- 
versions, in  all  of  which  the  emotions  also  play  a  part. 
]n  this  connection,  it  is  important  for  precise  classi- 
fication, to  consider  for  the  present  only  cases  which 
are  unequivocal ;  and  Babinski  relates  how,  though 
he  can  no  longer  count  his  cases  of  inveterate  hys- 
teria cured  by  suggestion  and  persuasion,  yet  he 
cannot  quote  a  single  case  of  any  other  neurosis 
completely  cured  in  this  way,  for  instance,  psychas- 
thenia (maladic  de  doute).  In  this  opinion,  there 
was  no  dissent,  though  Dejerine  and  Pitres  pointed 
out  that  such  cases  might  be  ameliorated  by  a  long 
course  of  persuasion. 

The  length  of  time  required  in  these  cases  was 
emphasized  by  Meige ;  but  as  Dejerine  and  Crocq 
pointed  out,  fundamental  distinctions  cannot  be  de- 
cided by  duration ;  and  in  any  case,  everyone  is 
familiar  with  the  long  time  required  to  influence 
some  cases  even  of  hysteria  by  suggestion. 

The  discussion  was  complicated  by,  and  failed  to 
bring  out  the  fact,  that  phobias,  tics,  obsessions,  and 
other  psychasthenic  symptoms,  as  well  as  those  of 
simple  neurasthenia,  may  each  and  all  be  induced 
by  suggestion,  and  therefore  conform  to  the  charac- 
ters of  paragraph  one ;  in  this  case,  however,  as 
Raymond  has  often  insisted,  being  fundamentally 
different  from  truly  psychasthenic  manifestations, 
and  the  diagnosis  generally  being  easy. 

It  requires  time  to  persuade  and,  often,  to  influ- 
ence the  feelings ;  but  a  suggestion  may  be  instan- 
taneous, and  is  generally  rapid.  The  psychasthenic 
possesses  a  susceptibility  to  persuasion,  his  difficulty 
being  to  decide.  In  the  hysteric,  decision  is  too 
easy ;  he  cannot  wait  to  be  persuaded,  but  must  act ; 
and  so  jumps  to  conclusions  and  is  hence  ripe  for 
suggestion.  In  any  case,  if  a  particular  phenomenon 
after  disappearing  by  suggestion  can  be  reproduced 
thereby,  there  can  be  no  doubt  in  what  category  it 
should  be  placed,  the  distinction  depending  not  upon 
the  time  taken  but  upon  the  nature  of  the  psycliic 
process  at  work. 

Cases  of  nosophobia  derived  from  the  suggestions 
of  doctors  and  curable  by  suggestion  are  not  hys- 
terical (according  to  Dejerine)  ;  because  they  are 
anxious  about  their  health,  while  (he  states)  an 
hysteric  is  not.  But  this  cannot  be  a  distinction ;  for 
many  hysterics  are  much  troubled  by  their  condi- 
tion, ^loreover,  just  as  hysteria  is  readily  excited 
by  an  organic  disease  present,  so  it  is  sometimes  as- 
sociated with  a  neurasthenic  state,  just  as  it  may 
indeed  create  a  neurasthenic  state,  from  the  vice  of 
nutrition  engendered  by  a  suggested  nosophobia. 
Besides  this,  some  cases  of  nosophobia  are  really 
due  to  disturbances  of  the  sensibilitv  arising  in  the 
internal  organs  (coensesthopathies).  From  which  it 
follows  that  a  so  called  neurotic  stomach  may  arise 
as  ( I )  a  manifestation  of  the  psychasthenic  consti- 
tution, (2)  a  modification  of  coenesthesia,  and  (  3) 
a  false  idea  arising  from  suggestion,  the  last  onlv 
being  hysterical  and  the  only  one  susceptible  to 
suggestion,  the  first  being  more  or  less  amenable  to 
rational  persuasion  and  the  second  requiring  medi- 
cal or  surgical  measures  for  which  we  have  as  yet 
no  definite  indication.  The  same  considerations  ap- 
ply to  disorders  of  other  internal  organs. 

No  member  was  able  to  give  an  instance  of  a.iv 


58 


/f'-G/L;  PUERPERAL  SEPSIS. 


[New  York 
Medical  Journal. 


Other  condition  than  hysteria  which  was  curable  by 
suggestion  alone ;  hence  question  six  must  be  an- 
swered in  the  negative. 

Question  8  was  whether  we  should  change  the 
name  hysteria  to  one  less  misleading. 

The  name  of  psychosis  by  imitation  was  proposed 
by  Dufour  as  being  better  than  either  pithiatism  or 
hysteria ;  and  Ballet  pointed  out  that  the  infantile 
mentality  must  be  included  if  Babinski's  ideas  pre- 
vail, and  believes  that  hysteria  is  less  the  trouble 
suggested  than  the  psychic  manifestation,  probably 
emotional,  which  permits  it,  as  in  the  case  of  a 
traumatic  neurosis,  which  for  him  is  not  the  result 
but  the  cause  of  the  suggestibility.  No  decision  was 
arrived  at ;  and  the  nomenclature  difficulty  along 
with  Question  ATI  (upon  the  relation  of  emotion 
to  the  phenomena  under  consideration)  has  been 
postponed  until  the  end  of  the  year.  Its  discussion 
will  be  considered  and  the  whole  question  summed 
up  about  that  time. 

21 18  WvoMTXG  Avenue. 


PUERPERAL  SEPSIS. 

By  Henry  Weil,  M.  D., 
New  York. 

Puerperal  infection  has  for  years  occupied  the  at- 
tention of  obstetricians,  much  has  been  written  on 
this  subject,  and  much  progress  made.  We  have  seen 
the  mortality  of  childbirth  gradually  decrease  until 
at  the  present  time  it  is  a  small  percentage  of  one  in 
institutions,  and  but  slightly  greater  in  private  prac- 
tice. The  technique  of  childbirth  is  well  worked  out ; 
the  days  of  douches,  sprays,  and  antiseptics  are  past. 
The  physician  of  to-day  makes  few  examinations  and 
depends  on  asepsis  rather  than  antisepsis.  Infection 
following  abortion  is  entirelv  different.  Very  little 
time  is  devoted  to  this  subject  in  the  lecture  room, 
so  that  the  knowledge  of  the  general  profession  has 
made  but  small  progress.  The  teachings  of  Fritsch. 
Fehling,  and  Virchow,  and  the  early  teachings  of 
Doederlein  and  Bumm,  are  still  evident.  The  gen- 
eral profession  places  too  much  reliance  in  vaginal 
douching  in  treating  these  cases  ;  the  curette  is  still 
handled  in  a  gingerly  fashion,  and  there  is  much  de- 
lay in  its  use.  Fully  ninety-five  per  cent,  or  more  of 
the  cases  of  infection  seen  at  present  follow  abortion, 
and  if  the  truth  was  known,  a  greater  percentage  of 
deaths  occur.  There  must,  therefore,  be  something 
materially  wrong ;  for  with  modern  methods  these 
infections  could  be  in  a  large  measure  avoided,  and 
even  if  not  avoided  .should  and  can  be  readily  con- 
trolled by  the  early  application  of  proper  treatment. 

The  subject  of  abortion  is  avoided  by  medical 
writers  for  obvious  reasons,  and  this,  perhaps,  also 
helps  to  account  for  the  lack  of  knowledge  of  the 
subject  on  the  part  of  the  profession  in  general. 
Yet  the  condition  is  widespread.  There  is  hardly  a 
married  woman  who  at  some  time  or  other  does  not 
miscarry,  and  many  with  such  persistent  regularity 
as  to  suggest  deliberate  induction.  Abortion  forms 
a  respectable  percentage  of  the  general  practitioner's 
work.  For  this  reason  I  will  approach  the  subject 
of  puerperal  infection  from  the  standpoint  of  abor- 
tion, reviewing  the  modern  treatment  of  the  same, 
paying  particular  attention  to  the  treatment  of  ca.ses 


which,  because  of  the  severity  of  the  infection  or 
because  of  delay  in  seeking  treatment,  do  not  show 
improvement  from  curettage. 

Abortion  simple,  uncomplicated,  and  complete  de- 
mands no  extraordinary  treatment,  but  let  any  of 
these  qualifications  be  absent,  and  the  treatment  be- 
comes of  utmost  importance.  It  is  an  exceedingly 
common  condition,  but  its  nature  is  such  that  defi- 
nite and  reliable  statistics  are  not  available.  So  as 
to  clearly  understand  the  treatment,  it  will  be  well  to 
recall  its  aims.  They  are,  i,  to  secure  complete  dis- 
charge of  the  uterine  contents ;  2,  to  secure  thorough 
contraction  of  the  uterus  :  and,  3,  to  avoid  infection. 
If  we  fulfill  these  conditions,  the  case  must  neces- 
sarily make  a  perfect  recovery.  It  is  to  be  borne  in 
mind  that  these  conditions  bear  certain  aetiological 
relationship  to  one  another :  For  example,  if  the 
ovum  is  completely  discharged,  the  uterus  will  prob- 
ably contract  of  itself,  and  with  a  clean  and  contract- 
ed uterus,  infection  is  hardly  likely  to  obtain  any 
foothold.  Thus  it  would  seem  that  the  prime  indi- 
cation is  to  empty  the  womb.  This  is  universally 
conceded,  but  there  is  still  considerable  differt-nce  of 
opinion  as  to  the  best  time  to  curette. 

If  we  set  out  to  deliberately  induce  an  abortion  the 
results  with  proper  methods  should  be  fairly  con- 
stant. As  a  means  of  inducing  labor  pains,  some 
foreign  body  should  be  inserted  into  the  uterus. 
Soft  rubber  catheters  or  bougies  answer  this  purpose 
best,  although  gauze  strips  and  Barnes'  bags  are  also 
of  value  in  selected  cases.  In  any  event,  a  double 
result  is  obtained.  The  cervix  dilates  under  repeat- 
ed contraction,  the  placental  tissue  separates  from 
the  uterine  wall,  and  finally  the  ovum  is  expelled, 
complete  or  otherwise.  However,  it  is  usually  diffi- 
cult to  determine  whether  the  ovum  is  completelv 
expelled  or  not ;  yet  this  is  the  basis  of  the  entire 
treatment,  for,  with  tissue  retained  in  the  uterus,  the 
patient  is  exposed  to  the  principal  dangers,  haemor- 
rhage and  infection.  For  this  reason  it  is  my  prac- 
tice to  curette  all  cases  as  early  as  possible.  This 
ensures  an  empty  organ  and  removes  all  doubt.  I 
have  followed  this  practice  in  a  great  many  cases  and 
have  been  amply  repaid  for  the  extra  labor  involved. 
My  cases  convalesce  rapidly,  the  loss  of  blood  is  re- 
duced to  a  minimum,  and  the  pains  cease  at  once. 

T  his  curettage  anticipates  the  complications.  h;eni- 
orrhage  and  infection,  and  thus  avoids  them  both. 
After  a  curettage  haemorrhage  is  almost  unheard  of 
and  infection  rare ;  when  it  does  occur,  it  is  decided- 
ly mild.  Compare  this  with  the  results  where  the 
curette  is  not  used  at  once:  i,  Some  women  get 
along  nicely  ;  2,  in  many  cases  the  convalescence  is 
much  prolonged;  3,  it  is  often  necessary  to  operate 
to  check  severe  haemorrhage ;  4,  a  not  inconsiderable 
])ercentage  of  women  becomes  infected  and  must  be 
curetted;  5,  in  a  certain  number  severe  infection  de- 
velops. The  first  group  represents  those  cases  in 
which  the  expulsion  is  complete.  The  second  group, 
those  in  which  the  abortion  is  incomplete,  but  is  sub- 
.sequentlv  completed  by  the  efforts  of  uterine  con- 
traction and  drainage  ;  the  third  group  represents  a 
condition  that  may  be  expected  in  almost  any  case  ; 
the  fourth  group  represents  a  large  proportion  of 
the  total.  To  realize  this,  it  is  only  necessary  to  re- 
member that  by  far  the  greater  number  of  cases  are 
induced  deliberately  for  the  purpose  of  avoiding  ma- 


IVEIL:  PUERPERAL  SEPSIS. 


59 


ternity,  often  by  the  woman  herself,  and  often  by 
niidwives  or  physicians  of  doubtful  surgical  knowl- 
edge. The  last  group  includes  all  patients  who,  as  a 
result  of  severe  infection,  never  fully  recover  and 
occasionally  die.  When  cases  of  this  class  occur  in 
the  earlier  months  of  gestation,  they  tend  to  run  into 
pus  cases  with  pelvic  peritonitis,  adhesions,  etc.  If 
the  miscarriage  occurs  during  the  later  period  of 
pregnancy,  the  septicaemia  predominates,  as  a  rule. 

If  the  miscarriage  is  partially  complete  or  inevita- 
ble when  first  seen,  our  course  must  depend  on  the 
period  of  gestation,  the  degree  of  dilatation  of  the 
cervix,  the  amount  of  haemorrhage,  the  infection, 
etc.  In  the  later  periods  of  gestation  it  is  well  to 
let  the  case  deliver  itself.  This  insures  proper  dila- 
tation, placental  separation,  and  subsequent  drain- 
age ;  besides,  it  is  an  extremely  difficult  matter  to 
deliver,  say  a  six  or  seven  months"  foetus  in  the  ab- 
sence of  fair  dilatation,  and  it  is  occasionally  impos- 
sible to  completely  separate  the  placental  tissue  from 
the  uterine  wall.  If  the  pains  are  sluggish  or  ab- 
sent, they  may  be  hastened  by  the  usual  methods  in 
full  term  cases.  Or  if  the  case  is  urgent,  due  to  in- 
fection or  haemorrhage,  catheters  of  large  size  may 
be  inserted  into  the  uterus  and  the  vagina  packed. 
In  case  of  alarming  bleeding,  such  as  results  from 
extensive  placental  separation,  nothing  short  of  rapid 
dilatation  is  to  be  considered,  and  where  this  is  not 
obtainable,  the  foetus  must  be  macerated  with  pow- 
erful placental  forceps  and  delivered  piecemeal.  If 
tlie  case  is  one  in  the  earlier  months  of  gestation, 
and  there  is  sufficient  dilatation,  the  woman  should 
be  curetted  at  once.  This  insures  cessation  of  pain 
and  stops  haemorrhage  at  once. 

There  is  another  class  of  cases  which  the  physi- 
cian sees  only  after  the  foetus  is  expelled.  These 
cases  may  or  may  not  be  complete ;  at  any  rate,  we 
only  see  them  when  bleeding  alarmingly  or  when 
severe  infection  is  present.  In  case  of  haemorrhage, 
^ve  must  look  for  retained  placenta,  and,  no  matter 
what  the  stage  of  gestation,  the  uterus  must  be  emp- 
tied and  packed.  If  the  case  is  one  of  severe  infec- 
tion, the  treatment  will  depend  upon  several  factors, 
such  as  the  period  of  gestation,  the  duration  and 
progress  of  the  infection,  the  condition  of  the  pa- 
tient, etc.  In  every  case  all  retained  tissue  must  be 
removed  at  once,  and  the  curette  should  be  used  for 
this.  I  make  this  last  statement  with  full  knowl- 
edge of  the  objections  urged  against  the  curette, 
such  as  the  danger  of  perforation  and  the  opening 
up  of  new  channels  for  absorption,  not  to  mention 
the  breaking  through  the  protecting  layer  of  leuco- 
cytes and  the  danger  of  fresh  haemorrhage.  As  to 
the  danger  of  perforation,  I  can  speak  from  experi- 
ence, inasmuch  as  I  once  perforated  a  septic  uterus 
in  an  effort  to  expel  adherent  tissue,  and  I  even  de- 
livered a  loop  of  gut  through  the  uterine  tear  into 
the  vagina.  But  I  did  this  with  my  finger.  I  am 
firmly  convinced  that  manual  exploration  of  the  ute- 
rine cavity  involves  more  traumatism  than  the  cur- 
ette and  is  much  more  painful.  It  demands  absolute 
relaxation,  and  this  necessitates  an  anaesthetic, 
whereas  curettage  in  skillful  hands  can  almost  al- 
ways be  done  without  it.  This  is  often  an  impor- 
tant consideration.  Our  next  efforts  should  be  to 
contract  the  uterus,  if  possible.  I  urge  this  strong- 
ly.   One  cannot  spend  too  much  time  in  this  at- 


tempt, even  though  we  are  only  partially  successful. 
Unfortunately,  it  is  impossible  to  contract  the  cases 
that  need  it  most,  and  we  must  look  for  the  symp- 
toms to  continue  if  we  permit  the  toxine  and  germ 
laden  lochia  to  remain  in  contact  with  the  relaxed 
uterine  walls  and  vessels. 

This  leads  to  the  question  of  uterine  drainage  and 
the  treatment  of  infections  that  are  not  controlled 
by  curettage.  The  curette  in  proper  hands  will  re- 
move all  of  the  placental  tissue  ;  it  will  even  remove 
most  of  the  necrotic  uterine  tissue  also ;  but  it  will 
not  remove  all  of  the  infecting  germs,  neither  will  it 
prevent  subsequent  accumulation  of  lochia  within  the 
relaxed  uterus.  This  lochia  speedily  becomes  load- 
ed up  with  germs  and  their  toxines,  and  this  leads 
to  fresh  absorption.  There  is  no  question  but  that 
curettage,  if  it  is  performed  early  enough,  will  usu- 
ally control  the  case,  no  matter  how  drained ;  but 
when  the  operation  is  delayed  and  when  the  infec- 
tion is  particularly  virulent,  the  curette  fails.  Then 
drainage  becomes  of  utmost  importance.  This  drain- 
age must  be  of  a  character  to  meet  the  peculiar  indi- 
cations present  and  differs  from  drainage,  as  ordi- 
narily conceived. 

A  gauze  drain  in  the  uterus,  under  these  condi- 
tions, fails  absolutely  in  its  purpose.  In  fact,  gauze 
or  passive  drainage  of  any  sort  must  fail  wherever 
absorption  of  toxine  plays  a  principal  role.  We 
would  hardly  drain  the  stomach  with  gauze  in  strych- 
nine poisoning,  and  yet  the  conditions  of  the  stom- 
ach and  uterus  are  essentially  similar.  We  wash  out 
the  stomach  and  we  continue  this  washing  until  the 
strychnine  is  practically  all  washed  out.  This  is  a 
perfectly  rational  procedure  and  has  been  the  means 
of  saving  a  great  many  lives.  Xor  do  we  abandon 
the  stomach  tube  because  the  patient  shows  evidence 
of  absorption.  On  the  contrary,  we  know  it  to  be  all 
the  more  urgent.  Who  of  us  would  hesitate  to  irri- 
gate the  stomach  because  of  the  possibility  of  some 
poison  having  passed  into  the  bowel  and  beyond  our 
reach?  Yet  in  the  case  of  uterine  poisoning,  what 
do  we  do?    Pack  the  uterus  with  gauze! 

Drainage  by  irrigation  is  the  only  rational  drain- 
age imder  these  circumstances.  It  is  just  as  impera- 
tive as  the  stomach  tube  is  in  narcotic  poisoning,  and 
differs  only  inasmuch  as,  whereas  in  the  stomach 
case  the  poison  is  of  definite  amount  and  a  few 
washings  out  sufficient  to  eliminate  it,  yet  in  the  ute- 
rine case,  since  the  poison  is  being  continuallv  sup- 
plied, so  mu.';t  the  irrigation  be  more  or  less  fre- 
quently used.  That  some  of  the  germs  have  pene- 
trated the  uterine  wall  and  are  beyond  the  reach  of 
irrigation  no  mor^  argues  against  irrigation  than 
does  the  fact  that  the  patient  shows  evidence  of  poi- 
soning argue  against  the  stomach  tube.  The  irriga- 
tions, to  be  of  value,  must  be  frequently  applied,  and 
the  graver  the  case  the  oftener,  even  to  continuous 
irirgation  in  extreme  cases. 

It  is  my  practice,  when  the  curette  fails  to  control 
the  case,  to  resort  to  irrigations  at  once,  and  utilize 
a  sort  of  recurrent  irrigator  made  of  soft  rubber  tub- 
ing and  held  in  place  by  a  light  vaginal  tampon. 
With  this  device  it  is  only  necessary  to  disturb  the 
patient  once  to  insert  the  tube,  after  which  they  are 
given  on  a  bed  pan  with  the  aid  of  a  fountain  syringe 
coupled  to  one  of  the  two  tubes.  I  irrigate  rather 
often  at  first,  till  the  woman  shows  signs  of  improve- 


6o 


WEIL:  PUERPERAL  SEPSIS. 


[New  York 
Medical  Journal. 


ment,  after  which  I  cautiously  reduce  the  number  of 
daily  irrigations.  In  grave  cases  it  may  be  necessary 
to  irrigate  continuously  day  and  night  for  a  time. 
This  involves  considerable  labor,  but  it  effectively 
checks  further  absorption. 

I  have  purposely  avoided  all  reference  to  sapraemic 
infection,  because  I  consider  the  difference  between 
it  and  septicaemia  merely  one  of  degree.  We  are  un- 
able to  distinguish  in  advance,  and  even  if  we  were, 
there  is  no  assurance  that  one  may  not  turn  into  the 
other,  and,  finally,  because  the  treatment  of  both  is 
to  my  mind  the  same. 

As  to  practical  results  covering  a  large  and  varied 
experience,  I  have  been  universally  successful  in  all 
cases  in  w-hich  I  took  the  initial  steps,  in  all  cases  that 
I  was  able  to  see  before  the  expulsion  of  the  ovum 
and  in  which  no  infection  existed.  Every  patient  of 
this  group  was  curetted  as  soon  as  dilatation  was 
sufficient,  or,  immediately  after  expulsion  of  the 
ovum.  The  infected  cases — that  is,  those  that  were 
seen  by  me  only  after  infection  was  established — 
consisted  of  over  a  hundred  women  and  comprised 
a  variety  of  conditions.  Thirty  per  cent,  of  the 
women  were  undelivered ;  all  stages  of  gestation 
were  represented ;  some  were  seen  early  and  others 
late  in  the  infection,  and  the  infections  varied  from 
a  simple  saprjemic  condition  to  a  general  pelvic  cellu- 
litis with  abscess,  or  a  profound  septicaemia.  The 
undelivered  cases  were  most  easily  controlled ;  the 
same  is  true  of  the  earlier  periods  of  gestation  and 
the  early  infections.  Where  pelvic  abscess  was  pres- 
ent, it  was  incised  at  once.  In  every  case  the  uterus 
was  immediately  curetted  and  then  irrigated  with 
salt,  iodine,  or  alcoholic  solution.  All  cases  but  the 
most  severe  were  controlled  by  this  procedure  alone ; 
but  those  women  that  failed  to  show  improvement 
within  forty-eight  hours,  and  those  women  that  got 
worse  in  spite  of  the  curettage,  were  immediately  put 
on  frequent  irrigation.  The  urgency  of  the  case  deter- 
mined this  frequency,  and  in  one  case  continuous 
irrigation  was  carried  out.  This  case  was  the  first 
and  one  of  the  most  severe  that  I  was  called  upon  to 
resort  to  frequent  irrigations.  The  history  follows : 
Case. — F.  W.,  married,  age  twenty-six,  no  children.  Mis- 
carriage at  six  and  one  half  months,  foetus  still  born;  de- 
livery normal,  cervix  badly  lacerated  ;  peritonaeum  slightly 
torn.  From  the  beginning,  the  lochia  discharged  in  large 
amount.  On  the  third  day  she  had  a  severe  chill  with 
marked  rise  in  pulse  and  temperature.  The  next  day  she 
had  a  second  chill,  at  this  time  her  temperature  was  102°  F., 
pulse  145.  Oh  the  fifth  day  I  was  called.  Her  temperature 
was  then  103°  F,  pulse  above  160  and  of  bad  character. 
Her  appearance  was  characteristically  septic.  She  was  im- 
diately  placed  on  a  table  and  the  uterus  explored  and  then 
curetted.  The  organ  was  extremely  relaxed,  the  cervix  looked 
ugly,  and  pus  poured  from  the  uterine  cavity.  The  uterine 
measurements  were  fully  ten  inches  from  fundus  to  exter- 
nal OS.  The  currettagc  was  carefully  done  and  resulted  in 
detaching  considerable  placental  debris.  Then  I  irrigated 
and  packed  the  canal  with  iodoform  gauze.  The  expected 
improvement  was  not  evident  the  next  day,  on  the  contrary 
the  pulse  was  more  rapid  and  the  appearance  worse.  She 
was  again  ciuxtted  for  fear  1  had  failed  to  clean  the  organ 
thoroughly  at  the  first  sitting.  The  organ  was  again  irri- 
gated but  no  pack  inserted.  This  procedure  was  of  no 
avail,  for  on  the  following  day  her  pulse  was  almost  un- 
countable and  her  mind  wandering.  I  had  predicted  a  fatal 
outcome,  and  in  sheer  desperation  again  placed  the  patient 
on  the  table  and  inserted  two  rubber  tubes  well  into  the 
uterine  cavity,  retaining  them  by  tampon.  I  then  irrigated 
by  coupling  the  syringe  to  one  of  the  tubes  and  put  the  pa- 
tient back  in  bed.  The  irrigations  were  repeated  hourly, 
day  and  night,  by  putting  the  patient  on  the  bed  pan  and 


without  materially  disturbing  her  or  causing  any  pain.  The 
following  day  the  patient  was  still  alive  and  in  about  the 
same  condition;  if  anything  her  mind  was  a  trifle  clearer, 
so  I  hopefully  ordered  the  irrigation  every  fifteen  minutes, 
or  almost  continuously. 

On  the  next,  or  ninth,  day  she  was  distinctly  improved ; 
the  pulse  of  better  character  and  under  150;  the  mind  was 
clearer,  the  eye  brighter,  but  the  face  was  still  very  much 
pinched.  The  three  following  days  she  improved  steadily, 
so  much  so  that  on  the  twelfth  day  she  was  again  placed 
on  the  table,  the  tubes  removed,  and  fresh  ones  inserted. 
I  found  the  uterus  m.uch  firmer  and  the  cavity  smaller ;  the 
discharge  was  still  pouring  out  in  large  quantity.  Fresh 
tubes  were  inserted,  and  the  irrigation  continued  hourly 
and  rapidly  reduced,  so  that  by  the  seventeenth  day  she  was 
getting  but  four  irrigations  a  day.  With  the  general  improve- 
ment the  temperature  dropped  also  but  remained  around  100° 
F.  The  tubes  were  removed  on  the  twenty-second  day;  the 
organ  then  measured  about  four  and  one  half  inches,  but 
was  rigidly  fixed  by  adhesions,  the  pelvis  was  filled  with 
an  indurated  mass  and  the  cul-de-sacs  were  bulging.  A 
few  days  later  I  opened  a  pelvic  abscess,  liberating  consid- 
erable pus.  From  then  on  the  patient  slowly  regained  her 
health.  She  now  menstruates  with  perfect  regularity  and 
is  without  pelvic  symptoms. 

This  case  is  a  fair  example  of  the  seven  others  in  which 
I  used  irrigation.    All  the  patients  recovered. 

Intrauterine  irrigations  were  first  recommended  by 
Reculin  in  1757.  This  author  and  his  followers  em- 
ployed them  for  the  purpose  of  expelling  retained 
tissue  only.  There  were  others  who  employed  them 
to  check  haemorrhage,  using  astringents,  such  as 
iodine  and  iron  perchloride.  A  century  later,  in  1850 
to  '60,  they  were  used  as  a  prophylactic  against  sep- 
ticaemia by  Lige,  in  France,  and  Grunewaldt.  in  St. 
Petersburg.  In  1878  von  Winckel  advised  intra- 
uterine injections  in  puerperal  endometritis,  haemor- 
rhage, and  retained  tissue.  Schiicking  was  the  first 
to  suggest  repeated  or  continuous  irrigations,  and 
advised  them  for  expelling  retained  putrid  material. 
Playfair,  Braxton  Hicks,  Schroder,  and  in  fact  al- 
most all  of  the  prominent  obstetricians  of  the  period 
of  antisepsis  and  earlier,  resorted  to  irrigations  un- 
der some  conditions  or  other.  Tarnier,  Bailly,  and 
Hoffmeier  are  among  those  who  took  an  opposite 
stand.  Reported  accidents  w-ere  numerous  and  the 
oponents  objected  for  the  following  reasons :  There 
was  danger  of  forcing  fluids  into  the  peritoneal  cav- 
ity through  the  tubes :  they  caused  haemorrhage,, 
there  was  danger  of  forcing  air  into  the  uterine 
sinuses,  and  they  provoked  chills,  metritis,  and  peri- 
tonitis. In  the  light  of  our  better  knowledge,  it  is 
not  necessary  to  comment  upon  these  objections. 
Munde  and  Lusk  both  recommended  irrigations: 
Munde  for  the  purpose  of  removing  decomposing 
matter  from  the  uterus,  but  he  discontinued  them 
after  two  or  three  trials,  even  if  they  failed  to  re- 
move the  offending  material  or  to  reduce  the  tem- 
perature. And  Lusk  mentions  two  fonns  of  fever 
that  cannot  be  reached  by  the  uterine  douche,  "one 
derived  from  sewer  poisoning  and  the  other  from 
peritonitis  starting  from  some  form  of  tubal  dis- 
ease." 

Still  later,  Fritsch,  in  a  work  published  first  in 
1884,  recommended  periodic  flushing.  He  recog- 
nized the  necessity  for  early  action  and  recommend- 
ed exploration  with  the  finger  to  remove  the  prod- 
ucts of  conception.  Fehling's  work  was  published 
from  1890  to  1897.  Ho  put  nnich  faith  in  vaginal 
douching,  occasionally  resorted  to  intrauterine  irri- 
gation, rarely  used  the  curette,  and  was  .strongly  op- 
posed to  subiimate  solution,  even  in  its  weakest  form. 


January  9.  1 909.  ] 


MARKLEY:  MYOCARDITIS. 


61 


The  works  of  Biimm  and  Doederlein  have,  in  a  great 
measure  cleared  the  bacteriology  of  this  disease.  The 
parts  played  by  toxines  and  absorption  are  generally 
conceded,  and  the  early  use  of  the  curette  is  now 
well  nigh  universal.  The  whole  question  has  been 
approached  on  the  theory  that  once  infected  tissue  is 
removed,  the  condition  is  relieved.  Irrigations,  bot- 
tle brush,  and  finger  have  each  served  for  this  pur- 
pose in  their  turn,  and  the  curette  now  enjoys  popu- 
lar favor.  But  what  about  the  treatment  of  those 
women  not  cured  by  the  curette? 

In  a  recent  article  by  Sir  William  Sinclair,  the 
subject  of  puerperal  infection  is  exhaustively  treat- 
ed, yet  he  fails  to  consider  this  question ;  and  Peter- 
son's Obstetrics,  published  very  recently,  containing 
among  its  authors  some  of  the  most  prominent  ob- 
stetricians of  to-day,  and  which  may  therefore  be 
taken  as  a  standard  of  our  present  practice,  also 
overlooks  this  point.  On  the  subject  of  salt  solu- 
tion, upon  the  virtues  of  which  we  are  wont  to  place 
so  much  dependence  under  these  very  circumstances, 
this  book  states  (p.  869)  :  "The  treatment  has  the 
advantage  that  it  cannot  possibly  do  any  harm  and 
cannot  help  but  do  good  in  more  ways  than  one. 
Besides  impressing  the  patient  and  her  friends  with 
the  idea  that  something  is  being  done  for  her.  .  .  . 
It  is  the  treatment  par  excellence  for  puerperal  sep- 
sis of  almost  any  variety,  either  alone  or  in  conjunc- 
tion with  other  indicated  measures."  So  that  our 
efforts  to  save  the  patient's  life  are  to  consist  of  "do- 
ing no  harm  and  impressing  the  patient  and  her 
friends."  This  is  considered  an  advantage  and  may 
be  trusted  to  alone,  if  we  choose,  with  perfect  equa- 
nimity, for  we  are  assured  on  such  high  authority 
that  it  is  "the  treatment  par  excellence."  With  all 
due  respect  to  medical  authorities,  but  with  a  view 
to  saving  the  lives  of  these  unfortunate  women,  I 
humbly  take  exception  to  this,  I  realize  full  well 
that  I  thus  run  counter  to  the  concensus  of  medical 
opinion,  but  I  also  realize  that  w^ithout  dissension 
there  can  be  no  progress.  Let  us  look  further  into 
the  subject. 

At  the  present  time  certain  facts  are  absolutely 
established:  i.  The  uterine  walls  can  and  do  absorb, 
and  this  power  is  greater  following  abortion  and 
labor  with  its  more  numerous  veins  and  lymphatics. 
2,  The  products  of  germ  metabolism  are  poisonous ; 
these  poisons  called  toxines,  when  derived  from  path- 
ogenic bacteria,  are  capable  of  producing  violent 
.symptoms  and  death  when  injected  into  animals,  3, 
The  lochial  discharges  of  a  puerperal  infection  are 
loaded  with  pathogenic  germs  and  toxine.  Each  of 
these  facts  are  easily  demonstrated  and  incontest- 
able. This  being  the  case,  it  only  remains  to  dem- 
onstrate that,  4,  absorption  plays  an  important  part 
in  the  disease.  Of  this  there  can  be  little  doubt. 
Perhaps  the  most  convincing  proof  lies  in  the  fact 
that  we  produce  identical  symptoms  by  the  injection 
of  isolated  toxine  easily  obtained  in  this  disease  b}' 
repeatedly  filtering  the  lochia.  Again,  there  are  dis- 
eases, such  as  diphtheria  and  tetanus,  in  which  the 
bacterial  growth  is  comparatively  limited,  yet  ab- 
sorption of  the  toxine  causes  profotmd  symptoms,  or 
even  death.  The  entire  theory  of  serum  therapy  is 
based  upon  toxine  absorption.  If  these  four  hypoth- 
eses are  conceded,  it  is  our  clear  duty  to  apply  active 
drainage  to  every  case  that  resists  curettage,  and  we 
fail  in  our  duty  if  we  stand  idly  by  and  permit  our 


patients  to  slowly  poison  themselves,  while  we  pin 
our  faith  to  such  procedures  as  high  enemas  and  in- 
travenous injections,  which  every  physician  realizes 
are  useless  except  that  "it  cannot  possibly  do  any 
harm  —  besides  impressing  the  patient  and  her 
friends,"  etc.  Permit  me  to  observe  that  intraute- 
rine irrigation  also  possesses  these  latter  virtues, 
241  West  Oxe  Huxdred  axd  First  Street. 


MYOCARDITIS. 
Its  Pathology  Syuil'toms. 

Bv  P.  H.  Marklev.  M.  D., 
Camden,  N,  J., 

Visiting  Physician  to  Cooper  Hospital. 

Reference  to  heart  disease  ordinarily  suggests 
some  lesion  of  the  endocardium,  though  the  con- 
stant and  important  factor  is  the  extent  of  in- 
volvement of  the  myocardium,  the  one  interfering 
merely  mechanically  with  the  heart's  action,  whilst 
the  effects  of  the  other  are  manifold,  myocarditis 
being  the  underlying  element  of  danger  in  all  heart 
conditions,  for  any  deviation  from  the  normal,  not 
only  of  the  endocardium,  but  of  the  membrane  in- 
vesting the  heart,  the  pericardium,  or  of  the  blood 
supply  of  the  heart,  be  they  ever  so  slight,  have,  in 
most  instances,  associated  with  them  some  involve- 
ment of  the  heart  muscle,  as  the  membrane  sur- 
rounding the  cells  of  the  heart  is  not  a  separable 
membrane,  as  is  found  in  voluntary  muscular  fibre, 
but  is  really  a  continuation  of  the  connective  tissue 
of  the  endocardium  and  pericardium,  and  explains 
how,  by  continuity  of  structure,  inflammatory  or 
degenerative  changes,  originating  either  in  the  en- 
docardium, or  in  the  pericardium,  will,  or  may  at 
least',  involve  the,entire  structure.  Recall  also  that 
the  blood  supply  of  the  heart  is  dependent  entirely 
upon  the  coronary  arteries,  and  also  the  important 
fact  that  these  vessels  do  not  anastomose,  therefore 
precluding  anv  possibility  of  collateral  circulation 
becoming  established,  so  that  it  can  be  readily  un- 
derstood that  any  interference  with  the  free  circu- 
lation of  either  of  these  arteries  must  result  in  a 
lack  of  the  supply  of  pabulum  to  the  heart,  and  con- 
sequent degenerations.    Experimentally,  a  number 
of  observers  have  shown  that  obliteration  of  one 
coronary  artery  is  followed  by  marked  irregularity 
and  weakness  of  ventricular  contraction  with,  in 
some  instances,  complete  arrest  of  the  cardiac  cycle, 
and  invariably  followed  by  local  or  degenerative 
changes  in  the  heart  muscle,  confirming  the  views 
long  held  by  clinicians.    Myocarditis  being  so  fre- 
quently preceded  by  local  conditions,  its  indepen- 
dent existence  was  long  denied,  and  it  is  onlv  com- 
paratively recently  that  affections  of  the  muscular 
structure  of  the  heart  have  received  their  true  value 
and  consideration,  not  only  as  an  aetiological  factor, 
but,  owing  to  the  extreme  vulnerability  of  the  heart, 
as  an  important,  frequent,  and  serious  complication, 
and  one  always  to  be  reckoned  with  in  formulating 
a  prognosis,  for  w^e  now  know  that  the  many  cases 
of  sudden  death,  occurring  toward  the  close  of  the 
infectious  diseases,  or  indeed,  as  most  practitioners 
iiave  seen,  when  convalescence  seemed  w^ell  estab- 
lished, are  due  to  degenerations  of  the  heart  muscle, 
and  the  mystery  formerly  surrounding  these  cases 
was  not  satisfactorily  explained  until  myocarditis, 
had  been  given  its  proper  recognition. 


62 


.1/.  IKKI.ILV :  MYOCARDITIS. 


[N    \   v.. UK 

.\llll.C\L  JllLKXAI., 


Myocarditis  may  be  either  acute  or  chronic,  cir- 
cumscribed or  diffused.  The  most  frequent  cause 
of  the  acute  form  are  the  infections,  beheved  to  be 
due  to  the  direct  destructive  action  of  the  toxines  on 
the  heart  muscle ;  in  the  acute  cases  the  autopsy  re- 
veals but  little  macroscopically,  though  the  heart 
muscle  is  generally  somewhat  enlarged  and  darker 
in  color  than  normal ;  microscopically,  the  intra- 
cellular tissue  is  found  to  be  swollen  and  infil- 
trated with  leucocytes,  while  the  cardiac  fibres  and 
cells  show  a  beginning  disintegration,  the  so  called 
"cloudv  swelling,"  which  in  most  cases  subsides 
with  the  subsidence  of  the  infection,  though  its  ef- 
fects may  be  manifested,  after  a  prolonged  period 
of  latency.  Acute  myocarditis,  usually  insidious  in 
its  onset,  the  symptoms  mingling  with  those  of  the 
primary  disease,  is  often  most  difficult  of  recogni- 
tion, and  therefore  not  infrequently  overlooked, 
especially  the  milder  attacks,  which  seem  merely  to 
aggravate  the  general  weakness  and  to  retard  re- 
covery. The  physical  signs  of  acute  myocarditis, 
other  than  weakened  tone  of  the  heart  muscle,  are 
practically  negative.  Cardiac  enfeeblement,  however, 
is  quite  suggestive,  and  if  accompanied  with  a  dis- 
turbance of  the  normal  pulse  and  respiration  ratio, 
particularly  if  occurring  during  the  course  of  an 
acute  infection,  should  be  viewed  with  suspicion, 
and  if  the  additional  symptoms  of  faintness  and 
pallor  are  present,  the  picture  of  cardiac  involve- 
ment is  complete. 

Suppurative  interstitial  myocarditis,  or  abscess  of 
.the  heart,  may  be  induced  by  any  of  the  causes  that 
produce  pyaemia.  It  is  generally  embolic  in  origin, 
.and  frequently  multiple,  the  abscesses  varying  in 
:size  from  a  mere  spot  to  that  of  a  hen's  egg.  These 
leases  usually  quickly  terminate  iii  perforation  and 
death. 

Chronic  myocarditis,  like  the  acute,  may  be  either 
circumscribed  or  diffused,  and  is  almost  constantly 
accompanied  with  some  form  of  degeneration  of  the 
heart  muscle,  fibroid  induration,  and  fatty  disinte- 
gration, being  the  most  common.  In  chronic  myo- 
carditis the  heart  is  always  enlarged,  due  in  the  early 
stages  to  hypertrophy,  and  in  the  later  stages  to  the 
hypertrophy  plus  dilatation  of  the  heart  cavities. 
The  color  of  the  heart  is  normal,  except  in  those 
cases  of  superficial  circumscribed  areas  of  indura- 
tion, which  are  yellowish  or  grey  in  color.  In  the 
fibroid  form  the  consistency  of  the  tissue  is  in- 
creased, and  the  muscle  hard  and  resistent,  present- 
ing on  section  numerous  sclerotic  areas,  which  are 
generally  discreet,  though  they  may  be  confluent, 
giving  the  appearance  of  an  almost  solid  mass. 

In  fatty  degeneration  the  heart  muscle  is  relaxed, 
•  soft,  and  flabby,  falling  into  a  shapeless  mass  when 
left  unsupported,  and  when  placed  in  alcohol,  fat 
globules  mav  be  seen  floating  upon  the  surface  of 
the  liquid.  The  term  "fatty  heart"  is  often  incor- 
rectly applied  to  fatty  degeneration.  "Fatty  heart" 
is  an  accumulation  of  fat  about  the  heart,  such  as 
frequently  occurs  in  obesity,  and  sometimes  re- 
ferred to  as  fatty  infiltration  ;  it  is  not  a  degenera- 
tion, though  it  may  cause  marked  weakness  of  the 
heart  nnT^clc. 

The  chief  physical  signs  of  chronic  myocarditis 
are  weakened  muscular  tone  of  the  heart,  height- 
ened arterial  tension  (the  fibroid  form)  in  the  early 
?tage<.  or  a  low  tension  pulse  in  the  later  stage,  in- 


creased area  of  cardiac  dulness,  and  displacement 
of  the  apex,  which  signs  are  fairly  constant,  though 
extensive  disease  of  the  myocardium  may  be  pres- 
ent with  but  slight,  or  perhaps,  no  appreciable 
signs,  or,  a  small  lesion  situated  in  a  more  vital  por- 
tion of  the  heart  may  remain  latent  for  a  long  time 
to  suddenly  induce  urgent  and  distressing  symp- 
toms, where  no  heart  lesion  had  been  suspected,  and 
revealed  only  by  the  autopsy.  Such  cases  offer  a 
probable  explanation  of  the  many  instances  of  heart 
failure  occurring  during  a  trivial  disturbance,  and 
quickly  followed  by  death.  They  also  show  the 
importance  of  making  a  careful  study  of  the  heart 
condition  in  all  cases,  and  Babcock  truthfully  says 
that  "in  no  disease  does  the  diagnosis  depend  more 
upon  judgment  and  experience  than  in  myocardial 
disease." 

No  murmurs  are  heard  in  myocarditis,  except  in 
the  later  stages,  when  they  are  probably  due  to  the 
advancing  dilatation  interfering  with  the  closure  of 
the  valves.  Cases  coming  under  observation  at  this 
time  may  lead  to  serious  mistakes  for  if  but  a  super- 
ficial examination  should  be  made,  and  the  diagnosis 
determined  from  the  character  and  location  of  the 
murmur  alone,  without  regard  to  the  condition  of 
the  heart  muscle,  we  are  overlooking  the  most  im- 
portant factor.  The  mere  presence  of  a  murnuir, 
without  definite  knowledge  of  the  condition  of  the 
heart  muscle,  is  of  but  little  value  in  the  diagnosis 
or  prognosis  of  any  heart  affection.  ,  Bearing  upon 
this  fact,  von  Leyden,  of  Berlin,  in  a  recent  article, 
says :  "The  study  of  valvular  disease  of  the  heart, 
since  the  discovery  of  the  more  exact  methods  of 
physical  diagnosis  at  the  beginning  of  the  century, 
has  occupied  so  much  attention  that  myocarditis  has 
been  forced  into  the  background.  In  the  days  when 
the  pulse  formed  the  physician's  standby  for  the 
diagnosis  of  heart  affections,  it  must  be  confessed 
that  clearer  notions  of  the  state  of  the  muscle  itself 
seemed  to  exist  than  later,  when  the  study  of  the 
pulse  was  more  neglected  because  deemed  less  im- 
portant." And  A.  O.  J.  Kelly  remarks  that  "  the 
presence  of  a  cardiac  murmur  alone  is  no  more 
diagnostic  of  valvular  disease  than  is  the  presence 
of  albumin  in  the  urine,  without  other  signs  of  dis- 
ease, pathognomonic  of  nephritis.  We  all  know  that 
we  find  albumin  in  the  urine  of  persons  who  are  not 
the  subjects  of  nephritis,  and  similarly,  we  detect 
the  presence  of  a  murmur  in  patients  who  have  not 
heart  disease."  And  Cabot  says:  "The  majority  of 
all  heart  murmurs  are  functional." 

It  is  a  notable  fact  that  in  uncomplicated  myo- 
carditis, be  the  heart  ever  so  weak,  we  have  no 
dropsy,  and  rarely  any  cedema.  ff,  however,  there 
is,  in  addition  to  the  myocarditis,  a  defect  of  the 
valves,  dropsy  is  almost  certain.  The  reason  for  this 
absence  of  oedema  in  the  one  condition  and  its 
almost  invariable  presence  in  the  other,  is  perhajis 
to  be  found  in  the  fact  that  in  uncomplicated  myo- 
carditis there  is  no  distention  of  the  venous  circula- 
tion, and  the  volume  of  blood,  the  stimulus  to  the 
arteries,  is  not  dminished.  so  that  the  arteries  be- 
come compensatory  to  the  weakened  heart  muscle, 
whilst  valvular  defects  permit  of  a  drainage  froni 
the  arterial  into  the  venous  system,  which,  liecause 
of  the  weakened  general  circulation,  is  soon  fol- 
lowed bv  a  leakage  into  the  various  tissues.  .\r- 
rhvfhmia,  especiallv  occurring  in  persons  past  forty 


January  9,  I9<J9  J 


MARKLEV:  MYOCARDITIS. 


63 


years  of  age,  was  at  one  time  thought  to  be  ahnost 
pathognomonic  of  myocarditis,  but  we  now  know 
that  it  may  be  due  to  a  variety  of  causes,  though, 
if  occurring  in  persons  past  middle  hfe,  it  should 
not  be  disregarded.  Arriiythmia  includes  both 
irregularity  and  intermittence  of  the  pulse  rhythm, 
and  may  be  but  temporary  and  functional,  especially 
intermittence  of  the  pulse,  which  may,  in  some  in- 
stances, be  considered  physiological,  as  it  is  fre- 
quently present  in  normal  children,  and  may  even 
continue  throughout  life  in  perfectly  healthy  men. 
Irregularity  of  the  pulse,  however,  is  of  much  more 
significance,  and  not  infrequently  means  a  begin- 
ning failure  of  compensation.  Irregularity,  not  only 
of  the  rhythm,  but  also  of  the  impulse,  should  be 
considered,  myocarditis  often  manifesting  itself  by 
perceptible  changes  in  the  forces  of  the  pulse  wave, 
although  the  character  of  pulse  that  is  most  con- 
stant is  the  so  called  pulsus  paradoxicns.  the  para- 
doxical pulse,  wherein  the  normal  variation  due  to 
deep  inspiration  may  be  so  exaggerated  as  to  make 
the  radial  pulse  perceptibly  weak,  or,  as  occurs  in 
some  cases,  quite  imperceptible  at  the  wrist. 

Bradycardia,  or  extremely  slow  pulse,  may  also 
occur  in  many  conditions,  and  is  not  always  patho- 
logical, a  noted  exception  being  the  case  of  the 
famous  Napoleon  I,  who.  throughout  his  active  Hfe, 
had  an  average  pulse  of  but  40.  When,  however, 
bradycardia  is  accompanied  with  vertigo,  or  epilep- 
tiform seizures,  it  becomes  distinctly  pathological 
and  points  conclusively  to  disor,dered  function  of 
the  heart  muscle.  This  condition  was  simultane- 
ously described  by  Stokes  of  Dublin,  and  Adams  of 
London,  in  1846,  since  which  time  it  has  been 
known  as  Stokes-Adams  disease,  and  was.  until  the 
.  recent  investigations  of  W.  His,  regarded  as  a  dis- 
tinct affection.  His,  in  1904,  discovered  a  bundle 
of  muscular  fibres,  which  bear  his  name,  and  which 
constitute  the  connection  between  the  auricles  and 
ventricles.  His's  discovery  is  one  of  the  most  valu- 
able contributions  to  modern  medicine,  and  "heart 
block"  was  at  once  recognized  as  an  important 
pathological  condition.  His  demonstrated  that  im- 
pulses originating  in  the  auricle  did  not,  in  some 
cases,  succeed  in  passing  over  into  the  ventricula, 
being  blocked  in  their  progress,  because  the  perpen- 
dicular fibres,  the  bundle  of  His,  had  their  function 
interefered  with,  which  prevented  the  passage  of 
the  impulse,  and  resulted  in  a  divorce  between  the 
auricle  and  the  ventricle,  so  that,  instead  of  follow- 
ing the  auricular  beat  immediately  the  ventricular 
beat  was  distinctly  delayed  for  one  or  more  im- 
pulses, thus  causing  a  slowing  of  the  pulse  rate, 
and  explaining  the  phenomena  that  had  been  ob- 
served by  Stokes  and  Adams  more  than  half  a 
century  before.  The  correctness  of  the  conclusions 
of  His  have  been  amply  demonstrated  by  experi- 
mental and  clinical  studies  described  by  Erlanger 
in  1905,  and  bv  clinical  and  autopsy  findings  re- 
ported by  Stengel  in  1906.  Slowness  of  the  pulse, 
however,  may  be  more  apparent  than  real,  for  the 
radial  pulse  may  be  remarkably  slow,  and  yet  aus- 
cultation of  the  heart  may  show^  that  the  beats  are 
nearly  or  quite  normal  in  frequency,  due  to  the  fact 
that  some  of  the  cardiac  impulses  are  too  feeble  to 
transmit  the  pulse  save  to  the  wrist,  which  shows 
the  importance  of  verifying  the  pulse  observed  at 
the  wrist  by  counting  the  actual  heart  pulsations. 


Tachycardia,  like  bradycardia,  may  be  physio- 
logical, and  is  frequently  observed  in  neurotic  states 
and  from  functional  disturbances.  In  organic  heart 
disease  it  is  quite  usual  during  broken  compensa- 
tion, though  hardly  suggestive  of  the  earlier  stages. 

Recent  writers  refer  to  what  is  termed  the  "beer 
heart,"  a  form  of  myocardial  degeneration  occur- 
ring in  excessive  beer  drinkers,  and  believed  to  be 
due  to  the  toxic  action  of  the  alcohol  on  the  heart 
muscle  plus  a  dilatation  of  the  heart  cavities,  from 
the  large  quantities  of  liquid  the  heart  is  obliged 
to  propel. 

About  the  middle  of  the  last  century,  Heberden. 
an  English  physician,  pointed  out  that  attacks  of 
angina  pectoris  were  the  result  of  pathological 
changes  in  the  coronary  arteries  and  resultant  de- 
generation of  the  cardiac  muscles,  which  changes 
were  later  proved  by  Gull  and  Sutton  to  be  a  hard- 
ening of  these  arteries,  usually  in  connection  with  a 
general  hardening  or  fibrosis  of  the  entire  arterial 
system,  a  condition  long  know  as  Gull  and  Sutton's 
disease,  and  now  known  as  arteriosclerosis.  Since 
the  time  of  these  investigators  but  little  has  been 
added  to  the  pathology  of  angina  pectoris,  though 
leading  practitioners  believe  that  some  other  ele- 
ments, as  yet  not  understood,  enter  into  its  causation, 
for,  says  Osier:  "While  the  association  of  angina 
pectoris  with  sclerosis  of  the  coronary  arteries  is 
unquestionable,  there  is  something  additional,  some 
other  element,  for  which  as  yet  we  have  no  explana- 
tion." Many  theories  have  been  advanced  to  ac- 
count for  this  additional  element,  some  of  them 
most  interesting  and  ingenious,  and  I  regret  that 
the  limits  of  the  present  paper  will  not  permit  of 
their  discussion,  suffice  it  to  say,  that  they  all  lack 
confirmation,  as  nothing  definite  and  conclusive,  has 
been  added  to  the  pathology  of  angina  pectoris, 
since  Heberden  announced,  now  more  than  a  cen- 
tury ago,  that  angina  pectoris  was  due  to  impair- 
ment of  the  circulation  of  the  heart  muscle,  and 
consequent  degeneration.  The  occurrence  of  those 
exceptional  cases  of  angina  without  pain,  the  so 
called  angina  sine  dolorc.  is  held  by  Zinsser  to  be 
due  to  the  fact  that  ordinarily  in  angina  the  pain 
is  not  due  to  neuralgia,  as  has  been  suggested,  but 
is  caused  by  intracardiac  pressure,  and  that  in  those 
cases  without  pain  the  pressure  is  reheved,  as  is  also 
consequent  pain,  on  account  of  dilatation  of  the 
heart  cavities. 

Angina  vera,  or  true  angina   pectoris,  is  often 
most  difficult  to  distinguish  from  those  cases  arising 
from  reflex  causes  and  known  as  pseudo  or  false 
angina.    Indeed,  in  cases  of  true  angina  occurring- 
in  neurotic  subjects,  the  diagnosis  can  scarcelv  be- 
determined  beyond  a  reasonable  probability,  and  in; 
such  cases  the  physician  should  be  extremely  care- 
ful in  giving  a  positive  opinion,  a  propos  of  which 
Osier  says :  "One  must  be  a  professional  Ulysses  in 
craft  and  wisdom  not  to  sometimes  err  in  estimat- 
ing the  nature  of  a   severe  attack  of  heart  pain. 
There  is  no  group  of  cases  so  calculated  to  keep  one- 
in  a  state  of  wholesome  humility,  w^hen  vou  jostle 
against  a  hale,  vigorous  specimen  of  humanitv,  who 
slaps  you  on  the  back,  and  says  'Plague  take  vou 
doctors.  I  have  scarcely  yet  gotten  over  my  fright' ; 
you  would  like  to  forget  that  five  years  before  vou 
had  almost  signed  his  death  warrant,  in  a  verv  posi- 
tive diagnosis  of  angina  pectoris  vera.  On  the  other 


64 


MARKLEY:  MYOCARDITIS. 


[New  York 
Medical  Jolrxal. 


hand.  Mr.  X.  has  left  you  with  the  full  assurance 
that  his  cardiac  pains  were  due  to  overwork  or  to- 
bacco, and  you  have  comforted  his  \vife,  and  lifted 
a  weight  of  sorrow  from  both,  by  your  most  favor- 
able prognosis.  \\"\x\\  what  sort  of  appetite  can  you 
eat  your  breakfast  when,  a  week  later,  you  read  in 
the  morning  paper,  the  announcement  of  his  sud- 
den death  in  the  railway  station?  Or.  take  another 
example,  poor  Mrs.  Doc  has  gone  softly  all  these 
years,  in  the  bitterness  of  her  soul,  since  you  took 
so  grave  a  view  of  her  vasomotor  or  hysterical 
angina." 

Cases,  then,  with  the  pronounced  symptoms  of 
''heart  block."  or  angina  pectoris  vera,  may  be  ac- 
cepted as  being  undoubtedly  of  myocardial  origin. 
In  the  absence  of  such  pronounced  symptoms,  how- 
ever, the  diagnosis  of  chronic  myocarditis  must  de- 
pend upon  a  careful  study  of  the  entire  symptom 
complex,  together  with  the  etiological  factors  and 
the  personal  history  of  the  patient,  who  will  fre- 
quently be  found  to  have  been  either  an  alcoholic 
or  to  have  been  the  subject  of  some  venereal  infec- 
tion, most  often  syphilis,  or,  to  put  it  more  tersely, 
as  I  have  seen  it  expressed,  "a  votary  of  Bacchus 
and  Venus." 

Other  than  these  general  causes,  the  aetiology  of 
fibroid  induration  differs  materially  from  that  of 
fatty  degeneration,  so  that  a  thorough  analysis  must 
include  a  consideration  of  all  factors  which  have 
been  found  to  be  associated  with  each  type.  The 
aetiology  of  fibroid  induration  is  in  reality  the 
ietiology  of  arteriosclerosis,  for  in  all  cases  of  arte- 
riosclerosis the  heart  muscle  is  'more  or  less  in- 
volved in  the  fibroid  process ;  so  constant  is  this  as- 
sociation that  it  would  suggest  that  the  myocardium 
should  not  be  considered  as  a  separate  organ,  but 
should  rather  be  regarded  as  a  portion  of  the  arte- 
rial system.  Other  than  alcohol  and  syphilis,  and 
the  effects  of  senility,  lithaemia.  chronic  metallic 
poisoning,  and  overfeeding  are  frequent  causes  of 
arteriosclerosis.  In  fact,  any  irritant  circulating  in 
the  blood,  or  chemical  alteration  of  the  blood,  will 
cause  pathological  changes  in  the  bloodvessel  walls. 
Whilst  constant  overfilling  of  the  bloodvessels  re- 
sulting from  excesses  in  eating  and  drinking  is  a 
well  recognized  cause,  in  old  persons  fibrosis  is  so 
constantly  present  that  it  may  almost  be  considered 
physiological,  and  the  well  known  saying,  that  "a 
man  as  old  as  his  arteries,"  expresses  the  belief 
long  held,  that  hardening  of  the  arteries  indicates 
premature  aging.  That  form  of  gout,  first  de- 
scribed by  the  late  Dr.  J.  M.  Da  Costa,  and  known 
as  Da  Costa's  disease,  frequently  leads  to  vascular 
changes,  and  evidences  of  this  disease  .should  be 
carefully  sought,  particularly  in  those  addicted  to 
the  i)leasures  of  "dine  and  wine." 

.Another  factor  which  has  probably  not  been 
given  the  consideration  which  its  frequency  as  a 
causative  factor  of  circulatory  disturbances  would 
suggest  is  heredity,  for  it  is  a  well  established  fact 
that  senile  changes  in  the  arteries  occur  at  a  much 
earlier  period  of  life  in  >  )me  families  than  in  others. 
Whilst  it  is  not  remark;il)le  to  find  a  history  of  or- 
ganic heart  conditions  runnning  through  a  family 
f(jr  a  generation  or  more,  these  family  predisposi- 
tions have  i)een  so  frequently  observed  that  they 
must  be  regarded  as  more  than  a  mere  coincidence. 

Not  infrequently  myocarditis  is  first  manifested 


by  a  loss  of  vigor,  and  marked  nervous  symptoms, 
which  we  should  not  too  hastily  include  under  the 
broad  term  "neurasthenia/'  a  condition  which  is 
held  responsible  for  numerous  ailments,  which,  if 
properly  considered,  would,  in  many  instances,  be 
found  to  be  due  in  part,  at  least,  to  other  causes. 
In  this  respect  neurasthenia  seems  to  rank  with 
malaria,  grippe,  and  teething  in  children,  as  an  easi- 
ly applied  n?tiological  factor.  This  indisposition  and 
nervousness  may  exist  for  a  long  time  before  the 
myocardial  disease  has  become  sufficiently  pro- 
nounced to  be  recognized  by  the  usual  signs  and 
symptoms,  though  it  should  always  be  recalled  that 
the  myocardium  may  have  been  previouslv  weak- 
ened by  some  infection  that  the  patient  may  have 
had  years  before,  or,  excessive  exercises  may  occa- 
sion changes  in  the  heart  muscle  that  during  the 
period  of  early  manhood  are  of  little  consequence, 
but  later  increase  in  degree  and  seriousness,  show- 
ing the  importance  of  careful  study  of  the  personal 
history  in  suspected  patients. 

The  first  effect  of  fibroid  changes  in  the  arteries 
is  a  loss  of  elasticity  of  the  vessel  walls,  and  conse- 
quent rise  of  blood  pressure,  which  continues 
throughout  the  course  of  the  aft'ection  until  the 
later  or  terminal  stages,  when  the  blood  pressure 
is  reduced  from  degenerative  changes  and  conse- 
quent weakness  of  the  heart  muscle. 

Recent  experiments  seem  to  indicate  that  arterio- 
sclerosis may  bear  some  relationship  to  morbid 
processes  affecting  the  adrenal  gland,  and  Erb, 
Pierce,  and  other  investigators  have  produced 
arteriosclerosis  by  the  intravenous  injection  of  adre- 
nalin, whilst  Coplin,  of  Philadelphia,  has  shown 
that  in  patients  having  arteriosclerosis,  the  adrenal 
is  rarely  if  ever  a  normal  organ.  These  investiga- 
tions and  experiments  have  no  doubt  been  suggested 
by  the  well  known  prompt  and  decided  action  of 
adrenalin,  in  raising  the  blood  pressure.  The  con- 
dition of  the  walls  of  the  radial  artery  may  be  con- 
sidered a  fair  index  of  the  entire  arterial  system, 
as  it  has  been  amply  demonstrated,  that  when  the 
radial  was  thickened,  the  same  condition  was  found 
to  exist  in  the  aorta  and  splanchnics. 

Besides  the  infections,  the  astiological  factors  con- 
cerned in  the  causation  of  fatty  degeneration  include 
all  prolonged  nutritional  disorders,  such  as  phthisis, 
carcinoma,  and  the  primary  anaemias ;  and  evidences 
of  cardiac  enfeeblcment  occurring  during  the  course 
of  these  affections,  should  ahvays  arouse  suspicion. 
In  fatty  degeneration  the  symptoms  are  negative, 
until  dilatation  occurs,  which  is  generally  early, 
when,  instead  of  the  increased  arterial  pressure,  so 
constantly  present  in  the  fibroid  form  of  myocarditis, 
we  have  a  lowering  of  blood  pressure,  and  in  place 
of  the  angenoid  attacks  of  fibrosis,  ajxiplectiform 
seizures  are  more  frequent,  closely  resembling  true 
cerebral  haemorrhage,  even  to  hemiplegia,  stertorous 
breathing,  unconsciousness,  and  Cheyne-Stokes 
respiration.  In  such  cases  the  distincton  from  true 
cerebral  apoplexy  depends  almost  entirely  upon  the 
fact  that  in  cerebral  haemorrhage  the  pulse  is  of 
high  tension,  .so  that  it  becomes  important  to  keep 
constantlv  in  mind  tiie  low  tension  pulse  of  fatty 
degeneration.  Other  than  these  exceptions,  the 
symptoms  of  cardiac  enfeeblcment  found  in  connec- 
tion with  the  two  forms  of  degeneration  do  not 
materiallv  dift'er.  and  mav  be  combined  because  of 


January  9,  7909.] 


LEDEREIi:  DENTAL  AND  SYSTEMIC  DISTURBANCES^ 


65 


the  possible  coexistence  of  the  two  conditions,  nor  is 
their  distinction  important  as  regards  the  treatment, 
whilst  the  prognosis  is  equally  unfavorable  in  each, 
and  organic  heart  disease  is  exceeded  only  by  tuber- 
culosis and  pneumonia  in  the  mortality  tables. 

According  to  the  last  census  of  the  United  States, 
70,000  persons  of  both  sexes  and  of  all  ages  died 
from  heart  disease  during  the  year  igo.  The  defi- 
nite pathology  not  being  given,  it  is  impossible  to 
determine  what  proportion  was  endocardial,  or 
valvular,  and  in  what  proportion  the  myocardial 
symptoms  were  predominant,  though  if  the  statistics 
of  Germany  will  apply  to  this  country,  it  is  fair  to 
conclude  that  the  larger  proportion  was  dtie  to  myo- 
cardial conditions ;  for,  says  Schott,  of  Xauheim : 
"Diseases  of  the  myocardium  are  more  frequent 
than  those  of  the  endocardium,  in  the  proportion  of 
500  to  200."  In  addition  to  this  high  mortality, 
statistics  further  show  that  a  large  proportion  of 
the  deaths  occur  in  the  very  prime  of  life.  The 
report  of  the  Board  of  Health  of  the  State  of  New 
Jersey  for  the  year  1905  shows  that  in  Camden, 
during  that  year,  there  were  124  deaths  reported 
from  organic  heart  disease ;  of  these  cases  thirty- 
eight,  or  about  thirty-five  per  cent.,  occurred  be- 
tween the  ages  of  twenty  and  fifty,  indicating  that 
heart  disease,  as  a  cause  of  death,  should  not  be 
regarded  as  a  terminal  condition,  occurring  in  old 
people,  and  considering  that  so  much  attention  has 
been  given  to  the  prevention  of  tuberculosis,  and 
that  penumonia  is  most  prevalent  at  the  extremes 
of  life  and  at  an  age  which  in  itself  precludes  recov- 
ery, the  high -mortality  from  organic  heart  disease 
would  seem  to  indicate  that  sufficient  attention  has 
not  been  given  to  the  prophylaxis  and  treatment  of 
these  imfxirtant  conditions. 

Tn  conclusion  I  wish  to  state  that  the  few  points 
of  interest  which  at  first  presented  themselves  have 
so  developed  that  very  much  has  been  omitted  that 
I  ha'd  hoped  to  refer  to,  and  though  nothing  very 
new  may  have  been  presented,  yet  I  feel  that  the 
subject  is  of  such  vital  importance  that  the  rehearsal 
of  our  common  knowledge  cannot  fail  to  be  profit- 
able, and,  I  trust,  will  stimulate  a  more  careful 
observance  of  clinical  methods  as  applied  to  heart 
conditions. 


THE  RELATIONSHIP   BETWEEN   DENTAL  AND 
SYSTEMIC  DISfURBANCES.* 

By  William  J.  Lederer,  D.  D.  S., 
New  York, 

Lecturer  in  the  New  York  College  of   Dental  and  Oral  Surgery: 
Attending  Dental  burgeon  to  the  German  Hospital  Dispensary. 

The  relationship  between  dental  and  systemic  dis- 
turbances cannot  be  ignored,  as  the  teeth,  gums, 
alveolar  process,  and  jaws  are  part  and  parcel  of 
the  human  economy,  endowed  with  blood,  lymph, 
and  nerve  supply,  as  any  other  part  of  the  body. 
The  buccal  structure  thus  being  intimately  con- 
nected with  the  centres  of  life  are  subject  to  the 
same  physiological  and  pathological  laws  which 
govern  other  tissues. 

Many  peripheral  lesions  which  formerly  were 
considered  conditions  per  se  are  now  recognized  to 

^  *Paper  read  at  a  meeting  of  the  Triprofessional  Medical  Society, 
November  17,  1908. 


be  but  local  symptoms  of  systemic  disease  and  can- 
not be  treated  successfully  until  the  underlying  sys- 
temic cause  is  recognized  and  removed.  Thus 
facial  neuralgia,  for  whose  relief  at  times  almost 
entire  dentures  were  uselessly  sacrificed,  is  often 
found  to  be  a  sequel  of  malaria,  and  the  treatment 
of  this  condition  will  relieve  the  painful  symptoms. 
There  are  many  dental  and  buccal  conditions  which 
the  dentist  is  confronted  by,  which  may  be  pro- 
duced by  local  disturbances  as  well  as  by  systemic 
disease.  For  example,  gingivitis  is  often  caused  by 
local  irritation,  as  accumulations  of  tartar,  ill  fitting 
crowns,  etc.,  or  it  may  be  the  sequel  of  intestinal  dis- 
turbances. The  former  type  will  readily  yield  to 
local  treatment,  while  the  latter  form  of  the  disease 
will  not  be  cured  until  the  digestive  factor  be  recog- 
nized and  treated.  This  relationship  between  buccal 
and  systemic  disturbances  is  too  vast  a  subject  to 
exhaust  it  in  an  evening's  paper,  as  a  volume  might 
be  written  upon  this  interesting  topic,  I  therefore  will 
have  to  confine  myself  to  only  a  few  important 
points  of  interest  to  the  dental  practitioner. 

Odontalgia,  or  toothache,  is  a  symptom  of  irrita- 
tion of  the  fine  nerve  filaments  permeating  the  den- 
tal pulp.  This  irritation  is  most  often  produced  by 
dental  caries,  a  destructive  process,  chemicobacte- 
rial  in  character,  involving  the  tooth  substance, 
causing  an  actual  breaking  down  of  the  tooth  body, 
with  subsequent  involvement  of  the  tooth  pulp. 
This  irritation  of  the  pulp  nerves  may  be  an  actual 
neuritis  or  it  may  be  a  degenerative  process,  the  re- 
sult of  suppuration,  or  may  be  caused  by  pressure 
resulting  from  a  hyperjemic  pulp  or  calcic  infiltra- 
tion of  this  organ,  as  the  result  of  traumatism  or  de- 
generation. This  is,  in  short,  the  pathology  of  tooth- 
ache. Sifting  all  these  facts  down  it  will  be  found 
that  the  initial  irritation  is  always  followed  by  a 
circulatory  disturbance  of  blood  or  lymph  vessels 
of  the  tissues  involved.  "Inflammations  of  the  gum 
and  deeper  structures  result  from  chemical  or  me- 
chanical causes,  bacterial  factors  being  incidental 
complications.  From  such  action  (mechanical  or 
chemical)  the  blood  stream  is  increased,  and  dilata- 
tion of  the  capillaries  is  produced.  The  capillaries 
become  crowded  with  blood  corpuscles.  These  ac- 
cumulate along  the  walls  of  the  vessels  to  which 
they  adhere.  Accumulations  of  small  round  cells 
occur  in  the  submucous  connective  tissue,  the  spaces 
of  which  are  filled  with  inflammatory  exudate.  The 
papillae  become  enlarged.  The  epithelial  layer  be- 
comes hyperplastic;  as  a  result  the  gum  tissues 
swell  and  become  intensely  red.  They  bleed  upon 
the  slightest  touch.  Inflammation  may  be  confined 
to  point  upon  the  side  of  a  tooth.  This  localization 
often  results  from  predisposition  due  to  a  local  in- 
jury." (Talbot.) 

Reviewing  the  last  sentence  we  again  find  that  a 
circulatory  disturbance  is  the  first  result  of  the  m- 
itial.  irritation.  Such  being  the  case  it  follows  that 
any  condition  affecting  the  circulation,  and  such  al- 
tering or  modifications  of  the  normal  status  being 
projected  to  the  buccal  or  dental  tissues  is  capable 
of  producing  the  identical  results,  which  are  sequels 
to  local  disturbances ;  therefore  such  irritating  influ- 
ences may  become  aetiological  factors  in  dental  and 
buccal  disturbances,  even  though  the  source  of  irri- 
tation be  distal  from  the  month.     It,  therefore,  be- 


66 


'lEDERER:  dental  AND  SYSTEMIC  DISTURBANCES. 


[Neu'  \'ork 
Medical  JocrN/vl. 


comes  clear  that  systemic  disturbances  af¥ecting  cir- 
culation, increasing  blood  pressure  may  cause  dental 
disturbances  in  a  sound  tooth,  or  inflammatory  con- 
ditions of  the  gingivse  with  little  or  no  local  irrita- 
tion. 

A  point  of  particular  interest  to  the  stomatologist 
is  the  fact  that  the  teeth  and  alveolar  strucures  are 
more  predisposed  to  disease  than  many  structures 
in  as  much  that  they  are  end  organs  and  traverse 
solid  bone  structures  and  cannot  yield  as  the  peri- 
pheral vessels  of  other  end  organs.  Therefore  they 
fall  prey  to  disease  sooner  than  other  vessels,  and 
the  structures  they  supply  often  exhibit  pathological 
changes  before  they  are  noted  elsewhere. 

What  are  the  systemic  disturbances  which  will 
involve  the  buccal  and  dental  tissues  of  interest  to 
the  dental  practitioner?  What  conditions  will  pro- 
duce pathological  conditions  in  the  mouth  simulat- 
ing dental  disease?  All  such  disturbances  which 
will  modify  the  circulation  of  the  gums  and  teeth — 
all  diseases  attended  by  high  arterial  tension  or  in- 
creased blood  pressure. 

General  conditions  aftecting  blood  pressure,  ac- 
cording to  Musser,  are : 

Age,  sex,  and  heredity  are  predisposing  factors  in 
the  production  of  high  arterial  tension.  Diseases 
associated  with  high  blood  pressure  are  more  com- 
mon in  middle  life  and  advanced  age  than  in  youth, 
and  men  are  more  frequently  attacked  than  women, 
because  they  are  more  exposed  by  their  occupations 
and  mode  of  life  to  the  exciting  causes.  Three  fac- 
tors contribute  to  the  production  of  high  arterial 
tension : 

Increased  peripheral  resistance,  increased  strength 
in  the  heart,  and  increased  volume  of  blood.  Thus 
deficient  oxygenation  of  the  tissues,  as  in  respira- 
tory disease,  imperfect  elimination  of  waste  mate- 
rial as  in  renal  disease,  and  in  gout,  result  in  tox- 
aemic  condition,  in  which  the  altered  blood,  acting 
on  the  capillary  walls,  keeps  them  in  a  constant 
state  of  contraction.  Plethora  and  hypertrophy  of 
the  cardiac  muscle  bring  about  the  same  result  each 
in  its  own  way. 

The  conditions  which  bring  about  obstructions  of 
the  capillaries  in  order  in  which  they  are  enumer- 
ated by  Broadbent  are:  i.  Age.  The  liability  to  high 
arterial  tension  increases  with  age,  especially  after 
middle  life.  2.  Heredity.  There  is  in  some  families 
a  marked  tendency  to  high  tension.  3.  Disease  of 
the  kidney.  4.  Gout.  5.  Diabetes.  6.  Lead  poison- 
ing. 7.  Pregnancy.  8.  Anaemia.  9.  Emphysema 
and  chronic  bronchitis.  10.  Mitral  stenoses,  and 
to  this  I  would  add  all  toxaemias. 

Whatever  has  been  said  here  about  high  arterial 
tension  can  be  applied  to  pyorrhoea  alveolaris.  Age, 
sex,  and  heredity  arc  predisposing  factors.  It  oc- 
curs more  often  in  middle  life,  men  are  more  often 
subject  to  it  than  women,  it  occurs  in  whole  fam 
ilies  in  different  generations,  and  is  often  a  sequel 
of  all  diseases  enumerated. 

The  relationship  between  menstruation  and  preg- 
nancy as  well  as  many  other  conditions  and  the  buc- 
cal structures  constitute  an  important  chapter  in 
dental  and  medical  diagnosis. 

Dudley,  in  his  latest  edition  of  7' he  Principles  and 
Practice  of  Gyncccology,  speaks  of  the  general  phe- 
nomena of  menstruation,  and  states  among  other 
facts : 


The  general  phenomena  of  menstruation  are  as  follows : 
I.  Slight  deviation  of  pulse  and  temperature.  2.  Tendency 
to  slight  physical  depression  and  inactivity.  3.  Sensations 
of  heat  and  cold.  4.  Swelling  of  the  breast  and  thyreoid 
gland.  5.  Discomfort  and  throbbing  in  the  head.  These 
disturbances  are  subject  to  wide  variations.  In  some  cases 
they  are  absent,  in  others  they  are  so  slight  as  to  escape 
notice,  or  so  severe  as  to  'make  life  miserable  and  useless. 

As  stated  before,  different  degrees  of  blood  pres- 
sure will  affect  the  teeth  and  gums.  Hyperaemia 
and  anaemia  are  frequently  associated  with  facial 
and  dental  neuralgia,  and  it  is  well  known  that  some 
nervous  affections  are  ushered  in  with  odontalgia, 
also  that  diseased  conditions  of  accessory  sinuses 
(maxillary,  frontal,  etc.),  yes,  even  pelvic  condi- 
tions will  produce  odontalgia  reflexly. 

It  is  not  a  rare  occurrence  that  women  subject  to 
sexual  disease  suffer  from  toothache  in  perfectly 
sound  teeth,  caused  by  stasis  in  expanded  pulp  ves- 
sels, producing  pressure  on  nerve  filaments  of  the 
pulp.  Patients  often  complain  of  toothache  and 
painful  gums  during  or  shortly  before  and  after  the 
menstrual  period,  especially  about  sensitiveness  of 
the  teeth  to  heat  and  cold.  If  there  are  carious  teeth 
present,  menstruation  cannot  be  looked  upon  as  the 
cause  of  the  odontalgia,  but  it  happens  frequently 
that  young  women  with  carefully  kept  mouths  com- 
plain of  pain  in  perfectly  sound  teeth,  and  it  is  here 
that  the  dentist  should  bear  in  mind  hyperaemia  pro- 
duced by  increased  blood  pressure  as  a  possible 
cause  of  disturbed  pulp  or  pericental  conditions. 
Often  there  is  also  an  increased  flow  of  saliva.  The 
treatment  in  these  cases  consists  in  the  local  applica- 
tion of  tincture  of  iodine,  once  a  day,  and  the  use  of 
an  astringent  mouth  wash.  If  the  saliva  is  acid  an 
alkaline  wash  would  be  indicated.  These  symptoms 
are  most  frequently  observed  in  young  girls  about 
to  reach  puberty,  before  their  first  menstrual  period, 
the  advance  of  which  is  sometimes  indicated  not  only 
by  pelvic  discomfort,  but  by  violent  facial  pains, 
radiating  to  the  ear,  caused  by  what  we  might  call  a 
menstrual  gingivitis,  which  causes  the  gums  to  be- 
come puffy  and  loose  and  hasmorrhagic  in  character. 
In  many  cases  it  is  advisable  to  hasten  menstruation 
to  reduce  the  blood  pressure. 

Similar  conditions  may  appear  in  women  suffer- 
ing from  amenorrhoea,  as  well  as  in  patients  during 
the  climacteric  period. 

The  following  cases  illustrating  the  foregoing 
came  to  my  clinic  at  the  German  Hospital : 

C.'\SE  I. — L.  B.,  aged  eighteen,  complained  of  bleeding 
gums  for  two  years  ;  teeth  were  very  sensitive  to  thermal 
changes,  especially  cold ;  patient  had  consulted  a  dentist 
without  obtaining  relief.  She  was  a  tall,  spare  girl  of  nor- 
mal development.  Menstruation  appeared  at  sixteen,  al- 
though very  irregular,  sometimes  at  an  interval  of  three 
months.  Patient  looked  very  anaemic.  She  was  given  an 
astringent  and  alkaline  wash,  and  a  tonic  was  prescribed. 
Patient  returned  in  two  weeks  much  improved,  and  after  ,i 
month  her  gums  appeared  normal  and  the  condition  of  the 
teeth  were  comfortable. 

Case  II. — S.  M.,  aged  sixteen,  complained  of  bleeding 
gums.  She  was  not  menstruating  yet.  Headaches,  diz/y 
spells,  pelvic  tenderness.  Tincture  of  iodine  was  applied 
locally,  and  she  was  given  an  astringent  mouth  wash.  She 
returned  after  ten  days,  had  menstruated  for  the  lirst  time. 
Mouth  was  in  good  shape. 

Odontalgia  during  pregnancy  is  a  condition 
known  to  all,  also  is  gingivitis  in  its  various  forms 
a  frequent  attending  condition  during  this  state. 
The  high  arterial  tension  during  pregnancy  has  no 
doubt  a  good  <leal  to  do  with  these  symptoms,  al- 


January  9,  1909. 1 


LEDERER:  DEXTAL  AND  SYSTEMIC  DISTU RBASCES. 


67 


though  of  course  mouths  containing  neglected  teeth 
are  more  often  the  seat  of  pain  than  those  whose 
denture  are  intact ;  however,  odontalgia  in  sound 
teeth  is  a  common  occurrence,  and  inflammatory 
processes,  ranging  from  a  mere  gingivitis  to  perio- 
stitis, osteomyelitis  with  glandular  involvement, 
have  been  observed. 

Extraction  in  these  cases  unless  absolutely  inevi- 
table should  be  avoided.  Unfortunately  there  are 
many  instances  where  dentists,  not  taking  the  sys- 
temic physiological  modification  into  consideration, 
have  extracted  perfectly  sound  teeth.  The  question 
frequently  arises  should  a  dentist  extract  during 
pregnancy,  up  to  what  stage  of  pregnancy  is  a 
tooth  extraction  a  safe  procedure,  and  when  and 
how  should  it  be  practised.  Some  men  go  so  far 
as  to  deny  a  pregnant  woman  all  dental  help.  This 
is  not  only  absurd,  but  most  cruel,  for  the  nerve 
exhaustion  attending  and  following  a  period  of  se- 
vere suffering  is  of  greater  harm  to  the  patient  than 
the  shock  attending  a  necessary  tooth  extraction 
Teeth  which  can  possibly  be  saved  should  never  be 
extracted.  Long,  trying,  and  painful  dental  opera- 
tions should  be  avoided.  Pulp  removal  should  be 
postponed  if  possible ;  rather  some  conservative 
"bridging  over"  method,  as  a  guttapercha  filling  or 
a  cotton  and  cement  dressing,  should  be  employed. 
If  a  tooth  is  beyond  saving  and  is  a  source  of  se- 
vere constant  pain  or  the  cause  of  infection,  it 
should  be  removed  at  any  time  when  necessary.  I 
never  hesitate  to  use  forceps  when  there  is  a  timely 
indication,  but  I  prefer  an  anaesthetic,  as  I  consider 
a  narcosis,  properly  administered,  a  safeguard  for 
the  patient.  Some  men  hesitate  to  extract  during 
the  first  three  months  of  pregnancy,  as  there  is  more 
tendency  to  abort  during  this  period. 

If  an  anaesthetic  is  employed  it  should  be  admin- 
istered carefully,  in  case  of  nitrous  oxide,  in  order 
to  avoid  clonic  spasms.  I  personally  employ  nitrous 
oxide  only  up  to  the  sixth  or  seventh  month  of  preg- 
nancy; after  that  chloroform,  to  be  able  to  induce 
and  maintain  a  deep  surgical  anaesthetic  to  avoid 
spasms.  I  have  extracted  teeth  for  women  in  all 
stages  of  pregnancy,  and  am  happy  to  say  never  had 
a  mishap. 

Conservative  treatment  of  the  teeth  is  more  im- 
portant during  pregnancy  than  at  any  other  time, 
for  there  is  not  only  a  predisposition  to  dental  dis- 
turbances due  to  the  altered  physiological  condition 
of  the  patient,  but  the  buccal  secretions  are  most 
always  rendered  acid  by  acid  eructations  and  vom- 
iting attending  this  state,  which  acts  as  an  additional 
predisposing  factor  to  dental  caries. 

Pregnancy  itself  does  not  directly  affect  the  teeth 
or  cause  a  loss  of  lime  salts  to  provide  calcic  mate- 
rial for  the  osseous  system  of  the  foetus.  Hygienic 
measures  observed  by  the  mother,  and  these  include 
proper  care  of  the  teeth,  the  full  use  of  an  alkaline 
mouthwash  and  toothpowder,  coupled  with  a  ra- 
tional mode  of  living,  will  not  only  keep  her  in  good 
health,  but  will  insure  her  a  sound,  normal  child. 

It  may  not  be  out  of  place  here  to  mention  the 
fact  that  tooth  extractions,  as  well  as  long,  painful 
dental  operations,  should  be  avoided  during  lacta- 
tion, as  the  anxiety  and  nervous  strain  which  the 
patient  is  subjected  to,  though  of  little  harm  to 
herself,  is  apt  to  so  alter  the  character  of  her  milk 


that  her  child  may  suft'er  from  digestive  disturb- 
ances. If  any  trying  operation  cannot  be  avoided, 
the  child  should  receive  artificial  food  for  twenty- 
four  hours. 

Locomotor  ataxia  or  tabes  dorsalis  or  posterior 
spinal  sclerosis  is  a  chronic  disease  of  the  posterior 
portion  of  the  nervous  system,  the  primary  lesion  of 
which  usually  occurs  in  the  posterior  spinal  gangha 
as  well  as  in  the  ganglia  of  the  cranial  nerves,  how- 
ever the  ganglia  of  the  sympathetic  nerves  may  be 
involved.  The  symptoms  of  this  disease  are,  first,  a 
stage  of  pain,  then  a  stage  of  ataxia,  which  is  an 
imperfect  coordination  of  muscular  action,  and  final- 
ly there  obtains  a  stage  of  paralysis.  Frequently 
there  obtain  disturbances  in  the  action  of  bladder 
and  rectum,  sometimes  earlier,  sometimes  later,  in 
the  course  of  the  disease.  All  these  symptoms  are 
caused  by  a  structural  degeneration  of  the  columns 
of  the  spinal  cord.  The  sequence  of  symptoms  va- 
ries in  dift'erent  cases  according  to  the  locality  of  the 
initial  lesions.  Tabes  affects  all  organs,  and  all  spe- 
cialities of  medicine  have  men  investigating  this  af- 
fliction. The  mouth  and  teeth  are  not  exempt  from 
tabetic  symptoms,  but  the  buccal  signs  have  not  been 
paid  as  much  attention  as  they  deserve. 

Atrophy,  a  loss  of  tissue  or  shrinking  of  tissue, 
is  a  ohysiological  condition  if  caused  by  senility  (old 
age).  Where  atrophy  ensues  and  senility  cannot  be 
demonstrated  it  is  pathological. 

^^'e  are  often  confronted  by  an  atrophic  condition 
of  the  gum,  absorption  of  the  alveolar  process,  spon- 
taneous loosening,  and  finally  dropping  out  of  the 
teeth.  If  these  conditions  are  not  associated  with 
senility  we  must  bear  in  mind  a  pathological  condi- 
tion. 

Sometimes  in  opening  a  tooth  we  find  that,  in 
spite  of  having  entered  the  pulp  chamber  and  ob- 
tained profuse  haemorrhage,  there  is  no  sign  of  pain 
on  part  of  the  patient ;  this  is  a  suspicious  symptom 
and  may  be  one  of  the  first  signs  of  spinal  disease. 
If  in  conjunction  there  is  a  decreased  patellar  re- 
flex and  perhaps  a  loss  of  the  reflex  action  of  the 
pupil  to  light  (Argyll  Robertson  pupil)  you  may  be 
certain  your  patient  is  suffering  from  tabetic  dis- 
ease. Another  symptom  is  that  of  not  being  able 
to  approximate  the  two  extended  first  fingers  with 
closed  eyes,  and  a  feeling  of  muscular  uncertainty 
when  entering  a  dark  room :  this  is  known  as  Rom- 
berg's sign. 

The  onset  of  the  disease  is  so  uncertain  that  some- 
times the  dental  are  the  first  signs  of  the  disease. 
Sometimes  there  obtain  spontaneous  suppurative 
conditions  of  the  maxillae  with  the  exfoliation  of  a 
sequestrum. 

To  review  the  dental  symptoms  of  tabes  we  ob- 
tain: I,  Painless  pulps;  2,  atrophy  of  gum;  3.  ab- 
sorption of  alveolar  process ;  4,  spontaneous,  pain- 
less shedding  of  teeth :  5,  spontaneous  suppurative 
conditions  of  the  maxillae  with  necrosis ;  6,  patients 
sometimes  experience  a  sort  of  drawing  facial  neu- 
ralgia, which  is  followed  by  a  sensation  as  though 
the  teeth  are  elongated  and  the  gums  and  lips  are 
swelling.  However,  there  is  no  sign  of  inflamma- 
tion. If  these  symptoms  are  coupled  with  an  Argyll 
Robertson  pupil,  if  there  obtains  a  decreased  or 
abolished  knee  jerk  or  Romberg's  symptom  is  pres- 
ent, you  can  be  certain  your  patient  is  a  tabetic,  and 


68 


LEDERER:  DENTAL  AND  SYSTEMIC  DISTURBANCES. 


[New  York 
Medical  Journau 


besides  your  help  needs  the  aid  of  the  physician. 
The  simple  atrophy  of  the  gum  tissue,  associated 
as  a  rule  with  acid  saliva,  the  writer  has  frequently 
found  associated  with  neurasthenia. 

Diabetes  mellitus  is  a  disease  of  nutrition  which 
is  marked  by  the  appearance  of  glucose  in  the  urine, 
by  frequent  voiding  of  urine,  thirst,  excessive  appe- 
tite with  impairment  of  nutritive,  and  in  some  cases 
of  marked  emaciation,  with  loss  of  sexual  power. 

Diabetes  is  one  of  the  conditions  where  we  have 
high  arterial  tension  unless  the  disease  appears  in 
younger  subjects,  when  the  blood  pressure  is  dimin- 
ished, which  is  looked  upon  as  a  grave  prognostic 
omen.  As  the  result  of  the  frequent  acid  reaction 
of  the  saliva  the  teeth  of  the  diabetic  are  predis- 
posed to  caries ;  it  is  also  assumed  that  considerable 
fermentation  goes  on  in  the  diabetic's  mouth  due  to 
the  fact  that  sugar  is  contained  in  the  saliva.  Some 
years  ago  the  writer  read  a  paper  before  the  Stoma- 
tological Section  of  the  American  Medical  Associa- 
tion on  Changes  in  the  Salivary  Secretion  Afifected 
by  Systemic  Disease.  The  data  for  which  paper 
were  gathered  by  Dr.  H.  Stern,  and  the  writer  ex- 
amined the  saliva  of  158  cases  of  diabetes  mellitus. 
The  reaction  was  found  to  be  acid  in  forty-seven 
patients,  alkaline  in  ninety-two  patients,  and  neutral 
in  eight  patients.  Sugar  was  found  in  the  saliva 
in  eighty-five  patients,  while  no  glucose  was  found 
in  seventy-three  patients,  which  findings  demon- 
strated, as  those  of  others  (Naunyn,  Mosler,  Kulz, 
Frerichs,  von  Noorden),  that  the  saliva  is  not  al- 
ways glucosuric  in  diabetes. 

Pyorrhoea  alveolaris,  or  interstitial  gingivitis,  is 
frequently  associated  with  diabetes,  and  it  is  a  wise 
precaution  to  always  examine  the  urine  for  sugar  in 
all  cases  of  pyorrhoea  alveolaris. 

Some  investigators  assert  that  in  recent  cases  of 
diabetes  there  obtain  small  white  or  greyish  papules 
along  the  gum,  which  ofifer  considerable  resistance 
and  if  removed  leave  a  red  bleeding  spot.  Von 
Noorden  considers  these  sprue,  caused  by  a  fungus 
which  develops  in  the  slightly  acid  buccal  secretion. 

Another  buccal  symptom  is  the  sour,  chloroform- 
like breath  of  the  diabetic. 

Another  point  of  interest  to  the  dentist  is  the  fact 
that  in  diabetics  there  often  obtains  a  slow  process 
of  healing  in  wounds,  and  an  alveolar  socket  which 
does  not  close  in  due  time  should  call  to  mind  the 
possibility  of  some  constitutional  disease. 

Gout,  which  also  presents  its  dental  symptoms,  is 
also  a  disease  of  nutrition,  depending  for  its  exist- 
ence upon  a  disorder  of  metabolism,  as  a  result  of 
which  deposits  of  sodium  bivirate  take  place  in 
the  joints  and  in  the  fibrous  tissues  surround- 
ing them. 

The  precise  cause  of  gout  is  not  known,  but  cer- 
tain a-tiological  factors  in  its  development  are  uni- 
versally recognized  as  being  active:  i,  Heredity. 
2,  Our  mode  of  life  as  to  exercise  and  mental  labor ; 
great  mental  and  nervous  stress,  with  little  physical 
exercise,  frequently  produce  gouty  diathesis,  and 
often  bring  on  an  attack  in  the  already  gouty.  3, 
Age  is  also  an  important  factor ;  while  cases  of  well 
developed  gout  are  met  with  in  children,  and  even 
in  infancy,  the  malady  commonly  does  not  develop 
till  after  the  thirtieth  year,  but  rarely  awaits  the 
fifth  decade  of  life.    4,  The  abuse  of  alcohol.  5, 


Overeating.  6,  Exposure  to  metal,  as  men  who 
constantly  handle  lead. 

The  chief  causes  of  gout  are  lack  of  exercise, 
nervous  stress,  and  the  ingestion  of  more  food  and 
drink  than  the  body  can  deal  with.  I  shall  not  speak 
of  the  pathology  of  gout,  but  simply  state  it  also 
produces  high  arterial  tension. 

Patients  suffering  from  gout  are  frequently  sub- 
ject to  neuralgia  of  sudden  onset  and  disappearance. 
A  good  deal  has  been  written  about  the  uric  acid 
diathesis  and  pyorrhoea  alveolaris.  I  believe  that  too 
much  stress  has  been  laid  upon  a  particularly  uric 
acid  diathesis,  though  gouty  states  are  frequently 
accompanied  by  gingivitis  in  all  its  forms ;  the  pres- 
ence of  pyorrhoetic  condition  is  no  more  often  found 
in  gouty  conditions  that  in  other  systemic  disturb- 
ances. There  have  been  found  uric  acid  deposits 
on  the  roots  of  teeth  in  this  condition,  which  teaches 
us  we  should  bear  this  systemic  disorder  in  mind 
when  treating  buccal  disease.  Pulp  stones  may  be 
the  result  of  this  condition.  A  uranalysis  will  also  be 
of  help  here,  to  help  recognize  the  disease. 

There  is  no  doubt  that  the  majority  of  diseased 
states  that  man  is  heir  to  emanate  from  a  deranged 
digestive  apparatus.  Food  is  taken  into  the  body 
to  replace  broken  down  tissue  used  up  in  perform- 
ing the  functions  of  life,  to  store  up  reserve  mate- 
rials, and  to  further  growth  of  the  organism,  dur- 
ing infancy,  childhood,  and  adolescence.  The  food- 
stuffs, carbohydrates,  fats,  proteids,  salts,  and  water 
are  acted  upon  by  the  various  processes  of  digestion 
and  rendered  absorbable. 

We  have,  as  you  will  remember,  mouth,  gastric, 
and  intestinal  digestion.  The  food  being  masticated 
and  insalivated  in  the  buccal  cavity,  where  starch  is 
converted  into  maltose,  then  the  food  is  passed  into 
the  stomach,  where  the  gastric  juice  acts  upon  the 
proteids,  converting  them  into  peptones,  while  the 
amylolytic  action  of  the  saliva  is  continued  for  some 
time.  After  the  food  has  been  converted  into  chyme 
in  the  stomach,  it  is  expressed  by  the  pyloric  orifice 
into  the  small  intestine,  where  the  pancreatic  and 
hepatic  secretion,  with  the  succus  entericus  convert 
chyme  into  chyle,  splitting  up  fats,  etc.,  and  after 
the  foodstuffs  have  been  thoroughly  acted  upon  by 
all  digestive  ferments,  the  chyle  is  taken  up  by  the 
chyleferous  vessels  of  the  intestines  and  enters  the 
general  system  by  the  way  of  the  portal  circulation. 
The  residue  of  undigested  materials,  the  faeces,  pass 
along  the  large  intestine  and  are  excreted  via  rectum 
by  the  anal  orifice. 

If  any  part  of  this  digestive  machinery  fails  to 
do  its  work  there  immediately  obtains  bodily  dis- 
harmony ;  as  a  result  the  foodstuffs  are  not  rendered 
absorbable  as  they  should  be,  and  fermentation  is 
the  consequence,  which  induces  toxic  states,  which 
in  turn  is  one  of  the  causes  of  high  arterial  tension. 

If,  on  the  other  hand,  digestion  goes  on  normal- 
ly, and  waste  material  is  not  eliminated  properly, 
there  obtains  an  accumulation  of  faecal  matter  in  the 
intestine,  due  to  atony  of  the  bowels  or  other 
causes,  these  faecal  matter  will  not  only  undergo  de- 
composition by  the  action  of  bacteria,  but  the  ab- 
sorption of  such  materials  will  produce  a  state  of 
toxaemia.  If  the  body  is  in  a  state  of  lessened  re- 
sistance the  retention  of  such  toxic  materials  will 
produce   nephritis,    diabetes,    gout,  neurasthenia, 


January  9,  1909. 1 


MOSKOll'ITZ:  SPONTANEOUS  ABSORPTION  OF  CATARACT. 


69 


anaemia,  and  other  serious  conditions.  The  cir- 
culatory structures  will  suffer  as  described  before, 
and  we  have  laid  again  the  foundation  for  buccal 
disorder. 

The  end  products  of  albumin  decomposition, 
indol,  skatol,  cresol,  phenol,  acted  upon  by  the  bile, 
are  eliminated  by  the  kidneys  and  are  recognized 
in  the  urine  as  indican.  Normal  urine  contains 
traces  of  indican,  but  if  the  decomposition  of  albu- 
minous material  goes  on  in  the  body  the  urinary  in- 
dican is  increased.  Herter,  in  speaking  of  excessive 
gastroenteric  fermentation,  says:  "Intestinal  dis- 
turbances attended  with  decreased  secretion  of  bile 
or  pancreatic  juice  (or  both)  are  usually  associated 
with  an  increase  of  indican.  The  most  frequent 
pathological  causes  for  increase  of  urinary  indican 
are:  l,  The  diminished  secretion  of  hydrochloric 
acid ;  2,  the  diminished  secretion  of  intestinal  di- 
gestive juices  ;  and,, 3,  the  excessive  use  of  proteid 
food,  especially  meat." 

Gastrointestinal  fermentation  is  often  the  cause 
of  interstitial  gingivitis  (pyorrhcea  alveolaris),  and 
a  careful  study  of  the  urine  will  help  to  ascertain  the 
systemic  cause  of  the  condition. 

All  patients  who  suffer  from  gingivitis  whom  I  see 
must  bring  a  sample  of  urine,  a  blood  examination, 
an  estimation  of  haemoglobin  is  made,  which  meas- 
ures prove  invaluable  in  the  recognition  of  systemic 
disturbances  which  cause  buccal  disease. 

The  treatment  in  many  of  these  cases  consists 
merelv  in  the  correction  of  dietary  faults,  the  ad- 
ministration of  cathartics,  the  ingestion  of  water  to 
stimulate  excretion  of  waste  materials. 

The  following  case  I  saw  last  week  in  consulta- 
tion. 

Case  III. — Mr.  R.  F.,  aged  twenty-two,  was  a  well  built 
young  man  apparently  in  good  health,  who  complained  of 
sensitiveness  of  upper  centrals  to  thermal  changes,  while 
the  gingival  border  m  the  same  region  was  slightly  red- 
dened. He  had  no  headache,  but  bowels  were  irregular;  he 
drank  little  water,  but  was  given  to  excesses  of  eating.  An 
examination  of  the  saliva  showed  it  to  be  acid,  the  urine 
contained  excess  of  indican. 

Diagnosis :  Intestinal  fermentation  and  retention  of  waste 
materials. 

Treatment :  Alkaline  mouth  wash ;  diet  less  rich  in  meat, 
more  vegetables,  especially  fruit.  He  was  ordered  to  drink 
buttermilk,  two  to  three  glasses  a  daj',  and  more  water ; 
was  told  to  abstain  from  excesses  of  all  kinds ;  and  was 
given  a  cathartic  to  keep  open  his  bowels. 

Time  being  limited.  I  have  but  outlined  a  few 
systemic  disturbances  and  their  effect  upon  the  den- 
tal and  alveolar  structures.  The  time  has  come 
that  the  dental  practitioner  must  recognize  the  re- 
lationship between  buccal  and  systemic  conditions 
(we  have  treated  pyorrhoea  alveolaris  locally  for 
fifty  years  without  success),  and,  recognizing  such 
relationship,  treatment  must  be  on  broader  lines  than 
heretofore. 

In  treating  buccal  conditions  which  resist  local 
treatment  there  must  be  borne  in  mind:  r.  Circula- 
tory disturbance.  2.  Nervous  disorder.  3.  Diseases 
of  nutrition.  4.  Infectious  diseases.  5.  Abnormal 
physiological  conditions.  Then  the  treatment  of 
many  conditions  which  so  far  have  baffled  the  den- 
tal specialist  will  be  attended  with  success,  and  the 
dentist  will  become  what  he  should,  not  only  the  sur- 
geon, but  also  the  physician  of  the  teeth  and  mouth, 
a  stomatologist. 

150  East  Sevexty-focrth  Street. 


REPORT  OF  A  CASE  OF  SPONTANEOUS  ABSORP- 
TION OF  INCIPIENT  CATARACT. 

By  Samuel  Moskowitz,  M.  D., 
New  York. 

I  have  had  a  similar  case  to  the  one  I  shall  report 
here  about  a  year  ago,  but  never  having  much  faith 
in  treating  cataract  otherwise  than  by  operation,  I 
did  not  follow  up  the  case  then. 

Patient,  S.  R.,  male,  age  thirty-one,  occupation,  draughts- 
man, came  to  my  office  on  October  11,  1908,  with  the  fol- 
lowing history : 

For  two  months  his  vision  had  been  failing  him,  espe- 
cially in  his  left  eye ;  he  said  that  his  vision  when  his  right 
eye  was  closed  was  very  poor,  while  with  his  left  eye  closed 
vision  was  better  than  when  the  eye  remained  open. 

Examination  :  V.  O.  D.  |^  W  —  25  =  |§  ;  V.  0S|^  — 
I  letter.   No  lens  improved.  sphere 

When  making  the  retinoscopic  test  I  found  that  I  could 
not  get  a  clear  shadow  in  his  left  eye.  Indirect  illumination 
and  ophthalmoscope  revealed  an  incipient  anterior  polar 
cataract.  I  then  instilled  homatropine  in  the  eye  and  found 
the  cataract  situated  in  the  centre  of  the  lens  close  on  to 
anterior  capsule,  occupying  nearly  the  whole  surface  of  the 
lens. 

I  had  there  and  then  decided  to  have  the  patient  come  to 
me  at  intervals  and  to  wait  until  the  cataract  became  ma- 
ture, and  then  to  perform  an  operation.  I  prescribed,  as  I 
do  in  such  patients  with  a  rheumatic  or  a  syphilitic  history, 
the  former  being  true  in  this  case,  sodium  salicylate  at  first 
without  any  effect,  later  potassium  iodide,  5  grains  three 
times  a  day. 

On  October  24th  I  applied  galvanic  electricity  to  the  eye, 
giving  about  twelve  milliamperes  for  2  minutes;  there  was 
a  reaction  and  the  eye  began  to  water. 

On  October  31st  I  gave  the  same  treatment  and  pre- 
scribed a  laxative,  the  patient  feeling  bilious  and  suffering 
from  indigestion. 

On  November  loth,  the  examination  of  eye  under  hom- 
atropine showed  a  perfectly  clear  lens  of  the  left  eye;  the 
fundus  could  be  seen  easily,  and  retinoscopic  shadow  was  as 
marked  as  in  the  other  eye.  Vision  without  the  homatro- 
pine was  |-2^  with  the  homatropine,  |^^.  The  patient  took 
then  TO  grains  of  potassium  iodide  daily,  and  was  dieted 
as  a  rheumatic,  abstained  from  alcoholic  liquors,  and  did 
not  smoke. 

November  14th  was  the  day  I  last  examined  him,  and 
vision  in  both  eyes  was  -|i  ;  the  patient  was  again  at- 
tending to  his  business  as  formerly. 

I  wish  to  mention  here  that  Dr.  Duane,  on  page 
458  of  Fuchs's  Ophthalmology,  makes  the  following 
statefhent  in  regard  to  such  cases :  "Tt  seems  possible 
that  absorption  of  incipient  cataract,  which  some- 
times occurs  spontaneously,  may  be  effected  in  some 
patients,  especially  those  of  a  plethoric  habit  and  of 
rheumatic  tendencies,  by  thoroughgoing  change  of 
diet  and  measures  for  the  prevention  of  intestinal 
autointo.xication." 

After  reading  this  I  felt  that  such  must  have  been 
the  case  with  my  patient. 

The  patient  has  so  much  confidence  in  my  treat- 
ment that  he  promised  to  come  for  a  year  at  inter- 
vals, so  that  in  case  I  find  any  recurrence  or  other 
symptom  of  special  interest  I  will  report  same  later. 

I  submit  this  case  to  the  profession  in  the  manner 
it  has  presented  itself  to  me,  and  do  not  mean  to  say 
or  infer  from  this  case  that  potassium  iodide,  gal- 
vanism, or  any  special  form  of  treatment  will  cure 
a  cataract,  but  simply  state  that  this  was  the  treat- 
ment. I  do  administer  in  cataracts  of  a  short  dura- 
tion potassium  iodide,  or  sodium  salicylate,  or  both, 
as  the  case  may  be,  and  try  galvanism,  as  neither  of 
these  does  any  harm,  while  waiting  for  the  cataract 
to  ripen  for  an  extraction. 

317  East  Thirteenth  Street. 


TORRANCE:   GASTRIC  AXD  DUODENAL  DILATATION. 


[New  York 
Medical  Journal. 


A  CASE  OF  ACUTE  GASTRIC  AND  DUODENAL 
DILATATION  TREATED  BY  GASTROJEJU- 
NOSTOMY WITH  RECOVERY* 
By  Gaston  Torrance.  AI.  D., 
Birmingham,  Ala., 
Surgeon  to  St.  Vincent's  and  the  Hillman  Hospitals. 

Byron  Robinson's  case  was  probably  the  first  on 
which  a  gastroenterostomy  was  done  for  acute  dila- 
tation of  the  stomach.  This  operation  was  per- 
formed in  1895  on  a  very  much  emaciated  woman 
whose  stomach  was  so  much  dilated  as  to  sag  down 
into  the  true  pelvis ;  she  made  a  satisfactory  recov- 
ery and  was  reported  well  in  1907,  twelve  years 
after  operation.  Kehr  reported  an  unsuccessful  case 
in  1899.  IMayo  Robson  suggested  gastroenterosto- 
my in  1900.  Korte  reported  a  fatal  case  in  1904. 
Remond's  case  also  had  a  fatal  termination.  Tschudy, 
in  1905,  did  an  anterior  gastroenterostomy  and  re- 
lieved the  dilatation,  but  his  patient  died  later  of 
pneumonia.  Heile  reported  a  case  in  1907  that  re- 
covered after  a  posterior  gastrojejunostomy.  Six- 
teen days  previous  to  this  time  he  had  resected  the 
pylorus  for  cancer  and  had  sutured  the  duodenum 
to  the  resected  portion  of  the  stomach.  At  the  sec- 
ond operation  there  w-as  no  obstruction  at  this  point 
and  no  dilatation  of  the  duodenum. 

The  following  case  was  referred  to  mv  service  at 
the  Hillman  Hospital  by  Dr.  E.  H.  Sholl,  of  Bir- 
mingham, on  May  18,  1908  : 

Case. — B.  F.,  a  colored  female,  twenty-two  years  of  age, 
widow;  family  history  negative.  She  had  pneumonia  eight 
years  ago ;  her  general  health  had  always  been  good ;  men- 
struation began  at  twelve  years  of  age,  was  always  regular 
and  normal ;  she  had  never  been  pregnant,  and  as  a  conse- 
quence had  no  relaxed  condition  of  the  abdominal  walls. 

Two  months  ago  she  began  to  have  pain  and  nausea  after 
eating — some  pain  in  the  region  of  the  umbilicus,  but  most 
marked  in  the  epigastrium  to  the  left  of  the  mid  line.  She 
pressed  her  hand  on  this  point  when  walking.  Appetite 
was  poor,  and  she  vomited  occasionally.  Pain  commenced  a 
few  minutes  after  eating  and  soon  became  more  marked. 
She  was  troubled  with  gas  distension  and  acid  eructations ; 
this  was  relieved  some  by  taking  soda.  She  had  some  pal- 
pitation and  pain  around  her  heart,  and  had  been  in  bed 
for  four  weeks,  vomiting  almost  daily,  sometimes  blood ; 
stools  were  tarry  and  she  was  very  constipated.  She  vom- 
ited incessantly  for  two  weeks  almost  as  soon  as  any  food 
was  ingested ;  this  contained  considerable  bright  blc^d  at 
times. 

There  was  marked  pain  and  tenderness  on  the  left  side 
near  the  tip  of  the  ninth  rib;  left  rectus  quite  rigid;  the 
stomach  was  apparently  not  much  dilated.  She  complained 
of  pain  under  the  right  shoulder  and  over  the  eighth  and 
ninth  ribs  to  the  right  of  the  spinal  column.  For  the  past 
few  days  before  I  saw  her  she  had  been  vomiting  large 
quantities  of  dark  greenish  fluid. 

She  had  been  in  the  hospital  a  week  before  consenting  to 
operation,  and  in  the  meantime  had  been  taking  an  alka- 
line treatment  without  any  improvement  in  her  condition. 

On  May  25tli  I  opened  the  abdomen  tiirough  the  right 
rectus  muscle  and  found  the  duodenum  dilated  to  nearly 
three  times  the  size  of  the  jejunum  below  where  it  was 
crossed  by  the  mesentery ;  the  stomach  was  somewhat  di- 
lated, but  not  in  proportion  to  the  duodenum.  I  found  an 
indurated  ulcer  about  the  size  of  a  silver  quarter  on  the 
posterior  surface  of  the  stomach,  near  the  greater  curva- 
ture, about  three  inches  from  the  pylorus.  I  did  Mayo's  no 
loop  gastrojejunostomy,  using  Moynihan's  clamps  and  linen 
sutures  for  both  layers.  She  left  the  table  in  good  condition. 

On  account  of  the  duodenal  condition  I  decided  to  only 
elevate  the  head  of  the  bed  about  eighteen  inches.  She  was 
given  nutrient  and  saline  enemas  and  strychnine  liypoder- 
mically.  She  continued  to  vomit  some  dark  fluid.  Two 
days  after  operation  she  was  given  sterile  water  and  orange 
juice  by  mouth.  Four  days  after  operation  I  decided  to  put 
her  on  a  bed  rest  to  see  if  this  would  relieve  the  vomiting; 

•Presented  at  the  meeting  of  the  American  Association  of  Ob- 
stetricians and  Cyngecologists,  Baltimore,  September  22,  1908. 


it  seemed  to  make  her  condition  worse ;  she  continued  to 
vomit  large  quantities  of  dark  fluid  at  intervals  of  a  few 
hours  (probably  the  accumulation  in  the  duodenum).  The 
bed  rest  and  all  elevation  was  removed  and  the  foot  of  the 
bed  elevated,  she  was  kept  on  her  side,  and  her  stomach 
washed  out  once  daily  for  three  successive  days.  At  the 
end  of  two  weeks  all  vomiting  had  disappeared  and  she  was 
taking  liquid  diet,  and  in  a  few  days  was  out  of  bed  walk- 
ing about  the  ward. 

She  became  considerably  emaciated,  but  quickly  regained 
her  flesh,  and  when  discharged,  a  month  after  operation, 
she  seemed  perfectly  well  and  was  taking  a  fairly  liberal 
diet. 

When  seen  four  months  after  operation  she  had  gained 
twenty  or  twenty-five  pounds,  and  said  she  was  eating  any- 
thing she  wished  and  had  not  had  any  digestive  trouble 
since  leaving  the  hospital. 

References. 

Robson  and  Moynihan.  Diseases  of  the  Stomach,  Sec- 
ond Edition. 

Kehr.    Archiv  fur  klinische  Chirurgie,  Iviii,  p.  632,  1899 

(Conner  j. 

Byron  Robinson.    Lancet-Clinic,  December  8,  1900. 
Mayo  Robson.    Lancet,  1900,  p.  8.J2. 

Korte.     Deutsche   niedicinische   IVochcnschrift,  xxx,  p. 
^554-  1904  (Conner). 
Laffer.    Annals  of  Surgery,  March  and  April,  1908. 
Remond.    Quoted  by  Laffer. 

Conner.  American  Journal  of  the  Medical  Sciences, 
March,  1907. 

Tschudy.    Quoted  by  Laffer. 

Bloodgood.  Annals  of  Surgery,  November,  1907. 

Mayo  Robson.    Keen"s  Surgery,  iii,  1908. 

Heile.  Mitthcilungen  aus  den  Grensgebciten  der  Medi- 
zin  und  Chirurgie,  1907,  supplement,  p.  707,  von  Mikulicz 
(Bloodgood). 

Byron  Robinson.  Splanchnoptosia,  Medical  Standard, 
1907. 

325-328  \\'ooDWARD  Building. 



(8ur  llfabm'  f  istussions. 

A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXI. — How  do  you  treat  chronic  eczema?  {Closed 
December  15,  igoS.) 

LXXXII. — How  do  you  treat  chronic  lead  poisoningt 
{Answers  due  not  later  than  January  15,  /pop.) 

LXXXIII. — Hozv  do  you  treat  acute  dysentery?  {An- 
swers due  not  later  than  February  15,  1909.) 

Whoever  anszvers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prise  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  zvill  be  based  solely 
on  the  value  of  the  substance  of  the  anszcer.  It  is  requested 
{but  not  required)  that  the  answers  be  short;  if  practica- 
ble, no  one  answer  to  contain  more'  than  six  hundred 
words. 

All  persons  will  be  entitled  to  compete  for  the  prize, 
ivhether  subscribers  or  not.  This  prize  ivill  not  be  azvarded 
to  any  one  person  more  than  once  zuithin  one  year.  Every 
answer  must  be  accompanied  by  the  zvriter's  full  name  and 
address,  both  of  which  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal, 
Our  readers  are  asked  to  suggest  topics  for  discussion. 

The  prize  of  $25  for  the  best  essay  submitted  in  anszcer 
to  question  LXXX  has  been  azvarded  to  Dr.  Paul  F.  Ela. 
of  East  Douglass,  Mass.,  zi'hose  article  appeared  on  page 
1225  of  the  previous  volume. 

PRIZE  QUESTION  LXXX. 
THE  TREATMENT  OF  ASPHYXIA  NEONATORUM. 

{Continued  from  page  38.) 
Dr.  Charles  H.  Halliday,  of  Beaufort,  South  Caro- 
lina, states: 

In  all  cases  of  prolonged  and  diflficult  labors, 
from  whatever  cause,  the  obstetrician  should  be 
prepared  to  treat  an  asphyxiated  child.  To  meet 
this  condition,  the  following  articles  should  be  in 


January  9,  1 909.  | 


OUR  READERS'  DISCUSSIONS. 


71 


readiness.  A  soft  rubber  catheter,  a  hypodermic 
syringe,  whiskey,  ether,  towels,  blankets,  a  soft  piece 
of  flannel,  two  buckets  or  tubs,  cold  water,  and  ar- 
rangements made  for  a  liberal  amount  of  hot  water ; 
and  a  table  upon  which  should  be  placed  a  pillow. 
The  foregoing  preparations  should  be  made  in  a 
room  adjoining  the  lying  in  chamber. 

The  treatment  of  an  asphyxiated  child  will  depend 
upon  the  grade,  asphyxia  livida  or  asphyxia  pallida. 
In  the  first  the  feet  should  be  grasped  with  one 
hand,  and  the  child  suspended  head  downward,  the 
body  slapped  vigorously  with  the  other.  If  attempts 
at  respiration  are  accompanied  by  gurgling  sounds, 
the  finger  should  be  passed  to  the  back  of  the  phar- 
ynx and  any  foreign  material  removed,  care  being 
taken  not  to  produce  injury  to  the  pharyngeal  space. 
Further  to  remove  mucus  from  the  trachea^  grasp 
the  trachea  at  the  bifurcation  and  gently  squeeze 
toward  the  larynx.  Generally  these  measures  will 
suffice  in  asphyxia  livida,  but  if  respiratory  efforts 
are  not  begun  in  a  few  minutes,  the  child  should  be 
placed  on  the  bed,  and  its  thorax  compressed  five  to 
six  times  per  minute.  If  this  does  not  bring  about 
th<^  desired  result,  the  treatment  should  be  more 
raaical.  and  preparations  made  to  treat  the  more 
severe  form — asphyxia  pallida. 

The  cord  should  now  be  ligated  and  cut,  and  the 
child  removed  to  the  next  room;  (the  mother  being 
cared  for  by  an  assistant).  Two  tubs  or  buckets 
should  now  be  filled,  one  with  hot,  the  other  with 
cold  water,  and  the  child  placed  alternately  in 
one  then  the  -  other,  its  head  only  protruding, 
and  massaged  vigorously,  care  being  taken  not 
to  produce  enough  friction  to  cause  abrasion  of 
the  skin.  If  symptoms  point  to  the  bronchial 
tubes  containing  mucus  or  amniotic  fluid  the 
small  rubber  catheter  should  be  introduced  into 
the  larynx  and  the  material  removed  by  suction  ex- 
erted by  the  obstetrician,  or  if  at  hand  a  Ribesmont- 
Dessargnes  insufflator  may  be  employed.  If  respira- 
tory movements  are  not  begun,  the  child  should  be 
removed  from  the  water,  given  a  hypodermic  injec- 
tion of  a  few  drops  of  whiskey  or  ether,  wrapped  in 
a  blanket,  placed  on  the  table  with  head  hanging 
pver  the  edge  and  Laborde's  method  of  resuscitation 
begun.  The  tongue  grasped  with  an  artery  forceps 
is  drawn  as  far  forward  as  possible  and  allowed  to 
recede.  This  manoeuvre  being  repeated  at  the  rate 
of  ten  to  fifteen  times  per  minute.  During  this 
method  an  assistant  should  massage  the  extremities. 
By  practising  this  method,  with  the  child  in  hot  water 
and  massage  its  value  may'be  increased.  If  in  from 
fifteen  to  thirty  minutes  we  are  not  rewarded, 
Schultze's  method  should  next  be  tried.  Wrap  the 
child  in  a  towel  or  piece  of  flannel,  and  grasp  in 
such  a  manner  .that  the  index  fingers  of  the  operator 
are  under  the  axillae,  the  thumbs  over  the  thorax, 
the  palmar  surface  of  the  middle,  ring,  and  little 
fingers  applied  to  the  child's  back.  Standing  with 
feet  apart,  the  operator  holds  the  child  between  his 
legs,  feet  downward ;  the  child  is  now  carried  over 
the  operator's  head,  so  its  feet  fall  toward  its  face, 
thus  sharply  flexing  the  trunk, and  then  carried  back 
to  its  original  position.  This  is  to  be  repeated  si.x  to 
eight  times  a  minute.  This  mancEUvre  is  contrain- 
dicated  when  the  clavicle  or  humerus  has  been  frac- 


tured during  a  difficult  extraction.  Practise  this 
method  three  or  four  minutes,  and  then  place  the 
child  in  warm  water  and  massage.  Continue  alter- 
nating between  Schultze's  method  and  hot  bath  with 
massage  for  at  least  half  an  hour. 

If  we  are  not  rewarded  by  this  method,  repeat 
the  hypodermic  injection  of  whiskey  or  ether,  place 
the  child  in  a  hot  bath,  and  practise  mouth  to  mouth 
insufflation.  In  this  manoeuvre  a  towel  or  several 
layers  of  gauze  should  be  placed  over  tlie  child's 
mouth,  then  taking  a  deep  inspiration  the  operator 
quickly  and  gently  blows  into  the  child's  mouth,  an 
assistant  then  compressing  the  chest.  This  method 
failing,  insufflation  through  a  catheter  passed  into 
the  larynx  should  be  tried. 

If  the  asphyxia  is  due  to  a  depressed  fracture 
of  the  skull  a  perforation  may  be  made  with  a  suit- 
able instrument,  and  effort  made  to  remove  the  pres- 
sure by  replacing  the  depressed  portion.  However, 
this  should  only  be  attempted  when  all  other  pro- 
cedures have  failed. 

Successful  results  can  only  be  obtained  by  per- 
sistence in  treatment.  Method  after  method  should 
be  tried  and  as  long  as  the  heart  continues  to  beat,, 
our  efforts  should  not  cease.  Two  hours  should  not 
be  considered  too  long  a  time,  in  which  to  hope  to 
bring  about  a  happy  termination.  ' 

Dr.  C.  L.  Sigler,  of  Pinckney,  Mich.,  zvrites: 

There  are  two  general  forms  of  asph}xia  neo- 
natorum, the  first  of  which  is  characterized  by  a 
swollen  face,  which  may  vary  in  color  from  red  to 
a  dusky  purple,  a  slow,  irregularly  pulsating  heart 
and  cord,  and  a  greater  or  less  tonicity  of  the  mus- 
cles. This  is  the  so  called  sthenic  form,  and  forms  a 
sharp  contrast  to  the  asthenic  or  anaemic  form,  in 
which  the  .skin  is  pale,  the  muscles  relaxed  and 
flabby,  the  cord  and  heart  nonpulsating  or  nearlv 
so,  and  the  child  apparently  lifeless.  In  this  form 
there  is  rarely  a  spontaneous  effort  to  breathe,  and 
when  the  finger  is  inserted  into  the  pharyn.x  to  clear 
it  of  mucus  there  is  but  a  feeble  or  no  reflex  elicited. 
This  is  not  the  case  in  the  sthenic  form,  for  here 
there  are  more  often  spasmodic  efforts  at  respira- 
tion, and  when  the  pharynx  is  entered  or  cleansed, 
successful  efforts  at  breathing  may  result.  Thus  it 
is  seen  that  on  the  whole  the  sthenic  form  offers 
the  more  favorable  prognosis,  although  this  fact 
should  not  deter  the  accoucheur  from  continuing 
vigorous  efforts  in  any  case. 

The  causes  of  asphyxia  neonatorum  "are  princi- 
pally due  to  pressure  in  different  forms  as  from 
the  maternal  parts  on  the  child's  head,  neck,  or  tho- 
rax, and  on  the  cord.  The  same  may  be  due  to 
prolonged  or  improper  use  of  the  forceps  in  deliv- 
ery, or  more  rarely  to  knotting  or  twisting  of  the 
cord.  Breech  delivery  followed  by  a  slow  coming- 
head  is  a  prolific  cause,  and  indeed,  slow,  tedious 
deliveries  of  any  kind  may  be  followed  by  this 
trouble.  Premature  separation  of  the  placenta  mav 
be  a  cause,  and  it  is  asserted  that  ergot  mav  here 
be  a  factor  and  that  it  may  also  hinder  the  maternal 
fcetal  circulation  by  closing  the  uterine  sinuses.  Chil- 
dren prematurely  born  are  more  liable  to  this  aflfec- 
tion,  as  are  children  of  feeble  development  from 
other  causes.  I  am  inclined  to  think  that  the  condi- 
tion is  more  apt  to  occur  when  large  doses  of  chloral 


72 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


or  chloroform  have  been  given  during  labor,  al- 
though I  have  never  seen  a  fatal  case  under  such 
circumstances.  At  times  the  cause  may  be  found  in 
some  pathological  condition  in  the  foetus,  as  poorly 
developed  heart  or  lungs,  pleural  exudate,  hered- 
itary syphilis  of  one  of  the  vital  organs,  or  to  me- 
chanical injury  to  one  of  these  organs  or  to  the 
nerve  centres  governing  them. 

It  is  plainly  seen  from  this  review  of  the  aetiology 
that  the  prognosis  must  depend  largely  upon  the 
cause.  As  a  rule,  the  sthenic  cases  respond  much 
more  to  treatment  and  many  times  require  only  the 
most  simple  remedies  to  promote  respiration.  An 
unfavorable  result  should  not  be  prognosticated  too 
hastily,  as  continued  efforts  may  resuscitate  infants 
apparently  quite  hopeless.  Should  the  condition  be 
caused  by  cerebral  hjemorrhage  from  pressure  or 
injury  by  forceps,  the  prognosis  is  grave  not  only 
as  to  life,  but  as  to  the  future  mental  condition 
should  the  termination  not  be  fatal. 

In  all  cases  the  treatment  should  be  begun  by 
cleansing  the  child's  mouth  and  pharynx  with  a 
piece  of  cloth  wrapped  about  the  finger,  and  sus- 
pending it  by  the  feet  for  an  instant.  This  proced- 
ure will  frequently  be  sufficient,  in  which  case  the 
cord  may  be  cut  and  the  child  be  turned  over  to  the 
nurse.  In  sthenic  cases  where  there  seems  to  be  much 
venous  congestion,  one  or  two  drachms  of  blood 
may  be  allowed  to  escape  before  the  cord  is  tied, 
but  in  the  anaemic  cases  the  cord  should  not  be  tied 
so  long  as  it  pulsates,  and  then  just  before  cutting 
it  the  blood  in  the  cord  should  be  "stripped"  to 
the  body  of  the  child. ,  Slapping  the  chest  or  but- 
tocks with  a  towel  wet  in  cold  water  or  even  with 
the  hand  is  effectual  in  mild  cases,  and,  as  in  later 
years,  will  often  provoke  a  lusty  cry.  If  there  is 
any  effort  at  all  at  respiration,  inhalation  of  stimu- 
lants, as  aromatic  spirit  of  ammonia  or  camphor, 
may  be  tried. 

While  these  measures  are  being  tried,  two  wash 
bowls  of  water  should  be  prepared,  one  cold  (65°  to 
75°  F.,)  and  one  rather  warm  (85°  to  100  F°.). 
The  child  should  be  lifted  into  the  cold  water,  and 
if  a  cry  is  not  elicited  to  the  warm  water  for  a  few 
seconds.  This  procedure  may  be  repeated  two  or 
three  times,  and  if  unsuccessful  the  cord  may  be 
cut  and  some  sort  of  artificial  respiration  be  applied. 
The  simplest  way  to  perform  this  is  by  the  mouth 
to  mouth  method.  In  this  the  child's  mouth  is  cov- 
ered with  a  clean  towel,  the  nostrils  grasped,  and 
the  physician  inflates  the  child's  lungs  by  applying 
his  own  mouth  to  that  of  the  child  and  blowing. 
The  air  is  then  expelled  by  compressing  the  thorax 
gently,  and  the  operation  repeated.  This  may  be 
modified  by  inserting  a  soft  rubber  catheter  through 
the  glottis  and  blowing  air  into  the  lungs  by  this 
method.  If  such  efforts  are  to  be  maintained  for 
any  length  of  time,  artificial  heat  must  be  applied  to 
the  child's  body,  as  by  warm  cloths  or  by  leaving  the 
child  in  the  bowl  of  warm  water.  Should  other 
means  of  artificial  respiration  be  adopted,  it  should 
be  seen  that  the  tongue  is  not  allowed  to  drop  back 
and  ob.struct  respiration. 

Another  method  is  similar  to  that  used  in  attempt- 
ing to  resuscitate  persons  apparently  drowned.  In 
this  the  child  is  jjlaced  on  its  back,  its  shoulders 


slightly  elevated,  as  on  a  folded  towel  or  pillow 
slip.  The  accoucheur,  standing  behind  the  child, 
grasps  one  arm  in  each  hand  and  draws  them  up- 
ward over  the  head  so  as  to  raise  the  ribs  and  facili- 
tate the  ingress  of  air.  After  this  position  has  been 
maintained  for  four  or  five  seconds,  the  arms  are 
to  be  lowered  and  pressed  against  the  sides  of  the 
thorax  to  expel  the  contained  air.  These  move- 
ments are  to  be  repeated  from  twelve  to  sixteen 
times  a  minute.  Or  the  child  may  be  laid  on  its 
back  across  the  palms  of  the  operator's  outstretched 
hands,  and  its  body  alternately  extended  and  flexed 
so  as  to  cause  expansion  and  compression  of  the 
lungs.  Rhythmic  traction  of  the  tongue  may  be 
tried,  the  tongue  being  grasped  by  tongue  forceps, 
haemostats,  or  the  thumb  and  finger  covered  with 
cloth  to  prevent  slipping.  The  tongue  is  pulled 
firmly  forward,  and  then  allowed  to  drop  back  from 
twelve  to  sixteen  times  per  minute. 

It  is  not  to  be  supposed  that  the  accoucheur  will 
utilize  all  the  different  methods  in  each  case,  but  it 
will  be  seen  that  the  principle  involved  is  the  same 
in  most  of  them,  and  that  it  is  to  produce  alternate 
compression  and  expansion  of  the  chest.  Another 
method  of  performing  this  is  to  grasp  the  child  by 
the  shoulders  while  standing  behind  it  as  it  rests 
upon  its  back,  and  swing  it  upward  until  the  legs 
and  trunk  come  forward,  thereby  compressing  the 
chest.  Reversing  this  process  allows  the  body  to 
extend,  thus  expanding  the  chest.  On  account  of 
the  apparent  roughness  of  this  method  it  is  not  apt 
to  be  greatly  appreciated  by  the  female  relatives  who 
are  invariably  present.  This  is  the  well  known 
Schultze  method,  and  is  not  so  easily  .described  as 
demonstrated.  While  undoubtedly  a  good  method, 
I  very  rarely  use  it,  foi-,  in  the  first  place,  it  is  rarely 
necessary,  and  in  the  second  place  I  would  not  like 
to  try  it  and  not  be  successful,  for  it  is  not  apt  to 
be  popular  with  the  spectators  on  account  of  it 
seeming  much  more  harsh  than  it  really  is. 

Now,  ior  fear  that  so  many  methods  will  provoke 
confusion,  let  us  list  these  various  remedies  in  the 
order  that  they  should  be  tried,  ceasing  efforts,  of 
course,  as  soon  as  they  prove  successful:  i.  Clean 
the  pharynx ;  2,  slap  the  chest  or  buttocks  smartly ; 
3,  apply  stimulants  to  nostrils ;  4,  lift  from  warm  to  * 
cold  water ;  5,  cut  cord  as  directed ;  6,  use  artificial 
respiration. 

it  is  not  at  all  necessary  to  commit  to  memory 
the  directions  for  using  artificial  respiration  in  its 
many  forms.  Simply  familiarize  yourself  with  the 
principles  involved  and  the  method  will  suggest  it- 
self. Never  give  up  so  long  as  there  is  a  shadow 
of  hope,  as  in  more  than  one  case  the  child  has  l^een 
found  to  be  alive  after  being  abandoned  as  dead  by 
the  attendant.  Never  forget  that  in  Catholic  fami- 
lies it  is  considered  imperative  that  the  child  be  bap- 
tized before  death,  and  should  there  be  a  doubt  of 
the  child's  living  it  should  be  done  at  once.  The 
ceremony  takes  but  a  few  seconds,  and  in  an  emer- 
gency may  be  performed  by  a  noncatholic,  and 
every  accoucheur  should  be  prepared  to  perform  it  if 
necessary.  Remembering  this  will  not  only  avoid 
regret  on  the  part  of  the  family  in  case  of  a  fatal 
termination,  but  will  often  gain  many  friends  for 
the  accoucheur. 


January  9,  1909. 1 


THERAPEUTICAL  NOTES. 


73 


Dv.  E.  H.  Sichler,  of  Detroit,  Mich.,  remarks: 

Every  obstetrician  should  bear  in  mind  the  ne- 
cessity of  having  to  cope  with  this  troublesome  and 
frequently  preventive  condition.  If  he  is  on  the 
alert  for  the  symptoms  that  will  appear,  even  though 
the  cause  of  the  asphyxia  may  not  be  apparent,  he 
can  do  much  to  lower  the  infant  mortality  from  this 
cause.  The  treatment  of  this  condition  must  be 
classed  as  prophylatic  and  active,  depending  some- 
what upon  the  causative  factor. 

Prophylatic  treatment.  The  setiological  agent  caus- 
ing the  asphyxiation  must  be  here  considered.  This 
may  be  apparent  as  in  i,  prolapsus  of  the  cord,  or 
in  breech  presentations,  or  maybe  merely  surmised 
as  in  2,  cerebral  compression  (use  of  forceps  or  pres- 
sure of  vertex  against  bony  pelvis  by  uterine  force), 
twisting  or  constriction  (pressure)  of  the  cord,  or 
premature  separation  of  the  placenta.  The  result  is 
the  same  in  all  these  conditions,  carbon  dioxide 
poisoning,  brought  about  by  the  interruption  of  the 
placental  blood  supply  with  its  oxygenating  powers. 
The  mechanism  by  which  the  asphyxiation  occurs 
will  not  be  dwelt  upon  here. 

In  the  first  class  of  cases,  asphyxiation  will  occur 
and  measures  must  be  taken  to  relieve  the  under- 
lying causes.  If  possible,  reposition  of  the  cord  will 
be  done — if  this  is  not  feasible,  and  dilation  is  not 
complete,  forceps  is  to  be  used,  if  dilation  is  incom- 
plete, podalic  version  is  to  be  performed.  In  breech 
presentations  a  good  technique  is  necessary,  as  slow 
delivery  of  the  after  coming  head  is  the  largest 
single  factor  in  our  mortality  rate  from  asphyxia 
neonatorum.  '  In  the  second  class  of  cases  our  first 
notification  of  an  asphyxiation  will  be  a  disturbance 
of  the  foetal  rhythm.  Another  symptom  of  diagnostic 
value  is  the  finding  of  meconium  in  the  vaginal  dis- 
charge other  than  in  breech  presentation.  Meconium 
so  found  indicates  a  relaxation  of  the  sphincter, 
which  in  turn  is  due  usually  to  an  asphyxiation.  If 
during  the  second  stage  of  labor  the  foetal  cardiac 
movements  become  slower  and  are  heard  less  dis- 
tinctly, carbon  dioxide  poisoning  is  probably  occur- 
ring. Dehvery  should  be  hastened  as  in  class  one.  If 
the  dilation  is  complete  forceps  is  to  be  used,  if  in- 
complete version  is  to  be  performed. 

Given  the  birth  of  an  asphyxiated  child,  a  certain 
routine  method  should  be  observed,  in  this  way  it 
will  become  a  fixed  habit  and  several  things  will  not 
be  attempted  at  the  same  time,  either  of  which 
being  followed  by  equally  good  results.  First,  the 
form  of  asphyxia  should  be  noted,  whether  Hvid  or 
pallid.  After  delivery,  if  the  child  is  cyanotic,  and 
makes  no  respiratory  effort,  it  is  best  to  cut  the  cord 
at  once,  allowing  an  ounce  of  blood  to  escape  be- 
fore tying.  In  the  pallid  cases,  the  child  is  to  be 
covered  with  hot  blankets,  and  the  pulsation  in  the 
cord  allowed  to  cease  before  tying.  All  mucus  is  to 
be  cleaned  out  of  the  mouth  and  throat  with  the 
finger.  Then  grasp  the  child  by  the  feet  with  one 
hand  allowing  the  head  to  hang  down,  and  slap  the 
body  vigorously  with  the  other.  Usually  this  will 
bring  forth  a  gurgling  respiratory  sound,  especially 
in  asphyxia  livida.  If  the  symptoms  seem  to  war- 
rant it  a  small  catheter  is  to  be  introduced  into  the 
larynx,  and  any  mucus  or  amniotic  fluid  in  the  bron- 
chial tubes  withdrawn  by  suction. 

Should  none  of  these  measures  be  successful,  then 
artificial  respiration  is  to  be  done.    Of  the  several 


forms,  that  of  Byrd  is  probably  the  best.  This  is  per- 
formed briefly  in  the  following  manner :  Rest  the 
child's  neck  between  the  thumb  and  index  finger  of 
the  right  hand,  allowing  the  head  to  fall  backward ; 
the  palm  supporting  the  shoulders  and  the  last  three 
fingers  between  the  arm  and  body.  The  left  palm  is 
placed  between  the  thighs,  the  finger  grasping  the 
knees.  To  procure  inspiration  the  body  is  arched, 
expiration  is  produced  by  reversing  the  movement, 
i.  e.,  bringing  the  child's  knees  on  thorax.  This  man- 
oeuver  should  be  done  six  or  eight  times  a  minute, 
with  the  child  placed  in  hot  water. 

If  unsuccessful,  follow  this  with  Laborde's  method 
of  resuscitation.  This  consists  of  placing  the  child's 
head  over  the  back  of  a  chair  or  table  and  making 
rhythmical  tractions  upon  the  tongue  with  a  forceps. 
If  neither  of  the  last  two  measures  result  in  success, 
the  outlook  is  gloomy.  Recourse  may,  however,  be 
had  to  infusion  of  the  umbilical  vein.  All  that  is 
needed  is  a  graduated  bottle,  tubing,  and  cannula. 
The  latter  is  inserted  into  the  umbilical  vein,  and  the 
solution  allowed  to  run  in  slowly.  When  heart  and 
respiration  start  up,  the  regular  measures  are  re- 
employed. This  procedure  is  sometimes  extremely 
successful.  At  any  time  during  asphyxiation  hypo- 
dermic injections  of  strychnine  may  be  used  if  neces- 
sary. 

In  cases  where  the  child  is  not  cyanotic,  but 
simply  does  not  respire  automatically  as  the  head 
emerges,  the  trouble  is  sometimes  due  to  a  depres- 
sion fracture  of  the  skull.  This  is,  of  course  most 
frequent  when  mid  or  high  forceps  extraction  is 
used.  Should  a  fracture  occur,  the  depressed  por- 
tion is  to  be  raised  with  a  pair  of  scissors. 

\Miatever  method  is  adopted,  in  all  cases  of  as- 
phyxiation efforts  of  resuscitation  should  continue 
until  the  child's  heart  has  ceased  to  functionate,  for 
excellent  results  are  obtained  when  we  have  ceased 
to  expect  them.  It  is  also  best  to  map  out  a  plan  of 
action  in  these  cases,  and  practise  so  that  it  will  be- 
come almost  automatic  on  the  part  of  the  obstetri- 
cian. 

(To  be  continued.) 


^btrapeutital  |[otes. 


The  Treatment  of  Asthma. — In  the  course  of  a 
comprehensive  review  of  the  treatment  of  asthma 
published  in  the  Journal  of  the  American  Medical 
Association  (Vol.  LI,  p.  2160  and  Vol.  LII,  p.  50) 
it  is  noted  that  there  is  no  best  treatment  for  the 
control  of  the  paraxysm.  A  careful  study  of  each 
individual  patient  is  necessary  in  order  to  determine 
what  shall  be  used.  The  drug  that  most  frequently 
is  successful  m  rendering  the  patient  comfortable 
and  shortening  the  paroxysm  is,  of  course,  mor- 
phine, but  before  the  physician  begins  the  treatment 
of  the  asthmatic  attacks  with  morphine  he  should 
have  exhausted  his  other  resources,  as  he  is  not  sure 
that  he  can  cure  the  asthma,  even  if  he  removes  the 
reflex  cause,  and  such  patients  readily  acquire  the 
morphine  habit.  If  a  given  patient  is  incurable 
under  the  surroundings  and  conditions  in  which  he 
must  live  and  no  other  drug  will  relieve  his  suffer- 
ing, he  doubtless  has  the  right  to  receive  morphine, 
even  if  he  does  form  the  habit.  The  inhalation  of 
fumes  from  burning  medicinal  substances  has  been 


74 


IH  l-iKAPE  U TICAL  NO  TES. 


[New  York 
Medical  Journal. 


used  almost  from  ancient  times  for  the  asthmatic 
attack.  Almost  all  the  powders  and  cigarettes  rec- 
ommended for  use  in  this  Wa}-  contain  potassium 
nitrate  and  stramonium,  or  belladonna,  or  other 
atropine  containing  drug.  By  the  burning  of  stram- 
onium atropine  is  administered  by  inhalation,  which 
serves  to  dull  the  irritability  of  the  peripheral  nerves 
in  the  nose,  throat,  and  larger  bronchial  tubes.  It 
acts  at  the  same  time  as  a  circulatory  stimulant. 
The  following  formula  is  given  for  a  French  asthma 
cigarette : 

Belladonna  leaves,   parts; 

Hyoscyamus  leaves,   234  parts; 

Stramonium  leaves,   2j4  parts; 

Phellandrium    aquaticum    [Qinanthe  Phellan- 

drium],   i  part; 

Extract  of  opium,   Y^,  part ; 

Cherry  laurel  water,   A  sufficiency. 

—  (Yeo). 

The  dried  leaves  are  cut  small,  mixed  well,  and 
moistened  with  the  opium  which  has  been  dissolved 
in  the  cherry  laurel  water.  A  small  amount  of  po- 
tassium nitrate  is  added  in  order  that  the  cigarettes 
may  burn  readily. 

In  sutnmarizing  the  best  treatment  for  the  parox- 
ysms of  asthma  the  article  from  which  we  have 
quoted  mentions  morphine  and  atropine  hypoder- 
mically,  the  administration  of  nitroglycerin  by  the 
mouth,  adrenalin  or  other  suprarenal  sprays  into 
the  nostrils  or  throat,  or  tablets  containing  supra- 
renal [extract]  dissolved  in  the  mouth,  fumigations 
with  potassium  nitrate  and  stramonium,  and  cocaine 
applications  and  sprays  if  must  be. 

Tincture  of  Horse  Chestnut  for  Varicose  Veins. 

— The  use  of  a  tincture  of  horse  chestnut  (Aisculus 
Hippocastanum  L.)  for  painful  haemorrhoids,  taken 
internally  in  doses  of  ten  minims  night  and  morn- 
ing, the  tincture  being  made  of  the  strength  of  ten 
per  cent,  in  diluted  alcohol,  has  been  previously 
recommended.  According  to  Artault  {Bulletin  gen- 
eral de  iherapeiitiqne,  December  15,  igo8)  a  similar 
tincture  has  been  used  successfully  in  the  treatment 
of  varicose  veins,  ten  drops  being  taken  before  each 
meal.  In  cases  of  chronic  varices  the  author  ap- 
plies a  compress  saturated  with  a  liniment  composed 
of  two  parts  of  tincture  of  horse  chestnut  and  six 
parts  of  wool  fat,  covering  the  whole  with  a  layer  of 
cotton  and  oiled  silk.  The  tincture  is  given  internally 
at  the  same  time.  As  an  external  vasoconstrictive 
the  action  of  the  tincture  is  slow,  but  its  analgesic 
action  in  painful  haemorrhoids  is  said  to  be  extreme- 
ly rapid.  The  author  has  used  the  tincture  with 
good  results  in  haemoptysis  due  to  a  varicose  condi- 
tion of  the  trachea.  Horse  chestnut  appears  to 
exert  a  peculiar  action  on  the  venous  system,  and 
Dr.  Artault  considers  it  a  remedy  of  great  interest 
and  possibilities. 

Mercury  Succinimide.— This,  the  mercuric  salt 
of  succinic  acid  imide,  has  been  favorably  spoken  of 
in  the  treatment  of  syphilis.  Its  solutions  are  said 
to  be  nonirritating.  While  it  is  used  mainly  by 
hypodermic  injection,  a  2^  per  cent,  solution  being 
employed,  of  which  j'/>  to  15  minims  are  given  once 
daily,  it  may  also  l)e  given  by  the  mouth  in  doses 
of  1/6  to  1/4  grain.  The  pharmacology  of  mercury 
succinimide  is  the  subject  of  a  note  in  a  recent  num- 
ber of  the  Journal  of  the  American  Medical  Asso- 
cialion.  The  salt  may  be  prepared  by  dissolving 
freshly  precipitated  mercuric  oxide  in  warm  aque- 


ous solution  of  succinimide  and  evaporating-  the 
mixture,  which  then  deposits  crystalline  needles. 
(Schmidt's  Pharniakologische  Chemie,  II,  pt.  I,  p. 
482.)  It  may  also  be  prepared  by  adding  an  alco- 
holic solution  of  succinimide  containing  a  few  drops 
of  ammonia  to  an  ethereal  solution  of  mercuric 
chloride  {Proceedings  of  the  American  Pharmaco- 
logical Association,  XL,  p.  1029).  Mercury  suc- 
cinimide is  a  white  crystalline  powder,  soluble  in  25 
parts  hot  water  and  in  75  parts  of  cold  water,  and 
in  300  parts  of  alcohol.  It  is  very  stable  in  solution, 
the  aqueous  solution  is  not  affected  by  albumin. 
Mercury  succmimide  shoitld  be  protected  from  light. 

Phosphergot. — This  name  is  applied  to  a  mixture 
of  dried  sodium  phosphate  and  freshly  pulverized 
ergot  of  rye,  which,  according  to  Bellot  {Journal  de 
medicine  ct  de  chirurgie  pratiques,  July  10,  1908), 
was  proposed  by  Dr.  Luton,  of  Rheims,  as  a  prepa- 
ration which  combined  the  properties  of  ergot  and 
of  sodium  phosphate,  and  acts  as  a  tonic  and 
strengthener  in  nervous  debility,  anaemia,  and  neur- 
asthenic conditions  generally.  In  neurasthenia  it  is 
said  to  restore  the  bodily  vigor  and  at  the  same  time 
to  improve  the  nerve  tone  {I'energie  morale).  It  is 
also  said  to  be  employed  with  excellent  results  in 
the  treatment  of  anaemic  patients  who  are  troubled 
with  either  amenorrhcea  or  menorrhagia.  Bellot 
also  prescribes  the  mixture  in  the  treatment  of 
spermatorrhoea,  incontinence  of  urine,  and  in  the 
weakness  of  diabetes.  It  has  the  advantage,  accord- 
ing to  Bellot,  of  not  proving  disturbing  to  the  stom- 
ach, or  of  causing  symptoms  of  ergotism.  Bellot 
employs  the  following  prescription  : 

1«    Dried  sodium  phosphate,  gr.  iv; 

Pulverized  fresh  ergot,   gr.  iv. 

Mix  and  dispense  twenty  such  powders :  one  or  two  pow- 
ders to  be  given  after  each  meal. 

The  remedy  is  to  be  continued  from  ten  to  twenty 
days  and  repeated  after  a  period  of  rest  if  necessary. 

Liniments  for  Neuralgia. — Lemoine  {Le  Nord 
medical.  December  i,  1908)  mentions  a  number  of 
preparations  that  are  used  for  the  relief  of  neuralgia 
by  rubbing  over  the  seat  of  pain.  Huchard's  for- 
mula is  given  as  follows : 

R    Spirit  of  camphor,  .Siiss  ; 

Spirit  of  juniper,  5iiss  ; 

Spirit  of  lavender,  5ii, 

Chloroform,   5ss ; 

Tincture  of  opium,  5ss. 

M. 

Sig. :  One  or  two  teaspoonfuls  of  the  liniment  to  be 
rubbed  on  the  part  affected  night  and  morning. 

Sablatani  employs  guaiacol  in  combination  with 
menthol : 

R    Absolute  alcohol  5ivss; 

Menthol  gr.  xv; 

Gnaiaco!  gr.  xv. 

Lemoine  himself  prescribes  the  following  lini- 
ments : 

H    Oil  of  hyoscyamus  5v  ; 

Tincture  of  opium  n\,lxxv; 

Chloroform  X![,  Ixxv.  » 

M.  ct  Sig. :  .-Vpply  twice  daily. 

Tincture  of  belladonna,   3iiss ; 

Guaiacol  3ss ; 

Oil  of  hyoscyamus,   5'- 

M.  et  Sig. :  To  be  well  shaken  before  applying. 

B    Menthol  salicylate,   3ijss; 

Guaiacol  5ss; 

Liquid  petrolatum,   3x. 

M. 


January  9,  1909.] 


EDITORIAL  ARTICLES. 


75 


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ing Co.,  or  by  registered  mail,  as  the  publishers  are  not  responsible 
for  money  sent  Dy  unregistered  mail. 

Entered  at  the  Post  Office  at  New  York  and  admitted  for  trans- 
portation through  the  mail  as  second  class  matter. 

NEW  YORK,  SATURDAY.  JANUARY  9,  1909. 


NEWSPAPER  .MEDICINE. 

We  object  to  the  publication  of  medical  items  in 
the  daily  newspapers,  because  such  publications  are 
usually  not  true ;  they  put  the  physician  whom  they 
report  in  a  bad  light  before  his  colleagues,  and  they 
give  the  public  an  erroneous  idea  of  the  aims  and 
methods  of  physicians.  Take,  for  example,  the  pub- 
lication of  the  item  in  the  New  York  Sim  for  Jan- 
uary 6th.  On  the  front  page  we  find  the  head  lines 
"May  be  Consumption  Cure."  "Bacillus  to  be  De- 
stroyed by  an  Antitoxine."  All  this  has  reference 
to  the  so  called  discovery  by  Dr.  Randle  C.  Rosen- 
berger,  of  Philadelphia,  that  the  "tuberculosis  germ 
can  be  readily  found  in  the  blood  before  it  reaches 
the  lungs ;  that  it  is  then  in  a  condition  which  makes 
it  easily  destroyed  by  simple  treatment  and  fresh  air ; 
and  that  it  will  soon  be  possible  to  use  an  antitoxine 
which  will  stamp  the  disease  out." 

The  Sun's  item  spells  Dr.  Rosenberger's  name 
"Rosenbergh,"  and  says  that  he  is  a  famous  biolo- 
gist and  that  he  holds  the  chair  of  bacteriology  at 
the  Jefferson  Medical  College.  To  our  knowledge 
Dr.  Rosenberger  does  not  profess  to  be  a  biologist. 
He  is  assistant  professor  of  bacteriology  in  the  Jef- 
ferson Medical  College.  The  item  then  says  that 
this  great  discovery  has  been  announced  to  the  Col- 
lege of  Physicians.  Dr.  Rosenberger  read  his  paper 
before  the  Philadelphia  Pathological  Society  on  De- 
cember loth,  where  he  made  no  reference  to  the 
therapeutic  possibilities  opened  up  by  his  work.  He 


alleged  no  "discovery."'  He  said  that  he  had  per- 
fected a  method  by  which  tubercle  bacilli  could  be 
detected  in  the  blood  of  patients  suffering  from  tu- 
berculosis. Everybody  knew  that  they  were  in  the 
blood,  but  'it  was  difficult  for  anybody  to  show  them 
stained  on  a  microscopic  slide.  Dr.  Rosenberger  de- 
serves much  credit  for  perfecting  a  technique  which 
should  demonstrate  the  tubercle  bacilli,  which,  as 
long  ago  as  in  1883,  Landouzy  said  were  in  the  blood. 

The  article  goes  on  to  quote  Dr.  Lawrence  Flick, 
"president  of  the  Phillips  Institute  for  Consump- 
tives." There  is  no  Phillips  Institute.  There  is  a 
Phipps  Institute.  These  facts  show  how  a  news- 
paper can  spoil  a  physician's  reputation  for  accuracy 
and  truth. 

The  whole  article,  from  the  viewpoint  of  scientific 
medicine,  is  absurd  to  the  highest  degree.  It  is 
stated  that  the  article  is  published  by  official  an- 
nouncement. It  does  not  say  by  the  officials  of 
what  institution,  but  one  infers  by  the  officials  of  the 
Jefferson  Medical  College,  ^^■e  are  able  to  state, 
after  consultation  with  one  of  these  officials,  that 
they  not  only  did  not  authorize  the  publication  of  the 
"story,"  but  that  they  were  entirely  in  ignorance  of 
the  proposition  to  publish  it,  and  that  they  are  ab- 
solutely opposed  to  the  publication  of  it  in  the  daily 
newspapers.  The  Philadelphia  Xorth  American  is 
as  culpable  as  the  New  York  Sun.  for  it  published 
the  same  article  on  January  5th.  If  the  daily  press 
intends  to  go  into  the  business  of  publishing  medi- 
cal news,  we  should  advise  it  to  engage  a  competent 
physician  to  edit  its  items. 


•  THE  POLLUTION  OF  WATER  SUPPLIES. 

The  recent  epidemic  of  typhoid  fever  in  Reading, 
Pa.,  has  resulted  in  the  recording  of  652  cases  of 
the  disease,  with  twenty-six  deaths,  up  to  Wednes- 
day, December  22d.  This  country  has  had  several 
historic  epidemics  of  typhoid  fever,  the  best  known 
of  which  are  the  Plymouth,  Pa.,  epidemic  of  1885 ; 
the  Lowell  and  Lawrence,  Mass.,  epidemic  of  1890; 
and  the  Butler,  Pa.,  epidemic  of  1903.  It  is  well 
known-  that  these  great  epidemics,  each  of  which 
was  preventable,  were  due  to  water  pollution.  With 
all  past  experience  at  command,  municipalities  are 
as  careless  to-day  about  water  supplies  as  they  were 
jn  the  past.  The  majority  of  cities  in  this  country 
are  in  all  probability  supplied  with  drinking  water 
by  private  corporations,  so  that  the  city  govern- 
ments have  no  direct  control  over  the  water  supply 
for  the  populations  for  which  they  are  the  nominal 
guardians.  We  would  not  accuse  any  water  com- 
pany of  wilfully  endangering  the  health  of  the  com- 


76 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


munity  which  it  supplies;  but  we  would  accuse 
many  of  them  of  gross  carelessness  in  the  collection 
and  the  distribution  of  their  water.  How  many 
companies  in  this  country  have  daily  examinations 
made  of  their  water  for  the  presence  of  Bacillus 
coli  counnunis,  that  great  indicator  of  pollution? 
The  employment  of  a  bacteriologist  who  should 
give  a  daily  report  of  the  number  of  bacteria  to  the 
cubic  centimetre  and  of  the  proportion  of  Bacillus 
coli  communis  would  enable  a  community  to  escape 
a  typhoid  epidemic,  provided  a  pollution  warning 
was  sent  out  to  the  consumers.  The  expense  con- 
nected with  such  an  ofificial  would  be  small  com- 
pared with  the  benefit  resulting. 

We  think  it  strange  that  suits  for  damages  are 
never  entered  against  a  community  or  a  corpora- 
tion which  distributes  Bacillus  typhosus  in  its 
drinking  water.  Both  bodies  are  as  liable,  in  our 
opinion,  as  though  the  affected  members  of  the 
population  had  fallen  over  a  defective  pavement  and 
broken  their  legs.  Possibly  suits  of  this  kind  have 
been  entered,  but  they  are  not  so  numerous  or  made 
so  prominent  as  suits  for  damages  as  the  result  of 
accidents  of  a  surgical  nature.  In  connection  with 
the  Reading  epidemic,  however,  we  find  that  the 
Pennsylvania  State  Department  of  Health  has  been 
active  in  examining  the  water  in  and  about  Read- 
ing since  the  beginning  of  the  outbreak,  and  it  has 
found  that  the  water  from  Maiden  Creek  and  other 
streams  was  highly  polluted.  As  a  result  of  this 
four  farmers  have  been  found  guilty  of  polluting  the 
stream ;  two  b\'  pig  pens,  one  by  a  pig  pen  and  a 
barn  yard,  and  one  by  simple  "pollution."  These 
offenders  were  fined.  Such  methods  are  merely 
makeshifts — locking  the  door  after  the  theft.  What 
is  needed  in  every  community  in  this  country  is  an 
honest  and  competent  bacteriologist,  well  supplied 
with  common  sense,  who  shall  see  to  it  that  notice 
is  given  when  a  water  supply  becomes  polluted. 
Compared  with  the  benefit  to  the  population  the  ex- 
pense would  be  infinitesimal. 


MORE  MEDICAL  "NEWS"  P.V  CABLE. 
In  our  issue  for  December  26th,  in  an  article  en- 
titled "Coals  to  Newcastle,"  we  commented  briefly 
on  a  jiiece  of  "news"  concerning  the  operation  of 
appcndicostomy  that  an  enterprising  London  corre-  > 
spondcnt  had  telegraphed  to  the  Ndw  York  Times, 
which  published  the  dispatch  on  December  19th. 
Last  Sunday,  in  its  section  devoted  to  wireless  and 
cable  dispatches,  the  Times  published  a  cable  mes- 
sage, perhaps  from  the  same  indefatigable  anti- 
quarian,  in   which   the   following   statement  was 


made:  "The  Lancet  this  week  contains  a  paper  read 
by  Dr.  C.  B.  Keetley,  senior  surgeon  at  the  West 
London  Hospital,  before  the  Surgical  Section  of  the 
Royal  Society  of  Medicine,  on  why  and  how  the 
surgeon  should  attempt  to  preserve  the  appendix 
vermiformis."  The  remainder  of  the  dispatch  con- 
sists of  a  summary  of  the  article,  dwelling  particu- 
larly on  the  advantage  of  possessing  an  appendix 
in  case  appcndicostomy  should  ever  become  desirable. 
"Dr.  Keetley's  experience,"  says  the  correspondent, 
"is  summed  up  in  the  phrase  'An  appendix  trans- 
planted is  an  appendix  disarmed."  " 

Now,  all  this  may  be  A^ery  interesting  to  the  gen- 
eral public,  but  it  is  not  very  new,  for  in  a  Caven- 
dish Lecture,  delivered  more  than  a  year  ago  {West 
London  Medical  Journal,  1907,  page  17),  Mr.  Keet- 
ley suggested  "parietal  transplantation"  of  the  ap- 
pendix in  such  cases  of  appendicular  disease  as, 
while  calling  for  surgical  intervention,  might  admit 
with  safety  of  the  procedure  of  anchoring  the  ap- 
pendix in  the  abdominal  wall,  where,  he  intimated, 
it  might  at  any  time  be  turned  to  account  by  open- 
ing it  and  using  it  as  a  channel  for  irrigation  of  the 
colon.  We  do  not  suppose  that  at  so  late  a  date  as 
January  2,  1909,  the  Lancet  has  reproduced  that 
Cavendish  Lecture,  but  the  Times's  corresf>ondent 
fails  to  show  that  there  is  anything  in  the  Lancet 
article  that  could  not  have  been  gathered  from  the 
lecture.  At  the  time  of  this  writing,  of  course,  the 
Lancet  of  January  2d  has  not  reached  us,  but  it  may 
safely  be  said  that  the  newspaper  correspondent  has 
missed  the  point  of  anything  new  and  important 
which  it  may  contain  concerning  the  advantages  of 
preserving  the  vermiform  appendix  for  the  purposes 
of  an  ulterior  appendicostomv. 


STATE  LICENSING  BOARDS. 

The  opinion  seems  to  be  gaining  ground  that  the 
State  examining  and  licensing  boards  are  not,  on 
the  whole,  doing  the  work  expected  of  them  in  a 
manner  altogether  satisfactory  to  the  profession.  Of 
late  there  have  appeared  several  notable  publications 
on  the  subject.  Among  them  is  a  paper  by  Dr. 
Willis  G.  Tucker,  professor  of  chemistry  in  the  Al- 
bany Medical  College,  entitled  On  State  Licensing 
Examinations  and  State  Control  in  Medicine.  It 
appeared  in  the  December  issue  of  the  Bulleti)i  of 
the  American  Academy  of  Medicine.  In  that  paper 
it  is  not  for  the  first  time  that  Dr.  Tucker  criticises 
the  examinations  as  they  are  conducted  by  some  of 
the  boards,  and  we  have  before  had  occasion  to  com- 
mcru:l  his  criticisms.  The  burden  of  them  is  that 
certain  questions  on  the  examination  papers  are  un- 


January  9,  1909.  J 


EDITORIAL  ARTICLES. 


77 


fair  and  of  no  value  whatever  in  ascertaining  a  can- 
didate's real  qualifications  as  a  practitioner  of  medi- 
cine, their  sole  result  being  to  test  the  fleeting  mem- 
ory of  a  crammer. 

In  his  customary  temperate  manner,  Dr.  Tucker 
points  to  some  examples  of  questions  which  he  re- 
gards as  objectionable,  and  from  his  pertinent  com- 
ments we  may  cite  the  following:  ""A  person  may 
be  a  very  competent  practitioner  of  medicine  and 
yet  unable  to  say  very  much  about  "valence'  or  the 
'four  functions  of  a  symbol'  (So.  Dak.  exam.,  Jan., 
1908),  though  a  pupil  fresh  from  a  high  school 
course  might  find  no  difficulty  in  answering  such 
questions."  "Such  questions  as  What  is  the  rarest 
element,  the  heaviest  metal?  etc.,  should  not  be 
given.  Probably  no  one  knows,  and  if  any  one  does 
it  is  of  little  interest  or  importance.''  "Questions 
involving  methods  of  manufacture  of  chemical  and 
medicinal  compounds  are  seldom  justifiable.  For 
example,  'How  is  tartar  emetic  made?'  (Michigan, 
June,  1908).  It  never  is  made  either  by  the  physi- 
cian or  pharmacist,  and  no  process  of  manufacture 
is  given  in  the  U.  S.  Pharmacopoeia." 

Much  more  radical  is  a  ponderous  pamphlet  (of 
200  pages)  by  Dr.  P.  C.  Remondino,  ex-president 
of  the  State  Medical  Society  of  California,  professor 
of  history  of  medicine  and  of  medical  bibliography 
in  the  College  of  Physicians  and  Surgeons  of  Los 
Angeles,  etc.,  entitled  Soiie  Random  Thoughts  and 
Reflections  on  the  Methods  and  Uses  of  State 
Boards  of  Medical  Examiners,  etc.  From  the  lite- 
rary point  of  view  this  production  is  peculiar,  but 
it  contains  some  very  effective  remarks.  Dr.  Remon- 
dino would  do  away  with  the  whole  system,  as  we 
understand  him,  and  he  virtually  charges  a  partic- 
ular State  board  with  exercising  favoritism  in  some 
cases  and  seeking  to  gratify  malice  in  others.  He 
blames  the  Association  of  American  ISIedical  Col- 
leges in  great  measure  for  the  objectionable  features 
of  the  work  of  State  examining  boards. 

It  is  in  California  that  the  battle  seems  to  be 
raging  fiercest.  Another  physician  of  that  State, 
Dr.  F.  C.  E.  Mattison,  of  Pasadena,  a  member  of 
the  California  State  Board  of  Medical  Examiners, 
attempts  to  tell  w'hy  it  is  that  so  many  applicants  fail 
to  pass  that  board's  examinations.  His  article  ap- 
pears in  the  December  number  of  the  Southern 
California  Practitioner.  It  is  largely  illustrated  by 
citations  of  certain  applicants'  more  or  less  stupid 
answers  to  printed  questions.  One  of  them  does  not 
seem  to  us  so  very  foolish.  The  candidate  was  re- 
quired to  describe  the  movements  of  the  intestines, 
and  his  answer  was :  "The  movement  is  a  peristaltic 
action.  A  moving  up  and  down — look  as  if  they 
were  crawling  over  each  other."    We  should  not 


mark  a  man  very  low  for  such  an  answer.  It  is  to 
be  hoped  that  the  whole  controversy  will  result  in 
some  decided  improvements  in  the  methods  of  State 
boards. 


THE  KENTUCKY  STATE  BOARD  OF 
HEALTH. 

It  is  with  reason  that  our  professional  brethren 
of  Kentucky  regret  the  recent  resignation  of  Dr. 
Joseph  jNI.  Mathews  as  president  and  member  of  the 
board,  and  not  they  alone,  but  also  the  community 
in  that  State,  as  is  shown  by  an  editorial  published 
in  the  Courier-Journal  for  December  27th  and 
quoted  in  the  January  number  of  the  Louisville 
Monthly  Journal  of  Medicine  and  Surgery,  w'hich 
journal  also  publishes  resolutions  adopted  by  the 
Jefiferson  County  Medical  Society  requesting  the 
governor  of  the  State  to  defer  action  upon  the  resig- 
nation and  requesting  Dr.  Mathews  to  withdraw  it 
and  '"continue  to  serve  the  people  and  the  medical 
profession  of  the  State  as  heretofore."  The  reso- 
lutions, introduced  by  Dr.  Lewis  S.  McMurtry,  were 
passed  unanimously,  and  it  is  to  be  hoped  that  their 
purpose  will  be  accomplished.  Dr.  Mathews  has 
held  his  office  for  sixteen  years.  He  is  still  at  the 
height  of  his  intellectual  powers,  and  the  State  can 
ill  afford  to  dispense  with  his  great  knowledge  of 
affairs  and  his  sound  judgment  as  an  officer  of 
health.  W'^e  trust  that  matters  may  be  so  arranged 
that  he  will  find  himself  continuing  in  the  duties  of 
the  office,  and  such,  we  feel  sure,  is  the  wish  of  all 
who  know  him. 


THE  MESSINA  DISASTER. 
Xot  the  least  important  feature  of  the  appalling 
disaster  which  has  overtaken  a  portion  of  Italy  is 
the  destruction  of  the  Royal  University  of  Messina, 
the  Faculty  of  Medicine  and  Surgery  of  which  re- 
cently consisted  of  such  men  as  Giuseppe  Ziino,  .An- 
tonio Zincone,  Giovanni  W^eiss.  Pasquale  Ferraro, 
Erasmo  Scimemi,  Arturo  Guzzoni  degli  Ancarani, 
Gaspare  D'Urso,  Francesco  Sanfelice,  Umberto 
Gabbi,  Annibale  Salomoni,  Giovanni  Melle,  and 
Agatino  Barbera.  A  considerable  school  of  medi- 
cine is  wiped  out.  and  it  is  probable  that  all  these 
men  have  perished,  so  that  the  flower  of  the  medical 
profession  of  the  stricken  district  is  no  longer  left 
to  care  for  the  survivors.  Fortunately,  medical  aid 
from  without  the  afflicted  area  has  been  promptly 
furnished,  largely  as  the  result  of  American  gen- 
erosity, and  there  need  be  but  little  fear,  we  think, 
that  the  sanitary  problems  consequent  on  the  dis- 
aster will  be  met  intelligently  and  energetically. 


78 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


Changes  of  Address. — Dr.  ilciiry  C.  Becker,  to  142 
West  One  Hundred  and  Fourth  Street,  New  York. 

Popularizing  Medical  Greek.  —Many  New  York  phy- 
sicians liave  received  copies  of  Ur.  Achilles  Rose's  work 
on  Medical  Greek  tlirough  the  courtesy  of  Messrs.  Elmer 
and  Amend. 

A  Charity  Fair  for  the  People's  Hospital  will  be  held 
in  tl.e  Twenty-second  Regiment  Armory  from  February 
20tii  to  27th.  Tnis  hospital  is  situated  at  203  Second  Ave- 
nue, Nciv  York. 

The  Pennsylvania  State  Board  of  Medical  Examiners 
has  granted  licenses  to  practice  medicine  in  tlie  State  of 
Pennsyl\ania  to  sixty-seven  candidates,  as  a  result  of  the 
Deccmlicr  examinations. 

The  Ambulance  Service  of  Roosevelt  Hospital,  New 
York,  is  to  be  abolished  on  March  i,  190Q.  As,  a  result  of 
this,  it  is  said  that  a  new  ambulance  district  will  be  created 
for  lieiievue  Hospital. 

Ophthalmology. — This  periodical,  which  was  for- 
merly published  in  Milwaukee,  Wis.,  will  hereafter  be  pub- 
lished in  Seattle,  Wash.  The  publication  offices  w  ill  be  in 
the  Wiiite  Buildinp,  corner  of  Fourth  Avenue  and  Union 
Street. 

The  Cost  of  Tuberculosis  in  New  York  State.— It  is 

estimated  by  the  State  Board  of  Charities  that  the  annual 
cost  of  tuberculosis  in  this  State  is  approximately  $63,000,- 
000.  This  includes  the  cost  of  workers  prematurely  lost 
In  the  State. 

Officers  of  the  Philadelphia  Medical  Examiners'  As- 
sociation.— The  following  officers  were  elected  at  a  re- 
cent meeting  of  the  association  :  President,  Dr.  George  fi. 
Clark :  vice-president,  Dr.  Samuel  E.  Walker ;  treasurer. 
Dr.  George  D.  Morton;  secretary,  Dr.  Francis  S.  Ferris. 

The  Syracuse,  N.  Y.,  Academy  of  Medicine.— At  the 
regular  meeting  of  this  academy,  held  on  Tuesday  evening, 
January  5th,  the  retiring  president.  Dr.  F.  W.  Sears,  deliv 
ered  an  address,  and  reports  were  read  of  the  health  com- 
mittee and  the  special  committee  on  rooms  and  sectional 
meetings. 

The  Buffalo,  N.  Y.,  Academy  of  Medicine.— At  the 

regular  meeting  of  this  academy,  held  on  Tuesday  evening, 
January  5th,  Dr.  Edward  H.  Ochsncr,  of  Chicago,  read  a 
paper  entitled  Surgical  Treatment  of  Chronic  Arthritis. 
The  discussion  was  opened  by  Dr.  Bernard  Bartow  and 
Dr.  Prcscott  Le  Breton. 

The  Harvey  Society  Lectures.— The  seventh  lecture 
in  the  cour.se  will  be  delivered  on  Saturday,  January  gth,  at 
8:30  p.  m.,  at  the  New  York  Academy  of  Medicine.'by  Pro- 
fessor J.  B.  Leathes.  of  the  Lister  Institute  of  Preventive 
Medicine,  London.  The  sitbjcct  will  be  The  Relation  of 
the  Liver  to  the  Metabolism  of  Fat. 

The  Medical  Society  of  the  County  of  Lewis,  N.  Y., 
will  meet  in  annual  session  at  Lowviile  on  Tuesday,  Janu- 
ary I2th.  A  good  programme  has  been  provided,  and  the 
meeting  will  probably  be  both  interesting  and  instructive. 
Full  information  regarding  the  meeting  can  be  obtained 
from  the  secretary  of  the  society.  Dr.  H.  A.  Pawling,  Low- 
viUe,  N.  Y. 

Dr.  Thomas  Morgan  Rotch,  professor  of  p;cdiatrics  at 
Har\;ird  Universitv,  delivered  a  lecture  to  the  students  of 
the  New  York  University  and  Bellcvue  Hospital  Medical 
College  in  Professor  Will  iam  P.  Northrup's  usual  hour,  on 
Tuesday,  January  5th.  The  subject  was  Living  Anatomv  , 
Its  Practical  Utility  in  the  Safeguarding  of  Early  Life. 
The  lecture  was  illustrated  by  lantern  slides  and  the  epi- 
diascope. 

Trachoma. — At  a  recent  meeting  of  the  Northwestern 
Meilic.il  Socii'ty.  Philadelphia,  the  evening  was  devoted  to 
a  consideration  of  the  subject  of  trachoma.  Dr.  C.  P. 
Franklin  read  a  paper  entitled  The  Public  Management  of 
Trachoma  as  a  Sociological  Problem.  The  general  discus- 
sion was  opened  by  Dr.  G.  E.  de  Scliwcinitz,  by  invitation, 
and  imrticipatcd  in  hy  over  twenty  invited  guests  and  mem- 
bers of  the  society. 

Contagious  Diseases  in  Chicago.— The  following  cases 
of  communicable  diseases  were  reported  to  the  Department 
of  Health  during  the  week  ending  December  26,  igoS: 
Diphtheria,  187  cases;  scarlet  fever,  158  cases;  measles,  89 
cases;  cliickcnpox,  6j  cases;  pneumonia,  12  cases;  typhoid 
fever,  41  cases;  whooping  cough,  11  cases:  tuberculosis.  65 
cases;  purperal  fever,  i  case;  di-eases  of  minor  importance. 
18  cases;  total,  644  cases. 


College  of  Physicians  of  Philadelphia. — At  a  stated 

meeting  held  on  Wednesday  evening,  January  6th,  Dr. 
John  H.  Gibbon  read  a  memoir  of  the  late  Dr.  John  H. 
Packard,  and  Dr.  George  E.  Pfahler  read  a  paper  entitled 
The  Rontgen  Rays  as  an  Aid  in  the  Diagnosis  of  Carci- 
noma of  the  Stomach,  which  was  illustrated  by  lantern 
slides.  The  librarian  annouiiccd  the  addition  of  seventy 
volumes  to  the  library  during  December. 

The  Presidency  of  the  Kentucky  State  Board  of 
Health.— It  is  reported  that  Dr.  J.  M.  Matthews,  who 
recently  resigned  as  president  of  the  board,  has  been  pei- 
suaded  by  Governor  Willson  and  a  majority  of  the  physi- 
cians of  I^ouisville  to  remain  in  the  position  until  a  suitable 
successor  can  be  decided  upon.  Every  effort  is  being  made 
to  induce  Dr.  Matthews  to  reconsider  his  resignation,  but 
at  present  he  says  that  he  will  hold  the  position  only 
temporarily. 

A  Rabies  Quarantine  in  Pennsylvania. — It  is  reported 
that  three  counties  in  the  western  part  of  Pennsylvania 
have  been  quarantined  on  account  of  the  prevalence  of  hy- 
drophobia in  that  locality.  More  than  a  hundred  persons 
have  been  bitten.  One  death  has  occurred,  sixteen  danger- 
ous patients  are  in  the  Pasteur  Institute  in  Pittsburgh,  and 
about  twenty  more  are  waiting  to  get  in.  The  dogs  are 
being  rapidly  killed  off,  o\er  five  hundred  having  been 
killed  so  far  in  the  three  infected  counties. 

The  New  York  Academy  of  Medicine.— A  stated 
meeting  of  the  academy  was  held  on  Thursday  evening, 
January  7th.  After  the  reading  of  the  annual  reports,  the 
president,  Dr.  John  A.  Wyeth,  presented  a  synopsis  of  two 
years'  work  of  the  academy.  Under  the  auspices  of  the 
Section  in  Public  Health,  George  A.  Soper,  I^i.  D.,  presi- 
dent of  the  Metropolitan  Sewerage  Coinmission,  read  a  pa- 
per entitled  The  Pollution  of  our  Tidal  Harbors.  A  col- 
lation was  served  at  the  close  of  the  meeting. 

The  American  Red  Cross  Society  announces  that  con- 
tributions for  the  relief  of  the  earthquake  sufferers  in  Italy 
so  far  received  amount  to  $400,000,  of  which  $320,000  has 
been  sent  to  the  American  embassy  in  Rome.  Subscrip- 
tions are  still  being  received,  despite  the  fact  that  Congress 
has  made  an  appropriation  of  $800,000  for  the  purpose. 
New  York's  contributions  amount  to  $165,000,  which  is  the 
largest  amount  received  from  any  one  State;  California 
comes  second  with  contributions  amounting  to  $80,000. 

The  Elmira,  N.  Y.,  Academy  of  Medicine. — The  an- 
nual meeting  of  this  academy  was  held  in  the  society  rooms 
in  the  Federation  Building  on  Wednesday,  January  6th.  In 
addition  to  the  address  of  the  president,  Dr.  Ross  G.'Loop, 
the  programme  included  the  following  papers :  Digestive 
Disturbances  from  Eye  Strain,  by  Dr.  G.  M.  Case;  Pneu- 
monia, by  Dr.  Isabel  Stanley;  Gunshot  Wounds  of  the  Ab- 
domen, by  Dr.  Arthur  W.  Booth ;  Abdominal  Pain,  by  Dr. 
A.  H.  Barker ;  and  Accouchement  Force,  by  Dr.  H.  W. 
Fudge. 

The  Association  of  Tuberculosis  Clinics,  New  York, 

held  a  meeting  in  the  Waldorf-Astoria  on  Tuesday,  De- 
cember 5lh.  Governor  Hughes  was  the  principal  speaker, 
his  subject  being  The  Next  Step  in  the  Fight  Against 
Tuberculosis  in  New  York  City.  This  association  was 
formed  about  a  year  ago,  its  object  being  to  reach  ever)- 
case  of  tuberculosis  in  the  city.  At  present  about  thirty- 
eight  thousand  cases  are  receiving  attention.  Dr.  James 
Alexander  Miller  is  president  of  the  association,  and  Dr. 
J.  H.  Huddlcston  is  vice-president. 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  January  16,  1909: 

Monday,  January  uth. — Section  in  General  Medicine,  Col- 
lege of  Physicians. 

Tuesday,  January  ijlh. — Philadelphia  P;ediatric  Society. 

Wednesday,  January  — Philadelphia  County  Medical 
Society. 

Thursday,  January  14th. — Pathological  Society;  Section 

Meeting,  Franklin  Institute. 
i'"riday,  January  15th. — .American  Philosophical  Society. 

The  Philadelphia  Academy  of  Surgery. — .\t  a  stated 
meeting  of  this  academ\.  held  on  Monday  evening.  Janu- 
ary 4th,  the  programme  consisted  of  the  reports  of  case*. 
Dr.  Francis  T.  Stewart  reported  a  case  of  congenital  hernia 
of  the  umbilical  cord,  a  case  of  hernia  of  the  ileocjecal 
fossa,  and  a  case  of  properitoncal  hernia.  Dr.  Robert  G.  Lc 
Conte  reported  a  case  of  ureteral  calculus.  Dr.  Henry  R. 
Wharton  reported  three  cases  of  fracture  of  the  pelvis 
Dr.  William  J.  Taylor  reported  a  case  showing  the  effecl 
of  X  ray  treatment  for  goitre. 


January  9.  1909.] 


NEIVS  ITEMS. 


79 


The  Mortality  of  New  Orleans,  L^. — During  the 
month  of  November,  1908,  there  were  reported  to  the 
Board  of  Heahh  of  the  City  of  Xew  Orleans  576  deaths 
from  all  causes,  360  white  and  216  colored.  The  annual 
death  rate  in  a  thousand  population  was  16.74  for  the  white 
population,  27.87  for  the  colored,  and  19.69  for  the  total 
white  and  colored  population.  There  were  46  still  births, 
2t  white  and  25  colored.  The  total  infant  mortality  was  96; 
82  under  one  year  of  age,  and  14  between  one  and  two  years 
of  age. 

Talbot  County.  Md.,  Medical  Society. — The  annual 
meeting  of  this  society  was  held  in  Easton  recently,  when 
the  following  officers  were  elected :  President,  Dr.  Charles 
H.  Rose,  of  Cordova;  first  vice-president,  Dr.  Charles  F. 
Davidson,  of  Easton ;  second  vice-president.  Dr.  William 
S.  Seymour,  of  Trappe :  secretary  and  treasurer.  Dr.  S. 
Denny  Wilson,  of  Easton :  censor  for  three  years,  Dr. 
Charles  M.  Stelle,  of  Cordova:  censor  for  one  year.  Dr. 
Samuel  C.  Trippe,  of  Royal  Oak:  delegate  to  the  State  as- 
sociation. Dr.  Philip  Lee  Travers.  of  Easton ;  alternate,  Dr. 
James  A.  Stevens,  of  Easton. 

The  Health  of  Pittsburgh. — During  the  week  ending 
December  19,  1908.  the  following  cases  of  transmissible 
diseases  v.ere  reported  to  the  Bureau  of  Health  :  Smallpox, 
I  case,  o  deaths ;  chickenpox,  22  cases,  o  deaths :  typhoid 
fever,  31  cases,  6  deaths;  scarlet  fever,  35  cases.  3  deaths; 
diplitheria,  19  cases,  3  deaths;  measles,  21  cases,  i  death; 
whooping  cough,  18  cases,  o  deaths ;  pulmonary  tubercu- 
lo>is,  19  cases,  10  deaths.  The  total  deaths  for  the  week 
numbered  144,  in  an  estimated  population  of  565.000,  cor- 
responding to  an  annual  death  rate  of  13.25  in  a  thousand 
population.  During  .August  there  were  651  deaths,  a  mor- 
tality of  13.83  in  a  thousand  population. 

Wills  Hospital  Ophthalmic  Society,  Philadelphia. — A 
stated  meeting  of  this  society  was  held  Tuesday  afternoon, 
January  5th.  A  paper  entitled  A  Case  of  Glioma  was  read 
by  Dr.  William  Zentmayer  and  discussed  by  Dr.  S.  Lewis 
Ziegler.  Dr.  Samuel  D.  Risley  presented  some  clinical 
memoranda.  Dr.  Harold  Goldberg,  the  pathologist,  detailed 
the  findings  in  a  .case  of  ciliary  wound  with  strange  path- 
ological characteristics :  the  clinical  notes  were  given  by 
Dr.  Burton  Chance,  and  the  discussion  was  opened  by  Dr. 
H.  Dewey.  Dr.  Norman  Risley  reported  a  case  of  corneal 
.-taphyloma  and  exhibited  the  patient.  Dr.  McCluney  Rad- 
cliffe  opened  the  discussion.  Dr.  William  Campbell  Posey 
read  a  paper  entitled  Observations  on  Congenital  .Anom- 
alies of  the  Iris,  and  exhibited  a  patient  with  coloboma. 

The  Mortality  of  San  Francisco. — During  the  month 
of  October,  1908,  there  were  reported  to  the  Health  Depart- 
ment of  the  City  and  County  of  San  Francisco,  Cal.,  498 
deaths  from  all  causes,  corresponding  to  an  annual  death 
rate  of  11.60  in  a  thousand  population.  The  annual  birth 
rate  in  a  thousand  population  was  15.96.  The  causes  of 
■death,  according  to  the  international  classification,  were  as 
follows  :  General  diseases,  139  deaths :  diseases  of  the  ner- 
vous system,  51  deaths;  diseases  of  the  circulatory  system, 
63  deaths;  diseases  of  the  respiratory  system,  54  deaths; 
diseases  of  the  digestive  system.  45  deaths ;  diseases  of  the 
genitourinary  system,  45  deaths:  childbirth,  6  deaths;  dis- 
eases of  the  skin,  i  death:  malformations,  4  deaths;  early 
infancy,  26  deaths:  old  age,  6  deaths:  violence,  49  deaths; 
ill  defined  diseases,  9  deaths. 

The  Officers  of  the  Sections  of  the  New  York  Acad- 
emy of  Medicine  for  the  year  1909  are  as  follows: 
Dcnnatology — Dr.  Sigmund  PoUitzer,  chairman,  and  Dr. 
C.  M.  Williams,  secretary;  Surgery — Dr.  Ellsworth  Eliot, 
Jr..  chairman,  and  Dr.  H.  H.  M.  Lewis,  secretary ;  Neu- 
rology and  Psychiatry — Dr.  W.  B.  Pritchard,  chairman,  and 
Dr.  M.  G.  Schlapp.  secretary:  Public  Health— Dr.  L.  F. 
Frissell,  chairman,  and  Dr.  R.  S.  Hooker,  secretary; 
Pardiatrics — Dr.  John  Howland.  chairman,  and  Dr.  E.  Long, 
secretary ;  Otology — Dr.  Robert  Lewis,  chairman,  and  Dr. 
J.  B.  Rae,  secretary;  Ophthalmology — Dr.  W.  E.  Lambert, 
chairman,  and  Dr.  H.  W.  Wootton,  secretary ;  Medicine — 
Dr.  F.  P.  SoUey,  chairman,  and  Dr.  C.  N.  B.  Camac,  sec- 
retary: Genitourinary  Diseases — Dr.  Martin  Ware, 
chairman,  and  Dr.  V.  C.  Pedersen,  secretary;  Orthof^cvdic 
Surgery— Dt.  Charles  H.  Jaeger,  chairman,  and  Dr.  Charl- 
ton Wallace,  secretary ;  Laryngology  and  Rhinology — Dr. 
Harmon  Smith,  chairman,  and  Dr.  John  J.  McCoy,  secre- 
tary: Obstetrics  and  Gyncecology — Dr.  J.  O.  Polak,  chair- 
man, nnd  Dr.  S.  M.  Brickner.  secretarv. 


The  American  Rdntgen  Ray  Society. — .At  the  annual 

meeting  of  the  society,  held  in  New  York  last  week,  the 
following  officers  were  elected :  President,  Dr..  George  C. 
Johnston,  of  Pittsburgh;  vice-president.  Dr.  William  Allen 
Pusey,  of  Chicago ;  Dr.  Sidney  Lange,  of  Cincinnati ;  Dr. 
A.  W.  Crane,  of  Kalamazoo,  Mich. ;  Dr.  W.  S.  Newcomet, 
of  Philadelphia,  and  Dr.  H.  W.  Van  Allen,  of  Springfield, 
Mass. ;  treasurer,  Dr.  C.  F.  Bowen,  of  Columbus,  Ohio : 
secretary.  Dr.  Percy  Brown,  of  Boston ;  executive  commit- 
tee, Dr.  Alfred  T.  Osgood,  of  New  York,  and  Dr.  Henry 
K.  Pancoast,  of  Philadelphia. 

Infectious  Disease  in  New  York: 

]Vc  arc  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  follozving  statistics  of  nezi' 
cases  and  deaths  reported  for  the  tzuo  zveeks  tnding  Janu- 
ary 2^  igog: 

,  Dec.  26  ,     ,  Tan.  2  , 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis   pulmonalis    384         135         361  172 

Diphtheria    392  37         392  36 

Measles    36g  12         363  16 

Scarlet  fevi-r    2S1  17         296  19 

Smallpo.x   

X'aricella    204  .  .  105 

Typhoid  fever    41  2  48  12 

Whooping  cough   28  3  24  3 

Cerebrospinal  meningitis    5  4  *>  4 

Totals   1.705         210       i,5Q5  262 

Milk  and  Tuberculosis. — The  New  York  Milk  Com- 
mittee held  a  meeting  at  the  American  Museum  of  Natural 
History  in  connection  with  the  International  Tuberculosis 
Exhibit  on  Wednesday  afternoon,  January  6th.  The  fol- 
lowing papers  were  read  and  discussed :  Tuberculosis  In- 
fection as  related  to  the  City's  Milk  Supply,  by  Dr.  .Alex- 
ander Lambert ;  Bovine  Tuberculosis  as  a  Source  of  Human 
Tuberculosis,  by  Dr.  William  H.  Park,  of  the  New  York 
Health  Department ;  Bovine  Tuberculosis— Its  Prevalence 
among  Cattle  Supplying  Milk  to  New  York  City,  by  Dr. 
H.  D.  Gill,  veterinarian  to  the  State  Department  of  Agri- 
culture ;  Lessons  from  the  Chicago  Clean  Milk  Campaign, 
bv  Dr.  B  F.  Biehn,  of  the  Chicago  Health  Department : 
fubercfe  Bacilli  in  Milk,  by  Dr.  Alfred  S.  Hess,  of  the 
New  York  Health  Department;  The  Prevention  of  Tuber- 
culosis Infection  through  Alilk,  bv  Dr.  Charles  E.  North  : 
The  Problem  for  New" York  City^  by  Dr.  Wilbur  C.  Phil- 
lips, secretary  of  the  committee. 

Vital  Statistics  of  New  Jersey. — The  number  of  deaths 
reported  to  the  Bureau  of  Vital  Statistics  of  the  State  of  New 
Jersey  for  the  month  ending  December  15,  1908,  was  2.695. 
Of  the  total  number  of  deaths  564  were  of  children  under 
one  year  of  age ;  198  of  children  between  one  and  five  years 
ot  age;  and  750  of  persons  over  sixty  j'cars  of  age.  The 
principal  causes  of  death  were :  Typhoid  fever,  31  deaths ; 
measles,  11  deaths;  scarlet  fever,  24  deaths;  whooping 
cough,  6  deaths ;  diphtheria,  68  deaths ;  malarial  fever,  i 
death  ;  tuberculosis  of  the  lungs,  283  deaths ;  tuberculosis 
of  other  organs,  40  deaths;  cancer,  141  deaths;  cerebro- 
spinal meningitis,  12  deaths ;  diseases  of  the  nervous  sys- 
tem, 259  deaths ;  diseases  of  the  circulatory  system,  336 
deaths;  diseases  of  respiratory  system  (pneumonia  and 
tuberculosis  excepted),  166  deaths;  pneumonia,  203  deaths; 
infantile  diarrhoea,  98  deaths;  diseases  of  digestive  system 
(i'.ifantile  diarrhoea  excepted),  176  deaths;  Eright's  disease, 
165  deaths;  suicide,  28  deaths;  all  other  causes,  647  deaths. 

Personal. — Dr.  James  R.  Freeland,  of  Philadelphia, 
has  been  appointed  assistant  master  to  the  Rotunda  Hos- 
pital, Dublin,  for  three  years. 

Dr.  Brown  Pusey  has  been  appointed  head  of  the  Depart- 
ment of  Ophthalmology  in  the  Northwestern  Medical 
School,  Chicago,  to  fill  the  position  left  vacant  by  the  re- 
cent resignation  of  Dr.  Casey  E.  Wood. 

The  honorary  degree  of  Doctor  of  Laws  was  conferred 
upon  Dr.  James  Tyson  and  Dr.  Louis  Starr,  both  of  Phila- 
delphia, on  the  occasion  of  the  seventy-fifth  anniversary  of 
Haverford  College. 

Miss  Yvonne  Mason,  daughter  of  Mr.  and  Mrs.  Frederic 
S.  Mason,  of  New  'York,  was  married  in  Paris,  on  Decem- 
ber 29,  1908,  to  Mr.  Jacques  Wesztfried,  of  Vienna. 

Dr.  Arthur  J.  Herzig,  of  New  York,,  has  been  appointed 
adjunct  rhinologist  and  otologist  to  Sydenham  Hospital. 

Dr.  D.  B.  Blake,  of  the  Medical  Department  of  the  Uni- 
versity of  Nashville,  was  recently  presented  with  a  silver 
loving  cup  by  the  members  of  his  class. 


8o 


NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


The   Wayne   County,   Mich.,   Medical   Society. — On 

Monday  evening,  January  4th,  a  general  meeting  of  the  so- 
ciety was  held.  Dr.  B.  D.  Harrison,  secretary  of  the  State 
Board  of  Registration  in  Medicine,  read  a  paper  on  Medi- 
cal Legislation,  and  The  Layman  Practising  Medicine  was 
the  title  of  a  paper  read  by  Dr.  Leartus  Connor.  On  Mon- 
day, January  iith,  the  medical  section  will  hold  a  clinical 
meeting.  On  January  i8th,  a  general  meeting  of  the  society 
win  be  held,  and  the  principal  feature  of  the  programme 
will  be  a  paper  by  Dr.  C.  C.  Frederick,  of  Buffalo,  on  Up 
to  Date  Obstetrics.  The  January  25th  meeting  will  be  held 
in  the  Detroit  Museum  of  Art.  In  addition  to  the  presenta- 
tion of  patients,  the  exhibition  of  specimens,  etc.,  the  pro- 
gramme will  include  a  paper  by  Dr.  W.  B.  Coley,  of  New 
York,  on  The  Mixed  Toxines  of  Erysipelas  and  Bacillus 
Prodigiosus  in  the  Treatment  of  Inoperable  Sarcoma; 
Technique  and  Results. 

The  Mortality  of  Chicago. — During  the  week  ending 
December  26,  1908,  there  were  reported  to  the  Department 
of  Health  of  the  City  of  Chicago  482  deaths  from  all  causes, 
as  compared  with  580  for  the  preceding  week  and  569  for 
the  corresponding  period  in  1907.  The  annual  death  rate 
in  a  thousand  population  was  11.59,  as  against  a  death  rate 
of  14.08  for  the  corresponding  week  last  year.  The  total 
infant  mortality  was  137;  96  under  one  year  of  age,  and  41 
between  one  and  five  years  of  age.  The  principal  causes  of 
death  were:  Apoplexy,  13  deaths;  Bright's  disease,  31 
deaths;  bronchitis,  11  deaths;  consumption,  48  deaths;  can- 
cer, 29  deaths ;  diphtheria,  14  deaths ;  heart  diseases,  49 
deaths ;  influenza,  2  deaths ;  intestinal  diseases,  acute,  33 
deaths;  measles,  3  deaths;  nervous  diseases,  11  deaths; 
pneumonia,  69  deaths;  scarlet  fever,  14  deaths;  suicide,  6 
deaths ;  typhoid  fever,  4  deaths ;  violence,  other  than  sui- 
cide, 31  deaths;  whooping  cough,  2  deaths;  all  other  causes, 
112  deaths. 

The  East  Side  Physicians'  Association,  New  York. — 

A  stated  meeting  (jf  this  association  will  be  held  at  the  Cafe 
Boulevard,  Second  Avenue  and  Tenth  Street,  on  Friday, 
January  15th,  at  8:30  p.  m.  Dr.  E.  W.  Dittrich  will  pre- 
sent a  patient  with  tuberculosis  of  the  hard  palate.  Dr. 
W.  S.  Gottheil  will  demonstrate  the  use  of  solid  carbon 
dioxide.  Dr.  H.  C.  Frauerrthal  will  present  reports  of  cases 
of  hemiplegia  in  children.  The  paper  of  the  evening  will 
be  read  by  Dr.  William  M.  Leszynsky  on  the  Management 
and  Care  of  Patients  with  Hemiplegia  resulting  from  Cere- 
bral Apoplexy.  Among  those  who  will  take  part  in  the 
discussion  are  Dr.  Charles  E.  Quimby,  Dr.  Heinrich  Stern, 
Dr.  Robert  Abrahams,  and  Dr.  H.  C.  Frauenthal.  The  offi- 
cers of  the  association  for  the  year  1909  are  as  follows : 
President,  Dr.  C.  A.  von  Ramdohr ;  first  vice-president,  Dr. 
Charles  Dow  Scott ;  second  vice-president.  Dr.  Max  Ghert- 
ler ;  secretary.  Dr.  Sigmund  Epstein ;  treasurer.  Dr.  1.  Seth 
Hirsch;  trustees,  Dr.  William  M.  Leszynsky,  Dr.  Abram 
Brothers,  and  Dr.  H.  C.  Frauenthal. 

The  Newark,  N.  J.,  Medical  League  held  its  annual 
meeting  on  the  evening  of  December  28,  1908.  Officers  for 
the  ensuing  year  were  elected  as  follows:  Dr.  Herbert  W. 
Long,  president;  Dr.  Nathaniel  G.  Price,  vice-president; 
Dr.  Edwin  Steiner,  treasurer ;  Dr.  Philip  G.  Hood,  record- 
ing and  corresponding  secretary ;  Dr.  Louis  Weiss,  finan- 
cial secretary;  Dr.  Julius  Levy,  reporter.  The  council  will 
consist  of  the  following,  in  addition  to  the  officers  of  the 
league :  Dr.  David  A.  Kraker,  Dr.  Theodore  Teimer,  Dr. 
Armin  Fischer,  Dr.  Victor  Parsonnet,  Dr.  L.  L.  Davidson, 
and  Dr.  Elmanuel  Yadkowsky.  At  the  close  of  the  meeting 
a  banquet  was  served.  Dr.  David  A.  Kraker,  expresident 
of  the  league,  acted  as  toastmaster,  and  in  his  speech  out- 
lined the  growth  of  the  league  during  his  two  terms  of 
office.  Dr.  Louis  Weiss  then  gave  a  brief  history  of  the 
league  since  its  organization,  and  Dr.  Theodore  Teimer 
read  a  paper  on  the  future  of  the  league.  Dr.  Nathaniel  G. 
Price  read  a  humorous  article  on  the  automobile.  Dr. 
Julius  Levy  spoke  on  the  Feeding  of  Infants,  and  remarks 
were  also  made  by  Dr.  Herbert  W.  Long,  Dr.  C.  C.  Beling, 
Dr.  E.  Steiner,  Dr.  Victor  Parsonnet,  Dr.  .\rmin  Fischer, 
Dr.  Emanuel  Yadkowsky,  and  Dr.  IVank  Devlin.  Other 
members  of  the  league  who  were  present  were  Dr.  C.  J. 
Hailperin,  Dr.  B.  E.  Kaplan,  Dr.  C.  Lippe,  Dr.  S.  Hirsch- 
berg.  Dr.  A.  Finkelstein,  Dr.  S.  Smith,  Dr.  M.  Jedel,  Dr. 
B.  H.  Woolff,  Dr.  I.  Kupperman,  Dr.  H.  B.  Kessler,  Dr. 
A.  J.  Mitchell,  Dr.  I.  J.  Rachlin,  Dr  Philip  G.  Hood,  Dr. 
W.  E.  Hitchcock.  Dr.  L.  S.  Blnmenberg.  Dr.  T.  E.  Bleick, 
and  Dr.  William  Buerniann. 


Society  Meetings  for  the  Coming  Week: 

Monday,  Januayy  iith. — New  York  Academy  of  Medicine 
(Section  in  Neurology  and  Psychiatry)  ;  Society  of 
Medical  Jurisprudence,  New  York;  New  York  Oph- 
thalmological  Society;  Society  of  Alumni  of  St.  Mary's 
Hospital,  Brooklyn;  Corning,  N.  Y.,  Medical  Associa 
tion  (annual);  Waterbury,  Conn.,  Medical  Associatioii 
(annual.) 

Tuesday,  January  12th. — New  York  Academy  of  Medicine 
(Section  in  Public  Health)  ;  Medical  Society  of  the 
County  of  Schenectady,  N.  Y.  (annual)  ;  Practitioners" 
Club  of  Jersey  City,  N.  J.;  Medical  Society  of  the 
County  of  Rensselaer,  N.  Y. ;  Buffalo  Academy  of  Med- 
icine (Section  in  Medicine)  ;  Newburgh  Bay  Medical 
Society;  New  York  Obstetrical  Society. 

Wednesday,  January  /j^/j.— New  York  Pathological  So- 
ciety (annual)  ;  New  York  Surgical  Society;  Medical 
Society  of  the  Borough  of  The  Bronx,  New  York; 
Alumni  Association  of  the  City  (Charity)  Hospital, 
New  York ;  Brooklyn  Medical  and  Pharmaceutical  As- 
sociation (annual)  ;  Medical  Society  of  the  County  of 
Richmond,  N.  Y.  (annual.) 

Thursday,  January  14th. — New  York  Academy  of  Medi- 
cine (Section  in  Paediatrics)  ;  Brooklyn  Pathological 
Society ;  Blackwell  Medical  Society  of  Rochester,  N.  Y. 
(annual)  ;  Jenkins  Medical  Association,  Yonkers,  N.  Y. 

Friday,  January  isth. — New  York  Academy  of  Medicine 
(Section  in  Orthopaedic  Surgery)  ;  Clinical  Society  of 
the  New  York  Postgraduate  Medical  School  and  Hos- 
pital ;  East  Side  Physicians'  Association  of  the  City  of 
New  York ;  New  York  Microscopical  Society ;  Brook- 
lyn Medical  Society. 

Meetings  of  Sections  of  the  New  York  Academy  of 
Medicine. — On  Friday  evening,  January  8th,  a  meeting 
of  the  Section  in  Otology  was  held.  Dr.  Edmund  Prince 
Fowler  demonstrated  a  new  method  of  inflating  the  middle 
ear.  Dr.  John  B.  Rae  reported  a  case  of  sinus  thrombosis. 
Dr.  Alfred  Michaelis  reported  a  case  of  necrosis  of  cochlea, 
with  analysis  of  the  auditory  tests.  The  paper  of  the  even- 
ing was  read  by  Dr.  Frank  T.  Hopkins  on  a  Plastic  Mastoid 
Operation :  A  New  Method  of  Operating  in  Acute  Mastoid- 
itis. A  general  discussion  followed,  after  which  an  execu- 
tive session  was  held. 

The  Section  in  Surgery  also  held  a  meeting  on  Friday 
evening,  January  8th.  Dr.  E.  W.  Peterson  presented  a 
patient  with  fractures  of  the  os  magnum.  Dr.  Burton  J. 
Lee  presented  a  patient  showing  acute  intestinal  obstruction 
from  a  band.  Dr.  Charles  H.  Peck  exhibited  a  patient 
upon  whom  he  had  performed  direct  blood  transfusion  for 
gastric  haemorrhage.  Dr.  Joseph  Wiener  exhibited  a  series 
of  X  ray  pictures,  and  Dr.  W.  S.  Schley  presented  a  speci- 
men of  kidney  with  pyonephrosis  containing  calculus.  Two 
papers  were  read,  one  entitled  Operation  of  Direct  Blood 
Transfusion,  by  Dr.  J.  A.  Hartwell,  and  the  other  by  Dr. 
I.  Levin  on  Plastic  Surgery  of  the  Bloodvessels  and  Direct 
Transfusion  of  the  Blood. 

Tlie  Section  in  Neurology  and  Psychiatry  will  meet  on 
Monday  evening.  January  nth.  The  programme  will  con- 
sist of  the  exhibition  of  patients  and  the  presentation  of 
reports  of  cases.  Dr.  C.  Floyd  Haviland,  of  Ward's  Island, 
will  present  a  patient  showing  Korsakoff's  syndrome,  and 
three  patients  with  atypical  alcoholic  psychoses.  Dr.  J.  J. 
Lynch,  of  Bridgeport,  Conn.,  will  present  a  patient  witii 
taboparesis,  and  another  patient  with  cerebrospinal  syphilid.. 
Dr.  D.  E.  Hoag  will  exhibit  a  patient  with  infantilism.  Dr. 
J.  J.  McPhee  will  report  a  case  of  brain  tumor,  and  Dr. 
Max  G.  Schlapp  will  report  a  case  of  arsenical  poisonin;^. 

The  Section  in  Pediatrics  will  hold  a  clinical  meeting  ou 
Thursday  evening,  January  14th.  Among  those  who  will 
present  reports  of  cases  and  exhibit  patients  arc  Dr.  Row- 
land G.  Freeman.  Dr.  Charles  Gilniore  Kerley,  Dr.  Joseph 
E.  Winters,  Dr.  John  llaviland,  Dr.  William  P.  Northruv.. 
Dr.  Edward  D.  I'isher.  Dr.  Henry  Dwight  Chapin,  Dr.  L. 
E.  La  Fetra,  and  Dr.  Josephine  Hemcnway. 

The  Section  in  Orthopedic  Surgery  will  meet  on  Friday 
evening,  January  15th.  Dr.  Russell  A.  Hibbs  will  present 
a  final  report  on  the  cases,  previously  shown,  of  congenit.'il 
dislocation  of  the  hip.  Dr.  Leo  Buerger  will  read  a  paper 
entitled  Bone  Sarcoma  from  the  Pathological  Aspect,  which 
will  be  illustrated  with  lantern  slides.  Dr.  Fred  H.  .Albec 
will  read  a  paper  describing  a  new  operation  for  deformi- 
ties and  osteoarthritis  of  the  hip. 


January  9,  loc  ^i  ] 


PITH  OF  CURRENT  LITERATURE. 


81 


Jitjj  at  €nmni  f  iterattirt. 

BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

December  31.  1908. 

1.  Tuberculosis  of  the  Peritonaeum,  By  F.  B.  Lund. 

2.  Dementia  Pr.xcox,  Paranoid,  Associated  with  Bronchi- 

crtatic  Lung  Disease  and  Terminated  by  Brain  Ab- 
scesses  (Micrococcus  Cafarrhalis) , 

By  E.  E.  SouTH.ARD  and  J.  B.  Ayer,  Jr. 

3.  Morris's  Point  of  Tcnderncis  as  an  Aid  in  Diagnosis, 

By  J.  C.  Hubbard. 

3.  Morris's  Point  of  Tenderness  as  an  Aid  in 
Diagnosis. — Hubbard  states  that  the  abdominal 
lymphatic  elands,  becomin"-  .secondarily  inflamed, 
cause  tender  areas.  The  area  found  tender  on  ex- 
amination is  somewhat  of  a  guide  to  the  organ  pri- 
marily infected,  and,  th.erefore,  in  certain  cases 
may  be  an  aid  in  distinctive  diagnosis.  In  acute  ap- 
pendicular inflammation  tenderness  at  Morris's 
point  is  of  less  importance  than  the  symptoms 
caused  by  the  appenclix  itself,  while  in  chronic  ap- 
pendicular inflammation  tenderness  at  ?iIorris's 
point  may  beA)f  distinct  diagnostic  value.  Tender- 
ness at  this  point,  even  though  the  only  physical 
sign,  makes  the  diagnosis  of  appendicular  inflam- 
mation by  the  rtile  of  chance  probable ;  when  com- 
bined with  tenderness  at  McBurney's  point,  the  di- 
agnosis becomes  more  certain.  Its  absence  does  not 
rule  out  appendicitis,  and  it  may  occur  in  other 
conditions.  Morris  has  described  his  point  as  fol- 
lows :  "Instead  of  going  out  on  the  line  to  a  point 
an  inch  and  a  half  from  the  anterior  superior  spine 
of  the  ilium,  come  back  on  the  line  to  a  point  sit- 
uated an  inch  and  a  half  from  the  navel.  Here  we 
find  another  tender  point  of  definite  diagnostic 
value."  The  point  here  described  has  reference  to 
the  right  lumbar  ganglia  of  the  sympathetic  nerv- 
ous system,  and  notable  tenderness  of  these  ganglia 
has  a  diagnostic  value. 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

January  2,  1909. 

1.  Principles    Underlying    the    Operative    Treatment  of 

Strabismus,  Edward  Jackson. 

2.  Tincture  of  Strophanthus  and  Strophanthin, 

By  Robert  A.  Hatcher  and  Harold  C.  Bailey. 

3.  Departments  of  Hygiene  under  Boards  of  Education, 

By  Luther  H.  Gulick. 

4.  The  Causes  and  Treatment  of  Backache  in  Women, 

By  Leon  F.  Garrigues. 

5.  Typhoid  Agglutinin  Reaction  in  a  Case  of  Epidemic 

Cerebrospinal  Meningitis, 

By  WiLHEi.M  Becker  and  George  C.  Ruhland. 

6.  To.xic  Effects  from  Bismuth  Subnitrate.  with  Reports 

of  Cases  to  Date,  By  Emil  G.  Beck. 

7.  A  Deceptive  Case  of  Leprosy, 

By  Charles  J.  White  and  Oscar  Richardson. 
S.    The  Hygiene  of  Tuberculosis, 

By  Clarence  L.  Wheaton. 

9.  The  Conjunctival  Tuberculin  Reaction  as  a  Means  of 

Diagnosis  and  Control, 

By  Frank  Smithies  and  R.  E.  W.\lker. 

10.  Eiirly  Diagnosis  of  Tuberculosis  as  a  Measure  of  Con- 

trol, Especially  the  Relation  of  Tuberculin  thereto. 

By  William  A.  Evans. 

11.  Diagnostic  Value  of  the  Cutaneous  and  Conjunctival 

Tuberculin  Reactions, 

By  William  Engelbach  and  J.  W.  Shankland. 

12.  Condition  of  the  Peripheral  Blood  Vessels  in  Shock, 

By  M.  G.  Seelig  and  G.  T.  Lyon. 

I.  Principles  Underlying  the  Operative  Treat- 
ment of  Strabismus. — Jackson  remarks  that  tlie 
ocular  movements  are  executed  and  controlled  by 
nerve  impulses,  originated  and  guided  by  visual  im- 
pressions.   When  these  nerve  impulses  are  faulty 


and  cannot  otherwise  be  sufficiently  modified  to  pro- 
duce normal  movements,  readjtistment  by  operative 
treatment  may  be  resorted  to.  This  readjustment 
may  be  accomplished  :  ( i )  By  giving  greater  effect 
to  certain  impulses,  advancing  the  insertion  of  a 
muscle;  (2)  by  diminishing  the  effect  of  certain  im- 
pulses through  tenotomy,  setting  back  the  insertion 
of  a  muscle;  (3)  by  transferring  the  impulses,  so 
that  they  will  produce  results  different  from  those 
to  which  they  were  originally  directed,  lateral  dis- 
placement of  insertions;  (4)  by  combining  two  or' 
all  of  these  changes.  Tenotomy  allows  retraction  of 
the  tenotomized  muscle  and  also  retraction  of  its  op- 
ponent, which  is  no  longer  resisted.  The  increase  of 
power  secured  by  muscular  advancement  may  be 
temporary  or  illusory.  Only  modified  nerve  impulses 
are  required  to  increase  or  diminish  the  power  of 
any  muscle.  All  muscle  operations,  temporarily  sus- 
pending function,  are  followed  by  degenerative 
changes  in  the  muscle  substance.  Operation  on  a 
muscle  should  be  undertaken  only  after  careful  con- 
sideration of  all  the  movements  in  which  it  takes 
part,  either  as  a  primary  or  secondary  rotator  of  the 
eyeball.  The  more  important  object  in  the  treatment 
of  strabismus  is  to  bring  about  a  muscular  equilib- 
rium. Static  equilibrium  so  that  muscular  rest  will 
leave  the  two  eyes  fixing  the  same  point  in  a  central 
position,  and  dynamic  equilibrium,  balanced  move- 
ments, easy  binocular  fixation  are  of  greatest  useful- 
ness around  this  central  point.  A  less  important  ob- 
ject is  to  secure  movements,  from  this  central  point, 
of  greatest  range  and  with  the  least  expenditure  of 
effort.  Where  these  objects  are  not  attainable  by  in- 
creasing the  power  of  a  certain  muscle  or  muscles 
they  are  to  be  sought  by  diminishing  the  power  of 
opposing  muscles  or  by  transference  of  muscular 
power  from  one  movement  to  another. 

2.  Strophanthus  and  Strophanthin. — Hatcher 
and  Bailey  describe  their  experiments  on  animals 
with  strophanthus  and  strophanthin,  and  conclude 
that  the  dosage  and  the  proper  mode  of  exhibiting 
strophanthus  and  strophanthin  require  clinical  in- 
vestigation. The  action  of  strophanthin  may  be  elic- 
ited promptly  in  suitable  cases  by  injecting  it  sub- 
cutaneously.  Three  tenths  to  half  a  milligramme  of 
the  crystallized  strophanthin  in  sterile  (boiled)  salt 
solution,  I  in  4,000,  may  be  injected  deeply  into  the 
gluteal  muscle  once  in  twenty-four  hours  without 
fear  of  abscess  formation  or  other  side  actions.  The 
single  adult  dose  of  crystallized  strophanthin  by  the 
mouth  is  about  5  milligrammes  or  less,  the  daily 
dose  30  miligrammes  or  less.  The  single  adult  dose 
of  the  official  strophanthin  by  the  mouth  is  probably 
about  10  milligrammes,  and  the  daily  adult  dose  by 
the  mouth  is  probably  about  60  milligrammes,  but 
the  latter  dose  should  not  be  used  until  we  have  fur- 
ther clinical  experience  concerning  the  various  fac- 
tors governing  its  absorption.  The  action  of  tinc- 
ture of  strophanthus  by  the  mouth  and  the  factors 
modifying  its  absorption  require  further  clinical 
study.  Uniformity  of  action  can  only  be  secured  by 
uniform  absorption,  and  this  is  influenced  by  the 
menstruum  in  which  the  drug  is  given  and  the  con- 
dition of  the  alimentary  canal  at  the  time  of  admin- 
istration. It  is  quite  possible  that  diet  may  influence 
the  absorption  of  strophanthin  in  the  human  ali- 
mentary canal,  so  that  man  may  at  one  time  resem- 
ble the  rodent  and  at  another  time  the  carnivorous 


82 


PITH  Of  CURREXT  LITERATURE. 


[Ntw  York 
Medical  Journ.m,, 


animals  (cat  and  dog)  in  susceptibility  to  strophan- 
thin. 

6.    Toxic  Effects  from  Bismuth  Subnitrate. — 

See  Journal,  page  i6. 

9.  The  Conjunctival  Tuberculin  Reaction  as  a 
Means  of  Diagnosis  and  Control. — Smithies  and 
Walker  remark  that  in  the  routine  examination  of 
many  individuals  tuberculosis  is  readily  overlooked 
unless  some  form  of  tuberculin  test  is  administered. 
These  tests,  however,  are  but  confirmatory  of  physi- 
cal findings.  The  conjunctival  tuberculin  test  as  di- 
rected to  be  practised  by  Calmette  and  others  is 
convenient,  rapid  in  application  and  manifestation, 
inexpensive,  can  be  used  in  febrile  cases,  is  practi- 
cally harmless  when  properly  carried  out  and  con- 
trolled, and  is,  in  the  hands  of  the  general  practi- 
tioner, for  incipient  and  early  cases,  as  dependable 
as  are  any  other  forms  of  tuberculin  test.  Proper 
technique,  proper  preparation,  discrimination  in  the 
interpretation  of  both  positive  and  negative  reac- 
tions, and  care  of  the  patients  following  instillation 
are  necessary  for  the  success  of  the  reaction.  Pa- 
tients presenting  disease  of  the  eye  other  than  sim- 
ple conjunctivitis  should  not  be  instilled.  Second 
instillations  should  be  made  in  the  opposite  eye. 
Positive  reaction  in  this  is  dubious  after  the  tenth 
day,  if  the  suspected  focus  is  not  examined.  Care 
should  be  taken  to  eliminate  recent  typhoid,  colon 
infections,  syphilis,  and  acute  infections,  as  diph- 
theria, sepsis,  scarlet  fever,  and  articular  rheuma- 
tism. Patients  receiving  tuberculin  subcutaneously 
for  diagnostic  or  therapeutic  purposes  may  be  ex- 
pected to  react,  frequently  irrespective  of  active  tu- 
berculous foci.  Prompt,  positive  manifestation  gen- 
erally means  an  active  focus  with  good  systemic 
resistence.  This  is  especially  so  in  early  cases. 
Delayed  response,  with  feeble  ocular  changes,  may 
be  considered  as  of  bad  prognosific  import  in  both 
early  and  late  stages  of  the  disease.  Severe  con- 
junctival disturbances  may  result  from  reinstillation 
in  the  same  eye,  particularly  in  tuberculous  individ- 
uals, and  after  the  tenth  day  in  others.  Sensitiza- 
tion of  the  conjunctiva  may  persist  for  months,  and 
reinstillation  may  be  responsible  for  violent  reac- 
tion. This  may  be  aggravated  by  synchronous  or 
subsequent  subcutaneous  use  of  tuberculin. 

12.  Condition  of  the  Peripheral  Bloodvessels 
in  Shock. — Seelig  and  Lyon  try  to  show  explicit- 
ly that  in  shock  the  peripheral  vessels  are  con- 
tracted, and  implicitly  that  not  all  the  vasomotor 
centres  can  be  exhausted.  The  complexity  of  the 
vasomotor  apparatus,  with  its  multiplicity  of  cen- 
tres, and  the  seemingly  independent  action  of  many 
of  these  centres,  render  it  impossible  to  frame  a  sat- 
isfactory theory  based  on  their  results.  They  con- 
clude that  if  the  work  herein  detailed  stands  the  test 
of  confirmation,  then  the  doctrine  that  shock  is  due 
to  vasomotor  exhaustion  must  be  revised. 

MEDICAL  RECORD. 

J uiiiuiry  J.  igog. 

1.  l"i;rther  Oliscrvations  on  Injuries  of  the  Neck  of  Ihc 

I'cniur  in  Early  Life;  with  Reference  to  the  Distinc- 
tion between  I'Vaclnre  of  the  Neck  and  Epiphyse.il 
l^isjnnction  as  Influencing  Positive  Treatment. 

Ry  Rov.M.  Whitman. 

2.  Two  Important  .Angeioneuroses, 

By  .Arthur  J.  Whiting. 


3.  Headaches  of  Ocular  and  Xasal  Origin, 

By  Charlks  Gkaef. 

4.  A  Table  of  Standard  \^■eights  for  Women, 

By  Faneuil  S.  Weisse. 
3.    Is  Food  Containing  Benzoates  Injurious  to  Health? 

By  E.  E.  S-MiTH. 

6.    A  Modified  Bowels  Stethoscope, 

B3'  George  ?^Iaxheimer. 

I.  Injuries  to  the  Neck  of  the  Femur  in  Early 
Life. — The  cases  outlined  in  Whitman'-  paper 
have  been  selected  to  illustrate  four  types  of  frac- 
ture of  the  neck  of  the  femur  in  early  life  as  they 
are  likely  to  be  presented  for  treatment:  i.  The  un- 
usual cases,  in  which  a  correct  diagnosis  f>ermits 
immediate  correction  of  deformity  by  manipulation. 
2.  Cases  in  which  the  fracture  has  consolidated,  the 
deformity  being  of  the  coxa  vara  type,  which  may 
be  corrected  by  cuneiform  osteotomy  of  the  shaft 
without  disturbing  the  joint.  3.  Ununited  frac- 
tures, which  require  direct  operation  for  the  pur- 
pose of  fixing  the  fragments.  4.  Epiphyseal  frac- 
tures, in  which,  as  a  rule,  the  capsule  must  be  opened. 
The  aim  in  the  treatment  of  all  the  cases  has  been 
functional  cure,  to  which  the  removal  of  deformity, 
by  means  adapted  to  its  character  and  duration, 
must  be  the  essential  preliminary.  The  author  says 
that  the  results  attained,  as  contrasted  with  disabil- 
ity, distortion,  and  nonunion,  even  in  cases  of  the 
same  favored  class,  in  which  the  treatment  or  non- 
treatment  had  followed  accepted  methods,  encour- 
ages the  belief  that  the  application  of  the  same  prin- 
ciples to  all  cases  in  which  the  condition  of  the  pa- 
tient permits  local  treatment,  would  lead  to  a  cor- 
responding improvement  in  the  final  results. 

3.  Headaches  of  Ocular  and  Nasal  Origin. — 
Graef,  in  speaking  of  the  treatment,  says  that  little 
or  no  real  benefit  can  be  had  in  these  cases  from 
drug  treatment.  Mechanical  and  surgical  measures 
judiciously  selected  for  each  case  are  much  more  to 
the  purpose.  Carefully  chosen  glasses,  properly  set 
in  comfortable  frames,  are  absolutely  the  only  per- 
manent relief  from  headaches  due  to  errors  of  re- 
fraction, of  which  the  commonest  type  is  hyperopia 
with  astigmatism.  ^Muscular  weakness,  or  imbal- 
ance, is  also  a  prolific  source  of  such  .symptoms  and 
demands  much  care  and  judgment  for  its  proper 
correction  ;  not  infrequently  operative  interference 
must  be  added  to  such  glasses  as  are  necessary. 
The  physician  should  use  his  authority  with  his  pa- 
tients to  break  down  the  widespread  error  that  suf- 
ferers, especially  children,  are  likely  to  outgrow  the 
conditions  responsible  for  ocular  and  nasal  reflexes. 
INIany  of  the  nasal  cases  can  be  cured  by  operatic^n. 
Ill  a  still  larger  number,  a  combined  study  and  cor- 
rection of  faults  in  both  eyes  and  nose  will  be  found 
necessary. 

4.  Standard  Weights  of  Women. — \\'eisse  pub- 
lishes a  tal)le  which  is  based  on  the  study  of  the 
heights  and  weights  of  59.525  insured  women, 
clothed  and  shod,  ranging  in  height  between  4  ft. 
1  in.  and  6  ft.  I  in.,  and  in  age  between  15  and  69 
years  inclusive.  The  height  and  weight  in  every 
case  were  taken  from  the  medical  examiner's  report. 
The  records  of  24.626  of  these  women  were  ob- 
tained from  the  Mutual  Life  Insurance  Co.,  and  the 
balance,  34,899,  were  furnished  by  Dr.  O.  H.  Rog- 
ers, of  the  New  York  Life  Insurance  Co.    In  the 


January  9,  1909.  J 


PITH  OF  CURREXT  LITERATURE. 


83 


height  groups  those  under  4  ft.  1 1  in.  and  over  5  ft. 
10  in.  contain  so  few  individuals — only  578  in  all — 
that  they  have  been  eliminated  from  the  calcula- 
tions. In  the  same  way  the  last  age  group  or  quin- 
quennium— 65  to  69 — has  been  eliminated,  as  it  was 
.made  up  of  but  92  individuals.  The  average  height 
was  5  ft.  4^4  in.;  the  average  weight  was  133 
lbs.  The  average  height  of  males  is  5  ft.  7  3/10  in., 
.and  average  weight  151^2  lbs.  The  tendency  in  the 
female  is  for  the  weight  to  increase  during  the  years 
from  20  to  50  more  rapidly  than  it  does  in  males. 
This  corresponds  with  the  child  bearing  period,  and, 
taken  in  conjunction  with  the  sedentary  habits  of 
women,  accounts  for  the  difterence. 

5.  Is  Food  Containing  Benzoates  Injurious  to 
Health? — Smith  reviews  the  experiments  made 
by  Dr.  Wiley  on  twelve  healthy  men  to  determine 
the  effect  upon  health  of  benzoic  acid  and  the  benzo- 
ates. published  in  Bulletin  No.  84  of  the  Bureau  of 
Chemistry  of  the  Department  of  Agriculture.  He 
comes  to  the  conclusion  that  the  loss  of  weight  was 
not  evidence  of  an  injurious  action  of  the  preserva- 
tive administered  since  it  was  on  account  of  a  diet  in- 
sufficient to  maintain  body  weight.  The  disturbances 
of  metabolic  functions,  as  evidenced  by  a  supposed 
increased  elimination  of  metabolic  prodticts.  did  not 
show  any  injurious  action  of  the  preservative  admin- 
istered, since  no  real  increase  was  produced,  except- 
ing only  the  increase  of  urinary  solids,  which  was 
largely  due  to  the  elimination  of  the  benzoic  acid 
and  its  products..  The  increase  of  microscopic  bod- 
ies of  the  urine  did  not  show  any  general  tendency 
to  stimulate  the  destructive  activities  of  the  body, 
and  hence  is  not  indicative  of  an  injurious  action  of 
the  preservative.  The  disturbances  in  digestion  can- 
not be  attributed  to  the  action  of  the  preservative, 
since  the  subjects  were  not  in  a  healthy  condition, 
but  were  suffering  from  acute  coryza  and  .sore 
throats  with  the  accompanying  fever,  which  condi- 
tions are  themselves  causes  of  gastric  disturbTnccs. 

BRITISH  MEDICAL  JOURNAL 

December  13.  igo8. 

1.  Some  Difficulties  in  Diagnosis  and  Treatment  of  Cases 

of  Suppuration  in  the  Xeighborhood  of  the  Dia- 
phragm. By  W.  H.  White. 

2.  Three  Demonstrations  on  ^Malformations  of  the  Hind 

End  of  the  Body.  By  A.  Keith. 

3.  Food  Extracts  Made  from  Yeast.    By  A.  C.  Chap.m.xn. 

4.  An  Epideniic  of  Influenza  Giaracterized  by  (Edema  of 

the  Eyelids.  By  N.  I.  Spriggs. 

5.  Rupture  of  the  Bulbar  Branch  of  the  Internal  Pubic 

Artery,  By  T.  S.  Mackintosh. 

6.  Notes  on  a  Case  of  Buphthalniia,     By  J.  H.  McIlroy. 

I.  Suppuration  Near  the  Diaphragm. — \\'hite 
discusses  the  difficulties  of  diagnosis  and  treatment 
of  cases  of  suppuration  near  the  diaphragm.  Most 
instances  of  suppuration  just  below  the  diaphragm 
are  due  to  abscess  of  the  liver,  and  the  following 
points  should  be  borne  in  mind :  ( i )  ^^^^en  con- 
sidering the  possibility  of  hepatic  abscesses,  avoid 
confounding  it  with  (a)  malignant  disease  of  the 
liver,  fb")  tropical  liver,  or  hepatitis,  (c)  malaria, 
(d)  rectirrent  influenza.  (2)  Bv  perctission  seek  for  a 
small  local  increase  upwards  of  hepatic  dulness :  this 
almost  always  is  due  to  abscess  or  hydatid  cyst :  it 
is.  hardly  ever  caused  by  growth  or  gumma.  ('3') 
Local  tenderness  is  of  great  help  in  locating  abscess. 


(4j  The  occurrence  of  solitary  hepatic  abscesses  in 
England  with  or  without  intestinal  tilceration  and  in 
the  tropics  apart  from  amoebic  dysentery,  and  the 
fact  that  the  abscess  is  solitary,  show  we  are  far  from 
understanding  the  production  of  it.  (5)  If  an  ab- 
scess is  present  and  has  not  ruptured  in  such  a  way 
that  the  pus  can  be  ultimately  discharged  otitside 
the  body  it  should  be  opened  at  once,  and  probably 
it  is  usually  better  to  do  this  in  India  rather  than  to 
send  the  patients  home  for  operation.  (6)  Abscesses 
may  be  latent  in  the  liver  for  years  and  only  give 
rise  to  symptoms  occasionally.  (7)  We  often  see 
those  in  whom  a  hepatic  abscess  is  discharging  into 
the  lung.  Because  such  are  often  very  small,  are 
often  deepseated,  and  rarely,  owing  to  frequent 
discharge,  contain  much  pus,  they  ma}'  be  very  diffi- 
cult to  find  surgically.  Therefore,  whenever  possi- 
ble, the  patient  should  be  given  the  chance  of  open 
air  treatment,  change  of  climate,  and  good  food. 
(8)  The  cure  of  such  cases  may  be  accelerated  by 
the  administration  of  the  proper  vaccine.  As  re- 
gards supptirative  conditions  above  the  diaphragm, 
nearly  all  cases  of  sttppuration  confined  to  the  cavity 
of  the  chest  are  instances  of  pleural  empyema.  Em- 
pyema and  general  peritonitis  are  occasionally  as- 
sociated, and  such  cases  are  generally  fatal. 

3.  Yeast  Food  Extracts, — Chapman  answers 
the  recently  published  strictures  of  Gamgee  against 
food  extracts  made  from  yeast  as  compared  with 
those  made  from  meat.  Gamgee's  points  are  given 
in  quotation  marks:  (i)  "'Yeast  extract  differs  from 
meat  extract  in  a  startling  manner."  Apart  from 
the  presence  of  creatine  and  creatinine  in  the  latter, 
and  its  absence  in  the  former,  there  is  no  estab- 
lished difference  of  any  importance.  The  creatine 
and  creatinine  are  not  known  to  possess  any  phys- 
iological value.  (2)  "They  contain  none  of  the 
flavoring  and  odoriferous  principles  which  cause  ex- 
tracts of  beef  to  be  palatable."  This  is  quite  incor- 
rect. In  the  case  of  the  best  preparations  they  are 
almost  indistinguishable.  (3)  "They  (yeast  ex- 
tracts) abound  in  the  nucleoproteids.  This  is  not 
the  case.  The  nucleoproteids  are  destroyed  in  the 
process  of  manufacture.  (4)  "That  the  purin  ni- 
trogeri  contained  in  the  yeast  extract  is  half  as  much 
more  as  in  meat  extract."  This  is  a  mistake,  but 
even  if  true,  the  fact  would  have  no  practical  signifi- 
cance with  quantities  such  as  are  in  qtiestion.  (5) 
"That  our  knowledge  in  no  way  permits  us  to  affirm 
that  the  ademic  of  yeast  extract  is  not  a  much  more 
injurious  body,  in  so  far  as  the  animal  body  is  con- 
cerned, than  the  hypoxanthin  of  beef."  The  writer 
contends  that  our  knowledge  does  not  permit  us  to 
affirm  anything  at  all,  as  regards  the  relative  injuri- 
ousness  of  these  two  bases,  when  dealing  with  such 
'Itiantities. 

4.  Influenza  and  CEdema  of  the  Eyelids. — 

Spriggs  reports  a  series  of  ten  or  twelve  cases  of 
influenza  in  which  oedema  of  the  eyelids  was  a 
prominent  symptom.  The  usual  history  was  that 
the  patient  went  to  bed  well,  but  waked  with  marked 
(xdema.  There  was  no  redness,  or  at  most  a  faint 
pinkish  tinge.  At  this  stage  there  were  no  general 
symptoms.  During  the  next  twenty-four  hours  a 
bad  headache  developed,  strictly  localized  to  the 
supraorbital  region.  The  oedema  advanced  till  the 
eyes   were   completely   closed,  and   might  spread 


84 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal^ 


downward  into  the  cheeks.  In  at  least  half  the 
cases  there  was  deep  congestion,  often  accompanied 
by  cedema  of  the  conjunctiva,  but  there  was  no  dis- 
charge. The  temperature  never  rose  above  ioi°  F. 
In  more  than  half  the  cases  the  above  symptoms 
constituted  all  the  illness ;  but  in  a  fair  proportion, 
perhaps  nearly  half,  after  a  few  days,  as  the  oedema 
receded  the  ordinary  symptoms  of  influenza  set  in, 
and  there  were  pains  in  the  back,  legs,  etc.,  and 
great  prostration.  The  urine  was  normal.  Most  of 
the  cases  occurred  in  women.  There  was  little  doubt 
of  the  influenzal  origin  of  the  oedema.  xA.bout  half 
the  patients  had  other  influenzal  symptoms,  and  of 
those  who  did  not  many  were  found  to  reside  in  a 
house  where  influenza  was  prevalent.  No  cases  were 
recorded  apart  from  an  epidemic  of  influenza.  The 
diagnosis  may  be  hard  or  impossible  in  an  isolated 
case,  and  frontal  sinusitis  or  angeioneurotic  oedema 
may  be  considered.  The  presence  of  other  influenzal 
symptoms  will  soon  clear  up  the  difficulty,  however. 
The  prognosis  is  excellent.  The  usual  lines  of  treat- 
ment for  influenza  should  be  followed.  Cold  com- 
presses or  cold  boric  eye  washes  hasten  the  subsid- 
ence of  the  oedema. 

LANCET. 

December  12,  igo8. 

1.  The  Pathology  and  Treatment  of  Diabetes  Mellitus, 

Viewed  by  the  Light  of  Present  Day  Knowledge, 
(Lecture  III),  By  F.  W.  Pavy. 

2.  The   Agglutinating   Power   in   Tuberculous  Patients; 

Serum  Diagnosis  and  Serum  Prognosis, 

By  P.  COURMONT. 

3.  The  Milk  Supply  for  Infants :  Recent  Aspects  and 

Possibilities,  By  W.  Ewaet. 

4.  A  Case  of  Neurasthenia  Complicated  with  (?)  "Vaso- 

vagal Attacks,"       ■  B.  M.  M.  Burgess. 

5.  A  Case  of  Cerebellar  Abscess  Following  Middle  Ear 

Suppuration ;  Operation ;  Death,        By  G.  N.  Biggs. 

6.  A  Case  of  Lateral  Sinus  Thrombosis  with  Pyasmic  Pul- 

monary and  Pericardial  Complications,  etc. ;  Opera- 
tion; Recovery,        By  J.  Mackie  and  H.  B.  Tawse. 

7.  A  Simple  Method  of  Obtaining  a  Preparation  of  Living 

Isolated  Leucocytes,  By  C.  W.  Pouder. 

I.  Diabetes  Mellitus. — Pavy  in  his  third  lec- 
ture on  this  subject  discusses  the  acidosis  of  diabetes 
and  the  general  treatment  of  the  disease.  Malappli- 
cation  of  carbohydrate  food  within  the  system  con- 
stitutes the  essential  error  existing  in  diabetes,  and 
what  is  wanted  to  be  effected  by  treatment  is  to 
bring  conditions  back  into  line  for  it  to  be  again 
turned  to  proper  account.  In  health,  carbohydrate 
is  taken  and  can  be  followed  to  the  seat  of  absorp- 
tion belonging  to  the  alimentary  canal.  Here,  how- 
ever, it  becomes  lost  to  view.  Neither  the  blood  nor 
the  urine  affords  evidence  of  the  absorption  that 
manifestly  occurs.  To  regard  it  as  the  natural 
course  of  events  that  the  food  carbohydrate  should 
pass  through  the  circulation  to  the  tissues  in  the 
form  of  sugar  is  tantamount  to  taking  the  patho- 
logical as  representative  of  the  physiological  state, 
seeing  that  it  is  just  such  passage  which  is  produc- 
tive of  diabetes.  To  escape  from  diabetes,  the  food 
carbohydrate  must  not  be  allowed  to  reach  the  gen- 
eral circulation  in  the  form  of  sugar.  The  writer 
contends  that  the  absorbed  sugar  becomes  dealt  with 
at  the  seat  of  absorption,  and.  in  company  with  the 
products  derived  from  protein  digestion,  is.  by  the 
bioplasmic  action  attendine  lymphocyte  growth,  put 
into  an  elaborated  state.  The  process  falls  under  the 
denomination  of  assimilation,  and  when  the  sugar  is 


thus  disposed  of  and  incorporated  as  a  constituent 
of  the  large,  newly  constructed  molecule,  it  is  placed 
in  a  position  to  be  secure  from  running  off  with  the 
urine  during  the  transit  of  the  blood  through  the 
kidney.  Looked  at  in  this  way,  the  error  in  diabetes 
consists  of  a  faulty  assimilation  of  the  sugar  ab- 
sorbed from  the  alimentary  canal.  Digestion  pre- 
pares for  absorption,  and  assimilation,  which  follows 
immediately  upon  it,  puts  the  absorbed  digestion 
products  into  an  elaborated  state,  in  which  form 
they  pass  through  the  thoracic  duct  into  the  blood 
and  there  constitute  the  pabulum  from  which  the 
tissues  draw  their  nutrient  supply.  Under  this  view 
the  error  is  located  in  the  first  link  of  the  metabolic 
chain  instead  of  the  last,  which  is  assigned  as  its  seat 
under  the  glycogenic  doctrine.  There  is  nothing  to 
support  the  view  that  the  fault  in  diabetes  (the  sim- 
ple or  alimentary  form  of  it)  consists  in  a  noncon- 
sumption  of  carbohydrate,  except  in  so  far  as  con- 
sumption is  prevented  by  exit  in  the  form  of  sugar 
with  the  urine  in  consequence  of  being  permitted  to 
enter  the  circulation  as  free  sugar.  Return  of  assim- 
ilative power  is  revealed  by  unmistakable  signs,  con- 
sisting of  a  fall  in  weight  and  a  bodily  feeling  of 
sinking  or  food  want.  Success  in  treatment  depends 
entirely  upon  the  food  taken  by  the  patient.  Satis- 
factory diabetic  foodstuffs  can  now  be  obtained,  bin 
many  of  those  on  the  market  are  no  better  than  ordi- 
nary domestic  foods.  No  drug  by  itself  exerts  a 
direct  and  immediate  arresting  influence  over  the 
elimination  of  sugar.  On  the  other,  hand  something 
is  wanted  to  set  metabolism  right,  just  as  it  is  set 
right  by  thyreoid  extract  in  myxoedema.  But  the 
author  believes  strongly  in  the  helpful  influence  of 
opium  and  some  of  its  derivatives  toward  promoting 
the  restoration  of  carbohydrate  assimilative  power. 

2.  Serum  Diagnosis  and  Prognosis  in  Tuber- 
culosis.— Cotirmont's  conclusions  regardinc"  the 
agglutination  reaction  in  tuberculosis  are  as  follows : 
I.  Value  of  the  method.  The  agglutinating  power 
of  serous  effusions  in  ttiberculous  patients  is  a  very 
important  point  in  diagnosis  and  prognosis.  It  must 
be  studied  in  all  its  variations,  according  to  the  ages 
of  the  patients,  localisation,  form,  and  degree  of 
lesions,  and  also  in  relation  to  the  subsequent  reac- 
tions which  may  be  obtained.  2.  Necessary  precau- 
tions. In  order  to  make  the  investigation  valuable, 
sercreaction  must  be  looked  for  under  the  most  ex- 
act conditions  as  regards  the  choice  of  the  culture 
and  the  general  technique  of  the  reaction.  3.  Limi- 
tations of  the  method.  Given  that  the  agglutinating 
power  of  normal  serum  varies  according  to  age  and 
to  the  animal  species  investigated,  serum  reaction 
has  a  diagnostic  value  only  when  the  degree  of  ag- 
glutination is  higher  than  the  ordinary  degree  of 
agglutinating  power  of  the  serum  of  normnl  indi- 
viduals of  the  same  age  and  belonging  to  the  same 
species.  4.  Serum  diagnosis.  For  practical  pur- 
poses the  serum  reaction  must  be  applied  w  itii  great 
clinical  discrimination ;  its  results  must  be  compared 
with  the  other  symptoms  and  not  interpreted  blindly. 
A  patient  should  not  be  regarded  as  clinically  tuber- 
culous for  the  sole  reason  that  his  serum  agglu- 
tinates Koch's  bacilli.  Where  there  arc  other  symp- 
toms iustifying  a  suspicion  of  tuberculosis,  a  posi- 
tive serum  reaction  is  of  srrcat  value ;  negative  reac- 
tions are  of  less  value.    Diagnostically,  serum  reac- 


January  9,  :90a.  1 


PITH  OF  CURRENT  LITERATURE. 


85 


tion  can  be  considered  under  two  heads:  (a)  Gen- 
eral reaction  (with  blood  serum).  This  gives  no  in- 
formation as  to  the  location  of  the  lesions  and  indi- 
cates only  that  the  system  has  been  or  is  actually 
under  the  influence  of  tuberculosis.  It  is  for  the 
clinician  to  interpret  this  information.  It  is  of  espe- 
cial use  in  children,  in  old  people,  and  in  adults  suf- 
fering from  chronic  or  latent  forms  of  tuberculosis. 
The  results  in  the  last  class  of  patients  are  almost 
the  same  asi  with  tuberculin  (subcutaneously  or  in 
the  eye),  (b)  Local  serum  reaction.  This  consists 
in  testing  the  agglutinating  power  of  serous  efifu- 
sions  and  indicates  the  site  of  the  lesions.  It  is  pai"- 
ticularly  useful  for  the  diagnosis  of  tuberculous 
pleurisy,  and  its  results  accord  with  those  of  tuber- 
culin injection  or  cytodiagnosis.  5.  Serum  prog- 
nosis. The  agglutinating  power  of  blood  serum  is 
proportional  to  the  resisting  power  of  the  patient, 
and  is  in  an  inverse  ratio  with  the  virulence  of  in- 
fection. Serum  reaction  is  very  frequently  absent 
in  very  serious  or  very  advanced  cases  of  tuber- 
culosis. It  reaches  its  maximum  height  in  cases  in 
the  process  of  healing.  It  can  diminish  or  disappear 
sometimes  before  death ;  it  can,  on  the  contrary,  in- 
crease where  there  is  a  tendency  toward  healing  or 
arrest.  It  seems  to  be  an  index  of  the  protective 
reaction  of  the  system.  6.  In  tuberculous  pleurisy 
with  effusion  an  increasing  agglutinating  power  car- 
ries with  it  a  good  prognosis,  but  failing  any  reac- 
tion, must  be  prepared  sooner  or  later  for  a  fatal 
result. 

3.  Milk  for  Infants. — Ewart  gives  the  follow- 
ing as  the  guiding  principles  in  the  milk  supply  for 
bottle  fed  infants,  i.  There  is  only  one  perfect  milk 
for  the  infant,  the  living  milk  straight  from  the 
breast.  2.  One  of  the  perfections  of  mother's  milk 
is  that  it  is  highly  specialised  for  the  infant.  3.  Sin- 
gleness of  supply  is  another  of  Nature's  principles. 
4.  Sustained  quality  of  the  single  supply  is  the  most 
important  but  the  least  probable  attainment.  5.  In 
its  composition  nursery  milk  should  be  the  nearest 
approach  tO'  the  maternal.  6.  The  sine  qua  non  is 
absolute  freedom  from  the  agents  of  disease,  whether 
special  to  the  milk,  as  in  scurvy  rickets,  or  imported 
into  it,  as  in  tuberculosis  and  all  other  infections. 

LA  PRESSE  MEDICALF. 
November  7,  igo8. 

1.  Infantile  Bacillary  Endocarditis.    Secondary  Endocar- 

ditis. Primitive  Septicemic  Nonfollicular  Endocar- 
ditis, By  Landouzy  and  Gougerot. 

2.  Proceedings  of  the  Congress  at  Washington, 

By  Leon  Bernard. 

3.  Bacteriotherapy  and  the  Opsonic  Index  in  the  Vulvo- 

vaginitis of  Little  Girls,  By  R.  Romme. 

I.  Endocarditis. — Landouzy  and  Gougerot  re- 
port two  very  interesting  cases.  The  first  was  one 
of  an  acute  endocarditis  secondary  to  pulmonary 
phthisis  in  an  infant,  the  second  was  one  of  nodular 
fibrinous  endocarditis  of  the  mitral  valve  and  bacil- 
lary septicaemia  without  tubercles  or  miliary  gran- 
ulations, likewise  in  a  child,  four  weeks  old.  The 
two  observations  demonstrate  that  in  the  infant,  as 
well  as  in  the  adolescent,  the  adult,  and  the  aged, 
nonfollicular  bacillary  lesions  exist. 

November  11,  igoS. 
Syphilitic  Polioencephalitis.     Total   Bilateral  Ophthalmo- 
plegia Accompanying  the  Bulbar  Symptoms.  Effi- 
cacy of  Specific  Treatment,  By  Dieulafoy. 


Syphiliti(i  Polioencephalitis. — Dieulafoy  reports 
in  detail  a  case  that  a  syphilitic  polioencephalitis 
can  exist  which  can  be  diagnosticated  by  the 
ophthalmoplegia  and  the  bulbar  symptoms.  The 
ophthalmoplegia  and  the  bulbar  symptoms  may  be 
associated  or  isolated,  but  when  the  actuating  cause 
is  of  a  syphilitic  nature  the  polioencephalitis  is 
amenable  to  antisyphilitic  treatment  pushed  hard 
and  for  a  considerable  length  of  time. 

November  14,  igo8. 

1.  Experimental  and  Comparative  Pathology.  Feiments 

of  the  Digestive  Canal,  By  Professor  Rogi:k. 

2.  Yellow  Fever,  By  E.  Brumit. 

3.  Transactions  of  the   Congress  at  Washington  {Con- 

tinued), By  L.  Bernard. 

4.  Surgery  of  the  Great  Cardiac  Vessels,     By  R.  Romme. 

1.  Ferments  of  the  Digestive  CanaL — Roger 
outlines  the  studies  to  be  pursued  during  the  com- 
ing year  along  this  line  in  the  course  of  experimen- 
tal and  comparative  pathology  of  the  Faculte  de 
medecine  de  Paris. 

2.  Yellow  Fever. — Brumpt  considers  first  the 
geographical  distribution  of  yellow  fever,  which  he 
illustrates  by  means  of  maps,  and  then  the  mos- 
quitoes that  carry  the  disease  from  one  patient  to 
another.  Prophylaxis  of  the  disease  consists  of  de- 
struction of  the  Stegomyia  calopiis. 

November  18,  jgo8. 
Digestive  Troubles  in  Rickets,  By  A.  B.  Marfan. 

Digestive  Troubles  in  Rickets. — Marfan  de- 
scribes two  sorts  of  digestive  troubles  in  patients 
sufferings  from  rickets ;  the  one,  prodromic  or  in- 
itiative, usually  consists  of  recurrent  gastrointes- 
tinal catarrh,  more  rarely  of  a  spasmodic  dyspepsia 
with  repeated  vomitings,  the  other  met  with  in  con- 
firmed rickets,  consists  of  a  special  form  of  atonic 
dyspepsia,  with  large,  flabby  abdomen. 

LA  SEMAINE  MEDICALE. 
November  11,  igo8. 
The  Chalazion,  Acne  of  the  Meibomian  Glands.  Histology 
and  Pathogeny,        By  J.  Sabrazes  and  Ch.  Lafon. 

Chalazion. — Sabrazes  and  Lafon,  after  an  ex- 
tensive study  of  the  histology,  bacteriology,  and 
pathogeny  of  acne  and  of  chalazion,  together  with  a 
review  of  the  literature  on  the  subject,  have  decided 
that  chalazion  is  nothing  else  than  acne  of  the 
Meibomian  glands. 

November  18,  J908. 
Treatment  of  the  Chorea  of  Sydenham  by  Intraarachnoid 
Injections  of  Magnesium  Sulphate, 

By  Professor  G.  Marinesco. 

Treatment  of  the  Chorea  of  Sydenham  by  In- 
traarachnoid Injections  of  Magnesium  Sulphate. 

— Marinesco  reports  a  case  successfully  treated  in 
the  manner  indicated. 

November  25,  igo8. 

1.  Concerning  the  Value  of  the  Phenomenon  of  Comple- 

mentary Opposition  as  a  Means  of  Diagnosis  between 
Organic  and  Functional  Hemiplegia, 

By  J.  Lhebmitte. 

2.  Anaphylaxia  as  a  Means  of  Diagnosis  of  Human  Tu- 

berculosis. 

BERLINER  KLINISCHE  WOCHENSCHRIFT 
November  g,  igo8. 

1.  The  Occurrence  of  Ulcer  of  the  Duodenum  in  the  First 

Decennium.  By  L.  Kuttner. 

2.  Permanent  Results  after  Transplantation  of  Vessels 

and  Organs,  By  Capelle. 

3.  Microsporia  and  Macrosporia  of  the  Heads  of  Children, 

By  F.  Glaser. 


86  .  '"'-TH  OF  CURREXT  LITERATURE.  INew  York 

Medical  Journal. 


4.  Animal  Experiments  with  Spengler's  Tub'erculosis  Im 

mune  Bodies,  By  Gustave  Landmann. 

5.  A  Case  of  Dwarf  Growth  Caused  by  Traumatism  to 

the  Skull,  By  Schabad. 

6.  A  New  Treatment  for  Bronchial  Asthma, 

By  Otto  Gunzel. 

7.  Thyresol.  a  New  Preparntion  of  Oil  of  Santal, 

By  Paul  Richtek. 

8.  Two  Cases  of  Death  Mechanically  Caused  by  the  Thy- 

mus, By  L.  HuiSMANs. 

Q.  Studies  Concerning  the  Relations  between  Human  Tu- 
berculosis and  Tubercle  Bacilli  and  the  Tuberculosis 
and  Tubercle  Bacilli  of  Cattle  (Concluded) , 

By  JoHAXXES  FiBTGEK  and  C.  O.  Jensen. 

1.  Ulcer  of  the  Duodenum  in  the  First  De- 
cennium. —  Kuttner  report.^  two  ca.ses  of  ulcer  of 
the  duodenum.  The  first  was  met  with  in  a  child,  one 
month  old.  the  other  in  a  child,  four  years  old.  The 
diagnosis  was  confirmed  by  autopsy  in  both  cases. 

2.  Transplantation  of  Vessels  and  Organs. — 
Capelle  reports  the  general  results  of  his  experi- 
mental transplantion  of  portions  of  arteries  from  one 
animal  to  another,  and  of  thyreoid  glands  and  kid- 
neys, lie  warmly  recommends  that  the  attempt 
should  be  made  to  unite  severed  bloodvessels  by 
means  of  sutures,  and  to  replace  resected  portions 
of  arteries  by  the  implantation  of  new  pieces  in  hu- 
man surgery. 

6.  A  New  Treatment  for  Bronchial  Asthma. — - 
Gunzel  recommends  the  application  of  the  inter- 
mittent high  frequency  current  to  the  region  of  the 
larynx. 

8.  Death  Mechanically  Caused  by  the  Thymus. 

— Huismans  reports  two  cases  of  unexpected  death 
in  children,  preceded  by  no  signs  of  danger,  which 
he  ascribes  to  the  mechanical  interference  of  the 
thymus  with  the  respiration  and  circulation.  The 
first  patient  was  six  months  old.  At  five  o'clock  one 
morning  he  began  to  breathe  stertorously,  become 
cyanotic,  and  was  dead  in  half  an  hour.  Autopsy 
showed  that  the  trachea  contained  much  bloody 
seromucous  fluid,  both  lungs  partially  hepatised,  the 
thymus  developed  almost  entirely  within  the  thorax 
and  of  normal  consistence.  The  second  patient  was 
six  weeks  old.  who  died  after  breathing  stertorously 
for  a  short  time.  Autopsy  showed  that  the  lungs 
were  hepatised  to  a  large  degree  and  the  apertura 
cordis  almost  completely  filled  by  a  ver\-  large 
thynnis. 

9.  Relations  between  Human  Tuberculosis  and 
that  of  Cattle. —  Fibiger  and  Jensen  conclude  their 
very  long  and  exhaustive  paper  with  the  statement 
that  there  are  no  peculiarities  which  can  be  called 
characteristic  and  will  serve  as  a  means  for  a  posi- 
tive diagnosis  the  types  of  tuberculosis  met  with  in 
man  and  in  cattle.  Between  the  human  and  bovine 
types  are  intermediate  forms  which  present  one  or 
more  chanicteristics  of  the  one  type  and  the  remain- 
ing peculiarities  of  the  other. 

MUNCHENER   MEDIZINISCHE  WOCHENSCHRIFT, 
X oveiiiber  jo,  1908. 

1.  The  Signification  of  tlie  Conjunctival  Reaction  Accord- 

ing to  Four  Thousand  Clinical  Observations, 

By  Wolff- Ills NER. 

2.  I'atliology  of  Epilepsy,  By  Kaukmann. 

3.  The  I  iistopathoiogy  of  the  Cerebral  Cortex  at  the  Pres- 

ent Time,  By  Ranke. 

4.  Prophylaxis  of  Pulmonar>-  Tuberculosis,    By  IIakuass. 

5.  Internal  Use  of  Tuberculin  and  of  Preparations  Re- 

sembling Tuberculin.  By  Mollek. 

6.  Complicatccl  Fractures  .^f  the  Skull.    By  Schonwerth. 


7.  Radical    Operation    for    Epigastric   and  Subumbilical 

Hernias  in  the  Linea  Alba  by  Transverse  Division 
of  the  Fascia  and  Shelling  out  of  the  Muscle, 

By  Bruning. 

8.  Anaesthetization  of  the  Eye  and  of  its  Annexa. 

By  Messmer. 

9.  Kefir  as  a   Food  for  ■  Infants  w  ith   Oironic  Disturb- 

ances of  Digestion,  By  Tollens. 

10.  A  Peculiar  Case  of  Periosteal  Cyst  of  the  Root  of  a 

Tooth  of  the  Upper  Jaw,  By  Schmidt. 

11.  The  Full  Correction  of  Myopia  in  Children  a  Necessity 

during  School  Life,  By  Weiss. 

12.  German  Health  Insurance,  1906,  By  Fischer. 

8.  Anaesthetization  of  the  Eye  and  of  its  An- 
nexa. —  Messmer  employs  dififerent  anaesthetic 
procedures  in  various  operations  in  the  following 
manner :  In  operations  for  cataract  without  iridec- 
tomy he  instills  two  drops  of  a  five  per  cent,  solu- 
tion of  cocaine  hydrochlorate  into  the  conjunctival 
sac  with  an  interval  between  them  of  five  minutes. 
He  then  washes  out  the  conjunctival  sac,  disinfects 
the  lids  and  the  neighborhood  of  the  eye,  and  then 
again  instills  two  drops  of  cocaine  within  ten  min- 
utes. The  cocaine  is  sufficient  to  render  the  opera- 
tion for  cataract  absolutely  painless  when  no  iridec- 
tomy is  performed.  When  a-n  iridectomy  is  to  b,.' 
performed  one  drop  of  cocaine  is  instilled  into  the 
conjunctival  sac  alternately  with  a  drop  of  holocain 
every  five  minutes  until  three  drops  of  each  solution 
have  been  used.  He  uses  holocain  because  of  the 
greater  depth  of  its  action.  If  half  an  hour  is  al- 
lowed for  the  anaesthetization  of  an  uninflamed  eye 
the  iridectomv  can  be  performed  without  pain.  This 
he  considers  much  superior  to  the  instillation  of  a  so- 
lution of  cocaine  upon  the  iris  after  the  section  has 
been  made,  or  the  introduction  of  cocaine  itself  into 
the  anterior  chamber,  because  such  procedures  tend 
to  make  a  restless  patient  more  restless.  Before  iri- 
dectomy or  sclerotomy  for  glaucoma  he  first  instills 
a  drope  of  eserine  and  then  cocainizes  the  eye.  If 
the  cocaine  dilates  the  pupil  too  widely  he  repeats 
the  instillation  of  eserine.  In  operations  in  inflamed 
eyes  he  combines  the  use  of  suprarenin  with  that  of 
cocaine  in  order  to  lessen  the  engorgement  of  the 
vessels  and  thus  favor  the  anaesthetic  efifect  of  the 
cocaine.  For  enucleation  he  has  been  unable  to  ob- 
tain perfect  local  anaesthesia  and  prefers  to  use  ether. 
When  this  is  impracticable  he  first  cocainizes  the  eye 
in  the  usual  way  and  then  injects  deeply  into  the 
orbit  beside  each  of  the  recti  muscles  a  two  per  cent, 
solution  of  tropocain.  Before  tenotomies  and  ad- 
vancements he  first  cocainizes  the  eye  and  then  se- 
cures a  bit  of  cotton  wet  with  a  five  per  cent,  solu- 
tion of  cocaine  over  the  insertion  of  the  tendon  to  be 
operated  on.  During  the  operation  pledgets  wet  with 
cocaine  and  suprarenin  may  be  applied  to  the  site  of 
operation.  In  this  way  a  tenotomy  may  be  rendered 
painless  and  in  advancements  the  pain  rendered  btar- 
ablc.  The  injection  of  cocaine  into  the  insertions  of 
the  muscles  is  less  desirable  becau.>^e  of  the  bleeding 
and  swelling  so  produced.  He  also  recommends  this 
application  of  cocaine  or  of  cocaine  and  suprarenin 
on  pledgets  of  cotton  in  the  removal  of  small  tumors 
from  the  conjunctiva  or  eyeball,  as  he  has  fo-und  that 
he  obtains  in  tliis  manner  a  deeper  an;esthetization 
than  after  simple  instillation,  lie  likewise  uses  this 
method  of  aniestliesia  as  more  rapid  in  ambulatory 
work,  such  as  subconjunctival  injections.  In  cer- 
tnin  injuries  and  erosions  of  the  eyeball  he  in.stills 


January  9,  1909.  J 


I'lTH  Of  CURREXT  LITERATURE. 


87 


cocaine  in  spite  of  tlicoretical  objections  and  binds 
up  the  eye  for  several  days.  For  infiltration  anaes- 
thesia of  the  lids  he  uses  a  two  per  cent,  solution  of 
cocaine  with  adrenalin  in  the  proportion  of  one  drop 
of  a  I  in  1,000  solution  of  the  latter  in  i  c.c.  of  the 
former.  For  complete  anaesthesia  by  this  method 
one  must  know  how  the  infiltration  is  generally  per- 
formed and  must  wait  from  five  to  ten  minutes  after 
its  completion  before  beginning  to  operate.  This 
method  is  used  in  a  special  way  to  produce  local 
anaesthesia  prior  to  extirpation  of  the  lachrymal  sac. 

Xovcmber  17,  igo8. 

1.  Dementia  Choreoasthenica  with  Juvenile  Nodular  Hy- 

perplasia of  the  Liver,  By  Axtox. 

2.  Concernir.g  the  Use  of  High  Percentage  Mixtures  of 

Mercury  in  the  Treatment  of  Syphilis,       By  Zieler. 

3.  Concerning  Narcosis  with  Artificially  Diminished  Cir- 

culation, By  ZUR  Verth. 

4.  A  Frequent  hitherto  Apparently  Unrecognized  Disease 

of  a  Certain  Bone  in  Children,  By  H.\xisch. 

5.  Two  Cases  of  Perforating  Wound  of  the  Right  Ven- 

tricle of  the  Heart    Suture  of  the  Heart, 

By  Grasm.\xx. 

6.  Ruminatio  Humana,  By  Brugel. 

7.  A  Case  of  Raynaud's  Disease,  By  Lustig. 

8.  A  Contribution  to  the  Knowledge  Concerning  Hirsch- 

sprung's Disease,  By  Hellwig. 

9.  A  Contribution  to  the  Casuistics  of  Fractures  of  the 

Cervical  Vertebra.  By  Federschmidt. 

10.  A  New  Treatment  fpr  Appendicitis,  By  Jager. 

11.  Abortive  Pneumonia,  By  Kapeli. 

12.  Casuistics  of  Abortive  Pneumonia.  By  Ruhl. 

13.  Exophthalmic  Goitre  Associated  with  Tuberculous  Dis- 

eases, By  HUFXAGEL. 

14.  Histopathology  of  the  Cerebral  Cortex  at  the  Present 

Day  (Concluded).  By  Ranke. 

1.  Dementia  Choreoasthenica  with  Juvenile 
Nodular  Hyperplasia  of  the  Liver. — An;<ip.  re- 
ports the  clinical  history  and  the  findings  on  autopsy 
in  a  case  of  this  nature  met  with  in  a  girl,  fourteen 
years  of  age. 

2.  The  Use  of  High  Percentage  Mixtures  of 
Mercury  in  the  Treatment  of  Syphilis. — Zieler 
speaks  verv  highly  of  the  results  he  has  obtained  in 
the  treatment  of  syphilis  from  the  injection  in  the 
gluteal  region  of  gray  oil,  a  mixture  of  pure  mer- 
cury, and  of  calomel  oil.  He  insists  on  the  necessity 
of  chemical  purity  of  the  mercury  or  calomel  em- 
ployed and  on  the  choice  of  a  proper  needle  and 
syringe.  With  these  precautions  he  asserts  that  the 
procedure  is  without  danger. 

3.  Narcosis  'with  Artificially  Diminished  Cir- 
culation.— Zur  \'erth  finds  that  after  exclusion  of 
a  portion  of  the  blood  from  the  circulation  by  liga- 
tion of  the  extremities  so  that  they  will  contain  the 
amount  of  blood  normally  to  be  found  in  them  a  pa- 
tient will  require  less  ether  or  chloroform  to  induce 
narcosis,  and  that  he  will  awake  from  the  narcosis 
quickly  after  the  ligating  bands  have  been  removed. 

4.  A  Frequent  Hitherto  Apparently  Unrecog- 
nized Disease  of  a  Certain  Bone  in  Children. — 
Hanisch  refers  to  the  paper  published  by  Kohler 
under  this  title,  in  which  three  cases  of  small  na- 
vicular bones  were  reported,  and  adds  a  case  to  the 
number,  illustrated  with  radiographs.  He  is  in- 
clined to  ascribe  the  condition  to  a  faulty  develop- 
ment primarily  dependent  on  traumatism. 

5.  Perforating  Wound  of  the  Right  Ventricle. 
— Grasmann  reports  two  cases  of  perforating  wound 
of  the  heart  in  which  the  heart  was  sutured.  The 
operation  was  successfvil  in  one  case. 


6.  Ruminatio  Humana. — Briigel  reports  the 
case  of  a  man,  twenty-six  years  old,  who  had  been 
accustomed  for  seven  years  to  regurgitate  his  food 
into  his  mouth  from  ten  to  thirty  minutes  after  each 
meal  and  chew  it  again.  He  thinks  that  there  was 
a  spasmodic  stricture  of  the  oesophagus  through 
which  fluids  easily  passed,  but  which  held  back  the 
solid  portions  of  the  food.  Xo  actual  stenosis 
could  be  detected  with  the  sotmd. 

8.  Hirschsprung's  Disease. —  Helhvig  reports 
a  case  of  congenital  malformation  of  the  colon,  con- 
genital megacolon  of  Mya,  first  described  by 
Hirschsprung  in  1888,  in  which  a  good  result  was 
obtained  by  an  anastomosis  between  the  transverse 
colon  and  the  descending  portion  of  the  sigmoid 
flexure. 

THE  PRACTITIONER. 
December,  igo8. 

1.  Two  Cases  of  Multiple  Congenital  Deformities, 

By  G.  T.  Be.xtsox. 

2.  The  Pathogenesis  of  Arteriosclerosis, 

By  E.  H.  Colbeck. 

3.  The  Evolution  of  the  Modern  Operation  of  Hysterec- 

tomy, By  E.  5.  Bishop. 

4.  The  Radical  Cure   of  Complete  Procidentia  of  the 

Uterus  with  an  Account  of  a  New  Method  of  Op- 
eration for  this  Condition,  By  L.  McGavix. 

5.  .\  Review  of  Forty-six  Consecutive  Cases  Operated 

in  for  Cholecystitis,  By  H.  M.  Rigbv. 

6.  Cholelithiasis,    its  Early  Recognition  and  Early  Sur- 

gical Treatment.        '        By  B.  G.  A.  Moyxihax. 

7.  Industrial  Diseases,  By  A.  Scott. 
S.    .\n  Account  of  the  Theory  and  Employment  of  Bier's 

^lethod  of  Treatment  by  Passive  Congestion  in 
Cases  of  Rheumatoid  Arthritis.  Tubercle.  Sepsis, 
and  Various  Other  Conditions, 

By  A.  \V.  Wakefield. 
9.    A  Review  of  Dental  Surgery,  By  J.  G.  Turxer. 

10.  The  Tree  Branch  Striations  Occasionally  Seen  in  Skia- 

grams of  Tuberculous  Lungs, 

By  C.  Willett-Cunxixgtox. 

11.  A  Note  on  the  Diagnosis  of  a  Fracture. 

By  P.  R.  Croseie. 

1.  Two  Cases  of  Multiple  Congenital  Deform- 
ities.— Beatson  tliinks  especial  interest  attaches 
to  those  cases  in  which  such  congenital  malforma- 
tions as  constrictions,  defiencies  of  parts,  and  cer- 
tain forms  of  club  foot  are  all  present  in  the  same 
individual,  especially  when  the  individual  is  healthy, 
physically  and  mentally,  in  other  respects.  Such  a 
coincidence  is  very  rare  and  justifies  the  author  in 
reporting  two  such  cases.  The  deformities  in  these 
cases  were  (i)  constriction  of  legs,  arms,  and  fin- 
gers, (2)  apparent  absence  of  toes  and  fingers.  (3) 
club  feet.  The  noteworthy  questions  in  such  cases 
are  (i)  the  exciting  cause  of  the  defects,  and  (2) 
how  far  are  such  cases  amenable  to  the  ordinary  sur- 
gical treatment  of  club  foot.  The  first  is  answered 
in  the  conclusion  that  the  causation  of  malforma- 
tions and  monstrosities  is  no  longer  assigned  to  ma- 
ternal impressions,  to  defects  in  the  male  and  female 
generative  elements,  or  to  foetal  diseases,  but  to  de- 
fective embryological  processes  and  to  mechanical 
pressure,  not  so  commonly  external  as  internal  and 
intrauterine,  especially  from  the  amnion  and  amniotic 
adhesions.  The  second  is  answered  afiirmatively, 
the  ordinary  surgical  treatment  of  club  foot  having 
been  found  quite  efficacious. 

2.  The  Pathogenesis  of  Arteriosclerosis. — Col- 
beck attributes  the  recent  increase  of  attention  to  the 
clinical  study  of  the  peripheral  circulation  to  the  in- 


88 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


troduction  of  mechanical  appliances  for  the  meas- 
urement and  registration  of  blood  pressure.  Athe- 
roma, it  is  affirmed,  is  a  purely  local  afifection  of  the 
arterial  wall,  the  lumen  of  the  vessel  being  narrowed, 
while  its  walls  bulge  and  are  weakened  and  distort- 
ed. Arteriosclerosis  consists  in  thickening  of  the 
whole  circumference  of  the  arterial  wall  along  con- 
siderable stretches  of  the  vessel  and  usually  over  a 
large  vascular  area.  The  two  diseases  are  quite  dis- 
tinct from  each  other  as  to  mode  of  origin,  area  of 
distribution,  and  ultimate  effects  on  arterial  walls 
and  circulation.  The  exact  cause  of  arteriosclerosis 
has  not  yet  been  positively  determined.  Theories 
abound  which  differ  materially  from  each  other,  but 
the  author  regards  as  most  probable,  in  view  of  the 
absence  of  uniformity,  in  conjunction  with  the  cor- 
relation of  the  morbid  changes  in  the  disease,  that 
such  changes  represent  stages  in  the  operation  of  a 
single  pathogenetic  process,  which  commences  with 
increase  of  function  and  hypertrophy  of  the  arterial 
muscular  coat,  progresses  with  functional  failure  and 
degeneration  of  the  muscular  substance,  and  culmi- 
nates in  hyperplasia  of  the  fibrous  tissue  elements  of 
the  arterial  wall. 

3.  The  Evolution  of  the  Modern  Operation  of 
Hysterectomy. — Bishop  considers  principally  the 
operation  as  performed  for  fibromyoma,  fibroadeno- 
ma, and  chronic  intractable  metritis.  The  earlier 
operations  were  completed  by  the  extraperitoneal 
fixation  of  the  lower  part  of  the  cervix,  with  intra- 
peritoneal drainage.  If  the  patient  recovered  it  was 
after  much  suffering,  and  usually  with  very  imper- 
fect results.  Cancer  of  the  cervix  was  almost  in- 
variably attacked  through"  the  vagina  and  the  organ 
removed  as  completely  as  possible  with  or  without 
the  appendages.  The  various  chatiges  in  technique 
which  have  been  suggested  are  described,  and  as  a 
summary  the  author  notes  the  following  methods 
which  are  at  present  in  vogue:  i.  Vaginal,  simple 
excision  with  preliminary  haemostasis,  with  or  with- 
out removal  of  upper  vaginal  wall.  Landau's  split- 
ting operation  with  consecutive  hjemostasis,  with  or 
without  morcellation.  2.  Abdominal,  excision  and 
haemostasis,  with  or  without  removal  of  upper  vag- 
inal wall.  Landau's  splitting  method  from  above 
with  secondary  haemostasis.  Doyen's  operation. 
Kelly's  operation  with  or  without  removal  of  the 
cervix.  3.  Combined,  beginning  from  the  vagina 
and  completing  from  the  abdomen. 

4.  The  Radical  Cure  of  Complete  Procidentia 
of  the  Uterus. — McGavin  considers  the  causes  of 
tliis  condition  as  (i)  those  which  depend  on  the 
uterus  itself ;  (2)  on  the  pelvic  floor  ;  (3)  on  the  ute- 
rine ligaments;  (4)  on  the  condition  of  the  bladder 
and  rectum;  and  (5)  on  general  increase  of  intra- 
abdominal pressure.  Hysterectomy  is  objected  to  as 
a  means  of  treatment  on  the  ground  that  it  is  a  mu- 
tilation and  not  without  danger.  It  is  also  frequent- 
ly followed  by  prolapse  of  the  vagina  and  remaining 
[K'lvic  organs.  X'entrosuspension  and  ventrofixation 
are  then  discussed,  both  as  to  their  disadvantages  and 
their  advantages.  As  some  of  the  latter  are  obvious, 
the  author  seeks  to  take  advantage  of  them,  and  sug- 
gests as  a  new  procedure  the  formation  of  dn  un- 
yielding ligament  of  silver  filagree  which  shall  be 
attached  to  the  posterior  aspect  of  the  fundus  uteri 
and  to  the  parietal  peritonaeum.    In  the  three  cases 


in  which  the  operation  has  been  tried,  the  last  two 
in  women  of  the  child  bearing  period,  it  is  said  that 
the  results  have  been  satisfactory. 

6.  Cholelithiasis,  Its  Early  Recognition  and 
Early  Surgical  Treatment.  —  Moynihan  thinks 
that  most  of  the  work  which  is  done  in  gallbladder 
surgery  concerns  advanced  pathological  changes. 
This  is  due  to  the  fact  that  heretofore  the  early 
stages  of  the  disease  have  seldom  been  recognized. 
The  author  believes  that  the  early  symptoms  are 
usually  referred  to  the  stomach,  and  that  which  has 
often  been  regarded  as  indigestion  accompanied  with 
more  or  less  severe  pain,  spasm  of  the  diaphragm, 
chilliness,  and  headache  are  usually  inaugural  symp- 
toms of  cholelithiasis.  If,  therefore,  these  early 
symptoms  can  be  noted  and  a  diagnosis  of  gallstone 
disease  in  its  incipiency  determined,  much  valuable 
time  may  be  saved  and  a  possible  fatal  result  avert- 
ed if,  at  that  time,  surgical  instead  of  medical  meas- 
ures are  resorted  to.  At  .  that  time  the  gallbladder 
is  unchanged  and  does  not  require  removal.  Med- 
ical measures  are  believed  to  be  insufficient,  and  the 
future  abounds  in  hopefulness  because,  in  the  au- 
thor's opinion,  early  operation  and  early  diagnosis 
will  be  the  rule. 

 <S>  

|m«Mngs  ai  ^sjcittits. 


AMERICAN    ASSOCIATION   OF  OBSTETRICIANS 
AND  GYN.¥:COLOGISTS. 

Ticciity-firsl  Annual  Meeting,  held  in  Baltimore,  Septem- 
ber 23,  32,  and  34,  iQoS. 

The  President,  Dr.  E.  Gustav  Zinke,  of  Cincinnati,  in  the 
Chair. 

(Concluded  from  page  46.) 

Ectopic  Gestation — Dr.  Charles  L.  Boxifield, 
of  Cincinnati,  divided  cases  of  tubal  pregnancy  into 
five  classes :  i .  Those  in  which  a  slight  haemorrhage 
occurred  at  an  early  period,  six  to  eight  weeks,  and 
killed  the  ovum.  Such  an  ovum  with  the  blood  clot 
might  be  absorbed  and  the  patient  regain  her  health. 
He  reported  a  case  representing  this  class.  2.  Those 
in  which  the  rupture  occurred  a  little  later  than  eight 
to  ten  weeks.  In  these  the  haemorrhage  was  so  pro- 
fuse as  to  cause  well  marked  classical  symptoms,  but 
was  not  so  profuse  as  to  menace  at  once  the  life  of 
the  patient.  3.  Those  with  immediate  danger  of  death 
frojii  haemorrhage.  This  class  was  not  numerous,  but 
it  gave  rise  to  practically  all  the  argument  as  to  the 
relative  virtues  of  immediate  and  deferred  opera- 
tions. The  best  course  to  pursue  in  the  treatment 
of  these  cases  was  to  operate  at  once  if  the  haemor- 
rhage was  in  progress  when  the  operator  saw  the 
case,  and  to  defer  operation  if  it  had  ceased.  4. 
Cases  with  a  living  foetus  which  had  developed  to 
the  sixteenth  week  or  later.  About  fifteen  years  ago 
he  operated  in  such  a  case  at  the  sixth  month.  The 
child  died  in  a  few  minutes,  and  the  mother  survived 
only  twenty-four  hours.  Her  death  was  due  to  loss 
of  blood  caused  by  the  separation  of  the  placenta 
from  the  intestines  and  omentum,  to  which  a  large 
part  of  it  was  attached.  5.  Cases  with  a  dead  foetus 
which  had  attained  an  advanced  stage  of  develop- 
ment.   The  death  of  the  foetus  rendered  the  opera- 


January  9,  1909.] 


PROCEEDIXGS  OF  SOCIETIES. 


89 


tion  safer  for  the  mother,  provided  it  was  not  under- 
taken until  a  sufficient  time  had  elapsed  for  a  change 
to  take  place  in  the  placenta.  He  had  operated  in 
two  such  cases. 

Dr.  GoLDSPOHK  did  not  think  that  all  patients 
with  extrauterine  pregnancy  should  be  operated  on 
at  once.  In  cases  of  tubal  abortion,  in  which  the 
ovum  slipped  out  of  a  somewhat  dilated  abdominal 
end  of  the  tube,  they  did  not  bleed  very  much,  and 
they  did  not  have  profound  shock.  The  natural 
course  was  for  the  haemorrhage  to  stop  by  the  for- 
mation of  a  haematoma  to  a  limited  degree,  and  there 
was  no  danger  to  life,  either  immediate  or  remote. 
An  operation  was  usually  advised  in  case  invalidism 
resulted  more  or  less  from  the  cicatricial  mass  of 
coagulated  blood  that  would  not  be  entirely  ab- 
sorbed, which  would  usually  form  an  entanglement 
about  the  ovary,  a  disease  which  would  require 
operation  later.  \\'hen  haemorrhage  was  stopped 
and  the  haematoma  was  accessible,  it  could  be  emp- 
tied by  the  vagina  if  one  made  the  proper  incision  for 
vaginal  drainage.  On  the  other  hand,  it  was  not 
safe  to  assume  that  in  rupture  of  a  tubal  gestation 
sac  haemorrhage  was  going  to  stop;  hence  it  was 
necessary  to  operate. 

Dr.  Frederick  had  operated  133  times  for  rup- 
tured ectopic  gestation  sac.  There  were  cases  of 
tubal  abortion  where  the  amount  of  haemorrage  was 
so  small,  and  finally  ceased,  that  eventually  the 
women  got  well  without  an  operation. 

Dr.  Henry  Schwarz,  of  St.  Louis,  said  there 
were  several- cases  on  record  in  which  women  with 
tubal  pregnancy  went  to  term.  He  had  himself 
operated  in  such  a  case.  The  sac  was  removed  in  its 
entirety,  and  then  opened,  disclosing  a  mature  mace- 
rated male  foetus  above  the  average  weight. 

Dr.  A.  B.  Miller^  of  Syracuse,  said  that  no  one 
could  lay  down  any  law  which  would  guide  the  or- 
dinary practitioner  as  to  the  time  for  operation  as  he 
came  in  contact  with  these  cases.  Some  patients 
with  a  ruptured  sac  undoubtedly  might  have  had 
their  lives  saved  if  they  had  been  operated  on  im- 
mediately. 

Dr.  Chase  said  that  every  case  must  be  a  law 
unto  itself  as  to  whether  to  operate  or  not. 

Dr.  Miles  F.  Porter,  of  Fort  Wayne,  Indiana, 
said  that  if  a  surgeon  was  called  to  see  a  person  with 
a  history  of  having  received  a  stab  wound  in  the 
neck,  and  there  were  indications  of  fatal  bleeding, 
naturally  he  would  search  for  and  tie  the  bleeding 
vessel.  This  was  the  thing  to  do  in  a  case  of  rup- 
tured ectopic  gestation  sac  in  which  haemorrhags  was 
going  on.  If  one  could  tell  when  haemorrhage  had 
ceased,  he  could  wait,  but  who  could  tell  this  ? 

Dr.  Thomas  B.  Noble,  of  Indianapolis,  believed 
in  the  doctrine  and  preached  the  philosophy  of  im- 
mediate operation  in  cases,  for  the  reason  that  if  the 
information  went  out  that  these  cases  were  to  be 
treated  by  procrastination  until  the  diagnosis  was 
certain,  these  patients  would  be  tinkered  with  by 
general  practitioners,  and  the  specialist  would  be 
called  in  only  to  sign  a  death  certificate. 

Dr.  Blume  emphasized  the  importance  of  distin- 
guishing which  patients  should  be  operated  on  and 
which  should  be  left  alone. 


Acute  Pancreatitis. — Dr.  Frank  said  that  pan- 
creatic disease  until  recent  years  had  been  very  much 
neglected,  and  referred  to  the  growing  importance 
of  its  study.  Pancreatic  diseases  were  not  all  in- 
curable. He  referred  to  the  anatomical  and  aetio- 
logical  factors  concerned.  He  laid  stress  on  the 
necessity  of  early  recognition.  After  describing  the 
svmptoms  he  spoke  of  the  treatment  as  being  sur- 
gical, and  in  order  to  be  effective  it  must  be  prompt. 
He  reported  three  cases  in  which  he  had  operated. 

Abscess  of  Gartner's  Canal. — Dr.  Magnus  A. 
Tate,  of  Cincinnati,  spoke  of  the  rarity  of  this  con- 
dition, and  reviewed  the  literature  of  the  subject 
He  reported  the  following  case:  Patient,  thirty-six 
vears  of  age  ;  normal  weight,  135  pounds.  Married 
fifteen  years ;  had  never  been  pregnant,  and  had 
never  been  unwell.  Had  never  had  any  discharge 
of  a  bloody  character  from  the  vagina,  and  never 
had  had  any  of  the  other  symptoms  which  often  ac- 
company a  menstrual  discharge.  For  some  years 
she  had  had  a  number  of  very  peculiar  attacks,  never 
knowing  what  caused  them,  and  she  had  never 
had  anv  satisfactorv  explanation.  The  trouble  be- 
gan with  a  pain  in  the  pelvic  region  accompanied 
by  rigors,  this  being  followed  by  distinct  chills,  rapid 
pulse,  and  high  temperature.  This  would  last  from 
a  few  days  to  a  week  or  two,  then  there  would  be  a 
vaginal  discharge  of  a  little  pus,  which  was  always 
followed  bv  a  subsidence  of  symptoms,  and  an  ap- 
parent recovery  would  ensue.  The  patient  would 
then  get  up,  go  about  her  household  duties,  and  be 
free  from  another  spell  from  six  months  to  a  year,, 
when  she  would  be  attacked  by  a  similar  sickness. 
She  was  somewhat  emaciated,  only  weighing  about 
100  pounds,  was  very  feeble,  her  temperature  rang- 
ing from  102°  to  104°,  and  the  pulse  from  120  to 
130.  Upon  abdominal  examination  there  was  some 
tenderness  elicited  over  both  the  right  and  left  lower 
sides  of  the  pelvis.  Vaginal  examination  was  very 
painful,  and  the  patient  said  there  had  been  for  a 
few  days  a  slight  watery  flow  mixed  with  a  little 
pus.  The  vagina  was  very  hot  and  exquisitely  ten- 
der, so  that  an  unsatisfactory  examination  was  made. 
The  patient  consented  to  go  to  a  hospital.  After 
complete  anaesthesia  a  vaginal  examination  disclosed 
a  small  anteverted  uterus,  but  no  tubes  or  ovaries 
could  be  felt.  On  the  right  wall,  at  a  central  point 
between  the  anterior  and  posterior  vaginal  walls,  was 
found  a  decided  thickening,  and  on  tracing  it  up  it 
felt  like  a  ridge  of  massed  tissue,  which  passed  up  to 
the  side  of  the  cervix  in  the  vaginal  vault.  Being- 
still  at  a  loss  to  account  for  symptoms,  he  opened  the 
posterior  cul-de-sac,  and  on  careful  palpation  thought 
he  detected  a  small  fluctuating  mass  in  the  right 
broad  ligament,  but  no  ovaries  or  tubes  were  pres- 
ent to  the  examining  finger.  After  packing  some 
gauze  in  the  back  of  the  uterus  he  opened  up  this 
ridge  of  vaginal  ligament  as  far  as  he  could.  He 
thought  best  at  this  time  to  stop  hunting  and  make 
an  abdominal  section  later  if  the  woman's  condition 
would  allow  of  it.  The  following  day  the  gauze 
which  had  been  placed  in  the  ridge  tissue  was  batbed 
in  pus  which  was  constantly  being  discharged.  The 
temperature  subsided  and  the  patient  recovered.  For 
nine  months  her  health  had  been  excellent ;  no  p-iin 
or  tenderness  :  no  vaginal  discharge  ;  she  had  gained 


90 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


her  usual  weight,  and  was  normal  except  for  the  ab- 
sence of  menstrual  flow. 

Cesarean  Section. — Dr.  Frederick  gave  a 
resume  of  the  present  status  of  this  operation,  and 
said  that  until  within  recent  years  it  was  appealed  to 
only  as  a  last  resort.  The  operation  now  was  as  safe 
as  any  other  abdominal  operation,  if  done  early. 
The  consensus  was  becoming  favorable  to  Cjesarean 
section  as  being  preferable  in  contracted  or  deformed 
pelves  to  a  protracted  high  forceps  operation,  ver- 
sion, symphysiotomy,  or  pubiotomy.  Was  it  not 
preferable  also  to  accouchement  force  in  severe 
urjemic  convulsions  or  in  placenta  prsevia  with  cen- 
tral implantation? 

The  Development  of  the  Human  Ovum  during 
the  First  Eight  Weeks  of  Pregnancy. — Dr. 
ScHWARZ  called  attention  to  the  fact  that  all  text- 
books of  obstetrics  described  the  ovum  and  foetus  at 
the  end  of  ten  periods  of  twenty-eight  days  each, 
and  they  all,  without  exception,  declared  the  ovum 
to  be  of  the  size  of  a  pigeon's  egg,  and  the  foetus  of 
a  length  of  seven  to  ten  millimetres  at  the  end  of  the 
first  lunar  month,  that  is  to  say,  before  the  woman's 
menstruation  was  overdue.  The  fact  was,  the  young- 
est ovum  on  record,  that  of  Peter,  which  was  of  the 
size  of  a  hemp  seed,  was  found  when  menstruation 
was  three  days  overdue,  and  belonged  therefore  to 
the  middle  of  the  fifth  week  of  pregnancy,  or  to  the 
beginning  of  the  second  lunar  month.  At  the  end  of 
the  first  lunar  month  the  ovum  was  still  a  very  small 
body,  and  passed  through  the  uterine  end  of  the  tube 
at  just  about  the  time  when  menstruation  became 
overdue.  All  ova  varying  in  size  from  a  millet  seed 
to  a  hen's  egg  belonged  to  a  second  lunar  month, 
and  their  description  had  to  be  rearranged. 

Dr.  ScHWARZ  believed  and  had  taught  for  twenty- 
five  years  that  ovulation  as  a  rule  preceded  menstru- 
ation, and  that  the  impregnated  ovum  dated  from 
the  first  menstrual  period  which  had  been  sup- 
pressed ;  that  during  the  first  lunar  month  of  our 
present  counting  pregnancy  existed  only  during  the 
last  few  days,  and  that  during  these  days  the  ovum 
migrated  -through  the  tube  without  noticeable  in- 
crease in  size,  reaching  the  uterine  cavity  about  the 
day  of  the  expected  menstruation,  and  there  casing 
off  its  shell  of  zona  pellucida,  as  demonstrated  by 
Spec  for  the  ovum  of  the  guinea  pig. 

The  President's  Address :  Solving  the  Prob- 
lem of  Obstetrics. — Tlie  president.  Dr.  E.  Gust.w 
ZiXKE,  of  Cincinnati,  reviewed  at  length  some  of  the 
important  events  in  medicine  and  surgery  of  the  last 
one  hundred  years.  He  compared  the  old  and  new 
methods  of  managing  the  pregnant,  parturient,  and 
puer]Hral  states.  Reference  was  made  to  the  changes 
in  the  practice  of  midwifery  within  the  last  fifty 
years.  There  was  practically  no  improvement  in  the 
maternal  and  foetal  mortality  and  morbidity  of  mid- 
wifery during  the  last  twenty  years.  The  present 
rate  of  obstetric  mortality  followed  immediately  that 
of  tuberculosis.  Eclampsia,  placenta  praevia,  oblique 
and  transverse  presentations,  and  narrow  and  con- 
tracted pelves  were  conditions  which  precipitated  in 
every  instance  a  conflict  unto  death  l)etween  mother 
and  child.  The  problem  of  preventing  this  conflict 
was  gradually  being  solved  by  the  aid  of  anaesthesia, 
anti.scpsis,  asepsis,  the  forceps,  symphysiotomy,  pu- 
biotomy, hebosteotomy,  and  Cresarean  section.  The 


gradual  elimination  of  the  induction  of  premature 
labor,  prophylactic  version,  the  high  forceps,  and 
perforation  of  the  living  child  had  begun.  The  prob- 
lem of  obstetrics  would  be  solved  when  the  custom 
of  sending  pregnant  and  parturient  women  with 
complications  to  a  maternity  hospital  had  become 
an  established  practice. 

Intraligamentous  Fibroids. — Dr.  Joiix  F.  Erd- 
MANN,  of  Xew  York,  said  that  during  the  past  seven 
years  he  had  operated  in  sixty-one  cases  of  fibroids, 
doing  forty-eight  hysterectomies  and  thirteen  myo- 
mectomies. Of  this  entire  number,  he  had  met  with 
five  of  intraligamentous  fibroids,  one  of  which  was 
a  case  of  multiple  fibroids  of  the  uterus,  with  two 
discrete  ones  in  the  right  broad  ligament.  The  four 
remaining  cases  were  instances  of  true  intraliga- 
mentous fibroids  in  the  full  sense  of  the  word.  None 
of  these  intraligamentous  masses  in  any  of  the  five 
cases  had  any  association  with  the  uterus,  except 
one,  in  which  the  association  was  due  to  an  inflam- 
mation occurring  in  the  pelvis,  and  an  exudative  or 
plastic  adhesion  to  the  uterus  was  evident.  In  four 
of  these  cases  the  tumors  were  hard  or  of  the  same 
consistence  as  ordinary  fibroids.  In  the  large  ro'md 
one  the  feeling  was  of  a  decidedly  soft  nature.  The 
author  reported  the  five  cases  in  detail,  with  recov- 
ery in  all  of  them. 

Uterine  Fibroids  Complicating  Pregnancy.  - 
Dr.  William  J.  Gillette,  of  Toledo,  read  a  paper 
on  this  subject  in  which  he  reported  cases.  The 
points  he  desired  to  bring  out  were  that  in  the  pres- 
ence of  a  pregnancy:  i.  Should  operations  for  the 
removal  of  fibroids  be  limited  to  the  fifth  month, 
and  if  not,  and  limited  to  any  time,  what  should  tha. 
time  be?  2.  That  not  only  pedunculated  and  sub- 
peritoneal tumors  might  be  removed,  but  interstitial 
as  well,  without  the  interruption  of  pregnancy.  3. 
That  even  very  small  fibroids  might  be  so  situated 
as  to  become  of  lethal  significance.  4.  That  fibroid 
tumors  might  practically  disappear  at  this  time  or 
shortly  subsequent  to  it.  5.  The  possibility  of  the 
removal  of  pedunculated  fibroids  during  labor,  al- 
lowing it  to  progress  naturally. 

Myoma  of  the  Cervix  Uteri. — Dr.  Frax<  i?  R  - 
DER,  of  St.  Louis,  made  some  remarks  on  this  sub- 
ject, reported  cases,  and  exhibited  specimens. 

Ovarian  Cystoma  Complicating  Pregnancy. — 
Dr.  CuMSTON  said  that  the  indication  for  operative 
interference  during  pregnancy  was  usually  the  sever- 
ity of  the  s)  mptoms.  The  cyst  should  be  removed 
by  abdominal  incision  or  posterior  colpotomy.  ac- 
cording to  the  situation  and  size  of  the  neoplasm. 
Cooling  of  the  abdominal  cavity  was  to  be  avoided 
during  the  operation,  as  it  was  an  important  factor 
in  tlie  production  of  premature  labor.  The  favorable 
results  obtained  when  an  operation  was  done  dur- 
ing the  first  few  months  of  pregnancy  were  not  acci- 
dental, and  a  timely  removal  of  the  cyst  might  pre- 
vent threatened  miscarriage.  An  operation  should 
be  advised  as  soon  as  a  diagnosis  of  cyst  had  been 
made,  in  order  to  avoid  complications  due  to  the 
presence  of  the  tumor  during  pregnancy  and  labor, 
or  post  oartum. 

Subdiaphragmatic  Abscess. —  Dr.  Jiuin  \\  . 
Keefe,  of  Providence.  R.  I.,  defined  an  abscess  of 
this  character  as  a  collection  of  pus,  or  pus  and  gas, 
which  lay  in  contact  with  some  portion  of  the  lower 


January  9,  1909.  | 


PROCEEDINGS  OF  SOCIETIES. 


91 


surface  of  the  diaphragm.  It  was  rarely  the  resuU 
of  traumatism,  but  was  generally  due  to  some  previ- 
ously diseased  condition.  The  author  reported  six 
cases,  and  the  main  points  which  he  emphasized 
were  the  avoidance  of  the  transpleural  route ;  the 
dangers  attending  the  use  of  the  aspirator  needle 
and  the  unnecessary  resection  of  the  ribs ;  the  advo- 
cacy of  exploratory  abdominal  incision,  with  drain- 
age through  the  same  or  in  the  tenth  or  eleventh 
interspace,  in  the  postaxillary  line. 

Injuries  to  the  Bladder  During  Hernia  Opera- 
tions.— Dr.  Skeel  said  that  since  the  appearance 
of  Bruener's  article  in  1898  and  Moynihan's  in  1901, 
bladder  herniae  were  apparently  increasing  in  fre- 
quency, as  shown  by  144  cases  collected  since  1896, 
to  be  compared  with  the  181  in  the  literature  previ- 
ous to  that  date.  These  herniae  were  no  more  fre- 
quent than  before,  but  present  methods  of  operating 
as  well  as  increased  care  in  looking  for  them  ac- 
counted for  the  more  frequent  reports  of  such  cases. 
The  cases  reported  showed  a  large  proportion  not 
diagnosticated  until  the  operation,  and  unfortunately 
a  great  number  were  not  recognized  until  the  blad- 
der was  injured,  and  a  fair  per  cent,  were  not  recog- 
nized even  at  the  time  of  injury.  Alany  of  these 
cases  were  artificially  produced  by  traction  upon  the 
sac.  and  efforts  to  place  the  ligature  high  up  resulted 
in  catching  the  bladder  wall  in  it.  In  addition  to  the 
ordinar}-  method  of  recognizing  the  bladder  by  the 
appearance  of  the  prevesical  fat  and  the  large  veins 
on  the  fundus,  the  administration  of  methylene  blue 
for  a  day  or  two  previous  to  hernia  operations  would 
cause  instant -recognition  of  the  bladder  injury  if  it 
occurred.  .Such  a  routine  measure  was  justified  by 
the  fact  that  the  mortality  rate  for  hernia  operations 
was  practically  uil  aside  from  accident. 

Surgery  of  the  Spleen,  with  Special  Reference 
to  Trauma. — A  Method  of  Encapsulation. — Dr. 
Walter  C.  G.  Kirchxer,  cf  St.  Louis,  reported 
twenty-two  cases  of  injury  to  the  spleen  treated  by 
splenectomy  and  other  methods.  After  describing 
the  various  symptoms  of  injury  to  the  spleen,  the 
writer  described  a  method  of  treating  haemorrhage 
from  the  spleen  by  encapsulation.  In  this  operation 
the  spleen  was  brought  forward  and  placed  in  the 
wound  as  in  splenectomy.  W^ide  sutures  were  in- 
serted through  the  spleen  to  approximate  the  frac- 
tured or  cut  edges,  and  these  sutures  were  also  used 
to  retain  the  omentum,  which  was  wrapped  over  the 
spleen  to  form,  a  sort  of  capsule.  The  organ  was 
then  replaced  in  the  splenic  fossa  and  held  in  posi- 
tion by  means  of  packs. 

The  author  reported  a  case  of  gunshot  wound  and 
two  cases  of  rupture  of  the  spleen  treated  by  this 
method,  with  recovery.  He  emphasized  the  serious- 
ness of  injury  of  the  spleen  and  advocated  an  early 
'Operation.  If  the  spleen  alone  was  involved,  and 
the  patient's  condition  warranted  it,  the  method  of 
encapsulating  the  spleen  with  orrentum  was  advo- 
cated for  the  following  reasons :  That  the  spleen 
need  not  necessarily  be  sacrificed  in  the  control  of 
haemorrhage;  that  a  portion  of  the  spleen  might  be 
removed,  arn'.  when  thus  treated  splenectomy  need 
not  necessarily  be  performed :  that  the  danger  of 
secondary  haemorrhage  was  very  greatly  lessened; 
ind  that  favorable  results  in  suitable  cases  warranted 
3  continuation  of  the  use  of  the  method. 


Treatment  of  Typhoid  Fever  Perforation. — Dr. 

John  D.  S.  Davis,  of  Birmingham,  Ala.,  had  op- 
erated in  ten  cases  of  typhoid  fever.  In  nine  perfo- 
rations were  found.  There  were  eight  recoveries 
arid  two  deaths.  One  typhoid  patient  was  operated 
upon,  with  recovery,  in  whom  no  perforation  was 
found.  Two  had  perforations  of  the  ileum ;  one 
had  a  perforation  in  the  ileum  and  at  the  base  of  the 
appendix ;  one  had  two  perforations  of  the  colon, 
ascending  and  transverse ;  four  had  appendicular 
trouble,  one  of  whom  later  had  a  perforating  anasto- 
mosis between  the  ascending  and  transverse  colon. 
In  the  last  fatal  case  there  were  two  perforations. in 
the  ileum. 

In  the  progress  of  typhoid  perforation,  the  indi- 
vidual's physical  condition,  the  power  of  resistance, 
the  character  and  virulence  of  the  organism  in  the 
peritoneal  cavity,  the  age  of  the  patient,  and  the  time 
elapsing  between  perforation  and  the  performance 
of  the  operation  were  important  factors  in  deter- 
mining the  result.  Perforation  occurred  in  all  grades 
of  severity,  from  the  ambulatory  to  the  haemorrhagic 
type.  It  was  most  common  in  those  with  severe  in- 
fection. It  was  more  common  in  the  haemorrhagic 
than  in  the  mild  cases.  It  was  frequent  in  the  so 
called  ambulatory  cases  of  typhoid.  The  ileum  was 
the  common  site  of  perforation,  the  majority  occur- 
ring within  twelve  inches  of  the  ileocaecal  valve ;  the 
appendix  and  colon  were  the  most  frequent  sites  of 
perforation.  Bacteriological  examination  of  the  peri- 
toneal fluid  was  an  aid  to  prognosis.  Bloi^d  e.xam- 
ination  was  important  in  making  a  diagnosis  of  ty- 
phoid fever.  All  the  patients  were  drained  except 
the  one  in  whom  no  perforation  was  found.  Inci- 
sion in  the  outer  border  of  the  right  rectus  fascia 
was  made  in  each  case.  In  one  case  the  pus  was 
mopped  out  and  drainage  eft'ected  through  a  stab 
wound.  He  recommended  the  Murphy  method  in 
treating  manv  of  this  class  of  cases,  with  accumula- 
tions of  pus,  large  or  small,  particularly  where  there 
was  not  much  faecal  extravasation. 

Some  Old  Fallacies  in  Retroversion  Surgery 
Revived. — Dr.  Goldspohx.  in  a  paper  on  this 
subject,  said  it  was  an  anatomical  fact  that  the  round 
ligaments  of  the  uterus,  irrespective  .':if  what  might 
be  their  normal  function  ordinarily,  were  the  only 
available  means  or  medium  for  a  harmless  and  per- 
manent cure  of  retroversion  in  fruitful  women,  be- 
cause they  alone  among  the  various  uterine  attach- 
ments were  a  part  of  the  uterus  itself,  and  as  such 
underwent  evolution  and  involution  with  that  organ 
during  and  after  gestation.  Years  of  abundant  clin- 
ical experience  had  set  forth  the  great  value  practi- 
cally of  this  anatomical  fact.  This  experience  had 
been  dearly  paid  for  by  numerous  shameful  parturi- 
ent deaths  from  dystocia  following  vicious  surgery 
for  a  minor  ailment  that,  in  itself,  would  never  cause 
death.  Nevertheless,  two  articles  had  recently  ap- 
peared that  rather  ignored  the  above  mentioned  ex- 
perience, and  advocated  principles  and  procedures 
which  g}-naecologists  had  threshed  out  and  discarded 
as  old  straw  some  time  ago. 

Typhlitis. — Dr.  Johx  A.  Lyoxs,  of  Chicago, 
stated  that  all  cases  of  typhlitis  and  perityphlitis  need 
not  necessarily  be  secondary  to  appendicitis.  He  re- 
ported a  case  of  abscess  of  the  caecum  in  support  of 
this  contention.    The  patient,  aged  sixteen,  had  suf- 


92 


LETTERS  TO  THE  EDITOR.— BOOK  NOTICES. 


[New  York 
Medical  Journal. 


fered  for  several  months  from  what  were  supposed  to 
be  recurrent  attacks  of  appendicitis,  and  during  the 
last  one,  in  November,  1907,  the  speaker  was  called 
in  and  found  the  patient  had  sufifered  ( i )  from  sud- 
den severe  abdominal  pain,  (2)  from  nausea  and 
vomiting,  (3)  from  general  abdominal  sensitiveness 
over  the  appendix,  and  (4)  from  elevation  of  tem- 
perature to  102°  F.,  soon  after  the  onset  of  the  severe 
pain.  These  were  Murphy's  cardinal  symptoms  for 
appendicitis,  and  making  a  diagnosis  of  appendicu- 
lar abscess,  because  of  a  large  Huctuating  mass  in- 
volving the  entire  iliopsoas  region,  the  patient  was 
ordered  to  the  hospital,  and  after  a  hurried  prepara- 
tion the  author  made  an  incision  over  the  tumor, 
when,  to  his  surprise,  he  found  a  large  abscess  of 
the  caecum.  The  appendix  was  in  its  usual  position 
and  apparently  normal  in  every  respect,  except  where 
it  was  about  to  be  involved  at  its  extreme  distal  end 
in  the  perityphlitic  inflammation.  After  cleaning  out 
the  abscess  cavity,  cutting  away  all  gangrenous  tis- 
sue, loose  and  raw  edges,  he_  removed  the  appendix, 
which,  upon  examination,  proved  to  be  normal,  ex- 
cept as  above  noted.  A  peculiar  feature  followed  the 
■operation,  in  that  the  patient,  who  had  suffered  from 
childhood  with  enuresis,  wetting  the  clothes  both 
night  and  day,  had  been  entirely  relieved  of  this  an- 
noying condition.  The  author  accounted  for  the  cure 
of  the  enuresis  by  saying  that  ganglionic  sympa- 
thetic fibres  joined  to  the  fourth  sacral  nerve,  which 
latter  supplied  the  neck  of  the  bladder,  must  have 
been  released  from  abnormal  pressure  by  the  com- 
plete cure  of  the  inflammatory  product. 

Repair  rather  than  Removal  of  the  Generative 
Organs  of  Women. — Dr.  John  E.  Canxaday,  of 
Charleston,  W.  Va.,  discussed  the  advisability  of 
trusting  pelvic  inflammation,  especially  that  of  the 
gonorrhoeal  type,  to  Nature,  and  treating  the  results 
of  infection  by  operation,  if  need  be,  later.  He  spoke 
of  the  need  for  treating  certain  cases  of  infection  in 
accordance  with  the  social  condition  of  the  woman. 
The  time  requirements  of  palliative  treatment  were 
being  extended.  He  pointed  out  the  advantages  of 
not  operating  until  physiological  resistance  to  infec- 
tion had  been  well  established.  Much  of  the  so 
called  palliative  treatment  was  useful  only  as  a  means 
of  diverting  the  mind  of  the  patient.  Subinvoluted 
prolapsed  organs  after  suspension  and  perinasor- 
rhaphy  would,  as  a  rule,  be  speedily  restored  to  the 
ni)rmal  size  by  the  relief  of  congestion  incident  to 
malposition.  Local  infections  might  be  best  attacked 
by  local  applications.  Repair  ratlicr  tiian  removal 
was  to  be  commended  in  general. 

Experiments  upon  Animals  Relative  to  the 
Question  of  Abdominal  Supporters  after  Laparo- 
tomy.— Dr.  KoiiKKT  T.  Morris,  of  New  York,  de- 
scrilxd  a  .series  of  experiments  whicli  he  had  con- 
ducted upon  animals  which  showerl  tiiat  it  was  un- 
necessary to  subject  patients  to  the  annoyance  of  ab- 
dominal supporters  so  frequently  as  was  commonly 
proposed.  The  author  did  not  employ  them  in  one 
per  cent,  of  hi.s'  laparotomies. 

The  following  papers  were  also  read :  Factors  of 
Safety  in  Abdominal  Operations,  Rased  on  Opera- 
tions, by  Dr.  (ieorge  VV.  Crile.  of  Cleveland;  Report 
of  a  Case  of  Castric  Tetany;  Operation,  Recovery, 
by  Dr.  John  Young  Brown  and  I^r.  W^illiam  Engel- 
bach,  of  St.  Louis. 


Officers  for  the  Ensuing  Year  were  elected  as 
follows :  President,  Dr.  William  H.  Humiston,  of 
Cleveland ;  vice-presidents.  Dr.  James  Edgar  Sad- 
lier,  of  Poughkeepsie,  N.  Y.,  and  Dr.  William  A.  B. 
Sellman,  of  Baltimore ;  secretary.  Dr.  William  War- 
ren Potter,  of  Buffalo  ;  treasurer.  Dr.  X.  O.  Werder, 
of  Pittsburgh.  Fort  Wayne,  Ind.,  was  selected  as 
the  place  for  holding  the  next  annual  meeting,  be- 
ginning on  the  third  Tuesday  in  September,  1909. 



DEMENTIA  PRECOX. 

247  West  135th  St., 
New  York,  December  5,  /yo^. 

To  the  Editor: 

Apropos  of  Dr.  Karpas's  contribution  of  this  date 
to  our  knowledge  of  the  aetiology  of  dementia  prae- 
cox — which  is  an  able  and  learned  disquisition  on 
"one  of  the  most  difficult  problems  of  psychiatry" — 
I  have  taken  the  liberty  of  questioning  the  diagnosis 
in  the  adult  cases,  Nos.  iv,  v,  and  vi.  A  careful 
perusal  and  study  of  the  symptoms  and  course  as 
outlined  in  the  article  give  one  a  composite  picture 
of  involution  melancholia  and  manic-depressive  in- 
sanity. Since  dementia  pr.xcox  is  essentially  a  dis- 
ease of  puberty  and  adolescence,  associated  with  the 
developmental  period  of  life,  we  encounter  a  serious 
stumbling  block  in  attempting  a  diagnosis  of  such 
a  condition  in  the  involutional  period.  Dementia 
praecox  is  associated  with  growth — mental  and  phy- 
sical— and  not  retrogression,  as  is  implied  in  adults 
past  forty,  unless  Shakespeare  implies  a  state  of  re- 
newed puberty  when  he  speaks  of  "a  second  child- 
hood and  mere  oblivion." 

The  psychoses  in  adults  of  middle  life  are  mani- 
fold and  bizarre  in  their  manifestations;  hence  a 
differential  diagnosis  at  times  is  well  nigh  impossi- 
ble. Psychic  alienation  in  an  adult  diflfers  markedly 
from  that  present  at  the  age  of  puberty.  Intense 
motor  and  psychical  activity  are  the  predominating 
features  in  the  former,  while  a  condition  of  hebe- 
tude, emotional  apathy,  and  psychic  deterioration  is 
glaringly  shown  in  the  latter.  This  should,  broadly 
speaking,  be  the  keynote  in  the  diagnosis  of  the 
prtecox  state,  for  the  prognosis  diflFers  and  interests 
us  mightily.  Charles  Rosenheck. 



{We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.\ 


Diseases  of  the  Skin  and  the  Eruptive  Fevers.  By  Jay 
Frank  Schambkrg,  A.  B.,  M.  D.,  Professor  of  Derma- 
tology and  Infectious  Eruptive  Diseases  in  the  Philadel- 
pliia  I'olyclinic  and  College  for  Graduates  in  Medicine, 
etc.  Fully  Illustrated.  Philadelphia  and  London :  W.  B. 
.Saunders  Coiiipnny,  lyoiS.    Pp.  10  to  534. 

The  reputation  of  I'hiladclphia  as  a  birthplace  of 
medical  classics  is  in  no  wise  diminished  by  the  ap- 
pearance of  this  the  latest  book  on  dermatology. 
While  it  does  not  rank  with  such  exhaustive  treat- 
ises as  those  of  Stelwagon,  Hyde  and  Montgomery, 


January  9,  1909.) 


BOOK  NOTICES. 


93 


Crocker,  and  others  of  that  class,  it  does  stand  high 
in  the  class  commonly  spoken  of  as  manuals,  or 
handbooks.  Its  style  is  clear  and  concise.  The 
more  important  diseases  are  written  of  at  some 
length,  while  those  of  lesser  importance  are  briefly 
described.  '^I'he  author's  endeavor  seems  to  have 
been  to  give  the  latter  only  in  sharp  outline. 

What  the  author's  idea  of  classification  is  we  learn 
from  the  table  of  contents.  It  differs  from  that 
usually  followed  in  several  particulars ;  but  in  such 
a  matter  who  can  criticise  when  he  remembers  the 
difficulties  that  beset  the  way?  His  first  class  is 
auc-emias,  with  two  divisions,  transient  and  persist- 
ent. Under  the  class  exudations,  or  inflammations, 
are  placed  all  the  parasitic  diseases,  scabies,  pedi- 
culosis, ringworm,  etc.  While  it  would  seem  to  be 
more  convenient  both  for  the  teacher  and  for  the 
student  to  preserve  the  old  class  of  parasitic  dis- 
eases, yet  they  are  inflammatory,  and  why  should 
they  not  be  included  under  the  inflammations?  It 
is  more  difficult  to  understand  why  sclerema  neona- 
torum, cedema  neonatorum,  and  plica  polonica  are 
found  under  the  atrophies.  Leucoplakia  stands  as 
the  only  representative  of  diseases  of  the  mucous 
membranes,  an  unnumbered  class. 

The  vocabulary  is  full.  Few  old  titles  are  omit- 
ttrl.  and  some  new  ones  are  introduced.  ()f  the 
latter  we  note  resistant  scaly  erythrodermias.  Under 
this  title  the  author  includes,  as  probably  identical 
or  at  least  closely  related,  parakeratosis  variegata, 
er}throdermie  pityriasique  en  plaques  disseminees. 
pityriasis  lichenoides  chronica,  dermatitis  psoriasi- 
formis  nodularis,  and  lichenoid  psoriasiform  exan- 
them.  Only  the  first  and  second  are  described.  All 
such  attempts  at  reducing  the  overburdened  derma- 
tological  nomenclature  are  most  welcome.  We  wait 
the  advent  of  the  master  mind  that  will  sweep  away 
many  of  the  diseases  now  regarded  as  entities,  and 
group  them  under  single  comprehensive  headings. 
Progressive  pigmentary  dermatoses  and  multiple 
cutaneous  tumors  associated  with  itching  are  two  of 
the  newer  claimants  of  our  attention. 

Dr.  Schamberg  is  familiar  with  the  newer  meth- 
ods of  application  of  electrical  energy,  and  the  sec- 
tion on  actinotherapy  and  radiotherapy  is  an  excel- 
lent one.  liis  judgment  of  radium  is  that  there  is 
no  adef|nate  evidence  to  show  that  it  will  accom- 
plish more  than  x  rays.  As  long  as  its  cost  is  so 
great  as  to  put  it  beyond  the  reach  of  most  of  us 
poor  doctors,  it  is  a  comfort  to  believe  as  he  does. 

-As  diagnostician  to  the  Bureau  of  Health  of  Phil- 
adelphia and  consultant  to  the  Municipal  Hospital, 
Dr.  Schamberg  has  had  great  opportunities  for 
studying  eruptive  fevers,  and  has  made  good  use 
of  them.  About  one  fourth  of  the  book  is  devoted 
to  the  consideration  of  those  diseases  and  the  erup- 
tions that  occur  in  such  diseases  as  typhoid  and 
t\phus  fever.  While  to  eczema  he  allots  twenty- 
one  pages,  to  smallpox  he  gives  forty-four  and  to 
scarlatina  twenty.  This  part  of  the  book  is  specially 
commendable,  and  so  exhaustive  that  it  would  be 
appropriate  to  reverse  the  title  of  the  book  so  that 
it  would  read,  The  Eruptive  Diseases  and  Diseases 
■of  the  Skin. 

The  publishers  have  done  their  work  well.  We 
have  noticed  but  one  typographical  error,  that  on 


page  29,  where  erythema  parayrimma  is  given  in 
place  of  erythema  paratrimma.  The  author  sup- 
plied excellent  negatives,  and  the  illustrations  are  of 
remarkabh'  high  grade.  We  heartily  commend  the 
book  to  all  who  wish  a  treatise  on  the  eruptive 
fevers  and  a  safe  guide  to  the  study  of  skin  diseases. 
The  opinions  expressed  are  conservative,  and  the 
treatment  advised  is  judicious. 

Diseases  and  Surgery  of  the  Genitourinary  System.  By 
Francis  S.  Watson,  M.  D.,  Senior  Visiting  Surgeon  to 
the  Boston  City  Hospital ;  lecturer  on  Genitourinary  Sur- 
gery, Harvard  Medical  School,  etc.  Assisted  by  John 
H.  Cunningham,  Jr.,  M.  D.,  Visiting  Surgeon  to  the 
Long  Island  Hospital,  Boston;  Assistant  Visiting  Sur- 
geon to  tlie  Boston  City  Hospital,  etc.  Two  Volumes : 
Vol.  I  The  External  Genitals,  the  Prostate  and  Bladder. 
Vol.  H  The  Kidneys  and  Ureters.  Philadelphia  and  New 
York:  Lea  &  Febiger,  igo8. 

This  work  is  alone  among  the  textbooks  on. 
genitourinary  diseases  recently  published  in  the 
English  language  in  that  it  deals  with  the  subject 
from  the  viewpoint  of  the  surgeon,  and  not  from 
the  aspect  of  the  "venereal  specialist"  or  the  "genito- 
urinary man."  To  illustrate  this  we  need  only  men- 
tion the  fact  that  the  local  treatment  of  gonorrhoea 
is  presented  in  three  pages,  while  over  fifty  pages 
are  devoted  to  the  consideration  of  urethral  stric- 
tures. The  medical  or  rather  the  nonoperative  treat- 
ment of  genitourinary  diseases  is  merely  sketched  in 
without  any  attempt  to  elaborate. 

The  authors  have  followed  the  fashion  set  within 
the  past  few  years  by  several  American  writers  on 
surgical  specialties,  and  have  presented  the  operative 
surgery  of  their  special  field  not  only  with  profuse 
and  admirable  illustrations,  but  also  with  minute  and 
precise  directions,  beginning  with  the  preparation 
and  position  of  the  patient  and  the  instrumentarium, 
to  the  conclusion  of  the  after  treatment.  While  this 
feature  of  the  book  will  prove  of  great  usefulness  to 
the  beginner  in  operative  genitourinary  surgery,  it 
is  to  be  distinctly  regretted  that  inore  space  was  not 
allotted  to  those  methods  of  urological  diagnosis 
which  must  be  at  the  command  of  the  surgeon  be- 
fore he  presumes  to  take  up  the  knife.  It  would 
have  been  desirable,  for  instance,  if  the  sections  on 
cystoscopy,  on  ureteral  catheterism,  on  x  ray  diag- 
nosis, on  the  functional  efficiency  of  the  kidneys, 
etc.,  were  more  fully  treated,  and  if  more  attention 
was  paid  to  such  diseases  as  do  not  require  opera- 
tive treatment.  As  an  example  of  this  class  of  affec- 
tions we  might  mention  chronic  prostatitis,  which  is 
not  regarded  as  of  sufficient  importance  by  the 
authors  to  merit  mention  in  the  book  under  review. 

Compilations  of  statistics,  with  clever  analyses  of 
the  results,  are  features  of  many  of  the  chapters  of 
the  book,  and  while  such  statistics  are  of  the  utmost 
value  in  casting  the  prognosis  of  a  case  and  in  de- 
ciding as  to  the  type  of  operation  best  suited  for  a 
certain  condition,  it  is  questionable  whether  the 
introduction  of  so  much  material  which  rightly  be- 
longs to  special  monographs  is  of  advantage  in  a 
general  textbook.  Perhaps  in  future  editions  a 
better  balance  will  be  attained  between  subjects 
which  have  been  merely  outlined  and  those  that  have 
been  most  thoroughly  dealt  with. 

It  could  not  be  expected  that  in  a  large  work  of 
this  kind  no  errors  should  have  found  their  way  into 


94 


BOOK  NOTICES. 


[New  Vork 
Medical  Jourxal. 


prim.  Watson  and  Cunningham's  book  is  singu- 
larly free  from  these,  aside  from  a  few  misspellings 
of  proper  names.  We  cannot  excuse  so  leniently, 
however,  the  interchanging  of  the  legends  of  Plates 
xii  and  xiii.  Readers  who  fail  to  read  the  context 
will  gain  an  erroneous  idea  of  Gram's  method  from 
these  plates  as  they  stand  now. 

After  the  senior  author  had  worked  for  four  years 
on  the  preparation  of  the  manuscript,  he  invited  a 
former  house  surgeon.  Dr.  J.  H.  Cunningham.  Jr., 
to  aid  him  in  finishing  the  book.  It  is  as  praise- 
worthy as  it  is  unusual  to  find  the  junior  author's 
name  on  the  title  page.  All  too  frequently,  we  fear, 
a  mere  mention  in  the  preface  is  all  that  falls  to  the 
lot  of  the  younger  colleague,  who  may  be  entitled  to 
more  prominent  recognition  in  virtue  of  both  the 
quality  and  the  quantity  of  his  contributions. 

With  the  limitations  in  scope  that  have  been  noted, 
and  that  are  due  to  an  individual  viewpoint  rather 
than  to  a  lack  of  a  broad  and  comprehensive  view  of 
the  subject — a  lack  of  which  the  distinguished 
authors  certainly  cannot  be  accused — Watson  and 
Cunningham's  book  may  well  be  called  a  masterly 
treatise,  preeminent  among  its  contemporaries. 

The  illustrations,  which  have  already  been  re- 
ferred to,  are  of  the  highest  excellence,  and  the 
typography  is  equally  choice. 

Diagnose  und  Therapic  dcr  Gonorrhoa  beim  Maiiitc.  Von 
Dr.  S.  Jessxer,  Konigsburg,  i,  Pr.  Wurzburg:  (C. 
Kabitzsch)  A.  Stuber,  1909.    Pp.  164. 

Dr.  Jessner's  handy  little  manual  forms  a  part 
of  his  well  known  series  of  lectures  on  dermatology 
and  venereal  diseases  for  practitioners.  As  such,  it 
is  probably  one  of  the  most  valuable  contributions 
to  this  series.  It  is  written  in  the  easy  going,  in- 
formal style  of  a  didactic  lecture,  without  the  cum- 
bersomeness  and  stiftness  of  textbook  style,  and 
makes  pleasant  as  well  as  instructive  reading.  It 
can  be  read  in  a  few  hours,  and  gives  one  a  very 
practical,  conservative,  yet  up  to  date  idea  of  the 
present  status  of  the  diagnosis  and  treatment  of 
gonorrhoea.  There  is  nothing  essentially  new  in 
the  author's  methods  of  treatment,  though  it  may 
be  said  that  he  comes  perhaps  nearer,  in  his  ways 
of  handling  gonorrhoea,  to  the  methods  in  vogue  in 
this  countn,-  than  any  other  recent  German  writer. 
In  his  practice,  irrigations  by  the  Janet  method  find 
a  prominent  place,  and  he  does  not  hesitate  to  use 
this  method  even  in  cases  of  subacute  posterior 
urethritis.  In  this,  perhaps,  he  will  find  but  few 
American  specialists  who  will  agree  with  him.  His 
methods  of  treatment  appeal  especially  to  the  gen- 
eral practitioner,  as  they  require  but  very  simple  ap- 
paratus and  confine  themselves  to  the  simplest  and 
safest  procedures.  Thus,  he  rejects  the  complicated 
dilators  as  belonging  to  the  domain  of  the  specialist, 
and  telKs  the  practitioner  to  use  metallic  sounds  in- 
stead, followed  by  dilating  irrigations  by  the  Janet 
method.  Great  caution  is  advised  in  all  procedures, 
and  the  most  minute  care  for  all  details  is  urged. 
One  point,  however,  deserves  special  mention  and 
particular  commendation — the  author's  insistence 
upon  the  unfortunately  but  too  often  disregarded 
principle  of  primuiu  nan  nocere.  He  strongly  warns 
against  overtreatment.  and  he  is  right,  for,  if  there 
were  less  polypragmasia  in  this  disease,  there  would 
be  fewer  "perpetual  gonorrhneics." 


The  Doctor  in  .-lit.  Twenty-rive  Reproductions  of  World, 
Famous  Masterpieces.  Edited,  with  Authentic  Text,  by 
Charles  Wells  Movltox.  Buitalo:  The  Douglas  Pub- 
lishing Company. 

This  is  a  sumptuous  quarto  volume  of  well  exe- 
cuted reproductions,  in  black  and  white,  of  noted- 
paintings  having  for  their  subjects  scenes  and  inci- 
dents illustrative  of  medical  practice.  It  is  exceed- 
ingly suitable  as  a  present  for  a  physician. 

7  licrapcuti^s  of  the  Circulation.    Eight  Lectures  Delivered 
in  the  Spring  of  1905  in  the  Physiological  Laboratory  of 
the  University  of  London.   Bv  i1\uder  Brunton,  Kt.,  M. 
D.,  D.  Sc..  LL  D.  (.Edin.),  LL.  D.  (.Aber.),  F.  R.  C.  P., 
F.  R.  S.,  Consulting  Paysician  to  St.  Bartholomew's  Hos- 
pital.   Published  under  the  Auspices  of  the  University 
of  London.     With  240  Illustrations.     Philadelphia :  P. 
Blakiston's  Son  &  Co.,  1908.    Pp.  xi-280. 
The  author  states  in  his  preface  that  these  lectures- 
were  not  originally  written  out.  but  now  appear  in 
the  form  of  a  revision  of  a  stenographer's  notes. 
The  length  of  time  which  has  elapsed  has  given  him. 
the  opportunity  to  add  several  appendices  largely 
devoted  to  descriptions  of  new  instruments.  Instru- 
ments for  registering"  the  circulatory  action  are,  in- 
deed, the  subjects  of  many  of  the  illustrations  in  the 
text.    They  answer  the  pttrpose,  but  most  of  them 
are  not  very  fine  specimens  of  the  engraver's  art. 
The  legend  under  one  of  them  (Fig.  8,  page  11) 
seems  to  be  erroneous  in  the  statement  "c,  b.  and  g 
are  the  float,"'  which,  we  suppose,  should  be  e,  f, 
and  g,  etc. 

Sir  Lauder  Brunton's  eminence  as  a  therapeutist 
will  doubtless  lead  to  wide  reading  of  these  lectures., 
They  give  clear  explanations  of  many  circulatory 
phenomena,  both  normal  and  pathological,  and  of 
particular  interest  is  the  author's  exposition  of  what 
he  calls  "'self  massage"  of  the  heart  and  arteries. 
There  is  little  if  anything  in  the  lectures  that  pur- 
ports to  be  new,  but  the  author's  inculcation  of  the 
best  teaching  in  regard  to  the  employment  of  reme- 
dies that  act  especially  on  the  circulation  is  clear 
and  for  the  most  part  impressive. 

There  has  been  an  inclination  of  late  to  credit 
plants  with  the  possession  of  something  like  a  nerv- 
ous system.  With  regard  to  this  matter  the  author 
expresses  a  conservative  view  (page  211).  Perhaps 
the  most  valuable  thing  in  the  book  is  his  synopsis 
of  the  action  of  digitalis  (page  149).  We  believe 
that  Sir  Lauder's  views  concerning  the  injurious 
effects  of  inhaling  tobacco  smoke  (page  169)  are 
erroneous.  ^lany  years  ago  an  esteemed  contrib- 
utor to  our  own  columns  gave  what  amounted  al- 
most to  a  demonstration  of  the  fallacy  of  such  views. 

Beitrage  aur  topographisch-chiritrgischen  Anatomic  der 
Pars  mastoidca.  "Von  Hakase  Dr.  H.  E.  Kanasuct.  Mit 
40  Tafeln  nach  photographi>clien  .'^ufnahmen  der  Prapa- 
rate  in  natiirlicher  Grosse.  Wien  und  Leipzig:  .Alfred 
Holder,  1908.    Pp.  25. 

Kanasugi  has  made  a  careful  study  of  4,000  hu- 
man skulls  in  the  anthropological  and  anatomical 
institutes  of  \'ienna  and  P>uda-Pesth,  and  has  tab- 
ulated the  data  of  this  vast  material  for  the  pur- 
poses of  practical  otology.  The  bulk  of  the  volume 
consists  of  photographs  of  skulls  and  of  some  of 
Onodi's  injected  specimens,  and  of  a  few  x  rav  pic- 
tures, all  in  natural  size,  allowing  the  measurements 
and  details  of  relations  to  be  applied  directly  in  op- 
erative work.  In  the  text,  which  is  short,  the  au- 
thor rliscusses  the  form,  size,  and  relations  of  the 


January  o.  :  909. 1 


MISCELLANY.— OFFICIAL  NEWS. 


95 


mastoid  process  and  its  anomalies,  anatomical  and 
topographical.  The  definite  conception  of  the  nor- 
mal measurements  and  the  usual  relations  between 
this  anatomical  landmark  and  the  deeper  struct- 
ures, such  as  the  lateral  sinus,  tympanic  cavity,  and 
inner  ear,  supplied  by  the  illustrations  and  the 
text,  must  be  valuable,  not  only  for  a  knowledge  of 
the  aetiolog)-  of  otitic  disease  and  intracranial  com- 
plications, but  for  the  requirements  of  operative 
procedures  on  the  mastoid  and  cranium  as  well. 

BOOKS,  PAMPHLETS.  ETC..  RECEIVED 

Gynakologic.  Von  Professor  Dr.  Sigmund  Gott.schalk 
in  BLrlin.  Mil  46  Abbildungen  iin  Te.Kt,  darunter  i  Farben- 
druck.  Wien  und  Leipzig:  Alfred  Holder,  1909.  Pp. 
-■<iv-355- 

The  Cure  of  Consumption  with  Subcutaneous  Injections 
of  Oils.  By  Thomas  Bassett  Keys,  M.  D.,  of  Chicago, 
Chairman  of  the  First  Organization  Committee  of  the 
American  Congress  of  Tuberculosis,  etc. 

La  Tuberculose  renale.  Rapport  presente  au  IV  Congres 
de  r.Association  des  medecins  de  langue  frangaise  de 
r.\merique  du  Xord,  a  Quebec,  Juillet  1908.  Par  le  Dr. 
Eugene  Saint-Jacques,  Prof,  agrege  a  la  I'Universite  Laval, 
Montreal,  Charge  de  la  Clinique  Chirurgicale  a  I'Hotel- 
Dieu,  etc.  Tricentenaire  de  la  Fondation  de  Quebec,  1608- 
1908.  Montreal :  Imprinieric  Lc  Progrcs,  Limitee,  1908. 
Pp.  40. 

Hints  to  Ships'  Surgeons.  By  J.  F.  Elliott,  L.  R.  C.  S., 
L.  R.  C.  P.  (Irel.).  London:  John  Bale,  Sons,  &  Daniels- 
son,  Ltd.,  1908.    Pp.  xii-64. 

Lehrbuch  der  physiologischen  Chemie.  In  zweiunddreis- 
iig  Vorlesungen.  Von  Emil  Abderhalden,  o.  Professor  der 
Physiologie  an  der  koniglichen  tierarztlichen  Hochsschule, 
Berlin.  Zwcite,  vollstandig  umgearbeitete  und  erweiterte 
.\uflage.  Mit  19  Figuren.  Berlin  und  Wien:  Urban  & 
Scliwarzenberg,  1909.    Pp.  vii-984. 

Traite  methodique  et  clinique  des  maladies  de  I'appareil 
respiratoire.  Base  sur  les  doctrines  medicales  de  I'Ecole 
le  Montpellier.  Par  le  Docteur  Germain  Key,  medecin  du 
preventorium  et  dispensaire  anti-tuberculeux  au  Bureau  de 
)ienfaisance  de  Toulouse.  Montpellier:  Coulet  et  Fils,  Edi- 
eurs,  1909.    Pp.  912. 

The  '  National  Standard  Dispensatory.     Containing  the 
Natural  History,  Chemistry.  Pharmacy,  Actions,  and  Uses 
if  Medicines.    Including  those  recognized  in  the  Pharma- 
;opceia?  of  the  United  States.  Great  Britain,  and  Germanv, 
vith  Numerous  References  to  other  Pharmacopoeias.  In 
\ccordance  with  the  Eighth  Decennial  Revision  of  the 
Jnited  States  Pharmacopuuia,  as  Amended  to  1908.  By 
lobart  Amory  Hare,  B.  Sc.,  M.  D.,  Professor  of  Thera- 
leutic^  and  Materia  Medica  in  the  Jefferson  Medical  Col- 
ege  of  Philadelphia,  etc. ;  Charles  Caspari.  Jr.,  Ph.  G., 
'har.  D.,  Professor  of  Theoretical  and  .\pplied  Pharmacy 
1  the  Maryland  College  of  Pharmacy  ( Department  of  the 
'niversity  of  Maryland),  Baltimore,  etc.:  Henry  H.  Rusby, 
I.  D..  Professor  of  Botany  and  Materia  Medica  in  the 
"ollege  of  Pharmacy  of  the  City  of  New  York  (Columbia 
niversity),  etc.,  Joseph  F.  Geisler.  Ph.  C.  Chemist,  New 
ork  State  Department  of  .■\griculture ;  Edward  Kremers, 
'h.  D.,  Professor  of  Chemistry,  L'niversity  of  Wisconsin, 
nd  I>aniel  Base,  Ph.  D.,  Professor  of  Inorganic  and  .\n- 
lytical  Chemistry,  University  of  Maryland.    Second  Edi- 
on.  Thoroughly  Revised  and  Much  Enlarged.  Philadel- 
lia  and  New  York:  Lea  &  Febiger.  1909.    Pp.  xlviii-2011. 
Der  Hirnabszess.    Von  Prof.  Dr.  H.  Oppenheim  und 
rivatdozent  Dr.  R.  Cassirer  m  Berlin.    Zweite,  umgear- 
-itete  Auflage.    Mit     Tafeln  in  Farbendruck  und  6  .^b- 
Idungen  im  Texte.    Wien  und  Leipzig:  Alfred  Holder, 
09.    Pp.  304. 

Die  Tetanic  der  Kinder.  Von  Prof.  Dr.  Theodor  Esch- 
ich,  Vorstand  der  k.k.  Universitats-Kinderklinik  in 
ien.  Mit  15  .Abbildungen  imd  2  Tafeln.  Wien  und  Leip- 
?:  .Alfred  Holder,  1909.    Pp.  ix-268. 

.-Viiatomische  Veranderungen  in  vier  wegen  Drucksteiger- 
ig  cnukleierten  Augen  mit  Netzhauthamorrhagien.  Von 
.  Dahlstrom,  Med.  Lie.  Mit  fiinf  chromolithographischen 
ifelii.  Leipzig:  Alexander  Edelmann,  1908.  Pp.  148. 
Nfurasthenie  et  nevroses.  Leur  guerison  definitive  en 
rc  libre.    Paris:  Felix  .Alcan.  1909.    Pp.  407. 


MiscellanD. 


How  to  Remove  Stuck  Stoppers. — The  Sun  for 
January  3d  quotes  the  following  from^the  Scientific 

American: 

"Reagent  bottles  holding  caustic  alkalies,  alkaline  car- 
bonates, etc.,  very  frequently  become  fixed  and  the  usual 
method  has  been  to  tap  the  stopper  with  a  wooden  block 
or  the  application  of  heat  to  the  neck,  or  a  combination  of 
both.  Results  are  poor  in  certain  cases  and  often  result 
in  the  fracture  of  the  neck. 

"The  inverse  process  may  be  used  to  advantage.  In 
other  words,  freeze  the  stopper,  thus  causing  a  contraction 
of  the  stopper  from  the  neck.  The  bottles  which  I  used 
for  experiment  had  failed  to  open  under  the  heating  and 
tapping,  and  were  bad  cases  of  tixed  stoppers.  The  bottles 
held  sodium  carbonate  that  had  formed  sodium  silicate,  an 
excellent  cement,  and  so  were  firmly  fixed.  They  were 
inverted  in  a  mi.x.ture  of  crushed  ice  and  calcium  chloride, 
taking  care  that  the  freezing  solution  did  not  touch  the  lips 
Qf  the  bottles. 

"After  standing  twenty  minutes  each  stopper  was  re- 
moved without  the  slightest  exertion.  This  is  the  neatest 
and  safest  way  to  remove  stoppers  from  bromine  bottks 
and  ether  corrosive  chemicals." 

 e  


(Official  Beius. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports : 

The  follo-wiiig  cases  of  smallpox,  yellozv  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  zveek  ending  January  i,  iqcX): 

Smallpox — United  States. 
Places.  Cases.  Deaths. 

.Arkansas — Te.xarkana  .Nov.  22-28   3 

California — Los  .Angeles  Dec.    51J   1 

California — S211  Francisco  Dec.    12-19   ' 

Illinois — Belleville  Dec.    13-20   3 

Indiana — La  Fayette  Dec.    19-2;   i  i 

Kansas — Topeka  Dec.    5-12   7 

Maine- -Canadian  Border  Dec.    12   Present. 

Mississippi — De  Soto  Nov.  i-Dec.  22   136 

Montana  Nov.  24-Dec.  15   9 

New  Hampsiiire — Hinsdale  Dec.    23   6 

New    Hampshire — West  Chester- 
field  Dec.    23   I 

New  Hampshire — Westmoreland.  .  .Dec.    23   i 

Ohio- — Cincinnati  Dec.    11-18   S 

Texas — Gonzales  County  Oct.   1-19   Present. 

Texas — Laredo  Dec.    26   2 

Texas — San  .Antonio  Nov.  28-Dec.  19   6 

W^ashington — Spokane  Dec.  5-12   i 

Wisconsin — La  Crosse  Dec.   5-19   4 

Wisconsin — Manitowoc  Dec.    12-IQ   4 

Wisconsin — Milv.aukee  Nov.  21-28   3 

Smallpo.r — Fo  reign . 

-Algeria — .Algiers  Nov.  1-30   20 

Brazil — Bahia  Oct.  31-Nov.   14   51  2 

Brazil — Santos  Oct.    1-3:   26  11 

Canada — Kingston  Dec.   5-12   2 

Ceylon — Colombo  Nov.   1-7   25  4 

China — Shanghai  Nov.    14-21   Present. 

France — Marseille  Nov.  i-jo   i 

France — Nantes  Nov.  22-29   2 

France — Paris  Nov.   21-Dec.    5   6  i 

Italy — Florence  Nov.  23-30   2 

Java — Batavia  Oct.    3-10   2 

Nov.  I- 1 4   2 

Malta  Nov.  21-28   i    On  ship. 

Portugal — Lisbon  Nov.  28-Dec.  25   i 

Russia — Riga  Nov.  28-Dec.  3   3 

Russia — St.  Petersburg  Nov.    17-24   6  4 

Scriia — Belgrade  J^ov.  18-25   ? 

Spain — Barcelona   Nov.  27-Dec.  5   3 

Yellow  Fever — Foreign. 

Barbadoes  Dec.  29   2  2 

Brazil — Bahia  Oct.  31-Nov.  6   i 

Brazil — Manaos  Nov.  21-28   2 

Ecuador — Guayaquil  Nov.  21-28   2 

Martinique — Fort  de  France  Nov.  21-28   2  i 

Mexico — Itzincal  I>ec.   6-12   2  2 

Me.vico- — Mexcanii  Dec.   6-12   2  i 

Me.xico — Merida  Dec.  6-12   3  i 

Mexico — Vera  Cruz  Dec.   6-12   3 

Cholera — Foreign. 

India — Rangoon  Nov.  7-14  

Russia— General  Nm  .  7-14  4r9 


6 
i8g 


96 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  Vork 
Medical  Jouknai. 


Plague — Foreign. 

Australia — Brisbane  Nov.  1-7   i 

Brazil — Bahia  Oct.  30-Nov.  14   3  7 

Brazil — Rio  de  Janeiro  Nov.  8-15   7  ^  3 

Ecuador- — Guayaquil  Nov.  21-28   '  i 

Egypt — Genera]  Nov.   1-21  7.4'6  5.569 

Egypt — Bombay  Nov.    18-24   5 

Indo-CIiina — Cholen  Oct.    18-24   5  5 

Turkey — Bagdad  Nov.  7-14   4  i 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  chances  and  duties  of  commissioned  and 
other  ofUcers  of  the  United  States  Public  Health  and  Ma- 
rine Hospital  Service  for  the  seven  days  ending  Deceinbci 
23,  igo8: 

Billings,  W.  C,  Passed  Assistant  Surgeon.  Granted  four- 
teen days'  leave  of  absence  from  December  25,  1908. 

Blanch.ard,  J.  F.,  Acting  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  December  17,  1908. 

BowEKS,  Paul  E.,  Acting  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  December  17,  1908, 
under  paragraph  210,  Service  Regulations. 

CreeLj  R.  H.,  Passed  Assistant  Surgeon.  Granted  seven 
days  leave  of  absence  from  December  21,  1908,  under 
paragraph  191,  Service  Regulations. 

CuM.MiNG,  Hugh  S.,  Passed  Assistant  Surgeon.  Lea\e  of 
absence  for  one  month  from  October  29,  1908,  granted 
September  2,  1908,  amended  to  read  twenty-six  da^s 
from  October  29,  1908. 

Frost,  W.  H.,  Assistant  Surgeon.  Directed  to  report  to 
Surgeon  G.  W.  Stoner,  chairman  of  board  of  examin- 
ers, January  12,  1909,  to  determine  fitness  for  promo- 
tion to  the  grade  of  Passed  Assistant  Surgeon. 

Kastle,  Jos.  H.,  Chief  Division  of  Chemistry,  Hygienic 
Laboratory.  Granted  ten  days'  leave  of  absence  from 
December  15,  1908. 

KoRN,  W.  A.,  Passed  Assistant  Surgeon.  Granted  ten 
days  leave  of  absence  from  December  24,  1908. 

Light,  S.  D.  W.,  Acting  Assistant  Surgeon.  Granted  three 
days'  leave  of  absence  from  December  24,  1908,  without 
pay. 

Mead,  F.  W.,  Surgeon.  Granted  two  days'  leave  of  absence 
from  December  25, -1908. 

MuLLAN,  E.  H.,  Assistant  Surgeon.  Directed  to  report  to 
Surgeon  G.  W.  Stoner,  chairman  of  lioard  of  exam- 
iners, January  12,  1909,  to  determine  fitness  for  pro- 
motion to  the  grade  of  Passed  Assistant  Surgeon. 

Oakley,  J.  H.,  Passed  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  December  18,  1908. 

Wakefield,  H.  C,  Acting  Assistant  Surgeon.  Granted  six 
days'  leave  of  absence  from  December  14,  1908,  under 
paragraph  210,  Service  Regulations. 

Walkij;y,  W.  S.,  Acting  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  December  23,  1908. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  ofR,- 
cers  serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  week  ending  lanuary  2,  igog: 
Alle.n",  J.  H.,  Captain,  Medical  Corps.    Ordered  to  Fort 

Monroe,  Va.,  for  duty,  upon  return  from  Cuba. 
Anderson,  E.  A.,  First  Lieutenant,  Medical  Reserve  Corps. 

Ordered  to  accompany  Third  Squadron,  Fifth  Cavalry, 

from  Fort  Wingate,  N.  M.,  to  San  Francisco,  Cal. 
Bevans,  J.  L.,  Captain,  Medical  Corps.    Ordered  to  A.  G. 

H.,  San  Francisco,  Cal.,  for  duty  with  Company  B.,  H. 

C,  upon  return  from  Cuba. 
Church,  J.  R.,  Major,  Medical  Corps.    Ordered  to  rejoin 

proper  station.  Fort  Robinson,  Neb.,  upon  return  from 

Cuba. 

Davidson,  W.  T.,  Captain,  Medical  Corps.    Sailed  from 

San  Francisco,  Cal.,  for  Manila,  P.  I.,  returning  from 

leave  of  absence  in  the  United  States. 
Fauntleroy,  p.  S.,  Major.  Medical  Corps.    Ordered  to 

Fort  Benjamin  Harrison,  Ind.,  for  duty,  upon  return 

from  Cuba. 

Hart,  W.  L.,  First  Lieutenant,  Medical  Corps.  Granted 

leave  of  absence  for  ten  days. 
Hartxett,  F.  H.,  Captain,  Medical  Corps.    Granted  leave 

of  absence  for  four  months,  with  permission  to  return 

to  the  United  States  via  Europe. 
Hartsock,  F.  M.,  Major,  Medical  Corps.    Ordered  to  Fort 

Meade,  S.  D.,  for  duty,  upon  return  from  Cuba. 
Humphreys,  H.   G.,  Captain,   Medical   Corps.  Granted 

leave  of  absence  for  seven  days. 


Johnson,  R.  W.,  Major,  Medical  Corps.  Ordered  to  St. 
Louis,  Mo.,  to  take  charge  of  the  medical  supply  depot 
at  that  city,  upon  return  from  Cuba. 

Lemmon,  Robert,  First  Lieutenant,  Medical  Reserve  Corps. 
When  relieved  from  duty  at  Fort  Caswell,  N.  C,  or- 
dered to  Fort  Howard,  Md.,  for  duty. 

Lewis,  W.  F.,  Major,  Medical  Corps.  Granted  an  exten- 
sion of  ten  days  to  his  leave  of  absence. 

PiNKSTON,  O.  W.,  First  Lieutenant,  Medical  Crops. 
Granted  leave  of  absence  for  seven  days. 

Reasoner,  M.  a.,  First  Lieutenant,  Medical  Corps.  Or- 
dered from  San  Francisco,  Cal.,  to  Fort  Caswell,  N.  C, 
for  duty. 

Rhoads,  T.  L.,  Captain,  Medical  Corps.    Leave  of  absence 

extended  two  monihs. 
Tefkt,  W.  H.,  Captain,  Medical  Corps.    Ordered  to  Fort 

Baker,  Cal.,  for  duty,  upon  return  from  Cuba. 
Thomason,  H.  D.,  Captain,  Medical  Corps.    Ordered  to 

Fort  Douglass,   Utah,    for  duty,   upon   return  from 

Cuba. 

Tyler,  G.  T.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  from  Fort  Jay,  N.  Y.,  to  Fort  H.  G.  Wright, 
N.  Y..  for  temporary  duty. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers ser7'ing  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  it'cek  ending  January  2,  igog: 
BiELLO,  J.  A.,  Assistant  Surgeon.     Detached  from  duty 
with  Pacific  Fleet  and  ordered  to  duty  at  the  Naval- 
Hospital,  Mare  Island,  Cal. 
DuiiiGG,  J.   T.,  Assistant   Surgeon.     Detached  from  the 
Navy  Yard,  Mare  Island,  Cal.,  and  ordered  to  duty 
with  the  Pacific  Torpedo  Fleet. 
KiNDi.EBERGER,  C.  P.,  Surgeon.    Ordered  to  the  Navy  Yard, 
Mare  Island,  Cal..  and  to  additional  duly  in  command 
of  the  Naval  Medical  Supply  Depot. 
Lowndes,  C.  H.  T.,  Surgeon.    Orders  to  the  Navy  Yard,. 
Mare  Island,  Cal.,  revoked ;  ordered  to  continue  treat- 
ment at  the  Naval  Medical  School  Hospital,  Washing- 
ton, D.  C. 

RiGGS,  R.  E.,  Passed  Assistant  Surgeon.  Detached  from 
duty  with  Marines  in  Cuba  and  ordered  home  to  await 
orders. 

 ^  

Sirt^s,  Parriagw,  ani  i^at^s. 


Married. 

Cone — W'akner. — In  Brooklyn,  N.  Y.,  on  Friday,  De- 
cember 25th,  Dr.  Ralph  Spencer  Cone  and  Miss  Zoe 
Warner. 

Forest — Grove. — In  Chambcrsburg.  Peimsylvania,  on 
Tuesday,  December  29th,  Dr.  Fletcher  Bliss  Forrest  and 
Miss  Pearl  Grove. 

Gaudet — Mathews. — In  Philadelphia,  on  Tuesday,  De- 
cember 22nd,  Dr.  A.  B.  Gaudet,  of  New  Orleans,  and  Miss 
Clara  M.  Mathews. 

Died. 

Dunn. — In  Greenville,  Mississippi,  on  Sunday,  Decem- 
ber 20th,  Dr.  Samuel  Reed  Dunn,  aged  sixty-six  years. 

EisBEiN. — In  Buffalo,  New  York,  on  Thursday,  Dccom- 
ber  24th,  Dr.  David  C.  Eisbcin,  aged  sixty-five  years. 

Fowler. — In  Buffalo.  New  York,  on  Wednesday,  Decem- 
ber i6th.  Dr.  Joseph  Fowler,  aged  sixty-one  years. 

Hill. — In  Baltimore,  Marvland,  on  Friday,  December 
25th,  Dr.  William  Nevin  Hill'. 

KiEFFER. — In  Cheyetme,  Wyoming,  on  Thursday,  Decem- 
ber 31st,  Dr.  Charles  F.  KiefTer. 

Knowles. — In  Three  Rivers,  Michigan,  on  Wednesday, 
December  .'^oth.  Dr.  I^wrcnce  D.  Knowles. 

Lewis. — In  North  Norwich,  New  York,  on  Tliin-sday. 
December  24th,  Dr.  James  B.  Lewis,  aged  seventy-eight 
years. 

Penrose. — In  Philadelphia,  on  Saturday,  December  26tli, 
Dr.  Richard  \.  F.  Penrose,  aged  eighty-one  years. 

Plummkr. — In  Shoals,  Indiana,  on  Wednesday,  Decem- 
ber 23d,  Dr.  I.  Nutt  Plumnier,  aged  seventy  years. 

Shepherd. — In  .Salt  Lake  City,  Utah,  on  Friday,  Decem- 
ber iitli.  Dr.  John  M.  Shepherd,  aged  thirty-eight  years. 

Taylor. — In  .Atlanta,  Georgia,  on  Friday,  December  _'5th. 
Dr.  Walter  .-\.  Taylor,  aged  fifty  years. 

Weaver, —  In  Wilkesbarre,  Pennsylvania,  on  Monda\  .  !  )<- 
ccmber  28th,  Dr.  W.  G.  Weaver,  aged  sixty-two  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  rlt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  3. 


NEW  YORK,  JANUARY  16,  1909. 


Whole  No.  1572. 


(Original  Commaniratwns. 


"SYMPOSIUM"  ON  VACCINATION. 
THE  ROLE  OF  THE  BUREAU  OF  HEALTH  IN 
PUBLIC  VACCINATION.* 
By  Alexander  C.  Abbott,  M.  D., 

Philadelphia, 

Chief  of  the  Bureau  of  Health. 

If  we  were  assembled  this  evening,  to  debate  the 
efficacy  of  vaccination,  I  for  one  should  feel  myself  in 
rather  a  foolish  position  ;  but,  as  we  are  not  here  for 
this  purpose,  but  to  emphasize  what  it  has  done  and 
can  do,  I  am  pleased  to  take  part  in  these  proceed- 
ings and  contribute  what  I  can  from  the  official 
standpoint.  When  smallpox  appears  in  a  community, 
those  who  are  responsible  for  suppressing  the  out- 
break are  usually  supplied  with  two  weapons  of  de- 
fense against  the  disease,  one  being  hospitals  for  the 
segregation  of  -cases,  and  the  other  being  vaccina- 
tion. The  former  is  of  great  convenience  in  lessen- 
ing the  number  of  foci  in  private  houses,  placing 
patients  under  conditions  in  which  they  can  be  prop- 
erly cared  for,  and  enabling  the  authorities  to  clean 
up  the  localities  from  which  the  cases  come.  While 
this  is  an  advantage  and  should  not  be  minimized,  it 
is  insignificant  as  compared  with  the  value  of  vac- 
cination in  getting  smallpox  out  of  the  community 
and  preventing  it  from  reappearing. 

There  is  no  law  in  Pennsylvania  providing  for 
general  compulsory  vaccination.  Whether  there 
ever  will  be,  I  cannot  say ;  but  we  have  a  very  good 
law,  which,  if  carefully,  conscientiously,  and  dis- 
cretely administered,  will,  I  feel  sure,  prevent  any 
subsequent  outbreaks  of  smallpox  of  any  degree  of 
seriousness.  In  Philadelphia,  the  first  Vule  of  the 
Bureau  of  Health  is  to  pay  particular  attention  to 
systematic  vaccination,  doing  the  work  without  hys- 
teria, and  as  a  routine  matter  of  course.  In  past 
days,  every  reliable  practitioner,  after  he  had  deliv- 
ered a  woman,  would  come  back  within  a  short  time 
and  vaccinate  the  infant.  We  are  trying  to  revive 
this  custom,  and  I  think  that  I  see  some  degree  of 
success  ahead  of  us.  Every  medical  inspector  of  the 
Bureau  of  Health,  when  sent  to  examine  a  case  of 
diphtheria  or  of  any  other  contagious  disease,  carries 
a  slip,  on  the  bottom  of  which  are  printed  the  fol- 
lowing questions :  "Are  there  any  persons  unvac- 
cinated?  If  so,  how  many?  and  what  are  their 
names?"  If  any  unvaccinated  persons  are  found, 
the  bureau  takes  the  matter  up  with  the  family  doc- 

*This  and  the  following  three  articles  were  read  at  a  "symposium" 
on  Vaccination,  held  at  a  meeting  of  the  Philadelphia  County  Medi- 
cal Society,  November  25,  1908. 


tor;  and  if  he  is  not  interested,  the  bureau  attends 
to  the  vaccination.  Any  doctor  so  neglectful  of  the 
interests  of  the  community  as  to  allow  children  to 
grow  up  unvaccinated  deserves  no  consideration 
from  those  responsible  for  the  public  health. 

It  may  be  of  interest  to  you  to  know  the  number 
of  vaccinations  that  have  been  done  by  the  Bureau 
of  Health.  In  the  routine  course  of  events  since 
July  I,  1903,  324,816  persons  have  been  vaccinated 
by  the  medical  inspectors  alone.  This  number  does 
not  include  vaccinations  done  by  private  physicians, 
hospitals,  dispensaries,  orphan  asylums,  and  other 
institutions,  all  of  which  we  encourage  to  perform 
vaccinations  bv  supplying  virus  of  the  best  quality 
obtainable.  Therefore,  in  this  period,  probably  two 
or  three  times  as  many  persons  have  been  vacci- 
nated in  Philadelphia  as  have  been  vaccinated  by 
the  representatives  of  the  Bureau  of  Health.  Since 
January  i,  1904,  we  have  paid  $19,110  for  vaccine 
virus,  and  it  is  estimated  that  it  costs  about  twenty- 
seven  cents  for  a  single  vaccination,  including  the 
time  of  the  physician,  stationery,  postage,  and  other 
incidental  expenses. 

In  1903,  during  the  smallpox  outbreak,  we  had 
an  interesting  experience.  We  were  vaccinating 
right  and  left ;  yet  in  some  neighborhoods  in  which 
we  had  done  the  most  vaccinating,  the  disease  per- 
sisted, in  spite  of  the  fact  that  few  new  residents 
had  moved  into  the  neighborhoods.  We  could  not 
understand  the  reason  for  this,  but  two  conclusions 
seemed  to  be  justified.  One  was  that  the  vaccina- 
tions were  not  carefully  done,  and  we  suspected 
that  this  was  sometimes  the  case;  and  the  other, 
that  poor  material  was  used.  Upon  carefully  test- 
ing some  of  the  virus  then  employed  on  newborn 
children,  we  got  just  ten  per  cent,  of  successful 
vaccinations  on  a  group  of  fifty  children.  This 
explained  the  persistence  of  the  disease  in  localities 
mentioned. 

In  this  epidemic  we  found  that  the  intelligent 
members  of  the  community  were  with  us  in  regard 
to  the  matter  of  vaccination.  We  had  no  difficulty 
in  persuading  the  great  majority  of  the  employers 
of  labor,  department  store  keepers,  mill  owners, 
hotel  proprietors,  etc.,  to  require  a  certificate  of 
successful  vaccination  from  their  employes.  Though 
some  refused,  the  great  majority  saw  that  it  would 
be  to  their  advantage ;  as  it  would  prevent  their  em- 
ployes from  acquiring  smallpox.  I  believe  that,  in 
trying  to  stamp  out  an  epidemic,  the  cooperation  of 
such  persons  is  a  matter  well  worth  bearing  in  mind. 

Another  class  of  persons  from  whom  we  received 
intelligent  aid  were  the  authorities  of  hospitals. 
Those  that  have  anything  to  do  with  such  institu- 


Copyright.  1909,  by  A.  R.  Elliott  Publishing  Company. 


SCHAMBERG:  SMALLPOX  BEFORE  AND  SINCE   VACCINATION.  LNew  York 

Medical  Journal. 


tioiis  know  that  the  banc  of  hospitals  is  promiscuous 
visiting.  If  such  visiting  should  introduce  a  case  of 
smallpox  into  a  general  hospital,  the  result  would 
be  most  awkward ;  and  we  had  no  trouble  in  per- 
suading the  authorities  to  require  certificates  of 
successful  vaccination  of  visitors.  To  this  day,  one 
hospital  sends  to  the  bureau  a  daily  list  of  un vac- 
cinated visitors ;  and  I  think  it  would  be  a  good 
thing  if  all  other  hospitals  would  do  the  same. 

Another  point  that  we  have  insisted  upon  with  a 
reasonable  degree  of  success  is  that,  as  the  State, 
by  its  statutes,  has  declared  itself  in  favor  of  vac- 
cination, any  institution  receiving  State  aid  should 
see  that  its  inmates  are  vaccinated.  This  point  is 
well  taken ;  and  the  rule  should  be  enforced,  in  or- 
der to  protect  hospital  patients  against  smallpox. 

We  have  been  told  by  the  antivaccinationists  that 
not  only  does  vaccination  not  prevent  smallpox,  but 
it  causes  very  serious  results.  Now,  for  some  cu- 
rious psychological  reason,  the  man  in  public  life  is 
the  one  that  every  citizen  feels  at  liberty  to  criticise. 
If  the  bureau  happens  to  make  any  mistake  what- 
ever, my  telephone  is  sure  to  be  rung  up,  and  very 
unpleasant  things  are  sometimes  said.  Conse- 
quently, if  there  had  been  any  evil  results  from  this 
wholesale  vaccination,  the  news  of  it  would  have 
reached  me.  The  fact,  however,  is  that  I  have 
heard  of  but  one  death.  In  this  instance,  a  certifi- 
cate presented  to  the  bureau  stated  vaccination  to 
be  the  primary  or  secondary  cause  of  death.  (I  do 
(not  remember  which.)  I  investigated  the  matter  at 
■once,  in  order  to  learn  the  truth  about  it.  The  child 
iiad  septic  pneumonia  when  it  died,  and  had  had 
some  sort  of  rhinitis  vvhen  vaccinated.  The  physi- 
•cian  who  signed  this  certificate,  said  that  he  was  not 
lin  favor  of  vaccination,  but  of  variolation.  1  asked 
him  what  this  was,  and  he  said :  "You  put  a  drop 
of  it  on  the  tongue."  He  did  not  know  what  the 
child  had  died  of  unless  from  vaccination. 

In  regard  to  the  bad  arms  produced  by  this  pro- 
cedure, I  would  say  that  I  have  seen  enough  of 
these,  possibly  six  or  seven,  to  have  an  impression 
made  on  my  mind.  Half  a  dozen  mothers  have 
brought  children  to  my  office,  and  the  arms  of  one 
or  two  of  these  children  looked  pretty  bad.  One 
was  a  punched  out  sore,  nearly  as  large  as  a  quarter 
of  a  dollar.  The  mother  took  off  a  dirty  rag. 
smeared  with  a  mixture  consisting  of  soap  and 
something  else.  The  child  had  been  wearing  this 
over  the  wound,  which  had  become  infected  and 
was  suppurating  actively.  After  having  been  at- 
tended to  by  a  competent  person  the  child  made  a 
rapid  recovery,  though  she  had  a  pretty  large  mark 
on  her  arm.  The  bulk  of  such  cases  comprises  chil- 
dren whose  wounds  had  i)cen  infected  through  dirt 
after  the  vaccination. 

Another  point  in  the  experience  of  the  Bureau 
of  Health  upon  which  I  wish  to  dwell  feelingly  is 
that  every  year,  at  the  time  of  the  opening  of  school, 
dozens  of  children  in  each  school  present  to  tlie 
inspector  certificates  of  successful  vaccination  signed 
by  perfectly  competent,  and,  I  believe,  honest  physi- 
cians ;  yet  the  most  careful  investigation  fails  to 
show  anv  evidence  of  a  vaccinative  scar  on  the 
child.  I  have  in  my  office  a  pile  consisting  of  about 
five  hundred  such  certificates.  This  needed  some 
inquiry,  for,  if  the  spot  had  disapi^eared  as  quickly 


as  this,  vaccination  must  have  changed  greatly  in 
recent  years.  We  looked  into  the  matter  and  found 
■that,  in  the  majority  of  cases,  the  doctor  vaccinated 
the  child,  and,  while  the  wound  was  drying,  signed 
the  certificate,  never  having  seen  the  child  again. 
Such  certificates  are  worthless.  All  tha,t  the  doctors 
had  testified  to  was  that  they  had  vaccinated  the 
children,  not  that  the  vaccinations  had  been  suc- 
cessful. 

Many  of  the  parents  of  these  children  thought 
that  it  was  hard  to  have  us  refuse  to  take  their  doc- 
tors' certificates,  but  after  a  little  persuasion  on  our 
part  most  of  them  consented  to  have  their  children 
revaccinated,  and  the  law  was  fully  met  with  in 
ninety-seven  per  cent,  of  these  cases. 

Another  interesting  point  is  in  regard  to  the  so 
called  immunes  to  vaccination.  The  parent  will 
often  say :  "Johnny  cannot  be  vaccinated ;  it  will 
not  take."  One  does  not  find  many  immunes,  if 
good  virus  is  used ;  and  practically  all  the  so  called 
immunes  have  given  the  most  typical  and  beauti- 
fully successful  vaccinations  when  the  vaccination 
was  done  under  proper  conditions  with  virus  that 
was  properly  prepared. 

In  regard  to  the  bad  results  of  vaccination,  let  us 
admit  that  some  do  get  bad  results.  We  do  not 
want  this  to  happen  at  all,  because  there  is  no  neces- 
sity for  it.  Careless  methods  always  do  harm,  and 
I  believe  that  in  every  large  city  some  of  the  vacci- 
nations are  performed  so  carelessly  as  to  justify  one 
in  expecting  bad  results.  The  operation  should  be 
done  with  surgical  care,  through  a  perfectly  clean 
skin,  with  clean  instruments,  and  with  perfectly  pre- 
pared virus,  and  the  subsequent  care  of  the  vaccina- 
tion wound  should  receive  attention. 

I  do  not  know  what  is  the  best  method  of  pro- 
tecting a  vaccination  wound,  but  if  the  child  wears 
clean  underclothes  and  is  reasonably  cleanly  in  its 
person,  I  do  not  think  that  any  dressing  is  neces- 
sary. I  believe  that  if  the  vaccination  is  done  with 
the  precautions  mentioned  and  the  child  is  subse- 
quently kept  clean,  even  the  few  bad  results  that  we 
hear  of  can  be  eliminated. 

Does  vaccination  protect  against  smallpox  infec- 
tion ?  That  question  was  answered,  so  far  as  I  am 
concerned,  many  years  ago.  I  do  not  know  that  it 
has  a  practical  bearing  on  the  matter  to  discuss  if 
vaccine  originates  from  vaccinia,  smallpox,  cowpox, 
or  anything  else ;  the  main  point  is  that,  since  the 
introduction  of  vaccination,  smallpox  has  become  a 
medical  curiosity  in  those  countries  where  it  is 
systematically  practised,  and  Germany  since  1874 
stands  out  conspicuously  as  an  illustration. 

712  City  Hall. 


SMALLPOX  BEFORE  AND  SINCE  THE  DISCOV- 
ERY OF  VACCINATION. 

By  Jay  Fr.\nk  Schamberg.  M.  D., 
Philadelphia. 

The  date  of  the  origin  of  smallpox,  as  is  the  case 
with  other  similar  diseases,  has  not  been  definitely 
established.  The  probabilities  arc  that  it  made  its 
first  appearance  in  the  Orient  and  was  thence  intro- 
duced into  western  Europe.  A  severe  epidemic  ot 
smallpox  is  said  to  have  occurred  in  Iceland  in 


January  16.  1909.) 


SCHAMBERG:  SMALLPOX  BEFORE  ASD  SL\CE  I'ACLLXA'l  lOX. 


99 


1241  ;  we  have  no  trustworthy  record,  however,  of 
the  disease  before  the  fifteenth  century,  when  it  be- 
gan to  appear  in  Europe.  Epidemics  became  pro- 
gressively more  common  in  the  sixteenth  and  seven- 
teenth centuries,  and  readied  their  maximum  of 
frequency  and  extent  in  the  eighteenth  century.  For 
official  data  concerning  the  disease  in  the  seven- 
teenth and  eighteenth  centuries  we  are  largely  in- 
debted to  the  London  Bills  of  Mortality,  which  gave 
a  weekly  account  of  burials  and  christenings,  and 
from  1629  to  1845  the  specific  causes  of  death,  in- 
cluding smallpox. 

It  has  been  estimated  that  the  population  of  Lon- 
don in  1685  was  530,000.  The  mortality  from  small- 
pox for  an  average  of  ten  years  from  1681  to  1690 
was  over  three  in  a  thousand.  In  most  of  the  years 
of  the  century,  indeed,  the  mortality  was  in  the 
neighborhood  of  two  in  a  thousand,  sometimes  more 
and  at  other  times  less.  This  would  mean  an  aver- 
age of  over  a  thousand  smallpox  deaths  in  London 
a  year.  As  it  has  been  reckoned  that  about  one  in 
five  would  die,  there  were  evidently  about  5.000 
cases  of  smallpox  annually  in  the  English  capital. 

As  will  be  readily  comprehended,  smallpox  was 
a  great  scourge  before  the  days  of  vaccination ;  but 
a  small  percentage  of  people  escaped  from  its  rav- 
ages. It  is  asserted  by  contemporaneous  writers 
that  in  the  eighteenth  century  from  eighty-five  to 
ninety-five  per  cent,  of  the  inhabitants  of  European 
countries  suffered  at  one  time  or  another  from  the 
smallpox.  Indeed,  smallpox  was  as  prevalent  in 
the  eighteenth  century  as  measles  is  at  the  present 
time,  llaygarth  gives  an  account  of  an  epidemic 
of  smallpox  in  ■Chester.  England,  in  1774,  at  which 
time,  out  of  a  population  of  14.713,  1,202  persons 
took  the  disease  and  202  died.  At  the  termination 
of  the  epidemic  there  were  but  1,060  persons,  or 
seven  per  cent,  of  tlje  population,  who  had  never  had 
smallpox.  In  1722  smallpox  devastated  the  small 
English  town  of  Ware,  wliose  population  numbered 
2.515  souls;  of  this  number  there  were  only  914 
persons  susceptible  to  smallpox,  inasmuch  as  1.601 
had  already  passed  through  an  attack  of  the  disease. 
During  the  epidemic  referred  to  612  persons  were 
attacked,  leaving  but  302  individuals  in  the  entire 
tow^n  who  had  never  had  smallpox.  Eighty-five  per 
cent,  of  the  population,  therefore,  were  smallpox 
survivors. 

With  these  official  figures  in  mind  we  may  be 
better  able  to  appreciate  the  general  estimate  of  the 
extent  of  smallpox  given  by  writers  of  the  day.  In 
1802  Admiral  Berkeley,  in  a  speech  before  the 
House  of  Commons,  said:  "It  is  proved  that  in  this 
United  Kingdom  alone  45,000  persons  die  annually 
of  the  smallpox ;  but  throughout  the  world  what  is 
it?  Not  a  second  is  struck  by  the  hand  of  Time 
but  a  victim  is  sacrificed  upon  the  altar  of  that  most 
horrible  of  all  disorders,  the  smallpox."  King 
Frederick  William  III,  of  Pnissia.  in  a  despatch, 
dated  1803,  stated  that  40,000  people  succumbed 
annually  to  smallpox  in  his  kingdom.  The  French 
minister  of  the  interior,  in  reporting  on  vaccination 
in  181 1,  estimated  that  150,000  people  died  in 
France  annually  from  smallpox.  Smallpox  is  re- 
portcil  to  have  destroyed  in  Russia  2.000.000  lives 
in  a  single  year.  The  distinguished  mathematician, 
Daniel  Bernouille,  writing  in  1760  to  1765,  calcu- 


lated that  not  less  than  15.000,000  human  beings 
died  of  smallpox  every  twenty-five  years.  This 
would  give  a  yearly  average  of  600,000.  Dr.  Lett- 
som  estimated  that  Europe  alone  claimed  210,000 
victims  annually.  Juncker  placed  the  yearly  sacri- 
fice from  smallpox  in  Europe  at  400,000.  When  to 
these  figures  are  added  the  deaths  due  to  devas- 
tating epidemics  in  Asia,  Africa,  and  America,  the 
estimate  of  Bernouille  does  not  appear  to  be  over- 
stated. 

It  is  alleged  that  in  Mexico  smallpox  has  exter- 
minated whole  tribes  of  Indians,  sparing  no  one  to 
tell  the  story  of  the  annihilation.  Catlin  states,  of 
12,000.000  American  Indians,  6,000,000  fell  victims 
to  smallpox. 

According  to  records  published  by  the  govern- 
ment of  Denmark,  a  terrible  epidemic  of  smallpo.x 
appeared  in  Iceland  in  1707  which  destroyed  18,000 
out  of  the  50,000  inhabitants ;  thirty-six  per  cent,  of 
the  total  population  perished.  It  is  stated  on  good 
authority  that  in  Greenland  in  1734  6,000  to  7,000 
persons  perished  from  smallpox,  representing  nearly 
two  thirds  of  the  population. 

In  1752  Boston  had  a  severe  epidemic  of  this 
dread  disease.  The  population  of  Boston  at  that 
time  was  15,684;  of  this  number  5,998  had  previ- 
ously had  smallpox.  During  the  epidemic,  5,545 
persons  contracted  the  disease  in  the  usual  manner, 
and  2,124  took  it  by  inoculation.  1,843  people  es- 
caped from  the  town  to  avoid  the  danger  of  infec- 
tion. There  were,  therefore,  left  in  the  city  but 
174  people  who  had  never  had  smallpox.  The  popu- 
lation at  the  end  of  the  epidemic  practically  con- 
sisted of  persons  who  had  survived  an  attack  of  the 
fear  inspiring  malady.  Instead  of  appreciating  the 
enormous  benefits  conferred  by  vaccination,  some 
dissenters  at  the  present  day  are  arguing  that  this 
remedy  is  no  longer  needed,  failing  to  recognize  the 
fact  that  the  immunity  from  smallpox  that  we  are 
now  enjoying  is  entirely  due  to  Jenner's  discovery. 

Change  i)i  the  Age  hicidcnce.  Smallpox  was 
essentially  a  disease  of  children  in  former  times ;  to 
such  an  extent  was  this  true  that  the  disease  was 
called  Kindspockcn  (childpox)  or  Kindsblattent. 
Owing  to  the  pronounced  contagiousness  of  the  dis- 
ease and  the  almost  universal  susceptibility  to  it, 
smallpox  was  largely  contracted  during  child  life, 
as  measles  is  at  the  present  time.  But  comparatively 
few  adults  contract  measles  at  the  present  day  be- 
cause they  are  protected  by  a  previous  attack  in 
infancy  or  childhood.  The  same  conditions  obtained 
with  relation  to  smallpox  in  the  days  before  vaccina- 
tion. The  adult  population  represented  mostly  the 
survivors  from  smallpox  in  childhood.  It  was  esti- 
mated that  only  about  five  per  cent,  of  persons  were 
naturally  insusceptible  to  the  disease.  \'accinaiion 
has  totally  changed  the  age  period  of  smallpox.  It 
is  now  excessively  rare  for  a  successfully  vaccinated 
child  under  five  years  of  age  to  die  of  the  smallpox : 
it  is  even  uncommon  for  a  successfully  vaccinated 
child  under  ten  years  to  die  of  the  disease,  as  was 
adequately  proved  in  the  testimony  presented  before 
the  British  Roval  Commission  on  A'accination. 

In  most  of  the  countries  of  western  Europe  there 
was  noted  about  the  beginning  of  the  nineteenth 
century  a  sudden  and  pronounced  decrease  in  the 
morbidity  and  mortality  of  smallpox.    Inasmuch  as 


lOO 


SCHAMBERG:  SMALLPOX  BEFORE  AND  SINCE  VACCINATION. 


[New  York 
Medical  Journal. 


this  was  coincident  with  the  diffusion  of  the  practice 
•of  vaccination,  there  is  strong  reason  to  regard  Jen- 
Tier's  epoch  making  discovery  as  the  causative  influ- 
ence. The  careful  records  of  smallpox  mortality 
which  were  kept  in  various  countries,  particularly 
in  Sweden  and  England,  make  it  possible  to  prove 
by  documentary  evidence  that  a  marvelous  decrease 
in  the  deaths  from  smallpox  occurred  within  a  short 
period  after  the  introduction  of  vaccination.  In  the 
twenty-eight  years  before  vaccination  in  Szceden 
there  died  each  year  from  smallpox  out  of  each 
1,000,000  of  population,  ,2,050  persons;  during  the 
forty  years  follozving  ivccination,  out  of  each  1,000,- 
000  of  population  the  smallpox  deaths  annually 
averaged  158. 

During  the  seven  years  preceding  the  introduction 
of  vaccination  in  Prague,  smallpox  caused  one 
twelfth  of  the  total  number  of  deaths;  during  the 
twenty  years  following  the  introduction  of  vaccina- 
tion, smallpox  caused  but  one  four  hnndred  and 
fifty-seventh  of  the  total  number  of  deaths.  Such 
figures  as  these  might  be  multiplied  by  reference  to 
the  records  of  other  countries,  but  they  suffice  to 
confirm  the  statement  concerning  the  remarkable  de- 
cline of  smallpox  after  Jenner's  discovery. 

The  opponents  of  vaccination,  and  they  have  been 
with  us  since  the  days  of  Jenner,  admit  the  decHne 
in  smallpox  referred  to,  but  deny  that  the  decrease 
was  the  result  of  vaccination.  They  declare  that  it 
was  due  rather  to  the  discontinuance  of  iiioctdation. 
This  argument  was  carefully  considered  by  the  Brit- 
ish Royal  Commission.  There  can  be  no  question 
that  smallpox  prevailed  to  a  greater  extent  during 
the  eighteenth  century  than  during  any  period  of 
which  we  have  records.  We  must  furthermore  ad- 
mit that  the  practice  of  inoculation  tended  to  diffuse 
the  infection  of  smallpox,  inasmuch  as  inoculated 
smallpox  was  contagious  and  could  be  contracted 
much  in  the  same  manner  as  natural  smallpox.  The 
effect  of  inoculation  was  really  twofold  in  character : 
It  tended  to  lessen  the  number  of  deaths  from  small- 
pox by  producing  a  mild  form  of  the  disease,  accom- 
panied by  mortality  varying  between  one  third  of  a 
per  cent,  and  two  per  cent.,  and  by  conferring  pro- 
tection against  the  dangerous  natural  smallpox.  On 
the  other  hand,  it  tended  to  perpetuate  smallpox  in 
the  community  by  reason  of  the  fact  that  the  inocu- 
lated persons,  often  scarcely  ill,  diffused  the  disease 
among  others.  The  lessening  of  the  death  rate  by 
protection  from  natural  smallpox  on  the  one  hand 
and  the  tendency  to  diffuse  the  disease  on  the  other 
hand,  constitute  two  opposing  influences  which 
largely  neutralize  each  other  as  far  as  the  aggregate 
number  of  deaths  from  smallpox  is  concerned.  Un- 
fortunately for  the  contention  of  the  vaccination 
opponents,  the  increase  in  the  prevalence  of  small- 
pox during  the  eighteenth  century  cannot  be  attrib- 
uted to  inoculation,  for  were  this  the  case,  then  the 
increase  should  have  been  apparent  only  after  the 
introduction  of  inoculation ;  whereas,  as  a  matter  of 
fact,  the  increased  prevalence  was  noted  before  that 
period. 

Inoculation  was  introduced  into  England  in  1721, 
so  that  during  the  first  quarter  of  the  century  no 
such  cause  can  be  invoked  to  have  increased  the 
prevalence  of  smallpox.   During  the  first  quarter  of 


the  century,  when  there  was  practically  no  inocula- 
tion, the  mortality  from  smallpox  was  as  great,  if 
not  greater,  than  during  the  last  quarter  of  the 
century,  when  inoculation  was  much  in  vogue.  In 
Sweden,  where  inoculation  was  never  practised  to 
any  extent,  the  fall  in  smallpox  after  the  introduc- 
tion of  vaccination  was  as  marked  as  in  any  country. 

Lady  Mary  Wortley  Montagu,  the  wife  of  the 
English  ambassador,  introduced  inoculation  into 
England.  She  had  had  her  own  son  inoculated  in 
Turkey,  and  in  a  letter  written  to  her  friend,  Miss 
Sarah  Chiswell,  in  1717,  she  refers  to  this  procedure. 
This  letter  is  of  considerable  literary  and  historical 
interest,  and,  with  your  permission,  I  shall  read  part 
of  it.    It  is  as  follows  : 

"  .  .  .  Apropos  of  distempers,  I  am  going  to 
tell  you  a  thing,  that  will  make  you  wish  yourself 
here.  The  smallpox,  so  fatal  and  so  general  amongst 
us,  is  here  entirely  harmless  by  the  invention  of  en- 
grafting, which  is  the  term  they  give  it.  There  is  a 
set  of  old  women  who  make  it  their  business  to 
perform  the  operation,  every  autumn  in  the  month 
of  September,  when  the  great  heat  is  abated.  People 
send  to  each  other  to  know  if  any  of  their  family 
has  a  mind  to  have  the  smallpox ;  they  make  parties 
for  this  purpose,  and  when  they  are  met  (commonly 
fifteen  or  sixteen  together),  the  old  woman  comes 
with  a  nut  shell  full  of  matter  of  the  best  sort  of 
smallpox,  and  asks  what  vein  you  please  to  have 
opened.  She  immediately  rips  open  that  you  offer 
to  her,  with  a  large  needle  (which  gives  no  more 
pain  than  a  common  scratch)  and  puts  into  the  vein 
as  much  matter  as  can  lie  upon  the  head  of  her 
needle,  and  after  that,  binds  up  the  wound  with  a 
hollow  bit  of  shell,  and  in  this  manner  opens  four 
or  five  veins.  .  .  .  The  children  or  young  patients 
play  together  all  the  rest  of  the  day,  and  are  in  per- 
fect health  to  the  eighth.  Then,  the  fever  begins  to 
seize  them,  and  they  keep  their  beds  two  days,  very 
seldom  three.  They  have  very  rarely  above  twenty 
or  thirty  on  their  faces  (sic),  which  never  mark, 
and  in  eight  days  time  they  are  well  as  before  their 
illness.  Where  they  are  wounded  there  remains 
running  sores  during  the  distemper,  which  I  don't 
doubt  is  a  great  relief  to  it.  Every  year  thousand.^ 
undergo  this  operation,  and  the  French  ambassador 
says  pleasantly  that  they  take  the  smallpox  here  by 
way  of  diversion,  as  they  take  the  waters  in  other 
countries.  There  is  no  example  of  any  one  who  has 
died  of  it,  and  you  may  believe  that  I  am  well  satis- 
fied of  the  safety  of  this  experiment  since  I  intend 
to  try  it  on  my  dear  little  son.  T  am  patriot  enough 
to  take  pains  to  bring  this  useful  invention  into 
fashion  in  England,  and  I  should  not  fail  to  write  to 
some  of  our  doctors  very  particularly  about  it,  if  I 
knew  any  one  of  them  that  I  thought  had  virtue 
enough  to  destroy  such  a  considerable  branch  of 
their  revenue,  for  the  good  of  mankind.  But  that 
distemper  is  too  beneficial  to  them,  not  to  e.xpose  to 
all  their  resentment  the  hardy  wight  that  should 
undertake  to  put  an  end  to  it.  Perhaps  if  I  live  to 
return.  T  may,  however,  have  courage  to  war  with 
them.  Upon  this  occasion,  admire  the  heroism  in 
the  heart  of  Your  friend,  etc." 

Physicians  are  sometimes  accused  by  the  anti- 
vaccinationists  of  advocating  vaccination  on  account 


January  >6.  1909.]        SCHAMBERG:  SMALLPOX  BEFORE  AND  SINCE  VACCINATION. 


lor 


of  the  income  to  be  derived  from  it,  but  I  do  not 
consider  it  necessary  to  make  any  comment  upon 
this  charge. 

It  has  been  furthermore  alleged  by  the  opponents 
of  A-accination  that  the  decline  in  the  prevalence  of 
smallpox  at  or  about  the  beginning  of  the  nineteenth 
century  was  the  result  of  improvement  in  sanitary 
conditions.  ■  It  may  be  conceded  that  such  improve- 
ments as  better  drainage  and  sewerage,  freer  venti- 
lation, purer  water  supply,  lessened  crowding  in 
dwellings,  and  the  like,  would,  by  improving  the 
average  individual  health,  tend  to  lessen  the  fatality 
of  all  infectious  diseases,  not  excluding  smallpox. 
But  such  influences  are  totally  inadequate  to  explain 
the  striking  and  progressive  decline  in  the  preva- 
lence and  mortality  from  smallpox  that  followed  the 
introduction  of  vaccination. 

If  sanitary  improvements  were  responsible  for  the 
lessened  mortality  from  smallpox,  why  did  they  not 
similarly  influence  the  mortality  from  measles,  scarlet 
fever,  and  whooping  cough,  which  are  favored  b\-  the 
same  conditions  that  aid  the  dissemination  of  small- 
pox? Dr.  Dixon,  in  the  1907  Report  of  the  Depart- 
ment of  Health  of  Pennsylvania,  stated  that  3,000 
children  died  of  measles  and  its  complications  last 
year.  Smallpox  and  measles  resemble  each  other  in 
the  sense  that  the  spread  of  both  diseases  is  not  de- 
pendent upon  any  special  sanitary  defect.  Unlike 
typhoid  fever  ^nd  cholera,  their  occurrence  is  influ- 
enced by  personal  infection  rather  than  by  any  defi- 
nite vices  of  sanitation.  Measles  and  smallpox  are 
the  most  contagious  of  all  diseases ;  a  momentary 
exposure  of  an  unprotected  person  to  the  infection 
of  smallpox  or  -measles  suffices  for  such  individual 
to  contract  the  disease.  According  to  the  Registrar 
General's  Reports,  during  the  same  period  in  Eng- 
land that  smallpox  mortality  has  declined  seventy- 
two  per  cent.,  the  mortality  from  measles  has  fallen 
only  nine  per  cent.  Furthermore,  the  death  rate 
from  whooping  cough  has  declined  but  a  little  more 
than  one  per  cent,  (at  present  w-hooping  cough  is  the 
most  fatal  of  all  diseases  in  children  under  two  years 
of  age),  and  the  diminution  in  the  mortality  of  scar- 
let fever  has  only  become  apparent  within  compara- 
tively recent  years.  Again,  the  improvement  in 
sanitation  and  mode  of  living  has  only  caused  a  re- 
duction of  the  general  death  rate  of  the  country 
(  England)  of  nine  per  cent. 

Another  noteworthy  fact  must  not  be  forgotten, 
namely,  that  the  decline  in  the  death  rate  from  small- 
pox has  been  entirely  limited  to  persons  below  the 
age  of  fifteen.  It  is  evident,  therefore,  that  the  lives 
of  an  enormous  number  of  children  have  been  saved. 
Above  fifteen  3'ears  of  age  the  smallpox  mortality  for 
obvious  reasons  has  not  decreased,  because  of  the 
lack  of  revaccination  in  adults.  It  is  the  height  of 
absurdity  to  attempt  to  explain  such  an  inequality 
in  the  decline  of  smallpox  mortality  on  the  grounds 
of  improved  sanitation.  The  percentage  of  mortal- 
ity borne  by  children  the  subjects  of  measles,  scarlet 
fever,  and  whooping  cough  does  not  differ  materi- 
ally from  what  it  was  a  century  ago. 

During  the  nineteenth  century  smallpox  has  pre- 
vailed in  epidemic  form  in  different  countries  usu- 
ally in  proportion  to  the  neglect  of  vaccination  in 
these  countries.  It  must  be  remembered  that  in 
order  to  exterminate  smallpox  we  must  have  not 


only  universal  vaccination,  but  also  its  logical  com- 
plement, universal  revaccination.  The  only  country 
of  importance  uhich  has  for  any  period  of  time 
carried  out  vaccination  in  this  manner  is  Germany, 
and  of  all  the  important  countries  of  the  globe,  Ger- 
many is  freest  from  smallpox.  If  there  were  in 
existence  no  other  statistical  evidence  of  the  efficacy 
of  vaccination  as  a  preventive  measure  against 
smallpox,  the  official  figures  of  Germany  since  the 
enactment  and  provision  for  proper  enforcement  of 
the  compulsory  vaccination  and  revaccination  act  in 
1874,  would  constitute  adequate  and  convincing 
testimony.  Germany  has  taught  the  world  how  to 
utilize  Jenner's  discovery  so  as  to  exterminate  small- 
pox. Since  the  law  of  1874  went  into  effect,  there 
have  been  no  epidemics  of  smallpox  in  that  country. 
The  disease  is  frequently  introduced  by  foreigners, 
particularly  on  the  frontiers,  but  it  can  obtain  no 
foothold.  In  1899,  among  a  population  of  54,000,- 
000  in  Germany,  there  were  only  twenty-eight 
deaths  from  smallpox,  and  these  occurred  in  tw-enty- 
one  different  districts,  the  largest  number  in  any  one 
district  being  three.  In  1897,  there  were  but  five 
deaths  irpm  smallpox  in  the  entire  German  empire. 
The  large  German  cities,  Berlin,  Hamburg,  Breslau, 
Munich,  and  Dresden,  have  a  perfectly  insignificant 
mortality  from  smallpox  when  compared  with  Lon- 
don, Paris,  Menna,  St.  Petersburg,  and  Prague, 
in  all  of  which  cities  the  vaccination  laws  and  the 
enforcement  thereof  are  relatively  lax. 

This  information  is  graphically  conveyed  in  a  re- 
port published  by  the  German  Government,  and  dis- 
tributed at  the  St.  Louis  Exposition. 

We  are  sometimes  prone  to  believe  that  the  dread- 
ful ravages  of  smallpox  belong  rather  to  ancient  his- 
tory than  to  modern  times.  We  should  not,  how- 
ever, delude  ourselves  by  such  a  thought,  for  small- 
pox in  all  its  devastating  terrors  w'ill  visit  us  again 
if  we  fail  to  make  use  of  the  light  that  has  been 
given  us.  That  this  disease  may  still  kill  by  the 
thousands  is  evidenced  in  certain  of  the  countries  of 
Europe.  The  Imperial  Board  of  Health  of  the 
German  Empire  publishes  the  mortality  from  small- 
pox in  various  European  countries  between  1893 
and  1897,  inclusive.  We  are  startled  to  note  in  this 
period  there  died  in  the  Russian  empire,  including 
Asiatic  Russia,  275.502  persons  from  smallpox, 
Spain  lost  over  23,000  fives,  Hungary  over  12,000, 
Austria  and  Italy  over  11,000.  In  Germany  the 
number  of  smallpox  deaths  during  this  period  was 
only  287,  representing  one  death  to  every  1.000,000 
of  population  a  year.  In  our  own  city  of  Phila- 
delphia, in  the  epidemic  lasting  from  1901  to  1905, 
over  5,000  persons  were  attacked,  of  whom  over  500 
lost  their  lives.  No  death  occurred  in  a  person  suc- 
cessfully vaccinated  within  a  period  of  ten  years.  If 
vaccination  and  revaccination  were  universally  car- 
ried out,  then  the  prophecy  expressed  in  the  letter  of 
Thomas'  Jefferson  to  Jenner  would  be  fulfilled. 
Thomas  Jefferson,  in  1806.  wrote:  "You  have 
erased  from  the  calendar  of  human  affliction  one  of 
its  greatest.  Yours  is  the  comfortable  reflection 
that  mankind  can  never  forget  that  you  have  lived ; 
future  nations  will  know  by  history  only  that  the 
loathsome  smallpox  has  existed,  and  by  you  has 
been  extirpated." 

1922  Spruce  Street. 


I02 


WELCH:  SO  CALLED  DANGERS  OF  VACCINATION. 


[New  York 
Medical  Journal. 


REMARKS  ON  THE  "SO  CALLED"  DANGERS  OF 
VACCINATION. 

By  William  M.  Welch,  M.  D., 
Philadelphia. 

No  disciple  of  Jenner  can  fail  to  take  a  deep  in- 
terest in  anything  that  tends  to  detract  from  the 
reputation  of  vaccination,  which,  for  more  than  a 
century,  has  over  and  over  again  proved  its  efficacy 
against  smallpox  under  the  severest  possible  tests, 
and  has  satisfied  the  judgment  of  medical  men  the 
world  over.  It  must,  however,  be  admitted  that  the 
practice  of  this  measure  is  not  absolutely  devoid  of 
some  danger.  But  what  human  act  of  any  impor- 
tance, particularly  in  medicine,  is  wholly  unattended 
with  risk?  The  slightest  surgical  operation  has 
been  followed  by  unfortunate  results,  and  drugs  are 
powerful  for  evil  as  well  as  good,  yet  no  one  has 
ever  thought  of  contending  that  this  is  sufficient  rea- 
son to  abandon  surgery  and  drugs.  Accidents  from 
this  source,  rare  as  they  are,  are  infinitely  more  com- 
mon than  those  consequent  upon  vaccination.  When 
we  consider  the  inestimable  benefits  to  the  human 
race  from  Jenner 's  discovery,  the  few  accidents  that 
happen  now  and  then  from  the  procedure  fade  into 
insignificance  by  comparison. 

Deaths  have  from  time  to  time  been  reported  as 
resulting  from  vaccination,  and  if  we  were  to  accept 
them  all  as  a  direct  result  of  this  procedure,  the  num- 
ber is  extremely  small  when  compared  with  the  enor- 
mous number  of  vaccinations  performed. 

In  England,  where  antivaccination  prejudice  is  strong, 
the  alleged  death  rate  is  the  highest.  According  to  the 
registrar  general's  return  from  1881  to  1889  the  number  of 
■deaths  certified  as  connected  with  vaccinations  was  476,  or 
•about  fifty-three  a  year..  Inasmuch  as  6,739,902  primary 
vaccinations  were  performed  during  this  period  of  nine 
years,  we  have  an  average  death  rate  of  one  to  14,159  pri- 
mary vaccinations.  Admitting  that  vaccination  was  really 
accountable  for  all  of  these  deaths,  the  mortality  rate  is,  as 
Acland  has  pointed  out,  still  far  below  that  attendant  upon 
the  use  of  chloroform  as  an  anaesthetic. 

The  mortality  of  vaccination  in  Germany  carefully  esti- 
mated by  Voigt  is  stated  to  have  been  35  in  2,275,000  vaccin- 
ations (a  ratio  of  one  death  to  65,000  vaccinations),  includ- 
ing both  primary  and  secondary  insertions.  Of  the  deaths, 
nineteen  were  due  to  erysipelas,  eight  to  gangrene,  two  to 
cellulitis,  three  to  "blood  poisoning,"  and  three  to  other 
causes. 

Voigt  himself  during  an  experience  of  twenty  yeai"s  vac- 
■cinated  over  a  quarter  of  million  of  people.  Within  the  last 
five  years  he  has  vaccinated  100,000  people  with  but  a  single 
death.  This  is  an  evidence  of  the  results  that  may  be  ex- 
pected when  all  precautions  are  taken.  (Welch  and  Scham- 
berg). 

Assuming  that  this  record  of  deaths  from  vaccina- 
tion is  reliable,  then  let  it  be  compared  with  the 
frightful  loss  of  life  from  smallpox  in  the  prevac- 
cination  period,  knowing  as  we  do  that  vaccination, 
properly  repeated,  is  an  absolute  safeguard  against 
that  exceedingly  fatal  and  horrifying  disease,  who 
then  is  prepared  to  say  that  the  slight  risk  from 
vaccination  is  not  warranted? 

My  interest  in  vaccination  and  careful  study  of 
the  vaccine  process  covers  a  period  of  many  years. 
For  about  five  years  prior  to  1870 — the  date  of  my 
appointment  to  the  Municipal  Hospital — I  was  one 
of  the  public  vaccine  physicians  of  this  city.  Dur- 
ing that  time  I  must  have  vaccinated  a  few  thousand 
children.  As  a  matter  of  course  the  vast  majority 
of  those  who  accepted  this  charitable  act  of  the  city 


was  almost  constantly  exposed  to  environments  that 
were  not  the  niost  sanitary.  Many,  indeed,  were  ex- 
tremely dirty,  even  filthy,  in  their  general  habits. 
But  little  regard  was  paid  at  that  time  to  what  is 
now  called  "surgical  cleanliness"  in  the  operation  of 
vaccination ;  and  it  should  be  stated  that  the  vaccine 
material  used  was  humanized  virus  in  the  form  of 
scabs  taken  from  the  arms  of  previously  vaccinated 
children.  Yet,  despite  these  unfavorable  conditions, 
I  never  saw  any  serious  consequences  from  the  vac- 
cine disease.  I  should,  perhaps,  make  an  exception 
of  a  small  series  of  cases  in  which  I  unwittingly 
used  decomposed  virus,  which  caused  erysipelas  in 
a  few  of  the  subjects.  But  this  was  clearly  my  own 
blunder  and  cannot  be  reasonably  charged  up 
against  vaccination. 

Since  the  time  I  served  as  one  of  the  vaccine 
physicians  of  the  city  my  interest  in  the  general  sub- 
ject of  vaccination  has  constantly  increased,  as  well 
as  my  opportunities  for  studying  the  vaccine  disease. 
It  is,  I  am  sure,  no  exaggeration  to  say  that  my 
attention  has  been  given  to  the  vaccine  process  in 
many  thousands  of  persons — just  how  many  I  can- 
not tell — without  having  seen  a  single  death,  or  any 
near  approach  to  it,  resulting  therefrom.  Gentle- 
men, vaccination  is  a  life  saving  agent,  while  small- 
pox is  the  dread  destroyer  of  human  life ! 

We  have  all  seen  deaths  from  vaccination  re- 
ported in  the  newspapers  and  in  antivaccination 
literature.  The  latter,  indeed,  is  made  up  almost 
entirely  of  such  reports.  In  a  number  of  instances 
I  have  taken  pains  to  ascertain  the  real  truth  con- 
cerning such  newspaper  reports,  and  have  almost 
always  found  that  the  death  was  caused  by  some 
disease  entirely  independent  of  vaccination,  or  else 
by  some  virulent  infection  introduced  in  the  course 
of  the  vaccine  process  through  gross  carelessness  of 
the  vaccinee  or  his  caretaker. 

"Kiibler  states  that  in  the  thirteen  years  from 
1885  to  1897  there  were  recorded  113  deaths  among 
32,000,000  vaccinations  in  the  German  Empire ; 
forty-six  of  these  deaths  were  shown  to  have  been 
caused  by  subsequent  wound  infection  through 
some  neglect  on  the  part  of  the  patient.  In  only 
sixty-seven  cases  was  there  a  connection  with  the 
vaccination  itself ;  even  in  these  cases  the  relation 
was  not  proved,  but  it  could  not  be  disproved.  Ad- 
mitting that  all  of  the  113  deaths  resulted  from 
vaccination,  this  would  give  a  death  rate  of  one 
death  in  every  283,177  vaccinations."  (Welch  and 
Schamberg.) 

It  is  often  easy  to  confound  sequence  and  conse- 
quence. Such  weakness  of  judgment  seems  to  be  a 
marked  characteristic  of  the  antivaccinationists,  as 
they  invariably  attribute  any  disease  that  may  de- 
velop after  vaccination  to  the  vaccination  it.self. 
They  even  assert  that  vaccination  introduces  into  the 
human  system  such  diseases  as  smallpox,  scarlet 
fever,  croup,  typhoid  fever,  scrofula,  consumption, 
syphilis,  cancer,  tuberculous  formations,  diphtheria, 
and  many  other  affections.  Of  course,  I  need  not 
tell  my  medical  audience  how  absurd  this  assertion 
is,  but  to  the  laity  I  would  say  that  vaccination  pro- 
tects the  individual  against  no  disease  but  smallpox, 
and  it  may  sometimes  happen  that  some  one  of  the 
diseases  just  mentioned  will  make  its  appearance  in 


January  i6,  1909. J 


WELCH:  SO  CALLED  DANGERS  OF  VACCINATION. 


103 


a  person  who  has  been  recently  vaccinated.  This 
surely  must  happen  now  and  then  among  the  mil- 
lions of  people  who  are  vaccinated  in  the  various 
countries  of  the  world.  While  the  relation  between 
vaccination  and  the  affections  named,  when  the 
latter  follow  the  former,  cannot  be  other  than  a 
chronological  one,  yet  the  laity  is  prone  to  believe 
to  the  contrary,  and  the  attitude  of  the  antivaccina- 
tionists  toward  this  question  is  best  expressed  in 
the  old  Latin  phrase,  post  hoc  ergo  propter  hoc. 

No  one  has  ever  studied  the  vaccine  process  with 
gr,eater  care  than  Jenner.  Being  the  discoverer  of 
vaccination,  it  was  but  natural  that  he  should  do  so. 
He  took  great  pains  to  demonstrate  in  the  most 
conclusive  manner  that  it  was,  first  of  all,  a  prophy- 
lactic against  smallpox,  and,  also,  that  it  was  wholly 
unattended  with  danger  or  any  unpleasant  conse- 
quences before  he  ventured  to  publish  his  discovery 
to  the  world.  Quoting  his  own  words:  "I  placed  it 
on  a  rock,  where  I  knew  it  would  be  immovable, 
before  I  invited  the  public  to  look  at  it."  He  was 
very  exact  in  his  description  of  true  vaccinia,  and 
distinctly  stated  that  any  considerable  deviation  in 
the  development  of  the  vaccine  vesicle  from  that 
which  he  described  should  be  regarded  as  a  spurious 
result.  He  was  very  explicit  as  to  the  proper  time 
for  collecting  virus  for  further  use.  and  very  definite 
in  his  description  as  to  the  proper  method  of  scari- 
fying the  skin  upon  the  arm  preparatory  to  the  in- 
sertion of  the  virus.  I  should  perhaps  state  that  all 
vaccine  virus  at  that  time  was  collected  from  vaccine 
vesicles  in  their  early  course  of  evolution  upon 
human  subjects.  The  vaccine  scab  was  not  used 
until  several  years  later. 

Soon  after  Jenner's  discovery  was  made  known 
to  the  civilized  world  he  was  literally  overwhelmed 
with  correspondence.  Some  wrote  requesting  virus 
with  which  to  begin  the  "new  inoculation,"  others 
were  desirous  of  further  information  concerning 
the  appearance  and  course  of  the  vaccine  disease, 
and  there  were  many  who  wrote  complaining  of  dis- 
appointment in  that  the  inoculation  did  not  succeed, 
or  that  the  process  was  attended  with  evil  results. 
With  commendable  zeal  he  hastened  to  forward 
virus  as  far  as  possible  to  all  who  requested  it,  and 
encouraged  his  professional  friends  to  do  likewise. 
To  those  who  desired  information,  his  letters  of  in- 
struction as  to  the  proper  time  for  collecting  the 
virus,  how  to  insert  it,  and  as  to  the  course  and 
appearance  of  true  vaccinia,  were  full  and  explicit. 
To  all  complaints  that  the  virus  did  not  succeed,  or, 
worse  than  that,  that  it  gave  rise  to  unfavorable 
results,  Jenner  gave  his  immediate  and  most  careful 
attention.  In  such  cases  he  invariably  found  that 
the  virus  was  either  inert  on  account  of  imperfect 
preservation,  or  that  it  had  been  collected  at  too  late 
a  period  in  the  development  of  the  vesicle,  and  hence 
the  bad  results.  In  this  way  Jenner  labored  inces- 
santly to  correct  mistakes  and  disseminate  a  true 
knowledge  of  vaccination,  and  he  had  the  satisfac- 
tion of  knowing  that  wherever  his  instructions  were 
carefully  observed  nothing  but  good  results  fol- 
lowed. 

In  spite  of  the  fact  that  vaccination  was  shown 
to  possess  complete  mastery  over  smallpox,  there 
arose  in  the  early  days  of  the  practice  a  band  of  dis- 


senters, or  antivaccinationists,  who  persistently  con- 
tended that  the  agent  had  no  merit  whatsoever. 
They  diligently  sought  and  collected  the  reports  of 
all  cases  of  ill  result  occurring  in  the  practice  of 
those  who  utterly  disregarded  the  teaching  of  Jen- 
ner, and  constantly  quoted  them  against  vaccination. 
Their  opposition  assumed  even  a  virulent  form. 
They  attacked  even  the  honesty  and  integrity  of 
Jenner  and  called  in  question  his  veracity.  They 
expressed  the  belief  that  the  practice  of  vaccination 
would  add  to  the  already  large  number  of  diseases 
to  which  human  flesh  was  heir  those  peculiar  to  the 
bovine  animal.  And  they  even  predicted  that  if  the 
practice  was  continued  of  introducing  this  '"beastly 
matter,"  as  they  called  it,  into  human  subjects,  it 
would  eventually  have  the  effect  of  transforming 
man  into  a  hideous  monster  presenting  some  of  the 
characteristics  of  both  the  human  being  and  the 
bovine  animal.  Very  ludicrous  pictures  were  made 
and  scattered  about  the  country  illustrating  how 
human  beings  would  appear  in  this  transformed 
state.  I  have  the  pleasure  of  showing  you  a  copy 
of  one  of  these  illustrations,  made  in  1802.  and  you 
can  see  at  a  glance  that  after  a  century  and  more  of 
the  practice  how  false  has  been  their  prophecy. 

Following  the  publication  of  Jenner's  brochure  on 
vaccination  there  arose  in  almost  every  civilized 
country  one  or  more  promulgators  of  the  new  dis- 
covery who  adhered  more  faithfully  than  others  to 
the  teachings  of  the  master,  and  consequently 
achieved  distinction  in  this  new  field  of  beneficent 
work.  Tht  ^ne  entitled  to  such  distinction  in  this 
country  is  Dr.  Benjamin  Waterhouse,  the  first  pro- 
fessor of  theory  and  practice  of  medicine  in  Harvard 
Univer'Tty.  Of  all  the  disciples  of  Jenner.  Water- 
house  was,  without  much  doubt,  the  ablest  and 
worthiest.  As  soon  as  this  worthy  man  had  collected 
a  mass  of  evidence  in  support  of  the  efficacy  of  vac- 
cination "too  great,"  as  he  says,  "to  be  resisted  by 
any  mind  not  perverted  by  prejudice,"  he  sought 
and  obtained  some  vaccine  virus  from  England. 
With  this  he  vaccinated  at  once  the  members  of  his 
own  family.  A  few  of  the  physicians  of  Boston  and 
adjacent  towns  who  felt  an  interest  in  the  matter 
visited  the  vaccinated  subjects  for  the  purpose  of 
learning  something  about  the  new  disease.  These 
visits  gave  rise  to  a  malicious  report  that  one  of 
Waterhouse's  children  was  so  dangerously  ill  from 
the  "new  inoculation"  as  to  require  a  consultation  of 
several  physicians.  This  was  but  the  beginning  of 
a  long  series  of  perversion  of  facts  against  which 
this  worthy  man  had  to  contend  in  his  work  of  in- 
troducing vaccination  into  this  country. 

After  observing  very  carefully  the  vaccine  pro- 
cess in  his  children,  and  feeling  sure  that  it  con- 
formed exactly  to  the  description  given  by  Jenner. 
Waterhouse  was  anxious  to  know  whether  this  be- 
nign and  simple  affection  was  really  protective 
against  smallpox.  In  order  to  prove  this  he  sent 
his  children  into  the  smallpox  hospital  of  Boston 
and  had  them  inoculated  with  smallpox  virus  taken 
directly  from  a  vesicle  upon  a  patient  ill  with  that 
disease.  Finding  that  the  children  resisted  the  dis- 
ease absolutely  when  subjected  to  this  most  crucial 
test.  Waterhouse  exclaimed  :  "One  fact  in  such  cases 
is  worth  a  thousand  arguments." 


104 


WELCH:  SO  CALLED  DANGERS  OF  VACCINATION. 


[New 
Medical 


York 

JOURNAU 


Having  thus  demonstrated  in  a  concrete  and  con- 
vincing form  the  real  proof  of  the  prophylactic 
power  of  vaccination,  Waterhouse  was  now  ready 
and  anxious  to  disseminate  its  benefits  as  widely  as 
possible.  At  the  same  time  he  was  desirous  that 
this  new  agent  should  be  placed  at  first  only  in  care- 
ful hands,  for  he  remembered  that  a  few  unsuccess- 
ful cases  at  the  beginning  of  smallpox  inoculation 
ill  Scotland  deprived  that  country  of  the  benefits  of 
this  measure  for  more  than  twenty  years.  It  is 
worthy  of  remark  that  he  received  efficient  aid  from 
Thomas  Jefiferson,  then  President  of  the  United 
States,  in  extending  the  benefits  of  vaccination  to 
the  people  of  the  southern  States. 

But  despite  the  great  care  taken  by  Waterhouse 
in  distributing  the  virus,  it  not  infrequently  fell  into 
the  hands  of  practitioners  who  not  only  misjudged 
and  disregarded  his  cautions,  but  violated  almost 
every  rule  laid  down  by  Jenner.  Some  regarded  the 
whole  matter  as  so  extremely  simple  that  they  en- 
couraged women  and  children  to  vaccinate  each 
other.  As  a  result  of  such  careless  practice,  vaccina- 
tion was  threatened  for  a  time  with  serious  discredit, 
for  we  are  told  that  early  in  the  fall  of  1800,  vac- 
cinia, in  several  localities,  had  degenerated  from  its 
originally  mild  character,  and  not  infrequently  there 
were  seen  various  forms  of  spurious  results,  even 
extremely  sore  arms  with  alarming  constitutional 
disturbance.  In  some  of  these  cases  the  test  of 
smallpox  inoculation,  still  commonly  practised,  was 
followed  by  the  development  of  that  disease,  thus 
proving  the  vaccinations  to  have  been  spurious. 

"During  this  period,"  says  Waterhouse,  "a  sin- 
gular traffic  was  carried  on  in  the  article  of  kind- 
pock  matter  by  persons  not  in  the  least  connected 
with  the  medical  profession,  such  as  stage  drivers, 
'peddlers,  and,  in  one  instance,  the  sexton  of  a 
church !  I  have  known  the  shirt  sleeve  of  a  patient 
— stiff  from  the  purulent  discharge  from  a  foul 
ulcer,  made  so  by  unskilful  management,  and  fully 
three  weeks  after  vaccination,  and  in  which  there 
could  have  been  none  of  the  specific  virus — I  have 
known  this  cut  up  into  small  strips  and  sold  about 
the  country  as  genuine  cowpox  matter  coming  di- 
rectly from  me."  After  describing  the  result  of 
introducing  this  septic  matter  into  the  system,  and 
expressing  surprise  that,  in  such  a  country  as  ours, 
people  should  be  found  credulous  enough  to  receive 
vaccination  from  such  utterly  incompetent  hands,  he 
concludes  the  paragraph  by  saying:  "If  any  dis- 
agreeable occurrence  arose  in  the  course  of  this  im- 
prudent practice,  the  odium  reverted  to  me." 

Within  a  comparatively  short  time  Waterhouse 
saw  that,  in  spite  of  his  best  efiforts,  the  vaccine 
virus  in  this  country  had  degenerated  to  such  an 
extent  as  to  produce  a  vaccine  vesicle  showing  con- 
siderable deviation  from  the  original,  concerning 
which  fact  he  was  greatly  perplexed,  being  in  some 
doubt  as  to  the  real  cause.  At  this  gloomy  period 
he  wrote  to  England  for  a  fresh  supply  of  virus, 
intimating  at  the  same  time  that  its  loss  in  this 
country  was  owing  to  the  cold  weather.  He  gave 
Jenner  a  minute  description  of  all  the  unfortunate 
occurrences  he  had  met  with,  and  begged  him  to 
explain  the  deterioration  of  the  virus,  stating  that  he 
himself  was  much  perplexed  about  the  matter.  This 


worthy  man  replied  that  he  had  heard  of  the  dis- 
asters in  this  country,  and,  in  his  great  anxiety,  had 
often  wished  he  could  convey  these  words  on  the 
wings  of  the  wind  across  the  wide  ocean :  "Take  the 
virus  before  the  efflorescence  appears."  And  again, 
to  be  still  more  emphatic  on  this  point,  he  wrote: 
"I  don't  care  what  British  laws  the  Americans  dis- 
card, so  that  they  stick  to  this — never  to  take  the 
virus  from  a  vaccine  pustule  for  the  purpose  of 
inoculation  after  the  efflorescence  is  formed  around 
it.  I  wish  this  efflorescence  to  be  considered  as  a 
sacred  boundary  over  which  the  lancet  shall  never 
pass." 

This  advice  was  so  constantly  given  by  Jenner, 
and  was  deemed  of  so  great  importance  by  him,  that 
it  became  known  everywhere  as  the  "golden  rule" 
of  vaccination. 

Early  in  the  spring  of  1801  Waterhouse  received 
a  fresh  supply  of  virus  from  England,  and  was 
gratified  to  find  that  the  vaccine  disease  produced 
by  it  was  benign  and  innocent,  and  presented  all  the 
characteristics  seen  in  the  first  cases  of  vaccination 
in  his  own  family. 

At  a  comparatively  early  period  of  the  propaga- 
tion of  bovine  virus  in  this  country,  a  certain  propa- 
gator, in  Boston,  with  an  utter  lack  of  appreciation 
of  the  importance  of  pure  virus,  conceived  the  idea 
that,  from  a  commercial  standpoint,  it  would  be 
advantageous  to  make  up  a  compound  containing 
some  vaccine  virus  in  combination  with  a  lot  of 
gross  material,  the  real  nature  of  which  was  known 
only  in  the  Patent  Office  at  Washington.  This  com- 
pound was  put  on  the  market  under  the  name  of 
"solid  lymph  cones."  An  analysis  of  these  cones 
showed  that  under  favorable  conditions  they  were 
quite  sure  to  take  on  putrefactive  changes.  Very 
bad  results  followed  the  use  of  this  compound  in 
several  localities,  but  the  worst  of  all  occurred  at 
Thomasville,  Ga.  In  a  communication  to  the  Na- 
tional Board  of  Health,  Dr.  L.  S.  Hopkins,  of 
Thomasville,  wrote "Our  town  authorities  have 
employed  a  physician  to  vaccinate  all  persons  pre- 
senting themselves  for  the  purpose.  The  'virus'  was 
furnished  by  the  town,  and  procured  from  the  New 
England  Vaccine  Company,  Chelsea,  Mass.,  as  'bo- 
vine matter.'  The  result  has  been  fearful.  Nearly 
every  one  vaccinated  has  suffered  severely  from 
erythema  or  erysipelas,  the  arm  swollen  from  shoul- 
der to  wrist,  and  the  point  of  puncture  presenting 
the  appearance  of  a  sloughing  ulcer,  discharging 
freely  sanious  pus.  Many  of  the  patients  have  been 
confined  to  bed  with  high  fever  from  five  to  ten 
days,  requiring  the  constant  application  of  poultices 
to  the  arm,  and  the  free  use  of  morphine  for  the 
relief  of  pain.  ...  It  came  in  'cones'  said  to 
contain  (each  cone)  enough  to  vaccinate  one  hun- 
dred persons,  at  a  cost  of  $1  per  'cone.'  It  'takes' 
in  all  cases,  regardless  of  previous  vaccination,  as 
shown  by  w-ell  pitted  marks,  and  the  inflammation 
begins  frequently  on  the  second  day.  Those  who 
have  tried  it  tell  me  they  would  much  prefer  to  have 
smallpox." 

There  is  no  doubt  that  such  unfortunate  occur- 
rences as  this  tend  to  discredit  vaccination.  But  it 
should  be  remembered  that  such  work  is  not  vacci- 

^Natiotial  Board  of  Health  Bulletin,  March  4,  i88a. 


January  16,  1909.] 


WELCH:  SO  CALLED  DANGERS  OF  VACCINATION. 


nation  at  all ;  it  is  only  a  coarse  and  dangerous  coun- 
terfeit. When  Jenner's  most  emphatic  injunction  to 
collect  nothing  but  pure  virus  for  the  purpose  of  in- 
oculation is  so  flagrantly  violated,  surely  his  great 
discovery  should  not  be  held  responsible  for  the  evil 
consequences.  All  true  followers  of  Jenner  regret 
such  occurrences  as  those  just  mentioned  as  much  as 
the  antivaccinationists  delight  in  reporting  them. 

If  one  were  to  undertake  to  arrange  a  list  includ- 
ing the  abnormal  phenomena  seen  in  the  evolution 
of  the  vaccine  vesicle,  and  further,  the  diseases 
which  have  been  reported  as  occurring  in  conse- 
quence of  vaccination,  the  list,  it  is  true,  would  be 
quite  formidable.  But  when  we  exclude  those  that 
are  of  great  rarity  and  those  which  are  distinctly 
preventable,  we  have  left  only  an  insignificant  re- 
mainder. 

It  is  stated  on  good  authority  that  such  cutaneous 
affections  as  eczema,  lichen,  erythema  multiforme, 
impetigo,  pemphygus,  psoriasis,  and  a  number  of 
others,  may  occur  as  the  result  of  vaccination.  W'wh 
the  exception  of  impetigo  contagiosa,  it  is  hardly 
possible  that  any  of  these  diseases  could  be  inocu- 
lated with  vaccine  virus.  But  there  is  no  doubt  that 
the  constitutional  disturbances  incident  to  vaccinia 
may  sometimes  excite  into  action  some  disease  to 
which  the  subject  is  specially  predisposed. 

On  the  other  hand,  we  all  know  how  often  these 
skin  affections  are  seen  entirely  independent  of  vac- 
cination. When  we  consider  the  thousands  and  tens 
of  thousands  of  people  who  are  vaccinated,  and  how 
seldom  these  affections  follow,  it  is  not  difficult  to 
believe  that  their  occurrence  after  vaccination  is  in 
many  instances  a  mere  coincidence. 

Erysipelas  is  a  very  infrequent  complication  in 
vaccinia.  So  far  as  I  can  recall  my  own  experience 
with  erysipelas,  it  is  limited  to  a  single  series  of 
vaccinations,  and  I  have  already  assumed  responsi- 
bility for  its  development  in  that  instance.  When 
pure  virus  is  used  it  is  certainly  not  liable  to  occur, 
except  as  the  result  of  secondary  infection.  One 
must  not  mistake  the  redness  of  the  inflamed  area 
around  the  vesicle  for  erysipelas. 

The  possibility  of  invaccinating  leprosy  can  now 
be  positively  eliminated  from  the  list  of  dangers,  or 
alleged  dangers,  from  vaccination.  Indeed,  many 
high  authorities  doubt  the  possibility  of  thus  trans- 
mitting leprosy.  Beavan  Rake  and  Buckmaster, 
who  have  given  this  matter  much  study,  believe  that 
the  alleged  cases  of  transmission  of  leprosy  by  vacci- 
nation are  open  to  serious  doubt.  It  is,  of  course, 
only  possible  when  the  vaccine  material  is  taken 
directly  from  a  leprous  subject.  Surely  no  one 
would  think  of  taking  virus  from  such  a  source. 
The  bovine  animal,  from  which  all  vaccine  virus  is 
now  taken,  is  not  subject  to  leprosy. 

It  must  be  admitted  that  it  is  possible  to  convey 
the  infection  of  syphilis  by  the  employment  of 
humanized  vaccine  virus.  It  is.  however,  a  fact  that 
in  the  days  when  humanized  virus  was  employed 
exclusively  syphilitic  infection  therefrom  was  of  ex- 
tremely rare  occurrence.  The  most  of  the  cases 
authoritatively  reported  occurred  in  Italy  and 
France.  It  is  stated  in  the  report  of  the  English 
Vaccination  Commission,  in  its  judicial  sessions, 
that  many  physicians  who  had  practised  vaccination 


extensively  for  many  years  testified  that  they  had 
never  observed  vaccinal  syphilis  themselves  nor  had 
they  ever  heard  of  it  in  the  practice  of  their  col- 
leagues. 

Inasmuch  as  the  bovine  animal  is  totally  insus- 
ceptible to  syphilis,  it  is  obviously  impossible  to 
communicate  this  infection  with  vaccine  lymph  from 
this  source.  "The  employment  of  calf  lymph  and 
the  complete  elimination  of  the  risk  of  transferring 
syphilis  to  the  vaccinee  have  robbed  the  opponents 
of  vaccination  of  one  of  their  most  pyotent  arguments 
against  the  enforcement  of  vaccination."  (Welch 
and  Schamberg.) 

Since  the  contention  of  the  antivaccinationists  that 
syphilis  is  communicated  by  vaccination  is  no  longer 
tenable,  they  are  directing  their  efforts  toward  ex- 
aggerating the  danger  from  tuberculosis,  knowing 
that  the  bovine  animal  is  subject  to  that  disease. 
Whether  or  not  it  is  possible  to  transmit  tuberculosis 
through  the  agency  of  vaccine  lymph  is  a  question 
that  has  never  been  fully  determined.  One  experi- 
menter asserts  to  have  succeeded  in  developing 
tuberculosis  in  the  rabbit  and  pig  with  vaccine  virus 
taken  from  a  tuberculous  cow,  while  another  failed 
to  transmit  the  disease  after  injecting  vaccine  lymph 
taken  from  a  tuberculous  individual  into  the  peri- 
toneal cavity,  under  the  skin,  and  into  the  anterior 
chamber  of  the  eye  in  forty-seven  animals.  It  is 
evident,  therefore,  that  the  danger  is  not  great.  But 
fortunately  we  are  able  to  obviate  entirely  the  slight 
danger  that  may  exist. 

All  vaccine  virus  is  now  taken  from  calves,  and  it 
is  a  well  established  fact  that  tuberculosis  in  the  calf 
is  extremely  rare.  Pfeift'er  states  that  but  one  case 
of  tuberculosis  was  found  among  34.400  calves 
under  four  months  of  age.  At  Augsburg  only  one 
tuberculous  calf  was  discovered  among  22,230  that 
were  slaughtered. 

As  a  precautionary  measure,  in  all  well  regulated 
establishments  for  the  propagation  of  the  bovine 
virus,  the  calves  are  either  subjected  to  the  tuber- 
culin test  before  they  are  vaccinated  or  are  autop- 
sied  before  the  virus  is  distributed  for  use.  Dr. 
W.  F.  Elgin,  a  well  known  authority  on  the  propa- 
gation of  animal  vaccine  virus,  says  that  for  five  or 
more  years  all  calves  which  he  vaccinated  were  sub- 
jected to  the  tuberculin  test,  but  as  tuberculosis  was 
not  found  in  a  single  instance,  the  test  was  discon- 
tinued. He  says  his  practice  is,  after  collecting  the 
virus,  to  slaughter  the  calves  and  have  them  sub- 
jected to  autopsy  by  a  trained  veterinarian,  and  if 
tubercle  bacilli  are  found  the  virus  is  discarded. 

Even  though  it  were  possible,  despite  these  pre- 
cautions, for  tubercle  bacilli  to  get  into  the  lymph, 
they  would  perish  if  the  lymph  were  glycerinated. 
which  is  now  the  general  practice.  In  speaking  of 
glycerinated  lymph  Copeman  says :  "The  tubercle 
bacillus  is  eflfectually  destroyed  even  when  large 
quantities  of  virulent  cultures  have  been  purposely 
added  to  the  lymph."    (Welch  and  Schamberg.) 

It  is  frequently  alleged  that  vaccination  causes 
tetanus.  Tetanus  following  vaccination  is  said  to  be 
unknown  in  France,  Germany,  and  other  continental 
countries  of  Europe.  A  number  of  cases,  it  is  true, 
have  been  reported  in  this  country  within  recent 
years.    But  when  a  careful  inquiry  is  made  con*om- 


io6 


CARSON:  LEGAL  ASPECT  OF  VACCINATION. 


[New  York 
Medical  Joukxal. 


ing  the  histories  of  these  cases  it  is  invariably  found 
that  the  tetanus  poison  was  not  introduced  simul- 
taneously with  the  vaccine  virus,  but  subsequently. 
In  practically  all  of  the  cases  which  have  been  ex- 
amined there  has  been  found  evidence  of  a  gross 
breach  in  the  care  of  the  vaccine  lesion,  such  as  a 
ruptured  vesicle  and  an  open  wound  in  a  filthy  con- 
dition, with  insanitary  environments,  thus  affording 
a  favorable  opportunity  for  the  entrance  of  the  teta- 
nus poison,  or  any  other  infection. 

As  showing  that  the  tetanus  infection,  whenever 
this  complication  has  appeared,  was  introduced  sub- 
sequently to  the  vaccination,  I  would  say  that,  so  far 
as  I  know,  no  case  of  tetanus  after  vaccination  has 
been  reported  in  which  the  tetanic  symptoms  ap- 
peared earlier  than  about  two  weeks  subsequent  to 
the  vaccination.  The  interval  between  the  vaccina- 
tion and  the  development  of  tetanus  has  varied  from 
fourteen  days  to  seven  weeks,  whereas  the  incuba- 
tion period  of  tetanus  is  seldom  longer  than  seven 
days. 

In  a  study  of  the  bacterial  impurities  of  vaccine 
virus,  Rosenau  was  unable  to  find  tetanus  organisms 
in  any  of  a  considerable  number  of  glycerinated 
points  and  tubes  bought  in  open  market  and  exam- 
ined with  this  object  in  view.  He  states  that  tetanus 
organisms  cannot  grow  or  produce  their  toxine 
either  in  glycerinated  virus  or  on  dry  points.  He 
further  states :  "It  would  take  gross  carelessness  to 
contaminate  the  vaccine  with  a  sufficient  number  of 
tetanus  spores  to  carry  the  disease  to  those  vacci- 
nated. It  is  not  a  matter  of  surprise  that  some  out- 
breaks of  tetanus  have  occurred  when  thousands  of 
open  wounds  are  presented  for  the  reception  of  this 
infection  so  widely  distributed  in  nature."  (Welch 
and  Schamberg.) 

In  all  well  regulated  vaccine  establishments  the 
stables  and  the  calves  are  kept  scrupulously  clean, 
and  every  possible  care  is  taken  to  guard  against 
contamination  of  the  virus.  In  speaking  of  his  own 
methods.  Dr.  Elgin  says  that  all  calves  brought  to 
the  establishment  for  vaccination  are  at  once  placed 
in  quarantine  and  subjected  to  a  faecal  test.  At  the 
end  of  three  days  an  anaerobic  culture  from  the 
faeces  of  each  animal  is  examined  microscopically 
for  the  tetanus  organism.  If  such  organism,  or  any- 
thing resembling  it,  is  found  the  animal  is  rejected, 
and  does  not  get  into  the  stables  at  all. 

Dr.  Elgin  states,  furthermore,  that  the  virus  itself 
is  subjected  to  both  the  microscopic  and  toxine  tests 
for  the  tetanus  poison.  Anaerobic  cultures  are 
grown  and  examined  for  the  organism,  and,  whether 
it  is  found  or  not,  the  bouillon  culture  is  filtered 
through  a  Pasteur-Chamberlin  filter,  and  5  c.c.  of 
the  filtrate  is  injected  into  a  guinea  pig  to  determine 
the  presence  of  the  toxine.  In  addition  to  this,  i 
c.c.  of  the  untreated  virus  is  injected  subcutaneously 
in  a  pig  to  note  its  pathogenic  action,  if  any. 

With  the  safeguards  which  at  the  present  time 
surround  the  propagation  of  calf  lymph,  I  feel  per- 
fectly sure  in  saying  that  if  the  individual  is  in  a 
normal  condition  when  vaccinated,  if  the  vaccina- 
tion is  conducted  with  due  regard  to  surgical  clean- 
liness, and  if  the  vesicle  is  properly  guarded  until 
the  scab  forms  and  falls  ofT  naturally,  no  dangerous 
consequences  need  be  feared. 

141 1  Jefferson  Street. 


THE  LEGAL  ASPECTS  OF  VACCINATION. 

By  Hampton  L.  Carson,  Esq., 
Philadelphia. 

I  have  been  asked  to  present  a  paper  upon  the 
legal  aspects  of  vaccination,  and  I  shall  confine  m\  - 
self  to  the  judicial  aspects  of  the  matter,  leaving  out 
of  view  those  considerations  which  appeal  solely  to 
legislative  discretion. 

The  distinction  between  the  judicial  and  the  legis- 
lative view  may  be  pointed  by  the  remark  that  a 
court,  in  passing  upon  the  validity  of  any  law  adopt- 
ed by  a  legislature,  will  not  consider  the  motives 
which  induced  the  legislature  to  pass  the  bill,  nor 
subject  the  wisdom  or  propriety  of  the  action  of  the 
legislature  to  judicial  criticism  or  review.  It  is 
enough  for  a  court  to  be  satisfied  that  the  legisla- 
ture has  passed  the  law,  and  the  sole  question  for 
a  court  is  whether  the  legislature  had  the  power  un- 
der the  Constitution  to  pass  the  statute.  Hence,  I 
shall  say  nothing  in  regard  to  the  grounds,  scientific 
or  otherwise,  upon  which  such  legislation  rests,  that 
being  a  matter  which  doctors  and  scientific  men  are 
much  better  able  to  determine,  and  the  combating 
of  psuedoarguments  against  vaccination  must  be 
left  with  medical  men. 

The  question  to  be  dealt  with  in  this  paper  is 
whether,  assuming  that  the  legislature,  after  listen- 
ing to  debate  upon  the  propriety  of  safeguarding 
the  public  health  by  legislation  enforcing  compul- 
sory vaccination,  adopts  such  a  statute,  such  a  stat- 
ute is  within  the  constitutional  power  of  the  legis- 
lature, and  whether  it  is  free  from  the  objection 
often  urged  that  it  is  an  invasion  of  the  personal 
liberty  of  the  citizen  ?  This  aspect  of  the  matter  was 
within  a  few  days  presented  to  my  attention  by  a 
letter  from  a  most  distinguished  surgeon,  who  re- 
ferred me  to  Osier's  Practice  of  Medicine,  third  edi- 
tion, 1898,  page  57,  in  which  it  is  stated  substantially 
that  a  large  unvaccinated  population  had  grown  up 
in  Montreal  in  consequence  of  the  prejudice  against 
vaccination,  especially  amongst  the  French-Cana- 
dians. One  Pullman  car  conductor  suffering  from 
smallpox  came  from  Chicago  to  Montreal  on  Feb- 
ruary 28,  1885.  Within  the  next  ten  months  several 
thousand  cases  of  smallpox  occurred,  and  3,184  per- 
sons died  out  of  a  population  of  185,000 — that  is  to 
say,  one  person  in  every  fifty-eight  died — to  say 
nothing  of  the  deformity,  blindness,  and  other  un- 
fortunate and  repulsive  results.  This  impressive 
statement  was  added  to  by  the  remark  of  my  corre- 
spondent that  he  had  found  a  number  of  persons 
who  objected  to  vaccination  on  the  ground  that  it 
was  an  invasion  of  personal  liberty,  and  he  added 
that  he  would  like  to  ask  per  contra  whether  it  was 
not  an  invasion  of  the  personal  liberty  of  all  the 
citizens  of  Montreal  when  one  man  was  allowed  to 
make  thousands  sick  and  deformed,  and  kill  3,184 
people  simply  because  that  one  person  was  not  vac- 
cinated ;  and  he  added :  "And  it  seems  to  me  as 
clear  as  daylight  that  the  community  has  a  right  to 
protect  itself  and  prevent  any  such  death  dealing  in- 
vasion as  shown  in  this  particular  instance  and  many 
other  similar  ones." 

The  question  is  plain.  Assuming  that  a  legislature, 
after  listening  to  arguments  pro  and  con,  is  satisfied 
that  the  presence  of  an  unvaccinated  person  is  a 


♦ 


Jaiiuary  i6,  1909.] 


CARSON:  LEGAL  ASPECT  OF  VACCINATION. 


menace  to  public  health,  and  therefore  passes  a  stat- 
ute upon  the  subject  making  vaccination  more  or 
less  compulsory,  is  the  passage  of  such  a  statute 
within  the  constitutional  powers  of  a  legislature,  and 
is  it  free  from  the  objection  that  it  is  an  invasion 
of  the  personal  liberty  of  a  citizen  who  does  not  be- 
lieve in  vaccination?  The  answer  to  this  question 
under  the  law  is  plain  and  certain  and  free  from 
doubt. 

In  every  well  ordered  community — and  such  every 
State  in  the  Union  can  fairly  claim  to  be — there  ex- 
ists a  power  generally  known  as  the  police  power. 
It  is  true  that  the  police  power  is  incapable  of  exact 
definition  and  of  a  precise  limitation,  for  legal  defi- 
nitions do  not  sum  themselves  up  in  single  sentences. 
They  are  and  of  necessity  must  be  more  or  less  gen- 
eral and  elastic,  in  order  that  the  courts  may  apply 
them  to  the  infinite  variety  of  circumstances  which 
may  arise  in  the  relations  and  affairs  of  mankind  in 
civilized  society.  What  is  termed  the  police  power 
has  been  the  subject  of  much  consideration  by  both 
the  Federal  and  State  courts,  and  all  agree  that 
every  well  organized  government  has  the  inherent 
right  to  protect  the  health  and  provide  for  the  safety 
and  welfare  of  its  people.  It  is  not  only  the  right, 
but  it  is  a  duty  and  obligation  which  the  sovereign 
power  owes  to  the  public,  and  as  no  one  can  foresee 
the  emergency  or  necessity  which  may  call  for  its 
exercise,  it  is  not  an  easy  matter  to  prescribe  the 
precise  limits  within  which  it  may  be  exercised.  It 
may  be  said  to  rest  upon  the  maxim,  "Salus  populi 
snprema  lex." 

Such  is  the  substance  of  the  ruling  of  the  Su- 
preme Court  of  Maryland  in  the  case  of  Deems  vs. 
the  City  of  Baltimore,  80  Md.  164. 

The  same  view  was  taken  by  the  Supreme  Court 
of  the  United  States,  which,  in  the  language  of  Mr. 
Justice  Grier,  in  the  License  Cases,  46  U.  S.  Rep., 
5th  Howard,  504,  said : 

'"Without  attempting  to  define  what  are  the  pe- 
culiar subjects  or  limits  of  this  power,  it  may  safely 
be  affirmed  that  every  law  for  the  restriction  or  pun- 
ishment of  crime,  for  the  preservation  of  the  public 
peace,  health,  morals,  must  come  within  this  cate- 
gory ;"  and  in  the  case  of  In  re  Marriage  License 
Docket,  4th  Pa.  District  Court  Reports,  162,  it  was 
ruled  that  by  the  general  police  power  of  the  State, 
persons  and  property  are  subjected  to  all  kinds  of 
restraints  and  burdens  in  order  to  secure  the  general 
comfort,  health,  and  prosperity  of  the  State. 

The  police  power  is  an  attribute  of  sovereignty. 
It  is  such  an  attribute  of  sovereign  power  as  may 
properly  restrain  and  control  a  citizen  and  his  occu- 
pation in  such  a  manner  as  may  be  necessary  to  pro- 
mote the  health,  safety,  and  welfare  of  society.  It 
is  that  inherent  and  plenary  power  in  the  State 
which  enables  it  to  prohibit  things  hurtful  to  the 
comfort,  safety,  and  welfare  of  society.  It  is  a 
power,  moreover,  which  belongs  to  the  several 
States  and  has  not  been  delegated  to  the  general 
Federal  government,  but  remains  with  the  State 
governments,  to  enable  them  to  regulate  for  their 
own  welfare,  as  they  understand  it,  their  internal 
or  domestic  concerns. 

The  legislature  cannot  by  any  contract  divest  itself 
of  the  jx)wer  to  designate  the  objects  over  which  the 
police  power  extends,  and  in  a  case  arising  upon  the 


Pacific  Coast,  based  upon  the  authority  of  Judge 
Cooley,  a  most  eminent  authority  upon  constitutional 
law,  it  was  said  that  the  power,  like  that  of  taxation, 
pervades  every  business,  reaches  to  every  interest 
and  every  subject  of  profit  or  enjoyment,  and  com- 
prehends legislation  for  the  public  health,  the  public 
safety,  the  public  morals,  and  the  public  welfare. 
In  short,  the  police  power  is  an  equivalent  term  for 
legislative  power.  Health  Department  vs.  Rector  of 
Trinity  Church,  i/th  Nezv  York  Supplement,  510. 
New  Orleans  Gas  Light  Company  vs.  Louisiana 
Heat  &  Light  Company,  j/5  U.  S.  Rep.  650. 

Again,  it  was  said  by  Judge  Andrews  in  the  case 
of  City  of  Geneva  vs.  Geneva  Telephone  Company: 

"By  means  of  this  power  the  legislature  exercises 
a  supervision  over  matters  involving  the  common 
weal  and  enforces  the  observance  by  each  individual 
member  of  society  of  the  duties  which  he  owes  to 
others  and  the  community  at  large." 

So,  too,  in  re  Jacobs,  98  New  York,  50  American 
Reports,  636,  it  was  ruled  that  the  police  power  ex- 
tends to  legislation  having  for  its  object  the  promo- 
tion of  the  health,  comfort,  safety,  and  the  welfare 
of  society.  Under  it  the  conduct  of  an  individual 
in  the  use  of  property  may  be  regulated  so  as  to 
interfere  to  some  extent  with  the  freedom  of  the 
one  and  the  enjoyment  of  the  other. 

In  Webster  vs.  State,  75  Southivestern  Reporter, 
page  1020,  it  was  said : 

"The  police  power  extends  over  a  large  range  of 
subjects — the  public  health,  the  public  morals,  the 
public  safety,  the  public  welfare." 

Without  multiplying  authorities,  one  other  may 
be  added  to  the  list : 

"The  police  power  is  a  broad  and  comprehensive 
power  by  which  the  rights  of  an  individual,  both  as 
to  his  liberty  and  his  enjoyment  of  property,  may 
be  curtailed  in  the  interests  of  the  public  welfare." 
Huber  vs.  Merkel,  117  Wisconsin,  355.  And  in  ac- 
cord with  this  is  the  Supreme  Co>:rt  of  Vermont, 
in  the  case  of  Thorpe  vs.  Rutland,  3/  Vermont,  140, 
where  it  was  said  : 

"The  police  power  of  the  State  extends  to  the 
protection  of  the  fives,  limbs,  health,  comfort,  and 
quiet  of  all  persons  and  the  protection  of  all  prop- 
erty within  the  State  by  which  persons  and  property 
are  subjected  to  all  kinds  of  restraints  and  burdens 
in  order  to  secure  the  general  comfort,  health,  and 
prosperity  of  the  State." 

Coming  now  to  the  specific  matter  of  vaccination, 
the  Supreme  Court  of  Pennsylvania  has  expressed 
itself  in  no  uncertain  terms.  The  writer,  while 
attorney  general  of  the  commonwealth,  argued  the 
case  of  Stull,  appellant,  vs.  Reeber,  reported  in  21^ 
Pa.  Supreme  Court  Reports,  page  160.  The  opinion 
was  delivered  by  Chief  Justice  Mitchell  on  the  sev- 
enth of  May,  1906,  and  is  the  undisputed  law  of 
the  State.   He  said  : 

"The  substantial  question  in  this  case  is  whethei 
the  Act  of  June  18,  1895,  P.  L.  203,  requiring  the 
exclusion  from  the  public  schools  of  children  who 
have  not  been  vaccinated  is  a  valid  exercise  of  the 
police  power  of  the  State.  It  has  been  twice  so  de- 
cided by  this  Court.  In  Duffield  vs.  School  District 
of  Williamsport.  162  Pa.  476,  a  similar  regulation 
not  even  enacted  by  the  legislature  but  enforced  by 
the  school  directors  under  an  ordinance  of  the  City 


loS  CARSON:  LEGAL  ASPECT  OF  VACCINATION.  [Neh-  York 

Medical  Journau 


of  W'illiamsport  was  held  valid.  And  in  Field  vs. 
Robinson,  198  Pa.  638,  this  very  statute  of  1895  was 
held  constitutional.  It  appears  to  be  thought  that 
because  the  decision  was  given  in  a  brief  opinion 
per  curiam  the  subject  was  not  fully  considered. 
But  the  proper  inference  is  precisely  the  reverse, 
that  the  conclusion  was  so  perfectly  clear  to  the 
whole  Court  that  it  did  not  require  any  extended 
argumentative  support.  After  these  two  decisions 
the  question  ought  to  have  been  considered  as 
closed." 

The  court,  in  considering  the  contention  that  the 
vaccination  of  school  children  conflicted  with  the 
statutes  requiring  compulsory  attendance  upon  the 
schools,  said : 

■'It  is  furthei'  said  that  Section  12  contravenes 
Section  i  of  Article  10  of  the  Constitution,  requir- 
ing the  maintenance  of  an  efficient  system  of  public 
schools  wherein  all  children  above  the  age  of  six 
years  may  be  educated.  It  is  sufficient  to  say  that 
this  article,  like  all  others,  must  be  construed  and 
applied  in  connection  with  other  fundamental  gov- 
ernmental powers.  The  schools  and  school  children, 
important  as  they  are,  are  only  fractions  of  the  com- 
munity, and  the  police  power  of  the  commonwealth, 
in  the  preservation  of  the  public  health,  must,  if 
necessity  arises,  sacrifice  the  less  to  the  greater  in- 
terest. Salus  popiili  suprema  lex.  If  a  child  mani- 
festly suffering  from  smallpox  in  its  contagious 
stage  should  be  excluded  from  school,  it  is  hardly 
conceivable  that  the  propriety  of  such  action  should 
be  questioned.  At  what  period  before  or  after  the 
outbreak  of  the  disease  the  right  of  exclusion  should 
arise  is  a  legislative,  not  a  judicial  question.  As  said 
by  our  late  Brother  Williams  in  Duffield  vs.  School 
District,  162  Pa.  476,  already  cited:  Tt  is  conceded 
that  the  board  might  rightfully  exclude  the  plain- 
tiff's son  if  he  was  actually  sick  with  or  just  recov- 
ering from  the  smallpox.  Though  he  might  not  be 
affected  by  it,  yet  if  another  member  of  the  same 
family  was,  the  right  to  exclude  him,  notwithstand- 
ing he  might  be  in  perfect  health,  would  be  con- 
ceded. How  far  shall  this  right  to  exclude  one  for 
the  good  of  many  be  carried?  That  is  a  question 
addressed  to  the  official  discretion  of  the  proper 
officers ;  and  when  that  discretion  is  honestly  and 
impartially  exercised,  the  courts  will  not  interfere.' 
These  words,  it  should  be  remembered,  were  writ- 
ten with  reference  to  authority  exercised  under  a 
city  ordinance,  and  a  fortiori  when  the  police  power 
of  the  State  intervenes  under  the  authority  of  a 
statute,  its  directions  are  commands  that  may  not  be 
disputed." 

The  learned  chief  justice,  in  further  discussion  of 
the  case,  said : 

"Section  12  of  the  Statute  is  a  cautionary  and 
prospective  regulation,  having  in  view  not  the  actual 
presence  of  the  disease,  but  its  appearance  in  the 
future.  ...  In  this  connection  the  learned 
Judge  below  found  as  a  fact  'that  there  is  not  at  the 
time  of  the  filing  of  this  Bill,  nor  has  there  been  for 
a  period  of  about  forty  years,  any  person  in  the  said 
borough  of  Waynesboro  or  within  many  miles 
thereof,  suffering  from  smallpox,'  and  it  is  argued 
that  this  feature  distinguishes  the  case  from  those 
heretofore  decided  by  this  Court.  But  the  language 
of  the  Act  is  general  and  its  intent  plain.  The  legis- 
lature may  well  have  it  in  mind  that  the  good  for- 


tune of  such  a  community  may  not  continue  indefi- 
nitely. Immunity  for  forty  years  in  the  past  aft'ords 
no  guaranty  of  immunity  for  even  forty  days  in  the 
future  if  a  chance  visitor  from  an  infected  locality 
or  a  borough  resident  returning  from  a  visit  to  such 
locality  should  bring  with  him  the  germs  of  infec- 
tion. Section  12  is  precautionary  and  preventive, 
and  it  is  an  old  and  sound  maxim  that  an  ounce  of 
prevention  is  worth  a  pound  of  cure." 

The  learned  chief  justice  dealt  with  another  aspect 
of  the  question,  and  that  raised  by  the  communica- 
tion of  my  correspondent.    He  said : 

"Lastly,  it  is  argued  that  construing  Section  12 
as  we  have  done,  it  authorizes  a  trespass  upon  the 
reserved  rights  of  the  individual  which  are  beyond 
the  reach  of  even  the  police  power.  Vaccination, 
it  is  said,  is  the  infliction  of  a  disease,  cowpox,  on 
the  subject,  and  if  that  can  be  done  irrespective  of 
his  consent,  then  the  next  step  may  be  to  require 
submission  to  inoculation  with  antitoxine  or  serum 
for  diphtheria,  tuberculosis,  cancer,  etc.,  and  we 
have  rather  a  dismal  picture  of  the  possible  conse- 
quences. It  will  be  time  enough  to  consider  such 
matters  when  they  arise.  At  present  the  vast  pre- 
ponderance of  opinion  among  intelligent  and  edu- 
cated people,  under  the  guidance  of  the  best  medical 
authority,  is  that  vaccination  is  a  highly  useful 
ameliorative,  if  not  always  a  preventive,  of  one  of 
the  greatest  scourges  that  have  in  past  times  afflicted 
humanity,  and  that  regulation  of  it  by  statute  is  not 
only  a  justifiable  but  a  wise  and  beneficent  exertion 
of  the  police  power  over  the  public  health." 

As  our  highest  judicial  tribunal  has  delivered  it- 
self in  such  unmistakable  terms  upon  the  constitu- 
tionality of  the  power,  it  is  entirely  unnecessary  to 
prolong  this  paper  by  a  review  of  the  numerous  de- 
cisions all  tending  to  the  same  result,  which  have 
arisen  in  the  inferior  tribunals  of  the  common- 
wealth. But  it  may  be  of  importance  to  point 
out  in  conclusion  that  there  is  not  at  the  present 
time  upon  the  statute  books  of  the  State  a  law 
which  enjoins  vaccination ;  in  other  words,  the 
legislature  has  not  yet  gone  to  the  length  of  com- 
pulsory vaccination.  The  legislature  has  required 
the  exclusion  from  all  schools — public  and  private, 
parochial,  Sunday,  or  other  schools — of  unvac- 
cinated  pupils  or  pupils  who  could  not  produce  to 
the  teacher,  principal,  or  superintendent  a  certifi- 
cate of  prior  successful  vaccination,  and  the  law  of 
exclusion  is  binding  upon  teachers,  superintend- 
ents, and  principals,  but  as  yet  there  is  no  fine  im- 
posed upon  the  parent  for  declining  to  have  his 
child  vaccinated,  nor  is  there  any  statute  which  com- 
pels the  child  to  submit  to  vaccination  or  the  parent 
to  vaccinate.  The  penalty  seems  to  be  the  loss  of 
education  at  the  expense  of  the  State. 

I  have  dealt  with  the  general  features  of  the 
question  and  not  with  matters  of  detail  arising  as  to 
the  powers  of  health  boards  in  infected  communities, 
being  satisfied  that  the  purposes  of  this  paper  are 
met  by  the  demonstration  of  the  existence  of  the 
power,  and  therefore  it  follows  that  should  the  con- 
sensus of  medical  opinion  require  more  stringent 
and  drastic  provisions  than  arc  now  found  in  the 
law,  and  the  legislature  can  be  persuaded  of  the 
propriety  of  adopting  them,  no  question  can  be 
successfully  raised  in  the  courts  to  challenge  the 
authoritv  of  the  statute. 


January  i6,  1909.] 


DISCUSS  10 X  OX  THE  "SYMPOSIUM"  OX  VACCIXATION. 


Discussion  on  Papers  by  Dr.  Abbott.  Dr.  Schamberg, 
Dr.  Welch,  and  Mr.  Carsox. 

Dr.  W.  W.  Keen  referred  to  the  epidemic  in  Montreal 
that  had  been  mentioned  by  Mr.  Carson.  He  thought  that 
it  was  a  much  greater  violation  of  personal  liberty  to  seize 
a  man  and  confine  him  in  a  hospital  -for  contagious  diseases 
until  he  was  well  than  to  subject  him  to  vaccination.  The 
former  was  done  in  the  case  of  the  Pullman  car  conductor 
that  introduced  smallpox  into  Montreal,  causing  the  death 
of  more  than  three  thousand  persons,  and  making  about 
twelve  thousand  ill.  Apart  from  the  illness  and  death  from 
the  disease,  the  people  were  subjected  to  great  expense 
for  nurses,  doctors,  drugs,  and  loss  of  business.  Dr.  Welch 
had  called  attention  to  the  fact  that,  during  a  certain  period, 
there  were  in  England  more  than  6,000,000  vaccinations 
and  about  430  deaths.  Dr.  Keen  gave  a  view  of  the  other 
side  of  the  picture,  and  said  that  if  these  6,000,000  persons 
had  grown  up  to  adult  life  unvaccinated,  and  an  epidemic 
of  smallpo-x  had  broken  out,  a  great  many  more  lives 
would  probably  have  been  lost.  The  mortality  from  small- 
pox was  scarcely  ever  less  than  twenty-five  per  cent.,  and 
rose  to  thirty-five.  At  the  former  rate,  1,500.000  persons 
would  have  died,  rather  than  450. 

The  speaker  then  called  attention  to  the  experience  in 
combating  smallpox  in  the  insular  possessions  of  the  United 
States.  Soon  after  this  country  took  possession  of  Puerto 
Rico,  there  was  an  e.xtensive  epidemic  of  the  disease  in 
that  island.  The  United  States  government  immediately 
vaccinated  over  800,000  people,  and  within  four  months 
smallpox  was  obliterated.  No  change  in  sanitarj'  condi- 
tions had  been  made,  for  none  was  possible.  Therefore 
this  result  could  not  be  attributed  to  improved  hygiene. 

In  reading  the  last  annual  report  of  Dr.  V.  G.  Heyser, 
the  chief  of  the  Sanitary  Department  in  the  Philippine 
Islands,  Dr.  Keen  had  been  struck  with  the  statement  that 
in  seventeen  (  ?)  provinces  there  had  been  an  annual  mor- 
tality of  6,000  from  smallpox,  probably  25.000  or  30,000 
cases  in  all ;  but  in  the  twelve  months  following  the  com- 
pletion of  vaccination  in  these  provinces  there  was  not  one 
death.  Vaccination  had  been  completed  about  a  year  be- 
fore the  report  was  written.  There  could  be  no  better 
illustration,  on  a  large  scale,  of  the  value  of  vaccination. 

Dr.  J.  Madisox  Taylor  said  that  he  was  convinced  that 
the  vaccination  of  previously  unvaccinated  children  during 
an  attack  of  whooping  cough  exercised  a  modifying  effect 
upon  the  progress  of  that  disease. 

Dr.  Erxest  W.  Kelsey  referred  to  his  experience  dur- 
ing an  outbreak  of  smallpox  in  the  Aleutian  Islands.  The 
virus  at  hand  was  poor,  but  had  to  be  used.  The  epidemic 
was  verj-  widespread  and,  In  Alaska,  extended  as  far 
north  as  Point  Barrow.  The  eflFects  of  the  first  vaccine 
used  being  extremely  unsatisfactory-,  new  ^arus  was  ob- 
tained, and  the  epidemic  among  the  Indians  and  Eskimos 
was  stamped  out  within  four  months. 

Dr.  B.  F.  Royer  emphasized  the  fact  that  those  who 
feared  vaccination  because  of  its  untoward  action  and  be- 
cause of  the  diseases  said  to  be  inoculated  with  the  virus 
were  largely  misled  by  vicious  literature.  Even  under  the 
worst  conditions,  the  very  sore  arms  pictured  in  such  liter- 
ature were  but  rarely  seen.  While  connected  with  the 
Municipal  Hospital,  Dr.  Royer  had  been  compelled,  in  the 
face  of  smallpox,  to  vaccinate  from  600  to  1,200  children 
ill  with  other  diseases ;  and  it  was  but  seldom  that  the 
"takes"  in  these  cases  were  at  all  dangerous.  He  had 
never  seen  any  child  lose  its  life  as  the  result  of  vaccina- 
tion, even  when  already  ill  with  a  serious  disease. 


Dr.  M.  Clayton  Thrush  referred  to  the  meeting  of  the 
Antivaccination  League  of  America,  held  in  Philadelphia 
a  few  weeks  ago,  with  the  object  of  establishing  similar 
leagues  in  ever>-  city  in  the  Union  for  the  purpose  of  com- 
bating the  proposed  compulsory  vaccination  laws  of  this 
and  other  cities.  Dr.  Thrush  attended  this  meeting,  in 
order  to  find  out  what  methods  these  men  used  to  induce 
intelligent  men  to  think  as  they  did.  He  took  down  their 
statements  word  for  word,  and  found  many  misrepresenta- 
tions. If  they  had  adhered  to  the  truth,  he  would  have 
had  no  objection,  but  as  thjy  had  not  done  so,  he  re- 
quested permission  to  read  to  the  society  some  of  the  state- 
ments. A  prominent  Philadelphia  representative  of  the 
league,  a  cultured  literarj-  man,  said :  "The  only  people 
who  can  take  smallpox  are  those  whose  bodies  are  filthy." 
This  was  an  absurd  statement,  as  people  of  most  cleanly 
habits  acquired  the  disease  frequently.  Of  course,  filthy 
habits  predisposed  to  the  disease  at  any  time ;  but  it  was 
not  necessary  to  be  filthy  in  order  to  contract  smallpox  or 
any  other  disease.  He  also  stated  that  people  died  from 
vaccination  on  account  of  being  inoculated  with  poison. 
Their  own  representatives,  which  included  Dr.  Dobson,  of 
Connecticut,  and  Dr.  Levison,  of  New  York,  quarreled 
among  themselves,  in  open  meeting  of  the  league,  over 
this  very  question;  and  the  majority  argued  that  vaccine 
was  not  a  poison  to  the  blood.  Vaccine  was  not  poison- 
ous, unless  the  virus  was  not  pure,  and  we  should  obtain 
only  a  reliable  virus  for  our  work.  Another  statement 
was :  "If  men  will  only  think  for  themselves,  they  cannot 
help  hut  condemn  vaccination."  On  the  contrary,  if  they 
would  think  for  themselves,  they  would  recognize  its  great 
value  to  the  human  race  in  saving  thousands  of  lives  an- 
nuallj'.  He  added :  "You  cannot  have  a  race  of  real  men 
and  women,  as  long  as  you  put  poison  in  them.  If  you 
want  people  that  are  nonentities  and  do  not  think,  con- 
tinue vaccination."  It  was  strange  that  we  did  not  see 
this  statement  proved  among  thousands  who  had  been 
vaccinated,  and  whose  forefathers  for  generations  before 
them  had  done  likewise.  Such  statements  were  nonsen- 
sical and  required  no  answer  by  any  intelligent  mind. 

He  then  cited  the  lowered  birth  rate  in  France,  and  even 
had  the  audacity  to  attribute  this  to  vaccination,  which 
everj'  one  knew  was  not  the  cause  at  all.  "The  only  thing 
that  saves  this  country  is  immigration.  The  immigrants 
keep  up  the  birth  rate  on  account  of  not  having  been  vac- 
cinated." Vaccination  must  be  a  powerful  agent  when  it 
destroys  the  power  of  reproduction.  The  speaker  would 
like  to  have  evidence  of  this. 

A  prominent  English  representative  of  the  league  then 
spoke  and  quoted  Dr.  Walter  Hadwin.  of  England,  as 
having  said :  "Vaccination  is  not  purely  a  medical  opera- 
tion, but  it  is  a  superstitious  creed."  This  statement  was 
not  true  of  vaccination,  as  historj'  proved.  He  further 
said :  "Antivaccinationists  know  more  than  medical  men." 
How  exalted  was  their  opinion !  Fortunately,  it  was  con- 
fined to  themselves  alone. 

"In  1875,  the  Public  Health  Bill  was  passed  in  England, 
with  sanitary  and  sewage  regulations,  also  a  good  water 
supply.  The  dwellings  were  made  sanitary,  and  people 
lived  clean.  Vaccination  fell  into  disuse,  and,  as  the  result, 
a  stronger  and  healthier  race,  with  the  death  race  reduced 
from  27  to  12.5  per  1,000.  Mortality-  was  less  than  one 
half  what  it  used  to  be.  The  absence  of  vaccination  and 
the  presence  of  hygiene  produced  these  results."  As  a  mat- 
ter of  fact,  vaccination  produced  these  results,  as  the  health 
records  of  Great  Britain  showed,  although  hygiene  and 
cleanliness  were  important  factors  in  preventing  any  dis- 
ease. 


no 


DISCUSSION  ON  THE  ■'SYMPOSIUM"  ON  VACCINATION. 


[New  York 
Medical  Journal. 


He  termed  the  boards  of  health  the  "boards  of  ill  health," 
driving  people  wild  with  vaccination,  when  it  was  not 
necessary  to  prevent  smallpox.  "When  a  case  of  smallpox 
develops,  it  is  removed  to  the  pest  house.  Then,  why 
should  your  bodies  be  poisoned  with  the  stuf?  by  having 
your  bodies  inoculated?  Vaccination  is  absolutely  useless 
and  dangerous."  That  such  a  statement  originated  in  an 
intelligent  man  appeared  almost  incredible. 

Then  followed:  "Those  that  vaccinate  are  worse  than 
murderers,  as  the  murderer  puts  his  victims  out  of  pain, 
while  the  vaccinator  does  not."  According  to  this  state- 
ment, there  would  be  plenty  of  murderers  in  this  country 
all  the  time.  "How  many  more  people's  children  must  be 
sacrificed  before  we  rise  against  the  golden  calf?  The 
time  is  not  far  distant  when  a  bullet  will  be  put  in  those 
that  vaccinate.  Vaccination  is  perpetrated  by  the  medical 
men  for  what  they  can  get  out  of  it ;  and  they  look  at  it 
through  gold  glasses — with  the  accent  on  the  gOld."  He 
had  never  heard  of  any  physician's  growing  wealthy  on 
his  income  from  vaccinations.  This  statement  was  an  in- 
sult and  a  slur  on  the  medical  profession.  Not  only  did 
they  not  deserve  it,  but  it  would  cause  all  right  thinking 
people  to  condemn  and  oppose  any  assertions  that  these 
nntivaccinationists  might  make. 

Another  Philadelphia  representative  said :  "Vaccination 
is  polluting  the  blood  of  your  people.  Vaccination  appears 
to  us,  in  the  twentieth  century,  the  same  as  bloodletting 
does  to  medical  men  at  present.  It  is  now  condemned  as 
brutal,  like  vaccination.  'What  fools  these  mortals  be'  to 
allow  themselves  to  be  poisoned,  and  by  men  who  pose  as 
physicians."  This  was  hard  on  the  medical  profession ;  but 
it  was,  like  the  remainder  of  their  statements,  untrue,  as 
the  medical  men  not  only  believed  in  bloodletting,  but  were 
resorting  to  it  when  it  was  indicated,  with  good  results. 

He  then  exhibited  lantern-  slides  showing  persons  sufJer- 
ing  with  syphilitic  lesions  in  various  forms,  tuberculous 
conditions  of  various  parts  of  the  body,  deformities  of  all 
kinds,  and  various  skin  affections ;  and,  strange  to  say, 
they  were  all  the  direct  result  of  vaccination !  Dr.  Thrush 
said  that  he  would  like  to  know  how  these  statements 
could  be  proved.  They  could  not.  With  pure  vaccine,  no 
disease  of  any  kind  could  be  transmitted.  This  had  been 
proved  beyond  all  question  and  argument;  so  that  these 
people,  by  their  own  representation,  were  injuring  no  one 
but  themselves.  Vaccination  was  one  of  the  greatest  boons 
to  the  human  race ;  and  it  would  always  continue  to  be  so, 
except  among  a  few  persons  whose  minds  were  in  a  con- 
dition to  oppose  scientific  facts  that  had  proved  conclu- 
sively, all  over  the  world,  the  efficacy  of  vaccination  in  pre- 
venting smallpox.  Tf  such  had  not  been  the  case,  vaccina- 
tion would  not  have  continued  to  flourish  as  it  had  done 
up  to  the  present  time,  as  everyone  must  admit  to  be  true. 

Dr.  ScHAMBERG  Said  that  if  there  was  one  sane  argument 
that  arrtivaccinationists  might  urge,  it  was  that  this  pro- 
cedure was  not  unattended  with  risk.  Neither,  however, 
was  any  other  surgical  procedure.  Persons  had  been 
known  to  die  as  the  result  of  cutting  their  corns  or  of  cuts 
made  with  a  razor.  As  vaccination  produced  a  wound,  the 
vaccinated  person  was  subject  to  the  same  danger  as  were 
persons  with  any  other  wounds.  When  the  antivaccina- 
tionists  denied  the  efficacy  of  vaccination  in  preventing 
smallpox,  however,  the  question  was  no  longer  debatable. 
He  had  had  conversations  with  these  men,  and  believed 
the  most  of  them  to  be  sincere  in  their  convictions;  but  if 
they  shut  their  minds  to  logical  facts,  they  put  themselves 
in  the  position  of  those  suffering  from  delusions.  He 
thought  that  if  some  of  them  were  taken  to  the  Municipal 


Hospital  and  shown  the  protection  conferred  by  vaccina- 
tion upon  the  nurses  and  attendants,  though  the  unvac- 
cinated  immediately  fell  victims  to  the  disease,  he  was  not 
sure  that  they  would  be  convinced ;  because  these  things 
had  been  demonstrated  to  them  by  means  of  photographs 
and  statistics.  He  thought  that  the  great  fault  of  physi- 
cians was  that  they  ihaintained  silence  upon  the  subject, 
and  allowed  a  small  but  determined  band  of  antivaccina- 
tionists  to  distribute  their  literature  among  the  people.  He 
considered  it  time  for  this  to  cease,  and  said  that  sensible 
people  would  adopt  the  views  of  the  medical  profession. 
There  might  be  a  temporary  wave  of  opposition,  due  to 
the  silence  of  physicians  and  the  activity  of  the  other  side, 
but  he  believed  that  if  the  legislature  should  be  induced 
by  these  men  to  pass  a  bill  restricting  vaccination  in  this 
State,  the  vaccination  law  would  certainly  be  reenacted 
within  from  two  to  four  years,  with  increased  rigor  and 
vigor  The  first  epidemic  of  smallpox  that  occurred  would 
lead  to  the  passage  of  a  law  much  more  widespread  and 
positive  in  its  requirements.  We  might  trust  without  fear 
in  the  good  sense  of  the  American  people. 

Dr.  Welch  referred  to  a  circumstance  showing  the  great 
efficacy  of  vaccination  that  had  come  to  his  notice  during 
the  last  smallpox  epidemic  in  Philadelphia,  1901-1904. 
Himdreds  of  thousands  were  vaccinated  during  that  epi- 
demic. More  than  four  thousand  persons  suffering  with 
the  disease  were  admitted  into  the  Municipal  Hospital ; 
yet  among  those  cases  there  was  not  a  single  admission 
of  a  person  that  had  been  successfully  vaccinated  within 
five  years.  There  were  very  few  admissions  among  those 
who  had  been  successfully  vaccinated  within  ten  years,  and 
no  deaths.  Of  course,  the  more  the  time  since  the  vaccina- 
tion was  increased,  the  greater  was  the  loss  of  protection. 
There  was  increased  susceptibility,  and  the  individual 
might  take  smallpox  in  either  a  mild  or  a  severe  form,  ac- 
cording to  the  amount  of  protection  remaining  from  the 
original  vaccination. 

During  this  epidemic  several  hundred  students  came  to 
the  Municipal  Hospital  to  study  this  and  other  diseases. 
They  were  taken  through  the  wards  and  examined  the 
cases  and  studied  the  disease  carefully.  The  faculties  of 
the  colleges  from  which  the  students  came  were  asked  to 
see  that  they  had  been  properly  vaccinated.  It  happened, 
however,  that  one  young  man  among  this  number  of  sev- 
eral hundred  was  opposed  to  vaccination  and  was  unvac- 
cinated.  The  authorities  of  the  hospital  did  not  know  this, 
or  he  would  not  have  been  admitted.  About  two  weeks 
after  his  visit  he  came  back  as  a  patient.  He  was  very 
ill  and,  though  he  recovered,  he  was  badly  disfigured.  He 
was  the  only  one  unvaccinated,  and  he  alone  took  the 
disease.  In  response  to  a  request  from  the  chairman  Dr. 
Welch  said  that  he  had  vaccinated  a  large  number  of  babies 
as  soon  as  they  were  born,  because  their  mothers  were 
suffering  with  mild  forms  of  varioloid.  Many  of  these 
vaccinations  took  well,  and  the  infants  continued  to  lie 
in  bed  with  their  mothers  and  to  nurse  from  their  mother's 
breasts,  perfectly  protected  against  smallpox.  He  men- 
tioned an  instance  in  which  an  entire  family  was  admitted 
on  account  of  smallpox  in  some  of  its  members.  Two  of 
the  children,  who  had  reached  the  school  age,  were  vac- 
cinated, though  the  parents  and  the  three  or  four  other 
children  were  unvaccinated.  The  vaccinated  children  had 
to  come  in  with  the  rest  of  the  family,  because  they  could 
not  be  left  at  home  alone.  They  lived  in  the  hospital  for 
four  to  six  weeks.  Though  they  slept  in  bed  with  the 
other  members  of  the  family  and  ate  with  them,  they  en- 
joyed perfectly  good  health  throughout  their  stay.  The 


January  16,  1909] 


IVAINIVRIGHT:  JAMES  BLAKE. 


Ill 


speaker  had  seen  many  similar  instances.  He  said  that  he 
had  heard  before  that  vaccination  exerted  some  influence 
over  whooping  cough,  but  he  had  never  had  any  experience 
with  such  a  case,  and  did  not  beheve  that  there  was  much 
truth  in  the  idea.  He  had  never  thought  that  vaccination 
protected  against  anything  but  smallpox. 

Dr.  W.  S.  HiGBEE  said  that  the  operation  of  vaccination 
should  be  performed  with  surgical  cleanliness,  just  as  if 
a  major  operation  were  to  be  performed.  The  skin  should 
be  cleased,  the  lancet  should  be  sterile,  and  the  lymph 
used  should  be  all  right.  The  chief  rule  of  Jenner  was 
that  the  vaccination  material,  in  human  subjects,  should 
be  obtained  before  the  appearance  of  the  efflorescence,  and 
it  was  a  matter  of  the  greatest  importance  that  the  lymph 
used  should  be  properly  obtained.  At  the  present  time 
physicians  were  obliged  to  accept  the  lymph  as  it  came 
from  the  manufacturer,  and  Dr.  Higbee  preferred  the  glyc- 
erinated  kind.  The  glycerin  would  probably  destroy  any 
extraneous  organisms,  such  as  the  tubercle  bacillus,  that 
might  happen  to  get  in.  He  thought  it  well  not  to  scarify 
too  deeply.  The  epidermis  should  be  merely  scraped  ofif, 
in  order  to  get  down  to  the  absorbents.  If  too  much 
blood  was  drawn,  it  would  keep  the  virus  up  so  that  it 
could  not  be  absorbed,  and  no  result  would  be  obtained. 
If  the  patient  came  to  the  physician's  office,  the  wound 
should  be  protected  with  some  simple  shield  until  the  pa- 
tient reached  home,  so  as  to  keep  the  sleeve  from  rubbing 
the  virus  off  before  it  was  dry.  Otherwise,  he  was  op- 
posed to  shields,  as  he  had  seen  bad  results  from  their  use. 
They  sometimes  acted  as  cupping  glasses  and  did  a  great 
deal  of  harm.  All  that  was  really  necessary  was  for  the 
child  to  have  on  clean  underclothes ;  but  if  it  wore  a  shirt, 
a  piece  of  clean  muslin  might  be  sewed  on  the  inside  of 
the  shirt  sleeve,  which  should  be  perfectly  loose.  The  vac- 
cination vesicle  should  not  be  disturbed.  He  saw  no  ob- 
jection to  a  contrivance  made  of  wire  to  keep  the  clothing 
away  from  the  wound.  Vaccination  shields,  however,  often 
became  very  filthy.  The  wound  needed  very  little  treat- 
ment, but  should  be  properly  guarded  against  injury. 

JAMES  BLAKE: 

A  Sketch  of  the  Man  and  a  Brief  Account  of  His 
Scientific  Work. 
By  John  W.  Wainwright,  RI.  D., 
New  York. 

In  1839  James  Blake  of  England  laid  the  foun- 
dation of  our  present  knowledge  of  the  relations  ex- 
isting between  the  atomic  weight  of  the  metals  and 
their  physiological  action,  showing  by  experiments 
that  the  action  of  solutions  of  different  salts  when 
introduced  into  the  circulation  depended  upon  the 
electropositive  element,  the  electronegative  or  acid 
radical  having  no  or  little  infltience.  Later,  or  in 
1874,  he  demonstrated  the  efficiency  of  metals  be- 
longing to  the  same  group  of  isomers  as  propor- 
tioned to  their  atomic  weight.  The  greater  the 
atomic  weight,  the  greater  the  physiological  action. 
Thus  the  monovalent  metals,  lithium,  sodiuin,  rubid- 
ium, thallium,  calcium,  silver,  agree  exactly  with 
one  another  in  their  qualitative  physiological  action. 
Between  the  divalent  metals,  magnesium,  tellurium, 
manganese, cobalt,  nickel, copper,  zinc,  and  cadmium, 
a  similarity  can  be  observed  as  in  the  calcium,  sul- 
phur, and  baritim  group. 

The  quadrivalent  elements,  thorium,  palladium. 


platinum,  osmium,  and  the  monovalent  or  trivalent 
gold,  exercise  a  uniform  and  intense  physiological 
action.  The  three  haloge^is,  chlorine,  bromine,  and 
iodine,  agree  in  their  physiological  action,  btit  in  this, 
group  the  increase  of  intensity  is  not  coincident, 
with  the  increase  of  atomic  weight,  hydrochloric, 
acid  being  of  greater  efficiency  than  hydrobromic 
acid,  and  bromic  acid  stronger  than  iodic  acid.. 
Phosphorus  and  antimony  introduced  into  the  cir- 
culation cause  no  immediate  physiological  reaction. 
Sulphur  and  selenium  exemplify  the  law  of  isomor- 
phism, the  latter  acting  more  energetically  than  the 
former.  The  only  exceptions  to  Blake's  rule  of  the 
analogous  action  of  isomorphous  substances  are 
potassium  and  ammonium,  their  action  being  quite 
different  from  that  of  the  other  members  of  the  iso- 
morphous group.  He  supposed  the  physiological 
actions  of  the  elements  were  based  upon  intramole- 
cular vibrations  which  are  apparent  in  the  spectrum. 

In  the  case  of  the  alkali  metals  and  of  phosphorus 
we  have  coincidently  the  property  to  affect  only  the 
periphery  nerve  centres  but  not  the  cerebrospinal 
nerves.  Nitrogen,  however,  which  has  a  compli- 
cated spectrum,  acts  very  distinctively  upon  the 
cerebrospinal  nerve  centres. 

The  action  of  the  monovalent  elements  upon  the 
pulmonary  capillaries  (contraction  after  injection), 
is  so  specific,  accordmg  to  Blake,  that  the  metals 
cause  death  upon  injection  into  the  arteries.  They 
circulate  through  the  nerve  centres  in  a  more  con- 
centrated form  than  through  the  lungs,  and  pass 
through  the  capillaries  of  the  body  without  pro- 
nounced physiological  action. 

Salts  of  the  divalent  elements  pass  through  the 
pulmonary  capillaries  without  causing  contraction, 
but  quickly  stop  the  action  of  the  heart.  The  phy- 
siological action  of  the  salts  of  the  magnesium 
group  are  quite  different  from  that  of  the  barium 
group  when  injected  in  small  quantities.  The  mag- 
nesium group  acts  upon  the  vomiting  centre,  either 
direct  or  through  reflex  action  upon  the  splaijchnic 
nerves,  while  salts  of  the  barium  group  act  upon 
the  spinal  cord  causing  twitchings  of  the  voluntary 
muscles  even  for  several  minutes  after  death. 

The  salts  of  the  trivalent  and  quadrivalent  metals 
act  chiefly  upon  the  inhibitory  and  vasomotor  cen- 
tres of  the  medulla  oblongata.  According  to  Blake's 
researches,  relation  exists  between  the  molecular 
constitution  and  the  action  of  inorganic  substances, 
the  valency  of  an  element  being  a  deciding  factor  of 
its  biological  action.  The  valency,  however,  docs 
not  influence  the  general  character  or  intensity  of 
the  biological  action,  but  its  extension.  With  the 
raising  of  the  valency,  the  nttmber  of  the  organs 
acted  upon  increases. 

The  magnesium  group  acts  tipon  the  intestinal 
nerves ;  the  barittm  upon  those  of  the  voluntary- 
muscles.  The  action  of  salts  of  one  and  the  same- 
element  belonging  to  two  different  isomorphous, 
groups  are  not  identical,  but  depend  upon  the  isc-- 
morphous  groups  to  which  the  salt  belongs.  The- 
difference  for  instance  between  the  biological  action: 
of  the  ferric  and  ferrous  salts  is  very  pronounced  ;; 
ferrous  salts  do  not  affect  the  pulmonary  capilla- 
ries ;  ferric  salts  cause  their  contraction.  The  for- 
mer suspend  the  action  of  the  heart,  the  latter  aug- 
ment and  reinforce  it.    Ferric  salts  act  very  dis- 


112 


IVAINWRIGHT:  JAMES  BLAKE. 


[New  York 
Medical  Jol^rn-.\l. 


tinctly  upon  the  nerve  centres,  ferrous  salts  affect 
them  but  slightly.  Ferrous  salts  delay  or  prevent 
coagulation  of  the  blood/ ferric  salts  hasten  it.  The 
same  quantity  of  a  ferric  salt  is  thirty  times  more 
poisonous  than  that  of  a  ferrous  salt. 

The  biological  action  of  inorganic  compounds  is 
only  secondarily  influenced  by  the  valency,  and  is 
similar  to  that  of  the  molecular  weight.  Valency 
determines  only  the  direction  of  the  action.  Ele- 
ments of  the  same  valency  belonging  to  different  iso- 
morphous  groups  may  differ  very  widely  in  their 
biological  action,  but  no  monovalent  element  acts 
upon  as  many  nerve  centres  as  does  a  divalent  ele- 
ment. The  range  of  action  of  a  divalent  element  is 
more  restricted  than  that  of  a  trivalent  or  quad- 
rivalent element. 

Blake's  researches  caused  other  scientists  to  study 
the  subject,  and  Buchardal  and  Stewart  Cooper 
criticised  his  theories  and  experiments.  Rabuteau 
followed,  Binet  disagreeing  with  or  failing  to  con- 
firm Rabuteau's  rules  on  the  relations  between  poi- 
sonous qualities  and  atomic  weight  of  the  metals. 
Blake  replied  to  Richet  and  restated  his  law  of  the 
relation  between  poisonous  action  and  atomic  weight. 

Blake  arranged  the  elements  into  isomorphous 
groups,  according  to  their  atomic  weight  and  poi- 
sonous qualities  as  follows: 


Atomic 

Fatal  dose 

Atomic 

Fatal  dos 

weight: 

per  kilo: 

weight : 

per  kilo: 

7 

1.2 

Zinc   

.  .  65 

o.:8 

Rubidium  . . .  . 

85 

0.12 

Cadmium  ■• 

.  .  112 

0.08s 

133 

0.12 

:o8 

0.028 

. .  40 

0.50 

■Gold   

196 

0.003 

Strontium  . 

..  87 

0.38 

0.08 

Beryllium    . . . 

9 

0.023 

0.062 

Aluminum  . .  . 

27 

0.007 

. .  231 

0.034 

Ferrum  (Fej- 

O3)   

56 

0.004 

Lanthanum 

•  •  139 

0.025 

90 

0.004 

Didymium  . 

.  •  147 

0.017 

140 

0.005 

Magnesium   .  . 

24 

0.97 

Palladium 

.  .  106 

0.008 

Ferrum  (FeO) 

S6 

0.32 

Platinum   .  . 

■  •  195 

0.027 

58 

0.18 

Cobalt   

58 

0.17 

0. 1 10 

63 

0.17 

Phosphoric  acid,  arsenic  acid,  and  tartaremetic 
from  0.7  to  0.3  per  kilogramme  for  arsenic  acid. 
Blake  found  selenic  acid  more  active  than  sulphuric 
acid,  and  the  hydrogen  and  oxygen  acids  of  chlo- 
rine the  most  poisonous  of  the  halogen  compounds, 
while  those  of  iodine  were  the  least  toxic. 

It  will  be  seen  from  the  too  brief  outline  of  Dr. 
Blake's  work  as  given  above  that  he  lai(J  the  foun- 
dation of  our  present  knowledge  of  the  definite  re- 
lations between  reacting  salts  of  chemicals,  and  their 
significance,  when  injected  into  the  circulation — 
blood.  The  sole  objection  to  Blake's  law  is  in  the 
analogous  behavior  of  the  salts  of  potassium  and 
ammonium,  for  these  act  very  differently,  from  the 
other  members  of  the  same  group. 

The  writings  of  Dr.  James  Blake,  which  have  ac- 
tuated me  to  this  brief  reference,  have  been  sought 
only  to  give  recognition  to  the  development  of  his 
law  which  has  not  received  the  attention  its  impor- 
tance demands  excepting  by  the  professional  scien- 
tist ;  the  belief  that  his  deductions  should  be  known 
to  the  rank  and  file  of  medical  men,  and  to  give 
whatever  I  have  found  after  much  time  spent  in 
getting  together  available  data  concerning  his  work, 
traits,  and  personality,  and  finally  to  place  the  credit 
for  the  epoch  making  investigations  where  they 


properly  belong,  have  induced  me  to  place  the  fol- 
lowing before  the  medical  profession. 

It  is  true  that  Frankel  in  his  Arzneimittel-Synthese, 
second  edition,  Berlin,  gives  Dr.  Blake  full  credit 
for  his  work,  but  this  admirable  work  has  not  as 
yet  to  my  knowledge  appeared  in  English  and  is 
therefore  not  available  to  the  average  American 
physician.  Having  set  forth  as  above  a  resume  of 
Dr.  Blake's  scientific  work  I  shall  proceed  to  give 
such  information  concerning  the  man  as  is  to  be 
found.  Naturally  Dr.  Blake  wrote  much  on  topics 
associated  with  his  most  important  work,  but  these 
do  not  so  much  concern  us  in  this  study. 

James  Blake  was  born  in  Gosport,  near  Ports- 
mouth, England,  in  181 5.  Nothing  is  known  of  his 
ancestry,  or  indeed  of  his  youth.  The  first  docu- 
mentary evidence  I  have  been  able  to  find  is  a  re- 
port of  a  paper  which  be  read  before  the  British 
Association  for  the  Advancement  of  Science  in  1838, 
published  the  following  year  in  the  Edinburgh  Med- 
ical Journal.  The  subject  of  this  paper  was  The 
Effects  of  Certain  Salts  when  Introduced  into  the 
Economy.  He  appears  to  have  been  led  to  investi- 
gate this  subject  by  Sharpey  and  Magendie's  works. 

Blake  wasjtherefore  but  twenty-three  years  of  age 
when  he  addressed  the  learned  body  above  men- 
tioned, an  age  at  which  we  would  hardly  expect  to 
find  our  young  men  of  today  sufficiently  equipped  to 
discuss  before  such  a  body  results  of  his  own  re- 
searches. It  is  reasonably  certain  that  Blake's  un- 
dergraduate studies  were  pursued  in  both  London 
and  Paris.  In  the  former  city  he  studied  under 
Sharpey  and  Anthony  Todd  Thompson,  as  in  one 
of  his  papers  he  makes  mention  of  both  of  these 
gentlemen.  We  know  nothing  of  his  student  life  in 
Paris  excepting  that  he  was  pursuing  his  studies 
under  that  famous  master,  Magendie. 

The  second  paper  published  by  Dr.  Blake,  like 
his  first  in  the  Edinburgh  Medical  Journal  in  1839, 
was  devoted  to  the  study  of  hasmodynamometry.  He 
detailed  his  experiments  with  various  substances 
when  introduced  into  the  circulation,  and  here  ad- 
mits being  influenced  to  this  line  of  study  by .  Pro- 
fessor Sharpey's  lectures  on  physiology.  Thus  far, 
however,  he  does  not  seem  to  have  grasped  the  con- 
nection between  chemical  constitution  and  physio- 
logical action.  At  this  time  he  signs  himself  "Mr. 
James  Blake,  London,"  indicating  that  he  must  have 
acquired  the  right  to  practise  surgery.  In  the  same 
year,  1839,  we  find  him  communicating  much  the 
same  paper  as  above  alluded  to  to  the  Academy  of 
Sciences  of  Paris,  another  stroke  of  genius  in  one 
so  young.  This  paper  was  presented  in  French  and 
published  in  the  Archives  generates  dc  mcdecinc, 
1839. 

Again  in  1839  we  find  Dr.  Blake  reading  a  paper 
before  the  Royal  Society  of  London  on  poisons  as 
studied  by  haemodynamometry.  Professor  Sharpey 
was  present  at  most  of  the  experiments  that  were 
reported  when  presenting  the  paper.  This  paper 
was  published  in  1840  in  the  Edinburgh  Medical 
Journal,  liii. 

Blake  wrote  again  on  the  action  of  inorganic  salts 
when  introduced  into  the  circulation,  publishing  it 
also  in  the  Edinburgh  Medical  Journal  oi  1841, 

As  far  as  can  be  learned,  Dr.  Blake's  original 


January  i6,  1909. 1 


IVAINIVRIGHT:  JAMES  BLAKE. 


paper  on  the  Relation  between  Chemical  Constitu- 
tion and  Physiological  Action  was  published  first  in 
Paris  in  1839,  and  again  in  Edinburgh  in  1841.  In 
signing  the  latter  paper  the  author  did  so  as  follows : 
"James  Blake,  Esq.,  M.  R.  C.  S.  L.  and  F.  R.  M. 
C.  S." 

To  completely  unravel  the  undergraduate  and 
early  professional  career  or  postgraduate  life  of  Dr. 
Blake  fr6m  the  data  at  our  command  is  impossible ; 
this  must  be  left  to  experts  of  his  own  country.  His 
obituary  notice  states  that  he  was  a  graduate  of  both 
London  and  Paris  universities,  but  gives  no  data. 
He  was  about  London  until  1846  and  seems  to  have 
been  connected  with  the  University  of  London  dur- 
ing this  period.  He  made  himself  felt  in  various 
ways,  being  a  frequent  contributor  to  the  Lancet 
in  1838  and  1844.  In  the  Index  Catalogue  of  the 
Library  of  the  Surgeon  General  of  the  United  States 
Army,  1881,  page  116,  are  noted  no  less  than  eight 
books,  etc.,  by  James  Blake. 

Sir  Lauder  Brunton,  London,  writes  me  on  Jan- 
uary 15,  1906,  that  "James  Blake  studied  at  the  Uni- 
versity College  London  under  Dr.  Sharpey,  and  that 
his  first  paper,  Observations  on  the  Physiological 
Effects  of  Various  Agents  Introduced  into  the  Cir- 
culation as  Indicated  by  the  Haemodynomometer 
was  read  before  the  Students'  Medical  Society  at 
the  University  College  and  printed  in  the  Edinburgh 
Medical  and  Surgical  Journal  of  1839,  LI,  page 
330.  (Vide  On  the  Action  of  Digitalis,  Journal  of 
Physiology,  IV,  p.  365,  1883-4).  After  1846,  when 
he  read  a  report  to  the  British  Association  on  The 
Physiological  Action  of  Medicines,  Blake  seems, 
with  the  possible  exception  of  the  address  at  St. 
Louis,  Mo.,  to  have  published  nothing  more  until 
1883,  when  he  sent  the  paper  on  the  Action  of  Digi- 
talis above  referred  to  to  the  Journal  of  Physiology. 
He  was  then  living  in  San  Francisco,  Cal.,  and  in 
practice  there.  He  contributed  other  papers  to  the 
Journal  of  Physiology  as  follows :  vi,  pp.  35  and 
124,  1884-5,  ^"fl  vi,  p.  143,  1885,  writing  from  San 
Francisco,  Cal. 

"He  then  came  to  England  and  attended  the 
meetings  of  the  Physiological  Society,  when  I  saw 
him  in  1886-87.  See  Journal  of  Physiology,  vii,  xiii, 
and  viii.  v  and  xiii.  I  think  that  he  returned  to  San 
Francisco,  where  he  died." 

In  1847  Dr.  Blake  appeared  in  St.  Louis,  Mo. 
Why  he  went  there  no  one  will  ever  know.  He  was 
an  accomplished  French  scholar,  and  for  this  rea- 
son probably  chose  the  rapidly  growing  town  where 
both  French  and  English  peoples  flourished. 

In  the  year  1847  Blake  signalized  his  arrival  in 
St.  Louis  by  publishing  in  the  St.  Louis  Medical 
and  Surgical  Journal  a  sketch  of  his  much  studied 
subject.  The  Physiological  Action  of  Medicines. 

In  the  same  Journal  for  1848  we  find  that  he  had 
been  appointed  professor  of  anatomy  in  the  St. 
Louis  University,  where  he  gave  an  introductory 
lecture  to  the  faculty.  In  1847  he  was  advanced 
from  the  chair  of  anatomy  to  that  of  surgery,  but 
for  some  reason  later  resumed  that  of  anatomy.  In 
1848  St.  Louis  was  visited  by  an  epidemic  of  chol- 
era ;  the  city  depopulated  and  everything  brought  to 
a  standstill.  Many  permanently  left  the  city  to  bet- 
ter their  fortunes,  and  we  find  Dr.  Blake  moving  to 
Sacramento,  Cal.,  not  San  Francisco,  as  Sir  Lauder 


Brunton  has  it.  Here  Blake  remained  for  ove' 
twelve  years.  This  year,  1849,  when  Blake  moved 
to  California,  was  the  year  of  the  argonauts,  the 
year  of  the  exodus  west  of  the  gold  hunter.  While 
a  medical  journal  was  issued  in  Sacramento  duruig 
a  portion  of  the  years  that  Blake  was  there,  we  find 
no  mention  of  his  name.  It  is  therefore  not  known 
whether  for  these  few  years  Dr.  Blake  was  practi- 
tioner, gold  miner,  or  both. 

In  1862,  we  find  Blake  in  San  Francisco.  Here 
he  is  known  to  have  engaged  in  active  medical  prac- 
tice until  1876.  At  the  time  of  establishing  Toland's 
Medical  College  in  San  Francisco  in  1864,  Dr.  Blake 
was  made  professor  of  obstetrics  and  diseases  of 
women  and  children.  From  1866  to  1875  he  wrote 
a  number  of  brief  clinical  reports  for  the  Pacific 
Medical  and  Surgical  Journal:  Inversion  of  the- 
Uterus ;  Obstinate  V omiting  Due  to  Foreign  Body 
in  the  Uterus ;  Spondylolisthesis  Causing  Difficult 
Labor ;  Typhoid  Fever  in  an  Infant ;  New  Form  of 
Pessary,  and  Anomalies  in  Digestion,  etc. 

He  seems  to  have  given  up  his  college  work  in 
1872^  so  that  but  eight  years  were  given  to  teach- 
ing. He  was  a  founder  of  the  California  Academy 
of  Sciences  while  in  San  Francisco,  and  there  read 
his  essay  upon  the  Action  of  Medicines  before  this 
body  in  1871. 

-After  retiring  from  the  practice  of  medicine  in 
San  Francisco  Dr.  Blake  moved  to  Middletown,  a 
"quiet  nook  in  the  State,"  not  far  from  the  city, 
where  he  contemplated  devoting  the  remainder  of 
his  days  to  scientific  research,  but  he  was  shortly 
again  writing  on  scientific  subjects  in  the  newlv  is- 
sued Journal  of  Physiology,  London.  In  several  of 
these  papers  he  claims  priority  to  the  discovery  of 
the  action  of  digitalis  on  the  capillaries.  These 
papers  appeared  in  the  above  mentioned  journal  in 
V,  1884-5.  of  these  communications,  Feb- 

ruary 8,  1884,  he  again  states  his  theory  of  the  re- 
lation between  chemical  constitution  and  physiologi- 
cal action,  while  in  V,  1884-5,  he  criticizes  an  article 
by  Ringer  on  the  action  of  potassium,  rubidium,  and 
calcuim. 

Blake  returned  to  London  in  1887  (see  quotation 
from  Sir  Lauder  Brunton's  letter),  but  could  not 
have  remained  long,  as  we  find  him  again  at  about 
this  time  in  San  Francisco,  with  the  apparent  desire 
to  return  to  his  work  of  original  research  and  get- 
ting it  into  shape  for  the  press,  but  unfortunately  at 
this  time  he  sustained  a  severe  fracture  of  the  femur 
which  accident  accomplished  the  distinction  of  end- 
ing both  his  lifework  and  his  life  itself.  The  manu- 
script for  his  book  which  was  known  to  have  been 
nearly  completed,  seems  to  have  been  lost,  for  it 
has  never  been  printed,  a  severe  loss  to  science. 

Dr.  Blake's  death  occurred  at  Middletown,  Lake 
County,  California,  in  1893. 

C.  F.  Buckley,  B.  A.,  M.  D.,  of  San  Francisco, 
who  was  intimately  associated  with  Dr.  Blake  in  the 
faculty  of  Toland  Medical  College  in  that  city  as 
well  as  socially,  writes  me  on  March  10,  1908,  as. 
follows:  "Dr.  James  Blake  was  tall,  thin,  and  of 
over  six  feet  in  height,  with  a  scholarly  stoop.  His 
features  were  those  of  the  classical  type  of  the  stu- 
dent and  resembled  much  those  of  Huxley  with  less 
severity  of  expression. 

"He  was  a  man  of  broad  culture,  education,,  and.  of 


114 


BRAXTH:    STATIC  ELECTRICITY  IN  NEURASTHEXIA. 


[Xew  York 
Medical  Journal. 


distinctively  scholarly  appearance,  who  always 
dressed  in  the  British  fashion.  He  was  highly  es- 
teemed by  his  patients  and  associates ;  was  a  delight- 
ful conversationist,  fond  of  young  people,  and  a 
bachelor.  Both  as  a  teacher  and  clinician,  he  was 
always  seeking  new  discoveries.  If  tiring  of  one 
branch  of  science,  he  would  turn  to  another.  He 
was  very  learned  and  especially  interested  in  geol- 
ogy, and  this  is  probably  one  of  the  reasons  why  he 
moved  to  INIiddletown,  where  he  could  be  much  out 
of  doors  ;  in  the  woods,  near  Nature.  With  his  books 
and  favorite  studies  he  cheerfully,  notwithstanding 
he  was  badly  crippled  by  the  ununited  fracture  of 
his  leg,  spent  the  evening  of  his  most  eventful  life." 
References. 

1.  Comptes  rcndus,  Proceedings  of  the  Royal  Society, 
xi'i,  p.  394. 

2.  American  Journal  of  Science  and  Arts,  1874. 

3.  Coinptcs  rcndus,  cvi,  p.  1250. 

4.  Lauder  Brunton,  Haudhook  of  Pliysiology,  Leipzig, 
1893. 

5.  Ibid. 

6.  Comptes  rcndus.  cxv,  p.  251. 

7.  Ibid,  xciv,  p.  1005. 

8.  Journal  of  Physiology,  v,  35. 

9.  Friinkel  Arznciuiitfel  Synthese,  Second  Edition,  Ber- 
lin. 

177  West  Eighty-third  Street. 


THE  TREATMENT  OF  NEURASTHENIA  BY 
STATIC  ELECTRICITY.* 

i  By  John  Herman  Br.\nth,  M.  D., 

New  York. 

The  deeper  one  delves  into  the  physics  of  elec- 
tricity, the  more  striking  becomes  the  seeming  end- 
less variety  of  manifestations  and  forms  of  this 
elusive  force.  By  patient  research  and  experiment 
the  pioneers  in  electrotherapeutics  have  determined 
the  best  methods  of  administering  electricity  in  me- 
dicinal doses.  Now,  as  electricity  is  akin  to  the 
moving  force  in  nerves,  the  nerves  being  merely 
conductors  like  telephone  wires,  it  appears,  perhaps, 
opportune  to  assert,  that,  if  anything,  a  more  care- 
ful weighing  in  choosing  modality,  quantity,  ten- 
sion, etc.,  is  necessary  than  in  the  administration  of 
drugs  for  remedial  measures. 

Electrotherapeutics  is  as  yet  in  its  infancy,  but 
the  field  of  application  widens  rapidly,  and  at  the 
present  time  many  chronic  and  subacute  diseases 
are  treated  by  this  remedy. 

This  evening  we  have  a  "symposium"  on  neuras- 
thenia, and  your  officers  have  invited  me  to  discuss 
the  application  of  static  electricity  in  this  disease. 
The  time  allotted  me  is  ten  minutes,  hence  I  have 
curtailed  my  remarks  as  much  as  possible ;  true,  it 
is  perhaps  unfair  to  the  subject  to  leave  so  much 
unsaid,  perhaps  saying  so  little,  that  the  real  reme- 
dial importance  is  hardly  grasped.  One  point  I 
would  endeavor  to  make,  that  is,  that  static  elec- 
tricity becomes  a  much  better  servant  if  used  in 
conjunction  with  the  proper  remedies  of  the  phar- 
macopoeia. To  rely  on  electricity  alone  and  by  it- 
self as  a  remedy,  may  often,  like  drugs  alone,  lead 
to  failure,  especially  in  ailments  of  longer  duration, 

•Read  before  the  Medical  Associatitin  of  the  Greater  City  of  New 
York,  October  19,  1908. 


where  whole  systems,  yes,,  the  whole  organization, 
suffers  from  lowered  vitality;  here  all  the  help  pro- 
curable will  be  of  avail. 

In  looking  up  the  literature  on  the  subject  of 
neurasthenia  it  is  found  that  many  authors  mention 
as  a  complication  a  derangement  of  the  great  sym- 
pathetic nervous  system. 

Dr.  William  Hanna  Thomson  says  that  "the 
chemistry  of  the  blood  is  largely,  though  not  ex- 
clusively, controlled  by  the  third  (sympathetic") 
great  nervous  system  in  us,  a  nervous  system, 
whose  very  existence  the  public  has  hardly  heard 
of,  but  which  physicians  already  know  to  be  more 
directly  connected  with  the  life  of  the  body  than 
are  brain  and  spinal  cord  put  together.  Physicians 
do  not  often  mention  it,  simply  because  they  know 
so  little  for  certain  about  it." 

The  great  sympathetic  presides  as  regulator  over 
the  vital  functions  and  nutrition.  Intestinal  auto- 
intoxication is,  for  instance,  a  functional  derange- 
ment of  the  great  sympathetic.  Neurasthenia  fur- 
nishes all  the  symptoms  pointing  to  derangement  of 
this  system,  of  course  differing  somewhat  in  each 
individual.  To  establish  a  nervous  equilibrium, 
that  is,  promoting  a  restoration  to  health,  the  phar- 
macopoeia gives  us  little  help,  just  because  the  vita! 
processes  are  so  low,  that  assimilation  of  a  medi- 
cine is  just  as  much  hindered  as  the  assimilation  of 
food.  However,  with  a  stimulation  of  the  sympa- 
thetic nervous  system  by  electricity  (which  is  per- 
haps the  nearest  to  nervous  motion  we  have)  the 
processes  of  nutrition  will  become  more  active,  and 
then  we  may  be  able  to  observe  that  medicines  will 
produce  results. 

Commonly  it  is  accepted  that  high  potential  cur- 
rents travel  on  the  surface.  I  believe  that  Houston 
and  Maxwell  assert  this.  If  this  were  so,  then  high 
potential  currents  would  be  of  no  assistance,  except 
perhaps  in  surface  affections.  Now  let  me  demon- 
strate to  you  this  as  an  error.  Electricity,  and  espe- 
cially high  potential,  seeks  a  straight  and  the  short- 
est course.  If  a  poor  conductor  is  interposed,  elec- 
tricity may  be  thwarted  to  a  degree,  if  by  a  round- 
about circuit  it  can  travel  through  a  better  con- 
ductor, than  the  interposed  obstruction.  But  if 
quantity  and  pressure  are  great  enough,  electricity 
will  travel  through  every  and  all  bodies ;  there  is  no 
absolute  nonconductor. 

Of  a  large  static  machine  connect  the  poles  with 
Leyden  jars,  then  connect  outside  of  Leyden  jars 
(each  jar  to  one  pole)  with  ends  of  primary  of  a 
large  Tesla  (coreless)  coil;  one  end  of  the  sec- 
ondary of  the  Tesla  coil  is  joined  to  an  electrode ; 
the  end  of  this  electrode  is  held  in  a  glass  tumbler 
half  full  of  water,  which  rests  on  a  thick  rubber 
plate,  which  plate  is  supported  by  the  spread  fin 
gers  of  the  operator  or  an  assistant.  The  spark 
gap  of  the  static  machine  should  be  as  long  as  the 
medium  sized  or  large  Leyden  jars  permit,  without 
short  circuit.  The  rim  of  the  glass  tumbler  con- 
taining the  water  must  be  perfectly  dry.  On  oper 
ating  the  static  machine  the  current  will  pass  from 
the  electrode  through  the  water,  through  the  bot- 
tom of  glass  tumbler,  through  the  rubber  plate,  into 
the  spread  fingers  and  hand  supporting  the  rubber 
plate  and  tumbler;  thence  the  circuit  passes  to  the 


January  i6,  1909.] 


SILKWORTH:  JUNGLE  P.LANT. 


"5 


ground.  The  current  does  not  pass  on  the  surface 
over  the  brim  of  the  glass  tumbler,  nor  over  the 
edge  of  the  large  rubber  plate,  but  goes  directly 
through.^  The  current,  owing  to  the  obstruction 
by  the  poor  conductors,  will  mushroom,  that  is, 
spread  out,  but  it  passes  through  by  the  shortest 
route.  Insulation  of  electrode,  of  course,  must  be 
as  effective  as  possible. — This  current,  by  means  of 
the  Tesla  coil,  which  acts  as  a  stepup  transformer, 
has  an  extremely  high  tension,  high  voltage,  but 
the  low  amperage  of  the  static  generator  is  reduced 
in  inverse  ratio. 

On  this  argument  the  treatment  of  neurasthenic 
patients  with  high  tension  and  high  frequency  cur- 
rents may  find  a  reasonable  basis,  and  results  seem 
to  confirm  this  in  my  observation.  By  the  applica- 
tion of  static  electricity  all  vital  functions  can  be 
stimulated.  We  can  send' a  high  frequency  current 
directly  through  the  trunk,  and  so  through  the  solar 
plexus,  enervating  the  stomach,  liver,  spleen  and  in- 
testines, and  the  ganglia  inervating  the  kidneys  and 
pelvic  organs,  and  thereby  bring  about  not  only  the 
assimilation  of  food,  but  also  absorption  of  medi- 
cines, which  w'ould,  perhaps,  in  other  conditions, 
pass  out  of  the  body  like  the  unassimilated  food. 
It  seems,  therefore,  rational  to  employ  high  ten- 
sion electricity  together  with  medicines.  Of  the 
latter  I  wish  to  make  mention  of  strontium  bro- 
mide, sometimes  combined  with  small  .doses  of 
chloral  hydrate,  to  produce  nervous  calm  and  sleep. 
The  strontium  bromide  deranges  the  stomach  less 
than  the  other  bromides.  Arsenic  and  zinc  phos- 
phide are  also  -of  value.  I  have  little  faith  in  the 
rest  cure,  because  here  the  patient's  mind  is  hardly 
ever  drawn  away  from  his  condition.  In  order  to 
successfully  treat  the  mental  symptoms  of  neuras- 
thenia the  physician  must  win  thoroughly  the  con- 
fidence of  the  patient ;  he  must  provide  suitable  em- 
ployment for  the  patient's  mind.  Neurasthenic  pa- 
tients are  cured  not  by  physic,  but  by  the  physi- 
cian. Intestinal  irregularities  must  be  corrected. 
The  diet  should  be  simple  and  free  from  sweets. 
Stimulants,  like  coffee,  tea,  alcohol,  etc.,  are  for- 
bidden. Cheerful  surroundings  are  very  helpful  to 
draw  the  patient's  mind  away  from  his  morbid 
thoughts. 

In  neurasthenia  the  despondency,  the  dejection, 
the  low  spirits,  the  loss  of  confidence  in  his  sur- 
roundings and  friends,  the  utter  loss  of  self  con- 
trol, the  morbid  longing  for  sympathy  in  a  misery 
which  looks  hopeless  and  greater  in  the  patient's 
eyes  than  in  the  eyes  of  others,  makes  existence  a 
wretched  one  for  the  patient  as  well  as  for  the 
friends.  The  patient's  mind  dwells  only  on  his 
misery,  on  his  errors  and  disappointment  in  life,  on 
his  pain  that  he  cannot  locate ;  he,  who,  when 
healthy,  was  industrious  and  active,  is  now  unable 
to  tear  himself  away  from  his  morbid  thoughts  and 
from  indolence.  It  is  a  slow  but  generally  pro- 
gressive ailment  leading  to  general  debility.  With 
the  most  successful  management  recovery  is  slow, 
and  the  patient,  when  well,  knowing  the  causes  of 
his  ailment,  will  be  wise  enough  to  "go  easv"  with 
his  occupation,  his  social  functions,  his  struggle  for 
the  front  rank  in  business  and  society.  Neuras- 
thenia may,  perhaps,  be  justly  called  "the  American 
disease;"  yes,  it  might  be  even  termed  "the  New 
York  disease." 


Static  electricity  is  Nature's  safest  and  most  ra- 
tional remedy  for  stimulating  healthy  metabolism. 
We  all  know  that  some  forms  of  electricity  act  as 
a  powerful  stimulus  to  nerve  and  muscle,  and  so 
rapidly  impart  tone,  buoyancy,  and  firmness  to  re- 
laxed and  enfeebled  tissues.  Electricity  stimulates 
the  glandular  organs  to  a  greater  functional  activ- 
ity, and  is  equally  powerful  in  increasing  cellular 
activity,  favoring  the  elimination  of  waste  and 
residual  poisons,  obviating  autointoxication,  so  that 
new  nourishment  maj;  be  taken  up  by  the  cells.  It 
is  through  faulty  combustion,  imperfect  oxidation — 
that  is,  faulty  metabolism — that  we  get  many  disor- 
ders like  rheumatism,  neuralgia,  neurasthenia,  etc., 
caused  often  by  improper  work,  or  improper  feed- 
ing, or  irregular  rest.  The  nerves  stand  every- 
where as  sentinels  and  are  the  first  to  suffer.  If 
the  patient  disregards  these  warnings,  symptoms  of 
deeper  invasion,  of  greater  disturbance  of  healthy 
metabolism,  will  become  apparent. 

In  closing  it  is  claimed  that  the  proper  form  of 
electricity  appears  as  the  most  rational  remedy  for 
the  treatment  of  neurasthenia. 

183  West  Eighty-seventh  Street. 


A  FURTHER  REPORT  OX  THE  JUXGLE  PLANT 
(COMBRETUM  SUNDIACUM)  IX  MORPHINE 
ADDICTION.* 

By  W.  Duncan  Silkworth,  M.  D., 
Xew  York. 

The  value  of  treatment  lies  in  its  permanency. 
For  this  reason  I  bring  before  you  again  those  pa- 
tients presented  last  February.'  Mr.  M.  has  again 
kindly  consented  to  say  a  few  words  for  himself 
and  the  others,  showing  that  there  has  been  no  de- 
sire for  a  return  to  the  drug. 

When  the  governments  of  the  world  are  consid- 
ering the  advisability  of  the  complete  suppression 
of  the  opium  and  morphine  trade,  and  our  own 
country  is  making  every  effort  to  solve  this  great 
problem,  a  striking  contrast  is  offered  by  the  seem- 
ing apathy  and  indifference  of  the  medical  profes- 
sion to  the  growing  prevalence  of  the  drug  habit. 
If  we  are  to  delegate  to  the  government  the  task  of 
suppressing  the  growth  of  the  drug  habit,  w^e  should 
at  least  be  deeply  interested  in  caring  for  those  who, 
now  numbered  among  the  thousands,  seemingly  de- 
pend on  the  drug  for  their  daily  existence.  The 
habit  of  opium  smoking  is  of  small  concern,  being 
hmited  by  its  nature  to  the  sporting  element  of  large 
cities.  It  should  be,  as  in  China,  regulated  by  gov- 
ernment control.  As  the  habit  of  using  morphine  is 
very  often  introduced,  directly  or  indirectly,  through 
the  medium  of  a  physician's  prescription,  it  would 
seem  that  the  responsibility  of  caring  for  those  ad- 
dicted to  the  drug  rests  primarily  with  the  medical 
profession.  Through  neglect  of  this  responsibility 
some  very  astonishing  conditions  have  developed. 
Numerous  corporations  have  been  formed  who  of- 
fer their  services  to  the  patient  on  a  very  lucrative 
basis,  and  a  goodly  number  of  individuals,  them- 

*Read  before  the  Medical  Society  of  the  County  of  X.  V.,  De- 
cember  28,  IQOS. 

'See  .V^ic  York  Medical  Journal,  Ixxxviii,  pp.  1032  et  seq.,  May 
30,  1 90S. 


ii6 


PETEP.'i:  SEXUAL  FACTOR  IN  TUBERCULOSIS. 


[New  York 
Medical  Journai.. 


selves  addicted  to  morphine,  actually  have  hundreds 
of  victims  under  their  care. 

A  general  classification  of  the  habitue  should  be 
of  some  assistance  to  the  physician,  for  example: 
First,  the  morphinomaniac  corresponding  to  the 
dipsomaniac ;  second,  those  surrounded  and  pam- 
pered by  friends  in  their  own  homes,  showing  the 
mental  effects  of  the  drug  more  prominently ;  third, 
those  who  are  either  dependent  on  their  own  efforts 
to  live,  or  possess  some  responsibility  which  they 
cannot  shirk,  and  who  often  continue  the  use  of  the 
drug  for  years  without  very  disastrous  results; 
fourth,  a  class  among  whom  the  use  of  the  drug 
forms  a  part  of  the  social  life.  The  value  of  some 
such  classification  can  be  recognized  in  determining 
the  possibilities  of  successful  treatment  and  the 
method  to  be  pursued  in  each  case.  With  the  first 
three,  the  morphine  habit  is  acquired  generally  to 
relieve  a  discomfort,  and  not  from  wrong  motives. 
Fear  and  distrust  follow  after,  induced  largely  by 
the  attitude  of  the  public  and  profession.  These  un- 
fortunate people  are  even  supposed  by  some  to  be 
possessed  of  a  devil  and  to  represent  the  acme  of 
falsehood  and  deceit.  On  all  sides  they  are  con- 
fronted with  pessimistic  views  of  their  ultimate  re- 
covery. By  a  wrong  mental  attitude  we  have  set 
in  motion  a  train  of  events  that  ends  in  disaster. 

I  believe  that  every  physician  of  integrity  and 
sound  judgment  has  the  ability  to  successfully  treat 
any  normal  case  of  drug  addiction  that  comes  to 
him.  One  such  physician  in  each  community  will- 
ing to  devote  his  time  to  this  subject  would  actually 
solve  the  entire  problem. 

Am  I  not  correct  in  stating  that  two  ideas  are 
generally  accepted  by  the  physician  as  essential  to 
successful  treatment?  First,  that  the  patient  must 
cooperate  with  the  physician ;  and,  second,  that  the 
patient  will  secretly  take  morphine  unless  most  care- 
fully watched.  These  ideas  are  certainly  not  com- 
patible. Briefly,  the  physician  must  have  the  entire 
confidence  of  the  patient  and  keep  it.  This  cannot 
be  emphasized  too  strongly.  He  also  must  exert  to 
the  utmost  encouragement,  tact,  sympathy,  and  per- 
severance. If  he  has  a  secret  understanding  with 
the  relatives  or  friends,  the  patient  will  almost  sure- 
ly detect  it  and  resent  it  deeply. 

The  patient  must  be  imbued  with  the  idea  that 
you  have  confidence  in  him.  Too  much  must  not  be 
expected  at  first.  That  would  lead  at  once  to  mis- 
understanding. The  withdrawal  of  the  drug  must 
be  undertaken  according  to  the  judgment  of  the 
physician  in  each  individual  case,  the  tendency  be- 
ing to  hurry  and  to  overmedicate  the  patient  for  the 
purpose  of  relieving  unavoidable  or  natural  symp- 
toms. Ask  the  patient  to  do  only  what  your  ex- 
perience teaches  you  he  can  do ;  as  you  increase  his 
responsibilities  he  will  take  them  up  cheerfully,  and 
you  will  find  that  almost  imperceptibly  the  patient 
changes  from  a  vacillating  drug  victim  to  an  earnest 
man,  who  needs  no  watchful  attendance,  has  no 
thought  of  his  former  drug,  and  who,  by  complet- 
ing your  treatment  of  his  own  volition,  assures  you 
doubly  of  its  permanency. 

We  are  continually  searching  for  a  specific  cure, 
as  of  old  men  sought  the  fountain  of  perpetual 
youth.  In  reality,  the  cure  lies  within  ourselves,  as 
these  cases  I  present  must  convince  you.     No  un- 


known drug  has  been  used ;  the  same  method  is  at 
the  command  of  every  physician  who  will  give  suf- 
ficient time  and  study  to  the  subject,  being  simply 
an  application  of  the  laws  of  nature,  which  we  all 
uphold.  We  will  meet  with  some  faifures,  of 
course.  We  will  not  be  paid  in  proportion  to  our 
services,  but  our  reward  will  be  beyond  price.  Let 
us  be  most  careful  in  prescribing  morphine.  Let 
us  throw  off  our  attitude  of  indifference.  Let  us 
invite  the  confidence  of  these  unfortunate  people 
and  the  government  at  Washington  will  not  be 
placed  in  the  position  of  protecting  the  people 
against  the  physician's  prescription. 

These  five  cases  were  selected  carefully  as  repre- 
senting the  maximum  length  of  addiction,  which 
primarily  determines  the  possibility  of  a  permanent 
cure. 

Case  I. — Mr.  W.  P.  M.  Verified  length  of  addiction  to 
morphine,  twenty-eight  years.  Mr.  M.  has  injected  over 
200,000  grains  of  morphine  at  a  minimum  cost  of  $2,000. 
To  the  best  of  my  knowledge  and  his  own  he  is  now  a 
normal,  healthy  man. 

Case  11. — Mr.  W.  D.  Mr.  D.  had  smoked  opium  for 
thirty-five  years.  He  is  now  sixty-four  years  of  age,  and 
has  been  completely  cured  for  ten  months. 

Case  III.— Mr.  W.  W.  Mr.  W.  had  been  addicted  to 
opium  and  morpliine  for  a  period  of  twenty-two  years. 
Like  the  others  he  had  not  succeeded  in  giving  up  the  drug 
until  put  upon  his  honor  and  shown  how  to  help  himself. 

Case  IV. — Mr.  McP.  Mr.  McP.  had  been  addicted  to 
opium  smoking  for  a  period  of  eighteen  years.  His  recov- 
ery has  been  complete  and  covers  a  period  of  nine  months. 
Mr.  McP.  has  spent  for  opium  a  little  over  $4,000. 

Case  V. — Mr.  S.  Mr.  S.  has  been  addicted  to  morphine 
for  twenty-one  years.  He  is  just  completing  his  treatment 
and  is  apparently  in  a  perfectly  normal  condition. 

Space  will  not  permit  a  detailed  account  of  the 
treatment  as  carried  out  in  each  of  these  cases,-  but 
a  general  application  of  the  methods,  as  outlined  in 
my  former  article,^  proved  sufficient  to  bring  about 
the  very  excellent  and  permanent  results  you  have 
observed.  No  permanent  tissue  changes  were  pro- 
duced from  the  use  of  the  drug. 

Case  VI. — Mr.  D.  M.  H.  This  case  is  of  special  interest 
as  representing  four  years  of  addiction  to  heroin,  it  being 
generally  considered  that  this  drug  does  not  produce  a 
habit.  The  daily  amount  the  patient  used  was  seven  grains 
hypodermically.    Recovery  has  been  complete. 

Case  VII. — Mr.  J.  B.  This  case  especially  illustrates  the 
results  that  can  be  accomplished.  The  man  is  known  to 
hundreds  of  those  using  the  drug  in  New  York  city.  He 
was  held  up  as  an  example  of  the  effect  of  cocaine  and 
morphine.  He  is  just  now  completing  his  treatment  and 
has  his  mind  firmly  fixed  on  a  permanent  cure. 

124  East  Sixteenth  Street. 


THE  SEXUAL  FACTOR  IN  TUBERCULOSIS. 

By  W.  H.  Peters,  M.  D., 

Providence,  R.  I., 

Formerly  Secretary.  Board  of  Trustees,  State  Sanatorium;  and  Ad- 
mitting Physician,  Pine  Ridge  Camp  for  Consumptives;  Exam- 
ining Physician  for  State  Sanatorium   and  Department  of 
Diseases  of  Chest,  North  End  Dispensary,  etc. 

In  a  former  paper  on  the  management  of  the 
sexual  factor  in  tuberculosis  and  its  relation  to  the 
home  treatment,  I  submitted  the  following  consid- 
erations': The  problem  how  to  regulate  sexual  in- 
tercourse is  one  of  the  most  important,  and,  at  the 

'Loc.  cit. 

'Jowtial  of  the  American  Medical  Association,  March  21.  iqoS. 


January  i6,  1909.] 


PETERS:  SEXUAL  FACTOR  IN  TUBERCULOSIS. 


117 


same  time,  one  of  the  most  difficult  in  phthisis 
therapy.  Such  abnormal  erethism  is  due  first  to 
lack  of  occupation,  to  the  rise  of  temperature  which 
manifests  active  tuberculous  processes,  the  forced 
feeding  essential  to  the  cure  of  tuberculosis,  the  in- 
dulgence in  alcohol,  the  tonics  prescribed,  especially 
strychnine,  the  stimulating  life  in  the  open  air  and 
sunshine,  and  the  reflection  by  many  consumptives, 
based  upon  the  oftentimes  erroneous  presumption 
that  their  disease  dooms  them  to  an  early  death, 
that  they  had  but  to  enjoy  themselves  to  the  full 
while  they  may.  And  I  pointed  out  the  possibility 
of  immediate  infection,  as  when  there  is  a  tuber- 
culous lesion  of  the  testicle  or  epididymis.  I  espe- 
cially emphasized  the  difficulty  of  managing  this 
factor  among  married  couples  in  the  home  treat- 
ment of  tuberculosis,  and  I  considered  how  even 
among  sanatorium  patients,  where  constant  regula- 
tion and  supervision  is  the  rule,  the  most  beneficient 
councils,  the  most  salutary  orders  are  oftentimes 
disregarded. 

I  expressed  my  conviction  of  the  dreadful  ex- 
haustion which  inordinate  coitus  must  bring  about 
in  a  sufferer  from  a  disease  so  enervating  as  tuber- 
culosis under  circumstances  where  the  sufferer  so 
greatly  needs  for  his  recovery  the  conservation  of 
all  his  forces,  the  nonimpairment  of  his  factors  of 
safety,  and  I  set  forth  the  difficulties  which  beset 
the  practitioner  in  the  management  of  this  phase  of 
the  tuberculosis  problem,  especially  when  his  pa- 
tients cannot  leave  their  homes.  I  outlined  the  the- 
rapeusis  to  be  followed ;  to  counsel  the  patient  most 
earnestly  concerning  the  grave  dangers  to  be  feared 
from  excessive  coitus ;  to  represent  to  him  that  the 
treatment  now  in  vogue — rest,  nourishing  food,  out- 
door life,  and  the  use  of  tonics — is  essential  for  the 
restoration  of  the  subnormal  organism,  and  that 
such  attempts  at  restoration  are  hopelessly  defeated 
by  enervating  and  depleting  acts,  that  such  indis- 
cretions might  result  in  premature  and  occasional 
death,  that  if  the  consumptive  husband  should  im- 
pregnate his  wife,  the  result  would  be  most  un- 
fortunate, particularly  regarding  the  offspring  to  be 
anticipated.  I  felt  conscious  that  this  important 
problem  was  not  settled,  that  it  has  not  yet  received 
the  adequate  consideration  it  deserves.  I  therefore 
determined  to  seek  the  opinions  of  men  experienced 
in  the  treatment  of  this  disease,  and  I  sent  the  fol- 
lowing letter  to  a  number  of  colleagues : 

Twenty-two  adult  patients,  both  sexes,  out  of  a  series  of 
thirty-one  cases,  that  have  been  under  my  observation  of 
incipient,  moderately  advanced,  and  advanced  pulmonary 
tuberculosis,  have  given  a  history  of  an  abnormal  sexual 
desire.  Some  of  these  patients  were  taking  either  strych- 
nine or  whiskey  in  connection  with  the  cure ;  the  majority, 
however,  were  taking  only  nourishing  food  and  resting  in 
the  open  air. 

All  complained  to  a  greater  or  less  degree  of  exhaustion 
following  sexual  intercourse,  stating  that  recovery  from 
the  exhaustion  required  from  two  to  four  daj's.  These 
cases  were  all  taking  treatment  at  home,  and  were  advised 
to  abstain  from  everything  requiring  exertion. 

I  will  be  greatly  obliged  if  you  will  send  me  your  views 
on  the  management  of  the  sexual  factor  and  its  relation  to 
the  home  treatment,  also  your  opinion  as  to  the  abnormal 
sexual  desire  in  the  adult  consumptive. 

Dr.  Lawrence  F.  Flick,  of  Philadelphia,  is  in- 
clined to  think  that  the  data  at  my  command  over- 
state the  facts.  In  the  early  stages  of  tuberculosis 
if  is  quite  possible  there  may  be  excessive  sexual 


desire,  but  the  reverse  is  probably  true  in  the  late 
stages  of  the  disease.  Dr.  FHck's  practice  is  to 
recommend  the  greatest  possible  moderation  in  sex- 
ual indulgence,  as  he  has  long  recognized  the  injury 
which  comes  from  overindulgence. 

Dr.  Joseph  Walsh,  of  Philadelphia,  writes  his  im- 
pression that  the  sexual  desire  is  no  greater  in  con- 
sumptives than  in  other  people  under  the  same 
regime.  On  rest  during  forced  nourishment,  the 
rest  naturally  gives  them  much  time  to  think  about 
themselves,  and  the  forced  nourishment,  somewhat 
stimulating.  Apart  from  these  two  factors,  Dr. 
Walsh  thinks  the  sexual  desire  is  less  in  consump- 
tives than  in  other  people.  Dr.  Walsh  notes  also,  in 
acquiescence  with  Dr.  Flick,  that  when  there  is 
slight  rise  of  temperature  there  may  be  slight  stim- 
ulation of  the  sexual  desire. 

Dr.  John  S.  Fulton,  of  Baltimore,  Md.,  has  al- 
ways doubted  the  current  statements  about  the  fre- 
quency of  sexual  aberrations^  in  early  tuberculosis, 
without  having  made  any  systematic  observations. 
Dr.  Fulton  ventures  the  purely  tentative  suggestion 
that  these  aberrations  are  the  phenomena  of  idle- 
ness far  more  than  those  of  tuberculosis. 

Dr.  Hermann  M.  Biggs,  of  New  York  city,  has 
made  no  special  observations  on  this  point. 

Dr.  S.  A.  Knopf,  of  New  York  city,  refers  to  his 
paper  on  the  Marriage  of  the  Tuberculous  and  the 
Size  of  the  Family  in  their  Bearing  on  the  Tuber- 
culosis Problem.'  He  there  questions  whether  the 
often  made  statements  that  tuberculosis  increases 
the  desire  for  sexual  intercourse,  and  that  the  pro- 
creative  power  of  the  tuberculous  is  really  in- 
creased, have  any  foundation.  A  number  of  pa- 
tients have  confessed  to  him  that  their  sexual  de- 
sire has  become  more  intense  than  in  their  former 
healthy  state,  and  that  he  has  in  such  cases  traced 
such  desire  to  the  following:  The  patients  have 
abandoned  all  occupations,  not  only  physical,  but 
also  mental,  and  their  thoughts  divert  upon  sexual 
pleasures.  Often,  in  addition  to  this,  the  patient 
who  formerly  spent  perhaps  the  greater  part  of  his 
life  occupied  away  from  home  in  workshop,  office, 
or  factory,  has  been  compelled,  owing  to  his  in- 
firmity, to  remain  constantly  at  home.  Here,  and 
here  alone,  are  to  be  found  the  explanations  of  in- 
creased sexual  desires  and  the  supposed  increased 
procreative  faculty.  Dr.  Knopf  has  often  been  able 
to  remedy  this  real  or  imaginary  desire  by  directing 
the  patient's  attention  to  sound  literature  and  light, 
healthful  outdoor  occupation.  The  absolute  pro- 
scription of  sextial  intercourse  will  probably  never 
be  carried  out,  nor  will  the  tuberculous  always  obey 
when  we  forbid  them  to  enter  the  matrimonial  state. 
Some  marry  without  knowing  they  are  tuberculous ; 
some  marry  even  though  they  know  it,  no  matter 
what  the  doctor  says,  and  there  is  no  law  to  prevent 
it.  Dr.  Knopf  believes  in  such  preventive  measures, 
or  would  make  impossible  the  procreation  of  a  pre- 
disposed case,  he  would  council  a  tuberculous  hus- 
band to  this  object,  being  not  for  quantity,  but  for 
quality. 

Dr.  Maurice  Fishberg,  of  New  York  city,  writes 
that  in  his  experience  as  physician  to  the  United 
Hebrew  Charities  he  comes  in  contact  yearly  with 
more  than  a  thousand  consumptives,  mostly  in- 

-American  Medicine,  January  6,  1908. 


ii8 


PETERS:  SEXUAL  FACTOR  IN  TUBERCULOSIS. 


[New  York 
Medical  Journal 


digent.  It  is  a  most  important  problem,  how  to  pre- 
vent them  from  impregnating  their  wives,  by  which 
economic  havoc  is  worked  among  them.  In  the  vast 
majority  of  cases  it  is  impossible  to  keep  a  tuber- 
culous husband  away  from  his  wife.  Promises 
made  in  sanatorium  are  broken  whenever  a  day's 
leave  is  secured  to  return  to  the  family,  and  at  such 
times  wives  are  often  impregnated.  The  sexual  im- 
pulse is  rather  diminished  than  increased  in  the  con- 
sumptive. Their  aptitude  to  have  intercourse  when 
prohibited  by  their  physician  is  probably  due  to  the 
egotism,  which  is  very  strong  in  the  tuberculous. 
Desperate,  they  believe  that  having  nothing  to  lose, 
they  might  as  well  enjoy  their  remaining  days,  or,  in 
their  characteristic  optimism  they  imagine  they  are 
not  in  so  bad  a  plight  as  the  physician  has  indicated. 
Either  such  egotism  or  such  optimism  is  the  psycho- 
logical factor  which  encourages  the  consumptive  to 
sexual  acts  even  when  their  physical  condition  does 
not  warrant  it.  Women  have  declared  their  mis- 
fortune to  be  that  their  husbands  torture  them  for 
hours  every  night,  attempting,  though  incapable  of 
having  intercourse.  Men  have,  on  the  other  hand, 
stated  that  their  actively  tuberculous  wives  are,  nev- 
ertheless, anxious  to  have  intercourse.  Here  we 
have  no  increased  sexual  desire  per  se,  and  still  the 
attempts  at  intercourse  are  made. 

Dr.  Alfred  Meyer,  of  New  York  city,  has  not 
learned  of  an  abnormal  sexual  desire  in  either  sex 
in  pulmonary  tuberculosis,  though  he  has  limited  his 
inquiry  mostly  to  males.  He  has  not  found  the  lat- 
ter to  differ  in  this  respect  from  the  average  sufferer 
from  other  diseases.  Dr.  Meyer  has  learned  of 
some  cases  after  long  "abstinence  in  isolated  in- 
stances. His  practice  has  been  to  advise  abstinence, 
and  to  separate  husband  and  wife,  separate  beds, 
preferably  separate  rooms ;  all  this  with  the  idea  to 
remove  extra  temptation  rather  than  to  correct  over 
indulgence. 

Dr.  John  B.  Hubcr,  of  New  York  city,  writes  that 
he  has  not  sufficient  data  upon  which  to  base  a  cal- 
culation of  the  proportion  of  consumptives  who  are 
excessive  regarding  the  sexual  function,  but  be- 
lieves that  such  abnormality  is  sufficiently  frequent 
to  require  the  practitioner's  grave  consideration. 
Exhaustion  following  sexual  intercourse  by  the  con- 
sumptive would  be  all  the  greater  by  reason  that 
his  disease  has  in  great  measure  come  about  through 
organic  depletion.  One  must  reflect  that  sexual  ex- 
cess and  alcoholism  may  have  acted  upon  the  or- 
ganism before  the  development  of  tuberculosis,  they 
may  have  weakened  the  body,  and  thus  predisposed 
it  to  the  visit  of  the  tubercle  bacillus.  The  sexual 
excess  may  have  long  antedated  the  tuberculous, 
and  may,  indeed,  have  been  the  cause.  One  could 
not  then  attribute  such  abnormal  desire  to  tuber- 
culosis per  se  with  regard  to  the  management  of  tu- 
berculosis. Dr.  Huber  has  nothing  to  add  to  the 
well  known  principles.  The  physician  should  most 
earnestly  advise,  carefully  individualizing,  and  here 
his  responsibility  must  end.  The  management  of 
the  sexual  appetite  in  the  very  poor  (among  whom 
are  most  of  the  sufferers  from  tuberculosis)  is  all 
the  more  difficult  by  reason  of  the  melancholy  fact 
established  by  Mathews,  that  never  is  the  procre- 
ative  force  more  active  than  when  the  conditions  of 


life  become  miserable  and  squalid,  than  when  pov- 
erty, starvation,  and  inevitable  distress  prevail. 

Dr.  Herbert  M.  King,  of  Liberty,  N.  Y.,  has 
never  noticed  that  tuberculosis  patients  differ  ma- 
terially from  other  classes  of  chronic  invalids,  or, 
indeed,  from  the  healthy,  regarding  the  sexual  func- 
tion. When  sexual  excess  is  present  in  the  con- 
sumptive it  is  far  more  apt  to  be  due  to  overnutri- 
tion  than  to  any  distinctively  tuberculous  condition 
per  se. 

Dr.  Edward  O.  Otis,  of  Boston,  finds  that  while 
in  some  cases  the  sexual  desire  is  abnormal,  his  per- 
sonal experience  would  lead  him  to  think  that  such 
condition  was  not  so  common  as  my  (Peters)  figures 
seem  to  indicate.  Regarding  the  sexual  factor,  Dr. 
Otis  advises  very  limited  or  entire  abstinence,  ac- 
cording to  individual  condition.  When  possible,  it 
is  best  to  separate  husband  and  wife,  more  espe- 
cially when  it  is  the  latter  who  is  consumptive.  The 
dangers  of  pregnancy  to  a  consumptive  woman 
should  always  be  emphatically  stated  to  the  hus- 
band, or  better,  to  both. 

Dr.  Vincent  Y.  Bowditch,  of  Boston,  writes  that 
he  has  no  data  going  to  prove  that  consumptives  are 
abnormal  in  sexual  desire,  but  one  case  can  be  re- 
called of  a  patient  who  exhausted  himself  by  daily 
illicit  intercourse  with  a  woman  not  his  wife.  Dr. 
Bowditch  is  inclined  to  the  belief  that  the  propensity 
must  be  explained  by  the  nature  of  the  individual 
and  not  the  disease.  In  cases  of  overindulgence, 
strychnine  and  whiskey  should  be  interdicted  as  be- 
ing possible  causes  of  over  stimulation.  Dr.  Bow- 
ditch does  not  for  any  consumptive  prescribe  such 
stimulants  as  whiskey. 

Dr.  J.  P.  C.  Foster,  of  New  Haven,  Conn.,  ex- 
presses his  skepticism  as  to  the  abnormal  sexual  de- 
sire of  adult  consumptives.  He  has  never  noticed 
any  very  pronounced  absence  of  such  desire  in  early 
adult  life,  even  in  the  nontuberculous.  Apparent 
excess  in  the  consumptive  is  to  be  attributed  to  idle- 
ness of  mind  and  body.  After  residence  for  years 
in  resorts  for  wealthy  consumptives,  Dr.  Foster 
found  no  more  excess  in  these  patients  than  could 
be  found  in  any  fashionable  resort  for  healthy  peo- 
ple. A  patient  of  Dr.  Foster,  a  young  man  who 
had  recently  returned  from  a  city  largely  inhabited 
by  consumptives,  declared  his  belief  that  the  young 
men  he  had  been  associated  with  during  his  treat- 
ment were  no  more  passionate  than  healthy  boys, 
but  they  were  very  excessive  in  sexual  indulgence 
because  they  were  idle,  and  in  many  instances 
meant  to  have  a  good  time.  Dr.  Foster  has  seen 
the  exhaustion  following  intercourse  destroy  a  pa- 
tient many  and  many  a  time.  As  for  regulation, 
the  only  way  is  to  point  out  the  dangers  of  over  in- 
dulgence to  them,  after  which  they  must  be  left  to 
themselves. 

Dr.  Royal  Hatch,  of  Boston,  Mass.,  writes  that 
in  the  work  of  the  tuberculosis  class  in  which  he 
assists  Dr.  Pratt,  sexual  intercourse  on  the  part  of 
its  members  is  discouraged. 

Dr.  Sherman  S.  Bonney,  of  Denver,  Col.,  states 
his  belief  that  the  sexual  factor  should  be  held  in 
abeyance  as  far  as  practicable  among  pulmonary  in- 
valids. This  consideration  constitutes  one  objection 
to  the  home  treatment  in  some  cases.    The  abnormal 


January  i6,  1909.] 


PETERS:  SEXUAL  FACTOR  IN  TUBERCULOSIS. 


119 


sexual  desire  is  undoubtedly  occasioned  by  the  life 
of  idleness,  the  superalimentation  (particularly  the 
raw  egg's),  the  strychnine,  and  frequently  the  ab- 
sence of  diverting  thoughts. 

Dr.  Walter  Holden,  of  Denver,  Col.,  while  recog- 
nizing the  fact  that  many  textbooks  emphasize  ab- 
normal sexual  desire  among  the  tuberculous,  has 
not  observed  among  his  hundreds  of  cases  that  such 
so  called  increased  desire  was  directly  due  to  the 
disease  alone.  The  open  air  rest  treatment,  together 
with  a  stimulating  egg  and  meat  diet,  stimulants, 
and  not  having  anything  in  particular  to  occupy 
their  restless  minds,  may  in  many  cases  account  for 
this  fact.  Of  course,  exhaustion  in  proportion  to 
the  physical  condition  must  follow  sexual  inter- 
course. The  management  of  the  sexual  desire  in 
home  cases  is  a  problem  which  attending  physicians 
must  work  out.  If  the  case  be  under  thorough  con- 
trol a  candid  statement  of  the  facts  (upon  which  the 
physician's  duty  ends)  will  usually  bring  about  the 
desired  results. 

Dr.  V.  C.  \'aughan,  of  Ann  Arbor,  Mich.,  agrees 
that  the  sexual  factor  is  an  important  one  in  han- 
dling cases  of  tuberculosis.  Even  in  the  last  stages 
sexual  desire  seems  to  be  abnormal,  and  its  gratifi- 
cation is  certainly  harmful  to  the  patient. 

Dr.  P.  F.  Gilden,  of  Colorado  Springs,  writes 
that  Dr.  Solly,  with  whom  he  had  been  associated 
during  fifteen  years,  advised  total  abstinence  in  cases 
where  sexual  excess  was  in  evidence ;  he  prescribed 
asafoetida  and  regulated  the  bowels,  etc.,  when  there 
was  oversensitiveness. 

Dr.  C.  O.  Probst,  of  Columbus,  Ohio,  has  little 
personal  knowledge  of  the  subject,  not  having  as  a 
rule  made  inquiries,  but  instances  of  sexual  excess 
in  the  tuberculous  have  come  to  his  attention,  and 
he  has  always  understood  it  to  be  a  rather  com- 
mon sypmtom.  In  planning  the  Ohio  State  Sana- 
torium, Dr.  Probst  has  been  very  careful  to  limit 
the  number  of  beds,  with  the  idea  that  if  there 
should  be  a  great  demand  for  increased  accommoda- 
tions, he  would  urge  the  building  of  another  institu- 
tion, so  that  the  sexes  might  be  separated. 

Dr.  S.  H.  Bushnell,  major  and  surgeon  command- 
ing at  Fort  Bayard,  N.  M.,  states  that  his  records 
do  not  contain  data  relative  to  the  subject  in  whom 
considerable  sexual  activity  is  to  be  expected,  but 
he  has  not  found  that  the  appetite  has  been  present 
to  a  degree  that  could  be  considered  abnormal.  Al- 
though one  does  not  usually  learn  regarding  such 
matters  unless  the  manifestations  are  extreme,  with 
regard  to  home  conditions  Dr.  Bushnell  has  found 
that  men  are  much  better  when  their  wives  are 
away,  but  does  not  know  whether  the  explanation 
of  this  is  sexual  rest. 

Dr.  Charles  L.  Minor,  of  Asheville,  N.  C,  s  tates 
his  belief  that  abnormal  sexual  desire  does  not  exist 
in  tuberculosis  per  se,  but  is  only  such  as  is  common 
to  those  who  are  idle,  resting  and  eating  largely, 
especially  of  eggs,  and  who  are  thrown  into  intimate 
contact  with  the  other  sex.  Normal  individuals 
would  under  such  circumstances  be  tempted  to  sex- 
ual over  indulgence.  No  increased  desire  has  been 
found  in  patients  able  to  exercise  and  who  are  kept 
busy.  Dr.  Minor  has  always  advocated  the  disuse 
of  the  sexual  function  in  tuberculosis  so  far  as  pos- 
sible, but  in  inactive  cases  he  rarely  or  never  found 
moderate  coitus  (once  in  a  fortnight  or  in  a  month) 


harmful  or  exhausting.  Those  who  are  thus  ex- 
cited to  a  troublesome  degree  should  avoid  idleness 
and  opportunit>% 

Dr.  A.  C.  Klebs,  of  Chicago,  111.,  does  not  believe 
that  tuberculous  disease  as  such  can  be  made  re- 
sponsible for  an  abnormal  sexual  desire  in  its  vic- 
tims. It  is  abnormal  in  certain  cases,  but  not  more 
than  in  any  chronic  disease.  Languor  and  lack  of 
energy  are  primary  symptoms  more  or  less  specific 
of  tuberculous  intoxication ;  abnormal  sexual  desire 
is  to  be  traced  more  to  these  two  psychic  factors 
than  to  the  infection  itself.  In  temperamental  types 
showing  these  two  factors  we  often  find  abnormal 
sexual  desire  without  any  infection.  Again,  mod- 
ern phthisiotherapy  rather  accentuates  the  psychic 
factors  leading  to  abnormal  sexual  desire,  on  the 
one  hand,  by  increasing  bodily  vigor  through  out- 
door life,  on  the  other  hand,  by  restraining  it 
physically,  and  through  lack  of  exercise  and  occu- 
pation leaving  free  rein  to  introspection  and  pas- 
sionate desires,  the  latter  being  often  increased 
through  medicinal  stimulation  (strychnine,  alcohol, 
etc.).  Again,  the  management  of  this  factor,  physi- 
cally and  morally  debilitating  for  the  patient  as  it  is, 
should  come  about  by  an  entire  change  of  the  pres- 
ent sanatorium  regime,  whether  this  be  followed  in 
a  special  institution  or  at  home  by  limiting  the  abso- 
lute "rest  cure"  as  much  as  possible  (out  door 
sleeping  being  put  where  it  belongs,  in  the  night), 
by  giving  the  patients  useful  occupations  during  the 
day  (not  only  sports  and  games,  but  with  such  work 
as  is  instituted  by  Paterson  and  Inman  at  Frimley). 
Dr.  Klebs  believes  proper  occupation  adapted  to  the 
patient's  individuality  to  be  vastly  more  important 
than  rest  and  overfeeding  combined,  despite  theo- 
retical considerations  to  the  contrary.  No  tuber- 
culous patient  can  be  permanently  restored  by  fac- 
tors which  bring  about  increase  of  weight  only.  In 
the  often  observed  increase  of  abnormal  sexual  de- 
sire. Dr.  Klebs  sees  one  of  the  principal  expressions 
of  faulty  management  of  a  case,  and  one  which  must 
be  combated  by  a  modification  of  the  commonly 
practised  regime.  The  value  of  occupation  proper- 
ly directed  is  educational  chiefly,  and  there  is  need, 
in  addition,  of  course,  of  proper  and  direct  psychic 
and  moral  influence  exerted  over  the  patient  by  the 
physician. 

Dr.  H.  L.  Barnes,  superintendent,  Rhode  Island 
State  Sanatarium,  writes  that,  while  not  attempting 
to  collect  accurate  data  on  the  subject,  he  has  no 
reason  to  believe  that  tuberculous  infection  increases 
sexual  desire.  In  normal  individuals  overfeeding, 
combined  with  physical"  and  mental  rest,  will  in- 
crease the  sexual  appetite,  while  underfeeding,  com- 
bined with  hard  mental  and  physical  work,  will  re- 
duce it.  The  treatment  of  active  tuberculosis  re- 
quires physical  rest  and  a  full  diet,  and  if  increased 
sexual  desire  results,  the  reaction  is  a  normal  one. 
The  natural  remedies  of  underfeeding  and  hard 
physical  work  are  not  available,  and  one  can  only 
rely  on  mental  occupation  and  an  exercise  of  will 
power.  Temporary  separation  of  married  people 
is  indicated  if  excess  can  be  prevented  in  no  other 
way.  Many  cases  undergc  ing  arrest  are  not  injured 
by  a  moderate  exercise  of  the  sexual  function. 

Dr.  H.  A.  Smith,  of  Delta,  Col.,  writes  that  in 
both  dispensary  and  sanatorium  work  it  is  im- 
pressed on  him  that  girls  with  the  tuberculous  dia- 


I20 


OUR  READERS'  DISCUSSIONS. 


[New  Yohk 
Medical  Journal, 


thesis  do  not  have  the  same  moral  stamina  that 
girls  in  robust  health  had.  He  thinks  this  explains 
in  a  measure  why  so  many  prostitutes  are  tubercu- 
lar. My  (Peters's)  paper  explains  why,  even  if  a 
girl's  training  and  ideas  were  correct,  with  an  ex- 
citing cause,  such  as  tuberculosis,  they  might  not 
be  able  to  overcome  the  erotic  excitement.  He 
states  that  he  has  not  given  the  matter  the  careful 
study  that  it  would  require  to  come  to  a  definite 
conclusion,  but  in  a  general  way  believes  that  any 
girl  with  tuberculous  tendencies,  or  what  is  termed 
by  some,  the  tuberculous  stage,  should  be  safe- 
guarded in  every  manner. 

Dr.  A.  J.  Richer,  of  Montreal,  Can.,  has  found 
the  abnormal  desire,  which  is  well  nigh  a  perver- 
sion, existing  in  the  majority  of  consumptives,  to 
be  ascribed  to  sedentary  habits,  generous  nitro- 
genous feeding,  toxine  irritation  corresponding  to 
fever,  the  deperdition  phosphates  of  French  authors 
— ^this  last  explaining  a  deal:  "The  phosphatic  ele- 
ments which  exist  as  nitrogenous  combinations  are 
not  absorbed  and  utilized  to  replace  broken  down 
tissue,  or  else  they  are  metabolized  in  excess  of  the 
needs  and  find  their  way  to  and  engorge  the  seminal 
vesicles  in  the  male ;  whilst  in  the  female,  the  acces- 
sory vaginal  glands  seem  to  be  the  ultimate  goal 
of  such  phosphatic  material."  Dr.  Richer  has  in 
such  cases  had  good  results  from  the  use  of  mineral 
phosphates,  which  seemed  at  first  to  increase  the 
trouble,  but  later  to  have  a  regulative  influence 
upon  the  phosphatic  metabolism. 

(3ne  must  then  conclude,  from  a  consideration  of 
these  important  expressions  of  opinion,  that  the  sub- 
ject is  of  the  first  importance,  that  its  inherent  dif- 
ficulties are  very  great,  and,  in  some  respects,  im- 
possible to  cope  with,  and  that  the  principle  of 
therapeusis,  which  should  guide  the  practitioner  in 
dealing  with  inordinate  sexual  desire  in  the  con- 
sumptive, is  such  as  has  been  set  forth  in  the  begin- 
ning of  this  paper.  One  must  add  regarding  the 
moderate  exercise  of  which  Dr.  Minor  and  Dr. 
Klebs  have  written,  that  (as  these  vastly  experi- 
enced physicians  fully  realize),  such  exercise,  or 
any  exercise,  should  not  be  prescribed  for  the  tu- 
berculous except  after  most  careful  examination, 
both  of  the  history  and  of  the  physical  conditions. 

I  am  more  convinced  than  ever  since  receiving 
these  opinions  that  isolation  and  the  education  re- 
ceived in  the  sanatorium  are  of  the  utmost  impor- 
tance before- beginning  the  home  treatment.  The 
consumptive  taking  treatment  at  home  will,  as  a 
rule,  follow  directions  to  .the  letter  in  everything 
except  sexual  matters,  and  many  a  case  in  both 
sexes  would  be  on  the  road  to  recovery  to-day,  in- 
stead of  gradually  losing  ground,  if  isolation  was  a 
compulsory  rule  instead  of  being  insisted  upon  in  a 
half  hearted  way.  The  consensus  of  opinion  from 
the  prominent  and  experienced  men  interviewed 
shows  that  the  majority  were  of  the  opinion  that 
increased  sexual  desire  is  not  a  condition  due  to 
the  toxines  generated  in  the  tuberculous;  that  such 
a  desire  was  due  chiefly  to  idleness,  and  occupation 
on  the  part  of  the  consumptive  was  a  necessary  ad- 
junct to  the  treatment.  Sexual  indulgence,  how- 
ever, is  a  serious  bar  to  the  home  treatment;  mar- 
ried patients  gain  faster  in  sanatoria. 

195  Benefit  Street. 


(But  Sitahrs'  §mximms. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXI. — How  do  you  treat  chronic  eczemat  (Closed 
December  15,  igoS.) 

LXXXII. — How  do  you  treat  chronic  lead  poisoning? 
{Closed  January  i§,  igog.) 

LXXXIII. — How  do  you  treat  acute  dysentery?  {An- 
swers due  not  later  than  February  15,  1909.) 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
{but  not  required)  that  the  answers  be  short;  if  practica- 
ble, no  one  answer  to  contain  more  than  six  hundred 
words. 

All  persons  will  be  entitled  to  compete  for  the  prize, 
whether  subscribers  or  not.  This  prize  will  not  be  awarded 
to  any  one  person  more  than  once  within  one  year.  Every 
answer  must  be  accompanied  by  the  writer's  full  name  arid 
address,  both  of  which  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal. 
Our  readers  are  asked  to  suggest  topics  for  discussion. 

The  prize  of  $25  for  the  best  essay  submitted  in  answer 
to  question  LXXX  has  been  awarded  to  Dr.  Paul  F.  Ela, 
of  East  Douglass,  Mass.,  whose  article  appeared  on  page 
1223  of  the  previous  volume. 


PRIZE  QUESTION  LXXX. 
THE  TREATMENT  OF  ASPHYXIA  NEONATORUM. 

{Continued  from  p.  75.) 

Dr.  Wm.  S.  McCorniick,  of  Philadelphia,  says: 

To  treat  asyphyxia  neonatorum,  or  the  inability 
of  the  new  born  to  respire,  it  is  important  to  under- 
stand its  causes.  While  our  term  applies  to  the 
"new  born,'"  the  asphyxia  may  occur  in  utero. 

Normally  the  foetus  in  utero  is  in  a  state  of 
apnoea,  the  oxygen  being  supplied  through  the  pla- 
cental circulation.  After  birth  cause  for  active  res- 
piration arises  because  the  oxygen  supply  is  cut  off 
by  the  separation  of  the  placenta  or  by  its  area  of 
attachment  being  greatly  reduced.  These  conditions 
cause  imperfect  oxygenation — the  primary  cause  of 
respiration. 

Accidents  may  arise  and  cause  improper  oxygen- 
ation of  the  foetus  in  utero.  Some  of  these  causes 
are :  Premature  detachment  of  placenta ;  pressure 
on  prolapsed  cord ;  maternal  death ;  tetanic  contrac- 
tions of  uterus.  Any  of  these  factors  may  cause  the 
child  to  take  its  first  breath  while  in  the  uterus  or 
birth  canal.  If  in  the  uterus,  unless  mouth  and  nose 
are  covered  by  membrane  or  pressed  close  to  the 
wall  of  the  uterus,  some  amniotic  fluid  may  enter 
the  lungs.  If  the  first  breath  occurs  in  the  lower 
birth  canal,  mucus  may  enter  the  lungs.  No  mat- 
ter where  this  occurs  the  necessary  amount  of  oxy- 
gen is  not  inhaled  and  this  causes  increased  respira- 
tions which  are  of  no  value.  The  accumulation  of 
carbon  dioxide  and  excrementitious  materials, 
causes  a  decrease  in  the  irritability  of  the  medulla, 
and  the  child  is  asphyxiated.  Pressure  on  the  brain 
in  difficult  labors,  intracranial  haemorrhage,  mater- 
nal uterine  or  pulmonary  haemorrhage,  or  too  great 
pressure  of  forceps  may  cause  the  same  result. 

To  recognize   intrauterine  asphyxia   we  must 


January  i6,  1909.] 


OUR  READERS'  DISCUSSIONS. 


121 


watch  closely  the  foetal  pulse  rate.  Whether  caused 
by  compression  of  the  brain  or  by  some  interference 
*  with  the  placental  circulation,  the  pulse  rate  at  first 
becomes  slower  during  the  contractions  of  the 
uterus,  but  becomes  normal  between  the  pains.  As 
the  condition  advances,  these  remissions  do  not  oc- 
cur, the  heart  beats  slower  and  slower  and  finally 
ceases. 

Rapid  delivery  is  indicated  if  pulse  rate  is  lOO  per 
minute,  or  less,  providing  the  mother's  conditio!! 
warrants  such  a  procedure.  Another  sign  may  be 
the  escape  of  meconium.  This  sign  can  only  be  re- 
lied on  in  vertex  presentations  as  mechanical  causes 
may  bring  this  about  in  a  breech  presentation.  The 
amniotic  fluid  in  these  cases  is  a  yellowish  green,  the 
meconium  being  seen  in  flakes.  In  vertex  cases  this 
is  an  indication  for  quick  delivery.  Occasionally  air 
has  been  introduced  into  the  uterus  by  the  hands  or 
instruments,  and  the  child  has  breathed. 

After  delivery  we  have  two  forms  of  asphyxia, 
asphyxia  pallida  and  asphyxia  livida.  In  both  forms 
the  breathing  is  by  gasps  or  else  not  at  all,  and  the 
heart  beats  are  slow  and  weak.  In  asphyxia  pallida 
the  skin  is  cold  and  pale,  the  arms  and  legs  hang 
limp,  and  the  usual  external  stimulants  fail  to  pro- 
duce the  normal  breathing.  In  asphyxia  livida  the 
child  has  a  congested  appearance,  caiised  by  an  over- 
distention  of  the  right  heart  and  inferior  vena  cava. 
Prognosis  is  always  serious.  It  is  more  favorable 
when  due  to  mechanical  interference  with  the  pla- 
cental circulation  than  when  caused  by  depressed 
skull,  brain  injuries,  or  intracranial  haemorrhage. 

Treatment.— If  the  child  does  not  make  an  inspir- 
atory movement  within  a  few  moments  after  birth, 
grasp  it  by  the  feet  and  hold  it  up,  head  downward, 
at  the  same  time  passing  one  finger  of  the  free 
hand  into  its  mouth  to  remove  any  mucus.  Then 
slap  its  body. 

If  this  fails,  commence  artificial  respiration  by 
compressing  the  thorax  five  or  six  times  a  minute. 
If  this  fails,  ligate  and  cut  the  umbilical  cord,  even 
though  pulsations  have  not  ceased,  and  immerse  the 
child  alternately  in  hot  and  cold  water,  rubbing  well 
its  body  all  the  time  and  keeping  its  head  above 
water.  If  this  fails,  wrap  it  in  a  blanket  and  lay 
it  on  a  table,  allowing  its  head  to  hang  over.  Grasp 
its  tongue  and  pull  it  forward,  then  allowing  it  to 
recede.  Do  this  about  fifteen  times  a  minute.  If 
this  fails,  try  mouth  to  mouth  insufflation. 

If  the  physician  believes  there  is  amniotic  fluid  or 
mucus  in  the  bronchial  tubes,  he  can  introduce  a 
small  rubber  catheter  into  the  larynx  and  remove 
fluid  by  suction.  ?Tere  the  catheter  may  push  aside 
or  remove  any  mechanical  cause  which  would  pre- 
vent the  air  from  entering. 

Schultze's  method  may  next  be  tried.  This  is 
practised  by  placing  the  operator's  thumbs  over  the 
child's  thorax,  index  fingers  in  axillae,  and  palmar 
surfaces  of  remaining  fingers  on  its  back.  Allow 
child  to  hang  down,  then  carry  it  over  operator's 
head  and  allow  its  legs  to  fall  towards  its  face,  then 
back  to  original  position.  Do  this  five  or  six  times 
a  minute. 

A  few  drops  of  ether  or  whiskey  hypodermically 
can  be  tried. 

If  the  skull  has  a  depressed  fracture,  elevate  the 
depressed  bone. 


Tracheotomy  can  be  performed  and  catherization 
performed  through  the  wound. 

Artificial  means  of  respiration  should  be  contin- 
ued as  long  as  the  child's  heart  beats,  as  infants  have 
breathed  after  over  an  hour's  hard  work. 

Dr.  T.  A.  Clay,  of  Paterson,  N.  J.,  observes: 

The  preventive  methods  of  ashyxia  neonatorum 
are  care  in  giving  the  mother  anaesthetics  when  it  is 
necessary;  the  replacing  of  a  prolapsed  cord,  if 
present  on  vaginal  examination ;  the  delivery  of  the 
after  coming  head  within  four  to  eight  minutes  after 
the  body,  in  breech  presentations,  and  in  normal 
vertex  cases,  immediate  examination  of  the  head  to 
see  if  the  cord  is  around  the  neck,  that  it  can  be  re- 
moved over  the  delivered  head.  When  we  believe 
the  condition  to  be  present,  immediately  after  the  de- 
livery, hold  the  child  up  by  the  feet  and  slap  the 
buttocks  four  or  five  times,  so  as  to  make  the  child 
cry,  and  thus  cause  it  to  inspire.  If  this  is  not 
successful,  lay  the  child  on  the  bed  and  wipe  the 
child's  throat  and  mouth  out  with  a  cloth  applied 
to  the  index  finger.  Then  hold  a  cloth  over  the 
mouth  and  blow  into  the  child's  mouth.  Then  pre- 
pare to  tie  the  cord  (in  the  meantime  ordering  hot 
and  cold  water  in  different  basins).  Cut  the  cord, 
allow  two  or  three  drachms  of  blood  to  escape  from 
the  umbilical  cord  and  then  ligate  it.  Allowing  the 
blood  to  escape  sometimes  relieves  the  congestion, 
and  respiration  takes  place. 

Next  immerse  the  child  in  the  hot  and  cold  water 
alternately,  rubbing  the  chest  briskly,  and  at  times 
compressing  the  thorax,  and  then  allowing  it  to  re- 
lax, or  exert  pressure  along  the  posterior  thoracic 
nerve.  This  alternate  immersing  in  hot  or  cold 
water  should  be  repeated  eight  or  ten  times.  Then 
the  Sylvester  method  may  be  used  by  flexing  the 
forearms  on  the  arms  and  grasping  the  child's  el- 
bows, compress  the  chest  by  pressing  the  arms 
against  it,  causing  expiration,  and  expand  the  chest 
by  elevating  the  arms  slowly  above  the  head  in  an 
effort  to  produce  inspiration. 

If  these  methods  fail,  different  methods  which  are 
modifications  of  the  Sylvester  method  of  artificial 
respiration  may  be  tried.  The  child  having  been 
wrapped  in  a  warm  blanket,  the  tongue  may  be 
seized  with  an  artery  clamp,  and  the  tongue  drawn 
out  as  far  as  possible  and  allowed  to  fall  back,  this 
repeated  for  two  or  three  minutes,  or  in  all  about 
ten  or  twenty  times.  Then  the  child  may  be  held  by 
the  axillae,  the  thumbs  being  held  over  the  thorax, 
the  index  fingers  lying  in  the  axillae,  and  the  palms 
of  the  hands  resting  on  the  back  of  the  child,  the 
physician,  then  carrying  the  child  slowly  over  the 
head,  so  that  its  legs  fall  over  the  face,  thus  the 
thorax  is  alternately  compressed  and  relaxed  in  the 
effort  to  induce  inspiration.  Or  the  child  may  be 
held,  resting  on  the  palmar  surface  of  both  hands 
which  support  its  back,  while  the  thighs  are  flexed 
upon  the  body,  bringing  the  child's  head  and  feet 
together  so  that  when  the  chest  is  compressed  ex- 
piration takes  place  and  when  relaxed,  inspiration. 
Another  modification  of  this  method  is  to  rest  the 
child's  head  and  shoulders  on  the  edge  of  a  table, 
the  palmar  surface  of  the  left  hand  holding  the  child 
in  position ;  while  the  feet  are  brought  to  the  head, 
flexing  them  on  the  body,  thus  alternately  compress- 


122 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


ing  and  relaxing  the  chest.  Finally  cardiac  massage 
may  be  tried,  by  endeavoring  to  grasp  the  heart 
with  the  hand,  grasping  the  thorax  and  compressing 
it,  and  allowing  it  to  relax,  in  an  endeavor  to  pro- 
mote systole  and  dyastole  of  the  heart.  This  ef- 
fort at  cardiac  massage  is  carried  out  by  letting  the 
child  rest  on  its  back  and  holding  it  in  position  with 
the  left  hand,  inserting  the  fingers  of  the  right  hand 
up  toward  the  diaphragm  and  heart,  the  back  of  the 
hand  resting  on  the  abdomen  and  the  thumb  being 
held  over  the  nipple  area,  thus  allowing  the  heart  to 
be  stimulated  by  the  contracting  and  relaxing  of  the 
hand. 

These  methods  are  the  ones  I  would  use  in  treat- 
ing a  case  of  asphyxia  neonatorum  and  can  be  used 
under  any  circumstances  or  conditions  of  life.  In 
the  treatment  of  this  condition,  efforts  in  causing  the 
child  to  inspire  should  be  carried  out  at  least  from 
thirty  to  sixty  minutes. 

In  conclusion  I  would  say  that  in  the  treatment 
of  the  cases  of  asphyxia  neonatorum,  where  there 
is  anaemia,  I  would  not  advise  the  allowing  of  blood 
to  escape  from  the  umbilical  cord,  but  that  all  the 
other  methods  mentioned  might  be  tried. 

There  are  two  other  methwls  which  may  be  used 
in  any  type  of  asphyxia  neonatorum,  that  of  intro- 
ducing a  catheter  into  the  trachea,  which  is  difficult 
to  do,  and  usually  the  physician  has  not  the  proper 
sized  catheter  with  him ;  and  the  faradic  current  may 
be  applied  over  the  phrenic  nerves  if  a  battery  is 
at  hand. 

Dr.  Joseph  Baum,  of  New  York,  states: 

The  efficiency  of  treatment  depends  not  only  on 
the  promptness  and  persistency  of  our  efforts,  but 
also  on  an  intelligent  comprehension  of  the  causa- 
tion of  the  condition  under  treatment. 

The  superficial,  gasping,  respiratory  efforts  at 
longer  and  longer  intervals  point  at  once  to  the 
patent  fact  that  the  weak  heart  is  unable  to  send 
enough  blood  to  nourish  and  stimulate  the  respira- 
tory centre  in  the  medulla,  and  the  intermittent, 
superficial  respiration  cannot  oxygenate  sufficient 
blood  to  properly  stimulate  the  cardiac  apparatus, 
and  so  the  vicious  circle  is  completed ;  and  a  method 
of  treatment  based  on  this  knowledge  is  rational 
and  logical. 

Asphyxia  neonatorum  has  always  appealed  to  me 
as  similar  in  some  of  its  aspects  to  the  asphyxia  of 
apparent  drowning,  and  my  methods  of  treatment 
are  laid  along  the  same  line. 

As  soon  as  the  baby's  head  is  free  of  the  vaginal 
outlet  and  it  looks  and  acts  asphyxiated,  even  to  a 
mild  degree,  expedite  the  tying  of  the  umbilical 
cord  and  proceed  at  once  with  restorative  measures ; 
a  quick  swab  of  the  mouth  with  a  gauze  covered 
finger  clears  the  buccal  and  postnasal  spaces  of 
mucus  or  other  detritus;  mild  cases  of  asphyxia 
need  but  the  action  of  the  fresh  air  on  their  uncov- 
ered bodies,  aided  by  a  vigorous  slap  on  the  but- 
tocks, or  dash  a  handful  of  cold  water  on  the  chest, 
and  the  deep  inspiration,  followed  by  an  effort  to 
cry,  causes  the  cardiac  and  respiratory  functions  to 
at  once  start  on  their  ceaseless,  lifelong  work. 

If  no  response  is  forthcoming  to  these  measures, 
place  a  folded  cloth  (or  a  large  wad  of  absorbent 
cotton),  wrung  out  of  hot  water,  over  the  prjecor- 


dium,  and  at  the  same  time  have  an  attendant  hold 
the  baby  with  its  head  downward,  while  you  start 
in  on  artificial  respiration,  approximating  about  fif- 
teen or  twenty  inspirations  to  the  minute.  If  in  a 
short  time  no  improvement  is  noticed,  grasp  the 
tongue  with  a  volsella,  and  while  the  efforts  at  arti- 
ficial respiration  are  continued,  have  some  intelligent 
person  make  regular,  intermittent  traction  on  the 
tongue,  pulling  the  tongue  out  with  each  expiratory 
effort.  I  have  found  that  the  volsella  often  crushes 
and  so  mutilates  the  tongue  that  the  resuscitated  in- 
fant refuses  the  breast  for  several  days  on  account 
of  pain  and  tenderness  of  the  wounded  member,  so 
I  now  use  a  curved  needle  with  the  ordinary  silk  or 
catgut  sutre  (which  is  prepared  before  the  onset  of 
the  final  stage  of  labor),  and  carry  the  needle  en- 
tirely through  the  tongue  at  least  half  an  inch  back 
from  the  tip,  and  the  intermittent  tractions  can  be 
easily  performed  with  no  painful  after  effects  on 
the  tongue. 

A  rectal  injection  of  a  pint  of  hot  water  can  be 
given  by  the  nurse  while  all  the  preceding  measures 
are  being  carried  out ;  and  in  extreme  cases  the 
inhalation  of  strong  ammonia  and  the  hypodermic 
injection  of  strychnine  sulphate  (grain  1/150)  are 
of  great  use. 

The  promptness,  intelligence,  and  the  persistency 
with  which  such  treatment  is  proceeded  with  will 
suffice  to  resuscitate  the  usual  case  of  asphyxia  neo- 
natorum. 

A  rarer  form  of  this  condition  is  the  anaemic 
types,  in  which  the  infant  looks  to  be  in  a  condition 
of  acute  shock.  The  indication  for  treatment  here 
is  the  application  of  heat  to  the  entire  surface  of  the 
body,  and  this  is  best  obtained  by  a  full  bath  of  hot 
water,  the  entire  body  being  submerged,  combined 
with  a  rectal  injection  of  a  pint  of  hot  water. 
Prompt  artificial  respiration  should  be  resorted  to, 
while  the  baby  is  kept  in  the  hot  bath.  The  prog- 
nosis in  this  form  of  asphyxia  neonatorum  is  usu- 
ally not  favorable. 

Dr.  Walter  F.  Bopp,  of  New  York,  writes: 

Asphyxia  of  the  newborn  may  roughly  be  divided 
into  two  great  classes :  Asphyxia  livida  and  as- 
phyxia pallida,  the  treatment  differing  radically  in 
each  case. 

In  the  first  case,  where  the  child  is  cyanotic,  the 
heart  slow  and  forcible,  the  pulse  full,  I  cut  the  cord, 
wrap  a  piece  of  fine  gauze  around  my  index  finger, 
and  cleanse  mouth  and  nasopharynx  quickly  of  the 
aspirated  blood  and  mucus ;  then  I  rub  the  back  of 
the  child  briskly  with  a  rough  towel,  varying  this 
by  slapping  the  buttocks  of  the  child  sharply  from 
time  to  time.  Should  this  fail  I  dash  a  little  cold 
water  on  the  child's  abdomen,  and  finally  put  the 
child  alternately  in  a  bath  of  very  hot  and  very  cold 
water.  Tongue  traction,  which  has  been  recom- 
mended, I  have  never  tried. 

In  the  second  case,  where  the  skin  is  pale  and  the 
child  limp,  the  heart  sounds  very  quick  and  rapid, 
the  treatment  must  be  more  energetic.  I  clamp  the 
cord  in  two  places,  cut,  and  then  wipe  out  the 
mouth ;  with  the  index  finger  of  the  left  hand  I  feel 
for  the  small  larynx,  into  which  I  (juickly  insert  a 
fine  catheter,  i)assing  it  into  the  trachea,  and  aspi- 
rate the  inspired  fluids.    I  then  resort  at  once  to 


January  i6,  1909.] 


CORRESPONDENCE. 


123 


Schultze's  method.  I  take  the  child  by  the  shoulders, 
the  thumbs  resting  on  the  thorax,  the  fingers  on  the 
back,  the  balls  of  my  thumbs  supporting  the  child's 
head.  In  this  position  I  let  the  child  hang  between 
my  braced  and  separated  legs.  Then  I  slowly  swing 
the  child  upward  until  the  head  hangs  down  and  the 
buttocks  fall  over  toward  the  abdomen  of  the  child. 
The  movement  is  now  reversed  and  the  child  swimg 
back  into  the  original  position.  I  repeat  this  eight 
to  ten  times,  taking  about  one  minute  for  these 
manoeuvres,  and  then  immerse  the  child  in  a  warm 
bath  to  prevent  chilling.  The  swinging  rnust  never 
be  done  hurriedly  and  must  be  persisted  in  as  long 
as  the  foetal  heart  sounds  are  perceptible.  I  have 
seen  children  recover  from  their  asphyxia  after  one 
and  a  half  hours  of  treatment.  As  soon  as  the  child 
begins  to  breathe  spontaneously  I  go  back  to  the 
less  forcible  procedures — friction,  spanking,  etc. 

Insufflation  I  never  resort  to,  as  I  believe  that 
much  harm  can  be  done  unless  the  air  pressure  is 
very  low,  and  it  is  rather  difficult  to  measure  the 
amount  of  air  pressure. 

Even  after  we  have  gotten  the  child  to  breathe  we 
must  be  on  our  guard,  for  the  child  will  frequently 
become  drowsy,  the  respiration  become  slower  and 
shallower,  and  we  must  again  resort  to  spanking 
to  stimulate  respiration.  It  is  advisable  to  keep  the 
infant's  head  a  trifle  lower  than  the  body  for  the 
first  twenty-four  hours,  and  to  be  on  the  guard  for 
a  possible  bronchopneumonia  or  an  atelectasis. 
(To  be  concluded.) 
 <^  


LETTER  FROM  LONDON. 

A  Royal  Commission  on  Coroners'  Inquests. — The  New 
Pharmacy  Law. — The  Untoward  Consequences  of  Athletics. 
— Compulsory  Notification  of  Tuberculous  Disease. — Re- 
sponsibility for  Injury. — The  Late  Surgeon  General  Tuson. 

London,  December  zg,  igo8. 
An  announcement  was  made  last  week  thdt  the 
Home  Secretary  had  appointed  a  departmental 
committee  to  inquire  into  the  law  relating  to  cor- 
oners and  coroners'  inquests  and  into  the  practice 
of  coroners"  courts.  Sir  Mackenzie  Chalmers,  of 
the  Home  Office,  is  chairman  of  the  committee,  and 
the  medical  members  are  Sir  Malcolm  ]Morris  and 
Dr.  Wilcox.  This  commission  has  been  appointed 
as  a  result  of  the  recent  agitation  by  medical  men 
to  inquire  into  the  practices  of  certain  coroners  in 
London.  It  has  been  the  usual  custom  to  call  in  to 
give  evidence  the  medical  man  who  treated  or  saw 
the  patient  during  life,  but  one  of  the  London  cor- 
oners has  repeatedly  called  on  an  outside  patholo- 
gist to  make  the  post  mortem  examination  and  to 
give  evidence,  resulting,  of  course,  in  a  loss  of  fees 
to  the  medical  man  in  ordinary  attendance  on  the 
deceased.  The  question  raised  by  a  London  cor- 
oner that  all  deaths  after  operations  should  be  in- 
quired into,  and  an  inquest  held  if  necessary,  is  also 
to  be  dealt  with.  The  whole  subject  of  the  correla- 
tion of  death  certification  with  inquests  should 
come  under  review,  in  order  to  stimulate  the  legis- 
lature to  act  upon  the  recommendation  made  nearly 
tweqty  years  ago  by  the  previous  committee,  which 
inquired   into  the   system  of  death  certification. 


Medical  men^  therefore,  are  pleased  that  this  sub- 
ject will  undergo  a  thorough  inquiry  at  the  hands 
of  the  commission,  and  hope  that  something  may 
at  last  be  done  to  bring  about  the  removal  of  a 
public  danger. 

An  important  act  has  been  passed  by  this  Parlia- 
ment and  comes  into  force  in  April.  This  is  the 
new  Poisons  and  Pharmacy  Act.  One  of  the  chief 
provisions  is  that  every  apothecary's  store  must  be 
managed  by  a  qualified  man,  a  clause  aimed  at  the 
large  companies  with  numerous  stores,  under  un- 
qualified control.  In  each  of  these  there  must  now 
be  a  qualified  pharmacist,  and  his  name  must  be 
conspicuously  placed.  Another  provision  is  with 
regard  to  the  selling  of  poisons.  The  poison  sched- 
ules have  been  rearranged,  and  sulphonal  has  been 
added  to  the  list.  The  act  also  defines  the  official 
title  of  the  registered  "chemist,"  who  is  now  to  be 
called  a  pharmacist,  a  title  formerly  confined  to 
pharmaceutical  "chemists."  The  whole  trend  of 
the  act  is  to  plage  the  profession  of  pharmacy  upon 
a  better  footing  as  regards  its  status  and  to  protect 
the  duly  qualified  pharmacist  from  his  unqualified 
rivals  and  from  limited  companies  controlled  by 
those  who  are  not  "chemists."  It  has,  therefore, 
been  very  favorably  received  by  the  pharmaceutical 
profession  in  England. 

At  a  meeting  of  the  Royal  Society  of  Medicine 
on  December  14th  a  very  interesting  discussion 
took  place  on  the  relation  of  athletics  to  disease. 
Mr.  R.  H.  A.  Whitelocke,  of  Oxford,  explained  the 
phenomenon  of  "second  wind"  by  supposing  a  kind 
of  "physiological  emphysema"  to  be  produced  in 
the  lungs,  due  to  the  violent  exercise.  This  would 
account  well  for  the  phenomenon.  The  first  effect 
of  violent  and  sustained  efforts  was  dilatation  of 
the  heart,  the  right  ventricle  being  first  affected. 
Those  who  had  suffered  from  heart  strain  in  youth 
seemed  to  show  a  distinct  tendency  to  recurrences 
in  later  life  when  attempting  such  exercises  as 
mountain  climbing.  Violent  exercise  also  affected 
the  kidneys,  producing  a  condition  of  functional 
albuminuria.  He  also  dealt  with  the  external  in- 
juries seen  in  athletes.  Contusions  were  met  with 
in  every  degree,  and  for  treatment  elastic  pressure 
was  a  convenient ,  remedy.  For  sprains  he  used  a 
wash  leather  plaster.  Massage  should  not  be  be- 
gun until  at  least  twenty-four  hours  had  elapsed. 
Fixed  apparatus  or  rigid  splints  should  never  be 
used  for  sprains.  Gentle  voluntary  movements 
should  be  encouraged  from  the  first,  as  that  alone 
would  prevent  muscular  atrophy.  A  want  of  proper 
training  predisposed  to  athletic  injuries,  and  tem- 
perature had  an  influence,  for  rupture  of  muscle 
was  more  common  in  dry,  frosty  weather  than  dur- 
ing damp  weather.  The  speaker  also  dealt  with 
the  remote  consequences  of  sprains,  such  as  myo- 
sitis ossificans,  osteoarthritis,  tumors,  paralysis, 
loose  bodies  in  joints,  and  hysterical  joints. 

Sir  Lauder  Brunton  said  that  athletics  without 
previous  training  or  with  imperfect  training  might 
be  very  injurious,  and  overstrain,  especially  in 
growing  boys,  might  lead  to  cardiac  weakness  that 
might  ruin  their  future  lives.  All  those  who  took 
part  in  athletics  should  be  subjected  to  careful  med- 
ical examination. 

Dr.  de  Haviland  Hall  related  three  cases  of  vio- 


124  THERAPEUTICAL  NOTES. 


lent  exercise  producing  dilatation  of  the  heart,  the 
first  from  cycling,  the  second  from  horse  riding, 
and  the  third  from  high  jumping.  He  always  ad- 
vised medical  examination  of  children  before  indul- 
gence in  athletic  competitions. 

The  Local  Government  Board  in  England  has  is- 
sued an  order  rendering  compulsory  the  notification 
of  cases  of  pulmonary  tuberculosis  by  the  medical 
officer  of  a  Poor  Law  institution  and  by  the  district 
medical  officer  in  the  case  of  any  poor  person  he 
is  attending,  according  to  his  agreement  with  the 
Board  of  Guardians.  The  notifications  are  to  be 
made  to  the  medical  officer  of  health  within  forty- 
eight  hours  after  the  symptoms  of  pulmonary  tu- 
berculosis are  first  recognized.  The  remuneration 
is  at  the  rate  of  one  shilling  for  every  notification, 
but  where  in  relation  to  any  one  case  two  or  more 
notification  have  been  posted  to  the  same  medical 
officer  of  health,  the  remuneration  will  be  at  the 
rate  of  sixpence  for  every  such  notification  after 
the  first.  The  order  is  not  to  authorize  any  one  to 
put  into  force  any  enactment  which  renders  the 
person  notified  or  any  other  person  liable  to  a  pen- 
alty or  subjects  him  to  any  restriction,  prohibition, 
or  disability  affecting  him  or  his  employment,  occu- 
pation, means  of  livelihood,  or  residence  on  the 
ground  of  his  suffering  from  pulmonary  tuberculo- 
sis. This  order  comes  into  force  on  January  i, 
1909. 

The  Bill  for  the  Prevention  of  Tuberculosis  in 
Ireland  has  also  become  law,  as  well  as  the  Chil- 
dren's Bill,  so  that  the  present  session  of  Parlia- 
ment has  successfully  passed  several  bills  of  great 
medical  importance. 

An  important  case  from  a  medicolegal  stand- 
point came  before  the  Court  of  Appeal  recently. 
The  point  was  as  to  whether  the  refusal  of  a  work- 
man to  undergo  a  simple  operation  debarred  him 
from  claiming  compensation  for  continued  inca- 
pacity caused  by  an  accident  for  which  the  em- 
ployers had  already  been  declared  liable.  The  facts 
were  as  follows :  The  workman  was  injured  on 
February  18,  1907,  by  two  stanchions  falling  on  his 
foot.  The  foot  was  treated  at  the  hospital,  with 
the  result  that  after  two  or  three  small  operations 
the  applicant  had  his  second  toe  and  part  of  the 
big  toe  removed.  He,  nevertheless,  still  continued 
to  have  pain,  and  the  x  rays  showed  that  there  was 
a  piece  of  bone  which  was  detached  from  the  bone 
of  the  big  toe  at  the  time  of  the  accident  and  was 
now  loose  in  the  stump  of  the  big  toe.  The  doctors 
advised  the  man  to  undergo  another  operation  to 
have  the  piece  of  bone  removed,  but  the  man  re- 
fused. Up  to  the  time  of  his  refusal  he  was  paid 
compensation  by  his  employers  at  the  rate  of  14s. 
lod.  a  week.  When  he  refused  to  submit  to  the 
operation  his  employers  stopped  the  payments. 
The  man  therefore  summoned  them,  and  the  county 
court  decided  in  his  favor.  This  decision  was, 
however,  reversed  by  the  Appeal  Court,  which  al- 
lowed judgment  for  the  employers,  stating  that,  al- 
though a  man  could  not  be  compelled  to  undergo 
an  operation,  yet  if  an  operation  was  not  performed 
the  continuance  of  the  disability  or  incapacity 
would  be  due,  not  to  the  original  accident,  but  to 
the  unreasonable  conduct  of  the  workman  in  re- 


[New  Yokk 
Medical  Jourxal. 

fusing  to  submit  himself  to  a  comparatively  trivial 
operation. 

The  death  occurred  a  few  days  ago  of  Surgeon 
General  Tuson,  M.  D.,  F.  R.  C.  S.,  at  the  age  of 
seventy-nine.  He  was  formerly  a  distinguished 
figure  in  the  army  medical  service.  He  joined  the 
Bengal  medical  service  in  1853,  and  took  part  in 
the  Indian  mutiny  campaigns,  being  mentioned  in 
dispatches  and  receiving  the  mutiny  medal.  He  in- 
vented a  new  form  of  bullet  extractor,  and  wrote  a 
work  on  the  hypodermic  injection  of  quinine  in  in- 
termittent fever. 

 <^  


Therapeutics  of  Aneurysm  of  the  Aorta. — The 

following  method  of  treatment  of  aneurysm  of  the 
aorta  is  followed  by  A.  Robin  {Bulletin  de  thera- 
peiitique;  through  Journal  de  medicine  de  Paris, 
December  26,  1908).  Prescribe  a  milk  and  vege- 
table diet ;  insure  rest  and  repose  for  the  patient.  If 
a  syphilitic  subject,  give  the  following  mixture: 
^    Corrosive  sublimate,   gr.  iii; 

Potassium  iodide,   5v; 

Distilled  water,   5v; 

Syrup  of  viola  tricolor,   3v; 

Simple  syrup,   Jvi. 

M.  et  Sig. :  One  teaspoonful  twice  daily  before  meals. 

If  the  patient  is  not  affected  with  syphilis,  the 
following  is  prescribed : 

R    Potassium  iodide,   5iiss; 

Extract  of  opium,   gr.  vi; 

Chloral  hydrate  3i; 

Distilled  water,   ^ix. 

M.  et  Sig. :  One  teasponful  twice  daily  before  meals. 

Inject  every  week  deep  in  the  subcutaneous  tissue 
of  the  buttocks,  taking  proper  antiseptic  precautions, 
ten  drachms  of  the  following  solution,  and  increase 
the  dose  each  week  by  five  drachms  until  about  three 


ounces  are  taken : 

R    Gelatin,   5ss; 

•Sodium  chloride  gr.  xxi; 

Sterilized  water,   5vi  3ii. 


Make  a  solution,  and  sterilize  at  a  temperature  of  248°  F. 

To  overcome  any  dyspnoea,  draw  off  about  five 
ounces  of  blood,  but  do  not  repeat  the  operation ; 
or  give  three  or  four  times  daily  on  a  piece  of  sugar 
or  in  water  ten  drops  of  a  fifty  per  cent,  solution  of 
oxycamphor  in  alcohol. 

To  lower  the  arterial  tension  if  it  is  high  give, 
during  the  day,  in  divided  doses,  two,  three,  four, 
and  up  to  ten  drops  of  a  one  per  cent,  solution  of 
nitroglycerin  in  a  tablespoonful  of  water.  Inhala- 
tions of  amyl  nitrite  are  also  useful.  Break  a  pearl 
of  the  nitrite  in  a  handkerchief  and  hold  it  near  the 
patient's  face. 

In  haemoptysis  the  following  is  prescribed : 

R    Calcium  chloride,     3i; 

Syrup  of  opium  {Pharmacopie  Franqaise),  5''. 

Cinnamon  water  5iv. 

M.  et  Sig.:  One  tablesponful  every  one  or  two  hours  as 
needed. 

The  cough  may  be  alleviated  by  the  following 


pill: 

R    Extract  of  opium,   gr.  iii ; 

Extract  of  stramonium  gr.  54. 

Mix  and  make  ten  pills. 


Sig. :  One  pill  every  three  or  four  hours. 


January  i6,  1909.] 


EDITORIAL  ARTICLES. 


125 


NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

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XEW  YORK,  SATURDAY,  JANUARY  16,  1909. 


VACCINATION. 

After  more  than  a  hundred  years  of  the  beneficent 
action  of  vaccination  throughout  the  civilized  world, 
an  action  never  questioned  by  any  person  who  was 
at  once  reasonable  and  well  informed,  it  would  seem 
a  work  of  supererogation  to  argue  in  favor  of  the 
practice.  So  it  would  be  but  for  the  pernicious 
activity  of  the  fanatics  who  oppose  it.  They  are 
constantly  disseminating  their  false  doctrines,  and 
at  present,  it  appears,  with  more  than  their  usual 
ardor,  for  within  the  last  few  days  we  have  received 
a  batch  of  their  diatribes  emitted  from  Boston,  the 
very  city  from  which  Waterhouse  spread  the  bles- 
sing of  vaccination  over  the  United  States. 

Unfortunately,  the  weaklings  who  are  influenced 
by  these  incendiary  emanations  are  often  in  a  posi- 
tion to  enforce  the  false  teachings  which  they  have 
imbibed,  for  they  may  be  parents  and  deny  to  their 
children  the  only  known  safeguard  against  a  most 
loathsome  and  deadly  pestilence.  It  is  highly  neces- 
sary, therefore,  that  the  antivaccination  propaganda 
be  energetically  and  unremittingly  combated,  and 
it  is  gratifying  to  note  that  the  antidote  to  the  bane- 
ful crusade  is  so  efficiently  brought  to  public  notice 
from  time  to  time  as  it  was  at  a  meeting  of  the 
Philadelphia  County  Medical  Society  held  on  No- 
vember 25th.  In  this  issue  we  present  the  papers 
read  at  that  meeting,  together  with  an  abstract  of 
the  discussion.  The  papers  were  read  by  Dr.  Alex- 
ander C.  Abbott,  Dr.  William  M.  Welch,  Dr.  Jay 
Frank  Schamberg,  and  Mr.  Hampton  L.  Carson, 


the  last  named  gentleman  presenting  the  legal 
aspects  of  the  subject. 

From  other  quarters  also  come  evidences  of  an 
active  and  efficient  campaign  against  the  antivacci- 
nation delusion.  The  New  York  State  Department 
of  Health  has  lately  issued  a  very  telling  pamphlet 
on  the  subject,  the  Legislative  Assembly  of  the  prov- 
ince of  Ontario  recently  took  action  which  has  re- 
sulted in  the  publication  of  a  new  edition  of  Dr. 
Charles  A.  Hodgetts's  excellent  essay,  and  the 
Michigan  State  Board  of  Health  has  graphically  set 
forth  for  popular  consideration  the  advantages  of 
vaccination  and  the  dire  effects  of  neglecting  the 
practice.  These  are  only  a  few  examples  of  the 
beneficent  efforts  of  individuals  and  organizations ; 
every  authoritative  sanitary  body  in  the  United 
States  and  Canada  is  taking  a  more  or  less  promi- 
nent part  in  the  good  work.  But  it  is  necessary  that 
the  undertaking  should  be  prosecuted  without  cessa- 
tion ;  the  public  should  at  all  times  and  in  all  places 
be  amply  supplied  with  such  statements  of  unques- 
tionable facts  as  shall  arm  them  against  the  wiles 
of  those  who  inculcate  distrust  of  Jenner's  immor- 
tal demonstration  of  the  safety  and  efficiency  of 
vaccination. 


OSMOSIS. 

Our  knowledge  concerning  the  nature  of  osmosis 
is  still  far  from  complete,  despite  the  fact  that  the 
phenomenon  is  recognized  as  one  of  the  funda- 
mentals of  biology,  and  despite,  also,  considerable 
careful  investigation,  especially  of  recent  years.  In 
a  recent  review  of  the  subject,  Callender  discusses 
the  four  main  theories  which  have  been  formulated 
to  explain  osmosis,  namely,  the  gas  pressure  theory, 
the  surface  tension  theory,  the  association  theory, 
and  the  vapor  tension  theory,  and  shows  that  not 
one  of  these  suffices  to  explain  all  the  facts,  though 
there  is  probably  some  truth  in  each.  At  the  last 
meeting  of  the  Harvey  Society,  Macallum,  of  To- 
ronto, gave  a  scholarly  account  of  osmosis,  espe- 
cially as  applied  to  biology,  and  pointed  out  that  the 
gas  pressure  theory,  despite  its  inadequacy,  was 
still  largely  followed  by  physiologists  because  of  its 
great  heuristic  value.  After  all,  a  theory  does  not 
need  to  represent  actual  truth,  as  long  as  it  affords 
a  reasonable  foothold  from  which  to  push  further 
inquiries.  In  fact,  that  is  the  criterion  by  which 
the  value  of  theories  is  measured.  With  new  facts 
brought  to  light,  the  theory  may  have  to  undergo 
considerable  modification  or  even  be  abandoned,  but 
this  will  in  no  way  impair  the  value  of  the  results 
obtained. 

For  the  past  thirty  years,  according  to  Macallum, 
a  great  deal  has  been  written  about  permeable  and 
semipermeable  membranes,  and  writer  has  copied 


126 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


from  writer,  so  that  at  the  present  time  many  text- 
books explain  osmosis  by  assuming  that  the  dialyz- 
ing  membrane  acts  as  a  kind  of  sieve,  permitting 
only  certain  sized  molecules  to  pass.  A  great  mass 
of  evidence  is  disregarded  which  shows  that  under 
certain  conditions  the  larger  molecules  pass  through 
the  membrane,  while  the  smaller  ones  are  held  back. 
At  the  present  time  it  is  well  established  that  one 
of  the  main  factors  in  osmosis  is  the  affinity  of  the 
dissolved  substance  for  the  material  constituting  the 
membrane.  In  fact,  by  using  a  rubber  membrane  it 
has  been  found  that  the  rigid  division  which  has 
been  made  between  crystalloids  and  colloids  no 
longer  holds.  Kahlberg,  for  example,  used  a  rubber 
membrane  with  pyridine  on  either  side,  and  then 
tested  the  diffusibility  of  sugar  and  of  copper  oleate. 
The  so  called  colloid,  copper  oleate,  passed  through 
the  membrane,  while  the  crystalloid,  sugar,  did  not. 
In  like  manner,  when  camphor  and  sugar  were  stud- 
ied, the  camphor  passed  through,  while  the  sugar 
remained  behind.  When  a  parchment  membrane 
was  used,  benzin  being  on  either  side,  the  copper 
oleate  did  not  pass  through.  We  see,  therefore,  that 
the  membrane  is  not  a  passive  element  in  osmosis. 
With  a  proper  sjeptum  it  is  even  possible  to  sepa- 
rate crystalloids,  such  as  sugar  and  metallic  salts, 
the  sugar  passing  through,  while  the  salts  do  not. 

A  great  deal  of  Macallum's  work  has  been  on  the 
osmotic  processes  of  the  animal  cell.  It  is  known, 
for  example,  that  when  egg  albumin  is  introduced 
into  the  intestines  it  may  pass  unchanged  through 
the  cell  membrane  of  the  intestine  and  into  the 
blood,  and  may  pass  through  the  cell  membrane  of 
the  cells  reflected  on  Bowman's  capsule  in  the  kid- 
ney, so  that  it  is  excreted  in  the  urine.  The  pas- 
sage of  fat  droplets  through  the  cells  of  the  intes- 
tines into  the  lymph  is  another  well  known  example 
of  osmosis.  It  is  thus  seen  that  the  membrane  of 
the  cell  body  readily  allows  various  substances  to 
pass  through  it.  In  the  nuclear  membrane,  on  the 
other  hand,  conditions  are  quite  the  reverse.  It  has 
been  shown,  for  example,  that  the  nucleus  of  the 
animal  cell  is  free  from  chlorides  and  phosphates, 
and  since  these  are  the  predominating  compounds 
of  sodium,  potassium,  magnesium,  and  calcium 
found  in  the  body,  it  follows  that  these  elements  are 
absent  from  the  nucleus.  In  fact,  at  times  the  cyto- 
plasm may  be  surcharged  with  potassium,  while  the 
nucleus  is  entirely  free  from  this  element.  In  some 
way  the  nuclear  membrane  has  become  impermeable 
to  inorganic  crystalloids,  a  fact  which  has  been  no- 
ticed also  by  Hamburger. 

Furthermore,  fat  is  also  not  demonstrable  in  the 
nucleus,  unless  in  pathological  conditions,  and  free 
carbohydrate  is  also  excluded.  Free  proteid  is  prob- 
ably absent.    The  chief  constituents  of  the  nucleus 


are  iron  holding  nucleoproteids  in  the  form  of  chro- 
matin. The  nuclear  membrane  is  permeable  to  such 
iron  holding  nucleoproteids.  The  diffusion  of  the 
chromatin  substance  is  well  demonstrated  by  study- 
ing nerve  cells  in  various  periods  of  their  develop- 
ment. Macallum  has  shown  that  this  diffusion  gives 
rise  to  what  are  termed  the  Nissl  bodies  in  the  body 
of  the  nerve  cell.  If  the  nuclear  membrane  is  per- 
meable to  the  chromatin  substance,  why  does  not 
most  of  it  pass  out  of  the  nucleus?  According  to 
Macallum,  it  is  possible  that  the  chromatin  substance 
exists  in  two  "phases,"  just  as  agar  does.  In  the 
case  of  the  latter  substance  we  distinguish  an  agar- 
water  phase  and  a  water-agar  phase.  So  in  the  case 
of  the  nucleoproteid  there  may  be  a  water-nucleo- 
proteid  phase  and  a  nucleoproteid-water  phase.  Only 
in  one  of  these  phases  would  the  chromatin  material 
be  diffusible.  Macallum  has  applied  his  theory  of 
cell  osmosis  to  the  problem  of  heredity,  and  sees  in 
the  impermeability  of  the  nuclear  membrane  a  pro- 
tection of  the  germ  cells  against  outside  disturb- 
ances, a  method  of  insuring  the  stability  of  trans- 
mitted characteristics.  Under  normal  circumstances, 
he  believes,  the  nuclear  membrane  of  the  germ  cells 
allows  only  nucleoproteid  of  a  certain  definite  type 
to  pass  through.  This  nucleoproteid,  in  a  way,  rep- 
resents the  composite  of  all  the  cells  in  the  body, 
and  thus  corresponds  to  what  Darwin  embodied  in 
the  idea  of  "gemmules."  In  fact,  Macallum's  the- 
ory of  heredity  may  be  regarded  as  a  combination 
of  the  theories  of  Darwin  and  Weissmann.  It  is 
interesting  to  note  how  a  thorough  analysis  of  an 
apparently  simple  physical  phenomenon  brings  one 
face  to  face  with  some  of  the  profoundest  problems 
of  life. 


THE  NOMENCLATURE  AND  CLASSIFICA- 
TION OF  DISEASES. 
In  his  recent  annual  report,  covering  the  work  of 
the  Bureau  of  the  Census  for  the  year  1907  to  1908, 
Director  North  expresses  the  high  appreciation  in 
which  the  bureau  holds  the  subject  of  uniformity  in 
the  nomenclature  and  classification  of  diseases.  "The 
foundation  of  mortality  statistics,"  he  says,  "so  far 
as  the  study  of  the  causes  of  death  is  concerned, 
rests  upon  the  accuracy  of  the  information  afforded 
by  individual  physicians  in  regard  to  the  diseases  or 
the  forms  of  violence  causing  death.  To  secure  pre- 
cision, it  is  necessary  that  there  shall  be  a  standard 
nomenclature  of  diseases — something  which  has 
never  existed  in  this  country."  He  is  gratified, 
therefore,  at  the  steps  taken  by  the  American  Med- 
ical Association  in  providing  for  a  committee  on  no- 
menclature and  classification,  also  at  the  organiza- 
tion of  the  Section  in  Vital  Statistics  of  the  Ameri- 


January  i6,  1909.] 


EDITORIAL  ARTICLES. 


127 


can  Public  Health  Association.  These  bodies,  to- 
gether with  the  Bureau  of  the  Census,  the  govern- 
ment medical  services,  the  American  Medical  Asso- 
ciation's sections,  and  various  national  medical  socie- 
ties, are  cooperating  in  the  task  of  providing  a 
classification  and  nomenclature  which  will  commend 
themselves  to  the  medical  profession  and  be  observed 
by  individual  physicians  in  clinical  reports  and  death 
certificates. 

As  regards  classification,  the  American  revision 
has  now  been  completed  and  is  ready  to  be  submit- 
ted to  the  international  committee  of  revision,  which 
meets  in  Paris  in  1909.  It  is  expected  that  the  re- 
vised nomenclature  will  be  ready  for  action  by  the 
House  of  Delegates  of  the  American  Medical  /\sso- 
ciation  at  the  next  annual  meeting,  though  much 
work  has  yet  to  be  done  upon  it,  in  spite  of  the  asso- 
ciation's having  simplified  its  committee's  labors  by 
restricting  them  to  a  revision  of  the  nomenclature 
of  the  Royal  College  of  Physicians  of  England. 
That  nomenclature  has  been  largely  followed  in  the 
United  States,  but  some  modification  of  it  seems  to 
be  needed  for  American  use,  and  many  new  entries 
will  probably  have  to  be  made,  especially  in  the  do- 
main of  tropical  medicine. 


STANDARDIZING  DISINFECTANTS. 
American  readers  of  English  medical  and  sani- 
ary  journals  will  have  noticed  the  great  amount  of 
attention  given  by  these  journals  to  the  subject  of 
disinfection.  The  advertising  pages  teem  with  an- 
nouncements of  disinfectants  of  all  kinds,  and  nu- 
merous scientific  articles  discuss  various  phases  of 
the  subject.  Altogether  one  gets  the  impression 
that  the  subject  has  been  much  more  thoroughly 
studied  in  England  than  elsewhere.  We  venture  to 
say  that  few  of  our  readers  understand  what  is 
meant  by  "Rideal-Walker  coefficient  r6  to  17,"  and 
yet  such  a  phrase  is  quite  common  in  the  English 
advertisements  of  various  disinfectants.  The  fact 
is  that  serious  attempts  have  been  made  in  England 
to  devise  a  standard  for  comparing  various  disin- 
fectants, and  one  of  these  standards,  that  of  Rideal 
and  Walker,  has  come  into  quite  general  use.  In 
this  method  the  strength  of  the  disinfectant  is 
tested  on  pure  cultures  of  typhoid  bacilli  and  is  com- 
pared with  carbolic  acid  solution  of  a  known 
strength.  This  method  is  admirable  for  determining 
the  relative  efficiency  of  disinfectants  on  naked 
organisms  in  the  absence  of  organic  matter,  but  in 
practice  disinfection  is  almost  always  carried  out  in 
the  presence  of  organic  matter,  and  when  this  factor 
is  introduced  the  results  obtained  by  the  Rideal- 
Walker  method  are  sometimes  misleading.  What 
the  hygienist  wants  to  know  is  whether  a  disinfect- 


ant mixed  with  sputum,  faeces,  or  urine  or  spread 
on  walls,  floor,  or  soil  or  applied  to  infected  prod- 
ucts, such  as  wool  or  hides,  is  capable  of  rendering 
them  harmless ;  what  amount  of  disinfectant  is 
necessary  to  produce  the  desired  effect;  and  how 
that  quantity  of  disinfectant  compares,  as  to  rapidity 
of  action,  safety  to  employer,  and  cost,  with  equally 
efficient  quantities  of  other  disinfectants.  In  order 
to  approximate  these  conditions,  a  number  of  bac- 
teriologists have  introduced  faeces,  milk,  and  other 
substances  into  their  tests,  but  it  is  obvious  that  this 
does  not  yield  the  desired  information.  It  would 
be  well  if  some  means  could  be  found  to  induce  the 
manufacturers  to  state  the  antiseptic  strength  of 
their  preparations  on  the  label. 


RELIEF  FROM  OVERCROWDING  OF 
THE  PROFESSION. 

In  the  report  of  the  Commissioner  of  Education 
for  the  year  ending  June  30,  1907,  recently  issued, 
we  find  some  interesting  figures  showing  signs 
of  abatement  of  the  overcrowding  of  the  medical 
profession  that  has  been  going  on  for  many  years. 
The  commissioner  finds  that  there  was  an  annual 
decrease  of  about  a  thousand  in  the  number  of 
medical  students  during  the  four  years  preceding 
the  year  covered  by  the  report,  also  a  corresponding 
though  less  decided  diminution  of  the  number  of 
graduates.  Admitting  that  opinions  would  prob- 
ably differ  as  to  the  causes  of  this  state  of  things, 
the  commissioner  seems  inclined  to  attribute  it  to 
the  increasing  rigor  of  the  State  examinations. 

The  decrease,  it  will  be  noticed,  is  absolute,  not 
merely  in  proportion  to  the  increasing  population, 
and  has  been  going  on  for  several  successive  years. 
Perhaps  it  is  to  be  expected,  and  certainly  it  is  to 
be  hoped,  that  the  diminution  will  continue,  for  it 
cannot  be  denied  that  the  profession  is  at  present 
much  overcrowded.  It  is  getting  to  be  harder  and 
harder  to  make  a  living  by  the  practice  of  medicine, 
and  we  see  no  signs  of  any  amelioration  in  this  re- 
spect. Fortunately,  the  number  of  actual  practi- 
tioners is  diminishing  more  than  the  number  of 
graduates,  for  every  year  there  is  some  increase  of 
the  number  of  graduates  who  never  enter  upon 
practice,  but  devote  themselves  to  research  work  or 
to  an  ofiicial  career  requiring  a  medical  education. 


FORMALDEHYDE  AS  A  FOOD 
PRESERVATIVE. 
The  fifth  of  the  series  of  reports  by  Dr.  Harvey 
W.  Wiley,  chief  of  the  Bureau  of  Chemistry  of  the 
Department  of  Agriculture,  published  on  Decem- 
ber 23d,  brings  the  investigation  of  the  influence  of 


128 


OBITUARY— NEWS  ITEMS. 


TNew  York 
Medical  Journal. 


focxl  preservatives  and  artificial  colors  on  digestion 
and  health  to  the  subject  of  formaldehyde.  In  the 
experiments  on  which  the  report  is  founded  the 
members  of  a  "poison  squad"  were  caused  to  ingest 
daily  amounts  of  milk  to  which  an  aqueous  solution 
of  formaldehyde  had  been  added,  usually  not  in 
sufficient  quantity  to  affect  the  flavor  of  the  milk, 
but  in  some  instances  to  the  extent  of  giving  it  a 
rather  unpleasant  taste.  The  text  of  the  report, 
with  the  tabular  and  graphic  illustrations,  fills  205 
octavo  pages. 

Dr.  Wiley  remarks  that  formaldehyde  is  of  no 
value  either  as  a  nutriment  or  as  a  condiment,  and  he 
finds  that  its  continued  ingestion  in  small  amounts 
exercises  an  unfavorable  action  on  the  general 
health.  It  is  an  irritant  to  the  mucous  membrane 
of  the  digestive  canal,  he  says,  and  it  disturbs  the 
normal  metabolism  and  has  a  slight  tendency  to  pro- 
duce albuminuria.  If  it  has  these  effects  on  young 
and  healthy  men,  he  argues,  it  must  be  decidedly 
deleterious  to  infants.  He  concludes  that  its  em- 
ployment as  a  preservative  of  articles  of  food  is 
never  justifiable.  We  have  no  doubt  that  he  is 
perfectly  warranted  in  all  these  deductions. 

 ^  


GEORG  EDUARD  RINDFLEISCH,  M.  D., 
of  Wiirzburg. 

In  Wiirzburg,  Germany,  died  on  December  6, 
1908,  at  the  age  of  seventy-two,  Georg  Eduard 
Rindfleisch,  one  of  Germany's  leading  pathologists 
and  a  pupil  of  Virchow's.  Born  at  Kothen,  De- 
cember 15,  1836,  he  studied  medicine  at  the  Uni- 
versity of  Berlin,  and  was  graduated  in  i860.  The 
following  year  he  was  admitted  as  Privatdozent  to 
the  medical  faculty  of  the  University  of  Breslau, 
where  he  lectured  for  only  a  year,  when  he  was 
called  as  assistant  professor  to  the  University  of 
Zurich.  In  1865  he  was  appointed  professor  of 
pathology  at  the  University  of  Bonn  and  in  1874 
to  the  same  chair  in  Wiirzburg,  which  position  he 
held  until  1906. 

Besides  his  many  contributions  to  pathology, 
Rindfleisch  has  been  well  known  as  the  foremost 
German  neovitalist,  developing  his  medical  philos- 
ophy in  his  speech  as  rector  of  the  Wiirzburg  Uni- 
versity in  1887  and  eight  years  later  at  the  German 
Naturforscher  meeting  at  Liibeck. 


CHARLES  DENISON,  M.  D., 
of  Denver. 

Dr.  Denison  died  on  Sunday,  January  loth,  in  his 
sixty-fourth  year.  He  was  a  native  of  Vermont, 
but  had  lived  in  Colorado  since  1873.  He  took  his 
medical  degree  from  the  University  of  Vermont  in 
1869.  For  many  years  he  had  been  widely  known 
as  a  climatologist  and  as  an  efficient  worker  in  ef- 
forts to  mitigate  the  ravages  of  tuberculous  disease. 


MATTHEW  CHALMERS,  M.  D., 
of  New  York. 
Dr.  Chalmers  died  on  Wednesday,  January  6th, 
in  his  seventy-third  year.  He  was  a  graduate  of  the 
College  of  Physicians  and  Surgeons,  of  the  class  of 
1862.  He  served  as  a  medical  officer  of  the  navy  in 
the  civil  war,  and  then  entered  upon  general  prac- 
tice in  New  York,  the  city  of  his  birth.  He  was  a 
member  of  the  Loyal  Legion  and  of  the  Union 
League  Club.  He  was  a  typical  family  practitioner 
and  a  most  amiable  gentleman. 

 <^  

ittos  limy 


The  Alumni  Association  of  the  College  of  Physicians 
of  Memphis,  Tenn.,  was  organized  recently.    Dr.  W. 

E.  Ragsdale  is  president.  Dr.  C.  M.  Beck  is  secretary,  and 
Dr.  W.  R.  Wallace  is  treasurer  of  the  association. 

The  Regulation  of  the  Introduction  of  Medical  Ex- 
pert Testimony  will  be  one  of  the  principal  topics  dis- 
cussed at  the  annual  meeting  of  the  New  York  State  Bar 
Association,  to  be  held  in  Buffalo  on  January  28th  and  29th. 

Vacancies  in  the  House  Staff  of  St.  Mark's  Hospital. 
— Candidates  for  positions  on  the  house  staff  of  St.  Mark's 
Hospital,  177-179  Second  Avenue,  New  York,  may  apply  at 
once  to  the  superintendent  of  the  hospital.  The  term  of 
service  is  two  years. 

To  Discuss  Industrial  Diseases. — ^The  Organizing 
Committee  of  the  International  Medical  Congress,  which  is 
to  be  held  in  Budapest  in  August  of  this  year,  has  formed 
a  subsection  of  the  Section  in  Hygiene  for  the  discussion 
of  industrial  diseases. 

The  Superintendency  of  Bellevue  Hospital. — Dr.  John 

F.  Fitzgerald,  general  medical  superintendent  of  the  De- 
partment of  Public  Charities,  who  was  recently  asked  to 
accept  the  position  of  medical  superintendent  of  Bellevue, 
has  declined  the  ofYer. 

Contributions  to  the  Sydenham  Hospital,  New  York, 
to  be  Doubled  by  Mr.  Guggenheim. — Announcement  has 
been  made  by  Mr.  Isaac  Guggenheim  that  he  will  contribute 
to  the  funds  of  the  hospital  as  much  as  all  other  contribu- 
tions combined  during  the  year  1909. 

The  Reciprocal  Relations  of  the  Legal  and  Medical 
Professions  was  the  title  of  a  paper  read  by  Dr.  Robert 
A.  Murray,  president  elect  of  the  New  York  Society  of 
Medical  Jurisprudence,  at  the  two  hundred  and  eighteenth 
regular  meeting  of  the  society,  held  on  Monday  evening, 
January  nth. 

The  Kansas  City,  Mo.,  Academy  of  Medicine. — The 

following  officers  were  elected  at  the  annual  meeting  of 
the  academy,  which  was  held  recently:  President.  Dr. 
George  B.  Norberg;  vice-president.  Dr.  F.  T.  Van  Eman; 
treasurer,  Dr.  C.  B.  Hardin  ;  secretary,  Dr.  J.  E.  Kimber- 
lin ;  and  censor.  Dr.  G.  A.  Beedle. 

Vermont  to  Furnish  its  Citizens  with  Antitoxine. — 
The  State  legislature,  now  in  session,  has  passed  a  law  di- 
recting the  State  Board  of  Health  to  furnish  diphtheria 
antitoxine  free  to  its  citizens,  when  called  for  by  physi- 
cians. Sixty-four  stations  have  been  established  by  the 
board  where  the  antitoxine  will  be  dispensed. 

The  Annual  Meeting  of  the  Medical  Staff  of  St.  Mary's 
Hospital,  Philadelphia,  was  held  on  Tuesday,  January 
5th.  The  following  appointments  were  announced:  Pathol- 
ogist, Dr.  Joseph  A.  Moore ;  physician  to  the  dispensary 
for  the  diseases  of  children,  Dr.  Thomas  Kelly;  surgeons 
in  the  dispensary,  Dr.  James  Cullen  and  Dr.  George  A. 
Nofcr. 

The  First  Official  Hospital  Photographer. — Mr.  Oscar 
Gleason  Mason,  the  first  official  hospit«il  photographer  in 
the  world,  has  resigned  as  photographer  and  radiographer 
to  Rcilcvuc  Hospital.  He  was  official  photographer  to  the 
hospital  for  over  forty  years  and  worked  in  a  little  studio 
at  the  top  of  the  building,  without  salary,  his  income  con- 
sisting of  fees  received  fioni  physicians  and  from  the  De- 
partment of  Charities  for  photographing  the  city's  >miden- 
tified  dead.  When  the  x  ray  came  into  use,  he  took  up  the 
study  of  the  method,  and  tlie  constant  use  of  it  so  crippled 
his  hands  and  arms  that  he  was  obliged  to  give  up  his 
work.  His  successor  in  charge  of  the  x  ray  work  at  Belle- 
vue will  be  Dr.  Byron  C.  Darling,  a  graduate  of  Harvard 
Medical  School. 


January  16,  1909.] 


NEIVS  ITEMS. 


129 


The  Postgraduate  Academy  dl  Medicine  of  North- 
eastern Philadelphia  has  just  issued  a  roster  of  meetings 
for  1909,  which  are  held  in  the  Frankford  Hospital,  at  9:15 
p.  m.  The  officers  for  the  current  season  are :  President, 
Dr.  Elmer  E.  Keiser;  secretary,  Dr.  Albert.  C.  Buckley: 
treasurer.  Dr.  George  C.  Hanna;  executive  council.  Dr. 
George  E.  Levis  and  Dr.  Frank  Embery. 

Contagious  Diseases  in  Chicago.— Seven  hundred  and 
twenty-eight  cases  of  contagious  diseases  were  reported  to 
the  Department  of  Health  during  the  week  ending  January 
2,  1909.  Of  these  193  were  of  diphtheria,  229  of  scarlet 
fever,  97  of  measles,  41  of  typhoid  fever,  35  of  pneumonia, 
36  of  chickenpox,  14  of  whooping  cough,  3  of  puerperal 
fever,  65  of  tuberculosis,  and  15  of  minor  communicable 
diseases. 

Officers  of  the  Cincinnati  Academy  of  Medicine. — At 

the  annual  meeting  of  the  academy,  which  was  held  on  the 
evening  of  January  5th,  the  following  officers  were  elected: 
President,  Dr.  R.  B.  Hall ;  first  vice-president,  Dr.  S.  E. 
Allen ;  second  vice-president.  Dr.  E.  S.  McKee ;  secretary, 
Dr.  E.  O.  Smith ;  treasurer,  Dr.  A.  G.  Drury ;  librarian, 
Dr.  A.  I.  Carson ;  censor,  Dr.  J.  E.  Greiwe ;  trustee.  Dr.  J. 
F.  Heady. 

The  Northern  California  District  Medical  Association 

elected  the  following  officers  at  a  meeting  held  in  Chico 
recently:  President,  Dr.  Edward  W.  Twitchell,  of  Sacra- 
mento; first  vice-president.  Dr.  William  J.  Hanna,  of  Sac- 
ramento ;  second  vice-president.  Dr.  D.  H.  Moulton,  of 
Chico ;  third  vice-president.  Dr.  Albert  Osborne,  of  Hamil- 
ton City ;  secretary  and  treasurer.  Dr.  Joseph  W.  James,  of 
Sacramento,  reelected. 

Medical  Legislation. — The  Januarj'  13th  meeting  of 
the  Central  Branch  of  the  Philadelphia  County  Medical 
Society  was  devoted  to  a  consideration  of  the  subject  of 
medical  legislation.  The  programme  was  arranged  under 
the  auspices  of  the  Committee  on  Public  Policy  and  Legis- 
lation of  the  society,  which  is  composed  of  Dr.  James  M. 
Anders,  Dr.  William  S.  Higbee.  Dr.  John  Ruoft,  Dr.  James 
B.  Walker,  and  Dr.  L.  Webster  Fox.  chairman. 

The  Medical  Society  of  the  District  of  Columbia  held 
its  annual  meeting  in  Georgetown  University,  Washington, 
D.  C,  on  Monday  evening,  January  4th.  Several  topics 
bearing  on  matters  of  interest  to  the  medical  profession 
were  discussed,  after  which  the  annual  election  of  officers 
was  held.  Dr.  E.  A.  Ballock  was  elected  president  of  the 
society;  Dr.  John  Van  Rensselaer  and  Dr.  George  Tally 
'\''aughan,  vice-presidents;  Dr.  C.  W.  Franzoni,  treasurer; 
and  Dr.  H.  C.  McAtee,  recording  secretary. 

Testing  Pasteurizing  Machines. — A  thorough  and 
complete  test  of  pasteurizing  machines  is  being  made  in 
the  laboratories  of  the  Chicago  Department  of  Health,  to 
determine  at  what  temperature  each  tjpe  and  make  of  ma- 
chine will  destroy  tubercle  bacilli,  typhoid  bacilli,  diphtheria 
bacilli,  staphylococci  and  streptococci  and  99  per  cent,  of 
all  bacteria  contained  in  market  milk  having  3,000,000  or 
more  bacteria.  These  tests  are  made  on  the  machines  them- 
selves, running  under  normal,  practical  conditions. 

Officers  of  the  Western  Surgical  and  Gynaecological 
-Association. — At  the  annual  meeting  of  this  association, 
which  was  held  in  Minneapolis  on  December  29th  and  30th, 
the  following  officers  were  elected  to  serve  for  the  ensuing 
year:  President.  Dr.  A.  L.  Wright,  of  Carroll,  Iowa;  first 
vice-president.  Dr.  J.  F.  Percy,  of  Galesburg,  111. ;  second 
vice-president.  Dr.  W.  B.  Haines,  of  Cincinnati,  Ohio;  sec- 
retary and  treasurer,  Dr.  Arthur  T.  Mann,  of  Minneapolis. 
The  next  meeting  of  th  association  will  be  held  in  Omaha, 
Neb.,  on  December  20  and  21,  1909. 

The  Medical  Association  of  the  Greater  City  of  New 
York. — The  annua!  meeting  of  the  association  will  be 
held  in  Du  Bois  Hall,  New  York  Academy  of  Medicine,  on 
Monday  evening,  January  i8th,  at  8:30  o'clock.  Dr.  Homer 
Wakefield  will  read  a  paper  entitled  Some  Serious  Lapses 
in  Administrative  Hygiene,  which  will  deal  with  the  Path- 
ogenesis of  Undrawn  Cold  Storage  Poultry,  the  Prime  Evil 
of  Cold  Storage  Egg  Preservation,  and  the  Hygiene  of  the 
Cow  zersus  that  of  Milking,  and  the  Preservation  and  De- 
livery of  Milk.  A  general  discussion  will  follow.  Dr.  Wil- 
liam S.  Gottheil  will  give  a  demonstration  of  models  illus- 
trating certain  phases  of  syphilis.  The  remainder  of  the 
programme  will  be  devoted  to  a  consideration  of  the  serum 
reaction  ( Wassermann's  reaction)  in  syphilis.  Dr.  Howard 
Fox  will  read  a  paper  on  the  Principles  and  Technique  of 
the  Reaction  and  Dr.  Boleslaw  Lapowski  will  read  a  paper 
on  the  Practical  Application  of  the  Reaction  and  its  Value 
in  the  Diagnosis  and  Treatment  of  Sv-philis.    Among  those 


who  will  take  part  in  the  discussion  of  the  subject  will  be 
Dr.  H.  Noguchi,  Dr.  Charles  Wood  McMurtry,  Dr.  Ed- 
ward D.  Fisher,  Dr.  James  Pedersen,  and  Dr.  J.  Bentley 
Squier,  Jr.  The  next  special  meeting  of  the  association 
will  be  held  in  Brooklyn  in  the  first  week  of  February. 

The  Health  of  Pittsburgh.— During  the  week  ending 
December  26,  1908,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
13  cases,  0  deaths;  typhoid  fever,  14  cases,  3  deaths;  scarlet 
fever,  24  cases,  3  deaths ;  diphtheria,  15  cases,  4  deaths ; 
measles,  32  cases,  r  death ;  whooping  cough,  6  cases,  i 
death;  pulmonary  tuberculosis,  12  cases,  9  deaths.  The  to- 
tal deaths  for  the  week  numbered  156,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  14.35  in  a  thousand  population. 

The  Gloucester  County,  N.  J.,  Medical  Society  will 
meet  in  Woodbury  on  Wednesday,  January  20th,  at  i  :30 
p.  m.  This  is  the  annual  meeting,  and  officers  for  the  en- 
suing year  will  be  elected.  Dr.  Judson  I>aland,  professor 
of  clinical  medicine  in  the  Medico-Chirurgical  College  of 
Philadelphia,  will  deliver  a  lecture  on  Leprosy,  which  will 
be  illustrated  by  stereopticon  views  of  actual  cases  seen 
by  him  when  on  a  visit  to  Molokai,  Hawaii,  some  years 
ago.  Dr.  Joseph  E.  HurfT,  of  Blackvvood,  N.  J.,  will  report 
a  case  of  leprosy  which  is  under  his  care  at  the  Camden 
County  Almshouse. 

Lectures  for  the  Tuberculosis  Exhibition  in  Philadel- 
phia.— A  tentative  programme  of  the  course  of  lectures 
to  be  delivered  at  the  International  Congress  on  Tubercu- 
losis has  been  arranged  and  approved  by  the  Executive 
Committee.  Special  lectures  are  to  be  given  in  Polish,  Ital- 
ian, German,  and  Yiddish.  The  heads  of  educational  insti- 
tutions in  and  about  the  city  have  been  asked  to  speak,  and 
an  effort  is  being  made  to  arrange  "State  Days"  for  Penn- 
sylvania, Delaware,  and  New  Jersey,  at  which  the  govern- 
ors of  the  States  will  deliver  addresses.  Dr.  Martin  G. 
Brumbaugh  was  the  first  to  offer  his  services. 

Gongs  Taken  From  Ambulances. — It  is  reported  that 
the  authorities  of  the  Roosevelt  and  Presbyterian  Hospi- 
tals, New  York,  have  ordered  the  gongs  removed  from  the 
ambulances  of  these  two  institutions.  They  have  been 
removed  from  all  the  ambulances  of  Roosevelt  Hospital, 
but  the  electric  ambulances  of  the  Presbyterian  Hospital 
retain  their  alarm  signals.  It  is  thought  that  the  gongs,  in 
addition  to  creating  a  great  deal  of  noise,  have  tended  to 
cause  much  reckless  driving  of  the  ambulances,  and  it  is 
for  this  reason  that  they  are  being  done  away  with.  The 
ambulances  of  Bellevue  Hospital  still  carry  gongs,  as  do  the 
police  ambulances. 

A  Permanent  Home  for  the  Buffalo  Academy  of 
Medicine. — The  committee  appointed  recently  to  make 
arrangements  for  a  permanent  home, for  the  academy  re- 
ports that  an  option  has  been  obtained  on  the  property  on 
High  Street,  between  Washington  and  Ellkrott  Streets,  one 
hundred  feet  front  and  one  hundred  feet  deep,  and  tenta- 
tive plans  have  been  submitted  for  a  simple  building,  which 
will  provide  the  academy  with  a  good  auditorium,  a  room 
for  collations,  a  large  reading  room,  a  committee  room,  coat 
rooms,  etc.,  and  living  rooms  for  a  janitor.  The  cost  of  the 
lot  is  $8,000  and  the  estimated  cost  of  the  building  is  from 
$18,000  to  $20,000.  The  permanent  fund  available  for  the 
purpose  amounts  to  $6,000,  and  the  committee  intends  to 
raise  the  rest  by  subscriptions. 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  January  23,  1909: 

MoxD.w,  January  iSth. — Society  of  Normal  and  Patholog- 
ical Physiology;  Medical  Society  of  the  Woman's  Hos- 
pital. 

TuESD.w,  January  igth. — Dermatological  Society;  Academy 

of   Natural    Sciences ;    North    Branch,  Philadelphia 

County  Medical  Society. 
Wednesday,  January  20th. — Philadelphia  County  Medical 

Society   (Business  Meeting  open  to  members  only)  ; 

Section  in  Otology,  College  of  Physicians;  Franklin 

Institute. 

Thursday,  January  21st. — Section  in  Ophthalmology,  Col- 
lege of  Physicians ;  Section  Meeting,  Franklin  Insti- 
tute ;  Southwark  Medical  Society ;  Northeast  Branch, 
Philadelphia  County  Medical  Society ;  West  Branch, 
Philadelphia  County  Medical  Society ;  Delaware  Valley 
Ornithological  Club. 

Frid.\y,  January  23d. — Philadelphia  Neurological  Society; 
Northern  Medical  Association. 

Saturday,  January  23d. — Samaritan  Hospital  Medical  So- 
ciety. 


I30 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


Organized  Labor  in  the  Tuberculosis  Campaign  in 
New  York  State, — The  State  Charities  Aid  Association 
opened  on  Monday,  January  nth,  a  new  labor  department 
in  the  campaign  on  the  prevention  of  tuberculosis  in  the 
State.  Mr.  Philip  V.  Danahy,  of  the  Commission  on  Im- 
migration, has  been  added  to  the  staff  of  the  association, 
and  will  conduct  an  educational  campaign  among  the  vari- 
ous labor  unions,  urging  the  adoption  of  measures  similar 
to  those  taken  in  Albany  which  resulted  in  the  establish- 
ment of  a  tuberculosis  pavilion  in  that  city  by  organized 
labor.  It  is  hoped  that,  m  addition  to  tbe  establishment  of 
labor  pavilions  for  the  treatment  of  tuberculosis,  other  de- 
cisive steps  will  be  taken  toward  improving  the  conditions 
which  make  toward  so  high  a  death  rate  in  certain  trades, 
such  as  stone  cutters,  cigar  makers,  tobacco  workers,  print- 
ers, compositors,  and  pressmen. 
Infectious  Disease  in  New  York: 

We  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  following  statistics  of  new 
cases  and  deaths  reported  for  the  two  weeks  ending  Janu- 
ary IT,  igog: 

,  Jan.  2  ,      ,  Jan.  1 1  1 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulnionalis    361         172         507  162 

Diphtheria    392  36         394  42 

Measles    363  16         538  12 

Scarlet  fever    296  19         305  15 

Smallpox   

Varicella    105  .  .  206 

Typhoid  fever    48  12  46  6 

Whooping  cough   ...    24  3  30  5 

Cerebrospinal  meningitis    6  4  8  8 

Totals   i>595         262       2,034  250 

The  Medical  Society  of  the  Borough  of  The  Bronx 

held  a  stated  meeting  on  Wednesday  evening,  January  13th. 
The  topic  chosen  for  consideration  was  pneumonia.  Two 
interesting  papers  were  read,  one  by  Dr.  Herman  T.  Radin 
on  the  ^Etiology,  Symptoms,  Diagnosis  and  Prognosis  in 
Pneumonia,  and  the  other  by  Dr.  T.  J.  Dunn  on  the  Treat- 
ment of  Pneumonia.  After  the  general  discussion  which 
followed  the  reading  of  the  papers,  a  collation  was  served. 
The  officers  of  the  society  for  the  year  1909  are :  President, 
Dr.  Frederic  W.  Loughran ;  first  vice-president.  Dr.  Nathan 
B.  Van  Etten ;  second  vice-president,  Dr.  Thomas  D. 
Brown ;  secretary.  Dr.  Clarence  H.  Smith,  654  East  One 
Hundred  and  Sixty-fifth  Street;  treasurer.  Dr.  Clarence  A. 
Holmes ;  financial  secretary.  Dr.  Herman  T.  Radin ;  coun- 
sel, H.  Gerald  Chapin,  Esq. ;  board  of  directors.  Dr.  Wil- 
liam A.  Boyd,  to  serve  one  year;  Dr.  John  B.  Rae,  to  serve 
two  years ;  Dr.  Henry  Roth,  to  serve  three  years ;  Dr.  Gus- 
tave  H.  E.  Starke,  to  serve  four  years ;  Dr.  William  Mc- 
Christie.  to  serve  five  years. 

The  Health  of  Philadelphia. — During  the  week  ending 
January  2.  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  of  Philadel- 
phia :  Typhoid  fever,  97  cases,  5  deaths ;  scarlet  fever,  48 
cases,  I  death;  chicken  pox,  80  cases,  o  deaths;  diphtheria, 
79  cases,  17  deaths ;  measles,  59  cases,  4  deaths ;  whooping 
cough,  9  cases,  i  death;  tuberculosis  of  the  lungs,  85  cases, 
51  deaths;  pneumonia,  123  cases,  90  deaths;  erysipelas,  13 
cases.  0  deaths;  mumps,  13  cases,  0  deaths;  cancer,  15  cases, 
18  deaths.  The  following  deaths  were  reported  from  other 
transmissible  diseases;  Tuberculosis,  other  than  tubercu- 
losis of  the  lungs,  6  deaths;  puerperal  fever,  i  death;  diar- 
rhoea and  enteritis  under  two  years,  12  deaths.  The  total 
deaths  numbered  516  in  an  estimated  population  of  1,532.- 
738,  corresponding  to  an  annual  death  rate  of  17.50  in  a 
thousand  population.  The  total  infant  mortality  was  149; 
123  under  one  year  of  age,  26  between  one  and  two  years 
of  age.  There  were  36  still  births;  20  males,  and  16  fe- 
males.   The  total  precipitation  was  0.09  inch. 

Medical  Society  of  the  State  of  New  York. — The  an- 
nual meeting  of  this  society  will  be  held  in  the  Common 
Council  Chamber,  City  Hall,  Albany,  N.  Y.,  on  January 
26th  and  27th,  and  the  regular  annual  meeting  of  the 
House  of  Delegates  of  the  society  will  be  held  on  Monday 
evening,  January  2Sth,  at  8:30  o'clock.  There  will  be  three 
sessions  on  Tuesday  and  two  on  Wednesday.  The  election 
of  officers  will  he  held  on  Tuesday.  At  the  morning  ses- 
sion on  Tuesday  the  presidential  address  will  be  delivered 
by  Dr.  Arthur  G.  Root,  of  Albany,  and  Dr.  Abraham 
Jacobi.  of  New  York,  will  deliver  an  address  on  the  Mod- 
ern Hippocrates.  Two  "symposia"  are  included  in  the  pro- 
gramme, one  on  Tuesday  evening  on  Purulent  Diseases  of 
the  Middle  Ear,  and  the  other  on  Wednesday  evening  on 
Fractures.    The  remainder  of  the  programme  is  made  up 


of  over  thirty  papers  on  subjects  of  interest  to  the  general 
practitioner,  and  the  list  of  authors  contains  the  names  of 
many  of  the  foremost  members  of  the  profession  in  the 
State,  in  addition  to  such  well  known  men  as  Dr.  Harvey 
W.  Gushing,  of  Baltimore ;  Dr.  Charles  L.  Scudder,  of 
Boston ;  and  Dr.  S.  MacCuen  Smith  and  Dr.  James  M. 
Anders,  of  Philadelphia.  The  annual  banquet  will  be  held 
at  the  Hotel  Ten  Eyck  on  Wednesday  evening,  January 
27th,  at  8  o'clock.  Those  desiring  seats  should  apply  at 
once  to  Dr.  W.  J.  Nellis,  chairman  of  the  Committee  on 
Arrangements,  210  State  Street,  Albany.  Dr.  Arthur  G. 
Root,  of  Albany,  is  president  of  the  society,  and  Dr.  Wis- 
ner  R.  Townsend,  of  New  York,  is  secretary. 

Officers  and  Elective  Committees  of  the  College  of 
Physicians  of  Philadelphia  for  the  year  1909  have  been 
elected  as  follows:  President,  Dr.  James  Tyson;  vice-presi- 
dent. Dr.  George  E.  de  Schweinitz ;  censors.  Dr.  Richard 
A.  Cleeman,  Dr.  S.  Weir  Mitchell,  Dr.  Louis  Starr,  and 
Dr.  Arthur  V.  Meigs;  secretary.  Dr.  Thomas  R.  Neilson; 
treasurer.  Dr.  Richard  H.  Harte ;  honorary  librarian.  Dr. 
Frederick  P.  Henry;  councilors,  to  serve  until  January, 
1912,  Dr.  John  H.  Gibbon,  and  Dr.  William  Pepper;  com- 
mittee on  publication.  Dr.  G.  G.  Davis,  Dr.  Thompson  S. 
Westcott,  and  Dr.  William  Zentmayer ;  library  committee, 
Dr.  George  G.  Harlan,  Dr.  Francis  X.  Dercum,  Dr.  William 
J.  Taylor,  Dr.  S.  Weir  Mitchell,  and  Dr.  Francis  R.  Pack- 
ard; committee  on  Miitter  Museum,  Dr.  George  McClellan, 
Dr.  J.  Allison  Scott,  and  Dr.  Henry  Morris ;  hall  commit- 
tee. Dr.  John  K.  Mitchell,  Dr.  Thomas  H.  Fenton,  Dr.  B. 
Alexander  Randall,  Dr.  E.  Hollingsworth  Siter,  and  Dr. 
A.  O.  J.  Kelly ;  committee  on  directory  for  nurses.  Dr. 
James  C.  Wilson,  Dr.  Wharton  Sinkler,  and  Dr.  Thomas 
G.  Ashton. 

Personal.— Dr.  H.  A.  Halsey,  a  graduate  of  Rush  Medi- 
cal College,  Chicago,  has  been  appointed  a  house  surgeon 
in  the  Emergency  Hospital,  Milwaukee,  to  fill  the  position 
left  vacant  by  the  recent  resignation  of  Dr.  Spiegelberg. 

Dr.  Mark  W.  Richardson  has  been  elected  secretary  of  the 
Massachusetts  State  Board  of  Health,  to  succeed  Dr.  Har- 
rington, who  died  recently. 

Dr.  Eugene  A.  McCarthy,  of  Boston,  has  severed  his 
connection  with  Carney  Hospital,  in  order  to  accept  the 
position  of  assistant  city  physician  at  Fall  River,  Mass. 

Dr.  Henry  Cadwalader  Chapman  has  announced  his  res- 
ignation from  the  faculty  of  Jefferson  Medical  College, 
Philadelphia,  where  he  has  been  a  professor  for  more  than 
thirty  years.    His  resignation  has  been  accepted. 

Dr.  C.  A.  L.  Reed,  of  Cinc'nnati,  has  been  appointed  a 
first  lieutenant  in  the  Medical  Reserve  Corps  in  the  United 
Stales  Army. 

Dr.  James  J.  Walsh,  dean  of  the  medical  faculty  of  Ford- 
ham  University,  New  York,  delivered  a  lecture  in  Brooklyn 
recently.    His  subject  was  Women  Workers  of  the  Past. 

Dr.  Charles  K.  Mills  and  Dr.  DeForest  Willard  have 
been  elected  to  the  Medical  Council  of  the  University  of 
Pennsylvania  by  the  Trustees  of  the  University. 

Charitable  Bequests  and  Donations. — The  Hospital 
for  Sick  Children.  Toronto,  Canada,  received  on  New 
Year's  morning  a  check  for  $10,000  from  Mr.  J.  Ross  Rob- 
ertson. 

It  is  reported  that  Mr.  John  W.  Gates  has  given  the  sum 
of  $100,000  to  the  city  of  Port  Arthur,  Texas,  for  the  erec- 
tion of  a  hospital  in  memory  of  his  mother,  who  died  there 
recently. 

By  the  will  of  Anna  Vandenberg,  who  died  recently  in 
Albany,  N.  Y.,  the  Homoeopathic  Hospital  of  that  city  re- 
ceived $2,000. 

The  chairman  of  the  executive  committee  of  the  New 
Hampshire  Sunday  Hospital  Association  reports  total  col- 
lections during  the  past  season  of  $1,092.42; 

Mr.  and  Mrs.  Charles  E.  Rapelyea  have  given  to  the  city 
of  Elmira,  N.  Y.,  a  suitable  site  and  a  thoroughly  modern 
and  well  equipped  hospital  for  tuberculosis  patients,  on 
condition  that  it  shall  be  properly  maintained  by  the  city 
at  public  expense. 

Ry  the  \\ill  of  George  M.  Lauphlin.  of  Pittsburgh,  the 
T*ittsburgh  Hospital  for  Children,  the  South  Side  Hospital, 
of  Pittsburgh,  the  Mercy  flospital,  of  Pittsburgh,  the 
Protestant  Home  for  Incurables,  of  Pittsburgh,  and  the 
Memorial  Home  for  Crippled  Oiildren,  of  Pittsburgh,  re- 
ceive $25,000  each. 

By  the  will  of  Sarah  D.  Shur  the  Methodist  Hospital  of 
Philadelphia  receives  $1,000.  the  Methodist  Orphanage  and 
the  Old  People's  Home  of  the  Methodist  Episcopal  Church 
receive  $!;oo  each. 


January  i6.  1909.  J 


PITH  OF  CURRENT  LITERATURE. 


The  Mortality  of  Chicago.— During  the  week  ending 
January  2,  1909,  there  were  reported  to  the  Department  of 
Heahh  of  the  City  of  Chicago  615  deaths  from  all  causes, 
as  compared  with  482  for  the  preceding  week,  and  665  for 
the  corresponding  period  in  1907.  The  annual  death  rate 
in  a  thousand  population  was  14.41,  as  against  a  death  rate 
of  11.59  for  the  preceding  week.  There  were  93  deaths  of 
children  under  one  year  of  age,  and  49  of  children  between 
one  and  five  years  of  age.  The  principal  causes  of  death 
were :  Apoplexy,  16  deaths ;  Bright's  disease,  66  deaths ; 
Ijronchitis,  16  deaths;  consumption.  68  deaths;  cancer,  33 
deaths;  convulsions,  3  deaths;  diphtheria,  20  deaths:  heart 
diseases,  73  deaths ;  influenza,  2  deaths ;  intestinal  diseases, 
lacute,  33  deaths ;  nervous  diseases,  18  deaths ;  pneumonia, 
80  deaths;  scarlet  fever.  12  deaths;  suicide,  6  deaths;  ty- 
phoid fever,  8  deaths :  violence,  other  than  suicide,  33 
deaths ;  whooping  cough,  i  death ;  all  other  causes,  127 
■deaths. 

The  Dr.  Andrew  J.  McCosh  Memorial. — A  meeting 
of  the  many  friends  and  patients  of  the  late  Dr.  Andrew 
J.  McCosh  was  held  recently  in  the  United  Charities  Build- 
mg  for  the  purpose  of  considering  what  steps  should  be 
taken  to  commemorate  the  valuable  service  rendered  to  the 
community  by  Dr.  .McCosh,  who  was  for  twenty-one  j'ears 
a  visiting  surgeon  to  the  Presbyterian  Hospital  in  New 
York.  Professor  H.  Fairfield  Osborn  presided.  The  con- 
sensus of  opinion  seemed  to  be  that  the  most  fitting  tribute 
to  Dr.  McCosh's  memory-  would  be  the  erection  of  a  me- 
morial building  bearing  his  name,  for  surgical  purposes,  in 
connection  with  the  institution  which  he  served  so  long. 
It  was  finally  moved  by  Dr.  \V.  Oilman  Thompson  and 
duly  seconded,  "That  those  here  present  constitute  them- 
selves a  memorial  committee  for  the  purpose  of  suitably 
commemorating  the  life  and  services  of  Dr.  McCosh.  with 
power  to  add  to  their  number ;  also  that  a  committee  of 
seven  be  appointed  by  the  chairman,  with  power  to  add  to 
its  number,  as  an  executive  committee  to  receive  such  con- 
tributions as  may  be  offered,  to  formulate  a  plan  for  an 
appropriate  memorial,  and  to  report  at  some  future  date  to 
this  committee,  which  was  unanimously  agreed  to."  Until 
such  time  as  the  ^literations  contemplated  in  the  Presby- 
terian Hospital  are  decided  upon,  the  interest  on  the  fund 
collected  is  to  be  expended  for  the  benefit  of  self  supporting 
surgical  patients,  who  cannot  afford  the  accommodations 
which  their  education  and  station  in  life  warrant,  a  class  of 
patients  generously  aided  by  Dr.  McCosh  in  his  lifetime. 
The  memorial  committee  consists  of  sixty-four  mernbers, 
and  the  names  of  many  prominent  New  York  physicians 
appear  in  the  list. 

Society  Meetings  for  the  Coming  Week: 

:\IoxDAY.  January  i8th.—^ew  York  .Academy  of  Medicine 
(Section  in 'Ophthalmolog\- )  ;  Medical  Association  of 
the  Greater  City  of  New  York  (annual)  ;  Hartford, 
Conn.,  Medical  Society. 

Tuesday.  January  igth. — New  York  Academy  of  Medicine 
(Section  in  Medicine)  ;  Buffalo  Academy  of  Medicine 
(Section  in  Pathology);  Tri-Professional  Medical  So- 
ciety of  New  York;  iSIcdical  Society  of  the  Counn'  of 
Kings.  N.  Y.  (annual )  :  Binghamton.  N.  Y.,  Academy 
of  Medicine:  Clinical  Society  of  Elizabeth,  N.  J.,  (gen- 
eral Hospital;  Syracuse.  N.  Y.,  .\cademy  of  Medicine; 
Ogdensburgh.  N!  Y.,  Medical  Association ;  Medical  So- 
ciety of  the  County  of  Westchester,  N.  Y. 

Wednesb.w,  January  20th. — New  York  Academy  of  Medi- 
cine ^(Section  in  Genitourinary  Diseases)  ;  New  York 
Society  of  Dermatolog>-  and  Genitourinary  Surgery; 
Woman's  Medical  Association  of  New  York  City  (New 
York  .Academy  of  Medicine)  :  Medicolegal  Society, 
New  York:  New  Jersev  .Academv  of  Medicine  (Jersey 
City)  ;  Buffalo  Medical  Club:  New  Haven,  Conn.,  Med- 
ical Association  (annuaH  :  New  York  Society  of  In- 
ternal Medicine:  Northwestern  Medical  and  Surgical 
Society  of  New  York. 

Thursday.  January  21st. — New  York  Academv^  of  Medi- 
cine :  German  Medical  Society.  BrookhTi :  Newark.  N. 
J.,  Medical  and  Surgical  Societv :  .Tlsculapian  Club  of 
Buffalo,  N.  Y. 

Friday.  January  22d. — .Academy  of  Pathological  Science. 
New  York  Society  of  German  Physicians:  New  York 
Clinical  Societv. 

Saturday,  January  j-^rf.— West  End  Medical  Society,  New 
York:  New  York  Medical  and  Surgical  Society;  Har- 
vard Medical  Society.  New  York;  Lenox  Medical  and 
Surgical  Society,  New  York. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

January  7,  igog. 

1.  The  Historical  Aspect  of  Professional  Relationship, 

By  Carroll  K  Edson. 

2.  Some  Aspects  of  Psychotherapy, 

By  John  Jinks  Thomas. 

3.  Acute  Intussusception.    Its  Early  Diagnosis  and  Treat- 

ment, with  a  Report  of  Four  Cases, 

By  Henry  S.  Bowen. 

4.  The  Composition  of  Small  Curds  in  Infants'  Stools, 

By  Fritz  B.  Talbot. 

5.  The  Association  Test  and  Psychoanalysis, 

By  Arthur  H.  Ring. 

2.  Some  Aspects  of  Psychotherapy. — Thomas 
speaks  in  his  paper  also  of  the  "Emmanuel  move- 
ment." He  does  not  oppose  the  broadening  of  the 
work  of  any  church,  in  this  or  in  any  other  socio- 
logical direction,  as  this  is  a  question  for  the 
churches  to  decide  according  to  their  individual 
needs  and  situations.  It  seems  to  him,  however, 
that  the  moral  bearings  which  arise  in  certain  cases 
of  functional  ner\'Ous  disease  are  better  treated  by 
the  physicians  than  by  the  clergymen,  just  as  the 
moral  bearings  of  venereal  diseases  and  the  sexual 
relations  can  be,  and  are,  better  handled  by  the 
physician,  as  they  are  being  handled  in  the  broadest 
and  best  way  by  many  conscientious  Christian 
physicians  every  day  of  their  lives.  The  introduc- 
tion of  religious  sentiment,  not  to  say  sentimental- 
ity, in  the  treatment  of  psychic  disorders  is  dis- 
tinctly harmful.  The  careful  individual  study  re- 
quired for  the  proper  selection  of  the  method  best 
adapted  to  the  cure  of  the  particular  case  precludes 
their  being  treated  and  handled  in  numbers  in 
classes.  The  real  dangers  in  this  movement,  to 
which  most  forms  of  mental  healing  sooner  or  later 
succumb,  are  of  attempting  the  cure  of  conditions 
unsuited  for  psychic  methods.  It  is  his  opinion 
that  all  methods  of  treatment  of  disease  are  with 
greater  safety  left  in  the  hands  of  medical  men  and 
that  by  cooperation  with  clergymen  in  the  future, 
as  in  the  past,  the  often  perplexing  moral  and  re- 
ligious questions  that  may  arise  in  these  curious 
functional  nervous  disorders  can  be  best  met.  This 
presupposes,  however,  that  medical  men,  at  least 
those  fitted  for  the  work,  shall  interest  and  inform 
themselves  of  methods  of  study  and  treatment  of 
such  patients,  or,  like  other  neglected  chronical 
cases,  such  as  cancer,  tabes,  and  many  others,  the 
patients  will  fall  into  the  hands  of  quacks  and  pre- 
tenders to  treat,  and  because  of  their  possibility  of 
cure  by  suggestion  and  other  psychic  means  will 
probably  prove  to  be  the  cases  which  spread  the 
fame  and  prolong  the  activity  of  this  ignorant  and 
imscrupulous  class. 

4.  The  Composition  of  Small  Curds  in  In- 
fants' Stools. — Talbot  remarks  that,  according  to 
Blauberg.  in  infants  fed  on  cows'  milk  during  the 
first  week  of  life,  fifty  per  cent,  of  the  dried  stool 
consists  of  fat.  This  percentage  decreases  as  the 
child  grows  older,  and,  according  to  Uffelman,  the 
total  fat  in  stools  of  babies  over  that  age  is  fourteen 
per  cent,  to  25.8  per  cent,  of  the  dried  stool.  Our 
author's  figures  agree  in  general  with  these  state- 
ments. His  table  shows  that  the  sum  of  fatty  acids 
and  soaps  is  seventy-five  per  cent,  or  more  of  the 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


total  fat  and  the  neutral  fat  is  twenty-five  per  cent, 
or  less.  This  also  agrees  with  Miiller's  figures  ob- 
tained in  adult  stools,  in  which  he  gave  for  an  aver- 
age, neutral  fat  24.2  per  cent.,  fatty  acids  38.8  per 
cent.,  and  soaps  thirty-seven  per  cent.  In  other 
words,  about  seventy-five  per  cent,  of  the  excreted 
fat  was  split.  The  average  percentage  of  nitro- 
gen in  dried  stools  was  3.38,  which  is  somewhat 
lower  than  the  figures  given  by  Biedert,  who  found 
in  the  stool  of  an  infant  fed  on  cows'  milk  an  aver- 
age of  4.23.  Like  casein,  the  large  curds  are  easily 
soluble  in  five  per  cent,  sodium  hydrate  and  are 
precipitated  in  a  heavy  flocculent  precipitate  by 
acetic  acid.  This  precipitate  was  washed  with  hot 
ninety-five  per  cent,  alcohol  until  the  washings  gave 
no  precipitate  with  silver  nitrate  solution.  It  was 
then  dried  to  constant  weight  and  contained  in  one 
case  14. 1  per  cent,  of  nitrogen  and  in  another  six- 
teen per  cent,  of  nitrogen  by  the  Kjeldahl  method. 
The  small  curds,  on  the  other  hand,  are  only  slight- 
ly soluble  in  five  per  cent,  sodium  hydrate,  for  on 
the  addition  of  acetic  acid  only  a  slight  cloudy  pre- 
cipitate appears,  and  the  bulk  of  the  curd  is  ap- 
parently undiminished.  Dr.  Talbot,  from  his  own 
experiments,  concludes  that  small  curds  are  com- 
posed mainly  of  fat,  mostly  in  the  form  of  fatty 
acid  and  soaps.  There  is  no  evidence  that  they 
contain  caseinlike  material,  and  they  have,  like  the 
normal  stool,  a  less  percentage  of  nitrogen.  They 
represent  the  fat  in  the  food  rather  than  protein. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

January  9,  1909. 

1.  The  General  Practitioner  and  the  Functional  Nervous 

Diseases.  "  By  Joseph  Collins. 

2.  Present  Relations  of  Psychotherapy, 

By  Robert  T.  Edes. 

3.  Sanitation   in  the   Philippine  Islands  since  American 

Occupation,  with  Particular  Reference  to  Reduction 
in  Mortality  by  Elimination  of  Intestinal  Parasites, 
Especially  Uncinaria,  By  Victor  G.  Heiser. 

4.  Cranial  Tt^chnique,  By  Fr.\nk  Hartley. 

5.  Intracranial  Complications  of  Acute  and  Chronic  Mid- 

dle Har  Suppuration.  Their  Symptomatology,  Diag- 
nosis, and  Treatment,        By  J.\mes  F.  McKernon. 

6.  Intracranial  Lesions  Consecutive  to  Nasal  and  Access- 

ory Sinus  Infections.       By  Cornelius  G.  Co.akley. 

7.  Diphtheria  Carriers.    Their  Discovery  and  Control, 

By  Myer  Solis-Cohen. 

8.  Bismuth  Paste  in  Treatment  of  Suppuratiion  of  the 

Ear,  Nose,  and  Throat,  By  Joseph  C.  Beck. 

9.  Prophylaxis    against    Infectious    Diseases    from  the 

Standpoint  of  the  Practitioner,  By  David  L.  Edsall. 
10.  The  Amount  of  Infection  and  Reasonable  Sanitary 
.Standard-,  By  .M.  J.  RosicXAr. 

6.  Intracranial  Lesions  Consecutive  to  Nasal 
and  Accessory  Sinus  Infections. — Coakley  says 
that  the  operative  technique  which  has  been  most 
satisfactory  to  him  in  exploring  the  sinuses  has  been 
what  is  known  as  the  ethmoidal  route.  He  describes 
it  thus :  Skin  incision  begins  beneath  the  eyebrow  at 
the  supraorbital  notch,  is  carried  downward  mid- 
way between  the  inner  canthus  of  the  eye  and 
the  dorsum  of  the  nose,  and  terminates  at  the  mid- 
dle portion  of  the  nasal  bone.  The  periosteum  is 
peeled  forward  and  backward,  the  capsule  of  the 
orbit  freed  from  its  attachment  to  the  inner  wall  of 
the  orbit.  With  chisel,  mallet,  and  rongeur  the 
nasal  process  of  the  superior  maxilla  is  cut  away, 
opening  at  once  into  the  anterior  group  of  ethmoid 
cells,    Ry  following  this  back  through  the  whole  of 


the  ellimoid  labyrinth  and  opening  and  enlarging 
the  sphenoid  sinus  one  traverses  and  explores  very 
thoroughly  the  region  from  which  the  majority  of 
infections  reach  the  cranial  and  orbital  cavities. 
The  operation  is  a  bloody  one  and  should  be  per- 
formed only  by  one  who  has  acquired  the  ability  to 
reriect  light  into  the  cavity  so  as  to  see  into  the 
depths  01  the  ethmoid  and  sphenoid  regions.  Bv 
this  route  one  is  working  parallel  with  the  floor  of 
the  cranium  and  is  much  less  Hkely  to  perforate  the 
fioor  than  by  the  maxillary  route,  which  is  advocated 
by  some.  This  exposure  enables  one  to  remove  the 
fioor  of  the  frontal  sinus  and  by  means  of  a  probe 
CO  explore  the  frontal  sinus,  and  in  that  way  to  de- 
termine whether  this  cavity  may  be  the  seat  of  the 
trouble.  If  this  is  found  to  be  the  case,  then  a  hori- 
zontal incision  through  the  eyebrow  with  the  eleva- 
tion of  the  periosteum  over  the  frontal  bone  and  the 
removal  of  the  entire  anterior  wall  of  the  frontal 
sinus  is  indicated.  As  many  of  these  patients  are 
desperately  ill,  it  is  exceedingly  important  that  what- 
ever operative  procedure  is  undertaken  shall  be  ter- 
minated as  quickly  as  possible.  The  shock  of  a  short 
operation  is  much  less  than  that  of  a  long  one.  It  is 
advisable  in  these  cases  not  to  attempt  to  do  the 
most  thorough  operation  that  one  does  in  chronic 
suppurative  sinusitis  without  cranial  complications, 
but  to  obliterate  all  the  cells  as  quickly  as  possible, 
introduce  iodoform  gauze  drainage  through  the 
opening,  and  leave  the  wound  open  without  any  at- 
tempt at  suture.  Should  the  patient  recover  from 
his  acute  symptoms,  secondary  suturing  may  be 
done  in  the  course  of  a  few  days  with  but  little 
more  scar  than  if  the  wound  had  been  closed  at  the 
time  of  operation. 

7.  Diphtheria  Carriers.  —  Solis-Cohen  states 
that  persons  corning  in  contact  with  a  diphtheria 
patient  frequently  have  virulent  Klebs-Lofifler  bacilli 
deposited  on  their  mucous  membranes.  Such  in- 
fected contacts  may  later  develop  diphtheria,  or,  re- 
maining healthy,  they  may  act  as  diphtheria  carriers, 
transmitting  the  bacilli  to  others,  who  thereupon 
may  develop  the  disease  or  who  may  themselves  be- 
come diphtheria  carriers.  To  prevent  their  becom- 
ing a  source  of  danger  to  others,  diphtheria  carriers 
should  be  isolated  until  bacteriologically  clean. 
Recognition  of  the  infected  contacts  must  precede 
their  control.  This  can  be  brought  about  only  by 
taking  cultures  of  the  throats  of  all  the  inmates  of  a 
house  where  diphtheria  exists.  Little  progress  need 
be  expected  in  the  prophylaxis  of  diphtheria  so  long 
as  we  neglect  the  animate  carriers  of  the  contagion. 

8.  Bismuth  Paste. — Reck  observes  that  the 
anatomical  physiological  conditions  of  the  nose,  mid- 
dle ear,  and  their  accessory  cavities  play  ah  import- 
ant part  in  the  healing  of  chronic  suppurations, 
because  they  are  noncollapsible,  lined  by  mucoids 
membrane,  and  the  mastoid  and  ethmoids  are  multi- 
cellular. In  the  majority  of  cases  of  nasal  accessory 
sinus  suppurations  some  slight  operation,  as  punc- 
ture or  middle  turbinectomy,  is  essential  to  a  cure : 
that  is,  in  order  to  enable  one  to  inject  the  sinuses 
properly.  The  middle  ear  suppuration?  respond  very 
readily  to  the  treatment  if  the  disease  process  is  con- 
fined to  the  cavity  of  the  middle  ear,  attic,  and  en- 
trance of  Highmore's  antrum,  and  if  no  necrosis  is 
present :  but  when  the  mastoid  cells  are  involved. 


January  i6,  1009.] 


P/7//  OF  CURRENT  LITERATURE. 


and  necrosis  is  present,  the  result  will  be  practically 
nil.  The  simple  mastoid  operation  for  acute  mas- 
toiditis is  markedly  simplified  and  healing  much 
shortened  by  the  filling  up  of  the  created  defect.  As 
a  dressing  in  the  radical  mastoid  it  is  the  procedure 
par  excellence  and  produces  more  rapid  epidermiza- 
tion  than  any  other  treatment.  When  a  chronic  sup- 
purative middle  ear  treated  for  some  time  by  the 
injection  of  bismuth  paste  does  not  heal  well,  this  is 
an  indication  for  operation,  either  semiradical  or 
radical.  As  a  nasal  dressing  in  turbinectomies  and 
sasptal  operations,  bismuth  paste  has  served  our  au- 
thor better  than  any  other  in  that  it  checked  the 
bleeding,  prevented  infection  and  decomposition 
and  synechial  formation,  especially  in  ethmoidal 
operations.  From  the  great  variety  of  conditions 
that  he  has  treated  and  the  large  number  of 
injections  made,  he  states  that  he  has  never  had 
any  serious  results  or  complications.  He  considers 
this  a  very  safe  procedure.  At  the  same  time  a 
thorough  knowledge  of  the  pathological  anatomy 
and  diagnosis  is  absolutely  indispensable  in  obtain- 
ing good  results.  Not  enough  time  has  elapsed 
to  say  definitely  what  the  limitation  of  the  bismuth 
paste'  treatment  is.  and  Beck  uses  it  in  any  case  of 
chronic  suppurations  of  the  nose,  throat,  and  ear, 
but  not  in  acute  conditions.  But  this  is  not  the  only 
treatment  which  will  cure  or  improve  chronic  sup- 
puration, aside  from  surgery.  Especially  are  some 
of  the  modern  modes  of  treatment,  as  vaccine  ther- 
apy, Bier's  suction  treatment,  and  irrigation  of  the 
sinuses,  of  inestimable  value.  The  author  uses  four 
pastes:  I,  Bismuth  subnitrate.  33  parts;  petrolatum, 
67  parts.  2,  Bismuth  subnitrate,  30  parts ;  petrola- 
tum, 60  parts ;  white  wax,  5  parts ;  paraffin,  5  parts. 
3,  Bismuth  subnitrate,  30  parts ;  petrolatum,  50 
parts;  paraffin,  10  parts;  white  wax,  10  parts.  4. 
Bismuth  subnitrate,  30  parts ;  petrolatum,  35  parts ; 
paraffin,  25  parts ;  white  wax,  10  parts.  The  paraffin 
and  white  wax  are  added  for  the  purpose  of  obtain- 
ing more  firm  preparations,  when  so  specially  indi- 
cated. Paste  I  is  used  principally  in  the  localities 
where  one  wishes  to  cover  rather  than  to  distend, 
and  he  has  used  it  as  a  local  treatment  in  the  nasal 
mucous  membrane  in  hypertrophic  rhinitis,  and  has 
given  it  to  the  patient  in  the  collapsible  tube.  Paste 
2  he  has  employed  universally  for  all  the  conditions 
except  in  the  filling  up  of  the  defect  of  the  simple 
mastoid  operation,  when  paste  3  is  used.  This  is 
also  employed  as  a  dressing  for  the  sseptum  and  tur- 
binated operations  and  again  as  the  primary  dress- 
ing of  the  radical  mastoid  (plastic).  Paste  4  is  used 
only  in  the  radical  frontal  sinus  operation  to  act 
like  a  plug. 

MEDICAL  RECORD 

January  g,  iQog. 

1.  Pulmonary  Enilxilism  Following  Operation. 

By  C.  L.  Gibson. 

2.  A  Case  of  Addison's  Disease,  with  Autopsy, 

By  Charles  H.  Lewis. 

3.  Congenital  Abnormalities  of  the  Penis  and  Their  In- 

fluence upon  the  Acquisition  and  Course  of  Gonor- 
rhoea, By  E.  Wood  Ruggles. 

4.  Methods  and  Results  of  Drainage  in  Twenty-two  Cases 

of  Abscess  of  the  Appendix.        By  R.  M.  Harbin. 

5.  The  Conservation  of  Hearing  in  the  Radical  Mastoid 

Operation,  By  Seymour  Oppenheimer. 

6.  ^  Medical  Educatio;i  in  Russia.  By  Leox  Louria. 


7.  The  Hasmolytic  Properties  of  Cancer  Serum, 

By  A.  S.  Blumg.\rten. 

8.  A  New  Apparatus  for  Intrathoracic  Operations  under 

Distinctive  Pressure.  A  Preliminary  Communica- 
tion, By  Willy  Meyer. 

I.  Pulmonary  Embolism  Following  Operation. 

— Gibson  states  that  since  1899  there  occurred  in 
St.  Luke's  Hospital  fifteen  cases  of  sudden  death 
following  operation  which  have  been  attributed  to 
pulmonary  embolism.  Such  autopsies  as  have  been 
performed  have  verified  the  condition.  He  calls 
special  attention  to  three  main  factors:  i,  The  age 
of  the  patients — young  individuals  are  more  or  less 
exempt,  and  if  aflFected  may  perhaps  recover  pre- 
sumably on  account  of  the  yielding  elasticity  of 
their  vessels,  which  may  allow  the  blood  to  push  its 
way  beside  a  clot.  The  age  from  forty  to  sixty  be- 
ing most  afflicted,  we  are  probably  dealing  with 
conditions  of  vascular  changes  over  which  the  oper- 
ator has  little  or  no  control.  He  should,  however, 
be  more  on  the  alert  to  recognize  or  anticipate  such 
changes,  and  their  existence  should  be  considered 
in  operations  which  are  a  matter  of  expediency 
rather  than  actual  necessity.  2,  Practically  all  those 
cases  of  embolism  follow  interventions  below  the 
diaphragm  and  even  lower  "below  the  belt."  There- 
fore we  must  study  the  local  conditions  more  close- 
ly for  further  light.  3,  At  the  present  time  there 
is  little  or  no  justification  in  rushing  patients  out 
of  bed  as  a  routine  measure,  it  being  granted  that 
in  individual  cases  and  conditions  a  preexistent  or 
suspected  tendency  to  stagnation  or  coagulation 
should  be  counteracted  by  this  and  other  measures. 

4.  Methods  and  Results  of  Drainage  in  Twenty- 
two  Cases  of  Abscess  of  the  Appendix. — Harbin 
states  that  having  opened  the  peritonaeum  and  in- 
troduced a  protective  gauze  packing,  the  finger 
should  follow  the  abdominal  wall  until  the  in- 
durated mass  is  reached,  and  then  with  the  finger 
a  process  of  blunt  dissection  should  be  begun,  hug- 
ging the  posterior  wall  of  the  abdomen  until  the 
abscess  is  reached.  If  the  abscess  is  larger,  the  pa- 
tient should  be  turned  on  the  right  side,  and  the 
exit  enlarged.  The  wound  having  been  mopped 
out,  a  careful  search  should  be  made  for  concre- 
tions, remains  of  the  appendix,  etc.  A  piece  of 
plain  gauze,  one  and  a  half  to  four  inches  wide, 
with  a  double  layer,  should  be  carried  with  the 
finger  to  the  bottom  of  the  cavity,  li  the  surgeon 
has  any  respect  for  the  olfactor}^  sense,  iodoform 
gauze  will  not  be  used,  for  appendical  pus  and  iodo- 
form add  a  reciprocal  intensity  to  the  stench.  Per- 
haps the  most  unsurgical  custom  prevails  in  allow- 
ing a  soppy  piece  of  gauze  to  remain  in  a  wound 
for  a  period  of  several  weeks,  making  the  most  of- 
fensive condition  ever  seen  in  surgery.  The  outer 
wound  should  be  mopped  and  cleaned  with  hydro- 
gen peroxide,  as  needed.  There  can  be  but  little 
danger  of  spreading  infection  by  changing  the 
packing  after  the  third  day,  where  the  direction  of 
the  sinus  is  well  known,  and  drainage  is  facilitated. 
Rarely  there  may  be  circuitous  tracts  to  drain,  when 
it  is  better  to  leave  the  packing,  and,  as  a  rule,  in 
children  it  is  better  to  leave  the  gauze  undisturbed. 
After  the  first  dressing,  the  removal  of  gauze  need 
not  be  specially  painful,  and  it  should  be  changed 
every  two  or  three  days.  Changing  the  gauze  fur- 
nishes a  sort  of  mopping   for  the  wound.  The 


134 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal, 


debris  of  a  sloughing  appendix,  etc.,  cannot  escape 
where  the  packing  is  not  changed  until  a  process 
of  fermentation  reduces  such  material  to  a  liquid 
state.  In  conclusion  the  author  remarks  that  sta- 
tistics of  recoveries  from  drainage  of  cases  of  dif- 
fuse peritonitis  are  of  no  value  unless  the  date  of 
the  perforation  is  known.  In  the  absence  of  proper 
facilities,  it  is  better  to  adopt  the  Ochsner  pro- 
cedure and  the  F"owler  position,  pending  consulta- 
tion. The  doubtful  propriety  of  waiting  for  the 
walling  of¥  process  may  merge  a  certain  number  of 
cases  into  a  diffuse  form  of  peritonitis.  Deferred 
operations,  under  favorable  conditions,  give  the  pa- 
tient time  to  undergo  a  sort  of  autoinoculation  with 
bacterial  vaccines.  The  uncertain  course  of  peri- 
tonitis argues  for  immediate  operation.  Infections 
low  in  the  right  iliac  fossa  can  safely  be  trusted  to 
Nature.  Short  incisions  and  few  manipulations 
should  be  the  rule.  As  a  rule,  it  is  unsurgical  to 
leave  the  same  gauze  in  the  wound  over  four  or 
five  days.  The  right  lateral  and  ventral  positions 
are  of  great  value  in  supplementing  other  methods 
of  drainage.  Drainage  in  diffuse  peritonitis  should 
not  only  give  exit  to  pus,  but  should  provoke  a  re- 
verse current  of  serum  from  the  wound.  Intermit- 
tent injection  of  normal  salt  solution  seemed  to  gain 
a  greater  amount  of  absorption  in  the  rectum  than 
the  instillation  method. 

5.  The  Conservation  of  Hearing  in  the  Rad- 
ical Mastoid  Operation. — Oppenheimer  says  that 
a  distinct  factor  in  the  preservation  of  the  hearing 
is  the  adoption  of  early  operation  in  those  cases 
where  topical  measures  used  for  a  reasonable  period 
of  time  prove  of  no  value.  That  this  is  so  is  made 
evident  by  the  operative  procedure  anticipating  the 
further  destruction  of  tissue  and  thus  conserving 
the  hearing  to  that  degree,  while  at  the  same  time 
certain  important  structures  may  be  saved  that 
would  tmdoubtedly  later  become  involved  in  the 
morbid  process  and  be  in  greater  or  lesser  part  de- 
stroyed. The  more  perfected  the  technique  of  the 
mastoid  operation,  the  more  will  the  hearing  be  con- 
served, other  things  being  equal ;  and  the  greater  the 
experience  of  the  operator,  the  greater  will  be  the 
care  exercised  both  in  the  selection  of  cases  and  in 
the  discrimination  of  tissue  to  be  saved  during  the 
course  of  the  operative  procedures.  While  the  an- 
trum is  the  most  important  point  as  regards  the 
focus  of  the  pathological  changes,  the  tympanic  cav- 
ity proper,  with  its  contents,  is  the  prominent  factor 
concerned  with  audition  so  far  as  operative  pro- 
cedures are  concerned,  and  it  is  essential,  so  far  as 
is  consistent  with  the  morbid  conditions  present  in 
the  individual  case,  that  all  parts  concerned  in  the 
conduction  of  sound  waves  be  interfered  with  as 
Httle  as  possible.  Should  the  usual  hearing  tests 
show  that  the  ossicles,  whether  partially  removed 
or  remaining  in  their  entirety,  are  of  some  value  in 
the  conduction  of  sound  previous  to  operation,  much 
will  be  gained  by  their  retention,  and  even  if  super- 
ficial necrosis  here  exists  in  part,  it  will  be  found 
that  after  the  original  source  of  the  pus  supply  has 
been  removed,  healing  will  take  place  and  this  tissue 
can  thus  be  ultimately  saved,  instead  of  being  use- 
lessly sacrificed  in  every  case  that  is  operated  upon. 
As  far  as  the  membrana  tympani  is  concerned,  it 


is  unnecessary  to  remove  it  in  its  entirety  in  many- 
cases,  and  if  adhesions  are  freed,  should  such  be 
present,  a  small  perforation  is  enlarged  for  free 
drainage,  or  if  necessary,  and  this  is  not  infrequently^ 
so,  a  large  incision  is  made  in  other  portions,  so  that 
drainage  can  be  readily,  carried  out. 

BRITISH  MEDICAL  JOURNAL. 

December  19,  igo8. 

1.  Mitral  Stenosis,  By  Sir  J.  Barr.. 

2.  The  Occurrence  of  Heartblock  in  Man  and  Its  Causa- 

tion, By  T.  Lewis. 

3.  Retardation  of  the  Pulse  Wave  in  Aortic  Regurgita- 

tion, By  W.  Broadbext^ 

4.  Three  Demonstrations  of  Malformations  of  the  Hind 

End  of  the  Body,  By  A.  Keith. 

I,  Mitral  Stenosis. — Barr  tells  us  that  the  char- 
acteristic murmur  of  mitral  stenosis  was  first  clearly 
recognized  by  Fauvel,  but  that  it  was  Gairdner  who- 
first  clearly  depicted  the  clinical  signs  of  the  dis- 
ease and  their  pathological  importance.    It  should 
be  clearly  understood  that  the  disease  is  easily  diag- 
nosticated apart  from  any  murmur,  but  such  diag- 
nosis is  very  imperfect  unless  it  takes  into  account  the 
extent  of  the  lesion  and  its  effects.   Of  all  the  causes- 
or  exciting  conditions  of  endocarditis  and  pericar- 
ditis, rheumatism  holds  the  first  place.    The  fibrous- 
tissue  appears  to  be  specially  vulnerable  to  the  rheu- 
matic poison,  but  the  myocardium  as  well  as  the 
whole  endocardium  and  pericardium  may  be  in- 
volved in  the  inflammatory  process.    The  valvular 
lesion  is  determined  by  the  violent  collision  of  the 
vulnerable  valves.    In  mitral  stenosis  the  systole  of 
the  ventricle  is  slow  and  labored  to  overcome  the 
high  intracardiac  pressure  which  is  set  up  by  in- 
creased peripheral  resistance.    As  compared  with 
the  temperature  the  pulse  in  these  cases  is  not  very 
frequent  and  may  not  exceed  90  even  with  a  tem- 
perature of  103°  F.    The  pulse  is  slow,  full,  and 
moderately  strong,  and  the  tension  is  well  main- 
tained.   The  blood  pressure  is  much  higher  than  it 
is   in  pneumonia,   diphtheria,   or   typhoid  fever. 
Among  the  earliest  signs  of  acute  mitral  endocar- 
ditis are  a  dull  first  sound  and  a  delayed  radial 
pulse,  so  that  the  former  can  be  heard  in  an  appre- 
ciable interval  before  the  latter  can  be  felt.  By  careful 
attention  to  these  signs  endocarditis  can  usually  be 
diagnosticated  some  days  before  any  murmur  can  be 
heard.   The  much  more  frequent  occurrence  of  val- 
vular disease  in  the  left  heart  than  in  the  right  is 
due  to  the  much  greater  strain  and  more  violent 
collision  to  which  the  valves  are  subjected.  Chil- 
dren are  very  liable  to  rheumatism,  but  the  joint  af- 
fection may  be  so  slight  as  to  escape  notice,  and  in 
many  cases  endocarditis  is  the  only  gross  expres- 
sion of  the  rheumatic  afl^ection.    Alitral  stenosis  is 
frequently  associated  with  chorea,  and  here  the  me- 
chanical determination  of  the  disease  is  very  appar- 
ent.   It  may  arise  in  cases  of  protracted  anaemia 
associated  with  high  blood  pressure  and  frequent 
emotional  excitement,  but  it  does  not  arise  in  cases 
of  exophthalmic  goitre  in  spite  of  the  violent  palpi- 
tation, because  the  blood  pressure  is  low  and  the 
lime  salts,  which  are  another  determining  factor,  are 
deficient.    It  is  more  common  in  females  than  in 
males  for  the  simple  reason  that  rheumatism  and 
chorea  occur  more  frequently  in  girls  than  in  boys, 
and  anaemia  and  all  emotional  disturbances  have'  a 


January  ;6,  1909.] 


PiTH  OF  CURRENT  LITERATURE. 


135 


special  predilection  for  the  female  sex.    But  men 
are  much  more  liable  to  the  disease  than  is  gener- 
ally supposed.    Mitral  stenosis  is  frequently  asso- 
ciated with  pericardial  adhesions,  due  to  the  fact 
that  pericarditis  is  almost  as  common  as  endocar- 
ditis in  children.    The  disease  is,  as  a  rule,  slowly 
progressive,  and  although  sooner  or  later  it  leads  to 
the  death  of  the  individual,  yet  under  proper  care 
and  treatment  it  is  very  slow  in  its  progress,  and  is 
quite  compatible  with  a  fairly  long  existence.  In 
the  evolution  of  mitral  stenosis  any  excess  of  cal- 
cium ions  in  the  blood  plays  a  very  important  part. 
So  called  "good  healing  flesh"  simply  means  that 
there  is  an  excess  of  calcium  cement  in  the  blood 
and  tissues.    Under  certain  circumstances  this  may 
be  very  beneficial,  but  whenever  there  is  any  ten- 
dency to  sclerotic  changes  in  the  body,  nature's  at- 
tempts at  repair  are  apt  to  be  far  in  excess  of  the 
requirem.ents.    In  the  case  of  mitral  stenosis  these 
excessive  calcium  ions  may  be  the  determining  fac- 
tors in  the  production  of  the  disease.    They  raise 
the  blood  pressure,  increase  the  force  of  the  cardiac 
contraction,  give  rise  to  hypertrophy  of  the  papillary 
muscles,  cause  violent  collision  of  the  mitral  cusps, 
increase  the  formation  of  the  fibroid  tissue,  and 
gradually  cement  and  unite  the  edges  of  the  cusps 
together'    Of  all  the  signs  of  mitral  stenosis  the 
murmur  is  the  most  obtrusive  and  therefore  has  re- 
ceived undue  attention  to  the  neglect  of  other  more 
constant  and  more  important  signs.    The  opinion  is 
now  unanimous  that  the  murmur  occurs  prior  to 
the  systole  of  the  ventricle.    "Auricular  systolic"  is 
a  happy  term  in  that  it  implies  a  theory  as  to  causa- 
tion as  well  as  rhythm.    When  the  muscular  con- 
traction of  the  auricle  is  so  weak  as  to  be  incapable 
of  giving  rise  to  a  murmur  through  the  narrow  or 
roughened  orifice,  it  is  not  an  imaginary  recoil  which 
can  do  so.    Under  these  circumstances  there  is  no 
murmur,  or  it  occurs  at  an  earlier  period  owing  to 
the  suction  action  of  the  ventricle.    A  rough,  rasp- 
ing, low  pitched  mtirmur  immediately  preceding  the 
first  sound  must  be  due  to  the  contraction  of  the 
auricle  or  of  the  auricular  appendix,  and  is  there- 
fore auricular  systolic.    At  an  early  stage  of  mitral 
stenosis,  when  it  is  still  possible  to  modify  if  not  to 
arrest  the  further  course  of  the  disease,  the  charac- 
teristic murmur  is  usually  absent,  or  there  may  be 
only  a  mitral  systolic  murmur.    Again  the  murmur 
may  be  absent  in  the  very  late  stage,  when  much 
can  be  done  for  the  comfort  of  the  patient,  and 
when  it  is  most  important  to  distinguish  between  mi- 
tral stenosis  and  mitral  incompetence.    A  very  im- 
portant sign  of  mitral  stenosis  is  extension  of  the 
cardiac  dulness  in  the  direction  of  the  left  auricle. 
The  pulmonic  second  sound  is  accentuated.  The 
intensity  of  this  sound  at  the  pulmonic  cartilage 
largely  depends  on  the  amount  of  lung  intervening 
between  the  artery  and  the  chest  w'alls.  Frequently 
the  sound  is  better  heard  over  the  conus  arteriosus 
or  right  ventricle.    In  a  few  cases  there  is  a  short, 
soft,  blowing,  diastolic  murm.ur  in  the  pulmonic  area, 
due  to  slight  regurgitation  through  the  pulmonic 
orifice.    Doubling  of  the  second  sound  of  the  heart 
is  a  very  common  event  in  mitral  stenosis ;  it  is  not 
pathognomonic,  but  merely  an  exaggerated  expres- 
sion of  a  normal  doubling  which  can  be  heard  in 


almost  every  normal  heart  at  the  end  of  inspiration 
or  at  the  commencement  of  expiration.  The  second 
element  of  the  double  sound  is  invariably  pulmonic, 
and  the  duplication  undoubtedly  arises  from  asyn- 
chronous closure  of  the  aortic  and  pulmonic  semi- 
lunar valves.  A  double  first  sound  is  a  common 
event  in  mitral  stenosis,  notwithstanding  the  fact 
that  it  is  not  mentioned  in  any  of  the  textbooks. 
The  pulse  is  very  variable,  according  to  the  state  of 
compensation  of  the  heart.  The  lungs,  as  a  result 
of  the  chronic  overloading  with  heightened  pressure 
in  the  pulmonary  circulation,  show  the  condition 
known  as  brown  induration,  with  bronchial  catarrh, 
and  not  infrequently  haemoptysis.  Areas  of  col- 
lapse of  pulmonic  lobules  can  also  be  made  out.  The 
liver  is  passively  congested  and  enlarged,  but  not 
the  spleen.  \"isible  pulsation  in  the  veins  of  the 
neck  is  common,  and  may  be  either  auricular  or 
ventricular  in  rhythm,  or  both.  Dropsy  does  not 
occur  until  there  is  failure  of  the  right  heart,  and 
unlike  that  in  mitral  regurgitation,  it  frequently  be- 
gins as  ascites. 

LANCET. 

December  ig,  190S. 

1.  The  Treatment  of  \\'ounds  (Bradshaw  Lecture), 

By  Sir  W.  W.  Cheyxe. 

2.  Further  Observations  on  the  Treatment  of  Gout  by 

Thyminic  Acid,  By  R.  Fenner. 

3.  Otosclerosis :  Some  Points  in  Its  .'Etiology,  Diagnosis, 

and  Treatment,  By  A.  R.  Tweedie. 

4.  The  Mercurial  Reaction  as  an  Element  of  Diagnosis  in 

Syphilis,  By  F.  Curioni. 

5.  A  Case  of  Ruptured  Small  Intestine;  Operation;  Sub- 

sequent Transpleural  Drainage  of  Two  Subdia- 
phragmatic Abscesses;  Recovery, 

By  L.  E.  C.  NoRBURY. 

6.  A  Method  of  Performing  Abdominoperineal  Excision 

for  Carcinoma  of  the  Rectum  and  of  the  Terminal 
Portion  of  the  Pelvic  Colon,  By  W.  E.  Miles. 

7.  A  Note  on  the  Treatment  in  a  Case  of  Arthritis  De- 

formans, By  F.  Booth. 

8.  Streptococcse  (''Septic")  Throats,        By  J.  O.  Hollic. 

I.  Treatment  of  Wounds. — Cheyne  sums  up 
his  criticisms  on  the  most  recent  ideas  on  the  treat- 
ment of  wounds,  in  the  statement  that  the  pendulum 
has  swung  too  far  in  the  direction  of  avoidance  of 
antiseptics,  and  that  the  reasonable  use  of  all  the 
means  at 'our  disposal  for  securing  asepticity  of 
Wounds  will  furnish  more  constant  results.  The 
chief  point  to  which  he  takes  exception  is  the  em- 
ployment of  dressings  which  do  not  contain  an  an- 
tiseptic in  sufficient  amount  to  render  the  discharges 
which  flow  through  them  imsuitable  for  the  growth 
of  bacteria.  A  second  very  important  point  is  the 
absence  of  antiseptic  solutions  during  the  operation 
in  which  hands,  instruments,  etc..  may  be  washed 
from  time  to  time  to  ensure  a  continued  asepsis.  A 
retrograde  step  is  the  substitution  of  gauze  plugs 
for  drainage  tubes,  more  especially  for  the  drainage 
of  abscesses  and  sinuses.  Minor  points  are  the  use 
of  swabs  instead  of  marine  sponges,  and  the  avoid- 
ance of  catgut.  This  extreme  view  has,  however, 
done  good,  especially  in  the  way  of  directing  atten- 
tion to  the  value  of  heat  as  a  disinfectant  for  various 
purposes  in  connection  with  operations.  There  is 
no  doubt  that  the  sterilization  of  instruments,  towels, 
etc.,  by  boiling,  and  of  dressings  by  a  current  of 
superheated  steam,  adds  very  distinctly  to  the  cer- 
tainty of  the  results.   It  has  also  done  good  by  call- 


136 


PITH  OF  CURRENT  LITERATURE. 


INew  York 
Medical  Journal. 


ing  attention  to  the  importance  of  diminishing  the 
amount  of  dust  which  may  get  into  wounds  at  the 
tim.e  of  the  operation,  although  some  of  these  pre- 
cautions have  been  given  an  importance  which  they 
do  not  deserve.  The  attempt  to  treat  wounds  without 
anv  antiseptics  is  a  very  unnecessary  complication. 
It  had  its  origin  largely  in  the  excessive  use  of  anti- 
septics by  overenthusiastic  Listerians,  who  neglect- 
ed the  second  tenet  of  their  master — avoidance  of 
irritation  of  the  surface  of  the  wound  so  as  not  to 
interfere  with  healing,  nor  with  the  power  of  the 
tissues  in  preventing  the  growth  of  any  bacteria 
which  may  have  entered.  Other  factors  have  been : 
The  slow  action  of  antiseptics  in  destroying  spores ; 
the  difficulty  of  disinfecting  the  skin;  and,  finally, 
an  exaggerated  belief  in  the  resisting  power  of  the 
body  towards  bacteria.  A  surgeon  who  does  not 
have  to  constantly  consider  every  possible  loophole 
by  which  bacteria  can  enter  the  field  of  operation, 
and  can  concentrate  all  his  thoughts  upon  the  opera- 
tion itself,  can  obtain  better  results  than  the  man 
who  has  to  think  along  both  lines  at  the  same  time. 

2.  Gout  and  Thyminic  Acid. — Fenner  states 
that  the  use  of  thyminic  acid  for  the  elimination  of 
uric  acid  (as  in  gout)  has  its  support  on  a  solid 
scientific  basis.  The  synthetic  manufacture  of  thy- 
minic acid  is  now  an  accomplished  fact,  and  the 
writer  has  obtained  most  excellent  results  by  its  use 
in  cases  of  gout.  By  the  oxidation  of  the  purin 
bodies  thyminic  acid  is  produced  as  well  as  uric 
acid,  and  these  two  substances  form  a  combination 
in  which  the  uric  acid  loses  its  identity  and  can  no 
longer  be  precipitated.  It  is  as  a  constituent  of  this 
compound  that  uric  acid  circulates  in  normal  blood. 
In  gout  the  amount  of  uric  acid  in  the  blood  may 
not  exceed  the  normal,  the  trouble  being  that  its 
combination  with  thyminic  acid  has  not  taken  place 
or  has  become  unstable.  If  thyminic  acid  can  be 
introduced  into  the  blood  by  ingestion  or  other 
method  in  sufficient  quantities  to  retain  the  free 
uric  acid  in  circulation,  the  method  of  rendering  the 
latter  soluble  is  found.  Turning  to  the  clinical  re- 
sults of  the  treatment  of  the  gouty  state  by  thymin- 
ic acid,  the  writer  is  convinced  that  we;  possess  a 
very  valuable  and  powerful  agent,  especially  in  the 
l^revention  of  recurrent  attacks  of  acute  gout  and  in 
the  cure  or  amelioration  of  the  more  chronic  forms, 
and  of  the  many  ailments  that  are  marked  by  the 
excessive  formation  of  uric  acid  within  the  system. 
It  is  in  the  prevention  of  attacks  of  acute  gout,  in 
the  obesitv  so  often  allied  with  the  gouty  state,  in 
gouty  eczema,  a.sthma,  glycosuria,  and  stomachic 
derangements  that  thyminic  acid  attains  its  maxi- 
mum of  usefulness.  A  small  dose  (four  grains) 
taken  daily  after  meals  for  a  prolonged  period,  say 
of  three  months,  and  then  every  alternate  week,  will 
in  most  cases  entirelv  avert  the  onset  of  acute  symp- 
toms. When  an  acute  attack  of  arthritic  gout  is 
actually  in  evidence,  thyminic  acid  is  not  invariably 
successful,  and  the  author  prescribes  mercurials 
with  colchicum,  or  colchicine  with  asperin ;  then  as 
the  symptoms  abate  large  doses  of  thyminic  acid  arc 
given  in  conjunction  with  local  treatment  by  the  x 
ray  light  bath,  and  the  pain  and  swelling  quickly 
';ul)sidc.  It  is  a  decided  proof  of  the  efficacy  of  the 
drug  that  it  renders  inert  any  excess  of  uric  acid, 
which  in  some  peculiar  way  alcohol  in  any  form 
often  produces. 


LA  PRESSE  MEDICALE. 
November  21,  1908. 

1.  Direct  Inguinal  Hernia,  By  Emile  Forgue. 

2.  Contribution  to  the  Study  of  Mixed  Tumors  of  the 

Lids.     The  Pure  "Conjunctivoma," 

By  Maurice  Letulle. 
3    Secondary  Canceroiis  Septichaemia, 

By  Le  Noir  and  Courcoux. 

2.  The  Pure  "Conjunctivoma." — Letulle  asserts 
that  among  the  congenital  tumors  of  the  eyelids 
there  exists  a  variety  that  is  very  rare,  if  we  may 
judge  from  the  silence  of  authors  on  the  subject, 
which  he  denominates  an  "embryonal  conjunctivo- 
ma." The  clear  cells  of  which  it  is  composed  may 
undergo  liquefaction  in  the  centre  of  the  mass  and 
give  place  to  the  formation  of  a  seroalbuminous 
cyst  which  can  be  distinguished  from  the  congenital 
mucous  cysts  of  the  lid.  The  prognosis  of  a  "pure 
conjunctivoma"  is  good;  it  does  not  recur  after  ex- 
tirpation. 

November  25.  jgoS. 
Hereditary  Sudden  Death, 

By  A.  Gilbert  and  A.  Baudouin. 
Hereditary  Sudden  Death.— Gilbert  and  Bau- 
douin seek  to  explain  certain  facts  met  with  in  sud- 
den death  on  the  basis  of  heredity.  They  are  unable 
to  suggest  anything  in  the  way  of  treatment  or  pre- 
vention. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT 

November  24,  igoS. 

1.  Surgery  of  the  Lungs,  By  Friedrich. 

2.  The  Theory  and  Practice  of  Treatment  by  Difiference 

of  Pressure,  By  Brat  and  Schmieden. 

3.  Tuberculin  Treatment  in  Practice, 

By  John  and  Volhard. 

4.  The  Diagnosis  of  Irregularities  of  the  Heart  without 

Consideration  of  Curves,  By  Hering. 

5.  Limitation  of  Aseptic  Precautions  in  Obstetrics. 

By  Kronig. 

6.  Dysmenorrhoea,  By  Veit. 

7.  Lumbar  Anaesthesia  and  Slumbering,         By  Klein. 

8.  A  Decrease  of  the  Ability  to  Nurse  on  the  Part  of 

Our  Women  does  Not  Exist  on  Anatomical  Grounds, 

By  Walcher. 

9.  The  Demonstration  of  Typhobacilii  in  Gastric  Con- 

tents Containing  Bile,  By  Weber. 

10.  The  Operative  Treatment  of  Purulent  Meningitis  with 

Purulent  Inflammation  of  the  Labyrinth, 

By  WiTTMAACK. 

11.  Parabiosis  of  Mammals  o£  Different  Sexes, 

„,   ,   .  By  Morpurgo. 

12.  lechnique  of  the  Secondary  Tendon  Suture, 

By  Kolliker. 

13-    Ihe  Pyrenol  Question,  from    ai.    Entirely  Different 
c.^'.'^?,'.  .    T  r  Straub. 

14.  Syphilitic  Infection  of  Physicians,       By  Heermann. 

15.  From  the  Island  of  Jamaica,  By  Beck. 

3.  Tuberculin  Treatment  in  Practice. — lohn 
and  Volhard  speak  highly  of  the  results  thev  have 
obtained  from  this  form  of  treatment.  They  use  six 
solutions  of  different  strength,  a  varying  dose  of 
each  of  which  is  injected  at  intervals  of  from  one  to 
seven  days,  according  to  the  demands  of  the  indi- 
vidual patient.  The  technique  of  the  administration 
of  the  remedy  is  given  in  detail.  Physical  and  die- 
tetic measures  must  not  be  neglected. 

4.  Diagnosis  of  Irregularities  of  the  Heart. — 
ITering  argues  that  it  is  not  difficult  for  the  practi- 
tioner to  recognize  the  five  types  of  cardiac  irregu- 
larities, pulsus  irregularis  re'spiratorius,  pulsus  ex- 
trasystollicus,  pulsus  irregularis  perpetuus,  pulsus 
iran.smissorius,  and  pulsus  alternans,  without  re- 
course to  instruments  for  diagnostic  purposes. 

,  5.  Limitation  of  Aseptic  Precautions  in  Ob- 
stetrics.— Kninig  objects  to  complicated  meas- 


January  i6,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


'37 


ures  for  maintaining  asepsis  in  obstetrics,  and  thinks 
that  better  results  will  be  obtained  by  a  return  to 
the  observation  of  the  simplest  precautions  only. 

6.  Dysmenorrhoea. — Veit  insists  that  we  must 
recognize  the  fact  that  there  is  a  nervous  form  of 
dvsmenorrhoea  which  should  be  treated  not  locally 
through  the  genitals,  but  with  general  antinervous 
regulation,  or  by  local  treatment  of  the  nose. 

7.  Lumbar  Anaesthetic  and  Slumbering. — Klein 
repeats  what  he  has  said  before,  that  lumbar  anaes- 
thesia is  neither  easy  nor  without  danger,  and  that 
it  is  indicated  in  those  cases  in  which  inhalation 
narcosis  is  contraindicated.  He  then  passes  to  the 
technique  and  dangers  of  lumbar  anaesthesia,  and 
the  indications  for  the  same.  Then  he  speaks  of 
scopolamine  in  slumbering  and  pronounces  this  drug 
unreliable,  many  times  failing  to  produce  sleep,  at 
other  times  half  numbing  the  patient,  and  in  still 
other  cases  causing  the  patient  to  sleep  with  loud 
snoring.  Then  he  considers  the  indications  for  this 
slumbering  alone,  of  lumbar  anaesthesia  alone,  of 
these  two  combined,  of  these  two  combined  with  in- 
halation narcosis,  and  of  slumbering  and  inhalation 
narcosis. 

10.  Operative  Treatment  of  Purulent  Menin- 
gitis with  Purulent  Inflammation  of  the  Laby- 
rinth.— Wittmaack  reports  two  cases  successfully 
treated  for  purulent  meningitis  by  a  radical  opera- 
tion on  the  labyrinth  of  the  ear.  He  finds  that  the 
point  of  difficulty  in  the  treatment  of  purulent  men- 
ingitis of  otogenous  origin  is  in  the  early  diagnosis, 
which  may  be  made  by  lumbar  puncture,  and  in  the 
performance  of-the  operation  at  the  earliest  possible 
moment. 

11.  Parabiosis  of  Mammals  of  Different  Sexes. 

— ]Morpurgo  has  succeeded  in  obtaining  permanent 
organic  union  between  two  rats  of  different  sexes 
which  have  developed  normally  for  over  three 
months. 

14.  Syphilitic  Infection  of  Physicians. — Heer- 
mann  urges  that  every  wound  on  the  finger  of  a 
physician  or  nurse  which  does  not  heal  readily  should 
be  suspected  of  a  syphilitic  infection  until  proof  to 
the  contrary  is  obtained.  If  this  rule  is  observed  in- 
fection of  the  wufe  and  children  can  easily  be  pre- 
vented. 

AMERICAN  JOURNAL  OF  SURGERY. 
January,  igog. 

1.  Acute  Dilatation  of  the  Stomach, 

i3y  Cl.\rence  D.  Selby. 

2.  Catarrhal  Dea{ness  and  Its  Treatment,  By  A.  C.  Geyser. 

3.  The  Diagnostic  Indications  of  Uterine  Bleeding, 

By  S.  S.  Gr.\ber. 

4.  Placenta  Prsevia  Centralis,  By  Harold  A.  Mh-ler. 

5.  The  Correction  of  External  Nasal  Deformities ;  Report 

of  Case,  By  John  C.  Lester. 

6.  Report  of  a  Case  of  Pulmonary  Embolism  Following 

Injection  of  Salicylate  of  Mercury  in  Aboline, 

By  Eugene  H.  Eising. 

7.  Acute  Perforating  Gastric  and  Duodenal  Ulcer  {Con- 

cluded), By  Ellsworth  Eliot,  Jr. 

I.  Acute  Dilatation  of  the  Stomach. — Selby 
states  that  many  cases  of  acute  gastric  dilatation, 
when  closely  inquired  into,  will  be  found  to  origi- 
nate in  splanchnic  stimulation,  superimposed  upon 
some  chronic  malady  of  the  stomach  and  aided  by 
the  presence  of  some  fermentative,  irritant,  or 
hypertonic  solution  in  the  stomach.  He  had  ob- 
served six  cases  of  acute  dilatation  of  the  stomach. 


of  which  five  patients  recovered.  All  but  one  were 
gynaecological  in  character  of  the  operation,  and 
without  exception  gave  a  history  of  previous  stom- 
ach trouble;  and  in  one  a  chronically  dilated  stom- 
ach was  observed  during  the  operation.  This  last 
was  the  first  case  seen,  and  it  was  the  observation 
relative  to  the  stomach  that  led  to  the  diagnosis  of 
acute  dilatation  when  the  alarming  symptoms  arose 
and  suggested  the  proper  lines  of  treatment.  For 
such  reasons  he  is  inclined  to  lay  stress  upon  the 
predisposition  of  the  stomach.  So  far  as  inhibition 
of  the  alimentary  motility  is  concerned,  every  one 
knows  how  easy  it  is  to  accomplish.  In  fact,  so 
common  is  it  after  operation  that  it  has  grown  to 
be  an  accepted  fact,  and  we  administer  our  cathar- 
tics to  counteract  its  effects.  He  therefore  sug- 
gests that  it  is  frequently  of  importance  to  the 
aetiology  of  acute  gastric  dilatation — not  alone  suf- 
ficie;it,  but  working  in  conjunction  with  other  im- 
portant causes.  He  also  believes  there  must  be,  or 
usually  is,  something  within  the  stomach  that  en- 
hances the  process  through  fermentation,  irritation, 
or  osmosis. 

4.  Placenta  Prsevia  Centralis. — Miller  observes 
that  the  operation  of  vaginal  ligation  of  the  uterine 
artery  and  its  branches  may  be  considered  as  a  sim- 
ple operation,  devoid  of  danger,  and  may  be  done 
without  anaesthesia,  by  any  one  who  is  familiar 
with  the  anatomical  and  the  surgical  technique  of 
the  parts  involved.  The  operation  does  not  re- 
move nor  permanently  injure  any  of  the  essential 
organs  of  generation,  and  therefore  does  not  in  any 
manner  decrease  the  possibility  of  future  child 
bearing,  nor  increase  the  hazard  if  conception 
should  take  place.  The  tying  of  the  uterine  artery 
immediately  and  absolutely  control  all  ante  partum 
haemorrhages  by  cutting  off  the  blood  supply  to  the 
placenta.  The  single  exception  is  the  rare  haemor- 
rhage during  delivery  caused  by  injury  to  the  foetal 
vessels.  Collateral  circulation  will  not  be  estab- 
lished until  sufficient  time  has  elapsed  to  success- 
fully combat  a  moderately  severe  degree  of  anaemia 
before  proceeding  to  deliver.  It  permits  of  leisure- 
ly dilating  the  os  either  bimanually  or  by  means  of 
one  of  the  many  forms  of  the  instrumental  dilators. 
The  foetus  may  be  delivered  either  by  version  or 
the  head  may  be  delivered  first  by  the  application 
of  forceps.  The  operation  will  become  a  routine 
practice  of  great  value  in  all  bleeding  from  placenta 
praevia  prior  to  any  attempt  at  delivery.  The  liga- 
tion of  the  uterine  artery  will  absolutely  control 
post  partum  haemorrhage  from  the  placental  site  and 
with  careful  attention  to  the  proper  method  of  de- 
liver}- post  partum  haemorrhage  in  cases  of  placenta 
praevia  from  other  sources  are  rare.  It  will  slight- 
ly increase  the  foetal  mortality  on  account  of  the 
early  shutting  off  of  the  placental  circulation. 

AMERICAN  JOURNAL  OF  OBSTETRICS. 

January,  1909. 

1.  Comparison  of  Lesions  Found  Post  Mortem  in  Cases 

Diagnosticated  Clinically  as  Eclampsia  and  Toxaemia 
of  Pregnancy,  By  J.  E.  Welch. 

2.  Cardiac  Disease  as  a  Complication  of  Pregnancy, 

By  G.  H."  Ryder. 

3.  When  Shall  the  Operation  for  Tubal  Pregnancy  be 

Performed?  By  B.  F.  Baer. 

4.  Delayed  Operation  in  Terminated  Ectopic  Pre^ancy, 

By  C.  A.  Stillwagen. 
.>    Psychotherapy  and  Reeducation,  By  E.  Garrigue. 


138 


PROCEEDINGS  OF  SOCIETIES, 


[New  York 
Medical  Journal. 


6.  Abdominal  Surgery  without  Detached  Pads  or  Sponges, 

B}'  H.  S.  Crossen. 

7.  Typhlitis,  By  J.  A.  Lyons. 

8.  Vaginal  Cesarean  Section  in  the  Treatment  of  Eclamp- 

sia, By  O.  P.  HUMPSTONE. 

9.  Splenic  Anaemia  of  Infancy,  By  A.  D.  Smith. 

1.  Comparison  of  Lesions  Found  Post  Mor- 
tem in  Cases  Diagnosticated  Clinically  as  Eclamp- 
sia and  Toxaemia  of  Pregnancy. — W elch  speaks 
of  the  idea,  long  prevalent,  that  eclampsia  was  a 
manifestation  of  deranged  kidney  function.  He 
also  refers  to  the  fact  that  in  the  so  called  eclamp- 
sia without  convulsions  we  now  look  for  changes 
in  other  organs,  especially  the  liver,  in  which 
hjemorrhagic  changes  were  first  noted  by  Jurgens. 
These  changes  were  related  to  an  inflammatory  pro- 
cess, and  with  them  were  found  liver  cell  emboli  in 
the  Itmg  capillaries.  The  most  recent  investigations 
attribute  the  liver  changes  to  thromboses  in  its  ves- 
sels, with  haemorrhages  in  and  about  the  portal 
spaces  and  coagulation  of  the  blood.  In  the  so 
called  toxaemia  of  pregnancy  are  found  acute  yel- 
low atrophy  of  the  liver  with  extensive  degenera- 
tion and  disintegration  of  its  parenchyma.  The  his- 
tories of  twelve  very  interesting  autopsies  are  nar- 
rated, and  it  is  concluded  that  the  cause  of  the  ex- 
tensive changes  which  were  found  in  the  liver  was 
an  enzyme  or  a  combination  of  enzymes  in  the 
blood,  the  liver  cells  being  especially  rich  in  them. 
These  enzymes  being  disturbed  in  some  way  not  yet 
known,  they  will  attack  the  cells  in  which  they  re- 
side, and  cause  their  destruction.  This  zymotic  di- 
gestion may  also  occur  in  the  endothelium  of  the 
vessels  with  consequent  haemorrhage. 

2.  Cardiac  Disease  .as  a  Complication  of  Preg- 
nancy.— Ryder  finds  cardiac  disease  during  preg- 
nancy a  very  frequent  complication.  If  the  heart  is 
well  compensated  no  danger  need  be  expected  from 
the  lesion,  the  patient  will  probably  go  through 
pregnancy  without  inconvenience,  and  will  stand  an 
ordinary  labor  and  puerperium  without  much  trou- 
ble. Marriage  need  not  be  feared  so  long  as  car- 
diac compensation  is  good  and  the  lesion  is  not  a 
recent  one.  The  only  treatment  required  is  watch- 
fulness during  the  entire  parturient  state.  If  the 
labor  should  be  difficult  the  heart  action  may  be- 
come irregular,  intermittent,  or  suddenly  rapid, 
and  this  will  require  the  use  of  morphine,  digitalis, 
and  strychnine.  If  there  is  failure  of  compensa- 
tion the  complication  is  a  very  grave  one,  both  ma- 
ternal and  foetal  mortality  in  such  cases  being  very 
high.  Such  a  patient  should  be  put  to  bed  on  light 
diet  and  should  receive  heart  stimulants.  Bad 
symptoms  in  such  cases  may  be  due  mainly  to  the 
kidneys,  with  toxaemia  of  pregnancy.  The  treat- 
ment should  be  colon  irrigation,  arterial  dilators, 
warm  baths.  If  failure  of  compensation  becomes 
more  marked  with  oedema,  dyspnoea,  bad  heart  ac- 
tion, and  cyanosis,  pregnancy  should  be  terminated 
as  rapidly  and  as  simply  as  possible.  Death  fre- 
quently occurs  a  few  hours  after  the  conclusion  of 
labor. 

7.  Typhlitis. — Lyons  presents  the  following 
conclusions:  i,  Typhlitis  and  perityphlitis  may  oc- 
cur independently  of  appendicular  inflammation.  2, 
Appendicular  inflammation  may  be  secondary  to  or 
may  follow  these  diseases.  3,  It  is  not  necessary 
in  appendicular  inflammation  that  the  mucosa  of  the 


appendix  be  the  seat  of  primary  inflammation.  4, 
Catarrhal  inflammation  of  the  ca;cal  mucosa  may 
precede  and  cause  a  similar  condition  in  the  appen- 
dix, from  which  periappendicular  disturbances  may 
follow.  5,  The  variety  of  opinions  on  this  subject 
show  that  the  question  is  still  unsettled.  6,  There 
may  be  twice  as  many  retrocaecal  peritoneal  adhe- 
sions as  periappendicular  peritoneal  adhesions,  as 
proved  by  observation,  autopsies,  and  surgical  op- 
erations. 7,  Pathologists  believe  that  the  caecum  is 
frequently  and  primarily  involved.  8,  Appendicu- 
lar inflammation  may  result  from  primary  typhlitis. 
9,  In  cascitis  the  appendix  is  not  always  the  root  of 
the  evil.  10,  Stercoral  ulcer  has  a  definite  position 
in  the  production  of  perityphlitis.  11,  The  appen- 
dix is  frequently  infected  from  a  diseased  caecum. 
 <i>  

IromMngs  at  Batutm. 


MEDICAL  ASSOCIATION  OF  THE  GREATER  CITY 
OF  NEW  YORK. 
Meeting  of  October  ig,  igoS. 

The  President,  Dr.  Robert  T.  Morris,  in  the  Chair. 

Glandular  Tumors  of  the  Neck  Treated  by 
Means  of  the  X  Ray  and  High  Frequency  Cur- 
rents.— Dr.  J.  H.  Branth  presented  two  patients 
whom  he  had  successfully  treated  for  large  glandu- 
lar tumors  of  the  neck.  In  both  instances  the 
growth  was  on  the  right  side,  and  in  neither  was 
there  a  history  of  any  indication  of  syphilis.  The 
first  patient  was  a  man  in  middle  life,  who  had  been 
sent  to  him  by  Dr.  C.  R.  Gulick.  The  growth, 
which  was  25^.  inches  in  diameter,  had  now  entire- 
ly disappeared  after  forty-six  treatments.  The 
second  case  was  that  of  a  young  lady,  and  the 
tumor  in  this  instance  was  of  about  the  size  of  a 
goose's  egg.  She  had  had  seventy-two  treatments 
thus  far,  and,  as  a  slight  amount  of  enlargement 
yet  remained,  she  was  still  under  treatment,  though 
the  treatments  were  now  given  less  frequently  than 
formerly.  Dr.  Branth  said  that  he  had, had  the 
same  good  results  in  three  other  similar  cases.  He 
was  inclined  to  believe  that  the  high  frequency  cur- 
rents were  really  the  active  agent  in  causing  the 
resolution,  but  as  it  was  possible  that  the  x  ray  also 
had  some  influence,  and  as  such  patients  were  nat- 
urally anxious  to  get  well  as  soon  as  possible,  he 
had  not  ventured  to  abandon  the  use  of  the  x  ray. 

Dr.  Edward  Wallace  Lee  said  that  such  tumors 
were  not  at  all  uncommon,  and  he  believed  they  were 
due  either  to  a  constitutional  condition  or  to  some 
local  source  of  irritation  about  the  throat.  They 
generally  disappeared  under  constitutional  or  local 
treatment  of  the  source  of  trouble,  and  often  sub- 
sided without  any  treatment.  He  had  seen  five 
times  as  many  cases  as  those  reported  by  Dr. 
Branth  in  which  the  tumor  had  gone  away,  either 
with  or  without  such  treatment.  It  was  a  question, 
in  his  mind,  he  said,  whether  this  application  of 
electricity,  by  stimulating  the  circulation  of  the 
parts,  did  not  really  retard  the  resolution  of  such 
growths. 

In  answer  to  a  question  by  Dr.  H.  G.  PiflFard, 
Dr.  Branth  explained  his  manner  of  applying  high 
frequency  currents,  and  stated  that  in  these  cases  it 


January  i6,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


139 


was  his  practice  to  apply  the  x  ray  for  from  eight 
to  twelve  minutes  and  then  the  high  frequency  cur- 
rents from  six  to  eight  minutes. 

Dr.  Charlton  R.  Gulick  said  that  he  had  seen 
perhaps  hundreds  of  cases  such  as  Dr.  Lee  had  re- 
ferred to.  In  the  case  which  he  had  sent  to  Dr. 
Branth  the  enlargement  was  not  at  all  of  this  de- 
scription. The  gland,  which  was  hypertrophied, 
was  the  only  gland  in  the  body  which  was  affected, 
and  when  the  patient,  whose  medical  attendant  he 
had  been  for  a  number  of  years,  called  his  attention 
to  the  growth,  he  at  once  recognized  that  it  was  a 
serious  condition.  He  had  felt  anxious  as  to  the 
ultimate  result,  and  was  therefore  much  gratified 
when  the  tumor  disappeared  under  Dr.  Branth's 
treatment.  The  patient  had  always  enjoyed  good 
health  previously,  but  after  the  glandular  enlarge- 
ment began  he  became  much  debilitated  and  lost 
twenty-five  pounds  in  weight.  Within  three  weeks 
after  the  electrical  treatment  was  begun  the  tumor 
had  almost  entirely  gone  away.  Notwithstanding 
active  tonic  treatment,  the  patient  gained  very  lit- 
tle in  his  general  condition  during  Dr.  Branth's  ap- 
plications, but  as  soon  as  the  resolution  was  com- 
plete, and  these  were  stopped,  he  rapidly  regained 
his  normal  state. 

The  Presidemt  said  it  was  important  that  the 
cases  should  be  very  carefully  examined,  so  that 
appropriate  constitutional  treatment  could  be  given 
where  this  was  called  for.  In  the  class  of  cases 
shown  by  Dr.  Branth  he  believed  that  the  kind  of 
treatment  he  had  described  constituted  a  very  val- 
uable resource. 

Neurasthenia  and  its  Treatment. 

.ffitiology,  Pathology,  and  Course. — The  intro- 
ductory paper  was  by  Dr.  Edward  D.  Fisher.  He 
defined  neurasthenia  as  exhaustion  of  the  nervous 
system,  characterized  by  marked  functional  inef- 
ficiency, and  said  that  its  principal  symptom  was 
functional  disturbance  of  nervous  activity,  shown 
in  incapacity  for  continuous  mental  action,  with  loss 
of  control  over  the  emotions ;  added  to  which  was 
defective  nutrition,  with  loss  of  physical  endur- 
ance. It  had,  therefore,  both  a  psychic  and  a 
physical  element,  and  its  aetiology  and  treatment 
must  be  studied  from  both  these  points  of  view.  As 
it  was  an  affection  of  the  entire  nervous  system, 
the  multiform  variety  of  the  symptoms  had  led  to 
many  plans  of  treatment.  The  author  expressed 
the  opinion  that  neurasthenia  was  not,  as  had  often 
been  alleged,  a  disease  peculiar  to  Americans,  but 
one  which  belonged  to  all  nationalities  where  sim- 
ilar conditions  of  stress  existed.  In  treating  of  the 
aetiolog}^  he  said  it  was  much  more  frequently  met 
with  in  men  than  in  women,  who  were  more  subject 
to  hysteria,  an  affection  closely  allied  clinically  to 
neurasthenia.  Heredity,  which  was  present  in 
forty  per  cent,  of  all  cases,  according  to  Ziehen, 
was  certainly  an  important  factor  in  the  way  of 
predisposition.  Among  the  exciting  causes  were 
alcoholism,  syphilis,  trauma,  shock,  mental  strain, 
and  the  effects  of  exhaustive  disease,  also  irrita- 
tions of  the  special  organs,  such  as  the  eye,  ear, 
stomach,  heart,  and  sexual  apparatus. 

In  speaking  of  the  symptomology  and  course  he 
said  there  was  often  a  fear  of  insanity,  and  at  times 
a  near  approach  to  mental  disturbance — rapid  flight 


of  ideas,  fears  of  going  out  or  being  alone  and  of 
sudden  death,  and  impulses  to  suicide,  with  a  fear 
of  committing  it.  All  these  manifestations  were  in- 
cluded under  the  term  psychasthenia.  There  was  a 
general  feeling  of  discontent,  unhappiness,  and  un- 
rest, together  with  marked  self  consciousness.  Hav- 
ing referred  to  vertigo,  sleeplessness,  eye  symptoms, 
disturbed  general  sensation,  muscular  weakness 
(often,  when  extreme,  depending  on  physical  con- 
ditions such  as  colitis),  and  exaggerated  tendon  re- 
flexes, he  said  it  was  important  to  remember  that  in 
neurasthenia  the  pupil  reflex  to  light  was  normal, 
since  the  multiple  character  of  the  mental  symp- 
toms m.ight  otherwise  suggest  general  paresis.  The 
absence  of  the  Argyl  Robertson  pupil  enabled  us  to 
make  the  diagnosis.  There  were  many  subjective 
disturbances  of  sensation,  such  as  tingling,  numb- 
ness and  itching,  and  also  vasomotor  disturbances, 
such  as  rush  of  blood  to  the  head,  erythematous 
manifestations,  urticaria,  etc.  Perhaps  the  heart 
called  for  most  attention,  and  in  this  connection  he 
spoke  of  palpitation,  intermittent  pulse,  and  attacks 
of  pseudoangina  pectoris,  with  marked  tachycardia 
and  the  appearances  of  impending  death.  In  fact, 
in  some  cases  death  could  occur  from  fear.  In 
other  instances  there  was  bradycardia,  with  a  pulse 
of  from  30  to  40,  and  in  these  there  was  often  a 
systolic  murmur,  with  abdominal  pulsation.  Time 
would  not  permit  him  to  more  than  allude  to  the 
respiratory  disturbances,  nor  would  he  go  into  the 
vast  field  of  sexual  anomalies.  Intestinal  disturb- 
ance was  almost  always  present,  especially  marked 
by  constipation.  Colitis,  when  present,  was  a  symp- 
tom, and  not  an  aetiological  factor,  as  it  was  often 
considered.  At  times  there  were  severe  attacks  of 
pain  simulating  appendicular  inflammation  or  biliary 
colic. 

The  pathology,  he  said,  had  already  been  outlined 
in  the  clinical  description  given.  There  were  nerve 
cell  exhaustion  and  changes  of  a  chemical  nature, 
though  not  destructive  in  character  :  probably  re- 
sulting from  any  slight  excitement  or  exertion.  In 
neurasthenia  the  restoration  to  ^lormal  conditions 
was  slow,  if  ever  complete.  The  course  of  the  dis- 
ease was  often  a  prolonged  one.  so  that  no  time  limit 
could  be  given  in  regard  to  the  matter  of  recovery. 
This,  however,  was  always  possible,  and  generally 
possible  under  proper  management.  Not  infre- 
quently some  great  exciting  motive  or  desire  was 
the  cause  of  a  sudden  and  complete  disappearance 
of  all  the  symptoms.  He  knew  of  no  class  of  pa- 
tients who  required  more  careful  examination  in 
every  respect  than  neurasthenics,  and  of  none  where 
the  nerve  examination  with  all  the  modern  appar- 
atus had  a  more  beneficial  effect,  irrespective  of  any 
lesion  which  might  be  present :  nor  did  he  know  of 
a  more  grateful  and  appreciative  class  if  they  could 
be  assured  of  any  actual  physical  lesion  which  might 
possibly  be  considered  a  cause  of  their  many  obscure 
feelings. 

True  Neurasthenia ;  its  Nature  and  Treatment. 

— In  this  paper  Dr.  A.  D.  Rockwell  said  that  the 
term  neurasthenia  was  a  convenient  refuge  in  diag- 
nosis. It  was  easy  for  the  physician  and  most  sat- 
isfactory to  that  large  class  of  patients  who  ate  too 
much  and  exercised  too  little,  and  who  were  simply 
poisoned  by  the  unassirnilated  products  of  diges- 


I40 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


tion.  While,  therefore,  there  was  a  false  neuras- 
thenia, he  was  a  firm  believer  in  the  propriety  of 
classifying  under  this  head  a  great  family  of  symp- 
toms, and  he  considered  true  neurasthenia  one  of 
the  most  important  of  all  so  called  functional  dis- 
eases, in  consequence  of  its  power  to  completely 
wreck  the  life  of  a  man,  the  persistence  of  its  symp- 
toms, and  the  frequent  futlity  of  methods  of  treat- 
ment adopted,  due  mainly  to  mistaken  ideas  as  to 
its  nature  and  course.  One  of  the  astonishing  things 
in  connection  with  it  was  the  infinite  variety  of 
symptoms  complained  of,  though  the  sum  total  of 
these  symptoms  was  by  no  means  to  be  met  with  in 
any  individual  case.  It  was  the  rapidity  with  which 
nervous  force  was  exhausted  which  made  possible 
this  infinite  variety,  since  such  exhaustion  was  not 
confined  to  any  one  centre  of  organic  or  functional 
life.  He  considered  it  important  to  distinguish  be- 
tween hereditary  and  acquired  neurasthenia,  and 
was  of  the  opinion  that  in  the  majority  of  cases 
there  was  an  undoubted  hereditary  tendency.  A 
nervous  system  endowed  with  normal  strength  was 
not  readily  influenced  to  its  permanent  detriment  by 
the  effect  of  severe  and  proloneed  mental  and  phy- 
sical distress,  while  nerve  tracts  inherently  weak 
from  any  cause  might  be  powerfully  influenced  by 
irritations  absurdly  slight.  There  might  have  been 
no  neurasthenia,  as  now  understood,  among  the  an- 
cestors of  the  hereditary  neurasthenic,  but  it  would 
be  found  that  there  was  a  history  of  one  or  more 
of  such  neuropathic  conditions  as  epilepsy,  hysteria, 
alcoholism,  and  insanity.  Indeed,  when  there  exist- 
ed a  strong,  nervous  heredity  neurasthenia  might 
develop  without  any  apparent  exciting  cause  what- 
ever, and,  what  was  exceedingly  rare  in  acquired 
neurasthenia,  might  even  develop  at  puberty ;  while 
a  case  of  the  disease  was  seldom  if  ever  met  with 
before  the  age  of  twenty-five  where  the  heredity  was 
good.  Hysteria,  while  a  kindred  condition,  was  by 
no  means  identical,  and  one  interesting  distinctive 
point  between  neurasthenia  in  man  and  hysteria  in 
woman  was  the  difference  in  the  degree  of  suscept- 
ibility to  stimulation.  A  typical  neurasthenic  was 
as  a  rule  more  than  ordinarily  susceptible  to  alco- 
hol, while  an  hysterical  woman  could  usually  great- 
ly exceed  the  usual  amount  without  perceptibly  feel- 
ing its  eff'ects.  Of  the  causative  factors  of  neuras- 
thenia, he  emphasized  as  the  most  important  sexual 
•  excesses,  especially  among  the  unmarried,  and  it 
was  naturally  among  the  hereditarily  weak  that 
such  excesses  worked  the  greatest  havoc.  In  re- 
gard to  what  was  termed  traumatic  neurasthenia, 
he  was  more  and  more  of  the  opinion  that  it  was 
not  a  special  neurosis  distinct  from  the  ordinary 
form  of  the  affection.  In  a  way,  all  neurasthenia 
was  traumatic,  since  profound  mental  disturbance 
and  the  physical  abuse  of  function  were  just  as  trulv 
blows  as  were  physical  .strokes.  The  one  overmas- 
tering symptom  among  the  many  associated  with 
the  neurasthenic  state  was  morbid  fear,  so  that  lit- 
tle by  little,  because  of  his  feeble  powers  of  resist- 
ance, his  fears  dominated  the  patient's  life,  grad- 
ually destroying  the  results  of  years  of  health  anrl 
education. 

In  tlic  treatment,  tlie  question  of  rest  or  work 
was  of  great  importance:  in  no  condition  was  there 


more  need  of  an  intelligent  distinction.  If  there 
was  cerebral  excitement  associated  with  physical 
exhaustion,  rest  was  imperatively  demanded,  and 
this  was  also  to  be  recommended  in  cases  of  the 
myelasthenic  type.  For  those  of  the  lithaemic  type 
— hearty  eaters  who  suffered  from  autoinfection, 
with  frequent  irritability  and  unreasonable  out- 
bursts of  temper — work  and  activity,  and  plenty  of 
it,  were  what  was  required.  While  success  in  treat- 
merit  frequently  followed  very  little  active  medica- 
tion, judicious  drugging  was  at  times  distinctly 
called  for,  and  in  certain  cases  the  occasional  use 
of  well  selected  remedies  for  soothing  and  sustain- 
ing a  weak  and  erratic  nervous  system,  such  as  the 
bromides,  alone  or  in  combination  with  belladonna, 
cannabis  indica,  etc.,  was  advisable.  Of  all  physi- 
cal means  of  treatment,  Dr.  Rockwell  considered 
electricity  the  most  valuable.  No  single  remedy 
quite  equalled  it,  and  in  reality  it  was  many  reme- 
dies in  one,  for  so  numerous  were  its  manifesta- 
tions, and  so  varied  its  effects,  that  for  all  practical 
purposes  we  might  say  that  we  had  many  kinds  of 
electricity.  Neurasthenia  was  a  disease  of  exhaus- 
tion, and  tJierefore  one  of  impaired  nutrition,  and 
electricity  in  its  various  forms  aided  powerfully  in 
the  restoration  of  perverted  cell  nutrition.  The  in- 
fluence of  light  and  heat  he  had  also  found  useful. 
If  a  physician  had  not  time  or  inclination  to  do 
more  than  drug  his  patient,  or  give  him  the  ordi- 
nary office  advice  and  treatment,  he  was  not  quite 
fitted  to  take  charge  of  many  a  case  of  neuras- 
thenia. To  a  certain  extent  he  should  associate 
with  the  patient,  and  by  his  personal  presence  and 
encouragement  reinforce  his  feeble  and  wavering 
will.  While  neurasthenia  was  no  imaginary  dis- 
ease, and  while  no  appeal  to  the  imagination  alone 
could  overcome  the  profound  loss  of  nerve  tone 
characteristic  of  it  or  rearrange  the  delicate  fibril- 
lary connection  of  the  neurones  that  might  have 
been  disturbed  by  the  constant  impact  of  physical 
forces,  mental  therapeutics  was  yet  an  important 
factor  in  many  instances.  In  every  respect  the 
physician  should  treat  the  patient  with  respectful 
and  sympathetic  consideration,  and,  while  recogniz- 
ing his  infirmities,  assure  him  in  no  uncertain  tone 
that  he  was  by  no  means  incurable.  This  could  be 
done  honestly,  for,  among  hundreds  of  cases.  Dr. 
Rockwell  had  seldom  met  with  one  of  which  he  had 
been  able  to  keep  track  that  did  not  finally  respond 
to  time  and  treatment. 

Treatment  by  the  Ultra  Violet  Ray  and  High 
Frequency  Currents. — Dr.  Sincl.mr  Tousey  read 
this  paper.  When  produced  by  electricity,  the  use 
of  violet  ray  in  neurasthenia,  he  said,  might  be  di- 
vided into  two  separate  methods:  i.  It  might  form 
part  of  the  combined  heat  and  light  radiation  ap- 
plied in  local  or  general  electric  light  baths.  2,  It 
might  form  the  essential  factor  in  several  different 
applications  of  high  frequency  currents.  The  arc 
light  was  richer  in  ultra  violet  rays  than  the  incan- 
descent, and  hence  was  preferable,  but  the  incan- 
descent light  was  so  much  easier  to  handle  that  it 
was  often  employed.  The  effect  of  electric  light 
baths  was  due  only  in  part  to  the  ultra  violet  rays. 
These  were  all  absorbed  by  the  skin,  producing  a 
general  tonic  effect,  but  having  no  direct  action 


January  i6,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


141 


upon  any  vital  organ.  Under  the  use  of  the  violet 
ray  in  connection  with  high  frequency  currents  the 
oxygen  of  the  air  might  be  changed  into  ozone, 
which,  being  unstable,  was  very  active  chemically. 
Ley  den  jars  charged  by  a  static  machine  or  an  in- 
duction coil  formed  part  of  the  apparatus  designed 
to  give  high  frequency  discharges  which  were  ex- 
tremely efficient  in  this  regard.  Glass  vacuum  elec- 
trodes were  employed  for  applying  these  discharges 
to  the  surface  of  the  body,  and  the  odor  of  ozone 
might  sometimes  be  detected  on  the  following  day. 
The  effect  was  heightened  if  the  electrode  was  ap- 
plied over  their  clothing,  or  if  it  was  held  at  a  lit- 
tle distance  from  the  surface,  when  thousands  of 
tiny  violet  colored  sparks  could  be  seen  traversing 
the  air  covering  the  skin.  The  ozone  generated  in 
this  way  penetrated  the  tissues  and  produced  an 
effect  upon  the  solids  and  liquids  making  up  the 
body.  This  effect  was  the  characteristic  one  of 
nascent  oxygen,  namely,  to  increase  the  rapidity 
and  favor  completeness  of  oxidation.  It  also  fa- 
vored the  elimination  of  nitrogenous  substances  as 
urea,  while  autointoxication  by  other  products  was 
relieved  by  the  same  application ;  not  perhaps  so 
much  by  a  direct  oxidation  as  by  a  stimulant  effect 
upon  the  tissues  which  resulted  in  normal  activity. 
The  ozonizing  effect  of  the  application  of  vacuum 
electrodes  was  practically  the  same,  no  matter  what 
particular  form  of  high  tension  generator  was  em- 
ployed. It  was  requisite  to  apply  the  electrode  over 
a  considerable  portion  (one  fourth,  if  practicable) 
of  the  surface  of  the  body  in  order  to  obtain  the 
full  benefit  of  this  effect  of  the  treatment,  and  this 
should  include  the  part  affected  by  any  local  symp- 
toms— the  prsecordia  in  cases  of  palpitation  or  car- 
diac neurosis,  the  abdomen  in  cases  of  dyspepsia 
and  constipation,  the  spine  or  different  nerves  in 
cases  of  neuralgia. 

Another  part  of  the  effect  from  glass  vacuum 
tubes  was  dependent  upon  the  nature  of  the  electric 
current  which  excited  the  tube.  The  higher  ten- 
sion discharges  were  especially  useful  in  cases  of 
neurasthenia  with  low  arterial  tension,  and  the  low 
tension  high  frequency  discharges  were  a  specific  in 
cases  with  high  arterial  tension.  A  shower  of  high 
tension  sparks  from  a  glass  vacuum  electrode 
passed  rapidly  along  the  spine  was  very  serviceable 
in  atonic  cases.  In  some  cases  of  neurasthenia  in 
which  the  blood  pressure  had  been  so  high  as  to 
lead  to  grave  and  threatening  secondary  lesions, 
Dr.  Tousey  had  employed  d'Arsonval  or  Oudin 
high  frequency  but  low  tension  discharges,  applied 
partly  by  means  of  the  autocondensation  couch  and 
partly  by  means  of  glass  vacuum  electrodes  passed 
along  the  spine  and  over  the  abdomen. 

Having  given  some  further  details  of  the  meth- 
ods employed  by  him.  he  said  that  he  had  endeav- 
ored to  make  it  plain  that  there  were  several  forms 
in  which  the  high  frequency  currents  might  be  ap- 
plied, with  and  without  the  use  of  vacuum  elec- 
trodes, and  especially  that  the  use  of  such  electrodes 
gave  results  dependent  upon  the  exact  form  of 
high  frequency  current  transmitted  by  them.  What 
was  equally  important  was  that  other  forms  of  elec- 
tricity than  the  high  frequency  currents  might  be 
transmitted  by  them,  with  the  same  production  of 
the  violet  colored  light,  but  with  radically  different 


physiological  and  therapeutic  effects.  The  neuras- 
thenic persons  who  had  been  referred  to  him  for 
this  kind  of  treatment  had  usually  had  some  cfefinite 
nervous,  circulatory,  reproductive,  or  alimentary 
disturbance,  and  the  results  had  often  been  ex- 
tremely gratifying.  Two  illustrative  cases  were 
cited ;  after  which  he  gave  a  brief  demonstration  of 
the  apparatus  referred  to  in  the  paper. 

Treatment  by  Static  Electricity. — F"or  this  i)a- 
per,  by  Dr.  J.  Herm.an  Braxth,  see  page  114  of 
this  issue. 

After  reading  the  paper  Dr.  Branth  gave  a  dem- 
onstration of  the  penetrating  power  of  high  fre- 
quency currents.  It  had  been  stated,  he  said,  that 
such  currents  reached  only  the  surface  of  the  body, 
but  the  internal,  tissues  and  fluids,  which  were  sim- 
ilar in  constitution  to  normal  salt  solution,  w^ere 
really  much  better  conductors  than  the  skin. 

Dr.  WiLLi.\M  M.  Leszynskv  said  that  patients 
supposed  to  be  sulfering  from  neurasthenia  should 
be  given  a  very  thorough  examination  as  to  the 
presence  or  absence  of  organic  disease,  so  that  the 
true  diagnosis  could  l>e  arrived  at.  In  all  cases 
great  care  should  be  taken  to  ascertain  the  aetiology 
of  the  condition.  Like  many  others,  he  believed  he 
had  had  patients  with  obstinate  constipation  in 
whom  the  prolonged  use  of  saline  cathartics  had 
been  responsible  for  the  neurasthenia.  In  other  in- 
stances the  trouble  appeared  to  be  due  to  the  exces- 
sive use  of  tea,  coffee,  or  alcohol.  In  regard  to  the 
treatment,  it  seemed  to  him  that  we  had  to  divide 
neurasthenics  into  two  classes,  the  rich  and  the 
poor.  In  the  case  of  the  rich  we  had  full  opportun- 
ity to  carry  out  whatever  measures  might  be  deemed 
advisable,  but  with  poor  patients  the  circumstances 
were  entirely  different.  Here  a  great  problem  pre- 
sented itself.  Such  patients  were  in  a  pitiable  condi- 
tion, because  so  little  could  be  done  for  their  re- 
lief. They  would  not  be  admitted  into  any  of  the 
general  hospitals,  and  it  seemed  likely  to  be  a  long 
time  before  v.e  had  an  institution  where  the  poor 
could  be  treated  for  functional  nervous  affections. 
As  to  the  treatment  by  electricity,  he  did  not  believe 
that  any  form  of  this  could  take  the  place  of  hydro- 
therapy. It  was,  however,  a  valuable  agent,  and  he 
had  found  static  electricity  especially  serviceable. 
Aside  from  its  physical  effects,  it  impressed  the 
mind  of  the  patient,  and  in  connection  with  his  visits 
to  the  office  we  could  make  use  of  psychotherapy  at 
the  same  time.  The  faradic  current  he  thought  of 
very  little  value.  He  was  glad  to  hear  the  rest  cure 
spoken  of  as  it  had  been,  and,  so  far  as  he  knew, 
this  was  not  now  carried  out  to  anything  like  the 
extent  that  was  formerly  the  case. 

Dr.  William  Broaddus  Pritchard  said  that  it 
was  apparently  an  impossibility  to  get  any  two  men 
to  agree  on  the  subject  of  neurasthenia.  It  seemed 
to  him,  however,  that  there  would  not  be  any  need 
of  this  wide  divergence  of  opinion  if  we  would  take 
a  broader  view  in  regard  to  its  management.  The 
main  point  was  to  pay  due  attention  to  the  personal 
equation  of  the  patient,  as  every  individual  had  his 
own  peculiarities.  Any  single  factor  might  be  in- 
significant, and  the  condition  the  result  of  a  dozen 
or  more  causes.  Personally,  he  did  not  believe  in 
heredity  in  connection  with  neurasthenia.    The  only 


142 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


thing  especially  characteristic  about  the  subjects  of 
the  afi^ction  was  a  highly  developed  cerebral  cortex, 
with  plenty  of  gray  matter.  Contrary  to  the  opin- 
ion of  Dr.  Fisher,  he  regarded  it  as  essentially  an 
American  disease,  and  he  thought  that  the  great 
underlying  cause  for  it  was  the  strenuous  life  which 
the  people  led  in  this  country.  Fifteen  or  twenty 
\'ears  ago  it  was  the  practice  to  treat  neurasthenia 
with  much  drugging,  but  to-day  patients  got  well 
in  greater  numbers  the  fewer  the  medicines  they 
were  given.  The  first  element  of  successful  treat- 
inent  was  the  recognition  of  the  vitally  important 
relation  between  the  patient  and  the  physician,  and 
useful  agencies  which  might  be  variously  employed 
according  to  the  requirements  of  the  individual  case 
were  suggestion,  electricity,  hydrotherapy,  massage, 
and  passive  exercise.  There  appeared  to  be  unan- 
imity of  opinion  as  to  the  inadvisability  of  the  ab- 
solute rest  cure.  In  this  the  isolation  of  the  patient 
fostered  morbid  introspection,  which  was  very 
harmful.  It  was  also  a  condition  of  idleness,  and 
what  the  neurasthenic  needed  was  occupation, 
though  on  different  lines  from  those  to  which  he 
had  been  accustomed. 

Dr.  Joseph  Fraenkel  said  it  was  difficult  to 
find  one's  bearings  in  all  the  confusion  of  symptoms 
which  had  been  spoken  of.  There  was  a  true  neu- 
rasthenia, but  it  was  a  very  rare  disease.  It  was  of 
hereditary  type  and  occupied  a  position  on  the  bor- 
der line  of  organic  affections.  It  was  a  psycho- 
neurosis  characterized  particularly  by  morbid  fear. 
( )utside  of  this  special  condition  we  had  infinite 
variety,  and  every  view  was  right  so  far  as  it  went ; 
but  for  the  successful  treatment  of  neurasthenia, 
as  he  understood  it,  there  were  required  the  most 
earnest  efforts  of  the  greatest  artists  iy  the  profes- 
sion of  medicine. 

Dr.  Theodore  K.  Tutiiill  said  he  had  been 
somewhat  disappointed  to  find  that  no  mention  had 
been  made  of  what  he  regarded  as  unquestionably 
the  best  treatment  for  neurasthenia.  This  was  to 
send  the  patient  out  into  the  woods  with  a  guide  to 
rough  it  and  hunt  and  fish,  or  to  learn  these  accom- 
plishments if  they  were  new  to  him.  There  was  noth- 
ing like  the  ]>rim?eval  forest  to  bring  about  a  cure 
in  this  class  of  cases.  It  seemed  to  him  that  Dr. 
Tousey  was  in  error  in  stating  that  ozone  was  lib- 
erated by  the  processes  which  he  had  described. 
He  believed  that  he  had  mistaken  for  this  what  was 
really  nitrogen  pentoxide,  NOr.. 

Dr.  Lee  expressed  the  opinion  that  as  a  rule  phy- 
sicians were  not  sufficiently  painstaking  in  the  ex- 
amination of  patients,  and  that  it  was  too  often  the 
case  that  a  diagnosis  of  neurasthenia  was  given 
offhand  when  a  more  careful  investigation  of  the 
history  and  physical  signs  would  have  revealed  a 
definite  cause,  other  than  this,  for  the  symptoms 
complained  of.  In  obscure  cases  every  means  of 
physical  explanation,  including  the  use  of  the  x  ray, 
and  all  the  resources  of  the  laboratory,  should  be 
called  into  requisition  before  a  conclusion  as  to  the 
condition  present  was  arrived  at. 

Dr.  Tousey  defended  his  position,  and  said  that 
it  was  unquestionably  ozone  which  was  responsible 
for  the  oxygenation  of  the  tissues,  as  he  had  de- 
scribed. 


[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.^ 


Obstetrical  and  Gynwcological  Nursing.  By  Edward  P. 
Davis,  A.  M.,  M.  D.,  Professor  of  Obstetrics  in  the  Jef- 
ferson Medical  College,  Philadelphia ;  Obstetrician  to 
the  Jefferson  Hospital,  etc.  Third  Edition,  Thoroughly 
Revised.  Philadelphia  and  London:  W.  B.  Saunders 
Company,  1908.    Pp.  436.    (Price,  $1.75.) 

This  edition  has  been  considerably  enlarged.  The 
title  would  have  been  more  explicit  if  it  had  been 
given  as  the  science  of  midwifery,  for  the  book  is 
really  a  compendium  for  midwives,  so  full  and  de- 
tailed are  its  contents.  As  the  author  says  in  his 
preface,  "it  is  offered  to  trained  nurses" ;  that 
means  it  is  to  be  taken  as  a  postgraduate  course  for 
nurses. 

The  book  is  divided  into  two  parts,  obstetrical 
nursing,  containing  nineteen  chapters,  and  gynaeco- 
logical nursing,  with  sixteen  chapters.  An  appen- 
dix refers  to  both  parts  and  contains  a  dietary  and  a 
short  synopsis  on  how  to  prepare  surgical  supplies. 
An  index  is  also  to  be  found. 

About  motoring  the  author  says,  page  27:  "If  a 
motor  car  is  used,  a  smoothly  running  machine 
should  be  chosen.  In  most  large  cars  the  patient 
will  feel  least  jarring  on  the  front  seat.  If  possi- 
ble, the  car  should  not  run  at  high  speed,  and  the 
patient  should  be  suitably  dressed  to  avoid  chill. 
Motoring  at  a  rapid  rate  is  excessively  fatiguing, 
and  pregnant  women  should  take  special  care  to 
avoid  exhaustion  from  this  source.  A  patient  may 
become  easily  chilled  in  rapid  riding,  and  this 
should  be  avoided."  This  shows  how  fully  the 
author  covers  his  ground. 

A  Laboratory  Guide  for  Histology.  Laboratory  Outlines  for 
the  Study  of  Histology  and  Microscopic  Anatomy.  By 
Irving  Hardestv,  A.  B.,  Ph.  D.,  Associate  Professor  of 
Anatomy  in  the  University  of  California.  With  a  Chap- 
ter on  Laboratory  Drawing  by  Adelbert  Watts  Lee, 
M.  D.,  Assistant  in  Anatomy  in  the  University  of  Cali- 
fornia. With  30  Illustrations,  2  of  which  are  in  colors. 
Philadelphia :  P.  Blakiston's  Son  &  Co.,  1908. 

This  laboratory  guide  for  histology  differs  from 
other  books  of  the  kind  in  several  ways.  In  the 
first  place,  no  attempt  is  made  to  describe  the  tis- 
sues studied.  The  student  is  directed  to  make  cer- 
tain manipulations,  and  he  is  then  asked  certain 
questions  which  he  is  supposed  to  answer  either 
from  observation  or  from  the  results  of  studies 
made  on  his  own  account  in  the  standard  textbooks. 
At  the  end  of  each  section  there  is  a  list  of  refer- 
ences to  the  recent  periodical  literature  on  the  sub- 
ject under  consideration.  The  first  chapter  in  the 
book  is  a  very  interesting  treatise  on  laboratory 
drawing,  and  the  second  chapter  is  devoted  to  gen- 
eral instructions  to  the  student  for  his  information 
as  to  the  methods  to  be  employed  in  his  work.  The 
last  chapter  is  a  summary  of  the  details  of  the  va- 
rious fixing,  embedding,  and  staining  methods  em- 
ployed. 

The  reviewer  confesses  to  a  pleasant  sensation  of 
disappointment.  He  expected  to  see  the  usual 
laboratory  manual  with  abstracts  of  the  standard 


January  i6,  1909.] 


MISCELLANY. 


143 


textbook  descriptions.  Instead  of  that  he  finds  an 
original  plan  well  carried  out,  and  one  that  is  de- 
signed to  make  a  student  think  for  himself.  He 
would  question  only  whether  it  is  for  the  best  to 
refer  students  to  French  and  German  periodical  lit- 
erature. For  example,  the  list  of  references  to  the 
recent  papers  on  the  urinary  apparatus  contains 
twenty-three  titles ;  of  these  references,  fourteen 
are  to  articles  in  German,  seven  to  publications  in 
English,  and  two  to  papers  in  French.  It  may  be 
well  to  begin  early  to  send  students  to  original 
sources  for  their  information,  but  teachers  must  re- 
member that  there  are  only  twent\--four  hours  in  a 
•day,  that  a  student  cannot  work  during  the  entire 
twenty-four,  and  that  he  has  other  things  to  study 
besides  the  branch  taught  by  a  single  individual. 

Selections  from  the  Writings,  Medical  and  Neurological, 
of  Sir  William  Broadbcnt.  Bart.,  K.  C.  V.  O.,  Com- 
mander of  the  Legion  of  Honor,  M.  D.,  F.  R.  C.  P., 

F.  R.  S.,  D.  Sc.,  Leeds ;  LL.  D.,  Edinburgh,  St.  Andrews, 
and  Toronto,  etc.  Edited  by  Walter  Broadbext,  M.  D., 
M.  R.  C.  P.  London :  Henry  Frowde,  Oxford  L'niversity 
Press,  and  Hodder  and  Stoughton,  1908. 

The  volume  imder  notice  is  one  of  the  Oxford 
Medical  Publications,  and  contains  a  collection  of  the 
more  important  contributions  of  Sir  \\'illiam  Broad- 
bent  to  periodical  medical  literature.  The  best 
"known  of  the  papers  are  probably  the  one  on  the 
Examination  of  the  Heart,  which  appeared  in  the 
St.  Louis  Medical  Reviezi:  in  1907 ;  the  one  on  Ad- 
Tierent  Pericardium,  which  appeared  in  the  Medical 
Society's  Transactions  in  1898 ;  and  the  one  on 
Sleeplessness,  which  appeared  in  the  Lancet  for  the 
'first  half  of  1900. 

The  book  is  well  manufactured,  and  it  is  printed 
on  such  light  weight  paper  that  it  is  easy  to  hold 
the  volume  while  reading. 

Climate  Considered  Especially  in  Relation  to  Man.  By 
Robert  DeCourcv  Ward,  Assistant  Professor  of  Clima- 
tology in  Harvard  University.    Illustrated.    New  York : 

G.  P.  Putnam's  Sons.  London :  John  Murray,  1908.  Pp. 
xiv-372. 

This  volume,  the  twentieth  in  the  admirable 
science  series  of  G.  P.  Putnam's  Sons,  is  based  upon 
materials  collected  by  Professor  Ward  in  his  prep- 
aration of  lecture  courses  at  Harvard  Universitv. 
V\'ithout  being  too  technical,  there  is  much  to  inter- 
est the  medical  reader.  In  the  early  chapters,  along 
with  the  discussion  of  classification,  there  are  con- 
sidered the  general  influence  of  winds,  rainfall,  tem- 
perature, barometic  pressure,  humidity,  and  the  top- 
ography of  a  countr)'  upon  its  climate.  The  char- 
acteristics of  marine,  littoral,  continental,  desert, 
forest,  and  mountain  climates  as  aft'ected  by  the  dif- 
ferent geographical  zones  are  fully  described.  There 
is  a  very  good  account  of  the  various  climatic  dis- 
eases, especially  in  the  tropics,  a  subject  which  has 
been  of  growing  practical  importance  to  physicians 
in  this  country  in  the  past  decade.  The  hygiene  of 
life  in  hot  countries  is  very  ably  treated.  In  the 
final  chapter  the  popular  fallacy  of  changes  of  cli- 
mate within  historical  periods  is  definitively  explod- 
•ed.  The  evidence,  when  sifted,  shows  that  the  cli- 
mate of  a  given  place  within  normal  variations  re- 
nnains  remarkably  constant.  Everv  medical  man  is 
frequently  called  upon  in  his  practice  to  advise  hi^ 
patients  as  to  health  resorts  and  climate.  The  peru- 
sal of  Professor  Ward's  well  written  work  will  aid 
liim  to  do  so  intelligently. 


The  Surgery  of  the  Ear.  By  Samuel  J.  Kopetzky,  M.  D., 
Attending  Otologist,  New  York  City  Children's  Hospi- 
tals and  Schools,  Attending  Otologist  to  the  New  York 
Red  Cross  Hospital,  etc.  Illustrated  with  Sixty-three 
Half  Tone  and  Line  Drawings,  Eight  Charts,  and  Four 
Colored  Plates.  ~~New  York :  Rebman  Company,  1908. 
Pp.  xvii-368. 

Kopetzky  has  given  us  a  useful  and  well  written 
guide  which  includes  the  surgery,  not  only  of  the 
middle  ear  and  mastoid  region,  but  also  that  of  the 
external  auditory  canal,  the  drum  membrane,  the 
labyrinth,  the  meninges,  and  the  large  blocdves=^els. 
The  work  is  that  of  a  student  whose  experience  is 
tempered  by  good  traditions,  and  the  presentation 
is  that  of  a  natural  teacher.  Besides  the  operative 
techniqque  in  each  procedure  we  have  a  clear  if 
brief  resume  of  the  history,  indications,  special  prep- 
arations, local  anatomy,  dangers,  faults  in  tech- 
nique, and  after  treatment.  The  after  effects  and 
the  value  of  each  operation  are  also  analyzed,  a  fea- 
ture favorably  commented  upon  in  our  review  of 
Heine's  work  on  the  same  subject.  The  chapters 
on  surgery  of  the  facial  nerve  and  on  lumbar  and 
ventricular  puncture  indicate  the  progressive  atti- 
tude of  the  author.  The  volume  is,  besides,  an  un- 
usually attractive  one  in  its  rich  but  dignified  gray, 
well  printed  on  fine,  heavy  paper  which,  fortun- 
ately, is  entirely  free  from  the  annoying,  if  popular, 
glaze  so  trying  to  the  eyes  of  the  reader.  Most  of 
the  illustrations  are  in  half  tone  and  on  separate 
plates,  and  are  excellent,  not  only  artistically,  but 
as  explanations  of  the  text.  A  few  minor  flaws, 
such  as  an  occasional  lapsus  calami  in  spelling  and 
phraseology,  will  undoubtedlv  be  corrected  in  the 
next  edition,  in  which  we  may  also  hope  to  find  a 
plate  showing  in  detail  the  exposure  of  the  jugular 
bulb  and  vein. 

 <$>  

gliscellans. 


Further  Notes  Concerning  the  Relation  be- 
tween Infant  Foods  and  Tuberculosis. — Dr.  B. 

Heymann,  in  Zeitschrift  fiir  Hygiene,  ix,  p.  424, 
1908,  contributes  very  interesting  notes  to  the  ques- 
tion on  the  relation  between  infant  foods  and  tuber- 
culosis. The  author  first  states  von  Behring's  well 
known  dictum  that  tuberculosis  is  in  general  the 
result  of  milk  infection  during  infancy  and  child- 
hood, and  Koch's  denial  of  this  contention,  and 
adds,  'Tf  a  general  conclusion  is  to  be  drawn  from 
the  material  offered,  it  will  certainly  be  in  Koch's 
favor."  He  then  alludes  briefly  to  cutaneous  in- 
fection in  slaughter  houses  and  goes  on  to  say : 

While,  however,  as  now  generally  admitted,  cutaneous 
infection  with  bovine  bacilli  is  of  minor  import,  there  ex- 
ists considerable  difference  of  opinion  with  regard  to  their 
activity  in  the  intestinal  tract.  As  Ostermann's  investiga- 
tions show,  bovine  bacilli  are  rather  frequently  ingested  in 
raw  or  insufficiently  cooked  milk,  in  butter,  etc. ;  also,  as 
demonstrated  by  Ostertag.  in  meat  and  especially  in  sau- 
sage. That  they  then  cause  infection  in  the  intestines  or 
adjacent  lymph  glands,  and  particularly  in  childhood,  is, 
as  in  the  discussion  of  Koch's  London  paper,  frequently 
maintained  to-day,  especially  by  English  scientists,  who  lay 
emphasis  upcn  the  frequency  of  tabes  mesenterica.  But 
the  disease  syndrome  just  mentioned  is,  according  to  the 
best  known  authorities  on  children's  diseases,  capable  of 
more  than  one  interpretation.  Swelling  of  the  mesenteric 
glands  is  found  in  most  chronic  disturbances  of  nutrition, 
and  is  not  to  be  peremptorily  diagnosticated  as  tubercu- 
losis— a  favorite  diagnosis  in  England,  according  to  Caut- 
ley,  Tatham,  and  others — even  as  a  positive  tuberculin  re- 


144 


MISCELLANY. 


[New  York 
Medical  Journal. 


action  merely  lends  support  to  the  theory,  but  is  not  abso- 
lutely confirmatory,  for  in  discovering  palpable  abdominal 
glands,  clinical  investigation  may  overlook  pathological 
changes  in  other  organs  which  alone  are  tuberculous  before 
its  occurrence  in  the  mesenteric  glands.  This  assertion  is 
based  upon  the  experience  of  clinicians  who  have  for  years 
Ijeen  able  to  check  up  their  bedside  observations  by  autop- 
sies. According  to  the  coincident  opinions  of  Heubner, 
Medins,  Baginsky,  Finkelstein.  and  many  others,  autopsy 
almost  invariably  shows,  particularly  in  tuberculous  cases, 
other  affected  organs,  the  bronchial  and  mediastinal  glands 
almost  without  exception,  and  also — though  often  by  the 
most  careful  search — the  "primary  affection"  in  the  paren- 
chyma of  the  lungs.  Very  often  a  tuberculosis  of  the 
respiratory  tract  alone  is  present.  If  both  thoracic  and 
abdominal  organs  are  involved,  pathology,  almost  without 
exception,  declares  the  thoracic  focus  the  first  and  primary. 
If  a  few  authors  are  of  other  opinions,  and  if,  for  example, 
Fibiger  and  Jensen  find  primary  intestinal  tuberculosis  in 
about  six  per  cent,  of  all  patients ;  in  about  eleven  per  cent, 
of  all  tuberculous  patients ;  in  children,  about  sixteen  per 
cent. ;  Baumgarten  considers  these  figures  as  entirely  too 
high,  and  remarks:  "Indubitable  primary  intestinal  tuber- 
culosis is,  according  to  my  experience,  extremely  rare,  an 
opinion  shared  by  most  pathologists."  Virchow,  Orth,  Rib- 
bert,  Allbrecht,  and  many  others  agree  in  this.  Of  131 
children,  Orth  found  only  one  and  one  half  per  cent,  of 
indubitable  primary  tuberculosis  of  the  intestines  and 
mesenteric  glands ;  Biedert,  in  3,104  autopsies  of  tuber- 
culous children,  found  sixteen  cases  of  primary  intestinal 
tuberculosis ;  Baginsky  in  933  cases,  none ;  Grosser  in  1,407 
cases,  one ;  Winkler,  who  in  the  last  ten  years  has  autop- 
sied  557  tuberculous  children,  with  most  careful  search  for 
the  primary  focus,  found  240  pulmonic  cases  without  intes- 
tinal in\  olvement ;  in  nearly  all  the  others  intestinal  lesions 
were  present,  which,  however,  must  be  considered  as 
"secondary"  to  the  existing  pulmonic  foci,  whilst  the  cases 
where  "serious  intestinal  tuberculosis  was  found,  with  little 
or  no  pulmonic  involvement,  so  that  the  lungs  could  scarce- 
ly be  considered  the  primary  seat  of  the  disease,  were  ex- 
tremely rare,"  and  adds,  "most  careful  observation  of  both 
lungs  is  essential  to  their  elimination  as  primary  foci,  for 
not  infrequently  there  is  discovered  in  an  apparently  sound 
lung  a  minute  focus  which,  serves  to  clear  up  the  case." 

Hamburger  and  Sluka,  in  autopsies  of  335  tuberculous 
children,  did  not  observe  a  single  certain  case  of  intestinal 
tuberculosis,  foci  in  intestinal  or  mesenteric  glands  not  be- 
ing considered.  From  these  data  we  may  consider  it  cer- 
tain that  a  primary  location  of  tubercle  bacilli  in  the  intes- 
tine or  in  the  regional  glands  is  extremely  rare  in  children. 

The  great  majority  of  authors  have  concluded,  therefore, 
that  intestinal  infection  is  minimal  as  compared  to  the 
bronchogenic ;  that  alimentary  infection  is  also  of  second- 
ary importance,  since  it  furnishes  but  one  part  of  intestinal 
tuberculosis,  whilst  the  other  part  of  the  infection  is  de- 
rived from  man — by  contact,  by  inhalation,  and  lodgment 
in  the  pharynx,  and  thence  to  the  gastrointestinal  tract. 
But  such  conclusion  is  not  universally  accepted.  Accord- 
ing to  von  Behring,  Calmette,  and  others,  tubercle  bacilli 
penetrate  the  gut  mucosa  without  injuring  it,  enter  the 
blood  and  lymph  vessels,  and  then,  after  years  of  latency, 
colonize  in  their  focus  of  election — the  pulmonary  tissue. 

The  author  then  considers  the  distinctive  differ- 
ences between  bovine  and  human  bacilli  and  criti- 
cises the  conchisions  drawn  by  many  writers  as 
founded  on  insufficient  data.  He  inchides  vol- 
uminous tables  and  continues: 

According  to  these  tables,  in  the  organs  from  275  human 
cadavers,  cultures  were  obtained  in  232  cases  of  the  typus 
hum  anus ;  in  thirty-nine  cases,  cultures  of  the  typus  bo- 
vinus;  in  three  cases,  cultures  containing  both  types.  But 
it  would  be  very  erroneous  to  conclude  from  these  data 
(without  further  consideration)  that  bovine  tuberculosis, 
as  compared  with  the  totality  of  tuberculosis  in  man,  is 
represented  by  18  per  cent.  In  the  first  place,  many  more 
children  than  adults  were  examined,  since,  qiiite  compre- 
hensibly, the  chief  concern  was  for  the  former.  But,  with 
the  single  exception  of  an  adult  harboring  both  bacillary 
types,  every  case  of  bovine  tuberculosis  cited  by  German 
authors  is  found  in  children.  Also,  of  the  fourteen  cases, 
bovine  in  type,  furnished  by  the  English  commission,  ten, 
as  explicitly  stated,  are  intestinal  tuberculosis  in  children ; 
whether  the  other  four  bacillary  strains  which  were  cul- 


tured from  cervical  glands  were  found  in  children  is  not 
mentioned.  If  we  consider,  furthermore,  that  in  the  critical 
literature  to  date,  among  many  serial  investigations,  there 
are  only  five  adult  cases  where  the  bovine  type  was  found,, 
whilst,  on  the  contrary,  there  were  twenty  children  with 
bovine  tuberculosis,  the  conclusion  may  be  justified  that 
the  frequent  appearance  of  the  bovine  type  in  the  material 
at  hand  is  m  ratio  with  the  preponderance  of  the  infantile 
element. 

Secondly,  however,  the  German  (and  apparently  the 
English)  commissions,  m  an  endeavor  to  find  the  greatest 
possible  number  of  bovine  cases,  have  particularly  empha- 
sized in  children  the  most  suspiciously  bovine  types,  i.  e.,. 
tuberculosis  of  the  cervical  glands  as  well  as  those  primar- 
ily intestinal  and  mesenteric.  That  the  expectations  of  the 
investigators  were  gratified  is  shown  by  the  table ;  that 
also,  by  this  election  of  cases,  any  conclusions  as  to  the 
actual  frequency  of  the  bovine  type  (even  only  in  children) 
become  impossible  beyond  dispute.  Recognizing  this,  the 
German  commission  was  careful  to  avoid  any  unjustifiable 
general  conclusions  from  the  results  of  its  labors.  The 
English  commission,  however,  capped  the  climax  in  the 
dictum :  "A  very  great  part  of  the  illnesses  and  deaths  due 
to  tuberculosis,  i.  e.,  in  children,  must  be  referred  to  the 
use  of  tuberculous  milk."  How  premature  such  deductions- 
are  is  best  shown  in  the  experimental  series  of  Gaffky  and 
Beitzke.  Gaffky  reports  investigation  of  the  bronchial  and 
mesenteric  glands  in  300  (not  selected)  children  dying  in 
two  well  known  hospitals  in  Berlin  from  the  most  various 
diseases.  Fifty-seven  of  these  were  tuberculously  infecteJ,, 
and  of  these  fifty-three  showed  the  typus  huuianits;  in  two 
cases  the  results  of  rabbit  inoculation  had  not  been  reached, 
yet  in  these  there  was  no  suspicion  of  the  presence  of  the 
bovine  bacillus.  In  two  cases  only,  where,  because  of 
great  difficulty  in  getting  pure  cultures  from  the  guinea 
pig,  a  decision  had  not  been  reached,  was  there  any  sus- 
picion of  bovine  infection.  "The  investigations  confirm," 
concludes  Gaffky,  "the  correctness  of  the  thesis  that  even 
in  childhood  the  chief  danger  of  tuberculosis  in  man  is  not 
due  to  the  typus  boviiius,  but  to  the  typus  hiimanus."  Less 
cautious  is  Beitzke,  who.  during  the  summer  of  1905,  autop- 
sied  the  bodies  of  all  tuberculous  children  in  search  of  the 
human  or  bovine  bacilli ;  not  alone  the  bronchial  and 
mesenteric  glands  (Gaffky),  but,  according  to  the  case,  the 
bronchial,  mesenteric,  and  cervical  glands,  lungs,  cerebral 
substance,  etc.  In  two  cases  only  (primary  intestinal  tuber- 
culosis and  a  phthisis  with  intestinal  ulcerations)  did  he 
find  the  typus  bovinus,  but  considers  it,  because  of  two 
"atypic"  strains  (cultured  from  one  and  the  same  case), 
possible  that  in  the  other  twenty-three  cases  there  might 
have  been  a  bovine  bacillary  infection  "not  distinguishable 
(or,  at  least,  not  with  certainty)  from  the  human  type. 
Erom  this  it  follows  that  we  have  to  deal  with  a  much 
more  frequent  tuberculous  infection  in  man  from  the 
bovine  source  than  hitherto  established  by  means  of  bac- 
teriological methods,  and  that,  therefore,  the  eight  per  cent, 
frequency  of  bovine  tuberculous  infection  in  children  is  too 
moderate  an  estimate."  Without  discussing  the  exhaustive 
bacteriological  researches,  I  cannot  (though  appreciative  of 
the  laborious  work  accomplished  in  this  direction)  hold  it 
proper  to  build  further  theory  upon  so  scanty  a  founda- 
tion, nor  to  draw  therefrom  conclusions  as  to  the  actual 
frequency  of  infection  with  the  bovine  bacillus  in  child- 
hood. The  inmates  of  our  hospitals  present,  because  of 
age,  social  standing,  causes  of  illness,  etc..  too  peculiar  and' 
too  changeable  a  human  category  to  permit  the  extension 
of  statistical  deductions  to  cover  the  remaining  and  free 
part  of  tlie  population,  and  we  should  proceed  even  more 
cautiously  in  a  similar  valuation  of  autopsical  data. 

If  we  consider  the  sources  of  errors  which  undoubtedly 
have  crept  into  such  research  series  because  of  the  material 
selected,  we  must,  in  order  to  obtain  the  actual  frequency 
of  bovine  infection,  fall  far  below  the  above  mentioned 
average  of  eighteen  per  cent.  Even  ten  per  cent,  is  still 
too  high  a  figure  in  most  of  the  series.  This  is  clear  from- 
the  percentage  obtained  when  we  confine  ourselves  to  the 
data  of  research  limited  to  adults  (over  fifteen  years  of 
age)  or  to  those  affected  by  tuberculosis  of  the  lungs  (and 
bronchial  glands).  In  both  of  these  conditions  we  have 
nearly  one  hundred  per  cent,  of  the  typus  humanus;  of  the 
fifty-six  phthises  investigated,  the  bovine  type  was  found 
•but  once  (and  that  in  a  child)  or  two  per  cent,  (nearly"), 
of  the  cases,  whilst  phthisis  in  the  adults  was,  without 
exception,  of  the  typus  humanus.  On  the  other  hand,  the 
mortality  of  tuberculous  adults,  and  further,  the  mortality 


January  16.  1909.) 


MISCELLANY. 


145 


from  pluhisib,  dominate  in  the  picture  of  the  extent  of 
human  tuberculosis.  In  Germany  we  estimate  fifteen  deaths 
in  childhood  for  every  eight-hve  adult  deaths;  and  for 
€very  one  hundred  and  eight  deaths  from  phthisis  we  esti- 
mate ten  lethal  cases  from  tuberculosis  in  other  organs. 
The  enormous,  overwhelming  significance  of  the  typus 
humaiius  in  the  frequency  of  tuberculosis  with  which  we 
are  now  interested  is  quite  clear  in  view  of  these  figures. 

It  will  take  years  more  of  earnest,  objective  research 
ere  accurate  computation  of  the  frequency  of  bovine  infec- 
tion can  be  obtained  by  means  of  bacteriological  investiga- 
tion. ■ 

Koch,  however,  from  the  beginning  has  pointed  out  a  pro- 
cedure whereb}-  it  will  be  possible  to  gain  knowledge  of 
the  danger  threatening  mankind  from  bovine  bacilli,  viz., 
statistical  and  ethnographic  data.  Along  such  lines  we 
already  possess  manifold  material.  Investigations  could 
be  made  of  the  fate  of  humans  who  indubitably  and  for 
long  periods  have  ingested  bovine  bacilli.  The  conditions 
for  the  gathering  of  reliable,  demonstrable  data  of  such 
■description  were  formulated  by  Koch  himself  in  the  Inter- 
national Tuberculosis  Congress  (Berlin,  *i502j  and  encour- 
agement given  to  such  research,  which,  "by  order  of  the 
chancellor  and  tlie  local  courts  in  Prussia,  Bavaria,  Sax- 
ony. Wurttemberg,  Baden,  and  Hesse,  should  cover  cases 
where  for  long  periods  milk  from  cows  with  tuberculous 
udders  had  been  drunk  by  man."'  The  results  of  such  data 
(up  to  April,  1907;,  recently  published,  were  that  in  the 
fifty-three  cases  cited  there  was  but  one  really  sick  and 
actually  infected  with  the  typus  bovimts,  whilst  in  three 
■others  there  was  only  a  suspicion  of  a  tuberculous  condi- 
tion, possibly  attributable  to  the  use  of  milk.  In  four  other 
cases,  together  with  the  use  of  the  milk  from  a  cow  with 
tuberculous  udders,  there  developed  tuberculosis  in  the 
family,  which,  because  of  the  positive  presence  of  bovine 
Itacilli  in  the  milk  and  of  human  bacilli  in  the  two  children 
afifected,  certainly  was  not  attributable  to  the  milk  supply. 
Hence,  the  results  hitherto  of  such  investigation  have  been 
very  meagre." 

In  harmony  with  the  above  are  the  reports  of  investiga- 
tors who  have  studied  the  relation  of  human  to  bovine 
tuberculosis  in  localities  where  the  latter  was  particularly 
widespread.  Data  of  this  nature  have  been  given  by  Bie- 
dert  in  Bavaria,  Ganghofer  in  Bohemia,  von  Starck  in 
certain  parts  of  Prussia,  Rordam  for  Danish  provinces. 
Regner  for  some  localities  in  Sweden ;  not  one  of  these 
authors  has  been  able  to  verify  any  augmentation  of  tuber- 
culosis in  man  in  regions  where  bovine  tuberculosis  was 
present:  nor  in  countries  where  infection  with  bovine 
bacilli  could  be  excluded  do  we  find  any  particularly  favor- 
able tuberculous  data. 

Only  Raw  has  attributed,  from  investigations  of  like 
■character,  a  role  of  any  significance  to  the  bo\  ine  infection 
in  a  number  of  localities.  Because  of  clinical,  pathological, 
anatomical,  and  experimental  investigations,  Raw  con- 
cluded that  phthisis  with  (secondary)  intestinal  ulceration 
and  swelling  of  the  mesenteric  glands  was  due  to  the  typus 
humanns,  whilst,  on  the  contrary,  primary  affections  of  the 
mesenteric  glands,  particularly  wehn  going  on  to  caseation 
without  intestinal  ulceration ;  articular  osseous  (probably)  ; 
meningeal  inflammations ;  lupus :  and  acute  miliary  tuber- 
culosis were  caused  by  the  bovine  type.  In  this  opinion. 
Raw  was  especially  fortified  by  reports  received  from  other 
countries,  whilst  the  report  from  an  agricultural  district 
of  North  America,  where  much  raw  milk  was  consumed, 
showed  a  striking  excess  of  tuberculosis  of  the  abdomen, 
bones,  joints,  and  glands  as  compared  with  pulmonary 
troubles.  The  government  medical  officer  at  Bangkok, 
where  the  Siamese  population  never  use  cow's  milk,  said 
that  in  his  eleven  years'  practice  he  had  never  seen  a  case 
of  tuberculous  glands,  lupus,  or  tabes  iitesenterica,  though 
phthisis  in  the  adult  population  of  Bangkok  was  very  com- 
mon. Other  confirmations  are  reported  by  Raw.  Never- 
theless, experiences  in  other  countries  (Japan.  Turkey, 
Faroe  Islands,  etc.)  are  diametrically  opposed  to  such 
reports.  There,  likewise,  infection  from  cow's  milk  is  out 
of  the  question,  despite  which  tuberculous  glands  are  ex- 
tremely common.  Moreover,  bacteriological  investigations 
of  tuberculous  material  removed  surgically  are  far  from 
certifying  the  correctness  of  Raw's  views :  Oehlecker,  in 
■fifty  surgical  tuberculoses,  found  the  typus  humanus  forty- 
live  times,  the  typus  bovinus  only  five  times  (four  cervical 
glands,  one  bone  case).  If,  then,  there  really  are  localities 
in  whicb  certain  tuberculoses  are  -0  markedly  absent,  it  is 
very  probable  that  other  conditions,  the  habits  of  the  popu- 


lation, etc.,  are  involved,  conditions  needing  further  investi- 
gation. 

In  this  regard  I  have  been  able  to  collect  a  number  of 
ethnographical  data  confirming  and  completing  my  previ- 
ous communications  and  well  adapted  to  strengthen  the 
conviction  that,  in  the  propagation  of  tuberculosis  in  gen- 
eral, alimentary  infection  plays  a  very  minimal  role. 

Kitasolo,  tor  Japan,  in  his  St.  Louis  communication. 
Concerning  the  Relation  of  Native  Cattle  to  Tuberculosis 
(Bovine),  fully  confirmed  the  statistical  data  and  reports 
verified  by  myself.  As  proof  thereof  the  following  excerpts 
from  his  conclusions  will  serve. 

"Human  tuberculosis  is  as  common  in  Japan  as  in  other 
civilized  countries  of  Europe  and  America.  .  .  .  The 
native  cattle,  under  natural  conditions,  are  almost  insus- 
ceptible to  bovine  tuberculosis  (Perlsucht).  .  .  .  The 
introduction  of  foreign  cattle  occurred  about  thirty  years 
ago,  whilst  human  tuberculosis  has  always  been  existent  in 
Japan.  ...  In  regard  to  von  Behring's  view  as  to  the 
avenue  of  infection,  I  must  confess  that  the  milk  for  in- 
fants (cow's  milk)  plays  no  role  with  us  in  Japan  in  re 
tuberculosis."  And  finally,  keeping  in  mind  Raw's  view,  we 
find  Kitasato  saying;  "The  occurrence  of  primary  intestinal 
tuberculosis  is  somewhat  common  both  in  adults  and  chil- 
dren, though  the  nourishment  of  children — and  of  adults 
also — has  no  relation  to  cow's  milk.'' 

For  Greenland,  confirmations  are  at  hand  from  H.  Ror- 
dam, which  contain  not  only  Kjier's  work  already  cited  by 
me  but  also  a  communication  from  Meldorf.  The  latter, 
whilst  on  a  vaccinating  trip  through  West  Greenland, 
examined  thirty-seven  immigrants  from  East  Greenland 
the  day  after  their  arrival ;  in  seventeen  he  found  un- 
healthj-  lungs,  in  three  indubitably  tuberculous  changes,  in 
four  there  was  a  history  of  haemoptysis.  Rordam  also  as- 
sures us  that  infection  with  bovine  tuberculosis  in  Green- 
land is  ''absolutely  out  of  the  question,"  and  attributes,  as 
pictured  in  my  former  communication,  the  wide  spread  of 
tuberculosis  in  the  Greenlanders,  to  the  miserable  housing 
and  reprehensible  social  conditions.  The  children  also  are 
frequent  victims,  and  with  them,  as  expressly  stated  by 
Kjier,  "meningitis  tuberculosa  is  one  of  the  most  common 
causes  of  death." 

For  Asiatic  Turkey,  elucidative  material  is  found  in  the 
reports  of  Christ,  who  for  four  years  labored  in  the  Hos- 
pital of  the  German  Oriental  ]\Iission  at  Ourfa  in  upper 
Mesopotamia.  He  says  that  in  his  region  tuberculosis  is 
extraordinarily  widespread ;  of  the  ambulatory  patients  ten 
per  cent,  suffer  from  tuberculous  lesions.  Pulmonary  tuber- 
losis  runs  its  course  more  rapidly,  more  viciously,  than  in 
Europe.  Chronic  cases  showing  an  inclination  to  stoppage 
or  retrogression  of  the  disease  are  rare.  Extremely  fre- 
quent— contrary  to  Raw's  views — are  tuberculous  lympho- 
mata  in  children  and  young  people :  tuberculosis  of  the 
bony  system  rather  less  common. 

Infants  are  fed  from  the  breast  and  commonly  for  a 
period  of  two  years.  If  the  mother  is  not  able  to  provide 
so  long  a  lactation,  a  relative  or  neighbor  takes  the  child 
and  nurses  it  with  her  own.  Milk  is  never  ingested  raw, 
not  even  by  adults,  as  the  people  consider  it  unhealthful  in 
this  condition,  but  is  almost  exclusively  used  in  the  form 
of  sour  milk  (prepared  from  cooked  milk)  or  in  the  form 
of  cheese  or  in  a  sweet  broth  cooked  with  rice.  Of  meats, 
the  flesh  of  sheep  and  cows  is  almost  entirely  employed,  not 
only  boiled  or  roasted  but  also  cut  up  raw  for  broth  and 
mixed  with  dry  wheat,  cut  up  onions,  peppers,  etc.  As  the 
cause  of  the  prevalency  of  tuberculosis,  Christ  emphasizes 
the  utterly  careless  expectoration  "in  cavelike  rooms,  often 
totally  unlighted,"  and  in  which  many  individuals  are  often 
crowded  together." 

Of  reports  from  regions  not  hitherto  mentioned  I  have 
the  following  to  offer : 

I.  ROUMANIA. 

The  marked  prevalence  of  tuberculosis  in  Roumania  has 
been  much  emphasized  in  the  last  few  years  by  Babes,  who 
has  therefrom  developed  an  organization  of  wide  scope  for 
its  conquest.  In  the  cities  (where  alone  there  is  registra- 
tion of  the  cause  of  death)  eleven  to  12  per  cent,  of  the 
mortality  is  from  pulmonary  tuberculosis ;  in  rural  districts 
Babes  estimates  deaths  from  this  cause  at  about  ten  per 
cent.  But  in  Bucharest,  with  a  population  of  almost  300,000, 
the  average  death  rate  for  the  years  1890  to  1897  was  849,  or 
the  high  ratio  of  36.6  to  10,000  living;  in  Galatz  (1896  to 
1897)  it  rose  to  39.6;  in  Jassy  (1896  to  1897)  even  to  46.6. 
For  all  of  the  urban  population  of  the  country,  Babes  esti- 
mates it  at  from  thirty-four  to  thirty-eight,  whilst  in  Ger- 


146 


OFFICIAL  NEWS. 


[New  yo«K 
Medical  Journal. 


man  towns  with  more  than  15,000  inhabitants  on  the  aver- 
age, for  the  years  1891  to  1900,  the  rate  was  22.4. 

But,  with  this  great  prevalency,  cow's  milk,  particularly 
as  an  infant's  food,  has  nothing  to  do.  As  Babes  briefly 
reported  before,  and  as  he  more  explicitly  stated  in  a  very 
friendly  personal  letter,  "In  most  of  the  districts  and  lo- 
calities where  tuberculosis  is  prevalent  there  are  no  milch 
cows,  and  nursing  children  in  particular  are  not  fed  cow's 
milk."  Dr.  F.  Schroter,  also,  of  Campina  in  Roumania, 
who,  as  chief  engineer  of  a  chemical  company,  has  traveled 
about  the  country  for  many  years,  and  is  perfectly  familiar 
with  the  customs  of  the  people,  assures  me  that  children  are 
fed  only  from  the  breast  and  often  for  an  extended  period, 
and  that  cattle  are  employed  almost  exclusively  as  laboring 
animals. 

Positive  aetiology  of  the  great  frequency  of  phthisis  in 
Roumania  is  not  obtainable.  Babes  is  plainly  of  the  opinion 
that  certain  unsanitary  conditions,  particularly  crowded 
dwellings,  together  with  the  absolute  ignorance  in  many 
classes  of  the  population  of  the  contagiousness  of  the  dis- 
ease, are  chiefly  responsible. 

2.     THE  FAROE  ISLANDS. 

This  Danish  Island  group  is  composed  of  many  islets 
containing  about  one  hundred  villages  and  districts,  all  of 
which  are  situated  on  the  coast.  The  inhabitants  (16,349 
by  the  last  census,  February  i,  1906)  support  a  laborious 
and  perilous  existence  by  sheep  raising,  bird  catching,  fish- 
ing, and  whaling.  Until  recently  they  lived  almost  isolated 
from  the  world ;  even  between  single  islands  and  villages, 
communication  is  extremely  difificult  because  of  wide  bays 
with  strong  currents  and  heavy  surf  or  the  precipitous, 
rocky  nature  of  the  country.  Hence  it  is  quite  comprehen- 
sible that  the  population  has  sufYered  little  change  in  com- 
position or  social  habits  either  from  its  own  initiative  or 
because  of  foreign  elements,  but  has  maintained  itself  and 
its  customs  in  a  wonderful  uniformity  for  centuries.  These 
peculiar  circumstances  have  long  interested  physicians, 
particularly  with  regard  to  the  epidemiological  studies,  for 
which,  since  time  immemorial,  officially  ordered  statistics, 
based  as  little  as  possible  upon  oral  tradition,  have  fur- 
nished material  "of  almost  perfect  historical  value"  (or 
truth).  The  best  known  of  such  studies  is  Panum's  de- 
scription of  a  violent  epidemic  of  measles  spreading  from 
an  English  ship  in  the  year  1846.  The  recognition  of  the 
great  significance  of  the  Faroe  Islands  in  the  investigation 
of  tuberculosis  is  to  be  credited  to  Boeg.  Based  upon  wide 
practical  experience  and  most  precise  investigations  during 
more  than  ten  years'  activity  as  official  physician  in  the 
islands  as  well  as  upon  all  the  pertinent  material  found  in 
church  records,  hospital  journals,  and  official  documents,  he 
negates  the  widely  spread  impression  that  pulmonary  tuber- 
culosis is  very  infrequent  in  the  Faroe  Islands,  "a  report 
so  often  made  that  it  has  been  credited  with  actuality." 
Already  towards  the  end  of  the  eighteenth  century  indubi- 
table cases  are  noted  in  the  church  records;  in  the  first 
half  of  the  nineteenth  century  they  grew  to  "house  epi- 
demics," so  that  the  report  of  the  Board  of  Health  for  1843 
already  mentions  the  "endemic  phthisis"  prevalent,  and 
year  by  year  the  official  reports  point  with  greater  earnest- 
ness to  the  frequency  and  farther  extension  of  the  disease. 
Full  concept  of  conditions  is  gained  only  in  1879,  'n  which 
year  examination  of  the  dead  was  made  obligatory,  and  the 
control  of  death  certificates  was  turned  over  to  the  official 
physicians.  "Since  then,  it  is  impossible  not  to  observe  the 
very  common  incidence  of  pulmonary  phthisis."  From  1879 
to  1898  a  total  of  305  deaths  were  from  this  cause,  i.  e., 
eight  per  cent,  of  the  total  death  rate  or  11.8  in  10,000  of 
population,  if  in  this  last  computation  we  take  the  census  of 
1890  (12,955  population)  is  taken  as  basis — a  phthisis  rate 
not  attained  (or  but  slightly  surpassed)  in  many  English 
countries,  in  Japan  (1886  to  1895,  11.8),  or  in  the  smaller 
cities  of  Denmark  and  France. 

According  to  Westergaard,  it  is  the  general  custom  for 
mothers  to  nurse  the  children.  Infant  mortality  is,  therefore, 
very  small,  6.3  in  100  live  births,  whilst  in  Denmark  and 
Norway,  two  continental  countries  boasting  a  particularly 
low  infant  mortality,  the  corresponding  figures  are  13.3 
(1895  to  1900).  But  in  later  life  also,  until  a  few  years 
ago,  infection  with  cow's  milk,  dairy  products,  or  other 
tuberculous  (bovine)  material  was  entirely  to  be  excluded. 
Boeg  has  investigated  the  prevalence  of  tuberculosis  among 
Faroe  cattle  with  the  utmost  care,  and  with  the  aid  of 
official  veterinaries  by  means  of  examinations,  autopsies, 
injection  of  tuberculin,  etc.,  and  states  positively  that  the 
native  cattle  were  free  from  tuberculosis,  and  that  the  few 


cattle  imported  in  the  last  decennium  of  the  previous  cen- 
tury were  easily  located  and  found  to  be  healthy,  and  that 
only  the  more  active  importation  of  Danish  breeds  toward 
the  close  of  the  nineteenth  century  is  responsible  for  the  ap- 
parition of  bovine  tuberculosis  and  its  spread  among  native 
cattle.  Hence,  bovine  tuberculosis  has  no  relation  to  the 
morbid  material  with  which  we  are  concerned.  So  much 
the  more  intere>ting,  then,  is  the  fact  that  Boeg  reports  a 
long  list  of  glandular,  articular,  and  osseous  tuberculoses, 
cases  which  markedly  elevate  the  general  frequency  of 
tuberculosis  above  the  previously  mentioned  mortality  due 
only  to  pulmonary  affection. 

To  discover  the  cause  of  this  frightful  prevalence  of 
phthisis,  Boeg  investigated  the  cases  of  305  individuals 
whose  death  certificates  were  signed  by  a  physician,  as  well 
as  forty-nine  still  living  and  examined  by  himself,  and, 
with  decisive  negation  of  any  hereditary  influences,  arrives 
at  the  conclusion  that  "the  fresh  and  actively  virulent  ex- 
pectoration of  phthisical  patients  expelled  in  coughing  as 
a  fine  spray  is  the  common  source  of  infection.  In  not  less 
than  262  of  342  cases  of  pulmonary  tuberculosis  in  which 
data  as  to  the  lahiily  relations  and  conditions  were  avail- 
able, infection,  after  this  manner,  was  demonstrable,  i.  e., 
in  seventy-seven  per  cent,  of  the  cases — an  imposing  con- 
firmation, in  fact,  of  the  significance  of  Fliigge's  theory  of 
"droplet  infection." 

It  may  be  briefly  mentioned  here  that  conditions  similar 
to  those  cited  of  Greenland  and  the  Faroe  Islands,  but  with- 
out statistical  support,  are  found  in  Iceland  and  among  the 
Indians  of  Arctic  North  America,  among  whom,  according 
to  J.  Lang,  tuberculosis  is  extremely  prevalent. 

3.    EGYPT.  (Abstract.) 

Egyptian  data  exclude  infection  from  bovine  products 
and  according  to  Gotschlich,  "it  is  only  necessary  to  have 
seen  once  the  disgusting  habit  of  the  closely  crowded  pop- 
ulation of  almost  uninterruptedly  spitting  about  to  under- 
stand the  frequency  of  tuberculous  infection  from  man  to 
man  among  a  population  living  in  such  orderless  and  un- 
hygienic conditions." 

4.    THE  GOLD  COAST  OF  AFRICA.  (Abstract.) 

According  to  R.  Fisch,  twenty  years  missionary  physi- 
cian, tuberculosis  is  extremely  prevalent,  twelve  per  cent, 
of  patients  suffering  from  it,  mostly  phthisis  (galloping), 
much  more  rarely  intestinal,  glandular,  etc. ;  bone  and  skin 
tuberculosis  not  observed. .  Cow's  milk  not  used.  Infectiorf 
is  particularly  attributed  to  expectoration  and  contact. 

An  enormous  quantity  of  data  could  be  cited  in  proof 
that  tuberculosis  (without  the  ingestion  of  food  containing- 
tubercle  bacilli)  can  be  just  as  prevalent  as  in  conditions- 
where  there  is  opportunity  for  infection  with  bovine  bacilli. 
In  considering  them,  the  relative  frequency  of  the  various- 
methods  or  modes  of  infection  in  the  develonment  of  tuber- 
culosis, no  particular  and  preponderant  significance  is  to  be 
attributed  to  food  stuffs  containing  tubercle  bacilli,  but 
rather,  on  the  contran.'.  one  minimally  minute. 

 ^  


Affinal  Sftos. 


Public   Health   and    Marine   Hospital  Service 
Health  Reports : 

The  foUo'ving  cases  of  sinalhox,  yellow  fever,  cholera^ 
and  plague  have  been  reported  to  the  surgeon  general,. 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  zveek  ending  January  8,  igog: 

Smallpox — United  States. 
Places.                                                              Cases.  Deaths. 
Arkansas — Little  Rock  Dec.  15- Jan.  2   23 


Present. 


Present. 


Indiana — LaFayette  Feb.  21-2H   7 

Kansas — Wichita  Dec.  19-26   i 

Maine — General — 

Maine — Canadian    Border  Dec.  19-26  

Maine — St.  Agatha  Dec.  29   15 

Maine — \'an  Buren  Dec.  29   2 

Nebraska — South   Omaha  Dec.  19-26   i 

Pennsylvania — New  Kingston  Dec.  29  

Pennsylvania — Philadelphia  Dec.  18-25   ' 

Pennsylvania — Pittsburgh  Dec.  12-19   i  Imported 

Tennessee — Nashville  Dec.  19-26   i 

Texas — San  Antonio  Dec.  19-26   i 

Sninllfox — Foreign. 

Arabia — Aden  Nov.  23-Dec.  7   2- 

Brazil — Santos  Nov.  2-15   J 

Canada — Halifax   Dec.  12-19   ' 

Canada — Toronto  Nov.  7-14   5 

Canada— \'ictoria  Dec.  5-12   i 

Ceylon — Colombo  Dec.  i-Nov.   7   25 

Elmira— Shanghai  Nov.  7-Dec.  i  


I- 

Present. 


January  16,  1909. J 


OFFICIAL  NEWS. 


H7 


^gypi — Cairo  Dec.  2  

France — Paris  Dec.  5-12  

Greece — Athens  Nov.  21-28  

India — Bombay  Nov.  24-Dec.  i 

India — Calcutta  Oct. 

Italy — General  ' '.  "Dec. 

Italy — Naples  '. .  '.Nov. 

Java — Batavia  Nov. 

Norway — Christiana  Nov. 

Portugal — Lisbon  Dec. 

Russia — Riga  Dec. 

Russia — St.  Petersburg  Nov. 

Russia — Warsaw  Oct. 

Spain — Barcelona  Dec. 

Spain — Valencia  Nov. 

Spain — Vigo  Nov. 


3  i-Nov.  7 .  . 

6-13  

6-13  

15-21  

21-28  

5-1-'  

5-12  

15-22  

3I-N0V.  14. 


-14. 


12-19. 
20-26. 


12-26. 
12-26 . 


28- Dec. 
28-Dec. 
Yellow  Fever — Foreign. 

Brazil — Para  Nov.  21-Dec. 

Cuba — San  Luis  Jan.  1-2.... 

Ecuador — Guavaquil  Nov. 

Nov. 

Mexico — Maxcanu  Dec. 

Mexico — Merida  Dec. 

Mexico — Sodsil  plantation  (Vicin- 
ity of  Merida)  Dec. 

ile.xico — Vera  Cruz  Dec. 

Chole  ra  — Fo  re  ign . 

India — Calcutta  Oct.  31-Nov.  7 

India — Madras  Nov.  14-20.... 

Indo-China — Cholen  Nov.  9-15  

Russia — General  Nov.   1 5-28. .  . . 

Straits  Settlements — Singapore. . .  Nov.  1-14  

Plague — Foreign. 

Ecuador — Guayaquil  Nov. 

Ecuador — Milagro  Nov. 

Egypt — General  Nov. 

Egypt — Alexandria  Nov. 

Eg>-pt — Port  Said   Dec. 

Formosa  Nov. 

India — Bombay  Nov.  24-Dec. 

India — Calcutta  Nov.  1-7.... 

India — Rangoon  Nov.  14-21.. 


7-2S 


-31- 


25-Dec.  8  1 

30-Dec.  7  

7  

7-14 


248 
33 


6 
28 


Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  coin- 
missioned  and  otiier  officers  of  tJte  United  States  Public 
Healtit  and  Marine  Hospital  Service  for  the  seven  days 
ending  December  30,  ipo8: 

Bowers^  P-xul  E.,.  Acting  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  December  25,  1908. 

Brooks^  S.  D.,  Surgeon.  Granted  fifteen  days'  leave  of  ab- 
sence from  December  26,  1908,  on  account  of  sickness. 

CoFER,  L.  E.,  Passed  Assistant  Surgedn.  Granted  seven 
days'  leave  of  absence  from  December  24,  1908. 

Collins,  G.  L.,  Passed  Assistant  Surgeon.  Granted  one 
day's  leave,  December  27,  1908. 

FauntleroV,  Charles  M.,  Assistant  Surgeon.  Relieved 
from  duty  at  Marine  Hospital,  New  Orleans,  La.,  and 
directed  to  proceed  to  New  Orleans  Quarantine  Station 
for  duty  and  assignment  to  quarters. 

Foster,  M.  H.,  Passed  Assistant  Surgeon.  Upon  being  re- 
lieved by  Passed  .Assistant  Surgeon  S.  B.  Grubbs,  to 
proceed  to  New  York  and  report  to  the  chief  medical 
officer,  Ellis  Island  Immigration  Station,  for  duty. 

Foster,  A.  D.,  Passed  Assistant  Surgeon.  Granted  eleven 
days'  leave  of  absence  from  December  23,  1908. 

Grubbs.  S.  B.,  Passed  Assistant  Surgeon.  Upon  expiration 
of  leave,  to  proceed  to  San  Juan,  Porto  Rico,  for  duty 
as  chief  quarantine  officer,  relieving  Passed  Assistant 
Surgeon  M.  H.  Foster. 

McKay,  Malcolm,  Pharmacist.  Leave  of  absence  granted 
February'  8,  1908,  for  thirty  days  from  March  i,  1908, 
amended  to  read  twenty-five  days  from  March  i.  1908. 
Granted  three  days'  leave  from  December  16,  1908,  un- 
der paragraph  210,  Service  Regulations. 

Oakley,  J.  H.,  Passed  Assistant  Surgeon.  Detailed  as  a 
member  of  a  Revenue  Cutter  Service  retiring  board  at 
Port  Townsend,  Wash.,  January  9,  1909. 

Preble,  Paul.  Assistant  Surgeon.  Orders  to  report  to 
medical  officer  in  command  at  Baltimore,  Md.,  revoked. 
Directed  to  proceed  to  Stapleton,  N.  Y..  and  report  to 
medical  officer  in  command  for  duty  and  assignment  to 
quarters. 

Stimpsok,  W.  G.,  Surgeon.  Detailed  as  member  of  a  Rev- 
enue Cutter  Service  retiring  board  at  Port  Townsend, 
'Wash.,  January  9,  1909. 

Sweet,  Ernest  A.,  Passed  Assistant  Surgeon.  Directed 
to  proceed  to  Boston,  Mass.,  and  report  to  medical 
officer  in  command  for  temporary  duty. 

Wright,  F.  T.,  Acting  Assistant  Surgeon.  Granted  five 
rnonths'  leave  of  absence  from  December  23,  1908,  with- 
out pay. 


Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  officers 
serving  in  the  Medical  Corps  of  the  Untied  States  Army 
for  the  Txjeefi  ending  January  g,  igog: 

Bloombergh,  H.  D.,  Captain,  Medical  Corps.  Sailed  from 
San  Francisco,  Cal.,  January  5,  1909,  on  the  Thomas. 
for  duty  in  the  Philippines  Division. 

Borden,  W.  C,  Major,  Medical  Corps.  Retired  from  act- 
ive service. 

Brewer,  I.  W.,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  twenty  days. 

Ebert,  R.  G.,  Lieutenant  Colonel,  Medical  Corps.  Granted 
leave  of  absence  for  fifteen  days. 

Fauntleroy,  p.  C,  Major  Medical  Corps.  Granted  leave 
of  absence  for  three  months,  fifteen  days,  with  permis- 
sion to  go  beyond  sea. 

Hadra,  Frederick,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  in  Philippines  Division,  and  or- 
dered to  San  Francisco,  Cal.,  for  further  orders. 

KiERSTED,  H.  S.,  Captain,  Medical  Corps.  Granted  an  ex- 
tension of  fifteen  days  to  leave  of  absence. 

KoERPER,  C.  E.,  Captain,  Medical  Corps.  Ordered  to  Fort 
Slocum,  N.  Y.,  for  duty,  upon  return  from  Cuba. 

Kress,  C.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  one  month. 

LeHardy,  J.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Sailed  from  San  Francisco,  Cal.,  January  5,  1909,  on 
the  Thomas,  for  duty  in  the  Philippines  Division. 

Lincoln,  H.  F.,  First  Lieutenant,  Medical  Reserve  Corps. 
Sailed  from  San  Francisco,  Cal.,  January  5,  1909,  on 
the  Th  onias,  for  duty  in  the  Philippines  Division. 

McC-\LLUM,  F.  M..  First  Lieutenant,  Medical  Reserve 
Corps.  Sailed  from  San  Francisco,  Cal.,  January  5. 
1909,  on  the  Tliomas,  for  duty  in  the  Hawaiian  Islands. 

Mearns,  E.  a..  Major,  Medical  Corps.  Retired  from  act- 
•    ive  service. 

Morse,  C.  F.,  Captain,  Medical  Corps.  Sailed  from  San 
Francisco,  Cal.,  January  5,  1909,  on  the  Thomas,  for 
duty  in  the  Hawaiian  Islands. 

PuRNELL,  H.  S.,  Captain,  Medical  Corps.  Sailed  from  San 
Francisco,  Cal.,  January  5,  1909,  on  the  Thomas,  for 
duty  in  the  Philippines  Division. 

Richardson,  G.  H.,  First  Lieutenant,  Medical  Reserve 
Corps.  Honorably  discharged  from  the  service  of  the 
United  States,  his  services  being  no  longer  required. 

Sparrenberger,  F.  H.,  First  Lieutenant,  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  ten  days. 

Stark,  A.  N.,  Major,  Medical  Corps.  Granted  an  exten- 
sion of  fifteen  days  to  his  leave  of  absence. 

Webb,  W.  D.,  Captain.  Medical  Corps.  Retired  from  active 
service. 

Navy  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 

Navy  for  tlie  ZL'eefi  ending  January  9.  igog: 

Allen,  A.  H.,  Assistant  Surgeon.  Detached  from  duty 
with  the  first  provisional  regiment  of  Marines  in  Cuba 
and  ordered  to  the  Naval  Hospital,  Las  Animas,  Colo. 

B.\CKUS,  J.  W.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Station,  Guantanamo,  Cuba,  and  ordered 
home  to  await  orders. 

Benton,  F.  L..  Surgeon.  Detached  from  duty  with  the 
first  provisional  regiment  of  Mari'nes  in  Cuba  and  or- 
dered to  the  Franklin. 

Bishop,  L.  W.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  Omaha,  Nebr.,  and  or- 
dered to  the  Hancock. 

Campbell,  R.  A.,  Acting  Assistant  Surgeon.  Detached 
from  the  Franklin  and  ordered  home  to  await  orders. 

Dixox,  W.  S..  Medical  Director.  Transferred  to  the  re- 
tired list,  January  5,  1909,  in  accordance  with  the  pro- 
visions of  section  1444,  Revised  Statutes ;  ordered  to 
continue  duty  at  the  Naval  Dispensary,  Washington, 
D.  C,  until  further  orders. 

Hayden.  R.,  Assistant  Surgeon.  Detached  from  duty  with 
the  first  provisional  regiment  of  Marines  in  Cuba  and 
ordered  home  to  await  orders ;  ordered  to  the  Naval 
Station,  Guantanamo.  Cuba. 

Hollaway,  J.  H..  Passed  Assistant  Surgeon.  Detached 
from  duty  with  the  first  provisional  regiment  of  Ma- 
rines in  Cuba  and  ordered  to  the  Franklin. 


148 


BIRTHS.  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journai.. 


Iden,  J.  H.,  Passed  Assistant  Surgeon.  Detached  from 
duty  with  the  first  provisional  regiment  of  Marines  in 
Cuba  and  ordered  to  the  Naval  Hospital,  Pensacola, 
Fla. 

Lowndes,  G.  H.  T.,  Surgeon.   Ordered  to  duty  at  the  Naval 

Dispensary,  Washington,  D.  C. 
Mears,  J.  B.,  Assistant  Surgeon.    Detached  from  duty  with 

the  first  provisional  regiment  of  Marines  in  Cuba  and 

ordered  to  the  Franklin. 
Murphy,  J.  A.,  Surgeon.    Detached  from  the  Franklin 

and  ordered  home  to  wait  orders. 
Plummer,  G.  R.,  Acting  Assistant  Surgeon.  Detached 

from  the  Naval  Station,  Key  West,  Fla.,  and  ordered 

home  to  await  orders. 
RiGGS,  R.  E.,  Passed  Assistant  Surgeon.    Ordered  to  the 

Texas. 

Robnett,  a.  H.,  Assistant  Surgeon.  Detached  from  duty 
with  the  first  provisional  regiment  of  Marines  in  Cuba 
and  ordered  to  the  Naval  Recruiting  Station,  Omaha, 
Ncbr. 

Sellers,  F.  E.,  Assistant  Surgeon.  Detached  from  the 
Texas  and  ordered  to  the  Naval  Station,  Key  West, 
Fla.;  orders  of  December  31st  modified;  detached  from 
the  Texas  and  ordered  to  the  Naval  Recruiting  Station, 
New  Orleans,  La. 

Zalesky,  W.  J.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  New  Orleans,  La.,  and 
ordered  to  continue  duty  at  the  Naval  Station,  New 
Orleans,  La. 

 <$>  

§irt^s,  Parriagts,  ani  ieatfes. 


Married. 

Bailev — Travehs. — In  Philadelphia,  on  Thursday,  Janu- 
ary 7th,  Dr.  Thomas  W.  Bailey  and  Miss  Mary  Travers. 

Caraway— Ellington. — In  Birmingham,  Alabama,  on 
Wednesday,  December  30th,  Dr.  Archibald  Ferdinand  Cara- 
way and  Mrs.  Margaret  Roe  Ellington. 

Guild — Adams. — In  Wheaton,  Illinois,  on  Saturday,  Jan- 
uary 2nd,  Dr.  W.  L.  Guild,  of  Wayne,  III,  and  Miss  Susan 
M.  Adams. 

J ARRATT— Phillips. — In  Washington,  D.  C,  on  Monday, 
January  4th,  Dr.  R.  B.  Jarratt,  Jr.,  of  Richmond,  Virginia, 
and  Miss  Phillips. 

Rush — Pitts.— In  Jackson,  Mississippi,  on  Wednesday, 
December  30th,  Dr.  J.  C.  Rush,  of  Waynesboro,  and  Mrs. 
Mary  F.  Pitts. 

Thomas — Stackhouse. — In  Philadelphia,  on  Tuesday, 
January  5th,  Dr.  Benjamin  A.  Thomas  and  Miss  Lucy 
Buchanan  Stackhouse. 

Trout — Cocke. — In  HoUins,  Virginia,  on  Thursday,  De- 
cember 31st,  Dr.  Hugh  Trout,  of  Roanoke,  and  Miss  Leo- 
nora Cocke. 

Died. 

Adams. — In  Pine  Apple,  Teimessee,  on  Tuesday,  Decem- 
ber 29th,  Dr.  David  Adams,  aged  seventy-nine  years. 

Anderson. — In  New  York,  on  Monday,  January  4th,  Dr. 
Henry  A.  C.  Anderson,  aged  seventy  years. 

Beale. — In  Cynthiana,  Kentucky,  on  Tuesday,  January 
5th,  Dr.  A.  J.  Beale,  aged  seventy-three  years. 

Belden. — In  Glen  Ellen,  California,  on  Monday,  Decem- 
ber 28th,  Dr.  lulwin  S.  Belden,  of  San  Francisco,  aged 
sixty-five  years. 

Berry. —  In  Olean,  New  York,  on  Friday,  December  2Sth, 
Dr.  A.  F.  Berry,  aged  seventy-one  years. 

Brasted. — In  Hornell,  New  York,  on  Friday,  January 
ist.,  Dr.  C.  M.  Brasted,  aged  seventy  years. 

Bressenhan. — In  Athol,  Massachusetts,  on  Tuesday, 
January  5th,  Dr.  C.  W.  Bressenhan,  of  Millers  Falls. 

Campbell. — In  Brooklyn,  New  York,  on  Thursday,  De- 
cember 3Tst,  Dr.  Alice  Boole  Campbell,  aged  seventy-two 
years. 

Chalmers. — In  New  York,  on  Wednesday,  January  6th, 
Dr.  Matthew  Chalmers,  aged  seventy-two  years. 

Cheney. — In  Messina,  Italy,  on  Monday,  December  28th, 
Dr.  Arthur  S.  Cheney. 

Dalby. — In  Oxford.  North  Carolina,  on  Friday,  January 
1st,  Dr.  Adoniram  J.  Dalby. 

Dameron. — In  Wildersville,  Tennessee,  on  Saturday, 
January  2d,  Dr.  George  Dameron,  aged  twenty-eight  years. 


Davis. — In  San  Antonio,  Texas,  on  Friday,  January  ist. 
Dr.  James  Davis,  aged  seventy-six  years. 

Denison. — In  Denver,  Colorado,  on  Sunday,  January 
loth,  Dr.  Charles  Denison,  aged  si.xty-three  years. 

De  Wolf. — In  Port  of  Spain,  Trinidad,  on  Saturday,  Jan- 
uary 2nd,  Dr.  James  Andrews  De  Wolf,  aged  sixty-nine 
years. 

Dortch. — In  Shreveport,  Louisiana,  on  Saturday,  Janu- 
ary 2nd,  Dr.  Fred  W.  Dortch. 

Gilbert.— In  Roxbury,  Massachusetts,  on  Sunday,  Janu- 
ary 3d,  Dr.  Daniel  Dudley  Gilbert,  aged  seventy  years. 

IIayes. — In  El  Paso,  Texas,  on  Sunday,  January  3d,  Dr. 
Irving  B.  Hayes,  aged  forty-eight  years. 

HicKS. — In  Shreveport,  Louisiana,  on  Tuesday,  Decem- 
ber 29th,  Dr.  Samuel  H.  Hicks,  aged  forty-four  years. 

Johns. — In  Norfolk,  Virginia,  on  Sunday,  January  3d, 
Dr.  Kensey  Johns,  aged  seventy-five  years. 

Johnson. — In  Detroit,  Michigan,  on  Thursday,  Decem- 
ber 31st,  Dr.  J.  G.  Johnson,  aged  sixty-six  years. 

Knight. — In  Asotin,  Washington,  on  Sunday,  December 
27th,  Dr.  J.  E.  Knight,  aged  eighty-seven  years. 

Lee. — In  Pomeroy,  Ohio,  on  Wednesday,  December  30th, 
Dr.  Pearl  Lee,  of  Rutland,  Ohio. 

Lewis. — In  Canal  Dover,  Ohio,  on  Sunday,  January  3d, 
Dr.  E.  C.  Lewis,  aged  sixty-eight  years. 

Lewman. — In  Louisville,  Kentucky,  on  Wednesday,  Jan- 
uary 6th,  Dr.  George  W.  Lewman,  aged  seventy-five  years. 

LooMis. — In  Peniberviile,  Ohio,  on  Monday,  December 
28th,  Dr.  L.  L.  Loomis,  aged  eighty  years. 

Maddren. — In  Brooklyn,  on  Friday,  January  8th,  Dr. 
William  Maddren,  aged  sixty-three  years. 

Marshall. — In  Aguilar,  Colorado,  on  Wednesday,  De- 
cember 30th,  Dr.  George  E.  Marshall,  aged  thirty-nine 
years. 

Maxon. — In  Chatham,  Maine,  on  Wednesday,  January 
6th,  Dr.  Frank  C.  Maxon,  aged  sixty-nine  years. 

McFarland. — In  St.  Clairsville,  Ohio,  on  Saturday,  Jan- 
uary 2nd,  Dr.  Andrew  J.  McFarland,  aged  eighty-five  years. 

MizNER. — In  Edgerton,  Missouri,  on  Tuesday,  January 
Sth,  Dr.  L.  J.  Mizner,  aged  seventy  years. 

NowLiN.— In  Shelbyville,  Tennessee,  on  Tliursday,  De- 
cember 31st,  Dr.  J.  S.  Nowlin,  aged  seventy  years. 

O'SuLLivAN. — In  Denver,  Colorado,  on  Sunday,  Decem- 
ber 27th,  Dr.  James  J.  O'Sullivan,  of  Pittsburgh,  Pennsyl- 
vania, aged  twenty-four  years. 

QuiGLEY. — In  New  York,  on  Friday,  January  Sth,  Dr. 
John  J.  Quigley,  aged  forty-three  years. 

Reed. — In  Pittsburgh,  Pennsylvania,  on  Thursday,  De- 
cember 31st,  Dr.  J.  Ross  Reed,  of  Greensburg,  aged  thirty- 
four  years. 

Scarlett. — In  Fads,  Colorado,  on  Sunday,  January  3d, 
Dr.  A.  W.  Scarlett,  of  Pueblo,  aged  thirty-five  years. 

Schofield. — In  Maumee,  Ohio,  on  Tuesday,  December 
29th,  Dr.  Luther  Schofield. 

Sharkey. — In  Hamilton,  Ohio,  on  Saturday,  January 
2nd,  Dr.  Thomas  D.  Sharkey,  aged  forty-two  years. 

Snader. — In  Philadelphia,  on  Tuesday,  January  5th,  Dr. 
Edward  R.  Snader. 

Stiles. — In  Lake  George,  New  York,  on  Friday,  January 
Sth,  Dr.  Henry  R.  Stiles,  aged  seventy-six  years. 

Stockard. — In  Atlanta,  Georgia,  on  Friday,  January  1st, 
Dr.  Charles  Cecil  Stockard,  aged  fifty-five  years. 

Tankard.- — In  Baltimore,  Maryland,  on  Friday,  January 
1st,  Dr.  James  W.  Tankard,  of  Lillian,  Virginia,  aged  sixty- 
two  years. 

Tindall.— In  Philadelphia,  on  Tuesday,  January  5th,  Dr. 
Vanroom  R.  Tindall,  aged  sixty-nine  years. 

Vandkrvoort. — In  New  York,  on  Monday,  January  nth, 
Elizabeth  H.,  widow  of  Dr.  John  L.  Vandervoort,  aged 
ninety  years. 

Wade. — In  Denver,  Colorado,  on  Tuesday,  December 
29th,  Dr.  John  Wesley  Wade,  aged  sixty-eight  years. 

We.st. — In  Washington,  D.  C,  on  Thursday,  January  Sth, 
Dr.  Max  West,  aged  thirty-eight  years. 

White. — In  Floral  Hill,  Washington,  D.  C.  on  Sunday, 
January  3d,  Dr.  W.  Lee  White,  aged  eighty-eight  years. 

Whitworth. — In  Berkeley,  California,  on  Thursday,  De- 
cember 28th,  Dr.  George  Frederick  Whitworth.  aged  fifty - 
one  years. 

Williams. — In  Oak  ClifT,  Texas,  on  Friday,  January  1st, 
Dr.  Otis  I^awrence  Williams,  aged  sixty-six  years. 

Wise. — In  Oklahoma  City,  Oklahoma,  on  Friday.  Janu- 
ary 1st,  Dr.  George  W.  Wise,  aged  seventy-two  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal 


tSc  Medical  News 


A   Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  4. 


XEW  YORK,  JANUARY  23.  1909. 


Whole  No.  1573. 


^Brigmal  Communitatians. 


THE  TREATMENT  OF  ACUTE  GONOCOCCIC  URE- 
THRITIS IN  THE  MALE.* 

By  James  Pedeesen,  M.  D., 
New  York, 

Adjunct  Professor  of  Genitourinary  Surgery,  New  York  Postgrad- 
uate Medical  School  and  Hospital. 

Under  the  steady  pressure  of  the  pen  in  the  hands 
of  those  who,  having  given  the  subject  much  study 
and  thought,  have  pleaded  earnestly  for  a  serious 
comprehension  of  a  serious  disease,  the  profession 
at  large  is  at  last  yielding  to  the  conviction  that  the 
long  lived,  subtle  gonococcus  is  by  far  a  more 
potent  depopulator  than  the  insidious  cause  of  syphi- 
lis.' That  gonococcic  urethritis  is  the  greater  men- 
ace to  the  body  politic  is  becoming  an  universally 
admitted  fact.  The  popular  impression  of  the  rela- 
tive character  of  the  two  diseases  has  been  revolu- 
tionized. No  better  summary  of  the  facts  need  be 
given  than  that  deduced  by  the  late  R.  W.  Taylor. 
Speaking  through  the  pages  of  his  still  living  book 
he  says:  "When  we  consider  the  vast  range  of 
pathological  conditions  which  gonorrhoea  may  cause 
or  lead  to,  we  are  certainlv  warranted  in  asserting 
that  it  is,  taken  as  a  whole,  one  of  the  most  formid- 
able and  far  reaching  infections  by  which  the  human 
race  is  attacked." 

When  the  cause  of  a  disease  can  be  attacked  and 
the  method  of  its  conveyance  can  be  governed,  the 
treatment  of  that  disease  has  acquired  not  only  a 
certain  definiteness,  but  also  a  great  importance,  it 
having  risen  to  the  dignity  of  a  preventive  measure 
as  well.  The  prevention  of  disease  is  the  sublimest 
function  of  medicine.  The  cause  of  gonococcic 
urethritis  is  known  and  can  be  attacked ;  the  method 
of  its  conveyance  can  be  governed — at  least  to  a 
great  extent.  Therefore,  as  physicians  ever  laboring 
for  the  physical,  mental,  and  moral  welfare  of  the 
race,  it  behooves  us  to  arrest  the  progress  and  rav- 
ages of  gonococcic  urethritis,  knowing  well  that 
thorough  treatment  of  each  individual  case  works 
for  the  prevention  of  this  all  too  prevalent  disease. 
This  is  our  duty  for  the  sake  of  the  familv  and  the 
state. 

Let  me  open  the  subject  proper  of  my  lecture  with 
the  oft  heard  question :  "What  is  the  best  treatment 
for  gonorrhoea  ?" — meaning  gonococcic  urethritis.  I 
would  reply  by  saying  that  no  one  of  the  advocated 
methods  implied  in  the  question  can  be  named  alone 
— much  less  heralded  alone  as  the  "best"  treatment. 

'Read  by  invitation  before  the  Scranton  (Pa.)  Clinical  and  Patho- 
Jogical  Society. 

Copyright,  1909,  by  A.  R. 


I  would  make  a  point  of  this  and  emphasize  it  by 
adding,  that  no  one  method  or  set  of  means  is  appli- 
cable to  every  case  of  gonococcic  urethritis.  The 
"best"  treatment,  therefore,  may  be  defined  as  that 
which  consists  of  a  rational  application  of  all  the 
advocated  or  admissible  methods  and  means  for 
combating  this  very  serious  disease,  and  their  intel- 
ligent adaptation  to  the  patient  in  hand.  The  "best" 
treatment  is  a  composite  treatment.  If  I  may  be 
allowed  to  quote  from  one  of  my  previous  papers,  I 
shall  briefly  describe  the  several  methods  and  their 
means,  which  may  be  said  to  form  the  component 
parts  of  the  composite  treatment.  That  done,  I 
shall  endeavor  to  apply  them  to  the  indications  based 
on  the  present  day  knowledge  of  the  biology  and 
pathological  anatomy  of  the  disease.  The  several 
methods  implied  in  the  question  may  be  classified 
as:  I,  The  expectant  method ;  2,  the  modified  expect- 
ant method;  3,  the  hand  injection  method;  4,  the 
irrigation  method. 

I.  The  expectant  method  places  the  patient  under 
the  best  possible  conditions  for  allowing  the  disease- 
to  mn  its  normal  course  of  from  five  to  six  weeks. 
The  rneans  are :  Absolute  rest  in  bed,  milk  or  milk 
and  vichy  diet,  from  one  to  two  quarts  of  plain  or 
mildly  alkaline  water  a  day,  mild  laxatives,  rigid 
regulation  of  alcoholic  beverages,  tobacco,  and  cof- 
fee. The  conventionalities  of  life,  the  average  pa- 
tient's uncompromising  protest  against  having  his 
business  interrupted,  not  to  mention  the  existence  of 
a  more  scientific  method  for  treating  the  disease, 
make  this  method  as  such  an  impbssibilitv  and  a 
deficient  method  to-day.  Its  means,  however,  are 
rational  means,  and  comprise  all  the  essentials  of 
the  general  treatment  applicable  to  everv  case,  as 
opposed  to  the  purely  local  treatment.  It 'quiets  the 
circulation  throughout  the  body ;  it  puts  the  urethra 
at  rest  as  far  as  possible,  consistent  with  its  function 
as  a  urinary  canal ;  it  maintains  the  urine  in  a  bland 
state  and  supplies  it  in  quantities  sufficient  to  pro- 
duce a  frequent  flushing  of  the  urethra  bv  phvsio- 
logical  means  without  the  possibilitv  of  traumatism 
—unless  a  stricture  of  small  calibre  is  present  as  a 
complication. 

2.  The  modified  expectant  method  adds  the  ad- 
ministration of  drugs  for  one  or  more  of  three  pur- 
poses :  ( I )  To  influence  the  volume  and  reaction  of 
the  urine;  (2)  to  render  the  .urine  more  or  less  anti- 
septic: (3)  to  charge  the  urine  with  a  medicament 
in  solution  which  shall  act  upon  the  inflamed  mucous 
membrane.  For  the  first  purpose  there  are  the  de- 
mulcents, the  alkalies,  sodium  benzoate,  sodium  sali- 
cylate, salol,  and  saccharine.  For  the  second  pur- 
pose there  are  the  several  urinary  antiseptics,  of 

Elliott  Publish  ing  Company. 


PEDERSEN:  GONOCOCCIC  URETHRITIS. 


[New  York 
Medical  Journal. 


which  urotrOpin,  cystogen,  lysidin,  uriseptin,  and 
helmitol  serve  as  examples.  For  the  third  purpose, 
the  balsams,  of  which  copaiba,  sandalwood,  and  cu- 
bebs  remain  the  essential  ones.  Plain  water  in  quan- 
tity is  the  best  diluent.  As  to  .whether  the  reaction 
of  the  urine  should  be  made  alkaline  or  kept  acid, 
there  is  a  difference  of  opinion.  Some  authorities 
maintain  that  the  alkalinity  of  the  urine  distinctly 
inhibits  the  growth  of  the  gonococcus  in  the  urethra, 
while  others  contend  that  the  acidity  of  the  urine 
prevents  the  gonococcus  from  invading  the  wall  of 
the  bladder.  If  the  former  view  is  accepted  and  alka- 
lies are  given,  the  tendency  to  ardor  urinse  will  be 
lessened,  if  not  prevented,  as  an  additional  effect ;  if 
the  latter  view  is  accepted  and  the  newer  acidifying 
drugs  are  given  (called  the  modern  urinary  anti- 
septics, of  which  urotropin  is  the  type),  the  presence 
in  the  urine  of  the  potent  antiseptic,  formalin,  will 
be  obtained  as  an  additional  advantage.  As  there 
exist,  however,  far  more  direct  and  conclusive 
means  for  not  only  inhibiting  the  gonococcus  in  its 
first  culture  chamber — the  anterior  urethra — but 
also  for  destroying  it  there,  the  feebly  effective  alka- 
lies on  the  one  hand,  and  the  scarcely  less  feebly 
effective  acidifying  and  formalin  liberating  drugs  on 
the  other,  are  not  necessarily  demanded.  As  the 
gonococcus  invades  by  continuity  of  tissue  through 
the  intracellular  spaces  and  lymphatics,  medicaments 
that  do  not  penetrate  below  the  surface  can  have  but 
a  negative  value.  Any  prevention  of  invasion  of  the 
bladder,  attributed  to  the  presence  in  it  of  acid  urine 
containing  formalin,  has  been  more  apparent  than 
real ;  the  gonococcus,  even  under  favoring  condi- 
tions, very  rarely  invades  the  bladder  mucosa  be- 
yond the  trigone.  The  drugs  under  immediate  con- 
sideration may,  therefore,  be  withheld  until  ardor 
urinae  develops  and  furnishes  a  positive  indication 
for  the  alkalies,  with  or  without  a  demulcent  or  a 
balsam.  Even  this  indication  can  usually  be  met  by 
the  milk  and  vichy  diet.  Thus  the  patient's  stomach 
may  be  spared  considerable  medication. 

The  balsams  (sandalwood,  copaiba,  and  cubebs) 
certainly  render  the  urine  less  irritating,  and,  in 
spite  of  their  stimulating  effect  upon  the  urethral 
mucous  membrane  (as  indeed  upon  all  mucous 
membranes)  they  contribute  materially  to  the  pa- 
tient's comfort  when  ardor  urinae  exists,  even  during 
the  acutest  stages  of  an  acute  urethritis,  in  all  stages 
of  which  .they  are  contraindicated  theoretically. 
This  happy  effect  is  especially  noticeable  in  acute 
posterior  urethritis,  from  the  mild  up  to  the  fairly 
severe  grade ;  they  promptly  lessen  the  frequency 
and  diminish  the  tenesmus  to  the  great  relief  of 
the  sufferer.  But,  because  the' balsams  usually  check 
the  discharge  (the  symptom)  without  attacking  the 
gonococcus  (the  cause),  thus  handicapping  Nature's 
effort  to  rid  the  urethral  tissues  of  the  offending 
microorganism  and  misleading  the  patient  into 
thinking  he  is  alreadv  cured  of  what  he  is  only  too 
willing  to  regard  as  a  trivial  disease ;  because  they 
tend  to  disorder  the  digestion,  and.  in  full  dose,  to 
prrxluce  renal  hypcnxmia,  they  should  he  withheld 
until  needed  as  adjmcmts  in  ardor  urinre  or  as  prin- 
cipals in  acute  posterior  urethritis. 

3.  The  hand  injection  method  brings  prominently 
forward  the  present  day  medicinal  means  for  direct- 
ly attacking  the  gonococcus  at  the  site  of  its  invasion 


and  development.  Those  means  are  the  various 
silver  albuminoid  compounds,  such  as  argonin,  pro- 
targol,  albargin,  argyrol,  and  novargon.  They  rep- 
resent the  nearest  approach  yet  made  to  specifics  in 
gonococcic  inflammation  of  the  mucous  membranes. 
That  they  exhibit  so  destructive  an  activity  toward 
the  gonococcus  as  to  deserve  the  credit  of  having  an 
affinity  for  it,  and  that  they  accomplish  this  destruc- 
tion without,  as  yet,  any  appreciable  damage  to  the 
mucous  membrane,  has  been  proved  clinically  to  the 
satisfaction  of  many  observers.  They  seem  to  fulfill 
Neisser's  specifications  for  an  ideal  antibacterial 
agent  for  use  in  the  urethra.  As  quoted  by  Finger, 
those  specifications  are :  ( i )  It  must  kill  the  gono- 
coccus;  (2)  It  must  not  injure  the  mucous  mem- 
brane; and  (3)  it  must  not  increase  the  inflamma- 
tion. 

My  personal  experience  with  the  silver  albumin- 
oid compounds  has  been  confined  to  argonin,  pro- 
targol,  and  argyrol.  Following  their  use  I  have 
noted  the  disappearance  of  the  gonococci  and  the 
subsidence  of  the  discharge  within  from  twenty-four 
hours  to  fourteen  days,  with  few  exceptions.  When 
such  an  exception  occurs,  one  or  more  conditions 
may  be  suspected  and  should  be  searched  for  as 
soon  as  possible  or  permissible :  ( i )  A  preexisting 
focus  of  latent  gonococci,  such  as  a  chronic  vesicu- 
litis, prostatitis,  or  Cowperitis  affords;  (2)  oxaluria, 
or  urine  loaded  with  uric  acid;  (3)  glycosuria;  (4) 
tuberculosis  as  such  or  the  diathesis. 

The  disappearance  of  the  gonococci  and  the  sub-  . 
sidence  of  the  discharge  within  the  first  forty-eight 
hours — not  an  infrequent  occurrence,  especially 
when  the  patient  is  seen  in  the  very  incipiency  of 
the  urethritis — is  practically  an  abortion  of  the  dis- 
ease. A  paragraph  on  this  interesting  and  much 
desired  effect  is,  therefore,  appropriate  at  this  point. 

When  silver  nitrate  was  the  only  available  means 
for  this  purpose,  the  fact  was  well  recognized  that 
any  attempt  to  abort  the  disease  was  futile  unless 
made  at  the  very  earliest  stage.  The  discharge  con- 
sists then  only  of  a  little  serum  and  mucus,  floating 
epithelium,  and  a  very  few  pus  cells,  together  with  a 
few  gonococci  lying  free  or  upon  the  epithelium. 
Relatively  few  patients  were  seen  so  early  in  the  dis- 
ease, therefore  cases  of  true  abortion  were  rare. 
Much  more  frequently  the  results  amounted  only  to 
an  inhibition  of  the  disease,  and  the  end  results  were 
not  always  of  the  best,  inasmuch  as  the  cauterizing 
effect  of  the  silver  nitrate  solution  ( from  i  to  5  per 
cent.)  used  in  the  attempts,  often  left  the  patient 
with  a  deeply  damaged  mucous  membrane,  eventu- 
ating in  stricture.  These  experiences  led  conserva- 
tive genitourinary  surgeons  to  abandon  attempts  to 
abort  the  disease.  Now,  however,  with  the  present 
potent  but  jiractically  noncaustic  silver  alljuminoid 
compounds,  there  exists  the  certainty  of  better  re- 
sults without  the  danger  of  subsequent  stricture. 
In  my  experience  with  these  compounds  in  solutions 
of  suitable  strength,  the  injection  of  two  drachms 
into  the  anterior  urethra  and  their  retention  there 
for  from  five  to  ten  minutes  in  the  incipient  stage, 
or  stage  of  invasion,  of  a  gonococcic  infection  of  the 
urethra,  will  abort  the  acute  stage  of  the  disease  and 
materially  shorten  its  subsequent  course,  unless  there 
is  present  a  complicating  sequel  of  an  antecedent 
urethritis. 


J;inuarj-  jj,  1909- 1 


PEDERSEN:  GOXOCOCCIC  URETHRITIS. 


Convinced  of  the  affinity  of  these  compounds  for 
the  gonococcus,  and  admitting  that  they  seem  to 
possess  the  power  of  penetrating  tlie  mucous  mem- 
brane and  of  attacking  the  gonococcus  there,  as  weU 
as  on  the  surface,  without  damage  to  the  mucous 
membrane,  the  direct,  immediate,  and  prompt  appH- 
cation  of  some  one  of  tliem  and  its  retention  in  con- 
tact with  the  urethral  mucous  membrane  for  from 
five  to  ten  minutes  as  soon  as  gonococci  have  been 
demonstrated,  appeals  to  me  as  a  most  rational 
method  of  treatment.  It  stands  to  reason  that  the 
more  promptlv  the  gonococcus  is  destroyed  the 
fewer  will  be  the  complications  and  the  "pathological 
conditions  which  it  may  cause."  As  a  consequence, 
the  shorter  will  be  the  course  of  the  disease.  The 
argument  holds  good,  even  though  no  more  than  an 
inhibition  of  the  gonococcus  is  admitted  as  the 
maximum  effect  of  this  treatment.  Xot  only  is  the 
method  rational,  but  also  very  practical,  when  car- 
ried out  by  means  of  a  hand  syringe  which  the  pa- 
tient can  use  himself  as  frequently  as  directed.  This 
•entails  a  minimum  of  discomfort  and  loss  of  time. 
After  having  been  taught  how  to  apply  the  blunt  tip 
of  the  hand  syringe  against  the  meatus  to  avoid 
leakage,  and  how  to  inject  slowly  and  gently,  the 
onh"  accident  he  has  to  guard  against  is  a  staining 
of  his  clothing  when  releasing  the  solution  from  the 
urethra. 

Another  means  of  using  these  solutions  is  the 
familiar  irrigator.  To  use  it  properly  is  an  art  that 
few  patients  can  acquire  within  the  time  limit  of  its 
greatest  utility.  It  is  not  possible  for  every  patient 
to  learn  how  to  irrigate  his  anterior  urethra  without 
subjecting  it  to  the  traumatism  of  overdistention, 
nor  how  to  avoid  an  inadvertent  intravesical  irriga- 
tion. The  former  causes  pain ;  the  latter  exposes 
him  to  urethrocystitis  and  epididymitis.  Taking  an- 
other point  of  view,  it  is  not  easy  to  understand  how 
the  average  patient  can  be  taught  to  manage  a  quart 
of  solution  as  conveniently,  as  expeditiously,  and  as 
effectively  as  he  can  a  quarter  of  an  ounce  of  a 
stronger  and  therefore  more  efficacious  solution. 

4.  The  irrigation  method,  that  is.  the  copious 
flushing  from  the  meatus  of  the  anterior  urethra 
alone  or  of  the  whole  urethra  with  a  warm  solution 
of  some  medicament,  has  superseded  and  is  an  im- 
provement upon  the  older  retrograde  irrigation  by 
means  of  the  various  soft  rubber  and  metal  cathe- 
ters and  bulbous  tipped  irrigating  instruments  in- 
troduced into  the  urethra.  There  are  to-dav  only 
two  indications  that  justify  instrumentation  of  an 
acutely  inflamed  urethra ;  (  i  )  Retention  of  urine, 
not  yielding  to  all  the  lesser  means  for  its  relief,  (2) 
extremely  severe  posterior  urethritis — to  which  a 
definite  reference  will  be  made  later.  The  means  of 
applying  the  irrigations  are  a  six  ounce  hand  syringe 
with  shield  and  adjustable  tip.  or  a  suitable  glass 
nozzle  and  shield  at  the  end  of  the  tubing  from  an 
irrigator  jar.  By  its  advocates,  the  irrigation  method 
is  credited  with  results  equal  to  those  of  the  hand 
injection  method.  To  my  mind,  however,  the  meth- 
od is  not  as  rational  unless  the  medicament  used  be 
a  silver  albuminoid  compound  in  weak  solution,  and 
unless  the  irrigation  be  given  so  gently  and  skilfully 
as  not  to  subject  the  sensitive,  acutely  inflamed 
urethra  to  the  additional  traumatism  of  overdisten- 
tion. nor  force  the  fluid  nast  the  sphincter  into  the 
bladder.     The  intentional  carrying  out  of  intra- 


vesical irrigations .  during  acute  urethritis  is  irra- 
tional and  unwarranted.  They  cannot  but  lead  to 
hypera^mia  of  the  nmcous  membrane  of  the  deep 
urethra.  This  in  turn  invites  infection.  The  dan- 
gers, as  already  mentioned,  are,  urethrocystitis  and 
epididymitis.  The  main  utility  of  this  method  Hls 
in  the  effect  that  moist  heat  has  upon  any  inflamma- 
tion. Hence,  irrigations  of  the  anterior  urethra  in 
conjunction  with  hand  inj-ections  of  one  of  the  silver 
albuminoid  compounds  are  to  be  employed  in  those 
neglected  cases  in  whicii  the  inflammatory  symp- 
toms have  become  paramount,  as  shown  by  a  red 
and  oedematous  condition  of  the  meatus,  and  a  copi- 
ous greenish  yellow  discharge.  The  irrigations 
should  be  discontinued  as  soon  as  these  signs  have 
disappeared. 

It  is  a  subject  for  regret  and  criticism  that  the 
irrigation  method,  or  the  irrigation  treatment,  as  it 
is  popularly  known,  should  have  been  revived  at  the 
time  when  argonin,  the  first  of  the  silver  albuminoid 
compounds,  was  offered  as  a  potent  and  supplanting- 
substitute  for  the  long  list  of  sedative,  antiseptic, 
and  astringent  injections,  which  for  years  had 
proved  unsatisfactory  and  disappointing.  It  wa& 
this  very  disappointment,  long  continued  and  oft 
repeated,  that  had  made  the  profession  receptive  of, 
in  fact,  eager  for  any  change,  the  more  radical  the 
better,  that  bore  a  hint  of  promise  in  it.  In  spite 
of  the  fact  that  irrigation  had  been  tried  many  years 
before  and  found  wanting — so  many  }ears  before 
that  its  negative  results  had  been  lost  sight  of — the 
"treatment"  was  resurrected  and  vaunted  with  the 
enthusiasm  of  originality.  The  sober  judgment  of 
the  profession  at  large,  taken  unawares,  was  swept 
away.  Attention  was  diverted  from  the  trulv  potent 
and  convenient  argonin.  and  it  was  some  time  before 
its  value  was  noticed  by  the  general  practitioner. 
Gradually,  however,  the  results  obtained  with  argo- 
nin became  obvious.  An  item  of  great  practical 
value  from  the  view  point  of  the  patient  is  the  fact 
that  the  hand  injection  method,  as  opposed  to  the 
irrigation  method,  does  not  oblige  him  to  visit  his 
physician  from  once  to  twice  daily  during  the  acute 
stage,  nor  to  provide  himself  with  specialized  appa- 
ratus for  use  at  home  after  preliminary  instruction- 
Such,  in  more  or  less  detail,  are  the  four  applica- 
ble methods  for  the  treatment  of  gonococcic  urethri- 
tis. Before  applving  them  to  the  several  indications 
and  moulding  them  into  what  I  have  called  a  com- 
posite treatment,  it  will  be  in  order  to  refer  to  the 
indications,  based  on  the  biology  and  pathology  of 
the  disease  as  understood  to-day.  W  hat  is  gonococ- 
cic urethritis?  It  is  a  purulent  inflammation  of  a 
delicate,  highly  sensitized  mucous  membrane,  caused 
liy  a  virulent,  penetrating,  long  lived  microorgan- 
ism. The  inflammation  inflicts  more  or  less  damage 
upon  one  or  more  of  the  layers  composing  that  mu- 
cous membrane  and  tends  to  chronicity.  It  follows, 
therefore,  that  the  indications  for  treatment  are: 
(i)  The  destruction  of  the  gonococcus  without  in- 
creasing the  damage  done  or  being  done  to  the  mu- 
cous membrane:  (2)  the  termination  of  the  inflam- 
matory process  excited  b\-  and  left  behind  by  the 
gonococcus;  (3)  the  repair  of  the  damaged  mucous 
membrane. 

(i)  The  destruction  of  the  gonococcus  zdtliout 
increasing  the  damage  done  or  being  done  to  the 
mucous  membrane.  That  the  silver  albuminoid  com- 


PEDERSEN:  GOS'OCOCCIC  URETHRITIS. 


[New  York 
Medical  Journal. 


pounds,  ill  solutions  not  strong  enough  to  cause  any 
appreciable  damage  to  the  urethral  mucous  mem- 
brane, exert  a  potently  destructive  action  on  the 
gonococcus,  cannot  be  denied.  The  clinical  evidence 
is  overwhelming.  In  a  way  that  is  unique  they 
fulfill  those  requirements  named  by  Neisser  already 
quoted.  They  do  kill  the  gonococcus,  they  do  not 
injure  the  mucous  membrane,  they  do  not  increase 
the  inflammation.  Therefore,  they  are  employed  as 
injections  into  the  anterior  urethra  and  are  retained 
there  for  from  five  to  ten  minutes  if  the  discharge 
contain  gonococci.  The  same  is  done  as  a  prophy- 
lactic measure  if  the  history  is  at  all  suspicious, 
even  though  the  microscopical  examination,  made 
on  the  instant,  be  negative.  The  patient  is  then 
taught  how  to  use  the  injection  for  himself  every 
three  hours  for  the  first  twenty-four  hours  and  every 
four  hours  thereafter.  Every  fourth  day  he  reports 
for  inspection,  and  each  time  a  smear  is  examined. 
As  the  gonococci  diminish  in  number,  the  strength 
of  the  injection  is  reduced,  and  the  frequency  of 
its  use  is  gradually  changed  from  four  times  daily 
to  twice  daily.  After  the  gonococci  have  been  ab- 
sent for  from  three  to  seven  days  (depending  upon 
the  severity  of  the  infection  in  the  given  patient), 
the  injection  is  reduced  to  once  a  day.  From  five 
to  ten  days  later  (again  depending  upon  the  pa- 
tient) it  is  discontinued  altogether. 

If  the  inflammatory  signs  of  the  disease  are  ex- 
cessive at  the  outset  or  if  they  become  so  at  any 
time  during  the  course  of  this,  the  acute  stage,  the 
patient  is  provided  with  a  tablet  of  bichloride  of 
mercury  one  of  which  in  eight  ounces  of  water 
makes  a  solution  of  one  in  thirty  thousand.  He  is 
to  make  a  solution  of  fhat  strength,  using  hot  water, 
and  with  his  one  quarter  ounce  hand  syringe  he  is  to 
gently  flush  the  anterior  urethra  six  or  eight  times 
before  each  use  of  the  silver  albuminoid  solution.  If 
necessary,  an  additional  and  more  copious  irrigation 
is  given  daily  or  every  other  day  by  the  physician. 

(2)  The  termination  of  the  inflammatory  process 
excited  by  and  left  behind  by  the  gonococcus.  Al- 
most any  one  of  the  mineral  or  vegetable  astringents 
will  meet  this  indication,  provided  strong  solutions 
are  avoided.  The  mineral  astringents  seem  to  have 
the  preference.  Zinc  sulphate  may  be  used  up  to  gr. 
2  in  §1.  Zinc  sulphocarbonate  up  to  gr.  5  in  §i.  Zinc 
iodide  and  zinc  chloride,  each,  up  to  gr.  5^  in  §i.  The 
astringent  injection  is  used  twice  daily — rarely 
three  times  daily,  at  first.  This  frequency  is  grad- 
ually reduced  as  the  catarrhal  discharge  diminishes, 
and  when  it  has  totally  or  practically  disappeared, 
as  shown  by  the  presence  of  a  mucoid  morning  drop 
at  most,  the  injection  in  use  is  discontinued.  If  the 
catarrhal  discharge  persists  longer  than  two  weeks 
in  a  case  of  average  severity,  some  complication — 
either  antecedent  or  recent — is  to  be  sought.  Micro- 
scopical examinations  of  the  catarrhal  discharge  are 
made  regularly  throughout  this,  the  subacute  stage, 
and  if  gonococci  reappear,  the  silver  albuminoid  in- 
jection is  at  once  resumed.  The  restrictions  as  to 
diet,  alcohol,  tobacco,  coffee,  and  sexual  excitement, 
both  active  and  passive,  arc  not  abated  ;  but  a  little 
more  exercise  is  allowed. 

(3)  The  repair  of  tlw  damaged  mucous  mem- 
brane. Silver  nitrate  in  solution  is  by  far  the  best 
agent  for  this  purpose,  because  the  safest  and  most 
efficient.    In  solutions  of  from  i  in  5.000  to  t  in 


250  it  is  brought  into  contact  with  the  mucous  mem- 
brane by  means  of  the  Ultzman  syringe  or  ('better) 
the  Bangs's  syringe  sound.  In  solutions  of  from 
gr.  5  in  §1  up  to  gr.  10  in  §1,  it  is  applied  by  means 
of  a  cotton  swab  through  the  endoscope.  Stronger 
than  gr.  10  in  §1  (2  per  cent.)  is  not  advised. 
Every  instrumentation  should  be  carried  out  gently, 
and  no'  form  of  instrumentation  employed  for  this 
indication  should  be  repeated  oftener  than  once  in 
five  days.  Once  in  seven  days  is  often  a  safer  aver- 
age. The  lubricant  used  should  be  soluble  in  water 
Experience  alone  will  teach  when  the  treatment  ot 
this,  the  chronic  stage,  may  be  begun.  Speaking 
generally,  if  the  case  has  been  one  of  mild  infection 
and  the  previous  history  is  negative  as  to  stricture, 
the  instrumental  treatment  may  be  delayed.  If  the 
contrary  has  obtained,  especially  if  there  is  reason 
to  suspect  stricture — antecedent  or  recent — the 
treatment  may  be  begun  earlier — even  before  the 
morning  drop  has  disappeared.  Indeed,  without  ju- 
dicious instrumentation — not  repeated  oftener  than 
every  five  days- — the  catarrhal  discharge  will  persist 
indefinitely  in  some  cases.  In  such  cases,  as  in  all 
obstinate  cases,  prostatitis  and  seminal  vesiculitis 
should  be  examined  for. 

When  the  morning  drop  persists  in  consequence 
of  an  unusual  involvement  of  the  urethral  follicles 
(follicular  urethritis)  the  irrigation  method  is  of 
service  as  an  adjuvant.  The  irrigations  should  be 
given  to  both  the  anterior  and  posterior  portions  of 
the  urethra.  This  is  now  permissible,  the  chronic 
stage  having  been  present  for  perhaps  two  to  three 
weeks.  The  irrigating  fluid,  flowing  from  the  mea- 
tus backward  into  the  bladder,  enters  the  follicles 
— their  mouths  being  directed  forward — and  re- 
moves their  retained  secretions.  The  solution  may 
be  one  to  thirty  thousand  bichloride,  full  strength 
boric  acid,  i  in  2,000  potassium  permanganate  or 
one  per  cent,  (or  less)  of  one  of  the  silver  albu- 
minoid compounds. 

For  the  sake  of  clearness,  the  treatment  of  acute 
posterior  urethritis  has  not  been  mentioned  thus  far. 
It  occurs  in  ninety  per  cent,  of  all  cases  of  anterior 
urethritis  and  develops  early  in  the  course — on  or 
about  the  eleventh  day.  The  majority  of  cases  give 
no  symptoms.  This  fact  should  be  kept  in  mind  that 
the  treatment  of  the  posterior  urethra  is  not  over- 
looked or  omitted  while  the  treatment  of  the  an- 
terior urethra  is  being  carried  out  during  the  chron- 
ic stage,  for  the  repair  of  the  damaged  mucous 
membrane.  A  fair  number  of  cases  give,  as  symp- 
toms of  the  acute  invasion,  more  or  less  frequency 
alone,  or  frequency  plus  urgency,  or  frequency,  urg- 
ency, and  tenesmus. 

As  long  as  the  tenesmus  is  not  severe,  what  has 
been  called  the  modified  expectant  treatment  will  be 
found  sufficient.  The  patient  should  go  to  bed.  his 
diet  should  be  confined  to  milk  and  vichy,  the  alka- 
lies or  a  balsam  should  be  prescribed,  and  a  saline 
laxative  given  if  neccssarv.  When  the  tenesmus 
has  become  unbearable  and  is  uncontrollable  by  the 
other  means,  one  of  the  two  indications  for  instru- 
mentation of  an  acutely  inflamed  urethra  has  arisen. 
The  anterior  urethra  having  been  gently  irrigated 
with  warm  boric  solution,  and  anaesthetized  with  a 
two  per  cent,  solution  of  eucain,  a  soft  rubber  cathe- 
ter, in  size  from  14  to  16  French,  is  passed  and  the 
deep  urethra  is  gently  flushed  with  two  or  three 


Jcnuary  23,  1909.] 


HIRST:  LACERATIONS  OF  CERVIX  UTERI. 


153 


drachms  of  a  silver  albuminoid  solution,  or  a  solu- 
tion of  silver  nitrate,  in  strength  from  i  in  5,000  to 
I  in  1,000.  The  relief  is  often  suprisingly  great  and 
prompt.  One  such  instillation,  or  flushing,  may 
prove  sufficient  to  finally  relieve  the  patient  of  his 
distressing  symptoms.  If,  however,  they  recur — as 
they  may  after  a  day  or  two  in  cases  of  severe  infec- 
tion— the  instillation  may  be  repeated.  At  the  same 
time  the  possibility  of  a  complicating  acute  prosta- 
titis should  be  considered,  and  a  prostatic  abscess,  as 
the  cause  of  a  frequent  recurrence  of  the  symptoms 
in  spite  of  careful  treatment,  should  not  be  over- 
looked. 

20  East  Forty-sixth  Street. 


THE  REPAIR  OF  LACERATION'S  OF  THE  CERVIX 
DURING  PUERPERAL  CONVALESCENCE. 
By  Johx  Cooke  Hirst^  M.  D., 
Philadelphia. 

There  is  no  valid  reason  why  injuries  to  the  cer- 
vi.x  or  anterior  wall,  resulting  from  labor,  should 
be  allowed  to  persist  uncorrected,  to  necessitate  a 
secondary  operation  later.  No  obstetrician  would 
consider  himself  justified  in  neglecting  injuries  to 
the  perin?eum ;  there  is  no  more  justification  in  neg- 
lecting those  of  the  cervix  or  anterior  wall. 

Injuries  to  the  cervi.x  cannot  safely  be  repaired 
prior  to  the  fifth  day  after  delivery,  owing  to  the 
danger  of  infection  ;  but  at  any  time  after  the  fifth 
day  they  and  all  other  injuries  to  the  genital  tract 
can  be  repaired,  and  the  patient  leave  her  bed  at 


KiG.  I.— First  layer  of  sutures,  the  last  two  stitches  of  the  needle 
taking  in  the  mucous  membrane  of  the  vaginal  aspect  of  the 
cervix. 

the  end  of  the  third  week  after  the  child's  birth  with 
the  assurance  that  she  is  in  good  condition  anatom- 
ically, and  much  less  likely  to  suffer  from  many  of 
the  consequences  of  childbirth,  such  as  retroversion, 
subinvolution,  erosion  of  the  cervix,  etc.,  than  if  the 


proper  repair  of  whatever  injuries  she  may  have 
suffered  had  been  neglected. 

Many  objections  have  been  urged  against  the 
primary — or  intermediate — repair  of  the  cervix, 
none  of  which  are  valid,  (a)  that  the  danger  of  in- 
fection does  not  exist  after  the  fifth  day;  (b)  that 
many  of  these  injuries  will  heal  spontaneously  (the 


Fig. 


-Second   layer  of  sutures,   single   knot   at  upper   angle  of 
cervical  wound. 


vast  majority  will  not)  ;  (c)  that,  from  the  involu- 
tion of  the  cervix,  the  stitches  will  loosen  after  a 
few  days,  which  is  not  borne  out  in  practice;  (d) 
the  difficulty  of  the  operation,  which  is  not  sufficient 
to  bother  any  one  with  even  slight  training  in  the 
technique  of  plastic  surgery.  The  same  objections 
are  raised  to-day  to  the  primary  repair  of  the  cer- 
vix as  were  raised  twenty  years  ago  to  the  repair  of 
the  perinjeum,  and  in  a  few  years  from  now  will 
seem  just  as  invalid  and  absurd  as  those  applied  to 
the  perinjEuni  seem  to-day. 

The  frequency  of  injuries  to  the  cervi.x  is,  com- 
pared to  those  of  the  perinsum,  about  thirty-three 
per  cent.  Of  every  one  hundred  women  with  peri- 
nseal  tears  at  least  one  third  will  have  cervical  tears 
in  addition. 

The  diagnosis  of  cervical  tears  is  best  made 
through  a  bivalve  speculum  and  not  by  the  sense  of 
touch,  which  is  most  imreliable.  The  best  time  to 
make  this  examination  is  about  the  fourth  day  after 
delivery. 

The  best  time  to  repair  the  injury  is,  like  all  other 
injuries  to  the  genital  tract,  on  the  seventh  day  after 
labor. 

I  have  for  the  past  three  years  applied  to  these 
cervical  tears  the  principle  of  the  double  tier  contin- 
uous suture  of  Xo.  i  catgut,  chromicized  to  last 
about  forty  days,  in  the  fascia.  In  these  plastic 
operations  a  durability  of  only  about  one  third  this 
time  can  be  counted  on.  This  suture  makes  the 
operation  shorter,  easier,  gives  a  much  cleaner  line 
of  scar,  and,  I  believe,  secures  a  better  approxima- 


l-OSTEli  AXU  GERHARD:  H  V FERS EFHROM A  AXD  CARCIXOMA. 


-MlCDlCAL  JoVRXM.  . 


lion  of  tlie  muscle  than  is  gained  by  interrupted 
.sutures.  It  is  not  recommended,  however,  for  the 
stiff,  hard  cervix  met  with  in  secondary  operations. 

The  technique  of  the  operation  is  as  follows : 
'J'he  anterior  and  posterior  lips  of  the  cervix  are 
grasped  with  double  tenacula  and  the  area  for  de- 
nudation marked  out  as  in  any  ordinary  cervical  re- 
]xiir.  In  making  this  denudation  due  allowance 
must  be  made  for  the  cervical  canal ;  and  the  re- 
moval of  tissue  confined  to  the  narrow  injured  mus- 
cle, not  encroaching  upon  the  comparatively  wide 
ex])anse  of  mucous  membrane  lining  the  cervical 
canal.  The  border  line  of  this  membrane  is  usual- 
ly plainly  visible.  Then  the  needle,  armed  with  a 
long  strand  of  Xo.  i  chromic  gut,  is  inserted  on 
the  vaginal  aspect  of  the  anterior  lip  and  the  point 
brought  out  in  the  raw  denuded  surface,  just  short 
of  the  mucous  membrane  of  the  canal,  but  about 
half  an  inch  nearer  the  external  os  than  the  point 
of  insertion.  The  needle  is  then  inserted  on  the 
l)ostcri()r  lip,  just  short  of  the  mucous  membrane  of 
the  canal,  and  is  brought  out  opposite  the  point  of 
insertion  on  the  anterior  lip,  but  in  the  raw  sur- 
face, the  stitch  being  shaped  like  a  \'.  These 
\'  shaped  sutures  are  continued,  now  only  in  the 
raw  surface,  except  for  the  last  two  insertions  of  the 
needle,  which  take  in  the  mucous  membrane  of  the 
vaginal  aspect  of  the  cervix,  till  the  level  of  the  ex- 
ternal OS  is  reached,  when  the  muscle  is  united,  but 
the  mucous  membrane  of  the  vaginal  aspect  of  the 
cervix  is  still  gaping.  This  is  then  whipped  over 
with  the  same  catgut  thread,  and  the  suture  is  tied 
at  the  upper  angle  of  the  wound,  only  one  knot  be- 
ing thus  necessary.  The  other  side  is  then  repaired 
in  the  same  way.  To  avoid  the  'danger  of  acquired 
stenosis,  the  cervical  canal,  when  the  repair  is  com- 
pleted, should  have  a  calibre  just  sufficient  to  admit 
the  forefinger. 

The  accompanying  drawings  will,  I  trust,  make 
my  meaning  clear. 

In  case  of  a  stellate  tear,  each  area  of  the  tear 
can  be  repaired  in  exactly  the  same  way,  and  the 
cervix  restored  to  its  normal  appearance. 

1618  Pixii:  Street. 


TWO  IXSTAXCIiS  OF  THP:  SLMULTANEOUS  OC- 
CURRENCE OF  HYPERNEPHROMA  AND 
CARCINOMA.* 

Bv  George  H.  Foster.  Jr.,  M.  D., 
Philack-lpliia, 

Kesi'leiit   Physician   at   the  Pliiladelpliia  General  Hospital, 

and 

C.  H.  Gerhard,  M.  D., 
Philadelphia, 

Assistant  Demonstrator  of  I'allioloKy  at  tlic  University  of  Pennsyl- 
vania, and  Assistant  Pathologist  to  the  I'hiladelphia 
(lencral  Hospital. 

In  1896.  Birch-Hirschfield  employed  the  term 
"hyj)ernephroma"  in  describing  certain  neoplasms  of 
tlie  kidney,  which  up  to  that  time  had  been  variously 
clas>ified  as  lipomata,  sarcomata,  carcinomata,  en- 
{lotluliomata.  and  adenomata. 

'J'iie  recognition  of  these  growths  as  definite  |)atho- 
logical  entities  was  established  I)\  the  contention  of 

•Mead  Ijtf.pri-  the  Patliolngieal   Society  of    Philadelphia.  December 

10,     M)^  ^. 


Grawitz,  in  1883,  that  the\  arose  from  aberrant  ad- 
renal tissue,  and  for  them  he  suggested  the  name 
strumae  lipomatodes  aberrata;  renis.  Even  now  hy- 
pernephroma is  rarely  diagnosticated  clinically,  and 
that  it  may  remain  unrecognized  even  at  operation 
is  attested  b}-  the  fact  that  so  eminent  a  surgeon  as 
Professor  W.W.Keen  thought  one  of  these  growths, 
which  he  removed  before  his  clinic  in  1900,  a  sar- 
coma, until  enlightened  as  to  its  true  nature  by  the 
pathological  report. 

It  is  not  our  intention  to  give  an  exhaustive  re- 
view of  the  literature  on  hypernephroma  in  this 
paper,  but  it  may  be  well  to  outline  briefly  the  es- 
sential features  of  the  condition,  as  established  by 
the  consensus  of  opinion  of  those  who  have  studied 
the  ccndition  carefully. 

H\ pernephroma  usually  occurs  in  the  fifth  and 
sixth  decades  of  life,  is  rather  more  common  in  men 
than  in  women,  and  like  other  malignant  growths, 
appears  to  be  influenced  by  heredity,  a  family  history 
of  malignant  disease  being  obtainable  in  about  forty- 
five  per  cent,  of  the  cases.  Traumatism  is  apparently 
an  exciting  cause  in  some  cases.  The  kidney  is  the 
site  of  election  m  these  growths,  but  the  primary 
growth  has  been  observed  in  many  of  the  tissues  of 
the  body  and,  theoretically,  may  occur  anywhere  that 
primitive  "rests'"  of  adrenal  tissue  are  found.  The 
relative  frequency  of  involvement  of  either  kidney  is 
a  question  which  is  open  to  argument ;  the  statistics 
showing  that  in  certain  series  of  cases  the  right  kid- 
ney was  afifected  more  commonly,  while  in  other  se- 
ries, the  left  organ  was  attacked  more  frequently. 
Metastasis  usually  occtirs  by  the  renal  veins,  but 
may  take  place  by  way  of  the  l\  niphatics.  by  contig- 
uity, or  by  continuity.  Metastases  are  most  fre- 
quently- found  in  the  lung,  but  have  been  demon- 
strated in  practically  every  organ  of  the  body. 

The  histogenesis  of  hypernephroma  is  a  much 
mooted  question.  It  would  seem,  however,  that  the 
theory  of  its  origin  from  primitive  ectopic  deposits 
of  adrenal  tissue,  or  "rests,"  is  the  most  tangible  one. 
inasmuch  as  it  is  most  prone  to  occur  along  the  geni- 
tourinary tract,  where  these  "rests"'  are  found  most 
frequently,  and  because  of  the  resemblance  of  its 
histological  elements  to  those  of  the  adrenal  glands. 

The  symptomatology  of  the  condition  is  obscure, 
in  some  cases  the  growth  giving  rise  to  no  .symptom 
by  which  it  could  be  recognized  during  life,  as  in  our 
first  case.  The  cardinal  points  upon  which  a  tenta- 
tive diagnosis  can  be  made  are  the  presence  of  a 
mass  in  the  kidney  region ;  pain,  which  may  assume 
the  character  of  renal  colic,  hsematuria.  and  gastro- 
intestinal disturbances.  The  presence  and  recogni- 
tion of  adrenal  cells  in  the  urine  may  be  the  "straw 
which  shows  which  way  the  wind  blows."'  The  blcod 
picture  is  not  constant.  .\n  x  ray  examination  may 
show  the  existence  of  the  mass,  but  failed  to  do  so 
in  our  first  case.  Cachexia  appears  late,  if  at  all.  and 
is  not  so  profound  as  in  other  malignant  growths. 
If  recognized  clinically  there  is  but  one  course  to 
pursue  as  regards  treatment. — nephrectomy.  Opera- 
tion should  be  resorted  to  unless  metastasis  has  oc- 
curred or  the  condition  of  the  patient  contraindicates 
such  procedure. 

The  following  cases  are  of  interest  because  of  the 
association  of  hyperne])hroma  with  carcinoma  of  the 
stomach.  The  first  case,  which  one  of  us  (I'oster) 
had  the  opportunity  of  studying  daily  in  the  wards 


Ja.uKMj —3.  1909.]         J'USTLK  .L\IJ  GliKHAliU:  UV I'EKXEPHROMA   AXD  CAKCIKOMA. 


of  the  Philadelphia  General  Hospital,  presents  the 
following  points  of  interest :  1 ,  The  association  of 
hypernephroma  of  the  kidney  with  carcinoma  of  the 
stomach,  the  latter  dominating  the  clinical  picture ; 
2,  the  entire  absence  of  symptoms,  physical  signs,  or 
signs  of  research,  which  would  even  cause  suspicion 
of  its  presence ;  3,  the  tardiness  with  which  cachexia 
asserted  itself,  especially  as  the  condition  was  com- 
plicated by  gastric  carcinoma,  the  latter  malady  usu- 
ally being  characterized  by  a  rather  early  onset  of 
cachexia ;  and,  4,  failure  of  the  skiagraph  to  detect 
the  growth,  although,  in  justice  to  the  skiagrapher, 
it  may  be  stated  that  a  small  shadow  was  demon- 
strated in  the  kidney  region  upon  reexamination  of 
the  plate,  after  finding  the  growth  at  autopsy,  which 
w^as  thought  to  have  been  cast  by  the  bonv  portion 
of  the  tumor. 

Abstract  of  clinical  history  of  this  case  : 

Case  I. — Patient  a  white  adult,  male,  sixty-eight  years  of 
age,  driver  by  occupation,  asked  admission  to  the  medical 
wards  of  tlie  Philadelphia  General  Hospital  on  March  12, 
1908,  suffering  with  persistent  vomiting  and  epigastric  pain. 
Family  history  was  negative.  Patient  chewed  and  smoked 
tobacco,  drank  tliree  or  four  glasses  of.  beer  a  day  and  an 
occasional  whiskey,  for  a  number  of  years.  His  past  medi- 
cal history  was  good.    At  the  age  of  twehc  lie  was  cou- 


fined  to  bed  with  "inflammation  of  the  stomach."  From 
that  time  on  his  health  had  been  excellent.  He  denied 
\enercal  infection.  Flis  present  illness  began  three  months 
ago  with  belching  of  gas,  sour  eructations,  occasional  vom- 
iting, gradually  becoming  more  frequent,  until  now  he  can 
retain  iiothing  but  warm  water.  He  had  as  much  difficulty 
in  retaining  liquid  food  as  in  retaining  solids.  Epigastric 
distress  also  had  grown  progressively  worse.  He  experi- 
enced gnawing  pain  in  epigastrium,  after  abstaining  from 
food  for  a  few  hours,  which  was  relieved  by  eating.  An- 
orexia was  orofound  and  bowels  were  habitual'y  con'^tip^fd. 
Weight  had  been  reduced  fifteen  pounds  since  onset  of  ill- 
ness. No  histor)-  of  hremateniesis,  jaundice,  dyspnoea, 
cough,  or  oedema. 

Points  of  interest  in  the  physical  examination  were  as 
follows :  Body  was  much  emaciated  ;  color  was  good,  and 
there  was  no  evidence  of  cachexia.  Conjunctivae  were 
muddy,  otherwise  the  eyes  were  normal.  Upper  teeth  miss- 
ing and  only  four  careous  "snags'"  remained  in  the  lower 
jaw:  gums  and  mucosa  were  atrophic.  The  pulse  was  reg- 
ular, very  slow  (fifty  per  minute),  of  poor  tension  and  vol- 
ume. There  was  moderate  radial  sclerosis.  Lymphatic 
glands  were  not  enlarged.  Examination  of  lungs  revealed 
nothing  abnormal.  The  heart  outlines  were  normal.  Mu*;- 
cle  tone  was  poor  in  the  mitral  area.    Aortic  and  pulmonic 


Fig.  2. — Metastatic  hypernephroma  in  the  lung. 

sounds  were  inaudible.  The  abdomen  was  scaphoid  in  con- 
tour;  parieties  flaccid:  no  tenderness  or  rigidity.  Peristalsis 
could  not  be  observed.  Deep  palpation  in  epigastric  region 
caused  patient  some  discomfort,  but  this  did  not  amount  to 
true  tenderness.  No  palpable  masses  were  detected.  Nor- 
mal area  of  liver  dulness  was  slightly  decreased.  Spleen 
could  just  be  palpated  below  costal  margin.  Percussion 
elicited  tympany  over  entire  epigastrium,  apparently  due  to 
a  dilated  and  ptosed  stoinach. 

Laborator\'  Findings :  Urine,  amber,  clear,  acid,  specific 
gravity  1.022,  negative  for  albumin  and  sugar,  showed  the 
presence  of  an  occasional  hyaline  cast,  amorphous  urates, 
and  a  few  epithelial  cells.  Gastric  contents  showed  absence 
of  free  hydrochloric  acid,  total  acidity  of  twenty  per  cent., 
and  the  presence  of  lactic  acid  and  Oppler-Boas  bacilli. 
Freces,  negative  for  occult  blood.  Blood  examination 
showed  seventy  per  cent,  haemoglobin,  4,470  000  erythro- 
cytes, and  7,800  leucocytes.  Differential  leucocytic  counts 
showed  sixty-two  per  cent,  polymornhonuclears,  twenty- 
eight  per  cent,  small  lymphocytes,  eight  per  cent,  large 
lymphocytes,  and  two  per  cent,  eosinophiles. 

Second  gastric  analysis  showed  the  absence  of  free  hydro- 
chloric acid  and  the  presence  of  lactic  acid  and  Oppler-Boas 
bacilli,  with  a  total  acidity  of  twenty  per  cent,  confirming 
the  first  report. 

Course  of  Disease:  All  food  was  withheld  for  the  first 
twenty-four  hours,  the  patient  being  allowed  small  quanti- 
ties of  hot  water  at  frequent  intervals.  Concentrated  and 
predigested  liquid  foods  were  then  administered  cautiously 
and  vomiting  was  allayed.  Four  days  after  admission  the 
patient's  stomach  tolerated  a  test  meal,  which  was  with- 
drawn with  a  stomach  pump  and  snbtnitted  to  the  clinical 
laboratory  for  examination.  A  diagnosis  of  carcinoma  of 
the  stomach  was  made  upon  the  report  of  the  gastric  analy- 


Fic.  3. — Cavomoma  in  the  stuinach  wall. 


Fig.  I. — Primary  hypernephroma  in  the  kidney. 


1^5  1-OSTER  AND  GERHARD:  HYPERNEPHROMA  AND  CARCINOMA.         medL^al  Jourkau 


sis  and  a  history  of  the  ca^e:  although  pliysical  examina- 
tion was  negative.  This  diagnosis  was  confirmed  by  Dr.  La 
Place,  of  the  visiting  surgical  staff,  who  advised  laparoto- 
my. The  patient  refused  to  submit  to  the  operation,  began 
to  grow  stronger,  and  wished  to  get  up.  Condition-  oscil- 
lated between  better  and  worse,  with  an  occasional  attack 
of  vomiting  and  pain.  No  mass  could  be  detected  in  the 
epigastrium,  though  watched  for  religiously.  Three  weeks 
after  admission  the  patient  began  to  fail  rapidly,  became 
cachectic,  and  on  April  9th  the  right  leg  became  swollen, 
(Edematous,  painful,  and  the  course  of  the  saphenous  vein 
was  indicated  by  an  indurated  red  line.  In  twenty-four 
hours  it  was  almost  black,  and  gangrene  was  feared.  Two 
days  later  the  patient  died — twenty-seven  days  after  admis- 
sion and  about  four  months  from  the  onset  of  the  disease. 

The  anatomical  diagnosis  at  autopsy  was:  Brown  at- 
rophy of  heart ;  chronic  pericarditis ;  chronic  mitral  and 
aortic  valvulitis ;  cedema  and  congestion  of  lungs ;  metas- 
tatic growth  (hypernephroma)  of  lung;  atrophy  of  spleen; 
chronic  intei-stitial  nephritis,  with  hypernephroma;  hyper- 
nephroma of  renal  vein  and  inferior  vena  cava;  chronic 
hypertrophic  gastritis  with  carcinoma;  tuberculous  ulcera- 
tion of  small  intestine;  secondary  carcinoma  of  colon;  cel- 
lulitis of  right  lower  extremity. 

Abstracts  of  the  gross  and  histological  descriptions  fol- 
low:  The  left  kidney  weighed  no  grammes:  measured  iix 
6x6.5  cm. ;  the  upper  portion  was  enlarged ;  beneath  the 
capsule  over  this  enlarged  part  of  the  organ  there  were 
numerous  elevated  yellowish  white  areas  varying  in  size : 
on  cut  section  the  upper  portion  was  seen  to  be  made  up  of 
a  central  tumor  mass  surrounded  by  stratified  kidney  sub- 
stance, from  which  in  places  it  was  separated  by  bands  of 
connective  tissue.  The  cut  surface  of  the  new  growth  was 
yellowish  white,  semitranslucent  and  mottled  with  opaque, 
yellow  areas  of  degeneration  and  with  points  of  haemor- 
rhage. The  tumor  was  more  or  less  lobulated.  The  renal 
vein  was  distended  by  a  yellowish  white  mass,  which  was 
adherent  to  its  walls.  The  inferior  vena  cava  from  the 
point  of  entrance  of  the  left  renal  vein  upward  to  the  liver 
was  occupied  by  a  mass  of  tissue  similar  to  that  found  in 
the  kidney.  This  mass  was  adherent  in  places  to  the  wall 
of  the  vessel.  Histological  examination  of  a  section  of  a 
portion  of  kidney  containing  primary  tumor  (Fig.  i) 
showed  the  new  growth  taking  up  almost  the  entire  sec- 
tion. Pressed  to  one  side  was  seen  a  portion  of  the  kidney 
which  is  markedly  sclerotic.  In  most  places  the  tumor  was 
separated  from  the  kidney  by  a  broad  band  of  dense  fibrous 
tissue,  but  here  and  there  could  be  seen  islets  of  the  neoplasm 
lying  in  more  intimate  relation  with  the  kidney  substance. 
The  tumor  had  a  general  lobular  structure.  The  primary 
lobules  were  subdivided  by  strings  of  dilated  capillaries, 
around  which  the  tumor  cells  were  arranged.  There  was 
no  development  of  acini,  but  instead  the  lobule  was  made 
up  of  broad  anastomosing  columns  of  cells,  between  which 
were  the  capillaries.  The  cells  lying  on  the  latter  and  ex- 
tending for  some  distance  toward  the  centre  of  the  column 
were  cylindrical.  Nearer  the  centre  the  cells  were  poly- 
hedral in  shape.  The  central  portions  were  generally  ne- 
crotic. The  cells  had  abundant  protoplasm  taking  the  eosin 
stain,  were  at  times  vacuolated,  contained  from  one  to  sev- 
eral nuclei  rich  in  chromatin  and  with  a  metachromatic 
nucleolus. 

A  calcified  piece  of  tissue  taken  from  the  central  part  of 
the  tumor  and  examined  by  Dr.  Karsner  showed  true  bone 
formation. 

Histological  examination  of  a  section  of  the  renal  vein 
showed  the  lumen  occupied  by  a  tumor  mass  similar  to 
that  found  in  the  kidney.  In  most  places  the  neoplasm 
merely  pressed  against  the  intima,  hu}.  in  several  situations 
it  was  invading  the  venous  wall  reaching  into  the  media. 

Grossly,  each  lung  contained  a  metastatic  nodule,  situ- 
ated in  the  lower  lobe  lying  under  the  pleura.  On  histo- 
logical examination  of  one  of  these  nodules  (Fig.  2)  it  was 
seen  to  be  made  up  of  hypernephromatous  tissue  sin'ilar  to 
that  described  under  the  kidney.  Intracellular  vacuoles 
were,  however,  much  more  numerous,  the  cell  columns  were 
narrower,  and  there  was  more  of  a  tendency  toward  an 
alveolar  arrangement  of  the  cells.  In  one  part  of  the  sec- 
tion there  was  noted  a  vein  which  contained  a  tumor  mass 
in  every  way  similar,  both  as  to  stroma  and  tumor  cells,  to 
that  surrounding  it.  At  one  place  the  vessel  wall  was  infil- 
trated with  the  growth. 

Grossly,  the  stomach  was  much  contracted,  measuring 
10.5  cm.  along  the  lesser  curvature,  the  submucosa  was 


thickened  and  sent  prolongations  down  into  the  muscular 
coat. 

In  the  colon  there  were  several  areas  in  which  the  sub- 
niucosa  was  thickened,  the  thickening  being  rather  nodular 
in  appearance  and  sending  prolongations  into  the  muscular 
coat. 

On  histological  examination  of  a  piece  of  tissue  from  the 
stomach  (Fig.  3)  the  latter  was  seen  to  be  the  seat  of  a 
scirrhous  carcinoma,  which  in  several  places  could  be  seen 
taking  its  origin  from  the  deeper  portions  of  the  mucous 
membrane,  passing  through  the  muscularis  mucosa,  and  at 
some  places  extending  into  the  muscular  coat.  Histolog- 
ical examination  of  one  of  the  nodules  found  in  the  colon 
presented  a  similar  picture,  except  that,  although  a  num- 
ber of  sections  were  made,  no  connection  between  the 
glands  of  the  mucosa  and  the  cell  nests  and  strings  lying 
more  deeply  could  be  demonstrated,  nor  could  any  irregu- 
larity of  the  glands  of  the  mucosa  be  detected,  hence  it 
might  be  inferred  that  the  growth  was  a  metastatic  forma- 
tion from  primary  gastric  cancer. 

The  pancreas  showed  no  change  grossly.  On  histological 
examination  the  tissue  was  seen  to  be  very  poorly  pre- 
served. There  was  evidence  of  slight  chronic  inflanmia- 
tion. 

In  the  records  of  the  pathological  department  of 
the  University  of  Pennsylvania  we  have  encountered 
a  similar  combined  occurrence  of  hypernephroma 
and  cancer  of  the  stomach. 

Case  II. — This  second  case  was  that  of  a  patient  of  Dr. 
Stengel's  service  in  the  University  Hospital.  The  clinical 
history  is  brief — being  that  of  a  male,  aged  forty-nine  years, 
whose  illness  dated  back  ten  months  previous  to  admis- 
sion, starting  with  pain  in  the  left  hypochondrium  coming 
on  while  lifting.  Later  there  was  loss  of  appetite  with 
progressive  loss  of  weight  and  strength.  Physical  signs 
were  generally  negative.  Gastric  analysis  showed  no  free 
hydrochloric  acid,  the  presence  of  lactic  acid,  Oppler-Boas 
bacilli,  and  blood  stained  tissue  shreds.  Blood  examina- 
tion was:    Reds,  4,050,000;  haemoglobin,  65:  whites,  11,600. 

The  autopsy  was  performed  by  Dr.  Nesbit. 

Abstracts  of  gross  and  histological  notes  follow :  The 
right  adrenal  on  section  showed  several  nodules,  measuring 
2  mm.  in  diameter,  pale,  glistening,  and  firm.  Histological 
examination  of  a  portion  of  adrenal  containing  one  of  these 
nodes  showed  the  tumor  to  be  made  up  of  a  delicate  con- 
nective tissue  stroma  containing  many  dilated  bloodves- 
sels and  of  parenchymatous  cells  arranged  as  branching 
hollow  cylinders,  in  manj-  instances  lying  directly  on  the 
capillary  wall.  The  cells  were  rather  large,  rich  in  refrac- 
tile  protoplasm,  polyhedral  in  form,  with  distinct  cell  wall. 
The  nucleus  was  generally  centrically  placed,  round  or 
slightly  oval  in  shape,  rich  in  chromatin ;  the  nucleolus 
stained  metachroniatically.  The  basal  cells  were  often  co- 
lumnar in  shape.  Many  of  the  cells  contained  large  vacu- 
oles with  clearly  defined  margins.  The  neoplasm  was  not 
well  marked  off  from  the  surrounding  portions  of  the 
adrenal,  merging  almost  imperceptibly  with  the  latter.  In 
some  places  immediately  adjacent  to  definite  neoplastic  tis- 
sue there  were  islands  of  suprarenal  parenchymatous  tissue 
containing  a  cell  or  two  exactly  of  the  same  size  and  stain- 
ing properties  as  those  of  the  tumor. 

The  stomach,  grossly,  presented  the  following  appear- 
ances :  It  was  normal  in  size  and  shape.  Firm  adhesions 
were  present  between  the  left  lobe  of  the  liver  and  the  dia- 
phragm. At  the  cardiac  orifice,  in  the  fundus,  and  gener- 
ally in  the  cardiac  half  of  the  viscus  the  wall  was  diffusely 
infiltrated  with  an  irregularly  flat,  ulcerative,  tumor  mass. 
Stomach  contents  were  bloody,  foul,  and  decomposing. 

Mesenteric  and  gastrohepatic  glands  were  enlarged  sHght- 
ly  and  firmer  than  normal,  but  apparently  not  involved  by 
the  tumor. 

The  liver  was  uninvaded  by  the  tumor. 

Histological  examination  of  a  piece  of  tissue  from  the 
stomach  showed  only  the  muscular  coat  and  peritonaeum 
remaining.  The  upper  portion  of  the  former  contained 
chains  and  nests  of  cells  lying  in  the  interfascicular  spaces 
and  extending  to  the  surface.  The  superficial  portions  of 
the  infiltrated  muscle  were  necrotic.  On  contrasting  the 
cells  making  up  this  neoplasm  with  those  found  in  the  su- 
prarenal it  was  found  that  the  former  had  larger,  more 
evenly  and  less  deeply  stained  nuclei,  the  protoplasm  was 
very  much  smaller  in  amount,  and  stained  much  more 
lightly.    The  cells  were  crowded  together  more,  were  not 


January  23,  1909.I 


BRICKXER:  VESICOVAGINAL  FISTULA. 


arranged  as  hollow  branching  cylinders,  but  in  strings  and 
nests,  and  occupied  the  spaces  of  the  preexisting  tissue. 
There  were  no  columnar  cells  present.  Many  caryocinetic 
figures  were  seen. 

The  pancreas,  grossly,  showed  no  change.  On  histolog- 
ical examination  it  was  seen  to  be  the  seat  of  chronic  inter- 
stitial inflammation,  with  fatty  infiltration.  In  one  area  at 
the  periphery  there  remained  only  the  islands  of  Langer- 
hans  surrounded  by  fatty  areolar  tissue. 

The  writers  have  thought  that  the  simuUaneous 
occurrence  of  two  such  growths  of  mahgnant  char- 
acter is  worthy  of  record,  suggestive  of  a  possible 
similarity  of  causation.  Of  course,  there  is  possi- 
bility of  coincidence  of  different  causes.  One  might 
easily  fancy,  however,  the  presence  of  some  chem- 
ical stimulus  or  the  removal  of  some  cherhical  re- 
straint of  growth  operating  at  the  same  time  upon 
the  epithelium  of  the  stomach  and  upon  the  cells  of 
an  adrenal  "rest,"  or  of  the  adrenal  tissue  itself.  It 
is  of  interest  to  add  that  in  the  second  case  there 
were  definite  atrophic  changes  in  the  pancreas  and 
that  the  well  known  rapidity  of  growth  and  the  veg- 
etative appearances  of  the  cells  in  many  hyperneph- 
romata  have  some  importance  if  one  thinks  of  malig- 
nant tumors  as  arising,  according  to  Beard's  recent 
theory,  from  trophoblastic  cells.  However,  even  if 
one  were  to  acknowledge  the  existence  of  some  de- 
gre  of  value  in  Beard's  suggestion,  the  sharp  differ- 
ence between  the  simultaneously  occurring  tumors 
would  argue  against  the  general  applicability  of  his 
idea,  since,  if  both  types  of  tumors  arise  from  unused 
germ  cells,  the  tumors  should  have  been  identical, 
whereas  in  each  case  they  are  distinct  and  the  me- 
tastatic growths  have  followed  the  type,  now  of  one, 
now  of  the  otheT.  The  occurrence  of  bone  in  the 
hypernephroma  of  the  first  case  is  in  line  with  the 
suggestion  which  has  previously  been  made  that 
these  adrenal  tumors  are  in  reality  of  teratomatous 
type  and  adds  somewhat  to  a  restricted  application 
of  Beard's  theory  to  this  class  of  adrenal  tumors. 

In  further  comment  upon  the  applicability  of 
Beard's  theory  it  may  be  said  that  while  it  is  true 
there  existed  definite  atrophy  in  the  pancreas  of  the 
second  case,  and  a  slight  grade  of  chronic  interstitial 
pancreatitis  in  the  first,  the  grade  of  these  changes 
was  by  no  means  excessive  or  beyond  that  which  is 
found  in  a  large  proportion  of  autopsies  on  subjects 
vvithout  any  neoplastic  formations  whatever. 

In  conclusion,  the  authors  wish  to  acknowledge 
the  courtesy  of  Dr.  Frederick  P.  Henry  in  allowing 
the  publication  of  this  report,  and  also  to  thank  Dr. 
A.  J.  Smith  for  his  valuable  suggestions  and  help  in 
the  preparation  of  this  paper  and  for  his  kindness 
in  making  photomicrographs. 

VESICOVAGINAL  FI.STUL.A  FOLLOWING  ABOR- 
TION IN  AN  "OPERATED''  CASE  OF  INCOM- 
PLETE   CONGENITAL  TRANSVERSE 
S.^PTUM  OF  THE  VAGINA.* 
By  Samuel  M.  Brickner.  A.  M.,  M.  D.. 
New  York. 

The  data  in  this  case  are  self-explanatory : 
Case:  B.  G.,  aged  twenty-four,  was  originally  admitted 
to  the  First  Gynaecological  service  of  Mount  Sinai  Hos- 
pital on  July  19th,  1907. 

Previous  history :  She  had  had  measles'  and  smallpox  in 
childhood,  and  typhoid  fever  at  fourteen  years ;  but  no 
scarlet  fever  or  diphtheria.    Her  menses  began  at  thirteen ; 

*Paper  read  and  patient  presented  before  the  Obstetrical  Section 
of  the  New  York  .'\cademy  of  Medicine,  November  27,  1908. 


and  a  doctor  made  a  puncture  to  allow  the  menstrual  fluid 
and  blood  to  escape.  The  flow  had  been  always  regular, 
four  weekly,  for  three  days,  moderately  profuse,  with  no 
pain.  She  had  been  married  eleven  months,  but  was 
never  pregnant.    Coitus  was  very  painful. 

Examination :  On  examination,  the  urethra  and  outlet 
were  found  normal ;  but  the  vagina  ended  about  one  and 
one  half  inches  from  the  vulva.  At  the  internal  end  a 
pin  hole  opening  and  a  mucus  discharge  could  be  seen. 


Fig.   I. — Vaginal  saeptum  as  originally  seen,  opening  in  upper  left 
quadrant. 

By  rectal  examination,  a  small,  retroverted,  movable  uterus 
was  felt,  and  a  boggy  mass  over  the  cervix  and  saeptum. 
This  was  evidently  the  vagina  filled  with  secretion.  The 
appendages  v.'ere  not  felt,  and  her  condition  was  otherwise 
negative. 

Operation :  On  July  22d  a  cross  shaped  incision  was 
made  through  the  mirute  opening,  which  was  situated  a 
little  to  the  left  ir.  the  upper  left  quadrant  of  the  saeptum. 
This  incision  was  extended  to  the  right,  left,  and  down- 
ward. It  could  not  be  extended  upward,  because  the  pos- 
terior wall  of  the  saeptum  was  tightly  adherent  to  the 
cervix.  Thi.>  was  bluntly  dissected  away  from  the  cervix. 
The  saeptutn  was  then  completely  excised  circularly,  the 
cervi.x  being  well  exposed,  and  a  piece  of  gauze  inserted 
into  it.    The  cervix  was  infantile  in  size  and  shape. 

The  saeptum  was  extremely  thick,  its  base  occupying 
practically  the  entire  floor  of  the  vagina.  A  continuous 
suture  was  passed  through  the  cut  edges,  no  mucous  mem- 
brane being  available  for  the  upper  part  of  the  posterior 
wall.  The  vagina  was  then  tightly  packed  with  gauze. 
The  specimen  was  covered  by  squamous  epithelium,  as 


Fig.  2. — Diagrammatic  section  of  saeptum  and  its  opening;  a,  opening 
of  saeptum;  b,  floor  of  vagina;  c,  vulva. 

shown  by  the  examination  of  the  pathologist.  Dr.  F.  S. 
Mandlebaum. 

Within  the  next  few  days  the  gauze  was  removed  and 
reinserted  several  times;  and  after  August  ist  glass  plugs 
were  used,  which  the  patient  was  taught  to  remove,  clean, 
and  reinsert  daily. 

Condition  on  discharge :  She  was  discharged  on  August 


BRICKXER:  VESICOVAGINAL  FISTULA. 


[New  York 
Medical  Journal. 


f)th,  vvitli  the  vagina  easily  admitting  a  large  glass  plug. 
The  walls  were  thick,  and  lined  with  mucous  membrane. 

The  patient  was  told  to  clean  and  reinsert  the  plug 
daily :  but  when  she  returned  for  inspection  on  September 
1st,  she  had  not  worn  it  regularly,  and  considerable  con- 
traction of  the  vagina  had  taken  place.  She  passed  from 
our  observation  from  this  time  until  she  returned  to  us 
in  October,  1908. 

Rcadniission  :  Upon  her  return,  she  stated  that  she  had 
become  pregnant  last  spring,  and  at  four  and  one  half 
months  had  entered  the  Lying-in  Hospital,  where  she  had 
aborted  and  was  curetted.  After  leaving  the  maternity 
hospital  she  observed  lack  of  urinary  control.  At  first  she 
had  incontinence  only  during  the  day.  but  later  it  con- 
tinued both  day  and  night.  The  urine  dribbled  continu- 
ously, more  011  her  standing  or  walking  than  when  sitting 
or  lying,  Init  never  stopping  altogether. 

Second  examination :  The  second  examination  showed  a 
\-agina  about  two  inches  deep.  The  upper  vault  was 
rounded  off,  and  in  its  summit  was  a  small  orifice  which 
leaked  urine  and  entered  directly  into  the  bladder.  The 


Fig.  3. — Kclation  of  the  6stula,  sseptum,  and  uterus  after  abortion; 
a,  bladder;  b,  fistula;  c,  sscptum  and  scar  tissue;  d,  vagina. 

cervix  could  not  be  seen  ;  but  in  the  middle  third  of  the 
vagina  was  a  small  orifice  through  which  a  probe  could  be 
passed  for  two  and  one  half  inches,  evidently  into  the 
uterus.  The  uterine  bod\-  could  be  felt  anteriorly.  A 
vaginal  sasptum  consisting  of  scar  tissue  now  occupied  the 
vagina  transversely. 

Second  operation.  Fistula :  On  October  24th,  the  sreptun: 
was  incised  transverselv  between  the  fistulous  opening  and 
the  orifice  leading  to  the  cervical  canal,  exposing  the  cer- 
vix and  the  fistula,  which  was  one  half  inch  long  and 
one  quarter  iixh  wide.  The  cervix  was  seized  with  bullet 
forceps,  and  the  edges  of  the  fistula  freshened.  The  blad- 
der nuicosa  was  separated  from  the  muscularis,  the  bladder 
nuicosa  inverted,  anfl  siUured  with  interrupted  chromic 
siitnres.  'J'he  overlying  tissues  were  also  sutured  with 
chromic  :^ut,  and  a  i)crmanent  c.-itheter  inserted. 

Postoperative:  Four  days  later  the  catheter  was  drain- 
ing well,  about  1,200  c.c.  of  urine  passing  daily.  The  urine 
was  somewhat  cloudy  and  alkaline,  witli  a  faint  trace  of 
albumin,  a  few  pus  cells,  and  red  blood  cells.  On  the 
eleventh  day  the  catheter  was  removetl,  and  the  bladder 
irrigated,  the  return  flow  being  clear. 

On  N<)v:mber  12th.  eighteen  days  after  operation,  the 
vagina  was  seen  to  be  filled  with  scar  tissue.    The  patient 


urinated  about  every  three  to  five  hours.  A  small  open- 
ing into  the  uterus  still  remained.    The  fistula  was  closed- 

Summary. 

The  features  of  interest  in  this  case  He:  i,  In  the 
pregnancy  following  the'  operation  for  the  reHef  of 
the  saeptum  ;  2,  in  the  difficuhy  of  deHvering  even  a 


Fig. 


-Fistula  exposed,   submucous  tissues  retracted; 
opening;  b,  opening  into  uterus. 


a,  tistulous- 


four  and  one  half  month  ohl  foetus;  3,  in  the  com- 
plete subsequent  scarification  of  the  vagina  ;  and  4, 
in  the  origin  of  the  s.Tjitum. 

The  patient  had  evidently  had  a  sufificiently  capa- 
cious vagina  to  permit  a  coitus,  and  therefore  an 
easy  impregnation.  Why  she  aborted  we  do  not 
know.  The  development  of  the  fistula  is  not  quite 
clear ;  but  it  is  plain  that  it  was  the  resuh  of  a  very 
difficult  operation,  for  when  the  patient  returned  to 
Mount  Sinai  Hospital  only  a  small  sized  sound  could 
be  introduced  into  the  cervical  canal.    (See  Fig.  3.) 

The  subsequent  complete  scarring  over  of  the- 
vagina,  leaving  the  patient  worse  oflf  than  she  wai 
originally,  was  undoubtedly  due  to  the  tearing  and 
stretching  of  the  vaginal  walls  at  the  time  of  her 
abortion.  It  is  curious,  however,  tO'  note  tiiat  this- 
has  taken  place  in  a  much  more  marked  degree  than 
one  sees  in  a  normal  vagina. 

It  is  evident  now  that  this  particular  patient  should 
not  again  be  allowed  to  become  pregnant,  for  the 
vagina,  from  an  inch  and  a  half  from  the  vulva  up- 
ward, is  one  mass  of  scar  tissue.  There  are  a  few 
cases  recorded  of  pregnancy  to  term  after  operations 
of  this  character ;  but  it  is  quite  clear  that  delivery 
in  this  patient  at  full  term  could  be  accomplished' 
only  by  Caesarean  section. 

Origin  of  Scrpfa. — The  origin  of  congenital  trans- 
verse .s?epta  is  of  great  embryological  interest .  T 


a 

Ir 
c 


Fic.  5. — Method  of  suture;  a.  bladder  nuicosa;  />,  submucous  tissues; 
r,  vagina!  mucosa. 

showed  in  a  former  paper'  that  transverse  vaginal 
Scxpta  are  normal  in  adult  sheep,  whales,  dugongs. 
the  manatee,  and  the  chimpanzee.  When  they  occur 
in  the  human  female  they  may  represent  "a  return 
to  an  ancestral  type."     Their  function  is  purely 

'Inroniplcte  Transverse  Congenital  Occlusion  of  the  Vagina,  New 
York  Medical  Journal,  March  7,  1503,  and  Zeitschrift  fiir  Cebnrt- 
shilfe,  L,  No.  i. 


January  23,  1909.]  LAXGE:  ROENTGEN  EXAMINATION  OF  THE  (ESOPHAGUS. 


speculative,  but  may  have  to  do  with  the  facilitation 
of  conception,  and  when  they  appear  in  the  human 
being  they  niay  have  the  same  purpose,  to  aid  in 
overcoming  other  minor  defects  of  development. 

Many  authors,  especially  the  German,  and  those 
intiuenced  by  German  thought,  and  more  particu- 
larly Breisky  and  Schroder,  have  taken  the  attitude 
that  transverse  vaginal  saepta  have  their  origin  either 
in  inflammatory  processes  in  the  vagina  during 
childhood,  or  appear  as  the  result  of  some  of  the 
acute  infectious  diseases.  The  present  patient,  for 
instance,  has  had  smallpox  and  measles.  There  are 
good  and  substantial  reasons,  however,  for  not  ac- 
cepting this  dictum  as  an  explanation  of  all  cases. 
In  the  first  place,  transverse  ssepta  occur  but  once 
in  1,250  cases,"  and  it  is  very  plain  that  more  than 
one  patient  out  of  this  number  has  suffered  from 
one  or  several  of  the  acute  infectious  diseases  during 
childhood :  so  that  a  vaginal  atresia  as  a  result  is  of 
extremely  rare  occurrence.  It  does  certainly  occur, 
especially  as  a  sequel  of  smallpox,-  diphtheria,  and 
scarlatina ;  but  it  is  very  exceptional.  Such  cases, 
moreover,  usually  show  the  vagina  completely  agglu- 
tinated, the  saeptum  consisting  of  dense  scar  tissue, 
and  usually  without  an  opening  leading  into  the 
uterus.  In  this  case,  and  in  three  others  of  the 
series  which  I  have  studied,  the  wall  of  the  saeptum 
was  covered  with  squamous  epithelium,  as  the  rest 
of  the  vagina  normally  is,  and  the  edges  of  the  sjep- 
tum  lay  free  in  the  vagina,  although  the  posterior 
wall  was  adherent  to  the  cervi.x.  In  four  other  cases 
I  have  noted  the  adhesion  between  the  cervix  and 
the  posterior  wall  of  the  saeptum,  and  it  is  easy  to 
believe  that,  through  the  influence  of  uterine  dis- 
charges, an  adhesive  inflammation  has  taken  place 
quite  independent  of  any  infectious  disease.  This  is 
the  gist  of  the  argument  which  leads  me  to  the 
belief  that  the  case  under  discussion,  and  others  of 
its  class,  are  congenital  rather  than  acquired.  The 
embryological  basis  of  my  belief  I  have  gone  into 
quite  extensively  in  the  article  alreadv  cited. 

136  West  Eighty-fifth  Street. 


THE  ROENTGEN  EXAMINATION  OF  THE 
CKSOPHAGUS. 

By  Sidney  Lange,  M.  D.. 
Cincinnati, 

Radiographer  to  the  Cincinnati  Hospital. 

At  first  hand  it  may  appear  that  the  application  of 
the  Rontgen  ray  to  the  diagnosis  of  tesophageal 
disorders  is  a  superfluous  refinement.  The  intricacy 
of  modern  diagnosis,  necessitating  as  it  does  the  use 
of  the  various  '"scopes"  and  the  many  laboratory 
tests,  argues  against  multiplying  diagnostic 
methods. 

We  may  say,  offhand,  that  oesophageal  disorders 
mean  practically  one  thing,  namely,  hindrance  to 
the  passage  of  food. 

In  the  main  there  is  but  one  symptom  of  disease 
of  the  oesophagus,  namely,  disturbance  of  degluti- 
tion. Of  the  objective  signs  there  is  like\vise  but 
one,  namely,  the  resistance  encountered  in  passing 
a  stomach  tube  or  bougie.  But  Rosenheim  says  that 
a  disproportion  between  the  natural  power  of  de- 

-Loc.  cit. 


glutition  and  the  results  of  probing  may  be  found 
in  all  the  various  affections  of  the  oesophagus.  The 
patient  may  complain  of  increasing  difficulty  in  de- 
glutition, so  that  even  fluids  fail  to  pass,  and  yet  it 
may  be  possible  to  pass  an  oesophageal  bougie  into 
the' stomach  readily.  This  peculiar  circumstance  is 
met  with  chiefly  in  compression  of  the  oesophagus 
from  without  and  in  neuroses,  but  occasionally  it 
will  be  found  in  flat  carcinoma,  which  does  not  in- 
filtrate the  rjesophagus  in  aimular  form,  but  disturbs 
deglutition  only  in  a  reflex  manner.  And  in  any 
organic  stricture  there  may  be  an  early  stage  in 
which  the  tube  encounters  no  resistance,  but  in 
which  oesophageal  peristalsis  W'ill  be  interfered  with 
either  bv  spasm  or  paralysis  of  the  musculature  sec- 
ondary to  the  lesion.  Thus  the  ultimate  cause  of 
disturbance  of  deglutition  may  be  the  result  of  me- 
chanical or  nervous  factors  or  a  combination  of 
both. 

The  examination  of  oesophageal  obstruction  has 
for  its  object  the  determination  of  the  existence  of 
an  obstruction  (either  mechanical  or  nervous)  to 
the  passage  of  food.  But  since  both  organic  and 
functional  stricture  may  be  of  such  a  nature  as  to 
either  permit  of  the  ready  passage  of  oesophageal 
bougies  or  so  tight  as  to  absolutely  prevent  their 
passage,  the  results  of  such  instrumentation  are 
sometimes  not  conclusive. 

Having  determined  the  presence  of  an  obstruc- 
tion, it  becomes  necessary  to  discover  whether  the 
stricture  is  functional  or  organic.  Rosenheim  says 
the  diagnosis  of  spasm  of  the  oesophagus  is  rarely 
easy.  Such  points  as  the  sudden  appearance  of  the 
difficulty  in  deglutition,  the  difiierences  in  degree 
of  permeability  from  time  to  time,  variations  in  the 
seat  of  the  constriction  and  the  presence  of  other 
hysterical  stigmata  speak  for  spasm  of  the  oesopha- 
gus. The  spasm  may  be  brought  on  by  eating 
coarse  food  or  by  the  passage  of  the  stomach  tube, 
and  mav  relax  after  rapid  efforts  at  swallowing. 

In  organic  stricture  the  resistance  offered  to  the 
tube  is  more  permanent  in  its  degree  and  situation, 
and  there  is  usually  a  history  of  associated  symp- 
toms that  speak  for  the  possibility  of  the  occurrence 
of  such  a  stricture  and  its  nature.  In  cancer,  which 
is  the  most  common  organic  obstruction,  we  con- 
sider the  age  of  the  patient,  but  cancer  may  occur 
early  in  \  outh ;  we  look  for  the  cachexia,  but  it  is 
well  known  that  patients  may  maintain  their  nutri- 
tion for  a  considerable  time  in  cancer  of  the 
oesophagus,  and,  on  the  other  hand,  a  neurotic 
stricture  may  be  so  persistent  as  to  cause  severe 
inanition  and  even  death. 

A  careful  chest  examination  may  reveal  a  medi- 
astinal tumor  which  is  exerting  pressure  upon  the 
oesophagus  from  without,  but  a  mediastinal  tumor 
may  be  of  such  size  and  position  as  to  escape  recog- 
nition by  phvsical  examination. 

While  organic  strictures  are  usually  constant  and 
permanent,  it  should  not  be  forgotten  that  there 
may  be  a  combination  of  spasmodic  and  organic 
stricture,  and,  furthermore,  organic  strictures  are 
subject  to  inflammatory  exacerbations,  so  that  the 
symptoms  in  any  given  case  may  not  be  distinctive 
of  either  organic  or  spasmodic  stricture,  but  may 
have  features  in  common  with  both.  For  this  rea- 
son the  observation  that  in  organic  stricture  semi- 


LANGE: 


ROENTGEN  EXAMINATION  OF  THE  (ESOPHAGUS. 


[New  Vohk 
Medical  Journal. 


solids  and  litiuids  will  pass  while  in  spasmodic  stric- 
ture nothing  will  pass,  may  fail  to  hold  good. 

The  before  mentioned  points  of  possible  error  are 
enumerated  simply  to  suggest  that  in  certain  diffi- 
cult cases  of  oesophageal  obstruction  there  is  room 
for  additional  methods  of  examination.  Rosen- 
heim advances  the  use  of  the  oesophagoscope  to 
clear  up  these  difficulties.  Being  able  to  look  di- 
rectly at  the  seat  of  obstruction  he  distinguishes  or- 
ganic and  spasmodic  strictures,  by  the  picture  thus 


Fig.  I. — Author's  apparatus  for  examining  oesophagus  and  chest. 


presented  spasmodic  strictures  presenting  simply 
puckered  folds  of  mucous  membrane,  organic  varie- 
ties presenting  tumor  masses,  ulcers,  cicatrices,  etc. 

By  the  Rontgcn  method  the  act  of  deglutition  it- 
self can  be  studied.  Its  ease  and  safety  of  execu- 
tion and  the  additional  information  which  it  sup- 
plies make  it  preferable  in  some  ways  to  the  older 
clinical  methods,  not,  however,  displacing  the  older 
methods,  but  rather  aiding  and  reinforcing  them. 


In  selected  cases,  however,  the  use  of  the  Ront- 
gen  method  is  imperative.  In  very  neurotic  or  very 
feeble  patients  oesophageal  instrumentation  often 
cannot  be  carried  out.  while  in  valvular  heart  dis- 
ease the  passage  of  oesophageal  bougies  is  distinctly 
dangerous.  In  any  case,  the  possibility  of  an  un 
discovered  aneurysm  or  other  mediastinal  tumor 
lends  an  element  of  risk  to  such  procedures. 

1.  We  have  in  the  x  ray  a  means  (both  ocular 
and  graphic)  of  determining  the  function,  position, 
and  size  of  the  oesophagus  from  the  pharynx  to  the 
diaphragm,  and  since  but  one  half  inch  of  the  tube 
lays  below  the  phrenic  hiatus,  any  obstruction  at  or 
below  the  diaphragm  will  be  manifest  above  it. 
Therefore  the  entire  tube  can  be  studied.  The 
Rontgen  method  has  to  do  only  with  the  lumen  of 
the  oesophagus,  and  takes  no  account  of  changes  in 
its  walls  pej-  se,  for  a  cancer  or  gumma  of  the 
CESophagus  rarely  reaches  a  size  large  enough  to  be 
rendered  visible  by  the  x  ray. 

2.  The  rays  afford  a  safe  means  of  examining  the 
oesophagus.  The  passage  of  tubes,  bougies,  cesoph- 
agoscopes,  etc.,  being  dispensed  with.  The  materi- 
als used  for  the  x  ray  examination  being  gelatin  or 
rice  powder  capsules  and  bismuth  subnitrate,  con- 
not  possibly  do  harm. 

3.  Basing  the  conclusion  upon  a  limited  experi- 
ence, it  would  seem  that  diminution  in  the  size  of 
the  lumen  of  the  oesophagus  can  be  detected  earlier 
by  this  method.  If  there  is  any  value  at  all  in 
the  recognition  of  oesophageal  obstructions  it  lies 
in  their  early  recognition.  .For  if  the  obstruction  be 
cancerous  (  and  more  than  seventy-five  per  cent, 
are),  the  prognosis  can  be  laid  before  the  patient  or 
his  relatives  early  in  the  course  of  the  disease,  and 
preparations  made  for  proper  feeding,  etc.,  in  order 
to  prolong  life.  If  the  obstruction  is  cicatricial  or 
gummatous  or  spasmodic  its  early  recognition  be- 
comes doubly  important,  so  that  the  proper  medica- 
tion or  surgical  procedures  may  be  adopted  in  time. 

The  ordinary  stomach  tube  meets  with  resistance 
only  when  there  is  considerable  reduction  in  the 
lumen  of  the  oesophagus.  The  oesophagus  is  elas- 
tic and  permits  of  considerable  stretching,  so  that 
a  stomach  tube  or  small  bougie  may  pass  a  partial 
obstruction  without  resistance.  It  is  only  by  the 
use  of  the  larger  sounds  that  a  slight  narrowing  of 
the  oesophageal  lumen  may  be  detected,  and  the  use 
of  these  large  instruments  is  not  only  verv  disagree- 
able to  the  patient,  to  say  the  least,  but  also  dan- 
gerous. By  giving  the  patient  a  capsule  (the  size 
of  a  quarter)  filled  with  bismuth  subnitrate  and 
watching  its  passage  through  the  oesophagus,  any 
slight  decrease  in  the  size  of  the  lumen  will  be  evi- 
denced by  the  temporary  stoppage  of  the  capsule 
at  the  point  of  constriction. 

The  retardation  or  stoppage  of  such  a  bismuth 
capsule  depends  not  entirely  upon  the  actual  nar- 
rowing of  the  lumen  of  the  tube,  for  gravity  plays 
little  part  in  the  function  of  the  oesophagus.  The 
movement  of  a  bolus  through  the  oesophagiis  de- 
pends primarily  upon  the  progressive  peristaltic 
muscular  wave  behind  the  bolus.  The  bolus  may  be 
retarded  not  only  by  a  constricted  lumen,  but  by 
absent  or  deficient  peristalsis  as  well. 

In  infiltrating  lesions,  such  as  cancer  or  gumma, 
there  must  be  an  early  stage  of  infiltration  of  the 


January  23.  ■909.J  LANGE:  ROENTGEN  EXAMINATION  OF  THE  (ESOPHAGUS.  ifn 


oesophageal  wall  before  the  lumen  is  appreciably 
diminished,  and  this  infiltration  will  in  all  probabil- 
ity either  diminish  the  vigor  of,  or  stop  altogether, 
the  peristaltic  wave  at  this  point,  and  the  bolus  will 
pause  here  for  a  longer  or  shorter  period  of  time. 
Thus  our  bismuth  capsule  would  register  the  pres- 
ence of  such  a  paretic  or  paralytic  section  of  the 
oesophagus  by  its  stoppage  at  that  section.  An 
oesophageal  bougie  passed  at  this  stage  may  meet 
with  no  appreciably  resistance. 

4.  Another  favorable  feature  of  this  method  is 
the  fact  that  it  is  agreeable  to  the  patient.  A  pa- 
tient who  fights  the  stomach  tube  will  readily  swal- 
low a  bismuth  capsule  or  eat  a  few  teaspoonfuls  of 
bismuth  mush. 

5.  The  X  ray  also  affords  information  regarding 
the  presence  of  mediastinal  tumors  which  may  be 
pressing  upon  the  cesophagns,  and  the  examination 
of  the  oesophagus  should  always  include  an  exam- 
ination of  the  chest  for  such  tumors.  Aside  from 
the  dangers  of  using  oesophageal  sounds  and  the 
oesophagoscope  in  cases  of  mediastinal  tumors,  the 
latter  instrument  would  not  necessarily  clear  up  the 
condition  in  any  given  case,  for  the  mucosa  at  the 
site  of  compression  may  be  either  healthy  or  it  may 
be  ulcerated  from  pressure  of  tumor. 

The  normal  oesophagus  is  not  visible  to  the  x  ray 
nor  is  an  ordinary  bolus  of  food  visible.  In  order 
to  examine  the  aesophagus  with  the  x  ray,  some- 
thing must  be  introduced  to  cast  a  shadow.  Bis- 
muth subnitrate  answers  the  purpose  admirably,  be- 
ing very  opaque  to  the  ray  and  inert  so  far  as  any 
effect  upon  the  patient  is  concerned. 

But  because  of  the  deep  position  of  the  oesopha- 
gus in  the  chest,  even  the  introduction  of  bismuth 
into  the  food  passage  will  fail  to  show  upon  the 
flviorescent  screen  or  photographic  plate.  For  the 
heavy  shadows  of  the  spine,  heart  and  great  vessels, 
and  sternum  will  be  superimposed  upon  that  of  the 
bismuth  filled  oesophagus,  obscuring  it  entirely.  It 
becomes  therefore  necessary  to  place  the  patient  in 
what  the  Germans  have  called  the  Fechterstellung, 
the  oblique  position  assumed  in  fencing.  In  this 
position  the  rays  traverse  the  chest  obliquely  from 
left  posterior  to  right  anterior  or  vice  versa.  A 
clear  space  between  the  heart  and  the  spine  thus 
comes  into  view.  It  represents  the  retrocardial 
space  or  posterior  mediastinum — the  path  of  the 
oesophagus.  For  safe  and  accurate  x  ray  work  of 
this  kind  special  apparatus  is  necessary.  For  the 
protection  of  the  operator  the  x  ray  tube  should  be 
enclosed  in  a  lead  lined  box  or  lead  glass  shield, 
while  the  fluorescent  screens  should  be  covered  with 
lead  glass.  For  obtaining  a  normal  ray  and  con- 
trolling the  axis  of  the  ray,  the  tube  and  fluorescent 
screen  should  maintain  parallel  relations  with  each 
other  by  means  of  an  orthodiagraphic  apparatus 
after  the  principle  of  Moritz. 

The  examination  is  carried  out  as  follows:  The 
patient  is  placed  in  proper  position  in  the  orthodia- 
graph, the  room  darkened  completely,  and  the  ray 
turned  on.  The  path  of  the  oesophagus  is  exam- 
ined to  ascertain  that  it  is  not  obstructed  by  any 
tumor  mass.  Now  a  five  grain  gelatin  capsule 
filled  with  bismuth  subnitrate  is  placed  in  the  pa- 
tient's mouth,  and  when  ready  the  patient  is  in- 
structed to  swallow.    The  capsule  at  once  lands  in 


the  hypopharynx  just  behind  the  cricoid  cartilage. 
It  may  simply  pause  here  for  an  instant  or  it 
may  remain  several  seconds  before  entering  the 
mouth  of  the  oesophagus.  The  capsule  then  enters 
the  oesophagus  and  proceeds  rapidly,  disappearing 
through  the  diaphragm  in  2  to  4  seconds.  In  some 
cases,  particularly  in  patients  past  middle  age,  the 
capsule  halts  under  the  upper  part  of  the  sternum, 
where  the  arch  of  the  aorta  and  the  bifurcation  of 
the  trachea  overlie  the  oesophagus.  This  point  cor- 
responds in  situation  with  Treve's  second  point  of 
normal  narrowing  of  the  oesophagus,  and  is  due  ap- 
parently to  the  slight  pressure  of  a  thickened  or  di- 
lated aortic  arch.  In  some  cases  it  may  be  neces- 
sary to  give  the  patient  a  swallow  of  water  to  carry 
the  capsule  past  this  point.  It  has  been  my  experi- 
ence that  partial  oesophageal  obstruction  is  a  rather 
constant  accompaniment  of  aortic  aneurysm  as  evi- 
denced by  the  stoppage  of  a  bismuth  bolus  at  the 
aortic  crossing,  although  in  such  cases  the  patient 


Fig.  2. — Spasmodic  stricture,  upper  third  of  cesophagus  (Case  XI). 

as  a  rule  will  not  complain  of  dysphagia.  And  this 
fact  suggested  to  me  the  possibility  of  the  existence 
of  partial  oesophageal  obstruction  without  giving 
rise  to  any  subjective  symptoms. 

If  there  is  a  complete  stenosis  (which  is  usually 
spasmodic)  anywhere  along  the  passage  the  cap- 
sule will  halt  at  that  point.  If  the  obstruction  is 
partial  the  capsule  may  pass  readily  or  it  may  re- 
quire a  swallow  of  water  to  force  it  through. 

A  large,  fiat,  rice  powder  capsule  about  the  size 
of  a  quarter  is  filled  with  bismuth  and  given  to  the 
patient  in  a  tablespoonful  of  water.  This  also  lands 
at  the  mouth  of  the  oesophagus,  enters  it,  and  nor- 
mally proceeds  rapidly  to  disappear  under  the  dia- 
phragm with  or  without  making  a  short  pause  at  the 
aortic  crossing.  If  a  spasmodic  stricture  exists  the 
capsule  stops  and  cannot  be  made  to  pass  further. 
If  organic  stricture  exists  the  capsule  will  stop, 
even  though  the  stricture  has  encroached  but  slight- 
ly upon  the  passage.  The  cause  of  the  stoppage  may 
be  either  mechanical  hindrance  by  the  lesion  or  by 
a  spasm  or  paralysis  secondary  to  the  lesion.  A 


t62 


LANGE:  ROENTGEN  EXAMINATION  OF  THE  CF.SOPHAGUS 


[Nhw  York 
Medical  Jocrnai. 


swallow  of  water  may  force  it  past,  or  if  the  ob- 
struction is  considerable  it  will  remain  until  dis- 
solved and  broken  up,  and  the  bismuth  will  then 
trickle  through  slowly. 

A  cornmcal  mush  is  now  cooked  up  and  a  few 
drachms  of  bismuth  subnitrate  stirred  into  it  and  tht 
patient  allowed  to  eat  a  few  tablespoonfuls  slowly 
It  normally  enters  the  cesophagus  readily  and  pro 


3. — OrKariic  '•tricturc  (cancer)  about  middle  of  the  (Esophagus 
(Case  Mil ). 


cccds  in  one  or  more  elongated  masses  to  the  dia- 
phragm. If  there  is  a  spasmodic  stricture  the  mush 
collects  above  the  stricture.  As  the  patient  con- 
tinues to  eat  the  mush,  the  accumulation  gradually 
increa.ses  until  the  weight  of  it  becomes  sufficient 
to  relax  the  spasm  and  then  the  whole  mass  passes 
suddenly  into  the  stomach,  after  which  everything 


swallowed  passes  readily  without  hindrance.  In 
cases  of  very  tight  spasmodic  stricture  of  the  cardia 
relaxation  may  be  secured  by  causing  the  patient  to 
gag,  whereupon  the  violent  attempts  at  vomiting 
may  open  the  cardia  and  then  the  mush  enters 
quickly.  If  the  obstrtiction  is  organic  and  incom- 
plete, the  mush  wall  lodge  above  it  and  slowly 
trickle  through,  especially  if  aided  by  a  few  swal- 
lows of  water,  and  the  size  and  length  of  the  con- 
sticted  bismuth  stream  may  give  some  idea  of  the 
size  and  length  of  the  obstruction.  If  the  obstruc- 
tion is  organic  and  complete,  which  is  very  rare,  the 
mush  remains  at  the  site  of  obstruction  until  re- 
gurgitated. 

In  a  case  of  (^esophageal  obstruction  without 
atony  and  dilatation  of  the  cesophageal  walls,  active 
up  and  down  movements  of  the  capsules  may  be 
seen,  indicating  active  peristalsis. 

If  there  is  atony  and  dilatation  above  the  stricture 
the  bismuth  mush  collects  here  and  its  mass  gives 
a  fair  idea  of  the  size  and  shape  of  the  pouch.  For 
filling  and  outlining  such  dilatations  an  emulsion  of 
bismuth  in  milk  or  in  kefir  (which  holds  the  bis- 
muth in  suspension  for  hours)  may  be  preferable  to 
the  mush,  the  patient  being  able  to  regurgitate  the 
liquid  emulsion  easier  than  the  tenacious  mush. 

At  an}'  stage  in  the  examination  a  skiagraph  mav 
be  made,  providing  the  capsule  or  the  mush  remain 
quiet  and  are  not  agitated  by  active  peristalsis. 

The  following  case  first  called  the  writer's  atten- 
tion to  his  method  : 

Case  I.— A  young  married  woman,  age  about  thirty- 
five,  was  referred  to  the  Cincinnati  Hospital  for  a  Rontgen 
examination  of  the  oesophagus.  For  some  months  she  had 
complained  of  dysphagia,  locating  the  point  of  obstruction 
under  the  middle  of  the  sternum.  She  had  vomited  infre- 
quently and  lost  a  little  in  weight.  Owing  to  the  fact 
that  she  had  a  very  evident  mitral  lesion,  her  physician 
did  not  use  the  stomach  tube.  The  neurotic  nature  of  the 
patient  suggested  the  presence  of  a  spasmodic  stricture. 
Proceeding  with  the  x  ray  examination  as  outlined  before, 
we  gave  her  the  small  bismuth  capsule.  It  lodged  at  a  point 
opposite  the  seventh  dorsal  vertebra.  Several  swallows  of 
water  failed  to  dislodge  it.  The  large  capsule  was  then 
given  and  it  shared  the  same  fate.  We  waited  perhaps 
twenty  minutes  and  the  capsules  had  not  moved  down- 
ward. We  then  gave  her  the  bismuth  mush.  It  collected 
slowly  around  the  capsule  until  about  two  tablespoonfuls 
had  been  taken  when  suddenly  the  entire  mass  dropped 
quickly  into  the  stomach.  After  that  everything  swal- 
lowed, mush  and  capsules,  both  large  and  small,  passed 
into  the  stomach  at  once  without  encountering  any  ob- 
struction. The  diagnosis  of  spasinodic  stricture  was  made. 
Her  phvsician  informed  me  that  the  patient  did  not  again 
complain,  of  dysphagia.  Apparently  the  weight  of  the  mush 
during  the  examination  permanently  overcame  the  spas- 
modic stricture. 

The  following  cases  represent  three  types  of  or- 
ganic strictures : 

Cask  It. — Mr.  A.  S.,  aged  fifty-three,  had  for  some 
months  complained  of  dysphagia,  semisolids  and  liquids 
however  giving  little  trouble.  Fhcre  was  no  regurgitation. 
The  stomach  tube  met  with  slight  resistance  a  short  dis- 
tance above  the  cardia,  but  no  pressure  was  used  for  fear 
of  doing  harm.  I'pon  x  ray  examination  the  small  cap- 
sule stopped  at  about  the  seventh  dorsal  vertebra.  .\ 
swallow  of  water  served  to  carry  it  past.  The  large  cap- 
sule lodged  here  permanently.  The  mush  likewise  stopped 
here,  but  inmiediateh'  violent  up  and  down  movements  of 
the  bismuth  mass  were  seen,  and  the  mass  was  slowly 
forced  past  the  obstruction  in  a  thin  stream  about  the 
size  of  a  small  lead  pencil  and  about  one  and  one  half 
inches  long.    A  diagnosis  of  organic  obstruction  was  made. 

Case  III. — Mr.  J.  G.,  aged  sixty,  had  been  able  to  take 
only  semisolids  and  liquids  for  some  months,  solids  being 


Jan-.ary  .^^  ,900.)  LAXGh:  ROENTGEN  EXAMINATION     OF  THE  (ESOPHAGI'S. 


promptly  rcgurgitateil.  The  stomach  tube  met  with  firm 
resistance  at  the  cardia.  Upon  x  ra\'  examination,  both 
large  and  small  capsules  stopped  permantly  at  about  one 
inch  above  'ihe  diaphragm.  The  mush  also  collected  here 
in  an  elongated  pouch,  and  very  feeble  peristalsis  could 
be  seen,  which  forced  the  mass  through  the  cardia  very 
slowly  and  in  a  very  thin  stream.  The  greater  part  of  the 
mass  was  still  in  the  oesophagus  one  hour  after  swallow- 
i)ig.  The  diagnosis  of  organic  obstruction  with  partial 
atony  and  dilatation  of  the  cesophageal  walls  was  made. 

Case  IV. — Mr.  A.  R.,  aged  fifty-five,  had  for  more 
than  a  year  been  able  to  take  only  liquids  and  semisolids. 
Any  indiscretion  in  diet  produced  regurgitation  several  hours 
later.  The  stomach  tube  met  with  a  firm  resistance  sev- 
eral inches  above  the  cardia.  Upon  x  ray  examination, 
both  capsules  lodged  about  three  inches  above  the  dia- 
phragm, and  the  mush  likewise  collected  here  in  a  wide 
pouchlike  reservoir  with  a  horizontal  upper  margin  about 
three  and  one  half  inches  wide  and  tapering  oflf  below  to 
a  point.  'J'he  mass  was  unagitated  by  peristalsis  and  re- 
mained here  until  regurgitated.  The  diagnosis  of  organic 
obstruction  with  complete  atony  and  pouchlike  dilatation 
of  the  cesophageal  walls  was  made. 

The  division  line  between  pharynx  and  oesopha- 
gus is  an  uncertain  one.  and  there  is  a  neutral  area 
behind  the  cricoid  cartilage  which  may  be  either 
pharynx  or  cesophagus.  ]Much  interest  attaches  to 
this  region,  for  the  musculature  of  this  part  of  the 
tube  plays  an  important  part  in  deglutition.  It  is 
here  that  the  bolus  of  food  first  pauses  during  the 
act  of  swallowing.  It  is  here  that  swallowed  for- 
eign bodies  (especially  large  ones)  tend  to  lodge, 
and  it  is  here  that  the  stomach  tube  first  encounters 
resistance. 

Killian  ( i )  in  making  routine  laryngoscopical  ex- 
aminations was  able  in  selected  cases  to  look  behind 
the  larynx.  If  the  larynx  occupied  the  position  of 
phonation  with  epiglottis  raised  only  a  small  slit 
could  be  seen  behind  the  larynx.  If,  however,  the 
patient  executed  the  deglutition  reflex,  a  distinct 
opening  appeared  behind  the  laryngeal  cartilages, 
enabling  the  observer  to  look  into  the  oesophagus. 
Because  of  the  sphincteric  action  of  this  slitlike  en- 
trance to  the  oesophagus,  Killian  called  it  the 
Ocsophagusmund  or  mouth  of  the  oesophagus.  The 
resistance  offered  by'this  entrance  of  the  oesophagus 
may  be  so  energetic  that  the  stomach  tube  cannot 
be  passed  until  the  patient  executes  the  deglutition 
reflex,  relaxing  the  sphincter.  He  states  that  this 
M itnd  is  invisible  upon  a  skiagram,  but  I  was  re- 
cently able  to  show  it  upon  the  skiagram  of  an  old 
man  with  calcified  laryngeal  cartilages  which  ap- 
parently held  the  entrance  of  oesophagus  open. 

Killian  found  by  dissection  that  this  sphincter 
was  formed  by  three  muscles,  namely,  (i)  the 
lower  part  of  the  inferior  constricture,  (2)  the 
cricopharyngeus.  and  (3)  the  levator  oesophagi,  the 
cricopharyngeus  being  the  most  important,  hold- 
ing by  its  tonic  contraction  the  posterior  wall  of  the 
oesophagus  against  the  cricoid  cartilage,  thus  clos- 
ing the  passageway.  Eyckman  (3),  in  a  Rontgen 
study  of  the  act  of  deglutition,  found  that  as  a  bolus 
is  passed  back  upon  the  tongue,  the  larynx  and 
hyoid  bone  are  drawn  forward,  the  epiglottis  closes, 
and  the  Ocsophagusmund  gaps  wide.  But  the  sitn- 
ple  pulling  forward  of  the  larynx  will  not  ordinarily 
open  the  oesophagus ;  there  must  be  an  inhibition  of 
the  tonus  of  the  cricopharyngeus,  an  inhibition 
which  seems  to  be  a  part  of  the  act  of  deglutition. 
After  the  bolus  enters  the  oesophagus,  the  sphincter 
becomes  tonic  again,  and  thus  prevents  regurgita- 


tion 0/  the  food  into  the  pharynx.  The  crico- 
pharyngeus and  inferior  constrictor  are  innervated 
by  the  superior  laryngeal  nerve,  but  the  pharyngeal 
plexus  also  innervates  this  part  of  the  food  passage, 
and  this  ple.xus  is  made  up  of  glos.sopharyngeal, 
pncumogastric.  recurrent  laryngeal,  and  sympa- 
thetic fibres.  According  to  .Schif¥,  the  sympathetic 
system  maintains  the  tonic  contraction  of  the 
sphincter  at  the  cardiac  cud  of  the  oesophagu.^,  w  hile 
the  vagtis  acts  as  an  inhibitor,  causing  relaxation  of 


-J. — Organic  stricture   Ccai;cer)   at  cardia   (Case  \'II>. 


this  muscle.  Since  the  sphincter  st  the  upper  end 
of  the  tube  receives  both  sympathetic  and  pncumo- 
gastric fibres  it  is  not  impossible  that  the  tonic  con- 
traction and  relaxation  ma\-  be  brought  about 
in  the  same  way.  Indeed,  the  close  relation 
between  the  upfycr  and  lozccr  ends  of  the 
oesophagus  is  shown  by  the  fact  that  in 
cardiospasm  there  is  often  an  associated  spasm  of 
the  Oesophagus)nund.  and  an  organic  cardiac  ob- 
struction  or  an  obstruction  anywhere  along  the  .• 


LANCE:  ROENTGEN  EXAMINATION  OF  THE  (ESOPHAGUS. 


[New  Vobk 
Medical  Journal. 


■oesophagus  may  reflexly  cause  spasm  of  the  en- 
trance of  the  oesophagus,  preventing  the  passage  of 
stomach  tubes.  In  hysteria,  the  globus  hystericus 
may  be  explained  as  a  spasm  or  lack  of  inhibition 


•Fic.   5. — Organic  stricture    (({uiniiiatous) ,  middle  of  u-'supliagus 
(Case  XV). 

of  the  musculature  of  the  Oesophagusmund,  and 
when  the  spasm  is  excessive  symptoms  of  stricture 
■of  the  oesophagus  are  imitated,  the  stricture  being 


referred  to  the  upper  third  of  the  oesophagus,  when 
in  reality  it  lies  at  the  very  entrance. 

In  the  light  of  Killian's  investigation,  we  may 
regard  the  oesophagus  as  a  muscular  tube  closed  at 
either  end  by  sphincters.  The  muscular  tube  be- 
tween the  apertures  is  also  closed  except  when  food 
is  passmg  through,  during  which  passage  the  mus- 
culature executes  peristaltic  contraction.  Excessive 
sympathetic  stimulation  or  lack  of  inhibition  on  the 
part  of  the  vagus  may  cause  persistent  tonic  con- 
traction of  the  musculature,  giving  rise  to  the  so 
called  spasmodic  stricture  of  the  passage.  This 
spasm  may  occur  at  the  mouth  of  the  oesophagus, 
at  the  cardiac  orifice,  or  less  frequently  anywhere 
along  the  tube.  Spasm  of  the  oesophageal  sphincters 
is  produced  normally  by  any  excessive  stimulus,  as 
by  the  swallowing  of  imperfectly  masticated  food, 
foreign  bodies,  or  the  passage  of  the  stomach  tube. 
Increased  pressure  upon  a  stomach  tube  to  force  it 
past  the  sphincter  often  increases  the  spasmodic  re- 
sistance of  the  sphincter.  On  the  other  hand,  the 
gentle  uniform  pressure  exerted  upon  such  a  spas- 
modic stricture  by  a  well  masticated  (semisolid) 
bolus  may  be  sufficient  to  relax  the  spasm,  for  it  is 
a  common  observation  that  in  spasmodic  stricture 
a  large  bolus  of  semisolid  food  will  pass  while  a 
little  water  may  be  regurgitated.  The  use  of  the  x 
ray  in  diagnosticating  spasmodic  stricture  and  in 
distinguishing  it  from  organic  stricture  depends 
upon  these  observations.  The  bismuth  capsules  be- 
ing foreign  bodies  irritate  the  spasmodic  area  and 
the  spasm  is  increased,  but  the  even,  uniform  pressure 
of  the  bismuth  mush  slowly  overcomes  the  spasm. 
Of  the  usual  clinical  methods  for  recognizing  spas- 
modic strictures,  the  various  water  pressure  tests 
approach  this  method  closely,  being  based  upon  the 
same  principle.  Occasionally,  however,  such  an  ex- 
cessively tight  and  persistent  spasmodic  stricture 
will  be  met  with  that  the  mush  plus  the  peristalsis 
fails  to  relax  it ;  indeed,  it  may  require  a  general 
anaesthetic  to  overcome  it  or  necessitate  a  gas- 
trostomy to  administer  food.  Such  tight  varieties 
occur  practically  always  at  the  cardia,  where  the 
musculature  of  the  oesophagus  is  reinforced  by  that 
of  the  stomach. 

The  normal  action  of  the  cardia  is  imperfectly 
understood  and  much  less  is  known  of  its  disturb- 
ance in  cardiospasm.  Its  musculature  is,  however, 
of  the  involuntary  type,  and  we  may  expect  it  to 
conform  to  the  established  physiology  of  involun- 
tary muscle.  In  other  words,  we  may  infer  its  con- 
tractions and  relaxations  to  be  maximal.  It  is 
either  completely  relaxed  or  completely  closed.  If 
relaxed  the  bismuth  mush  goes  through  in  a  mass. 
If  closed  absolutely  none  of  the  bismuth  gets 
through.  Since  organic  strictures  are  practically 
always  partial  and  will  allow  some  bismuth,  al- 
though often  in  a  very  thin  stream,  to  trickle 
through,  the  fact  that  a  stricture  is  impermeable  to 
the  mush  speaks  for  spasm. 

The  following  case  shows  how  a  spasm  of  the 
Oesophagusmund  may  be  recognized  by  the  rav. 

Case  V.— An  old  man,  aged  seventy,  gave  symptoms 
of  dysphagia  and  indicated  a  sense  of  constriction 
in  the  upper  part  of  the  oesophagus,  being  able  to 
swallow  only  mushy  foods  and  liquids.  He  did  not  vomit. 
He  was  e.xtremely  neurotic  and  had  a  hysterical  tremor 
and  at  times  suflfered  attacks  of  muscular  incoordination. 


January  23,  1909. J 


LAXGE:  ROEXTGEX'  EXAMINATIOX  OF  THE  (ESOPHAGUS. 


Any  attempt  at  swallowing  produced  violent  spasm  of  the 
muscles  of  deglutition  and  for  this  reason  the  stomach 
tube  was  not  passed.  When  this  patient  was  given  a  five 
grain  bismuth  capsule  h  was  with  great  difficulty  that  the 
deglutition  reflex  was  initiated.  The  capsule  finally  passed 
to  the  Oesophagusinund  and  there  remained  until  finally 
dislodged  by  a  large  swallow  of  water,  after  which  it 
passed  quickly  into  the  stomach.  The  larger  capsule  was 
then  given,  but  the  reflex  spasm  set  up  and  made  it  im- 
possible for  him  to  swallow  it.  Finally  about  three  tea- 
spoonfuls  of  bismuth  mush  was  fed  slowly  with  little  diffi- 
culty, causing  but  slight  reflex  spasm.  It  collected  for  a 
short  time  at  the  Ocsophagusniund,  and  then  the  whole 
mass  passed  quickly  into  the  stomach. 

The  fact  that  in  patients  with  dilated  aorta  and 
small  aortic  aneurysms  the  large  bismuth  capsule 
will  pause  behind  the  aorta,  although  the  patients 
do  not  complain  of  dysphagia,  has  suggested  the 
use  of  this  method  in  the  early  recognition  of  medi- 
astinal enlargements.  The  large  capsule,  by  main- 
taining its  shape  more  or  less  throughout  its  pas- 
sage through  the  oesophagus  and  not  conforming  to 
constrictions  as  does  the  soft  bolus,  will  test  the 
capacity  of  the  entire  tube,  and  should  register  in- 
creased mediastinal  pressure  before  dysphagia  and 
resistance  to  the  stomach  tube  are  present. 

The  following"  case  exemplifies  this  application : 

C.\sF.  VI. — Mr.  W.  C.  S.,  aged  thirty-five,  had  suffered 
for  several  months  with  distress  in  the  mediastinum,  with 
some  dyspncea  and  paroxysmal  attacks  of  pain,  starting 
deep  under  the  sternum,  and  radiating  into  the  neck  and 
arms.  The  heart,  except  for  a  faint  systolic  bruit  to  be 
heard  over  the  aortic  valve,  seemed  normal  in  size  and 
action.  The  lungs  seemed  normal  and  there  were  no 
other  pressure  symptoms'  evident. 

The  patient  was  referred  for  an  x  ray  examination.  The 
skiagraph  showed  a  very  slight  broadening  of  the  medi- 
astinal shadow  under  the  upper  part  of  the  sternum,  which 
in  the  light  of  his  symptoms  was  suggestive  of  mediastinal 
enlargement. 

Upon  testing  the  act  of  swallowing,  the  mush  passed 
readily  and  normally,  but  the  large  capsule  lodged  several 
inches  below  the  aortic  crossing,  and  would  not  pass  until 
dissolved.  Upon  questioning  the  patient  regarding  de- 
glutition, he  stated  to  have  occasional  difficulty  in  swallow- 
ing a  large  bolus,  as  it  seemed  to  "stick  in  his  chest."  We 
thought  the  circumstance  too  trivial  to  mention.  A  tenta- 
tive diagnosis  of  mediastinal  enlargement  causing  pres- 
sure upon  the  oesophagus  was  made.  The  case  is  still 
under  observation. 

Dysphagia  in  oesophageal  disorders  seems  to  de- 
velop only  after  the  obstruction  reaches  consider- 
able proportions.  In  practically  all  of  the  cases  of 
organic  stricture  examined,  the  lesion  was  well  ad- 
vanced before  the  patient  sought  medical  attention, 
and  in  those  cases  of  slight  pressure  upon  the 
oesophagus  as  by  a  small  aneurysm,  discovered  acci- 
dentally, the  patients  did  not  complain  of  dysphagia 
until  their  attention  was  directed  to  their  swallow- 
ing. 

Dilatation  and  diverticula  of  the  oesophagus  lend 
themselves  beautifully  to  the  Rontgen  method. 
Clinically  a  dilatation  can  be  recognized  by  the  fact 
that  the  patient  regurgitates  a  large  quantity  of  al- 
kaline undigested  food  sometimes  after  having  been 
swallowed.  While  to  diagnosticate  a  diverticulum  it 
is  recommended  to  use  two  sounds  and  to  pass  one 
into  the  blind  sac  and  the  other  into  the  stomach. 
It  is  an  easy  matter  to  fill  the  dilated  portion  of  the 
oesophagus  with  bismuth  emulsion  and  to  actually 
see  its  size  and  shape  or  to  record  the  same  upon  a 
photographic  plate. 

While  dilatation  usually  indicates  organic  stric- 
ture below  ihem,  this  is  not  the  infallible  rule,  for 
it  is  entirely  possible  for  a  spasmodic  stricture  to  be 


so  tight  as  to  resist  the  weight  of  the  food  above  it 
and  result  in  dilatation. 

Instances  of  dilatation  from  spasmodic  stricture 
both  of  the  mouth  of  the  oesophagus  and  of  the  car- 
diac end  have  been  observed. 

Von  Eicken  (4)  and  Killian  (5)  have  described 
seven  cases  of  so  called  pulsion  divertical  of  the 
oesophagus,  a  pouchlike  dilatation  of  the  hypo- 
pharynx  just  above  the  Oesophagusinund.  There 
exists  here  normally  a  weak  spot  in  the  posterior 
wall  of  the  upper  end  of  the  oesophagus,  due  to  a 
divarication  of  the  fibres  of  the  cricopharyngeus. 
According  to  these  authorities,  a  spasmodic  stric- 
ture below  converts  this  weak  spot  into  a  distinct 
pouch.  The  occurrence  of  such  a  dilatation  with- 
out apparent  cause  just  above  the  mouth  of  the 
oesophagus  strengthens  the  statement  that  there  is  a 
sphincter  at  this  point,  for  such  a  dilatation  could 
occur  only  in  the  presence  of  a  stricture  below. 

An  analogous  dilatation  is  met  with  at  the  car- 
diac orifice.  Neuman  (6),  in  1900,  collected  sev- 
enty cases  of  so  called  idiopathic  or  atonic  dilatation 
of  the  oesophagus.  In  this  condition  there  is  a  uni- 
form dilatation  of  the  entire  thoracic  portion  of  the 
oesophagus  which  when  filled  with  food  or  bismuth 
einulsion  resembles  a  thick  sausage.  In  such  an  idi- 
opathic or  atonic  dilatation  of  the  oesophagus,  the 
stomach  tube  may  pass  readilv  into  the  stomach. 
Furthermore,  the  patient  may  not  vomit,  for  the  food 
after  remaining  in  the  oesophagus  a  short  while 
usually  passes  into  the  stomach.  The  x  ray  will  re- 
veal it  at  once. 

Hunter  recognized  the  condition  in  the  following 
way :  He  gave  the  patient  a  glass  of  cacao,  some 
hours  later  a  glass  of  milk.  By  passing  the  stomach 
tube  into  the  oesophagus  he  recovered  the  milk. 
Then  by  passing  the  tube  on  into  the  stomach  he 
recovered  the  cacao,  which  had  trickled  through  the 
cardia  before  the  milk  was  drunk. 

Killian  regards  cardiospasm  as  the  cause  of  this 
dilatation,  but  Kraus  has  shown  that  there  is  a 
paralysis  of  the  oesophagus  consequent  upon  partial 
atrophy  of  the  vagus.  The  fact  that  the  dilatation 
is  uniform  throughout  the  lower  part  of  the  oesoph- 
agus makes  the  diagnosis  probable  and  speaks  for 
paralysis  of  the  musculature  associated  with  cardio- 
spasm, for  if  the  dilatation  is  due  alone  to  a  stric- 
ture below  it,  the  dilatation  would  be  not  diffuse, 
but  limited  to  the  region  above  the  stricture.  Fur- 
thermore, it  does  not  seem  probable  that  in  the  pres- 
ence of  active  oesophageal  peristalsis  that  a  spasm  of 
the  cardia  could  support  such  a  weight. 

In  conclusion,  let  it  be  understood  that  it  is  the 
purpose  of  this  paper  simply  to  call  attention  to  the 
fact  that  the  Rontgen  ray  may  be  of  great  value  in 
the  recognition  and  study  of  oesophageal  disorders. 
Further  observations  are  necessary  to  confirm  the 
interpretation  of  the  motile  phenomena  seen  upoa 
the  fluorescent  screen. 

The  method  of  diagnosis  as  outlined  is  based 
upon  the  examination  of  many  normal  cases  and 
upon  sixteen  cases  of  oesophageal  obstruction.  Four 
of  these  cases  were  from  the  wards  of  the  Cincin- 
nati Hospital,  and  the  remaining  twelve  were  re- 
ferred for  x  ray  examination  by  various  physicians. 

C.-vSE  I.— Female,  aged  thirty-five.  Diagnosis,  spasmodic 
stricture  in  middle  third  of  cesophagus.  Patient  alive  and 
well  at  present  date.    Reported  in  full  in  text. 


ll'JLSOX:  IWIPILSI  TUBERCULOSIS. 


[Niiu  York 
Medical  Journal. 


Case  II. — Male,  aged  seventy,  spasm  of  Oesophagusmuiid, 
condition  unchanged.    Reported  in  lull  m  te.xt. 

C.KSE  III. — Male,  aged  titty-live.  Organic  stricture,  lower 
third  of  tlio  oesophagus.  Died  six  monlhs  after  examina- 
tion.   Reported  in.  full  in  text. 

C.^.sE  IV.— .Male,  aged  about  sixty.  Organic  stricture  at 
cardia.    Died  about  nine  months  after  examination. 

C.vsE  V. — Female,  aged  sixty-two.  Organic  stricture 
of  cardia.    Condition  gradually  growing  worse. 

Cask  VI.— Female,  aged  tifty-.^ix.  Organic  stricture  of 
cardia.  G.isirostomy  performed,  much  improved.  Is  alile 
to  take  nourislmient  naturall\'  at  times. 

C.\SE  V'll. — Male,  aged  sixty.  Organic  stricture  at 
cardia.  Died  one  year  after  the  examination.  Reported 
in  full  in  text. 

C.\SE  VIII. — Male,  aged  about  sixty-five.  Organic  ob- 
struction af  cardia.    Present  condition  unknown. 

Case  IX. — Female,  aged  sixty-two.  .  Organic  obstruc- 
tion at  cardia.    Still  alive. 

Case  X. — Male,  aged  fifty-seven.  Organic  olistruction 
about  three  inches  above  diaphragm  with  dilatation  of 
(Esophagus  above.  Died  about  a  year  after  the  examin- 
ation, having  lived  more  than  two  years  after  the  onset. 
Reported  in  full  in  text. 

C.vse  XI. — Female,  aged  sixty.  Spasmodic  stricture  up- 
per third  of  cEsophagus.  Was  alive  and  not  losing  weight 
or  strength  over  three  years  after  the  onset,  although  con- 
tinued to  suffer  with  intermittent  dysphagia. 

Case  XII. — Male,  aged  about  forty-tive.  Organic  stric- 
ture, Ocsofiluigusiiiund.  Diagnosis  verified  by  oesophagoscope. 
Gastrostomy  performed  and  excision  of  growth  undertaken. 
Outcome  doubtful. 

Case  XIII. — Male,  aged  fifty.  Organic  stricture  about 
middle  of  ossophagus.    Still  under  observation. 

Case  XIV. — ^^lale,  aged  sixty.  Organic  stricture,  middle 
third  of  oesophagus,  supposedly  malignant.  Sudden  death 
several  weeks  later.  Autops}-  showed  ruptured  caseous 
glands  pressing  upon  the  ctsophagus  and  advanced  pul- 
monary tuberculosis.  I  failed  to  examine  chest  with  x 
ray  for  mediastinal  tumor.  l)ut  came  to  make  the  diag- 
nosis of  cancer  because  of  age  and  condition  of  patient. 

Case  XV. — Male,  aged  fifty-eight.  Organic  stricture 
middle  third  of  oesophagus.  Great  improvement  under 
potassium  iodide  and  passage  of  bougies.  Tentative  diag- 
nosis of  syphilitic  stricture.    Still  under  observation. 

Case  XVI. — Male,  aged  thirty-five.  Stricture,  middle 
tliird  of  oesophagus  due  to  increased  mediastinal  pressure. 
Nature  unknown.  Still  under  observation.  Reported  in 
full  in  text. 

Referexces. 

1.  Killian.  Za'tschrift  fiir  Olii  enhcilkunde ,  October, 
1908. 

2.  Huber.  Corrcst<ondciizhlatt  fiir  Schzi,'ei::cr  Acrste, 
February,  1908. 

3.  Eyckman.    Pfiiigers  Archh',  xic,  p.  513. 

4.  Von  Eicken.    Archw  fiir  Laryiigologic ,  xv,  p.  3. 

5.  Killian.  Miiiicliciicr  mcdizinische  IVochcnschrift, 
1900.  No.  4. 

6.  Xeuman.  MiUcilnngcn  aus  den  Grcnzgcbictcn  dcr 
Med'i.zin  und  Cliinirgic,  iii,  1900. 

7.  Schroeder.    Lav.cct  Clinic.  March  31,  1906. 

22  Wk.st  Sf.vextii  Stkeizt. 

INCIPIENT  TUBERCULOSIS  OF  THE  LUNGS  AND 
ITS  DIAGNOSIS. 
Bv  GoKDox  Wilson,  M.  D., 
Baltimore, 

AoMicinIc  Professor  of  tlu-  Practice  of  Medicine,  University  of  Mary- 
land; X'isiting  Physician  to  Emlowood  Sanatorium;  Physician 
in  Charge  of  the  Municipal  Hospital  for  Tuberculosis. 

My  object  in  presenting  this  paper  is  not  that  I 
have  anything  new  to  say  on  this  subject,  but  the 
fact  that  of  late  years  i;  has  assumed  importance, 
for  tlic  reason  tliat  so  many  sanatoria  admit  only 
cases  in  the  inci])ient  t  rm.  I  liave  lately  looked 
over  the  dififcrent  tcxtlx  oks  on  practice  of  medi- 
cine at  our  lii)rary,  scmiic  fifteen  in  number,  and  I 
have  failed  to  find  in  any  of  them  a  clear  and  exact 


description  of  this  stage  of  tuberculosis  of  the  lungs. 
1  here  is  and  always  will  be  a  diflference  in  opinion 
as  to  whether  certain  cases  are  incipient  or  not,  but 
we  are  fortunate  enough  to  have  had  a  definition 
laid  down  by  an  authoritative  body,  The  National 
Association  for  the  Study  and  Prevention  of  Tuber- 
culosis, which,  through  its  committee  on  Clinical 
Nomenclature  at  its  meeting  in  Washington,  in  I\Iay, 
1907,  defined,  both  clinically  and  anatomically  the 
incipient  stages  as  follows  : 

SHi^ht  initial  lesion  in  the  form  of  infiltration 
limited  to  the  apex  of  one  or  both  liuigs  or  a  small 
part  of  one  lobe.  \o  tiibereiilons  complications. 
Slio:ht  \or  no  constitiitiona!  symptoms — (particu- 
larly including  gastric  or  intestinal  disturbance  or 
rapid  loss  of  zvcight). 

Slight  or  no  elevation  of  temperature  or  aceele- 
tion  of  pulse  at  any  time  during  the  tzventy-four 
hours,  especially  after  rest.  Expectoration  usually 
small  in  amount  or  absent.  Tubercle  bacilli  may  be 
present  or  absent.  A'o  marked  impairment  of  func- 
tion., cither  local  or  constitutional. 

To  diagnosticate  the  disease  in  this  stage  is  by  no 
means  easy  and  requires  an  attention  to  detail  and 
a  thoroughness  in  the  physical  examination  that 
seems  almost  absurd,  if  we  only  consider  the  mild 
svmptoms  of  which  the  patient  complains. 

The  data  on  which  a  diagnosis  should  be  made 
are  obtained,  first,  from  the  history  of  the  case  ;  sec- 
ond, the  physical  examination ;  and,  third,  the  exam- 
ination of  the  sputum,  the  study  of  the  patient's 
temperature,  and  the  ti>e  of  tuberculin — and  though 
in  man\-  cases  the  examination  of  the  sputum  alone 
gives  the  diagnosis,  yet  there  is  a  very  large  number 
in  which  there  is  either  no  sputitm,  or  frequent  ex- 
aminations are  made  with  negative  findings ;  and 
vet  our  history  and  physical  examination  are  so 
very  suggestive  that  we  can  only-  rule  out  active 
disease  by  means  of  one  of  the  forms  of  the  tuber- 
culin test- 
In  obtaining  the  history  of  the  patient  and  follow- 
ing the  classical  method  of  "family  history,"  "past 
history."  and  "present  illness."  we  find  that  under 
each  of  these  headings  information  may  be  found 
that  will  be  of  service  to  us  in  arriving  at  a  di- 
agnosis. 

With  the  present  knowledge  of  the  cTtiologv  of 
the  disease,  and  laying  aside  all  questions  as  to  di- 
rect hereditary  transmission  of  a  "weakened  re- 
sistance" to  it,  one  readily  sees  how  the  constant 
and  long  continued  exposure  in  the  home  in  which 
there  lives  one  tuberculous  menil)er  may  forge  a 
link  in  the  chain  of  evidence. 

ITnder  ''past  history."  statistics  have  demon- 
strated that  certain  diseases,  such  as  measles  and 
whooping  cough,  are  not  infrequently  followed  by 
tuberculosis ;  however,  of  the  far  greater  importance 
under  tiiis  head  comes  a  past  history  of  h;emo])tysis 
and  pleurisy;  and  for  the  first  I  can  not  better  ex- 
])ress  it  than  to  quote  Cornet's  article  in  the 
English  translation  of  Xothnagel.  who  says:  ".\1I 
in  all,  one  does  not  err  in  considering  actual  pul- 
monary hiemorrhages  to  be  of  tuberculous  nature 
although  hajmorrhages  do  occiu'  in  certain  other 
diseases."  .As  to  pleurisy  with  effusion,  it  is  otily 
of  late  \ears  that  the  question  of  .-etiology  has  been 
at  all  elucidated  ;  but  with  this  elucidation  has  come 


J.-Uiiiary  -3.  i<j..<>.  | 


IVILSOX:  IXCIPIENT  TUBERCULOSIS. 


167 


a  clearer  understanding  of  the  importance  of  always 
finding  out  whether  the  patient  has  had  pleurisy  in 
the  past.  It  is  sufficient  to  state  here  that  of  ^21 
uncomplicated  cases  of  pleural  eitusion  that  were 
under  observation  for  a  period  of  five  years  by  R.  C. 
Cabot,  only  ninety-six  patients  were  alive  and  ap- 
parently free  from  tuberculosis  and  117  were  either 
dead  or  suffering  with  phthisis.  Bacteriologically, 
the  fluid  in  "idiopathic  pleurisy"  has  been  shown  by 
inoculation  tests  to  be  in  a  very  large  number  of 
cites  definitely  tuberculous.  Le  Damany  demon- 
strating the  bacillus  by  this  means  in  fifty-one  out 
of  hfty-five  cases. 

It  is,  however,  under  the  heading  of  "present  ill- 
ness" that  we  obtain  our  most  valuable  data,  though 
these  are  frequently  only  gotten  by  careful  ques- 
tioning, as  the  symptoms  are  so  slight  that  they 
often  escape  the  observation  of  the  patient  until  his 
attention  is  called  to  them.  For  this  reason  we  rare- 
ly see  incipient  cases  in  dispensary  work,  for  the  man 
absolutely  dependent  on  his  daily  wage  does  not  seek 
medical  advice  until  the  symptoms  cannot  be  ig- 
nored. Of  late,  however,  we  have  had  these  patients 
applying  at  the  dispensary  for  examination,  sent 
there  by  the  visiting  nurses  on  account  of  exposure 
to  infection  and  slight  symptoms,  or  else  because  of 
some  friend  who  has  the  disease  and  suspecting  it 
in  the  patient,  on  account  of  similarity  of  symptoms, 
has  advised  his  seeing  a  physician.  An  example  of 
this  occurred  in  the  practice  of  a  friend  of  mine. 
He  had  as  a  patient  a  young  girl  in  the  early  stage 
of  the  disease  who  was  engaged,  and  she  noticed 
that  her  fiance  had  a  slight  but  chronic  cough.  As 
he  was  not  able  to  obtain  expert  advice  at  his  home, 
and  knowing  that  the  State  Board  of  Health  exam- 
ined sputum  free,  she  advised  him  to  send  his  spu- 
tum in  for  examination,  which  he  did,  and  was  noti- 
fied that  tubercle  bacilli  had  been  found  in  his  spu- 
tum. He  then  consulted  my  friend,  who  confirmed 
the  diagnosis  by  the  physical  signs  in  the  chest. 

The  symptoms  of  the  incipient  stage  are:  I, 
Cough.  This  is  frequently  slight  and  of  only  a 
few  weeks'  duration,  and  at  times  with  little  or  no 
sputum.  The  cough  may  be  present  only  in  the 
morning  when  the  patient  first  wakens,  and  not  in- 
frequently consists  simply  of  a  clearing  of  the 
throat. 

2,  Hjemorrhage.  Xot  infrequently  this  is  the  first 
svmptom  and  can  be  looked  on  almost  as  a  blessing, 
as  it  warns  both  the  patient  and  the  physician  of  the 
dangerous  condition  at  a  time  when  the  disease  can 
be  cured.  The  initial  haemorrhage  is  not  infre- 
quently unaccompanied  by  cough,  the  patient  sud- 
denly noticing  a  salty  taste  in  the  mouth  and  is  sur- 
prised on  spitting  out  blood.  In  women  the  haemor- 
rhage comes  not  unusually  at  the  time  of  the  men- 
strual period,  and  for  this  reason  is  at  times  put 
down  as  vicarious  menstruation. 

In  regard  to  vicarious  menstruation  as  a  cause 
of  haemoptysis.  I  cannot  do  more  than  quote  Sir 
Samuel  West,  who  says :  "I  suppose  it  is  right  to  re- 
fer to  vicarious  menstruation  as  a  cause  of  haemop- 
tysis, but  I  have  never  seen  a  reputed  instance  of  it 
which  stood  critical  examination.  I  do  not  know  of 
any  satisfactory  case  recorded,  and  the  majority  of 
those  best  qualified  to  judge  either  doubt  or  deny  its 
existence." 


3,  A  moderate  loss  of  weight  for  which  the  pa- 
tient can  not  account. 

4,  A  moderate  degree  of  malaise  that  is  best  ex- 
pressed in  the  "slang"  term  of  "not  feeling  up  to 
the  mark." 

5,  Night  sweats.  This  symptom  is  well  classified 
by  Cornet,  who  says :  "The  sweating  is,  as  a  rule, 
proportionate  to  the  severity  of  the  disease,  or 
rather,  the  acuteness  of  its  course." 

6,  Fever.  This  symptom  is  frequently  unknown 
to  the  patient  on  account  of  the  very  slight  rise  of 
the  temperature  above  normal.  In  doubtful  cases 
niy  own  practice  is  to  give  a  thermometer  to  the  pa- 
tient and  instruct  him  how  to  take  his  temperature 
and  to  keep  an  accurate  record  of  it  for  me,  taking 
it  three  times  a  day — in  the  morning,  in  midafter- 
noon.  and  again,  between  six  and  seven.  An  after- 
noon fever  of  about  99°  F.  is.  I  think,  one  of  the 
most  valuable  symptoms  we  have.  In  addition  to 
these  symptoms,  a  complaint  of  the  patient  that  he 
has  lost  interest  in  things  and  is  lacking  in  his  ac- 
customed initiative  is  certainly  suggestive,  especially 
so  when  there  are  mild  gastrointestinal  symptoms. 

Having  obtained  the  history  along  these  lines,  we 
are  now  ready  for  the  physical  examination,  and  the 
patient  to  be  satisfactorily  examined  must  be 
stripped  to  the  ivaist,  with  a  sheet  or  light  blanket 
thrown  over  the  shoulders ;  and  in  the  case  of  a 
woman  a  towel  may  be  spread  over  the  breasts.  To 
my  mind,  it  is  absolutely  impossible  to  make  a  sat-, 
isfactory,  thoruugh  examination  of  the  lungs  if 
there  is  any  garment  worn  over  the  thorax. 

The  position  of  the  patient  depends  upon  the  ex- 
aminer, though  most  specialists  prefer  to  have  the 
patient  seated  or  standing  rather  than  lying  down. 

A  good  light,  falling  evenly  on  the  surface  to  be 
examined,  is,  of  course,  to  be  desired. 

I  will  not  attempt  to  go  into  all  the  different  meth- 
ods used  in  the  physical  examination  :  but  will  only 
mention  those  I  have  found  of  use.  and  use  constant- 
ly, and  will  take  them  up  in  their  classical  order, 
simply  from  the  standpoint  of  incipient  cases : 

Inspection. — Even  in  very  early  cases,  this  is  of 
value,  and  if  the  chest  is  watched  carefully  from 
just  in  front  of  the  median  line,  or  from  behind, 
looking  down  over  the  front  of  the  chest,  we  can 
frequently  detect  a  slightly  lessened  movement  of 
the  affected  side  best  seen  on  ordinan,'  respiration. 
A  method  of  apparently  exaggerating  this  inequal- 
itv  of  movement  is  by  placing  the  hands  flat  on,  the 
chest  -wall,  just  above  the  mammae. 

The  general  shape  of  the  thorax  I  have  found  of 
little  service  in  the  diagnosis  of  these  cases,  save 
where  it  may  be  classed  under  the  general  head  of 
"undeveloped." 

Palpation. — In  my  hands,  this  has  afforded  me 
practically  no  information  that  I  could  not  obtain 
better  bv  other  means,  and  on  that  account  I  rarely 
use  it. 

Percussion. — This  is  of  great  value,  coming  sec- 
ond only  to  auscultation,  but  unfortunately  is  only 
mastered  with  difficulty  and  by  long  practice,  and  I 
have  fotmd  that  srudents.  good  in  other  methods  of 
physical  diaenosis.  are  unable  to  gain  information 
by  this  method  in  these  cases  where  the  difference 
of  note  is  slight  and  only  apparent  on  very  light  per- 
cussion.   I  believe  the  lack  of  success  with  this 


WILSON:  INCIPIENT  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


method  is  due  to  failure  in  holding  the  finger  very 
firmly  and  flat  against  the  chest  wall  and  to  the 
striking  with  the  pulp  instead  of  the  end  of  the  fin- 
ger, and  not  letting  it  rebound. 

Cabot,  in  his  Physical  Diagnosis,  states  the  rules 
clearly  as  follows : 

'"I,  Always  press  as  firmly  as  possible  upon  the 
surface  of  the  chest  with  the  second  finger  of  the 
left  hand  on  the  dorsum  of  which  the  blow  is  to  be 
struck.  2,  Strike  a  quick,  perpendicular,  rebound- 
ing blow  with  the  tip  of  the  second  finger  of  the 
right  hand  just  behind  the  nail,  imitating  as  far  as 
possible  with  the  right  hand  the  action  of  a  piano 
hammer.  3,  Let  all  blows  struck  in  any  one  part 
of  the  chest  be  uniform  in  force.  4,  Strike  from  the 
wrist  and  not  from  the  elbow.  The  wrist  must  be 
perfectly  loose.  5,  Keep  the  percussing"  finger  bent 
at  a  right  angle." 

In  addition  to  these  rules,  it  is  well  to  bear  in 
mind  that  the  lightest  percussion  that  elicits  a  clear 
note  is  the  best  in  this  class  of  cases,  as  a  smaller 
volume  of  lung  is  set  in  vibration,  and  if  diseased 
the  note  will  not  be  masked  by  the  vibration  of  the 
larger  amount  of  healthy  tissue  about  it. 

In  percussing  especial  pains  should  be  taken  in 
two  regions,  the  supraclavicular  and  supraspinous 
fossae,  as  it  is  here  that  the  lesion  is  most  frequently 
found.  Osier  stating  that  in  427  patients  he  found 
one  or  both  apices  involved  in  413.  C.  L.  Minor,  of 
Asheville,  has  strongly  recommended  the  outlining 
of  the  apices  in  the  supraclavicular  fossae  by  light 
percussing,  and  has  found  that  in  many  cases  the 
resonant  area  is  decidedly  less  on  the  afl:'ected  side — 
this  is  undoubtedly  so  in  many  healed  apical  lesions, 
and  the  "puckering"  of  the  apex  as  found  at  autopsy 
bears  this  out. 

That  a  slight  impairment  of  the  percussion  note 
may  be  the  only  sign,  is  well  shown  by  Hamman 
and  Wolman,  who  in  cases  giving  suggestive  his- 
tories, and  no  other  physical  signs  than  the  above, 
were  able  to  prove  them  tuberculous  later  by  either 
finding  the  bacilli  in  the  sputum  or  obtaining  a  posi- 
tive tuberculous  reaction,  with  a  later  development 
at  this  point  of  signs  of  which  there  could  be  no 
doubt. 

A  very  slight  impairment  of  the  note  on  percus- 
sion in  either  of  these  fossae  as  compared  with  its 
companion  should  be  considered  as  evidence  of  a 
lesion,  perhaps  healed,  though  it  should  not  be  con- 
sidered proof. 

Aiisciiltatiou. — For  the  reason  given  before,  most 
of  our  attention  is  to  be  directed  to  the  four  fossae, 
suT)raclavicular  and  supraspinous.  In  auscultating, 
I  e.xamine  thoroughly  above  the  level  of  the  third 
rib,  in  front,  and  above  the  fifth  vertebra,  behind, 
before  examining  the  bases,  as  one  is  more  apt  to 
find  lesion  there,  and  the  perceptions  are  not  dulled 
by  being  tired,  and  above  all  becau.se  the  fine  rales 
are  not  dissipated  by  the  deep  breathing  in  examin- 
ing the  bases. 

In  listening  for  adventitious  sounds  and  changes 
in  the  respiratory  murmur  three  types  of  breathing 
should  be  used  by  the  i)atient :  i ,  Listen  over  the ''dan- 
ger zones"  while  the  patient  breathes  naturally,  and 
it  is  here  that  one  finds  the  earliest  physical  sign. 
Lawrason  Brown  has  pointed  out  the  fact  that  the 
very  earliest  sign  is  the  slight  alteration  in  the  char- 
acter of  the  vesicular  niurnnir.    This  together  with 


a  diflference  in  the  intensity  of  the  breath  sounds  in 
corresponding  areas  should  undoubtedly  be  put 
down  as  important  evidence  of  disease,  especially  if 
backed  by  a  suggestive  history.  2,  Get  the  patient 
to  breath  deeply,  but  naturally,  as  one  does  after 
climbing  a  long  flight  of  stairs.  This  way  of  breath- 
ing many  patients  will  not  do  unless  shown,  but  by 
doing  it  yourself,  and  telling  him  to  breathe  like  you 
and  with  you.  he  soon  does  it  in  a  satisfactory  man- 
ner. This  type  of  respiration  will  frequently  "bring 
out"  fine  crepitant  rales,  and  will  make  more  clear 
the  dift'erence  in  intensity  between  the  correspond- 
ing areas.  3,  This  is  a  modification  of  the  breathing 
in  2,  obtained  by  getting  the  patient  to  give  a  slight 
cough  at  the  end  of  expiration,  and  then  take  a  deep 
inspiration.  This  very  frequently  brings  out  rales 
that  you  are  unable  to  hear  by  any  other  means,  and 
by  many  is  considered  the  most  important  of  all 
auscultation  methods  in  incipient  tuberculosis  of  the 
lungs. 

Other  data  from  the  physical  examination,  such  as 
small  glands  of  the  neck,  inequality  of  the  pupils, 
etc.,  I  consider  of  minor  importance,  though  the 
relative  high  pulse  rate  and  low  blood  pressure  are 
factors  that  must  be  considered. 

It  is  not  necessary  to  consider  here  the  question 
of  the  sputum  examination,  as  that  is  dealt  with  sat- 
isfactorily in  the  textbooks,  simply  bearing  in  mind 
that  even  numerous  negative  findings  in  no  sense 
rule  out  the  diagnosis  of  tuberculosis. 

To  justify  us  in  making  a  definite  diagnosis  in  an 
adult  w^e  must  have  a  "history"  that  is  at  least  sug- 
gestive, and  either  find  bacilli  in  the  sputum  or  per- 
sistent physical  signs  in  the  lungs,  especially  at  the 
apices,  which  cannot  be  accounted  for  by  syphilis, 
a  clearing  up  of  a  pneumonia  or  an  vindoubted  at- 
tack of  influenza,  bearing  in  mind  that  the  tuber- 
culous invasion  may  simulate  influenza,  and  it  is  in 
this  latter  group  where  there  is  no  sputum,  or  fre- 
quent examinations  are  negative  that  tuberculin  is 
of  greatest  value,  and  fortunately  most  exact. 

Hjemoptysis  in  a  person  under  thirty-five,  even 
though  accompanied  by  slight  symptoms  and  no 
physical  signs  on  frequent  examinations,  should 
make  us  suspect  tuberculosis  so  strongly  that  we 
should  advise  the  use  of  tuberculin. 

Finally,  in  that  group  of  patients  where  we  are 
not  justified  in  making  a  diagnosis,  but  where  there 
is  a  history  of  exposure  to  infection  and  symptoms, 
though  slight,  yet  suspicious,  we  should  be  frank 
and  make  them  realize  the  necessity  of  fresh  air, 
especially  in  their  sleeping  rooms,  the  building  up  of 
the  body  by  extra  feeding  in  the  form  of  milk  and 
eggs,  and  the  avoidance  of  overfatigue,  and  remain- 
ing under  the  care  of  their  physician  until  the  sus- 
picions have  been  justified  or  removed. 

Before  closing,  I  would  like  to  say  a  word  of 
warning  as  to  the  opthalniotuberculin  test,  which  is 
becoming  popular  on  account  of  its  simplicity.  In 
addition  to  the  severe  reactions  which  have  been  re- 
ported in  the  .A.merican  medica^l^  journals,  there  have 
been  reported  in  the  Furopean  journals  cases  of  cor- 
nical  ulcers  following  the  use  of  the  ocular  test,  and 
also  recurring  conjunctivitis  in  the  eye  used  for  the 
reaction.  I,  myself,  know  of  one  case  of  comical 
ulcer  here  in  Baltimore,  that  followed  the  opthal- 
motuberculin  reaction. 

8o<^  C.\tiii:dral  Street. 


January  23,  1909.] 


HUHXER:  GONORRHOEA. 


169 


CLINICAL  GONORRHCEA  IX  THE  MALE. 

By  Max  Huhner,  M.  D., 
New  York. 

INTRODUCTORY. 

So  many  excellent  books  and  monographs  have 
been  devoted  to  the  subject  of  gonorrhoea,  and  it 
has  been  presented  from  every  possible  viewpoint, 
that  one  ought  not  to  write  upon  this  subject  un- 
less one  can  actually  add  some  new  facts  to  increase 
our  store  of  knowledge.  The  writer  considers  it 
unfair  to  the  medical  public  to  rehash  what  has  al- 
ready been  written  on  the  plea  of  presenting  the 
matter  in  "better  light."  It  is  with  this  object  in 
view  that  this  paper  is  written.  Except  in  the 
chapter  on  prophylaxis  it  presents  exclusively  the 
results  of  the  writer's  experience,  gathered  from  a 
large  dispensary  class  and  also  from  private  prac- 
tice. No  books  have  been  consulted  in  its  prepa- 
ration, and  nothing  is  stated  in  its  pages  upon  the 
authority  of  any  one  else. 

The  object  of  this  paper  is  partly  indicated  by  its 
title ;  it  is  essentially  clinical.  Theoretical  and  path- 
ological questions  will  not  be  entered  into  except  in 
so  far  as  they  are  necessary  to  elucidate  some  clin- 
ical point.  Nor  does  it  intend  to  give  a  com.plete 
textbook  description  of  the  course  and  treatment  of 
gonorrhoea  from  its  inception  through  all  its  vari- 
ous stages.  Such  a  description  is  entirely  unneces- 
sary, as  any  amount  of  such  descriptions  is  found 
excellently  handled  in  various  textbooks  and  mono- 
graphs upon  this  subject. 

It  is  the  object  of  this  paper  to  give  the  results 
of  the  writer's  "observation  and  experience  in  the 
treatment  of  gonorrhoea  in  a  large  number  of  pa- 
tients in  dispensary  and  private  practice ;  to  draw 
attention  to  facts  in  diagnosis  and  treatment  that 
have  either  not  at  all  been  treated  of  before,  or  have 
not  been  properly  emphasized ;  to  state  what  has 
been  the  writer's  experience  with  the  many  methods 
now  in  vogue  and  what  are  their  advantages  and 
shortcomings. 

In  the  chapter  treating  on  the  subject  of  the  de- 
termination of  the  cure  of  gonorrhoea  the  writer 
has  set  forth  views  based  upon  very  close  observa- 
tion of  a  very  large  number  of  cases.  Few  points 
connected  with  the  subject  of  gonorrhoea  are  of 
more  importance  than  the  determination  of  the  cure 
of  the  disease,  and  this  phase  of  the  subject  fully 
warrants  the  enormous  amount  of  literature  de- 
voted to  it.  The  writer  fully  realizes  the  terrible 
responsibility  the  physician  often  must  take  in  de- 
termining this  question,  and  has  therefore  placed 
before  the  profession  a  simple,  though  absolutely 
safe,  method  of  determining  this  important  ques- 
tion. His  views  may,  perhaps,  appear  startling  in 
their  simplicity,  but  they  would  not  have  been 
placed  before  the  profession  had  the  writer  not  been 
absolutely  thoroughly  convinced  after  the  most  rigid 
examination  and  experience  that  they  are  correct 
and  safe. 

The  writer  has  deemed  it  advisable  to  leave  the 
subject  of  prophylaxis  to  the  end.  thus  reversing 
the  usual  order  of  description,  for  he  considers  this 
the  most  important  phase  of  the  whole  subject.  The 
writer  has  held  certain  definite  views  upon  this  sub- 
ject for  a  very  long  time,  and  has  been  frequently 


mildly  derided  for  them,  though  similar  views  have 
been  advocated  by  others  before  him.  He  has  the 
satisfaction,  however,  that  there  now  exists  in  New 
York  city  (and  also  similar  societies  in  other  cities) 
a  Society  of  Sanitary  and  Moral  Prophylaxis,  by 
which  these  very  views  have  been  practically  ad- 
vanced by  some  of  the  leading  genitourinary  special- 
ists of  America.  If  there  is  one  thing  that  this 
society  can,  and  undoubtedly  will  do,  it  is  the  edu- 
cation of  the  medical  profession.  Once  this  is  ac- 
complished a  large  part  of  the  battle  is  won.  The 
writer  has  no  hesitancy  in  stating  that  the  medical 
profession  is  the  cause  of  not  a  small  portion  of  the 
spread  of  gonorrhsea.  Numerous  examples  of  this 
neglect  on  the  part  of  fellow  physicians  crowd  upon 
the  memory,  of  which  the  following  are  but  a  few : 

A  young  man  consulted  the  writer  for  masturba- 
tion. He  had  previously  consulted  a  prominent  spe- 
cialist, who  advised  him  to  indulge  in  sexual  inter- 
course, be  a  little  careful  (I),  but  be  certain  to  seek 
treatment  at. the  first  sign  of  trouble. 

A  patient  under  treatment  for  gonorrhoea  was 
told  by  his  physician  not  to  indulge  in  sexual  inter- 
course too  frequently  while  under  treatment,  once 
in  a  while  was  all  right. 

A  physician  read  a  paper  at  a  medical  meeting  in 
which  he  stated  that  before  he  pronounced  a  patient 
cured  of  gonorrhoea  he  ordered  him  to  indulge  in 
sexual  intercourse  and  watch  the  result. 

Another  patient  was  given  by  his  physician  the 
address  of  a  house  of  prostitution,  where  he  would 
probably  be  safe,  etc.,  etc. 

It  must  be  remembered  that  none  of  these  physi- 
cians were  quacks ;  they  were  all  reputable  physi- 
cians, all  members  of  the  Medical  Society  of  the 
State  of  New  York,  and  some  also  of  the  New  York 
Academy  of  Medicine.  Years  ago,  when  little  was 
known  of  the  pathology  of  gonorrhoea,  and  when 
it  was  still  regarded  as  a  simple  local  disease,  such 
opinions  might  have  been  possibly  excusable,  but 
in  the  light  of  our  present  knowledge  of  the  path- 
ology and  terrible  consequences  of  the  disease  in 
both  sexes,  such  opinions,  and  especially  such  ad- 
vice to  patients,  cannot  but  be  considered  positive- 
ly criminal.  It  is  for  this  reason  that  the  writer 
emphasizes  the  statement  that  the  medical  profes- 
sion is  responsible  for  a  portion  at  least  of  the 
spread  of  gonorrhcEa.  As  long  as  the  physician  be- 
comes the  ally  of  the  harlot,  so  long  gonorrhoea 
must  continue  to  be  on  the  increase.  It  will  only  be 
when  the  rank  and  file  of  physicians  become  edu- 
cated up  to  the  point  of  appreciating  the  gravity  of 
the  disease,  of  appreciating  the  fact  (which  is  now 
admitted  by  all  those  who  have  made  a  study  of  the 
subject)  that  once  a  woman  becomes  infected  with 
gonorrhoea  there  is  no  way  of  telling  when  she  is 
safe,  and,  lastly  and  most  important  of  all,  that 
sexual  intercourse  is  not  necessary  for  the  health  of 
a  man  or.  the  preservation  of  his  sexual  functions — 
when  these  three  dicta  shall  become  general  knowl- 
edge among  physicians,  then,  and  then  only,  can  we 
hope  to  find  a  decrease  in  the  spread  of  two  of  the 
most  formidable  diseases  that  infest  mankind. 

Although  the  views  of  the  writer  are  shared  by 
many  prominent  physicians,  and  have  been  promul- 
gated by  prominent  specialists  for  many  years  before 
this  paper  had  been  written,  it  is  nevertheless  a  fact 


170 


HUHNER:  GONORRHCEA. 


[New  York 
Medical  Journal. 


that  the  majority  of  physicians  do  Jiot  agree  with 
him.  It  is  for  this  reason  that  the  writer  has  gone 
into  the  subject  quite  extensively,  giving  both  sides 
of  the  question,  and  stating  facts  rather  than  theo- 
ries. For  this  reason  also  has  he  deemed  it  neces- 
sary to  quote  rather  liberally  from  the  works  of 
men,  both  here  and  abroad,  whose' names  have  be- 
come prominent  in  the  fields  of  anatomy,  physiol- 
ogy, surgery,  neurology,  and  psychology,  so  that 
when  he  speaks,  he  speaks  with  the  aid  of  author- 
ity, in  the  hope  that  names  that  have  become  famous 
in  these  particular  branches  may  be  the  means  of 
causing  the  universal  recognition  of  some  of  the 
grandest  and  most  important  truths  in  medicine. 

Clinical  Gonorrhcea  in  the  Male. 
In  the  treatment  of  acute  gonorrhoea  our  thera- 
peutic annamentarium  consists  of  internal  medica- 
tion and  injections.  I  think  I  may  safely  say  that 
it  is  rare  to  cure  a  genuine  case  of  gonorrhoea  by 
internal  medication  alone ;  I  will  not  say  that  it  is 
impossible,  as  I  have  seen  undoubted  cases  of  acute 
gonorrhoea  cured,  and  positively  cured,  without  any 
treatment  ivhatsoever,  either  internal  or  external. 
As  the  main  reliance,  howeVer,  has  been  justly 
placed  in  injections,  the  discussion  of  internal  treat- 
ment will  necessarily  be  brief  and  therefore  will  be 
considered  first. 

Internal  Medication.  Pain  on  Urination. — One 
of  the  first  symptoms  of  gonorrhoea;  even  preceding 
the  appearance  of  the  discharge,  is  a  burning  or 
scalding  pain  on  urination.  The  intensity  of  this 
burnmg  may  vary  from  merely  a  slight  inconven- 
ience to  the  most  severe  and  agonizing  pain  appre- 
ciable, a  pain  that  causes  agony  at  every  urination, 
and,  to  make  matters  worse,  the  very  condition  that 
causes  the  pain  very  frequently  also  causes  fre- 
quency of  urination,  so  that  we  have  the  combina- 
tion of  frequent  urination  and  painful  urination. 
This  pain  is  generally  most  severe  in  a  first  gon- 
orrhoea, less  severe  in  the  so  called  relapses,  and 
may  hardly  be  more  than  a  mere  inconvenience  to 
persons  who  have  had  many  attacks. 

.As  regards  treatment,  nothing  answers  so  well  as 
the  alkaline  mixture  of  Professor  Taylor: 

Potassium  bicarbonate,   '  i  oz. ; 

Tincture  of  hyoscyamus,   I/2  oz. ; 

Water,  enough  to  make  8  oz. 

M.  S.  y>  oz.  in  Yz  glass  of  water  every  2  to  3  or  4  hours 
as  necessary,  after  meals. 

Although  there  are  any  number  of  alkaline  mix- 
tures, some  undoubtedly  good,  this  formula  answers 
the  indications  so  perfectly  as  to  leave  little  to  be 
desired.  The  urine  becomes  alkaline,  the  burning 
soon  ceases,  and  the  patient  becomes  comfortable. 
The  taste  is  rather  unpleasant,  but  if  taken  with 
plenty  of  water  and  between  meals,  few  patients 
will  object  to  it.  This  mixture  is  also  good  in  any 
condition  where  we  wish  to  reduce  the  acidity  of 
the  urine. 

It  must,  however,  be  emphasized  that  this  treat- 
ment is  entirely  symptomatic,  and  is  in  no  sense 
to  be  considered  curative.  1  employ  it  only  to  fulfill 
one  condition--to  alkalinizc  the  urine  and  keep  it 
alkaline,  and  as  soon  as  there  is  no  more  need  to 
have  the  urine  alkaline,  I  dispense  with  it.  To  illus- 
trate my  meaning  more  fully,  I  will  observe  that  T 
sometimes  do  not  use  it  at  all  in  acute  urethritis  if 


no  burning  or  scalding  is  present,  and  that  I  do  not 
hesitate  to  use  it  at  any  stage  of  the  disease  if  burn- 
ing exists.  I  sometimes  also  employ  it  when  I  am 
using  a  strong  injection  to  moderate  the  pain  of  the 
injection. 

It  should,  however,  be  remembered  that  this  very 
severe  scalding  generally  exists  only  at  the  com- 
mencement of  the  urethritis  and  gradually  becomes 
less  and  less  severe,  and  finally  disappears  entirely. 
It  follows  this  course  even  if  no  medication  or  treat- 
ment is  employed,  and  this  fact  ought  therefore  to 
be  taken  into  consideration  in  estimating  the  value 
of  any  new  method  of  treatment  for  this  condition. 

Chordce. — Another  painful  affection  that  often 
confronts  us  is  chordee.  This  is  most  painful  in 
first  gonorrhoeas  and  becomes  less  marked  in  sub- 
sequent attacks,  although  erections,  but  not  painful 
ones,  may  occur  at  any  time.  Chordee  is  an  almost 
constant  attendant  of  untreated  gonorrhoea  and  in 
those  treated  only  by  internal  medication.  It  is  very 
rare,  or  only  of  slight  severity  and  short  duration, 
in  cases  treated  by  intravesical  irritation  from  the 
very  beginning  of  the  disease.  If  a  case  of  gonor- 
rhoea is  seen  before  chordee  has  developed  it  ought 
not  occur  if  proper  treatment  for  the  disease  is  em- 
ployed.   It  is  an  entirely  preventable  complication. 

Treatment  of  Chordee. — If,  however,  we  have  a 
case  of  chordee  nothing  acts  so  well  as  the  following 
prescription  (after  Taylor)  : 

R    E.K.  belladonnas,   2  gr. ; 

E.\.  opii  aq  6  gr. 

M.  et  fiat  suppos.  No.  6. 

I  instruct  my  patients  to  insert  one  in  the  rectum 
about  three  or  four  hours  before  retiring,  one  just 
before  retiring,  and  one  if  awakened  by  the  chordee 
during  the  night.  This  prescription  generally  acts 
like  magic.  The  pain  either  does  not  appear,  or  if 
it  does  it  is  much  less  severe.  If  so  treated  the 
chordee  generally  has  entirely  disappeared  bv  the 
third  night.  I  also  wish  to  emphasize  the  fact  that 
these  suppositories  are  only  used  symptomatically 
and  not  curatively,  and  are  reduced  in  frequency  or 
dispensed  with  entirely  as  the  chordee  gets  less  and 
disappears.  I  might  add  in  passing  that  these  sup- 
positories may  be  used  with  excellent  results  in 
acute  prostatitis  and  also  in  acute  cystitis  with 
marked  tenesmus  and  frequency  of  urination. 

The  chordee  has  a  decided  tendency  to  become 
less  severe  and  to  disappear  by  itself  whether  treat- 
ed or  not,  and  the  same  remarks  are  applicable  con- 
cerning the  use  of  newer  remedies  for  it  as  has  been 
made  about  the  treatment  of  burning  urination. 

Lafayette  Mixture. — As  the  gonorrhoea  subsides 
and  becomes  subacute,  there  is  one  mixture  that  has 
served  me  for  a  long  while  and  has  served  me  well 
and  that  is  the  Lafayette  mixture. 

New  drugs  are  constantly  brought  forward  from 
time  to  time  with  allegations  of  doing  wonders ;  I 
have  tried  most  of  them,  and  can  only  say  that  not 
one  of  them  comes  anywhere  near  the  field  of  use- 
fulness exerted  by  Lafayette  mixture.  It  is  a  pitv 
that  there  seems  to  be  so  much  discrcpancv  in  the 
method  of  its  preparation.  I  have  seen  any  amount 
of  varietv  in  the  color  and  taste  of  this  same  mix- 
ture made  up  by  diflferent  druggists.  As  sold,  its 
color  varies  from  a  light  yellow  to  a  dark  brown 
and  .sometimes  red.  Its  taste  is  sometimes  sweet  and 


J;.iiuary  jj,  1909.] 


HUHNER:  GONORRHCEA. 


171 


sometimes  a  nauseous  oily  taste,  and  any  amount 
of  variations  and  combinations  of  these  tastes.  The 
formula  I  prefer  is  the  following: 


B    Bals.  copaibae,   i  oz. ; 

Liq.  potassii  hydrox.,   2  dr.; 

Ext.  glycyrrhizae  ^  oz. ; 

Spts.  ether  nitrosi  i  oz. ; 

Syrup  acaciae  6  oz. ; 

01.  gaultheriae  16  gtt. 


M.  et.  S.    A  dessertspoonful  four  times  a  day. 

The  disadvantages  are  its  taste ;  it  sometimes  pro- 
duces diarrhcea  or  even  vomiting,  and  occasionally 
produces  an  irritating  rash  due  to  its  components. 
But  in  spite  of  all  this  there  are,  indeed,  very  few 
patients  who  cannot  be  induced  to  take  it.  I  have 
found  no  exception  to  this  rule  even  in  private  prac- 
tice. It  ought  not  to  be  given  before  the  third  week 
of  gonorrhoea.  I  want  it,  however,  distinctly  under- 
stood that  in  no  case  do  I  rely  upon  this  prescrip- 
tion alone  to  cure  the  disease.  As  stated  at  the  com- 
mencement of  this  paper,  my  main  reliance  is  in  in- 
jections, but  Lafayette  mixture  given  at  the  same 
time  greatly  helps  towards  the  cure.  I  have  espe- 
cially in  mind  a  case  treated  by  me  with  daily  intra- 
vesical irrigations  of  potassium  permanganate,  but 
in  which  the  discharge  continued  to  persist  in  a 
marked  degree.  As  soon,  however,  as  I  put  the 
patient  upon  the  internal  administration  of  Lafayette 
mixture,  at  the  same  time  continuing  my  daily  irri- 
gations, the  discharge  promptly  and  permanently 
ceased. 

After  much  experimenting  and  very  careful  ob- 
servations, I  have  discovered  somewhat  of  an  anal- 
ogy between  the  administration  of  Lafayette  mixture 
in  gonorrhoea  and  mercury  in  syphilis.  If  Lafayette 
mixture  is  given  at  the  commencement  of  the  dis- 
ease, it  is  worse  than  useless,  for  not  only  does  it  do 
no  good,  but  the  system  seems  to  get  used  to  it,  and 
it  becomes  innocuous,  even  if  continued  past  the 
third  week,  when  it  would  undoubtedly  have  done 
great  good  had  it  not  been  given  before. 

Oil  of  Santal  and  its  Derivatives. — I  desire  here 
in  emphatic*  terms  to  express  my  firm  conviction  in 
the  utter  uselessness  of  oil  of  santal  or  any  of  the 
numerous  preparations  of  which  it  forms  the  main 
constituent.  I  have  used  the  pure  oil  of  santal  wood 
manufactured  by  a  reliable  firm.  I  have  given  it  a 
most  careful  trial  in  many  cases  of  several  weeks 
and  months,  but  have  never  found  the  slightest  good 
come  from  it. 

Methyle)ie  Blue. — Of  equal  little  utility  is  methy- 
lene blue.  I  have  given  this  drug  internally  to  a 
large  number  of  patients  both  in  dispensary  and  pri- 
vate practice,  in  combination  with  santalwood  oil 
and  also  without  it,  with  injection  treatment  and 
without  it,  but  have  rarely,  if  ever,  seen  any  good 
come  from  it.  It  rapidly  colors  the  urine  blue,  makes 
in  some  cases  thereby  a  great  mental  impression  on 
the  patient,  but  that  is  all. 

Before  closing  my  discussion  on  the  internal  rem- 
edies, I  would  like  to  draw  attention  to  the  three 
drugs  which  are  used  more  or  less  indirectly  in  con- 
nection with  gonorrhoea,  to  wit,  salol,  sodium  sal- 
icylate, and  hexamethylenetetramine  (urotropin)  : 

Salol. — Salol  is  the  best  drug  to  be  used  after  any 
kind  of  instrumentation  of  the  urethra.  At  my  dis- 
pensary at  Bellevue  Hospital  (Out  Patient  Depart- 


ment) I  had  as  bad  a  set  of  patients  as  I  think  can  be 
found  anywhere.  A  very  large  percentage  of  them 
are  chronic  alcoholics,  patients  who  most  of  the  time 
have  neither  food  nor  lodging,  and  who,  should 
they  make  a  little  money,  regularly  spend  it  on  drink. 
I  have  passed  any  amount  of  instruments  on  these 
patients  and  have  regularly  prescribed  salol  capsules 
in  five  grain  doses  every  two  hours  till  four  or  five 
are  taken,  and  have  never  had  a  case  of  urethral 
chill  or  fever  or  epididymitis  following  such  instru- 
mentation. 

Sodium  salicylate. — Sodium  salicylate,  grains  15. 
every  two  hours  (stopped  if  symptoms  of  poisoning 
occur),  I  have  found  of  excellent  use  in  acute  epi- 
didymitis. I  have  never  relied  solely  upon  it,  as  I 
treat  this  condition  by  other  methods,  but  I  always 
give  this  drug  internally  at  the  same  time. 

Although  of  positive  value  in  certain  forms  of 
cystitis,  and  as  a  urinary  antiseptic,  urotopin  has  ab- 
solutely no  effect,  either  good  or  bad,  upon  gonor- 
rhoea, either  anterior  or  posterior,  acute  or  chronic. 

There  is  any  amount  more  of  internal  remedies, 
most  of  which  I  have  tried,  but  do  not  think  it  nec- 
essary to  discuss  them,  as  they  have  already  been 
condemned  by  eminent  critics. 

'In  concluding  this  portion  of  my  article,  I  wish 
to  state  that  it  is  no  easy  task  to  decide  clinically  the 
value  of  any  remedy  used  internally  or  externally. 
Most  of  these  internal  remedies  are  used  in  combina- 
tion with  other  methods  of  treatment,  and  it  takes 
years  of  close  observation  to  determine  just  exastly 
where  the  blame  or  praise  belongs. 

Injection  Treatment. 

Genera!  Remarks. — We  now  approach  the  very 
important  subject  of  treatment  by  injecting  certain 
substances  into  the  urethra,  anterior  or  posterior,  or 
both,  or  into  the  bladder.  Before  discussing  the 
various  remedies  used,  and  the  dift'erent  methods  of 
applying  these  remedies,  I  would  like  to  make  a  few 
general  remarks  that  apply  alike  to  all  injections. 
All  the  difificulties  in  estimating  the  value  of  internal 
medications  mentioned  before  apply  with  equal  force 
to  injections.  To  these  I  may  add  another  difficulty, 
a  difficulty  which  it  took  me  years  of  experience  and 
close  observation  to  appreciate,  and  which  I  do  not 
at  present  remember  having  seen  set  down,  or  at 
least  emphasized,  in  any  textbook  or  monograph. 
Any  gonorrhoea,  whether  acute  or  chronic,  anterior 
or  posterior,  zchcther  previously  treated  by  injections 
or  not,  will  be  temporarily  improved  by  any  new  in- 
jection material.  The  lack  of  appreciation  of  this 
fact  led  me  in  my  earlier  days  in  the  treatment  of 
gonorrhoea  to  make  many  false  deductions.  I  dis- 
tinctly remember  many  years  ago  when  a  new  rem- 
edy was  advanced  for  gonorrhoea  I  at  once  put  all 
the  patients  in  my  clinic  on  this  new  injection,  and 
was  agreeably  surprised  to  find  a  definite  improve- 
ment in  every  case.  I  felt  certain  that  the  ideal  in- 
jection had  at  last  been  discovered.  After  a  while, 
however,  the  disease  lapsed  back  into  its  previous 
indolent  condition,  and  on  returning  to  my  old  in- 
jection the  same  remarkable  improvement  occurred 
as  did  with  the  new  remedy.  This  very  fact  gives 
us  also  a  hint  regarding  the  therapeutics  of  this  dis- 
ease, namely,  that  it  is  wise  from  time  to  time  to 
change  the  injection,  or  even  the  strength  of  the  one 


172 


HUHNER:  GONORRHCEA. 


[New  York 
Medical  Journal. 


in  use.  It  is  just  a  nonappreciation  of  this  fact  also 
that  gives  the  boom  to  every  new  substance  proposed 
as  an  injection  for  gonorrhoea. 

Another  very  important  question  that  might  with 
advantage  be  considered  here  is  that  of  the  curabil- 
ity of  gonorrhoea.  Can  a  gonorrhoea  be  cured  or 
only  relieved? 

Curability  of  Gonorrhoea. — Incidentally  we  must 
ascertain,  when  is  a  gonorrhoea  cured?  Perhaps 
nothing  in  the  whole  subject  has  been  so  extensively 
discussed  as  this  very  question,  and  have  such  very 
widely  different  answers  been  given.  At  one  ex- 
treme we  have  the  enthusiast,  who  can  positively 
cure  his  patient  in  three  or  four  days.  At  the  other 
extreme  we  have  those  who  state  that  a  gonorrhoea 
can  never  be  cured,  or  that  it  may  apparently  be 
cured  and  present  no  symptoms  for  years,  but  may 
at  any  time  break  out  after  a  more  vigorous  coitus 
or  overindulgence  in  liquor. 

It  is  to  exactly  this  portion  of  the  subject  that  I 
have  given  the  closest  attention,  and  after  carefully 
watching  hundreds  of  cases,  I  have  come  to  a  defi- 
nite conclusion.  Of  course,  every  one  is  agreed  that 
if  gonococci  are  present,  either  in  the  discharge  or 
threads  in  the  urine,  the  disease  is  not  cured.  But 
if,  after  the  most  careful  examination,  gonococci 
cannot  be  found,  can  we  consider  the  patient  cured  ? 
Certainly  not  A  vast  number  of  cases  have  been 
reported  in  which  gonococci  have  been  absent  for 
long  periods  of  time  to  reappear  later.  After  most 
careful  consideration  of  the  question,  I  will  state 
what  I  consider  an  axiom:  A  person  recovering 
from  gonorrhoea  is  not  cured  as  long  as  there  is  any 
discharge  from  the  meatus.  It  makes  little  differ- 
ence whether  the  discharge  does  or  does  not  contain 
gonococci ;  clinically  I  consider  any  discharge  in 
such  a  person  gonorrhoeal.  Even  if  the  discharge  is 
so  slight  as  only  to  produce  stickiness  or  agglutina- 
tion of  the  lips  of  the  meatus,  such  a  person  is  not 
cured,  for  it  is  only  a  question  of  time  when  sonie 
irirtation,  as  alcoholic  or  oversexual  indulgence,  will 
increase  this  slight  discharge  to  an  enormous  one. 
I  think  a  great  deal  of  harm  is  done  by  certain  spe- 
cialists, who  prefer  to  distinguish  between  a  gonor- 
rhoeal urethritis  and  a  so  called  postgonorrhoeal  ure- 
thritis, or,  in  other  words,  to  say  to  the  patient, 
"your  gonorrhoea  is  cured,  but  the  urethritis  is  still 
present."  Could  we,  in  any  particular  case,  swear 
that  if  no  gonococci  are  found  either  in  the  urethral 
discharge  or  in  the  urinary  shreds,  etc.,  that  none 
existed,  these  conclusions  would  naturally  fall  to  the 
ground ;  but  as  we  know  by  experience  that  gono- 
cocci may  be  absent  for  a  very  long  time  from  the 
shreds  or  pus,  etc.,  and  still  be  present  in  the  genito- 
urinary organs,  we  are  fairly  safe  in  assuming  clin- 
ically that  every  so  called  postgonorrhoeal  discharge 
is  really  gonorrhoea. 

Having  shown  that  it  is  safer  to  consider  any  dis- 
charge that  continues  after  a  gonorrhoeal  infection 
as  gonorrhoeal,  and  also  that  it  is  universally  ac- 
knowledged that  the  nonappearance  of  gonococci  is 
no  proof  of  the  cure  of  gonorrhoea,  we  still  have  the 
question.  When  is  a  gonorrhoea  cured? 

In  looking  through  the  literature  on  the  subject, 
or  in  listening  to  papers  and  discussions  upon  this 
subject  in  medical  societies,  we  hear  a  great  deal 
about  relapses  in  gonorrhoea,  by  which  is  meant  that 
after  a  gonorrhoea  had  been  apparently  cured,  and 


after  an  interval  of  months  or  even  years  had 
elapsed,  during  which  no  symptoms  are  said  to  ex- 
ist, a  sudden  discharge  may  appear,  after  an  alco- 
holic or  sexual  excess,  without  a  fresh  infection. 
We  also  hear  a  great  deal  of  what  Professor  Tay- 
lor satirized  as  "the  phenixlike  reappearance  of  the 
gonococcus,"  that  is,  that  the  gonococcus  may  be 
hidden  away  in  the  urethra  or  its  annexa  for  years, 
producing  no  symptoms,  and  may  at  any  time  sud- 
denly appear  in  larger  or  smaller  quantities  without 
a  fresh  infection.  If  these  clinical  facts  are  true  a 
gonorrhoea  can  never  be  cured,  or,  if  so,  we  can 
never  positively  say  that  it  is  cured,  for  there  is  no 
way  of  telling  whether  the  gonococcus  is  hidden 
away  somewhere. 

I  will  admit  that  the  gonococcus  may  lie  dormant 
in  the  urethra  or  its  annexa  for  months  or  years, 
and  may  reproduce  itself  very  rapidly  on  overin- 
dulgence in  alcohol  or  sexual  excitement,  so  as  to  be 
found  in  enormous  numbers  in  a  urethral  discharge 
without  a  fresh  infection.  I  will  also  admit  that 
for  similar  reasons  a  minute  urethral  discharge  may 
be  enormously  augmented  and  appear  as  a  profuse 
discharge  at  the  meatus.  But  I  absolutely  deny 
that  the  urethra  or  its  annexa  can  harbor  gonococci 
ivithout  producing  symptoms.  Now,  there  is  just 
one  very  important  point,  that  to  my  mind  forms  the 
keynote  to  the  entire  situation,  and  that  is  the  time 
elapsed  between  the  last  urination  and  the  examina- 
tion of  the  urethra.  I  will  now  state  what  I  con- 
sider a  clinical  axiom,  an  axiom  that  I  have  never 
known  to  fail  after  the  most  careful  scrutiny  of 
thousands  of  cases,  and  that  is :  Whenever  a  per- 
son has  kept  his  urine  in  for  twelve  hours,  and  there 
is  repeatedly  found  no  discharge  after  several  sep- 
arate examinations,  that  person  is  cured.  I  desire 
most  emphatically  to  protest  against  the  statement 
that  the  genitourinary  organs  can  harbor  gonococci 
for  any  length  of  time  without  producing  symp- 
toms. In  looking"  over  the  reports  of  cases  of 
"cured"  gonorrhoea  which  are  said  to  have  relapsed 
after  the  space  of  months  or  years,  during  which 
time  no  symptoms  are  said  to  have  been  present, 
as  well  as  the  reports  of  those  cases  of  so  called  rapid 
"cures"  of  gonorrhoea,  we  find  exactly  the  same 
error  in  both,  to  wit,  either  we  are  left  entirely  in 
the  dark  as  to  what  the  writer  considers  a  "cure," 
or  we  are  told  that  there  has  been  no  "morning 
drop"  or  no  discharge  after  four  to  six  hours  from 
the  previous  urination.  I  have  very  often  had  such 
"cured"  patients  in  my  office  who  declared  that  they 
had  not  noticed  any  discharge  for  months,  ^md 
when  I  simply  had  them  refrain  from  urination  for 
twelve  hours,  I  very  easily  demonstrated  to  them  a 
very  large  drop  of  pus  at  the  meatus.  It  is  exact- 
ly such  cases  which  suddenly  show  a  large  amount 
of  discharge  and  many  gonococci  after  an  increased 
sexual  excitement  that  are  considered  relapses. 
They  are  not  relapses ;  the  discharge  has  been  there 
all  the  time,  if  we  had  only  looked  for  it.  If  we  con- 
sider every  continuous  discharge  from  the  urethra 
after  a  gonorrhoea  as  gonorrhoeal,  and  if  we  con- 
tinue treatment  till  there  is  absolutely  no  discharge, 
or  even  agglutination  of  the  lips  of  the  meatus  after 
holding  in  the  urine  for  twelve  hours,  we  will  be 
surprised  and  often  disgusted  to  see  for  what  a 
long  period  of  time  a  drop  of  pus  will  hang  on  to 
the  urethra,  and  how  long  it  occasionally  takes  to 


January  23,  1909.] 


iHUHNER:  GONORRHCEA. 


173 


cure  a  case,  but,  on  the  other  hand,  we  will  be  com- 
pelled to  admit  that  almost  every  gonorrhoea  is  cur- 
able, and  that  there  is  no  such  thing  as  a  relapse  in 
a  cured  gonorrhoea. 

There  are  some  who  say,  however,  that  it  is  prac- 
tically impossible,  or  at  least  very  difficult,  for  a 
person  to  hold  his  urine  for  twelve  hours  by  day. 
To  this  I  would  answer  that  not  only  have  I  not  had 
any  real  difficulty  in  getting  my  patients  to  do  so, 
but  that  the  very  fact  of  the  inability  of  a  patient 
to  retain  his  water  for  that  length  of  time  is  to  me 
a  very  suspicious  sign  that  the  patient  is  not  cured. 
Tt  is  true  that  an  old  man  with  an  enlarged  prostate 
cannot  hold  his  water  for  so  long  a  time,  but  such 
people  as  a  general  thing  are  not  sufferers  of  gonor- 
rhoea. As  the  vast  majority  of  our  patients  are 
young  people,  we  must  look  with  great  suspicion  on 
a  supposedly  cured  case  of  gonorrhoea  where  the 
patient  cannot  retain  his  urine  for  twelve  hours. 

Prostate  Gland. — I  would  like  to  say  a  few  words 
here,  before  commencing  the  study  of  the  injection 
treatment,  about  a  subject  that  has  been  greatly 
discussed,  especially  with  reference  to  the  different 
methods  of  treatment ;  I  mean  the  involvement  of 
the  prostate  gland  in  gonorrhoea.  Here,  again,  we 
find  thewidest  divergenceof  opinion.  Some  state  that 
the  gland  is  involved  in  twenty-five  per  cent,  of  all 
cases ;  others  place  the  figure  as  high  as  seventy- 
five  per  cent.,  and  still  others  assert  that  it  is  only 
involved  if  certain  methods  of  treatment  are  em- 
ployed, and  not  at  all,  or  in  only  a  small  percentage 
of  cases,  if  more  rational  ( ?)  and  less  energetic 
methods  are  used. 

After  a  most  careful  and  daily  examination  of  the 
prostates  of  a  large  number  of  patients  suffering 
from  gonorrhoea,  I  have  found  that  in  almost  every 
case,  and,  with  little  regard  to  the  mode  of  treat- 
ment employed,  and  in  almost  any  stage  of  the  dis- 
ease, there  occurs,  what  I  desire  to  call  for  want  of 
a  better  name,  a  reflex,  or  sympathetic,  enlargement 
of  the  prostate  gland.  This  enlargement  occurs  no 
matter  what  method  of  treatment  is  employed,  and 
even  independent  of  all  treatment,  though  it  does 
seem  to  occur  more  frequently  and  with  greater 
regularity  when  the  intravesical  method  of  irriga- 
tion is  employed.  It  may  also  occur  at  any  stage  of 
the  disease,  even  at  the  very  commencement.  This 
enlargement  is  purely  reflex  or  sympathetic,  and 
must  be  carefully  distinguished  from  that  enlarge- 
ment due  to  the  involvement  of  the  gland  by  direct 
extension  of  the  disease  from  the  urethra  along  the 
ducts  to  the  gland.  It  can  thus  be  readily  seen  that 
any  one  not  conser\'ant  with  these  facts,  and  find- 
ing an  enlarged  prostate,  or  noticing  that  the  pros- 
tate is  enlarging  under  treatment,  would  blame  this 
or  that  method  of  treatment.  The  fact  that  it  may 
be  found  a^  the  very  commencement  of  the  disease, 
while  the  inflammation  is  still  localized  to  the  ante- 
rior urethra,  shows  that  it  is  not  an  extension,  but 
a  purely  reflex  or  sympathetic  enlargement.  As  a 
matter  of  fact,  after  careful  examination  of  the  pus 
from  the  prostate,  carefully  excluding  the  secre- 
tions from  the  urethra,  we  would  find  that  in  well 
treated  cases  the  prostate  is  only  involved  in  a  very 
small  percentage  of  cases. 

Theory  of  Injections. — I  will  now  take  up  the 
discussion  of  the  treatment  of  gonorrhoea  by  injec- 


tions, but  before  doing  so  I  wish  to  say  a  few  words 
about  the  theory  of  injections  in  general  and  how 
they  are  supposed  to  act. 

It  stands  to  reason  that  if  the  urethra  was  a 
smooth  glass  tube  any  ordinary  irrigation  would 
easily  dislodge  and  wash  away  all  the  mucus  or 
pus  or  bacteria  that  may  be  therein.  But  unfortu- 
nately this  is  not  the  case.  The  mucous  membrane 
of  the  urethra  is  made  up  of  numerous  folds  to  al- 
low for  its  distensibility  when  necessary,  and  it  is 
between  these  folds  and  in  the  crypts  that  the  pus 
and  bacteria  lodge.  It  necessarily  follows  that  in 
order  to  dislodge  them  we  must  distend  the  urethra 
to  make  it  resemble  as  near  as  possible  a  glass  tube. 
With  this  end  in  view  it  has  been  suggested  to  wash 
out  the  urethra  with  a  catheter  and  then  pass  a 
catheter  into  the  bladder  and  fill  this  viscus  up  with 
some  antiseptic  fluid,  and  after  removing  the 
catheter  allow  the  patient  to  void  this  fluid  through 
his  urethra.  It  has  also  been  suggested  (but  never 
carried  out  as  far  as  I  know),  in  order  to  avoid  in- 
fection of  the  bladder  and  posterior  urethra  by  the 
catheter  passing  through  the  infected  anterior  ure- 
thra, to  inject  directly  into  the  bladder  with  an 
aspirating  needle  passed  into  that  viscus  supra- 
pubically,  some  antiseptic  fluid  and  allow  the  pa- 
tient to  pass  it  out  through  the  penis  in  the  ordi- 
nary way. 

Now,  I  am  going  to  show  that  those  who  make 
these  various  suggestions  miss  the  most  importint 
point  of  urethral  irrigation. 

If  we  watch  a  perfectly  normal  individual  urinate 
we  will  see  that  he  passes  a  stream  of  about  i8  F., 
yet  we  know  that  in  that  same  person's  urethra  we 
could  pass  a  28  or  30  F.  sound,  so  that  (even  if  we 
were  to  make  quite  an  allowance  for  the  smaller 
size  of  the  meatus  as  compared  to  the  calibre  of  the 
rest  of  the  urethra)  we  see  that  the  act  of  urination 
does  not  nearly  distend  the  urethra  to  its  maximum,, 
and  that  even  during  urination  there  must  remain 
certain  crypts  or  crevices  undistended  which  could 
harbor  germs  and  be  totally  unaffected  by  the  urine 
of  any  other  irrigation  fluid  voided  by  the  blad- 
der. It  is  just  for  this  reason  that  the  intravesical 
irrigation  method  of  treatment  shows  such  brilliant 
results.  Before  the  fluid  goes  into  the  bladder  and 
while  the  fluid  is  trying  to  overcome  the  resistance 
or  the  cut  off  muscle,  the  entire  urethra  in  front  of 
this  muscle  is  ballooned  out  and  distended  enor- 
mously (see  Fig.  3),  thus  ironing  out,  as  it  were, 
and  obliterating  all  the  folds  of  the  urethra  and  al- 
lowing the  irrigation  fluid  to  wash  it  out  thorough- 
ly and  come  in  contact  with  every  portion  thereof. 
Those  who  state  that  it  is  not  necessary  to  get  the 
fluid  into  the  bladder,  if  only  the  anterior  urethra  is, 
affected,  miss  the  chief  point  of  the  intravesical  irri- 
gation treatment.  The  good  part  of  the  treatment 
is  not  that  the  fluid  gets  into  the  bladder  (for  we- 
can  accomplish  this  by  better  means),  but  it  is  only 
by  getting  it  into  the  bladder  we  know  that  the  ure- 
thra must  have  become  distended.  It  is  exactly 
for  the  same  reason  that  irrigations  with  a  small' 
syringe  by  the  patient  himself  does  not  produce  the  • 
best  results  even  if  the  disease  is  limited  to  the  an- 
terior urethra,  for  the  folds  are  not  distended  by- 
the  limited  pressure  and  small  amount  of  fluid  in- 
troduced. 

(To  be  continued.) 


174 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Meuii  al  Journal. 


(^ur  llealiers'  fiscussious. 


A  SERIES  OF  PRIZE  ESSAYS. 

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decided  upon,  the  further  questions  are  as  follows: 

LXXXI. — Hozv  do  you  treat  chronic  eczema?  (Closed 
December  15,  igoS.) 

LXXXII. — How  do  you  treat  chronic  lead  poisoningf 
{Cic.  i  i/  Jainiarv  15,  iQog.) 

LXXXIII. — How  do  you  treat  acute  dysentery?  {An- 
swers due  not  later  than  February  15,  igog.) 

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to  question  LXXX  has  been  awarded  to  Dr.  Paul  F.  Ela, 
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J225  of  the  previous  volume. 


PRIZE  QUESTION  LXXX. 
THE  TREATMENT  OF  ASPHYXIA  NEONATORUM. 

(Concluded  from  page  123.) 

Dr.  Morris  J.  Keller,  of  Neia  York,  remarks: 

Asphyxia  of  the  new  born  may  be  of  a  very  mild 
or  of  a  very  severe  degree.  To  treat  the  latter  class 
of  cases  by  methods  which  would  unquestionably 
benefit  the  former,  would  only  be  a  waste  of  time 
which  might  prove  fatal  to  the  infant.  In  order  to 
be  able  to  distinguish  the  mild  from  the  severe  cases, 
the  accoucheur  must  know  the  symptoms  of  each. 
A  brief  description  of  symptoms  will  therefore  not 
be  out  of  place. 

Symptoms.  The  symptoms  of  asphyxia  are  due 
to  paralysis  of  the  respiratory  centre.  This  paraly- 
sis is  brought  about  by  the  excessive  amount  of 
carl)nn  dioxide  and  the  insufficient  amount  of  oxy- 
gen in  the  blood.  The  degree  of  asphyxiation  (and 
consequently  the  symptoms )  depend  upon  the  de- 
gree of  paralysis  of  the  respiratory  centre. 

In  the  mild  cases  of  asphyxiation,  the  face  and 
neck  of  the  infant  are  purplish  or  blue,  in  color. 
The  heart  acts  well  and  the  pulsations  in  the  cord 
are  strong.  The  muscles  are  neither  relaxed  nor 
contracted,  but  are  in  normal  tone.  The  reflexes 
are  present,  and  the  sphincters  are  under  control. 
The  child  makes  ineffectual  attempts  to  cry.  This 
degree  is  described  by  some  writers  as  asphyxia  liv- 
ida. 

In  the  severer  types,  corresponding  to  asphyxia 
pallida,  the  face  and  extremities  arc  pale.  The  heart 
heat  is  very  weak,  ahnost  inaudil)lc  and  the  pulsa- 
tion in  the  cord,  feeble.  .Ml  the  muscles  of  the  body 
are  relaxed.  The  reflexes  are  absent  and  the 
sphincters  not  under  cnntrol.  The  prognosis  in  this 
last  type  is  poor. 

T rcahucnt.     i.  P.efore  Labor.     .XUhough  it  can- 


not be  with  certainty  determined  beforehand  whether 
a  child  will  be  asphyxiated  or  not,  attention  to  the 
correction  of  malposition  of  the  foetus,  to  the  re- 
placement of  a  prolapsed  cord,  to  the  proper  care  of 
a  prematurely  separated  placenta,  or  to  any  cause 
that  would  interfere  with  the  circulation  through 
the  umbilical  cord,  will  tend  to  lessen  the  danger 
of  asphyxiation. 

2.  During  Labor.  This  treatment  is,  in  a  meas- 
ure, also  only  proph}  lactic.  x\s  soon  as  the  head 
is  born,  the  accoucheur  should  examine  for  coils 
of  cord  around  the  neck,  and  if  any  are  present,  slip 
them  over  the  head.  The  small  finger  wrapped  with 
sterile  gauze  should  then  be  inserted  into  the  in- 
fant's mouth,  and  any  strings  of  accumulated  mucus 
be  removed. 

3.  After  Labor.  If  the  child,  when  born,  is  in 
the  condition  described  as  mild  asphyxiation,  or 
asphyxia  livida,  the  cord  should  be  cut  immediately, 
and  about  an  ounce  of  blood  allowed  to  escape  before 
it  is  tied.  However,  if  the  asphyxiation  is  severe, 
the  cord  should  not  be  cut  until  pulsation  has  ceased. 
Respiration  should  then  be  induced  by  reflex  means 
in  the  mild  cases,  and  by  artificial  respiration  in  the 
severer  ones. 

Reflex  Means.  The  physician  should  grasp  the 
child  by  the  ankles,  holding  it  head  down,  and  slap 
it  vigorously  on  the  soles  of  the  feet  and  on  the  but- 
tocks. The  child  will  cry  lustily  in  a  few  moments 
if  the  asphyxiation  is  not  deep.  If  this  does  not 
succeed,  mouth  to  mouth  insufflation  should  next  be 
resorted  to.  A  clean  piece  of  gauze  is  placed  over 
the  child's  mouth.  The  physician  takes  a  deep  in- 
spiration and  breathes  the  first  part  of  the  expired 
air  into  the  child's  mouth.  After  each  insufflation, 
he  should  compress  the  thorax  of  the  infant.  If  this 
fails,  immerse  the  infant  alternately  in  warm  and 
cold  water,  the  sudden  change  in  temperature  tend- 
ing reflexly  to  produce  respiration. 

Artificial  Respiration.  Although  there  are  sev- 
eral very  good  methods  of  artificial  respiration,  I 
shall  describe  only  one,  which  I  have  found  very 
efficient — viz.  Byrd's  method.  The  neck  of  the  in- 
fant is  allowed  to  rest  between  the  thumb  and  index 
finger  of  one  hand.  The  back  rests  on  the  palm. 
The  remaining  fingers  are  placed  in  the  axilla.  The 
fingers  of  the  other  hand  surround  the  thighs.  The 
head  and  thighs  are  then  flexed,  until  the  chin 
touches  the  chest,  and  the  thighs  touch  the  abdomen. 
At  the  same  time  the  fingers  in  the  axilla  raise  the 
arm  upward.  These  motions  make  the  muscles  of 
the  chest  and  diaphragm  act  as  they  normally  do  in 
inspiration.  Expiration  is  simulated  by  allowing  the 
arms  to  fall  to  the  side  of  the  chest,  and  by  allow- 
ing head  and  thighs  to  hang  loose.  This  opera- 
tion should  be  rej^eated  about  eight  times  each  min- 
ute. These  motions  can  also  be  carried  out  with 
the  child  placed  in  warm  water.  Swinging  the  child 
from  side  to  side,  while  held  in  the  position  as  de- 
scribed, may  be  alternated  with  the  flexion  and  ex- 
tension movements. 

Hope  should  not  be  abandoned  if  resuscitation  is 
not  affected  at  once.  .-Xs  long  as  the  iieart  beats, 
there  are  excellent  chances  for  resuscitation.  In- 
fants have  been  brought  back  to  life  after  persistent 
treatment  lasting  more  than  half  an  hour.  Such 
children,  however,  need  careful  observation  for  the 


January  23.  1909. 1 


CORRESPONDENCE. 


175 


next  few  days,  to  prevent  sudden  death  from  atelec- 
tasis. Intubation  has  rarely  to  be  resorted  to.  How- 
ever, if  all  the  other  methods  fail,  this  may  be  the 
only  way  to  save  the  infant's  life. 

Dr.  George  A.  Graham,  of  Kansas  City.  Mo.,  says: 

Quite  a  large  percentage  of  children,  at  birth 
show  signs  of  a  greater  or  less  degree  of  asphyxia- 
tion. Most  of  these  are  only  slightly  asphyxiated, 
requiring  little  more  than  the  normal  stimulus  of 
cold  air  to  excite  the  respiratory  centre  and  cause 
efforts  at  respiration,  ending  in  the  welcome  sound 
of  a  good,  lung  expanding  squall.  Some  of  them, 
however,  are  profoundly  asphyxiated,  and  require 
rapid  and  energetic  work  on  the  part  of  the  attend- 
ant physician,  in  order  to  reanimate  them. 

In  all  cases  the  first  procedure,  after  quickly 
wiping  the  mucus   from   the  child's   mouth  and 
throat,  is  to  give  it  a  smart  slap  on  the  buttocks. 
Next,  dash  some  cold  water  over  the  chest.  If 
either  of  these  methods  causes  any  eftort  at  inspira- 
tion, repeat  it.    This  will  suffice  for  many  cases.  If 
not,  then  immerse  the  child's  body  in  hot  water  for 
a  few  moments :  remove  it  and  again  dash  cold 
water  on  it.    If  there  is  still  no  effort  at  inspiration 
on  the  part  of  the  child  it  is  profoundly  asphyxiated 
and  indifterent  to  external  stimuli,  and  we  must  at 
once  resort  to  artificial  respiration.    The  ordinary 
methods  of  artificial  respiration  in  adults  are  un- 
satisfactory and  of  little  use  in  infants.    The  child's 
lungs  are  as  yet  unexpanded.  uninflated,  and  in  a 
state  resembling  collapse  of  the  lung,  and  I  have 
found  the  following  to  be  the  only  quick  and  certain 
way  of  getting  results :  Lay  the  child  on  the  edge 
of  the  bed,  or  have  the  nurse  or  assistant  hold  the 
child  with  its  head  extended  and  slightly  lower 
than  its  body.    Then  take  several  deep  and  rapid 
breaths,  to  lessen  the  amount  of  carbonic  acid  gas 
in  your  lungs,  and,  after  the  last  deep  inspiration, 
place  your  mouth  over  that  of  the  child,  at  right 
angles  and  in  close  apposition  to  it,  and,  holding 
the  child's  nose,  blow  into  its  mouth,  thus  expand- 
ing its  lungs  and  replacing  the  first  inspiration. 
Expiration  is  then  easily  caused  by  pressing  the 
sides  of  the  child's  chest  between  the  thumb  and 
fingers  of  the  other  hand,  meanwhile  breathing 
deeply  and  rapidly  to  again  purify  the  air  in  your 
lungs.     Repeat  these  operations  of  inflating  the 
child's  lungs  and  compressing  his  chest  alternately 
about  five  times  a  minute  until  the  child  breathes 
voluntarily  or  until  you  are  convinced  that  your 
eft'orts  are  in  vain.    It  is  important  that  the  child's 
nose  is  firmly  pinched  to  prevent  the  escape  of  air 
while  inflating  its  lungs,  and  that  too  much  force 
is  not  used  when  blowing  into  the  child's  mouth, 
lest  emphysema  of  its  lungs  be  produced.  Cleanse 
the  child's  face  as  well  as  can  be  rapidly  done  be- 
fore using  this  method,  and  do  not  use  it  when  syphi- 
lis is  suspected.    It  is  remarkable  how  quickly  an 
infant  that  has  resisted  all  other  methods  of  arti- 
ficial respiration  will  be  restored  by  this  means. 
But  in  dropsy  of  the  amnion,  causing  oedema  of  the 
lungs,  in  severe  injury  to  the  head  or  neck,  causing 
disorganization  of  the  brain  or  spinal  cord,  and  in 
paralysis  of  the  pneumogastric  nerve  from  pressure 
of  the  forceps,  all  eflforts  are  useless ;  though  the 
pulse  may  be  still  perceptible  in  the  cord,  nothing 


will  establish  respiration.  Those  cases  where, 
through  delayed  labor,  prolonged  pressure  on  the 
cord,  or  other  cause,  the  heart  has  stopped,  are,  of 
course,  cases  not  of  asphyxia,  but  of  death. 

Some  have  recommended  cutting  the  umbilical 
cord  and  allowing  a  few  drachms  of  blood  to  escape 
before  tying,  in  order  to  relieve  the  engorged  heart, 
but  I  have  found  it  to  be  apparently  without  effect ; 
in  fact,  it  is  better  to  keep  the  cord  intact  as  long  as 
it  pulsates,  as  there  may  be  still  some  placental 
respiration. 

In  all  manipulations  we  should  endeavor  to  have 
the  child's  head  lower  than  its  body,  as  in  chloro- 
form poisoning,  and  to  keep  its  mouth  and  throat 
free  from  mucus,  the  tongue  well  forward  in  the 
mouth,  and  the  head  extended. 


Comspnkncc. 


LETTER  FROM  MONTREAL. 

The  Annual  Banquet  of  the  McGill  Faculty  of  Medicine. — 
Medical  Inspection  of  Schools  and  Factories. — Deaths 
by  Violence. — A  Tuberculosis  Class. — Typhoid  Fever 
and  the  Water  and  Milk  Supplies. — Strong  Drink  and 
Tobacco  in  Canada. 

MoxTREAL,  January  18,  igog. 
About  two  hundred  persons,  including  professors, 
graduates,  and  students,  sat  down  to  the  annual  ban- 
quet of  the  Faculty  of  ^Medicine  of  McGill  Uni- 
versity on  the  evening  of  January  9th.  The  feature 
of  the  evening  was  the  presentation  to  Dr.  T.  G. 
Roddick,  former  dean  of  the  faculty,  of  a  fine  bust 
of  himself,  executed  by  Dr.  J.  J.  Ross.  Mr.  T.  F. 
Cotton,  B.  A.,  of  the  fourth  year,  was  the  presi- 
dent of  the  dinner  committee  having  in  charge  the 
arrangements  for  the  banquet.  Dr.  Francis  J.  Shep- 
herd, the  new  dean,  was  the  guest  of  honor,  and  in 
his  address  briefly  sketched  his  connection  with  the 
university.  He  contrasted  the  "footing  spree"  din- 
ners of  former  days  with  the  present  well  conducted 
affairs,  and  referred  to  the  trsing  times  of  the  fac- 
ulty when  he  had  entered  on  his  deanship.  the  re- 
cent disastrous  fire,  and  the  advance  to  the  five  year 
course,  as  well  as  the  difficulty  in  securing  financial 
assistance  in  the  erection  of  the  new  building.  Dr. 
Roddick,  in  his  reply  to  the  presentation  made  him. 
referred  to  the  subject  of  Dominion  registration, 
with  which  his  name  had  been  connected  for  many 
years.  The  law  still  stands  on  the  statute  books  of 
the  Dominion,  and  can  be  made  use  of  any  day  the 
medical  profession  in  the  provinces  choose  to  avail 
themselves  of  it.  Six  of  the  nine  provinces,  he 
said,  were  ready  to  go  on  with  it,  while  the  three 
others  were  watching  each  other.  In  congratulat- 
ing his  successor  in  the  deanship,  he  said  his  efforts 
to  effect  reform  in  the  "footing  sprees"  were  never 
a  success,  though  he  thought  he  would  be  a  Good 
Shepherd  to  the  medical  students  of  McGill.  Mr. 
T.  A.  J.  Duff'  represented  Toronto  University :  Mr. 
Ulrich  Lafontaine.  Laval,  of  Montreal ;  Mr.  Conrad 
Geggie,  Laval,  of  Quebec  :  and  Mr.  H.  E.  Chapman, 
Queen's  University.  Kingston,  Ontario. 

Montreal  first  adopted  the  medical  inspection  of 
schools  in  September.  1906,  when  fifty  medical  men 
were  appointed  at  salaries  of  $20  a  month.  Each 
visited  155  schools,  with  an  average  attendance  of 


176 


CORRESPONDENCE. 


[New  York 
Medical  Journal, 


332  pupils.  These  visits  were  made  at  the  opening 
of  the  schools  in  September  and  again  in  January; 
the  sanitary  conditions  of  the  schools  were  also  in- 
spected. After  a  trial  of  two  years  this  system  was 
found  to  be  unsatisfactory  and  a  new  one  inaugu- 
rated. The  present  system  is  better  calculated  to 
meet  the  conditions  in  Montreal.  Under  this  ar- 
rangement the  city  is  divided  into  fourteen  districts, 
and  a  qualified  physician  is  appointed  to  each  dis- 
trict at  a  salary  of  $100  a  month.  He  inspects  each 
child  twice  annually,  vaccinates  all  those  who  are 
unvaccinated,  satisfies  himself  as  to  location  and 
sanitary  conditions  of  the  school,  makes  as  many 
additional  visits  as  he  deems  necessary,  and  notifies 
the  principals  to  send  home  all  children  with  any 
signs  of  infectious  disease.  He  inspects  factories 
and  vaccinates  employees  showing  no  sign  of  vac- 
cination, assures  himself  that  no  factory  employee  is 
suffering  from  any  infectious  disease,  and  particu- 
larly directs  his  attention  to  tuberculosis.  He  as 
well  visits  and  inspects  the  dwellings  where  there  is 
any  infectious  disease  or  where  it  might  be  sus- 
pected to  be  present.  Some  of  the  items  in  connec- 
tion with  the  inspection  of  the  pupils  made  in  Sep- 
tember, 1907,  show  that  13.385  had  decayed  teeth, 
3,825  enlarged  tonsils,  3,656  pediculosis,  1.333  de- 
fects of  vision,  and  1,661  enlarged  glands.  The  total 
number  of  children  requiring  medical  treatment,  out 
of  a  school  population  of  49,360,  was  30,133,  or 
60.37  P^^  cent. 

During  the  year  1908  there  were  850  deaths  from 
violence  in  Montreal.  Of  these,  there  were  twenty- 
three  deaths  from  foul  play,  ten  of  which  were  Ital- 
ian murders.  There  were  twenty-nine  suicides,  by 
poison  in  the  majority,  with  firearms  second,  while 
the  other  means  were  razors  and  the  rope.  There 
were  nineteen  people  asphyxiated  by  gas,  while  one 
was  registered  as  choked  while  laughing.  Seventy- 
nine  people  were  drowned.  Fifty  people  were 
killed  by  the  railways  and  twenty-two  by  the  street 
railways.  Fifteen  deaths  were  caused  by  explosions, 
ten  at  once  by  a  dynamite  affair  and  one  by  the  ex- 
plosion of  a  barrel  of  whiskey.  Motor  cars  killed 
only  two,  and  one  was  killed  in  hunting.  There 
were  21S  sudden  deaths,  fifty-seven  not  certified  to 
bv  a  physician.  One  fireman  was  killed  while  on 
duty,  and  fifty-seven  people  were  burned  to  death. 
Six  were  killed  by  scalding  and  two  frozen  to  death. 

Alpha  is  the  name  of  the  first  class  established  in 
this  city,  or,  for  that  matter,  in  Canada,  for  the 
treatment  of  tuberculosis.  During  the  progress  of- 
the  Tuberculosis  Exhibition  here  in  November,  Dr. 
Pratt,  of  Boston,  the  originator  of  this  means  of 
combating  tuberculosis,  was  present,  and  on  differ- 
ent occasions  gave  a  number  of  lectures  on  the  sub- 
ject. In  Boston  it  has  been  carried  on  with  distinct 
success,  and  Montreal  thought  it  wise  to  follow  suit. 
The  class,  which  is  in  charge  of  Dr.  FI.  S.  Harding 
and  a  trained  nurse,  numbers  seven,  and  on  joining 
they  promised  strictly  to  follow  out  the  instructions 
of  the  doctor  and  the  nurse.  If  this  proves  a  suc- 
cess, others  will  be  established. 

An  epidemic  of  typhoid  fever  has  been  raging  in 
this  city  since  Christmas.  All  the  hospitals  are  taxed 
to  their  utmost  capacity,  there  being  in  all  the  hospi- 
tals about  250  cases,  while  outside  in  different  sec- 


tions of  the  city  the  cases  number  about  800.  Mon- 
treal has  no  regular  system  of  water  examination  to 
warn  the  people  in  time  of  this  danger,  and  there  is 
no  milk  inspection.  Our  open  aqueduct  gets  its  ini- 
tial supply  of  water  from  the  soakings  of  the  shore 
all  the  way  past  the  towns  and  villages  that  Hne  the 
side  of  Montreal  Island,  from  St.  Anne's  to  Lachine, 
and  part  of  our  water  supply  is  from  Verdun.  Then 
this  water  is  carried  through  the  open  fields,  hurried 
across  a  settling  basin,  where  it  is  given  no  time  to 
settle,  and  then  sent  churning  through  the  taps  with 
all  its  impurities  and  perils  still  in  it.  Last  summer 
the  Standard  conducted  a  thorough  inquiry  into  the 
sources  of  our  milk  supply,  and  the  results  were 
startling.  Such  a  thing  as  a  really  clean  milk  can  was 
a  myth  in  this  city.  Cans  were  seen  with  putrid  mat- 
ter decaying  in  them,  with  worms  actually  alive  in 
them.  One  can  at  a  railway  station  drove  people 
away  from  it  by  its  stench.  Milk  was  kept  in  cow 
stables  or  in  the  dwelling  rooms  of  the  farmers,  and 
seldom  cooled.  In  the  city  groceries  it  was  kept  in  the 
most  unsanitary  surroundings.  No  wonder  we  have 
a  raging  epidemic  of  typhoid  fever. 

The  report  for  1907-1908  of  the  excise  division  of 
the  Department  of  Inland  Revenue  of  Canada  shows 
that  in  spite  of  the  local  option  movement  the  pro- 
duction of  alcoholic  beverages  continues  to  grow  in 
Canada.  Spirits,  of  course,  are  not  all  consumed  as 
beverages,  large  quantities  being  used  in  the  prepa- 
ration of  medicines  and  in  some  of  the  industrial  arts, 
though  for  the  latter  wood  spirit  is  to  some  extent 
taking  the  place  of  the  article  made  from  grain.  The 
greater  part  of  the  alcohol  made  from  grain  or  mo- 
lasses is  intended,  however,  for  beverages.  In  Can- 
ada last  year  the  new  output  of  the  distillers  was  at 
the  record  figure  of  6,849,763  proof  gallons,  there 
being  consumed  in  the  process  7,679,000  pounds  of 
malt,  72,997,000  pounds  of  Indian  corn,  14,921,000 
pounds  of  rye,  3,117,000  pounds  of  wheat,  395.000 
pounds  of  oats,  and  17.212,000  pounds  of  molasses. 
In  the  matter  of  production  Ontario  is  the  great 
whiskey  province.  It  has  within  its  bounds  seven  of 
the  twelve  distilleries  in  Canada.  The  increased  pro- 
duction of  spirits  is  small  compared  with  the  growth 
in  the  output  of  beer.  This  has  to  be  measured,  so 
far  as  the  returns  go,  by  the  increase  in  the  produc- 
tion of  malt.  In  i903-'4  the  amount  manufactured 
was  68,503,000  pounds,  while  last  year  it  was  99,- 
577,000  pounds.  Many  regard  the  increase  in  the 
consumption  of  malt  liquor  as  a  temperance  move- 
ment, and  they  have  some  reason,  as  it  is  well  known 
there  is  less  temptation  to  indulge  to  unseemly  ex- 
cess in  drinking  ales  and  beer  than  when  consuming 
the  highly  intoxicating  spirituous  beverages.  When 
the  records  are  gone  back  to,  the  figures  speak  for 
themselves.  In  1869  the  consumption  of  spirits, 
home  made  and  imported,  was  1.124  gallon  a  head 
of  the  population ;  last  year  o.88c)  gallon  a  head.  In 
the  same  time  the  quantity  of  beer  consumed  has 
risen  from  2.290  gallons  a  head  to  5.812  gallons.  As 
regards  tobacco,  there  were  taken  for  consumption 
32,088,000  pounds.  There  were  also  consumed  200,- 
133,000  cigars  and  385,000,000  cigarettes.  The  lat- 
ter fact  is  interesting  in  view  of  the  abuse  to  which 
the  cigarette  is  subjected.  It  is  apparently  becoming 
the  favorite  form  of  tobacco. 


January  23,  1909.] 


THERAPEUTICAL  NOTES. 


177 


The  Creosote  Treatment  of  Pulmonary  Tuber- 
culosis.— Dr.  Beverly  Robinson  insists  upon  the 
vise  of  pure  creosote  internally  as  well  as  by  inhala- 
tion. He  has  shown  and  emphasized  (The  Medical 
Times,  January,  1909)  the  important  fact  that  there 
are  many  patients  who  will  improve  more  when  they 
take  the  combined  treatment.  These  are  patients 
who  at  the  beginning  of  treatment  can  only  use  the 
inhaler  for  a  short  time  and  infrequently,  or  who 
never  are  able  to  use  it  sufficiently,  as  he  believes, 
for  one  reason  or  another.  The  following  formula 
has  long  been  used  by  Dr.  Robinson : 

R    Creosote  (Merck's),  gtt.  vi ; 

Glycerin,   .^i ; 

Rye  whiskey,   3ii. 

M.  et  Sig.  :A  dessertspoonful  four,  six,  or  eight  times  in 
twenty-four  hours,  and  rarely  every  two  hours  and  very 
infrequently  more  than  six  drops,  or  minims,  in  twenty- 
four  hours. 

Sometimes  he  finds  his  formula  unsuited  to  his 
case ;  then  he  varies  it  with  a  combination  in  which 
there  is  pepsin,  or  perhaps  with  lime  with  hydro- 
chloric acid. 

Dr.  Robinson  says  that  there  are  patients  who  for 
a  time  become  intolerant  of  inhalations,  so  that  their 
administration  has  to  be  modified,  and  perhaps  sus- 
pended for  a  while,  until  the  stomach  recovers, 
then  inhalations  can  be  resumed  with  distinct 
relief.  He  says  our  prescriptions  must  be  mixed 
with  brains,  and  we  must  study  closely  the  personal 
idiosyncrasy  of  the  patient  to  obtain  the  best  results. 
A  great  mistake"  of  many  is,  he  says,  to  give  creosote 
in  too  large  doses  or  not  properly  combined  or  di- 
luted. 

Precautions  Necessary  in  the  Use  of  Mercurial 
Oil  Injections. — It  is  recommended  by  Queyrat 
(Les  nonzeanx  remidcs,  December  24,  1908),  to 
take  precautions  preliminary  to  the  hypodermic  ad- 
ministration of  mercurial  oil  in  the  treatment  of 
syphilis.  The  absence  of  albumin  in  the  urine  should 
be  determined  first.  The  state  of  the  teeth  and 
gums  should  then  be  ascertained.  They  should  be 
in  good  condition.  The  hygiene  of  the  mouth  re- 
quires special  attention,  and  it  is  advised  to  cleanse 
the  teeth  regularly  by  means  of  a  soft  brush  and 
the  following  tooth  paste : 

B    Almond  soap,   3x; 

Glycerin,   5vi; 

Extract  of  thatany,  3i; 

Sodium  borate,   3i; 

Oil  of  anise,   gtt.  xxv; 

Oil  of  peppermint,  gtt.  xxv. 

M. 

Bromoform  in  Whooping  Cough. — Bromoform 
is  ver\-  beneficial  in  the  treatment  of  whooping  cough. 
Owing  to  its  immiscibility  with  water  it  should  be 
prescribed  either  as  an  emulsion,  or  an  alcoholic  so- 
lution. A  formula  devised  to  exhibit  one  minim  of 
bromoform  in  each  fluid  drachm  is  as  follows : 
R    Bromoform,   TTtxvi ; 

Alcohol,   3ii; 

Glycerin,   Siss ; 

Compound  tincture  of  cardamom,   5ii. 

M. 

As  an  emulsion  it  may  be  prescribed  thus : 
R    Bromoform,   TT^xx; 

Mucilage  of  acacia,   3ii; 

Water,   ad  3i. 

M. 


For  Brain  Fag. — The  following  is  given  in  The 

Prescribe)-  as  the  prescription  of  a  specialist : 

R    Caffeine  citrate,   5i; 

Diluted  phosphoric  acid  Siiss; 

Solution  of  strychnine  (B.  P.),   TT\lxxx ; 

Tincture  of  cannabis  indica,   5i ; 

Lithium  bromide,   5v; 

Fluid  extract  of  cinchona,   5iii; 

Syrup  of  orange  3x; 

Water,   ad  3x. 

Solve  et  Misce.  Sig. :  A  tablespoonful  in  half  a  wine- 
glassful  of  water  thrice  daily  after  meals.  Shake  the  bottle. 

[This  mixture  looks  to  us  like  an  incompatible 
compound.  The  strychnine  salt  is  apt  to  interact  with 
the  lithium  bromide,  while  the  tincture  of  Indian 
hemp  and  the  extract  of  cinchona  will  be  precipi- 
tated by  the  water  and  form  a  most  unsightly  com-- 
pound. — The  Abstractor.] 

Escharotic  Paste.  —  According  to  J.  Felix 
{Deutsche  iv.edizinische  Wnchenschrift,  1908,  p. 
2192),  the  following  compound  is  useful  in  the 
treatment  of  certain  ulcers  : 

Wheat  flour  Biiiss; 

Corn  starch,   5xi; 

Corrosive  sublimate,   gr.  xv; 

Thymol  iodide,   gr.  xv ; 

Cocaine,   gr.  xv; 

Camphor,  monobromated,   3iiss  ; 

Carbolic  acid  crystals,   3iiss ; 

Zinc  chloride  (dry),   3vi. 

Water, 

Glycerine  aa  enough  to  form  a  paste. 

The  Administration  of  Iron  in  Chlorosis. — The 

Prescribcr  for  January,  1909,  considers  the  follow- 
ing prescription  an  excellent  combination  to  give 
anaemic  patients,  where  dyspepsia  is  a  concomitant 
of  the  condition  : 

B    Iron  sulphate,   gr.  xii; 

Diluted  nitro-hydrochloric  acid,   3iii; 

Magnesium  sulphate,   Siss; 

Syrup  of  orange  peel,   3vi; 

Chloroform  water,   ad  5vi. 

M.  et  Sig. :  A  tablespoonful  in  water  thrice  daily  after 
food. 


NEW  REMEDIES. 

Aperitol  is  a  compound  of  phenolphthalein.  iso- 
valerianic  acid,  and  acetic  acid,  which  is  a  painless 
laxative,  in  doses  of  three  grains  and  upwards.  It 
is  insoluble  in  water. 

Asiphyl  is  the  mercury  salt  of  paraanilidarsenic 
acid,  which,  as  its  name  implies,  is  said  to  possess 
strong  antisyphilitic  properties.  It  is  a  colorless  salt, 
only  slightly  soluble  in  water. 

Asquirrol  is  one  of  the  numerous  new  mercury 
compounds  intended  for  hypodermic  use  in  syphilis. 
It  is  stated  to  be  a  mercury  dimethylate  and  is  put 
up  in  the  form  of  ampuls,  each  containing  i  c.c.  of 
a  five  per  cent,  sterilized  solution. 

Dipropaesin  is  a  condensation  product  of  pro- 
paesin  which  is  recommended  in  the  treatment  of 
intestinal  colic  in  doses  of  73^^  to  15  grains.  It  is 
stated  not  to  possess  any  anaesthetic  action  of  itself, 
but  propassin  is  liberated  from  it  in  contact  with  the 
secretions  of  the  stomach,  and  exerts  a  strong  seda- 
tive action. 

Eulaxans  is  one  of  the  numerous  phenolphtha- 
lein laxative  compounds,  being  a  combination  of  one 
molecule  of  phenolphthalein  and  two  molecules  of 
sodium  hydroxide.  It  is  said  to  be  more  active  than 
phenolphthalein  itself  in  doses  of  from  %  to  3 
grains. 


178 


EDITORIAL  ARTICLES. 


[New  York 
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NEW  Y'ORK.  S.VTURDAY,  JANUARY  23,  1909. 

THE  AR^IY  MEDICAL  SERV  ICE. 

In  the  January-February  number  of  the  Journal 
of  the  Military  Service  Institution  of  the  United 
States  there  is  published"  an  essay  entitled  The  Medi- 
cal Department  of  the  United  States  Army :  Upon 
What  Lines  Should  its  Much  Needed  Reorganiza- 
tion be  Instituted?  It  is  the  essay  for  which  the 
Seaman  Prize  for  1908  was  awarded  to  the  author, 
Major  Charles  F.  Mason,  of  the  Army  Medical 
Corps.  Major  INIason  argues  cogently  in  favor  of 
a  personnel  adequate  in  numbers  both  in  time  of 
peace  and  in  time  of  war — at  least  one  medical  of- 
ficer for  every  hundred  enlisted  men.  He  does  not 
contend  that  that  number  would  be  required  to  take 
care  of  the  sick  and  wounded,  but  that  care,  he  de- 
clares, is  only  a  "side  issue,"  the  true  function  of 
the  corps  being  to  maintain  the  efificiency  of  the 
army  in  war.  He  argues,  too,  that  the  Medical 
Corps  should  furnish  all  medical  and  sanitary  equip- 
ment and  have  control  of  its  transportation. 

Major  Mason  contends  also  for  greater  power 
on  the  part  of  medical  officers  in  the  execution  of 
their  sanitary  functions,  with  provision  for  throw- 
ing greater  responsibility  upon  such  officers  in  the 
matter  of  carrying  out  their  own  recommendations, 
so  that  they  would  be  very  careful  to  suggest  only 
measures  that  were  practicable  and  likely  to  give  re- 
sults. The  final  authorization  of  proposed  sanitary 
measures  would  continue  to  remain  in  the  hands  of 
the  commanding  officer,  "but  the  effect  of  the 
change  would  be  to  relieve  him  of  the  burden  of 


having  to  provide  the  ways  and  means,  and  especial- 
ly of  the  always  disagreeable  necessity  of  making 
details  for  the  purpose  from  his  fighting  force." 

There  should  always  be  kept  on  hand.  Major 
Mason  thinks,  a  year's  allowance  of  medical  and 
sanitary  appliances,  including  means  of  transporta- 
tion, for  an  army  of  four  times  the  authorized 
strength,  there  should  be  more  detailed  plans  for 
service  in  time  of  war,  and  closer  relations  should 
be  established  with  the  Red  Cross  .Society  and  with 
the  medical  officers  of  the  militia.  The  present  am- 
bulance wagon,  he  says,  could  be  made  satisfactory 
by  a  few  minor  changes,  but  it  is  too  large  and 
heavy  for  service  with  cavalry,  for  which  a  light 
ambulance  cart,  capable  of  rapid  motion,  ought  to 
be  adopted.  The  travels  would  be  a  useful  article, 
only  the  harness  which  goes  with  it,  and  without 
which  it  cannot  be  used,  is  supplied  by  the  Quarter- 
master's Department,  and  the  two  are  never  found 
together.  The  whole  equipment  should  be  supplied 
by  the  Medical  Department.  Another  important 
matter  is  that  an  experienced  medical  officer  placed 
in  charge  of  a  large  hospital  should  not  have  his 
time  so  encroached  upon  by  routine  duties  as  to 
hamper  him  in  his  professional  work ;  many  such 
duties  might  with  advantage  be  delegated  to  a  junior 
officer. 

We  have  mentioned  only  the  salient  points  of 
Major  Mason's  excellent  essay,  and  chiefly  those 
with  regard  to  which  general  misapprehension 
doubtless  stands  in  the  way  of  improvement.  When 
the  people  understand  what  is  needed,  they  will  see 
to  it  that  Congress  understands  and  acts  according- 
ly. Then  we  shall  have  an  army  medical  service 
well  organized  and  equipped  to  maintain  the  ef- 
ficiency of  the  fighting  force.  Major  Mason's  essay 
ought  to  serve  powerfuUv  toward  such  a  state  of 
things. 


THE  LIVER  AND  FAT  METABOLISM. 

Careful  physiological  research  conducted  in  the 
past  few  years  has  disclosed  the  fact  that  the  liver 
apparently  plays  an  important  part  in  the  metab- 
olism of  fat.  This  is  all  the  more  curious  because 
the  fat  absorbed  from  the  intestines  is  carried  by  a 
special  set  of  vessels  past  the  liver  directly  into  the 
circulation.  This  phase  of  the  hepatic  function  was 
the  subject  of  the  Harvey  Lecture  recently  delivered 
by  Professor  J.  B.  Leathes,  of  the  Lister  Institute 
of  Preventive  Medicine  of  London.  It  is  well 
known  that  a  large  number  of  poisons,  such  as 
phosphorus,  arsenic,  chloroform,  oil  of  pennyroyal, 
etc.,  are  capable  of  producing  local  accumulations  of 
fat,  especially  in  the  liver.  Furthermore,  in  a  num- 
ber of  diseases  the  condition  known  as  "fatty  degon- 


January  2,j,  19119. ) 


EDITORIAL  ARTICLES. 


179 


eration"  of  the  liver  coiibtiluies  a  marked  feature. 
For  a  long  time  it  was  believed  that  these  accumu- 
lations were  due  to  a  transformation  of  albumin 
into  fat.  It  was  also  thought  that  these  fatty  changes 
were  mostly  slow,  chronic  degenerations.  Support 
was  given  to  this  conception  by  the  fact  that  when 
some  sterile  liver  tissue  is  allowed  to  autolyze  in  an 
incubator  under  aseptic  precautions,  there  is  a  con- 
siderable increase  in  the  fatty  acids.  The  reaction 
which  occurs  closely  resembles  that  of  butyric  acid 
fermentation. 

The  work  of  Athanasiu,  Rosenfeld,  Leathes,  and . 
others,  however,  has  clearly  shown  that  large 
amounts  of  fat  in  the  liver  are  due  to  an  importation 
from  without.  Careful  determinations  of  the  total 
fat,  both  of  normal  animals  and  of  such  as  have 
been  poisoned  with  phosphorus,  show  that  there  is 
no  increase  in  the  whole  quantity  of  fat  in  the  body. 
While  the  fat  in  the  liver  has  increased,  there  is  a 
decrease  in  the  adipose  tissues.  Furthermore,  as 
Leathes  has  shown,  there  are  important  differences 
in  the  fats  normally  found  in  the  liver  and  heart 
and  those  found  in  the  adipose  tissues.  Xot  only 
does  the  proportion  of  ether  extracts  vary,  but  there 
is  also  a  marked  difference  in  the  iodine  value  of 
the  fatty  acids.  The  latter  represents  the  amount  of 
unsaturated  carbon  atoms  in  the  fatty  acids,  and  has 
come  to  be  an  extremely  important  guide  concern- 
ing the  constitution  of  the  fats.  Rosenfeld  showed 
that  the  fat  in  the  liver  varied  with  the  character  of 
the  fat  stored  in  the  tissues.  Hartley's  investiga- 
tions on  the  amount  and  nature  of  the  fat  in  human 
livers  in  different  conditions  show  that  as  the  fat 
increases  in  the  liver  the  iodine  value  of  the  fatty 
acids  decreases,  i.  e.,  the  character  of  the  fatty  acids 
becomes  practically  the  same  as  that  of  the  connec- 
tive tissue. fat.  If  animals  are  fed,  for  example,  on 
cod  liver  oil,  it  will  be  found  that  in  a  short  time  the 
fatty  acid  of  the  liver  increases  and  the  iodine  value 
of  the  acids  becomes  even  greater  than  that  of  the 
cod  liver  oil  ingested.  This  shows  that  the  liver  has 
in  some  way  rearranged  the  atoms  in  the  fatty  acid 
molecules.  Just  what  this  rearrangement  is,  or  how 
it  is  brought  about,  is  not  known. 

From  Mottram's  work  on  starving  animals  it 
would  appear  that  on  the  first  day  of  starvation  a 
call  goes  out  from  the  liver  to  the  adipose  tissue, 
and  this  results  in  an  increase  of  the  fat  in  the  liver. 
In  the  next  few  days  this  accumulation  is  appar- 
ently used  up,  so  that  on  about  the  fourth  day  a 
second  call  is  made  on  the  adipose  tissue ;  this  re- 
sults in  a  second  increase  of  the  fat  in  the  liver. 
This  suggests  that  before  the  stored  fat  can  be  used 
by  the  tissues  it  has  to  undergo  some  modification 
in  the  liver.  Some  suggestion  as  to  the  changes 
which  occur  is  given  by  the  changes  in  the  iodine 


value  already  alluded  to.  Altogether,  there  is  no 
doubt  that  the  liver  plays  an  important  part  in  the 
m.etabolism  of  fat.  Leathes  has  likened  this  to  the 
drying  of  gunpowder,  and  believes  that  the  fat 
stored  in  the  adipose  tissue  is  comparable  to  wet 
powder,  i.  e.,  it  is  stored  in  a  form  which  is  safe 
from  combustion,  and  needs  to  be  prepared  before 
it  can  become  available  for  the  organs  which  require 
it  in  their  activities.  This  alteration,  whatever  it  is, 
is  a  function  of  the  liver. 


LEPROSY  IX  HAWAII. 

The  United  States  Public  Health  and  [Marine  Hos- 
pital Service  has  recently  published  a  pamphlet  set- 
ting forth  certain  investigations  by  Dr.  \\'alter  R. 
Brinckerhoff,  director  of  the  Leprosy  Investigation 
Station  at  [Nlolokai,  under  the  headings  of  The  Pres- 
ent Status  of  the  Leprosy  Problem  in  Hawaii,  The 
Reaction  of  Lepers  to  ^^loro's  "Percutaneous"  Test, 
,and  A  Xote  upon  the  Possibility  of  the  Mosquito 
Acting  in  the  Transmission  of  Leprosy.  It  seems 
that  there  has  been  a  gradual  decrease  of  leprosy  in 
the  islands  during  the  last  ten  years,  but  an  actual 
increase  among  the  descendants  of  the  aboriginal 
Havvaiians,  who  are  decreasing  in  number,  not  only 
proportionately,  but  also  absolutely.  It  appears,  too, 
that  the  Hawaiians  seek  notably  to  conceal  the  oc- 
currence of  leprosy  among  their  people,  for  it  is 
often  four  or  five  years  from  the  inception  of  a  case 
before  the  subject  of  the  disease  declares  himself. 
.■\t  the  same  time,  we  are  told,  suspects  living  on 
other  islands  than  Oahu  (the  seat  of  Honolulu) 
comply  in  somewhat  astonishing  numbers  with  no- 
tices to  report  themselves  for  diagnosis. 

Leprosy  in  Hawaii,  says  Dr.  Brinckerhoff,  oftener 
comes  to  light  in  the  areas  of  dense  population,  like 
Honolulu,  than  in  the  rural  districts.  This  state  of 
things  may  be  o\\  ing  to  the  migration  of  rustic  lep- 
ers to  the  capital  for  treatment  or  for  better  conceal- 
ment, but  Dr.  Brinckerhoff  is  inclined  to  impute  it 
to  the  greater  facilities  for  infection  which  exist  in 
the  capital.  In  spite,  however,  of  the  continued  pre- 
ponderance of  leprosy  among  the  natives,  it  "is  be- 
coming more  and  more  a  disease  of  all  inhabitants, 
and  is  no  longer  almost  entirely  confined  to  the  na- 
tive race."  "In  the  present  state  of  our  knowledge," 
he  says,  "we  naust  assume  that  leprosy  is  infectious 
during  the  whole  of  its  course,"  and  he  intimates 
that  many  instances  of  its  conveyance  from  one  per- 
son to  another  take  place  during  the  four  or  five 
years  of  concealment  in  Honolulu.  He  concludes 
that  the  leprosy  problem  in  Hawaii  calls  for  more 
thorough  enforcement  of  the  laws  regarding  segre- 
gation. 

Moro's  test  by  the  application  of  a  tuberculin  salve 


i8o 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


to  the  skin,  he  thinks,  is  of  no  assistance  in  the  diag- 
nosis between  leprosy  and  tuberculous  disease.  "The 
only  deduction  to  be  made,"  he  says,  "is  that  a  slight 
and  delayed  reaction  would  be  in  favor  of  lepra, 
though  the  number  of  cases  on  which  this  generali- 
zation is  based  is  obviously  inadequate  and  the  selec- 
tion of  the  nonleper  patients  not  diversified  enough 
to  yield  it  proper  support."  He  thinks  that  the  prob- 
abilities are  against  the  proposition  that  the  mosquito 
plays  a  part  in  the  transmission  of  leprosy,  although 
he  does  not  deny  the  possibility  of  that  insect's  activ- 
ity in  propagating  the  disease. 


THE  SUPRARENAL  BODIES,  NEPHRITIS, 
AND  ARTERIOSCLEROSIS. 

The  French  observers  have  advocated  the  view 
that  nodular  adenoma  or  diffuse  hyperplasia  of  the 
suprarenal  bodies  is  commonly  associated  with  con- 
tracted kidney  and  arteriosclerosis,  when  the  disease 
does  not  run  a  too  rapid  course.  They  consider  that 
the  hyperplasia  is  an  indication  of  excessive  activity 
of  the  antitoxic  and  angeiotonic  functions  of  the 
suprarenal  body,  what  might  be  called  "superadre- 
nalism."  Pearce  examined  the  autopsy  records  of 
the  Bender  Laboratory  to  determine  the  relation  of 
vascular  lesions  to  changes  in  the  suprarenal  bodies 
and  the  relation  of  changes  in  the  suprarenal  bodies 
to  interstitial  nephritis  {Journal  of  Experimental 
Medicine,  November,  1908).  In  a  large  number  of 
■cases  it  was  shown  that  there  were  definite  changes 
in  the  suprarenal  bodies  in  cases  of  general  arterio- 
sclerosis, whether  associated  with  chronic  interstitial 
nephritis,  with  chronic  parenchymatous  nephritis, 
or  with  some  other  condition.  The  changes  included 
nodular  and  diffuse  hyperplasia  of  the  parenchyma 
of  the  organs,  variations  in  the  amount  of  chromat- 
affin  substance,  and  changes  in  the  cytoplasm  of  the 
cortical  cells,  as  well  as  thickening  of  the  capsule, 
diffuse  increase  of  connective  tissues,  and  round 
celled  infiltration.  These  changes  might  be  second- 
ary to  arteriosclerosis  or  they  might  be  independent 
of  it  and  of  importance  in  the  production  of  super- 
adrenalism  concerned  in  the  aetiology  of  a  vascular 
lesion.    The  author  inclined  to  the  former  view. 

THE  MEDICAL  SOCIETY  OF  THE  STATE 
OF  NEW  YORK. 
We  hope  that  the  annual  meeting,  which  is  to  be 
held  in  Albany  next  week,  will  be  well  attended,  but 
the  leading  editorial  article  in  the  January  number 
of  the  society's  official  publication,  the  Nezv  York 
State  Journal  of  Medicine,  is  not  encouraging.  The 
writer  of  the  article  points  out,  as  everybody  has 
known  for  many  years,  that  the   meeting  is  held 


every  year  in  a  city  which,  though  interesting  and 
attractive  in  itself,  has  its  hotel  accommodations 
taxed  to  the  utmost  at  this  time  of  the  year,  and 
that  it  is  often  exceedingly  inconvenient  for  a  busy 
physician  to  leave  his  practice  even  for  a  few  days 
in  midwinter.  If  we  give  up  the  old  and  apparent- 
ly fallacious  idea  that  the  meeting,  coming  during 
the  session  of  the  legislature,  impresses  that  body 
with  the  importance  of  the  medical  profession  of  the 
State,  we  do  not  see  why  the  date  or  place  of  the 
meeting,  or  both,  might  not  be  changed  with  advan- 
.  tage. 


THE  ABSORPTION  OF  LIGHT  BY  THE 
SKIN. 

Dr.  Ferdinand  Winkler,  of  Vienna,  has  studied 
the  penetrability  of  the  skin  by  light,  and  reports  the 
results  in  the  Monatshefte  fiir  praktische  Deniiato- 
logie,  Ixvii,  No.  9.  His  studies  and  the  conclusions 
to  be  deduced  from  them  are  especiall}'  of  value,  as 
the  researches  previously  conducted  contradict  each 
other  more  or  less  and  do  not  properly  answer  the 
two  important  questions  as  to  which  rays  penetrate 
the  skin  and  can  therefore  be  used  for  therapeutical 
purposes  in  the  body,  and  as  to  whether  it  is  really 
possible  to  influence  the  tissues  so  that  their  action 
toward  the  permeating  power  of  the  rays  may  be 
changed. 

Our  author  concludes  rightly  that  the  origin  of  the 
light  is  of  no  import  for  the  capability  of  absorption 
by  the  skin  ;  the  only  distinction  is  that  by  the  use  of 
light  from  different  sources  the  rays  of  the  spectrum 
are  of  great  variety  as  to  their  relative  strength. 
The  absorption  of  light  by  the  skin  and  the  influence 
of  light  upon  the  skin  are  identical  for  every  source 
of  light,  so  long  as  there  is  used  the  same  quantity 
of  energy  of  light  of  the  same  wave  length. 

Dr.  Winkler,  therefore,  divided  the  light  spectro- 
scopically,  and  made  his  experiments  under  vtry 
high  light  intensity.  He  found  that  in  normal  as 
well  as  in  experimentally  changed  conditions  the 
skin  showed  less  penetrability  for  the  violet  and  blue 
rays  than  for  the  other  colors  of  the  spectrum,  while 
ultraviolet  rays  did  not  even  pass  very  thin  layers  of 
tissue,  such  as  the  ear  of  a  rabbit.  Ultraviolet  rays 
will,  therefore,  have  no  influence  upon  the  deeper 
tissues.  We  can  reach  the  deep  seated  tissues  only 
with  the  following  rays,  which  are  cited  in  an  ascend- 
ing scale — green,  yellow,  and  red.  This  shows,  there- 
fore, that  blue,  violet,  and  ultraviolet  rays  are  more 
easily  absorbed  than  green,  yellow,  and  red,  as  they 
hardly  reach  the  deeper  tissues  at  all.  The  influence 
of  the  light  is  based  upon  its  absorption  by  the  tis- 
sue, and  the  best  results  from  the  actions  of  the  rays 
upon  the  skin  or  surface  tissue  can,  therefore,  only 


January  23,  1909.] 


NEWS  ITEMS. 


181 


.be  expected  from  blue,  violet,  and  ultraviolet  rays. 
If  we  wish  to  reach  deeper  layers  of  tissue,  we  shall 
have  to  use  very  strong  light,  which,  again,  will,  on 
account  of  the  absorbability  of  certain  rays,  prove  a 
•danger  to  the  surface  tissue. 

If  we  adapt  this  to  therapeutics,  we  must  add  that 
■this  is  only  the  case  if  normal  tissue  reacts  in  the 
same  manner  as  pathological  tissue.  If  diseased  tis- 
sue shows  a  greater  capability  of  reaction  to  the  rays 
than  the  normal,  as,  for  example,  in  the  action  of 
the  Rontgen  rays  upon  lupous  tissue,  it  will  be  pos- 
sible to  produce  a  reaction  of  the  pathological  tissue 
with  the  blue  ray,  but  not  with  the  ultraviolet,  and 
thus  exert  a  deeper  reaching  influence. 

The  therapeutical  influence  of  green,  yellow,  and 
Ted  rays  is  only  exceptional,  and  to  produce  such  in- 
fluence it  will  become  necessary  to  use  filters  which 
will  exclude  the  other  rays  and  permit  the  green, 
yellow,  or  red  to  penetrate.  But  even  then  we  shall 
have  to  use  very  strong  light,  as  these  rays  show 
poor  absorbability  in  the  human  body.  As,  there- 
fore, the  green,  yellow,  and  red  rays  are  only  slight- 
ly absorbed,  while  the  ultraviolet  rays  are  too  easily 
absorbed,  the  blue  rays  remain  the  onlj'  ones  which 
are  available  for  the  therapeutical  treatment  of  deep 
tissues. 

The  second  question  is.  Is  it  possible  to  influence 
the  tissues  so  that  their  power  of  absorption  may 
be  changed?  This  can  be  achieved  only  by  influ- 
•encing  the  tissue  to  which  we  wish  to  give  a  higher 
power  of  absorbability,  and  this  can  be  done  only 
with  surface  tissue,  as  it  is  hardly  possible  to  influ- 
ence the  deeper  layers.  A  medium,  such,  for  exam- 
ple, as  eosin,  introduced  into  the  deeper  layers,  will 
not  only  be  absorbed  by  these,  but  will  also  discolor 
the  surrounding  tissues  and  thus  increase  the  power 
•of  absorption  of  the  intervening  tissue,  which  was  to 
be  avoided ;  besides,  it  is  not  easy  to  locate  deeply 
situated  pathological  tissue  accurately.  It  will  thus 
.be  seen  that  the  experiments  and  researches  of  Dr. 
Winkler  are  of  great  practical  value. 


littus  |tms. 

Changes  of  Address. — Dr.  Nathaniel  W.  Emerson, 
from  1069  Boylston  Street,  to  244  Fairfield  Street,  Boston. 

Dr.  Charles  A.  Fife,  to  2033  Locust  Street,  Philadelphia. 

The  New  Police  Surgeon. — Dr.  Francis  J.  Murray  has 
been  appointed  a  police  surgeon,  to  succeed  Dr.  John  J. 
Quigley,  who  died  receiniy.  Dr.  Murray  is  a  graduate  of 
Yale  and  the  Medical  Department  of  Columbia. 

Gift  to  Hospital  from  Leader  of  Christian  Science 
Movement. — The  trustees  of  the  Xewton  Hospital, 
Xewton,  Mass.,  received  recently  from  Mrs.  Eddy  a  check 
for  $500,  to  aid  in  paying  off  a  debt  on  the  hospital. 

The  New  Beth  Israel  Hospital.— Mr.  Adolph  Lewi- 
sohn  has  given  $25,000  to  the  building  fund  of  this  hospi- 
tal, and  this  sum,  together  with  $75,000  donated  by  a  num- 
ber of  prominent  New  York  business  men,  brings  the  fund 
up  to  $160,000. 


Lectures  on  Tuberculosis  in  Cincinnati. — The  Anti- 
tuberculosis League  of  Cincinnati  is  holding  a  series  of 
free  lectures  on  tuberculosis.  Among  those  who  have  been 
engaged  to  speak  are  Dr.  B.  F.  Lyle,  Dr.  S.  P.  Withrow, 
Dr.  S.  E.  Allen,  and  Dr.  Louis  L.  Levy. 

A  Ball  in  Aid  of  the  Passavant  Memorial  Hospital, 
Chicago,  was  held  in  the  Congress  Hotel  recently, 
which  realized  about  $3,500  for  the  institution.  The  ball 
was  held  under  the  auspices  of  the  auxiliary  board  of  the 
hospital,  of  which  Mr.  Joseph  T.  Bowen  is  president. 

Scarlet  Fever  at  Cornell. — It  is  reported  that  an  out- 
break of  scarlet  fever  among  the  students  at  the  Cornell 
College  of  Agriculture,  Ithaca,  N.  Y.,  is  causing  much  con- 
cern to  the  local  health  authorities.  There  are  now  eleven 
students  conhned  in  the  contagious  wards. 

The  West  Side  Clinical  Society,  New  York,  has  elect- 
ed officers  for  1909  as  follows :  President,  Dr.  A.  C. 
McGuire;  vice-president.  Dr.  C.  A.  Haffner ;  secretary.  Dr. 
W.  G.  States ;  treasurer.  Dr.  C.  W.  Lj-nn.  The  annual 
dinner  of  the  society  was  held  at  the  Hotel  Belleclaire  on 
January  14th. 

Dr.  Thomas  Morgan  Rotch,  professor  of  paediatrics 
in  the  Harvard  Medical  School,  will  deliver  a  lecture  at  a 
special  meeting  of  the  Buffalo  Academy  of  Medicine  on 
Saturday  evening,  January  23d,  on  The  General  Principles 
of  Percentage  Feeding  and  the  Laboratory  Management  of 
All  Food  Stuffs. 

The  .ffisculapian  is  the  title  of  a  new  quarterly  jour- 
nal, the  first  number  of  which  is  dated  December,  1908. 
According  to  its  subtitle  it  is  to  be  devoted  to  medical  his- 
torj-,  literature  and  art.  The  editor  is  Dr.  Albert  Tracy 
Huntington.  It  is  designed  to  succeed  the  Medical  Library 
and  Historical  fountal. 

The  Tuberculosis  Exhibition  at  the  American  Mu- 
seum of  Natural  History,  New  York,  closed  on  the 
evening  of  January  17th,  having  been  open  since  November 
30th.  The  total  attendance  for  the  forty-nine  days  was 
750,000.  The  exhibit  is  to  be  taken  to  Philadelphia,  where 
it  will  open  on  February  5th. 

Banquet  and  Presentation  to  Dr.  Charles  W.  Bryson. 
— The  faculty  of  the  College  of  Physicians  and  Surgeons, 
San  Francisco,  Cal.,  gave  a  banquet  recently  in  honor  of 
Dr.  Bryson,  dean  of  the  faculty.  A  silver  chafing  dish 
was  presented  to  •him  by  the  mem.bers  of  the  faculty  as  a 
token  of  their  respect  and  esteem. 

Prominent  Philadelphia  Physicians  in  the  Army  Med- 
ical Reserve  Corps. — Dr.  L.  Webster  Fox,  Dr.  James  M. 
Anders,  Dr.  W.  Easterley  Ashton,  Dr.  John  V.  Shoemaker, 
Dr.  Ernest  La  Place,  and  Dr.  William  L.  Rodman  have 
been  appointed  assistant  surgeons  in  the  Medical  Reserve 
Corps  of  the  L'nited  States  Army. 

Smallpox  in  Guatemala. — It  is  reported  that  a  serious 
outbreak  of  smallpox  has  occurred  in  Guatemala.  In  Gua- 
temala Cit}'  alone  it  is  said  that  more  than  a  thousand  cases 
have  been  reported.  Port  Barrios  is  also  affected,  though 
to  a  lesser  extent.  A  strict  quarantine  against  Guatemala 
has  been  established  by  the  ports  of  Spanish  Honduras. 

Epidemic  of  Measles  in  Washington,  D.  C. — There  is 
at  present  an  epidemic  of  measles  in  Washington  and  the 
surrounding  country.  During  the  week  ending  January  9th 
there  were  457  cases  under  treatment,  an  increase  of  260 
".ases  over  the  previous  week.  The  disease  is  of  a  mild 
t3pe,  however,  and  it  is  expected  that  it  will  soon  be  under 
control. 

Suicides  in  New  York. — According  to  the  report  of 
the  coroners  of  New  York  County,  issued  on  January  15th, 
there  were  542  suicides  in  New  York  County  during  the 
year  1908.  Of  these  174  were  by  shooting,  160  by  gas  as- 
phyxiation, 63  by  poison,  54  by  hanging.  35  by  leaping  from 
the  roof,  etc.,  23  hy  cutting,  22  by  drowning,  and  11  by 
jumping  in  front  of  trains. 

The  New  Superintendent  of  Bellevue. — Dr.  Winford 
Henry  Smith,  superintendent  of  the  Hartford  Hospital, 
Hartford,  Conn.,  has  been  appointed  general  medical  super- 
intendent of  Bellevue  and  Allied  Hospitals.  Dr.  Smith  is 
thirty-three  years  of  age,  and  is  a  native  of  Maine.  He 
was  graduated  from  Bowdoin  College  in  1899,  and  received 
the  degree  of  Doctor  of  Medicine  from  the  Johns  Hopkins 
Medical  School,  Baltimore,  in  1903.  Dr.  Smith  will  be  the 
fourth  superintendent  Bellevue  has  had  in  seven  years. 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


The  Cholera  Situation  in  St.  Petersburg  does  not  im- 
prove. New  cases  are  being  reported  in  large  numbers 
everj'  day,  and  the  deaths  increase  in  number.  The  author- 
ities are  taking  steps  to  provide  the  people  with  boiled 
drinking  water,  and  they  hope  to  be  able  to  check  the  spread 
of  the  disease  before  long.  Three  cases  of  cholera  have 
been  discovered  at  Helsingfors,  Finland. 

The  Health  of  Pittsburgh. — During  the  week  ending 
January  2,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
13  cases,  o  deaths ;  typhoid  fever,  13  cases,  i  death ;  scarlet 
fever,  31  cases,  i  death;  diphtheria,  20  cases,  i  death; 
measle,s,  23  cases,  i  death ;  whooping  cough,  16  cases,  2 
deaths;  pulmonary  tuberculosis,  49  cases,  9  deaths. 

Naval  and  Military  Surgeons  May  Practice  in  the 
District  of  Columbia. — A  bill  has  been  introduced  into 
Congress  providing  that  surgeons  of  the  Army,  the  Navy, 
or  the  Public  Health  and  Marine  Hospital  Service,  either 
active  or  retired,  shall,  upon  application  to  the  Board  of 
Medical  Supervrsors  of  the  District  of  Columbia,  be  licensed 
to  practise  medicine  in  the  District  without  examination. 

The  Alumni  Association  of  the  Lying-in  Hospital  of 
the  City  of  New  York  was  organized  on  January  12, 
1909,  with  the  following  officers:  President,  Dr.  Asa  Barnes 
Davis;  vice-president,  Dr.  William  Preston  Macleod ;  sec- 
retary. Dr.  Joseph  Edward  Lumbard ;  treasurer,  Dr.  John 
Hamilton  Telfair ;  editor.  Dr.  C.  Frederick  Jellinghaus. 
The  secretary's  address  is  1925  Seventh  Avenue,  New  York. 

The  .ffisculapian  Club  of  Boston,  an  organization 
whose  membership  consists  of  graduates  of  the  Harvard 
Medical  School,  will  entertain  Dr.  Charles  W.  Eliot,  presi- 
dent of  Harvard  University,  at  a  dinner  to  be  held  on  the 
evenmg  of  January  28th.  Besides  the  guest  of  honor,  the 
speakers  will  be  Dr.  Sim.on  Fle.xner,  of  New  York,  and  Dr. 
Henry  A.  Christian,  dean  of  the  faculty  of  the  medical 
school. 

Federation  of  Jewish  Charities  in  New  York. — There 
i^  considerable  opposition  to  the  plan  outlined  in  the  will 
of  Mr.  Louis  A.  Heinsheimer,  who  left  $1,000,000  for  the 
consolidation  of  Jewish  benevolent  institutions  in  New 
York,  which  would  merge  the  institutions  into  one  corpora- 
tion under  the  control  of  a  board  of  trustees  and  under  the 
direction  of  one  head.  It  is  said  that  the  plan  for  federa- 
tion will  probably  be  adopted  instead. 

Duty  Free  Medical  Supplies  for  Hospitals. — The  lead- 
ing hospitals  of  New  York  have  joined  forces  to  oppose  the 
duty  on  all  medical  and  surgical  supplies  imported  into  this 
country  for  hospital  use.  A  movement  to  place  all  such 
supplies  on  the  free  list  has  been  started  in  this  city,  and  a 
petition  embodying  the  demands  of  the  hospital  authorities 
will  be  presented  to  the  House  Committee  on  Ways  and 
Means,  at  Washington,  D.  C. 

The  Tri-County  Medical  Society  of  South  Jersey  will 
meet  at  Paul's  Hotel,  Woodbury,  N.  J.,  on  Tuesday,  Jan- 
uary 26th,  at  1.30  p.  m.  Dr.  Edward  A.  Spitzka,  professor 
of  anatomy  at  the  Jefferson  Medical  College,  Philadelphia, 
will  read  a  paper  entitled  The  Resuscitation  of  Persons 
Shocked  by  Electricity.  Dr.  George  B.  Wood,  of  Philadel- 
phia, will  read  a  paper  entitled  Personal  Experiences  in  the 
Treatment  of  Laryngeal  Tuberculosis. 

Doctors  Need  Not  Tell  Ingredients  of  Medicines  Pre- 
scribed.— The  right  of  a  physician  to  withhold  from  the 
public  the  ingredients  of  medicines  prescribed  for  patients  has 
been  upheld  by  Justice  Lemuel  W.  Royse,  of  Warsaw,  Ind. 
In  a  damage  suit  which  he  heard  recently  one  of  the  witnesses 
was  Dr.  Anna  Grover  Kaufman,  of  Goshen,  who  in  her 
testimony,  refused  to  state  what  medicines  she  gave  the 
complainant,  who  was  her  patient,  and  the  judge  justified 
her  in  her  refusal. 

The  New  Surgeon  General. — Colonel  George  H.  Tor- 
ney  became  surgeon  general  of  the  United  States  Army  on 
January  14th,  General  O'Reilly  retiring  on  that  date,  on  ac- 
count of  age.  Colonel  Torney  is  a  native  of  Baltimore  and 
has  a  most  creditable  career.  He  has  been  in  the  service 
since  June  26,  1875.  .^t  that  time  he  was  appointed  a  first 
lieutenant  and  assistant  surgeon  ;  was  promoted  to  the  rank 
of  caotain  on  June  26,  t88o.  and  to  the  rank  of  major  on 
June  6,  1894;  was  made  a  lieutenant  colonel  and  deputy 
surgeon  general  on  August  6,  1903,  and  a  colonel  on  April 
23.  1908.  He  was  in  command  of  the  .Xrmy  General  Hospital 
af  -San  Francisco  at  the  time  of  the  earthquake,  and  won 
great  praise  for  the  way  in  which  he  conducted  lK)th  the 
medic-"!  relief  work  and  the  work  of  sanitation  after  the 
caiamitv. 


An  Endowment  Fund  for  the  Lincoln  Hospital,  New 
York. — An  effort  will  be  made  to  raise  $500,000  to  en- 
dow Lincoln  Hospital,  Southern  Boulevard  and  One  Hun- 
dred and  Forty-first  Street,  New  York,  as  a  permanent  me- 
morial to  Abraham  Lincoln.  Seventy-five  thousand  dollars 
has  already  been  donated  to  start  the  fund. 

Vital  Statistics  of  New  York  State. — During  the 
month  of  November,  1908,  there  were  10,306  deaths  re- 
corded, in  an  estimated  population  of  8,546,356,  correspond- 
ing to  an  annual  death  rate  of  14.5  in  a  thousand  population. 
For  the  corresponding  month  of  1907  the  death  rate  was 
15.6,  and  the  average  for  the  past  five  years  has  been  15.7.  The 
total  number  of  births  reported  was  16,075,  making  an  an- 
nual birth  rate  of  22.6.  Of  the  deaths  1,631  were  of  chil- 
dren under  one  year  of  age,  695  of  children  between  one 
and  five  years  of  age,  and  3,233  were  of  persons  sixty  years 
of  age  and  over;  5,568  were  males  and  4.738  were  females. 

Suspension  from  Promotion  for  Majors  Who  Fail  in 
Examinations. — A  bill  has  been  introduced  into  Congress 
providing  that  where  a  major  in  the  Medical  Corps  of  the 
U.  S.  Army  fails  in  his  first  examination  for  promotion  to 
the  rank  of  lieutenant  colonel,  he  shall  be  suspended  from 
promotion,  pending  a  reexamination,  which  shall  take  place 
after  one  year.  If  on  reexamination  the  officer  fails,  he 
shall  be  retired,  with  promotion,  if  his  failure  is  due  to 
physical  disability ;  otherwise,  without  promotion. 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  January,  30,  1909: 

Monday,  January  s^th. — Mineralogical  and  Geological  Sec- 
tion, Academy  of  Natural  Sciences. 

TuEsn.AY,  January  26th. — Medico-Legal  Society. 

Wednesd.w,  January  syth. — Philadelphia  County  Medical 
Society. 

Thuksd.w,  January  28th. — Pathological  Society;  American 
Entomological  Society  and  the  Entomological  Society 
of  the  Academy  of  Natural  Sciences  ;  Section  Meeting, 
Franklin  Institute;  Philadelphia  Botanical  Club. 
Friday,  January  2Qth.—So\M\\  Branch,  Philadelphia  County 
Medical  Society. 
The  Indiana  State  Board  of  Medical  Registration  met 
in  Indianapolis  on  January  12th.    Some  slight  changes  in 
the  requirements  necessary  for  entrance  to  medical  colleges 
were  made  and  the  dates  for  holding  examinations  for 
licensing  physicians  were  changed  from  the  last  Tuesday 
in  May  and  October  to  the  first  Tuesday  in  January  and 
July,  to  become  effective  in  July,  1909.    Dr.  W.  A.  Spur- 
geon,  of  Muncie,  was  elected  president  of_  the  board,  to- 
succeed  Dr.  J.  E.  P.  Holland,  of  Bloomington ;  Dr.  J.  C. 
Webster,  of  Lafaj-ette,  was  elected  vice-president,  succeed- 
ing Dr.  Spurgeon  ;  Dr.  W.  T.  Gott,  of  Crawfordsville,  was 
reelected  secretary,  and  Dr.  M.  S.  Canfield,  of  Frankfort,, 
w  as  reelected  treasurer. 

Infectious  Disease  in  New  York: 

We  arc  indebted  to  tlie  Bureau  of  Records  of  the  Dc- 
l^artmcnt  of  Health  for  the  folloiving  statistics  of  ncTV 
cases  and  deaths  reported  for  the  tzco  n'cehs  ending  Janu- 
ary 18,  igog: 

,  Jan.  II  .   Jan.  18  , 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  imlmonalis    507  162         484  166 

Diphtheria    394  42         394  47 

Measles    538  12         462  16 

Scarlet  fever    305  i  337  18 

Smallpox  

Varicella    206  ..  163 

Typhoid  fever    46  6  39  9' 

Whooping  cough    30  5  39  3 

Cerebrospinal  meningitis    8  8  3  2 

Totals  2,034         250       1.921  261 

Bellevue  Robberies. — A  number  of  robberies  have  oc- 
curred in  Bellevue  during  the  past  three  or  four  months. 
Dr.  Joseph  Bissell,  a  surgeon  to  the  hospital,  was  perform- 
ing an  operation  in  the  Crane  room  at  the  hospital,  one  day 
last  week,  when  $20  was  taken  from  his  clothes,  which  were 
locked  in  a  locker  in  the  surgical  division  next  to  the  op- 
crating  room.  Dr.  Bissell's  assistant.  Dr.  Harold  Garrigan, 
had  $25  taken  at  the  same  time.  Both  doctors  had  valu- 
able jewelry  in  their  clothes  at  the  time,  which  the  thief 
overlooked.  Dr.  Jolin  Douglas,  a  visiting  physician  to  the 
hospital,  had  $48  dollars  stolen  from  him  under  like  cir- 
cumstances on  December  T5th.  Most  of  the  robberies  be- 
fore that  time  were  of  overcoats,  jewelry,  and  money  be- 
longing to  the  internes. 


jEnuary  33,  1909.] 


NEWS  ITEMS. 


183 


Society  Meetings  for  the  Coming  Week: 

Tuesday.  January  26th. — New    York  Otological  Society; 
New  York  Medical  Union;  New  Y'ork  Dermatological 
Societv;  Metropolitan  :Medical  Society  of  New  Y'ork 
City;  'Buffalo  Academy  of  Medicine  (.Section  in  Ob- 
stetrics and  Gynsecologj- ) . 
Weuxesdav.  January  S/tli. — New  Y'ork  Academy  of  Medi- 
cine (Section  in  Laryngology  and  Rhinology)  ;  New 
York  Surgical  Society. 
Thl-rsday.  January  sSth.—'Sew  York  Academy  of  Medi- 
cine (Section  in  Obstetrics  and  Gynaecology)  ;  Brook- 
lyn Pathological   Society :   Hospital  Graduates'  Club, 
New  York  (annual);  New  Y'ork  Celtic  Medical  So- 
ciety ;  Brooklvn  Society  for  Neurology. 
New  Staff  for  the  Toledo,  Ohio,  Hospital.— Dr.  Byron 
\V.  Dawlev.  chief  of  staff  of  the  hospital,  has  announced 
his  appointments  for  1909,  w  hich  are  as  follows  :  Surgery 
(six  months"  service).  Ur.  J.  H.  McVay  and  Dr.  A.  T.  Bar- 
num;  junior  surgeons.  Dr.  Carl  \Vatson  and  Dr.  J.  C.  Price; 
e>e,  ear,  nose  and  throat  (four  months"  service),  Dr.  C.  H. 
Strong.  Dr.  N.  R.  Simmons.  Dr.  G.  A.  Denman.  Dr.  J.  H 
Harvey,  and  Dr.  H.  M.  Flower;  gyn^-ecology  and  obstetrics 
( three'  months"  service).  Dr.  M.  H.  Parmalee;  Dr.  L.  K. 
Maxwell,  Dr.  W.  A.  Humphrey,  and  Dr.  B.  W.  Dawley ; 
medical  (six  months"  service).  Dr.  J.  S.  Fisher  and  Dr. 
\V.  S.  Walker;  children  (six  months"  service),  Dr.  Emma 
Butnian  and   Dr.  Ola  Buckman ;  pathologist.  Dr.  L.  P. 
Gardiner;  Rontgenologist.  Dr.  H.  \V.  Dachtler. 

The  Illinois  State  Board  of  Health. — At  a  recent 
meeting  of  the  lioard  it  was  decided  to  recommend  an  ap- 
propriation for  the  erection  of  a  State  colony  for  epileptics, 
and  an  increase  in  the  appropriation  for  making  investiga- 
tions into  contagious  and  infectious  diseases,  and  for  the 
free  distribution  of  antitoxine.  It  was  also  decided  to 
recommend  the  erection  of  a  State  sanatorium  for  con- 
sumptives, provided  cities  and  villages  did  not  take  advan- 
tage of  the  power  conferred  upon  them  to  erect  municipal 
hospitals.  The  board  resolved  to  continue  its  crusade 
against  tuberculosis  and  to  make  a  thorough  investigation 
into  the  milk  supply  of  the  State.  Dr.  George  \V.  Webster, 
of  Chicago,  was  reelected  president  of  the  board,  and  Dr. 
J.  A.  Egan,  of  Springtield.  was  reelected  secretary. 

Medical  Inspectors  Wanted  in  the  Philippine  Service. 
— The  United  States  Civil  Service  Commission  announces 
an  e.Kamination  on  February  17th  and  i8th  to  secure  eligi- 
bles  from  whicli  to  make  certification  to  till  seven  vacancies 
in  the  position  of  medical  inspector  in  the  Philippine  Ser- 
vice, at  a  salary  of  $2,000  a  year  each,  and  vacancies  re- 
quiring similar  qualifications  as  they  may  occur  in  that  ser- 
vice, at  salaries  ranging  from  $i.JOO  to  $1,800  a  year.  .Ap- 
plicants must  be  graduates  of  reputable  medical  colleges, 
must  have  had  the  training  and  experience  that  would  en- 
able them  to  take  charge  of  quarantine  work,  and  must 
have  a  knowledge  of  the  Spanish  language.  The  age  limit 
is  eighteen  to  forty  years  on  the  date  of  the  examination. 
Applicants  should  apply  at  once  to  the  United  States  Civil 
Service  Commission.  Washington.  D.  C,  for  application 
Forms  2  and  375. 

Personal. — Dr.  Edward  C.  Hill,  of  Denver,  has  been 
appointed  chemist  in  charge  of  tlie  State  station  of  the 
United  States  Department  of  .Agriculture  recently  opened 
in  Denver. 

Dr.  J.  J.  Kinyoun  has  been  appointed  pathologist  to  the 
Tuberculosis  Hospital.  Washington,  D.  C,  and  Dr.  Truman 
.Abbe,  radiologost  to  this  institution. 

Dr.  Charles  H.  Judd,  professor  of  psychology-  at  Y'ale 
University,  has  been  elected  president  of  the  American 
Psychological  .Association. 

Dr.  David  Starr  Jordan,  president  of  the  Leland  Stan- 
ford University.  California,  was  elected  president  of  the 
.American  Association  for  the  Advancement  of  Science,  at 
the  recent  meeting  of  the  association. 

King  Edward  has  appointed  Dr.  Harold  Spitta.  of  the  St. 
George  Hospital  Medical  School,  bacteriologist  to  his 
household. 

Dr.  J.  M.  Mathews,  of  Louisville,  president  of  the  Ken- 
tucky Slate  Board  of  Health,  has  gone  to  Southern  Cali- 
fornia to  spend  the  winter.  He  was  accompanied  by  Mrs. 
Mafhews. 

Dr.  J.  Clyde  Butler,  of  Mountain  City.  Tenn.,  has  been 
appointed  chief  surgeon  of  the  National  Soldiers'  Home  at 
Johnson  City. 

Dr.  J.  F.  Edwards,  superintendent  of  the  Bureau  of 
Health  of  Pittsburgh.  Pa.,  has  been  appointd  a  member  of 
the  Medical  Reserve  Corps  of  the  United  States  Army. 


University  News. — Berlin:  Dr.  Fliigge.  of  Breslau, 
has  been  appointed  director  of  the  Institute  of  Hygiene; 
Dr.  Ma.x  Rubner,  professor  of  hygiene,  has  been  appointed 
professor  of  physiology,  to  succeed  Professor  W.  Engel- 
man. — Jena:  Professor  Platte,  of  Berlin,  has  been  appointed 
professor  of  zoology,  to  succeed  Dr.  Ernst  Haeckel,  who 
will  retire  from  active  service  at  the  close  of  the  present 
semester. — I^eeds:  Dr.  F.  W.  Eurich  has  been  appointed 
professor  of  forensic  medicine  in  the  university. — Halle: 
Dr.  E.  Hoffmann,  of  Berlin,  has  been  appointed  extraor- 
dinary professor  of  dermatology. — X antes:  Dr.  G.  Bureau 
has  been  appointed  professor  of  therapeutics  in  succession 
to  Dr.  Maurice  Bureau. — Rostock:  An  Institute  of  Public 
Health  is  being  established  with  departments  for  (i)  the 
investigation  of  infectious  diseases,  (2)  animal  hygiene, 
and  (3)  examination  of  foodstuffs. 

The  Mortality  of  San  Francisco. — During  the  month 
of  November,  1908,  there  were  reported  to  the  Health  De- 
partment of  the  City  and  County  of  San  Francisco  519 
deaths  from  all  causes,  corresponding  to  an  annual  death 
rate  of  12.81  in  a  thousand  population.  The  annual  birth 
rate  in  a  thousand  population  was  18.36.  The  causes  of 
death,  according  to  the  international  classification,  were : 
General  diseases,  153  deaths ;  diseases  of  the  nervous  sys- 
tem. 31  deaths;  diseases  of  the  circulatory  system,  84 
deaths ;  diseases  of  the  respiratory  system,  70  deaths ;  dis- 
eases of  the  digestive  system.  45  deaths ;  diseases  of  the 
genitourinary  system,  48  deaths;  childbirth,  4  deaths;  dis- 
eases of  the  skin,  2  deaths ;  diseases  of  the  locomotor  sys- 
tem, I  death ;  malformations.  3  deaths ;  early  infancy.  19 
deaths;  old  age,  15  deaths;  violence,  41  deaths;  ill  defined 
diseases,  3  deaths.  Of  the  41  deaths  by  violence,  17  were 
due  to  suicide. 

The  Medical  Society  of  the  County  of  New  York, 
N.  Y. — .A  stated  meeting  of  the  society  was  held  on 
Monday  evening,  January  i8th.  The  nrogramme  consisted 
of  the  address  of  the  retiring  president.  Dr.  J.  Riddle 
Goffe ;  the  inaugural  address  of  the  president  elect,  Dr.  H. 
Seymour  Houghton ;  the  report  of  the  committee  on  Oph- 
thalmia Neonatorum,  by  Dr.  J.  Van  Doren  Y'oung;  and  a 
paper  by  Dr.  Joseph  E.  Winters  entitled  Correlation  of 
Physiology  and  Infant  Feeding ;  Indispensability  of  Breast 
IMilk ;  .Ability  to  Nurse ;  .Artificial  Feeding.  Dr.  Barton 
Cook  Hirst,  of  Philadelphia,  opened  the  discussion,  and 
among  those  who  participated  in  it  were  Dr.  William  M. 
Polk.  Dr.  Otto  G.  Ramsay,  of  New  Haven,  Dr.  Edwin  R. 
Cragin.  Dr.  Henry  M.  Painter,  Dr.  Asa  Barnes  Davis,  Dr. 
George  Livingston  Brodhead,  and  Dr.  James  D.  Voorhees. 
The  next  meeting  of  the  society  will  be  held  on  Friday, 
Feh'-".irv  ?6th. 

Medical  Society  of  the  Missouri  Valley. — Prepara- 
tions are  well  under  way  for  the  meeting  of  this  society, 
which  is  to  be  held  in  St.  Joseph,  Mo.,  on  March  i8th  and 
19th,  under  the  presidency  of  Dr.  C.  B.  Hardin,  of  Kansas 
City.  Invitations  have  been  sent  to  a  number  of  men  of 
national  reputation,  as  well  as  to  the  presidents  of  all  the 
State  associations  in  the  province  of  the  society,  and  al- 
ready many  applications  have  been  received  for  places  on 
the  programme.  Dr.  N.  S.  Davis,  of  Chicago,  will  deliver 
the  address  in  medicine,  and  Dr.  H.  J.  Boldt.  of  New  York, 
the  address  in  surgery-.  Elaborate  plans  for  the  entertain- 
ment of  the  visiting  members  and  their  friends  are  being 
made  by  the  committee  on  arrangements,  of  which  Dr. 
Jacob  Geiger  is  chairman,  and  a  good  time  is  expected. 
Those  desiring  to  present  papers  must  inform  the  secretary, 
Dr.  Charles  Wood  Fassett.  of  St.  Joseph.  Mo.,  prior  to  Feb- 
ruary i^t.  of  their  wishes  in  the  matter. 

Section  Meetings  of  the  New  York  Acadmy  of  Medi- 
cine.—  The  Section  in  Obstetrics  and  Gyncecology  will 
meet  on  Thursday  evening.  January  28th,  at  8 :30  o"clock. 
A  portable  electric  light  equipment  for  operating  in  private 
will  be  demonstrated.  Dr.  Henry  Dawson  Furniss  will 
read  a  paper  describing  a  simple  method  of  more  easily  de- 
tecting injuries  of  the  ureter  during  operation.  Dr.  John 
Van  Doren  Y'oung  w  ill  read  a  paper  entitled  .A  New-  Opera- 
tion for  the  Correction  of  Retrodeviations  of  the  Uterus. 
There  will  be  a  general  discussion. 

The  Section  in  Laryngology  and  Rhinology  will  meet  on 
Wednesday  evening.  January  27th.  at  8:15  o"clock.  Dr.  J. 
W.  Gleitsman  will  present  a  patient  on  whom  laryngectomy 
had  been  performed  for  carcinoma,  and  w-ill  demonstrate  a 
method  of  artificial  voice  production.  Dr.  T.  B.  Berens 
will  show  a  specimen  of  angeioma  of  the  tonsil  and  Dr.  E. 
W.  Scripture  will  exhibit  a  new-  laryngostroboscope  for  ob- 
serving the  separate  vibrations  of  the  vocal  cords. 


184 


PITH  OF  CURRENT  LITERATURE. 


[Xeu  York 
Medical  Journal. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

lanuary  14,  JQOQ. 

1.  Football   Injuries  of  the  Harvard  Squad   for  Three 

Years  under  the  Revised  Rules, 

By  Edward  H.  Nichols  and  Frank  L.  Richardson. 

2.  Typhoid  Fever  Carriers  Found  in  a  Series  of  Typhoid 

Fever  Patients  at  the  Time  of  Their  Discharge  from 
the  Boston  City  Hospital,    By  W.  T.  Graham,  C.  L. 

OVERLANDER,  JOHN  E.  OVERLANDER,  and  M.  A.  DaILEY. 

3.  Reminiscences  of  America,  By  Max  Boehm. 

4.  An  Epidemic  of  Dengue  in  the  Philippine  Islands, 

By  Harold  W.  Jones. 

5.  How  May  the  Medical  and  Scientific  Spirit  Be  Best 

Promoted  in  Our  Institutions  ? 

By  Charles  A.  Drew. 

1.  Football  Injuries. — Nichols  and  Richardson 
present  the  statistics  of  football  injuries  received  by 
members  of  the  Harvard  Varsity  squad  during  the 
season  of  1906,  1907,  and  1908.  All  of  the  games 
were  played  under  the  revised  rules,  which  very 
much  lessen  the  old  fashioned  "mass  plays"  and 
make  open  plays  much  more  profitable.  For  com- 
parison's sake  they  also  review  shortly  the  injuries 
received  in  1905.  We  thus  find  that  during  1905, 
1906.  1907,  and  1908,  out  of  a  total  number  of  men 
in  the  squad  of  70,  64,  98,  and  75,  there  were  145, 
34,  45,  and  34  injuries,  while  the  number  of  days 
tor  men  out  of  play  were  1,057,  445-  4^0,  and  312, 
and  out  of  college  12S,  73,  153,  and  60.  Further- 
more, instead  of  leaving  it  to  the  option  of  the 
players,  in  1908  all  men  were  absolutely  compelled 
to  wear  proper  protection,  which  included  head- 
gears, pads  for  the  collar  bone  and  shoulders,  pads 
over  the  anterior  superior  spines  for  all  "backs," 
thigh  guards,  pads  for  the  knees,  and  braced  shoes. 

2.  Typhoid  Carriers  in  Typhoid  Fever  Pa- 
tients at  Discharge  from  Hospital. — Graham,  C. 
L.  and  John  E.  Overlander,  and  Dailey  examined 
the  stools  and  urines  of  sixty-five  patients  within 
ten  days  of  their  discharge  from  the  hospital.  Of 
this  number  thirty-three  were  males  and  thirty-two 
were  females.  The  average  length  of  time  each 
patient  was  in  the  hospital  was  forty-one  days,  and 
the  average  number  of  days  intervening  between 
the  first  normal  temperature  and  the  time  of  dis- 
charge of  the  patient  was  nineteen  days.  Approxi- 
mately the  same  duration  of  hospital  convalescence 
held  good  for  the  cases  shown  to  be  carriers  of 
typhoid.  Thus  patients  discharged  with  positive 
stools  remained  in  the  hospital  for  twenty-three  days 
with  a  normal  temperature,  and  patients  with  posi- 
tive urines  for  nineteen  days.  Eleven,  or  16.9  per 
cent,  of  the  patients  examined  had  typhoid  or  para- 
typhoid bacilli  in  their  stools  and  seven,  or  10.8 
per  cent,  had  typhoid  or  paratyphoid  bacilli  in  their 
urines.  Three  had  bacilli  in  both  stools  and'urines. 
There  were,  therefore,  fifteen  typhoid  carriers 
among  the  sixty-five  patients  discharged ;  in  other 
words,  twenty-three  per  cent,  of  the  cases  in  this 
series  were  a  menace  to  the  community  at  the  time 
they  left  the  hospital.  The  authors  came  to  the 
conclusion  that  the  stools  and  urines  of  all  typhoid 
fever  patients  should  be  examined  for  typhoid  bacilli 
during  the  last  ten  days  preceding  their  discharge 
from  medical  care.  Typhoid  patients  with  positive 
stools  or  urines  should  he  dctnined  in  the  hospital. 


If  at  the  end  of  ten  weeks  they  still  show  typhoid 
bacilli,  they  should  be  allowed  to  leave  the  hospital, 
but  should  remain  under  the  supervision  of  the 
Board  of  Health  until  they  cease  to  be  carriers. 
Until  that  is  the  case  such  typhoid  distributers 
should  have  their  occupations  restricted  ;  they  should 
not  be  allowed  to  follow  those  pursuits  which  would 
endanger  others.  These  regulations  are  essentially 
those  which  have  been  in  force  in  Germany  for 
some  years. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 
January  16,  1909. 

1.  Bilibid  Prison  Sanitation,        By  Edwin  C.  Shattuck. 

2.  A  Case  of  Acute  Human  Glanders, 

By  F.  Robert  Zeit. 

3.  Prevention  of  Cancer  Cell  Implantation.    A  Prelimi- 

nary Report,  By  Edmund  A.  Babler. 

4.  Principles  of  Cerebral  Surgery,    By  Harvey  Gushing. 

5.  Decapsulation  of  the  Kidneys   for  Chronic  Bright's 

Disease.    With  a  Report  of  the  Results, 

By  George  M.  Edebohls. 

6.  The  Suture  :  Its  Place  in  Surgery, 

By  Henry  O.  Marcy. 

2.  Acute  Human  Glanders. — Zeit  remarks  that 
the  small  number  of  cases  reported  in  the  literature 
of  acute  glanders  in  man  has  given  rise  to  the  opin- 
ion that  the  disease  is  rare  and  human  stisceptibilitv 
to  infection  small ;  but  it  is  quite  probable  that  fatal 
cases  of  glanders  are  reported  under  other  causes  of 
death,  notably  smallpox.  Among  laboratory  work- 
ers numerous  deaths  from  infection  by  the  Bacillus 
mallei  have  been  reported  because  the  nature  of  the 
infection  was  properly  determined.  It  is  to  be  pre- 
sumed that  the  infectious  material,  fresh  from  the 
nose  or  farcy  bud  of  a  horse,  is  no  less  virulent  than 
the  various  subcultures  and  strains  used  in  the  lab- 
orator}''  experiments.  He  describes  a  case  of  acute 
human  glanders,  which  began  with  a  thin  watery 
discharge  from  the  nose,  pains  in  the  left  shoulder, 
and  a  severe  chill  of  one  half  hour's  duration,  fol- 
lowed by  extreme  weakness  in  the  lower  extremities. 
The  patient  remained  at  home  during  the  following 
week,  complaining  of  sharp  shooting  pains  in  his 
left  shoulder,  increasing  weakness  and  dull  headache 
with  a  slightly  blood  tinged  purulent  nasal  dis- 
charge. He  had  some  fever  at  night  and  always  felt 
better  in  the  morning.  Typhoid  symptoms  devel- 
oped during  the  next  week.  He  became  delirious  at 
night,  had  high  fever,  much  headache,  diarrhoea, 
and  pain  in  the  left  shoulder.  He  had  some  swelling 
and  pain  in  left  leg,  some  rigidity  of  the  muscles  of 
the  neck,  increased  excitability  of  the  reflexes,  and 
normal  morning  temperatures.  A  few  vesicles,  con- 
taining clear  serum,  appeared  on  his  left  shoulder. 
His  physician  was  called  to  see  the  patient  on  the 
twenty-sixth  day  after  his  initial  chill  and  found  him 
lying  in  bed,  with  his  head  slightly  draw-n  back,  the 
eyes  staring  at  the  ceiling,  the  mouth  open,  the  limbs 
moving  in  a  muttering  delirium,  tongue  dry  and  red 
at  the  tip  and  heavily  coated  at  the  base,  the  nose 
obstructed.  The  left  shoulder  was  covered  by  a 
large  number  of  pustules,  and  there  were  a  few  pus- 
tules on  the  scalp  and  right  wrist  of  the  patient  at 
that  time.  The  heart  was  ♦luttering,  markedly  in- 
termittent, missing  as  many  as  ten  beats  at  times. 
There  were  no  murnnirs.  The  examination  of  the 
lungs  and  spleen  were  negative ;  the  abdomen  tym- 
panitic.  There  was  a  very  painful,  small,  hard,  and 


T.inuary  23.  1009.] 


PITH  OF  CURRENT  LITERATURE. 


185 


uneven  nodule,  about  the  size  oi  a  50  cent  piece, 
over  the  fibia,  just  below  the  left  knee.  The  pus- 
tulous eruption  soon  extended  over  the  left  side  of 
the  chest  to  the  umbilicus  and  upward  onto  the  face 
and  into  the  hair  and  froir,  the  right  wrist  upward 
to  the  elbow.  The  urine  contained  some  albumin, 
and  gave  no  D'Azo  reaction  ;  a  Widal  test  proved 
negative.  The  bacilli  were  Gram  negative.  Char- 
acteristic cultures  were  obtained  on  the  different  cul- 
ture media.  Potato  cultures,  direct  from  the  pus- 
tules, showed  rich,  glossy,  elevated  yellowish  and 
semitransparent  colonies  with  sharp  borders  on  the 
second  day,  which  became  like  amber  or  honey  on 
the  third  and  fourth  days  and  opaque  and  reddish 
on  the  seventh  and  eighth  days.  Subcutaneous  and 
intraperitoneal  inoculation  proved  fatal  to  guinea 
pigs. 

3.  Prevention  of  Cancer  Cell  Implantation. — 

Babler  has  used  lately  Harrington's  solution — alco- 
hol, bichloride,  hydrochloric  acid — in  cancer  opera- 
tions, applying  it  to  the  diseased  tissues  during  re- 
moval, and  directly  to  the  operative  wound  after  the 
diseased  tissues  had  been  excised.  The  results  have 
been  all  that  could  be  desired.  He  states  that  the 
solution  undoubtedly  destroys  the  superficial  parts 
of  the  operative  field,  closes  the  cut  ends  of  the  cap- 
illaries and  lymphatic  channels,  and  apparently  elim- 
inates the  danger  of  cancer  cell  implantation.  He 
applies  Harrington's  solution  to  every  part  of  the 
cut  surface  of  the  carcinomatous  mass  that  is  being 
removed ;  the  growth  is  excised  as  rapidly  and  as 
carefully  as  possible,  after  the  infected  lymphatics 
and  their  periglandular  tissue  have  been  excised. 
After  stoppage  of  haemorrhage  in  the  wound  the 
solution  is  applied  to  the  entire  field  for  one  half  to 
one  minute,  depending  on  the  character  of  the  sur- 
face. In  delicate  flap  operations  the  solution  is  very 
carefully  applied.  It  is  essential  that  all  parts  of  the 
wound  be  touched  with  the  solution.  Where  ex- 
tensive dissections  have  been  it  is  advisable  to  use  a 
rubber  tissue  drain.  In  intraabdominal  carcinoma 
the  solution  is  applied  to  the  abdominal  wound  after 
closure  of  the  peritonaeum.  When  the  extraabdom- 
inal  tumor  is  ulcerated  Harrington's  solution  is  ap- 
plied for  two  minutes  to  the  ulcerated  portion. 

4.  Principles  of  Cerebral  Surgery. — Gushing 
emphasizes  the  following  technical  points  in  cere- 
bral surgery:  i.  The  continuous  auscultation  of  the 
heart  beat  and  respiration  during  anaesthesia.  2. 
The  subtemporal  decompressive  operation  as  an 
early  measure  and  a  step  preliminary  to  a  possible 
subsequent  tumor  extirpation.  3.  The  dangers  of 
lumbar  puncture  in  the  presence  of  a  degree  of  sub- 
tentoria!  pressure  sufficient  to  produce  a  cerebello- 
medullary  foraminal  hernia.  4.  The  value  of  a 
continuous  lumbar  drain  during  the  course  of  ex- 
plorations for  lesions  of  the  hemispheres.  5.  The 
principle  of  outward  dislocation  of  normal  tissue  to 
avoid  the  risks  of  compression  or  mutilation  during 
deep  explorations.  6.  The  satisfaction  of  such  in- 
tracranial procedures  as  the  ganglion  operation  for 
trigeminal  neuralgia  when  once  they  are  put  on  a 
basis  of  comparative  safety. 

5.  Renal  Decapsulation. — The  late  Dr.  Ede- 
bohls  reported  his  results  in  102  decapsulations  of 
the  kidneys  for  chronic  Bright's  disease,  fifty  patients 
being inales,  fifty-two  females.   The  youngest  patient 


was  four  and  one  half  years,  the  oldest  sixty-seven 
years  of  age,  the  average  age  being  thirty-nine  years 
and  eight  months.  The  majority  of  the  patients  at 
and  before  the  time  of  operation  presented  either  all 
or  the  most  serious  of  the  well  known  clinical  fea- 
tures of  the  disease.  Some  suffered  in  one  way  or 
another  without  having  such  a  pointed  history  as 
unmistakably  to  indicate  chronic  Bright's  disease. 
A  few  were  absolutely  unaware  of  any  serious  im- 
pairment of  health  until  the  occurrence  of  paralysis, 
of  retinitis  albuminurica,  of  uraemic  convulsions,  or 
the  discovery  of  albumin  and  casts  in  the  urine  on 
application  for  life  insurance  brought  them  suddenly 
face  to  face  with  the  fact  that  they  v/ere  affected 
with  a  fatal  malady.  Of  the  102  patients  ten  died 
within  two  weeks  following  operation,  thirty-nine 
died  at  periods  of  time  more  or  less  remote  from 
operation,  three  disappeared  from  observation  after 
leaving  the  ho.spital.  and  lift}  are  known  to  be  liv- 
ing. Thus  the  operative  mortality  may  be  stated  as 
9.S  per  cent.  In  reality,  however,  as  seven  patients 
Vv^ere  operated  upon  twice,  109  operations  were  per- 
formed on  one  or  both  kidneys.  One  of  these  pa- 
tients died  after  a  second  decapsulation.  Figured 
in  this  way,  there  were  eleven  deaths  in  109  renal 
decapsulations  for  chronic  Bright's  disease,  an  oper- 
ative mortality  of  10.  i  per  cent.  In  round  numbers, 
therefore,  his  operative  mortality  was  10  per  cent. 
Edebohls  advised  renal  decapsulation  for  every  suf- 
ferer for  chronic  Bright's  disease,  and  who  had  a 
reasonable  expectation  of  not  less  than  a  month  of 
life  without  operation.  The  three  conditions  which 
lead  him  to  advise  renal  decapsulation  are:  First, 
the  clear  and  imequivocal  establishment  of  the  diag- 
nosis of  chronic  Bright's  disease ;  second,  the  ab- 
sence in  a  given  case  of  absolute  contraindications 
to  any  operation ;  third,  the  possibility  of  securing 
the  services  of  a  surgeon  practically  familiar  with 
the  surgery  of  the  kidney.  As  soon  as  a  nephritis 
has  become  chronic  it  is  an  absolute  indication  for 
decapsulation.  The  earlier  in  the  course  of  chronic 
nephritis  an  operation  is  performed  the  better  w^ill 
be  the  patient's  chances  of  a  perfect  cure.  Renal 
decapsulation  is  indicated  in  all  varieties  of  chronic 
nephritis. 

MEDICAL  RECORD. 

January  16,  igog. 

1.  Darwinism  and  Malaria,  By  R.  G.  Eccles. 

2.  The  Vaccine  Treatment  of  Typhoid  Fever, 

By  W.  H.  Watters  and  C.  A.  Eaton. 

3.  The  Practical  Value  of  Tincture  of  Iodine  and  Iodine 

Catgut  in  Major  Surgerj% 

By  Walter  T.  Dannreuther. 

4.  The  Immediate  versus  the  Deferred  Operation  for  Ex- 

trauterine Pregnancy,  By  Arnold  Sturmdorf. 

5.  A  Cyst  of  the  Prostatic  Vesicle,  By  N.  A.  Mikhailoff. 

6.  The  Early  Recognition  of  CEsophageal  Stricture.  A 

New  Sign  of  Increased  Mediastinal  Pressure, 

By  Sidney  Lange. 

2.    The  Vaccine  Treatment  of  Typhoid  Fever. 

— Watters  and  Eaton  report  thirty  cases  of  typhoid 
fever,  the  patients  receiving  vaccine  treatment.  It 
is  of  interest  to  note,  however,  how  similar  are  a 
number  of  these  cases.  In  not  a  few  instances  a 
period  of  aggravation,  the  "negative"  phase  first  ap- 
pears, followed  shortly  by  the  period  of  ameliora- 
tion, the  "positive"  phase.  Occasionally  the  authors 
noticed  a  first  slight  amelioration,  a  short  aggrava- 
tion, and  finally  a  longer  amelioration,  this  also  oc- 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medual  Jiivrn\l. 


curring  in  some  opsonic  determination  as  reported 
by  various  writers.  It  has  seemed  to  the  writers 
that  the  best  results  have  been  obtained  in  those 
cases  in  which  a  brief  "negative"  phase  first  oc- 
curred. In  the  thirty-cases  here  reported  two  deaths 
are  recorded.  As  one  was  a  patient  practical!}'  be- 
yond help  when  treatment  was  begun,  after  the  dis- 
ease had  been  in  progress  a  month,  it  might  seem 
fair  to  eliminate  it  from  the  reckoning.  This  leaves 
one  fatality  in  a  patient  where  treatment  was  begun 
at  the  end  of  the  second  week.  It  is  probable  that 
here,  as  with  so  many  other  infectious  diseases,  the 
earlier  proper  treatment  is  begun  the  better  will  be 
the  prognosis.  If  any  modification  of  method  would 
be  advisable  in  a  second  series  of  cases  it  would 
probably  lie  in  the  direction  of  using  larger  doses. 

3.  Iodine  and  Iodine  Catgut  in  Major  Surgery. 
— Dannreuther  describes  his  method  of  preparation  : 
The  raw  strands  of  catgut  of  appropriate  sizes  are 
immersed  in  a  watery  solution  of  i  per  cent,  iodine 
and  I  per  cent,  potassium  iodide  crystals,  allowed  to 
remain  for  eight  days,  and  then  transferred  to  a  dry 
sterile  jar  covered  with  gauze.  The  result  is  that 
this  catgut  is  antiseptic  as  well  as  aseptic  (proved  by 
bacteriological  experiments),  it  absolutely  caimot  be 
infected,  its  tensile  strength  and  pliability  are  in- 
creased, and  it  is  exceedingly  cheap.  The  cost  of 
raw  catgut  strands  amounts  to  very  little,  anyone 
can  prepare  them  with  the  iodine  solution,  and  have 
a  suture  that  can  be  thoroughly  relied  upon.  The 
solution  used  for  irrigating  the  wound  is  rather 
strong:  a  drachm  of  the  tincture  to  a  pint  of  water. 
It  is  poured  directly  from  a  pitcher  into  the  wound. 
This  promotes  union  of  the  incision,  and  is  the  very 
best  method  of  procuring  sterilization  of  the  abdo- 
minal wound.  The  subcuticular  suture  of  iodine 
catgut  is  introduced  in  much  the  same  way  as  one 
of  any  other  material.  But  the  upper  end  is  tied,  the 
skin  pushed  up  on  the  suture,  and  the  lower  end 
tied,  thus  converting  a  five  or  six  inch  incision  into 
a  one  or  two  inch  scar.  The  author  has  also  used 
this  suture  in  numerous  minor  surgical  operations, 
and  has  found  it  equally  as  satisfactory.  The  gut- 
tapercha drain  is  inserted  only  in  very  fat  abdominal 
walls,  and  simply  for  the  purpose  of  draining  the 
excessive  amount  of  serum  usually  extruded  in  such 
instances.  As  a  rule,  it  is  removed  about  the  second 
day.  The  strip  of  rubber  tissue  over  the  wound  pre- 
vents the  serous  exudate  from  causing  the  gauze 
dressing  to  adhere  to  the  abdominal  wall. 

6.  Early  Recognition  of  CEsophageal  Stricture. 
— Lange  says  that  stricture  of  the  cesophagus  as  a 
result  of  increased  mediastinal  pressure  is  not  an 
uncommon  occurrence  and  is  rightfully  looked  upon 
as  an  imi)ortant  sign  of  mediastinal  disease.  Such 
a  pressure  upon  the  (esophagus  may  l)e  exerted  by 
enlarged  mediastinal  glands,  malignant  disease  of 
the  mediastinum,  aortic  aneurysm,  mediastinal  or 
spinal  abscess,  pericardial  effusion,  chronic  adhesive 
mediastinitis,  etc.  Clinically  such  pressure  is  rec- 
ognized in  two  ways,  the  patient  complains  of 
dysphagia  and  the  stomach  tube  or  (esophageal 
bougie  meets  with  resistance  at  the  site  of  com- 
pression. l')y  the  introduction  of  the  bismuth  x  ray 
method  in  the  examinati(-n  of  the  oesophagus  it  has 
been  shown  that  the  stomach  tube  or  bougie  will  not 
register  the  very  earliest  encroachment  upon  the 


lumen  of  the  cesophagus.  but  will  show  only  those 
constrictions  that  are  of  considerable  degree.  The 
oesophagus  is  elastic  and  will  stretch  to  compensate 
for  any  slight  narrowing  of  its  lumen,  and  will  allow 
the  stomach  tube  or  bougie  to  pass.  It  is  only  by 
the  use  of  a  very  large  bougie  (and  these  large  in- 
struments are  distinctly  dangerous)  that  a  slight 
(xsophageal  obstruction  can  be  detected.  And  this 
same  inaccuracy  attaches  to  the  subjective  sign  of 
dysphagia.  The  patient  will  complain  of  difficulty 
in  swallowing  ordinary  food  onlv  after  the  lumen 
is  considerably  narrowed.  But  he  advises  to  give 
bismuth  mush  to  represent  the  small  bolus  of  soft 
food,  while  the  rice  powder  capsules  about  the  size 
of  a  Cjuarter  are  given  to  represent  the  larger  and 
more  solid  bolus.  In  many  patients  with  slightly 
dilated  and  arteriosclerotic  aortae  and  with  small 
aneurysms,  it  was  found  that  while  the  bismuth 
mush  would  traverse  the  oesophagus  rapidly  and 
normally,  the  large  capsules  would  pause  at  the 
point  where  the  aorta  crosses  the  oesophagus.  In 
some  cases  a  swallow  of  water  would  serve  to  carry 
the  bolus  past  the  apparent  obstruction ;  in  other 
cases  the  capsule  would  pass  onlv  after  it  had  be- 
come partially  dissolved.  In  a  majority  of  these 
cases  the  patients  were  unconscious  of  this  slight 
pressure  upon  the  cesophagus,  not  complaining"  of 
dysphagia,  although  after  having  their  attention  di- 
rected to  it,  some  patients  would  state  to  experience 
a  "sticking"'  of  a  large  bolus  of  food,  such  as  a  par- 
tially masticated  piece  of  meat  or  a  bit  of  dry  bread. 
It  would  thus  seem  to  follow  that,  by  the  use  of 
the  X  ray  and  a  large  bismuth  capsule,  which  would 
maintain  its  shape  and  size  more  or  less  through- 
out its  passage  through  the  (^esophagus,  thus  testing 
the  capacity  of  the  entire  tube  and  not  conforming 
to  any  narrow  places  as  does  the  soft  mush  bolus, 
a  constriction  in  the  (^esophagus  can  be  recognized 
before  the  dysphagia  and  resistance  to  the  stomach 
tube  are  present.  This  bismuth  method  is  of  espe- 
cial value  in  the  early  recognition  of  true  (esopha- 
geal strictures,  viz..  those  in  which  the  cause  is  lo- 
cated in  the  a-sophageal  wall.  The  large  bismuth 
capsule  will  register  not  only  mechanical  obstruc- 
tion, but  impaired  or  absent  peristalsis  as  well,  and. 
since  with  the  earliest  cancerous  infiltration  of  the 
oesophageal  wall  there  must  be  an  interference  with 
peristalsis,  the  value  of  this  method  is  at  once  evi- 
dent. 

BRITISH   MEDICAL  JOURNAL. 

December  26.  igoS. 

1,  The  Treatment  of  Fractures  of  the  Base  of  the  Skull, 

By  R.  Maclarex. 

2.  A  Lecture  on  .Asthma,  By  A.  G.  .A.uld. 
.3.  Pyrexia  chiring  tlie  Puerpcrinni.  By  L.  B.  Cave. 
4.  Three  Demonstrations  on  Malformations  of  the  Hind 

End  of  the  Body.  By  .\.  Kkith. 

I.  Fractures  of  the  Base  of  the  Skull. — Mac- 
laren  states  that  the  case  fatality  of  fractures  of  the 
base  of  the  skull  is  almost  three  times  that  of  the 
vault  alone.  This  is  due  to  several  causes.  The 
functions  of  the  basal  parts  of  the  brain  are  more 
important  and  more  necessary  to  life  than  tiio.se  of 
the  hemispheres.  Close  to  the  base  are  the  cardiac 
and  respiratory  centres.  Bloodvessels  pass  through 
many  foramina  in  the  base,  and  their  injury  may 
lead  to  fatal  h.emorrhage.     .Mmost  all  injuries  to 


January  23.  1909.] 


PITH  OF  CURREXT  LITERATURE. 


187 


the  base  of  the  skull  are  compound,  this  being  the 
main  cause  of  the  heavy  mortality.  A  basic  frac- 
ture may  involve  any  of  the  three  cups  on  which  the 
brain  rests,  but  the  middle  fossa  is  the  one  most 
commonly  implicated,  and  even  when  fractures 
originate  elsewhere  they  very  commonly  extend  so 
as  to  involve  it.  Injuries  which  open  the  subarach- 
noid space  into  the  nose  or  pharynx  involve  less 
danger  of  sepsis  than  those  which  communicate 
with  the  external  meatus.  The  external  openings 
of  the  nasal  cavities  and  of  the  mouth  are  a  long 
wav  from  the  site  of  any  fracture  of  the  base,  and 
the  channels  act  as  filters  for  the  air.  So  that,  un- 
less the  fracture  is  the  result  of  direct  violence, 
there  is  a  better  chance  of  internal  sepsis  being 
avoided  than  when  there  is  a  communication  be- 
tween an  unclean  ear  and  the  interior  of  the  skull. 
.\  very  usual  story  with  a  fracture  of  the  base  is 
immediate  insensibility  after  the  accident,  general- 
ly amounting  to  deep  coma.  After  a  time,  which 
varies  much,  this  gradually  passes  oft,  and  the  pa- 
tient seems  to  do  well  until  the  third,  fourth,  or 
fifth  day.  Then  he  complains  of  severe  headache, 
and  light  distresses  him.  He  is  seen  to  be  flushed 
and  restless ;  presently  he  vomits.  His  pulse  is 
either  abnormally  slow  or  unduly  fast.  Jactitations, 
delirium,  and  convulsions  follow,  and  then  as  a  last 
stage  paralysis  of  sphincters  and  advancing  gen- 
eral muscular  paralysis.  Profound  coma  ends  the 
scene.  The  original  lesion  was  not  a  necessarily 
fatal  one  by  direct  damage,  but  septic  meningitis 
has  occurred,  and  has  produced  the  symptoms  and 
the  fatal  result.  'If  basic  fractures  could  be  treated 
as  are  those  of  the  vault,  the  difference  in  mortal- 
ity should  not  be  great.  The  writer  reports  two 
cases  of  fracture  of  the  base  with  discharge  of 
fluid  from  the  ear.  In  both  the  ear  was  kept  as 
far  as  possible  aseptic  with  boric  acid,  and  both  pa- 
tients recovered.  Boric  acid  is  admirably  fitted  for 
keeping  the  external  ear  and  meatus  aseptic.  It 
is  used  dry,  but  is  readily  soluble,  \^'hen  in  contact 
with  a  fluid  discharge  it  first  becomes  converted 
into  a  paste,  and  then  undergoes  complete  solution. 
It  cannot  form  a  retaining  plug.  There  is  no 
means  of  making  an  effective  application  or  em- 
ploying any  useful  treatment  to  the  nasal  or  pharyn- 
geal cavities.  External  cleanliness  and  pure  air  can 
be  secured,  however :  decayed  teeth  should  be  re- 
moved and  the  mouth  kept  clean.  Trephining  may 
have  a  useful  place  in  the  treatment  of  fractures  of 
the  base :  the  continual  oozing  of  cerebrospinal 
fluid  is  a  most  important  factor  in  the  evolution  of 
septic  meningitis.  A  trephine  opening  and  drain- 
age of  the  subarachnoid  cavity  prevents  the  fluid 
from  being  under  tension  and  allows  it  to  escape 
by  a  safely  arranged  route.  Tension  is  equally  re- 
lieved by  a  spinal  as  well  as  a  cephalic  drain,  but 
trephining  allows  of  an  examination  of  the  skull 
and  brain  at  the  point  of  injury. 

2.  Asthma. — Auld  states  that  the  asthmatic 
paroxysm  from  start  to  finish — the  spasm  of  the 
bronchial  and  inspiratory  muscles,  the  inflation  of 
the  lungs,  the  carbonsemia,  the  leucocytosis,  the 
output  of  mucous  bodies,  spirals,  eosinophiles,  and 
the  rest — is  truly  and  strictlv  a  process  of  defense. 
The  disease,  therefore,  or  specific  source  of  irrita- 
tion, is  for  the  time  being  in  the  lungs  :  and,  what- 
ever its  nature,  it  seems  early  to  excite  contraction 


of  the  bronchial  muscles,  probably  much  in  the 
same  wav  as  impure  blood  is  believed  to  excite  con- 
traction of  the  arterioles.  In  the  absence  of  a  spe- 
cific organism,  it  is  the  secretion — the  expectora- 
tion— and  the  blood  changes,  on  which  we  are  to 
rely  in  the  diagnosis  of  asthma,  and  not  the  spasm. 
.After  cessation  of  the  spasm  the  disease  is  still 
there.  Reflex  bronchial  spasm  can  be  set  up  in 
many  other  ways,  and  especially  by  irritation  of  the 
nasal  mucosa.  The  causative  agent  of  asthma  is 
merelv  a  matter  of  speculation.  The  long  duration 
of  the  afl:'ection  is  not  necessarily  against  its  being 
microbial.  It  may,  however,  be  a  toxine  or  leuco- 
mania,  which  is  either  of  distinctly  pathological 
origin  or  else  a  product  of  normal  metabolism, 
which  gradually  accumulates  in  the  blood  by  reason- 
of  some  defect,  congenital  or  acquired,  in  the  e.x- 
cretorv  function  of  the  lungs.  There  is  little  doubt 
that  the  lungs  are  avenues  for  the  excretion  of  un- 
known poisons.  Asthma  commences  usually  about 
2  or  3  a.  m..  when  the  opsonin  or  preopsonin  con- 
tent of  the  blood  reaches  its  minimum :  there  is  per- 
haps a  parallel  instance  in  cramp,  which  is  supposed 
to  be  due  to  a  toxine  acting  on  the  muscles.  Dur- 
ing the  actual  attack  of  asthma  the  most  we  can  do 
is  to  relieve  the  dyspncea.  Any  attempt  to  check 
it  suddenly  bv  powerful  agents  is  not  good  practice. 
It  is  best  to  mitigate  the  spasm  by  agents  which, 
like  the  nitrites  and  potassium  iodide,  do  not  at 
the  same  time  imperil  the  natural  order  of  cure. 
[Morphine,  cocaine,  etc..  are  apt  to  suppress  the  se- 
cretion, and  act  prejudicially  by  diverting  the  dis- 
ease into  fresh  channels.  The  supposition  that 
asthma  is  an  incurable  disease  should  be  dismissed. 
Careful  search  should  first  be  made  for  any  irri- 
tative lesion  capable  of  exciting  bronchial  spasm. 
The  nose,  nasopharynx,  and  the  stomach  are  our 
chief  concern.  Xext  it  should  be  noted  that  asth- 
matics exhibit  idiosyncrasies  in  respect  to  environ- 
ment just  as  they  do  to  drugs.  Some  do  well  in 
cities,  others  in  the  open  countries.  The  lungs 
must  be  properly  ventilated,  and  regulated  hill 
climbing  is  an  excellent  form  of  pulmonary  exer- 
cise. Swimming  is  an  ideal  form  of  exercise  for 
asthmatics.  Asthmatics  do  not  bear  large  or  full 
meals,  nor  any  food  that  is  slow  and  difficult  of  so- 
lution in  the  stomach,  but  they  do  well  on  animal 
foods  of  the  lighter  kind  and  in  moderate  quantity. 
Few  asthmatics  can  tolerate  alcohol  in  any  form. 
A  peculiar  anjemia  often  characterizes  the  asth- 
matic diathesis,  and  for  this  iron,  with  or  without 
arsenic,  is  often  beneficial. 

LANCET 

December  26.  igo8. 

1.  -Arthritis  Deformans   ('Osteoarthritis:  Rheumatoid  Ar- 

thritis) :  with  a  Notice  of  its  Surgical  Treatment, 

By  A.  H.  TuBBV. 

2.  Clinical  and  Post  Mortem  Observations  on  the  Status 

Lymphaticus.  with  Deductions,  and  a  Plea  against 
the  ^laligning  of  Ethylchloride  as  a  General  Anses- 
thetic.  By  R.  E.  Humphry. 

3.  Compound    Comminuted   and   Depressed    Fracture  of 

Skull,  with  Laceration  of  Brain  and  Rupture  of  Mid- 
dle Meningeal  .\rter>-.  By  R.  Hill. 
4-  A  Case  of  Extrauterine  Gestation  :  Operation  during  the 
Sixth  Month  of  Pregnancy,          By  H.  J.  Patersox. 

I.  Arthritis  Deformans. — Tubby  classifies  the 
various  conditions   met  with   under   the   head  of 


i88 


riTH  Of  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


arthritis  deformans  as  follows:   i.  A  peculiar  joint 
afifection   of   infancy  and  childhood  called  Still's 
disease.    2.  A  hypertrophic  form  of  arthritis — that 
is,  hypertrophic  as  the  articular  ends  of  the  bones 
and  the  joint  structures  are  concerned,  and  usual- 
ly designated  osteoarthritis ;  it  is  seen  in  two  forms 
—  (a)  the  monarticular  form  of  old  age,  as  in  the 
osteoarthritic  hip  joint;  and  (b)  the  polyarticular 
type,  met  with  largely  in  women  past  middle  age, 
and  exemplified  by  Heberden's  nodosities.    3.  A 
third  or  atrophic  type,  atrophic  so  far  as  the  bone 
is  concerned,  but  accompanied  by  hypertrophy  of 
the  synovial  membrane  and  fringes,  and  seen  in  two 
forms — (a)  an  acute  polyarticular  variety,  affect- 
ing children  and  young  adults,  and  not  to  be  con- 
founded with  Still's  disease  ;  and  (b)  a  chronic  form, 
seen  m  middle  life.    In  the  hypertrophic  or  osteo- 
arthritic form  the  changes  commence  in  the  bone, 
and  destruction  of  it  is  combined  with  new  forma- 
tion and  overgrowth.    The  changes  in  the  soft  tis- 
sues are  secondary  to  the  bony  changes.     In  the 
atrophic  type  the  disease  is  primarily  m  the  soft  tis- 
sues.    The  synovial  membrane  and  its  fringes  are 
hypertrophied,  and  the  bone  is  secondarily  and  only 
superficially  involved,  and  ultimately  becomes  atro- 
phied. Still's  disease  is  probably  of  bacterial  origin, 
as  the  glands  and  spleen  are  enlarged.    There  is  no 
bony  irregularity  or  grating,  but  creaking  of  the 
tendons  in  their  sheaths  is  present.    The  affection 
is  polyarticular,  and  neighboring  lymphatic  glands 
become  enlarged  and  tender.    Sweating  is  profuse, 
and  there  is  intermittent  fever.    There  is  a  marked 
arrest  of  bodily  development.    Arsenic,  good  food, 
and  a  dry,  warm  climate  are  indicated.    This  form 
should  be  clearly  distinguished   from  rheumatoid 
arthritis  in  children.     In  the  hypertrophic  type  of 
arthritis  deformans,  or   osteoarthritis,  certain  fac- 
tors are  prominent.    The  most  marked  is  senility, 
and  the  disease  is  also  met  with  in  the  premature- 
ly old  with  arteriosclerosis  and  degeneration  of  the 
kidneys.     This  hypertrophic  form  may  supervene 
upon  the  atrophic   form  which  has  persisted  for 
many  years.     Its  pathology  may  be  briefly  sum- 
marized as  bone  destruction,  combined  with  bone 
formation,  resulting  in  an  irregularly  solid  enlarge- 
ment of  the  joint.     The  first  signs  of  the  disease 
are  found  in  the  articular  cartilage,  the  cells  of 
which  undergo  proliferation.     The  bone  becomes 
sclerotic,  and  osteophytes  develop  on  the  articular 
ends.     The  synovial  membrane  is  injected  and 
thickened  and  later  becomes  hypertrophied.  De- 
crease in  the  amount  of  synovial  fluid  is  the  rule, 
and   increase  the   exception.     Somewhat  similar 
changes  occur   in  ataxic  patients  (Charcot's  dis- 
ease), but  here  the  onset  is  sudden,  the  joint  be- 
comes disorganized  in  a  few  days,  and  fluid  is  al- 
most invariably  plentiful.    Osteophytes  are  usually 
absent.     The  disease  usually  begins  in  the  hip  or 
knee  or  one  of  the  larger  joints.    The  onset  is  in- 
sidious, and  the  pain  is  fairly  constant,  being  re- 
lieved at  first  by  movement,  but  the  joint  when  at 
rest  becomes  stiff.    The  joint  is  not  hot  nor  mark- 
edly tender  to  the  touch,  but  it  is  enlarged,  and 
grating  can  be  felt  and  creaking  heard.    The  mus- 
cles atrophy  and   contraction  with   ankylosis  fol- 
lows.    Heberden's  nodosities,  which  are  examples 


of  the  polyarticular  hypertrophic  form,  are  at  first 
confined  to  the  bases  of  the  terminal  phalanges  of 
the  fingers.    The  afifection  gradually  spreads  to  the 
proximal  phalanges  until  motion  is  lost  and  the  fin- 
gers become  crooked  and  distorted.     The  pain  is 
slight,  and  the  affection  is  slowly  progressive,  with 
implication  of  other  and  larger  joints.     It  is  fre- 
quently seen  in  women  in  late  life.  Atrophic 
arthritis  (rheumatoid   arthritis)  is   a   subacute  or 
chronic  specific  disease,  liable  to  exacerbations, 
with  definite  symptoms.     It  is   more  common  in 
women  than  in  men,  and  at  the  ages  of  fifteen  to 
thirty  years,  and  at  the  climacteric.    But  no  age  is 
exempt.    It  is  essentially  a  disease  of  debility  and 
follows   worry,  overwork,   loss   of   blood,  leucor- 
rhoea,  frequent  childbearing,  and  prolonged  lacta- 
tion. Chronic  indigestion  is  common.  Joints  which 
have  been  much  used  are  liable  to  degenerate,  but 
overexertion  is  not  a  necessary  antecedent  of  the 
disorder.    The  weight  of  evidence  is  in  favor  of  the 
disease  being  an  autotoxremia  due  to  chronic  exces- 
sive intestinal  putrefaction.     Anaemia  is  a  constant 
and  early  sign,,  but  does  not  go  on  to  chlorosis. 
There  is  general  weakness,  emaciation,  and  loss  of 
appetite.     Periodical  sweatings,  first  general  and 
then  local,  with  intermittent  fever,  occur.    The  af- 
fection is  primarily  one  of  the  fibrous  coverings 
and  membranes  of  the  joints.    Spindle  shaped  en- 
largements of  the  finger  joints  are  common.  At 
first  there  are   signs  of   inflammation ;   when  this 
subsides  a  coarse  crackling  can  be  felt  on  handling 
the  joint.     At  first  there  is  but  little  loss  of  flex- 
ibility, but  later  the  overgrown  villi  obstruct  move- 
ment, the  limitation,  being  aggravated  by  muscular 
spasm  and  contraction.     The  joints  are  finally  left 
distorted,  thickened,  and  more  or  less  useless.  The 
skin  is  glossy  and  pink,  and  the  subcutaneous  tis- 
sues undergo  nodular  thickening.     The  prognosis 
in  the  polyarticular  form  of  the  disease  in  young 
people  is  often  disastrous,  but  when  it  comes  on  in 
middle  life  it  is  often  of  an  intermittent  character. 
The  treatment  of  the  hypertrophic  or  osteoarthritic 
form  consists  of  maintaining  the  general  health  of 
the  patient.     He  should  live  on  a  dry  soil,  and 
should  use  the  joint  within  the  limits  of  fatigue. 
The  diet  should  be  plentiful,  but  sparing  in  nitro- 
genous extractives  and  carbohydrates.  In  the  atrophic 
form  (rheumatoid  arthritis)  the  treatment  should 
be  much  like  that  of  a  case  of  early  pulmonary  tu- 
berculosis.    Tonics,  iron,  cod  liver  oil,  and  rest. 
But  the  dietary  is  the  important  thing;  it  should  be 
such  as  to  check  the  intestinal  putrefaction.  And 
for  this  purpose  fermented  milk  gives  by  far  the 
best   results.     It   can    be  prepared   according  to 
Metchnikofif,  or  with  lactic  acid  bacilli,  the  former 
being  more  efficacious.     Five  cases  treated  in  this 
way  are  cited,  with  excellent  results.     The  joint 
should  be  supported,  but  never  fixed.  Radiant 
heat,  vibration,  and  hot  air  baths  all  give  good  re- 
sults.    The  objects  of  surgical  measures  are:  i. 
To  rid  a  joint  of  the  products  of  inflammation, 
either  toxines  or  bacteria.    2.  To  remove  hypertro- 
phied villi  and  osteophytes.    3.  To  correct  deform- 
ity.   In  all  surgical  procedures  the  after  treatment 
is  as  important  as  the  operation  itself,  the  secret  of 
success  being  early  and  gentle  manipulations. 


January  -'3,  1909.1 


PJTH  OF  CURREXT  LITERATURE. 


LA  PRESSE  MEDICALE. 
December  5,  1908. 

Conference  on  Legal  Medicine  at  the  Palais  de  Justice, 

By  DuPRE. 

December  g,  igo8. 

1.  Adamantine    Epithelioma,    Its    Two  Anatomoclinicai 

Forms,  Deep  and  Superfiicial, 

By  L.  BoiDiN  and  Ch.  Delval. 

2.  Tetanus  of  Uterine  Origin, 

By  A.  Brault  and  G.  Farcy. 

3.  Isotonic  Collyria,  By  A.  Cantonnet. 

1.  Adamantine  Epithelioma. — Bcidin  and  Del- 
val assert  that  adamantine  epithelioma,  a  form  of 
epithelioma  found  about  the  jaws,  characterized  by 
the  presence  of  adamantine  epithelium,  is  not  a  sim- 
ple curiosity  of  pathological  histology,  but  a  condi- 
tion of  interest  to  the  clinician,  because  its  diagnosis 
permits  a  favorable  prognosis  and  forms  an  indi- 
cation for  as  conservative  a  surgical  intervention  as 
possible.  They  divide  this  form  of  epithelioma  into 
two  varieties,  one  deep  or  maxillary,  the  other  super- 
ficial or  gingival,  which  differ  both  clinically  and 
anatomically.  The  superficial  variety  is  much  the 
more  rare.  Two  cases  are  reported  in  detail  that 
portray  the  extremes  of  these  two  varieties.  The 
tumor  should  be  thoroughly  extirpated  with  the 
neighboring  glands  if  they  are  enlarged.  Simple 
curettage  is  insufficient.  The  clinical  and  anatom 
ical  diagnosis  is  considered  quite  extensively. 

2.  Tetanus  of  Uterine  Origin.  —  Brault  and 
Faroy  report  a  case  of  tetanus  following  absorption. 

LA  SEMAINE  MEDICALE. 
December  2,  ipo8. 
Phlegmonous  Gastritis,  By  L.  Cheinisse. 

Phlegmonous  Gastritis. — Cheinisse  furnishes  a 
rather  extensive  resume  of  the  literature  on  this 
subject. 

December  p,  ipo8. 
The  Placental  Theory  of  Puerperal  Eclampsia, 

By  Professor  R.  de  Bovis. 

Placental  Theory  of  Puerperal  Eclampsia. — Da 

Bovis  presents  the  arguments  for  and  against  the 
theory  of  the  placental  origin  of  puerperal  eclamp- 
sia. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 
November  23.  igo8. 

1.  The  Origin  of  the  Changes  in  the  Ureters  and  Kidneys 

in  Hypertrophy  of  the  Prostate, 

By  Julius  Taxdler  and  O.  Zuckerkandl. 

2.  Magnet  Operations,  By  J.  Hirschberg. 

3.  The  Ophthalmodiaphanoscope  and  Its  Use  in  the  Va- 

rious Branches  of  Medicine,        By  Carl  Hertzell. 

4.  Experimental  Influencing  of  Pregnancy, 

By  J.  HOFBAUER. 

5.  A  Case  of  So  Called  Acusticus  Tumor  at  the  Base  of 

the  Brain,  By  Rose. 

6.  Cholera  in  Odessa  in  September,  1908, 

By  N.  T.  Gamaleia. 
7-    A  Simple  Method  for  the  Serum  Diagnosis  of  Syphilis, 

By  Tschernogubow. 
8.    Modern  Surgery  in  Pulmonarv  Tuberculosis, 

By  J.  W.  Samson. 

I.  Changes  in  the  Ureters  and  Kidneys  in 
Prostatic  Hypertrophy.  —  Tandler  and  Zucker- 
kandl state  that  in  advanced  cases  particularly  of 
prostatic  hypertrophy  the  ureters  and  pelves  of  the 
kidney  are  dilated  and  yet  no  change  can  be  seen 
in  the  mouths  of  the  ureters  on  cystoscopic  exami- 
nation, and  they  have  sought  an  explanation  of  these 
paradoxical  facts.    They  find  that  in  prostatic  hy- 


pertrophy the  entire  bladder  is  displaced  upward, 
especially  when  the  median  lobe  is  hypertrophic,  and 
that  the  constriction  of  the  ureter  is  to  be  found 
regularly  at  the  place  where  it  crosses  the  vas  de- 
ferens. Hence  they  are  inclined  to  ascribe  the  con- 
striction of  the  ureter  to  the  bending  about  the  vas 
deferens  produced  by  the  displacement  of  the  blad- 
der. 

2.  Magnet  Operations.  —  Hirschberg  reports 
four  cases  of  removal  of  iron  or  steel  from  the  eye 
by  means  of  the  magnet  with  resultant  preservation 
of  more  or  less  good  vision. 

3.  The  Ophthalmodiaphanoscope. — Hertzell  in 
a  previous  number  described  the  ophthalmodia- 
phanoscope, which  practically  consists  of  a  strong 
electric  light  to  be  introduced  into  the  mouth,  over 
which  the  lips  are  to  be  closed,  and  a  mask  to  cover 
the  entire  face  except  the  eyes  so  that  the  observer 
looking  through  the  apertures  in  the  mask  can  see 
the  details  in  the  fundus  by  transillumination  with- 
out the  aid  of  an  opthalmoscope,  and  now  speaks  of 
the  uses  to  which  it  may  be  put  for  diagnostic  pur- 
poses. 

4.  Experim.ental  Influencing  of  Pregnancy. — 

Hofbauer  has  found  by  experiment  that  serious  de- 
generative changes  may  be  induced  in  the  placenta 
with  deleterious  consequences  to  the  foetus,  by  over- 
feeding with  cholesterin. 

5.  Acusticus  Tumor. — Rose  adds  one  more  to 
the  very  small  number  of  tumors  of  the  eighth 
nerve  that  have  been  reported  in  which  the  diagnosis 
was  made  during  life.  The  diagnosis  is  very  diffi- 
cult, for  the  tumors  long  remain  latent  and  only  in  a 
late  stage  produce  symptoms  that  induce  the  patient 
to  seek  a  physician.  Then  sometimes  one  symptom, 
sometimes  another  is  predominant.  The  results  of 
operation  are  very  unfavorable,  no  patient  operated 
upon  has  yet  survived. 

November  30,  igo8. 

1.  Treatment  of  an  Ulcer  of  the  Stomach  Perforating  into 

the  Pancreas,  By  R.  Klapp. 

2.  Treatment  of  Neuralgias  by  Means  of  Injections  of 

Alcohol.  By  W.  Alexander. 

3.  Bilateral  Crural  Paralysis  after  Gynaecological  Opera- 

tions, By  Kurt  Mendel  and  Bruno  Wolff. 

4.  Digestion  of  Living  Tissue,  By  Hans  Kathe. 

5.  The  Clinical  Picture  of  Achondroplasia  (chondrody- 

strophia)  m  Adults,  and  a  very  Similar,  hitherto 
Undescribed,  Form  of  Micromelic  Dwarf  Growth  in 
a  Woman,  Fifty-six  Years  Old,      By  P.  Schrumpf. 

6.  Aortic  Insufficiency  and  Syphilis,     By  Julius  Citron. 

7.  Radiotherapy,  By  Franz  Nagelschmidt. 

8.  Hessing's  Orthopaedic  Technique,        By  Max  Bohm. 

9.  Pathological  Anatomy  of  Appendicular  Inflammation, 

By  H.  Beitzke. 

1.  Treatment  of  an  Ulcer  of  the  Stomach  Per- 
forating into  the  Pancreas. — Klapp's  case  was  one 
of  ulcer  on  the  posterior  surface  of  the  stomach, 
two  fingers'  breadth  below  the  cardia,  at  a  point 
where  the  wall  of  the  stomach  had  become  adherent 
to  the  pancreas.  The  diagnosis  was  made  after 
laparotomy  for  a  supposed  tumor.  The  details  of 
the  operation  and  the  questions  of  technique  that 
assailed  the  operator  how  best  to  deal  with  the  un- 
expected conditions  he  had  met  with  are  given  quite 
succinctly.    The  patient  made  a  good  recovery. 

2.  Treatment  of  Neuralgias  by  Injections  of 
Alcohol. — Alexander  urges  that  injections  of  alco- 
hol should  be  tried  in  cases  of  severe  neuralgia  be- 
fore recourse  is  made  to  operative  intervention. 


igo  PITH  OF  CURRENT  LITERATURE. 


5.  Achondroplasia. — Schrunipf  reports  the  case 
of  a  woman,  fift\  -six  years  old.  who  was  normal  at 
birth  and  displayed  no  signs  of  developmental  dis- 
turbance, particularly  no  symptoms  of  micromelia, 
until  her  seventh  year.  After  that  age  her  extrem- 
ities failed  to  develop.  The  various  measurements 
of  the  patient  are  given  in  full.  The  question 
whether  this  is  a  case  of  achondroplasia  is  discussed, 
and  the  following  are  given  for  and  against  such  a 
diagnosis.  In  favor  of  this  disease  are  the  dwarf 
growth,  the  micromelia,  the  normal  intelligence,  the 
slight  absorption  of  the  root  of  the  nose,  the  accent- 
uation of  the  lumbar  lordosis,  the  marked  develop- 
ment of  the  soft  parts,  especially  of  fat,  the  narrow- 
ness of  the  pelvis,  and  the  absence  of  anomalies  of 
the  thyreoid.  Contraindicative  of  this  diagnosis  are 
the  fact  that  the  condition  was  not  congenital,  the 
great  length  of  the  arm  and  thigh  as  compared  with 
the  forearm  and  leg,  the  absence  of  the  character- 
istic changes  in  the  hands,  the  presence  of  agglu- 
tination of  the  epiphyses,  together  with  the  spongy 
nature  of  the  epiphyses  as  shown  by  the  x  ray  pic- 
tures, and  the  unequal  length  of  the  lower  extrem- 
ities. 

6.  Aortic  Insufficiency  and  Syphilis. — Citron 
states  that  syphilis  is  very  frequently  the  cause  of 
aortic  insufficiency. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT 
December  i,  1008. 

1.  The  Influence  Exerted  by  Trjptic  Ferment  Solutions 

upon  Local  Surgical  Tuberculosis,  and  the  Antifer- 
nient  Treatment  of  Purulent  Processes, 

By  JocHMANX  and  Batzner. 

2.  The  Practical  Importance  of  the  Serum  Diagnosis  in 

Syphilis.  By  Bering. 

,^.    Wassermann's  Reaction  on  the  Cadaver, 

By  Frankel  and  Much. 

4.  Physiology  and  Pathology  of  Gastric  Digestion, 

By  CoHNHEiM  and  Dreyfus. 

5.  The  Origin  and  Treatment  of  Intestinal  Hernia, 

By  Kocn. 

().    A  Case  of  Tetragenous  Sepsis  Ending  in  Recovery, 

By  ZlEGLER. 

7.  A  Case  of  Retroperitoneal  Ganglion  Neuroma, 

By  Oelsner. 

8.  A  Case  of  Friedreich's  Disease  with  Diabetes  Mellitus, 

By  Meltzer. 

9.  A  New  Suction  Speculum  for  the  Treatment  of  Inflam- 

mations of  the  Ute  rus  and  Its  .\nne.\a. 

By  Schindler. 

10.  Treatment  of  Seasickness  with  Bromural, 

By  Hoffmann. 

11.  Studies  Concerning  Smallpox,  By  Paschen. 

12.  Our  Official  Examination  of  Dead  Bodies  (Coroner's 

Inquests),  By  Kolb. 

1.3.  Surgery  of  the  Lungs  (Concluded) .         By  Friedrich. 

I.  Influence  Exerted  by  Tryptic  Ferment  So- 
lutions.—  Jochmann  deals  with  the  theoretical 
considerations,  I'.atzner  with  the  clinical  portion  of 
this  paper.  Tiic  latter  says  that  clinical  observations 
indicate  that  the  tryptic  ferment  is  in  position  to 
'■(■izc  upon  and  digest  tuberculous  tissue  which  has 
become  weakened  in  its  physical  and  chemical  prop- 
erties, while  healthy  tissue  protects  itself  through 
its  unvveakened  vital  power  against  the  action  of 
trypsin,  and  is  at  the  .same  time  stimulated  to 
strengthen  the  granulation  tissue  by  the  strong  irri- 
tation and  by  the  breaking  down  of  the  former  lesion 
with  local  hyper.-emia.  The  antifcrment  treatment 
may  he  used  in  divers  forms  of  suppuration,  such  as 


[New  York 
Mediv.:al  .1ourn.\l. 

simple  abscesses,  glandular  abscesses,  suppurative 
mastitis,  furuncles,  carbuncles,  whitlow,  plegmons, 
bone  abscesses,  purulent  fistulse  of  the  soft  parts, 
chronic  suppuration,  and  infected  wounds. 

2.  Practical  Importance  of  the  Serum  Diag- 
nosis in  Syphilis.- — llering  gives  a  great  impor- 
tance to  the  serum  diagnosis  of  syphilis,  as  without 
it  a  clinical  diagnosis  is  not  entirely  unobjectionable, 
and  states  that  it  is  also  of  importance  in  the  treat- 
ment of  the  disease,  at  least  it  has  thus  far  been 
ascertained  as  positive  that  a  negative  result  is  ob- 
tained much  more  frequently  in  well  treated  syphi- 
lis than  in  syphilis  less  well  treated. 

4.  Physiology  and  Pathology  of  Gastric  Di- 
gestion.— Cohnheim  and  Drey^fus  state  as  the 
most  important  result  of  their  studies  that  marked 
and  perfectly  typical  disturbances  of  the  secretion  of 
the  gastric  juice  and  of  the  motility  of  the  stomach 
may  be  called  forth  by  the  intestine.  Hence  in  all 
disttirbances  of  the  digestive  organs  the  stomach 
should  not  be  the  only  one  subjected  to  investiga- 
tion. Among  the  diseases  they  met  with  that  had 
been  diagnosticated  as  gastric  but  really  had  their 
lesions  elsewhere  than  in  the  stomach  were  chronic 
catarrh  of  the  stomach,  atonia  ventriculi,  and  ulctis 
ventriculi  without  haematemesis. 

6.  Tetragenous  Sepsis. — Ziegler  reports  the  case 
of  a  girl,  seventeen  years  old,  who  was  attacked 
several  days  after  recovery  from  an  attack  of 
amygdalitis  with  a  high  fever  very  suddenly  and 
without  warning.  On  the  fourth  day  of  the  fever 
the  blood  was  examined  and  found  to  contain  the 
Micrococcus  fcfragcnus.  The  characteristics  of  the 
fever  were  those  of  a  ptirely  septic  disease  without 
local  symptoms,  or  a  demonstrable  local  point  of 
outbreak.  It  could  neither  be  proved  nor  disproved 
that  the  cocci  entered  through  the  tonsillar  abscess. 
This  case  shows  that  the  tetragenus  may  excite  mild 
conditions  of  sepsis  which  go  on  to  complete  recov- 
ery after  brief  attacks  of  fever. 

8.  Friedreich's  Disease  with  Diabetes  Melli- 
tus.— Meltzer  describes  an  attack  of  diabetes  mel- 
litus which  he  observed  in  the  course  of  Friedreich's 
disease  in  a  man  twenty-eight  years  of  age.  This 
occurrence  he  considers  to  be  very  rare  after  a  study 
of  the  literature. 

13.  Surgery  of  the  Lungs. — Friedrich.  in  his 
very  long  paper,  deals  particularly  with  the  modern 
surgical  interventions  in  emphysema  and  tubercu- 
losis, and  speaks  strongly  in  favor  of  Freund's  ope- 
ration in  carefully  .selected  cases. 

AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 
January,  igoQ. 

1.  The  Clinical  Significance  of  Glycosuria  in  Pregnant 

Women.  By  J.  W.  Williams. 

2.  Medical   Gymnastics   in   Early   Myocardial  Incompe- 

tence without  Valvular  Disease, 

By  R.  FT.  BAnrocK. 

.3.    The  Value  of  the  Inunction  Method  of  .'\dministering 
Drugs  to  Children.  By  B.  K.  Rachfokd. 

4.  The  Treatment  of  Irreducible  Congenital  Luxations 

of  the  Hip  by  Operative  Means.        By  G.  C.  Davis. 

5.  The  P()stoi)erative  Treatment  of  Malignant  Disease, 

By  E.  G.  Williams. 

6.  The    Distinction    of   Common   Types   of  Protracted 

Fever,  By  D.  Bovaird.  Jr. 

7.  Certain  Complications  of  Pneumonia, 

By  M.  H.  FtrssELL. 

8.  Tnnucnzal  Meningitis,  By  B.  A.  Cohol. 

9.  Illuminating  Gas  Poisoning,  By  G.  I.  Jones. 


January  23,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


191 


10.  Circumscribed    Serous    Spinal    ]\Ieningilis.    A  Little 

Recognized  Condition  Amenable  to  Surgical  Treat- 
ment, By  W.  G.  Spillek. 

11.  Varix  of  a  Papilla  of  the  Kidney  a  Cause  of  Persist- 

ent Hematuria,  By  H.  Cabot. 

12.  Tlie  Problem  of  Immunity  in  Tuberculosis, 

By  E.  R.  B.\LD\\  iN. 

ij.    The  Cammidge  Reaction  in  Experimental  Pancreatitis, 
By  J.  Speese  and  E.  H.  Goodm.x.v. 
14.    Some  Observations  on  the  Surgery  of  the  Gallbladder 
and  Bile  Ducts,  By  W.  D.  H.\milton. 

1.  The  Clinical  Significance  of  Glycosuria  in 
Pregnant  Women. — \\  illiams  reaches  the  follow- 
ine;-  conckisions :  i.  A  positive  reaction  with  Fehl- 
ing-'s  sokition  during  pregnancy  is  ustially  due  to 
lactosuria,  or  to  transient,  alimentary,  or  recurrent 
glvcostiria.  2.  In  stich  cases  lactostiria  is  probably 
as,sociated  with  premature  activity  of  the  breasts.  3. 
If  glycosuria  in  such  cases  is  alimentary  it  may  be 
disregarded.  Otherwise  it  may  be  transient  or  re- 
current, or  may  indicate  true  diabetes.  4.  Glyco- 
suria late  in  pregnancy,  not  exceeding  two  per  cent., 
unaccompanied  by  symptoms  is  tisually  transient,  but 
may  persist  to  the  end  of  pregnancy.  It  is  usually 
of  slight  clinical  significance,  but  the  patient  should 
be  carefully  watched.  5.  If  mtich  sugar  is  observed, 
early  in  pregnancy,  it  may  be  impossible  to  make  a 
diagnosis  until  after  delivery.  The  condition  will 
then  disappear  in  glycosuria  cases,  but  persist  in  true 
diabetes.  6.  Pregnancy  may  occur  in  diabetic  wo- 
men, or  diabetes  may  become  manifest  during  preg- 
nancy. Either  complication  is  serious  :  some  patients 
will  survive,  others  will  die,  in  coma  or  collapse  at 
the  end  of  pregnaficy  or  during  or  after  labor.  7. 
If  the  quantity  of  sugar  is  large  and  cannot  be  con- 
trolled by  dietetic  and  medicinal  treatment,  indtiction 
of  abortion  or  premature  labor  will  be  indicated, 
even  though  serious  symptoms  may  be  absent. 

2.  Medical  Gymnastics  in  Early  Myocardial 
Incompetence  without  Valvular  Disease. — Bab- 
cock  refers  to  cases  found  especially  among  men 
who  have  led  very  active  lives,  have  taken  very  lit- 
tle exercise,  and  have  grown  very  stotit.  The  car- 
diovascular system  and  the  kidneys  in  such  men 
often  give  out  in  the  late  fifties  or  early  sixties.  The 
degenerative  process  begins  with  increased  blood 
pressure  in  the  intraabdominal  vessels  controlled  by 
the  splanchnic  nerves,  extends  to  the  entire  vascular 
system,  and  strain  on  the  myocardium  restilts.  The 
indication  is  to  lessen  the  peripheral  resistance  in 
the  sluggish  circulation  within  the  mesenteric  ves- 
sels. The  treatment  indicated  is  medical  gymnastics 
consisting  of  both  active  and  passive  movements, 
according  to  the  degree  of  myocardial  incompetence. 
One  essential  principle  tinderlies  all  such  exercise, 
namely,  that  the  patient  must  not  be  allowed  to  hold 
his  breath,  but  must  breathe  regularly  and  deeply  in 
rhythm  with  the  movements,  the  object  in  view  be- 
ing the  restoration  of  the  functional  integrity  of  the 
myocarditim.  The  atithor's  experience  warrants  him 
in  recommending  such  gymnastics,  believing  that 
they  would  delay,  if  not  prevent,  the  onset  of  car- 
diac inadequacy. 

3.  The  Value  of  the  Inunction  Method  of  Ad- 
ministering Drugs  to  Children. — Rachford  insists 
that  this  mode  of  treatment  is  more  efficacious  in 
children  than  in  adults  because  of  the  following  rea- 
sons: I.  In  infants  the  .surface  of  the  skin  in  pro- 
portion to  tlie  body  weight  is  four  times  greater 


than  in  adults,  the  increased  blood  and  lymph  area 
favoring  absorption  with  reappearance  in  the  urine, 
fsces,  bronchial  mucus,  etc.  2.  In  infants  the  vaso- 
motor mechanism  is  much  more  responsive  to  reflex 
stimuli  than  in  adults,  the  capillary  circulation  being 
made  much  more  active  by  the  application  of  heat 
and  friction.  3.  All  lymphatic  structures  in  the  child 
are  the  more  active  than  in  the  adult,  and  function- 
ally more  important,  ^ledicines  easily  pass  into  the 
lymphatic  circulation.  4.  Xtitritional  problems  in 
the  treatment  of  disease  in  children  are  relatively 
more  important,  hence  the  stomach  and  intestines 
should  be  reserved  for  food  if  possible.  5.  Diseases 
which  are  accessible  by  intmction  are  more  common 
and  more  severe  in  children  than  in  adults.  6.  Ex- 
periments prove  that  medicines  may  be  introduced 
into  the  circulating  media  of  the  body  more  readily 
in  infants  and  voung  children  than  in  adults. 

5.  The  Postoperative  Treatment  of  Malignant 
Disease. — \\  illiams  affirms  that  the  fundamental 
principles  upon  which  the  postoperative  treatment  of 
malignant  disease  with  the  x  ray  are  based  arc  ( i ) 
that  some  of  the  cells  of  the  malignant  growth  have 
been  left  in  the  tissues,  and  (2)  that  the  x  rays  have 
a  selective,  destructive  action  upon  such  malignant 
cells.  If  the  first  of  these  conditions  is  absent  the 
X  ray  treatment  would  not  be  indicated,  and  the 
treatment  would  be  useless  if  the  second  were  not 
well  founded.  Recurrence,  which  is  so  common 
after  operation  for  malignant  disease,  is  indisputable 
evidence  that  the  disease  was  not  eradicated.  On  the 
other  hand,  diminution  in  the  number  of  recurrences 
is  evidence  that  the  disease  is  more  thoroughly  re- 
moved than  was  once  the  custom.  The  author  thinks 
the  X  rays  will  destroy  the  cells  of  malignant  disease 
when  they  are  not  more  than  an  inch  below  the  sur- 
face, and  by  suitable  contintiance  of  the  treatment  he 
thinks  they  may  all  be  destroyed.  A  guarded  prog- 
nosis should  always  be  given,  however,  for  as  yet 
we  have  no  means  of  knowing  how  deeply  or  how 
widely  the  cells  may  have  penetrated.  The  treat- 
ment should  be  commenced  five  days  after  the  oper- 
ation, and  two  series  of  daily  exposures  with  an  in- 
terval of  two  between  them  will  usually  suffice.  Each 
series  should  have  at  least  five  exposures. 

6.  The  Distinction  of  Common  Types  of  Pro- 
tracted Fever. — Bovaird  stnnmarizes  his  paper  as 
follows:  I.  Malarial  fever  is  easily  recognized  by 
the  presence  of  the  characteristic  microorganisms  in 
the  blood  and  by  amenability  to  qtiinine.  (3ther  feb- 
rile conditions  are  not  malarial.  2.  Typhoid  can  also 
be  accurately  recognized  or  excluded  by  the  combi- 
nation of  clinical  and  laboratory  evidence.  3.  Tu- 
berculosis and  sepsis  of  certain  types  often  .show 
stich  similar  clinical  pictures  that  they  can  be  distin- 
guished only  by  the  outcome  of  the  case,  perhaps  by 
autopsy.  4.  Influenza  may  cause  protracted  fever, 
which  can  usually  be  recognized  from  the  condition 
under  which  it  occurs,  sudden  onset,  characteristic 
symptoms,  and  course.  5.  Sepsis  may  be  clearly  in- 
dicated by  high  leucocyte  count,  with  high  polynu- 
clear  percentage,  before  any  localization  of  the  pro- 
cess can  be  made.  6.  Blood  cultures  are  of  great 
value  in  distinguishing  fevers,  especially  in  typhoid 
fever,  and  in  such  conditions  as  malignant  endo- 
carditis. 7.  In  some  cases  of  protracted  fever  a 
satisfactory  classification  is  not  possible  with  exist- 
ing means  of  determination. 


192 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


EDINBURGH  MEDICAL  JOURNAL. 

January,  KjO'.j. 

1.  Our  Four  Forefathers  in  Midwifery, 

By  William  Stephenson. 

2.  A  Case  of  Congenital  Heart  Disease,  with  Extreme 

Secondary  Polycythoemia  and  Orthostatic  Albumi- 
nuria.; also  some  Remarks  on  Polycythaemia  in  Car- 
diac Cases,  By  F.  Parkes  Weber. 

3.  Sarcoma  of  Female  Mamma, 

By  Sir  George  Thomas  Beatson. 

4.  Some  Notes  on  Acute  Rheumatism  in  Childhood, 

By  Horace  Colman. 

I.  Our  Four  Forefathers  in  Midwifery. — Ste- 
phenson remarks  that  in  the  middle  of  the  eight- 
eenth century  the  science  and  art  of  midwifery 
emerged  from  the  murky  atmosphere  and  false 
imaginings  of  ignorance.  He  refers  to  Smellie, 
Hunter,  Denman,  and  Burns,  who  must  be  regarded 
as  strictly  the  four  forefathers  of  British  midwifery. 
Their  eminence  and  the  classical  character  of  their 
works  rest  on  the  true  scientific  and  practical  spirit 
that  pervades  their  writings,  on  the  soundness  of 
the  principles  they  inculcate,  and  on  an  absence  of 
the  false  reasoning,  the  timidity,  and  grandmotherly 
advice,  that  mar  the  writings  of  many  of  their  suc- 
cessors. The  first  three  names  are  familiar  and  well 
remembered ;  that  of  the  last,  Professor  John  Burns, 
of  Glasgow,  is  almost  forgotten.  And  yet  his  work 
on  The  Principles  of  Midimfery  went  through  seven 
editions,  and  will  be  found  stimulating  and  instruct- 
ing to  the  practitioner  even  of  to-day.  He  follows 
closely  the  teaching  of  Denman,  and  develops  the 
important  subject  of  fatigue  of  the  uterus  and  its 
management. 

3.  Sarcoma  of  Female  Mamma. — Sir  George 
Beatson  reports  sucli  a  case.  He  says  that  the 
prognosis  after  removal  of  a  mammary  sarcoma 
must  always  be  a  guarded  one,  although  statistics 
seem  to  give  more  favorable  results  in  excisions 
of  the  breast  for  sarcoma  than  for  carcinoma.  Thus, 
Horner's  figures  show  76.9  per  cent,  free  of  recur- 
rences after  two  years,  and  ultimately  61.5  per  cent, 
of  total  recoveries,  but  their  statistical  value  depends 
entirely  on  whether  or  not  the  cases  were  all  true 
sarcomatous  tumors.  The  spindlecelled  variety  of 
tumor  is  undoubtedly  the  least  malignant.  Proba- 
bly the  most  important  element  in  prognosis  is  the 
rate  at  which  the  tumor  has  grown  before  operation 
— the  more  rapid  that  has  been,  the  more  unfavor- 
able. In  fact,  clinical  experience  teaches  that  the 
malignancy  of  some  sarcomata  exceeds  that  of  the 
carcinomata,  and  that  early  invasion  of  the  axillary 
glands  is  an  unfavorable  feature.  Schmidt  holds 
that  these  growths  originate  from  the  endothelial 
cells  of  the  perivascular  spaces,  a  fact  which  sug- 
gested to  him  the  name  of  peritheliomata  or  en- 
dothelial sarcomata.  Others  have  preferred  to  call 
them  alveolar  sarcomata  or  angeiosarcomata,  but 
both  these  terms  fail  to  express  the  exact  nature  of 
the  structural  origin  of  the  tumors,  whereas  the  ex- 
pressions peritheliomata  and  endothelial  sarcomata 
do.  In  connection  with  this  matter  of  nomencla- 
ture, it  must  be  remembered  that  there  are  two 
distinct  views  as  to  the  origin  of  the  bloodvessels  in 
such  tumors.  Some  regard  them  as  furnished  by 
the  local  tissues  they  have  invaded  and  replaced. 
Others,  like  Creighton,  favor  the  opinion  that  the 
embryonic  connective  cells  themselves  originate  the 


bloodvessels  and  blood  corpuscles  as  a  pathological 
process,  just  as  they  are  known  to  do  in  foetal  life 
physiologically ;  is  that,  the  vessel  forming  func- 
tions of  the  connective  tissues  of  the  mesoblast  in 
embryonic  life  have  been  reawakened  after  their 
normal  period  of  activity  has  long  passed  away, 
with  the  result  that  there  has  been  developed  a  sar- 
comatous tumor  of  a  sanguineous  type.  As  to  which 
of  these  views  is  right  it  is  -not  easy  to  be  dog- 
matic, but  to  tumors  formed  according  to  this  latter 
theory  the  term  perithelioma  is  best  applied,  while 
the  expression  endothelial  sarcoma  is  more  appli- 
cable to  the  view  that  they  have  sprung  from  the 
endothelium  of  the  perivascular  spaces  of  the  pre- 
existing bloodvessels. 

 ^  

f  rotefbings  at  ^acittm. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  PENNSYL- 
VANIA. 

Annual.  Meeting,  held  in  Cambridge  Springs,  September 

14,  15,  16,  and  17,  1908. 
The  President,  Dr.  William  L.  Estes,  of  South  Bethle- 
hem,  in  the  Chair. 

The  President's  Address. — Dr.  Estes  empha- 
sized the  importance  of  thorough  organization  of 
the  profession,  mentioned  leading  factors  in  the  pre- 
vention of  this  movement,  and  suggested  corrective 
methods.  Hospital  abuse  and  contract  practice  were 
specifically  considered  as  tending  toward  the  disor- 
ganization of  the  profession.  The  necessity  for  and 
the  advantages  of  examination  before  a  common 
board  were  shown,  and  the  support  of  legal  practi- 
tioners of  the  State  toward  such  legislation  wa.<" 
urged  as  a  duty.  The  importance  of  animal  experi- 
mentation was  noted  and  every  effort  urged  to  pre- 
vent prohibitive  legislation.  The  necessity  for  the 
inauguration  of  methods  along  the  line  of  preventive 
medicine  in  regard  to  venereal  diseases,  and  espe- 
cially in  connection  with  gonorrhoea,  was  mentioned. 
In  order  to  meet  the  indications,  should  there  be 
such  calamitous  happenings  in  Pennsylvania  as  in 
San  Francisco,  the  advantages  of  the  organization 
of  a  Red  Cross  Society  were  emphasized.  The 
necessity  for  physicians'  continuing  their  study  after 
entering  practice  was  considered,  and  the  absolute 
need  of  some  sort  of  postgraduate  course  and  sys- 
tematic work,  especially  among  the  country  societies, 
was  urged. 

The  Oration  in  Hygiene.  The  Opportunities  of 
the  Medical  Profession  in  the  Far  East. — Dr. 

Thomas  Grier  Simonton,  of  Pittsburgh,  inter- 
preted the  word  hygiene  in  its  broadest  sense  to 
mean  good  for  the  health  of  the  whole  world,  and 
believed  that  the  taking  of  the  oath  of  Hippocrate."- 
carried  with  it  an  obligation  to  aid  in  the  relief  of 
suffering  humanity  wherever  located.  Proofs  of 
the  awakening  of  China  were  given  to  show  that 
the  medical  profession  must  keep  abreast  with  ad- 
vancement made  along  other  lines.  He  felt  that  the 
medical  profession  as  an  organized  whole  was  doing 
nothing  for  the  advancement  of  medicine  in  the  Far 
East,  and  cxprcs.sod  the  belief  that  State  societies, 


January  23,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


193 


universities,  and  medical  colleges  should  engage  in 
the  work.  The  University  of  Pennsylvania  had  al- 
ready started  such  a  movement  and  Harvard  was 
working  along  the  same  lines  in  India.  It  was  sug- 
gested that  the  Medical  Society  of  the  State  of 
Pennsylvania  might  be  instrumental  in  the  estab- 
lishment of  measures  for  the  relief  of  leprosy  in 
China  and  in  the  sending  out  of  young  scientific  men 
to  the  Far  East.  While  Philadelphia  and  Pittsburgh 
had  one  physician  for  every  350  and  650  persons, 
China  had  one  for  every  miUion  people.  Among 
medical  books  which  had  been  translated  into  Chi- 
nese were  mentioned  Gray's  Anatomy,  Norris  and 
Oliver  on  the  Eye,  and  Penrose's  Gynaecology. 

The  Oration  in  Otology.  —  Dr.  Fremont  W. 
Frankhauser,  of  Reading,  said  that  the  otologist 
had  become  more  of  a  surgeon,  and  that  when  otolo- 
gists became  sufficiently  brave  to  open,  under  aseptic 
conditions,  the  mastoid  cells,  the  lateral  sinus,  and 
the  internal  jugular  vein,  abscesses  of  the  brain 
would  be  unknow-n.  As  the  death  rate  of  appendi- 
citis had  been  lowered  by  earlier  recognition  of  the 
condition  and  operation,  so  in  mastoid  disease  the 
mortality  would  be  lowered  by  early  diagnosis  and 
the  establishment  of  drainage.  With  the  combined 
work  of  the  rhinologist  and  otologist  advancement 
would  be  along  the  line  of  prevention  rather  than 
that  of  cure.  No  field  in  medicine  ofifered  a  greater 
opportunity  than  the  preventive  treatment  of  ca- 
tarrhal deafness. 

The  Oration  in  Paediatrics. — Dr.  Theodore  J. 
Elterich,  of  Pittsburgh,  remarked  upon  the  pres- 
ent statistics  of  the  various  towns  and  cities  in  that 
they  showed  a  remarkable  decrease  in  infant  mor- 
tality. The  education  of  laymen  and  physicians 
rather  than  improved  methods  of  treatment  was  re- 
garded as  the  causative  factor.  It  was  noted  that  in 
almost  all  colleges  paediatrics  was  now  fully  recog- 
nized as  an  important  part  of  the  curriculum,  and 
the  subject  was  taught  by  competent  teachers.  The 
enlightenment  of  the  public  to  the  dangers  of  con- 
taminated milk  and  legislation  regarding  the  pro- 
duction and  sale  of  milk,  it  was  thought,  had  done 
more  to  decrease  infant  mortality  than  the  combina- 
tion of  all  modern  methods  of  treatment.  An  im- 
portant factor  also  was  the  tendency  among  mothers 
of  the  so  called  upper  classes  to  nurse  their  children. 
Full  credit,  however,  was  given  to  present  methods 
of  treatment,  and  nihilism  \vas  disclaimed. 

The  Oration  in  Obstetrics.  Some  Obstetrical 
"Kicks. — Dr.  Jefferson  H.  Wilson,  of  Beaver, 
gave  this  oration,  which  was  incidentally  a  plea  for 
the  higher  education,  a  step  in  the  direction  of 
which  was  the  One  Board  Bill,  w  hich  it  was  hoped 
would  result  in  the  abolition  of  the  incompetent 
medical  man  and  the  ignorant  midwife.  Primarily 
the  paper  was  a  plea  for  the  better  care  of  the  preg- 
nant women,  of  whom  there  should  be  a  close  super- 
vision and  frequent  inspection.  With  the  adoption 
of  the  proper  precautions  it  was  believed  that  the 
lying-in  chamber  would  be  robbed  of  many  of  its 
horrors,  that  there  would  be  a  less  number  of  crip- 
pled women  seeking  the  aid  of  the  surgeon,  and 
there  would  be  fewer  female  angels  and  infant  cher- 
ubs. The  need  of  thorough  teaching  upon  obstetrics 
in  medical  colleges  w^as  emphasized.    Protest  was 


made  against  the  abandonment  of  the  abdominal 
binder  and  the  misuse  of  the  vaginal  douche  before 
and  after  confinement.  The  too  frequent  use  of  the 
obstetrical  forceps  was  also  criticised  with  severity. 

The  Mental  Aspect  of  Neurasthenia. — Dr.  J.  E. 
McCuAiG,  of  Erie,  contended  that  in  primary  neu- 
rasthenia there  was  a  well  marked  mental  condition 
dif¥ering  from  other  mental  states  which  resembled 
it.  In  this  type  of  neurasthenia  it  was  shown  that 
the  mental  state  was  of  the  first  importance  and 
often  the  cause  of  the  disease.  A  correct  diagnosis 
was  of  the  utmost  importance,  and  it  could  be  made 
by  exclusion  and  facilitated  by  consideration  of  the 
mental  condition,  which  was  fundamentally  one  of 
fear.  This  fear  might  be  subconscious  and  varying 
in  degree.  The  desire  was  to  draw  from  some  ulte- 
rior source  the  strength  the  patient  felt  was  lacking 
in  himself.  He  must  be  taught  healthful  habits  of 
thought,  and  the  outcome  would  depend  upon  the  in- 
tellectual capacity  of  the  individual  and  his  ability 
to  control  his  mental  processes.  The  need  of  the 
neurasthenic  was  a  physical  morale.  He  must  be 
taught  to  depend  upon  his  own  resources.  This  at- 
tainment was  a  question  primarily  of  the  individual 
patient  and  the  individual  physician.  The  patient 
must  overcome  his  dependence  upon  drugs,  culti- 
vate a  healthful  mind,  which  would  result  in  a 
healthful  body,  and  realize  that  his  needed  strength 
and  courage  could  come  only  from  within. 

Dr.  E.  E.  AI.WER,  of  Pittsburgh,  emphasized  the 
value  of  the  personality  of  the  physician  in  the  treat- 
ment of  disease  and  the  need  of  taking  into  account 
the  personality  of  the  patient,  which  was  especially 
true  in  neurasthenia.  ,  He  agreed  with  Dr.  !McCuaig 
that  drugs  when  given  must  be  given  with  optimism 
as  a  part  of  what  might  be  called  psychic  treatment. 
He  referred  especially  to  the  attitude  taken  by  many 
of  the  advocates  of  the  so  called  religiomedical 
treatment  of  neurasthenia  and  other  neuroses,  that 
the  condition  was  merely  one  of  belief.  With  the 
failure  of  this  treatment  the  patients  were  hopeless 
and  helpless.  While  medicines  in  themselves  in  this 
class  of  cases  practically  did  no  good,  if  given  with 
the  reenforcement  of  the  physician's  personality  and 
his  knowledge  of  the  conditions,  good  would  result. 

Dr.  McCuAiG  said  that  his  idea  coincided  with 
that  expressed  by  Dr.  Mayer  that  in  the  use  of  sug- 
gestion in  this  class  of  cases  the  patient  was  merely 
being  supplied  with  a  pair  of  crutches  and  being  told 
that  he  was  well.  The  cure  of  neurasthenia,  how- 
ever, was  not  accomplished  by  supplying  a  prop.  In 
his  experience  the  prop  lost  its  power  and  the  patient 
was  w^orse  than  before. 

The  Need  of  Better  Provision  for  the  Treat- 
ment of  Mental  Disease  in  its  Early  Stage. — Dr. 
J.  jMontgomery  Mosher,  of  Albany,  N.  Y.,  read 
this  paper  by  invitation.  Reference  was  made  to  the 
opening  of  a  pavilion  at  the  Albany  Hospital  in  1902 
for  the  treatment  of  mental  diseases,  in  which  pa- 
tients might  be  admitted  with  the  same  freedom  as 
the  sick  and  injured.  It  was  recalled  that  the  first 
hospital  of  this  country,  the  Pennsylvania  Hospital, 
in  Philadelphia,  obtained  its  charter  mainly  upon 
representations  of  the  needs  of  persons  "distemper'd 
in  mind  and  depriv'd  of  their  rational  faculties." 
The  work  as  carried  on  in  the  pavilion  at  the  Hos- 


194 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


pital  was  fully  described.  From  igo2  to  igo8  there 
had  been  admitted  1,332  patients,  of  whom  765  had 
recovered  or  been  improved,  446  had  remained  sta- 
tionary, and  106  had  died.  The  author  concluded 
that:  I.  Many  cases  of  mental  diseases  presented 
symptoms  of  exhaustion  and  toxaemia,  which  placed 
them  in  the  class  of  acute  general  diseases,  and,  as 
they  were  as  amenable  to  treatment  as  these,  they 
should  be  dealt  with  accordingly.  2.  Many  cases  of 
acute  physical  disease  and  many  surgical  cases  were 
complicated  by  mental  symptoms,  the  cause  of  which 
might  not  be  clear.  3.  Incipient  and  doubtful  men- 
tal cases  had  a  legitimate  claim  for  treatment  upon 
the  general  hospital.  4.  Special  wards  were  needed 
in  general  hospitals  for  the  care  of  acute  mental 
cases,  whether  idiopathic  or  complicating  medical  or 
surgical  disease.  5.  These  wards  should  be  so  situ- 
ated and  so  constructed  that  the  mental  cases  should 
neither  be  disturbed  by  the  activities  of  the  general 
ward  nor  in  turn  prove  an  annoyance.  6.  The  value 
of  treatment  near  home,  and  of  the  presence  of 
friends  and  cooperation  of  friends  of  patients,  could 
not  be  overestimated.  7.  The  training  of  hospital  in- 
ternes and  nurses  and  familiarity  of  the  public  with 
mental  diseases  were  most  important  educating  in- 
fluences. 8.  General  hospitals  should  be  permitted 
and  encouraged  to  receive  mental  cases  until  the  lim- 
itations of  their  resources  or  the  probable  incurabil- 
ity of  the  patient  had  been  reasonably  established. 

Dr.  Morris  S.  (iuTii,  of  Warren,  agreed  with  Dr. 
INIosher  regarding  the  advantages  of  a  psychopathic 
ward,  but  thought  it  should  be  in  connection  with 
the  large  hospitals  for  the  insane.  One  reason  for 
this  was  the  matter  of  expense  ;  another  was  the  ad- 
vantage of  observation  b\'  physicians  who  had  stud- 
ied the  subject.  He  felt  that  such  cases  were  not  in- 
teresting to  the  general  practitioner,  and  that  suc- 
cessful treatment  of  them  was  bound  up  in  the  per- 
sonality of  the  physician.  He  believed  also  that  the 
stigma,  if  such  there  was,  would  attach  itself  to  a 
ward  of  this  kind  just  as  surely  as  to  an  entire  hos- 
pital. Far  better,  he  thought,  would  be  a  united 
effort  on  the  part  of  the  profession  in  removing  this 
unwarranted  prejudice  from  any  of  the  insane.  This 
would  be  the  most  effective  advance  in  bettering 
their  condition.  A  psychopathic  ward  accessible  to 
each  medical  college  and  a  comprehensive  course  in 
mental  diseases,  he  believed,  would  do  more  to  edu- 
cate the  physician  and  improve  the  early  care  and 
treatment  of  the  cases  under  consideration  than  any- 
thing else.  Personally,  he  found  that  as  i)ersons  be- 
came better  acquainted  with  the  insane  and  with 
large  hospitals  for  their  u.se  the  prejudice  vanished. 

I)r.  K.  E.  M.wilK,  of  Pittsburgh,  referred  to  cases 
illustrative  of  the  need  of  an  observation  or  phycho- 
pathic  ward  in  a  general  hospital.  He  thought  that 
New  York  had  better  methods  than  Pennsylvania  in 
the  custodial  care  and  treatment  of  the  insane,  and 
he  would  favor  the  establishment  of  a  board  such 
as  they  had  in  New  York  to  i)ass  upon  mental  cases 
rather  than  having  the  work  done  by  the  P.oard  of 
Charities,  as  now  obtained  in  Penn.sylvania. 

Dr.  JosKi'M  K.  Wii.wER,  of  Norristown,  favored 
the  establishment  of  psychopathic  wards  or  hospi- 
tals, l)ecause  the  general  public  would  more  readily 
permit  their  friends  to  enter  such  an  institutifin. 


and  because  mental  patients  thus  escaped  the  stigma 
attaching  to  their  commitment  to  insane  asylums.  A 
third  reason  was  that  there  were  avoided  the  annoy- 
ance and  excitement  attendant  upon  the  making  out 
of  commitment  papers.  Such  a  hospital  should  not 
be  placed  in  a  city  where  the  services  of  a  physician 
specially  trained  in  nervous  and  mental  diseases 
were  not  available. 

Dr.  Ei.LiOTT,  of  Pittsburgh,  favored  the  establish- 
ment of  a  psychopathic  ward,  not  only  for  the  ob- 
servation of  mental  patients  before  their  possible 
commitment  to  an  insane  asylum,  but  for  patients 
who  might  pass  into  a  state  of  mental  aberration  fol- 
lowing a  major  operation  or  other  condition. 

Dr.  Winters  D.  Ham.\ker  thought  the  general 
practitioner  should  be  ready  to  treat  many  of  these 
patients  successfully  in  their  homes.  This  was  often 
difficult,  but  could  sometimes  be  accomplished,  par- 
ticularly in  the  conditions  due  to  overwork,  great 
mental  strain,  the  intense  heat,  or  injury  to  the  brain 
by  a  blow.  In  such  cases  he  believed  the  trouble 
was  often  caused  by  a  vasomotor  disturbance.  He 
had  had  success  with  the  use  of  digitalin  in  large 
doses,  securing  the  constrictive  effect  of  the  drug 
upon  the  small  vessels  of  the  brain.  He  had  also 
used  ergot  with  great  benefit. 

Dr.  Theodore  Diller,  of  Pittsburgh,  favored  the 
establishment  of  a  psychopathic  ward  and  spoke  of 
the  work  carried  on  in  connection  with  St.  Francis 
Hospital,  in  Pittsburgh.  He  felt  that  nothing  would 
so  emphasize  to  the  laity  the  fact  that  sickness  and 
insanity  should  be  regarded  as  one  and  the  same 
thing  as  the  establishment  of  a  psychopathic  ward 
in  a  general  hospital.  Such  a  ward  was  also  needed 
for  cases  of  pneumonia,  typhoid  fever,  or  nervous 
prostration,  in  which  mental  symptoms  may  develop. 
This  ward  should  be  the  smallest  part  of  the  hos- 
pital, .so  that  it  would  not  become  conspicuous  and 
be  know^n  as  an  insane  w'ard. 

The  Mechanical  Treatment  of  Visceral  Ptosis 
and  a  New  Method  of  Applying  a  Bandage. — Dr. 
J.  Torrence  Rl'c.ii,  of  Philadelphia,  presented  this 
paper,  in  which  he  described  a  bandage  which  he 
had  evolved  since  his  first  employment  of  the  Rose 
bandage.  Two  strips  of  zinc  oxide  plaster  consti- 
tuted the  bandage,  the  first  being  from  7  to  9  inches 
wide  and  from  24  to  32  inches  long,  while  the  sec- 
ond is  from  3  to  4  inches  wide  and  36  to  40  inches 
long.  The  patient  was  placed  supine  on  a  flat  and 
firm  surface  and  the  hips  were  raised  two  or  three 
inches  to  favor  reposition  of  the  viscera  and  to 
facilitate  the  application  of  the  bandage.  The  first 
strip  was  then  laid  across  the  lower  abdomen,  the 
lower  border  being  in  close  relation  to  the  pubes. 
A  strip  about  iy'2  inches  wide  was  cut  longitudin- 
ally from  each  end,  running  just  past  Poupart's  liga- 
ment. Another  cut  was  made  higher  up,  just  oppo- 
site to  and  penetrating  as  far  as  the  iliac  crests,  and 
this  was  then  turned  obliquely  downward  so  as  to 
pass  directly  over  the  anterior  superior  iliac  spine 
and  was  terminated  just  l^elow  this  landiuark.  The 
first  strips  were  now  stretched  firmly  over  each  side 
and  carried  about  the  pelvis  in  a  markedly  upward 
direction  and  were  carefully  smoothed  in  place.  The 
seconfl  strii^s  were  then  similarly  stretched  and  car- 
ried high  up  on  the  pelvis  posteriorly.    The  remain- 


Jiiuiary  23.  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


i95 


ing  top  pieces  are  now  drawn  loosely  about  the  waist 
and  would  be  found  to  run  naturally  downward  over 
the  first  two.  After  all  had  been  carefully  smoothed 
into  position,  the  second  strip  was  passed  under  the 
body  and,  its  ends  being  seized,  it  was  firmly 
stretched,  laid  against  the  back,  and  the  ends  drawn 
forward,  resting  just  above  the  iliac  crests  and  curv- 
ing downward  over  each  groin,  meeting  just  over 
the  pubes  in  the  same  manner  as  the  Rose  bandage. 

Dr.  S.  SoLis  Cohen  agreed  with  Dr.  Rugh  that 
the  nonremovable  bandage  should  not  be  used  where 
a  movable  one  would  answer,  nor  did  he  advocate 
the  use  of  any  bandage  where  an  operation  is  clearly 
necessary.  Furthermore,  he  did  not  regard  the 
bandage  alone  as  sufficient,  but  believed  that  there 
must  be  in  most  cases  exercises  appropriate  to  the 
condition  of  the  patient  to  restore  the  muscular  tone 
of  the  belly  wall,  which,  with  the  visceral  fat,  was 
the  important  factor  in  retaining  the  abdominal  vis- 
cera in  position.  He  had  observed  much  benefit 
from  the  use  of  the  bandage  as  applied  by  Dr.  Rugh 
in  displaced  kidney,  causing  Dietl's  crises  and  other 
well  known  symptoms.  Irritation  of  the  skin  under 
the  bandage  was  mentioned  as  the  great  disadvan- 
tage in  connection  with  its  use.  With  the  discovery 
of  a  preventive  of  this  itching  the  bandage  would 
present  about  the  best  crutch  that  could  possibly  be 
supplied  to  a  patient.  That  it  was  a  temporary 
matter,  and  that  the  real  treatment  must  be  dietetic 
and  strengthening  to  restore  the  fat  and  tone  of  the 
muscles,  was  emphasized. 

Dr.  E.  \'.  SwixG,  of  Coatesville,  had  used  the 
zinc  oxide  bandage  with  good  results,  and  for  the 
irritation  produced  had  suggested  that  the  manu- 
facturer make  a  bandage  with  perforations. 

Dr.  MvER  SoLis  CoHEX,  of  Philadelphia,  re- 
ferred to  the  theory  of  Goldthwait.  of  Boston,  and 
others,  that  faulty  positions  in  standing  and  walk- 
mg,  by  which  undue  weight  was  put  upon  the  ilio- 
sacral  ligaments,  were  factors  in  the  aetiology  of 
enteroptosis. 

Dr.  The()DORE  Dillek,  of  Pittsburgh,  emphasized 
the  remarks  of  Dr.  Myer  Solis  Cohen,  regarding 
the  strain  put  upon  the  iliosacral  joint.  He  had  seen 
cases  in  which  this  condition  had  produced  symp- 
toms apparently  of  nervous  origin,  but  in  which 
relief  was  afforded  upon  the  application  of  a  band- 
age about  the  hips,  as  described. 

Dr.  Rugh  emphasized  the  fact  that  any  mechan- 
ical support  must  be  looked  upon  merely  as  an  aid. 
Any  form  of  treatment  which  would  improve  the 
muscular  tone  of  the  abdominal  parietes  should  be 
employed.  He  agreed  that  faulty  positions  in  stand- 
mg  and  walking  had  a  strong  influence  in  the  pro- 
duction of  visceral  ptosis.  He  agreed  to  the  view 
of  Dr.  Goldthwait  that  the  tone  of  the  abdominal 
parietes  was  one  of  the  most  effective  factors  in 
maintaining  the  abdominal  organs  in  their  proper 
relationships.  Contrary  to  the  common  impression 
that  a  floating  kidney  could  not  be  strapped  back. 
Dr.  Rugh  declared  that  it  could  be  done,  and  that  as 
a  sequence  the  suspensory  ligaments  would  contract. 

The  Questionable  Ethics  of  Medical  Journals, 
etc. — Dr.  Oscar  H.  Allis.  of  Philadelphia,  pre- 
sented this  subject  (see  vol.  Ixxxviii,  page  1041). 


Delegates  to  the  American  Medical  Associa- 
tion.— Dr.  William  L.  Estes,  Dr.  Thomas  D. 
D.wis,  Dr.  Fremont  W.  Fkankhau.ser,  and  Dr. 
Saml'el  Wolfe  were  elected  delegates. 

A  recommendation  from  the  Board  of  Trustees  to 
the  House  of  Delegates  w  as  that  there  be  an  appoint- 
ment of  a  committee  of  three  to  act  in  conjunction 
with  the  Board  of  Public  Instruction  of  the  Ameri- 
can Medical  Association. 

^liss  Elizabeth  B.  Reid.  first  vice  president  of 
the  State  Xurses'  Association,  explained  a  proposed 
bill  for  the  registration  of  nurses,  which  communi- 
cation was  referred  to  the  Committee  on  Public  Pol- 
icy and  Legislation. 

A  resolution  was  received  and  referred  to  the 
Committee  on  Public  Policy  and  Legislation  that  the 
president  of  the  ^ledical  Society  of  the  State  of 
Pennsylvania  appoint  a  committee  of  seven  to  coop- 
erate with  tlie  Commissioner  of  Health  of  Pennsyl- 
vania with  a  view  of  preventing  the  passage  of  acts 
inimical  to  the  present  vaccination  statutes  of  the 
State. 

The  Reference  Committee  on  Scientific  Business 
endorsed  the  work  done  by  the  Committee  on  Mal- 
Practice  and  concurred  in  the  provision  in  the  med- 
ical act  providing  for  revocation  of  licensure  for 
cause. 

The  Report  of  the  Committee  upon  Inebriate  Hos- 
pital was  heartily  endorsed  and  tJie  committee  con- 
tinued. The  suggestion  was  made  that  the  Bar  As- 
sociation be  asked  to  appoint  a  similar  committee  to 
assist  in  the  furtherance  of  this  charity.  It  was  rec- 
ommended that  the  members  of  the  State  society  use 
their  influence  with  legislators  to  insure  the  passage 
of  the  bill  and  that  the  profession  interest  the  laity. 

The  Committee  upon  Religious  Newspaper  Ad- 
vertising was  continued  and  the  committee  congrat- 
ulated upon  the  progress  made  in  that  decided  im- 
provement had  been  noted  in  the  character  of  adver- 
tisements. 

In  the  matter  of  the  address  of  Dr.  J.  M.  Baldy 
as  president  of  the  American  Gyn?ecoIogical  Society 
regarding  the  use  of  general  anaesthesia.  Dr.  Baldy 
was  commended  for  the  fearless  manner  in  which  he 
had  called  attention  to  an  evil  undoubtedlv  existing 
in  a  great  part  of  the  Common w-ealth.  The  secre- 
tary-editor was  requested  to  write  several  editorials 
upon  the  subject  during  the  year,  directing  attention 
to  this  danger. 

The  resolution  relating  to  the  Fourth  of  July  fa- 
talities was  recommended,  and  the  appointment  of  a 
committee  of  three  suggested  to  devise  ways  and 
means  for  the  amelioration  of  the  conditions  named. 

Dr.  Jay  F.  Schamberg  oflPered  a  resolution  to  the 
effect  that  a  committee  of  five  be  appointed  by  the 
president  of  the  society,  whose  duty  should  be  to  se- 
cure appropriate  literature  upon  the  medical  act  and 
the  questions  of  vaccination  and  vivisection ;  and, 
further,  through  cooperation  with  the  county  socie- 
ties' committees  on  Public  Policy,  secure  the  influ- 
ence of  family  physicians  with  their  legislators  in 
these  matters. 

A  resolution  was  passed  congratulating  the  sur- 
geon general  of  the  Cnited  States  Public  Health  and 
Marine  Hospital  Service  for  his  work  in  providing 


iq6  letters  to 

for  the  publication  of  a  series  of  bulletins  embodying 
a  digest  of  comments  upon  the  U.  S.  Pharmacopoeia. 

Dr.  Wendell  Reber  offered  a  resolution,  which 
was  adopted,  to  the  efYect  that  the  Medical  Society 
of  the  State  of  Pennsylvania  appoint  a  committee  to 
investigate  the  subject  of  trachoma,  inquiring  into 
the  probable  number  of  cases  existing,  obtaining  sta- 
tistics relative  to  its  establishment  and  control,  and 
securing  opinions  upon  the  subject  from  the  various 
eye  specialists  of  the  State,  which  material  should  be 
presented  at  the  next  annual  meeting,  with  a  work- 
ing plan  for  the  stamping  out  of  the  disease. 

New  Officers.  —  The  following  officers  were 
elected :  President,  Dr.  George  W.  Wagoner,  of 
Johnstown ;  vice-president.  Dr.  James  I.  Johnston, 
of  Pittsburgh  ;  secretary-editor,  Dr.  C.  L.  Stevens, 
of  Athens.  Next  place  of  meeting,  Bedford  Springs. 
{To  be  continued.) 

 €>  

fetters  to  tl]c  (teMtor. 


A  NEW  THESAURUS  OF  THE  GREEK  LANGUAGE. 

126  East  Thirty-fourth  Street, 
New  York,  January  g,  igog. 

To  the  Editor: 

Last  July  I  received  a  letter  from  Professor 
Hatzidakis  about  his  idea  of  a  Greek  lexicon,  which 
is  to  comprise  the  entire  language  from  the  days  of 
Homer  to  the  present  time.  He  expressed  a  desire 
that  in  Greece  there  might  exist  a  Carnegie  to  help 
carry  out  his  plan,  but  it  appears  that  even  without 
such  help  the  plan  is  going  to  be  realized. 

At  the  second  general  meeting  of  the  Interna- 
tional Association  of  Academies,  the  British  Acad- 
emy submitted  a  plan  for  the  production  of  a  Greek 
lexicon  worthy  of  the  giant  work  undertaken  by  the 
Committee  of  German  Academies — the  Latin  The- 
saurus. This  plan,  however,  was  abandoned  after 
mature  consideration.  The  idea  was  strenuously 
opposed  by  prominent  German  philologists — a  fact 
readily  understood,  because  it  would  have  demon- 
strated that  these  gentlemen  did  not  or  would  not 
understand  more  than  a  mere  fragment  of  the  Greek 
language ;  also  that  they  were  grievously  in  error 
when  they  designated  as  New  Greek  any  words  not 
used  by  the  ancient  classical  writers ;  in  short,  that 
they  had  .suspended  science  and  truth  in  regard  to 
the  Greek  language  as  actually  spoken.  I  have 
demonstrated  in  various  writings  how  pernicious 
this  error  has  proved  for  medical  onomatology. 
While  Latin  at  a  comparatively  early  time  was  cleft 
into  a  number  of  languages,  the  Greek  language 
retained  its  linguistic  tradition  and  uniformity,  and 
that  is  the  point  which  the  German  scientists  decline 
to  admit. 

The  plan  to  demonstrate  the  history  of  the  entire 
thesaurus  of  the  Greek  language  in  a  giant  work, 
comprising  the  times  from  Homer  to  our  own,  is 
grand.  As  regards  medical  science,  a  work  of  this 
kind  means  a  considerable  gain,  because  by  its  aid 
the  correct  scientific  denomination  of  words  of 
Greek  origin  can  be  definitelv  established.  But  we 
need  not  wait  for  the  completion  of  the  entire  work ; 
the  scientists  engaged  upon  it  will  give  us  all  the  aid 


THE  EDITOR.  [New  York 

Medical  Journal. 

we  need  for  a  special  medical  lexicon,  to  be  a  sup- 
plement to  those  which^  exist  at  present. 

This  thesaurus,  which  will  comprise  all  times  and 
dialects,  all  forms  of  the  written  and  spoken  lan- 
guage, will  reflect  the  inner  and  outer  history  of 
the  Greek  nation,  a  history  of  thousands  of  years 
of  strife  prolific  in  glorious  victories  and  smashing 
defeats,  a  tremendous  series  of  deep  changes  in  the 
nation's  political,  religious,  and  social  life,  both  from 
a  spiritual  and  material  point  of  view.  This  the- 
saurus will  instructively  show  thousands  of  exam- 
ples that  the  Greek  nation  has  remained  an  entity, 
both  ethnographically  and  linguistically,  from  the 
times  of  antiquity,  in  spite  of  all  evolutions,  the 
most  noteworthy  of  which  are  the  Christianizing  of 
the  national  soul,  the  Romanizing  of  the  constitu- 
tion, and  the  Orientalization  of  many  cultural 
branches,  and  in  spite  of  the  admixture  of  foreign 
blood. 

Professor  G.  N.  Hatzidakis,  the  originator  of  the 
plan  to  carry  out  this  work  in  Greece,  says  this : 
"This  work  is  expected  and  demanded  of  us,  and 
only  of  us,  by  the  scientific  world,  inasmuch  as  the 
other  scientific  branches  of  classical  philology  and 
archaeology  can  be  studied  independently  by  the 
scientists  of  the  other  civilized  nations,  but  not  the 
long  development  of  our  language." 

And  now,  thanks  to  the  instigation  of  Hatzidakis, 
this  plan  is  going  to  be  realized  in  Greece  herself. 
The  official  organ  of  the  Greek  government,  in  its 
number  of  November  8,  1908,  contained  a  royal 
edict  to  the  following  efifect :  For  the  centennial  cele- 
bration of  the  Greek  fight  of  liberty,  which  will  take 
place  in  192 1,  it  is  intended  to  create,  as  an  ever- 
lasting montiment  to  the  immortality  and  unanimity 
of  the  Greek  nation,  an  historic  lexicon  of  our  lan- 
guage, comprising  all  times  from  the  remotest  an- 
tiquity to  the  present  date.  To  compile  and  edit  this 
work,  a  committee  has  been  appointed,  consisting  of 
professors  Th.  Kontos,  G.  N.  Hatzidakis,  and  S. 
Menardos.  To  finance  this  undertaking,  an  annual 
contribution  of  ten  thousand  drachmas  out  of  the 
Dorides  Foundation  has  been  voted,  also  a  state  con- 
tribution and  other  donations.  The  publication  of 
the  lexicon  will  begin  on  March  25,  192 1. 

There  is  no  doubt  that  both  the  Greek  state  and 
the  frequently  attested  liberality  of  Greek  patriots 
will  not  fail  to  make  this  work,  which  is  destined 
alike  to  contribute  to  the  spiritual  welfare  of  Greece 
and  to  its  recognition  among  the  council  of  nations, 
a  complete  success.  He  who  knows  the  scientific 
life  of  Greece  will  have  no  doubt  that  there  will  be 
a  sufficient  number  of  collaborators  possessed  of  the 
necessary  philological  training,  power  of  work,  and 
the  rare  qualifications  of  devotion,  perseverance, 
and  care.  At  this  juncture  the  undertaking  deeply 
touches  the  question  of  the  psychological  condition 
of  the  nation,  forming  a  test  of  its  ability.  Krum- 
bacher,  whose  communications  about  this  intended 
Greek  thesaurus  in  the  International  Weekly  Sup- 
plement of  the  Munich  .AUgeweine  Zeititiig  of  De- 
cember 19,  1908,  I  have  drawn  upon,  sometimes 
textuallv.  for  the  purposes  of  this  letter,  states : 
"New  Greece  has  the  opportunity  to  prove  to  the 
whole  world  what  mental  maturity,  scientific  educa- 
tion, and  ability  it  has  acquired  in  its  work  of  a 
hundred  vears  of  cultural  endeavor."      .\.  Rose. 


January  ^3,  1909.] 


BOOK  NOTICES. 


197 


[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


Modern  Medicine.  Its  Theory  and  Practice.  In  Original 
Contributions  by  American  and  Foreign  Authors.  Edited 
by  William  Osler,  M.  D.,  Regius  Professor  of  Medicine 
in  Oxford  University,  England,  etc.,  Assisted  by  Thomas 
McCrae,  M.  D.,  Associate  Professor  of  Medicine,  and 
Clinical  Therapeutics  in  the  Johns  Hopkins  University, 
Baltimore,  etc.  Volume  V,  Diseases  of  the  Alimentary 
Tract.  Illustrated.  Philadelphia  and  New  York :  Lea  & 
Febiger,  1908.    Pp.  viii-17  to  903. 

As  this  great  work  advances  toward  completion 
it  maintains  the  excellence  of  the  earlier  volumes. 
The  contribtitors  to  this  volume  are  Dr.  Thomas  R. 
Brown,  of  Baltimore ;  Dr.  Julius  Friedenwald,  of 
Baltimore ;  Dr.  A.  O.  J.  Kelly,  of  Philadelphia ;  Dr. 
John  McCrae,  of  Montreal;  Dr.  C.  F.  Martin,  of 
Montreal ;  Dr.  Eugene  L.  Opie,  of  New  York ;  Dr. 
David  Riesman,  of  Philadelphia ;  Dr.  Humphry 
Davy  Rolleston,  of  London ;  Dr.  Alfred  Stengel,  of 
Philadelphia,  and  Dr.  Charles  G.  Stockton,  of  Buf- 
falo. The  diseases  treated  of,  which  are  among  the 
most  important  that  come  under  the  practitioner's 
notice,  are  handled  in  the  masterly  way  that  one 
would  look  for  at  the  hands  of  such  eminent  au- 
thors as  we  have  enumerated.  The  introductory 
chapter,  by  Dr.  Stockton,  strikes  us  as  particularly 
excellent. 

Dr.  Stengel,  who  contributes  the  chapter  on  dis- 
eases of  the  intestines,  gives  a  short  paragraph  on 
the  surgical  treatment  of  constipation,  but  does  not 
mention  appendicostomy,  though  he  says  with  re- 
gard to  mucous  colitis  :  "Some  obstinate  cases  have 
been  treated  by  attaching  the  tip  of  the  appendix  to 
an  abdominal  opening  and  flushing  out  the  bowel 
daily  or  at  stated  intervals" — rather  a  meagre  state- 
ment, it  seems  to  us,  in  view  of  the  brilliant  results 
that  have  followed  the  operation  in  the  hands  of 
various  surgeons.  On  the  other  hand,  apparently 
on  the  strength  of  some  supposed  connection  be- 
tween nephroptosis  and  dilatation  of  the  stomach, 
Dr.  Brown  gives  considerable  attention  to  floating 
kidney,  which  of  itself  can  hardly  be  termed  an 
affection  of  the  alimentary  tract. 

Surgery.  Its  Principles  and  Practice.  By  Various  Authors. 
Edited  by  William  Williams  Keen,  M.  D.,  LL.  D., 
Erneritns  Professor  of  the  Principles  of  Surgery  and  of 
Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia, and  John  Chalmers  Da  Costa,  M.  D.,  Professor 
of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  "Philadelphia.  Volume  IX. 
With  582  Illustrations,  22  of  them  in  Colors.  Philadel- 
phia and  London:  W.  B.  Saunders  Company,  1908.  Pp. 
II94- 

In  this  volume  of  Keen  and  Da  Costa's  great 
work  Dr.  William  B.  Coley,  of  New  York,  writes 
on  hernia ;  Dr.  Robert  Abbe,  of  New  York,  on  the 
surgerv  of  the  rectum  and  anus ;  Dr.  David  L.  Ed- 
sall,  of  Philadelphia,  on  examination  of  the  urine  in 
relation  to  surgical  measttrcs ;  Dr.  Joseph  Ranso- 
hofif.  of  Cincinnati,  on  the  surgery  of  the  kidney, 
the  ureter,  and  the  suprarenal  gland ;  Dr.  Bransford 
Lewis,  of  St.  Louis,  on  the  surgery  of  the  bladder; 
Dr.  Arthur  T.  Cabot,  of  Boston,  on  stone  in  the 
bladder ;  Dr.  Htigh  M.  Young,  of  Baltimore,  on  the 
surgery  of  the  prostate ;  Dr.  Orville  Horwitz,  of 


Philadelphia,  on  the  surgery  of  the  penis  and  ure- 
thra ;  Dr.  Arthur  D.  Bevan,  of  Chicago,  on  the  sur- 
gery of  the  scrotum,  testicle,  spermatic  cord,  and 
seminal  vesicles ;  Dr.  Weller  Van  Hook,  of  Chicago 
(in  conjunction  with  Dr.  Allen  B.  Kanavel,  of  Chi- 
cago), on  the  surgery  of  the  intestines  (excluding 
the  appendix,  the  rectum,  and  the  anus),  the  omen- 
tum, and  the  mesentery ;  Dr.  John  B.  Murphy,  of 
Chicago,  on  the  surgery  of  the  appendix  vermi- 
formis;  Dr.  Edward  B.  Dench,  of  New  York,  on  the 
surgery  of  the  ear ;  Dr.  George  E.  de  Schweinitz,  of 
Philadelphia,  on  the  surgery  of  the  eye ;  Surgeon 
General  Robert  M.  O'Reilly,  of  the  army,  on  mili- 
tary surgery;  Surgeon  General  Presley  M.  Rixey,  of 
the  navy,  on  naval  surgery;  Major  Walter  D.  Mc- 
Caw,  of  the  Army  Medical  Corps,  on  tropical  sur- 
gery ;  and  Dr.  William  L.  Rodman,  of  Philadelphia, 
on  the  influence  of  race,  sex,  and  age  in  surgical  af- 
fections. 

It  is  no  mean  achievement  for  the  editors  of  a 
variorum  work  to  bring  together  such  an  array  of 
capable  authors.  Every  chapter  in  the  volume  is 
almost  a  complete  treatise,  and  it  would  be  invidious 
to  single  out  any  one  of  them  for  commendation. 
We  are  glad  to  see  that  Major  McCaw  warmly  ad- 
vocates appendicostomy,  that  Dr.  Young  vigorously 
insists  on  American  priority  in  the  performance  of 
complete  suprapubic  prostatectomy,  and  that  Dr. 
Murphy  effectually  controverts  the  notion  that  in- 
flammation of  the  veriform  appendix  is  an  "Amer- 
ican disease."  We  regret  that  Dr.  Young  uses  the 
defective  word  "urinalysis,"  and  we  regret  that  the 
publishers  saw  fit  to  tise  painfully  glazed  paper 
throughout  the  volume. 

Stories  of  a  Country  Doctor.  By  Willis  P.  King,  M.  D., 
First  Vice-President  of  the  American  Medical  Associa- 
tion, Ex-President  of  the  Missouri  State  Medical  Asso- 
ciation, etc.  Chicago:  Clinic  Publishing  Company,  1908. 
Pp.  398. 

This  book  appeared  for  the  first  time  in  1891.  It 
makes  very  interesting  reading  and  gives  a  true 
picture  of  the  West,  as  most  of  the  things  written 
about  in  the  book  have  been  seen  and  experienced 
by  the  author  himself.  It  describes  the  West  from 
the  pioneers'  days,  reproducing  the  life,  the  work, 
the  play,  the  education  of  the  early  settlers,  and 
compares  the  past  with  the  present.  Besides  these 
chapters  we  find  other  interesting  stories  dealing 
with  various  subjects,  all  showing  the  author's  pro- 
found knowledge  of  human  nature,  such  as  super- 
stition, the  branch  waterman,  the  experience  of  a 
country  doctor,  sham  suicides,  liars  and  their  lies, 
and  quacks  and  quackery.  Wit  is  well  combined 
with  seriousness. 

Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  A.  M.,  M.  D., 
Professor  of  Obstetrics,  Northwestern  University  Med- 
ical School ;  Obstetrician  to  Mercy,  Wesley,  Provident, 
Cook  County,  and  Chicago  Lying-in  Hospitals,  etc. 
Third  Edition.  Thoroughly  Revised  and  Enlarged. 
Philadelphia  and  London :  W.  B.  Saunders  Company, 
1908.    Pp.  512.    (Price,  $2.50.) 

The  first  edition  of  this  book  appeared  four  years 
ago.  The  present  edition  is  dedicated  to  "the  wo- 
man abotit  to  become  a  mother  or  with  a  new  born 
infant  upon  her  bosom  wherever  she  bears  her  ten- 
der burden."  But  we  do  sincerely  hope  a  pregnant 
woman  will  not  read  the  book,  as  it  contains  such 
material  as  should  rather  be  kept  from  the  gravida. 
A  trained  nurse,  a  medical  student,  or  a  general 


198 


BOOK  NOTICES.— NEIV  PUBLICATIOXS. 


[New  York 
Mefiical  Journal. 


practitioner  will  receive  a  great  amount  of  knowl- 
edge from  perusing  it. 

It  is  divided  into  four  parts,  anatomy  and  physi- 
ology of  the  reproductive  system ;  nursing  during 
labor  and  in  the  j)uerperium  ;  pathology  of  preg- 
nancy, labor,  and  the  puerperium  ;  and  an  appendix 
which  contains  among  other  valuable  hints  a 
dietary. 

Among  the  illustrations,  which  are  more  or  less 
well  executed,  are  some  very  good  ones,  but  one. 
Fig.  14,  should  be  altered;  it  is  neither  anatomically 
nor  gyn.necologically  correct,  and  gives  absolutely  a 
wrong  impression  of  the  object. 

The  Dissociation  of  a  Personality.  A  Biographical  Study 
in  Abnormal  Psychology.  By  Morton  Prince,  M.  D., 
Professor  of  Diseases  of  the  Nervous  System.  Tufts 
Medical  College,  etc.  Second  Edition.  New  York.  Lon- 
don. Bombay,  and  Calcutta :  Longmans,  Green,  &  Co., 
igo8.    Pp.  x-575. 

This  considerable  volume  is  devoted  to  the  study 
and  analysis  of  a  striking  case  of  multiple  "person- 
ality," or  "dissociation  of  personality,"  as  the  au- 
thor prefers  to  call  it.  Consisting,  as  it  does,  of 
Parts  i  and  ii  of  a  larger  work.  Problems  in  Ab- 
normal Psychology,  it  is,  nevertheless,  complete  in 
itself.  Since  the  appearance  of  the  first  edition,  in 
1905,  the  author  has  continued  his  studies,  and  to 
this,  the  second  edition,  he  has  added  an  appendix 
on  the  Psychology  of  Sudden  Religious  Conver- 
sion, and  a  second  case  of  conversion  (nonreligious 
type),  which  was  analyzed  by  the  author  shortly 
after  the  occurrence  of  the  phenomenon.  It  is  the 
author's  purpose  jiresently  to  publish,  in  separate 
volumes.  Parts  iii  and  iv,  a  continuation  of  his 
studies. 

"Multiple  personality,"  as  the  affection  under 
consideration  is  commonly  known,  or  "dissociated 
personality,"  the  name  preferred  by  the  author  of 
this  volume,  or  "changeful  personality,"  as  Corning 
called  it  in  a  paper  published,  if  our  memory  serves 
us,  full  ten  years  ago,  calls  up  a  train  of  phenomena 
so  -Startling  as  to  cause  physicians  and  laymen  alike 
to  stand  agog. 

Aside  from  the  interest  in  the  subject  popularly 
evoked  by  the  contributions  of  novelists  and  play- 
wrights, the  curiosity  of  the  profession  itself  has 
been  stimulated  by  a  technical  literature  already 
quite  extensive.  Among  those  who  have  helped  to 
swell  the.  archives  are  Arsimoles,  Bourru  and 
Burot.  Baker,  Burnett,  Corning,  Cuttera,  Dreury, 
Gilbert,  Gordon,  Gumpertz,  Howard,  Kueffner, 
Laufts.  Lowenfeld,  McDougall,  Moran,  Mitchell, 
Moll,  Newbold,  Patrick,  Prince,  Richet,  de  Rochos, 
Rosu,  Scully,  Sidis,  Starr,  Taylor,  Walsh,  and 
Woltar- — a  goodly  list  surely,  but  one  far  from  ex- 
hausting the  names  of  contributory  workers. 

The  subject  of  this  study,  Miss  Christine  L. 
Beauchamp,  developed  several  "personalities," 
changing  from  one  to  the  other  at  varying  intervals, 
often  from  hour  to  hour ;  and,  with  each  such 
change,  there  was  an  alteration  of  character  and 
memory.  Besides  her  real,  original  self,  she  was 
given  to  transformations  by  virtue  of  which  three 
additional  and  distinct  personalities  could  be  made 
out. 

It  is  worthy  of  remark  that  the  disintegrations  of 
personality  involved  were   not   ethical,  but  intel- 


lectual and  temperamental.  Of  the  dififerent  per- 
sonalities at  various  times  appearing,  not  one  was 
capable  of  causing  distress  to  others. 

Here,  then,  is  a  portly  volume,  of  which  consid- 
erably over  500  pages  are  devoted  to  the  sayings 
and  doings  of  ^liss  Beauchamp  and  her  other 
"selves" — a  large  clinical  record,  in  short,  some  of 
which,  in  our  judgment,  might  well  have  been  con- 
densed or  omitted  altogether.  Perhaps  we  are 
wrong  in  this — reviewers  are  not  infallible  ;  but  are 
we  wrong  when  we  ex])ress  regret  that  the  author 
has  not  entered  more  ftdly  into  the  discussion  of 
the  theory  of  disintegrated  (multiple)  personality, 
instead  of  reserving  such  discussions  for  a  future 
communication  ? 

Plowever  this  may  be,  we  are  glad  to  pay  a  trib- 
ute of  unstinted  praise  to  the  author  for  the  pains- 
taking fidelity  with  which  he  has  collected  the  data 
of  a  case  of  unique  interest  to  the  practitioner  and 
of  unquestionable  value  to  the  student  of  morbid 
psychology. 

Jiilircsbcricht  iibcr  die  Leislitngen  uiid  F ortschritte  auf  deni 
Gebiete  der  Erkrankuitgen  des  Urogcnitalapparates.  Rcdi- 
giert  von  Prof.  Dr.  Koll.m.\nn  in  Leipzig  und  Dr.  S. 
J.ACOBV  in  Berlin.  Ill  Jahrgang:  Bericht  iiber  das  Jahr 
1907.    Berlin  :  S.  Karger,  1908. 

The  appearance  of  this,  the  third,  volume  of  the 
Jahrcsbcricht  fiir  Urologic,  as  the  work  has  come  to 
known  (in  spite  of  its  tapeworm  title),  will  be 
greeted  with  pleasure  by  all  those  who  are  interested 
in  the  progress  of  urology.  The  Jahrcsbcricht, 
which  was  founded  by  the  late  Max  Nitze,  has,  in- 
deed, come  to  be  regarded  as  an  indispensable 
source  of  reference  upon  all  current  urological  cpies- 
tions.  In  appearance,  makeup,  and  scope  the  new 
volume  is  identical  with  the  two  which  preceded  it. 
On  its  editorial  board  this  country  is  ably  repre- 
sented by  Dr.  Hugh  Young,  of  Baltimore,  while  Dr. 
M.  Krotoczyner,  of  San  Prancisco.  has  very  credit- 
ably handled  the  abstracts  of  American  urological 
literature  embodied  in  this  yearbook.  The  work  as 
a  whole  is  singularly  free  from  errors,  though  in 
some  in.stances  articles  have  been  slightly  misplaced, 
their  subject  matter  making  them  fit  for  other  sec- 
tions than  those  in  which  they  appear.  The  year- 
book should  be  in  the  hands  of  all  who  pretend  to 
be  an  couraiit  in  the  vast  field  of  modern  urology. 

NEW  PUBLICATIONS. 

Hepatozoon  Perniciosum  (  N.  G.,  N.  Sp. )  ;  A  Hxmogrc- 
garine  Pathogenic  for  White  Rats :  With  a  Description  of 
the  Sexual  Cycle  in  the  Intermediate  Host,  a  Mite  (Lclaps 
Echidninus).  By  W.  W.  Miller.  Hygienic  Laboratory. — 
Bulletin  No.  46.  June.  1908.  Washington:  Government 
Printing  Ofifice,  1908.    Pp.  51. 

The  Systematic  Relationsliips  of  the  Coccace?e.  witli  a 
Discussion  of  the  Principles  of  Bacterial  Classification.  By 
Charles  Edward  Amory  Winslow.  .Assistant  Prof-.ssor  of 
Biology  at  the  Massacluisetts  Institute  of  Technology,  and 
Anne  Rogers  Winslow.  First  Edition.  First  Thousand. 
New  York :  John  Wiley  &  Sons.  London  :  Chapman  & 
Hall,  Limited,  1908.    Pp.  yiii-300.    Price.  $2.50. 

Lc  Tabes  maladie  de  la  sensibilite  profonde.  Par  Ic  Dr. 
J.  Grasset.  professcur  a  la  P'aculte  de  medecine  de  Mont- 
pellier.  Legons  clinicpies  rccueillies  et  publiees  par  le  Dr. 
Rimbaud,  chef  dc  cliniquc  medicale.  Montpellier:  Conlet 
et  Fils,  1909.    Pp.  124. 

The  Rat  Problem.  By  W.  R.  Boelter,  Corresponding 
Member  of  the  Commission  Internationale.  Association  In- 
ternationale pour  la  destruction  rationnelle  des  rats.  Witii 


January  23,  1909.] 


OFFICIAL  NEWS. 


199 


Portrait  of  Sir  James  Crichton-Browne,  F.  R.  S.,  and  Sev- 
enty-five other  Illustrations.  London :  John  Bale,  Sons, 
&  Danielsson,  Ltd.,  1909.    Pp.  vii-165. 

Bref  och  Skrifvelser.  Af  och  till  Carl  von  Linne.  Forsta 
Afdelningen.  Del.  II.  Skrifvelser  och  Bref  till  K.  Svenska 
Vetenskaps-Akademien  och  dess  Sekreterare.  Utgifna  och 
med  Uppiysande  Noter  Forsedda.  Af  Th.  M.  Fries.  Stock- 
holm :    Aktiebolaget  Ljus.  1908.    Pp.  ix-347. 

Report  of  the  Commissioner  of  Education,  1907.  Vol.  II. 
Pp.  vii-1,214. 


2  Imported. 
3 


Public   Health   and   Marine    Hospital  Service 
Health  Reports: 

The  follon'ing  cases  of  smallfox,  yellon'  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  zveek  ending  January  15,  igog: 

Smallpox — United  States. 
Places.  Date.  Cases.  Deaths. 

California — Los  Angeles  Dec.  19-26   i 

California — Oakland  Dec.  26-.Tan.  2   4 

California — San  Francisco  Dec.  19-26   8 

District  of  Columbia — Washington .  Dec.  26-_Tan.   2   i 

Illinois — Cairo  To  January  7   12 

Illinois — Peoria  Dec.  19-26   4 

Indiana — .Anderson  Dec.  1-31   i 

Indiana — La  Fayette  Dec.  27-Jan.  4   3 

Kansas — .Atchison  Dec.  26-Jan.  2   i 

Kansas — Pittsburgh  Dec.  1-3 1   36 

Kentucky — Covington  Dec.  26-Jan.  2   2 

Kentucky — Lexington  Dec.  26-Tan.   2   2 

Louisiana — New  Orleans  Dec.  19-Jan.  2... 

Minnesota — Stillwater  Dec.  1-31  

Missouri — St.  Louis  Dec.  19-26  

Nebraska — Lincoln  Nov.  1-30   3 

Ohio — Cincinnati  Dec.  26-Jan.  2   20 

Pennsylvania — Gracedale  Oct.  24   i 

Tennessee — Knoxville.T  Dec.  26-Jan.  2   i 

Texas — Falfurriass  Dec.  26   12 

Texas — San  .\ntonio  Dec.  26-Jan.   2   6 

Washington — Seattle  Nov.  1-30   7 

Washington — .Spokane  Dec.  19-26   1 

Washington — Tacoma  Dec.  13-Tan.   3   14 

Wisconsin — La  Crosse  Dec.  19-Jan.  2   6 

Small  pox — Fo  reign. 

Brazil — Pernambuco  Nov.  1-15   3 

Brazil — Rio  de  Janeiro  Ncv.  15-29  420 

Brazil — Sao  Paulo,   Santos  Nov.  23-Dec.  6  

Brazil — Santos  Nov.  15-22  

Canada — Halifax  Dec.  19-26   2 

Canada — Winnipeg  Dec.  19-26   i 

Canada — Yarmouth  Dec.  1-31   i 

China — Shanghai  Dec.  8  

Egypt — Cairo  Dec.  2-9   4 

Greece — .\thens  Dec.  5-12  

India — General  Nov.  21-28  2,156 

India — Bombay  Dec.  1-8  

India — Calcutta  Nov.  7-28   10 

India — Afadras  Nov.  28-Dec.  4   i 

India — Rangoon  Nov.  21-28   i 

Indo-China — Cholen  Ncv.  14-21   i 

Indo-China — Saigon  Oct.  31-Nov.  21   2 

Italy — General  Dec.  13-20   10 

Italy — Naples  Dec.  13-20   18 

Persia — Teheran  Nov.  14-28  

Russia — Warsaw  Nov.  14-28  

Spain — Barcelona  Dec.  12-19  

Spain — Madrid  Nov.  1-30  

Turkey — Constantinople  Dec.  3-13  

Yellow  Fever — Foreign. 

Brazil — Manaos  Nov.   28-Dec.  5  

Ecuador — Guayaquil  Nov.  28-Dec.  2  

Martinique — Fort  de  France  Dec.  12-19   ' 

Cholera — Foreign. 

India — Calcutta  Nov.  7-28  

India — Madras  Nov.  21-Dec.  4  

India — Rangoon  Nov.  21-28  

Indo-China — Cholen  Nov.  8-15   1 

Russia — St.  Petersburg  Dec.  15-23   89 

Straits  Settlements — Singapore ...  Nov.  15-22  

Philippine   Islands — Manila  Nov.  14-28   24 

Philippine  Islands — Provinces....  Nov.  14-28  518 

Plague — Foreign. 

Brazil — Rio  de  Janeiro  Nov.  15-29   18 

Ecuador — Guayaquil  Nov.  28-Dec.  5  

India — Bombay  Dec.  1-8  

India — Calcutta  Nov.  7-28  

India — Rangoon  Nov.  21-28  

Indc-China — Cholen  Oct.  24-Nov.  21   10 

Indo-China — Saigon  Oct.  24-Nov.  7   3 

Mauritius  Oct.  22-29   5 

Turkey — Bagdad  Nov.   6-Dec.   5   14 


200 
31 


Present. 


1,646 


31 
19 


18 
345 


Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public 
Health  and  Marine  Hospital  Service  for  the  seven  days 
ending  January  6,  igog: 

Beck,  J.  E.,  Pharmacist.  Leave  of  absence  granted  Decem- 
ber 4,  1908,  for  twenty-one  days  from  January  7,  1909, 
amended  to  read  twenty-one  days  from  January  20, 
1909. 

Cobb,  J.  O.,  Surgeon.  Leave  of  absence  granted  November 
30,  1908,  for  tifteen  days  from  December  22,  1908, 
revoked. 

CoFER,  L.  E.,  Passed  Assistant  Surgeon.  Granted  .one  day's 
leave  of  absence,  December  31,  1908. 

De  V.alin,  Hugh,  Assistant  Surgeon.  Granted  twenty-one 
days'  leave  of  absence  from  December  30,  1908. 

Goi.DBERGER,  JosEPH,  Passed  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  December  26,  1908, 
under  paragraph  191,  Service  Regulations. 

Goodman,  F.  S.,  Pharmacist.  Granted  sixteen  days'  leave 
of  absence  from  January  i,  1909. 

Grace,  John  J.,  Acting  Assistant  Surgeon.  Granted  three 
months'  leave  of  absence  from  January  10,  1909,  with- 
out pay. 

Light,  S.  D.  W.,  Acting  Assistant  Surgeon.  Leave  of  ab- 
sence granted  December  16,  1908,  for  three  days  with- 
out pay,  revoked. 

Parker,  Thomas  F.,  Acting  Assistant  Surgeon.  Granted 
five  days'  leave  of  absence  from  January  i,  1909. 

RiDLON,  Joseph  R.,  Assistant  Surgeon.  Relieved  from  duty 
at  Stapleton,  N.  Y. ;  directed  to  proceed  to  New  Or- 
leans, La.,  and  report  to  the  medical  officer  in  com- 
mand for  duty  and  assignment  to  quarters. ' 

Wetmore,  W.  O.,  Acting  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  December  18,  1908, 
under  paragraph  210,  Service  Regulations. 

Wilson,  J.  G.,  Acting  Assistant  Surgeon.  Granted  one 
days'  leave  of  absence,  December  27,  1908,  under  para- 
graph 210,  Service  Regulations. 

Army  Intelligence: 

Official  list  of  changes  in   the  stations  and  duties  of 
officers  serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  zveek  ending  January  16,  igog: 
Adair,  G.  W.,  Colonel,  Medical  Corps.    Ordered  for  exam- 
ination by  an  Army  retiring  board  at  Chicago,  111. 
Ashburn,  p.  M.,  Major.  Medical  Corps.    Ordered  from 
Fort  Banks,  Mass.,  to  Jefferson  Barracks,  Mo.,  for 
temporary  duty  and  return. 
Betts,  C.  a..  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  from  Fort  Lawton,  Wash.,  to  Fort  Worden, 
Wash.,  for  temporary  duty. 
Brooks,  W.  H.,  Captain,  Medical  Corps.    Granted  leave  of 
absence  for  one  month  on  arrival  in  the  United  States. 
Clarke,  J.  T.,  Major,  Medical  Corps.    Ordered  to  Fort 

Crook,  Neb.,  upon  return  with  troops  from  Cuba. 
D.wis,  W.  T.,   Captain.  Medical  Corps.    Relieved  from 
duty  with  Army  of  Cuban  Pacification,  and  ordered  to 
Washington,  D.  C,  for  duty  as  assistant  to  the  attend- 
ing surgeon. 

Edie.  G.  L.,  Major,  i\Iedical  Corps.  Ordered  to  Hot 
Springs,  Ark.,  for  observation  and  treatment  at  the 
Army  and  Navy  General  Hospital. 

Farr.  C.  W.,  Captain,  Medical  Corps.  Ordered  from  Fort 
]\IcKin!ey,  Me.,  to  Fort  Banks,  Mass.,  for  temporary 
duty  and  return. 

Kean,  J.  R.,  Major,  Medical  Corps.  Upon  relief  from  duty 
with  the  Provisional  Government  of  Cuba,  ordered  to 
return  to  duty  in  the  Surgeon  General's  Office,  Wash- 
ington. 

Krebs,  L.  L..  Captain,  Medical  Corps.  Relieved  from  duty 
in  the  Philippine  Division  and  ordered  to  duty  as  sur- 
geon of  the  Transport  Thomas. 

Lowe,  T.  S.,  First  Lieutenant,  Medical  Reserve  Corps.  Or- 
dered from  Fort  Walla  Walla,  Wash.,  to  Vancouver 
Barracks.  Wash.,  for  temporary  duty. 

Miller.  R.  B.,  Captain,  Medical  Corps.  Ordered  to  Fort 
Meade,  S.  D.,  upon  return  with  troops  from  Cuba. 


200 


BIRTHS,  MARRIAGES.  AND  DEATHS. 


[New  York 
Medical  Journal. 


Nichols,  H.  J.,  First  Lieutenant,  Medical  Corps.  Relieved 
From  duty  in  the  Philippines  Division ;  will  sail  on 
first  available  transport  from  Manila  for  San  Fran- 
cisco, Cal. 

O'Reilly,  R.  M.,  Brigadier  General,  Medical  Corps.  Re- 
tired from  active  service  January  14,  1909,  as  a  major 
general. 

Porter,  E.  H.,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  one  month. 

QuiNTON,  W.  W.,  Captain,  Medical  Corps.  Granted  an  ex- 
tension of  one  month  to  his  sick  leave  of  absence. 

Ragan,  C.  a.,  Captam,  Medical  Corps.  Relieved  from  duty 
at  Fort  Monroe,  Va.,  and  ordered  to  duty  as  surgeon 
of  the  transport  Kilpatrick  en  route  to  the  Philippine 
Islands ;  and  on  arrival  at  Manila,  to  duty  in  the  Phil- 
ippines Division. 

Smith,  A.  M.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  four  months,  when  relieved  from  duty  in 
the  Philippines  Division. 

Smith,  R,  D.,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  an  extension  of  one  month  to  leave  of  absence. 

Tefft,  W.  H.,  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  two  months. 

Woodson,  R.  S.,  Major,  Medical  Corps.  Relieved  from 
duty  in  the  Philippines  Division;  will  sail  March  15th 
from  Manila  for  San  Francisco,  Cal. 

Worthington,  J.  A.,  First  Lieutenant,  Medical  Corps.  Re- 
lieved from  duty  on  the  transport  Thomas,  and  or- 
dered to  duty  in  the  Philippines  Division. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of 
officers  serving  in  the  Medical  Corps  of  the  United  States 
.Vavy  for  the  week  ending  January  16,  ii)og: 
Campbell.  R.  A.,  Acting  Assistant  Surgeon.  Appointed 

an  acting  assistant  surgeon  from  January  9,  1909. 
De  Lancy,  G.  H.,  Passed  Assistant  Surgeon.  Detached 

from  the  Navy  Yard,  New  York,  N.  Y.,  and  ordered  to 

the  Naval  Medical  School- Hospital,  Washington,  D.  C, 

for  treatment. 

Fauntleroy,  a.  M.,  Passed  Assistant  Surgeon.  Detached 
from  the  Naval  Hospital,  Annapolis,  Md.,  and  ordered 
to  the  Naval  Hospital,  Philadelphia,  Pa. 

Hart,  G.  G.,  Acting  Assistant  Surgeon.  Appointed  an  act- 
ing assistant  surgeon  from  January  10,  1909. 

Iden,  J.  H.,  Passed  Assistant  Surgeon.  Orders  to  the 
Naval  Hospital,  Pensacola,  Fla.,  revoked ;  ordered  to 
the  Naval  Hospital,  Annapolis,  Md. 

Kindleberger,  C.  p..  Surgeon.  Detached  from  the  Naval 
Station,  Cavite,  P.  L,  and  ordered  to  the  Navy  Yard, 
Mare  Island,  Cal. 

Ledbetter,  R.  E.,  Surgeon.  Commissioned  a  surgeon  from 
October  11,  1908. 

Melhorn,  K.  C.,  Assistant  Surgeon.  Ordered  to  the  Navy 
Yard,  Philadelphia,  Pa.,  for  duty  in  connection  with 
fitting  out  of  the  Dixie  and  ordered  to  duty  on  board 
that  vessel  when  commissioned. 

Old,  E.  H.  H.,  Passed  Assistant  Surgeon.  Commissioned 
a  passed  assistant  surgeon  from  September  21,  1908. 

ScOTT,  T.  .W.,  Pharmacist.  Unexpired  portion  of  leave  re- 
voked ;  ordered  to  dutv  at  the  Naval  Hospital,  Annapo- 
lis, Md. 

Sellers,  F.  E.,  Passed  Assistant  Surgeon.  Commissioned 

a  passed  assistant  surgeon  from  August  i,  1908. 
Trible,  G.   B.,   Assistant   Surgeon.     Detached  from  the 

Relief  and  ordered  to 'the  Naval  Station,  Olongapo, 

P.  I.,  for  temporary  duty. 
White,  E.  C,  passed  Assistant  Sureeon.    Commissioned  a 

passed  assistant  surgeon  from  September  21,  1908. 

 ^  


Born. 

Kellogg. — In  Atlanta,  Georgia,  on  Monday,  January  iitli, 
to  Dr.  Arthur  Kellogg  and  Mrs.  Kellogg,  a  daughter. 
Married. 

Barroi-r — Akin. — In  Louisville,  Kentucky,  on  Wednes- 
day, January  6th,  Dr.  Philip  Foster  Barbour  and  Miss  Eliz- 
abeth Akin. 


HuFFiNES — Wanen. — In  Joplin,  Missouri,  on  Saturday, 
December  19th,  Dr.  Huffines  and  Miss  Natalie  Wanen. 

Lunney — Campion. — In  Darlington,  South  Carolina,  on 
Wednesday,  January  6th,  Dr.  John  Lunney  and  Miss  Mag- 
gie Campion. 

Died. 

Adams. — In  Pittsburgh,  Pennsylvania,  on  Monday,  Janu- 
ary nth,  Dr.  Lucy  Harkey  Adams,  aged  fifty-one  years. 

Baker. — In  Leon,  Iowa,  on  Saturday,  January  oth,  Dr. 
G.  W.  Baker,  aged  ninety-two  years. 

Betts. — In  Philadelphia,  on  Saturday,  January  i6th.  Dr. 
B.  Franklin  Betts,  aged  sixty-four  years. 

Brown. — In  Everett,  Massachusetts,  on  Thursday,  Janu- 
ary 7th,  Dr.  Roscoe  E.  Brown,  aged  fifty-seven  years. 

Bryan. — In  Charlotte,  North  Carolina,  on  Wednesday, 
January  6th,  Dr.  E.  S.  E.  Bryan,  aged  seventy-four  years. 

Chadburn. — In  Pasadena,  California,  on  Monday,  Janu- 
ary nth.  Dr.  E.  R.  Chadburn,  aged  fifty-three  years. 

Chapman. — In  Geneva,  Texas,  on  Monday,  January  4th, 
Dr.  R.  W.  Chapman. 

Davis. — In  Braxton,  Kentucky,  on  Monday,  January  nth. 
Dr.  H.  Clay  Davis. 

EwEL. — In  Vienna,  Maryland,  on  Saturday,  January  9th, 
Dr.  Sorrian  S.  Ewel,  aged  eighty-two  years. 

Getty. — In  Athens,  New  York,  on  Thursday,  January 
14th,  Dr.  Andrew  Henry  Getty,  aged  sixty  years. 

Geyer. — In  Frankfort,  Germany,  on  Saturday,  January 
9th,  Dr.  Harold  C.  Geyer,  of  Powerville,  N.  J.,  aged  thirty- 
four  years. 

Goodman. — In  New  York,  on  Tuesday,  January  12th,  Dr. 
Henry  L.  Goodman,  aged  thirty-six  years. 

Green. — In  Waltham,  Massachusetts,  on  Saturday,  Janu- 
ary 9th,  Dr.  George  Green,  of  Aurora,  Illinois,  aged  sev- 
enty-four years. 

Harrison. — In  Denver,  Colorado,  on  Tuesday,  December 
29th,  Dr.  Benjamin  Thomas  Harrison. 

Holcomb. — In  Whitehall,  New  York,  on  Thursday,  De- 
cember 31st,  Dr.  B.  R.  Holcomb,  aged  sixty-nine  years. 

Kerhoff. — In  Philadelphia,  on  Wednesday,  January  13th, 
Dr.  William  A.  Kerhoff. 

King. — In  Cleveland,  Ohio,  on  Friday,  January  8th,  Dr. 
Arthur  Ward  King,  aged  twenty-six  years. 

Lynd. — In  Pasadena,  California,  on  Thursday,  December 
31st,  Dr.  Earnest  Lynd,  aged  forty  years. 

Matthews. — In  Carlinville.  Illinois,  on  Friday,  January 
8th,  Dr.  John  Pitt  Matthews,  aged  sixty-four  j'ears. 

Oleson. — In  Dotsero,  Colorado,  on  Saturday,  January 
i6th.  Dr.  Arvilla  Oleson,  of  Hildreth,  Nebraska. 

RuGGLES. — In  Dorchester,  Massachusetts,  on  Monday, 
January  nth.  Dr.  Willard  O.  Ruggles. 

Russell. — In  Warren,  Pennsylvania,  on  Thursday,  Janu- 
ary 7th,  Dr.  Walter  J.  Russell,  of  Bradford,  aged  forty- 
nine  years. 

Shivers. — In  Selma,  Alabama,  on  Monday,  January  4th, 
Dr.  Offa  Lunsford  Shivers,  of  Marion,  aged  sixty  years. 

Sill. — In  Cooperstown,  New  York,  on  Monday,  Janu- 
ary nth.  Dr.  Henry  D.  Sill,  aged  forty-two  years. 

Slusher. — In  Denver,  Colorado,  on  Wednesday,  January 
6th,  Dr.  R.  S.  Slusher. 

Smith. — In  Pittsburgh,  Pennsylvania,  on  Saturday,  Jan- 
uary i6th.  Dr.  Alexander  Conde  Smith,  of  the  United 
States  Public  Health  and  Marine  Hospital  Service,  aged 
forty-five  years. 

Smith. — In  Longmont,  Colorado,  on  Tuesday,  January 
5th,  Dr.  Lowell  H.  Smith,  aged  seventy-six  years. 

Stockwell. — In  Chnrlestown,  Indiana,  on  Wednesday, 
January  6th,  Dr.  John  Stockwell,  aged  sixty-one  years. 

Stonestreet. — In  Barnesville,  Maryland,  on  Thursday, 
January  14th,  Dr.  J.  Harris  Stonestreet,  aged  forty-eight 
years. 

Wagenhals. — In  Columbus,  Ohio,  on  Saturday.  January 
9th,  Dr.  F.  S.  Wagenhals.  aged  sixty  years. 

Ward. — In  Harrisonville,  Maryland,  on  Thursday.  Janu- 
ary 7th,  Dr.  William  W.  Ward,  aged  thirty- four  years. 

Wilcox. — In  New  Albany,  Indiana,  on  Tuesday,  January 
T2tli.  Dr.  Seymour  C.  Wilcox,  aged  ninety  years. 

Williamson. — In  Jolict,  Illinois,  on  Wednesday,  January 
7th,  Dr.  Marion  F.  Williamson,  aged  seventy-six  years. 

Winters. — ^Tn  Merion  Square.  Pennsylvania,  on  Tliurs- 
d.nv.  January  T4th,  Dr.  Joseph  W.  Winters,  aged  sixty-eight 
years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  ^he  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  5. 


NEW  YORK,  JANUARY  30,  1909. 


Whole  No.  1574. 


(Anginal  (HiommuHKatiJons. 


THE  ETHICS  OF  OUR  PROFESSION.* 

By  Albert  Vander  Veer,  M.  D., 
Albany,  N.  Y. 

Webster,  in  giving  the  definition  of  "ethics,"  says, 
"The  science  which  treats  of  the  nature  and  laws  of 
the  actions  of  intelHgent  beings,  these  actions  being 
considered  in  relation  to  their  moral  qualities ;  the 
science  which  treats  of  the  nature  and  grounds  of 
moral  obligations ;  the  science  of  human  duty." 

The  Century  Dictionary  says,  "A  particular  sys- 
tem of  rules  and  regulations  concerning  moral  obli- 
gations and  regard  for  the  rights  of  others,  whether 
false  or  true ;  rules  of  practice  in  respect  to  a  single 
class  of  human  actions  and  duties ;  as  social  ethics, 
medical  ethics." 

Of  these  definitions  I  wish  to  refer,  more  particu- 
larly, to  the  terms  intelHgent  beings ;  moral  quali- 
ties ;  moral  obligations ;  the  science  of  human  duty ; 
the  rights  of  others,  whether  false  or  true ;  medical 
ethics.  In  an  analysis  of  this  subject  it  is  my  desire, 
more  especially,  to  bring  out  the  points  pertaining  to 
the  observations  I  have  made  regarding  the  attitude 
of  our  profession  toward  its  students  and  individual 
members,  and  toward  the  changes  that  have  oc- 
curred, of  which  I  have  been  cognizant  for  a  period 
of  more  than  forty  years.  That  I  may  not  be  mis- 
understood I  wish  to  state  that  it  is  not  my  inten- 
tion to  discuss  codes,  but  rather  that  side  of  the 
question  relating  to  scientific  medicine. 

My  first  thought  is  in  the  direction  of  the  discus- 
sion given  to  and  the  care  exercised  in  the  instruc- 
tion of  our  original  protoplasm,  the  medical  student. 
In  a  general  way,  what  has  been  the  attitude  of  the 
so  called  preceptor,  the  private  instructor,  the  fac- 
ulty of  our  medical  colleges?  That  the  comparison 
may  be  somewhat  more  impartial  and  impressive  let 
us  go  back  for  a  century,  and  I  might  say  here  that 
what  I  wish  to  refer  to  will  be  more  particularly  in 
connection  with  the  profession  of  our  own  State. 
The  history  of  the  care  of  the  medical  student  pre- 
vious to  that  time  will  bear  a  most  flattering  com- 
parison with  the  half  century  that  followed.  We 
are  apt  to  say  to-day  how  well  we  are  looking  after 
this  class  of  embryo  physicians,  but  in  the  good  old 
days  of  riding  about  with  the  preceptor  that  which 
was  then  acquired  is.  to  a  certain  extent,  being  lost 
at  the  present  time. 

In  the  study  of  medical  education  from  1784, 

*Read  at  the  meeting  of  the  Medical  .Society  of  the  County  of 
King?,  held  at  Brooklyn,  November  17,  1908. 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


three  forces  contended  for  nearl)-  one  hundred  years 
for  the  control  of  the  licensing  of  practitioners  of 
medicine:  ist,  the  medical  profession,  through  its 
county  and  State  societies;  2d,  the  medical  colleges, 
and  3d,  the  Board  of  Regents  of  the  University  of 
the  State  of  New  York,  and  until  more  recent  legis- 
lation very  little  actual  enforced  regulations  were 
followed  out  in  reference  to  the  education  of  the 
medical  student.  In  1787  the  law  was  amended 
authorizing  the  regents  to  visit  and  inspect  all  the 
colleges,  academies,  and  schools  of  the  State ;  it 
gave  them  power  to  confer  degrees  and  made  them 
responsible  for  the  charters  of  educational  institu- 
tions. A  great  portion  of  this  authority  has  contin- 
ued for  a  period  of  one  hundred  and  thirty  years.. 
This  original  statute  required  a  four  years.'  appren- 
ticeship with  the  provision  that  the  graduate  of  a 
college  or  university  should  serve  three  years.  In 
181  8  a  law  provided  that  attendance  at  a  medical 
school  could  be  accepted  in  lieu  of  instruction  under 
a  preceptor,  and  in  1819  an  amendment  provided  for 
resident  work  in  the  expression  "have  attended  one 
complete  course  of  lectures  delivered  by  each  of  the 
professors  of  such  college." 

The  New  York  statute  of  1853  relative  to  the  in- 
corporation of  colleges  and  academies  by  the  regents 
specifically  provided  that  no  person  should  receive 
a  diploma  conferring  a  degree  of  Doctor  of  Medi- 
cine from  a  medical  school  thus  incorporated  unless 
he  "shall  have  received  a  good  English  education, 
and  shall  have  pursued  the  study  of  medicine  and 
science  connected  therewith  for  at  least  three  years, 
and  shall  also  have  attended  two  complete  courses 
of  lectures  delivered  in  some  incorporated  medical 
college."  It  will  be  observed  that  this  statement,  "a 
.good  English  education,"  has  helped  manv  a  med- 
ical college  to  obtain  good  sized  classes,  the  facultv 
of  the  college  being  the  judges  as  to  such  a  prelim'- 
inary  education. 

Dr.  Rogers,  president  of  the  State  Medical  Soci- 
ety, referring  to  this  clause,  states  : 

In  rny  opinion  the  greatest  defect  is  in  the  preliminarv 
education  of  students  of  medicine.  Alnch  the  greater  nun-'- 
ber  of  them  are  destitute  of  classical  attainments,  and  even 
their  English  education  is  often  very  imperfect.  Not  a  few 
ot  the  graduates  in  medicine  are  unable  to  tran=Iate  a  lin'^ 
of  then-  diploma.  A  certain  degree  of  knowledge  of  the 
Latin  language  at  least  is  necessary  to  enable  the  medical 
student  to  nroflt  to  the  utmost  advantage  bv  the  books  he 
reads  and  the  lectures  he  hears.  Most  of  the  terms  in 
anatomy,  materia  medica.  botany,  and  chemistry  are  derived 
from  that  language.  Those,  therefore,  who  have  to  commit 
to  memorv  those  numberless  names  as  arbitrary  terms  havr 
a  most  irksome  labor  to  perform,  which  would  be  avoided 
had  they  understood  the  language.  Candidates  for  the  de- 
gree of  doctor  of  medicine  are  only  required  to  be  able  to 
write  an  English  dissertation  on  =ome  medical  subject  with 


202 


yANDER  VEER:  PROFESSIONAL  ETHICS. 


[New  York 
Medical  Journal. 


graniiiiatical  accuracy,  and  freedom  from  gross  violation  of 
orthography,  in  addition  to  the  requisite  knowledge  of  tlie 
several  branches  of  medicine. 

There  exists  on  our  eastern  border  a  cordon  of  medical 
schools,  some  of  which  are  so  accommodating  as  to  give 
two  courses  of  lectures  in  a  year,  to  which  the  students  of 
ihis  State  could  resort,  even  in  greater  number  than  they 
do  now,  if  the  requirements  for  degrees  were  much  higher 
with  us,  than  in  other  States.  By  the  printed  regulations 
of  some  of  the  medical  schools  of  the  adjoining  States,  it 
would  seem  that  the  requisites  for  degrees  are  higher  than 
in  this  State,  for  a  competent  knowledge  of  Latin  and  nat- 
ural philosophy  is  required;  but  notwithstanding,  it  is 
found  in  practice  that  the  want  of  such  requirements  is  no 
insuperable  objection  to  the  success  of  a  candidate  for  the 
degree. 

One  seems  to  be  reading  from  the  current  dis- 
cussions of  1907  rather  than  from  a  report  of  tlie 
progress  of  medicine  in  1837. 

The  law  of  1818  put  a  premium  on  college  studies. 
It  was  questioned  by  some  after  the  passage  of  this 
act  whether  other  cases  might  not  arise  in  which 
students  could  justly  claim  a  deduction  of  two 
years'  study,  having,  for  example,  attended  classical 
studies  for  one  year  after  the  age  of  sixteen  and 
also  attended  a  full  course  of  medical  lectures. 

We  here  find  the  source  of  legislation  enacted 
seventy  years  later.  The  law  of  1872,  which  estab- 
lished boards  of  examiners,  required  of  applicants 
for  admission  to  examination  evidence  "of  a  com- 
{)etent  knowledge  of  all  the  branches  of  learning 
taught  in  the  common  schools  of  this  State  and  of 
the  Latin  language."  In  June,  1889,  an  act  provid- 
ing for  the  preliminary  education  of  medical  stu- 
dents required  of  all  that  had  not  received  a  bacca- 
laureate degree  an  examination  under  the  regents 
in  arithmetic,  grammar,  geography,  orthography, 
American  history,  English  composition,  and  the  ele- 
ments of  natural  philosophy. 

Beginning  with  1870,  decided  unrest  showed  it- 
self in  regard  to  medical  education.  Papers  were 
presented  in  the  various  societies  by  members  of  the 
profession  advocating  a  longer  period  of  instruction 
in  our  colleges  and  better  hospital  advantages — 
laboratory  work  was  only  hinted  at — but  the  strong 
point  was  soon  brought  out  that  the  weak  factor  in 
our  medical  education  was  the  imperfect  prepara- 
tion of  our  students.  Remarkable  as  it  may  seem, 
this  was  emphasized  and  presented  more  forcefully 
in  the  attempt  made  to  secure  a  registration  of  the 
physicians  who  were  in  practice  at  that  time,  and  to 
establish  a  State  Board  of  Medical  Examiners.  I 
fancy  there  are  but  few  present  here  to-night  who 
have  any  personal  recollection  of  the  efforts  made 
in  approaching  our  legislators  regarding  this  sub- 
ject. Few  will  be  able  to  call  to  mind  the  appear- 
ance of  the  committee  rooms  at  Albany  when  "the 
seventh  .son  of  the  seventh  .son,"  the  natural  bone- 
setter,  clairvoyants,  the  so  called  dfjctors  of  every 
creed  and  "pathy,"  presented  their  claims  to  be 
recognized  and  their  rights  not  to  be  infringed  upon 
by  any  medical  legislation.  Many  years  were  spent 
in  a  fruitless  effort  to  secure  a  State  Board  of  Med- 
ical Examiners,  and  the  only  progress  made  at  first 
was  the  act  of  registration,  that  simply  required  the 
practitioner  to  register  with  the  county  clerk  his 
college  of  graduation,  whether  he  had  been  admit- 
ted to  practice  by  the  county  or  State  licensing 
board,  whether  he  held  an  honorary  degree,  or  what 
may  have  been  his  authority  of  admission. 

Singularly  enough,  during  this  period  of  medical 


evolution  there  was  appointed,  on  two  occasions,  a 
State  Board  of  Medical  Examiners,  of  which  at  one 
time  Dr.  A.  Jacobi  was  president  and  the  writer  vice 
president.  It  is  needless  to  say  that  in  the  few 
years  of  existence  of  this  board  few  applicants  pre- 
sented. However,  as  you  will  remember,  the  agita- 
tion continued,  and  resulted  in  the  establishing  of 
the  three  different  State  Boards.  The  result  of  this 
campaign  of  education  inured  to  the  benefit  of  the 
medical  student.  Preliminary  examination  was 
finally  established  by  the  colleges  in  this  State,  some 
early,  some  quite  late,  the  State  finally  enacting  a 
law,  in  i8g6,  in  connection  with  this  State  Board  of 
Medical  Examiners,  whereby  the  student  must  pre- 
sent a  certificate  of  graduation  from  some  high 
school,  or  its  equivalent  in  counts,  that  would  indi- 
cate he  had  had  a  sufficiently  well  arranged  pre- 
liminary education  to  entitle  him  to  matriculate  at 
a  medical  college.  This  was,  and  is  at  present,  the 
minimum  of  requirement,  and  just  here,  in  the  mak- 
ing up  of  counts,  has  been  the  centre  of  great  weak- 
ness. With  the  improved  methods  of  instruction, 
the  advanced  grade  of  our  high  schools,  and  the 
encouragement  to  our  medical  students  to  secure 
their  baccalaureate  degree,  a  marked  progress  has 
been  made.  When  we  take  into  consideration  the 
many  appeals  from  the  cross  roads  and  smaller 
towns  in  the  State  for  a  physician,  it  is  a  question 
whether  we  can  advance  much  farther  at  the  pres- 
ent time  in  insisting  upon  greater  requirements 
from  our  medical  students.  It  must  be  remem- 
bered that  the  advanced  student,  after  a  careful 
preliminary  education,  gives  seven  or  eight  years 
additional  work  that  will  lead  to  his  baccalaureate 
and  medical  degree,  then  one  or  two  years'  work 
in  laboratory  or  hospital,  and  reaching,  perhaps,  the 
age  of  tvv^enty-eight  before  he  becomes  a  bread- 
winner for  himself,  can  hardly  afford  to  go  to  these 
smaller  towns.  Men  who  have  not  taken  their  sci- 
entific or  academic  degree  in  the  college  of  arts 
must  be  content  since  they  are  able  to  enter  earlier 
into  the  practice  of  their  profession,  to  occupy  these 
fields  of  labor  that  carry  with  them  the  hard  prac- 
tice of  long  drives,  or  greater  physical  exertion,  and 
better  their  condition  later  as  the  opportunity  offers. 

To  require  a  preliminary  graduation  from  some 
literary  college,  or  one  year  in  the  college  of  arts, 
is,  perhaps,  somewhat  more  than  we  should  exact 
from  the  medical  student  at  present,  but  that  he 
should  be  made  to  live  up  to  the  requirements  of 
the  present  dav  is  for  his  good,  and  he  is  to  be 
congratulated  that  this  great  commonwealth  has 
taken  that  much  interest  in  his  welfare  by  establish- 
ing rules  and  regulations  that  must  ultimately  make 
him  a  stronger  and  better  professional  worker  in 
every  respect.  He  is  no  longer  to  be  left  to  his  own 
wishes  to  begin  the  study  of  medicine  when  he 
pleases,  but  he  is  to  be  impressed  with  the  idea  that 
after  his  preliminary  work  has  been  accomplished 
as  a  student,  say  at  the  age  of  sixteen,  he  can  then 
make  a  selection,  and  his  choice  being  in  the  direc- 
tion of  the  study  of  medicine  he  is  given  ample  op- 
portunity to  conserve  his  time  and  forces  by  choos- 
ing an  elective  method.  By  giving  his  time  and  at- 
tention from  then  on  he  can  secure  a  thorough  med- 
ical education,  with  which  he  ma\  be  well  pleased, 
and  which  will  be  recognized  the  world  over. 

.\s  is  well  known  for  several  vears  I  have  advo- 


January  30,  1909.] 


I'AXDER  VEER:  PROFESSIONAL  ETHICS. 


203 


cated  a  combined  course  whereby  the  student  could 
enter  upon  his  studies,  and  secure  his  baccalaureate 
and  medical  degree  sufficiently  early  so  as  to  begin 
his  professional  life  at  a  less  advanced  age.  It 
seems  to  me  that  the  University  of  Rochester  has 
made  very  clear  the  method  whereby  this  combined 
course  can  be  carried  out,  by  the  following  resolu- 
tion of  the  faculty,  adopted  April  8,  1908:  "Re- 
solved, That  any  student  who  wishes  to  save  a  year 
in  securing  the  combined  degrees,  may  enter  in 
any  one  of  the  courses  for  the  bachelor's  degree, 
and  arrange  with  his  class  officer  to  complete  in 
three  years  the  prescribed  studies  in  his  course ;  he 
may  then  proceed  to  an  approved  medical  school, 
with  the  understanding  that  the  Rochester  faculty 
will  accept  for  one  year  of  college  work  an  equiva- 
lent amount  in  medical  subjects  of  a  character  which 
this  faculty  judges  to  be  suitable  to  receive  college 
credit.  On  completion  of  this  work  the  student  will 
return  to  Rochester  to  receive  his  degree.  Medi- 
cal schools  which  maintain  a  high  standard  of  re- 
quirements for  admission  will  ordinarily  cover  in 
the  first  year  subjects  which  Rochester  will  accept 
as  an  equivalent  for  the  fourth  year  of  college  work. 
A  student  who  has  completed  such  a  year  in  medi- 
cine will  be  able  to  take  his  bachelor's  degree  with 
the  class  of  which  he  was  a  member  in  college." 

President  Butler  has  said  on  this  subject:  "It 
will  be  observed  that  the  Rochester  plan  has  the  ad- 
vantage of  offering  'to  the  individual  student  in  a 
separate  college  the  advantages  of  the  combined 
courses  without  -involving  the  college  in  expense 
and  without  depriving  the  student  of  his  member- 
ship in  his  separate  college.  He  may  choose  to  pur- 
sue the  study  of  medicine  at  any  one  of  a  dozen  uni- 
versity medical  schools,  but  he  remains,  in  sentiment 
and  in  feeling,  a  student  of  the  University  of 
Rochester,  is  graduated  with  his  class,  and  takes  his 
place  with  its  alumni.  If  it  be  objected  that  by  this 
plan  a  student  passes  one  of  the  best  years  of  his 
college  life  in  another  institution  than  that  to  which 
he  is  to  owe  allegiance,  the  answer  is  that  if  this 
opportunity  be  denied  him  he  is  likely  to  pass  all 
the  years  of  his  undergraduate  life  in  another  in- 
stitution. The  Rochester  plan,  in  other  words,  ap- 
pears to  point  to  a  practicable  plan  by  which  the 
separate  colleges  may  save  their  alumni  by  shar- 
ing their  students.  It  certainly  seems  to  be  wiser 
than  any  alternative  that  has  yet  been  suggested.'' 

Then  I  would  say  that  the  ethics  of  our  profes- 
sion, in  the  direction  of  caring  for  our  medical  stu- 
dents, have  been  most  commendable.  In  the  estab- 
lishing of  laboratories,  in  connection  with  our  col- 
leges and  hospitals,  we  have,  perhaps,  done  more 
tor  the  student  than  has  been  fully  understood  or 
appreciated.  The  student  who  follows  out  his  course 
carefully  in  laboratory  work  becomes  a  thinker,  and 
when  once  this  development  of  his  brain  cells  is 
brought  about  he  becomes  a  more  valuable  member 
of  our  profession.  The  thorough  working  student 
in  the  laboratory  becomes  the  thorough,  careful 
younger  member  of  our  profession,  who  collates  his 
notes  judiciously,  and  his  mental  digestion  is  such 
that  he  is  able  to  make  safe  application  of  the  facts 
he  has  acquired  when  he  comes  into  actual  practice. 
It  is  delightful  to  see  the  way  in  which  some  of  the 


younger  men  of  our  profession  approach  their  cases 
at  the  present  time. 

If  1  were  to  be  somewhat  reminiscent  tonight  I 
might  go  back  and  refer  to  my  student  days,  when 
so  little  was  known  of  the  proper  analysis  of  urine, 
and  when  the  various  functions  of  the  organs  of 
the  human  body  were  so  little  understood ;  when  an 
examination  of  the  sputum,  to  aid  us  in  the  diag- 
nosis of  our  respiratory  diseases,  was  unknown ; 
when  an  observation  of  the  excretions  of  the  intes- 
tinal tract  in  their  macroscopic  appearance  was 
repugnant;  careful  microscopical  and  chemical  ex- 
amination of  the  secretions,  also  the  analysis  of  the 
blood,  and  a  proper  understanding  of  blood  pres- 
sure, were  unthought  of,  and  yet  how  valuable  do 
we  consider  them  to-day.  How  great  has  been  the 
advance. 

Then  let  me  say,  let  us  be  just  to  our  student, 
not,  perhaps,  exacting  the  absolute  graduation  from 
a  college  of  arts,  possibly  not  so  far  as  to  exact  the 
year  that  is  now  being  discussed  so  earnestly.  Glad- 
ly would  I  see  it  accomplished,  but  let  our  laws  of 
to-day  see  that  our  high  schools  do  their  work  thor- 
oughly well.  Let  us  encourage  them  to  secure  their 
baccalaureate  and  medical  degree,  and  if  the  latter 
is  not  possible,  then  give  the  best  attention  to  the 
medical  education  that  is  to  be  secured  in  our  med- 
ical colleges,  and  in  our  hospital  and  laboratory 
instruction. 

The  laws  of  New  York  State  provide  for  prelim- 
inaries which  should  vouchsafe  for  the  profession 
such  a  status  as  to  morals  and  ethics  as  would  cause 
an  intending  violator  of  our  unwritten  code  to  pause. 
Before  being  admitted  to  examinations  for  license, 
the  candidate  must  have  had  a  high  school  (stand- 
ard) education  or  its  equivalent;  he  must  have 
graduated  after  four  full  years  of  study  from  a 
school  of  medicine  recognized  as  standard  and  must 
be  vouched  for  as  to  character  and  morals  by  at 
least  two  known  members  of  the  profession. 

President  Nicholas  Murray  Butler,  in  his  Annual 
Report  to  the  Trustees  of  Coliimhia  University,  re- 
cently published,  presents  in  a  most  forceful  manner 
the  subject  of  education  pertaining  to  the  students 
in  the  profession  of  medicine,  law  and  engineering. 
In  the  former  he  advocates  the  six  years'  combined 
course  and  I  quite  agree  with  him  in  his  conclu- 
sions. 

He  says:  'Tf  one  may  judge  by  the  evidences  of 
favor  with  which  the  combined  course  has  been  re- 
ceived, it  bids  fair  to  be  well  nigh  universal  through- 
out the  United  States  before  many  years  have 
passed.  Of  the  twenty  largest  universities  in  the 
United  States  offering  instruction  in  law  or  medi- 
cine, or  both,  as  shown  in  Bulletin  No.  2  of  the 
Carnegie  Foundation  for  the  Advancement  of 
Teaching  (Table  II,  pp.  10,  ii),  all  but  two.  Har- 
vard and  Johns  Hopkins,  make  provision  whereby 
a  student  may  count  certain  academic  courses  for 
the  bachelor's  degree  and  for  a  professional  degree, 
thereby  shortening  his  university  residence  by  at 
least  one  year.  In  addition  to  Columbia,  these  insti- 
tvitions  are :  Chicago,  Michigan,  Yale,  Cornell,  Illi- 
nois, Wisconsin,  Pennsylvania,  California.  Stanford, 
Minnesota.  Ohio,  Nebraska,  Missouri,  New  York, 
Northwestern,  Texas,  and  Syracuse.    In  a  majority 


204 


PANDER  VEER:  PROFESSIONAL  ETHICS. 


[New  York 
Medical  Journal. 


of  these  institutions,  namely,  Columbia,  Chicago, 
Michigan,  Yale,  Illinois,  Wisconsin,  California, 
Stanford,  Minnesota,  Nebraska,  Missouri,  and 
Northwestern,  the  requirements  for  a  baccalaureate 
and  a  medical  degree  may  be  completed  by  a  thor- 
oughly prepared  and  devoted  student  in  six  years." 

This  address  should  be  carefully  studied  by  every 
one  interested  in  medical  education 

I  believe  this  method  would  induce  a  large  pro- 
portion of  our  graduates  of  high  schools  to  take  the 
two  additional  years  in  a  college  of  arts,  if  thereby 
they  could  secure  their  bachelor's  degree. 

Next  let  us  consider  somewhat  the  standing  of 
our  younger  graduates,  the  members  of  our  profes- 
sion. What  have  we  accomplished  in  a  period  of  a 
half  century,  historically  a  little  more  than  that,  for 
the  development  of  the  ethics  along  the  lines  given 
U5  in  the  definition  at  the  beginning  of  this  paper? 

Coming,  more  especially,  to  the  recognition  and 
practice  of  our  profession,  we  must  briefly  review 
what  has  been  the  attitude  of  the  commonwealth  in 
protecting  the  public,  by  demanding  that  all  prop- 
erly qualified  doctors  do  what  they  profess  to  do, 
and  perform  their  full  duty  in  caring  for  the  sick. 

Dr.  Draper,  state  commissioner  of  education,  in 
a  recent  able  address,  asked  the  question  "What  is 
our  profession,  anvway?"  and  goes  on  to  say,  ''It 
is  an  association  of  persons  united  in  spirit  because 
engaged  in  the  same  business,  occupied  by  the  same 
studies,  and  moved  by  the  same  aims.  The  busi- 
ness cannot  be  performed  by  mere  physical  efifort, 
nor,  indeed,  by  mere  repetition  and  copying.  It  is 
intellectual  business  and  must  rest  upon  a  scientific 
basis.  There  must  be  training  for  it  which  will 
enable  one  to  recognize  somewhat  obscure  indica- 
tions, to  ascertain  facts  on  his  own  account,  to  rea- 
son logically  about  them,  and  to  come  to  inde- 
pendent conclusions  worthy  of  the  common  support 
of  all  because  the  conclusions  are  the  inevitable  re- 
sult of  man's  sincere,  intellectual  experimental 
study  of  God's  unalterable  truths.  Between  these 
persons  there  must  be  respect  and  fraternity ;  there 
must  be  genuineness  and  generosity.  Jealous  re- 
gard for  the  honor  of  the  guild  must  control  the 
meannesses,  which  were  given  in  some  measure  to 
all  of  us,  and  genuine  enthusiasm  for  the  success 
of  the  guild's  business  must  travel  in  double  harness 
with  earnest  desire  for  the  progress  of  the  world's 
good.  Moving  and  inspiring  these  persons  there 
must  be  a  proud  history,  stirring  traditions,  time 
honored  usages,  mountain  peaks  of  particular 
achievement,  and  a  literature  with  substance,  flavor, 
and  inspiration  in  it." 

Acting,  then,  in  the  capacity  of  intelligent  be- 
ings, what  has  been  our  attitude  toward  the  rights 
of  those  who  have  presented  important  subjects, 
and,  at  times,  have  made  serious  criticisms  regard- 
ing our  moral  obligations  as  receptive  beings,  and 
our  methods  of  carrying  out  the  doctrine  of  man's 
duty  in  respect  to  himself,  to  his  profession,  and 
that  of  the  public  at  large?  If  I  read  aright  the 
growing  sentiment,  which  has  gradually  evolved 
during  the  past  fifty  years,  it  is  this:  That  it  is  our 
duty  to  be  more  frank  with  our  patients  and  to  the 
public  in  giving  them,  so  far  as  our  scientific  knowl- 
edge and  their  welfare  will  permit,  a  clear  state- 


ment of  their  case  and  its  bearing  upon  their  present 
and  prospective  health. 

I  must  say  I  lean  in  the  direction  of  believing  that 
a  truthful  statement  should  be  made  to  those  pa- 
tients in  whom  we  realize  there  is  absolutely  no 
known  organic  lesion,  but  an  undeveloped  field  of 
nerve  function  at  fault  necessitating  treatment,  not 
through  hospitals,  sanitoria,  or  foreign  trips,  but 
through  an  appeal  to  the  conscience  of  the  individ- 
ual. This  course  might  be  said  by  some  to  favrr 
Christian  science.,  but  it  would  have  counteracted 
many  of  the  evils  caused  by  a  belief  in  that  doc- 
trine. Those  whose  personal  efforts  were  needed 
would  be  helped  and  valuable  lives  saved  where 
other  treatment  was  necessarv. 

The  history  of  medicine  shows  that  medical  men 
have  not  been  imbued  with  a  liberal  spirit.  Sci- 
ence has  ever  had  to  battle  with  superstition  and 
with  fears,  with  the  "eternal  fitness  of  things,"  and 
with  jeers.  A  truth  once  ascertained  surrounds  it- 
self with  a  wall  of  smugness,  and  the  new  facts  to 
be  derived  therefrom  are  frequently  barred  from 
exploitation  by  the  very  disciples  of  the  new  idea. 
Does  any  one  suppose  that  homoeopathy  would  to- 
day be  a  sect  of  its  own  had  the  contemporaries  of 
Hahneman  given  proper  attention  to  his  theories 
and  their  application,  had  they  weighed  thoroughly 
the  contention  of  the  day  that  the  abuses  of  medi- 
cine, as  manifested  in  the  immense  dosage  system 
then  in  vogue,  was  an  evil  demanding  mitigation? 
Is  it  presumable  that  osteopathy  would  have  grown 
to  such  proportions  if  surgeons  had  recognized  the 
minor  ills  of  their  patients,  studied  their  needs  and 
applied  themselves  to  their  relief,  instead  of  re- 
ferring them  to  incompetent  assistants,  masseurs, 
and  nurses  ? 

In  the  days  of  long  ago  medicine  reared  itself  on 
a  pedestal  and  arrogated  to  itself  the  sum  total  of 
all  knowledge  pertaining  to  all  of  the  sciences. 

To-day  we  are  living  in  an  age  as  different  as  it 
is  remote  from  the  one  mentioned.  Views  are 
brighter,  the  people  are  more  enlightened  and  hence 
more  exacting.  The  average  layman  cares  naught 
for  conventions  and  scoffs  at  ways  and  means  when 
bodilv  comfort  and  the  health  of  his  family  are  at 
stake.  The  medical  profession  has  failed  to  recog- 
nize this,  and  so  it  has  come  to  pass  that  the  hal- 
lowed relations  between  patient  and  physician  have 
become  a  mejnory. 

Wherein  lies  the  cause  of  the  changed  state  of 
affairs  which  makes  the  medical  man  of  to-day  less 
than  the  doctor  of  a  century  ago?  \\'e  are  our- 
selves at  fault.  The  city  which  fails  to  meet  the 
needs  of  its  citizens  of  to-day.  and  to  anticipate  the 
needs  of  its  future  inhabitants,  is  not  abreast  of  the 
times !  Is  this  not  equally  true  of  the  medical  pro- 
fession ? 

Why  not  then  avail  ourselves  of  the  opportunity 
at  our  very  doors  to  instil  the  fruit  of  the  wisdom 
gleaned  by  the  specialists  in  the  laboratory  and  in 
the  clinic,  at  the  operating  table  and  in  the  sick 
room  ?  Public  acknowleclgmcnt  of  such  service 
would  be  generously  accorded,  and  the  proud  ac- 
claim which  would  thus  reach  the  profession  would 
in  turn  create  an  unwritten  code  of  ethics  in  the 
minds  and  m  the  hearts  of  the  peo])le  such  as  no  set 


January  30,  1909.] 


VANDER  VEER:  PROFESSIONAL  ETHICS. 


205 


of  resolutions  adopted  by  the  unanimous  vote  of  all 
the  doctors  of  the  country  in  convention  gathered 
could  hope  to  equal. 

The  nobility  of  our  calling  has  not  abated  one  jot 
and  aggressiveness  along  all  scientific  lines  should 
run  on  all  fours  with  the  pronouncement  of  doc- 
trines tending  to  still  farther  dignify  the  calling  of 
medicine.  The  aloofness  which  marked  the  doctor 
in  the  past  should,  however,  be  dissipated  the  mo- 
ment he  enters  upon  his  active  life  career.  His 
morals  having  been  conserved,  he  can  safely  enter 
the  arena  of  life  with  a  zest  for  accomplishment 
which  will  be  stimulated  with  every  additional  act 
of  aggression  along  the  lines  of  public  benefaction, 
and  the  code  of  ethics  which  the  public  will  have 
established  for  him  will  prove  to  be  the  needle  point- 
ing to  the  north  pole  of  his  success. 

Dr.  Draper  speaks  of  us  as  a  "guild,  an  association 
of  members  seeking  scientific  truths."  To  this  I 
would  add  that  in  the  early  evolution,  and  in  the 
later  decades,  when  medicine  was  first  taught  as  a 
profession,  and  in  the  advancement  that  has  since 
taken  place,  I  know  of  no  other  profession  that  has 
shown  so  unselfish  and  earnest  a  devotion  to  the 
elimination  of  false  factors.  What  profession  has 
ever  exhibited  so  great  a  desire  to  secure  knowl- 
edge by  which  its  members  may  be  enabled  to  ac- 
quire honor,  reputation,  and  livelihood,  and  by 
which  humanity  may  be  benefited  ?  What  is  nobler 
than  tlie  relief  of  sufifering,  such  as  has  been  ac- 
complished by  vaccination?  This  was  the  out- 
growth of  vivisection,  and  yet  there  are  those  who 
give  of  their  ability  and  furnish  aid  to  those  who 
attempt  to  criticise  and  destroy  the  good  that  is  so 
absolutely  evident ;  however,  these  are  of  the  class 
whose  rights  we  must  respect,  even  though  we  be- 
lieve them  to  be  in  the  wrong. 

I  have  in  my  possession  possibly  as  valuable  a 
correspondence  and  collection  of  facts  as  is  often 
found  bearing  upon  the  so  called  Amick  treatment 
of  consumption,  wherein  a  physician  expressed  the 
early  belief  there  was  no  real  merit  in  the  remedy, 
he  having  investigated  it  thoroughly.  He  was 
threatened  with  a  libel  suit,  in  which  I  was  con- 
sulted, and  advised  him  to  stand  firmly  to  his  as- 
sertion ;  that  I  had  no  doubt  the  law  would  ultimate- 
ly sustain  his  decision.  We  all  know  what  became 
of  the  Amick  cure,  and  this  is  only  one  of  a  num- 
ber of  such  conditions  presenting  from  time  to  time, 
but  I  do  not  think  it  wise,  nor  in  keeping  with  the 
ethics  of  our  profession,  to  attack  individuals  who 
may  present  something  on  the  subject  of  medicine 
or  surgery,  that  has  in  it  any  substance  or  value 
that  will  attract  the  attention  of  the  public  at  large, 
or  to  absolutely  ignore  it  with  a  brutality  of  asser- 
tion that  almost  immediately  makes  friends  for  its 
author,  however  much  they  may  be  in  the  wrong. 
We  cannot  say  that  our  diagnosis  is  always  so  abso- 
lutely correct  that  we  do  not  err,  or  that  some  intel- 
ligent jurist,  clear  thinking  business  man,  or  honest 
theologian  cannot  criticise. 

There  is  a  feeling  on  the  part  of  certain  families 
that  the  doctor  is  not  to  be  received  with  that  pro- 
found and  cordial  respect  which  perhaps  at  one 
time  was  too  confiding.  We  must  eliminate  this 
spirit,  that  is  almost  in  the  line  of  cynical  criticism. 
It  is  a  comfort  to  know  that  part  of  our  ethics  has 


been  in  this  direction,  that  above  all  "pathies"  and 
methods  of  advertising  there  is  constant  progress 
in  the  line  of  scientific  medicine.  I  am  of  the  im- 
pression that  in  no  period  since  we  were  known  as 
a  profession  has  there  been  such  an  advance  and 
such  a  clear  reaching  of  the  truth,  as  in  the  last 
three  decades.  In  an  audience  like  this,  in  an  at- 
mosphere where  has  been  developed  some  of  the 
best  work  in  modern  aseptic  surgery  and  operative 
skill,  it  does  not  become  me  to  review  or  cover  this 
ground  anew.  I  wish  to  take  this  opportunity  of 
placing  on  record  my  profound  gratitude  for  be- 
longing to  a  profession  in  that  portion  of  which  the 
best  years  of  my  life  have  been  spent,  which  has 
solved  so  many  serious  problems,  and  done  so  much 
to  make  the  department  of  surgery  a  fixed  science. 
Already  it  has  brought  to  bay  and  held  the  legal 
mind,  and  Stopped  the  question  that  used  to  be  pro- 
pounded with  such  subtle  force,  i.  e.,  "Doctor,  the 
science  of  medicine  and  surgery  is  not  a  fixed  one, 
is  it?"  To  a  great  extent  we  may  say  that  it  is, 
and  that  it  applies  with  great  force  to  the  depart- 
ment of  medicine.  Think  for  just  one  moment 
what  has  been  accomplished  by  our  absolute  knowl- 
edge of  the  JEtiology  of  cholera,  of  malaria,  and 
yellow  fever ;  knowledge  that  has  been  acquired  by 
the  careful  study  of  the  habits  of  mosquitoes,  car- 
ried out  by  members  of  our  own  profession.  It  was 
my  good  fortune  to  be  an  eye  witness  to  these  ex- 
periments, as  they  were  conducted  in  Cuba. 

Think  of  the  positive  facts  now  presented  in  re- 
gard to  the  activities  of  rats  and  fleas  in  the  trans- 
mission of  bubonic  plague ;  consider  the  remarkable 
advances  made  by  the  discovery  of  the  bacillus  of 
tuberculosis,  and  the  treatment  carried  out  for  the 
eradication  of  that  disease.  Did  time  permit  it 
would  give  me  personal  comfort  to  refer  to  my  early 
impressions  made  by  the  discovery  of  several  cases 
of  phthisis  occurring  in  one  family,  and  witnessing 
a  same  recurrence  when  another  family  moved  into 
the  already  infected  house.  The  mystery  so  great 
then  is  clearly  solved  at  present,  and  the  public  does 
not  criticise,  but  gives  just  endorsement  to  our  pro- 
fession. Seldom  has  the  investigation  of  any  one 
disease  brought  so  much  credit  to  the  physician,  and 
in  which  he  has  given  so  freely  of  his  time,  as  in 
the  discovery  of  the  origin  of  typhoid  fever.  Who 
can  estimate  how  much  good  has  resulted  from  the 
advice  given  by  the  physician  to  the  public  on  this 
subject,  and  how  cruel  has  been  the  judgment  vis- 
ited upon  the  communities  that  have  neglected  to 
follow  out  this  advice  and  admonition. 

Preventive  medicine  is  not  to  be  neglected.  The 
investigation  that  has  been  carried  out  in  reference 
to  the  house  fly  demands  our  most  earnest  consid- 
eration, and  great  credit  is  due  that  public  spirited 
organization,  the  Merchants'  Association  of  New 
York,  for  their  work  in  this  direction  and  also  in 
regard  to  the  pollution  of  our  water  sources,  and 
disposal  of  house  sewage. 

In  the  study  of  milk  supplies  one  cause  of  intes- 
tinal diseases  in  children  is  clearly  defined. 

The  ethics  of  our  profession,  as  I  have  endeav- 
ored to  define  them  in  the  beginning  of  this  paper, 
have  brought  about  most  wonderful  results.  Men 
of  my  age  in  early  practice  look  back  with  sorrow 
to  the  death  of  manv  a  loved  one  from  cholera  in- 


206 


VANDER  VEER:  PROFESSIONAL  ETHICS. 


[New  York 
Medical  Journal. 


fantum  that  medicine  did  not  reach.  The  proper 
understanding  of  these  conditions  has,  to  a  large 
extent,  eliminated  medication.  Sanitary  conditions 
and  the  removal  of  unhealthy  surroundings  have 
been  the  materia  medica  and  therapeutics  that  have 
brought  a  percentage  of  recoveries  most  pleasing  to 
the  scientific  physician. 

This  paper  cannot  attempt  to  properly  analyze 
the  work  in  bacteriology  and  pathology,  but  to  sim- 
ply refer  to  that  one  very  important  factor  in  their 
brilliant  investigations,  i.  e.,  the  development  and 
use  of  the  laboratory.  It  has  always  seemed  to  me 
that  laboratories,  like  hospitals,  should  be  endowed, 
and  that  the  splendid  work  done  by  Mr.  Rockefeller 
and  others  is  to  be  our  aid.  Not  a  direct  sum  of 
money  or  financial  aid  to  be  given  to  the  body  of 
men  who  may  call  themselves  professors,  and  are 
organized  as  a  faculty  to  continue  instructions  to 
our  students,  on  older  methods,  or  on  recent  lines 
of  advanced  teaching,  such  as  we  have  briefly  re- 
ferred to,  but  rather  in  the  direction  of  the  investi- 
gation of  facts  that  may  result  in  benefit  to  the  pro- 
fession and  to  the  patient.  I  have  no  doubt  that  the 
donor  of  millions  for  research  work  to  develop  the 
germ  and  the  serum  that  will  cure  cerebrospinal 
meningitis  and  exophthalmic  goitre  has  been  fully 
repaid  by  the  knowledge  that  he  has  been  the  means 
of  saving  life  and  benefiting  the  human  race.  This, 
it  seems  to  me,  constitutes  the  ethics  of  our  pro- 
fession. It  requires  the  best  minds,  the  combina- 
tion of  the  scientist,  pathologist,  and  physician, 
those  who  possess  a  judicial  brain,  and  it  is  the 
moral  obligation  of  each  to  retain  within  our  fold 
and  to  properly  assimilate  whatever  may  be  pre- 
sented that  is  right. 

During  all  these  advances,  in  all  that  pertains  to 
the  better  development  of  our  profession,  there  has 
rightfully  come  into  the  field  the  so  called  specialist. 
There  was  never  yet  an  advance  in  scientific  medi- 
cine of  real  value  that  the  charlatan  and  ignorant 
were  not  willing  to  make  use  of,  yet  their  lack  of 
knowledge  of  the  fundamental  principles  of  our  pro- 
fession has  generally  driven  them  to  the  wall. 

Take,  for  instance,  the  orificial  surgeons,  who,  a 
few  years  ago,  when  the  subject  of  haemorrhoids 
was  so  thoroughly  discussed,  attempted  to  establish 
a  pathy  by  themselves.  These  very  discussions, 
however,  have  resulted  in  good  to  our  profession, 
yet  it  is  a  very  difficult  problem,  in  the  presence  of 
the  public,  to  maintain  the  advances  we  often  gain, 
and  not  to  yield  to  the  individuals  who  claim  merit 
for  some  wonderful  discovery  and  of  which  they  are 
entirely  unworthy.  Here,  it  appears  to  me,  we  must 
exercise  our  greatest  patience.  In  this  State,  as  I 
view  the  situation,  we  are  passing  through  a  period 
of  great  trial,  but  we  have  entered  upon  solid 
ground ;  we  have  in  our  medical  laws  of  to-day  a 
foundation  that  is  to  lead  to  ultimate  good,  but  we 
must  remember  that  as  yet  we  are  not  free  from 
criticism.  Errors  of  judgment  exist  even  now  as  of 
old.  We  cannot  in  any  manner  relax  our  thorough 
investigation  of  cases  and  our  endeavor  to  present 
lines  of  treatment  for  relief  of  the  sick. 

The  Thompsonian  practice  was,  at  one  time,  rec- 
ognized by  the  laws  of  this  State  as  a  special  prac- 
tice. There  has  been  so  persistently  presented  to 
our  legi.slators  .some  phases  of  medical  science,  like 


that  of  osteopathy  and  optometry,  that  it  became 
necessary  to  have  their  rights  defined,  and  when 
those  who  choose  such  a  line  of  practice  were  com- 
pelled to  have  their  preparation  for  that  work  regu- 
lated by  the  State  as  in  scientific  medicine.  The 
good  they  possess  will  soon  be  assimilated,  and 
decades  to  come  will  see  a  harmony  of  action  that 
must  inure  to  the  healing  of  the  sick,  and  in  this 
manner  the  moral  qualities,  the  moral  obligations, 
and  the  medical  ethics  of  our  individuals  will  be 
sustained.  We  must  cultivate  a  broad  spirit  of  faith 
in  the  men  whom  we  call  our  State  legislators.  A 
close  acquaintance  for  many  years  with  not  a  few 
who  come  under  this  classification  leads  me  to  as- 
sert that  they  are  often  cruelly  and  undeservedly 
criticised.  I  wish  to  emphasize  the  assistance  ren- 
dered us  by  worthy  members  of  the  legislature  when 
we  were  securing  our  early  medical  laws  in  this 
State.  I  might  refer  with  pride  and  gratitude  to 
the  members  of  the  Finance  Committee,  in  the  Sen- 
ate, especially  Senator,  and  afterward  Governor, 
Higgins,  Senator  Elsworth,  Senator  Erwin,  and 
others,  when  we  were  endeavoring  to  have  the  State 
take  an  interest  in  the  research  work  in  the  study 
of  tetanus  and  pneumonia.  What  has  been  accom- 
plished in  the  past  few  years  in  the  treatment  of 
diphtheria  is  now  possible  in  the  treatment  of  tetanus. 
At  present,  through  the  generosity  of  our  lawmak- 
ers, and  the  endorsement  of  our  energetic  State 
commissioner  of  health,  our  State  Laboratory  is 
able  to  furnish  every  health  officer,  in  every  town, 
be  it  ever  so  small,  with  the  serum  for  the  treatment 
of  diphtheria  and  tetanus  without  cost.  I  only  touch 
upon  this  as  one  of  the  many  good  things  that  can 
be  said  in  behalf  of  what  our  lawmakers  have  done 
for  us. 

We  now  have  a  law  giving  us  the  one  board  of 
medical  examiners,  accomplished  through  the  ef- 
forts of  the  majority  of  the  doctors  of  this  State. 
This  is  yet  on  trial,  but,  I  believe,  notwithstandirrg 
the  discouragements  occurring  at  present,  it  will 
produce  such  a  vast  amount  of  good  as  to  ultimate- 
ly sustain  itself,  and  be  the  means  of  advancing  sci- 
entific medicine  and  the  ethics  of  our  profession  in 
such  a  manner  as  no  other  enactment  has  brought 
about.  We  have  certain  environments  that  are 
somewhat  difficult  to  overcome,  but  I  assure  }-ou  we 
are  passing  through  an  analysis  of  the  rights  in  the 
appointment  of  the  members  of  this  board  that  will 
soon  clear  this  atmosphere. 

We  have  led  in  this  State  for  man}-  years  in  ad- 
vanced medical  education.  I  am  not  at  the  present 
time  one  of  that  number  who  are  pessimistic  re- 
garding the  future.  I  believe  we  have  a  bright  out- 
look, and  that  if  we  study  the  ethics  of  our  profes- 
sion aright  it  will  be  in  the  line  of  upbuilding  and 
not  of  criticism  and  tearing  them  down  that  will 
succeed.  We  will  always  have  serious  problems  to 
solve. 

To  sum  up,  then,  what  have  we  gained  in  all  these 
years? 

1,  A  clearer  insight  into  the  history  and  develop- 
ment of  the  ethics  of  our  profession. 

2,  A  gradual  but  certain  protection  to  the  medical 
student  in  his  preparation  for  the  study  of  medi- 
cine. 

3,  Laws  that  oblige  whatever  sect  may  desire  to 


January  30,  1909.] 


BUTLER:  SERUM  DIAGNOSIS  OF  SYPHILIS. 


207 


practise  medicine  to  acquire  a  knowledge  of  the 
principles  of  that  work  which  is  basic  to  the  profes- 
sion. 

4,  That  there  shall  be  no  short  cut  to  the  practice 
of  medicine  or  any  branch  of  the  honorable  calling. 

5,  That  which  is  equally  valuable  with  compell- 
ing laws — a  harmonizing  of  the  desires  of  the  prac- 
titioners in  all  schools  to  elevate  the  profession. 

6,  A  spirit  of  hearty  cooperation  among  all  prac- 
titioners to  stop  acrimony  and  recrimination  and  to 
work  only  idv  the  common  purpose  of  elevating  the 
profession. 

28  Eagle  Street. 


THE  SERUM  DL\GNOSIS  OF  SYPHILIS  AND  ITS 
CLINICAL  VALUE. 

By  W  illiam  J.  Butler,  M.  D., 
Chicago. 

In  1902  Bordet  showed  that  it  was  possible  to  de- 
termine the  bacteria  causing  an  infection  by  an  ex- 
amination of  the  blood  serum  by  a  special  method 
known  as  complement  deviation.  Complement  is  a 
substance  present  in  the  blood  of  man  and  animals. 
It  is  destroyed  or  rendered  inactive  by  heating  blood 
serum  to  56°  C.  for  one  half  hour,  on  account  of 
which  property  it  is  called  thermolabile. 

When  the  body  is  invaded  by  any  pathogenic 
organism  which  sets  up  the  infection  it  is  capable  of 
producing,  the  body  cells  react  against  the  infecting 
organism  and  its  products,  producing  an  opposing 
body  that  finds  its  way  into  the  blood  stream.  This 
is  called  an  immune  or  antibody,  which  is  also  called 
an  amboceptor,  the  purpose  of  which  is  to  destroy 
in  the  special  manner  peculiar  to  it  the  infectious 
agent.  This  amboceptor  is  unaffected  by  heating 
the  blood  serum  in  which  it  is  contained  to  56°  C. 
for  one  half  hour,  and  it  is  therefore  termed  thermo- 
stabile.  Other  substances,  as  blood  corpuscles,  pro- 
teids,  lipoids,  etc.,  may  ^Iso  give  rise  to  the  forma- 
tion of  antibodies  when  injected  into  the  body. 

An  individual  suflfering  from  an  infection,  there- 
fore, will  have  in  his  blood  serum  two  substances, 
■one  called  complement,  which  is  present  in  all  blood 
sera,  and  a  second  specific  substance  known  as  an 
antibody  or  amboceptor,  the  first  being  destroyed  by 
a  certain  temperature  (56°  C.)  in  a  half  hour,  and 
the  second  unaffected  thereby. 

The  amboceptor  or  antibody  has  two  points  of 
affinity,  one  of  which  will  always  unite  with  the  bac- 
terium or  product  the  injection  of  which  gives  rise  to 
its  production  by  the  body,  and  the  other  with  com- 
plement when  it  is  present,  this  union  causing  the 
destruction  of  the  bacteria  or  toxic  product.  This 
action  will  occur  in  a  test  tube  under  favorable  con- 
ditions as  well  as  in  the  body. 

The  following  is  an  example  :  If  you  inject  into 
an  animal  of  one  species,  as  represented  by  the 
rabbit,  the  blood  corpuscles  of  another,  as  repre- 
sented by  the  sheep,  the  rabbit  will  react  against  the 
foreign  corpuscles,  producing  an  antibody,  called 
in  this  instance  a  hsemolytic  amboceptor.  This  ambo- 
ceptor has,  as  mentioned  before,  two  points  of  affin- 
it> ,  one  of  which  will  unite  with  sheep'?  corpuscles 
and  the  other  with  complement,  the  union  resulting 
in  the  destruction  or  solution  of  the  corpuscles.  In 


this  way  the  foreign  corpuscles  are  disposed  of  in 
the  body  of  the  rabbit.  This  rabbit,  however,  has 
manufactured  antibodies  in  excess  of  its  needs,  and 
it  will  be  found  that  if  you  bring  into  contact  in  a 
test  tube  the  serum  of  the  rabbit  and  sheep's  corpus- 
cles, the  solution  of  the  latter  will  occur.  This  solu- 
tion has  resulted  because  the  rabbit's  serum  contains 
the  two  bodies  necessary  to  the  solution,  namely,  a 
specific  antibody  (haemolytic  amboceptor)  and  com- 
plement. 

If  this  rabbit  serum  is  first  heated  to  56°  C.  in  a 
water  bath  for  one  half  hour  the  complement  will  be 
destroyed,  as  described  before.  If  now  you  mix  this 
heated  serum  with  the  blood  corpuscles  in  a  test 
tube  the  amboceptor,  which  was  unaffected,  will 
unite  with  the  corpuscles  with  one  point  of  affinity, 
but  the  other  point  for  complement  will  be  unsatis- 
fied (as  the  complement  was  destroyed  by  heat), 
and  therefore  solution  of  the  corpuscles,  for  which 
it  is  essential,  will  not  occur.  If,  however,  you  add 
any  other  fresh  blood  serum,  as  guinea  pig  serum, 
which  always  contains  complement,  this  necessary 
factor  will  be  supplied  and  solution  will  occur. 

I  have  thus  explained  at  length  this  phenomenon, 
as  on  this  question  of  complement  fixation  the  en- 
tire syphilis  reaction  depends. 

To  recapitulate  somewhat,  it  was  stated  that  when 
you  bring  the  blood  serum  (immune  sera)  of  one 
infected  patient  in  contact  with  the  agent  that  caused 
the  infection,  the  antibodv  of  the  serum  would  unite 
with  the  infectious  agent  with  one  of  its  points  of 
affinity  and  with  the  other  it  would  unite  with  or 
bind  complement. 

As  the  infectious  agent  in  syphilis  is  not  definitely 
known,  at  least  has  not  been  cultivated,  it  occurred 
to  Wassermann  that  an  extract  of  a  syphilitic  organ 
might  contain  the  infectious  agent  or  its  soluble  pro- 
ducts, and  enable  one  to  demonstrate  the  correspond- 
ing antibody  in  the  serum  of  a  syphilitic,  and  in  this 
manner  enable  one  to  diagnosticate  syphilis  from  the 
blood. 

While  subsequent  work  has  indicated  that  the  in- 
fectious agent  is  not  the  one  concerned  in  the  test 
in  this  instance,  it  has  proved  that  the  antibodies  to 
which  this  something  gives  rise  are  found  only  in 
the  blood  of  syphilitics,  and  therefore  we  have  a 
specific  blood  serum  test  for  syphihs. 

If  the  organ  extract,  the  preparation  of  which  will 
be  described  below,  is  brought  in  contact  with  syphi- 
litic sera,  the  antibody  contained  in  the  latter  will 
unite  by  one  point  of  affinity  with  the  organ  extract 
and  by  the  other  with  complement.  As  this  change 
!S  not  visible  to  the  eye,  because  no  precipitate  or 
color  change  occurs,  it  is  necessary  to  resort  to  some 
means  or  indicator  for  finding  out  whether  such 
union  had  occurerd.  To  this  end  the  Bordet  princi- 
ple is  used  as  follows : 

If  the  serum  of  the  suspected  syphilitic  is  heated 
to  56°  C,  to  destroy  the  complement,  before  it  is 
mixed  with  the  syphilitic  organ  extract,  the  antibody 
of  the  serum  if  present  will  unite  by  one  point  of 
affinity  with  the  organ  extract ;  a  fresh  serum,  as 
guinea  pig  serum,  is  added  to  supply  complement. 
If  the  serum  was  syphilitic  and  contained  the  spe- 
cific antibody  the  added  complement  will  be  fixed  on 
it.  To  demonstrate  whether  the  latter  has  occurred 
or  not.  vou  now  add  the  heated  serum  of  a  rabbit 


2o8 


BUTLER:  SERUM  DIAGNOSIS  OF  SYPHILIS. 


[Neu-  York 
Medical  Journal. 


that  contains  an  antibody  which  will  destroy  in  the 
presence  of  complement  sheep's  corpuscles.  Sheep's 
corpuscles  are  also  added.  If  the  complement  con- 
tained in  the  guinea  pig  serum  that  was  added  was 
taken  up  or  united  with  by  the  syphihtic  antibody, 
there  will  be  none  left  over  and  consequently  the 
added  sheep's  corpuscles  will  not  be  dissolved.  If, 
however,  the  serum  was  not  syphilitic,  the  comple- 
ment will  not  have  been  taken  up,  but  will  be  left 
over  for  union  with  the  haemolytic  amboceptor  of 
the  inactivated  rabbit  serum,  which  latter  unites  with 
the  blood  corpuscles,  and  the  combination  causes  the 
solution  of  the  latter. 

Substances  Employed  in  the  Test  and  the 

Methods  of  Their  Preparation 
are  as  follows : 

1st — Organ  Extract.  This  should  be  made  pref- 
erably from  the  liver  of  a  dead  syphilitic  newborn. 
The  liver  is  ground  up  with  sterile  sand  in  a  mortar 
and  thereafter  placed  in  a  flask.  Alcohol  is  added 
in  the  proportion  of  five  c.c.  for  every  gramme  of 
liver.  The  mixture  is  well  shaken  and  kept  in  the 
flask.  Enough  of  the  extract  may  be  filtered  of? 
through  filter  paper  as  needed  in  the  test.  An  alco- 
holic extract,  made  in  this  manner,  is  very  stable. 

Senun  of  Patient.  The  blood  of  the  patient  is 
("■btained  either  from  a  puncture  in  the  end  of  the 
finger  that  has  been  constricted  by  a  bandage,  or  by 
a  hypodermic  needle  from  a  vein.  Two  to  ten  c.c. 
should  be  secured.  It  is  allowed  to  clot  and  stand 
on  ice  until  the  serum  separates,  which  takes  about 
twelve  hours.  The  serum  is  poured  or  pipetted  off 
into  a  sterile  tube.  "  If  not  clear,  it  is  centrifuged 
and  the  clear  serum  only  removed.  This  is  heated 
to  56°  C.  for  thirty  minutes  to  destroy  the  comple- 
ment. 

Complement.  Guinea  pig  serum  is  used  for  its 
complement.  The  animal  may  be  bled  from  the 
jugular.  The  blood  is  allowed  to  clot  and  the  serum 
is  poured  of¥  and  centrifuged,  or  the  blood  may  be 
defibrinated  and  centrifuged  at  once  and  the  serum 
removed.  This  is  best  obtained  fresh  every  time  a 
test  is  undertaken.  Sometimes  complement  may 
remain  good  for  three  or  four  days  if  kept  on  ice. 
This,  however,  is  never  certain,  and  many  failures 
in  making  the  tests  are  due  to  the  serum  having 
lost  much  of  its  complement. 

Specific  Hccniolyiic  Amboceptor.  It  is  my  cus- 
tom to  use  the  serum  of  a  rabbit  that  has  been  im- 
munized with  sheep's  corpuscles.  This  is  obtained 
by  injecting  the  rabbit  with  a  five  per  cent,  suspen- 
sion of  washed  sheep's  corpuscles  into  a  vein,  under 
the  skin,  or  into  the  peritoneal  cavity,  weekly  for 
several  weeks.  The  rabbit  is  then  bled  from  the 
heart  or  jugular,  the  blood  collected,  allowed  to  clot, 
and  the  serum  collected  and  centrifuged.  The  clear 
serum  is  removed  and  heated  to  56°  C.  for  half  an 
hour  to  inactivate  it. 

Sheep's  Corpuscles.  About  an  ounce  of  blood  is 
removed  from  the  jugular  of  a  sheep  through  an 
aspirating  needle.  It  is  defibrinated  by  a  sterile  rod 
of  wire  or  by  glass  pearls.  About  five  c.c.  of  the 
flefibrinated  blood  is  placed  in  each  of  two  centri- 
fuge tubes.  The  tubes  are  then  equally  filled  with 
salt  solution,  the  tubes  inverted  to  mix  the  blood 
well,  and  they  are  then  centrifuged.  When  the  cells 
have  .sottled  to  the  bottom  the  salt  solution  is  poured 


oflf  and  fresh  salt  solution  added.  The  process  is 
repeated,  and  all  of  the  supernatent  fluid  is  care- 
fully removed. 

An  equal  quantity  of  salt  solution  is  now  added 
to  one  of  them  which  gives  a  fifty  per  cent,  sus- 
pension for  the  test.  The  corpuscles  contained  in 
the  other  tube  are  suspended  in  enough  salt  solu- 
tion to  make  them  a  five  per  cent,  suspension.  This 
is  available  for  injecting  rabbit. 

Before  beginning  the  actual  reaction  it  is  neces- 
sary to  examine  the  different  ingredients  used  in 
the  reaction,  i.  To  see  that  the  extracts  do  not  in 
the  proportion  used  in  the  reaction  bind  comple- 
ment ;  2,  to  see  that  the  complement  is  active ;  3,  to 
determine  the  strength  of  the  amboceptor ;  4.  to  see 
that  the  blood  corpuscles  are  not  haemolyzed. 

I,  The  extract  should  be  tried  out  with  a  known 
syphilitic  and  normal  serum  to  see  that  in  the  first 
instance  it  inhibits  haemolysis  and  in  the  second 
case  does  not  do  so.  It  will  be  found  that  in  trying 
fresh  extracts  they  may  bind  complement  alone  in 
the  proportions  generally  used.     Under  these  cir- 


■a 


■a 


Fig.  I. — a,  bacterium  ambo- 
ceptor; b,  bacterium. 


Fig.  2. — a,  complement;  b, 
bacterium  amboceptor;  c,  bac- 
terium. 


cumstances  they  should  be  diluted  to  that  point 
where  they  will  not,  in  twice  or  three  times  the 
quantities  used  in  the  reaction,  inhibit  haemolysis 
alone. 

2,  Complement.  If  the  guinea  pig  serum  is  ob- 
tained the  day  of  the  reaction,  it  will  always  be 
found  active.  Occasionally  it  will  hold  good  if  kept 
on  ice  for  two  or  three  days. 

3,  Amboceptor.  The  inactivated  rabbit  serum  is 
tested  in  various  dilutions  of  one  drop  to  one  c.c, 
etc.,  up  to  eight  or  ten  c.c.  of  salt  solution.  .A.  drop 
of  each  dilution  to  a  drop  of  complement,  and  a 
drop  of  a  fifty  per  cent,  suspension  of  sheep's  cor- 
puscles arc  placed  in  separate  test  tubes  to  which 
had  been  added  in  each  instance  ten  drops  of  sail 
solution:  all  are  placed  in  an  incubator  for  one  half 
hour.  Note  is  made  of  the  highest  dilution  of  am- 
boceptor that  caused  solution.  Three  tiiues  the 
strength  of  this  is  used  in  the  reaction. 

4,  The  blood  corpuscle  suspension  may  remain 


January  30,  J909.] 


BUTLER:  SERUM  DIAGNOSIS  OF  SYPHILIS. 


209 


good,  if  kept  on  ice,  for  four  or  five  days.  If  there 
is  a  trace  of  hgemolysis,  as  is  indicated  by  the  dark 
red  color  of  the  supernatent  sokition,  they  had  bet- 
ter not  be  used,  and  a  fresh  suspension  prepared. 

The  performance  of  the  reaction. — A  series  of 
test  tubes  are  required,  to  each  of  which  ten  drops 
of  salt  solution  has  been  added.  For  every  serum 
two  test  tubes  are  necessary.  To  each  add  a  drop 
of  serum  to  be  tested,  and  to  one  of  these  add  a 
drop  of  organ  extract ;  to  both  add  a  drop  of  com- 
plement. 

Controls. — To  one  tube  add  a  drop  of  extract  and 
one  of  complement,  this  serving  as  a  control  on  the 
extract.  To  one  tube  add  a  drop  of  complement 
only.  To  another  tube  add  a  drop  of  one  of  the 
sera,  being  tested  to  see  if  it  has  been  sufficiently 
inactivated.  Place  all  tubes  in  an  incubator  for  one 
half  hour.  Remove  and  add  to  each  a  drop  of  di- 
luted amboceptor  and  one  of  blood  corpuscles. 

As  additional  controls  add  a  drop  of  amboceptor 
and  one  of  blood  corpuscles  to  a  test  tube  to  see  if 
the  amboceptor  alone  dissolves  blood  corpuscles. 

Replace  in  the  incubator  for  an  hour  and  a 
half.  On  removing  the  tubes  from  the  incubator 
a  reading  is  made  and  noted,  and  a  second  read- 
ing, which  is  the  final  one,  is  made  twelve  to 
twenty-four  hours  later. 

For  the  test  to  have  been  reliable  all  controls 
must  have  been  satisfactory.  In  tubes  containing 
extract  and  no  serum,  haemolysis  should  have  oc- 
curred. Tubes  containing,  sera  and  complement 
without  extract-  should  be  hsemolyzed.  In  case  the 
controls  are  satisfactory  all  tubes  containing  sera 
and  extract,  in  which  haemolysis  has  either  not  oc- 
curred at  all  or  only  incompletely,  are  regarded  as 
positive ;  all  those  in  which  hemolysis  is  complete 
or  practically  complete  are  negative.  In  every  test 
known  syphilitic  and  normal  sera  should  be  used  as 
controls  against  the  suspicious  sera.  It  is  to  be  ob- 
served, however,  that  occasionally  normal  sera  and 
also  syphilitic  sera  will  undergo  such  changes  on 
standing  some  days  as  to  entirely  alter  their  action 
with  syphilitic  extract.  This  should  always  be 
borne  in  mind  where  in  subsequent  reactions  they 
act  differently  from  previous  examination. 

Specificity  of  tJie  Serum  Reaction. — For  the  re- 
action to  be  considered  specific  for  syphilis  it  was 
necessary  that  the  reaction  should  not  only  be  found 
positive  in  cases  of  syphilis,  but  that  it  should  prove 
uniformly  negative  in  nonsyphilitic  cases. 

Up  to  this  time  controls  into  the  thousands  have 
been  examined,  and  the  in  frequency  of  positive  re- 
actions obtained  in  those  certainly  nonsyphilitic 
cases  has  been  so  evident  as  to  remove  all  doubt  as 
to  its  specificity  and  clinical  applicability. 

Landsteiner,  however,  found  that  the  serum  of 
rabbits  that  had  been  inoculated  with  Trypanosoma 
equiperdiDn,  producing  doiiri)ic  Krankheit,  caused 
an  inhibition  of  haemolysis.  He  suggested  that  it 
might  be  found  that  diseases  caused  by  trypan- 
osoma  and  protozoa  would  give  the  reaction.  Much 
and  Eichelberg  have  recently  reported  finding  an 
inhibition,  never  complete,  of  haemolysis  in  a  num- 
ber of  scarlet  fever  cases,  and,  holding  Landstein- 
er's  experience  in  mind,  suggest  that  scarlet  fever 
may  be  due  to  a  protozoa  infection. 


I  obtained. the  reaction  in  three  cases  of  noma  in 
which  the  Bacillus  fiisiformis  and  a  spirillum  are 
regarded  as  the  aetiological  factors. 

PR.\CTICAL  RESULTS  OF  THE  REACTION. 

The  results  of  the  reaction  in  cases  of  syphilis, 
latent  syphilis,  and  metasyphilis  show  a  relative 
constancy  in  the  frecjuency  of  positive  reactions. 

In  the  earlier  work,  with  the  reaction  by  Neisser, 
Bruck,  and  Schucht,  the  incompleteness  in  the 
technique  probably  was  responsible  for  the  com- 
paratively small  per  cent,  of  results  obtained  by 
them  in  cases  of  syphilis. 

Wassermann's  and  Plant's  examinations  of  the 
spinal  fluid  of  tabes  cases  showed  positive  reactions 
in  seventy-eight  per  cent,  of  them.  Marie  and 
Levaditi  obtained  practically  the  same  results  in 
cases  of  general  paresis. 

Without  entering  into  an  extended  discourse  on 
the  results  obtained  by  various  investigators,  I  will 
give  the  results  obtained  bv  me  in  203  examinations 
with  the  serum  reaction.  Fifty-three  of  these  cases 
were  controls,  made  up  of  cases  of  various  infec- 
tions, including  typhoid,  pneumonia,  tuberculosis, 
etc.  The  results  of  these  examinations  were  uni- 
formly negative,  except  in  three  cases  of  noma  and 
four  of  scarlet  fever.  The  reactions  in  the  noma 
cases  were  quite  marked,  while  in  the  scarlet  fever 
cases  that  gave  a  positive  result  the  inhibition  of 
haemolysis  was  slight.  It  is  possible  that  in  the 
noma  cases  the  suggestion  of  Wassermann  that 
cases  of  infection  caused  by  spirilla  might  give  the 
reaction  is  exemplified,  in  view  of  the  fact  that 
noma  is  said  to  be  due  to  the  fusiform  bacillus  and 
a  spirillum.  Whether  the  same  explanation  will 
hold  good  for  scarlet  fever  cases  giving  a  reaction 
must  be  decided  in  the  future.  In  any  event,  these 
are  both  infections  with  which  syphilis  would  hard- 
ly come  into  conflict  in  differential  diagnosis.  Thus, 
instead  of  lessening  the  value  of  the  serum  reaction, 
it  may  be  looked  upon,  as  Wassermann  suggested, 
as  a  broadening  of  the  application  of  the  test  to 
other  diseases  caused  by  spirochetae,  protozoa  infec- 
tions, etc.,  that  would  not  come  into  consideration 
in  the  differential  diagnosis  of  syphilis. 

Of  the  150  cases  of  syphilis,  suspected  syphilis, 
latent  syphilis,  and  metasyphilis  examined,  123  were 
positive  and  twenty-seven  negative,  making  eighty- 
two  per  cent,  of  positive  reactions.  This  corre- 
sponds quite  closely  to  the  later  results  obtained  by 
various  investigators  in  these  cases.  The  gross  fig- 
ures, however,  do  not  indicate  sufficiently  close  the 
results  obtained  by  the  reaction  at  different  stages 
of  the  disease,  as  will  be  seen  from  the  following: 

Of  ten  cases  in  the  primary  stage,  including  all 
cases  prior  to  the  appearance  of  secondary  symp- 
toms, all,  or  one  hundred  per  cent.,  gave  a  positive 
reaction. 

Of  thirty-six  cases  in  the  secondary  stage,  thirty- 
four,  or  ninety-five  per  cent.,  gave  a  positive  reac- 
tion. 

Of  thirty-one  cases  in  the  tertiary  stage,  twenty- 
nine,  or  ninety-four  per  cent.,  gave  a  positive  reac- 
tion. 

Of  sixteen  latent  cases,  nine,  or  fifty-six  per  cent., 
gave  a  positive  reaction. 


210 


BUTLER:  SERUM  DIAGNOSIS  OF  SYPHILIS. 


[New  York 
Medical  Journal. 


Of  fifty-five  cases  of  parasyphilis  and  visceral 
syphilis,  forty-one,  or  seventy-six  per  cent.,  gave  a 
positive  reaction. 

Two  cases  in  which  the  patients  had  been  treated 
energetically  by  mercury,  the  one  with  injections 
and  the  other  with  inunctions,  gave  a  negative  reac- 
tion. The  latter  case,  had  before  the  beginning  of 
the  treatment,  given  a  strong  reaction. 

The  result  of  the  reaction  in  diseases  of  the  cen- 
tral nervous  system  has  been  especially  illuminat- 
ing. This  has  been  particularly  so  in  cases  of  gen- 
eral paresis  and  tabes.  In  first  examinations  of  this 
class  of  cases  the  spinal  fluid  was  examined  by 
Wassermann  and  Plant,  by  Marie  and  Levaditi,  by 
Schutze,  and  by  Morgenrath  and  Stertz.  They 
found  from  seventy  to  eighty  per  cent,  of  thesv. 
cases  to  give  a  positive  reaction,  and  more  recent 
examinations  of  the  sera  of  this  class  of  cases  by 
Plaut  and  others  show  them  to  be  positive  in  from 
ninety  to  one  hundred  per  cent.  Whatever  doubt 
may  have  existed  as  to  their  relation  to  syphilis  has 
been  fully  dispelled.  In  fact,  as  asserted  by  Lesser, 
they  might,  as  well  as  all  other  parasyphilitic  pro- 
cesses, be  considered  as  a  quartan  stage  of  syphilis, 
in  w  hich  another  form  of  pathological  changes  dif- 
fering from  the  usual  gummatous  or  diffuse  fibrous 
changes  exist,  but  are  dependent  on  the  same  source 
directly  or  indirectly. 

Among  the  cases  of  visceral  syphilis  examined  by 
me  were  cirrhosis  hepatis,  aortic  aneurysms,  myo- 
carditis, specific  arteritis,  etc.  It  is  quite  interest- 
ing in  this  connection  to  note  the  infrequency  with 
which  visceral  syphilis,  excepting  syphilis  of  the 
nervous  system,  is  clinically  diagnosticated.  Gum- 
mata  of  the  brain  are  usually  recognized  symp- 
tomatically,  because  of  the  pronounced  clinical 
manifestations  to  which  they  give  rise.  Not  so, 
however,  with  gummata  of  the  other  viscera.  This 
may  be  either  because  the  gumma  is  so  located  that 
it  (iocs  not  interfere  with  the  function  of  the  organ, 
and  therefore  does  not  give  rise  to  symptoms,  and 
its  site  may  be  out  of  reach  of  the  palpating  hand, 
or  because,  on  the  other  hand,  syphilis  of  an  inter- 
nal organ  may  produce  a  clinical  picture  simulating 
other  conditions.  No  better  example  of  this  might 
be  cited  than  syphilis  of  the  liver,  which  may  simu- 
late malignant  growth  of  this  organ,  cholecystitis, 
obstructive  jaundice,  etc.  Failure  to  consider  syph- 
ilis as  an  .  aetiological  factor  under  such  circum- 
stances is  due  sometimes  to  lack  of  acquaintance 
with  such  conditions,  at  other  times  to  the  fact  that 
no  evidence  of  past  syphilis  is  present,  nor  any  his- 
tory of  the  same  obtainable.  And  still  in  every  dis- 
order of  the  liver,  and  in  every  prolonged  febrile 
disturbance  in  which  the  aetiological  factor  is  un- 
certain, syphilis  should  receive  consideration  and 
the  scrum  test  should  be  resorted  to.  It  is  a  nota- 
ble thing  that,  while  an  infection  in  one  organ  may 
give  rise  to  little  or  no  febrile  disturbance,  the  most 
decided  febrile  reaction  may  result  from  the  same 
infection  when  it  attacks  another  organ.  No  bet- 
ter example  of  this  could  be  cited  than  the  infection 
known  as  mumps,  which,  while  it  may  cause  but 
slight  variations  in  temperature  while  confined  to 
the  panitids,  shows  a  marked  febrile  disturbance 
when  it  attacks  the  testicle.  A  reversal  of  this  is 
noted  as  between  syphilis  attacking  the  testicle  and 


liver.  Occasional  reports  have  appeared  during  the 
past  decade  and  a  half  on  temperature  accompany- 
ing syphilis  of  the  liver.  These  cases  are  more  fre- 
quent than  is  generally  recognized,  and  not  a  few 
of  these  patients  corne  to  the  operating  table^  and 
occasionally  even  there  the  cases  are  unrecognized. 
Lesser  in  his  post  mortem  studies  of  visceral  syph- 
ilis saw  thirty  cases  of  liver  gumma  that  had  not 
been  diagnosticated  clinically.  In  twenty-two  cases 
no  clinical  symptoms  pointing  to  them  occurred.  In 
eight  case  of  liver  cirrhosis  their  syphilitic  charac- 
ter had  not  been  recognized.  Nineteen  cases  of 
gumma  of  the  lung,  often  combined  with  tubercu- 
losis, had  not  been  recognized  clinically,  and  like- 
wise three  cases  of  gumma  of  the  heart,  two  of  the 
spleen,  two  of  the  suprarenals,  and  two  of  the 
radix  mesenterica.  A  not  infrequent  result  of 
syphilis  which  is  practically  never  diagnosticated 
clinically  is  the  mesoaortitis  retrahens  of  Heller,  and 
syphilis  of  the  arteries  in  general,  until  the  secondary 
manifestations  arising  therefrom  render  them  evi- 
dent. A  forcible  emphasis  of  this  serious  shortcom- 
ing in  our  diagnostic  methods  is  the  fact  that  about 
eighty  per  cent,  of  all  aortic  aneurysms  have  their 
origin  in  a  mesoaortitis  retrahens.  As  this  condition 
is  therefore  only  recognizable,  practically,  with  the 
appearance  of  a  full-fledged  aneurysm,  the  vitally 
important  period  of  therapeutic  intervention  b}'  spe- 
cific treatment  has  elapsed.  While  it  should  concern 
us  seriously  to  recognize  at  the  earliest  possible  mo- 
ment aneurysms  by  means  of  the  x  ray,  etc.,  know- 
ing the  apparent  advantages  occurring  in  early  treat- 
ment, we  are  placed  in  a  far  stronger  position,  paral- 
lel to  what  the  surgeon  is  wont  to  term  with  relation 
to  cancer  the  "precancerous  stage,"  by  virtue  of  the 
serum  reaction,  which  enables  us,  in  the  vast  major- 
ity of  cases,  to  determine  the  existence  of  active 
syphilis,  hence  is  of  incalculable  value  from  a  thera- 
peutic standpoint  in  syphilis  of  internal  organs  that 
obscure  themselves  from  early  diagnosis,  or  that  un- 
fortunately simulate  other  pathological  conditions. 

An  exceedingly  interesting  observation  from  Les- 
ser is  that  in  Berlin  in  about  nine  per  cent,  of  all 
men  over  twenty-five  years  that  come  to  autopsy, 
syphilis  is  anatomically  demonstrable.  And  in  most 
of  these  symptoms  immediately  depending  on  the 
changes  may  not  have  been  complained  of,  to  wit. 
gumma  of  the  liver,  mesoaortitis  retrahens,  orchitis 
fibrosa,  etc.  In  this  connection  our  present  concep- 
tion of  latent  syphilis  must  undergo  considerable  ad- 
justment. As  it  is  estimated  that  about  twenty  per 
cent,  of  the  male  population  of  Berlin  over  twenty- 
five  years  of  age  have  syphilis,  this  nine  per  cent, 
presenting  evidence  of  visceral  syphilis,  would  repre- 
sent about  half  the  cases  that  have  had  syphilis. 
While  the  majority  of  those  cases  are  apparently 
free  from  evident  manifestations  of  syphilis  during 
life  either  by  virtue  of  treatment  or  apparent  abey- 
ance of  the  infection,  it  is  more  than  probable  that 
in  this  fifty  per  cent,  of  cases  the  apparently  quies- 
cent virus  sits  in  some  internal  organ  or  organs  sur- 
rounded by  more  or  less  of  pathological  changes. 

A  remarkable  coincidence  and  apparent  substan- 
tiation of  this  statement  lies  in  the  fact  that  in  round 
numbers  about  half  of  the  latent  cases  of  syphilis,  in 
the  experience  of  various  investigators,  give  thr 
serum  reaction.    In  other  words  the  frequency  ot 


January  30,  19:9.] 


BUTLER:  SERUM  DIAGNOSIS  OF  SYPHILIS. 


211 


the  serum  reaction  in  latent  cases  is  about  the  same 
as  the  frequency  of  syphiUtic  processes  in  the  in- 
ternal organs  that  are  not  generally  recognized  dar- 
ing life.  Xo  stronger  possible  argument  than  this 
could  be  introduced  to  prove  that  a  positive  Wasser- 
mann  reaction  indicates  an  existing  syphilitic  pro- 
cess in  the  organism. 

The  clinical  advantages  of  the  serum  reaction  for 
detecting  such  cases  and  subjecting  them  to  treat- 
ment is  clearly  evident,  especially  when  we  remem- 
ber that  next  to  tuberculosis,  syphilis  is  the  most 
important  cause  of  death  in  man. 

HEREDITARY  SYPHILIS. 

One  of  the  interesting  chapters  in  the  syphilis 
question  is  that  which  relates  to  congenital  syphilis. 

I  have  examined  eleven  cases  of  congenital  or  sus- 
pected congenital  syphilis ;  these  are  not  included  in 
my  statistics.  Six  of  these  were  under  one  year ; 
five  were  older  children,  from  one  and  one  half  to 
twelve  years.  Of  the  latter,  one  a  girl  of  twelve 
years,  had  bilateral  periostitis,  a  boy  of  ten  years 
mentally  defective,  had  extensive  ulcers  on  both 
thighs  and  legs,  a  boy  of  two  and  one  half  years  had 
a  large  ulcer  at  the  margin  of  the  anus,  the  other 
two  had  specific  skin  lesions.  All  of  these  children 
gave  a  strong  positive  reaction  for  syphilis.  As  they 
were  hospital  cases  in  which  close  historical  data 
as  to  maternal  and  paternal  infection  was  unobtain- 
able, any  analysis  of  them  with  relation  to  the  latter 
was  not  possible.  It  simply  demonstrated  the  cer- 
tainty of  obtaining  the  serum  reaction  in  congenital, 
as  well  as  acquired  syphilis,  and  its  constancy  in  the 
presence  of  manifestations. 

Among  the  suckling  children  were  two  that  had 
had  manifestations  of  syphilis  from  the  sixth  or 
eighth  week  of  life,  although  at  the  time  of  examin- 
ation all  external  manifestations  had  disappeared, 
both  havins:  been  under  treatment.  These  babies 
gave  a  positive  reaction.  The  parental  history  in 
one  of  these  is  as  follows :  Father  had  contracted 
syphilis  within  a  year  of  his  marriage,  during  the 
greater  part  of  which  time  he  was  under  treatment. 
Mother  had  not  shown  any  evidence  of  syphilis  be- 
fore or  subsequent  to  the  birth  of  the  child.  Xo 
glandular  enlargements.  Skin  and  muco.sae  were 
free  from  any  lesions  or  scars.  The  blood  serum 
and  milk  of  the  mother  were  examined  several  times 
and  were  always  found  negative.  In  the  other  case 
both  parents  had  syphilis,  the  mother  having  con- 
tracted it  from  her  husband  before  the  conception 
of  this  child.  The  parents  and  child  gave  a  positive 
reaction. 

An  infant  of  four  months  was  brought  to  Dr. 
Wolf  on  account  of  a  large  head  and  because  it  did 
not  seem  as  lively  as  other  infants.  The  child  had 
not  shown  any  of  the  skin  or  mucous  membrane 
symptoms  of  syphilis.  The  mother  had  never  to  her 
knowledge  presente-^l  any  symptoms.  The  blood 
serum  of  both  and  the  milk  of  the  mother  were  ex- 
amined. The  infant  gave  a  positive  reaction  and  the 
mother  a  negative  one. 

We  apparently  have  here  as  well  as  in  the  first 
case  a  concurrence  with  Colles's  law,  namely  the  ap- 
parent immunity  of  the  mother  and  a  syphilitic  child. 
Attention  was  first  called  to  the  association  of  hy- 
drocephalus with  congenital  syphilis  by  Virchow, 


and  we  have  here  a  case  which  would  seem  to  con- 
firm this  connection. 

It  is  to  be  particularly  noted  here  that  so  far  as 
the  parent  had  observed  no  eruption  or  snuffles  had 
existed  in  her  baby.  In  another  case  an  infant  of 
five  months  born  of  a  mother  sufiFering  from  tertiary 
syphilis  had  not  shown  at  any  time  any  evidence  of 
syphilis,  and  was  an  unusually  well  nourished  and 
healthy  child.  Examination  of  the  child's  blood  re- 
vealed a  positive  reaction  for  syphilis. 

This  is  a  class  of  mfants  to  which  I  directed  at- 
tention in  a  1-eport  on  two  cases  of  syphilis  of  the 
nervous  system  occurring  in  children  who  so  far  as 
obtainable  history  was  dependable  had  not  shown 
symptoms  of  syphilis.  The  syphilitic  character  of  a 
cerebrospinal  meningitis  in  one  case  was  revealed 
by  the  appearance  during  the  attack  of  interstitial 
keratitis  and  in  the  other  case,  one  of  cerebral  pal- 
sy with  almost  complete  amaurosis,  an  old  atrophic 
choroiditis  existed.  As  infants  with  hereditary 
syphilis  are  liable  to  all  the  lesions  of  the  nervous 
system  and  other  internal  organs  that  a  case  of  ac- 
quired syphilis  is  subject  to,  the  detection  of  this 
class  of  cases  whose  luetic  symptoms  were  sufficient- 
ly insignificant  to  be  overlooked  by  the  parent,  is  all 
important  in  order  to  anticipate  and  prevent  the  out- 
break of  lesions  of  the  viscera. 

In  another  case,  a  newborn  infant,  born  of  a 
syphilitic  mother,  whose  symptoms  first  appeared  in 
the  fourth  month  after  conception,  appeared  to  be 
healthy.  The  child's  blood  was  examined  several 
times  during  the  first  four  or  six  weeks  of  life  and 
each  time  it  proved  negative.  The  mother's  blood 
serum  and  milk  gave  a  strong  reaction.  It  seemed 
probable  that  this  woman  contracted  her  syphilis 
after  conception.  In  this  event,  according  to  Pro- 
feta's  law,  it  might  be  expected  that  the  child  would 
remain  immune,  and  while  our  obser\-ation  had  only 
stretched  over  several  weeks,  during  this  time  the 
serum  reaction  remained  negative  and  no  symptoms 
appeared  in  the  baby. 

It  is  a  matter  of  interest  to  note  that  this  test  may 
be  made  with  the  breast  milk  of  nursing  mothers  as 
well  as  with  their  serum.  The  results  with  milk  are 
not  quite  as  satisfactory  as  with  the  serum  because 
the  milk  serum  is  always  m.ore  or  less  turbid.  This 
turbidity  of  milk  serum  unless  due  allowance  is 
made,  may  give  rise  to  a  false  interpretation  of  the 
reaction  when  used  in  the  test,  and  might  therefore 
be  misleading.  If  due  allowance,  however,  is  made 
for  this,  an  examination  of  milk  may  be  found  satis- 
facton-. 

The  adxantage  of  this  would  be  considerable  in 
places  where  wet  nurses  are  employed,  as  by  an  ex- 
amination of  the  milk  a  determination  of  the  non- 
syphilitic  or  syphilitic  character  of  the  nurse  may- 
be determined. 

There  is  nothing  more  difficult  at  times  to  decide 
than  whether  a  given  individual  has  had  syphilis  or 
not.  This  is  particularly  true  of  women  who  may 
present  such  transient  manifestations  as  to  have  es- 
caped serious  attention ;  or  who  on  the  other  hand 
m.ay  have  denied  an  infection,  all  evidences  of  which 
have  disappeared,  as  is  not  infrequently  the  case. 
In  these  cases  we  have  heretofore  had  no  really  de- 
cisive diagnostic  recourse  up  to  the  present  time. 
Hence  the  importance  of  the  serum  reaction  in  this 


212  BUTLER:  SERUM  DL- 

class  of  cases.  While  it  miglit  be  impracticable  to 
attempt  to  estimate  the  degree  of  danger  of  infection 
through  a  wet  nurse  that  had  latent  syphilis.  I  think 
no  one  would  hesitate  in  his  decision  as  to  her  un- 
suitableness. 

On  the  other  hand,  it  is  no  less  important  to  the 
wet  nurse  that  the  infant  should  not  be  syphilitic,  as 
was  the  case  in  a  report  by  Watson,  in  which  he 
stated  that  in  Baltimore  a  nursing  mother  received 
from  some  charitable  organization  into  her  own 
home  to  board,  a  suckling  that  proved  to  be  syphili- 
tic. The  wet  nurse  contracted  syphilis  from  the 
child,  gave  it  to  her  own  infant,  and  from  her  own 
infant,  her  little  girl  of  six  or  eight  years  of  age 
contracted  syphilis  by  kissing.  This  deplorable  sit- 
uation could  hardly  have  arisen  had  ordinary  medi- 
cal care  in  inspecting  children,  before  placing  them 
in  homes,  been  observed.  As  an  additional  safe- 
guard, however,  in  all  cases  the  serum  reaction 
might  be  resorted  to,  as  it, was  noted  above,  that  a 
child  born  of  a  syphilitic  mother  had  been  free  of 
all  manifestations  of  syphilis,  and  still  gave  a  posi- 
tive serum  reaction. 

Wet  nursing  is  not  as  common  a  practice  in  our 
country  as  it  is  in  some  foreign  countries.  Where  it 
is  resorted  to,  and  it  can  be  at  times  with  greatest 
advantage  to  the  infants,  the  most  rigid  inspection 
of  both  should  be  carried  out,  preferably  reinforced 
by  the  serum  reaction. 

Success  in  obtaining  the  reaction  in  the  milk  of 
syphilitic  women,  led  to  examining  the  urine.  Blum- 
enthal  and  Wile  reported  finding  a  positive  reaction 
with  the  urine  of  n>any  syphilitics.  indicating  that 
the  substance  contained  in  the  blood  serum  that 
gives  the  reaction  is  not  only  excreted  by  the  mam- 
mary gland  but  also  by  the  kidney.  Since  they  found 
that  all  urines  delay  haemolysis  and  in  many  in- 
stances inhibit  in  some  degree,  it  is  evident  that  this 
method  is  not  dependable. 

INFLUENCE  OF  .\XTISVPHILITIC  TRE.\TMEXT  OX  THE 
RE.SlCTION. 

Citron  was  the  first  to  observe  that  the  antiluetic 
treatment  exerted  a  considerable  influence  on  the  re- 
sult of  the  reaction.  He  considered  this  so  evident 
that  he  incorporated  his  views  on  this  question  into 
two  laws,  as  follows : 

1.  The  longer  the  syphilis  virus  has  worked  in  the 
body,  and  the  oftener  it  has  caused  recurrences,  the 
more  constant  and  stronger  is  the  antibody  content 
of  the  serum. 

2.  The  earlier  the  mercurial  treatment  is  started, 
the  longer  continued,  the  more  frequently  it  is  re- 
peated, the  more  advantageous  the  method  of  appli- 
cation, and  the  shorter  the  interval  since  the  last 
cure,  the  less  is  the  content  of  the  antibody  and  the 
more  frequently  the  reaction  is  negative. 

While  it  is  not  by  any  means  a  uniform  observa- 
tion, one  is  constantly  impressed  with  the  diminu- 
tion in  the  intensity  of  the  reaction  (ir  its  complete 
disappearance  in  many  such  cases.  Some  authors 
have  ventured  to  give  figures  indicating  the  number 
that  have  and  have  not  i)een  influenced  by  therapv 
as  interpreted  from  the  reaction.  The.se.  however, 
have  usually  based  their  observation  on  more  or  less 
'iniited  periods  of  treatment,  and  furthermore  fail 
to  consider  the  persistence  of  the  activity  of  the  in- 


NOSIS  OF  SYPHILIS.  [N^w  Vork 

Medical  Jqur.\-al. 

fection  in  internal  organs  long  after  it  has  ceased  to 
show  its  eti'ect  on  visible  structures. 

It  is  quite  noticeable  that  recent  cases  of  syphilis, 
under  rigid  antisyphilitic  treatment,  will  often  show 
on  examinations  a  lessened  intensity  or  disappear- 
ance of  the  reaction,  while  old  cases  with  tertiary 
recurrences  appear  to  show  less  efifect  on  the  serum 
reaction  in  similar  courses  of  treatment.  This,  how- 
ever, is  readily  comprehensible  when  we  remember 
the  difference  in  time  that  the  virus  is  exerting  its 
effect  on  the  organism  and  likewise  the,  in  all  proba- 
bility, more  deeply  seated  lesions  in  the  late  forms, 
possibly  involving  hidden  structures. 

Cases  that  have  been  well  treated  and  managed 
show  a  positive  reaction  less  frequently  than  those 
that  have  been  treated  indifferently  or  practically 
not  at  all.  While  the  latter  class  of  cases  occasion- 
ally may  not  show  a  tendency  to  recurrences,  in  the 
main  they  are  disposed  to  them,  and  consequently 
the  serum  reaction  is  likely  to  be  found  positive,  as 
it  is  in  the  vast  majority  of  cases  with  manifesta- 
tions. 

A  notable  feature  in  all  reports  with  regard  to  the 
effect  of  treatment  on  the  reaction  is  that  the  results 
have  been  based  on  comparatively  short  periods  of 
treatment. 

It  is  more  than  probable  that  such  results,  if  ob- 
tained after  treatment  for  the  usual  time  that  cases 
of  syphilis  are  ordinarily  treated,  would  show  a  far 
greater  per  cent,  of  disappearance  of  the  reaction 
and  that  we  would  have  in  the  reaction  a  reliable 
index  of  the  cure  or  abeyance  of  the  affection. 

In  old  syphilitics  in  whom  the  mahifestations  do 
not  seem  amenable  to  mercurial  treatment,  the  serum 
reaction  might  be  expected  to  exist.  Fleischmann 
suggests,  on  the  basis  of  Ehrlich's  work  with  atoxyl 
in  trypanosoma  infections,  that  in  these  cases  the 
virus  becomes  mercury  immune,  and  consequently  is 
unaffected  by  mercurial  treatment. 

Citron  in  his  first  publication  thought  that  not 
only  did  he  observe  an  influence  of  treatment  in 
general  on  the  reaction,  but  also  a  more  pronounced 
effect  in  cases  under  inunction  than  in  those  under 
injection  treatment.  The  obser.vations  on  this  phase 
of  the  subject  are  insufficient  to  justify  a  positive 
opinion. 

Dl.\GN0SIS. 

The  diagnostic  value  of  the  .serum  reaction  ha> 
been  placed  beyond  all  doubt.  Excepting  in  the  few 
instances  which  I  have  referred  to.  a  positive  serum 
reaction  for  syphilis  may  be  looked  upon  as  certain 
evidence  of  the  patient  having  syphilis. 

The  great  advantage  of  a  positive  means  of  diag- 
nosis for  syphilis  will  be  appreciated  by  every  prac- 
titioner of  medicine,  because  of  the  not  infrequent 
instances  in  which  clinical  history  and  physical  ex- 
amination leave  one  unable  to  decide  whether  or  not 
the  patient  has  had  syphilis.  The  point  should  be 
emphasized  that  it  is  positive  in  from  ninety-five  to 
ninety-eight  per  cent  of  all  cases  with  manifesta- 
tions. So  that  given  a  case  in  which  syphilis  is  sus- 
pected from  the  presence  of  certain  manifestations, 
a  positive  reaction  establishes  the  letiology  :  on  the 
other  hand,  a  negative  reaction  carries  considerable 
weight  in  excluding  it.  And  by  manifestations  I 
refer  also  to  lesions  of  internal  organs  in  which  T 
personally  am  most  interested.    The  fact  should  he 


January  30.  1909.] 


UHLE  AXD  MACKIXXEY:  CHRONIC  GOXORRHCEA. 


213 


held  in  mind,  however,  that  while  a  positive  reaction 
indicates  that  the  individual  has  syphilis,  it  does  not 
necessarily  prove  that  the  particular  lesion  from 
which  the  patient  is  suffering  is  syphilitic.  This 
same  point  holds  good  in  practically  all  imniuno- 
diagnostics.  They  indicate  positively,  however,  a 
systemic  reaction  against  the  particular  infection  for 
which  they  have  been  tested  where  the  reaction  is 
found.  ^^  hether  this  result  may  be  brought  in  jetio- 
logical  relation  with  the  particular  condition  from 
which  the  patient  suffers  must  be  decided  by  clinical 
data. 

Prognosis. 

W  hat  interests  us  particularly  in  the  prognosis  is 
what  value  we  may  place  on  the  presence  or  absence 
of  the  reaction  in  judging  (ij  the  status  of  a  pa- 
tient, (2)  contagiousness. 

The  intensity  of  the  reaction  in  dift'erent  cases 
varies  considerably.  It  might  be  of  considerable 
assistance  could  we  judge  from  its  intensity  the 
mildness  or  severity  of  the  infection  or  likewise  of 
the  slight  or  marked  virulence  of  the  virus.  Any 
deductions  based  on  the  intensity  of  the  reaction 
would  seem  to  be  unfounded,  and  there  is  no  uni- 
formity with  regard  to  this  in  different  cases  so  far 
as  one  by  clinical  data  could  decide. 

The  presence  or  failure  of  the  reaction,  however, 
permits  of  conclusions  in  the  majority  of  cases  of 
vital  importance  to  the  patient.  Attention  was  di- 
rected to  the  fact  that  cases  with  manifestations 
gave  in  the  vast  majority  of  cases  the  reaction,  while 
in  many  cases  without  manifestations,  to  wit,  those 
that  had  been  well  treated,  the  reaction  failed. 

Of  great  importance  at  all  times  is  the  finding  of 
a  positive  reaction.  Where  evident  manifestations 
are  present  we  expect  this,  but  where  they  are  ap- 
parently absent  a  positive  reaction  should  cause  us 
to  think  seriously  on  the  possible  ravages  of  the 
virus  elsewhere,  hidden  from  view.  It  is  possible 
that  in  this  class  of  cases,  apparently  latent,  but  still 
giving  a  positive  reaction  for  syphilis,  we  are  deal- 
ing with  changes  in  internal  organs,  possibly  of 
minor  import  or  perchance  of  a  serious  character, 
attacking,  for  instance,  the  nervous  system,  etc. 

If  we  are  justified  by  a  positive  reaction  to  assume 
activity  of  the  virus,  and  most  investigators  are  in- 
clined to  take  this  position,  then  we  may  possibly 
have  in  the  serum  reaction  a  means  to  control  our 
patient's  destiny  and  protect  him  from  the  serious 
consequences  of  late  syphilis  of  internal  organs  or 
possibly  the  parasyphilitic  affections  to  which  some 
of  them  are  prone,  by  instituting,  if  the  result  of  the 
reaction  is  positive,  vigorous  antisyphilitic  treatment, 
and  possibly  by  this  means  protect  him  from  these 
visceral  and  parasyphilitic  affections. 

For  this  method  of  control  to  be  effective,  how- 
ever, it  would  necessitate  comparatively  frequent 
examinations  of  the  blood,  as  there  is  no  means  of 
knowing  how  long  this  reaction  would  remain  nega- 
tive and  consequently  how  long  the  patient  would  be 
protected  from  the  ravages  of  the  disease. 

While  the  present  status  of  tfiis  work  would  not 
permit  any  positive  statements  with  regard  to  pro- 
tecting the  syphilitic  from  these  late  forms  of  syphi- 
lis and  parasyphilis,  the  serum  reaction  is  the  first 
thing  that  promises  any  possibility  of  its  solution. 

It  has  placed  beyond  all  doubt  the  getiological  rela- 
tion of  syphilis  to  progressive  paresis  and  to  tabes. 


and  it  is  not  beyond  the  range  of  possibility  that  it 
might  enable  us  to  avoid  their  development  in  well 
controlled  cases.  Xo  greater  responsibility  of  the 
profession  could  be  imagined  than  its  responsibility 
to  syphilitics  in  protecting  them  from  these  conse- 
quences, and  it  is  to  be  hoped  at  least  that  the  serum 
reaction  will  enable  us  to  solve  this  problem. 

It  is  self  evident  that  no  statements  concerning 
the  contagiousness  of  syphilis  during  periods  of  a 
negative  reaction  could  be  made. 

The  Relation  ui"  the  Reaction  to  Antisyphi- 
litic Treatment. 

The  significance  of  the  reaction  with  regard  to 
therapeutics  n^ay  be  summed  up  as  follows : 

The  reaction  when  positive  is  an  indication  of 
activity  of  syphilis,  and  it  therefore  follows  that  a 
positive  reaction  is  an  indication  for  antisyphilitic 
therapy. 

On  the  other  hand,  we  could  not  consistently  ad- 
vise its  interruption  with  the  disappearance  of  the 
reaction,  because  we  know  that  the  disappearance 
of  the  reaction  and  likewise  of  all  specific  manifesta- 
tions may  be  followed  in  a  shorter  or  longer  time  by 
the  appearance  of  both.  1  do  not  believe  that  we 
would  be  justified  in  awaiting  the  reappearance  of 
the  reaction  always  before  resorting  to  a  systematic, 
periodic,  antiluetic  treatment  in  a  case  of  syphilis, 
because  the  point  should  be  kept  in  mind  that  this, 
like  many  other  immunodiagnostic  recourses,  may 
at  times  fail. 

It  has  emphasized  one  point,  and  that  is  not  to 
await  the  appearance  of  external  manifestations  be- 
fore instituting  treatment,  that  syphilis  is  not  cured 
even  when  the  skin  and  mucous  membrane  lesions 
have  long  since  ceased  to  appear. 

In  the  present  light  of  our  knowledge  of  syphilis 
it  would  seem  that  intelligent  management  of  syphi- 
litic cases  not  only  demands  clinical  judgment,  but 
another  important  factor,  namely,  the  serum  reac- 
tion for  syphilis.  Irrespective  of  absence  of  all  ex- 
ternal luetic  manifestations,  the  serum  reaction  is 
an  indication  for  antisyphilitic  treatment. 

In  conclusion  I  wish  to  thank  Dr.  W.  T.  Meft'ord 
and  Dr.  J.  P.  Long  for  valuable  assistance  in  labora- 
tory work. 

1487  Jackson  Boulevard. 

ORIGINAL  THOUGHTS  OX  THE  PATHOLOGY  AND 
TREATMENT  OF  CHRONIC  GONORRHOEA. 

By  Alexander  A.  L'hle,  M.  D., 
Philadelphia, 

Instructor  in  Genitourinary  Diseases.   L'niversity  of  Pennsylvania: 
.Assistant    Genitourinary    Surgeon,    Philadelphia  Hospital: 
Special  Assistant,  Surgical  Dispensary,  German  Hospital, 

and 

William  H.  Mackixxev,  M.  D., 
Philadelphia, 

Assistant  Surgeon,   Genitourinary  Dispensary,  University   Hospital ; 
Assistant,   Surgical  Dispensary,  German  Hospital. 

The  vast  number  of  drugs  that  have  flooded  the 
market  in  the  past  few  years,  accompanied  with 
their  glaring  advertisements,  testimonials  to  their 
specificity  in  the  treatment  of  gonorrhoea,  have  privi- 
leged physicians  and  the  public  at  large  to  regard 
this  disease  as  a  mild  affection,  one  easily  controlled 
and  promptly  cured.  That  this  view  is  erroneous 
and  based  upon  an   improper  conception  of  the 


214 


UHLE  AND  MACKINNEY: 


CHRONIC  CUNORRHCEA. 


[New  York 
Medical  Journal. 


palholoi;}-  of  gunorrhuea  all  physicians  of  large  ex- 
perience in  the  treatment  of  this  disease  agree. 

It  has  only  been  in  recent  years  that  gonorrhoea 
has  been  properly  studied  and  scientifically  treated. 
1  heoretically  it  would  appear  that  when  drugs  pos- 
sessing bactericidal  properties  and  tolerant  to  the 
inx'thral  mucous  membrane  are  brought  into  direct 
contact  with  the  disease  part,  the  infection  should 
be  promptly  eradicated.  Upon  this  principle  many 
drugs,  chiefly  organic  salts  of  silver,  have  been  ex- 
tensively employed.  In  the  acute  stage  of  gonorrhoea 
the  nonirritating  silver  salts  relieve  the  acute  symp- 
toms, lessen  the  amount  of  discharge,  and  shorten 
the  duration  of  the  stationary  stage,  but  in  the  sub- 
acute and  chronic  stages  they  have  little  or  no  value 
as  curative  agents. 

The  reason  of  this  failure  to  cure  is  found  in  the 
fact  that  bactericidal  drugs  which  arc  tolerant  to  the 
acutely  inflamed  urethral  mucous  membrane  do  not 
possess  penetrating  powers  sufficient  to  destroy  all 
of  the  gonococci  lying  in  the  deeper  structures  of 
the  urethra,  particularly  in  the  crypts  and  glands 
Avhose  ducts  communicate  therewith. 

A\'hen  the  infection  is  very  recent  and  has  not 
reached  the  purulent  stage,  that  is,  before  the  pene- 
tration of  the  gonococcus  into  the  depths  of  the 
mucous  membrane,  treatment  with  these  antiseptics 
may  be  carried  out  with  success,  the  gonococcus  be- 
ing destroyed  and  removed  by  mechanical  action. 
Few  patients  are  seen  before  the  development  of  a 
purulent  discharge,  and  if  the  silver  salts  and  anti- 
septics possessed  sufficient  penetrating  power  to  de- 
.stro\-  the  deeply  seated  gonococci,  their  continued 
use  should  bring  about  a  cure  in  all  cases  in  a  com- 
paratively short  time.  That  this  is  not  the  case  is 
proved  by  clinical  experience.  Many  patients  appar- 
ently cured  or  having  but  mild  catarrhal  symptoms, 
<;enerally  attributed  to  postgonorrhceal  changes,  suf- 
■*^er  from  acute  exacerbations  after  such  provocations 
as  drink,  sexual  intercourse,  or  the  use  of  irritating 
injections. 

'i'his  apparently  mild  catarrhal  condition  is  not 
<hie  to  the  changes  in  the  mucous  membrane  the 
result  of  gonorrhcea,  but  to  the  presence  of  deeply 
situated  gonococci,  in  a  low  degree  of  activity.  Mi- 
croscfipical  examination  of  the  mucoid  discharge  or 
of  {he  shreds  which  appear  in  the  urine  rarely  shows 
oonococci,  but  their  presence  can  be  readilv  demon- 
strated in  .the  discharge,  which  is  provoked  bv  an 
irritating  injection. 

It  is  the  failure  to  appreciate  the  fact  that  the 
ijonococcus  is  the  cause  of  these  catarrhal  symptoms 
that  relapses  are  .so  frequent,  that  the  disease  is  so 
innocently  transmitted,  and  that  the  insidious 
changes  in  the  urethra  and  the  annexa  result,  consti- 
tuting the  pathology  of  chronic  gonorrlKra. 

In  the  anterior  urethra  these  chronic  changes  are 
particularly  confined  to  Littre's  glands,  which  nm 
()l)li(|uely  from  before  backward,  most  prominent  on 
the  upper  wall  of  the  urethra,  .some  being  quite 
superficial,  others  extending  deeply  even  into  the 
erectile  tissue.  The  lacun?e  of  Morgagni,  likewi.se 
here  present,  are  also  involved.  They  cannot  be 
regarded  as  true  glands,  but  as  crypts  or  depres- 
sions in  tlie  mucous  mem;)rane.  Tn  the  posterior 
urethra  glandular  structures  arc  rudimentarv,  but 
their  pathological  ec|uivalent  is  found  in  the  numer- 
ous prostatic  ducts  and  the  ejaculatory  ducts. 


The  result  of  this  chronic  irritant,  the  gonococcus, 
is  always  a  round  cell  infiltration,  which,  depending 
upon  the  structure  involved,  leads  to  various  patho- 
logical conditions,  such  as  chronic  urethral  follicu-" 
litis,  infiltrations  of  the  deeper  layers  of  the  mucous 
membrane,  strictures  of  the  urethra,  and  prostatitis. 
The  earliest  evidences  of  pathological  changes  in 
the  anterior  urethra  are  seen  when  the  disease  is 
confined  to  the  glandular  structures.  It  is  clinically 
manifested  by  a  mucoid  discharge  and  the  presence 
of  shreds  in  the  urine.  These  shreds  are  composed 
of  mucus,  desquamated  epithelium,  pus  cells,  and 
bacteria,  and  are  the  products  of  superficial  erosion. 
Shreds  should  be  regarded  as  a  macroscopic  evi- 
dence of  an  active  gonorrhoeal  process,  and  a  nega- 
tive microscopical  examination  of  shreds  for  gono- 
cocci should  not  be  considered  as  evidence  of  a  post- 
gonorrhceal catarrh.  A  urethroscopic  examination 
shows  these  disease  areas  very  distinctly.  They  ap- 
pear as  small,  discrete,  red  points  of  inflammation, 
slightly  elevated  on  the  periphery,  with  a  depressed 
centre,  marking  the  opening  of  the  gland  duct. 
When  several  of  these  inflamed  follicles  lie  closely 
together  they  simulate  the  appearance  of  granula- 
tion tissue.  The  condition  has  been  erroneously  de- 
scribed as  a  "granular  patch,"  inferring  an  ulcera- 
tion with  excessive  granulations.  A  later  stage  of 
this. condition  exists  when  one  or  more  of  the  ducts 
become  occluded,  and  the  secretion  confined  within 
the  gland  forms  a  small  cyst  within  the  mucous 
membrane.  They  are  felt  distinctly  as  small,  shot- 
like bodies,  when  the  urethra  is  massaged  over  a 
sound. 

When  the  embryonal  cellular  infiltration  is  more 
diffuse,  involving  the  deep  portions  of  the  mucous 
membrane  and  the  submucous  connective  tissue,  a 
thickeneing  of  the  wall  occurs,  readily  demonstrated 
by  the  use  of  bulbous  bougies ;  upon  organization 
and  contraction  of  this  tissue  stricture  of  the  urethra 
results.  In  the  posterior  urethra  the  pathological 
j:)rocess  is  the  same,  but  is  modified  because  of  the 
presence  of  the  prostate  gland.  The  posterior  ure- 
thra being  lined  with  squamous  epithelium  of  the 
transitional  type,  a  direct  continuation  of  that  lining 
the  bladder,  is  not  so  susceptible  to  changes  similar 
to  those  met  with  in  the  anterior  urethra.  The  pres- 
ence of  the  prostate  gland,  with  its  numerous  ducts 
emptying  directly  into  the  posterior  urethra,  give  a 
most  favorable  site  for  the  lodgment  and  growth  of 
the  gonococcus,  so  that  the  pathology  of  chronic 
posterior  urethritis  is  essentially  the  pathology  of 
chronic  prostatitis.  Depending  upon  the  extent  of 
involvement,  three  varieties  of  chronic  gonorrhoeal 
prostatitis  are  recognized,  the  catarrhal,  follicular, 
and  parenchymatous. 

The  catarrhal  and  the  follicular  varieties  are  the 
most  frequent  forms  met  with  in  chronic  gonorrhfea. 
and  the  pathological  process  is  here  the  same  as  in 
the  anterior  urethra.  The  gonococcus  invades  the 
ducts  of  the  prostate,  considerable  exudate  results, 
shutting  oflf  the  lumen  of  the  duct.  The  contents 
are  thus  retained  within  the  ducts,  constituting  the 
catarrhal  prostatitis,  or,  what  is  probably  more  fre- 
(juent,  the  ,glands  themselves  become  inflamed,  either 
with  or  without  occlusion  of  the  prostatic  ducts, 
giving  rise  to  the  follicular  prostatitis.  Clinically, 
in  this  condition  symptoms  may  be  entirely  absent  at 
the  time  of  examination,  the  urine  mav  even  he  free 


January  30,  1009.] 


UHLE  AND  MACKIXXEV:  CHRONIC  GONORRHCEA. 


215 


of  solid  elements,  but  the  history  of  the  occurrence 
of  a  slight  mucoid  or  mucopurulent  discharge  at 
various  mtervals,  lasting  for  a  few  days,  especially 
after  the  free  imbibition  of  alcohol  or  after  sexual 
intejcourse,  perhaps  a  little  frequency  of  urination 
or  frequent  nocturnal  pollutions  with  sexual  irrita- 
bility, are  some  of  the  symptoms  which  should  lead 
to  a  thorough  examination  of  the  prostate. 

The  diagnosis  of  this  condition  rests  upon  the 
■examination  of  the  prostate  by  the  rectum,  the  mi- 
croscopical examination  of  the  expressed  prostatic 
secretion,  and  the  occurrence  of  solid  bodies  in  the 
third  urine  of  the  three  glass  test  after  a  thorough 
prostatic  massage.  In  the  catarrhal  and  the  mild 
follicular  varieties  the  prostate  may  feel  normal,  but 
in  a  well  defined  case  the  gland  is  enlarged,  irreg- 
ular in  contour,  as  a  whole  diminished  in  consis- 
tency, and  tender.  At  several  points  nodules  of 
firmer  consistency  may  be  felt  and  represent  follicles 
distended  with  retained  inflammatory  products. 
From  the  examination  of  many  normal  prostates  we 
have  noted  that  the  left  lobe  is  apt  to  be  larger  than 
the  right,  a  point  which  should  be  taken  into  account 
in  the  diagnosis  and  treatment. 

The  quantity  of  secretion  appearing  at  the  meatus, 
after  massage  of  the  prostate,  varies  from  one  to 
several  drops,  Normally  this  fluid  is  turbid,  some- 
what milky  in  color,  slightly  tenacious,  faintly  alka- 
line in  reaction,  and  dries  white  upon  a  slfde.  Under 
pathological  conditions  its  macroscopic  appearance 
may  remain  unaltered  or  it  may  become  thicker, 
more  tenacious,  slightly  yellow,  and  contain  small 
solid  shreds  best  seen  when  the  secretion  is  dried. 
Microscopical  examination  of  the  normal  stained 
secretion  shows  the  presence  of  a  structureless 
granular  material,  a  very  few  epithelial  cells,  leuco- 
cytes, and  spermatozoa.  In  pathological  conditions 
there  is  always  an  abundance  of  leucocytes,  desqua- 
mated epithelium,  and  bacteria.  Among  the  latter 
are  staphylococci,  short  chains  of  streptococci,  few 
bacilli,  not  infrequently  intracellular  and  extracellu- 
lar gonococci,  and  small  diplococci,  which  decolorize 
by  Gram's  method.  From  a  study  of  a  large  num- 
ber of  slides  made  from  the  prostatic  secretion  we 
would  conclude  that  the  presence  of  these  small  dip- 
lococci is  diagnostic  of  gonorrhoeal  infection,  and 
that  they  are  to  be  regarded  as  involution  forms  of 
the  gonococcus.  Our  reasons  for  believing  this  are, 
that  when  a  reaction  is  excited  in  the  posterior 
urethra  and  prostate  by  the  injection  of  irritants  into 
the  ixisterior  urethra,  or  by  alcohol,  or  intercourse, 
typical  gonococci  can  be  demonstrated  without  diffi- 
culty in  the  massaged  prostatic  secretion  after  irriga- 
tion of  the  urethra ;  there  is  a  decided  diminution  in 
number  of  diplococci,  and  those  which  remain  are 
larger  and  show  more  decidedly  the  coffee  bean  shape 
of  the  adult  gonococcus.  They  disappear  entirely 
when  a  cure  is  effected.  It  is  the  general  teaching 
that  gonococci  are  not  to  be  demonstrated  in  the  pros- 
tatic secretion  eighteen  months  to  two  years  after  the 
initial  infection,  as  they  are  destroyed  by  the  mixed 
pyogenic  infection  which  replaces  it.  That  a  mixed  in- 
fection does  exist  is  evident,  but  that  the  gonococcus 
is  destroyed  is  not  borne  out  by  careful  microscopical 
examination,  and  by  the  clinical  course  of  these  cases. 
We  have  repeatedly  demonstrated  the  presence  of 
gonococci  three,  four,  and  five  years,  and  as  long 
as  twelve  vears  after  the  initial  infection.    The  most 


important  points  to  be  observed  in  demonstrating 
gonococci  in  these  cases  of  long  duration  are  to 
thoroughly  massage  the  prostate,  to  look  long  and 
carefully,  and  if  not  successful,  employ  the  provoca- 
tion instillations  of  silver  nitrate. 

After  thoroughly  irrigating  the  urethra,  allow 
part  of  the  clear  fluid  to  remain  in  the  bladder,  then 
massage  the  prostate,  and  have  the  contents  of  the 
bladder  evacuated  into  a  glass.  Normally  the  fluid 
is  turbid,  varying  in  density,  and  as  a  rule  contains 
no  solid  elements,  or,  solid  elements  being  present, 
they  are  all  of  a  hyaline  amylacious  type.  From  our 
investigations  we  would  regard  the  presence  of 
other  solid  elements  as  pathological.  We  have  found 
these  hyaline  bodies  in  the  prostates  of  men  w'ho 
have  denied  ever  having  had  sexual  intercourse,  in 
others  having  no  history  of  gonorrhoea,  and  in  oth- 
ers with  chronic  gonorrhoeal  prostatitis,  where  h\  a- 
line  bodies  have  existed  in  conjunction  with  other 
solid  elements,  the  hyaline  lx)dies  have  remained 
after  all  others  had  disappeared.  In  pathological 
conditions  the  solid  elements  vary  from  mere  specks 
to  large  masses  of  irregular  contour  and  often  large, 
"skinlike"  bodies.  All  of  these  varieties  we  regard 
as  pathological,  and  significant  of  various  degrees 
of  prostatitis.  That  the  seminal  vesicles  are  fre- 
quently involved  in  the  process  is  shown  by  the 
appearance  in  the  massaged  urine  of  convoluted 
casts  bearing  a  close  resemblance  to  the  convolu- 
tions of  the  seminal  vesicles.  It  is  only  in  excep- 
tional cases  that  the  seminal  vesicles  can  be  accu- 
rately distinguished  from  the  prostate  by  a  rectal 
examination,  but  an  involvement  of  them  should  be 
suspected  by  the  presence  of  these  characteristic 
casts  in  the  massaged  urine  and  the  occurrence  of 
blood  tinged  pollutions  and  ejaculations. 

Microscopically  the  solid  bodies  consist  of  an  in- 
spissated mucoid  base,  covered  with  epithelium,  leu- 
cocytes, few  spermatozoa,  and  bacteria.  They  are 
much  less  satisfactory  to  examine  for  gonococci 
than  the  expressed  secretion,  because  of  their  den- 
sity and  deep  staining  properties  a  sharp  definition 
is  not  obtained.  Chronic  parenchymatous  prosta- 
titis or  interstitial  prostatitis  varies  from  the  other 
forms  in  that  the  entire  gland  is  involved.  It  is  the 
least  frequent  of  the  varieties  and  is  only  met  with 
after  the  subsidence  of  very  severe  inflammation 
leading  to  abscess  of  the  entire  gland  or  of  one  lobe. 
The  entire  gland  may  have  been  destroyed  and  noth- 
ing remains  but  a  dense,  fibrous  mass  of  connective 
tissue,  or  one  lobe  alone  may  be  involved.  If,  as 
most  frequently  happens,  the  abscess  ruptures  into 
the  urethra,  the  cavity  may  persist  and  drain  by  a 
fistulous  opening  into  the  urethra,  simulating  closely 
the  follicular  variety.  The  prostate  may  be  enlarged 
or  atrophied,  the  consistency  is  very  firm  throughout 
or  shows  scattered  areas  of  boggy  consistency.  In 
this  condition  the  gonococci  invade  the  entire  gland 
and  it  is  the  most  serious  variety  to  deal  with,  a 
complete  cure  being  most  difficult  or  impossible. 

While  it  is  true  that  the  silver  salts  exercise  a  ben- 
eficial influence  when  employed  in  the  acute  inflam- 
matory stage  of  anterior  urethritis,  and  no  doubt 
many  gonococci  are  killed  by  their  germicidal  prop- 
erties, it  is  questionable  whether  the  improvement 
rnnnot  be  attributed  more  to  the  frequentlv  repeated 
flushings  of  the  urethra.  If  their  bactericidal  prop- 
erties were  so  pronounced,  the  limitation  of  the  dis- 


2l6 


UHLE  AND  MACKINNEY:  CHRONIC  GONORRHCEA. 


[New  Vork 
Medical  Journal. 


case  to  the  anterior  urethra  should  be  the  rule,  while 
as  a  matter  of  fact  the  posterior  urethra  becomes  in- 
fected in  about  seventy  per  cent,  of  cases.  Further- 
more, in  those  cases  where  an  apparent  cure  has 
been  effected,  the  discharge  being  entirely  absent  and 
the  urine  clear,  cessation  of  treatment  promptly 
brings  about  a  relapse,  as  also  will  the  employment 
of  various  provocation  treatments.  This  relapse  is 
caused  by  the  deeply  situated  gonococci,  which  are 
uninfluenced  by  nonirritating  antiseptics. 

The  apparent  cure  just  considered,  and  the  unfor- 
tunate belief  which  is  still  far  too  prevalent,  that 
with  the  subsidence  of  subjective  symptoms  a  cure 
lias  been  effected,  are  the  most  important  factors  re- 
sponsible for  a  large  percentage  of  chronic  gonor- 
rlioea.  The  results  attained,  in  many  cases,  by  the 
use  of  the  silver  salts  alone  in  the  treatment  of  gon- 
orrhcea  may  be  compared  favorably  with  the  results 
when  the  disease  is  left  to  Nature,  except  in  the  lat- 
ter the  course  is  a  more  prolonged  one. 

If  it  is  true  that  nonirritating  silver  salts  and  anti- 
septics do  not  cure  a  gonorrhoea,  how  and  by  what 
means  is  the  final  eradication  of  the  infection  accom- 
plished? All  writers  on  gonorrhoea  recognize  the 
employment  of  astringent  injections  in  the  subsiding 
stages,  when  the  symptoms  are  catarrhal  rather  than 
inflammatory,  and  as  the  disease  progresses  in  chro- 
nicity  the  use  of  urethral  sounds  and  dilators,  mas- 
sage of  the  prostate,  and  deep  injections  are  the 
measures  recommended,  but  they  fail  to  explain  how 
these  measures  act  in  bringing  about  a  cure.  or.  in 
other  words,  destruction  of  the  gonococcus.  Chronic 
gonorrhoea  is  cured -by  the  utilization  of  the  same 
natural  process  as  act  in  the  cure  of  any  infection 
which,  because  of  anatomical  or  pathological  condi- 
tions, is  not  accessible  to  the  direct  action  of  a  germi- 
cide. These  natural  antagonists  to  infection  are 
inherent  properties  of  all  cells,  and  more  special- 
ized properties  of  the  white  blood  cells,  which  act 
chiefly  by  the  process  of  phagocytosis.  When  this 
"natural  resistance"  is  sufficient  to  destroy  the  gono- 
coccus at  the  moment  of  its  entrance  into  the  urethral 
canal,  gonorrhoea  does  not  develop.  This  explains, 
partially  at  least,  why  one  of  two  persons  exposed  to 
the  same  source  of  infection  escapes,  while  the  other 
becomes  infected.  It  further  explains  why  one  of 
two  cases  contracted  from  the  same  source,  other 
factors  being  equal,  takes  a  mild  course,  the  other 
being  severe,  and  best  explains  the  occasional  cure 
of  gonorrhoea  by  purely  hygienic  measures  or  inter- 
nal treatment  alone. 

In  attempting  to  explain  the  cure  of  chronic  gon- 
orrhoea by  utilizing  the  natural  forces  of  resistance 
we  must  consider  that  we  are  dealing  not  only  with 
the  gonococcus  per  se,  but  with  certain  pathological 
processes  which  are  incident  to  its  activity.  From 
what  has  been  said  regarding  the  pathology  of 
chronic  gonorrhoea,  it  will  be  seen  that  certain  me- 
chanical barriers  are  offered  to  the  free  circulation 
of  the  most  important  bactericidal  fluids,  namely, 
the  blood  and  lymph.  The  round  cell  infiltration,  a 
constant  factor  in  all  chronic  gonorrhceal  inflanuna- 
tions,  results  in  lymph  stasis  and  poor  circulation, 
and  it  is  through  the  rcestablishment  of  a  normal 
circulation  by  artificial  means  that  we  mu.st  look  for 
a  cure. 

It  has  been  held  recently  by  many  writers  that 
gonorrhoea  is  most  successfully  combated  by.  the  use 


of  bacterial  emulsions,  or  opsonic  therapy.  From 
clinical  experience  their  action  in  the  treatment  of 
acute  gonorrhoea  is  nil.  Their  use  alone  in  the  treat- 
ment of  chronic  urethral  gonorrhoea  has  not  been 
productive  of  good  results  in  our  hands.  Their  fail- 
ure may  be  explained  by  the  fact  that,  even  if  the 
natural  resistance  of  the  body  to  the  gonococcus  is 
enhanced,  their  local  action  is  prevented  by  the  me- 
chanical factors  which  have  been  reviewed  under  the 
pathology  of  chronic  gonorrhoea.  We  have  employed 
the  bacterial  emulsions,  both  stock  and  autogenous, 
as  adjuncts  to  local  treatment,  and  theoretically  bet- 
ter results  should  be  obtained,  but  clinically  we  know' 
the  marked  variations  in  the  susceptibility  of  these 
patients  to  local  treatment,  and,  as  there  is  no  index 
to  be  guided  by,  conclusions  are  impossible.  The 
great  majority  of  these  cases  are  cured  by  the  appli- 
cation of  a  rational  local  therapy,  all  parts  of  which 
aim  in  the  production  of  local  congestion  in  the  dis- 
eased parts,  thus  promoting  the  absorbative  and  bac- 
tericidal properties  of  the  blood  manifested  chiefly 
in  phagocytosis. 

It  should  be  our  aim  to  provoke  only  a  congestion 
and  avoid  a  reaction  which  is  likely  to  be  decidedly 
inflammatory  in  character.  For  this  reason  always 
begin  with  the  employment  of  mild  measures  and 
gradually  increase  as  the  case  will  warrant.  In  the 
subsiding  stage  of  gonorrhoea  the  mild  astringents 
are  first  employed  and  their  strength  gradually  in- 
creased, depending  upon  the  degree  of  reaction 
which  follows.  This  reaction  is  manifested  by  an  in- 
crease in  the  amount  of  discharge,  a  change  in  its 
character  from  mucoid  to  mucopurulent  or  purulent, 
a  mild  burning  on  urination,  and  a  turbidity  of  the 
first  glass  of  the  two  glass  test.  This  reaction  is  due 
entirely  to  the  irritation  of  the  injection  and  prompt- 
ly subsides  when  the  injection  is  discontinued.  It  is 
well  to  employ  the  injection  only  for  the  time 
necessary  to  provoke  the  reaction  desired,  then 
to  discontinue  it,  allow  a  few  days  of  rest,  and 
then  again  excite.  Gradually  stronger  irritants  must 
be  employed  to  provoke  a  similar  degree  of  reaction. 
The  discharge  provoked  at  the  height  of  the  reaction 
should  be  carefully  examined  for  gonococci,  and 
when  they  are  no  longer  to  be  demonstrated  it  will 
be  observed  that  upon  the  subsidence  of  the  reaction- 
ary symptoms  the  urine  is  free  from  true  shreds,  al- 
though a  very  slight  mucoid  discharge  and  mucus  in 
the  urine  may  still  persist.  This  may  be  regarded 
as  the  sign  for  cessation  of  local  treatment. 

In  chronic  cases  the  use  of  weak  solutions  of  sil- 
ver nitrate  in  the  provocation  of  reactions  is  best. 
When  infiltrations  of  the  mucous  membrane  exist 
urethral  sounds  or  dilators  should  be  employed  either 
alone  or  in  conjunction  with  astringents  to  produce 
reactions.  A  sound  to  be  efficacious  must  stretch  the 
urethra  at  the  site  of  constriction.  It  does  not  act 
by  "ironing  out"  granulations,  but  by  provoking  con- 
gestion in  the  infiltrated  area,  acting  the  same  as 
massage  in  promoting  the  absorption  of  any  exudate. 
As  long  as  this  infiltration  remains  composed  of  em- 
bryonal cells  the  prognosis  for  its  complete  removal 
is  good,  but  where  the  process  is  deeply  situated  and 
organization  of  the  tissue  has  occurred  a  true  stric- 
ture results,  which  can  be  dilated  to  a  certain  ex- 
tent, but  cannot  be  completely  removed. 

In  chronic  gonorrlutal  inflammations  of  the  pos- 
terior urctlira   and  prostate,  deep  instillations  of 


January  30>  1909. 1  HUHXER:  GOXORRHCEA. 


drugs  produce  the  same  type  of  reactions  as  hand 
injections  provoke  in  the  anterior  urethra.  As  the 
posterior  urethra  has  less  surface  to  be  treated  only 
a  small  quantity  of  the  drug  is  employed  ( lo  to  20 
minims),  and  as  its  mucous  membrane  is  lined  with 
stratified  squamous  epithelium  and  contains  but  few 
rudimentary  glands,  stronger  drugs  are  used. 

Instrumental  treatment  of  the  posterior  urethra 
by  the  passage  of  sounds  is  not  productive  of  the 
.same  good  results  as  their  use  in  the  anterior  ure- 
thra. The  several  varieties  of  conical  pointed  sounds 
cause  no  stretching  of  the  posterior  urethra  whatso- 
ever :  the  smallest  part  of  the  sound  is  introduced 
into  the  largest  part  of  the  urethra.  The  best  in- 
strument to  employ  is  the  Kollmann  posterior  dilat- 
ors, which  can  be  opened  to  a  sufficient  degree  to 
stretch  and  cause  reaction  in  the  posterior  urethra. 

In  chronic  prostatitis,  some  degree  of  which  may 
be  regarded  as  an  invariable  accompaniment  of 
chronic  posterior  urethritis,  no  form  of  treatment  is 
so  efficacious  as  massage  of  the  gland  by  the  rectum. 
The  first  few  treatments  are  apt  to  be  decidedly  pain- 
ful and  disagreeable  to  the  patient,  and  should  be 
conducted  very  gently.  Later  the  pressure  may  be 
gradually  increased,  thus  expressing  the  inflamma- 
tory products  retained  in  the  acini.  The  principles 
underlying  the  application  of  massage  of  the  pros- 
t  ite  are  the  same  as  those  which  apply  to  its  action 
in  the  removal  of  exudation  wherever  situated,  and 
h.ere  it  has  the  further  advantage,  in  common  with 
all  glandular  organs,  that  part  of  the  inflammatory 
products  are  removed  directly. 

It  will  be  seen  from  what  has  been  said  that,  in 
our  opinion,  there  are  no  drugs  known  at  the  pres- 
ent time,  tolerant  to  the  urethra,  which  possess  the 
power  of  pentrating  the  mucous  membrane  and  the 
glands  and  ducts  communicating  therewith  to  a  suf- 
ficient degree  to  destroy  all  the  gonococci,  and.  fur- 
ther, that  all  the  means  used  in  the  cure  of  subsiding 
and  chronic  gonorrhoea,  be  they  injections,  instilla- 
tions, instrumentations,  massage,  etc..  have  as  a  basis 
of  action  the  production  of  local,  artificial  conges- 
tions, which  make  possible  the  activit}-  of  the  natural 
defenses  of  the  body  against  the  continued  activity 
of  infectious  organisms. 

Profes.sioxal  Building. 


CLINICAL  GONORRHCEA  IX  THE  MALE. 

By  Max  Huhner.  M.  D., 
New  York. 
(Continued  from  page  I/3-) 

Having  discussed  the  theory  of  the  injection 
treatment  of  gonorrhoea  I  will  now  take  up  a  dis- 
cussion of  some  of  the  various  substances  and 
methods  that  have  been  used  as  injections  in  the 
treatment  of  gonorrhoea. 

Intravesical  Irrigation. — One  of  the  most  impor- 
tant methods  is  that  of  intravesical  irrigation,  first 
introduced  by  Janet  and  popularized  in  this  coun- 
try by  \'alentine.  Few  methods  have  been  more 
"run  down"  than  this  one.  It  has  been  pronounced 
dirty,  unscientific,  and  the  direct  cause  of  many  of 
the  complications  of  gonorrhoea.  In  answer  to  all 
these  objections  I  can  only  say  that  I  have  person- 


217 

ally  performed  several  thousands  of  intravesical 
irrigations,  and  have  neither  found  it  dirty  nor  the 
cause  of  any  complication.  On  the  contrary,  since 
adopting  this  method  from  the  very  commencement 
of  treatment,  complications  have  been  exceedingly 
rare,  and  as  regards  the  dirtiness  of  the  method,  I 
can  and  would  not  hesitate,  if  need  be,  to  give  an 
intravesical  irrigation  of  potassium  permanganate 
with  both  the  patient  and  myself  in  evening  dress. 
Experience  has  led  me  to  disregard  the  rather  heavy 
and  cumbersome  apparatus  of  \'alentine  and  sub- 
stitute therefor  an  ordinary  douche  bag  (preferably 


Urethral. 


Urethra  at  rest. 

Urethra. 


Urethra  during  ordinary  urination. 


Urethra  during  intravesical  irrigation. 


Urethra 


Urethra  during  intravesical  irrigation  with  spasm  of  cut  off  muscles. 
Fic.  I, — Diagrammatic  scheme  of  the  urethra. 


one  which  has  a  valve,  so  that  the  liquid  can  be 
shaken  up  without  spilling)  and  attaching  to  the 
tubing  the  ordinary  nasal  nozzle  which  comes  in  the 
box  and  is  shaped  as  shown  in  Fig.  i. 

I  have  a  douche  bag  which  mav  be  elevated  or 
lowered  by  a  cord  and  pulley  arrangement.  The 
bag  is  lowered,  the  solution  poured  in,  and  it  is  then 
elevated  and  kept  elevated  to  a  height  of  about  four 
and  one  half  feet  above  the  level  of  the  penis.  The 
patient  sits  on  a  chair,  ^is  shirt  rolled  up,  his 


2l8 


HUHNER:  GONORRHCEA. 


[New  York 
Medical  Journal, 


trousers  pulled  down  to  below  his  knees,  and  with 
one  hand  he  holds  an  ordinary  agate  basin  on  his  lap, 
and  allows  his  penis  to  hang  therein.  I  have  a 
quantity  of  nozzles  always  ready  in  a  i  in  500  bi- 
chloride solution,  one  of  which  is  rinsed  out  with 
water  and  attached  to  the  tubing.  It  is  well  always 
to  test  the  temperature  of  the  water  on  one's  own 
hands,  remembering  that  the  first  portion  is  always 
considerably  cooler  than  the  rest.  The  tubing  just 
above  the  nozzle  js  then  pinched  with  the  finger  and 
the  stopcock  opened.  The  first  portion  of  the  solu- 
tion is  allowed  to  flow  over  the  outside  of  the  penis, 
thus  cleansing  it,  as  well  as  the  meatus  and  prepuce. 
The  nozzle  (as  described  in  Fig.  4)  is  then  applied 
to  the  meatus  in  such  a  manner  that  the  broad  part 


Fig.  2. — Intravesical  irrigation. 


complctly  closes  the.  meatus,  effectively  preventing 
any  leakage  from  the  side.   (See  Fig.  2.) 

It  is  this  little  point  about  using  this  particular 
kind  of  nozzle  that  makes  all  the  difiference  between 
an  easy  and  clean  irrigation,  and  one  in  which  the 
patient  and  floor  and  physician  become  soaked  with 
the  solution.  The  solution  is  then  allowed  to  enter 
the  urethra,  at  first  slowly  and  not  full  force,  the 
rapidity,  force,  and  pressure  being  accurately  regu- 
lated by  the  fingers  pressing  the  tubing.  At  each 
irrigation  I  first  wash  out  the  anterior  urethra,  re- 
moving the  nozzle  from  the  meatus,  as  soon  as  the 
resistance  of  the  cut  ofl"  nuiscle  is  appreciated.  As 
soon  as  the  anterior  urethra  is  thoroughly  irrigated 


I  let  the  solution  run  into  the  bladdtr.  As  a  general 
thing,  if  the  solution  is  warm  enough,  and  after 
several  irrigations  of  the  urethra  up  to  the  cut  ofif 
muscle,  the  solution  will  by  this  time  have  overcome 
the  resistance  of  this  muscle  and  will  flow  easily 
into  the  bladder.  Should  this  not  be  the  case  (which 
sometimes  happens  if  the  solution  is  too  cold,  or  the 
cut  off  muscle  very  powerful)  we  may  continue  a 
few  more  times  with  the  irrigation  up  to  the  con- 
strictor muscle,  at  the  same  time  occasionally  squeez- 
ing the  anterior  urethra  near  the  meatus,  this  having 
the  eifect  of  pushing  the  fluid  onward  towards  the 
bladder,  and  also  on  relaxing  the  pressure  creating  » 
a  vacuum,  thus  further  aiding  the  onward  flow  of 
the  fluid.  If  even  now  the  fluid  does  not  enter  the 
bladder,  we  may  simply  hold  the  nozzle  to  the  ure- 
thra as  before,  till  the  cut  off  is  paralyzed,  and  we 
will  certainly  get  the  solution  into  the  bladder.  This 
last  method  has  the  slight  disadvantage  that  it  is 
more  painful  and  more  irritating  to  the  prostate ;  it 
has,  however,  the  advantage  that  it  more  fully  dis- 

 This    part    goes  into 

the  meatus. 

 This  part  closes  meatus 

preventing  leakage. 


Fig.  3. — -Nozzle. 

tends  the  urethra  than  any  other  method.  (See 
Fig.  3-) 

This  last  method  need  but  seldom  be  employed,  as 
in  the  vast  majority  of  cases  the  fluid  enters  the 
bladder  by  the  other  methods.  Unless  there  exists 
a  very  tight  stricture,  ex'ery  bladder  can  be  irrigated 
by  the  intravesical  method.  I  have  had  one  neuras- 
thenic patient  who,  although  the  fluid  went  into  the 
bladder  quite  easily,  complained  bitterly  of  the  pain 
and  pressure  feeling.  In  this  case  all  unpleasant 
feelings  were  done  away  with  by  first  giving  a  deep 
urethral  injection  of  i  in  1,000  solution  of  adrenalin 
chloride.  With  this  single  exception  I  have  never 
had  any  difiiculty  of  injecting  patients  and  have 
never  used  any  drugs  to  deaden  sensibility ;  especial- 
ly have  T  always  avoided  the  use  of  cocaine  in  any 
form  of  intraurethral  work. 

During  the  first  few  days  of  intravesical  treat- 
ment I  simply  wash  out  the  anterior  urethra  in  or- 
der to  allow  the  patient  to  become  used  to  this 
method  of  treatment.  On  the  second,  third,  or 
fourth  day  at  the  latest  I  allow  the  fluid  to  enter  the 
bladder.  At  first  I  use  a  i  in  5,000  solution  of 
potassium  permanganate,  but  increase  the  strength 
each  day  till  i  in  3,000,  and  then  I  remain  at  this 
strength.  I  have  the  patient  come  daily  till  the  dis- 
charge has  entirely  ceased  ;  then  every  other  day ; 
then  every  fourth  day,  and  so  on.  Should  there  be 
any  tendency  to  chronicity  either  in  the  form  of  a 
morning  drop  or  a  large  amount  of  discharge,  I 
change  off  after  two  weeks'  treatment  to  silver  ni- 
trate. Starting  with  a  i  in  20,000  solution  the  first 
day,  I  increase  as  follows : 


January  30,  19C9.  | 


HUHXER:  GONORRHCEA. 


219 


1:15000,  second  day, 
I  :  1 2000,  third  day, 
I  :  10000.  fourth  day, 
I  :8ooo.  fifth  day, 
1 :6ooo,  sixth  day, 
I  :5000,  seventh  day, 
I  :4000.  eighth  day, 
T  :3O0O,  ninth  day, 
I  :2000,  tenth  day, 
1:1000.  eleventh  day, 


I  :iooo,  twelfth  day, 
1 :2000,  thirteenth  day, 
I  :4000,  fourteenth  day, 
I  :6ooo,  fifteenth  day, 
1 :8ooo,  sixteenth  day, 
I  :  10000.  seventeenth  day. 
Potassium  permanga- 
nate, I  :3000  eighteenth 
day,    nineteenth  day, 
twentieth  day,  etc. 


Should  at  any  time  the  solution  appear  too  strong, 
as  shown  by  too  great  a  reaction.  I  do  not  increase 
the  strength,  but  keep  the  patient  on  the  same 
strength  till  he  is  accustomed  to  it.  and  then  in- 
crease. I  generally  try  to  run  up  to  i  in  i.ooo  solu- 
tion. After  a  few  days'  treatment  or  by  the  time 
we  have  reached  a  i  in  8.000  solution,  a  marked 
change  is  noticed  in  the  discharge  ;  it  rapidly  gets 
less  and  scon  disappears  entirely.  It  is,  however, 
not  wise  to  stop  treatment  at  this  point  or  even  to 
stop  increasing  the  strength  of  the  solution.  I  go 
right  on  increasing,  my  only  guide  being  the  pain 
that  it  causes.  As  we  approach  the  i  in  i.ooo  mark 
the  discharge  may  reappear,  but  different  in  char- 
acter ;  it  is  not  the  yellowish  pus  of  gonorrhoea,  but 
is  whitish  and  watery,  due  to  the  silver  nitrate.  I 
then  recede  in  strength,  as  indicated  in  the  table, 
ending  up  with  a  few  days'  treatment  of  potassium 
permanganate,  which  clears  up  any  discharge  due 
to  the  silver  nitrate. 

It  will  be  seen  from  this  description  what  a  long 
winded  affair  some  cases  of  gonorrhoea  are,  but,  on 
the  other  hand,  a  patient  pronounced  cured  is  cured 
— there  is  no  relapse.  The  only  sign  by  which  I  go 
IS  the  presence  of  any  sort  of  discharge  after  re- 
fraining from  urination  for  a  period  of  twelve 
hours. 

Besides  silver  nitrate  and  potassium  perman- 
ganate, there  is  another  drug  which  I  occasionally 
employ  for  intravesical  irrigation,  and  that  is  the 
protein  silver  salt,  protargol.  While  my  experience 
with  this  drug,  and  m\-  most  excellent  results  with 
it  have  been  obtained  by  having  the  patient  use  it 
himself  with  the  ordinary  syringe,  I  have  employed 
it  also  with  good  results  as  an  intravesical  irriga- 
tion. Given  in  this  w-ay  it  should  never  be  made 
stronger  than  a  i  per  cent,  solution,  and  many  pa- 
tients can  hardly  stand  that  strength.  I  start  with 
a  I  in  16.000  solution  and  run  it  up  as  far  as  pos- 
sible. I  have  employed  it  in  acute  (within  the  first 
few  days  of  the  discharge),  subacute,  and  chronic 
cases.  While  it  does  fairly  well  ( intra vesically)  in 
acute  cases,  it  is,  however,  far  inferior  to  potassiimi 
permanganate  (employed  intravesically) .  I  want  to 
distinctly  emphasize  that  what  I  now  say  about 
protargol.  potassium  permanganate,  and  silver  ni- 
trate refers  solely  to  their  use  as  an  intravesical 
irrigation.  There  is  all  the  difference  in  the  world 
between  the  use  of  protargol  with  a  hand  syringe 
in  solutions  varying  between  i  and  2  per  cent,  and 
the  intravesical  use  of  the  drug,  ranging  in  solu- 
tions between  i  in  16.000  to  i  per  cent.  When  I 
order  my  patient  to  use  a  solution  of  protargol  (be- 
tween I  and  2  per  cent.)  himself  with  a  small 
syringe,  I  expect  the  gonococci  either  to  entirely 
disappear  or  at  least  be  greatly  diminished  in  num- 
bers in  the  pus  within  a  few  days ;  but  given  intra- 


vesically in  the  weak  solutions  as  mentioned  its 
gonococcidal  properties  cannot  at  all  be  relied  upon. 
I  have  seen  the  gonococci  disappear  from  the  pus 
after  a  i  in  14,000  solution  (intravesically)  and 
have  also  seen  them  persist  even  if  the  strength  of 
the  solution  was  run  tip  to  i  per  cent.  Xor  is  the 
discharge  or  other  clinical  symptoms  so  promptly 
abated  as  with  the  potassium  permanganate  irriga- 
tions. Another  disadvantage  is  that  the  solutions 
must  not  be  used  warm  (as  heat  spoils  protargol), 
and  it  is  therefore  more  difficult  to  get  it  into  the 
bladder.  In  subacute  and  chronic  cases  it  is  an  ex- 
cellent substitute  for  silver  nitrate,  and  sometimes 
cures  where  the  latter  fails.  Here  we  do  not  rely 
upon  its  gonococcidal  properties  as  much  as  upon 
its  astringent  action.  I  have  also  noticed  that,  while 
in  the  anterior  urethra  protargol  is  much  less  of  an 
irritant  than  the  corresponding  dilution  of  silver 
nitrate,  in  the  intravesical  treatment  there  is  verv 
little  dift'erence  between  them,  that  is,  a  i  in  1,000 
solution  of  protargol  hurts  about  as  much  as  a  i  in 
1,000  solution  of  silver  nitrate. 

Before  closing  the  chapter  on  intravesical  irriga- 
tion, I  wish  to  state  that  I  have  experimented  with 
quite  a  number  of  other  drugs,  including  gelatose 
silver  (albargin),  boric  acid,  and  bichloride  of  mer- 
cury, but  with  little  or  no  success,  and  will  therefore 
merely  mention  them. 

We  now  come  to  the  important  consideration  of 
the  treatment  of  gonorrhoea  by  injection  into  the 
anterior  urethra  by  the  patient  himself.  No  mat- 
ter how  many  advantages  the  intravesical  method 
of  treatment  presents  there  will  always  be  a  large 
percentage  of  patients  who  have  not  the  time  to 
come  to  their  physician  every  day,  especially  as  I 
have  shown  that  even  then  it  is  not  a  ten  or  a 
twelve  da\'  affair.  A  simple  gonorrhoea  limited 
strictly  to  the  anterior  urethra  can  undoubtedly  be 
cured  by  this  method,  although  even  here  the  intra- 
vesical method  is  superior,  but  I  absolutely  deny  the 
possibility  of  a  cure  in  cases  where  the  posterior 
urethra  is  involved. 

By  far  the  two  most  important  drugs  to  be  used 
by  this  method  are  protargol  and  potassium  per- 
manganate. If  a  patient  comes  to  me  with  an  acute 
gonorrhoea,  especially  at  the  beginning  of  the  dis- 
ease, and  the  discharge  shows  gonococci.  and  he  is 
not  willing  to  submit  to  the  intravesical  method,  I 
prescribe  for  him  a  i  per  cent,  solution  of  protargol, 
with  instructions  to  use  it  full  strength  if  not  too 
irritating,  but  if  it  burns  him  too  much  to  dilute 
some  of  it  with  an  equal  quantity  of  water  (i.  e., 
half  strength),  and  as  soon  as  he  can  stand  it  to  go 
back  to  full  strength.  The  solution  is  not  to  be 
warmed  in  summer  time,  and  only  slightlv  in  winter. 
Heating  it  or  adding  hot  water  spoils  the  solution. 
I  would  add,  in  passing,  that  there  are  two  ways  of 
making  up  a  solution  of  protargol.  One  is  a  rapid 
method  and  consists  in  mixing  up  the  dry  powder 
with  glycerin,  thus  making  an  em.ulsion,  and  add- 
ing cold  water  and  more  glycerin,  stirring  all  the 
time  till  we  have  made  it  of  the  required  dilution. 
The  other  method  is  much  slower  and  consists  in 
measuring  out  the  required  quantity  of  cold  w-ater 
and  then  spilling  the  dry  powder  on  the  surface 
zvifhout  stirring  and  then  waiting  a  few  hours  till  it 
dissolves  in  the  water.  After  trying  both  methods  I 
imagine  I  obtained  slightly  better  results  from  the 


220 


HUHXER:  GOXOKRHCEA. 


LXew  York 
Medical  Jdurnal. 


latter  method,  although  the  difference  was  so  slight 
that  I  would  not  at  all  hesitate  to  use  the  other  if 
in  a  hurry. 

The  patient  is  instructed  always  to  urinate  first 
and  then  to  inject  the  solution  with  a  blunt  pointed 
two  drachm  penis  syringe,  as  shown  in  Fig.  4. 

It  is  very  important  to  have  a  syringe  that  works 
easily  without  a  jerk  and   does   not  leak.  Only 


Bro&d ph.rt  clostnp  meatus 


Vic.   4. — Showing  nozzle   introduced  into  meatus. 

enough  should  be  injected  into  the  anterior  urethra 
as  it  can  conveniently  hold.  The  solution  must  be 
kept  in  for  from  ten  to  fifteen  minutes  by  the  clock. 
It  is  very  important  to  tell  the  patient  to  use  a  time- 
piece, as  otherwise  a  minute  will  appear  to  him  an 
hour.  The  injections  are  to  be  repeated  every  four 
hours  by  day  and  if  convenient  once  during  the 
night,  although  this  is  not  absolutely  necessary. 

It  is  remarkable  how  quickly  the  gonococci  dis- 
appear from  the  secretion,  sometimes  within  forty- 
eight  hours  from  the  commencement  of  treatment. 
In  some  cases,  besides  the  disappearance  of  the 
germs,  there  is  also  a  diminution  of  the  discharge, 
while  in  other  cases  the  discharge  remains  the  same, 
and  in  still  others  {though  these  are  in  the  minor- 
ity) the  discharge  is  increased;  but  one  thing  is 
certain,  and  that  is  the  disappearance  of  the 
gonococci. 

In  this  method  of  treatment  no  regard  is  taken 
whether  the  discharge  remains  the  same,  is  decreas- 
ing, or  increasing.  I  go  right  ahead  using  a  i  oer 
cent,  or  0.5  per  cent,  solution  for  three  or  four 
days,  then  a  1.5  per  cent.,  and  finally  2  per  cent. 
My  only  criterion  of  increase  is  the  amount  of  pain 
caused  to  the  patient.  At  the  end  of  ten  days  I 
have  him  use  the  protargol  solution  three  times  a 
day,  and  order  a  i  per  cent,  zinc  sulphate  solution 
once  a  day.  In  three  or  four  more  days  I  have  him 
use  each  solution  twice  a  day  alternately,  and  in  a 
few  more  days  the  protargol  once  and  the  zinc 
sulphate  three  times  a  day,  and  finally  I  drop  the 
protargol  entirely  and  use  the  zinc  sulphate  four 
times  and  later  three  times  a  day,  and  then  twice, 
and  finally  once  a  day.  Of  course  the  secretion  is 
examined  every  few  days  for  gonococci.  As  a  gen- 
eral thing  by  this  time  the  patient  will  be  cured ;  if, 
however,  there  is  a  tendency  towards  chronicity  it 
is  well  to  change  off,  giving  instead  of  zinc  "sul- 
phate a  I  in  2,000  solution  of  potassium  perman- 
ganate, and  in  some  cases  the  results  will  be  truly 
remarkable.  This,  as  before  explained,  is  not  due 
so  much  to  any  particular  virtue  of  the  potassium 
permanganate,  but  is  simply  due  to  a  change  in  the 
injection  fluid,  as  the  urethra  seems  to  get  used  to 
one  fluid  and  does  not  respond  to  it  after  a  while. 

A  very  excellent  method  of  treating  a  recent  an- 
terior gonorrhoea  is  the  one  advocated  by  Wqlbarst. 
of  New  York,  of  which  the  one  just  described  is 
a  modification  to  suit  the  home  treatment  by  the 
patient  himself.  The  patient  comes  daily  to  the 
physician's  office  and  a  i  per  cent,  solution  of  pro- 


targol is  injected  with  a  small  syringe  into  the  ante- 
rior urethra  (after  urination),  and  is  held  there  for 
fifteen  minutes.  I  have  devised  a  special  clamp 
which  may  be  applied  to  the  meatus,  compressing  it 
for  the  desired  time  without  injuring  the  parts  or 
causing  pain  to  the  patient.  After  the  gonococci 
have  disappeared  a  i  per  cent,  zinc  sulphate  solu- 
tion is  used  in  the  same  way.  I  have  tried  this 
method  with  excellent  results,  but  it  necessitates  the 
patient's  coming  every  day  to  the  office,  having 
herein  the  same  disadvantage  as  the  Janet  method, 
and,  on  the  whole,  it  is  not  as  certain.  If  I  can  get 
a  patient  to  come  daily  I  would  much  rather  use 
the  Janet  treatment  than  this. 

Next  to  protargol  the  drug  that  stands  preemi- 
nent for  home  injections  is  potassium  permanga- 
nate. Not  only  is  it  used  as  an  adjuvant  to  the 
protargol  treatment  as  indicated,  but  it  is  the  best 
nniversal  injection  material  for  urethritis.  In  anv 
case  of  discharge  from  the  urethra  iinthont  gono- 
cocci, whether  due  to  ulcers,  stricture,  or  what  not, 
it  is  the  best  drug  to  use  to  keep  the  urethra  clean. 
It  certainly  limits,  and  very  often  stops  the  dis- 
charge. To  illustrate  my  meaning:  If  a  person  has 
a  chronic  discharge  due  to  any  pathological  con- 
dition either  in  the  seminal  vesicles,  prostate,  or 
urethra,  it  stands  to  reason  that  that  patient  cannot 
be  cured  vuitil  the  original  cause  is  removed,  but 
while  we  are  treating  the  original  cause  by  massage, 
sounds,  or  deep  urethral  injection,  if  we  at  the  same 
time  order  self  injections  of  potassium  permanga- 
nate we  will  certainly  limit  the  discharge  or  even 
stop  it  altogether.  Of  course,  if  we  stop  the  home 
injection  the  discharge  often  promptly  reappears, 
showing  that  it  is  not  curative,  but  this  temporary 
stoppage  greatly  aids  the  cure  of  the  origmal 
trouble. 

The  other  substances  that  have  been  used  for  an- 
terior self  injections  are  too  numerous  to  be  dis- 
cussed. ]\Iost  of  them  are  useless  or  at  least  far 
inferior  to  the  ones  mentioned,  and  have,  moreover, 
been  condemned  by  excellent  authorities,  so  no  men- 
tion of  them  will  be  made  here.  I  will  therefore 
only  confine  myself  to  a  few  which  we  note  from 
time  to  time  praised  in  the  medical  journals  and 
have  thus  not  been  totally  shelved  away.  I  will 
first  discuss  the  comparatively  newer  drugs,  some 
of  which  have  been  produced  as  a  substitute  for 


Fic.   5. — Urethral  syringe. 


protargol,  as  silver  vitellin  (argyrol).  gelatose  sil- 
ver (albargin).  silver  sulphichthyolate  fichthar- 
gan).  etc. 

Argyrol  has.  it  is  alleged  by  its  sponsi^rs.  certain 
advantages  over  protargol.  It  is  said  that  it  is 
much  less  irritating  than  protargol,  while  it  contains 
a  much  larger  percentage  of  silver,  and  is  therefore 
more  effective,  less  irritating,  and  can  be  employed 
in  greater  strength.  I  have  made  a  very  careful 
and  extensive  study  of  argyrol.  and  have  come  to 
the  following  conclusions :  I  have  no  reason  to 
doubt  that  argyrol  contains  a  much  larger  per- 
centage of  silver  than  does  protargol.  I  am  abso- 
lutely certain  that  it  is  much  less  irritating.  In  fact. 


January  30,  1909.) 


HUHXER:  GOXORRHCEA. 


221 


it  is  remarkable  what  strong  injections  can  be  used 
of  this  drug.  I  have  used  lo  and  15  per  cent,  solu- 
tions of  argyrol  in  the  anterior  urethra  with  no 
more  burning  complained  of  than  so  much  water, 
and  a  25  per  cent,  solution  causes  about  as  much 
irritation  as  a  i  per  cent,  protargol  solution.  But 
I  am  also  certain,  as  far  as  gonorrhoea  of  the  ure- 
thra is  concerned,  its  usefulness  is  very  little.  As 
before  said,  I  have  made  a  careful  and  extensive 
trial,  and  can  say  that  neither  does  it  cause  the  dis- 
appearance of  the  gonococci  with  an}-  degree  of 
certainty,  nor  does  it  stop  or  ameliorate  the  dis- 
charge. On  the  contrary,  strange  as  it  may  seem, 
while  it  produces  no  pain,  it  seems  to  increase  the 
discharge.  Lest  I  be  misunderstood  I  would  dis- 
tinctly state  that  I  have  employed  the  weak  solu- 
tions as  well  as  the  strong.  It  has,  moreover,  the 
disagreeable  feature  of  oozing  out  of  the  urethra 
for  some  time  after  the  injection  and  thus  staining 
the  underwear.  Of  course,  all  I  have  to  say  applies 
strictly  to  its  use  in  the  urethra,  for  I  understand 
that  ophthalmologists  report  excellent  results  from 
its  use  in  the  eye. 

With  albargin  my  experience  has  not  been  as  ex- 
tensive as  with  argyrol.  After  employing  it  for 
some  time  I  saw  no  reason  to  substitute  it  for  pro- 
targol. It  has  no  advantage  over  the  latter,  either 
as  regards  irritation,  destruction  of  gonococci,  or 
limitation  of  the  discharge,  and  it  is,  moreover,  not 
as  certain  in  its  results. 

Ichthargan  does  very  promptly  kill  the  gonococci 
even  in  very  weak  solutions  (i  in  3,000  anterior  in- 
jections), but  even  with  this  weak  solution  there  is 
caused  such  a  marked  reaction,  as  shown  by  in- 
crease in  discharge  and  pain,  that  I  have  discon- 
tinued its  use.  as  protargol  will  do  just  as  much 
good  with  far  less  reaction. 

There  is  one  other  drug  recommended  for  ante- 
rior self  injection,  that  I  would  like  to  mention  only 
to  condemn  it.  and  that  is  picric  acid.  From  time 
to  time  articles  appear  in  the  medical  journals  mak- 
ing the  most  extravagant  assertions  for  picric  acid 
in  0.5  to  I  per  cent,  solutions.  I  have  tried  it  on  a 
series  of  cases  at  the  dispensary  and  can  find  abso- 
lutely no  confirmation  of  these  statements.  It  is  not 
very  irritating  and  stains  the  discharge  a  urine 
color,  so  that  one  cannot  tell  if  the  discharge  is 
present  or  not,  as  it  looks  more  like  urine  than  pus. 
It  is  probably  for  this  reason  that  observers  have 
alleged  that  the  discharge  disappears.  I  have  also 
had  a  case  in  which  large  casts  of  the  urethra  were 
expelled  after  its  use. 

Before  closing  this  portion  of  my  paper  I  wish  to 
refer  to  one  drug  which,  though  not  used  as  an  in- 
jection, is  still  ver\-  useful  in  certain  cases,  and  that 
is  adrenalin  chloride  (i  in  1,000  solution).  It  is  an 
excellent  drug  that  can  be  used  at  times  in  place  of 
silver  nitrate,  and  at  times  in  place  of  cocaine.  It 
has  an  analgesic  and  soothing  effect  on  the  urethra. 
I  have  used  it  mainly  in  connection  with  endoscopic 
work,  especially  if  any  oozing  of  blood  interferes 
with  good  vision.  About  fifteen  or  thirty  drops 
poured  into  the  endoscope  stops  the  oozing  and 
makes  examination  possible.  It  is  also  good  to  ap- 
ply with  a  cotton  applicator  to  ulcers  or  granula- 
tions in  the  urethra,  through  the  endoscope,  in 
cases  where  silver  nitrate  has  failed.  I  have  also 
used  it  with  good  result  as  a  deep  urethral  injection 


in  extreme  congestions  of  the  prostatic  urethra,  and 
also  in  one  case  previously  referred  to  in  which  in- 
travesical irrigation  caused  su.ch  pain  and  irritation 
of  the  prostatic  urethra  as  to  render  its  employment 
impossible  until  I  hit  upon  the  scheme  of  injecting 
some  adrenalin  solution  into  the  posterior  urethra 
and  after  about  ten  minutes  giving  the  intravesical 
irrigation.  It  worked  like  a  charm,  giving  the  pa- 
tient a  comfortable,  soothing  effect,  and  absolutely 
doing  away  with  the  pressure  symptoms  which  the 
intravesical  treatment  had  previously  given  him. 
As  regards  the  amount,  I  have  given  as  much  as  one 
drachm  without  noticing  any  bad  or  poisonous  ef- 
fect whatsoever. 

Before  leaving  the  subject  of  the  treatment  of 
gonorrhoea  I  would  like  to  say  a  few  words  on  the 
subject  of  stimulants.  When  I  was  a  student,  it 
was  impressed  upon  us  that  coffee,  tea,  and  alco- 
holics should  be  prohibited  during  the  entire  course 
of  gonorrhcEa  and  some  time  thereafter.  For  many 
years  I  had  ample  opportunity  of  seeing  the  ap- 
parent truth  of  this  statement,  that  is  to  say,  I  have 
had  a  number  of  patients  who  were  getting  along 
perfectly  lovely,  and  even  were  apparently  cured, 
when  upon  taking  a  small  amount  of  beer,  tea,  or 
coffee  the  discharge  would  immediately  reappear. 
It  was  quite  a  problem  when  I  should  allow  the  use 
especially  of  coffee.  Fortunately,  I  came  across  a 
statement  on  this  very  question  in  Finger's  work. 
He  says  that  if  alcohol,  tea,  or  coffee  are  gradually 
resumed  there  will  be  no  trouble,  while  if  they  are 
suddenly  taken  after  a  long  period  of  abstinence 
there  may  occur  a  reappearance  of  the  discharge.  I 
have  followed  this  motto  with  excellent  results.  At 
first  I  absolutely  prohibited  their  use,  but  as  the  pa- 
tient is  getting  better,  but  n'hile  still  under  treat- 
ment, I  allow  a  small  quantity  of  coffee  or  tea,  care- 
fully watching  the  effect;  later  one  glass  of  beer  (if 
the  patient  has  been  in  the  habit  of  taking  it)  is  al- 
lowed at  bedtime.  As  the  patient  progresses  he  is 
allowed  more  and  more  liberties,  till  by  the  time  he 
is  well  he  will  be  on  his  regular  diet. 

The  Abortive  Treatment  of  Gonorrhoea. 

I  believe  that  in  some  cases  a  gonorrhoea  can  be 
aborted.  I  am  at  present  experimenting  with  an 
original  method,  but  the  amout  of  cases  are  as  yet 
entirely  too  small  for  scientific  precision,  and  this 
therefore  must  be  considered  as  a  preliminary  re- 
port. In  everv  case  the  pus  showed  an  abundance 
of  t^  "pical  gonococci  under  the  microscope. 

The  method  of  procedure  is  as  follows :  The  pa- 
tient first  urinates  and  the  meatus  is  cleansed  with  a 
bichloride  cotton  swab.  About  two  drachms  of  a 
freshly  prepared  10  per  cent,  protargol  solution  is 
injected  into  the  urethra  and  kept  there  by  the 
physician  (patient  lying  down)  for  fifteen  minutes 
by  the  watch.  During  this  time  ever}-  once  in  a 
while  a  few  drops  are  allowed  to  run  out  of  the 
metaus  to  be  certain  that  the  very  tip  of  the  ure- 
thra, that  is,  the  part  that  is  being  compressed,  gets 
the  benefit  of  it.  After  fifteen  minutes  the  solution 
is  allowed  to  run  out ;  the  patient  is  directed  to  take 
the  alkaline  mixture  to  allay  the  burning  on  urina- 
tion. If  his  first  visit  was  in  the  morning  a  similar 
injection  is  given  in  the  evening,  and  another  the 
following  morning.  This  last  injection  need  only 
be  held  in  for  five  minutes.    Nothing  more  is  done. 


222 


BRYANT:  PREVENTION  OF  MASTOIDITIS. 


[New  York 
Medical  Journal. 


Course. — The  first  injection  is  only  moderatiMy 
painful ;  the  second  is  more  severe  on  account  of  the 
reaction  caused  by  the  previous  injection,  and  the 
third  is  more  severe  for  the  same  reason.  After  the 
third  injection,  and  sometimes  even  after  the  sec- 
ond, there  may  be  quite  a  severe  reaction,  showing" 
itself  by  some  blood  at  the  meatus,  and  also  some- 
times swelling  and  oedema  of  the  glans  and  prepuce. 
This,  while  it  may  present  to  the  inexperienced  an 
alarming  picture,  is  absolutely  without  danger,  gen- 
erally subsiding  in  a  few  (lays,  especially  if  treated 
by  either  very  cold  or  very  hot  applications. 

If  the  case  will  terminate  successfully,  the  puru- 
lent discharge  will  almost  entirely  disappear  after 
the  second  injection,  and  will  be  replaced  by  a 
serous,  somewhat  bloody  discharge,  which  on  mi- 
croscopical examination  shows  many  epithelial  cells, 
a  few  pus  cells,  and  no  gonococci.  Nothing  in 
medicine,  with  the  possible  exception  of  the  crisis 
in  pneumonia,  is  as  striking  as  a  case  of  aborted 
gonorrhoea.  To  see  a  patient  with  a  profuse, 
thick,  purulent  discharge  from  the  penis,  and  in  the 
course  of  a  few  hours  to  see  that  same  penis  with 
practically  no  discharge,  is  certainly  remarkable. 
]n  a  few  more  days,  after  the  reaction  has  disap- 
peared, I  order  a  home  injection  of  0.5  to  i  per  cent, 
zinc  sulphate  solution  as  an  astringent,  with  the  re- 
sult that  every  vestige  of  even  serous  discharge  dis- 
appears rapidly.  The  entire  course  of  the  case 
from  the  commencement  of  the  treatment  until  ab- 
solutely no  more  treatment  is  necessary  is  one  week, 
although  the  case  is  practically  terminated  after  the 
third  injection  on  the' second  day  of  treatment. 

If  the  case  is  one  that  will  not  be  aborted,  the 
discharge  continues  and  contains  gonococci,  and  the 
disease  continues  the  regular  course.  It  seems  to 
me,  in  the  limited  number  of  cases  I  have  treated, 
that  even  these  unsuccessful  cases  respond  better  to 
the  usual  treatment  than  do  others.  One  fact  is 
certain,  and  this  is  of  supreme  importance,  that  the 
patients  are  not  made  zvorse  by  the  abortive  method, 
even  if  unsuccessful. 

Prognosis. — As  before  stated,  the  number  of 
cases  in  which  I  have  tried  this  method  is  entirely 
too  small  to  draw  any  conclusions.  So  far  I  have 
had  twenty-five  per  cent,  successes  and  seventy-five 
per  cent,  failures.  This  is  apparently  not  a  brilliant 
showing,  bj-it  when  we  consider  the  long  course  of  a 
gonorrhoea  it  is  something  to  know  that  every 
fourth  case  was  spared  this  experience.  Still  I 
would  not  recommend  it,  were  there  any  danger  in 
it,  and  here,  as  before  said,  it  has  the  great  ad- 
vantage over  every  previous  method.  It  is  not  nec- 
essary for  me  to  review  the  various  abortive  treat- 
ments recommended,  but  they  all  have  this  in  com- 
mon, that  their  sponsors  say  that  it  should  only  be 
used  in  special  cases,  where  it  is  extremely  imi)or- 
tant  to  cure  a  gonorrhoea  in  a  sort  time  ( in  case  of 
a  coming  wedding,  etc.),  for  if  the  treatment  is  not 
successful  the  disease  is  made  much  worse,  the  in- 
llammation  is  increased,  and  epididymitis,  prosta- 
titis, and  other  complications  are  common.  In  spe- 
cial cases  it  is  worth  while  taking  this  cliance.  In 
my  method,  however,  no  such  dangers,  at  least  in 
the  limited  number  of  ca.ses  em])loyed,  seem  to  ex- 
ist. No  complications  have  occurred  in  the  unsuc- 
cessful cases,  and  if  anything  the  patients  have  been 
improved  by  this  treatment. 


Conditions. — The  only  condition  of  success  is 
that  the  patient  receive  the  first  injection  within 
thirty-six  hours  from  the  commencement  of  the  dis- 
charge. It  is  true  I  have  aborted  some  cases  as  late 
as  forty-eight  hours,'  but  have  met  with  so  many 
failures  that  I  think  it  is  useless  if  more  than  thir- 
*tv-six  hours  have  elapsed.  The  earlier  the  treat- 
ment is  commenced  the  more  certain  success  will 
appear.  It  apparently  makes  no  difference  whether 
we  are  dealing  with  a  virgin  gonorrhoea  or  the  sec- 
ond, third,  or  fourth  attack. 

{To  be  concluded.) 

PREVENTIVE  AND  ABORTIVE  TREATMENT  OF 
MASTOIDITIS.* 

By  W.  Sohier  Bryant,  A.  M.,  M.  D., 
New  York. 

What  can  we  do  to  prevent  or  abort  mastoiditis? 
Fortunately  much  can  be  accomplished  and  great 
benefit  can  be  derived,  provided  the  diagnosis  of  the 
existence  of  predisposing  conditions  or  of  com- 
mencing mastoiditis  be  made  out  sufficiently  early, 
and  appropriate  measures  instituted. 

In  order  to  give  our  points  force,  we  may  recall 
a  few  anatomical  and  physiological  facts  about  the 
ear.  The  middle  ear,  including  the  mastoid,  is  lined 
with  a  pouch  or  tube  of  mucous  membrane — a  di- 
verticulum from  the  nasopharynx  which  passes 
through  and  lines  the  Eustachian  tube.  Physiolog- 
ically the  importance  of  this  connection  is  for  ven- 
tilation and  drainage  ;  pathologically  it  furnishes  a 
road  for  the  entrance  of  microorganisms  into  the  re- 
cesses of  the  mastoid  cells.  It  is  evident,  therefore, 
that  any  systemic  or  local  condition  which  interferes 
with  the  action  of  the  ciliated  epithelium  lining  of 
the  middle  ear  tract  and  with  the  functions  of  the 
Eustachian  tube,  also  lowers  the  resistance  of  the 
mucous  membrane  lining  and  will  predispose  to 
mastoiditis. 

Constitutional  conditions,  which  alter  the  secre- 
tions, cause  swelling  of  the  mucous  membrane,  in- 
terfere with  the  ciliated  epithelium,  and  lower  the 
resistance  of  the  lining  mucosa  are  usually  the  re- 
sult of  general  diseases  or  digestive  disturbances 
which  quickly  attract  the  attention  of  the  general 
]:)ractitioner  and  consequently  receive  early  appro- 
priate treatment.  Local  conditions  are  quite  as  ini- 
l^ortant,  but  are  more  easily  overlooked  by  the  gen- 
eral practitioner.  Locally  the  patient  may  be  ren- 
dered more  susceptible  to  mastoiditis  by  certain 
conditions  prevailing  in  the  upper  air  tract.  Some 
of  these  conditions  we  observe  every  day,  viz. :  in- 
fected or  livpertrophied  tonsils  and  adenoids.  In- 
tranasal irregularities  which  cause  partial  or  total 
occlusion  of  the  nasal  fossae,  though  not  as  easily 
recognized,  are  nevertheless  equally  im])ortant.  Un- 
der tliis  head  come  relaxation  of  the  turbinates,  hy- 
pu-trophic  turbinates,  cystic  turbinates,  tletiected 
turbinates,  polypi,  sinusitis,  spines,  .sieptal  deflec- 
tions, .s<-cptal  thickening,  and  imperfectly  developed 
nasal  fos.s.e.  These  nasopharyngeal  conditions  may 
all  be  present  without  any  interference  with  respi- 
ration. In  these  ca.ses  their  existence  can  only  be 
determined  by  careful  examination.    All  of  the  con- 

•Rcad  before  the  Kirst  District  Branch  of  the  Medical  Society 
of  the  State  of  New  York,  October,  1908. 


January  30,  1909.] 


FILES:  REPAIR  OF  FRACTURES. 


223 


(litions  enumerated  may  be  observed  bv  the  general 
practitioner,  althougli  some  of  the  intranasal  defects 
might  be  overlooked.  Traumatism  and  mastoiditis 
from  contiguity  are  rare,  and  inhalation  mastoiditis 
is  seldom  seen. 

Constitutional  conditions  alone  are  not  sufficient 
cause  of  mastoiditis.  These  conditions  serve  only  to 
aggravate  the  local  defects.  We  will  not  consider 
them  further. 

The  method  of  action  of  the  local  predisposing 
factors  is  fourfold.  First,  direct  mechanical  ob- 
struction to  the  Eustachian  tube ;  second,  direct  in- 
terference with  the  circulation  of  the  Eustachian 
tube,  causing  congestion ;  third,  reflex  vasomotor 
disturbances  of  nasopharyngeal  origin  which  may 
affect  the  middle  ear  and  mastoid  cells :  fourth,  the 
impairment  of  the  activity  of  the  ciliated  epithelium 
and  of  the  bactericidal  properties  of  the  mucous  se- 
cretions. 

Prczciitioii. — The  protection  of  the  patient  from 
mastoiditis,  therefore,  depends  upon  a  perfect  physi- 
ological condition  of  the  upper  air  tract.  This  is 
best  maintained  by  good  hygiene.  This  desirable 
condition  may  be  attained  when  any  structural  or 
functional  defect  is  present,  by  operative  or  medical 
intervention.  Operative  treatment  is  necessary  when 
the  conditions  have  passed  beyond  simple  functional 
disturbances  with  structural  and  tissue  abnormalities 
and  degenerations.  \\"here  the  functions  alone  are 
at  fault,  local  applications  will  be  foimd  of  benefit. 
Mastoiditis  occurs  but  seldom,  in  fact  almost  never, 
where  some  of  the  local  conditions  which  have  been 
cited  before  are  not  present.  In  general  diseases, 
even  in  the  exanthemata,  the  preservation  of  a  nor- 
mal upper  air  tract  will  safeguard  against  mastoidi- 
tis. The  same  holds  good  in  coryza,  pneumonia, 
tuberculosis,  typhoid  fever,  and  influenza. 

Preoperative  Treatment  of  Mastoiditis. — In  order 
to  be  effective  the  preoperative  treatment  should  be- 
gin before  the  signs  of  mastoiditis  have  become 
marked,  as  after  this  it  is  too  late.  The  sooner  an 
operation  is  performed  the  better  for  the  patient 
with  mastoiditis  and  otitis.  As  soon  as  infection  of 
the  middle  ear  appears  or  is  even  suspected,  preven- 
tive treatment  is  in  order.  Our  efforts  should  be 
directed  to  assisting  Xature  and  preserving  the 
functions  of  the  Eustachian  tube.  This  is  brought 
about  by  nasopharyngeal  aid,  through  the  use  of 
astringent  and  antiseptic  applications  such  as  adre- 
nalin, Dobell's  solution,  silver  albuminoid  com- 
pounds, or  weak  nitrate  of  silver.  Occasionally  the 
assistance  of  nasopharyngeal  operations  is  needed  in 
.special  cases.  As  a  rule  we  require  more  drainage 
than  we  can  expect  from  the  tube,  consequently  we 
nuTst  incise,  not  puncture  the  drum  membrane.  The 
patient  with  the  signs  of  beginning  mastoiditis 
should  receive  the  same  careful  attention  as  the  pa- 
tient with  the  symptoms  of  appendicular  inflamma- 
tion. Rest  in  bed  should  be  insisted  upon,  a  saline 
purgative  given,  and  local  treatment  promptly  be- 
gun. Personally  I  prefer  hot,  rather  than  cold  ap- 
plications over  the  mastoid  process.  The  hot  water 
ear  bag  or  a  hot  salt  bag  (doughnut  shaped  because 
pressure  over  the  auricle  is  apt  to  be  painful)  should 
be. used.  Hot  douching  with  a  saturated  boric  so- 
lution, as  hot  as  the  patient  can  tolerate  without  dis- 
comfort, should  be  frequently  repeated  for  the  mid- 


dle ear — every  hour  while  the  patient  is  awake.  The 
hot  douching  is  especiallv  useful  in  the  cases  where 
there  is  much  swelling  and  congestion. 

L'nder  the  head  of  preoperative  treatment  we 
must  include  cupping,  bloodletting,  and  Wilde's  in- 
cision, the  latter,-as  you  are  aware,  being  an  incision 
through  the  skin  and  periosteum  over  the  mastoid 
process.  A  wet  antiseptic  dressing  should  be  kept 
upon  the  wound  until  it  is  healed. 

It  has  been  my  good  fortune  to  observe  the  suc- 
cess of  these  methods  of  prevention  and  preoperative 
treatment  in  nearly  all  of  the  patients  who  came  tO' 
me  for  treatment  before  bone  involvement  of  the 
mastoid  cells  had  begun.  A  brief  history  may  serve 
to  illustrate : 

C.\SE  I. — A  young  woman,  two  weeks  after  the  com- 
mencement of  an  attack  of  grippe,  was  seized  with  severe 
pain  in  one  ear ;  when  seen  the  other  ear  had  begun  to  ache^ 
She  had  a  narrow,  occluded  nose,  and  was  exhausted  from 
long  lactation  as  well  as  from  the  infection.  The  drum; 
membranes  were  slightly  congested.  Alkaline  nasal  spray 
with  adrenalin,  hot  water  bags,  rest  in  bed.  and  saline  laxa- 
tive were  ordered.  Two  days  later  the  earache  and  headache- 
had  increased,  and  the  temperature  had  risen  above  100"  F. 
The  drum  membranes  were  red  and  bulging  in  the  upper 
posterior  region,  and  the  auditory  canals  were  narrowed. 
There  was  considerable  tenderness  on  pressure  all  over 
both  mastoids.  A  double  mj'ringotomy  was  thoroughly 
done  under  general  anaesthesia  and  considerable  blood  and 
a  few  drops  of  thin  pus  evacuated.  This  was  followed  by 
hot  boric  acid  douches  every  hour.  Two  days  later  there 
could  be  observed  marked  improvement  in  the  general 
symptoms.  The  discharge  was  nonpurulent.  Tliree  days 
later  the  discharge  had  ceased  and  the  drum  membranes- 
had  healed  entirely.  Ten  days  later  the  hearing  was  re- 
stored to  normal. 

In  a  case  such  as  this,  without  prompt  atttntion, 
mastoiditis  would  undoubtedly  have  developed,  re- 
quiring double  mastoidectomy. 

Sitiniiiary.— The.  preventive  treatment  of  mas- 
toiditis should  be  directed  to  the  nasopharynx  and' 
its  preservation  in  norinal  condition.  Preoperative 
treatment  is  a  question  of :  ( i )  General  systemic 
treatment  with  saline  laxative  and  rest  in  bed;  (2), 
the  application  of  heat,  as  described,  for  the  pain  ;. 
(3) ..  drainage  of  the  middle  ear  ;  and,  (4).  treat- 
ment of  the  nasopharynx.  What  I  wish  especially 
to  emphasize  is  that  nasopharyngeal  treatment  is  the 
treatment  for  prevention  and  abortion  of  mastoiditis. 

57  We.st  Fifty-third  Street. 


REPAIR  OF  FRACTURES. 

Bv  Charles  O.  Files,  A.  M.,  M.  D., 
Portland,  Me. 

The  process  of  repair  in  the  human  organism, 
wdien  left  to  the  unassisted,  undirected  course  of 
Xature.  always  goes  on  in  a  desultory,  bungling 
manner.  In  the  case  of  a  ragged  wound,  for  in- 
stance, if  unassisted,  the  I'is  mcdicatrix  naturce  will, 
in  the  course  of  weeks,  slough  off  the  portions  too 
badly  damaged  for  any  hope  of  repair,  and  fill  in 
the  space  with  new  tissue.  If  the  surgeon  carefully 
trims  away  the  useless  tissues  and  brings  the  edges 
together  properly  with  antiseptic  treattuent.  recov- 
ery is  only  a  question  of  days  instead  of  weeks,  and 
the  result  will  be  more  satisfactory  in  everv  wav. 
Advance  in  surgery  has  made  healing  by  first  inten- 
tion the  rule  instead  of  the  exception.  Antiseptic 
surgery,  greater  skill,  and  greater   knowledge  of 


224 


JEXKJXS:  EVE  AND  NERrOUS  SYSTEM. 


[New  Vork 
Medical  Jovrxai.. 


anatomy,  physiology,  and  pathology  have  made 
many  operations  possible  and  successful,  that  would 
have  been  entirely  foolhardy  a  generation  ago. 

The  treatment  of  simple  fracture  has  not  changed 
in  any  important  detail  up  to  the  present  time.  Osse- 
ous union  of  a  broken  bone  takes  place  in  about  thir- 
ty-three days,  although  complete  repair  is  not  ac- 
complished in  less  than  four  or  six  months.  All 
the  surgeon  has  to  do  is  to  place  the  broken  ends 
of  the  bone  in  perfect  coaptation  and  kee]:)  them  so 
for  from  four  to  six  weeks.  During  this  period  the 
regular  inflammatory  changes  are  going  on.  These 
are  dilatation  of  the  bloodvessels,  increase,  followed 
by  lessening,  of  the  rapidity  of  the  circulation,  exu- 
dation of  liquor  sanguinis  and  leucocytes.  These 
symptoms  are  accompanied  by  the  necessary  swell- 
ing, heat,  and  pain.  There  is  a  considerable  extra- 
vasation of  blood  into  the  tissues  due  to  the  injury 
of  the  soft  parts.  After  two  or  three  days  or  even 
more,  there  is  a  stasis  of  repair  for  a  week  or  ten 
days  or  more,  during  which  absorption  is  going  on 
more  or  less  rapidly.  There  are  two  questions 
which  may  now  be  considered.  Can  repair  of  osse- 
ous tissue  be  accomplished  without  inflammation? 
and  the  period  of  healing  be  shortened  by  at  least  a 
week  or  ten  days  during  which  the  work  of  repair 
seems  to  be  held  up?  The  answer  to  the  first  ques- 
tion must  be  in  the  affirmative.  The  results  of  mod- 
ern antiseptic  treatment  of  external  wounds  would 
lead  one  to  this  belief,  even  without  further  proof. 
In  the  treatment  of  sprains,  however,  we  have  facts 
that  really  settle  the  matter.  In  the  case  of  a  severe 
sprained  ankle  the  early  and  frequent  use  of  elec- 
tricity and  massage  practically  prevents  swelling  and 
greatly  accelerates  the  recovery.  It  does  not  pre- 
vent, probably,  the  dilatation  of  the  bloodvessels,  nor 
the  exudation  of  liquor  sanguinis  and  leucocytes,  but 
it  prevents  the  engorgement  of  the  tissues  and  the 
stasis  of  blood.  The  work  of  repair  goes  on  faster 
when  it  is  not  impeded  by  the  extravasation  from 
the  crowded  vessels  into  the  surrounding  textures. 
It  is  often  the  case  when  there  is  a  sprained  ankle, 
and  the  foot  cannot  be  brought  to  the  floor,  that  the 
use  of  static  electricity  with  the  massage  roller  will 
Igive  such  relief  that  the  patient  can  walk  ofif  with 
comparatively  no  hurt  or  pain.  This  result  has  been 
obtained  by  many  other  physicians  by  the  use  of 
other  modalities  of  electricity.  When  a  sprain  has 
been  treated  by  any  of  these  methods,  swelling  and 
pain  are  largely  prevented,  and  the  recovery  is 
speedy.  It  certainly  is  a  long  step  in  advance  to 
find  that  actual,  potent  treatment  can  be  adminis- 
tered to  deep  tissues  hypodermically,  by  means  of 
electric  treatment. 

Now,  if  these  things  are  true  in  respect  to  sprains 
it  is  self  evident  that  similar  results  will  take  place 
in  case  of  fractures.  All  vascular  tissues  are  re- 
paired in  practically  the  same  manner.  If  the  swell- 
ing and  pain  of  a  sprain  are  relieved  and  the  injured 
tissues  are  cured  by  electricity,  then  the  fractured 
bone  will  be  restored  by  the  .same  process.  The 
swelling  and  ])ain,  or  in  other  words  the  inflamma- 
tory changes,  are  as  unnecessary  in  a  fracture  as  in 
an  external  wound.  The  conditions  are  in  fact  more 
favorable  in  a  simple  fracture,  because  there  is  no 
occasion  for  antiseptic  treatment.  The  tight  ban- 
daging of  a  broken  limb  is  an  efF(irt  in  the  right  di- 
rection, in  |)revcnting  ton  much  extravasation,  and 


in  favoring  absorption,  but  the  result  is  almost  nil 
as  compared  with  the  efficiency  of  electricity. 

If  the  affirmative  answer  is  given  to  the  first,  the 
same  must  surely  be  given  to  the  second  question. 
It  is  acknowledged  that  there  is  a  period  of  from 
seven  to  ten  days,  and  sometimes  much  longer,  when 
there  is  no  progress  whatever  in  the  work  of  re- 
pair. This  time  is  spent  in  bringing  to  the  parts  an 
excess  of  material  and  in  laboriously  absorbing  that 
excess.  The  whole  trend  of  knowledge  in  regard  to 
the  therapeutics  of  electricity  goes  to  show  that  this 
period  may  be  diminished  if  not  eliminated,  and  that 
the  subsequent  stages  of  the  process  of  osseous  re- 
generation may  be  much  hastened  by  the  careful  use 
of  electricity. 

It  is  a  fact  beyond  dispute,  a  fundamental  and 
basic  fact  in  medical  science,  that  electricity  has  a 
powerful  influence  on  the  circulation  of  the  blood 
and  on  respiration.  Who  would  dare  to  say  just 
how  many  diseased  conditions  are  dependent  on 
faulty  circulation  and  imperfect  aeration  of  the 
blood?  Is  it  too  much  to  expect  that  electricity  may 
do  for  internal  medicine  and  surgery  what  antisep- 
sis has  done  for  surgery? 

195  High  Street. 


METHODICAL  OCCLUSION  OF  THE  EYES  IN  THE 
STUDY  OF  THEIR  .^ITIOLOGICAL  SIGNIFI- 
CANCE IN  DISTURBANCES  OF  THE 
NERVOUS  SYSTEM. 

By  N.  B.  Jenkins,  M.  D., 
New  York. 

A  method  of  occlusion  of  the  eyes  described  in 
the  following  may  be  an  aid  in  the  observation  and 
treatment  of  spasms  of  the  facial  muscles,  chorea, 
and  other  disturbances  of  the  nervous  system,  which 
Stevens*  long  ago  attributed  to  disorder  of  the  eyes. 

A  surgical  bandage,  preferably  of  dark  material, 
is  so  applied  as  to  wholly  exclude  light  from  both 
eyes.  In  suitable  cases  atropine  may  be  instilled  be- 
fore bandaging.  If  the  bandage  is  worn  for  several 
days  without  producing  any  mitigation  of  the  symp- 
toms, it  is  reasonable  to  infer  that  disorder  of  the 
eyes  is  not  a  cause  of  the  disturbance.  If  the  symp- 
toms disappear  while  the  patient  is  wearing  the 
bandage,  the  following  supplementary  te.st  may  be 
tried : 

The  bandage  is  applied  to  one  eye  only.  If  the 
symptoms  subside  it  is  ])ossible  that  the  disturbance 
is  more  or  less  due  to  the  excessive  work,  the  weak- 
ness, or  the  insufficient  exercise  of  the  ciliary  muscle 
of  the  bandaged  eye. 

If  the  symptoms  continue  when  both  eyes  are  in 
use,  but  subside  when  the  right,  the  left,  or  both 
eyes  are  bandaged,  disorder  of  the  extraocular  mus- 
cles, anisometropia,  or  inequality  of  the  intraocular 
nuiscles  may  be  present. 

If  the  patient  uses  spectacles  the  supplementary 
test  may  be  made  by  replacing  with  a  frosted 
(opaque)  glass  first  one  and  then  the  other  spectacle 
lens,  thus  partially  excluding  from  vision  each  eye 
in  turn,  but  this  is  less  satisfactory  than  the  bandage. 

175  FiETii  Avenue, 

^Transactions  of  the  Netu  York  Academy  of  Medicine,  1876,  2S., 
ii,  1'.  438. 


January  30,  1909.] 


OVR  READERS'  DISCUSSIOXS. 


22- 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  arc  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follozvs: 

LXXXII. — Hoiu  do  you  treat  chronic  lead  poisoning? 
(Closed  January  13,  igog.) 

LXXXIII. — Ho'dJ  do  you  treat  acute  dysentery?  (An- 
szcers  due  not  later  than  February  15,  igog.)- 

LXXXIV. — Hoii:  do  you  use  alcohol  the ra peuiic ally ? 
(Ansivers  due  not  later  than  March  13,  igog.) 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $23.  Xo  importance  li'hatever  will  be  at- 
tached to  literary  style,  but  the  award  wnll  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  REQUIRED^  that  the  answers  be  short;  if  practica- 
ble no  one  answer  to  contain  more  than  six  hundred 
zcords. 

All  persons  will  be  entitled  to  compete  for  the  prize, 
'whether  subscribers  or  not.  This  prize  will  not  be  azcarded 
to  any  one  person  more  than  once  -within  one  year.  Every 
answer  must  be  accompanied  by  the  ziTite/s  full  name  and 
address,  both  of  which  zee  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal. 
Our  readers  are  asked  to  suggest  topics  for  discussion. 

The  prize  of  $23  for  the  best  essay  submitted  in  answer 
to  question  LXXXI  has  been  azcarded  to  Dr.  R.  T.  Sutton, 
of  Kansas  City,  Mo.,  zvhose  article  appears  below. 


PRIZE  QUESTION  LXXXI. 
THE  TREATMENT  OF  CHRONIC  ECZEMA. 
By  R.  T.  Sutton,  M.  D., 
Kansas  City,  Mo. 

In  every  case  of  chronic  eczema  the  general  phy- 
sical condition  of  the  patient  should  receive  careful 
attention. 

The  disturbing  cause  must  be  removed  if  pos- 
sible for,  so  long  as  it  persists,  the  benefit  to  be 
derived  from  therapeutic  measures  is,  at  best,  but 
transitory.  And  especially  is  this  true  if  the  aflFec- 
tion  has  resulted  from  long  continued  local  irrita- 
tion, as  in  some  of  the  occupation  dermatoses. 

Of  the  internal  factors  which  tend  to  promote 
and  prolong  an  attack  of  eczema,  by  either  lowering 
the  resistance  of  the  skin  or  increasing  its  suscepti- 
bility to  external  irritation,  disturbances  of  the  in- 
testinal tract  hold  first  place.  For  this  reason  the 
proper  regulation  of  the  diet,  in  both  quantity  and 
quality,  is  very  desirable.  If  the  patient  is  weak, 
anaemic,  and  poorly  nourished  liberal  amounts  of 
nutritious  food  are  indicated,  but  in  the  majority 
of  instances  it  is  advisable  to  restrict  the  diet  to 
the  simple  and  more  easily  digested  substances.  Salt 
meats,  pork,  fried  foods,  pastries,  hot  breads,  sweets, 
cheese,  and  excessive  amounts  of  sugar  are  to  be 
avoided.  Tea,  cof¥ee.  alcohol,  and  tobacco  are  also 
harmful.  Plentiful  amounts  of  water  are  to  be 
drunk  between  meals. 

The  bowels  should  be  cleaned  out  with  calomel, 
followed  by  a  saline,  every  ten  days,  and  so  regu- 
lated, by  means  of  one  of  the  cascara  preparations 
if  necessary,  as  to  move  once  or  twice  daily  during 
the  intervening  periods.  In  plethoric  and  gouty 
individuals  an  early  morning  dose  of  sodium  phos- 
phate is  very  beneficial.  In  some  cases,  and  partic- 
ularly if  the  nails  are  involved,  small  amounts  of 
arsenic  (liquor  potassii  arsenitis,  0.2  to  0.3  c.  c,  well 


diluted  with  water,  after  each  meal),  long  continued, 
may  be  of  service. 

In  rheumatic  individuals  the  following  prescrip- 
tion will  often  be  found  valuable : 

Sodium  salicylate,    lo.o  grammes ; 

Sodium  iodide,    4.0  grammes; 

Sodium  citrate,    20.0  grammes ; 

Sodium  acetate,    20.0  grammes ; 

Infusion  of  buchu,  sufficient  to  make,  200.0  grammes. 
'Si.  S.    Two  teaspoonfuls,  in  water,  after  each  meal. 

If  the  itching  is  very  troublesome  the  hypodermic 
administration  of  pilocarpine,  0.005  t°  0.007 
grammes,  will  frequently  afiford  relief. 

Generally  speaking,  the  use  of  soap  and  water  is 
contraindicated,  and  especially  so  if  the  water  is 
hard  or  the  soap  contains  excessive  quantities  of 
uncombined  alkali.  An  occasional  sponge  bath  in 
soft  water,  heated  until  comfortably  warm  to  the 
touch,  and  containing  two  ounces  of  bran  or  oat- 
meal to  the  gallon,  is  permissable. 

Dirt  and  grease  on  the  affected  parts  can  be  read- 
ily removed  with  a  soft  cloth  which  has  been  pre- 
viously dipped  in  benzin,  the  surface  being  after- 
ward coated  with  olive  oil. 

In  the  local  treatment  of  chronic  eczema  there 
are  two  pathological  conditions  to  overcome,  thick- 
ening and  infiltration.  If  the  first  predominates,, 
keratolytic  substances,  to  soften  and-  remove  the 
excess  of  horny  epidermis,  are  required ;  if  the  last, 
reducing  agents,  which  promote  absorption,  are  in- 
dicated. 

Owing  to  the  variations  in  character  and  strength 
of  the  topical  applications  employed  when  the  dis- 
ease attacks  different  parts  of  the  body,  its  treat- 
ment in  the  various  regions  will  be  considered  sepa- 
rately : 

Chronic  eczema  of  the  face. — When  this  locality 
is  attacked  soothing  and  antipruritic  remedies  give 
the  best  results. 

R     Liquor  carbonis  detergens   15.0  grammes; 

Zinc  o.xide  25.0  grammes ; 

Starch,    25.0  grammes ; 

Glycerin.   20.0  grammes  ; 

Water,  sufficient  to  make  100.0  grammes. 

M.  S.  Shake  well  and  apply,  by  means  of  a  cotton  swab, 
several  times  daily. 

When  the  outer  layers  of  the  epidermis  have  be- 
come dry  and  scaly  the  af¥ected  skin  is  thoroughly 
coated,  three  or  four  times  daily,  with  carbolated 
zinc  oil : 

I*    Phenol,    5.0  grammes  ; 

Zinc  oxide,   60.0  grammes; 

Olive  oil  35.0  grammes. 

Mix  thoroughly. 

Chronic  eczema  of  the  hands  and  feet. — On  the 
backs  of  the  hands  and  the  tops  of  the  feet  the  dis- 
ease is  usually  of  the  papular  type,  with  consider- 
able infiltration  and  but  slight  thickening.  A  rather 
strong  tar  preparation  is  the  most  efficient : 

R    Oil  of  tar,    5.0  grammes  ; 

•      Petrolatum  25.0  grammes. 

Mix  thoroughly.    S.  Rub  in  well,  once  or  twice  daily. 

If  this  proves  too  irritating,  alternate  it  with  the 
zinc  oil.  When  the  skin  along  the  knuckle  line  is 
involved,  with  considerable  infiltration  and  fissuring, 
the  best  remedy  is  undiluted  coal  tar,  as  first  sug- 
gested by  Brocq. 

The  substance  is  applied  on  strips  of  gauze,  held 


226 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


in  place  by  a  snug  bandage.  The  resulting  exfoli- 
ated area  is  dressed  with  zinc  oil  for  a  few  days 
until  the  inflammation  subsides.  In  many  instances 
one  application  ot  the  tar  is  sufficient  to  bring  about 
a  cure.  If  not,  it  is  repeated  as  needed.  In  chronic 
eczema  of  the  palms  and  soles  the  thickening  and 
infiltration  are  both  very  marked,  and  the  treatment, 
in  order  to  be  successtul,  must  be  vigorous.  Sali- 
cylic plasters,  with  or  without  soap  added,  give  the 
greatest  degree  of  satisiaction.  ihe  strength  em- 
ployed varies  with  the  amount  of  hyperkeratosis 
present.  An  excellent  combination  is  soap  plaster, 
<;o  parts;  with  olive  oil,  lo  parts;  to  which  is  added 
twenty  per  cent,  of  salicylic  acid.  This  is  carefully 
applied  to  the  surface,  and  covered  with  gutta 
percha  tissue,  cotton,  and  a  bandage.  At  the  end 
of  twenty-four  hours  it  is  removed,  the  area  cleaned 
with  benzin,  and  the  carbolated  zinc  oil  used  freely 
for  two  or  three  days.  Then,  if  necessary,  the  plas- 
ter is  reapplied.  As  a  rule,  however,  the  zinc  oil 
should  be  followed  by  a  reducing  agent : 

R     Oil  of  tar   4.0  grammes; 

Rose  water  ointment,   30.0  grammes. 

Alix.   S.  Apply  twice  daily,  on  closely  woven  cotton  cloth. 

Chronic  eccema  of  the  nails. — For  the  thickened, 
red  patches  at  the  bases  and  sides  of  the  nails  a  five 
per  cent,  salicylic  acid  and  petrolatum  ointment  is 
to  be  prefefred.  The  horny  masses  beneath  the 
free  margin  may  be  dissolved  out  with  a  solution  of 
potassium  hydroxide,  applied  by  means  of  a  small 
cotton  swab  on  the  end  of  a  toothpick.  Salicylic 
acid  and  collodion  (twenty  per  cent.)  may  benubt 
the  nails,  but  1  have  found  the  x  rays  to  be  the 
most  reliable  aid.  A  soft  tube  is  used  and  long  ex- 
posures given.  Many  of  these  cases  fail  to  respond 
to  all  treatment. 

Chronic  eczema  of  the  nipples. — If  any  cracks 
are  present  they  should  be  touched  with  a  five  per 
cent,  solution  of  silver  nitrate.  The  nipple  must  be 
o;ently  but  thoroughly  cleansed  after  each  nursing, 
and  diachylon  ointment  applied.  The  salve  is  re- 
moved with  olive  oil  before  each  feeding.  The  in- 
fant is  to  be  nursed  through  a  rubber  shield. 

Chronic  eczema  of  the  genitals  and  anus. — 'Vhe 
intense  itching  to  which  the  disease  gives  rise  when 
these  localities  are  involved  is  most  quickly  and 
satisfactorily  relieved  by  bathing  the  parts,  for  fif- 
teen or  twenty  minutes,  in  water  as  hot  as  can  he 
borne.  The  surface  is  then  dried,  by  pressure  with 
a  soft  towel,  and  a  strong  ""shake"  mixture  em- 


ployed. 

R.    Liquor  carbonis  dctergens,   25.0  grammes; 

Zinc  oxide   20.0  grammes ; 

Starch   20.0  grammes  ; 

Glycerin   18.0  grammes; 

Water,  sufficient  to  make  100.0  grammes. 


Mix.    S.  Shake  well,  and  apply  several  times  daily. 
When  the  infiltration  has  become  less  and  the  sur- 
face commences  to  peel  this  mixture  is  discontinued 
and  the  carbolated  zinc  oil  substituted. 

The  parts  must  not  be  allowed  to  cnnie  in  con- 
tact, soft  cloths  being  interposed.  In  men  a  sus- 
pensory should  l)e  worn.  The  urine  should  be 
tested  for  sugar.  If  the  anus  is  involved  a  careful 
search  is  to  be  made  for  h?emorrhoids.  fissures,  and 
fistula?.  Vaginal  discharges,  if  present,  should  re- 
ceive attention.    In  long  standing,  intractable  ecze- 


ma of  the  vulva  the  x  rays  may  often  be  employed 
with  benefit. 

chronic  eczem'a  of  the  legs. — Eczema  of  this  re- 
gion is  almost  invariably  associated  with  varicose 
veins.  Because  of  the  venous  stasis  the  application 
of  smooth,  uniform  pressure  is  very  beneficial.  To 
relieve  itching  and  hasten  absorption  the  milder 
'"shake"  mixture  recommended  before  is  applied 
twice  daily.  During  the  intervals  the  leg  is  covered 
with  several  layers  of  soft  gauze,  evenly  bound  down 
by  a  snugly  fitting,  slightly  elastic,  cloth  roller  ban- 
dage. Rubber  bandages  or  stockings  should  not  be 
worn.  They  prevent  evaporation  and  the  retained 
excretions  prolong  the  inflammation  by  irritating 
the  already  weakened  and  hypersensitive  integu- 
ment. The  limbs  are  to  be  kept  at  rest,  and  elevated 
as  much  of  the  time  as  possible.  When  the  infiltra- 
tion and  induration  have  partially  subsided  a  phe- 
nolated  glycogelatin  dressing  answers  admirably. 


Phenol   4.0  grammes  ; 

Gelatin   30.0  grammes; 

Glycerin   30.0  grammes  ; 

Zinc  oxide   60.0  grammes; 

Water,  sufficient  to  make,   200.0  grammes. 


The  mixture  is  heated  on  a  water  bath  until  it  can  be 
pcjured.  Then,  after  thorough  mixing,  it  is  painted  on  the 
affected  part  with  an  ordinary  sash  brush.  This  is  followed 
i)y  a  laser  of  absorbent  cotton  and  a  second  coating  of  the 
jelly.  If  desired,  the  dressing  may  be  left  on  for  several 
days  or  weeks. 

A  genero'l  plan  for  ilic  tteatment  of  a  case  of 
chronic  eczema  may  be  suiiDiiarizcd  as  follows: 
Remove  all  external  irritation.  Clean  out  the  in- 
testinal tract.  ProhilMt  the  ingestion  of  stimulating 
and  fermentative  foods.  Get  rid  of  redundant  epi- 
thelium, if  present,  by  the  application  of  salicylic 
acid  plasters  or  like  keratolytics.  If  necessary,  has- 
ten the  absorption  of  exudates  by  the  employment  of 
a  rather  strong  tar  preparation.  Soothe  inflamma- 
tion and  allay  itching  by  the  use  of  carbolated  zin  ■ 
oil  or  a  mixture  containing  a  small  percentage  of 
liquor  carbonis  detergens. 

709  CokiiiN  Tei?raci£. 

Dr.  Walter  E.  Hays,  of  A'cw  York,  zcritcs: 

Many  are  the  reputed  cures  for  eczema  or  salt 
rheum,  l)ut  chronic  eczema  still  stands  as  one  of  the 
most  baffling  conditions  that  the  physician  is  called 
upon  to  treat.  In  chronic  eczema,  the  epidermis  is 
reddened,  infiltrated,  and  scaly,  the  cell  infiltration 
extending  deep  intf)  the  dermis,  sometimes  even  to 
the  subcutanous  tissue.  The  papilkx  are  hypertro- 
phied.  However,  this  chronic  condition  may  at  any 
time  take  on  the  characteristics  of  the  acute  stage, 
those  of  an  active  inflammation,  with  possible  con- 
stitutional disturl)ance. 

The  aim  in  tiie  treatment  of  chronic  eczema 
should  ])c  to  aid  in  the  absorption  of  the  infiltrate 
and  ])r()ni()te  healtliier  tissue  formation.  The  itching 
must  also  be  relieved.  The  patient  must  at  the  sam  * 
time  receive  a])propriate  systemic  medication  and  th? 
diet  ])v  regulated.  The  tar  preparations  arc  espe- 
ciallv  valuable  and  may  be  employed  in  several 
forms.  As  an  ointment,  one  drachm  of  oil  of  cade 
or  l.'ir  ointment  in  seven  drachms  of  zinc  oxide  oint- 
ment, ajiplicd  once  or  twice  daily,  is  serviceable. 
Oil  of  cade,  one  drachm  to  an  ounce  of  collodion. 


January  30,  1909.] 


CORRESPOXDESCk. 


227 


may  be  painted  on  the  affected  surface  daily.  Where 
the  skin  is  very  much  thickened,  the  pure  oil  of 
cade  may  be  rubbed  in  thoroughly,  if  a  lotion 
seems  better,  dissolve  an  ounce  of  potash  in  five 
ounces  of  water  and  add  slowly  to  two  ounces  of 
tar  in  a  mortar  with  friction.  This  must  then  be 
diluted  with  five  or  six  quarts  of  water  and  should 
be  used  daily.  The  diseased  surface  should  be  thor- 
oughly sopped  with  the  lotion.  For  the  most  satis- 
factory result  from  any  of  these  preparations,  all 
crusts  should  be  removed.  These  frequently  retard 
healing.  Resorcin  sometimes  acts  better  than  the 
tar.  Resorcinol  in  the  proportion  of  ten  to  thirty 
grains  to  the  ounce  of  lard,  either  with  or  without 
a  like  amount  of  salicylic  acid,  is  very  stimulating. 
Or  the  resorcin  may  be  combined  with  Lassar's 
paste.  This  paste  alone  is  very  serviceable  in  the 
eczema  of  the  cheeks  seen  frequently  in  infants  and 
children.  Salicylic  acid,  in  the  same  strength  as  the 
resorcinol,  may  be  tried  alone  in  the  ointment  form. 
In  eczema  of  the  hands,  of  the  horny  variety,  a  ten 
to  twenty-five  per  cent,  salicylic  acid  plaster  is  valu- 
able. Mercurial  ointments  are  of  service  in  the 
pustular  type  of  chronic  eczema,  the  white  precipi- 
tate ointment  or  even  a  stronger  ointment  of  am- 
moniated  mercury  being  most  satisfactory.  For 
keeping  the  skin  surface  clean,  tincture  of  green 
soap  or  formalin  soap  (five  parts  of  pure  forma- 
lin in  joo  parts  of  tincture  of  green  soap),  is  to 
be  used  with  hot  water. 

The  glycogelatin  fixed  dressing  of  Unna  has 
been  used  by  the  writer  with  advantage.  This 
dressing  consists  of  fifteen  parts  each  of  glycerin 
and  gelatin,  thirty  parts  of  zinc  oxide  in  forty  parts 
of  water.  This  has  a  light  rubbery  consistence  at 
the  ordinary  temperature  of  the  air  and  should  be 
lieated  in  a  water  bath  when  it  is  to  be  used.  When 
of  liquid  consistence,  it  is  painted  on  the  affected 
surface  and  a  layer  of  absorbent  cotton  applied,  the 
excess  of  cotton  being  plucked  of¥  when  the  dressing 
is  dry.  This  dressing  has  the  advantage  of  exclud- 
ing the  air,  relieving  the  itching  and  giving  the  dis- 
eased skin  an  opportimity  to  heal.  It  may  be  ap- 
plied once  or  twice  a  week  or  less  often,  depending 
on  the  results. 

Baths  are  often  of  service,  being  especially  so  in 
eczema  universalis,  where  the  suffering  on  account 
of  the  itching  is  severe.  Alkalies  are  best,  such  as 
starch,  soda,  or  borax.  Frequently  bran  baths  give 
relief. 

The  systemic  treatment  is  important  in  connec- 
tion with  the  local  remedial  measures.  The  mis- 
tura  ferri  acida,  as  used  in  the  Philadelphia  Poly- 
clinic, serves  as  a  tonic  and  relieves  the  obstinate 
<:onstipation  often  present.    This  is : 

R    Ferrous  sulphate  grs.  xxxvi ; 

Magnesium  sulphate,   .'ij ; 

Dihited  sulphuric  acid,   5ij  ; 

Compound  infusion  of  gentian,  q.  s.  ad  jvj. 

M.  S.  A  tablespoonf ul  in  water  before  breakfast,  or  two 
teaspoonfuls  in  water  after  meals,  as  indicated. 

If  no  ansmia  is  present  the  saline  waters  may  be 
tised.  A  rhubarb  and  soda  mixture  is  sometimes  best 
employed  as  a  hepatic  stimulant  and  to  relieve  intes- 
tinal sluggishness.  Mercury  and  podophyllin  may 
also  be  tried.  Gastric  di.sorders  should  receive  atten- 
tion. Gouty  and  rheumatic  tendencies  must  be  recog- 


nized and  properly  treated.  The  acetate  and  citrate 
of  potassium  should  be  given  to  relieve  torpidity  of 
the  kidneys.  Arsenic,  in  the  form  of  Fowler's  solu- 
tion, on  a  full  stomach,  is  a  useful  alterative.  Potas- 
siimi  iodide  is  indicated  in  any  cases  with  a  syphilitic 
history.  Cod  liver  oil  is  ver\  efficient  in  strumous 
individuals  with  marked  glandular  enlargement. 
The  diet  should  be  regulated  so  as  to  include  only 
nourishing  foods.  Excess  of  starchy  foods,  tea,  and 
cof¥ee,  and  alcohol  should  be  avoided. 

■(  To  be  continued.) 
 ^  

Corresponbfnce. 


LETTER  FROM  LONDON. 

Tile  Reopening  of  flic  Medical  Schools. — The  Treafiiieiif 
of  Defective  School  Children. — The  Antiviiisection 
Elospitat. — U' hooping  Cough. — The  African  Sleeping 
Sickness. 

LoxDOx,  January  12.  190Q. 

After  the  short  C  hristmas  vacation  lectures  and 
classes  have  now  been  resumed  at  all  the  medical 
schools.  At  most  of  the  larger  schools  a  few  new 
entries  have  been  made,  but  not  many  new  students 
begin  their  medical  career  at  this  time  of  the  year, 
and  as  usual  the  lists  of  new  names  at  the  medical 
schools  are  small.  On  glancing  down  the  schedules 
of  lecttires  of  the  various  hospitals  one  is  struck  by 
the  marked  facilities  now  offered  to  qualified  doc- 
tors who  wish  to  brush  up  their  knowdedge  of  medi- 
cine and  surgery.  Postgraduate  schools  are  to  be 
found  in  connection  with  the  Seamen's  Hospital  at 
Greenwich,  the  West  London  Hospital,  and  the 
Prince  of  AVales  General  Hospital,  Tottenham, 
while  at  the  special  hospitals  numerous  courses  of 
lectures  are  announced.  The  result  of  this  is  that 
an  increasing  number  of  practitioners  from  the 
country  and  even  from  the  colonies,  as  well  as  many 
army  and  navy  surgeons  on  leave,  come  to  London 
to  attend  the  various  hospitals  which  now  cater  espe- 
cially for  senior  men. 

A  course  of  lectures  and  demonstrations  has  been 
arranged  for  the  help  and  instruction  of  doctors 
who  are  employed  in  the  medical  inspection  of 
school  children.  The  first  lecture  of  the  series  was 
given  yesterday  by  Dr.  James  Kerr,  chief  medical 
officer  of  the  London  Education  Committee,  at  the 
rooms  of  the  Society  of  Medical  Officers  of  Health, 
in  Upper  Montagu  Street.  Considering  the  large 
number  of  medical  inspectorships  that  have  recent- 
ly been  created  in  connection  with  the  various  local 
government  schools,  and  that  there  is  every  likeli- 
hood of  a  steady  increase  in  the  number  of  medical 
men  taking  up  this  branch  of  ptiblic  health  work, 
such  courses  of  lectures  are  very  greatly  needed  just 
now. 

The  medical  inspection  of  school  children  has  nat- 
urally had  the  eflfect  of  drawling  attention  to  the 
facilities  that  exist  for  the  treatment  of  such  chil- 
dren as  are  fotmd  defective  in  health.  This  opens 
up  a  very  large  problem  and  is  being  considered  in 
all  its  bearings  by  the  London  County  Council.  A 
subcommittee  was  appointed  to  inquire  into  the  mat- 
ter, and  in  the  course  of  their  investigations  the  sub- 
committee found  it  desirable  to  ascertain  how  far 


228 


CORRESPONDENCE. 


[New  York 
Medical  Journal. 


existing  medical  institutions  would  be  in  a  ])()sitinn 
to  meet  the  increased  demands  for  tlie  medical  treat- 
ment of  elementary  school  children  expected  to  arise 
spection.  It  was  found  that  the  existing-  institutions 
as  a  consequence  of  the  institution  of  medical  in- 
were  quite  insufficient  to  cope  with  the  increased 
demand  for  treatment  and  that  the  health  of  many 
children  was  impaired,  temporarily  or  permanently, 
for  want  of  medical  treatment.  The  only  remedy  for 
this  state  of  affairs  is  to  increase  the  facilities  for 
providing  special  treatment  as  in  eye  and  car  dis- 
eases, and  for  ordinary  cases  the  general  practition- 
ers could  undertake  the  treatment,  and  there  are  two 
wa)'S  in  which  they  could  be  remunerated,  either  by 
a  great  extension  of  the  provident  dispensaries  and 
clubs  or  bv  the  municipality,  and  the  latter  method 
is  preferable. 

A  very  curious  case  was  investigated  at  an  in- 
quest in  the  city  last  week.  An  institution  at  Bat- 
tersea  known  as  the  Antivivisection  Hospital  was 
called  upon  to  treat  a  little  girl  that  had  received  an 
injury  to  the  head.  The  wound  was  examined  by 
the  resident  medical  officer  and  was  then  stitched 
up  by  a  nurse. 

Some  weeks  later  the  child  was  admitted  into  St. 
Bartholomew's  Hospital  with  a  cerebral  abscess,  a 
condition  which  in  spite  of  operation  proved  fatal. 
It  was  found  that  there  was  a  depressed  fracture  of 
the  skull  which  had  not  been  detected  at  the  Bat- 
tersea  Hospital,  and  death  was  thus  produced.  It 
was  contended  for  the  Battersea  Hospital  that  there 
had  been  a  subsequent  .injury  which  had  produced 
the  fracture,  none  having  been  present  at  the  time 
she  was  first  seen,  but  the  verdict  of  the  jury  was 
against  this  contention.  A  point  was  brought  out  in 
evidence  which  struck  the  coroner  as  being-  very  pe- 
culiar. In  the  annual  report  of  the  Antivivisection 
Hospital  appeared  the  words  "No  experiments  on 
patients."  The  secretary,  when  questioned  as  to  the 
meaning  of  this  phrase,  stated  that  the  poor  were 
often  shy  of  hospitals,  and  denied  that  it  suggested 
that  experiments  were  performed  on  patients  at 
other  hospitals.  The  solicitor  who  appeared  for  the 
hospital  admitted  that  he  had  heard  it  said  that  sur- 
geons liked  to  try  experiments  on  poor  patients  in 
hospital.  There  can,  however,  be  no  doubt  in  the 
mind  of  any  impartial  person  as  to  what  is  intended 
by  printing  these  w'ords  in  the  report,  and  it  is  an- 
other instance  of  the  methods  of  the  antivivisec- 
tionists. 

.•\t  a  meeting  of  the  Royal  Society  of  Medicine 
held  recently  a  verv  interesting  discussion  took  place 
on  whooping  cough.  Dr.  J.  Porter  Parkin.son  point- 
ed out  that  m  England  the  death  rate  from  this  dis- 
ease had  diminished  of  late  years.  The  contagium 
nnist  be  a  specific  organism  which  had  not  yet  been 
isolated  with  any  degree  of  certainty.  The  infection 
was  conveyed  by  the  sputum,  which  was  .«iaid  to  be 
most  virulent  during  the  catarrhal  and  earlv  parox- 
ysmal stages.  Tiie  virus  remained  active  after  drv- 
ing  for  at  least  several  weeks,  as  had  been  proved  by 
epidemics  arising  on  board  ship,  where  no  other 
source  was  prf)bal)le.  Dr.  Parkinson  described  the 
case  of  an  infant,  twelve  days  old,  that  had  got  the 
disea.sc  from  the  mother,  who  had  it  at  the  time  the 
child  was  born.     In  the  ])aro\ysmal  stage  examina- 


tion of  the  blood  showed  the  presence  of  leucocx  to- 
sis.  The  complications  of  the  disease  were  impor- 
tant and  serious.  Bronchiectasis,  glottic  spasm,  polv- 
neuritis,  albuminuria,  and  emphysema  were  men- 
tioned. Two  thirds  of  the  deaths  from  whooping 
cough  occurred  in  the  first  year  of  life,  most  fre- 
quently from  lung  complications.  A  short  survey 
was  then  given  of  the  methods  of  treatment,  includ- 
ing the  diet  and  various  drugs,  and  bromoform  was 
recommended,  w^hich  should  be  given,  according  to 
Dr.  Parkinson,  in  the  strength  of  one  drop  to  the 
ounce  of  water  with  a  few  drops  of  alcohol,  from 
one  to  six  drachms  being  given  in  a  dose. 

Dr.  Guthrie  mentioned  the  term  "chin  cough,"  still 
used  in  some  parts  of  the  country,  as  being  derived 
from  the  name  "la  quintain,"  or  "tussis  quintara," 
by  which  the  disease  was  known  in  Paris  in  1578, 
the  paroxysms  being  believed  to  occur  every  five 
hours.  The  diagnosis  had  sometimes  to  be  made 
from  the  paroxysmal  cough  of  influenza  and  of  en- 
larged bronchial  glands.  He  believed  the  cough  de- 
pending on  enlarged  glands  commonly  occured  in 
children  who  had  already  had  whooping  cough.  He 
had  witnessed  one  death  after  a  paroxysm  in  a  boy 
aged  three  years  who  died  in  the  waiting  room  of 
the  out  patient  department.  He  thought  cerebral 
haemorrhage  was  very  rare.  Bromide  of  potassium 
and  belladonna  were' his  favorite  drugs  for  relieving 
the  symptoms. 

Dr.  W.  Ewart  pointed  out  the  serious  effects 
which  frequently  followed  whooping  cough  in  chil- 
dren. He  advocated  systematic  hygiene  of  the  up- 
per respiratory  tract,  so  as  to  inhibit  the  growth  of 
anv  microorganisms.  He  had  often  seen  relief  fol- 
low the  instillation  of  oil  into  the  nostrils.  Iodide 
of  potassium  was  of  value,  and  he  believes  in  the  in- 
halation of  terebene  and  in  its  use  in  a  liniment.  A 
respiratory  belt  was  also  useful. 

The  Sleeping  Sickness  Bureau,  which  was  estab- 
lished in  London  in  May  last,  has  now  issued  two 
valuable  bulletins  edited  by  Dr.  Bagshawe,  the  di- 
rector of  the  bureau.  In  the  first  of  these  bulletins 
the  chemotherapy  of  the  disease  has  been  dealt  with 
in  an  exhaustive  fashion.  From  it  we  learn  that 
practically  all  patients  suffering  from  sleeping  sick- 
ness are  now  treated  by  atoxyl  or  some  chemically 
allied  substance,  either  alone  or  in  combination  with 
other  drugs.  The  effect  of  the  administration  of 
atoxyl  is  to  banish  the  trypanosomes  from  the  blood 
and  the  glands.  Unfortunately,  all  the  trypanosomes 
are  not  killed,  for  usually  a  few  remain,  attenuated 
in  virulence,  and  acquire  tolerance  of  the  drug.  They 
are  said  to  take  refuge  in  the  bone  marrow,  where 
after  a  time,  notwithstanding  the  continued  use  of 
atoxyl,  they  recover  virulence,  multiply,  and  again 
invade  the  body  of  the  patient,  causing  a  recurrence 
of  the  symptoms  of  the  disease.  It  is  therefore  nec- 
essarv  to  follow  up  the  atoxyl  treatment  by  the  use 
of  other  trypanocidal  drugs,  among  which  may  be 
mentioned  mercury  and  antunony.  In  the  second 
bulletin  the  diagnosis  of  human  trypanosomiasis  is 
dealt  with,  and  also  the  modes  of  infection  are  dis- 
cussed. 

Dr.  l>ag.shawe  arrives  at  the  conclusion  that  the 
C'lossiiui  l^alf^alis,  or  tsetse  fly,  plays  the  chief  part  as 
a  carrier  of  infection. 


January  30,  1909.] 


THERAPEUTICAL  XOTES. 


22f) 


Mercurial  Oil  Injections. — The  following  prep- 
arations are  employed  by  K.  Zieler  (Mimcheiicr 
medicinische  Wochoisclirift,  November  17,  1908)  : 
Gray  Oil. 

R    Mercury,   4.0  gramines  ; 

Anhj^drous  wool  fat,   2.6  grammes; 

Dericin  oil,*   ■■■  ■6.5  grammes. 

.  M. 

Calomel  Oil. 

R    Calomel,   4.0  grammes  ; 

Campiiorated  wool  tat  (5  j 

per  cent.),  25  per  cent.,  f    n  c  m  rr 

Camphorated   dericin   oil  f 
(5  per  cent.),  75  per  cent,  ) 

M. 

A  syringe  that  is  graduated  in  cubic  centimetres 
should  be  used  for  the  introduction  of  the  oil.  The 
dose  of  gray  oil  for  vigorous  patients  should  repre- 
sent 7  centigrammes  of  mercury  and  such  a  dose 
should  be  administered  every  four  or  five  days,  the 
dose  being  lessened  as  the  treatment  is  continued. 
The  dose  of  the  calomel  oil  should  be  the  equivalent 
of  I  decigramme  of  calomel.  The  two  preparations 
are  said  to  be  well  tolerated  and  cause  no  disturb- 
ance. 

The  Administration  of  Calomel  as  a  Cathartic. 

— Commenting  on  the  growing  practice  of  giving 
calomel  in  minute  doses  repeated  at  regular  inter- 
vals, the  Journal  of  the  American  Medical  Associa- 
iion  for  January  23,  1909,  expresses  preference  for 
single  doses  of  the  quantity  deemed  sufficient,  the 
calomel  being  combined  with  sodium  bicarbonate, 
as  in  the  following  prescription  : 

R    Calomel,   gr.  iii; 

Sodium  bicarbonate  gr.  viiss. 

Mix  and  make  one  powder. 
Sig. :  To  be  taken  at  once. 

The  giving  of  calomel  in  small  doses,  as  perhaps 
one  tenth  of  a  grain,  every  half  hour  until  one  grain 
has  been  taken,  which  is  often  advised,  is  objected 
to  for  the  reason  that  a  troublesome  diarrhcea  often 
results  when  calomel  is  thus  administered.  It  is 
pointed  out,  too,  that  patients  susceptible  to  calomel 
may  be  salivated  by  small  doses,  when  they  are  not 
affected  by  a  single  large  dose. 

The  Treatment  of  Diabetes. — Genty  cites  in  La 
Clinique  for  January  i.  1909,  the  experiments  of 
Maignon  on  dogs  in  which  it  was  shown  that  under 
a  special  dietetic  regime  the  quantity  of  urine  passed 
was  lessened  and  the  amount  of  sugar  and  of  urea 
was  greatly  diminished.  The  results  reported  by 
Maignon  led  Dr.  Genty  to  adopt  a  special  dietetic 
treatment  for  diabetes  in  man  and  with  excellent  re- 
sults. The  treatment  consists  of  a  more  or  less  complete 
abstention  from  carbohydrates ;  a  reduction  of  the 
albuminous  foods  to  the  minimum  required  to  re- 
place organic  w'aste,  and  the  administration  of  fats 
with  the  food.  Bread,  starches,  cereals,  and  dried 
vegetables  are  interdicted.  On  the  contrary,  a  large 
place  is  given  in  the  scheme  of  alimentation  to  fresh 
green  vegetables  which  contain  comparatively  little 

*Dericin  oil  is  a  distillation  product  of  castor  oil  which,  unlike 
the  latter,  is  miscible  with  mineral  oils  and  takes  up  water  and 
.aqueous  solutions  readily. 


carbohydrates  and  considerable  water  and  mineral 
salts.  It  is  permitted  to  take  meats,  eggs,  cheese, 
and  the  fatty  substances  as  they  exist  in  nature,  such 
as  butter,  oil,  etc.  If  the  patient  finds  it  difficult  to 
digest  fats  in  their  natural  state  it  is  recommended 
to  administer  the  fats  in  an  emulsionized  form  by 
a  saponifying  process.  Genty  says  the  best  time  to 
administer  fats  is  one  hour  and  a  half  after  break- 
fast and  three  hours  after  the  principal  meals,'  when 
the  stomach  has  been  emptied  and  digestion  in  the 
intestines  has  commenced.  Under  the  influence  of 
this  treatment  there  was  a  rapid  and  complete  dis- 
appearance of  sugar,  a  lowering  of  the  amount  of 
urea  excreted,  and  the  wasting  process,  if  it  existed, 
was  stopped.  The  thirst  was  removed  and  the  gen- 
eral condition  of  the  patient  showed  great  improve- 
ment. 

The  Treatment  of  Infantile  Ichthyosis. — (ias- 
ton  (Hygiene  ct  patlwlogie  cutanccs  da  premier  age, 
through  Journal  de  mcdecine  dc  Paris,  January  2, 
1909)  recommends  the  following  treatment:  Re- 
move the  skin  so  as  to  prevent  the  reformation  of 
hardened  cuticle  and  stimulate  the  functions  of  the 
skin  generally.  The  removal  of  the  skin  is  effected 
with  saponified  ointments  and  alkali  baths.  Soft 
soap,  diluted  with  a  slight  amount  of  fresh  lard  or 
petrolatum  to  lessen  the  irritant  action  of  the  potash 
contained  in  it,  is  allowed  to  remain  in  contact  with 
the  skin  for  several  hours,  or  all  night  or  day  if  it 
is  tolerated.  If  the  soap  proves  too  irritating,  a  sim- 
ple application  of  white  petrolatum  may  be  used. 
On  the  following  morning  the  patient  is  given  a  bath 
in  which  is  dissolved  from  one  quarter  to  half  an 
ounce  of  sodium  carbonate,  and  if  this  proves  too 
irritating  or  stimulating  the  addition  of  from  one 
and  one  half  ounces  to  two  ounces  of  gelatin  is 
recommended.  If  a  tonic  effect  is  desired  the  fol- 
lowing ingredients  should  be  added  to  the  bath : 

R    Gh'cerin,   oii ; 

Sodium  carbonate,   5! ; 

Sodium  chloride,         )  --  =jj 

Ammonium  sulphide,  ) 

The  application  of  soap  and  the  use  of  the  med- 
icated baths  may  be  repeated  for  several  days  in  suc- 
cession, but  care  should  be  exercised  to  prevent  un- 
due irritation  of  the  skin. 

After  desquamation  has  resulted  glycerite  of 
starch  is  applied,  or  an  ointment  of  the  following 
composition : 

B  Petrolatum, 

Wool  fat  ■. .  .aa  .i?s ; 

Tartaric  acid  gr.  viiss  to  gr.  .xv. 

The  treatment  should  be  repeated  on  the  first  sign 
of  the  return,  of  the.  disease. 

The  general  treatment  should  be  based  on  the 
diathesis  and  constitution  of  the  child.  Iron  prepa- 
rations, cod  liver  oil,  the  iodotannin  compounds  and 
arsenic  should  be  given  in  form  and  strength  pro- 
portionate to  the  age  of  the  child. 

Condurango  and  Kawar. — According  to  recent 
researches  condurango  is  regarded  as  second  onlv 
to  absinthe  as  a  stomachic.  The  active  principle 
of  the  bark  appears  to  have  a  similar  constitution 
to  cinnamic  acid.     It  has  been  known  popularly 


230 


THEliAl'llUTICAL  NOTES.— NEW  REMEDIES. 


[New  York 
Meuical  Jol'Rxal. 


from  1 8/ 1  as  a  cure  for  cancer,  but  this  reputation 
has  not  been  justified  in  practice.  To  what  active 
constituent  it  owes  any  therapeutic  value  it  may  pos- 
sess has  not  yet  been  definitely  determined.  Curi- 
ously enough  Bohm  (Miiiichencr  mcdidnischc 
Wochcnschrift,  August  25,  1908)  found  that  a  plant 
indigenous  to  the  Transvaal  (called  kawar),  also 
used  as  a  cure  for  cancer,  bore  a  striking  resem- 
blance to  condurango  in  its  characteristics,  and  he 
suggested  that  there  might  be  some  value  in  both 
condurango  and  kawar  which  he  had  not  yet  learned 
to  make  use  of.  Condurango  occurs  in  quilled  or 
curved  pieces  having  a  grayish  brown  corky  cover- 
ing. It  is  variously  known  as  the  bark  of  Marsdenia 
Condurango  and  Gonolobus  Condurango,  of  the  fam- 
ily of  Asclcpiadacccc.  Condurango  is  prescribed  in 
powder  form  combined  with  cascara  sagrada  and 
flowers  of  sulphur  as  a  laxative  in  the  following 
formula : 

Pulverized  condurango  bark,   gr.  ii  ^; 

Pulverized  cascara  sagrada,   gr.  ivss; 

Sublimed  sulphur,   gr.  vi  ^/i. 

iVlix  and  divide  into  three  powders. 
Sig. :  One  powder  at  night. 

Condurango  has  been  prescribed  in  carcinoma  of 
the  stomach,  combined  with  benzonaphfhol  in  equal 
proportions,  four  grains  of  each  being  given  four 
times  a  day  in  one  cachet. 

For  the  Headache  of  Neurasthenia. — Bingl  pre- 
scribes the  following  pill  to  be  taken  at  bedtime: 


R    Quinine  sulphate,   gr.  xv; 

Arsenic  trioxide  gr.  i; 

Extract  of  cannabis  iiidica,  gr.  vii ; 

Pulverized  valerian  root, 

Extract  of  valerian,   aa  q.  s. 


Mix  and  divide  into  thirty  pills. 

Test  for  Indican  in  the  Urine. — To  a  quantity 
of  freshly  drawn  urine  in  a  test  tube  add  an  equal 
amount  of  hydrochloric  acid  and  mix  thoroughly. 
Then  add  a  few  drops  of  solution  of  hydrogen  di- 
oxide, again  mix,  and  finally  add  an  excess  of 
chloroform.  If  indican  is  present  the  solution  will 
become  blue  in  color.  The  same  test  is  applicable 
to  the  detection  of  the  salts  of  iodine  in  the  urine,  in 
this  case  the  solution  becoming  a  brilliant  rose  red. 

Application  for  Pruritus   in  Pregnancy. — The 

a])plication  of  the  following  |jaste  is  recommended 
by  Rudaux  and  Cartier  {/onnial  dc  mcdecine  dc 
Paris,  January  2,  1909)  : 


r»    Flienol  gr.  xv ; 

Salicylic  acid  3ss; 

Tartaric  acid  gr.  xlv ; 

Glvcerite  of  ftarch  jii'- 

M. 


NEW  REMEDIES. 

Allophanic  Acid,  an  ether  formed  when  the  va- 
])or  of  c\anogen  is  passed  into  alcohol,  has  the 
property  of  combining  with  fluids  to  form  solid 
compounds  devoid  of  taste  or  odor.  The  acid  is  a 
chemical  compound  of  urea  and  carbon  dioxide,  and 
it  splits  up  into  its  components  in  the  intestines,  the 
drug  that  may  be  combined  with  it  being  then  set 
free.  Allophanates  of  santal  oil.  creosote,  and  sim- 
ilar substances  have  been  propo.sed. 


Brovalol  is  the  latest  name  adopted  for  a  bro- 
mine derivative  of  isovaleric  acid  and  borneol,  which 
is  richer  in  bromine  than  the  original  compound 
named  valisan.  It  is  intended  for  use  as  a  sedative 
in  doses  of  frotn  four  to  twelve  drops  enclosed  in 
gelatin  pearls,  each  containing  about  four  minims 
(0.25  gramme)  of  the  drug. 

Camphosan  is  a  name  that  has  been  incorrectly 
given  to  a  preparation  of  camphoric  acid  methyl 
ester  in  santalol  originally  called  camphosal.  It  is 
regarded  as  a  prophylactic  in  urinar\-  troubles  and 
is  administered  in  the  form  of  capsules  containing 
about  five  grains  of  the  solution,  two  of  the  capsules 
being  given  three  to  five  times  daily. 

Diplosal  is  the  name  of  a  new  salicylic  acid 
compound  in  which  the  acid  exists  as  a  salicylosali- 
cylic  ester.  It  is  obtained  by  a  dehydrating  action  on 
salicylic  acid  or  salicylates.  It  forms  a  white  crys- 
talline powder  of  bitter  taste,  insoluble  in  water  and 
dilute  acids,  but  soluble  in  alcohol  and  ether,  as  well 
as  in  alkaline  solutions,  which  latter,  however,  de- 
compose. It  is  recommended  for  use  in  the  treat- 
ment of  acute  and  chronic  rheumatism  of  the  mus- 
cles and  joints,  neuralgia,  pleurisy,  and  cystitis  in 
doses  of  fifteen  grains  repeated  four  or  five  times  a 
day. 

Euphyllin  is  the  name  given  to  a  compound  of 
theophyllin  and  ethylenediamine  which  is  credited, 
with  diuretic  properties,  and  is  given  in  doses  of 
from  I  to  8  grains,  either  by  the  mouth,  intramuscu- 
larly, or  by  suppository. 

Filicone  is  the  name  applied  to  a  principle  de- 
rived from  Aspidinni  spimilosnm,  which  is  said  to 
possess  anthelmintic  properties  when  combined  with 
castor  oil  in  the  proportion  of  about  thirty  grains  of 
filicone  to  half  an  ounce  of  the  oil. 

Meligrin  is  the  name  of  a  recent  addition  to  the 
list  of  antineuralgics  of  the  antipyrine  class.  It  is 
stated  to  be  a  condensation  product  of  phenyldi- 
methylpyrazolon  and  methylphenylacetamide,  form- 
ing a  colorless  powder  soluble  in  water.  It  is  rec- 
ommended for  use  in  the  treatment  of  migraine. 

Nizine  is  the  commercial  name  for  zinc  sul- 
|)hanilate,  made  by  saturating  sulphanilic  acid  with 
zinc  oxide.  It  is  recommended  for  use  in  urethral 
and  vaginal  injections,  being  freely  soluble  in  water. 
For  such  purposes  it  is  employed  in  solutions  of  one 
part  in  250  parts,  or  stronger.  Nizine  is  aflfected  by 
light  and  should  be  kept  in  amber  colored  vials. 

Plejapyrine  is  the  brand  name  of  a  condensa- 
tion product  of  benzamide  and  antipyrine.  It  occurs 
as  a  white  crystalline  powder  without  odor,  soluble 
in  fifteen  parts  of  water.  It  is  reconnnended  in  the 
treatment  of  migraine  in  doses  of  fifteen  grains. 

Propaesin  is  the  name  of  anew  local  anaesthetic, 
the  propyl  ester  of  paramidobenzoic  acid,  which 
forms  colorless  crystals  of  alkaline  reaction,  only 
slightly  soluble  in  water,  but  readily  soluble  in  alco- 
holic solutions.  It  is  considered  a  useful  application 
to  nnicous  surfaces,  and  is  recommended  for  in- 
ternal use  in  the  treatment  of  gastrointestinal  affec- 
tions. 


January  30,  1909.] 


EDITORIAL  ARTICLES. 


231 


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NEW  YORK,  SATURDAY,  JANUARY  30,  1909. 

TESTS  OF  ARMY  OFFICERS'  ENDURANCE. 

In  the  old  days  when  deeds  of  prowess  were 
thought  to  be  the  only  fitting  work  for  gentlemen, 
and  when  nations  were  almost  continuously  in  con- 
flict, there  was  very  little  opportunity  for  physical 
deterioration  to  steal  over  the  soldier ;  he  was  usual- 
ly killed  on  the  field  sooner  or  later.  Nowadays, 
however,  whole  armies  grow  rusty,  so  exceptional 
have  great  campaigns  become,  and  individuals  fall 
n  prey  to  premature  senility  due  to  a  life  which  is 
more  sedentary  than  that  of  a  majority  of  those  who 
are  devoted  to  the  arts  of  peace.  Therefore  our 
people  generally  have  felt  that  it  was  well  to  test  the 
physical  efficiency  of  army  officers,  though  there  has 
been  considerable  doubt  as  to  the  fitness  of  the  tests 
recently  enforced.  This  doubt  is  shared  by  so 
capable  an  officer  as  Lieutenant  Colonel  Charles 
Richard,  of  the  Army  Medical  Corps,  who  contrib- 
utes to  the  January-February  number  of  the  Joiir- 
iial  of  tlw  Military  Serz'icc  Institution  a  very  care- 
fully prepared  article  entitled  Suggestions  for  the 
Physical  Training  of  Officers  on  the  Active  List  of 
the  Army.    Colonel  Richard  says : — 

I'hc  object  sought  in  prescribing  an  annual  endurance 
test  for  field  officers,  viz :  that  every  officer  of  this  class 
shall  demonstrate  his  piiysical  fitness  for  active  field  ser- 
vice, is  unquestionably  an  excellent  one.  Neither  should 
there  be  any  question  that  officers  who  are  not  physically 
al-.le  to  perform  any  duty  they  may  be  called  upon  to  per- 
form should  be  retired  ;  but  the  method  of  attaining  this 
object  is  neither  rational  nor  satisfactory.  The  manner  in 
which  it  is  carried  out  in  practice  is  somewhat  as  follows: 
A  lew  weeks  before  the  time  set  for  the  test  the  officer 
jjoes  into  trainmg  with  the  sole  object  of  passing  it  suc- 


cessfully, perhaps  to  the  neglect  of  his  other  duties ;  after 
its  completion  he  relapses  into  a  state  of  physical  inertia 
which  continues  until  the  time  approaches  for  the  next 
trial,  when  he  again  goes  through  a  similar  process.  In 
the  intervals  between  tests  he  grows  fat,  his  muscles  be- 
come soft,  and  he  soon  becomes  physically  unfit  to  with- 
stand the  strains  and  hardships  of  a  campaign.  To  be 
sure,  by  this  system,  he  is  enabled  to  undergo  the  pre- 
scribed test,  but  does  it  really  increase  his  physical  efficiency 
as  an  officer  of  the  army?  Should  he  not  be  efficient  at 
all  times?  Would  it  not  be  more  rational  to  require  him 
to  be  continuously  efficient,  rather  than  to  call  upon  him 
fo  demonstrate  his  fitness  at  a  certain  fixed  time  in  each 
year  ? 

Colonel  Richard  goes  on  to  show  that  the  endur- 
ance test  is  not  free  from  danger  to  health  or  life. 
Immediately  after  it  has  been  undergone,  he  says, 
the  pulse  is  not  infrequently  120  or  more,  even  in 
officers  who  are  only  approaching  middle  life.  In 
some  instances,  he  adds,  this  indicates  a  fatigued 
heart,  in  others  an  exhausted  heart.  Though  usual- 
ly the  fatigue  is  quickly  recovered  from,  the  state  of 
exhaustion  is  more  serious  and  many  end  in  organic 
disease.  Regtilar  exercise  in  moderation  is  much 
better  in  every  way  than  a  severe  annual  test,  and 
even  that  should  be  carefully  apportioned  to  the  in- 
dividual's condition.  It  is  well  that  exercise  should 
take  the  form  of  recreation,  as  in  a  game ;  other- 
wise it  is  apt  to  become  irksome.  The  game,  too, 
should  be  fitted  to  the  subject.  The  game  of  golf 
is  excellent  for  the  purpose ;  it  "increases  muscular 
strength,  trains  the  muscles  to  coordinate  with  each 
other,  is  an  excellent  teacher  of  patience,  and  af- 
fords diversion  and  entertainment."  Tennis,  which 
is  more  exacting,  is  better  suited  to  younger  men. 
Swimming  and  bicycling,  if  not  overdone,  are  excel- 
lent forms  of  diverting  exercise. 


A  COUNTERBLAST  TO  THE  ANTIVIMSEC- 
TIOX  MOVEMENT. 

'  The  Committee  on  Experimental  Medicine  of  the 
2\Iedical  Society  of  the  State  of  New  York  has  be- 
gun the  publication  of  a  series  of  tracts  on  the  stib- 
ject  of  animal  experimentation.  Ten  of  the  tracts 
have  been  received  at  this  office.  The  authors  whose 
names  are  given  are  President  Eliot,  of  Harvard 
University.  Dr.  Frederic  S.  Lee.  of  Columbia  Uni- 
versity, Dr.  James  Ewing,  of  Cornell  University 
Medical  College,  Dr.  Edward  L.  Trudeau,  of  Sar- 
anac  Lake.  X.  Y.,  Dr.  S.  J.  }^Ieltzer  and  Dr.  Simo'i 
Flexner,  of  the  Rockefeller  Institute  for  Medical 
Research,  Dr.  Robert*  A.  Hatcher,  of  Cornell  Uni- 
versity Medical  College,  Dr.  William  H.  Park,  o: 
the  New  York  University  and  Bellevue  Hospita; 
Medical  College,  and  Lord  Cromer,  of  the  Research 
Defense  Society,  of  London.  Copies  of  the  article 
may  be  obtained  at  the  office  of  the  Medical  Society 
of  the  State  of  New  York,  in  the  New  York  Acad- 


232 


EDITORIAL  ARTICLES. 


[Xew  York 
JIedical  Journal. 


cmy  of  Medicine's  building,  No.  17  West  Forty- 
third  Street.  They  are  temperate  and  truthful  e.x- 
positions  of  the  fallacies  upon  which  the  opposition 
to  experiments  on  animals  is  largely  based  and  of 
the  unfortunate  results  that  would  surely  follow  the 
prohibition  or  fanatical  "regulation"  of  such  experi- 
ments. They  ought  to  be  widely  read  by  legislators 
and  by  reasonable  persons  who  are  not  hopelessly  en- 
thralled bv  morbid  sentimentalism. 


IXHIBITION  OF  INTESTINAL 
PUTREFACTION. 

The  physiology  of  intestinal  digestion,  in  so  far  as 
the  action  of  the  intestinal  secretion  itself,  the  pan- 
creatic juice,  and  the  bile  is  concerned,  has  been  rea- 
sonably well  understood  for  many  years ;  an  appre- 
ciation of  the  role  played  by  certain  benign  germs, 
notably  the  lactobacillus,  is  of  comparatively  recent 
date.  In  these  days,  when  we  attribute  a  steadily 
increasing  number  of  ills  to  intoxication  from  the 
intestinal  tract,  the  action  of  these  bacteria  hi  assist- 
ing to  maintain  the  normal  equilibrium  of  digestion 
cannot  well  be  overestimated.  The  investigations  of 
Metchnikofif  regarding  the  action  of  the  lactobacillus 
in  albuminoid  digestion  are  so  well  known  that  de- 
tailed mention  here  of  his  findings  is  unnecessary. 
While  clinical  tests  undoubtedly  have  substantiated 
his  theories,  in  some  respects  it  is  difficult  to  make 
these  findings  coincide  with  accepted  notions  relat- 
ing to  digestion. 

The  amylolytic  period  of  gastric  digestion  is 
known  to  vary  in  accordance  with  the  size  and  char- 
acter of  the  meal  ingested,  but  is  generally  some- 
thing like  three  quarters  of  an  hour.  During  the 
second,  or  hydrochloric  acid,  period  of  digestion  the 
antiseptic  action  of  the  free  hydrochloric  acid  of  the 
gastric  juice  comes  into  play,  and  the  great  majority 
of  the  bacteria  ingested  with  the  food,  and  notably 
those  that  cause  fermentation  and  putrefaction,  are 
destroyed.  In  from  four  to  six  hours  after  an  or- 
dinary meal  the  stomach  has  become  entirely  empty 
of  food  and  contains  a  small  amount  of  clear  fiuid 
of  a  neutral  reaction  devoid  of  hydrochloric  acid  and 
of  pepsin. 

Diminished  secretion  of  hydrochloric  acid,  as  is 
well  known,  interferes  with  albuminoid  digestion 
and  decidedly  lessens  the  power  of  the  stomach  to 
prevent  decomposition  and  fermentation ;  in  other 
words  albuminous  bodies  are  imperfectly  digested, 
the  development  of  fermentative  and  putrefactive 
microorganisms  is  unrestrained,  and  lactic  acid  pro- 
duction occurs  in  pronounced  excess.  This  abnor- 
mal chemical  activity  in  turn  produces  a  paralysis  of 
peristalsis  and  of  muscular  tone,  necessarily  the 
period  of  gastric  digestion  is  greatly  prolonged, 
and  the  antiseptic   action  of  the  secretions  is  de- 


stroyed. During  the  entire  period  of  stomach  di- 
gestion a  separation  of  the  solid  and  fluid  contents 
is  taking  place,  and  the  latter,  little  by  little,  are 
passed  through  the  pylorus  into  the  duodenum. 

Leaving  out  of  consideration  possible  abnormities 
in  the  several  digestive  secretions  present  in  the  up- 
per part  of  the  intestinal  tract,  it  is  acknowledged 
that  putrefaction  and  fermentation  in  this  area  are 
largely  due  to  the  action  of  Bacillus  biityricits. 
When  amylolytic  digestion  and  the  succeeding  gas- 
tric processes  as  well  have  been  interfered  with,  the 
imperfectly  transformed  stomach  contents  when 
passed  into  the  intestine  prove  a  perfect  nidus  for 
the  development  of  butyric  fermentation.  Metchni- 
koff  has  shown  that  the  introduction  into  the  duode- 
num during  digestion  of  pure  cultures  of  Bacillus 
lebeiiis,  a  bacillus  peculiar  to  Bulgarian  sour  milk, 
definitely  arrests  putrefaction,  not  only  because  the 
lactic  acid  prctduced  inhibits  the  multiplication  of 
the  putrefactive  microbes,  but  because  of  the  anti- 
septic properties  of  another,  as  yet  unknown,  sub- 
stance produced  by  it.  Furthermore,  the  Bulgarian 
bacillus  forms  neither  alcohol  nor  acetone,  two  pro- 
ducts frequently  resulting  from  bacterial  fermenta- 
tion. It  also  differs  from  other  lactic  ferments  in- 
asmuch as  it  exerts  no  action  on  albuminoids  (case- 
in, etc.)  or  on  fats.  According  to  Aletchnikoff,  '"all 
these  qualitfes  make  it  much  the  most  useful  of  the 
microbes  which  can  be  acclimatized  in  the  digestive 
tube  for  the  purpose  of  arresting  putrefaction  and 
pernicious  fermentation,  such  as  is  produced  by 
Bacilhis  butyriciis  and  other  germs." 

While  diseases  of  the  alimentary  canal  as  a  rule 
do  not  decidedly  affect  the  urine  pathologically,  it 
is  a  well  known  fact  that,  in  the  absence  of  pus 
formation  in  the  body  and  of  a  cachexia,  albuminous 
putrefaction  in  the  intestines  increases  the  amount 
of  indoxylsulphuric  acid  salts  and  of  phenol.  In- 
dicanuria,  therefore,  while  varying  in  accordance 
with  the  severity  and  the  length  of  time  the  putre- 
factive process  has  existed,  is  accepted  as  a  positive 
sign  of  its  presence.  Proof  of  the  soundness  of 
Metchnikoff's  argument  is  found  in  an  amelioration 
of  subjective  symptoms  and  a  marked  diminution  in 
the  amount  of  indol  and  of  phenol  in  the  urine  afier 
the  inhibition  of  putrefaction  has  been  brought  about 
by  the  ingestion  of  the  Bulgarian  bacillus. 

In  view  of  the  somewhat  remarkable  enthusiasm 
with  which  the  teachings  of  Metchnikoft"  have  been 
accepted  in  this  country  and  of  the  prodigious  quan- 
tity of  lactic  ferment  products  now  being  prescribed, 
it  seems  advisable  to  call  attention  to  Tissier's  dic- 
tum:  "From  a  practical  point  of  view,  when  it  is  de- 
sirable to  arrest  intestinal  putrefaction,  we  must 
first  of  all  modify  the  chemical  condition  of  the  in- 
testinal tract  in  order  to  render  it  unfavorable  to  the 
microorganisms  which  attack  the  albuminoids  and 


January  30.  .909.I  EDITORIAL  ARTICLES. 


which,  on  tlie  contrary,  are  favorable  to  mixed  acid 
ferments." 

The  lactobacillus,  as  compared  with  many  others, 
is  not  tenacious  of  life.  Because  of  this  fact  and 
also  because  the  object  to  be  attained  b}'  its  intro- 
duction into  the  human  organism  is  its  rapid  and 
unimpeded  multiplication,  it  stands  to  reason  that 
conditions  in  the  stomach  and  intestinal  tract  should 
be  made  as  favorable  to  this  end  as  possible.  Ordi- 
narily the  bacillus  is  prescribed  in  pure  culture  de- 
veloped in  bouillon  or  other  suitable  medium,  in 
milk,  or  in  tablet  or  powder  form,  immediatelv  after 
meals.  It  is  reasonable  to  suppose  that  practically 
in  every  case  in  which  this  course  of  treatment  is 
indicated  not  only  is  intestinal  digestion  impaired, 
but  gastric  digestion  as  well ;  yet  apparently  this  fact 
is  not  considered  important.  From  what  has  been 
said  above,  it  would  appear  in  every  instance  that 
if  favorable  results  are  to  be  expected,  existing  gas- 
tric conditions  should  be  carefully  studied  and.  if 
necessary,  corrected  as  far  as  is  possible  before  the 
bacillus  treatment  is  begun  :  also,  under  all  circum- 
stances, that  far  greater  benefit  will  be  achieved  by 
administering  the  germs  at  such  times  as  the  stom- 
ach is  empty  of  food  and  the  reaction  of  its  fluid 
contents  is  similar  to  that  of  the  intestine  in  which 
the  microbes  are  to  accomplish  their  mission,  that 
is  to  .say,  from  four  to  five  hours  after  meals. 


RELIGION  AND  MEDICIXE. 

In  the  January  niunber  of  the  Hihbert  Journal 
there  is  published  a  notable  article,  entitled  Psycho- 
therapeutics and  Religion,  by  Mr.  Henry  Rutgers 
Marshall,  of  Xew  York.  The  author  deals  chiefl>- 
with  Christian  Science  and  the  Emmanuel  Church 
movement  in  their  relations  to  scientific  medicine. 
The  state  of  mind  in  which  he  writes  is  that  of  per- 
fect fairness,  but  it  is  easy  to  see  that  he  has  little 
patience  with  Christian  Science.  He  recognizes  at 
the  outset  the  ancient  bond  between  medical  treat- 
ment and  the  priestly  office.  "In  a  large  proportion 
of  cases  at  least,"  he  says,  '"the  first  crude  therapeu- 
tics of  the  uncivilized  man  probably  had  its  origin 
among  those  of  the  priestly  class,  which,  in  the  na- 
ture of  the  case,  included  all  men  of  special  wis- 
dom." 

Mr.  Marshall  thinks  it  is  not  unlikely  that  at  times 
the  religious  healer  brings  about  in  his  patient 
"something  closely  allied  to  a  real  religious  cotiver- 
sion."  "In  religious  conversions  of  a  profound  type,'" 
he  continues,  "we  see  the  replacement  of  one  mor- 
bid individuality  by  a  new  and  more  moral  one."  so 
that  "ideas  and  aims  which  were  formerly  persistent 
give  place  to  others."  The  displaced  ideas,  he  says, 
may  have  been  correlated  with  morbid  physical  con- 


ditions, and  their  displacement  "means  the  appear- 
ance of  new  physical  conditions  which  may  effect 
the  disappearance  of  what  is  morbid."  When  the 
physician  learns  that  a  patient  has  not  felt  the  influ- 
ence of  religion,  and  surmises  that  religious  conver- 
sion may  bring  relief,  it  may  appear  wise,  he  says, 
for  him  to  call  the  clergyman  to  his  aid.  "We  are 
thus  led,"  he  concludes,  "to  hold  that  collaboration 
between  the  medical  doctor  and  the  religious  leader 
is  greatly  to  be  desired,  but  are  surely  not  warranted 
in  suggesting  the  assumption  by  either  of  the  role  of 
the  other  in  addition  to  his  own." 


THE  HIGH  FREQUENCY  CURRENT  IN 
TABES  DORSALIS. 

Dr.  Henry  G.  PifTard,  of  New  York,  appears  to 
have  been  the  first  to  report  on  the  treatment  of 
locomotor  ataxia  by  high  frequency  currents,  and 
his  paper  appeared  in  the  A  rte  York  Medical  Jour- 
nal for  June  i6,  1906.  He  cited  two  cases  in  which 
the  patients  were  much  improved,  the  pains  were  re- 
markably ameliorated,  the  ataxic  gait  was  greatly 
changed  for  the  better,  and  the  mental  condition 
cleared  up  considerably.  Besides  the  high  frequency 
currents.  Dr.  PifTard  ordered  his  patients  to  take 
sodium  iodide,  which  drug  had  to  be  discontinued 
after  a  short  trial  in  the  second  case,  on  account  of 
severe  catarrhal  symptoms  that  it  evoked. 

Dr.  Nagelschmidt,  of  Berlin,  adds  his  experience 
to  Dr.  Piftard's  investigations.  In  the  Miinchcner 
medizinischc  IVochcnschrifi  of  December  8.  1908, 
he  reports  his  results  with  high  frequency  currents 
in  twenty-two  cases  of  tabes.  He  found  that  the 
general  condition  of  the  patients  was  greatly  amelio- 
rated, the  pains  disappeared  partly  or  entirely,  and 
incontinence  where  it  had  been  present  was  stopped, 
bitt  the  ataxia  remained  nearly  the  same,  although 
the  motor  power  was  increased,  and  only  when  elec- 
tricity was  used  with  Frankel  exercise.  (See  also 
page  249  of  this  issue.)  The  high  frequency  cur- 
rent, from  these  reports,  seems  to  exert  a  certain  in- 
fluence on  tabetics,  and  it  would  be  interesting  if 
further  researches  were  made  in  this  line. 


ARBITRARY  STANDARDS  IX  MEDICAL 
EDUCATION. 

For  a  number  of  years  now  legislation  and  the 
other  agencies  which  control  the  requirements  for 
the  license  to  practise  medicine  have  been  urging  us 
on  toward  a  condition  of  things  which  is  generally 
contemplated  with  pride,  but  which  may  have  its 
disadvantages.  It  has  been  growing  harder  and 
harder  to  gain  admission  into  the  medical  profession 
with  a  promising  status.     One  result  of  this  in- 


234 


OBITUARY.— NEH'S  ITEMS. 


[New  York. 
Medical  Jouknal. 


creased  difficulty  is  that  the  number  of  students  of 
medicine  has  been  decidedly  reduced,  with  an  in- 
cipient reduction  of  the  general  body  of  physicians. 
This  in  itself  is  by  no  means  to  be  regretted,  but  it 
is  to  be  feared  that  our  constantly  increasing  re- 
quirements, particularly  the  requirements  for  admis- 
sion to  the  medical  school,  are  actually  barring  out 
young  men  who,  even  without  the  amount  of  col- 
legiate or  academic  training  required,  might  add  lus- 
tre to  the  medicine  of  the  present  day.  We  should 
not  plume  ourselves  on  piling  up  difficulties  in  the 
way  of  such  men.  We  fear  that  the  law  of  supply 
and  demand  is  in  great  danger  of  being  lost  sight  of. 
We  are  not  advocating  a  return  to  the  slipshod 
methods,  or  lack  of  method,  of  the  distant  past,  but 
we  believe  that  there  is  danger  of  overdoing  a  good 
work,  of  putting  the  bars  up  too  high,  and  we  feel 
that  no  unnecessary  restriction  should  be  put  upon 
entrance  into  the  medical  profession. 



(iDbituara. 


DOUGLAS  ARGYLL  ROBERTSON,  M.   D.,  LL.  D., 
of  Edinburgh. 

Dr.  Robertson,  an  ophthalmologist  of  worldwide 
fame,  died  on  Sunday,  January  3d,  in  the  seventy- 
second  year  of  his  age.  After  his  retirement  from 
practice,  in  1904,  he  made  his  home  on  the  island  of 
Jersey,  and  it  was  there  that  he  died.  The  phenom- 
enon known  as  the  Argyll  Robertson  pupil  was  dis- 
covered by  him  about  forty  years  ago. 

 <$>  

Items. 


Changes  of  Address. — Dr.  Sidney  J.  Repplier,  to  4521 
Chester  Avenue,  Philadelphia. 

Dr.  Edwin  T.  Robinson,  to  igo6  Pine  Street,  Philadelphia. 

In  Honor  of  the  Late  Dr.  Joseph  Eichberg,  of  Cin- 
cinnati.— A  fund  is  being  collected  to  endow  a  chair  of 
physiology  in  the  University  of  Cincinnati  that  will  bear 
his  name. 

Ten  Years'  Progress  in  Electrotherapeutics  was  the 

subject  of  an  address  delivered  by  Dr.  William  Benham 
Snow,  of  New  York,  at  a  meeting  of  the  Pennsylvania  So- 
ciety of  Physicothcrapy,  held  in  Philadelphia  on  the  even- 
ing of  January  26th. 

The  Wayne  County,  Mich.,  Medical  Society. — Dr. 
W.  B.  Coley,  of  New  ^'ork,  presented  a  paper  entitled  The 
Mixed  Toxines  of  ICrysipelas  and  Bacillus  Prodigiosns  in 
tlie  Treatment  of  Inoperable  Sarcoma  at  a  meeting  of  this 
society,  held  in  Detroit  on  Mondav,  January  25th. 

The  Dental  Origin  of  Facial  Neuralgia  is  the  princi- 
pal topic  sekcled  for  discussion  at  llie  meeting  of  the  Phila- 
delphia .'Xcadcmy  of  Stomatology  to  be  held  on  the  cveiu'ng 
of  i''ebruary  lOth.  .Ml  uhysicians  and  dentists  are  invited 
to  attend  the  meeting  and  lake  p.'irt  in  (he  discussion. 

The  New  Jewish  Maternity  Hospital,  at  270  and  272 
East  Broadway,  New  York,  was  dedicated  with  suitable 
exercises  on  Sunday,  Jaiuiary  24th.  While  the  hospital  has 
been  built  by  Jews,  it  will  be  nonscctarian.  It  has  no  en- 
dowment, and  will  be  supported  by  voluntary  contributions. 
I-'vcry  one  of  the  sixty  beds  is  free.  There  are  a  few  pri^ 
vatc  rooms,  the  charge  for  which  will  be  low.  There  will 
be  fifteen  nurses,  and  an  obstetrical  training  school  will  be 
conducted  in  connection  with  the  hospital. 


The  Alumni  Association  of  the  College  of  Physicians 

and  Surgeons,  Columbia  University,  will  award  the  prize 
of  $500,  which  is  ofYered  biennially,  in  June,  1909.  Essays 
in  competition  for  the  prize  must  be  forwarded  to  Dr. 
Henry  E.  Hale,  752  West  End  Avenue,  New  York,  on  or 
before  April  ist. 

The  Harvey  Society  Lectures. — The  next  lecture  in 
the  course  will  be  delivered  on  Saturday  evening,  February 
6th,  at  8:30  o'clock,  at  the  New  York  Academy  of  Medi- 
cine, by  Professor  Philip  Hanson  Hiss,  of  Columbia  Uni- 
versity. The  subject  will  be  Some  Problems  in  Immunity 
and  the  Treatment  ol  Infectious  Diseases. 

The  Twelfth  International  Congress  on  Alcoholism 
will  be  held  in  London  on  July  18  to  24,  1909.  The  Duke 
of  Connaught  is  honorary  president  of  the  congress,  and 
there  is  a  distinguished  list  of  vice-presidents.  Information 
regarding  the  congress  can  be  obtained  from  the  Honorary 
Secretaries,  34  Paternoster  Row,  London,  E.  C. 

The  Section  in  Obstetrics  and  Gynaecology  of  the 
Buffalo  Academy  of  Medicine  met  on  Tuesday  evening,^ 
January  26th.  The  Frequency,  .-Etiology,  and  Practical 
Significance  of  Funnel  Shaped  Pelves  was  tlie  title  of  a 
paper  read  by  Dr.  J.  Whitbridge  Williams,  professor  of  ob- 
stetrics in  the  Johns  Hopkins  Medical  School. 

The  Pennsylvania  Society  for  the  Prevention  of  So- 
cial Diseases  elected  the  following  officers  recently  to 
serve  for  the  year  1909:  President,  Dr.  Edgar  F.  Smith; 
vice-presidents,  Mr.  Charles  C.  Harrison,  LL.D.,  Dr.  W. 
W.  Keen,  and  Colonel  R.  Dale  Benson ;  secretary,  Dr.  Rob- 
ert N.  Willson ;  treasurer.  Dr.  Jay  Frank  Schamberg. 

To  Investigate  Sanitary  Conditions  at  the  Naval 
Academy. — A  board  has  been  appointed  to  make  a  gen- 
eral investigation  of  the  sanitary  conditions  at  the  United 
States  Naval  Academy  at  Annapolis,  Md.  The  members  of 
the  board  are  Medical  Director  John  C.  Boyd,  Medical  Di- 
rector John  E.  Harman,  and  Aledical  Inspector  Henry  1. 
Perc)'. 

Tne  Regulation  of  Medical  Expert  Testimony. — .At 

a  meeting  of  the  legislative  council  of  the  American  Medi- 
cal Association,  held  in  Washington  on  January  2ath,  a 
committee  was  appointed  to  inquire  into  the  medical  ex- 
pert testimony  laws  existing  in  the  various  States,  with  a. 
view  to  formulating  a  uniform  law  to  serve  as  a  model  for 
future  legislation. 

The  Ohio  State  Board  of  Medical  Registration  and 
Examination  held  its  annual  meeting  in  Columbus,  on 
January  5th.  The  following  officers  were  elected  to  serve 
for  the  year  1909:  Dr.  A.  Ravogli,  of  Cincinnati,  president; 
Dr.  S.  M.  Sherman,  of  Columbus,  vice-president;  Dr.  E. 
J.  Wilson,  of  Columbus,  treasurer ;  and  Dr.  George  H. 
Matso,  of  Columbus,  secretary. 

Presentation  to  Dr.  Roddick. — The  undergraduates 
in  the  department  of  medicine  of  McGill  University,  Mon- 
treal, at  their  annual  dinner  held  recently,  presented  Dr. 
T.  G.  Roddick,  former  dean  of  the  medical  faculty,  with  a 
bronze  bust  of  himself,  as  a  mark  of  appreciation  of  his 
services  to  the  medical  faculty,  with  whom  he  had  been 
connected  for  over  thirty  six  years. 

The  Richmond,  Va.,  Academy  of  Medicine  and  Sur- 
gery.— At  a  recent  meeting  of  the  academy,  Dr.  Bev- 
erley R.  Tucker  read  a  paper  on  Paranoia,  which  was  lis- 
tened to  by  a  large  and  appreciative  audience.  The  rela- 
tions existing  between  physicians  and  pharmacists  was  the 
subject  of  a  paper  by  Dr.  Jacob  Michaux.  A  general  dis- 
cussion of  the  two  papers  followed. 

Mr.  Morton's  Gift  to  the  State  of  West  Virginia.— It 
is  announced  that  Mr.  Levi  P.  Morton,  of  New  \'ork.  has 
presented  to  the  Slate  of  West  Virginia  his  summer  resort 
property  at  Red  Sulphur  Springs  for  a  State  sanatorium 
for  consumptives.  The  property  contains  a  famous  sulphur 
spriiig  and  a.  hotel  that  will  accommodate  five  hundred 
persons.  The  gift  is  \ahu'd  at  about  $150,000,  and  is  given 
unC'iiditionally. 

The  Philadelphia  County  Medical  Society  elected  the 
following  orticers  al  its  annual  meeting,  held  on  January 
20II1 :  President.  Dr.  I'rederick  P.  Henry;  vice-i)residents. 
Dr.  William  I-"..  I^arke,  Dr.  C.  J.  Iloban.  Dr.  V.  Mortimer 
Cleveland,  Dr.  J.  1'.  Roderer,  Dr.  W.  H.  Morrison.  Dr. 
I'Vank  W.  Thomas,  and  Dr.  Ernest  W.  Kclscy ;  secretary. 
Dr.  William  S.  Wray ;  assistant  secretary,  Dr.  Alexander 
R.  Craig;  treasurer.  Dr.  Collier  L.  Bower;  censors.  Dr.  Jay 
I'Vank  Schamberg  and  Dr.  Lewis  H.  .^dler.  Jr. :  rcconi- 
meudation  to  the  Medical  Society  of  the  State  of  Pennsyl- 
vania for  district  censor,  Dr.  M.  B.  Ilartzcll. 


January  30,  1909.] 


NEIVS  ITEMS. 


235 


The  Classification  of  Insanity. — At  a  meeting  of  the 
Maryland  Psychiatric  Society,  held  in  the  Mai-yland  Hos- 
pital for  the  Insane,  Baltimore,  on  January  20th,  a  com- 
mittee was  appointed  to  formulate  a  classification  of  the 
different  forms  of  insanity,  to  be  presented  for  discussion 
at  the  April  meeting  of  the  association.  The  committee 
is  composed  of  Dr.  William  P.  Spratling,  Dr.  A.  P.  Her- 
ring, and  Dr.  Clement  Clark. 

The  International  Opium  Commission  will  convene 
on  February  i,  1909,  at  Shanghai.  The  following  coun- 
tries have  signified  their  intention  of  having  representatives 
present :  Great  Britain,  Germany,  Russia,  Portgual,  the 
Netherlands,  France,  China,  Japan,  Turkey,  Persia,  and 
Siam.  The  conference  has  been  called  at  the  incidence 
of  the  Government  of  the  United  States,  which  will,  of 
course,  take  an  active  part  in  the  proceedings. 

Officers  of  the  Medical  Club  of  Philadelphia  for  the 
year  1909  were  elected  on  January  15th  as  follows:  Presi- 
dent, Dr.  Wharton  Sinkler;  first  vice-president.  Dr.  James 
B.  Walker;  second  vice-president,  Dr.  Alexander  Marcy. 
Jr. ;  secretary,  Dr.  J.  Gurney  Taylor ;  treasurer,  Dr.  Lewis 
H.  Adler  Jr. ;  governor.  Dr.  L.  Webster  Fox ;  additional 
directors.  Dr.  George  A.  Knowles,  Dr.  S.  Lewis  Ziegler,  Dr. 
Walter  L.  Pvle,  Dr.  Judson  Daland,  and  Dr.  Wendell  Reber. 

The  Chicago  Eye,  Ear,  Nose,  and  Throat  College. — 
At  the  annual  meeting  of  the  stockholders  of  the  college, 
held  on  December  I,  1908,  the  reports  submitted  by  the 
officers  showed  that  both  the  college  and  the  hospital  were 
in  a  satisfactory  condition.  The  election  resulted  in  the  re- 
election of  the  old  board  of  directors,  which  consists  of  the 
following  members :  Dr.  W.  A.  Fisher,  Dr.  A.  G.  Wippern, 
Dr.  H.  W.  Woodruff,  Dr.  Thomas  Faith,  and  Dr.  J.  R. 
Hoffman. 

A  "Symposium"  on  Syphilis. — The  January  27th 
meeting  of  the  Philadelphia  County  Medical  Society,  Cen- 
tral Branch,  was  devoted  to  a  discussion  of  syphilis.  Dr. 
Francis  D.  Patterson  read  a  paper  entitled  Pre-Columbian 
Syphilis  in  the  United  States,  and  presented  specimens. 
Dr.  Hilary  M.  Christian  read  a  paper  on  the  Modern 
Method  of  Treatment  of  Syphilis,  and  Syphilis  in  its  Re- 
lation to  Nervous  and  Mental  Disease  was  the  title  of  a 
paper  read  by  Dr.  Alfred  Gordon.  An  interesting  discus- 
sion followed. 

The  Proposed  Changes  in  the  Pennsylvania  Medical 
Practice  Act  was  the  topic  discussed  at  the  meeting  of 
the  Medicolegal  Society  of  Philadelphia  held  on  January 
26th,  John  P.  Connelly,  Esq..  reviewed  the  new  medical 
act  that  is  to  be  submitted  to  the  legislature.  Dr.  L.  Web- 
ster Fox,  chiirm.an  of  the  committee  on  public  policy  and 
legislation  of  the  Philadelphia  County  Medical  Society, 
opened  the  discussion,  and  Dr.  A.  R.  Craig,  a  member  of 
the  State  council,  and  Dr.  J.  B.  Walker,  a  member  of  the 
State  examining  board,  took  part  in  it. 

The  Health  of  Pittsburgh. — During  the  week  ending 
January  23,  1909.  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  :  Chickenpo.x, 
17  cases,  o  deaths;  typhoid  fever,  25  cases,  o  deaths;  scarlet 
fever.  21  cases,  2  deaths ;  diphtheria,  14  cases,  2  deaths ; 
measles,  24  cases,  o  deaths;  whooping  cough,  17  cases,  o 
deaths;  pulmonary  tuberculosis,  34  cases,  13  deaths.  The 
total  deaths  for  the  week  numbered  175  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  16.47       a  thousand  population. 

St.  Vincent's  Hospital  Opens  Tuberculosis  Clinic. — 
Dr,  John  J.  Cotter  has  charge  of  a  new  clinic  for  tubercu- 
losis cases  opened  by  the  St.  Vincent's  Hospital,  at  149 
West  Eleventh  Street,  New  York.  These  clinics  will  be 
held  on  Monday,  Wednesday,  and  Friday  mornings  be- 
tween ten  and  eleven  o'clock,  and  those  suffering  from 
tuberculosis  who  live  in  the  vicinity  will  receive  medical 
treatment  and  advice  free  of  charge.  They  w-ill  also  be 
visited  regularly  at  their  homes  by  trained  nurses,  and 
where  necessary  milk  and  eg£;s  will  be  provided. 

Mark  Twain  the  Guest  of  Honor  at  Banquet  of  Post- 
graduate Medical  School. — The  annual  dinner  of  the 
(hrectors  and  faculty  of  the  New  York  Postgraduate  Medi- 
cal School  arid  Hospital  was  held  at  Delmonico's  on  Thurs- 
day- evening,  January  21st.  Dr.  George  N.  Miller  acted  as 
toastmaster.  Among  the  speakers,  in  addition  to  Mr.  Clem- 
ens, were  Colonel  George  Harvey,  President  Nicholas  Alur- 
rav  Butler,  of  Columbia  L^niversitv,  Dr.  John  W.  Musser, 
of  Philadelphia,  Dr.  W.  S.  Thayer,  of  Baltimore,  Dr. 
Adami,  of  Alontreal,  Dr.  Charles  L.  Dana,  of  New  York, 
Dr.  Bache  Emmet,  of  New  York,  and  Dr.  Simon  Flexner, 
of  the  Rockefeller  Institute. 


The  Philadelphia  Paediatric  Society.— At  the  regular 

meeting  of  this  society,  held  on  Tuesday  evening,  January 
I2th,  the  programme  consisted  of  the  following  papers,  i.i 
addition  to  the  annual  address  of  the  president :  Unusual 
Case  of  Bromide  Eruption  in  Childhood,  by  Dr.  Frank 
Crozer  Knowles ;  Some  Points  in  the  Diagnosis  of  Pleu- 
ritic Effusion  in  Young  Infants,  by  Dr.  D.  J.  Milton  Miller ; 
Report  of  a  Case  of  Subcutaneous  Emphysema  complicat- 
ing Pneumonia  by  Dr.  Charles  A.  Fife;  Report  of  a  Case 
of  Pneumothorax  complicating  Pneumonia,  by  Dr.  C.  H. 
VVeber  and  Dr.  C.  Y.  White.  Officers  to  serve  for  the  \  e  r 
1909  were  elected. 

A  Consolidation  of  Medical  Journals. — The  Indiana 
Medical  Journal  will  merge  with  the  Central  States  Medi- 
cal Monitor  in  February,  the  name  of  the  consolidated 
journal  being  Tlie  Indianapolis  Medical  Journal.  Dr.  S. 
E.  Earp,  for  many  years  editor  of  the  Central  States  Medi- 
cal Monitor,  will  be  the  editor  of  the  new  publication,  and 
Dr.  A.  W.  Brayton,  formerly  editor  of  the  Indiana  Medical 
Journal,  will  be  a  member  of  the  editorial  staff.  The  In- 
diana Medical  Journal  was  established  eighteen  years  ago, 
and  was  at  one  time  the  only  medical  journal  published  in 
the  State,  while  the  Monitor  made  its  first  appearance 
eleven  years  ago. 

The  Importation  of  Opium  for  Smoking  Prohibited. — 

On  January-  26th  the  United  States  Senate  passed  a  bill 
prohibiting  the  importation  into  the  United  States  of  opium 
for  other  than  medicinal  purposes.  The  measure  is  aimed 
to  exclude  prepared  opium,  which  is  used  only  for  smoking. 
The  opium  used  for  medicinal  purposes  is  imported  in  the 
crude  state,  and  is  even  of  different  origin  from  that  used 
for  smoking,  the  medicinal  opium  having  a  high  content  of 
morphine  and  coming  usually  from  Turkey,  though  a  small 
quantity  comes  also  from  Persia,  while  the  smoking  opium 
is  prepared  almost  exclusively  from  the  drug  grown  in 
India,  and  has  a  very  small  proportion  of  morphine. 

The  Mortality  of  North  Carolina. — The  mortuary  re- 
ports for  the  month  of  November,  1908,  from  twenty-two 
towns  in  North  Carolina,  show  that  248  deaths  were  re- 
ported, 120  white  and  128  colored,  in  an  estimated  popu- 
lation of  234,200,  corresponding  to  an  annual  death  rate 
of  12.7  in  a  thousand  population.  The  annual  death  rate 
among  the  white  population  was  9.9  in  a  thousand,  and  in 
the  colored  population  12,17  in  a  thousand.  Of  the  total 
number  of  deaths,  7  were  due  to  typhoid  fever,  2  to  scarlet 
fever,  3  to  malarial  fever,  4  to  diphtheria,  i  to  whooping 
cough,  16  to  pneumonia,  33  to  tuberculosis,  17  to  brain  dis- 
eases, 27  to  heart  diseases,  6  to  nervous  diseases,  20  to 
diarrhoeal  diseases,  3  to  accident,  5  to  violence,  and  104 
to  all  other  diseases. 

Infectious  Disease  in  New  York: 

JVe  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  follozi'ing  statistics  of  new 
cases  and  deaths  reported  for  the  tn'o  weeks  ending  Janu- 
ary 23,  i()og: 

 Jan.  16  V    ,  Jan.  23  ^ 

Cases.     Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    484         166         457  179 

Diphtheria    394  47         377  49 

Measles    462  16         468  21 

Scarlet  fever    337  18         359  18 

•Smallpox  

Varicella    163  , .  1 52 

Typhoid  fever    39  9  34  8 

Whooping  cough    39  3  23  4 

Cerebrospinal  meningitis    3  2  ..  3 

Totals    1. 921  261       1.870  282 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  February  6,  1909: 

^loxD.w,  February  ist. — Philadelphia  Academy  of  Su'-gery; 
Biological  and  IMicroscopical  Section,  Academy  of  Nat- 
ural Sciences  ;  West  Philadelphia  Medical  Association  ; 
Northwestern  IMedical  Society. 

TuESD.AY,  February  2d. — Academy  of  Natural  Sciences; 
Philadelphia  Medical  Examiner's  Association. 

Wednesday,  February  sd. — College  of  Physicians. 

Thursd.w.  February  4th. — Obstetrical  Society ;  German- 
town  Branch,  Philadelphia  County  Medical  Society; 
Southwark  Medical  Society :  Section  Meeting,  Frank- 
lin Institute;  Delaware  Valley  Ornithologist's  Club, 

Frid.av,  February  -,th. — American  Philosophical  Society; 
Kensington  Branch,  Philadelphia  County  Medical  So- 
ciety. 


NEUS  ITEMS. 


[New  York 
Medical  Journal. 


The    College   of   Physicians   of   Philadelphia.— The 

principal  feature  of  the  programme  of  the  meeting  of  the 
Section  in  General  Medicine,  held  on  Monday  evening,  Jan- 
uary nth.  was  a  paper  entitled  The  Treatment  of  Acute 
Infectious  Diseases  with  Extracts  of  Leucocytes,  by  Dr. 
Samuel  W.  Lambert,  professor  of  applied  therapeutics_  m 
the  College  of  Physicians  and  Surgeons  of  Columbia  Uni- 
versity. New  York.  Dr.  T.  Mellor  Tyson  and  Dr.  R.  S. 
Lavenson  presented  a  patient  with  an  aneurysm  of  the 
aortic  arch  treated  by  wiring,  and  Dr.  H.  R.  M.  Landis  ex- 
hibited some  specimens  in  pulmonary  fibrosis. 

Deaths    of    Eminent    Foreign    Medical    Men.— The 

deaths  of  the  following  eminent  medical  men  are  an- 
nounced :  Dr.  Andrew  Robertson,  late  professor  of  medi- 
cine in  St.  Mungo's  College,  Glasgow,  aged  seventy-foui 
years.  He  was  a  voluminous  contributor  to  the  literature 
of  medicine.— Dr.  Isidor  Schnabel,  professor  of  ophthal- 
mology in  Vienna.  He  wrote  numerous  papers  on  glau- 
coma and  other  subjects  connected  with  the  eye.— Dr.  W. 
Kudrin,  medical  inspector  in  the  Russian  Navy,  aged  sev- 
enty-four years. — Dr.  Charles  Edward  Beevor,  of  London, 
wll  known  for  his  contributions  to  the  knowledge  of  the 
nervous  system,  aged  fifty-four  years. 

The  New  York  Academy  of  Medicine.— At  a  stated 
meeting  of  the  academy,  held  on  Tliursday,  January  2ist, 
the  evening  was  devoted  to  a  consideration  of  can- 
cer of  the  breast.  Papers  on  the  subject  were  read  by 
Dr.  VV.  L.  Rodman,  of  Philadelphia,  Dr.  Maurice  H.  Rich- 
ardson, of  Boston,  and  Dr.  Willy  Meyer,  of  New  York.  The 
next  stated  meeting  will  be  held  on  the  evening  of  Feb- 
ruarv  4th.  Dr.  Walter  Mendelson  will  read  a  paper  on 
Card'iac  Insufficiency,  and  Dr.  Walter  B.  James  will  pre- 
sent a  paper  entitled  Some  Recent  Clinical  Improvement  in 
Methods  of  Studying  the  Diseased  Heart.  Among  those 
who  will  take  part  in  the  discussion  are  Dr.  Haven  Emer- 
son, Dr.  Lewis  A.  Conner,  and  Dr.  T.  B.  Barringer. 

To  Aid  Dr.  Carroll's  Widow.— At  the  meeting  of  the 
legislative  council  of  the  American  Medical  Association, 
held  in  Washington  on  January  20th,  a  committee  was  ap- 
pointed to  raise  $7,000  to  'pay  ofif  a  mortgage  on  the  borne 
of  the  late  Dr.  James  Carroll,  who  died  as  a  result  of  his 
experiments  to  determine  the  source  of  yellow  fever  in- 
fection The  committee  which  has  undertaken  to  collect 
the  subscription  is  composed  of  Major  W.  M.  Ireland,  of 
the  United  States  Army;  Surgeon  W.  S.  Bell,  of  the  United 
States  Navy  ;  Surgeon  John  R.  Anderson,  of  the  United 
States  Public  Health  and  Marine  Hospital  Service;  Dr. 
John  D.  Thomas,  of  Washington,  D.  C,  and  Dr.  Alexander 
S.  von  Mansfelde.  of  Ashland,  Neb. 

King  Edward  Founds  a  Radium  Institute. — It  is  re 

ported  that  King  Edward,  who  has  always  taken  a  keen 
personal  interest  in  experimental  work  with  radium  in  the 
treatment  of  disease,  will  soon  grant  a  charter  establishing 
a  Royal  British  Radium  Institute,  the  purpose  of  which 
will  be  to  pursue  investigations  into  the  potentialities  of  the 
substance,  especially  as  a  therapeutic  agent.  Among  the 
directors  will  be  Sir  William  Ramsay,  Sir  Frederick  Treves, 
and  Professor  J.  J.  Thomson.  A  donation  from  Sir  Ernest 
Cassel  has  made  possible  the  foundation  of  such  an  insti- 
tute. A  syndicate  has  been  formed  in  connection  with  the 
institute  to  extract  radium  from  the  pitchblende  deposits 
in  a  copper  mine  at  St.  Ives,  Cornwall,  which  is  said  to  be 
the  only  place  outside  of  Austria  where  radium  can  be 
produced. 

The  Health  of  Dr.  William  T.  Bull.— .A.  statement 
signed  by  Dr.  hVancis  Delafield,  Dr.  Joseph  A.  Blake 
and  Dr.  Nathaniel  Bowditch  Potter,  who  have  been  in 
dailj'  attendance  upon  Dr.  Bull,  has  been  issued,  as  fol- 
lows: 

"Owing  to  the  continued  erroneous  and  misleading  re- 
ports concerning  Dr.  Bull  in  certain  newspaper  articles 
and  to  the  fact  that  these  reports  are  arousing  false 
hopes  in  the  minds  of  many  sufferers  from  cancer 
throughout  the  country,  it  seems  wise  to  issue  the  fol- 
lowing statement: 

Dr.  Bull's  general  condition  and  the  rheumatic  com- 
plications have  improved  sufficiently  to  warrant  his  de- 
parture for  Savannah  in  the  near  future.  The  original 
growth  which  wa-^  the  real  cause  of  his  illness  has  never 
been  cured." 


Students  in  German  Medical  Colleges  are  allowed  to 
spend  the  sixth  year  of  the  course,  that  is,  the  last  year  be- 
fore their  final  examinations,  as  under  assistants  in  certain 
hospitals  outside  of  Germany,  if  they  desire.  The  fifteen 
eligible  hospitals  are  the  German  Hospitals  in  New  York, 
Philadelphia,  London,  Naples,  Rome,  Constantinople,  Alex- 
andria, Beirut,  Buenos  Aires,  and  Valparaiso ;  the  German 
Sanatorium  in  Davos,  Switzerland;  the  Evangelical  Hos- 
pital in  St.  Petersburg ;  the  St.  Mary's  Hospital  for  Chil- 
dren in  Jerusalem  ;  the  Victoria  Hospital  in  Cario,  and  the 
German  Marine  Hospital  in  Yokohama,  Japan. 

The  Health  of  the  Canal  Zone. — During  the  month 
of  November,  1908,  there  were  247  deaths  in  the  Canal 
ione,  in  a  population  of  124.989,  corresponding  to  annual 
death  rate  of  23.71  in  1,000  population.  There  were  5 
deaths  from  typhoid  fever,  17  from  malarial  fever,  3  from 
jestivoautumnal  malaria,  4  from  hsemoglobinuric  fever,  4 
from  dysentery,  i  from  leprosy,  5  from  beriberi,  3  from 
purulent  infection  and  septicaemia,  22  from  tuberculosis  of 
the  lungs,  8  from  other  forms  of  tuberculosis,  2  from 
syphilis,  3  from  cancer,  i  from  articular  rheumatism,  i 
from  chlorosis,  i  from  cerebrospinal  fever,  i  from  tetanus, 
5  from  bronchopneumonia,  13  from  pneumonia,  19  from 
diarrhoea  and  enteritis  under  two  years  of  age,  2  from  un- 
cinariasis, and  I  from  puerperal  septicaemia.  Tlie  morbidity 
rate  was  27.16  in  a  thousand  among  the  employees  of  tlie 
canal  commission. 

The  Hundredth  Meeting  of  the  Norwegian  Hospital 
Alumni  Association  was  held  at  the  residence  of  Dr. 
Sewell  Matheson,  Brooklyn,  on  the  evening  of  January 
13th.  The  first  president  of  the  association,  Dr.  Robert 
Coughlin,  who  was  also  the  first  inteme  appointed  at  the 
hospital,  was  reelected  president,  and  acted  as  toastmaster 
at  the  dinner  which  was  a  feature  of  the  meeting.  The 
speakers  were  Dr.  W.  Carl  Schoenijahn,  Dr.  C.  Eugene 
Lack,  Dr.  Sewell  Matheson,  Dr.  Robert  G.  Moore,  and  Dr. 
Louis  Stork,  Jr.  This  association  has  met  nine  times  every 
year,  at  the  residences  of  its  members  in  turn,  ever  since 
it  was  organized  in  1898.  The  reelection  of  Dr.  Coughlin 
as  president  was  a  recognition,  not  only  of  his  seniority, 
but  of  his  personal  popularity  among  the  members  of  the 
association.  Dr.  John  Ohly  was  elected  vice-president,  and 
Dr.  Louis  Stork,  Jr.,  was  elected  secretary  and  treasurer. 

The  Medical  Society  of  the  County  of  Kings,  N.  Y. — 
Syphilis  was  the  subject  chosen  for  discussion  at  the  ninety- 
third  regular  meeting  of  the  Section  in  Pediatrics  of  this 
society,  held  in  Brooklyn,  on  Friday  evening,  January  15th. 
Dr.  Benjamin  Edson  presented  some  clinical  notes  on  hered- 
itary syphilis,  and  Dr.  Archibald  D.  Smith  read  a  paper  en- 
titled The  Symptomatology  and  Diagnosis  of  Hereditary 
Syphilis,  An  interesting  discussion  followed  the  reading 
of  the  papers.  The  officers  of  the  section  are :  Dr.  John 
W.  Parrish,  chairman;  Dr.  W.  D.  Ludlum,  vice-chairman, 
secretary  and  treasurer.  Dr.  Sigmund  Beck ;  publication 
committee.  Dr.  Louis  C.  Ager,  chairman.  Dr.  William  M 
Hutchinson,  and  Dr.  Rollin  Hills ;  committee  on  member- 
ship. Dr.  Elias  H.  Bartley,  chairman.  Dr.  Archibald  1). 
Smith,  and  Dr.  W.  B.  Meister ;  committee  on  clinical  meet- 
ings, Dr.  Alexander  Spingarn,  chairman.  Dr.  L.  C.  Ager. 
Dr.  Le  Grand  Kerr,  Dr.  W.  A.  Northridge,  Dr.  F.  B.  Cros-, 
Dr.  G.  F.  Little,  and  Dr.  Jerome  Walker. 

The  Officers  of  the  Medical  Association  of  the 
Greater  City  of  New  York  for  1909  are  as  follow  s  :  Presi- 
dent, Dr.  Robert  T.  Morris  ;  vice-president.  Dr.  Ransford  E. 
Van  Giesoii ;  recording  secretary.  Dr.  P.  Brynberg  Porter ; 
corresponding  secretary.  Dr.  Frank  C.  Raynor ;  treasurer. 
Dr.  A.  Ernest  Gallant;  chairman  for  the  Borough  of  Man- 
hattan, Dr,  J.  Blake  White ;  chairman  for  the  Borough  of 
the  Bronx,  Dr.  Nathan  B.  Van  Etten ;  chairman  for  the 
Borough  of  Brooklyn,  Dr.  J.  Scott  Wood;  chairman  for  the 
Borough  of  Queens.  Dr.  Neil  Orrin  Fitch ;  chairman  for 
the  Borough  of  Richmond,  Dr.  Henry  C.  Johnston.  A 
special  meeting  of  the  association  will  be  held  in  Brooklyn 
on  February  1st.  Dr.  Edward  E.  Cornwall  will  read  a 
paper  on  the  Rational  Treatment  of  T>T)hoid  Fever.  Dr. 
Warren  L.  Duffield  will  read  a  paper  on  Hypernephroma 
of  the  Kidney,  which  w  ill  be  discussed  by  Dr.  A.  T.  Bris- 
tovv.  Dr.  Robert  T.  Morris  and  Dr.  A.  Murray.  Electricity 
in  the  Treatment  of  Genitourinary  Diseases  is  the  title  of 
a  paper  to  be  rend  by  Dr.  Francis  H.  Bermingham  antl 
discussed  by  Dr.  Lewis  Gregory  Cole  and  Dr.  Sinclair 
Tousey. 


January  30.  1909.] 


XEiyS  ITEMS. 


A  Professorship  in  Cornell  for  Dr.  Lusk. — The"  trus- 
tees of  Cornell  University  announce  ihe  appointment  of 
Dr.  Graham  Lusk  as  professor  of  physiology  in  the  Cornell 
L'niveisity  .Medical  School.  Dr.  Lusk  is  the  son  of  the 
late  Dr.  William  Lusk,  who  was  professor  of  obstetrics  in 
the  old  Bellevue  Medical  College.  He  is  forty-three  years 
of  age,  and  graduated  from  Columbia  University,  with  the 
degree  of  Ph.  B.,  in  1887,  after  which  he  took  a  course  in 
physiology  in  Munich,  under  Professor  Voit,  obtaining  the 
degree  of  Ph.  D.,  in  1891.  On  his  return  to  the  United 
States,  Dr.  Lusk  was  appointed  professor  of  physiology  m 
the  Yale  Medical  School,  and  he  held  this  chair  from  1891 
to  1898.  From  that  time  until  the  present  he  has  been  pro- 
fessor of  physiology  in  the  University  and  Bellevue  Medi- 
cal College.  '  Dr.  Lusk  is  well  known  both  in  this  country 
and  abroad  for  his  studies  and  researches  in  subjects  per- 
taining to  physiology. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing January  9,  1909,  the  following  cases  of  transmissible 
diseases  were  reported  to  the  Bureau  of  Health  of  Phila- 
delphia :  Malarial  fever,  i  case,  o  deaths ;  typhoid  fever,  145 
cases,  9  deaths;  scarlet  fever,  66  cases,  2  deaths;  chicken 
pox.  89  cases,  o  deaths;  diphtheria,  79  cases,  11  deaths; 
tetanus,  i  case,  i  death;  measles,  88  cases,  3  deaths;  whoop- 
ing cough,  18  cases,  3  deaths ;  tuberculosis  of  the  lungs, 
142  cases,  62  deaths;  pneumonia,  143  cases,  90  deaths;  ery- 
sipelas, 7  cases,  I  death;  puerperal  fever,  2  cases,  o  deaths; 
mumps,  16  cases,  o  deaths ;  cancer,  22  case,  26  deaths.  The 
following  deaths  were  reported  from  other  transmissible 
diseases :  Tuberculosis,  other  than  tuberculosis  of  the  lungs, 
2  deaths;  diarrhoea  and  enteritis,  under  two  years  of  age, 
II  deaths.  The  total  deaths  numbered  553  in  an  estimated 
population  of  1,565,569,  corresponding  to  an  annual  death- 
rate  of  18.38  in  a  thousand  population.  The  total  infant 
mortality  was  125;  101  under  one  year  of  age,  24  between 
one  and"  two  years  of  age.  There  were  34  still  births ;  23 
males  and  11  females.    The  total  precipitation  was  0.98  inch. 

Free  Lectures  on  Public  Health. — Columbia  Univer- 
sity has  made  arrangements  for  a  series  of  lectures  on  sub- 
jects bearing  on  the  question  of  public  health,  especially  in 
large  cities.  These  lectures  will  be  held  in  the  large  lecture 
room  of  the  College  of  Physicians  and  Surgeons,  437  \\  est 
Fifty-ninth  Street,  New  York,  on  Mondays  and  Wednes- 
days during  February,  March  and  April,  and  are  free  to 
all  who  are  interested.  The  first  lecture  will  be  delivered 
by  Dr.  William  Thompson  Sedgwick,  professor  of  biology 
at  the  Massachusetts  Institute  of  Technology,  on  February 
1st,  on  The  Rise  and  Significance  of  the  Public  Health 
Movement.  Among  the  other  lecturers  are  Professor 
Adami,  of  McGill  University,  Montreal ;  Dr.  Thomas  Darl- 
ington, health  commissioner  of  New  York  City;  Dr.  Eu- 
gene H.  Porter,  health  commissioner  of  the  State  of  New 
York;  Surgeon  General  Walter  Wyman.  Public  Health  and 
Marine  Hospital  Service;  Dr.  W.  H.  Burr,  professor  of 
engineering  at  Columbia  University;  Dr.  H.  M.  Biggs,  chief 
medical  officer  of  the  New  York  Health  Department ;  and 
Dr.  Theobald  Smith,  professor  of  pathology  at  the  Harvard 
Medical  School. 

Personal. — Dr.  C.  C.  Terry,  of  South  Bend,  Ind.,  who 
has  been  spending  several  months  abroad  with  his  wife 
and  daughter,  returned  home  recently,  and  has  resumed 
practice  in  new  offices  at  132  North  Lafayette  Street. 

Dr.  William  H.  Wishard,  a  veteran  physician  of  Indian- 
apolis, celebrated  the  ninety-third  anniversary  of  his  birth 
on  January  i6th.  Dr.  Wishard  prides  himself  on  being 
eleven  months  older  than  the  State  of  Indiana,  where  he 
has  lived  for  eighty-four  years. 

Dr.  Charles  S.  Minot,  professor  of  histology  and  human 
embryology-  in  the  Harvard  Medical  School,  has  been  ap- 
pointed a  foreign  corresponding  member  of  the  Acadeinie 
Royale  de  Medicine  de  Belgique. 

Dr.  E.  J.  Butler,  of  Wilkes  Barre,  Pa.,  is  registered  at 
the  Philadelphia  Polyclinic  and  College  for  Graduates  in 
Medicine. 

Dr.  Charles  V.  Chapin,  superintendent  of  health  of  Prov- 
idence, R.  I.,  has  been  appointed  lecturer  on  hygiene  at 
Harvard  University.  The  course  begins  about  February 
1st.  As  the  lectures  are  given  at  five  o'clock  in  the  after- 
noon, three  times  a  week,  the  appointment  will  not  inter- 
fere with  Dr.  Chapin's  duties  as  health  officer  in  Providence. 

Dr.  James  P.  Warbasse,  formerly  editor  of  the  Neze  York 
State  Journal  of  Medicine,  has  joined  the  editorial  staff  of 
the  American  Journal  of  Surgery. 


Foreign  Items  of  Interest. — By  the  will  of  the  late 
Piolcsscr  Sacharjin  tht  city  of  Moscow,  Russia,  receives 
two  million  roubles  for  the  erection  of  a  hospital. 

A  number  of  medical  officers  of  the  Turkish  Army  have 
been  sent  by  the  government  to  take  a  course  of  study  in 
I'Yench  and  German  Universities. 

Professor  Robert  Koch  has  been  elected  president  of  the 
German  Central  Committee  for  the  Prevention  of  Tubei- 
culosis. 

1  he  German  Urological  Society  will  hold  its  second  con- 
gress in  Berlin  on  April  i8th  to  22d  this  year.    All  com 
munications  in  relation  to  the  congress  should  be  addressed 
to  Sanitatsrat  Dr.  Wossidlo,  Victoriastrasse  19,  Berlin  \\. 

The  Third  Congress  on  School  Hygiene  will  be  held  in 
Paris  from  March  29  to  April  2,  1909.  The  first  meeting 
of  the  congress  was  held  in  Nuremberg  in  1904,  and  the 
second  in  London  in  1907. 

The  Eighth  International  Congress  on  Hydrology,  Cli- 
matology, Geology,  and  Therapeutics  will  be  held,  as  pre- 
viously announced,  in  .\lgiers  on  April  4  to  10.  1909.  _  Dr. 
Max  Einhorn,  of  20  East  Sixty-third  Street,  New  York, 
is  the  representative  of  the  United  States  on  the  foreign 
committee. 

Society  Meetings  for  the  Coming  Week: 

MoND-^v,  February  ist. — German  Medical  Society  of  the 
City  of  New  York ;  Utica,  N.  Y.,  Medical  Library  As- 
sociation ;  Niagara  Falls,  N.  Y.,  Academy  of  Medicine ; 
Practitioners"  Club,  Newark,  N.  J. ;  Hartford,  Conn., 
Medical  Society. 
TuESD.w,  February  >d. — New  York  Academy  of  Medicine 
(Section  in  Dermatology)  ;  New  York  Neurological 
Society;   Buffalo  Academy  of  Medicine   (Section  in 
Surgery);  Ogdensburgh,  N.  Y.,  Medical  Association; 
Syracuse,    N.    Y.,    Academy    of    Medicine ;  Hudson 
County,   N.   J.,   Medical   .A.ssociation    (Jersey   City)  ;, 
Medical  Association  of  Troy  and  Vicinity ;  Hornells- 
ville,  N.  Y.,  Medical  and  Surgical  Association ;  Long 
Island,   N.   Y..   Medical   Society ;   Bridgeport,  Conn., 
Medical  .Association. 
Wednesd-^y,  February  jd. — Society  of  .A-lumni  of  Belle- 
vue Hospital:  Harlem  Medical  Association,  New  York; 
Elmira,  N.  Y..  .Academy  of  Medicine. 
Thursd.\y,  February  4th. — New  York  Academy  of  Medi- 
cine ;  Dansville,  N.  Y.,  Medical  Association. 
Friday,  February  jtlt. — New  York  .Academy  of  Medicine 
(Section  in  Surgery)  ;  New  York  Microscopical  So- 
ciety; Gynaecological  Society,  Brooklyn,  N.  Y. ;  Man- 
hattan Clinical  Society,  New  York;  Practitioners'  So- 
ciety of  New  York. 
Sodium  Benzoate  Unobjectionable  as  a  Preservative. 
— The  referee  lioard  of  distinguished  chemists,  appointed 
by  President  Roosevelt  to  study  the  effect  on  the  human 
economy  of  preservatives  used  in  the  food  supply,  has  made 
a  report  to  the  Secretary  of  Agriculture  of  the  United 
States  to  the  effect  that  when  mixed  in  small  doses,  under 
half  a  gramme  a  day,  sodium  benzoate  is  without  deleteri- 
ous or  poisonous  action  and  is    not  injurious  to  health ; 
and  that  it  has  not  been   found  deleterious  or  poison- 
ous  in   the   general    acceptation    of   that   term  in  quan- 
tities of  up  to  four  grammes  a  day,  though  such  large 
doses  cause  slight  modifications  in  certain  physiological 
processes,  the  e.xact  significance  of  which  is  not  understood. 
The  admixture  of  sodium  benzoate  with  the  food  has  not 
been  found  to  injuriously  affect  or  impair  the  quality  or  the 
nutritive  value  of  the  food.    The  report  is  based  on  the  re- 
sults of  three  separate  series  of  investigations  carried  on 
independently  in  the  private  laboratory  of  Dr.  Christian  A. 
Herter,  of  Columbia  University,  New  York ;  in  the  labora- 
tories of  the  Sheffield  Scientific  School  of  Yale  University, 
under  the  supervision  of  Professor  Russell  H.  Chittenden ; 
and  in  the  laboratories  of  the  Medical  School  of  the  North- 
western University,  Chicago,  under  the  suptervision  of  Pro- 
fessor J.  H.  Long.    llTis  finding  is  diametrically  opposed  to 
that  of  Dr.  H.  W.  Wiley,  Chief  of  the  Bureau  of  Chemistry, 
of  the  Department  of  .Agriculture,  and  the  publication  has 
led  to  the  revival  of  the  rumor  that  Dr.  Wiley  may  resign. 
The  possibility  of  such  an  outcome  is  denied  by  Dr.  Wiley's 
friends,  and  an  association  of  food  manufacturers  has  been 
organized  with  the  avowed  purpose  of  supporting  the  views 
of  Dr.  Wiley  and  opposing  those  of  the  National  Food 
Manufacturers"  .Association,  which  has  advocated  the  use  of 
sodium  benzoate  and  similar  preservatives. 


238 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal 


Charitable  Bequests. —  By  the  will  of  Ellen  Coughlin, 
the'  Little  Sisters  of  the  Poor  and  St.  John's  Home  for 
Homeless  Boys,  Philadelphia,  receive  a  share  of  $4,000 

By  the  will  of  James  H.  Flint,  the  Orphan  Asylum  of 
Philadelphia  becomes  a  contingent  legatee. 

By  the  will  of  Mary  A.  Badger,  St.  Joseph's  Hospital, 
Philadelphia,  receives  $300. 

By  the  will  of  Mrs.  Aiirelia  Leake,  of  Vineland,  N.  J., 
the  Episcopal  Hospital  of  Philadelphia  receives  a  portion 
of  the  residuary  estate. 

By  the  will  of  Mary  Farrell,  the  Little  Sisters  of  the 
Poor  and  St.  Timothy's  Hospital,  Philadelphia,  receive 
$500  each,  St.  Vincent's  Home  for  Orphans,  St.  John's 
Orphan  Asylum,  and  St.  Joseph's  Home  for  Orphan  Boys, 
Philadelphia,  receive  $300  each. 

By  the  will  of  Dr.  James  G.  Wheeler,  of  Broughton,  III., 
the  James  Millikin  University.  Decatur,  will  receive  his 
entire  estate,  estimated  to  be  worth  between  $75,000  and 
$125,000. 

By  the  will  of  Augustus  Bachrach,  the  Jewish  Hos- 
pital of  Philadelphia  and  the  Jewish  F"oster  Home  and 
Orphan  Asylum  of  Philadelphia  receive  $1,000  each;  the 
United  Hebrew  Charities  of  Philadelphia  receives  $500, 
and  the  Jewish  Maternity  Association  of  Philadelphia 
receives  $250. 

By  the  will  of  S.  Emily  Ford,  the  Children's  Country 
Week  Association  of  Philadelphia  receives  $250. 

 ^  


MEDICAL  SOCIETY  OF  THE  STATE  OF  NEW 
YORK. 

lOjrd  Annual  Meeting,  Held  in  Albany,  January  25,  26, 
and  27,  igog. 

The  President,  Dr.  Arthur  G.  Root,  of  Albany,  in 
the  Chair. 

The  House  of  Delegates  met  on  the  evening  of 
Monday,  January  25th,  when  the  usual  reports  were 
received. 

Report  of  the  Secretary. — The  total  member- 
ship was  6,595  December  31,  1908,  against  6,323 
in  1907.  The  deaths  numbered  98,  and  the  net  in- 
crease for  1908  was  241  members. 

County  Bacteriological  Laboratories. — In  the 
report  of  the  Committee  on  Public  Health  it  was 
stated  that  the  inauguration  of  county  bacterio- 
logical laboratories,  which  was  first  advocated  by 
the  committee,  was  no  longer  legally  impossible,  and 
that  many  counties  had  taken  advantage  of  the  law 
and  had  established  well  equipped  lal)oratories.  It 
was  recommended  that,  in  counties  not  yet  so 
equipped,  this  subject  should  be  so  presented  to  the 
public  that  the  Board  of  Supervisors  should  feel 
that  they  were  executing  the  will  of  the  people  in 
voting  appropriations  for  the  establishment  and 
maintenance  of  a  bacteriological  laboratory. 

The  President's  Address :  The  Physician  and 
Law  Making  — .\t  the  opening  of  the  general  .ses- 
>i()n  on  Tuesday  morning,  the  president  said  that  he 
had  selected  for  his  subject  the  Relation  between 
the  Physician  and  Medical  Laws.  The  aim  of  the 
profession  in  this  regard  was  to  put  into  operation 
reforms  for  the  public  good  ;  measures  designed  to 
afTord  the  greatest  good  to  the  greatest  nimiber.  It 
was  only  right  that  health  laws  should  have  a 
prominent  place  in  the  laws  of  tlie  .State.  To  useful 
laws  relating  to  hygiene  and  the  prevention  of  dis- 
ease it  was  in  a  great  measure  due  that  the  longevity 
of  the  race  had  been  increased.    Sanitation  was  in 


fact  -vastly  more  important  than  the  protection  of 
property  rights.  '1  he  wisdom  of  referring  matters 
relating  to  this  to  the  medical  profession  by  the  law- 
makers was  apparent  from  the  good  results  of  such 
measures  as  the  pure  food  and  drugs  act,  the  com- 
pulsory vaccination  of  school  children,  and  the  pro- 
tection of  streams  used  for  water  supplies  from  pol- 
lution. Many  public  benefits  were  thus  conferred, 
and  the  laws  relating  to  the  prevention  of  the  spread 
of  infectious  diseases  had  robbed  these  alifections 
of  many  of  their  terrors.  In  New  York  the  ptiblic 
was  permanently  protected  by  the  system  of  uni- 
form examinations  for  candidates  for  the  degree  of 
M.  D.,  which  placed  all  upon  the  same  footing.  In 
speaking  of  the  subject  of  vivisection,  he  said  it  had 
conferred  benefits  upon  mankind  which  were  almost 
beyond  calculation,  and  that  the  physician  was  the 
only  logical  referendum  for  matters  like  this,  which 
affected  health  and  life.  Any  yielding  to  the  clamor 
of  the  antivivisectionists  could  only  result  in  a  long 
step  backward. 

The  Modern  Hippocrates. — Dr.  Abraham  J.\- 
coBi^  of  New  York,  made  an  address  with  this  title. 
He  gave  a  sketch  of  the  work  of  Hippocrates,  the 
conditions  existing  in  his  times,  and  the  literatttre 
relating  to  him,  and  showed  how  there  were  men 
at  the  present  time  who  w-ere  worthy  exponents  of 
his  principles  and  condtict.  He  went  on  to  say  that 
Hippocrates  was  a  philosopher  as  well  as  a  physi- 
cian. The  modern  Hippocrates  was  a  good  citizen, 
and  entered  into  public  life.  He  was  a  ptiblic  teach- 
er, not  only  of  science,  but  of  ethics.  There  was 
now  a  great  chance  for  the  sanitarian,  and  the 
speaker  quoted  an  aphorism  of  Hippocrates  :  "Where 
there  is  love  of  mankind  there  is  love  of  the  medi  'al 
art."  In  conclusion.  Dr.  Jacobi  showed  how'  when 
the  physician  lost  sight  of  high  aims  and  stooped  to 
questionable  practices  there  was  demoralization  both 
of  himself  and  of  the  public. 

The  Serum  Treatment  of  Cerebrospinal  Men- 
ingitis.— Dr.  L.  E^^^^ETT  IP^lt,  of  Ve^^■  York, 
having  briefly  described  the  serum  of  Flexner  and 
Jobling,  said  it  was  necessary  that  this  should  l)e 
brought  into  direct  contact  with  the  meningococci, 
and  that  the  earlier  it  was  applied  the  better  the  ef- 
fect. The  f^.uid  withdrawn  by  spinal  puncture 
should  first  be  examined  bacterinlogically.  but  if 
such  fluid  was  found  to  be  very  cloudy,  it  was  ad- 
visable to  make  the  injection  at  once,  without  wait- 
ing for  the  bacteriological  examination.  For  punc- 
turing and  injecting,  local  anaesthesia  was  often 
desirable,  and  in  some  cases  a  few  whiffs  of  chloro- 
form were  of  service.  The  entire  operation  should, 
of  course,  be  done  under  the  strictest  aseptic  pre- 
cautions. Considerable  experience  was  required  for 
the  best  technique.  In  regard  to  the  dose,  as  the 
serum  was  not  yet  standardized,  it  was  measured  hy 
cubic  centimetres,  not  by  units.  .\t  first  from  5  to 
10  c.c.  had  been  given,  but  at  present  it  was  the 
practice  to  give  at  least  30  c.c.  as  the  initial  dose. 
In  very  severe  cases  from  40  to  50  c.c.  were  re- 
(|uired.  It  had  been  found  to  be  the  best  plan  to 
give  a  dailv  dose  for  three  or  four  days,  and  in  the 
fulminating  type  of  the  disease  a  number  of  doses 
should  be  quicklv  repeated.  The  indicat'ons  f-^r 
repeating  the  injeclions  were  seen  in  the  symptoms 
and  the  state  of  tiie  cerebrospinal  tluid  extracted. 


January  30,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


239 


and  they  should  be  repeated  until  the  fluid  became 
quite  clear.  As  to  the  results  obtained,  Dr.  Flexner 
had  kindly  furnished  a  report  embracing  all  the 
cases  treated  up  to  January  i.  igoQ.  Total  number 
of  patients,  523;  recovered.  368;  died.  155:  mortal- 
ity. 29.6  per  cent. 

Results  according  to  time  of  injection : 

No.  of 

Day.  patients.       Died.  Mortality. 

First  to  Third   172  41  23.9  per  cent. 

Fourth  to  Seventh   196  53  27.4  per  cent. 

.After  Seventh   155  61  39.3  per  cent. 

The  only  cases  excluded  were  twenty  in  which 
the  patients  were  practically  moribund  when  the  in- 
jection was  made.  In  contrast  with  these  admirable 
results  Dr.  Holt  said  that  in  his  own  cases  in  chil- 
dren under  two  years,  treated  before  the  serum  came 
into  use,  the  mortality  had  been  no  less  than  90  per 
cent.  The  serum  was  of  no  value  in  cases  when 
the  meningitis  was  not  due  to  the  meningococcus  or 
in  cases  where  grave  permanent  lesions  had  already 
occurred  from  the  disease.  In  proper  cases  the 
serum  not  only  shortened  the  attack,  but  prevented 
distressing  sequelae. 

Scarlatina. — Dr.  H.  H.  Fairbair.v,  of  Brook- 
lyn, referred  to  the  difficulty  of  diagnosis  in  certain 
instances,  and  the  great  care  necessary  to  avoid 
making  a  mistake.  Scarlatiniform  erythema  had 
not  infrequently  been  mistaken  for  scarlet  fever.  In 
one  instance  a  well  known  New  York  obstetrician 
had  been  charged  with  carrying  scarlet  fever  to  a 
lying-in  patient,  and  suit  for  damages  brought 
against  him.  The  case  was  never  brought  to  trial, 
however,  the  plaintiff's  side  concluding  to  withdraw, 
as  the  burden  of  proof  lay  with  them  and  they 
would  undoubtedly  have  lost.  There  were  many 
atypical  cases  of  scarlatina.  In  the  very  mild  cases 
great  caution  was  necessary  lest  an  incorrect  diag- 
nosis be  made,  and  mild  cases  might  be  followed  by 
very  grave  sequelae,  in  addition  to  spreading  the  in- 
fection among  other  individuals.  In  the  treatment, 
the  care  of  the  skin  was  most  important.  The  pa- 
tient should  be  washed  with  formaldehyde  soap,  and 
plain  petrolatum  which  had  been  sterilized  by  means 
of  heat  was  all  that  was  required  as  an  unguent. 
Antistreptococcic  serum  was  of  service  in  cases  with 
toxic  complications,  but  had  no  effect  on  the  un- 
known agent  which  caused  the  disease.  It  seemed 
to  the  speaker  that  the  epithelial  scales  might  be  able 
to  furnish  us  with  a  true  remedy  against  scarlatina. 
The  blood  of  convalescents  had  been  tried  for  the 
preparation  of  a  serum,  but  he  thought  it  would  be 
better  to  use  for  this  purpose  the  blood  of  person.' 
who  had  long  recovered  from  the  disease. 

Physical  Training  of  Children.— Dr.  F.  W. 
Sears,  of  Binghamton,  said  that  every  child  over 
twelve  years  of  age,  he  thought,  should  have  the 
benefit  of  systematic  physical  training.  Athletics 
were  all  right,  as  far  as  they  went,  but  they  did  not 
reach  all.  Military  training  was  by  far  the  best  for 
boys,  and  he  thought  it  would  be  advisable,  both  for 
the  physical  culture  involved  and  for  other  reasons, 
that  all  young  lads  should  be  required  by  law  to 
have  such  training  for  a  period  of  four  years.  The 
teachers  for  this  could  be  supplied  by  the  Federal 
and  State  governments.  That  a  thorough  physical 
training  did  not  interfere  with  the  attainment  of  a 
high  class  of  scholarship  was  amply  attested  by  the 
United  States  Military  and  Xaval  Academies.  A 


military  training  also  included  the  principles  of  sani- 
tation and  preventive  medicine. 

Glandular  (Pfeiffer's)  Fever. — Dr.  \V.  B.  Gar- 
lock,  of  Little  Falls,  said  that  this  disease,  first 
described  in  1889,  was  but  little  mentioned  in  text- 
books or  current  literature.  The  only  good  descrip- 
tion of  it  was  by  Boggs,  in  Osier's  System  of  Medi- 
cine. It  was  a  sporadic  or  an  epidemic  infectious 
disea.se  usually  affecting  children  between  the  ages 
of  two  and  ten  years,  but  might  occur  in  adults.  In 
from  six  to  ten  days  after  exposure  there  developed 
a  slight  redness  of  the  pharyngeal  and  faucial  mu- 
cous membrane,  accompanied  by  a  febrile  tempera- 
ture ranging  from  100°  to  105°  F.,  and  followed  in 
the  course  of  a  day  or  two  by  swelling  of  the  l\-m- 
phatic  glands,  especially  of  the  neck.  Usually  there 
was  no  general  glandular  implication,  but  the  other 
glands  most  apt  to  be  aft'ected  were  the  mediastinal, 
inguinal,  and  a.xillary.  Occasionally  the  spleen  be- 
came enlarged.  The  course  of  the  disease  was  de- 
cidedly irregular,  and  the  febrile  movement  lasted 
for  from  two  to  ten  days,  with  the  general  disturb- 
ances incident  to  such  a  condition.  When  there  was 
tenderness  on  deep  pressure  of  the  abdomen,  it 
might  be  inferred  that  the  abdominal  glands  were 
affected.  Clemens  had  reported  an  epidemic  of  six- 
teen cases  in  which  there  was  no  enlargement  of 
the  spleen.  The  cause  of  the  disease  was  unknown, 
but  would  seem  to  be  either  a  particular  germ  or  a 
group  of  related  organisms.  By  some  this  disease 
had  been  regarded  as  a  special  form  of  influenza. 
The  prognosis  was  good.  Dr.  Garlock  then  de- 
scribed a  case  recently  treated  by  him  in  a  child  of 
four  years,  in  which  the  findings  from  laboratory 
tests  were  mostly  negative. 

Dr.  L.  W.  Bacox,  of  Xew  Haven,  Conn.,  de- 
scribed a  case  of  acute  adenitis,  in  a  young  man, 
which  suggested  a  very  acute  form  of  Hodgkin's 
disease.  The  cervical,  axillary,  and  inguinal  glands 
were  affected,  and  after  a  few  days  there  developed 
acute  abdominal  symptoms  indicative  of  obstruction. 
Laparotomy  was  performed  and  a  band  was  found 
near  some  old  appendicular  adhesions.  The  patient 
died  from  peritonitis.  This  was  apparently  a  case 
of  to.xic  adenitis. 

Improvement  in  the  Technique  of  the  Extrac- 
tion of  Cataract. — Dr.  Luciex  Howe,  of  Buffalo, 
first  called  attention  to  the  fixation  of  the  globe.  One 
great  trouble  had  been  that  the  conjunctiva  was 
very  apt  to  tear,  and  this  was  the  case  also  when 
the  double  forceps  devised  long  ago  was  employed. 
To  obviate  this  he  had  devised  a  special  form  of 
forceps  which  had  the  advantage  of  securing  two 
points  of  fixation,  as  it  grasped  the  internal  rectus 
on  one  side  and  the  external  rectus  on  the  other. 
A  second  modification  in  the  technique  which  he 
described  was  a  forceps  for  extracting  the  lens  in 
cases  in  which  the  lens  presented  properly  in  the 
wound,  but  could  not  be  easily  expelled.  Both 
these  forms  of  forceps,  he  said,  had  been  employed 
in  a  sufficient  number  of  cases  to  prove  their  useful- 
ness. 

Meller's  Operation  for  the  Removal  of  the  Tear 
Sac. — Dr.  .\.  E.  D.wis,  of  New  York,  described 
the  operation  in  detail  and  said  that  one  of  its  ad- 
vantages was  that  it  left  practically  no  scar.  An- 
other was  that  it  could  be  done  under  local  anaes- 
thesia.    For  this  purpose  solutions  of  cocaine  and 


PROCEEDINGS  OF  SOCIETIES. 


Meoical  Jovrxal. 


adrenalin  were  used,  and  the  injections  were  made 
at  three  (hfFerent  points.  Prevention  of  haemor- 
rha<i^c  was  also  secured.  Dr.  Davis  had  performed 
this  operation  in  five  cases,  and  they  all  healed  by 
first  intention. 

Ophthalmia  Neonatorum. — Dr.  Juliex  .\.  Geh- 
RUNG,  of  New  York,  described  his  modification  of 
Crede's  method  when  the  head  was  born,  and  ad- 
vised that  later,  when  the  child  had  been  cleansed 
and  dressed,  and  the  nurse's  hands  had  been  disin- 
fected, the  infant's  eyes  should  be  cleansed  again, 
and  a  drop  of  one  per  cent,  silver  nitrate  solution  in- 
stilled, to  be  followed  by  salt  solution  or  adrenalin 
chloride,  i  in  1,500.  The  latter  acted  as  an  anaes- 
thetic and  neutralized  the  action  of  silver  nitrate. 
Careful  instructions  should  be  given  to  all  mid- 
wives,  and  the  prophylactic  should  be  distributed 
free.  It  was  the  duty  of  all  physicians  to  report 
and  to  tabulate  cases.  Moreover,  the  use  of  a 
prophylactic  which  had  the  sanction  of  the  majority 
should  be  required  by  law.  Any  physician  who  em- 
ployed a  different  method  must  be  able  to  justify  its 
use  to  the  authorities  of  the  county  medical  society. 
The  State  had  a  perfect  right  to  pass  laws  protect- 
ing the  public,  and  in  this  instance  there  were  strong 
economic  as  well  as  humanitarian  reasons  for  legal 
enactment.  New  York  should  set  the  example  in 
this  matter,  and  then  other  States  would  be  sure  to 
follow  in  its  lead.  Midwives  should  be  licensed  and 
it  should  be  made  a  misdemeanor  not  to  have  a 
license.  They  should  also  be  required  to  subject 
their  obstetric  bags  to  examination  once  a  month. 
Dr.  Gehrung  concluded  by  offering  a  resolution  to 
the  efi^ect  that,  in  the  opinion  of  the  Medical  So- 
ciety of  the  State  of  New  York,  the  omission  on  the 
part  of  any  accoucheur  to  use  a  proper  method  of 
prophylaxis  should  render  him  open  to  the  charge 
of  culpable  neglect  and  liable  to  prosecution. 

Dr.  H.  J.  BoLDT,  of  New  York,  offered  some  reso- 
lutions of  similar  character,  but  somewhat  more 
comprehensive  scope,  and  on  motion  of  Dr.  \".  C. 
Pedersen.  both  sets  of  resolutions  were  referred  to 
the  House  of  Delegates  with  the  endorsement  of  the 
meeting.  In  seconding  the  motion  Dr.  Curtis  said 
that  every  year  some  special  question  came  up 
prominently,  and  this  year  it  was  the  prevention  of 
ophthalmia  neonatorum.  This  was  largely  due  to 
the  action  of  the  American  Medical  Association  on 
the  subject,  and  also  to  advanced  thought  through- 
out the  country.  He  thought  each  birth  return 
should  state  whether  a  prophylactic  had  been  used, 
and  that  by  a  return  card  every  physician  in  the 
State  should  pledge  himself  to  use  such  measures 
as  seemed  proper  in  the  light  of  our  present  knowl- 
edge to  prevent  this  di.scase. 

Dr.  Howe  said  that  netirly  twenty  years  ago  this 
subject  had  been  agitated  before  the  society,  and 
now  it  had  come  up  again.  He  thought  that  to 
make  true  progress  we  should  go  slowly  in  the  mat- 
ter, taking  each  step  carefully.  Through  the  in- 
fluence of  this  society  the  State  already  had  a  law 
wiiich  required  midwives  to  report  to  some  physi- 
cian within  twenty-four  hours  any  case  of  redness 
in  the  eyes  of  an  infant  which  developed  within  ten 
days  after  birth.  This  seemed  a  simple  measure, 
and  yet  it  had  accomplished  an  immense  aiuount  of 
good.    A  few  i)rosecutions  had  taught  the  midwives 


their  lesson,  and  the  statistics  showed  that  there 
were  now  nearly  one  third  fewer  cases  than  twenty 
years  ago.  It  might  be  advisable,  however,  to  pass 
a  law  which  required  the  accoucheur  to  use  some 
form  of  prophylaxis  which  had  been  proved  as  ef- 
ficient as  the  two  per  cent,  silver  solution  of 
Crede. 

Intramuscular  Injections  in  the  Treatment  of 
Syphilis.  —  Dr.  \'ict(jk  C.  Pedersex.  of  New- 
York,  having  referred  to  a  previous  paper  by  him- 
self, spoke  of  the  general  advantages  of  the  injec- 
tion method.  By  dividing  the  glutial  region  into 
quadrants,  and  making  the  successive  injections  two 
inches  apart,  thirteen  weeks  would  elapse  before  the 
same  point  was  reached  again.  A  twenty  per  cent, 
solution  of  salicylate  of  mercury  was  now  employed 
by  him  for  injecting. 

Some  of  the  Problems  relating  to  Prostatecto- 
my.—  Dr.  L.  BoETO.x  B.\x(;s.  of  New  York, 
thought  that  much  careful  discrimination  should  be 
exercised  as  to  the  patients  to  be  operated  upon, 
and  illustrative  cases  were  cited.  Urinary  fistulae 
after  the  operation  were  often  a  source  of  much 
trouble.  If  they  persisted  the  injection  of  tincture 
of  iodine  might  be  resorted  to.  Postoperative  de- 
velopment of  stone  in  the  bladder  might  possibly 
occur,  and  one  case  of  this  kind  had  been  met  with 
in  his  experience.  He  also  referred  to  postoperative 
dysuria  and  retention  of  urine. 

Some  Further  Observations  on  Prostatectomy, 
Based  on  One  Hundred  Cases. —  Dr.  J.  Bextlev 
Squier,  of  New  York,  said  that,  while  the  perineal 
operation  was  to  be  preferred  on  the  score  of  safety, 
its  mortality  heretofore  having  been  only  about  one 
half  of  that  of  the  suprapubic,  the  later  results  from 
the  latter  had  not  been  so  unfavorable.  Other 
things  being  equal,  he  would  prefer  the  perineal 
route.  Both  operations,  however,  had  their  advan- 
tages in  certain  conditions,  and  in  any  given  case 
we  must  be  guided  by  the  special  circumstances  at- 
tending it.  The  most  prominent  causes  of  death 
were  uraemia,  sepsis,  and  shock.  It  was  often  a 
question  whether  prostatectomy  was  not  to  be  pre- 
ferred to  catheter  life  with  its  resulting  evils.  If 
the  operation  had  to  be  performed  eventually,  the 
prospect  of  recovery  would  be  much  reduced  by  the 
conditions  then  present. 

Untoward  Results  of  Diphtheria  Antitoxine. — 
Dr.  H.  F.  Gillette,  of  Cuba,  said  that  an  effort  was 
made  to  account  for  death  or  collapse  following  the 
use  of  horse  serum.  A  series  of  experiments  on 
guinea  pigs  was  described.  Reports  of  twenty-seven 
cases  were  given,  in  which  twenty  gave  a  history  of 
asthma  or  some  form  of  respiratory  distress.  It  was 
advisable,  therefore,  to  find  out,  before  using  the 
antitoxine,  whether  the  patient  had  been  the  subject 
of  asthma,  hay  fever,  chronic  bronchitis,  or  other  re- 
-spiratory  affection,  and  to  warn  him  or  the  i)arents. 
if  a  child,  of  the  possibility  of  danger  from  its  use. 

Epilepsy. — Dr.  W.  B.  Kidder,  of  Oswego,  ex- 
pressed the  opinion  that  epilepsy  was  due  as  a  rule 
to  some  biochemical  defect  in  the  processes  of  the 
body.  Such  defect  might  not  originally  be  sufficient 
to  cause  epileptic  symptoms,  but  various  forms  of 
exciting  cause  luight  result  in  their  appearance.  He 
spoke  of  the  importance  in  this  disease  of  a  careful- 
Iv  regulated  diet,  hygienic  surroundings,  and  phys- 


January  30,  1909.  | 


PROCEEDINGS  OF  SOCIETIES. 


241 


ical  and  mental  training,  stating  that  the  treatment 
must  be  comprehensive. 

Short  Duration  Typhoid  Fever. — Dr.  Warrex 
Coleman,  of  New  York,  said  that  this  form  of  ty- 
phoid included  those  known  as  ambulatory  and  light 
cases.  The  name  applied  only  to  cases  lasting  less 
than  three  weeks.  Until  1891  he  had  regarded  cases 
of  this  kind  as  instances  of  the  simple  continued  fe- 
ver of  the  books,  but  he  then  began  to  find  that  they 
often  showed  the  presence  of  the  typhoid  bacillus. 
He  gave  a  review  of  the  literature,  showing  the 
state  of  confusion  existing  concerning  the  milder 
forms  of  typhoid  fever.  In  229  cases  at  Bellevue 
Hospital,  during  the  past  five  years,  five  per  cent., 
had  lasted  only  two  weeks  or  less,  and  the  charac- 
teristic bacillus  was  recovered  from  the  blood  in 
about  half  of  these  short  duration  cases.  There  was 
no  clinical  means  by  which  a  diagnosis  could  be  pos- 
itively made,  and  he  relied  on  both  macroscopical 
and  microscopical  tests.  In  the  recovery  of  the  ba- 
cillus both  the  serum  reaction  and  blood  culture  were 
employed. 

Voluntary  Patients  in  State  Hospitals. — Dr. 

Albert  Warren  Ferris,  president  of  the  State 
Commission  in  Lunacy,  said  that  during  the  year 
ending  October  i,  igo8,  there  were  6,200  new  ad- 
missions into  the  State  hospitals  for  the  insane,  an 
increase  of  1,247,  against  750  the  previous  year. 
There  was  but  one  economic  as  well  as  scientific  so- 
lution of  the  problem,  and  that  consisted  of  prophy- 
laxis and  early  treatment.  In  order  to  limit  the  in- 
creasing numbers  of  the  insane,  the  incipient  case, 
the  border  line  case,  must  be  reached  and  prevented 
from  developing  into  a  profound  psychosis.  With 
this  end  in  view  he  had  last  year  secured  legislation 
permitting  the  State  hospitals  to  invite  application 
for  admission  from  patients  who  were  sensible  of 
wavering  mentality,  while  comparative  reason,  will, 
and  judgment  still  remained  in  control.  Heretofore 
the  insane  patient  had  been  treated  in  a  measure  as 
a  criminal,  and  it  was  a  great  advance  to  shake  off 
the  shackles  of  court  procedure. 

Dr.  R.  H.  HuTCHiNGS,  of  Ogdensburg,  thought 
this  new  law  would  mark  an  epoch  in  the  history  of 
the  State  hospitals,  and  that  these  institutions  would 
now  become  the  poor  man's  sanatoria. 

Dr.  Ely  thought  there  were  very  few  who  would 
voluntarily  enter  the  hospitals  for  the  insane,  and 
emphasized  the  desirability  of  having  a  psychiatric 
ward  in  every  large  hospital. 

Dr.  E.  p.  Fisher  agreed  with  Dr.  Ely.  At  the 
same  time  he  was  very  much  in  favor  of  the  early 
treatment  of  incipient  cases,  and  he  thought  that  in 
the  larger  cities  there  should  be  special  psychiatric 
hospitals,  which  patients  could  enter  without  the 
stigma  attaching  to  institutions  for  the  insane. 

The  First  Interview  with  the  Patient. — Dr. 
William  S.  Ely,  of  Rochester,  said  that  the  first 
examination  was  often  inadequate,  leading  to  er- 
roneous diagnosis.  He  considered  four  phases  of 
the  subject:  i.  The  importance  of  searching  for 
causes  of  numerous  disturbances  which  often  re- 
ceived only  symptomatic  treatment.  Skilled  ob- 
servatioii  was  required,  and  the  physician  must  act 
as  a  detective  to  discover  the  points  in  which  the 
patient  had  fallen  short  in  the  requirements  of 
health.     2,  A  correct  estimate  of  nutritive  changes 


must  be  made.  Macroscopical  conditions  were  as 
important  as  the  microscopical,  and  scales  of  as 
much  service  as  the  microscope.  3,  The  significance 
of  heredity.  4,  The  psychological  aspects  of  many 
disorders  were  largely  neglected  in  textbooks,  in  the 
colleges,  and  among  the  profession  generally.  This 
neglect  accounted  for  Christian  Science  and  like 
cults,  and  reflected  vmfavorably  upon  the  medical 
profession. 

X  Ray  Treatment  of  Leuchasmia. —  Dr.  W.  J. 

Schuyler,  of  Utica,  read  a  paper  mainly  devoted  to 
the  history  of  a  successful  case  of  myelogenous 
leuchsemia,  in  which  the  treatment  was  applied  over 
the  region  of  the  spleen,  over  the  long  bones  from 
the  pelvis  to  the  knee,  and  over  the  long  bones  from 
the  knee  to  the  ankle,  after  the  manner  recom- 
mended of  Stengel  and  Pancoast,  of  Philadelphia. 
These  observers  had  reported  several  cases  of  ap- 
parent cure,  though,  as  in  his  own  case,  the  time 
was  as  yet  too  short  to  pronounce  positively  upon 
them.  He  agreed  with  them  that  the  disease  was 
primarilv  one  of  the  bone  marrow  and  that  the 
splenic  enlargement  was  a  secondary  manifestation. 

A  Brief  Review  of  the  Application  of  Rontgen 
Rays  in  Diagnosis. — Dr.  E.  \\  .  Caldwell,  of 
Xew  York,  read  a  paper  illustrated  with  lantern 
slides  showing  the  localization  of  foreign  bodies, 
fractures  and  dislocations,  bone  diseases,  urinary 
calculi,  pulmonary  tuberculosis,  etc.  The  paper  con- 
cluded with  a  reference  to  the  dangers  of  the  x  ray 
and  the  methods  of  avoiding  them  and  with  sugges- 
tions for  hospital  x  ray  laboratories. 

Infections  of  the  Middle  Ear  of  Interest  to  the 
General  Practitioner. — The  ietiology  and  pathol- 
ogy were  treated  of  by  Dr.  J.  E.  Sheppard,  of 
Brooklyn ;  nonoperative  methods  of  treatment  by 
Dr.  Edward  P.  Fowler,  of  New  York ;  the  indica- 
tions for  and  results  of  operative  treatment,  includ- 
ing the  simple  and  radical  mastoid  operations,  by 
Dr.  Wendell  C.  Phillips,  of  New  York ;  and  the 
treatment  of  meningeal  sinus,  and  labyrinthine  com- 
plications by  Dr.  S.  MacCuen  Smith,  of  Phila- 
delphia. 

Rabies  and  its  Prevention. — Dr.  Herp.rrt  D. 
Pease,  of  Albany,  discussed  the  problems  relating 
to  the  aetiology,  pathology,  epidermiology,  and  diag- 
nosis of  rabies  in  animals  and  the  transmission  and 
conditions  of  infection  in  man.  He  then  took  up 
the  preparation,  distribution,  and  administration  of 
the  Pasteur  treatment  vaccine  for  the  prevention  of 
the  disease. 

The  Nature  of  Foot  and  Mouth  Disease. — Dr. 

Veranus  a.  Moore,  of  Ithaca,  said  that  fresh,  pure 
lymph,  injected  into  the  veins  of  susceptible  cattle 
in  quantities  as  small  as  0.005  would  produce 
this  infectious  disease.  Immunity  established  by  one 
attack  of  the  affection  was  of  short  duration.  In 
speaking  of  the  symptomatology  he  said  that  vesi- 
cles appeared  on  and  about  the  mouth,  udder,  and 
feet.  The  membrane  covering  them  was  thin  and 
it  soon  gave  way,  leaving  the  epithelial  layer  at- 
tached at  the  borders.  In  the  human  subject  the 
localization  of  the  lesions  appeared  to  correspond 
with  those  in  cattle. 

Election  of  Officers. — The  following  officers 
were  elected  for  the  ensuing  year :  President,  Dr. 
Charles  G.  .Stockton,  of  P)uffalo :  vice-presidents. 


242 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


Dr.  D.  C.  Moriarta,  of  Saratoga,  Dr.  J.  A.  Glass, 
of  Utica.  and  Dr.  J.  B.  Harvie,  of  Troy;  secretary, 
Dr.  Wisner  R.  Townsend,  of  New  York;  treasurer. 
Dr.  Alexander  Lambert,  of  New  York.  Chairmen 
■of  Committees — on  Legislation,  Dr.  Frank  Van 
Fleet,  of  New  York ;  on  Scientific  Work,  Dr.  L.  H. 
A'euman,  of  Albany ;  on  Public  Health,  Dr.  J.  F. 
FlefFron,  of  Syracuse;  on  Arrangements,  Dr.  W.  J. 
Xellis,  of  Albany. 

Vivisection  and  Expert  Witnesses. —  In  the 
House  of  Delegates  two  sets  of  resolutions  were 
adopted  respectively  against  legislation  designed  to 
interfere  with  vivisection  and  looking  to  the  provi- 
sion of  a  limited  and  uniform  system  for  expert 
testimony  in  civil  and  criminal  court  cases.  The 
-committee  appointed  last  year  to  act  jointly  with  a 
.similar  committee  representing  the  State  Bar  Asso- 
ciation reported  that  it  was  the  sense  of  the  joint 
committee  that  the  legislature  be  petitioned  to  pass 
a  bill  authorizing  the  Appellate  Divisions  of  the 
Supreme  Court  to  appoint  not  more  than  sixty  phy- 
.sicians  from  their  respective  judicial  departments, 
who  should  be  qualified  to  act  as  medical  experts, 
and  that  the  expense  of  their  services  should  be 
l3orne  Ijy  the  county  in  which  the  action  was  tried. 

The  Problem  of  Efficient  Nursing  of  Persons 
of  Moderate  Income. — Dr.  \\  .  ().  Still.max,  of 
Albany,  dealt  with  this  subject  from  the  standpoint 
■of  a  practical  experiment  in  educating  domestic 
nurses  for  their  duties  by  a  six  months'  course  of 
instruction.  About  a  hundred  lectures,  by  eighteen 
or  twenty  physicians  and  trained  nurses,  supplied 
the  didactic  part  of  the  course,  and  diet  kitchen  in- 
struction in  preparing  food  was  given  by  competent 
teachers,  while  practical  nursing  under  the  super- 
vision of  the  head  nurses  was  taught  toward  the  end 
of  the  course.  The  fee  for  the  whole  was  $25,  and 
a  satisfactory  examination  was  required. 

Report  of  a  Case  of  Scleroderma. — Dr.  Sam- 
ui-:l  B.  Ward  and  Dr.  Era.stu.s  Corning,  of  Al- 
bany, presented  the  patient,  a  man  twenty-six  vears 
■old,  married,  a  clerk.  He  was  first  seen  on  July  23, 
1908.  The  onset  occurred  two  months  previous,  tlie 
first  symptom  being  stiffness  of  the  hands  and  feet. 
This  had  since  involved  the  arms  and  legs  also. 
The  liver  was  now  enlarged,  tho*ugh  not  at  first. 
The  patient  had  lost  eleven  pounds  since  he  was 
first  .seen.  The  blood  examination  revealed  eosino- 
philia,  erythrocytosis,  and  leucocytosis.  The  disease 
was  believed  to  be  due  to  some  toxic  agent  at  pres- 
ent unknown.  The  patient  had  been  treated  at  first 
with  gold  and  arsenic  chloride,  and  later  witli 
iodides,  but  without  efTect. 

Dr.  RuGCLKS,  of  Rochester,  cited  a  case  treated 
by  him  some  time  ago,  in  which  the  skin  of  the  al)- 
domcn  and  lower  extremities  was  principally  afTect- 
cd.  The  condition  was  very  strongly  marked,  but 
under  x  ray  treatment,  extending  over  a  year  and 
more,  the  patient  had  entirely  recovered  and  still  re- 
mained well.  g 

Relative  Aortic  Incompetency  of  Muscular  Ori- 
gin.—  Dr.  J.\MK.s  M.  Anders,  cf  I'hi]adcli)liia,  said 
there  were  three  well  defined  divisions  of  this  chss 
•of  ca.ses :  i,  Those  of  muscular  and  nervous  origin, 
independently  of  valvulitis  or  advanced  changes  in 
the  acirta.    2,  Those  secondary  to  chrf)nic  valvulitis 


afTecting  the  mitral  segments,  with  failure  of  the 
left  ventricle.  3,  Those  occurring  in  the  course  of 
or  following  acute  infectious  diseases  due  to  the  ac- 
tion of  specific  toxines  upon  the  myocardium.  Hav- 
ing cited  some  illustrative  cases,  he  said  the  princi- 
pal object  of  the  paper  was  to  show  that  functional 
incompetency  of  the  aortic  segments  due  to  dilata- 
tion of  the  left  ventricle  was  not  sufficiently  recog- 
nized. 

The  Relation  of  Ocular  and  Cardiovascular 
Diseases. — Dr.  Arthur  J.  Bedell,  of  Albany,  de- 
scribed the  eye  signs  and  spoke  of  their  significance 
to  the  general  practitioner,  showing  their  relative 
frequency,  the  stage  of  disease  at  which  they  made 
their  appearance,  and  their  diagnostic  and  prognos- 
tic value.  The  paper  concluded  with  reports  of 
cases  and  control  examinations. 

Lessons  from  Physiology  and  the  Treatment 
of  Cardiovascular  Diseases. — Dr.  W.  H.  Gibson, 
of  Utica,  said  that  there  was  an  apparent  increase 
in  cardiovascular  disease,  as  noted  in  general  prac- 
tice, and  an  actual  increase  in  the  last  decade,  as 
shown  by  a  study  of  vital  statistics.  He  spoke  of 
the  uselessness  of  therapeutic  measures  after  de- 
generative changes  had  ensued,  and  urged  the  value 
of  preventive  measures  suggested  by  a  study  of  the 
cardiovascular  mechanism. 

Baths  and  Exercises  in  the  Treatment  of  Ab- 
normal Tone  of  the  Heart  and  Bloodvessels. — ■ 
Dr.  Louts  F.  Bishop,  of  New  York,  having  spoken 
of  the  nature  and  diagnosis  of  abnormal  tension  in 
the  vessels  and  of  the  tone  of  the  heart  muscle  and 
its  estimation,  said  that  hypertonicity  of  the  blood- 
vessels and  cardiac  dilatation  were  found  in  a  large 
number  of  cases  as  the  result  of  valvular  disease 
and  of  impairment  of  the  heart  muscle  by  toxic  sub- 
stances and  as  a  sequence  of  hypertrophy  of  the 
heart  and  bloodvessels.  He  gave  the  ordinary  course 
of  a  valvular  case,  the  course  of  a  toxic  case,  such 
as  those  with  indicanuria,  and  the  course  of  a  case 
of  nervous  origin.  He  then  described  the  Xauheim- 
Schott  treatment  and  explained  its  philosophy,  and 
spoke  of  the  application  of  its  principles  in  Amer- 
ica, concluding  with  a  report  of  cases  observed  here 
and  abroad.  Last  year  Dr.  Bishop  had  presented  a 
sphygmomanometer  he  had  devised,  in  which  water 
was  employed.  As  the  height  at  which  the  water 
bag  had  to  be  placed  was  inconvenient,  he  had  now 
substituted  cadmium  borotungstate  for  water. 

Acute  Anaemia. — Dr.  George  W.  Crile,  of 
Cleveland,  Ohio,  remarked  that  tissues  and  organs 
endured  ansemia  inversely  to  their  philOgeny ;  in 
other  words,  the  higher  the  function  the  greater  the 
suscei)tibility  to  ana?mia.  Thus,  the  skin  and  frame- 
work of  the  body  endured  it  far  better  than  the  or- 
gans they  supported.  In  acute  anctmia  the  highest 
brain  centres  were  the  first  of  all  to  lose  their  func- 
tion, to  become  practically  dead.  Hence  the  impor- 
tance of  the  most  energetic  measures  in  cases  of 
haemorrhage  in  which  clotting  did  not  take  place 
soon. 

The  Therapeutic  Value  of  Blood  Transfusion. 

— Dr.  W.  F.  Camit.ell.  of  Brooklyn,  having  given 
an  historical  resume  of  the  subject,  described 
Crile's  method,  and  gave  some  of  the  indications 
for  direct  transfusion.    He  related  his  personal  ob- 


January  30,  1909.J 


PROCEEDINGS  OF  SOCIETIES. 


243 


scrvations  and  experiments,  and  expressed  the  opin- 
ion that  no  other  fluid  was  capable  of  taking  the 
place  of  human  blood.  Objections  were  haemolysis 
and  possible  thrombosis,  but  it  was  to  be  hoped  that 
these  might  in  time  be  overcome. 

Dr.  Algerxon  T.  Bristow,  of  Brooklyn,  took  the 
same  view  of  the  superiority  of  blood,  and  related 
an  urgent  case  in  which  blood  transfusion  had  suc- 
ceeded after  a  large  saline  infusion  had  failed. 

The  Exercise  of  Descending  in  the  Treat- 
ment of  Disease. — Dr.  Heixricii  Stp:rx,  of  Xew 
York,  described  this  as  an  auxiliary  remedial  meas- 
ure consisting  in  the  application  of  the  definite  and 
graded  exercise  of  descending  hills  or  stairways. 
He  explained  the  exercises  more  particularly  and 
their  physiological  action,  and  mentioned  the  classes 
of  cases  in  which  he  had  found  them  of  service. 
They  were  principally  applicable  in  noninflamma- 
tory abdominal  disturbances  and  metabolic  disor- 
ders, and  also  in  certain  forms  of  cardiac  disease. 

Report  of  a  Case  of  Thorax  Transfixion. — Dr. 
E.  ]M.  HvLAXD,  of  Utica,  reported  a  case  in  which 
a  piece  of  board  edging  twenty-three  inches  long 
was  forced  through  the  chest,  lungs,  and  arm.  and 
recovery  took  place. 

Some  Congenital  Abnormities  of  Cervical  and 
Spinal  Origin. — Dr.  Xaihax  Jacop.sox,  of  Syra- 
cuse, considered  the  following  conditions:  i.  Bron- 
chial cysts  in  unusual  positions.  2.  Aberrant  thy- 
reoid glands.  3.  Spina  bifida,  presenting  urgent 
manifestations  at  birth.  In  a  case  of  the  last  named 
character  in  which  Dr.  Jacobson  operated  with  suc- 
cess gangrene  had  set  in  within  twenty-four  hours. 

Some  Points  in  the  Diagnosis  and  Operative 
Treatment  of  Fractures. — Dr.  Lewis  A.  Sti.msox, 
of  Xew  York,  said  that  in  the  diagnosis  systematic 
search  for  localized  pain  by  various  means  was  a 
ready  and  accurate  measure  in  obscure  cases.  In 
simple  fractures  the  exact  adjustment  which  an 
operation  made  possible  was  comparatively  unim- 
portant and  was  habitually  not  maintained.  The 
metallic  suture  was  inadequate  to  maintain  apposi- 
tion and  might  be  a  cause  of  delay  or  even  of  failure 
of  the  bone  to  unite.  The  manipulations  necessary 
to  place  a  suture  might  delay  union  by  causing 
additional  injury  to  the  periosteum,  and  suppura- 
tion was  much  more  frequent  after  these  operations 
than  in  other  clean  cases.  Moreover,  the  injur}-  done 
to  the  muscles  in  the  course  of  such  an  operation  and 
the  subsequent  implication  of  the  muscles  in  the 
callus  often  restricted  the  mobility  of  the  neighbor- 
ing joint.  Open  operations  should  be  confined  to 
the  few  cases  in  which  their  need  was  clearly  evi- 
dent. 

Fractures  of  the  Neck  of  the  Femur. — Dr. 

RovAL  Whitmax,  of  Xew  York,  spoke  particularly 
of  the  advantages  of  abduction  in  the  treatment  of 
complete  fracture,  after  the  shortening  had  been  en- 
tirely overcome  by  traction.  It  made  tension  on  the 
capsule  and  thus  aligned  displaced  fragments ;  it 
directed  the  surface  of  the  outer  fragment  toward 
that  of  the  inner ;  it  relaxed  the  muscles  whose  con- 
traction caused  displacement :  it  apposed  the  tro- 
chanter to  the  side  of  the  pelvis,  and  thus  checked 
the  tendency  toward  upward  displacement ;  and  in 
the  treatment  of  impacted  fracture  it  provided  a 
leverage  by  which  deformity  might  be  overcome 
Avithout  violence  or  danger  to  the  patient. 


The  Treatment  of  Compound  Fractures. — Dr. 

Martix  B.  Tixker,  of  Ithaca,  said  that  the  first 
essential  was  the  successful  management  of  the  lace- 
rated and  contused  wound.  The  usual  methods  of 
treatment  were  unsatisfactory,  and  during  scrubbing 
infectious  material  was  often  scrubbed  into  the 
wound.  He  recommended  packing  the  wound  with 
oiled  tampons  while  the  surrounding  skin  was  being 
scrubbed,  and  later  swabbing  with  some  efficient 
disinfectant,  followed  by  excision  of  damaged  tissue 
(except  in  cases  with  complete  crushing)  and  clos- 
ure as  an  incised  wound.  An  immunizing  dose  of 
tetanus  antitoxine  should  be  given  in  doubtful  cases. 
He  also  advised  bloodvessel  anastomosis,  bone 
grafting  and  plantation,  skin  grafting."  and  nerve 
and  tendon  .suture  in  a  w-ider  range  of  cases  than 
was  now  usual. 

Volkmann's  Ischaemic  Paralysis  and  Contrac- 
tures.— Dr.  Regixald  H.  Savre,  of  Xew  York, 
said  that  this  affection  was  the  result  of  undue  pres- 
sure applied  to  an  extremity,  usually  in  the  treat- 
ment of  fracture.  Muscle  inflammation  was  caused, 
and  this  was  followed  by  fibroid  degeneration,  with 
marked  contraction.  Efforts  to  restore  vitality  by 
means  of  intermittent  massage  and  electricitv  had 
almost  invariably  proved  useless,  and  operative  pro- 
cedures had  therefore  been  adopted.  The  case  Dr. 
Sayre  reported  in  the  paper  brought  the  cases  of 
X'olkmann's  paralysis  on  record  up  to  sixty.  In  i( 
he  had  employed  the  method  of  gradual  straighten- 
ing recently  proposed  by  Robert  Jones,  of  Liver- 
pool, and  the  result  had  proved  so  satisfactory  that 
it  had  been  unnecessary  to  resort  to  a  cutting  op- 
eration. 

Remote  Results  Following  Excision  of  the 
Shoulder  Joint  for  Trauma  and  Disease. — Dr. 

Charles  L.  Scudder,  of  Boston,  having  referred  to 
the  conditions  for  which  such  excision  w^as  to  be 
made,  spoke  of  the  great  uncertainty  of  the  results 
of  the  operation  in  the  minds  of  the  profession.  He 
gave  an  analysis  of  nineteen  cases  of  operation  by 
himself  and  colleagues  at  the  Massachusetts  General 
Hospital.  In  about  fifty  per  cent,  of  these  the  re- 
sult v.-as  designated  as  fair.  In  two  of  the  cases  it 
was  good,  in  nine  fair,  and  in  eight  improved.  It 
was  to  be  remembered,  however,  that  the  results  in 
excision  were  never  equal  to  those  of  reposition.  It 
was  therefore  important  to  employ  the  latter  in 
every  possible  case. 

A  New  Plastic  Operation  for  Cicatricial  Palato- 
pharyngeal Contractures  and  Adhesions. — Dr. 
JoHx  O.  Roe.  of  Rochester,  said  that  cicatricial  con- 
tractures or  occlusions  of  the  post  nasal  space  re- 
sulting from  ulceration  or  traumatism  were  of  con- 
siderable frequency,  and  the  persistence  wdth  which 
the  adhesions  recurred  was  the  cause  of  much  dif- 
ficulty in  attempting  to  relieve  the  condition.  The 
operation  which  he  had  devised  for  affording  per- 
manent relief  consisted  in  covering  the  opposing 
raw  surfaces,  after  liberation  of  adhesions,  with 
mucous  membrane  taken  from  neighboring  parts. 

The  Annual  Banquet. — The  annual  banquet  of 
the  society  was  held  on  the  evening  of  the  27th  at 
the  Hotel  Ten  Eyck.  Dr.  Wisner  R.  Tow  nsend  was 
the  toastmaster,  and  among  those  who  spoke  were 
President-elect  Stockton,  the  Rt.  Rev.  Richard  H. 
X'elson.  Assistant  Bishop  of  the  Diocese  of  Albany, 
State  Senator  Grady,  and  Speaker  W'adsworth. 


244 


PITH-  OF  CURRENT  LITERATURE. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 
January  2i,  igog. 

1.  Surgical  Treatment  of  Cancer  of  the  Bladder, 

By  Arthur  T.  Cabot. 

2.  Some  Aspects  of  Cystitis,  By  Arthur  L.  Chute. 
Tumors  of  the  Bladder  and  Cystitis, 

By  Edgar  Garceau. 

4.    The  Value  of  Haemolysis  in  the  Diagnosis  of  Carci- 
noma, By  Wyman  Whittemore. 

I,  2,  3.  Cystitis. — Cabot  remarks  tliat  cystitis 
is  a  surgical  disease.  Its  proper  treatment,  to  be 
sure,  is  often  medical,  but  the  fact  that  it  is  so  fre- 
quently associated  with  serious  surgical  conditions 
and  that  its  treatment  involves  manipulations  fa- 
miliar to  the  surgeon  makes  it  wise  that  the  respon- 
sibility of  it  should  be  put  upon  his  shoulders  in  a 
greater  degree  than  has  been  the  habit  in  the  past. 
It  is  unfortunately  true  that  even  in  the  hands  of 
skilled  surgeons  cases  of  bladder  tumor  will  go  long 
unrecognized.  From  his  personal  experience  he  is 
inclined  to  think  that  it  would  not  be  far  from  the 
truth  to  say  that  all  papillomata  in  the  bladder  be- 
come cancerous  unless  they  are  thoroughly  removed 
early.  If  this  opinion  is  well  founded  it  is  evidently 
of  the  utmo.st  importance  to  make  the  removal  of 
every  papilloma  with  the  same  thoroughness  that  we 
use  in  approaching  distinctly  cancerous  growths. 
Skilled  cystoscopists  have  succeeded  in  removing 
papillomata  throtigh  operative  cystoscopes,  and  this 
method  of  removal  has  the  endorsement  and  sup- 
port of  such  men  as  Nitze,  Casper,  Weinrich,  and 
others  who  have  undoubtedly  achieved  wonderful 
immediate  results  with  this  method  of  operating. 
Rut  our  author  believes  that  these  growths  even 
when  quite  insignificant,  should  be  removed  by  open 
incision.  The  bladder  should  be  opened  widelv 
enough  to  allow  easy  access.  If  the  peritonaeum  is 
pushed  back  somewhat  from  the  front  and  vertex  of 
the  bladder  a  large  opening  may  be  made  extra- 
peritoneally,  and  this  is  usually  sufficient  for  any 
operation  which  does  not  remove  the  whole  thick- 
ness of  the  bladder  wall  with  its  peritoneal  coat.  If. 
now,  we  have  a  movable  papilloma  and  are  easily 
able  to  lift  a  considerable  fold  of  mucous  membrane 
with  the  tumor  on  its  apex,  and  can  satisfy  our- 
selves that  the  mucous  membrane  is  not  thickened 
nor  attached  to  the  muscular  wall,  we  may  then  con- 
tent ourselves  with  widely  removing  the  mucous 
membrane  to  which  the  tiunor  is  attached.  Thi? 
should  be  done  when  possible  with  the  cautery,  antl 
it  is  a  good  precaution  to  cauterize  the  surface  of 
the  tumor  lightly  before  removing  it  in  order  that, 
during  subsequent  manipulations,  the  wound  in  the 
Ijladder  wall  may  not  become  infected  with  tumor 
cells. —  Dr.  Chute  observes  that  the  changes  in  acute 
cystitis  involve  for  the  most  part  the  mucous  men;- 
brane,  though  the  whole  bladder  wall  may  be  in- 
vaded. There  is  first  an  intense  congestion,  then  an 
infiltration,  just  under  the  epithelium,  with  leuco- 
cytes and  round  cells.  The  cells  from  these  collec- 
tions under  the  epithelium  wander  through  the 
changed  epithelium  to  appear  in  the  urine  as  pus. 
These  collections  of  cells  are  the  source  of  the  pus 
in  the  cases  that  show  no  ulceration.  In  more 
marked  cases  there  is  a  proliferation  of  capillaries 


[New  York 
Medical  Journal,. 

in  the  submucosa  that  is  sometimes  attended  with 
haemorrhagic  areas  in  the  mucotts  membrane.  The 
changed  epithelium,  especially  that  on  the  folds  and 
ridges  into  which  the  bladder  is  thrown,  often  be- 
comes necrotic,  leaving  ulcers  that  are  for  the  most 
part  small,  but  may  be  of  moderate  extent.  In  a 
rare  form  of  cystitis,  the  so  called  diphtheritic  type, 
there  is  a  layer  of  fibrin  filled  with  cell  fragments 
and  leucocytes  on  the  mucotis  membrane.  When 
this  process  is  more  intense,  the  mucous  membrane 
through  its  whole  depth  may  be  necrotic ;  in  fact, 
thfe  process  ma}-  extend  deeper  than  the  mucous 
membrane  and  involve  the  muscular  layer  of  the 
bladder  and  occasionally-  even  the  perivesical  tissue. 
— Garceau  states  that  local  treatment  in  tuberculous 
cystitis  shotild  not  be  attempted  in  the  early  stage 
of  the  disease  because  here  we  have  intense  conges- 
tion with  excessive  irritation.  But  in  the  later 
stages  when  ulcers  have  formed,  local  applications 
through  a  Kelly  tube  do  a  great  deal  of  good.  lie 
has  repeatedly  seen  tuberculous  ulcers  heal  under 
this  treatment  even  when  there  was  pus  coming 
down  from  a  tuberculous  kidney  above.  The  Guyon 
treatment  has,  on  the  whole,  given  good  results  in 
his  hands. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 
January  23,  1909. 

1.  Antibacterial  or  Antitoxic  Immunization  in  Tubercu- 

lin Treatment.  By  E.  L.  Trudeau. 

2.  Hyperasmia  Treatment  in  Gyna;cology  and  Obstetrics, 

By  Arthur  Stein. 

3.  Purulent  Pleuritis  :  Pathology  and  Treatment, 

By  F.  T.  BiLLiNGis. 

4.  Some    Factors   in    the   History   of  Hsemoglobinuric 

Fever,  By  William  H.  Deaderick. 

5.  The  Philippine  Medical  School,     By  Paul  C.  Freer. 

6.  A  Further  Contribution  to  Palliative  Operations  for 

Brain  Tumor,  By  William  G.  Spiller. 

7.  Dislocation  of  the  Astragalus  around  Its  Anteropos- 

terior Axis.    Operation,  Reduction,  Recovery,  with- 
out the  Removal  of  the  Bone,     By  W.  H.  Luckett. 

8.  Treatment  of  Suppuration  of  Renal  Pelvis  and  Ure- 

ters by  Lavage,  By  Edgar  Garceau. 

9.  Expectant  Treatment  of  Ureteral  Calculus.    Its  Indi- 

cations and  Results,     By  Charles  Lester  Leonard. 

10.  .Acute  Form  of  Abdominal  Tuberculosis, 

By  Daniel  M.  Eisendrath. 

11.  -A   Method   for  Increasing  the  Diagnostic  Value  of 

Sputum  Reports,  By  Arthur  T.  Laird. 

I.  Antibacterial  or  Antitoxic  Immunization  in 
Tuberculin  Treatment. — Trudeau  remarks  that  if 
we  accept  the  toxine  immunization  conception  as  the 
essential  feature  and  guide  to  the  treatment,  instead 
of  measuring  the  degree  of  a  questionable  antibac- 
terial immunity  by  the  opsonic  index,  or  attempting 
to  produce  it  more  or  less  empirically  by  a  series  of 
moderate  reactions,  the  severity  of  which  we  cannot 
in  any  way  control,  the  main  features  in  our  treat- 
ment would  be:  i.  To  raise  the  degree  of  tolerance 
to  tuberculin  to  the  highest  point  attainable  in  each 
case  by  an  almost  imperceptible  and  long  continued 
progression  in  dosage.  2.  To  avoid  general  and 
focal  reactions  as  much  as  possible  and  consider 
them  merely  as  evidences  of  intolerance.  3.  To  fol- 
low no  arbitrary  rule  as  to  rate  of  increase  or  the 
maximum  dose  to  be  reached,  but  to  Ik  guided  mere- 
ly bv  the  degree  of  toxine  tolerance  of  each  patient 
as  shown  by  the  symptoms  and  general  condition, 
whether  the  highest  individual  maximum  dose  at- 
tainable is  only  a  small  frnctfon  of  a  milligramme  or 
a  cubic  centimeter  or  more. 


January  30,  1909.] 


PITH  or  CURRENT  LITERATURE. 


245 


3.  Purulent  Pleuritis. — I*>illi;ia:s,  of  Pittsburgh, 
observes  that  at  the  present  time,  w  henever  pus  is  di- 
agnosticated in  the  pleural  sac,  in  the  great  ma  jority 
of  cases  a  rib  resection  is  performed.  Unquestion- 
ably this  is  absolutely  necessary  in  many  instances, 
but  in  others  it  is  certainly  uncalled  for,  since  it 
prolongs  the  convalescence  and  produces  more  or 
less  deformity,  and  occasionally  a  stubborn  and  pro- 
tracted sinus.  Empyema,  before  the  days  of  radi- 
cal operative  interference,  was  cured  frequently  by 
simple  paracentesis.  It  seems  possible  that  in  the 
near  future  more  discrimination  will  be  shown  by 
surgeons  in  dealing  with  this  condition.  From  the 
work  done  by  bacteriologists,  we  know  that  the 
pneumococcus  infections  within  the  pleural  cavity 
are  comparatively  benign :  therefore  it  is  possible 
that  a  simple  thoracentesis,  or  at  most,  a  small  in- 
cision drained  for  a  few  days,  will  be  found  to  meet 
the  requirements  of  this  condition.  Streptococcus 
or  mixed  infections  containing  this  organism  are 
known  to  be  virulent,  and  a  thoracotomv  with  drain- 
age is  unquestionably  indicated  in  cases  of  such  in- 
fections. In  tuberculous  empyema,  uncomplicated 
by  pyogenic  cocci,  repeated  aspirations  at  long  inter- 
vals will  probably  be  found  to  give  the  best  results, 
^lurphy's  method,  when  the  indications  and  contra- 
indications are  more  fully  understood  and  Dr. 
Murphy  has  reported  his  clinical  results,  will  per- 
haps be  of  great  value.  It  may  be  found  of  great- 
est benefit  in  empyemas  of  long  standing,  for,  as 
Capps  and  Lewis  have  shown,  formalin  injected  into 
a  pleural  cavity  in  which  the  inflamed  membranes 
are  not  fully  protected  seems  to  be  a  procedure  of 
some  danger.  Our  knowledge  of  all  the  conditions 
existing  in  the  pleura  and  lung  during  an  empyema 
is  incomplete,  but  certainly  a  careful  and  systematic 
bacteriologic  study  of  each  case  will  go  far  toward 
indicating  a  line  of  treatment. 

5.  The  Philippine  Medical  School. — Freer  says 
that  the  Philippine  ]\Iedical  School  is  in  a  position 
to  give  adequate  and  careful  laboratory  instruction  ; 
it  has  filled  its  chairs  of  anatomy,  pathology,  bacte- 
riology, physiology,  and  chemistry  with  well  trained 
men.  some  of  them  called  to  the  Philippines  espe- 
cially for  the  purposes  of  the  school,  others  directly 
comiected  with  the  Bureau  of  Science,  but  doing 
their  share  in  the  work  of  teaching.  In  the  more  ad- 
vanced years,  after  the  foundation  of  laboratory 
training  is  laid,  it  gives  equal  advantages  to  its  stu- 
dents in  having  on  its  facult}-  men  who  have  made 
reputations  in  their  lines  of  work  in  tropical  and 
clinical  medicine,  in  surgery,  obstetrics,  hygiene,  and 
public  health,  in  medical  zoology,  clinical  micros- 
copy, paediatrics,  medical  entomology,  and  other 
branches,  some  of  these  teachers  being  from  the 
profession  at  large,  others  from  the  Bureau  of  Sci- 
ence, and  yet  others  from  the  Bureau  of  Health  and 
the  medical  staf¥  of  the  constabulary.  The  school 
has  ample  laboratory  equipment :  it  is  about  to  con- 
struct a  new  laboratory  building ;  the  plans  for  a 
new  pavilion  hospital  are  complete,  and  construction 
work  will  soon  begin.  In  other  words,  the  school  is 
equipped  to  give  a  thorough,  modern  course  in  med- 
icine with  all  the  exactness  incident  to  a  good  foun- 
dation of  laboratory  work.  The  course  extends  over 
five  vears. 


8.  Treatment  of  Suppuration  of  Renal  Pelvis 
and  Ureter  by  Lavage. — Garceau  states  that  renal 
lavage  is  but  seldom  required,  and  it  should  not  be 
used  indiscriminately.  There  must  be  careful  delib- 
eration before  resorting  to  this  method  of  treatment, 
and  the  patient  should  have  been  under  observation 
a  considerable  length  of  time  before  the  treatment  is 
proposed  ;  acute  cases  are  not  suitable  for  this  method 
of  treatment.  The  most  .suitable  cases  are  those  of 
simple  chronic  suppurative  pyelitis  without  obstruc- 
tion, but  these  cases  are  very  rare,  and,  unless  the 
germ  is  a  very  virulent  one,  such  patients  usually 
get  well  in  the  course  of  time.  Thorough  free  drain- 
age of  the  kidney  through  the  ureter  must  be  se- 
cured before  permanent  relief  can  be  expected.  The 
method  may  be  used  in  an  endeavor  to  cure  an  in- 
flammation in  a  hydronephrotic  sac  as  a  preliminary 
to  nephropexy,  but  the  kidney  should  be  supported 
meanwhile  by  an  appropriate  apparatus.  It  will  at 
times  get  rid  of  the  infection  in  pyonephrosis,  but 
this  rarely  occurs.  It  should  never  be  permitted  in 
severe  pyonephrosis  with  general  systemic  infec- 
tion. A  permanent  catheter  in  the  ureter  is  very 
dangerous,  especially  in  the  presence  of  acute  infec- 
tion with  general  symptoms.  The  treatment  does 
little  or  no  good  in  a  case  of  ureteritis  with  marked 
tissue  changes  in  the  ureter  leading  to  sclerosis  and 
thickening.  Renal  lavage  is  seldom  followed  by  any 
serious  harmful  sequelae.  But  enough  cases  have  not 
>  et  been  reported  to  give  a  definite  standing  to  the 
treatment,  and  further  trial  is  needed. 

9.  Expectant  Treatment  of  Ureteral  Calculus. 
Leonard  writes  that  the  value  and  applicability  of 
the  expectant  method  of  treatment  in  small  ureteral 
calculi  have  been  demonstrated  by  the  passage  and 
recovery  of  calculi  in  thirty-one  cases,  as  compared 
with  fifteen  in  which  operation  has  been  deemed 
necessary.  By  expectant  treatment  is  meant  the 
emplovment  of  known  medical  measures  under  care- 
ful medical  supervision,  with  frequent  analyses  of 
the  urine.  Such  treatment  is  based  on  the  data  de- 
rived from  a  careful  Rontgen  ray  examination  with 
a  study  of  the  symptoms  and  signs  as  shown  by 
other  methods  of  clinical  examination.  The  results 
obtained  by  this  course  of  treatment  show  that  in 
fifty  per  cent,  of  the  cases  of  urinary  lithiasis  pre- 
senting marked  symptoms  natural  forces  are  capable 
of  expelling  the  calculus.  With  the  accurate  knowl- 
edge obtainable  by  known  clinical  methods  of  diag- 
nosis this  procedure  is  not  only  rational  and  justi- 
fied, but  should  be  employed  rather  than  resort  to 
the  dangers  of  ureterolithotomy. 

10.  The  Acute  Form  of  Abdominal  Tubercu- 
losis.— Eisendrath  observes  that  a  primary  tuber- 
culous appendicular  inflammation  is  not  as  rare  an 
aftection  as  was  formerly  thought.  Such  an  infec- 
tion can  be  followed  by  secondary  involvement  of 
the  ileocaecal  lymph  nodes  which  is  out  of  all  pro- 
portion to  the  pathological  changes  in  the  case.  In 
the  majority  of  cases  there  are  evidences  of  tubercu- 
lous foci  in  the  appendix,  but  secondary  lymph  case- 
ous nodes  may  be  found  without  visible  macroscopic 
or  microscopic  tuberculous  changes.  Butter,  milk, 
and  cheese  from  tuberculous  cows  are  the  chief 
sources  of  infection  in  primary  intestinal  tubercu- 
losis.   In  a  fair  proportion  (twenty-seven  per  cent.) 


246 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  JourxaI- 


of  the  twenty-nine  published  cases  of  tuberculous 
appendicular  inflammation  the  clinical  picture  resem- 
bled an  acute  nontuberculous  appendicular  inflam- 
mation. No  statistics  are  available  to  estimate  the 
proportion  of  cases  of  tuberculous  peritonitis  which 
begin  acutely,  but  it  is  larger  than  is  usually 
thought.  Through  early  diagnosis'  and  radical  re- 
moval of  the  tuberculous  appendix  and  infected 
lymph  nodes  (as  far  as  practicable)  complete  and 
permanent  recovery  can  occur.  Some  of  the  cases 
of  ileocecal  tuberculosis  and  of  tuberculous  perito- 
nitis may  thus  be  avoided  through  removal  of  the 
probable  starting  point. 

II.  Diagnosis  from  Sputum. — Laird  remarks 
that  when  a  record  is  made  of  the  macroscopic  ap- 
pearance of  a  specimen  of  sputum,  together  with 
notes  as  to  the  predominating  cells  seen  in  microscop- 
ical examination,  and  a  statement  is  made  whether 
secondary  organisms  are  few  or  many,  it  is  possible 
to  determine,  from  the  report,  with  some  degree  of 
probability,  whether  a  specimen  was  derived  mainly 
I'rom  the  lungs  or  from  the  upper  respiratory  tract. 
V  certain  type  of  specimen,  the  "bronchial  type," 
ihould  be  secured  if  possible  when  it  is  desired  to 
determine  the  presence  of  tubercle  bacilli  or  of  or- 
ganisms causing  mixed  infection.  The  selection  of 
ihis  same  type  for  use  in  securing  pure  cultures  of 
secondary  organisms  or  of  tubercle  bacilli  will  save 
time  and  trouble.  Tubercle  bacilli  are  occasionally 
found  in  specimens  of  the  "mouth  droplet"  type,  and 
these  should  be  examined  if  no  other  can  be  ob- 
tained. Such  specimens  are  usually  in  large  part 
derived  from  the  mouth  or  throat.  No  inferences  as 
to  the  presence  of  mixed  infection  should  be  drawn 
from  the  examination  of  such  specimens..  The  pa- 
tient should  state  whether  the  specimen  was  obtained 
by  coughing  or  by  clearing  the  throat. 

MEDICAL  RECORD. 

January  23,  igog. 

1.  The  Common  and  Uncommon  Localization  of  Otitic 

Brain  Abscess,  as  Illustrated  by  Two  Cases,  with 
Recovery,  By  B.  Sachs  and  A.  A.  Berg. 

2.  Adequate  Drainage  the  Essential  Step  in  the  Successful 

Surgery  of  Brain  Abscess,  By  F.  Whiting. 

3.  Clinical  and  Anatomical  Manifestations  of  Otitic  Brain 

Abscess,  By  Alfred  Wiener. 

4.  Pyloric  Stenosis,  By  James  Spencer  Brown. 

5.  The  Symptomatology  of  Tuberculosis  of  the  Larynx, 

By  George  Fetterolf. 

I.  Otitic  Brain  Abscess. — Sachs  and  Berg  re- 
port three  such  cases  and  remark  .that,  when  a 
surgeon  is  asked  to  deal  with  an  abscess  of  the  brain 
that  is  as  accurately  localized,  his  concern  is  entire- 
ly with  the  technical  parts  of  the  operation.  He 
does  not  have  to  consider  those  technical  details  that 
nuist  always  receive  attention  when  we  open  the 
skull  for  exploratory  purposes.  His  concern  is  to 
approach  the  abscess  by  the  most  direct  route,  evac- 
uate the  pus,  and  establish  satisfactory  drainage  of 
the  cavity.  It  is  evident  that  in  any  case  there  are 
three  main  considerations:  i.  A  wide  exposure  of 
the  area  of  the  brain  in  which  the  abscess  is  sup- 
))Oscd  to  lie.  This  is  best,  done  by  raising  an  osteo- 
plastic flap.  Some  otologists,  when  operating  for 
tcmporos])henoidal  abscess,  are  in  the  habit  of  re- 
moving the  bone  in  that  region  with  rongeur  forceps, 
creating  a  defect   in   the  skull.     There  arc  num- 


erous objections  to  this  procedure,  the  chief  being 
that  the  exposure  of  a  large  area  demands  a  wide 
removal  of  bone,  and  further,  that  such  a  large  de- 
fect predisposes  to  the  development  of  cerebral 
hernia.  Again,  it  is  a  more  time  consuming  pro- 
cedure than  is  the  raising  of  the  osteoplastic  flap. 
2.  The  second,  and  a  most  important  consideration, 
is  the  protection  of  the  meninges  against  infection 
by  the  purulent  contents  of  the  abscess  cavity.  If 
this  lies  near  to  the  cortex  of  the  brain,  or  upon  it, 
it  is  more  than  likely  that  the  meninges  will  be  pro- 
tected from  infection  by  a  barrier  of  natural  adhe- 
sions that  have  formed  before  the  operation  is  done. 
These  are  the  most  favorable  cases  for  surgical  in- 
terference. When,  however,  the  abscess  lies  deep 
within  the  substance  of  the  brain  and  there  is  no 
such  barrier  of  natural  meningeal  adhesions,  the 
question  arises  whether  it  is  not  preferable  to  oper- 
ate in  such  cases  in  two  stages.  In  the  first  stage 
open  the  skull  and  incise  the  dura,  and  by  gauze 
packings  around  the  margin  of  the  dural  incision 
establish  a  barrier  of  protective  adhesions  between 
the  pia  and  the  dura  mater,  and  at  the  second  sitting 
which  might  take  place  after  twenty-four  hours, 
incise  and  properly  drain  the  abscess  cavity.  3.  The 
third  consideration  is  the  proper  drainage  of  the 
abscess  cavity.  Here  we  must  remember  that  there 
are  two  entirely  different  kind  of  abscess  cavities  in 
the  brain — one,  with  soft  walls  that  readily  collapse 
when  the  contained  pus  is  evacuated ;  and  the  other 
with  rigid  walls  that  show  no  tendency  to  fall  to- 
gether, and  that  must  be  obliterated  by  the  slow  pro- 
cess of  granulation.  It  is  evident  that  an  entirely 
dififerent  method  of  drainage  must  be  employed  in 
these  two  types.  In  the  former,  all  that  is  required 
is  the  establishment  of  drainage  by  a  thin  slip  of 
rubber  tissue  at  the  most  dependent  point  of  the  cav- 
ity. This  is  to  be  removed  after  forty-eight  hours, 
and  not  reinserted.  The  opening  in  the  scalp  and 
skull,  however,  should  be  maintained  by  a  piece  of 
gauze  packing,  so  that  if  pus  or  other  secretion  be 
retained,  it  will  find  its  way  out  along  the  tract 
established  by  the  rubber  tissue.  In  the  latter  type 
of  abscess  cavity,  the  drainage  must  be  by  a  tube  of 
some  kind,  whether  rubber  or  decalcified  bone,  or 
other  material — according  to  the  choice  of  the  oper- 
ator. This  tube  must  be  inserted  at  the  lowest 
point  of  the  abscess  cavity,  otherwise  there  is  bound 
to  be  retention  of  pus.  Inasmuch  as  gauze  ceases  to 
act  as  a  drain  a  few  hours  after  its  insertion,  its  use 
for  drainage  of  such  thickly  walled  brain  abscesses 
is  inadvisable.  When  the  abscess  occupies  the  tem- 
porosphenoidal  or  occipital  lobe,  or  the  cerebellum, 
the  drainage  of  the  most  dependent  part  of  the  ab- 
scess cavity  is  easily  established  through  the  pri- 
mary wound,  because  this  already  lies  at  a  point 
below  the  most  dependent  part  of  the  abscess.  This 
does  not  obtain,  however,  when  the  abscess  occu|)ies 
the  frontal  or  parietal  lobe.  In  such  cases  the  ab- 
scess is  approached  from  the  higher  parts  of  the 
cranial  vault,  and  its  lowest  part  is  often  one  or  two 
inches  in  the  depths  of  the  brain,  considerably  be- 
low the  lowest  point  of  the  primary  wound.  If  we 
wish  to  establish  satisfactory  drainage  under  siK'h 
conditions,  it  mu.st  be  done  through  a  counter  in- 
cision, the  site  of  which  corresponds  to  the  lowest 
point  of  the  abscess  cavity.     This  incision  may  be 


January  30,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


247 


made  at  the  time  of  the  primary  operation,  if  the 
patient's  condition  warrants  it,  or  at  a  later  period. 

2.  Drainage  in  Brain  Abscess. — W  hiting  gives 
the  following  three  essential  factors  of  successful 
drainage  in  a  brain  abscess:  i.  Scrupulous  care  to 
be  exercised  in  inducing  complete  evacuation  of  all 
pus  and  pyogenic  material  at  the  time  of  operation. 
2.  The  establishment  and  maintenance  of  an  unin- 
terrupted communication,  by  means  of  gauze  or 
other  drains,  between  the  deeper  portion  of  the  ab- 
scess cavity  and  the  drainage  opening,  without  add- 
ing unduly  to  the  pressure  upon  the  brain  substance 
surrounding  the  walls  of  the  abscess.  3.  The  avoid- 
ance not  only  at  the  time  of  operation  but  especially 
during  the  after  treatment  of  gratuitous  infection  of 
healthy  surrounding  brain  tissue  by  misdirected  ef- 
forts at  the  introduction  of  gauze  or  other  drainage 
material  attempted  without  the  assistance  of  actual 
inspection  of  the  abscess  path. 

BRITISH  MEDICAL  JOURNAL. 

January  2,  igo^. 

1.  The   Results   of  Operations   for   Carcinoma   of  the 

Tongue,  with  an  Analysis  of  197  Cases, 

By  H.  T.  BuTLiN. 

2.  The  Operative  Treatment  of  Intraoral  Cancer:  with 

Special  Reference  to  the  Choice  of  Operation,  Order 
of  Operation,  and  Ligature  of  the  Lingual  and  Facial 
Arteries.   From  an  Experience  of  Thirty-nine  Cases, 

By  C.  P.  Childe. 

3.  The  Surgerj-  of  Colitis,  By  F.  C.  Wallis. 

4.  The  Treatment  of  Chronic  Rheumatic  and  Rheumatoid 

Arthritis  by  Radiant  Heat  and  Cataphoresis, 

By  C.  F.  B.AiLEY. 

5    The  Restoration  of  Vision  in  the  Squinting  Eye, 

By  A.  A.  Bradburne. 

6.    Persistent  Thymus  and  Sudden  Death, 

By  S.  H.  Dankes. 

I,  2.  Cancer  of  the  Tongue. — Butlin  gives  the 
results  obtained  in  a  series  of  197  operations  for 
cancer  of  the  tongue.  The  first  operation  was  per- 
formed in  1881.  In  1895  he  first  performed  a 
planned  operation  for  the  retnoval  of  the  contents 
of  the  anterior  triangle  of  the  neck,  that  being  the 
place  in  the  neck  in  which  the  glands  are  most  liable 
to  be  diseased.  The  operations  on  the  tongue  were 
performed  almost  entirely  through  the  mouth,  and 
the  lower  jaw  was  never  divided.  In  1900  he  began 
to  perform  a  preliminary  lar\'ngotomy  before  re- 
moving the  tongue.  This  operation  has  all  the  ad- 
vantages of  tracheotomy,  without  its  disadvantages. 
It  can  be  performed  in  less  than  one  minute,  and 
enables  the  operator  to  deal  with  the  disease  of  the 
tongvie  much  more  deliberately  and  effectually.  Of 
the  197  cases,  twenty  patients  died  of  the  operation, 
eighty-eight  patients  died  of  recurrence  of  the  dis- 
ease, and  in  fifty-five  patients  the  operation  was 
successful,  i.  e.,  the  patients  lived  for  from  three  to 
twenty-two  years  free  from  recurrence :  most  of 
them  are  still  alive  and  well.  Since  1895  114  cases 
were  operated  in.  Of  these,  the  contents  of  the 
anterior  triangle  were  removed  in  seventy  patients ; 
six  patients  died  of  the  operation,  twenty-seven 
patients  died  of  recurrence,  and  in  twenty-four  pa- 
tients (thirty-four  per  cent.)  the  operation  was 
successful.  Of  the  forty-four  cases  in  which  the 
contents  of  the  anterior  triangle  were  not  removed, 
six  patients  died  of  the  operation,  twenty-three  pa- 
tients died  of  recurrence,  and  in  twelve  patients  the 
operation  was  successful  (twenty-seven  per  cent.). 


There  is  no  advantage  in  postponing  the  operation 
on  the  glands  of  the  neck  until  they  are  enlarged. 
The  dissection  should  be  carried  into  the  posterior 
triangle  of  the  neck  in  those  cases  in  which  the 
primary  disease  is  seated  far  back  on  the  border  of 
the  tongue,  and  in  those  cases  in  which  the  glands 
are  badly  affected  in  the  parotid  (upper  carotid) 
region.  While  the  writer  is  unwilling  to  say  that 
the  glands  on  both  sides  of  the  neck  should  always 
be  removed,  yet  the  following  conditions  call  for 
wider  removal  of  glands:  i.  Those  cases  in  which 
the  glands  on  both  sides  of  the  neck  are  enlarged. 

2.  Those  in  which  the  glands  are  affected  only  on 
the   side  of   the   neck  opposite   to   the  disease. 

3.  Those  in  which  the  disease  is  situated  on  both 
sides  of  the  tongue,  or  in  which  it  reaches  to  the 
middle  line  of  the  tongue.  Perhaps  the  anterior 
part  of  the  dorsum  of  the  tongue  is  the  least  dan- 
gerous seat  of  cancer,  as  regards  affection  of  the 
glands.  In  eighteen  cases  the  cancer  was  diagnos- 
ticated and  operated  on  at  a  very  early  stage,  the 
percentage  of  successes  (eight  in  eighteen  pa- 
tients) being  forty-three.  No  fewer  than  six  pa- 
tients died  at  a  later  period  of  affection  of  the 
glands  without  recurrence  in  the  tongue.  Contrary 
to  the  general  belief  of  surgeons,  cancer  originating 
in  the  floor  of  the  mouth  can  be  removed  with  a 
good  prospect  of  success,  provided  it  is  not  too  ex- 
tensive and  has  not  involved  the  bone. — Childe  ad- 
vocates the  following  two  main  principles  in  the 
operative  treatment  of  cancer  of  the  tongue  and 
floor  of  the  mouth:  i.  The  neck  should  always  be 
attacked  first,  with  ligature  of  the  lingual  or  facial 
arteries  on  one  or  both  sides.  This  reduces  the  ex- 
cision of  the  primary  growth,  provided  it  can  be 
extirpated  without  division  of  the  jaw.  to  an  insig- 
nificant and  bloodless  operation,  which  can  fre- 
quently be  performed  without  danger  immediately 
after  the  neck  operation.  It  does  away  with  all 
necessity  for  preliminary  larjngotomy  or  trache- 
otomy, and  cuts  off  the  blood  supply  to  the  tumor 
in  the  interval,  and  will  possibly  starve  cancer  cells 
which  may  be  left  behind  after  attempted  extirpa- 
tion of  the  tumor.  2.  A  communication  between 
the  mouth  and  a  large  wound  in  the  neck  should 
always  be  avoided  where  possible.  Unless  the  dis- 
ease is  situated  in  the  tonsil,  and  except  the  patient 
insists  on  a  single  operation,  this  can  always  be  ac- 
complished by  dividing  the  operation  into  two  stages. 
The  neck  is  attacked  first,  and  the  lingual  and 
facial  arteries  are  tied.  When,  in  a  fortnight,  the 
large  wound  in  the  neck  is  healed,  the  jaw  is  di- 
vided, and  the  primar)^  growth  is  excised  blood- 
lessly.  Early  diagnosis  is  the  only  hope.  Immedi- 
ate microscopical  examination  of  a  piece  of  the 
growth  is  the  only  test  that  should  be  employed. 

3.  Colitis. — Wallis,  in  summing  up  the  present 
position  of  surgery  in  the  treatment  of  colitis,  states 
that  the  sooner  all  forms  of  hjemorrhagic  and  ul- 
cerative colitis  are  submitted  to  surgical  treatment 
the  better.  There  can  be  no  doubt  but  that  irriga- 
tion of  the  bowel  through  a  surgical  hole  made  in 
it  is  the  best — one  would  almost  say  the  only — 
chance  there  is  of  recovery  from  this  condition.  In 
acute  cases  the  condition  is  very  serious,  and  the 
one  chance  they  have,  however  great  the  risk,  is  the 
free  irrigation  of  the  large  bowel  by  one  of  the  vari- 
ous surgical  measures.    The  sole  aim  and  object  of 


248 


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both  medical  and  surgical  treatment  is  to  get  the 
colon  free  of  the  infective  contents,  and  thus,  by 
keeping  the  bowel  clean,  give  it  the  best  chance 
of  recovery.  Any  application  of  a  chemical  nature, 
whether  stimulant  or  astringent,  must  be  used  with 
caution  as  most  of  such  applications  are  irritant, 
whatever  other  properties  they  possess.  The  best 
treatment  for  the  ulcerated  areas  is  cataphoresis, 
but  so  far  only  those  cases  limited  to  the  lower 
seven  or  eight  inches  of  the  bowel  can  be  satisfac- 
torily treated.  In  the  case  of  membranous  colitis 
no  definite  conclusion  as  to  surgical  procedure  can 
be  arrived  at.  The  various  kinds  of  surgical  treat- 
ment at  present  carried  out  are  as  follows:  i.  Ap- 
pendicostomy.  This  is  probably  the  best  operation 
for  those  chronic  cases  of  membranous  or  ulcer- 
ative colitis  which  are  at  present  referred  to  the 
surgeon.  The  great  point  of  practical  importance 
is  to  leave  as  little  of  the  appendix  as  possible. 
2.  Caecostomy.  This  is  a  bad  substitute  for  appen- 
dicostomy,  and  should  never  be  resorted  to  if  in 
any  way  the  appendix  can  be  made  use  of.  3.  Co- 
lostomy. This  is  of  the  greatest  benefit  in  cases  of 
dysenteric  ulceration,  where  usually  the  ulceration 
is  limited  to  the  sigmoid  and  rectum.  4.  Posterior 
median  proctotomy.  This  is  of  great  use  in  those 
cases  in  which  the  ulceration  is  low  down  in  the 
rectum,  and  the  pain  is  so  great  that  there  is  much 
spasm  of  the  sphincters.  A  posterior  incision 
through  both  sphincters  and  extending  back  to  the 
coccyx  relieves  the  spasm  and  insures  free  drainage, 
and  after  a  day  or  two  the  rectum  and  sigmoid  can 
be  thoroughly  irrigated  with  very  little  discomfort 
to  the  patient. 

LANCET. 

January  2,  igog. 

1.  Why  and  How  the  Surgeon  Should  Attempt  to  Preserve 

the  Appendix  Veriformis,  Its  Value  in  the  Surgical 
Treatment  of  Constipation ;  with  a  Series  of  Cases 
Briefly  Reported,  By  C.  B.  Keetley. 

2.  Renal  Calculus,  Diagnosis  and  Treatment,  with  Cases 

Selected  to  Illustrate  Special  Points  of  Difficulty  in 
Diagnosis,  By  D.  Newman. 

3.  The  Absorption  of  Proteins,     By  W.  D.  Halliburton. 

4.  The  Treatment  of  Inguinal  Hernia  in  Children, 

By  W.  H.  Evans. 

5.  Acromegaly,  with  Illustrative  Cases. 

By  G.  Rankin  and  R.  O.  Moon. 

6.  Features  of  Some  Chronic  Affections  of  the  Lungs  in 

Children,  By  T.  Fisher. 

7.  A  Prospective  Cure  for  Elephantiasis, 

By  W.  S.  Handley. 

8.  Motoring  Notes,  By  C.  T.  W.  Hirsch. 

I.  Preservation  of  the  Appendix. — Keetley's 
object  is  to  show :  ( i )  That  transplantation  of  the 
appendix  vermiformis,  so  that  the  whole  or  the 
greater  part  of  it,  from  its  root  in  the  caecum,  lies 
p>ermanently  imbedded  in  the  abdominal  wall,  will 
•produce  the  good  results  of  excising  it;  (2)  that  it 
is  a  practicable  and  safe  operation;  and  (3)  that 
transplantation  of  the  appendix  should  in  many 
cases  be  preferred  to  appendicectomy.  He  also  at- 
tempts to  prove  that  when  constipation  requires  to 
be  treated  surgically,  appendicostomy  .should  be  the 
operation  chosen.  The  uses  of  appendicostomy 
practised  or  suggested  up  to  date  may  he  tabulated 
as  follows:  For  colitis  of  various  kinds,  mucomeni- 
branous,  ulcerative,  amnebic.  syphilitic,  tuberculous, 
etc.:  certain  forms  of  intussusception  (to  prevent 
recurrence,  etc.);  intestinal  haemorrhage:  typhoid 


fever ;  cases  of  enterectomy  and  colectomy,  as  safety 
valve ;  intestinal  distention  in  toxic  conditions ;  the 
administration  of  nutrient  enemata  per  appendicem ; 
and  constipation.  And  further,  as  first  mentioned, 
there  is  appendicostomy  as  part  of  the  technique  in 
the  conservative  practice  of  transplanting  the  whole 
or  the  greater  part  of  the  appendix  into  the  abdom- 
inal wall  instead  of  removing  it  by  an  appendicec-  ^ 
tomy.  Appendicitis  is  a  dangerous  disease,  not  be- 
cause of  the  nature  of  the  appendix,  but  because  of 
its  position.  Its  dangerous  and  even  it>  serious, 
troublesome  results  are  due  to  its  relation  to  the 
peritoneal  wall.  Two  of  the  writer's  cases  indicate 
how  trivial  a  malady  even  perforative  appendicitis 
becomes  when  the  appendix  is  securely  imbedded  in 
the  substance  of  the  abdominal  wall.  It  is  probable 
that  the  appendix  has  physiological  uses,  possibly, 
if  not  probably,  of  considerable  importance,  and  that 
it  is  not  the  useless,  merely  vestigial  organ  it  has 
been  represented.  But  it  has  also  a  potential  sur- 
gical value  in  the  treatment  of  a  certain  class  of 
abdominal  troubles.  The  writer  has  already,  at  least 
twice,  been  unable  to  attempt  appendicostomy  in 
cases  in  which  that  operation  was  indicated,  because 
the  appendix  had  been  previously  removed.  Metch- 
nikof?  believes  that  the  degenerations  of  old  age  are 
to  a  large  extent  the  effects  of  toxines  manufactured 
by  the  bacteria  which  swarm  in  the  large  intestine. 
Among  the  facts  bearing  on  this  question  are  the 
great  ages  of  birds,  such  as  parrots  and  ravens, 
which  have  no  large  intestine.  Appendicostomy, 
when  used  for  regular,  frequent,  and  considerable 
injections  of  water,  at  one  and  the  same  time  feeds 
the  blood  with  liquid  and  washes  out  of  the  large 
intestine  its  noxious  germs  and  their  toxines.  The 
writer  describes  the  technique  of  transplantation  of 
the  appendix.  Among  the  points  to  be  noted  are  the 
following:  Appendix  transplantation  is  a  plastic 
operation,  so  that  tension  must  be  avoided.  But 
patience  and  coaxing  will  often  succeed  in  bringing 
the  appendix  to  the  surface.  It  should  be  laid  in 
an  easy  position  obliquely  in  the  abdominal  wall,  by 
preference  with  its  apex  upward  and  outward.  The 
appendix  should  not  be  opened  for  at  least  forty- 
eight  hours,  by  which  time  it  is  adherent  in  its  new 
place.  In  order  to  prevent  gangrene,  a  catheter 
should  not  be  left  in  the  appendix ;  if  it  be  necessary, 
let  the  catheter  be  a  very  small  one.  The  appendix 
is  quite  insensitive  and  needs  no  anaesthetic.  Cases 
suited  for  parietal  transplantation  of  the  appendix 
are  as  follows:  (i)  The  healthy  appendix  in  some 
cases  of  colitis,  and  in  some  of  doubtful  nature ; 
(2)  appendices  of  which  a  fair  length  of  the  prox- 
imal part  is  free  from  stricture,  kink,  ulceration,  and 
perforation,  or  which  can  be  opened  toward  the 
distal  end  and  cured  of  their  defects.  The  follow- 
ing cases  are  more  or  less  unsuited  to  the  operation : 
(i)  Obliterated  appendices:  (2)  tuberculous,  acti- 
nomycotic, and  cancerous  appendices:  (3")  appen- 
dices gangrenous  or  perforated  near  the  proximal 
end  :  (4)  appendices  of  which  the  base  cannot  be 
brought  up  to  the  parietal  peritonaeum  without  un- 
due tension:  (5)  those  of  which  the  mesoappendix 
is  not  long  enough  to  permit  them  to  be  sufficiently 
straightened  out  or  to  be  brought  into  the  abdominal 
wall  without  dangerously  interfering  with  their 
blood  supply,  but  this  may  be  ignored  if  the  appen- 


January  30,  1909.] 


PITH  or  CURRENT  LITERATURE. 


249 


dix  is  not  opened  too  early;  (6)  appendices  which 
cannot  be  placed  in  good  position  in  the  abdominal 
wall  without  interfering  with  such  drainage  as  the 
case  may  require.  An  extremely  fat  and  thick  meso- 
appendix  is  unfavorable,  but  not  an  absolute  contra- 
indication. 

7.  Operation  for  Elephantiasis. — Handley  re- 
ports a  case  of  that  supposedly  incurable  disease, 
elephantiasis  arabum,  in  which  so  great  and  striking 
improvement  followed  the  operation  of  angioplasty, 
as  to  justify  the  hope  that  a  cure  had  been  found. 
In  this  operation  a  number  of  stout  silk  threads 
running  the  whole  length  of  the  limb  are  introduced 
into  the  subcutaneous  tissue  of  the  swollen  part. 
The  threads  are  completely  and  permanently  buried. 
Their  capillary  action  enables  them  to  replace  the 
trunk  lymphatics  and  to  transfer  the  excess  of  fluid 
from  the  area  of  lymphatic  oedema  to  regions  where 
the  lymphatic  circulation  is  normal,  and  where  con- 
sequently the  excess  of  fluid  is  absorbed  and  car- 
ried of?  into  the  general  circulation. 

BERLINER  KLINISCHE  WOCHENSCHRIFT 

December  14,  igo8. 

1.  Madelung's  Wrist  Joint  Deformity, 

By  Richard  Levy. 

2.  Treatment  of  Cysticercus  and  Ecliinococcus  with  the 

Etherial  Extract  of  Filix  Mas,  By  de  Renzi. 

3.  The  Toxic  Action  of  Common  Salt  in  Subcutaneous 

Infusions  and  Its  Antidote, 

By  LuDwiG  F.  Meyer  and  Hans  Rietschel. 

4.  Thyreogenous  Disintegration  of  Albumin, 

By  Kurt  Meyer. 

5.  Hysteric  Fever,  _  By  Friedrich  Morchen. 

6.  The  Present  Position  of  Intravenous  Therapy, 

By  Felix  Mendel. 

7.  Pseudoleuchaemia  and  Similar  Pathological  Conditions, 

By  Hirschfeld. 

8.  Symphyseotomy  and  Hebosteotomy,  By  Ernst  Runge. 

1.  Madelung's  Wrist  Joint  Deformity. — Levy 
asserts  that  Madelung's  deformity  of  the  wrist  joint 
appears  in  childhood  as  the  result  of  rickets,  and 
that  its  development  in  later  life  is  caused  by  late 
rickets.  A  connection  with  exostosis  cartilaginea 
multiplex  is  not  probable,  but  the  exostoses  which 
appear  in  typical  places  in  Madelung's  deformity 
should  be  looked  upon  as  deformities  associated  with 
and  dependent  on  the  disease. 

2.  Treatment  of  Cysticercus  and  Echinococcus 
with  the  Etherial  Extract  of  Filix  Mas. — De 
Renzi  says  that  the  surgical  treatment  of  echino- 
coccus and  cysticercus  is  generally  considered  to  be 
the  only  form  indicated  because  it  is  assumed  that 
specific  remedies  can  act  upon  parasites  only  when 
the  latter  are  so  situated  as  to  be  subjected  to  the 
direct  influence  of  the  former,  as  when  the  para- 
sites are  in  the  intestine,  and  at  the  same  time  the 
surgical  treatment  is  diiftcult,  dangerous,  and  even 
impossible  in  many  patients,  as  in  the  case  of  cysti- 
cercus of  the  brain.  He  reports  four  cases,  two  of 
cysticercus  cerebri,  one  of  echinococcus  of  the  liver, 
one  of  echinococcus  of  the  lung,  in  which  medicinal 
treatment  with  the  ethereal  extract  of  filix  mas 
caused  a  rapid  disappearance  of  all  clinical  symp- 
toms. 

3.  Toxic  Action  of  Common  Salt. — Meyer  and 
Rietschel  confirm  the  statement  that  the  subcutan- 
eous injection  of  physiological  salt  solution  is  pro- 
ductive of  fever.  They  found  that  in  sixty  per  cent, 
of  all  infants  injected  with  twenty  to  fifty  grammes 


of  physiological  salt  solution  there  was  a  reaction 
with  a  rise  of  temperature  sometimes  to  over  39°  C. 
They  also  confirm  the  statement  of  Loeb  that  this 
toxic  action  may  be  prevented  by  the  addition  of 
potassium  and  calcium  in  proper  quantities. 

6.  Intravenous  Therapy. — Mendel  discusses  in 
this  the  conclusion  of  a  long  article  on  the  intra- 
venous administration  of  arsenic,  sodium  salicylate, 
digitalis,  and  of  some  other  drugs  which  have  been 
used  in  this  way. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 
December  8,  1908. 

1.  Indirect  Demonstration  of  a  Ferment  by  Injections  of 

Alcohol,  together  with  a  Contribution  to  the  Question 
of  Hypersensibility,  By  Heilner. 

2.  The  Quantitative  Estimation  of  Creatinine  in  the  Urine, 

By  Edlefsen, 

3.  High  Frequency  Treatment  of  Tabes, 

By  Nagleschmidt. 

4.  The  Danger  to  the  Cornea  in  the  Operative  Removal  of 

the  Gasserian  Ganglion,  By  Kollner. 

5.  A  Contribution  to  the  Operation  for  Gangrenous  Her- 

nia by  Means  of  Laparotomy,  By  Hesse. 

6.  Treatment  of  Fistulas  by  Injections  of  Beck's  Oint- 

ment, By  Steimaxn. 

7.  Demonstration  of  Urobilin  in  the  Urine,     By  Strauss. 

8.  Blood  Test  with  Benzidin  Paper,  By  Weinberger. 
g.    A  New,  Simple  Instrument  for  the  Measurement  of  the 

Blood  Pressure,  By  Herz. 

10.  The  Value  of  the  Histological  Diagnosis  of  Tumors  in 

Surgical  Treatment,  By  Frankel. 

11.  The  Full  Correction  of  Myopia  in  Children, 

By  Neustatter. 

12.  The  Origin  and  Treatment  of  Intestinal  Hernia  (Con- 

tinued), By  Koch. 

13.  Obituary  of  Friedrich  Althoff. 

14.  Changes  in  Medicine  and  in  the  Standing  of  Physicians 

during  the  Last  Fifty  Years,       By  vox  Bollinger. 

I.  Indirect  Demonstration  of  a  Ferment  by 
Injections  of  Alcohol. — Heilner  concludes  from 
his  experiments  that  the  introduction  of  alcohol  con- 
siderably accelerates  the  decomposition  of  the  hete- 
rologous albumin  circulating  in  the  blood,  it  may 
"fee  by  excitation  of  the  specific  ferment,  or  it  may 
be  by  the  promotion  of  the  activity  of  the  ferment. 

3.  High  Frequency  Treatment  of  Tabes.— Na- 
gelschmidt  reports  twenty-two  cases  of  tabes  treated 
with  the  high  frequency  current.  The  general  con- 
dition was  much  improved,  so  that  the  patients  felt 
fresher,  did  not  get  tired  so  easily,  and  slept  better, 
in  all  except  one.  The  ataxia  was  only  slightly  in- 
fluenced, if  at  all,  yet  the  motor  power  was  increased 
by  the  systematic  exercise  of  indivdual  muscles  by 
the  contraction  induced  by  the  electric  current.  In 
two  patients  there  was  a  return  of  the  previously 
lost  pupillary  reaction.  No  influence  on  the  knee 
jerk  or  other  reflexes  was  noted.  In  almost  all 
patients  the  sexual  functions  were  stimulated.  Five 
patients  complained  of  incontinence,  which  was 
stopped  after  varying  lengths  of  treatment.  The 
painful  symptoms  he  divides  into  three  categories : 
I,  The  typical  lancinating  pains;  2,  the  neuralgic 
or  rheumatic  pains,  among  which  are  classed  the 
hypersesthesias  of  the  skin ;  3,  the  crises.  Then  lanci- 
nating pains  are  the  ones  most  easily  affected  by  the 
treatment,  sometimes  disappearing  after  ten  or 
twenty  seconds  of  irradiation,  and  in  many  cases  a 
few  sittings  were  sufficient  to  render  the  patient  free 
from  pain  for  months.  In  other  cases  a  more  pro- 
longed treatment  was  necessary  in  order  to  obtain 
a  respite  of  three  months.    The  other  pains  were 


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PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


also  greatly  relieved  by  the  current.  From  his  ex- 
perience he  concludes  that  the  pains  in  tabes  can  be 
influenced  in  a  manner  to  a  certain  degree  specific 
by  proper  local  application  of  the  high  tension  cur- 
rent of  sufficient  intensity. 

4.  Danger  to  the  Cornea  in  Removal  of  the 
Oasserian  Ganglion.  —  Kollner  analyzes  twelve 
■cases  of  removal  of  the  Gasserian  ganglion,  and 
shows  that  ten  of  the  twelve  patients  suffered  from 
keratitis  after  the  operation,  which  caused  the  loss 
of  the  eye  in  one.  In  the  two  cases  in  which  the 
cornea  remained  normal  the  sensation  of  touch  in 
the  region  supplied  by  the  first  branch  of  the  fifth 
nerve,  particularly  in  the  conjunctiva  and  cornea, 
was  not  lost,  but  was  normal  in  the  one  case  and 
■only  reduced  in  the  other.  In  all  the  other  cases 
there  was  a  complete  insensibility  of  the  cornea. 

6.  Treatment  of  Fistulae. — Steimann  reports 
good  results  in  five  cases  of  fistulae  in  the  limbs  and 
about  joints  from  the  injection  of  the  ointment 
recommended  by  Beck.  The  ointment  is  composed 
of: 

Bismuth  subnitrate  30.0  grammes; 

White  petrolatum,   60.0  grammes; 

Liquid  parafifin,    5.0  grammes ; 

Yellow  wax,   50  grammes. 

The  technique  of  the  injections  is  described  rather 
briefly. 

THE  MILITARY  SURGEON. 
January,  igog. 

1.  Military  Sanitary  Problems  in  the  Philippine  Islands, 

By  Louis  Mervin  Maus. 

2.  Battleship  Neurasthenia,    By  Sheldon  Guthrie  Evans. 

3.  Hygienic  Maxims  for  the  Soldier  in  Camp  and  Field, 

By  Joseph  K.  Weaver. 

4.  Medical  versus  Surgical  Treatment  of  Amoebic  Dysen- 

tery, By  John  Milton  Holt. 

5.  Dry  Earth  Closets  for  Feld  Use, 

By  George  F.  Campbell. 

I.  Military  Sanitary  Problems  in  the  Philip- 
pine Islands. — Maus  gives  a  very  interesting  re^ 
view  of  the  military  sanitary  problems  in  the  Philip- 
pine Islands.  He  makes,  among  other  statements, 
the  following:  The  effects  of  climate  on  the  Ameri- 
can soldier  in  the  tropics  has  been  a  prolific  subject 
of  discussion  and  observation  by  army  surgeons,  sta- 
tioned in  Cuba,  Porto  Rico,  and  the  Philippines, 
since  1898.  The  earlier  visitors  unreservedly  de- 
clared that  Americans  could  not  live  in  the  tropics 
without  rapid  physical  and  mental  deterioration. 
He  cites  Colonel  Henry  Lippincott,  Colonel  Charles 
R.  Greenleaf,  and  Major  Charles  E.  Woodruff. 
Without  discussing  their  statements  he  remarks  that 
it  is  only  necessary  to  refer  to  the  thousands  of 
American  men  and  women  who,  without  absence 
from  the  archipelago  during  the  past  five  or  ten 
years,  have  enjoyed  the  very  best  of  health,  and  in- 
deed many  of  them,  delicate  on  arrival,  have  become 
strong  and  robust.  There  can  be  no  question  but 
that  the  seasoning  or  acclimatizing  process  has  pro- 
moted this  adaptability  to  life  in  the  Philippines,  as 
it  docs,  within  certain  limitations,  to  any  climate 
or  zone.  It  was  quite  natural  that  adverse  opinions 
should  be  formulated  by  medical  officers  on  duty  in 
ihc  Plii]ipj)incs  at  the  time,  on  account  of  the  ex- 
traortlinarily  high  sick  rate,  by  which  they  were  no 
doubt  influenced.  The  practice  of  the  knowledge 
acquired  against  the  contraction  of  preventable  dis- 
ea.ses  must  be  put  into  execution  before  any  absolute 
and  accurate  statistics  can  be  secured  relative  to 


diseases  resulting  from  climatic  conditions  in  the 
tropics.  There  is  no  doubt  but  that  people  migrat- 
ing from  a  temperate  zone  to  the  tropics  must  un- 
dergo a  seasoning  process  before  they  can  adjust 
themselves  to  the  new  conditions.  This  gradual 
change,  known  as  acclimatization,  has  been  uni- 
versally recognized,  and  affects  animals  equally  with 
man.  Americans,  born  north  of  Mason  and  Dixon's 
line  in  the  States,  who  transplant  themselves  in 
southern  Texas,  or  States  along  the  Gulf  of  Mex- 
ico, require  at  least  two  years'  residence  there  be- 
fore they  become  acclimatized. 

2.  Battleship  Neurasthenia. — Evans  says  that 
the  frequency  of  this  condition  in  both  the  army  and 
the  navy  in  recent  year  has  been  amazing,  and  in  the 
naval  branch  there  are  so  many  cases  of  varying 
types  that  the  train  of  symptoms  has  been  designated 
by  one  of  our  confreres  as  "'battleship  neurasthenia." 
a  name  well  suited  as  far  as  the  battleship  part  is 
concerned,  but  not  the  neurasthenia,  for  the  disease 
is  not  one  of  the  nervous  system  at  all,  but  one  alto- 
gether of  the  intestinal  tract  and  digestive  organs, 
and  the  symptoms  referable  to  the  nervous  system 
are  but  the  results  of  toxic  materials  absorbed  from 
the  intestinal  tract.  Our  object,  then,  is  to  get  the 
remedy  into  the  intestinal  canal  unchanged,  and  this 
is  done  by  having  it  in  pill  form  or  in  capsules  and 
then  coating  the  capsule  or  pill  with  shellac,  which 
is  insoluble  in  an  acid  and  perfectly  soluble  in  an 
alkali,  so  thus  we  have  the  remedy  remaining  un- 
changed in  the  stomach  and  immediately  dissolving 
in  the  alkaline  pancreatic  secretion  and  doing  its 
work  exactly  where  we  want  it.  The  choice  of  rem- 
edies is  large.  In  some  cases  the  salicylates  will  be 
found  useful,  particularly  the  magnesium  salt  and 
salol,  while  in  others  we  find  the  alkalies  more 
readily  borne  and  efficacious.  He  has  had  the  great- 
est success  Vi^ith  a  combination  of  the  sulphocar- 
bolate  of  zinc,  bismuth,  betanaphthol  and  aloin,  in 
pill  form,  well  coated  with  shellac  and  over  the 
shellac  coating  a  simple  gelatin  coating.  In  addi- 
tion to  the  medicinal  treatment,  exercise  is  of  the 
utmost  importance,  and  he  believes  it  is  the  lack  of 
exercise  that  makes  these  conditions  so  common  on 
board  ship.  It  should  not  be  overlooked  that  work 
is  not  exercise.  The  hardest  working  day  laborer 
needs  exercise  almost  as  much  as  the  closely  confined 
bookkeeper.  This  is  an  important  point  we  too  fre- 
quently lose  sight  of.  Exercise,  to  be  beneficial, 
must  be  associated  with  pleasurable  mental  sensa- 
tions and  interest.  Diet  is  of  secondary  importance 
and  must  be  individual. 

ANNALS  OF  SURGERY. 
January,  igofj. 

1.  Studies  in  Cancer — Historical  and  Critical, 

By  J.  G.  MUMFOBD. 

2.  The  Scrum  Reaction  in  Cancer,      By  U.  H.  Janeway. 

3.  Newer  Conceptions  of  Operative  Technique  in  Cleft 

Palate  and  Harelip,  By  J.  R.  Eastman. 

4.  Aberrant  Thyreoid,  By  B.  C.  Cushway. 

5.  Suppurative  Pericarditis,  By  E.  Eliot,  Jr. 

6.  Restoration  of  the  Perinseal   Portion  of  the  Urethra 

after  Destruction  by  Fracture  of  the  Pelvis, 

By  H.  Cabot. 

7.  Catheter  Fever,  By  L.  J.  Hammond. 

8.  Cruroscrotal  Hernia,  By  A.  H.  Ferguson. 

9.  Giant  Ceil  Sarcoma  of  the  Forearm,        By  A.  C.  Wood. 

10.  A  Modification  of  the  Bradford  Frame  for  the  Treat- 

nunt  hv  .Sn>pe'isi<)ii  of  I-'racturc^  of  the  Fenuir  in 
VouiiR  Children.  By  l^.  Silver. 


January  30,  1909.]  LETTERS  TO 

11.  Portable  Traction  Apparatus  for  Treating  Fractures  of 

the  Femur  and  for  Various  Orthopaedic  Operations, 

By  C.  M.  Echols. 

12.  Intestinal  Intussusception  Complicating  Typhoid  Fever, 

By  O.  C.  Smith. 

13.  A  Modified  Crile  Tube  for  the  Direct  Transfusion  of 

Blood,  By  T.  N.  Hepburn. 

14.  Surgical  Progress.    Reports  on  Cancer  of  the  Kidney 

and  Bladder  from  the  Second  Congress  of  Interna- 
tional Society  of  Surgery,  September,  1908. 

1.  Studies  in  Cancer,  Historical  and  Critical. 

— Muinford  thinks  those  writers  err  who  state  that 
cancer  was  not  recognized  by  the  ancients.  Its  fre- 
quency and  destructive  nature  have  been  recognized 
more  than  two  thousand  years,  but  it  has  often  been 
confounded  with  other  diseases.  The  laity  has  long 
believed  in  its  hopelessness,  the  best  physicians  in 
the  possibility  of  its  cure.  Many  have  supposed 
that  there  were  those  who  were  immune  to  it.  No 
disease  has  been  more  discussed ;  hypothesis  and 
assumption  have  been  substituted  for  theory  and 
theory  for  unquestioned  fact.  It  always  has,  and  still 
presents,  two  questions  for  solution,  its  cause  and 
cure,  both  still  unsettled.  It  was  studied  and  dis- 
cussed by  Hippocrates,  Celsus,  Galen,  and  other  an- 
cient writers.  In  the  twelfth  century  Avengoar  af- 
firmed that  the  stomach  and  uterus  as  well  as  the 
breast  were  favorite  victims  for  its  attack.  It  was 
classified  by  Pare,  while  he  and  his  followers  vig- 
orou.sly  attacked  the  disease  with  knife  and  cautery. 
Ever  since  his  time  surgeons  and  anatomists  have 
been  continuing  the  investigation  of  the  subject.  In 
the  old  days  diagnosis  depended  upon  the  results  of 
treatment.  Diagnosis  now  is  largely  influenced  by 
the  verdict  of  the  microscope.  The  haemolysis  test 
of  Crile  is  the  most  recent  addition  to  diagnostic 
knowledge.  The  hypotheses  as  to  its  aetiology  are 
almost  innumerable. 

2.  The  Serurn  Reaction  in  Cancer. — Janeway 
states  that  only  within  ten  years  has  the  attempt 
been  made  to  apply  the  method  of  serum  pathology 
to  human  disease.  An  important  recent  discovery  is 
that  the  isoha;molysins  in  cancer,  tuberculosis,  syph- 
ilis, and  some  other  diseases  will  destroy  red  cor- 
puscles to  which  they  may  be  applied.  Unfortunate- 
ly, this  discovery  has  not  yet  been  capable  of 
diagnostic  application.  The  essentials  for  obtaining 
the  desired  reaction  are  clear  serum  from  a  cancer 
patient  and  clear  serum  from  a  normal  individual ; 
also  a  ten  per  cent,  emulsion  of  red  blood  cells  from 
a  cancer  patient  and  a  ten  per  cent,  emulsion  of  the 
red  cells  of  a  normal  individual.  From  these  ingre- 
dients six  mixtures  are  prepared,  placed  in  an  in- 
cubator for  two  hours,  and  then  in  an  ice  chest  over 
night.  The  results  may  be  read  within  twenty-four 
hours  from  the  time  the  blood  was  taken.  Haemoly- 
sis is  shown  by  the  reddish  color  of  the  fluid,  com- 
paiison  being  made  with  controls  of  salt  solution. 
The  author  concludes  that  suspected  cases  of  cancer 
should  have  their  serum  tested  against  the  normal 
corpuscle  emulsion. 

3.  Newer  Conceptions  of  Operative  Technique 
in  Cleft  Palate  and  Harelip. — Eastman  states  that 
it  is  a  matter  of  tradition  that  to  operate  upon  a 
child  under  three  months  of  age  for  cleft  palate. 
Recent  experience,  however,  shows  that  under  or- 
dinary conditions  this  cleft  palate  should  be  operated 
on  within  the  first  week  after  birth.   The  arguments 


THE  EDITORS.  251 

for  early  operation  are  the  following:  i,  The  baby 
weighs  more  just  after  birth  than  for  a  few  weeks 
subsequently.  2,  Resisting  power  has  not  been  re- 
duced by  breathing  cold  air  through  a  roofless 
mouth.  3,  Digestion  has  not  been  impaired  by  un- 
satisfactory feeding.  4,  The  bones  are  softer.  5,  Im- 
pressions as  to  pain  are  not  so  acute.  6,  The  habit  of 
articulating  has  not  developed  through  the  cavern 
of  the  nose.  7,  By  immediate  operation  the  muscles 
of  the  palate  are  allowed  to  develop  and  not  to 
atrophy,  and  there  is  the  greatest  possibility  for  the 
development  of  the  nasopharynx.  8,  After  early 
operations  the  nose  is  gradually  pushed  forward  by 
the  growth  of  the  saeptum. 

 ^  

'gtttm  ta  tilt  m\m. 


TUBERCULOUS  DISEASE  AND  DIPHTHERIA 
ANTITOXINE. 

660  North  Salina  Street, 
Syracuse,  N.  Y.,  January  i,  igog. 

To  the  Editor: 

Your  editorial  of  December  19th,  on  Anaphylaxis,, 
recalls  to  my  mind  a  case  of  pulmonary  tuberculosis 
in  a  young  man  under  my  care  who  contracted  diph- 
theria. It  was  in  the  early  days  of  antitoxine,  when 
many  things  were  being  said  against  its  use.  I 
promptly  gave  2,000  c.c.  of  Behring's  antitoxine. 
The  patient  quickly  recovered  from  his  diphtheria 
infection,  and  shortly  afterward  the  cough  disap- 
peared, and  I  found  upon  physical  examination  that 
the  lungs  had  cleared  up  and  the  patient  was  appar- 
ently restored  to  perfect  health. 

Have  you  heard  of  any  other  practitioner's  meet- 
ing with  a  similar  experience  ? 

J.  H.  Drum. 


RHUS  POISONING. 

442  South  Beech  Street, 
Syracuse,  N.  Y.,  January  6,  igog. 

To  the  Editor: 

In  your  issue  of  December  26th  Dr.  Ralph  Fran- 
cis Ward  has  an  article  on  Severe  Ivy  Poisoning,  in 
which  he  states  that  toxicodendric  acid  is  the  astio- 
logical  factor,  "which  is  no  doubt  combined  with  a 
volatile  oil."  In  1865  Dr.  John  M.  Maisch  pub- 
lished his  discovery  of  toxicodendric  acid,  which 
was  accepted  as  correct  until  Dr.  Franz  Pfaff  pub- 
lished the  results  of  his  thorough  investigations  of 
the  subject  (see  Journal  of  Experimental  Medicine, 
1897).  Dr.  Pfaf¥  found  that  the  so  called  toxico- 
dendric acid  was  acetic  acid,  and  that  the  real  poi- 
sonous principle  was  a  nonvolatile  viscid  oil,  which 
he  isolated.  This  substance  would  produce  the  erup- 
tion in  so  minute  an  amount  as  i/iooo  mg. ;  and  that 
there  was  a  latent  period  of  from  three  to  ten  days 
from  the  application  of  the  poison  until  the  erup- 
tion began.  From  a  study  of  the  chemistry  of  the 
poison  Dr.  Pfaff  indicated  the  treatment.  In  view 
of  the  almost  universal  misconception  of  the  subject 
of  ivy  poisoning,  I  would  suggest  that  you  publish  a 
comprehensive  abstract  of  Dr.  Pfafif's  study. 

John  B.  Todd. 


252 


BOOK  NOTICES. 


[New  York 
Medical  Journaj,. 


[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 

Typhoid  Fever.  Its  Causation,  Transmission,  and  Preven- 
tion. By  Geokge  C.  Whipple,  Consulting  Engineer,  with 
an  Introductory  Essaj'  by  William  T.  Sedgwick,  Profes- 
sor of  Biologj',  Massachusetts  Institute  of  Technology 
First  Edition.  First  Tliousand.  New  York :  John  Wiley 
&  Sons ;  London  :  Chapman  &  Hall,  Limited,  1908.  Pp. 
xii-407.    (Price,  $3.) 

In  this  reasonable  volume  the  manifold  and  varied 
problems  of  the  prevention  and  hygiene  of  typhoid 
fever  are  approached  from  the  standpoint  of  the  sani- 
tary engineer.  The  important  questions  of  the 
origin  and  distribution  of  typhoid  fever  and  its  re- 
lations to  public  water  supplies  and  disposal  of  sew- 
age are  dealt  with  in  adequate  detail  and  with  expert 
knowledge  which  will  make  i\Ir.  Whipple's  work  an 
authoritative  guide  for  officers  of  municipalities  and 
boards  of  health.  An  instructive  and  carefully  pre- 
pared map  of  the  geographical  distribution  of  ty- 
phoid fever  in  the  United  States  shows  that  the 
number  of  cases  in  a  community  is,  on  the  whole,  a 
very  fair  index  of  the  degree  of  intelligence  and 
sta.^e  of  development  of  the  citizens.  Brief  histor- 
ies of  important  recent  typhoid  epidemics  are  given, 
"t}  phoid  carriers"  are  fully  discussed,  and  in  the  ap- 
pendices are  included  the  various  bacteriological 
methods,  the  comparative  values  of  disinfectants 
and  practical  instructions  as  to  their  use.  and  the 
most  recent  compilations  of  statistics  from  this 
country  and  Europe.  The  more  strictly  medical  as- 
pects of  the  subject,  where  touched  upon,  are  con- 
servatively and  judiciously  treated. 

A  Common  Sense  View  of  the  Mind  Cure.  By  L.\ura  M. 
Westall.  New  York  and  London :  Funk  &  Wagnalls 
Company,  1908.    Pp.  124. 

In  launching  this  little  book  the  author  is  actuated 
by  a  desire  to  give  a  plausible  explanation  of  the 
phenomena,  real  or  supposititious,  which  ensue  upon 
psychical  states  of  various  kinds.  A  paragraph  on 
page  60  afi^ords  at  once  a  synopsis  of  her  views  and 
a  measure  of  her  logic.  "Well"  (she  has  been  speak- 
ing of  the  imagination),  "it  is  a  poor  rule  that  won't 
Avork  both  ways.  If  morbid  attention  and  imagina- 
tion can  cause  disease,  then  a  sane,  intelligent  use 
of  them  should  cure  disease." 

Alas  that  we  should  feel  impelled  to  declare  that, 
in  our  humble  judgment,  this  is  one  of  the  "poor" 
rides;  that,  not  to  put  too  fine  a  point  on  it,  more 
disease — a  good  deal  more — is  caused  by  mental  im- 
pression than  will  ever  be  cured  by  it ;  and  that,  in 
fine,  in  matters  therapeutic,  we  shall  have  to  grope 
our  way  in  the  future,  as  in  the  past,  by  the  aid  of 
experimental  ob.servation  in  the  laboratory  and  in 
the  clinic,  rather  than  blithely  amble  after  some 
spurious  beacon,  some  ignis  fatuus  of  optimistic 
casuistry.  Yet  how  sweet  it  is  to  soar  upon  the 
wings  of  self  sufficing  generality !  Listen  to  this, 
all  ye  who  doubt  the  truth  and  substance  of  our 
apostrophe:  "It  is  strongly  probable  that  slight 
structural  defects,  like  outstanding  ears,  round 
shoulders,  or  a  misshapen  nose,  may  be  remedied  by 
psychophysical  treatment,  provided  such  work  is 
undertaken  before  the  age  of  thirty"  (page  122). 
And,  again:  "Daily  concentration  of  attention  upon 


the  scalp  will  put  an  end  to  this  condition  (  falling 
hair)  and  new  hair  may  be  grown,  if  the  hair  glands 
have  not  been  destroyed  by  bacilli"  (  !)  This  should 
be  good  news  for  those  bald  headed  gentry  who  at 
the  theatre  are  wont  to  crane  their  necks  from  the 
front  benches.  But,  shades  of  intrusive  doubt — 
could  they  be  bribed  to  transfer  their  allegiance 
from  the  footlights  to  the  follicles  ? 

Space  and  time,  heedless  of  inclination,  prevent 
otir  further  nomadizing,  hand  in  hand,  as  it  were 
with  the  author  of  this  peculiar  gift  to  science. 
Enough  that  the  true  disciple  may,  if  fat,  grow  lean, 
and  if  lean,  grow  fat,  by  taking  the  same  psychical 
prescription.  Then  there  is  catarrh,  and — and — but 
why  strive  to  catalogue  the  marvels  ?  A  melancholy 
king,  a  facetious  creation  of  the  genius  of  comic 
opera,  shuffled  down  the  stage  not  many  years  since.- 
\s  his  majesty  neared  the  footlights.  "Oh,  make  me 
smile  !"  he  lamented  ;  "Oh,  make  me  smile !"  But 
the  sad  clownery  of  his  consorting  courtiers,  them- 
selves sufferers  from  a  kind  of  subordinate  "blues," 
brotight  him  no  relief.  He  should  have  read  this 
book. 

Spectacles  and  Eyeglasses.  Their  Forms.  Mounting,  and 
Proper  Adjustment.  By  R.  J.  Phillips,  M.  D.,  Ophthal- 
mologist, Presbyterian  Orphanage,  Philadelphia,  etc. 
Fourth  Edition,  Revised,  with  56  Illustrations.  Phila- 
delphia: P.  Blakiston's  Son  &  Co.,  1908. 

The  fourth  edition  of  Phillips's  nractical  little 
manual  describes  the  lacest  forms  and  methods  of 
eyeglass  fittings,  and  contains  descriptions  of  some 
new  testing  instrument';  and  of  the  most  modem 
types  of  bifocal  lenses.  The  practical  oculist  will 
will  find  information  much  of  which,  as  the  author 
says,  was  before  scattered  in  trade  jotirnals  or  op- 
ticians' magazines.  These  details  of  appHcation  are 
not  considered  in  the  treatises  on  refraction,  so  that, 
whatever  we  may  think  of  the  optician  as  an  oph- 
thalmologist, the  average  ophthalmologist  is  apt  to 
be  a  very  poor  optician. 

I. — Transactions  of  the  Society  of  Tropical  Medicine  and 
Hygiene.  1907-1908.  II. — Papers  Read  Before  the 
American  Society  of  Tropical  Medicine  and  Published 
under  Its  Auspices,  Volume  iii,  1907-1908. 

In  1579  Thomas  Stevens  sailed  from  Lisbon  to 
Goa,  the  first  Englishman  to  visit  India;  in  1583 
three  English  merchants  started  overland  for  India ; 
and  in  1591  three  ships  started  on  the  first  voyage 
from  an  English  port  to  India.  The  East  India 
Company  was  chartered  in  1600,  and  its  first  expe- 
dition sailed  in  1601.  Since  that  time  England  has 
had  continuous  tropical  possessions  and  interests,  as 
indeed  have  most  European  countries.  So  little  were 
the  special  conditions  of  tropical  life  appreciated  at 
home,  and  so  little  attention  was  paid  to  the  hygiene 
of  life  in  the  tropics,  that  the  native  East  Indian 
has  a  saying  that  only  Englishmen  and  dogs  are 
found  about  in  the  heat  of  the  day.  Under  the  lead- 
ership of  Sir  Patrick  Manson  and  some  other  far 
seeing  Englishmen,  the  special  field  of  tropical  sani- 
tation, tropical  pathology,  and  tropical  parasitology 
has  been  constantly  held  before  the  English  |>eople, 
and  at  last  a  partial  sense  of  appreciation  has  been 
developed  in  the  English  government  official  and 
merchant  of  the  work  of  men  investigating  the  prob- 
lems of  the  tropical  and  subtropical  world.  The 
foundation  of  the  Liverpool  School  of  Tropical 
Medicine,  in  1898,  and  of  the  London  School  of 


January  30.  1909  ] 


BOOK  NOTICES. 


253 


Tropical  Medicine,  and  the  organization  of  the  So- 
ciety of  Tropical  Medicine  and  Hygiene,  in  1907,  are 
some  of  the  results  of  the  work  of  the  three  hun- 
dred years  that  England  has  been  in  the  tropics. 

The  Transactions  of  the  Society  of  Tropical 
Medicine  and  Hygiene  contains  the  papers  read  dur- 
ing the  first  year  of  the  existence  of  that  society. 
Although  a  large  portion  of  the  home  territory  of 
the  United  States  is  subtropical  in  its  climate,  no 
really  close  and  important  connections  e.xisted  be- 
tween the  United  States  and  the  tropics  until  the 
period  of  the  Spanish- American  war  (1898  )  with 
its  attendant  events  gave  Americans  permanent  in- 
terests in  Puerto  Rico  and  the  Philippine  Islands 
and  temporar>-  interests  in  other  tropical  countries. 
There  is.  however,  another  source  of  permanent  in- 
terest in  the  tropics  for  the  American  in  the  six 
hundred  thousand  immigrants  who  annually  arrive 
in  this  country  from  tropical  lands.  The  incorpora- 
tion of  the  American  Societ}'  of  Tropical  Medicine, 
in  IQ03.  five  years  after  the  Spanish-American  war. 
showed  that  the  medical  man  in  the  United  States 
appreciated  his  hygienic  and  sanitary  problems  and 
opportunities.  The  third  volume  of  papers  read  be- 
fore this  society  and  published  under  its  auspices 
shows  a  healthy  growth  and  an  increase  of  interest 
and  range  of  activity  over  the  former  volumes. 

Les  Erythcmes  graves  (syndrome  erythemateux),  princi- 
palemcnt  au  cours  de  la  fievre  nphoTde,  par  le  Dr.  M.vr- 
CEL  PoisoT,  ancien  interne  des  hopitaux  de  Paris,  etc 
Paris :  Jules  Rousset,  1908.    Broche.  pp.  208. 

This  work  is  a  detailed  study  of  seventy-two 
cases  of  severe  eruptions  supervening  in  the  course 
of  tuberculosis  and  other  diseases,  mainly  typhoid 
fever,  in  which,  especially  in  children,  they  consti- 
tuted what  the  author  calls  a  true  erythematous  syn- 
drome, accompanied  by  high  fever,  vomiting,  green 
diarrhoea,  ulceration  of  the  nasal  and  labial  margins, 
prostration,  the  peritoneal  facies,  and  a  modification 
of  the  fever  curve.  The  last  had  a  marked  terminal 
ascent  in  fatal  cases. 

These  eruptions  denote  an  abnormal  and  malig- 
nant form  of  t}  phoid ;  they  may  be  unique  in  a  ward 
or  appear  in  series  with  great  frequency,  although 
by  no  means  contagious.  The  prognosis  is  very 
grave,  the  mortality  varying  from  sixty  to  eighty 
per  cent.,  and  depends  upon  the  concomitant  symp- 
toms, which,  appearing  together,  almost  invariably 
forebode  a  fatal  result.  Convalescence  in  more  for- 
tunate patients  is  tedious. 

These  er^'themata  are  not  characteristic  of  ty- 
phoid, are  not  drug  eruptions,  and  are  probably  not 
infectious  eruptions  due  to  secondarv  septicaemia. 

The  author  submits  the  hypothesis  of  a  sapro- 
phyte, capable  under  certain  conditions  of  becoming 
directly  dangerous,  but  more  probably  able  to  impart 
virulent  properties  to  the  Eberth  bacillus.  Toxines 
elaborated  in  the  intestine  and  being  reabsorbed  de- 
termine a  rapid  and  intense  granulofatty  degenera- 
tion of  the  glandular  parenchyma,  chiefly  that  of 
the  liver,  which  invariably  shows  lesions. 

This  malignant  eruption  is  not  confined  to  typhoid 
fever,  but  is  noted,  although  rarely,  in  paratvphoid, 
pneumonia,  and  nephritis :  and  a  similar  phenom- 
enon has  been  noted  in  measles,  scarlatina,  and 
diphtheria.  This  is  probably  not  due  to  glandular 
lesions,  but,  whatever  the  aetiologv.  seems  to  have 
some  definite  relation  to  involvement  of  the  liver  or 
kidnev?  in  the  course  of  the  disease. 


A  good  bibliography  completes  the  work,  which  is 
dedicated  to  no  fewer  than  forty-one  individuals, 
living  and  dead. 

A  Correction. — By  an  error  we  spoke  in  our  last 
issue  of  the  volume  of  Keen's  Surgery  under  re- 
view as  "Volume  IX."  It  should  have  read  Vol- 
ume IV. 

NEW  PUBLICATIONS. 

Anatomy,  Histology,  and  Microscopy. 
Schultzc.  Oskar. — Atlas  und  Grundriss  der  topographischen 

und    angewandten    Anatomic.     2.    vermehrte  Auflage. 

Miinchen:  J.  F.  Lehmann.  1909.  Pp.  224.  (Price,  Mk.  16.) 
Monckeberg,  J.  G. — Untersuchungen  iiber  das  Atrioventri- 

kularbundel  im  menschlichen  Herzen.  Mit  10  Tafeln  und 

4  Abbildungen  im  Text.    Jena:  Gustav  Fischer,  1908. 

Pp-  329- 

Chemistry. 

Koch,  A. — Jahresberichfr  fiber  die  Fortschritte  in  der  Lehre 
von  den  Garungs-Organismen.  16.  Jahrgang,  1905.  Leip- 
zig: S.  Hirzei,  1908. 

Holland.  J.  W. — The  Urine  and  Clinical  Chemistrj-  of  the 
(jastric  Contents,  the  Common  Poisons,  and  Milk.  Forty 
Illustrations.     Eighth   Edition.   Revised  and  Enlarged. 
Philadelphia :  P.  Blakiston's  Son  &  Co..  190S.  Pp. 
160.    (Price,  Si.) 

Physiology. 

Blaincourt. — Tableaux  sj-noptiques  de  physiologic.  Paris  : 
Bailliere  et  fils.    Pp.  171.    (Price,  3L  50.) 

Bacteriology. 

Stitt,  E.  R. — Practical  Bacteriology.  Blood  Work,  and  Ani- 
mal Parasitology.  Including  Bacteriological  Keys,  Zoo- 
logical Tables  and  Explanatory  Clinical  Notes.  With  86 
Illustrations.  Philadelphia :  P.  Blakiston's  Son  &  Co., 
1909.    Pp.  viii-294. 

Pathology. 

Beattie.  J.  M.,  and  Dickson.  IV.  E.  C. — A  Textbook  of  Gen- 
eral Patholog>'.    London:  Rcbman.    (Price,  17s.  6d.) 

Aschoff,  L..  und  Marchand,  F. — Beitrage  zur  pathologischen 
Anatomic  und  zur  allgemeinen  Pathologic.  Begriindel 
von  E.  Ziegler.   Jena :  G.  Fischer,  1908. 

Aichel.  O. — Eine  neue  Hj'pothese  iiber  Ursachen  und  Wesen 
bosartiger  Geschwiilste.  Miinchen :  J.  F.  Lehmann.  1908. 
Pp.  36.    (Price,  Mk.  1.50.) 

Josue,  O. — Traite  de  IWrterio-sclerose.  Avec  20  figures 
noires  et  coloriees.  Paris :  J.  B.  Bailliere  et  fils.  1909. 
Pp.  400.    (Paris.  lof.) 

Internal  Medicine. 

Desguin,  L. — La  Septicemic  a  pneumocoques.  Paris  :  Bail- 
Here  et  fils.    (Price.  5!  ) 

Gauitier,  R. — Les  Dilatations  de  I'estomac.  Paris  :  Bailliere 
et  fils.    Pp.  96.    (Price  if.  so.) 

Goodall,  E.  JV..  and  Washburn.  J.  W. — Manual  of  Infec- 
tious Diseases.  Second  Edition.  London :  H.  K.  Lewis. 
Pp.  438.    (Price.  14s.) 

Liebe,  Georg. — Vorlesungen  iiber  Tuberkulose.  I.  Die 
mechanische  und  psychische  Behandlung  der  Tuberku- 
losen  besonders  in  Heilstatten.  Miinchen :  J.  F.  Leh- 
mann, 1909.    Pp.  viii-267.    (Price,  Mk.  5.) 

Surgery. 

Aschoff. — Die  Wurmfortsatzentziindung.  Eine  patholo- 
gisch-histologische  und  pathogenetische  Studie.  Mit  18 
lithog^aphischen  Tafeln  imd  22  Abbildungen  im  Text. 
Pp.  114.    Jena:  Gustav  Fischer.  1908. 

Distot  et  Vignard. — Les  Fractures  du  coude  chez  I'enfant. 
Avec  5  planches,  contenant  76  radiographics  hors  texte. 
Paris:  Octave  Doin,  1909.    Pp.  225.    (Price.  6f.) 

Monod.  Ch..  et  J'anz-erts.  J. — Traite  de  technique  opera- 
toire.  2me  ed..  refondue.  2  vol.  Avec  2337  figures. 
Paris:  Masson  et  Cie.    (Price,  58f.) 

Sonnenburg.  Eduard. — Pathologic  und  Therapie  der  Peri- 
typhlitis. Sechste  um.bearbeitete  Auflage.  Mit  38  Abbil- 
dungen und  farbigen  Kurven.  Leipzig :  F.  C.  W.  Vogel, 
1908.    Pp.  282. 

Xeurology  and  Psychiatry. 

Araky.  S. — Studien  iiber  Kniereflexkur\-en.  Miinchen :  G. 
C.  Steinicke.  1908. 

Dost.  Max. — Kurzer  Abriss  der  Psychologic,  Psychiatric 
und  gerichtlichen  Psychiatric,  nebst  einer  aiisfuhrlichen 
Zusammenstellung  der  gebrauchlichen  Methoden  der  In- 
telligenz-  und  Kenntnisprufung.  Fiir  Juristen  und  Medi- 
ziner.  Mit  21  Abbildungen  und  i  Tafeln.  Leipzig:  F.  C 
W.  \'ogel.  1908.    Pp.  142.    (Price.  Mk.  4^ 


254 


MISCELLANY. 


[New  York 
ilEDiCAL  Journal. 


Gerllng,  Rlwld. — Handbuch  der  hypnotischen  Suggestion. 

3.  vermehrte  Aullage  neubearbeitet  von  Jaques  Groll. 

Leipzig:  A.  Strauch,  igo8.  Pp.  268.  (Price,  Mk.  4.50.) 
Schula,  Ludicig. — Leitfaden  fiir  Irrenpfleger.  Vom  deutsch- 

en   Verein    fiir    Psychiatric    gekronte    Preisschrift.  6. 

Aiiflage.    Halle:  C.  Marhold,  1909.    Pp.  100.  (Price, 

Mk.  1.50.) 

Marinesco,  G. — La  Cellule  nerveuse.    Preface  de  Ramon 
y  Cajal.    2  vol.    Avec  252  figures  dans  le  texte.  Paris: 
Octave  Doin  et  fils,  1909.    Pp.  1175.    (Price,  lof.) 
Obstetrics  and  Gyncecology. 

Fischer,  J. — Geschichte  der  Geburtshilfe  in  Wien.  Im  Auf- 
trage  der  Wiener  geburtshilflichen  und  gynakologischen 
Gesellschaft  bearbeitet.  Mit  einem  Vorwort  von  F. 
Schauta.    Wien :  F.  Deuticke,  1909.    Pp.  523. 

Schultze,  B.  S. — Lehrbuch  der  Hebammenkunst.  Vierzehnte, 
verbesserte  Auflage.  Mit  103  Abbildungen.  Leipzig : 
Wilhelm  Engelmann,  1908.    Pp.  404. 

Ophthalmology. 

Axenfeld,  et  al. — Lehrbuch  der  Augenheilkunde.  Mit  10 
Farbentafeln  und  455  zum  grossen  Teil  mehrfarbigen 
Abbildungen  im  Text.  Jena :  Gustav  Fischer,  1909.  Pp. 
xiii-679.    (Price,  Mk.  14.) 

Nose  and  Throat. 

Coakley,  C.  G. — Manual  of  the  Diseases  of  the  Nose  and 
Throat.    4th  ed.    London :' H.  Kimpton.    (Price,  14s.) 
Rectum  and  Anus. 

Ball,  Sir  Charles. — The  Rectum,  its  Diseases  and  Develop- 
mental Defects.  London:  Frowde.  Pp.  346.   (Price,  30s.) 

Gant,  S.  G. — Constipation  and  Intestinal  Obstruction  (Ob- 
stipation). With  250  Original  Illustrations.  Philadel- 
phia and  London  :  W.  B.  Saunders  Company,  1909.  Pp. 
559-    (Price,  $6.) 

Dermatology  and  Syphilology. 

Emery,  E.,  et  Chatin,  A. — Therapeutique  clinique  de  la 
syphilis.    Paris:  Masson  et  Cie.    Pp.  639.    (Price,  lof.) 
Genitourinary. 

Casper,  Leopold. — A  Textbook  of  Genitourinary  Diseases. 
Including  Functional  Sexual  Disorders  in  Man.  Trans- 
lated and  Edited,  with  A.dditions,  by  Charles  W.  Bonney. 
Second  Edition,  Revised  and  Enlarged.  With  230  Illus- 
trations and  24  Full  Page  Plates,  of  which  8  are  in 
Colors.  Philadelphia :  P.  Blakiston's  Son  &  Co.,  1909. 
Pp.  xvi-645-    (Price,  $5.) 

Mann,  }.  Physiolog>'  and  Pathology  of  the  Urine,  with 
Methods  for  its  Examination.  Second  Edition.  Lon- 
don: Grifhn.    Pp.  338.    (Price,  los.  6d.) 

Therapeutics. 

Broicn,  IV.  L. — Physiological  Principles  in  Treatment.  Lon- 
don :  Bailliere.    Pp.  352.    (Price,  5s.) 

Pas,  Eugene. — La  Gymnastique  raisonnee.  Preface  de 
Jules  Simon.  Avec  120  figures  et  4  planches  anatomiques. 
Paris:  Jules  Rousset,  1908.    Pp.  256.    (Price,  2f.) 

Schultze,  F. — Die  neuere  Entwicklung  der  Therapie  in  der 
inneren  Medizin.  (Rektoratsrede.)  Bonn:  F.  Cohen, 
1909-    Pp.  27.    (Price,  I  Mk.) 

Sutherland,  C.  A.~A  System  of  Diet  and  Dietetics.  Lon- 
don:  Frowde.   Pp.908.    (Price,  30s.) 

Carnot,  P.,  et  al. — Physiotherapie.    Kinesitherapie.  Mas- 
sage— mobilisation — gymnastique.    Avec  356  figures  dans 
le  texte.    Paris :  J.  B.  Bailliere  et  fils,  1909.    Pp.  xii-559. 
Electricity,  Rontgen  Rays,  and  Emanations. 

Bordier,  H. — Technique  radiotherapique.  Paris  :  Masson  et 
Cie.    Pp.  172.    (Price,  2f.  50.) 

Machado,  Les  Applications  directes  et  indirectes  de 
I'electricite  a  la  medecine  et  a  la  chirurgie.  Lisbonne :  Im- 
primerie  de  I'Academie  royale  des  sciences. 

Wetterer,  /oje/)/!.— Handbuch  der  Rontgentherapie  nebst 
Anhang:  die  Radiumtherapie.  Ein  Lehrbuch  fiir  Aerzte 
und  Studierende.  Mit  198  Figuren  im  Text,  11  Tafeln  in 
Vierfarbcndruck  und  4  Tafeln  in  Schwarzdruck.  Leip- 
zig: Otto  Nemnich,  1908.    Pp.  799. 

Onomatology. 

Guttmann,  W. — Medizinische  Terminologie.  Ableitung  und 
I'.rklarung  der  gebrauchlichsten  Fachausdriicke  allcr 
Zweige  der  Medizin  und  ihrcr  Hilfswissenschaften.  3. 
umgearbeitete  Auflage.  Wien :  Urban  &  Schwarzenberg, 
1909. 

Hygiene  and  Public  Health. 
Ccaplewski,  /•.— Kiirzes  Lehrbuch  der  Desinfektion,  unter 
Zugrundelegung  der  Einrichtungen  der  Desinfektionsan- 
stalt  der  Stadt  Coin.    3.  umgearbeitete  Auflage.    Bonn : 
M.  Hager,  190R.    Pp.  178.    (Price,  3  Mk.) 


GuUlcrmond,  G. — Les  Services  d'hygiene  de  la  ville  le 
Paris  en  1908.    Paris:  Jules  Rousset.    (Price,  3f.) 

Nocht. — Tropenhvgiene.  Leipzig :  Goeschen.  Pp.92.  (Price, 
Mk.  0.80.) 

Iranjen. — Das  .Altern  als  abwendbare  Krankheit.  Eine 
biologische  Studie.  Halle :  C.  Marhold,  1909.  Pp.  35. 
(Price,  Mk.  0.75.) 

Villiers,  A.,  Collin,  E.,  ct  Fayolle,  M. — Traite  des  falsifica- 
tions et  alterations  des_  substances  alimentaires.  2me  ed. 
augmentee.  Avec  750"  figures.  Paris :  O.  Doin  et  his. 
Pp.  2800, 

Nursing. 

Salzwedel. — Handbuch  der  Krankenpflege.  Neunte  .Au- 
flage. Mit  3  Tafeln  in  Farbendruck  und  75  Abbildungen 
im  Text.    Berlin :  August  Hirschwald,  1909.    Pp.  513. 

Miscellaneous. 

Annual  Report  of  the  Board  Df  Regents  of  the  Smithsonian 
Institution.  Showing  the  Operations,  Expenditures,  and 
Condition  of  the  Institution  for  the  Year  Ending  June 
30,  1907.  Washington :  Government  Printing  Office,  1908. 
Pp.  lvii-726. 

Von  Behr. — ]\Ietrische  Studien  an  152  Guanchenschadeln. 

Mit  21   Strichatzungen  lind   12  Autotypen.  Stuttgart: 

Strecker  &  Schroder,  1908.    Pp.  83. 
Chervin,  Arthur. — Anthropologic  bolivienne,  tome  I.  Paris: 

Le  Soudier.  Pp.  412.    (Price,  2of. ) 

 <^  

Itisrdlang. 


The  American  Hospital  Association. — The  As- 
sociation has  sent  the  following  letter  to  its  mem- 
bers : 

The  cooperation  and  assistance  of  hospital  superintend- 
ents and  trustees  toward  securing  a  reduction  in  the  tariff 
on  surgical  instruments  and  scientific  appliances  is  earnestly 
requested  at  the  present  time.  The  Ways  and  Means  Com- 
mittee of  the  House  of  Representatives  (Hon.  Sereno  E. 
Payne,  chairman)  is  now  in  session,  and  will  make  a  re- 
port on  tariiY  revision  late  in  February. 

Few  surgical  instruments  and  scientific  appliances  are 
manufactured  in  this  country.  It  is  believed  that  over 
eighty  per  cent,  are  imported.  An  average  tariff  duty  of 
forty  per  cent,  is  imposed  by  law  on  surgical  instruments, 
scientific  appliances  and  apparatus,  which  increases  their 
cost  to  hospitals,  physicians,  and  others  to  a  corresponding 
degree. 

Address  the  senators  from  your  State  and  the  congress- 
man from  your  district,  and  do  so  at  once,  as  the  time  is 
short.  A  petition  has  already  been  made  to  the  chairman 
of  the  Ways  and  Aleans  Committee,  suggesting  the  follow- 
ing amendment  to  Paragraph  638  of  the  present  tarilT  act. 
The  section  in  capitals  is  new. 

No.  638.  Philosophical  and  scientific  apparatus,  utensils, 
instruments,  and  preparations,  including  bottles  and  boxes 
containing  the  same  specially  imported  in  good  faith  for  the 
use  and  by  order  of  any  society  or  institution  incorporated 
or  established  solely  for  religious,  philosophical,  educa- 
tional, scientific,  or  literary  purposes,  or  for  the  encourage- 
ment of  the  fine  arts,  or  for  the  use  or  by  order  of  any 
college,  academy,  school,  or  seminary  of  learning  in  the 
LTnited  States,  or  anv  State  or  public  librarv,  and  not  for 
sale,  AND  ALL  MEDICAL  AND  SURGICAL  INSTRU- 
MENTS. APPLIANCES,  AND  APPAR.\TUS  SPECIAL- 
LY IMPORTED  IN  GOOD  FAITH  FOR  THE  USE 
AND  BY  ORDER  OF  ANY  INCORPORATED  HOSPI- 
TAL, ASYLUM  OR  OTHER  INSTITUTION  REN- 
DERING MEDICAL  OR  SURGICAL  AID  TO  THE 
PUBLIC  OR  ANY  PORTION  THEREOF  FREE  OF 
CHARGE,  AND  WHOSE  EXPENSES  ARE  BORNE 
WHOLLY  OR  IX  PART  BY  PUBLIC  FUNDS  OR  BY 
PRIVATE  SUBSCRIPTION,  SAID  ARTICLES  TO 
REMAIN  THE  PERMANENT  PROPERTY  OF  SUCH 
HOSPITAL,  ASYLUM  OR  OTHER  INSTITUTION, 
subject  to  such  regulations  as  the  Secretary  of  the  Treas- 
ury shall  prescribe. 

Newspaper  Medicine. — Dr.  E.  Franklin  Smith, 
of  New  York,  has  sent  the  following  letter  to  the 
.S"!*;;,  of  Xew  York,  dated  January  21.  190): 

To  the  Editor  of  the  Sun:  Sir — On  page  three  of  the 
Sun  for  January  17.  appears  an  item  entitled  Paralysis 


January  30.  1909.] 


OFFICIAL  NEWS. 


255 


among  Children.  Strange  Epidemic  in  Vienna.  Polio- 
myeitis  Cripples  and  Kills.  This  is  a  special  cable  dispatch 
to  the  Sun.  Medical  journals  have  for  a  long  time  called 
attention  to  the  absurdities  foisted  upon  the  public  as  med- 
ical news,  and  the  daily  papers  still  continue  to  publish 
statements  that  are  an  insult  to  intelligent  readers.  In  the 
item  above  alluded  to,  the  first  error  is  in  the  word  "polio- 
myetis."  The  writer  evidently  meant  poliomyelitis.  Who 
ever  heard  of  a  malignant  epidemic?  Again  we  suspect 
the  writer  intended  to  say  an  epidemic  of  malignant  spinal 
paralysis.  To  say  that  the  name  was  hardly  known  until 
this  epidemic  broke  out  is  erroneous.  The  disease  has  been 
known  and  mentioned  in  textbooks  on  medicine  for  at  least 
sixty  }-ears.  Colmar  wrote  about  it  sixty  years  ago.  As  we 
had  an  epidemic  here  several  years  ago,  it  is  quite  evident 
that  the  disease  was  known  before  the  present  epidemic  in 
Vienna.  The  description  of  symptoms,  while  sensational, 
cannot  by  any  stretch  of  the  imagination  be  called  accurate 
or  truthful.  Excellent  research  work  in  the  study  of  this 
affection  has  been  carried  on  here  in  our  city  by  the  Rock- 
efeller Institute  of  Medical  Research.  The  editorial  on 
Newspaper  Medicine  which  appeared  in  The  Xe<v  York 
Medical  Journal,  of  January  9,  1909,  should  be  suggestive. 
In  an  address  Dr.  A.  Jacobi  made  a  brilliant  plea  for  the 
employment  on  the  editorial  staff  of  every  newspaper  of  a 
competent  medical  man  m  order  that  the  public  might  be 
protected  from  the  misstatements  of  those  who  attempt  to 
write  on  subjects  upon  which  they  are  utterly  uninformed. 

Resolutions  on  the  Death  of  Dr.  John  J.  Quig- 
ley. — At  a  special  meeting  of  the  Medical  Board 
of  Fordham  Hospital,  January  9,  1909,  the  following 
resolutions  were  adopted  upon  the  death  of  Dr.  John 
J.  Ouigley:  " 

Whereas.  Through  the  death  of  Dr.  John  J.  Ouig- 
ley, the  Medical  Board  of  Fordham  Hospital  has 
lost  one  of  its  original  members  and  a  former  presi- 
dent ;  one  who  had  -been  connected  with  the  hospital 
as  visiting  surgeon  for  seventeen  years ;  whose  vig- 
orous personality  won  for  him  the  respect,  admira- 
tion, and  love  of  his  colleagues ;  Therefore  be  it 

Resolved.  That  the  members  of  the  Medical 
Board  of  Fordham  Flospital  express  their  profound 
sorrow  at  the  loss  of  their  associate  and  extend  to 
the  bereaved  family  heartfelt  sympath}-.  And  be 
it  further 

Resolved,  That  these  resolutions  be  spread  upon 
the  minutes  of  the  Board  and  that  a  copy  be  fur- 
nished to  the  medical  press  for  publication,  and  that 
a  further  copy  be  transmitted  to  the  famil\-  of  the 
deceased. 

Alexander  Xtcoll,  ^L.  D.. 
Secretary  of  the  Medical  Board. 
January  19,  1909. 

 ^  


Public   Health   and   Marine    Hospital  Service 
Health  Reports : 

The  following  cases  of  smallpox-,  yellovj  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  seven  days  ending  January  22,  igog: 

Smallpox — United  States. 
Places.  Date.  Cases.  Deaths. 

California — Los  Angeles  Dec.  26-Jan.  2   2 

California — San  Francisco  Dec.  26-Jan.  2   3 

Illinois — La  Fayette  Jan.  4-11   7 

Kansas — Topeka  Dec.  26-Jan.  2   5 

Kentucky — Covington  Jan.  2-9   i 

Maine — Van  Buren  Jan.  2-9   4. 

Massachusetts — Taunton  Jan.  2-9  

Minnesota — St.  Paul  Nov.  1-30  

Missouri — St.  Joseph  Dec.  12-19  

Missouri-^^t.   Louis  Jan.  2-9  

Missouri — Snringfield  Dec.  1-31  

North  Carolina — In  five  counties.  Nov.  1-30  


38 


Places.  Date. 

Ohio — Cincinnati  Jan.  1-8  

Ohio — Tiffin  Jan.  2-9  

Tennessee — Knoxville  Jan.  2-9  

Texas — San  .Augustine  County ...  .Jan.  9  

Washington — Spokane  Dec.  26-Jan.  2.. 

Wisconsin — La  Crosse  Jan.  2-9  

Wisconsin — Milwaukee  Dec.  26-Jan.  9.. 

Smallpox — Foreign. 

Arabia — -.Aden  Dec. 

Brazil — Rio  de  Janeiro  Nov. 

Brazil — Santos  Nov. 

Canada — Halifax  Dec. 

Canada — Montreal  Dec. 

Canada- — Winnipeg  Dec. 

Chile — Talcahuano,  vicinitj-  of.  .  .  Nov. 

China — Shanghai  Nov. 

Ceylon — Colombo  Nov. 

Egypt — Alexandria  Nov. 

Egypt — Cairo  Dec. 

Great  Britain — Bristol  Dec. 

Guatemala — Guatemala  City  To  Dec.  21 

India — Bombay  Dec.  8-15  

India- — Calcutta  Nov.  25-Dec  5 

India — Rangoon  Nov.  28-Dec.  5 


Cases. 


Deaths. 


7-21  

28-Dec. 

22-Dec. 
26-Jan. 
26-Jan. 
26-Jan. 


,  .29S 


21-28.  . 

7-22 .  . 
27-Dec. 
9-16. . . 

12-19. . 


37 


.600 


21-28   I 

20-27   38 

8-  15   1 

20-27   24 

i-Dec.   5   7 

7-Dec.  5  

9-  Dec.  9  


ig-26. . 
i2-Jan. 
5-19-  ■ . 
12-19.. 
S-12.  . . 


13-20. 


Indo-China — Saigon  Nov. 

Italy — General  Dec. 

Italy — Genoa  Dec. 

Italy — Naples  Dec. 

Java — Batavia  Nov. 

Mexico — Mexico  City  Nov. 

Persia — Tabriz   Oct. 

Peru — Lima  Dec. 

Porto  Rico — ^Mayaguez  Dec. 

Portugal — Lisbon  Dec. 

Russia — Moscow  Dec. 

Russia — Riga  Dec. 

Russia — St.  Petersburg  Dec. 

Servia — Belgrade  Dec. 

Turkey — Constantinople  Dec. 

Yellow  Fever — Foreign. 

Brazil — Para  Dec.   12-26.  . 

Dutch  Guiana — Paramaribo  Dec.  1-31... 

Ecuador — Guayaquil  Nov.  28-Dec. 

Mexico — Mexcanu,  vicinity  of.... Dec.  26-Jan. 

Mexico — Merida  Dec.  26-Jan. 

Mexico — Sodzil.  plantation  Dec.  26-Jan. 

Mexico — Vera  Cruz  Dec.  26-Jan. 

Cholera — Insular. 

Philippine  Islands — Manila  Nov.  aS-Dec. 

Philippine  Islands — Provinces  Nov.  28-Dec. 

Cholera — Foreign. 

India — Bombay  Dec.  8-15  

India — Calcutta  Nov.  28-Dec.  5  

India — Madras  Dec.  5-1 1  

India — Rangoon  Mar.  28-Dec.  5   i 

Persia — Tabriz  Dec.  9  

Russia — General  Nov.  28-Dec.  19  778 

Siam — Bangkok  Nov.  1-30  

Plague — Foreign. 

Brazil — Rio  de  Janeiro  Nov.  28-Dec.  13 

Ecuador — Guayaquil  Nov.  28-Dec.  12 

Ecuador — Mialgro  Dec. 

Egypt — General  Dec. 

India — General  Nov. 

India — Bombay  Dec. 

India— Calcutta  Nov. 

India — Rangoon  Nov. 

Indo-China — Saigon  Nov.   2i-2»   i 

Peru- — General  Nov.  2o-Dec.  3   55 

Peru — Lima  Nov.  20-Dec.  3   7 

Turkey — Bagdad  Nov.  28-Dec.  12   6 

Siam — Bangkok  Nov.  1-30  


Present. 


•  7 
169 
4 


Present. 

Present. 
9 
I 


200 
5 
14 


Present. 


5-  ■  ■ 

5  •  ■  • 


•  .360 


16-20. 

18-30  

28-Dec.  5, 

8-15  

28-Dec.  5. 
28-Dec.  5 


13 


•  ■  31 
.2.196 


5 

22/ 

16 
9 
3 
I 

Present. 

332 
Present^ 

6 
3 

2 
4 

1.626 

8 

6 
3 


Present. 


Public  Health  and  Marine  Hospital  Service:  . 

OfRcial  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  ofUcers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
January  20,  igog: 

Amesse.  J.  W.,  Passed  Assistant  Surgeon.  Directed  to 
proceed  to  Nuevitas.  Cuba,  upon  special  temporary 
duty. 

AxDERSOx,  John  F.,  Passed  Assistant  Surgeon.  Detailed 
to  represent  the  Service  at  the  annual  meeting  of  the 
Legislative  Council  of  the  American  Medical  Associa- 
tion to  be  held  at  Washington,  D.  C,  January  18,  1909. 

AxDERSOx,  JoHX  F.,  Passed  Assistant  Surgeon.  Granted 
two  days'  leave  of  absence  from  January  14,  1909,  on 
account  of  sickness. 

B.xxKS,  Ch.arles  E.,  Surgeon.  Directed  to  proceed  to  St. 
Johns  River  Quarantine  Station  for  special  temporary 
duty. 

Brooks,  S.  D.,  Surgeon.  Granted  twenty-two  days'  leave 
of  absence  from  January  10,  1909,  on  account  of 
sickness. 

Fricks,  L.  D.,  Passed  Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence  from  January  9,  1909.  under  par- 
agraph 210,  Service  Regulations. 


256 


BIRTHS.  MARRIAGES,  AND  DEATHS. 


LNevv  York 
Medical  Journal. 


Hurley,  J.  R.,  Assistant  Surgeon.  Relieved  from  duty  on 
revenue  cutter  Bear  and  directed  to  report  to  the  medi- 
cal officer  in  command,  San  Francisco  Quarantine,  An- 
gel Island,  Cal.,  for  duty  and  assignment  to  quarters. 

Hurley,  J.  R.,  Assistant  Surgeon.  Granted  two  days'  leave 
of  absence,  December  25,  1908,  and  January  i,  1909. 

Wertenbaker,  C.  p.,  Surgeon.  Directed  to  proceed  to 
Savannah  and  South  Atlantic  Quarantine  Stations,  Ga., 
upon  special  temporary  duty. 

Board  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  office 
of  the  Marine  Hospital  in  Norfolk,  Va.,  January  18,  1909, 
for  the  purpose  of  conducting  a  physical  examination  of  an 
officer  of  the  U.  S.  Revenue  Cutter  Service.  Detail  for  the 
board :  Surgeon  C.  P.  Wertenbaker,  chairman ;  Acting  As- 
sisting Surgeon  R.  W.  Browne,  recorder. 

Casualty. 

Surgeon  Alexander  C.  Smith  died  in  Pittsburgh,  Pa., 
January  15,  1909. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  medical  corps  of  the  United  States^ 
Army  for  the  week  ending  January  23,  1909: 
Baker,  D.wid,  Major,  Medical  Corps.    Ordered  to  report 

for  duty  at  Fort  McPherson,  Ga. 
Bratton,  T.  S.,  Major,  Medical  Corps.    Detailed  on  gen- 
eral court  martial  to  meet  at  I'^ort  Robinson,  Neb.,  Jan- 
uary 15th. 

Brooks,  W.  H.,  Captain,  Medical  Corps.  Ordered  to  Fort 
Mackenzie,  Wyo.,  for  duty,  upon  return  from  Culia. 

Craig,  C.  F.,  Captain,  Medical  Corps.  Detailed  on  general 
court  martial  to  meet  at  Fort  Robinson,  Neb.,  Jan- 
uary 15th. 

D.^vi.s,  W.  B.,  Lieutenant  Colonel,  Medical  Corps.  Or- 
dered to  duty  in  the  Philippines  Division,  sailing  from 
San  Francisco,  Cal.,  February  5. 

EwiNG,  C.  B.,  Major,  Medical  Corps.  Granted  leave  of  ab- 
sence for  one  month. 

Freeman,  C.  E.,  First  Lieutenant,  Medical  Corps.  Ar- 
rived at  San  Francisco,  Cal.,  from  Philippine  service, 
and  ordered  to  duty  at  Fort  Miley,  Cal. 

Gibner,  H.  C,  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  ten  days. 

HopwooD,  L.  L.,  First  Lieutenant,  Medical  Corps.  Ar- 
rived at  San  Francisco,  Cal.,  from  Philippine  service, 
and  ordered  to  duty  at  the  General  Hospital,  San  Fran- 
cisco, Cal. 

McIntyre,  H.  B.,  First  Lieutenant,  Medical  Corps.  Ar- 
rived at  San  Francisco,  Cal.,  from  Philippine  service, 
and  ordered  to  duty  at  the  General  Hospital,  San  Fran- 
cisco, Cal. 

Manly,  C.  J.,  Major,  Medical  Corps.  Ordered  to  Fort 
Bliss,  Tex.,  for  duty,  upon  return  from  Cuba. 

Morse,  A.  W.,  Captain,  Medical  Corps.  Detailed  on  gen- 
eral court  martial  to  meet  at  Fort  Robinson,  Neb., 
January  isth. 

Persons,  E.  E.,  Captain,  Medical  Corps.  Ordered  to  re- 
port for  examination  for  promotion  at  San  Francisco, 
Cal.,  and  upon  completion  to  proceed  to  Fort  Jav, 
N.  Y.,  for  'duty. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  medical  corps  of  the  United  States 
Navy  for  the  week  ending  January  23,  1909: 
Campbell,  R.  A.,  Acting  Assistant  Surgeon.  Appointment 

as  an  acting  assistant  surgeon,  dated  January  9,  1909, 

revoked. 

Fauntleroy,  a.  M.,  Passed  .Assistant  Surgeon.  Detached 
from  the  Naval  Academy,  and  ordered  to  the  Marine 
Recruiting  Station,  Philadelphia,  Pa.,  and  to  additional 
duty  in  attendance  on  officers  not  otherwise  provided 
with  medical  aid. 

Mayers,  G.  M.,  Passed  Assistant  Surgeon.  Transferred  to 
the  retired  list,  from  January  16,  1909,  in  accordance 
with  the  provisions  of  section  1453,  Revised  Statutes. 

Murphy,  J.  A.,  Surgeon.  Ordered  to  the  Naval  Hospital, 
Annapolis,  Md. 

Rich,  E.  W.,  Captain,  Medical  Corps.  Granted  leave  of  ab- 
sence for  four  months,  with  permission  to  visit  the 
United  States. 


Snvdek,  J.  J.,  Surgeon.  Detached  from  the  Marine  Re- 
cruiting Station,  Philadelphia,  Pa.,  and  ordered  to  the 
Naval  Station,  Port  Royal,  S.  C. 

Vax  Dusen,  J.  W.,  Captain,  Medical  Corps.  Designated 
as  acting  chief  surgeon,  Department  of  the  Missouri,  in 
addition  to  present  duty  at  Fort  Crook,  Neb. 

Webber,  H.  A.,  Major,  Medical  Corps.  Ordered  to  Hot 
Springs,  Ark.,  for  observation  and  treatment. 

Whitcomb.  C.  C.  Captain,  Medical  Corps.  Ordered  to 
Fort  Wingate,  N.  M.,  for  duty,  upon  return  from  Cuba. 
 ®  

iirtfes,  Parriaps,  ani  f  eatfes. 


Married. 

Groom— Anderson.— In  Philadelphia,  on  Wednesday, 
January  20th,  Dr.  Evan  J.  Groom  and  Miss  Elizabeth  E. 
Anderson. 

Jones — Reiley. — In  Clinton,  Louisiana,  on  Tuesday,  Jan- 
uary I2th,  Dr.  Thomas  S.  Jones,  of  St,  Francisvillc.  and 
Miss  May  T.  Reiley. 

Manker — Krauss. — In  Jersey  City,  New  Jersey,  on 
Sunday,  January  17th,  Dr.  Rieves  Andrew  Manker,  of  New 
York,  and  Miss  Anna  J.  Krauss. 

M.A.TTHEWS— Hopkins.— In  Seattle,  Washington,  on 
Wednesday,  January  27th,  Dr.  Andrew  Aldridge  Matthews 
and  Miss  Eva  Davenport  Hopkins. 

Michaelis — Thoma.';. — In  Brooklyn,  on  Wednesday, 
January  20th,  Dr.  Julius  Michaelis  and  Miss  Ethel  S. 
Thomas. 

Noble — O'Neal. — In  Philadelphia,  on  Wednesday,  Jan- 
uary 20th,  Dr.  Edward  Noble  and  Miss  Adele  M.  O'Neal. 

Porter— King. — In  Catskill,  New  York,  on  Thursday, 
December  31st.  Dr.  William  C.  Porter,  of  Poughkeepsie, 
and  Miss  Ethel  Losee  King. 

Died. 

Bennett. — In  Prattsburg,  New  York,  on  Thursday,  Jan- 
uary 14th,  Dr.  James  A.  Bennett,  aged  seventy-eight  years. 

Benson. — In  Omaha,  Nebraska,  on  Fridav.  Januarv  istli. 
Dr.  O.  D.  Benson. 

BiGELOw, — In  New  York,  on  Friday,  January  22d,  Dr. 
Alfred  J.  Bigelow,  aged  seventy-three  years. 

Bryant. — In  P"ranklin.  yirginia,  on  Saturday,  January 
1 6th,  Dr.  James  Fenton  Bryant,  aged  sixty-seven  years. 

Campbell.— In  Cherryville,  Kansas,  on  Friday,  January 
iSth,  Dr.  Cyrus  Campbell,  aged  seventy-four  years. 

Chase. — In  Easton,  Kansas,  on  Thursday,  December 
31st,  Dr.  A.  J.  Chase,  aged  sixty-nine  years. 

Dwyer. — In  Syracuse,  New  York,  on  Friday.  January 
1st,  Dr.  Thomas  B.  Dwyer,  aged  fifty-one  years. 

Easton. ^ — In  Brockville,  Ontario,  Canada,  on  Monday, 
January  iith.  Dr.  John  Easton,  aged  eighty-seven  years. 

Edwards. — In  Siler  City,  North  Carolina,  on  Friday, 
January  15th,  Dr.  W.  S.  Edwards,  aged  seventy-seven 
years. 

Gray. — In  Summit,  New  Jersey,  on  Friday.  January  23d, 
Dr.  John  Walter  Gray,  aged  thirty-two  years. 

Halberstadt. — In  Pottsville.  Pennsylvania,  on  Tuesday, 
January  19th,  Dr.  A.  H.  f lalberstadt,  aged  seventy-seven 
years. 

Harper. — In  Hattiesbiirg,  Mississippi,  on  Thursday,  Jan- 
uary 14th,  Dr.  John  A.  Harper,  of  Eatonville. 

Heithaus. — In  St.  Louis.  Missouri,  on  Saturdax-.  Jan- 
uary i6th.  Dr.  G.  P.  Heithaus. 

Hicks. — In  Mt.  Vernon,  Indiana,  on  Tuesday,  January 
T2th,  Dr.  Cadawaldef  Hicks,  aged  sixty-one  years. 


Howell. — In  Dothan,  Alabama,  on  Saturday,  January 
i6th.  Dr.  J.  R.  G.  Howell,  aged  forty-eight  years. 

James. — In  Springfield,  Missouri,  on  Tuesday,  January 
T2th,  Dr.  W.  C.  James. 

Lord. — In  Schenectady.  New  York,  on  Saturday.  January 
i6th.  Dr.  Sheldon  D.  Lord,  of  Sacketts  Harbor,  aged  sixty- 
seven  years. 

Phillips. — In  Whitneyville,  Connecticut,  on  Thursday, 
January  7th,  Dr.  M.  E.  Phillips,  aged  sixty-three  years. 

ScHAPiRO. — In  Vienna.  .Austria,  on  Monday.  January 
iSlh,  Dr.  Salo  Schapiro. 

Smith. — In  Pittsburgh.  Pennsylvania,  on  Friday.  Janu- 
ary 15th.  Dr.  A.  C.  Smith,  aged  forty-five  years. 

Smith. —  In  Vancou\cr.  Washington,  on  Tlnirsday,  Janu- 
ary 7th.  Dr.  J.  Rudoli)li  .Suiith.  aged  sixty-five  years. 

Tow.vsENL). — In  B.'iltiniore.  Maryland,  on  Friday,  January 
15th,  Dr.  John  S.  Tnwn-.(nd,  aged  fifty-nine  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  rlt  Medical  News 

A   Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  6.        NEW  YORK,  FEBRUARY  6,  1909.  Whole  No.  1575. 


ADDRESS  AT  THE  TUBERCULOSIS  EXHIBITION.* 

By  Joseph  D.  Bryant,  M.  D., 
New  York. 

As  it  appears  to  me,  it  is  eminently  fitting  that 
a  certain  number  of  those  who  were  not  bom  yes- 
terday should  participate  in  this  discussion.  And 
in  this  regard,  already,  I  find  a  fair  number  here 
who  need  not  feel  obliged  to  move  forward  the  dial 
shadows,  in  a  marked  degree,  to  establish  an  undis- 
puted claim  to  a  hearing  on  this  occasion. 

The  period  of  proposed  contention  in  this  coun- 
try against  the  spread  of  tuberculosis  is  yet  young, 
being  scarcely  twenty-one  years  of  age.  And  the 
time  of  rational  systematic  opposition  to  its  prog- 
ress in  the  human  subject  is  scarcely  more  than  in 
the  period  of  beginning  manhood.  Hence  the  rea- 
son why  some  of  those,  the  dimensions  of  whose 
professional  career,  easil}''  measure  the  scope  of  the 
budding  and  early  bloom  of  systematic  contention 
against  tuberculosis  in  our  country,  should  be  in 
evidence  on  this  occasion.  It  is  not  needful  that 
the  speaker  should  say  more  than  this  to  justify  his 
presence,  but  instead,  should  add  something  to  the 
total,  to  justify,  if  possible,  the  notions  of  those 
who  were  more  insistent  than  wise,  in  this  regard. 

As  you  might  suppose,  I  can  easily  recall  in  con- 
nection with  this  matter,  the  "primitive  trace"  of 
Dr.  Trudeau's  efforts  in  the  Adirondacks.  Dr.  Tru- 
deau's  convictions,  his  labors,  and  his  successes 
there,  were  the  stimulus  and  strength  to  broader 
and  higher  means  of  combative  method.  To  our 
very  doors,  he  brought  evidence  which  was  positive 
proof  of  the  beneficence  of  his  undertaking. 
Friends  and  patients  by  their  presence  and  their 
vigor,  testified  to  the  truth  of  Trudeau's  teaching, 
and  to  the  wisdom  of  his  treatment.  Indeed,  it 
would  seem  as  if  a  voice  from  out  of  the  wilderness 
had  then  arisen  proclaiming  the  way  and  the  means 
of  restoration  to  health  of  those  who  were  afflicted 
with  the  direst  disease  that  haunts  the  human  fam- 
ily. At  the  present,  the  early  voice  of  Trudeau 
finds  its  echo  in  the  voices  of  the  multitude,  each 
of  which  would  fain  surpass  the  others  in  the  de- 
mand for  aid  and  for  action,  in  the  alleviation  and 
cure  of  tuberculosis.  In  this  connection,  it  may  be 
a  matter  of  some  interest  to  recall  a  pertinent  fact, 
not  known  to  many.  That  in  1887,  the  then  chair- 
man of  the  Sanitary  Committee  of  the  New  York 

'Address  delivered  on  the  evening  of  December  ii,  1908,  at  a 
mass  meeting  for  physicians,  held  at  the  American  Museum  of  Natu- 
ral History  during  the  International  Tuberculosis  Exhibition. 


Board  of  Health  wrote  to  each  of  twenty-five  lead- 
ing physicians  of  this  city,  a  letter  requesting  to 
know  if  in  their  judgment  the  time  had  come  for 
the  Health  Department  of  the  city  to  declare  tuber- 
culosis a  communicable  disease,  and  to  require  that 
all  of  such  cases  be  reported.  Two  of  the  number 
promptly  replied  in  the  affirmative,  Dr.  Frank  P. 
Foster,  editor  of  the  New  York  Medical  Journal, 
and  Dr.  Austin  Flint,  professor  of  physiology. 
These  two  are  yet  living,  and  are  still  endowed 
with  the  courage  and  the  judgment  which  prompted 
their  replies  twenty-one  years  ago.  Three  or  four 
others  indulged  theinselves  in  friendly  communica- 
tions, based  on  the  "yes,  I  guess  not,"  style  of  en- 
lightenment. One  other,  it  is  said,  replied,  that  he 
would  think  over  the  matter  and  express  his  views 
relative  thereto  whenever  he  should  happen  to  meet 
the  writer  of  the  letters.  A  little  later,  as  it  is  told, 
they  happened  to  meet  in  a  public  thoroughfare, 
whereupon  the  Thoughtful  One  transfixed  the  air 
with  words,  words,  words.  Words  of  doubt  and 
fear ;  words  halting  and  blind  in  purpose ;  words 
that  left  one  where  he  began,  and  would  counsel 
him  to  reitiain  there  ever  after.  From  a  large  ma- 
joritv  of  the  twenty-five  to  whom  the  letters  were 
written,  twenty-one  years  ago,  no  answers  have  as 
yet  been  forthcoming.  Such  as  this  is  the  presump- 
tive record  of  the  status  of  the  medical  profession 
of  the  city,  on  the  question  of  fighting  tuberculosis, 
twenty-one  years  ago.  And  this  was  not  all.  For, 
following  the  failure  of  the  Health  Department  to 
enlist  the  support  of  the  medical  profession  in  re- 
<rard  to  the  reporting  of  tuberculosis  cases,  the  de- 
partment then  issued  circulars  of  caution  to  the 
people,  in  which  circulars  a  goodly  number  of 
"don'ts"  relating  to  the  avoidance  of  tuberculosis, 
were  incorporated,  for  their  information  and  guid- 
ance. Shortly  thereafter,  there  appeared  in  the 
public  press,  written  by  a  member  of  our  profes- 
sion who  should  have  known  better,  a  communica- 
tion which  was  characterized  by  abundant  sarcas- 
tic parody,  based  on  the  negative  features  of  the 
Public  Health  Circular.  It  is  needless  to  add  that 
the  phraseology  of  the  article,  though  enjoyed  by 
many,  was  not  regarded  by  the  health  officials,  or 
by  thoughtful  people,  as  being  either  funny,  polite, 
or  wise.  As  we  all  know  comparisons  are  likely  to 
be  odious.  But,  in  regard  to  the  period  of  this  in- 
cident as  related  to  the  present  time,  it  should  be 
said  that  the  initial  silence  of  the  great  majority  of 
the  historic  twenty-five,  has  long  since  been  broken, 
and  their  efiforts  are  registered  along  with  those 
who  have  labored  faithfully  in  the  cause  of  health. 
Regarding  the  humorous  member,  whose  shafts  of 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


BRYANT:  ADDRESS  AT  TUBERCULOSIS  EXHIBITION. 


[New  York 
Medical  Journal. 


vicarious  satire  hurt  more  than  a  little — he  long 
ago  passed  away,  and  before  he  had  enjoyed  the 
opjjortunity  of  recasting  his  lot  along  with  those 
who  later  saw  with  corrected  vision.  However, 
those  who  inspired  the  sending  of  the  letters  of 
1887,  Dr.  Biggs  and  Dr.  Prudden,  have  since  given 
inspiration  and  counsel  to  the  cause  and  are  still  in 
the  van,  urging  completer  and  greater  effort  in  the 
elimination  of  tuberculosis  from  the  list  of  human 
inflictions. 

Not  before  this  time  have  I  heard  the  name  of 
Prudden  mentioned  among  the  encomiums  of  the 
occasion.  The  perverse  modesty  of  this  gracious 
man,  the  wilful  reticence  which  he  exhibits  in  public 
ways  in  this  connection  should  no  longer  conceal 
him  from  fitting  public  recognition. 

It  seems  to  me  that  this  occasion  is  a  fruitful  one 
during  which  to  register  emphatic  morsels  of  pre- 
vious history.  As  a  student  in  medicine,  I  can  re- 
call the  expressions,  stnmia,  scrofula,  and  tubercle, 
as  sometimes  being  used  synonymously.  The  first 
two  with  the  frank  emphasis  of  conviction ;  the  last 
one  (tubercle)  at  much  longer  intervals,  and  in  a 
hesitating  manner  suggestive  of  recent  and  timid 
belief.  And,  too,  I  can  recall  to  mind  how,  later  on, 
I,  myself,  with  increasing  confidence  pointed  out 
tuberculosis  joints  to  beginners,  without  reference 
to  struma,  or  scrofula.  Also,  the  changes  in  the 
form  of  expression  relating  to  enlarged  and  ulcer- 
ating cervical  nodes  and  to  their  scars  which  told  of 
previous  and  completer  trouble,  are  a  measure  of 
the  triumph  of  scientific  attainment  over  assumptive 
declaration. 

One  with  reluctant  inclination  now  recalls  to 
mind  the  disturbing  doses  of  cod  liver  oil,  syrup  of 
the  iodide  of  iron,  repeatedly  given  separately,  or 
in  mysterious  therapeutic  combination,  and  other 
similar  drugs  which  cloyed  the  market  and  the  pa- 
tient at  the  same  time.  Sheet  anchor  remedies,  if 
you  please,  addressed  to  the  constitution  of  the  pa- 
tient ;  and,  indeed,  but  little  emphasis  was  placed 
upon  the  need  for  fresh  air,  except  when  it  could 
be  dispensed  under  pleasant  surroundings.  That 
these  remedies  had  their  virtues  no  one  will  deny, 
and  that  they  are  serviceable  to-day  cannot  be  gain- 
said, and  that  yet  other  remedies  with  past  and 
present  virtues  are  not  to  be  blindly  excluded  in 
favor  of  fresh  milk,  fresh  eggs,  and  fresh  air, 
should  be  kept  closely  in  mind. 

Who,  familiar  with  the  earlier  forms  of  surgical 
treatment  of  this  class  of  disease,  does  not  remem- 
ber the  prompt  and  persistent  blistering,  the  pro- 
found and  repeated  cauterizing,  later  followed,  per- 
haps, by  the  insistent  borings  and  gougings  of  bone 
that  were  practised,  supplemented  with  stetons  of 
various  kinds  and  sizes,  and  to  the  practical  neglect 
of  outdoor  therapy,  and  the  need  of  studied  nutri- 
tion. Surgical  coniplaisancy  in  respect  to  these  lat- 
ter, was  common,  and  surgical  insistence  relating 
thereto,  correspondingly  infrequent.  The  control- 
ing  value  of  these  measures,  as  elements  in  treat- 
ment, was  gradually  developed  by  the  force  of  good 
sense  and  example,  receiving,  at  last,  the  impetus 
of  scientific  support  and  surgical  insistence.  The 
mechanical  tlicrapeutics  of  surgical  tuberculosis, 
especially  as  relating  to  joints,  are  as  essential  now 
as  ever  before,  and  the  products  of  human  ingenu- 


ity thus  employed  bear  witness  of  patient  and  pro- 
found study  and  wise  therapeutic  conclusion. 

But,  the  burden  formally  imposed  by  this  means 
of  treatment,  is  now  lessened  in  time  and  lightened 
in  purse,  correspondingly  to  the  heed  given  by  the 
surgeon  to  the  potency  in  treatment,  of  ample  suit- 
able nourishment  and  abundant  fresh  air  supply. 
The  discouraging  doubt,  especially  of  the  past,  re- 
lating to  the  outcome  in  diseased  joints,  emphasized 
by  the  steadfast  delay  in  recovery,  the  pain,  and  the 
expense  of  treatment,  frequently  led  to  joint  ex- 
cision, and  always  with  assurance  of  certain  loss  of 
function,  and  perhaps  relapse  and  amputation  of  the 
offending  part.  I,  myself,  in  this  class  of  cases, 
contributed  more  than  twenty  instances  of  excision 
of  the  knee  before  I  was  overtaken  with  the  higher 
sense  of  attainment  related  to  abundant  fresh  food 
and  air.  Since  which  time,  both  opportunity  and 
inclination  have  contributed  in  a  miserly  way  to  this 
phase  of  operative  surgery.  The  improvement  in 
dogmatic  perception  and  in  rational  methods,  has 
reduced  decidedly  the  number  and  severity  of  these 
cases  and  correspondingly  lessened  the  frequency 
and  vigor  of  operative  treatment.  Without  further 
multiplying  of  words  in  this  respect,  I  believe  it  fair 
to  say  that  each  surgeon,  to  the  fullest  measure  of 
his  understanding,  did  the  best  he  could  to  comfort 
and  cure  those  afflicted  of  this  disease.  Who  could 
have  done  more  than  this?  Those  of  later  growth, 
and  of  improved  method,  whose  ability  to  cure  has 
the  sanction  of  broader  experience,  and  the  suppor>; 
of  modern  scientific  determination,  should  treat 
with  respectful  consideration  the  measures  of  rem- 
edy and  the  consequences  of  the  acts  of  those  who 
were  less  favored  than  themselves,  since  it  is  hoped 
that  they,  in  time,  will  be  subjected  to  conditions 
akin  to  those  under  which  the  forefathers  labored. 

For,  further  advance  in  human  relief  by  surgical 
means,  requires  that  history  shall  repeat  itself  in 
this  regard,  the  same  as  in  other  advancing  affairs 
of  human  existence.  Surgical  tubeiCi  li  sis,  espe- 
cially of  bones  and  joints,  is  a  grave  and  far  reach- 
ing form  of  infliction.  One  which  appeals  to  the 
surgeon,  the  pathologist,  and  the  layman,  in  no  un- 
certain manner.  The  surgeon  realizes  the  difficult} , 
the  danger,  and  the  delay  in  the  acquiring  of  a 
functional  cure ;  the  pathologist  comprehends  the 
gravity  of  the  morbid  processes,  of  initial,  and  of  a 
later  character ;  the  layman  views  with  profound 
sentiment,  and  with  economic  concern  the  disabling 
hindrances  which  keep  step  with  the  frequency  and 
the  severity  of  this  disease.  Indeed,  the  sadness  of 
the  picture,  as  based  on  past  experience  and  on 
prospective  outcome,  causes  each  'alike  to  wonder 
whether  or  not,  the  freedom  of  action  which  per- 
.sonal  liberty  insures,  should  much  longer  be  heeded 
in  the  social  instances  which  so  often  breed  vulner- 
ability to  morbid  processes,  and  transmit  them  Lo 
subsequent  generations.  Is  not  judicious  thought 
and  decided  action  demanded  in  striking  instances, 
in  behalf  of  sub.stantial  physical  manhood  ?  Human 
mating  based  on  good  sense  rather  than  on  beguil- 
ing sentiment  alone,  would  add  much,  indeed,  to  the 
enduring  fibre  of  the  human  race. 

That  ])ulnionary  tuberculosis  affords  a  large  field 
for  the  activities  of  the  physician  in  the  exercise  of 
his  knowledge  and  skill,  is  a  self  evident  fact  of 


February  6,  1909.] 


BRYANT:  ADDRESS  AT  TUBERCULOSIS  EXHIBITION. 


259 


long  established  tenure.  The  insidiousness  of  the 
attacks  m  these  cases,  and  the  reluctancy  of  the  pa- 
tient to  acknowledge  the  possibility  of  its  presence, 
together  with  the  fruitful  opportunities  of  propaga- 
tion, invests  the  medical  practitioner  with  grave  re- 
sponsibilities. The  disfigurements,  the  incapacities 
incident  to  this  disease  falling  under  the  care  of  the 
surgeon,  early,  and  of  themselves  speak  earnestly 
and  loudly  with  many  tongues,  in  the  cause  of  early 
diagnosis  and  prompt  relief. 

The  majority  of  the  victims  of  surgical  tubercu- 
losis appeal  more  to  the  sense  of  pity  of  a  lay  ob- 
server, than  to  that  of  his  personal  security.  This 
is  as  it  should  be  in  point  of  fact,  and,  too,  as  allied 
with  sympathetic  support.  For,  if  pity  were  put  to 
flight  in  these  cases  by  personal  dread,  then  would 
its  sufferers  be  wretched,  indeed.  Many  lay  people 
give  much  greater  heed,  at  first,  to  a  halt  in  their 
gait  than  to  a  halt  in  their  respiratory  functions.  A 
picturesque  locomotion  is  often  more  abhorrent  to 
them  than  is  a  purulent  expectoration.  In  the  in- 
stance of  medical  tuberculosis,  the  greater  activity 
of  the  contention  is  against  the  latter  expression  of 
the  disease.  Quite  naturally  the  public  hazard  from 
medical  tuberculosis,  largely  exceeds  that  of  the 
surgical  variety.  There  seems  to  be  no  reasonable 
doubt  that  common  examples  of  distressing  physi- 
cal deformity,  dependent  on  tuberculosis  are,  un- 
fortunately, not  so  regarded  by  the  major  part  of  a 
lay  community.  But  it  now  appears  that  an  un- 
usual cough  occurring  in  the  midst  of  those  who 
are  associated  with  each  other  in  the  social  and 
business  activities  Of  the  day,  prompts  the  timid  and 
often  the  discreet,  to  look  askance  at  those  who  are 
thus  ailing,  and,  perhaps,  to  hasten  away.  This 
comparatively  recent  manifestation  of  dread  is  a 
rude  outcome  of  proper  agitation,  and  should  not 
be  discouraged  so  long  as  the  afflicted  are  not  per- 
mitted to  suffer  uncared  for.  I  am  clearly  of  the 
opinion  that  the  dangers  arising  from  the  presence 
in  public  of  the  various  phases  of  medical  and  sur- 
gical tuberculosis,  and  each  in  importance  with  its 
comparative  significance,  should  be  continually  ex- 
plained and  strongly  impressed  upon  the  minds  of 
the  people.  As  it  appears  to  me,  it  should  be  un- 
derstood by  all  that  the  presence  of  tubercle  bacilli, 
inside  or  outside,  of  a  human  being,  constitutes  a 
real  danger.  It  should  be  understood  that  the  res- 
piratory and  buccal  passages  are  common  ports  of 
entrance.  Warthin,  of  Ann  Arbor,  has  quite  re- 
cently presented  the  startling  possibilitv  that  the 
intestinal  tract  may  be  as  important  in  this  regard 
as  the  respiratory  tract.  It  is  well  known  that  from 
these  passages  the  human  economy  may  become 
specially  or  generally  infected.  Also,  that  any  site 
of  tuberculosis  infection,  through  unaided  tendency, 
diseased  action,  or  traumatic  influence,  may  dissemi- 
nate its  kind  to  any  tissue  of  the  human  economy. 
The  surgeon  is  familiar  with  the  fact  that  treatment 
of  traumatisms  directed  to  diseased  bone  and  dis- 
eased joints,  especially  the  knee  or  the  spine,  not  in- 
frequently arouse  the  silent  energy  of  tuberculous 
deposits  there  which  multiply  and  spread  often  wdth 
the  destructive  fury  of  the  forest  fire.  Fortunate, 
however,  it  is,  that  in  tuberculous  disease  of  bone 
and  joints  but  little  danger  attends  personal  con- 
tact, not  enough,  in  fact,  to  constitute  an  item  of 


special  significance  except  in  the  presence  of  gross 
carelessness  or  studied  intention. 

The  wide  geographical  and  anatomical  spread  of 
tuberculous  disease  is  amazing.  Practically  the  peo- 
ple of  every  country  and  chme,  and  every  tissue  of 
these  people,  are  beset  in  a  greater  or  lesser  degree 
by  this  infection.  The  estimates  regarding  the  am- 
plitude of  this  disease  necessarily  vary,  because  of 
the  different  sources  from  which  the  testimony  is 
obtained.  But  that  tuberculosis  in  some  form  de- 
stroys more  people  than  does  any  other  disease  seems 
not  to  admit  of  gainsay.  Craig  in  1902  estimated 
that  there  were  a  miUion  cases  of  tuberculosis  in  the 
United  States,  and  that  fourteen  per  cent,  of  record- 
ed deaths  for  ten  years  were  due  to  some  form  of 
this  disease.  In  a  recent  foreign  estimate  of  the 
•death  rate  of  forty-nine  and  a  half  millions  of  peo- 
ple, eighteen  plus  per  cent,  of  the  total  death  rate 
was  dependent  on  tuberculosis.  Adami  and  McCrae, 
very  recently,  in  one  thousand  miscellaneous  autop- 
sies on  hospital  patients,  report  eighty-five  with  pul- 
monary, and  twelve  with  bone  lesions  of  this  dis- 
ease. In  children  bones  and  joints  especially  suffer, 
laying  the  foundations  for  the  distressing  deform- 
ities which  torment  alike  the  victims  and  the  sympa- 
thetic beholders.  It  appears  that  one  third  of  this 
class  of  disease  occurs  within  the  first  ten,  and  one 
half  before  the  first  twenty  years  of  life.  The  spine 
suffers  in  twenty-six  per  cent.,  the  ankle  in  twenty- 
one  per  cent.,  the  hip  in  thirteen  per  cent.,  the  knee 
in  ten  per  cent.,  the  carpus  in  nine  per  cent.,  and  the 
elbow  in  four  per  cent,  of  the  cases. 

Thus  far,  the  outcome  in  medical  treatment  of 
tuberculosis  has  been  more  fruitful  for  good  than 
the  fondest  expectation  could  reasonably  have  pic- 
tured. The  results  in  surgical  treatment  are  much  in 
advance  of  those  of  but  a  few  years  ago.  For  a  time 
the  campaign  of  education  directed  against  tubercu- 
losis exercised  a  reflex  rather  than  a  direct  influ- 
ence on  the  treatment  of  the  surgical  forms  of  this 
disease.  Private  and  public  appreciation  of  the  im- 
portance and  the  dangers  of  this  form  of  tubercu- 
losis are  yet  somewhat  belated.  But  increased  par- 
ental apprehension  and  wisdom  have  led  to  earlier 
detection  and  prompter  diagnosis  in  these  cases, 
which,  with  improved  mechanical  therapy  cilong 
with  abundant  fresh  air  and  good  food  insistence, 
are  rapidly  lessening  the  course,  the  severity,  and 
the  sad  sequels  of  surgical  tuberculosis.  I  am  now 
prompted  to  express  the  hope  that  physicians,  in 
contradistinction  to  surgeons,  will  in  the  future  as 
faithfully  impress  the  fact  of  the  importance  of 
surgical  as  of  medical  tuberculosis  upon  the  people. 
Also  that  the  physicians  will  become  as  skilled  in 
making  an  early  diagnosis  of  incipient  tuberculosis 
of  the  spine,  for  instance,  as  of  the  apices  of  the 
lungs. 

When  circumstances  will  permit,  I  can  conceive 
of  no  good  reason  why  the  hygienic  and  dietetic  in- 
sistence of  medical  treatment  should  not  precede, 
and  possibly,  in  a  degree  supplant  operative  treat- 
ment, especially  in  instances  of  lymphatic  tubercu- 
losis. In  any  event,  there  is  ample  reason  to  re- 
quire that  postoperative  treatment  should  include, 
at  least  in  a  recrudescent  sense,  the  established  cura- 
tive means  employed  in  other  forms  of  tuberculosis. 
No  statements  regarding  the  means  addressed  to  the 


26o 


GORDON:  AMNESIA. 


[New  York 
Medical  Journal. 


cure  of  surgical  tuberculosis  would  be  complete  if 
the  sea  air  feature  were  not  given  permanent  sta- 
tion. The  Sea  Breeze  Colony  at  Coney  Island  is  a 
prophetic  exhibition  of  what  this  plan  of  action  can 
accomplish. 

Lest  we  forget,  it  should  be  said  that  with  all  of 
this  contention  we  should  not  supplant  sense  with 
science,  but,  instead,  should  keep  in  mind  the  solemn 
facts  that  the  burdens  of  the  poor  and  the  helpless, 
and  the  vices  of  the  thrifty  and  the  reckless,  and  the 
indifferences  of  the  wealthy  and  the  responsible,  do 
now  and  will  for  long  contribute  a  potent  share  in 
opposition  to  arrest  and  cure  of  this  disease.  The 
means  for  the  destruction  of  the  bacilli  of  these  evils 
lie  not  alone  in  the  power  of  man. 

32  West  Forty-eighth  Street. 

 <s>  

friginal  C0mmtinitati0ns. 


AMNESIA  FROM  A  MEDICOLEGAL  STAND- 
POINT.* 
By  Alfred  Gordon,  M.  D., 
Philadelphia, 

Associate  in  Nervous  and  Mental  Diseases,  Jefferson  Medical  Col- 
lege; Neurologist  to  Mount  Sinai,  Northwestern  and 
Douglass  Hospitals. 

The  most  important  medicolegal  problems  are 
those  concerning  human  will  and  intelligence.  The 
questions  of  culpability  and  responsibility  in  civil 
and  criminal  cases  can  be  determined  upon  a  careful 
and  scientific  analysis  of  facts  dealing  with  the  great 
variability  of  human  intellect. 

The  extraordinary  diversity  of  the  latter  prevents 
me  from  embracing  the  entire  subject  in  one  dis- 
course. Among  all  the  elements  constituting  intelli- 
gence there  is  one  particularly  that  is  of  a  special 
importance,  and  this  is  the  integrit}  or  disturbance 
of  memory. 

The  alterations  of  this  faculty  may  present  the 
most  peculiar  and  various  forms.  But  before  enter- 
ing into  the  substance  of  the  subject  I  wish  to  relate 
an  example  of  the  most  curious  form  of  amnesia, 
a  form  which  is  rare  in  the  medical  annals,  difficult 
and  embarrassing  from  a  legal  standpoint : 

Frank  Endrukat  committed  murder  in  April,  1908.  He 
killed  a  girl  with  whom  he  had  relations  at  various  inter- 
vals within  the  last  few  years.  Immediately  after  the 
shooting  he  turned  the  revolver  to  his  right  temple  and 
shot  at  himself.  The  bullet  entered  his  brain.  He  fell  un- 
conscious. On  admission  to  the  hospital  he  could  not  be 
aroused ;  would  groan  frequently.  The  right  eye  was 
swollen  and  ecchymotic.  The  bullet  wound  was  dressed 
temporarily,  and  it  was  decided  that  if  the  man  lived  for 
at  least  two  hours  that  it  would  be  advisable  to  probe  for 
the  bullet  by  an  operation.  His  condition  improved  in  the 
course  of  two  hours  and  he  was  taken  to  the  operating 
room,  where  the  wound  was  enlarged,  the  tragk  of  the 
bullet  traced  to  the  opening  in  the  skull,  the  latter  being  in 
the  tcm.poral  bone  just  behind  the  bony  orbit.  The  bone 
here  was  depressed  and  fractured;  brain  substance  was 
found  to  be  emerging  from  the  opening.  The  bullet  was 
probed  but  not  located.  A  gauze  drainage  was  then  put 
down  just  over  the  opening  in  the  skull  and  tiie  wound 
was  partly  closed.  The  wound  gradually  healed.  An  x  ray 
examination  showed  the  bullet  in  the  left  temporal  region. 
As  he  refused  an  operation,  he  was  discharged  from  the 
hospital  about  two  months  after  admission.  He  was  then 
taken  (o  Moyanicnsing  prison. 

Since  the  patient  regained  consciousness  after  the  shoot- 

•Afldress  delivered  before  the  Medical  Jurisprudence  Society,  De- 
cember 21,  1908. 


ing  up  to  the  time  of  the  trial  he  would  not  believe  that 
there  was  a  bullet  in  his  brain;  even  the  x  ray  picture 
shown  to  him  could  not  convince  him. 

The  other  peculiarity  in  this  case  was  the  fact  that  the 
man  had  no  recollection  of  having  shot  at  himself  or  the 
woman.  When  spoken  to  about  it,  he  ridiculed  the  idea. 
A  man  cannot,  said  he,  be  a  carrier  of  a  bullet  in  his  head, 
as  he  could  not  live  with  a  foreign  body  in  the  brain.  That 
the  girl  lived  he  was  absolutely  certain,  and  he  could  not 
understand  why  he  was  detained  by  the  authorities. 

I  saw  the  prisoner  on  two  occasions.  Physically  he  was  in 
an  excellent  shape.  Tliere  was  no  indication  as  to  localized 
symptoms.  The  absence  of  the  latter  pointed  evidently  to 
a  location  of  the  bullet  in  some  silent  region  of  the  brain. 
His  faculties  of  seemg,  writing,  reading,  hearing,  tasting, 
smelling,  his  power  of  motion  and  sensation,  were  all  pre- 
served and  intact. 

The  examination  for  his  mentality  proved  also  to  be 
negative,  except  for  his  memory  as  to  the  act  of  shooting 
and  death  of  the  woman  killed  by  him.  He  could  com- 
prehend every  question  asked  of  him,  was  able  to  give  an 
account  of  his  boyhood,  of  all  the  events  of  his  life.  I 
made  him  go  over  his  life  for  the  past  few  years.  I  made 
him  describe  his  relations  with  the  woman  he  killed  from 
the  day  he  became  acquainted  with  her  to  the  day  of  the 
shooting.  Correct  or  not  correct,  the  recital  of  the  facts 
connected  with  her  were  given  by  him  in  the  most  co- 
herent and  connected  manner.  He  stated  that  several  years 
ago  they  had  been  living  in  the  southern  part  of  Russia. 
The  girl  was  then  in  love  with  him,  but  she  was  being 
forced  mto  a  marriage  with  an  older  man.  Once  she  re- 
quested him  to  kill  her  in  preference  to  marrying  this  other 
man.  He  complied  with  her  request,  because  if  he  could 
not  have  her,  no  one  else  should.  Having  a  military  pistol 
in  his  pocket  (he  was  in  the  army  at  that  time),  he  shot  at 
her,  but  the  girl  was  not  killed.  He  then  went  into  the 
next  room  and  picked  up  an  axe  or  mallet  and  hit  her  on 
the  head.  Her  father  happened  to  come  in  at  that  time 
and  tried  to  take  him,  but  fearing  a  calamity,  he  did. not 
persist.  Frank  was  arrested  and  convicted  for  murder  in 
Russia.  Upon  appeal  the  girl  admitted  that  she  had  re- 
quested him  to  kill  her  and  for  that  reason  he  was  given 
a  term  of  two  years'  imprisonment.  He  only  served  a  short 
term.    In  the  meantime  the  girl  left  for  America. 

For  some  reason  he  went  to  Paris  and  from  there  came 
to  this  country.  He  did  not  come,  he  said,  for  her  sake, 
but  nevertheless  he  never  ceased  to  inquire  about  her.  In 
Philadelphia  they  met  again  and  became  intimate.  On  one 
occasion,  after  spending  the  night  together,  he  noticed  that 
his  watch  and  a  sum  of  money,  over  $800.00,  had  disap- 
peared from  his  room.  In  the  meantime,  having  learned 
that  she  was  going  to  leave  town  with  another  man,  he 
brought  charge  against  her  for  theft.  She  in  turn  brought 
an  action  of  rape  against  him  and  he  was  arrested. 
Through  some  arrangement  the  rape  action  was  squashed. 
He  followed  her  out  of  the  court  and  that  was  the  last 
'time  he  says  he  saw  her.  The  crime  was  committed  on  the 
same  day. 

The  recital  of  events  of  his  life  in  connection  with  the 
life  of  the  woman  up  to  the  commission  of  the  crime  was 
clear  and  without  the  least  trace  of  incoherence  or  incon- 
sistence. It  was  the  recital  of  a  man  of  sound  mind.  A 
more  detailed  examination  with  reference  to  other  facts  of 
his  life,  also  the  present  manner  of  speaking,  acting  and 
feeling,  the  complete  freedom  from  delusions,  hallucina- 
tions or  illusions,  the  perfect  and  gentlemanly  behavior  in 
my  presence,  the  inability  on  my  part  of  confusing  him 
while  he  was  giving  me  the  history  of  his  life — all  these 
circumstances  corroborated  my  former  conclusion,  viz., 
that  I  was  in  presence  of  a  perfectly  sane  man.  Moreover, 
he  impressed  me  as  being  a  man  of  some  culture  and  re- 
finement. 

The  crucial  question  is  how  to  explain  the  aston- 
ishing fact  as  to  his  absolute  loss  of  memory  of 
the  crime  and  of  the  attempt  at  suicide. 

The  problem  is  certainly  a  difficult  one  from  a 
medical  as  well  as  legal  standpoint.  On  one  hand, 
liow  to  prove  that  the  amnesia  is  genuine  or  simu- 
lated? What  are  the  elements  of  a  correct  diag- 
nosis? Memory  is  the  result  of  impressions  of  facts 
upon  the  cerebral  tissue.    It  is  a  general  function  of 


February  6,  1909.] 


GORDON:  AMNESIA. 


the  intellect,  which  consists  of  reproducing  images, 
ideas,  emotions,  and  sensations  previously  acquired. 
It  is  the  basis  of  the  entire  intellectual  edifice.  With- 
out it,  says  Ribot,  there  can  be  no  judgment,  reason- 
ing, conscience,  or  personality ;  without  it  formation 
of  ideas  is  impossible. 

In  studying  the  mnemonic  faculty  two  main  ele- 
ments are  therefore  to  be  considered,  viz.,  fixation 
of  facts,  images,  etc.,  and  their  reproduction. 

The  external  manifestation  of  these  impressions, 
if  they  are  intact,  otherwise  speaking,  recollection  of 
events,  depends  upon  the  will  of  the  individual  him- 
self. The  memory  for  certain  facts  may  therefore 
be  admitted  or  denied.  On  the  other  hand,  diminu- 
tion or  complete  loss  of  mnemonic  faculties  (am- 
nesia) is  a  well  known  fact  in  cerebral  nosology. 

Amnesia  in  its  broad  sense  embraces  many  vari- 
eties of  alteration  in  cerebral  impression  pictures. 
From  a  pathogenetic  standpoint  amnesia  may  be 
functional  or  organic.  Each  of  these  varieties  can 
be  partial  or  general.  From  the  point  of  view  of 
its  evolution,  amnesia  may  be  temporary  or  perma- 
nent, sudden  or  progressive,  periodic  or  intermit- 
tent. 

Organic  amnesias,  which  characterize  par  excel- 
lence the  dementias,  are  usually  progressive  and 
permanent.  Here  the  gradual  destruction  follows 
a  well  defined  law.  It  affects  first  recent  events ;  the 
latter  by  virtue  of  their  recent  development  not  be- 
ing frequently  repeated  and  consequently  loosely 
attached  to  conscience,  are  feebly  organized.  Here 
the  deficient  mental  synthesis  is  facilitated  by  the 
usual  feebleness  of  will,  of  attention,  and  the  images 
seen,  heard,  felt,  pass  rapidly  into  the  unconscious 
state.  Old  intellectual  acquisitions  commence  to 
disappear  next,  and  with  the  advancement  of  the 
demented  state  the  old  memories  gradually  become 
effaced.  In  functional  amnesias  the  memory  dis- 
turbances present  still  more  variations  than  in  the 
organic.  Here  an  individual  may  lose  his  memory 
for  a  certain  group  of  ideas,  or  for  a  fact  or  facts 
occurring  during  a  certain  period  of  his  life.  In  the 
latter  case  amnesia  may  extend  to  the  period  of 
time  immediately  preceding  a  certain  forgotten 
event  (retrograde)  or  following  it  (anterograde). 
In  exceptional  cases  the  amnesia  may  be  general. 
The  individual  has  lost  the  memory  of  all  his  past 
life. 

The  essential  distinction  between  the  organic  and 
functional  amnesias  lies  in  the  fact  that  the  former 
are  progressive  and  intimately  associated  with  the 
gradual  deterioration  of  the  psychic  functions,  while 
the  latter  are  sudden  in  their  onset.  The  former  are 
incurable,  the  latter  may  be  curable. 

When  a  crime  or  any  illegal  act  is  committed  by 
an  individual  suffering  or  having  suffered  from  any 
of  these  forms  of  amnesia,  the  first  step  is  to  deter- 
mine whether  the  loss  of  memory  is  organic — other- 
wise speaking,  whether  it  is  dependent  upon  any 
cerebral  irreparable  lesion,  upon  any  of  the  forms 
of  insanity,  of  which  amnesia  is  a  grave  symptom — 
or  else  the  loss  of  memory  is  functional,  as,  for 
instance,  in  hysteria,  with  its  periodical  attacks  of 
double  consciousness. 

When  an  individual  is  mentally  der&nged,  when 
he  presents  delusions,  hallucinations,  illusions,  the 
crime  committed  by  him  cannot  be  punishable  on 
the  basis  of  his  general  mental  irresponsibility  and 


not  exclusively  upon  his  amnesia,  in  case  the  latter 
occurs.  A  case  of  mild  dementia,  as,  for  example, 
senile  dementia,  or  the  insidiously  progressive  de- 
mentia of  chronic  alcoholic  or  other  intoxications, 
may  present  attacks  of  amnesia.  In  paresis,  in 
which  the  character  and  sentiments  are  affected  first, 
the  memory  becomes  strikingly  involved.  Here  am- 
nesia is  inevitably  progressive.  The  disease  is  of 
great  importance  in  legal  medicine,  as  at  its  onset 
it  may  show  only  signs  of  moral  perversion,  and  if 
we  are  not  on  our  guard,  we  may  convict  the  un- 
fortunate paretic,  who  belongs  rather  to  the  domain 
of  the  physician  and  not  to  that  of  the  judge,  to  the 
asylum  and  not  to  prison. 

In  all  these  cases  impulsive  acts  of  all  varieties 
are  not  infrequently  committed,  and  the  individuals 
may  not  have  the  least  recollection  of  the  commis- 
sion of  a  crime.  Whether  the  amnesia  is  simulated 
or  genuine,  such  a  criminal  is  a  diseased  individual, 
and  full  penalty  cannot  be  imposed  on  persons 
whose  mentality  is  impaired. 

In  epilepsy  a  convulsive  attack  may  be  followed 
by  an  impulsive  act  of  which  the  patient  has  not  the 
least  recollection  after  he  regains  consciousness.  An 
epileptic  attack  itself  may  consist  of  intellectual  dis- 
turbances instead  of  the  habitual  muscular  mani- 
festations, and  instead  of  convulsions  there  may  be 
unconscious  aggressive  acts ;  the  patient  may  steal, 
rob,  attack,  or  kill.  These  disturbances  of  con- 
sciousness may  be  of  various  degrees  and  cover  a 
period  of  various  duration.  One  of  my  recent  pa- 
tients, a  cashier  of  a  bank,  would  suddenly  leave 
his  usual  place,  walk  to  the  safe,  open  it  uncere- 
moniously in  presence  of  the  employees,  fill  up  his 
pockets  with  money  or  papers.  Another  patient,  a 
tailor,  would  suddenly  leave  his  work,  go  out  on 
the  street,  walk  a  few  squares,  then  enter  any  of 
the  stores,  pick  up  some  goods,  and  walk  out  lei- 
surely. When  arrested  he  denied  the  theft  most 
vigorously,  and  when  confronted  with  people  who 
saw  him  in  the  act,  he  could  not  believe  it.  He 
then  went  to  a  physician  to  seek  relief,  suspecting 
that  he  was  probably  ill. 

In  such  cases  there  is  no  special  difficulty  in 
establishing  the  genuineness  of  the  attacks  of  uncon- 
sciousness and  consequently  of  the  amnesia.  It 
should,  however,  be  borne  in  mind  that  the  influence 
of  epileptic  seizures  upon  the  memory  is  variable. 
In  the  majority  of  cases  epileptic  amnesia  concerns 
the  attack  itself,  but  there  is  a  large  number  of 
cases  in  which  the  amnesia  may  be  retrograde,  viz., 
affecting  a  certain  period  of  time  preceding  a  seiz- 
ure, or  may  be  anterograde,  viz.,  aflfecting  also  a 
period  of  time  following  a  seizure.  Such  periods 
may  be  of  an  hour,  a  day,  a  week,  one  month,  or 
several  months'  duration. 

The  epileptic  amnesia  may  be  anteroretrograde. 
Finally,  it  may  be  delayed.  In  the  latter  case  the  in- 
dividual may  have  some  vague  recollection  of  acts 
committed  by  him  during  a  seizure,  but  some  time 
later  these  acts  are  totally  forgotten.  Such  a  person 
is  precisely  in  the  same  position  as  when  we  wake 
up  after  a  profound  sleep ;  at  first  moment  we  recall 
clearly  all  the  details  of  our  dream,  but  we  soon 
forget  them  all. 

The  legal  importance  of  such  a  case  is  too  obvious 
to  dwell  upon. 

Feeble  minded  individuals,  imbeciles,  idiots,  whose 


262 


GORDON: 


AMNESIA. 


[New  York 
Medical  Jouenau 


mentality  has  never  developed  above  a  certain  de- 
gree, whose  low  mentality  is  due  to  congenital 
anomalies  of  the  brain,  present  all  varieties  of  am- 
nesia. During  their  entire  life  they  are  frequently 
seized  with  morbid  impulses  of  the  most  criminal 
nature,  and  then  present  amnesias,  complete  or  par- 
tial, anterograde  or  retrograde.  Such  individuals 
cannot  be  held  responsible,  not  only  on  the  ground 
of  the  true  amnesias,  but  also  and  chiefly  for  the 
reason  of  their  general  mental  status,  of  which 
amnesia  is  one  of  the  many  manifestations. 

A  very  large  field  for  the  study  of  amnesia  is 
presented  by  hysteria.  Here  we  find  multiple  vari- 
eties of  disturbance  of  memory.  It  may  be  systema- 
tized when  remembrance  of  a  certain  group  of  ideas 
concerning  one  subject  or  one  person  is  lost.  It 
may  be  general  (rare,  however),  in  which  the  per- 
son thus  affected  has  completely  lost  the  memory 
for  all  past  events  of  his  life,  and  like  an  infant  must 
be  taught  to  acquire  new  knowledge.  An  example 
of  such  a  remarkable  condition  can  be  found  in  the 
history  of  the  Rev.  Hanna  (Sidis  and  Goodhart), 
or  in  the  old  celebrated  case  of  Mary  Reynolds 
(Weir  Mitchell).  The  amnesia  may  be  partial. 
Examples  of  this  variety  can  be  found  in  cases  of 
double  personality.  The  characteristic  feature  of 
them  lies  in  the  fact  that  the  psychomotor  sphere  is 
not  inhibited  in  either  state.  Each  personality  in  its 
own  state  acts  in  response  to  inner  stimulations,  and 
one  state  has  not  the  remotest  association  with  the 
other.  It  may  happen  that  the  lives  the  two  person- 
alities lead  are  diametrically  opposite  to  each  other. 
In  the  case  of  the  Rev.  Hanna  consciousness  was  so 
profoundly  dissociated_  that  the  two  personalities  he 
presented  before  treatment  was  instituted  had  indi- 
vidual systems  of  psychic  states,  which  carried  on 
their  functions  in  an  absolutely  independent  manner. 
If  such  patients  recover,  one  state  gradually  be- 
comes aware  of  the  existence  of  the  other,  and  the 
two  egos  may  finally  become  synthetized  into  one 
personality.  Those  patients  who  do  not  recover 
present  during  their  entire  life  the  before  men- 
tioned alterations  of  personalities,  with  complete  am- 
nesia of  each  preceding  state. 

A  patient,  whom  I  still  have  under  observation,  is  other- 
wise an  intelligent  man  of  thirty-nine  and  occupies  a  re- 
sponsible position  in  a  newspaper's  office.  Several  years 
ago  he  drank  excessively,  but  he  gradually  learned  how  to 
overcome  the  desire  for  alcohol.  Instead  of  it,  however, 
he  developed  double  consciousness.  He  related  that  with 
his  total  horror  and  repugnance  for  alcoholic  drinks  he 
suddenly  wandered  off,  disappeared  for  several  hours,  en- 
tered bars  and  drank.  He  found  it  out  only  a  few  hours 
later  by  tasting  whiskey.  He  could  not  give  an  account 
where  he  received  the  money  from  to  buy  the  drink  and 
what  places  he  visited.  This  happened  on  several  occasions 
when,  after  leaving  his  office,  he  disappeared  instead  of 
going  home,  as  he  intended  to  do. 

In  this  state  the  ego  No.  i  does  not  remember  No. 
2,  and  No.  2  has  no  knowledge  of  No.  i.  Amnesia 
for  No.  2  is  complete.  Sometimes  the  number  of 
personalities  may  be  multiple.  In  Wilson's  case 
(Journal  of  Mental  Science,  October,  1903,  p.  640), 
for  example,  there  were  as  many  as  twelve  person- 
alities, each  of  which  was  foreign  to  the  other. 

The  knowledge  of  this  peculiar  phenomena  is,  of 
course,  of  the  highest  legal  importance. 

Among  other  conditions  in  which  amnesia  may  be 


encountered  we  find  intoxications.  The  latter  may 
be  due  to  some  poison  introduced  from  outside,  as 
carbonic  gas,  lead,  mercury,  belladonna,  haschish, 
and  alcohol,  or  to  some  infectious  disease,  as  typhoid 
fever,  grippe,  scarlet  fever.  Insolation  may  be  also 
placed  here.  Each  of  these  morbid  conditions  may 
produce  cerebral  disturbances,  among  which  amnesia 
is  met  with.  In  one  of  my  cases  (New  York  Med- 
ical Journal,  March  3,  1906)  a  man  of  forty-seven 
slept  in  a  room  filled  accidentally  with  gas  from  a 
radiator.  He  remained  unconscious  for  thirty-six 
hours.  For  the  following  six  weeks  he  was  in  a  stu- 
porous condition,  and  since  then  it  was  impossilbe 
for  him  to  recall  the  occurrence,  also  the  fact  that 
his  two  children  slept  in  the  same  room.  He  could 
not  equally  remember  events  prior  to  the  intoxica- 
tion with  gas,  also  events  following  the  accident,  for 
several  months.  He  also  forgot  the  exact  age  of  his 
children  and  had  only  a  faint  recollection  of  the 
child  that  died  during  asphyxiation. 

A  very  important  chapter  in  the  history  of  amne- 
sias presents  traniiiatisni,  accompanied  or  not  by  loss 
of  consciousness.  It  is  not  at  all  necessary  that  the 
injury  be  severe.  Insignificant  traumata  are  some- 
times followed  by  genuine  amnesia.  Sometimes  after 
a  physical  exertion  without  trauma  amnesia  may  de- 
velop, as  it  can  be  seen  from  Ch.  Fere's  case 
{Comptes  rendus  de  la  Societe  biologique,  1897,  p. 
154),  in  which  a  young  man  of  eighteen  after  a  long 
ride  on  a  bicycle  slept  fourteen  hours ;  when  he 
awoke  he  could  not  recall  what  occurred  four  hours 
prior  to  his  sleep. 

The  majority  of  cases  with  traumatic  amnesia  have 
reference  to  instances  in  which  the  injury  to  the 
head  consisted  of  a  fall  against  the  ground  or  some 
hard  object.  Cases  with  amnesia  following  penetra- 
tion and  lodging  of  bullets  in  the  brain  caused  by  at- 
tempts at  suicide  are  rare.  One  of  my  patients 
(Medical  Record,  April  18,  1908)  suffering  from  an 
attack  of  acute  melancholia  attempted  suicide  and 
shot  himself.  The  bullet  entered  the  right  temple 
and  lodged  on  the  opposite  side  in  the  parietal  lobe, 
which  was  proved  by  an  x  ray  picture  and  an  oper- 
ation. The  latter  was  performed  many  months  later, 
and  during  all  that  time,  as  well  as  after  the  opera- 
tion, he  presented  a  total  amnesia  for  that  act,  for 
events  some  time  prior  and  some  time  after  the 
shooting.  He  therefore  had  a  retroanterograde  am- 
nesia. 

The  case  which  forms  the  basis  of  the  present 
essay  is  interesting  from  the  latter  standpoint.  It 
deserves  a  special  study  both  from  a  clinical  and 
legal  standpoints.  The  difficulty  for  the  jurist  is  and 
was  undoubtedly  very  great.  Here  is  a  man  ap- 
parently in  full  possession  of  his  mental  faculties, 
able  to  understand  problems  of  a  general  character, 
capable  to  distinguish  between  right  and  wrong, 
capable  to  appreciate  his  present  situation,  who  as- 
serts to  have  no  recollection  of  the  commission  of  the 
crime  and  of  the  attempt  at  his  own  life ;  moreover, 
he  does  not  accept  the  evidence  that  he  is  a  carrier 
of  a  bullet  in  his  brain.  He  can  clearly  give  an  ac- 
count of  all  the  facts  preceding  the  shooting  and 
after  his  discharge  from  the  hospital,  but  the  double 
shooting  itself  he  is  absolutely  unaware  of.  The 
case,  therefore,  belongs  to  the  group  of  traumatic 


February  6,  1909.] 


GORDON:  AMNESIA. 


263 


amnesias  mentioned  before.  Clinically  we  have  no 
difficulty  in  accepting  it,  but  legally  the  problem  be- 
comes complicated,  and  therefore  very  serious.  At 
first  glance  we  may  argue  that  the  criminal  was  in 
full  possession  of  his  faculties  at  the  time  of  shoot- 
ing ;  even  admitting  the  genuineness  of  the  present 
amnesia,  he  deserves  punishment  according  to  the 
law.  In  fact,  it  has  been  demonstrated  from  the 
events  of  his  former  life  that  at  the  time  of  the  com- 
mission of  the  crime  there  was  apparently  no  indica- 
tion of  mental  derangement  caused  either  by  alco- 
holic or  other  intoxications.  He  w^as  therefore  re- 
sponsible, one  may  say,  for  what  he  did  at  that  time. 

The  question  consequently  is  reduced  to  the  fol- 
lowing proposition :  Does  or  does  not  the  loss  of 
memory  for  a  former  criminal  act,  of  w^hich  the  au- 
thor was  then  responsible,  destroy  his  responsibility  ? 
This  question  is  purely  legal  and  the  expert  should 
leave  it  entirely  to  the  court.  From  a  medical  point 
of  view,  whatever  the  degree  of  loss  of  memory  may 
be,  the  amnesic  cannot  be  determined,  as  by  virtue 
of  the  amnesia  itself  the  patient  is  incapable  to  pre- 
sent properly  his  defense  and  consequently  confer 
with  counsel  upon  an  act  of  which  he  is  totally  ig- 
norant. This  is  the  process  of  the  arguing  presented 
by  me  at  Endrukat's  trial. 

The  law  concerning  lunacy  as  used  in  Section  67 
of  the  Act  of  i860  assumes  an  inability  on  the  part 
of  the  prisoner  to  understand  and  comprehend  suffi- 
ciently his  position  to  be  able  to  confer  with  counsel 
and  prepare  a  defense. 

In  the  present  case  this  inability  exists  not  because 
of  any  special  for-m  of  insanity,  but  because  of  the 
amnesia ;  a  man  cannot  confer  with  counsel  upon  an 
act,  although  committed  by  him,  but  of  w-hich  he 
has  no  recollection.  As  the  legal  definition  of  insan- 
ity, I  said  in  reply  to  a  question,  covers  practically 
all  forms  of  mental  deficiencies,  an  amnesic  individ- 
ual must  necessarily  be  placed  in  the  category  of 
lunatics. 

The  eminent  judge  before  whom  the  case  was 
tried,  with  a  remarkable  clearness  and  fairness,  pre- 
sented the  entire  position  of  the  subject  to  the  jury 
and  the  verdict  rendered  by  them  read  as  follows : 
"We  find  the  defendant,  Frank  Endrukat,  guilty  of 
murder  in  the  first  degree,  also  that  he  is  now  a  luna- 
tic and  unable  to  confer  with  counsel  in  regard  to 
the  tragedy." 

The  verdict  was  not  only  in  conformity  with  the 
legal  conception  of  insanity,  but  also  with  the  re- 
quirements of  medical  science.  It  admitted,  there- 
fore, that  the  criminal  was  responsible  at  the  time  of 
the  commission  of  the  crime,  as  there  was  no  evi- 
dence to  the  contrary,  but  the  subsequent  develop- 
ment of  amnesia  by  reason  of  the  injury  to  his  own 
brain  by  the  bullet,  which  is  still  present  there,  placed 
him  in  an  impossible  position  to  confer  with  counsel. 

The  foregoing  remarks  appear  to  be  logical  when 
the  amnesia  is  assumed  to  be  genuine.  A  history  of 
trauma  alone  is  not  a  sufficient  guarantee  that  the 
individual  is  suffering  from  a  real  amnesia.  There 
are  on  record  many  cases  with  accidents  and  injuries 
to  the  head  with  loss  of  consciousness  not  followed 
by  amnesia.  Frank  Endrukat,  in  spite  of  the  bul- 
let in  his  head,  may  have  been  free  from  amnesia, 
and  his  persistence  in  denying  it  may  have  been  due 


to  simulation.  The  truth  in  this,  like  in  any  other 
similar  case,  can  be  ascertained  only  after  a  pro- 
longed, repeated,  and  most  minute  examination.  In 
mental  medicine  it  is  difficult  to  formulate  strict 
rules ;  each  case  requires  a  special  investigation  and 
has  to  be  judged  upon  its  own  merits.  The  varia- 
bility of  the  manifestations  in  different  individuals 
affected  with  the  same  mental  disorder  is  considera- 
ble. Detection  of  simulation  can  be  accomplished  by 
a  thorough  and  skillful  questioning.  It  should,  how- 
ever, be  borne  in  mind  that  an  alleged  amnesia  may 
be  present  in  a  mentally  diseased  individual,  and 
then  the  simulation  itself  constitutes  one  of  the 
symptoms  of  the  pathological  condition. 

The  discrimination  is  surrounded  with  great  diffi- 
culties, and  in  order  to  accomplish  this  task  one  must 
possess  a  correct  clinical  knowledge,  which  alone  can 
procure  a  scientific  solution  of  medicolegal  problems. 

The  first  duty  is  to  determine  to  what  variety  the 
alleged  amnesia  belongs.  The  next  step  is  to  in- 
quire into  all  the  circumstances  which  precede,  ac- 
company, or  follow  a  certain  act  of  which  the  indi- 
vidual suffering  from  the  amnesia  is  accused.  If  it 
is  necessary  and  useful  to  know  the  circumstances  of 
the  crime  in  all  its  details,  it  is  especially  indispensa- 
ble to  make  a  thorough  study  of  the  criminal  himself 
and  build  up  his  biological  history.  With  this  ob- 
ject in  view  the  man's  manner  of  speaking,  of  an- 
swering questions,  of  explaining  facts,  of  arguing, 
the  tone  of  his  voice  in  his  endeavor  to  show  convic- 
tion must  be  closely  watched  and  his  facial  expres- 
sion closely  scrutinized.  Attempts  must  be  made  to 
confuse  him  and  watch  at  the  same  time  his  methods 
of  extricating  himself.  His  memory  for  old  and  re- 
cent events,  manner  of  thinking  and  reasoning,  his 
knowledge  in  a  general  way  and  of  specific  subjects, 
his  moral  conception,  must  be  thoroughly  and  re- 
peatedly tested.  We  must  ascertain  that  there  is  no 
history  of  infectious  diseases  or  chronic  toxic  condi- 
tions, or  else  outbreaks  of  toxicity,  any  previous 
mental  disorders,  any  injury  to  the  head  or  severe 
shocks,  violent  emotions,  fright,  etc.  We  must  de- 
termine the  question  of  epilepsy,  hysteria,  psychas- 
thenia.  We  must  inquire  into  the  criminal's  child- 
hood and  ascertain  whether  his  mental  or  physical 
development  were  in  any  way  disturbed.  We  must 
.also  determine  the  general  state  of  his  mentality, 
whether  the  man  is  an  imbecile  or  only  feeble  mind- 
ed. Finally,  we  must  inquire  into  the  family  history 
and  see  if  there  is  any  hereditary  taint,  as  the  latter 
plays  an  important  predisposing  role  in  the  life  of 
an  individual.  Tuberculosis,  syphilis,  alcoholism,  in- 
sanity in  parents,  constitute  the  most  potent  influ- 
ences in  the  life  of  the  offspring. 

This  is  a  general  method  for  investigating  any 
case  of  amnesia.  Simulation  will  be  determined  only 
after  complete  and  prolonged  investigation  of  all  the 
elements  just  outlined.  In  the  majority  of  cases  a 
simulator  will  be  detected  quite  rapidly  from  his 
grotesque  and  awkward  attempts  of  imitating  psychic 
S}Tnptoms.  With  regard  to  amnesia,  he  will  forget 
when  skillfully  questioned  all  about  his  amnesia,  or 
else  will  now  and  then  exaggerate  it.  He  w'ill  show 
lack  of  frankness  characteristic  of  a  genuine  patient, 
will  apologize  or  defend  himself  when  it  is  not  nec- 
essary, and  will  invariably  present  the  picture  of  a 


264 


SHAFFER:  CRIPPLED  AND  DEFORMED  CHILDREN. 


[New  York 
Medical  Journal. 


man  who  is  making  an  effort  to  acquit  himself  of  a 
certain  given  task.  The  failure  of  simulation  will 
be  particularly  noticeable  in  organic  amnesias,  where 
the  simulator  is  ignorant  of  the  fact  that  the  deteri- 
oration of  memory  grows  parallel  with  the  general 
mental  decrepitude  of  which  it  constitutes  an  inte- 
gral part. 

Genuine  amnesia  may  develop  in  all  individuals. 
While  it  may  occur  in  individuals  apparently  free 
from  a  degenerative  taint,  nevertheless  neuropathic 
persons  are  especially  apt  to  disturbances  of  mem- 
ory, which  is  the  most  fragile  of  cerebral  functions. 
Endrukat's  personality  presents  from  this  standpoint 
some  peculiarities  worth  mentioning.  His  demeanor 
during  my  examination  was  that  of  an  eccentric  in- 
dividual, which  was  revealed  by  his  gestures,  occa- 
sional exaltation  over  simple  facts,  lowering  and 
raising  of  his  voice  in  rapid  succession.  The  most 
striking  moment  was  when  he  gave  an  account  of 
his  first  attempt  to  kill  the  woman  and  her  father, 
which  was  done  in  Russia  upon  her  own  request. 
He  recited  in  the  most  indifferent  and  detailed  man- 
ner the  effect  of  this  attempt,  how  the  blood  ran 
from  her,  how  the  father  came  in,  and  at  that  mo- 
ment he  struck  him,  adding,  "that  is  funny  how  they 
could  not  die  from  those  wounds."  He  also  de- 
scribed with  laughter  how  he  tried  to  kill  himself  by 
cutting  his  throat,  just  as  if  it  was  a  thing  to  laugh  at. 

In  the  presence  of  such  an  individual  one  must  ad- 
mit that  there  is  some  deviation  from  normal.  A 
person  like  Endrukat  may  preserve  the  integrity  of 
individual  functions,  may  answer  questions  clearly 
and  distinctly,  may  even  exhibit  a  certain  amount  of 
intellectual  acumen,"  may  understand  perfectly  well 
the  great  distinction  between  right  and  wrong — and 
still  he  cannot  be  considered  perfectly  normal  in  the 
physiological  sense  of  the  word.  Should  such  an  in- 
dividual sustain  a  trauma,  a  shock,  and  especially  a 
real  destruction  of  brain  tissue  fas  this  is  the  case), 
mental  deficiencies  of  all  forms  will  find  a  favorable 
ground  for  their  development— and  such  a  fragile 
mental  faculty  like  memory  will  naturally  be  affect- 
ed first. 

These  are  the  deductions  to  which  I  was  led  after 
a  profound  analysis  of  the  history  of  the  case  and 
the  thorough  examination  of  the  criminal  from  every 
possible  standpoint. 

Problems  of  such  a  delicate  discrimination  like  am- 
nesia are  unquestionably  difficult  to  both  alienist  and 
jurist.  The  former's  task  is  facilitated  by  his  knowl- 
edge of  the  physiological  and  clinical  phenomena. 
The  jurist  is  confronted  with  greater  obstacles,  the 
foremost  among  which  is  the  question  of  his  own 
responsibility  before  the  community  in  his  endeavors 
to  show  whether  a  certain  amnesia  is  genuine  or 
simulated. 

In  the  majority  of  cases  he  will  overcome  the  dif- 
ficulty by  surrounding  himself  with  competent  ex- 
perts, and  especially  by  allowing  the  latter  to  pre- 
sent all  the  details  of  the  medical  aspect  of  the  case 
without  exception,  but  not  restricting  them  to  cer- 
tain technical  questions.  This  is  the  only  method 
which  enables  one  to  form  a  correct  conception  of 
certain  phenomena  in  which  cerebral  disturbances 
are  manifest. 

1430  Pine  Street. 


ON  THE  CARE  AND  TREATMENT  OF  THE  DE- 
PENDENT AND  NEGLECTED,  CRIPPLED 
AND  DEFORMED  CHILDREN.* 
By  Newton  M.  Shaffer,  M.  D., 
New  York, 

Professor  of  Orthopaedic  Surgery,  Cornell  University  Medical  Col- 
lege; and  Surgeon  in  Chief  to  the  New  York  State  Hospital 
for  the  Care  of  Crippled  and  Deformed  Children. 

The  subject  I  wish  especially  to  bring  to  the  at- 
tention of  this  conference  is  that  which  involves  the 
care  of  the  destitute  or  neglected,  crippled  or  de- 
formed child. 

All  that  has  been  said  in  the  circular  letter  ad- 
dressed by  the  committee  to  President  Roosevelt  re- 
garding the  destitute  dependent  child  may  be  re- 
peated here,  with  great  emphasis,  in  behalf  of  those 
for  whom  I  appeal,  and  of  whom  it  may  also  be  said 
that  they,  under  the  circumstances,  must  form  a 
class  by  themselves.  Their  disabilities  and  suffer- 
ings make  them  ineligible  to  ordinary  care,  or  to  the 
more  or  less  inflexible  rules  that  necessarily  exist 
and  are  followed  for  the  government  and  control  of 
the  normal  destitute  child,  and  whose  condition,  be 
it  disease  or  simple  deformity,  calls  for  definite 
work  and  permanent  relief,  on  the  part  of  those  who 
will  work  under  the  guidance  or  advice  of  this  con- 
ference. 

Statistics  which  would  be  of  great  importance  in 
considering  this  matter  are  unfortunately  not  avail- 
able. It  may  be  stated,  however,  that  there  are 
many  thousands  of  this  unfortunate  class  in  every 
State  in  the  Union.  Of  these  there  are  a  good  pro- 
portion who  are  neglected,  and  many  who  are  hope- 
lessly dependent. 

When  it  was  proposed  to  establish  the  New  York 
State  Hospital  for  the  Care  of  Crippled  and  De- 
formed Children  in  18Q9,  the  State  Board  of  Chari- 
ties prepared  a  census  of  the  institutions  under  their 
jurisdiction,  and  among  the  inmates  there  were 
found  in  the  almshouses,  etc.,  over  one  hundred  de- 
formed children  who  were  receiving  no  surgical 
care,  whose  condition  was  in  many  ways  neglected, 
and  who  were,  and  would  continue  to  be  until  their 
death,  a  burden  upon  the  State.  Add  to  this  the 
suffering  and  deformed  children  of  the  poor  me- 
chanic, the  poverty  stricken  widow,  the  struggling 
seamstress,  and  others,  and  the  neglected  and  desti- 
tute children  of  this  class  becomes  very  much  en- 
larged. It  is  apparent  that  this  class  calls  for  spe- 
cial attention  in  some  institution  devoted  to  their 
care  and  treatment  before  they  can  be  returned  to 
their  homes.  A  few  months  or  years  of  treatment 
and  cure  will,  at  least,  suffice  for  their  return  to 
active  life. 

The  destitute,  crippled,  and  deformed  children 
may  be  roughly  divided,  in  a  medical  sense,  into 
two  classes : 

First:  Those  whose  deformities  arise  from  some 
diseased  condition,  like  tuberculous  disease  of  the 
joints  or  spine ;  and 

Second  :  Those  afflicted  with  some  deforming  con- 
dition not  accompanied  by  active  disease,  like  the  de- 
formities arising  from  infantile  paralysis,  knock 
knee,  club  foot,  etc.  The  former  require,  as  a 
rule,  special  surgical  care  not  always  afforded  by 

•Read  before  the  Conference  on  Dependent  Children,  held  in 
Washington,  D.  C,  on  January  25.  1909. 


February  6,  1909  ]  SHOEMAKER:  TYPHOID  PROPHYLACTIC  IXOCULATION. 


265 


the  dispensaries  and  schools  estabHshed  for  their  re- 
Hef,  and  inchide  many  who,  especially  if  they  have 
tuberculous  abscesses,  ought  to  be  more  or  less  iso- 
lated ;  while  the  latter  need,  after  a  comparatively 
short  period  of  care  in  a  hospital,  mechanical  sup- 
ports which  under  ordinary  circumstances  enable 
these  afflicted  ones  to  get  about  with  comparative 
ease. 

I  think  it  will  be  admitted  that  the  larger  portion 
of  this  dependent  class  need  hospital  care  for  a 
more  or  less  prolonged  period.  Their  home  envi- 
ronment demands  it,  or  if  they  have  no  home  it  is 
imperative.  For  instance,  the  average  duration  of 
treatment  for  both  classes  of  cases  above  referred 
to  at  the  New  York  State  Hospital  for  the  Care  of 
Crippled  and  Deformed  Children  at  West  Haver- 
straw,  New  York,  is  one  year,  six  months,  and 
twenty-seven  days ;  for  the  tuberculosis  cases  it  is 
over  three  years ;  and  this  question  of  prolonged 
hospital  care  brings  up  the  secondary  one  of  envi- 
ronment and  education. 

Luckily  this  class  of  dependents,  eliminating  those 
whose  deformities  are  due  to  a  cerebral  lesion,  have 
as  a  rule  excellent  brains,  oftentimes  they  are  ex- 
ceptionally bright,  and  most  fortunately  the  hands 
and  arms  are  not  often  af¥ected.  The  question  of 
both  mental  and  manual  training  is  therefore  quite 
easily  solved,  and  a  careful  consideration  as  to  the 
proper  course  to  be  pursued  for  each  child  should 
be  studied  before  a  selection  is  made.  Telegraphy, 
stenography,  typewriting,  plain  and  ornamental  sew- 
ing, etc.,  suggest  themselves  as  being  appropriate 
occupations  for  the  brighter  minds  and  for  the  girls 
especially;  while" carpentry,  shoe  making,  cane  seat- 
ing, etc.,  for  some,  but  not  all,  of  the  boys.  In  any 
event,  all  should  be  well  grounded  in  the  elementary 
branches  of  education,  either  coincidentally  with  the 
manual  work  or  before  it. 

Their  environment  in  institution  life  should  in- 
clude as  nearly  as  possible  the  home  life.  The  bring- 
ing together  of  a  large  number  of  children,  espe- 
cially of  this  class,  should  be  discouraged.  The 
family  of  destitute,  crippled,  and  deformed  children 
in  hospital  or  school  life  should  not  exceed,  in  my 
judgment,  more  than  thirty  or  forty,  and  great  care 
should  be  exercised  in  the  selection  of  those  in 
control. 

This  has  been  the  policy  of  the  State  Hospital  at 
West  Haverstraw,  with  a  limited  number,  only 
about  forty-five,  under  its  care.  Many  of  them  are 
too  ill  to  pursue  a  regular  industrial  training 
course,  and  much  time  and  effort  are  given  to  the 
fresh  air  treatment  of  tuberculous  patients.  Xo 
class  could  be  formed  under  these  circumstances 
large  enough  to  warrant  the  employment  of  a  spe- 
cial teacher  for  manual  training,  but  there  is  a 
teacher  employed  under  the  civil  service  rules,  who 
instructs,  under  the  advice  of  the  medical  staff,  all 
those  able  to  attend  school,  and  who  gives,  so  far  as 
possible,  graduated  instruction.  In  addition  to  this 
the  various  officers  of  the  institution  have  volun- 
tarily given  instruction  in  some  of  the  branches  be- 
fore'mentioned.  With  five  or  six  similar  small  cot- 
tages, and  with  a  large  central  hospital,  sufficient 
convalescents  would  exist  to  form  a  large  school 
for  any  desired  form  of  instruction. 

There  are  some  excellent  schools  or  hospitals, 
both  State  and  private,  where  good  work  is  being 


done  in  this  direction,  and  of  which  time  will  not 
permit  me  to  speak  on  this  occasion.  Their  number 
should  be  increased  until  every  State  has  its  well 
equipped  hospital  for  the  care  and  treatment  of  in- 
digent neglected  or  destitute  children. 

My  final  plea  in  institution  work  of  this  class  is 
to  recognize  the  hospital  work  first ;  to  put  the  pa- 
tients in  a  condition  where  they  are  competent  and 
able  to  receive  manual  training  before  the  question 
of  stated  and  regular  industrial  education  is  made 
prominent  in  the  work. 

28  East  Thirty-eighth  Street.  ■  : 


OBSERVATIONS  OX  PROPHYLACTIC  INOCULA- 
TIONS AGAINST  TYPHOID  FEVER* 
By  Harlan  Shoemaker,  A.  B.,  M.  D., 
Philadelphia. 

Sir  Almroth  E.  Wright,  of  London,  while  on  a 
visit  to  Professor  R.  Pfeiffer  in  1896,  was  shown 
for  the  first  time  that  typhoid  bacilli  killed  by  heat,, 
when  inoculated  into  a  human  being,  produced,  in 
the  course  of  time,  changes  in  the  blood  which  were 
identical  with  those  changes  observed  during  and 
after  convalescence  from  typhoid  fever. 

Wright,  returning  to  England,  took  up  this  sub- 
ject, which,  as  he  expresses  it,  was  destined,  so  far 
as  he  was  concerned,  to  remain  indefinitely  inoper- 
ative, and  published  the  results  of  two  inoculations 
(Lancet,  September  19,  1896),  while  Pfeiffer  and 
Kolle  published  the  results  of  their  two  inoculations 
(Deutsche  medizinische  Wochoischrift,  November 
12,  1896).  However,  E.  Fraenkel  (Deutsche  medi- 
zinische Wochenschrift,  October  12,  1893),  reported 
the  use  of  typhoid  bacilli  killed  at  63°  C.  in  the 
treatment  of  this  disease. 

Notwithstanding,  to  Wright  belongs  the  credit  of 
having  developed  and  placed  upon  a  scientific  basis 
the  prophylactic  inoculation  against  typhoid  fever. 
He  prepared  gratuitously  400,000  vaccines  during 
the  Boer  War  for  the  inoculation  of  the  British  sol- 
diery, and  made  4,000  inoculations  personally.  (See 
A  Short  Treatise  on  Antityphoid  Inoculation,  by  A. 
E.  Wright,  M.  D.,  published  by  Archibald  Consta- 
ble and  Co.,  Ltd.,  London,  1904.)  The  appendix  of 
this  admirable  work  contains  a  bibliography  of  pa- 
pers bearing  upon  immunity  to  bacterial  disease  up 
to  the  date  of  the  publication  by  the  author. 

Criticism  and  opposition  to  Wright's  method  grew 
so  strong  that  it  was  discontinued  in  the  British 
army.  Subsequently  the  Army  ^ledical  School  ap- 
pointed a  commission  to  investigate  Wright's  meth- 
ods scientifically  and  statistically.  Colonel  Leish- 
man  headed  this  commission,  which  was  appointed 
October  21,  1904,  and  reported  its  findings  in  the 
Journal  of  Hygiene,  1905. 

In  this  report  a  careful  estimate  is  made  of  the 
effects  produced  in  the  blood  stream  by  dosage,  upon 
I,  a  negative  and  positive  phase;  2,  stimulus  vs.  op- 
sonins ;  3,  bacteriocidal  substances ;  4,  bacteriolytic 
substances ;  and  5,  agglutination.  The  entire  report 
is  confirmatory  of  Wright's  experience,  and  still  re- 
mains essentially  his  technique,  with  minor  modifi- 
cations. 

Clinical  Ohserivtions. — On  November  9,  1908,  I 

*Read  before  the  Philadelphia  Pathological  Socie'y,  January  14, 
1909. 


266 


SHOEMAKER:  TYPHOID  PROPHYLACTIC  INOCULATION. 


[New  York 
■Medical  Journal. 


inoculated  four  persons — two  nurses,  a  doctor,  and 
myself — with  a  typhoid  vaccine,  and  the  following 
symptoms  were  observed : 

Case  I. — M.  B.,  nurse.  First  dose  of  0.33  c.c.  In  four 
hours  local  reaction  at  site  of  injection  over  insertion  of 
deltoid  muscle  tendon  and  humerus  began  with  pain, 
swelling,  heat,  and  redness.  During  second  twenty-four 
hours  temperature  rose  to  101°  F.  with  malaise  and  general 
aches.  Vomited.  Was  off  duty  two  hours.  During  third 
twenty-four  hours,  sweats,  normal  temperature,  and  disap- 
pearing local  reaction. 

Case  II. — N.,  nurse.  Dose  and  symptoms  both  local  and 
general  same  as  Case  I. 

Case  III. — Dr.  M.  Weight,  200  pounds.  Dose,  0.66  c.c. 
Local  reaction  about  site  of  inoculation  very  angry.  Con- 
stitutional symptoms  marked.  Temperature  102°  F.  Vom- 
ited. Went  to  bed.  Symptoms  passed  off  in  about  the 
same  order  as  in  Cases  I  and  II. 

Case  IV. — Dr.  H.  S.  Weight,  180  pounds.  Dose,  0.66  c.c. 
Local  reaction  extended  from  shoulder  to  elbow,  red  and 
swollen,  but  not  angry.  Constitutional  reaction,  tempera- 
ture 101°  F.  No  prostration.  Did  usual  amount  of  work. 
Had  profuse  sweat  the  two  nights  succeeding  vaccination, 
with  a  disappearance  of  general  symptoms. 

General  Remarks. — This  experience  is  identical 
with  that  which  the  Royal  Army  Medical  Commis- 
sion met  when  they  prepared  and  inoculated  them- 
selves with  a  vaccine  prior  to  their  attempts  upon 
volunteers.  I  thought  that  I  had  profited  by  their 
experience,  but  fell  into  an  error  from  another  source. 
As  others  may  have  a  similar  experience,  I  shall  en- 
deavor to  point  out  one  of  the  chief  precautions  nec- 
essary to  the  preparation  and  standardization  of  a 
vaccine. 

Preparation  of  Vaccine. — The  vaccine  used  for 
the  first  inoculation  was  prepared  by  washing  ofif 
the  twenty-four  hour  growth  from  three  agar  slants 
and  treating  the  same  in  a  water  bath  to  53°  C.  for 
one  hour.  53°  C.  is  the  temperature,  and  one  hour 
the  time,  that  the  Royal  Army  Medical  Commission 
found  necessary  to  kill  the  bacillus  typhosus.  Here 
I  found  my  chief  difficulty  because  the  strain  of  the 
Bacillus  typhosus  with  which  I  worked,  was  not  to 
"be  killed  at  this  temperature.  The  saline  solution 
(85  per  cent,  sodium  chloride)  of  Bacillus  typhosus 
germinated,  and  the  vaccine  was  finally  killed  by 
■prolonged  heating  to  55°  C,  when  lysol,  0.25  per 
cent.,  was  added  as  a  preservative  to  the  cooled  vac- 
-cine.  Lysol  added  to  hot  vaccine  robs  it  of  all  activ- 
ity. 

Harrison,  Journal  of  Hygiene,  viii,  p.  472,  1908, 
gives  the  results  of  very  elaborate  experimentation 
in  the  preservation  of  vaccines  of  various  sorts  with 
a  variety  of  preservatives,  concluding  that  lysol,  0.25 
per  cent.,  is  in  every  way  a  very  safe  margin  for  the 
prevention  of  contamination.  He  found  0.20  per 
cent,  of  this  compound  would  sterilize  tetanus,  an- 
thrax, and  Bacillus  subtilis  in  solution. 

The  degree  of  temperature  at  which  various  or- 
ganisms yield  the  power  of  reproduction,  evidently 
varies,  not  only  with  the  organism  under  observa- 
tion, but  also  with  the  strain  of  that  organism.  Not- 
withstanding the  fact  that  I  presented  to  the  society 
last  year  a  paper  {New  York  Medical  Journal, 
March  28,  1908),  setting  forth  this  important  obser- 
vation, I  failed  to  apply  it  to  Bacillus  typhosus. 

So  every  experimenter  with  bacterial  vaccines, 
who  wishes  to  arrive  .safely  and  expeditiously  at  a 
vaccine  which  retains  the  greatest  immunizing  pow- 
er, is  cautioned,  first  carefully  to  ascertain  the  least 
degree  of  heat  which  is  necessary  to  kill  the  strain. 
The  strain  of  Bacillus  typhosus  used  in  my  experi- 


ment had  been  obtained  in  August  from  the  blood  of 
a  patient  suffering  with  a  profound  typhoid  intoxi- 
cation. A  twenty-four  hour  broth  culture  of  this 
strain  was  not  virulent  to  a  250  gramme  guinea  pig. 

Owing  to  the  extreme  motility  of  the  organism, 
counting  was  difficult,  and  as  the' addition  of  forma- 
lin to  the  solution  produced  a  slight  amount  of 
clumping,  this  method  added  nothing  to  the  facility 
or  accuracy  of  the  count.  The  standardization  of 
the  virus  was  by  Wright's  method  of  enumeration, 
and  was  estimated  to  be  400,000,000  germs  to  i  c.c. 

It  was  the  experience  of  the  commission  from  the 
laboratory  standpoint,  as  well  as  Wright's  experi- 
ence from  his  observations  of  those  men  to  whom  a 
second  inoculation  had  been  given,  that  they  not 
only  exhibited  a  greater  agglutination,  or  Widal 
curve,  but  also,  that  there  was  no  record  of  a  single 
case  of  typhoid  among  them.  A  few  cases  of  mild 
typhoid  without  mortality  have  been  reported  among 
those  who  had  received  but  one  vaccination. 

Second  Inocidation. — The  proper  interval  for  a 
second  inoculation  is  ten  full  days.  The  Royal 
Army  Medical  Commission  determined  this  inter- 
val by  observation  of  the  agglutination  curve  which 
begins  to  rise  on  the  ninth  day  after  inoculation,  and 
attains  its  maximum  height  on  the  eleventh  day. 
Here  we  see  that  the  Widal  reaction  in  the  disease, 
as  well  as  in  the  artificially  produced  agglutination 
is  synchronous  in  its  appearance.  During  the  inter- 
vals of  the  inoculation,  which  should  be  ten  full 
days,  total  abstinence  from  all  alcoholic  liquors  must 
be  observed.  By  still  persisting  in  an  unsuccessful 
eflfort  to  rob  the  germ  of  its  reproductive  power  by 
an  exposure  to  53°  C,  the  second  inoculation  was 
delayed  several  days.  In  my  cases  the  second  inocu- 
lation was  given  seventeen  days  later.  The  vaccine 
was  killed  at  59°  C.  for  one  hour — one  degree  lower 
than  Wright  originally  recommended — and  double 
the  quantity  was  givei\,  as  previously  stated.  The 
constitutional  symptoms  were  inconsiderable,  and 
the  local  reaction  very  slight. 

In  my  own  arm  where  the  needle  penetrated  the 
muscle,  the  inoculation  produced  pain  immediately. 
This  was  not  the  experience  with  the  first  inocula- 
tion. 

Protective  Substances  in  the  Blood  Serum. — 
Prior  to  the  first  inoculation  the  highest  dilution  of 
the  blood  serum  with  which  it  was  possible  to  pro- 
duce agglutination,  varied  from  i  in  7  to  i  in  10 
in  the  four  subjects.  On  the  eleventh  day  after  the 
first  inoculation,  the  highest  agglutination  obtained 
was  I  in  12,872.  This  high  tide  mark  fell  some- 
what. The  second  inoculation  seven  days  later 
again  produced  a  rising  curve,  i  in  8,000  apparently 
being  its  limit.  I  also  noticed  a  rise  of  the  agglu- 
tination curve  beginning  about  the  tenth  day  after 
the  second  inoculation.  This  latter  curve  is  not 
mentioned  in  the  report  of  the  British  Commission. 

No  observations  were  made  by  me  on  stimulus  vs. 
opsonins.  The  commission  found  the  former  over- 
balanced, the  latter  2  to  i.  Stimulin  is  that  sub- 
stance  which  is  stable  in  the  blood  serunl'  at  60°  C. 
— that  is,  the  blood  serum  which  has  been  exposed 
to  this  degree  of  heat,  loses  its  opsonin,  and  the  sub- 
stance remaining  which  prepares  for  phagocytosis, 
is  called  stimulin.  Heated  immune  sera  exhibited 
twice  the  power  to  stimulate  phagocytosis  as  that 
observed  in  unheated  sera. 


February  6,  1909. J 


HERZIG:  SEQUELM  OF  ADENOIDS. 


267 


Bactericidal  Pozvcr. — In  my  observations  I  found 
that  the  blood  serum  exhibited  after  inoculation,  a 
bactericidal  power  in  a  dilution  of  i  to  20.  Viable 
bacteria  when  mixed  with  immune  blood  serum  in 
the  above  dilution  failed  to  produce  colonies  when 
spread  over  an  agar  plate  and  kept  at  37.5°  C.  for 
twenty-four  hours. 

Bacteriolysis.- — The  immune  blood  serum  of  my 
cases  diluted  i  in  4  to  i  in  6  and  mixed  with  liv- 
ing Bacillus  typhosus  either  produced  spherulated 
forms,  or  a  complete  disappearance  of  the  organism. 
This  was  determined  by  spreading  the  serum  mix- 
ture on  cover  slips  and  staining  with  methylin  blue. 

Prophylactic  inoculation  for  typhoid  is  to  be 
avoided  in  those  cases  suspected  of  an  oncoming  at- 
tack. Richardson,  Massachusetts  Medical  Society, 
1907,  in  his  experience  of  eight  years  in  the  treat- 
ment of  this  disease  with  bacterial  products,  reports 
a  high  mortality. 

In  this  concise  report  I  have  endeavored  to  pre- 
sent the  principal  papers  which  have  advanced  this 
•subject  to  its  present  status,  and  I  have  set  forth 
briefly  my  experiences  with  prophylactic  inoculation, 
which  may  aid  in  the  solution  of  this  intricate  prob- 
lem. One  new  point,  that  of  the  variation  in  the 
degree  of  temperature  necessary  to  kill  Bacillus 
typhosus,  has  been  brought  out.  In  the  main  I  have 
endeavored  to  follow  the  most  recent  development 
in  this  subject  as  accurately  as  possible. 

Conclitsions. 

The  evidence  of  bacteriolytic  and  bactericidal  ac- 
tivity higher  than  the  normal,  and  the  presence  of 
agglutin,  can  be 'obtained  from  the  serum  of  those 
who  have  been  inoculated. 

The  immunity  to  typhoid  conferred  upon  those 
officers  and  men  of  the  17th  Lancers,  inoculated, 
would  seem  to  confirm  the  laboratory  findings. 

1618  Spruce  Street. 


SEQUELS  OF  ADENOIDS.* 

By  Arthur  J.  Herzig,  M.  D., 
New  York, 

Adjunct  Rhinologist  and  Otologist,  Sydenham  Hospital;  Surgeon  in 
Chief,  Eye  Department,  Beth  Israel  Hospital. 

Etiology  and  Heredity. — Some  authors  assert 
that  heredity  is  a  factor  and  that  adenoids  are  more 
common  in  females  than  in  males.  In  the  author's 
experience,  the  latter  has  just  been  the  reverse. 

The  growth  of  adenoids  is  stimulated  by  constant 
irritation  from  dust,  cold  and  damp  climate,  also  the 
various  exanthemata,  e.  g.,  influenza,  scarlet  fever, 
etc.,  acute  and  chronic  catarrhal  nasal  conditions. 

Adenoids  are  present  in  all  children  at  birth. 
These  growths  cause  various  troubles  in  seventy 
per  cent,  of  all  cases.  Thirty  per  cent,  remain  with- 
out any  further  trouble,  and  as  the  patient  nears 
puberty  these  masses  gradually  atrophy  and  disap- 
pear. 

Out  of  1,000  cases  of  adenoids  that  the  author  has 
collected,  the  greatest  number  were  present  from 
the  ages  of  one  to  twelve  years,  and  the  least  after 
fifteen  years  of  age. 

Postnasal  adenoid  hypertrophy  is  a  disease  of 
earlv  childhood,  a  period  when  all  lymphatic  struc- 
tures are  active.   These  growths  show  their  greatest 

*Read  by  invitation  at  the  Triprofessional  Medical  Society,  Sep- 
tember 15,  1908. 


activity  from  the  second  to  the  third,  year  of  life. 
Just  a  word  as  to  the  anatomy  of  Rosenmiiller's 
fossa  in  the  infant.  The  vertical  diameter  is  short 
at  hirth  and  the  anteroposterior  diameter  long,  this 
distance  being  nearly  as  great  as  that  of  a  child 
twelve  years  old ;  also  the  eustachian  orifice  is  low 
down  in  very  ycung  children,  and  hence  adenoid 
hypertrophies  have  their  worst  etfect  upon  these 
children.  Older  children  are  less  liable  to  the 
sequelae  of  adenoid  hypertrophies,  as  the  tubal  ori- 
fice is  high  up. 

Pathology. — According  to  Kyle,  we  have  four 
different  varieties  of  adenoid  hypertrophies. 

1.  Soft  variety,  which  appears  as  a  soft,  fluctu- 
ating mass  that  spreads  itself  almost  entirely  over 
the  posterior  nasopharynx.  This  variety  is  com- 
posed almost  entirely  of  the  lymphoid  structure,  is 
very  friable,  is  covered  with  a  thin  layer  of  epithe- 
lium, with  ill  formed  basement  membrane  and  sub- 
mucosa.  This  structure  feels  soft  and  friable  to  the 
examining  finger. 

2.  The  oedematous  or  cyanotic  variety  has  very 
little  increase  in  actual  gland  structure,  the  enlarge- 
ment being  due  to  a  venous  stasis  and  oedema  pro- 
duced by  the  leakage  from  the  bloodvessels.  This 
variety  is  most  frecjuently  seen  in  children  suffering 
from  intestinal  parasites.  This  structure  is  smooth 
and  easily  compressible. 

3.  The  hard  or  hypertrophic  variety  shows  an 
increase  in  lymphatic  structure,  with  a  decided  over- 
growth of  the  connective  tissue  element,  the  mucous 
membrane  element  being  well  formed,  there  also 
being  present  several  layers  of  epithelial  cells.  The 
surface  feels  lobulated  and  smooth  to  the  touch. 

4.  Another  hard  variety  is  that  which  follows 
inflammatory  lesions  of  the  lymphoid  .structure,  in 
which  there  is  inflammatory  organization  in  the 
connective  tissue  element,  followed  by  cicatrization. 

In  early  life — that  is.  before  the  first  year- — the 
author  believes  adenoid  hypertrophies  to  be  of  value 
in  preventing  infectious  diseases  by  the  same  means 
as  the  tonsils,  that  is,  by  leucocytosis  (phagocytosis), 
and  hence  the  author  never  removes  an  adenoid 
under  one  year  of  age,  except  for  absolute  necessity, 
such  as  inability  to  nurse.  After  one  year  of  age  this 
mass  has  an  opposite  effect,  as  it  acts  as  a  carrier  of 
various  microorganisms,  e.  g.,  tuberculosis. 

Under  one  year  of  age  it  has  been  frequently- 
noted  that  children  are  less  liable  to  the  various 
exanthemata,  such  as  diphtheria,  scarlet  fever, 
measles,  etc.,  which  bears  out  the  author's  theories 
that  the  course  of  infection  of  these  diseases  is 
mainly  through  the  nose  and  that  the  adenoid  vege- 
tations act  as  a  stopping  point  or  filter.  After  the 
first  year  of  age  certain  changes  take  place  in  the 
adenoid  structure,  which  tends  to  become  harder, 
less  well  supplied  with  bloodvessels,  and  the  inter- 
stitial network  of  fibrinous  tissue  becomes  more 
complex.  There  is  a  decreased  leucocytosis  and 
hence  less  protection  against  invasion  from  a  for- 
eign host.  The  contrary  action  of  adenoid  hyper- 
trophy in  adults  and  older  children  is  due  to  the 
aforegoing  remarks  and  also  to  the  fact  that  the 
hypertrophy  is  a  good  carrier  and  also  nidus  for 
microorganisms,  so  that  children  after  one  year  of 
age  are  more  susceptible  to  the  various  exanthemata, 
and  when  present  are  usually  very  severe  in  char- 
acter. 


268 


HERZIG:  SEQUELS  OF  ADENOIDS. 


[New  York 
Medical  Journai,. 


Uiagiiosis. — The  positive  diagnosis  of  adenoids 
can  be  made  by  a  digital  examination  and  by  no 
other  method.  Some  authors  assert  to  make  a 
diagnosis  by  examining  the  posterior  pharyngeal 
wall  for  small  granular  hypertrophies.  The  latter 
are  not  convincing  to  the  author,  as  many  children 
have  adenoids  without  the  appearance  of  these  small 
posteiior  hypertrophies;  also  children  having  a 
recent  itmoval  of  adenoids  are  sent  to  a  different 
doctor  because  of  continuance  of  the  symptoms  of 
adenoid  hypertrophies.  In  examining  these  children 
v^^e  find  these  granular  hypertropiiies  upon  the  pos- 
terior pharyngeal  wall,  but  no  adenoids,  the  patient 
having  a  postnasal  catarrh  and  all  the  symptoms 
of  an  ill  trained  mouth  breather.  In  adults  these 
hypertrophies  may  occur  upon  the  posterior  wall 
when  nothing  else  is  present,  and  are  due  mostly  to 
the  constant  irritation  of  the  throat,  as  in  singers, 
public  speakers,  and  smokers. 

A  word  as  to  the  examination  of  these  children. 
It  is  impossible  to  make  a  posterior  rhinoscopic 
examination  with  a  mirror  in  very  young  children, 
hence  a  digital  examination  is  necessary.  It  is  per- 
formed as  follows : 

The  child  or  infant  is  placed  upon  the  mother's 
or  nurse's  lap,  with  the  head  resting  between  the 
doctor's  knees,  or  the  child  sitting  upright  in  a 
small  chair,  having  the  hands  held ;  the  index  finger 
of  the  right  hand  is  placed  in  the  child's  mouth  and 
carried  upward  laterally  until  the  roof  of  the  naso- 
pharynx is  reached,  the  left  hand  in  the  meantime 
pushing  the  child's  cheek  between  its  teeth,  so  as  to 
prevent  the  examining  finger  being  bitten. 

In  the  first  instance  the  examination  is  done  with 
the  child  lying  down.  In  the  second  case  the  doctor 
stands  behind  the  child.  In  adults  the  diagnosis  is 
made  by  means  of  the  postrhinoscopic  mirror.  The 
examining  surgeon  should  first  feel  for  the  central 
adenoid  mass  and  locate  it,  then  examine  the  lateral 
walls  to  see  how  much  of  the  hypertrophy  is  pres- 
ent above  or  around  the  Eustachian  tubes.  This 
must  be  carefully  noted  before  operating,  as'  it  is 
most  vital  to  the  child's  hearing.  Note  is  also 
taken  of  the  dimensions  of  the  postnasal  space  as 
to  height  and  breadth. 

The  diagnosis  is  also  aided  by  the  facial  expres- 
sion of  these  children,  etc.,  which  will  be  fully  de- 
scribed under  the  heading  of  symptoms. 

Symptoms. — These  symptoms  may  be  present  in 
part  or  in  total,  no  one  case  resembling  the  other 
exactly.  This  subject  has  been  so  well  threshed  out 
that  the  author  will  enumerate  them  but  briefly  : 

1.  The  most  common  symptom  is  that  of  nasal 
obstruction. 

2.  Mouth  breathing,  caused  by  the  nasal  obstruc- 
tion. 

3.  Postnasal  catarrh  is  present,  due  to  the  in- 
creased secretion  of  the  hypertrophic  tissue. 

4.  A  high,  V  shaped  arched  palate,  due  to  mal- 
formation of  the  cranial  bones  during  the  period  of 
development,  caused  by  improper  respiration. 

5.  Pinched  nares.  dilated  aL'c. 

6.  pile,  unhealthy  looking  child. 

7.  Xocturnal  enuresis. 

8.  .\ight  terrors.  This  is  a  rather  common  symp- 
tom, being  present  in  a  great  majority  of  cases.  The 
little  OIK'S  are  restless  at  night  and  start  easily  out 
of  their  sleep. 


9.  Nose  bleed  may  or  may  not  occur.  When  it 
does  occur  it  is  due  to  the  extreme  friability  of  the 
adenoid  tissue  introduced  by  sneezing  or  coughing. 

10.  Snoring  at  night.  These  children  sleep  with 
their  mouths  open,  and  the  influx  and  expulsion  of 
air  causes  a  flapping  of  the  soft  palate  and  uvula, 
producing  a  rattling  noise  commonly  known  as 
snoring. 

11.  Dry  pharynx,  especially  upon  waking  in  the 
morning.  This  is  due  to  the  irritation  by  the  un- 
filtered  air  striking  the  pharynx  and  drying  it  of  its 
secretions. 

12.  A  dry,  harsh,  barking  cough,  independent  of 
any  other  lesion  that  may  be  present. 

13.  Chronic  rhinopharyngeal  catarrh. 

14.  Dry  nose. 

15.  These  children  are  subject  to  recurrent  at- 
tacks of  rhinitis  and  bronchitis,  due  to  the  unfiltered 
air  reaching  these  parts. 

16.  Enlarged  anterior  and  posterior  cervical 
glands. 

17.  Some  of  these  patients  may  be  subject  to 
attacks  of  dyspnoea. 

18.  Stunted  growth  is  seen  in  a  great  number  of 
these  cases. 

19.  Spinal  curvatures,  such  as  lateral  scoliosis, 
caused  by  carrying  of  books  in  early  adult  life ;  im- 
proper breathing  also  causing  various  deformities 
of  the  chest,  such  as  chicken  breast.  The  maldevel- 
opment  of  the  bones  in  rickets,  especially  the  forma- 
tion of  the  upper  thoracic  structures,  is  increased 
by  the  improper  function  of  breathing. 

20.  Several  cases  of  epilepsy  have  been  com- 
pletely cured  by  the  removal  of  adenoids. 

21.  Stupidity  even  to  the  extent  of  idiocy. 

22.  Inability  to  concentrate  their  attention  upon 
any  special  subject. 

23.  A  nasal  twang  to  the  voice. 

24.  in  infants  there  is  often  a  thin,  watery,  ms'il 
discharge,  and  a  history  that  these  children  could 
not  nurse  well,  having  to  stop  every  minute  to  take 
a  breath.  Snuffles,  coated  tongue,  or  some  gastro- 
intestinal disturbance  is  present. 

25.  Attacks  of  chorea,  major  and  minor,  are  often 
lessened  in  severity  by  the  prompt  removal  of  the 
associated  adenoid  hypertrophies. 

Sequchr — Besides  all  the  enumerated  symptoms 
described  in  the  previous  chapter,  we  have  various 
secjueke  resulting  from  the  presence  of  adenoids 
which  injure  the  health  and  in  some  cases  the  life 
of  the  patient.  These  vegetations  act  first  by 
mechanical  obstruction,  and  secondly  by  withdraw- 
ing the  blood  supply  from  the  Eustachian  tubes  and 
middle  ear. 

In  nursing  infants  the  nasal  obstruction  due  to 
adenoids  causes  improper  feeding,  and  many  infants 
lose  flesh  and  strength  owing  to  their  inability  to 
nurse.  A  complete  removal  of  the  adenoid  vegeta- 
tions gives  the  baby  an  opportunity  to  draw  air 
through  its  nostrils,  which  is  essential  in  the  action 
of  sucking.  These  children  quickly  gain  in  weight 
soon  after  these  growths  are  removed. 

Deafness  in  early  life  finds  its  most  frequent  cause 
in  adenoids,  as  the  author  will  show  by  future  case 
reports. 

Laryngismus  stridulus,  also  called  false  croup,  is 
mainly  ascribable  to  adenoids  and  consequently 
mouth  breathing,  which  in  its  turn  cau.ses  a  dry  and 


February  0,  1909.I 


hhRZU,:  SEQUELS  Of  ADENOIDS. 


269 


irritable  larynx.  Choreiform  movements  of  the  soft 
palate  were  observed  by  the  author  in  one  of  his 
cases,  which  disappeared  promptly  upon  the  removal 
of  adenoid  vegetations.  Enlarged  tonsils  are  also 
helped  in  their  growth  by  the  presence  of  adenoids, 
and  vice  versa.  In  cases  of  pertussis,  where  the 
cough  remains  unusually  long,  look  for  adenoids. 
If  these  are  found,  a  complete  removal  of  the  latter 
will  shorten  the  attack. 

The  common  facies  of  children  having  adenoids 
is  as  follows :  These  children  show  dull,  apathetic, 
heavy,  and  stupid  features,  pinched  noses  and  in- 
drawn alae,  depressed  inner  canthi,  elevated  eye- 
brows, and  wrinkled  foreheads.  These  facies  are 
typical.  After  removal  of  adenoids  the  change  in 
features  is  most  pronounced  six  to  ten  months  after 
the  operation,  when  they  return  to  normal.  In  ex- 
treme cases  anaesthesia  of  the  soft  palate  and  uvula 
are  seen,  also  constantly  recurring  cases  of  bron- 
chitis and  laryngitis.  Finally  pulmonary  tubercu- 
losis. 

All  sorts  of  spinal  deformities  may  be  increased 
by  improper  respiration,  such  as  round  shoulder  and 
lateral  curvature,  due  to  improper  aeration  of  the 
lungs.  These  children  are  mostly  all  anaemic  and 
show  a  sluggish  metabolism. 

The  most  common  sequela  of  adenoids  is  ear 
affection,  such  as  acute  purtilent  otitis  media  and 
all  its  complications,  as  mastoiditis,  sinus  throm- 
bosis, and  brain  abscess.  The  adenoids  act  by 
diminishing  the  blood  supply  of  the  middle  ear  and 
so  placing  the  middle  ear  in  a  good  position  for  the 
development  of  colonies  of  microorganisms. 

The  author  wishes  to  report  a  few  statistics  in  a 
number  of  cases  he  has  noted,  namely,  142. 

In  142  cases  of  ear  troubles,  associated  with 
adenoids,  retraction  of  one  drum  membrane  showed 
in  eight  cases ;  retraction  of  both  dri:m  membranes, 
in  fifty-two  cases ;  retraction  and  congestion  of  both 
drum  membranes,  in  eighteen  cases ;  retraction  of 
one  drum  mebrane  and  acute  purulent  otitis  media 
in  the  other  ear,  in  thirty-six  cases :  double  acute 
purulent  otitis  media,  in  twenty  cases  ;  cicatricial  ad- 
hesions, in  eight  cases. 

Hearing  was  good  in  fifteen  cases,  not  easily  de- 
termined in  thirty  cases,  and  distinctly  impaired  in 
ninety-seven  cases.  Out  of  over  10,000  throats  the 
author  examined,  he  has  found  that  enlarged  tonsils 
are  associated  with  adenoids  in  about  one  third  of 
the  cases. 

Dr.  Arslan  (1895,  Journal  of  Laryngology)  re- 
ports the  presence  of  adenoids  in  426  patients  out 
of  4,080  examined.  Of  these  426  cases.  294,  or 
sixty-nine  per  cent.,  showed  nasal  obstruction.  252 
cases,  or  fifty-nine  per  cent.,  had  ear  complications. 
158  cases,  or  thirty-seven  per  cent.,  had  accompany- 
ing amygdalitis  and  pharyngitis.  Of  252  cases  hav- 
ing ear  complications,  no  cases  were  of  suppurative 
otitis  media,  and  142  were  cases  of  deafness  with- 
out suppuration. 

Dr.  Hein  (British  Medical  Journal,  August  26, 
1905)  associates  the  following  conditions  with  ade- 
noids :  Phlyctenular  keratitis  and  conjunctivitis,  ulcer 
of  the  cornea,  and  oversensitiveness  of  the  cornea. 

Dr.  Marfan  (Scmaine  mcdicalc,  xxvii.  No.  38,  pp. 
445  to  456,  1907)  remarks  that  adenoid  vegetations 
were  present  in  jevcntv-tbree  per  cent,  of  all  young 


children  he  examined,  and  enlarged  tonsils  in  sixty- 
three  per  cent. 

The  author  wishes  to  state  that  in  his  10,000 
cases  which  he  has  examined  and  reports,  one  third 
were  associated  with  large  tonsils ;  these  cases  are 
those  in  which  the  tonsils  are  markedly  enlarged  and 
extending  well  beyond  the  pillars  of  the  fauces. 

Indications  for  Operation. — The  author  wishes  to 
plead  for  a  greater  conservatism  in  the  treatment 
of  cases  of  adenoids.  .Vdenoid  vegetations,  when 
small  in  amount,  not  causing  any  of  the  indications 
which  the  author  will  enumerate,  should  be  left 
alone,  and  may  be  treated  by  hygienic  measures  and 
local  astringents.  The  author  has  found  hydrargyri 
chloridum  mite,  i/io  grain  tablet,  taken  three  times 
daily  after  eating  and  continued  for  thirty  days, 
stopping  a  week  and  then  continuing  again  for  a 
month,  and  so  on  until  a  year  or  a  year  and  a  half 
is  passed,  of  the  greatest  benefit  in  reducing  the  size 
of  these  vegetations. 

As  regards  the  astringents  used,  the  author  pre- 
fers a  ten  per  cent,  solution  of  silver  nitrate,  appHed 


Fig.   I.— Self  retaining  mouth  gag. 

directly  to  the  postnasal  growth,  this  to  be  done 
three  times  a  week  for  eight  to  twelve  weeks.  The 
indications  for  the  complete  removal  of  adenoid 
vegetations  are  as  follows : 

I,  nasal  obstruction,  causing  mouth  breathing  and 
its  sequelae ;  2,  recurring  attacks  of  earache ;  3,  stu- 
pidity and  inability  of  the  children  to  concentrate 
attention ;  4,  stunted  growth,  and  in  all  cases  of 
purulent  otitis  media  in  children ;  5,  in  infants  whose 
inability  to  nurse  is  due  to  adenoids,  otherwise  the 
author  never  operates  upon  infants  under  one  year 
of  age,  and  believes  it  a  crime  to  do  so. 

Operation. — The  author  prefers  the  use  of  chlo- 
roform anaesthesia  in  operating  upon  nearly  all  his 
patients.  The  patient  is  prepared  for  opertion  in 
the  following  manner :  The  night  previous  a  good 
dose  of  Epsom  salts  is  given  to  the  patient,  a  light 
supper  consisting  of  two  soft  boiled  eggs,  milk,  or  tea. 
or  coflee,  bread  or  Uneeda  biscuits.  The  following 
morning  the  patient  is  given  a  glass  of  milk  and 
two  or  three  crackers  with  butter.  This  is  usually 
given  at  half  past  nine.    Xothing  is  given  in  the 


270 


CUMS'i'OX:  EPIPLOITIS. 


[New  ^'ork 
Medical  Journal. 


interval,  and  great  care  should  be  taken  that  the 
parents  follow  out  these  rules  successfully,  as  the 
success  of  the  anaesthesia  and  operation  depend  upon 
them.  The  patient  being  anaesthetized  (the  author 
preferring  the  second  stage  of  anaesthesia),  the 
author  introduces  his  self  retaining  mouth  gag  (see 
Fig.  I )  between  the  two  bicuspids,  and  elevates  it 
to  the  greatest  extent  possible  by  means  of  turning 
a  screw  to  the  left.  If  any  doubt  should  be  experi- 
enced as  to  this  instrument  slipping,  a  thick  thread 
may  be  tied  around  it,  and  the  other  end  left 
dangling  or  attached  to  the  patient's  ear.  Then  the 
author  introduces  his  self  retaining  tongue  depressor 
(see  Fig.  2),  which  is  introduced  and  the  tongue 


Fig.  2. — Self  retaining  tongue  depressor. 


well  fixed.  The  patient  is  now  ready  for  operation. 
The  electric  head  light  or  head  mirror  throws  the 
light  into  the  pharynx.  The  author  prefers  to  intro- 
duce a  cutting  forceps,  with  which  he  removes  the 
main  masses  of  adenoid  tissue.  Then  the  author 
introduces  his  three-  side  cutting  edge  adenoid  cu- 
rette (see  Fig  3).    This  is  swept  up  and  down, 


clearing  the  posterior  wall  and  then  moved  laterally, 
removing  all  vegetations  over  the  Eustachian  tubes 
and  lateral  walls.  This  latter  part  of  the  operation 
is  the  most  important,  as,  when  the  lateral  adenoid 
masses  are  left  in  situ,  the  adenoids  grow  again,  and 
we  hear  of  cases  of  the  frequent  recurrence  of  ade- 
noids. This  only  occurs  in  about  two  per  cent,  of 
the  cases  where  the  adenoids  are  thoroughly  re- 
moved. The  author  follows  this  up  by  winding 
some  sterilized  gauze  around  his  index  finger  and 
introducing  it  into  the  postnasal  space  and  going 
over  the  tissue  very  thoroughly ;  this  brings  away 
small  excrescences  of  tissue  which  would  otherwise 
have  to  slough  ofT.  The  patient  is  then  quickly 
turned  to  one  side  and  the  gag  and  tongue  depressor 
removed.  Profuse  h.emorrhage  occurs,  but  ceases 
within  two  or  three  minutes  after  the  operation. 


The  author  then  has  the  patient  put  to  bed  and  no 
spray  applied  to  the  throat  or  nose,  as  is  the  custom 
with  a  great  number  of  operators.  A  blood  clot 
forms  upon  the  cut  surface,  and  to  use  a  spray 
would  be  to  disturb  Nature's  efforts  to  protect  a 
postoperative  wound.  Sprays  are  only  used  by  the 
author  in  infections  or  in  cases  where  the  patients 
vomit  during  operation,  and  then  the  author  uses  a 
I  in  5,000  solution  of  bichloride  of  mercury.  The 
patients  remain  in  bed  the  entire  day.  They  are 
permitted  to  get  up  the  next  morning.  Nothing  is 
given  to  the  child  until  five  o'clock  in  the  afternoon, 
the  operation  having  taken  place  between  twelve 
and  two. 

In  conclusion,  the  author  wishes  to  sum  up  that 
the  object  of  this  paper  is  not  to  describe  any  special 
operation  or  symptom,  but  to  enforce  the  fact  that 
the  people  should  be  educated  to  the  sequelae  of 
adenoids,  and  to  have  their  eyes  opened  as  to  the 
good  results  obtained  by  their  timely  and  speedy 
removal.  The  author  wishes  to  emphasize  the  fol- 
lowing : 

1,  That  adenoids  act  as  a  prevention  of  infectious 
diseases  in  children  under  one  year  of  age,  and 
should  never  be  removed,  except  for  two  indications, 
namely,  poor  nursing  and  purulent  otitis  media. 

2,  AH  subjects  of  adenoids  need  not  be  oper- 
ated upon. 

3,  The  author  believes  the  entrance  of  micro- 
organisms (of  scarlet  fever,  etc)  to  be  through  the 
adenoid  tissue. 

2040  Seventh  Avenue. 


A  CASE  OF  EPIPLOITIS  FOLLOWING  THE  RADI- 
CAL CURE  OF  INGUINAL  HERNIA. 

By  Charles  Greene  Cumston,  M.  D., 
Boston. 

H.  J.,  t\vent)'-four  years  of  age,  was  operated  upon  for 
a  right  sided  inguinal  hernia  in  March,  1906.  The  contents 
of  the  sac  were  composed  entirely  of  omentum,  a  large  mass 
of  which  was  resected,  kangaroo  tendon  being  used  for 
ligature.  The  day  following  the  operation,  which,  by  the 
way,  was  easy  and  rapidly  executed,  the  patient  com- 
plained of  abdominal  pain,  while  the  abdomen  was  dis- 
tended. On  accoiuit  of  the  distension  respiration  was 
somewhat  difficult,  although  unaccompanied  by  pain.  The 
ne.Kt  day  the  patient  was  extremely  restless,  but  there  was  • 
no  elevation  of  the  temperature.  The  bowels  moved  with 
an  enema,  but  the  distension  still  continued. 

This  condition  of  affairs  remained  about  the  same  until 
the  eighth  day  following  the  operation,  when  the  tempera- 
ture went  up  2°  C.  and  at  the  same  time  there  was  an  in- 
crease in  the  symptoms  already  mentioned.  The  abdomen 
became  still  more  distended  and  was  painful  on  percus- 
sion.   The  tongue  was  dry,  the  patient  most  restless. 

By  palpation  a  tumefaction  was  detected  in  tbe  right 
hypochondrinm,  extending  from  the  costal  border  above, 
clown  to  the  iliac  fossa  on  the  same  side,  and  was  princi- 
pally marked  under  the  cicatrix  of  the  hernia  incision.  The 
latter  was  in  perfect  condition  and  the  stitches  were  re- 
moved on  this  day. 

The  tumefaction  was  elongated  in  shape  with  its  long 
axis  running  vertically  from  above  downward,  and  it  ap- 
peared to  be  in  direct  contact  with  the  abdominal  wall.  It 
felt  resistant,  apparently  immovable,  and  all  over  its  extent 
dullness  was  elicited  by  percussion.  This  mass  was  pain- 
ful, the  pain  being  increased  by  both  palpation  and  .percus- 
sion. The  abdomen  was  still  distended  and  constipation 
was  extremely  difficult  to  overcome  in  spite  of  high  on- 
emata.  The  temperature  was  40°  C,  and  tbe  patient  had 
an  abdominal  facies. 

The  diagnosis  of  epiploitis  was  made.  Ice  bags  were 
placed  upon  the  abdomen  and  a  pill  containing  2  centi- 
grammes of  colloid  silver  was  given  four  times  daily. 


February  6,  1909.  J 


LESHURE:  STROXG  COCAINE-ADREXALIX  SOLL  TIOXS. 


271 


At  the  end  of  twelve  days  the  temperature  had  reached 
normal  and.  after  this  time,  remained  so.  The  bowels  he- 
gan  to  work  naturally,  the  pain  diminished,  likewise  the 
tumefaction,  so  that  seven  weeks  after  the  operation  the 
patient  was  discharged  in  perfect  health.  The  colloid  silver 
was  continued  for  three  weeks. 

There  are  several  types  of  epiploitis,  the  patholo2;v 
of  which  would  be  too  long  to  discuss  here,  and  I 
would  merely  briefly  refer  to  the  variations  met  with 
in  the  symptoms  of  his  postoperative  complication. 
There  is  a  benign  form  of  epiploitis  which  makes 
itself  e*'ident  by  a  slight  tumefaction,  giving  rise  to 
very  little  pain,  and  these  mild  types  are  recovered 
from  very  rapidly  by  rest  in  bed. 

Occasionally,^  an  epiploitis  will  make  itself  mani- 
fest by  ordinary  symptoms  of  intestinal  occlusion, 
and  the  latter  will  represent  the  only  manifestations 
of  the  affection.  A  secondary  epiploitis  may  be  of 
such  intensity  that  a  neoplasm  may  be  suspected, 
while  in  other  instances  all  the  evidences  of  a  sup- 
purative focus  are  manifest,  these  including  a  high 
elevation  of  the  temperattire  and  the  presence  of  an 
intraabdominal  fluctuating  mass,  combined  with 
symptoms  of  intestinal  occlusion,  these  being  ab- 
dominal distention  and  faecal  vomiting. 

In  these  cases  one  is  obliged  to  do  a  secondary 
laparotomy  and  attend  to  the  conditions  found,  such 
as  opening  and  draining  the  pocket  of  suppuration 
or  breaking  down  adhesions,  if  these  are  the  cause 
of  the  occlusion.  The  latter  form,  clinically  speak- 
ing, may  be  called  the  mixed  type  and  makes  evident 
that  a  classification  of  the  various  evolutions  of  this 
affection  present  nothing  absolute,  because  several 
complications  arising  from  the  epiploitis  may  be 
present  in  the  same  patient. 

871  Be.\cox  Street. 


THE    PHYSIOLOGICAL    ACTION    OF  STROXG 
COCAINE-ADRENALIN  SOLUTIONS. 
Methods  of  Cocainizing  the  Uf'per  Air  Passages. 

By  JoHX  Leshure,  M.  D., 
New  York. 

The  marked  absorptive  power  possessed  by  mu- 
cous membranes  retiders  them  pectiliarly  susceptible 
to  the  action  of  drugs  applied  directly  to  their  sur- 
faces. 

In  the  case  of  cocaine  tised  for  the  purpose  of 
inducing  local  anaesthesia  a  certain  amount  of  ab- 
sorption is  desirable,  that  is.  it  is  necessary  that 
the  drug  should  reach  the  level  of  the  nerve  end- 
ings, but  it  is  undesirable  that  it  should  enter  the 
large  venous  and  lymphatic  radicles,  which  are 
placed  at  a  deeper  level,  since  by  way  of  these  ves- 
sels general  absorption  takes  place,  and  toxic  symp- 
toms of  greater  or  lesser  degree  are  likely  to  occur. 

Both  cocaine  and  adrenalin  have  the  power  of 
contracting  superficial  and  deep  vessels,  but  the  de- 
gree and  rapidity  of  this  contraction  appear  to  be 
proportionate  to  the  strength  of  drug  solution 
used. 

This  is  particularly  true  of  the  deep  vessels,  and 
it  is  necessary  to  apply  strong  solutions  of  cocaine 
and  adrenalin  to  contract  these  deeper  structures 
promptly,  for  the  solutions  are  rapidly  diluted  by 
the  copious  mucous  secretions,  and  osmosis  through 
the  vessel  walls  can  then  take  place  readily.    \\  e 


wish  to  bring  the  drugs  to  the  vessel  wall,  but  not 
tlirougli  it,  and  to  influence  the  vasomotor  fibres 
which  surround  the  vessel. 

Fluids  of  high  density,  such  as  the  cocaine  solu- 
tion to  be  mentioned,  are  not  readily  taken  up  by 
the  bloodvessels,  and  by  the  time  they  are  sufficient- 
ly diluted  to  be  so  taken  up  the  local  circulation  has 
been  blocked  oflf  by  the  drug. 

By  a  strong  cocaine-adrenalin  solution  is  meant 
one  made  by  dissolving  one  gramme  of  cocaine 
hydrochloride  (flaky  crystals)  in  one  cubic  centi- 
metre of  a  one  to  one  thousand  solution  of  adrena- 
lin chloride.  This  solution  contains  about  fifty-five 
per  cent.  of. cocaine  by  volume,  and  has  a  specific 
gravity  of  i,iio. 

The  following  table  gives  the  specific  gravity  of 
some  commonly  used  solutions  of  cocaine : 

2  per  cent   -  >[).  gr.  1.004 

4  '■      ■'   =  ■■    "  1,008 

10  "      '■    =    ■    ■'  1,020 

20         "    =  "    ■■  1,040 

25  ■'    =  1,050 

55  ■'      '■    =  "    ■'    I.I  10 

Certain  laws  governing  the  absorption  of  aqueous 
drug  solutions  are:  i.  A  fluid  passes  through  a 
membrane  with  a  rapidity  inversely  proportional  to 
the  density  of  the  fluid.  2.  The  rate  of  absorption 
varies  directly  with  the  fulness  and  tensity  of  the 
bloodvessels  and  lymphatics.  3.  The  sloxver  the 
movement  of  the  blood  and  lymph  streams  the  sIowt 
er  will  be  the  rate  of  absorption  of  the  fluid. 

These  well  recognized  laws  of  physiology  explain 
the  local  retention  in  the  tissues  of  the  strong 
cocaine-adrenalin  solution,  and  the  lasting  auc^es- 
thesia  and  ischcemia  following  its  use. 

As  the  specific  gravity  of  blood  serum  is  from 
1,025  to  I, -032.  reference  to  law  one  shows  that, 
other  things  being  equal,  the  strong  cocaine  solu- 
tion having  a  specific  gravity  of  i.iio  will  pass 
through  the  mucous  membrane  of  the  nose  slowly 
as  compared  with  the  weaker  solutions  (four  to 
twenty  per  cent.). 

The  seqtience  of  events  resulting  from  the  appli- 
cation of  the  strong  cocaine-adrenalin  solution  to 
the  mucous  membrane  of  the  nose  seems  to  be  as 
follows : 

A  prompt,  powerful  stimulus  is  transmitted  to 
the  vasoconstrictor  fibres  surrotinding  the  more 
deeply  placed  arterioles.  The  latter  then  strongly 
contract,  slowing  the  local  blood  stream.  At  the 
same  time  the  calibre  of  the  venous  and  lymphatic 
radicles  is  narrowed,  and  the  proximal  pressure 
having  been  reduced,  venous  stasis  occurs,  as  is  evi- 
denced by  the  deep  redness  of  the  membrane. 

General  absorption  is  thus  blocked  off,  and  the 
inembrane  contracting,  the  nerve  endings  and 
nerve  trunks  are  brought  nearer  to  the  periphery, 
and  consequently  more  directly  under  the  influence 
of  the  local  anaesthetic. 

All  this  time  the  cocaine  solution  is  becoming  less 
dense,  being  diluted  by  the  mucous  membrane  se- 
cretion, and  a  certain  amount  of  absorption  is  tak- 
ing place  into  the  nerve  trunks  through  the  axis 
cylinder,  since  this  latter  structure  is  nonmedullated 
near  its  distal  end. 

Areas  quite  remote  from  the  point  of  application 
often  are  complained  of  by  the  patient  as  being 
anaesthetic,  e.  g.,  the  teeth.  The  passage  of  the 
drug  up  the  axis  cylinder  to  a  ganglion  distributing 


2/2 


LESHURE:  STRONG  COCAINE-ADRENALIN  SOLUTIONS. 


[New  York 
Medical  Journai.. 


fibres  to  neighboring  regions  may  explain  this  phe- 
nomenon. 

It  has  been  recently  demonstrated  that  toxic  sub- 
stances may  reach  the  central  nervous  system  by 
way  of  the  axis  cylinder,  also  that  absorption  may 
take  place  at  the  nodes  of  Ranvier,  there  being  a 
defective  insulation  of  the  axis  cylinder  at  these 
nodes. 

In  operating,  nerve  trunks  as  well  as  nerve  end- 
ings are  sure  to  be  wounded,  and  the  former  must 
be  rendered  absolutely  anaesthetic  to  insure  the  pa- 
tient immunity  from  pain. 

The  physiological  action  of  the  strong  cocaine- 
adrenalin  solution  can  be  practically  demonstrated, 
so  far  as  its  effect  upon  the  bloodvessels  is  con- 
cerned, using  tadpoles  as  the  subjects  of  investiga- 
tion. 

When  from  thirty  to  thirty-five  millimetres  in 
length  these  animals  have  a  thin,  membranous, 
lateral  outgrowth  from  the  caudal  appendage.  This 
is  highly  vascular,  and  each  half  is  supplied  by 
branches  from  the  aorta  and  central  vein  of  the  cor- 
responding side,  which  pass  down  the  thick  central 
stem.  The  point  of  practical  importance  is  that 
there  is  no  direct  communication  between  the  blood- 
vessels of  the  two  sides. 

It  is  possible,  therefore,  to  compare  the  results 
obtained  by  simultaneously  applying  drug  solutions 
of  different  strength  to  corresponding  portions  of 
the  structure  referred  to,  which  resembles  in  many 
respects  a  mucous  membrane.  The  animal  is  first 
curarized  by  placing  it  in  a  small  dish  containing 
about  two  ounces  of  water  in  which  one  fifteenth 
of  a  grain  of  curarine  sulphate  has  been  dissolved. 
In  from  fifteen  to  twenty  minutes  the  muscular 
system  is  paralyzed,  and  the  tadpole  will  lie  quietly 
upon  the  microscope  stage.  The  small  vessels  can 
be  satisfactorily  studied  with  a  two  thirds  objective 
and  a  one  inch  eye  piece.  A  mechanical  stage  con- 
tibutes  greatly  to  the  ease  of  examination.  A  small 
drop  of  the  strong  cocaine-adrenalin  solution  (fifty- 
five  per  cent,  strength)  is  placed  upon  the  mem- 
braneous structure  near  the  tale  of  the  tadpole,  and 
a  drop  of  the  same  size  of  a  four  per  cent,  solution 
of  cocaine  in  i  :iooo  adrenalin  is  placed  at  a  cor- 
responding point  on  the  opposite  side  of  the  caudal 
appendage.  Slowing  of  the  blood  stream  and 
venous  stasis  occurs  at  a  much  earlier  period  on 
the  side  treated  with  the  first  named  solution  than 
on  that  treated  with  the  weaker  solution.  In  about 
twenty  seconds  the  circulation  in  the  smaller  ves- 
sels has  practically  ceased.  The  tadpole  being  a 
gill  breather  at  this  stage  of  its  existence  cannot  be 
kept  alive  more  than  five  or  six  minutes  out  of 
water,  but  control  tests  made  with  uncocainized  ani- 
mals showed  that  death  occurred  as  early  in  these 
individuals  as  when  cocaine  was  used. 

This  fact  would  seem  to  prove  that  general  ab- 
sorption could  hardly  have  taken  place,  since 
cocaine  is  a  powerful  cardiac  paralyzant,  and  would 
have  caused  death  promptly  had  it  entered  the  gen- 
eral circulation. 

The  writer  had  had  a  number  of  patients  who 
may  be  considered  control  cases,  inasmuch  as  they 
were  idiosyncratic  to  cocaine,  and  exhibited  symp- 
toms of  cocaine  poisoning  when  the  nose  was 
packed  with  cotton  pledgets  wet  with  a  ten  per  cent. 


solution  of  the  drug.  The  same  individuals  were 
cocainized  on  different  occasions,  applying  ac- 
curately to  the  operative  field  by  means  of  cotton 
wound  applicators  the  strong  cocaine-adrenalin  so- 
lution. In  no  instance  was  there  any  indication 
of  poisoning,  or  general  absorption,  while  the  auccs- 
thesia  was  complete,  and  lasted  for  two  hours. 

Freer's  method  of  swabbing  the  membrane  with 
cotton  wound  applicators  moistened  in  adrenalin 
and  then  passed  through  powdered  cocaine  gives 
very  complete  anaesthesia,  but  the  method  I  am  de- 
scribing has  a  distinct  advantage,  inasmuch  as  the 
percentage  strength  of  the  anaesthetic  is  accurately 
known,  and  no  loose  crystals  can  be  drawn  in  witli 
the  patient's  breath  to  points  bevohd  the  operative 
field. 

A  few  minutes  before  making  the  application  the 
patient  is  given  the  following  mixture : 

^    Morphine  sulphate  gr.  54  ; 

Hyoscine  hydrobromide,   gr.  i/iooi 

Strychnine  sulphate,   gr.  1/30; 

Water,  q.  s.  ad.,  

M. 

This  solution  can  be  readily  made  with  the  stand- 
ard hypodermic  tablets,  and  it  allays  to  a  great  ex- 
tent the  nervous  symptoms  often  present  before  op- 
eration. 

Nausea  is  a  troublesome  complication,  and  can 
usually  be  relieved  by  inhaling  a  few  drops  of  the 
aromatic  spirit  of  ammonia  sprinkled  on  a  napkin. 
Lowering  the  head  is  also  useful  to  alleviate  this 
symptom  and  that  of  faintness.  As  the  technique 
varies  somewhat  with  the  part  to  be  cocainized,  the 
regions  will  be  considered  in  their  natural  anatomi- 
cal arrangement. 

The  anterior  end  of  the  nose. — For  the  removal 
of  a  dislocated  saeptal  cartilage,  situated  far  for- 
ward, and  covered  with  tissue  resembling  skin  more 
than  mucous  membrane,  infiltration  is  usually  nec- 
essary, as  this  mucocutaneous  covering  has  very 
little  absorptive  power.  A  one  per  cent,  solution  of 
cocaine  in  a  one  to  ten  thousand  adrenalin  solution 
is  of  convenient  strength,  and  can  be  used  in  an  or- 
dinary hypodermic  syringe,  armed,  preferably,  with 
a  curved,  so  called,  dental  needle. 

The  latter  is  introduced  at  the  lowest  point  of  the 
region  to  be  anaesthetized,  and  one  or  two  drops  of 
the  .solution  are  injected,  the  operator  being  careful 
lo  keep  the  needle  parallel  with  the  mucocutaneous 
surface.  The  needle  is  then  thrust  in  deeper,  and 
injections  made  in  difi'ercnt  directions  until  a  tense, 
white  wheal  is  raised  covering  the  area  to  be  op- 
erated in. 

A  similar  procedure  may  be  adopted  preliminary 
to  dissecting  out  portions  of  the  lateral  cartilages 
when  these  encroach  upon  the  breathing  space.  It 
is  best  to  avoid  injecting  more  than  ten  minims  of 
a  one  per  cent,  solution  of  cocaine,  and  with  c  ire 
in  distributing  this  amount  complete  anaesthesia  can 
be  promptly  induced.  After  elevating  the  nuico- 
cutaneous  covering  referred  to,  the  underlying 
structures  should  be  swabbed  with  the  strong 
cocaine-adrenalin  mixture,  particularly  in  the  re- 
gion of  the  nasopalatine  nerves,  otherwise  pain  in 
the  front  teeth  is  complained  of  when  the  operation 
is  begun,  and  these  nerve  trunks  arc  wounded. 

Nasal  scrptiini. — ( )f  all  portions  of  the  u]ipcr  air 


February  6,  1909.] 


LESHURE:  STRONG  COCAINE-ADRENALIN  SOLUTIONS. 


273 


passages  this  structure  is  perhaps  the  most  easily 
and  completely  anaesthetized.  Two  methods  may 
be  used,  viz.:  i.  Pack  the  nose  with  pledgets  of  cot- 
ton wet  W'ith  ten  per  cent,  solution  of  cocaine  as  a 
preliminary  measure,  then  paint  the  saeptum  with 
the  strong  cocaine-adrenalin  solution.  The  packing 
may  be  left  in  situ  for  about  twenty  minutes.  2. 
Paint  the  saeptum  without  previous  packing. 

This  latter  method  is  preferable  when  dealing 
with  individuals  susceptible  to  cocaine,  since  when 
packing  is  used  absorption  takes  place  through  the 
mucous  membrane  covering  the  turbinated  bodies 
as  well  as  through  that  covering  the  sasptum,  and 
a  large  surface  is  exposed  to  the  drug.  The  dilut- 
ing effect  of  the  nasal  secretions  must  be  borne  in 
mind.  These  secretions  are  greatly  increased  by 
the  presence  of  a  foreign  body,  such  as  a  cotton 
pledget,  and  they  readily  wash  the  cocaine  solution 
through  the  nasopharynx  down  to  the  parts  below^ 
where  it  is  swallowed  or  absorbed  locally. 

x\  more  satisfactory  method  is  to  dip  a  cotton 
wound  applicator  into  the  strong  cocaine-adrenalin 
solution,  applying  it  to  the  anterior  portion  of  the 
saeptum,  a  region  which  is  but  slightly  sensitive. 
After  holding  it  there  a  few  seconds  an  area  of 
anaesthesia  will  be  induced  which  spreads  in  all  di- 
rections from  the  point  of  primary  contact.  The 
applicator  is  then  carried  backwards  a  short  dis- 
tance, but  not  beyond  the  limits  of  the  anaesthetic 
area,  then  upward  and  downward,  gradually  in- 
creasing the  area  of  anaesthesia  in  a  manner  sim- 
ilar to  that  utilized  for  infiltration  with  the  hypo- 
dermic needle.  '  In  this  way  the  patient  suffers 
neither  pain  nor  discomfort,  and  profound  anaes- 
thesia and  ischaemia  are  induced  with  little  or  no 
constitutional  disturbance. 

Ten  or  fifteen  minutes  suffice  for  anaesthetizing 
both  sides  of  the  saeptum,  but  one  should  test  every 
part  of  the  field  before  beginning  to  operate.  Three 
or  four  applicators  are  required,  and  they  should 
be  rewound  before  being  dipped  a  second  time  into 
the  cocaine  solution,  as  the  latter  would  otherwise 
be  diluted  by  the  nasal  secretion  absorbed  by  the 
applicator. 

Particular  attention  should  be  given  to  the  infe- 
rior and  posterior  surfaces  of  sharp,  overhanging 
spurs  or  angular  deviations,  and  applicators'  should 
be  suitably  curved  to  reach  all  portions  of  the 
saeptum. 

\\'hen  operating  upon  children  for  spurs  or 
sseptal  deviations  under  a  general  anaesthetic,  it  is  a 
good  plan  to  cocainize  the  operative  field,  as  then 
it  is  only  necessary  to  keep  the  child  asleep,  pain  be- 
ing abolished,  and  a  small  amount  only  of  general 
anaesthetic  is  required  for  this  purpose.  Shock  is 
also  diminished,  and  the  mask  can  be  removed  for 
long  periods,  shortening  the  time  of  operation. 

The  rectal  method  of  etherization  should  be  use- 
ful in  this  class  of  cases,  but  I  have  had,  as  yet,  no 
personal  exDerience  with  it. 

Ether  is  preferable  to  chloroform,  since  it  is  a 
physiological  antidote  to  cocaine,  and  allows  the  use 
of  the  seniirecum.bent  position,  which  with  chloro- 
form is  decidedly  dangerous. 

Individuals  who  have  had  small  pox  are  particu- 
larly difficult  to  operate  upon  by  the  submucous 
method,  for  the  mucoperichondrium  is  often  pitted 


with  small  depressed  areas  of  scartissue  very  adher- 
ent to  the  underlying  saeptum.  The  membrane  has 
very  little  absorptive  power,  and  it  is  usually  neces- 
sary in  these  cases  to  infiltrate  to  secure  satisfactory 
anaesthesia. 

Elevation  of  the  mucoperichondrium  can  be  facil- 
itated by  making  the  vertical  incision  at  a  point  con- 
siderably posterior  to  the  region  usually  selected,  as 
the  membrane  in  the  latter  situation  will  be  found 
less  adherent. 

The  hook  shaped  elevator  can  be  used  here  to 
good  advantage,  the  operator  elevating  from  behind 
forward  if  necessary,  and  applying  the  cocaine  solu- 
tion to  the  bared  cartilage  as  exposed. 

Killian  (Laryngoscope,  July,  1907,  page  516) 
recommends  stibmucous,  perineural  injections  for 
anaesthetizing  the  saeptum.  He  injects  at  two  points, 
viz.:  I.  '"Just  anterior  to  the  tuberculum  saepti  in 
an  upward  direction."  2.  Opposite  a  "point  just  be- 
low the  middle  of  the  lower  border  of  the  iriiddle 
turbinate."  This  deposits  the  solution  over  the  an- 
terior and  posterior  divisions  of  the  saeptal  nerve. 
For  the  injections  he  uses  "a  .solution  made  by  dis- 
solving two  tablets  of  suprarenin-cocaine  (Braun — 
form  A)  in  five  c.  c.  of  sterilized  physiological  salt 
solution." 

The  inferior  turbinated  body. — It  is  often  difficult 
to  completely  anaesthetize  this  structure,  especially 
when  the  bony  portion  is  so  developed  as  to  ap- 
proach closely  the  floor  of  the  nose.  If  cocaine 
soaked  pledgets  are  used  considerable  force  is  re- 
quired to  bring  them  in  contact  with  the  external 
surface  of  the  turbinate,  and  a  certain  amount  of 
the  drug  generally  finds  its  way  down  into  the  throat 
with  the  disagreeable  results  referred  to.  It  is  prac- 
tically impossible  to  reach  the  posterior  tip  by  pack- 
ing, and  the  direct  applicator  method  here  also 
proves  more  satisfactory. 

The  general  plan  is  identical  with  that  used  for 
the  saeptum.  Beginning  with  the  saeptal  surface  of 
the  turbinate  the  solution  is  carried  on  a  bent  ap- 
plicator under  the  free  edge  to  the  external  surface, 
finally  reaching  the  tip.  A  satisfactory  way  of  treat- 
ing large  hypertrophies  of  this  latter  structure  is  to 
introduce  a  sharply  curved  applicator  behind  the 
soft  palate,  sweeping  the  applicator  across  the  pos- 
terior surface  of  the  tip. 

Killian  (op.  cit.)  calls  attention  to  the  danger  of 
injecting  cocaine  into  the  inferior  turbinated  body, 
a  caution  which  it  is  wise  to  heed,  for  this  structure 
has  a  much  greater  absorptive  power  than  the  mu- 
cous membrane  covering  :he  saeptiun,  or,  in  fact, 
that  covering  the  middle  turbinated  body. 

The  middle  turbinated  body. — Several  applica- 
tions of  cocaine  are  necessary  to  insure  a  painless 
operation  upon  the  middle  turbinated  body  and  eth- 
moid cells.  The  first  is  made  in  the  manner  de- 
scribed for  the  inferior  turbinate,  precautions  being 
taken  to  reach  well  up  to  the  base  of  its  attachment 
on  the  external  or  lateral  aspect.  After  removal 
of  the  body  of  the  middle  turbinate  a  number  of  eth- 
moid cells  are  exposed  which  were  covered  by  the 
overhanging  mass.  This  area  is  then  cocainized  and 
curetted,  the  operator  ceasing  from  time  to  time  and 
cocainizing  fresh  areas  as  exposed. 

If  the  anaesthesia  induced  by  this  method  is  not 
complete,  infiltration  may  be  resorted  to,  and  thr?e 


274 


LESHURE:  STROXG  COCAINE-ADRENALIN  SOLUTIONS. 


[New  York 
Medical  Journal. 


or  four  drops  of  a  one  per  cent,  solution  of  cocaine 
injected  into  the  base  of  the  middle  turbinated  body 
will  aid  materially  in  securing  the  desired  result. 
An  extra  long  needle  is  required  for  this  purpose. 

As  this  operation  is  often  a  preliminary  to  ex- 
ploration of  the  frontal  sinus  via  the  intranasal 
route,  the  nasofrontal  duct  may  be  readily  cocain- 
ized by  suitably  curved  applicators,  as  may  also  the 
ostium  of  the  antrum  of  Highmore.  . 

The  maxillary  antrum. — Killian  (op.  cit.)  sug- 
gests that  the  nerves  supplying  the  antrum  proba- 
bly gain  entrance  through  the  ostium,  and  that  an 
injection  near  this  opening  will  induce  anjjesthesia 
in  the  area  supplied  by  these  nerves.  He  also  "adds 
to  this  an  injection  in  the  nose  above  the  anterior 
end  of  the  lower  turbinal." 

He  -stated  that  on  tolerant  patients  he  has  been 
able  to  do  a  radical  operation  under  cocaine  anaes- 
thesia, first,  infiltrating  the  external  wall  of  the 
antrum,  and  after  an  opening  has  been  nlade  he 
swabs  the  interior  of  the  antrum  with  cocaine. 

The  iiasopharyii.v. — This  may  best  be  anaesthet- 
ized by  a  combination  of  two  ways,  viz. :  i.  By  way 
of  the  nose.    2.  By  way  of  the  mouth. 

A  straight  applicator  introduced  along  the  floor 
of  the  nose  is  made  to  sweep  all  portions  of  the 
nasopharynx  which  can  be  thus  reached,  repeating 
the  process  through  the  opposite  nostril.  Untouched 
areas  should  be  treated  with  a  long,  bent  applicator 
passed  behind  the  soft  palate  to  the  vault  of  the 
pharynx. 

One  should  be  particular  to  thoroughly  cocainize 
the  posterior  border  of  the  saeptum,  a  region  which 
is  often  overlooked,  otherwise  pain  will  be  caused 
by  the  curette  when  the  instrument  is  crowded  for- 
ward before  making  the  downward  sweep  in  adeno- 
tomy. 

It  is  difficult  to  secure  a  satisfactory  degree  of 
anaesthesia  in  the  nasopharynx,  covered  as  it  is  in 
operative  cases  by  a  thick  mass  of  lymphoid  tissue 
which  prevents  the  cocaine  from  readily  reaching 
the  real  operative  field,  viz. :  the  fascia  and  muscle, 
these  constituting  the  structures  actually  wounded 
by  the  curette.  A  painless  adenotomy  is  therefore 
practically  impossible,  since  the  anaesthesia  is  only 
relative. 

For  the  reasons  just  stated,  operations  made  with 
instruments  resembling  the  so  called  adenotome  of 
Schuetz  are  probably  less  painful  than  those  made 
with  the  ciirette,  since  the  former  instrument  is  so 
constructed  as  to  protect  the  deep  structures  from 
injury,  and  the  superficial  tissues  through  which  the 
knife  passes  can  be  rendered  fairly  insensitive  by 
cocaine. 

Infiltration  anaesthesia  in  this  region  would  seem 
to  be  dangerous  as  well  as  difficult,  wdiile  the  cata- 
phoric ajjplication  of  cocaine  would  be  impossible 
with  most  children  who  furnish  the  great  majority 
of  nasopharyngeal  operations. 

The  uvula  and  lingual  tonsil. — Two  or  three  ap- 
plications of  a  ten  per  cent,  solution  of  cocaine  suf- 
fice to  fully  ana-sthetize  the  uvula,  and  no  detailed 
description  of  the  technique  is  necessary. 

The  lingual  .tonsil,  on  the  other  hand,  presents  a 
nmnbcr  of  difficulties,  and  to  insure  a  painless  oper- 
ation upon  this  structure  one  should  cocainize  with 
great  care.   Tiiis  is  particularly  true  if  the  galvano- 


cautery  is  to  be  used.  The  intense  heat  radiates 
from  the  platinum  point  to  regions  quite  remote 
from  the  area  of  application,  and  powerfully  stimu- 
lates the  local  nerve  trunks  as  well  as  the  nerve  end- 
ings. 

The  lymphoid  tissue  constituting  the  lingual  ton- 
sil is  often  thrown  up  into  folds,  and  a  right  angle 
applicator  wet  with  the  strong  cocaine-adrenalin  so- 
lution should  be  rather  forcibly  carried  to  the  bottom 
of  the  fissures  between  these  folds,  otherwise  the 
sensitive  base  of  the  tonsil,  i.  e.,  the  tongue,  will  not 
be  reached  by  the  drug. 

Masses  of  lymphoid  tissue  on  the  posterior  and 
lateral  walls  of  the  pharynx  are  managed  in  the 
same  way. 

The  fanciai  tonsils. — At  a  recent  meeting  of  the 
Section  in  Laryngology  of  the  New  York  Academy 
of  Medicine  methods  of  ablation  of  the  tonsils  were 
discussed,  and  great  stress  was  laid  upon  the  diffi- 
culty of  securing  satisfactory  anaesthesia  of  these 
structures,  particularly  when  the  snare  was  selected 
as  the  operative  instrument.  The  pain  is  probably 
due  to  the  bruising  and  stretching  of  the  nerve 
crunks  as  the  wire  tears  rather  than  cuts  through 
the  tissues. 

The  method  of  inducing  anaesthesia  that  has  given 
the  best  results  is  the  following : 

Strong  cocaine-adrenalin  solution  is  brushed  over 
the  anterior  and  posterior  pillars,  and  the  tonsil  it- 
self, particular  attention  being  given  to  the  supra- 
lonsillar  fossa,  since  some  of  the  nerve  trunks  sup- 
plying the  tonsil  are  quite  superficially  placed  in  this 
region.  The  solution  is  worked  into  the  crypts  of 
the  tonsil,  and  the  space  between  the  pillars  and  the 
consil.  A  mixture  of  equal  parts  of  two  per  cent, 
cocaine  solution  and  one  in  five  thousand  solution 
of  adrenalin  is  then  injected  through  a  curved  hy- 
podermatic needle  into  the  anterior  and  posterior 
pillars. 

The  pillars  can  now  be  freed  with  but  little  pain, 
and  slight  haemorrhage,  by  a  tonsil  separator  or 
knife  down  to  the  base  of  the  tonsil.  These  en- 
larged sulci  are  then  swabbed  with  strong  cocaine- 
adrenalin  solution  until  anaesthesia  seems  complete. 

If  the  pillars  are  carefully  separated  from  the  ton- 
sils one  can  remove  the  tonsils  as  completely  with 
the  tonsillotome  as  with  the  snare.  It  is  worth  men- 
tioning that  the  best  results  are  obtained  when  the 
ring  of  the  tonsillotome  accurately  fits  the  tonsil, 
since  it  then  acts  as  a  retractor,  forcing  the  pillars 
down  to  the  base  of  the  tonsil,  causing  the  latter  to 
project  well  beyond  the  level  of  the  instrument's 
blade. 

A  valuable  aid  in  operations  upon  the  tonsils,  or, 
in  fact,  any  operations  in  the  mouth,  is  the  White- 
head gag.  This  is  fitted  with  an  adjustable  tongue 
depressor,  wiiich  dispenses  with  the  services  of  an 
assistant,  and  leaves  the  operator's  hands  free,  a  de- 
cided advantage  when  operating  under  general  an- 
aesthesia. Care  should  be  taken  to  draw  the  base 
of  the  tongue  well  forward  before  depressing  the 
spatula,  for  the  latter  has  a  tendency  to  crowd  the 
tongue  down  over  the  larynx,  and  interfere  with 
breathing. 

The  laryn.r  and  trachea. — A  preliminary  spray- 
ing of  the  larynx  with  a  four  to  ten  per  cent,  solu- 
tion of  cocaine  renders  subsequent  applications  of 


February  6,  1909.] 


M'COY:  RATS  FOR  LABORATORY  PURPOSES. 


275 


stronger  solutions  with  brush  or  appHcator  much 
easier. 

If  the  patient  is  instructed  to  inhale  deeply  at 
the  moment  of  spraying  a  considerable  amount  of 
drug  solution  will  be  carried  by  the  air  current  into 
the  trachea  as  well  as  into  the  larynx.  A  ten  per 
cent,  solution  of  cocaine  usually  induces  complete 
an.-esthesia  of  these  regions ;  stronger  solutions  are 
apt  to  cause  reactionary  oedema. 

Summary. 

1.  To  induce  a  maximum  degree  of  local  anaes- 
thesia and  ischsemia,  with  a  minimum  of  general 
drug  absorption,  it  is  necessary  to  use  solutions  of 
high  density,  which  do  not  readily  enter  the  larger 
blood  and  lymphatic  streams. 

2.  The  diluting  effect  of  the  mucous  membrane 
secretions  must  be  bcrne  in  mind,  and  cotton  wound 
applicators  should  be  frequently  changed,  and  fresh- 
ly charged  with  the  cocaine-adrenalin  solution. 

3.  Before  beginning  to  operate  one  should  care- 
fully test  every  part  of  the  field  with  a  probe  to 
determine  whether  the  anaesthesia  is  complete.  It 
is  difficult  to  anaesthetize  when  bleeding  has  once 
begun,  and  the  patient  will  greatly  appreciate  the 
extra  effort  made  to  spare  him  needless  pain. 

423  Convent  Avenue. 

THE  KEEPING  AND  HAXDLIXG  OF  RATS  FOR 
LABORATORY  PURPOSES. 

By  George  W.  McCoy,  M.  D., 

San  Francisco, 

Passed  Assistant  Surgeon,  United  States  Public  Health  and  Marine 
Hospital  Service. 

We  have  used  wild  rats  somewhat  extensively 
in  our  work  in  the  Federal  Laboratory  in  San  Fran- 
cisco, and  in  view  of  the  statement  made  in  many 
books  and  monographs  to  the  effect  that  these  ani- 
mals are  not  well  suited  for  experimental  purposes 
we  thought  that  a  brief  description  of  the  methods 
we  employ  in  keeping  and  handling  them  might  be 
of  assistance  to  others  engaged  in  laboratory  work. 

It  is  generally  said  that  these  animals  do  not  live 
long  in  captivity,  that  the  mortality  from  fighting  is 
high,  and  that  they  are  too  vicious  to  be  handled. 
Our  experience  has  not  justified  these  objections. 
We  have  rats  living  that  were  inoculated  more  than 
six  months  ago.  The  mortality  from  fighting  may 
be  almost  entirely  eliminated  by  appropriate  meas- 
ures. The  viciousness  of  the  animals  ceases  to  be 
a  material  factor  if  they  are  anaesthetized  prior  to 
inoculation.  In  our  experience  wild  rats  may  be 
used  almost  as  successfully  as  one  uses  guineapigs, 
white  rats,  or  rabbits. 

We  have  used  the  animals  for  two  purposes. 
First,  in  experiments  especially  designed  to  deter- 
mine the  reaction  of  wild  rats  to  toxic  agents,  espe- 
cially those  recommended  or  sold  as  rat  extermi- 
nators, and  to  various  microorganisms.  Second,  as 
a  substitute  for  white  rats  and  guineapigs  when  we 
were  unable  to  obtain  the  tame  rodents. 

The  wild  rats  we  get  are  nearly  all  of  the  gray 
variety  (Mus  norvegicus) .  They  are  caught  in 
traps  in  the  routine  antirat  work  in  this  city.  Only 
a  few  black  rats  (Mits  rattus)  have  been  used  as 
only  a  few  of  this  species  are  caught  in  San  Fran- 
cisco. 


Stock  Cages. — The  cages  we  use  for  stock  rats 
were  devised  by  the  late  Passed  Assistant  Surgeon 
H.  A.  Stansfieid.  They  are  made  of  wood,  lined 
on  the  sides  with  zinc,  and  have  a  half  inch  mesh 
wire  screen  top  and  bottom.  A  door  about  a  foot 
square  is  placed  in  the  centre  of  the  top  of  the  cage. 
The  cages  stand  in  zinc  trays  which  are  kept  full  of 
sawdust  that  is  changed  once  a  week.  This  ar- 
rangement permits  of  the  cleaning  of  the  cages 
without  any  necessity  for  handling  the  rodents.  The 
cage  with  the  rats  in  it  is  lifted  out  of  the  tray,  the 
dirty  sawdust  removed,  and  a  fresh  supply  put  in. 
From  twelve  to  twenty  rats,  depending  on  their  size, 
mav  be  kept  in  a  cage  two  feet  square  and  eighteen 
inches  high. 

Segregation  of  Rats  of  Different  Si:;es. — When  we 
began  using  wild  rats  all  that  were  brought  in  were 
kept  in  one  large  stock  cage  and  as  a  result  a  con- 
siderable number  of  the  young  rats  were  killed  by 
the  larger  ones.  On  one  occasion  we  saw  a  large  rat 
kill  seven  small  ones  before  it  could  be  caught  and 
removed  from  the  cage.  The  losses  from  fighting 
led  us  to  keep  the  large  and  the  small  rats  in  sepa- 
rate cages.  This  plan  worked  well,  but  we  find  it 
even  better  to  divide  the  rats  into  three  groups  ac- 
cording to  size,  keeping  each  group  in  a  separate 
stock  cage  and  never  putting  together  in  the  same 
cage  or  container  rats  from  dift'erent  groups.  We 
try  to  segregate  the  rats  as  follows :  Small  rats, 
weighing  less  than  ninety  grammes ;  medium  sized 
rats,  weighing  from  ninety  to  one  hundred  and 
seventy-five  grammes  ;  large  rats,  all  above  the  lat- 
ter weight.  This  plan  almost  entirely  prevents  fight- 
ing- 

The  rats  separated  as  indicated  are  not  used  until 
they  have  been  kept  in  quarantine  for  at  least  a 
week.  During  this  period  a  few  will  die  from  the 
effects  of  poison  eaten  before  they  were  brought  in, 
and  occasionally  one  will  die  without  any  apparent 
cause.  The  primary  object  of  the  quarantine  is  to 
permit  the  development  of  plague  or  any  other  acute 
disease  with  which  the  animal  may  be  infected.  An- 
other important  advantage  in  keeping  the  rats  for  a 
week  before  they  are  used  is  the  fact  that  in  this 
time  they  will  almost  entirely  rid  themselves  of 
fleas — a  most  important  matter  if  they  are  to  be 
used  for  plague  inoculations.  It  is  exceptional  to 
find  a  flea  on  one  of  our  stock  rats,  though  we  make 
it  a  rule  to  comb  all  of  them  just  prior  to  inocula- 
tion. 

Cages. — For  keeping  rats  other  than  those  inocu- 
lated with  Bacillus  f^cstis  we  use  cages  similar  to 
the  stock  cages  mentioned  before.  The  ordinary 
cage  traps  also  serve  satisfactorily  for  this  purpose. 

For  rats  inoculated  with  plague  we  use  galvanized 
iron  garbage  cans  two  feet  high  and  fifteen  inches 
in  diameter.  They  are  provided  with  an  insect  proof 
cover — a  sieve  covered  with  gauze  (or  muslin) 
serves  for  this  purpose.  Rats  can  jump  out  of  such 
a  can  when  the  cover  is  removed  and  to  obviate  this 
and  yet  to  be  able  to  feed  them  and  to  observe  them 
we  have  a  half  inch  mesh  wire  screen  diaphragm 
placed  about  eight  inches  from  the  top  of  the  can. 
The  diaphragm,  which  is  not  fastened  to  the  can, 
rests  on  three  small  angle  irons  attached  to  the  in- 
side of  the  container.  The  inner  surface  of  the  can 
between  the  cover  and  the  diaphragm  is  smeared 


I 


276 


HUHNER:  GONORRHCEA. 


[New  York 
Medical  Journal. 


with  petrolatum.  The  object  of  the  petrolatum  is  to 
keep  any  insects  from  crawling  or  hopping  out.  The 
one  objection  to  these  containers  is  the  difficulty  of 
getting  out  a  dead  rat  when  there  are  live  ones  re- 
maining in  the  can.  A  long  pair  of  tongs  is  used 
and  great  care  is  exercised  that  none  of  the  rats 
escape.  The  most  serviceable  tongs  for  this  purpose 
and  for  handling  rats  in  general  is  made  of  two 
pieces  of  one  quarter  inch  cold  rolled  steel  rod  flat- 
tened toward  one  end  so  that  they  may  be  fastened 
together  like  a  pair  of  scissors.  The  end  used  to 
grasp  the  rat  has  the  rods  flattened  for  about  an 
inch,  and  this  flattened  portion  is  bent  at  a  right 
ingle  to  the  shaft  of  the  tongs.  This  gives  a  grasp- 
ing surface  that  answers  the  purpose  admirably  for 
.vhich  it  is  used.  The  steel  rods  are  about  twenty 
inches  long  and  the  joint  is  made  about  four  inches 
from  the  end  used  to  grasp  the  rat. 

Food. — The  rats  are  fed  daily.  We  use  bread, 
cheese,  bacon,  and  at  least  twice  a  week,  carrots  or 
cabbage.  From  our  experience  it  seems  that  unless 
some  green  food  is  given  the  rats  are  likely  to  de- 
velop oedema  and  ulcerations  of  the  feet.  Water 
should  be  provided  regularly,  although  when  an 
abundance  of  green  food  is  given  it  is  not  necessary . 
Feeding  experiments  are  conducted  by  starving  the 
animals  for  a  day,  then  giving  the  food  mixed  with 
the  culture  or  other  agent  that  it  is  desired  to  ad- 
minister, and  withholding  other  food  until  the  mix- 
ture given  for  experimental  purposes  has  been 
eaten. 

Inoculation. — After  a  few  attempts  at  handling 
wild  rats  with  gloves  and  with  tongs  when  we  de- 
sired to  inoculate  them,  these  methods  were  given 
up  and  we  began  to  anjEsthetize  them.  The  rat  is 
put  in  a  mouse  jar  with  a  handful  of  cotton  on 
which  is  poured  about  10  c.c.  of  ether.  As  soon  as 
the  animal  is  quite  limp,  we  proceed  with  whatever 
inoculation  is  contemplated.  It  is  very  rare  to  have 
an  animal  die  from  the  anjT^sthetic.  So  satisfactory 
is  this  use  of  ether  that  we  have  adopted  it  even 
with  white  rats  when  inoculating  them  with  Bacillus 
pestis.  An  additional  advantage  in  using  ether  is 
the  ease  with  which  one  can  search  for  fleas  when 
the  rat  is  narcotized. 


CLINICAL  GONORRHCEA  IN  THE  MALE. 

By  Max  Hi;hner,  M.  D., 

New  York. 
{Concluded  from  page  222.) 

Resume  of  the  Treatment  of  Acute  Gonorrhoea  in 
the  Male. 

If  the  case  is  seen  within  thirty-six  hours  of  the 
inception  of  the  discharge,  try  to  abort  it  by  giving 
three  injections  of  a  ro  per  cent,  solution  of  protar- 
gol,  the  first  in  the  morning  (if  the  patient  should 
come  then),  the  second  in  the  evening,  and  the  third 
the  next  morning;  the  first  two  lasting  fifteen  min- 
utes and  the  last  five  minutes.  Give  alkaline  mix- 
ture internally  as  long  as  pain  on  urination  exists, 
and  hot  and  cold  applications  to  genitals  if  swell- 
ing a])pears.  Later  give  zinc  sulphate  0.5  to  i  per 
cent,  solution.  If  the  treatment  is  unsuccessful 
treat  as  ordinary  case  {z'idc  infra). 


If  the  case  is  seen  too  late  to  be  aborted,  or  if  at- 
tempt at  the  latter  was  unsuccessful,  and  the  patient 
can  come  daily  for  treatment,  give  alkaline  mixture 
internally  and  intravesical  irrigation  of  potassium 
permanganate  (i  in  3,000)  every  day  (for  the  first 
two  or  three  days  5nly  as  far  as  the  constrictor 
muscle).  After  two  weeks  give  Lafayette  mixture 
internally,  and  if  there  is  no  discharge,  give  the  irri- 
gations every  second  or  third  day,  watching  the  ef- 
fect. If  there  is  a  tendency  toward  a  chronicity  of 
the  discharge  stop  the  permanganate  solution,  and 
use  instead  silver  nitrate  solution  (intravesically), 
starting  with  a  i  in  20,000  solution  and  increasing 
daily  as  follows:  i  in  20,000,  i  in  15,000,  i  in 
10,000,  I  in  8,000,  I  in  6,000,  I  in  5,000,  I  in  4,000, 
I  in  3,000,  I  in  2,000.  I  in  1,000,  i  in  500;  then  i  in 
1,000,  I  in  3,000,  I  in  5,000,  and  finish  up  with  one 
or  two  potassium  permanganate  (i  in  3,000)  irri- 
gations. During  the  first  part  of  the  treatment  for- 
bid absolutely  all  alcoholics  as  well  as  tea  and  coffee  ; 
later,  as  the  patient  is  getting  well,  but  while  still 
under  treatment,  gradually  allow  these  beverages, 
watching  the  effect  closely,  so  that  when  well  he 
will  be  on  his  ordinary  diet. 

If  the  patient  cannot  come  daily  for  treatment, 
give  the  same  internal  medication  and  diet  as  above, 
and  for  the  first  three  days  a  home  injection  of  a 
0.5  per  cent,  protargol  solution,  four  times  a  day, 
this  increased  to  0.75  per  cent,  in  three  more  daysf 
and  if  the  patient  can  stand  it,  this  is  increased  to  i 
per  cent,  in  another  three  days.  If  the  gonococci 
have  entirely  disappeared,  keep  up  the  i  per  cent, 
protargol  four  times  a  day  for  about  a  week.  If 
they  have  not  disappeared  increase  the  strength 
gradually  to  1.5  per  cent,  or  2  per  cent.  At  the  end 
of  a  week  of  no  gonococci  use  the  protargol  three 
times  a  day,  and  in  addition  a  0.5  to  i  per  cent, 
zinc  sulphate  solution  once  a  day.  After  a  few  days 
give  each  alternately  twice  a  day ;  then  protargol 
once  a  day  and  zinc  sulphate  three  times  a  day.  and 
lastly  the  zinc  sulphate  four  times  a  day. 

Never  pronounce  a  patient  cured  until  all  treat- 
ment has  been  stopped  for  at  least  a  week,  and  the 
patient  has  been  on  his  regular  diet,  and  no  dis- 
charge, stickiness,  or  agglutination  of  the  lips  of 
the  meatus  exists  on  several  examinations  held 
twelve  hours  after  the  last  urination. 

PrOI'IIVL.\XIS  of  GoXORRIIGi.A. 

I  now  come  to  a  subject  which  I  consider  of 
greatest  importance,  and  have  therefore  left  it  for 
the  end,  namely,  that  of  prophylaxis.  This,  in  a 
general  way,  includes  the  whole  subject  of  the  pre- 
vention of  venereal  diseases,  a  subject  too  vast  to 
be  considered  in  a  paper  like  this.  But  there  is  an 
entire  new  phase  of  the  qviestion  which  to  my  mind 
is  of  supreme  importance  in  this  connection. 

The  Medical  Profession  Partly  Responsible  for 
the  Spread  of  Venereal  Diseases. — I  have  no  hesi- 
tancy in  saying  that  the  medical  profession  (and  by 
that  I  include  only  the  ethical  members)  is  directly 
responsible  for  a  large  portion  of  the  spread  of 
venereal  disease.  Although  at  congresses  devoted 
to  the  prevention  of  the  spread  of  venereal  diseases 
it  has  been  resolved  to  inculcate  and  advise  greater 
chastity  upon  our  young  men,  it  is  nevertheless  a 
fact  that  in  the  majority  of  cases  a  man  with  gonor- 


February  6.  1909. J 


HUHXER:  GONORRHCEA. 


rhcea  too  often  hears  from  his  physician  such 
phrases  as  "Xever  mind,  we  have  all  had  the  clap," 
or  "A  man  is  not  a  man  until  he  has  had  the  clap," 
etc.  Let  us  therefore  review  the  subject  openly, 
not  from  a  religious  or  moral  standpoint,  hwt  pure- 
ly from  a  medical  one. 

Chances  of  Infection. — Let  us  first  consider  what 
are  the  chances  of  contracting  venereal  disease  from 
illicit  intercourse.  It  goes  without  saying  that  if 
a  person  has  connection  with  a  prostitute  he  ought 
not  to  be  surprised  if  she  infects  him.  Even  those 
houses  that  have  a  visiting  physician  are  not  safe, 
especially  as  regards  gonorrhoea,  for  the  following 
reasons : 

L  It  is  easv  for  the  women  to  douche  before  ex- 
amination and  so  deceive  the  physician. 

II.  The  woman  may  become  infected  between  the 
doctor's  visits,  or  show  the  first  signs  of  the  disease 
between  the  visits. 

III.  The  chronic  or  so  called  "cured"  cases  form 
the  most  important  source  of  contamination  in  this 
group.  It  is  perfectly  possible  that  a  woman  who 
has  had  gonorrhoea  may  show  absolutely  no  pus 
or  discharge  whatsoever  on  her  genital  organs,  and 
that  scrapings  from  them  may  show  no  gonococci 
either  if  directly  examined  or  even  on  culture ;  and 
yet  this  woman,  under  the  stimulus  of  sexual  ex- 
citement, mav  pour  out  millions  of  gonococci  with 
the  mucus  from  the  glands  where  they  are  hidden 
and  infect  her  partner.  Thc)se  who  have  paid  par- 
ticular and  careful  attention  to  this  source  "bf  infec- 
tion will  agree  with  me  that  practically  once  a  wo- 
man has  had  gonorrhoea  there  is  no  way  of  telling 
from  physical  examination  whether  she  is  cured  or 
not. 

Then  we  have  the  servant  girls,  chamber  maids, 
and  other  "sure  things."  To  any  one  who  has  had 
a  large  experience  in  venereal  diseases  it  is  a  stand- 
ing joke  to  see  the  large  amount  of  disease  con- 
tracted from  these  so  called  "sure  things."  To  all 
patients  of  mine  alleging  to  have  such  a  "sure 
thing"  I  have  but  one  answer,  and  that  is  "If  they 
go  with  you  they  go  with  others,  and  so  you  are  not 
safe." 

Lastly  we  have  married  women,  especially  the  so 
called  "respectable  married  women."  I  have  had 
several  cases  that  have  made  a  deep  impression 
upon  me  in  this  respect.  I  have  at  present  two 
ladies  under  treatment  who  are  eminently  and  abso- 
lutely respectable  and  above  all  suspicion,  and  yet 
both  are  suffering  from  gonorrhoea,  having  been  in- 
fected by  their  husbands,  who,  by  the  way,  are  also 
under  my  care.  Xow,  here  is  the  point  I  wish  to 
emphasize:  Surely,  if  any  stranger  could  entice 
either  of  these  ladies  to  have  connection  with  him, 
he  could  be  absolutely  certain  of  their  respectability 
and  also  as  absolutely  certain  to  contract  gonor- 
rhoea. If  one  has  connection  with  a  married  wo- 
man he  must  be  able  to  guarrantee  for  her  husband, 
which  is  indeed  a  very  difficult  matter.  Besides  the 
very  fact  that  she  has  connection  with  him  proves 
that  she  is  not  respectable,  and  brings  her  in  line 
with  the  arguments  advanced  against  the  other 
"sure  things." 

As  a  practical  proof  of  all  these  arguments,  it 
may  be  advanced  that  the  rich,  who  surely  can  ob- 
tain anything  they  want  with  their  money,  suflFer 


just  as  much  from  venereal  diseases  as  do  others. 
Taking  it  all  and  all  we  may  practically  sum  up  the 
whole  thing  by  the  formula :  Illicit  connection  is 
equal  to  venereal  disease. 

Having  shown  that  it  is  practically  impossible  to 
avoid  venereal  disease  by  having  illicit  intercourse, 
we  now  come  to  the  second  question :  "Is  illicit  in- 
tercourse necessary?"  Is  continence  physiological 
and  in  harmony  with  perfect  health?  This,  of 
course,  applies  only  to  unmarried  adults.  Can  a 
young  unmarried  man  remain  health\'  and  still  be 
continent  ? 

L'pon  the  answer  to  this  question  hinges  a  large 
portion  of  the  causes  of  the  spread  of  venereal  dis- 
ease, for  it  must  be  acknowledged  that  this  portion 
of  medicine  bears  exactly  the  same  relation,  and  of 
right  ought  to  bear  the  same  relation  to  morality 
and  religion  as  every  other  portion  of  practical  med- 
icine. In  every  religion  the  most  stringent  laws  are 
to  a  certain  extent  subservient  to  those  of  health. 
The  orthodox  Hebrew  may  eat  articles  of  food  pro- 
scribed by  its  dietary  laws  if  necessary  to  his  health. 
Even  the  rite  of  circumcision  and  the  abstinence 
from  food  on  the  day  of  atonement,  the  most  sacred 
customs  to  the  orthodox  Hebrew,  may  be  interfered 
with  if  health  is  at  stake.  The  religious  Catholic 
and  Protestant  may  neglect  abstaining  from  food  on 
certain  fast  days  if  prejudicial  to  his  health.  And  so 
it  is  with  the  subject  under  consideration.  Our 
clergymen  may  preach  chastity  and  purit\-  from 
morning  till  night,  and  may  bring  to  their  aid  the 
most  potent  religious,  moral,  and  ethical  arguments ; 
if  the  physician,  however,  says  that  it  is  detrimental 
to  the  health  to  be  continent,  that  connection  is  ab- 
solutely necessary  for  the  healthy  adult,  our  patient 
will  throw  aside  the  teachings  of  the  clergymen  and 
listen  to  those  of  his  physician,  and  (I  say  it  with 
deep  religious  feeling)  will  be  perfectly  right  in  so 
doing.  No  matter  what  the  law  says,  no  one  would 
condemn  a  hungry  man  for  stealing  a  loaf  of  bread 
to  eat,  and  none  ought  to  condemn  a  healthy  adult 
for  having  connection  if  such  is  absolutely  essential 
to  his  existence.  And,  as  I  have  shown  that  practi- 
cally illicit  connection  equals  venereal  disease,  if  we 
physicians  consider  illicit  connection  necessary,  we 
ought  not  to  wonder  or  even  hope  to  find  venereal 
disease  on  the  decrease. 

In  the  following  pages  I  shall  endeavor  to  prove 
that  absolute  continence  is  not  detrimental  to  health, 
considered  either  from  a  physiological  or  psycho- 
logical standpoint. 

First,  considered  from  the  point  of  view  of  physi- 
ology. It  is  indeed  remarkable  that,  although  I  have 
consulted  almost  every  work  on  physiology  pub- 
lished in  the  English  language  during  the  last  ten 
years,  not  one  has  anything  to  say  on  the  question. 
This  search  includes,  besides  others,  textbooks  by 
the  following  authors:  Landois  (i),  Kirk  (2), 
Brubaker  (3),  Shatler  (4),  Raymond  (5),  Ott  (6), 
Foster  (7),  Hall  (8),  Stirling  (9),  Johnson  (10), 
Hare  (Ti),  and  American  Textbook  of  Physio- 
logy. In  1875,  Austin  Flint,  Jr.  (12),  makes  a 
slight  reference  to  the  question,  when  he  says  that 
"sexual  intercourse  is  only  physiological  when  con- 
fined within  the  limits  of  legitimacy."  With  this 
one  slight  reference  as  an  exception,  I  could  find  no 
data  in  recent  works  on  physiology.    I  have,  how- 


278 


HUHXER:  GONORRHCEA. 


[Xew  York 
Medical  JouRNiL. 


ever,  no  doubt  that  there  are  works  in  foreign  lan- 
guages or  in  our  older  textbooks,  but  I  mention  this 
fact  merely  to  emphasize  how  meagre  the  literature 
on  this  subject  is,  at  least  in  our  American  and  Eng- 
lish physiologies. 

But  we  have  other  authorities  (outside  of  physi- 
ology) who  have  expressed  opinions  on  this  ques- 
tion. No  less  an  authority  than  Professor  Bryant 
(13),  the  great  English  surgeon,  says:  "The  stu- 
dent should  remember  that  the  functions  of  the  testi- 
cle, like  those  of  the  mammary  gland  and  uterus, 
may  be  suspended  for  a  long  period,  possibly  for 
life,  and  yet  its  structure  may  be  sound  and  capable 
of  being  roused  into  activity  on  any  health}'  stimu- 
lation. Unlike  other  glands,  it  does  not  waste  or 
atrophy  for  want  of  use."  This  opinion  from  the 
great  English  surgeon  answers  a  very  important  ob- 
jection to  continence  which  I  have  seen  urged  by 
many  physicians.  I  have  heard  physicians  argue  as 
follows :  "Every  organ  of  the  body,  if  not  in  use  for 
a  long  time,  atrophies,  muscles  lose  their  power, 
joints  become  stifif,  the  stomach  and  intestines  re- 
fuse to  secrete  the  proper  digestive  ferments,  if 
these  are  artificially  supplied  for  a  long  time ;  even 
the  higher  functions  of  the  brain  become  'rusty'  if 
not  made  use  of,  therefore  the  genital  apparatus 
ought  to  be  kept  active  or  else  it  will  atrophy  and 
become  useless."  It  is,  however,  a  fact  that  the 
sexual  organs  are  constructed  upon  entirely  differ- 
ent principles  than  most  of  the  other  organs  of  the 
bodv.  Thev  are  constructed  for  intermittent  action 
and  their  functions  may  be  suspended  indefinitely 
without  harm  to  either  their  anatomy  or  physi- 
ologv.  \\'itness  the  mammary  gland.  A  woman 
becomes  pregnant  and  gives  birth  to  a  child,  and 
immediately  the  gland,  which  had  remained  dor- 
mant for  years,  swells  up  and  secretes  milk. 
After  lactation  is  finished  the  gland  becomes 
smaller  and  inactive.  She  may  not  become  preg- 
nant again  for  ten  or  more  years,  and  during  all 
this  while  the  gland  is  not  in  use,  but  even  after  this 
long  period,  should  she  again  become  pregnant,  it 
will  again  swell  up  and  be  absolutely  useful  in  spite 
of  the  long  period  of  disuse.  The  same  is  true  of 
the  uterus.  I  have  gone  into  this  question  some- 
what in  detail,  because  it  is  very  important,  and  is 
being  constantly  brought  up  by  the  opponents  of  the 
continence  theory  and  is  very  apt  to  impress  the 
laity. 

James  Foster  Scott  (14)  the  great  authority  on 
sexual  instinct,  etc.,  says:  'Tf  the  penalties  meted 
out  to  the  impure  are  so  many,  there  is  yet  comfort 
for  the  unmarried  man  in  those  pages  which  show 
that  perfect  continence  is  quite  compatible  with  per- 
fect health,  and  thus  a  great  load  is  at  once  lifted 
from  the  mind  of  him  who  wishes  to  be  conscien- 
tious as  well  as  virile  and  in  health  with  all  the  or- 
gans of  the  body  performing  their  proper  func- 
tions." And  again  on  page  95:  "There  is  an  erro- 
neous and  widely  spread  belief  that  exercise  of  the 
se.xual  functions  is  necessary  in  order  to  maintain 
health  .  .  .  the  reproductive  glands  have  been 
so  constructed  that  their  specific  activities  can  be 
suspended  for  long  periods  of  time  without  their 
atrophy  or  the  slightest  impairment  of  function.  In 
this  particular  they  resemble  the  inherent  capa- 
bilities of  a  woman's  brea.sts,  wliich  can  remain 


quiescent  for  years  and  when  called  into  demand 
physiologically  respond  with  perfect  function." 
And  again  on  page  99:  "It  is  a  pernicious  pseudo- 
physiology  which  teaches  that  the  exercise  of  the 
generative  functions  is  necessary  in  order  to  main- 
tain one's  physical  and  mental  vigor  of  manhood.'" 

Acton  (15)  says:  "One  argument  in  favor  of 
incontinence  deserves  special  notice,  as  it  purports 
to  be  founded  on  physiology.  I  have  been  consulted 
by  persons  who  feared,  or  professed  to  fear,  that  if 
the  organs  were  not  regularly  exercised  they  would 
become  atrophied,  or  that  in  some  way  impotence 
might  be  the  result  of  chastity.  This  is  the  assigned 
reason  for  committing  fornication.  There  exists 
no  greater  error  than  this  or  one  more  opposed  to 
physiological  truth.  In  the  first  place,  I  may  state 
that  I  have,  after  many  years'  experience,  never  seen 
a  single  instance  of  atrophy  of  the  generative  organs 
from  this  cause.  .  .  .  Physiologically  considered, 
it  is  not  a  fact  that  the  power  of  secreting  semen  is 
annihilated  in  well  formed  adults  leading  a  healthy 
life  and  yet  remaining  continent.  .  .  .  No  con- 
tinent man  need  be  deterred  by  this  apocryphal  fear 
of  atrophy  of  the  testes  from  living  a  chaste  life." 

Beale  (16),  professor  at  King's  College,  London, 
says:  "And  I  would  remark  here  that,  notwith- 
standing very  strong  assertions  to  the  contrary,  and 
by  authorities  who  profess  to  have  thoroughly  stud- 
ied the  question,  no  sufficiently  valid  objections  have 
been  established  upon  reasonable  grounds,  or  upon 
facts  of  'physiology  and  health,  to  living,  nay,  ta 
passing,  life  in  a  state  of  celibacy."  And  again  on 
page  64,  in  the  chapter  called  Question  of  Physio- 
logical Necessity,  he  says:  "The  argument  that  if 
marriage  cannot  for  various  reasons  be  carried  out, 
it  is  nevertheless  necessary,  upon  physiological 
grounds,  that  a  substitute  of  some  kind  should  be 
found,  is  altogether  erroneous  and  without  founda- 
tion. It  cannot  be  too  distinctly  stated  that  the 
strictest  temperance  and  purity  is  as  much  in  ac- 
cordance with  physiological  as  moral  law,  and  that 
the  yielding  to  desire,  appetite,  and  passion  is  no 
more  to  be  justified  upon  physiological  or  physical 
than  upon  moral  or  religious  grounds.'" 

Sir  James  Paget  (17.J,  the  eminent  English  sur- 
geon, says:  "Many  of  your  patients  will  ask  you 
about  sexual  intercourse,  and  some  will  expect  you 
to  prescribe  fornication.  .  .  .  Chastity  does  no 
harm  to  mind  or  body ;  its  discipline  is  excellent, 
marriage  can  be  safely  waited  for,  etc."' 

It  must,  however,  in  all  fairness  be  mentioned 
that  there  are  some  who  hold  directly  opposite  views 
on  this  question,  and  in  order  to  be  candid  I  shall 
cite  some  of  these  views  and  attempt  to  point  out 
their  fallacies. 

Lvdston  (18),  in  his  book  on 'venereal  and  sex- 
ual diseases,  says :  "No  man  or  woman  at  adult  age 
is  in  perfect  physiological  condition  until  the  sexual 
function  is  naturally  and  regularly  performed."" 

This  would,  indeed,  be  a  remarkable  statement, 
but  it  loses  its  remarkability  as  we  turn  to  another 
chapter  in  the  same  work,  that  on  masturbation. 
Herein  we  see,  as  I  shall  presently  quote,  that  even 
this  author,  who  holds  such  extreme  views,  cannot 
(lenv  that  continence  is  perfectly  in  accord  with 
phvsiological  condition.  He  says : 
There  is  one  point  in  sexual  physiology  that  should  be 


February  6,  1909.J 


HUHNER:  GONORRHCEA. 


279 


impressed  upon  our  patients.  The  impression  prevails 
among  young  men  that  exercise  of  the  sexual  function  is 
an  absolute  physical  necessity,  irrespective  of  the  method 
of  its  accomplishment.  Indeed,  it  is  probable  that  some 
physicians  who  certainly  ought  to  know  better  foster  this 
idea  by  ill  weighed  and  injudicious  counsel.  This  idea  is 
most  pernicious  in  its  effects,  and  it  becomes  our  duty  to 
correct  it.  Although  no  adult  man  or  woman  under  exist- 
ing social  conditions  is  physiologically  well  balanced  in  a 
state  of  celibacy,  one  may  be  perfectly  healthy  and  physi- 
cally vigorous  while  leading  a  life  of  absolute  continence,  if 
the  mind  is  properh'  disciplined  and  the  body  made  com- 
pletely subservient  to  the  will.  The  excuse  of  physical 
necessity  is  too  often  a  subterfuge  to  justify  fornication 
and  even  masturbation.  That  such  an  excuse  should  ever 
be  offered  is  striking  testimony  regarding  the  prevalent  ig- 
norance of  sexual  physiology.  A  better  education  in  the 
ethics  and  physiological  aspects  of  the  sexual  function  is  a 
crying  neces'sity.  The  patient  should  be  impressed  with  the 
idea  that  its  (the  sexual  apparatus)  function  may  be  held 
in  abeyance  for  very  long  periods,  even  for  life,  without 
necessarily  producing  physical  injury.  When  thus  held  in 
abeyance  the  generative  function  may  be  called  into  action 
at  any  time  and  present  no  evidences  of  deterioration  from 
the  compulsory  rest. 

The  writer  evidently  means  that  sexual  inter- 
course in  adult  life  is  desirable  for  the  maintenance 
of  the  physiological  balance,  but  is  not  a  necessit}- 
under  ideal  conditions  of  sexual  education ;  but  he 
would  lead  us  to  infer  that  under  the  artificial  con- 
dition; that  constitute  society  to-day  it  may,  antl 
often  does,  become  a  necessity. 

It  is,  of  course,  obvious  that  the  purer  one  is 
brought  up  and  the  purer  his  associates  are,  the 
purer  his  thoughts  will  be.  and  the  easier  it  will  be 
for  him  to  remain  continent.  And,  on  the  other 
hand,  if  the  mind  is  constantly  kept  excited  by  the 
reading  of  immoral  literature,  or  the  presence  of 
lewd  associates,  ii  becomes  extremely  difficult  to 
refrain  froin  sexual  intercourse.  This  difficulty  is 
enormously  increased  if  sexual  connection  has 
been  already  indulged  in,  so  that  that  which  was  at 
first  a  novelty  finally  becomes  a  habit.  At  this  stage 
fornication  may  become  a  necessitj-  in  the  same 
sense  as  alcohol  to  the  habitual  drunkard  or  mor- 
phine to  the  morphine  fiend. 

In  carefully  looking  over  the  authorities  that  be- 
l.'eve  sexual  intercouise  z  necessit)',  two  important 
facts  are  observed.  The  first  is  the  two  sidedness  of 
their  statements,  the  hemming  and  hawing  about  the 
matter,  showing  that  they  themselves  are  not  quite 
certain  about  it.  Thus  they  say  that  sexual  inter- 
course is  a  necessity,  and  at  the  same  time  they  cau- 
tion us  against  telling  our  patients  this  fact.  It  is  for 
this  reason  that  I  have  at  the  cotnmencement  of  this 
chapter  stated  the  issue  fairly  and  squarely.  I  said 
there,  and  T  repeat  it  here,  that  if  sexual  intercourse 
is  a  necessity,  it  ought  not  only  be  allowed,  but  en- 
couraged ;  also,  if  continence  is  prejudicial  to  health, 
it  should  be  discouraged,  no  matter  what  religion  or 
morality  says. 

The  second  important  fact  that  strikes  one  is.  that 
these  authorities  consider  that  the  only  alternative  to 
sexual  intercourse  is  masturbation,  or,  in  other 
words,  that  if  a  healthy  adult  does  not  indulge  in 
sexual  intercourse  he  is  bound  to  masturbate.  There 
never  was  a  graver  scientific  error  than  this.  ^^  hile 
it  is  admitted  that  a  very  large  number  of  boys  and 
young  men  masturbate,  it  is  absolutely  denied  that 
masturbation  is  in  any  way  a  physical  necessity  or 
alternative  to  sexual  intercourse.    ]Masturbation  is 


generally  acquired  at  puberty,  following  the  awak- 
ening of  the  sexual  sense,  but  it  is  also  exceedingly 
common  in  very  young  boys  and  even  infants,  long 
before  the  sexual  sense  is  developed.  As  a  matter 
of  fact,  in  a  large  percentage  of  cases  the  habit  is 
dropped  before  sexual  intercourse  is  commenced.  I 
have  also  found  the  habit  continued  in  married  men 
while  indulging  in  regular  sexual  intercourse. 

While  admitting  that  masturbation  docs  cause  for 
the  time  being  pronounced  nervous  symptoms,  such 
as  dreaminess  instead  of  being  wide  a\yake,  also 
readiness  to  submit  to  insult  rather  than  fight,  etc., 
etc.,  and  even  if  it  were  true  that  some  young  men 
who  do  not  indulge  in  sexual  intercourse  mastur- 
bate, I  would  still  unhesitatingly  say,  better  ten 
years  of  masturbation  than  one  year  of  gonorrhoea. 
There  is  not  the  slightest  shadow  of  a  proof  that 
masturbation  ever  produced  insanity,  loss  of  mem- 
ory, or  even  permanent  neurasthenia.    While,  as 
before  stated,  masturbation  may  produce  various 
nerA-ous  phenomena,  it  has  been  the  author's  experi- 
ence that  in  practically  every  case  these  symptoms 
were  only  temporary,  and  no  matter  how  long  they 
had  existed  or  how  long  masturbation  had  been 
practised,  all  the  symptoms  promptly  disappeared 
as  soon  as  treatment  was  instituted  and  the  habit 
dropped.    Again,  when  we  consider  that  the  vast 
majority  of  adults  have  at  one  time  or  another  mas- 
turbated, we  must  not  be  surprised  that  also  among 
the  insane  we  get  a  history  of  masturbation  in  quite 
a  good  many  cases.    Alasturbation  does  hardly  more 
harm  than  would  sexual  intercourse  were  it  in- 
dulged in  as  often.    If  persons  were  to  indulge  in 
sexual  intercourse  every  day,  and  sometimes  two, 
three,  or  more  times  a  day,  their  nervous  system 
would  be  temporarily  impaired  about  as  much  as 
in  the  chronic  masturbator.     Alasturbation  is,  of 
course,  exceedingly  harmful  in  young  children,  but 
so  would  also  sexual  intercourse  be  at  that  age.  Any 
impairment  of  the  nervous  system  due  to  masturba- 
tion is  only  temporary  and  disappears  as  soon  as 
the  habit  is  given  up.     To  further  carry  the  simile 
between  masturbation  and  gonorrhoea,  we  must  bear 
in  mind  that  Bangs  has  shown  that  masturbation, 
even  if  indulged  in  for  years,  can  be  permanently 
cured  by  massage  of  the  prostate,  deep  urethral  in- 
jections of  silver  nitrate,  and  avoidance  of  certain 
articles  of  diet  (tea,  coffee,  eggs,  and  alcoholics), 
whereas  gonorrhoea  if  neglected  is  one  of  the  most 
obstinate  of  diseases  and  often  does  produce  perma- 
nent incurable  conditions.    To  sum  up,  then,  the 
whole  matter,  I  would  say  that  masturbation  is  not 
at  all  a  physical  necessity  or  substitute  for  sexual 
intercourse  in  the  chaste,  but  even  if  it  were,  it  is 
not  nearly  as  great  an  evil  as  gonorrhoea  or  syphi- 
lis and  can  be  rapidly  and  permanently  cured. 

I  will  quote  just  one  more  authority  who  holds 
the  extreme  view  that  sexual  intercourse  is  neces- 
sary to  physiological  well  being. 

Von  Schrenck-Xotzing  (19),  page  30,  says: 
"Likewise  in  man  enforced  abstinence  may  endanger 
the  freedom  of  the  will  and  lead  to  perversity  of  the 
sexual  act."  Again  on  page  39  he  says :  "The  best 
cure  for  onanism  and  other  manifestations  of  sexual 
hypersesthesia — with  few  exceptions  there  can  be 
no  doubt  upon  that  point — lies  in  regular  sexual 


28o 


HUHNER:  GONORRHCEA. 


[New  York 
Medical  Journal. 


intercourse."  And  on  page  40:  "Therefore,  the 
chaste  youth  should  exercise  sexual  abstinence  as 
long  as  he  is  able  to  restrain  the  instinct  without 
injury  to  his  health.  Should  he  be  in  danger  owing 
to  increasing  strength  of  his  sexual  impulse,  of  onan- 
ism, of  falling  a  victim  to  satyriasis  or  perverse 
sexual  indulgence,  then  it  becomes  the  duty  of  his 
teacher  and  his  physician  to  cause  indulgence  in 
coitus  and,  too,  to  acquaint  the  neophyte  with  pre- 
cautionary measures  which  will  guard  against  ex- 
cesses, infection,  and  the  procreation  of  illegitimate 
ofYspring.'** 

The  views  here  expressed  are  so  decided  that  they 
cannot  be  left  unnoticed,  and  it  behooves  us  to  ex- 
amine them  closely. 

The  theory  that  abstinence  causes  satyriasis  or 
other  sexual  perversions  is  analogous  to  the  theory 
that  .=exual  intercourse  is  a  physical  necessity.  Af- 
ter most  carefully  studying  this  very  important 
question,  I  do  not  believe  that  sexual  perversion 
any  more  than  insanity  is  caused  by  abstinence,  but 
rather  that  abstinence  is  but  one  of  the  many  symp- 
toms of  sexual  perversions.  The  fact  that  a  sexual  per- 
vert who  satisfies  his  sexual  cravings  through  vari- 
ous disgusting  means  is  abstinent  from  regular  sexual 
intercourse  does  not  say  that  because  he  is  abstinent, 
therefore,  he  is  led  into  sexual  perversity.  His  mind 
is  so  constituted  that  he  simply  prefers  this  method 
to  the  other.  If  one  follows  up  the  history  of  these 
sexual  perverts  he  would  be  struck  by  the  fact  that 
in  not  a  few  instances  these  pervert  tendencies 
started  quite  early  in  life,  even  before  puberty,  when 
surely  abstinence  could  not  have  been  the  cause  of 
them.  So  also  have  I  seen  satyriasis  in  persons  who 
at  the  same  time  practise  and  always  have  practised 
regular  sexual  intercourse.  The  entire  question  of 
sexual  perversion,  while  very  interesting,  would  lc?d 
me  far  beyond  the  limits  of  this  paper,  and  only 
the  results  of  my  careful  study  of  the  subject  have 
been  alluded  to. 

The  next  proposition  is  even  more  startling:  "The 
best  cure  for  onanism  and  other  manifestations  of 
sexual  hypersesthesia — with  few  exceptions — lies  in 
regular  sexual  intercourse."  It  is  a  pity  that  the 
author  does  not  give  us  the  "few  exceptions,"  for 
then  it  might  be  seen  that  they  embrace  practically 
the  entire  subject.  As  is  well  known,  onanism  gen- 
erally starts  around  puberty  and  continues  for  a 
few  years  .thereafter.  Docs  this  authority  mean  to 
recommend  sexual  intercourse  at  the  ages  of  twelve, 
thirteen,  fourteen,  or  fifteen,  in  order  to  cure  the 
habit?  If  not,  then  one  of  his  "few  exceptions"  cuts 
off  certainly  over  eighty  per  cent,  of  the  cases,  for 
the  largest  portion  of  our  cases  start  and  continue 
during  these  ages. 

Ikit  let  us  say  that  the  author  only  refers  to 
adults.  Even  if  there  were  no  other  remedy  for 
rexual  hyperzesthesia  than  sexual  intercourse,  I 
\.ould  very  much  hesitate  to  prescribe  a  remedy 
which  carries  with  it  the  almost  certain  risk  of 
gonorrhoea  or  syphilis.  Surely  the  "cure"  is  much 
worse  than  the  disease.  But,  happily  for  mankind, 
there  is  another  safe  and  certain  remedy.  Bangs, 
of  Xew  York,  has  shown  that  with  every  irritation 
of  the  urethra  there  is  a  corresponding  irritation  of 
a  certain  portion  of  the  brain,  which  irritation  ex- 
cites the  person  to  increased  sexual  desire ;  this  in- 


creased sexual  desire  leads  to  onanism  and  further 
increases  the  local  hyperjesthesia.  A  vicious  circle 
is  thus  formed.  He  has  shown  that  all  that  is  neces- 
sary is  to  cure  the  original  irritation  or  hypergesthe- 
sia  in  the  prostatic  urethra,  which  can  be  most  cer- 
tainly done  by  massage  of  the  prostate  and  injec- 
tions of  increasing  strength  of  silver  nitrate  into  the 
prostatic  urethra  with  the  Bangs  sound  syringe, 
regulating  the  diet  (vide  supra),  and  the  irritation 
in  the  brain  will  get  well ;  as  soon  as  the  local  irri- 
tation is  removed  there  will  then  no  longer  be  that 
intense  desire  for  sexual  intercourse ;  in  other  words, 
the  patient  will  be  restored  to  a  perfectly  normal 
condition. 

Let  us  now  consider  the  last  proposition,  which, 
to  state  it  briefly,  in  order  to  prevent  repetition,  is 
that  the  chaste  youth  should  refrain  from  sexual  in- 
tercourse as  long  as  he  can,  but  as  soon  as  such 
abstinence  seems  to  interfere  with  his  health,  his 
physician  is  to  advise  sexual  connection,  telling  him 
how  to  avoid  venereal  disease  and  illegitimate  off- 
spring. 

The  first  part  of  this  paragraph  peculiarly  illus- 
trates the  hemming  and  hawingaboutthe  subject  that 
I  have  previously  alluded  to.  It  is  simply  a  most 
cowardly  throwing  off  of  the  responsibility  by  the 
physician  on  to  the  patient.  It  may  be  good  poli- 
tics, but  it  is  neither  scientific  nor  in  accord  with 
the  ethical  obligation  that  the  physician  owes  to  his 
patient.  To  tell  a  young  man  "don't  have  connec- 
tion, but  when  you  can  no  longer  refrain  from  it, 
have  it,"  is  simply  to  give  a  silent  consent  to  it,  for 
every  young  man  will  quickly  come  back  and  say 
that  he  cannot  refrain  from  it.  If  he  later  presents 
himself  with  a  venereal  disease,  the  doctor  will  say: 
"I  told  you  so  ;  I  told  you  not  to  have  connection, 
but  you  would  not  listen  to  me." 

But  the  advice  (according  to  the  author)  does 
not  end  here.  The  physician  is  to  instruct  the 
youth  how  to  avoid  venereal  disease  and  illegiti- 
mate offspring.  The  author  very  wisely  omits  to 
tell  us  what  those  instructions  consist  in.  •  A  state- 
ment like  this  may  possibly  be  swallowed  by  the 
general  public,  but  to  the  physician,  especially  one 
with  experience  in  genitourinary  work,  it  is  the 
rankest  hypocrisy.  If  the  physician,  with  the 
proper  light  and  instruments,  the  woman  in  the 
proper  position,  with  the  aid  of  the  speculum,  mi- 
croscope, and  culture  tube,  cannot  always,  or  even 
generally,  be  positive  that  his  patient  is  free  from 
infection,  how  in  the  name  of  all  the  gods  at  once 
can  the  young  man,  without  this  knowledge  and  fa- 
cilities, tell  whether  the  woman  is  safe  or  not  ?  It  can- 
not be  too  firinly  impressed  upon  the  public  that  a 
man  does  not  generally  become  infected  by  a  woman 
with  an  acute  gonorrhoea ;  it  is  mostl\-  from  women 
with  chronic  gonorrhoea,  with  little  or  no  visible 
pus,  that  most  gonorrhreas  are  contracted.  It  is 
just  at  this  stage  that  the  physician  needs  all  mod- 
ern resources  to  determine  whether  the  case  is  in- 
fectious or  not,  and  it  is  ridiculous  to  expect  the  lay 
young  man  to  make  the  diagnosis.  The  second 
part  of  the  proposition,  i.  e,,  the  prevention  of 
illegitimate  oft'spring,  leads  us  into  the  realms  of 
criminality,  and  such  a  statement  ought  not  to  be 
tolerated  in  any  legitimate  monograph. 

I  have  entered  somewhat  in  detail  in  the  discus- 


February  *>,  1909.  J 


HUHXER:  GONORRHCEA. 


sion  of  this  theory  of  von  Schrenck-Xotzing,  be- 
cause it  is  a  typical  illustration  of  the  arguments 
advanced  by  those  who  hold  this  theory. 

I  have  thus  far  discussed  the  question  from  the 
point  of  view  of  the  anatomist  and  physiologist.  I 
will  now  briefly  discuss  it  from  the  neurologist's 
viewpoint.  In  so  doing  I  cannot  do  better  than 
quote  from  one  of  the  greatest  neurologists  in  his- 
tory. In  the  Lettsomian  Lectures  on  Syphilis  and 
the  Nervous  System.  Professor  Gowers  (20)  says: 
"With  all  the  force  that  any  knowledge  I  possess  can 
give,  and  with  any  authority  I  may  have,  I  assert 
as  the  result  of  long  observation  and  consideration 
of  facts  of  every  kind — that  no  man  ever  yet  was  in 
the  slightest  degree  or  way  the  better  for  inconti- 
nence— and  I  am  sure  further^  that  no  man  was 
ever  yet  anything  but  the  better  for  perfect  conti- 
nence. My  warning  is  let  us  beware  lest  we  give 
even  a  silent  sanction  to  that  against  which  I  am  sure 
we  should  resolutely  set  our  face  and  raise  our 
voice."  Surely,  such  an  assurance  from  the  great 
neurologist  ought  forever  to  allay  the  fears  of  those 
who  fear  wreck  of  the  nervous  system,  submersion 
of  the  freedom  of  will,  insanity,  sexual  neuroses, 
and  degenerations  as  the  result  of  continence. 

Having  shown  on  anatomical,  physiological,  and 
psychological  grounds  that  sexual  intercourse  is  not 
a  necessity  to  normal  health.  I  will  now  show  what 
I  started  out  to  prove — that  the  medical  profession, 
and  by  that  I  only  include  the  ethical  members 
thereof,  are  directly  responsible  for  not  a  small 
share  of  the  spread  of  venereal  disease. 

I  have  already  referred  to  the  loose  method  many 
physicians  have  in  speaking  to  young  men  with 
gonorrhoea.  But  there  are  others  who  even  go 
further.  I  have  in  mind  the  case  of  a  young  man 
who  consulted  me  for  masturbation  and  the  advisa- 
bility of  indulging  in  sexual  intercourse.  Of  course. 
I  advised  against  it.  Later  he  informed  me  that 
he  had  consulted  a  physician  who  has  the  reputa- 
tion, and  I  may  say  deservedly  so,  of  being  one  of 
the  greatest  genitourinary  specialists  in  this  coun- 
try ;  this  physician  strongly  advised  him  to  indulge 
in  sexual  intercourse,  and  that  if  he  only  consulted 
his  physician  early  enough  if  anything  happens  to 
him.  nothing  serious  could  develop.  So  long  as  we 
have  physicians  who  give  such  advice  we  cannot 
expect  a  decrease  in  venereal  disease. 

There  is  still  another  class  of  physicians  against 
whose  advice  and  teachings  I  would  most  strenu- 
ously raise  my  voice.  There  are  some  who  sug- 
gest, and  it  has  also  been  suggested  in  certain  other- 
wise excellent  works  on  venereal  diseases,  that  be- 
fore a  patient  with  a  gonorrhoea  is  pronounced 
cured  he  should  be  ordered  to  have  connection,  pro- 
tected by  a  condom,  and  then  be  examined. 

In  the  first  place,  for  reasons  which  I  cannot  now 
go  into,  I  do  not  think  this  an  absolutely  reliable 
test,  and  in  the  second  place,  I  have  given  in  the 
earlier  pages  of  this  paper  a  safer,  easier,  and  re- 
liable test. 

But  even  if  this  test  just  given  were  absolutely 
reliable,  and  even  if  it  were  the  only  test  of  the 
cure  of  a  gonorrhoea,  I  do  not  believe  that  the  game 
is  worth  the  candle,  and  for  the  following  reasons : 

I  desire  right  here  to  call  attention  to  a  most 


peculiar  psychological  influence  that  gonorrhoea 
exerts  on  most  people.  I  was  for  many  years  chief 
of  clinic  of  the  genitourinary  department  of  a  dis- 
pensar}-  visited  by  about  the  lowest  grade  of  pa- 
tients imaginable.  Most  of  them  were  chronic  alco- 
holics who  were  only  sober  when  penniless.  They 
were  either  drunk  or  hungry.  As  soon  as  they 
made  some  money  the}-  generally  went  out  on  an 
alcoholic  or  sexual  debauch.  And  yet  I  have  seen 
these  very  people,  who  ordinarily  could  not  abstain 
from  drink,  not  touch  a  drop  of  alcohol  in  any  form 
for  weeks  at  a  time  while  under  treatment  for 
gonorrhoea,  nor  have  sexual  connection.  That  this 
psychological  influence  is  not  limited  to  the  lower 
grades  of  society,  I  will  mention  onlv  a  single  in- 
stance of  the  same  fact  in  a  private  patient  of  my 
own.  He  was  a  young  neurasthenic,  aged  thirty 
years,  who  during  six  months^  treatment  of  an  obsti- 
nate chronic  gonorrhoea,  abstained  from  sexual  in- 
tercourse during  this  entire  period,  whereas  previ- 
ously he  could  not  stay  away  from  women  for  two 
consecutive  weeks. 

I  think  that  we  ought  to  take  advantage  of  this 
]3sychological  influence.  If  ever  there  was  a  time  to 
reclaim  the  debauchee,  the  youth  who  has  sowed 
his  wild  oats,  it  is  just  after  an  attack  of  gonor- 
rhoea. After  the  youth  has  become  infected  by  his 
"sure  thing,"  after  he  has  passed  through  the  trou- 
bles and  inconveniences  attached  to  the  treatment 
*  of  the  disease,  aided  by  this  peculiar  psychological 
temperament,  then  is  the  time  to  again  impress  upon 
his  mind  the  danger  he  is  running.  Even  granted 
that  coitus  ad  condom  is  free  from  danger,  the  pro- 
cedure leads  back  the  youth  to  that  dangerous  path 
against  which  we  ought  to  warn  him.  It  reawakens 
his  sexual  appetite  and  it  will  not  be  long  before 
he  will  more  frequently  indulge  in  sexual  relations 
and  throw  awa}-  his  condom.  For  a  physician  at 
this  time  to  neglect  sounding  a  word  of  warning  as 
to  his  future  is  a  grave  sin  of  omission,  unworthy 
of  the  high  duties  the  physician  has  obligated  him- 
self to  perform ;  for  him,  merely  for  the  sake  of 
diagnosis,  to  advise  his  patient  to  have  sexual  inter- 
course, is,  to  my  mind,  to  place  himseff  on  a  lower 
level  than  the  professional  prostitute.  It  may  be  a 
sad  sight  to  see  on  certain  of  our  public  highways 
after  midnight,  women  of  the  town  enticing  young 
men  to  wicked  ways,  but  the  young  man  who  sub- 
mits does  so  to  a  certain  extent  at  least  with  his 
eyes  open ;  he  knows  he  is  doing  something  wrong ; 
he  also  knows  that  these  women  have  absolutely  no 
interest  in  him  except  to  get  his  money.  But  to 
my  mind  it  is  a  far  sadder  sight  to  see  those  more 
dangerous  persons,  some  members  of  our  own  med- 
ical profession,  to  whom  the  young  man  comes  for 
advice  and  counsel,  and  in  whom  he  has  placed  his 
confidence,  direct  him  into  the  same  path  that  the 
prostitute  does.  So  long  as  physicians  continue  to 
recommend  such  procedure,  so  long  will  venereal 
disease  continue  to  be  on  the  increase. 

In  conclusion,  I  wish  to  emphasize  that  the 
prophylaxis  of  venereal  disease  belongs  just  as  mAich 
to  the  physician  as  do  the  aetiology,  the  diagnosis, 
and  treatment  thereof.  It  has  too  long  been  "left  to^ 
the  moralist,  the  clergyman,  and  the  reformer.  As. 
soon  as  we  take  up  the  question  from  a  purely  med- 


282 


I-ISKE:  CRIPPLED  CHILDREN. 


[New  York 
Medical  Journal 


ical  point  of  view,  we  may  hope  to  have  it  as  much 
under  control  as  the  prophj'laxis  of  other  infectious 
diseases. 

Bibliography. 

1.  Landois.    Physiology,  1904. 

2.  Kirke.    Physiology,  1904. 

3.  Bnibaker.    Textbook  of  Physiology,  1901. 

4.  E.  A.  Scliafler.    Textbook  of  Physiology,  1900. 
5-    Raymond.    Human  Physiology,  1901. 

6.  Ott.    Textbook  of  Physiology,  1904. 

7.  Foster.    Physiology,  1898. 

8.  Hall.    Physiology,  1900. 

■9.    Stirling.    Physiology,  1895. 

10.  Johnson.    Physiology  of  the  Senses. 

11.  Hare.    Physiology,  1895. 

12.  Austin  Flint,  Jr.    Physiology  of  Man,  1875. 

13.  Bryant.  Surgery. 

14.  James  Foster  Scott.    Sexual  Instinct,  p.  39. 

15.  William  Acton.  The  Functions  and  Disorders  of  the 
Reproductive  Organs,  etc.,  4th  edition,  p.  97. 

16.  Lionel  S.  Beale.  Our  Morality  and  the  Moral  Ques- 
tion, etc. 

17.  Sir  James  Paget.    Sexual  Hypochondriasis. 

18.  G.  Frank  Lydston.    Venereal  and  Sexual  Diseases. 

19.  A.  von  Schrenck-Notzing.  Therapeutic  Suggestion 
in  Psychopathia  Sexualis,  etc. 

20.  Gowers.  Lectures  on  Syphilis  and  the  Nervous  Sys- 
tem.   Lettsonnian  Lectures,  Lancet,  1889,  Lecture  HI. 

64  East  Fifty-eighth  Street. 


THE  CARE  OF  THE  CRIPPLED  CHILDREN  OF 
THE  POOR  BY  THE  STATE  OF  NEW  YORK. 

Bv  J.\.\1ES   PORTEU    I'lSKE,  M.  D., 

New  York, 

State  Manager  of  the  Hospital  for  Criiipled  and  Deformed  Children 
at  West  Haverstraw:  Late  President  of  the  Guild  for  Crippled 
Children;  Formerly  Orthopedic  Surgeon  at  the  New  York 
Postgraduate    Hospital^   Cornell    University  Medical 
College,  and  the  Roosevelt  Hospital. 

Under  any  circumstances  a  crippled  child  is  a 
gTcat  care,  and  there  are  special  problems  both 
physical  and  mental  in  each  case.  About  sixty  per 
cent,  of  all  crippled  children  are  suffering  from 
some  form  of  bone  or  joint  tuberculosis.  A  large 
number  of  the  remainder  are  suffering  from  some 
form  of  paralysis.  This  disability,  always  pro- 
tracted, requiring  years  of  orthopaedic  treatment, 
is  a  great  drain  on  the  strength  and  resources  of 
the  parents,  and  in  the  families  of  the  poor  not  in- 
frequently the  cause  of  privation.  Many  of  these 
children  even  when  convalescent  cannot  attend  the 
public  schools,  and  so  in  every  large  community 
we  have  thi.s.  special  problem,  the  education  of  its 
crippled  children.  New  York  city  has  attempted 
to  care  for  a  small  army  of  crippled  children 
through  special  hospitals  and  clinics  where  these 
•children  receive  the  necessary  treatment,  and 
through  the  establishment  of  special  schools,  where 
these  children  are  given  a  simple  education  com- 
bined with  niaiuial  training.  Many  of  these  schools 
have  wagonettes  to  convey  the  children  to  and  from 
the  schools,  and  several  provide  a  hot  dinner  in 
the  middle  of  the  day.  Manual  training  is  the 
feature  of  this  work,  and  no  time  is  lost  in  teaching 
these  unfortunate  children  to  learn  to  use  their 
hands.  In  the  summer  time  an  attempt  is  made  to 
send  the.se  children  away  to  the  country,  and  a  good 
number  are  kept  at  the  various  country  homes  dur- 
ing tbic  entire  summer. 

A  few  years  ago  Xew  York  .Slate  established  a 
hospital  for  crippled  children.    This  institution,  the 


New  York  State  Hospital  for  Crippled  and  De- 
formed Children,  is  now  located  at  West  Haver- 
straw, thirty-three  miles  north  of  this  city,  and  for 
some  time  has  cared  for  forty-seven  children  com- 
ing from  various  parts  of  the  State.  The  hospital 
building  is  an  old,  comfortable  residence  with  a  fine 
view  of  the  Hudson  River.  A  resident  physician 
is  in  immediate  charge  of  the  inmates,  and  one 
teacher  is  provided.  There  is  no  manual  training 
teacher.  The  hospital  and  grounds  look  pleasant, 
but  there  are  swamps  m  the  neighborhood,  and  there 
have  been  a  number  of  cases  of  malaria  among 
the  inmates.  Malaria  has  been  prevalent  in  this 
district,  and  the  malarial  mosquito  probably  breeds 
in  the  neighboring  swamps,  as  well  as  in  the  Haver- 
straw brickpits. 

The  two  great  problems  in  this  institution  are  the 
same  as  elsewhere:  i,  The  physical  welfare  of  these 
crippled  children ;  and,  2,  their  educational  needs. 

The  physical  welfare  of  these  children  requires 
that  they  be  housed  in  a  district  free  from  malaria. 
As  many  are  tuberculous,  we  should  prefer  either 
sea  air  as  at  Sea  Breeze,  or  mountain  air.  Certainly 
the  special  problems  cannot  be  met  in  such  an  inac- 
cessible place  as  West  Haverstraw  with  its  very 
poor  train  service,  and  we  believe  that  if  the  State 
intends  to  continue  this  work,  it  should  be  done  in 
a  place  quite  accessible  to  a  large  city,  so  as  to  be 
of  easy  access  to  the  specialists  so  necessary  in  this 
work,  as  well  as  easy  of  inspection.  From  a  physi- 
cian's point  of  view,  at  present  this  "material  is 
lost,"  and  aside  from  promoting  the  welfare  of  the 
patients  this  institution  serves  no  good  purpose. 
How  different  it  would  be  if  this  hospital  could  be 
moved  to  some  pleasant  and  healthy  site  near 
.•\lbany.  This  location  would  be  more  central  to 
the  State,  of  easy  access  to  the  specialists  of 
Albany,  and  the  students  of  the  Albany  Medical 
College  at  stated  times  could  visit  the  institution 
and  study  the  progress  of  the  patients.  Here  near 
Albany  this  hospital  would  serve  as  a  model,  being 
easy  of  inspection,  for  this  special  work,  not  only 
in  this  State,  but  throughout  the  country  to  philan- 
thropists and  social  workers.  Manual  training 
would,  of  course,  be  introduced,  and  it  would  be 
wise  to  have  the  educational  features  supervised  by 
the  State  Education  Department. 

It  does  not  appear  that  in  selecting  West  Haver- 
straw as  a  site  the  needs  of  the  State  were  con- 
sidered, or  that  the  special  needs  of  the  children 
have  been  met.  Most  of  the  inmates  brought  from 
New  York  city  can  be  better  cared  for  there,  when 
we  recognize  the  scope  of  the  work  in  that  city, 
which  includes  free  hospital  treatment,  educational 
features,  a  good  part  of  which  is  manual  training, 
special  meals  and  home  visits,  and  the  placing  of 
these  children  in  the  country  during  the  summer. 
It  is  a  great  advantage  in  the  long  run  for  the 
child  to  stay  at  home,  rather  than  enter  an  institu- 
tion and  acquire  the  taint  of  institution  life.  Some 
of  these  cases,  however,  do  require  removal  from 
the  city,  and  to  meet  this  need  we  have  Sea  Breeze 
at  Coney  Island,  the  country  branch  of  the  Ortho- 
paedic Hospital  at  White  Plains,  the  country  branch 
of  St.  Mary's  Hosi)ital,  and  the  Campbell  Cottage 
at  White  Plains  under  the  New  York  Hospital. 
There  are  many  other  out  of  town  stations  open  a 


Tetruary  6,  1909. J 


OUR  READERS'  DISCUSSIONS. 


283 


part  or  the  whole  of  the  year,  all  accessible  to  New 
York  city. 

At  West  Haverstraw,  so  inaccessible,  one  hesi- 
tates before  subscribing^  to  a  proposition  to  expend 
money  and  enlarge.  The  State  cannot  possibly  care 
for  all  the  crippled  children  of  the  poor,  so  I  advo- 
cate, if  the  State  is  to  stay  in  the  business,  the  estab- 
lishing of  a  model  hospital  and  school  accessible  to 
some  large  city,  where  it  will  be  easy  of  inspection, 
to  serve  as  a  model  for  this  work  to  be  carried  on 
elsewhere.  Such  an  institution  should  care  special- 
ly for  the  crippled  children  in  the  rural  districts. 
Scattered  throughout  this  State  in  the  rural  dis- 
tricts are  many  cases  of  deforming  disease  in  chil- 
dren, some  tuijerculous  in  nature,  others  paralytic. 
]Most  of  these  patients  are  far  removed  from  hospi- 
tals where  orthopjedic  work  is  done,  and  far  from 
the  special  schools  with  the  manual  training  fea- 
tures. 

Given  these  conditions  in  New  York  State  we 
have  here  a  rare  opportunity  for  private  philan- 
thropy combined  with  organized  charity.  An  at- 
tempt should  be  made  to  care  for  all  crippled  chil- 
dren throughout  the  State  who  require  aid.  Each 
community  should  be  encouraged  to  care  for  its  own. 
An  association  incorporated  to  do  this  work  through- 
out this  State  would  find  plenty  to  do.  Receiving 
reports  of  crippled  children,  inspections,  and  exam- 
inations of  the  applicants,  the  placing  of  the  child 
in  the  nearest  proper  hospital  or  home,  meeting  the 
cost  of  dressings  and  braces,  paying  the  necessary 
traveling  expenses,  and  establishing  where  necessary 
proper  country  "homes  on  the  pavilion  plan  for  the 
out  of  door  treatment,  seem  to  me  to  constitute 
sufficient  reason  for  the  establishment  of  a  Society 
for  the  Aid  of  Crippled  Children  in  the  State  of 
New  York,  preferably  to  be  maintained  in  coopera- 
tion with  organized  charity.  Private  philanthropy 
can  do  this  work  better  than  the  State,  and  can  do 
it  at  less  expense. 

As  for  the  cities,  they  should  be  encouraged  to 
care  for  their  own  crippled  children,  just  as  we  are 
attempting  to  do  in  New  York,  and  at  present  any 
attempt  on  the  part  of  the  State  to  care  for  the  crip- 
pled children  in  this  city  would  be  a  disturbing  fac- 
tor. 

76  West  Eighty-sixth  Street, 
 <^  


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
■decided  upon,  the  further  questions  are  as  follows: 

LXXXH.—Hozv  do  you  treat  chronic  lead  poisoning? 
(Closed  January  15,  1909.) 

LXXXIII. — How  do  you  treat  acute  dysentery?  (An- 
swers due  not  later  than  February  15,  1909.) 

LXXXIV. — Hew  do  you  use  alcohol  therapeutically? 
(Answers  due  not  later  than  March  15,  1909J 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prise  of  5'5-  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  REQUiRZDj  that  the  answers  be  short;  if  practica- 
ble no  one  answer  to  contain  more  than  six  hundred 
words. 


All  persons  will  be  entitled  to  compete  for  the  prise, 
whether  subscribers  or  not.  This  prize  will  not  be  awarded 
to  any  one_  person  more  than  once  within  one  year.  Every 
answer  must  be  accompanied  by  the  writer's  full  name  and 
address,  both  of  'which  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal. 
Our  re.\ders  are  asked  to  suggest  topics  for  discussion. 

The  prize  of  $25  for  the  best  essay  submitted  in  answer 
to  question  LXXXI  has  been  awarded  to  Dr.  R.  T.  Sutton, 
of  Kansas  City,  Mo.,  whose  article  appeared  on  page  22^. 


PRIZE  QUESTION  LXXXI. 
THE  TREATMENT  OF  CHRONIC  ECZEMA. 
(Continued  front  page  22/.) 

Dr.  John  B.  Talmage,  of  New  York,  says: 

The  treatment  of  chronic  eczema  resolves  into 
constitutional  and  external.  This  latter  has  certain 
general  aspects,  but  is  modified  according  to  the 
locality  of  the  lesion,  i.  e.,  regional  treatment. 

Constitutional  Treatment. — Diet  consists  of  meat 
(beef,  mutton,  chicken)  once  a  day,  at  midday  meal. 
Breakfast  and  supper  simple,  crackers  or  bread  and 
milk ;  well  cooked  cereals  eaten  without  sugar ;  fish ; 
an  occasional  egg  in  the  morning,  but  not  every 
day ;  butter  and  vegetables  freely ;  fruits  dried  or 
stewed,  freely ;  coffee,  one  cup  at  breakfast ;  water 
freely,  both  at  and  between  meals.  Abstain  from 
pies,  cake,  confections,  and  alcoholic  beverages. 

Exercise  in  open  air,  and  good  personal  hygiene 
are  necessary.  This  diet  together  with  exercises, 
will,  as  a  rule,  overcome  constipation,  if  not  laxa- 
tives must  be  used. 

Constitutional  diseases  such  as  anjemia,  stru- 
mous habit,  nervous  exhaustion,  dyspepsia,  gout, 
rheumatism,  and  diabetes  must  be  recognized  and 
properly  treated.  Nearly  all  patients  are  benefited 
by  a  prolonged  course  of  potassium  acetate,  citrate, 
and  bicarbonate  in  water  taken  in  moderate  doses 
three  times  a  day. 

The  two  cardinal  principles  of  local  treatment  are : 
Stimulate  the  chronic  eczema,  and  protect  the  part 
from  external  irritation,  especially  water. 

Regional  Treatment-— \Jni\ersa\  Eczema:  Get  at 
the  underlying  cause  first.  Give  warm  alkaline 
baths  (sodium  bicarbonate  54  lb.  in  ^2  bath  tub  of 
water) ,  once  a  day,  duration  fifteen  to  twenty  min- 
utes. Dry  by  gently  patting  with  hot  towel.  Mas- 
sage into  skin  carron  oil,  or  cotton  seed  oil  with 
one-quarter  per  cent,  carbolic  acid.  Wear  cotton 
underclothing,  and  when  the  eczema  begin  to  yield 
stop  the  oil,  and  use  in  its  place  Lassar's  paste  with 
salic3dic  acid,  grains  XV  to  the  ounce. 

Eczema  of  Hands  and  Feet. — This  is  the  same 
with  the  exception  of  applying  rubber  to  the  feet. 
Soften  the  skin  by  the  constant  wearing  of  rubber 
gloves.  Keep  away  from  water.  Remove  scales 
by  scrubbing  with  tincture  saponis  viridis.  Stimu- 
late by  tar  ointment,  twenty-five  to  fifty  per  cent. 
For  the  cracks  and  fissures  use  silver  nitrate  solu- 
tion, ten  to  twenty  per  cent.  When  a  good  reac- 
tion has  been  aroused,  stop  the  tar  and  rub  in  twice 
a  day  oleate  of  mercury.  If,  when  first  seen  the 
disease  is  just  merging  into  a  chronic  state,  the  dia- 
chylon ointment  of  Hebra  is  effective.  Painting 
with  silver  nitrate  solution,  ten  per  cent,  up  to  a 
saturated  solution,  is  very  effective  in  relieving  the 
severe  pain  which  sometimes  accompanies  this  le- 


284 


OUR  READERS'  'DISCUSSIONS. 


[New  York 
.Medical  Journal. 


sion.  If  the  disease  is  due  to  an  occupation,  this 
must  be  stopped,  for  some  time  at  least,  to  insure  a 
cure. 

Eczema  of  the  Nails  and  Nail  Bed. — Constantly 
wear  rubber  finger  cots ;  to  soften  the  diseased  area, 
apply  silver  nitrate  solution,  ten  to  fifteen  grains  to 
the  ounce  daily. 

Eczema  of  the  Head. — Shampoo  the  head  vigor- 
ously every  three  nights  with  tinctura  saponis  viridis 
and  hot  water.  Dry  with  hot  towel.  Massage  the 
.scalp  with  pulv.  sulph.,  drachm  one  to  the  ounce  of 
olive  oil,  every  night  and  morning  until  the  scalp 
becomes  soft  and  pliable,  then  change  to  oil  of  cade, 
15  drops  to  one  ounce  of  olive  oil,  and  as  the  treat- 
ment progresses  increase  the  strength  of  the  oil  of 
cade  gradually  to  2  drachms  in  the  same  amount  of 
oil.  Cut  the  hair  short  so  as  to  remove  vermin  and 
aid  in  the  application  of  the  medication.  A  rubber 
cap  is  a  good  agent  when  the  scalp  is  very  thick, 
hard,  and  cracked. 

Eczema  of  the  Beard. — Epilate  all  the  hair  over 
the  diseased  area.  If  the  area  is  pustular  Lassar's 
paste  with  salicylic  acid,  grains  15  to  the  ounce; 
if  dry  and  scaly  oleum  cadi ;  20  drops  to  i  drachm 
to  the  ounce  of  oHve  oil. 

Eczema  of  the  Ear. — Treat  any  discharge  of  the 
ear,  if  present.  Apply  to  the  canal  diachylon  oint- 
ment, one  part  in  two  parts  of  unguentum  aquae 
rosae.  Never  block  up  the  canal.  Protect  the  lobe 
from  the  discharge  by  applications  of  sweet  oil.  For 
the  lobe  of  the  ear  silver  nitrate  solution  ten  to  fif- 
teen grains  to  the  ounce  for  the  cracks  and  fissures. 
Remove  the  crusts  with  sweet  oil,  and  apply  Las- 
sar's paste  with  salicylic  acid  ten  to  fifteen  grains  to 
the  ounce,  over  the  diseased  areas.  Keep  the  lobe 
of  the  ear  and  side  of  the  head  separate  by  a  pledget 
of  cotton. 

Eczema  of  the  Eyelids. — Treat  the  accompanying 
conjunctivitis.  Anoint  lids  with  hydrarg.  oxid.  flav. 
one  per  cent,  in  petrolatum  every  night  and  morn- 
ing. Keep  the  edges  at  night  moist  with  petrolatum 
to  prevent  them  sticking  together,  and  epilate  the 
eyelashes  if  necessary. 

Eczma  of  the  Nose  and  Lip. — Cure  the  rhinitis, 
pull  out  the  hairs,  and  keep  the  diseased  area  always 
covered  with  a  ten  per  cent,  ammoniated  mercury 
ointment. 

Eczema  of  the  Legs. — Treat  the  ulcers  usually 
present.  Keep  the  legs  bound  in  a  snug  bandage  from 
the  base'  of  the  toes  to  the  knee,  and  keep  the  legs 
elevated  as  much  as  possible.  Paint  the  seat  of  the 
eczema  with  mcthvlene  blue,  aqueous  solution,  one 
])er  cent.,  every  other  day ;  or  rub  into  skin  salicy- 
lated  olive  oil,  two  to  five  per  cent.,  every  day. 

Eczema  of  the  Folds  of  the  Skin. — Apply  Las-, 
sar's  paste  with  salicylic  acid,  15  grains  to  the  ounce, 
every  night  and  morning,  and  keep  parts  bandaged 
lo  prevent  opposing  skin  surfaces  from  rubbing  each 
dther. 

Eczema  of  the  Nipples. — If  a  child  is  nursing  let 
it  use  a  shield,  being  very  careful  to  remove  all 
medication  used  before  each  nursing,  and  when  the 
child  is  through  carefully  dry  the  part  and  apply 
the  dressing  as  before.  Keep  a  pledget  of  absorlient 
cotton  over  the  nipple  to  prevent  any  milk  from 
dropping  upon  the  sore  areas.  Apply  silver  nitrate 
solution  five  lo  ten  per  cent,  to  the  cracks  and  fis- 


sures, and  either  ten  per  cent.  ungt.  hydrarg.  am- 
nion, or  diachylon  omtnient,  one  part ;  and  cold 
cream,  two  p^.rts,  to  the  areolae. 

Eczema  of  the  Genitals. — Treat  any  existing  dis- 
charge, diabetes,  syphilis,  etc.  Steam  parts  by  sit- 
ting over  a  commode  filled  with  boiling  water.  Add 
to  the  water  two  or  three  drachms  of  glycerite  of 
phenol,  and  as  soon  as  the  water  is  cool  enough  to 
bear,  sop  the  parts  gently  with  the  solution.  If  the 
skin  is  very  much  toughened,  constant  wearing  of  a 
rubber  tissue,  held  firmly  in  place  by  a  suspensory 
or  T  bandage,  will  soften  it.  Applications  of  silver 
nitrate  solution,  ten  per  cent.,  or  of  Lassar's  paste 
with  salicylic  acid,  grs.  xv  to  xx  to  the  ounce,  or 
ungt.  hydrarg.  ammon.,  ten  per  cent.,  are  very  ef- 
fective. 

Eczema  of  the  Anus  and  Gluteal  Region. — Limit 
exercise.  Use  cotton  underdrawers  next  to  skin, 
and  have  them  loose.  Keep  bowels  soft  and  evacua- 
tions easy  by  cascara  sagrada.  Relieve  liver  or  other 
congestion  if  it  is  present.  Cure  haemorrhoids,  fis- 
sures, and  fistulae  if  present.  Be  extremely  careful 
that  cleanliness  is  absolute.  Add  sodium  bicarbonate, 
oiii,  to  a  basin  of  warm  water  and  use  this  solution 
for  washing  parts.  Paint  parts  with  silver  nitrate 
solution,  ten  to  thirty  per  cent.,  or  apply  salicylic 
acid,  10  to  20  grains  to  the  ounce  of  collodion,  to 
which  a  little  ext.  cannab.  indie,  may  be  added  if 
pain  is  great.  Always  keep  buttocks  separated  by 
absorbent  cotton,  and  hold  the  dressing  in  place  by 
a  snug  T  bandage. 

Dr.  Franklin  C.  Clark,  of  Proiidence.  R.  /.,  re- 
marks: 

One  of  the  most  w-idely  spread  of  skin  diseases, 
and  the  most  resistent  to  medication,  whether  in  the 
acute  or  chronic  stage,  is  eczema.  But  in  the  latter 
form  of  it  we  note  a  periodicity  of  occurrence  which 
is  many  times  persistent  and  extremely  difficult  to 
ward  off ;  for  we  have  not  only  an  acute  stage  to 
treat,  but  a  constant  recurrence  of  attacks  of  greater 
or  less  severity.  The  object  of  all  medication  here 
is  therefore,  twofold :  To  cure  the  immediate  as  well 
as  to  prevent  every  subsequent  attack. 

Our  treatment  then  resolves  itself  into  two  kinds, 
namely,  constitutional  and  local.  Some  physicians 
emphasize  the  first,  while  others  would  have  it  that 
local  treatment  gives  the  only  satisfactory  results. 
But  neither  one  should  be  ignored. 

Among  the  constitutional  helps  should  be  noted 
attention  to  diet.  All  food  should  be  light  and  nour- 
ishing ;  fatty  and  highly  seasoned  foods  and  drinks 
avoided.  At  the  same  time  dietetic  idiosyncrasies 
should  be  ascertained  and  respected.  The  eating  of 
fish,  lobsters,  crabs,  and  all  forms  of  shellfish  are 
rank  poison  to  some  constitutions  and  often  aggra- 
vate the  disease,  if  not  induce  a  new  attack  of  it. 
All  drinks  should  be  cold ;  those  most  acceptable  are 
of  an  acid  character,  such  as  a  solution  of  cream  of 
tartar,  and  drinks  made  of  the  vegetable  acids.  For 
the  same  reason  the  temperature  of  the  room  ought 
not  to  be  too  high.  Certain  occupations,  like  those 
of  cooks  and  bakers,  accentuate  this  fact  only  too 
well.  Among  other  things  to  be  avoided  are  alco- 
holic liquors,  which  should  not  be  advised  except  in 
weak  and  broken  down  constitutions,  or  where  the 
system  needs  toning  up;  or,  again,  in  the  case  of 


■February  6,  1909.  J 


THERAPEUTICAL  NOTES. 


285 


elderly  and  infirm  persons  in  whom  the  recuperative 
powers  are  at  a  discount.  W  ith  these  exceptions 
alcoholic  drinks  are  to  be  tabooed.  And  the  same 
rule  holds  good  with  most  of  the  beers  and  ales. 

Cleanliness  of  person  must  not  be  neglected.  Sea 
baths,  when  available,  are  excellent.  The  best  kind 
of  soap  is  Castile.  Tepid  rather  than  hot  baths  give 
the  best  results. 

All  clothing  should  be  light  and  adapted  to  the 
wearer's  peculiarities  and  to  the  season  of  the  year. 
If  woolen  garments  are  too  irritating,  as  they  are  in 
many  cases,  a  soft  cotton  or  linen  garment  may  be 
worn  next  the  skin ;  or,  if  the  eruption  is  confined 
to  one  or  more  limbs,  the  aftected  parts  may  be 
advantageously  swathed  in  pieces  of  old  linen. 

Change  of  scene,  habits,  or  of  business  sometimes 
have  a  tendency  to  lessen  or  even  prevent  the  affec- 
tion. Certain  occupations  exacerbate  if  they  do  not 
originate  the  disease,  or  act  as  exciting  causes. 

As  to  medication  little  and  much  can  be  said. 
Tonics  and  a  good,  generous  regimen  are  sometimes 
indicated,  as  well  as  some  purgative,  together  with 
a  sparing  diet.  ^Mild  aperients,  such  as  Rochelle 
salts,  saline  mineral  waters,  or  their  salts,  together 
with  other  saline  cathartics  which  may  suit  the  case, 
often  do  excellent  service.  These  salines  should  be 
taken  every  morning  or  two  to  keep  the  emunctories 
in  good  condition. 

As  to  direct  medication,  many  remedies  have  been 
oflFcred  from  time  to  time.  That  which  has  enjoyed 
the  greatest  reputation  is  some  preparation  of  ar- 
senic, usually  iij  a  liquid  form  under  the  name  of 
Fowler's  solution.  This  is  nothing  more  than  a 
solution  of  potassium  arsenite.  But  in  cases  of 
elderly  and  delicate  persons  and  of  children  I  prefer 
to  use  a  solution  of  sodiimi  arsenite.  which  has  a 
nuich  milder  effect  upon  the  system.  But  in  what- 
ever form  administered,  arsenic  does  not  always 
give  us  the  expected  results.  Too  much  dependence 
must  not  be  placed  upon  its  employment. 

The  remedies  used  for  the  local  treatment  of 
eczema  are  as  various  as  they  are  multitudinous : 
each  practitioner  has  his  favorite  lotion  or  ointment, 
which  he  regards  as  his  sheet  anchor.  Under  this 
class  of  remedies  come  emollient  washes,  pomades, 
and  ointments  too  numerous  to  mention.  Lotions  of 
the  most  elHciency  are  solutions  of  borax,  boric 
acid,  and  of  potassium  carbonate  (sal  tartar).  Any 
one  of  these  will  allay  the  intense  itching  and  burn- 
ing attendant  upon  the  disease,  and  soften  the  skin 
and  thus  prepare  it  for  inunction. 

Among  the  ointments  a  combination  of  diachylon 
plaster  and  olive  oil,  as  prepared  according  to  the 
formula  of  Hebra,  has  often  worked  well.  The  ox- 
ide of  zinc  combined  with  benzoated  lard  is  another 
excellent  preparation.  But  the  best  ointment  is  a 
combination  of  certain  salts  of  mercury  with  a 
cerate  of  some  sort.  The  white  precipitate  ointment 
(img.  hydr.  ammoniati),  in  the  proportion  of  one 
part  to  three  of  some  cerate,  lard,  wool  fat,  etc.. 
occupies  the  highest  place  in  the  list  of  ointments. 
If  its  use  does  not  prevent  a  subsequent  attack  of 
the  affection  it  will  scarcely  fail  to  exert  some 
marked  effect.  After  an  experience  of  its  employ- 
ment for  over  thirty  years  I  still  find  it  an  efficient 
remedy,  sometimes  preventing  a  return  of  the  dis- 
ease. 


Another  remedy  which  has  proved  in  my  hands 
to  be  of  great  value  in  chronic  as  well  as  in  acute 
eczema  is  resorcin.  I  introduced  it  to  the  profession 
some  years  ago  as  an  efficient  remedy  for  the  acute 
form  of  eczema.  Since  then  I  have  found  it  of 
great  service  even  in  chronic  eczema.  It  is,  of 
course,  too  early  to  emphasize  its  importance ;  but 
it  almost  instantly  allays  the  intense  burning  and 
itching  of  eczema,  and  also  seems  to  cut  short  the 
disease.  Though,  so  far  as  my  experience  goes,  if 
it  cannot  be  depended  upon  to  avert  all  future  at- 
tacks, it  is  at  least  worth  a  trial,  and  is  the  best  pal- 
liative with  which  I  am  acquainted.  The  following 
is  my  formula  for  its  preparation : 

R    Unguenti  zinci  benzoati,   5j ! 

Pulveris  resorcini,   gr.  xx; 

Acidi  salicjlici,   gr.  v. 

Misce. 

To  make  this  ointment  as  smooth  as  possible,  the 
resorcin  and  salicylic  acid  should  first  be  dissolved 
in  alcohol  and  then  rubbed  up  thoroughly  with  the 
zinc  ointment.  In  large  quantities  the  ointment 
should  contain  four  per  cent,  of  resorcin  and  one  of 
the  salicylic  acid.  But  when  used  to  the  extent  of 
an  ounce  or  two,  the  prescription  as  given  above 
answers  as  well.  A  solution  of  resorcin  is  as  effi- 
cient, but  I  prefer  the  ointment. 

The  local  treatment  of  this  disorder  will  be  much 
facilitated,  when  confined  to  one  or  both  the  lower 
extremities,  if  the  limb  is  snugly  bandaged.  Those 
who  cannot  bear  comfortably  an  elastic  bandage,  one 
of  soft  linen  will  answer  equally  as  well. 

Such  are  the  few  selected  remedies  offered  for 
the  treatment. of  an  affection  that  has  baffled  the 
skill  of  the  most  distinguished  dermatologists.  But 
this  form  of  treatment  is  not  presented  as  specific, 
but  such  as  my  own  experience  has  led  me  to  regard 
as  the  most  efficacious. 

(To  be  concluded.) 
 ^  


Therapeutics  of  Amyl  Nitrite  and  Nitroglyc- 
erin.— The  therapeutic  actio'i  of  nitroglycerin 
and  amyl  nitrite  are  stated  by  R.  J.  Smith  (Pacific 
Medical  Journal,  January.  1909)  to  be  identical,  the 
amyl  nitrite  being  administered  by  inhalation  and  the 
nitroglycerin  by  the  mouth  or  by  hypodermic  injec- 
tion. Within  a  few  minutes  after  taking  a  small 
dose,  there  is  decided  fulness  in  the  head,  the  face 
flushes,  the  heart  palpitates  or  is  quickened,  often 
there  is  quite  severe  headache.  The  usual  dose  of 
nitroglycerin  is  one  one-hundredth  grain,  and  of 
amyl  nitrite  three  to  five  drops  rapidly  inhaled.  Dur- 
ing paroxysms  of  pain,  as  in  renal,  hepatic,  uterine, 
or  intestinal  colic,  the  face  is  pale  and  the  skin  moist 
and  cold.  Here,  the  administration  of  either  of  the 
drugs  produces  rapid  amelioration  of  the  symptoms 
by  overcoming  constriction  of  the  arterioles,  permit- 
ting free  flow  of  the  blood  from  the  congested  capil- 
laries. Congestive  pain  anywhere  will  be  relieved 
by  nitroglycerin,  in  doses  of  one  two  hundred  and 
fiftieth  grain  every  half  hour  until  the  face  flushes. 
In  syncope  the  same  dose  may  be  given  every  ten 
minutes  until  flushing  of  face,  then  every  hour  to 
keep  up  the  effect. 


286 


THERAPEUTICAL  NOTES. 


[Nesv  York 
Medical  Journal. 


In  feeble  heart  action,  nitroglycerin  improves  the 
circulation  and  stimulates  the  heart  to  increased  ac- 
tivity. In  syncope  of  pneumonia,  typhoid  fever,  or 
other  acute  disease,  it  is  a  life  saver  and  our  most 
efficient  remedy.  Amyl  nitrite  is  useful  in  poisoning 
hy  illuminating  gas.  Hypodermic  injections  of  ni- 
troglycerin are  speedily  restorative.  In  asph3'xia 
neonatorum,  nitroglycerin  should  be  used. 

The  nitrites  reduce  blood  pressure  and  are  valuable 
adjuncts  to  treatment  of  incipient  arteriosclerosis 
and  hypertension.  Advanced  cases  are  not  relieved 
as  effectively,  and  the  nitrites  should  be  reserved  for 
critical  need.  Spirit  of  nitrous  ether  may  be  admin- 
istered for  prolonged  periods  in  thirty  to  sixty  min- 
im doses  daily  in  these  cases,  and  is  a  circulatory 
sedative  of  value.  This  use  of  nitrous  ether  does  not 
prevent  the  use  of  the  other  nitrites  at  critical  peri- 
ods. Nitroglycerin  must  be  given  at  short  periods 
ro  produce  physiological  effects,  and  active  prepara- 
tions should  be  used.  If  flushing  is  not  produced  or 
tension  reduced,  either  sufficient  has  not  been  given 
or  the  preparation  is  stale.  Sodium  nitrite  is  more 
stable  and  less  apt  to  cause  headache.  It  should  be 
used  where  prolonged  effect  is  desired. 

In  pulmonary  haemorrhage,  amyl  nitrite  is  most 
efficient.  In  most  cases,  the  haemorrhage  is  immedi- 
ately checked. 

As  a  hypodermic  in  puerperal  eclampsia,  it  acts  by 
lowering  the  high  blood  pressure,  and  promoting 
elimination  of  toxines.  Both  amyl  nitrite  and  nitro- 
glycerin have  also  marked  sedative  action  on  spinal 
motor  nerves. 

In  neuritis  nitroglycerin  has  given  excellent  re- 
sults. In  sciatica  it  is  of  great  benefit.  No  doubt  it 
acts  by  dilating  the  arterioles  of  the  sheath  and 
nerve,  aiding  circulation  and  removal  of  inflamma- 
tory deposits. 

In  cirrhotic  nephritis,  with  small  tense  pulse,  car- 
diac hypertrophy,  nitroglycerin  has  been  given  with 
the  best  results. 

In  heat  exhaustion  with  feeble  pulse,  cold  skin, 
nitroglycerin  is  indicated  and  acts  well. 

Amyl  nitrite  inhaled  wards  off  threatened  chills, 
is  of  use  in  puerperal  hjemorrhage,  to  be  followed 
by  atropine  for  prolonged  effect. 

Test  for  Bile  in  Urine. — In  The  Hospital  for 
January,  1909,  it  is  remarked  that  tests  for  bile  con- 
stituents in  urine  are  usually  not  very  satisfactory  in 
private  practice  when  all  the  various  reagents  are 
not  at  hand.  The  nitric  acid  test  is  one  of  the  most 
unsatisfactory  of  all,  and  it  is,  besides,  a  particular- 
ly unpleasant  one  w-hcn  performed  in  a  small  sur- 
gery. Yet  it  is  often  very  useful  to  detect  the  pres- 
ence of  small  cjuantities  of  bile  constituents  in  urine. 
A  positive  result  usually  helps  towards  the  diag- 
nosis ;  a  negative  result,  though  not  so  useful,  is 
sometimes  helpful.  Popper  and  Obermayer  have 
recently  taken  up  the  subject  of  tests  for  bile  pig- 
ments, and  have  stated  their  results  in  an  interest- 
ing article  in  the  Wiener  kliinschc  Woclicnschrift. 
They  recommend  the  employment  of  a  test  solution 
consisting  of  water,  625  c.c. ;  alcohol  (95  per  cent.), 
1.25  c.c;  sodium  chloride,  1,100  grammes;  potas- 
sium iodide,  180  grammes;  and  10  per  cent,  solution 
of  tincture  of  iodine,  3.5  c.c.  Five  cubic  centimetres 
of  this  test  solution  is  put  into  a  test  tube  and  the 


urine  to  be  examined  is  carefully  poured  on  to  the 
surface.  If  bile  is  present  a  blue  green  ring  forms 
at  the  zone  of  contact ;  if  the  urine  contains  merely 
a  trace  of  bile  the  ring  is  faintly  blue  in  color.  The 
test  solution  keeps  for  an  indefinite  time^  is  always 
ready  for  use,  and  appears  to  be  excellent  for  or- 
dinary purposes. 

Dry  Pleurisy. — x\ccording  to  Sir  James  Barr 
(quoted  in  The  Hospital)  cases  of  dry  pleurisy  re- 
quire very  little  treatment  except  some  counter- 
irritation,  a  diaphoretic,  a  purgative,  and  perhaps  a 
sedative  to  relieve  pain,  or  some  strapping  of  the 
chest  to  limit  the  amount  of  movement. 

Application  for  Sciatica. — Yzeta  {Gazette  dcs 
Hopitatix)  prescribes  the  follow-ing  liniment  for  the 
relief  of  the  pain  of  sciatica : 

R    Olive  oil,  jviii; 

Oil  of  turpentine,   5ii ; 

Ammonia  water  5!; 

Tincture  of  cantharides,   Jss- 

Mix.    Apply  with  friction  twice  daily. 

Almond  Cakes  for  Diabetics. — Le  Gott'  {Jour- 
nal de  medecine  interne)  gives  the  following  recipe 
for  making  almond  cakes  for  use  in  the  feeding  of 
diabetic  patients :  Pulverized  sweet  almonds,  250 
grammes ;  eggs.  No.  2 ;  sodium  bicarbonate,  2 
grammes ;  tartaric  acid,  i  gramme.  Triturate  to  a 
paste  and  cook  for  twenty-five  minutes.  Each  cake 
of  the  combined  weight  of  ingredients  is  said  to  con- 
tain from  five  to  seven  per  cent,  of  carbohydrates. 

Graves's  Disease. — Mackenzie  {The  Hospital. 
January,  1909)  considers  the  diet  an  important  part 
of  the  treatment,  and  he  recommends  for  most  cases 
plenty  of  fruit,  vegetables,  cream,  bread,  butter, 
eggs,  and  very  little  meat.  Further,  patients  with 
this  malady  cannot  have  too  much  fresh  air. 

A  Simple  Method  of  Detecting  Free  Hydro- 
chloric Acid  in  the  Gastric  Juice. — F.  A.  Steensma 
{Biochemische  Zeitschrift,  1908,  210;  through 
Pharmaceutical  Journal)  proposes  a  modification  of 
Giinsburg's  reaction  for  the  detection  of  free  hydro- 
chloric acid  in  the  gastric  juice  which  is  believed  to 
be  more  delicate  than  the  original  method.  The  re- 
agent he  uses  is  composed  of  philoridzin,  2 
grammes ;  vanillin,  i  gramme ;  dissolved  in  absolute 
alcohol,  30  c.c.  A  drop  of  this  reagent  is  placed  in 
a  small  porcelain  capsule,  and  the  capsule  placed  on 
a  boiling  w-ater  bath ;  when  the  alcohol  has  evap- 
orated, there  remains  a  feebly  yellow  colored  ring 
on  the  capsule.  One  or  two  drops  of  the  liquid  to 
be  tested  are  placed,  by  means  of  a  glass  rod,  in  the 
centre  of  this  ring,  in  such  a  way  that  the  liquid  is 
in  contact  with  the  internal  edge  of  the  ring.  If  the 
liquid  contains  free  hydrochloric  acid,  there  is 
formed  on  the  internal  edge  of  the  ring  a  bright  red 
band  which  is  reduced  to  a  simple  line  when  hydro- 
chloric acid  is  present  in  very  minute  quantity.  The 
use  of  a  water  l)ath  is  essential  for  the  success  of  the 
reaction.  This  reagent,  like  that  of  Giinsburg,  does 
not  keep  for  any  length  of  time.  On  replacing  ethyl 
alcohol  by  methyl  alcohol,  the  reaction  is  more  deli- 
cate, but  the  solution  of  phloridzin  and  vanillin  in 
methyl  alcohol  alters  very  rapidly,  so  that  it  is  neces- 
sarv  to  prepare  the  reagent  extemporaneously  for 
each  test. 


February  6,  1909. J 


EDITORIAL  ARTICLES. 


2S7 


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NEW  YORK,  SATURDAY,  FERUARY  6,  1909. 


EXTRACTS  OF  LEUCOCYTES  IN 
THERAPEUTICS. 

The  employment  of  extracts  of  leucocytes  in  the 
treatment  of  bacterial  disease  was  suggested  by  Hiss 
(Journal  of  Medical  Research,  November,  1908). 
Rabbits  were  used  and  aleuronat  was  injected  into 
the  pleural  cavity.  The  resulting  exudate,  which 
was  rich  in  polymorphonuclear  leucocytes,  was  with- 
drawn, centrifuged,  washed  free  from  serum,  and 
extracted  with  distilled  water.  This  watery  extract 
was  then  injected  subcutaneously  in  doses  of  ten 
cubic  centimetres  daily.  In  some  cases  twent}-  cubic 
centimetres  were  used,  and  in  a  few  instances  two 
injections  were  given  in  one  day.  As  a  rule  normal 
rabbits  were  used  to  produce  the  leucocytes,  but 
some  experiments  were  tried  with  rabbits  previous- 
ly immunized  against  a  known  organism.  These 
animals  gave  an  extract  that  was  more  powerful 
than  that  given  by  normal  rabbits.  The  treatment 
appears  to  act  by  neutralizing  the  toxines  of  an  in- 
fection, and  to  help  the  leucocytes  of  the  patient  de- 
stroy the  infecting  bacteria.  It  is  a  unique  employ- 
ment of  biological  products,  because  it  allows  of  the 
treatment  of  many  dif¥erent  infections  with  a  single 
substance  of  antitoxic  character. 

Before  the  Section  in  General  [Medicine  of  the 
College  of  Physicians  of  Philadelphia,  on  the  even- 
ing of  January  iith.  Dr.  Samuel  W.  Lambert,  of 
New  York,  described  the  results  of  the  application 
of  this  method  of  treatment  in  human  therapeutics. 


i-'our  patients  with  cerebrospinal  fever  had  been 
treated  in  Dr.  Lambert's  wards  in  the  New  York 
Hospital,  of  whom  three  recovered  and  one  died.  One 
patient  with  pneumonia  due  to  Friedlander's  bacillus 
died.  One  with  pneumonia  in  which  no  bacterio- 
logical diagnosis  was  made  recovered.  Of  five  with 
general  pneumococcus  infection,  two  of  the  cerebro- 
spinal meninges  and  three  of  the  endocardium,  none 
recovered.  In  two  of  the  cases  of  acute  ulcerative 
endocarditis  pneumococci  were  isolated  from  the 
blood.  The  most  brilliant  results  were  obtained  in 
the  treatment  of  boils,  acne,  and  other  infections 
with  the  pyogenic  cocci.  Six  cases  of  furuncles  due 
to  Staphylococcus  aureus,  two  of  chronic  acne,  and 
several  of  erysipelas  were  cured.  A  case  of  otitis 
media  with  thrombosis  of  the  internal  jugular  vein 
was  cured.  The  cases  selected  for  the  application 
of  the  treatment  were  always  the  most  unfavorable. 
The  treatment  seemed  to  have  no  influence  on  the 
course  of  typhoid  fever. 

Hiss  and  Zinsser,  in  the  same  journal,  report  the 
results  of  treatment  of  twenty-lour  cases  of  cerebro- 
spinal fever,  seven  cases  of  lobar  pneumonia,  and 
one  case  of  pneumococcus  empyema  with  the  leuco- 
cyte extract.  The  cases  were  in  the  wards  of  vari- 
ous New  York  hospitals,  with  the  exception  of  one, 
which  occurred  in  private  practice.  Of  the  patients 
with  cerebrospinal  fever,  fourteen  were  cured,  eight 
died,  and  two  left  the  hospital  against  advice.  All 
the  cases  of  pneumonia  and  the  case  of  pneumo- 
coccus empyema  were  cured. 

It  was  used  in  three  cases  of  benign  tertian  ma- 
larial fever.  In  one  it  checked  the  occurrence  of 
the  chills  for  a  short  period,  but  they  soon  returned. 
This  is  as  might  be  expected.  Alalarial  disease  is 
due  to  a  protozoan  parasite,  not  to  a  bacterium.  It 
is  attended  by  an  increase  in  the  number  of 
large  uninuclear  leucocytes.  The  extract  used  in  the 
treatment  under  discussion  is  an  extract  of  poly- 
morphonuclear cells.  This  fact  may  explain  its  fail- 
ure in  infection  with  Bacilltis  typhosus,  which  is  also 
attended  with  an  increase  of  the  uninuclear  leuco- 
cytes. 

The  theoretical  neutralizing  body  which  is  intro- 
duced with  this  leucocytic  extract  has  been  called 
■'endoantitoxine."  The  treatment  is  a  direct  attempt 
to  neutralize  the  deleterious  efifects  of  the  endotox- 
ines,  which  are  the  products  of  infection  with  bac- 
teria that  do  not  produce  dii¥usible  extracellular 
toxines.  So  far,  the  results  of  animal  experiment 
have  been  more  satisfactory  than  those  of  clinical 
tests.  In  the  animal  experiments  the  most  satisfac- 
tory results  were  obtained  when  the  treatment  was 
started  early  in  the  infection.  This  is,  of  course,  to 
be  expected ;  it  has  been  the  history  of  all  attempts 
at  treatment  of  disease  with  biological  products.  The 


288 


EDITORIAL  ARTICLES. 


1  New  York 
Medical  Journal. 


treatment  is  applicable  to  infections  with  many 
kinds  of  organisms,  particularly  to  those  in  which 
the  organisms  produce  an  endotoxine.  It  cannot,  of 
course,  replace  the  antitoxic  treatment  of  diseases 
due  to  organisms  which  produce  a  diffuse  extracel- 
lular toxine,  like  diphtheria. 


MEDICAL  -EXPERT"  TESTIMONY. 

It  is  no  news  to  our  readers  that  much  of  the  tes- 
limonv  of  so  called  medical  "experts,"  especially  in 
homicide  cases  in  which  the  defense  of  insanity  has 
been  lugged  in,  has  been  a  stench  in  the  nostrils  of 
physicians  who  respect  themselves  and  love  their 
profession.  Agam  and  again  have  efforts  been  made 
by  medical  men  to  put  a  stop  to  the  scandal.  Quite 
recently,  so  far  as  the  State  of  New  York  is  con- 
cerned, such  efforts  have  given  promise  of  success. 
Last  week,  in  our  report  of  the  proceedings  of  the 
annual  meeting  of  the  Medical  Society  of  the  State 
of  New  York,  held  on  the  25th,  26th,  and  27th  of 
January,  we  printed  the  following  paragraph: — 

In  the  House  of  Delegates  two  sets  of  resolutions  were 
adopted  respectively  against  legislation  designed  to  inter- 
fere with  vivisection  and  looking  to  the  provision  of  a  lim- 
ited and  uniform  system  for  expert  testimony  in  civil  and 
criminal  court  cases.  The  committee  appointed  last  year 
to  act  jointly  with  a  similar  committee  representing  the 
State  Bar  Association  reported  that  it  was  the  sense  of  the 
joint  committee  that  the  legislature  be  petitioned  to  pass  a 
bill  authorizing  the  Appellate  Divisions  of  the  Supreme 
Court  to  appoint  not  more  than  sixty  physicians  from  their 
respective  judicial  departments,  who  should  be  qualified  to 
act  as  medical  experts,  and  that  the  expense  of  their  serv- 
ices should  be  borne  by  the  county  in  which  the  action  was 
tried. 

A  little  later  in  the  same  week  the  New  York 
State  Bar  Association  met  in  Buffalo,  and  its  com- 
mittee reported.  According  to  press  dispatches,  the 
following  passages  appeared  in  the  report : — 

It  is  apparent  to  all  that  theoretically  an  expert  is  the 
scientist  interested  solely  in  facts,  who  should  retain  free- 
dom of  judgment  and  liberty  of  speech  and  should  be  free 
from  the  embarrassment  of  any  personal  relations  to  or 
with  the  parties  to  an  action :  that  he  should  have  no  client 
to  serve  and  no  partisan  interest  or  opinions  to  vindicate; 
that  he  should  give  his  opinion  as  the  advocate  neither  of 
another  nor  himself;  that  when  he  speaks  he  should  do  so 
judicially  as  the  representative  of  the  special  branch  of 
science  which  he  invokes,  governed  by  the  opinion  of  the 
great  body  of  scientists  in  this  relation  and  in  accordance 
with  their  most  recent  investigations. 

That  no  one  should  be  permitted  to  distort,  pervert,  or 
misrepresent  his  testimony;  that  when  this  is  done  and  not 
until  it  is  done  shall  we  have  expert  testimony  rescued 
from  the  disrepute  into  which  it  has  fallen,  and  thus  ele- 
vated to  its  true  position  as  the  expression  of  the  particular 
science  for  which  it  speaks ;  that  by  the  adoption  of  some 
such  system  the  mature  judgment  of  the  best  minck  could 
he  obtained  and  the  superficial  opinions  of  quacks  and 


mountebanks  would  not  be  thrust  upon  the  jury  to  their 
confusion  and  the  hindrance  of  justice;  that  such  scientific 
openmindedness  is  almost  impossible  where  the  expert  en- 
tirely depends  for  his  emolument  upon  the  good  graces  of 
contending  parties  and  largely  is  without  the  recognition 
and  protection  of  the  court. 

That  the  commercializing  of  scientific  knowledge  under 
the  existing  conditions  lessens  its  accuracy  and  value ;  that 
the  enormous  modern  development  of  special  knowledge 
makes  doubt  and  controversy  among  experts  hired  to  cre- 
ate it  inevitable  and  aggravates  the  evils  of  private  expert 
hire,  unscrupulous  so  called  experts  finding  it  easy  to  lease 
themselves  and  their  opinions  to  aggrieved  and  aggressive 
parties  who  may  profit  either  fairly  or  unfairly  by  the  tech- 
nicalities and  doubts  which  they  are  able  to  inject  into  the 
case,  in  full  consciousness  that  no  rebuke  will  be  adminis- 
tered by  the  tribunal  before  which  their  testimony  is  given  : 
that  therefore  the  gravest  abuses,  not  to  say  scandals,  in 
the  introduction  of  medical  expert  testimony  have  arisen, 
until  it  has  come  commonly  to  be  believed  that  such  wit- 
nesses are  so  biased  if  not  corrupt  that  hardly  any  weight 
should  be  given  to  their  opinions. 

The  expression  "quacks  and  mountebanks"  may 
not  often  be  quite  deserved,  but  our  friends  of  the 
legal  profession  criticised  lawyers  also  in  no  mealy 
mouthed  fashion — witness  the  following: — 

Nor  is  the  bar  blameless.  Not  only  do  some  of  its  mem- 
bers connive  at  the  hiring  of  corrupt  and  incompetent  so 
called  experts,  but  they  artfully  and  selfishly  cultivate  and 
largely  are  responsible  for  the  fallacy  that  a  witness  is  to 
he  discredited  if  he  can  be  disconcerted.  Thus  the  art  of 
cross  examination,  so  potent  for  good  when  fairly  and 
properly  used,  plays  havoc  with  hard  earned  and  well  de- 
served reputations  in  the  hands  of  lawyers  whose  sole  am- 
bition is  to  win. 

The  two  professions  of  law  and  medicine  havin 
joined  forces  for  the  attainment  of  so  lofty  a  pur- 
pose as  that  of  purging  themselves  of  complicity  in 
tttrning  judicial  inquiries  into  farces,  we  may  well 
hope  and  expect  that  there  will  soon  be  enacted 
legislation  that  will  prove  effective  in  bringing  about 
the  desired  result,  even  if  the  precise  measures  at 
first  recommended  turn  out  to  call  for  amendment 
as  to  some  matters  of  detail.  Indeed,  a  bill  em- 
bodving  the  recommendations  has  already  been  pre- 
pared. For  the  text  of  the  bill  the  reader  is  referre'I 
to  our  news  columns. 


DIAGNOSTIC  INJECTIONS  OF 
TUBERCULIN. 

Whatever  may  be  the  value  of  tuberculin  injec- 
tions given  with  therajx-utic  intent,  many  question 
the  propriety  of  usin'g  them  for  diagnostic  purposes. 
Our  own  views  on  this  point  have  already  been  ex- 
pressed (Sciv  York  Medical  Journal,  July  11. 
1908).  The  ophthalmic  test  of  Wolf-Eissner  and 
Calmette  and  the  skin  tests  of  von  Pirqiiet  and 
Moro  have  in  a  measure  supplanted  the  old  style 
Koch  injections,  and  certainly  appear,  when  posi- 


February  6,  1909.] 


EDITORIAL  ARTICLES. 


289 


tive,  to  afford  strong  presumptive  evidence  of  the 
existence  of  tuberculous  infection. 

Quite  recently,  however,  two  new  aids  to  diag- 
nosis have  been  brought  forward.  Yamananchi 
{Wiener  kUnischc  Wochenschrift,  November  ig, 
1908)  obtains  two  or  three  cubic  centimetres  of 
blood  serum,  or  blister  serum  from  the  suspected 
individual  and  injects  it  into  a  rabbit,  and  a  few 
days  later  injects  tuberculin  into  the  rabbit.  If  the 
serum  was  from  a  tuberculous  subject  the  rabbit 
experiences  a  severe  and  even  fatal  reaction.  If  the 
original  subject  was  free  from  tuberculous  disease 
there  will  be  no  reaction  in  the  rabbit. 

That  tubercle  bacilli  have  occasionally  been 
found  in  the  circulating  blood  is  well  known,  but 
that  they  are  constantly  present  in  all  forms  of  tu- 
berculous infection  has  recently  been  rendered 
probable.  Dr.  Randle  C.  Rosenberger.  assistant 
professor  of  bacteriology  in  the  Jefferson  Medical 
College,  of  Philadelphia,  in  a  paper  read  before  the 
Pathological  Society  of  Philadelphia  on  December 
loth,  published  in  the  Americati  Journal  of  the 
Medical  Sciences  for  February,  explained  his  tech- 
nique in  detail.  Briefly,  he  draws  five  cubic  centi- 
inetres  of  blood  from  the  arm  and  immediately  in- 
troduces it  into  a  test  tube  already  containing  an 
equal  amount  of  a  two  per  cent,  solution  of  sodium 
citrate  in  normal  salt  solution.  The  tube  is  then 
placed  at  rest  in  a  cool  place  to  deposit  sediment 
for  twenty-four  hours.  Smears  of  the  sediment  are 
then  made  and  fixed  and  stained  with  carbol  fuch- 
sin  in  the  usual  manner.  Rosenberger  has  found 
the  bacilli  in  every  case  where  the  disease  had  been 
diagnosticated,  clinically,  and  in  some  in  which  it 
had  not  been  suspected.  A\'e  await  with  interest  the 
reports  of  other  investigators  who  may  follow  this 
method. 


THE  CACTUS  PAMMEXTARIUS 
CAXIXUS. 

Xo  matter  how  inferior  its  Latinity  may  be.  no 
university  student  needs  to  be  told  what  the 
cactus  pavimentarius  is,  for  the  expression  has  long 
been  current  in  the  halls  of  learning.  As  regards 
the  human  variety  (the  cacce  of  some  of  the  old 
writers),  he  who  takes  his  ''constitutional"  early  in 
the  morning  probably  encounters  it  less  frequently 
now  than  in  years  gone  by.  but  the  article  that  be- 
tokens the  dog's  night  airing  is  still  too  common  a 
reminder  of  that  sum  of  all  nuisances,  the  urban 
dog.  A  touching  complaint  founded  on  the  abun- 
dance of  the  canine  variety  has  lately  been  sent  to 
us  by  a  prominent  Xew  York  physician.  It  is  ad- 
dressed to  dog  ownerSj  and  it  reads  as  follows : — 

'  If  you  wish  to  be  popular,  observe  the  following :  On 
first  going  for  an  outing,  avoid  the  middle  of  the  sidewalk. 


Other  beings  may  pass  during  the  next  eighteen  hours,  pos- 
sibly in  the  dark.  Many  so  passing  will  have  skirts ;  most 
will  later  pass  over  rugs  and  carpets,  coming  in  contact 
with  lounges  and  foot  rests.  There  seems  to  be  a  natural 
tendency  in  all  aforesaid  beings  to  select  the  middle  of  the 
smoothest  sidewalk — hence  accidents.  Question :  Where 
does  the  poor  public  come  in?  Between  excavations,  cart- 
ing of  construction  iron,  running  amuck  of  taxicabs.  where 
may  the  poor  tax  payer  betake  himself  but  to  the  middle  of 
the  sidewalk — and  then  ?  Listen :  I  have  a  floor,  carpets, 
family,  and  I  shine  my  own  shoes.  As  I  write,  Sabean 
odors  well  up  from  one  shoe.  Will  you  please  try  the 
gutter  ? 

We  are  confident  that  even  the  mediaeval  believers 
in  the  medicinal  virtues  of  album  grsecum  would 
have  preferred  to  find  their  raw  material  in  places 
more  secluded  than  the  public  promenade,  and  cer- 
tainly the  men  and  women  of  the  present  time  detest 
the  pavement  reminder  of  the  dog's  nocturnal  out- 
ing. Hence  we  join  in  our  correspondent's  appeal. 
It  is  doubtful,  however,  if  any  consideration  for 
others  is  likely  to  be  harbored  by  owners  of  city 
dogs. 


MORE  NEWSPAPER  MEDICIXE. 
Within  the  last  few  days  an  absurd  report  from 
Fort  ^^'ayne.  Indiana,  has  been  going  the  rounds  of 
the  newspapers.  It  was  to  the  effect  that  a  physi- 
cian living  in  Indiana,  having  conceived  the  idea 
that  a  portion  of  the  digestive  tract — "'that  part 
which  serves  as  the  cesspool  of  the  poisons  of  the 
body  and  becomes  the  culture  bed  of  certain  dis- 
eases''— was  superfluous,  resolved  to  test  his 
hypothesis  on  his  own  person  by  having  his  large 
intestine  removed,  wholly  or  in  part.  According 
to  the  report,  he  vainly  endeavored  to  induce  one 
surgeon  after  another  to  perform  the  operation,  but 
finally  persuaded  Dr.  McOscar,  of  Fort  ^^'ayne.  to 
Undertake  it,  and  it  was  followed  by  a  fatal  result. 
We  have  communicated  with  Dr.  McOscar.  and  he 
has  telegraphed  to  us  as  follows :  "Report  un- 
founded. The  operation  performed  consisted  of  a 
simple  anastomosis  ileum  to  distending  colon." 


THE  UNR'ERSITY  OF  PENXSYL\'AXIA. 

We  learn  from  the  Old  Penn  Weekly  Review  for 
January  i6th.  a  "special  medical  number.''  that  the 
^ledical  Department  of  the  University  of  Pennsyl- 
vania has  arranged  for  its  first  annual  "home  com- 
ing week."  or  "progressive  medicine  week,"  to  oc- 
cupy the  Easter  vacation  period,  a  series  of  clinics, 
laboratory  demonstrations,  and  other  interesting 
proceedings  for  the  particular  benefit  of  the  alumni, 
many  of  whom  will  themselves  take  an  active  part 
in  the  exercises.  The  idea  is  excellent,  and  the  oc- 
casion may  be  expected  to  draw  a  great  number  of, 
the  graduates  together  in  Philadelphia. 


290 


NEWS  ITEMS. 


[New  York 
Meoical  Journal. 


A  JOURNAL  OF  PHYSICAL  AND  DIETETIC 
TREATMENT.  - 
Dr,  Wilhelm  Winternitz  founded  in  1891  the 
Blatter  fiir  klinische  Hydrotherapie,  and  that  jour- 
nal now  appears  in  an  entirely  new  form.  The 
Monatsschrift  fiir  die  physikalisch-didteiischen  Heil- 
methoden  is  but  a  very  remote  successor  to  Winter- 
nitz's  journal,  only  the  tradition  remaining  that 
hydriatics  should  be  made  an  important  addendum 
to  therapeutics.  Added  to  this  are  other  branches 
of  therapeutics,  such  as  electrical,  climatological, 
dietetic,  gymnastic,  and  massage  treatment.  The 
editors  are  Dr.  Julian  Marcuse,  of  Munich,  and  Dr. 
Alois  Strasser,  of  Vienna.  Among  the  collabora- 
tors we  find  the  names  of  Dr.  S.  Baruch,  Dr.  C. 
Beck,  and  Dr.  H.  F.  Wolfif,  of  New  York.  The 
journal  is  published  by  the  well  known  medical  pub- 
lishing house  of  J.  F.  Lehmann,  of  INIunich. 
 ^>  

^etos  |Um<. 

The  World's  Leprosy  Congress  meets  in  Christiania, 
Morway,  this  year.  The  United  States  representative  at 
the  congress  will  be  Dr.  William  J.  Goodhue,  who,  for  the 
last  four  years,  has  been  resident  physician  at  the  Leper 
Settlement  in  Molokai,  Hawaii. 

Smallpox  in  Guatemala. — Rigid  sanitary  rules  are 
being  enforced  in  Guatemala  on  account  of  the  prevalence 
of  smallpox  there,  and  an  order  requiring  vaccination  was 
issued  some  weeks  ago  by  President  Cabrera.  Up  to  Janu- 
ary 1st,  it  is  reported,  over  500,000  persons  had  been  vac- 
cinated. 

Some  Cases  of  Tropical  Diseases  Seen  in  Philadelphia 

was  the  subject  of  an  address  delivered  by  Dr.  John  M. 
Swan  at  a  recent  meeting  of  the  Kensington  Branch  of  the 
Philadelphia  County  iMedical  Society.  The  lecture  was  il- 
lustrated with  lantern  views,  microscopic  slides,  and 
specimens. 

Yellow  Fever  in  Barbados. — According  to  press  dis- 
patches yellow  fever  is  now  epidemic  in  Barbados,  and  the 
situation  is  rapidly  growing  worse.  Twelve  deaths  from 
the  disease  have  been  reported.  Quarantine  against  both 
Barbados  and  Martinique  is  being  enforced  by  the  Dutch 
and  French  governments. 

The  New  Superintendent  of  Hartford  Hospital. — Dr. 
Appleton  W.  Smith,  superintendent  of  the  Boston  City 
Hospital,  has  been  appointed  superintendent  of  the  Hart- 
ford Hospital,  to  fill  the  vacancy  caused  by  the  recent  ap- 
pointment of  Dr.  Winford  H.  Smith  as  superintendent  of 
Bellevue  and  Allied  Hospitals. 

A  Generous  Gift  to  the  Rochester,  N.  Y.,  Hospital.— 
Mr.  George-  Eastman  has  presented  to  the  Rocliester  City 
Hospital  $400,000,  which  will  be  used  in  erecting  a  new 
main  building  and  reconstructing  the  other  buildings  of 
that  institution.  Last  December  Mr.  Eastman  gave  $60,000 
to  the  Homoeopathic  Hospital  for  a  new  nurses'  home  and 
other  improvements. 

The  Red  Cross  Christmas  Stamps. — The  net  receipts 
from  the  sale  of  these  stamps  in  Manhattan  and  the  Bronx 
amounted  to  $11,270.38.  Of  this  amount  $5,000  will  be 
given  to  the  tuberculosis  camp  on  the  roof  of  the  Vander- 
bilt  Clinic;  $1,000  will  be  given  to  help  defray  the  expenses 
of  the  Tuberculosis  Exhibition  in  the  American  Museum  of 
Natural  History,  and  the  remainder  will  be  used  to  help 
maintain  day  camps  for  the  tuberculous  in  various  parts  of 
the  Stale. 

Change  in  the  Medical  Faculty  of  Columbia  Univer- 
sity.— Dr.  T.  Mitcliell  I'rudden,  who  has  been  professor 
of  patliology  at  the  College  of  Physicians  and  Surgeons 
(Medical  Department  of  Columbia  University)  since  1877, 
will  retire  at  tlic  end  of  the  present  academic  year.  He  will 
be  succeeded  by  Dr.  William  G.  MacCallum,  who  is  now 
professor  of  pathological  physiology  and  lecturer  on  foren- 
sic medicine  in  the  Medical  Department  of  Johns  Hopkins 
University. 


Officers  of  the  Philadelphia  Neurological  Society  for 

tlie  year  1909  were  elected  at  the  recent  annual  meeting  of 
the  society  as  follows:  President,  Dr.  T.  H.  Weisenburg; 
vice-presidents,  Dr.  H.  H.  Donaldson  and  Dr.  George  E. 
Price;  secretarv.  Dr.  A.  R.  Allen;  treasurer.  Dr.  J.  H.  W. 
Rhein;  council.  Dr.  J.  W.  McConnell,  Dr.  W.  G.  Spiller, 
and  Dr.  A.  A.  Eshner.' 

"Faust"  Sung  for  the  Benefit  of  the  French  Hospital, 
New  York. — On  the  evening  of  January  30th  "Faust" 
was  sung  in  French  at  the  Metropolitan  Opera  House,  un- 
der the  auspices  of  the  Societe  frangaise  de  bicnfaisance  dc 
New  York,  which  maintains  the  French  Hospital  in  West 
Thirty-fourth  street.  The  gross  receipts  amounted  to 
$13,800,  of  which  $7,000  was  given  to  the  hospital. 

Dr.  Stelwagon  Honored. — Dr.  Henry  Weightman 
Stelwagon,  professor  of  dermatology  in  the  Jefferson  Med- 
ical College,  Philadelphia,  has  been  elected  an  associate 
member  of  the  Vienna  Dermatological  Society.  This  is  the 
third  time  Dr.  Stelwagon  has  been  honored  by  being  elected 
to  membership  in  foreign  dermatological  societies — in  1897 
by  the  Society  of  Dermatology  of  Italy,  and  in  1903  by  the 
Society  of  Dermatology  of  France. 

The  Medico-Chirurgical  College  of  Philadelphia  has 
purchased  the  property  at  1719  Arch  Street  and  1720 
Cherry  Street  at  a  cost  of  $35,000,  as  the  course  of  the  new 
central  parkway  will  be  through  the  present  buildings  of 
the  college  and  hospital.  The  property  at  141  North  Eight- 
eenth Street,  which  adjoins  the  hospital  building  at  the 
corner  of  Eighteenth  and  Qierry  Streets,  has  been  pur- 
chased by  the  Medico-Chirurgical  Hospital. 

Openings  for  Young  Physicians  in  the  West. — Ac- 
cording to  press  dispatches,  the  town  of  Winthrop,  Wash., 
is  in  great  need  of  a  physician,  as  the  nearest  doctor  is  at 
Tv.-isp,  ten  miles  away,  and  the  only  drugs  available  are 
those  carried  by  two  general  stores.  The  town  of  Kamiah, 
Idaho,  also  has  no  physician  within  a  radius  of  seven  miles. 
The  surrounding  country  is  thickly  settled,  and  would 
probably  offer  a  good  field  for  a  young  physician. 
Scientific   Society   Meetings  in   Philadelphia   for  the 

Week  End/ng  February  13,  1909: 
Tuesday,  February  gth. — Philadelphia  Pjediatric  Society. 
Wednesd.w,  February  loth. — Philadelphia  County  Medical 
Society. 

Thursday,  February  iith. — Pathological  Society;  Section 

Meeting,  Franklin  Institute. 
Friday,  February   j.?th. — Northern   Medical   Association ; 

West  Branch,  Philadelphia  County  Medical  Society. 
The  Buffalo  Academy  of  Medicine. — Dr.  Hugh  H. 
Young,  professor  of  geiiitourinary  surgery  in  the  Medical 
Department  of  the  Johns  Hopkins  University,  Baltimore, 
read  a  paper  entitled  The  Diagnosis  and  Treatment  of  Vesi- 
cal Tumors,  at  a  stated  meeting  of  the  academy,  held  on 
Tuesday  evening,  February  2d.  After  the  reading  of  the 
paper,  which  was  listened  to  by  a  large  and  appreciative 
audience.  Dr.  Young  gave  a  demonstration  of  an  operating 
cystoscope. 

Contagious  Diseases  in  Chicago. — During  the  w^eek 
ending  January  23,  1909,  there  were  905  cases  of  contagious 
diseases  reported  to  the  department,  as  follows :  Scarlet 
fever,  228  cases,  an  increase  of  18  over  the  preceding  week ; 
diphtheria,  175  cases;  tuberculosis,  119  cases,  an  increase  ot 
47  over  the  week  before  ;  measles,  no  cases  ;  chickenpox,  loi 
cases  ;  pneumonia,  54  cases ;  typhoid  fever,  46  cases  ;  whoop- 
ing cough,  18  cases ;  smallpox,  2  cases ;  diseases  of  minor 
importance,  52  cases. 

A  Reception  to  Dr.  A.  D.  Blackader. — The  members 
of  the  Pliiladelpb.ia  Prcdiatric  Society  will  tender  a  recep- 
tion to  Dr.  A.  D.  Blackader.  of  Montreal,  at  the  close  of 
a  meeting  of  the  society  to  be  held  on  Tuesday  evening, 
February  gtli,  at  which  Dr.  Blackader  will  deliver  an  ad- 
dress on  The  Respiratory  Spasms  of  Infancy.  The  recep- 
tion will  be  held  in  the  Hotel  Walton,  and  those  who  desire 
to  attend  should  communicate  with  Dr.  Howard  Childs 
Carpenter,  1805  Spruce  Street.  Philadelphia,  before  Feb- 
ruary 6th. 

Reward  Offered  for  a  Tuberculosis  Remedy. — A  bill 

has  been  introduced  into  the  Pennsylvania  State  Legislature 
by  Dr.  John  M.  Martin,  of  Grove  City,  Mercer  County, 
whch,  if  passed,  will  give  a  reward  of  $50,000  to  the  discov- 
erer of  a  remedy  for  tuberculosis  which  will  prove  as  ef- 
fective as  antitoxine  in  diphtheria.  The  bill  authorizes  the 
State  Board  of  Health  to  advertise  for  a  remedy,  and  to 
receive  and  investigate  all  proposed  remedies.  For  the  ad- 
vertising and  conducting  of  the  investigation  $5,000  is  to  be 
appropriated. 


February  6,  1909.  J 


NEJVS  ITEMS. 


2()l 


The  Health  of  Pittsburgh. — During  the  week  ending 
January  23,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
15  cases,  o  deaths;  typhoid  fever,  14  cases,  i  death;  scarlet 
fever,  28  cases,  2  deaths ;  diphtheria,  13  cases,  2  deaths ; 
measles,  29  cases,  i  death ;  whooping  cough,  21  cases,  o 
deaths;  pulmonary  tuberculosis,  42  cases,  11  deaths.  The 
total  deaths  for  the  week  numbered  166.  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  15.27  in  1,000  of  population. 

A  "S}rmposium"  on  Tjrphoid  Fever. — At  the  regular 
meeting  of  the  Elmira,  X.  Y.,  Academy  of  Medicine,  held 
on  the  evening  of  February  3d,  the  evening  was  devoted  to 
a  consideration  of  typhoid  fever.  Papers  were  read  dealing 
with  the  history  and  aetiology-,  the  pathologj-  and  prophy- 
laxis, the  diagnosis  and  prognosis,  the  complications  aiid 
treatment  of  the  disease.  Among  those  who  contributed 
papers  to  the  ■■s\-mposium"'  were  Dr.  P.  Barker,  Dr.  E. 
T.  Bush,  Dr.  A.  J.  Westlake,  Dr.  C.  G.  R.  Jennings,  Dr.  S. 
E.  Palmer,  and  Dr.  C.  W.  ^I.  Brown. 

University  News.— Dr.  Arthur  William  Meyer,  profes- 
sor of  an.atomy  in  the  Xorthwesfern  University  Medical 
School,  Chicago,  has  been  called  to  the  chair  of  anatomy 
in  the  Leland  Stanford  University. 

Dr.  Wilhelm,  professor  of  anatomy  in  the  University  of 
Berlin,  has  been  elected  a  foreign  member  of  the  Stock- 
holm Academy  of  Sciences. 

Dr.  John  Gordon  Wilson,  of  the  Rush  Medical  College, 
has  been  appointed  professor  of  otolog>'  in  the  Northwest- 
ern University  :\Ied!C?.l  School,  to  succeed  Dr.  Frank  All- 
port,  who  resigned  recently. 

The  Columbia  University  Public  Lectures  on  Sanitary 
Science. — Dr.  George  Adami,  Strathcona  professor  of 
pathology  at  McGill  University.  Montreal,  delivered  the 
second  lecture  in  the  course  on  Wednesday  afternoon.  Feb- 
ruary 3d.  His  subject  was  The  Great  Pathological  Discov- 
eries and  Their  Bearing  upon  Public  Health  Problems. 
The  Control  of  Environment  is  the  subject  of  the  third  lec- 
ture, which  is  to  be  delivered  on  Monday  afternoon,  Feb- 
riian.;  8th,  by  Dr.  William  Thompson  Sedgwick,  professor 
of  biology  in  the  -Massachusetts  Institute  of  Technology. 
Dr.  William  Hallock  Park,  director  of  the  Research  Lab- 
oratories of  the  New  York  City  Health  Department,  will 
deliver  the  fourth  lecture  on  February  loth.  Modes  of 
Transmission  and  Methods  of  Prevention  of  Communicable 
Diseases  will  be  his  subject. 

The  Health  of  Chicago. — A  material  improvement  in 
health  conditions  in  Chicago  was  noted  during  the  week 
ending  January-  23,  1909.  The  number  of  deaths  from  all 
caiises  reported  to  the  Department  of  Health  was  622. 
which  was  104  less  than  for  the  preceding  week,  and  65 
less  than  in  the  corresponding  period  a  year  ago.  The  death 
rate  was  much  lower  than  the  general  average  for  this 
season,  being  14.57  in  a  thousand  population,  as  against 
16.54  for  the  corresponding  period  in  1908  and  17.05  for  the 
preceding  week.  The  important  causes  of  death  were : 
Pneumonia,  in  deaths:  pulmonary  tuberculosis,  58  deaths; 
other  forms  of  tuberculosis,  7  deaths ;  diarrhoeal  diseases, 
34  deaths,  of  which  33  were  under  two  years  of  age;  diph- 
theria, 19  deaths :  scarlet  fever,  10  deaths ;  whooping  cough' 
I  death;  influenza.  3  deaths:  typhoid  fever,  3  deaths:  can- 
cer, 31  deaths;  nervous  diseases.  21  deaths;  heart  diseases, 
60  deaths;  apoplexy.  15  deaths;  bronchitis.  26  deaths; 
Brieht's  disease.  51  deaths:  violence.  27  deaths,  of  which 
6  were  suicides :  all  other  causes,  141  deaths. 

February  Meetings  of  the  Wajme  County,  Mich., 
Medical  Society.— Dr.  Albion  W.  Hewlett,  professor  of 
the  theory  and  practice  of  medicine,  at  the  University  of 
Michigan.  Ann  Arbor,  read  the  paper  of  the  evening  at  a 
general  meeting  of  the  society  held  in  Detroit  on  Monday, 
February  ist.  The  title  of  the  paper  was  Forms  and  Clin- 
ical Significance  of  Irregular  Heart  Action,  and  it  was  il- 
lustrated by  lantern  slides.  Psychotherapeutics  is  the  topic 
chosen  for  discussion  at  the  Februarv  8th  meeting  of  the 
medical  section  of  the  society.  Dr.  Charles  W.  Hitchcock, 
of  Detroit,  will  read  a  paper  on  the  subject  and  there  will 
be  a  general  discussion.  On  Monday  evening,  February 
15th,  a  general  meeting  of  the  societv  will  be  held  in  the 
Detroit  Museum  of  .\rt,  at  which  Dr.  John  B.  ^lurphy, 
of  Chicago,  will  read  a  paper  entitled  Surgery  of  the  Spinal 
Cord  and  Peripheral  Xerves,  with  Analysis  of  Results. 
The  surgical  section  will  meet  on  February  22d.  The  even- 
ing will  be  devoted  to  a  consideration  of  infectious  arthritis, 
and  papers  on  the  subject  will  be  read  by  Dr.  W.  E.  Blod- 
gett  and  Dr.  J.  E.  Gleason. 


The  Emmanuel  Movement. — It  is  reported  that  a 
change  is  to  be  made  in  the  methods  under  which  the  Em- 
manuel Movement  has  been  carried  on  by  the  clergy,  and  all 
patients  treated  by  the  clergj^  connected  with  the  movement 
will  first  have  the  care  of  a  physician.  An  advisory  board 
composed  of  a  number  of  prominent  Boston  physicians 
who  believe  in  the  movement,  but  do  not  approve  of 
the  methods  as  practised,  so  far,  has  drawn  up  a  set  of 
rules,  designed  to  avoid  some  of  the  earlier  mistakes  made 
by  the  clergj-  in  treating  patients  who  have  no  family  phy- 
sician. The  rules  iiave  been  adopted  by  the  clergy. 
Infectious  Disease  in  New  York: 

IVe  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folloiving  statistics  of  neiv 
cases  and  deaths  reported  for  the  tzco  zi^eeks  ending  Janu- 
ary so,  i<)og: 

,  Jan.  23  ,     ,  Jan.  30  ^ 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    457  179         462  173 

Diphtheria    377  A9         369  43 

ileasles    46S  21  50;  iS 

Scarlet  fever    359  18         360  26 

Smallpox   

Varicella    152  ..  234 

Typhoid  fever    34  8  32  7 

Whooping   cough    23  4  b8  5 

Cerebrospinal  meningitis   3  5  4 

Totals   1.S70         2t<2       2.035  276 

The  Annual  Dinner  of  the  West  End  Medical  Society, 
New  York,  which  was  held  in  the  Hotel  Ansonia  on  the 
evening  of  January  23-:l,  was  one  of  the  most  successful  in 
the  historv'  of  the  organization.  The  attendance  was  good, 
and  the  addresses  were  especially  interesting.  At  the  an- 
nual meeting  of  the  society,  held  011  December  19th,  the 
following  officers  were  elected  to  serve  for  the  year  1909 : 
President,  Dr.  Ward  B.  Hoag :  vice-president,  Dr.  Frank 
S.  Fielder;  secretary,  Dr.  W.  Howe  Morrison;  treasurer. 
Dr.  Ernest  V.  Hubbard ;  trustees,  to  serve  for  three  years. 
Dr.  LeRo\'  Broun  and  Dr.  Charles  X.  Dowd ;  members  of 
membership  committee,  to  serve  for  two  years,  Dr.  Fielding 
L.  Taylor  and  Dr.  Theron  W.  Kilmer. 

American  Society  of  Sanitary  and  Moral  Prophylaxis. 
— A  meeting  of  this  society  wiil  be  held  on  Thursday  even- 
ing, February  nth,  at  the  Xew  \  ork  Academy  of  Medicine, 
under  the  auspices  of  the  Committee  on  the  Social  Evil. 
The  Hon.  William  McAdoo  will  preside.  The  general  sub- 
ject for  discussion  will  be  The  Afiluents  of  Prostitution, 
and  the  following  papers  will  be  read :  The  \\'hite  Slave 
Traffic,  by  Dr.  O.  Edward  Jannej-;  Dance  Halls.  Steamboat 
Excursions  and  the  Beaches,  by  Mrs.  Charles  Israels ;  The 
Raines  Law  Hotels,  Saloons,  etc.,  hy  a  member  of  the  Com- 
mittee of  Fourteen ;  Exhibition  Amusements,  by  Frank 
Moss,  Esq.  Prominent  members  of  the  medical  profession 
and  the  laity  will  take  part  in  the  discussion.  Dr.  Prince 
A.  ^Morrow  is  president  of  this  society,  and  Dr.  Edward  L. 
Keyes,  Jr.,  is  secretar\-. 

Meetings  of  Sections  of  the  New  York  Academy  of 
Medicine. — The  Section  in  Xeurology  and  Psychiatry  will 
meet  on  Mondaj'  evening,  February  8th,  at  8:30  o'clock. 
Dr.  Richard  Cole  Xewton  will  read  a  paper  entitled  The 
Clinical  History  of  Some  Cases  of  Socalled  Cardiac  Epi- 
lepsy, which  will  be  discussed  by  Dr.  Woods  Hutchinson. 
A  paper  on  the  -^Etiological  Factors  and  Racial  Distribution 
of  the  Various  Psychoses  will  be  presented  hy  Dr.  William 
Mabon  and  Dr.  George  H.  Kirb\-,  of  the  ^Manhattan  State 
Hospital  for  the  Insane.  The  discussion  of  this  paper  will 
be  opened  by  Dr.  Carlos  F.  MacDonald. 

The  Section  in  Public  Health  will  meet  on  Tuesday 
evening,  February  9th,  at  8:30  o'clock.  The  paper  of  the 
evening  will  be  read  by  Dr.  Charles  Gilmore  Kerley  on  the 
Influence  of  City  Schools  on  the  Health  of  the  Community. 
The  discussion  will  be  opened  by  !Mr.  James  E.  Russell, 
dean  of  the  Teachers'  College. 

1  he  Section  in  Pediatrics  will  meet  on  Thursday  evening. 
February  iith,  at  8:30  o'clock.  After  the  usual  report  of 
cases  and  presentation  of  patients,  a  paper  entitled  A  Study 
of  the  Eye  in  Mental  Defectives  will  be  presented  by  Dr. 
L.  Pierce  Clark  and  Dr.  Martin  Cohen,  and  Dr.  Charles 
Gilmore  Kerlej-  will  give  the  result  of  his  observations  on 
the  use  of  lactic  acid  bacilli  at  the  Babies'  Hospital  last 
summer.    There  will  be  a  general  discussion  of  both  papers. 

The  Section  in  Otology  will  meet  on  Friday  evening,  Feb- 
ruary i2th,  at  8:15  o'clock.  The  programme  will  consist 
largely  of  the  presentation  of  patients,  reports  of  cases,  ex- 
hibition of  specimens,  and  the  demonstration  vf  instruments 
and  apparatus.  The  paper  of  the  evening  will  be  read  by 
Dr.  W.  Sohier  Bry^ant  on  A  Theory  of  Sound  Perception. 


292 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


A  Remarkable  Tribute  to  the  Distinguished  Surgeon, 
Dr.  John  B.  Deaver. — A  dinner  will  be  tendered  to  Dr. 
Deaver  at  the  University  Club,  15 10  Arch  Street,  Philadel- 
phia, on  February  15,  1909,  which  will  be  a  unique  testi- 
monial to  the  skill  of  the  great  surgeon.  Over  one  hundred 
and  lifty  physicians  will  be  present,  and  of  these  about  one 
hundred  and  thirty  have  had  their  appendices  removed  by 
Dr.  Deaver,  while  the  remainder  have  been  operated  upon 
by  him  for  other  diseases.  The  dinner  is  given  as  a  public 
expression  of  the  high  appreciation  and  warm  regard  in 
which  he  is  held  by  his  medical  clientele.  A  pleasing  inci- 
dent of  the  dinner  will  be  the  presentation  of  a  loving  cup. 
It  is  said  that  Dr.  Deaver  performed  over  600  operations  for 
appendicitis  in  one  year,  and  has  probably  performed  more 
such  operations  than  any  other  physician  in  Philadelphia. 
The  committee  in  charge  of  the  dinner  believes  that  an- 
nouncements have  been  mailed  to  all  who  are  eligible  to 
participate,  but  if  any  one  has  been  overlooked,  a  notice  of 
such  omission  should  be  sent  at  once  to  the  chairman  of  the 
committee.  Dr.  Henry  W.  Stelwagon,  1634  Spruce  Street, 
Philadelphia.  The  otber  members  of  the  committee  are 
Dr.  Thomas  C.  Elv,  Dr.  Francis  M.  Perkins,  Dr.  George  G. 
Ross,  Dr.  B.  Franklin  Stahl,  and  Dr.  William  S.  Wads- 
worth. 

Society  Meetings  for  the  Coming  Week: 

MoND.w,  Fcbnmry  5//;.— New  York  Academy  of  Medicine 
(Section  in  Neurology  and  Psychiatry)  ;  Society  of 
Medical  Jurisprudence,  New  York ;  New  York  Ophthal- 
mological  Society ;  Corning,  N.  Y.,  Medical  Associa- 
tion ;  Waterbury.  Conn.,  Medical  Association. 
TuESD.w,  February  Qtli. — New  York  Academy  of  Medicine 
(Section  in  Public  Health)  ;  Medical  Society  of  the 
Count\^  of  Schenectady,  N.  Y. ;  Practitioners'  Club  of 
Jersey  City.  N.  J. ;  Medical  Society  of  the  County  of 
Rensselaer.  N.  Y. :  Buffalo  Academy  of  Medicine  (Sec- 
tion in,  Aledicine). 
Wednesd.w,  February  jotli. — New  York  Pathological  So- 
ciety ;  New  York  Surgical  Society ;  Medical  Society  of 
the  Borough  of  the  Bronx,  New  York ;  Alumni  Asso- 
ciation of  the  City  Hospital,  New  York;  Brooklyn 
Medical  and  Pharmaceutical  Association ;  Medical  So- 
ciety of  the  County  of  Ricbmond,  N.  Y. 
Thur.sd.-\v.  February  iitli. — New  York  Academy  of  Medi- 
cine (Section  in  Pediatrics)  ;  Brooklyn  Pathological  So- 
ciety: Blackwell  Medical  Society  of  Rochester,  N.  Y. ; 
Jenkins  Medical  Association,  Yonkers,  N.  Y. 
Friday,  February  12th. — New  York  Academy  of  Medicine 
(Section  in  Otology)  ;  New  York  Society  of  Derma- 
tology and  Genitourinary  Surgery;  Eastern  Medical 
Society  of  the  City  of  New  York ;  Saratoga  Spring^,, 
N.  Y.,  Medical  Society. 
Saturd-AY.  February  jsth. — Therapeutic  Club,  New  York. 

Charitable  Bequests.— By  the  will  of  Stephanie  E. 
Joly,  the  Children's  Seashore  Home,  Atlantic  City,  receives 
$200  and  the  Pennsylvania  Society  to  Protect  Children 
from  Cruelty  receives  $100. 

By  the  will  of  ]\Iary  E.  Beck,  St.  "Vincent's  Orphan  As3- 
lum,  Philadelphia,  receives  $500. 

By  the  will  of  Mary  A.  Ross,  the  Methodist  Episcopal 
Home  for  the  Aged,  Philadelphia,  .receives  $500. 

By  the  will  of  Jane  G.  Phelps,  of  Tarrytown.  N.  Y.,  the 
Presbyterian  Hospital,  New  York,  receives  $10,000,  and  the 
Tarrytown  Hospital  receives  $S,ooo. 

By  the  will  of  Emma  Louise  Lathrop  Booth,  tbc  Presby- 
terian Hospital,  New  York,  receives  $2,000.  • 

By  the  will  of  Mrs.  Joseph  G.  Lord,  of  Mincola,  L.  L, 
w'ho  died  on  January  29th,  the  Presbyterian  Hospital,  New 
York,  receives  $5,000  to  endow  a  bed  in  memory  of  Mrs. 
Lord's  husband. 

The  General  Hospital  Society  of  New  Haven,  Conn.,  re- 
ceives $200  by  the  will  of  the  late  Mr.  John  S.  Cannon. 

By  the  will  of  Mrs.  Helen  Wood  Miller,  widow  of  the 
late  Dr.  Horace  George  Miller,  an  e\-e  and  ear  specialist,  of 
Providence,  R.  I.,  Brown  University  receives  $20,000  to  be 
applied  for  the  general  uses  and  purposes  of  the  biological 
lalx)ratory  of  the  department  of  comparative  anatomy ;  the 
Rhode  Island  Hospital  receives  $8,000  for  the  establishment 
and  maintenance  of  two  free  beds,  to  be  known  as  the 
Horace  George  Miller  Bed  and  the  Helen  Woods  Miller 
Bed :  the  Rhode  Island  Medical  Societv,  of  which  Dr.  Mil- 
ler was  formerly  president,  receives  $5,000  to  be  held  in 
perpetual  trust  and  its  income  applied  either  to  caring  for 
books  presented  to  the  society  by  Dr.  Miller  or  for  the  pur- 
chase of  new  books  on  the  eye  and  car  for  the  library  of 
the  •-n(-ict\-. 


New  York  State  Pharmacy  Law  to  be  Amended. — 

.\  bill  has  been  introduced  into  the  legislature  of  the  State 
of  New  York  by  Assemblyman  Robert  S.  Conklin  to  abolish 
the  present  elective  State  board  of  pharmacy  with  its  three 
divisions,  and  provides  for  an  appointive  board,  as  reconi- 
mended  by  Governor  Hughes  in  his  annual  message.  Nine 
members  are  to  be  appointed  by  the  Governor,  to  hold  office 
for  three  years,  and  it  ■  is  so  arranged  that  three  member.^ 
shall  be  appointed  each  year  after  the  initial  appointment 
which  shall  be  within  thirty  days  after  the  bill  takes  effect. 
The  members  of  the  board  must  be  licensed  pharmacists  of 
at  least  five  years'  standing,  and  seven  out  of  the  nine  must 
be  persons  who  have  been  actively  engaged  in  the  busine.- s 
of  pharmacy  for  at  least  two  years  prior  to  their  appoint- 
ment. The  examination  of  applicants  is  to  be  placed  under 
the  supervision  of  the  board  of  regents.  Further  provision 
aims  at  the  abolition  of  tlie  abuse  that  has  grown  up  in  the 
exercise  by  the  present  board  of  the  power  to  impose  and 
exact  penalties  for  violation  of  the  law.  Under  the  provis- 
ions of  this  act  no  fine  can  be  imposed  and  no  action 
brought  until  the  druggist  has  been  formally  notified  of  the 
complaint  against  him  and  an  opportunity  given  him  for  a 
hearing.  The  measure  has  the  endorsement  of  a  large  pro- 
portion of  the  independent  druggists  of  New'  York  City 
and  fhe  other  large  cities  of  the  State. 

Bill  to  Regulate  Medical  Expert  Testimony. — The 

text  oi  the  measure  designed  to  regulate  existing-evils  in  con- 
nection with  the  introduction  of  expert  medical  testimonj , 
which  has  been  approved  by  the  New  York  State  Bar  As- 
sociation and  the  leading  medical  societies  of  the  State,  and 
which  will  be  at  once  sent  to  the  legislature,  is  as  follows; 

Section  i.  Within  ninety  daj's  after  this  act  shall  take 
effect  the  justices  of  the  Supreme  Court  assigned  to  the 
Appellate  Divisions  thereof,  in  the  several  departments, 
shall  designate  at  least  ten  and  not  more  than  sixty  physi- 
cians in  each  judicial  district,  who  may  be  called  as  medical 
expert  witnesses  by  the  trial  court  or  by  any  part  to  a  civil 
or  criminal  action,  in  any  of  the  courts  of  this  State,  and 
who,  W'hen  so  called,  shall  testify  and  be  subject  to  full  ex- 
amination and  cross-examination  as  other  witnesses  art. 
Any  designation  may  at  any  time  be  revoked  without  notice 
or  cause  shown,  and  any  vacancy  may  at  any  time  be  filled 
by  the  justice  sitting  in  the  Appellate  Division. 

Sec.  2.  When  so  directed  by  the  trial  court,  witnesses 
so  called  shall  receive  for  their  services  and  attendance 
suc'h  sums  as  the  presiding  judge  may  allow,  to  be  at  once 
paid  by  the  treasurer  or  other  fiscal  officer  of  the  county  in 
which  the  trial  is  had. 

Sec.  3.  This  act  shall  not  be  construed  as  limiting  the 
right  of  parties  to  call  other  expert  witnesses  as  hereto- 
fore. 

Sec.  4.  This  act  shall  talce  effect  on  September  i,  1909. 

Foreign  Items  of  Interest. — .At  the  recent  congress 
on  the  care  of  the  insane,  in  Vienha,  a  momnnent  was  un- 
veiled to  Professor  von  Krafft-Ebing  in  the  hall  of  the 
university. 

The  seventy-seventli  annual  meeting  of  the  British  Medi- 
cal Association  will  be  held  in  Belfast,  Ireland,  July  23  to 
31,  1909. 

Sir  Malcolm  Morris,  K.  C.  V.  O.,  presided  at  a  recent 
meeting  of  the  Ro.val  Society  of  Arts.  London,  at  which 
Dr.  James  Cantlie  read  a  paper  on  the  Part  Played  by 
Vermin  in  the  Spread  of  Disease. 

Surgeon  General  John  Edward  Tuson.  a  retired  officer 
of  the  Indian  Medical  Service,  died  recently  at  the  age  of 
eighty  years. 

Queen  .'Mexandra  has  given  £[,000  for  the  purchase  of 
articles,  not  provided  for  by  the  regulations,  which  will  add 
to  the  comfort  of  sick  soldiers  in  military  hospitals  at  home 
stations. 

The  British  .Association  for  the  .Advancement  of  Science 
meets  this  year  in  Winnipeg.  Canada,  from  August  25th 
to  September  ist.  Sir  J.  J.  Thompson,  F.  R.  S.,  is  the 
president-elect. 

Professor  Sanfelice,  of  Messina,  well  known  for  his  stud- 
ies on  tumors,  is  one  of  the  survivors  of  the  recent  great 
disaster  at  Messina.  It  was  thought  at  first  that  he  was 
among  the  victims,  as  his  whereabouts  could  not  be  ascer- 
tained, but  it  was  learned  recently  that  he  had  landed  safely 
at  Naples,  with  several  other  survivors  of  the  earthquake. 

It  is  stated  that  the  Paris  Radium  Institute  now  pos- 
sesses fifteen  grains  f)f  radium,  v;ilued  at  $85,000.  The 
work  of  extractiii'j;  the  substance  from  pitchblende  is  under 
the  supervision  of  Mme.  Curie. 


February  6,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


293 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 
January  28,  1909. 

1.  Some  of  the  Vagaries  of  the  Obstetrician  from  the 

Standpoint  of  the  Pjediatrician,    By  John  L.  Morse. 

2.  WTiat  Tj-pe  of  Operation  Is  Best  Adapted  for  the  Re- 

lief of  Disease  of  the  Frontal  Sinus, 

By  G.  A.  Crockett. 

3.  Laryngotomy  and  Laryngectomy  for  Cancer,  with  Re- 

port of  Four  Cases,  By  D.  Crosbv  Greene. 

4.  Care  of  Fractures  in  General  Practice, 

By  George  H.  Francis. 

5.  Exhibit  of  X  Ray  Plates  of  Fractures, 

By  Channixg  C.  Simmons. 

6.  On  the  Cold  Storage  of  Poultry, 

By  William  F.  Boos. 

7.  Report  of  Cases,  By  Frederic  S.  Crossfield. 

3.  Laryngotomy  and  Laryngectomy  for  Can- 
cer, with  Report  of  Four  Cases. — Greene  observes 
that  the  mortahty  of  operations  for  cancer  and  the 
lar}nx  can  be  kept  at  a  comparatively  low  figure,  if 
attention  is  given  to  certain  essential  details :  A 
.careful  selection  of  cases  :  attention  to  the  cleanliness 
of  the  mouth ;  the  avoidance  of  shock  by  the  use 
of  atropine  before  operation,  local  t:se  of  cocaine 
during  operation,  and  the  Trendelenburg  position 
during  the  second  stage :  the  avoidance  of  inhala- 
tion pnevnnonia  by  the  Trendelenburg  position  dur- 
ing operation  ;  and  rectal  feeding  and  elevation  of  the 
foot  of  the  bed  after  operation.  The  brilliant  re- 
sults obtained  by  Butlin  and  Semon  in  England,  and 
Jackson  in  this  country,  in  the  permanent  cure  of  a 
large  percentage  of  their  cases  of  early  intrinsic 
cancer  of  the  larynx  by  laryngotomy  should  lead  to 
the  more  general  adoption  of  this  method  of  opera- 
tion in  such  cases.  The  technique  of  laryngotomy 
Greene  describes  as  follows :  The  position  of  the  pa- 
tient up  to  the  time  of  opening  the  trachea  is  the 
horizontal  dorsal  position  with  a  flat  pillow  under 
the  shoulders.  This  brings  the  larynx  and  trachea 
into  greater  prominence  and  facilitates  the  dissec- 
tion. When  the  trachea  is  opened  a  change  is  made 
to  the  extreme  Trendelenburg  position,  the  long  axis 
of  the  patient's  body  being  put  at  an  angle  of  nearly 
45°  to  the  horizontal  plane.  In  order  to  hold  the 
patient  in  this  position  the  legs  must  be  securely  at- 
tached to  the  foot  of  the  table.  The  first  stage  of 
the  operation  comprises  the  exposure  of  the  larynx 
and  trachea  by  a  median  incision  extending  from  the 
hyoid  to  just  above  the  upper  end  of  the  sternum, 
which  is  interrupted  for  an  inch  below  the  cricoid 
by  a  bridge  of  skin  which  serves  to  separate  the 
tracheal  and  laryngeal  openings.  The  incision  is 
carried  down  successively  through  the  fascia,  sep- 
arating the  sternohyoid  and  sternothyreoid  muscles 
until  the  trachea  and  larynx  have  been  well  exposed. 
The  position  of  the  patient  is  now  changed  to  the 
extreme  Trendelenburg  position,  which  is  main- 
tained throughout  the  remainder  of  the  operation. 
The  trachea  is  now  opened  below  the  thyreoid  isth- 
mus and  an  ordinary  tracheotomy  tube  inserted 
into  the  trachea  and  held  in  position  with  tape.  The 
second  stage  of  the  operation  comprises  the  di- 
vision of  the  thyreoid  cartilage  in  the  median  line 
and  the  removal  of  the  growth.  Before  doing  this 
the  cricothyreoid  membrane  is  opened  by  a  short 
transverse  incision  and  a  ten  per  cent,  solution  of 
cocaine  applied  on  a  cotton  swab  to  the  interior  of 


the  larynx.  The  thyreoid  cartilage  is  next  divided 
from,  below  upwards.  In  young  subjects  this  may 
be  done  with  a  knife,'  but  inasmuch  as  in  the  majori- 
ty of  cases  the  thyreoid  cartilage  has  become  ossi- 
fied with  age,  it  will  usually  be  found  necessary  to 
use  a  saw  or  preferably  bone  shears  with  the  blade 
set  at  an  agle  of  about  135°  to  the  handle.  This 
step  must  be  taken  with  great  care  in  order  to  divide 
the  anterior  commissure  without  injuring  the  cords. 
The  wings  of  the  thyreoid  are  now  held  widely  apart 
with  retractors  or  stout  ligatures.  As  the  larynx  is 
opened  up  the  upper  end  of  the  trachea  may  be  firm- 
ly packed  with  gauze.  The  interior  of  the  larynx 
is  then  carefully  inspected  under  good  illumination 
with  a  head  mirror  or  head  light,  and  the  limits  of 
the  growth  made  out.  A  strong  solution  of  adre- 
nalin I  in  1,000  applied  to  the  region  of  th-e  growth 
helps  to  define  its  limits.  Two  elliptical  incisions 
are  made  surrounding  the  neoplasm  and  including" 
fully  one  half  inch  of  apparently  health}-  tissue. 
These  are  carried  down  to  the  cartilage  and  the  en- 
tire mass  including  the  perichondrium  stripped  ofT 
the  cartilage.  The  ensuing  haemorrhage  is  not  great 
and  is  controlled  b\-  pressure.  The  use  of  the  ther- 
mocautery at  this  point  is  not  evident,  although  it  is 
advocated  by  some  authorities.  It  is.  "of  course, 
necessary  before  reapproximating  the  wings  of  the 
thyreoid  to  make  the  wounds  within  the  larynx  dry. 
This  can  usually  be  accomplished  by  pressure,  al- 
though it  mav  be  necessary  to  tie  a  few  vessels.  The 
third  stage  of  the  operation  consists  in  the  closure  of 
the  lar\-nx.  The  plug  is  removed  from  the  upper 
end  of  the  trachea  and  the  cut  edges  of  the  thyreoid 
cartilage  placed  in  as  accurate  apposition  as  possi- 
ble. They  are  held  together  preferably  by  silk 
sutures  through  the  external  perichondrium.  The 
muscles  and  skin  are  next  sutured  in  separate  layers 
in  the  median  line,  and  a  small  gauze  wick  is  left 
in  the  lower  end  of  the  \\  ound.  A  dry  dressing  is 
applied  over  the  laryngeal  wound  and  a  light  moist 
antiseptic  dressing  over  the  tracheal  tube,  which  is 
retained  for  twenty-four  hours.  In  the  after  care 
of  these  cases  the  attention  is  especially  directed  to 
the  avoidance  of  shock  and  pneumonia. 

JOURNAL  OF  THE  AMERICAN  M EDICAL  ASSOCIATION  . 
January  30,  igog. 

1.  Classification  of  Pulmonar\'  Tuberculosis  and  Statisti- 

cal Reports  of  Sanatoria,       By  Lawrason  Brown. 

2.  Tuberculosis  in  Panama.     Incidence  and  Association 
with  Pleural  Adhesions,  By  \\'alter  V.  Brem. 

3.  The  Care  and  Treatment  of  Opium  Smokers  in  the 

Philippines,  By  A.  S.  Rochester. 

4.  Observations  on  Choked  Disk  with  Special  Reference 

to  Decompressive  Cranial  Operations, 

By  James  Bordley,  Jr.,  and  Harvev  Cushing. 

5.  A  Study  of  the  Respiratory  Signs  of  Chorea  Minor, 

By  William  W.  Gra\'es. 

6.  Lactic  Acid  as  an  Agent  to  Reduce  Intestinal  Putrefac- 

tion, By  P.  G.  Heinemann. 

7.  Xight  Camps  for  the  Tuberculous.    The  Utilization  of 

the  Consumptive's  Labor  Power, 

By  William  Ch.\rles  White. 

8.  Economics  of  Graduation  of  Medical  Candidates, 

By  A.  L.  Benedict. 

2.  Tuberculosis  in  Panama. — Brem  found  tu- 
berculous lesions  in  74.2  per  cent,  of  287  consecu- 
tive autopsies,  a  great  majorit}*  of  which  were  small 
focal  ones  and  appeared  to  be  healed  or  arrested. 
Only  twenty-one,  or  7.3  per  cent.,  of  the  287  deaths 
were  due  to  tuberculosis.    Pleural  adhesions  were 


294 


PlIH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


present  in  65  +  per  cent.,  and  of  these  54.5  per  cent, 
was  probably  the  minimum  due  to  tuberculosis  But 
adhesions  occurred  much  more  frequently  when  tu- 
berculous lesions  were  on  both  sides  of  the  thorax 
than  when  on  one  side  only,  and  much  more  fre- 
quently also  when  the  lungs  or  the  pleurae  were  in- 
volved than  when  the  involvement  was  limited  to 
the  peribronchial  lymph  nodes. 

3.   Opium  in  Philippines. — Rochester  describes 
the  treatment  of  opium  smokers  as  carried  on  at  San 
Juan  de  Dios  Hospital  and  later  at  the  San  Lazaro 
Hospital  to  which  the  patients  were  transferred. 
There  were  200  patients,  197  Chinamen  and  three 
Filipinos.    All  were  of  the  male  sex.    Their  ages 
were  from  seventeen  to  sixty-three  years,  with  an 
average  of  35^  years.    The  length  of  time  in  which 
they  had  been  habitues  of  the  drug  was  from  six 
months  to  thirty-three  years,  with  an  average  of 
seven  and  one  half  years.    This  average,  subtracted 
from  the  first  average,  shows  that  the  average  age 
at  which  they  became  addicted  to  the  habit  was  275^ 
years.     A  very  interesting  fact  which  developed 
while  ascertaining  the  most  popular  method  of  self- 
administration  was  the  great  number  who  were 
found  to  use  the  hypodermic  syringe.     Our  usual 
mind  picture  of  the  Chinese  opium  fiend  is  one  in 
which  he  is  reclining  on  a  couch  with  his  alcohol 
lamp  and  crude  opium  in  front  of  him,  his  pipe  in 
his  mouth,  and  surrounded  by  the  reeking  smoke 
of  the  burning  opium.    This  picture  has,  however, 
to  a  great  extent  become  a  thing  of  the  past.  Al- 
though the  Chinaman  may  have  been  slow  in  ac- 
cepting most  of  the  new  ideas  and  inventions  of  the 
Occident,  he  has  very  quickly  seen  the  true  worth  of 
the  hypodermic  syringe  and  its  great  advantages 
over  the  old  opium  pipe.    In  it  he  has  an  instrument 
whose  action  is  swift  and  sure.    It  was  found  that 
twenty-nine  per  cent,  of  the  patients  at  San  Lazaro 
had  used  the  drug  in  this  manner.    On  close  ques- 
tioning, however,  it  developed  that  all  but  two  or 
three  had  got  their  first  taste  of  the  eft'ects  of  the 
juice  of  the  popp}-  by  the  smoking  method.  The 
smallest  number  was  those  whose  favorite  method 
was  the  eating  of  the  drug,  the  percentage  of  those 
who  used  it  in  this  manner  being  only  nineteen. 
The  patients  were  separated  into  three  classes,  each 
in  a  separate  ward.   \\'ard  i  was  the  receiving  ward. 
A  careful  examination  of  the  patient's  physical  con- 
dition was  first  made,  a  bath  was  given  him,  he  was 
carefully  searched  for  'any  concealed  opium,  and  was 
questioned  through  an^  interpreter  as  to  the  amount 
of  opium  or  morphine  he  had  been  accustomed  to 
take,  his  method  of  administering  it,  and  the  length 
of  time  that  he  had  been  using  it.  -  He  was  kept  in 
this  ward,  where  he  was  always  under  close  obser- 
vation of  trained  male  nurses,  as  long  as  he  was  re- 
ceiving opium  or  sedatives  in  any  form  and  as  long 
as  his  physical  condition  demanded  attention.  Ward 
2  might  be  called  the  hospital  ward,  for  it  was  here 
that  all  patients  were  sent  on  development  of  seri- 
ous symptoms  or  intercurrent  diseases.    This  ward 
was  under  the  care  of  graduate  female  nurses,  and 
the  patients  here  received  clo.se  attention  as  to  diet, 
nursing,  etc.    Ward  3  may  be  classed  as  the  conva- 
lescent ward.    When  a  patient  seemed  to  have  re- 
turned to  a  normal  state,  both  physically  and  men- 
tally, he  was  removed  to  this  ward.    No  opiates  of 
any  kind  were  given  here,  and  if  a  patient  should 


develop  symptoms  calling  for  the  administration  of 
his  favorite  drug  he  was  first  returned  to  Ward  i 
before  same  was  given.    Briefly,  this  ward  was  a 
sort  of  detention  station  in  which  the  apparently 
cured   patients   were   confined   under  observation 
awaiting  dismissal..   The  only  treatment  given  here 
was  a  one  drachm  dose  of  the  elixir  of  iron,  quinine, 
and  strychnine  after  meals.    The  points  of  interest 
developed  during  the  treatment  of  this  series  of 
cases  of  opium  smokers  were :  First,  the  rapid  with- 
drawal of  opium  from  the  habitual  Chinese  opium 
smoker  is  attended  with  very  little  danger  and  a 
surprisingly  small  amount  of  suffering.    Second,  in 
a  comparatively  short  time  his  system  regulates  it- 
self to  carry  out  its  functions  without  the  aid  of  the 
narcotic.    Third,  the  constipating  effect  of  opium 
when  taken  into  the  system  by  smoking  is  not  great, 
for  its  withdrawal  after  long  use  by  this  method  is 
attended  by  very  little  diarrhoea.    Fourth,  the  dete- 
riorating effects  of  long  continued  opium  smoking 
on  the  physique  of  the  Asiatic  is  of  no  alarming  im- 
portance ;  the  results  of  opium  seem  to  be  less  in- 
jurious to  the  Asiatic  than  the  continued  use  of  al- 
cohol when  taken  by  the  Caucasian.     The  patients 
who  used  morphine  hypodermically  or  opium  by 
mouth,  were  by  far  harder  to  treat  than  the  smokers, 
and  their  treatment  presented  no  ideas  other  than 
those  which  have  been  reported  in  the  past.  They 
were  gradually  reduced  in  their  daily  dose  and  treat- 
ed symptomatically.    Only  one  matter  of  interest 
occurred  during  the  treatment  of  these  patients,  and 
that  was  the  results  of  experimenting  with  the  hyo- 
scine  substitution  treatment.    Fifteen  patients  who 
used  morphine  hypodermically  were  picked  out  for 
the  experiment,  and  at  7  o'clock  one  evening  were 
each  given  one  quarter  of  a  grain  of  morphine  and 
one  one  hundredth  of  a  grain  of  hyoscine.  This 
first  night  the  result  seemed  to  be  fairly  good.  The 
second  evening  the  procedure  was  repeated,  but  not 
so  successfully.    Some  of  the  patients  were  very 
restless  all  night,  others  seemed  to  be  dazed,  and 
four  were  delirious.    Despite  these  facts,  however, 
the  dose  was  again  repeated  on  the  third  night. 
Within  fifteen  minutes  after  the  administration  of 
the  hyoscine,  in  one  half  of  the  patients  developed  a 
wild,  talkative  delirium,  they  were  wandering  about 
the  ward  if  not  held  in  bed,  absolutely  oblivious  to 
their  surroundings,  not  recognizing  their  friends  or 
hearing  or  heeding  what  was  said  to  them.    Of  the 
remaining  patients  only  two  were  entirely  unaffect- 
ed ;  in  two  developed  the  most  violent  gastric  symp- 
toms, expressed  by  excruciating  pains  in  the  stom- 
ach and  abdomen  and  most  violent  retching  and 
vomiting;  the  breathing  apparatus  of  one  was  so 
disarranged  as  to  require  artificial  respiration  ;  the 
rest  suffered  cardiac  collapse  with  pulse  that  could 
hardly  be  felt  at  the  wrist. 

4.  Choked  Disk. —  Bordley  and  Cushing  are  of 
the  opinion  that  the  early  injection  with  stasis  of 
the  vessels,  the  marked  cedcma  with  projection  of 
the  papilla,  and  the  ultimate  round  celled  infiltration 
with  new  tissue  formation  which  leads  to  atrophy, 
are  merely  stages  of  the  same  process.  They  believe 
that  the  mechanical  views  of  Schmidt-Rimplcr  and 
Manz  are  largely  correct,  and  that  the  lesion  is  pri- 
marily due  to  tiie  crowding  into  and  distention  of 
the  sheath  of  Schwalbe  b}-  obstructed  cerebrospinal 
fluid,  resulting  in  an  oedema  of  the  nerve  head,  in 


February  6,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


295 


which  toxic  elements  play  an  insignificant  part. 
They  believe,  with  Parinaud  and  his  followers,  that 
an  acute  internal  hydrocephalus  in  the  closed  adult 
skull  almost  inevitably  leads  to  a  choked  disk,  but 
they  attribute  this  to  the  presence  of  arachnoidal 
riuid  forced  into  the  optic  sheath  rather  than  to  an 
oedema  spreading  from  the  brain  to  the  optic  nerve ; 
choked  disk  is  often  present  with  tumors  which  have 
not  led  to  hydrocephalus,  and  is  usually  absent  in 
the  ""essential"  hydrocephalus  of  infancy.  They 
think,  since  a  small,  benign,  slow  growing  and  re- 
mote tumor  so  situated  as  to  cause  hydrocephalus 
can  lead  to  a  high  grade  of  choked  disk,  whereas  a 
malignant,  rapidly  growing  glioma  which  causes  but 
little  pressure,  owing  to  the  way  in  which  it  infil- 
trates the  brain,  may  produce  no  change  whatsoever, 
even  though  situated  near  the  optic  nerve,  that  toxic 
products  in  the  cerebrospinal  fluid  can  hardly  be  held 
responsible  for  any  stage  of  choked  disk,  ^^'ith 
others,  they  have  observ^ed  cases  of  sella  turcica 
tumors,  which  have  led  to  optic  atrophy  from  direct 
pressure  without  producing  choked  disk.  In  these 
cases,  owing  to  the  situation  of  the  lesion,  fluid  is 
not  crowded  into  Schwalbe's  sheath.  They  believe, 
since  choked  disk,  contrary  to  many  authorities,  is 
rare  in  meningitis  and  equally  so  in  abscess  unless 
there  is  an  obstructive  hydrocephalits  leading  to 
greatly  increased  pressure,  that  meningeal  inflam- 
mation of  itself  must  be  looked  on  as  an  unlikely 
source  of  the  lesion.  Furthermore,  the  process  is 
frequently  seen  after  cranial  fractures,  apoplexies, 
and  not  uncommonly  after  simple  operations  when 
the  question  of  an  infection  can  safely  be  ruled  out. 
They  conclude,  "therefore,  that  a  mechanical  rather 
than  a  toxic  process  must  play  the  chief  role  in  the 
causation  of  this  well  recognized  lesion. 

MEDICAL  RECORD. 

January  30,  igog. 

1.  Ler.chsemia  in  Advanced  Life. 

By  A.  Alex.xxder  Smith. 

2.  Some  Common  Injuries  of  the  Elbow, 

By  James  P.  Warb.\sse. 

3.  Motor  Car  Miscarriage,  By  Edward  P.  Davis. 

4.  Medical  Psycholog>-.         By  George  V.  N.  Dearborx. 

5.  Some  Points  on  the  Early  Diagnosis  of  Pulmonary 

Tuberculosis,  By  Albert  H.  Garvix. 

1.  Leuchaemia  in  Advanced  Life. — .^mith  re- 
marks that  while  leuchsmia  mav  K5ccur  in  individ- 
uals at  any  age  the  two  decades  between  twenty-five 
and  forty-five  seem  to  be  the  favorite  periods  for  its 
development,  very  few  cases  have  been  reported 
after  the  age  of  sixty.  The  very  few  cases  oc- 
curring after  fifty-five  years  of  age  have  been  almost 
all  in  men.  He  has  obsen'ed  lately  three  cases  in 
persons  between  the  ages  of  sixty  and  seventy,  two 
of  whom  were  women. 

2.  ElboviT  Injuries. — Warbasse  states  that  the 
first  essential  in  the  treatment  of  elbow  injuries  is 
a  fam.iliarity  with  the  bony  landmarks ;  this  makes 
accuracy  of  diagnosis  possible.  Xor  should  there 
be  any  hesitancy  in  the  tise  of  general  anaesthesia. 
For  the  diagnosis  of  fracture  or  dislocation  one 
should  expose  both  elbows  and  with  a  pencil  or  ink 
mark  upon  the  uninjured  joint  the  three  bony 
points,  the  tips  of  the  internal  and  external  condyles 
and  the  tip  of  the  olecranon.  With  the  arm  in  a 
straight  position  these  three  points  should  be  near- 


ly in  a  straight  line.  \\'ith  the  elbow  at  a  right 
angle  they  should  make  approximately  an  equilateral 
triangle.  The  same  marks  should  be  made  on  the 
injured  side,  and  the  examination  proceeded  with. 
Even  when  there  is  much  swelling,  steady  pressure 
will  reveal  the  condyles.  The  head  of  the  radius 
should  be  identified,  and  with  both  arms  extended, 
the  carrying  angle  of  the  two  sides  should  be  com- 
pared. These  are  the  important  points  of  inspec- 
tion. Systematic  examination  is  important.  One 
should  take  up  separately  each  location  and  feature 
of  the  injury.  Is  the  swelling  or  ecchymosis  local- 
ized or  diffuse?  Locate  the  point  of  tenderness.  Is 
crepitus  present?"  Is  either  condyle  movable?  Ex- 
amine the  olecranon  process.  Is  there  fracture  or 
dislocation  of  the  head  of  the  radius?  Each  part  of 
the  three  bones  entering  into  the  joint  should  be 
considered  separately.  Xo  matter  how  skillful  and 
thorough  one  is  in  these  examinations  the  x  ray  is 
an  almost  indispensable  adjunct  to  treatment.  It 
makes  the  diagnosis  without  inflicting  pain  or  trau- 
matism and  without  the  necessity  of  anaesthesia. 
Many  cases  which  we  would  be  satisfied  with  after 
manual  examination  will  be  found  to  be  imperfectly 
replaced  in  the  light  of  the  x  ray.  The  manipula- 
tion usually  necessary  for  reduction  consists  in 
downward  pressure  upon  the  fragment,  combined 
with  traction  upon  the  elbow  and  flexion  to  the 
strongest  degree  consistent  ^vith  comfort  and  the 
integrity  of  the  circulation.  The  arm  is  held  in 
this  position  by  means  of  a  broad  adhesive  strap 
passed  about  the  arm  and  forearm,  with  a  layer  of 
bandage  interposed  to  keep  it  from  the  skin.  To 
this  is  added  a  simple  muslin  bandage  to  keep  the 
arm  to  the  side  and  to  support  the  elbow.  An  x 
ray  picture  of  the  bones  in  this  position  should  be 
taken,  it  sometimes  reveals  the  fact  that  a  trifle 
more  flexion  is  desirable,  or  it  gives  one  the  satis- 
faction of  knowing  that  the  desired  position  has 
been  secured.  OccasionalU^  we  have  a  case  in 
which  extreme  flexion  does  not  bring  the  fragments 
in  position.  This  occurs  in  condyloid  fractures 
rhrough  the  joint,  associated  with  traumatic  relaxa- 
tion of  the  attached  ligaments,  and  with  a  tendency 
of  the  fragment  to  longitudinal  displacement.  Some 
of  these  cases  seem  to  do  better  put  up  at  a  right 
angle,  others  in  the  straight  position  in  extension. 
There  are  cases  in  which  manipulation  fails  to  pro- 
duce a  satisfactory  reduction.  These  cases  should 
have  the  benefit  of  operative  exposure  of  the  frac- 
ture and  its  reduction  by  sight  and  touch.  These 
patients  have  a  right  to  expect  a  good  joint,  and  the 
surgeon  should  not  withhold  from  them  any  advan- 
tage which  his  art  has  to  offer. 

BRITISH  MEDICAL  JOURNAL. 

January  g,  igog. 

1.  Abdominal  Emergencies,  Bj'  S.  White. 

2.  Appendicostomy  in  Diffuse  Septic  Peritonitis, 

By  W.  BiLLIXGTOX. 

3.  •'Appendicostomy,  with  Xotes  on  the  Surgical  Aspect  of 

Colitis,  By  J.  B.  Dawson. 

4.  Leucocytosis  in  Appendicitis.  By  G.  Mitchell. 

5.  Syphilitic  Leucoderma  and  the  Pigmentary  Syphilide, 

By  Sir  J.  Hutchixson. 

6.  A  Case  of  Vincent's  Angina,  By  J.  T.  C.  Nash. 

I.  Abdominal  Emergencies.  —  White  states 
that  the  majority  of  acute  abdominal  cases  may  be 
referred  to  one  or  other  of  the  following  groups: 


296 


I'lj H  ui'  lurrent  literature. 


LN'eu  York 
Medical  Journal. 


I.  Acute  intestinal  obstruction.  This,  as  a  primary 
afYection,  is  most  often  due  to  strangulated  hernia, 
external  or  internal ;  intussusception  comes  second 
in  the  order  of  frequency,  while  impacted  gallstones 
and  volvulus  are  less  common  causes.  Not  infre- 
quently acute  obstruction  is  grafted  on  the  chronic 
type.  2.  Gastric  and  intestinal  ulcers  that  have  per- 
forated. Perforating  ulcers  are  found  in  the  stom- 
ach, the  duodenum,  the  lower  end  of  the  ileum,  and 
in  the  large  intestine.  In  the  latter  situation  they 
arc  usually  secondary  to  malignant  disease.  3. 
Acute  inflammatory  lesions  of  septic  origin.  Un- 
der this  head  come  the  different  varieties  of  appen- 
dicular inflammation,  ruptured  tubal  gestation, 
twisted  ovarian  pedicle.  4.  Injuries  to  the  abdomi- 
nal viscera;  these  may  result  in  acute  infective  peri- 
tonitis from  escape  of  intestinal  contents.  The  chief 
difficulties  in  abdominal  diagnoses  are  a  fat  abdo- 
men, the  advent  of  peritonitis,  and  the  pernicious 
habit  of  giving  opiates — all  of  which  mask  the 
symptoms.  The  treatment  of  the  grave  cases  in 
which  the  infection  has  spread  to  the  general  peri- 
tonaeum, is  summed  up  as  follows:  i.  Removal  of 
the  primary  cause  of  infection  with  the  least  possi- 
ble interference  with  the  surrounding  tissues.  No 
attempt  is  made  to  wash  away  pus  or  to  remove 
exuded  lymph.  In  very  bad  cases  removal  of  the 
appendix  may  be  omitted.  2.  The  provision  of  free 
abdominal  drainage  so  as  to  relieve  tension  with  all 
its  accompanying  evils.  A  Keith's  tube  inserted  into 
the  pelvis  is  usually  sufificient,  but  it  may  be  supple- 
mented by  others  of  india  rubber  leading  down  to 
the  site  of  the  appendix  and  elsewhere.  3.  Placing 
the  patient  on  a  sloping  couch  so  that  the  shoulders 
shall  be  on  a  considerably  higher  level  than  the  pel- 
vis. Sufificient  elevation  is  secured  by  placing  the 
head  castors  of  the  bed  on  two  kitchen  chairs.  The 
primary  object  of  this  posture  is  to  permit  of  the 
descent  of  septic  material  toward  the  pelvic  basin, 
where  the  rate  of  absorption  by  the  lymphatic  ves- 
sels is  much  slower  than  in  the  upper  abdomen.  It 
likewise  enables  the  patient  to  breathe  better  and  to 
more  easily  get  rid  of  accumulations  of  gases  in  the 
stomach.  4.  Giving  large  quantities  of  saline  solu- 
tion by  the  bowel.  The  large  intestine,  particularly 
the  caecum,  readily  absorbs  water,  which  is  badly 
needed  by  the  poisoned  tissues,  but  which  cannot  be 
retained  by  the  stomach.  By  introducing  a  large 
amount  of  water  into  the  system  it  is  contended  that 
])eritoneal  absorption  is  not  only  arrested,  but  that, 
by  a  reversal  of  the  stream,  the  poisons  already 
taken  up  are  eliminated.  The  saline  solution  may 
be  given  continuously  by  means  of  a  rectal  tube  con- 
nected with  a  reservoir  placed  a  few  inches  higher 
than  the  level  of  rectum.  The  flow  should  be  so 
adjusted  that  from  one  to  two  drops  escape  each 
second.  In  very  bad  cases  antistreptococcal  serum 
may  be  given.  Secondary  abscesses  should  be 
promptly  opened  and  drained.  Nothing  should,  be 
given  by  the  mouth  for  twenty-four  hours.  This 
constitutes  Murphy's  method  of  dealing  with  diffuse 
septic  peritonitis. 

4.  Leucocytosis  in  Appendicitis.  —  Mitchell 
states  that  the  behavior  of  the  leucocytes  in  most 
cases  of  appendicitis  gives  a  sure  index  both  of  the 
intensity  of  the  morbid  irritant  and  of  the  individu- 
al's powers  of  resistance.    But  it  must  be  considered 


along  with  the  other  clinical  signs,  otherwise  it  will 
be  frequently  misleading.  It  is  of  more  service  to 
know  the  rate  at  which  the  leucocytosis  is  increasing 
than  to  know  the  actual  number  of  leucocytes  in  a 
given  case.  An  increasing  leucocytosis  means  that 
the  patient  is  fighting  the  toxines,  while  if  the  leu- 
cocyte count  rises  above  that  indicating  pus  forma- 
tion or  gangrene,  and  keeps  on  rising  rapidly,  it  in- 
dicates that  virulent  poison  is  being  freely  circulated 
in  the  sy  stem,  which  may  gain  the  upper  hand  at  any 
moment  if  operation  is  not  resorted  to.  The  leu- 
cocytosis in  acute  appendicular  abscess  averages 
from  15,000  to  17,000;  in  gangrenous  appendicitis 
it  may  be  as  high  as  40.000.  Patients  in  whom  the 
general  symptoms  arc  severe  and  the  absolute  leu- 
cocyte count  low,  frequently  die.  In  cases  with  sud- 
den onset  and  severe  shock,  there  may  be  little  in- 
crease in  the  leucocytes ;  but  if  the  individual  reacts 
from  the  shock  the  count  rises.  If  the  leucocytosis 
is  not  increasing  to  any  appreciable  extent  in  cases 
where  there  are  clinical  signs  of  abscess  formation, 
it  is  safe  to  conclude  that  the  abscess  is  becoming 
"walled  off"  by  adhesions,  and  that  operation  can  be 
postponed  until  the  abscess  cavity  is  thoroughly  shut 
off  from  the  general  peritoneal  cavity.  \^ariation  in 
size  of  the  leucocytes  is  of  little  significance.  The 
most  important  changes  in  the  distinctive  count  of 
the  leucocytes  are  the  great  increase  in  the  percen- 
tage of  polynuclear  cells  and  the  diminution  in  the 
percentage  of  lymphocytes  and  eosinophiles.  The 
ratio  between  the  increase  in  the  absolute  number  of 
leucocytes  and  the  increased  percentage  of  poly- 
nuclear cells  is  about  i.ooo  to  1.5,  that  is  to  say,  tak- 
ing the  normal  number  of  leucocytes  to  be  10,000 
per  c.mm.  and  the  percentage  of  polynuclear  cells  as 
72,  then  for  every  1,000  of  increase  in  the  absolute 
count  there  would  be  a  corresponding  increase  of 
1.5  per  cent,  in  the  polynuclear  cells.  There  seems 
to  be  but  little  relation  between  temperature  and  leu- 
cocytosis. 

LANCET. 
January  9,  igog. 

1.  Cardiac  iMotion  as  Revealed  by  the  Vivisection  of  Dis- 

ease, By  A.  MoRisoN. 

2.  Nasoantral  Polypus,  By  A.  B.  Kelly. 

3.  Five  Years'  Experience  with  Dubois's  Apparatus  for 

Administering  Chloroform,         By  P.  M.  Ch.apman. 

4.  An  Unusual  Carse  of  German  Measles, 

By  G.  C.  Garratt. 

5.  Two  Cases  of  "Obscure"  Rectal  Pain  and  their  Treat- 

ment, By  F.  C.  Wallis. 

6.  -A.  Preliminary  Note  on  the  Examination  of  Fat  in  the 

Liver  in  Health  and  Disease, 

By  E.  L.  Kexnawav  and  J.  B.  Leathes. 

7.  A  Case  of  Excision  of  the  Scapula, 

By  H.   B.  MVLVAGANAM. 

8.  Motoring  Notes,  By  C.  T.  W.  Hirsch. 

I.  Action  of  the  Heart. — M orison  has  studied 
the  factors  of  cardiac  movement,  taking  advantage 
especially  of  the  new  light  thrown  on  the  disease  bv 
operations  on  the  diseased  heart  and  pericardium. 
He  comes  to  the  conclusion  that  the  maintenance  of 
the  circulation  and  preservation  of  the  life  of  the  or- 
ganism chiefly  depend  upon  the  action  of  the  ven- 
tricles of  the  heart.  .\  man  does  not  die  from  ven- 
tricular failure  because  cardiac  motion  from  the 
veins  and  auricles  towards  the  ventricles  is  blocked 
or  prevented  from  reaching  the  latter  with  normal 
ease  and  regularity,  but  because  the  independent 


February  6,  igog.] 


rriH  Oh  CURRENT  LITERATURE. 


297 


motile  power  of  the  ventricle  has  been  abolished,  by 
the  failure  on  its  own  part  to  produce  the  stimulus 
to  contraction  in  a  sufficient  mass  of  its  substance, 
and  with  sufficient  regularity,  to  maintain  its  effec- 
tive contraction.  The  regulation  of  this  property  of 
cardiac  muscle'  and  of  every  other  manifestation  of 
its  life,  like  the  regulation  of  all  other  functions,  de- 
pends upon  the  visceral  nervous  system  and  its  cen- 
tral sources  The  general  conclusion  reached  is  that 
man  lives  upon  his  ventricles,  and  chiefly  upon  his 
left  ventricle,  not  upon  his  veins  or  auricles,  and  that 
the  normal  action  of  the  ventricles  is  dependent 
upon  the  healthy  action  and  interaction  of  the  three 
fundamental  factors  in  organic  life — blood,  cell,  and 
nerves ;  a  trinity  in  which  the  blood  supplies  the 
force  necessary  to  the  production  and  continuance 
of  vital  action,  in  which  the  cell  is  the  specific 
agency  or  mechanism  for  a  given  organic  act,  and 
in  which  the  nerves  regulate  alike  the  production  of 
the  motive  force  and  the  degree  and  regularity  of 
its  manifestation  in  the  specific  cell.  A  corollary  to 
this  conclusion  is.  that  as  man  lives  on  his  ventricle, 
hot  in  his  auricle,  the  examination  and  registration 
of  ventricular  action  are  of  greater  practical  impor- 
tance than  a  similar  investigation  of  the  action  of 
the  veins  and  auricles. 

2.  Nasoantral  Polypus. — Kelly  discusses  that 
variety  of  nasal  polypus  known  as  the  nasopharyn- 
geal or  choanal  form.  This  neoplasm  presents  sev- 
eral distinct  features.  The  patient  in  many  instances 
is  a  child.  The  neoplasm  is  single.  If  small  it  is 
situated  in  the  posterior  part  of  the  nasal  fossa:  if 
large,  it  projects  iiito  the  nasopharynx  and  may  even 
hang  below  the  palate.  A  lobe  or  prolongation  may 
extend  forward  in  the  nose  and  reach  the  anterior 
naris,  so  that  the  case  may  look  like  an  ordinar\- 
one  of  nasal  polypus.  In  spite  of  the  unilateral 
character  of  the  growth  there  is.  as  a  rule,  no  asso- 
ciated discharge  of  pus.  Removal  through  the 
mouth  will  probably  suggest  itself  as  most  feasible 
when  the  polypus  is  large.  If  caught  firmly  it  can 
be  torn  away  entirely,  so  that  on  examining  the 
nasopharynx  not  only  is  no  trace  of  the  growth  seen, 
but  even  the  bleeding  point  of  attachment  is  not  dis- 
coverable. A  large  cyst  is  usually  present  in  the 
polypus.  Recurrence  is  not  uncommon.  Even  with 
such  well  marked  characteristics,  but  little  attention 
has  been  paid  to  the  growths,  and  their  antral  origin 
was  only  recognized  three  years  ago  by  Killian. 
Tli.e  youth  of  the  patients  is  a  striking  peculiarity ; 
ordinary  nasal  polypus  occurs  almost  exclusively  in 
adults.  From  the  comparatively  sudden  onset  of  the 
symptoms,  it  is  probable  that  these  antral  polypi  are 
of  quite  rapid  growth.  Two  symptoms  are  almost 
invariably  present — namely,  snoring  and  thick 
speech.  A  watery  discharge  from  the  affected  side 
is  sometimes  complained  of.  The  morbid  condition 
in  the  antrum  is  most  frequently  a  cyst ;  on  transil- 
lumination the  affected  side  is  often  brighter  than 
the  healthy  side,  due  to  condensation  of  refraction 
by  the  fluid  in  the  sac.  After  removal  of  the  cyst 
from  the  antrum,  the  affected  side  is  darker  on 
transillumination,  due  to  the  thickened,  dulled,  lining 
membrane.  Some  weeks  later,  after  the  lining  mem- 
brane has  regained  its  polish,  both  sides  transil- 
lumine  equallv  well.  The  writer  formerly  removed 
the  growth  by  a  snare.    He  now  opens  the  antrum. 


determines  the  intraantral  attachments  of  the 
growth,  and  completely  removes  these  together  with 
the  polypus  in  the  nose.  Owing  to  the  constriction 
at  the  ostium  of  the  antrum,  there  is  a  tendency  to 
oedema  of  the  polypus  and  to  the  formation  of  false 
cysts  in  its  substance.  The  cysts  usualh'  spring 
from  the  inner  wall  of  the  antral  cavity. 

7.  Excision  of  the  Scapula. — Alylvaganam  re- 
ports a  case  of  excision  of  the  scapula  for  malignant 
disease.  His  conclusions  are  as  follows:  i.  The  T 
shaped  incision  is  the  best  suited  for  excision  of  the 
scapula.  2.  In  all  malignant  tumors  of  the  scapula, 
whether  in  its  early  or  late  stage,  total  excision  is  to 
be  preferred,  as  the  chances  of  local  recurrence  after 
partial  excision  are  great.  3.  The  retention  of  the 
glenoid  fossa  and  the  coracoid  process,  instead  ot 
being  an  advantage,  may  render  movements  of  the 
head  of  the  humerus  painful  on  account  of  the  rough 
surface  of  the  remaining  piece  of  the  scapula  press- 
ing on  the  surrounding  parts,  or  may  limit  its  move- 
ments by  its  irregular  surface.  A  traumatic  or  in- 
fective synovitis  may  take  place  or  the  fragments 
may  undergo  necrosis  on  account  of  the  diminished 
blood  supply  rendered  unavoidable  by  the  necessary 
dissection  of  the  surrounding  parts.  This  fragment 
cannot  take  the  place  of  the  normal  scapula  even  to 
a  small  extent,  as  it  is  no  longer  connected  with  the 
chief  muscles  which  give  stability  to  the  normal 
scapula  during  the  wide  range  of  movement  of  the 
humerus — viz.,  the  serratus  magnus,  trapezius,  leva- 
tor anguli  scapulae,  rhombodei,  omohyoid — so  that 
it  is  likely  to  move  with  the  head  of  the  humerus. 
Moreover,  the  long  head  of  the  biceps  and  the  tri- 
ceps, and  the  coracobrachialis  will  tend  to  draw  the 
fragment  downwards  and  keep  it  well  fixed  to  the 
head  of  the  humerus,  so  that  during  the  movements 
of  the  joint  there  will  be  no  movement  between  the 
head  of  the  humerus  and  the  glenoid  cavity,  but  the 
whole  piece  will  move  as  a  whole.  4.  The  operation 
must  be  completed  as  quickly  as  possible,  otherwise 
there  will  be  a  lot  of  haemorrhage  from  the  surface 
of  the  tumor  which  cannot  be  effectively  stopped 
even  after  ligating  the  main  vessels.  5.  In  innocent 
growths  our  aim  should  be  to  preserve  as  much  of 
the  scapula  as  compatible  with  safety.  Only  that 
portion  of  the  scapula  to  which  the  tumor  is  at- 
tached should  be  excised,  but  the  rest  should  be  left 
intact.  The  larger  the  portion  of  the  scapula  left 
the  greater  is  the  movement  of  the  joint.  6.  Success 
of  the  operation  largely  depends  on  strict  asepsis 
and  the  early  adoption  of  systematic  active  and  pas-/ 
sive  movements  of  the  shoulder.  A  false  joint  is 
sure  to  form  around  the  head  of  the  humerus  in 
course  of  time. 

LA  PRESSE  MEDICALE 

December  16,  1908. 

1.  Resistance  of  the  Stomach  to  Aiitodigestion.  Path- 

ogen}^ of  Ulcer  of  the  Stomach,  By  Albert  Frouin. 

2.  Tropical  Hypochlorhydria,  By  E.  Marchoux. 

I.  Resistance  of  the  Stomach  to  Autodiges- 
tion.  Pathogeny  of  Ulcer  of  the  Stomach. — 
Frouin  gives  the  following  as  the  practical  conclu- 
sions to  be  drawn  from,  his  observations:  i.  By 
varying  the  quantity  of  salt  introduced  with  the 
food  the  gastric  secretion  may  be  modified  both 
qualitatively  and  quantitatively.    2.  An  incomplete 


298  PITH  OF  CURRENT  LITERATURE. 


evacuation,  a  permanent  stagnation  of  the  gastric 
juice  in  a  case  of  hypersecretion,  may  set  up  an 
almost  total  autodigestion  of  the  mucous  membrane. 
3.  A  hypersecretion  set  up  and  continuing  for  eight 
or  ten  hours  causes  gastric  haemorrhage  if  the  se- 
creted juice  is  left  in  contact  with  the  mucous  mem- 
brane. 4.  Introduction  of  the  products  of  digestion 
of  albumenoids  and  contact  for  twenty-four  to  thirty- 
six  hours  likewise  causes  gastric  haemorrhage.  5. 
In  surgical  interventions,  above  all  in  cases  of  over- 
secretion  and  hyperchlorhydria,  the  complete  evacu- 
ation of  the  contents  of  the  stomach  should  be 
assured. 

2.  Tropical  Hypochlorhydria.  —  Marchonx 
points  out  that  hypochlorhydria  is  very  frequent  in 
hot  climates  and  the  source  of  many  troubles.  Ap- 
propiiate  diet  and  the  administration  of  hydro- 
chloric acid  brings  about  a  rapid  improvement. 

Deceviber  19,  igo8. 

1.  Protection  and  Prospects  of  the  Prematurely  Born, 

By  Ch.  Maygrier. 

2.  Diagnosis  and  Treatment  \;>y  BronchocesSphagoscopy  of 

Some  Little  Recognized  Intrathoracic  Affections, 

By  GuiSEZ. 

3.  Sexual  Continence  and  Arteriosclerosis, 

By  P.  Remlinger. 

4.  Physiology  of  the  ^Muscles.    Gymnastics  of  the  Instep, 

By  P.  Desfosses. 

5.  Perforating  Ulcer  of  the  Foot  of  Tuberculous  Origin, 

By  L.  Arnaud. 

6.  Injections  of  Heterogenous  Blood  in  the  Treatment  of 

Hypertrophy  of  the  Prostate,  By  R.  Rom  me. 

1.  Protection  and  Prospects  of  the  Premature- 
ly Born. — Maygrier  deals  in  this  paper  with  the 
maintenance  of  a  proper  degree  of  heat  about  the 
prematurely  born  infant,  its  food,  and  the  avoidance 
of  every  kind  of  infection. 

2.  Bronchooesophagoscopy. — Guisez  portrays 
the  recognition  of  compression  of  the  trachea  by 
goitre,  or  by  enlarged  tracheobronchial  glands,  of 
the  presence  of  intratracheal  valves,  and  of  intra- 
tracheal tumors,  which  may  be  seen  and  operated  on 
by  direct  tracheoscopy.  He  also  shows  how  dilata- 
tion and  pouching  of  the  lower  end  of  the  CESopha- 
gus  may  be  distinguished  from  cicatricial  stenosis, 
and  the  results  of  dilatation  of  the  latter.  Finally 
he  deals  with  the  recognition  and  removal  of  foreign 
bodies  from  the  bronchi  and  the  oesophagus. 

3.  Sexual  Continence  and  Arteriosclerosis. — 
Remlinger  reports  three  cases  in  which  arterioscle- 
rosis appeared  and  followed  a  rapid  course  between 
the  ages  erf  thirty  and  forty  in  men  who  had  lived 
quiet,  exemplary  lives,  and  presented  no  hereditary 
or  personal  pathological  history  to  account  for  the 
development  of  this  affection.  He  is  inclined  to 
ascribe  it  to  their  sexual  continence. 

5.  Perforating  Ulcer  of  the  Foot  of  Tubercu- 
lous Origin. — Arnaud  reports  a  case  of  multiple, 
bilateral  perforating  ulcers  of  the  foot  of  a  man, 
twenty-three  years  of  age,  who  was  sufifering  from 
tuberculosis.  An  excellent  immediate  result  was 
obtained  by  curettage  of  the  ulcers  and  excision  of 
their  margins,  together  with  strctcliing  of  the  right 
posterior  tibial  nerve  and  denudation  of  the  left 
femoral  artery.  The  patient  had  no  syphilis,  dia- 
l)ctcs.  tabes,  professional  intoxication,  nor  nervous 
disea.se.   He  was  tuberculous  and  drank  to  excess. 


[New  York 
Medical  Journal.. 

December  23,  igo8. 

1.  Tuberculous  Infection  and  Immunization  against  Tu- 

berculosis through  the  Digestive  Tract, 

By  Professor  A.  Calmette. 

2.  The  Dressing  of  the  Day  in  Dermatology, 

By  L.  M.  Pautrier. 

1.  Immunization  against  Tuberculosis. — Cal- 
mette asserts  that  by  the  intestinal  absorption  of  a 
minute  dose  of  tubercle  bacilli  very  finely  divided 
one  may  obtain,  through  the  total  resorption  of  these 
bacilli  in  the  lymphatic  system,  a  state  of  immunity 
against  great  infections  through  the  digestive  canal 
that  will  last  a  year  or  less. 

December  26,  igoS. 

1.  The  Expulsion  of  a  Decidua  always  the  Sign  of  an 
Ectopic  Pregnancy,  By  S.  Remy. 

2.  Hydriatic  Treatment  of  Arteriosclerosis, 

By  Alfred  Martinet. 

3.  Reduced  Circulation  and  Narcosis,        By  R.  Rom  me. 

2.  Hydriatic  Treatment  of  Arteriosclerosis. — 

Martinet  says  that  baths  of  all  sorts  should  be  at  a 
temperature  between  34°  and  36°  C.  Hot  baths  are 
dangerous,  because  their  primary  effect  is  an  eleva- 
tion of  the  arterial  tension  which  may  cause  a  rup- 
ture of  an  affected  vessel  in  the  brain  or  elsewhere. 
Cold  baths  of  all  sorts  should  also  be  rigorously 
interdicted.  The  wet  pack  at  night,  preceded  and 
followed  by  friction,  is  of  great  value.  Baths  of 
electric  light  applied  to  different  parts  of  the  body 
in  succession  form  an  efficacious  means  to  dilate  the 
cutaneous  vessels  and  relieve  the  tissues  of  the  re- 
sults of  metabolism. 

LA  SEMAINE  MEDICALE. 
December  16,  190S. 

Treatment  of  Varicose  Veins  of  the  Legs  by  Intravenous 
Injections  of  a  Solution  of  Iodine. 

By  B.  Schiassi. 

Treatment  of  Varicose  Veins. — Schiassi  asserts 
to  have  obtained  good  results  from  an  attempt  to 
obliterate  the  affected  veins  by  rneans  of  a  throm- 
bosis set  up  by  the  intravenous  injection  of  a  solu- 
tion of  which  the  following  is  the  formula : 

R    Iodine  i  gramme; 

Potassium  iodide,   1.6  grammes; 

Sterilized  distilled  water,   100  grammes. 

M. 

December  23,  lOoS. 

1.  Does  the  Jewish  Race  Enjoy  an  Immunity  with  Regard 

to  Alcoholism?,  By  L.  Cheinisse. 

2.  How  Certain  Amyotrophies  of  Tabes  Reveal  a  Syph- 

ilitic Origin,  By  J.  Lhermitt'e. 

I.  Does  the  Jewish  Race  Enjoy  an  Immunity 
with  Regard  to  Alcohol? — Clieinisse  discusses 
the  slight  amount  of  alcoholism  met  with  in  the 
Jewish  race  in  all  parts  of  the  world  and  questions 
whether  this  is  due  to  an  immunity. 

BERLINER  KLINISCHE  WOCHENSCHRIFT 
December  31,  1908. 

1.  The  Classification  of  Symptomatic  Psychoses. 

By  K.  BONHOFFER. 

2.  The  Cachexia  Reaction,  Particularly  in  Cancer  Patients, 

By  L.  Brif.ger  and  Johannes  Trebinc. 

3.  The  Diagnosis  of  Carcinomatous  Meningitis, 

By  E.  Stadelmann. 

4.  Experiments    witli    New    Combinations    of  Arsenic 

against  Trypanosoniata  in  Rats  and  the  Blindness 
Observed,  By  H.  Wendelstaw. 


February  6,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


299 


5.    Scarlet  Fever  and  the  Serum  Reaction  of  Syphilis, 

By  Bruck  and  Cohn. 
■6.    Pleuritic  Deposits  and  Their  Treatment  with  Fibrolysin, 

By  SCHNUTGEN. 

7.    Contribution  to  the  Results  of  Treatment  of  Pulmonary 
Tuberculosis  with  Kuhn's  Pulmonary  Suction  Mask, 

By  A.  Vehling. 

2.  Cachexia  Reaction. — Brieger  and  Trebing 
report  the  reactions  obtained  from  the  administra- 
tion of  pancreatin  in  sixteen  cases  of  carcinoma, 
three  of  sarcoma,  five  cases  of  serious  cachexia  from 
various  diseases,  two  cases  of  slight  diabetes,  and 
two  sHght  cases  of  pulmonary  tuberculosis. 

3.  Diagnosis  of  Carcinomatous  Meningitis. — ■ 
Stadelmann  points  out  that  the  diagnosis  may 
sometimes  be  made  from  finding  carcinoma  cells  in 
the  fluid  obtained  by  lumbar  puncture.  He  says 
that  in  two  cases  these  cells  were  found,  in  three  they 
were  not. 

5.  Scarlet  Fever  and  the  Serum  Reaction  of 
Syphilis. — Bruck  and  Cohn  maintain  that  the  im- 
pression that  the  syphiHs  reaction  is  present  in  scar- 
let fever  is  erroneous,  and  that  the  value  of  the  test 
for  syphilis  is  in  no  way  diminished  by  the  presence 
of  scarlet  fever  in  the  patient. 

6.  Pleuritic  Deposits  and  Fibrolysin. — Schniit- 
gen  asserts  that  good  results  have  been  obtained  in 
the  dissolution  of  pleuritic  deposits  which  were  not 
too  old  by  the  action  of  fibrolysin. 

MUNCHENER  MEDIZINISCHE  WOCH ENSCH Rl FT. 
December  22,  igoS* 

1.  Treatment  with  Digitalis,  By  Muller. 

2.  New  Methods  in  the  Treatment  of  Purulent  Processes, 

By  KOLACZEK. 

3.  The  Importance  of  Examination  of  the  Blood  in  Sur- 

gical Diagnosis,  By  Fabian. 

4.  Senile  Anaesthesias,  By  Ehret. 

5.  The  Different  Action  of  Arsenic  in  Muscle  Work  and 

Muscle  Rest,  By  Riehl. 

6.  Results  of  Treatment  of  Severe  Cases  of  Infantile 

Paralysis,  By  Vulpius. 

7.  Thorerde,  Thorium  Oxydatum  Anhydricum,  a  Com- 

plement and  Partial  Substitute  for  the  Preparations 
of  Bismuth  in  Rontgenology  of  the  Human  Gastro- 
intestinal Canal,  By  Kastle. 

8.  Rachitic  Traces  in  the  Thoraxes  of  Adults, 

By  Ebstein. 

9.  Asthma  and  Stuttering.    Two  Nearly  Related  Neu- 

roses, By  Knopf. 

10.  Calcium  Chloride  and  Sea  Sickness,         By  Gewin. 

11.  The  Frequency  and  Conditions  Provocative  of  Pollu- 

tions in  Healthy  Men,  By  Friedjung. 

12.  Decapsulation  of  the  Kidneys  in  Eclampsia, 

By  Gminder. 

13.  A  Case  of  Posttraumatic  Hernia  of  the  Lungs, 

By  LoGES. 

14.  Cervical  Ribs,  By  Schafer. 

15.  Invalidity  and  the  Eye,  By  Cramer. 

16.  Operating   Table    for    Obstetric   and  Gynaecological 

Work,  By  Manger. 

17.  Oral  or  Nasal  Resection  of  the  Nasal  Saeptum, 

By  Brunings. 

18.  The  Presence  and  Importance  of  Monolaterally  Ele- 

vated Temperatures  in  Pulmonary  Affections, 

By  Muller. 

19.  The  Origin  and  Treatment  of  Intestinal  Hernia  (Con- 

cluded), By  Koch. 

20.  Obituary  of  Georg  Eduard  von  Rindfleisch, 

By  Borst. 

21.  The  "Wunderdoctor"  Felke,  By  Neustatter. 

22.  An  Anecdote  of  Ewald  von  Kleist,         By  Stabrin. 

I.  Treatment  with  Digitalis. — ]Miiller  tabu- 
lates twenty-three  clinical  observations  of  the  action 
of  extractum  digitalis  depuratum  Knoll  (digipura- 
tum)  in  various  forms  of  heart  disease  and  recom- 
mends it  whenever  digitalis  is  indicated. 


2,  New  Methods  of  Treatment  of  Purulent 
Processes. — Kolaczek  asserts  that  the  advantages 
presented  by  the  treatment  of  both  cold  and  hot 
abscesses  by  puncture  and  injection  of  antiferment 
serum  over  that  by  incision  are  a  more  protective 
intervention,  shortening  of  the  period  of  recovery, 
and  a  better  cosmetic  and  even  functional  result. 

3.  Examination  of  the  Blood  and  Surgical  Di- 
agnosis.— Fabian  points  out  the  great  help  sur- 
geons may  obtain  from  examination  of  the  blood  in 
the  early  stage  of  diseases  of  the  lymphatic  and 
haematopoietic  systems  when  the  only  clinical  symp- 
toms are  those  of  localized  tumors. 

5.  Arsenic  in  Muscle  Work  and  Muscle  Rest. 
— Riehl  finds  as  the  result  of  his  experiments  that 
the  muscle  work  or  muscle  rest  during  the  adminis- 
tration of  arsenic  has  a  great  influence  upon  the 
metabolism  and  body  weight  in  both  man  and  ani- 
mals. 

8,  Rachitic  Traces  in  Adults. — Ebstein  re- 
ports the  case  of  a  man  twenty  years  of  age  who 
presented  a  pecifliar  depression  of  one  side  of  the 
anterior  curvature  of  the  thorax.  This  condition 
Ebstein  is  inclined  to  ascribe  to  rickets  during  child- 
hood. 

10.  Calcium  Chloride  and  Sea  Sickness. — Gewin 
is  of  the  opinion  that  this  calcium  salt  has  a  certain 
degree  of  efficiency  in  the  prevention  and  mitigation 
of  sea  sickness. 

14.  Cervical  Ribs. — Schafer  adds  four  cases  to 
those  already  recorded  of  cervical  ribs.  In  all  four 
the  diagnosis  was  confirmed  by  the  x  ray  picture. 

THE  PRACTITIONER. 
January,  iQOg. 

1.  The  Complications  of  Scarlet  Fever,    By  W.  Hunter. 

2.  The  Heart  in  Scarlet  Fever  and  Diphtheria, 

By  Sir  J.  F.  H.  Broadbent. 

3.  The  Renal  Complications  of  Scarlet  Fever  and  Diph- 

theria, By  N.  Tirard. 

4.  Ocular  Complications  of  Scarlet  Fever  and  Diphtheria, 

By  J.  H.  Parsons. 

5.  The  Ear  Complications  of  Scarlet  Fever  and  Diph- 

theria, By  M.  Yearsley. 

6.  On  the  Diagnosis  of  Scarlet  Fever  and  Diphtheria, 

By  E.  W.  GooDALL. 

7.  Notes  on  the  Diagnosis  of  Scarlet  Fever  and  Diph- 

theria, By  H.  E.  Cuff. 

8.  The  Distinctive  Diagnosis  of  Scarlet  Fever, 

By  J.  E.  Beggs. 

9.  On  the  Distinctive  Diagnosis  between  the  Rashes  of 

Scarlatina,  Diphtheria,  and  other  Skin  Eruptions, 

By  A.  Whitfield. 

10.  Observations  bearing  on  the  Convalescent  Stage  of 

Diphtheria,  By  F.  F.  Caiger. 

11.  The  Treatment  of  Scarlet  Fever,      By  A.  K.  Gordon. 

12.  Treatment  of  Diphtheria,  By  C.  B.  Ker. 

13.  Diphtheritic  Paralysis,  By  J.  D.  Rolleston. 

14.  On  Tracheotomy,  By  F.  M.  Turner. 

15.  The  Bacteriology  of  Scarlet  Fever,    By  M.  H.  Gordon. 

16.  The  Bacteriology  of  Diphtheria,     By  R.  T.  Hewlett. 

17.  Antistreptococcus  Serum  in  Scarlet  Fever  and  Diph- 

theria, By  M.  Young. 

18.  Scarlet  Fever  and  Diphtheria  from  the  Public  Health 

Point  of  View,  By  J.  F.  C.  Nash. 

I.  The  Complications  of  Scarlet  Fever.  — 
Hunter  observes  that  the  mere  mortality  of  this  dis- 
ease is  not  large  and  does  not  justify  the  public 
dread  of  it  or  the  public  expenditure,  on  that  ground 
alone.  Both  these  factors  are  justified  on  the 
grounds  of  the  treacherousness  of  the  disease,  and 
the  complications  to  which  it  is  subject  to  an  un- 


300 


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[New  York 
Medical  Journal.. 


usual  degree.  Two  groups  of  complications  majf  be 
mentioned;  i,  those  connected  with  the  scarlatinal 
infection  itself,  and,  2,  those  connected  with  the  sep- 
tic infection  with  which  it  is  so  often  associated,  and 
by  which  it  is  so  frequently  aggravated.  In  the  first 
group  are  local  conditions,  secondary  angina,  sec- 
ondary adenitis,  cellulitis,  glandular  suppuration, 
rhinitis,  and  otitis;  in  the  second  are  general  con- 
ditions, albuminuria,  nephritis,  and  rheumatism. 
Two  facts  are  believed  to  be  of  great  importance, 
namely,  that  the  general  conditions  have  in  recent 
years  remained  uniform  while  in  the  same  period  the 
local  complications  have  steadily  and  uniformly  di- 
minished. The  latter  is  due  to  the  prevalence  of 
antiseptic  measures,  and  particularly  to  the  greater 
care  and  attention  which  are  now  given  to  adenoids 
and  diseased  tonsils.  It  is  important  to  note  that 
albuminuria  is  most  common  in  the  early  days  of  the 
disease  and  calls  for  daily  examinations  of  the  urine. 
No  sharp  line  can  be  drawn  between  severe  albu- 
minuria and  nephritis,  but  the  presence  of  blood  in 
the  urine  makes  an  important  distinction  and  may  be 
followed  by  uraemic  complications. 

2.  The  Heart  in  Scarlet  Fever  and  Diphtheria. 
— Broadbent  thinks  endocarditis  and  pericarditis  are 
infrequent  with  scarlatina.  The  scarlatina  toxine 
does,  however,  produce  a  myocarditis  similar  to  that 
which  occurs  with  rheumatism.  Its  most  striking 
physical  sign  is  a  marked  tachycardia  which  may 
persist  long  after  convalescence  has  begun.  This  is 
not  usually  due  entirely  to  the  myocarditis  or  to 
cardiac  dilatation,  but  to  disturbance  of  the  nervous 
mechanism  of  the  heart.  The  pulse  may  also  be 
irregular,  and  these  facts  indicate  that  scarlatinal 
patients  should  take  .convalescence  very  slowly.  In 
diphtheria  heart  failure  during  the  disease  or  during 
convalescence  is  to  be  dreaded.  The  myocardial 
lesions  with  diphtheria  are  extensive,  especially 
fatty,  hyaline,  and  granular  degeneration.  Periph- 
eral neuritis,  affecting  the  vagus,  may  account  for 
the  tendency  to  cardiac  syncope  in  diphtheria.  A 
dilated  heart  or  a  systolic  murmur  with  diphtheria 
is  not  necessarily  serious,  but  always  serious  are 
irregular  and  intermittent  pulse,  tachycardia,  and 
vomiting,  especially  when  attended  with  prsecordial 
pain  and  distress.  Hence  in  diphtheria,  the  heart 
should  be  carefully  examined  daily,  and  the  patient 
should  be  kept  in  bed  a  long  time  under  careful  diet, 
with  brandy  and  strychnine  as  cardiac  stimulants. 

3.  The  Renal  Complications  of  Scarlet  Fever 
and  Diphtheria.  —  Tirard  says  that  the  risks  of 
renal  disease  in  scarlatina  are  so  grave  that  attention 
is  often  diverted  from  the  original  illness  and  con- 
centrated upon  the  complication  which  may  result  in 
acute  or  chronic  tubal  nephritis.  In  diphtheria,  on 
the  other  hand,  renal  complications  are  rare,  and  are 
seldom  of  serious  importance.  In  scarlatina  the  con- 
ditions vary  between  slight  albuminuria  and  acute 
nephritis  with  urjemia  and  with  more  or  less  dropsy. 
The  albuminuria  is  often  of  toxic  origin,  and  must 
not  be  neglected,  however  slight  the  symptoms. 
Causes  of  albuminuria  and  nephritis  are  found  in 
adenoid  disease,  heredity,  bad  atmospheric  condi- 
tions, but  especially  in  a  toxine  which  is  developed 
within  the  body.  The  severity  of  the  nephritis  is  not 
governed  by  the  severity  of  the  original  fever. 
Oidema  following  scarlatina  must  always  be  re- 


garded as  a  serious  symptom.  Albuminuria  is  rela- 
tively more  frequent  with  diphtheria  than  with  scar- 
latina, but  has  less  serious  significance.  In  some  in- 
stances, however,  it  is  followed  by  suppression  of 
urine  and  uraemia  and  these  by  vomiting  and  heart 
failure  with  fatal  issue.  With  large  quantities  of 
albumin  there  may  also  be  haematuria,  but  there  is 
seldom  the  serious  urgency  which  accompanies  diph- 
theritic toxrTmia  including  interference  with  the 
respiration,  circulation,  and  nervous  system. 

4.  Ocular  Complications  of  Scarlet  Fever  and 
Diphtheria. — Parsons  states  that  ocular  compli- 
cations with  scarlatina  are  infrequent.  Conjunc- 
tivitis is  of  occasional  occurrence  and  may  be  fatal 
to  the  eye.  Rarely  there  are  abscess  and  gangrene 
of  the  lids.  The  most  important  complications  are 
secondary  to  scarlatinal  nephritis,  uraemic  amauro- 
sis being  most  frequent.  Of  rare  occurrence  are 
retinitis,  embolism,  optic  neuritis,  orbital  cellulitis, 
etc.  With  diphtheria  the  most  frequent  ocular  com- 
plication is  membranous  conjunctivitis.  It  may  be 
caused  by  the  xerosis  bacillus  in  the  conjunctival 
sac,  this  microorganism  being  morphologically  iden- 
tical with  the  Klebs-Loffier  bacillus.  The  diph- 
theritic bacillus  is  seldom  found  in  pure  culture  in 
membranous  conjunctivitis,  being  usually  associated 
with  streptococci,  staphylococci,  and  other  patho- 
genic organisms.  Gangrene  of  the  lid,  diphtheria 
of  the  lacrimal  sac,  dacryadenitis,  orbital  abscess, 
and  optic  neuritis  are  rare  complications.  Postdiph- 
theritic paralysis,  rare  after  conjunctival  diphtheria, 
are  frequent  after  other  forms.  They  may  affect 
the  ciliary  muscle,  the  accommodation,  and  some- 
times the  iris.  It  is  important  that  children  who 
have  had  diphtheria  should  be  examined  both  for 
near  and  distant  vision,  before  the  instillation  of  a 
mydriatic. 

 ^  


SOUTHERN   SURGICAL  AND  GYN.^COLOGIC.\L 
ASSOCIATION. 

Twenty-first  Annual  Meeting,  Held  in  St.  Louis,  December 
15,  16,  and  17,  1908. 
The  President,  Dr.  F.  W.  Parham,  of  New  Orleans, 
in  the  Chair. 

Syphilitic  Hyperplasia  of  Bone. — Dr.   C.  E. 

Caldwell,  of  Cincinnati,  said  that  this  condition 
was  characterized  by  the  deposition,  without  ap- 
parent coincident  inflammatory  symptoms,  of  a  bony 
substance  from  the  osteogenetic  layer  of  the  peri- 
osteum. When  occurring  in  the  long  bones,  partic- 
ularly in  the  tibia,  it  resulted  in  overgrowth  or  a 
species  of  gigantism  of  the  affected  bone.  Occurring 
as  it  frequently  did  in  the  epiphyseal  ends  of  the 
long  bones,  it"  might,  through  juxtaposition  to  a 
joint,  be  mistaken  either  for  tuberculous  epiphysitis, 
or,  as  in  one  case,  closely  simulate  in  its  clinical  his- 
tory and  appearance  a  myeloma  of  the  epiphysis. 
Fortunately,  in  the  Rontgen  ray  we  had  a  very  sat- 
isfactory means  of  diagnosis,  and  we  were  usually 
rewarded  with  a  picture  which  quite  definitely  classi- 
fied the  condition.  The  class  of  cases  to  which  he 
referred  had  usually  a  remote  and  not  always  clear- 


February  6,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


301 


ly  defined  history  of  syphilitic  infection.  The  pro- 
gress of  the  affection  was  so  gradual  and  accom- 
panied by  such  slight  disturbance  of  tlie  comfort  of 
the  patient  that  he  did  not  usually  present  himself  for 
treatment  imtil  the  bony  overgrowth  was  such  as  to 
attract  his  attention.  Inasmuch  as  the  patients  who 
had  come  under  the  author's  observation  had  not 
undergone  operation,  but  had  more  or  less  promptly 
yielded  to  treatment  with  potassium  iodide  in 
large  doses  in  a  period  varying  from  six  weeks  to 
three  months,  with  local  inunctions  of  mercurial 
ointment,  there  had  been  no  opportunity  for  patho- 
logicohistological  investigation.  Inferentially,  from 
the  X  ray  pictures,  there  was  a  formative  osteitis  of 
chronic  form,  which  might  not  inaptly  be  compared 
to  the  chronic  interstitial  hyperplasia  of  internal  vis- 
cera and  to  the  syphilitic  hyperplasia  of  the  coats  of 
arteries  resulting  in  obliterating  endarteritis.  It  was 
not  at  all  improbable  that  in  this  class  of  cases  there 
might  be  nutritive  changes  in  the  periosteum  which 
produced  a  condition  not  dissimilar  to  leontiasis  or 
to  Paget's  disease.  In  one  case  affecting  the  lower 
end  of  the  tibia  the  tumor  was  so  circumscribed  and 
had  grown  so  large  as  to  have  deceived  certain  sur- 
geons into  the  belief  of  its  sarcomatous  or  mye- 
lomatous  nature.  In  this  case,  that  of  a  man,  aged 
thirty-four,  in  whom  there  were  found  no  stigmata 
of  syphilis,  a  history  was  elicited  of  a  sore  which 
had  been  contracted  seventeen  years  before,  al- 
though there  was  no  history  of  secondary  trouble. 
A  diagnosis  of  syphiloma  or  formative  osteoperi- 
ostitis was  made,  and«confirmed  by  the  x  ray.  Potas- 
sium iodide  in  large  doses  cured  the  patient  in 
three  months.  " 

Dr.  Arthur  Dean  Bevax,  of  Chicago,  said  he 
had  had  such  an  experience  as  this,  that  of  a  man 
brought  to  him  by  a  good  practitioner  with  a  diag- 
nosis of  sarcoma  of  the  thigh,  the  patient,  the  father 
of  four  or  five  healthy  children,  denying  absolutely 
any  history  of  syphilis,  and,  when  informed  that 
amputation  at  the  hip  joint  was  necessary,  being 
quite  willing  to  submit  to  the  operation.  Fortunate- 
ly, before  doing  this  extensive  operation,  massive 
doses  of  potassium  iodide  were  employed  for  a  few 
months,  with  entire  disappearance  of  the  tumor,  and 
then  the  patient  confessed  to  a  syphilitic  lesion  long 
before  he  was  married,  stating  that  he  had  not  said 
so  before  because  he  was  confident  that  there  could 
not  be  any  connection  between  that  initial  lesion  and 
his  present  condition. 

Myoma  and  Myosarcoma  of  the  Stomach. — Dr. 
James  E.  Thompson,  of  Galveston,  Texas,  reported 
a  case  with  the  following  symptoms :  ^larked 
hsematemesis  and  melsena,  muscular  cramps  (tet- 
any), no  tumor  palpable.  Examination  of  the  gas- 
tric juice  showed  free  hydrochloric  acid,  40;  no  lac- 
tic acid-  A  partial  gastrectomy  was  performed  suc- 
cessfully. The  tumor  was  found  to  spring  from  the 
anterior  wall  of  the  stomach,  and  projected  into  the 
interior.    Miscroscopically,  it  was  a  pure  myoma. 

The  author  had  reviewed  the  literature,  and  found 
in  all  sixty-two  cases  of  myoma  and  myosarcoma ; 
nineteen  were  subjected  to  operation,  and  forty- 
three  were  found  at  autopsy  or  in  different  patho- 
logical museums.  He  said  the  histories  of  cases 
were  too  meagre  to  build  up  a  symptomatology. 

Dr.  Maurice  H.  Richardson,  of  Boston,  had 


been  unable  to  tell  the  difference  between  a  malig- 
nant tumor  of  the  pylorus  and  a  chronic  ulcer  at  the 
time  of  operation.  In  these  cases  the  surgeon  could 
not  always  have  at  hand  an  expert  microscopist, 
with  freezing  apparatus,  making  sections,  etc.,  to  aid 
him,  and  yet  he  must  know  on  the  spot  what  the  di- 
agnosis was.  If  the  surgeon  could  not  make  a  di- 
agnosis he  did  not  know  the  possibilities  of  these 
growths.  Every  case  of  the  kind  reported  by  the 
essayist  widened  a  man's  horizon  and  added  to  his 
knowledge. 

Dr.  Charles  H.  Mayo,  of  Rochester,  Minn.,  said 
that  benign  tumors  of  the  stomach  were  so  rare  as 
compared  with  malignant  growths  that  they  were 
very  seldom  thought  of;  at  the  same  time,  there 
were  quite  a  number  of  them  in  which  the  tumors 
had  been  found  to  be  malignant  at  autopsy.  He  re- 
called a  case  of  adenoma  of  the  stomach  which  was 
as  large  as  a  pear,  with  a  large  pedicle,  yet  not  eroded 
and  not  bleeding,  which  was  situated  in  the  posterior 
wall,  projecting  into  the  stomach,  and  was  removed 
by  excision.  He  also  recalled  three  cases  of  mus- 
cular hypertrophy  of  the  stomach  that  produced  ob- 
structive symptoms.  These  occurred  at  the  pyloric 
end.  and  were  similar  to  those  that  \ve  knew  of  as 
occurring  in  children  with  muscular  hypertrophy, 
encircling  the  pyloric  end  of  the  stomach,  producing 
starvation  and  death.  The  patients  were  adults,  yet 
the  condition  was  the  same,  requiring  a  resection  of 
the  stomach  as  for  pyloric  tumors. 

Dr.  George  W.  Crile,  of  Cleveland,  added  a  case 
of  myoma  of  the  stomach  which  was  operated  on  by 
his  associate,  Dr.  Lower.  The  case  conformed  to 
the  one  described  by  the  essayist.  He  reported  a 
case  of  adenomyoma  from  his  own  experience, 
which  was  situated  in  the  wall  of  the  stomach,  but 
at  the  time  of  operation  it  was  supposed  to  be  a  sar- 
coma. The  stomach  wall  was  resected,  and  the  pa- 
tient recovered. 

Dr.  Thompson  thought  he  was  dealing  with  a 
malignant  growth,  and  if  he  had  only  known  it  was 
a  benign  tum.or,  a  more  simple  operation  would  have 
sufficed. 

Conclusions  Based  upon  Observations  of  Five 
Hundred  Cases  of  Fracture  of  the  SkuU. — Dr. 

Walter  C.  G.  Kirchner,  of  St.  Louis,  emphasized 
the  importance  of  studying  these  cases  at  the  au- 
topsy table  and  in  the  operating  room.  From  a 
pathological  consideration  the  nutritional  changes 
of  brain  structure  were  very  important,  because  they 
served  to  explain  many  complications  and  doubtful 
cases.  The  symptoms  of  various  phases  of  frac- 
tured skull  were  reviewed,  also  prognosis  and  treat- 
ment. Linear  fractures  of  the  vault  usually  did  not 
require  an  operation  unless  they  involved  important 
vessels  or  sinuses.  In  depressed  fractures  the  de- 
pressed fragments  should  be  elevated  or  removed. 
Experience  had  shown  that  in  compound  fractures, 
especially  where  there  was  injury  to  the  dura  or 
brain,  drainage  of  the  wound  was  usually  desirable. 
An  operation  for  fracture  at  the  base  was  indicated 
where  haemorrhage  was  extradural  and  where  there 
were  no  signs  of  compression.  The  middle  fossa 
was  most  frequently  involved,  and  drainage  here 
could  be  easily  instituted.  The  practice  of  examin- 
ing haematomata  by  means  of  exploratory  incision 
was  practically  without  danger  when  reasonable  pre- 


302 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


cautions  were  taken,  and  often  gave  most  valuable 
information  as  an  aid  in  diagnosis.  The  neurologi- 
cal findings  were  of  value  in  determining  focal 
symptoms,  but  when  complex  brain  disturbances  ex- 
isted, they  might  be  unreliable  as  diagnostic  aids  and 
require  special  interpretation.  Brain  compression 
was  a  positive  indication  for  operation,  and  as  a 
rule  the  sooner  compression  was  removed  the  better 
the  prognosis.  At  the  operation  shock  and  haemor- 
rhage were  factors  that  should  be  carefully  regarded, 
and  the  operation  should  be  done  as  speedily  as  pos- 
sible. In  doubtful  cases,  where  it  was  probable  that 
the  symptoms  were  caused  by  brain  compression, 
exploratory  operations  were  indicated.  The  ex- 
pectant treatment  was  to  be  advocated  in  those  cases 
in  which  there  were  no  symptoms  of  brain  com- 
pression, in  which  the  temperature  and  pulse  re- 
mained nearly  normal,  and  in  which  the  reflexes 
were  but  little  altered.  Unconsciousness  in  itself 
was  no  index  of  the  seriovisness  of  the  trouble.  An 
operation  was  contraindicated  in  those  cases  in 
which  the  symptoms  were  the  result  of  intrinsic 
destruction  of  brain  tissue,  when  the  temperature 
was  high,  the  pulse  rapid,  and  the  blood  pressure  di- 
minished. The  importance  of  a  longer  period  of 
rest  in  bed  should  be  strongly  emphasized,  so  that 
the  danger  of  secondary  complications  might  be 
avoided. 

Fractures  of  the  Elbow  Joint. — Dr.  Robert 
Carothers,  of  Cincinnati,  selected  three  points  for 
consideration:  i.  The  importance  of  a  correct  di- 
agnosis. 2,  Correct  apposition  and  maintenance  of 
the  fragments.  3.  Early  passive  motion.  A.  diag- 
nosis was  based  upon  the  physical  signs  present  and 
confirmed  by  x  ray  plates  of  the  injured  elbow 
made  at  right  angles  to  each  other.  It  was  the  care- 
ful study  of  the  case  that  cotmted.  The  cause  of 
the  accident,  the  age,  comparison  of  the  injured 
with  the  uninjured  elbow,  and  then  an  elucidation 
of  any  and  all  the  signs  of  fracture  were  consid- 
ered, especially  as  applied  to  the  part  under  discus- 
sion. After  this  evidence  had  been  obtained,  with 
a  careful  study  of  the  x  ray  plates,  one  was  able  to 
arrive  at  a  diagnosis  which  was  not  only  complete, 
but  scientific.  Since  these  injuries  occurred  with 
such  frequency  in  childhood,  in  reading  an  x  ray 
plate  in  such  a  case  one  must  have  in  mind  the  os- 
sifying centres  in  the  immediate  neighborhood  of  the 
elbow  joint,  and  not  be  misled  thereby.  He  could 
not  lay  enough  stress  on  the  x  ray  examination  of 
fractured  elbow  joints,  for  a  diagnosis  otherwise 
made  was  a  guess  at  best. 

The  most  frequent  fractures  of  the  elbow  joint 
were  pointed  out,  and  their  treatment  was  discussed. 
In  the  so  called  chisel  fractures  of  the  head  of  the 
radius  the  repair  was  usually  with  so  much  callus 
and  impairment  of  function  of  the  joint  that  it  was 
advisable,  unless  for  some  good  reason  contraindi- 
cated, to  remove  the  detached  fragment.  In  the 
fractures  of  the  neck  of  the  radius,  the  best  results 
would  be  obtained  by  making  apposition,  which  or- 
dinarily was  easy  by  manipulation  and  maintaining 
the  same  with  thcj'orearm  in  a  semiflexed  position 
to  overcome  a  possible  displacement  of  the  biceps. 

Suprapubic  Prostatectomy. — Dr.  Arthur  Dean 
Bevan,  of  Chicago,  said  tl:at  suprapubic  enucleation 
of  the  prostate  had  the  widest  field  of  usefulness.  It 


was  practically  applicable  to  all  cases  of  prostatic 
hypertrophy  in  which  prostatectomy  was  indicated. 
It  gave  full  and  complete  information  of  not  only 
the  prostate,  but  the  bladder  and  its  contents.  It 
did  not  injure  or  interfere  with  the  musculature 
and  nerve  supply  of  the  perinseum  and  structures 
devoted  to  continence.  It  carried  with  it  little  risk 
of  injury  to  the  rectum,  and  it  was  seldom  followed 
by  incontinence,  fistula,  or  stricture.  The  disad- 
vantages alleged  against  it  were  greater  mortality 
and  the  necessity  of  longer  residence  in  a  hospital. 
He  felt  confident  that  there  were  fewer  complica- 
tions after  the  suprapubic  than  after  the  perineal  op- 
eration. This  operation  was  preferable  to  other 
methods  which  had  been  advocated. 

Dermoid  Cyst  of  the  Kidney. — Dr.  William  S. 
Goldsmith,  of  Atlanta,  Ga.,  said  that  only  two  cases 
of  dermoid  cyst  of  the  kidney  had  been  reported  up 
to  this  time,  one  by  Paget,  in  1853,  and  the  other 
by  Haeckel,  in  1902.  The  symptoms  in  the  author's 
case  were  those  of  a  solid  tumor  of  the  kidney,  prob- 
ably of  the  malignant  type.  It  was  of  slow  growth 
and  associated  with  it  were  haematuria,  pain,  and 
tumor.  The  patient,  aged  twenty,  at  two  years  of 
age  suffered  with  pain  in  the  right  lumbar  region, 
and  at  intervals  of  two  or  three  years  was  treated 
for  kidney  trouble.  When  sixteen  years  old  he  ex- 
perienced the  beginning  of  a  dull  pain  in  the  right 
side,  which  progressively  increased  until  two  weeks 
ago,  when  the  pressure  and  pain  radius  was  com- 
pared with  that  of  a  heavy  watch  lying  in  the  abdo- 
men. Four  years  ago  he  had  attacks  of  colic,  fol- 
lowed by  slight  haematuria.  These  attacks  confined 
him  to  the  house  for  twenty-four  hours,  and  were 
relieved  by  hypodermic  injections  of  morphine.  Re- 
currences occurred  two  or  three  months  apart,  and 
for  the  past  two  years  were  characterized  by  the 
appearance  of  a  solid  tumor  in  the  right  lumbar 
region.  Haematuria  and  great  pain  were  also  ac- 
companying features,  and  the  disappearance  of  the 
outline  of  the  tumor  was  frequently  followed  by  a 
cessation  of  the  pain.  Having  witnessed  an  attack 
three  days  before  the  operation,  when  the  tumor  was 
most  manifest,  he  was  convinced  that  these  symp- 
toms were  due  to  a  twisted  ureter,  since  the  return 
of  the  kidney  to  its  normal  position  practically  ob- 
literated the  tumor  outline.  Twenty-four  collections 
of  urine  showed  insignificant  deviations  from  the 
normal  quantity,  and  microscopical  and  chemical  ex- 
aminations were  negative,  except  for  red  blood  cells. 
The  patient's  weight  was  normal  and  his  general 
condition  good.  An  exploratory  operation  was  ad- 
vised and  consented  to.  A  lumbar  incision  was 
made,  which  exposed  a  large  semisolid  tumor  of  the 
upper  pole  of  the  kidney  Efforts  to  extract  the  kid- 
ney resulted  in  a  rupture  of  the  tumor,  and  a  quan- 
tity of  red,  granular  material  was  scooped  out  with 
the  fingers.  Nephrectomy  was  quickly  performed, 
and  recovery  was  prompt  and  uneventful.  A  path- 
ologist pronounced  the  tumor  to  be  a  dermoid  cyst. 

Stone  in  the  Kidney. — Dr.  Maurice  H.  Rich- 
ardson, of  Boston,  said  that  operations  for  stone  in 
the  kidney  and  ureter  were  becoming  of  greater  fre- 
quency and  importance.  In  early  and  difficult  cases 
the  diagnosis  rested  upon  a  history  of  pain  in  some 
of  its  forms,  usually  without  confirmation  by  the  x 
ray,  cystoscopy,  or  urethral  catheterism,  the  touch, 


I 


February  6,  1909.]  PROCEEDINGS  OF  SOCIETIES.  ■  303 


or  marked  signs  in  the  urine.  The  history  in  such 
cases,' as  in  many  gallstone  cases,  gave  the  only  clue; 
hence  we  should  study  with  renewed  care  the  his- 
tory of  stones  demonstrated  in  the  kidney  or  ureter, 
just  as  w^e  did  the  history  of  stones  demonstrated  in 
the  gallbladder.  The  indications  for  operation  were 
hopeless  impaction  of  a  stone  in  the  ureter;  in  the 
kidney  the  mere  presence  of  a  stone.  The  contrain- 
dications were  a  local  pathology  which  either  for- 
bade an  operation  or  made  it  so  dangerous  or  so 
uncertain  that  the  patient  had  much  to  lose  and  little 
to  gain.  The  great  operative  danger  in  nephrotomy, 
as  well  as  nephrectomy,  was  hjemorrhage ;  and  when 
this  was  from  the  renal  artery  or  vein  or  vena  cava, 
easy  and  instant  accessibility  was  essential  to  avert 
death  on  the  table ;  hence  the  anterolateral  approach 
was  the  best.  Nephrectomy  was  unjustifiable  unless 
the  changes  in  the  kidney  demanded  it,  especially 
when  the  remaining  kidney  was  so  likely  to  contain 
the  nuclei  of  stones.  Before  a  nephrectomy  was 
done,  the  remaining  kidney  should  be  very  carefully 
palpated  by  the  hands.  As  a  stone  might  be  over- 
looked, so  might  tuberculosis  or  other  infections. 

Conservative  Surgery,  Then  and  Now. — Dr.  F. 
W.  Parham,  the  president,  selected  this  title  for  his 
presidential  address.  The  aggressive  surgeon,  who 
always  felt  sure  he  was  right  and  then  went  ahead, 
would  do  well  to  temper  the  enthusiasm  born  of  the 
present  brilliant  achievements  of  surgery  by  giving 
reverent  heed  to  the  admonitions  of  the  past.  In 
renal  surgery  conservatism  and  radicalism  displayed 
their  coincidence  most  conspicuously.  Here  results 
demonstrated  that  often  the  most  conservative  treat- 
ment was  also  the  most  radical.  The  glory  of  the 
present  day  surgery  rested  primarily  upon  more  ac- 
curate diagnosis,  but  the  refinements  of  scientific  in- 
vestigation must  always  be  subjected  to  the  criticism 
of  common  sense.  It  was  becoming  more  and  more 
characteristic  of  the  modern  surgeon  that,  while 
recognizing  the  value  of  data  furnished  him  by  the 
laboratory,  he  would  relentlessly  subject  them  all  to 
the  test  of  reason  and  would  only  decide  upon  his 
surgical  therapeusis  when,  after  a  thorough  study 
of  all  the  facts,  he  had  obtained  a  true  perspective 
of  the  case. 

Appendicostomy  in  Pernicious  Anaemia. — Dr. 

L.  E.  BuRCH,  of  Nashville,  reported  the  case  of  a 
negro,  forty-five  years  of  age.  He  concluded  by 
saying  that  in  all  cases  the  stools  should  be  exam- 
ined, in  order  to  determine  the  presence  of  infection 
by  the  Bacillus  capsxilatus  aerogenes.  If  these  bac- 
teria were  present  in  great  numbers,  then  high  ir- 
rigation, combined  with  arsenic  internally,  should 
be  used,  and  if  the  patient  failed  to  improve,  the 
appendix  offered  the  best  route  for  thorough  irriga- 
tion. 

Dr.  H.  S.  McLean,  of  Richmond,  Va.,  said  that 
twenty  months  ago  he  operated  in  a  case  similar  to 
the  one  narrated  by  the  essayist.  The  man  had  been 
ill  for  years.  He  was  brought  to  him  with  an  acute 
attack  of  catarrhal  appendicitis,  and  the  history  dis- 
closed anaemia,  continued  weakness,  and  bowel  trou- 
ble. He  performed  appendicostomy.  The  man  had 
been  living  on  zwieback,  buttermilk,  and  the  like, 
for  years,  but  six  weeks  after  the  operation  the  red 
blood  cell  count  was  over  four  million.    He  soon 


gained  fifteen  pounds,  went  to  Europe,  and  was  now 
in  excellent  health. 

The  Porro  Caesarean  Section.  —  Dr.  F.  D. 
Smythe,  of  Memphis,  Tenn.,  reported  a  case  in 
which  he  had  done  this  operation,  and  gave  his  rea- 
sons for  doing  so.  The  rapidity  with  which  the  Porro 
operation  could  be  performed  increased  the  chances 
of  the  patient's  surviving  the  operation.  The  re- 
maining ovary  was  cystic  and,  in  all  probability, 
there  was  a  cyst  of  the  same  character  as  the  one 
removed.  The  patient  was  in  a  condition  too  much 
weakened  to  be  subjected  to  any  avoidable  risk  of 
the  puerperium ;  hence  the  Porro  operation.  There 
would  always  occur  cases  demanding  Caesarean  sec- 
tion in  the'  interest  of  the  child  and  mother.  In 
elective  cases  there  should  be  no  infant  mortality 
attending  either  operation ;  hence  the  surgeon  should 
select  the  operation  that  subjected  the  mother  to  the 
least  risk  of  losing  her  life.  The  author  was  fully 
convinced  that  the  Porro  operation  was  the  safer, 
and  that  the  surgeon  performing  the  Sanger  oper- 
ation in  an  honest  effort  to  preserve  the  reproduc- 
tive organs  would  have  occasion  to  congratulate 
himself  now  and  then  on  the  result  of  his  eflforts  in 
that  plausible  undertaking,  but  he  could  not  escape 
the  responsibility  of  the  loss  at  times  of  a  mother, 
whose  life  could  have  been  saved  had  the  simpler 
and  safer  operation  been  selected  at  the  outset.  Un- 
til he  was  convinced  that  the  so  called  conservative 
operation  was  as  safe  to  the  mother  as  the  Porro  op- 
eration, it  would  be  his  practice  to  choose  the  latter. 

Elective  Caesarean  Section.  — •  Dr.  Miles  F. 
Porter,  of  Fort  Wayne,  Ind.,  discussed  Caesarean 
section  as  an  operation  of  choice,  especially  in  such 
women  as  were  usually  delivered  by  so  called  minor 
operations  or  by  unaided  natural  forces  after  long 
labor.  On  summarizing  the  reports  of  126  elective 
Cesarean  sections  collected  by  personal  correspond- 
ence, the  maternal  mortality  was  found  to  be  1.58 
per  cent. ;  the  foetal  mortality,  o ;  the  maternal  mor- 
bidity, 12.69  cent. ;  the  foetal  morbidity,  o.  It 
should  not  be  forgotten  that  the  foetal  morbidity 
following  the  forceps  operation,  etc.,  was  often 
worse  than  death.  The  results  of  these  cases  were 
in  accord  with  the  opinions  of  many  men  of  experi- 
ence. No  method  of  delivery  entailed  so  little  risk 
to  the  child  as  Caesarean  section.  Remote  ulterior 
results  of  Caesarean  section,  including  hernia,  rup- 
ture of  the  uterus,  and  adhesions,  could  be  prevent- 
ed by  proper  technique  so  nearly  completely  as  to 
render  the  dangers  arising  therefrom  practically  nil. 
Barring  infection,  some  hours  of  labor  did  not  in- 
crease the  danger  from  Caesarean  section.  Other 
obstetric  operations  no  less  than  Caesarean  section 
required  surgical  skill  and  judgment;  indeed,  the 
inherent  difficulties  of  the  former  were  perhaps  the 
greater,  and  no  one,  unless  he  possessed  both  skill 
and  judgment,  should  undertake  either.  In  con- 
tracted pelvis  the  Caesarean  section  should  be  the 
operation  of  choice  in  many  multiparae  and  practical- 
ly all  primiparje.  In  placenta  prsevia  with  a  viable 
child  Caesarean  section  should  be  the  operation  of 
choice.  In  eclampsia  in  the  primipara,  with  a  viable 
child.  Caesarean  section  was  the  best  method  of  de- 
livery usually.  With  a  capacious  pelvis  and  vagina, 
Diihrssen's  operation  might  be  preferred.  Abdom- 


304 


NEW  INDENTIONS. 


[New  York 
Medical  Journal. 


inal  section  for  uterine  or  ovarian  tumors  done  at 
term  siiould  be  followed  by  extraction  of  the  child 
by  CiEsarean  section.  Given  an  elderly  primipara 
at  term  with  a  vigorous  child,  with  a  normal  pelvis, 
but  with  rigid  soft  parts,  usually  sensitive  to  pain 
and  physically  below  par,  Cassarean  section  offered 
both  mother  and  child  a  better  chance  of  life  and 
health  than  the  so  called  conservative  operations. 

The  Necessity  of  a  Second  Operation  for  the 
Removal  of  the  Appendix  in  Cases  where  an  Ap- 
pendicular Abscess  had  been  Treated  by  Simple 
Incision  and  Drainage, — Dr.  Stuart  McGuire, 
of  Richmond,  Va.,  supplemented  a  paper  read  by 
him  in  November,  1907,  in  which  he  discussed  the 
necessity  of  a  second  operation  for  the  removal  of 
the  appendix  after  simple  incision  and  drainage  of 
an  appendicular  abscess.  Among  the  cases  reported 
in  the  former  paper,  there  were  twenty-three  of  ap- 
pendicular abscess  of  the  class  adherent  to  the  parie- 
tal peritonaeum.  In  this  group  the  treatment  had 
been  simple  incision  and  drainage,  no  effort  being 
made  to  locate  or  remove  the  diseased  appendix.  In 
every  instance  the  patient  was  told  that  the  operation 
was  not  for  appendicitis,  but  for  an  abscess  which 
was  the  result  of  appendicitis,  and  that  the  appendix 
had  not  been  removed. 

To  reach  conclusions,  two  methods  of  investiga- 
tion were  followed — first,  the  opinions  and  practice 
of  a  number  of  eminent  surgeons  were  obtained, 
and,  second,  the  twenty-three  patients  whose  cases 
were  reported  were  written  to  and  their  subsequent 
histories  ascertained.  Dr.  McGuire  quoted  the  opin- 
ions of  the  twenty-six  surgeons  responding  to  the 
inquiry,  and  from- the  two  lines  of  investigation 
drew  the  following  conclusions :  While  a  surgeon 
might  be  justified  in  advising  a  secondary  opera- 
tion in  all  cases  as  theoretically  the  safest  plan  to 
follow,  he  was  not  justified  in  persuading,  urging, 
or  starving  a  patient  until  he  consented  to  have  it 
done.  The  appendix  should  always  be  removed  at 
the  first  operation,  if  the  abscess  was  small  and  not 
adherent  to  the  abdominal  wall  beneath  the  incision. 
It  should  be  left  only  in  neglected  cases,  where  the 
abscess  was  large  and  attached  to  the  parietal  peri- 
tonaeum. When  this  condition  existed,  the  appendix 
was  usually  gangrenous,  underwent  liquefaction, 
and  was  eliminated  with  the  discharges.  In  such 
cases  suppuration  continued  as  a  rule  for  several 
weeks,  and  before  a  secondary  operation  could  safe- 
ly be  done  the  patient  was  homesick,  weakened  phy- 
sically by  confinement,  and  depleted  financially  by 
the  expense  incident  to  his  stay  in  the  hospital.  Ex- 
perience showed  that  if  subsequent  trouble  devel- 
oped, the  infection  was  not  usually  acute,  and  pus, 
if  it  was  formed,  was  walled  in  by  old  adhesions. 
Therefore  the  siirgeon  did  his  duty  if  he  made  it 
clear  to  the  patient  that,  owing  to  the  complications 
which  existed,  it  was  not  found  safe  to  remove  the 
appendix,  and  told  him  that  while  a  second  opera- 
tion was  advisable,  it  was  not  imperative  unless  he 
had  tenderness  over  the  incision,  colicky  pains  in 
the  bowels,  or  persistent  digestive  disturbances,  in 
any  of  which  instances  it  was  distinctly  necessary 
for  him  to  seek  surgical  assistance  promptly. 

Resection  of  the  Bowel,  with  a  Report  of 
Eleven   Cases. — Dr.   J.   Shelton   Horsi.ey,  of 


Richmond,  Va.,  first  discussed  the  technique  of  the 
operation  and  described  the  advantages  of  a  contin- 
uous right  angle  suture  penetrating  all  coats  over 
interrupted  sutures  and  mechanical  appliances.  In 
order  to  procure  satisfactory  union,  there  must  not 
only  be  approximation  of  the  serous  coat  of  the 
bowel,  but  a  mild  degree  of  pressure  as  well,  and 
this  pressure  must  be  uniform  along  the  line  of  su- 
tures. Experiments  showed  that  mere  approxima- 
tion of  the  peritoneal  coat  in  dogs  did  not  always 
secure  union.  In  resecting  the  bowel,  he  first  divid- 
ed the  mesenteric  border  and  clamped  and  ligated 
this  area  before  opening  the  bowel.  Union  was 
made  by  a  continuous  suture  inserted  in  the  follow- 
ing manner :  Starting  about  an  inch  from  the  mesen- 
teric border,  a  mattress  suture  was  inserted,  so  that 
the  knot  was  on  the  mucous  membrane,  in  the  man- 
ner advocated  by  Connell.  The  short  end  of  this 
suture  was  clamped  and  the  needle  with  the  long 
end  made  a  continuous  mattress  suture  toward  the 
mesentery.  After  one  third  of  the  bowel  was  ap- 
proximated in  this  manner,  the  needle  was  brought 
through  on  to  the  peritoneal  surface,  and  the  rest 
of  the  union  was  effected  by  a  continuous  right 
angle  suture  penetrating  all  the  coats.  When  the 
point  where  the  original  knot  was  tied  was  reached, 
the  suture  was  terminated  by  tying  the  thread  to 
the  short  end  of  this  knot.  This  made  practically 
one  knot  for  the  whole  line  of  sutures  and  brought 
this  knot  within  the  lumen.  In  the  eleven  cases  re- 
ported, there  was  only  one  death.  This  was  in  a 
patient  with  strangulated  hernia  who  had  been  a 
chronic  alcoholic  for  years.  The  post  mortem 
examination  showed  no  sign  of  leakage  or  peri- 
toneal inflammation.  Death  was  evidently  due  to 
suppression  of  the  liver  and  kidney  functions.  There 
were  twelve  resections  in  the  eleven  cases,  as  in  one 
patient  a  double  resection  was  necessary.  The  oper- 
ations included  five  resections  in  four  patients  foi 
strangulated  hernia,  one  for  gangrene  from  a  band, 
one  for  volvulus  of  the  sigmoid,  two  for  malignant 
disease  of  the  large  intestine,  one  for  tuberculosis 
of  the  caecum,  and  two  for  damaged  intestine  dur- 
ing pelvic  operations. 

(To  be  conchided.) 

 €^  

Jlelu  Inkntimts. 


A  NEW  TONSIL  FORCEPS. 
By  Charles  E.  Perkins,  M.  D., 
New  York. 

A  forceps  that  will  take  firm  hold  of  the  tonsil 
and  not  tear  out  is  herewith  presented.  This  is 
brought  about  by  the  peculiar  construction  of  the 
grasping  jaws,  which  are  bowl  shaped.  The  edges 
of  the  bowl,  being  dull  and  smooth,  on  closing  firm- 
ly hold  the  fibrous  tissue  of  the  tonsil  and  do  not 
tear  out  on  traction,  as  so  often  occurs  with  a  vol- 
sella  or  a  forceps  with  serrated  blades. 

The  form  of  the  jaw  makes  wounding  of  the  sur- 
geons impossible  in  the  enucleation  of  the  tonsil. 
The  bowl  is  round  and  about  three  eighths  of  an  inch 
in  diameter,  which  seems  quite  satisfactory,  but  it 


February  6,  igog.J 


BOOK  NOTICES. 


305 


may  be  varied  in  size  or  shape,  or  the  blades  may  be 
curved  to  suit  each  individual  operator.  The  prin- 
ciple remains  the  same  and  is  unique  so  far  as  I 
know. 


A  new  tonsil  forceps. 


The  handles  are  constructed  with  open  rings,  so 
that  a  small  sized  snare  loop  will  easily  pass  over, 
and  yet  they  enable  one  to  maintain  a  firm  hold. 

105  West  Seventy-seventh  Street. 

 ^  

[We  publish  full  lists  of  books  received,  but  we  acknowl- 
•edge  no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


Cataract  Extraction.  By  H.  Herbert,  F.  R.  C.  S.,  late 
Lieutenant  Colonel,  I.  M.  S.,  Professor  of  Ophthalmic 
Medicine  and  Surgery,  Grant  Medical  College,  and  in 
charge  of  the  Sir  Cowasjee  Jehangir  Ophthalmic  Hos- 
pital, Bombay.  New  York:  William  Wood  &  Co.,  1908. 
Pp.  391. 

Herbert  has  had  an  enormous  amount  of  material, 
from  our  point  of  view,  as  his  volume  is  based  on 
abotit  five  thousand  cases.  It  is  rather  odd  to  note 
the  author's  quasiapology  for  his  comparatively 
small  experience  for  an  ophthalmic  surgeon  of 
standing  in  India.  The  material  has  been  more 
thoroughly  investigated,  he  thinks,  than,  if  the  num- 
bers had  been  larger.  He  gives  most  instructive 
and  interesting  data  as  to  the  varieties  of  operable 
•cataract,  local  evidence  of  maturity  and  of  the  con- 
sistence of  the  cortex,  and  the  charactenstic 
changes,  such  as  liquefaction,  imbibition,  shrinking, 
and  sclerosis.  The  operation  of  choice  is  that  com- 
bined with  iridectomy,  capsulotomy,  and  instru- 
mental expression  of  the  lens.  The  main  variations 
in  procedure  and  the  various  complications  and  ac- 
cidents are  dis-cussed  at  length.  The  illustrations 
from  photographs  are  inferior  and  so  indistinct  as 
to  be  of  little  didactic  value. 

A  Manual  of  Clinical  Diagnosis.  By  James  Campbell 
Todd,  Ph.  B.,  M.  D.,  Associate  Professor  of  Pathology, 
Denver  and  Gross  College  of  Medicine  (University  of 
Denver),  etc.  Illustrated.  Philadelphia:  W.  B.  Saun- 
ders Company,  1908.    Pp.  319.    (Price,  $2.) 

This  book  gives  a  clear  and  concise  idea  of  the 
more  important  laboratory  methods  which  have  clin- 
ical value,  and  is,  as  such,  a  good  guide  for  the  stu- 
dent and  general  practitioner  in  the  interpretation 
of  the  results  gained  by  such  adjuvants  to  clinical 
diagnosis.  The  methods  described  here  are  nearly 
always  practical,  such  as  would  be  used  in  an  office 
laboratory,  where  simplicity  and  the  least  expendi- 
ture are  of  great  irnportance. 

After  an  introduction  as  to  the  use  of  the  micro- 
scope, the  author  gives  a  chapter  each  to  the  exam- 
ination of  the  sputum,  urine,  blood,  stomach  con- 


tents, fjeces,  animal  parasites,  pus,  and  the  miscel- 
laneous fluids  and  discharges.  An  appendix  con- 
tains a  description  of  the  apparatus,  reagents,  and 
stains,  also  an  index.  The  illustrations  are  well 
made  and  show  good  selection. 

Points  of  Practice  in  Maladies  of  the  Heart.  Lumleian 
Lectures  at  the  Royal  College  of  Physicians  of  London. 
By  James  Sawyer,  Knt.,  Md.  (Lond.),  F.  R.  C.  P.,  F.  R. 
S.  (Ed.),  F.  S.  A.,  Consulting  Physician  to  the  Queen's 
Hospital,  Lately  a  Professor  of  Medicine  in  the  Queen's 
College.  Birmingham :  Cornish  Brothers,  Ltd.,  1908. 
Pp.  96. 

This  volume  is  a  reprint  of  the  Lumleian  lectures 
delivered  by  the  author  last  year,  and  in  the  three 
lectures  he  gives  an  interesting  review  of  our  pres- 
ent knowledge  of  the  physical  examination,  aetiol- 
ogy, and  pathology  of  heart  disease,  his  wide  read- 
ing and  experience  resulting  in  a  most  admirable 
brochure. 

Report  on  the  Prevention  of  Malaria  in  Mauritius.  By 
Ronald  Ross,  D.  P.  H.,  F.  R.  C.  S.,  D.  Sc.,  LL.  D., 
F.  R.  S.,  C.  13.,  etc.  London :  Waterlow  &  Sons,  Ltd., 
1908. 

Sir  Ronald  Ross  was  requested  to  investigate  the 
sanitary  conditions  on  the  Island  of  Mauritius,  in 
order  to  report  on  measures  for  the  prevention  of 
malaria  there,  by  the  governor  of  that  island,  in 
1907.  He  left  England  on  October  23,  1907,  and  , 
completed  his  studies  on  the  25th  of  February  of  the 
following  year.  The  report  under  review  gives  the 
result  of  his  work.  He  starts  with  a  general  review 
of  malaria,  its  history,  its  parasitology,  its  trans- 
mission, and  its  clinical  characters.  He  then  de- 
scribes the  geographical  position,  the  geological 
formation,  and  the  climate  of  the  island,  and  traces 
the  history  of  malaria  there  from  the  tiiue  of  the 
first  epidemic  of  the  disease,  in  1867,  to  the  present 
time.  This  epidemic  is  ascribed  to  the  probable  in- 
troduction at  that  time  of  the  African  malaria  car- 
rier, Pyretophorus  costalis,  into  the  island.  Ever 
since  the  discovery  of  the  island,  in  1507,  it  had  been 
free  from  malarial  fevers  except  for  the  few  cases 
of  relapse  that  occurred  in  the  persons  of  slaves 
brought  from  malarial  countries  and  troops  invalid- 
ed from.  India.  In  1867  the  incidence  of  malaria 
among  the  military  population  rose  to  1,000  in 
1,487.06^  from  21.32  in  1,000  in  1866,  and  the  deaths 
to  16.61  from  0.53  in  1,000  in  1866,  with  a  corre- 
sponding increase  among  the  civil  population.  Since 
this  first  epidemic  of  the  disease,  malaria  has  been 
constantly  present  and  the  death  rate  from  it  is  high. 
The  figures  are,  of  course,  not  very  accurate,  on 
account  of  the  large  and  ignorant  native  population  ;  . 
but  hospital  statistics  show  that  one  quarter  of  the 
admissions  are  for  the  malarial  fevers,  and  that  the 
deaths  from  malaria  form  7.1  per  cent,  of  the  total 
deaths.  Further,  out  of  31,022  children  examined, 
34.1  per  cent,  had  enlargement  of  the  spleen;  hence, 
of  the  182,000  children  in  the  island,  about  62,000 
have  enlarged  spleens  and  are  centres  for  the  dis- 
tribution of  malaria. 

The  report  then  takes  up  the  methods  of  preven- 
tion of  the  disease.  The  author  recommends  a  peri- 
odical medical  examination  of  children  in  schools 
and  on  estates,  and  the  continuous  treatment  of  all 
of  them  who  are  found  to  be  suffering  from  enlarge- 
ment of  the  spleen ;  a  continuous  house  to  house 

'These  figures  are  perhaps  to  be  accounted  for  by  the  occurrence 
of  several  attacks  in  the  same  men. 


3o6 


MISCELLANY. 


[New  York 
Medical  Journal, 


distribution  of  quinine,  where  necessary,  and  the 
continuous  treatment  of  fever  patients  on  estates ; 
the  continuous  performance  of  minor  works  in 
towns,  villages,  and  populous  areas,  and  on  estates ; 
and  the  performance  of  major  works  when  called 
for.  He  recommends  the  appointment  of  a  malaria 
authority,  moustiquiers,  a  committee  to  consider 
house  protection,  a  special  spleen  census  for  the 
principal  city,  an  annual  malaria  report,  and  some 
special  legislation.  He  estimates  that  the  measures 
recommended  will  cost  135,000  rupees,  9,000  pounds 
sterling,  or  $45,000  per  annum,  a  rate  of  0.36  rupee 
for  each  individual,  or  about  nine  cents  for  each 
inhabitant  of  the  island.  By  "minor  works"  the 
cleaning  of  small  streams  and  mosquito  breeding 
places  is  meant ;  "major  works"  include  the  drain- 
ing of  large  areas  of  marsh  land  and  the  cleaning 
of  the  larger  streams. 

The  author  persists  in  calling  mosquitoes  gnats. 
It  is  probable  that  gnat  is  as  correct  a  term  as  mos- 
quito ;  but  the  term  mosquito,  or  its  equivalent,  is 
used  all  over  the  world,  while  the  word  gnat  is  a 
true  Britannicism.  He  also  makes  use  of  the  word 
bonification,  which  means  to  be  the  paying  of  a 
bonus,  according  to  the  Standard  Dictionary.  The 
mechanical  portion  of  the  report  is  well  done. 

Sl>e2ielle  Diagnose  der  inneren  Krankheiten.  Ein  Hand- 
buch  fiir  Aerzte  und  Studierende.  Nach  Vorlesungen 
bearbeitet  von  Dr.  Wilhelm  v.  Leube,  Professor  der 
mediz.  Klinik  und  Oberarzt  am  Juliusspital  in  Wiirz- 
burg.  II.  Band.  Siebente  vollstandig  umgearbeitete 
Auflage.  Mit  78  Abbildungen.  Leipzig :  F.  C.  W.  Vogel, 
1908.    Pp.  xii-692.    (Price,  16  marks.) 

Four  years  have  elapsed  between  the  appearance 
of  the  first  and  that-  of  the  second  volume  of  the 
seventh  edition  of  von  Leube's  masterly  treatise  on 
diagnosis,  which  in  former  editions  is  almost  as  well 
and  favorably  known  in  this  country  as  in  Germany. 
The  distinguished  author  modestly  states  in  the  pre- 
face that  this  time  was  necessary  on  account  of  the 
revision  necessary  to  keep  pace  with  the  great  ad- 
vances made  in  the  subjects  considered  in  this  vol- 
ume— diseases  of  the  nervous  system,  diseases  of 
the  blood,  metabolism,  and  infectious  diseases.  Such 
conscientious  revision,  amounting  to  rewriting  of 
most  of  the  chapters,  is  indeed  rare  and  commend- 
able in  medical  authorship.  Owing  to  his  disinclin- 
ation to  include  subjects  of  which  he  has  not  first 
hand  knowledge,  certain  omissions  are  to  be  noted. 
Very  few  tropical  diseases  are  included,  Asiatic 
plague  is  briefly  described,  and  leprosy  is  wholly 
omitted. 

In  the  brief  space  allotted  for  book  notices  it  is 
impossible  to  give  an  adequate  review  of  this  fine 
volume.  Especially  noteworthy,  however,  are  the 
chapters  on  syphilis  of  the  central  nervous  system, 
arthritis,  gout,  diabetes,  obesity,  and  rhachitis. 
Among  the  newer  subjects  adequately  treated  are 
polyerythrocythaemia  and  alkaptonuria.  Insuffi- 
ciency of  the  pancreas  is  pretty  definitely  accepted 
as  the  sole  cause  of  true  diabetes.  The  author  is 
more  cautious  in  deciding  as  to  the  status  of  any  of 
the  cocci  described  as  the  specific  cause  of  acute 
articular  rheumatism.  We  rather  regret  to  observe 
the  retention  in  this  edition  of  the  objectionable 
term  "cryptogenetic  sepsis."  Von  Leube  years  ago 
taught  his  students  to  reject  "idiopathic  peritonitis" 


and  in  every  case  to  look  for  a  definite  cause.  Sim- 
ilarly, it  must  be  admitted  that  in  most  cases  of 
"cryptogenetic  sepsis"  the  application  of  von 
Leube's  rigid  methods  will  discover  the  source  of 
the  mischief.  There  is  scarcely  a  subject  touched 
upon  which  is  not ,  enriched  by  the  author's  own 
large  experience,  and  it  is  this  strong  personal  note 
which  makes  the  work  especially  valuable  among 
others  of  its  kind.  To  know  well  von  Leube's  work 
on  diagnosis  is  going  a  long  way  toward  the  mak- 
ing of  an  educated  physician. 

Technique  precise  de  radiotherapie  et  de  radioscopie  (in- 
strumentation pratique).  Par  le  Dr.  Paul  Vaudet,  de 
la  Faculte  de  medecine  de  Paris.  Preface  de  M.  E. 
Gaucher,  professeur  a  la  Faculte  de  medecine  de  Paris,, 
niedecin  de  I'Hopital  Saint-Louis.  Ouvrage  recompense 
par  I'Academie  de  medecin  (1906).  Deuxieme  edition. 
Paris :  Alfred  Leclerc,  1908.    Pp.  227. 

As  indicated  by  the  title,  this  book  is  intended  to 
be  practical  rather  than  theoretical.  It  is  divided 
into  two  parts.  The  first  part  deals  with  the  produc- 
tion and  measurement,  etc.,  of  the  x  ray,  and  in- 
cludes the  subject  of  radiotherapy.  The  second  part 
is  devoted  to  radiography  and  fluoroscopic  examina- 
tions. The  chapters  on  apparatus  deal  only  with 
foreign  types,  and  the  subject  is  well  presented,  with 
the  exception  of  the  short  chapter  on  static  machines. 
Most  of  the  space  under  radiotherapy  is  given  to 
a  report  of  cases  which  have  been  treated  by  various 
physicians  and  which  have  been  previously  reported. 
The  general  technique  of  application  is  closely 
associated  with  the  Holtzknecht  scale  and  similar 
methods  of  precision,  which  have  been  received  with 
more  favor  in  Europe  than  in  America.  The  book 
has  a  paper  cover,  is  well  printed,  is  not  indexed,  and 
with  the  exception  of  the  chapters  on  apparatus  is 
not  illustrated.  Although  it  will  introduce  one  to- 
the  possibilities  of  the  Rontgen  ray  in  therapy  and 
diagnosis,  it  is  doubtful  if  the  book  is  sufficiently 
exhaustive  or  descriptive  to  guide  the  beginner  in 
this  difficult  and  important  work. 

 ^  

llisallang. 


Resolution  on  the  Death  of  Dr.  Carleton  P. 
Flint. — At  a  meeting  of  the  Harvard  Medical  So- 
ciety of  the  City  of  New  York,  held  on  Saturday 
evening,  November  28,  1908,  the  following  resolu- 
tion was  unanimously  adopted : 

Whereas,  Death  has  removed  from  the  roll  of  this  So- 
ciety Dr.  Carleton  P.  Flint ;  and 

Whereas,  During  the  ten  years  of  his  association  with 
us  Dr.  Flint  has  been  one  of  our  most  active  and  enthu- 
siastic members ;  and 

Whereas,  In  his  professional  life  in  this  city  Dr.  Flint, 
by  his  industry,  painstaking  vtork  and  unusual  ability,  has 
raised  himself  to  an  enviable  position  in  the  profession ; 
by  his  integrity,  manliness  and  high  ideals,  has  endeared 
himself  to  his  patients  and  professional  associates,  and  by 
his  broad-mindedness  and  public  spirit  has  created  for 
himself  a  position  of  distinction  in  the  community;  be  it 

Resolved,  That  in  the  death  of  Dr.  Flint  the  Harvard 
Medical  Society  has  lost  an  honored  member  whose  ex- 
ample will  always  be  an  inspiration  to  its  members  and 
whose  brief  but  brilliant  professional  career  gives  evidence 
of  the  fact  that  success  almost  invariablv  follows  persistent 
and  well  directed  effort  when  combined  with  ability,  good 
judgment  and  a  high  standard  of  pefsonal  and  professional 
integrity. 


February  6,  1909.] 


OFFICIAL  NEWS. 


307 


Be  it  further  Resolved,  That  a  copy  of  these  resolutions 
be  transmitted  to  the  family  of  Dr.  Flint,  to  the  Secretary 
of  his  class  in  the  Medical  School  of  Harvard  University, 
and  to  one  of  the  medical  periodicals  of  this  city. 

Lactic  Acid  Therapy. — Heineniann  says  that 
the  usefulness  of  lactic  acid  or  lactic  ferments 
as  curative  agents  for  intestinal  putrefaction  is  still 
problematical.  Much  evidence  in  its  favor  has  ac- 
cumulated of  late  years  and  it  is  to  be  desired  that 
exact  scientific  investigations  of  a  decisive  character 
will  be  undertaken.  The  evidence  in  favor  of  the 
use  of  Bacillus  bulgaricns  as  a  lactic  acid  pro- 
ducing organism  for  the  purpose  of  arresting  intes- 
tinal putrefaction  is  not  convincing.  The  associa- 
tion of  Streptococcus  lacticus  with  the  Bulgarian 
bacillus  leaves  doubt  which  one  of  the  two  organ- 
isms is  the  one  responsible  for  the  beneficial  effects 
claimed.  The  Bulgarian  bacillus  produces  a  dis- 
agreeable taste  in  milk  by  decomposing  some  of  the 
fat  and  the  addition  of  Streptococcus  lacticus  is  uni- 
versally practised  to  overcome  this  difficulti-.  The 
experiments  which  have  been  reported  in  regard  to 
finding  the  Bulgarian  bacillus  in  the  fasces  are  in- 
complete in  so  far  as  no  statements  are  made  in  re- 
gard to  the  number  of  these  bacilli  found  in  relation 
to  other  intestinal  bacteria,  especially  in  relation  to 
intestinal  streptococci.  Assuming  that  the  presence 
of  free  lactic  acid  in  the  digestive  tract  is  beneficial, 
it  has  not  been  definitely  shown  that  lactic  acid  is 
actually  produced  in  considerable  quantity  by  the 
presence  of  lactic  acid  bacteria  in  the  intestines.  The 
evidence  is  decidedly  in  favor  of  the  introduction  of 
sour  milk,  or  pure  cultures  of  lactic  acid  bacteria  in 
connection  with 'a  diet  in  which  milk  is  a  prominent 
feature.  Lactic  acid  forming  bacteria  are  constantly 
present  in  the  digestive  tract,  and  we  have  no  con- 
vincing evidence  that  the  additional  introduction  of 
lactic  acid  bacteria  is  of  benefit.  There  is  so  far  no 
convincing  evidence  that  sour  milk  prepared  with 
commercial  cultures  is  preferable  to  naturally  sour 
milk',  as  far  as  the  therapeutic  ef¥ect  is  concerned. 
It  seems  advisable,  however,  to  boil  or  pasteurize 
milk  if  good  reliable  "certified"  milk  is  not  obtain- 
able, and  if  this  is  done  an  artificial  starter  is  neces- 
sary. In  those  countries  where  sour  milk  is  general- 
ly used  the  starter  consists  in  a  small  amount  of  the 
previously  prepared  milk.  This  can  be  done  with 
any  other  starter.  A  small  amount  of  the  prepared 
sour  milk  may  be  used  for  inoculation  of  the  next 
lot  after  this  has  been  boiled  or  pasteurized. — Jour- 
nal of  the  American  Medical  Association,  January 
30,  1909. 

 ^  


Cases.  Deaths. 


Public   Health   and   Marine    Hospital  Service 
Health  Reports: 

The  follozving  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  n'cek  ending  January  2g.  jgog: 
Smallpox — United  Stales. 
Places.  Pate.  Cases.  Deaths. 

Alabama — Tutcaloosa  Dec.    1-31   20 

Alabama — Mobile  Jan.  21    i 

Arkansas — Texarkana  Nov.  22-Tan.   11   10 

California — I  os  -Angeles  Jan.    2-9   2 

California — San  Francisco  Jan.    2-9   2 

Illinois — Browning  Oct.  25-Jan.  20   75 

Illinois — Centralia  July   i-jan.   20   50 

Illinois — Chicago  Jan.    2-9   i 


  4 

  4" 

9-16   2 

11-18   12 

9-16   I 

2-  16   2 

3-  10   1° 

9-16   2 

1-18  200 


2-16. 


9-16   7 

g-i6   I 

9-16   1 

15-Jan.    12   12 

9-16   I 

22   I  I 

 103 


9-16. 

22.  .  . 


2-16. 


I  I 

4 
30 


mported. 
mported. 


Present. 
Present. 


Places.  Date. 

Illinois — Danville  Jan.  lo-i 

Illinois — Ladd  Nov.  1-30 

Illinois — Taylorville  Jan. 

Indiana — Evansville  .".Jan. 

Indiana — La  Fayette  Jan. 

Kansas — Atchison  Jan. 

Kansas — Kansas  City  Jan. 

Kansas — Topeka  Dec. 

Kentucky — Covington  Jan. 

Kentucky — Lawrenceburg  Oct. 

Kentucky — Lexington  Jan. 

Louisiana— Arcadia  Parish  Dec.  20-Jan.  11 

Louisiana — New  Orleans  Jan.  2-16  

Maine — Van  Buren  Jan. 

Michigan — Detroit  Jan. 

Missouri- — St.  Louis  Jan. 

Montana — Butte  Dec. 

Nebraska — South  Omaha  Jan. 

North  Carolina — Wilmington  Jan.  22... 

Tennessee — Green  County  To  Jan. 

Tennessee — Knoxville  Jan.  9-16 

Tennessee — Memphis  Jan.  18... 

Tennessee — Nashville  .Jan. 

Tennessee — Polk  County  Jan. 

Texas — Cotulla  Jan. 

Texas — Laredo  Jan. 

Texas — San  Antonio  Jan. 

Vermont — East  Dover  Jan.  21   10 

Vermont — Newfme  Jan.  11   8 

Vermont — West  Dunnerston  Jan.  21   i 

Virginia — Lynchburg  Jan.  9-16   i  Imported. 

Wisconsin — La  Crosse  Jan.  9-16  

Smallpox — Foreign. 

Brazil — Bahia  Nov.  14-Dec.  5   61  4. 

Canada — Halifax  Nov. 

Canada — Winnipeg  Jan. 

Egypt — -Alexandria  Dec. 

Egypt — Cairo  Dec. 

India — Bombay  Dec. 

Java — Batavia  Dec. 

Mexico — Guadalajara  Jan. 

Me.xicc — Monterey  Jan. 

Mexico — Salina  Cruz  Jan. 

Mexico — Vera  Cruz  Dec. 

Mexico — Yucatan  Dec. 

Newfoundland — St.  Johns  Jan. 

Peru — Lima  Dec. 

Porto  Rico — Mayaguez  ....Dec. 

Portugal — Lisbon  Jan. 

Russia — St.  Petersburg  Dec.  12-19   » 

Spain — Valencia  Dec.   19-26   i 

Turkey — Constantinople  Dec.  20-27  

Yellow  Fever — Foreign. 

Barbados — Bridgetown  and  vicinity  Dec.  29-Jan.  10   4 

Ecuador — Guayaquil  Dec.  12-19  

Mexico — Mexcanu  Jan.    2-9   i 

Trinidad — Port  of  Spain  Jan.  20  

Brazil — Bahia  Nov.  21-Dec.  5   3 

Cholera — Foreign. 

India — Bombay  Dec. 

India — Madras  Dec. 

India — Rangoon  -.  Dec. 

Russia — General  Nov 

Russia — St.   Petersburg  Dec. 

Straits  Settlements — Singapore.  ..  Nov.  29-Dec.  5 

Plague — Foreign. 

Brazil — Bahia  Nov.    14-Dec.    5   12 

China — Hongkong  Nov. 

Ecuador — Guayaquil  Dec. 

Ecuador — Milagro  Dec. 

India — CJeneral  Dec. 

India — Bombay  Dec. 

Peru — General  Dec. 

Peru — Lima  Dee. 

Straits  Settlements — Singapore...  Nov. 


2-9  

4-  1 1. . . 

2-  9  

16-23.  • 
15-22-  - 

5-  12. .  . 
1-7  

3-  10.  .  . 
I-I5-  ■  • 
12-26.  . 
1-31  •  •  • 
g-i6.  .  . 

19  

26-Jan. 
5-12. 


1 5-22 . .  . 
12-18.  .  . 

5-12  

15-Jan. 
3-31- 


...2,976 
 114 


7-14   I 

12-  19  

13-  19  

S-12  2,044 

15-22  

4-17   60 

4-17   9 

28-Dec.  5  


2,V 
■! 
I 

1 ,20.< 
43 

29. 


Present. 
1,58s 
4 

3 


Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  staiio)is  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
January  zy,  jgog: 

Blount,  B.  B.,  Acting  Assistant  Surgeon.  Granted  thirty 
days'  leave  of  absence  from  February  i,  1909. 

BussEV,  Joseph  C-,  Acting  Assistant  Surgeon.  Granted" 
seven  days'  leave  of  absence,  under  paragraph  -191  Ser- 
vice Regulations. 

Gumming,  Hugh  S.,  Passed  Assistant  Surgeon.  Directed' 
to  proceed  to  Nagasaki,  Japan,  upon  special  temporary 
duty. 

Fricks,  L.  D.,  Passed  Assistant  Surgeon.  Leave  of  ab- 
sence granted  January  8,  1909,  for  seven  days  fronr 
January  9,  1909,  amended  to  read  five  days  from  Janu- 
uary  9,  1909. 

H.AMiLTON,  H.  J.,  Acting  Assistant  Surgeon.  Granted  three- 
days'  leave  of  absence  from  January  27,  1909. 

MoNcURE.  J.  A.,  Acting  Assistant  Surgeon.  Granted  thirty 
days'  leave  of  absence  from  February  18.  1909. 

Ott,  C.  R.,  Pharmacist.  Granted  thirty  days'  leave  of  ab- 
sence from  March  25,  1909. 


3o8 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal. 


Richardson,  Samuel  W.,  Pharmacist.  Granted  sixteen 
days'  leave  of  absence  from  February  i,  1909. 

Stiles,  C.  W.,  Chief  Division  of  Zoology,  Hygienic  Labor- 
atory. Granted  three  days'  extension  of  annual  leave, 
on  account  of  sickness,  from  January  12,  1909. 

Sweet,  Ernest  A.,  Passed  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  December  25,  igo8, 
under  paragraph  189,  Service  Regulations. 

Young,  G.  B.,  Surgeon.  Directed  to  attend  the  meeting  of 
the  Lake  Michigan  Water  Commission,  to  be  held  at 
Indiana  Harbor,  Ind.,  January  23,  1909. 

Promotion. 

Pharmacist  Cletus  O.  Sterns  promoted  to  pharmacist  of 
the  second  class  to  date  from  November  6,  1908. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  medical  corps  of  the  United  States  Army 

for  the  iveek  ending  January  30,  igog: 

Bevans,  J.  L.,  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  two  months. 

Church,  J.  R.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  one  month. 

Clarke,  J.  T.,  Major,  Medical  Corps.  Granted  an  exten- 
sion of  fifteen  days  to  his  leave  of  absence. 

Coffey,  A.  M.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  from  Fort  Sam  Houston,  Texas,  to  Fort  Sill, 
Oklahoma,  for  temporary  duty. 

Davis,  W.  R.,  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  fifteen  days. 

Greenleaf,  H.  S.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  one  month. 

Jordan,  E.  H.,  First  Lieutenant,  Medical  Reserve  Corps.' 
Granted  leave  of  absence  for  two  months,  with  per- 
mission to  return  to  the  United  States  via  Europe. 

Kendall,  W.  P.,  Major,  Medical  Corps.  Ordered  to  ac- 
company troops  from  Fort  Ethan  Allen,  Vt.,  to  Fort 
Leavenworth,  Kans.,  and  return  to  station. 

Koerpek,  C.  E.,  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  fourteen  days. 

Shook,  J.  R.,  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  one  month. 

Winter,  F.  A.,  Major,  Medical  Corps.  Ordered  to  accom- 
pany troops  to  San  Francisco,  Cal. 

Navy  Intelligence: 

Official  list  of  changes  in  the  station  and  duties  of  offi- 
cers sc7-ving  in  the  medical  corps  of  the  United  States  Navy 
for  the  week  ending  January  30,  igog:. 
Hart,  G.  G.,  Acting  Assistant  Surgeon.    Appointment  dated 

January  10,  1909,  revoked. 
Huffman,  O.  V.,  .A^ssistant  SurgeoiL    Discharged  from 
treatment  at  the  Naval  Medical  School  Hospital,  Wash- 
ington, D.  C. ;  granted  sick  leave  for  three  months ;  and 
resignation  accepted  to  take  effect  April  28,  1909. 
May,  H.  a..  Passed  Assistant  Surgeon.    Detached  from 
duty  with  flotilla  of  lighthouse  vessels,  San  Francisco, 
Cal.,  and  ordered  to  the  Pacific  Fleet,  sailing  from  San 
Francisco,  Cal.,  February  5,  1909. 
Old,  E.  M.  H.,  Passed  Assistant  Surgeon.    Detached  from 
the  Nav.al  Hospital,  Norfolk,  Va.,  and  ordered  to  tem- 
porary duty  at  the  Navy  Yard,  Washington,  D.  C,  and 
to  aelditional  duty  on  board  the  M ayfloivcr. 
Stokes,  C.  F.,  Surgeon.    Ordered  to  report  to  the  surgeon 
General  of  the  Navy  for  special  temporary  duty  in  con- 
nection with  the  repair  of  hospital  ships. 
Thomas,  G.  E.,  Acting  Assistant  Surgeon.    Detached  from 
the  Naval  Hospital,  Boston,  Mass.,  and  ordered  to  the 
Naval  Hospital,  Norfolk,  Va. 

 ^  

girths,  3lamagt5,  irnb  itat^s. 


Married. 

Dunlap — Walton. — Tn  Greensboro,  Alabama,  on  Wednes- 
day, January  20th,  Dr.  Ernest  B.  Dunlap,  of  Lawton,  Ok- 
lahoma, and  Miss  Wyllie  Walton. 

Dunphy— Santos. — Tn  Holyoke,  Ma.ssachusetts,  on  Wed- 
nesday, January  20th,  Dr.  Henry  .\.  Dnnphy  and  ATiss 
Helen  Santos. 


Marks — Strauss. — In  New  York,  on  Thursday,  January 
28th,  Dr.  Lewis  Hart  Marks,  of  New  Orleans,  Louisiana, 
and  Miss  Marguerite  Julie  Strauss. 

Noble — Newland. — In  Selma,  North  Carolina,  on 
Wednesday,  December  30th,  Dr.  Robert  P.  Noble  and  Miss 
Marie  Newland. 

Shadman — Doyle. — In  New  York,  on  Thursday,  Janu- 
ary 28th,  Dr.  Alonzo  Jay  Shadman,  of  Boston,  Massachu- 
setts, and  Miss  Grace  Parker  Doyle. 

Wlaber — Dehnhardt.— In  Allentown,  Pennsylvania,  on 
Wednesday,  January  20t1i  Dr.  Thomas  Hewitt  Weaber  and 
Miss  Laura  E.  Denhardt. 

Died. 

Alderman. — In  Lebanon,  Pennsylvania,  on  Friday,  Janu- 
ary 29th,  Assistant  Surgeon  Charles  G.  Alderman,  United 
States  Navy. 

Allen. — In  Chicago,  on  Friday,  January  22d,  Dr.  Henry 
C.  Allen  aged  seventy-two  years. 

B.\LLARD. — In  Saginaw,  Michigan,  on  Thursday,  January 
2ist,  Dr.  Robert  W.  Ballard,  aged  seventy-two  years. 

Bartlett. — In  Olean,  New  York,  on  Friday,  January  22d, 
Dr.  Cornelius  H.  Bartlett,  aged  eighty-three  years. 

Bowen. — In  Manistique,  Michigan,  on  Wednesday,  Janu- 
ary 20th,  Dr.  Omer  C.  Bowen,  aged  sixty-nine  years. 

Capdau. — In  New  Orleans,  Louisiana,  on  Sunday,  Janu- 
ary 17th,  Dr.  J.  Ernest  Capdau,  aged  thirty-three  years. 

Clendexin. — In  Louisville,  Kentucky,  on  Monday,  Janu- 
ary 25th,  Dr.  Hugh  M.  Clendenin,  aged  twenty-nine  years. 

Collins. — In  Detroit,  Michigan,  on  Friday,  January  22d, 
Dr.  Thomas  J.  Collins,  aged  fifty  years. 

Donnald. — In  Piedmont,  South  Carolina,  on  Friday, 
January  22d,  Dr.  J.  H.  Donnald,  aged  fifty-six  years. 

DoRRANCE. — In  Ann  Arbor,  Michigan,  on  Friday,  January 
22d,  Dr.  W.  H.  Dorrance. 

Dove. — In  Westfield,  Indiana,  on  Monday,  January  i8th. 
Dr.  Silas  C.  Dove,  aged  seventy  years. 

Escobar. — In  Cavite,  Philippine  Islands,  on  Saturday, 
December  12th,  Dr.  Julius  A.  Escobar,  of  the  United  States 
Army  and  Medical  Corps. 

FucHEY. — In  Winamac,  Indiana,  on  Saturday,  January 
23d,  Dr.  J.  B.  Fuchey,  aged  ninety-two  years. 

Hanlon. — In  Hyde  Park,  Massachusetts,  on  Sunday, 
January  24th,  Dr.  Daniel  James  Hanlon,  aged  forty-two 
years. 

Hills. — In  Willimantic,  Connecticut,  on  Saturday,  Janu- 
ary 23d,  Dr.  Thomas  M.  Hills,  aged  seventy  years. 

Howard. — In  West  Baden.  Indiana,  on  Saturday,  Janu- 
ary, 23d,  Dr.  John  Leslie  Howard,  aged  forty-three  years. 

KoENiG.— In  Philadelphia,  on  Monday,  January  i8th.  Dr. 
Frank  Koenig,  aged  forty-eiglit  years. 

Langford. — In  Meridian,  Mississippi,  on  Friday,  January 
22d,  Dr.  Thomas  D.  Langford,  aged  eighty  years. 

Logan. — In  St.  Joseph,  Missouri,  on  Monday,  January 
i8th.  Dr.  John  S.  Logan,  aged  seventy  years. 

McGee. — In  Ravenden  Springs,  .Arkansas,  on  Wednes- 
day, January  20th,  Dr.  James  B.  McGee,  aged  sixty-eight 
years. 

McNamara. — In  Milwaukee,  Wisconsin,  on  Friday,  Jan- 
uary 22d,  Dr.  F.  S.  McNamara,  aged  eighty-seven  years. 

Miller. — In  Washington,  D.  C,  on  Saturday,  January 
23d,  Dr.  J.  Preston  Miller,  aged  fifty-eight  years. 

Moran. — In  Chicago,  Illinois,  on  Sunday,  January  241!], 
Dr.  M.  C.  Moran,  aged  fifty-six  years. 

Naylor. — In  Crawfordsville,  Indiana,  on  Thursday,  Jan- 
uary 2ist,  Dr.  I.  E.  G.  Naylor,  aged  ninety  years. 

Rogers. — In  Stamford.  Connecticut,  on  Wednesday,  Jan- 
ary  27th,  Dr.  Francis  J.  Rogers,  aged  sixty  years. 

SiiiNNicK. — Tn  Santa  Cnu.  Mexico,  on  Monday,  Janu- 
ary iith.  Dr.  Charles  C.  Shinnick,  aged  sixty-one  years. 

Smith. — Tn  Carlisle,  Pennsylvania,  on  Thursday,  Janu- 
ary 28th,  Dr.  Thomas  Smith,  aged  fiftv-six  years. 

Troth. — In  Homestead,  Pennsylvania,  on  Friday,  Janu- 
ary 22nd,  Dr.  A.  R.  Troth,  aged  sixty  years. 

Wallace. — In  Cayuga,  Indiana,  on  Tuesday,  January 
igtli,  Dr.  James  Wallace,  of  Newport. 

Young. — In  Slatington,  Pennsylvania,  on  Friday,  Janu- 
ary 22d,  Dr.  Robert  W.  Young,  aged  sixty-two  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  ilt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


\'oL.  LXXXIX,  No.  7.    "  •  NEW  YORK,  FEBRUARY  13,   1909.  Whole  No.  1576. 


Original  iiommuniratioib. 


THEORIES  AND  PROBLEMS  OF  HEREDITY. 

//.   The  Fundamental  Problevi.    The  Inheritance  of 
Acquired  Characters. 
Bv  JoxATHAX  Wright,  M.  D., 
New  York. 
Article  II. 

the  medical  man  of  middle  age  turns  to  the 
perusal  of  modern  neo-Darwinian  literature,  he 
meets  with  a  number  of  statements  as  to  the  history 
of  the  theory  of  evolution  which  are  depressing,  as 
they  seem  to  intimate  to  him  that  his  memory  has 
been  impaired  by  the  march  of  time.  The  neo- 
Darwinian  tells  him  there  never  has  been  a  place 
in  the  doctrine  of  Darwin  for  the  inheritance  of  ac- 
quired characters.  It  is  true  this  statement  is  oc- 
casionally modified,  but  the  admission  is  so  evanes- 
cent that  Darwjn  did  admit  its  possibility,  that  the 
rebuke  reir.ains.  Rarely  is  it  so  frankly  adniitted  as 
in  the  recent  paper  of  Wallace.'  The  associate  of 
Darwin  in  the  formulation  of  the  theory  of  natural 
selection,  still  living  a  wonderful  old  age  and  still 
the  defender  of  the  all  sufificiency  of  small  varia- 
tions as  material  for  it,  declares  that  Darwin  ac- 
cepted the  view  which  coincided  with  "one  of  La- 
marck's fundamental  assumptions — the  inheritance 
of  whatever  changes  were  produced  in  the  individ- 
ual by  the  use  of  its  own  organs,  or  by  the  direct 
agency  of  the  environment,"  but  that  this,  if  a  fac- 
tor of  evolution  at  all,  is  insignificant. 

He  is  also  informed  by  a  not  inconsiderable  num- 
ber of  neo-Darwinian  writings  that  the  majority  of 
competent  biologists  deny  that  somatic  adaptations 
are  ever  transmitted,  and  assert  that  selective  agen- 
cies are  alone  the  shapers  of  the  forms  and  ways  of 
protoplasm,  as  it  is  handed  on  from  being  to  being 
by  inheritance.  After  a  time,  and  no  very  long 
time  of  reading,  the  seeker  after  knowledge  of  bio- 
logical theory  find?  that  the  truth  of  this  declaration 
as  to  the  belief  of  biologists  turns  on  the  word 
"competent."  By  constant  iteration  and  reiteration 
it  has  been  made  to  appear  that  the  majority  ac- 
quiesce explicitly  or  tacitly  in  the  theories  of  Weis- 
mann.  On  analysis  this  majority  seems  to  have 
been  obtained  by  a  form  of  artificial  selection  very 
familiar  in  scientific  argument,  but  not  natural  selec- 
tion by  any  means.  By  eliminating  from  the  ranks 
of  "competent"  those  who  bring  forward  any  evi- 
dence to  invalidate  or  express  any  opinion  adverse 
to  their  theories,  and  by  excluding  the  neo-La- 

^The  Contemporary  Review,  August,  1908. 


marckians,  the  neo-\'italists  and  those  who  frankly 
avow  a  teleological  view  of  life  from  the  ranks  of 
the  competent,  the  followers  of  Weismann  have  in- 
deed narrowed  the  elect  down  to  a  paucity  of  num- 
bers where  a  majority  is  easily  obtained^  In  a  mys- 
terious subject  where  we  are  all  groping  for  the 
light,  they  exclude  any  presumptive  evidence  fur- 
nished by  observation,  when  by  any  possibility  they 
can  stretch  natural  selection  into  an  explanation  of 
it  and  escape  the  charge  of  insanity. 

This  irritating  attitude  of  English  zoologists  has 
met  with  considerable  protest,  and  it  has  recently 
drawn  the  fire  of  Professor  IMarcus  Hartog,'  himself 
a  biologist  who  cannot  be  ignored.  Indeed,  it  be- 
hooves the  neo-Darwinians  to  look  well  to  their 
armor,  already  showing  many  rents  in  a  somewhat 
feeble  process  of  repair,  since  assuming  such  an  atti- 
tude drives  common  human  nature  into  an  attitude 
of  attack.  It  has  been  pointed  out  by  one  of  the  most 
intolerant  of  the  neo-Darwinians  that  medical  men, 
concerned  all  their  lives  with  the  biology  of  man. 
and  that  breeders  of  domestic  animals,  whose  busi- 
ness in  life  is  dealing  with  experimental  work  where 
failure  spells  financial  ruin,  are  not  supporters  of 
the  exclusive  doctrine  of  natural  selection.^  Bur- 
bank,  the  man  who  has  dealt  most  extensively  and 
most  successfully  in  an  experimental  way  with  plant 
life,  and  who  has  been  too  busy  to  bother  with  any 
one's  theories  but  his  own,  drawn  direct  from  the 
breast  of  Nature,  repudiates  it.  There  is  hardly  a 
French  biologist  who  supports  it.  Haeckel  and  a 
host  of  Germans,  especially  medical  men,  are  \\'cis- 
mann's  critics.  It  has  never  gained  a  broad  accepta- 
tion here  in  America,  and  in  France  it  has  produced 
little  but  criticism.  Hartog  gives  a  formidable  l)Ut 
not  an  exhaustive  list  of  those  who  do  not  accept  the 
views  of  Weismann.  These  are  the  men  who  more 
or  less  absolutely  deny,  with  varying  arguments,  the 
exclusive  action  of  natural  selection,  and  yet  for- 
sooth, the  English  zoologists  say,  and  after  them  it 
is  repeated  in  popular  treatises  on  evolution — "the 
authority"  is  for  the  most  part  on  their  side. 

It  has  been  denied  that  Weismann  ever  refused 
to  the  environment  an  influence  on  the  germ  plasm. 
It  is  said  that  he  has  always  denied  only  its  influence 
through  the  soma  or  body  cells.  However  that  may 
be,  this  retreat  by  his  followers  is  comparatively 
recent.  Darwin  himself  declared  his  ignorance  of 
the  causes  of  variation.    In  early  days  it  was  repeat- 

-Professor  Marcus  Hartog.  Tlie  Transmission  of  .Acquired  Char- 
acters.   The  Contciiiporn'-y  Rc-ievn,  September,  190S. 

See  also  article  by  Charles  Mercier,  Contemporary  Review,  De- 
cember. 1908. 

'Professor  Hartog  also  draws  attention  to  this  fact:  In  E.  Daven- 
I'ort's  Principles  of  Breeding,  recently  published  (Ginn  &  Co., 
IQ05)  it  may  be  s'cn  how  infirm  is  the  foothold  among  them 
gained  by  the  neo-Darwinians. 


Copyright,  1909,  by  A.  R.  hlliott  Publishing  Company. 


310 


WRIGHT:   THEORIES  AND  PROBLEMS  OF  HEREDITY. 


[New  Vork 
Medical  Journal 


edly  denied  by  the  followers  of  W'eismann,  if  no. 
by  him,  that  the  environment  had  anything  to  do 
with  their  origin.  A  perusal  of  t'oulton's*  attempt 
to  define  the  term  "acquired  character,"  citing  the 
definitions  that  have  been  advanced  in  the  last 
twenty  years,  will  show  that  many  of  them  included 
'.he  conception  of  a  character  acquired  by  the  germ 
plasm  by  any  influence  of  the  environment,  direct  or 
otherwise.  Archdall  Reid,  who  still  assumes""  this 
position,  with  a  slight  wavering  of  late,"  also  is  much 
concerned  about  the  obtuseness  of  the  recalcitrants, 
and  Professor  Thomson'  kindly  supplies  them  with 
a  list  of  their  misunderstandings.  Notwithstanding 
such  protestation,  the  admission  that  the  germ  plasm 
can  be  affected  directly  but  not  specifically  through 
the  body  cells  seems  a  later  neo-Darwinian  refine- 
ment. There  seems  reason  for  the  remark  that  by 
proper  ingenuity  in  framing  the  definition,  the 
demonstration  of  the  inheritance  of  an  acquired  char- 
acter would  indeed  be  impossible.  Putting  it  in 
such  a  form  as  Poulton  suggests,  the  question  "Can 
the  acquired  characters  of  the  pnrent  be  handed 
down  as  inherent  characters  in  the  ofifspring?"  places 
the  answering  neo-Lamarckian  at  the  mercy  of  a 
neo-Darwinian  definition  for  "inherent." 

Returning  to  the  question  of  "authority"  again, 
here  is  the  distinguished  son  of  his  immortal  father. 
Dr.  Francis  Darwin,  president  this  year  of  the  Brit- 
ish Association  for  the  Advancement  of  Science.' 
who,  with  a  modesty  which  is  hereditary  and  not  a 
characteristic  acquired  in  the  field  of  English  zool- 
ogy, joins  the  ranks  of  those  who  look  upon  Weis- 
niann's  determinants  as  more  mysterious  than  the 
phenomena  they  were  advanced  to  explain.  On  the 
basis  of  the  general  idea  (the  idea  of  Hering  and 
Haeckel)  that  heredity  is  but  the  memory  of  matter 
— the  sum  of  all  past  experience  as  Burbank  puts 
it — he  impliedly  rejects  the  all  sufficiency  of  natural 
selection  as  an  explanation  of  the  present  state  of 
the  living  world.  That  the  somatic  or  body  cells  are 
affected  by  use  and  disuse  and  by  their  environment 
we  all  know.  It  is  a  fundamental  argument  of 
Weismannism  that  the  germ  cells  of  the  metazoa  are 
radically  differentiated  from  the  body  cells;  but  Dr. 
Francis  Darwin  sees  no  good  reason  for  believing 
that  there  is  any  hard  and  fast  line  between  them. 
Anatomically  and  embryogenetically  it  does  not  ex- 
ist, since  in  studying  the  metazoa  from  the  lowest 
lo  the  highest,  it  seems  to  be  the  exception  rather 
than  the  rule  that  the  germ  cells  arc  an  e^rly  differ- 
entiation of  embryonic  life.  Tt  h-'s  loiur  been  ad- 
mitted by  all  that  acquired  characters  are  transmit- 
ted in  the  unicellular  organisms. 

As  I  write,  the  first  installment  of  the  excellent 
work  of  Professor  Jennings  comes  to  hand.  So  far 
as  he  has  gone,  this  cautious  observer,  in  his  Hered- 
ity, \'ariation  and  Evolution  in  the  Protozoa,"  reveals 
his  opinion  that  the  only  difference  between  the 
inheritance  processes  of  unicellular  and  pluricellular 
organisms  is  that  of  complexity. 

In  fact,  the  weight  of  competent  authority,  newlv 
expressed  and  added  to  an  always  very  large  bodv 
of  dis.sent  from  Weismannism.  is  becoming  so  great 

*Essayx  cm  Evolution,  1908. 
•T/ic  Principles  of  Heredity,  1905. 
'Contemporary  Re-,  iew,  October,  1908. 
''Heredity.  igo8. 

'Science.   .Scntcmbrr   18,   25,  1908. 

*The  Journal  of  B.rfierimentat  Xoology.  v.  No.  4,  June,  1908. 


that  the  tone  of  neo-Darwinian  intolerance,  so  long 
predominant,  is  less  obtrusive  of  late. 

While  Professor  Thornson,  in  his  review  in 
Nature  of  Kellogg's  impartial  summary'"  is  not  very 
generous  toward  the  impartiality,  in  his  own  most 
excellent  book  on  Heredity"  there  is  a  suggestion, 
but  only  a  suggestion  ,of  "audi  alteram  partem," 
which,  for  those  of  us  who  do  not  find  Weismann's 
"ids"  thinkable,  is  very  gratifying ;  but  it  meets  with 
a  rebuke  at  the  hands  of  a  violent  neo-Darwinian" 
reviewer  for  its  excessive  kindliness  and  toleration. 
Whatever  else  may  be  said  about  the  reviewer's  own 
book,"  it  is  not  open  to  that  criticism,  and  yet  in  his 
most  recent  article"  Dr.  Reid.  too,  softens  his  tone 
of  asperity,  and  his  contribution  to  the  discussion, 
lacking  much  of  its  pristine  vehemence,  loses  all  of 
its  impressiveness. 

Those  who  accept  natural  selection  of  chance 
variations  as  the  sole  shaper  of  life  forms  and  life 
activities,  have  had  the  great  advantage,  for  their 
argument,  of  an  almost  unanimous  admission  of  its 
preponderant  influence  at  least,  and  the  momentum 
of  the  crowd  which  goes  thus  far  has  carried  its 
weight  to  those  who  go  further,  and  regard  it  as 
an  exclusive  and  all  sufficient  dogma.  They  have 
the  advantage  of  the  prestige  of  a  formula  whose 
equations  were  used  in  the  politicoeconomic  philos- 
ophy of  the  past  century  by  all  but  a  mere  handful 
of  thinking  men.  Not  only  did  both  Darwin  and 
Wallace  draw  inspiration  from  the  work  of  Malthus. 
but  their  theory  took  its  rise  while  the  principles  of 
the  Manchester  school  of  political  economy,  unre 
stricted  competition  between  man  and  man,  were  still 
all  but  unquestioned. 

Spencer  hir-'self  entered  upon  his  enormous  work 
from  the  politico-economic  incentive  of  his  early 
essays.  They  have  the  advantage  also  of  the  most 
obvious  facts — at  least,  obvious  enough  after  they 
were  pointed  out  by  Darwin  and  Spencer.  To  the 
latter,  one  of  the  three  or  four  Englishmen  who  have 
done  more  than  all  others  to  shape  the  thoughts  of  a 
world,  they  have  denied  a  place  in  Westminster  Ab- 
bey, yet  the  only  answer  to  the  query  why  English 
biology  no  longer  wields  the  power  it  once  did  over 
men's  thoughts — for  biology  is  indeed  the  science  of 
life — is  that  Darwin  and  Spencer  are  dead.  The  the- 
ory of  natural  selection,  of  the  gentle  and  generous 
Darwin,  does  not  need  to  be  bolstered  up  by  a  rejec- 
tion of  all  evidence  as  unreliable  which  impeaches 
either  the  pristine  or  the  more  recent  position  of 
Weismann.  Those  whose  memory  of  biological  lit- 
erature goes  back  to  the  early  publications  of  Weis- 
mann, and  who  drew  their  still  more  youthful  inspi- 
ration from  the  writings  of  Darwin  and  Spencer, 
cannot  subscribe  to  the  statement  of  Thomson,  from 
which  one  might  infer  that  the  neo-Darwinians  never 
defended  the  thesis  of  the  inviolability  of  the  germ 
plasm.  Among  those  old  enough  to  remember  the 
scientific  discussions  of  the  day,  the  impression  seems 
to  be  all  but  imanimous  that  that  was  the  ground  on 
which  they  made  their  first  stand.  Weismann  may 
indeed  himself  never  have  explicitly  asserted  that. 
He  says  he  never  did,  and  that  ought  to  settle  it. 
L'nfortunately.  he  seems  to  have  given  that  impres- 

'"Vernon  L.  Kcllogtt.     Darwinism  To-day,  1907. 
"J.  A.  Tlionison,     Heredity,  .goS. 
'-Nature.   AuRrist   20.  iqo8. 

'"Archdall  Ki-id.     The  Principles  of  Heredity.  1905. 
"TIte  ConlcnifoKiiy  Re-.ie'.v.  October,  1908. 


February  13.  1909.]  WRIGHT:  THEORIES  AND  PROBLEMS  OF  HEREDITY. 


3" 


sion  to  others  besides  myself,  for  Dr.  Francis  Dar- 
win, who  surely  was  in  a  position,  social  and  scien- 
tific, to  absorb  the  impressions  of  biological  discus- 
sion of  the  last  two  decades  of  the  nineteenth  cen- 
tury, remarks  {loc.  citat.)  :  "Weismann  has  greatly 
strengthened  his  theory  of  heredity  by  giving  up  the 
absolute  stability  and  perpetual  continuity  of  the 
germ  plasm."  Weismann,  in  claiming  to  be  misun- 
derstood, partakes  of  the  fate  of  his  great  antago- 
nist, Herbert  Spencer,"  who  was  always  complaining 
of  having  been  misunderstood. 

Professor  Thomson  has  drawn  up  categorically  a 
list  of  misunderstandings  under  which  Weismann's 
adversaries  labor.  It  is  convenient,  but  not  very  in- 
structive. [Misunderstandings  as  to  the  question  at 
issue  seem  to  be  rife  even  in  neo-Darwinian  cir- 
cles. I  have  alluded  to  the  trouble  of  Poulton  with 
it.  Reid  declares :  "The  practical  question,  there- 
fore, is  not  whether  conditions  can  be  discovered  in 
which  the  germ  plasm  is  altered  by  its  surroundings, 
but  whether  the  alteration  is  a  comm.on  thing  in  na- 
ture. .  .  .  But  there  is  no  evidence  that  such 
conditions  are  common  causes  of  variation."  Weis- 
mann and  Thomson,  while  diflfering  a  little  as  to  the 
frequency  of  this,  say  that  is  not  the  question  at  all. 
They  say  the  question  is:  "Does  somatic  change 
ever  affect  the  germ  plasm  ?"  Others  declare  that 
if  it  is  admitted  that  the  germ  plasm  is  affected  in 
any  way  by  the  environment,  the  cumulative  effects 
of  millions  of  years  of  experience  must  outrival  in 
efficiency  the  influence  of  natural  selection.  How  all 
this  may  be  as  to  definitions  we  must  leave  it  to  the 
neo-Darwinians  to  decide,  with  the  remark  that  some 
sympathy  is  due  their  critics  for  their  difficulties  in 
discussion,  which  much  resemble  that  which  the 
Dutchman  had  with  the  flea.  As  for  myself,  I  can- 
not see  that  there  is  anything  else  to  effect  the  varia- 
tions of  the  germ  plasm  except  the  environment,  un- 
less we  admit  the  intrusion  of  that  ever  present  spec- 
tre, "vitalism." 

Galton,  I  suppose,  may  be  considered  the  founder 
of  the  school  of  neo-Darwinism  rather  than  Weis- 
mann. His  first  formulation  of  the  law  of  heredity, 
according  to  Thomson,  was  that  one's  parents  con- 
tribute a  half,  grandparents  a  fourth,  great-grand- 
parents an  eighth,  etc.,  etc.,  to  the  sum  of  the  child's 
mheritance.  Theoretically  this  seems  to  be  the  ratio 
that  ought  to  obtain,  if  the  germ  plasm  is  transmitted 
unaltered  by  the  environment,  and  this  many  of  iis 
thought  was  the  original  doctrine  of  the  school.  Karl 
Pearson,  however,  again  according  to  Thomson,  by 
more  careful  inquiry  into  such  facts  as  he  and  his 
co-workers  have  been  able  to  reduce  to  arithmetical 
compuation.  thinks  the  true  ratio  is .  more  like, 
0.6244,  0.1988,  0.0630,  etc.  Using  this  decimal 
form  for  Galton's  first  surmise,  0.525,  0.1250,  etc., 
is  it  possible  that  the  difference  between  Galton's 
figures  and  Pearson's,  0.1244,  0.0512,  0.0620,  etc., 
etc.,  represents  the  degree  of  modification  of  the 
germ  plasm  by  the  environment  which  the  present 
neo-Darwinian  school  will  concede  to  the  neo-La- 
marckian  contention?  There  really  seems  to  be  a 
very  considerable  discrepancy  between  the  theoreti- 
cal and  the  observed  valency  of  ancestral  influence. 

However  much  we  may  be  disposed  to  jest  with 
those  who  solemnly  asseverate  that  their  opinions, 

"See  his  Autobiography  and  Dr.  Duncan's  more  recent  Biography. 
Professor  Thomson  has  also  written  a  very  inadequate  life  of  him. 


like  the  laws  of  the  Medes  and  Persians,  never 
change,  the  fact  of  the  matter  is,  the  mind  which 
has  ceased  to  be  in  a  state  of  flux,  taking  its  hue 
from  the  new  facts  that  are  constantly  arising  on  the 
world's  horizon,  is  not  a  mind  at  all — -it  is  a  parrot's 
organ.  While  we  are  constantly  boasting  of  our 
consistency  and  believing  in  it,  there  is  really  noth- 
ing to  boast  of ;  on  the  other  hand,  there  is  much  to 
deplore.  Even  if  such  huge  rocks  of  intellect  as 
Weismann  and  Spencer  believe  in  their  own  stabil- 
ity, they  move  with  the  rest. 

It  is  hardly  worth  the  trouble  to  seek  out  scientific 
writings  twenty-five  years  old  to  settle  the  point  that 
Thomson  raises  as  to  Weismann's  early  views.  That 
may  be  safely  left  to  the  historian  of  the  progress  of 
human  thought.  Suffice  it  to  say  that  Weismann,  in 
his  more  recent  and  more  extensive  work,'*  while  ad- 
mitting that  he  may  have  been  a  little  too  abrupt  and 
absolute,  repudiates  the  view  imputed  to  him  of  the 
inviolability  of  the  primordial  protoplasm.  He  de- 
clares he  only  meant  to  claim  that  it  was  only  very 
slowly  and  with  great  difficulty  changed  by  the  en- 
vironment. Thomson,  however,  concedes,  it  seems 
to  me^  very  much  more  to  the  influence  of  the  en- 
vironment than  is  warranted  by  Weismann's  text. 
There  really  seems  to  be  taking  place  among  the 
neo-Darwinians  themselves  that  flux  of  mind,  to- 
ward the  standpoint  of  the  neo-Lamarckians  at  which 
I  have  hinted,  but  we  will  accept  their  assertion  of  a 
misunderstanding.  Briefly  we  may,  with  diffidence 
bred  from  a  long  experience  with  our  errors,  state 
their  position  again  as  admitting  that  the  environ- 
ment effects  changes  in  the  germ  plasm  by  direct  ac- 
tion on  it,  but  it  does  not  do  this  in  such  a  way  that 
the  germ  plasm  reproduces  somatic  cells  presenting 
the  characters  the  somatic  cells  derive  direct  from 
the  environment  except  by  accident.  In  arguing  this 
point  we  are  handicapped  in  not  being  allowed  to  in- 
troduce circumstantial  evidence,  which  is  often 
deemed  sufficient  to  hang  a  man.  We  are  practical- 
ly limited  to  making  use  of  such  direct  evidence  as 
the  neo-Darwinians  admit  is  trustworthy — that  is 
confirmed  by  themselves.  Personally  I  have  less  re- 
spect for  this  sort  of  evidence  than  I  have  for  the 
cumulative  eft'ect  of  circumstantial  evidence,  incon- 
clusive in  its  separate  parts,  perhaps,  but  over- 
whelming in  its  coincidences  and  corroborations. 

Let  us  confine  ourselves  then  to  the  testimony  ac- 
cepted by  Weismann  as  reliable,  and  which  he  ad- 
mits seems  to  tell  against  his  doctrine  of  the  non- 
transmissibility  of  acquired  characteristics.  He 
repeated  the  experiments  of  Fischer  as  to  the  effects 
of  cold  on  the  inheritance  of  pigment  in  the  butter- 
fly's wing.  He  found"  that  the  animal  developed 
from  the  cocoon  thus  subjected  to  an  unusual  en- 
vironment had  more  or  less  pigment  in  the  wings 
according  to  the  degree  of  cold  used.  This  of 
course  was  affecting  the  ontogeny  or  the  body  cells, 
and  that  we  know  is  vulnerable;  but  it  was  also 
found  that  this  pigment  change  lasted  for  a  genera- 
tion or  two  after  the  cocoons  resumed  their  normal 
environment.  I  trust  I  have  not  misstated  this  ex- 
periment, but  reference  is  easily  made  to  either  the 

^'Vortrage  iiber  Descendenztheorie,  ii,  p.  164.  I  may  say,  to 
clear  rnvself  of  Thomson's  charge  of  unfamiliarity  with  the  views 
of  Weismann  on  the  part  of  his  critics,  that  I  have  never  read 
a  book  with  more  attention  than  I  have  this  book  of  Weismann's, 
unless  it  is  Thomson's  own  work  on  Heredity.  Thomson's  transla- 
tion of  Weismann  I  have  not  seen. 

^''Loc.  citat,  ii,  p.  231. 


312 


WRIGHT:  THEORIES  AND  PROBLEMS  OF  HEREDITY. 


[New  YeRK 
Medical  Journal. 


translated  work  of  Weismann  or  to  the  similar  ex- 
periments and  results  of  Morgan."  Now  Weismann 
says  that  it  is  mere  coincidence.  It  so  happens  that 
the  somatic  cells  were  affected  in  such  a  way  that 
they  fixed  pigment  in  the  first  generation,  and  the 
germ  cells  were  so  affected,  directly,  that  they  re- 
produced somatic  cells  having  the  same  fixative 
power  for  the  pigment. 

It  is  necessary  that  I  should  again  digress  in  order 
to  develop  the  objections  more  clearly  which  I  have 
in  mind,  although  they  easily  suggest  themselves  on 
a  first  consideration  of  this  bold  view  of  the  matter. 
I  have  referred"  to  the  distinction  made  by  the  neo- 
Darwinians  between  the  unicellular  organisms  and 
the  multicellular  in  the  matter  of  heredity,  and  I  am 
constrained  to  discuss  it  again  in  this  connection. 
In  spite  of  the  weight  of  authority  and  its  reiterated 
expression  to  the  contrary,  I  have  been  unable  to 
perceive  the  fundamental  difference  between  the 
multiplication  of  bacteria  into  an  adhering  colony 
and  the  multiplication  of  the  germ  cell  into  a  co- 
herent metazoon.  The  symbiosis  is  more  perfect  and 
the  activities  of  the  cells  are  more  interdependent 
in  the  one  case  than  in  the  other,  but  this  is  a  mat- 
ter of  evolution.  There  are  all  sorts  of  gradations 
through  chains  and  looselv  united  zooglea  from  the 
adherent  to  the  coherent  cells.  This,  I  take  it,  is  the 
position  assumed  by  Dr.  Francis  Darwin  and  is  the 
indication  of  Jenning's  observations, — to  both  of 
which  I  have  referred.  It  is  universally  admitted 
that  acquisitions  both  of  form  and  function  caused 
by  the  environment  are  transmitted  from  culture  to 
culture  of  bacteria.  We  are  told  by  the  neo-Dar- 
winians  that  the  germ  plasm  of  bacteria  is  not  only 
directly  exposed,  but,  divided  ad  infinitum  though 
it  is  at  the  end  of  a  year,  there  is  in  each  one  of 
the  myriad  offspring  a  bit  of  its  original  parent  germ 
plasm.  Consequently  the  modification  is  trans- 
mitted. We  may  well  inquire  whether  the  subdivi- 
sion is  subatomic,  made  up  of  an  electron  or  two, 
but  we  should  probably  receive  the  answer  that 
there  is  a  determinant  in  each.  Manifestly  we  are 
plunged  into  absurdity.  The  character,  whatever 
it  is,  is  one  of  molecules,  and  what  we  want  to  know 
is  how  molecule  hands  it  on  to  molecule.  I  have 
referred  to  the  rust  of  wheat ;  of  two  varieties  of 
wheat,  one  may  be  immune  to  it  and  the  other  not. 
When  bred  together,  all  the  offspring  are  suscepti- 
ble, these  again  interbred  show  the  Mendelian  ratio 
of  three  susceptible  to  one  immune  against  rust. 
Manifestly  in  this  mosaic  inheritance  we  have  here 
some  such  dynamic  molecular  arrangement  which  is 
transmitted  in  the  multicellular  plant,  as  we  have 
had  to  assume  for  the  unicellular  bacterium.  I  see 
no  escape  from  the  same  conclusion  for  the  butter- 
fly's wing  pigment.  It  is  in  the  germ  plasm  evi- 
dently a  case  of  molecular  dynamics, — the  represen- 
tation of  a  chemical  affinity  in  the  undifferentiated 
germ  plasm  of  the  bacterium,  of  the  differentiated 
germ  plasm  of  the  wheat  kernel  and  of  the  butterfly. 
Even  the  complexity  of  man  is  also  a  characteristic 
of  the  bacterium  when  it  comes  to  the  transmission 
of  molecular  ac(|uisitions.  The  mystery  is  the  same 
between  molecule  and  molecule,  as  between  coccus 
and  coccus,  as  between  man  and  man.  The  subtle 
chemical  difference  between  a  virulent  bacterium 
and  its  saphophytic  offspring,  after  the  countless 

"Thom.is  Hunt  Morgan.    Experimental  Zoology,  1907. 
'•See  New  York  Medical  Journal,  January  9,  1909. 


generations  elapsing  in  six  months,  has  been 
wrought  by  the  environment ;  it  is  in  no  way  differ- 
ent from  the  change  of  pigment  in  the  wing  of  the 
butterfly.  The  mystery  is  just  as  great  how  mole- 
cule hands  the  acquisition  on  to  molecule  as  how 
somatic  cell  hands  it  on  to  germ  cell.  The  only 
question  we  can  hope  to  answer  is :  Does  the  so- 
matic cell  really  do  so?  It  would  seem  so  in  the 
case  of  the  butterfly's  pigment,  or  again,  is  it  a  coin- 
cidence ?  The  answer  to  this  question  furnishes 
the  excuse  for  a  repetition  of  the  consideration  of 
molecular  characters. 

This  reduction  of  the  inherited  thing  to  molecular 
dimensions  helps  us  to  consider  the  force  of  coinci- 
dences in  the  argument  of  Weismann.  Sour  grapes 
eaten  by  the  father  may  not  set  the  son's  teeth  on 
edge,  some  one  lias  said,  but  it  may  give  him  a  wry 
neck.  Weismann  says  the  son  may  have  teeth  set  on 
edge,  but  if  he  has,  the  grapes  his  father  ate  not 
only  set  his  father's  teeth  on  edge  but  altered  the 
tooth  rudiment  in  his  father's  spermatozoon  simul- 
taneously and  independently.  There  are  millions 
of  other  things  the  sour  grapes  could  have  done, 
there  are  many  millions  of  other  things  the  cold 
might  have  done  to  the  butterfly's  germ  plasm.  If 
some  one  would  calculate  just  how  many,  Karl 
Pearson  could  doubtless  tell  us  how  liable  the  coin- 
cidence is  to  occur.  Weism.ann's  explanation  may 
be  valid,  but  one  or  two  more  such  coincidences 
would  wreck  any  theory.  Others  have  been  re- 
ported. 

Now  it  is  one  thing  to  believe  that  some  of  the 
somatic  effects  of  environment  influence  the  germ 
plasm  to  reproduce  the  effect  in  a  subsequent  so- 
matic cell,  and  it  is  another  thing  to  claim  that  all 
somatic  changes  are  transmitted  specifically.  Jen- 
nings, who  is  much  influenced  in  theoretical  consid- 
erations by  the  very  helpful  teaching  of  Baldwin, 
Lloyd-Morgan,  Osborn,  and  others  as  to  organic  se- 
lection'" has  apparently  applied  the  facts  he  has  ob- 
served in  studying  the  heredity  of  the  protozoa  to 
the  support  of  the  idea.  He  says"  that  when  the 
germ  plasm  is  directly  affected  by  the  environment 
"it  evidently  would  be  only  general  changes  in  the 
germ  plasm  that  would  be  thus  directly  trans- 
mitted." It  would  seem  that  such  inheritance  as  the 
molecular  change  in  the  germ  plasm  or  in  the  so- 
m^atic  cells  producing  pigment  in  the  butterfly's 
wing,  might  be  called  a  very  specialized  kind  of  in- 
heritance. This  "organic  selection"  conception  is  a 
very  valuable  one,  and  it  no  doubt  can  be  applied 
to  a  large  number  of  facts  observed  in  the  study  of 
heredity ;  but  it  certainly  is  not,  and  it  is  not  claimed 
to  be  by  its  authors,  an  universal  formula.  Yet  Jen- 
nings very  properly  declares  that  such  coincidental 
effects  of  the  environment  as  I  have  alluded  to,  the 
production  of  a  complex  structure  "in  two  quite 
heterogeneous  ways  would  be  most  extraordinary." 
While  in  the  protozoa,  Jennings  points  out,  the 
changes  are  sometimes  so  simple  that  it  can  be  seen 
how  an  acquired  characteristic  produces  modifica- 
tions by  which  the  fission  is  influenced,  the  com- 
plexity even  here  is  often  so  great  that  the  course 
of  events  can  not  be  followed.    In  the  metazoa  the 

"A  badly  selected  term  to  indicate  indefinite  variations  at  first 
without  selective  value,  then  seized  upon  by  ontogenetic  adaptation 
for  the  benefit  of  the  animal  and  finally  becoming  fixud  in  heredity 
by  definite  variation  and  natural  selection. 

"/oi/rjia/  of  Experimental  Zoology,  June,  1908. 


February  13,  1909.]  WRIGHT:   THEORIES  AND 

mind  is  incapable  of  following  the  thread  of  the 
tangled  skein.  Notwithstanding  the  discouragement 
now  seemingly  warranted,  I  can  not  but  believe  fu- 
ture work  will  finally  follow  the  path  of  the  impulse 
which  starts  in  the  environment.  At  present  the 
enormous  complexity  of  the  problem  only  empha- 
sizes the  significance  of  the  coincidence  admitted  by 
Weismann  in  at  least  one  instance.  If  it  is  repeated 
I  can  not  understand  how  a  candid  mind  will  be  able 
to  deny  that  the  path  leads  through  the  somatic  ef- 
fect, in  such  cases. 

I  have  alluded  in  a  former  paper  on  the  evolution 
of  the  tonsil"  to  the  tendency  of  protoplasm  to  vary 
more  easily  and  promptly  with  the  changes  in  the 
heat  scale,  and  1  have  referred  that  tendency  to  the 
experience  of  protoplasm  from  its  birth  through  un- 
told aeons  of  phylogenetic  history.  In  a  sense  it  is 
often  seen  to  be  due  to  natural  selection.  In  fact  it 
is  then  the  price  of  its  survival.  The  pigment  in 
the  butterfly's  wing  is  an  instance  not  to  be  ex- 
plained by  natural  selection  of  the  individual.  There 
seems  reason  to  believe  that  not  only  does  this  pig- 
mentation vary  now  with  the  temperature  of  the 
habitat  of  the  butterfly  in  a  state  of  nature,  but  this 
is  a  character  which  has  varied  for  ages  in  the  phy- 
logeny  of  the  race.  Kammerer^^  having  observed 
that  eels  and  salamanders  of  certain  kinds  vary  as 
to  their  method  of  reproduction  according  to  the 
temperature  and  the  influence  of  water,"*  he  thus 
experimentally  caused  salamanders,  accustomed  to 
reproduce  their  young  viviparously  to  reproduce 
their  young  by  egg.  The  effect  of  the  influence  thus 
impressed  on  these  salamanders  for  a  generation  or 
two  was  inherited  for  a  generation  or  two  after  they 
had  returned  to  an  environment  in  which  they  were 
accustomed  to  reproduce  their  young  alive.  Com- 
menting on  his  work  Kammerer  says  "In  the  theo- 
retical considerations  of  these  results,  I  have 
pointed  out  that  they  compel  us  to  recognize  the 
heritable  effects  of  external  influences,  yet  it  is 
doubtful  if  these  are  truly  characteristics  acquired 
through  the  choice  of  the  experimenter,  somato- 
genic phenomena  in  the  strict  sense, — in  other  words 
directly  physical,  or  whether  they  are  indirectly  phy- 
siologically coaxed  by  the  body  cells  out  of  the  germ 
plasm."  The  criticism  of  Plate,  the  most  frank  and 
the  most  formidable  of  the  adversaries  of  Weis- 
mann, to  which  he  refers,  does  not  seem  to  me  well 
taken.  Plate  objects  that  this  is  a  characteristic  of 
the  salamander  which  varies  in  nature  according  to 
the  environment ;  the  inherited  action  of  the  experi- 
mental low  or  high  temperature  is  but  rendering 
dominant  that  characteristic  which  was  for  the  time 
latent.  The  same,  it  must  be  admitted,  can  be  said, 
with  less  force  perhaps,  of  the  pigment  in  the  butter- 
fly's wing  in  the  experiments  of  Fischer  and  Mor- 
gan ;  but  I  can  not  see  that  this  invalidates  the  proof 
of  the  determinate  action  of  the  somatic  habit  upon 
the  germ  plasm,  or  without  it,  that  it  is  an  explana- 
tion of  the  remarkable  coincidence.  We  may  be 
permitted  to  apply  here  the  principle  of  Jennings."' 
The  resolution  of  one  physiological  state  into  an- 
other becomes  easier  and  more  rapid  after  it  has 

^New  York  Medical  Journal,  August  8,  1908. 

^^Archiv  fiir  Entzvickelungsmechanik  der  Organismen,  xxv,  parts 
I  and  2,  December,  1907.  Also  see  his  Autoreferat:  Zeitschrift 
fir  indiikitive  Abstammungs  und  Verebungslehre,  i,  parts  i  and 
2,  September,  1008. 

^'This  tendency  to  vary,  we  can  conceive,  may  be  the  result  of 
natural  selection. 


PROBLEMS  OF  HEREDITY.  313 

taken  place  a  number  of  times.  This  then  is  the  sort 
of  reaction  that  germ  plasm  most  easily  gives,  the 
kind  of  reaction  to  which  it  has  been  accustomed 
by  use  in  its  phylogeny.  The  universal  agent,  tem- 
perature, played  the  most  important  part  in  the 
chemical  combination  at  the  birth  of  protoplasm, 
just  as  it  plays  a  most  important  part  at  the  birth 
of  other  chemical  compounds ;  and  it  has  continued 
its  importance  ever  since.  To  my  mind  this  in  no 
way  invalidates  the  demonstration  in  this  instance 
of  the  somatogenetic  influence  on  the  germ  plasm. 
The  soma  more  easily  produces  this  specific  effect 
on  the  germ  plasm  on  account  of  the  habit  of  the 
germ  plasm,  but  unless  a  coincidence  is  again 
pleaded,  the  path  of  the  influence  seems  to  have  been 
through  the  somatic  habit.  To  be  fair,  however,  we 
must  recognize  that  it  may  be  urged  the  direct  influ- 
ence of  the  temperature  on  the  germ  plasm  in  a  spe- 
cific direction  is  also  thus  more  easily  effective.  This 
principle  of  habit  then,  the  memory  of  matter,  the 
very  essence  of  heredity,  use  and  disuse,  plays  the 
same  important  part  in  the  nature  of  the  germ  cell 
as  it  does  in  the  cells  of  the  soma. 

If  we  are  to  exclude  this  sort  of  proof  of  the  in- 
fluence of  the  changes  in  the  soma,  if  we  are  asked 
to  point  out  instances  in  which  protoplasm  acts  in  a 
way  it  has  never  acted  before,  reacts  to  stimuli  of 
the  environment  with  which  it  has  had  no  phylo- 
genetic experience,  we  are  necessarily  forced  to  de- 
fend the  thesis  that  we  can  impress  upon  protoplasm 
a  stability  which  can  only  be  the  result  of  ages  of 
experience.  That  as  yet  we  cannot  do  experimentally 
through  the  soma,  but  the  environment  does  it  in 
causing  mutations.  As  I  have  said,  it  is  one  thing  to 
believe  that  the  somatic  change  always  makes  its  in- 
fluence felt  by  the  germ  cell  and  quite  another  to 
believe  there  are  certain  kinds  w'hich  impress  the 
germ  plasm  specifically.  The  first  may  be  a  thesis 
defensible  on  general  principles,  but  all  we  can  hope 
to  do  is  to  prove  specific  instances.  It  is  one  thing 
to  believe  in  the  transmission  of  acquired  characters 
and  another  thing  to  deny  the  preponderating  influ- 
ence of  natural  selection  in  the  formation  of  species. 
Whatever  may  be  true  in  the  plant  world,  the  latter 
factor  is  certainly  the  most  obvious  in  zoology.  Just 
as  it  has  been  declared,  (after  DeVries  had  insisted 
on  the  exclusive  method  by  mutation),  that  species 
formation  in  the  plant  world  comes  about  in  various 
ways,  and  mutation  is  only  one  way,  so  it  may  be 
said  that  the  factors  giving  rise  to  individual  varia- 
tions and  mutations  must  be  as  diverse  as  their  re- 
sults. Whether  somatogenous  influences  can  effect 
stable  mutations  along  new  lines  is  probably  to  be 
answered  in  the  affirmative.  At  present,  however, 
neo-Lamarckian  evidence  as  to  this  will  not  be  ac- 
cepted bt  the  neo-Darwinians  as  conclusive. 

Finally  the  neo-Lamarckians  are  asked  to  explain 
how  the  influence  is  transmitted  from  the  somatic 
cell  to  the  germ  cell.  If  we  followed  Weismann's 
example  when  he  finds  himself  pressed  to  explain 
how  the  determinants  transmit  their  influence  to  the 
somatic  cells,  we  might  say  doubtless  there  is  some 
vital  influence  which  the  somatic  cells  exert  on  the 
germ  plasm.  Let  us  say  frankly  ignoramus.  Any 
theory  which  has  finally  to  take  refuge  in  such  a 
term  as  vitalism,  I  have  insisted,  has  failed  of  its 
purpose.   That  the  subtlety  and  complexity  of  such 

"Behavior  of  the  Lower  Organisms,  1906,  p.  291. 


314 


CALHOUN:  OPERATIVE  MASTOIDITIS. 


[New  York 
Medical  Journal. 


a  transfer  baffles  us,  is  not  strange,  but  that  it  will 
always  baffle  us,  it  is  the  suicide  of  science  to  admit. 

In  a  previous  paper  I  have  referred  to  the  theory 
of  the  shifting  of  molecules  in  the  benzol  group, 
whereby  it  is  explained  how  a  change  of  color  is 
noted  in  the  spectroscopic  image,  yet  chemical  analy- 
sis is  powerless  to  detect  the  change  in  structure. 
I  have  shown  how  probable  it  is  that  some  slight 
change  in  local  surface  tension  forces  resulting  from 
a  molecular  disturbance  in  the  sympathetic  nerves 
allows  of  infection  through  the  mucous  surfaces. 

The  chameleon  changes  his  hue  with  his  environ- 
ment. A  short  time  ago  who  could  venture  to  point 
out  all  the  molecular  and  ethereal  vibrations  where- 
by the  chain  of  action  is  made  complete  between 
external  environment  and  peripheral  tissue  change? 
Yet  Sollaud'°  found  that  the  pigmentary  changes  by 
virtue  of  which  the  frog  harmonizes  itself  more  or 
less  with  the  color  of  its  environment  are  governed 
by  two  sorts  of  nerves.  It  results  from  the  action 
of  two  reflexes,  both  originating  in  the  retina;  and 
by  his  investigations  he  is  able  to  map  out  the  paths 
from  the  brain  to  the  periphery  by  each  of  the  re- 
flexes. Now  let  us  picture  to  ourselves  the  delicacy 
of  this  process.  First,  the  green  foliage,  causing 
vibrations  in  the  ether  in  certain  wave  lengths,  sets 
up  certain  molecular  vibrations  in  the  retina,  which, 
translated  to  the  brain,  issue  forth  at  the  periphery 
in  such  form  that  neither  the  skin  nor  the  pigment 
granules  in  it  are  changed  irreversibly,  but  certain 
molecular  combinations  are  made  for  the  time,  or 
certain  intramolecular  changes  of  the  atomic  struc- 
ture are  set  up  in  the  pigment  for  the  time,  by  vir- 
tue of  which  a  protective  color  is  given  to  the  ani- 
mal. Before  such'  phenomena  as  this  and  many 
others,  it  is  idle  to  deny  there  is  any  path  by  which 
the  most  subtle  of  influences  are  translated  into  the 
most  obvious  of  phenomena. 

Now  the  neo-Darwinians  seize  upon  this  mimicry 
of  the  chameleon  as  one  of  the  most  convincing 
proofs  of  the  wonders  of  natural  selection,  but  so 
far  as  I  know  there  has  not  been  a  voice  raised  in 
disbelief  on  the  ground  that  they  could  not  thirty 
.  years  ago  point  out  how  the  thing  came  about.  Just 
what  constitutes  proof,  just  how  closely  one  feels 
obliged  to  point  out  the  connection  between  the  va- 
rious steps  in  a  chain  of  events  seems  to  depend 
largely  upon  whether  one  is  asking  for  proof  or  giv- 
ing it. 

44  West  Forty-ninth  Street. 


RESULTS   IN  FOUR  HUNDRED  OPERATIVE 
CASES   OF  MASTOIDITIS. 

By  F.  Phinizy  Calhoun,  A.  B.,  M.  D., 
Atlanta,  Ga.,  • 
Associate    Professor,    Atlanta    College    Physicians   and  Surgeons; 
Oculist  and  Aurist,  St.  Joseph's  Infirmary,  Presbyterian 
Hospital  and  Grady  Hospital. 

The  following  paper  is  based  on  four  hundred 
cases  of  operative  mastoiditis,  occurring  in  the  New 
York  Eye  and  Ear  Infirmary  during  the  year  1905. 

I  have  purposely  divided  these  cases  into  three 
groupings,  according  to  their  acuteness  or  chron- 
icity — or  more  properly,  the  operations  as  they  were 
performed,  viz.,  the  Schwartze,  the  Schwartze- 

"Ref. :  Revue  Scientifique,  October  3,  1908,  No.  14,  p.  446. 


Stacke,  and  the  Stacke,  so  called  after  the  manner 
done  at  this  institution. 

In  this  series  of  four  hundred  cases  there  was  no 
distinction  in  sex.  The  number  was  exactly  the 
same  in  each.  The  right  side  was  affected  two  hun- 
dred and  eight  times;  the  left  one  hundred  and 
ninety-two  times.  Only  two  negroes  were  operated 
upon,  and  both  had  enormously  thickened  cortices. 
Mastoiditis  from  otitis  media  purulenta  acuta,  the 

Schwartze  operation. 

Aural  trouble  within  three  months'  time,  with 
mastoid  involvement,  was  considered  an  acute  case. 
There  were  of  that  number  two  hundred  and 
seventy-one  cases.  Cases  of  longer  standing  were 
classified  as  chronic,  and  generally  the  radical  opera- 
tion was  required. 

Among  the  influences  which  played  important 
parts  in  the  causation  of  aural  trouble,  season  was 
most  important.  Acute  middle  ear  conditions  were 
more  frequent  in  midwinter  and  early  summer  in 
this  locality  than  at  other  times.  A  sudden  change 
in  the  weather  always  brought  an  increase  in  the 
number  of  acute  ears  to  the  clinics.  The  following 
is  the  number  of  operations  for  acute  mastoiditis 
done  by  months  :  January,  33  ;  February,  39;  March, 
29 ;  April,  26 ;  May,  27  ;  June,  27 ;  July,  22 ;  August. 
17;  September,  12;  October,  3;  November,  13; 
December,  23. 

Age  was  also  an  important  factor,  for  about  one- 
half  the  total  number  were  under  ten  years.  There 
were  fifty-seven  patients  under  two  years;  twenty- 
three  from  two  to  five  years ;  thirty-two  from  five  to 
ten ;  forty-four  from  ten  to  twenty ;  forty-four  from 
twenty  to  thirty ;  thirty-four  from  thirty  to  forty ; 
twenty-one  from  forty  to  fifty ;  and  one  at  sixty- 
three.   The  youngest  was  eight  weeks. 

Double  mastoid  operations  were  required  in  six 
cases. 

Bacteriology.  Cover  glass  smears  were  made  of 
all  aural  discharges  on  admission  to  the  wards,  and 
a  microscopical  examination  made  in  every  case.  In 
just  the  same  way,  at  the  time  of  the  operation 
smears  were  made,  if  pus  was  found  in  the  mastoid 
cells.  Cultures  were  made  when  an  important  case 
demanded  it. 

These  examinations  gave,  in  a  fairly  accurate  way, 
the  nature  of  the  infection,  and  due  weight  was 
given  to  its  character.  The  aural  pus  often  gave 
misleading  information,  for  the  nature  of  the  infec- 
tion was  termed  "mixed."  The  fact  that  the  infec- 
tion was  not  understood  did  not  signify  that  it  was 
not  violent,  for  there  were  several  cases  where  the 
mastoid  pus  showed  this  doubtful  character  of  infec- 
tion, and  there  was  one  case  each  of  sinus  throm- 
bosis and  brain  abscess  having  this  mixed  type  of 
infection. 

The  infection  of  most  virulence  was  the  strepto- 
coccus or  some  of  its  family.  Generally  it  was  rapid 
in  its  destruction,  and  most  of  the  extradural  ab- 
scesses were  in  bones  infected  with  this  organism. 
Whenever  there  was  a  case  with  a  streptococcus 
infection,  presenting  doubtful  operative  symptoms, 
where  subsequently  an  operation  was  performed, 
pus  was  found  in  the  mastoid  cells  in  the  vast 
majority  of  cases. 

Of  the  cases  of  Bezold's  mastoiditis  in  which 


February  13,  1909.] 


CALHOUN:  OPERATIVE  MASTOIDITIS. 


315 


smears  were  made,  seven  of  the  nine  showed  strepto- 
coccus, either  in  the  aural  or  mastoid  pus,  and  in 
one  case  the  perforation  occurred  within  one  week 
after  the  onset.  The  others  were  from  three  to  five 
weeks'  standing. 

The  pneumococcus  was  next  in  point  of  number 
and  virulence,  and  in  many  cases  as  rapid  as  the 
streptococcus. 

The  staphylococcus,  grippe  bacillus  and  pyo- 
cyaneus,  occurred  in  something  less  than  fifteen 
cases,  in  that  order  of  frequency ;  there  was  nothing 
distinctive  about  these  infections,  except  in  the  one 
case  of  grippe  there  were  the  accompanying  well 
marked,  depresing,  systemic  symptoms.  Again,  in 
all  of  the  pyocyaneus  cases,  the  mastoid  pus  was 
greenish  yellow  and  the  dressings  were  always 
stained  the  same. 

The  Spirillum  of  Vincent  was  found  in  the  aural 
secretions  five  times,  and  in  mastoid  pus  five,  all 
occurring  in  chronic  cases. 

The  pathologist  to  the  hospital.  Dr.  G.  S.  Dixon, 
was  the  first,  so  far  as  I  am  aware,  to  call  attention 
to  the  violence  of  the  Streptococcus  capsulatus,  and 
the  peculiar  manner  in  which  it  acts.  He  maintains 
that  it  is  slow  and  treacherous,  and  whenever  the 
middle  ear  does  not  show  signs  of  resolution  within 
three  weeks'  time  with  this  infection,  radical  meas- 
ures should  be  entertained  and  an  exploratory  mas- 
toid operation  performed.  Experience  with  these 
cases  has  substantiated  Dr.  Dixon's  observation. 
The  nature  of  the  infection  may  be  best  understood 
in  the  following  typical  case : 

Case  I. — Three  "weeks  before  admission,  the  patient,  a 
man,  complained  of  fullness  in  his  left  ear,  and  consulted 
an  aurist.  when  the  ear  commenced  to  discharge  a  few  days 
later.  There  was  only  a  moderate  amount  of  pain  up  to 
that  time,  when  there  developed  mastoid  symptoms.  He 
was  placed  in  the  infirmary  for  observation.  His  symptoms 
on  admission  were  the  usual  ones  for  acute  mastoiditis, 
a  free  mucopurulent  discharge;  a  reddened,  beefy  looking 
drum;  a  moderate  amount  of  tip  and  antrum  tenderness, 
and  a  temperature  of  101°  F.  A  bacteriological  examina- 
tion of  the  discharge  was  made  after  a  myringotomy  was 
done  and  found  to  be  streptococcus.  With  five  days'  rest 
in  bed  and  appropriate  treatment,  all  symptoms  except  the 
profuse  aural  discharge  ceased,  and  the  patient  felt  unus- 
ually well.  There  was,  however,  that  same  angry  looking 
canal  condition,  with  perhaps  some  oedema  of  the  postero- 
superior  canal  wall.  A  second  bacteriological  examination 
was  made,  and  the  Streptococcus  capsulatus  was  found.  An 
operation  was  advised  solely  on  the  bacteriological  findings 
and  the  profuse,  persistent  aural  discharge. 

The  operation  revealed  a  well  distinegrated  bone,  and 
epidural  abscess,  and  a  large  exposure  of  dura.  The  patient 
entirely  recovered. 

The  other  cases,  while  not  as  typical  in  every 
detail  as  the  one  mentioned,  all,  however,  illustrate 
the  slowness  of  the  infection,  and  have  the  charac- 
teristic features.  There  were  serious  complications 
in  all  of  the  ten  operative  cases.  The  eleventh 
patient  demanded  his  discharge  when  an  operation 
was  advised. 

It  will  be  interesting  to  note,  in  connection  with 
the  subject  of  bacteriology,  that  all  of  the  cases  of 
erysipelas  which  developed  in  the  infirmary  after 
operation,  and  that  number  was  six,  occurred  in 
patients  w^hose  aural  or  mastoid  pus  showed  strepto- 
coccus or  one  of  its  forms. 

As  to  the  value  of  a  bacteriological  examination 
of  the  aural  secretion  in  determining  the  prognosis 


or  progress  of  a  case  of  acute  mastoiditis,  the  differ- 
ent surgeons  had  their  different  views  as  to  its  effi- 
ciency. Some  placed  considerable  faith,  others  little, 
in  an  examination. 

An  examination  is  of  little  value  unless  the  smear 
is  taken  from  a  clean  canal,  or  one  rendered  as  clean 
as  possible,  for  only  then  does  one  get  the  pus  fresh 
from,  the  tympanum,  and  it  is  not  contaminated  by 
saproph^lic  bacteria  and  other  organisms  ever  pres- 
ent in  any  canal.  It  is  no  w^onder  that  the  majority 
of  the  smears  show  a  mixed  infection,  meaning 
nothing  to  the  otologist,  or  that  the  canal  pus  pre- 
sents one  type  of  organism  entirely  distinct  from 
the  one  found  in  the  mastoid  pus  after  operation. 
When  the  canal  was  irrigated  with  some  mild  anti- 
septic solution  like  saline,  then  wiped  dry  with  a 
solution  of  alcohol  and  bichloride,  and  reirrigated  at 
intervals  according  to  the  discharge,  and  the  secre- 
tions collected  on  a  small  pledget  of  cotton  placed 
in  the  meatus,  the  microscopical  findings  by  culture 
or  smear  represented  as  near  as  possible  the  true 
tympanic  infection. 

The  streptococcus  and  pneumococcus  respectively 
in  point  of  frequency  and  virulence  were  the  organ- 
isms usually  found. 

The  value  of  a  knowledge  of  the  infection  lies  in 
the  fact  that  one  would  be  more  tempted  to  operate 
in  a  case  of  mastoiditis,  with  doubtful  operative 
symptoms,  with  a  streptococcus  invasion,  than  in  the 
same  case  with  a  pneumococcus  infection.  I  do  not 
recall  a  case  of  pneumococcus  infection  where  a 
delay  of  a  day  or  so  brought  about  bad  results. 
Complications  did  arise  in  delayed  operations  in 
streptococcus  cases,  and  at  the  same  time  some 
recovered  without  an  Of>eration. 

The  Streptococcus  capsulatus,  whenever  found  in 
an  aural  discharge,  that  case  should  receive  careful 
attention,  and  in  cases  of  one  month's  standing  at 
least,  as  recommended  by  the  bacteriologist  to  the 
infirmary,  should  have  an  exploratory  operation. 
To  some  this  might  seem  radical  surgery,  but  the 
cases  occurring  in  this  series,  and  the  many  more 
that  I  have  had  occasion  to  follow,  proved  without 
a  single  exception  the  treacherousness  and  the  slow 
but  sure  acting  manner  of  the  organism.  And  in 
every  case  where  an  operation  was  performed  the 
mastoid  was  found  thoroughly  destructive,  and  there 
was  usually  some  complication. 

Etiology.  Causes  were  assigned  in  sixty-four 
patients  only,  the  remaining  one  hundred  and  seven 
patients  could  give  none,  and  in  many  instances  an 
intelligent  history  could  not  be  obtained.  "Cold  in 
head"  was  given  by  the  patients  as  the  beginning  of 
their  aural  affection.  It  occurred  in  twenty-six 
cases.  The  other  causes  were  due  in  eight  patients 
to  measles,  eight  to  grippe,  four  to  nasal  douche, 
one  to  nasal  spray,  two  to  nasal  operation,  one  to 
nasal  plug  following  operation,  one  to  throat  spray, 
three  to  sore  throat,  three  to  sea  bathing,  eleven  to 
scarlet  fever,  three  to  traumatism,  one  to  syphilis, 
and  two  to  pneumonia.  The  acute  catarrhal  condi- 
tions of  the  nasophan,'nx  were  the  most  frequent 
causes. 

There  were  two  fractures  of  the  apophysis  due  to 
falls.   Both  fractures  were  in  the  line  of  the  squamo- 


31(3 


CALHOUN:  OPERATIVE  MASTOIDITIS. 


[New  York 
Medical  Journal. 


mastoid  suture,  extending  backward  into  the  pari- 
etal bone.  In  one  case  the  posterior  bony  canal  wall 
was  involved  in  the  fracture. 

Symptoms  and  examination.  Patients  sought 
medical  advice,  either  on  account  of  pain  in  the  ear, 
in  the  region  of  the  mastoid  or  its  vicinity,  aural 
discharge,  fever,  or  swelling.  Any  one,  or  combi- 
nations of  these  symptoms  w^ere  present,  or  all  com- 
bined. Generally  adults  came  on  account  of  pain, 
babies  were  brought  on  account  of  postaural  swel- 
ling. Chills,  sweats,  nausea,  vomiting,  and  vertigo 
were  not  uncommon  symptoms  in  uncomplicated 
mastoiditis.  Optic  neuritis  has  also  been  observed 
in  small  extradural  abscesses. 

Temperature  was  an  important  symptom,  and  on 
admission  it  was  found  to  be  normal  or  subnormal 
in  only  twelve  cases.  The  majority  of  temperatures 
were  between  99°  and  101°  F.  When  the  tempera- 
ture was  above  103°  F.  the  surgeon's  suspicion 
was  aroused,  fearing  some  compHcation.  There 
were  five  cases  where  the  temperature  on  admission 
was  between  103°  and  105°  F.,  and  four  patients 
had  sinus  thrombosis,  and  one  meningitis  and  brain 
abscess. 

Sii'eliing  was  present  over  or  about  the  mastoid 
in  fifty  per  cent,  of  the  cases.  Pus  was  found 
eighty-eight  times  in  one  hundred  and  thirty-three 
cases  having  swelling,  and  fifty-four  of  the  eighty- 
eight  were  in  children  under  five  years,  and  thirty- 
nine  were  less  than  two  years  of  age.  It  is  thus  seen 
that  over  one  half  of  the  subperiosteal  abscess 
formations  occurred  in  babies,  and  of  the  eighty 
babies  imder  five  years,  over  one  half  of  them  had 
subperiosteal  abscess.  In  addition  there  were  seven- 
teen babies  under  five  years  that  had  swelling  not 
reaching  the  stage  of  pus  formation.  So  swelling 
as  a  symptom  of  mastoditis  in  infants  and  children 
was  present  in  about  ninety  per  cent.  The  remain- 
ing thirty-four  abscesses  occurred  twelve  times  in 
ages  of  from  five  to  ten,  ten  times  from  ten  to 
twenty,  four  from  twenty  to  thirty,  three  from  thirty 
to  forty,  four  from  forty  to  fifty,  and  one  from  fifty 
to  sixty. 

Swelling  usually  occurred  as  an  early  symptom 
in  children  and  infants,  as  was  the  abscess  forma- 
tion, and  a  late  manifestation  in  adults.  Where  an 
abscess  had  formed  superficially  in  an  adult  it  was 
an  evidence  of  a  long  standing  process,  except  in 
one  case  of  a  Bezold's  perforation  of  one  week's 
duration,  due  to  a  streptococcus  infection. 

There  were  in  all  nine  cases  where  perforation  of 
the  medial  plate  had  taken  place,  constituting  a 
Bezold's  mastoiditis.  All  were  in  adults,  and  with 
the  exception  of  the  case  just  mentioned,  were  from 
three  to  five  w'eeks'  duration. 

It  was  a  frequent  occurrence  for  mothers  to 
bring  their  babies  to  the  clinic  with  a  postaural 
swelling  as  the  only  symptom  of  the  little  one's 
sickness. 

Palpation  was  the  most  valuable  sign  of  mastoid 
involvement,  and  even  then,  in  a  few  cases,  it  was 
misleading  entirely.  The  tenderest  portion  did  not 
always  indicate  the  location  of  the  most  destructive 
part  of  the  process.  In  fact,  many  cases  were  ob- 
served in  which  tenderness  alone  over  the  region  of 
the  antrum  found  at  the  operation  the  tip  cells  only 
involved,  and  vice  versa.   The  tip  was  the  maximum 


point  of  sensitiveness  in  relation  to  the  antrum,  and 
posttip  in  the  relative  proportion  of  three,  two  and 
one.  The  posttip  was  usually  involved  in  cases  of 
long  standing,  or  where  there  was  marked  destruc- 
tion. Associated  with  antrum  and  tip  tenderness, 
posttip  tenderness  .  occurred  thirty-eight  times,  or 
fourteen  per  cent. 

Frequently  cases  were  found  where  ma:stoid 
tenderness  was  not  present,  yet  an  operation  was 
indicated  on  account  of  a  profuse,  continuous,  aural 
discharge,  a  septic  temperature,  or  headache. 

There  were  two  cases  in  nervous,  hysterical 
women,  with  slightly  secreting  ears,  where  the  mas- 
toid tenderness  was  well  marked,  yet  the  operation 
revealed  a  normal  bone. 

There  was  found  by  examination  fourteen  pos- 
terior discharging  sinuses  from  abscess  formation. 
Eight  had  had  Wilde's  incisions  by  outside  surgeons, 
and  six  had  ruptured  spontaneously. 

Four  other  patients  presented  themselves  with  un- 
healed mastoid  wounds  of  long  standing.  Two  had 
been  operated  upon  at  this  infirmary,  the  others  at 
outside  hospitals. 

There  were  also  four  cases  of  recurrent  mastoid- 
itis, which  at  one  time  or  another  had  received  mas- 
toid operations.  The  wounds  had  healed,  but  a 
subsequent  infection  occurred.  Two  of  these  pa- 
tients had  a  subperiosteal  abscess  in  the  line  of  the 
old  scar.  All  showed  that  a  thorough  mastoid 
operation  had  not  previously  been  done. 

Sagging  of  the  posterosuperior  canal  wall  as  a 
symptom  of  mastoiditis  occurred  in  forty  per  cent, 
of  the  cases  examined.  Twenty-one  of  the  sixty- 
three  were  subperiosteal  abscesses,  chiefly  in  babies. 
Where  it  was  found  it  usually  meant  that  pus  was 
present  in  the  mastoid,  and  the  surgeon  generally 
considered  it  an  operative  symptom. 

The  drum  membrane  showed  the  usual  appear- 
ances of  an  acute  purulent  ear,  reddened,  bulging, 
with  or  without  perforation,  and  landmarks  gener- 
ally destroyed. 

The  discharge  varied  from  a  scanty,  serous  or 
bloody  one  in  early  tympanic  affections  to  a  profuse, 
thick  yellow,  purulent  one  in  cases  of  long  standing. 

Frequently  there  was  no  discharge,  especially  true 
in  infants,  and  the  postaural  swelling  was  the  first 
indication  of  the  baby's  illness.  In  a  few  cases 
where  a  myringotomy  had  been  done,  the  postaural 
swelling  in  these  babies  would  subside  in  a  night's 
time,  draining  through  the  canal. 

Even  with  a  subsidence  of  the  subperiosteal  ab- 
scess, a  drop  in  temperature  to  normal,  the  baby 
seemingly  bright  and  in  no  sense  ill,  it  was  not  an- 
indication  that  an  operation  was  unnecessary,  for 
mastoid  involvement  was  always  found.  The  fol- 
lowing case  well  illustrates  this  point : 

Gase  it. — An  infant,  ten  weeks  old,  was.  so  far  as  the 
parents  knew,  in  good  health,  and  had  not  fretted  or  cried 
any  more  than  usual.  The  day  before  admission,  the 
mother,  on  giving  it  its  morning  bath,  had  noticed  a  slight 
swelling  and  redness  behind  the  auricle.  The  examination 
showed  a  small  fluctuating  swelling  below  and  posterior  to- 
where  the  tip  should  be.  The  drum  appeared  reddened, 
bulging,  with  no  perforation.  The  temperature  was  100° 
F.  A  myringotomy  was  done,  with  a  free  gush  of  thick 
yellow  pus  containing  streptococci.  The  next  morning  the 
swelling  had  disappeared,  the  temperature  was  normal,  and 
there  was  a  free  discharge  from  the  canal.  At  the  opera- 
tion, the  most  destructive  mastoid  I  have  yet  seen  in  an  in- 


February  13,  1909.  J 


CALHOUX:  OPERATIVE  MASTOIDITIS. 


fant  was  found,  and  besides  a  large  extradural,  cerebellar 
abscess,  the  cells  in  the  zygomatic  region  being  well  devel- 
oped for  one  of  this  age,  were  thoroughly  infected.  The 
patient  recovered. 

In  eighteen  cases  there  was  no  discharge  in  the 
canal,  and  as  one  would  naturally  suppose,  this  con- 
dition occurred  in  cases  of  short  duration,  within 
one  week,  although  one  patient  positively  stated  that 
he  had  had  pain  in  the  ear  and  mastoid  region  for 
nearly  two  months,  and  no  aural  discharge. 

Facial  paralysis  occurred  as  a  symptom  in  four 
cases.  They  were  in  cases  of  from  three  to  five 
weeks'  duration,  and  the  paralysis  occurred  as  a  late 
symptom.  Two  patients  recovered  after  operation, 
one  died,  and  the  fourth  could  not  be  followed  up 
after  his  dismissal  from  the  Infirmary. 

Operation.  The  usual  preparation  of  all  cases 
consisted  in  shaving  and  cleaning  a  space  about 
three  inches  surrounding  the  auricle.  After  shav- 
ing, the  parts  were  washed  well  with  green  soap, 
wiped  off  with  alcohol  and  ether,  then  a  moist  bi- 
chloride dressing  applied  for  the  operation,  after 
the  canal  had  been  irrigated  and  a  light  strip  of 
bichloride  gauze  inserted. 

No  attempt  will  be  made  to  describe  the  methods 
of  operating  or  the  differences  in  technique  as  em- 
ployed by  the  several  operators.  All  endeavored  to 
remove  all  of  the  diseased  tissue.  Some  were  more 
radical  than  others. 

It  might  be  mentioned  in  this  connection  that  one 
Wilde's  incision  was  performed  for  the  relief  of 
mastoiditis.  The  patient  was  a  child,  four  years  old, 
with  a  subperiosteal  abscess,  and  had  been  sick  for 
one  month.  A  constant  discharge  persisted  for  over 
one  month  from  the  wound  after  the  operation,  and 
finally  healed  after  two  months  of  faithful,  daily 
dressings. 

The  usual  curved  postaural  incision  was  made,  ex- 
tending from  the  tip  to  a  level  of  the  upper  auricular 
attachment.  The  posterior  horizontal  extension  was 
made,  either  by  selection  or  necessity,  in  one  hun- 
dred and  twenty-four  cases,  or  about  fifty  per  cent. 

The  cortex,  on  being  exposed,  was  found  dis- 
colored in  fifty  cases,  and  usually  meant  a  highly 
pneumatic  process  or  a  very  destructive  mastoid. 
The  tip  was  the  part  most  involved. 
•  An  evacuation  of  a  subperiosteal  abscess  was  done 
in  thirty-two  per  cent,  of  the  cases  (88)  by  the 
original  postaural  incision.  The  abscess  or  swelling 
usually  occurred  in  the  postauricular  fold.  There 
were  nine  cases  of  Bezold's  mastoiditis,  where  ab- 
scess formation  had  taken  place  in  the  neck.  Swell- 
ing posterior  to  the  apophysis  occurred  once.  Pus 
was  not  found  until  the  fibres  of  the  sternomastoid 
muscle  had  been  freed  from  its  tip  attachment. 
There  was  no  cortical  perforation  in  this  case,  and 
the  pus  in  the  cavity  evidently  found  its  way 
through  the  mastoid  foramen,  for  later  an  epidural 
abscess  was  found  beneath  that  part.  About  sixty- 
five  per  cent,  of  the  eighty-eight  subperiosteal  ab- 
scesses occurred  in  young  children  and  in  infants. 

Cortical  perforations  in  the  region  of  the  antrum 
and  leading  to  it  was  a  finding  in  seventy  cases, 
leaving  only  eighteen  cases  for  the  pus  to  find  its 
way  outward  through  the  Rivinian  segment  or 
otherwise. 

Sequestra  were  found  in  three  cases ;  nothing  un- 


usual in  these  cases,  except  they  were  of  long  dura- 
tion. 

A  foreign  body,  a  sea  sponge,  was  found  in  one 
case,  having  been  accidentally  left  in  the  cavity  at  a 
former  mastoid  operation  at  some  other  hospital. 
The  mastoid  wound  had  healed,  but  a  slight  aural 
discharge  persisted.  It  was  the  intention  of  the 
surgeon  to  do  a  radical  operation,  but  the  findings 
proved  it  unnecessary. 

The  cells  posterior  to  the  root  of  the  zygoma,  the 
so  called  zygomatic  cells,  were  frequently  infected 
in  the  extension  of  the  mastoid  involvement,  and 
were  curetted  in  twenty-one  per  cent,  of  the  cases. 

The  tip  was  the  most  frequent  site  for  pus  to  be 
found,  other  than  where  the  whole  process  was 
found  involved.  As  was  pointed  out  in  the  exam- 
ination, it  was  not  always  the  point  of  greatest  ten- 
derness on  palpation  that  indicated  the  area  of  the 
greatest  destruction. 

No  free  pus  was  found  in  twenty-three  cases. 
Whether  pus  formation  would  have  taken  place 
from  the  congested,  granular  condition  of  the  cells, 
or  resolution  brought  about  without  an  operation,  I 
am  not  able  to  say. 

In  every  appearance  there  were  opened  four  per- 
fectly normal  mastoids.  A  mistaken  diagnosis  for 
ftirunculosis  was  in  one  patient,  hysteria  or  hyper- 
aesthesia  occurred  in  two,  and  the  fourth  was  ope- 
rated upon  because  the  aural  secretion  showed 
streptococci.  In  this  last  case  there  was  a  slight 
amount  of  mastoid  tenderness,  and  a  persistent  tem- 
perature of  about  ioo°  F.  As  the  mastoid  appeared 
normal,  and  the  antrum  had  not  been  entered,  the 
wound  was  allowed  to  fill  up  by  a  blood  clot,  then 
closed.  Three  days  later  it  was  dressed  and  found 
to  be  thoroughly  infected.  It  required  three  months 
for  the  wound  to  heal.  This  was  the  only  case  of 
"blood  clot  healing"  attempted  during  the  year. 

The  incus  was  accidentally  removed  in  four  cases, 
all  infants,  in  curetting  on  enlarging  the  aditus. 

The  semicircular  canal  (external)  was  found 
opened  in  two  cases.    No  bad  results  followed. 

Facial  twitching  occurred  five  times,  either  in  re- 
moving the  row  of  cells  behind  the  posterior  wall  or 
in  removing  the  tip.  Only  once  where  twitching 
occurred  was  there  any  subsequent  paralysis.  In 
addition  there  were  four  cases  of  paralysis  where  no 
twitching  occurred.  In  this  connection,  I  would 
mention  that  all  cases  of  paralysis  recovered  except 
one,  and  that  one  patient  showed  no  improvement  at 
the  end  of  eight  months.  Patients  with  paralysis  did 
quite  as  well  under  no  treatment  as  where  electricity 
was  given. 

Dura  or  sinus  were  exposed  in  one  hundred  and 
seventy  cases,  or  about  sixty-two  per  cent,  of  all 
acute  cases.  In  sixty-seven  cases  both  were  exposed, 
by  the  same  operation. 

The  dura  was  accidentally  or  intentionally  ex- 
posed one  hundred  and  seven  times,  and  was 
severely  injured  with  the  curette  twice  ;  one  of  these 
patients  died  of  meningitis.  An  epidural  abscess 
above  the  tegumen  was  found  eight  times,  although 
an  unhealthy  dural  condition,  either  granular  or 
congested,  was  discovered  fifty-seven  times. 

The  sinus  was  also  exposed  accidentally  or  inten- 
tionally one  hundred  and  thirty-two  times,  andi 


3i8 


CALHOUN:  OPERATIVE  MASTOIDITIS. 


[New  York 
Medical  Journal. 


Opened  accidentally  in  eighteen  cases,  with  no  bad 
results.  When  the  sinus  was  opened  and  a  free  flow 
followed,  the  opening  was  at  once  plugged  with  a 
small  strip  of  iodoform  gauze,  which  was  allowed 
to  remain  in  place  two  or  three  days  after  the  first 
dressing.  Perisinus  abscesses  were  discovered  by 
operation  fort}--one  times,  or  about  five  times  more 
frequent  than  localized  epidural  abscesses.  In  one 
hundred  and  thirty-two  sinus  exposures,  only  ninety 
were  unhealthy  in  appearance. 

Of  the  extradural  abscesses,  either  perisinus  or 
epidural,  there  were  five  where  the  odor  of  the  pus 
was  foul,  and  in  every  case  there  was  a  serious  intra- 
cranial complication,  four  being  sinus  thrombosis 
and  one  a  cerebella  abscess. 

When  the  dura  or  sinus  were  exposed  and  found 
unhealthy,  further  exposure  of  the  parts  was  usually 
made,  until  healthy  structures  were  reached. 

In  the  forty-nine  extradural  abscesses  only  nine 
were  in  infants  or  children  under  five  years,  while 
of  the  eighty-eight  subperiosteal  abscesses  over  one 
half  were  in  children  under  five  years — thus  show- 
uig  the  relative  frequency  of  perforations  of  the 
outer  and  inner  tables  of  the  skull  in  the  two  ex- 
tremes of  life. 

Complication.  Complications  that  may  arise  dur- 
ing an  attack  of  mastoiditis  are  many.  The  fol- 
lowing were  in  many  instances  due  to  the  infection 
spreading  from  the  original  focus,  the  tympanum, 
while  others  were  mere  coincidences  and  were  en- 
tirely independent  of  the  aural  condition. 

A  cervical  adenitis  accompanied  mastoiditis  in 
four  cases,  all  in  babies.  They  were  treated  along 
general  surgical  lines.  .  An  iodoform  dermatitis  with 
mild  toxic  symptoms  occurred  once  in  an  adult.  The 
symptoms  abated,  and  the  cutaneous  involvement 
disappeared  after  discontinuance  of  the  iodoform. 
Lobar  pneumonia  developed  three  times,  and  a 
bronchopneumonia  twice,  after  operation.  Three  of 
the  five  patients  died.  A  follicular  tonsilitis  devel- 
oped once;  peritonsillar  abscess  once  ;  acute  articular 
rheumatism  and  acute  catarrhal  jaundice,  all  devel- 
oped during  convalescence.  The  jaundice  case  was 
quite  puzzling  and  masked  mastoid  symptoms  for  a 
few  days.  The  leucocytosis  of  the  patient  ranged 
from  35,000  to  37,000,  and  his  polynuclear  count 
from  seventy-eight  per  cent,  to  eighty-nine  per  cent, 
in  several  blood  examinations. 

One  case  of  pertussis  developed  in  the  babies' 
ward,  and,  curiously  enough,  having  so  many  babies 
under  care  during  the  year,  no  cases  of  the  acute 
exanthemata  occurred.  There  did  develop  in  the 
babies'  ward  two  epidemics  of  a  specific  gonorrhceal 
vaginitis.    Xo  cause  could  be  assigned. 

The  cases  of  erysipelas,  six  in  number,  were  men- 
tioned under  the  head  of  bacteriology,  as  occurring 
in  mastoiditis,  where  the  infection  was  that  of  strep- 
tococcus. 

There  developed  two  interesting  cases  of  what 
were  diagnosticated  confusional  insanity,  from  toxic 
absorption.  Both  developed  in  women.  In  one 
four  davs  after  the  onset  of  her  ear  condition,  and 
slie  did  not  become  rational  for  two  weeks.  The 
other  was  in  a  case  of  sinus  thrombosis  with  jugular 
excision,  and  developed  one  week  after  the  opera- 
tion. She  became  most  violent  during  her  third 
•week,  and  finally  died  the  fourth. 


There  were  four  brain  abscesses,  two  temporal 
and  two  cerebellar.  Three  deaths  followed.  The 
recovery  was  in  one  temporal. 

Sinus  thrombosis  arose  as  a  complication  eleven 
times  in  this  series  of  two  hundred  and  seventy-one 
cases  of  acute  mastoiditis.  Internal  jugular  exci- 
sions were  made  in  all,  and  four  deaths  intervened. 

After  treatment.  As  a  rule,  on  the  fourth  day 
the  dressing  and  the  packing  from  the  mastoid 
wound  were  removed,  and  dressings  continued 
every  other  day  until  well.  There  was  always 
a  certain  amount  of  pain  connected  with  the 
first  dressing,  but  where  a  free  supply  of  hydrogen 
peroxide  or  plain  sterile  water  was  used,  the  pain 
was  lessened.  The  longer  the  dressing  was  undis- 
turbed, the  greater  the  pain  at  the  dressing,  due,  no 
doubt,  to  the  granulations  of  the  wound  growing 
into  the  meshes  of  the  gauze.  Iodoform  gauze 
strips  were  used  for  about  two  weeks,  depending 
upon  the  condition  of  the  wound,  and  where  granu- 
lations had  been  once  started,  the  plain  sterile  gauze 
was  substituted.  The  cavity  was  wiped  dry  and 
packed  as  any  other  general  surgical  wound.  Where 
the  aural  discharge  continued  it  was  irrigated  fre- 
quently during  the  day,  with  the  auricle  exposed 
from  the  dressing.  This  seemed  to  hasten  tympanic 
resolution.  Many  patients  complained  of  great  dis- 
comfort and  pain  in  the  wound  before  the  first 
dressing;  changing  the  outer  dressing  always  re- 
lieved them.  The  sutures,  silkworm  gut,  were  gener- 
ally removed  at  the  second  dressing. 

Results.  No  patient  was  considered  cured  until 
the  mastoid  wound  had  healed  entirely,  the  aural 
discharge  ceased,  and  the  middle  ear  returned  to 
normal. 

Results  are  known  in  one  hundred  and  eighty-six 
of  the  two  hundred  and  seventy-one  cases.  The 
shortest  time  of  healing  was  thirty-four  days,  and 
the  longest,  to  my  knowledge,  was  one  year.  This 
last  case  was  in  a  tuberculous  patient,  and  the  wound 
repeatedly  healed,  then  broke  down,  requiring  sev- 
eral curettements  and  all  varieties  of  medicated 
dressings  to  perfect  a  cure.  On  the  other  hand, 
there  was  another  tuberculous  patient  in  a  more  ad- 
vanced stage  whose  wound  healed  in  six  weeks. 
The  average  mastoid  healed  in  ten  weeks. 

One  hundred  and  twenty-six  patients  were  cured. 
Seventeen  v^'ere  in  a  state  of  healing  when  last  seen. 
Fourteen  did  not  heal,  and  when  last  seen  had  pos- 
terior discharging  sinuses.  The  posterior  wound 
healed  entirely,  but  the  aural  discharge  still  con- 
tinued in  eight  cases,  and  there  were  twenty-one 
deaths. 

Of  the  fourteen  cases  that  did  not  heal,  fifty  per 
cent,  were  in  children  or  infants  under  five  years. 
The  only  explanation  offered  for  this  failure  is  the 
fact  that  they  were  neglected  by  their  parents  when 
dismissed  from  the  Infirmary,  and  did  not  report 
promptly  for  clinical  dressings  or  observation. 
Five  of  this  number  required  secondary  operations 
(Schwartze-Staoke)  ;  the  remainder  were  either 
tmder  observation  or  attending  some  other  hospital. 

There  was  noticed  twenty-four  times  following 
healing  a  marked  sagging  of  the  posterosuperior 
canal  wall,  due  to  the  separation  from  its  bony 
attachment  or  to  some  other  form  of  traumatism 
during  the  operation.     Over  one  half  of  these 


February  13,  1909.] 


CALHOUN:  OPERATIVE  MASTOIDITIS. 


patients  had  impacted  cerumen  or  beginning  impac- 
tion, due,  no  doubt,  to  the  canal  distortion  having 
disturbed  the  glands  and  their  outlets. 

Tinnitus  was  a  postoperative  complication  in  ten 
cases,  or  five  per  cent. :  impairment  in  hearing  in 
twelve  cases,  or  six  and  one  half  per  cent.  These 
two  complications  were  treated  by  tympanic  infla- 
tions, with  improvement  in  some  cases. 

Facial  paralysis  occurred  in  nine  patients ;  five 
as  a  symptom  of  njastoid  involvement  before  opera- 
tion :  four  being  caused  by  the  operation.  Four  of 
the  first  class  cleared'  in  from  four  days  to  one  year 
after  operation.  One  escaped  observation.  In  the 
second  class  all  patients  cleared  under  six  months 
except  one,  and  that  was  as  well  marked  when  last 
seen  as  at  the  time  of  operation. 

Mastoiditis  from  Otitis  media  pnrnlenta  chronica. 
The  Schzvartze-Stacke  Operation. 

^^'here  the  middle  ear  and  the  mastoid  were  both 
involved  in  a  chronic  condition,  the  Schwartze- 
Stacke  operation  was  indicated,  and  it  was  per- 
formed eight)--one  times,  or  twenty  per  cent,  of  the 
four  hundred  cases  were  of  this  class. 

Age  as  a  causative  agent  did  not  play  the  impor- 
tant part  in  this  series  as  it  did  in  the  acute  cases, 
although  there  were  many  more  adults  than  there 
were  infants  or  children. 

The  oldest  patient  was  sixty-two,  the  youngest 
was  five  months.  The  infant  died  of  meningitis. 
The  next  two  youngest  were  seven  and  nineteen 
months  respectively.  The  former  was  in  a  state  of 
healing  when  last  seen.  The  latter  healed  in  two 
months'  time. 

Exacerbations  of  chronic  discharging  ears  with 
mastoid  involvement  generally  manifested  them- 
selves with  any  sudden  change  in  the  weather.  More 
radicals  were  done  during  the  months  from  July  to 
December,  probably  due  to  the  fact  that  there  were 
fewer  acute  cases. 

A  bacteriological  examination  gave  very  little 
information  in  these  chronic  cases,  as  the  infections, 
both  aural  and  mastoid,  were  usually  "mixed." 
Cholesteatoma  crystals  were  found  in  twenty  per 
cent,  of  these  chronic  cases,  and  a  permanent  pos- 
terior opening  was  left  in  four  of  these  sixteen 
cases. 

Aitioiogy  and  symptoms.  The  causes  in  general 
were  those  of  any  acute  ear  inflammation,  and  either 
from  neglect  or  otherwise  the  condition  became 
chronic. 

It  was  the  intention  of  the  operator,  in  twenty- 
seven  cases,  to  do  the  Stacke  operation  for  a  chronic 
discharging  ear,  but  at  the  time  of  the  operation 
the  mastoid  was  found  involved,  and  the  complete 
radical  operation,  or  Schwartze-Stacke,  was  found 
necessary. 

Fifteen  patients  had  had  previous  mastoid  opera- 
tions, months  or  years  ago,  and  the  aural  discharge 
had  never  ceased.  Ten  other  cases  were  in  un- 
healed posterior  wounds  of  former  mastoid  opera- 
tions, or  where  there  had  been  a  recurrence. 

Acute  mastoiditis  from  a  chronic  discharging  ear 
occurred  twenty-six  times,  and  the  majority  had 
subperiosteal  abscesses :  one  of  these  cases  was 
caused  from  a  fall,  lighting  up  a  chronic  process. 
-All  complained  of  headaches.   The  temperature  was 


not  higher  than  99°  F.,  but  there  was  more  or  less 
mastoid  tenderness. 

There  were  three  double  operations,  and  two 
cases  where  the  radical  cavity  had  to  be  curetted  a 
second  time. 

In  two  cases  an  acute  process  was  precipitated  by 
a  fall,  and  the  operation  showed  that  both  patients 
had  fractured  mastoids,  the  fracture  extending  back- 
ward. In  one  sinus  thrombosis  and  facial  paralysis 
developed,  and  in  the  other  an  epidural  abscess. 
Both  patients  recovered,  and  the  paralysis  disap- 
peared. 

There  was  one  case  with  diabetes  mellitus,  giving 
brain  abscess  symptoms,  including  aphasia,  which 
showed  by  operation  and  later  by  autopsy  that  there 
was  a  sinus  thrombosis  and  a  hasmorrhagic  infarct 
into  the  brain  substance.  The  death  in  this  case  and 
in  one  of  the  acute  mastoiditis  cases  substantiates 
recent  observations  made  in  regard  to  a  general 
anresthetic  (ether  especially)  being  administered  to 
diabetic  cases  where  sugar  is  present  in  five  per 
cent,  or  over ;  the  patients  invariably  die. 

Facial  paralysis  as  a  symptom  occurred  in  about 
three  per  cent. ;  one  of  the  three  patients  recovered. 

There  was  a  recurrence  of  cholesteatoma  in  two 
of  the  cases  where  former  radical  operations  had 
been  done.  These  cases  required  another  curetting 
of  the  former  radical  cavity,  and  a  subsequent  graft- 
ing, leaving  a  permanent  posterior  opening ;  when 
last  seen,  two  months  later,  there  was  no  evidence 
of  a  recurrence. 

Examination.  The  examination  in  these  patients 
revealed  nothing  especially  characteristic,  except  the 
foul  aural  discharge.  The  membrapa  tympani  was 
partially  or  completely  destroyed,  and  by  probing 
the  tympanum,  bare  or  roughened  bone  could  be 
felt.  The  subperiosteal  abscesses,  seventeen  in  num- 
ber, occurred  for  the  most  part  in  children. 

^^l^ile  tenderness  on  palpation  was  not  an  infre- 
quent symptom  in  the  very  acute  cases,  resulting 
from  chronic  discharging  ears,  cases  were  often 
found  where  no  mastoid  tenderness  existed,  yet  there 
was  an  extradural  abscess  placed  deep  beneath  a 
thick  sclerotic  cortex.  This  fact  proved  the  serious- 
ness of  these  chronic  cases,  where  there  is  a  tend- 
ency for  pus  to  burrow  inward,  producing  its  dan- 
gerous intracranial  complications. 

Hearing  tests  were  made  before  operation  in 
order  that  a  comparison  might  be  had  on  recovery. 

The  average  temperature  on  admission  was  99-8° 
F. ;  where  the  temperature  was  102°  F.  or  over, 
serious  complications  were  anticipated. 

It  was  a  frequent  occurrence  to  have  a  patient 
date  his  present  illness  from  a  sudden  cessation  of 
the  aural  discharge  :  then  the  symptoms  of  headache, 
dizziness,  temperature,  etc.,  would  develop  promptly 

Operation.  The  same  preparation  was  given  the 
patient  in  a  chronic  care  as  in  an  acute  one,  although 
more  attention  was  directed  toward  making  the 
canal  as  aseptic  as  possible,  in  cases  where  the  rad- 
ical operation  was  anticipated,  on  account  of  the 
plastic  part  of  the  operation  at  the  conclusion  of 
the  bone  work. 

The  usual  posterior  curvilinear  incision  was  made, 
and,  when  necessary,  the  horizontal  extension. 

Cortical  perforations  were  foimd  nine  times,  in 
about  half  of  the  subperiosteal  abscess  cases.  The 


320 


CALHOUX:  OPERATIVE  MASTOIDITIS. 


LXevv  Vork 
Medical  Journal. 


cortex  and  subcortical  structure  was  found  hard  and 
sclerosed  in  the  majority  of  mastoids,  and  frequently 
no  pus  could  be  found  until  the  antrum  was  reached. 
In  many  of  the  cases  where  a  Stacke  operation  was 
anticipated,  a  row  of  infected  cells  was  found  along 
the  posterior  bony  canal  wall,  and  in  following 
these  cells  they  were  found  to  lead  to  the  tip,  which 
was  infected  also,  necessitating  its  removal. 

Sequestra  were  found  in  one  case.  In  one  seques- 
trum the  external  semicircular  canal  was  involved ; 
the  other,  the  Falloppian  canal.  Both  were  removed 
without  bad  results. 

The  membranous  portion  of  the  external  semi- 
circular canal  was  found  exposed  in  two  cases  and 
found  opened  in  two.  Except  for  a  slight  dizziness 
in  one  that  was  found  opened,  and  nausea  in  one 
that  was  exposed,  w:hich  might  have  been  due  to  the 
anaisthesia,  no  bad  results  followed. 

The  dura  was  either  accidentally  exposed  or 
found  diseased  thirty-five  times.  The  same  was  true 
of  the  sinus  in  thirty-two  cases.  No  complication 
followed  these  exposures. 

There  were  twelve  perisinus  and  seven  epidural 
abscesses,  with  more  or  less  mastoid  involvement, 
complicating  these  chronic  tympanic  infections. 

The  stapes  was  removed  only  in  one  case,  and 
that  accidentally.  The  case  being  a  private  one,  1 
could  not  follow  the  ultimate  result,  but  the  surgeon 
in  charge  told  me  that  complete  epidermization  took 
place  in  fifty-six  days,  and  the  hearing  was  equally 
as  good  as  before  the  operation. 

Facial  twitching  occurred  in  eleven  cases ;  once 
in  removing  the  tip,  ten  times  when  the  curette  was 
within  the  tympanum,  and  not  once  in  lowering  the 
posterior  bony  canal  wall.  There  was  subsequent 
paralysis  in  two  cases.  In  tw  o  other  cases  there  was 
a  postoperative  paralysis  where  no  twitching  had 
occurred. 

The  Pause.  Whiting,  or  Balance  flap,  or  modifica- 
tions, were  the  ones  most  frequently  used  in  the 
plastic  part  of  the  operation ;  they  were  held  in  posi- 
tion by  catgut  sutures  or  gauze  plugs.  The  raw 
edge  of  the  concha  was  often  covered  with  a  small 
Thiersch  graft,  which  always  adhered  and  prevented 
a  tedious  process  of  healing  in  this  particular  local- 
ity. 

Complications.  Erysipelas  occurred  in  one  patient 
while  an  inmate  of  the  Infirmary,  and  in  two  others 
as  out  patients.  While  the  aural  discharges  of  these 
cases  were  regarded  as  types  of  the  mixed  infec- 
tion, common  to  chronic  ears,  a  form  of  strepto- 
coccus was  present.  The  infection  was  never  in  the 
wound ;  always  on  the  cheek  or  the  auricle. 

A  perichondritis  developed  in  two  cases  where 
the  usual  plastic  operation  was  done  in  which  the 
cartilage  had  not  been  removed.  They  were  treated 
by  the  method  of  free  incision  and  drainage,  termi- 
nating in  a  cure  after  a  long,  tedious  process  of 
dressing,  and  with  marked  aural  deformity.  The 
infection  was  one  of  pyocyaneus,  in  accordance  with 
the  views  of  Korner. 

Abscess  of  the  auricle  developed  in  one  case,  due 
undoubtedly  to  the  flap,  but  it  cleared  up  in  a  few 
days  with  no  deformity. 

A  peritonsillar  abscess  was  an  accessory  following 
one  operation.  Cervical  adenitis  occurred  in  two 
ca.ses. 


A  marked  cellulitis  of  the  scalp  resulted  in  one 
case,  which  was  primarily  grafted.  A  cellulitis  of 
the  tissues  surrounding  the  auricle,  with  a  praeauric- 
ular  abscess,  also  occurred  in  a  case  secondarily 
grafted. 

Sinus  thrombosis  vvas  a  complication  in  eight 
cases,  meningitis  in  four,  brain  abscess  in  one,  and 
cavernus  sinus  thrombosis  in  one. 

The  internal  jugular  vein  was  excised  in  six  of 
the  eight  cases  of  thrombosis.  Four  of  the  eight 
patients  died. 

After  treatment.  The  dressing  and  packing  from 
the  canal  was  removed  on  the  fourth  day  following 
the  operation.  Usually  there  was  a  great  amount  of 
pain  when  the  gauze  in  the  tympanum  was  removed, 
and  in  many  instances  an  anaesthetic  (nitrous  oxide 
gas  preferable)  was  required.  The  cavity  was 
wiped  dry  and  repacked  with  iodoform  or  sterile 
gauze,  as  the  condition  demanded.  The  silkworm 
gut  sutures  were  removed  at  the  second  or  third 
dressing.  The  cavity  of  the  tympanum  was  packed 
tightly,  even  after  the  excavation  made  by  the  re- 
moval of  the  tip  and  other  surroiuiding  structures 
had  filled  in  with  granulations  and  had  contracted, 
and  the  best  results  were  obtained  by  the  use  of 
small  pledgets  of  gauze  saturated  with  aristol,  zinc 
oxide,  or  other  similar  astringent  dusting  powders. 
As  epidermization  reached  the  true  radical  cavity, 
care  was  taken  to  remove  the  gauze  pledgets  in 
time,  thus  preventing  a  false  membrane,  which  did 
form  in  a  few  cases.  These  patients  were  dressed 
daily. 

In  the  cases  where  there  was  much  secretion  from 
the  granulations  during  the  process  of  healing,  free 
irrigation  was  used,  the  exuberant  granulations 
were  either  curetted  or  cauterized.  The  success  of 
healing  depended  upon  keeping  the  cavity  clean,  dry, 
and  well  ventilated. 

There  were  four  cholesteatomatous  cases  where 
an  intentional  posterior  opening  was  made.  This 
opening  hastened  epidermization,  due  to  the  ventila- 
tion of  the  cavity  and  the  several  avenues  from 
which  the  process  of  skinning  could  take  place. 

There  were  twelve  other  cases  where  the  posterior 
wound  was  left  open,  to  heal  by  second  intention, 
on  account  of  large  or  unhealthy  areas  of  exposed 
dura  or  sinus.  Five  of  these  failed  to  heal,  but  the 
small  openings  were  subsequently  closed  by  plastic 
operations. 

Ten  cases  of  this  series  of  Schwartze-Stacke 
operations  were  grafted,  five  primarily  and  five 
secondarily. 

The  Thiersch  graft  was  taken  from  the  inner 
aspect  of  the  arm,  fore  arm,  or  thigh,  after  the  usual 
preparation  for  any  skin  graft,  and  held  in  place 
in  the  radical  cavity  by  means  of  aristol  pledgets. 

Results.  In  this  series  of  eighty-one  cases  results 
were  followed  in  sixty-four.  The  average  time  of 
healing  was  about  four  and  one  half  months.  The 
longest  was  nine  months.  The  shortest  forty-nine 
days.  The  ten  cases  grafted  did  not  give  the  results 
as  one  would  ordinarily  expect.  The  majority  of 
the  grafts  sloughed,  causing  in  two  cases  complica- 
tions. The  shortest  time  of  healing  with  a  skin 
graft  was  three  months. 

Thirty-nine  cases  healed  completely;  eight  pa- 
tients were  in  a  state  of  healing  when  last  seen,  two 


February  13,  1909.  J 


CALHOUN:  OPERATIVE  MASTOIDITIS. 


321 


months  after  operation ;  ten  were  discharging,  with 
no  prospects  of  a  permanent  cure ;  seventeen  were 
lost  sight  of;  there  occurred  seven  deaths. 

The  deaths  were  due  to  the  following  causes :  One 
case  of  diabetic  coma  following  operation ;  menin- 
gitis in  two  cases ;  brain  abscess  with  meningitis  in 
one;  sinus  thrombosis  (operative);  sinus  throm- 
bosis (unoperative)  and  cavernus  sinus  thrombosis. 

Facial  paralysis  occurred  seven  times — three  be- 
fore and  four  following  operation.  One  of  the  three 
patients  recovered  in  three  months'  time ;  three  of 
the  four  patients  recovered  in  from  two  weeks  to 
nine  months,  and  the  fourth  patient  died. 

Hearing  tests  similar  to  the  ones  made  before  the 
operation  were  made  in  thirty-eight  cases,  and  in 
only  one  patient  was  there  any  sign  of  improve- 
ment. Fifteen  patients  remained  the  same,  while  in 
twenty-six  patients  there  was  an  appreciable  de- 
crease. In  the  majority  of  the  patients  in  whom  the 
hearing  was  made  worse  by  operation  it  was  due, 
no  doubt,  to  the  fact  that  the  tvmpanum  proper  was 
allowed  to  fill  with  granulation,  firmly  imbedding 
the  stapes  and  the  foramen  rotundum  in  a  mass  of 
fibrous  tissue,  and  while  these  cases  would  be  the 
last  to  break  down  from  any  future  tubal  disturb- 
ance, it  was  done  at  a  sacrifice  of  hearing. 

Chronic  Pnnilcjif  0 litis  Media.  The  Sfackc  Opera- 
tion. 

In  this  series  of  forty-eight  cases,  the  Stacke 
ofveration  (so  called)  was  performed  solely  for  the 
relief  of  a  chronic  aural  discharge. 

In  addition  "to  this  chronic  aural  discharge,  the 
following  other  symptoms  were  given,  viz.,  tinnitu* 
in  two  cases,  dizziness  in  thirteen,  severe  headaches 
in  ten,  and  periodic  attacks  of  nausea  or  vomiting 
in  two. 

The  average  temperature  on  admission  was 
99.2°  F. 

The  usual  radical  Stacke  was  performed,  the  tech- 
nique varying  with  each  surgeon,  but  all  having  the 
same  object  in  view,  viz.,  to  convert  the  cavity  of 
the  tympanum  and  antrum  into  one,  by  lowering  the 
bony  posterior  canal  wall. 

The  dura  and  sinus  were  accidentally  exposed 
seven  and  thirteen  times  respectively.  Cholestea- 
toma was  found  in  ten  cases. 

The  external  membranous  semicircular  canal  was 
found  exposed  in  three  cases  and  opened  once.  Xo 
untoward  results  followed,  except  dizziness  for  a 
few  days  in  the  one  that  was  opened. 

The  facial  nerve  in  the  Falloppian  canal  was 
found  exposed  three  times,  with  one  subsequent 
paralysis.  The  malleus  and  incus  were  removed  in 
all  cases  when  found,  and  the  stapes  removed  once 
accidentally. 

In  one  of  the  cases  of  cholesteatoma  a  complete 
and  perfect  Stacke  radical  operation  had  been  per- 
formed by  Nature,  and  there  was  nothing  left  to  do 
in  this  case  but  to  curette  the  cavity  of  its  capsule, 
and  make  the  usual  meatal  flap.  This  patient,  how- 
ever, has  failed  to  recover.  The  type  of  flap,  as  in 
the  Schwartze-Stacke  operation,  was  the  Pause, 
Whiting,  or  Balance,  or  some  modification.  It 
was  always  reflected  upward  into  the  Stacke  cav- 
ity, unless  exposed  dura  was  in  immediate  contact ; 
then  it  was  placed  downward. 

Facial  twitching  was  observed  in  ten  cases  when 


the  tympanum  was  curetted.  There  was  observed 
in  one  case  facial  twitching  thirty-five  times  during 
the  operation,  with  no  paresis  or  paralysis  following. 

The  cavity  was  grafted  primarily  in  fifteen  cases; 
secondarily  in  five.  The  posterior  auricular  wound 
was  closed  with  silkworm  gut  sutures  in  all  but  one 
cholesteatomatous  case,  and  that  left  open  perma- 
nently. The  meatal  graft  around  the  cut  margin  of 
the  concha  was  always  used  with  advantage. 

Complications.  Two  brain  abscesses,  one  temporal 
and  one  cerebellar,  developed  in  case<  where  pri- 
mary grafts  were  used.  The  patient  in  whom  the 
abscess  was  located  in  the  temporal  lobe  recovered 
after  operation.  The  patient  with  the  cerebellar 
abscess  died.  Erysipelas  developed  in  one  case, 
located  in  front  of  the  auricle.  Pneumonia  followed 
one  operation. 

The  after  treatment  was  about  the  same  as  that 
mentioned  under  the  heading  of  Schwartze-Stacke 
operations. 

Results.  The  results  of  the  Stacke  operation  can 
be  best  understood  by  a  tabulated  form,  as  given 
below;  the  reader  can  draw  his  own  conclusions: 

Grafts  in                                              No  grafts  in 
twenty  cases.                                       twemty-eight  cases. 
4  healed   13 

3  healing  when  last  seen  three  months 

after  operation    4 

II  discharging  when  last  seen  three  to 

twelve  months  after  operation....  5 
2  lost  sight  of   6 

TIE  XRTN'C. 

o  improved    i 

4  same    9 

8  worse    6 

8  no  tests  12 

Three  patients  of  the  thirteen  cases  in  which  no 
grafts  were  used,  and  where  the  discharge  had 
ceased,  had  false  membranes. 

Six  cases  of  facial  paralysis  followed  operation. 
Two  patients  completely  recovered  in  two  months' 
time,  two  were  improving  when  last  seen,  one  had 
been  lost  sight  of,  and  one  remained  permanent. 

The  extremes  in  healing  for  grafted  cases  were 
twenty-three  days  for  the  shortest  time,  and  three 
months  the  longest.  Forty-six  days  was  the  short- 
est, and  five  months  was  the  longest  time  in  non- 
grafted  cases. 

The  average  time  in  all  cases  was  seventy  days. 

A  brief  review  of  the  radical  operation  done,  both 
the  Stacke  and  the  Schwartze-Stacke,  would  nat- 
urally suggest  the  question,  what  were  the  indica- 
tions for  operation,  and  which  cases  would  have  re- 
covered without  an  operation  ?  In  the  acute  exacer- 
bations of  the  chronic  discharging  ears  with  mastoid 
involvement,  there  was  little  doubut  a?  to  the  efii- 
cacy  of  an  operation,  and  where  the  tympanum  was 
chronically  involved,  the  radical  operation  was  in- 
dicated, in  addition  to  the  operation  upon  the  mas- 
toid proper.  These  patients  needed  operation,  they 
would  not  have  recovered  without  one.  and  the  in- 
dication for  the  radical  operation  was  tympanic  de- 
struction. 

As  for  the  Stacke  operation,  the  different  sur- 
geons were  at  variance  in  their  views,  and  unques- 
tionably some  patients  were  operated  upon  who 
might  have  recovered  under  appropriate  medicinal 
treatment.  Pmt  after  a  few  days  or  weeks'  trial  of 
treatment  in  the  clinics  and  at  home,  with  no  im- 
provement, principally  because  this  particular  class 


322 


NICOLL:  SURGICAL  SERVICE  OF  FORDHAM  HOSPITAL. 


[New  York 
Medical  Journai 


of  patients  would  not  devote  sufficient  time  or  atten- 
tion to  their  ears,  an  operation  was  thought  to  be 
the  best  and  quickest  means  of  perfecting  a  cure,  and 
at  the  same  time  reheving  the  patient  of  a  certain 
amount  of  danger  in  carrying  about  this  chronic 
discharging  ear. 

The  indications,  as  I  saw  them,  for  a  Stacke  oper- 
ation, for  the  relief  of  a  chronic  discharging  ear  may- 
be summed  up  in  these  few  words :  Resistance  to 
all  forms  of  treatment,  a  rise  in  temperature,  head- 
aches or  dizziness,  and  forms  of  cholesteatoma,  for 
one  never  knows  how  far  the  destruction  has  gone 
in  these  cholesteatomatous  mastoids. 

The  results  in  this  series  of  radical  operations  rep- 
resent the  combined  efforts  of  all  operators,  about 
twenty  in  number,  in  a  class  of  clinical  patients, 
whom  even  if  under  the  most  favorable  home  sur- 
roundings, would  not  know  the  meaning  of  cleanli- 
ness. Frequently  patients  would  not  report  for  clin- 
ical dressings  after  operation  in  a  week's  time,  and 
it  is  not  surprising  that  the  ultimate  results  are  no 
more  brilliant  than  this  series  represents,  especially 
those  of  the  Stacke  operation. 

Skin  grafting  primarily  or  secondarily  did  not 
materially  hasten  healing,  as  the  records  in  these 
cases  show.  Where  a  graft  did  "take"  either  at  the 
first  or  second  operation,  the  time  of  healing  was 
lessened,  but  the  majority  of  the  grafts  did  not  ad- 
here, as  they  were  either  pulled  out  at  the  dressings 
by  the  pledgets  of  cotton  placed  in  the  tympanum,  or 
sloughed  away,  and  in  some  instances  thev  caused 
serious  complications. 

Chandler  Building. 


REPORT  OF  190  CONSECUTIVE  OPERATIONS 
FROM  THE  SURGICAL  SERVICE  OF 
FORDHAM  HOSPITAL. 

Reports  of  Special  Cases. 
By  Alexander  Nicoll,  M.  D., 
New  York, 

Associate   Professor   of   Surgery,   Fordham  University,    School  of 
Medicine;   Visiting  Surgeon  to  Fordham  Hospital;   Chief  of 
the  Surgical  Clinic,   St.   Vincent's  Hospital. 

The  list  of  190  consecutive  operations,  upon  a 
consideration  of  which  this  paper  is  based,  is  of  in- 
terest in  both  a  general  and  a  special  way.  The 
object  of  this  article  is  to  present  in  a  full  and  com- 
plete manner  the  cases  operated  in  and  to  indicate 
the  results  obtained,  to  indicate  the  nature  of  the 
cases  that  were  unusual,  and  to  summarize  the 
methods  of  treatment  employed  in  the  cases  which 
have  no  hard  and  fast  rule  for  their  management. 
I  have  endeavored  to  be  as  brief  as  possible,  but 
have  not  considered  it  wise  to  curtail  the  essential 
points  of  history  or  treatment  to  such  an  extent  that 
any  case  which  deserves  a  better  fate  should  be  pre- 
sented in  an  incomplete  manner.  All  of  the  cases 
rc])ortcd  herewith  were  operated  in  at  Fordham 
IIosi)ital,  and  represent  the  operative  service  of  the 
total  surgical  service  admitted  to  the  hospital  wards 
between  the  first  day  of  May  of  this  year  and  the 
first  day  of  September.  They  are  not  in  any  sense 
of  the  word  "selected  cases."  The  complete  report 
of  all  cases  admitted  to  my  service  this  vear  at 
Fordham  Hospital  has  appeared  elsewhere.' 

The^Hovving  tabulated  statement  shows  the  op- 

'New  York  Medical  Journal,  lxx.>cvii. 


erative  measures  employed  in  the  treatment  of  the 
cases,  together  with  the  results  obtained.  When  pa- 
tients have  left  the  hospital  well  on  the  road  to  re- 
covery, but  needing  further  treatment  they  had 
been  referred  to  the  dispensary  of  the  hospital,  and 
their  case  appears  in  the  following  tables  under  the 
heading  of  "patients  improved."  One  or  two  cases 
of  advanced  malignant  disease  were  operated  in, 
and  found,  at  operation,  to  be  in  such  an  advanced 
stage  of  the  disease  that  cuxative  measures  were  out 
of  the  question.  These  patients  recovered  from  the 
operation,  but  died,  subsequently,  of  the  accom- 
paning  cachexia.  These  cases  are  listed  as  "pa- 
tients died,"  although  the  death  was  in  no  way 
chargeable  to  the  operation. 


Nake  of  Operation. 


Amputation,  breast   

finger   

leg   

thigh   

toes   

Appendicectomy,    for    acute  catarrhal 

appendicular  inflammation   

acute  suppurative  appendicular  in- 
flammation   

acute  gangrenous  appendicular  in- 
flammation   

chronic  catarrhal  appendicular  in- 
flammation   

Appendicectomy,  removal  of  parovarian 

cyst,  curettage-   

Cholecystectomy,   for  cholelithiasis  

cholelithiasis,  acute  gangrenous,  cho- 
lecystitis, perforation  of  gall- 
bladder   

Circumcision   

Circumcision,   tonsillotomy,   removal  of 

adenoids   

Colostomy,    for    intestinal  obstruction 

due  to  rectal  carcinoma  

Curettage,  of  facial  sinus  

Curettage,  uterine,  for  endometritis.  . . 

incomplete  abortion   

Curettage,  uterine,  and  cauterization.. 

Enucleation,  resection  of  thyreoid  

Excision,  of  adenoma  of  parotid  gland. 

carcinoma  of  neck  

lymph  nodes,  cervical,   tuberculous.  . 
lymjih  nodes,  inguinal,  suppurative., 
palniar   fascia,    Dupuytren's  contrac- 
tion   

tunica  vaginalis  testis,  hydrocele.... 

varicocele   

varicose   veins  of  leg  

Hysterectomy,  for  fibromyomata  uteri.. 
Hysterotomy,   partial   hysterectomy,  re- 
section    of    ovaries,     plication  of 
round    ligaments    of  uterus,  repair 

of   indirect   inguinal  hernia-  

Incision  and  drainage  of  abscess,  cer- 
vical   

inguinal   

ischiorectal   

mammary   

of  leg   

of  liver-   

l>soas   

Laparotomy,  for  ectopic  gestation,  rup- 
tured-   

intestinal  adhesions,  postoperative,  re- 
section   of  ovaries  

intestinal   adhesions,  postoperative... 
intestinal  obstruction  due  to  gangren- 
ous appendix-   

intestinal  obstruction  due  to  peritoneal 
bands,  acute  suppurative  appendicu- 
lar inflammation   

intestinal  obstruction,  general  perito- 
nitis   

peritonitis,  acute,  plastic   

Laparotomy,  exploratory,  visceroptosis. 

sacroiliac  sarcoma   

carcinoma  ascending  colon  

Nephropexy   

Orchidopexy,  for  undescended  testis... 
Osteotomy,  of  humerus,  for  acute  osteo- 
myelitis   

tibia,  for  congenital  pes  planus  

tibia,  exploratory   

Pcrineorrhaiihy,  alone   

with  anterior  colporrhaphy  

with  anterior  colporrhaphy,  curettage 

with  curettage   

with  curettage,  trachcllorrhaphy .  . .  . 
with  Iracliellorrhaphy   


February  13,  1909.]  NICOLL:  SURGICAL  SERVICE  OF  FORDHAM  HOSPITAL. 


323 


Name  of  Operation. 

<ii 

^  i 

Reduction,  of  compound  fracture,  dis- 
location at  ankle    i 

Removal,    of    hsemorrhoids   5 

hemorrhoids,    division    of    fistula  in 

ano    I 

Resection,  of  knee,  for  acute  tubercu- 
lous osteoarthritis   

knee,   for  chronic  tuberculous  osteo- 
arthritis^   I 

rib,  for  empyema    3 

ovaries,   plication   of  round  ligament 

of  uterus    i 

ovaries,     trachelorrhaphy,  curettage, 

perineorrhaphy    i 

ovaries,  divijion  of  postoperative  ad- 
hesions   I 

Repair,  of  hernia,  indirect  inguinal....  11 

indirect   inguinal,    double   3 

indirect   inguinal,    strangulated   7 

femoral    i 

femoral,  strangulated    2 

ventral    i 

ventral,  strangulated    i 

Round  ligament  plication,  with  curettage  i 

with  curettage,  appendicectomy   2 

with   curettage,   appendicectomy,  tra- 
chelorrhaphy   I 

Salpingectomy,  for  gangrene  of  tube..  .. 

hsematosalpinx.  appendicectomy  ....  i 
Salpingectomy,  double,  for  suppurative 

salpingitis,    gonorrhoeal    2 

Salpingooophorectomy,  double,  for  tubo- 
ovarian  abscess,  with  appendicec- 
tomy   2 

with    appendicectomy,  ventrofixation 

of  uterus,  curettage    i 

Thoracotomy,  for  empyema   i 

Tonsillotomy,  with  removal  of  adenoids  3 

Trachelorrhaphy,    with   curettage   i 

Trephining,  for  fractured  vault  of  skull  3 
fractured  vault  of  skull,  brain  lacera- 
tion   

Urethrotomy,  internal  and  external  

Ventrosusi)ension,  of  uterus,  with  ner- 

ineorrhaphy    i 

with    perineorrhapliy,    curettage,  ap- 
pendicectomy   I 

with    perineorrhaphy,    curettage,  ap- 
pendicectomy, trachelorrhaphy  ....  i 
Wiring  of  fractured  pa'ella   i 


16 


-See  text  for  full  description. 

The  youngest  patient  operated  upon  was  eleven 
months  old,  and  required  operation  for  empyema. 
The  oldest  patient  was  ninety  years  old,  and  was 
operated  u])on  for  epithelioma  of  the  neck.  Both 
patients  were  cured. 

Seventy-five  of  the  one  hundred  and  ninet\'  oper- 
ations were  laparotomies. 

The  total  number  of  patients  operated  upon  was 
190. 

The  total  number  of  deaths  was  sixteen. 

The  total  mortalit}'  was  8.4  per  cent. 

The  patients  who  died  within  twenty-four  hours 
of  their  admission  to  the  hospital  were  ten  in 
number. 

Excluding  these  cases  the  mortality  of  the  opera- 
tive service  was  3.1  per  cent. 

Trauma  was  the  causative  factor  in  two  of  the 
fatal  cases. 

I  have  laid  some  stress  upon  the  fact  that  a  cer- 
tain number  of  patients  died  within  twenty-four 
hours  of  admission,  for  the  reason  that  any  man 
who  is  actively  engaged  in  surgical  work  in  hos- 
pitals will  appreciate  the  relation  of  this  class  ~of 
patients  to  the  patients  who  may  reasonably  be  con- 
sidered to  have  a  chance  for  recovery.  The  num- 
ber of  patients  who  are  admitted  to  charity  hos- 
pitals with  advanced  general  peritonitis,  due  to  a 
variety  of  causes,  is  appalling  and  needs  but  a  men- 
tion to  be  appreciated.  Some  of  these  patients  are 
saved  by  prompt  operation,  but  their  occurrence  as 


a  class  is  unfortunate,  and  especially  so  when  it  is 
considered  that  in  many  patients  an  early  operation 
would  have  rendered  recovery  practically  certain. 
This  class  of  cases  is  also  productive  of  a  vicious 
cycle  of  cause  and  effect :  The  patient  who  has  been 
treated  for  gangrenous  appendicular  inflammation, 
for  instance,  by  "the  expectant  method,"  comes  to 
the  hospital  with  all  his  powers  of  resistance  par- 
alyzed, and,  in  the  majority  of  cases,  succumbs  to 
the  infection  after  operation.  The  ignorant  look 
upon  such  an  outcome  as  the  strongest  sort  of  an 
argument  against  operation,  and  the  tendency  is  to 
look  tipon  hospital  treatment  in  general,  and  op- 
erative treatment  in  particular,  with  distrust  and 
dread ;  hence  the  increase  of  the  cases  which  are  de- 
layed and  the  resulting  increase  of  the  deaths.  One 
point  which  I  have  observed  is  this :  The  patients 
who  come  to  the  hospital  for  treatment  for  non- 
acute  conditions  such  as  hernia,  varicocele,  and  the 
quiescent  stage  of  a  chronic  catarrhal  appendicular 
inflammation,  for  example,  receive  the  announce- 
ment that  an  operation  is  necessary  for  their  relief 
without  fear  or  protestation.  The  reason  for  this 
is,  of  course,  that  they  have  been  told  and  their 
minds  prepared  by  some  outside  practitioner.  Even 
the  patients  who  have  had  no  suspicion  that  they  re- 
quired operation  usually  make  no  demur  when  the 
condition  is  frankly  and  simply  told  to  them  with- 
out exaggeration  or  concealment.  It  is  very  rare 
to  have  a  patient  refuse  operation  after  admission  to 
the  hospital  ward.  This  condition  of  affairs  admits 
of  but  one  conclusion ;  the  eventual  abolition  of  this 
class  of  cases,  the  "delayed"  class,  lies  wholly  with- 
in the  power  of  the  private  practitioners  of  the  hos- 
pital district.  It  has  been  especially  gratifying  and 
pleasant  to  see  the  number  of  cases  admitted  to 
Fordham  Hospital  for  operation  which  had  been 
seen  as  charity  patients  by  the  practitioners  of  the 
Bronx.  The  great  majority  of  the  desperate  cases 
had  not  been  seen  by  medical  men,  but  had  been 
the  victims  of  their  friends,  their  own  prejudices, 
and  old  doctor  So  and  so's  panaceas. 

The  following  cases  have  been  selected  as  worthy 
of  a  more  extended  report,  embodying,  as  they  do, 
some  unusual  point  either  of  pathological  condition 
or  operative  treatment. 

A  case  of  a  gynaecological  nature  which  has  some 
features  of  interest,  and  which  opens  up  the  ques- 
tion of  the  advisability  of  this  form  of  treatment  in 
cases  of  this  nature,  is  briefly  outlined  as  follows : 

Case  I.  (No.  600)  :  A  woman,  twenty-six  years  of  age. 
She  had  been  married  about  four  years  and  had  two  cliil- 
dren.  Following  the  birth  of  the  last  child  she  had  two 
rniscarriages,  the  latter,  which  occurred  four  months  pre- 
vious to  her  admission  to  the  hospital,  being  followed  by 
an  immediate  curettage.  She  continued  to  bleed  from  the 
uterus  after  this  operation,  and  during  the  course  of  the 
next  three  months  submitted  to  two  more  uterine  curet- 
tings.  These  operations  proved  without  avail,  and  the 
bleeding  persisted  and  was  associated  with  pain  low  in  the 
abdomir.al  cavity,  and  sensations  of  pressure  over  the 
sacral  area.  Upon  admission  to  the  hospital  she  was  still 
slight!}'^  bleeding  from  the  uterus  and  was  somewhat  anaemic 
and  thinned  out.  I  examined  her  by  vagina  and  found 
a  sharply  retroverted  and  retroflexed  uterus  held  by  ad- 
hesions. The  uterine  body  was  enlarged  and  somewhat 
tender,  and  the  cervical  canal  was  patulous,  the  edges  of 
the  cervix  being  everted.  The  tubes  and  ovaries  were  nor- 
mal. There  was,  in  addition,  a  right  sided  inguinal  hernia, 
a  relict  of  her  first  cliildbirth. 

Operation :  Under  nitrous  oxide  gas  and  ether  anaesthesia 


324 


NICOLL:  SURGICAL  SERVICE  OF  FORDHAM  HOSPITAL. 


[Ntw  York 
Medical  Journal, 


I  Opened  the  abdomen  in  the  median  line  below  the  umbili- 
cus. The  uterus  was  found  adherent  posteriorly,  these  ad- 
hesions were  broken  up  without  difficulty,  and  the  uterus 
was  brought  up  close  to  the  abdominal  wound.  The  body 
of  the  uterus  was  soft  and  somewhat  flaccid,  but  there  was 
no  area  of  increased  density  to  suggest  a  localized  intra- 
mural or  submucous  fibroid,  nor  did  the  uterus  have  the  ap- 
pearance suggestive  of  a  general  fibroid  degeneration.  A 
transverse  incision  through  the  peritonaeum  covering  the 
anterior  surface  of  the  uterus  freed  the  bladder  and  that 
viscus  was  pushed  down  in  order  to  e.xpose  the  entire 
uterus  in  front.  I  made  a  longitudinal  cut  into  the  cavity 
of  the  uterus,  extending  from  a  little  above  the  internal  os 
to  the  fundus,  and  retracted  the  edges  of  the  uterine  wound 
with  sutures.  This  gave  me  a  clear  view  of  the  cavity. 
The  mucosa  was  soft  and  unhealthy  in  appearance,  and  at  the 
fundus  midway  between  the  tubal  ostia  was  a  mass  of  tissue 
the  size  of  a  Lima  bean.  This  mass  was  raised  only  slightly 
above  the  level  of  the  surrounding  mucosa  and  was  covered 
with  tiny  bleeding  papills.  The  little  growth  was  sessile. 
I  could  not  scratch  the  mass  free  with  a  curette,  which 
accounts  for  the  failure  of  previous  curettings,  carried  on 
in  the  usual  manner,  to  remove  the  cause  of  the  persistent 
haemorrhage.  The  mass  was  removed,  together  with  the 
portion  of  uterine  wall  connected  with  it,  with  a  scalpel. 
The  cervix  was  dilated  with  a  broad  ligament  clamp,  and 
the  cavity  of  the  uterus  was  thoroughly  but  gently  curetted 
with  a  Volkmann  spoon,  a  considerable  quantity  of  un- 
healthy, granulomatous  tissue  coming  away  very  readil\. 
A  single  strip  of  half  inch  iodoform  gauze  was  then  intro- 
duced into  the  vagina  through  the  dilated  cervical  canal,  its 
upper  extremity  lying  just  within  the  internal  os.  The 
uterine  wound  was  then  closed  with  two  rows  of  sutures, 
the  first  or  deep  row  taking  in  the  mucosa  and  nuiscularis, 
and  the  second  row  serving  to  accurately  approximate  the 
peritonaeum  at  the  upper  part  of  the  uterine  wound.  The 
material  used  in  the  buried  layer  of  sutures  was  No.  2 
plain  catgut.  The  peritoneal  closure  was  accomplished  by 
meaiis  of  fine  sutures  of  black  silk.  The  bladder  was  stitched 
into  place  with  sutures  of  fine  silk.  The  round  ligaments 
were  shortened  and  fastened  to  the  anterior  surface  of  the 
uterus  with  sutures  of  the  same  material.  The  abdomen 
was  closed  by  layers  of  sutures  in  the  usual  manner.  Bas- 
sini"s  method  was  employed  in  the  repair  of  the  inguinal 
hernia,  and  the  patient  was  returned  to  bed  in  good  condi- 
tion. The  strip  of  gauze  placed  in  the  cervical  canal  was 
removed  on  the  second  day,  and  the  patient  made  a  com- 
plete and  satisfactory  recovery. 

There  has  been  no  further  lijemorrhage  and  the  pain  has 
subsided  completely. 

The  report  of  the  pathologist  of  the  hospital.  Dr.  A. 
MacD.  Bell,  indicated  that  the  mass  which  I  removed  was 
an  organized  portion  of  placental  tissue.  This  was  prob- 
ably missed  by  the  curette  of  the  first  operator,  due  un- 
doubtedly to  the  high  position  of  the  mass  in  the  fundus 
and  to  the  fact  that  it  lay  flat  upon  the  mucous  membrane. 
It  seems  likely  that  a  full  dilatation  and  the  use  of  the  finger 
and  sponge  forceps  would  ha\  e  been  succe-sful  in  bringing 
this  little  mass  away  v.hen  the  attachment  was  new  and 
not  firm. 

The  points  which  such  an  operation  naturally 
raises  are  these:  Is  the  uterus  left  in  an  unsafe  con- 
dition as  the  result  of  the  incision  into  its  substance  ? 
Would  not  a  hysterectomy  be  preferable?  Is  there 
any  belter  way  to  explore  the  uterine  cavity  and  re- 
move a  gfovvth  situated  as  this  one  was.  What  direc- 
tions should  be  given  a  woman  upon  whom  such  an 
operation  had  been  done  regarding  exposing  herself 
to  the  possibility  of  conception  ?  It  seems  to  me  that 
the  uterus  is  an  organ  of  such  splendid  recuperative 
and  reparative  powers  that  it  can  safely  be  trusted 
to  repair  fully  and  completely  the  wound  made  dur- 
ing such  an  operation,  providing  reasonable  surgical 
skill  be  exhibited  in  the  careful  approximation  of 
the  wound  edges  and  sedulous  avoidance  of  dead 
spaces  between  the  stitches.  Secondly,  in  a  woman 
in  early  life  the  results  of  a  complete  hysterectomy, 
with  or  without  the  removal  of  the  annexa,  are  of 
such  a  serious  and  severe  character  that  any  opera- 


tion which  is  designed  to  conserve  her  integrity  as  a 
female  individual  properly  has  such  a  horde  of 
argumentative  supports  that  it  would  be  absolutely 
impossible  to  mention  even  the  most  important  and 
impressive  of  them,  unless  I  were  to  devote  this  en- 
tire paper  to  the  discussion  of  this  subject  alone. 
Thirdly,  the  only  other  way  by  which  the  uterine 
cavity  can  be  thoroughly  explored  is  by  means  of 
anterior  colpotomy  and  hysterotomy.  The  only 
argument  in  favor  of  the  vaginal  route  is  the  les- 
sened shock  of  such  a  measure.  Whether  this  is  a 
good,  reason  for  the  choice  of  the  vaginal  route 
or  not  I  hesitate  to  say.  I  feel,  however,  that 
the  shock  following  the  vaginal  route  is  so  infini- 
tesimally  less  that  this  factor  can  be  ignored  ex- 
cept in  a  case  in  which  the  patient's  condition  is 
really  serious.  Against  this  one  reason  can  be  mar- 
shalled a  host  of  sound  argumentative  points  in 
favor  of  the  choice  of  the  abdominal  route ;  the  ab- 
dominal route  gives  a  better  exposure,  permits  a 
more  cleanly  and  surgical  removal  of  the  growth, 
allows  other  operative  measures  which  may  be  nec- 
essary, as  in  the  case  under  discussion,  and  enables 
the  surgeon  to  close  more  accurately  the  uterine 
wound.  Lastly,  regarding  the  directions  to  be  given 
to  the  patient,  I  have  not  warned  this  woman  to 
avoid  becoming  pregnant,  but  have  merely  told  her 
that  it  will  be  necessary  for  her  to  be  under  the 
constant  supervision  of  a  medical  man  during  the 
period  of  her  next  gestation.  She  has  been  referred 
to  the  dispensary  of  the  hospital  for  this  purpose. 
Anything  further  of  interest  in  this  case  will  be 
noted  and  properly  reported. 

In  the  operations  for  strangulated  hernia  with 
badly  injured  intestine  the  resection  of  the  gut  was 
accomplished  by  means  of  the  ^lurphy  button,  and 
in  this  procedure  I  have  made  use  of  a  time  saving- 
method  which  is,  as  far  as  I  know,  certainly  not  in 
common  use.  I  have  read  no  description  of  a  simi- 
lar method,  nor  have  I  been  able  to  find  any  surgeon 
who  has  used  it  or  heard  of  it.  The  operation  pro- 
ceeds in  the  usual  way  except  that  no  purse  string 
sutures  are  used.  When  the  mesentery  has  been 
tied  ofif  and  the  cut  ends  of  the  intestine  are  ready 
for  the  reception  of  the  divided  button  an  assistant 
introduces  one  half  into  the  lumen  of  the  gut,  hold- 
ing it  with  an  artery  forceps,  and  with  his  free  hand 
draws  the  intestine  up  on  the  button  ;  a  rubber  band 
is  then  either  passed  over  the  artery  forceps  and 
snapped  upon  the  button  and  intestine  at  about  the 
point  at  which  the  purse  string  suture  is  usually  in- 
troduced, or  the  rubber  band  is  cut  and  thrown 
around  the  button  and  intestine  at  the  same  point 
and  tied  snugly  with  a  square  knot.  I  make  use  of 
this  little  device  because,  before  using  it.  I  found 
that  the  introduction  of  the  purse  string  suture  re- 
quired some  time,  and  not  infrequently,  when  all 
was  ready  for  the  tightening  of  this  suture,  the  silk 
would  bind  and  refuse  to  pucker  the  intestine  about 
the  button  and  occasionally  it  would  break  and  cause 
annoying  delay  while  the  suture  was  being  replaced. 
I  believe  the  use  of  the  rubber  band  has  another  ad- 
vantage in  that  the  constant  pressure  which  it  makes 
certainlv  tends  to  free  the  button  from  the  point  of 
union  when  its  work  is  done.  The  time  saved  is  ap- 
preciable, and  it  is  on  this  account  that  I  have  men- 
tioned this  simple  device.  The  idea  was  suggested 


February  13,  iQog.i  NICOLL:  SURGICAL  SERVICE  OF  rORDHA.V  HOSPITAL. 


325 


by  a  consideration  of  the  use  of  the  elastic  hgature 
in  the  operations  producing  fistulas  between  different 
portions  of  the  gastrointestinal  tract. 

A  case  which  presented  some  puzzling  features  in 
the  course  of  treatment,  especially  in  the  actual  op- 
erative treatment  thereof,  is  the  following : 

Case  II  (No.  990)  :  A  boy  aged  eighteen  years  came  to 
the  hospital  for  the  relief  of  a  deformity  of  the  right  lower 
limb.  He  stated  that  he  had  been  imable  to  straighten  his  right 
leg  for  the  past  eight  or  nine  years  and  that  to  the  best  of 
his  recollection,  which  was  unusually  poor,  the  deformity 
of  that  member  dated  from  some  acute  illness  which  oc- 
curred at  his  ninth  year,  and  which  confined  him  to  bed 
for  several  months.  He  was  under  the  impression  tliat  he 
had  suffered  a  severe  attack  of  rheumatism.  The  leg  gave 
hun  no  pain  or  discomfort  other  than  that  arising  from  the 
necessity  of  using  crutches  to  get  about.  He  was  a  very 
well  developed  youth,  heavily  muscled,  and  big  for  his 
years.  He  showed  no  physical  abnormality  except  the  one 
fot  which  he  came  under  treatment.  His  right  leg  was 
flexed  sharply  upon  the  thigh,  making  an  angle  with  the 
normil  leg  line  of  about  110°.  Tlie  muscles  of  the  leg  and 
liiigh  were  markedly  atrophied,  and  the  leg  and  thigh  bones 
were  not  as  completely  developed  as  those  of  the  normal 
leg.  The  patella  was  fixed  immovably  to  the  intercondylar 
portion  of  the  femur.  The  external  condyle  of  the  femur 
was  markedly  enlarged.  The  tibia  and  fibula  were  dislo- 
cated backward  upon  the  femur.  Movement  at  the  knee 
joint  was  possible  only  through  an  arc  of  about  ten  degree-i, 
and  was  limited  by  strong  fibrous  bands  immediateh'  be- 
neath the  skin  posterior  to  the  knee,  and  by  ankylosis  of  the 
joint  itself.  The  slight  amount  of  movement  that  was  pos- 
sible was  not  accompanied  by  any  pain,  and  there  was  no 
point  of  tenderness  anywhere  about  the  joint  or  over  the 
articular  surfaces  of  the  tibia  or  femur.  The  tibiofibular 
articulation  was  not  abnormal  in  any  way.  Behind  the  knee 
i'pint  there  were  some  small  scars,  evidently  the  result  of 
subcutaneous  tenotomies  by  means  of  which,  apparently,  an 
unsuccessful  attempt  had  been  made  to  straighten  the  leg. 
He  was  unable  to -inform  me  accurately  about  the  time  of 
this  operation. 

Operation :  Under  nitrous  oxide  gas  and  ether  anaethesia 
I  made  a  curved  incision,  with  convexity  upward,  extending 
from  the  outer  to  the  inner  side  of  the  joint  posteriorly. 
The  flap  was  turned  down  so  as  to  give  a  clear  exposure  of 
the  constricting  bands.  From  the  slight  movement  which  I 
had  been  able  to  obtain  in  the  joint  it  was  my  intention  to 
see  what  extension  I  could  accomplish  by  a  thorough  free- 
ing of  the  soft  parts  limiting  motion.  .\  dense,  hard,  un- 
yielding band  of  thickened  fascial  tissue  was  encountered 
which  was  immediately  beneath  the  skin  and  adherent  to 
it  III  places.  This  fascial  la\-er  was  dissected  away  from 
the  skin  and  incised  at  the  sides,  the  portions  which  offered 
the  most  resistance  to  extension.  When  these  lateral  bands 
had  been  compltely  divided  a  somewhat  forcible  e.Ktension 
of  the  leg  brought  to  view  a  complication  which  forced 
me  to  give  up  the  attempt  to  straighten  the  limb  without 
opening  the  joint.  This  complication  arose  in  the  form  of 
the  appearance  of  the  very  much  shortened  tibial  and  loiv^ 
peroneal  nerves.  These  nerves  were  found  immediateh 
beneath  the  layer  of  fascia  which  had  already  been  divided. 
When  the  leg  had  been  extended  upon  tlie  thigh  until  the 
deformitv  was  reduced  to  a  right  angle,  a  procedure  which 
required  I  he  exhibition  of  considerable  muscular  effort,  the 
only  remaining  soft  structures  which  offered  resistance  to 
further  extension  were  these  two  important  nerves.  A  con- 
tinued effort  at  forcible  extension  brought  these  nerve 
trunks  upon  the  stretch  to  such  an  extent  that  I  was  con- 
vinced that  any  further  effort  to  gain  my  point  by  this 
method  would  be  disastrous,  by  either  seriously  impairing 
the  function  of  the  nerves  or  snapping  them  off  com- 
pletely. My  experience  with  the  surgery  of  nerve  repair 
has  tended  to  engender  a  most  wholesome  respect  for  the 
preservation  of  their  integrity.  In  spite  of  a  thorough  free- 
ing of  the  nerves  in  the  thigh  and  leg.  extension  of  the  leg 
at  the  knee  to  an  angle  of  less  than  80°  was  manifestly  im- 
possible. I  carried  the  skin  incision  around  the  knee  to  the 
anterior  surface  of  the  joint  and  opened  down  upon  the 
articular  surface  of  the  femur.  The  patella  w-as  firmly  ad- 
herent to  the  condyles  and  this  was  removed  with  a  chisel. 
The  joint  ca\  ity  was  practically  filled  with  fibrous  adhesions 
f*^'-  the  inner  half  of  the  articulation,  or  rather  disarticula- 
tion, and  union  betw  een  the  leg  and  thigh  bones  was  boin- 


at  the  outer  half.  The  fibrous  adhesions  were  cut  through, 
the  bony  ankylosis  was  broken  up  with  mallet  and  chisel, 
and  the  lower  end  of  the  femur  was  brought  into  the 
wound.  The  cause  of  the  trouble  was  found  in  the  en- 
larged external  condyle  of  the  femur.  Here  there  was  an 
old  healed  tuberculous  inflammatory  process  which  had 
apparently  secondarily  involved  the  joint  cavity  and  eroded 
the  external  portion  of  the  head  of  the  tibia.  I  resected  this 
portion  of  tl.e  femur  together  with  a  corresponding  por- 
tion of  the  internal  condyle.  A  thin  slice  of  the  articular 
surface  of  the  tibia  was  removed  with  a  saw,  and  the  bone 
was  found  healthy.  All  the  remnants  of  the  old  tubercu- 
lous process  were  dissected  away  and  the  displacement  of 
the  bones  was  corrected.  With  the  replacement  of  the 
ends  of  the  tibia  and  femur  I  found  that  the  reinoval  of  the 
resected  portions  of  the  two  bones  was  just  sufticient  to  al- 
low me  to  straighten  the  limb  without  putting  the  nerves 
unduly  upon  the  stretch.  Two  silver  wires  were  used  to 
accurately  approximate  the  ends  of  femur  and  tibia.  The 
skin  wound  across  the  anterior  surface  of  the  joint  was 
closed  with  sutures  of  silkworm  gut  and  silk,  and  drainage 
tubes  of  small  calibre  were  introduced  at  the  middle  of  the 
inner  and  outer  aspects  of  the  joint.  When  I  attempted  to 
close  the  posterior  and  original  skin  wound  I  found  that  the 
reduction  of  a  deformity  of  110°  had  left  a  gap  of  about 
four  and  one  half  inches  for  which  there  was  no  integu- 
ment. However,  by  freeing  the  skin  well  up  the  thigh  and 
by  the  sliding  of  flaps,  together  with  the  use  of  transverse 
incisions  sewed  longitu.dinally  at  the  points  of  greatest  ten- 
sion, a  complete  skin  investment  was  found  for  the  ex- 
posed popliteal  space.  The  application  of  a  light  tem- 
porary cast  over  dressings  completed  the  operation. 

The  patient  made  a  good  recovery,  his  postoperative  tem- 
perature never  rising  above  100'.  He  was  singularly  free 
from  pain  when  the  character  and  extent  of  the  operation 
are  taken  into  consideration,  and  suffered  no  ill  effects  from 
the  stretching  of  the  nerves  involved  other  than  the  ap- 
pearance of  a  small  area  of  anresthesia  over  the  dorsum  of 
the  foot  and  toes.  As  was  to  be  expected,  the  skin  union 
was  not  good  at  the  points  of  one  or  two  of  the  flaps,  but 
the  granulating  surfaces  were  all  together  no  larger  in 
.Trea  than  the  surface  of  a  half  dollar.  These  small  areas 
took  care  of  themselves  and  did  not  require  skin  grafting. 
L'nion  of  the  wired  bones  has  been  slow,  but  the  outlook 
for  complete  recover)-  is  particularly  bright. 

A  very  interesting  case,  which  shows  the  diffi- 
culty of  diagnosis  and  the  possibility  of  a  mistake, 
even  after  the  most  careful  and  painstaking  investi- 
gation combined  with  exploratory  operation,  is  as 
follows  : 

C.vsE  TII  (Xo.  790") — The  patient  was  a  man,  aged 
ihirty-five,  who  had  lived  in  Austria  up  to  one  year  pre- 
vious to  his  illness.  He  came  directly  to  New  York  after 
leaving  his  native  land  and  had  never  been  in  any  tropical 
country.  Up  to  four  weeks  before  his  admission  to  the 
hospital  ward  he  had  been  in  fairly  good  health  and  had 
never  had  an)'  attack  similar  to  the  one  for  which  he  came 
under  treatment.  He  had  never  had  any  attack  of  abdom- 
inal pain  nor  had  he  ever  been  jaundiced.  He  stated  that 
twenty-nine  days  before  admission  he  had  caught  cold  and 
was  confined  to  the  house  as  a  result  of  the  general  feeling 
of  malaise,  due.  he  thought,  to  exposure  to  cold.  He  im 
proved  sufficiently  to  return  to  work,  and  although  he  did 
not  feel  well  ne  remained  at  work  until  four  days  before 
he  was  taken  ill  enough  to  call  in  a  physician.  The  case 
was  apparently  a  puzzling  one  and  the  man  was  subjected 
to  an  exploratory  operation,  an  account  of  which  I  was 
able  to  secure.  The  abdomen  had  been  opened  and  liver 
and  gallbladder  found  apparently  healthv.  The  kidney  re- 
gion was  found  perfectly  normal  and  nothing  to  account 
tor  the  quite  apparent  sickness  of  the  man  was  discovered. 
The  patiem  was  admitted  to  my  service  two  weeks  after 
this  exploratory  oneration.  and  I  learned  that  his  acute  ill- 
ness previous  to  the  exploratory  operation  was  as  follows: 
Seven  days  before  his  abdominal  cavity  was  explored  he 
had  been  seized  with  sudden,  sharp  pains  in  the  region  of 
the  gallbladder.  This  pain  was  severe  and  constant.  He 
did  not  vomit.  He  had  no  cough,  dyspnoea,  diarrhoea,  head- 
ache, nor  jaundice.  The  main  symptom  was  pain  and  this 
was  constant,  not  lancinating  or  spasmodic  in  character, 
and  was  confined  to  the  upper  right  portion  of  the  ab- 
dominal cavity,  .\fter  operation  the  pain  was  of  exactly 
similar  character.    When  I  saw  him  his  temperature  was 


326 


ALLYN:  NONURINARY  DIAGNOSIS  OF  BKIGHT'S  DISEASE. 


[New  York 
Medical  Journal. 


103°,  pulse  120,  and  respirations  24.  He  was  decidedly 
septic  and  complained  ot  constant  pain  over  the  liver.  The 
last  three  intercostal  spaces  were  obliterated,  and  pain  was 
very  severe  when  the  chest  wall  over  the  liver  was  pressed 
upon.  There  was  no  pain  at  any  other  point  in  the  ab- 
dominal cavity.  The  diagnosis  of  abscess  of  the  liver  ^yas 
made  and  confirmed  by  the  recovery,  through  an  aspirating 
needle,  of  typical  thick  pink  liver  pus.  I  found  the  wounds 
of  the  previous  laparotomy  and  the  kidney  exploration  in 
good  condition  and  nearly  healed.  A  blood  count  taken 
immediately  before  operation  showed  25,000  leucocytes  to 
the  cubic  millimetre. 

Operation. — Under  ether  ansethesia  an  incision  was  made 
just  below  the  free  border  of  the  ribs  and  the  abdominal 
cavity  was  opened.  The  liver  was  adherent  to  the  parietal 
peritonaeum  and,  after  the  adherent  point  had  been  carefully 
isolated  from  the  general  peritoneal  cavity,  I  gently  pushed 
my  finger  into  the  mass  of  adhesions  and  opened  a  large 
pus  cavity  which  discharged  a  great  quantity  of  pus.  The 
cavity  was  found  to  extend  upward  upon  the  diaphragm 
for  about  three  inches  and  was  well  walled  ofif.  The  open- 
mg  into  the  liver  substance  was  found  upon  the  upper  sur- 
face of  the  right  lobe  one  inch  from  the  anterior  border  of 
the  liver  and  about  two  inches  to  the  right  of  the  situation 
of  the  gallbladder.  It  seemed  as  though  the  entire  right 
lobe  of  the  liver  had  undergone  liquefaction,  for,  after  care- 
fully sponging  out  the  cavity,  I  was  able  to  touch  the  bot- 
tom and  sides  of  the  cavity  with  the  tips  of  my  fingers  only 
with  the  greatest  difficulty.  There  were  no  trabeculse  and 
no  secondary  pockets  in  the  liver,  so  far  as  I  could  deter- 
mine. A  double  drainage  tube  was  inserted  into  the  cav- 
itv  of  the  liver,  and  drainage  was  supplied  for  the  sub- 
diaphragmatic space.  The  patient  was  returned  to  the 
ward  in  fair  condition. 

His  after  treatment  consisted  of  frequent  changing  of 
the  outside  dressing  when  the  gauze  became  moistened  with 
the  discharge,  and  a  gradual  shortening  of  the  tubes  as  the 
cavity  showed  an  inclination  to  decrease  in  size.  The  pa- 
tient's reco\'ery  was  uneventful  and  he  left  the  hospital  in 
six  weeks,  with  the  wound  of  his  operation  completely 
closed. 

The  remarkable  thing  about  this  case,  in  my  opinion, 
is  the  large  size  of  the  abscess  as  I  found  it  and  the 
comparatively  short  time  that  elapsed  between  the 
time  of  the  exploratory  operation,  at  which  no  such 
condition  was  discovered,  and  the  time  of  my  opera- 
tion. I  have  been  struck  quite  frequently  with  the 
apparently  normal  appearance  of  a  pus  kidney,  when 
at  operation  I  have  opened  down  upon  it  in  such  a 
way  as  to  see  the  kidney  first  before  the  pus  mani- 
fested itself,  which  after  a  little  further  manipulation 
has  shown  itself  to  be  merely  a  shell  of  fairly  normal 
lookiui^  kidney  tissue  filled  with  pus.  It  is  apparent 
that  certain  organs  will  occasionally  artfulW  conceal 
their  lesions.  Perhaps  the  liver  is  capable  of  simi- 
lar deception. 

123  West  Seventy-fourth  Street. 


THE  DIAGNOSIS  OF  CHRONIC   BRIGHT'S  DIS- 
EASE BY  SIGNS  OTHER  THAN  THOSE 
FURNISHED  BY  THE  URINE. 
By  Herman  B.  Allvn,  M.  D., 
Philadelphia, 

Associate  in  Medicine,  University  of  Pennsylvania;  Physician  to  the 
Philadelphia  General  Hospital. 

It  is  not  the  purpose  of  the  writer  to  minimize 
the  imi)()rtance  of  an  examination  of  the  urine ;  on 
the  contrary  he  regards  such  an  examination  as  es- 
sential not  only  in  suspected  Bright's  disease  but 
in  every  chronic  case,  and  in  all  acute  diseases  the 
cause  of  which  is  not  otherwise  obvious.  But  it  has 
not  infrccjucntly  happened  in  his  experience  that  the 
urine  has  given  very  little  help  in  the  diagnosis.  In 
the  ])ast  few  years,  since  the  establishment  of  the 
clinical  laboratory  of  the  Philadelphia  General  Hos- 


pital, it  is  by  no  means  ttncommon  to  have  the  urine 
in  cases  of  chronic  Bright's  disease  reported  nega- 
tive for  albumin  and  casts.  Moreover,  several  suc- 
cessive reports  at  varying  intei;vals  may  be  to  the 
same  tenor  (Case  III).  It  is  true  that  in  the  major- 
ity of  these  cases  a  persistent  low  specific  gravity 
of  the  urine  calls  attention  to  the  probable  disease 
of  the  kidneys.  But  this  is  not  always  so.  I  can  cite 
cases  in  which  the  specific  gravity  has  been  well 
maintained,  and  yet  extensive  disease  of  the  kidneys 
was  found  at  autopsy.  Again,  while  it  is  probable  that 
in  the  haste  of  examining  many  specimens  of  urine  in 
the  laboratory,  sufficient  care  is  not  invariably  exer- 
cised to  be  certain  of  accurate  results,  nevertheless  it 
must  be  obvious  that  if  enough  albumin  was  present 
to  react  to  the  ordinary  heat  and  nitric  acid  test  it 
would  not  often  be  overlooked ;  though  it  is  quite 
easy  to  understand  how  casts  may  fail  of  detection 
when  the  microscopical  examination  has  been  hur- 
ried or  careless.  I  am  sure,  however,  that  lack  of 
laboratory  care  and  skill  do  not  accoimt  for  all  the 
failures  to  secure  positive  results  in  chronic  Bright's 
disease,  for  in  private  cases  where  I  have  myself 
made  the  tests  the  results  have  not  always  been  posi- 
tive. So  that,  while  my  conviction  is  still  strong 
that  in  the  vast  majority  of  cases  the  ttrine,  if  re- 
peatedly and  carefully  examined,  will  at  some  time 
show  albumin  or  cases,  or  both,  or  will  have  a  per- 
sistent low  specific  gravity,  yet  in  a  few  cases  it 
will  give  us  no  help  in  diagnosis  or  may  mislead  us 
into  thinking  that  the  kidneys  are  sound.  (Case 
III.)  Moreover,  in  hospital  cases  particular!}"  we 
must  often  make  a  diagnosis  in  a  short  time  and 
with  very  inadequate  previous  history.  It  would  be 
better  to  regard  the  condition  of  the  urine  as  only  a 
part  of  the  clinical  picture  of  chronic  Bright's  dis- 
ease, and  not  necessarily  and  always  the  most  im- 
portant. But  experience  in  and  out  of  the  hospital 
convinces  me  that  too  much  dependence  is  placed 
upon  an  exainination  of  the  urine  and  too  little  atten- 
tion paid  to  the  general  phenomena  of  the  disease. 
The  net  result  is  that  Bright's  disease  is  often  over- 
looked and  the  patient  treated  for  heart  disease, 
anaemia,  or  weakness  and  malnutrition  of  unknown 
origin.  These  are  the  considerations  which  have 
induced  the  writer  to  endeavor  to  present  the  e.xtra- 
urinary  phenomena  of  Bright's  disease,  in  the  belief 
that  bv  them  we  can  often  diagnose  the  disease  even 
when  the  urine  is  negative. 

The  Cardiovascular  Signs. — The  cardiovascular 
signs  are  perhaps  the  most  constant  and  important 
of  all  the  signs  of  Bright's  disease.  They  consist 
briefly  in  enlargement  of  the  heart,  particularly  of 
the  left  ventricle,  in  accentuation  of  the  aortic  sec- 
ond sound,  in  raised  blood  pressure,  thickening  of 
the  walls  of  the  artery,  and  in  such  vascular  phenom- 
ena as  dizziness,  headache,  htemorrhages,  and  mal- 
nutrition. 

Hjgh  Blood  Pressure. — .\  rise  in  blood  pressure 
is  very  common  in  chronic  Bright's  disease.  Gen- 
erally it  can  be  perceived  by  the  finger,  if  a  person 
has  considerable  practice  in  feeling  pulses.  Jane- 
way'  refers  to  130  cases  observed  in  his  father's  and 
in  his  own  office  practice.  In  all  these  cases  the 
systolic  pressure  recorded  by  the  sphygmomano- 
meter was  200  mm.  or  more,  and  in  all  but  ten  or 
fifteen  per  cent,  there  was  chronic  nephriti.s.  Jane- 

^American  Journal  of  the  Medical  Sciences,  1906. 


February  13,  1909.] 


ALLYN:  NONURINARY  DIAGNOSIS  OF  BRIGHT'S  DISEASE. 


327 


way  does  not  think  it  possible  always  to  detect  hy- 
})ertension  with  the  finger.  He  says  that  even  pres- 
sures of  over  200  mm.  may  often  fail  to  be  appre- 
ciated where  the  pulse  is  small  or  the  artery  deepiy 
placed.  The  other  evidences  of  high  blood  pressure, 
h\pertrophy  of  the  left  ventricle  and  accentuation  of 
the  aortic  second  soimd  are  also  often  difficult  of  de- 
tection. Janeway'  studied  the  same  130  cases  from 
the  latter  standpoint  and  found  that  in  thirteen,  or 
ten  per  cent,  there  was  absolutely  no  evidence  of 
cardiovascular  disease,  except  the  blood  pressure 
reading,  in  a  number  of  cases  because  obesity  made 
examination  of  the  heart  almost  hopeless.  In  four 
cases  there  was  no  enlargement  of  the  heart,  but 
some  lifting  impulse  or  accentuation  of  the  aortic 
second  sound,  and  in  sixteen  other  cases  there  was 
evidence  of  very  slight  hypertrophy,  which  might 
easily  have  escaped  any  but  an  expert  in  physical 
diagnosis.  He  concludes  therefore,  that  one  quarter 
of  the  cases  would  have  been  recognized  with  diffi- 
culty or  not  at  all  without  the  sphygmomanometer, 
except  on  critical  examination  by  a  skilled  observer. 

The  frequency  of  high  blood  pressure  in  inter- 
stitial nephritis  has  been  noted  also  by  Norris.  It- 
was  especially  high  in  uraemia ;  nevertheless,  high 
blood  pressure  is  not  constant  and  persistent 
tliroughout  the  disease.  When  the  heart  becomes 
dilated  and  when  chronic  myocarditis  sets  in  the 
blood  pressure  falls.  xA.cute  dilatation  of  the  heart 
is  very  apt  to  occur  in  persons  with  high  blood  pres- 
sure who  are  subjected  to  some  added  strain.  In 
one  of  my  patients  the  occasion  w'as  shovelling  snow. 
Very  manv  of  the  patients  with  chronic  interstitial 
nephritis  who  are  admitted  to  the  Philadelphia  Gen- 
eral Hospital  enter  in  the  late  stages  of  the  disease. 
An  associated  chronic  myocarditis  is  very  common 
in  these  cases,  and  there  is  often  also  arteriosclerosis 
with  chronic  endocarditis  and  other  complications. 
T  regret  that  I  have  not  tested  the  blood  pressure  by 
a  pressure  apparatus,  but  I  have  very  constantly 
tested  the  pressure  with  the  finger  and  have  found 
it  normal  or  below  normal  in  such  late  complicated 
cases  of  chronic  Bright's  disease.  One  sign  of  their 
improvement  under  treatment  is  a  rise  in  blood  pres- 
sure. Therefore  if  the  physician  sees  the  patient 
during  an  acute  dilatation  of  the  heart  or  in  the  late 
stages  of  the  disease  he  may  easily  obtain  false  ideas 
of  the  blood  pressure  in  a  case  of  chronic  Bright's 
disease,  or  what  is  quite  as  likely,  he  may  think 
he  has  to  deal  Avith  failing  compensation  in  mitral 
valvular  disease  or  with  a  myocarditis  only.  Where- 
as, if  the  patient  had  been  seen  early  before  the 
heart  dilated  or  chronic  myocarditis  and  malnutri- 
tion set  in,  rhe  blood  pressure  would  have  been 
found  high.  This  A  ariation  of  blood  pressure  with 
the  integrity  and  energy  of  the  heart  and  the  general 
nerve  tonus  of  the  body  is  very  important  to  re- 
member. 

Tliickenii]^  of  the  Bloodvessels.-— This  is  also  very 
common ;  I  will  not  say  it  always  occurs,  but  the 
amount  of  the  thickening  varies  very  greatly  and 
does  not  always  bear  a  direct  relation  to  the  gravity 
of  the  nephritis.  Sometimes  it  is  so  slight  that  the 
radial  arterv  feels  like  a  piece  of  flattened  straw 
when  rolled  against  the  underlying  bone,  and  some- 
times it  feels  as  though  it  were  an  eighth  of  an  inch 
thick.  

-Ibidem,  May,  1903. 


Eiilavi^ement  of  the  Left  Voitricle. — The  enlarge- 
ment is  usually  made  out  easih'.  The  apex  beat  in- 
stead of  being  within  the  nipple  line  is  displaced  to 
the  left  so  as  to  be  flush  witli  the  nipple  line  or  be- 
yond it  toward  the  anterior  axillary  line.  At  the 
same  time  it  is  displaced  more  or  less  downward, 
so  as  to  be  beneath  the  sixth  rib  or  even  in  the  sixth 
interspace.  Its  position  can  best  be  detected  by  pal- 
pation, aided  by  inspection,  but  percussion  should 
also  be  employed.  The  latter  method  should  dis- 
cover an  area  of  the  heart  larger  than  normal  which 
is  uncovered  by  the  lung  tissue. 

If  the  apex  beat  is  not  readily  felt  and  seen,  the 
patient  should  be  instructed  to  lean  forward  and 
palpation  be  made  during  a  full  expiration  of  the 
patient.  Palpation,  moreover,  should  detect  not 
merely  the  apex  beat  but  a  forcible  heaving  impulse. 
In  women  with  large  mammae  and  in  stout  men  with 
thick  chest  walls  it  may  be  impossible  to  detect  a 
moderate  hypertrophy  without  an  x  ray  examina- 
tion. 

Other  cardiovascular  phenomena  are  hceinor- 
rhages.  These  are  sometimes  into  the  skin,  or  they 
may  take  place  from  the  kidneys,  stomach,  and 
bowels..  Petecheal  and  even  larger  haemorrhages 
are  b)'  no  means  uncommon.  They  occur  especially 
in  the  skin  of  the  legs.  They  are,  perhaps,  due  more 
to  an  arteriosclerosis  than  to  the  nephritis.  West 
says  haemorrhages  from  the  bowels  are  not  com- 
mon. I  have  met  with  one  case.  The  urine  was 
scanty  but  exhibited  neither  albumin  nor  casts.  The 
arteries  w^ere  somewhat  thickened,  the  color  bad, 
and  there  was  malnutrition.  Vomiting  of  blood  as  a 
symptom  of  Bright's  disease  I  have  not  seen ;  but 
cases  have  been  reported. 

Albuminuric  Retinitis  and  Detachment  of  the 
Retina  occur  in  a  number  of  cases,  the  former  being 
the  more  frequent.  It  is  no  uncommon  experience 
to  have  an  ophthalmologist  refer  a  patient  to  an 
internist  with  the  request  that  the  urine  be  carefully 
examined ;  for  sometimes  eye  changes  indicating 
nephritis  are  found  before  the  familv  physician  has 
had  any  suspicion  that  disease  of  the  kidney  exists. 
Much  more  frequently  I  have  sent  a  patient  to  an 
ophthalmologist  for  an  eyeground  examination,  but 
he  has  rarely  reported  a  positive  finding. 

Hcrmaturia  occurs  occasionally  especially  in  the 
gouty  form  of  nephritis  where  there  is  marked  ar- 
teriosclerosis of  the  kidney  vessels. 

Disciness  and  Vertigo  occur  under  two  conditions, 
as  symptoms  of  toxaemia,  and  as  effects  of  disturbed 
circulation.  In  the  latter  case  they  are  found  after 
myocardial  changes  have  weakened  the  heart  and 
some  dilatation  is  present.  But  they  may  also  be 
only  a  part  of  an  arteriosclerosis  which  by  impeding 
the  circulation  has  disturbed  brain  function.  Such 
vascular  dizziness  occurs  after  effort  or  during  mo- 
tion ;  that  due  to  toxaemia  may  occur  while  the  pa- 
tient is  at  rest. 

Nutritional  Changes. — W'hen  Bright's  disease  has 
continued  some  time  it  is  very  apt  to  cause  failure 
in  strength  and  flesh,  and  not  infrequently  also  a 
peculiar  pallor  w-ith  or  without  a  demonstrable 
anaemia.  Loss  of  stretigth  is  sometimes  the  most 
striking  characteristic,  in  other  cases  the  pallor  is 
the  most  easily  observed  objective  sign.  It  is  re- 
markable in  some  cases  ho\''  long  life  may  be  pre- 
served.   I  recall  one  old  man  who  lived  for  nine 


328 


ALLYX:  XOM'RJX.IKV  DIAGXOSIS  OF  BRIGHTS  DISEASE. 


LNew  York 
Medical  Journal. 


months  after  he  had  become  so  weak  that  he  could 
not  leave  his  bed.  He  passed  on  an  avcraiie  from 
twenty  to  twenty-four  ounces  of  urine  a  day,  the 
specific  gravity  being  from  i.ooi  to  1.005.  ''nee 
the  urine  fell  as  low  as  nine  ounces  in  twenty-four 
hours,  and  frequently  was  only  sixteen  ounces. 
Apart  from  his  great  feebleness  and  pallor  there 
were  no  prominent  symptoms.  He  slept  a  good  deal 
but  was  not  delirious.  There  v^-as  no  oedema.  He 
took  his  food  regularly  and  his  bowels  moved  with- 
out assistance  He  died  from  progressive  asth.'enia. 
In  other  cases  in  which  the  prominent  changes  may 
be  classed  as  nutritional  there  are  digestive  disturb- 
ances— nausea,  vomiting,  painful  digestion,  attacks 
of  diarrhoea  without  adequate  cause.  Some  of  the 
greatest  of  these  sufferers  show  marked  deficiency 
of  hydrochloric  acid  or  even  complete  anacidity. 
with  deficiency  of  pepsin.  It  is  easy  to  speak  of 
these  cases  as  gastric,  and  to  account  thus  for  all 
the  nausea,  the  disgust  for  food,  or  the  dread  of 
taking  it,  the  difficult  and  painful  digestion  and  the 
malnutrition ;  but  I  believe  that  in  some  of  the  cases, 
how  many  I  cannot  say,  that  is  much  too  narrow 
a  view  (Case  H).  They  are  much  benefited  by  hy- 
drochloric acid  and  pepsin,  it  is  true,  but  attention  to 
the  kidneys  and  to  increased  eliminatinn  through 
other  organs  must  be  provided  to  obtain  great  im- 
provement. 

Musser  has  very  happily  called  attention  to  ab- 
dominal  pain  as  a  urasmic  symptom.  It  is  later  in 
development  than  those  I  have  mentioned.  It  may 
be  confounded  with  the  pain  of  acute^  congestion  of 
the  left  lobe  of  the  liver  which  occurs  in  failing 
compensation  of  the  heart,  especially  as  the  latter 
may  also  occur  in  Bright's  disease. 

The  ancrmia  of  Bright's  disease  is  usually  moder- 
ate, the  haemoglobin  falling  to  sixty  or  seventy  per 
cent,  and  the  red  cells  to  about  3,000.000. 

Toxic  Phenomena. — Here  belong  nervous  symp- 
toms such  as  headache,  insomnia,  delirium,  coma, 
convulsions,  and  hemiplegia,  which  are  well  recog- 
nized as  clue  to  disease  of  the  kidneys.  Three  symp- 
toms belonging  in  the  group  which  are  not  so  com- 
monly recognized  are,  peripheral  neuritis,  melan- 
cholia, and  mania. 

Of  the  symptoms  first  mentioned  I  shall  say  lit- 
tle, not  because  they  are  not  important,  but  because 
they  are  so  well  known  that  only  temporary  forget- 
fulncss  on  the  part  of  the  physician  should  account 
for  failure  to  estimate  their  possible  significance. 
Coma,  con:  visions,  and  hemiplegia  of  ura?mic  origin 
are  very  apt  to  be  mistaken  for  the  same  symptoms 
due  to  brain  haE^tnorrhage  (Case  III).  I  have  made 
the  mistake  more  than  once.  Sometimes  it  is  im- 
possible to  tell  which  is  the  cause ;  for  on  the  one 
hand,  a  nephritis  is  a  common  accompaniuicnt  of 
arteries  so  degenerated  that  they  break,  and  on  the 
other  in  urncmic  coma  and  hemipleiiia  the  urine  mav 
give  no  indication  of  the  serious  disease  of  the  kid- 
neys which  actuallv  exists.  For  example,  last  win- 
ter there  entered  the  Philadelphia  General  Hospital 
a  woman  in  coma.  By  catheter  forty-three  ounces 
of  urine  were  obtained  which  showed  a  specific 
gravity  of  1.012  and  contained  neither  albumin  nor 
casts.  Two  subsequent  examinations  of  the  urine, 
made  within  the  following  few  days,  also  showed 
neither  albumin  nor  casts.  Yet  at  the  autopsy  the 
kidneys  were  almost  completely  transformed  into 


multiple  cysts  with  very  little  cortex  left.  In  this 
case  it  is  possible  that  a  more  careful  study  of  the 
blood  pressure  and  arteries  would  have  cleared  up 
the  diagnosis.  She  was  a  very  stout  woman  with 
large  mammae,  so  that  the  size  of  the  heart  could  not 
be  ascertained. 

Delirium  of  a  Melancholic  or  Maniacal  Type  is 
less  common.  1  have  seen  a  few  cases.  Usually 
these  patients  pass  from  observation  quickly,  because 
even  though  a  correct  diagnosis  is  made  such  pa- 
tients cannot  be  kept  very  long  in  a  general  hospital 
or  in  the  medical  wards  of  a  hospital.  In  the  cases 
I  have  seen  it  was  the  condition  of  the  heart  and 
blood  pressure  rather  than  the  urine  which  led  to 
the  diagnosis. 

I  have  met  with  several  cases  of  peripheral  neuri- 
tis In  one  case  (V)  there  were  recurring  attacks 
of  gastralgia  associated  with  anacidity.  At  other 
times  the  man  would  have  severe  pains  in  groins, 
rectum  or  head.  The  station  and  knee  jerks  were 
normal.  Cnder  toxic  phenomena  may  be  grouped 
also  the  bronchial  and  pulmonary  symptoms,  such 
as,  dyspncea.  bronchitis  and  cedema  of  the  lungs. 
The  dyspnoea  often  takes  the  form  of  pseudoasth- 
matic  attacks,  coming  on  in  the  early  morning  and 
disappearing  later  in  the  day.  If  it  <levelops  purely 
from  exertion  the  dvspnoea  is  generally  cardiac.  We 
must  remember,  however,  that  nephritis  does  not  ex- 
clude cardiac  disease  and  that  both  are  sometimes 
found  associated  with  emphysema  and  bronchial 
asthma.  I  have  seen  an  asthmatic  with  a  history  of 
the  disease  dating  back  twenty  years,  and  at  the  end 
of  that  time  a  high  blood  pressure,  thickened  arter- 
ies, and  an  enlarged  heart.  The  nephritis  in  such  a 
case  has  no  iloubt  been  a  late  development  and  is 
not  responsible  for  the  dyspnoea  ;  yet  in  this  man's 
family  there  was  a  marked  history  of  Bright's  dis- 
ease. On  the  other  hand  every  year  I  see  in  the 
I'lOspital  one  or  more  cases  of  Bright's  disease  asso- 
ciated with  myocarditis,  endocarditis,  and  bronchitis 
or  fedema  of  the  lungs.  The  cases  require  careful 
suidy  to  decide  whether  the  kidney  disease  is  pri- 
mary and  is  chiefly  responsible  for  the  pulmonary 
symptoms,  or  if  the  heart  disease  is  the  more  import- 
ant factor.  [  believe  that  the  importance  of  bron- 
chial symptoms  as  evidence  of  nephritis  is  too  fre- 
quently overlooked.  These  cases  are  often  regarded 
and  treated  as  primary  bronchitis  or  as  dependent 
upon  a  weak  heart. 

C.\SE  I. — Dyspitcra  from  dilated  heart,  tt/v  high  blood 
("rcisnrc.  Tliis  patient  was  a  stoutly  built,  strong  man, 
about  forty-h\e  years  old.  T'ornierly  lie  was  very  fond  of 
athletic  exercises,  especially  rowing  and  tennis,  but  for  the 
past  four  years  he  had  led  a  more  sedentary  life.  He  had 
never  been  ill  in  his  life  before  he  consulted  me  for  acute 
dyspnoea  accompanying  a  dilated  heart.  There  was  no  par- 
ticular phvsical  stress  preceding  the  dilation,  but  he  had 
been  under  considerable  mental  strain  and  had  eaten  irreg- 
ularly and  had  less  sleep  than  he  was  accusldincd  to  get. 

The  heart  was  hypcrtropliicd  and  dilated,  and  the  blood 
pressure  was  very  high.  This  combinatinn  of  heart  and 
high  blood  pressure  aroused  the  suspicion  that  there  was 
interstitial  nephritis.  The  first  examination  of  the  urine 
showed  some  pus  but  no  nephritis.  A  later  examination 
after  the  pus  had  disappeared  showed  a  trace  of  albumin 
and  a  few  hyalogranular  casts.  I  believe  that  the  high  blood 
pressure  was  dependent  upon  the  nephritis.  It  had  doubt- 
less existed  a  long  while,  long  enough  to  bring  about  a 
hypertrophy  of  the  heart.  Finally  the  heart  gave  way  im- 
dcr  the  strain  of  pumping  against  the  high  blood  pressure, 
and  dyspnoea  occurred. 

C.\SE  IT. —  JFcarinrss  and  somnolence ;  casilv  'ndurrd  f,i- 


i  .i,rua^y      .y..^.,  HEISER:  HOOK  WORM  DISEASE  iX   I  HE  EiilLlFPlXES. 


3^9 


I'igue;  dyspncea  on  exertion;  pufhtiess  of  hands,  headache, 
backache,  causeless  depression  of  spirits,  difficult  digestion 
Ik  ith  flatulence.  Pallor. 

This  patient  was  a  woman,  about  sixty  years  old,  who 
had  enjoyed  good  health  until  two  years  ago,  when  she  had 
what  was  called  ptomaine  poisoning,  by  the  physician  who 
attended  her.  Since  then  she  had  the  symptoms  alreadj' 
recorded.  A  myocarditis  with  occasional  attacks  of  acute 
<Jilatation  of  the  heart  accounted  for  the  dyspnoea.  She  had 
also  a  gastric  anacidity,  which  explained  her  digestive  difR- 
.culties.  But  I  believed  she  also  had  a  chronic  interstitial 
nephritis.  The  urine  varied  in  specific  gravity  from  1.003 
to  1.022;  the  volume  from  20  to  48  ounces  in  twenty-four 
hours.  Generally  it  was  free  from  albumin  and  casts,  but 
occasionally  one  could  tind  a  trace  of  albumin  and  a  hyalo 
granular  cast.  It  is  probable  that  defective  elimination 
from  the  kidneys  had  much  to  do  with  the  gastric  disorder 
and  that  the  contracting  kidney  made  it  difficult  to  keep  the 
heart  in  good  functional  tone. 

Case  III. — Right  sided  hemiplegia,  aphasia,  spasticity 
and  tremor  of  the  left  side  of  the  body,  especially  of  the 
left  arm;  absence  of  knee  jerks;  deviation  of  eyes,  head, 
and  tongue  to  left  side;  tenderness  over  entire  abdomen; 
tenderness  along  spinal  column  on  left  side ;  unequal  pupils, 
suggestive  Kernig's  sign  on  left  side;  and  fever. 

F.,  forty-two  years  old,  was  admitted  to  the  Philadel- 
phia General  Hospital,  October  12,  1908.  The  family  and 
social  history  are  unimportant.  She  had  always  done  house- 
■\vork.    Used  tea,  coffee,  and  alcoholic  beverages. 

Five  years  ago  the  patient  fell  and  hurt  her  back.  Since 
then  she  had  been  unable  to  walk  any  great  distance  unas- 
sisted and  had  had  constant  pain  in  the  small  of  the  back. 
Frequent  urination  and  polyuria.  About  six  months  ago 
the  patient  was  seized  with  vomiting,  especially  noticeable 
in  the  morning.  Copulation  became  painful  and  was  fol- 
owed  in  fifteen  minutes  by  haemorrhage.  Patient  become 
progressively  worse,  and  hsemorrhage  occurred  independ- 
ently of  copulation.  She  would  have  days  of  intermission 
of  marked  pain  and  haemorrhages,  and  then  she  was  able  to 
go  about  and  attend  to  her  houshold  duties. 

On  Friday  morning  the  patient  was  up  attending  to  her 
household  duties  -and  asserted  that  she  felt  fairly  well,  she 
cooked  her  husband's  breakfast  and  he  departed  for  his 
work.  On  his  return  at  7  :30  p.  m.  he  found  her  sitting  on 
the  floor  of  her  bedroom  vom.iting  and  unable  to  talk.  She 
was  put  to  bed  and  at  4  a.  m.  on  Sunday  morning,  during 
the  temporary  absence  of  her  attendant  she  made  an  effort 
to  get  out  of  bed  and  fell  upon  her  right  side,  which  was 
paralyzed.    She  again  fell  out  of  bed  at  11  :i5  p.  m. 

On  admission  she  was  semiconscious,  unable  to  talk,  par- 
alyzed on  the  right  side,  including  the  face,  arm,  and  leg ; 
the  left  side  was  spastic  and  had  marked  tremor.  There 
were  contusions  on  the  right  cheek,  right  portion  of  chin, 
right  hand,  arm,  shoulder,  right  side  of  chest  and  abdomen, 
and  also  on  both  knees. 

The  patient  was  an  adult  woman,  who  looked  prematurely 
aged ;  she  was  of  good  stature,  development,  and  nutrition. 
Right  arm  and  leg  were  flaccid,  with  absent  reflexes,  mouth 
drawn  to  left  side  and  tongue  protruded  to  left.  Patient 
cried  out  during  examination.  The  left  pupil  was  dilated 
and  immobile ;  the  right  contracted  with  very  sluggish  re- 
action to  light.  Breathing  was  stertorous  with  flapping  of 
cheeks.  Pulse  was  weak  and  frequent,  low  tension  and 
poor  volume,  at  times  could  not  be  felt. 

Lungs  were  normal.  Heart's  size  could  not  he  made  out 
■on  account  of  large  mamma.  Sounds  were  weak,  no  mur- 
murs. E.xamination  difficult  because  the  patient  cried  out 
constantly.    Abdomen  tender,  especially  toward  groins. 

On  admission  the  patient  was  catheterized  and  forty- 
three  ounces  of  urine  withdrawn.  It  was  acid  in  reaction, 
specific  gravity  1,012,  contained  neither  albumin  nor  casts ; 
urates  abundant.  A  lumbar  puncture  was  done  and  two 
and  a  half  test  tubes  full  of  turbid  fluid  withdrawn  with 
some  relief  to  the  patient. 

On  the  14th  it  was  noted  that  there  was  marked  conju- 
gate deviation  of  the  eyes  to  the  left  during  a  convulsion, 
the  right  pupil  was  larger  than  the  left,  an  ophthalmoscopic 
examination  showed  no  changes  except  a  distension  of  the 
retinal  vessels.  The  patient  had  a  convulsion  when  being- 
sponged  and  five  convulsions  later. 

Two  examinations  of  the  urine  on  the  13th  and  14th  re- 
sulted as  follows:  Specific  gravity  1.014.  no  albumin,  no 
cast,  a  few  leucocytes  and  epithelial  cells  and  uric  acid 
crystals;  specific  gravity  1.020,  no  albumin  or  sugar,  no 


casts,  a  few  leucocytes,  epithelial  cells,  and  uric  acid  crys- 
tals. Thirty-two  ounces  of  urine  were  obtained  by  cathe- 
terization on  the  14th.  so  that  the  secretion  of  urine  was 
not  greatlv  dinnni-hed,  as  some  was  passed  involuntarily. 
The  examination  of  tlie  spinal  fluid  was  negative. 

The  temperature  on  admission  was  102.4^  F.,  the  follow- 
ing day  103'  F.,  and  loi"  F.  on  the  14th,  the  day  before 
death. 

The  autopsy  showed  fatty  infiltration  and  degeneration  of 
the  heart ;  chronic  diffuse  nephritis  with  cystic  disease ;  car- 
cinoma of  cervix  uteri;  fatty  infiltration  of  the  liver; 
oedema  of  brain. 

C.\SE  I\'. — Palpitation  and  painful  digestion;  later  head- 
ache and  palpitation ;  scanty  urine;  loss  of  vi-eight;  some 
pallor. 

The  patient  was  a  woman,  fifty-nine  years  of  age.  The 
prominent  symptoms  for  some  years  had  been  tachycardia 
and  painful  digestion,  recently  headaches  with  dimness  of 
.vision  and  nausea  had  been  superadded.  She  generally 
w  oke  in  the  morning  w  ith  pain  in  the  back  of  the  head.  The 
pulse  was  no,  regular,  tension  slightly  increased  and  ar- 
tery a  little  thickened.  She  had  lost  twenty-two  pounds  in 
the  past  three  years.  The  present  weight  is  138  pounds. 
The  color  has  recently  changed  to  a  slight  grayish  pallor. 
The  urine  ranged  from  eighteen  to  twenty-seven  ounces  in 
twent>--four  hours.  After  forced  drinking  of  water  the 
volume  was  increased  to  forty-eight  ounces.  The  specific 
gravity  ranged  from  1.009  to  1.020.  I  have  never  found 
albumin  or  casts. 

Case  V. — Painful  and  difficult  digestion  for  years;  an- 
acidity; pyorrha-a  alveolaris;  ancemia;  loss  of  strength; 
headache;  repeated  attacks  of  neuritis;  nephritis. 

This  patient  was  a  man,  about  forty  years  of  age.  He 
had  had  for  years  a  weak  stomach,  which  necessitated  great 
care  in  eating:  in  spite  of  such  care  there  had  been  numer- 
ous attacks  of  nausea,  vomiting,  and  abdominal  pain.  In 
one  such  seizure  I  saw  him  first  about  eighteen  months  ago. 
He  was  of  course  anaemic.  The  gastric  contents  show  ed  ab- 
sence of  free  hydrochloric  acid.  He  had  lost  most  of  his 
teeth  from  recession  of  the  gums,  and  of  the  remaining 
teeth  most  of  them  showed  pyorrhoea  alveolaris.  The  tongue 
was  heavily  coated.^  the  urine  contained  a  small  amount  of 
albumin,  the  specific  gravity  was  from  i.oio  to  1.012. 

For  a  time  there  was  marked  improvement,  especially  in 
the  stomach  condition.  It  was  months  before  I  could  per- 
suade him  to  have  his  teeth  extracted.  After  their  removal 
the  albumin  lessened,  but  never  wholly  disappeared.  Oc- 
casionally a  few  fatty  casts  were  found. 

The  progress  of  the  case  was  characterized  by  attacks  of 
neuritis,  sometimes  in  the  groin,  thigh,  or  buttocks,  and 
sometimes  in  the  back,  hands,  or  arms,  and  sometimes  in 
the  abdomen  as  though  involving  the  solar  plexus.  The  last 
were  the  hardest  to  bear.  Occasionally  there  had  been 
slight  jaundice  and  constantly  of  late  there  had  been  sw  ell- 
ing  of  feet.  Death  occurred  from  convulsions  followed  by 
coma. 

501  South  Forty-secoxd  Street. 


THE  PRACTICAL  RESULTS  OBTAINED  IN  THE 
PHILIPPINES  IN  REDUCING  THE  GENERAL 
MORTALITY  BY  THE  ELLMINATION  OF 
INTESTINAL  PARASITES,  ESPE- 
CIALLY THE  HOOK  WORM.* 

Bv  Victor  G.  Heiser,  M.  D., 
Manila,  P.  I., 

Passed  Assistant  Surgeon.  United  States  Public  Health  and  Marine 
Hospital  Service:  Director  of  Health  and  Chief  Quarantine 
Officer   for   the    Philippine   Islands;    Professor  of 
Hygiene,  Philippine  Medical  School. 

T!ie  researcli  work  done  in  the  southern  States 
fluring  the  past  few  years  by  the  United  States  Pub- 
lic Health  and  ^Marine  Hospital  Service  and  by  in- 
dependent worlsers  has  shown  conclusively  that  the 
ankylostoma  or  hook  worm  is  exceedinglv  prevalent 
and,  no  doubt,  is  an  important  factor  in  the  morbid- 
ity and  mortality  among  the  residents  of  sections  in 

*Rs-ad  at  the  .Annval  Meeting  of  the  Southern  Medical  Associa- 
tion in  Atlanta,  Ga.,  Xovember  ii,  1908. 


330 


REISER:  HOOK   WORM  DISEASE  IN  THE  PHILIPPINES. 


[New  York 
Medical  Journal. 


which  they  prevail.  Judging  by  the  experience  had 
in  other  countries,  it  is  becoming  more  and  more 
evident  that  this  infection  should  receive  the  most 
serious  attention  not  only  by  the  profession,  but  by 
publicly  organized  effort  as  well.  The  problem  has 
passed  from  the  laboratory  to  the  practical  stage. 
The  lives  that  are  uselessly  sacrificed  and  the  thou- 
sands of  dollars  that  are  being  lost  are  well  dem- 
onstrated by  the  carefully  recorded  statistics  that 
have  recently  become  available  in  the  Philippines. 

In  the  large  insular  prison  called  Bilibid  over  three 
thousand  prisoners  are  constantly  confined.  From 
1902  to  1905  there  was  an  uninterrupted  increase  in 
the  death  rate  until  a  mortality  of  over  two  hundred 
a  thousand  in  a  year  was  reached.  The  sanitation 
of  the  prison  was  then  transferred  from  the  control 
of  laymen  and  placed  under  the  charge  of  the  Bureau 
of  Health.  Work  which  had  for  its  object  the  relief 
of  this  condition  was  begun  at  once,  overcrowding 
was  relieved,  sewage  disposal  improved,  adjacent 
lowlands  filled  in,  the  sick  placed  under  treatment 
more  promptly,  and  other  well  recognized  measures 
were  put  into  effect.  The  death  rate  in  a  few  months' 
time  soon  fell  to  about  seventy-five  in  a  thousand 
in  a  year,  but  further  reduction  seemed  impossible. 
For  a  period  of  about  six  months  every  effort  was 
made  to  lower  it,  but  without  success.  A  study  of 
the  hospital  patients  showed  that  they  were  dying 
with  ailments  that  should  not  have  killed  them. 
Their  powers  of  resistance  were  evidently  impaired. 
The  habits  of  the  natives  of  the  Philippines  sug- 
gested a  remedy.  The  evidence  pointed  to  some  ex- 
traordinary drain  on  the  system.  There  was  plenty 
of  food,  but  evidently  imperfect  nourishment.  With 
a  view  to  discovering  the  cause,  a  routine  practice 
of  microscopically  examining  the  faeces  of  every 
prisoner  was  inaugurated.  Eighty-four  per  cent, 
were  found  infected  with  intestinal  parasites.  Of 
these  sixty  per  cent.,  or  fifty-two  per  cent,  of  the 
total  number  of  prisoners,  had  hook  worms,  fifty- 
nine  per  cent,  had  whipworms,  twenty-three  per 
cent,  amoebae,  and  twenty-one  per  cent,  harbored 
some  other  species  of  the  parasite. 

Over  half  of  the  prisoners  were  hosts  for  at  least 
two  kinds  of  worms.  Active  therapeutic  measures 
were  taken  to  rid  the  prisoners  of  the  causes  of  these 
debilitating  troubles.  The  prisoners  are  kept  in 
buildings  which  hold  about  three  hundred  each.  One 
after  another  of  these  groups  was  treated,  and  it  was 
soon  noticed  that  the  health  of  groups  in  which  the 
treatment 'was  completed  was  much  better  than  of 
the  others,  and  when  the  intestinal  parasites  of  all 
the  prisoners  had  been  eliminated  it  was  seen  that 
the  result  was  much  more  satisfactory  than  could 
ever  have  been  expected.  The  death  rate  fell  to 
less  than  twenty  a  thousand. 

Some  thousands  of  stool  examinations  made  in 
the  Philippines  outside  of  Bilibid  show  that  about 
the  same  percentage  of  infections  may  be  expected 
among  the  general  population. 

One  of  the  most  striking  things,  however,  is  that 
the  records  of  the  prison  show  that  there  w^is  a  most 
marked  reduction  in  the  incidence  of  all  diseases, 
which  demonstrates  in  a  most  conclusive  manner 
that  parasitical  intestinal  infections  are  not  only  of 
direct  harm  to  the  human  organism,  but  their  indi- 


rect effect  in  lowering  the  resistance  of  an  individual 
to  disease  is  also  of  the  utmost  importance. 

In  a  disease  like  pulmonary  tuberculosis,  for  in- 
stance, even  after  segregation  of  the  cases  and  other 
approved  methods  had  been  carried  out,  the  number 
of  cases  in  the  prison  was  still  further  reduced  from 
fifty-one  to  twenty-eight  per  cent,  per  annum  by 
eliminating  the  intestinal  parasites  from  the  pris- 
oners. 

If  then  we  have  a  prophylactic  measure  which  will 
diminish  the  incidence  of  practically  all  the  diseases 
(See  Bilibid  Hospital  Statistics  published  in  the 
nnal  Reports  of  the  Bureau  of  Health  for  the  Phil- 
ippines during  the  past  four  years)  it  would  appear 
only  rational  that  this  should  receive  first  considera- 
tion. 

It  is  believed  that  the  foregoing  facts,  taken  in 
connection  w'ith  the  experience  alread\'  had  in  Puerto 
Rico  and  the  southern  States,  make  concrete  proof 
of  what  may  be  accomplished  in  tropical  and  semi- 
tropical  countries,  and  are  sufficient  evidence  to  lay 
before  a  legislative  body  in  order  that  the  necessary 
funds  may  be  provided  to  put  into  effect  the  pro- 
phylactic measures  which  are  indicated.  In  making 
the  foregoing  statement  the  w-riter  bears  in  mind 
that  it  is  most  desirable  before  a  government  is  asked 
to  give  any  substantial  support  to  a  public  health 
measure  that  it  should  always  be  shown  with  reason- 
able certainty  that  the  public  health  will  be  im- 
proved, that  the  estimated  cost  is  within  bounds, 
that  the  economic  value  is  apparent,  and  that  it  is 
backed  up  by  experimental  and  other  evidence. 

In  i^ecommending  public  health  legislation  not 
only  the  medical  men  directly  concerned,  but  the 
whole  medical  profession  as  well,  shares  in  the  re- 
sponsibility involved.  If  success  follows  the  adop- 
tion of  a  recommendation  it  redounds  to  the  credit 
of  the  whole  profession  and  if  failure  results  it  is 
frequently  used  as  evidence  of  the  unreliability  of 
medical  advice.  The  results  to  be  expected,  how- 
ever, from  the  hook  worm  campaign  seem  to  be  so 
certain  of  success  that  it  is  believed  the  time  has  now 
come  when  the  solution  of  this  problem  may  be  act- 
ively imdertaken. 

In  the  Philippines  it  is  proposed  to  attack  the 
problem  in  the  smaller  villages  by  the  installation  of 
a  pail  system,  the  contents  of  which  are  to  be  emp- 
tied regularly  into  pits  located  outside  of  the  town 
limits  and  in  wdiich  the  excrement  shall  remain  for 
a  period  of  at  least  six  months,  after  which  it  is  to 
be  used  for  fertilizing  mulberry  trees.  This  system 
is  believed  to  be  peculiarly  adaptable  in  the  Philip- 
pines, because  it  will  introduce  silk  worm  culture 
and  instead  of  being  a  drain  upon  the  resources  of 
the  community  it  will  be  a  source  of  revenue  and  at 
the  same  time  the  cause  of  public  health  will  be  ma- 
terially furthered.  In  addition  to  the  foregoing,  a 
pamphlet  on  the  hook  worm  disease  is  in  course  of 
preparation  which  will  be  taught  in  every  public 
school  in  the  Philippine  Islands. 

In  the  city  of  Manila,  for  instance,  it  is  confident- 
Iv  hoped  that  the  hook  worm  campaign  which  is 
about  to  be  undertaken  will  lower  the  death  rate  by 
at  least  ten  a  thousand  per  annum,  which  would  re- 
sult in  a  saving  of  approximately  2,250  lives.  These 
figures  are  for  one  city  alone.    If  then  a  campaign 


February  73,  1909.] 


FOLKES:  NEURASTHENIA. 


331 


of  this  kind  should  become  general  in  countries 
where  the  hook  worm  exists,  it  will  be  apparent  that 
one  of  the  greatest  sanitary  victories  would  be 
achieved  which  the  world  has  ever  known. 

The  same  measures  which  would  perhaps  be  suc- 
cessful in  eliminating  the  hook  worm  in  the  Philip- 
pines would  probably  not  be  applicable  in  the  south- 
ern States,  and  it  is  therefore  respectfully  suggested 
that  the  practical  side  of  this  question  should  receive 
consideration  by  this  association  in  order  that  some 
organized  effort  may  be  made  to  commence  the  work 
which  promises  such  magnificent  results  and  bids 
fair  to  save  more  lives,  more  money,  and  promote 
greater  happiness  than  any  victory  which  has  yet 
been  achieved  over  disease. 

Conclusion. 

It  is  believed  that  the  foregoing  facts  warrant  the 
assertion  that  in  countries  in  which  the  hook  worm 
disease  is  prevalent  its  eradication  will  produce  bet- 
ter results  in  diminishing  the  general  mortality  than 
any  one  other  public  health  measure  which  has  yet 
been  advocated. 


NEURASTHENIA* 

By  H.  M.  Folkes,  M.  D., 
Biloxi,  Miss. 

Neurasthenia,  as  I  see  it,  is  a  symptom  complex, 
divisable  into  two  distinct  groups.  In  the  first, 
heredity  enters  so  largely  into  the  question,  as.  in 
many  instances,  to  constitute  the  condition  a  psycho- 
sis. In  the  second  group,  neurasthenia  is  a  true  neu- 
rosis. It  were  well  to  sharply  distinguish  these  two, 
and  to  do  so  early,  in  many  cases,  aids  materially  in 
the  treatment  and  improvement  of  the  condition. 

The  disease  occurs  in  greater  proportion  in  men 
than  in  women,  and  is  most  frequent  between  the 
ages  of  twenty  and  forty.  From  those  living  an  in- 
door or  sedentary  life,  comes  the  larger  percentage 
of  victims,  though  no  really  accurate  conclusion  can 
be  drawn  as  to  the  classes  of  occupation  responsible 
for  the  condition. 

Causes  of  the  disease  may  be  stated  as :  Worry ; 
mental  strain  or  shock  ;  undue  or  excessive  responsi- 
bility ;  monotony  of  life  or  labor;  introspection;  irri- 
tative reflexes,  as  eye  strain  or  enlarged  prostate ; 
intestinal  putrefaction  ;  excessive  venery  ;  excessive 
drinking  of  stimulants,  as  alcohol,  tea,  or  cofifee. 
Briefly  stated,  the  symptoms  are  referable  to  two 
classes,  viz.  mental  and  physical. 

In  the  mental  group,  probably  the  most  pro- 
nounced symptom  is  the  tendency  of  the  patient  to 
constantly  dwell  upon  his  condition.  He  usually  be- 
lieves that  he  is  the  only  person  who  has  ever  had 
the  exact  symptoms  he  presents.  No  opportunity  is 
lost  to  impress  upon  the  physician  the  gravity  of  his 
especial  case.  His  sense  of  proportion  is  usually 
markedly  impaired  and  he  does  not  dare  to  under- 
take things,  the  execution  of  which,  to  the  normal 
mind,  is  trivial,  as  it  assumes  alarming  character- 
istics from  his  viewpoint. 

Prominent  among  the  other  mental  symptoms  pre- 
sented are  fear  of  being  left  alone,  making  a  jour- 

*Read  before  the  Southern  Medical  Association  at  its  meeting, 
held  at  Atlanta,  November  9,  1908. 


ney,  or  even  walking  from  one  room  to  another. 
These  subjects  dwell  in  large  measure  upon  their 
inability  to  earn  a  living.  Nearly  all  of  them  have 
insomnia.  About  a  third  are  decidedly  emotional. 
Fully  a  third  have  periods  of  depression,  loss  of 
memory,  inability,  at  times  for  maintained  effort, 
loss  of  confidence,  and  irritability. 

The  physical  symptoms  are  endless,  appearing  as 
fatigue,  weakness,  tremor,  parassthesia,  headache, 
dizziness,  anorexia,  an,^mia,  dyspepsia,  constipation, 
flatulence,  pain  in  various  parts  of  the  body,  vague, 
ill  defined  feelings,  impairment  of  the  special  senses, 
cold  extremities,  cold  sweating',  and  impairment  of 
the  reflexes.  Young  women  who  have  been  over- 
worked at  college,  as  well  as  the  house  wife,  fre- 
quently display  many  of  the  pelvic  symptoms  com- 
mon to  their  sex.    Relapses  are  the  rule. 

The  diagnosis  is  not  always  easy,  many  cases 
formerly  classed  as  neurasthenia  being  distinctly 
amenable  to  surgical  relief.  And  a  most  careful  ex- 
amination is  at  ail  times  important  in  order  that  this  ■ 
special  class  be  given  an  opportunity  for  immediate 
relief.  On  the  other  hand  there  are  many,  probably 
fifty  per  cent,  of  the  cases,  in  which  any  form  of 
surgery  would  be  positively  harmful. 

Hysteria,  melancholia,  psychasthenia,  incipient 
paresis,  and  brain  tumor  must  be  borne  fully  in  mind 
in  making  a  distinctive  diagnosis.  After  quite  a 
number  of  years  in  institution  work,  I  want  to  s-iy 
that  each  and  every  one  of  these  foregoing  condi- 
tions have  been-  diagnosticated  as  neurasthenia  and 
sent  to  us  as  such. 

Treatment  is  to  be  largely  psychic,  and  perma- 
nent results  are,  in  many  instances,  to  be  obtained 
only  in  this  way.  While  there  are  many  physicians, 
supposedly  called  to  treat  this  class  of  patients,  there 
are  really  few  chosen,  for  it  is  one  thing  to  talk 
about  this  treatment  and  quite  another  to  administer 
it.  The  first  desideratum  is  to  get  the  patient  away 
from  home,  friends,  and  every  day  associates,  for 
many  of  these  case?  are  simply  affected  by  the  un- 
varying monotonv  which  accompanies  many  lives, 
and  a  sojourn  in  new  surroundings  brings  prompt 
relief  ofttimes. 

Certain  classes  of  these  patients  do  best  in  an  in- 
stitution under  either  strict'  or  modified  Weir 
Mitchell  treatment,  while  others  are  most  benefited 
by  moderate  exercise  in  the  open  air.  All  are  ben- 
efited by  change  of  thought,  and  the  physician  who 
is  most  potent  in  making  the  neurasthenic  forget 
that  he  is  living,  is  the  one  who  achieves  the  quick- 
est and  most  certain  cures. 

It  must  never  be  forgotten  that  a  large  percentage 
of  these  unfortunates  have  all  kinds  of  intestinal  de-  . 
rangements  and  that  treatment  must  be  directed  to 
these  as  well  as  to  other  bodily  ailments,  either  real 
or  imaginary.  Though  the  physician  who  allows 
himself  to  give  more  than  passing  attention  to  one 
of  these  dwelt  upon  ills,  gives  the  patient  an  always 
desired  opportunity  to  pour  out  the  usual  unceasing- 
tale  of  woe.  The  moment  that  this  happens,  pro- 
vided you  are  so  thoughtless  as  to  give  any  promi- 
nence whatever  to  the  ill  in  question,  }'ou  have  lost 
a  certain  amount  of  influence  and  control  over  your 
patient. 

As  concerns  physical  treatment,  properly  selected 
baths,  electrical  treatments,  and  massage,  together 


332 


BRADLEY:  COXGEXITAL  STENOSIS  OF  THE  PYLORUS. 


[New  York 
Medical  Journal. 


with  thorough  elimination  tlirough  the  skin,  kidneys, 
and  lungs  is  the  course  advised.  General  thorough 
elimination  is  best  produced  by  the  drinking  of  an 
abundance  of  pure  water,  the  inhalation  of  fresh  air 
day  and  night,  together  with  the  use  of  such  drugs 
as  calomel,  castor  oil,  or  cascara  sagrada,  and  the 
judicial  use  of  high  rectal  irrigations.  A  cure  is 
usually  brought  about  in  from  three  to  twelve 
months. 

In  my  own  institution,  we  make  it  a  cardinal  rule 
not  to  use  drugs,  meaning  any  kind,  unless  absolute- 
ly necessary.  There  are  cases,  however,  in  which, 
to  initiate  a  change  for  the  better,  some  medication 
is  imperative. 

Never  for  a  moment  lose  grip  upon  the  patient's 
mentality,  for  here  lies  the  key  to  success. 


REPORT  OF  A  CASE  OF  CONGENITAL  HYPER- 
TROPHIC STENOSIS  OF  THE  PYLORUS.* 

Bv  William  N.  Bradley,  M.  D., 
Philadelphia, 

Assistant  Physician  to  the  Out  Patient  Department  of  the  Children's 
Hospital  of  Philadelphia. 

In  presenting  this  case  no  attempt  will  be  made  to 
enter  into  a  consideration  or  discussion  of  the  sub- 
ject as  presented  by  different  writers.  This  would 
be  unnecessar}'  in  view  of  the  large  number  of  re- 
cent papers  by  eminent  observers,  among  whom  I 
inay  mention :  Scudder  and  Ouimbey,  Pfaundler, 
Cautley,  Ashby,  Koplik,  and  Thompson.  I  would, 
however,  like  to  bring  out  the  main  symptoms  upon 
which  all  agree  as  diagnostic  of  the  condition,  and 
to  emphasize  some  others  by  mentioning  the  points 
upon  which  they  differ. 

It  is  conceded  by  pathologist  and  surgeon  that  a 
condition  of  hypertrophy  of  the  pylorus  in  infants 
does  occur  and  must  be  taken  into  consideration  in 
diagnosticating  abdominal  disorders  in  them. 

The  symptoms  depend  largely  upon  the  degree  of 
stenosis. 

\''omiting  ma}'  begin  with  birth  or  it  may  be  de- 
layed from  a  few  days  to  a  few  weeks. 

Voelcker  (i)  has  collected  thirty-seven  cases  in 
which  the  vomiting  began  as  follows :  From  birth, 
four  cases ;  during  the  first  four  weeks,  twenty-eight 
cases ;  and  between  the  fourth  and  eighth  weeks,  five 
cases ;  showing  the  great  preponderance  of  cases  be- 
ginning during  the  first  four  weeks  of  life. 

Vomiting  occurs  at  variable  times  after  feeding. 
The  intervals  are  long  at  first,  gradually  lessening 
until  it  occurs  from  a  few  minutes  to  several  hours 
after  taking  food.  The  vomiting  is  projectile,  re- 
tentive, and  is  uninfluenced  by  the  quantity  of  food 
taken.  The  quantity  is  often  surprising,  showing 
that  all  of  the  food  taken  in  two  or  three  feedings 
has  been  retained  iti  the  stomach.  Ilile  is  usually 
not  present,  tliere  being  but  one  case  reported  where 
a  condition  of  hypertrophy  was  found  at  autopsy 
(2).  Nausea  is  generally  absent.  Remissions  in 
the  vomiting  may  occur.  The  vomited  matter  may 
contain,  food,  lactic  or  hydrochloric  acids,  mucus, 
sometimes  it  may  be  like  beef  tea  or  coffee  grounds 
from  hsematemesis  of  late  stages. 

*Read  before  the  Philadelphia  Psediatric  Society,  October  13,  1908. 


The  bowel  movements  are  usually  infrequent, 
there  being  sometimes  not  any  for  days,  although 
some  cases  have  been  reported  with  diarrhoea.  The 
movements  are  slight  in  amount,  occasionally  con- 
tain some  faecal  matter,  are  sometimes  meconium- 
like,  and  sometimes  green  or  brown. 

The  urine  is  scanty,  infrequent,  and  high  col- 
ored. 

The  temperature  is  usually  normal  or  subnormal. 

The  weight  curve  is  progressively  downward,  and 
all  symptoms  of  emaciation  begin  to  manifest  them- 
selves. 

The  child  usually  is  eager  for  its  food,  takes  but 
little,  and  then  refuses  it.  The  epigastrium  is  full 
and  the  lower  abdomen  flattened.  On  inspection  a 
wave  of  peristalsis  may  be  seen  to  commence  in  the 
left  hypochondrium  and  pass  across  the  epigastrium 
culminating  in  the  pyloric  tumor,  which  may  be  felt 
to  become  denser  on  contraction.  In  Scudder's  re- 
port of  115  cases,  thirty-eight  patients  showed  peri- 
stalsis. AH  writers  agree  that  peristalsis  is  some- 
times absent. 

A  tumor  can  sometimes  be  felt  in  the  region  of 
the  pylorus.  Koplik  (3),  however,  states  that  some 
of  the  most  violent  cases  of  vomiting,  with  spasm 
or  congenital  stenosis  of  the  pylorus,  have  passed 
through  his  hands,  without  the  detection  of  the 
pylorus.  Cautley  (4)  states  that  the  tumor  is  sit- 
uated one  half  inch  to  the  right,  and  three  quarters 
of  an  inch  above  the  umbilicus,  midway  between  the 
umbilicus  and  costal  margin.  When  felt  the  tumor 
is  deep  seated  and  movable,  about  the  size  of  a  hazel 
nut  or  olive. 

Dilatation  occurs  probably  as  a  secondary  change, 
the  exact  nature  of  which  has  not  been  determined. 

Overacidity  of  the  stomach  contents  is  usually 
present  due  perhaj^s  to  defective  digestion. 

In  hypertrophic  stenosis  the  pylorus  is  found  to 
consist  of  a  hard,  elongated,  cylindrical  tumor, 
measuring  about  one  inch  in  length,  three  fourths  of 
an  inch  in  thickness,  and  one  half  to  two  inches  in 
circumference.  The  tumor  is  hard  and  fibrous, 
white  and  glistening  in  appearance.  It  is  more  fun- 
nel shaped  on  the  gastric  side.  The  lumen  is  some- 
times so  narrowed  as  to  permit  the  passage  only  of 
a  small  probe.  There  is  hypertrophy  of  the  walls 
of  the  stomach,  dilatation  of  the  stomach  and  gas- 
tric catarrh.  The  intestines  are  collapsed.  Section 
shows  that  the  enlargement  is  due  to  a  great  increase 
in  the  circular  muscle  fibres.  Scudder  asserts  that 
all  tissues  at  the  pylorus  are  hypertrophied  from  two 
to  three  times  the  normal  thickness. 

The  presence  of  pyloric  stenosis  in  the  foetus  is 
disputed  (5). 

Three  theories  as  to  jetiology  receive  recogni- 
tion (6). 

Nicoll's.  A  congenital  anomaly,  a  simple  over- 
growth of  the  sphincter  muscle  of  the  pylorus. 

Thompson's.  An  incoordinated  action  of  the  stom- 
ach muscles  dependent  on  functional  disorders  of 
the  gastric  nervous  system  resulting  in  gastric 
spasm,  superinducing  hypertrophy. 

Theory  of  simple  spasm.  From  some  underlying 
cause.  Some  writers  consider  these  cases  postoper- 
ative or  post  mortem. 

It  is  considered  by  some  that  the  hypertrophy  is 


February  i»,  1909.] 


BRADLEY:  COXGEXITAL  STENOSIS  Of  THE  PYLORUS. 


333 


probably  tbe  result  of  some  irritation  in  the  stomach 
causing  continued  irritation.  Koplik  {loc.  cif.),  in  a 
recent  monograph,  gives  an  exhaustive  study  of  a 
large  number  of  cases,  in  which  he  recognizes  two 
types:  i.  Simple  spasm.  2.  A  distinct  pathological 
condition  of  the  structure  of  the  pylorus  with  a 
spasm  of  the  pylorus  added. 

At  this  time  nothing-  is  known  positivelv  as  to  the 
exact  cause  of  the  condition  under  consideration,  as 
it  can  hardly  be  accounted  for  by  disturbance  of  di- 
gestion, disease  of  the  mucous  membrane,  or  pro- 
duced by  abnormal  chemical  processes.  Some  ob- 
servers have  suggested  a  family  predisposition  (7). 

The  condition  predominates  very  largely  in  male 
children. 

Breast  fed  babies  are  aftected  equally  with  those 
fed  by  hand. 

The  principal  condition  likely  to  be  mistaken  for 
pyloric  stenosis  is  simple  spasm.  Here  all  symp- 
toms w-ould  disappear  at  times,  constipation  alter- 
nate with  diarrhoea ;  dyspepsia  is  usually  present, 
vomiting  is  less  significant,  and  the  disturbance  of 
nutrition  less  progressive.  The  other  conditions  with 
which  it  may  be  confounded  need  only  be  mentioned, 
viz. :  Atresia  of  the  pvlorus,  narrowing  of  the  duo- 
denum, toxic  vomiting,  and  congenital  narrowing  of 
the  oesophagus.  The  diagnosis  rests  upon  a  careful 
study  of  the  history,  particularly  the  age  of  the  pa- 
tient at  the  time  of  onset ;  the  time  ancl  character  of 
the  onset,  and  the  symptoms  previously  mentioned. 
Cautley  considers  it  impossible  to  diagnosticate  the 
condition  without  the  presence  of  a  tumor.  Dr.  Car- 
penter, of  London  (8),  has  also  given  expression  to 
this  view. 

Pfaundler,  quoting  Hiibner,  says:  The  majority 
of  the  cases  offer,  in  spite  of  the  seriousness  of  the 
sickness,  a  good  prognosis,  even  under  expectant 
treatment.  The  longer  the  period  between  birth  and 
the  first  appearance  of  the  disease,  the  better  the 
prognosis.  Cautley,  on  the  other  hand,  states  that 
he  has  never  known  a  patient  in  whom  the  disease 
was  positively  present  to  get  well  without  operation. 

In  treating  the  condition,  breast  milk  should  be 
used  if  possible ;  the  greatest  possible  skill  and  care 
in  the  management  of  the  feeding,  if  other  than 
breast  feeding  is  resorted  to.  Systematic  stomach 
washing.  The  principal  medicinal  remedy  mentioned 
is  opium  given  in  gradually  increasing  doses.  Last- 
ly surgical  intervention. 

Case.— H.  R.  was  brought  to  the  Out  Patient  Depart- 
ment of  the  Children's  Hospital  on  September  4.  1908,  with 
the  following  history:  Born,  August  g,  1908.  Male,  white, 
United  States  nativity.  First  child,  born  at  full  time,  labor 
was  instrumental.  Weight  at  birth  given  as  eight  pounds. 
Severe  jaundice  developed  after  birth  but  disappeared. 

Father  and  m.other  well  and  apparently  healthy. 

The  baby  presented  all  appearance  of  being  healthy  at 
birth.  Breast  feeding  was  carried  out  for  the  first  three 
weeks  of  life,  during  which  time  it  gained  one  half  pound. 
On  the  seventeenth  day  of  life,  the  child  began  to  vomit: 
the  vomiting  at  first  occasional  became  more  frequent,  and 
when  I  first  saw  the  child  it  was  occurring  after  each  feed- 
ing or  every  second  feeding,  at  which  time  it  would  vomit 
as  mucli  as  had  been  taken  in  the  two  feedings.  When 
vomiting  first  began  it  would  occur  about  one  hour  after 
taking  food ;  this  time  however,  continued  to  grow  less 
until  food  w'as  ejected  almost  as  soon  as  taken.  On  the 
twenty-second  day  of  life  the  breast  feeding  was  stopped^ 
because  it  was  thought  it  did  not  agree  with  the  child.  It 
was  then  tried  within  a  few  days,  successively,  on  con- 


densed milk,  whey,  peptogenic  milk  powder,  and  an  infant 
food,  the  latter  two  made  up  with  equal  parts,  cow's  milk 
and  water.  .About  the  same  lime  that  the  child  began  to 
vomit,  the  bowels,  normal  at  first,  became  obstinately 
constipated. 

Examination.  The  child  was  small,  bright,  well  formed. 
Tongue  was  clean  and  breath  sweet.  A  fullness  was  noted 
in  the  region  of  the  epigastrium  and  a  flatness  of  the  lower 
abdomen.  There  was  no  palpable  tumor  m  the  region  of 
the  p\lorus,  and  no  visible  peristalsis.  Weight  six  pounds 
twelve  ounces.  The  mother  ^tated  that  the  child  had  lost 
weight  since  vomiting  began. 

A  diagnosis  of  probable  pyloric  stenosis  was  made  and 
the  following  treatment  adopted : 

Calomel  in  divided  doses,  to  be  followed  by  magnesium 
oxide :  barley  water,  every  two  hours ;  and  a  prepared  in- 
fant food,  every  four  hours.  The  ne.xt  day  the  vomiting 
still  persisted.  Xo  bowel  movement  for  the  past  fort>- 
eight  hours.  Albumin  water  was  now  substituted  for  bar- 
ley water. 

Until  September  loth,  while  under  observation  at  the  dis- 
pensary, the  vomiting  remained  persistent,  the  stools  were 
infrequent,  usually  of  a  meconiumlike  nature.  Various 
plans  of  feeding  were  tried  but  without  benefit.  On  Sep- 
tember loth,  Dr.  Edward  B.  Hodge  was  asked  to  see  the 
child  with  view  to  operation.  At  that  time  the  following 
notes  were  made :  Been  fed  regularly  for  the  past  twenty- 
four  hours,  had  vomited  twice  dark  mucus.  The  vomit  was 
not  now  ejected  forcibly  as  at  first,  and  was  apparently 
without  nausea.  Had  had  one  bowel  movement  by  enema, 
this  contained. a  little  ixcz\  matter  and  had  some  odor. 
The  infant  took  only  about  two  teaspoonfuls  at  a  feeding. 
The  vomit  contained  mucus  and  v\as  not  bile  stained.  The 
urine  throughout  had  been  scanty,  only  passing  about  twice 
a  day.  and  leaving  a  deep  stain  on  the  napkin.  Weight  six 
pounds  four  ounces.  The  pylorus  was  not  palpable,  and  no 
peristaltic  waves  were  visible. 

The  child  was  admitted  to  the  hospital  on  the  afternoon 
of  September  loth.  under  the  care  of  Dr.  Charles  Weber 
and  Dr.  Edward  B.  Hodge,  to  whom  I  am  indebted  for  the 
following  notes : 

The  temperature  was  practically  normal.  Tlie  pulse 
varied  from  92  to  140.  Respirations  ranged  from  20  to  32. 
The  child  on  admission  was  given  whey.  4  drachms,  every 
hour  during  the  day  and  four  hours  at  night.  Lavage  twice 
a  day.  Rectal  irrigation.  Nutritive  enema  of  two  ounces  of 
a  mi.xture  containing  one  fourth  peptonized  milk,  every 
three  hours  during  the  day,  and  four  hours  at  night.  Other 
medicinal  remedies  \\ere  given  as  indicated.  Two  da>s 
later  two  drachms  of  peptonized  milk  was  added  to  the 
whey  feeding. 

The  child  lost  progressively  in  weight,  until  September 
i6th,  the  day  before  operation,  it  weighed  five  pounds  ten 
ounces,  a  loss  of  eighteen  oinices  in  twelve  days. 

On  admission  vomiting  occurred  usually  about  twenty 
minutes  after  taking  food  or  medicine,  but  there  were  re- 
missions lasting  two  to  four  hours,  sometimes  longer.  The 
quantity  vomited  varied  from  one  drachm  to  two  ounces. 
Vomiting  or  regurgitation  was  sure  to  occur  after  almost 
every  ingestion  of  food  or  medicine,  the  vomit  containing 
mucus  and  later  becoming  sour.  The  bowel  movements 
after  admission  to  the  hospital  varied  usually  from  one 
to  two  a  day:  were  small,  dark  brown,  soft  or  loose  move- 
ments :  one  day  no  movement,  and  one  day  four,  all  of 
these  being  small,  dark  brown,  and  loose,  some  containing^ 
mucus.  Some  of  the  stools  recorded  followed  the  giving^ 
of  an  enema  or  irrigation.  In  two  stools  a  small  quantity 
of  faecal  matter  was  present. 

^  On  September  17th  the  infant  was  operated  upon  by  Dr. 
Edward  B.  Hodge,  who  described  as  follows  the  condition 
present :  The  pylorus  was  greatly  thickened,  hard  gristly, 
and  very  friable,  the  thickening  being  two  to  three  centi- 
metres long,  one  to  two  centimeters  thick,  extending  more 
on  the  stomach  than  the  duodenal  side ;  on  the  latter  it 
ended  abruptly,  on  the  former  gradually :  the  thickne';«  of 
each  wall  of  the  pylorus  being  slightly  more  than  one  half 
centimetre.  The  mucous  membrane  was  in  folds,  perhaps 
slightly  hypertrophied.  though  this  was  doubtful,  possibly 
enough  to  partially  prevent  the  passage  of  liquids,  though 
this  was  more  likely  due  to  spasms.  The  stomach  was 
much  dilated,  capacity  estimated  at  eight  to  ten  ounces ; 
walls  not  markedly  hypertrophied:  the  "small  intestine  was 
moderately  collapsed.   Very  little  anresthetic  was  used  dur- 


334 


THOMPSOX:  CASE  OF  BIRTH  MARK.— OUR  READERS'  DISCUSSIONS.         [New  York 

Medical  Journal. 


ing  the  operation.    The  infant  stood  the  operation  well,  but 
grciv  progressively  worse  and  died  twenty-four  hours  later. 
Xo  specimen  was  obtained  after  death. 

References. 

1.  Voelcker.    Lancet,  1907. 

2.  Scudder  and  Quimbey.  Journal  of  the  American 
RIcdical  Association,  May,  1905. 

3.  Koplik.  American  Journal  of  the  Medical  Sciences, 
July,  1908. 

4.  Cautley.    British  Medical  Journal,  1906,  ii. 

5.  Gilbride.    Nczc  York  Medical  Journal.  ]\Iay  25,  1907. 

6.  Scudder.  Boston  Medical  and  Surgical  Journal, 
August  6,  1908. 

7.  Pfaundier  and  Schlossman.    Diseases  of  Children. 

8.  Carpenter.   Lancet,  igo8,  i. 

1532  South  Sixth  Street. 


REPORT  OF  A  CASE  OF  SO  CALLED  B'IRTIi 
MARK. 

Bv  Francis  A.  Thompson,  M.  D., 
Milwaukee. 

The  question  as  to  whether  a  mother  had 
"marked"  her  child  during  the  childbearing  period, 
is  of  such  common  behef  and  so  generally  discred- 
ited by  the  medical  profession,  that  the  report  of  a 
presumable  birthmark  may  be  of  interest.  I  have 
never  heard  of  any  but  vmsubstantiated  cases,  with 
assertions  made  by  zealous  friends  and  mothers.  It 
is  a  common  statement  that  the  mother  has  "marked" 
her  child  as  to  some  special  food,  as  pickles,  ba- 
nana, fruit  of  some  special  kind,  and  foods  of  va- 
rious kinds  and  varieties,  and  an  inclination  in  the 
child  in  later  life  to  such  food  was  laid  to  the  desire 
of  the  mother  for  such  food  during  the  period  of 
gestation.  The  tendency  to  the  overindulgence  in 
alcohol  has  often  been  stated  as  a  "mark"  froin  the 
mother  who  had  used  alcohol  during  this  period. 
The  birth  of  some  monster,  said  to  have  a  horse  or 
snake  head,  is  usually  attributed  to  the  mother  being- 
frightened  by,  or  seeing  these  particular  animals 
during  some  period  of  fright  or  nervousness.  This 
is,  of  course,  given  as  the  sole  cause  of  the  peculiar 
anomaly  of  nature  or  birth. 

It  is  a  pleasure  to  report  a  case  in  which  the  facts, 
as  they  arose,  seemed  almost  to  point  to  the  truth  of 
these  beliefs : 

Case. — Mrs.  N.  L.,  about  thirty  years  old,  was  a  woman 
of  unusual  mental  attainments.  She  had  liad  the  advan- 
tage of  an  excellent  education  both  here  and  abroad,  so 
perfecting  herself  as  to  ultimately  be  a  teacher  of  German. 
She  was  not  of  a  neurotic  type  and  iii  this  matter  gave  no 
thoughts  of  the  possible  effect  on  the  child,  until  the  facts 
were  enumerated  to  her.  She  was  in  good  health  and  had 
a  normal  peh  is.  During  tlie  third  month  of  her  gestation, 
September  27,  1907,  she  v.  as  hanging  a  picture  on  the  wall 
(being  on  a  stepladder)  and  was  accidentally  precipitated 
to  the  floor,  on  the  way  striking  her  forehead  on  the  edge 
of  a  chair.  There  was  a  mark  on  the  forehead,  red  swollen 
between  the  eyebrows  and  up  on  the  forehead  about  two 
inches.  It  extended  over  the  orbit  on  the  left  side  so  that 
tlie  upper  eyelid  was  swollen  and  later  black. 

.At  term,  I\L'irch  10,  190S,  Mrs.  N.  L.  was  delivered  of  a 
healthy  male  child  of  normal  build  and  si/;e.  The  period 
of  labor  v.ns  normal,  not  protracted,  no  instruments  being 
used.  M  birth  there  was  a  very  small  and  faint  red  mark 
on  the  baby's  forehead,  hwX  as  the  mother's  fall  had  been 
forgotten,  it  was  thought  to  be  a  parturient  accident  and 
the  parents  were  told  that  it  would  disappear.  A  few  days 
later  the  mark  was  if  anything  plainer. 

T  saw  the  injury  to  the  mother  hut  a  short  time 
after  it  happened,  and  called  at  the  house  a  few 


hours  after  the  baby  was  born,  so  I  can  verify 
the  fact  that  the  mark  was  there.  The  mark  is  still 
present  on  the  child.  It  is  a  finely  lined  collection  of 
dilated  capillaries  and  occupies  the  exact  position  of 
the  mark  that  the  mother  had.  Another  peculiar  fact 
was  brought  out  in  talking  the  matter  over  with  the 
iTiother  recently.  She  states  that  she  noticed  at  the 
time  of  the  fall  a  sore  spot  on  the  occipital  region. 
She  paid  no  attention  to  it,  as  she  reasoned  that  she 
had  bumped  herself  in  her  fall.  The  child  now  has 
on  its  occipital  region  a  mark  similar  to  the  one  on 
the  forehead.  This  was  discovered  a  few  days  later 
than  the  one  previously  described. 

Of  course,  the  cause  may  be  of  doubt,  and  as  sci- 
entific datum  it  may  be  discounted,  but  the  case  is 
offered  simply  on  the  merits  that  the  facts  are  per- 
sonally verified. 

418  Camp  Building. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions   for   discussion    in    tin's   department   are  an 
nounced  at  frequent   intcrz'als.    So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXII. — How  do  you  treat  chronic  lead'  poisoning F 
(Closed  January  75,  iQog.) 

LXXXIII. — Hozu  do  you  treat  acute  dysentery f  (An- 
swers due  not  later  than  February  15,  iQog.) 

LXXXIJ^. — Hozv  do  you  use  alcohol  therapeutically? 
(Answers  due  not  later  than  March  15,  1909.) 

Whoever  anszvers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  zvill  re- 
ceive a  pri.'^e  of  $.25.  No  importance  zvhatever  zvill  be  ai- 
tached  to  literary  style,  but  the  azvard  zcill  be  based  solely 
on  the  value  of  the  substance  of  the  ansiver.  It  is  requested 
(but  not  required)  that  the  anszvers  be  short;  if  practica- 
ble no  one  answer  to  contain  more  than  six  hundred 
zvords. 

All  persons  zcill  be  entitled  to  compete  for  the  prize, 
zvhether  subscribers  or  not.  This  prise  zvill  not  be  awarded 
to  any  one  person  more  than  once  zuithin  one  year.  Every 
anszver  must  be  accompanied  by  the  zvriter's  full  name  and 
address,  both  of  zvhich  zve  must  be  at,  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journ.\l. 
Our  readers  are  asked  to  suggest  topics  for  discussion. 

The  pri::e  of  $.2^^  for  the  best  essay  submitted  in  anszvcr 
to  question  LXXXI  has  been  azvarded  to  Dr.  R.  T.  Sutton, 
of  Kansas  City,  Mo.,  zvhose  article  appeared  on  page  22^. 

PRIZE  QUESTION  LXXXI. 
THE  TREATMENT  OF  CHRONIC  ECZEMA. 
(Concluded  from  page  285.) 
Dr.  Samuel  M oskozvitr:.,  of  Nczv  York,  observes: 

The  causes  of  chronic  eczema  are  those  which 
tend  to  prolong  an  acute  eczema,  such  as  the  use  of 
water;  mechanical  irritation,  as  clothing,  etc.;  per- 
spiration ;  and  constitutional  conditions,  as  anjemia ; 
crirdiac  disease;  gastric  or  intestinal  disorders;  and 
also  the  use  of  dyes  in  certain  occupations. 

When  it  occurs  in  the  scalp,  it  may  be  due  to  the 
indiscriminate  use  of  a  fine  comb,  pediculi.  or  wash- 
ing the  scalp  too  frequently  with  wnter.  It  may  be 
due  to  promiscuous  use  of  ointments  containing  ran- 
cid lard,  etc. 

Having  as  a  basis  an  idea  of  the  exciting  causes 
of  chronic  eczema.  I  must  .state  before  proceeding 
that  when  one  is  treating  eczema  of  a  chronic  nature 


rebruary  ij,  1909.] 


OUR  READERS'  DISCUSSIONS. 


335 


lie  must  not  sav  such  and  such  a  treatment  will  do 
for  all  regions  of  the  body.  As.  for  example,  a  pre- 
scription given  for  the  palm  of  the  hand  would  not 
be  given  for  chronic  eczema  of  the  eyelids  or  of  the 
nares. 

The  principle  which  I  follow  is  to  treat  the  chronic 
eczema  for  a  week  or  two  with  sedative  or  soothing 
applications  to  see  if  it  is  really  a  chronic  eczema, 
as  I  have  in  mind  two  patients  who  got  well  by  this 
method. 

The  following  prescription  I  give  to  accomplish 


this: 

B    Pulv.  calamini,   gr.  xx  ; 

Zinci  oxidi,   5s5  ; 

Ung.  aquje  rosae,   ad  31. 

M.  S.    Apply  daily. 


The  parts  should  be  washed  ot¥  previously  with 
an  oil,  as  sweet  oil  or  olive  oil. 

If  nothing  is  accomplished  after  a  week  or  so. 
which  I  admit  is  usually  the  case,  I  begin  to  treat  it 
on  the  following  principle :  Stimulate  the  circula- 
tion to  the  part,  and  this  is  best  done  by  the  oil  of 
cade,  as  follows : 

B    Olei  cadini   .5ss; 

Ichthyol  gr.  xx  ; 

Pulv.  calamini  5ss; 

Ung.  aqus  rosae  ad  5i. 

M.  Sig.   Apply  daily. 

In  not  every  case,  though,  does  this  act  always  as 
desired,  so  I  either  increase  the  oil  of  cade  or  com- 
bine with  two  per  cent,  of  resorcin. 

A\'hen  we  have  a  reaction  and  find  it  to  be  an  acute 
eczema  I  then  treat  it  as  such  by  applving  sedative 
such  as  zinc  oxide  and  calamus  powder,  four  per 
cent,  each,  in  ointment  form. 

If  our  eczema  occurs  in  regions  where  there  is 
irritation  or  perspiration,  such  as  eczema  about  the 
anus,  between  the  fingers,  in  the  axilla,  eczema  in- 
tertrigo, etc..  an  excellent  treatment  is  for  the  physi- 
cian to  apply  every  second  day  a  two  to  four  per 
cent,  solution  of  silver  nitrate,  and  prescribe  a  dust- 
ing powder,  as  I  have  found  ointments  do  more 


harm  in  these  cases  : 

B    Pulv.  calamini,   3ss; 

Pulv.  zinci  oxidi,   3ss ; 

Pulv.  zinci  stearat.  comp.,   ad.  5i. 


M.  S.    Use  as  a  dusting  powder. 
This  is  excellent ;  it  relieves  the  weeping  and  scal- 
ing, and  the  pain. 

Most  important  in  the  last  mentioned  cases  of 
eczema  is  to  stop  the  causes — occupation  and  consti- 
tutional. Local,  I.  washing,  fur  dyeing,  painting, 
etc.,  on  hands :  horseback  riding  and  irritations  of 
all  kinds  to  the  rectal  region.  2,  Constitutional,  in- 
testinal disorder  should  be  regulated  by  saline  laxa- 
tives ;  alcohol  of  all  kinds  should  be  prohibited,  and 
smoking,  if  excessive,  should  also  be  stopped. 

The  cases  of  chronic  eczema  occurring  in  hairy 
parts  are  very  stubborn  to  treatment,  but  the  symp- 
tom here  is  mostly  scaling,  and  if  the  parts  are  un- 
clean I  advise  the  scalp  to  be  soaked  in  oil  over  night 
and  then  to  use  the  following: 

B    Oil  of  cade  TTLx — xxx; 

Olive  oil.   ad  j'- 

M.  S.    Apply  with  friction  to  the  scalp. 

Ointments  here,  again,  are  not  well  adapted  for 
this  purpose. 

In  some  cases  of  chronic  eczema,  especially  of  the 
genitals,  we  must  examine  the  urine  for  sugar,  as 


there  is  the  direct  cause  and  must  be  treated  accord- 
ingly. 

The  parts  must  be  painted  by  a  four  per  cent,  so- 
lution of  silver  nitrate.  Apply  the  dusting  powder 
mentioned  before  and  protect  the  part,  in  a  man  by 
a  suspensory  and  gauze  or  cotton,  and  in  a  woman 
by  a  bandage. 

The  best  treatment  for  eczema  labiorum  or 
chapped  lips  is  to  apply  nightly  camphor  ice.  In 
treating  chronic  eczema  of  the  hand  I  forgot  to  men- 
tion that  if  the  patient  is  not  able  to  stop  the  occu- 
pation rubber  gloves  may  be  worn. 

For  eczema  of  lids  and  of  nails  I  prescribe : 

B    Acidi  salicylici  gr.  vii; 

Hj'drargyii  oxid.  flav  g.  ii; 

Ung.  petrolati  ad  5'- 

Mft.  Ung.  Sig.  Apply  to  part  after  washing  of  crusts 
with  olive  oil. 

Last  of  all,  in  eczema  of  the  legs,  where  we  have 
a  retarded  circulation,  varicose  veins.  I  advise  the 
patient  to  elevate  the  legs,  if  practicable  to  the  pa- 
tient, or  wear  a  bandage  well  applied.  Locally  I 
use  applications  of  silver  nitrate  and  dusting  pow- 
der ;  if  stubborn  to  treatment  I  use  the  oil  of  cade. 

Dr.  H.  J/.  Hays,  of  New  York,  states: 

In  chronic  eczema,  as  in  all  chronic  skin  diseases, 
the  skin  eruption  is  merely  a  part  of  the  general 
body  condition.  Therefore  the  first  essential  in 
treatment  is  the  employtnent  of  remedies  which  will 
build  up  the  body  constitution — that  is,  correct 
errors  in  diet,  flush  out  the  kidneys,  relieve  an  ex- 
isting anaemia,  regulate  the  bowels,  and  correct  any 
habits  (such  as  alcoholism  or  excessive  smoking), 
which  have  a  tendency  to  lower  vitality.  A  moder- 
ate amount  of  outdoor  exercise  should  be  advised,  as 
it  is  a  prerequisite  to  a  healthy  constitution. 

The  general  management  of  chronic  eczema,  as 
exemplified  above,  will  more  than  half  cure  the  con- 
dition, provided  the  patient  is  willing  to  undergo  a 
more  or  less  extensive  treatment.  Chronic  eczema, 
as  a  rule,  takes  months  or  years  to  develop ;  there- 
fore we  cannot  expect  to  cure  the  disease  vmless  the 
patient  is  w'illing  to  give  a  certain  course  of  treat- 
ment a  trial  of  several  weeks  or  months. 

The  diet  of  patients  with  chronic  eczema  should 
be  simple,  wholesome,  and  nutritious.  Breakfast 
and  lunch  (or  supper)  should  be  very  light,  the  din- 
ner being  the  major  meal.  Meat  should  be  eaten 
once  a  day  only,  and  then  sparingly.  Sweets  and 
condiments  are  absolutely  interdicted.  It  is  a  safe 
rule  for  such  patients  to  go  aw^ay  hungry  rather 
than  satiated.  These  patients  soon  accustom  them- 
selves to  a  moderate,  wholesome  diet.  The  urine 
shou.ld  be  examined,  and  if  there  is  evidence  of  dis- 
ease, such  as  diabetes  or  nephritis,  this  should  be 
corrected.  The  kidneys  should  be  flushed  out  by 
drinking  six  to  eight  glasses  of  plain  w-ater  every 
day.  Patients  will  often  maintain  that  they  cannot 
drink  so  much  water.  It  is  best,  then,  to  tell  them 
how^  to  drink  it,  one  glass  before  and  after  break- 
fast, one  in  the  forenoon,  one  after  luncheon,  one 
in  the  afternoon,  one  after  dinner,  and  one  before 
going  to  bed.  Sometimes  the  water  is  more  palata- 
ble if  taken  with  a  slice  of  lemon  or  a  five  grain 
lithia  tablet.  For  the  anaemia,  any  simple  iron  prep- 
aration with  arsenic  answers  the  purpose.  For  the 
regulation  of  the  bowels,  nothing  is  more  suitable 


336 


OUR  READERS'  DISCUSSIONS. 


(New  York 
Medical  Jouknal. 


than  the  tablet  triturate  of  aloin,  lielladonna,  strych- 
nine, and  cascara. 

Naturally,  the  local  treatment  of  chronic  eczema 
depends  upon  whether  we  have  to  deal  with  the 
ulcerative  or  dry  form.  ]\Iany  remedies  may  have 
to  be  employed  until  the  right  one  is  reached.  One 
essential  is  to  relieve  the  irritation  as  much  as  pos- 
sible. Assuming  that  we  have  an  ulcerative  pro- 
cess, it  is  best  to  relieve  the  itching  and  inflamma- 
tion by  applying  a  dry  powder  of  one  half  per  cent, 
of  carbolic  acid  in  plam  talcum  powder  dusted  on 
twice  a  day,  and  covered  with  a  piece  of  sterile 
gauze.  Bathing  is  prohibited,  and  the  powder  is 
left  on,  to  be  covered  by  more  powder  the  following 
day.  A  protective  cast  is  thus  formed,  similar  to 
the  gelatin  cast  used  in  various  German  clinics. 
After  a  week  or  so  the  thick  layer  is  picked  of¥  and 
the  process  repeated  as  often  as  necessary.  The  dis- 
ease, as  a  rule,  goes  on  to  the  stage  of  crusting  and 
the  formation  of  new  epithelium  underneath.  Be- 
tween islands  of  new  epithelium  may  be  seen  numer- 
ous small  ulcerated  areas.  The  best  treatment  here 
consists  in  applying  a  lattice  work  of  adhesive  plas- 
ter strips  (zinc  oxide)  over  the  entire  eczematous 
area  and  a  little  beyond  it,  and  left  on  for  three 
days,  when  it  can  easily  be  removed.  The  adhesive 
plaster  retards  the  growth  of  bacteria,  stimulates  the 
growth  of  new  tissue,  and  at  the  same  time  is  pro- 
tective. The  process  is  repeated  as  often  as  neces- 
sary. The  ulcerated  areas  will  be  found  to  be  cov- 
ered with  fine  epithelium  when  the  dressing  is  re- 
moved, and  the  skin,  as  a  rule,  returns  almost  to 
normal.  If  a  dry  process  should  supervene,  the  skin 
can  be  softened  by  applying  a  one  per  cent,  carbolic 
acid  in  zinc  oxide  salve  by  means  of  a  clean  piece  of 
cotton  or  a  wooden  stick,  and  covered  by  a  piece  of 
rubber  tissue  or  oiled  silk,  worn  throughout  the 
night  after  taking  a  warm  bath  and  drying  the  parts 
well.  During  the  day  no  protective  dressing  is  nec- 
essary. 

The  author  realizes  the  enormous  number  of 
drugs  and  plans  of  treatment  which  have  been  used 
in  chronic  eczema.  The  foregoing  has  proved  an 
effective  plan  of  treatment.  The  various  "specifics" 
j^re  useless  in  the  majority  of  cases,  either  applied 
locally  or  taken  internally,  unless  the  patient  is  will- 
ing to  treat  the  body  as  well  as  the  skin  on  a  ra- 
tional, common  sense  basis. 

Dr.  W.  F.  Barclay,  of  Pittsburgh,  Pa.,  ivrites: 

Chronic  eczema  is  of  all  skin  diseases  most  fre- 
quent and  its  treatment  most  ineffectual  and  inert. 
General  and  special  medical  practitioners  of  medi- 
cine attempt  its  cure,  and  as  a  rule  with  like  results 
of  failure 

The  diagnosis  of  the  disease  in  its  multiforms  as 
a  general  rule  is  not  ea-^y,  and  many  mistakes  are 
•nade  in  the  rendition  of  opinion  as  to  the  correct  na- 
ture of  the  disease.  The  general  conclusion  that 
the  disease  is  not  dangerous  or  fatal  in  its  tendencies 
prevails,  and  the  profession  of  medicine  inclines  to 
dietetic  palliative  and  exjiectant  treatment. 

.Authorities  are  less  scientific  in  studies  and  re- 
searches than  might  be  reasonably  expected  in  a  dis- 
ease so  widely  prevalent  and  loathesome  in  its  many 
manifestations.  It  is  a  serious  consideration  to  con- 
clude that  a  large  number  of  children  in  infancy  and 
child  life  suffer  from  eczema  in  some  form.  The 


suffering  of  children  from  the  itching  and  pain 
caused  by  eczema  is  incalculable,  and  appeals  to  rea- 
son and  scientific  resources  in  extending  relief  for 
the  eczematous  sufferers.  Immediate  and  remote 
consequences  attend  the  cause  of  the  disease  in  its 
ravages  and  multiform  temporary  and  permanent 
results.  It  is  not  ' difficult  to  calculate  sequela;, 
psychic  and  physical,  from  the  disease  in  the  ma- 
jority of  children. 

From  local  and  general  symptoms  the  aetiology 
of  eczema  is  not  apparent.  The  profession  of  medi- 
cine in  dififerent  localities  and  countries  is  diversi- 
fied widely  as  to  its  pathology,  and  a  unit  as  to  its 
manifestations  and  noncontagious  tendencies.  Even 
heredity  is  generally  doubted,  and  by  many  denied. 
The  cause  is  seemingly  attributable  to  air  and  light, 
and  some  one  of  the  various  diatheses  is  believed  to 
be  the  provoking  cause  of  eczema,  but  the  intimate 
investigation  of  the  conditions  present  in  different 
cases  does  not  verify  the  assertion  that  systemic 
conditions  caused  the  disease  in  a  single  case. 

The  sexes  are  usually  evenly  divided  in  occur- 
rence of  the  disease,  in  children  the  male  and  in 
adults  the  female  being  more  subject  to  its  invasion. 

Local  and  general  causation  indicate  local  and 
general  treatment  in  the  minds  of  medical  men,  but 
persistent  application  of  both  methods  have  given 
like  results.  If  the  conclusion  prevails  that  the  cause 
is  general  and  not  local,  then  local  treatment  can 
only  afford   temporary  relief   and   not  permanent 
cure.     On  the  contrary,  if  the  cause  is  local,  then 
general  medication  is  practically  useless.    The  the- 
ory concluded  that  the  disease  is  of  neurotic  origin 
is  substantiated  by  local  and  general  nerve  irrita- 
tion.   In  health  and  disease  local  and  general  nerve 
irritation  cause  the  sensation  of  itching,  which  is  al- 
most always  present  in  eczema.    Chronic  eczema  is 
not  a  misnomer  under  general  conditions  and  ordi- 
nary treatment,  as  the  disease  as  a  rule  persists  and 
resists  obstinately  the  care  and  treatment  generally 
suggested  and  enforced.    The  persistence  in  the  use 
of  external  applications  disgusts  and  discourages  the 
sufferers-  from  chronic  eczema  and  relegates  them 
to  the  use  of  patent  medicines.   More  sufferers  from 
chronic  eczema  use  patent  medicines  than  from  all 
other  known  diseases.    The  uselessness  of  ordinary 
treatment  and  general  medication  has  caused  dis- 
trust and  loss  of  confidence  in  medical  practice,  and 
has  augmented  the  expense  incurred  in  useless  medi- 
cines, and  much  exaggerated  the  suffering.  The  pro- 
fessional opinion   given  that   all   known  remedial 
treatment  proves  unavailing  and  that  palliation  at 
most  can  be  promised  enervates  and  discourages  the 
sufferers  from  chronic  eczema.     The  general  dis- 
gusting and  useless  character  of  external  treatment 
and  the  destruction  of  wearing  apparel  by  its  use. 
as  well  as  bedding,  should  long  ere  this  advanced 
age  of  medical  science  have  suggested  its  disuse. 
Dietetic  treatment  impairs  the  digestive  system,  and 
as  a  rule  is  of  no  advantage  in  treatment.    The  mis- 
takes in  directing  patients  to   certain  resorts  for 
medical  baths  should  at  least  suggest  that  the  best 
external  medical  treatment  is  valuless  and  positive- 
ly injurious.     Finally,  arsenic  in  unheard  of  doses 
in  proper  combination  increases  innervation  and  gen- 
eral health.    It  cures  chronic  eczema. 

Psoriasis,  a  somewhat  similar  affection,  is  curable 
under  similar  treatment  without  external  applica- 


Vebruary  13.  1909. J 


CORRESPONDENCE. 


337 


tions  as  I  can  truthfully  aver  from  my  own  observa- 
tions. 

Dr.  Murray  B.  Kirkpatrick,  Jr.,  of  Trenton,  X.  J., 
says: 

The  first  seep  in  the  treatment  of  chronic  eczema 
is  the  reg:ulation  of  the  patient's  mode  of  living. 
Where  possible  he  should  have  an  abundance  of 
fresh  air,  sufficient  exercise,  a  definite  period  for 
rsleep,  and  meals  at  regular  hours. 

The  diet  should  be  plain  but  nutritious,  all  fancy 
-dishes,  indigestible  meats,  and  foods  being  avoided 
as  much  as  possible.  Coffee  and  tea  should  be  used 
•only  in  moderation,  while  alcoholic  beverages  and 
acid  fruits  should  be  absolutely  prohibited. 

After  regulating  the  hygiene  the  general  medical 
treatment  is  considered. 

First  and  foremost,  all  disturbances  of  the  gastro- 
intestinal tract  should  be  sought  after  and  given  the 
appropriate  treatment.  Especially  is  this  true  of 
■constipation,  which  is  best  combated  in  these  cases 
"bv  potassium  citrate  and  the  various  saline  aperient 
mineral  waters.  Cascara  sagrada,  aloes,  rhubarb, 
and  the  other  vegetable  cathartics  are  also  aften  use- 
ful. 

In  the  goutv  and  rheumatic  colchicum,  lithium, 
and  the  salicylates  are  especially  indicated ;  while  in 
children  and  the  debilitated  cod  liver  oil,  the  hypo- 
phosphites,  quinine,  nux  vomica,  iron,  arsenic,  man- 
ganese, and  the  vegetable  bitters  are  very  important. 
In  such  cases  I  have  found  the  following  combina- 


tion very  useful : 

^    Pepsin,  .  .  5ij; 

Pancreatin  •5j ; 

Spirit  of  glyceryl  trinitrate,   TTLxxiv; 

Tincture  of  nux  vomica,   ^.  ...3iij; 

Solution  of  potassium  arsenate,   5ss  to  i ; 

Elixir  of  calisaya,  q.  s.  ad  3iij. 


M.  S.  A  teaspoonful  in  water  thrice  daily  after  meals. 
We  now  come  to  the  local  treatment,  the  first  step 
of  which  is  the  thorough  cleansing  of  the  parts  from 
the  crusts  and  other  secondary  products.  This  is 
best  done  by  olive  oil  or  thin  strained  rice  milk,  both 
of  which  cleanse  well  and  are  soothing  to  the  tender 
and  inflamed  parts.  The  cleansing  should  be  thor- 
ough and  not  too  often  repeated,  two  or  three  times 
-a  week  being  often  enough.  Now  the  application  of 
the  local  remedy  may  be  made.  Salycilic  acid,  zinc 
oxide,  carbolic  acid,  boric  acid,  calamine,  mercury, 
Tesorcin,  tar,  ichthyol,  amylum,  benzoin,  menthol, 
and  sulphur  all  have  their  place  here.  The  choice 
•and  amount  of  each  or  any  drug  given  in  the  wash, 
ointment,  or  powder  must  necessarily  depend  on  the 
■condition  of  the  parts  and  the  experience  and  pref- 
erence of  the  physician. 

Each  case  is  a  law  unto  itself,  so  that  I  will  give  ■ 
liere  only  two  of  the  prescriptions  which,  in  my  prac- 


tice, have  given  good  results : 

^    Lignol  ^5i; 

Creolin,   5ss ; 

Petrolatum,  q.  s.  ji. 

iM.  S.    Apply  locally  two  or  three  times  daily. 

^    Resorcin  gr.  x  ; 

Benzosalicylic  acid,  gr.  xv  ; 

Ichthyol,  twenty  per  cent.,   3ii ; 

Sulphurous  iodide,   gr.  xx ; 

Eucalyptol,   TT^xx ; 

Wool  fat  q.  s.  ad  31. 


-IM.  S.    Apply  locally  two  or  three  times  daily. 


LETTER  FROM  LONDON. 

A  Windfall  for  the  London  Hosfital. — Kissing  the  Book. — 
IVIiat  Constitutes  an  Inebriate,  and  Hozu  He  Should 
be  Treated. — Medical  Certificates  of  Character  Given 
to  Midzi'ives. 

LoxDox,  January  36,  igog. 

The  London  Hospital  has  just  received  another 
handsome  and  unexpected  gift.  An  anonymous 
donor  has  given  £20,000,  not  for  the  ordinary  chari- 
table work  of  that  great  hospital,  but  for  its  med- 
ical school,  with  the  stipulation  that  the  interest 
shall  be  expended  on  advanced  research  work.  It 
is  one  of  the  most  glaring  defects  of  the  higher 
education  in  this  country  in  all  its  branches,  with- 
out exception,  that  postgraduate  study  is  so  inade- 
quately provided  for,  and  this  gift  should  prove  a 
most  useful  nucleus  of  a  great  endowment  fund 
lor  medical  research.  The  London  Hospital  author- 
ities will  not  restrict  its  benefits  to  their  own  men ; 
they  propose  to  throw  them  open  to  qualified  med- 
ical men  from  all  parts  of  the  British  Empire,  only 
insisting  that  they  shall  come  and  study  within  the 
London  laboratories.  The  compliment  implied  in 
the  selection  of  the  London  Hospital  for  this  pur- 
pose is  well  deserved,  and  if  the  fund  grows  as  it 
ought  to  it  should  attract  many  young  medical  men 
who  feel  they  have  a  real  capacity  for  such  ad- 
vanced work,  but  are  unable  without  financial 
assistance  to  devote  further  years  to  specialized 
study.  The  donor  of  this  munificent  gift  wishes  to 
remain  anonymous,  in  the  hope  that  the  fund  which 
he  has  thus  started  will  be  added  to  by  others,  and 
that  in  time  it  may  grow  to  such  magnitude  as  to 
be  of  great  value  in  the  prevention  and  conquest  of 
disease. 

Some  agitation  has  recently  occurred  in  legal  cir- 
cles in  England  with  reference  to  the  method  of 
taking  the  oath  in  courts  of  law.  The  matter 
reached  a  climax  recently  when  a  witness — a  med- 
ical man — brought  with  him  to  the  court  a  Bible 
which  alone  he  would  kiss  when  the  oath  was  ad- 
ministered to  him.  The  judge,  however,  would  not 
allow  him  to  do  so,  and,  as  he  persisted  in  his  re- 
fusal to  kiss  the  court  Bible,  he  was  fined  for  con- 
tempt of  court.  This  judgment  was  upheld  on  ap- 
peal on  the  ground  that  the  witness  ought  to  have 
obeyed  the  decision  of  the  judge,  as  the  discipline 
of  the  courts  must  be  maintained.  This  case  has 
brought  out  numerous  protests  from  medical  men, 
who  contend  rightly  that  the  custom  of  kissing  the 
court  testament,  which  is  often  old  and  dirty  in  the 
extreme,  is  very  unhygienic  and  might  be  in  certain 
cases  dangerous,  and  it  would  be  much  preferable 
to  administer  the  oath  in  the  Scotch  fashion,  which 
consists  in  holding  up  the  right  arm  and  repeating 
the  words  of  the  oath.  Several  judges  have  made 
public  statements  in  their  courts  that  witnesses  may 
take  the  oath  in  the  Scotch  fashion  if  they  prefer  it, 
and  in  a  very  short  time  it  is  probable  that  the 
method  will  become  universal  in  England.  This 
will  be  a  very  desirable  reform,  as,  apart  from  the 
hygienic  aspects  of  the  case,  many  sensitive  persons 
instead  of  kissing  the  book  have  interposed  their 
thumbs  between  it  and  the  book,  and  this  enabled 


338 


1  H  ERAFt  U  TIC  A  L  X  OTES. 


[Xi;.v  York 
Medical  Journal. 


ail  untruthful  witness  to  swear  with  an  easy  con- 
science. The  Scottish  method  removes  these  objec- 
tions completely,  and  there  is  something  dignified 
and  reverential  in  the  uplifted  arm  and  the  simple 
form  of  words  uttered  on  oath. 

The  committee  which  was  appointed  to  consider 
the  Inebriates'  Acts  has  now  issued  its  report,  and  it 
is  most  interesting.  The  committee  define  an  ine- 
briate as  a  person  who  habitually  takes  or  uses  any 
intoxicating  thing  or  things  and,  while  under  the  in- 
fluence of  such  thing  or  things  or  in  consequence  of 
the  efifects  thereof,  is  dangerous  to  himself  or  others 
or  a  cause  of  harm  or  serious  annoyance  to  his  fam- 
ily or  others  or  incapable  of  managing  himself  or  his 
affairs  or  of  ordinary  proper  conduct.  This  defini- 
tion includes  as  inebriates  not  only  habitual  drunk- 
ards, but  habitual  drug  takers,  and  is  so  far  a  great 
advance  on  the  previous  one,  which  did  not  include 
drug  takers  in  its  scope.  One  of  the  principal  rec- 
ommendations is  that  for  the  provision  of  guardians 
for  inebriates  who  cannot  be  persuaded  to  adopt  the 
more  serious  course  of  placing  themselves  in  a  re- 
treat. The  guardian  is  to  be  empowered  to  prescribe 
a  place  of  residence  for  the  inebriate,  to  deprive  the 
inebriate  of  intoxicants  and  prevent  him  from  ob- 
taining them,  to  require  the  inebriate  to  submit  to 
the  control  of  nurses  or  attendants,  and  to  warn  sell- 
ers of  drink  and  drugs  not  to  supply  the  inebriate — 
supply  after  warning  to  be  an  offense  under  the  act.  • 
(juardianship  may  be  voluntarily  submitted  to  or 
compulsorily  imposed,  the  provisions  in  the  latter 
case  being  slightly  more  stringent  than  in  the  for- 
mer. The  committee  endorse  the  opinion  of  two 
previous  committees  on  the  subject  that  "great  and 
widespread  distress"  is  caused  by  inebriates  who  do 
not  commit  offenses  and  therefore  cannot  be  dealt 
with  compulsorily  under  the  present  law.  The  com- 
mittee are  convinced  that  power  to  deal  with  such 
inebriates  is  urgently  needed.  They  have  failed  to 
find  satisfactory  reasons  against  the  constitution  of 
such  powers,  and  they  point  out  very  justly  that  the 
alternative  to  interfering  with  the  liberty  of  the  ine- 
briate is  permitting  him  to  interfere  with  the  liberty 
of  other  people.  It  is  now  thirty-six  years  since 
provisions  of  this  character  were  first  recommended 
as  urgent,  and  yet  nothing  has  been  done.  Much 
consideration  is  also  given  to  questions  of  finance. 
The  committee  say  in  plain  terms  that  the  expendi- 
ture of  the  various  county  councils  on  inebriate  re- 
formatories is  unjustifiable  and  a  waste  of  public 
money,  and  that  "the  mere  fact  that  a  person  has 
become  an  inebriate  should  not  of  itself  entitle  him 
to  be  maintained  under  conditions  altogether  supe- 
rior to  those  to  which  he  has  been  accustomed."  The 
cost  of  provision  ought  not,  in  the  opinion  of  the 
committee,  to  exceed  £150  a  bed,  nor  ought  the 
maintenance  rate  to  exceed  iis.  4d.  a  week.  It  is 
on  the  score  of  economy  largely  that  the  committee 
recommend  the  transfer  of  reformatories  to  the 
state. 

A  curious  case  which  is  of  interest  to  medical  men 
generally  was  heard  recently  at  the  Westminster  Po- 
lice Court.  Dr.  l*".  K.  .Marsh,  of  Bradford,  was 
charged  with  the  offense  of  knowingly  helping  a 
midwife  named  Inglis  to  secure  registration  on  the 
midwives'  roll  when  she  was  not  legally  admissible. 
Dr.  Marsh  has  been  in  practice  at  Bradford  for  many 


years  and  possesses  a  very  high  reputation  there.  He 
gave  a  certificate  of  character  to  this  woman  to  the 
eft'ect  that  she  had  been  in  bona  fide  practice  as  a 
midwife  since  1885  and  was  trustworthy,  sober,  and 
of  good  moral  character.  As  a  result  of  this  certifi- 
cate her  name  was  placed  upon  the  roll  and  remained 
there  until  igo8,  when  a  report  was  made  to  the 
central  Midwives'  Board  that  she  had  been  guilty  of 
negligence  and  misconduct  in  the  exercise  of  her 
calling.  Inquiries  were  then  made  and  it  was  found 
that  she  had  been  tried  at  the  Leeds  Assizes  for 
murder  on  the  ground  that  she  had  killed  a  woman 
by  performing  an  illegal  operation.  She  was  con- 
victed of  manslaughter  and  sentenced  to  three  years' 
penal  servitude.  However,  it  appeared  that  Dr. 
]\Iarsh  had  given  her  the  certificate  in  perfect  good 
faith,  and  the  magistrate  dismissed  the  charge 
against  him.  This  case  should  be  a  warning  to  med- 
ical men  to  exercise  the  greatest  care  in  giving  cer- 
tificates of  character. 

 ^  


Ophthalmic  Formulas. — A.  Beck,  of  Coburg, 
uses  a  set  of  formulas  for  eye  drops  under  names 
pertaining  to  the  indications  for  their  use.  Thus  in 
the  treatment  of  asthenopia  two  solutions  are  used 
according  to  requirement,  named  respectively  as- 
thenopine  a  and  asthenopine  b ;  and  in  dacryocysti- 
tis three  solutions  are  employed  under  the'  names 


dacrvocvstine  a.  b,  and  h  ciiDi  atropine,  as  follows; 
Asthenopine  a 
R     Cocaine  hydrochloride ; 

Boric  acid  aa  gr.  iii ; 

Distilled  water,   5iiss. 

Aslhcnopiiie  b 

R    Cocaine  hydrochloride,   gr.  iss ; 

Alum  (aluminum  potassium  sulphate),  gr.  1/3; 

Boric  acid,   gr.  iii; 

Distilled  water  3iiss. 

Dacryocystinc  a 

B    Cocaine  hydrochloride,   gr.  iii; 

Solution  of  mercuric  o.xycyanide  (,1  in  5000),. .  .3iiss. 

M. 

Dacryocystinc  b 

R     Cocaine  hydrochloride,   gr.  iss; 

Solution  of  mercuric  o.xvcyanide  (i  in  1000),. .  .3iiss. 

M. 

Dacryocystinc  b  ivitlt  Atropine 

R    Cocaine  hydrochloride,   gr.  iss; 

Solution  of  mercuric  oxycyanide  (i  in  looo) .  .5iiss ; 
Atropine  sulphate,   gr.  3/4- 

M. 

Rectal  Injection  of  Bromides  in  Puerperal 
Eclampsia. — In  a  comnuinicatiou  to  T}\c  Britisli 


Medical  Journal  for  January  23,  1909.  W.  A.  E. 
Hay  refers  to  a  severe  case  of  eclampsia  which  he 
had  in  a  primipara.  The  convulsions  came  on  be- 
fore delivery,  and  continued  for  nearly  two  days 
after.  The  head  was  shaved,  ice  applied  to  the  scalp, 
and  chloroform  was  constantly  administered,  but 
nothing  appeared  to  relieve  until  he  injected  by  the 
rectum  potassium  bromide,  gr.  xxx,  with  chloral' 
hvdrate.  gr.  xxx.  This  was  repeated  four  hours  af- 
terwards. Soon  after  the  convulsions  stopped  and 
the  patient  made  a  good  recovery. 


February  13,  1909.  J 


EDITORIAL  ARTICLES. 


339 


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THE  NAVAL  HOSPITAL  SHIP. 

At  the  last  annual  meeting  of  the  Medical  Society 
of  Virginia,  held  in  October,  Surgeon  General 
Rixey,  of  the  navy,  himself  a  Virginian,  read  by  in- 
vitation an  interesting  paper  entitled  The  Medical 
Profession  as  Represented  in  the  United  States 
Navy.  It  appears  in  the  Virginia  Medical  Semi- 
monthly for  December  25th.  It  is  comprehensive  in 
character,  dealing  with  many  phases  of  the  medical 
service  of  the  navy,  but  we  must  confine  our  consid- 
eration of  it  at  present  to  the  passages  which  relate 
to  the  naval  hospital  ship. 

Admiral  Rixey  reminded  his  hearers  that  the  bat- 
tleship of  the  present  day  was  an  elaborate  fighting 
machine,  and  that  the  spaces  on  board  which  could 
be  allowed  for  the  care  of  the  sick  and  wounded 
were  not  available  during  an  engagement,  for  they 
would  prove  insufficient  in  extent  and  were  lacking 
in  protection.  Hospital  ships,  therefore,  he  says,  are 
our  principal  means  of  meeting  the  reasonable  hu- 
mane demands  of  the  people  and  their  expectation 
that  those  who  fall  in  the  service  shall  be  properly 
cared  for.  The  hospital  ships  afiford  every  comfort 
and  facility  of  well  appointed  civil  hospitals,  and 
Admiral  Rixey  tells  us  that  it  is  now  strenuously 
urged  that  every  naval  force  of  over  10,000  men 
should  have  at  least  one  vessel  devoted  entirely  to 
hospital  work,  flying  the  Red  Cross  flag  and  com- 
plying in  every  respect  with  the  terms  of  the  Geneva 
Convention  and  those  of  the  Hague  Conference. 

In  this  way,  says  the  surgeon  general,  it  will  be 
possible  to  "give  reality  to  the  law  of  civilized  war- 


fare— that  no  unnecessary  suft'ering  shall  be  caused 
or  permitted."  The  worldwide  extent  and  earnest 
character  of  the  popular  interest  and  activity  in  all 
that  concerns  the  physical  and  moral  condition  of 
mankind,  he  continues,  arc  expressions  of  that  bene- 
ficial and  philanthropic  public  opinion  in  which  the 
government  services  are  participating,  as  was  shown 
when  Admiral  Evans  "diverted  two  ships  of  the 
fleet  under  his  command  in  an  effort  to  save  the 
lives  of  a  few  seriously  sick  men."  It  is  evident  that 
the  hospital  ship  is  a  necessity  in  the  navy  and  that 
its  command  must  be  vested  in  a  medical  officer. 


THE  DETECTION  OF  THE  TYPHOID 
CARRIER. 

Not  a  little  has  been  learned  within  the  past  few 
years  concerning  the  possibility  of  the  spread  of 
typhoid  fever  through  the  agency  of  tlie  so  called 
"typhoid  carriers."  Even  if  all  these  dangerous 
individuals  were  known  to  be  such,  the  difficulty 
of  rendering  them  harmless  would  not  be  small, 
but  a  knowledge  of  their  identity  is  the  first  step 
toward  at  least  a  proper  control.  Routine  examina- 
tion of  the  stools  of  suspected  persons  has  demon- 
strated the  fact  that  many  of  them  pass  living  ty- 
phoid bacilli  with  the  dejecta  at  intervals  only,  the 
stools  for  long  periods  being  free  from  them.  As 
in  most  of  these  cases  the  gallbladder  is  the  habitat 
of  the  infecting  colony,  from  which  myriads  of 
bacteria  pass  down  into  the  intestine — there  to  per- 
ish or  to  pass  on  and  be  thrown  ofl:'  with  the  faeces 
— it  occurred  to  Arthur  Weber  {Miincliener  niedi- 
zinische  Woclienschrift,  1908,  No.  24)  that  a  bac- 
teriological examination  of  the  bile  would  be  the 
surest  and  simplest  method  of  detecting  the  typhoid 
carrier. 

In  order  to  obtain  a  specimen  of  bile,  Weber 
made  use  of  the  procedure  devised  by  Volhard  (the 
same  journal,  1907,  No.  9)  for  the  study  of  the 
pancreatic  juice.  This  consists  in  introducing  200 
cubic  centimetres  (about  six  fluid  ounces)  of  olive 
oil  into  the  empty  stomach  and  withdrawing  the 
gastric  contents  after  an  interval  of  half  an  hour. 
The  oil  induces  a  copious  secretion  of  pancreatic 
juice,  some  of  which  finds  its  way  into  the  stomach 
and  carries  with  it  a  certain  amount  of  bile.  The 
gastric  contents  recovered  after  this  manner  soon 
separate  into  two  layers — a  lower,  watery  layer  and 
an  upper,  oily  layer.  Weber  states  that  if  bile  is 
present,  as  shown  by  chemical  tests,  the  typhoid 
bacillus  Mdll  always  be  found  in  the  case  of  typhoid 
carriers.  He  suggests  that  typhoid  convalescents 
should  invariably  be  subjected  to  this  simple  test. 

It  would  be  a  comparatively  easy  matter  to  estab- 
lish such  a  routine  in  hospital  practice,  and  even  in 
private  work    the    bile    stained    gastric  contents 


340 


EDITORIAL  ARTICLES. 


LXew  York 
Medical  Journal. 


might  be  obtained  without  difficuky  and  sent  to  a 
laboratory  for  examination.  Should  the  reliability 
of  the  test  be  demonstrated  by  further  investiga- 
tion, such  a  practice  might  prove  of  considerable 
value  in  preventing  the  spread  of  typhoid  fever. 


FOOD  PRESERX'ATIVES. 

A  recent  pronouncement  by  the  board  of  "ex- 
perts" employed  by  the  general  government  to  sit  in 
judgment,  as  it  were,  on  Dr.  Wiley's  decisions  con- 
cerning the  innocence  or  harmfulness  of  such  pre- 
servatives as  sodium  benzoate  added  to  food  prod- 
ucts put  up  in  cans  or  jars  must,  we  think,  be  looked 
upon  as  defective,  inasmuch  as  it  simply  declares 
what  the  board  has  not  found  to  be  the  results  in  a 
set  of  experiments  parallel  with  Dr.  Wiley's,  for  it 
is  generally  held  that  a  single  positive  observation 
outweighs  many  a  negative.  Moreover,  the  board's 
experiments  extended  over  a  period  far  short  of 
what  would  generally  be  required  to  prove  a  nega- 
tive. 

Practically,  as  it  seems  to  us,  the  American  Asso- 
ciation for  the  Promotion  of  Purity  in  Food  Prod- 
ucts has,  save  as  to  one  point,  settled  the  matter,  for 
it  has  proclaimed  that  chemical  preservatives  are 
not  necessary  for  the  due  conservation  of  the  essen- 
tial features  demanded  in  food  products.  The  asso- 
ciation is  composed  .of  manufacturers,  and  their 
statement  is  eminently  satisfactory.  Xevertheless, 
we  must  look  at  the  other  side  of  the  shield- — canned 
goods  do  not  always  keep  after  the  can  has  been 
opened — and  this  is  no  small  consideration. 


ACCTE  PULMONARY  CEDEINIA. 
The  pathogenesis  of  acute  pulmonary  cedema  is 
still  very  much  discussed.  Most  writers  have  sought 
for  a  satisfactory  explanation  by  clinical  observa- 
tion, astiological  conditions,  or  experiments.  A  re- 
cent work  by  Chemery  has  put  some  order  into 
these  various  theories.  It  would  appear  that  the 
mechanical  theory  has  been  almost  entirely  given 
up.  Grossmann  and  von  Basch  believed  that  acute 
pulmonary  oedema  was  due  to  cramp  of  the  left 
ventricle,  as  occurs  in  poisoning  from  muscarine. 
Tlie  blood,  thus  hindered  in  its  afflux  to  the  left 
ventricle,  accumulates  in  the  pulmonary  paren- 
chyma and  produces  an  oedema  by  stasis.  On  the 
other  hand,  Welch,  Cohnheim,  and  Fraentzel 
thought  pulmonary  stasis  consecutive  to  paralysis  of 
the  left  ventricle  and  not  to  spasm  of  the  latter. 
Both  these  theories  are  questioned  because  experi- 
jnentally  it  is  impossible  to  produce  a  true  pulmo- 
nary cedema  from  simple  disturbances  of  the  car- 
diac mechanism,  and,  still  more,  a  failing  action  of 
the  left  side  of  the  heart  never  produces  marked 


cedema,  but  only  passive  congestion  of  the  bases  of 
the  lungs. 

The  angeioneurotic  theory  is  upheld  by  a  few. 
In  the  first  place,  Huchard,  noting  the  frequency  of 
aortic  or  periaortic  lesions  in  subjects  having  at- 
tacks of  oedema,  believes  that  the  latter  is  due  to  a 
disturbance  in  the  vasomotor  pulmonary  reflex,  sec- 
ondary to  the  periaortitis,  resulting  in  a  consider- 
able increase  of  the  vascular  tension  in  the  pulmo- 
nary circulation,  and  followed  by  an  acute  and  rapid 
insufficiency  of  the  right  ventricle.  The  periaorti- 
tis is  not  alone  in  the  process,  because  renal  sclero- 
sis accompanies  it,  so  that  the  latter  should  also  be 
considered  as  partly  the  cause  of  the  pulmonary 
oedema.  This  opinion  leads  the  way  to  the  consid- 
eration of  the  toxic  accidents  in  the  interpretation 
of  acute  oedema,  and  the  toxic  theory  is  particularly 
upheld  by  Dieulafoy.  Acute  pulmonary  oedema  be- 
comes one  of  the  multiple  modalities  of  toxjemia  of 
renal  origin.  Every  renal  lesion  which  results  in 
functional  impairment  of  the  kidney  will  be  found, 
according  to  Dieulafoy,  as  a  point  of  origin  of  acute 
oedema.  Merklen  is  of  the  opinion  that  a  lesion  of 
the  myocardium  is  also  concerned.  This  theory  is 
based  on  experiment.  In  1900  Teissier  poisoned 
rabbits  with  methyl  salicylate  and,  after  dividing 
the  spinal  cord,  produced  cardiac  disturbances ;  each 
isolated  lesion  was  negative  in  results.  On  the  other 
hand,  by  combining  the  action  of  these  astiological 
factors,  it  was  quite  easy  to  obtain  considerable  dis- 
turbance of  the  pulmonary  circulation  with  oedema 
and  transudation.  He  points  out  that  the  acute 
oedema  is  the  ordinary  consequence  of  a  complex 
pathogenic  process  in  which  infection  or  intoxica- 
tion prepares  the  way ;  the  nervous  and  mechanical 
disorders  arise  secondarily,  to  end  in  an  extraalve- 
olar  and  intraalveolar  inundation. 

In  1903  Josua  brought  up  the  suprarenal  theory. 
He  noted  that  acute  oedema  arose  in  cases  of  ex- 
cessive tension,  and  was  struck  by  the  fact  that  ad- 
renalin possessed  very  marked  hypertonic  proper- 
ties and  easily  produced  pulmonary  oedema.  He 
consequently  concludes  that  both  experimental  and 
clinical  observation  demonstrate  that  acute  pulmo- 
nary oedema  is  often  the  result  of  an  exaggerated 
activity  of  the  suprarenal  bodies.  Vaquez  also  is 
of  this  opinion,  and  he  shows  what  an  important 
part  should  be  attributed  to  functional  disturbances 
of  the  suprarenal  gland.  Recent  experiments  un- 
dertaken in  Germany  advance  the  matter  still  fur- 
ther. When  there  is  unusual  suprarenal  activity 
adrenalin  may  be  found  in  the  serum,  being  detected 
by  a  certain  reaction  with  perchloride  of  iron  and 
by  its  mydriatic  action.  Rut  it  may  be  said  that 
these  phenomena  are  exceptional,  and  it  has  even 
been  maintained  that  they  never  exist.  We  must 
not  be  deceived,  however,  because  there  are  facts, 
both  clinical  and  experimental,  which  are.  against 


February  13,  1009.  J 


EDITORIAL  ARTICLES. 


the  above  mentioned  experiments.  Far  from  being 
a  cause,  the  changes  in  the  suprarenal  gland  may 
themselves  merely  be  secondary  to  the  renal 
changes,  so  that  the  latter  hold  a  prominent  place 
in  the  production  of  the  oedema,  while  myocardial 
insufficiency  or  a  disturbance  of  the  innervation  is 
merely  an  accessory  element.  It  will  be  seen  how 
complex  this  problem  is,  but  in  practice  it  is  partic- 
ularly essential  to  bear  in  mind  intoxication  and 
arterial  supertension.  Bloodletting  and  a  decrease 
in  the  amount  of  liquid  taken  by  the  patient  are  the 
most  powerful  means  at  our  di^]X)sal  in  the  treat- 
ment of  acute  pulmonary  cedema,  for  the  simple 
reason  that  they  attack  the  principal  causes  of  its 
production. 

DIACHYLOX  AS  A  POISON. 

A  thriving  business  in  the  culpable  sale  of  '"di- 
achylon pills,"  to  be  used  for  producing  abortion, 
seems  to  have  been  going  on  in  certain  parts  of 
England  of  late.  A  case  which  appears  to  have  re- 
sulted in  the  death  of  a  young  woman  is  reported 
by  Dr.  Arthur  J.  Hall,  of  Sheffield,  in  the  British 
Medical  Journal  for  January  30th,  and  he  refers 
to  previous  reports,  by  Dr.  Edmund  Hay  (the  same 
journal,  January  23d),  of  three  cases  of  plumbism 
due  to  taking  diachylon  to  procure  abortion.  The 
young  woman  whose  case  is  reported  by  Dr.  Hall 
had  had  albuminuria  for  some  years,  "so  that  the 
effect  of  the  diachylon  on  the  already  impaired  kid- 
neys was  doubly  severe." 

The  evil  has  been  checked  to  some  extent  by  the 
conviction  of  one  or  two  midwives  who  were  proved 
to  have  sold  the  pills  for  improper  purposes,  but 
Dr.  Hall's  communication  shows  that  it  is  still  going 
on.  "It  does  seem,"  says  Dr.  Hall,  "that  some 
steps  should  be  taken  to  put  a  stop  to  this  evil.  So 
far  it  has  been  found  impossible  to  move  the  au- 
thorities in  the  matter.  In  spite  of  much  trouble 
and  many  meetings,  with  strong  resolutions  passed, 
urging  the  desirability  of  putting  diachylon  on  the 
poisons  schedule  (as  is  ergot),  we  were  informed 
that,  acting  upon  'expert'  advice,  they  considered 
that  it  was  unnecessary."  He  adds,  very  properly, 
that  he  can  only  say  Xe  crcdc  experto! 

^^'e  presume  that  by  '"diachylon"  (a  much  abused 
name  in  modern  times,  the  word  having  been  trans- 
muted into  "diachylum"  and  generously  provided 
with  a  manufactured  genitive,  '"diachyli,"  though  it 
is  itself  formed  by  blending  a  Greek  preposition 
with  a  genitive  plural)  diachylon  plaster  is  meant — 
the  emplastrum  plumbi  of  the  United  States  and 
British  Pharmacopoeias.  A\'e  are  not  sure  that  this 
venerable  preparation  is  still  in  legitimate  use  to  any 
considerable  extent,  except  perhaps  for  making 
Hebra's  diachylon  ointment.    Xow  that  it  has  sunk 


so  low  as  to  be  vended  as  an  abortifacient  by  mid- 
wives  and  disreputable  apothecaries,  it  may  as  well 
be  dropped  altogether,  we  should  say. 


ERXST  HAECKEL. 

It  is  given  to  very  few  men  to  celebrate  their 
seventy-fifth  birthday  in  good  health,  surrounded  by 
a  large  circle  of  admirers  and  holding  a  position  in 
which  they  have  for  nearly  half  a  century  played  a 
leading  role  in  the  scientific  world.  Professor  Ernst 
Haeckel,  of  Jena,  was  born  on  February  16,  1834.  in 
Potsdam,  near  Berlin.  He  soon  became  an  ardent 
admirer  of  Darwin,  who  was  only  twenty-five  years 
his  senior  (Darwin  was  born  on  the  same  day  on 
which  Lincoln  was  born,  the  i2t!i  of  February, 
1809).  In  1865  Haeckel  was  appointed  professor 
of  zoology  at  Jena,  which  position  he  will  resign  at 
the  end  of  this  semester. 

Since  1863  Haeckel  has  supported  Darwin,  whose 
Origin  of  Species  appeared  in  185Q,  while  the  De- 
scent of  Man  was  published  in  1871  :  and  since  the 
death  of  Darwin,  on  April  19,  1882.  Haeckel  be- 
came the  leader  of  Darwin's  "school."  whose  theory 
he  fully  developed.  One  of  Haeckel  s  important 
doctrines  is  his  biogenetic  law,  the  statement  that 
the  embryological  development  of  the  individual  is 
a  condensed  reproduction  of  that  of  the  family  to 
which  it  belongs,  his  gastnea  theory.  He  has  been 
very  successful  in  formulating  his  ideas  on  embryol- 
ogy, although  his  theories  have  often  been  attacked. 
In  his  JVcltrcifsel  he  described  his  views  of  the  uni- 
verse, which;  according  to  hiin,  has  a  causal"  but  not 
a  teleological  origin,  and  which  therefore  must  ex- 
clude the  personal  immortality  idea  and  the  '"sitt- 
liche  Weltordnung.'  Haeckel  has  many  followers 
and  perhaps  as  many  opponents.  \\'e  hope  that  it 
will  be  granted  to  Professor  Haeckel  to  be  able  to 
enjoy  the  days  of  rest  which  he  has  well  earned 
after  so  many  years  of  arduous  labor. 

A  TOURXAL  OF  GYX.^ICOLOGICAL 
UROLOGY. 
The  publishing  house  of  Johann  Ambrosius 
Earth,  of  Leipsic,  which  for  about  a  year  now  has 
pitblished  several  Zeutralhllitter,  has  added  to  its 
list  of  medical  journals  the  Zcitschrift  fi'ir  gynd- 
kologische  Urologic,  edited  by  Professor  ^V. 
Stockel,  of  Marburg.  Among  the  collaborators  we 
find  Dr.  Baisch,  of  Mimich ;  Professor  Franz,  of 
Jena;  Professor  Henkel,  of  Greifswald ;  Professor 
Jung,  of  Erlangen ;  Dr.  Knorr,  of  Berlin ,  Pro- 
fessor Kromer,  of  Berlin;  Professor -Kronig,  of 
Freiburg ;  Professor  Menge,  of  Heidelberg ;  Pro- 
fessor Reifferscheid,  of  Bonn;  Professor  Sellheim. 
of  Tubingen ;  and  Professor  Zangemeister,  of 
Konigsberg,  Prussia. 


342 


NEIVS  ITEMS. 


[New  York 
Medical  Journat.. 


Changes  of  Address. — Dr.  Charlotte  Farrington,  from 
Dorchester.  Mass..  to  Atherton  and  Copley  Streets.  Boston. 

Dr.  Howard  A.  Sutton,  to  314  South  Fifteenth  Street, 
Philadelphia. 

Dr.  Osier  to  Visit  Baltimore. — It  is  announced  that 
Dr.  William  Osier  will  attend  the  dedication  of  the  Medical 
and  Chirurgical  Library,  Baltimore,  which  will  take  place 
on  May  13th.  He  is  expected  to  reach  Baltimore  about 
May  1st. 

An  Antispitting  Crusade  in  New  York. — The  Health 
Department  of  New  York  has  renewed  its  efforts  to  pre- 
vent spitting  in  public  places,  and  the  antispitting  ordinance 
is  being  rigidly  enforced.  In  one  day  over  two  hundred 
men  were  arrested  and  fined. 

Missouri  Physicians  in  the  Army  Medical  Reserve 
Corps. — Commissions  as  tirst  lieutenant  in  the  }iledical 
Reserve  Corps  of  the  United  States  Army  have  been  re- 
ceived by  Dr.  Harvey  G.  Mudd,  of  St.  Louis,  and  Dr.  Ed- 
ward H.  Skinner,  of  Kansas  City. 

Personal.— Dr.  .Andrew  F.  Currier,  of  Mount  Vernon, 
A'.  Y.,  has  been  appointed  one  of  the  associate  surgeons  of 
the  Woman's  Hospital,  West  One  Hundred  and  Tenth 
Street,  New  York. 

Dr.  R.  J.  Jones,  of  Vanderbilt  University,  has  been  elect- 
ed city  bacteriologist  and  chemist  of  Nashville,  Tenn. 

The  East  Side  Physicians'  Association  of  New  York 
w\\\  hold  a  clinical  meeting  at  the  Cafe  Boulevard  on  Fri- 
day evening,  February  19th.  An  extensive  programme, 
consisting  of  the  reports  of  interesting  cases  and  the  presen- 
tation of  patients,  has  been  prepared,  and  a  good  time  is 
expected.  The  annual  dinner  of  the  society  will  be  given  at 
the  Hotel  ^Majestic  on  Wednesday,  February  24th. 

Contagious  Diseases  in  Chicago. — During  the  week 
ending  January  30.  1909,  there  were  821  cases  of  contagious 
diseases  reported  to  the  Department  of  Health,  a  reduction 
of  84  from  the  preceding  week.  The  cases  reported  were 
as  follows :  Diphtheria.  173 ;  scarlet  fever,  190 ;  measles,  91 ; 
chickenpox,  no:  pneumonia,  39;  typhoid  fever,  48;  whoop- 
ing cough,  15;  tuberculosis,  53;  diseases  of  minor  impor- 
tance, T02. 

Legal  Psychology  and  Psychiatry. — The  second  inter- 
national postgraduate  course  of  lectures  on  the  legal  as- 
pects of  psychology  and  psychiatry  will  be  held  in  Giessen, 
Germany,  during  Easter  week.  Dr.  Robert  Sommer,  pro- 
fessor of  psychiatry  in  the  University  of  Giessen,  who  has 
the  matter  in  charge,  will  be  aided  by  Professor  Mitter- 
maier  and  Professor  Danncman,  of  Giessen,  and  Professor 
Aschaffenburg.  of  Cologne. 

The  Darwin  Centenary. — In  commemoration  of  the 
one  hundredth  anniversary  of  Darwin's  birth,  which  occurs 
on  Friday,  February  12th,  the  Pathological  Society  of  Phil- 
adelphia "arranged  a  special  programme  for  its  February 
nth  meeting.  Dr.  Arthur  Erwin  Brown,  of  the  Academy 
of  Natural  Sciences,  read,  by  invitation,  a  paper  on  Darwin 
and  his  Work,  and  Dr.  Charles  W.  Burr  read  a  paper  on 
the  Influence  nf  Darwin  on  Medical  Thought. 

Vacancies  in  the  House  Staff  of  Mount  Sinai  Hos- 
pital.—The  exani'nation  of  candidates  for  appointment 
on  the  house  staff  of  Mount  Sinai  Hospital  will  be  held 
at  the  hospital  -on  Tuesday,  March  23d,  and  Thursday, 
March  25th.  All  graduates  in  medicine,  or  men  to  be  grad- 
uated before  July  i.  1909,  are  eligible.  For  application 
blanks  and  circulars  of  information  address  Dr.  B.  Sachs, 
One  Mundredth  Street  and  Fifth  Avenue,  New  York. 

The  German  Students'  Association,  of  Philadelphia, 
whose  memlKT'^hip  consists  of  men  who  ha\e  studied  at 
German  universities,  met  at  the  Hotel  Walton  on  Thursday 
night,  February  4tli.  Among  those  present  were  the  fol- 
lowing well  known  Philadelphia  physicians :  Dr.  Hobart 
Amory  Flare,  Dr.  L.  Webster  Fox,  Dr.  Judson  Daland.  Dr. 
W.  D.  Van  Lennep.  Dr.  Isaac  Ott,  Dr.  Ross  H.  Skillern, 
Dr.  John  H.  Wa-ihbtirn,  Dr.  Charles  F.  Himes,  and  Dr. 
William  H.  Wahl. 

The  Health  of  Pittsburgh. — During  the  week  ending 
January  30.  iqoo.  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  :  Chickenpox, 
.76  cases,  o  deaths:  typhoid  fever.  19  cases,  i  death;  scarlet 
fever,  31  cases.  3  deaths:  diphtheria,  12  cases.  0  deaths: 
measles.  30  cases,  i  death ;  wliooping  cough,  14  cases,  4 
deaths :  pulmonary  tuberculosis,  42  cases,  10  deaths.  The 
total  denths  for  the  week  numbered  163,  in  an  estimated 
population  of  565.000,  corresponding  to  an  annual  death 
rate  of  15.00  in  i.ooo  of  population. 


Free  Tuberculin  for  Chicago  Physicians. — The  De- 
partment of  Health  of  Chicago  have  announced  that  tuber- 
culin for  diagnostic  purposes  will  be  furnished  free  of 
charge.  Physicians  can  obtain  a  supply  on  application  at 
the  laboratory,  215  Madison  Street,  Chicago. 

Gift  to  Springfield,  Mass.,  Hospital. — The  trustees  of 
this  hospital  announce  the  receipt  of  a  gift  of  $10,000  from 
Miss  Ella  M.  Gaylord,  Mr.  James  L.  Pease,  and  Miss 
Louise  Pease,  all  of  Chicopee.  The  money  was  given  for 
the  purpose  of  providing  aii  addition  to  the  operating  room 
of  the  hospital,  in  memory  of  Mrs.  Louise  J.  Gaylord 
Pease. 

The  Pathology  of  Childhood. — At  a  joint  meeting  of 
the  Philadelphia  Pathological  Society  and  the  Pasdiatric 
Society  of  Philadelphia,  to  be  held  in  the  College  of  Phy- 
sicians of  Philadelphia  on  the  evening  of  February  25th,  the 
various  phases  of  the  pathology  of  childhood  will  be  dis- 
cussed. There  will  be  an  exhibition  of  specimens,  to  which 
the  members  of  both  societies  are  asked  to  contribute. 
Among  the  papers  which  will  be  read  is  one  on  the  Pa- 
thology of  the  Thymus  Gland,  by  Dr.  John  Howland,  of 
New  York. 

The  Connecticut  Milch  Goat  Keepers'  Association 

held  its  first  annual  meeting  in  West  Hartford,  Conn.,  Feb- 
ruary 2d.  Mr.  George  W.  Smith,  of  Melrose,  the  president 
of  the  society,  made  a  demonstration  analysis  of  cows'  milk 
and  goats'  milk,  to  compare  the  amount  of  fats  and  solids 
in  each,  with  the  following  result:  Cows'  milk,  4.4  per  cent, 
fat.  14.16  per  cent,  solids;  goats'  milk,  5.8  per  cent,  fat, 
15.46  per  cent,  solids.  The  membership  of  the  organization 
includes  a  number  of  physicians. 

Prizes  for  Essays  on  the  Medicinal  Value  of  the  Sun's 
Rays. — The  will  of  Dr.  Charles  Denison,  who  died  re- 
cently in  Denver,  provides  for  a  bequest  of  $10,000  to  be 
used  for  prizes  for  essays  on  the  relations  of  the  sun's  rays 
to  health.  A  prize  of  $1,000  will  be  given  biennially  for  the 
best  essay  on  the  subject.  The  committee  appointed  to  take 
charge  of  the  matter  will  invest  the  money  so  as  to  pay  the 
prize  out  of  the  interest,  leaving  the  principal  intact,  and 
thus  perpetuate  the  contest,  which  was  Dr.  Denison's  wish. 

The  Ambulance  Service  of  New  York  City. — A  bil! 
was  introduced  into  the  Assembly  on  February  5th  by  Mr. 
James  J.  Hoey,  of  New  York,  providing  for  the  establish- 
ment of  a  more  adequate  ambulance  service  in  all  the  bor- 
oughs of  Greater  New  York.  Under  the  provisions  of  this 
measure  the  ambulance  system  would  be  placed  under  the 
control  of  the  Department  of  Health,  who  w'ould  divide  the 
city  into  districts  and  arrange  with  hospitals  for  ambu- 
lance service.  The  bill  provides  for  the  appointment  of  all 
the  employees  that  would  be  necessary  to  carry  out  the 
plan. 

A  Special  Train  to  Atlantic  City  from  the  West  and 
Southwest  IS  being  arranged  for  by  the  members  of  the 
Medical  Society  of  the  Missouri  Valley  and  the  Medical 
Association  of  the  Southwest,  who  intend  to  go  to  Atlantic 
City  next  June  to  attend  the  annual  meeting  of  the  Ameri- 
can Medical  Association,  This  train  will  start  from  St. 
Louis  via  the  Big  Four  and  the  C.  &  O.  railway,  stopping 
over  at  Flot  Springs,  Va.,  where  the  delegates  will  be  en- 
tertained at  the  Homestead,  and  plans  are  being  made  for 
a  boat  trip  to  New  York,  returning  by  way  of  Washington, 

D.  C.  or  Niagara  Falls. 

The  New  Presbyterian  Hospital. — A  site  for  the  new 
buildings  of  the  Presbyterian  Hospital  has  been  purchased 
at  Sixty-seventh  and  Si.Kty-eighth  streets  and  Avenue'  A. 
The  property  purchased  reaches  from  Avenue  A  to  the 
East  River.  No  building  can  be  undertaken  until  after 
the  exjiiration  of  leases  in  igio.  and  as  yet  no  plans  ha\e 
been  prepared.  The  hospital  has  occupied  its  present  site 
at  Seventieth  Street  and  Madison  Avenue  since  1872,  and, 
as  the  neighborhood  has  developed  into  a  fashionable  one. 
the  corporation  will  proliablv  reap  a  handsome  profit  from 
the  sale  of  the  property  when  the  present  buildings  are 
abandoned. 

The  Archives  of  Diagnosis  has  entered  upon  its  sec- 
ond year  under  very  faxorablc  auspices.  The  first  issue 
for  1909,  which  is  dated  January,  contains  nine  original 
comniuiiications  by  the  following  well  known  members  of 
the  medical  profession  :  Dr.  Henry  L.  Eisner,  of  Syracuse; 
Dr.  Henry  Koplik,  of  New  York;  Dr.  John  R.  Dcaver,  of 
Philadelphia:  Dr.  Charles  Greene  Cumston.  of  Boston; 
Dr.  Tom  A.  Williams,  of  Washington,  D.  C. ;  Dr.  George 

E.  Pfahler,  of  Philadelphia:  Dr.  W.  Sohier  Bryant,  of 
New  York:  and  Dr.  Franz  M.  Groedel,  of  Bad  Xauhcim. 
Germany.  The  publication  is  a  quarterly  and  is  edited  by 
Dr.  lleinrich  Stern. 


February  13,  1909.] 


NEWS  ITEMS. 


343 


Fellowship  in  Pathology. — Announcement  is  made 
that  a  meeting  of  the  Committee  on  the  George  Blumen- 
thal,  Jr.,  Fellowship  in  Pathology,  Mount  Sinai  Hospital, 
New  York,  will  be  held  in  March  to  appoint  a  fellow  for 
the  ensuing  year.  This  fellowship,  which  was  established 
for  the  purpose  of  furthering  the  scientific  work  of  the 
hospital,  and  also  to  aid  graduates  in  medicine  who  were 
desirous  of  obtaining  a  more  thorough  laboratory  training, 
carries  with  it  an  allowance  of  $500.  The  work  may  be 
done  in  Mount  Sinai  Hospital,  or  elsewhere,  according  to 
agreement  with  the  committee  in  charge.  All  graduates  in 
niedicine  are  eligible  for  this  appointment,  and  applications 
should  be  sent  on  or  before  March  15,  1909.  to  Dr.  F.  S. 
Mandlebaum.  pathologist  to  Mount  Sinai  Hospital. 

Infectious  Diseases  in  New  York: 

l!'e  are  indebted  fo  the  Bureau  of  Records  of  the  De- 
partiiteiit  of  Health  for  the  foUoiving  statement  of  nczv 
cases  and  deaths  reported  for  the  tzi'o  zveeks  ending  Feb- 
ruary 6,  igog: 

^January  30— ^  *  ^February  6-- 
Cases.    Deaths.    Cases.  Deatlis. 

Tuberculosis  pulmonalis    462         173         487  180 

Diphtheria    369  43         422  42 

Measles    505  18         521  28 

i>carlet  fever    360  26         370  21 

Smallpox  

Varicella    234  . .  225 

Typhoid  fever    32  7  26  7 

Whooping  cough    68  5  50  3 

Cerebrospinal  meningitis    5  4  12  11 

Totals   2,035         276       2.113  292 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  February  20,  1909: 

Monday,  February  13th. — Medical  Jurisprudence  Society; 
Medical  Society  of  the  Woman's  Hospital. 

TuESD.vY,  February  i6th. — Dermatological  Society ;  Acad- 
emy of  Natural  Sciences ;  North  Branch,  Philadelphia 
County  Medical  Society. 

Wedxesd.w,  February  jjih. — Section  in  Otology-  and  Lar- 
j'ngologj'.  College  of  Physicians ;  Franklin  Institute. 

Thursd.w,  February  i8th. — Section  in  Ophthalmology.  Col- 
lege of  Physicians;  Section  Meeting,  Franklin  Insti- 
tute ;  Southwark  IMedical  Society ;  Northeast  Branch, 
Philadelphia  County  Medical  Society ;  Delaware  Val- 
ley Ornithological  Club, 

Friday,  February  igth. — American  Philosophical  Society ; 
Philadelphia  Academy  of  Stomatology. 

The  Health  of  the  Canal  Zone. — During  the  month 
of  December,  1908,  there  were  275  deaths  in  the  Canal  Zone 
in  a  population  of  126,279,  corresponding  to  an  annual  death 
rate  of  26,15  in  one  thousand  population,  Tliere  was  one 
death  from  tj-phoid  fever,  35  from  malarial  fever,  4  from 
xstivoautumnal  malaria,  4  from  hsemoglobinuric  fever,  i 
from  dysentery,  3  from  amoebic  dysentery.  4  from  beriberi, 
3  from  purulent  infection  and  septicha;mia,  30  from  tuber- 
culosis of  the  lungs.  3  from  general  tuberculosis,  i  from 
syphilis,  4  from  carcinoma,  I  from  acute  articular  rheuma- 
tism, I  from  leuchsemia,  i  from  general  gangrene,  2  from 
epidemic  cerebrospinal  meningitis,  2  from  tetanus,  i  from 
bronchopneumonia,  30  from  pneumonia,  22  from  diarrhoea 
and  enteritis  under  two  years  of  age,  and  i  from  puerperal 
septich?emia.  There  were  50  deaths  from  violence ;  an  un- 
usual number,  which  helped  to  raise  the  mortality  rate  for 
the  month.  The  morbidity  rate  among  the  employees  of 
the  Canal  Commission  was  25.95  in  a  thousand. 

The  Prevention  of  Blindness. — The  New  York  Asso- 
ciation for  the  Blind  recently  organized  a  Special  Commit- 
tee on  the  Prevention  of  Blindness,  whose  purpose  it  was  to 
ascertain  the  direct  causes  of  preventable  blindness  and  to 
take  such  measures,  in  cooperation  with  the  medical  pro- 
fession, as  iTiight  lead  to  the  elimination  of  such  causes. 
This  comiTiittee  has  just  issued  a  very  interesting  and  in- 
forming pamphlet  entitled  Children  Who  Need  Not  Haze 
Been  Born  Blind.  From  statistics  compiled  by  this  com- 
mittee it  aopears  that  ophthalmia  neonatorum  is  responsible 
for  one  quarter  of  all  cases  of  total  blindness  from  birth, 
and  of  one  tenth  of  the  whole  number  of  the  totally  blind 
of  all  ages.  The  suppression  of  this  disease  is  the  aim  of 
the  committee,  by  means  of  education  and  legislation,  and 
they  seek  the  cooperation  of  the  medical  profession,  the 
State  and  City  boards  of  health,  the  State  and  county  med- 
ical societies,  and  all  organizations  and  individuals  inter- 
ested in  this  vitally  important  subject. 


The  Alumni  Association  of  the  Medical  College  o£ 
Ohio  met  recently  at  the  oltices  of  Dr.  Robert  Car- 
rothers  and  Dr,  Charles  L.  Bonifield,  Cincinnati,  and  elect- 
ed the  following  officers  for  the  year  1909:  President,  Dr. 
C.  C.  Fite;  first  vice-president,  Dr,  William  Mithoefer;  sec- 
ond vice-president,  Dr,  John  D.  Miller ;  third  vice-president. 
Dr.  Charles  T.  Souther;  treasurer,  Dr,  William  Strietman ; 
secretary.  Dr.  Sidney  Lange ;  chairman  of  membership  com- 
mittee. Dr.  T.  W.  Reev ;  chairman  of  programme  commit- 
tee, Dr.  R.  B.  Cofield. 
University  News: 

Dr.  H  P.  Cady,  professor  of  chemistry  in  the  University 
of  Kansas,  has  been  appointed  official  weather  observer  by 
the  board  of  regents,  to  carry  on  the  work  begun  by  the 
late  Dr.  Snow. 

The  University  of  Chicago  has  received  from  Mr,  Rocke- 
feller another  gift  of  $1,000,000, 

Dr.  Charles  W.  Duval  has  been  appointed  e.xtraordinary 
professor  of  pathological  anatomy  and  bacteriology  at  the 
Tulane  University,  New  Orleans. 

Dr.  John  H.  Landis  has  been  appointed  professor  of 
hygiene  at  the  Miami  Medical  College,  Cincinnati,  to  suc- 
ceed Dr.  Samuel  F.  Allen. 

The  Mortality  of  Chicago  during  the  week  ending 
January  30,  1909,  was  low.  The  total  number  of  deaths 
from  all  causes  reported  to  the  Department  of  Health  was 
545.  a  reduction  of  77  from  the  preceding  week,  and  166 
less  than  for  the  corresponding  period  in  1908.  The  annual 
death  rate  in  a  thousand  population  was  12.77,  as  against  a 
death  rate  of  14.57  for  the  previous  week,  and  17.12  for  the 
corresponding  week  of  last  year.  The  principal  causes  of 
death  were :  Diphtheria,  9  deaths ;  scarlet  fever,  16  deaths ; 
measles,  3  deaths ;  whooping  cough,  i  death ;  influenza,  3 
deaths ;  typhoid  fever,  4  deaths ;  diarrhoeal  diseases,  38 
deaths,  of  which  34  were  under  two  years  of  age;  pneu- 
monia, 87  deaths :  tuberculosis  of  the  lungs,  72  deaths ; 
other  forms  of  tuberculosis,  12  deaths ;  cancer,  22  deaths ; 
nervous  diseases,  16  deaths :  heart  diseases.  48  deaths ; 
apoplexy,  10  deaths ;  bronchitis,  6  deaths ;  Bright's  disease, 
44  deaths :  violence,  39  deaths,  of  which  1 1  were  suicides ; 
all  other  causes.  115  deaths. 

The  Herbst  Medical  Bill  has  been  introduced  into  the 
State  Legi>lature  of  Pennsylvania.  This  bill  provides  that 
everv  person  who  desires  to  practise  medicine  in  the  State 
of  Pennsylvania  shall  pass  an  examination  before  a  State 
Board  of  Medical  Examiners  composed  of  eight  physicians 
and  the  State  superintendent  of  public  instruction.  The 
new  law  will  abolish  the  old  plan  of  three  separate  exam- 
ining boards.  The  bill  also  contains  the  following  defini- 
tion of  the  practice  of  medicine  : 

"That  a  person  practises  medicine  within  the  meaning 
of  this  act  who  holds  himself  or  herself  out  as  being  able 
to  diagnose,  treat,  operate  upon  or  prescribe  for  any  human 
disease,  pain,  injury,  deformity  or  physical  condition,  and 
who  shall  either  offer  or  undertake,  whether  with  or  with- 
out drugs,  medicines  or  instruments,  and  whether  with  or 
without  fee  therefor,  by  any  means  or  method  to  diagnose, 
treat,  operate  upon  or  prescribe  for  any  luiman  disease, 
pain,  injury,  deformity  or  physical  condition ;  provided, 
however,  that  this  act  shall  not  apply  to  the  practice  of 
dentistry,  the  regulation  of  which  is  now  provided  for  by 
law." 

Lectures  on  Infant  Feeding. — A  series  of  lectures  on  in- 
fant feeding  and  hygiene  has  been  arranged  by  the  Associa- 
tion of  Physicians  of  the  New  York  City  Milk  Depots,  whose 
membership  consists  of  twenty-nine  physicians  who  are  at- 
tending to  the  feeding  and  work  of  instruction  carried  on 
in  connection  with  the  milk  stations  of  the  New  York  ^lilk 
Committee,  These  lectures,  which  will  be  held  in  the  As- 
sembly Hall  of  the  United  Charities  Building,  105  East 
Twenty-second  Street,  during  the  months  of  February, 
March,  and  April,  are  intended  not  only  for  doctors,  nurses, 
and  social  workers,  but  for  everybody  who  is  interested  in 
the  subject,  A  tentative  programme  of  lectures  has  been 
arranged  as  follows :  Friday,  February  19th — General  Prin- 
ciples of  Infant  Feeding,  by  Dr,  Godfrey  R.  Pisek :  Wed- 
nesday. March  3d — The  Value  of  Fats  in  Infant  Feeding, 
by  Dr.  John  Howland :  Saturday.  March  13th — Infant  Feed- 
ins::  Its  Relation  to  Infant  Mortality,  by  Dr,  Joseph  E. 
Winters:  Friday,  March  26th — Value  of  Carbohydrates  in 
Infant  Feeding,  by  Dr,  Henry  I>\vight  Chapin  ;  W'^ednesday, 
April  T4th — ^lilk  Sanitation,  by  Dr,  Rowland  G.  Freeman; 
Friday,  April  23d — -Hjgiene  of  Infancy,  by  Dr,  William  P. 
Northrup :  Friday,  April  .30th — Dietary  of  Children  after 
the  First  Year,  bv  Dr.  L.  E.  La  Fetra. 


344 


NEirS  HEMS. 


[New  Vokk 
Medical  Journal. 


A  "Symposium"  on  Trifacial  Neuralgia  has  been  ar- 
ranged for  the  February  19th  meeting  of  the  Philadelphia 
Academy  of  Stomatology.  Dr.  J.  Bethune  Stein,  of  New 
\ork,  will  show  some  interesting  lantern  slides  made  from 
the  jaw  of  a  dog,  where  the  inferior  dental  canal  has  been 
e.xtirpated  without  touchnig  the  tips  of  the  adjacent  teeth. 
Dr.  Truman  W.  Brophy,  of  Chicago,  will  rend  a  short 
paper  dealing  with  the  peripheral  causes  of  trifacial  neural- 
gia and  its  surgical  treatment.  Dr.  John  B.  Deaver,  of 
Philadelphia,  will  read  a  paper  on  the  intracranial  causes 
of  trifacial  neuralgia  and  its  surgical  treatment.  The 
symptomatology  and  medical  treatment  of  the  disease  will 
be  considered  in  a  paper  by  Dr.  John  K.  Mitchell,  of  Phila- 
delphia. Physicians  and  dentists  of  wyrld  wide  reputation 
will  take  part  in  the  discussion.  Arrangements  are  also 
being  made  for  a  number  of  surgical  clinics  to  be  held  on 
Saturday  afternoon 

The  State  Association  of  Boards  of  Health  of  Mas- 
sachusetts held  its  annual  meeting  in  Boston  on  Janu- 
uary  28th.  Dr.  Henry  P.  Walcott,  chairman  of  the  State 
Board  of  Health,  presided.  There  was  an  attendance  of 
about  seventy-five  health  connnissioners  from  various  pans 
of  the  State.  The  principal  subject  discussed  was  the  prac- 
tice of  exposing  food  stuflfs  to  street  dust,  and  its  effect 
upon  public  health.  Dr.  Francis  H.  Slack,  director  of  the 
Boston  Health  Laboratory,  read  a  paper  on  the  subject  in 
which  he  gave  the  results  of  an  investigation  of  the  subject 
from  a  bacteriological  standpoint.  Dr.  Elliott  Washburn, 
of  Taunton,  read  a  paper  on  the  duties  and  experiences  of 
State  health  inspectors,  which  was  well  received.  The  offi- 
cers of  the  association,  all  of  whom  were  reelected  at  the 
meeting,  are  as  follows :  President,  Dr.  H.  P.  Walcott,  of 
Cambridge,  chairman  of  the  State  Board  of  Health ;  vice- 
president,  Dr.  S.  H.  Durgin,  chairman  of  the  Boston  Board 
of  Health;  secretary,  James  C.  Coffey,  of  Worcester;  treas- 
urer, Dr.  James  B.  Field. 

Feebleminded  Children. — A  two  weeks'  course  of  lec- 
tures dealing  with  the  problems  relating  to  feebleminded 
and  psychopathic  children  has  been  arranged  by  the  Neu- 
rological Institute  in  Frankfort  on  the  Main,  to  be  held 
in  connection  with  tlie  Frankfort  Special  Classes  (Help 
Schools),  the  latter  part  of  June.  These  lectures,  which 
are  intended  for  those  who  are  cither  already  professionally 
engaged  in  the  work  or  who  wish  to  prepare  themselves  for 
it.  will  include  the  following  subjects:  Normal  and  patho- 
logical anatomy  of  the  juvenile  brain;  child  psj'chology ; 
p-~ychopathology  of  j'outh  ;  instruction  of  the  feebleminded; 
methods  of  teaching;  organization;  hand  training;  institu- 
tional affairs  and  care  of  the  inmates :  clinic  for  feeble- 
minded children;  care  and  education  in  institutions  and 
forensic  psychiatry;  juvenile  courts:  social  care;  speech 
tlierapeutics  (articulation);  hygiene:  care  for  the  deaf- 
diuTib,  the  blind,  and  cripples.  In  addition  to  the  lectures, 
which  will  be  accompanied  by  demonstrations  and  the  pre- 
sentation of  patients,  plans  are  being  made  to  visit  a  num- 
ber of  schools  for  the  feebleminded,  institutions  of  various 
kinds,  clinics,  etc.  A  detailed  programme  will  be  issued 
in  the  spring.  For  particulars  address  Dr.  ?I.  Vogt,  Neu- 
rologisches  Institut.  Gartenstrasse.  Frankfurt  a.  M. 

A  Discussion  of  the  Tuberculosis  Situation  took  the 
place  of  the  usual  programme  of  scientific  papers  at  the  an- 
nual meeting,  of  the  Associated  Physicians  of  Long  Island, 
held  on  Saturday,  January  30th.  Dr.  Walter  B.  Brinsmade 
presided.  The  first  speaker  was  Dr.  Livingston  Farrand, 
executive  secretary  of  the  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis,  who  presented  some 
startling  statistics  on  the  prevalence  of  tuberculosis  in  the 
Ignited  States  and  recommended  measures  for  the  preven- 
tion of  the  spread  of  the  disease.  The  Hon.  Robert  W. 
Hebberd,  Commissioner  of  Charities  of  the  City  of  New 
York,  was  the  next  speaker,  who  delivered  an  address  on 
what  the  city  is  doing  and  what  it  proposes  to  do  with  the 
tuberculosis  problem.  Mr.  James  Jenkins,  Jr.,  secretary  of 
the  Committee  on  the  Prevention  of  Tuberculosis  of  the 
Brooklyn  Bureau  of  Charities,  also  spoke.  Tlie  annual  bati- 
quet  of  the  association,  which  was  gi\en  in  the  evening, 
was  especially  enjoyable.  The  following  officers  were 
elected  to  serve  for  the  ensuing  year :  Dr.  Frank  T.  Delano, 
of  Brooklyn,  president ;  Dr.  Thomas  R.  French,  of  Brook- 
lyn, first  vice-president ;  Dr.  Frank  Overton,  of  Patchogue. 
second  vice-president;  Dr.  William  B.  Brinsmade,  of 
P.rooklyn,  third  vice-president ;  Dr.  James  Cole  Hancock, 
of  Brooklyn,  secretary,  and  Dr.  Cliarles  R.  Bacon,  of 
Brooklyn,  treasurer. 


The  Medical  Association  of  the  Greater  City  of  New 
York  will  hold  a  stated  meeting  in  Du  Bois  Hall,  New 
York  Academy  of  Medicine,  on  Monday  evening,  February 
15th,  at  8:30  o'clock.  The  Medical  Importance  of  the  Study 
of  Anthropology  is  the  title  of  a  paper  which  will  be  read 
by  Major  Charles  E.  Woodruff,  surgeon  in  the  United 
States  Army.  The  paper  will  be  illustrated  with  lantern 
slides,  and  will  contain  many  interesting  observations  made 
in  medical  practice  in  the  tropics.  It  will  be  discussed  by 
Dr.  Livingston  Farrand,  professor  of  anthropology'  in  Co- 
lumbia University,  and  Dr.  Woods  Hutchinson.  Dr.  Wil- 
liam B.  Coley  will  read  a  paper  on  the  Value  of  the  Mixed 
Toxines  of  Erysipelas  and  Bacillus  Prodigiosus  in  Inoper- 
able Sarcoma,  which  is  based  upon  a  study  of  cases  treated 
by  the  author  during  the  past  sixteen  years.  Among  those 
who  will  take  part  in  the  discussion  of  this  paper  are  Dr. 
Virgil  P.  Gibuc}-,  Dr.  A.  G.  Gerster,  Dr.  Howard  Lilienthal, 
and  Dr.  P.  M.  Pilcher.  A  Contribution  to  the  Treatment 
of  Cancers  is  the  title  of  a  paper  to  be  read  by  Dr.  G.  Am. 
Ende,  and  discussed  by  Dr.  Joseph  C.  Taylor. 

Charitable  Bequests. — By  the  will  of  Sylvester  Cun- 
ningham, of  Gloucester,  Mass.,  the  Addison  Gilbert  Hob- 
pital,  Gloucester,  receives  $10,000. 

By  the  will  of  Henry  C.  Jones,  who  died  recently,  the 
Delaware  Hospital,  Wilmington,  Del.,  receives  $10,000,  to 
endow  a  room  and  also  an  additional  bed  in  the  hospital. 

By  the  will  of  Mrs.  Catharine  Conant,  who  died  in  New- 
ark, N.  J.,  on  January  13,  1909,  the  Homoeopathic  Hospital, 
Newark,  receives  $5,000,  and  the  Hospital  for  Women  and 
Children  becomes  a  residuary  legatee. 

By  the  will  of  S.  B.  Latshaw,  of  Royersford,  Pa.,  the 
INIethodist  Episcopal  Hospital,  of  Philadelphia,  receives 
$5,000  for  the  establishment  of  the  Clarence  R.  Latshaw 
Memorial  Bed. 

By  the  will  of  Miss  Mary  Lewis,  the  Episcopal  Hospital, 
of  Philadelphia,  receves  $10,000;  the  Foulke  and  Long  In- 
stitute, of  Philadelphia,  the  Seaside  Home  for  Invalid 
Women,  the  Home  for  Consumptives,  the  West  Philadel- 
phia Hospital  for  Women,  the  Kensington  Hospital  for 
Women,  and  the  Women's  Pennsylvania  Society  for  the 
Prevention  of  Cruelty  to  Animals  receive  $2,000  each;  the 
Polyclinic  Hospital  and  the  Woman's  Hospital,  of  Phila- 
delphia, receive  $5,000  each ;  the  Children's  Hospital,  of 
Philadelphia,  receives  the  residuary  estate,  subject  to  an- 
nuities of  $720  a  year  during  the  lives  of  three  persons. 

By  the  will  of  Catherine  T.  Mealey.  the  Little  Sisters  of 
the  Poor.  St.  Joseph's  Home  for  Orphan  Boys,  St.  John's 
Orphan  Asylum  and  the  Catholic  Society  of  St.  Joseph,  for 
the  education  and  maintenance  of  poor  orphans,  Philadel- 
phia, receive  equal  shares  of  the  residuary  estate. 

Society  Meetings  for  the  Coming  Week: 

MoxD.XY,  February  ijtli. — New  York  Academy  of  Medicine 
(Section  in  Ophthalmology)  ;  Medical  Association  of 
the  Greater  City  of  New  York;  Hartford.  Conn.,  Medi- 
cal Society. 

TuESD.w,  February  j6tJi. — New  York  Academy  of  Medi- 
cine (Section  in  Medicine)  :  Buffalo  .Academy  of  Medi- 
cine (Section  in  Pathology)  ;  Tri-Professional  Medical 
Society  of  New  York ;  Aledical  Society  of  the  County 
of  Kings.  N.  Y. :  Binghamton,  N.  Y.,  Academy  of  Med- 
icine :  Clinical  Society  of  the  Elizabeth,  N.  J.,  General 
Hospital ;  Syracuse,  N.  Y.,  Academy  of  Medicine ;  Og- 
densburgh.  N.  Y..  Medical  .\ssociation. 

Wf.ii.ve.sd.w.  February  jyth. — New  York  Academy  of  Med- 
icine (Section  in  Genitourinary  Diseases)  :  New  York 
Society  of  Dermatology  and  Genitourinary  Surgery ; 
Woman's  Medical  .\ssociation  of  New  York  City 
(New  York  .Academy  of  Medicine):  Medicolegal  So- 
ciet}-.  New  York:  New  Jersey  .Academy  of  Medicine 
(Jersey  City):  Buffalo  Medical  Club:  New  Haven, 
Conn.,  Medical  .Association  ;  New  York  Society  of  In- 
ternal Medicine :  Northwestern  Medical  and  Surgical 
Society  of  New  York. 

Thursd.w.  February  iSlIt. — New  York  .Academy  of  Medi- 
cine ;  German  Medical  Society,  Brooklyn ;  Newark, 
N.  J..  Medical  and  Surgical  Societv;  .Esculapian  Club 
of  Buffalo.  N.  Y. 

Frtdw.  February  Toth. — New  York  .Academy  of  Medicine 
(Section  in  Orthop.Tdic  Surgery):  Clinical  Societv  of 
the  New  York  Postgraduate  Medical  School  and  Hos- 
pital :  F.ast  Side  Physicians'  Association  of  the  City 
of  New  York;  New  York  Microscopical  Society; 
P.rooklyn  Medical  Society. 


February  13,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


345 


Jit|}  uf  Camnt  f  itfraturt. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

February  4,  IQOQ. 

1.  Internal  Concealed  Hsemorrhage, 

By  James  R.  Torbert. 

2.  The  Feeding  of  the  Infant  in  Health, 

By  Daniel  Rollins  Brown. 

3.  Congenital  Neurologia  Tissue  Nests  in  the  ^leninges  of 

the  Spinal  Cord.  Report  of  a  Case  Associated  with 
Other  Congenital  Defects,      By  Charles  T.  Ryder. 

4.  Osmic  Acid  Injection  for  the  Relief  of  Trifacial  Neu- 

ralgia, By  H.  H.  Germain. 

I.  Internal  Concealed  Haemorrhage. — Torbert 
states  that  internal  concealed  hjemorrhage  is  a  com- 
paratively rare  complication  of  pregnancy.  Unless 
diagnosticated  early  it  has  a  serious  prognosis.  It 
occurs  generally  in  the  last  two  months  of  preg- 
nancy, although  it  may  occur  as  early  as  the  sev- 
enth month.  The  diagnosis  is  made  by  careful  ex- 
amination of  both  the  mother  and  the  infant  within 
the  uterus.  The  importance  is  urged  of  an  exami- 
nation of  all  obstetric  cases  in  the  last  months  of 
pregnancy  and  a  close  watch  kept  on  both  the  ma- 
ternal and  foetal  pulse  during  the  progress  of  the 
labor.  Palpation  is  important  in  diagnosticating 
these  cases,  as  the  uterus  is  much  increased  in  size 
and  of  a  boardlike  consistency.  The  appearance  of 
acute  anjemia  with  manifestations  of  shock  in  a  pa- 
tient in  the  later  months  of  pregnancy  should  al- 
ways suggest  the  possibility  of  internal  concealed 
hemorrhage.  Early  diagnosis  is  essential  in  offer- 
ing a  favorable  prognosis  to  the  mother ;  that  of  the 
infant  is  bad. 

4.  Osmic  Acid  Injection  for  the  Relief  of  Tri- 
facial Neuralgia. — Germain  remarks  that  in  con- 
sidering the  subject  of  trifacial  neuralgia  one  is 
strttck  by  the  diverse  conditions  said  to  be  the  cause 
of  the  disease.  These  cases  may  be  divided  into 
three  great  classes:  i,  Neuralgia,  as  a  symptom  of 
some  general  disease;  anaemia,  diabetes,  etc.,  where 
there  are  usually  definite  nerve  changes  ;  neuritis. 

2,  reflex  intermittent  pain  due  to  some  local  cause, 
as  a  carious  tooth,  sinus  disease,  etc. ;  and  3,  true 
epileptiform  neuralgia,  to  which  neither  true  cause 
nor  favoring  conditions  can  be  assigned.  It  is  the 
latter  condition  which  we  are  called  upon  to  treat 
surgically  sooner  or  later  in  its  course.  The  chief  fea- 
tures of  this  true  major  neuralgia  are  well  summar- 
ized by  Hutchinson:  i.  It  is  almost  invariably  uni- 
lateral. 2.  It  commences  in  the  second  or  third  di- 
vision of  the  fifth  nerve  and  tends  to  involve  both. 

3.  The  first  division  is  involved  to  a  much  less  de- 
gree. 4.  Attacks  of  pain  are  paroxysmal  or  spas- 
modic and  tend  to  increase  in  severity,  with  short- 
ening intervals  of  freedom  from  pain.  5.  During 
each  attack  there  is  usually  spasm  of  the  facial  mus- 
cle of  the  aft'ected  side.  6.  The  stibjects  of  the  dis- 
ease are  usually  adults  between  the  ages  of  thirty 
and  fifty.  7.  Its  progress  is  one  of  increasing  se- 
verity. 8.  Medical  treatment  has  little  or  no  eft'ect. 
9.  Operations  on  peripheral  branches  give  temporary 
relief.  Partial  or  complete  removal  of  the  Gasserian 
ganglion  usually  cures.  It  has  been  common  ex- 
perience that  nerve  stretching,  nerve  section  and 
avulsion  of  the  whole  nerve  according  to  the  method 
of  Thiersch  is  followed  by  relief  from  pain  for  a 


longer  or  shorter  period  of  time.  All  of  these  pro- 
cedures are  followed  by  regeneration  of  the  periph- 
eral nerve  and  recurrence  of  pain.  The  period  of 
relief  varies  from  three  months  to  two  years,  but  is 
almost  never  permanent.  Of  late  years  certain  in- 
jection methods  have  been  in  vogue,  notably  osmic 
acid  injection  and  injections  of  alcohol.  Germain 
has  used  a  two  per  cent,  soltition  of  osmic  acid  in- 
jected directly  into  the  nerve  trunk  in  eleven  cases. 
He  believes  that  osmic  acid  injections  will  relieve 
trifacial  neuralgia  for  a  longer  or  a  shorter  period 
of  timie.  Relief  from  pain  is  not  immediate,  but  fol- 
lows in  a  few  days  after  injection.  It  may  be  fol- 
lowed by  a  certain  amount  of  necrosis  of  tissue  at 
the  point  of  injection,  and  it  is  little  if  any  better 
than  other  peripheral  operations.  It  is  best  used  in 
a  two  per  cent,  solution  injected  directly  into  the 
nerve,  using  a  glass  syringe  and  a  platinum  needle, 
and  it  should  be  used  only  in  purely  sensory  ners'es, 
as  its  employment  in  mixed  nerves  is  followed  by 
motor  paralysis. 

JOURNAL  OF  THE  AMERICAN  M EDICAL  ASSOCIATION. 

February  6,  Kjog. 

1.  Suture  of  Wounds  of  the  Heart, 

By  George  Tully  Vaughan. 

2.  A  Diphtheritic  Epidemic.    Its  Bearing  on  the  Question 

of  Bacillus  Carriers,  Animal  Carriers,  and  the  Neces- 
sity of  !More  Strict  Quarantine  Regulations, 

By  Jessie  Weston  Fisher. 

3.  Ten  Years  of  American  Sanitation  in  the  Philippines, 

By  W.  E.  ]\Iusgrave. 

4.  Treatment  of  Sciatica  by  Deep  Perineural  Infiltrating 

Injections  of  Salt  Solution,        By  D"Orsay  Hecht. 

5.  The   Duration   of  the   Actively   Infectious   Stage  of 

Tuberculosis, 

By  Robert  N.  Willson  and  Raxdle  C.  Rosenbergek. 

6.  Anasmias  of  Infancy,  By  John  Lovett  Morse. 

I.  Suture  of  Wounds  of  the  Heart. — Vaughan 
presents  a  table  of  150  patients  in  whom  the  heart 
was  sutured,  with  fifty-two  recoveries,  a  percentage 
of  65.  Thirty-two  patients  died  in  less  than  twenty 
hours  after  operation  or  the  reception  of  the 
wound,  fifteen  on  the  operating  table  during  or  just 
after  operation — nearly  all  from  loss  of  blood, 
though  one  death  was  attributed  to  pneumothorax 
on  opening  the  left  pletira.  Thus  thirty-two,  or 
twenty  per  cent.,  of  the  patients  were  moribund 
when  the  surgeon  first  saw  them.  The  remaining 
sixty-six  deaths  occurred  from  twenty-four  hours 
to  five  months  after  operation;  six  of  pleurisy,  five 
of  pericarditis,  twent3'-one  of  pleurisy  and  pericar- 
ditis together,  three  of  pneumonia,  three  of  peri- 
tonitis, two  of  pericarditis  and  nephritis,  one  of 
pleurisy  and  cerebral  abscess,  one  of  pleurisy  and 
wotind  of  the  trictispid  valve,  one  of  pleurisy  and 
double  pneumonia,  one  of  gangrene  of  the  hmg, 
one  of  two  wounds  of  which  one  was  not  sutured, 
three  of  haemorrhage  in  the  pleura,  two  of  haemor- 
rhage in  the  pericardium,  one  of  clot  in  the  trictis- 
pid valve,  and  in  fifteen  the  cause  was  not  given.  \\'e 
see  that  forty-four  of  those  who  died  after  the  first 
twenty  hours,  or  eighty-six  per  cent,  (omitting  the 
fifteen  in  which  the  cause  of  death  was  not  given), 
died  of  infection,  and  of  the  fifty-two  who 'recov- 
ered only  twelve  escaped  without  infection ;  twenty- 
iwo  had  pericarditis  or  pleurisy,  and  in  eighteen  it 
was  not  stated.  Of  the  entire  118  patients  surviv- 
ing the  first  tw^enty  hours,  sixty-two.  or  fifty-two 
per  cent.,  suft'ered  from  infection.    The  mortality 


346 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


with  reference  to  the  cavity  wounded  is  as  follows : 
Sixty-eight  of  the  left  ventricle  with  forty-two 
deaths,  or  sixty-two  per  cent. ;  sixty-eight  of  the 
right  ventricle  with  forty-eight  deaths,  or  seventy 
per  cent. ;  four  of  the  left  auricle  with  two  deaths, 
and  four  of  the  right  auricle  with  one  death.  Six- 
teen gunshot  wounds  were  operated  on  with  nine 
deaths  and  seven  recoveries,  a  mortality  of  fifty-six 
per  cent.  Of  the  134  patients  with  other  wounds 
eighty-nine  died  and  forty-five  recovered — mortal- 
ity, sixty-six  per  cent.,  from  which  it  would  appear 
that  gunshot  wounds  of  the  heart  have  about  ten 
per  cent,  lower  mortality  than  other  kinds  of  heart 
wounds.  He  concludes  that  there  is  no  longer  any 
Cjuestion  as  to  the  propriety  of  the  operation,  since 
thirty-five  per  cent,  of  the  patients  recover,  com- 
pared with  fifteen  per  cent,  (according  to  Holmes 
and  Fisher,  1881)  of  recoveries  after  nonoperative 
treatme!"rt — a  gain  of  twenty  per  cent.  The  mortal- 
ity is  practically  the  same  that  it  was  twelve  years 
ago,  when  the  operation  was  first  introduced,  and 
it  behooves  the  surgeon  to  study  the  matter  and  find 
a  means  of  improvement.  The  two  great  causes  of 
death  are  haemorrhage  and  inflammation  of  the 
pleura  or  pericardium.  Probably  little  more  can  be 
done  than  has  been  done  to  prevent  death  from 
haemorrhage,  but  inasmuch  as  more  than  half  the 
patients  who  survive  twenty  hours  have  infection, 
there  is  room  for  great  improvement  in  preventing 
infection.  Besides  the  observance  of  strict  asepsis, 
the  question  of  opening  the  pleura  and  of  drainage 
of  pleura  or  pericardium  acting  as  predisposing" 
causes  of  infection  is  of  the  greatest  importance. 
As  a  rule,  therefore,,  the  pericardium  and  pleura 
should  not  be  drained. 

2.  A  Diphtheria  Epidemic. — Fisher  reports  a 
diphtheria  epidemic  in  the  Connecticut  Hospital  for 
Insane,  lasting  from  April.  1907,  until  Alay,  1908. 
There  occurred  ninety-two  cases,  fifty-seven  of 
which  were  in  employes  and  thirty-five  in  insane 
patients.  During  this  period  the  throats  of  4,081 
healthy  individuals  were  examined,  with  the  resuit 
that  ninety-five  (2.08  per  cent.)  revealed  the  pres- 
ence of  the  Klebs-Loeffler  bacillus,  so  that  the  total 
number  of  people  under  quarantine  was  187.  He 
concludes  that  the  chief  source  of.  infection  in  this 
epidemic  were  latent  cases  (bacilli  carriers),  rats 
and  cats.  One  negative  throat  culture  is  insuf- 
ficient for  diagnosis.  Two  and  even  three  suc- 
cessive negative  throat  and  nose  cultures  do  not  con- 
stitute sufficiently  strict  quarantine  regulations  to 
prevent  the  spread  of  diphtheria.  In  institutions  in 
which  large  numbers  arc  congregated,  at  least  four 
successive  negative  cultures,  including  at  least  two 
nose  cultures,  are  imperative.  All  healthy  individ- 
uals carrying  bacilli  in  their  throats  should  be  iso- 
lated during  a  time  of  epidemic  in  institutions,  un- 
less wholesale  immunization  can  be  undertaken 
The  isolation  of  bacilli  carriers  in  private  practice 
is  neither  reasonable  nor  expedient.  liacillus  car- 
riers harbored  the  bacilli  longer  than  did  the  clin- 
ical ca.scs  of  diphtheria.  All  hypertrophied  tonsils 
should  be  treated  as  a  prophylactic  measure.  The 
Neisscr  stain  has  distinct  advantages  over  the  Loct- 
ficr  stain,  and  no  disadvantages.  Stained  smea'? 
arc  of  great  value  for  immediate  diagnosis.  The 


early  diagnosis,  made  possible  by  careful  culturing, 
permitting  of  early  treatment  with  antitoxine,  un- 
doubtedly diminished  the  severity  of  the  individual 
case,  and  the  severity  and  duration  of  the  epi- 
demic. Of  healthy  individuals  during  epidemic 
2.08  per  cent,  were  found  to  be  bacillus  carriers. 
When  no  epidemic  existed  nonvirulent  Klebs-Loef- 
fler bacilli  were  found  in  1.1+  per  cent,  of  healthy 
individuals,  No  virulent  Klebs-Loeffler  bacilli  were 
found  in  506  throat  cultures  three  months  after 
epidemic.  Two  weeks  is  the  limit  of  immunization 
for  1,000  units  of  intoxication. 

3.  Ten  Years  of  American  Sanitation  in  the 
Philippine  Islands. — Musgrave  states  that  as  a 
result  of  the  combined  influence  of  the  forces  con- 
cerned, Manila  is  to-day  quite  free  from  epidemics 
and  should  remain  so  in  the  future.  At  the  time  of 
our  occupation  of  Manila,  although  the  Spanish 
government  had  vaccine  laboratories  in  operation, 
smallpox  was  epidemic  and  received  no  more  atten- 
tion from  the  officials  than  did  any  other  ordinary 
disease.  A  compulsory  vaccination  law  was  passed 
and  executed  by  the  American  military  administra- 
tion, and  revaccination  has  been  going  on  steadily 
for  these  ten  years.,  until  now  the  entire  civilized 
population  of  the  islands  is  protected,  and  smallpox 
has  been  reduced  from  a  pest  to  sporadic  cases, 
which,  when  they  occur  in  Manila,  are  cared  for  in 
the  splendidly  equipped  new  hospital  built  especially 
for  this  service.  Diseases  transmitted  by  water  and 
food,  such  as  dysentery,  cholera,  typhoid  fever,  etc., 
constitute  by  far  the  most  important  group  of  dis- 
eases found  in  the  tropics.  When  we  came  to  Ma- 
nila there  was  practically  no  safe  drinking  water  in 
the  city,  while  to-day  the  daily  output  of  bottled  car- 
bonated waters  alone  is  over  50,000  bottles,  and  in 
addition  to  this  there  is  a  distilled  water  capacity  of 
over  20,000  gallons  per  day.  Most  of  these  waters 
are  used  for  drinking  and  culinary  purposes.  Ten 
years  ago  cold  storage  was  very  limited,  and  as  a 
consequence  spoiled  meats  and  vegetables  were  com- 
mon. In  addition  to  all  this,  dirty  workers  and  bad 
methods  of  transporting  foodstufi's  made  bad  condi- 
tions worse.  From  the  beginning  gastrointestinal 
and  other  water  borne  diseases  were  epidemic  and 
continued  so  for  the  first  few  years.  Now,  how- 
ever, dysenteries  of  all  kinds  have  been  reduced  to 
merely  sporadic  cases,  and  a  case  of  the  acute  kind 
is  rarely  seen.  Typhoid  fever  is  comparatively  rare, 
onlv  seventy-five  cases  occurring  in  the  last  5,000 
patients  admitted  to  the  clinic  in  St.  Paul's  Hospital. 
Cholera  epidemics  have  been  reduced  to  occasional 
small  outbreaks,  and  should  not  ever  again  assume 
serious  proportions  in  Manila.  Parasitic  and  other 
less  important  diseases  have  been  reduced  in  like 
proportion  in  the  capital.  Plague  has  never  had  a 
serious  hold  in  Manila,  and  with  the  present  system 
of  cleanliness,  destruction  of  rats,  and  notification, 
there  is  no  danger  of  the  disease  ever  becoming  epi- 
demic here.  Leprosy  has  been  common  in  the  Phil- 
ippines for  centuries,  and,  while  our  Spanish  prede- 
cessors, or  rather  one  order  of  the  Catholic  Church, 
maintained  a  leprosy  hospital  in  Manila,  it  was  en- 
tirelv  insufficient  for  the  needs  of  the  situation,  and 
lepers  were  everywhere  to  be  seen  on  the  streets  and 
in  public  places.  At  the  present  time  there  is  a  satis- 


rebruary  13,  1909.  J 


PITH  OF  CURREXT  LITERATURE. 


347 


factory  leper  colony  in  good  working  order,  and  the 
segregation  of  the  lepers  of  the  islands  is  almost 
completed.  In  ten  years  America  has  made  Alanila 
one  of  the  cleanest,  healthiest,  and  most  attractive 
cities  under  American  rule. 

4.  Salt  Injections  in  Sciatica. — Hecht  states 
that  the  deep  infiltrating  perineural  injections  pal- 
liate the  pain  of  sciatica.  The  acute,  subacute,  and 
chronic  types  of.  sciatica  lend  themselves  to  this 
treatment,  and  whereas  the  number  of  injections  re- 
quired vaiies,  immediate  notable  relief  is  atTorded 
by  the  first  injection  in  nearly  all  cases.  The  treat- 
ment is  most  indicated  and  efilective  in  the  non- 
symptomatic  cases,  but  is  also  of  value  in  the  symp- 
tomatic variety.  Normal  salt  solution  of  varying 
temperature  and  quantity,  or  the  betaeucaine  solu- 
tion of  Lange,  is  to  be  preferred  to  other  anaesthetic 
or  mordant  solutions.  Alcohol  is  harmful  and  con- 
tramdicated.  The  sciatic  nerve  may  be  reached 
deep  in  the  ischiotrochanteric  hollow  (its  perineal 
branch  lower  down  at  the  capitiilum  fibulae) .  but  it 
is  more  surely  and  safely  reached  directly  after  its 
emergence  from  the  notch.  The  point  for  puncture 
and  penetration  to  the  nerve  is  best  determined  by 
drawing  a  line  between  the  posteroexiorral  border 
of  the  great  trochanter  and  the  sacrococcygeal 
joint;  at  the  junction  of  the  inner  third  and  outer 
two  thirds  of  this  line  is  the  spine  of  the  ischium. 
A  thumb's  breadth  to  the  outer  side  of  this  spine 
lies  the  sciatic  nerve.  The  method  requires  a 
syringe  (preferably  metal)  with  a  capacity  for  30 
to  60  c.c.  or  more,  and  a  needle  of  desirable  length 
(8  to  12  cm.)  directly  attachable  to  the  syringe. 

5.  Duration  of  the  Actively  Infectious  Stage 
of  Tuberculosis. — ^^'illson  and  Rosenberger  ob- 
serve that  intrauterine  tuberculous  infection  of  the 
ovum  through  the  semen  is  probably  a  frequent 
event.  Tubercle  bacilli  are  present  in  the  faeces  and 
in  the  urine  of  many,  and  probably  all  cases  of 
active  local  and  systemic  tuberculosis  of  the  human 
being.  The  bacilli  appear  in  the  faeces  and  urine  of 
tuberculous  subjects  within  the  first  few  days  fol- 
lowing an  acute  infection,  and  in  certain  instances 
long  prior  to  the  appearance  of  physical  signs.  The 
only  likely  means  of  rendering  tuberculous  excreta 
(sputimi,  f;eces,  urine)  innocuous  is  the  direct  and 
effectual  application  of  heat.  They  cannot  be  ex- 
pected certainly  to  overgrow  or  die  out  or  surely 
to  succumb  to  sunlight  or  drying.  Excreta  from 
which  formerly  demonstrable  tubercle  bacilli  have 
apparently  disappeared  may  still  prove  destructive  to 
animal  life,  and  the  bacilli  again  be  recovered  from 
the  test  animals  in  a  demonstrable  form,  both  b\' 
culture  and  by  tinctorial  methods  of  examination  of 
the  excreta. 

MEDICAL  RECORD. 
February  6,  1909. 

1.  The  Eye  of  Yesterdaj-  and  of  To-day, 

By  Fraxcis  \'alk. 

2.  Some  Serious  Lapses  in  Administrative  Hygiene. 

By  Homer  Wakefield. 
.3.    Acute   ( Hasmorrhagic)    Encephalitis,   with   Report  of 
Cases.  By  G.  B.  Hassix. 

4-    Some  Factors  in  the  .Etiology  of  a  Common  Cold. 

By  Robert  Curtis  Browx. 


5.  Interstitial  Gestation,  with  Report  of  a  Case, 

By  B.  AI.  Baker. 

6.  The  Avery  Nasal  Sjeptatome,     By  John  W.aite  Avery. 

4.  Some  Factors  in  the  .ffitiology  of  a  Com- 
mon Cold. — Brown  says  that  before  the  human 
race  had  become  accustomed  to  clothes  and  over- 
heated houses,  colds  were  probably  infrequent. 
Exposure  to  cold  and  catching  cold  are  by  no 
means  synonymous.  When  the  body  is  put  to  an 
effort  to  conserve  its  heat,  as  in  exposure  to  cold, 
there  is  not  much  danger  of  catching  cold,  but 
when  the  body  is  put  to  an  effort  to  lose  its  heat 
or  is,  in  other  words,  overheated,  there  is  great 
danger.  It  is  when  the  body  is  at  one  time  over- 
protected  and  at  another  underprotected,  that  there 
is  the  greatest  likelihood  of  colds.  When  a  skin 
area,  which  is  usually  overprotected,  is  exposed  to 
a  draft,  an  overimpulse  is  conveyed  to  the  vaso- 
motor centre,  an  exaggerated  response  is  sent  out, 
and  the  peripheral  blood  vessels  are  contracted  over 
a  large  area.  If,  under  these  conditions,  the  tem- 
perature is  taken,  it  will  be  found  to  have  risen 
slightly.  The  body,  which  was  attempting  to  lose 
heat,  finds  itself  further  embarrassed  as  the  radia- 
tion from  a  considerable  portion  of  the  skin  has 
been  shut  off.  The  turbinates  being  a  means  by 
which  heat  is  lost,  it  is  not  strange  that,  under  the 
circumstances,  vasomotor  impulses  should  be  sent 
to  them  and  that  the  tortuous  blood  vessels  of  the 
turbinated  bodies  should  be  dilated  to  the  point  of 
overcongestion.  On  this  theory,  both  the  so  called 
habit  of  taking  cold  and  treatment  for  prevention 
of  colds  can  be  explained.  If  a  common  cold  is,  in 
its  inception,  a  vasomotor  congestion,  caused  by 
the  exposure  of  sensitive  skin  areas,  why  does  the 
process  continue  unnecessarily  and  run  its  usual 
course?  If  the  congestion  and  increased  secretion 
rendered  the  nasal  mucous  membrane  more  liable 
to  infection,  the  mechanism  would  be  easy  to  un- 
derstand, for  Nature  would  naturally  keep  up  the 
depurative  process  as  long  as  the  microbes  were 
attempting  to  enter,  or  their  toxines  acted  as  an 
irritant,  but  the  very  conditions  of  congestion  and 
increased  secretion  are  admitted  to  be  those  under 
which  infection  ordinarily  is  least  likely  to  occur. 
Although  the  nasal  mucus  is  not  bactericidal,  yet 
Metchnikoft'  and  others  show  conclusively  that  it 
rids  the  nose  of  a  large  number  of  germs  in  a 
purely  mechanical  way. 

6.  The  Avery  Nasal  Saeptatome. — Avery  de- 
scribes his  instrument :  The  head,  angulated  at  45° 
from  the  handle,  prevents  the  operator's  hand  from 
obscuring  the  field  of  operation ;  gives  better  con- 
trol of  the  instrument ;  permits  of  more  delicacy 
of  touch,  and  is  better  adapted  to  extend  properly 
the  mucoperichondrial  incision,  both  superiorly  in 
the  saeptum  and  inferiorly  down  and  out  through 
the  floor  of  the  inferior  meatus.  The  blade  is  ad- 
justable to  cut  a  depth  varying  from  1/32  to 
6/32  of  an  inch.  By  the  screw  on  end  of  blade  any 
change  is  quickly  and  accurately  made.  Having 
determined  the  thickness  of  the  tissue  to  be  incised, 
the  blade  is  set  at  a  corresponding  length,  and 
jilunged  in  up  to  the  head,  which  prevents  too  deep 
a  cut,  and  so  lessens  the  danger  of  perforation.  An 
indicator  on  the  handle  registers  the  length  of  the 


348 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medicai  Journal, 


exposed  portion  of  the  blade,  and  hence  the  depth 
of  the  incision.  This  saeptatome  consists  of  three 
simple  parts  which  are  easil}-  exposed  for  cleaning 
and  sterilizing,  and  can  be  quickly  reassembled.  It 
is  light  and  well  balanced. 

BRITISH  MEDJCAL  JOURNAL. 
January  i6,  igop. 

1.  Alpine  or  Home  Climates  for  Early  Tuberculosis? 

By  W.  EwART. 

2.  The  Selection  of  Sanatorium   Cases  for  Treatment 

with  Tuberculin,  By  H.  H.  Thomson. 

3.  Contusion  of  the  Lung  without  External  Injuries, 

By  E.  M.  Payne. 

4.  A  Note  on  Body  Weight  in  Relation  to  Pulmonary 

Tuberculosis, 

By  F.  P.  Weber  and  W.  R.  Kirkness. 

5.  Asthma  :  Its  Causation  and  Treatment,  By  W.  Lloyd. 

6.  A  Case  of  Pancreatic  Diabetes  Associated  with  Dila- 

tation of  the  Stomach,  for  which  Gastroenterostomy 
had  been  Performed,  By  J.  S.  McKendrick. 

7.  The  Causation  of  Ingrowing  Toenail  and  the  Location 

of  Gout,  By  G.  A.  Stephens. 

8.  The   Effective   Treatment  of  Acute   and  Subacute 

Rheumatism,  By  D.  B.  Lees. 

(Science  Committee  of  the  British  Medical  Association. 
Reports  CIX,  CX,  CXI.) 

9.  On  the  Primitive  Muscle  Tissue  of  the  Human  Heart, 

By  A.  Gibson. 

ID.    On  the  Difference  in  Content  in  Immune  Substances 
in  Blood  Serum  and  Plasma, 

By  G.  Dreyer  and  E.  W.  A.  Walker. 

II.    Observations   on   the   Production   of   Immune  Sub- 
stances, By  G.  Drever  and  E.  W.  A.  Walker. 

I.  Alpine  Climates  in  Tuberculosis. — Ewart, 
in  this  paper,  establishes  the  two  fo]lo\ving-  proposi- 
tions regarding  the  treatment  of  early  cases  of  pul- 
monary tuberculosis  in  England:  i.  The  best  possi- 
ble value  will  be  received  from  the  home  sanatorium 
treatment  for  early  tuberculosis  when  the  patients 
shall  have  had  the  advantage  of  a  preliminary  course 
at  the  Alps.  2.  The  best  results  are  obtained  at  Davos 
when  patients  resort  to  it  at  their  earliest  stage,  be- 
fore any  time  has  been  spent  over  any  other  form  of 
treatment,  whether  at  their  homes  or  at  any  home 
sanatorium  in  England.  These  two  propositions 
make  for  one  practical  conclusion — namely,  that  the 
true  policy  is  one  of  systematic  combination  for  in- 
dividual cases  of  the  Alpine  and  of  the  Home  sana- 
torium treatment. 

4.  Body  Weight  and  Tuberculosis. — ^^'cber 
and  Kirkness  have  attempted  to  ascertain  as  far  as 
possible  what  the  average  weight  of  consumptive 
patients  in  a  large  hospital  for  consumptives  is  (  i) 
in  comparison  to  their  height  and  (2)  in  comparison 
to  the  average  of  their  former  ordinary  weights. 
They  found :  A.  In  a  series  of  five  hundred  male  pa- 
tients, all  v.ith  tul)ercle  bacilli  in  their  sputum,  and 
over  twenty-five  years  of  age,  the  average  of  their 
former  ordinary  weights  was  below^  standard, 
though  of  course  not  so  decidedly  "underweight"  as 
their  average  weight  on  admission  was.  B.  In  a 
series  of  one  hundred  female  patients,  all  over 
twenty-five  years  of  age  and  w  ith  tubercle  bacilli  in 
their  sputum,  the  average  of  their  fcirmer  ordinarv 
weights  was  very  little  below  standard,  allliough 
their  weights  on  admission  was  much  below  stand- 
ard. C.  In  a  series  of  one  hundred  men,  over  thirty 
years  of  age,  with  signs  of  old  tuberculosis,  but 
without  fever  or  tubercle  bacilli  in  the  sputum,  both 
the  average  weight  on  admission  and  the  average 
former  ordinary  weight  were  below  standard,  hut 
not  so  much  so  as  in  series  A. 


5.  Asthma. — Lloyd  holds  that  the  only  the- 
ory as  to  the  causation  of  asthma  which  can  be  suc- 
cessfully maintained  is  the  following:  Asthma, 
IS  essentially  a  nervous  disease,  and  it  is  due  to 
spasm  of  the  bronchial  muscles,  induced  reflexly 
either  by  irritation  of  the  nasal  mucous  membrane 
or  of  the  alimentary  canal.  There  are  three  factors- 
in  the  causation  of  asthma:  l.  The  presence  of  hy- 
persensitive areas  in  the  nasal  mucous  membrane, 
or  a  special  sensitiveness  of  the  gastric  mucous- 
membrane.  2.  A  special  irritability  of  the  pulmon- 
ary nervous  system,  which  constitutes  the  asthmatic 
idiosyncrasy  with  which  the  individual  was  born. 
3.  The  presence  of  an  irritant,  for  example,  odors, 
dust,  smoke,  the  absence  of  any  one  of  these  factors 
is  sufificient  to  prevent  the  disease.  Treatment. — 
First  find  out  if  there  is  any  exciting  cause  present, 
and  if  so  remedy  it.  Begin  treatment  as  soon  as 
possible,  as  it  is  much  easier  to  check  the  asthmatic 
paroxysm  when  it  is  just  established.  Among  the 
varioiis  remedies  which  may  prove  beneficial  are 
pipe  tobacco  smoking;  hot,  strong  coffee;  alcohol; 
chloroform ;  cocaine,  stramonium  smoking ;  inhala- 
tion of  fumes  of  burning  nitre  paper.  Asthmatics 
shoii.ld  dine  early,  so  as  to  allow  of  digestion  being- 
completed  and  the  stomach  empty  before  going  to 
rest.  Any  disease  or  deformity  of  the  nose  should 
be  rectified.  Where  no  disease  is  present  on  inspec- 
tion certain  parts  of  the  nasal  mucous  membrane, 
known  as  asthmogenic  areas,  must  be  cauterized, 
one  by  one.  at  several  sittings  until  improvement  is 
effected.  The  best  nasal  cleansing  lotion  is  salt  and 
water. 

7.  Ingrowing  Toenail.  —  Stephens  suggests 
that  the  most  likely  cause  of  ingrowing  toenail  is 
the  position  of  the  foot  during  sleep.  One  foot 
slides  off  the  other,  and  lies  with  its  weight  resting 
on  the  toes,  and  it  is  this  constant  pressure  on  the 
side  of  the  big  toe  during  hours  of  unconsciousness, 
that  gives  rise  to  the  pathological  condition.  This 
same  fact  may  account  for  the  frequent  localization 
of  attacks  of  gout  in  the  big  toe. 

8.  Treatment  of  Rheumatism. — Lees  states 
that  rheumatic  fever  is  as  definite  and  distinctive, 
and  as  certainly  microbical,  as  pneumonia  or  typhoid, 
one  of  the  most  virulent  diseases  of  childhood,  and 
never  produces  pus.  We  must  give  up  the  concep- 
tion of  acute  rheumatism  as  a  form  of  arthritis  of 
adults,  with  occasional  metastases  to  the  heart, "and 
with  certain  peculiarities  when  it  occures  in  chil- 
dren. We  must  insist  on  the  conception  that  it  is  a 
microbical  toxaemia  most  virulent  in  early  life,  in 
which  the  heart  is  invariably  affected  to  a  greater 
or  less  degree,  but  the  joints  slightly  and  often  not  at 
all,  with  the  peculiarity  that  when  it  occurs  in  adults 
the  most  prominent  symptom  is  often  a  painful  ar- 
thritis. Any  improvement  in  the  treatment  of  acute 
rheumatism  must  be  based  upon  the  curative  effect 
of  sodium  salicylate.  It  only  cures  rheumatic  ar- 
thritis— a  definite  antagonism  to  the  rheimiatic  pro- 
cess or  microbe.  But  the  doses  given  arc  usually 
so  small  that  only  the  more  easily  checked  mani- 
festations of  acute  rheumatism — the  arthritis  and 
the  pvrexia — arc  fairly  controlled.  The  addition  of 
double  the  amoimt  of  sodium  bicarbonate  to  each 
dose  of  the  salicylate  will  go  far  towards  preventing 
the  unpleasant  side  eff'ects  which  deter  pliy^icians 
from  giving  large  doses  of  the  drug. 


l-'ebruary  13,  1909.] 


FITH  or  CURREXT  LITERATURE. 


349 


January  23,  igog. 

1.  Myoma  and  Pregnancy,  By  Sir  W.  Smyly. 

2.  Adenomyoma  of  the  Uterus,       By  j.  Bland-Sutton. 

3.  Remarks  on  a  Series  of  Cases  of  Adenocarcinoma  of 

the  Body  of  the  Uterus,  By  J.  M.  M.  Kerf;. 

4.  Ruptured  Tubal  Pregnancy  at  Four  Months :  Opera- 

tion in  a  Cottage :  Recovery,     By  T.  L.  Llewellyn. 

5.  Pvehtis  of  Pregnancy  Treated  with  Coli  Vaccine. 

By  H.  T.  Hicks 

6.  Acute  Inversion  of  the  Uterus,  By  A.  W.  Holthusen. 

7.  An  Experiment  in  the  Treatment  of  Epilepsy, 

By  D.  GoYDEK. 

8.  On  the  Flagellation  of  Lymphocytes  in  the  Presence 

of  Excitant?  both  Artificial  and  Cancerous, 

By  H.  C.  Ross  and  C.  J.  M.\calister. 

9.  Note  on  the  Treatment  of  Pernicious  Anaemia, 

By  B.  Bramwell. 

10.  Some  Reflections  Regarding  the  Free  Use  of  Bac- 

teriological Cultures  for  the  Destruction  of  Rats 
and  Mice,  By  J.  Danvsz. 

11.  A-cute  Pancreatitis  followed  by  Pancreatic  Abscess: 

Operation  :  Recovery,  By  C.  H.  Robertson. 

12.  Arrows  and  Arrow  Wounds  in  Northern  Nigeria, 

By  A.  C.  P.VRSOXS. 

1.  Myoma  and  Pregnancy. — Smyly  discusses 
the  treatment  of  myoma  and  pregnancy,  as  follows : 
During  pregnancy  interference  is  seldom  called  for. 
though  tumors  have  been  successfully  removed 
without  interrupting  gestation.  But  excepting 
tliose  rare  case?  in  which  extreme  pressure  symp- 
toms, twisting  of  the  pedicle,  or  sloughing  of  the 
tumor  render  operative  interference  necessary,  it  is 
Ijetter  to  postpone  such  measures  until  full  term. 
The  induction  of  abortion  has  now  been  altogether 
abandoned.  At  terra  and  during  labor  those  tumors 
which  cause  no  obstruction  or  other  serious  trouble 
need  no  special  treatment.  Polypi  should  be  re- 
moved and  cervical  myomata  enucleated,  but  tu- 
mors which  grow  into  the  cellular  tissue  can  sel- 
dom be  removed  per  vaginam  without  great  dan- 
ger. When  the  tumor  is  so  large  and  in  such  a 
position  as  to  cause  serious  obstruction  to  the  pas- 
sage of  the  child,  the  best  method  of  delivery  is 
often  difficult  to  choose.  We  should  wait  as  long 
as  spontaneous  delivery  is  possible,  but  not  so  long 
as  to  render  operative  interference  hopeless.  Ef- 
forts to  drag  the  foetus  past  the  obstruction  by 
forceps,  version,  and  extraction,  or  after  perfora- 
tion, are  liable  to  cause  irreparable  damage,  and  are 
in  general  to  be  condemned.  As  regards  abdom- 
inal operation,  Csesarean  section  alone  is  seldom 
sufficient.  It  is  more  generally  advisable  to  com- 
bine it  with  enucleation  of  the  tumors  or  extirpation 
of  the  uterus.  As  a  rule  panhysterectomv  has 
proved  more  successful  than  the  supravaginal  op- 
eration, because,  after  a  prolonged  labor,  the  uterus 
is  often  more  or  less  septic,  and  the  retention  of  a 
septic  stump  is  not  only  in  itself  a  source  of  dan- 
ger, but  its  complete  removal  affords  better  drain- 
age. Another  reason  for  the  complete  operation  is 
that  the  tumors  which  cause  obstruction  are  always 
situated  so  low  in  the  uterus  that  it  is  difficult  to 
obtain  a  stump  altogether  free  from  disease.  When 
the  foetus  is  known  to  be  dead  it  is  better  to  re- 
move the  uteru?  unopened.  After  delivery  post 
])artum  haemorrhage  must  be  looked  for.  and  free 
drainage  of  discharges  secured.  In  no  other  class 
of  cases  is  complete  asepsis  from  start  to  finish  a 
more  absolute  necessity. 

2.  Adenomyoma  of  the  Uterus. — Bland-Sutton 
gives  the  chief  symptom  of  adenomyoma  of  the 


uterus  as  profuse  mcnorrhagia.  and  in  severe  cases 
bloody  fluid  may  flow  from  the  vagina,  sometimes 
for  five  or  six  weeks  without  intermission.  Pain 
at  the  menstrual  period  is  fairly  common.  On  ex- 
amination the  uterus  is  found  to  be  larger  than 
normal,  and  in  some  cases  the  fundus  may  be  high 
in  the  hypogastrium.  The  contour  of  the  uterus 
mav  be  quite  smooth,  but  in  many  instances  it  is 
irregular,  such  unevenness  being  due  to  the  locali- 
zation of  the  adenomyomatous  tissue  to  one  wall  of 
the  uterus,  or  the  disease  may  be  complicated  by  the 
presence  of  subserous  or  interstitial  fibroids.  These 
are,  however,  also  the  signs  and  symptoms  of 
submucous  uterine  fibroids,  and  of  fibrotic  uteri. 
Occasionally  a  shrewd  and  experienced  observer 
may  suspect  adenomyomatous  disease  before  opera- 
tion ;  even  then  the  use  of  the  microscope  is  indis- 
pensable for  its  identification.  The  only  effectual 
mode  of  dealing  with  the  disease  is  removal  of  the 
uetrus,  either  by  the  vagina,  or  preferably  by  the 
abdominal  route.  Subtotal  hysterectomy  with  con- 
servation of  an  ovary  gives  admirable  results,  im- 
mediate and  remote.  Drugs  are  absolutely  useless 
for  checking  the  bleeding. 

5.  Pyelitis  of  Pregnancy. — Hicks  reports  a 
case  of  pyelitis  of  pregnancy,  occurring  in  a  woman 
aged  twenty  years.  One  very  prominent  feature  of 
these  cases  is  the  somewhat  diffuse  area  of  great 
superficial  tenderness,  which  seems  to  be  confined 
to  the  cutaneous  distribution  of  the  anterior  branch 
of  the  twelfth  dorsal  nerve.  Pyelitis  of  pregnancy 
has  to  be  distinguished  in  its  early  stages  from 
pleurisy  at  the  base  of  the  right  lung,  and  in  the 
later  stages  from  typhoid  fever  and  appendicitis. 
The  presence  of  pus  in  the  urine  will  give  a  defi- 
nite clue  to  the  condition.  Constipation  plays  a 
prominent  part  in  the  aetiology,  and  almost  without 
exception  the  infection  is  due  to  an  invasion  of  the 
renal  pelvis  by  the  colon  bacillus.  The  renal  pelvis 
is  probably  infected  direct  from  the  colon  by  means 
of  the  lymphatics.  The  cases  can  be  divided  into 
three  groups :  i.  INIild.  For  these  rest  in  bed,  a  milk 
diet,  careful  regulation  of  the  bowels,  and  the  ad- 
ministration of  potassium  iodide  and  urotropin  will 
probably  be  sufficient.  2.  Moderate.  Here  the 
same  treatment  should  be  adopted,  with  the  addi- 
tion of  a  coli  vaccine.  3.  Severe.  When  the  above 
treatment  does  not  meet  with  success,  the  uterus 
should  be  emptied.  It  is  not  advisable  to  attempt  to 
drain  the  pelvis  of  the  kidney  through  the  loin  be- 
cause the  patients  cannot  stand  the  shock  of  the 
operation,  and  if  the  kidney  is  infected  there  will 
be  many  small  foci  which  cannot  be  effectively  dealt 
with.  The  safest  way  to  eft'ect  free  drainage  is  to 
relieve  the  pressure  of  the  uterus  upon  the  ureter. 

LANCET. 
January  16,  igog. 

1.  Thrombosis  and  Embolism  after  Operations  on  the 

Female  Pelvic  Organs  (Hunterian  Lecture), 

By  J.  Bland-Sutton. 

2.  On  a  Combination  of  Substances  which  Excites  Amoe- 

boid Movement  in  Leucocytes,  by  which  Living  can 
be  Distinguished  from  Dead  Cells,    By  H.  C.  Ross. 

3.  On  an  Excitant  for  the  Leucocytes  of  Healthy  Persons 

Found  in  the  Blood  Plasma  of  Patients  Suffering 
from  Carcinoma, 

By  C.  J.  j\L\calister  and  H.  C.  Ross. 


350 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medic.m.  Journai. 


4.  Ueosigmoidostomy  for  the  Relief  of  Inveterate  Consti- 

pation, By  C.  W.  M.  MouLLiN. 

5.  A  New  Method  of  Orchidopexy,      By  M.  Mamurian. 

6.  Fibrolysin  in  Ophthalmic  Practice,    By  K.  Grossmann. 

7.  An  Efficient  Treatment  for  Pneumonia, 

By  D.  Crowly. 

8.  A  New  Parasite  Seen  in  a  Case  of  Dysentery, 

By  J,  Bell. 

9.  Mumps,  By  J.  G.  Sharp. 

2,  3.  Excitants  for  Leucocytes.  —  Ross  has 
made  extensive  observations,  extending  over  a  pe- 
riod of  three  years,  concerning  the  diffusion  of  stain 
into  hving  leucocytes.  After  ascertaining  the  cyto- 
plasm of  leucocytes  exhibits  jellylike  properties  and 
knowing  that  the  rapidity  of  diffusion  of  haemoglo- 
bin into  agar  jelly  is  hastened  by  the  presence  of 
heat  and  alkahes,  he  made  experiments  which  have 
demonstrated  that  the  diffusion  of  methylene  blue 
into  leucocytes  is  influenced  by  the  same  two  fac- 
tors. He  then  turned  his  attention  to  the  diffusion 
of  substances  other  than  stain  into  the  cells,  experi- 
menting especially  with  alkaloids,  and  he  ascer- 
tained that  if  the  cells  are  resting  on  jelly  (agar) 
which  contains,  besides  neutralized  sodium  citrate 
and  sodium  chloride,  a  certain  proportion  of  methy- 
lene blue  and  atropine  sulphate,  the  leucocytes  will 
exhibit  exaggerated  amoeboid  movements,  consist- 
ing in  the  extrusion  and  retraction  of  long  curling 
pseudopodia.  The  stain  was  found  to  be  the  im- 
portant constituent  of  this  excitant.  If  the  jelly  is 
neutral  the  excitation  will  occur  without  the  addition 
of  the  alkaloid,  although  it  is  not  constant;  if,  how- 
ever, an  alkali,  such  as  sodium  bicarbonate,  is  added 
in  amount  proportionate  to  the  temperature  of  the 
room  in  which  the  experiment  is  made  so  as  to  pro- 
duce diffusion  of  the  stain  into  the  cells,  very 
marked  and  constant  excitation  takes  place,  only 
provided  the  alkaloid  is  present,  whereas  if  no  al- 
kaloid is  present  no  excitation  takes  place  in  the  al- 
kaline jelly.  In  other  words,  the  alkaloid  is  an  es- 
sential factor  for  the  production  of  excitation  in  an 
alkaline  stain  containing  jelly.  This  procedure  has 
proved  sufficiently  reliable  to  distinguish  living 
from  dead  leucocytes,  and  may  lead  to  important  de- 
v^elopments  in  the  diagnosis  of  infective  disease. 
Macalister  and  Ross  direct  attention  to  the  possibili- 
ty that  cancer  is  the  local  manifestation  of  a  disease 
which  is  dependent  upon  changes  in  the  blood,  dif- 
ficult to  account  for,  but  yet  so  constant  that  their 
association  with  the  neoplasm  cannot  be  disregarded. 
It  is  worthy  of  remark  that  cancer  is  most  apt 
to  occur  in  organs  which  are  tidal  in  character, 
such  as  the  breast  and  the  uterus.  Another  impor- 
tant pathological  condition  indicative  that  blood 
changes  are  constant  in  cancer,  is  the  diminished 
acid  secreting  function  of  the  stomach,  which  is 
present  not  only  in  cancer  of  that  organ  but  also 
wherever  cancer  occurs  in  the  body.  Based  upon 
the  observations  of  Ross,  described  above,  the  au- 
thors have  found  that  the  blood  plasma  from  cases 
of  cancer  acts  as  a  powerful  stinuilant  to  normal 
leucocytes.  It  is  possible  that  there  may  be  in  the 
blood  in  cases  of  cancer,  some  substance  resembling 
an  alkaloid  in  its  action  which  in  the  presence  of  the 
alkaline  plasma  excites  the  amoeboid  movements  of 
healthy  leucocytes.  It  is  possible  that  this  reaction 
mav  ])rovc  serviceable  as  an  aid  to  diagnosis  in 
douljtful  cases  of  cancer. 


6.  Fibrolysin. —  Grossman  has  used  fibrolvsiii 
in  ophthalmic  practice  for  the  relaxation,  etc.,  of 
scars,  with  great  benefit.  Fibrolysin  represents  a 
combination  of  one  molecule  of  thiosinamine  with 
half  a  molecule  of  salicylate  of  sodium.  Its  princi- 
pal advantage  over  thiosinamine  is  the  easy  solution 
in  water  and  the  absence  of  any  irritant  effect  when 
injected  subcutaneously.  The  drug  itself  is  a  white 
crystalline  substance  with  a  bitter  taste.  It  decom- 
poses easily  when  exposed  to  air  and  light  and  is 
therefore  put  up  in  closed  tubes  of  brown  glass  in 
doses  of  2.3  cubic  centimetres  of  a  15  per  cent, 
aqueous  solution,  equivalent  to  two  decigrammes 
(three  grains)  of  thiosinamine.  The  eft'ect  of  fibro- 
lysin on  cicatricial  tissue  is  very  remarkable ;  turges- 
cence  takes  place,  the  individual  fibres  lose  their 
sharpness  of  outline,  the  nuclei  are  pushed  asunder, 
and  the  tissue  appears  more  succulent  and  swollen 
and  altogether  enlarged.  The  whole  scar  becomes 
more  relaxed  and  permits  of  movements  altogether 
impossible  before  injection.  This  effect  is  consid- 
ered to  be  due  to  a  serous  infiltration  or  flooding" 
which  slackens  the  old  inflammatory  and  now  hard- 
ened fascicles  similarly  to  the  hyperjemia  of  the 
Bier  method,  and  renders  them  thereby  more  amen- 
able to  absorption  by  the  increased  lymph  stream. 
This  result,  transient  at  first,  becomes  more  and 
more  permanent  by  repeated  injections.  It  is  note- 
worthy that  fibrolysin  has  this  effect  only  on  patho- 
logical connective  tissue.  The  mode  of  application 
is  by  injection,  either  intravenous,  intramuscular,  or 
subcutaneous.  The  intravenous  method  is  suitable 
only  where  a  very  rapid  eft'ect  is  desired,  and  large 
veins  should  be  selected,  so  as  to  avoid  the  danger 
of  thrombosis.  The  author  prefers  to  administer  the 
drug  hypodermically  in  the  upper  arm.  Excellent 
results  have  been  obtained  in  the  treatment  of 
strictures  and  stenoses  due  to  inflammator}'  and 
cicatricial  contractions,  among  them  those  of  the 
(jesophagus  and  pylorus  due  to  injuries  from  caustic 
fluids.  Under  the  influence  of  the  drug  dilatation 
by  bougies  became  possible  and  ultimately  remained 
permanent.  Similarly  urethral  strictures  as  well  as 
prostatitis  after  gonorrhoea  yielded  satisfactorily  to 
the  treatment.  Cases  of  chronic  arthritis  have  also 
been  greatlv  benefited. 

7.  Pneumonia. — Crowley  has  treated  snccess- 
fullv  nine  cases  of  pneumonia  by  the  following 
course  of  therapeutics :  An  initial  dose  of  calomel 
was  given,  followed  bv  four  hourly  doses  of  a  mix- 
ture containing  four  grains  of  potassium  iodide,  ten 
grains  of  potassium  citrate,  and  one  half  drachm 
doses  of  a  solution  of  ammonia  citrate.  The  nine 
cases  all  terminated  in  resolution  in  a  remarkably 
short  space  of  time. 

January  33,  igOQ. 

1.  .\  Recapitulation  Lecture,         By  Sir  I.  Hi'tchinson. 

2.  Fractures  of  the  Olecranon  and  the  Value  of  thiir 
Treatment  by  Direct  and  Internal  Splintage. 

By  E.  M.  Cornkh. 

3.  Intestinal  Indigestion,  By  P.  J.  Ca.mmidgk. 

4.  On  tlie  Cause  of  Achromasia  in  Leucocytes. 

By  H.  C.  Ross. 

5.  "Endemic  Funiculitis,"  By  D.  K.  Coutts. 

6.  Infantile  Splenic  Anremia,  with  Notes  of  Ten  Cases, 

By  W.  K.  HuN'TEK. 

7.  Hospital  Work  in  Egypt,  By  H.  B.  Day. 


February  13.  1909.I 


PITH  OF  CURRENT  LITERATURE. 


351 


■8.    A  Precept  of  the  Archbishop  of  Canterbury  Forbid- 
ding Barbers  to  Carry  on  their  Trade  on  Sundays, 

By  D.  A.  Power. 

2.  Fractures  of  the  Olecranon.  —  Corner's 
studies  of  the  results  of  wiring  the  olecranon  have 
demonstrated  the  following  points:  i.  That  inter- 
nal splints  lead  to  absorption  of  the  hard  substances 
of  the  bone  round  them.  2.  This  condition  in  its 
turn  leads  to  loosening  of  the  internal  splint  and 
therefore  the  more  easily  to  its  breaking  with  a 
sudden  effort,  to  the  commencing  extrusion  of  a 
screw,  and  to  some  separation  of  the  fragments.  3. 
If  the  part  is  kept  at  rest  by  external  splints,  in  ad- 
dition, the  softened  bone  around  the  internal  splint 
will  harden  and  reossify,  bringing  about  bony 
tmion  between  the  fragments.  4.  If  the  part  is  ex-^ 
ercised,  as  it  must  be  when  the  fracture  is  in  the 
neighborhood  of  a  joint,  the  fragments  are  still  fur- 
ther separated  from  each  other  and  the  union  be- 
tween them  is  fibrous,  not  bony.  5.  A  perfectly 
good  and  excellently  functional  limb  is  obtained 
with  such  a  fibrous  union,  with  some  possible  lim- 
itation of  extreme  flexion  and  extreme  extension. 
6.  This  limitation  is  caused  by  the  adhesion  of 
cicatricial  contraction  of  the  attachments  of  the 
olecranon  to  the  humerus ;  putting  the  triceps  at  a 
mechanical  disadvantage,  arising  and  being  in- 
serted on  the  same  bone.  7.  The  advantage  of  di- 
rect and  internal  splintage  lies  solely  in  its  allow- 
ing movements  to  be  begun  early,  preventing  much 
limitation  to  the  movements  of  the  olecranon  on  the 
humerus.  8.  From  the  point  of  view  of  the  subse- 
quent value  of  the  limb  it  makes  little  or  no  differ- 
ence whether  the  union  between  the  fragments  is 
■fibrous  or  bony,  provided  that  the  olecranon  moves 
freely  on  the  humerus.  9.  It  is  a  matter  of  indiffer- 
ence as  to  the  nature  of  the  internal  splint  used, 
such  as  silver  wire,  copper  wire,  iron  wire,  or  silk. 
Screws  are  not  so  good  as  sutures  in  this  situation. 
An  absorbable  suture  is  not  a  good  internal  splint, 
because  its  presence  will  be  required  for  some  weeks 
at  least.  10.  For  success  the  operation  area  must 
not  suppurate.  11.  In  neglected  cases  the  frag- 
ments of  the  broken  ulna  may  become  more  and 
more  separated,  and  if  the  skin  becomes  adherent  a 
violent  effort  may  tear  open  the  joint.  12.  An  ex- 
cellent result  can  be  obtained  with  or  without  op- 
eration, provided  the  olecranon  does  not  become 
restricted  in  its  movements  on  the  humerus.  The 
more  its  restriction  the  worse  the  result.  Hence 
the  mobility  or  immobility  of  the  olecranon  on  the 
humerus  is  a  very  important  clinical  index  of  the 
value  of  operation  in  the  case.  13.  If  the  fragments 
are  to  be  sutured  the  operation  should  be  done  as 
soon  after  the  accident  as  the  condition  of  the  skin 
allows.  14.  Operation  is  indicated  in  the  majority 
of  cases,  particularly  by  a  wide  separation  of  the 
fragments  in  the  early  period  and  by  imperfect  mo- 
bility of  the  olecranon  in  the  later  stages.  15.  The 
earlier  that  operation  is  undertaken,  the  better  the 
prognosis  of  its  results. 

3.  Intestinal  Indigestion. — Cammidge  states 
that  there  is  no  single  pathognomonic  sign  of  in- 
testinal indigestion.  But  the  presence  of  abdomi- 
nal discomfort,  more  marked  two  or  three  hours 
after  food,  loss  of  appetite  and  distaste  for  certain 


articles  of  diet — fat  or  milk,  for  example — lassi- 
tude, inability  to  concentrate  the  attention,  with 
often  persistent  headache,  a  dirty  tongue  which  is 
frequently  fissured,  foetid  breath  with  eructations  of 
gas,  abdominal  distension  and  occasional  tenderness 
on  deep  pressure  in  the  region  of  the  head  of  the 
pancreas,  the  passage  of  much  flatus  with  often  foul 
smelling  stools,  and  either  diarrhoea  or  constipa- 
tion, are  often  suggestive  of  the  condition.  In  the 
anaylsis  of  the  urine  attention  must  be  particularly 
devoted  to  the  "pancreatic"  reaction  as  indicating 
degenerative  changes  in  the  gland,  to  an  excess  of 
indican  as  showing  abnormal  intestinal  putrefac- 
tive changes,  and  to  a  marked  reaction  for  urobilin, 
which  points  to  an  associated  cholangitis  and  dis- 
turbance of  the  liver.  In  treatment  the  choice  of 
a  suitable  diet  is  the  first  consideration.  There 
should  be  the  longest  possible  interval  between  the 
meals  so  that  the  digestive  organs  may  have  the 
maximum  amount  of  physiological  rest.  Foods 
rich  in  proteins  are  to  be  recommended  in  cases 
where  hydrochloric  acid  is  excessive.  Where  the 
bacterial  element  predominates  and  there  is  evi- 
dence of  toxaemia  the  use  of  buttermilk  or  of  milk 
■'soured"  by  the  lactic  acid  bacillus,  often  gives  very 
good  results.  The  early  recognition  and  treatment 
of  intestinal  indigestion  are  primarily  important  be- 
cause of  the  discomfort  and  interference  with  nutri- 
tion. A  remote  consequence  of  chronic  intestinal 
indigestion  is  the  ultimate  occurrence  of  diabetes. 
This  is  apparently  due  to  the  involvement  of  the 
pancreas  in  the  disease. 

4.  Ochromasia  in  Leucocytes. — Ross  defines 
achromasia  in  leucocytes  as  the  condition  when  its 
stained  nucleus  has  lost  its  stain,  or  when  its  un- 
stained nucleus  refuses  to  stain  with  the  cell  resting 
in  a  medium  which  will  stain  the  nuclei  of  fresh 
normal  leucocytes.  Such  achromasia  is  probably 
due  to  liquefaction  of  the  nucleus,  when  the  lobes 
"run"  together  to  form  a  single  nuclear  mass. 
Liquefaction  of  the  cytoplasm  begins  at  the  periph- 
ery and  gradually  progresses  towards  the  nucleus. 
As  long  as  there  is  unliquefied  cytoplasm  between 
the  nucleus  and  the  cell  wall,  no  dialysis  of  the 
chromatin  can  take  place,  and  the  nucleus  remains 
stained. 

6.  Infantile  Splenic  Anaemia. — ^Hunter's  study 
of  the  signs  of  infantile  anremia  has  led  him  to  the 
conclusion  that  the  condition  is  not  a  primary,  but 
rather  a  secondary  anaemia,  and  in  the  main  due  to 
a  functional  disorder  of  the  blood  forming  organs. 
Such  a  disorder  depends  chiefly  upon  a  debility  of 
the  hasmopoietic  tissues,  a  debility  perhaps  in- 
herited but  depending  (in  common  with  other  tis- 
sues) for  its  production  chiefly  on  such  faults  as 
lack  of  suitable  food  and  fresh  air,  but  at  times  de- 
termined by  the  toxines  of  measles,  syphilis,  and 
other  infections.  That  these  infantile  anaemias  are 
of  this  nature  is  shown  by  the  results  of  treatment. 
In  speaking  of  infantile  splenic  anaemia  in  this  way 
one  includes  the  three  types — (i)  the  cases  with 
leucopenia;  (2)  those  with  moderate  leucocytosis-; 
and  (3)  cases  grouped  as  von  Jaksch's  splenic 
anaemia;  and  one  regards  them  all  as  secondary 
anaemias  and  so  simply  different  phases  of  the  same 
disease. 


352 


PITH  OF  CURRENT  UTERATUBE. 


[Kew  Vokk 
Medical  Journal. 


LA  PRESSE  MEDICALE. 

December  30,  igoS. 

1.  Abdominal  Myomectomy,  By  Professor  S.  Pozzi. 

2.  The  Action  of  Paraguay  Tea  upon  the  Organism, 

By  J.  Lesage. 

1.  Abdominal  Myomectomy. — Pozzi  asserts 
that  myomectomy  is  preferable  to  hysterectomy  in 
yoimg  women,  in  every  case  in  which  the  fibroma  is 
single,  not  larger  than  a  fist,  not  penetrating  the 
uterine  cavity,  and  in  which  the  annexa,  at  least  of 
one  side,  are  healthy.  It  is  also  to  be  recommended 
when  the  fibromata  are  two  or  three  in  number  and 
easily  enucleable.  In  older  women  myomectomy  is 
equally  practicable  if  the  fibroma  is  single  and  if 
the  remainder  of  the  genital  apparatus  is  healthy. 
Myomectomy  should  be  performed  whenever  possi- 
ble as  a  complement  to  any  other  abdominal  opera- 
tion by  means  of  which  the  growth  has  been  discov- 
ered. Myomectomy  during  pregnancy  should  be 
performed  only  exceptionally  under  the  pressure  of 
imperious  indications.  It  should  be  performed  with 
special  precautions  that  the  pregnancy  may  not  be 
interfered  with,  but  may  continue  on  to  term. 

2.  Paraguay  Tea. — Lesage  pronounces  Para- 
guay tea  to  be  a  neuromuscular  tonic.  It  augments 
the  work  and,  momentarily,  the  production  of  the 
animal  machine.  The  action  is  different  from  that 
of  alcohol  in  that  while  the  latter  acts  immediately 
and  for  a  short  time  the  former  acts  more  slowly 
and  for  a  longer  time. 

January  2,  igog. 

1.  Hsemorrhagic  Complications  of  Appendicitis, 

By  A.  Broca  and  P.  Emile-Weil. 

2.  Anaesthesia  of  the  Dental  Pulp,  By  G.  Mare. 

3.  Apropos  of  the  Viscosity  of  the  Blood,    By  R.  Rom  me. 

January  6,  igog. 

1.  Pathological  Study  of  the  Relations  between  Experi- 

mental and  Spontaneous  Atheroma, 

By  M.  LuciEN  and  J.  Parisot. 

2.  The  Circumcision  of  Infants,  By  A.  Schwab. 

3.  Diagnosis  of  Tuberculosis  by  the  Method  of  the  Devia- 

tion of  the  Complement,   By  Alexander  Marmorek. 

1.  Experimental  and  Spontaneous  Atheroma. 

— Lucien  and  Parisot  conclude  that  in  the  rabbit  the 
lesions  of  spontaneous  and  experimental  atheroma 
are  identical. 

2.  Circumcision  of  Infants. — Schwab  gives  a 
historical  sketch  of  this  operation,  its  advantages, 
indications,  and  contraindications,  and  then  presents 
an  illustrated  description  of  its  technique. 

LA  SEMAINE  MEDICALE. 

January  6,  iQOg. 

Dismemberment  of  Traditional  Hysteria.  Pithiatism, 

By  J.  Babinski. 

Pithiatism. — Piabinski  asserts  that  the  ancient 
conception  of  hysteria  was  founded  on  insufficient 
and  erroneous  observations  that  will  not  be  able  to 
resist  criticism,  and  that  the  dismemberment  of  tra- 
ditional hysteria  is  an  inevitable  consequence  of  a 
series  of  facts  formerly  ignored  but  to-day  solidly 
established.  The  result  of  this  disaggregation  is  to 
set  at  liberty  a  group  of  phenomena  which  occupy 
a  very  important  place  in  pathology  to  which  the 
denomination  hysteria  may  be  reserved,  but  which  is 
designated  much  more  expressively  by  the  word 
pithiatism. 


BERLINER  KLINISCHE  WOCHENSCHRIFT. 

December  28.  igo8. 

1.  The  Treatment  of  Pernicious  Anaemia, 

By  G.  Klemperer. 

2.  The  Relation  of  Spirochstje  to  Cancer  in  Mice, 

By  H.  R.  Gaylord. 

3.  Functional  Care  of  Paralysis  of  the  Serratus  by  Op- 

eration, By  M.  Katzenstein. 

4.  Agglutination  of  the  Paratyphus  Bacilli  in  True  Ty- 

phoid, '  By  J.  Thies. 

5.  Blood  Conditions  by  the  North  Sea,        By  Haberlin. 

2.  Spirochaetas  and  Cancer  in  Mice. — Gaylord 
finds  spirochaitae  to  be  very  prevalent  in  cancers  in 
mice,  though  absent  in  cancer  in  human  beings  and 
in  other  animals. 

3.  Cure  of  Paralysis  of  the  Serratus  by  Op- 
eration.— Katzenstein  reports  a  case  of  total  par- 
alysis of  the  serratus  associated  with  a  paresis  of  the 
trapezius  in  which  he  restored  the  movements  of  the 
arm  and  shoulder  blade  by  suitable  transplantation 
of  muscles.  The  details  of  the  transplantation  are 
given  at  length  and  should  be  read  in  the  original 
by  anyone  who  is  interested  in  the  subject. 

4.  Agglutination  of  Paratyphus  Bacilli  in  True 
Typhoid. — Thies  shows  that  Widal's  reaction 
should  not  be  the  sole  reliance  in  the  diagnosis  of 
typhoid  because  a  negative  test  of  the  agglutination 
of  typhoid  bacilli  and  a  positive  result  of  the  test 
with  paratyphus  bacilli  does  not  necessarily  exclude 
the  presence  of  trtie  typhoid. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT 

December  2g,  igo8. 

1.  Inflammation  of  the  Subdeltoid  Bursa  with  Deposit  of 

Lime,  By  Bergemann  and  Stieda. 

2.  Tuberculosis  as  a  Disease  of  Childhood, 

By  Hamburger.  . 

3.  Increased  Euphoria  and  Activity  as  Initial  Symptoms 

in  Infections,  By  Bleuler. 

4.  The  Faradic  Interval,  By  Lowenthal. 

5.  The  Malignity  of  Ovarian  Cysts,     By  Lunckenbein. 

6.  A  Case  of  Luxation  of  the  Patella  Irreducible  without 

Operation,  By  Wildt. 

7.  A  Case   of  Cholecystitis   Gangrsenosa   sine  Concre- 

mento.  By  Schwarz. 

8.  Obstinate  Folliculitis  with  Formation  of  Abscess  and 

Fistula  Outward  in  the  Ala  Nasi,  By  Muhlenkamp. 
g.    Treatment  of  Acute  Catarrh  of  the  Nose  and  Throat, 

By  Schmidt. 

10.  Treatment  of  Anthrax  of  Animals  with  Creolin, 

By  ZuRN. 

11.  Treatment  of  Acute  Corysa,  By  Stirnimann. 

1.  Inflammation  of  the  Subdeltoid  Bursa  with 
Deposit  of  Lime. — Bergemann  and  Stieda  report 
three  cases  of  acute  inflammation  of  the  stibdeltoid 
bursa  in  which  deposits  of  lime  took  place  to  such 
a  degree  as  to  require  removal  by  operation. 

2.  Tuberculosis  as  a  Disease  of  Childhood. — 
Hamburger  maintains  that  tuberculosis  is  a  chil- 
dren's disease  in  the  ordinary  acceptation  of  the 
term.  He  says  that  just  as  nearly  every  man  has 
had  measles  once  during  his  life  and  usually  during 
childhood  so  almost  every  man  has  acquired  tuber- 
culosis once  during  his  life  and  in  most  cases  dur- 
ing childhood.  In  researches  carried  on  with  Dr. 
Monti  he  has  found  a  frequency  of  tuberculosis  of 
over  ninety  per  cent,  at  the  age  of  puberty.  All  chil- 
dren were  designated  as  tuberculous  who  reacted  to 
cutaneous  or  subcutaneous  applications  of  tubercu- 
lin. He  divides  the  children  into  three  classes: 
Those  in  whom  the  bacilli  penetrate  into  the  lym- 
phatic glands  or  other  organs,  without  producing 


February  13,  1909.J 


PROCEEDINGS  OF  SOCIETIES. 


353 


any  change  at  the  place  of  infection,  and  remain 
latent ;  those  in  whom  the  bacilli  produce  no  change 
at  the  place  of  entrance,  penetrate  into  the  lymphatic 
glands,  and  cause  swelling  and  hyperplasia,  without 
tubercle  formation ;  and  those  in  whom  a  primary 
affection  is  produced  at  the  place  of  entrance  and 
typical  tubercle  formation  while  caseation  takes 
place  in  the  lymphatic  glands  of  that  region.  He 
then  considers  the  extension  of  the  disease. 

3.  Increased  Euphoria  and  Activity  as  Initial 
Symptoms  of  Infections. — Bleuler  has  noticed 
that  shortly  after  certain  persons  have  spoken  of 
feeling  particularly  well  they  were  attacked  by  an 
infectious  disease,  and  questions  whether  this  is  not 
an  initial  symptom  of  the  infection. 

AMERICAN  JOURNAL  OF  SURGERY. 
February,  igog. 

1.  Movable  Kidney,                        By  Ernest  L.  Bell. 

2.  On  Pulmonary  Embolism  after  Injections  of  Mer- 

cury Salicylate  Suspensions, 

By  William  S.  Gottheil. 

3.  Borderline  Cases  in  Aledicine  and  Surgery, 

By  Charles  C.  Allison. 

4.  A  Modified  Operation  for  Ingrown  Toe  Nail, 

By  A.  Monae  Lesser. 

5.  A  Case  of  Acute  Mastoiditis      Complicated  by  Sig- 

moid Sinus  Thrombosis,  Extradural  Abscess,  En- 
cephalitis and  Meningitis — Operation — Recovery, 

By  Seymour  Oppenheimer. 

6.  .Submucous  Resection  of  the  Nasal  Sjeptum ;  Need  of 

More  Conservatism  in  Selection  of  Cases.  Technique 
of  Operation,  By  Gerhard  H.  Cocks. 

7.  Two  Atypical  Cases  of  Sinus  Thrombosis, 

By  S.  J.  KOPETZKY. 

8.  The  Diagnosis  of  Extrauterine  Gestation  and  a  Report 

of  a  Case  of  Primary  Ovarian  Pregnancy, 

By  James  A.  MacLeod. 

9.  Excision  of  the  Elbow  Joint ;  Report  of  Two  Cases, 

By  George  F.  Shiels. 
10.    A  Case  of  Extensive  Chest  Injury — Plastic  Operation 
— Recovery,  By  W.  H.  Axtell. 

2.  Pulmonary  Embolism  after  Injection  of 
Mercury  Salicylate  Suspensions. — Gottheil  ob- 
serves that  the  possibility  of  the  occurrence  of  pul- 
monary embolism  is  the  chief  practical  objection  of 
importance  that  has  been  urged  against  the  treat- 
ment of  syphilis  by  the  intramuscular  injection  of 
insoluble  mercurials.  If  it  was  inevitable,  even  in 
a  small  proportion  of  cases  it  would  be  a  legitimate 
objection  to  the  method.  But  it  is  not  inevitable. 
We  can  tell  when  the  needle  is  in  one  of  the  cir- 
culatory channels  by  observing  its  lumen  after  im- 
plantation and  before  injecting  the  fluid.  The 
needle  must  be  plunged  into  the  tissues  not  empty, 
but  thoroughly  filled  with  injection  fluid,  so  that 
when  the  syringe  is  disconnected  the  interior  of  the 
needle  cap  is  filled  with  the  suspension.  Capillary 
attraction  of  the  walls  of  the  cap  gives  a  concave 
surface  to  the  visible  end  of  the  column  of  fluid. 
The  least  flattening  of  the  concavity,  not  to  speak  of 
its  slow  bulging  forward  into  a  convexity,  is  proof 
of  the  existence  of  pressure  at  the  needle  point ; 
and  this  can  only  be  exerted  by  the  blood  in  a  ves- 
sel. It  is  the  signal  for  immediate  stoppage  of  the 
procedure  at  that  point.  It  is  not  only  unnecessary, 
but  improper  to  wait  until  the  suspension  in  the 
needle  has  been  forced  out,  and  blood  follows ; 
and  it  is  quite  wrong  to  regard  the  appearance  of 
blood  in  the  proximal  lumen  of  the  needle  as  the 
criterion  of  the  safety  of  the  injection.  The  needle 
point  must  not  be  displaced  whilst  reapplying  the 


syringe  and  making  the  injection.  Hence  the  needle 
should  be  plunged  hard  into  the  tissues  right  up  to 
the  hilt,  the  shoulder  of  which  should  rest  firmly 
against  the  skin ;  and  hence  also  the  connection  be- 
tween needle  and  syringe  should  be  of  the  slip  va- 
riety, permitting  the  ready  and  undisturbing  re- 
connection  of  the  instruments.  The  lumen  of  the 
needle  must  be  perfectly  patent.  If  it  is  partially 
obstructed  by  an  accumulation  of  the  granular 
salicylate  there  may  be  sufficient  resistance  to  the 
comparatively  slight  blood  pressure  to  prevent  any 
very  apparent  or  rapid  forward  propulsion  of  the 
suspension.  On  the  other  hand,  the  pressure  ex- 
erted through  the  piston  is  very  much  greater,  and 
may  force  the  fluid  through  a  partly  obstructed 
needle.    These  points  are  very  important. 

 «^  


SOUTHERN   SURGICAL   AND  GYNECOLOGICAL 
ASSOCIATION. 

Tzventy-first  Annual  Meeting,  Held  in  St.  Louis,  December 
ij,  16,  and  J7,  igo8. 

The  President,  Dr.  F.  W.  Parham,  of  New  Orleans, 
in  the  Chair. 

(Continued  from  page  304.) 

Obstruction  of  the  Bowels. — Dr.  T.  C.  With- 

ERSPOON,  of  Butte,  Montana,  said  that  after  reflect- 
ing upon  the  results  he  had  obtained  in  thirty-six 
cases  of  bowel  obstruction,  with  seven  deaths,  he 
was  prepared  to  go  to  less  extreme  measures  to 
bring  about  relief  than  formerly.  Most  surgeons 
were  inclined  to  look  too  much  to  the  mechanical 
side  of  the  problem  and  neglect  the  physiological. 
Even  in  strangulation  by  a  hernial  ring,  the  lumen 
of  the  bowel  loop  caught  in  the  hernia  did  not  suf- 
fer from  complete  closure,  but  rather  was  there  a 
vascular  obstruction.  The  bowel  shut  off  was  as 
complete  when  its  coat  died  from  a  thrombotic  pro- 
cess as  when  it  was  caught  in  a  hernial  ring.  The 
real  obstruction  was  one  of  function  and  not  of  pure 
mechanics.  The  danger  to  the  patient  arose  from 
toxic  absorption  proximal  to  the  infunctionate  seg- 
ment. With  this  in  view,  he  had  formulated  for 
himself  the  cardinal  principle  of  bowel  drainage. 
The  method  of  obtaining  this  might  vary  as  the  con- 
ditions varied,  but  it  was  the  part  of  wisdom  never 
to  tax  the  patient's  strength  by  long  procedures  ex- 
cept in  a  few  instances,  like  a  Meckel's  diverticulum 
strangulation.  If  the  condition  was  due  to  a  band, 
invagination,  hernia,  or  the  like,  which  admitted  of 
easy  remedying,  the  method  should  be  applied,  but 
if  the  case  was  one  of  uncertainty  or  necessitated  an 
exhaustive  and  dangerous  procedure,  it  was  always 
better  to  let  out  the  proximal  bowel  contents  by  an 
artificial  opening  until  the  general  toxic  state  was 
much  improved,  when  a  more  radical  measure  might 
be  adopted  to  bring  permanent  relief.  Inflammatory 
obstructions  cleared  up  beautifully  when  the  loop 
proximal  to  the  involved  segment  was  drained.  Neo- 
plastic or  granulomatous  processes  might  be  readi- 
ly handled  after  sufficient  drainage  was  given  the 
bowel  above  the  lesion.  The  danger  lay  in  attempt- 
ing a  complete  procedure  at  the  one  time.  Why 


354 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


should  one  attempt  to  resect  the  bowel  in  a  very  sick 
patient  when  a  strangulated  hernia  existed  ?  A  sim- 
ple local  anaesthetic  opening  would  suffice  to  bring 
about  relief  from  sufferings,  physical  and  toxic.  In 
a  week  the  anastomosis  became  a  matter  of  simple 
surgery.  In  one  of  his  patients,  a  child  of  twelve 
years,  obstruction  became  complete  nearly  three 
weeks  after  an  operation  for  general  peritonitis.  He 
opened  the  abdomen  only  to  find  a  conglomeration 
of  bowel  loops  which  to  unravel  would  have  prob- 
ably caused  death.  He  selected  a  portion  of  bowel 
which,  because  of  its  distention,  was  recognized  as 
proximal  to  the  obstruction,  and,  at  the  same  time, 
seemed  to  be  the  most  distant  distended  loop  from 
the  stomach.  This  was  drained  through  a  large  rub- 
ber tube.  In  less  than  two  weeks  the  faecal  move- 
ments were  passing  again  by  the  natural  route  and 
the  artificial  opening  was  allowed  to  close.  Again, 
in  the  treatment  for  obstruction  success  lay  in  seek- 
ing to  drain  rather  than  to  unravel  the  mechanical 
difficulty.  When  the  latter  could  be  done  without 
adding  a  material  chance  to  mortality,  it  was  wise 
to  adopt  the  measure,  but  when  one  added  to  the 
danger  of  the  condition  by  so  doing,  he  should  sim- 
ply drain  artificially,  and'  at  a  later  time  a  serious 
condition  would  have  become  simple. 

Penetrating  Wounds  of  the  Abdomen. — Dr. 
Floyd  W.  McRae,  of  Atlanta,  Ga.,  read  a  paper 
with  this  title  (to  be  published). 

Some  Rare  Forms  of  Haematoma. — Dr.  J.  Gar- 
land Sherrill,  of  Louisville,  reported  three  cases 
of  haematoma  presenting  symptoms  somewhat  in 
common  and  extending  beyond  the  usual  time  which 
these  conditions  lasted,  one  having  existed  for  more 
than  ten  years,  and  each  of  them  continuing  to  in- 
crease in  size  from  the  begining.  The  following 
hypotheses  were  oft'ered  as  possibilities  in  explana- 
tion of  this  condition:  i.  The  blood  might  flow 
through  a  sac  returning  into  the  vessel  and  remain 
fluid,  at  least  in  part,  just  as  was  the  case  in 
aneurysm.  This  proposition  would  seem  to  be  fal- 
lacious, because  these  haemorrhages  were  probably 
venous,  and  the  tendency  of  a  vein  was  to  collapse 
immediately  upon  injury,  and,  moreover,  no  such 
patent  vein  had  been  noted  in  any  of  these  cases. 
2.  The  cellular  tissues  possessed  the  power  of  se- 
creting a  substance  which  tended  to  prevent  coagu- 
lation. This  seemed  clearly  refuted,  because  the  in- 
frequency  of  the  occurrence  of  persistent  haema- 
toma would  appear  to  prove  the  lack  of  such  power 
of  secretion.  3.  That  slight  infection  present  in  in- 
sufficient amount  to  produce  suppuration  resulted 
in  such  change  that  the  blood  could  not  be  taken  up 
by  the  absorbent  vessels.  This  theory  seemed  to  the 
author  to  be  irreconcilable  with  the  facts  in  the 
case,  for  effused  blood  had  but  little  power  of  re- 
sistance, and  any  culture  of  bacteria  should  find 
here  an  excellent  pabulum,  and  suppuration  would 
be  inevitable.  4.  The  tissues  about  a  haematoma 
might  be  so  dense  or  so  compressed  that  the  ab- 
sorbent vessels  would  be  occluded  or  obliterated, 
and  thus  made  incapable  of  accomplishing  their 
normal  functions.  This  proposition  seemed  to  the 
writer  to  have  a  more  probable  foundation  in  fact, 
although  not  accounting  fully  for  the  phenomena. 
5.  That  coagulation  took  place,  but  when  disinte- 
gration occurred  the  blood  remained  fluid,  but  was 


not  absorbable.  This  contention  seemed  also  within 
the  range  of  probability.  6.  The  constant  escape 
of  fresh  blood  occurred  in  a  quantity  sufficient  to 
more  than  make  up  for  the  loss  in  voluine  from 
absorption.  In  proof  of  this  the  author  believed  it 
could  be  demonstrated  that  the  escape  of  fluid  into 
a  haematoma  did  occur,  as  was  shown  in  his  cases, 
in  which  the  tumor  increased  in  size  steadily.  In 
one  the  bleeding  occurred  from  a  wounded  vessel 
in  the  femur ;  in  another  the  source  of  the  blood 
could  not  be  discovered,  but  he  thought  it  came 
from  a  small  vein.  There  was  also  the  possibility 
of  blood  being  manufactured  inside  the  sac,  as  in 
the  case  of  the  development  of  the  circulatory  ap- 
paratus in  the  embryo,  although  it  seemed  highly 
improbable  that  this  could  occur  in  adult  life.  From 
the  evidence  at  hand,  the  author  concluded  that  the 
tissues  about  a  haematoma,  from  pressure,  lost  their 
power  of  absorption ;  that  even  though  coagulation 
and  disintegration  occurred,  resorption  did  not  re- 
sult ;  and  that  in  some  instances  there  was  a  con- 
tinual addition  to  the  amount  of  blood  in  the  sac 
by  an  efflux  from  the  damaged  vessel. 

Observations  on  the  Surgical  Treatment  of  Ex- 
ophthalmic Goitre. — Dr.  John  R.  Wathen,  of 
Louisville,  stated  that  preliminary  ligation  of  the 
superior  thyreoid  artery  on  one  or  both  sides  had 
not  only  better  prepared  the  patient  to  withstand 
the  more  severe  shock  of  thyreoidectomy,  but  had 
also  greatly  reduced  the  size  of  the  tumor  in  the 
otherwise  hopeless  cases,  and  he  had  had  occasion  to 
employ  it  to  great  advantage  in  several  of  his  worst 
cases.  In  the  preparation  of  the  patient  for  opera- 
tion he  had  tried  almost  every  remedy  usually  rec- 
ommended to  reduce  the  pulse  and  better  the  condi- 
tion, but  none  had  yielded  such  good  results  as  ab- 
solute rest  in  bed  and  tincture  of  strophanthus.  It 
was  that  class  of  cases  in  which  no  preliminary  treat- 
ment seemed  to  be  able  to  make  such  temporary  re- 
ductions which  were  especially  dangerous.  These 
patients  usually  had  an  irregular  pulse,  a  degener- 
ated heart  muscle,  and  low  blood  pressure  in  contra- 
distinction to  the  majority,  which  had  often  a  very 
much  increased  blood  pressure,  albumin  in  the  urine, 
or  enlargement  and  fatty  degeneration  of  the  liver. 
Aside  from  the  proper  selection  and  preparation  of 
the  case,  the  most  important  thing  was  a  rapid  and 
safe  technique,  suitable  to  the  average  surgeon,  and 
not  a  variety  of  complicated  methods.  The  tech- 
nique employed  in  his  last  fifteen  cases  had  been  a 
slight  departure  from  that  usually  recommended. 
With  the  head  elevated  in  the  reverse  Trendelen- 
burg position,  and  a  large  sand  pillow  under  the 
shoulders  and  neck,  the  skin  was  grasped  with  two 
of  Jacobs's  volsellae  in  the  median  line  and  traction 
made  upward.  With  the  Mayo  blunt  pointed  scis- 
sors, instead  of  a  knife,  the  skin  and  platysma  were 
incised,  then  with  constant  upward  traction  the  in- 
cision was  continued  around  the  neck  as  far  as  was 
needed,  using  the  scissors  without  in  any  way  in- 
juring the  deeper  structures.  Next  were  ligated  the 
anterior  veins  and  the  ribbon  muscles  of  the  neck, 
severed  high  up  and  retracted,  then  the  capsule 
opened,  and  the  tumor  grasped  with  a  stout,  large 
volsella,  and  traction  made  in  an  upward  and  oppo- 
site direction.  This  readily  allowed  the  operator  to 
wipe  off  the  capsule  of  the  gland  with  a  piece  of 


February  13,  1509.  J 


PROCEEDINGS  OF  SOCIETIES. 


355 


gauze,  and  placed  the  arteries  and  the  veins  to  be 
hgated  on  the  stretch.  Forceps  should  always  be 
used  to  clamp  rapidly,  and  these  could  be  placed 
close  upon  the  tumor  and  the  vessels  Hgated  later 
with  catgut  after  the  complete  enucleation.  The 
isthmus  was  clamped  with  a  large  forceps  and  cut 
V-shaped,  parallel  with  the  clamp,  so  that  the  raw 
edges  could  be  turned  inward  by  whipping  over 
with  catgut,  instead  of  the  usual  method  of  carbolic 
acid  cautery  and  alcohol  or  Harrington's  solution. 
The  wound  should  only  be  washed  out  with  hot 
saline  solution  and  closed  with  a  subcuticular  catgut 
suture.  Drainage  through  a  lower  stab  wound  with 
large  open  rubber  tube,  instead  of  gauze  or  a  cig- 
arette drain,  should  complete  the  operation. 

Consideration  of  the  Mortality  in  One  Thou- 
sand Operations  for  Goitre. — Dr.  Charles  H. 
Mayo,  of  Rochester,  Minn.,  said  that  in  conquering 
serious  diseases  by  surgical  means  it  was  important 
that  the  operation  itself  should  be  as  free  from  mor- 
tality as  possible.  Once  surgical  technique  and 
sound  judgment  rendered  operating  comparatively 
safe,  serious  procedures  were  chosen  as  operations 
of  expediency  and  the  operative  mortality  became 
lower,  the  disability  was  reduced,  and  the  pregnancy 
of  cure  was  increased.  Goitre  was  still  considered 
a  rare  disease  in  this  country,  and  serious  only  when 
operated  upon.  The  mortality  from  early  operations 
was  high  for  the  number  of  operations,  as  the  opera- 
tions were  performed  from  great  necessity  after  the 
delay  of  long  and  oft  changed  medication.  Opera- 
tions upon  colloid,  simple,  or  diffuse  adenomata  as 
a  rule  involved  slight  risk  to  life.  In  his  early  sur- 
gical work  in  hyperthyreoidism,  he  considered  re- 
sults up  to  the  average  which  gave  twenty-five  per 
cent,  mortality.  With  better  judgment  and  more 
careful  preparation  of  the  patient,  or  graduated 
operations,  the  mortality  had  been  reduced  to  three 
or  four  per  cent.  In  his  series  of  cases  he  had  574 
cases  of  simple,  colloid,  or  dift'use  adenomata,  in- 
cluding encapsulated  goitre,  treated  by  extirpation 
or  enucleation,  with  four  deaths ;  eighteen  malig- 
nant, with  one  death ;  ninety-seven  cases  of  hyper- 
thyreoidism treated  by  double  ligation  of  the  super- 
ior thyreoid  arteries  and  veins,  with  one  death,  and 
fifteen  cases  with  simple  ligation,  with  no  dealhs ; 
295  cases  where  more  or  less  of  the  gland  was  re- 
moved, with  eighteen  deaths,  seven  of  which  were 
in  the  first  forty-six  cases ;  one  of  ligation,  with 
shock ;  fifteen  of  hyperthyreoidisms,  and  two  of  em- 
bolism. Ether  was  preceded  by  atropine,  1/120,  and 
morphine  of  a  grain.  Twenty  odd  operations 
were  done  under  cocaine  (local)  anaesthesia.  Can- 
cer and  sarcoma  were  most  serious  conditions,  al- 
though a  cure  was  possible  in  the  early  stages.  As 
goitre  of  long  standing  might  become  malignant, 
surgeons  should  encourage  early  operations  in  sud- 
den growths  of  stationary  glands. 

Hypoplasia  in  its  Relation  to  Health  and  Dis- 
ease.— Dr.  Charles  P.  Noble,  of  Philadelphia, 
said  that  man  consisted  of  a  body  and  intellect  and 
a  moral  nature,  and  might  degenerate  in  either  one 
or  all  three  of  his  natures,  and  this  degeneracy 
might  be  inherited  or  acquired.  If  the  potential  of 
life  received  by  the  ovum  was  imperfect,  there  re- 
sulted an  imperfect  body.  The  effects  might  be 
most  marked  in  the  physical  body,  in  the  intellect, 


or  in  the  moral  nature.  When  the  potential  of  life 
was  deficient,  there  resulted  imperfect  evolution  and 
an  imperfect  adult,  that  is,  the  adult  was  imperfect- 
ly developed  in  all  his  parts — bones,  muscles,  cir- 
culatory apparatus,  nervous  system,  ligaments,  fas- 
ciae— in  other  words,  man  was  suffering  from  hy- 
poplasia, or  imperfect  development.  The  same  con- 
ditions in  kind,  if  not  in  degree,  might  be  brought 
about  by  environment,  malnutrition,  insanitary  con- 
ditions of  living,  traumatisms,  or  intercurrent  dis- 
eases which  acted  by  arresting  development,  that  is, 
by  causing  hypoplasia.  If  the  potential  of  life  re- 
ceived in  the  ovum  was  very  defective,  there  result- 
ed em.bryonal  or  foetal  death  and  abortion.  In  other 
cases  there  resulted  monsters  or  instances  of  imper- 
fect development,  such  as  spina  bifida,  cleft  palate, 
etc.  There  resulted  idiocy,  imbecility,  and  insanity 
of  hereditary  type,  or  the  lesser  degrees  of  what  had 
heretofore  been  called  functional  nervous  diseases  or 
such  conditions  as  epilepsy,  catalepsy,  hysteria,  ner- 
vous instability,  and  a  tendency  to  the  development 
of  nervous  prostration.  In  infancy  and  childhood 
there  resulted  a  tendency  to  nutritional  diseases 
which,  acting  as  environment,  tended  to  arrest  nor- 
mal evolution  or  development.  In  certain  cases 
chlorosis  followed,  due  to  hypoplasia  of  the  circula- 
tory apparatus  and  the  blood  making  organs.  Pu- 
berty was  delayed,  and  in  a  woman  menstruation 
was  abnormal  and  painful.  The  young  adult  and  the 
adult  through  imperfect  development  might  retain 
the  bodily  form  of  the  child,  that  is,  neuter.  This  was 
the  bodily  form  of  the  consumptive.  The  vertebral 
column  did  not  retain  its  normal  curves,  the  chest 
was  flattened,  and  the  abdomen  protuberant,  and, 
owing  to  the  imperfect  development,  the  hypoplasia 
of  the  ligaments  and  the  muscles,  the  attitude  of 
the  man  was  such  that,  as  it  was  said,  he  looked  as 
though  he  was  tied  together  with  yarn  string.  There 
resulted  a  loss  of  relative  immunity,  and  so  when 
we  contra.sted  the  diseases  of  civilized  man  with 
those  of  the  savage,  we  found  there  was  a  tendency 
to  the  so  called  surgical  infections,  including  puer- 
peral sepsis,  appendicitis,  tuberculosis,  etc.  There 
resulted  a  tendency  to  visceral  ptoses  due  to  the  im- 
perfect development  of  the  ligaments  of  these  or- 
gans and  to  the  insufBcient  support  of  the  abdom- 
inal muscles.  This  explained  the  failure  to  relieve 
symptoms  when  such  patients  were  operated  upon ; 
whereas,  when  normal  individuals  with  acquired 
ptoses  were  operated  upon,  the  local  diseases  were 
cured  and  the  patients  got  well.  There  resulted  im- 
perfect function  of  the  glandular  cells  of  the  body, 
with  consequent  imperfect  digestion,  so  called  nerv- 
ous dyspepsia,  when  this  was  not  acquired  from  en- 
vironment. There  resulted  nervous  instability,  hys- 
teria, catalepsy,  epilepsy,  insanity,  idiocy,  etc.,  which 
were  but  the  manifestations  of  the  various  degrees 
of  imperfection  in  the  development  of  the  nervous 
system,  and  these  conditions  bore  the  same  relations 
to  hypoplasia  of  the  central  nervous  .system  as  a 
cough  did  to  a  bronchitis.  Degenerates  or  defec- 
tives were  the  weaklings,  the  unfit,  and  the  process 
whereby  Nature  got  rid  of  them  was  through  pro- 
gressive degeneracy  until  they  lost  the  power  of 
generation  or  deliberately  refused  to  exercise  it.  In 
medicine  this  biological  principle  and  the  recognition 
of  its  results  upon  the  body  in  the  arrest  of  devel- 


356 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


opment  would  make  simple  many  things  heretofore 
obscure,  and  would  make  prognosis  and  treatment 
rational  instead  of  guesswork,  as  they  had  been. 
These  patients,  when  afflicted  with  diseases,  were 
different  from  norma!  individuals.  When  the  local 
condition  was  cured  in  a  normal  individual,  the  pa- 
tient was  well ;  whereas  in  the  defective,  when  the 
local  trouble  v.'as  cured,  he  still  had  hypoplasia,  and 
so  might  retain  the  most  of  his  symptoms. 

The  greatest  hope  in  the  future  lay  in  prevention. 
Through  state  medicine  and  through  individual 
prophylaxis,  the  children  of  defectives  and  those 
who  acquired  hypoplasia  must  not  be  brought  up 
under  the  usual  environment.  They  must  not  be 
sent  to  school  in  the  usual  way,  but  must  be  sent  to 
the  country  and  live  according  to  the  laws  of  Na- 
ture, whereby  their  development  might  become  as 
perfect  as  was  possible  under  the  conditions.  These 
people  were  the  weaklings  and  could  not  stand  the 
strains  and  stresses  of  life,  and  when  subjected  to 
them  they  always  gave  out  and  got  nervous  pros- 
tration. Therefore  the  physician  in  dealing  with 
these  people  should  first  treat  them  along  lines  of 
rest  and  improve  their  nutrition,  and  then  must  show 
that  they  could  not  perform  the  usual  labor  of  other 
people,  but  nuist  accept  this  as  a  fact  and  limit  the 
expenditure  of  their  energy  to  that  which  they 
evolved.  They  could  never  do  the  full  work  of  a 
normal  man  or  woman. 

Surgery  of  the  Pleura. — Dr.  John  B.  Murphy, 
of  Chicago,  said  that  pneumothorax  was  not  so 
dangerous  a  condition  as  was  formerly  believed.  In 
discussing  lesions  of  the  pleura,  one  should  first 
consider  the  primary-  infective,  perforative  lesions, 
which  demanded  prompt  and  immediate  action ; 
and,  second,  chronic  indurated  lesions,  which  called 
for  masterly  inactivity,  so  far  as  operations  were 
concerned.  In  the  first  class  of  cases  the  use  of 
the  exploring  needle  between  the  ribs  would  usual- 
ly afford  relief,  but  incision  would  give  these  pa- 
tients immediate  relief.  Aspiration  did  not  cure 
chronic  conditions  of  the  pleura.  According  to 
statistics,  of  one  thousand  cases  treated  by  simple 
aspiration,  there  were  only  two  cures  reported. 

In  the  suppurative  types  of  infection  of  the 
pleura,  absorption  of  the  toxic  products  could  be 
stopped,  sterilization  of  the  fluid  efifected,  and  the 
necessity  for  opening  the  chest  avoided.  A  number 
of  agents  had  been  used  for  this  purpose.  Per- 
chloride  of  mercury  had  been  used  with  success. 
Formalin,  which  had  little  or  no  toxic  effect,  had 
great  sterilizing  power.  The  author  had  used  it  in 
cases  of  excessive  hydrops,  where  a  lung  was  com- 
pressed, and  with  one  injection  the  secretion  was 
almost  stopped.  Purulent  cases  were  not  cured 
with  one  injection,  except  in  children.  Take  a  case 
of  pneumococcus  infection  in  a  child,  in  whom 
formerly  the  ribs  were  resected ;  if  one  aspirated 
and  injected  two  or  three  ounces  of  a  two  per  cent, 
solution  of  formalin  and  petrolatum,  prepared  twen- 
ty-four hours  before,  repeating  the  injections  from 
time  to  time,  as  a  rule  a  cure  would  be  effected. 
One  injection  might  bring  aboift  a  cure  in  some  in- 
stances. 

In  the  other  variety  of  cases,  in  which  there  was 
a  dense,  firm  mass  of  cicatricial  tissue  which  would 
not  contract,  wc  had  a  different  condition.  This 


tissue  would  remain  for  years  without  absorption, be- 
cause many  times  it  had  large  dep>osits  of  calcium 
salt  in  it  and  could  not  collapse.  In  these  cases  one 
could  make  use  of  the  same  injections,  but  they 
must  be  given  more  slowly.  The  injection  of 
formalin  and  petrolatum  sterilized  the  fluid  contents 
and  prepared  them  for  absorption,  and  finally  in  six 
months  thereafter  we  should  have  a  sanguinolent 
fluid,  and  in  twelve  months  the  patient  was  practi- 
cally well  without  having  any  tube  in  his  side. 

Splenectomy  for  Splenomegaly  of  Doubtful 
Classification. — Dr.  M.  C.  McGannon,  of  Nash- 
ville, Tenn.,  read  a  paper  with  this  title,  and  re- 
ported a  case  which  presented  some  unusual  feat- 
ures not  heretofore  recorded  in  connection  with  pri- 
rriary  splenomegaly.  The  patient  was  a  white  wo- 
man, aged  forty-three.  Chronicity  was  doubtful, 
since  the  patient  first  noticed  the  enlargement  of  the 
spleen  only  a  few  months  before  she  came  under  the 
author's  observation.  Her  physical  condition  had 
been  below  par  for  a  year  or  two ;  but  preceding  an 
attack  of  pneumonia,  which  was  four  months  before 
she  discovered  the  splenic  enlargement,  she  had 
not  considered  herself  in  any  sense  a  sick  woman. 
Anaemia,  haematemesis,  jaundice,  and  liver  enlarge- 
ment, all  terminal  symptoms,  might  have  arisen 
later  had  the  disease  been  permitted  to  continue. 
The  most  marked  and  unusual  features  of  the  case 
were  the  general  enlargement  of  the  superficial  lymph 
nodes  and  the  myxcedematous  symptoms — thick- 
ened, puffy  skin,  and  mental  hebetude,  with  com- 
plete disappearance  of  all  symptoms  and  pathologi- 
cal conditions  in  other  tissues  after  the  removal  of 
the  spleen. 

The  Relation  of  Surgery  to  the  Neuroses,  with 
Special  Reference  to  Neurasthenia. — Dr.  Charles 
M.  RossER,  of  Dallas,  Texas,  said  that  surgery  was 
the  most  definite  art  with  which  medicine  was  con» 
cerned,  and  neurasthenia  the  most  vague  of  dis- 
eases. Writers  mentioned  heredity  and  exercise, 
but  ignored  intercurrent  causes  independent  of 
which,  in  many  cases,  physiology  would  not  be  dis- 
turbed, on  account  of  predisposition  and  excitation. 
Neurasthenia  was  both  a  psychical  and  a  physical 
condition,  and  might  be  induced  by  surgical  con- 
ditions which  disfigured,  disabled,  or  caused  distress. 
.As  physical  causes,  deformities  which  might  not 
affect  vital  functions,  but  which  embarrassed  sensi- 
tive temperaments,  were  factors.  Extensive  scar- 
ring from  burns  upon  exposed  surfaces  was  pre- 
vented by  surgical  skin  grafting.  Goitre,  by  sight 
and  secretory  disturbances,  might  cause  stomach 
conditions  that  were  amenable  to  surgery  by  di- 
gestive deviations  and  those  disorders  of  the  bile 
passages,  as  was  true  of  chronic  appendicular  in- 
volvement, which  tended  toward  autointoxication, 
and  insomnia  was  the  most  frequent  forerunner  of 
mental  depression.  The  clinical  examination 
should  be  as  careful  as  though  the  symptoms  were 
not  exaggerated.  The  prognosis  should  be  more 
guarded,  but  the  patient  should  not  be  denied  op- 
portunity of  physical  relief  on  account  of  nervous 
and  mental  conditions,  and  should  be  subjected  to 
no  procedure  that  was  not  justified  by  clinical  find- 
ings. The  patients  should  always  have  the  benefit 
of  all  doubts  that  were  reasonable. 

( To  he  concluded.) 


February  13,  1909.  J 


BOOK  NOTICES. 


357 


§oflk  goto. 

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The  Problem  of  Age,  Grozvth,  and  Death.  A  Study  of 
Cytomorphosis  Based  on  Lectures  at  the  Lowell  Institute, 
March,  1907.  By  Charles  S.  Minot,  LL.  D.  (Yale,  To- 
ronto), D.  Sc.  (Oxford),  James  Stillman  Professor  of 
Comparative  Anatomy  in  the  Harvard  Medical  School, 
€tc.  Illustrated.  New  York  and  London:  G.  P.  Put- 
nam's Sons,  1908.    Pp.  x-274. 

The  author  states  that,  while  this  book  deals  with 
a  series  of  important  biological  problems,  it  is  es- 
sentially a  study  of  a  single  phenomenon,  the  in- 
crease in  the  amount  of  protoplasm  that  takes 
place  within  the  limits  of  single  calls,  and  occurs  in 
such  a  manner  that  the  .proportion  between  the  cell 
body  and  the  nucleus  is  changed.  He  believes  that 
variations  of  the  proportion  establish  conditions 
that  are  fundamental  to  the  correct  conception  of 
the  problems  of  growth,  differentiation,  death,  and 
sex.  Senescence  is  a  problem  of  living  matter,  it 
is  an  essential  feature  of  life,  and  it  finds  its  most 
familiar  expression  in  the  gradual  loss  of  the  func- 
tional powers  of  the  organism,  its  end  being  death. 

The  author's  experiments  were  made  largely 
with  guinea  pigs,  chickens,  and  rabbits,  and  ex- 
tended over  a  number  of  years.  He  formulated 
the  conclusions  that:  i.  Cytomorphosis  begins 
with  an  undifferentiated  cell.  2.  Cytomorphosis 
is  always  in  one -direction  through  progressive  dif- 
ferentiation and  degeneration  toward  the  death  of 
the  cells.  3.  Cytomorphosis  varies  in  degree  char- 
acteristically for  each  tissue.  He  did  not  find  that 
differentiated  material  could  be  restored  to  the 
imdifferentiated  condition. 

He  has  established  the  following  four  laws  of 
age:  i.  Rejuvenation  depends  on  the  increase  of 
the  nuclei.  2.  Senescence  depends  on  the  increase 
of  the  protoplasm  and  on  the  differentiation  of  the 
cells.  3.  The  rate  of  growth  depends  on  the  de- 
gree of  senescence.  4.  Senescence  is  at  its  maxi- 
mum in  the  very  young  stages,  and  the  rate  of 
senescence  diminishes  with  age.  From  these  laws 
there  follows  the  corollary  that  natural  death  is 
the  consequence  of  cellular  dift'erentiation. 

The  volume  is  extremely  interesting,  and,  while 
the  views  are  the  author's  personal  interpretation, 
it  seems  likely  that  the  profession  will  believe  them 
justified  by  the  evidence  presented. 

Pathological  Technique.  A  Practical  Manual  for  Work- 
ers in  Pathological  Histology  and  Bacteriology,  Includ- 
ing Directions  for  the  Performance  of  Autopsies  and  for 
Clinical  Diagnosis  by  Laboratory  Methods.  By  Fr.-\xk 
Burr  Mallorv,  A.  M.,  M.  D.,  Associate  Professor  of 
Pathologj',  Harvard  University  Medical  School,  First 
Assistant  Visiting  Pathologist  to  the  Boston  City  Hos- 
pital, etc.,  and  James  Homer  Wright,  A.  M.,  M.  D., 
S.  D.,  Director  of  the  Pathological  Laboratory  of  the 
Massachusetts  General  Hospital ;  Assistant  Professor  of 
Pathology,  Harvard  University  Medical  School.  Fourth 
Edition.  Revised  and  Enlarged,  with  152  Illustrations. 
Philadelphia  and  London :  W.  B.  Saunders  Company, 
1908.    Pp.  480.    (Price,  $3.) 

The  fourth  edition  of  this  work  in  eleven  years  is 
indicative  of  its  popularity,  and  the  authors  have 


availed  themselves  of  the  opportunity  to  give  it  a 
thorough  revision.  They  have  included  a  descrip- 
tion of  Zinsser's  anaerobic  method  for  plate  cul- 
tures, new  methods  for  the  cultivation  and  dis- 
tinction of  the  typhoid  bacillus,  Weigert's  iron 
haematoxylin  stain  for  nuclei,  improvements  in  the 
methods  of  staining  fibroglia,  myoglia,  and  neu- 
roglia fibrils,  Wright's  method  for  the  differential 
staining  of  blood  platelets  and  the  giant  cells  of  the 
bone  marrow,  Best's  improved  stain  for  glycogen, 
and  Sir  A.  E.  Wright's  method  of  preparing  bac- 
teria! vaccines,  and  there  is  a  revision  of  the  para- 
graphs on  actinomycosis.  The  illustrations  are  ex- 
cellent and  the  vohime  maintains  its  high  character. 

Glandular  Enlargement  and  Other  Diseases  of  the  Lymph- 
atic System.  By  Arthur  Edmunds,  M.  B.,  M.  S.,  B.  Sc., 
Lond.,  F.  R.  C.  S.,  Eng.,  Surgeon  to  the  Great  Northern 
Central  Hospital,  etc.  London  :  Henry  Frowde  and  Hod- 
der  &  Stoughton ;  New  York :  Oxford  University  Press, 
1908.    Pp.  vii-230. 

This  is  a  concise  and  practical  treatise  on  the 
diseases  of  the  lymphatic  system,  only  those  patho- 
logical conditions  being  considered  in  which  the 
affection  of  the  lymphatic  vessel  or  gland  consti- 
tutes the  essential  feature  of  the-  disease.  In  addi- 
tion, the  subject  has  been  considered  from  a  sur- 
gical standpoint,  and  the  description  of  the  surgical 
technique  to  be  used  in  those  conditions  that  would 
be  benefited  by  operation  is  very  practical.  There 
are  a  number  of  excellent  illustrations. 

Emergency  Surgery.  For  the  General  Practitioner.  By 
John  W.  Sluss,  A.  M.,  M.  D.,  Professor  of  Anatomy, 
Indiana  University  School  of  Medicine,  etc.  With  584 
Illustrations,  some  of  which  are  Printed  in  Colors.  Phil- 
adelphia :  P.  Blakiston's  Son  &  Co.,  1908.  Pp.  xi-692. 
(Price,  $3.50.) 

There  are  many  manuals  on  first  aid,  especially 
such  as  are  written  for  the  layman,  but  very  few 
compendia  for  the  physician.  Professor  Sluss  has 
done  the  medical  profession  a  very  good  service  in 
compiling  his  book  on  Emergency  Surgery.  It  is 
written  for  the  general  practitioner  and  should 
serve  especially  in  time  of  stress  as  a  guide.  For 
this  purpose  the  book  has  a  full  index. 

It  is  divided  into  two  parts ;  the  first  part,  con- 
taining twenty-two  chapters,  refers  to  minor  sur- 
gery, while  part  two,  with  twenty-six  chapters, 
takes  in  major  and  special  surgery.  In  part  one 
are  to  be  found  the  general  consideration  of  emer- 
gency equipment ;  antisepsis  ;  anaesthesia  ;  materials 
for  sutures,  drainage,  dressings,  bandages,  and 
splints ;  and  the  treatment  of  shock,  haemorrhages, 
and  wounds  in  general.  This,  demonstrated  in  ten 
chapters,  may  be  taken  as  an  introduction,  and  is 
followed  by  chapters  on  gunshot  wounds,  fractures, 
injuries  to  joints,  tendons,  and  nerves;  abscess, 
phlegmon,  acute  osteomyelitis ;  septic  arthritis ;  for- 
eign bodies ;  and  burns,  scalds,  and  frostbites.  In 
Part  II  we  read  about  tracheotomy,  trephining, 
laparotomy,  appendicular  inflammation,  artificial 
anus,  strangulated  hernia,  enterectomy,  tubal  gesta- 
tion, Csesarean  section,  amputations,  removal  of 
small  tumors,  skin  grafting,  suture  of  arteries,  and 
ingrowing  toenails.  \Nt  should  think  that  the  arti- 
cle on  suture  of  arteries,  although  sometimes  neces- 
sitating major  surgerv,  should  have  been  included 
in  Part  I. 


358 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


Neurological  and  Mental  Diagnosis.  A  Manual  of  Meth- 
ods. By  L.  Pierce  Clark,  M.  D.,  Senior  Attending 
Physician,  Hospital  for  Nervous  Diseases,  New  York, 
etc.,  and  A.  Ross  Diefendorf,  M.  D.,  Lecturer  in  Psy- 
chiatry in  Yale  University,  etc.  New  York :  Macmillan 
Company,  1908.    Pp.  188. 

This  little  textbook  is  divided  into  two  parts. 
l"he  first,  on  neurological  methods  of  diagnosis,  is 
by  Dr.  Clark;  the  second,  on  the  investigation  of 
the  mental  condition — the  larger  work  by  far — is 
by  Dr.  Diefendorf. 

The  purpose  of  the  book,  as  set  forth  by  the 
authors,  is  to  aid  the  student  and  practitioner  to 
make  thorough  and  systematic  examinations  in 
nervous  and  mental  diseases.  In  this,  we  think, 
they  have  succeeded.  The  second  portion  of  the 
book,  that  on  the  investigation  of  psychical  condi- 
tions, has  especially  appealed  to  us. 

The  Cure  of  Rupture  by  Paraffin  Injections.  By  Charles 
C.  Miller,  M.  D.  Comprising  a  Description  of  a  Method 
of  Treatment  Destined  to  Occupy  an  Important  Place  as 
a  Cure  for  Rupture  owing  to  the  Extreme  Simplicity  of 
the  Technique  and  its  Advantages  from  an  Economic 
Standpoint.  Chicago :  Oak  Printing  Co.,  1908.  Pp.  82. 
(Price,  $1.). 

The  author  of  this  booklet  takes  the  standpoint 
that  paraffin  has  a  tendency  to  promote  the  forma- 
tion of  connective  tissue,  and,  as  there  is  in  hernia 
usually  a  condition  of  the  tissues  which  can  be  in- 
duced to  throw  out  connective  tissue,  occlusion  of 
the  hernial  sac  will  be  produced.  The  injections  can 
be  made  in  the  physician's  office,  without  an  anaes- 
thetic, without  an  assistant,  and  without  much 
trouble  to  the  patient.  The  time  for  such  an  injec- 
tion is  about  from  two  to  four  minutes.  But  before 
undertaking  this  treatment  the  physician  should 
make  himself  thoroughly  acquainted  with  the  man- 
ner of  diffusion  of  paraffin  in  the  tissues ;  and  this 
experience  can  be  gained  by  making  experimental 
injections  into  animals.  Should,  finally,  the  injec- 
tion not  be  successful,  and  the  patient  suffer  from 
the  presence  of  the  paraffin,  it  can  be  removed  by  a 
surgical  operation  which  at  the  same  time  may  be 
made  so  as  to  cure  the  hernia.  The  author  gives  a 
full  description  of  his  method,  the  instruments,  the 
preparation  of  the  paraffin,  the  positbn  of  the 
patient,  the  effect  of  paraffin  compounds  upon  the 
tissues,  the  after  treatment,  etc.,  concluding  with  a 
report  of  ten  case  histories. 

NEW  PUBLICATIONS, 
Chemistry. 

Abdcrhalden,  Emil. — Lehrbuch  der  physiologischen 
Chemie.  Zweite  Auflage.  Berlin  und  Wien :  Urban  & 
Schwarzenberg,  1909.    Pp.  984. 

Physiology. 

Bonnier,  P. — La  Voix;  culture  physiologique.  Theorie 
nouvelle  de  la  phonation.  Deuxieme  edition.  Paris :  F. 
Alcan.    (Price,  3f.  50.) 

Bateson,  W. — The  Methods  and  Scope  of  Genetics. 
Cambridge :  The  University  Press,  1908.    Pp.  49. 

Pathology. 

Von  den  l-'elden,  p. — Konstitution  und  Vererbung.  Miin- 
chen:  Verlag  der  arztlichen  Rundschau,  1909.  Pp.  131, 
(Price,  2M  8a) 

Josue. — Traite  de  rarteriosclerose.  Paris :  Bailliere  et 
fils.    (Price,  lof.) 

Internal  Medicine. 
Jeanselme,  E.,  Weil,  P.  E.,  Chauffard,  A.  et  Laederich,  L. 
— Maladies  des  reins.    Avec  76  figures  intcrcalees  dans  le 
texte.    Paris :  J.  B.  Bailliere  ct  fils,  1909.    Pp.  462. 

Dahmer. — Die  ambulante   Behandlung  der  Tuberkulose 


mit  besonderer  Beriicksichtigung  der  Hetolinjektionen. 
Leipzig:  B.  Konegen,  1908. 

Surgery. 

Wullstein  und  Wilms. — Lehrbuch  der  Chirurgie.  Zweiter 
Band,  erste  Lieferung.  Mit  127  zum  Teil  mehrfarbigen 
Abbildungen.  Jena :  Gustav  Fischer,  1909.  Pp.  320. 
(Price,  5M.) 

The  Division  of  Surgery  of  the  Medical  School  of  Har- 
vard University.  Report  of  Research  Work,  1906-1908.  De- 
cember, 1908.    Bulletin  No.  V.  Boston. 

Hildebrand,  O. — Die  Entwicklung  der  plastischen  Chirur- 
gie.   Festrede.    Berlin  :  August  Hirschwald,  1909.    Pp.  36. 

Reichcl,  Paul. — Lehrbuch  der  Nachbehandlung  nach  Op- 
erationen.  In  Vorlesungen  fiir  Studierende  und  Aerzte. 
Mit  67  Abbildungen  im  Text.  Zweite  unigearbeitete  und 
vermehrte  .Auflage.  Wiesbaden :  J.  F.  Bergmann,  1909. 
Pp.  557. 

Holicncgg,  J. — E.  Albert's  Lehrbuch  der  speziellen  Chi- 
rurgie fiir  Studierende  und  Aerzte.  L  Teil.  Chirurgie  des 
Unterleibs.  Mit  374  Abbildungen.  Berlin  und  Wien :  Ur- 
ban &  Schwarzenberg,  1908. 

Taylor,  Henry  Ling. — Orthopaedic  Surgery  for  Practition- 
ers. With  254  Illustrations.  New  York  and  London :  D. 
Appleton  &  Co.,  1909.    Pp.  xxiv-503. 

Neurology  and  Psychiatry. 

Stoddari,  W.  H.  5.— Mind  and  its  Disorders.  A  Text- 
book for  Students  and  Practitioners.  With  Illustrations. 
Philadelphia :  P.  Blakiston's  Son  &  Co.,  1909.    Pp.  xvi-488. 

Deschamps,  A. — Les  maladies  de  I'energie,  les  asthenics 
generales,  epuisements,  insuffisances,  inhibitions  (clinique 
therapeutique).    Paris:  Felix  Alcan,  1909.    (Price,  8f.) 

Loewenfeld.  L. — Grenzfragen  des  Nerven-  und  Seelen- 
lebens.    Wiesbaden  :  J.  F.  Lehmann,  1909. 

Hartenberg,  P. — Psychologie  des  neurastheniques.  Deux- 
ieme edition.    Paris:  Felix  Alcan,  1909.    (Price,  3!  50.) 

H tiger,  W. — Die  Hypnose  und  die  Suggestion.  Ihr 
Wesen,  ihre  Wirkungsweise  und  ihre  Bedeutung  und  Stel- 
lung  unter  den  Heilmitteln.  Jena:  G.  Fischer.  (Price, 
4M.) 

Birnbauni,  Karl. — Psychosen  mit  Wahnbildung  und 
wahnhaf  te  Einbildungen  bei  Degenerativen.  Halle  a.S. : 
Karl  Marhold,  1908.    Pp.227.    (Price,  8f.) 

Hygiene  and  Public  Health. 

Report  relating  to  the  Registration  of  Births,  Marriages,, 
and  Deaths  in  the  Province  of  Ontario  for  the  Year  End- 
ing December  31,  1906  (being  the  37th  Annual  Report). 
Printed  by  Order  of  the  Legislative  Assembly  of  Ontario. 
Toronto :  L.  K.  Cameron,  1908.    Pp.  39-xc.xvii. 

Kiesezvetter,  Doris  und  Anderc. — Kleidung,  Schonheit, 
Gesundheit.  Berlin :  Verlag  der  Lebenskunst-Heilkunst,. 
1908. 

Burckhardt,  .ilbrecJit. — Demographic  und  Epidemiologic 
der  Stadt  Basel  wahrend  der  letzten  3  Jahrhunderte.  Leip- 
zig: C.  Beck,  1908.    (Price,  6M.) 

Loscner,  W. — Die  Trinkwasserversorgung  der  Truppe 
unter  besonderer  Beriicksichtigung  der  bei  den  ortlichen 
Priifungen  von  Wassergewinnungsanlagen  in  Betracht  kom- 
menden  Gesichtspunkte  bearbeitet.  Berlin  :  A.  Hirschwald, 
1909.    (Price,  iM.  60.) 

Schneider,  J. — Die  Pflege  der  Gesundheit  und  Schonheit. 
Vi,  310  Seiten,  mit  ill  Abbildungen.  Leipzig:  Theodor 
Thomas,  1908. 

Senator,  H.,  and  Kaininer,  S. — Marriage  and  Disease. 
Being  an  Abridged  Edition  of  Health  and  Disease  in  Rela- 
tion to  Marriage  and  the  Married  State.  Translated  from 
the  German  by  J.  Dulberg,  M.  D.,  Manchester,  England. 
New  York:  Paul  B.  Hoeber,  1909.  Pp.  ix-452.  (Price, 
$2.50.) 

Obstetrics  and  Gyncecology. 
Bouquet,  Paul. — Grossesse,  accouchement,  direction  du 
travail.    Avec  68  figures.    Pp.  80.    Paris :  G.  Steinheil. 
(Price,  3f-) 

.'^chultae.  Bernard  Sigm. — Lehrbuch  der  Hebammen- 
kunst.  Mit  103  Abbildungen.  Pp.  xxx,  404.  Leipzig: 
W.  Engelniann,  1908. 

Otology. 

Dahmer. — Die  Indikationen  zur  Eroffnung  und  Ausrau- 
mung  des  Warzenfortsatzes  bei  der  akuten  und  chronischcn 
Mittelohreitertung.    Leipzig :  B.  Konengen,  1908. 

Pediatrics. 

Variot.  G. — L'Hygiene  infantile,  allaitement  maternal  et 
artificiel.    Paris:  Hachcttc,  1908.    (Price  if.) 


February  13,  1909.] 


OFFICIAL  NEWS. 


359 


Nursing. 

Gregoirc,  R. — Manuel  d'anatomie  professionelle  des  in- 
firmieres.  Avec  108  figures.  Pp.  280.  Paris:  O.  Doin  et 
fils.    (Price,  5f.) 

Onoinatology. 

Kiihn,  IVilhcliit. — Neues  medicinisches  Fremdw  orterbucli 
fiir  Schwestern,  Samariter,  Heilgehilfen,  Kraukenpfleger 
usw.    Zvveite  verniehrte  Auflage.    Leipzig:  Kriiger  &  Co., 

lyOp.     Pp.  1I-IO3. 

Guttmann,  U'allcr. — Medizinisclie  Terminologie.  Dritte 
umgearbeitete  und  erw  eiterte  .\urtage.  Berlin  und  Wien : 
Urban  &  Schwarzenberg,  1909. 

Schobcr,  P. — Medizinisches  Worterbucb  der  deutschen 
und  franzosischen  Sprache.  Zweite  vermehrte  Auflage. 
Stuttgart :  Ferdinand  Enke,  1908.    Pp.  347. 

Electricity,  Rontgen  Rays,  ajid  Emanations. 

Remak,  Ernst. — Grundriss  der  Elektrodiagnostik  und 
Elektrotberapie.  Fiir  praktische  Aerzte.  Zweite,  umgear- 
beitete Auflage.  ]\Iit  25  Holzscbnitten.  198  Seiten.  Ber- 
lin und  Wien :  Urban  &  Schwarzenberg,  1909. 

Misceilancous. 

Drury,  A.  G. — Dante:  Physician.  Cincinnati:  The  Lan- 
cet-Clinic, 1908.    Pp.  89. 

Dittrich. — Handbuch  der  arztlichen  Sachverstiindigen- 
Tatigkeit.    19-27  Lieferungen.    Wien :  Brauniiiller. 


-4>- 


(gfficial  fcros. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports: 

The  follozuing  ijses  of  smallpox,  yelloiv  fever,  cholera, 
and  plague  haz'C  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Service 
during  the  zceck  ending  February  5.  I(^oq: 

Smallpox — United  States. 
Places.                   "                       Date.                 Cases.  Deaths 
Alabama — Mobile  Jan.    16-23   1  Imported 


Alabama — Mobile   County  Jan.  31   5 

California — Los  Angeles  Jan.    9-16   2 

Illinois — Danville  Jan.    17-24   1 

Indiana — Elkhart  Jan.    16-23   - 

Indiana — Fort  Wayne  Jan.    9-16   i 

Indiana — Indianapolis  Jan.    17-24   i 

Indiana — La  Fayette  Jan.    18-25   9 

Kansas — Kansas  City  Jan.    16-23   i 

Kansas — Topeka  Jan.    9-23   15 

Kentucky — Covington  Jan.    16-23   ^ 

Kentucky — Lexington  Jan.    16-23   6 

Louisiana — New  Orleans  Jan.    16-23   i 

Louisiana — Shreveport  ....Jan.    1-20   32  1 

Maine — Van  Duren  Jan.    16-23   ^ 

Maryland — Baltimore  Jan.    31   i  Imported 

Minnesota — Dulutn  Jan.    14-21   i 

Ohio — Cincinnati  Jan.    8-22   49  i 

Ohio — Tifiin  jan.    16-23   i 

Pennsylvania — Ilarrisburg  Lec.    18-29   3 

Tennessee — Nashville  Jan.    16-23   6 

Texas — Laredo  Feb.   4   i 

Texas — San  Antonio  Jan.    16-23   4 

Virginia — Lynchburg....  Jan.    16-23   i 

Washington — Tacoma...'  Jan.    3-17   17 

Wisconsin — La  Crosse  Jan.    16-23   3 

Wisconsin — Manitowoc  Jan.    16-23   ' 

Wisconsin — Milwaukee  Jan.    9-23   40 

Smallpox — Foreign. 

Australia — New  Castle  Nov.   23-30   i 

Brazil— Para                                     Dec.  26-Jan.  9   3  3 

Brazil — Rio  de  Janeiro                    Dec.    13-27   253  11: 

Canada — Halifax  Jan.   9-16   4 

Canada — Hamilton  Jan.    16-23   i 

Chile — Talcaguana  Ian.    2   Present 

China — Anioy  Dec.    12-19   Present 

China — Shanghai  iJec.   5-12   2 

Greece — .\thens  Dec.  26-Jan.  2   1 

India — Bombay  Dec.   22-29   4 

India — Calcutta  Dec.   5-12   6 

India — Rangoon  Dec.    12-19   i 

Indo-China — Saigon  Dec.    i-ig   4  2 

Italy — General  J'ec.  27-Jan.    lo   19 

Mexico — Monterey  Jan.    10-17   ' 

Mexico — \'era  Cruz  Jan.    2-9   i 

Netherlands,  The — Rotterdam  Jan.    9-16   i 

Newfoundland — St.   lohns  Jan.    16-23   1  Vessel 

Peru— Lima  Dec.  24   8 

In  Lazaretto 

Russia — Moscow  Dec.  9-16   13  7 

Siberia — Vladivostock  Dec.    13-20   i 

Spain— -Valencia  Dec.  26-Jan.  9   7 

Spain — Vieo  Dec.   26-Jan.  2   2 

Turkey — Constantinople  Dec.  27-Jan.   10   8 


Yellow  Fever — Foreign. 
Places.  Date.  Cases.  Deaths. 

Brazil — Bahia   Feb.    i   Epidemic 

Brazil — .\Ianaos  Dec.   12-19   ' 

Dutch  Guiana — Paramaribo  Dec.   i8-Jan.  2              21  0 

.Mexico — Merida  Jan.    9-16   2 

.Mexico — San    Bernadino,  vicinity 

of  Mexcanu   Jan.   9-16   : 

Cholera — Foreign. 

India — Bombay  Dec.    22-29   ■'^ 

India — Calcutta  Dec.   5-12   i  :> 

Russia — St.  Petersburg  Jan.    13-14                   67  2_ 

Plagu  e — Fo  reign . 

Brazil — Bahia   Feb.    i   Epidemi, 

Brazil — Rio  de  Janeiro  Dec.   15-27                     15  9 

Cliile — Iquique   Dec.    28   i 

India — General  Dec.    12-19  2,449  1,788 

India — Bombay  Dec.   22-29   4 

India — Calcutta  Dec.    5-12   9 

India — Rangoon  Dec.  12-19  

Peru — General  Dec.   18-24                    30  20 

Peru — Callao  Dec.    24-Jan.    2             2  i 

Peru — Lima  Dec.    24-Jan.    2             3  2 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  in  the  stations  and  duties  of  com- 
missioned and  other  officers  of  the  United  States  Public 
Health  and  Marine  Hospital  Service  for  the  seven  days 
ending  February  3,  igog: 

Gibson,  R.  H.,  Pharmacist.  Granted  seven  days'  leave  of 
absence  from  February  i,  1909,  under  paragraph  210, 
Service  Regulations. 

HoLSENDORF,  B.  E.,  Pharmacist.  Granted  thirty  days'  leave 
of  absence  from  February  17,  1909,  and  excused  with- 
out pay  for  seven  days  from  March  18,  1909. 

K.\STLE,  Joseph  H.,  Qiief  of  the  Division  of  Chemistry, 
Hygienic  Laboratory.  Granted  eleven  days'  extension 
of  leave  of  absence  from  January  2,  1909,  on  account 
of  sickness. 

Marshall,  E.  R.,  Assistant  Surgeon.    Granted  two  days' 

leave  of  absence  from  February  11,  1909. 
Nydegger,  James  A.,  Passed  Assistant  Surgeon.  Directed 
to  proceed  to  Washington,  D.  C,  and  report  to  the 
chairman  of  the  board  of  medical  examiners  to  deter- 
mine his  fitness  for  promotion  to  the  grade  of  surgeon. 
Preble,  Paul,  Assistant  Surgeon.    Granted  seventy-three 
days'  leave  of  absence  from  October  26,  1908,  on  ac- 
count of  sickness. 
Salmon,  Thomas  W.,  Passed  Assistant  Surgeon.  Granted 

thirty  days'  leave  of  absence  from  February  i,  1909. 
Signer,  G.  W.,  Surgeon.    Granted  two  day='  leave  of  ab- 
sence from  January  29,   1909,  und.  r  paragraph  189, 
Service  Regulations. 
Warren,  B.  S.,  Passed  Assistant  Surgeon.    Granted  ten 

days'  leave  of  absence  from  January  27,  1909. 
Wertenbaker,  C.  p..  Surgeon.     Directed  to  proceed  to 
Raleigh,  N.  C.,  upon  special  temporary  duty. 
Board  Coinxncd. 
Board  of  medical  officers  convened  to  meet  at  the  Bureau 
February  i,  1909,  for  the  examination  of  Passed  Assistant 
Surgeon  James  A.  Nydegger  to  determine  his  fitness  for 
promotion  to  the  grade  of  surgeon.    Detail  for  the  board  : 
Assistant  Surgeon  General  W.  J.  Pettus,  chairman :  As- 
sistant  Surgeon  General  J.   M.   Eager ;   Surgeon   W.  P. 
Mcintosh,  recorder. 

Army  Intelligence: 

Official  list  of  changes  in   the  stations  and  duties  of 
officers  serving  in  the  medical  corps  of  the  United  States 
Army  for  the  week  ending  February  6,  igoc): 
Banister,  J.  M.,  Lieutenant  Colonel,  Medical  Corps.  Or- 
dered to  Omaha,  Neb.,  for  temporary  duty  as  Oiief 
Surgeon,  Department  of  the  Missouri. 
Bartlett,  C.  J.,  Captain,  Medical  Corps.    Ordered  to  Fort 
Andrews,  Mass.,  for  duty  upon  return  from  Cuba  with 
troops. 

BisPHAM,  W.  N.,  Captain,  Medical  Corps.  Relieved  from 

duty  in  the  Philippines  Division  in  time  to  sail  on  April 

15th  for  San  Francisco,  Cal. 
Blanchard,  R.  M.,  Captain,  Medical  Corps.    Ordered  to 

accompany  troops  from   Fort   Sheridan,   111.,  to  San 

Francisco,  Cal. 

Carter,  E.  C,  Lieutenant  Colonel,  Medical  Corps.  Ordered 
to  Chicago,  111.,  for  temporary  duty  as  Chief  Surgeon, 
Department  of  the  Lakes. 

Co.x,  Walter,  Captain,  Medical  Corps.  Relieved  from 
duty  in  the  Pliilippines  Division  in  time  to  sail  on 
April  15th  for  San  Francisco,  Cal. 


360 


BIRTHS,  MARRIAGES.  AND  DEATHS. 


[Xew  York 
iltuicAL  Journal. 


Duval,  D.  F.,  Major,  Akdical  Corps.  Ordered  to  Fort  SiII, 
Okla.,  for  duty  upon  return  from  Cuba  with  troops. 

]m<u  k.  E.  B.,  Major,  Medical  Corps.  Ordered  to  Fort 
McDowell,  Cal.,  for  duty  upon  return  from  Cuba  witli 
troops. 

Gilchrist,  H.  T..,  iNlajor  Medical  Corps.  Ordered  to  Fort 
Omaha,  Xeb.,  for  duty  upon  return  from  Cuba  with 
troops. 

Hess,  L.  T.,  Major,  Medical  Corps.  Ordered  to  Fort 
Leavenworth,  Kans.,  for  duty  upon  return  from  Cuba 
witii  troops. 

HoFF,  J.  Van  R.,  Colonel,  Medical  Corps.    Ordered,  upon 

expiration  of  present  leave  of  absence,  to  Chicago,  III, 

for  duty  as  Chief  Surgeon,  Department  of  the  Lakes. 
MuRKAY,  Alex.,  Captain,  Medical  Corps.    Relieved  from 

duty  with  the  Isthmian  Canal   Commission;  granted 

lca\e  of  absence  for  three  months. 
Persons,  E.  E.,  Captain,  Medical  Corps.    Granted  leave  of 

absence  for  se\en  days. 
Rand,  L  VV.,  Major,  Medical  Corps.    Ordered  to  duty  at 

Fort  Dn  Pont,  Del.,  upon  arrival  in  the  United  States. 
Shook,  J.  R.,  Captain,  Medical  Corps.    Ordered  to  Chi- 
cago, 111.,  for  duty  as  attending  surgeon  upon  return 

from  Cuba  with  troops. 
Thomason,  11.  D.,  Captain,  Medical  Corps.    Granted  leave 

of  absence  for  one  month. 
Truby,  W.  F.,  Major,  Medical  Corps.    Ordered  to  Fort 

Bayard,  X.  M.,  for  duty  at  the  Army  General  Hospital, 

upon  return  from  Cuba  with  troops. 
Van  Dusen.  J.   W.,  Captain,   Medical  Corps.  Relieved 

from  duty  at  Fort  Crook,  Xeb.,  and  ordered  to  Fort 

Riley,  Kans.,  for  duty. 
Whitcomb,  C.  C.  Captain.  Medical  Corps.    Granted  leave 

of  absence  for  tour  months  on  arrival  in  United  States 

from  Cuba. 
Navy  Intelligence: 

Offirial  list  of  changes  in   the  stations  and  duties  of 
officers  sending  in  tlic  medical  carles  of  the  United  States 
Nai'x  for  the  iveek  ending  February  6,  igog: 
Des.-^ez,  p.  T.,  Passed  Assistant  Surgeon.    Ordered  to  the 

Denzer. 

Nash.  F.  S.,  Surgeon..  Detached  from  the  Xaval  Academy 
and  ordered  to  his  home  to  wait  orders. 

 <?>  

§irt|»s,  Parriagts,  uti  featfes. 


Born. 

Kendall. — In  Xew  York,  on  Saturday,  January  30th,  to 
Dr.  Henry  Kendall,  and  Mrs.  Kendall,  a  son. 

McLean. — Li  Detroit.  Michigan,  on  Saturday,  January 
30th,  to  Passed  Assistant  Surgeon  Allen  D.  McLean,  United 
States  Xavy,  and  Mrs.  McLean,  a  son. 

•  Married. 

Johnson — J.\.mison. — In  Morgantown.  West  Virginia,  on 
Thursday.  January  28th.  Dr.  G.  D.  Johnson  and  Miss  Jessie 
Lee  Jamison. 

Llekits — Irwin. — In  Baltimore,  Maryland,  on  Tuesday, 
January  1.2th,  Mr.  Delbert  Llekits,  of  Louisville,  Kentucky, 
and  Dr.  Rachael  G.  Irwin. 

Smith — Vickery. — In  Peoria,  Illinois,  on  Wednesday, 
January  13th,  Dr.  Ralph  Homer  Smith,  of  Lancaster,  Ohio, 
and  Miss  Theodora  Marshall  Vickery. 

Steoman — BouRBONNAis. — In  Saginaw,  Michigan,  on 
Tuesday,  January  12th.  Dr.  W.  G.  Stednian,  of  Rochester, 
New  York,  and  Miss  Una  H.  Bourbonnais. 

Stexckl— Pepper. — In  Philadelphia,  on  Tluirsday,  Febru- 
ary 4th,  Dr.  .Alfred  Stengel  and  Miss  Martha  O.  Pepper. 

Van  Kaa  ihoven — Hexry. — In  San  Francisco,  California, 
on  Monday.  I'Vbruary  1st,  Dr.  J.  J.  .\bram  Van  Kaathoven 
and  Mrs.  .Alice  Belknap  Henry. 

Wkic.ht — Barido. — In  Kane,  Pennsylvania,  on  Tuesday, 
Januarv  26th,  Dr.  Carl  Wright,  of  Yorktown,  Indiana, 
and  Miss  Josephine  Barido. 

Died. 

AiTciiEsoN. — In  Ortonville,  Michigan,  on  Sunday,  Janu- 
ary TOtli,  Dr.  William  Aitcheson,  aged  sixty-three  years. 

Anderson. — In  Xorfolk,  Virginia,  on  Sunday,  January 
24th,  Dr.  J.  H.  .Anderson,  aged  seventy-five  years. 

Anderson. — In  Managua,  Nicaragua,  Central  America, 


on  Sunday,  January  24th,  Dr.  Lomax  S.  Anderson,  of  Moss 
Point,  Mississippi,  aged  thirty-eight  years. 

Ash  more. — In  Topeka,  Kansas,  on  Tuesday,  January 
19th,  Dr.  Simon  Ashmore,  aged  eighty-three  years. 

Bash. — In  Warsaw,  Indiana,  on  Friday,  January  291I1, 
Dr.  John  M.  Bash,  aged  sixty  years. 

Bowers. — In  Greensboro.  Xorth  Carolina,  on  Wednesday, 
January  13th,  Dr.  A.,H.  Bowers,  of  Gold  Hill. 

Bribacu. — In  St.  Louis,  Missouri,  on  Friday,  January 
29th,  Dr.  Benno  Bribach,  aged  sixty-three  years. 

Campbell. — In  Philadelphia,  on  Thursday,  February  5th, 
Dr.  John  Campbell,  aged  eighty  years. 

Cheatham. — In  Sandersville,  Georgia,  on  Monday,  Jan- 
uary 25th,  Dr.  D.  L.  Cheatham,  aged  sixty  years. 

Dickson. — In  Paragould,  Arkansas,  on  Thursday.  Janu- 
ary 28th,  Dr.  A.  G.  Dickson. 

Dortch. — In  Shreveport,  Louisiana,  on  Tuesday,  January 
26th,  Dr.  F.  W.  Dortch,  of  De  Ridder,  aged  thirty-eight 
years. 

Downing. — In  Sugartown.  Pennsylvania,  on  Thursday, 
January  21st,  Dr.  Henry  Miller  Downing,  aged  forty-seven 
years. 

Easton. — In  Aliami,  Florida,  on  Tuesday,  February  2n(U 
Dr.  Andrew  Easton,  of  Allegheny,  Pennsyhania,  aged 
sixty-four  years. 

Faust. — ^^In  Washington,  D.  C,  on  Monday,  February  1st, 
Dr.  Ambrose  Faust,  aged  seventy-si.x  years. 

Forbes. — In  Pawtucket,  Rhode  Island,  on  Wednesday, 
January  27th,  Dr.  J.  Flarry  F'orbes,  aged  thirty  years. 

Garl.-vnd. — In  Clayton,  Georgia,  on  Friday,  Januarv  22nd, 
Dr.  D.  L.  Garland. 

Gordon. — In  Alexandria,  Louisiana,  on  Tuesday,  January 
26th,  Dr.  Smith  Gordon,  aged  seventy-five  years. 

Hale. — In  Lumberton,  Mississippi,  on  Saturday,  January 
30th,  Dr.  P.  S.  Hale,  aged  eighty-four  years. 

Harvey. — In  Alta,  Iowa,  on  Sundav,  Januarv  31st.  Dr. 
J.  L.  Harvey. 

1  [eald. — In  Millard,  Nebraska,  on  Sunday,  January  loth. 
Dr.  Harvey  P.  Heald,  aged  thirty-five  years. 

Henry. — In  Shippensburg,  Pennsylvania,  on  Monday, 
January  i8th,  Dr.  George  C.  Henry,  aged  fifty-two  years. 

Hicks. — In  Mount  Vernon,  Indiana,  on  Tuesdaj',  January 
Qtli,  Dr.  C.  Hicks,  aged  sixty-one  years. 

Holt. — In  Newlield,  Xew  York,  on  Tuesdav,  Februarv 
2nd,  Dr.  C.  M.  Holt. 

Holyoke. — In  Chicago,  on  Sunday,  January  31st.  Dr.  R.  ' 
H.  Holyoke.  of  Lincoln,  Xebraska,  aged  forty  years. 

Markt. — In  Hamilton,  Ohio,  on  Thursday,  January  28th, 
Dr.  Constantine  Markt.  aged  seventy-seven  years. 

Mauch. — In  Xew  York,  on  Tuesday,  February  2nd,  Dr. 
Dr.  Joseph  Bernhard  Mauch,  aged  sixty  years. 

Meredith. — In  Scottsville,  Kentucky,  on  Friday,  January 
29th,  Dr.  W.  E.  Meredith,  aged  thirty-nine  years. 

.Mitchell. — In  Xew  burgh,  Xew  York,  on  Monday.  Feb- 
ruary 1st,  Dr.  John  J.  Mitchell,  aged  seventy-five  years. 

.Vier.man. — In  Fort  Wayne,  Indiana,  on  Sunday,  January 
3 1. St.  Dr.  Herman  G.  Nierman,  aged  thirty-eight  years. 

OvEKToN. — In  Cleveland,  Texas,  on  Friday,  January  29th, 
Dr.  L.  F.  Overton,  aged  forty  years. 

Patterson. — In  New  "^'ork,  on  Saturday.  January  23d. 
Dr.  E.  L.  Patterson,  of  Barnwell.  South  Carolina. 

Payne. — In  Warrenton,  Virginia,  on  Wednesday,  Feb- 
ruary 3d,  Dr.  W.  W.  Payne,  aged  seventy-five  years. 

Phillips. — In  Erie.  Pennsvlvania,  on  Wednesday,  Janu- 
ary 27th,  Dr.  Joseph  R.  Phillips,  aged  fifty-eight  years. 

Prathep,. — In  Louisville,  Kentucky,  on  Tuesday.  Janu- 
ary 26th.  Dr.  T.  W.  Prather,  aged  forty  years. 

Rider. — In  Qiappaqua,  X^ew  York,  on  Sunday.  January 
31st.  Dr.  Charles  Everts  Rider,  aged  seventy  years. 

Robertson. — In  Monticcilo,  Arkansas,  on  Friday,  January 
29th,  Dr.  S.  G.  Robertson. 

Russell. — In  Hartford,  Connecticut,  on  Wednesday. 
February  3d,  Dr.  Gurdon  Wadsworth  Russell,  aged  ninety- 
four  years. 

Stewart. — In  Cleveland,  Ohio,  on  Thursday.  January 
2Sth,  Dr.  Thomas  Stewart,  of  Carlisle,  Pennsylvania,  aged 
lifty-five  years. 

Tayi  or. — In  Reynoldsburg.  Oiiio.  on  Friday,  January 
29th.  Dr.  Frank  G.  Taylor,  aged  fifty-nine  years. 

WiLi.i.wisoN. — In  Asbury  Park.  New  Jersey,  on  Monday, 
February  Tst.  Dr.  Alexander  Williamson,  aged  sixty-one 
years. 

Woi.FE. — In  Chicago.  Illinois,  on  Tinirsday,  January  28t1i, 
Dr.  Jrunes  J.  Wolfe,  aged  forty-eight  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  The  Medical  News 


A   Weekly  Review  of  Medicine,  Established  1S4J. 


Vol.  LXXXIX.  Xo.  8.         XEW  YORK,  FEBRUARY  20,   1909.  Whole  Xo.  1577. 


(^^riginiil  (Lomiiuinifatioiis. 

 r 

IS    THE   HUAIAX   BODY   SUPPLIED   WITH  AN 

AUTOPROTECTIVE  MECHANISM? 
A  iiezc  theory  of  Iiiuiniiiity  based  on  the  Ductless  Ghiids* 

By  Charles  E.  de  M.  Sajous,  M.  D., 
Philadelphia. 

The  subject  of  my  address  is  one  which,  I  may 
state,  has  been  uppermost  in  my  mind  durino-  the 
"better  part  of  my  working  Hfe.  To  understand  Xa- 
ture's  way  of  antagonizing  disease,  and  learn  how 
to  enhance  her  resources  when  these  fail,  has  always 
appeared  to  me  as  the  goal  for  which  we  should 
strive.  So  concordant  is  the  thought,  in  fact,  with 
our  highest  aims  as  physicians  and  humanitarians, 
that  it  may  be  said  to  have  seen  light  at  the  very 
dawn  of  medicine,  and  to  have  grown  apace  witii 
time.  Indeed,  twenty-three  centuries  ago  Hippo- 
crates taught:  "It  is  to  the  efforts  of  Xature  that 
the  attentive  and  able  physician  looks  for  guidance" 
(i)  ;  to-day,  the  most  virile  trend  of  modem  thought 
is  a  corresponding  principle,  that  conveyed  by  the 
term  "immunity."  Whether  we  seek  to  identify  the 
nature  of  antibodies,  the  process  through  which  they 
are  caused  to  appear  in  the  blood,  or  the  manner  in 
which  they  and  the  phagocytes  oppose  infection,  we 
are  but  following  the  path  opened  by  the  father  of 
medicine  400  years  before  the  Christian  era. 

^^  e  have  now  learned  through  the  painstaking 
labors  of  a  host  of  investigators  that  our  organism 
is  supplied  with  autoprotective  substances ;  is  the 
production  of  these  substances  regulated  by  a  mech- 
anism? The  sources  of  the  various  substances 
which  take  part  in  the  immunizing  process  have  not 
so  far  been  identified.  This,  I  believe,  is  , because 
pathologists  have  overlooked  the  one  field  which,  ex- 
perimentally and  clinically,  oft'ers  the  only  solid 
foundation  for  a  profitable  analysis  of  the  question, 
that  of  the  ductless  glands.  Brown-Sequard. 
Langlois,  Abelous,  Charrin,  Albanese,  Zucco,  and 
many  others,  for  example,  have  laid  stress  on  the 
antitoxic  functions  of  the  adrenals,  while  \'assale. 
Gley,  Fano  and  Zanda,  and  many  other  investigators 
and  clinicians  have  urged  a  similar  role  in  respect 
to  the  thyreoid  and  parathyreoids.  This  applies 
equally  well  to  the  pituitary  body  according  to 
!Marie.  Guerrini,  Gemelli,  and  others.  We  thus  have 
a  series  of  organs  found  experimentally  and  clini- 
cally to  protect  in  some  v.-ay  the  body  against  intox- 
ication.   Is  it  not  logical  to  conclude  that  they  claim 

•Read  by  invitation  before  the  Toronto  (Canada)  Academy  of 
Medicir.e.  lanuary  5,  1909. 


attention  as  the  more  likely  to  furnish  the  factors  for 
a  solution  of  this  all  important  problem? 

Prompted  !)y  these  indications  and  seme  of  the 
data  submitted  below,  I  suggested  in  a  volume 
(2)  published  early  in  1903,  and  intended  more 
to  offer  working  propositions  rather  than  solu- 
tions, that  the  adrenals  and  the  thyreoid  were 
the  sources  of  two  substances  regarded  by 
pathologists  as  prominent  agents  in  the  immuniz- 
ing process,  and  that  the  secretory  functions  of 
these  organs  were  governed  by  a  centre  located 
in  the  pituitary  body.  I  suggested,  moreover,  that 
it  was  probably  by  exciting  this  centre  that  various 
familiar  drugs,  mercury,  for  instance,  and  certain 
toxines,  tuberculin,  Coley's  toxines,  and  the  like, 
produced  their  beneficial  eft'ects.  The  six  years  that 
have  elapsed  since  I  submitted  these  propositions 
have  served  only  to  strengthen  them,  it  seems  to  me, 
and  my  object  this  evening  is  to  submit  to  you  the 
present  status  of  the  question. 

My  task  would  be  an  easy  one,  if  the  functions 
of  the  organs  which,  from  my  viewpoint,  constitute 
the  defensive  mechanism  (and  which  for  the  sake  of 
convenience  I  have  called  the  "adrenal  system") 
were  known.  Physiologists  are  familiar  with  the  ef- 
fects of  extracts  of  the  adrenals,  thyreoid,  and 
pituitary,  and  with  the  results  of  removal  of  these 
organs ;  they  have  furnished  us,  moreover,  a  rich 
store  of  isolated  facts  concerning  them ;  but  the 
functions  of  these  organs  in  the  body  have  remained 
obscure.  My  own  labors  appear  to  me  to  have 
filled  this  gap,  and  as  the  functions  I  have  been  led 
to  ascribe  to  these  organs  are  merged,  so  to  say, 
with  their  role  as  defenders  of  the  organism,  it  is 
necessary  to  submit  to  you  at  least  some  of  the  main 
data  upon  which  my  conclusions  to  this  effect  are 
based. 

To  facilitate  the  presentation  of  the  subject  with- 
out taxing  too  greatly  your  patience,  I  have,  present- 
ed my  deductions  and  a  portion  of  the  evidence 
which  led  to  them  in  their  logical  sequence.  This 
plan  may  be  said,  in  fact,  to  represent  a  brief  his- 
tory of  my  researches  in  the  order  that  they  were 
conducted. 

FUXCTIOXS  OF  THE  ADREXALS. 

To  all  but  physiologists  it  may  seem  strange  that 
the  process  through  which  the  body  is  supplied  with 
oxygen  should  still  be  obscure.  Paul  Bert  (3), 
thirty  years  ago.  showed  experimentallv  that  the 
absorption  of  oxygen  by  the  pulmonary  blood  per- 
sisted even  when  the  pressure  of  this  gas  was  almost 
nil.  Muller  also  observed  that  a  strangulated  ani- 
mal exhausted  the  air  in  its  lungs  of  al!  its  oxygen ; 
while  Setschenow  and  Holmgren  (4),  Zuntz  (5), 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


362 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


[Xew  York 
ilEDiCAL  Journal. 


and  others  found  but  traces  of  oxygen  in  the  arterial 
blood  of  asphyxiated  animals.  This  suggested  that 
the  diffusion  doctrine  was  defective  and  that  the  ab- 
sorption of  oxygen  from  the  air  was  due  to  the  pres- 
ence, in  the  blood  circulating  through  the  lungs,  of 
some  substance  capable  of  taking  up  this  gas.  This 
conclusion  was  sustained  by  the  researches  of  Bohr 
(6),  Haldane  and  Lorrain  Smith  (7),  Vaughan 
Harley  (8),  and  Bohr  and  Henriques  (9),  the  last 
named  investigators  concluding  that  the  substance 
"having  greater  avidity  for  oxygen  than  the  blood 
itself"  in  the  lungs  was  presumably  "a  kind  of  in- 
ternal secretion." 

This  view  has  been  antagonized  by  some  of  the 
advocates  of  the  diffusion  theory  (whose  aerotono- 
metric  figures,  by  the  way,  are  suggestively  dis- 
cordant), but  as  recently  stated  by  Pembrey,  in  the 
closing  remarks  of  an  impartial  review  of  the  ques- 
tion (10)  "the  body  of  evidence  has  been  steadily  in- 
creasing in  favor  of  the  secretory  theory,  especially 
as  regards  the  absorption  of  oxygen." 

Having  repeatedly  noted  the  powerful  reducing 
properties  of  adrenal  extractives,  it  occurred  to  me 
that  the  secretion  of  the  adrenals  might  fulfill  this 
role.  Anatomical  studies  in  various  lower  animals 
and  in  man,  and  a  systematic  research  in  the  litera- 
ture of  the  subject,  demonstrated  that  it  met  all  the 
conditions  required  to  satisfy  so  important  a  func- 
tion. 

The  first  deduction  imposed  upon  me  by  these  re- 
searches was  that 

The  secretion  of  the  adrenals  has  a  marked  af- 
finity for  oxyge}i,  and  inevitably  reaches  the  ptil- 
monary  air  cells. 

Vulpian  (11),  over  fifty  years  ago,  found  that  adrenal 
juice  reduced  iron  perchloride  and  iodine.  Cybulski  (12) 
recorded  a  similar  action  on  potassium  permanganate, 
Langlois  (13)  noted,  however,  that  adrenal  extract  lost  its 
reducing  properties  In  vitro  when  oxidizing  compounds 
were  added.  As  to  the  action  of  the  atmospheric  oxygen : 
Battelli  (14)  found  that  adrenalin  did  not  lose  its  proper- 
ties when  contact  with  air  was  prevented,  while  Abel  (15), 
Takamine  (16),  and  others  refer  to  this  property  as  a 
■source  of  trouble  in  laboratories,  the  latter  chemist  specify- 
ing, in  fact,  that  adrenalin  becomes  oxidized  by  contact 
with  the  air. 

That  the  adrenal  secretion  inevitably  reaches  the  air  cells 
was  made  clear  by  a  study  of  the  anatomical  relations  be- 
tween the  adrenals  and  the  lungs.  Tlie  blood  of  the  effer- 
ent vessels  of  the  adrenals,  their  veins,  passes  to  the  in- 
ferior vena  cava,  directly  on  the  right  side,  and  by  way  of 
the  renal  vein  on  the  left.  The  actual  presence  of  the 
adrenal  secretion  in  the  blood  of  the  adrenal  veins  is  shown 
by  many  experimental  facts.  Gottschau  (17),  for  example, 
traced  hyaline  granules  (found  subsequently  to  be  their 
secretion)  from  the  interior  of  the  adrenals  to  their  veins. 
This  observation  was  confirmed  and  amplified  by  Manasse 
(18),  Aulde  (19),  and  Stilling  (20).  Pfaundler  (21)  traced 
the  same  granules  from  the  interior  of  the  organ  along  the 
adrenal  veins  to  the  vena  cava  itself.  It  is  doubtless  the 
adrenal  secretion  and  no  other  which  is  carried  by  the 
blood  of  the  vena  cava,  for  when  blood  originating  from 
the  adrenals  on  its  way  to  this  great  trunk  was  injected 
into  animals  by  Cybulski  and  Scymonowicz  (22),  it  pro- 
duced the  characteristic  effects  of  adrenal  extract.  Tliese 
results  were  coiifirmed  by  Biedl  (33),  Langlois  (24),  and 
Dreyer  (25).  Scymonowicz,  Biedl,  Dreyer,  Salvioli,  and 
Pizzolini  (26)  found,  moreover,  that  such  effects  could  not 
be  obtained  with  venous  blood  obtained  from  other  parts  of 
the  body. 

The  next  fact  to  assert  itself  was  that 
On  reaching  the  air  cells,  the  adrenal  secretion  ab- 
sorbs oxygen  and  becomes  a  constituent  of  hccnio- 
globin  and  of  the  red  corpuscles. 


While  a  reducing  substance  has  been  found  necessary  we 
have  seen,  to  account  for  the  absorption  of  oxygen  from 
the  alveolar  air,  it  happened  that  the  greater  part  of  the 
haemoglobin  molecule  was  composed  almost  entirely  of  an 
albuminous  substance  which  had  remained  unidentified. 
Gamgee  (27),  for  instance,  states  that  '"hemoglobin  exists 
in  the  blood  corpuscles  in  the  form  of  a  compound  with  a 
yet  unknown  constituent  of  the  corpuscles."  This  body  he 
defines  as  the  "albuminous  moiety  of  the  haemoglobin  mole- 
cule" and  (28)  as  representing  ninety-six  per  cent,  of  this 
molecule,  the  remaining  four  per  cent,  being  the  iron  laden 
hsematin.  Now,  I  found  that  this  "unknown  constituent"  of 
haemoglobin  corresponded  in  its  physicochemical  properties 
with  the  adrenal  secretion.  Gamgee  (29),  for  example,  states 
that  haemoglobin  is  insoluble  in  absolute  alcohol,  chloro- 
form, benzol,  ether,  and  all  organic  solvents;  Vulpian  (30) 
had  already  noted  that  of  all  glandular  products,  that  of  the 
adrenals  alone  showed  this  peculiarity.  Gautier  (31^, 
Moore  (32),  and  Takamine*also  refer  to  it.  Again,  ac- 
cording to  Moore  and  Purinton  (33)  adrenal  extracts  are 
rapidly  destroyed  by  alkalies ;  this  is  also  a  characteristic 
of  haemoglobin.  This  pigment  likewise  resists  heat  up  to 
the  boiling  point;  this  applies  also,  according  to  Cybulski 
(34),  Moore  (35),  and  others  to  adrenal  extract.  Finally, 
Mulon  (36)  found  that  the  red  corpuscles  gave  the 
histochem.ical  reactions  of  the  active  principle  of  the  adren- 
als, thus  showing  that  these  blood  cells  actually  contain 
this  principle. 

In  confirmation  of  this  conclusion  is  the  fact  that 
The  oxygen  laden  adrenal  secretion  is  a  constitu- 
ent of  the  albuminous  hcemoglobin  in  the  blood 
plasma. 

Battelli  (37)  isolated  from  the  blood  a  product  endowed 
with  the  chemical  properties  of  adrenalin.  That  this 
adrenal  principle  is  a  constituent  of  the  albuminous  portion 
of  haemoglobin  voided  by  red  corpuscles  in  the  plasma,  sug- 
gested itself  when  Schmiedeberg  (38),  Jaquet  (39),  Abelous 
and  Biarnes  (40),  and  other  chemists  showed  that  blood 
plasma  contains  an  oxidizing  substance,  subsequently  known 
as  oxidase.  Not  only  was  it  found  to  resist  heat  at  least 
up  to  the  boiling  point  and  to  possess  other  chemical  char- 
acteristics of  the  adrenal  principle,  but  the  actual  presence 
of  the  latter  is  confirmed  by  other  facts.  Thus,  in  1853 
Traube  had  concluded  that  haemoglobin  could  not  fulfill  the 
physicochemical  functions  ascribed  to  it  without  the  aid  of 
a  catalyzer.  Poehl  (41)  showed  that  the  adrenal  principle 
was  a  catalyzer,  while  Jolles  (42)  pointed  out  that  the 
activity  of  a  given  volume  of  blood  as  a  catalyzer  corre- 
sponded with  the  number  of  blood  corpuscles  it  contained. 
Additional  evidence  to  this  effect  and  an  explanation  of 
the  role  of  these  corpuscles  were  afforded  by  the  next  con- 
clusion reached :  That 

The  red  corpuscles,  after  absorbing  the  oxygen- 
ized adrenal  secretion  {the  hlbnminous  constituent 
of  their  hcemoglobin)  yield  it  to  the  blood  plasma  in 
the  form  of  droplets,  the  so  called  "blood  platelets." 

As  Gamgee  (43)  teaches,  haemoglobin,  under  the  influ- 
ence of  various  chemical  agents,  "undergoes  a  decomposi- 
tion of  which  the  chief  products  are,  an  albuminous  sub- 
stance or  substances,  and  a  coloring  matter  which  contains 
the  whole  of  the  iron" ;  but,  as  he  also  says,  "the  coloring 
matter  of  the  red  corpuscles  is  not  extracted  from  them 
by  the  plasma."  This  docs  not,  however,  apply  to  their 
albuminous  substance.  That  they  discharge  the  latter  in 
the  plasma  is  rendered  evident  by  various  facts.  Louis  Els- 
berg  (44),  thirty  years  ago,  observed  "a  projection  of  a 
pediculated  granule  or  knob"  from  the  periphery  of  red 
corpuscles.  Hirshfcld  (45)  traced  these  granules  from  the 
interior  of  these  cells,  through  one  or  more  minute  aper- 
tures which  closed  up  again,  to  the  surrounding  plasma. 
Brockbank  (46)  gave  recently  a  beautiful  microphotograph 
of  "platelets  in,  or  being  extruded  from  red  cells."  Again, 
Detemann  (47)  noted  tliat  llie  buds  on  the  surface  of  the 
red  cells  "at  first  are  attached  to  the  cell  by  protoplasmic 
processes  and  contain  haemoglobin" :  but  that  "later,  the 
buds  become  separated  from  the  cell.  losing  their  haemo- 
globin." This  does  not  militate  against  Gamgee's  statement 
that  the  coloring  matter  remains  in  the  corpuscles,  but  it 
indicates  that  the  albuminous  constituent  is  voided  into 
the  plasma. 

These  albuminous  droplets  (which,  in  1903  (48)  I  iden- 


February  20,  1909.  i 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


363 


tified  as  the  familiar  blood  platelets)  having  absorbed  oxy- 
gen in  the  lungs,  should,  in  the  light  of  preceding  deduc- 
tions and  owing  to  the  catalyzing  property  of  their  adrenal 
principle,  be  able  to  surrender  their  oxygen  to  any  agent  in 
the  blood  or  tissues,  possessed  of  sufficient  reducing  power 
to  appropriate  it.  That  this  applies  to  the  droplets  is  shown 
by  the  reaction  to  certain  stains.  Litten  (49)  and  others 
found  for  example,  that  blood  platelets  derived  from  the 
red  corpuscles  are  best  stained  with  methylene  blue ;  Sten- 
gel, White,  and  Pepper  (50)  state,  in  fact,  that  "methylene 
blue  gave  the  only  positive  results."  This  indicates  that  the 
droplets  are  certainly  rich  in  oxygen — as  their  identity  as 
the  oxygenized  adrenal  secretion  would  suggest — for,  as 
Ehrlich  teaches,  one  of  the  conditions  ''essential  to  the 
methylene  blue  reaction"  is  "oxygen  saturation."  (51). 

A  Study  of  the  melanins  then  showed  that 
The  alhiiminoiis  constituent  of  the  hcemoglohin,  or 
oxygen  laden  adrenal  secretion,  is  distributed  by  the 
red  corpuscles  to  all  parts  of  the  body  as  an  oxidiz- 
ing agent. 

Leonard  Hill  (52),  Hirschfeld,  Chittenden,  and  Albro 
(53),  and  most  classic  writers  look  upon  melanins,  the 
brown  and  black  pigments  found  in  certain  forms  of  sar- 
coma, in  the  tissues,  the  blood,  the  urine,  etc.,  in  various 
morbid  states,  as  haemoglobin  derivatives.  While  Morner, 
Brandl,  and  L.  PfeifTer  (54)  found  that  it  contained  iron, 
and  accept  this  origin,  Nencki  and  Berdez  (55)  do  not,  be- 
cause they  failed  to  find  this  metal  in  the  pigment  isolated 
from  a  melanotic  sarcoma.  These  discordant  opinions  are 
harmonized,  however,  by  the  newer  conception  I  submit : 
The  first  named  authors  dealt  with  whole  haemoglobin, 
containing,  therefore,  its  iron ;  while  Nencki  and  Berdez 
dealt  quite  as  surely  with  haemoglobin,  but  only  with  its 
albuminous  constituent. 

Having  traced  to  the  adrenals  the  origin  of  the  active 
agent  of  this  albuminous  haemoglobin  and  this  substance 
being  melanin,  the  presence  of  the  adrenal  principle  in 
melanins  should  be  shown.  In  the  first  place  these  pigments 
were  found  by  Walter  Jones  (56)  insoluble  in  alcohol, 
ether,  benzol,  chloroform,  etc.,  i.  e.,  precisely  as  Vulpian, 
Moore,  and  others  had  found  to  be  the  case  with  the 
adrenal  principle.  This  applies  as  well  to  the  action  of 
alkalies  to  which  Jones,  Abel,  and  Davis  (57)  found  mel- 
anins very  sensitive,  and  to  other  tests.  In  the  second  place 
direct  evidence  was  afforded,  by  Boinet  (58)  who  found 
chemically  that  the  bronze  pigment  of  Addison's  disease 
was  identical  to  melanin,  and  also  by  Miihlmann  (59)  who 
discovered  independently  that  the  Addisonian  pigment  was 
a  product  of  the  adrenals. 

Finally,  as  the  connection  of  the  adrenal  product 
with  respiration  and  ox}'genation  I  urge  would 
suggest : 

An  excess  of  adrenal  secretion  causes  a  rise  of 
teniperatitrc. 

This  action  was  first  observed  by  Oliver  and  Schiifer 
(60).  Reichert  (61)  recorded  a  rise  of  1°  F.  in  rabbits, 
accompanied  by  increased  metabolism.  Morel  (62)  noted  a 
rise  of  0.5  to  1°  C.  (0.9°  to  1.8°  F.)  in  guinea  pigs.  Lepine 
(63)  states  that  the  increase  of  blood  pressure  caused  by 
adrenal  extract  is  always  followed  by  a  rise  of  temperature. 
This  is  controlled  by  the  familiar  fact,  first  observ^ed  by 
Brown-Sequard.  that  removal  of  the  adrenals  is  followed 
by  a.  steady  decline  of  temperature  and  by  the  hypothermia 
which  attends  Addison's  disease.  These  phenomena — which 
have  remained  unexplained — are  readily  accounted  for  by 
the  function  I  ascribe  to  the  adrenal  secretion.  Being  the 
agent  which  endows  haemoglobin  with  its  oxidizing  prop- 
erties, an  increase  of  this  secretion  enhances  oxidation,  a 
process  which,  of  course,  provokes  a  rise  of  temperature. 

On  the  whole,  this  evidence  seems  to  me  to  have 
shown  that 

It  is  the  adrenal  secretion  zvhich,  after  absorbing 
oxygen  from  the  pulmonary  air  and  being  taken  tip 
by  the  red  corpuscles,  supplies  the  zvhole  organism, 
including  the  blood,  with  its  oxygen. 

As  previously  stated,  this  is  but  a  part  of  the  evi- 
dence on  this  particular  feature  of  the  general  prob- 
lerri.    I  studied,  for  example,  the  evolution  of  the 


red  corpuscles  throughout  the  animal  scale  (64)  and 
learned  that  they  were  tardy  additions  to  the  blood 
as  storage  cells  when  the  haemoglobin  diffused  in  the 
plasma,  as  it  is  in  many  invertebrates  and  in  certain 
low  vertebrates,  failed  to  satisfy  the  needs  of  the 
vital  process.  Having  been  brought  to  the  conclu- 
sion that,  contrary  to  what  is  now  taught,  it  is  the 
plasmatic  haemoglobin  which  carries  oxygen  to  the 
tissues  and  not  the  red  cells,  I  traced  this  substance 
in  various  tissues  and  organs,  including  the  nervous 
system,  the  guaiac  and  methylene  blue  tests  being 
those  most  frequently  employed.  Again,  I  found 
that  the  oxidases  gave  the  reactions  of  the  oxygen- 
laden  adrenal  secretion.  Hence  the  term  I  applied 
to  the  latter:  adrenoxidase  (65). 

The  connection  between  this  function  and  the  im- 
munizing process  suggests  itself  when  the  role  of 
oxidation  in  fever  is  recalled.  Lazarus  Barlow  (66) 
in  the  last  edition  of  his  Pathology  says  that  "even  if 
we  grant  that  fever  is  beneficial  we  are  completely 
ignorant  of  the  manner  in  which  it  acts."  If,  as  I 
have  shown,  adrenoxidase  is  the  active  agent  in  all 
oxidation  processes  and  is  capable  of  raising  the 
temperature,  we  have  a  clue  to  a  possible  explana- 
tion of  this  all  important  phenomenon.  We  will  see 
not  only  that  this  clue  is  a  fruitful  one,  but  that 
adrenoxidase  and  another  internal  secretion  merged 
with  it  constitute  familiar  agents  in  the  immunizing 
process. 

Closely  related  with  this  function  is  the  manner 
in  which  the  adrenals  and,  therefore,  the  oxidation 
processes,  are  governed. 

The  Governing  Centre  of  the  Adren.als. 
The  first  deduction  reached  in  this  connection  was 
that : 

The  goz'crning  centre  of  the  adrenals  is  neither 
located  in  the  cerebrum  nor  in  the  medulla  oblon- 
gata, but  in  some  organ  of  the  base  of  the  brain. 

Removal  of  both  hemispheres  does  not  influence  temper- 
ature, as  shown  by  Fredericq  (67),  Goltz,  and  others. 
Corin  and  van  Beneden  (68)  found  in  fact  that  in  decere- 
brated pigeons,  the  oxygen  intake  and  the  carbonic  acid 
output  did  not  differ  from  that  of  normal  pigeons.  Pem- 
brey  (69)  states  moreqver  that  "the  rapid  rise  in  tempera- 
ture which  occurs  when  a  hibernating  marmot  awakens  is 
not  prevented  by  removal  of  the  cerebral  hemispheres." 
This  applies  as  well  to  so  high  a  mammal  as  the  dog,  in 
which,  as  shown  by  Goltz  (70),  removal  of  the  hemispheres 
including  a  part  of  the  optic  thalami  and  corpora  striata 
(whose  functions  are  also  annulled  by  removal  of  the  cor- 
tex, the  impulses  of  which  they  transform  and  transmit) 
did  not  interfere  with  any  purely  vegetative  function.  Evi- 
dently, therefore,  although  the  hemispheres  and  the  basal 
ganglia  can,  when  the  seat  of  lesions,  cause  a  rise  of  tem- 
perature, the  heat  centre  is  not  located  in  these  organs. 

The  base  of  the  brain,  however,  asserts  itself  as  a  path- 
way for  thermogenic  impulses.  While  Tschetschichin  in 
1866,  Schreiber  (71)  and  Reichert  (72)  located  a  thermo- 
augmentor  centre  in  the  pontobulbar  region,  Ott  (73), 
Tangl  (74),  and  Sakowitsch  (75)  obtained  a  marked  rise 
of  temperature  by  producing  lesions  higher  up,  i.  e.,  in  the 
floor  of  the  fourth  ventricle  and  the  tuber  cinereum.  But 
as  Richet  has  long  held,  and  as  Schafer  (76)  states,  exam- 
ination of  such  experiments  show-s  that  "the  results  are 
closely  dependent  upon  the  establishment  of  an  irritative 
lesion  in  parts  which  are  either  directly  in  or  in  close 
proximity  to,  the  path  taken  by  motor  impulses."  On  the 
whole,  the  therm.ogenic  lesions  in  the  basal  tissues  must 
have  irritated  nerve  paths  from  some  structure  beneath  the 
hemispheres. 

Further  study  of  the  question  then  showed  that : 
The  pituitary  body  sends  nerve  fibres  upward  to 
the  tuber  cinereum  and  the  zvalls  of  the  third  ven- 


364 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


[New  York 
Medical  Journ\l. 


tricle  and  thence  to  ihe  pontobulbar  region  and 
spinal  cord. 

As  just  shown,  the  heat  centre  can  only  be  located  be- 
neath the  brain  and  basal  ganglia.  Now,  anterior  to  the 
optic  thalami,  the  corpora  striata,  and  the  seat  of  the  ther- 
mogenic lesions  produced  by  Ott  and  others,  there  exists 
no  organ  capable  of  generating  nerve  impulses  by  way  of 
the  tuber  cinereum  other  than  the  pituitary  body — an  organ 
which  as  we  will  now  see,  satisfies  all  the  needs  of  such 
a  function.' 

Sappey,  Luschka,  Miiller,  and  others  of  the  older  anatom- 
ists refer  to  the  presence  of  nerve  fibres  passing  from  the 
pituitary  body  along  its  pedicle,  up  to  the  third  ventricle. 
But  it  was  only  after  the  Golgi  method  had  been  introduced 
that  this  fact  could  be  placed  on  a  solid  basis.  Ramon  y 
Cajal  (78)  then  found  that  the  fibres  passed  upward  to  a  large 
nucleus  behind  the  optic  thalami.  Joris  (79)  also  found  his- 
tologically that  "numerous  fibres  descend  in  parallel  lines 
along  the  pedicle  of  the  pituitary.  They  do  not  all  come 
from  the  retrooptic  nucleus"  he  writes,  "some  come  from 
regions  posterior  to  the  infundibulum  *  *  * "  Bearing 
directly  upon  the  production  of  thermogenic  impulses  is  the 
discovery  by  Gentes  (80)  of  fibres  which  pass  from  the 
pituitary  to  the  tuber  cinereum.  Andriezen  (81)  had  also 
traced,  in  the  white  mouse,  fibres  from  the  pituitary  to  the 
pons. 

We  thus  have  a  direct  nerve  path  from  the  pitui- 
tary to  the  pontobulbar  region — the  identical  tract 
along  which,  at  various  points,  the  lesions  produced 
by  Ott,  Tangl,  Sakowitsch,  and  Reichert  provoked 
a  marked  rise  of  temperature.  We  will  see  pres- 
ently that  this  path  is  continued  down  the  cord  and 
that  it  eventually  reaches  the  adrenals. 

The  next  feature  determined  was  a  striking  func- 
tional correlation  between  the  pituitary  and  the  adre- 
nals. Schafer  and  Herring  (82)  recently  empha- 
sized this  parallelism  not  only  as  to  their  function, 
but  also  as  to  their  development  and  structure.  I 
ascertained,  for  example,  that 

The  pituitary,  like  the  adrenals,  influenced  gen- 
eral oxidation  and  the  temperature,  and  also  general 
metabolism  and  nutrition. 

Although  removal  of  the  hemispheres  does  not  influence 
the  temperature,  as  we  have  seen,  removal  of  the  pituitary 
deeply  affects  tliis  process.  Marinesco  (83)  and  Vassale 
and  Sacchi  (84)  observed  that  it  was  followed  by  increas- 
ing hypothermia.  This  cannot  be  ascribed  to  operative 
shock,  for  Masay  (85)  first  trephined  the  sella  turcica  to 
expose  the  pituitary,  and  allowed  the  animal  to  recover 
after  this — the  most  violent  step  of  the  experiment.  The 
result  of  subsequent  removal  was  the  same.  Andriezen 
(86)  and  other  authors  also  refer  to  a  steady  decline  of 
temperature.  Paulesco  (87)  noted  that  this  decline  was 
progressive  until  death  occurred.  Pirone  (88)  states  that 
the  main  symptoms  are  referable  to  the  "vascular  and  re- 
spiratory systems  and  the  temperature."  The  relationship 
with  the  respiratory  process  is  further  shown  by  the  marked 
disturbances  of  this  class,  dyspnoea,  polypnoea,  etc.,  noted 
by  Cyon,  Andriezen,  Masay,  and  other  experimenters. 

The  impairment  of  general  metabolism  through  deficient 
oxygenation,  must  necessarily  inhibit  nutrition.  Practically 
all  investigators  refer  to  rapid  emaciation  and  cachexia  as 
a  prominent  symptom.  In  a  dog  which  survived  sixteen 
days'  removal  of  the  organ,  Thaon  (89)  observed  "a  pro- 
gressive emaciation,  followed  by  death  in  extreme  cach- 
exia." Caselli  (90),  Pirrone  (91),  and  Masay  (92)  also 
allude  to  this  phenomenon.  Fuchs  (93)  and  many  other 
authors  urge  the  close — though  obscure — relationship  be- 
tween the  pituitary  and  bodily  metabolism.  What  stronger 
evidence  can  we  have  of  the  influence  of  the  pituitary  on 
metabolism  and  nutrition  than  its  role  in  gigantism  and 
acromegaly,  excessive  growth  during  the  period  of  hyper- 

'Thc  labors  of  many  investigators  in  recent  years  have  ovcrtlirown 
the  view  that  any  part  of  the  pituitary  body  of  man  is  vestigial. 
As  Herring  (77)  concluded  recently  on  histological  grounds,  "it 
is  an  organ  of  physiological  importance."  The  various  Icinds  of 
nerve  cells,  neuroglia  cells,  and  cpendyma  cells  described  by  Berkley 
in  the  posterior  lobe  are  of  as  great  physiological  importance,  as  I 
urged  five  years  ago,  as  any  in  the  body  at  large.  S. 


plasia  of  the  organ,  and  steady  decline  from  the  time  de- 
generation of  its  anterior  lobe  begins?  A  relationship  with 
the  adrenals  is  suggested,  moreover,  by  a  familiar  symp- 
tom of  the  cachectic  stage  of  acromegaly,  of  which  Harlow 
Brooks  (94)  says :  "A  general  brownish  pigmentation  is 
present  in  the  average  case  which  at  times  strongly  resem- 
bles that  found  in  Addison's  disease." 

Another  feature  attesting  to  the  parallelism  be- 
tween the  pituitary  and  the  adrenals  is  that 

The  pituitary,  like  the  adrenals,  influences  the 
blood  pressure. 

Cyon  (95)  and  subsequently  Masay  (96)  found  that  ex- 
citation of  the  exposed  pituitary  caused  a  marked  rise  of 
blood  pressure— from  81  to  200  mm.  Hg.  in  one  instance. 
Masay  attributed  this  action  to  the  presence  in  the  organ 
of  a  secretion  which  the  excitation  and  accompanying  pres- 
sure forced  into  the  circulation.  A  close  examination  of 
his  report,  however,  does  not  sustain  this  conclusion.  The 
rise  of  pressure  was  immediate  and  general — a  fact  which 
points  either  to  vasoconstriction  through  nerves,  or  to  the 
action  of  some  intensely  active  and  evanescent  principle. 
Both  these  factors  are  available.  Not  only  is  the  pituitary 
known  to  be  related  with  the  sj'mpathetic  system,  but  Lang- 
ley  (97)  has  called  attention  to  the  remarkable  fact  that 
"the  effects  produced  by  adrenalin  upon  any  tissue  are  such 
as  follow  excitation  of  the  sympathetic  nerve  which  sup- 
plies the  tissue,"  a  conclusion  confirmed  by  several  observ- 
ers. This  paradoxical  fact  is  clearly  explained  by  the  pres- 
ence of  the  adrenal  principle  in  the  haemoglobin.  When 
Cyon  and  Masay  excited  the  pituitary,  therefore,  they  mere- 
ly caused  sympathetic  constriction  of  all  arterioles,  includ- 
ing their  off  shoots  the  vaso  vasorum ;  the  walls  of  all 
vessels  receiving  an  excess  of  albuminous  haemoglobin 
(adrenoxidase)  they  contracted,  thus  causing  a  rise  of  blood 
pressure." 

Again,  as  is  well  known,  the  adrenals  are  intimately  con- 
nected with  the  abdominal  ganglia  and  are,  embryologi- 
cally,  sympathetic  structures.  Their  vessels  being  likewise 
influenced,  a  sudden  excess  of  secretion,  furnished  a  second 
cause  for  the  ephemeral  rise  of  blood  pressure.  The  power 
of  the  adrenal  secretion  to  cause  such  a  rise  is  generally 
recognized.  Schafer  (98)  characterizes  as  "astounding" 
the  minuteness  of  the  dose  of  adrenal  extract  that  will  ex- 
cite physiological  effects ;  5.7  millionths  of  a  gramme  of 
Abel's  epinephrin  sulphate  to  each  kilo  of  body  weight  was 
found  by  Reid  Hunt  (99)  to  cause  a  rise  of  blood  pressure 
of  66  mm.  Hg.  As  to  the  action  on  the  heart,  Oliver  and 
Schafer  (100)  found,  as  is  well  known,  that  adrenal  prod- 
ucts not  only  acted  directly  on  the  muscular  walls  of  blood- 
vessels, causing  them  to  contract  (which  accounts  for  the 
rise  of  blood  pressure)  but  also  upon  the  muscular  wall  of 
the  heart.  Finally,  the  rise  of  pressure  is  undoubtedly  pro- 
duced by  the  adrenalin  extract  itself,  for  Strehl  and  Weiss 
(loi)  found  that  clamping  of  the  adrenal  veins  lowered 
the  blood  pressure,  while  release  of  these  vessels  restored  it 
to  its  previous  level. 

Another  suggestive  fact  attesting  to  the  pituitero- 
adrenal  parallelism,  is  that 

The  pituitary,  in  keeping  with  the  adrenals,  gives 
rise  to  glycosuria. 

Adrenal  extractives,  as  observed  by  Blum  (102),  Croftan 
(103),  Metzger  (104),  Herter,  and  others,  cause  glycosuria. 
The  adrenal  secretion  evidently  provokes  the  phenomenon 
also,for  Herter  and  Wakemann  (105)  found  that  compres- 
sion of  the  adrenals,  by  increasing  the  outflow  of  secretion 
into  the  adrenal  veins,  caused  glycosuria,  w'hile  conversely, 
adrenalectomy  was  followed  by  a  marked  diminution  of  the 
sugar  in  the  blood.  Again,  we  have  seen  that  the  adrenal 
secretion  passes  from  the  adrenal  veins  into  the  inferior 

_  *The  prevailing  belief  that  the  human  pituitary  produces  a  secre- 
tion does  not  seem  to  me  warranted.  The  substance  considered  as 
such  ia  rich  in  albuminous  ha5moglobin,  and  it  is  the  adrenal  prin- 
ciple it  contains  which  causes  the  rise  of  blood  pressure  obtained 
by  injections  of  the  extract.  W^hen  the  pressure  is  marked,  the 
kidneys,  being  passively  congested,  dilate,  and  diuresis  is  caused. 
All  the  effects  observed  experimentally  are  thus  accounted  for  with- 
out the  need  of  »  secretion  to  do  so. 

This  applies,  in  my  opinion,  to  several  so  called  "internal  secre- 
tions." Testicular  juice  or  orchitic  extract,  for  instance,  is  an 
oxidizing  ferment  and  catalyzer;  it  is  found  in  all  tissues,  in  the 
female  as  well  as  in  the  male;  it  gives  crystals  of  haemiu  with 
Florence's  test,  etc.,  and  other  reactions  peculiar  to  the  adrenal  and 
thyreoid  principles — both  of  which,  as  I  have  shown,  are  also  found 
in  all  tissues.  S. 


February  20,  1909.] 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


365 


vena  cava;  Kauffmann  (106)  found  that  when  this  great 
vessel  was  hgated  the  sugar  diminished  rapidly  both  in  the 
blood  and  in  the  urine. 

Now.  the  influence  of  the  pituitarj'  over  glycosuria  is 
quite  as  marked.  M.  Loeb  (107)  urged,  over  twenty  years 
ago.  that  the  glycosuria  which  accompanies  so  often  tumors 
of  the  pituitary  should  not  be  ascribed  to  mere  coincidence. 
Marie  observed  it  in  over  one  half  of  his  cases  of  acro- 
megaly. Borchardt  (108)  tabulated  176  patients  with  this 
disease,  seventy-one  of  whom  had  glycosuria;  as  I  had  five 
years  earlier  (109),  he  ascribes  this  symptom  to  overac- 
tivity of  the  pituitary,  and  its  cessation  to  final  degenera- 
tion of  this  organ.  In  sixteen  reported  cases  studied  by 
Launois  and  Roy  (110)  each  subject  presented  at  the 
autopsy  a  tumor  of  the  pituitary.  That  the  glycosuria  is 
not  due  to  pressure  of  the  enlarged  organ  upon  the  basal 
or  bulbar  tissues  is  shown  by  the  fact  that  it  can  be  pro- 
duced in  a  normal  organ.  Thus.  F.  W.  Pavy  (iii)  found 
that  "of  all  the  operations  on  the  sympathetic  of  the  dog 
that  have  yet  been  performed,  removal  of  the  superior  cer- 
vical ganglion  the  most  rapidly  and  strongly  produces  dia- 
betes." This  enigmatic  result  finds  its  explanation  in  the 
light  of  the  conclusions  I  have  submitted :  The  superior 
cervical  ganglion,  as  is  well  known,  supplies  vasoconstric- 
tor nlaments  to  the  pituitary;  removal  of  this  ganglion  by 
causing  relaxation  of  its  arteries  causes  the  organ  to  be- 
come hypcrjemic  and  therefore  overactive,  with  glycosuria 
as  a  result.  Control  of  this  conclusion  is  afforded  by  the 
fact  that,  as  in  all  exacerbations  of  activity  thus  induced, 
the  symptom  was  fleeting  as  shown  by  Pa\'y's  statement 
tiiat  the  glycosuria  was  "only-  of  a  temporarj'  nature." 

Having  ascertained  i,  that  the  pituitary  could 
alone  be  the  sotirce  of  impulses  to  the  adrenals ;  2, 
that  this  organ  projected  fibres  towards  the  bulb ; 
and  3,  that  the  pituitary  and  the  adrenals  gave  rise 
to  similar  experimental  and  clinical  phenomena,  it 
became  a  question  whether  a  nerve  path  actually 
united  these  organs.  Study  of  this  question,  of 
which  I  can  only  submit  a  few  features,  showed  that 

The  phenomena  provoked  by  both  the  pituitary 
and  the  adrenals  can  be  traced  by  irritation  or  sec- 
tions along  a  continuous  path  leading  from  the  pitu- 
itary to  the  adrenals. 

The  tuber  cinereum  which,  we  have  seen,  receives  fibres 
from  the  pituitary,  extends  backward  towards  the  bulb. 
Punctures  along  the  upper  part  of  this  path  by  Ott,  Tangl, 
and  others  not  only  raised  the  temperature  and  quickened 
the  respiration,  but  a  section  below  the  same  region  by 
Sawadowsky  (112)  and  Ott  and  Scott  (113)  rendered  im- 
possible the  production  of  fever  by  agents  known  to  pro- 
duce it.  Caselli  (114),  moreover,  found  that  irritation  of 
the  same  tissues  produced  glycosuria. 

The  nerve  path  continuing  downward,  we  meet  in  the 
pontobulbar  region,  the  thermogenic  centre  of  Tsche- 
schichin,  Schreiber,  and  Reichert.  Suggestive  in  this  con- 
nection  is  the  fact  that  Bruck  and  Giinther  (115)  found  that 
simple  puncture  with  a  probe  between  the  pons  and  medulla 
not  only  caused  a  marked  rise  of  temperature,  but  that  this 
rise  was  general.  The  respiratory  centre  is  a  familiar  clas- 
sic feature  of  the  medulla ;  we  have  seen  how  all  the  phe- 
nomena evoked  by  the  adrenals  are  linked  with  the  respira- 
tory process.  All  this  applies  as  well  to  Claude  Bernard's 
puncture  in  the  same  region,  as  a  cause  of  glycosuria  and 
due,  in  the  light  of  all  this  evidence  to  irritation  of  the 
path  from  the  pituitary  to  the  adrenals. 

In  the  upper  portion  of  the  spinal  cord  division  by 
Tscheschichin  (116),  Bernard  (117),  and  Pochoy  (118), 
respectively  in  various  animals  sent  the  temperature  down 
7  to  16°  C.  in  from  four  to  twenty-four  hours,  death  fol- 
lowing in  Pochoy's  animals.  Riegel  (119)  found  that  pro- 
duction of  heat  was  diminished.  That  gljxosuria  is  pro- 
duced through  efferent  fibres  passing  downward  in  the  upper 
cord  is  shown  by  the  well  known  fact,  mentioned  by  Stew- 
art (120)  that  puncture  of  the  bulb  does  not  cause  glyco- 
suria if  "the  spinal  cord  above  the  third  or  fourth  dorsal 
vertebra  be  cut  before  the  puncture  is  made." 

This  level  of  the  cord  is  of  special  interest,  since  it  is 
here  that  the  nerve  path  to  the  adrenals  leaves  the  spinal 
cord.  Here  can  be  evoked  a  rise  of  blood  pressure  occur- 
ring in  excess  of  that  due  to  vasomotor  nerves.  Thus, 
Frangois  Franck  and  Hallion  (121)  obtained  a  rise  of  pres- 


sure by  exciting  the  five  upper  'dorsal  rami,  and  also  by 
stimulating  the  corresponding  segment  of  the  sympathetic 
chain,  although  the  vasoconstrictor  nerves  to  the  organ 
studied,  the  liver,  was  known  to  reach  this  organ  through 
a  lower  ramus,  the  sixth — a  limit  confirmed  by  Langley 
(122).  But  they  could  not  account  for  this  phenomenon. 
Bulgak,  Bunch  (123),  Jacobi  (124),  and  others  also  obtained 
marked  vasoconstrictor  effects  by  exciting  these  upper  rami, 
although  the  vasomotor  nerves  to  the  organs  influenced  were 
known  to  leave  the  cord  lower  down.  In  other  words,  a 
duplicate  source  of  vasoconstriction,  as  it  were,  was  present 
whose  nature  remained  obscure.  It  was  brought  to  light, 
however,  by  the  fact  that  Jacobi  (125)  found  that  excessive 
inhibitory  constriction  of  the  intestinal  vessels  ceased,  and 
was  replaced  by  normal  vasoconstriction  when  he  severed 
the  nerves  to  the  adrenals.  The  intense  action  of  their 
secretion  on  the  blood  pressure  clearly  accounts,  from  my 
viewpoint,  for  the  excessive  constriction  observed. 

Briefly,  these  facts  jointly  suggest  that 
The  pituitary  adrenal  path  leaves  the  spinal  cord 
through  tlie  upper  four  or  five  rami  to  enter  the  sym- 
pathetic chain,  and  then  the  great  splanchnic,  which 
through  the  intermediary  of  the  semilunar  ganglia, 
supplies  nerves  to  the  adrenals. 

That  this  path  is  the  true  one  is  shown  by  additional 
data.  Thus,  Goltz  and  Ewald  (126)  found  that  animals 
deprived  of  their  spinal  cord  from  the  bulb  down,  could 
live  a  long  time — years  even — but  that  they  showed  a  strik- 
ing peculiarity  even  after  their  vessels  had  resumed  their 
normal  caliber,  that  of  dying  of  cold.  Ott  (127)  found, 
however,  that  the  animals  were  able  to  generate  their  usual 
heat  when  the  section  was  made  below  the  fifth  dorsal  ver- 
tebra. This  is  evidently  because  the  pituiteroadrenal  nerve 
paths  had  left  the  cord  above  this  lever  to  pass  over  to  the 
sympathetic  chain  and  the  splanchnic,  for  although  Biedi 
(128)  had  failed  to  increase  the  secretory  activity  of  the 
adrenals  by  exciting  electrically  all  the  median  and  lower 
dorsal  rami,  both  he  and  Drej-er  (129)  had  succeeded  in 
doing  so  by  stimulating  the  great  splanchnic  nerve.  Proof 
of  this  is  aft'orded  by  the  fact  that  the  greater  splanchnic 
also  transmits  the  impulse  to  the  adrenals  which  provoke 
glycosuria,  for  Laffont  (130)  caused  it  by  stimulating  this 
nerve.  Moreover,  it  is  evidently  through  a  nerve  path 
starting  at  least  in  the  medulla  that  glycosuria  is  caused ; 
for  Eckhard,  Kauffmann  (131),  and  others  found  that  even 
the  glycosuria  caused  by  Bernard's  puncture  ceased  when 
the  greater  splanchnic  was  severed.  There  can  be  no  doubt 
that  it  is  through  the  adrenals  that  the  glycosuria  is  caused 
for,  besides  the  evidence  I  have  already  adduced  to  this 
effect,  A.  Mayer  (132)  found  that  Bernard's  puncture  failed 
to  produce  this  symptom  after  removal  of  the  adrenals. 

On  the  whole,  all  the  evidence,  of  which  the  fore- 
going is  a  part,  seems  to  me  to  have  shown 

I,  That  the  pituitary  is  connected  zvith  the  adre- 
nals by  direct  nerve  paths;  2,  that  it  thus  governs, 
through  the  adrenals,  general  oxidation,  metabolism, 
and  nutrition. 

Functions  of  the  Thyreopar.\thyreoid 
Apparatus. 

Another  organ  belonging  to  what  I  regard  as  our 
autoprotective  mechanism,  the  thyreoid  gland,  has 
long  been  thought  by  investigators  to  be  related  in 
some  unexplained  way  with  the  pituitary,  owing  to 
the  frequency  of  concomitant  lesions  in  both  organs. 
Virchow,  Rogowitsch  (133),  Stieda  (134),  Schone- 
mann  (135),  and  others  have  laid  stress  on  the.  im- 
portance of  their  resemblance.  The  researches  I 
undertook  in  this  connection  not  onh'  sustained  this 
conclusion,  but  threw  some  light  upon  the  nature  of 
this  relationship  and  upon  a  feature  of  equal  impor- 
tance, the  identity  of  its  physiological  action. 

The  secretion  of  the  adrenals  proved  to  be  closely 
connected  chemically  with  the  thyreoparathyreoid 
functions.  The  first  dedttction  reached  in  this  con- 
nection is  that 

The  thyreoid  product  is  an  "iodiced  globulin"  (as 


366 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


[New  York 
JIedical  Journal. 


Oswald  maintains)  the  globulin  being  the  albumin- 
ous constituent  of  hanwglobin,  i.  e.,  adrenoxidase. 

As  Notkin  (136)  and  also  White  and  Davies  (137)  hold, 
the  action  of  the  thyreoid  secretion  resembles  that  of  an 
organized  ferment.  This  finds  its  explanation  in  the  fact 
that  the  thyreoidin,  to  which  this  applies,  is  mainly  a  fer- 
ment plus  iodine.  The  identity  of  this  ferment  becomes 
evident  when  we  consider  Baumann's  analyses  of  his  thy- 
reoiodin.  Among  other  tests,  for  example,  he  found  that  it 
was  practically  insoluble  in  ether  and  chloroform ;  that  it 
was  not  destroyed  by  digestive  ferments  and  that  it  stood 
a  temperature  of  100°  C.  (138).  These  are  the  specific 
tests  of  the  oxygen  laden  adrenal  product,  my  adrenoxidase. 
As  previously  stated,  I  found  that  this  substance  gave  the 
tests  of  the  plasmatic  oxidase ;  now  Lepinois  found  that  the 
thyreoid  secretion  contained  an  oxidase  which  gave  the 
blue  reaction  with  tincture  of  guaiac.  Again,  we  have  seen 
that  adrenoxidase  is  a  globulin :  Oswald  termed  his  product 
"thyreoglobulin"  and  described  it  as  an  "iodized  globulin."' 
Several  other  facts  could  be  adduced  to  show  that  this  con- 
stituent of  thyreoiodin  is  adrenoxidase.  This  means  that  it 
is  merely  the  albuminous  portion  of  the  haemoglobin  which 
enters  the  thyreoid  and  parathyreoids  in  large  quantities 
with  their  rich  blood  supply. 

Another  constituent  of  thyreoiodin  may  be  regarded  much 
in  the  same  light:  Nuclcoproteid.  Sherrington,  Milroy, 
and  Malcolm  (139),  and  others  have  found  that  the  granu- 
lations of  the  most  numerous  leucocytes  in  the  blood,  the 
neutrophiles,  are  composed  of  nuclcoproteid,  while  the  ob- 
servations of  Bail,  Stokes,  and  Wegefarth  (140),  Sangree 
(141),  and  others  have  as  clearly  shown  that  these  granu- 
lations leave  the  periphery  of  the  cell.  Here  again  we  find 
in  the  secretion  a  supposed  intrinsic  component  which,  in 
reality,  is  but  a  commonplace  constituent  of  the  blood. 

This  harmonizes  with  the  familiar  fact  that  in  the  ab- 
sence of  its  iodine,  the  thyreoid  product  is  inactive.  It  in- 
dicates, moreover,  the  true  nature  of  the  functions  of  the 
thyreoid  and  parathyreoids,  to  collect  iodine  (brought  to 
them  by  certain  leucocytes  as  I  have  shown  elsewhere)  and 
combine  it  organically  with  the  free  or  albuminous  haemo- 
globin and  nuclcoproteid.  As  Oswald  holds  therefore,  the 
thyreoid  product  is  an  "iodized  globulin." 

Why  should  this  combination  occur?  We  will  see 
presently  that  its  purpose  is  primarily  to  insure  the 
absorption  of  the  iodine  by  the  red  corpuscles, 
haemoglobin  being  the  normal  host  of  these  cells. 
Indeed, 

The  thyreoparathyreoid  secretion  ultimately 
reaches  the  superior  vena  cava  and  is  carried  to  the 
pulmonary  alveoli  zvhere  it  is  taken  up  by  the  red 
corpuscles,  along  with  the  adrenal  secretion. 

The  investigations  of  King,  Biondi  (142),  Zielinska 
(143),  Vassale  and  de  Brazza  (144)  on  the  thyreoid,  and 
those  of  Welsh  (145),  and  Capobianco  and  Mazziato  (146), 
and  others  on  the  parathyreoids,  have  shown  that  the  prod- 
uct of  these  organs  passes  into  perivascular  lymph  spaces. 
Being  then  transferred  to  the  larger  cervical  lymphatics 
they  are  discharged  by  the  right  and  left  lymphatic  ducts — 
the  thoracic  duct  according  to  Pembrey  (147) — into  the 
subclavian  veins,  and  by  way  of  the  superior  vena  cava  to 
the  heart.  Here  they  become  merged  with  the  venous  blood 
of  the  entire  organism,  forming  a  single  secretion — in  ac- 
cord with  Giey's  (148)  view — which  is  then  inevitably  car- 
ried to  the  heart,  and  thence  to  the  lungs.  As  the  venous 
blood  carrying  the  secretion  passes  to  these  organs  to  be 
oxygenized,  the  secretion  itself  is  likewise  carried  to  the 
air  cells. 

The  purpose  of  this  itinerary  suggests  itself  when  we 
recall  that,  as  stated  by  Nothnagel  and  Rossbach  (149), 
haemoglobin  can  fix  large  quantities  of  iodine.  It  accounts 
also  for  the  fact  that  Gley  (150)  and  Bourcet  found  iodine 
in  the  red  corpuscles.  Being  a  component  of  the  albumin- 
ous hremoglobin  of  these  cells  with  adrenoxidase,  however, 
iodine  should  be  found  in  all  tissues.  While  Bourcet  (151) 
ascertained  that  such  was  the  case,  Justus  {iS-)  found  it 
in  all  cellular  nuclei.  This  latter  feature  is  important,  since, 
as  I  will  show  presently,  iodine  serves  to  increase  the  in- 
flammability, as  it  were,  of  the  phosphorus  which  all  nuclei 
contain. 

The  presence  of  iodine  in  the  red  corpuscles  and 


the  importance  of  this  halogen  in  the  immunizing 
process  asserted  itself  conjointly  in  various  direc- 
tions.   Thus  it  becomes  apparent  that. 

The  thryeoparathyreoid  secretion  endows  the  al- 
buminous portion  of  the  hcemoglobin  with  sensitia- 
ing  properties.  As  such  it  is  the  blood  constituent 
zvhich  Sir  Ahnroth  E.  Wright  has  termed  "opsonin." 

Bordet's  sensitizing  substance  or  "sensibilisatrice"  was 
thought  by  this  investigator  and  also  by  von  Dugern  to  ap- 
pear in  the  blood  under  the  inftiicnce  of  the  red  corpuscles. 
Nolf  (153)  showed,  however,  that  it  is  owing  to  an  action 
of  the  alexins  or  complement  upon  these  cells  that  "the 
contents  of  the  latter"  is  caused  lo  leave  them;  he  found 
also  that  "the  injection  of  the  corpuscular  contents  incites 
haemolysis."  All  these  observations  are  sustained  in  other 
directions,  as  we  will  see.  Now,  Savtchenko  (154)  has 
pointed  out  that  the  "sensibilisatrice"  is  endowed  with  spe- 
cific opsonic  properties,  acting  both  on  bacteria  and  leuco- 
cytes— the  identical  sensitizing  action  discovered  by  Denys 
and  Leclef  (155)  in  1895,  and  which  Sir  A.  E.  Wright  has 
since  studied  with  such  promising  results.  Suggestive  in 
this  connection,  is  Nolf's  statement,  in  reference  to  the  pro- 
duction of  antibodies  that  "it  is  solely  to  the  injected  red 
corpuscles  that  the  power  to  bring  forth  these  new  sub- 
stances, must  be  attributed."  When  this  is  coupled  with 
Barratt's  (156)  observation  that  opsonins  "are  also  pro- 
duced by  injecting  red  blood  cells  in  the  peritoneal  cavity" 
of  experimental  animals,  and  also  Briscoe's  (157)  to  the 
effect  that  opsonin  is  present  in  the  fluid  of  the  peritoneal 
cavity  which  normally  contains  no  phagocytes,  it  becomes 
evident  that  opsonin  is  a  product  of  the  red  corpuscles. 

Under  these  conditions,  however,  the  administration  of 
thyreoid  preparations  should  increase  the  opsonic  proper- 
ties of  the  blood.  Fassin  (158)  found  that  the  bacteriolytic 
and  haemolytic  alexins  were  increased  when  thyreoid  prep- 
arations were  given  in  any  form;  Marbe  (159)  also  found,, 
in  accord  with  my  view  recorded  the  previous  year  (160), 
that  this  applied  to  opsonins,  the  phagocytic  activity  of 
leucocytes  for  various  bacteria,  including  the  tubercle  bacil- 
lus and  the  bacillus  coli,  being  markedly  increased. 

Again,  adding  these  to  previously  submitted  facts,  the  red 
corpuscles  should  contain  two  substances,  adrenoxidase  and' 
opsonin.  Bordet's  sensibilisatrice  is  usually  assimilated  to- 
Ehrlich's  amboceptor.  As  shown  by  Hektoen  (161),  how- 
ever, opsonin  is  distinct  from  the  amboceptor.  He  was 
able,  he  writes,  "to  separate  the  amboceptor  from  the  op- 
sonin for  goat  corpuscles  in  the  serum  of  rabbits  immunized 
with  goat's  blood."  He  found  also  (162)  that  the  ambo- 
ceptor (which  corresponds  with  my  adrenoxidase,  the  act- 
ive principle  of  which  resists  even  the  boiling  point,  100° 
C.)  is  not  af¥ected  by  a  temperature  of  65°  C.  during  thirty 
minutes,  whereas,  as  shown  by  Wright  and  Douglass,  op- 
sonins "lose  their  power  when  heated  to  60  or  65°  C.  for 
ten  or  fifteen  minutes."  Two  substances  are  thus  present 
in  the  red  corpuscles:  the  oxygen  laden  adrenal  secretion 
or  adrenoxidase  which  constitutes  the  amboceptor,  and  the 
iodine  in  organic  combination  I  regard  as  opsonin. 

The  next  deduction  reached  is  also  one  of  clinical 
importance : 

The  thyreoid  secretion,  acting  as  opsanin,  also- 
softens  bacteria  and  other  pathogenic  agents  to  fa- 
cilitate their  proteolysis  by  the  complement.  As 
such  it  is  known  as  "agglutinin." 

The  amboceptor  (adrenoxidase)  constituent  of  opsonin 
is  so  active  in  all  experimental  studies  of  the  latter,  that 
various  observers,  as  is  well  known,  have  considered  it 
the  sole  factor  in  the  process.  "In  most  immune  sera" 
writes  E.  R.  Baldwin  (163),  "removal  of  immune  ambo- 
ceptors by  absorption  is  accompanied  by  a  simultaneous 
loss  of  lytic,  agglutinative,  and  opsonic  functions.  The 
general  result  of  such  experiments  has  been  to  class  the 
specific  opsonins  with  the  amboceptors."  The  latter  we 
have  seen  is  not  afTected  by  a  temperature  of  65°  C,  while 
conversclv,  opsonin  loses  its  power  when  heated  up  to  60 
or  65°  C." 

Agglutination  is  evidently  a  feature  of,  the  action  of 
opsonins.  Bulloch  and  .'\tkins  (164),  for  example,  were 
led  experimentally  to  conclude  that  opsonins  were  "simple 
substances  resembling  agglutinins."    Indeed.  Wassermanni 


February  20,  1909.] 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


367 


•(165)  states  that  "agglutinins  are  fairly  resistant  sub- 
stances which  withstand  heating  to  60°  C.  and  lose  their 
power  only  on  heating  to  65°  C."  and  that  "it  is  possible, 
therefore,  to  make  a  serum  hsemolytically  inactive  by  heat- 
ing to  55°  C.  and  still  preserves  its  agglutinating  power." 
As  it  is  the  complement  which  is  rendered  inactive  by  a 
temperature  of  55°  it  cannot  be  the  primary  factor  in  the 
process.  It  is  evident  therefore,  that  it  is  the  opsonin 
which  is  the  agglutinin  since  its  activity  is  annulled  by  the 
same  heat,  60  to  65°  C. 

Other  facts  suggest  that  opsonin  and  agglutinin  are  the 
one  and  same  substance.  Thus,  Achard  and  Bensaude 
(166),  and  Widal  and  Sicard  (167)  found  that  the  produc- 
tion of  agglutinin  was  independent  of  the  leucocytes,  care- 
ful washing  of  the  latter  domg  away  with  agglutination. 
Again,  agglutinin  is  assimilated  by  Jemma  (168)  to  the 
glolDulins.  These  facts  point  clearly  to  the  red  corpuscles 
as  the  source  of  agglutinins — the  same  cells  to  which  I 
traced  the  opsonins.  Indeed,  while  Nolf  (169)  found  that 
the  addition  of  red  corpuscles  to  serum  gave  it  agglutinat- 
ing properties,  Arthur  Klein  (170)  found  that  agglutinin 
•could  be  dissolved  out  of  the  red  corpuscles  by  means  of 
salt  solution  or  distilled  water.  Finally,  as  previously 
stated,  I  traced  the  thyreoid  product  to  the  lungs.  _  Ruffer 
and  Crendiropoulo  (171)  in  a  study  of  agglutinins,  re- 
mark:  "Strangely  enough  the  lungs  of  nonimmunized 
guinea  pigs  were  the  only  organs  which  in  the  majority 
of  cases  possessed  agglutinating  properties  greater  than 
the  serum." 

This  and  other  data  which  cannot  be  introduced  here, 
seem  clearly  to  show  that  the  amboceptor  (adrenoxidase) 
is  an  autonomous  body  while  the  thyreoid  product,  opsonin, 
and  agglutinin  are  the  one  and  same  substance.  Its  object 
as  such  is  clearly  that  of  opsonin  and  agglutinin,  viz.,  to 
soften  pathogenic  germs  and  other  substances,  and  thus 
render  them  more  vulnerable  to  the  action  of  the  comple- 
ment and  its  homologue,  the  cystase  of  the  phagocytes. 

How  does  the  thyreoparathyreoid  secretion,  and 
therefore  opsonin  and  agglutinin  produce  these  ef- 
fects? Numerous  chemical  and  clinical  facts  show 
clearly  that 

The  thyreoid  constituent  of  the  hamoglobin  en- 
hances oxidation  of  the  tissues. 

Chantemesse  and  Marie,  Ballet  and  Enriques  (172), 
Bourneville  (173),  and  Shattuck  (174),  Lorand  (175),  and 
many  other  clinicians,  including  myself,  have  noted  that 
thyreoid  preparations  caused  a  rise  of  temperature  of  sev- 
eral degrees.  These  observations  are  controlled  by  those 
of  Stiive  and  Thiele  and  Nehring  (176)  that  thyreoid  ex- 
tract increases  over  twenty  per  cent,  the  oxygen  intake 
and  to  nearly  as  great  a  degree  the  carbonic  acid  output. 
This  is  evidently  produced  by  the  active  agent  of  the 
thyreoid  secretion,  iodin,  for  this  halogen  itself  increases 
oxidation  as  well.  Thus,  Rabuteau,  Milanese,  and  Bou- 
chard (177),  Henrijean  and  Corin  (178)  have  all  noted 
an  increase  of  nitrogen  excretion.  Wood  (179)  and  Cush- 
ny  (iSo)  state,  in  fact,  that  iodine  can  produce  fever. 

Removal  of  the  thyreoid,  on  the  other  hand,  lowers  oxi- 
dation. Albertoni  and  Tizzoni,  and  Magnus  Levy  (181) 
found,  for  example,  that  this  procedure  decreased  marked- 
ly the  output  of  carbon  dioxide  and  that  it  caused  hypo- 
thermia. The  fall  of  temperature  is  gradual  according 
to  Lorrain-Smith  (182)  and  most  marked  according  to 
Rouxeau  (183)  at  the  end  of  the  operation.  The  propor- 
tion of  red  corpuscles  is  reduced,  according  to  Moussu 
(184).  Reverdm  observed  in  man  that  the  haemoglobin 
was  also  diminished,  while  Horsley  noted  increased  sensi- 
tiveness to  cold  Albertoni  and  Tizzoni  and  Masoin  found 
that  the  blood  contained  less  oxygen  than  normally. 

This  applies  as  well  to  removal  of  the  parathyreoids 
which  was  found  by  Jeandelize  (185)  also  to  lower  the 
temperature.  That  the  thyreoid  apparatus  can  itself  raise 
the  temperature,  is  shown  by  the  feljrile  process  and  sense 
of  heat  with  flushing  observed  in  the  sthenic  stage  of  ex- 
ophthalmic goitre  and  when  the  thyreoid  apparatus  is  still 
overactive.  When  thyreoid  extract  is  given  to  such  cases, 
the  exchanges  may  be  increased  to  a  surprising  degree — 
seventy-seven  per  cent,  in  a  case  observed  by  Hirschlaff 
(186).  The  disease  may  in  fact  be  brought  on  by  thyreoid 
preparations  as  noted  by  Notthaft  (187)  and  other  clini- 
cians. 


Further  analysis  of  this  phenomenon  then  eluci- 
dated the  nature  of  the  process  itself — that  embod- 
ied in  the  following  deductions  : 

1,  The  thyreoparathyreoid  constituent  of  the 
hccmoglobin  enhances  oxidation  by  increasing,  as  a 
ferment,  the  inflammability  of  the  phosphorus  which 
all  cells,  particularly  their  nuclei,  contain. 

2,  As  such  it  combines  with  adrenoxidase  to  sus- 
tain metabolism  and  nutrition. 

3,  All  pathogenic  elements  in  which  phosphorus 
is  present:  bacteria,  their  toxines  or  endotoxines, 
toxic  ivastes,  etc.,  are  similarly  influenced  by  the 
thyreoid  product  acting  as  opsonin  or  agglutinin; 
they  are  thus  rendered  more  vulnerable  to  the  di- 
gestive action  of  the  plasmatic  and  phagocytic  com- 
plement. 

Telford  Smith  (188)  and  other  clinicians  have  observed 
that  the  use  of  thyreoid  preparations  in  young  cretins  was 
sometimes  attended  by  softening  of  the  bones  and  bending 
of  the  legs,  notwithstanding  marked  general  improvement. 
When  it  is  recalled  that  five  sixths  of  the  inorganic  matter 
of  bone  consists  of  calcium  phosphate,  it  becomes  a  ques- 
tion whether  the  thyreoid  extract  does  not  interfere  with 
the  building  up  of  this  tissue.  That  such  is  the  case  is 
further  suggested  by  the  facts  that  iodine,  the  active  con- 
stituent of  the  thyreoid  secretion,  and  its  salts,  as  shown 
by  Henrijean  and  Corin  (189),  Handfield  Jones  (190),  and 
others,  cause  excessive  elimination  of  phosphates  of  phos- 
phoric acid,  and  that  thyreoid  preparations,  according  to 
Roos,  Scholtz  (191),  Pouchet  (192),  and  others,  act  in 
the  same  way.  "Emphasis  must  be  laid,"  writes  Chitten- 
den (193),  "'upon  the  apparent  connection  between  the  thy- 
reoid gland  and  phosphoric  acid  metabolism"  giving  as 
example  "the  increased  excretion  of  P^Oe  after  feeding  thy- 
reoids to  normal  animals,  and  the  great  decrease  in  the  case 
of  animals  with  the  thyreoids  removed. 

The  untoward  effects  of  large  doses  of  thyreoid  prepara^ 
tions  on  the  nervous  system,  owing  to  its  wealth  in  phos- 
phorus and  fats  as  manifested  by  tremor,  tachycardia,  optic 
neuritis  CCoppez  (194))  etc.,  also  bespeaks  such  an  ac- 
tion; Cyon  (195)  in  fact,  found  that  injections  of  iodothy- 
rin  excited  the  depressor  nerve  directly  to  such  a  degree 
that  the  vascular  pressure  often  declined  to  two  thirds  of 
the  normal. 

A  familiar  action  of  the  thyreoid  preparations  is  a  rapid 
reduction  of  fat  in  obese  subjects  when  full  doses  are  ad- 
ministered. The  presence  in  the  fat  cell  of  a  nucleus,  rich 
in  phosphorus,  whose  purpose  is  promptly  to  promote  oxi- 
dation of  the  fat  when  the  organism  requires  additional 
carbohydrates  explains  this  action.  Schondorff  (196),  in 
fact,  found  that  the  reserve  fats  could  be  exhausted  be- 
fore the  nitrogenous  tissues  were  affected. 

The  mode  of  action  of  the  thyreoid  active  principle, 
iodine,  is  suggested  by  the  presence  of  this  halogen  in  all 
nuclei,  as  shown  by  Justus  (197)  and  others.  This  means 
that  iodine  is  found  wherever  phosphorus  is  present,  while, 
as  shown  above,  it  is  most  active  where  phosphorus  is 
known  to  be  most  plentiful.  Now,  chemistry  furnishes  a 
clue  to  the  manner  in  which  all  the  phenomena  I  have 
enumerated  are  present:  "If  a  fragment  of  phosphorus, 
lying  on  a  plate,  is  sprinkled  with  iodine."  writes  Wilson 
CigS),  "the  substances  unite,  and  heat  enough  is  produced 
to  kindle  the  phosphorus."  Nitrogen,  hydrogen,  and  chlor- 
ine are  ubiquitous  constituents  of  our  tissues,  and  the  vig- 
orous explosives  they  form  with  phosphorus  and  the  in- 
tense liberation  of  heat  the  reactions  entail  are  familiar 
features  of  the  laboratory.  Roos  (199)  found  that  in  a 
dog  in  nitrogenous  equilibrium,  iodothyrin  "caused  at  once 
a  marked  increase  in  the  output  sodium,  sodium  chloride, 
and  phosphoric  oxide  (200). 

Still,  as  Chittenden  states  (201)  "according  to  Baumann, 
doses  of  I  milligramme  of  iodothyrin,  which  contain  only 
o.i  milligramme  of  iodine  will  produce  a  decided  effect 
upon  a  goitre  after  three  or  four  applications,  thus  clearly 
indicating  that  it  is  not  the  iodine  per  se  that  is  effective, 
but  rather  the  iodine  compound."  This  will  recall  the  ob- 
servations of  Notkin  and  White  and  Davies  that  the  ac- 
tion of  the  adrenal  secretion  resembles  that  of  an  organized 
ferment,  and  my  own  that  the  adrenal  principle  with  which 


368 


BOLDT:  DRUGS  IN  GYNECOLOGY. 


[New  York 
Medical  Journal. 


the  iodine  is  combined  endows  with  the  properties  of  a 
ferment.  Hence  the  term  "thyroiodase"  I  have  applied  to 
the  thjTeoparathyreoid  secretion. 

So  important  are  the  function  of  the  thyreoid  ap- 
paratus, that  we  cannot  but  surmise  that,  in  keep- 
ing many  other  functions,  they  are  regtilated  by  a 
centre.  The  evidence  available,  a  part  of  which  is 
given  below^,  shovi^s  that  such  is  the  case. 

{To  be  concluded.) 


SOME  DRUGS  THAT  MAY  BE  USED  WITH  BENE- 
FIT TO  GYNECOLOGICAL  PATIENTS.* 

By  H.  J.  BoLDT,  M.  D., 
New  York. 

Let  me  say  at  the  outset  that  no  remedy  can  give 
benefit  unless  it  is  conjoined  with  proper  hygienic 
conditions,  and  the  necessary  remedial  treatment 
for  pathological  conditions.  Hygienic  conditions 
include  proper  diet,  exercise,  baths,  rest,  appropriate 
apparel,  etc.  While  it  must  be  acknowledged  that 
medicines,  internally  administered,  are  not  likely  to 
have  much  influence  on  local  conditions  in  gynaeco- 
logical affections,  it  happens  very  frequently  that 
the  local  conditions  of  a  patient  are  benefited  or 
cured,  though  she  is  not  conscious  of  the  improve- 
ment. 

In  choosing  remedies  I  wish  to  say  that  while  I 
agree  that  it  is  not  only  improper,  but  also  unprofes- 
sional, to  prescribe  patent  inedicines  and  proprie- 
tary medicaments  that  are  advertised  to  the  public 
at  large,  I  see  no  valid  reason  why  some  physicians 
take  the  antagonistic  attitude  they  do  toward  all 
proprietary  preparations ;  why,  when  some  such 
preparation  gives  satisfactory  results,  in  fact,  bet- 
ter results,  than  the  "ethical"  remedies,  the  physi- 
cian, on  some  supposed  ethical  ground,  should  de- 
cline to  mention  it  to  his  colleagues ;  or,  why,  if  he 
does  publish  the  results,  the  editors  of  some  jour- 
nals should  insist  on  substituting  the  long,  unpro- 
nounceable chemical  names  that  are  not  known  to 
one  physician  in  a  hundred. 

Antipyrine,  for  instance,  has  on  me,  personally, 
a  better  effect  in  supraorbital  neuralgia  than  any 
other  remedy,  but  how  many  pharmacists  or  physi- 
cians know  antipyrine  under  its  chemical  name  of 
phenyldimethylpyrazolon  ?  Again,  a  member  of  my 
family  gets  more  rapid  relief  from  phenacetine,  an 
intimate  acquaintance  from  pyramidon.  Now,  why 
shoidd  one  not  speak  frankly  about  such  drugs, 
using  the  short,  simple,  and  well  known  trade 
names?  It  has  happened  to  me  a  number  of  times 
that  when  I  prescribed  cotarnine  hydrochloride,  the 
pharmacist  telephoned  to  me  to  inquire  what  it  was, 
when  under  the  name  of  stypticin  he  at  once  recog- 
nized it. 

Take  protargol,  the  silver  salt  with  which  I  have 
had  more  satisfaction  than  any  other  in  some  in- 
stances of  chronic  gonorrhcca.  What  valid  reason 
is  there  for  not  using  the  trade  name,  which  every 
physician  and  pharmacist  understands?  How  many 
would  know  what  was  wanted  if  the  chemical  name 
were  used  for  the  protein  silver  salt.    I  might  say 

•Read  before  the  Medical  Association  of  the  Greater  City  of  New 
York,  December  7,  1908. 


in  this  connection  that  to  get  the  best  results  with 
protargol  in  chronic  gonorrhoea  of  women  the  solu- 
tions must  be  much  stronger  than  are  usually  rec- 
ommended. I  nearly  always  use  solutions  of  331^  per 
cent.,  or  even  to  50  per  cent.,  to  saturate  the  cotton 
or  gauze,  which  I  allow  to  remain  in  the  uterocer- 
vical  canal  for  two  hours  or  more.  I  have  never 
seen  irritation  caused  by  such  strong  solutions. 

I  realize,  of  course,  that  it  is  very  difficult  some- 
times to  draw  the  line.  Yet,  when  we  are  using  a 
remedy  from  a  well  known  chemical  firm  with  an  in- 
ternational reputation  on  matters  of  strict  ethics ; 
when  this  firm  has  set  forth  all  details  in  the  descrip- 
tion ;  and  when,  in  addition,  European  confreres  of 
international  reputation  do  not  hesitate  to  publish 
their  experiences  with  such  remedies,  I  see  no  valid 
reason  why  some  members  of  the  medical  press 
should  take  what  seems  to  me  a  narrow  view. 

Trade  names  are  of  comparatively  recent  date. 
Had  they  been  in  vogue  about  sixty  years  ago,  Lie- 
big  would  probably  have  put  one  on  chloral  hydrate. 
Indeed,  chloral  hydrate  became  practically  a  trade 
name  when  Liebig  conferred  the  sole  right  for  its 
manufacture  on  Schering  &  Co.  It  does  seem, 
therefore,  that  a  little  more  liberality  in  this  direc- 
tion would  not  be  harmful. 

Many  of  the  preparations  now  accepted  by  the 
profession  are  or  were  proprietary  remedies,  and  the 
prescribing  of  them  was  practically  forced  on  the 
profession  because  it  was  proved  that  for  certain 
conditions  they  were  more  valuable  than  any  officinal 
preparation  in  the  pharmacopoeia.  I  was  pleased  to 
see  The  Joiinial  of  the  American  Medical  Associa- 
tion, which  certainly  is  second  to  none  in  the  world, 
so  far  as  ethics  are  concerned,  make  a  departure 
from  custom  when  publishing  the  results  of  the  ex- 
periments of  Sollman  and  Hatcher,  and  use  the  sim- 
ple names,  such  as  isopral  (chemical  name  tri- 
chlorisopropyalcohol)  and  bromural  (the  chemical 
name  for  the  latter  being  alphamonobromisovaleryl- 
urea)  (see  Journal  of  the  American  Medical  Asso- 
ciation, August  8,  1908).  Such  proprietary  reme- 
dies have  come  to  stay ;  they  must  be  recognized, 
and  it  seems  the  duty  of  those  members  of  the  pro- 
fession who  are  willing  to  experiment  with  reme- 
dies to  publish  the  results,  as  Sollmann  and  Hatcher 
have  done. 

I  hope  my  professional  brethren  will  not  misun- 
derstand my  true  position  in  this  matter.  I  express 
my  opinion  with  conviction  and  honesty  of  purpose, 
and  put  my  views  on  record  because  of  the  criticism 
to  which  I  was  subjected  through  the  action  of  a 
certain  firm.  I  had  made  an  extensive  series  of  scien- 
tific experiments  with  an  antiseptic  (formaldehyde 
in  neutral  soap)  and  published  the  results  before  a 
section  of  the  American  Medical  Association.  The 
manufacturers  had  the  temerity  and  tactlessness  to 
send  a  reprint  of  my  paper  to  members  of  the  pro- 
fession, printing  their  business  address  on  the  cover 
of  the  pamphlet.  The  firm,  with  the  members  of 
which  I  had  no  direct  or  indirect  acquaintance,  hav- 
ing done  this  without  my  knowledge  or  sanction, 
made  the  most  himible  apology  over  their  signature, 
after  I  had  expressed  myself  in  forcible  language  as 
to  their  action. 

I  believe  it  to  be  strictlv  ethical  for  anv  one  to 


February  20,  1909. J 


BOLDT:  DRUGS  IN  GYNECOLOGY. 


369 


write  an  article  about  a  remedy,  if,  in  his  honest 
opinion,  the  remedy  is  strictly  ethical  and  of  value, 
and  he  has  had  sufficient  experience  with  it  to  form 
a  valid  opinion. 

I  beheve  that  most  gynaecologists  recognize  the 
fact  that  very  many  patients,  perhaps  even  the  ma- 
jority, have  some  nervous  disturbance,  in  addition  to 
their  local  disturbance,  and  not  infrequently  in  con- 
sequence of  it.  Many  suffer  from  various  kinds  of 
radiating  pains  for  which  no  definite  cause  can  be 
found.  Some  are  anaemic  and  lose  appetite ;  others 
have  gastric  or  intestinal  disturbance  or  both ;  others 
again  suffer  from  insomnia ;  still  others  show  a 
group  of  symptoms  which  we  are  in  the  habit  of 
classing  under  the  name  of  neurasthenia,  sometimes 
perhaps  because  we  are  unable  to  make  a  more  defi- 
nite diagnosis,  as  in  bygone  days  the  diagnosis  of 
malaria  was  frequently  made  to  cover  ignorance  as 
to  true  conditions. 

Among  the  remedies  which  I  have  found  of  value 
in  gynjecological  cases  are :  Calcium  phosphate ; 
•arsenic ;  apiol ;  hydrastis ;  gossypium,  ergot,  and 
aletris ;  chloride  of  gold  and  sodium ;  strychnine, 
bryonia ;  iron  preparations ;  veronal,  trional,  and 
bromural. 

I  give  in  brief  form  the  results  of  my  experience 
with  these  drugs,  with  the  indications  for  their  use, 
and  some  references  to  the  literature. 

CALCIUM  PHOSPHATE. 

There  is  a  difference  of  opinion  as  to  the  remedial 
value  of  calcium  phosphate.  While  some  author- 
ities give  it  no  therapeutic  value,  others  consider  it 
very  important.  We  know  that  it  is  an  ingredient 
found  in  all  the  tissues  of  the  body,  and  it  would, 
therefore,  seem  indicated  and  beneficial  in  conditions 
in  which  the  normal  amount  of  phosphates  in  those 
tissues  had  decreased.  It  has  seemed  to  me  that  in 
pelvic  disorders,  accompanied  by  an  extremely  nerv- 
ous condition,  with  an  excessive  secretion  of  phos- 
phates in  the  urine,  the  nervous  symptoms  of  the 
patients  were  benefited  by  small  doses  of  calcium 
glycrinophosphate.  Large  doses  should  be  avoided, 
so  as  not  to  interfere  with  digestion.  I  consider  the 
glycerinophosphates  especially  valuable,  particularly 
calcium  glycerinophosphate.  In  the  case  of  neuras- 
thenic patients,  who  have  torpidity  of  the  intestinal 
tract,  who  are  somewhat  anaemic  and  have  no  appe- 
tite, I  have  for  many  years  used  the  following : 


R    Calcium  gylcerinophosphate,   0.3; 

Haemogallol,   0.3; 

Strj'chnine  sulphate,   0.002; 

Arsenic  trioxide  0.002; 

Quinine  hydrochloride,  o.i. 

M.    Put  up  in  a  cachet. 


This  dose  is  to  be  taken  after  or  during  the  meal, 
three  .times  daily.  Circumstances  may  make  it  de- 
sirable to  omit  one  or  more  of  the  ingredients,  or 
to  change  the  dosage.  The  cachets  are  readily  taken 
by  the  patient,  if  they  are  first  dipped  into  water, 
placed  on  the  back  of  the  tongue,  and  rinsed  down 
with  water. 

APIOL. 

Apiol  is  said  to  have  been  introduced  by  Joret  and 
Homolle.  I  have  found  it  a  very  satisfactory  em- 
menagogue  in  the  case  of  patients  who  are  usually 
regiilar  and  in  whom  the  amenorrhoea  is  not  due  to 


a  physiological  cause.  In  such  cases  a  capsule  of 
apioline  every  three  hours,  for  two  or  three  days, 
generally  suffices  to  bring  about  the  menstrual  flow. 
Such  amenorrhoea  is  usually  ascribed  to  a  "cold."  I 
frankly  confess  that  I  do  not  know  what  the  cause 
is.  Cases  of  painful  men.struation,  with  scanty  flow, 
in  persons  otherwise  robust  and  without  any  patho- 
logical pelvic  condition,  are  often  benefited  by  a  cap- 
sule of  apioline  three  times  daily,  beginning  about 
one  week  before  the  expected  flow  and  continued 
through  the  period. 

One  of  the  most  satisfactory  remedies  I  have  used 
for  severe  dysmenorrhcea  without  any  definite  local 
lesion,  in  women  with  rheumatic  or  gouty  diathesis, 
is  the  following  combination  : 

Novaspirin,   1.3; 

Citrated  caffeine,  0.05; 

M.  S. :   Every  hour,  for  three  doses. 

If  the  patient  is  also  very  nervous  and  irritable, 
the  addition  of  0.6  potassium  bromide  is  desirable. 
A  repetition  may  be  necessary  after  the  lapse  of  six 
or  eight  hours. 

ARSENIC. 

According  to  Stockman  and  Charteris,  cited  by 
Wood,  "repeated  small  doses  of  arsenic  cause  an  in- 
crease in  the  formation  of  the  leucoblastic  cells  in 
the  bone  marrow,  with  consequent  stimulation  of  the 
formation  of  white  blood  corpuscles,  but  without 
marked  change  in  the  number  of  red  cells."  It  acts 
as  a  tonic  on  the  brain  and  nervous  system,  in  which 
parts  it  accumulates  in  largest  quantity  under  pro- 
longed use.  It  also  has  a  tendency  temporarily  to 
stimulate  the  heart  action. 

In  amenorrhoea  of  anaemic  and  chlorotic  persons, 
it  is  occasionally  more  serviceable  than  other  drugs, 
acting  as  a  direct  stimulant  to  nutrition  and  check- 
ing the  retrograde  metamorphosis.  In  some  parts 
of  Switzerland  and  in  Styria  arsenic  is  eaten  by 
many  male  inhabitants  to  increase  their  capacity  for 
physical  exertion.  There  is  reason  to  believe  in  its 
value  in  this  direction,  because  a  number  of  women 
who  have  felt  physically  unequal  to  the  exertion  of 
household  duties  have  been  able  to  perform  these 
duties  without  fatigue  after  taking  arsenic  for  a 
short  time. 

If  tolerated  by  the  patient,  arsenic  often  rapidly 
cures  the  symptoms  of  the  so  called  "irritative"  dys- 
pepsia sometimes  associated  with  pelvic  disorders. 
It  relieves  the  furred  tongue  with  red  and  prominent 
papillae,  the  distress  after  eating,  gastralgia,  and  in- 
testinal pain,  the  loss  of  appetite,  by  toning  the  ap- 
petite and  promoting  digestion,  increasing  the  gas- 
trointestinal secretion,  and  augmenting  the  peri- 
stalsis. 

Neurasthenic  women  who  pass  large  quantities  of 
mucous  shreds  with  their  bowel  evacuations,  espe- 
cially those  who  are  much  emaciated,  are  sometimes 
benefited  by  arsenic  when  all  other  remedies  fail. 
Many  such  patients  have  uterine  displacements, 
especially  retroflexion,  with  more  or  less  descensus, 
and  while  the  replacement  of  the  uterus  alone  does 
not  benefit  them,  they  profit  by  other  adjuvant  treat- 
ment, including  the  internal  administration  of  a 
remedy  like  arsenic,  perhaps  combined  with  syn- 
ergists. , 

In  the  administration  of  arsenic  it  must  be  re- 


370 


BOLDT:  DRUGS  IN  GYNECOLOGY. 


[New  York 
Medical  Journa:. 


membered  that  it  is  not  equally  well  tolerated  by  all 
persons.  A  single  moderate  dose  is  soon  eliminated 
from  the  body,  but  if  the  dose  is  large  or  the  drug 
is  continued  for  a  long  time,  it  accumulates  in  the 
tissues.  Prolonged  use  is  detrimental  to  the  system, 
as  in  anaemia,  where  in  the  beginning  it  increases 
both  the  white  and  the  red  corpuscles,  while  if  con- 
tinued too  long  it  diminishes  both. 

Untoward  symptoms  must  be  watched  for,  such 
as  colicky  pains,  mucous  or  dysenteric  stools,  nausea, 
itching  of  the  conjunctiva,  etc.,  and  the  drug  either 
discontinued  or  be  given  in  even  smaller  doses. 
With  this  class  of  patients  one  should  always  begin 
with  small  doses  after  meals.  Yet  I  recall  three  in- 
stances in  which  the  patients  had  nausea,  abdominal 
pain,  and  headache  from  doses  of  only  one  fortieth 
of  a  grain  three  times  daily  after  meals.  The  symp- 
toms promptly  disappeared  within  two  days  after 
the  stopping  of  the  arsenic,  and  later  reappeared 
when  the  drug  was  resumed. 

HYDRASTIS;  GOSSYPIUM  ;  ERGOT,*  ALETRIS. 

These  remedies  have  an  important  place  in  gynae- 
cological materia  medica.  Any  one  of  them  may  be 
employed  with  success  in  prolonged  or  too  profuse 
menstruation,  with  or  without  pain.  Some  cases 
yield  more  readily  to  one  drug  and  others  to  another. 
It  is  supposed  that  the  haemostatic  effect  is  due  to 
the  oxytocic  action  of  the  drugs.  While  this  may 
hold  good  for  ergot  and  gossypium,  it  is  doubtful 
whether  the  other  two  remedies  possess  oxytocic 
properties.  Furthermore,  I  have  observed  clinically 
several  times  that  when  one  of  these  remedies  alone, 
or  any  two  combined,  did  not  give  a  satisfactory 
therapeutic  action,  a  combination  of  the  four  often 
quickly  produced  good  results. 

The  medicines  are  especially  appHcable  in  chronic 
metritis,  the  uterus  being  somewhat  increased  in 
size,  not  sensitive  to  bimanual  examination,  and  the 
patients  menstruating  so  freely  and  with  such  a  long 
continued  flow  that  the  loss  of  blood  is  detrimental 
to  the  general  condition  of  the  patient.  In  some  pa- 
tients with  myoma,  who  decline  operation,  the  bleed- 
ing is  also  somewhat  checked  by  the  combination,  or 
by  one  of  the  remedies  alone,  more  especially  by 
Hydrastis.  If  the  endometrium  is  markedly  changed, 
internal  medication  alone  is  useless.  The  fluid  ex- 
tract is  the  best  form  of  administration.  Large 
doses  must  be  used  to  be  serviceable.  When  using 
the  combination,  for  instance,  I  prescribe  equal 
parts  and  order  from  one  half  to  one  teaspoonful 
every  four  hours,  resorting  to  the  larger  dose  if  the 
haemostatic  effect  is  not  produced  by  the  smaller. 

Should  the  stomach  not  tolerate  the  remedies, 
they  must  of  course  be  discontinued. 

What  I  have  said  on  a  former  occasion  of  cotar- 
nine  hydrochloride  for  the  control  of  uterine  bleed- 
ing, can  but  be  reiterated  at  this  time. 

CHLORIDE  OF  GOLD  AND  SODIUM. 

Scanty  menstruation,  associated  with  intense 
ovarian  dysmenorrhoea,  without  palpable  lesion  in 
the  pelvic  organs,  is  sometimes  relieved  by  the  fol- 
lowing combination : 

Chloride  of  gold  and  sodium,  o.i ; 

Ext.  cannab.  ind.,  i.S; 

Ext.  gentian,   q.  s; 

M.  Ft.  pil.  No.  xxiv. 


One  pill  three  times  daily,  beginning  four  or  five 
days  before  the  expected  period,  and  continuing  dur- 
ing the  flow.  If  constipation  is  caused  by  so  brief 
an  administration  of  gold  and  a  laxative  is  consid- 
ered necessary,  sodium  phosphate  at  bedtime,  or, 
still  better,  an  hour  or  two  before  breakfast,  is  de- 
sirable. It  is  most  active  if  given  dissolved  in  hot 
water. 

Why  the  remedies  give  relief  in  some  such  cases 
I  do  not  know.  Their  physiological  action  does  not 
explain  it.    It  is,  however,  an  empirical  fact. 

Two  patients  who  habitually  aborted  from  about 
the  third  to  the  fifth  month  were  cured,  or  rather  the 
abortion  was  averted  at  the  next  pregnancy,  by  the 
continuous  administration  of  chloride  of  gold  and 
sodium. 

The  extreme  neurasthenic  condition  sometimes 
met  with  during  the  early  stages  of  pregnancy,  espe- 
cially in  anaemic  women,  is  often  benefited  by  the 
solution  of  bromide  of  gold  and  arsenic,  according 
to  Dr.  Barclay's  formula. 

It  is  stated  that  sterility  dependent  upon  chronic 
metritis,  or  due  to  "coldness,"  is  cured  by  the  gold 
preparations.  I  cannot  confirm  this  assertion,  al- 
though I  have  prescribed  gold  in  many  cases.  It 
may  be  that  by  coincidence  a  woman  who  has  been 
sterile  for  several  years  has  become  pregnant  when 
gold  was  administered,  but  I  doubt  that  the  gold 
itself  was  the  cause. 

The  best  preparations  in  gynecological  practice  are 
chloride  of  gold  and  sodium  and  solution  of  bromide 
of  gold  and  arsenic. 

STRYCHNINE. 

Strychnine  acts  promptly.  Usually  it  can  be  de- 
tected in  the  urine  within  half  an  hour  from  its  ad- 
ministration, although  it  is  not  completely  excreted 
from  the  system  for  a  long  time.  Sometimes  sev- 
eral days  elapse  after  administration  before  the 
urine  fails  to  give  the  reaction.  Still,  strychnine  has 
no  cumulative  action. 

To  get  the  tonic  effects,  strychnine  is  best  given 
in  small  doses  three  times  daily.  Given  in  this 
way  it  will  increase  the  volume  and  the  digestive 
power  of  the  gastric  juice,  and  also  gastrointestinal 
peristalsis.  It  is,  therefore,  of  value  in  overcoming 
the  constipation  met  with  in  gynaecological  patients, 
due  to  lack  of  tone  in  the  muscles  of  the  intestinal 
wall.  The  irregular  action  of  the  heart  and  cardiac 
palpitation,  if  they  are  functional  disturbances  ac- 
companying hysteria,  especially  about  the  time  of 
the  menopause,  are  frequently  benefited  by  strych- 
nine. 

Painful  menstruation,  the  pains  being  sharp  and 
lancinating  and  of  a  peculiar  "tearing"  character, 
but  not  accompanied  by  backache  or  bearing  down 
pains,  is  sometimes  entirely  cured  by  strychnine 
given  continuously  for  three  or  four  months. 

Strychnine  should  not  be  given  during  pregnancy. 
But  patients  who,  during  previous  confinements, 
have  had  profuse  bleeding  or  actual  post  partum 
haemorrhage  or  subinvolution  of  the  uterus,  might 
be  given  strychnine,  with  the  expectation  of  a  tonic 
effect  on  the  uterine  muscularis,  through  its  action 
on  the  nerve  centres.  Administration  should  begin 
a  week  or  two  before  the  expected  labor  and  be 
continued  for  two  or  three  weeks.    I  do  not  believe 


February  :-'o,   lyoij  | 


BOLDT:  DRUGS  JN  GYNJECOI-OGy. 


the  statement  sometimes  made  that  strychnine  has 
a  direct  influence  on  the  muscles  of  the  uterus  so 
as  to  cause  uterine  contractions.  My  objection  to 
giving  it  during  pregnancy,  for  any  length  of  time, 
is  because  of  its  possible  injurious  effect  on  the  em- 
bryo or  the  foetus. 

Some  patients  have  an  idiosyncrasy  in  respect  to 
strychnine ;  it  is.  therefore,  advisable  to  begin  with 
small  doses.  On  the  other  hand,  one  may  become 
so  accustomed  to  its  use  that  large  single  doses  have 
no  serious  effect. 

BRYONI.\. 

The  irritability  of  the  bladder,  frequent  in  con- 
nection with  pelvic  lesions,  and  the  painful  micturi- 
tion associated  with  it,  in  many  instances  yield  to 
the  homecepathic  mother  tincture  of  bryonia,  usual- 
ly five  or  six  drop  doses  at  intervals  of  six  hours. 
In  other  instances  may  be  used  an  infusion  of 
buchu  and  uva  ursi  leaves,  of  each  60.0;  parsley 
seed,  20.0 ;  hyoscyamus  leaves,  6.0,  to  one  quart  of 
boiling  water.  Two  tablespoon fuls  of  the  infusion 
may  be  taken  every  three  or  four  hours.  The 
hyoscyamus  has  a  soothing  effect  on  the  painful 
condition,  especially  in  the  above  combination. 

IRON. 

While  it  is  usually  affirmed  that  chlorotic  and 
anaemic  patients  should  take  nonirritating  prepara- 
tions of  iron,  clinical  experience  shows  that  patients 
with  a  pale,  flabby,  broad,  and  tooth  indented  tongue 
are  most  benefited  by  astringent  preparations  in 
large  doses,  as,  for  instance,  2.0  of  the  tincture  of 
iron  perchloride. 

Reduced  iron  is  one  of  the  most  useful  iron  prep- 
arations, because  of  its  fairly  good  solubility  in  the 
gastric  juice  and  of  its  comparative  tastelessness. 
It  has  one  very  objectionable  feature,  however,  that 
in  some  patients  it  causes  eructations,  owing  to  the 
oxidation  of  iron  and  the  combination  of  nascent 
hydrogen  with  sulphur  or  phosphorus.  If  for  such 
reason  the  reduced  iron  cannot  be  tolerated,  iron 
carbonate  may  be  resorted  to,  which  is  also  a  desir- 
able preparation  because  of  its  solubility  in  the  gas- 
tric juice. 

There  is  a  difference  of  opinion  as  to  how  iron 
benefits  aniemic  patients.  Some,  maintain  that  it  is 
by  increasing  the  appetite  and  promoting  digestion, 
for  which  purpose  the  sulphate  of  iron  is  one  of  the 
best  preparations,  provided  the  stomach  tolerates  it. 
In  Germany,  especially,  the  chalybeates  are  highly 
regarded  for  this.  Others  hold  that  iron  acts  by 
being  absorbed  into  the  blood ;  but  it  is  not  likely 
that  much  is  absorbed  even  of  those  proprietary 
preparations  of  which  almost  complete  absorption 
is  alleged  by  their  manufacturers. 

It  is,  perhaps,  for  this  reason  that  small  doses  are 
given  by  those  who  believe  that  iron  acts  by  absorp- 
tion into  the  blood.  It  seems  to  me  that  an  observ- 
ing clinician  will  not  need  much  time  in  which  to 
make  up  his  mind  that  large  doses  of  iron  are  more 
effective  in  anaemia  and  chlorosis  than  small  doses. 
We  shall  find  that  the  per  cent,  of  haemoglobin  in 
chlorosis  is  much  more  rapidly  increased  bv  giving 
large  doses  than  by  small  doses  (the  number  of 
blood  corpuscles  being  but  slightly  reduced).  This 
is  readily  demonstrated  if  two  women  with  forty 


per  cent,  of  hemoglobin  are  treated  with  iron,  one 
with  large  doses  and  the  other  with  small.  The  same 
proposition  holds  good  with  anaemic  patients :  name- 
ly, the  number  of  blood  corpuscles  is  increased. 

It  is  agreed  by  most  clinicians  that  iron  does  not 
benefit  a  patient  if  it  does  not  improve  the  appetite 
and  promote  digestion. 

Sometimes,  when  the  official  preparations  are  not 
tolerated  at  all  by  a  patient,  the  preparation  brought 
to  the  notice  of  the  profession  by  Kobert,  h^emogal- 
lol,  an  organic  iron  preparation,  will  act  satisfactor- 
ily. Some  authors  indeed  assert  that  it  is  the  most 
readily  absorbable  iron  preparation  extant.  More- 
over, I  have  found  that  it  acts  admirably  in  connec- 
tion with  other  reconstructive  drugs  that  are  chem- 
ically incompatible  with  the  officinal  iron  prepara- 
tions. When  the  tonic  effect  of  iron  on  the  niucous 
membrane  of  the  digestive  tract  is  desired,  large 
doses  of  a  .soluble  astringent  preparation  are  usually 
preferable  to  the  bland  preparation  now  so  much  in 
use.  Personally,  I  prefer  in  such  instances  Blaud's 
pills,  composed  of  iron  sulphate  and  potassium  car- 
bonate. I  believe  that  much  of  the  favorable  opinion 
expressed  of  some  of  the  proprietary  remedies  is 
based  only  on  theory,  because  iron  sulphate  neither 
checks  the  solvent  action  of  the  gastric  juice,  nor 
diminishes  its  formation,  unless  the  mucosa  is  in  a 
pathological  condition  prior  to  the  taking  of  the  iron. 

In  all  cases  where  we  have  reason  to  believe  that 
dysmenorriioea  is  in  some  degree  due  to  an  impover- 
ished state  of  the  blood,  an  appropriate  form  of  iron 
is  likely  to  be  helpful. 

About  the  climateric,  the  nervous  symptoms,  such 
as  vertigo,  "flutter"  of  the  heart,  etc.,  if  associated 
with  anaemia,  are  most  benefitted  by  iron. 

Iron  must  not  be  given  for  too  long  a  period,  be- 
cause then  the  gastric  glands  become  overstimulated 
md  the  remedy  is  apt  to  cause  gastric  disturbances. 

BROMURAL  (aLPHAMOXOBROMISOVALERVLURE.x)  . 

For  a  long  time  1  have  looked  for  some  therapeu- 
tic agent  that  would  give  the  nerve  sedative  effects 
of  the  bromides  without  causing  their  undesirable 
after  effects ;  likewise  the  somnifacient  effect  of 
some  mild  hypnotics  without  the  heavy  feeling  that 
most  of  them  leave  several  hours  after  awaking.  I 
have  gone  through  the  entire  list,  experimenting  on 
my  own  person,  and  have  also  used  them  in  suitable 
instances  upon  patients. 

I  believe  we  have  in  bromural  such  a  remedy,  if 
my  own  extensive  use  of  it  for  a  period  of  about 
eighteen  months  is  a  criterion.  In  nervous  women 
who  are  in  the  climacteric  and  cannot  find  refresh- 
ing sleep,  we  can  usually  induce  such  healthful  rest 
by  letting  them  take  0.6  of  the  drug  at  bedtime. 

The  diff'erence  between  bromural  as  a  sleep  induc- 
er and  one  of  the  strong  hypnotics,  such  as  chloral, 
which  produce  a  sleep  forcing  effect,  may  be  likened 
to  the  difference  between  the  soothing  influence  of 
quiet  reasoning  with  an  excited  person,  or  of  the  so 
called  magnetic  .stroking  of  the  head,  and  the  forced 
quietness  of  such  a  person  under  the  influence  of  a 
dose  of  morphine  or  other  narcotic.  The  latter 
causes  a  feeling  of  numbness  and  forced  drowsiness, 
while  bromural  has  a  soothing  effect. 

It  is  maintained  that  bromural  does  not  give  rise 


372 


BEAKDSLEV :  GE\ ITOU RL\ ARY  COMPLICATION  OE  TYPHOID  FEl'ER.         [New  York 

Medical  Journal. 


to  a  habit.  \\'hile  I  do  not  believe  that  sufficient 
time  has  elapsed  since  its  introduction  to  prove  this, 
the  assertion  may  have  good  ground  because  the  ac- 
tion of  the  bromural  is  so  short  in  duration.  In  ex- 
perimenting upon  myself  with  it,  I  found  that  its 
sedative  effects  usually  passed  off  in  from  two  to 
four  hours.  It  never  causes  actual  narcotic  effects, 
even  in  doses  much  larger  than  those  advised  for 
therapeutic  purposes. 

Moreover,  I  found  that  it  acted  more  rapidly  than 
other  hypnotics,  and  further,  that  it  did  not  cause 
the  disagreeable  nausea  sometimes  induced  by 
chloral.  This  is  verified  by  the  experiments  of  Soll- 
mann  and  Hatcher,  published  in  the  Journal  of  the 
America!!  Medical  Association,  of  August  8,  1908, 
and  also  by  the  clinical  observations  published  by 
W.  H.  Porter  in  the  Boston  Medical  and  Siii'gical 
Journal  June  25,  and  July  2,  1908. 

In  short,  from  a  clinical  point  of  view,  bromural 
seems  to  induce  phy  siological  sleep  in  those  persons 
who  are  not  too  robust  physically  for  a  mild  nerve 
sedative. 

Of  even  greater  importance  than  its  hypnotic  ef- 
fects is  its  beneficent  action  on  that  large  class  of 
nervous  women  who  suffer  from  numerous  reflex 
nervous  symptoms  at  the  time  of  the  menopause, 
such  as  irritability,  cardiac  palpitation,  and  a  feel- 
ing of  fullness  in  the  head.  But  in  such  instances 
the  medication  should  be  dift'erent.  A  0.3  tablet  at 
intervals  of  three  or  four  hours  usually  allays  the 
nervousness.  It  is  evident  from  clinical  experience 
that  bromural  is  an  excellent  remedy  in  circulatory 
disturbances  of  nervous  origin. 

That  bromural  has  no  deleterious  influence,  is  evi- 
denced by  the  fact  tliat  during  sleep  the  pupils  are 
normally  contracted,  that  the  myosis  ceases  imme- 
diately u]^on  awakening,  and  that  its  effect  on  the 
condition  of  ihe  blood  is  positively  nil. 

An  excellent  contribution  on  the  comparative 
value  of  new  sedatives  and  those  of  older  date,  has 
been  published  in  Folia  Therapcutica  for  July,  1907, 
by  Professor  Foxwell,  of  the  Universit}'  of  Birm- 
ingham. England.  He,  too,  praises  bromural  very 
highly,  in  fact,  more  than  any  other  hypnotic  or 
sedative. 

If  a  stronger  hypnotic  is  necessary,  veronal — 
(Diethylmalonylurea)  or  trional — (  sulphonethylme- 
thanum)  may  be  tried.  Chemical  names  of  veronal 
and  trional  are  given  as  additional  proof  of  my 
contention  that  the  trade  or  proprietary  names  are 
more  desirable  for  use.  Among  the  older  remedies, 
chloral  hydrate  is  one  of  the  best,  although  the  nau- 
seating effect  it  frec|ucntly  has  is  undesirable,  es- 
pecially in  women  with  acute  inflammatory  pelvic 
conditions 

In  conclusion,  permit  me  to  say  that  in  my  opin- 
ion a  pliysician  who  is  guilty  of  giving  a  contribu- 
tion for  publication  without  having  had  sufficient 
experience  with  a  therapeutic  agent  to  justify  an 
opinion,  is  an  undesirable  member  of  the  profes- 
sion :  and  the  same  applies  to  those  phy.sicians  who 
write  articles  on  proprietary  remedies  for  remuner- 
ation, a  practice  which,  to  my  ]X'rsonal  knowledge. 
IS  prevalent. 

T,<)  East  SixTV-riRsx  Strf.f.t. 


THE  GENITOURINARY  COMPLICATIONS  OF 
TYPHOID  FEVER.* 

By  E.  J.  G.  Beardsley,  M.  D.,  L.  R.  C.  P.  (Loxd.), 
Philadelphia. 

Physician   to   Henry   Phipps   Institute;   Assistant    Physician   to  the 
Jefferson  Medical  College  Hospital. 

As  is  true  of  many  of  the  common  diseases,  the 
complications  of  typhoid  fever  are  likely  to  excite 
far  more  interest  than  does  the  disease  itself.  The 
reason  for  this  probably  lies  in  the  fact,  that,  al- 
though there  is  always  interest  in  any  morbid  pro- 
cess the  greatest  possible  interest  is  felt  in  any  un- 
usual phase  of  even  a  disease  which,  because  of  its 
prevalence  and  the  years  of  study  devoted  to  it,  is 
thought  well  understood. 

In  considering  the  subject  of  the  genitourinary 
complications  of  typhoid  fever,  it  is  well  to  bear  in 
mind  the  exact  nature  of  the  primary  infection  that 
we  may  better  understand  how  such  complications 
and  sequels  develop. 

Ten  years  ago  there  was  much  difference  of  opin- 
ion, even  among  authorities,  concerning  the  morbid 
anatomy,  the  pathology,  and  the  bacteriologv  of 
typhoid  fever.  However,  during  the  past  ten  years 
so  many  and  so  important  have  been  the  studies, 
while  their  results  have  so  changed  our  conception 
of  the  disease  that  it  may  be  profitable  to  review  the 
more  important  researches  which  have  thrown  such 
light  u])on  the  cause  of  the  development  of  the  com- 
plications which  are  the  subject  of  this  paper. 

Twenty-eight  vears  ago,  Eberth,  of  Zurich,  suc- 
ceeded in  demonstrating  in  sections  of  the  spleen 
and  mesenteric  gland  of  a  patient  dying  of  typhoid 
fever,  the  presence  of  the  specific  germ  of  this  dis- 
ease. Following  the  discovery  of  the  Bacillus 
typliosiis  and  particularly  after  Gaffky's  description 
of  its  cultural  characteristics,  it  seemed  a  simple 
matter  to  identify  it.  Just  about  this  time,  how- 
ever, Escherich  isolated  the  Bacillus  coli  coininiiiiis, 
and  it  was  soon  found  that  there  was  decided  diffi- 
culty in  distinguishing  this  latter  organism  from  the 
specific  organism  of  typhoid  fever. 

So  great  was  this  difficulty  that  many  bacteriolo- 
gists maintained  that  distinction  between  the  various 
members  of  the  colon  group  was  impossible.  W'e 
now  know,  as  the  result  of  careful  study  by  skilled 
bacteriologists,  that  the  typhoid  bacillus  and  the 
colon  bacillus,  though  having  a  common  ancestor, 
are,  in  reality,  distinct  species.  The  next  great  ad- 
vance in  our  knowledge  of  this  disease  was  brought 
about  by  the  discovery  of  the  Bacillus  typhosus  in 
the  blood,  in  the  urine,  and  in  the  fjeces  of  patients 
who  were  victims  of  the  disease.  These  findings 
rendered  the  old  view,  that  the  disease  was  a  local 
infection  of  the  bowel,  untenable.  It  was  easily 
seen  that  the  bacillus,  instead  of  being  localized  in 
the  lymphoid  tissues  of  the  intestine  and  mesenteric 
glands,  was  contained  in  the  blood  and  by  it  dis- 
tributed to  all  the  tissues  of  the  body.  Further 
study,  particularly  by  blood  culture,  proved  that 
typhoid  fever  is  primarily  a  sc])tic;cniia  and  that  in 
every  case  the  specific  organism  of  the  disease  is 
present  in  the  blood. 

With  this  understanding  of  the  disease,  it  becomes 

•Re.id  before  the  Phil.ndelphia  County  Medical  Society,  October 
28,  1908. 


February  20,  1909.J  BEARDSLEY :  GEXITOUR/XARY  COMPLICATIOXS  OF  TYPHOID  FEVER. 


373 


easy  to  understand  the  development  of  the  genito- 
urinary complications,  as  well  as  the  many  other 
visceral  lesions,  which  occur  during  or  following  an 
attack  of  this  septicaemia,  due  to  the  Bad!  I  us 
tyfylwstis. 

The  complications  which  occur  in  the  genitourin- 
ary tract  during,  or  subsequent  to,  typhoid  fcvtr  in- 
fection are  many.  Some  of  them  are  of  little  im- 
portance, cause  Httle  trouble,  and  are  transient  in 
duration,  while  others  are  so  severe  and  prolonged 
that  death  may  be  brought  about,  even  after  the  pa- 
tient has  apparently  convalesced  from  the  original 
illness.  Among  the  complications  are :  Retention  of 
urine,  polyuria,  albuminuria,  pyuria,  haematuria. 
hicmaglobinuria,  urobilinuria,  bacilluria,  infarcts 
and  abscess  of  the  kidney,  nephritis,  pyelitis,  cys- 
titis, epididymitis  and  orchitis,  oophoritis  and  salpin- 
gytis.  gangrene  of  the  genitals,  disturbed  menstrual 
function,  abortion,  miscarriage  or  premature  labor, 
and  inflammation  of  the  breasts. 

Several  of  these  complications  can  be  dismissed 
with  a  few  words.  Retention  of  urine,  particularly 
in  children,  is  a  common  minor  difficulty  during  the 
disease.  It  is  most  often  noted  in  children  early  in 
the  disease,  while  in  adults  it  appears  at  the  height 
of  the  fever  and  occasionally  persists  long  after  the 
patient  seems  much  improved. 

Polyuria,  on  the  other  hand,  although  it  may 
occur  during  the  fever,  usually  appears  during  con- 
valescence and  persists  for  weeks,  during  which 
time  the  patient  passes  large  quantities  of  urine, 
often  exceeding  lo.ooo  c.c.  in  twenty-four  hours. 

Albuminuria  during  the  disease  is  a  very  common 
finding.  Most  authorities  agree  that  fully  fifty  per 
cent,  of  all  patients,  suffering  from  typhoid  fever, 
will  reveal  albumin,  with  or  without  casts,  if  the 
urine  is  carefully  examined.  .Albuminuria  during 
typhoid  fever  may  be  due  to  one  or  more  of  five 
causes : 

1.  Febrile  albuminuria.  This  is  probably  the  most 
frequently  met  with  and  is  caused  by  either  the 
pyrexia  or  the  retention  of  toxic  materials  in  the 
blood  or  by  a  combination  of  both  causes.  Clin- 
ically this  form  of  albuminuria  is  usually  charac- 
terized by  the  small  amount  of  albumin,  usually 
without  the  presence  of  casts.  It  may  appear  early 
in  the  course  of  the  fever  and  may  persist  into  con- 
valescence, but  it  usually  occurs  during  the  second 
week  and  disappears  as  the  patient  recovers. 

2.  Albuminuria  due  to  nephritis  (haemorrhagic 
nephritis,  nephrotyphoid) .  In  this  form  of  al- 
buminuria the  quantity  of  albumin  is  likely  to  be 
large  and  is  often  associated  with  the  presence  of 
blood,  casts,  and  epithelial  debris.  This  symptom 
usually  occurs  during  the  second  or  third  week  and 
lasts  from  a  few  days  to  a  week,  when  the  symptoms 
clear  up  or  the  patient  sinks  into  a  ura;mic  condi- 
tion, and  recovery  is  very  much  delayed  or  death 
takes  place  either  from  the  primary  disease  or  the 
acute  nephritis. 

3,  Albuminuria  due  to  an  acute  suppurative  ne- 
phritis. This  is  a  comparatively  rare  complication 
of  typhoid  fever.  In  most  cases  it  results  from  sec- 
ondary septic  infection,  but  may  be  due  to  the  ac- 
tion of  the  typhoid  bacillus. 

4,  During  convalescence  albuminuria  mav  develop 
witli  other  symptoms  of  nephritis.     It  corresponds 


to  the  post  febrile  nephritis  seen  in  other  infective 
fevers. 

5,  Albuminuria  due  to  cystitis  (see  cystitis). 

Pyuria,  during  typhoid  fever,  is  a  not  uncommon 
complication,  as  might  be  expected  when  we  con- 
sider that  the  specific  bacilli  are  eliminated  in  large 
quantities  from  the  kidney.  This  complication  is 
most  frequent  in  severe  cases,  for  the  reason  that 
the  bladder  is  not  properly  emptied  and  the  residual 
urine,  under  those  conditions,  proves  an  all  too  ef- 
ficient culture  medium. 

Haematuria  and  haemaglobinuria  are  rare  com- 
plications and  occur  as  the  result  of  severe  toxaemia 
or  as  a  svmptom  of  the  general  haemorrhagic  ten- 
dency in  the  type  known  as  h?emorrhagic  t\phoid 
fever.  The  presence  of  blood  in  the  urine  is  al- 
wavs  a  seriotis  omen,  but  that  such  patients  recover, 
even  after  passing  large  quantities  of  blood,  is  well 
known.  It  must  not  be  forgotten  that  haematuria 
and  haemaglominuria  are  not  infrequently  brought 
about  by  the  action  of  certain  drugs,  turpentine, 
salol,  etc.,  while  the  administration  of  too  large,  too 
concentrated,  or  too  long  continued  doses  of  urinary 
antiseptics,  such  as  urotropin.  cysto.gen.  etc.,  will 
cause  the  appearance  of  both  haematuria  and 
haemaglobinuria. 

Bacilluria  is  so  common  a  complication  of  typhoid 
fever  that  we  must  consider  it  present  in  every  case 
at  some  time  during  the  disease,  although  the  bacillus 
has  been  found  in  but  twenty-five  per  cent,  of  the  pa- 
tients whose  urines  were  examined.  An  imjjortant 
and  a  very  interesting  fact  to  remember  concerning- 
the  bacilluria  of  typhoid  fever,  was  pointed  out  by 
P.  Horton  Smith,  in  1900.  when  he  stated  that  in 
the  usual  case  of  typhoid  bacilluria  the  number  of 
bacilli  were  so  great  that  the  urine  was  rendered 
turbid.  If  the  turbidity  of  the  urine  was  due  to  the 
presence  of  bacilli  this  was  easily  seen  by  holding- 
a  test  tube  filled  with  the  urine  to  the  light  and 
gentlv  shaking  it.  The  bacilli  cause  a  peculiar  shim- 
mer in  the  liquid,  similar  to  that  seen  in  shaking  a 
broth  culture  of  the  bacilli. 

Infarcts  and  abscesses  of  the  kidney,  during  ty- 
phoid fever,  are  rare,  but  instances  have  been  re- 
ported in  which  a  cultural  study  of  the  pus  in  the 
kidney  revealed  the  presence  of  tvphoid  bacilli. 

Xephritis  in  typhoid  fever  patients  is  a  very  im- 
portant complication.  The  exact  relation  of  the  pri- 
mary disease  to  the  inflammation  of  the  kidney, 
which  in  varying  degrees'of  severity,  occurs  so  com- 
monly during  its  course  is  a  very  difficult  question 
to  decide.  We  know  that  fifty  per  cent,  of  the  pa- 
tients who  suffer  from  typhoid  fever  reveal  both  al- 
bumin and  casts  if  the  urine  is  carefully  examined 
through  the  course  of  the  illness,  but  we  also  know 
that  a  large  percentage  of  these  patients  recover 
without  untoward  eft'ects.  In  the  usual  case  the  al- 
bumin and  casts  appear  at  the  height  of  the  fever, 
but  there  are  patients  who.  from  the  onset  of  the 
illness,  show  marked  changes  in  the  urine  and  re- 
veal symptoms  which,  for  a  time,  conceal  the  true 
nature  of  the  illness.  These  cases  are  classified  by 
the  French  clinicians  as  ncphro  typhoid,  and  thev 
are  by  no  means  infrequent.  In  America  we  call 
such  cases  haemorrhagic  nephritis  compHcating  tv- 
phoid fever.  It  is  by  no  means  infrequent  that 
cultures  from  the  kidney  reveal  the  presence  of  ty- 


374 


BEARDSLEY:  GENITOURINARY  COMPLICATIONS  OF  TYPHOID  FEVER.      [New  York 

Medical  Journai. 


plioid  bacilli,  but  it  is  doubtful  if  the  presence  of 
the  germ  is  accountable  for  the  numerous  cases  of 
albuminuria  with  tube  casts. 

Pyelitis,  cystitis,  and  pyuria  have  much  in  com- 
mon and  can  be  mentioned  together.  Pyelitis  is  a 
rare  complication  and  may  be  the  result  of  an  "as- 
cending affection"  from  the  bladder  or  the  infection 
may  come  from  the  bacteria  in  the  blood.  Cystitis 
and  pyuria  are  not  uncommon  complications  and 
usually  occur  in  severe  forms  of  the  primary  infec- 
tion during  the  height  of  which  fever  the  bladder 
is  not  properly  emptied  and  the  bacilli  that  escape 
into  the  urine  from  the  blood  multiply  readily  in 
the  residual  urine.  These  cases  are  likely  to  be  of 
long  duration  and  for  months  and  sometimes  for 
years  after  recovery  from  the  primary  disease  the 
patient  will  be  a  source  of  danger  to  others  because 
of  his  infected  bladder  and  urine. 

Among  the  unusual  complications  and  sequels  of 
typhoid  fever,  orchitis  and  epididymitis  are  always 
of  interest.  For  many  years,  in  fact,  vmtil  recent- 
ly, when  these  complications  occurred  during  or 
following  the  disease  the  true  cause  was  not,  as  a 
rule,  known  and  various  reasons  were  ascribed  for 
the  appearance  of  the  condition.  The  most  popular 
theor}-  was  that  the  complications  were  due  to  a 
preexisting  gonorrhoeal  infection,  and  this  view  was 
strengthened  by  the  knowledge  that  not  infrequent- 
ly there  was  at  the  onset  of  the  complication  a 
urethral  discharge,  and  at  times  the  patient  com- 
plained of  a  burning  pain  on  urination.  Next  in 
favor  was  the  traumatic  theory,  and,  in  man\'  in- 
stances slight  traumatisms,  such  as  injury  by  con- 
tact with  a  urinal  or  bed  pan,  or  injury  of  the  gen- 
ital tract  during  catheterization  was  held  accounta- 
ble for  the  appearance  of  the  complication.  When 
Schottmiiller,  in  1902,  proved  that  the  primary  dis- 
ease was  a  true  septicaemia  it  became  easy  to  ex- 
plain the  occurrence  of  the  various  visceral  compli- 
cations and  especially  after  the  discovery  of  the  ty- 
phoid bacillus  in  the  urine  of  the  patient  both  dur- 
ing the  disease  as  well  as  during  convalescence. 
The  bacilli  reach  these  organs  both  by  the  blood 
stream  and  through  the  urethra  by  way  of  the  vas 
deferens.  It  is  probable  that  the  blood  stream  is 
the  mode  of  infection  in  the  majority  of  cases,  but 
now  that  we  know  how  often  bacilluria  exist,  we 
must  consider  the  possibility  of  infection  by  way  of 
the  vas  deferens.  In  one  patient  reported  by  Kin- 
nicutt,  the  course  of  the  disease  could  be  watched 
in  the  cord,  the  disease  eventually  involving  the 
epididymis  and  testicle.  Thrombosis  of  the  sper- 
matic veins  has  been  held  accountable  for  the  com- 
plication in  certain  cases,  the  condition  often  being 
complicated  by  phlebitis  of  the  saphenous  veins. 
This  last  theory  was  advanced  by  Widal,  supported 
by  Hutchinson,  while  Gwyn  more  recently  reports 
a  case  which  appears  to  support  this  theory,  and 
concludes  that  many  of  the  cases  of  orchitis  in 
which  there  is  little  pain  arc  due  to  phlebitis  of  the 
veins  of  the  testicle. 

A  year  ago  I  had  occasion  to  consult  the  litera- 
ture U])on  this  subject  and  was  able  to  find  only  102 
case?  reported,  but  this  small  number  of  cases  re- 
ported does  not  give  a  true  idea  of  the  comparative 
frequence  of  the  complication.  A  brief  analysis  of 
this  series  of  cases  shows  that  the  condition  a])- 


peared  during  convalescence  following  typhoid  fever 
in  seventy-one,  and  during  the  fever  in  but  seven- 
teen, while  no  note  was  made  as  to  the  time  of  ap- 
pearance in  the  remaining  fourteen  cases.  In  thirty- 
seven  cases  the  right  testicle  was  affected,  in  twen- 
ty-seven the  left.  In  three  cases  the  condition  was 
bilateral,  while  in  thirty-five  instances  no  note  was 
made  as  to  the  testicle  affected.  There  were  forty- 
three  instances  in  which  both  testicle  and  epididymis 
were  affected ;  the  testicle  alone  thirty-one  times, 
and  the  epididymis  alone  ten  times ;  while  in 
eighteen  the  conditions  were  not  distinguished.  In 
a  number  of  the  cases  the  cord  was  also  involved. 
Suppuration  occurred  in  twenty-two  of  the  102 
cases  and  in  many  of  these  there  was  a  loss  of  tes- 
ticular tissue  and  subsequent  atrophy.  There  was 
noted  an  effusion  into  the  tunica  vaginalis  testis  in 
thirteen  instances,  and  in  six  cases  a  urethral  dis- 
charge was  seen,  while  in  several  others  an  exam- 
ination of  the  urine  revealed  the  presence  of  mu- 
cous and  pus. 

The  onset  of  the  complication  was,  as  a  rule, 
abrupt.  It  appeared  while  the  patient  was  still  in 
bed  or  shortly  after  the  beginning  of  convalescence, 
and  was  marked  in  the  majoritv  of  cases  by  an 
acute  pain  in  the  region  of  the  testicle  or  in  the 
groin,  in  which  case  it  became  radiating  in  charac- 
ter and  involved  the  testicle.  The  onset  was  not 
infrequently  marked  by  chilliness  or  by  a  severe 
chill,  and  sometimes  the  pain  was  so  severe  as  to 
cauSe  vomiting.  Following  the  initial  chill  and  p:iin 
there  was  usually  a  rise  in  temperature,  accelera- 
tion of  the  pulse,  and  a  feeling  of  general  wretcli- 
edness.  _  In  many  cases  the  patient  complained  of 
a  sense  of  weight  in  the  testicle,  and  the  scrotimi 
was  often  red,  swollen,  and  jedematous,  while  not 
infrequently  an  acute  hydrocele  developed.  Pain 
when  urinating  was  a  frequent  complaint,  and 
catheterization  was  necessary  in  several  instances. 
There  was  no  apparent  relation  between  the  se- 
verity of  the  initial  illness  and  the  occurrence  of 
the  complication,  which  attended  the  mild  and  mod- 
erately severe  cases  as  frequently  as  it  did  the  grave 
cases  of  fever.  The  complication  occurred  most 
frequently  in  the  youth  and  young  adults,  but  in- 
stances were  seen  in  a  child  of  four  years  and  in  a 
patient  seventy-eight  years  of  age. 

Kinnicutt  and  Gwyn  have  both  called  attention  to 
the  fact  that  a  sudden  acute  pain  in  the  abdomen 
may  be  due  to  a  thrombosis  of  the  mesenteric  veins, 
and  in  one  of  Kinnicutt's  patients  the  infection  of  the 
epididymis  evidently  originated  in  the  cord  above 
Poupart's  ligament,  for  the  process  could  be  traced 
downward  to  the  testicle,  the  epididymis  being  af- 
fected forty-eight  hours  after  the  cord  was  pal- 
pable. In  Gwyn's  case  there  was  a  sudden  pain  in 
the  region  of  the  appendix,  and  only  later  was  the 
discovery  of  the  enlarged  testicle  made.  The  im- 
plication of  the  cord  suggests,  as  pointed  out  by 
Kinnicutt,  an  original  infection  either  of  the  vas  or 
of  the  spermatic  veins,  producing  with  a  thrombosis 
and  secondary  im])lication  of  tlie  vas  deferens  by 
contiguity.  The  nearly  sinniltaneous  development 
of  a  phlebitis  of  the  internal  saphenous  vein,  which 
is  a  condition  not  infre(|uently  accompanying  these 
complications,  suggests  the  possibility  of  certain 
cases  being  due  rather  to  a  phlebitis  of  the  testicu- 


I-ebruary  jo,  1909.] 


DAllSOX:  SALIVARY  CALCULI. 


375 


lar  veins,  as  suggested  by  Gw  vn.  than  due  entirely 
to  bacterial  invasion.  The  prognosis  for  life  is  good 
and  as  the  disease  is  usually  unilateral  there  is  little 
complaint  of  loss  of  function.  The  condition  lasts 
from  a  few  days  to  a  week,  but  when  suppuration 
ensues  convalescence  is  much  delayed.  Incision 
and  free  drainage,  as  a  rule,  soon  gives  relief,  al- 
though induration  of  the  testicle  and  epididymis  fol- 
lowing convalescence  is  frequent. 

Gangrene  of  the  genitals,  in  female  patients  dur- 
ing typhoid  fever,  although  a  rare  complication,  is 
bv  no  means  a  unique  one.  CEdema  of  the  labia 
with  ulceration,  usually  due  to  pressure,  is  occasion- 
all\-  seen.  Acute  inflammation  of  Bartholin's  glands 
as  well  as  partial  and  infrequently  complete  gan- 
grene of  the  vulva  has  been  reported  by  several  ob- 
servers. Infrequently  inflammation  of  the  ovaries 
and  tubes  are  met  with  during  this  disease  and 
usuallv  this  occurs  early  in  the  disease.  As  is  true 
of  many  of  the  infectious  diseases,  typhoid  fever  has 
a  definite  influence  upon  the  menstrual  function. 
Menstruation  occurs  quite  frequently  during  the 
first  days  of  the  disease  and  is  likely  to  be  more  free 
than  usual.  Profuse  uterine  haemorrhages  during 
the  course  of  the  disease  are  rare,  and  when  they 
occur  are  combined  with  other  features  which  serve 
to  form  the  condition  we  know  as  haemorrhagic  ty- 
phoid fever. 

The  relation  of  the  pregnant  condition  to  an  at- 
tack of  typhoid  fever  is  verv  important.  A  number 
of  patients  pass  safely  through  the  attack  of  fever 
without  interruption  of  the  pregnancy  while  others 
recover,  in  spite  of  abortion  or  premature  labor.  In 
still  other  cases  death  takes  place  immediately  after 
the  interruption  of  the  pregnancy.  Regarding  the 
danger  of  an  attack  of  typhoid  fever  to  a  pregnant 
patient  we  may  quote  the  collected  statistics  of 
Sacquin,  who  found  that  in  223  cases  of  pregnancy 
complicated  by  this  disease,  abortion  or  premature 
labor  took  place  in  150,  with  a  mortality  rate  of 
sixteen  per  cent. 

Slight  inflammation  of  the  breasts  during  typhoid 
fever  is  often  seen  but  the  symptom  is  usually  trans- 
itory in  character.  Occasionally,  however,  the  in- 
flammation is  more  severe  and  abscesses  sometimes 
form  in  the  pus  of  which  the  Bacillus  typhosus  has 
several  times  been  found. 

2030  Chestnut  Strect. 


SALIV.\RY  CALCULI  WITH  REPORT  OF  A  CASE* 

By  Robert  E.  Davisox,  M.  D., 
Pittsburgh,  Pa. 

The  subject  of  this  paper  is  a  man,  aged  forty-one  years. 
He  used  tobacco  moderately,  but  no  alcoholic  beverages  or 
other  narcotics.  There  was  nothing  in  his  family  history 
bearing  on  his  present  condition.  He  was  married  at  twen 
ty-tive,  and  to  this  union  four  children  have  been  born. 
The  first  born  died  of  an  unknown  cause  a  few  minutes 
after  birth,  but  the  other  three  are  living  in  good  health. 
There  had  been  no  miscarriages.  He  denied  venereal  in- 
fection. With  the  exception  of  measles  and  whooping 
cough  in  infancy  he  had  not  been  sick  until  ten  years  ago, 
when  his  present  illness  began.  Its  onset  was  sudden  with 
sore  throat  and  swelling  about  the  left  angle  of  the  lower  jaw. 
rapidly  involving  the  face  and  neck.  At  times  it  was  very 
painful,  characterized  by  paroxysms  which  bore  a  direct 

'Read  before  the  Allegheny  County  Medical  Society,  December 
15.  1908. 


relation  to  the  size  of  the  swelling.  If  he  attempted  to  eat 
or  swallow  he  was  seized  with  pain  referred  to  the  jaw 
with  a  decided  increase  in  the  enlargement  of  the  swelling. 
During  the  paro.xysms  he  applied  hot  fomentations,  which 
slightly  relieved  the  pain.  In  a  few  hours  the  swelling  and 
pain  subsided,  leaving  him  comparatively  at  ease.  Even  the 
odor  of  cooking  brought  on  these  attacks.  Tliey  were 
rather  remittent  in  type  than  intermittent.  He  suffered  in 
this  way  for  two  weeks,  when  he  was  completely  relieved 
by  a  discharge  of  fluid  into  the  mouth.  This  discharge  had 
a  sweetish  taste  and  a  very  offensive  odor.  The  swelling 
about  the  jaw  rapidly  subsided,  and  in  a  few  days  he  was 
able  to  follow  his  usual  occupation.  Since  then  he  had 
many  of  these  attacks — once,  twice  or  thrice  a  year.  He 
thought  they  had  not  varied  in  their  manifestations. 

In  the  intervals  between  the  attacks  he  enjoyed  remark- 
ably good  health  and  worked  daily  at  tinsmithing.  He  was 
conscious  especially  in  the  mornings  of  a  bad  taste  in  the 
mouth  and  a  foul  odor  on  the  breath. 

Ice  cream  and  food  acidulated  with  vinegar  when  eaten 
set  up  paroxysms  of  pain  with  swelling  under  the  jaw. 
Pain  and  swelling  went  hand  in  hand,  and  the  one  was 
never  present  without  the  other.  If  he  went  to  the  table 
ravenously  hungry  and  began  eating  hurriedly  he  was  so 
pained  that  he  must  rest  a  while  before  finishing  the  meal. 

When  these  attacks  first  came  on  he  had  sound  teeth,  but 
in  a  few  years  the  gums  became  diseased  and  the  teeth 
loosened  and  dropped  out.  However,  he  saw  no  relation 
between  losing  his  teeth  and  this  affection,  but  attributed 
the  loss  of  his  teeth  to  the  effect  of  medicine  injected  sub- 
cutaneously  for  the  cure  of  inguinal  hernia.  He  had  always 
cleaned  his  teeth  regularly,  but  he  had  abused  them  by 
cracking  English  walnuts  with  them.  He  is  at  present 
wearing  upper  and  lower  artificial  teeth.  The  right  side 
of  the  jaw  had  never  given  him  any  trouble. 

Examination. — In  my  office  on  August  15,  1908,  I  saw 
this  patient  for  the  first  time.  He  complained  of  sore 
throat,  pain  m  the  left  side  of  the  lower  jaw,  and  difficulty 
in  mastication  and  deglutition.  He  was  in  the  eighth  day 
of  his  present  attack. 

His  temperature  was  101°  P.  and  his  pulse  was  80  beats 
a  minute.  He  had  the  appearance  of  a  man  in  much  dis- 
tress and  complained  of  general  weakness.  He  spoke  with 
effort  and  slurred  the  words.  Below  the  angle  of  the  left 
jaw  there  was  a  definite  prominence  extending  to  the  left 
side  of  the  face  and  neck.  This  tumor,  about  the  size  of 
an  English  walnut,  was  hard  and  painful  to  pressure  and 
freely  movable.  CEdema  and  discoloration  of  the  skin  were 
absent.  Examination  for  ear  disease  was  negative.  Pres- 
sure over  the  angle,  ramus  and  symphj-sis  of  the  jaw  gave 
neither  pain  nor  discomfort.  No  suggestions  of  malignant 
disease  existed,  since  there  were  neither  infiltration  of  the 
surrounding  tissue  nor  general  enlargement  of  the  cervical 
lymphatic  glands.  It  was  e\ndent  the  tumor  most  likely 
was  an  enlarged  submaxillary  salivary  gland.  The  tidelike 
rise  and  fall  of  the  tumor,  respectively,  with  the  activity 
and  rest  of  the  salivary  apparatus  was  highly  suggestive  of 
a  partial  obstruction  in  \\Tiarton"s  duct.  At  tiines  the  ob- 
struction became  absolutely  dependent  upon  the  inflamma- 
tory condition  of  the  duct.  Examination  of  the  moiuh 
showed  a  diffuse  acutely  inflamed  mucous  membrane  lim- 
ited to  the  left  side.  The  tonsils  were  atrophic.  On  the 
floor  of  the  mouth  along  the  left  border  -  of  the  tongue, 
there  was  a  row  of  shallow  ulcers  with  rounded  borders 
having  the  appearance  not  unlike  a  string  of  red  beads. 
Smears  were  taken  from  these  ulcers,  but  no  cultures  were 
made.  Spirochata:  pallidcc  and  tubercle  bacilli  were  ab- 
sent. Organisms  of  the  spirilla  type  predominated  in  all 
the  smears,  however ;  bacilli  and  cocci  were  also  present. 
Smears  made  from  the  saliva  were  rich  in  organisms  and 
pus  cells  showing  in  "a  very  marked  degree  an  infective 
process.  Mucopus  covered  the  posterior  wall  of  the 
pharynx.  The  tongue  was  deeply  forrowed,  but  not  scarred 
or  ulcerated.  A  fine  probe  failed  to  enter  Wharton's  duct. 
The  breath  emitted  a  foul  and  obnoxious  odor.  Owing  to 
the  sensitiveness  of  the  mucosa  to  touch  palpation  was  un- 
satisfactory. The  urine  end  blood  were  practically  normal. 
The  heart,  the  blood  vessels,  the  lymphatic  glands,  and  the 
respiratory  and  digestive  tracts  were  all  negative.  The  in- 
guinal rings  were  tight  and  no  hernia  existed. 

The  patient  was  advised  to  rest,  to  take  a  saline  laxative, 
and  to  use  a  mouth  wash  of  hydrogen  peroxide. 

Three  days  later  he  returned  to  my  office  considerably 
better.    He  had  less  pain  and  had  taken  some  food.  His 


376 


DAVISON:  SALIVARY  CALCULI. 


[New  York 
Medical  Journal. 


tt-mpcrature  was  99°  F.,  and  his  pulse  was  72  beats  a  min- 
ute. The  swelhng  was  decidedly  reduced.  The  inflam- 
mation of  the  mouth  was  less  acute,  and  palpation  was  not 
so  painful.  A  slitlike  opening  was  readily  found  in  the 
mucous  membrane  of  the  ramus  just  anterior  to  the  angle. 
Thick  creamy  pus  exuded  on  pressure  of  the  tumor.  The 
pus  was  free  of  bone  debris  and  tubercle  bacilli.  When  the 
sinus  was  probed  a  large  quantity  of  pus  poured  out  streaked 
with  blood,  and  a  distinct  grating  sensation  was  transmitted 
to  the  hand.  A  foreign  body  was  found,  but  it  could  not 
be  outlined  by  the  probe  nor  definitely  located,  although  it 
seemed  to  be  back  deep  in  the  floor  of  the  mouth,  above  the 
hyoid  bone  and  posterior  to  the  mylohyoid  muscle.  It  could 
not  be  felt  on  careful  palpation. 

Diagnosis.  A  diagnosis  of  salivary  calculus  of  Whar- 
ton's duct  was  made.  The  source  of  the  pus  discharging 
through  the  sinus  was  either  from  suppurating  tissue 
around  the  stone  or  from  a  suppurating  gland.  This  point 
could  not  be  clearly  determined.  Operation  was  advised 
and  accepted. 

Operatii)n.  On  August  24,  1908,  at  St.  Francis'  Hospital 
the  patient  was  given  ether  by  Dr.  Crile's  method  of  nasal 
administration. 

Naturally  two  operative  methods  suggested  themselves, 
the  simpler  enlarging  the  sinus  and  removing  the  stone 
through  the  mouth  ;  and  the  second,  excision  of  the  salivary 
gland  and  removal  of  the  stone  from  without.  The  first 
method  was  rejected  because  we  could  not  satisfy  our- 
selves that  the  salivary  gland  was  not  suppurating  and  did 
not  require  removal.  The  following  operation  was  chosen. 
An  incision  one  inch  in  length  was  made  parallel  to  the 
ramus  of  the  jaw  and  one  fourth  of  an  inch  below,  and  di- 
rectly over  the  tumor.  By  blunt  dissection  the  submaxil- 
lary salivary  gland  and  two  enlarged  lymphatic  glands  were 
removed.  The  salivary  gland  was  free  of  stone  and  ap- 
parently healtliy.  The  jaw  bone  was  not  diseased.  These 
findings  removed  any  doubt  as  to  diagnosis  and  source  of 
pus.  We  were  dealing  with  a  salivary  calculus  surrounded 
by  suppurating  tissue.  The  stone  lay  so  far  back  and  so 
deeply  in  the  floor  of  the  mouth  that  it  could  not  be  felt 
tlirough  the  incision,  consequently,  we  decided  to  remove 
it  through  the  mouth  rather  than  risk  the  danger  of  infec- 
tion by  enlarging  the  incision.  Accordingly  the  sinus  was 
enbrged  by  incisions  down  to  the  stone,  and  the  calculus 
grasped  by  forceps  and  removed.  It  was  a  large  stone 
weighing  dry  sixty-four  grains  and  measuring  three  fourths 
of  an  inch  long,  three  fourths  of  an  inch  wide,  and  a  half 
inch  thick.  The  skin  incision  was  partially  closed  with  silk- 
worm gut  and  a  wick  of  iodoform  gauze  inserted  for  drain- 
age. Both  wounds  were  cleansed  out  each  day  with  hydro- 
gen peroxide  and  a  weak  watery  solution  of  iodine,  and  in 
two  weeks  were  healed. 

There  was  a  slight  drooping  of  the  left  angle  of  the 
mouth,  scarcely  noticeable,  due  to  cutting  a  fibre  of  the 
facial  neive  supplying  this  region.  With  the  exception  of 
a  slight  difficulty  in  puckering  his  mouth  to  whistle,  it 
caused  no  disability.  He  was  relieved  of  all  his  symptoms 
and  was  entirely  cured. 

On  December  9th,  I  saw  the  patient  and  I  found  he  had 
entirely  recovered  from  the  slight  paralysis  of  the  angle  of 
the  mouth. 

In  reviewinjT;-  the  lliterattire  of  sialolithias  the 
writer  found  only  242  reported  cases,  which  would 
indicate  that  it  is  incleed  a  rare  affection.  As  to  its 
rarity  we  are  not  so  sure  but  rather  inclined  to  the 
belief  that  it  is  only  apparent  due  to  the  ne.c^ligcncc 
of  the  profession  in  rcj^ortinq-  these  cases.  A  defi- 
nite conception  of  salivary  calctili  must  be  possessed 
by  any  one  prctendint?;  to  make  a  distinctive  diaj?- 
nosis  of  swellincjs  about  the  face  and  neck. 

Calculi  may  be  located  in  any  of  the  salivary 
fjlands  and  their  ducts.  Fiitterer  and  Roberg-  have 
tabulated  eii?hty-four  cases  as  follows:  Submaxil- 
lary Rland.  ei,e;-hteen  cases;  Wharton's  duct,  fifty 
cases;  sublingual  inland,  two  cases;  Bartholin's  duct, 
six  cases;  parotid  t^land.  two  cases;  Stenson's  duct, 
six  cases.  Thus  in  seventy-four  per  cent,  of  the 
cases  a  stone  was  located  in  the  ducts,  and  in  fifty- 
nine  per  cent,  in  Wharton's  duct  alone. 


Etiology. — The  composition  of  these  stones  'ac- 
cording to  the  analysis  made  by  Gorup  Besanez  is 


as  follows : 

Calcium  carbonate,   81.3; 

Calcium  phosphate.,   4.1 ; 

Soluble  salts,   6.2 ; 

Organic  matter,    7.1  ; 

Water,  etc.,    1.3. 


Insoltible  lime  salts  form  85.4  per  cent,  of  the 
bulk  of  the  calculus.  The  saliva  contains  disodium 
phosphate,  magnesium  and  calcium  salts,  mucin, 
and  water.  There  is  nothing  in  the  calculi  but 
what  may  also  be  found  either  in  the  secretions  of 
the  salivary  glands  or  in  the  mouth,  consequently 
they  are  beyond  doubt  ptyalogenic  in  origin.  The 
lime  salts  in  saliva  are  soluble  whilst  the  lime  salts 
in  calctili  are  insoluble,  hence  a  precipitant  foreign 
to  the  normal  glandular  secretion  is  essential.  Ex- 
perimentation has  shown  that  the  solubility  of  the 
lime  salts  in  saliva  is  due  to  the  presence  of  carbonic 
anhydrid  and  whenever  reinoved  precipitation  im- 
mediately follows.  Decomposition  of  particles  of 
proteid  food  in  the  mouth  which  gives  rise  to  am- 
monia and  takes  up  carbonic  anhydrid  from  the  sa- 
liva, becomes  the  important  factor  in  the  aetiology 
of  this  affection.  Whether  this  is  the  only  active 
precipitant  or  not  is  at  present  hard  to  say,  some 
investigators  believe  that  both  lactic  and  acetic  acid 
play  an  important  role.  Decomposition  is  primarily 
the  cause  of  this  disease.  The  dental  tartar  prone 
to  form  in  all  mouths  is  in  composition  identical 
with  salivary  calculi,  and  differs  only  in  color  and 
location.  A  mouth  in  which  there  is  stifficient  am- 
monia to  enter  the  ducts  and  precipitate  the  salivary 
salts,  necessitates  a  very  active  decomposition — a 
filthy  mouth  polluted  with  saprophytic  organisms. 
This  may  explain  why  salivary  calculi  seldom  af- 
fect women,  for  men  are  more  careless  in  keeping 
their  mouths  clean.  The  nidtts  of  the  calctilus  is 
formed  by  precipitation  of  lime  salts  in  the  duct  or 
gland  and  grows  slowly  by  accretion,  blood  serum 
and  leucocytes  giving  it  cohesive  properties. 

The  stone  is  not  present  very  long  before  infec- 
tion by  pyogenic  organisms  takes  place,  and,  in  fact, 
dead  organisms  have  been  known  to  form  a  part  of 
the  calculus,  thus  giving  color  to  the  belief  that  the 
nidus  consisted  of  organisms. 

Syiiiptoijtatology — The  symptoms  of  stone  in  the 
salivary  glands  or  ducts  may  be  very  severe,  or  so 
slight  that  the  patient  experiences  little  incon- 
venience. At  first  the  symptoms  are  mostly  due  to 
retention  of  saliva  while  eating.  He  may  have  dis- 
comfort in  mastication  and  deglutition  with  a  pain- 
ful swelling  of  the  affected  gland.  These  symptoms 
usually  disappear  at  the  close  of  the  meal.  The  size 
of  the  stone  iiears  no  relation  to  the  .severity  of  the 
symptoms.  Sooner  or  later  suppuration  takes  place 
when  the  symptoms  are  all  accentuated.  The  en- 
larged gland  becomes  more  or  less  permanent.  An 
abscess  forms  which  may  be  discharged  along  the 
side  of  the  stone  through  the  dtict  into  the  mouth  or 
break  through  the  overlying  tisstte  creating  a  sinus. 
When  the  stone  is  sui)erficiall\-  lodged  ulceration 
may  ])r()duce  a  spontaneous  cure.  Upon  the  evac- 
uation of  the  pus  the  ]iatient  obtains  relief  and  re- 
mains fairly  comfortable  mitil  the  sinus  or  duct  be- 
comes occluded,  when  he  once  more  goes  through 


February  20,  1909.] 


SILL:  OPHTHALMIC  TUBERCULIX  TEST. 


377 


a  severe  attack  of  aggravating  pain.  The  French 
writers  have  aptly  called  these  attacks  "salivar\' 
colic."  During  the  attacks  there  is  fever  and  pros- 
tration, attempts  to  chew  or  to  swallow  heighten  the 
pain,  and  the  swelling  enlarges  and  becomes  ten- 
der. DiflFuse  cellulitis  of  the  face  and  neck  may 
follow.  The  pain  is  always  worse  while  eating,  in 
fact,  anvthing  stimulating  a  flow  of  saliva  causes 
pain.  The  patient  may  be  aware  of  a  foreign  body 
in  the  floor  of  the  mouth.  Pyorrhoea  alveolaris,  or 
Riggs  disease,  with  falling  of  the  teeth,  is  not  an 
uncommon  accompaniment. 

Eagle  relates  that  he  removed  a  stone  from  the 
submaxillary  gland  of  a  man,  forty-two  years  old, 
measuring  one  and  one  eighth  of  an  inch  wide,  one 
inch  thick,  and  one  and  one  half  inches  long,  and 
weighing  one  and  a  half  oimces.  The  man  came 
nearly  choking  to  death  from  spasm  of  the  glottis. 
He  was  unable  to  eject  mucus  and  saliva,  and  they 
entered  his  larynx.  Its  removal  was  easy  since  one 
end  was  exposed  and  freely  movable. 

In  calculus  of  the  submaxillary  and  the  sublin- 
gual glands  or  their  ducts,  there  is  frequently  a 
mass  of  granulation  tissue  in  the  floor  of  the  mouth. 
In  my  case  the  ulceration  was  along  the  floor  of 
the  mouth,  but  the  opening  of  the  sinus  was  along 
the  inner  surface  of  the  maxilla  an  inch  away  from 
the  granulation  tissue. 

Diagnosis. — The  diagnosis  of  salivary  calculus  is 
often  ver\-  easy,  as  it  was  in  my  case,  but  it  may  be 
very  difficult  and  sometimes  impossible  without  an 
exploratory  mcision.  The  history  of  the  case  is 
important.  Xo  detail  should  be  considered  too  in- 
significant to  gather  and  note.  The  simple  fact  that 
vinegar  when  eaten  caused  a  painful  swelling  in  the 
region  of  the  submaxillary  salivary  gland  proved 
to  be  an  important  clew  in  making  a  correct  diag- 
nosis in  my  case. 

Actinomycosis,  tuberculosis,  ranula,  syphilis,  and 
cancer  must  be  excluded.  The  salivary  ducts 
should  be  probed,  and  if  patulous  the  stone  may  be 
felt.  The  floor  of  the  mouth  should  be  carefully 
palpated  with  the  finger  and  any  nodules  noted.  If 
a  nodule  is  found  its  composition  can  often  be  de- 
termined by  passing  into  it  a  hypodermic  needle. 
This  procedure  is  important  when  a  ranula  is  sus- 
pected. The  mouth  must  be  searched  for  a  sup- 
purating sinus,  and  if  found  probed.  The  pus 
should  be  examined  for  bone  detritus  and  organ- 
isms. This  disease  has  been  mistaken  more  fre- 
quently for  cancer  than  any  other  affection.  The 
rarity  of  primary  cancer  of  the  salivary  glands  and 
the  absence  of  infiltration  should  assist  in  the  ex- 
clusion of  carcinoma.  This  disease  is  only  painful 
at  times,  while  eating  and  during  acute  attacks,  al- 
though chronic,  there  is  no  cachexia.  The  great- 
est aid  to  diagnosis  is  the  history. 

Treatment. — The  treatment  is  surgical.  It  may 
be  possible  at  times  to  leave  the  gland,  but  we  are 
never  certain  that  the  gland  is  not  diseased,  and  this 
is  especially  true  of  the  submaxillary. 

In  ease  there  is  much  purulent  discharge  coming 
from  the  floor  of  the  mouth  it  is  better  to  remove 
the  affected  gland. 

In  regard  to  the  parotid  gland  no  general  state- 
ment can  be  made,  since  each  case  will  have  to  be 
decided  according  to  the  condition  present. 

632  FULTOX  BuiLDIXG. 


THE  VALUE  AND  RELIABILITY  OF  CALMETTE'S 
OPHTHALMIC   REACTION   TO  TUBERCULIX 
FOR  THE  DIAGNOSIS  OF  TUBERCULOSIS 
AND   DIFFERENTIATION   OF  TUBER- 
CULOUS   LESIONS    FROM  OTHER 
DISEASES    IN    INFANTS  AND 
YOUNG  CHILDREN* 

By  E.  Mather  Sill,  M.  D., 
New  York, 

Chief   Attending    Phjsician    in    the   Children's   Department    at  the 
Gocd  Samaritan  Dispensary;  Instructor  in  Diseases  of  Children 
at  the  New  York  Polyclinic  Hospital  and  Medical  School. 

Any  new  and  practicable  method  for  the  deter- 
mining to  a  reasonably  certain  degree  the  presence 
or  absence  of  a  tuberculous  focus  in  the  body  is 
hailed  with  the  greatest  enthusiasm. 

One  seventh  of  all  deaths  in  animals  and  man  are 
due  to  tuberculosis  in  spite  of  the  fact  that  such 
great  advances  have  been  made  in  our  knowledge  of 
its  iEtiology,  diagnosis,  and  treatment. 

Frequency  in  Childhood. 

That  tuberculosis  in  infancy  and  childhood  is 
much  more  frequent  than  was  formerly  supposed  is 
shown  by  the  autopsy  records  of  many  prominent 
authorities.  This  frequency  increases  regularly  with 
the  age.^ 

^liiller,  of  Munich,  found  tuberculosis  present  in 
forty  per  cent,  of  50b  children  on  whom  autopsies 
were  performed,  and  in  ten  per  cent  of  these  the 
children  died  from  causes  other  than  tuberculosis. 
Of  319  autopsies  reported  by  Holt  at  the  Babies' 
Hospital,  fourteen  per  cent,  were  tuberculous. 
These  figures- go  to  show  its  frequency  in  childhood 
and  difficulty  of  diagnosis. 

That  tuberculous  conditions  are  so  slight  and  ob- 
scure in  many  instances  as  to  be  impossible  of  diag- 
nosis by  the  old  methods  is  instanced  by  the  experi- 
ments of  Loomis,'  who  inoculated  animals  with  the 
bronchial  lymph  nodes  of  thirty  people  dying  from 
violence  or  acute  diseases  in  whom  no  evidence  of 
tuberculosis  could  be  found  in  any  other  part  of 
the  body  at  autopsy,  and  from  eight  of  the  cases  he 
produced  tuberculosis  in  the  inoculated  animals. 

Until  the  last  year  there  have  been  hundreds  of 
young  children  with  incipient  or  latent  tuberculosis 
or  tuberculosis  outside  the  lungs  which  have  been 
undiagnosticated  or  diagnosticated  as  other  diseases, 
for  the  reason  that  there  was  no  means  of  proving 
they  had  any  tuberculous  lesion  in  the  body,  and 
thus  many  of  these  cases  have  gone  untreated. 

W'e  now  have  at  our  disposal  a  fairly  reliable  and 
apparently  harmless  means  of  determining  to  a  rea- 
sonable degree  of  certainty  whether  or  not  a  given 
case  has  a  tuberculous  focus.  This  is  the  ophthal- 
mic reaction  to  tuberculin.  The  important  points 
of  value  in  this  new  method  for  diagnosis  are  that : 
I,  Tuberculosis  reacts  to  the  agent:  2,  That  non- 
tuberculous  patients  do  not  show  this  reaction ;  and 
3,  The  test  has  an  effect  upon  old  cases  of  healed 
tuberculosis.  Since  autopsy  records  show  that  many 
cases  of  tuberculosis  are  healed. 

Method  of  Administration. 
Our  method  of  administration  has  been  the  same 
as  that  of  Calmette,  namely,  one  drop  of  a  one  per 

*raper  read  at  the  International  Congress  on  Tuberculosis,  Sec- 
tion IV,  at  Washington,  D.  C.  October  i,  1908. 
^Diseases  of  Infancy  and  Childhcod,  36. 
-Medical  Record,  December  20,  1890. 


378 


SILL:    OPHTHALMIC  TUBERCULIX  TEST. 


[New  York 
Medical  Journal. 


cent.  Sterile  solution  of  the  precipitated  tuberculin 
being  instilled  into  one  eye,  the  lower  lid  being 
drawn  well  down  and  held  for  one  minute  after  the 
instillation,  so  that  the  tuberculin  was  thoroughly 
diffused  over  the  eye  ball  and  conjunctiva.  The 
same  eye  should  not  be  used  for  more  than  one  test 
as  it  becomes  sensitized,  and  therefore  a  second  in- 
stillation in  the  same  eye  is  of  no  diagnostic  value 
(of  course  we  never  used  the  test  in  a  diseased 
eye).  The  lower  lid  was  drawn  down  and  con- 
junctiva and  inner  canthus  examined  every  hour  or 
two  and  the  time  and  amount  of  reaction  noted.  Re- 
actions varied  in  their  time  of  appearance  from 
three  to  si-xteen  hours  after  instillation,  but  in  a  few 
cases  the  reaction  did  not  show  for  twenty-four  to 
forty-eight  hours,  and  in  these  cases  it  sometimes 
continued  for  several  days. 

Occasionally  slight  discomfort  was  experienced 
and  a  feeling  that  some  foreign  substance  was  in 
the  eye,  but  in  the  majority  of  cases  no  subjective 
symptoms  were  present.  Usually  in  a  few  hours  a 
congestion  of  the  palpebral  and  ocular  conjunctiva 
occurred,  and  the  caruncle  was  hyperaemic  and  cov- 
ered in  some  cases  with  a  fibrinous  exudate.  (Red- 
ness of  the  conjunctiva  was  not  always  present).  As 
the  reaction  advanced  there  was  lacrimation  and  a 
fibrinous  exudate  resembling  pus  collected  at  the  in- 
ner canthus.  The  maximum  of  intensity  was  reached 
in  from  six  to  twelve  hours.  The  patients  did  not 
complain  of  pain,  but  there  was  sometimes  a  slight 
burning  in  thj  eye.  The  conjunctivitis  usually  showed 
signs  of  abatement  in  eighteen  to  thirty-six  hours, 
and  it  was  the  exception  when  a  case  lasted  ten 
days. 

Variety    of    Tuberculous    and    Other  Conditions 
Tested. 

The  following  diseases  were  tested  for  the  oph- 
thalmic reaction : 

I.  Pulmonary  tuberculosis.  2.  Tuberculous  glands 
of  the  neck.  3.  Tuberculous  peritonitis.  4.  Tuber- 
culous bone  diseases  of  various  kinds.  5.  Pertus- 
sis. 6.  Lobar  pneumonia.  7.  Bronchopneumonia. 
8.  Bronchitis  (acute  and  chronic),  g.  Asthma.  10. 
Rheumatism.  11.  Chorea.  12.  Nephritis  (acute, 
following  scarlet).  13.  Endocarditis.  14.  Ente- 
ritis. 15.  Gastroenteritis.  .16.  Malnutrition.  17. 
Marasmus.  18.  Anaemia.  19.  Rickets.  20.  Con- 
genital syphilis.    21.  Catarrhal  jaundice. 

It  has  been  stated  by  other  observers  that  the 
ophthalmic  reaction  is  present  in  congenital  syphilis 
and  rickets,  but  of  all  the  cases  of  these  diseases 
within  my  experience,  I  have  yet  to  see  one  positive 
reaction  except  where  complications  existed. 

The  patients  tested  were  those  clinically  tubercu- 
lous, which  included  pulmonary  tuberculosis  where 
the  bacilli  were  present,  tuberculous  peritonitis, 
tuberculous  glands  of  the  neck,  tuberculous  bone 
disease.  Under  this  heading  were  fourteen ;  all  gave 
positive  reactions. 

Very  suspicious  cases  included  those  with  sus- 
picious signs  in  the  chest,  cases  with  chronic  bron- 
chitis, with  malnutrition  and  anaemia,  or  chronically 
enlarged  or  suppurating  glands  of  the  neck  ;  patients 
having  a  slight  intermittent  fever  which  could  not 
be  accounted  for.    Of  these  thirteen  or  ninety  per 


cent,  gave  positive  reactions.  Less  suspicious  cases 
were  those  with  anaemia  malnutrition,  with  enlarged 
cervical  glands,  chronic  bronchitis,  with  family  his- 
tory of  tuberculosis,  often  having  adenoids  and  hy- 
pertrophied  tonsils,  and  possibly  indefinite  symptoms 
which  might  point  to  a  tuberculous  condition.  Of 
these  there  were  loi  with  eighteen  positive  reac- 
tions. The  age  of  the  children  tested  was  from  three 
months  to  ten  years,  and  the  youngest  that  gave  a 
positive  reaction  was  five  months.  The  reactions 
which  occurred  in  the  babies  were  all  mild.  There 
were  218  cases  tested,  forty-five  of  which  were  posi- 
tive and  173  negative.  There  were  eight  severe  re- 
actions and  thirty-seven  mild  ones.  In  a  number  of 
cases  a  second  test  was  made  in  the  other  eye ;  all 
patients  who  reacted  to  the  first  test  reacted  to  the 
second.  Patients  who  did  not  react  to  the  first  test 
did  not  react  to  the  second  test.  Practically  all 
those  giving  positive  .reactions  showed  signs  indi- 
cating tuberculosis  in  some  form. 

Of  fifty-four  cases  under  one  year  nine  were  posi- 
tive. Of  sixty-three  cases  from  one  to  three  years, 
fifteen  were  positive.  Of  thirty-eight  cases  from 
three  to  six  years,  seven  were  positive.  Of  sixty- 
three  cases  from  six  to  ten  years,  fourteen  were 
positive. 

All  clinically  tuberculous  gave  positive  reactions. 
Ninety  per  cent,  of  the  very  suspicious  cases  gave 
a  positive  reaction,  eighteen  per  cent,  of  the  less  sus- 
picious cases  gave  a  positive  reaction.  And  of  the 
eighty-nine  patients  with  slight  ailments  and  other 
diseases  none  gave  a  positive  reaction. 

Schick,  after  exhaustive  experimental  work,  be- 
lieves that  a  local  reaction  is  less  apt  to  fail  than  a 
general  constitutional  reaction,  as  he  says  that  in 
no  case  where  tuberculosis  has  been  excluded  has  a 
local  reaction  been  present. 

Dr.  J.  Comby  subjected  132  infants  to  the  oph- 
thalmoreaction, of  which  sixty-two  reacted  and  sev- 
enty failed  to  react.  Of  those  that  reacted  he  after- 
wards had  four  autopsies  and  confirmed  the  diag- 
nosis of  tuberculosis.  Autopsies  held  in  six  cases 
that  did  not  respond  to  the  test  showed  entire  ab- 
sence of  tuberculous  lesions. 

Barney  and  Brooke  tested  321  soldiers,  including 
250  tuberculous  cases,  and  got  ninety-eight  per  cent, 
of  reactions  in  active  cases,  twenty-three  per  cent, 
in  apparently  cured  cases,  and  ten  per  cent,  in  non- 
suspects.  This  would  plainly  seem  to  indicate  that 
the  reaction  is  dependent  upon  the  tubercle  poison 
in  the  body.  Barney  and  Brooke  consider  that  in 
general  the  diagnostic  value  of  the  ophthalmoreac- 
tion is  as  great  as  that  of  the  \\"idal  test  in  typhoid 
fever. 

The  test  is  of  special  value  in  diagnosis  where 
slight  signs  at  the  apex  of  the  lung  exist,  no  bacilli 
being  present  in  the  sputum,  or  where  no  sputum 
is  obtainable.  In  cases  where  the  lesion  is  outside 
the  lungs,  as  for  instance  the  bones,  glands,  etc.,  it 
is  of  value. 

The  test  may  indicate  clinically  active  or  clinically 
inactive  tuberculosis,  and  thus  although  a  tubercu- 
lous focus  may  be  present  in  the  body,  it  may  be  in- 
active, and  the  patient  may  be  suffering  from  an- 
other trouble  or  be  apparently  well. 

We  know  that  tuberculosis  in  infancy  and  child- 


February  20,  iprg.] 


IVILE:  AMYLURIA. 


379 


hood  is  largely  a  disease  of  the  lymph  nodes,  and 
in  this  respect  and  in  man\'  \\a\s  differs  from  that 
of  adult  life  and  is  more  difficult  of  diagnosis. 

We  know  also  that  virulent  bacilli  may  be  pres- 
ent in  life  without  showing  lesions  at  autopsy. 

As  with  the  adult,  so  it  is  with  the  child ;  the  ear- 
lier the  diagnosis  is  made  and  the  earlier  treatment 
is  instigated  the  better  will  be  the  ultimate  result, 
and  thus  we  see  the  importance  of  an  early  diag- 
nosis. 

In  conclusion  I  would  say  we  have  in  the  oph- 
thalmoreaction a  most  valuable  aid  to  the  diagnosis 
of  tuberculosis  in  children  in  its  various  and  early 
forms,  which  is  both  reliable  and  safe  when  used 
with  care.  While  this  test  is  not  infallible  and 
should  never  take  the  place  of  a  physical  examina- 
tion, it  is  often  more  accurate  than  the  ear  or  per- 
cussion finger  in  early  pulmonary  cases,  and  by 
demonstrating  a  negative  result  is  far  more  satis- 
factory than  a  negative  sputum  examination. 

Although  there  have  been  a  few  cases  reported 
of  permanent  injury  to  the  e\e  or  a  prolonged  in- 
flammation of  the  conjunctiva  these  occurrences 
have  been  exceedingly  rare,  and  taking  into  consid- 
eration the  fact  that  this  test  has  been  used  with 
safety  in  thousands  of  cases  all  over  the  world,  we 
should  perhaps  set  down  the  few  ill  results  to  errors 
in  technique,  the  test  having  been  used  in  a  diseased 
eye.  The  ophthalmoreaction  is  a  simple  method  of 
diagnosis  which  any  practicing  physician  can  carry 
out.  making  it  possible  for  him  to  confirm  or  ex- 
clude a  diagnosis,  and  with  no  danger  of  affecting  a 
tuberculous  lesion  or  causing  constitutional  symp- 
toms, as  the  reaction  is  purely  a  local  one. 

142  West  Sevextv-eighth  Street. 


PRELI.MIXARY  NOTE  ON  STARCH  IX  THE 
URINE,  AMYLURIA. 

Bv  Ir.\  S.  Wile.  M.  S..  M.  D.. 
New  York. 

Clinical   Pathologist,   Children's  Department.  Vanderbilt  Clinic. 

The  presence  of  starch  granules  in  urine  has  been 
noted  by  innumerable  observers.  The  general  con- 
ception of  such  findings  has  been  that  the  starch 
granules  are  accidental  and  result  from  contamina- 
tion by  starch  from  dusting  powder,  underwear, 
etc.  It  is  the  purpose  of  this  preliminary  note  to 
establish  the  existence  of  a  true  amyluria  or  the 
passage  of  starch  granules  through  the  kidney  into 
the  urinary  excretion. 

Bonders,  in  1859,  noted  that  starch  granules  pass 
over  into  the  blood  of  frogs  after  being  absorbed 
from  their  intestines. 

Halford.  in  1868,  reported  the  case  of  a  man,  fifty- 
three  years  old,  suffering  from  anasarca,  whose 
urine  always  contained  starch  granules.  The  urine 
was  secured  after  washing  the  man's  penis  thor- 
oughly and  inserting  it  into  a  bottle  so  as  to  exclude 
outside  contamination. 

Hirsch  (1906)  determined  that  potato  or  wheat 
starch  ingested  raw  is  passed  out  in  part  through 


the  kidneys  of  healthy  men  and  dogs.  He  also  re- 
covered starch  granules  from  the  blood.  Dogs' 
urine  contained  numerous  granules  while  that  of 
men  showed  a  less  amount.  A  fifteen  dav  faster 
after  ingesting  250  grammes  of  raw  potato  starch 
presented  many  starch  granules  in  his  urine  one  and 
a  quarter  hours  after  eating  the  starch.  The  gran- 
ules were  unchanged. 

Beale,  in  1864,  stated  that  "certain  cases  have 
been  recorded  in  which  it  was  maintained  that  the 
starch  granules  present  in  the  urine  had  passed  from 
the  kidney ;  but  it  need  scarcely  be  said  that  such  an 
origin  is  very  improbable,  if  not  quite  impossible." 

Reichardt  and  W.  Leube  found,  in  the  urine  of 
diabetics,  a  substance  turning  red  with  iodine  and 
reducing  copper  after  a  long  boiling.  Reichardt  re- 
garded the  substance  as  erythrodextrin  :  Leube  con- 
sidered it  glycogen. 

A'on  Xoorden  writing  on  diabetes  in  the  XX  Cen- 
tury Practice  of  Medicine  mentions  that  "starch 
cannot  be  absorbed  as  such  and  must  first  be  decom- 
posed by  a  process  of  fermentation  into  easily  solu- 
ble carbohydrates."  Holland  comments  that  "such 
objects  as  large  globules  of  free  oil  and  starch  gran- 
ules and  vegetable  cells  are  obviously  extraneous." 

The  general  attitude  of  observers  has  been  not  to 
question  the  possibility  of  starch  passing  through 
the  kidneys.  Tradition  has  carried  us  on  to  regard 
starch  in  the  urine  as  an  extraneous  substance. 

Leube  has  determined  that  bacteria  pass  through 
the  blood  and  kidneys  to  cause  a  bacteriuria.  Fat 
passes  through  the  kidney  to  cause  lipuria  and 
chyluria.  Rieder  and  Delepine  determined  that 
lipuria  can  be  caused  by  the  ingestion  of  large 
amounts  of  fatty  substances  as  cod  liver  oil,  etc. 

While  Ebstein  has  considered  .starch  in  the  urine 
under  the  head  of  contaminations,  he  remarks  that 
they  are  found  especially  in  the  urine  of  young  in- 
fants. The  inference  is  of  course  that  it  results 
from  powdering  the  genitalia.  Dusting  powders 
have  seldom  been  investigated  to  determine  whether 
or  not  a  starch  powder  was  used  in  specific  cases. 
Talcum  powders  as  a  rule  contain  no  starch. 

Rolfe  has  referred  to  our  pcrfunctorv  examina- 
tions of  urine,  noting  that  we  are  "content  with  de- 
termining the  presence  or  absence  of  albumin  and 
sugar,  the  nature  of  deposited  matters  and  recording 
the  specific  gravity  and  reaction  without,  however, 
reference  being  made  to  the  conditions  as  regard 
time,  food,  etc..  at  which  the  urine  was  passed." 

]\Iy  observations  have  been  based  in  part  upon  the 
urine  of  infants  and  children  because  of  the  large 
amount  and  variety  of  carbohydrate  food  supplied 
to  them.  Much  of  the  work  has  been  done  at  the 
Babies'  Hospital  through  the  courtesy  of  Dr.  L. 
Emmett  Holt  and  the  cooperation  of  Dr.  Josephine 
Hemenway  and  her  staff  of  resident  physicians. 

Amvluria  has  been  found  fifty  times  in  thirty-five 
children  under  observation.  A'arious  precautions 
were  taken  to  exclude  contamination  and  ensure 
favorable  conditions  for  fair  observations,  i.  Urine 
from  males  only  was  used.  2.  Lycopodium  was  used 
as  a  dusting  powder.  3.  Penis  washed  with  a  flow 
of  water  before  securing  specimen.  4.  Penis  inserted 
into  a  clean  bottle  and  held  in  place  through  the  use 


38o 


EGBERT:  ASTHMA. 


[\e\v  York 
Mei/Kal  Journal. 


of  adhesive  straps.  5.  Bottles  were  covered  imme- 
diately after  the  urine  was  secured.  6.  The  writer 
was  kept  in  ignorance  of  the  foods  used  until  after 
his  observations  were  completed.  7.  All  centrifuge 
tubes,  test  tubes,  glass  slides,  etc.,  were  tested  for 
starch  before  utilizing  them  for  the  work. 

A  resume  of  my  preliminary  observations  is  as 
follows : 

1.  Starch  granules  are  absent  in  the  urine  of 
breast  fed  infants. 

2.  Starch  granules  are  frequently  present  in  the 
urine  of  infants  on  carbohydrate  food. 

3.  The  degree  of  amyluria  varies  with  the  nature 
and  preparation  of  the  food,  the  quantity  ingested, 
and  the  condition  of  the  individual. 

4.  Starch  in  urine  at  times  gives  a  reaction  simu- 
lating that  of  albumin. 

5.  Starch  passing  through  the  kidney  may  cause 
albuminuria  with  casts. 

6.  Amyluria  does  exist,  and  starch  in  the  urine 
is  not  necessarilv  of  extraneous  origin. 

Hirsch's  experiments  with  adults  have  been  re- 
peated with  similar  results,  the  finding  of  an  amy- 
luria. One  interesting  case  was  a  woman  with  a 
perverted  taste  for  laundry  starch  from  whom  urine 
was  secured  through  courtesy  of  Dr.  Hale.  All  pos- 
sible precautions  were  observed  in  securing  the 
specimen.  Starch  granules  similar  to  those  of  laun- 
dry starch  were  found  in  the  urine.  In  two  healthy 
adults  a  transient  albuminuria  was  noted  to  accom- 
pany the  amyluria  after  ingesting  125  grammes  of 
raw  corn  starch. 

2493  Broadway. 


ASTHMA  A  NASAL  DISEASE.* 

By  J.  HoBART  Egbert,  A.  M.,  M.  D., 
Willimantic,  Conn., 
Oculist,  Aurist,  and  Laryngologist  to  St.  Joseph's  Hospital;  etc. 

i\Iost  physicians  appear  to  be  firmly  rooted  in  the 
belief  that  asthma  is  incurable.  Doubtless,  all  pres- 
ent here  this  evening  can  recall  cases  that  have  re- 
sisted their  every  effort  at  more  than  temporary  re- 
lief. All  have  seen  the  stricken  and  suffering  ones. 
The  chronic  asthmatic  struggling,  with  tense  mus- 
cles and  protruding  eyeballs,  for  breath  during  a 
severe  paroxysm  of  spasmodic  "bronchial"  asthma 
is  a  picture  over  which  many  of  us  have  pondered, 
sympathetically,  in  childhood.  The  odor  of  burn- 
ing stramonium,  nitre  paper,  and  cubebs  arc  famil- 
iar to  the  olfactory  sense  of  all  practitioners,  and  the 
mere  mention  of  them  calls  again  to  mind  the  dis- 
tressing scene  just  noted.  Is  it  strange  that,  after 
passing  through  various  attacks,  your  asthmatic  pa- 
tients no  longer  call  you  to  attend  them  during  their 
periodical  suffering?  Have  you  been  able  to  give 
them  the  relief  they  crave?  Is  it  not  true  that  they 
practically  all  employ  some  proprietary  remedy, 
instead  of  your  prescription,  for  relief  during  the 
paroxysms,  and  that  they  have  been,  or  are  even 
now,  consuming  some  nostrum  advertised  to  cure 
their  infirmity  or  exploiting  a  vaunted  cure  recom- 

"  Read  Ix  fore  llu-  VVilliiiiantic  Tity  .Medical  Society,  December  2, 
1908. 


mended  by  some  fellow  sufferer,  instead  of  looking 
to  you  for  further  benefit?'    Even  if  you  are  ready  to 
declare  asthma  incurable,,  you  will  find  the  suffer- 
ing ones — at  least  in  practice — still  clinging  to  some 
"straw"  of  hope. 

I  do  not  wish  to  appear  too  arbitrary  or  too  radi- 
cal in  the  presentation  of  my  own  ideas  and  my 
own  interpretation  of  clinical  facts,  especially  in  the 
present  instance,  where  they  dift'er  widely  from  the 
ancient  theories  and  doctrines  in  relation  to  the 
aetiology  and  treatment  of  asthma — which  teachings 
and  doctrines  are  still  taught  to  medical  students 
and  presented  in  the  very  latest  textbooks  on  theory 
and  practice.  For  this  reason  I  shall  not  urge  that 
all  cases  of  spasmodic  asthma — that  condition  com- 
monly known  as  merely  "asthma."  and  which  is 
characterized  by  recurring  spasmodic  attacks  of  dis- 
tressing expiratory  dyspnoea  continuing  a  few  hours 
or  even  a  few  days — I  shall  not  urge  that  all  cases 
of  true  spasmodic  asthma  are  of  nasal  origin,  but  I 
must  contend  that  all  cases  manifesting  these  dis- 
tressing attacks  zvliich  I  have  Jiad  opportunity  to  ex- 
ainiiic — and  they  are  many — have  presented  definite 
nasal  lesions ;  and,  further,  that  among  the  sufferers 
from  spasmodic  asthma  who  have  come  under  my 
observation  and  care,  all  who  have  submitted  to  op- 
eration or  radical  treatment  of  the  nasal  lesion  have 
been  either  entirely  cured  of  their  asthma  or  defi- 
nitely relieved  as  to  the  frequency  and  severity  of 
the  attacks.  From  these  facts  I  deduce  that 
"asthma"  (so  called)  is  not  a  definite  disease  but 
rather  a  symptom,  and  that  true  spasmodic  asthma  is 
a  definite  symptom  of  nasal  deformity  or  disease. 

If  you  cannot  mentally  recall  the  words,  kindly 
refer  to  your  manuals  or  textbooks  and  observe 
what  is  said  of  the  pathology — the  local  lesion — of 
"asthma."  Permit  me  to  quote  briefly  from  a  stand- 
ard textbook  on  practice  issued  this  year  and  bear- 
ing "1908"  on  its  title  page  as  the  year  of  publica- 
tion. More  than  four  pages  are  devoted  to  the  gen- 
eral consideration  of  asthma — which  is  described  as 
a  definite  affection — yet,  under  the  heading  Path- 
ology, I  read  :  "Except  in  the  presence  of  bronchitis 
or  other  affection,  there  are  no  structural  changes. 
The  attacks  consist  in  spasm  of  the  muscular  coat 
with  vasomotor  turgcscence  of  the  mucus  coat  of 
the  bronchi,"  Does  not  this  very  absence  of  path- 
ological change  in  the  region  of  chief  manifestation, 
the  periodical  recurrence,  the  uncertainty  and  inef- 
ficiency of  routine  methods  of  treatment,  all  point 
in  no  uncertain  manner  to  a  definite  causative  lesion 
existing  elsewhere  in  the  body,  and  stamp  the  re- 
spiratory disturbance  as  nothing  more  than  a  symp- 
tom and  unworthy  of  being  dignified  as  a  distinct 
aft'ection?  Add  to  this  constructive  logic  the  nat- 
ural deduction  \Yhich  must  follow  from  a  considera- 
tion of  cases  in  which  asthmatic  attacks  the  most 
severe  and  which  have  been  recurring  with  more  or 
less  regularity  for  many  years  have  been  at  once 
and  forever  ended  by  nasal  surger>-,  and  it  seems  to 
me  that  we  are  not  only  warranted  in,  but  compelled 
to,  the  assertion  that  asthma  is  not  a  distinct  disease 
but  a  symptom,  and  often  the  chief  symptom  of 
nasal  deformity  or  disease.  Even  so,  however,  we 
do  not  consider  .the  term  "asthma"  properly  applied 
to  those  attacks  of  dvspiKca  which  occur  in  emphy- 
sema, chronic  bronchitis,  vahular  disease  of  the 


February.  20,  1909.]  EGBERT:  ASTHMA. 


heart,  chronic  nephritis,  and  malarial  toxaemia,  any 
more  than  it  should  be  applied  to  the  shallow  and 
labored  respiration  in  ascites  or  the  dyspncea  occa- 
sioned by  obstruction  of  the  larynx  in  laryngeal 
diphtheria.  Attacks  of  spasmodic  asthma  from 
nasal  disease  may  in  time  lead  to  emphysema,  car- 
diac dilatation,  and  other  functional  and  organic  dis- 
turbances, and  may  even  be  complicated  by  cardiac 
or  renal  disease,  thus  obscuring  more  completely  the 
path  to  the  discovery  and  correction  of  the  original 
cause. 

It  would  be  superfluous  for  me  to  present  to  you 
the  clinical  picture  portrayed  in  an  attack  of  spas- 
modic asthma.  The  manifestations  are  markedly 
characteristic  and  doubtless  familiar  to  you.  They 
often  occur  at  night  and  not  infrequently  appear  to 
follow  some  trivial  exciting  cause — as  the  visit  of 
an  unexpected  guest,  attending  church  or  the  the- 
atre, riding  in  a  carriage  or  on  a  train,  etc.  The 
attacks  i^ractically  always  end  the  same.  After 
struggling  in  fearful  agony  for  breath  for  from  one, 
four,  six,  ten,  to  even  thirty-six  hours,  the  victim 
manages  to  expectorate  a  small  quantity  of  whitish, 
frothy  mucus.  Then  follows  a  moister  cough  and 
the  expectoration  of  mucus  and  mucopurulent  secre- 
tion. The  respiratory  relief  is  now  apparent,  and 
the  patient  begins  to  breathe  more  deeply  and  less 
rapidly,  and  the  expirations  no  longer  jump  with 
characteristic  stress  and  suddenness  into  inspiratory 
effort.  As  the  relaxation  progresses,  the  patient  is 
often  seized  with  an  irresistible  desire  to  urinate  and 
frequently  does  so  involuntarily. 

In  an  attack  of  asthma  there  is  a  spasmodic  con- 
traction of  the  smaller  bronchial  tubes.  The  condi- 
tion is  one  of  a  reflex  neurosis  and  results  from 
stimulation  from  without  and  transmitted  along  the 
nerves  supplying  the  muscular  walls  of  the  bronchi. 
There  is  also  a  vasomotor  disturbance,  manifested 
by  a  congestion  of  the  lining  mucous  membrane  of 
the  bronchi,  which  determines  a  still  further  reduc- 
tion of  the  calibre  of  the  tubes  and  adds  its  effect  in 
the  prevention  of  the  free  passage  of  air  through 
them.  The  locality  in  which  the  nerve  stimulation 
which  determines  this  contraction  and  congestion  is 
applied  is  untliin  the  nasal  fosses. 

It  is  not  within  the  province  of  the  present  paper 
to  enter  into  a  detailed  explanation  of  the  physio- 
logical relation  between  the  mucous  surfaces  of  the 
nares  and  the  vessels  and  mviscular  elements  of  the 
lower  respiratory  tract.  Anatomical  investigations 
and  carefully  conducted  experiments  upon  lower 
animals,  as  well  as  results  obtained  by  operations 
performed  upon  human  subjects,  conclusively  show 
that  a  very  important  relation  does  exist,  and  that 
elements  of  the  s\-nipathetic  system  supply  the  con- 
necting chain. 

The  nerves  "to  the  lungs  are  derived  from  the  tenth 
cranial  (vagus  or  pneumogastric)  and  the  sympa- 
thetic system — forming  the  anterior  and  posterior 
pulmonary  plexuses.  Filaments  from  these  plexuses 
are  distributed  to  each  lobule,  following  the  distribu- 
tion of  the  bronchi  and  having  close  relation  to  the 
"bronchial  vessels.  The  nerves  of  the  nasal  fossse — 
exclusive  of  the  nerve  of  olfactory  sense — are  de- 
'  rived  from  the  fifth  cranial  (trifacial)  and  the  sym- 
pathetic system.  The  nasal  branch  from  the  ophthal- 


mic division  of  the  fifth  reaches  the  saeptum  and 
outer  walls ;  the  anterior  branch  of  the  superior 
maxillary  division  of  the  fifth  may  be  traced  to  the 
inferior  turbinate  bodies  and  the  floor  of  the  fossae. 
Further  nasal  branches,  from  Meckel's  ganglion, 
are,  superior  nasal,  to  middle  and  superior  turbin- 
ates and  upper  portion  of  saeptum ;  nasopalatine,  to 
middle  portion  of  sjeptum ;  and  anterior  palatine  to 
middle  and  inferior  turbinates.  The  olfactory,  or 
first  cranial,  nerve  is  exclusivelv  a  nerve  of  special 
sense-  We  find  it  distributed  to  the  mucous 
( Schneiderian)  membrane  of  the  nose  by  three  ter- 
minal divisions,  an  inner  to  the  superior  portions  of 
the  saeptum  of  the  nose,  a  middle  to  the  roof  of  the 
fossae,  and  an  outer  to  the  superior  turbinated  and 
portion  of  middle  turbinated  bones. 

Through  the  sympathetic  chain,  then,  and,  indi- 
rectly, through  the  vagus  itself,  the  cavities  of  the 
nose  are  linked  in  nerve  connection  with  the  larynx, 
the  trachea,  the  lungs,  and  the  general  thoracic  cav- 
ity.    Years  ago  Graham  Brown  and  Roy  demon- 
strated that  section  of  one  vagus  caused  a  marked 
expansion  of  the  bronchi  of  the  corresponding  lung, 
but  that  stimulation  of  the  peripheral  (or  body)  end 
of  the  divided  vagus  caused  a  poiverful  contraction 
of  the  bronchi  of  both  lungs!    Subsequent  experi- 
ments have  shown  that  stimulation  of  the  central 
end  of  a  divided  vagus,  the  other  nerve  being  intact, 
also  occasions  some  contraction  of  the  bronchi,  while 
stimulation  applied  along  the  course  of  an  tindii'ided 
nerve  may  produce  actii'c  contraction.  Reasoning" 
further  along  the  same  line,  it  is  not  difficult  to  un- 
derstand how  irritation  (stimulation,  if  you  please,) 
of  the  exceedingly  sensitive  nerves  distributed  in  the 
nasal  mucous  membrane  can  set  up  contraction  of 
the  bronchi  and  unbalance  normal  respiration.  That 
this  can  and  does  occur  is  rather  positively  shown 
by  the  finding,  in  cases  of  recurrent  spasmodic 
asthma,  of  definite  nasal  disturbance  and  the  relief 
of  the  respiratory  disturbance  through  the  removal 
of  the  nasal  irritation. 

Let  us  consider  for  a  moment  the  nasal  conditions 
most  commonly  found  as  exciting  causes  of,  or,  at 
least,  concurrent  with,  asthma.  In  not  a  few  cases 
of  asthma  nasal  polyps — usually  of  the  mucous  va- 
riety— will  be  found.  Thorough  removal  of  these 
growths  not  infrequently  gives  relief  from  the  at- 
tacks, but  as  polyps  are  always  the  progeny  of 
nasal  deformity  or  disease,  it  is  usually  necessary 
to  carry  the  treatment  further  and  to  correct,  as  far 
as  possible,  the  condition  which  stimulates  their 
growth.  Ecchondroses,  spurs,  bands,  spreads,  and 
deflections  of  the  nasal  saeptum  will  call  for  removal 
or  reduction,  as  will  also  hypertrophies  and  deformi- 
ties elsewhere  in  the  fossae.  The  ethmoidal  region 
will  demand  attention,  while  drainage  of  the  acces- 
sory sinuses  must  be  maintained.  Some  cases  of 
asthma  have  no  polyps  at  all,  but  exhibit  decided  en- 
largement of  one  or  both  middle  turbinates — the 
bones  sometimes  amalgamating  in. some  part  of  their 
course  with  the  cartilaginous  sieptum  and  effectual- 
ly obliterating  the  middle  meatus.  A  still  smaller 
number  of  cases  will  show  only  an  oversensitive 
area  or  focus  in  some  portion  of  the  nasal  mucous 
membrane,  without  obstruction  or  serious  deform- 
ity, as  is  also  true  in  certain  cases  of  vasomotor 


382 


EGBERT:  ASTHMA. 


[Xew  \ork 
Medical  Journal. 


rhinitis,  or  "hay  fever" — to  which,  indeed,  asthma  is 
more  or  less  closely  related  in  aetiology  and  success- 
ful treatment. 

In  addition  to  the  nasal  disturbance,  there  are  two 
factors,  if  not  of  primary  cause,  at  least  of  perpet- 
uation of  asthma,  to  which  we  would  direct  atten- 
tion, first,  a  neurotic  habit  and,  second,  acquired 
nonresistance.  The  first  of  these  conditions  may  be 
said  to  exist  as  a  predisposing  cause,  for  it  is  true 
that  the  same  nasal  conditions  that  determine  asth- 
matic attacks  in  one  individual  do  not  do  so  in  an- 
other. The  second  factor  may  result  from  inherent 
weakness  and  reduced  vitality,  the  influence  of  en- 
vironment or  occupation,  and  may,  unquestionably, 
be  induced  by  the  treatment  employed  for  the  re- 
lief of  the  asthma  itself.  The  remedies  most  com- 
monly employed  to  relieve  asthma  are  enervating  de- 
pressants, while  not  a  few  of  the  agents  employed  by 
inhalation  are  directly  irritating  to  the  nasal  mucous 
membrane  or  otherwise  determine  a  loss  of  nerve 
and  tissue  tone.  Lobelia,  stramonium,  tobacco,  and 
allied  agents  which  are  capable  of  .allaying  the 
paroxysms  of  asthma,  do  so  by  depressing  the  pul- 
monary nerve  supply  to  the  verge  of  narcotism,  thus 
often  effecting  more  injury  than  benefit  by  occasion- 
ing general  systemic  derangement  and  by  further 
debilitating  an   already  atonic   nerve  organization. 

The  nitrites  are  open  to  similar  objections  for.  while 
these  agents  do  not  produce  the  same  profound  cen- 
tral narcotism,  they  exert  a  similar  paralyzing  influ- 
ence on  the  peripheral  ner\'e  supply  of  the  lungs  and 
so  long  as  this  is  maintained  asthmatic  paroxysms 
mav  be  held  in  control.  Pilocarpine  is  supposed  to 
act  somewhat  similarly  to  the  nitrites,  though  this 
drug  has.  oerhaps,  a  more  logical  application  in  that 
it  reduces  visceral  blood  pressure  by  occasioning 
dilatation  of  the  peripheral  capillaries.  Its  use,  how- 
ever, is  not  without  danger,  and  nausea,  extreme  de- 
pression, and  collapse  may  follow  its  exhibition  in 
regular  therapeutic  doses.  The  uselessness  of  mor- 
phine, chloral,  chloroform,  etc.,  in  asthma,  except  in 
the  temporary  amelioration  of  acute  symptoms,  is 
as  apparent  as  the  dangers  from  habit,  etc..  result- 
ing from  their  incautious  use. 

.Admitting  the  aetiolog}'  of  asthma  as  herein  pre- 
sented, its  rational  treatment  is  plain,  to  wit,  to  cor- 
rect, as  far  as  possible,  all  existing  nasal  disturb- 
ance ;  to  strengthen  the  nervous  system  ;  and  to  elim- 
inate all  practices  and  general  conditions  which  con- 
tribute to  the  ])erpetuation  of  the  disorder.  The 
nasal  treatment  has  already  been  briefly  outlined.  I 
hold  this  to  be  of  prime  importance.  The  means 
employed  to  elevate  the  tone  of  the  nervous  system 
and  to  combat  neurasthenia  are  both  general  and 
therapeutic.  Among  the  former  I  would  include 
cold  morning  baths,  congenial  environment,  change 
of  scene  and  climate,  etc.  Regardless  of  the  fact 
that  there  is  plainly  a  persistent  neurotic  clement 
manifested  in  many  cases  of  asthma,  I  hold  the  ex- 
citing cause  to  be  intrinsic  rather  than  extrinsic  and 
find  but  little  evidence  of  a  truly  psychological  fac- 
tor. Typical  spasmodic  asthma  is  quite  common  in 
childhood — at  an  age  when  the  psychological  ele- 
ment is  admittedly  in  abeyance.  Among  children 
the  nasal  lesion  or  disturbance  is  usually  very  mani- 
fest and,  as  with  adult  sufferers,  should  receive  early 
and  careful  attention. 


The  medicinal  agents  which  will  be  found  to  be 
most  generally  useful  in  the  treatment  of  asthma 
are  strychnine,  atropine,  phosphorus,  and  quinine — 
all  nerve  invigorators.  Granting  that  the  nose  has 
received  or  is  receiving  attention,  the  patient,  if  an 
adult,  may  well  receive  strychnine,  grain  1/50,  and 
atropine,  grain  1/150,  hypodermically,  every  day, 
and  the  dose  increased  to  1/30  of  a  grain  of  strych- 
nine and  i/roo  gram  of  atropine.  This  is  continued 
daily  until  the  physiological  effects  of  the  strychnine 
begin  to  manifest  themselves,  when  the  treatment  is 
administered  hypodermically  every  other  day,  or  the 
mixture  may  then  be  continued  by  the  mouth. 
Strychnine,  in  combination  with  hypophosphites  or 
with  small  doses  of  quinine,  acts  well  with  children.  In 
all  cases  the  rational  general  treatment  is  essentially 
tonic  and  invigorating  and,  as  you  can  readily  see, 
can  be  most  satisfactorily  carried  out.  together  with 
the  local  treatment,  in  hospital  or  sanatorium  prac- 
tice. What  drugs  shall  be  employed  to  mitigate  the 
paroxysms?  If  possible,  none.  In  severe  attacks 
where  it  would  appear  that  something  must  be  done 
to  alleviate  the  immediate  suffering,  paraldehyde  in 
drachm  doses,  by  mouth,  or  morphine  with  atropine, 
hypodermically,  will  afford  relief.  It  is  unnecessary 
to  add  that  the  administration  of  opiates  is.  for  ob- 
vious reasons,  objectionable  in  any  case  and  must 
not  be  followed  as  a  routine  practice. 

The  treatment  of  concurrent  disorders  —  both 
functional  and  organic — will  be  along  established 
lines.  Not  a  few  cases  of  asthma,  especially  among 
those  patients  approaching  or  past  middle  life,  will 
present  some  cardiac,  renal,  or  hepatic  disturbance 
which  must  be  carefully  determined  and  treated,  not 
only  by  such  therapeutic  measures  as  are  indicated, 
but  by  dietetic  and  hygienic  measures  as  well.  A 
uric  acid  diathesis  will  be  found  to  e.xist,  not  infre- 
quently, in  asthmatic  cases  and  should  always  re- 
ceive especial  consideration  and  treatment.  Detri- 
mental and  disturbing  practices — including  the  use 
of  narcotic  and  depressing  drugs  and  inhalations — 
must  be  given  up.  To  this  end.  it  will  be  necessary 
for  the  attending  physician  to  inquire  rather  care- 
fully into  the  life  and  habits  of  individual  sufiferers 
(vide  Case  II).  A  warm,  dry  climate  is  known  to 
be  beneficial  to,  and  in  some  cases  apparently  cura- 
tive of,  asthma  (vide  Case  III).  This  is  not  strange 
when  we  consider  the  beneficial  effect  of  such  cli- 
mate upon  nasal  disturbances,  nerves,  and  pulmon- 
ary tissues. 

And  now,  in  conclusion  and  in  practical  demon- 
stration of  the  doctrines  herein  set  forth,  kindly  per- 
mit me  to  place  before  you  abbreviated  clinical  rec- 
ords of  a  few  typical  cases,  selected  from  a  rather 
considerable  number  of  cases  of  asthma  which  have 
come  under  my  personal  observation  and  treatment 
during  the  past  fifteen  years.  The  cases  from  your 
own  city,  examined  and  treated  during  the  past  year, 
mav  prove  especially  interesting  to  you. 

Case  I.— During  the  month  of  September,  1906,  Miss 
M.  C,  of  Newark.  N.  J.,  age  twenty-four  years,  was  re- 
ferred to  me  by  her  attending  physician  in  order  that  I 
might  examine  her  eyes,  with  a  view  to  determining 
whether  or  not  there  existed  any  ocular  condition  that  could 
influence  the  atslima  from  which  she  was.  and  had  been 
for  years,  a  sufferer.  Inquiry  into  the  previous  history  of 
the  case  showed  that  patient  had  been  afflicted  with  asthma 
for  nineteen  years — or  since  she  was  five  years  old.  At 


February  _>o.  1909.  | 


EGBERT: 


ASTHMA. 


first  the  attacks  had  not  been  very  frequent,  occurring  on 
an  average  of  once  in  every  six  weeks  or  two  months.  For 
a  number  of  years,  about  ten,  however,  the  attacks  had 
been  more  frequent,  sometimes  recurring  as  often  as  twice 
a  week,  though  averaging  one  attack  in  about  two  weeks. 
As  a  rule  they  followed  some  trivial  affair — as  attending  the 
theatre  or  a  party,  riding  on  the  railroad,  etc.  Patient's 
appearance  was  good.  Family  history  was  good.  Exami- 
nation of  eyes  proved  negative,  beyond  an  inconsiderable 
amount  of  symmetrical  hyperopia  astigmatism,  for  the  cor- 
rection of  which  patient  had  already  worn  glasses.  In  view" 
of  the  history  of  the  case,  the  nose  and  throat  were  exam- 
ined. The  latter  presented  nothing  of  special  interest,  but 
the  nasal  examination  disclosed  the  fact  that  the  anterior 
heads  of  the  middle  turbinates  were  recurved  and  exten- 
sively hypertrophied,  the  left  one  being  impacted  between 
the  outer  nasal  wall  and  the  cartilaginous  saeptum — which 
latter  was  spread  and  somewhat  inflected  at  this  point. 
Removal  of  these  hypertrophies,  for  the  relief  of  the 
asthma,  was  advised  and  effected  in  two  sittings,  a  week 
apart,  the  left  side  being  operated  first.  Since  the  first 
operation  the  patient  has  had  no  asthma — or,  at  least,  had 
not  had  up  to  a  couple  of  months  ago,  when  I  last  heard 
from  her.  The  cure  was  prompt  and  apparently  complete. 
The  only  constitutional  treatment  employed  in  this  case 
was  a  nerve  tonic  of  strychnine  and  phosphorus. 

Case  II. — This  case  is  quite  unlike  the  preceding  one  and 
is  here  mentioned  to  show  the  effects  of  injurious  practices 
•and  conditions  resulting  therefrom  upon  recurring  attacks 
of  asthma.  It  is  one  of  the  earliest  cases  of  asthma  com- 
ing under  my  care  in  which  the  nasal  condition  w-as  given 
consideration. 

In  the  early  nineties,  while  in  general  practice,  I  was 
called  to  attend  Mr.  F.  S.,  aged  thirty-seven,  a  farmer — or, 
more  correctly,  a  farmer  s  son.  living  with  his  parents, — a 
native  and  resident  of  Hampshire  Countj-.  Massachusetts, 
during  an  attack  of  spasmodic  asthma.  The  patient  was 
known  to  me  as  a  confirmed  alcoholic  of  the  "hard  cider" 
variety.  He  had  been  the  victim  of  asthmatic  attacks  for 
years  and,  as  might  be  expected,  I  found  him  propped  up 
in  a  great  chair,  laboriously  inhaling  the  fumes  of  burning 
narcotic  poisons.  '  Having  administered  to  the  immediate 
exigency  of  the  case,  I  suggested  that  he  call  at  my  office, 
in  the  interval  of  the  attacks,  for  an  examination.  This  he 
did.  and  the  nose  was  found  to  be  the  seat  of  considerable 
hypertrophy  and  deformity  and,  in  addition,  of  mucous 
polyps.  These  latter  were  removed  and  nasal  treatment 
carried  on  with  the  result  that  immunity  from  asthmatic 
attacks  was  secured  for  about  four  months,  when  a  very 
severe  paroxysm,  lasting  about  three  days,  occurred.  The 
patient  had,  under  orders,  desisted  for  a  time  from  cider 
drinking,  but,  as  afterward  developed,  had  returned  to  the 
practice  of  pouring  out  more  or  less  frequent  daily  libations  to 
the  god  of  festivities  about  a  week  before  the  occurrence  of 
the  attack  just  mentioned.  He  then  gave  up  cider  for 
nearly  six  months — giving  attention  meanwhile  to  nasal  and 
general  treatment — and  during  that  time  had  immunity 
from  the  asthma.  He  subsequetly  lapsed  again  and  re- 
turned to  both  his  cider  drinking  and  his  asthma. 

C.\SE  III. — In  the  spring  of  1902,  a  child,  seven  years  of 
age,  came  under  my  observation.  She  had  been  brought 
east  from  Colorado  for  the  treatment  of  an  asthma  with 
which  she  had  been  suffering  since  infancy.  Two  years 
previously,  the  family  had  moved  from  Xew  York  to  Colo- 
rado ill  the  hope  that  the  Colorado  climate  would  benefit 
this  child's  condition.  The  asthma  was,  for  a  time,  relieved 
by  the  change,  and  the  child's  general  condition  manifestly 
improved,  but  the  relief  of  the  asthma  was  not  permanent. 
At  the  time  I  saw  her  in  IQ02,  the  attacks  of  asthma  were 
recurring  on  an  average  of  about  every  two  weeks.  The 
family  history  was  excellent.  On  examination  of  the  chest, 
slight  rnucous  and  sibilant  rales  were  discemable  through- 
out both  lungs.  Examination  of  the  nose  showed  hyper- 
trophic rhinitis — both  inferior  turbinates  being  enlarged — 
and  areas  of  hypersesthesia  in  the  region  of  the  middle 
turbinates.  During  her  stay  in  the  east,  the  child's  nose 
received  treatment,  with  resulting  benefit  to  her  asthma. 
It  was  recommended  that  the  child  be  taken  to  southern 
California.  This  was  done,  and  I  saw  her  there — near  San 
Diego,  in  the  extreme  southern  part  of  the  State— in  1905, 
and  she  had  not  had  an  attack  of  asthma  since  her  arrival 
in  California,  three  years  before. 

Case  IV. — H.,  five  years  of  age  and  residing  in  New  York 


State,  was  brought  to  me  July  28,  1908.  There  was  a  history 
of  asthma  since  infanc\.  The  attacks  were  severe  and  fre- 
quent, latelj'  averaging  almost  one  a  week.  The  child  had 
been  taking  the  "absent  treatment"  for  asthma  furnished  by 
Hayes  of  Rochester  since  last  October.  Paroxysms  were 
typical,  beginning  with  dry  choke  and  wheeze,  wit'ii 
dyspnoea  continuing  from  one  to  three  days,  and  followed 
by  bronchial  exudation,  moist  cough,  etc.  There  w"as  a 
history  of  earache  on  two  or  three  occasions  last  winter, 
since  when  diminution  of  hearing  power  on  the  part  of  the 
child  had  been  observed.  Patient  was  fairly  well  nour- 
ished, family  history  was  good.  Examination  of  chest, 
three  days  after  consummation  of  an  attack,  disclosed  both 
moist  and  sibilant  rales.  Examination  of  throat  showed 
general  tissue  atony,  moderately  enlarged  tonsils,  and  ad- 
enoids in  the  vault  of  the  pharj-nx.  On  examination  of  the 
nose,  the  inferior  turbinates  were  found  hypertrophied, 
and  the  membrane  covering  the  middle  turbinates  con- 
gested and  swollen.  Removal  of  the  adenoids  and  tonsils, 
and  treatment  of  the  nose  was  advised.  August  loth,  op- 
erating at  St.  Joseph's  Hospital,  I  removed  the  adenoids 
and  tonsils  and  cauterized  the  surfaces  of  the  middle  tur- 
binates. The  child  remained  in  Willimantic  only  about  a 
week  after  the  operation.  Strychnine  and  hypophosphites 
were  prescribed.  Returning  home,  he  was  referred  to  a 
local  rhinologist  for  further  nasal  treatment,  and.  about  a 
month  ago,  I  was  advised  that  while  not  then  entirely 
cured,  the  attacks  of  asthma  had  been  greatly  reduced  in 
frequency  and  severity,  that  the  child's  general  health  had 
much  improved,  and  that  there  was  every  promise  of  a 
complete  cure  as  soon  as  the  nasal  condition  could  be  satis- 
factorily controlled — a  matter  presenting  special  difficul- 
ties on  account  of  the  age  of  the  patient. 

Case  V. — Miss  H.,  age  twenty-eight  years,  resident  of 
Willimantic,  was  referred  to  me  by  Dr.  O'Neill,  August  16, 
1908.  There  had  been  numerous  attacks  of  asthma,  occur- 
ring mostly  at  night,  for  about  a  month,  with,  at  times,  dis- 
tressing symptoms  of  vasomotor  rhinitis  and  a  persistent 
cough.  Examination  of  the  nose  revealed  excessive  hyper- 
trophy of  the  anterior  portion  of  the  middle  turbinates,  the 
lining  membrane  of  the  superior  fossje  inflamed  and  exceed- 
ingl}-  irritable,  and,  in  the  region  of  the  entrance  to  the 
right  infund'bulum.  a  few  small  mucous  polyps.  These 
latter  were  removed,  the  hypertrophies  of  the  middle  tur- 
binated bodies  were  reduced  by  successive  cauterizations, 
and  the  irritability  and  inflam.mation  of  the  mucous  mem- 
brane controlled.  There  have  been  no  further  attacks  of 
asthma  and  the  vasomotor  rhinitis  and  cough  have  been  re- 
lieved. Internally,  this  patient  received  strychnine,  grain 
1/50,  and  acidum  nitrohydrochloricum  dilutum.  minims  10, 
well  diluted,  before  meals. 

Case  VI. — Mrs.  X.,  aged  thirty-four,  an  artist  and  resi- 
dent of  New  York  city  and  Hampton,  Conn.,  came  to  me 
this  fall  stating  that  her  nose  needed  treatment  as  her 
asthma  had  returned.  The  history  given  was,  briefly,  as 
follows :  Fiv£  years  ago  she  had  been  stricken  with  asthma 
and  suffered  from  m.ost  severe  attacks  for  two  years,  when 
she  consulted  a  New  York  rhinologist  who  rernoved  from 
her  nose  numerous  polpys,  portions  of  turbinates,  and  sap- 
turn  ecchondroses,  affording  her  complete  relief  from  the 
asthma  until  about  two  weeks  ago,  when  she  had  been 
taken  with  a  moderately  severe  attack  which  was  followed 
by  a  still  severer  paroxysm  two  days  prior  to  her  visit  to 
me.  1  removed  four  polyps  from  the  right  nasal  fossa  and 
one  from  the  left,  and  gave  the  nasal  membrane  palliati\c 
treatment,  since  w  hen  she  has  had  no  return  of  the  asthma. 

\\t  have  already  mentioned  the  close  relationship 
between  vasomotor  rhinitis  and  spasmodic  asthma. 
Xot  a  few  cases  in  which  the  hay  fever  is  com- 
plained of  as  the  chief  disturbance  will  show  histo- 
ries of  at  least  occasional  attacks  of  asthma — thus 
emphasizing  the  nasal  factor  as  the  cause  of  the 
latter  disturbance.  The  following  case  is  illustrative 
of  many. 

Case  VII.— Mrs.  B..  age  thirty-two.  wife  of  a  prominent 
citizen  of  Willimantic.  consulted  me  August  12,  1908.  There 
was  a  history  of  h;.y  fever  everj-  summer  or  fall  for 
past  eight  years,  the  paroj^sms  of  sneezing,  suffu-^ion  etc 
being  occasionally  followed  bv  severe  bronchial  spasms' 
lasting  from  eight  to  twenty-four  hours.    During  the  past 


384 


BASSLER:  GASTROENTERITIC  XEUROSES. 


[New  York 
Medical  Journal. 


five  years  patient  had  obtained  occasional  nasal  treatments 
■each  year  and  had  thus  managed  to  keep  both  the  hay  fever 
and  the  asthma  under  moderate  control.  She  had.  however, 
received  no  j-revious  nasal  treatment  this  summer,  and  recent 
attacks  of  both  hay  fever  and  asthma  had  been  very  disturb- 
ing and  haa  been  further  complicated  by  pain  in  the  left 
car, , at  first  dull  in  character  but  latterly  sharp  and  severe. 
Exami?iation  of  the  ear  disclosed  congestion  along  the 
handle  of  the  malleus  and  further  symptoms  of  subacute 
otitis  media.  Examination  of  the  nose  revealed  hyper- 
trophy and  turgescence  of  both  middle  turbinates,  with 
.superior  deviation  of  the  cartilaginous  sjeptum  to  left,  and 
extremely  oversensitive  areas  in  the  superior  fosss.  The 
nasopharynx  was  the  seat  of  catarrhal  inflammation.  Cau- 
terizations of  the  involved  portions  of  the  middle  turbinates 
and  sensitive  areas  controlled  both  the  hay  fever  and  the 
asthma.  Meanwhile,  of  course,  the  throat  and  ear  received 
due  attention. 

Thus  I  might  go  on,  reviewing  the  records  of 
many  more  cases  of  asthma  which  have  been  un- 
der my  observation  and  care — all  of  which  have 
been  found  to  present  nasal  disturbance  of  a  positive 
nature  and  all  of  which  have  been  treated  as  pri- 
marily nasal,  or  neuronasal,  disease — but  having  al- 
ready presumed  upon  your  time  and  patience  longer 
than  is  really  fair,  I  beg  your  indulgence  while  I 
refer  brieHy  to  but  one  more  case — a  case  which  is, 
so  far  as  I  have  been  able  to  learn,  the  worst  case 
of  asthma  in  this  conrmimity.  This  case  is  not  pre- 
sented because  it  represents  a  cure,  since  oppor- 
tunity for  that  most  fortunate  consummation  has 
not  been  granted  me,  but  because  it  is  broadly 
typical  of  long  standing  asthma  treated  as  a  disease 
rather  than  a  svmptom.  and  because  its  true  jetiol- 
ogy.  so  long  disregarded,  has  been,  to  my  mind,  at 
least,  well  confirmed. 

Case  Vlll. — Mrs.  C.  aged  fort\-two,  resident  of  Willi- 
mantic,  was  persuaded  by  a  friend — this  friend  a  physician, 
though  not  the  patient's  medical  adviser — to  present  herself 
for  nasal  examination  Tiiis  she  did,  October  ist  of  the 
present  year..  The  history  given  was,  briefly,  as  follows : 
Asthma  for  fully  twenty-five  years,  bad  paroxysms,  neces- 
sitating relief  by  hypodermic  injections  of  morphine,  oc- 
curring from  si.x  to  twelve  times  a  year :  with  lesser  at- 
tacks, necessitating  the  use  of  inhalations,  almost  nightly ! 
At  certain  seasons  of  the  year,  almost  daily  attacks  of  hay 
fever  added  to  the  suffering.  In  spite  of  the  twenty-five 
years  of  a<thma,  the  general  appearance  of  the  patient  was 
not  bad,  though,  naturally,  the  nervous  organization  was 
badly  disarranged.  An  examination  of  the  nose  at  once 
revealed  the  presence  of  mucous  polyps  in  the  superior 
fossjE.  hypcrtrophied  middle  turbinates  and  marked  hyper- 
esthesia of  the  mucous  membrane.  The  polyps  were  nu- 
merous but  not  large,  and  I  at  once  removed  a  mass  of 
them  from  each  nostril  and  gave  local  treatment  to  the 
hypersensitive  membrane.  The  patient  was  then  informed 
that  a  number  of  operations  and  treatments  would  be  nec- 
essary in  order  to  remedy  the  exciting  cause  of  her  asthma, 
strychnine  and  nitrf)hydrochloric  acid  prescribed,  and  the 
discontinuance  of  all  narcotics  and  inhalants  enjoined.  She 
came  but  once  more,  at  which  time  more  polyps  were  re- 
moved and  the  nasal  membrane  given  further  treatment. 
Since  then,  October  2nd.  I  have  not  seen  her — though  a 
week  or  so  later  she  telephoned  for  an  appointment  which 
she  did  not  keep.  Whether  she  has  had  radical  treatment 
elsewhere.  1  do  not  know.  Whcllur  her  asthma  is  better  or 
worse,  1  know  not,  but  this  1  do  know,  to  wit,  that  this 
case  presented  suflicient  nasal  involvement  to  warrant  the 
belief  that  therein  rested  the  immediate  and  active  cause  of 
the  asthma  and  that  without  removal  of  this  cause  there 
could  1'c  no  hope  of  lastin?  relief.  Unquestionably,  the 
neurotic  hal)it  was,  in  this  case,  well  established,  and  that 
in  order  to  effect  a  permanent  cure  persistent  tonic  treat 
mcnt — perhaps  even  travel,  or  residence  in  a  pro|)er  climate 
— would  aUd  be  necessary,  i)  it  all  this,  it  seems  to  me. 
would  be  but  a  moderate  pric.-  to  pay  for  relief  from  such 
agoniziiiK  and  almost  continuous  suffering. 

748  Main  Strf.et. 


THE   CO.MMOX    FORMS   OF  GASTROENTERITIC 
NEUROSES;  THEIR  ETIOLOGY  AND 
TREATMENT.* 

B3'  Anthoxy  Bassler,  M.  D., 
New  York. 

In  accepting  your'  kind  invitation  I  have  chosen 
for  the  theme  of  my  paper  a  consideration  of  what 
are  the  most  numerous  of  all  gastroenterological  af- 
fections. Jn  doing  this,  1  shall  transcend  most  timc 
honored  classifications  of  the  past  which  deal  with 
states  of  disturbed  sensations,  secretion,  and  motility 
of  the  gastroenteron,  include  only  those  which  most 
plausibly  seem  to  have  no  organic  change  of  tisstie  as 
reasons  for  their  existence,  and  present  these  along 
lines  of  rather  ordinary  clinical  observation.  Mani- 
festly, it  would  be  quite  impossible  in  a  short  time 
to  accomplish  more  than  just  touch  upon  this  vast 
and  varied  subject,  and  in  doing  this  I  shall  leave 
out  much  that  is  important,  although  I  shall  attempt 
to  dilate  somewhat  upon  the  setiolog)-  of  the  com- 
mon forms  of  neuroses  (since  in  doing  this  thera- 
peutic suggestions  can  be  gleaned)  and  not  consider 
detail  work  in  the  way  of  special  technique  in  the 
diagnosis  of  gastroenteric  affections. 

The  cases  of  true  neuroses  of  the  digestive  canal 
are  seen  in  individuals  old  enough  to  care  for  them- 
selves and  others,  and  young  enough  to  engage  in 
the  many  activities  of  life.  In  the  child  and  those 
advanced  in  years,  while  neither  are  exempt  from 
the  neurotic  conditions,  the  nervous  organisin  of  the 
body  is  less  assailed  or  impressionable  to  the  estab- 
lishment of  neurotic  states  in  the  first,  and  waning 
digestive  power  and  less  activity  of  life,  baneful  ef- 
fects from  them,  or  the  discretion  which  comes  from 
years  and  experience,  grants  somewhat  of  an  im- 
munity to  the  second.  In  these  two  extremes  of 
vears,  digestive  disturbances  are  more  commonly 
due  to  dietetic  errors,  and  in  addition  to  this  in  those 
pa^t  middle  life,  to  organic  or  malignant  affections. 
All  this  means  that  the  neurotic  disturbances  are 
inost  comm.on  among  those  whose  physical  as  well 
as  mental  activities  rule  in  the  nation.  State,  busi- 
ness, and  home.  Consequently  it  is,  that  these  case? 
are  found  mostly  in  those  between  the  twentieth  and 
fortieth  years  of  life,  in  men  somewhat  more  so  than 
in  women,  althotigh  for  reasons  of  the  more  bitter 
complaining  and  sensitiveness  of  the  female  sex.  and 
the  more  time  they  have  at  their  disposal,  the  women 
make  up  the  majority  of  the  slight  and  meditun 
cases  that  we  see. 

The  first  questions  that  must  be  answered  to  one- 
self in  the  care  of  these  conditions  are.  is  the  condi- 
tion distinctly  dtie  to  reasons  causing  direct  error 
in  digestion,  or  is  the  origin  of  the  condition  situated 
in  the  general  system,  and,  because  of  the  sensitive- 
ness of  the  digestive  tract  to  these,  they  here  mainly 
manifest  themselves,  or  is  there  present  a  combina- 
tion of  these  two?  The  practical  side  of  handling 
the  cases  as  they  clinically  present  themselves  hinges 
upon  these  points,  for  whatever  the  aspect  of  the 
case  may  be.  ])ermanent  results  to  be  obtained  de- 
pend more  upon  finding  the  cause  than  upon  applied 
fine  points  of  therapeutic  detail  in  the  symptomatic 

•Rend  before  the  Medical  .Vssoci&tioii  of  the  Greater  City  of  New 
York.  Occeiiiljer  7.  1908,  and  the  Long  Island  Practitioners'  Society, 
Oecember  17,  1908. 


February  20,  1909. 1 


BASSLER:  GASTROEXTERITJC  NEUROSES. 


385 


way.  Ihese  three  crucial  points  can  only  be,  and 
almost  always  are,  obtained  by  the  taking  of  a  com- 
plete history,  and  the  physical  examination  of  the 
patient. 

In  the  first,  or  local  reasons,  we  deal  with  factors 
which  from  irritating-  circumstances,  generate  ab- 
normal impulse  either  in  kind  or  in  exaggeration  of 
those  present  in  normal  digestion.  Plainly  such  dis- 
turbances could  only  ensue  from  dietetohygienic  er- 
ror connected  with  the  ingestion  of  foods  or  drink 
inasmuch  as  these  may  cause  alterations  in  the  nor- 
mal physiology  of  digestion.  Such  are  seen  in  those 
cases  in  which,  for  chemical,  mechanical,  or  thermal 
reasons,  irritation  has  been  applied  to  the  gastro- 
enteric mucosa  affecting  nerve  impulse  in  unfavor- 
able ways,  so  that  these  are  brought  within  the  cog- 
nizant sensibilities  of  the  subjective  sense.  To  setio- 
logically  delineate  such,  it  may  be  said  that  they  are 
found  in  hasty  eaters  (which  means  incomplete 
mastication,  salivation,  and  often  overfeeding)  ;  in 
those  who  partake  largely  of  irritating  foods,  such 
as  highly  spiced,  corned,  improperly  prepared,  heavy 
meat,  onion,  or  garlic  users ;  the  drinkers  of  much 
iced  or  too  hot  fluids :  the  intemperate  use  of  al- 
cohol, coffee,  tea,  or  tobacco  ;  and  in  those  who  eat 
in  quantity  or  kinds  beyond  the  digestive  power 
present  in  fatigued  states  of  body.  In  a  normal  in- 
dividual, when  these  abnormal  factors  have  been 
long  enough  existent,  gastroaesthenic  states  ensue  in 
the  way  of  disturbances  of  the  acid  enzymotic  se- 
cretion, motility,  or  sensation,  and  these  ma}'  un- 
favorably affect  intestinal  digestion.  Logically, 
when  such  improper  habits  are  stopped,  if  they  have 
not  existed  long  enougii  for  the  development  of  or- 
ganic change  in  the  glandularis,  digestion  returns  to 
a  normal  condition.  ]\Iedical  measures  of  substan- 
tial benefit  may  materially  shorten  the  time  this 
takes.  Among  such  of  practical  worth  are  the  use 
of  alkalies  and  belladonna  in  oversecretion,  the  more 
liuid  and  bland  diets  in  overmotility,  and  the  nerve 
sedatives  in  oversensation. 

In  considering  the  subject  of  digestive  neuroses 
which  have  a  primary  or  more  important  seat  in  the 
general  body,  a  much  broader  and  interesting  field 
of  factors  is  encountered.  For  the  primary  under- 
standing of  these,  all  irregular  processes  pertaining 
to  the  general  body  must  be  viewed  as  a  cause  mani- 
festing its  main  force  upon  the  most  vulnerable 
point  of  the  human  economy — the  gastroenteron.  In 
broad  divisions  I  will  consider  these  under  the  head- 
ings of  nutritional,  toxic,  reflex,  and  psychic  causes, 
since  into  these  groups  they  mav  be  clinically 
divided. 

The  nutritional  neuroses  are  those  digestive  dis- 
turbances which  ensue  from  abnormal  states  of  nu- 
trition of  the  general  nervous  system.  Such  ab- 
normal states  could  develop  from  habitual  insuffi- 
cient intake  of  food,  deficient  absorption  of  same, 
low  vitality  states  from  excessive  physical  or  men- 
tal work,  or  abnormal  catabolic  conditions  of  the 
general  system.  Naturally,  in  many  cases  which  ap- 
pear mainly  nutritional,  toxic  causes  must  also  be 
figured  in  the  makeup  of  factors.  But  since  clinical- 
ly, any  rightful  deduction  from  results  in  therapy, 
the  nutritional  side  deserves  first  consideration,  be- 
cause for  the  best  results  in  the  treatment  of  the 


case  the  toxic  causes  may  be  considered  as  of  sec- 
ondary importance. 

In  many  '"dyspeptics,"  in  men  who  are  too  busy 
to  eat,  and  women  who  eat  freakishly,  states  of  sub- 
nutrition  are  common.  It  is  often  a  difficult  matter 
to  diagnosticate  such  states  of  underfeeding  in  any 
definite  way,  because  in  appearance  many  of  these 
patients  look  quite  well  nourished,  and  such  a  condi- 
tion might  not  be  suspected  until  you  obtain  history 
details  of  the  quantities,  time,  and  quality  of  food 
that  is  customarily  partaken  of.  In  this  group  of 
cases,  it  is  an  interesting  fact  that  the  subjective 
dyspeptic  symptoms  usually  become  worse  and 
worse  the  more  stringently  they  diet  themselves  for 
its  relief.  A  plainer  type  of  these  cases  is  seen  in 
those  who  are  convalescing  from  acute  febrile  dis- 
ease, in  which,  because  of  the  effects  of  fever  upon 
the  body  and  the  low  feeding  at  the  time,  a  legacy 
of  subnutrition  is  left.  Tiie  great  accompaniment 
of  most  of  the  clinically  seen  cases  is  an  underlying 
neurasthenia,  and  to  what  cause  such  constant  ex- 
penditure of  nerve  energy  beyond  its  supply  may  be 
due  to,  alwavs  deserves  fi.rst  consideration  in  each 
instance  Remembering  that  in  neurasthenic  states, 
it  is  of  first  importance  to  remove  the  exciting  cause 
of  the  condition,  a  subdivision  to  analyze  the  aetiol- 
ogy present  must  be  made  if  possible  between  the 
primary  and  secondary  neurasthenias — that  is,  be- 
tween those  of  excessive  expenditure  of  nerve  ener- 
gy, and  those  of  #leficient  supply  of  same.  While 
this  is  important  in  the  detail  of  therapy,  all  of  such 
patients  should  be  looked  upon  as  subnourished. 
since  higher  nutrition  kept  up  over  a  length  of  time 
brings  about  the  best  clinical  results  in  the  end.  The 
same  is  also  true  in  the  cases  of  the  common  fomis 
of  simple  anremia.  It  is  true  that  many  of  these 
latter  are  of  toxic  origin,  but  for  relief  of  the  pic- 
ture as  a  whole,  the  establishment  of  higher  states 
of  nutrition  is  essential.  It  has  always  appeared 
to  me  that  the  less  the  degree  of  amemia.  the  less 
the  benefit  from  the  hsemitinic  tonics,  and  the  more 
is  derived  from  the  generally  constructive  dietetic 
measures.  In  all  of  these  conditions  the  employment 
of  higher  caloric  feedings  by  supplemental  meals  to 
the  quantities  then  taken,  and  the  severe  curtailment 
of  those  of  the  latter  which  are  of  little  or  no  benefit 
in  the  nutritional  way,  are  measures  of  much  im- 
portance. Lastly,  it  must  be  mentioned  that  in  catar- 
rhal or  ptosed  states  of  the  abdominal  organs,  neu- 
roses often  develop  which  are  benefited  most  when 
the  subnutritional  picture  is  kept  in  mind  along  with 
the  other  indicated  measures  of  treatment. 

The  toxic  factor  in  producing  gastroenteric  neu- 
roses is  a  subject  almost  as  large  as  medicine  is 
broad.  That  the  toxines  of  certain  infectious  dis- 
eases, and  autointoxications  from  the  intestinal  canal 
have,  through  their  toxines.  a  marked  eft'ect  on  the 
functional  status  of  digestion  is  almost  of  daily  ob- 
servation. In  a  paper  like  this,  one  can  only  draw 
attention  to  the  following  as  fruitful  causes :  Gout, 
rheumatism,  uric  acid  diathesis,  diabetes,  malaria, 
syphilis,  influenza,  typhoid,  diphtheria,  the  pyogenic 
aft'ections,  tetanus,  pneumoia,  pregnancy,  fermenta- 
tive and  putrefactive  states  of  the  intestinal  canal, 
and  so  on. 

Plainly  does  logic  point  to  the  removal  of  anv 


386 


BASSLER:  GASTROENTERITIC  NEUROSES. 


[New  York 
Medical  Journal. 


such  iDriniary  source  of  toxines  before  much  could 
be  expected  in  the  reHef  of  the  gastrointestinal  symp- 
toms. But  there  is  a  group  of  cases  about  which  ^ 
few  extra  words  would  not  be  amiss,  and  they  are 
the  instances  of  milder  toxic  conditions  found  in 
those  in  whom  a  definite  disease  does  not  exist,  and 
who  are  well  enough  to  be  about.  This  type  make 
up  a  bulk  of  our  office  and  our  clinical  cases  of  toxic 
neuroses.  There  is  little  doubt  to-day,  that  the  sap- 
rophytic and  pathogenic  organisms  found  normally 
in  the  digestive  tract,  could,  under  favorable  condi- 
tions for  their  proliferation,  generate  toxines,  which, 
gaining  the  circulation,  may  cause  the  development 
of  subjective  symptoms  in  the  digestive  canal.  While 
these,  therapeutically,  in  so  far  as  neuroses  are  con- 
cerned, occupy  a  subsidiary  role  to  the  primary 
condition  making  possible  their  origin,  how  many 
are  the  cases  that  we  see  which  clinically  are  just 
clean  cut  neuroses  and  for  which  condition  the 
patients  come  under  observation  ?  Over  nine 
tenths  of  the  food  is  absorbed  in  digestion,  and 
the  larger  portion  of  the  remainder  is  residual 
in  faeces  of  which  from  a  third  to  one  half  is  com- 
posed of  bacteria  which  further  act  putrefactively 
upon  it  in  the  lower  colon.  In  the  normal  individual, 
it  is  not  the  antiseptic  properties  of  the  digestive 
juices  (which  are  mild),  but  the  rapidity  of  the  pro- 
cesses of  digestion  and  absorption  and  the  brief  stay 
of  the  residue  in  the  tract  that  prevents  the  possibil- 
ity of  toxic  absorption.  Now,  when  these  processes 
arc  delayed,  greater  is  the  chance  for  bacterial  ac- 
tion and  toxaemia  ;  and  such  is  the  common  state  of 
affairs  in  habitual  constipation.  Let  us  not  lose 
sight  of  one  of  the  main  aetiological  factors  pro- 
ducing a  large  number- of  diseases  of  the  nervous 
system  (migraine,  neuritis,  neuralgia,  neurasthenia, 
psychoses,  melancholia,  and  others),  and  consider 
that  if  these  could  come  from  such  gastrointestinal 
origin,  then  constipation,  excessive  generation  of 
aromatic  substances,  occasional  acetonuria,  and  the 
like,  may  cause  many  of  our  "nervous  dyspepsias" 
as  well,  for  functional  change  comes  before  organic. 
In  this  same  light,  let  us  not  overlook  those,  who. 
from  necessity  or  choice,  live  sedentary  and  indoor 
lives,  and  in  whom,  therefore,  results  develop  from 
suboxidation,  obesity,  surfeit  breathing  of  carbon 
dioxide,  or  other  polluting  gases  into  the  circula- 
tion. We  must  never  forget  that  it  requires  about 
two  thousand  cubic  feet  of  air  to  pass  dail}'  through 
the  lungs  of  an  adult  in  order  to  furnish  enough 
oxygen  to  maint^n  good  digestion,  and  that  physi- 
cal exercise  in  the  open  does  much  to  enhance  more 
thorough  oxidation  of  the  body  tissue. 

Of  late  years,  largely  through  workers  in  the  spe- 
cial fields  of  medicine,  the  reflex  neuroses  are  com- 
manding more  and  more  attention.  Exactly  how 
such  effects  are  brought  about  is  still  somewhat  of 
a  question,  to  which  as  logical  reasons  for  the  un- 
derstanding of  their  development  are  the  facts  that 
viewing  the  body  as  a  whole  a  disease  or  marked 
physiological  disturbance  in  any  organ  outside  of 
the  digestivq  canal  acts  as  a  chestnut  burr  irritation 
in  throwing  over  the  normal  nervous  balance  of  the 
neurological  system,  and  that  these  abnormal 
stimuli  manifest  their  effects  most  easily  upon  the 
digestive  organs,  which,  through  abundant  sympa- 


thetic supply,  delicate  and  complex  functions,  are 
most  sensitively  balanced.  Almost  daily,  surgeons, 
ophthalmologists,  gynjecologists,  and  others,  are  con- 
tributing reports  of  cases  of  this  kind  in  which  the 
removal  of  the  primary  cause  restored  digestion  to 
normal  standards.  To  these  we  must  give  respect- 
ful attention,  although  it  must  not  be  forgotten  that 
moral  influence  from  special  treatment  of  such 
other  conditions,  and  the  better  general  state  of 
body  and  nervous  system  ensuing  from  same,  may 
cause  restoration  without  considering  such  in  the 
strict  nerve  reflex  sense.  In  a  broad  and  abundant 
experience  with  gastroenterological  conditions,  I 
freely  confess  to  still  having  many  uncleared 
doubts  on  this  subject,  but  it  seems  logical  to  be- 
lieve that  such  neuroses  can  occur  in  some  nervous- 
ly inclined  or  t^ndernourished  individuals.  It  is  one 
of  those  subjects  which  can  be  argued  from  two 
sides,  in  which  the  lack  of  accompanying  digestive 
symptoms  in  the  great  majority  of  outside  patho- 
logical conditions,  workers  in  the  other  departments 
of  medicine  cannot  answer  for,  and  the  multiple  or- 
gan pathology  found  in  many  patients  who  come 
under  the  observation  of  the  gastroenterologist  en- 
shrouds him  with  many  unanswerable  questions.  It 
is  a  subject  which  can  best  be  worked  out  by  the 
gastroenterologist  alone,  and  he  necessarily  must  be 
understanding  and  practical  in  broad  medicine.  I 
am  of  the  opinion  that  a  proportion  of  our  neurotic 
cases  rightfully  belong  to  others  for  best  treatment. 
Still,  without  statistics  to  substantiate  me,  it  must 
be  said  that  of  the  thousands  of  neurotics  that  I 
have  seen  but  few  indeed  have  been  absolutely  and 
singly  cured  of  digestive  disturbance  who  have  also 
been  treated  by  others  skilled  in  the  special  fields 
to  which  such  cases,  for  other  existing  conditions, 
belonged.  And  I  would  here  advance  the  admoni- 
tion to  the  surgeon,  ophthalmologist,  gynjecologist. 
and  others  to  be  somewhat  more  guarded  than  is 
common  to-day  in  promising  cure  of  all  digestive 
conditions  after  such  errors  as  he  had  found  and 
treated  had  been  corrected.  The  majority  of  his 
patients  are  not,  and  he  _should  never  forget  that 
most  of  the  gastrointestinal  cases  seen  are  due 
to  internal  medicine  conditions,  and  not  always 
to  such  as  chronic  appendicular  inflammation,  eye 
strain,  and  endometritis.  It  is  surprising  how  many 
persons  wear  glasses,  have  been  operated  upon  for 
other  existing  conditions,  or  treated  and  discharged 
cured,  continue  to  come  back  for  treatment  for  a 
digestive  disturbance,  the  relief  of  which  had  been 
promised  by  the  other.  Of  course,  when  disturb- 
ance is  found  in  other  organs  of  the  body,  it  is  the 
internist's  duty  to  his  patient  to  have  instituted 
means  for  its  cure  or  alleviation. 

To  encompass  in  a  few  words  the  interesting  sub- 
ject of  psychic  gastroenterological  neuroses  is  be- 
yond me.  When  we  deal  with  perversion  states  in 
the  mind  of  others  we  deal  with  effects  from  con- 
ception and  perception,  mental  habits,  inheritance 
and  early  training,  physical  and  mental  environ- 
ments and  education,  their  hopes,  fears,  ambitions, 
disappointments,  worry,  grief,  suspense,  and  an.x- 
icty.  To  understand  how  all  of  these  may  affect 
the  body  and  the  digestive  tract  in  particular,  one 
needs  onlv  to  analyze  moments  of  their  own  lives 


February  20,  1909.] 


KELLER:  OPERATION  FOR  INGROWING    TOE  NAIL 


387 


in  the  past,  those  of  others  about  who  are  dear  to 
us,  and  with  a  knowledge  of  the  researches  of  Can- 
non and  Pawlow,  to  understand  the  power  in  the 
functional  way  of  the  brain  over  the  body.  Need 
I  dilate  upon  the  commonly  seen  symptoms  of 
•cessation  of  digestion,  spasms  of  the  cardia  and 
pylorus,  anorexia ;  nausea,  diarrhoea,  or  vomiting 
from  emotional  reasons  ?  Here  again  is  the  ever 
ready  sensitiveness  of  the  digestive  tract.  Often  in 
a  patient  before  us  mental  habits,  environments  of 
life,  domestic  and  business  worries  hide  deep  in  the 
case  of  a  true  neurosis.  His  manner,  his  pupils,  and 
his  knee  jerks  do  not  manifest  their  presence,  and 
bad  effects  from  what  he  thinks  and  feels  don't  al- 
ways mean  the  presence  of  neurasthenia,  hysteria, 
hypochondria,  or  psychasthenia.  Ambition  is  a  far 
reaching  hand  from  a  body  not  always  equal  to  tol- 
erate its  disappointments.  In  our  day  and  land  con- 
tented minds  are  not  common  among  the  active. 
The  lost  opportimities,  and  hard  blows  of  the  past, 
often  live  as  virulently  in  our  minds  to-day  as  in 
the  moments  of  long  ago.  We  are  not  all  mentall\' 
broadened  by  education  or  intuition.  The  pleasures 
of  homie  life  are  often  mixed  with  sore  trials,  and 
business  does  not  always  run  the  w-ay  we  believe  it 
should.  In  these  instances  of  cases  we  are  not 
arbiters  of  the  imiverse,  with  power  to  correct  trou- 
bles for  the  individual,  nor  does  drugging  such  pa- 
tients meet  the  heights  of  rational  medicine.  We 
need  more  lasting  and  satisfying  aids,  and  these 
must  be  found  in  pure  human  direction,  assurance, 
kindness,  gentleness,  nonmorbid  sympathy,  and  ap- 
pealing treatment.  Xow  what  the  latter  in  each 
case  should  be  is  always  much  of  a  gamble.  As  the 
mental  analysis  of  the  case  may  be,  our  manner  at 
the  time,  and  how  we  approach  its  treatment, 
makes,  with  the  use  of  the  same  therapeutic  meas- 
ures, great  differences  among  us.  It  is  in  these  pa- 
tients that  the  personal  equation  of  the  physician 
in  the  way  of  instilling  confidence  and  enthusiasm 
are  strong  factors  for  results.  They  should  never 
be  overtreated,  or  too  lightly  handled.  Both  are 
sorrowful  measures.  There  is  residual  suggestion 
enough  in  the  artful  phvsician  to  meet  most  of  these 
patients,  to  which,  it  may  be  said,  as  a  strong  moral 
agent  is  the  employment  of  electricity.  I  believe 
that  the  day  is  past  when  we  should  be  always  on 
the  search  for  organic  and  malignant  disease,  and 
be  indift'erent  to  those  that  do  not  belong  to  these 
groups.  As  physicians  we  must  accept  the  duty  of 
treating  human  illness  in  all  its  phases.  \\^t  have 
learned  from  the  therapeutic  vagaries  and  creeds 
which,  in  the  past,  have  cured  many  of  these  cases 
for  us.  To  them  we  owe  thanks  for  teaching  us 
to  see  lower,  and  in  their  psychotherapeutic  meas- 
ures, born  of  ignorance  in  medicine  as  they  are, 
they  are  of  that  much  more  appealing  mystery  and 
strength  to  these  susceptible  individuals.  We  need 
not  pray  with  these  patients,  but  let  us  in  some  of 
our  idle  moments  view  the  human  being  abstract  to 
regular  medicine.  Mew  him  as  an  individual  alto- 
gether within  himself.  Thoughts  will  then  come  to 
us  which  will  make  possible  the  improving  of  our 
patients  and  oiirselves  still  more  materially,  and  we 
need  not  go  outside  of  legitimate  paths  of  medicine 
to  employ  the  means.    For  of  every  patient  of  these 


functional  cases,  whom  these  fads  have  cured,  there 
are  a  thousand  patients  whom  general  practitioners 
of  medicine  in  silent  manner  have  cured  in  some- 
what the  same  way,  although  some  physicians  may 
not  know  or  feel  it  as  such.  To  get  down  to  the 
human  being  as  he  exists  is  no  idle  effort  on  our 
part. 

There  is  one  therapeutic  measure  for  most  all 
neurotics  which  should  additionally  be  mentioned, 
and  that  is  a  sojourn  in  the  country.  In  the  more 
and  better  air,  in  new  and  relaxing  environments 
away  from  worries  of  business  and  home,  in  the 
regular  hours  for  sleep,  the  eating  at  special  times, 
and  the  outdoor  exercise,  most  of  the  subjective 
sym.ptoms,  the  introspection,  self  examination  and 
self  pity  fade  away,  and  at  this  time,  from  this  life 
truer  to  Nature,  benefits  come  to  the  great  majority 
of  them.  As  the  general  system  improves  from  this 
regular  living,  the  gastrointestinal  tract  is  thereby 
strengthened.  This  in  turn  makes  possible  re- 
strengthening  of  the  bodv,  and  this  again  benefits 
digestion,  and  so  a  charmed  circle  is  set  in  motion, 
and  the  patient  makes  progress  toward  substantial 
relief  and  cure. 

I  have  tried  in  this  brief  paper  to  present  the  di- 
gestive neuroses  along-  rather  simple  clinical  lines 
for  practical  application  by  the  general  workers  in 
medicine.  I  have  taken  some  liberties  with  the 
skilled  gastroenterologist,  but  none  with  the  patient 
of  the  general  practitioner.  My  themes  applv  to  the 
average  patient  whom  we  all  see,  and  if  I  have 
served  my  wish  that  some  lessons  might  be  better 
learned  I  have  gained  my  purpose  and  my  hopes 
have  been  realized. 

228  East  Xi.veteexth  Street. 


A  NEW  OPERATION  FOR  INGROWING  TOE  NAIL. 
By  William  L.  Keller,  M.  D., 

Captain,  United  States  Army  Medical  Corps, 

Manila,  P.  I. 

No  condition  of  a  trivial  character,  surgicallv,  en- 
tails more  discomfort  and  at  times  actual  sufifering 
than  that  of  an  untreated  ingrowing  toe  nail :  usually 
situated  as  it  is  on  the  side  of  the  great  toe,  it  is 
subjected  to  pressure  of  ill  fitting  shoes,  and  when 
brought  to  the  attention  of  the  surgeon  it  is  fre- 
quently found  to  be  in  a  condition  of  ulceration,  the 
curved  edge  of  the  ingrowing  nail  acting  as  a  for- 
eign body  constantly  subjecting  the  soft  parts  to 
painful  pressure  and  infection  which  may  develop 
into  an  extensive  cellulitis  of  the  surrounding  area. 

The  writer  on  consulting  various  authorities,  in- 
cluding most  of  the  latest  textbooks  on  surger}-,  finds 
several  methods  of  treatment  recommended  for  the 
relief  of  this  condition  none  of  which  have  been  as 
satisfactory  in  the  writer's  experience  as  the  opera- 
tion to  be  described.  Palliative  treatment,  which 
includes  the  scraping  of  the  nail,  elevation  of  same 
with  the  insertion  of  cotton  beneath  the  ingrowing 
margin,  the  use  of  lead  nitrate  applied  directly  to 
the  soft  tissues,  have  all  been  recommended  for  this 
condition,  but  while  some  temporary  benefit  may  be 
derived  from  these  expedients,  the  result  is  usuallv 


388 


KliLLHK:    OPERATION  FOR  IXGROU'IXG  TOE  XAIL. 


[New  York 
.Meuical  Journai 


unsatisfactory  and  some  form  of  operation  is  final- 
ly necessary. 

Of  the  operative  methods  described  those  of  Cot- 
ting  and  Anger  are  the  most  popular,  and  give  sat- 
isfactory results,  the  chief  objection  to  them  being 
the  time  required  for  healing  and  the  restoration  of 
function,  and  as  most  of  the  cases  of  this  condition 
seeking  relief  are  dependent  upon  their  physical  ac- 
tivity to  procure  a  livelihood,  the  tune  saved  in  the 
treatment  is  of  some  importance. 

The  method  described  below  is  believed  to  be  less 
susceptible  to  the  before  mentioned  criticism  than 
any  methods  known  to  the  writer,  and  has  the  addi- 
tional advantage  of  lessened  pain  and  discomfort  in 
the  after  treatment.  The  sunplicity  in  technique 
and  rapidity  with  which  the  condition  can  be  rem- 
edied will,  it  is  believed,  recommend  it,  and  it  is 
thought  that  a  description  of  the  method  would  be 
justified  and,  perhaps,  be  found  to  be  as  beneficial 
in  the  hands  of  others  as  it  has  been  in  the  experi- 
ence of  the  writer. 

Description  of  Operation. — Twenty-four  hours 
previous  to  time  of  operation  the  foot  and  toes  are 
thoroughly  scrubbed  with  tincture  of  green  soap, 
after  which  the  nail  is  trimmed  straight  across  its 
free  border  and  the  surface  exposed  and  thoroughly 
cleansed.  Tincture  of  iodine  is  now  applied  around 
the  entire  margin  of  the  nail  and  a  I  in  2000  bichlo- 
ride of  mercury  dressing  applied.  At  the  time  of 
operation,  the  parts  are  again  scrubbed  as  before, 
followed  by  application  of  Harrington's  solution, 
the  cleansing  being  finished  by  the  use  of  sterile 
water. 

Haemorrhage  is  controlled  by  the  use  of  a  rubber 
band  encircling  the  base  of  the  toe,  and  local  anaes- 
thesia is  secured  by  injection  of  weak  cocaine  solu- 
tion under  the  nail  form  a  to  b  and  along  the  side 
from  c  to  d  ( Fig.  i ) . 


The  nail  is  then  split  with  a  scalpel  from  a  to  & 
through  the  matrix  down  to  the  bone ;  this  incision 
is  the  most  important  mechanical  step  in  the  opera- 
tion and  permits  the  elevation  of  the  lateral  border 
of  the  nail.  The  second  step  consists  in  freeing  the 
matrix  and  lateral  border  of  the  nail  by  an  incision 
down  to  the  nail  at  c  about  three  sixteenths  of  an 
inch  from  the  lateral  border  extending  back  beyond 
its  base.  The  scalpel  is  then  carried  laterally  free- 
ing the  nail  from  the  tissues  in  which  it  is  imbedded, 
the  scalpel  is  then  directed  under  the  freed  border 


of  the  nail  and  carried  toward  the  median  line, 
hugging  the  bone  and  separating  the  matrix  from 
the  same  to  the  extent  of  one  quarter  of  an  inch  to- 
ward the  median  line. 

The  freed  lateral  border  is  then  elevated  with  the 
handle  of  the  scalpel,  and  carried  out  over  the  tis- 
sue between  c  and  d  and  the  matrix  of  the  elevated 
portion  in  the  same  area  is  removed.  This  leaves 
the  nail  as  shown  in  Fig.  2,  the  lateral  border  rest- 
ing on  healthy  tissue.  It  is  then  slightly  overcor- 
rected  by  the  msertion  of  a  small  strip  of  gauze  be- 
neath the  edge,  and  a  wet  dressing  of  saturated  so- 
lution of  magnesium  sulphate  applied  for  the  pur- 
pose of  reducing  the  inflammatory  reaction  which 


Fic.  2. 


usually  ensues.  This  application  is  renewed  daily 
for  three  days,  and  the  insertion  of  the  gauze  for 
the  same  period,  when  the  nail  has  assumed  a  posi- 
tion of  resting  on  normal  tissue  naturally  without 
undue  pressure.  This  result  is  attained  by  the  use 
of  the  median  incision  and  the  elevation  of  the  freed 
margin  of  the  nail. 

The  utility  of  the  median  incision  can  be  applied 
to  nails  of  any  thickness  by  increasing  the  width  of 
the  incision  which  may  vary  from  a  single  stroke  of 
the  scalpel  to  one  of  several  lines  in  width,  thus  per- 
mitting the  deviation  of  the  affected  portion  of  the 
nail  sufficiently  to  overlap  the  soft  tissues  in  which 
it  formerly  rested. 

In  infected  cases  the  anterior  corner  of  the  ele- 
vated portion  is  removed  to  facilitate  drainage,  and 
a  I  in  500  iodine  dres'^ing  is  substituted  for  the  mag- 
nesium sulphate  application. 

During  the  few  days  subsequent  to  the  operation 
the  use  of  the  affected  foot  should  be  prohibited, 
after  which  a  careful  return  to  the  usual  activity 
may  be  permitted. 

It  has  been  the  experience  of  the  writer  in  the  ten 
cases  operated  in  that  the  patients  have  been  able 
to  return  to  their  usual  occupations  in  less  than  half 
the  time  required  when  other  operations  have  been 
undertaken.  Subsequent  observation  of  these  cases 
shows  that  the  lateral  borders  of  the  nail  remain  in 
the  position  in  which  they  have  been  placed  with  Jio 
tendencv  to  curve  inward  or  become  imbedded  in  the 
tissues. 

The  advantages  of  the  operation  seem  to  be  that 
of  simplicity,  radical  cure,  mininunn  tissue  destruc- 
tion, and  decreased  suffering  from  pain,  rapid 
restoration  of  the  normal  condition  of  the  tissues, 
and  short  period  of  convalescence. 


February  20,  igog.J 


T  HER  APE  U  TICAL  NO  TES. 


389 


Treatment  of  Catarrhal  Pneumonia  in  Chil- 
dren.— A.  Stern  {Journal  of  the  American  Med- 
ical Association,  January  30,  1909)  is  of  the  opinion 
tliat  the  guaiacol  and  creosote  preparations  are  of 
some  vahie  in  the  bronchopneumonia  following 
bronchitis  in  children,  and  he  prescribes  the  follow- 
ing emulsion : 

B     Creosote  carbonate,   gr.  xv  to  5i ; 

Pulverized  sugar ; 

Mucilage  of  acacia,   aa  q.  s.  ad.  5iii. 

Mix  and  make  an  emulsion  with  distilled  water. 
Sig. :  One  teaspoonful  every  two  hours. 

Heubner's  Mustard  Treatment  of  Broncho- 
pneumonia in  Children. — Stern  {loc.  cif.)  de- 
scribes the  use  of  mustard  applications  in  the  treat- 
ment of  bronchopneumonia  in  childreii  as  practised 
by  Heubner.  of  Berlin,  as  follows;  Take  a  pound 
of  mustard  flower  and  to  this  add  a  quart  and  a  half 
of  warm  water,  stir  until  the  odor  of  mustard  is 
perceptible.  A  towel  is  dipped  into  this  mixture, 
wrung  out.  and  wrapped  around  the  child  from  the 
shoulders  to  the  feet,  and  then  a  woollen  blanket  is 
put  over  this.  The  neck  must  be  well  covered  so 
that  the  mustard  does  not  affect  the  eyes  and  lungs. 
The  child  stays  in  this  dressing  for  from  ten  to 
thirty  minutes,  or  until  the  skin  is  red.  It  is  then 
washed  with  lukewarm  water,  after  which  a  bath  of 
five  minutes"  duration  in  lukewarm  water  is  given. 
Then  a  moist  warm  towel  is  put  around  the  chest. 
This  procedure  may  be  repeated  the  next  day. 
Stern  says  the- result  of  this  treatment  is  sometimes 
surprising  and  a  life  despaired  of  may  be  saved. 

The  Removal  of  Wax  from  the  Ear. — The  follow- 
ing procedure  is  recommended  when  the  cerumen  is 
hard,  dry,  and  adherent.  Introduce  into  the  ear  sev- 
eral times  a  day  a  few  drops  of  a  solution  of  ten 
grains  of  sodium  carbonate  in  four  drachms  of  a 
mixture  of  equal  parts  of  glycerin  and  water.  In  the 
course  of  a  few  days  under  this  treatment  the  wax 
softens  and  can  be  removed  by  injections  of  warm 
water.  A  plug  of  absorbent  cotton  should  then  be 
introduced  into  the  meatus  and  left  for  twenty-four 
hours. 

Hygiene  of  the  Face  in  Acne. — In  the  course 
of  an  article  on  the  therapeutics  of  acne  in  the 
Journal  of  the  American  Medical  Association  for 
January  30.  1909,  some  useful  suggestions  are  given 
regarding  the  cleansing  of  the  face.  Acne  can 
never  be  cured,  the  atithor  savs,  unless  the  \oung 
boy  or  girl  is  taught  and  carries  out  the  hygiene 
of  thoroughlv  cleansing  the  face  before  going  to 
bed.  The  oil  secretions  of  the  day  have  accumu- 
lated the  dust  and  dirt  of  the  atmosphere,  and  at 
night  this  dust  dries  the  secretions  and  blocks  the 
channels  of  exit,  giving  rise  in  this  way  to  come- 
dones, indurations,  and  acne  nodules.  A  warning 
is  given  regarding  the  use  of  hot  and  of  cold  water. 
A  patient  who  has  profuse  oily  secretions  of  the 
face  should  not  use  hot  water  on  the  face.  Also 
it  is  well  never  to  use  cold  water  on  the  face.  The 
hot  water  tends  to  increase  the  oily  secretion  by 
causing  congestion,  and  the  cold  water  tends,  by  its 
reaction,  to  do  the  same  thing.     The  easiest,  most 


thorough  way  of  cleansing  the  face  is  to  remove  the 
dust  and  dirt  with  a  pure  cold  cream.  A  lump  of 
the  cold  cream  the  size  of  a  hazel  nut  or  hickory  nut 
is  taken  in  each  hand  and  rubbed  gently  over  the 
skin.  The  face  is  then  wiped  oft'  with  a  soft  towel 
and  then  washed  in  lukewarm  water  without  soap. 
In  some  cases  it  may  be  best  to  inhibit  the  proftise 
secretion  of  the  sebaceous  glands  by  bathing  the 
face  once  or  twice  a  day  with  dilute  alcohol,  bay 
rum,  or  other  astringent  solution. 

To  Stop  Gastric  and  Intestinal  Haemorrhages. 

— The  internal  administration  of  gelatin  in  the  fol- 
lowing form  is  recommended  (Journal  de  medecine 
de  Paris,  January  16,  1909)  for  the  treatment  of  gas- 
tric and  intestinal  haemorrhage : 

R    Gelatin   3v. 

Boil  with  water  for  six  hours  until  the  gelatin  is 
completely  liquefied  and  make  up  the  volume  to  six 
ounces  with  water.    Allow  to  cool,  filter,  and  add 

Citric  acid  gr.  xxx; 

Syrup  of  orange  peel,  3v. 

Sig. :  One  or  two  tablespoonfuls  to  be  taken  every  two 
hours. 

Atoxyl  Mercuric  Iodide  Injections  for  intra- 
muscular hypodermic  administration  are  prepared  of 
the  following  strengths,  according  to  Labat  {Bulle- 
tin de  la  Socicfie  de  pharmacie  de  Bordeaux,  1908)  : 

(1)  R    Atoxyl,   5iiss; 

Mercuric  iodide  gr.  viiss  ; 

Sodium  iodide  gr.  Ixxv  ; 

Distilled  w  ater,  q.  s.  ad  Jiii ; 

(2)  R    Atoxyl  5iiss; 

Mercuric  iodide  gr.  iii ; 

Sodium  iodide  gr.  xxx; 

Distilled  water,  q.  s.  ad  5iii ; 

The  solutions  are  dispensed  in  ampuls  of  amber 
colored  glass,  after  being'  sterilized  according  to 
Tyndal's  method. 


NEW  REMEDIES. 
Digipuratum  is  a  preparation  of  digitalis  which 
is  said  to  be  of  definite  physiological  power,  acting 
promptly  as  a  diuretic  and  heart  tonic.  It  is  put 
up  in  tablets,  each  of  which  is  represented  to  be 
equal  to  one  and  one  half  grains  of  digitalis  leaf. 

lodpeptide  is  a  compound  of  iodine  and  albu- 
men obtained  by  acting  on  peptonized  egg  albumen 
with  iodine.  Ten  grammes  of  egg  albumen  are  pep- 
tonized and  dissolved  in  100  c.c.  of  water.  Iodine 
in  the  nascent  state  is  then  introduced,  sufficient  be- 
ing added  to  leave  the  liquid  a  faint  yellow  color 
with  a  greenish  fluorescence.  The  liquid  is  put  up 
in  ampuls  of  a  capacity  of  5  c.c,  which  are  steril- 
ized by  Tyndall's  method.  Three  strengths  of  the 
liquid  as  regards  iodine  content  are  made.  No.  i 
containing  1.75  per  cent,  of  iodine;  No.  2,  2.45  per 
cent. ;  and  No.  3,  3.48  per  cent.  An  ampul  of  5  c.c. 
of  the  different  strengths  will  contain  of  iodine 
0.0875  grammes,  0.1 23  grammes,  and  0.175  grammes 
respectively.  Added  to  solutions  of  the  heavy  metals 
iodpeptide  causes  dense  coagulation.  lodpeptide  is 
described  by  the  inventor.  Dr.  A.  Cecchini,  of  Rome, 
in  the  Giorna.le  di  farmacia,  di  chimica  e  di  scicnse 
aifini,  x.  No.  41.  It  has  been  used  hypodermically  by 
Alessandrini  in  the  treatment  of  syphilis,  tubercu- 
losis, and  goitre  with  good  results. 


300 

NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

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and  The  Medical  News. 

A  Weekly  Review  of  Medtctne. 

Edited  by 
FRANK  P.  FOSTER.  M.  D. 

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NEW  YORK,  S.VrURD.XY,  FEP.RU.XRY  20.  1909. 

THE  DEAVER  DINNER. 
It  was  a  notable  occasion  wlien  in  Philadelphia 
last  Monday  evening  more  than  a  hundred  medical 
men  .sat  down  to  a  dinner  at  which  Dr.  John  B. 
Deaver  was  the  guest  of  honor.  Much  popular  in- 
terest was  excited  by  the  fact  that  every  one  of  the 
pliysicians  who  gave  the  dinner  had  been  operated 
upon  by  Dr.  Deaver  for  some  grave  abdominal 
trouble,  more  than  half  of  them  for  disease  of  the 
vermiform  appendix.  Dr.  Deaver's  preeminence  in 
abdominal  surgery  is  indeed  such  as  to  entitle  him 
to  unusual  honors  at  the  hands  of  his  professional 
brethren,  but  nobody  who  knows  him  can  doubt  that 
it  was  the  splendid  personal  qualities  of  the  man 
which  really  appealed  to  those  who  took  part  in  the 
dinner.  Dr.  Deaver  is  deservedly  held  in  high 
esteem  and  devoted  regard  among  those  who  are 
most  familiar  with  his  excellent  work,  but  his  per- 
sonality is  ])red()minantly  the  charm  that  leads  mem- 
bers of  tlic  profession  to  honor  liim. 


TIIF.    REMUNERATION    OF  GERMAN 
PHYSICIANS. 

The  distinguished  Professor  von  Bollinger,  who 
has  held  the  chair  of  pathology  at  the  University 
of  Munich  for  over  twenty-five  years,  again  became 
rector  of  his  alma  mater  for  the  ensuing  year  on 
November  28,  1908.  As  is  well  known,  it  is  the 
custom  for  the  new  rector  to  deliver  an  address, 
and  it  usually  refers  to  his  own  special  work.  Many 
important  essays  have  tlius  been  brought  forward. 


[New  York 
Medical  .Journal. 

but  lately  nothing  has  stirred  up  the  physicians  of 
(Germany  so  much  as  von  Bollinger's  speech  has. 

It  is  a  masterpiece'  of  the  author's,  who  other- 
wise very  seldom  appears  before  the  public.  He 
gives  an  historical  sketch  of  the  advances  of  medi- 
cine and  of  the  medical  profession  made  in  the  last 
fifty  years,  but  the  chief  point  is  to  be  found  in  the 
second  part,  in  which  he  refers  to  the  German 
Medical  Association  and  especially  to  the  fight  be- 
tween that  society  and  the  Krankenkasscn  (the  sub- 
scribed funds  out  of  which  contract  practice  is  paid 
for).  He  shows  that  in  Leipsic  the  visit  of  a  physi- 
cian is  paid  for  by  two  thirds  of  the  inhabitants  with 
an  amount  which  is  from  one  half  to  two  thirds  of 
the  minimum  charge  allowed  the  physicians  by  the 
Prussian  law  of  1815.  It  will  therefore  be  seen  that 
the  income  of  the  physician  has  in  reality  greatly 
decreased,  for  the  purchasing  power  of  money  has 
become  less,  the  cost  of  living  has  much  increased, 
and  the  present  expenditure  of  time  and  money  for 
a  medical  education  can  absolutely  not  be  reckoned 
as  on  a  par  with  that  of  a  hundred  years  ago.  To 
better  this  condition  has  been  the  aim  of  the  German 
Medical  Association  for  the  last  ten  years  under  the 
able  leadership  of  Professor  Lobker,  of  Bochum, 
and  at  tlie  same  time  the  association  has  had  on  its 
hands  a  contention  with  the  life  insurance  com- 
panies concerning  the  remuneration  for  the  physical 
examination  of  applicants  for  insurance.  This  con- 
tention has  been  settled  by  a  compromise.  While 
the  association  has  not  gained  all  that  it  has  striven 
for,  it  has  accomplished  considerable,  and  has 
shown  its  strength  and  the  loyalty  of  its  members. 
It  is  gratifying  to  note  tliat  the  rector  of  a  great 
university  has  concerned  Inmself  with  such  matters. 


CHEMICAL  CORRELATION  AND  THE 
PATHOLOGY  OF  THE  KIDNEY. 

In  the  1873  edition  of  the  late  Dr.  Austin  Flint's 
Treatise  on  the  Principles  and  Practice  of  Medicine, 
that  accurate  clinical  observer  said  :  "The  suprarenal 
capsules  have  no  known  connection  with  the  kidneys 
other  than  the  proximity  expressed  by  their  name." 
Within  recent  years  the  functions  of  the  ductless 
glands  have  been  diligently  investigated,  with  the 
result  that  we  have  developed  the  theory  of  internal 
secretions  to  account  for  a  number  of  known  phe- 
nomena. It  is  this  theorv  which  ascribes  to  the  supra- 
renal body,  the  thyreoid  body,  the  bodies  of  Langer- 
hans.  and  other  organs  the  elaboration  of  substances 
which,  passed  into  the  bloodvessels,  act  on  other 
organs,  assisting  in  their  normal  function.   It  is  now 

^IVandluitRCn  dcr  Mcdicin  und  dcs  Acrslcstaitdcs  in  den  letstc'ii 
SO  Jahren.  Rede  gehaitcn  von  Obermcdizinalrat  Professor  Dr.  O. 
von  Bollinger  beim  .'Xntritt  des  Rektorats  dcr  Ludwig-Maximilians- 
Universit.it,  Miinchen,  am  28  November,  1908.  MiincUen:  T.  t^. 
Lehmann,  1909. 


EDITORIAL  ARTICLES. 


February  20,  1909. J 


EDITORIAL  ARTICLES. 


believed  that  many  organs  produce  internal  secre- 
tions which  influence  other  organs  and  groups  of 
organs.  These  internal  secretions,  when  they  pro- 
ceed from  diseased  organs,  may  have  an  injurious 
influence  on  viscera  that  would  otherwise  be  bene- 
ficially influenced. 

I'earce  {Proceedings  of  the  Pathological  Society 
of  Philadelphia,  October,  1908)  uses  the  term 
"chemical  correlation"  to  designate  these  actions, 
and  he  defines  the  term  as  follows :  "Chemical  cor- 
relation includes  the  action  on  any  organ  or  tissue, 
or  group  of  organs  or  tissues,  of  any  substance  or 
substances  present  in  the  blood  as  the  result  of  the 
normal  or  abnormal  life  processes  of  any  other 
organ  or  tissue."  He  has  studied  the  action  of  the 
internal  secretions  especially  as  it  aftects  the  kidneys, 
the  bloodvessel  system,  the  heart,  and  the  supra- 
renal bodies.  It  has  been  suggested,  by  the  French 
observers  particularly,  that  a  disordered  metabolism 
of  the  suprarenal  bodies  results  in  arteriosclerosis 
and  chronic  interstitial  nephritis.  Pearce  examines 
the  subject  from  the  viewpoints  ( i )  of  clinical  ob- 
servation of  the  eflfects  of  nephrectomy  and  ligation 
of  the  ureter  in  man;  (2)  of  experimental  study  of 
similar  conditions  in  animals;  (3)  of  therapeutic  ex- 
periments on  nephrectomized  animals  vmder  the 
same  conditions;  (4)  of  therapeutic  experiments 
with  kidney  extracts  on  nephritics,  with  or  without 
uraemia;  (5)  of  metaboHsm  studies  in  chronic  ne- 
phritis in  man;  (6)  of  metabolism  studies  in  animals 
after  partial  extirpation  of  the  kidney;  (7)  of  ex- 
perimental study  of  the  eflfects  of  kidney  extracts  on 
blood  pressure;  (8)  of  the  effects  of  removal  of 
large  portions  of  the  kidney  on  the  heart  and  blood 
pressure;  (9)  of  the  effect  of  the  serum  of  animals 
with  experimental  nephritis  on  blood  pressure;  (10) 
of  the  relation  of  chronic  interstitial  nephritis  to  in- 
creased secretion  of  the  suprarenal  bodies  and  the 
influence  of  the  latter  upon  the  cardiovascular  sys- 
tem ;  (11)  of  the  determination  of  the  presence  of 
adrenalin  in  the  serum  of  nephritics  or  of  animals 
with  lesions  of  the  kidneys;  (12)  of  the  study  of 
nephrotoxic  or  endotheliotoxic  substances  in  the 
serum,  of  animals  with  experimental  nephritis. 

Some  of  the  conclusions  reached  under  these  vari- 
ous headings  may  be  mentioned.  Experiments  on 
dogs,  consisting  of  the  removal  of  varying  amounts 
of  kidney  substance,  led  to  the  conclusion  that  there 
was  no  evidence  that  the  kidney  had  any  influence 
on  general  metabolism,  either  through  an  internal 
secretion  or  in  any  other  manner.  In  fact,  there 
was  little  experimental  evidence  to  support  the  the- 
ory of  an  internal  secretion  of  the  kidnev.  Pearce 
found  that  the  removal  of  more  than  three  fourths 
of  the  kidney  substance  led  to  loss  of  appetite  and 
inanition.    There  seemed,  however,  to  be  no  impor- 


tant gastrointestinal  disturbance ;  but  when  a  gastric 
fistula  was  established,  the  stomach  of  the  animal 
would  not  retain  the  substances  introduced  into  it. 
So  it  was  concluded  that  the  removal  of  large  por- 
tions of  kidney  substance  did  interfere  with  the 
tunctions  of  the  alimentary  canal.  In  four  experi- 
ments the  total  nitrogen  contents  of  the  faeces  of 
nephrectomized  dogs  suffered  no  marked  change, 
and  the  inanition  and  gastrointestinal  disturbance 
could  not  be  explained  by  impaired  absorption  or  by 
undue  elimination  of  protein  substances. 

Xo  pressor  substance  exists  in  the  normal  kidney. 
The  blood  serum  of  animals  poisoned  by  uranium 
nitrate,  however,  contains  a  substance  which  has  a 
definite  effect  on  blood  pressure.  "Tt  matters  little 
whether  the  substances  causing  these  pressure  ef- 
fects are  retained  products  of  metabolism  or  are 
substances  increased  by  the  vicarious  action  of  other 
organs,  or,  for  that  matter,  are  the  result  of  an  in- 
ternal secretion  of  the  kidney  itself.  It  is  also  a 
matter  of  indifference  whether  the  immediate  effect 
is  pressor  or  depressor.  The  importance  is  that  in 
disease  of  the  kidney  there  occurs  in  the  blood 
serum  in  increased  amount  a  substance  or  substances 
affecting  blood  pressure,  and  therefore,  of  supreme 
importance  as  evidence  of  chemical  correlation  in 
the  pathology  of  diseases  of  the  kidney."  It  is  diffi- 
cult to  determine  whether  there  are  primary  changes 
in  the  suprarenal  bodies  of  patients  suffering  .from 
nephritis  and  increased  arterial  pressure  and  arterial 
degeneration  which  are  productive  of  an  increase  of 
the  secretion  of  that  organ  and.  in  turn,  produce 
arterial  supertension  and  degeneration,  or  whether 
the  changes  in  the  suprarenal  bodies  are  secondary 
to  the  disease  of  the  kidney  or  of  the  arterial  system. 

It  has  been  stated  that  it  is  possible  to  cause  dila- 
tation of  the  pupil  of  the  frog's  eye  after  enuclea- 
tion by  instilling  the  serum  from  a  subject  of  ne- 
phritis, thus  showing  that  such  a  serum  contains 
adrenalin.  The  presence  of  adrenalin  in  the  blood 
serum  may  also  be  determined  by  the  action  of  the 
serum  on  a  "vessel  strip"  preparation.  Pearce  has 
been  unable  to  confirm  these  results.  In  the  serum 
of  four  dogs  suffering  from  nephritis,  in  three  cases 
produced  experimentally,  the  frog's  pupil  reaction 
was  negative.  Xegative  results  were  obtained  with 
the  serum  of  rabbits  suffering  from  nephritis.  Ex- 
perimental work  has  indicated  that  the  serum  of 
dogs  suffering  from  nephritis  contains  nephrotoxic 
substances.  But  no  such  substances  can  be  demon- 
strated in  the  serum  of  man  during  the  course  of 
nephritis.  Experiments  with  vascular  poisons,  such 
as  the  salts  of  chromium  and  uranium,  arsenic  tri- 
oxide,  ricin,  snake  venom,  and  nephrotoxic  immune 
serum,  show  that  there  is  a  general  relation  between 
hydraemia  and  the  kidney  lesion  in  the  production 


392 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


of  oedema,  and  that  the  vascular  poisons  play  a  very 
important  part  in  the  aetiology  of  oedema.  Reason- 
ing from  the  results  of  these  experiments  to  human 
pathology,  one  would  appear  to  be  justitied  in  at 
least  suspecting  that  the  accumulation  of  toxic  sub- 
stances in  the  blood  was  a  factor  in  the  production 
of  oedema  by  their  injurious  action  on  the  endo- 
thelial lining  of  the  vessels.  It  will  be  seen  from 
this  review  that  there  is  much  experimental  evidence 
to  show  the  chemical  interrelationship  between 
chronic  renal  inflammation  and  degeneration,  arterio- 
sclerosis, oedema,  uraemia,  and  other  symptoms  of 
the  disease. 


Tl-l^:  ACCIDEXTS  AND  COMPLICATIOXS 
OF  CYSTOCELE. 

Inguinal  and  femoral  hernije  of  the  bladder 
usually  imdergo  their  evolution  without  any  com- 
plication arising,  so  that  it  is  during  the  operation 
for  radical  cure  that  they  are  recognized.  Hernia 
of  the  bladder,  however,  may  give  rise  to  a  certain 
number  of  complications  and  accidents  of  variable 
ini])OFtance.  A  careful  study  of  the  subject  by 
Gruget  {These  dc  Paris,  1907)  has  recently  been 
published  and  deserves  attention.  The  writer  con- 
siders the  following  complications:  i.  Irreducibility. 
2.  Lithiasis  in  the  vesical  diverticulum.  3.  L^rinarv 
accidents.  4.  Strangulation.  Irreducibility,  a  com- 
mon feature  in  cVstocele,  may  in  some  cases  be  con- 
sidered as  an  accident,  on  account  of  the  diag- 
nostic errors  to  which  it  may  give  rise.  Eithiasis 
is  an  infrequent  complication,  the  calculi  being  sec- 
(Midary  and  in  nature  pbosphatic,  which  may  form 
either  in  the  bladder,  entering  the  vesical  diverticu- 
lum, or  directly  in  the  latter.  They  give  rise  to  less 
distinct  symptoms  than  those  of  ordinary  stone  in 
the  bladder.  Their  presence  indicates  a  certain  de- 
gree of  vesical  infection.  • 

Th.e  urinarv  complications  are  retention,  incon- 
tinence, cystitis,  ascending  infection,  and  renal  re- 
tentions having  a  mechanical  cause,  such  as  kinks 
or  conapression  of  the  ureter.  They  originate  from 
two  diflferent  mechanisms,  which  may  aggravate 
each  other.  In  some  cases  they  are  due  directly  to 
the  cystocele,  and  then  they  arise  only  when  the 
vesical  hernia  is  quite  considerable.  In  other  cases, 
and  these  are  by  far  more  frequent,  they  are  the 
results  of  the  anatomical  lesions  which  create  the 
cystocele,  as  in  old  infected  bladders,  .strictures,  and 
enlargement  of  the  prostate.  Consequently  the 
urinary  accidents  in  cystocele  are  serious,  particu- 
larly on  account  of  the  lesions  which  ])ro(luce  the 
cystocele,  the  latter  in  its  turn  aggravating  them 
and  acting  as  an  obstacle  to  their  cure.  The  so 
called  accidents  of  strangulation  are  of  two  orders, 
differing  from  each   other   according  to  whether 


they  arise  in  an  enterocystocele  or  in  a  pure  cysto- 
cele. In  the  former  the  bladder  appears  to  have 
rather  a  favorable  action  from  the  standpoint  of 
the  evolution  of  the  accidents,  which  are  less  sudden 
and  intense,  probably  because  they  are  spread  over 
a  large  surface  and  consequently  alter  the  eflfects 
of  a  very  narrow  constriction.  In  pure  cystocele 
they  are  subject  to  a  more  complex  interpretation. 
One  may  be  dealing  with  an  extraperitoneal  cysto- 
cele, which  is  usually  the  case,  more  rarely  with  the 
paraperitoneal  type.  This  is  also  an  accident  which 
usually  occurs  in  adults  and  elderly  men. 

Anatomically,  the  classical  hernice  found  in  in- 
testinal strangulation  are  not  encountered  here. 
The  bladder  does  not  present  the  characteristic  le- 
sions utdess  there  is  a  more  or  less  marked  bend  in 
the  inguinal  canal.  Consequently  the  word  strangu- 
lation should  be  eliminated  so  far  as  pure  cystocele 
is  concerned,  and  with  a  few  rare  exceptions  the 
accidents  are  those  of  pseudostrangulation.  Pre- 
vesical lipoccle,  which  is  often  circumvesical,  should 
theoretically  be  a  protection  if  complications  occur. 
The  mechanism  appears  to  be  susceptible  of  a  d.if- 
ferent  interpretation  in  paraperitoneal  and  in  extra- 
peritoneal cystocele.  The  accidents  in  the  latter  are 
probably  reflex,  the  abdominal  sympathetic  appear- 
ing to  play  the  same  part  as  in  certain  lesions  of 
the  upper  urinary  tract,  such  as  movable  kidney, 
hydronephrosis,  and  renal  lithiasis.  In  paraperi- 
toneal cystocele  the  accidents  may  be  of  the  same 
kind,  but  it  may  happen  that  a  loop  of  intestine  or 
a  bit  of  omentum  may  have  been  in  the  sac,  although 
at  the  operation  the  latter  may  be  found  empty. 
Clinically,  the  symptoms  are  similar  to  those  of 
strangulated  epiplocele  or  a  lateral  pinching  of  the 
intestine,  less  commonly  accompanied  by  urinary 
manifestations,  which  for  that  matter  are  indefinite. 
The  anatomical  diagnosis  under  these  circumstances 
being  usually  impossible,  an  operation  should  be 
done  at  once  just  as  in  ordinary  strangulated 
hernia. 


CA.\CER  OF  THE  T.RFAST  IN'  MEN. 

The  rarity  of  malignant  disease  of  the  mammary 
gland  in  male  subjects  is  much  greater  according  to 
some  explorers  of  literature  than  according  to 
others.  In  tlie  December  number  of  the  Archives 
gcncrales  dc  mcdecinc  we  find  an  interesting  lec- 
ture on  the  rlevclo]MUcnt  of  the  male  mannna  and 
on  cancer  of  the  organ,  delivered  at  the  Lariboisiere 
Hospital  by  Dr.  I'.  E.  Launois.  He  tells  us  that 
until  recently  he  hin'.self  had  met  with  only  two  ex- 
amples of  mammary  cancer  in  the  male,  but  lately 
has  seen  two  others.  In  Poirier's  thesis  on  tumors 
of  the  breast  in  men,  written  in  1883,  that  author 


February  20,  1909.] 


NEWS  ITEMS. 


395 


stated  that,  after  a  long  search  with  the  aid  of 
earnest  assistants,  he  had  been  able  to  find  reports 
of  not  more  than  a  hundred  cases  of  cancer  of  the 
male  breast,  and  that  two  thirds  of  them  had  been 
recorded  in  English  medical  literature.  But  more 
recently,  in  1907,  an  Italian  author,  Dr.  Palermo 
(whose  essay,  curiously  enough,  was  published  in 
Palermo),  has  given  a  collection  of  750  cases  of 
tumor  of  the  male  breast,  649  of  which  were  car- 
cinomatous. So  far  as  M.  Launois"s  own  cases  go, 
they  warrant  the  conclusion  that  mammary  cancer 
in  a  man  is  of  the  same  type  that  it  would  be  like- 
ly to  present  in  a  woman  of  the  same  period  of  life. 

 <$:  

Jetos  |tms. 

Changes  of  Address. — Dr.  Alyer  Solis-Cohen,  to  4102 
Girard  Avenue,  Philadelphia. 

The  Eye,  Ear,  Nose,  and  Throat  Hospital,  of  New 

Orleans,  La.,  received  recently  from  Mrs.  E.  L.  Parker,  of 
Bultalo.  N.  Y.,  a  gift  of  $1,000,  to  be  used  in  promoting  the 
work  of  the  hospital. 

The  Chicago- Winfield  Tuberculosis  Sanatorium,  at 
Winfield,  111.,  was  dedicated  with  appropriate  ceremonies 
on  February  7th.  This  institution  was  built  by  the  Jews  of 
Chicago,  but  it  is  nonsectarian. 

Animal  Experimentation  in  Its  Relation  to  Human 
Life  was  the  title  of  a  paper  read  by  Dr.  James  P.  W'ar- 
basse  at  a  stated  meeting  of  the  New  York  Academy  of 
Medicine,  held  on  Thursday  evening,  February  i8th. 

Charitable  Bequests. — By  the  will  of  Lizzie  E.  Wil- 
son, of  Paris,  N.  Y.,  the  Hospital  of  the  Good  Shepherd, 
Syracuse,  receives  $2,500. 

By  the  w^ill  of  Afrs.  Eva  Smith  Cochran,  the  Homoeopa- 
thic Hospital,  Yonkers,  N.  Y.,  receives  $20,000. 

The  Harvey  Society  Lectures. — The  next  lecture  in 
the  course  will  be  given  on  Saturday  evening,  March  6th, 
at  8:30  o'clock,  by  Professor  C.  B.  Davenport,  of  the  Sta- 
tion for  Experimental  Evolution,  Coldspring  Harbor,  N.  Y. 
The  subject  will  be  Heredity  in  Man. 

Smallpox  Epidemic  in  Mexico. — .According  to  press 
despatches,  smallpox  is  raging  in  Tecajete  and  Tepeya- 
hualco,  and  a  special  corps  of  doctors  has  been  sent  to  these 
towns  from  Mexico  City.  Isolation  hospitals  have  been- 
established,  compulsory  vaccination  is  being  enforced,  and 
everything  is  being  done  to  stop  the  spread  of  the  disease. 

Medical  Legislation  to  Protect  the  Public. — The 
Medical  Jurisprudence  Society  of  Philadelphia  selected  this 
subject  for  discussion  at  its  February  15th  meeting.  Adolph 
Eichholz,  Esq.,  presented  the  citizen's  view  of  the  subject; 
Dr.  Seneca  Egbert  dealt  with  the  subject  from  the  medical 
college's  viewpoint ;  and  Dr.  L.  Webster  Fox  took  up  the 
subject  from  the  point  of  view  of  the  practitioner. 

The  Alumni  Association  of  the  Lying-in  Hospital, 
New  York,  will  hold  its  first  meeting  at  the  Harvard  Cluli, 
27  West  Forty-fourth  Street,  on  March  9th,  at  8:30  p.  m. 
The  paper  of  the  e\  ening  will  be  read  by  Dr.  Barton  Cooke 
Hirst,  of  Philadelphia,  on  The  Scope  of  Obstetrics  as  a 
Surgical  Specialty.  Dr.  J.  E.  Lumbard,  1925  Seventh  Ave- 
nue, New  York,  is  secretary  of  this  recently  organized  as- 
sociation. 

The  University  of  Pennsylvania  Medical  Society  of 
New  York  and  'Vicinity  will  hold  its  next  regular  meet- 
ing on  the  evening  of  Saturday,  February  20th,  at  8:30 
o'clock,  at  the  University  Club  Rooms,  124  jWest  Forty- 
seventh  Street,  New  York.  The  paper  of  the  evening  will 
be  read  by  Dr.  David  L.  lidsall,  of  Philadelphia,  on  Some 
Relations  of  Occupations  to  Disease.  The  discussion  will 
be  opened  by  Dr.  Theodore  C.  Janeway. 

New  York  Physicians  not  up  to  Physical  Standard 
in  Army  Test. — .A.t  a  recent  examination  of  candidates 
for  appointment  in  the  medical  corps  of  the  United  States 
Armj',  more  than  a  dozen  young  physicians  from  New 
York  were  disqualified  on  account  of  failing  to  reach  the 
physical  standard  required.  Of  the  fifty-six  candidates 
who  presented  themselves  for  examination  only  fourteen 
were  successful  in  passing,  and  of  these  not  one  was  from 
New  York. 


The  Federal  Food  and  Drugs  Act  and  Its  Enforce- 
ment was  the  subject  of  a  lecture  delivered  at  the  Mcd- 
ico-Chirurgical  College,  Philadelphia,  on  the  evening  of 
h'ebruary  15th,  by  Mr.  Clement  S.  Brinton,  chemist,  U.  S. 
Bureau  of  Chemistry.  This  lecture  is  one  of  the  special 
evening  lectures  on  practical  chemistry  arranged  by  the 
college,  which  are  open  to  the  public.  It  was  illustrated  by 
lantern  views  and  the  exhibition  of  materials  and  ap- 
paratus. 

The  Denver  and  Gross  College  of  Medicine. — At  tlie 

recent  annual  meeting  of  the  faculty  of  this  college  the  fol- 
lowuig  officers  were  elected :  Dr.  G.  H.  Stover,  dean ;  Dr. 
F.  C.  Buchtel,  secretary ;  Dr.  G.  M.  Black,  president  of  the 
hoard  of  trustees;  Dr.  G.  H.  Stover,  vice-president  of  the 
board  of  trustees ;  Dr.  F.  C.  Buchtel,  secretary  of  the  board 
of  trustees:  other  members  of  the  board.  Dr.  C.  B.  Van 
Zant,  Dr.  C.  K.  Fleming,  Dr.  Leonard  Freeman,  Dr.  D.  H. 
Coover,  Dr.  S.  B.  Childs,  and  Dr.  T.  IT.  Hawkins. 

Research  Fellowship  at  Johns  Hopkins.— The  Sarah 
Berliner  Research  Fellowship  for  Women,  which  is  given 
every  two  years  at  the  Johns  Hopkins  Medical  School,  car- 
ries with  if  an  allowance  of  $1,200,  to  be  devoted  to  study 
and  research  work  in  physics,  chemistry,  and  biology,  which 
may  be  carried  on  either  in  tbis  country  or  in  Europe.  The 
fellowship  is  open  to  women  holding  the  degree  of  doctor 
of  philosophy,  or  those  similarly  equipped  for  research 
work.  All  applications  must  reach  the  committee  before 
March  ist. 

A  Bill  to  Incorporate  the  American  Academy  of 
Medicine  has  been  introduced  into  Congress  by  Senator 
Gallinger,  of  New  Hampshire.  This  academy  was  organ- 
ized thirty-four  years  ago,  and  during  that  lime  has  been 
maintained  solely  by  the  dues  paid  by  the  members,  but  it 
is  planned  now  to  enlarge  the  scope  of  the  organization  b.v 
making  it  a  national  body.  Among  the  incorporators  named 
in  the  bill  are  prominent  members  of  the  medical  profes- 
sion in  all  parts  of  the  United  States.  The  headquarters 
of  the  new  association  will  be  in  Washington,  D.  C. 

Fair  for  the  People's  Hospital. — A  number  of  women, 
well  known  in  New  York  Society,  have  undertaken  t  ) 
erect  a  non-sectarian  hospital  on  Second  Avenue,  between 
Twelfth  and  Thirteenth  Streets,  New  York,  which  will  be 
known  as  the  People's  Hospital.  A  fair  in  aid  of  this  work 
will  be  held  in  the  Twenty-second  .\rmory,  Broadway  and 
Sixty-ninth  street.  President  Roosevelt,  by  pressing  an 
electric  button  in  Washington,  will  open  the  fair  on  Satur- 
day evening,  February  20th.  Governor  Hughes,  accom* 
panied  by  his  military  staff,  will  be  present  and  deliver  an 
address. 

The  International  .Medical  Congress. — The  Secretary 
General  of  the  Sixteenth  International  Medical  Congress, 
which  meets  in  Budapest,  August  29th  to  September  4th, 
again  announces  that  the  manuscripts  of  all  addresses  to  be 
presented  at  this  congress  must  be  sent,  not  later  than  Feb- 
ruary 28th,  to  the  office  of  the  congress,  VIII.  Esterhazy- 
utca  7,  Budapest,  Hungary.  He  also  wishes  to  direct  at- 
tention to  the  fact  that  the  subscription  to  this  scientific 
gathering  is  twenty-five  crowns  in  .Austro-Hungarian  cur- 
rency, which  sum  may  be  sent  by  post  office  money  order  to 
Dr.  de  Elischer,  treasurer  of  the  congress. 

The  Site  of  the  Long  Island  State  Hospital. — Senator 
Raines's  bill,  proxiding  for  the  sale  or  exchange  of  the 
Creedmore  rifle  range  for  lands  to  be  used  as  a  site  for  the 
hospital,  passed  the  senate  on  February  T6th,  and  will  be- 
come law  as  soon  as  Governor  Hughes's  approval  has 
been  obtained.  The  Creedmore  rifle  range  was  designated 
as  a  site  for  the  Long  Island  State  Hospital  by  an  act  of 
legislature  last  year,  but,  while  the  board  of  managers  of 
the  hospital  were  in  favor  of  these  lands  as  a  site  for  the 
hospital,  there  was  much  opposition  on  the  part  of  real 
estate  interests. 

A  Laboratory  for  Serum  Diagnosis  at  Harvard. — The 
department  of  path.ology  of  the  Harxard  Medical  School 
announces  the  estal)lishment  of  a  laboratory  for  serum 
diagnosis,  which  will  be  under  the  direction  of  Dr.  Freder- 
ick P.  Gay.  This  new  laboratorj-  offers  facilities  for  re- 
search work  in  the  physiology  and  pathology  of  blood 
serum  and  tissue  fluids,  and  also  for  diagnostic  work.  The 
fees  for  the  various  tests  will  be  based  on  the  amount  of 
skill  and  labor  involved.  Special  arrangements  will  be 
made  with  hospitals  and  dispensaries,  and  with  physicians 
for  their  charity  patients.  All  inquiries  regarding  the 
work  of  the  new  laboratory  should  be  addressed  to  Dr. 
Frederick  P.  Gay,  240  Longwood  Avenue.  Boston. 


394 


NEirS  ITEMS. 


[New  York 
Medical  Journal. 


The  German  Charity  Ball. — The  net  receipts  from 
this  ball,  which  was  given  on  the  evening  of  February  4th, 
at  the  Waldorf-Astoria,  amounted  to  $11,000.  This  sum 
has  been  distributed  among  various  New  York  institutions 
as  follows:  The  German  Hospital  and  Dispensar_v,  $2,000; 
St.  Mark's  Hospital,  $1,300;  St,  Francis's  Hospital,  $1,300; 
the  German  Society,  $1,300;  the  Isabella  Home,  $1,000;  the 
Wartburg  Orphans'  Farm  School,  $1,000;  the  Deutscher 
Frauen  V'erein,  $900;  and  the  West  Side  German  Dis- 
pensary. $900. 

The  Health  of  Pittsburgh.— During  the  week  ending 
February  6,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  :  Oiickenpox, 
13  cases,  o  deaths;  typhoid  fever,  24  cases,  i  death;  scar- 
let fever,  22  cases,  2  deaths;  diphtheria,  11  cases,  2  deaths; 
measles,  34  cases,  0  deaths ;  whooping  cough,  12  cases,  o 
deaths ;  pulmonary  tuberculosis,  48  cases,  16  deaths.  The 
total  deaths  for  the  week  numbered  158,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  14.54  in  a  thousand  population. 

The  Mortality  of  New  Orleans. — During  the  month 
of  January,  1909,  there  were  reported  to  the  Board  of 
Health  of  the  City  of  New  Orleans  657  deaths  from  all 
causes,  426  white  and  231  colored.  The  annual  death  rate 
in  a  thousand  population  for  the  month  was  19.29  for  the 
white,  28.58  for  the  colored,  and  21.78  for  the  total  white 
and  colored  population.  The  total  infant  mortality  was 
140,  90  white  and  50  colored :  80  whites  under  one  year  of 
age,  and  45  colored ;  10  whites  between  one  and  two  years 
of  age,  and  5  colored.  There  were  37  still  births ;  20  white 
and  17  colored. 

The  Lebanon  Hospital  and  Dispensary,  Philadelphia, 
which  was  chartered  m  1907,  was  opened  last  month.  The 
staff  of  the  hospital  is  as  follows :  Medical  department, 
which  includes  tuberculous  disease,  nervous  and  mental 
diseases,  and  skin  diseases.  Dr.  Albert  Bernheim ;  surgical 
department,  which  includes  a  dental  clinic,  Dr.  Herman  A. 
Br-.'v  and  Dr.  Joseph  M.  Asher ;  eye  department,  Dr.  B.  L. 
Gordon  and  Dr.  Aaron  Brav ;  diseases  of  children,  Dr. 
Harry  Lowenburg;  nose,  ear  and  throat  department.  Dr. 
B.  L.  Singer ;  genitourinary  department.  Dr.  S.  L.  Gans ; 
diseases  of  women.  Dr.  '.-Mfred  Heineberg  and  Dr.  M.  V. 
Leaf. 

Infectious  Diseases  in  New  York: 

IVc  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folloicing  statement  of  new 
cases  and  deaths  ref'orfed  for  the  tik'o  weeks  ending  Feb- 
ruary 7j,  1009: 

^February  6—,  ^February  1 3—, 
Cases.    Heaths.    Cases.  Deaths. 

Tuberculosis  j.ulniona'.is    4S7  180         444  180 

Diphtheria    42^  4-         496  56 

Measles    S3>  28         499  13 

Scarlet  fever  ...    370  21  367  18 

SmaIl|io.\   

Varicella    2^5  •  •  234 

Tyi-hoid  fever    26  7  25  9 

Wlmopnig  cough    5J  3  4S  4 

Cerebrospinal  meningitis    12  11  4  4 

Totals   2,113         292       2,117  284 

Lectures  on  Tumors. — Dr.  Harvey  Gushing,  of  Balti- 
more, on  Thursday,  February  25th,  will  deliver  the  next 
lecture  in  the  course  which  is  being  given  by  the  Cancer 
Commission  of  Harvard  University.  His  subject  will  be 
The  Physiological  Pathology  of  Intracranial  Tumors.  Dr. 
S.  B.  Wolbach,  of  .Albany,  N.  Y.,  will  give  the  fifth  lecture 
on  March  4th,  on  The  .'F.tiology  of  Tumors  considered 
from  nm  Knowledge  of  Congenital  Tumors  and  Tiunnrs 
following  Repeated  Injury.  The  last  lecture  in  the  series 
will  be  delivered  by  Dr.  F.  P.  Gay,  of  Boston,  on  March 
ilth,  on  the  Proiilem  of  Cancer  considered  from  the  Stand- 
point of  Immunity. 

Radiography  of  the  Accessory  Sinuses  of  the  Nose 
was  the  p.'-incipal  subject  discussed  at  the  twenty-tiiird 
stated  meeting  of  the  Tri-Professional  Medical  Soci'-tv, 
held  in  New  York  on  February  i6th.  A  paper  on  this  topic, 
accompanied  by  a  demonstration  of  plates,  was  presented  by 
Dr.  (ieorge  M.  Mac  Kee  and  Dr.  S.  J.  Kopetzky.  and  the 
various  aspect^  of  the  question  were  discussed  as  follows: 
The  technical  aspect,  by  Dr.  George  M.  Mac  Kee;  the  clin- 
ical, by  Dr.  S.  J.  Kopetzky  :  the  rhinological,  by  Dr.  R.  N. 
Disbrow;  the  dental.  hy  'W.  J.  Lederer.  D.  D.  S. :  and 
the  Rilntgcnological,  by  Dr.  L.  D.  Weiss,  who  exhibited 
plates.  Tlic  remainder  of  the  programme  consisted  of  a 
paper  by  Dr.  G.  K.  Dickinson  entitled  What  is  the  Practice 
of  Medicuie,  followed  by  a  general  discussion. 


The  Work  of  St.  John's  Guild.— The  forty-second  an- 
nual report  of  St.  John's  Guild,  which  has  just  been  issued, 
shows  that  a  total  of  1,339,214  mothers  and  children  have 
been  cared  for  by  the  different  departments  of  the  guild 
since  its  organization.  The  total  endowment  of  the  guild 
novy  amounts  to  $100,683,  and  it  is  expected  that  a  legacy, 
which  is  now  in  the  haiads  of  the  executors,  will  soon  be 
added  to  the  endowment.  The  work  of  the  guild  is  now 
iieing  carried  on  by  means  of  the  two  floating  hospitals 
and  the  Seaside  Hospital  at  New  Dorp,  Staten  Island. 

Alumni  Association  of  the  College  of  Physicians  and 
Surgeons,  New  York. — To  celebrate  the  fiftieth  anniver- 
sary of  the  founding  of  their  association,  the  alumni  of  the 
College  of  Physicians  and  Surgeons,  New  York,  will  meet 
at  a  dinner  to  be  given  at  Sherry's  on  March  2d.  at  seven 
o'clock.  Professor  Samuel  W.  Lambert,  dean  of  the  col- 
lege and  president  of  the  association,  will  preside,  and 
among  the  speakers  will  be  Dr.  Nicholas  Murray  Butler, 
president  of  Columbia  University  ;  Mr.  Seth  Low,  trustee 
and  former  president  of  Columbia  University;  Dr.  H.  A. 
Christian,  dean  of  the  Harvard  Medical  School ;  the  Rev. 
Dr.  Richards,  of  the  Brick  Presbyterian  Church,  New 
York ;  and  Professor  John  G.  Curtis,  of  the  College  of 
Physicians  and  Surgeons.  An  attempt  will  be  made  to 
seat  college  and  hospital  graduates  according  to  the  date 
of  graduation.  Tickets  for  the  dinner  may  be  obtained  on 
or  before  February  26th,  by  addressing  Mr.  E.  T.  Boag. 
College  of  Physicians  and  Surgeons,  437  West  Fifty-ninth 
Street,  New  York. 

A  Unique  Dinner  to  Dr.  Deaver. — Dr.  John  B.  Dea- 
ver,  the  distinguished  surgeon  of  Philadelphia,  was  the 
guest  of  honor  at  a  dinner  given  at  the  University  Club. 
Philadelphia,  on  the  evening  of  February  isth,  which  was 
certainly  one  of  the  most  e.xtraordinary  in  the  history  of 
the  profession.  One  hundred  and  five  members  of  the 
medical  profession  were  present,  and  upon  every  one  Dr. 
Deaver  had  performed  an  operation  for  abdominal  disease, 
sixty  of  the  operations  having  been  for  appendicitis.  Over 
fifty  who  had  been  invited  were  unable  to  be  present.  The 
guests  came  from  all  parts  of  the  United  States,  and  one 
came  from  Canada.  Even  the  waiters  had  been  reliexed 
of  their  appendices  by  the  guest  of  honor.  The  specia-' 
character  of  the  entertainment  was  einphasized  by  the  cos- 
tumes of  the  waiters,  who  were  dressed  in  the  white  duck 
uniforms  of  hospital  internes,  and  by  the  dinner  favors, 
which  were  surgical  manikins,  with  a  surgeon's  scalpel 
sticking  in  the  body  m  the  region  of  the  appendix.  A  lov- 
ing cup  was  presented  to  Dr.  Deaver,  Dr.  William  E. 
Hughes  making  the  presentation  address.  Dr.  Henry  W. 
Stelwagon  acted  as  toastmaster. 

Personal. — Dr.  John  H.  Lowman,  of  Cleveland,  has 
been  elected  president  of  the  Ohio  State  Tuberculosis  So- 
ciety. 

Dr.  Philip  B.  Matz,  former  resident  physician  of  the  New 
York  County  Penitentiary,  Blackwell's  Island,  has  just  re- 
turned from  Europe,  where  he  has  been  for  the  past  three 
months,  and  has  opened  an  office  for  private  practice  at  74 
West  Ninety-first  Street,  New  York. 

Dr.  George  H.  Stover  has  been  appointed  dean  of  the 
medical  faculty  in  the  Department  of  Medicine  of  the  Uni- 
versity of  Denver. 

Dr.  S.  Adolphus  Knopf,  of  New  York,  delivered  a  lec- 
ture at  Public  School  148,  Hopkins  Street,  Brooklyn,  on 
Thursday  evening,  February  i8th,  on  The  Prevention  of 
Tuberculosis. 

Dr.  G.  Morgan  Muren,  of  Brooklvn,  has  opened  an  office 
at  II  East  Forty-eighth  Street,  New  York,  but  will  con- 
tinue his  residence  and  former  hom-s  for  consultation  at 
38  Orange  Street.  Brooklyn. 

Dr.  S.  Weir  Mitchell,  of  Philadelphia,  celebrated  his 
eightieth  birthday  on  Monday.  February  15th. 

Dr.  11.  W.  Lincoln,  of  Brooklyn,  has  been  appointed  gas- 
1  roenterologist  to  the  Eastern  District  and  the  Samaritan 
I  lospitals. 

Dr.  Cahnette,  of  Lille:  Dr.  Sven  Hedin,  of  Stockholm; 
Dr.  Robert  F.  Scharff,  of  Dublin  :  and  Dr.  John  M.  Clarke, 
of  Albany,  N.  Y.,  have  been  appointed  correspondents  of 
the  Philadelphia  .-Xcademy  of  Natural  Sciences. 

Dr.  John  J,  Gilbride,  of  Philadelphia,  read  a  paper  en- 
titled Recent  .Advances  in  oit  Knowledge  of  Digestive 
Processes  at  ;i  meeting  of  the  Mercer  Comity.  N.  J.,  Medi- 
cal Society  heki  in  Trenton  receiUly. 

Dr.  Joseph  M.  Mathews,  of  Louisville.  Ky..  was  the  guest 
of  honor  at  a  recent  meeting  of  the  l>os  .Angeles,  Cal.,  .Acad- 
erny  of  Medicine.  Dr.  Mathews  is  spending  the  winter  in 
California. 


February  20,  1909.  J 


NEWS  ITEMS. 


395 


Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  ending  February  27,  1909: 

Monday,  February  S2d. — Alineralogical  and  Geological 
Section,  Academy  of  Natural  Sciences;  Society  of 
Normal  and  Pathological  Physiologj-. 

Wednesday,  February  34th. — Philadelphia  County  Medical 
Society. 

Thursday,  February  2^th. — Pathological  Society  ;  Ameri- 
can Entomological  Society  and  the  Entomological  Sec- 
■tion,  Academy  of  Natural  Sciences ;  Section  Meeting, 
Franklin  Institute ;  Philadelphia  Botanical  Club. 
Friday,  Feb^-uary  26th. — Philadelphia  Neurological  Society  ; 
Northern  Medical  Association ;  South  Branch,  Phila- 
delphia County  IMedical  Society. 
Health  Requirements  for  Marriage  Licenses  in  Penn- 
sylvania.— A  bill  has  been  presented  in  the  legislature 
of  Pennsylvania  which  provides  for  the  conditions  under 
which  marriage  licenses  may  be  issued  in  Pennsylvania. 
The  bill  is  similar  to  the  one  now  in  force  in  Indiana.  The 
important  clause  in  the  bill  is  the  following :  '"The  clerk  of 
the  Orphans'  Court  shall  not  issue  any  marriage  license 
until  each  of  the  parties  applying  therefor  shall  severally 
present  to  the  clerk  a  certificate,  under  oath  of  affirmation, 
from  a  medical  doctor,  duly  authorized  to  practise  medi- 
cine under  the  laws  of  the  Commonwealth,  setting  forth 
that  to  him,  the  said  medical  doctor  does  declare  that  to  the 
best  of  his  knowledge  and  belief  the  applicants  for  the 
license  are  not  afflicted  with  pulmonary  tuberculosis,  epi- 
lepsy, insanity,  imbecility,  idiocy,  or  other  hereditary  dis- 
ease, such  as  would  affect  the  other  contracting  party  to 
such  marriage  or  any  offspring  therefrom." 

The  Medical  Society  of  the  County  of  New  York  will 
hold  a  stated  meeting  in  Hosack  Hall,  New  York  Academy 
of  ^ledicine,  on  Friday  evening,  February  26th.  \  Study 
of  Eunuchoididmus  in  its  Various  Aspects  and  its  Relations 
to  Allied  Pathological  States  is  the  title  of  a  paper  to  be 
read  by  Dr.  B.  Onuf,  which  will  be  discussed  by  Dr.  Joseph 
Collins,  Dr.  Harlow  Brooks,  Dr.  Joseph  Fraenkel,  Dr. 
Michael  J.  Thornton,  and  Dr.  Abraham  L.  Wolbarst.  Dr. 
Edwin  J.  Banzhaf,  of  the  laboratory  of  the  Board  of 
Health,  will  readi  by  invitation,  a  paper  entitled  Proteins 
in  the  Serum  of  Immunized  Horses  and  the  Separation  of 
the  Antitoxines  for  Therapeutic  Uses.  This  paoer  will  be 
discussed  by  Dr.  William  H.  Park,  Dr.  H.  L.  Lynah,  and 
Dr.  Herbert  W.  Wootton.  A  paper  entitled  The  Value  of 
the  Milk  Free  Diet  and  Enteroclysis  in  Typhoid  Fever  will 
be  read  by  Dr.  Robert  Coleman  Kemp,  and  discussed  by 
Dr.  August  Seibert.  A  collation  will  be  served  at  the  close 
of  the  meeting,  to  which  guests  as  well  as  members  are  in- 
vited. 

The  International  Tuberculosis  Exhibition  in  Phila- 
delphia was  formally  opened  to  the  public  on  Monday 
evening,  February  15th.  Dr.  Joseph  S.  Neff.  presided,  and 
among  the  speakers  were  Mayor  Reyburn,  Dr.  Martin  G. 
Brumbaugh,  and  Dr.  Lawrence  F.  Flick.  A  private  view  of  the 
exhibition  was  afforded  the  newspaper  men  of  the  city  on 
the  Friday  preceding  the  formal  opening;  on  Saturday  and 
Sunday  school  teachers  were  shown  the  exhibit,  and  on 
Monday  morning  the  clergj'men  of  the  city  visited  it.  The 
exhibition  is  open  to  the  public  every  day,  and  addresses 
dealing  with  the  various  phases  of  tuberculosis  are  deliv- 
ered every  evening.  Thursday,  February  i8th.  was  "Path- 
ological Day  for  Physiciins,"  and  those  who  visited  the 
exhibit  on  that  day  had  the  privilege  of  inspecting  a  splen- 
did collection  of  pathological  specimens,  which  had  been 
arranged  especially  for  the  occasion.  .At  the  evening  meet- 
ing Dr.  W.  M.  L.  Coplin,  professor  of  pathologj'  in  the  Jef- 
ferson Medical  College,  presided,  and  addresses  were  de- 
livered by  Dr.  Joseph  McFarland,  professor  of  pathologj^  at 
the  Medico-Chirurgical  College,  and  Dr.  R.  M.  Pearce,  pro- 
fessor of  pathology  in  the  Bellevue  Medical  School.  Sat- 
urday, February  20th,  was  Children's  Day."  A  special  pro- 
gramme was  presented  in  the  afternoon,  at  which  Dr.  .\bra- 
ham  Jacobi,  of  New  York,  delivered  an  address.  Pure  food 
legislation,  diet,  and  cooking,  are  the  subjects  chosen  for 
consideration  at  the  meeting  to  be  held  on  Monday  evenine, 
February  22d,  and  the  lecturers  will  be  Dr.  Harvey  W. 
Wiley,  chief  of  the  Bureau  of  Chemistry,  U.  S.  Department 
of  .Agriculture,  and  Mr.  Charles  La  Wall,  chemist  to  the 
Pennsylvania  State  Dairy  and  Food  Commission.  Dr. 
James  Tyson  will  oreside.  On  Februarv  27th  a  ••>^e°tino- 
of  labor  unions  will  be  held,  at  which  Mr.  John  Mitchell 
will  preside. 


Society  Meetings  for  the  Coming  Week: 

Monday,  February  Medical  Society  of  the  County  of 

New  York. 

Tuesday,  February  jjrf.— New  York  Dermatological  So- 
ciety; New  York  Medical  Union;  Metropolitan  Medi- 
cal Society  of  New  York  City ;  Buffalo  Academy  of 
Medicine  (Section  in  Obstetrics  and  Gynsecology ). 
Wednesday,  February  24th. — New  York  Academy  of  Medi- 
cine (Section  in'  Laryngology  and  Rhinolog>  )  ;  New 
York  Surgical  Society. 
Thursday,  February  s^th. — New  York  .\cademy  of  Medi- 
cine (Section  in  Obstetrics  and  Gjnaecology)  :  Brook- 
lyn Pathological   Society;    Hospital  Graduates'  Club,. 
New  York ;  New  York  Celtic  Society :  Brooklyn  So- 
ciety of  Neurologj-. 
Friday,' February  26th. — Academy  of  Pathological  Science, 
New  York;  New  York  Society  of  German  Physicians; 
New  York  Clinical  Society. 
S.\TURDAY,  February    J/'/'.— West   End   Medical   Society ; 
New  York  Medical  and  Surgical   Society;   Harvar  ]• 
Medical  Society,  New  York ;  Lenox  Medical  and  Sur- 
gical Society,  New  York. 
The  Health  of  Chicago. — .\ccording  to  the  weekly 
bulletin  of  the  Chicago  Department  of  Health,  the  city  is 
enjoying  phenomenally  good  health.    The  death  rate  for 
the  week  ending  February  6,  190Q,  was  13.88.  which  was- 
19  per  cent,  lower  than  the  average  for  the  season,  and 
29.5  per  cent,  less  than  the  record  for  the  corresponding 
week  of  last  year.    The  total  number  of  deaths  from  all 
causes  was  592,  as  against  747  for  the  corresponding  period 
in  1908.   The  contagious  disease  situation  is  improving,  the 
mortality  from  transmissible  diseases  being  lower  than  for 
the  corresponding  period  last  year.    The  following  new 
cases  and  deaths  were  reported  during  the  week :  Diph- 
theria, 154  cases,  10  deaths;  scarlet  fever.  175  cases,  12 
deaths ;  measles,  136  cases,  2  deaths ;  smallpox,  2  cases,  o 
deaths ;   chickenpox,  85  cases,  o  deaths :   pneumonia,  47 
cases,  125  deaths ;  typhoid  fever,  35  cases,  6  deaths ;  whoop- 
ing cough,  12  cases,  i  death ;  tuberculosis  of  the  lungs,  139 
cases,  72  deaths.    Other  important  causes  of  death  were: 
Diarrhceal  diseases,  37  deaths,  of  which  34  were  of  children 
under  two  years  of  age ;  influenza.  5  deaths :  tuberculosis, 
other  than  that  of  the  lungs,  6  deaths;  cancer,  30  deaths; 
nervous  diseases,   10  deaths;   heart  diseases,  51  deaths; 
apoplexy,  11  deaths;  bronchitis,  4  deaths;  Bright's  disease, 
48  deaths;  violence,  31  deaths,  of  which  6  were  suicides; 
contagious  diseases  of  minor  importance,  72  deaths;  all 
other  causes,  131  deaths. 

Foreign  Items  of  Interest. — The  German  Society  of 
Surgery  will  hold  its  thirty-eighth  congress  in  Berlin  on 
.\pril  14th  to  17th.  The  titles  of  papers  to  be  read  at  this 
meeting  should  be  sent,  not  later  than  March  5th,  to  Dr. 
H.  Kummell,  Am  Langenzug  9,  Hamburg  21,  Germany. 

The  German  Society  of  Orthopjedic  Surgery  will  meet 
in  Berlin  on  April  13th.  Twelve  questions  relating  to  the 
congenital  dislocation  of  the  hip  joint  will  be  discussed. 
The  titles  of  papers  to  be  read  at  this  meeting  should  be 
sent  to  Professor  Johachinsthal,  of  Berlin,  prior  to  March 
1st. 

A  committee  consisting  of  the  leading  professors  of  the 
medical  faculties  of  the  four  Royal  universities  of  Brus- 
sels, Belgium,  has  been  formed  under  the  name  Pro  Italia 
Medical,  its  object  being  to  collect  money  for  the  support 
of  children  whose  parents  died  during  the  earthquake  in 
Italy.  It  is  planned  to  make  this  committee  international, 
and  already  societies  have  been  formed  in  Paris,  the  Neth- 
erlands, and  Italy.  The  Queen  of  Italy  is  to  become  the 
protector  of  the  committee. 

The  International  Congress  of  Applied  Chemistry  will 
meet  in  London  this  year  on  ^lay  27th  to  June  2d.  Meet- 
ings of  this  congress  have  been  held  in  the  past  in  Paris, 
Berlin,  Vienna,  and  Rome,  and  it  is  proposed  to  send  an 
invitation  to  the  London  congress  to  hold  its  next  meeting, 
which  will  take  place  in  the  spring  of  1912.  in  New  York. 

^Ir.  George  Berry,  M.  B..  M.  R.  C.  S.  (Edin.).  has  been 
appointed  honorary  surgeon  to  King  Edward  in  Scotland, 
to  succeed  Dr.  Douglas  Argyll  Robertson,  who  died  re- 
cently. 

A  Franco-Danish  Mission  for  the  Study  of  Leprosy  has 
been  suggested  by  Professor  Ehlers,  of  Copenhagen.  He 
has  invited  French  collaborators  to  organize  an  expedition 
to  St.  Croix.  Danish  Antilles,  where  there  are  two  large 
leper  hospitals,  to  study  the  role  of  bedbugs  and  fleas  in 
the  transmission  of  leprosy. 


30 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal 


^it\  si  feunt  f  ittratm. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

J'cbntary  ii,  igog. 
J.    The  Serum  Diagnosis  of  Syphilis, 

By  Frederick  P.  Gay  and  J.  S.  Fitzgerald. 
2.    lliiman  Milk  in  the  Treatment  of  Various  Infections, 

By  Francis  T.  Denny. 
2,.    Psychotherapy  as  Applied  to  Children, 

By  A.  C.  Eastman. 
4.    Medicine  in  the  Bible,  By  Harry  S.  Bernstein. 

1.  Serum  Diagnosis  of  Syphilis.  —  Gay  and 

Fitzs^eralcl  have  examined  the  blood  serum  from 
thirty-eight  patients  with  definite  syphilitic  history 
and  from  thirty-four  patients  in  whom  there  was  no 
history  of  syphilis.  The  cerebrospinal  fluid  was  ex- 
amined from  twelve  patients  with  positive  syphilitic 
history  and  from  twenty-six  patients  with  negative 
syphilitic  history.  So  far  as  was  practicable  each 
blood  serum  was  examined  by  these  methods  :  ( i ) 
The  Wassermann  fixation  method;  (2)  the  Noguchi 
butyric  acid  globulin  method  ,and  (3)  the  authors' 
modification  of  the  Noguchi  method.  The  cerebro- 
spinal fluids  were  all  examined  by  ( i )  the  Wasser- 
mann method  and. (2)  the  Noguchi  method.  The 
authors  conclude  that  a  positive  Wassermann  reac- 
tion with  the  blood  serum  or  cerebrospinal  fluid  is 
diagnostic  of  sypliilis,  but  that  a  negative  reaction, 
particularly  in  the  tertiary  stage,  is  of  little  absolute 
value.  The  W'assermann  reaction  is  usually  present 
in  secondary  syphilis  and  less  frequently  in  tertiary 
syphilis  and  parasyphilitic  conditions.  The  probable 
eft'ect  of  treatment  on  the  Wassermann  reaction 
may  explain  the  fact  that  the  reaction  is  not  so  fre- 
quent in  the  tertiary,  stage.  The  point  is  of  interest 
as  indicative  of  the  value  of  the  reaction  in  sug- 
gesting when  treatment  should  be  recommended. 
The  authors'  modification  of  Noguchi's  test  for 
globulins  (euglobulin  method)  is  preferable  to  No- 
guchi's original  method  on  account  of  its  rapidity 
and  clear  cut  result.  With  this  method  a  positive 
reaction  is  obtained  in  practically  every  case  with  a 
syphilitic  history.  Its  diagnostic  value  has  very  dis- 
tant limitations,  however,  as  it  is  also  obtained  in 
the  majority  of  sera  from  acute  infectious  diseases, 
although  apparently  never  in  other  conditions.  The 
Noguchi  method  as  applied  to  the  cerebrospinal 
fluid  gives  a  positive  result  in  syphilitic  meningeal 
compHcations  in  many  more  cases  than  does  the 
A\'assermann  reaction.  But  although  it  fails  to  give 
the  reaction  in  cases  without  meningeal  complica- 
tions, it  may  give  it  in  any  case  that  shows  them. 
The  reaction  is,  therefore,  probably  of  value  chiefly 
as  an  adjuvant  in  the  dififerential  diagnosis  of  gen- 
eral paresis.  It  seems  evident  that  the  Noguchi 
method  of  .syphilis  diagnosis,  whereas  of  distinct 
corroborative  value  and  under  certain  limitations  of 
positive  diagnostic  vahie  in  syphilis,  cannot  replace 
the  more  complicated  Wassermann  reaction. 

2.  Human  Milk  in  the  Treatment  of  Various 
Infections. — Denny  ol).serves  that  there  is  a  class 
of  cases  where  human  milk  should  be  used  for  pro- 
phylactic purposes  and  that  is  for  the  prevention  of 
infections  in  infants  in  the  early  stages  of  infantile 
atrophy.  Moro  found  the  complement  diminished 
almost  without  exception  in  the  blood  of  atrophic 
infants,  and  they  have  a  very  low  power  of  resist- 


ance. Infants  born  prematurely  and  those  who  are 
below  normal  size,  as  is  often  the  case  with  twins, 
are  most  likely  to  sufifer  from  atrophy.  When  one 
of  these  small  babies  does  not  begin  promptly  to  gain 
in  weight  human  milk  should  be  given  at  once. 
While  there  is  no  immediate  danger  of  the  infant's 
dying  of  atrophy,  and  while  after  a  time  some  of 
these  infants  will  begin  to  gain  in  weight  on  an  ex- 
clusive artificial  diet,  still  such  a  child  is  living  on 
the  edge  of  a  precipice  and  at  any  time  a  diarrhoea 
or  a  bronchopneumonia  may  develop  which  will 
sweep  it  off.  If  we  grant  that  human  milk,  apart 
from  its  value  as  a  food,  increases  the  resistance  of 
infants  to  infections,  the  question  at  once  arises,  at 
what  age  does  human  milk  cease  to  aid  the  individ- 
ual in  resisting  infections?  If  human  milk  will 
help  an  infant  with  pneumonia  at  the  end  of  its  first 
year,  why  should  it  not  help  a  two  year  old  child 
with  the  same  disease?  He  has  had  at  the  Massa- 
chusetts Infant  Asylum  three  cases  of  very  severe 
gastrointestinal  infections  in  infants  during  their 
second  year  who  were  treated  with  htmian  milk ; 
two  of  them  were  almost  moribund.  The  beneficial 
effects  were  as  prompt  and  decided  as  in  any  cases 
under  a  year  that  he  had  seen.  He  believes  that  hu- 
man milk  would  be  of  value  to  many  older  children 
in  infectious  diseases  running  a  prolonged  course. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

February  ss,  iQOg. 

1.  Therapeutic  Progress,     By  Charles  W.allis  Edmunds. 

2.  Combating   Tropical   Diseases   in   the   Philippines  by 

Scientific  Methods,  By  R.  P.  Strong. 

3.  Medical  Libraries,  By  W.  J.  Conklin,  A.  M. 

4.  Immunit}'  against  Tuberculosis  in  General  Paresis, 

By  A.  J.  Rosanoff. 

5.  History  of  Iridotomy.    Knife  and  Needle  vs.  Scissors — 

Description  of  Author's  V  Shaped  Method, 

By  S.  Lewis  Ziegler. 

6.  Proper  Method  of  Determining  Errors  of  Refraction 

and  Their  Actual  Relation  to  the  Ailments  of  the 
Human  Body,  By  D.  B.  St.  John  Roosa. 

7.  The  Faucial  Tonsils  :  A  Procedure  for  Their  Complete 

Excision,  By  Otto  T.  Freer. 

8.  Hereditary  Hypoplasia  in  Man  Due  to  Degeneracy, 

By  Charles  P.  Noble. 

4.  Immunity  against  Tuberculosis  in  General 
Paresis. — RosanofI"  reports  his  own  observations, 
and  those  made  at  the  State  hospitals  at  Ward's 
Island,  Flatbush,  Middletown,  and  Buffalo,  all  of 
New  York,  in  reference  to  the  relation  of  tubercu- 
losis to  general  paresis.  He  had,  thus,  the  oppor- 
timity  of  examining  the  records  of  1,056  patients, 
of  whom  214  were  sufferers  from  paresis.  He  found 
that  tuberculosis  is  very  prevalent  among  inmates  of 
insane  asylums,  active  lesions  having  been  foinid  in 
23.2  per  cent,  of  the  cases  of  all  p.sychoses  other  than 
general  paresis ;  yet  of  the  cases  of  general  paresis 
only  2.3  per  cent,  showed  the  presence  of  active  tu- 
berculous lesions.  These  statistics,  however,  would 
hardly  be  acceptable  as  proof  of  the  existence  in 
cases  of  paresis  of  imnninity  against  tuberculous  in- 
fection, for  the  reason  that  paresis  occurs  chiefly  be- 
tween the  ages  of  thirty-five  and  fifty-five  years,  that 
is  to  say,  practically  past  the  age  of  greatest  suscep- 
tibility to  tuberculosis.  He  has  found  that  in  gen- 
eral paresis  tuberculosis  was  absent  in  his  patients 
of  the  age  from  one  to  twenty-nine  years ;  present  in 
patients  from  thirty  to  thirty-nine  years  in  2.7  per 
cent. ;  from  forty  to  forty-nine  years  in  4.33  per 


February  20,  1909.  J 


PITH  OF  CURREXT  LITERATURE. 


397 


cent. ;  from  fifty  to  fifty-nine  years  in  2.9  per  cent. ; 
of  sixty  years  and  over  in  12.1  per  cent.  It  has 
been  shown  by  experimental  inoculations  that  pa- 
retics are  immune  against  syphilitic  infection.  This 
immunity  is  attributed  to  previous  syphilitic  infec- 
tion, which  is  now  generally  regarded  as  the  one 
essential  factor  in  the  aetiology  of  general  paresis. 
The  question  that  naturally  suggests  itself  is :  May 
not  the  immunity  against  tuberculosis  be  due  to  the 
same  cause?  Svphilitic  infection,  as  is  well  known, 
gives  rise  in  the  human  organism  to  an  inflammatory 
reaction  which  is  almost  identical  in  its  nature  with 
that  which  results  from  tuberculous  infection.  This 
fact,  it  seems  to  the  author,  adds  probability  to  the 
above  assumption.  In  this  connection  also  other 
questions  of  practical  interest  suggest  themselves : 
If  syphilis  does  confer  immunity  against  tuberculo- 
sis, at  what  clinical  stage  of  syphilis  does  this  im- 
munity develop?  How  would  the  course  of  a  case 
of  tuberculosis  be  affected  by  a  superadded  syphilitic 
infection  ?  He  found  among  all  the  pathological  rec- 
ords five  cases  of  insanity  due  to  syphilitic  brain  dis- 
ease. All  of  the  patients  were  entirely  free  from 
tuberculous  lesions. 

7.  The  Faucial  Tonsils. — Freer  observes  that 
the  most  satisfactory  and  perfect  method  for  the  re- 
moval of  all  varieties  of  diseased  tonsils  is  their  dis- 
section from  the  tonsillar  fossa  with  knives  of  suit- 
able form.  Tonsillotomy  with  the  tonsillotome  or 
snare,  cautery  dissection,  and  the  attempt  to  cause 
shrinkage  of  the  tonsil  by  galvanocaustic  slitting  of 
the  crvpts  are  timid  and  unreliable  methods  which 
should  be  abandoned.  There  is  less  danger  of  pro- 
longed haemorrhage  from  the  rational  excision  of 
the  tonsil  which  he  describes  in  this  paper  than  from 
the  usual  methods  of  its  removal.  Xot  only  tonsils 
which  act  as  obstacles  in  the  throat  because  of  their 
size,  but  all  varieties  of  chronically  diseased  tonsils 
should  be  completely  dissected  out.  The  first  step 
of  the  operation  is  the  dissection  of  the  plica  tri- 
angularis and  anterior  pillar  from  the  tonsil,  the 
sharply  pointed  blade  of  the  pillar  knife  cutting  up 
and  down  underneath  them  until  it  has  freed  them 
entirelv.  The  pillar  knife  must  be  very  sharp,  as  the 
tissues  to  be  cut  are  often  tough.  The  posterior 
pillar  is  then  dissected  from  the  posterior  surface 
of  the  tonsil  with  the  same  knife  or,  if  tonsils 
are  very  large,  one  with  a  longer  blade.  So  far  the 
tonsil  has  not  been  pulled  from  its  bed  with  forceps, 
for  drawing  out  the  tonsil  during  the  freeing  of  the 
pillars  distorts  the  natural  relation  of  the  parts  and 
makes  the  dissection  liable  to  cut  into  the  walls  of 
the  tonsillar  fossa.  The  next  step  is  the  dissection 
of  the  velar  lobe  out  of  its  bed  in  the  soft  palate. 
This  is  accomplished  bv  pulling  the  tonsil  strongly 
inward  and  downward  with  the  Casselberry  forceps 
until  the  velar  Icbe  becomes  visible,  when  it  can  be 
severed  by  the  sickle  shaped  knife  of  Tydings  from 
its  attachment  to  the  palate  above.  The  preliminary 
dissection  is  now  complete  and  the  tonsil  prepared 
for  removal.  So  far  the  operator  has  held  the 
tongue  depressor.  He  now  hands  it  to  an  assistant, 
and  grasping  the  tonsil  deeply  at  its  upper  and  lower 
poles  with  the  Casselberry  forceps  pulls  it  inward 
and  downward  as  far  as  it  w-ill  go.  As  it  has  been 
freed  from  the  pillars  and  palate  by  the  dissection 
described  it  can  usually  be  readily  drawn  out  bej-ond 


its  base  and  made  to  project  in  its  entirety  beyond 
the  plane  of  the  pillars.  As  the  deeper  tissues  of  the 
neck  Iving  in  the  pharyngomaxillary  fossa  outside 
of  the  dense  fascia  of  the  superior  constrictor  mus- 
cle do  not  follow  the  pull  upon  the  tonsil  it  becomes 
removed  by  the  traction  far  inward  from  the  danger 
of  wounding  larger  vessels  in  its  excision.  While 
the  tonsil  is  thus  held  drawn  out  of  the  tonsillar 
fossa  on  one  of  his  tonsil  knives,  bent  on  the  flat, 
which  curves  away  from  the  side  of  the  throat  when 
its  edge  looks  toward  the  base  of  the  tongue,  is  in- 
serted above  the  tonsil  and  made  to  cut  downward 
behind  its  base  until  the  tonsil  is  severed  completely 
from  its  bed.  When  general  anaesthesia  has  been 
used  free  bleeding  follows  for  a  few  seconds,  but  it 
may  always  be  controlled  by  placing  the  index  fin- 
ger in  the  wound  and  making  pressure.  After  the 
removal  of  the  tonsils  under  cocaine  and  adrenalin 
there  is  little  or  no  bleeding.  The  reason  for  the 
use  of  the  blades  curved  on  the  flat  instead  of 
straight  ones,  for  the  final  excision  of  the  tonsil,  is 
the  tendencv  of  the  point  of  a  straight  blade  to  cut 
into  and  buttonhole  the  posterior  pillar,  wdiile  that  of 
a  curved  one  trends  away  from  it.  Probe  pointed 
knives  cut  badly.  When  the  operation  is  done  un- 
der general  anaesthesia  it  is  occasionally  necessary 
to  remove,  with  the  Rhodes  punch,  fragments  which 
were  left  by  the  knife,  ^^^hen  local  anaesthesia  is 
emploved.  however,  the  excision  is  usually  so  exact 
and  complete  that  this  auxiliary  is  not  needed.  In 
ordinary  cases  the  time  needed  for  the  operation 
does  not  exceed  five  to  ten  minutes  for  each  ton- 
sil, but  a  longer  time  is  required  for  cicatricial  ton- 
sils. 

MEDICAL  RECORD. 

February  /j,  iQog. 

1.  Diet  as  a  Means  of  Increasing  Vital   Resistance  in 

Tuberculosis,  with  Special  Reference  to  the  Protein 
Ration.  By  J.  H.  Kellocig. 

2.  Cliolecsystectomy  zs.  Cholecsystotomy, 

By  JoHX  F.  Erd.manx. 

3.  The  Diagnostic  Use  of  Tuberculin  with  Special  Refer- 

ence to  the  Cutaneous  and  Percutaneous  Tests, 

By  Henry  Farnum  Stole. 

4.  The  Treatment  of  Erysipelas  by  Means  of  Carbolic  Acid 

and  Alcohol,  By  Aspinwall  Judd. 

I.  Protein  Ration  in  Tuberculosis. — Kellogg 
remarks  that  a  low  protein  dietary.  0.80  to  i.oo 
gramme  of  albumin  per  kilogramme  of  body  weight 
a  day.  is  entirely  consistent  with  health,  vigor,  and 
a  high  degree  of  efticiency  and  endurance  in  health. 
While  a  patient  suffering  from  pulmonary  tubercu- 
losis doubtless  requires  a  small  increase  in  the  in- 
take of  nitrogen,  an  excessive  increase  involves 
grave  dangers  to  the  patient,  both  (a)  by  decreas- 
ing his  general  vital  resistance,  and  (b)  by  impos- 
ing unnecessary  and  dangerous  burdens  upon  the 
liver,  kidneys,  thyreoid,  and  other  organs,  which  are 
already  overburdened  and  often  seriously  crippled 
in  this  disease.  There  is  no  evidence  that  a  larger 
proportion  of  consumptives  recover  under  a  high 
protein  diet  than  under  a  protein  ration  sufficiently 
above  the  Chittenden  standard  to  replace  the  nitro- 
gen loss  due  to  febrile  conditions  in  certain  states 
of  the  disease.  The  majority  of  consumptives  die 
from  disease  of  the  liver  and  kidneys.  The  toxines 
peculiar  to^  this  malady  and  to  the  process  of  im- 
munization against  tuberculous  disease,  while  tend- 


398  PITH  OF  CURRENT  LITERATURE. 


ing-  to  cure  the  latter,  tend  at  the  same  time  to  pro- 
duce disease  of  the  kidneys,  and  to  such  a  degree 
that  patients  not  infrequently  die  of  renal  disease 
after  having  apparently  recovered  from  tuberculous 
disease.  In  consumption  the  organism  is  required 
to  deal  with  various  highly  virulent  poisons  which 
overstimulate  and  ultimately  cripple  or  destroy  the 
thyreoid,  adrenals,  liver,  and  other  antitoxic  organs. 
A  high  protein  diet  produces  similar  effects  in 
healthy  animals  and  persons,  and  destroys  life  in 
animals  whose  poison  destroying  functions  are  seri- 
ously impaired.  A  high  protein  diet  is  recognized 
as  an  important  factor  in  the  causation  of  renal  dis- 
ease and  is  universally  condemned  in  grave  affec- 
tions of  the  liver  and  kidneys.  \'egetable  proteins 
are  much  less  objectionable  than  flesh  proteins  for 
the  reason  that  they  are  entirely  free  from  toxines 
and  very  much  less  readily  undergo  putrefactive 
changes  in  the  intestine. 

3.  The  Diagnostic  Use  of  Tuberculin. — .Stoll 
remarks  that  tuberculin  is  a  safe  and  valuable  aid 
to  diagnosis  is  not  appreciated  by  the  profession  at 
large.  There  exists  in  the  minds  of  many  a  natural 
aversion  to  the  use  of  a  substance  made  from  tuber- 
cle bacilli.  Some,  remembering  the  disastrous  re- 
sults which  followed  its  early  therapeutic  use,  be- 
fore the  correct  dosage  had  been  determined,  con- 
sider it  a  distinctly  dangerous  substance,  capable  of 
lighting  vip  an  old,  inactive  lesion,  or  of  increasing 
an  already  active  one.  Others  fear  that  possibly 
tuberculosis  might  be  given  to  one  free  from  the 
disease.  The  fear  that  tuberculin  might  cause  tuber- 
culosis is  due  to  a  misunderstanding  as  to  what  the 
tuberculin  used  for  diagnosis  consists.  This  par- 
ticular variety,  knowft  as  old  tuberculin  (T.  O.),  is 
the  glycerin  extract  made  from  cultures  of  human 
bacilli  which  have  been  evaporated  by  heat  to  i/io 
their  original  volume.  These  dead  bacilli  are  then 
removed  by  filtration  and  the  filtrate  is  the  part 
used.  The  methods  of  administration  are  the  sub- 
cutaneous, cutaneous,  percutaneous,  and  conjunc- 
tival, lentil  recently  the  first  has  been  the  one  most 
used.  The  disadvantages  of  this  method  are  (i)  it 
is  not  applicable  to  fever  cases ;  (2)  a  week  or  more 
is  sometimes  required  to  complete  the  test;  (3)  the 
patient^  feels  miserable  for  a  day  or  two;  (4)  it  re- 
quires the  frequent  taking  of  the  temperature.  The 
contraindications,  as  given  by  Brown,  are  a  tem- 
perature of  100°  F.,  extensive  physical  signs,  great 
dyspntiea,  hemoptysis  within  a  month,  general 
glandular  '  involvement,  meningitis,  kidney  and 
•  heart  disease,  and  epilepsy.  The  cutaneous  test  is 
the  most  important  addition  to  tuberculosis  work 
since  the  discovery  of  the  bacillus.  It  has  vast 
statistical  value,  and  when  used  understandingly 
will  prove  a  material  aid  in  diagnosis  and  prognosis. 
It  is  simple,  safe,  painless,  and  quickly  performed. 
The  undiluted  tuberculin  keeps  indefinitely  and  is 
conveniently  dropped  from  a  dropping  bottle.  The 
extract  will  keep  for  months  if  in  a  cool  place.  We 
thus  have  a  means  of  detecting  tuberculosis  in  chil- 
dren of  two  years  and  under,  which  practically 
never  fails.  His  experience  demonstrates  its  prac- 
ticability and  value  in  institutions,  kindergartens, 
sch()t)]<.  and  dispensaries,  as  well  as  in  private  prac- 
tice. One  hundred  children  can  be  given  the  test 
in  an  hour.    Children  who  react  should  .be  exam- 


[New  York 
Medical  Journal. 

ined  for  enlarged  tonsils,  adenoids,  and  enlarged 
cervical  glands.  The  school  nurse  should  investi- 
gate the  home  conditions  of  those  who  react  and 
usually  an  open  case  of  tuberculosis  will  be  found. 
Should  the  child  be  frail,  but  not  clinically  tuber- 
culous, half  a  day  in  school,  with  the  rest  of  the 
time  out  of  doors,  with  a  plentiful  supply  of  fresh 
air  at  night,  might  be  all  that  would  be  necessary  to 
make  a  sturdy  youth  out  of  one  who  in  the  natural 
course  of  events  would  become  a  tuberculous  in- 
valid. The  percutaneous  test,  especially  Moro's 
ointment  of  equal  parts  of  old  tuberculin  and  an- 
hydrous lanolin,  does  not  appear  to  be  reliable  in 
adults  with  pulmonary  tuberculosis,  but  in  children, 
especially  in  bone  and  gland  disease,  it  seems  about 
equal  to  von  Pirquet's  cutaneous  test.  Its  disad- 
vantages are  that  it  takes  longer  to  administer,  and 
does  not  appear  to  afford  as  much  help  in  distin- 
guishing between  an  active  and  inactive  process  as 
the  cutaneous  test  when  the  diameter  of  the  reac- 
tionary papule  is  considered.  Some  patients  who  at 
first  give  a  negative  response  to  the  test  will  react 
if  it  be  repeated.  The  conjunctival  test  was  developed 
independently  by  Wolff-Eisner  and  Calmette.  There 
are  a  sufficient  number  of  cases  on  record  where  its 
apparent  careful  use  resulted  disastrously  to  make 
one  use  the  test  with  considerable  hesitation.  Then, 
too,  Baldwin  concludes  that  it  is  of  "little  value 
where  the  symptoms  of  tuberculosis  lead  only  to  a 
suspicion."  The  conjunctival  test  should  never  be 
used  in  scrofulous  patients  or  where  a  conjunctivitis 
or  iritis  exists,  or  has  existed. 

BRITISH   MEDICAL  JOURNAL. 

Jatmavy  30,  jgog. 

1.  The  Physiology  and  Pathology  of  Work  in  Compressed 

Air,  By  Sir  T.  Oliver. 

2.  The  Uses  of  the  Calcium  Salts  in  Various  Morbid 

Conditions,  By  A.  P.  Luff. 

J.    Remarks  on  the  Use  of  Alkalis  in  Practical  Medicine. 

By  E.  Smith. 

4.  The  Remedial  Use  of  .■\lcohol.         By  J.  Macdon.vld. 

5.  Operation  at  the  End  of  Fifth  Month  for  E.xtrauterine 

Gestation  with  Living  Fcetus :  Recovery  without'  Re- 
current or  Secondary  Hemorrhage,      By  A..  Dor.\x. 

6.  A  Case  of  Tubal  Pregnancy  with  Early  Operation, 

By  H.  F.  \V.\RNER. 

7.  Perforative  Peritonitis  Following  Enteric  Fever:  Oper- 

ation •  Recovery,  By  H.  B.  Mylr.\gan.\m. 

8.  On  the  Method  of  Measuring  the  Systolic  Pressure  in 

Man,  and  the  Accuracy  of  this  Method, 

By  L.  Hill  and  M.  Fl.\ck. 
Q.    Treatment  of  Inoperable  Cancer  hy  Hypochlorites. 

By  J.  E.  A.  G.  Becker. 
10.  The  Treatment  of  Cancer  with  Cocaine, 

By  R.  M.  Gilchrist. 

2.  Use  of  Calcium  Salts. —  Luff'  reports  his  re- 
sults with  calcium  salts  in  the  treatment  of  certain 
affections  due  to  deficient  blood  coagulabilitv  and 
a  tendency  to  increased  transudation  of  plasma 
through  the  capillary  wall.  This  condition  of 
"serous  haemorrhage"  can  be  to  a  large  extent  con- 
trolled by  increasing  the  coagulability  of  the  blood 
by  the  administration  of  a  calcium  salt.  E.xamples 
of  such  serous  haemorrhages  are  urticaria,  chil- 
blains, oedema  of  the  feet  and  hands  not  clue  to 
heart  disease,  kidney  disease,  or  venous  obstruction, 
and  a  certain  form  of  headache  known  as  the 
"lymphatic  type  of  headache."  This  type  of  headache 
occurs  more  frequently  in  women  than  in  men,  and 
generally  manifests  itself  as  a  dull,  heavy  ache  in  the 


February  20,  1909.1 


PITH  OF  CURRENT  LITERATURE. 


399 


frontal  region,  or  occasionally  as  a  throbbing  pain 
in  the  frontal  and  temporal  regions.  It  is  gener- 
ally experienced  on  waking  in  the  morning,  and 
iisnaily  diminishes  in  intensity  or  disappears  after 
a  few  hours.  It  is  most  intractable  to  the  ordinan,^ 
methods  of  treatment  for  headache,  and  may  per- 
sist for  years  unless  the  association  of  it  with  a 
lowered  coagulability  of  the  blood  is  recognized 
and  suitable  treatment  for  that  condition  employed. 
The  subjects  of  this  form  of  headache  are  usually 
of  the  lymphatic  type,  with  a  tendency  to  slight 
oedema  of  the  face,  eyelids,  hands,  and  feet.  There 
is  generally  some  anjemia  and  a  varying  amount  of 
lassitude,  both  physical  and  mental.  Calcium  salts 
are  practically  specific  in  this  disorder.  The  writer 
employs  calcium  lactate,  which  has  scarcely  any 
taste,  and  is  practically  devoid  of  irritant  proper- 
ties. It  should  be  fresh,  as  it  decomposes  after  long 
keeping  when,  instead  of  forming  a  clear  solution 
in  water,  it  forms  a  turbid  one.  The  dose  for  adults 
should  be  fifteen  grains  dissolved  in  one  ounce  of 
chloroform  water  with  the  addition  of  one  half  to 
one  minim  of  tincture  of  capsicum.  This  is  to  be 
taken  three  times  a  day.  one  hour  before  meals.  It 
should  be  continued  for  about  six  weeks.  Consti- 
pation is  a  common  accompaniment  of  the  admin- 
istration of  the  calcium  salt,  and  should  be  con- 
trolled, preferably  by  an  infusion  of  senna.  Salines 
should  not  be  given,  as  they  precipitate  the  calcium 
salts.  Of  forty-five  patients  with  headache,  thirty- 
seven  or  eighty-two  per  cent,  were  cured,  and  four 
were  benefited.  Seventy-eight  per  cent,  of  the  pa- 
tients with  chilblains  were  cured.  In  eight  cases  of 
boils  associated'  with  cold  hands  and  feet,  recovery 
followed  the  use  of  calcium  lactate.  Five  patients 
with  aneurysm  of  the  arch  of  the  aorta  were  treated 
in  the  same  manner,  with  considerable  benefit  in 
every  case.  The  drug  appeared  to  encourage  the 
deposition  of  fibrin  within  the  aneurysmal  sac.  Very 
marked  benefit  also  resulted  in  three  cases  of  hasmo- 
globinuria. 

9.  Hypochlorites  in  Cancer. — Becker  reports 
three  cases  of  inoperable  cancer  treated  with  injec- 
tions of  hypochlorites,  with  great  benefit.  The  solution 
is  preparred  by  dissolving  five  grammes  of  potassium 
hydroxide  and  four  grammes  of  sodium  hydrox- 
ide in  a  litre  of  distilled  water,  and  passing  through 
it  washed  chlorine  gas.  Of  this  solution  one  and 
a  half  to  two  cubic  centimetres  are  injected  daily 
for  a  varying  period,  usually  under  the  skin  over 
the  deltoid  muscle  or  over  the  great  trochanter,  so 
that  the  solution  may  enter  the  system  at  a  site  in 
the  general  neighborhood  of  the  lym.phatic  glands. 
The  growth  itself  and  the  skin  over  it  are  carefully 
avoided.  An  ordinary  all  glass  syringe  with  a  plat- 
inum needle  i?  used,  and  the  ordinary  aseptic  pre- 
cautions adopted.  There  is  a  varyi'ng  amount  of 
local  pain,  lasting  for  from  two  to  five  minutes. 

10.  Cocaine  in  Cancer. — Gilchrist  reports  four- 
teen cases  of  c.mcer,  in  all  of  which  the  internal 
administration  of  cocaine  was  followed  by  benefit. 
In  every  case  the  general  constitutional  condition  of 
the  patient  was  very  much  improved,  even  if  that 
was  only  for  a  time.  As  far  as  the  relief  of  pain  is 
concerned,  cocaine  stands  unrivalled,  while  for  eas- 
ing or  altogether  taking  away  pain  there  is  none  of 
the  objectionable  conditions  which  opiates  produce. 


In  ever}'  case  of  uterine  cancer  where  hjemorrhage 
was  a  prominent  symptom  the  administration  of  co- 
caine was  followed  by  immediate  benefit ;  either 
stopping  the  flooding  entirely  or  leaving  only  a 
"show"  at  intervals.  Whether  the  drug  has  any 
power  over  or  effect  on,  the  embryonic  epitheliil 
cell,  whereby  a  malignant  is  converted  into  a  benign 
tissue,  or  whether  its  action  is  on  the  nerve  termin- 
als, or  whether  it  is  only  by  its  powerful  stimulating 
action  generally,  that  cocaine  controls  the  symp- 
toms is  not  known.  Cancer  patients  certainly  stand 
large  doses  ol  cocaine  with  impunity.  If  in  a  case 
of  suspected  cancer  the  administration  of  cocaine 
was  not  followed  by  improvement,  then  the  writer 
would  say  that  the  growth  was  not  malignant. 

LANCET. 

January  30,  190Q. 

1.  The  Physiology-  and  Pathology  of  Compressed  Air, 

By  Sir  T.  Oliver. 

2.  "Bacillus  F" :  an  Organism  Obtained  in  Case  of  Epi- 

demic Diarrhoea, 

By  J.  Orr,  R    S.   Williams,  H.  L.  Murray,  C. 

RuNDLE,  and  A.  E.  Williams 

3.  A  Case  of  Primary  Squamous  Celled  Epithehoma  of 

the  Epididymis, 

By  R.  P.  Rowlands  and  G.  W.  Nicholson. 

4.  The  Parasite  of  Kala  Azar  and  Allied  Organisms, 

By  W.  S.  Patton. 

5.  A  Note  on  the  Treatment  of  Syphilis, 

By  G.  G.  S.  Taylor. 

6.  On  a  "Typhoid  Carrier,"  Treated  Successfully  by  the 

Inoculation  of  Typhoid  Vaccine, 

By  S.  T.  Irwin  and  T.  Houston. 

7.  On  the  Modification  of  the  Excitant  for  Leucocytes 

Composed  of  Methylene  Blue  and  Atropine  in  Order 
to  Reduce  its  Poisonous  Effects  and  to  Render  it 
Suitable  to  be  Tried  Medicinally,       By  H.  C.  Ross. 

8.  Tuberculosis  in  Children,  Especially  with  Reference  to 

Tuberculosis  of  Lymphatic  Glands,  and  its  Import- 
ance in  the  Invasion  and  Dissemination  of  the  Dis- 
ease, By  T.  Shennan. 

2.  A  Bacillus  of  Epidemic  Diarrhoea.  —  Orr, 
Williams.  Murray,  Rundle,  and  Williams  have  iso- 
lated an  organism  which  thev  call  "bacillus  F"'  from 
a  case  of  epidemic  diarrhoea.  By  its  cultural  reac- 
tions it  is  readily  differentiated  from  the  bacillus  ty- 
phosus. The  absence  of  indol  separates  it  from 
Morgan's  No.  1  bacillus.  The  presence  of  Vv^ell 
marked  motility  is  sufficient  t6  distinguish  it  from 
Alorgan's  bacilH  Nos.  3  and  4  and  from  the  dysen- 
tery bacilli.  The  agglutination  reactions  show 
that  there  is  a  relationship  between  this  organism 
and  the  typhoid  bacillus  and  the  paratyphoid  bacil- 
liis  B.  The  bacillus  F  is  able  to  produce  diarrhoea 
in  animals  and  can  be  recovered  from  their  stools. 
The  writers  believe  therefore  that  it  may  be  an 
agent  in  the  production  of  epidemic  diarrhoea. 

5.  Syphilis. — Taylor,  in  treating  syphilis,  ad- 
vocates the  intramuscular  injection  of  grey  oil  which' 
contains  forty  per  cent,  by  weight  of  metallic  mer- 
cury. All  injection  methods  cause  a  certain  amount 
of  pain,  but  all  the  writer's  patients  usually  com- 
plain of  is  a  certain  amount  of  stifl'ness  coming  oh 
two  or  three  days  later.  In  only  one  instance  has 
it  been  necessary  to  discontinue  the  injections  be- 
cause of  pain.  The  gluteal  region  is  the  most  suit- 
able site  of  injection,  but  a  spot  sufficiently  far  away 
from  the  great  sacrosciatic  notch  should  be  chosen, 
so  as  to  avoid  wounding  the  large  vessels  and  nerves 
which  issue  therefrom.  The  best  spot  is  a  point 
midway  between  the  upper  end  of  the  gluteal  fur- 


400 


PITH  OF  CURRENT  LITERATURE. 


row  and  the  anterior  superior  spine  of  the  iliac  crest. 
The  patient  should  be  placed  in  a  stooping  posture, 
heels  together,  leaning  with  his  hands  on  a  chair. 
The  dose  of  mercury  depends  on  the  weight  and  ac- 
tivity of  the  patient.  An  active  man,  weighing  from 
170  to  190  pounds,  and  in  the  early  stages  of  the 
disease,  may  be  given  fourteen  centigrammes.  A 
woman  usually  needs  only  one  half  as  much.  From 
ten  to  twelve  injections  constitute  a  course,  after 
which  a  rest  of  two  months  is  taken,  and  a  repeti- 
tion of  the  treatment  is  begun.  Three  courses  a  year 
should  be  given  for  two  years  at  least ;  afterwards 
one  or  two  courses  a  year  annually  according  to  cir- 
cumstances. The  formula  of  grey  oil  is  as  follows : 
Mercury,  forty  grammes;  sterilized  lanoline,  twelve 
grammes  ;  white  petrolatum,  thirteen  gramines  ;  and 
medicinal  oil  of  petrolatum,  thirty-five  grammes. 
The  advantages  of  this  method  of  treatment  are:  i, 
Accurately  measured  doses  of  mercury  are  deposited 
in  the  muscles  at  regular  intervals  which  undergo 
slow  absorption  and  elimination,  during  which  pe- 
riods the  blood  and  tissues  in  which  the  spiroch?et:e 
swarm  are  mecurialized — or,  in  other  words,  the 
spirochaetae  is  in  a  mercurial  bath  ;  2,  the  stomach  is 
reserved  for  food ;  and  3,  during  the  courses  of 
treatment  the  oatient  is  obliged  to  visit  his  medical 
attendant  and  is  thus  kept  under  control.  If  a 
twenty-four  hours  specimen  of  urine  is  not  below 
specific  gravity  of  1.015  and  is  free  from  albumin 
and  sugar,  it  may  be  taken  for  granted  that  the  kid- 
neys are  working  well.  The  special  indications  for 
the  injection  method  are:  i.  When  a  rapid  thera- 
peutic efifect  is  desired.  2.  In  cases  of  syphilis  of  the 
central  nervous  system.  3.  In  hot  climates,  when  the 
gastrointestinal  system  is  more  liable  to  be  upset  by 
the  oral  administration  of  mercury. 

6.  Treatment  of  "Typhoid  Carrier." — Irwin 
and  Houston  report  the  case  of  a  girl,  aged  twenty- 
six  years,  who  contracted  typhoid  fever  seven  years 
previously,  since  when  she  had  had  typhoid  bacilli 
in  the  stools  and  urine,  and  six  people  living  in  the 
same  house  with  her  were  attacked  with  typhoid 
fever.  She  was  given  a  series  of  injections  of  a 
typhoid  vaccine  (sterilized  typhoid  bacilli)  with  the 
result  that  the  bacilli  disappeared  permanently  from 
the  stools  and  the  urine. 

7.  Tuberculosis  in  Children.  —  Shcnnan  lias 
studied  the  post  mortem  records  of  cases  of  tuber- 
culosis in  children,  at  the  Edinburgh  Hospital  for 
Sick  Children  for  twenty-one  years.  He  sum- 
marizes his  conclusions  as  follows:  r.  1,085  cases 
came  under  review,  of  which  413  patients  died  from 
tuberculosis.  These  were  examined  in  two  series, 
the  first  of  105,  and  the  second  of  308  cases.  2.  The 
hgcs  of  the  patients  varied  from  three  months  to 
thirteen  years,  approximately  sixty-eight  per  cent, 
being  under  five  years  of  age.  3.  The  lymphatic 
glands  were  tuberculous  in  97  patients,  (92.4  .per 
cent.)  in  the  first  series  and  in  243  patients  (78.8  per 
cent.)  in  the  second  scries.  The  nTediastinal  glands 
were  more  frequently  afifected  than  the  abdominal 
glands,  and  dis.semination  took  place  more  frequent- 
ly, apparently,  from  the  former  group.  4.  Tubercu- 
losis of  the  mediastinal  glands  was  commonly  unac- 
companied by  primary  tuberculosis  of  the  lungs,  but 
was  frequently  accom])anic(l  by  recent  tuberculosis 
of  these  organs,  in  many  cases  evidently  secondary 


[New  York 
Medical  Journal. 

to  the  gland  tuberculosis.  5.  In  nearly  half  the 
cases  of  tabes  mesenterica  there  was  no  ulceration 
of  the  intestines  and  in  one  third  of  the  cases  there 
was  no  excavation  of  the  lungs,  although  in  some 
of  them  the  lungs  showed  early  manifestations  of 
tuberculosis.  In  a  number  of  patients  excavation  of 
the  lungs  was  not  followed  by  ulceration  of  the  in- 
testines, although  in  about  one  half  of  such  patients 
tabes  mesenterica  had  resulted,  the  excavation  being 
of  some  standing.  6.  Primary  ulceration  of  the  in- 
testines, in  absence  of  a  previous  excavation  of  the 
lungs,  was  frequently  found.  It  was  usually  accom- 
panied by  caseation  of  lymphatic  glands,  mediastinal 
or  abdominal,  or  both  simultaneously.  In  a  large 
proportion  of  these  cases  the  immediate  cause  of 
death  was  tuberculous  meningitis.  7.  Death  was  due 
to  tuberculous  meningitis  in  44.5  per  cent,  of  the 
cases.  Apparently  the  dissemination  had  taken 
place  in  the  majority  of  the  patients  from  caseous 
lymphatic  glands,  and  more  often  from  the  medias- 
tinal than  from  the  abdominal  groups.  In  twenty- 
four  patients  with  tuberculous  meningitis  caseous 
nodules  were  found  in  some  part  of  the  encephalon, 
but  these  had  not  given  rise  to  the  meningeal  condi- 
tion in  every  instance. 

LA  PRESSE  M€DICALE. 
January  9,  /909. 

1.  Carriers  of  tiie  Germs  of  Typhoid  Fever, 

By  Robert  Debre 

2.  Influence  of  tlie  Outer  Temperature  upon  the  Glyco- 

suria of  Diabetics,  By  H.  Busquet. 

1.  Carriers  of  the  Germs  of  Typhoid  Fever. — 

Debre  would  absolutely  forbid  the  employment  in 
the  preparation  of  food  of  any  person  carrying  and 
excreting  typhoid  bacilli. 

2.  Influence  of  the  Outer  Temperature  upon 
the  Glycosuria  of  Diabetics.  —  Dusquet  draws 
from  his  studies  the  important  practical  conclusion 
that  diabetics  should  avoid  cold. 

January  is,  J<)og. 

1.  False  Sclerosis  of  the  Nervous  Tissue.  Pseudofibrosar- 

comata.  Pseudosclerosis,  By  G.  Durante. 

2.  Amceboid  Dysentery  and  Suppuration  of  the  Liver, 

By  E.  M.XRCHOUX. 

3.  Mydriatic  Action  of  the  Serum  and  of  the  Urine  of 

Persons  Suffering  from  Nephritis  and  in  Nephrecto- 
mized  Animals,  By  G.  Macaroi-f. 

3.  Mydriatic  Action  of  the  Serum  of  Nephrit- 
ics. — iVIacarof¥  asserts  that  there  is  in  the  blond 
and  in  the  urine  of  persons  suffering  from  nephritis 
a  substance  analogous  to  adrenalin  which  produces 
a  dilatation  of  the  pupils  of  frogs,  is  more  or  loss 
constant,  and  is  found  in  relation  with  a  rise  of  the 
blood  pressure.  In  other  diseases  its  presence  is 
exceptional,  save  in  arteriosclerosis,  in  which  it  is 
almost  constant. 

LA  SEMAINE  MEDICALE. 
January  13,  rgog. 

Alcasiirc  of  the  Pancreatic  Secretion  by  the  Starch  in  the 
Faeces,  By  E.  Enriquez,  L.  Ambard,  and  M.  E.  Bixet. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 
JtiHiiary  ./,  rgoQ. 

1.  Epileptic  Psychoses  and  their  Treatment, 

By  E.  SlEMERI.lNC. 

2.  A  l-'urlher  Contribution  to  the  Study  of  Bronchiolit;^ 

Obliterans  Fibrosa  .^cuta.  By  A.  Frankei.. 

3.  Clinical  and  Private  Obstetrics,     By  \V.  Bokei.manx- 


-February  20,  1909  1 


PITH  OF  CURRENT  LITERATURE. 


401 


4.  Perception  of  Light  and  of  Color. 

By  F.  \V.  Edkidge-Greex. 

5.  Pseudomyxoma  Peritonei  ex  Processii  Vermiformi, 

By  Alfred  Neumaxx. 

6.  An  Unusual  Case  of  Curvature  and  Stiffness  of  the 

Knee  Cured  by  Operation,       By  Arnold  Siegmund. 

7.  Treatment  of  Typhoid  Fever  with  Enemata  of  Collar- 

gol,  By  IMlRON'ESEN. 

■8.    The  Struggle  against  Scoliosis,  By  Bruxo  Bosse. 

1.  Epileptic  Psychoses  and  Their  Treatment. 
— Siemerling  deals  in  this  article  with  i.  emotional 
disturbances,  changes  of  temper,  usually  melan- 
cholic, productive  of  dysphoria,  and  a  marked  ten- 
dencv  to  melancholia  and  mania ;  2.  hallucinations, 
stupor,  and  delirium,  usually  with  sensory  illusions, 
and  a  marked  tendenc}'  toward  frenzy  ;  3,  paranoid 
conditions  and  paranoia ;  4,  dreamy  states  of  stupor. 
Under  treatment  he  speaks  of  bromine  as  the  sov- 
ereign remedy,  and  mentions  briefly  many  other 
forms  of  medication  as  well  as  the  indications  for 
operative  intervention. 

3.  Clinical  and  Private  Obstetrics. —  Bokehnann 
discusses  in  this  paper  the  treatment  of  placenta 
prrevia,  and  sa}s  he  does  not  favor  the  modern 
tendency  to  treat  all  such  cases  in  hospitals. 

5.  Pseudomyxoma  peritonei  ex  Processu  ver- 
miformi.— Xeumann  describes  a  case  of  this  na- 
ture found  on  autopsy  on  a  man.  seventy-nine  years 
of  age,  who  had  died  from  encephalomalacia.  The 
small  pelvis  was  filled  by  the  mass. 

6.  Unusual  Case  of  Curvature  of  the  Knee. — 
Siegmund  describes  a  case  met  with  in  a  boy.  thir- 
teen years  old,  in  whom  the  knee  was  bent  laterally 
so  as  to  form  an  angle  of  100°  and  permitted  of 
very  little  motion.  The  cause  of  the  deformity  was 
unknown,  but  "was  con  jectured  to  be  tuberculosis. 
The  deformit)'  Avas  corrected  by  operation. 

January  11,  1909. 

1.  Pathology    of    the    Atrioventricular    System    and  of 

Weakness  of  the  Heart,  Bj-  J.  G.  Monckeberg. 

2.  A  Case  of  Atrophy  of  the  Pancreas,     By  W.  Keuthe. 

3.  Casuistic  Contribution  to  the  So  Called  Ai'thropathia 

Psoriatica,  By  Gustave  Albert  \\'ollexberg. 

4.  Sequelae  to  Cerobrospinal  Meningitis.     By  Leo  Cohx. 

5.  Rare  Case  of  Intrauterine  Selfdecapitation, 

By  Theodor  Laxdau. 

6.  Antitryptic  Action  of  the  Blood  Serum. 

By  Valextix  Furst. 

7.  A  Case  of  Tabes  with  Bulbar  Symptoms. 

By  L.  Wacxer. 

8.  The  Position  of  Medical  Coinpetent  Judges  before  the 

Courts  According  to  the  Plan  of  the  New  Law. 

By  Hugo  ^L\rx 

q.    Primary  Glaucoma  and  its  Treatment,        By  Helbrox. 

2.  Atrophy  of  the  Pancreas. — Keuthe  reports 
a  case  of  this  nature  met  with  in  an  emaciated  pa- 
tient, fifty-six  years  old,  who  had  suffered  for  six 
years  from  attacks  of  diarrhoea  and  exhaustion. 
On  admission  he  complained  of  great  weakness 
and  emaciation,  lumbago,  at  times  a  sensation  of 
pressure  and  pain  in  the  region  of  the  stomach  and 
an  irregular  diarrhoea.  The  clinical  examination 
revealed  nothing  special  except  a  general  cachexia, 
some  pulmonary  catarrh,  and  a  slight  swelling  of 
the  liver  and  spleen.  As  the  result  of  a  number  of 
tests  of  the  alimentary  canal  the  clinical  diagnosis 
as  finally  made  out  was  chronic  disease  of  the  pan- 
creas with  atrophy,  together  with  pulmonar}-  phthi- 
sis. Autopsy  revealed  that  the  pancreas  was  ex- 
tremely small  and  contained  a  calculus  as  large  as 
the  head  of  a  pin.  Three  plates  are  given  showing 
the  histological  condition  of  the  gland. 


3.  Arthropathia  Psoriatica. — Wollenberg  re- 
ports a  case  of  this  disease  met  with  in  a  young 
woman,  twenty-four  years  of  age,  who  had  suf- 
fered from  psoriasis  from  the  time  she  was  ten 
years  old.  Several  x  ray  pictures  are  given  which 
display  the  condition  of  the  affected  joints,  and 
seem  to  show  that  in  the  early  stage  of  this  disease 
the  bones  and  cartilages  are  not  so  greatly  affected, 
but  that  the  initial  lesion  is  in  the  soft  parts  about 
the  joints. 

4.  Sequelae   to   Cerebrospinal   Meningitis.  — 

Cohn  investigated  twenty-seven  patients  who  had 
recovered  from  cerebrospinal  meningitis  and  has 
summed  up  his  results  as  follows:  i.  A  perfect 
clinical  recovery  takes  place  in  all  mild  cases.  2.  A 
complete  recovery  without  subsequent  troubles  is 
possible  even  in  the  severer  afid  worst  cases.  The 
probability  of  a  recovery  which  will  leave  no  trace 
is  greater  in  children  than  in  adults.  In  the  latter 
sequelae  may  appear  two  years  and  a  half  after  the 
disease.  3.  After  an  apparent  convalescence  has 
lasted  four  weeks  the  onset  of  hydrocephalus  is  pos- 
sible. 4.  The  complication  most  to  be  feared  is 
deafness.  \Miile  all  paralytic  sypmtoms  may  be 
recovered  from  and  a  choked  disc  may  disappear, 
deafness  once  caused  is  irreparable.  5.  The  ag- 
glutination of  the  blood  serum  with  meningococci 
was  postitive  in  two  patients  after  the  lapse  of  more 
than  two  vears. 

5.  Intrauterine  Selfdecapitation. — Landau  de- 
scribes a  monstrosit}  in  which  the  head  had  been 
removed  from  the  fcetus  and  implanted  in  the  mem- 
branes, there  was  micromelia  of  the  left  arm  and 
bilateral  clubfoot. 

9.  Primary  Glaucoma  and  Its  Treatment. — • 
Helbron  hardly  speaks  of  primary  glaucoma,  as  the 
term  is  usually  applied  to  mean  one  distinct  form 
of  glaucoma,  but  deals  in  a  general  way  with  the 
subject  of  acute  glaucoma,  including  the  infantile 
form,  or  hydrophthalmos.  The  treatment  advocated 
is  that  usually  recommended  for  acute  glaucoma, 
iridectomy  first  of  all,  then  the  use  of  myotics,  pilo- 
carpine and  eserine. 

MUNCHENER  MEDIZINISCHE  WOCH ENSCH Rl FT. 
January  5,  jgocj. 

1.  Disclosure  of  Fruitful  Sources  of  Protective  Materials, 

By  Heim. 

2.  Contributions  to  the  Formation  of  Concrements. 

By  SCHADE. 

3.  Haemolysis  of  the  Streptococci. 

By  LuDKE  and  Poland. 

4.  Benzin  Poisoning,  By  Wichern. 

5.  Intravenous  I'reatment  with  Arsenic  and  Tuberculin, 

By  Mexdel. 

6    The  Surgical  Treatment  of  Exophthalmic  Goitre, 

By  Krecke. 

7.  The  Injuries  which  May  be  Produced  by  X  Rays, 

Their  Prevention,  Their  Treatment,  and  Their  For- 
ensic Importance,  By  Gocht. 

8.  Tlie  Puncture  Reaction  in  the  Diagnosis  of  Tubercu- 

losis in  Children.  By  Hamburger. 

9.  IMacroscopic  Asthma  Spirals  in  Saliva.        By  Riehl. 

10.  A  Heart  Suture,  By  Neugebauer. 

11.  A  Case  of  Macies  Uteri,  By  Voigt. 

12.  The  Ferment  Treatment  of  Tuberculous  Abscesses, 

By  Goldexberg. 

13.  The  Phonendoskiascope,  By  Schmincke. 

2.  Contributions  to  the  Formation  of  Concre- 
ments.— Schade  deals  first  with  the  origin  of 
urinary  calculi  in  the  article  of  which  only  the  be- 
ginning is  presented  in  the  current  number,  and  de- 


402 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


scribes  the  method  followed  in  his  experiment,  the 
first  results  obtained,  the  determinaton  of  the  quan- 
tity of  fibrin  required,  its  concentration,  coagulation, 
and  other  important  matters. 

3.  Hasmolysis  of  the  Streptococci. — Liidke 
and  Polanc  assert  that  the  demonstration  whether 
the  streptococci  in  the  pus  or  secretions  of  a  patient 
are  haemolytic  or  not  is  of  no  importance  in  the 
prognosis  of  the  case. 

5.  Intravenous  Treatment  with  Arsenic  and 
Tuberculin. — Mendel  states  that  he  has  employed 
a  combmation  of  arsenic  and  tuberculin  injected 
into  the  veins  in  a  considerable  number  of  cases  of 
tuberculosis,  particularly  in  pulmonary  afifections  of 
the  first  and  second  degrees  which  run  their  course 
with  little  or  no  fever,  with  good  results. 

7.  -  Injuries  Produced  by  the  X  Rays. — Gocht 
divides  the  injuries  produced  by  the  x  rays  into  two 
general  classes,  the  acute  or  transient  and  the  chron- 
ic. In  a  special  way  he  divides  them  into  injuries 
I.  of  all  the  constituents  of  the  external  skin;  2,  of 
the  internal  organs,  particularly  a,  the  lymphatics, 
b.  the  germinal  glands,  c,  the  nervous  system  ;  3,  of 
the  growth  or  development;  4,  of  the  vital  energy; 
and  5,  certain  secondary  diseases  that  have  been  ob- 
served. He  considers  each  of  these  headings  sep- 
arately and  gives  the  results  obtained  by  animal 
experimentation.  He  goes  on  to  say  that  the  injur- 
ies inflicted  formerly  on  patients  by  the  pioneers  in 
X  ray  work  are  now  rare  as  they  can  be  avoided  to 
a  certain  degree.  The  question  of  dosage  is  de- 
pendent on  the  quantity  of  x  ray  light,  which  in  turn 
depends  on  the  quality  and  quantity  of  the  x  rays 
and  the  distance  between  the  source  of  the  rays  and 
the  irradiated  tissue,  and  the  sensitiveness  of  the  tis- 
sues. The  article  will  be  concluded  in  a  later 
number. 

8.  Tuberculosis  in  Children. — Hamburger  ap- 
pears to  maintain  that  no  child  is  free  from  tuber- 
culosis unless  it  fails  to  react  to  the  injection  of 
tuberculin.  When  there  is  no  reaction  to  the  cutane- 
ous test  then  the  injection  is  in  his  opinion  the  cru- 
cial test. 

10.  A  Heart  Suture. — Xcugebauer  reports  a 
successful  case  in  which  he  sutured  a  stab  wound  of 
the  heart.  The  wound  was  of  the  anterior  wall  of 
the  right  ventricle.  He  believes  that  this  operation 
can  be  of  great  service  if  performed  shortly  after 
the  receipt  of  the  injury  because  patients  with  per- 
forating wounds  of  the  heart  frequently  live  for 
hours  even  when  no  measures  are  taken  for  their 
relief. 

11.  Macies  Uteri. —  \  oigt  describes  a  very 
marked  case  of  uterine  atrophy  met  with  in  a  very 
corpulent  woman,  forty-two  years  of  age,  who  came 
under  observation  on  account  of  great  uterine  dis- 
charge with  irregular  h.'cmorrhages. 

January  12,  IQOQ. 

1.  Tlie  Latent  Microbism  of  the  Typhus  B?icilli, 

By  LuDKE. 

2.  Wassermann  s  Scrum  Reaction  in  Syphilis  and  in  other 

Infectious  Diseases,  By  Rolly. 

X    l-"at  Splitting  Ferment  in  the  Lymphocytes.    Hy  Hercel. 

4.  P:xtcrnal  Vision,  "    By  Labhardt. 

5.  Sterilization  and  Use  of  Rubber  Gloves.       Bv  Heye. 

6.  Concerning  the  Demonstration  of  Antigen  with  the 

Complement  Deviation  of  Tuberculosis,     By  Bauer. 


7.  Concerning  Fibrinous  Inflammation  of  Mucous  Mem 

branes  (Stomatitis  Fibrinosa)  from  Infection  with 
Pneumococci,  By  Mann. 

8.  An  Interesting  Case  of  Polydactylia,      By  Hochtlen. 

9.  A  Special  Electroscope  for  Urethroscopy  and  Direct 

Cystoscopy,  By  Bri^nings. 

ID.    Contributions  to  the  Formations  of  Concrements  (Con- 
cluded), By  SCHADE. 

11.  Tlie  Injuries  which  may  be  Produced  by  the  X  Raya. 

Their  Prevention,  Treatment,  and  Forensic  Im- 
portance (Concluded) ,  By  Gocht. 

12.  What  can  the  General  Practitioner  do  to  Spread  the 

Custom  of  Breast  Nursing?  By  Vidal. 

13.  Report  Concerning  the  Capacity  of  the  Central  Sta- 

tion for  the  Care  of  Infants  in  Munich.  1906  to  190S, 

By  Groth. 

2.  Wassermann's  Serum  Reaction.  —  Roily 
concludes:  l,  Positively  nonsyphilitic  patients  when 
suffering  from  other  diseases,  such  as  typhoid  or 
tuberculosis,  do  not  give  the  specific  Wassermann's 
reaction.  2.  In  syphilis,  hereditary  syphilis,  pa- 
ralysis, and  tabes  Wassermann's  reaction  is  posi- 
tive in  a  high  percentage  of  cases,  95.5  per  cent. 
3.  The  alcoholic  extract  of  a  syphilitic  liver  is  to 
be  preferred  as  antigen,  because  it  gives  positive  re- 
actions in  a  higher  percentage  of  cases  of  syphilis, 
tabes,  and  paralysis  than  an  alcoholic  extract  of  a 
nonsyphilitic  liver.  4.  In  typhoid  fever  and  tuber- 
culosis the  investigation  of  the  complement  joining 
by  the  use  of  extracts  of  typhoid  bacilli  and  tubercle 
bacilli  as  antigen  for  the  determination  of  the  clini- 
cal diagnosis  is  not  of  special  value,  because  on  the 
one  hand  positive  results  are  to  be  obtained  in  only 
a  portion  of  the  cases,  and  on  the  other  much  better 
and  simpler  means  are  at  hand  for  the  recognition, 
of  these  diseases. 

5.  Rubber  Gloves. — Heye  has  show  -  by  ex- 
periments that  rubber  gloves  can  be  made  absolutely 
sterile  and  that  thev  are  impermeable  to  streptococci, 
even  under  unfavorable  circumstances. 

6.  Antigen  of  Tuberculosis. —  Bauer  asserts 
that  tuberculin  and  bacilli  emulsions  have  a  com- 
mon antigen  group,  but  that  each  has  its  own  anti- 
gen character. 

II.  Injuries  that  may  be  Produced  by  the  X 
Rays. — Gocht  after  a  long  consideration  of  the  in- 
juries which  may  be  produced,  how  the\'  are  to  be 
treated,  and  how  avoided,  presents  the  following 
conclusions,  i.  The  x  rays  should  be  used  for 
diagnostic  or  therapeutic  purposes  only  under  re- 
sponsible medical  supervision.  2.  The  physician 
who  works  with  the  x  rays  must  know  the  prophy- 
lactic precautions  corresponding  to  the  present  con- 
dition of  this  special  science,  he  must  carefully 
study  the  question  of  dosage  and  always  observe 
the  necessary  precautions  in  every  direction.  3. 
The  physician  should  tell  his  patients  that  in  spite 
of  all  care  occasional  overdosing  luay  happen,  par- 
ticularly when  he  must  obtain  a  certain  reaction  of 
the  first  or  second  degree.  4.  It  is  necessary  for 
him  to  ask  the  patient  before  examination  or  treat- 
ment with  the  x  ray  whether  he  has  ever  been  ex- 
posed to  the  x  ray  ;  if  so.  when  and  how  often,  and 
whether  his  skin  is  particularly  sensitive.  5.  .\s 
occasionally  grave  charges  have  been  brought 
against  a  physician  when  lie  has  left  the  room  dur- 
ing the  treatment  he  must  expressly  state  that  no 
particular  harm  could  be  caused.  The  apparatus 
and  tubes  used  to-day  for  brief  exposures  are  suf- 
ficiently uniform.    6.    In  legal  trials  which  involve 


February  20,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


403 


claimed  or  real  injuries  from  the  x  rays  it  is  strong- 
ly to  be  recommended  that  the  opinions  of  physi- 
cians who  are  recognized  experts  in  x  ray  work  be 
obtained.  At  any  rate  the  experts  called  must  be 
thoroughly  acquainted  with  the  action  of  the  x  rays 
and  with  their  biological  properties,  if  possible  from 
their  own  experience.  7.  Finally,  it  should  be  par- 
ticularly borne  in  mind  that  in  the  present  state  of 
x  ray  technique  injuries  to  patients  from  the  x  rays 
are  and  will  continue  to  be  rare.  Those  who  have 
suffered  most  severely  are  not  the  patients,  but 
those  who  have  had  most  to  do  in  building  up  the 
science  of  the  x  rays,  electrical  engineers,  physi- 
cians, and  their  assistants. 

EDINBURGH  MEDICAL  JOURNAL, 
February,  igiog. 

1.  Medicine  among  the  Assyrians  and  Egyptians  in  1500 

B.  C,  By  John  D.  Comrie. 

2.  A  Remarkable  Case  of  Haemorrhage  of  the  Pons  Va- 

rolii and  Medulla  Oblongata, 

By  Byron  Bramwell. 

3.  The  Value  of  Bismuth   Injections   into  Cavities  for 

Diagnosis  and  Treatment,        By  Alexander  Don. 

4.  Surgical  Bearings  on  Tuberculin,        By  R.  W.  Philip. 

5.  The  Treatment  of  Perforating  Ulcer  in  the  Immediate 

Vicinity  of  the  Pylorus  by  Excision  in  the  Long 
Axis  of  the  Viscus  and  Suture  in  the  Transverse 
Axis,  By  J.  W.  Dowden. 

6.  Pulmonary  Abscess  and  Pneumothorax  from  Urinary 

Infection,  By  A.  I.  Shepheard-Walwyn. 

I.  Medicine  among  the  Assyrians  and  Egyp- 
tians in  1500  B.  C. — Comrie  gives  a  very  interest- 
ing review  of  ancient  medicine.  There  are  many 
evidences,  remarks  our  author,  that  the  healing  art 
among  the  Semitic  race,  which  founded  the  king- 
doms of  Babylon  about  3000  B.  C.  or  earlier,  that  of 
Assyria,  about  1,000  years  later,  spread  with  Abra- 
ham and  his  followers  to  Palestine,  and  migrated  to 
colonies  in  Phoenicia,  Carthage,  Sicily,  Spain,  and 
Western  Africa,  was  one  of  usefulness,  honor,  and 
profit.  One  of  the  most  important  results  of  ex- 
plorations in  Assyria  has  been  the  discovery  in  the 
palace  of  Assur-bani-pal  (668-626  B.  C),  at 
Nineveh,  of  a  large  library,  consisting  of  many 
thousand  tablets  of  baked  clay  inscribed  with  cunei- 
form characters  and  now  preserved  in  the  British 
Museum.  This  library  probably  owed  its  origin  to 
the  keen  political  insight  of  Esar-haddon  (681-668 
B.  C),  father  of  Assur-bani-pal  and  conqueror  of 
Egypt,  who  desired  to  prevent  the  youth  of  Assyria 
from  going  to  be  taught  at  Babylon  or  Borsippa, 
where  they  would  be  subjected  to  dangerous  politi- 
cal influences.  Careful  study  has  made  it  evident 
that  many  of  the  tablets  in  this  library  were  copied 
from  ancient  originals  in  the  temple  libraries  of 
Chaldea,  each  being  stated  to  be  "like  its  old  copy" 
or  "like  the  ancient  tablets  of  Sumir  and  Akkad." 
Many  of  these  tablets  have  been  found  duplicated  in 
the  libraries  of  other  Babylonian  cities,  and  thus  the 
original  composition  must  be  referred  to  a  much 
earlier  date.  The  library  of  Assur-bani-pal  found 
at  Nineveh,  which  city  was  wholly  destroyed  when 
Assyria  became  a  Median  province  in  606  B.  C, 
contained  textbooks  on  geography,  mathematics,  and 
natural  history,  together  with  poems  and  records  of 
kings;  and  we  may  judge  of  the  important  position 
occupied  by  the  healing  art  from  the  fact  that  out 
of  the  total  20,000  tablets  between  500  and  1,000  are 
stated  by  Oefele  to  consist  of    medical  works. 


Nineveh  was  for  over  1,500  years  the  capital  of  As- 
syria, between  which  country  and  Egypt  was  much 
intercourse,  and  a  regular  trade  route  with  letter 
posts  ran  from  Memphis  by  way  of  Palestine  and 
Carchemish  to  Nineveh.  Borsippa,  a  suburb  of 
Babylon,  where  another  library  had  been  estab- 
lished in  the  tem.ple  of  Nebo,  was,  as  we  learn  from 
Strabo,  the  seat  of  a  university  which  had  attained 
great  celebrity.  From  a  fragment  of  a  Babylonian 
medical  work,  now  in  the  British  Museum,  Pro- 
fessor Sayce  states :  "We  may  perhaps  infer  that  it 
was  chiefly  celebrated  as  a  school  of  medicine."  In 
Babylon  the  physician  is  mentioned  at  a  very  early 
date.  Thus  we  hear  of  Ilu-bani,  the  physician  of 
Gudea  and  High  Priest  of  Lagas,  at  a  period  about 
2700  B.  C.  In  the  Code  of  Laws  p/omulgated  by 
Hammurabi,  a  king  of  the  First  Dynasty  of  Baby- 
lon, dating  from  c.  2000  B.  C,  we  find  that  not  only 
is  the  doctor  mentioned,  but  his  remuneration  is 
fixed  by  law.  If  v/e  turn  to  early  Greek  literature 
we  find  that  in  the  Iliad  and  Odyssey,  composed 
somewhere  about  1000  B.  C,  and  referring  to 
events  of  some  centuries  previous  (about  1200 
B.  C),  there  are  references  to  the  physicians  of 
Egypt.  The  Egyptians  apparently  set  great  store 
by  the  medical  profession.  The  practitioners  of  this 
art  belonged  to  the  priestly  class,  though  they  were 
not  priests,  and  they  seem  to  have  been  not  only 
men  of  high  social  standing,  but  men  of  wealth  and 
substance,  who  were  regarded  as  devotees  of  Thoth, 
the  scribe  of  the  gods  and  prototype  of  Hermes. 
This  is  indicated  both  by  the  monuments  that  have 
been  erected  to  some  of  them,  and  by  the  elegant 
papyri  they  possessed.  That  they  occupied  a  posi- 
tion of  great  respect  and  influence  is  proved  by 
numerous  references.  We  must  remember  that, 
though  their  knowledge  of  the  healing  art  was  a 
purely  empiric  one,  and  though  they  were  entirely 
ignorant  of  the  principles  of  physiology  and  even 
of  the  simplest  systematic  anatomy,  yet  their  use  of 
these  remedies  was  the  fruit  of  the  experience  of 
many  centuries ;  and  their  knowledge  of  pathology, 
derived  from  the  constant  examination  of  the  bodies 
of  those  who  died,  must  have  conferred  upon  them 
great  skill  in  diagnosis.  Upon  this  point  all  the 
testimony  of  antiquity  accords.  The  record  of  this 
knowledge  has  come  down  to  us  in  part  through  va- 
rious papyri.  We  know  from  the  statement  of 
Clement  of  Alexandria  that  the  sacred  books  of 
Thoth,  preserved  in  the  temples  and  known  as  the 
Hermetic  Books,  were  forty-two  in  number,  of 
which  thirty-six  dealt  with  philosophy  and  six  with 
medicine.  These  Hermetic  Books,  which  were  car- 
ried by  pastophori,  or  priest  physicians,  in  the  sacred 
processions,  have  unfortunately  all  been  lost ;  but  we 
know  a  great  deal  regarding  the  actual  methods  of 
the  physician  from  some  medical  papyri  which  have 
come  down  to  us.  Of  these  the  chief  are:  i.  The 
Papyrus  Ebers,  preserved  at  Leipzig,  discovered  by 
Professor  Ebers  in  Egypt  in  1872.  It  dates  from 
about  1500  B.  C,  and  consists  of  1 10  pages.  2. 
The  Berlin  Medical  Papyrus,  published  by  Dr. 
Brugsch.  It  dates  from  about  1300  B.  C,  and  con- 
tains 21  pages.  There  is  also  a  smaller  one  in  the 
Berlin  Museum,  of  fifteen  pages.  3.  The  Kahun 
Papyrus,  published  by  F.  L.  Grifiith.  It  dates  from 
about  2000  B.  C,  but  is  a  short  papyrus,  consisting 


404 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


of  only  three  pages.  4.  The  Hearst  Medical  Papyrus, 
preserved  in  the  University  of  California,  and  pub- 
lished by  Dr.  George  A.  Reisner.  It  consists  of  sev- 
enteen pages.  5.  The  British  Museum  Medical  Papy- 
rus, which  has  not  yet  been  published.  It  dates, 
probably,  from  about  1000  B.  C.  6.  There  are  also 
papyri  of  medicomagical  contents  in  the  museums 
at  Leyden,  Turin,  Cairo,  and  Paris,  but  these  are 
said  to  be  of  little  value  as  regards  our  knowledge 
of  Egyptian  medicine. 

ARCHIVES  OF  P/EDIATRICS 
January  i,  i^og. 

1.  A  Report  upon  One  Thousand  Tuberculin  Tests  in 

Young  Children,  By  L.  E.  Holt. 

2.  Tics  and  their  Treatment,  By  E.  W.  Scripture. 

3.  Leontiasis  Ossea  developing  in  a  Child  with  Diabetes 

Insipidus.    Problem  of  Etiology,       By  L.  C.  Acer. 

4.  Some  Contributions  to  the  Calorimetric  Method  of  In- 

fant Feeding,  By  T.  Teimer. 

5.  Diagnostic  Value  of  the  Chemical  and  Bacteriological 

Examination  of  Cerebrospinal  Fluid, 

By  A.  Hand,  Jr. 

6.  Urinary  Infection.    A  Common  Cause  of  Fever  in  In- 

fancy and  Childhood,  By  M.  J.  Lippe. 

7.  A  Case  of  Ulcerative  Endocarditis  with  Necropsy.  Case 

Report,  By  K.  Schlivek. 

8.  A  Case  of  Congenital  Obstruction  of  the  Urethra, 

By  J.  Speese. 

2.  Tics  and  their  Treatment. — Scripture  states 
that  the  tic  on  a  neurasthenic  basis  is  often  benefited 
by  tonic  treatment,  Fowler's  solution  being  fre- 
quently helpful.  The  tic  on  an  hysterical  basis  de- 
mands treatment  aimed  at  the  mental  condition 
which  caused  it.  The  emotional  complex  may  be 
found  by  suitable  psychanalysis  and  may  be  re- 
moved by  appropriate  mental  treatment.  Hysteri- 
cal tremors,  cramps, 'paralysis,  as  well  as  tics  can 
often  be  completely  and  permanently  cured  in  this 
way.  The  method  of  treatment  which  the  author 
has  found  mo.st  efficient  is  that  of  conscious  repe- 
tition. This  consists  in  having  the  patient  hold  a 
mirror  in  front  of  himself,  and  when  the  tic  is  ap- 
parent, repeating  it  five  times  voluntarily.  First 
attempts  are  often  inadequate,  especially  when  the 
tics  are  unconscious  ones.  By  persistent  efforts  the 
tic  will  finally  be  brotight  entirely  under  control. 
The  probable  explanation  is  that  the  tic  is  carried 
out  by  mental  activity  of  less  than  full  conscious- 
ness, the  entire  act  may  be  completely  subcon- 
scious. Perfect  voluntary  imitation  of  the  act 
trains  the  mind  to  perform  exactly  the  same  act 
consciously.  The  act  then  becomes  a  voluntary 
conscious  one. 

4.  Some  Contributions  to  the  Calorimetric 
Method  of  Infant  Feeding. — Teimer  gives  for- 
mulae by  which  tables  haA^e  been  prepared  which 
permit  the  solution  of  practical  problems  of  infant 
feeding  without  difficult  mathematical  operations. 
Three  principal  factors  are  to  be  determined  by  the 
physician:  i.  The  proteid  quotient;  this  depends 
principally  upon  the  age  of  the  infant.  It  also  de- 
pends upon  the  individuality  and  is  influenced  by 
physical  conditions  of  health  and  disease.  It  is  a 
measure  for  growth  and  assimilation,  and  should 
not  be  increased  rapidly,  flooding  the  system  with 
proteids,  if  the  organism  has  not  been  gradually 
prepared  for  their  utilization.  2.  The  energy  quo- 
tient, which  is  a  measure  of  the  liberated  energy, 
derived  ultimately  from  the  fuel  value  of  the  food 
and  expressed  in  calories.    The  fat  in  the  milk  is 


the  most  important  factor  in  this  direction,  another 
influential  factor  being  the  muscular  activity  of  the 
infant.  3.  The  percentage  of  the  food  in  proteids. 
This  will  usually  give  an  insight  into  the  power  of 
the  digestive  processes.  The  proteid  percentage 
should  be  gradually,  increased  from  the  point  of 
toleration  to  the  full  strength. 

5.  Diagnostic  Value  of  the  Chemical  and  Bac- 
teriological Examination  of  the  Cerebrospinal 
Fluid. — Hand  emphasizes  the  importance  of  ex- 
act diagnosis  of  the  different  forms  of  meningitis. 
Lumbar  puncture  furnishes  the  means  of  making 
an  exact  diagnosis,  but  the  fluid  thus  obtained  must 
be  carefully  examined  in  order  to  arrive  at  a  cor- 
rect interpretation.  Two  types  of  cerebrospinal 
fluid  occur,  with  one  of  which  the  interpretation  is 
easy,  while  with  the  other  it  is  difficult.  With  one 
of  these  the  fluid  has  a  milky  opalescence,  which 
disappears  as  the  fibrin  network  forms,  leaving  a 
clear  fluid  with  excess  of  albumen,  and  diminished 
amount  of  sugar.  The  fibrin  network  contains 
principally  mononuclear  leucocytes  and  tubercle 
bacilli.  Such  a  specimen  would  indicate  tubercu- 
lous meningitis.  If  the  fluid  is  turbid,  of  a  yellow- 
ish tint,  with  an  abundance  of  polynuclear  leuco- 
cytes, some  of  which  contain  diplococci  in  their  pro- 
toplasm, the  diagnosis  would  be  epidemic  cerebro- 
spinal fever.  This  would  show  moderate  increase 
in  albumin  and  absence  of  sugar.  Pneumococcic 
meningitis  would  give  a  similar  fluid,  but  the  dip- 
lococcus  is  usually  absent  from  the  pus  cells, 
though  abundant  in  the  fluid.  Should  the  fluid  ob- 
tained not  have  these  characteristics  the  diagnosis 
would  be  doubtful,  and  to  remedy  this  the  author 
has  devised  a  method  of  examination  which  he  de- 
scribes in  detail. 

  • 


SOUTHERN   SURGICAL  AND  GYNAECOLOGICAL 
ASSOCIATION. 

Twenty-first  Annual  Meeting,  Held  in  St.  Louis,  December 
15,  16,  and  17,  1908. 

The  President,  Dr.  F.  W.  Parham,  of  New  Orleans, 
in  the  Chair. 

(Concluded  from  page  356.) 
Fibroid  Tumors  and  Pregnancy. — Dr.  Ch.vrles 
L.  BoNiFiELD,  of  Cincinnati,  pointed  out  that  fibroid 
tumors  of  the  uterus  were  said  to  be  the  penalty  a 
woman  paid  for  celibacy.  All  observers  agreed 
that  they  were  much  oftener  seen  in  women  who 
had  not  borne  children  than  in  those  who  had,  and 
one  could  safely  say  that  sterility  predisposed  to 
fibroids  and  that  fibroids  predisposed  to  sterility. 
Fibroid  tumors  had  a  tendency  to  render  women 
sterile  in  three  ways :  First,  the  hypertrophic  endo- 
metritis they  produced  rendered  the  endometrium 
unfit  to  receive  and  nourish  the  ovum.  The  nearer 
the  fibroid  was  to  the  endometrium  the  more 
marked  its  effect  on  this  membrane.  Second,  they 
were  frequently  complicated  by,  and  apparently 
caused,  disease  of  the  appendages,  which  prevented 
conception.  Third,  they  might  so  displace  the  cer- 
vix' that  it  was  not  bathed  in  seminal  fluid  during 
the  sexual  act.    But  as  a  fibroid  might  exist  with- 


February  20,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


405 


out  producing  any  of  these  conditions,  and  as  preg- 
nancy might  occur  in  spite  of  the  presence  of  one 
or  more  of  them,  the  coexistence  of  fibroid  tumors 
and  pregnancy  was  by  no  means  extremely  rare. 
It  was  probably  more  frequent  now  than  formerly, 
for  the  reason  that  women  were  marrying  later  in 
life  and  thus  putting  off  their  childbearing  until 
they  had  reached  the  age  when  fibroids  were  prone 
to  develop.  Pregnancy,  by  the  physiological  hyper- 
cxmia  of  the  uterus  to  which  it  gave  rise,' usually 
caused  fibroids  to  grow  rapidly.  During  the  process 
of  involution,  following  the  normal  termination  of 
pregnancy,  fibroids  might  decrease  in  size  very  per- 
ceptibly. Cases  had  been  reported  where  they  had 
disappeared  entirely.  Fibroid  tumors  might  have 
little  or  no  effect  on  pregnancy,  or  might  give  rise 
to  the  most  serious  complications.  Submucous 
fibroids  might  cause  the  premature  expulsion  of  the 
ovum.  Pregnancy  might  go  to  term  and  labor 
might  be  normal,  but  followed  by  severe  haemor- 
rhages, the  fibroid  acting  as  a  foreign  body  in  the 
uterus  and  preventing  normal  contraction  and  re- 
traction of  the  muscular  fibres.  The  efforts  of  the 
uterus  to  expel  the  fibroids  might  be  successful. 
There  was  danger  in  such  a  case,  if  the  fibroid  was 
attached  near  the  fundus,  that  inversion  might  fol- 
low the  expulsion,  for  if  a  fibroid  had  developed 
between  the  folds  of  the  broad  ligament,  it  might 
prevent  the  uterus  from  rising-  into  the  abdomen  as 
pregnancy  advanced,  and  give  rise  to  symptoms  so 
severe  as  to  demand  immediate  surgical  relief.  A 
fibroid  tumor  springing  from  the  lower  part  of  the 
uterus  might  so  fill  the  pelvis  as  to  prevent  the  pas- 
sage of  the  child,  either  prematurely  or  at  term. 
Subperitoneal  or  interstitial  fibroids  that  were  inter- 
fering with  pregnancy,  or  promised  to  interfere  se- 
riously with  delivery,  might  be  removed  by  myo- 
mectomy. Numerous  cases  had  been  reported 
where  this  operation  had  been  successfully  done 
without  interrupting  pregnancy.  Only  one  such 
case,  however,  had  come  under  the  author's  ob- 
servation. Myomectomy  should  usually  be  limited 
to  those  cases  in  which  the  tumors  were  not  numer- 
ous and  were  easily  accessible.  In  spite  of  the  re- 
ported cases  of  myomectomy,  one  could  not  ex- 
pect the  uterus  to  withstand  too  much  traumatism 
without  rebelling.  The  part  of  the  uterus  from 
which  the  tumor  sprang  was  important.  Fibroid 
tumors  might  be  the  cause  of  extrauterine  gesta- 
tion. Noble  had  reported  six  cases  of  ectopic 
gestation  complicating  fibroids.  Eight  cases  were 
reported  by  the  author  to  illustrate  the  various 
phases  of  surgical  interference  during  pregTiancy. 

Vaginal  Hysterectomy  for  Carcinoma  of  the 
Cervix. — Dr.  Henry  T.  Byford,  of  Chicago,  said 
the  relative  value  of  the  vaginal  and  abdominal 
routes  was  still  under  discussion.  The  advocates  of 
the  abdominal  route  were  inclined  to  be  less  radical 
than  its  propounder,  Emil  Ries,  in  order  to  diminish 
its  excessive  mortality,  while  some  of  the  German 
operators  in  their  attempts  to  be  more  radical  were 
increasing  the  dangers  of  the  vaginal  method  by 
splitting  the  vagina  and  opening  freely  into  the  pel- 
vic connective  tissue.  He  was  satisfied  that  the  per- 
manent results  might  be  improved  sufficiently  to 
give  it  an  important  place  in  the  future,  and  pro- 
posed a  method  of  causing  sloughing  of  the  broad 


ligaments  by  the  combined  use  of  silk  ligatures  and 
strong  forceps.  In  this  way  much  more  of  the 
connective  tissue  in  the  broad  ligament  and  about 
the  cervix  could  be  removed  than  by  either  ligatures 
or  forceps  as  ordinarily  employed. 

The  essential  part  of  the  method  consisted  in 
ligating  the  broad  and  sacrouterine  ligaments  as  far 
from  the  cervix  as  possible  after  having  pushed  the 
ureters  out  of  the  way.  After  the  uterus  had  been 
removed,  the  broad  ligaments  were  pulled  still  far- 
ther down  and  strong  forceps  applied  still  farther 
away,  which  were  clamped  so  as  to  cause  sloughing 
of  all  tissue  within  their  grasp.  Dr.  Byford  exhib- 
ited a  forceps  which  he  had  devised  which,  he 
thought,  obviated  some  of  the  objections  that  were 
found  to  the  ordinary  broad  ligament  forceps. 
Mast  forceps  projected  too  far  into  the  peritoneal 
cavity,  and  caused  pain ;  they  sometimes  failed  to 
grasp  the  tissues  firmly  at  all  points,  and  thus  might 
not  cause  prompt  and  complete  sloughing ;  and  they 
projected  too  far  out  of  the  vulva  and  were  in  the 
way  externally.  The  forceps  shown  was  short,  and 
would  not  only  hold  the  stump  down  near  or  at  the 
vaginal  edges,  but  did  not  form  a  large  mass  of 
metal  projecting  between  the  thighs.  It  was  blunt 
and  slightly  hooked  at  the  end  of  the  blades,  and 
thus  not  only  did  not  scratch  the  intestine,  but  did 
not  allow  the  pressure  to  force  the  edge  of  the  flat- 
tened stump  beyond  its  grasp.  It  was  strong 
enough  to  exert  a  uniform  pressure  that  caused 
sloughing  even  when  left  on  but  a  few  hours.  He 
usually  left  it  on  for  twenty-four  hours,  althovigh 
ten  or  twelve  would  probably  be  long  enough. 

Temporary  Ventrosuspension  of  the  Uterus ;  its 
Technique,  Indications,  and  End  Results.— Dr. 
Edward  H.  Ochsxer,  of  Chicago,  after  a  brief  re- 
view of  the  dangers  and  disadvantages  of  perma- 
nent ventrofixation  and  ventrosuspension,  gave  the 
technique,  indications,  and  final  results  of  a  tem- 
porary ventrosuspension  of  the  uterus.  The  op- 
eration consisted  in  passing  the  needle,  armed  with 
a  double  strand  of  ten  day  unchromicized  catgut, 
through  the  rectus  fascia,  rectus  muscle,  and  peri- 
tonaeum, on  the  right  side,  an  inch  below  the  lower 
angle  of  the  peritoneal  incision,  then  through  the 
fundus  of  the  uterus,  being  careful  not  to  injure 
the  peritoneal  covering  of  the  uterus  unnecessarily, 
then  cut  through  the  abdominal  wall  in  reverse  or- 
der to  its  introduction.  This  stitch  was  now  tied 
just  tight  enough  to  bring  the  uterus  in  contact 
with  the  parietal  peritonaeum,  but  not  tight  enough 
to  cause  necrosis  of  the  peritonaeum.  The  operation 
was  recommended  if,  after  pelvic  operations  for  in- 
flammatory conditions,  the  uterus  showed  a  ten- 
dency to  fall  'backward  after  the  intraabdominal 
work  was  completed.  It  was  contended  that,  if 
properly  applied,  it  would  prevent  the  uterus  from 
falling  backward  and  becoming  adherent  to  the  pel- 
vic floor  without  making  a  permanent  ventrosus- 
pension or  fixation  with  their  numerous  objection- 
able features. 

Abdominal  Aneurysm, — Dr.  Murat  Wiilis.  of 
Richmond,  Va.,  reported  a  case  of  abdominal  aneu- 
r\sm  treated  unsuccessfully  by  wiring.  A  critical 
study  of  twenty-one  cases  thus  far  reported  led  to 
the  conclusion  that  surgery  so  far  offered  no  certain 
relief  for  this  malady.    Of  these  twenty-one  cases, 


4o6 


PROCEEDINGS  OF  SOCIETIES. 


[New 
Medical 


York 
Journal. 


the  subsequent  history  of  three  was  not  recorded  ;  in 
the  eighteen  others  death  ensued  in  every  case.  The 
duration  of  Hfe  after  operation  in  this  series  varied 
from  an  hour  to  nine  months,  with  an  average  dura- 
tion of  less  than  fifty  days.  The  operative  tech- 
nique, as  developed  for  this  condition,  would  seem 
to  be  absolutely  perfect,  and  based  upon  sound  sur- 
gical principles,  but  the  fact  remained  that  this 
method  of  treatment  was  disappointing,  and  the  last 
word  had  not  yet  been  said  concerning  the  surgical 
treatment  of  abdominal  aneurysm. 

Dr.  R.  S.  Cathcart,  of  Charleston,  S.  C,  re- 
ported a  case  of  false  aneurysm  of  the  femoral  ar- 
tery following  typhoid  fever. 

Elephantiasis  of  the  Male  Genitalia. — Dr.  J. 
NoRMENT  Baker,  of  Montgomery,  Ala.,  said  the 
comparative  rarity  of  the  affection  in  America  fur- 
nished the  stimulus  for  preparing  a  paper  on  this 
subject.  He  reviewed  the  literature,  and  reported  a 
very  interesting  case  of  elephantiasis  in  a  colored 
man,  aged  fifty-two,  upon  whom  he  had  operated 
successfully  for  its  removal. 

Anatomical  and  Physiological  Restoration  ver- 
sus Removal  of  the  Internal  Generative  Organs 
of  Women. — Dr.  John  E.  Cannaday,  of  Charles- 
ton, W.  \"a.,  said  the  advantages  of  waiting  and  of 
giving  nature  a  full  opportunity  in  cases  of  infected 
Falloppian  tubes  were  great.  The  damage  done  by 
inflammation  in  many  cases  was  small.  He  spoke 
of  the  bearing  of  the  woman's  social  condition  on 
the  case,  and  pointed  out  the  necessity  for  the  wage 
earner  of  small  means  to  get  well  quickly.  He  dis- 
cussed the  desirability  pf  letting  his  patient  decide 
what  was  best  to  be.  done  in  many  cases.  The  non- 
operative  treatment  of  tubal  inflammation  was  really 
cautious  neglect.  The  measures  taken  were  to  di- 
vert the  attention  of  the  patient.  Pelvic  massage 
was  of  benefit  in  removing  the  results  of  inflamma- 
tory attacks.  There  were  numerous  valuable  meth- 
ods of  treating  uterine  disease  without  the  removal 
of  both  uterus  and  disease.  It  was  seldom  neces- 
sary or  advisable  to  remove  the  ovaries. 

Cancer  of  the  Parotid  Gland. — Dr.  George  A. 
Hendox,  of  Louisville,  read  a  paper  in  which  he  re- 
ported five  cases,  with  a  successful  operation  in  each 
case. 

Extensive  Injury  to  the  Abdominal  Wall;  Op- 
eration; Recovery. — Dr.  Rufus  B.  Hall,  of  Cin- 
cinnati, reported  a  case  of  an  accident  to  an  infant, 
seventeen  months  old,  with  extensive  injury  to  the 
abdominal  wall,  and  extrusion  of  the  entire  small 
intestine,  with  recovery  of  the  patient.  The  child's 
mother  was  giving  him  a  bath  by  holding  him  on 
her  lap  in  the  kitchen,  where  she  had  been  canning 
fruit.  To  facilitate  rinsing  off  the  soap,  she  stood 
the  child  on  the  drain  board  of  the  sink,  which  was 
two  feet  and  a  half  high.  The  mother  left  the  child 
standing,  and  went  across  the  room  for  a  towel. 
The  child  fell,  striking  the  right  side  of  the  abdo- 
men on  the  top  of  an  empty  half  gallon  glass  Mason 
fruit  jar.  The  impact  broke  the  jar,  telescoping  it, 
leaving  four  sharp  points  remaining  on  the  bottom 
of  the  can.  One  of  these  made  a  large  wound  in 
the  side  of  the  abdomen,  and  the  intestines  at  once 
protruded  on  to  the  dirty  kitchen  floor,  picking  up 
several  fragments  of  peelings  of  tomatoes  and  pears. 
The  child  had  lost  a  great  quantity  of  blood  on  ac- 


count of  injury  of  the  deep  epigastric  artery. 
One  prong  of  the  glass  cut  through  the  tenth  rib, 
dividing  the  intercostal  artery.  Another  one  made 
an  opening  into  the  abdomen  three  inches  above  the 
large  opening.  The  whole  of  the  small  intestine, 
the  pyloric  end  of  the  stomach,  and  four  inches  of 
the  ascending  colon  were  outside  of  the  abdomen. 
There  were  sticking  to  the  coils  of  bowel  and 
omentum  several  pieces  of  the  peelings  of  pears  and 
tomatoes.  When  Dr.  Hall  arrived  the  child  was 
semiconscious,  pulseless,  with  cold  extremities  and 
rapid,  superficial  breathing.  In  addition  to  the  di- 
vision of  the  deep  epigastric  artery  and  the  inter- 
costal artery,  there  was  a  ragged  wound  in  the 
omentum  and  one  in  the  mesentery.  The  intestines 
were  largely  distended  with  undigested  pears.  The 
temperature  twelve  hours  after  the  accident  was 
106.5°,  ^iid  remained  high  for  twelve  hours  longer, 
at  which  time  he  sticceeded  in  getting  the  intestinal 
tract  emptied.  Before  the  bowels  were  emptied,  the 
child  was  delirious,  with  general  twitching  of  the 
muscles  throughout  the  body.  Within  two  hours 
after  the  bowels  were  emptied,  the  temperature  de- 
clined to  100°,  and  convalescence  was  established. 
The  child  made  a  good  recovery. 

Surgical  Treatment  of  Epilepsy. — Dr.  W.  P. 
Carr,  of  Washington,  D.  C,  reported  twenty  oper- 
ations for  epilepsy,  and  said  that  eight  of  these 
patients  had  been  cured  to  date,  or  were  well  when 
last  heard  from ;  one  after  nine  years,  one  after 
eight  years  and  a  half,  one  after  seven  years  and  a 
half,  one  after  four  years,  one  after  three  years  and 
a  half,  one  after  one  year,  and  two  after  three 
months.  Five  of  these  cases,  probably  not  trau- 
matic, in  which  the  habit  was  well  established,  had 
been  cured  for  over  three  years ;  three  of  them  for 
seven,  eight,  and  nine  years  respectively.  Nearly 
all  the  patients  were  benefited  temporarily,  most  of 
them  being  so  much  improved  as  to  make  the  opera- 
tion justifiable.  One  was  confined  in  the  Govern- 
ment Hospital  for  the  Insane,  and  another  was  a 
complete  imbecile.  Both  regained  the  normal  men- 
tal condition  and  had  remained  mentally  sound  to 
date.  Only  one  patient  was  not  benefited.  The 
best  results  were  in  cases  apparently  most  unfavor- 
able. He  believed  that  operation  for  cases  of  long 
standing  traumatic  epilepsy,  and  idiopathic  or  he- 
reditary epilepsy,  had  been  abandoned  upon  theoret- 
ical grounds  without  a  fair  trial  of  modern  surgical 
methods,  and  that  such  patients  should  be  operated 
upon  for  the  following  reasons:  i.  There  was  very  • 
strong  evidence  to  show  that  a  considerable  propor- 
tion of  even  the  most  unpromising  cases  could  be 
cured.  2,  In  view  of  the  hopeless  and  progressive 
nature  of  the  malady,  the  operation  would  be  justi- 
fiable if  even  a  very  small  percentage  could  be  cured 
or  even  greatly  benefited.  3,  No  systematic  attempt 
had  been  made  to  find  what  percentage  of  cures 
might  be  obtained,  since  modern  methods  had  made 
the  operation  easy  and  safe,  and  such  attempts 
should  be  made.  4,  There  was  little  danger  in  the 
operation  of  either  death  or  unpleasant  sequel.-ie.  5, 
Because  of  the  freedom  from  pain  or  discomfort  of 
any  kind  following  the  operation,  which  was  in 
marked  contrast  to  the  discomfort  following  most 
other  operations  of  equal  severity. 

He  recommended  opening  the  skull  by  making  a 


February  20,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


large  osteoplastic  flap  over  the  region  indicated  by 
focal  symptoms,  when  they  were  present,  or  over 
the  Rolandic  area  on  either  side  when  there  were 
no  focal  symptoms.  A  careful  examination  should 
then  be  made  by  opening  the  dura  widely,  inspect- 
ing and  palpating  the  brain  and  meninges,  and  by 
careful  exploration  with  a  grooved  director,  and  any 
ot¥ending  body,  such  as  depressed  bone,  thickened 
dura,  abscess,  cyst,  tumor,  inflammatory  exudate,  or 
collection  of  liquid  should  be  removed  as  far  as  pos- 
sible. Most  epileptic  brains  were  oedematous  and 
the  serum  might  be  rapidly  drained  away  by  open- 
ing the  dura  and  inserting  several  grooved  directors 
into  the  brain  substance.  Good  results  had  followed 
oftenest  where  a  large  flap  was  made  and  a  large 
surface  of  the  brain  exposed.  The  flow  of  serum 
might  continue  for  several  days  when  a  soft  rubber 
drain  was  used. 

Successful  Operation  for  Vesicouterine  Fistula, 
with  Loss  of  Function  of  the  Vesical  and  Ure- 
thral Sphincters. — -Dr.  R.  S.  Hill,  of  Montgom- 
ery, Ala.,  reported  the  following  case :  The  patient, 
thirty-two  years  of  age,  weighing  155  pounds,  was 
delivered  of  her  second  child  in  February,  igo8, 
after  being  in  labor  eighteen  hours,  which  was  more 
severe  and  lasted  longer  than  her  first  confinement, 
eight  years  before.  The  child  was  born  dead,  though 
fully  developed,  and  the  presentation  was  normal. 
Within  an  hour  after  the  completion  of  labor,  she 
felt  an  intense  desire  to  urinate,  which  was  followed 
by  a  tremendous  gush  of  water  from  the  vagina. 
From  this  time  on  the  urine  passed  continually  and 
entirely  through  the  cervix  uteri.  Vesicouterine  fis- 
tula was  diagnosticated.  She  was  brought  to  the 
essayist  six  weeks  later,  and  through  a  T-shaped 
incision  in  front  of  the  cervix  uteri  the  openings 
into  the  bladder  and  uterus,  which  were  of  about 
the  size  of  the  end  of  the  index  finger,  were  closed 
with  catgut  sutures.  Union  was  perfect,  but  when 
the  patient  left  the  bed  it  became  evident,  from  the 
continuation  of  the  urinary  incontinence,  that  the 
vesical  and  urethral  sphincters  had  lost  their  func- 
tion. She  returned  home  and  remained  until  Octo- 
ber 15th,  when  she  came  back  in  the  same  condition, 
except  a  three  months'  pregnancy  to  complicate 
matters.  The  following  technique,  which,  so  far  as 
the  author  knew,  was  original,  was  used :  With  a 
metal  sound  in  the  urethra  as  a  guide,  a  median  in- 
cision was  made  through  the  vaginal  mucosa  from 
a  point  one  inch  on  the  bladder  wall  to  the  meatus 
urinarius,  and  then  around  this  orifice.  The  mucosa 
was  dissected  from  the  underlying  structures  to  the 
extent  of  one  inch  or  more  in  transverse  measure- 
ment. The  sound  in  the  urethra  was  now  changed 
for  one  of  smaller  size.  Beginning  at  the  bladder 
end  of  the  denudation,  the  muscular  structures  were 
folded  in  or  brought  together  with  a  continuous 
catgut  suture  passed  transversely,  but  never  deep 
enough  to  include  the  vesical  or  urethral  mucosa. 
As  the  gut  was  made  taut  after  each  passage  of  the 
needle,  the  sound  was  drawn  from  its  grasp.  The 
vaginal  mucosa  was  now  trimmed  and  made  to  fit 
snugly  over  the  underlying  tissue  and  held  in  posi- 
tion with  silkworm  gut  sutures,  some  of  which  were 
carried  through  the  muscular  tissues,  reenforcing 
the  catgut  sutures.  The  patient  was  catheterized 
with  a  small  soft  rubber  catheter  every  four  to  six 


hours.  The  author  was  opposed  to  leaving  an  in- 
strument in  the  urethra  after  this  operation,  and 
suggested  the  advisability  of  establishing  vesico- 
vaginal or  even  suprapubic  drainage  after  the  opera- 
tion, in  order  not  to  disturb  the  parts  until  firm 
union  was  established.  The  extent  of  the  dissection 
was  to  be  regulated  by  the  condition  found  in  the 
individual  case.  Furthermore,  if  any  one  part  of 
the  muscular  wall,  such,  for  instance,  as  either  of 
the  sphincter  muscles,  appeared  more  injured  than 
the  rest,  then  a  special  suture  of  catgut  should  be 
used  to  repair  it. 

The  following  papers  were  also  read :  Report  of 
a  Case  of  Urethral  Transplantation,  by  Dr.  John 
D.  S.  D.A,vis,  of  Birmingham,  Ala. ;  Operative  Treat- 
ment of  Tuberculous  Joints,  by  Dr.  Horace  J. 
Whitacre,  of  Cincinnati ;  The  Transverse  Abdom- 
inal Incision,  by  Dr.  S.  M.  D.  Clark,  of  New  Or- 
leans ;  and  Further  Observations  on  Transfusion, 
with  a  Note  on  Haemolysis,  by  Dr.  George  W. 
Crile,  of  Cleveland. 

Officers  for  the  ensuing  year  were  elected  as 
follows :  President,  Dr.  Stuart  McGuire,  of  Rich- 
mond, Va.  ;  vice-presidents,  Dr.  John  Young  Brown, 
of  St.  Louis,  and  Dr.  R.  S.  Cathcart,  of  Charleston, 
S.  C. ;  treasurer,  Dr.  William  S.  Goldsmith,  of  At- 
lanta, Ga. ;  secretary,  Dr.  William  D.  Haggard,  of 
Nashville,  Tenn. 

Hot  Springs,  Va.,  was  selected  as  the  place  for 
holding  the  next  annual  meeting,  beginning  on  the 
third  Tuesday  in  December,  1909. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  PENNSYL- 
VANIA. 

Annual  Meeting,  held  in  Cambridge  Springs,  September 
14,  J3,  16,  and  17,  1908. 

The  President,  Dr.  William  L.  Estes,  of  South  Bethle- 
hem, in  the  Chair. 

(Continued  from  page  196.) 
The  Need  of  Endowments  for  State  and  County 
Medical  Societies.  —  Dr.  John  B.  Roberts,  of 
Philadelphia,  contributed  a  paper  upon  this  subject, 
which  was  read  by  title. 

The  Doctor's  Income;  Its  Helps  and  Hin- 
drances. 

Fees  and  Fee  Bills. — Dr.  William  H.  Hart- 
ZELL,  of  Allentown,  read  this  paper,  in  which  a  com- 
parison of  medical  fees  with  those  of  law  and  theol- 
ogy was  made.  The  unjustness  of  a  table  of  charges 
for  professional  services  was  shown  and  the  sugges- 
tion made  that  it  was  the  duty  of  every  practitioner 
to  let  his  patients  understand  that  he  charged  for 
time,  inconvenience,  exposure,  skiU,  and  professional 
services  in  accordance  with  their  value  and  impor- 
tance ;  that  the  true  physician  had  for  his  opponent, 
not  a  rival  in  the  commercial  world,  but  the  inev- 
itable, victorious  death.  In  this  light  the  righteous- 
ness of  a  physician's  fee  and  fee  bills  was  easily 
apparent. 

Contract  Practice. — Dr.  John  B.  Dox.aldson, 
of  Canonsburg,  believed  that  contract  practice  could 
be  conducted  honorably,  and  that,  since  it  was  de- 
manded by  the  workingman  and  the  operators  who 
would  have  some  kind,  it  was  the  duty  of  the  pro- 


4o8 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


fession  to  make  it  clean  and  respectable.  To  his 
mind,  the  mill  and  the  mine  doctor  were  just  as 
respectable  and  had  a  more  dignified  calling  than 
the  petty  railroad  surgeon  who  worked  for  a  pass. 
Lodge  practice,  in  the  author's  opinion,  was  outside 
the  pale  of  respectability. 

Is  Lodge  Practice  a  Preventable  Evil? — Dr.  A. 
Bern  Hirsh,  of  Philadelphia,  presented  this  paper, 
which  was  read  by  title. 

Fees  for  Services  to  Corporations. — Dr.  George 
W.  Wagoner,  of  Johnstown,  regarded  this  question 
as  a  side  issue  of  the  far  greater  question  of  the 
responsibilities  of  corporations  to  their  workmen. 
Too  often  the  fact  was  lost  sight  of  that  the  neces- 
sities of  the  workingman's  existence  forced  him  to 
accept  conditions  advantageous  to  corporations, 
which  conditions  competition  had  made  in  their  final 
analysis :  The  greatest  amount  of  productive  energy 
for  the  least  return  in  money ;  the  assumption  of  all 
risks  to  health  and  body  by  the  employee ;  the  sub- 
stitution of  fresh  brain  and  muscle  for  that  which 
was  worn  out,  and  heartless  indifference  to  the  fate 
of  the  worn  out  worker.  Basic  facts  were  stated 
which  it  was  observed  must  modify  the  answer  to 
the  question  of  the  amount  of  fees  for  the  doctor's 
services  to  corporations.  Two  factors  in  the  social 
problem  were :  i .  That  the  workman  would  pay  his 
doctor  at  all  times,  but  could  not.  2.  That  the  doc- 
tor must  be  paid  something  for  his  services,  but 
was  expected  to  and  would  serve  the  needy  without 
pay  and  at  the  sacrifice  of  his  personal  comfort  and 
health.  Some  methods  adopted  by  corporations  to 
meet  the  situation  were  detailed,  showing  the  advan- 
tages and  disadvantages  which  obtained.  One  well 
managed  scheme  was  described  in  which  a  large 
corporation  caused  to  be  formed  among  its  em- 
ployees a  mutual  benefit  association  controlled  by 
representative  men  from  all  departments  of  its  im- 
mense mills.  Of  the  receipts  for  the  year  1907, 
amounting  to  $241,480,  the  corporation  contributed 
its  pro  rata  share  of  $16,978.31.  The  association 
maintained  an  excellent  hospital  and  employed  a 
competent  surgeon  and  assistant,  who  rendered  to 
the  injured  all  hospital  services  for  the  salaries  paid 
them. 

With  the  drift  of  public  opinion  toward  the 
doctrine  of  better  protection  for  workingmen  would 
come  a  new  system,  in  which  the  cost  of  this 
protection  would  be  added  to  the  cost  of  the  pro- 
ducts of  the  varied  industries.  This  bill  would 
eventually  be  paid  by  the  public.  As  disbursers  of 
the  fund  for  services  rendered  the  sick  and  injured 
tmder  this  new  system,  doctors  might  take  up  with 
vigor  the  question  of  fees  to  be  paid  by  corporations 
and  ask  for  fair  consideration  of  their  claims.  The 
individual  doctor's  fees  would  be  determined  by  his 
scientific  attainments,  reputation,  success,  perma- 
nency, and  methods  of  work ;  by  the  prosperity  of 
his  community  and  the  generous,  public  spirited, 
honorable  conduct  of  his  life.  Those  who  were  am- 
bitious to  attain  the  standard  by  which  all  would  be 
judged  would  keep  the  profession  sweet  and  clean. 
All  others  would  not  count. 

The  Influence  of  Hospitals  on  the  Doctor's 
Income. — T^r.  Ciiarlks  IT.  Ott,  of  Sayrc.  referred 
in  this  paper  to  the  advantages  other  than  pecuniary 
which  accrued  to  a  medical  man  in  his  association 


with  a  hospital.  The  advantages  from  equipment, 
clinical  material,  and  facilities  for  the  care  of  cases 
were  considered.  The  influence  of  the  hospital  upon 
the  doctor's  income,  it  was  believed,  would  depend 
largely  upon  the  doctor  himself.  In  this  the  dis- 
pensary work  was,  a  large  factor,  more  difficult  of 
solution  in  the  cities  than  in  small  communities, 
where  the  financial  status  of  individuals  was  easily 
obtained.  The  treatment  of  house  patients  was  re- 
garded as  particularly  affecting  the  doctor's  income. 
The  poor,  when  severely  sick,  must  be  cared  for  in 
the  hospital,  but  care  must  be  exercised  not  to  pau- 
perize either  the  individual  or  the  community.  The 
physician's  part  in  this  connection  was  &  difficult 
one.  The  author  believed  it  should  be  the  aim  and 
object  of  every  semistate  hospital  to  oblige  every  one 
to  pay  who  could. 

The  Influence  of  Hospitals  and  Dispensaries 
as  Viewed  from  the  Outside.  — ■  Dr.  James  B. 
Walker,  of  Philadelphia,  believed  that  it  should  be 
considered  unprofessional,  unethical  in  the  dispen- 
sary physician,  after  first  aid  to  the  injured  or  ill 
was  administered,  to  direct  such  patient  into  any 
other  channel  than  that  which  led  back  to  his  family 
physician  for  further  treatment,  unless  personal  rea- 
sons on  the  patient's  part  made  such  a  thing  impos- 
sible. In  the  opinion  of  the  writer,  however,  the 
ethics  of  the  profession  were  not  ignored  by  the  dis- 
pensary alone,  but  the  hospital  itself  was  not  above 
criticism.  The  hospital  should  have  as  one  of  its 
important  functions  the  education  of  the  "young, 
fresh  graduates"  in  the  relations  of  man  to  man,  in 
the  brotherhood  of  the  profession,  and  in  the  ordi- 
nary courtesies  of  life.  The  concentration  of  acci- 
dent cases  in  the  hospital  during  the  entire  treat- 
ment, independent  of  the  pecuniary  ability  of  the 
patient,  was  regarded  as  a  most  unprofessional 
method,  which  shoold  meet  the  condemnation  of  the 
profession.  Dispensaries  or  hospitals  which  habitu- 
ally ignored  correction  in  this  regard  should  be 
blacklisted  by  the  profession,  their  professional 
heads  should  be  disciplined,  and  a  concerted  effort 
should  be  made  to  prevent  State  aid  from  reaching 
their  coffers.  The  possibility  was  suggested  of  the 
exercise  of  a  censorship  by  the  Medical  Society  of 
the  State  of  Pennsylvania  over  hospitals  applying 
for  State  aid,  and  only  such  be  recommended  as 
were  worthy.  The  idea  was  expressed  that  suffi- 
cient money  could  thus  be  saved  to  enable  the  State 
authorities  to  supply  funds  for  the  crying  need  of 
the  day,  the  establishment  of  a  State  inebriate  hos- 
pital. 

Dr.  George  Erety  Shoemaker,  of  Philadelphia, 
said  that  one  of  the  difficulties  of  the  hospital  man 
doing  surgery  was  that,  after  his  first  dressing  of  a 
wound,  he  had  a  natural  hesitancy  in  sending  that 
patient  out  to  a  man  whom  he  did  not  know.  It 
was  of  practical  value  for  physicians  to  have  a 
copper  box  containing  sterile  gauze.  Then,  with 
sterile  instruments,  proper  dressings  could  be  ap- 
plied. If  this  became  well  known,  the  hospital  phy- 
sician would  not  so  often  have  the  cases  rctnrnod  to 
the  dispensary. 

Dr.  Alhert  M.  Eaton  said  that  we  did  not  care 
to  condemn  contract  practice  when  it  was  carried  on 
by  the  employment  of  men  in  large  industrial  estab- 
lishments who  were  paid  a  fair  compensation.  We 


February  20,  1909.] 


LETTERS  TO  THE  EDITOR.— BOOK  NOTICES. 


409 


did  object  to  it,  however,  done  under  a  scheme 
which  caused  the  public  to  lose  its  esteem  for  our 
profession.  We  were  not  stewards  of  our  interests 
to  the  extent  that  we  should  be. 

Dr.  Walker  felt  that,  if  the  gentlemen  in  charge 
of  dispensaries  would  instruct  the  young  men  under 
their  care  to  direct  patients  back  to  their  family  phy- 
sicians, they  would  be  doing  much  to  prevent  pau- 
perization of  the  community.  In  addition,  if  those 
in  charge  of  hospitals  would  instruct  the  young  resi- 
dents that  visiting  physicians  were  entitled  to  cour- 
teous treatment,  the  ethics  of  the  profession  would 
not  be  so  greatly  ignored  as  at  present. 

Medical  Words  Commonly  Mispronounced. — 
Dr.  Frederick  A.  Rhodes  presented  a  paper  which 
consisted  chiefly  of  a  list  of  medical  words  common- 
ly mispronounced,  knowledge  of  which  was  consid- 
ered of  value  to  the  profession. 

( To  be  continued.) 


fetters  to  the  aitffr. ' 


FISH  CONTAGION  IN  LEPROSY. 

50  West  io6th  Street, 
New  York,  lanuary  2g,  1909. 

To  the  Editor:  • 

Dr.  Charles  E.  AlacDonald's  presentation  of  a  tu- 
l-)erculous  theory  as  to  the  facts  of  leprosy  and  fish 
diet  is  not  so  new  as  might  be  imagined.  Hutchin- 
son wrote  me  on  February  29,  1908:  "You  and  I 
have  arrived  at  very  similar  conclusions  as  to  lep- 
rosy, with,  however,  the  important  divergence  that 
you  believe  in  skin  contagion,  and  I  almost  solely 
in  that  by  the  stomach.  V/e  both  regard  it  as  a 
form  of  tuberculosis.''  This  last  I  myself  have 
fought  for  for  a  number  of  years.  Hansen,  twelve 
years  ago,  wrote  me  refusing  to  follow  my  argu- 
ments for  the  identity  of  tubercle  and  leper  bacilli. 

Hutchinson  writes  me  also  as  follows :  "In  the 
autumn  of  1906  I  went  to  Switzerland  to  examine 
some  cases  which  have  recently  occurred  in  the 
Rhone  ^'alley.  up  on  the  mountain  side.  I  got  some 
most  interesting  facts  in  confirmation  of  bad  fish 
origin,  and  in  confutation  of  the  notion  of  personal 
contagion.  There  were  only  four  cases,  and  the 
patients  has  been  living  for  many  years-  amongst 
their  friends  without  the  least  precaution." 

Dr.  MacDonald's  idea  is  not  that  the  diet  itself 
is  at  fault,  but  that  there  is  an  infection  from  tu- 
berculous fish.  Xow,  if  the  bacilli  are  identical,  as 
I  have  maintained  for  years,  whether  the  infection 
took  place  internally  or  externally  does  not  matter 
to  the  human  body.  The  carp  of  Japan  is  the  fish 
most  usually  eaten  raw  and  while  it  still  lives,  and 
it  is  of  all  fishes  the  one  which  eats  the  most  mos- 
quitoes, which  would  infect  the  fish  if  the  insects 
had  previously  made  a  full  meal  on  a  leper  body. 
All  this  I  have  before  pointed  out  many  times,  and 
also  that  the  carp  of  Japan  is  the  most  diseased 
fish. 

During  i879-'8i  much  was  the  contemplation 
here  of  carp  culture  as  a  fish  economic.  Being 
then  interested  in  a  small  pond.  I  wrote  to  Herr 
\'on  Behr,  president  of  the  Deutsche  Fischeren 
X'erein,  Berlin,  for  information.    Replying,  he  sent 


me  a  German  authority,  illustrated,  on  pond  prepa- 
ration and  carp  culture.  In  the  letter  accom- 
panying, he  said  if  we  placed  carp  in  our  lakes, 
ponds,  and  streams,  we  should  regret  it ;  that  not 
only  did  they  destroy  all  other  fishes,  but  they  were 
"the  swine  of  the  water." 

Now,  if  the  sea  fishes,  or  any  particular  species  of 
them,  are  the  host  of  the  bacillus  of  leprosy,  why 
is  it  not  quite  likely  that  stagnant  water  fishes  are 
in  the  same  categor\-  ?  We  see  that  Japan  and  China, 
skilled  in  the  propagation  and  variation  of  pond 
fishes  for  food  and  art  purposes,  are  the  home  of 
leprosy.  I  am  not  possessed  of  information  as  to 
the  lands  and  peoples  among  which  were  the  lepers 
of  the  Bible. 

Since  1881  I  think  some  considerable  attention 
has  been  given  to  carp  culture  here.  The  scaleless 
leather  carp  is  repulsive  to  look  at  and  easily  inocu- 
lable  by  the  night  filth  infected  water  of  Japan  and 
China.  The  leprous  and  tuberculous  night  stuffs, 
after  they  have  drained  from  rice  fields,  might 
readily  inoculate  these  fishes  in  the  streams,  they 
not  being  protected  by  scales  as  other  fish  are.  At 
any  rate,  there  is,  in  my  opinion,  some  connection 
between  the  carp  and  leprosy,  as  yet  undetermined. 
I  am  interested  in  this  question.  I  believe  I  am  not 
an  overextreme  alarmist — not  an  extremist. 

Albert  S.  Ash  mead. 
Author  of  Fish  Ponds  of  Hawaii  as  Propagators  of 
Leprosy. 

 <S^— 

Sflffh  |i0tj«S. 

{We  publish  full  lists  of  books  received,  but  zee  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless^  so 
far  as  space  permits,  tue  revieiu  those  in  ■u.'hich  zi'e  think 
our  readers  are  likely  to  be  interested.] 


A  Textbook  of  General  Bacteriology.  By  Edwin  O.  Jor- 
dan, Ph.  D.,  Professor  of  Bacteriolog\-  in  the  University 
of  Chicago  and  in  Rush  [Medical  College.  Fully  Illus- 
trated. Philadelphia  and  London :  W.  B.  Saunders 
Company,  1908.    Pp.  557.    (Price,  $3.) 

As  may  be  gathered  from  the  title,  the  author 
has  undertaken  to  write  a  bacteriology  which  shall 
be  useful  not  merely  to  medical  students,  but  to 
college  students  generally  and  to  those  engaged  in 
occupations  in  which  bacteriology  plays  an  impor- 
tant part.  From  this  point  of  view  the  book  is 
admirably  written,  and  it  is  safe  to  say  that  the 
student  who  carefully  studies  its  pages  will  have  a 
better  general  knowledge  of  this  science  than  could 
have  been  obtained  from  any  of  the  recognized 
standard  books  on  the  subject.  We  have  carefully 
gone  over  the  various  chapters,  and  note  that  every- 
where the  author  has  been  at  pains  to  present  the 
latest  and  most  reliable  data.  This  is  a  relief  to  one 
who  sees  the  material  from  older  German  books 
presented  as  new  or  original  in  the  compilation  of 
many  of  our  standard  medical  works.  The  refer- 
ences given  are  also  most  excellent.  A  drawback 
of  all  works  of  extensive  scope  is  the  fact  that  the 
subject  matter  must  necessarily  be  considerably  con- 
densed, thus  impairing  their  value  for  purposes  of 
reference.  In  the  present  instance  this  drawback 
has  been  minimized,  and  is  far  outweighed  by  the 
excellence  of  the  work  as  a  textbook.    We  would 


BOOK  NOTICES. 


[New  York 
Medical  Journal 


suggest  that  the  author  in  the  next  edition  discuss 
also  the  bacteriology  of  sewage  purification.  The 
stain  mentioned  on  page  536  should  have  been  cred- 
ited to  Van  Gieson. 

Atlas  of  Clinical  Surgery.  With  Special  Reference  to 
Diagnosis  and  Treatment  for  Practitioners  and  Students. 
By  Dr.  Ph.  Bockenheimer,  Professor  of  Surgery  in  the 
University  of  Berlin.  English  Adaptation  by  C.  F. 
Marshall,  M.  D.,  F.  R.  C.  S.,  Late  Assistant  Surgeon 
to  the  Hospital  for  Diseases  of  the  Skin,  London.  With 
One  Hundred  and  Fifty  Colored  Figures,  from  Models 
by  F.  KoLBOw  in  the  Pathoplastic  Institute  of  Berlin. 
In  Three  Volumes.  New  York :  Rebman  Company,  1908. 
Pp.  419. 

This  is  one  of  the  best  medical  books  which  ap- 
peared in  1908.  The  English  translator  very  rightly 
mentions  in  his  preface  that,  with  the  exception  of 
Lister,  few  surgeons  have  exercised  more  influence 
on  the  progress  of  surgical  science  than  the  late 
von  Bergmann,  of  Berlin.  The  author  of  our  book, 
Philipp  Bockenheimer,  is  one  of  the  many  pupils  of 
the  great  German  surgeon  in  his  later  days,  and  he 
acknowledges  his  indebtedness  to  his  master  in  the 
introduction.  The  work  before  us  is  not  a  transla- 
tion but  an  adaptation,  and  Dr.  Marshall  has  well 
succeeded  in  rendering  the  German  into  English, 
adding  some  remarks  of  his  own  which  appear  in 
brackets.  But  to  the  names  of  Bockenheimer  and 
Marshall  must  also  be  added  that  of  Mr.  Kolbow, 
who  has  greatly  increased  the  value  of  the  book  by 
his  well  executed  illustrations. 

The  atlas  appears  in  three  volumes,  the  first  and 
second  having  each  a  separate  index,  while  in  vol- 
ume iii  is  to  be  found  the  index  for  the  whole  work. 
The  text  is  in  condensed  form,  and  gives  the  diag- 
nosis, prognosis,  and  treatment  of  each  of  the  more 
important  surgical  diseases,  profusely  illustrated. 

The  publishers  seem  to  have  spared  no  expense 
in  producing  the  atlas.  The  text  appears  in  good, 
clear  print  on  rough  paper,  not  the  coated  and  high- 
ly glossy  paper  so  frequently  met  with,  and  the 
volumes  are  of  handy  shape,  well  bound,  with  a 
flexible  leather  cover.  The  work  will  certainly 
assist  the  practitioner  in  diagnosis  and  treatment, 
and  will  give  the  student  a  good  general  survey  of 
clinical  surgery. 

Atlas  und  Grundriss  der  gerichtlichen  Mediztn.  Unter 
Beniitzung  von  E.  v.  Hofmann's  Atlas  der  gerichtlichen 
Medicin.  Herausgegeben  von  Dr.  GEORn  Puppe.  Pro- 
fessor der  gerichtlichen  Medizin  in  Konigsberg  i.  P.  In 
zwei  Brinden.  Mit  70  vielfarbigen  Tafeln  und  204 
schwar/en  Abbildungen.  Aliinchen  :  J.  F.  Lehmann,  1908. 
Pp.  xvi-692. 

The  two  volumes  before  us  comprise  Vol.  xvii 
of  Lehmann's  medizinische  Handatlantcn.  and  are 
based  upon  Eduard  von  Hofmann's  Lehrbnch  der 
gerichtlichen  Medizin.  which  appeared  for  the  first 
time  in  1878  and  has  since  then  seen  many  editions. 

Medical  jurisprudence  should  be  taught  by  dem- 
onstration. To  help  the  student  in  his  studies,  to 
assist  the  physician  in  reviewing  his  knowledge, 
and  to  help  him  as  a  guide  in  case  of  need  are  the 
objects  of  this  compendium.  It  is,  therefore,  only 
natural  that  a  great  importance  is  given  to  the  illus- 
trations, for,  next  to  actual  demonstrations,  illus- 
trations are  the  best  means  of  teaching  this  branch 
of  medicine.  Especially  the  colored  plates  are  very 
good  reproductions  of  actual  objects.     The  book 


refers  to  Austrian  and  German  law,  but  the  descrip- 
tion is  of  interest  to  every  health  official  and  cor- 
oner's physician,  lawyer,  and  judge — in  short,  to 
every  one  who  has  to  do  with  medical  jurispru- 
dence. 

The  introduction  gives  a  short  review  and  a  full 
copy  of  the  German  and  Austrian  law  referring  to 
the  duties  of  the  government  physician,  which  com- 
prises in  these  countries  the  giving  of  expert  testi- 
mony and  the  duties  of  a  health  officer,  of  a  cor- 
oner's physician,  etc.,  and  this  is  followed  by  a  de- 
scription of  the  technique  to  be  used  in  forensic 
demonstrations  of  blood,  hair,  semen,  gonorrhoea, 
and  syphilis.  The  remaining  chapters  treat  of  the 
subject  proper,  and  are  arranged  in  such  a  man- 
ner that  the  references  to  the  German  and  Austrian 
law,  with  commentaries,  come  first,  and  the  mate- 
rial later.  We  have,  thus,  chapters  on  bodily  in- 
juries, violent  death,  and  sexual  relations.  The 
next  two  chapters  speak  of  the  law  in  reference  to 
responsibility  for  injuries,  either  immediate  or  re- 
mote, identification  (Bertillon  system,  etc.),  and 
irresponsibility  arising  from  either  physical  or  men- 
tal causes.  The  author  cites  cases  demonstrating 
the  points  in  question,  which  are  well  selected  and 
absolutely  clear  without  going  too  much  into  detail. 
The  book  is  scientifically  written  and  of  great  in- 
terest. 

Klinik  der  Bronchoscopie.  Von  Hermann  von  Schrotter, 
Dr.  phil.  et  med.  in  Wien.  Mit  4  Tafeln  und  72  Abbil- 
dungen im  Texte.  Jena :  Gustav  Fischer,  1906.  Pp. 
x-688. 

This  \olume  represents  an  extensive  study  and 
rich  experience  in  a  comparatively  new  field.  The 
author  gives  a  clear  idea  of  the  methods  of  superior 
and  inferior  tracheobronchoscopy,  with  full  details 
as  to  instruments,  illumination,  and  anjesthesia.  In 
the  special  part  he  treats  of  the  endoscopic  picture 
of  the  normal  trachea  and  bronchi,  their  respiratory 
and  pulsatory  movements,  and  the  morbid  changes 
observed  in  specific  inflammatory  processes  such  as 
tuberculosis,  syphilis,  scleroma,  lepra,  tumors,  and 
foreign  bodies  in  the  lower  respiratory  tract.  The 
colored  illustrations  are  exceedingly  valuable  for 
those  who  wish  to  familiarize  themselves  with  the 
conditions  described  on  the  basis  of  repeated  obser- 
vations by  the  author,  but  which  naturally  rarely 
present  themselves  often  to  the  average  laryngolo- 
gist. 

Cholecysto-pancrcatite ,  essai  de  pathogenic.  Par  le  Doc- 
teur  Reine  Maugeret,  ancien  interne  des  hopitaux  de 
Paris.    Paris:  G.  Steinheil,  1908.    Pp.  150. 

The  author  has  made  a  careful  study  of  the  liter- 
ature of  this  condition  and  concludes  that  pancreati- 
tis associated  with  cholelithiasis  is  not  an  independ- 
ent disease,  but  a  contemporary  and  associated 
condition  due  to  the  same  initial  cause.  It  is  caused 
either  directly  or  indirectly  by  an  intestinal  infec- 
tion not  yet  known.  He  does  not  think  that  the 
infection  reaches  the  pancreas  by  the  duct,  because 
of  the  bactericidal  property  of  the  pancreatic  juice 
and  the  absence  of  any  reservoir  to  favor  stagnation. 
All  cases  are  associated  with  infection  of  the  gall- 
bladder, and  the  fact  suggests  that  this  form  of 
pancreatitis  should  be  treated  by  disinfection  or  re- 
moval of  the  gallbladder,  from  which  the  infection 
is  propagated  by  the  efferent  lymphatics. 


February  20,  1909.] 


OFFICIAL  NEWS. 


411 


The  Baby,  its  Care  and  Development.  For  the  use  of 
mothers.  By  Le  Granu  Kerr,  M.  D.  Author  of  Diag- 
nosis of  the  Diseases  of  Children;  Professor  of  the  Dis- 
eases of  Children  in  the  Brooklyn  Post-graduate  Medical 
School.  Illustrated.  Brooklyn :  Albert  T.  Huntington, 
1908.    Pp.  160.    (Price,  $1.) 

It  can  scarcely  be  said  that  there  was  a  crying 
need  for  another  book  for  mothers.  The  time  was 
when  every  progressive  gynaecologist  felt  it  neces- 
sary to  invent  a  pessary,  and  of  recent  years  the 
psediatrists  have  been  strongly  moved  to  write  popu- 
lar books  on  the  care  of  infants.  In  the  present 
case  a  somewhat  new  method  of  arrangement  has 
been  adopted.  The  management  and  feeding  are 
described  in  detail  for  the  various  ages  in  such  a 
way  as  to  make  each  section  complete  in  itself.  For 
example,  a  chapter  is  given  to  the  management  of 
each  month  for  the  first  year  and  of  the  various 
periods  thereafter.  The  work  is  well  done,  prac- 
tical, and  creditable  to  the  author. 

Index  of  1,180  Post  Mortems  of  the  Insane.  State  Hos- 
pital for  the  insane,  Norristown,  Pa.  By  H.  J.  Sommer, 
•  Jr.,  M.  D.,  Pathologist;  formerly  Assistant  Physician  to 
the  Institution.  With  an  introduction  by  Allen  J. 
Smith,  A.  M.,  M.  D.,  Professor  of  Pathology,  University 
of  Pennsylvania;  Consulting  Pathologist  to  the  Hospital; 
etc.  Published  and  distributed  by  authority  of  the 
Board  of  Trustees.  1908. 

The  volume  before  us  gives  a  list  of  autopsies 
made  at  the  Pennsylvania  State  Hospital  for  the 
Insane,  at  Norristown,  from  the  year  1884  to  1907. 
The  cases  are  listed  seriatim  under  the  titles  of  the 
clinical  type  of  insanity  from  which  the  patients 
suffered  during  life.  A  summary  of  the  patholog- 
ical diagnosis  is  added  to  the  clinical  diagnosis  in 
each  case.  Then  the  cases  are  grouped  under  the 
cHnical  types  of  insanity,  all  cases  of  dementia  be- 
ing grouped  and  numbered  to  correspond  to  the 
serial  number  in  the  first  part  of  the  index.  There 
is  next  a  cross  reference  for  the  sex  in  the  clinical 
cases,  and  one  for  the  color.  Then  there  is  a  cross 
reference  list  based  upon  the  anatomical  lesions. 
Finally,  there  is  a  list  of  museum  specimens.  The 
book  is  poorly  printed  on  cheap  paper. 

Tlie  Exploits  of  a  Physician  Detective.    By  George  F. 
Butler,  M.  D.,  Professor  and  Head  of  the  Department 
of  Therapeutics   and   Professor   of   Clinical  Medicine. 
Chicago:  Clinic  Publishing  Co.,  1908.    Pp.  322. 
Dr.  Butler  has,  before  this,  become  known  as  a 
novelist ;  he  is  the  author  of  the  Isle  of  Content  and 
Love  and  its  Affinities.    The  present  volume  is  well 
worthy   of   its   forerunners,  and  will   surely  find 
many  readers  among  the  professional  brethren  and 
lay  admirers  of  the  author. 

Jahreshericht  uber  die  Fortschritte  in  der  Lehre  von  den 
pathogenen  Mikroorganismen,  umfassend  Bakterien, 
Pilze  und  Protozoen.  Herausgegeben  von  Dr.  med.  P. 
VON  Baumgarten,  0.0.  Professor  der  Pathologic  an  der 
Universitat  Tiibingen,  und  Dr.  med.  F.  Tangl,  0.6.  Pro- 
fessor der  allgemeinen  und  experimentellen  Pathologic 
an  der  Universitat  Budapest.  Band  XXII.  Leipzig:  S. 
Hirzel,  1908.    Pp.  xii-964. 

This  volume,  like  its  predecessors,  gives  a  won- 
derfully complete  review  of  the  work  done  annually 
in  bacteriological  investigation,  and  makes  one  mar- 
vel at  the  immense  amount  of  highly  intelligent  labor 
which  foreign  publishers  seem  able  to  command. 
Altogether,  2,729  scientific  articles  are  critically  re- 
viewed, and  the  arrangement  of  the  material  is  such 


that  the  reader  has  the  impression  of  a  continuous 
narrative  concerning  the  particular  subject  dis- 
cussed. Unlike  certain  other  reviews,  von  Baum- 
garten's  Jahreshericht  does  not  present  "authors' 
abstracts,"  and  this  insures  the  same  critical  pre- 
sentation of  all  the  articles.  Almost  200  pages 
are  devoted  to  tuberculosis,  and  this  section  is  par- 
ticularly worthy  of  praise.  Altogether,  this  series 
of  annuals  has  come  to  be  indispensable  to  those  try- 
ing to  keep  track  of  progress  in  this  branch  of  med- 
ical science.  We  congratulate  the  editors  on  their 
ability  to  announce  that  the  volume  for  1907  is  al- 
ready in  press.  The  value  of  reviews  of  this  char- 
acter is  greatly  enhanced  by  their  prompt  appear- 
ance. 

Archives  of  the  Middlesex  Hospital.  Volume  XII.  Com- 
prising Clinical  Papers  and  Contributions  from  the  Clin- 
ical and  Pathological  Laboratories.  Volume  XIII.  Sev- 
enth Report  from  the  Cancer  Research  Laboratories. 
Edited  for  the  Cancer  Investigation  Committee,  by  W.  S. 
Lazarus-Barlow,  M.  D.,  F,  R.  C.  P.,  Director  of  the 
Cancer  Laboratories;  Foreign  Member  of  the  German 
Committee  for  the  Investigation  of  Cancer,  etc.  London: 
Macmillan  &  Co.,  Limited;  New  York:  The  Macmillan 
Company,  1908.    Pp.  208. 

Vohtme  XII  contains  a  paper  on  Wertheim's 
radical  operation  for  carcinoma  of  the  cervix  uteri, 
with  a  report  of  four  operations,  one  on  a  case  of 
acute  poliomyelitis  associated  with  a  diplococcal  in- 
fection of  the  spinal  sac,  one  on  the  operation  of 
lymphangeioplasty,  one  on  two  cases  of  diaphrag- 
matic hernia,  one  on  a  case  of  aneurysm  of  the 
corta,  and  one  on  acute  ovarian  abscess  simulating 
tubal  gestation. 

Volume  XIII  is  the  seventh  report  from  the  can- 
cer research  laboratories,  several  of  the  papers 
treating  of  cancer,  while  others  are  on  general  med- 
ical subjects. 

All  these  papers  would  have  been  timely  and  in- 
teresting in  medical  journals,  by  which  they  would 
reach  a  much  larger  audience  than  in  the  neces- 
sarily restricted  circulation  of  a  hospital  report. 


Public   Health   and   Marine   Hospital  Service 
Health  Reports : 

The  following  cases  of  smallpox,  yellow  fever,  cholera, 

and_  plague  have   been  reported  to  the  surgeon  general. 

United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  week  ending  February  12,  igog: 
Smallpo.r — United  States. 
Places.                                          Date.  Cases.  Deaths. 

Alabama — Mobile  Feb.  9   i 

California — Los  Angeles  Jan.  16-23   2 

California — San  Francisco  Jan.  16-23   i 

District  of  Colurabia — Washington.  Jan.  23-30   i 

Indiana — Elkhart  Jan.  23-30   i 

Indiana — Evansville  Jan.  23-30   4 

Indiana — Indianapolis  Jan.  24-31   2 

Indiana — La  Fayette  Jan.  25-Feb.  i   s 

Kansas — Topeka  Jan.  23-30   13 

Iowa — Dubuque  Oct.  i-Feb.    5   89  i 

Kentucky — Lexington  Jan.  23-30   3 

Kentucky — Newport  Jan.  23-30   13 

Louisiana — New  Orleans  Jan.  23-30   7 

Maine — Van  Buren  Jan.  23-30   8 

Michigan — Detroit  Jan.  23-30   3 

Michigan — Grand  Rapids  Tan.  23-30   i 

Michi  gan — Saginaw  Jan,  16-23   i 

Missouri — Kansas  City  Jan.  23-30   i 

Missouri — St,  Louis  Jan.  23-30   2 

Montana — Butte  Jan.  12-19   i 

Kebrask? — South  Omaha  Jan.  9-16   i 

New  York — Syracuse  Jan,  1-31  ,   3 


412 


BIRTHS.  MARRIAGES,  AND  DEATHS. 


[Xew  York 
Medical  Journal. 


Places.  Date. 

Ohio — Cincinnati  Jan.  8-27  

Ohio — i)ayton  Jan.   23-30   - 

Tennessee — Knox\illc  Jan.    23-30   i 

Tennessee — Nashvil!c  Jan.   23-30   7 

Utah — General  Dec.  1-30   24 

Virginia — Lynchburg  Jan.    23-30   i 

Wisconsin- — J-a  Crosse  Jan.   23-30   2 

Wisconsin — MiKvaukce  Jan.   23-30   19 

Smallpox — Insular. 
Philippine  Islands — Manila  Dec.  5-12   3 

Smallp  ox — h'ore  ig  11 . 

.■\rabia — .\den  Dec.  21-Jan.  5  

Canada — Ontario  Province  Dec.  1-31  

Ceylon — Colombo  Nov.  21-Dec.  5. 

Cliile — Valparaiso.   Dec.  5-12  

I'rance — Paris  Jan.  9-16  

Germany — General  Jan.  9-16  

Germany — Konigsberg  Jan.  29  

Great  Britain — Bristol  Jan.  9-16  


Cases.  Deaths. 
..42  1 


26 


India — Calcutta  Dec. 

Indo-China — Saigon  Nov 

Italy — General  Jan. 

Italy — Naples  Jan. 

Java — Batavia  Dec. 

Me-xico — .■\capuIco  Jan. 

Mexico — Guadalajara  Jan. 

Mexico — Mexico  Dec. 

Newfoundland— St.  Johns  Ian. 

Russia — Batoum  Dec. 

Russia — Moscow  Dec.  26'Jan.  2   29 

Russia — Riga  Jan.    16-23   2 

Russia — St.  Petersburg  Dec.    19-26   8 

Turkey — Trebizond  Jan.  9-16  

Vclhw  Fez'cr- — Foreign. 

Barbados  Jan.  28-Feb.  4   11 

Kcuador — Guayaquil  Jan.  29  

Mexico — Maxcanu  and  vicinity. . . .  Jan.    18-23   4 

Mexico — Merida  Jan.  18-23  


12-19   16 

28-Dcc.    5   5  4 

10-17   13 

10-17   46  7 

12-26   6 

10-17   6 

14-21   2 

5-12   5 

23-30   I  Imported. 

1-30 


Present. 


Cholera — Insular. 
-Manila  ..Dec.  5-19. 


Philippine  Islands- 

Pliilippine  Islands — Provinces  Dec.   5-19  475 

Cholera — Foreign. 

Ceylon — Colombo  Nov.   21-Dec.   5   3 

India — Calcutta  Dec.  12-19  

India — Rangoon  Dec.  19-26  

Plague — Foreign. 

Ecuador — Guayaquil  ^  Jan.  2-9  

Kgypt — General  Dec.  23-Jan.   14  22 

India — Calcutta  Dec.  12-19  

India — Rangoon  Dec.  19-26  

Indo-China — Cholen  Jan.  28-Dec.  ■  5   2 

Turkey — Bagdad...   Dec.    i2-Jan.    2   12 

Turkey — Jiddah  Feb.  3  


325 


Present. 


Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  officers 

sei'ving  in  the  Medical  Corps  of  the  United  States  Army 

for  the  iveek  ending  February  13,  igog: 

Ad.mr,  G.  W.,  Colonel,  Medical  Corps.  Granted  leave  of 
absence  for  four  months. 

Appel,  a.  H.,  Lieutenant  Colonel,  Medical  Corps.  Granted 
leave  of  absence  for  thirty  days. 

BiRMi.NT,H.\M,  l\.  p.,  Lieutenant  Colonel,  Medical  Corps. 
Relieved  from  duty  in  Cuba,  and  ordered  to  Washing- 
ton., D.  C,  for  temporary  duty  in  the  office  of  the  Sur- 
geon General. 

D.wis,  W.  B.,  Colonel,  Medical  Corps.  Sailed  on  the  Sher- 
idan from  San  Francisco,  Cal.,  for  Manila,  P.  L,  Feb- 
ruary 5th. 

"Duv.\L.  D.  F.,  Major,  Medical  Corps.  Granted  leave  of  ab- 
sence for  four  months. 

"Farrow,  E.  J.,  First  Lieutenant,  Medical  Reserve  Corps. 
Sailed  on  the  Sheridan  from  San  Francisco,  Cal.,  for 
Manila,  P.  L,  February  5th,  from  leave  of  absence. 

H.SRTSOCK,  F.  M..  Major,  Medical  Corps.  Granted  leave  of 
absence  for  four  months,  with  permission  to  go  beyond 
the  sea. 

.TuENEMA.N'N.  G.  F.,  Captain,  Medical  Corps.  Granted  leave 
of  absence  for  two  months. 

McIntyre,  H.  B.,  Lieutenant,  Medical  Corps.  Granted 
leave  of  absence  for  one  month. 

McPheeters.  S  p..,  First  Lieutenant.  Medical  Reserve 
Corps.  Ordered,  upon  arrival  at  San  Francisco,  Cal., 
to  proceed  to  his  home  and  report  for  orders. 

PiiKi.AX,  11.  mr  R.,  First  Lieutenant,  Medical  Reserve 
Corps.  Relieved  from  duty  at  Fort  Baker,  Cal.,  and 
ordered  to  Fort  Shafter,  H.  T.,  for  duty. 

Rhoads,  T.  L.,  Major,  Medical  Corps.  Sailed  on  tlie  Sher- 
idan from  San  Francisco,  Cal.,  for  Manila,  P.  L,  Feb- 
ruary 5th. 


SiLER,  J.  F.,  Captain,  Medical  Corps.  Relieved  from  duty 
at  Fort  Slocum,  N.  Y.,  and  ordered  to  Fort  Jay,  N.  Y., 
for  dutj-. 

Smith,  R.  D.,  First  Lieutenant,  Medical  Reserve  Corps. 

Honorably  discharged  from  the  service  of  the  United 

States,  February  i6th. 
Tyler,  G.  T.,  First  Lieutenant,  ^Medical  Reserve  Corps. 

Ordered  to  return  from  Fort  Jaj-,  X.  Y.,  to  his  proper 

station.  Fort  Porter,  X.  Y. 

Navy  Intelligence: 

No  changes  in  the  stations  and  duties  of  officers  serving 
in  the  Medical  Corps  of  the  United  States  N^ai'y  zcere  rc 
ported  for  the  zveek  ending  February  13,  igog: 




§irt^s,  glarriages,  anl)  feat^s. 


Married. 

Geppert — Wood. — In  JeffersonviUe,  Lidiana,  on  Monda>-, 
February  8th,  Dr.  Forrest  Geppert,  of  Louisville,  Kentucky, 
and  Miss  Virginia  ^^"ood. 

Marshall — Rowan. — In  Wheeling,  West  Virginia,  on 
Wednesday,  January  27th,  Dr.  J.  C.  Marshall  and  Miss  An- 
nette Rowan. 

Pressley — Page. — In  San  Francisco,  California,  on 
Thursday,  January  28th,  Dr.  James  Fowler  Pressley  and 
Miss  Ellen  Burwell  Page. 

Toll — Johxsox. — In  Scranton,  Pennsylvania,  on  Tues- 
day, February  i6th,  Dr.  Robert  M.  Toll  and  Miss  Julia 
Johnson. 

Died. 

Armstroxg. — In  Atlanta,  Georgia,  on  Tuesday,  February 
2nd,  Dr.  William  Buckingham  Armstrong,  aged  thirty-five 
years. 

Bailey. — In  Sioux  City,  Iowa,  on  Tuesday,  January  2nd, 
Dr.  John  Bailey,  aged  seventy-eight  years. 

Bryan. — In  Evansville,  Indiana,  on  iMonday,  February 
8th,  Dr.  Anthony  H.  Brj'an,  aged  seventy-six  years.  . 

Buel. — In  Franklin,  Michigan,  on  Thursday,  February 
4th,  Dr.  Julian  A.  Buel,  aged  sixtj'-nine  years. 

Bullen. — In  Philadelphia,  on  Tuesday,  February  9th, 
Dr.  Henry  Bullen,  aged  sixty-three  years. 

Cannon.— In  Ellenton,  South  Carolina,  on  Wednesday, 
February  3d,  Dr.  W.  S.  Cannon,  aged  seventy-three  years. 

Dearth. — In  Long  Beach,  California,  on  Tuesday,  Janu- 
ary 26th,  Dr.  Leonard  Dearth. 

Douglass. — In  Morristown,  New  Jersey,  on  Friday,  Feb- 
ruary 5th,  Dr.  David  F.  Douglass,  of  Colfax,  Illinois. 

Fritts. — In  Plainfield,  New  Jersey,  on  ]\Ionday,  Fetru- 
ary  8th,  Dr.  John  T.  Fritts,  aged  sixty-three  years. 

Gaskins. — In  Barton  Heights,  Virginia,  on  Wednesday, 
February  3d,  Dr.  R.  Fuller  Gaskins,  aged  sixty-two  years. 

Gerrish. — In  South  Berwick,  Maine,  on  Tuesday,  Feb- 
ruary 2nd,  Dr.  Christopher  P.  Gerrish,  aged  eighty  years. 

Hall. — In  Keyser,  West  Virginia,  on  Friday,  February 
5th,  Dr.  J.  W.  Hall,  aged  sixty-five  years. 

Hanna. — In  Covington,  Tennessee,  on  Friday,  January 
29th,  Dr.  James  H.  Hanna,  aged  fifty  years. 

James.— In  Chicago,  on  Monday,  February  Sth,  Dr.  Eliz- 
abeth James,  aged  seventy-eight  years. 

McCabe. — In  Dagsboro.  Delaware,  on  Saturday,  Febru- 
ary 6th,  Dr.  Edward  McCabe. 

McCalep.. — In  San  .Antonio,  Texas,  on  Tliursday,  Febru- 
ary 4th,  Dr.  J.  FI.  McCalcb,  of  Gonzales. 

Nye. — In  Hurricane,  West  Virginia,  on  Thursday,  Feb- 
ruary 4th,  Dr.  George  L.  Nye. 

P.\yne. — In  Warrenton,  Virginia,  on  Wednesday,  Feb- 
ruary 3d,  Dr.  William  W.  Payne,  aged  seventy-five  years. 

R.VMSAY. — In  Clarksburg.  West  Virginia,  on  Friday,  Feb- 
ruary 5th,  Dr.  John  W.  Ramsay,  aged  seventy-seven  years. 

Sherman. — In  East  Chattanooga,  Tennessee,  on  Friday, 
February  5th,  Dr.  \.  F.  Sherman. 

Von  Duerixg.— In  New  York,  on  Wednesday,  February 
lOth.  Dr.  Adolph  \on  Duering.  aged  fifty-seven  years. 

Wills. — In  Cliflford.  Virginia,  on  Thursday,  February 
4th.  Dr.  Alexander  F.  Wills,  aged  seventy-five  years. 

WooDRurr. — In  Pittstield.  ^Fassachnsotts,  on  Thursday, 
February  iith,  Dr.  Morgan  L.  Woodruff. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  ^It  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


\  oL.  LXXXIX,  No.  9.  NEW  YORK.  FEBRUARY  27,  1909. 


Whole  Xo.  157^ 


C^riainal  (Communifiitions. 


THE  CAXCER  QUESTION. 
With  Sficcial  Rcfcicncc  to  the  Treatment  of  Cancer  of 
the  Breast* 
By  Johx  E.  Summers.  M.  D., 
Omaha.  Xebr. 

The  world  wide  crusade  urged  in  the  education 
of  the  people  as  to  the  cause,  prevention,  and  treat- 
ment of  tuherculosis.  is  bearinq^  fruit,  and  pursued 
to  its  legitimate  end.  may  result  in  the  wiping  out 
of  tuberculosis  as  the  "white  plague." 

The  education  of  the  public  regarding  the  mean- 
ing of  certain  conditions  that  point  towards  begin- 
ning cancer,  and  the  importance  of  early  expert  ex- 
amination has  been  woefully  neglected.  And  it  is 
wellnigh  impossible  for  the  medical  profession  un- 
aided, to  accomplish  this :  We  need  the  cooperation 
of  an  honest  public  press.  In  fact,  only  within  the 
present  month  has  the  layman  had  the  subject  of 
cancer  presented  "to  him  in  its  true  light  as  we  know 
it  to-day ;  and  the  world  at  large  owes  a  debt  of 
gratitude  to  the  Saturday  Evening  Post  for  its  edu- 
cational campaign  in  this  direction  and  others,  look- 
ing towards  the  protection  of  the  public  in  matters 
of  hygiene,  the  cause  and  prevention  of  disease. 

Charles  P.  Childe  {The  Control  of  a  Scourge,  or 
Hoxv  Cancer  is  Curable)  has  just  published  a  most 
readable  and  instructive  book  intended  for  the  pub- 
lic which,  I  hope,  will  have  wide  recognition.  In 
this  book  Mr.  Childe  tells  in  plain,  simple  language 
what  we  know  about  cancer,  and  the  great  advance 
made  in  its  cure  by  early  operation.  It  is  the  best 
book  of  the  kind  that  has  ever  fallen  under  my 
recognition,  and  will  undoubtedly  result  in  the  sav- 
ing of  many  lives. 

2^Iany  physicians  living  to-day,  can  recall  the 
former  ravages  of  typhus  fever,  malaria,  cholera, 
dysentery,  yellow  fever,  diphtheria,  and  other 
zymotic  disea.ses ;  they  have  noted  the  waning  of 
tuberculosis.  The  public  knows  all  of  this  and  has 
legislated  accordingly.  Has  the  physician  tried  to 
educate  the  public  to  the  increasing  prevalence  of 
cancer? 

We  as  physicians  know  some  facts,  although  our 
interpretations  of  their  exact  meaning  mav  differ. 
Some  believe  cancer  is  hereditary  or  man  inherits 
a  weakened  resistance  toward  the  development  of 
cancer,  just  as  he  inherits  a  constitution  and  physi- 
cal makeup  favorable  to  the  infection  and  growth 

*Read  before  the  Western  Surgical  and  Gynaecological  Association, 
at  Minneapolis,  December  29,  1908. 

Copyright,  1900.  by  .\.  R. 


of  the  tubercle  bacillus.  \\'e  escape  from  and  over- 
come the  diseases  of  childhood  in  pro])ortiun  as  we 
spring  from  good  parent  stock  physically  and  men- 
tally, and  our  guardians  exercise  the  known  meas- 
ures against  such  as  are  preventable.  We  reach 
middle  life  in  direct  proportion  as  we  take  care  of 
our  inheritance,  and  keep  in  touch  with  the  educa- 
tional progress  of  our  times.  \'ital  statistics  show 
that  although  a  much  greater  percentage  of  the 
population  reach  middle  life  than  formerly,  fewer 
people  reach  old  age,  i.  e.,  "the  saving  of  life  in 
modern  times  has  mainly  been  confined  to  the  pre- 
cancerous years  of  existence,  the  death  rates  of 
males  over  thirty-five,  and  of  females  over  forty-five 
having  remained  almost  stationary,  while  the  num- 
bers attaining  old  age  have  decreased'"  (Williams). 
The  increase  in  the  death  rate  from  cancer  can  only 
in  small  measure  be  accounted  for  bv  increased  skill 
in  diagnosis,  and  more  accurate  vital  statistics.  In 
England,  while  the  population  barely  doubled  ( 1850 
to  1905)  the  cancer  mortality  increased  more  than 
sixfold  ( \\'illiams) ,  and  all  reliable  vital  .statistics 
go  to  prove  that  this  increase  in  cancer  mortality  is 
universal.  In  England,  the  registrar  general's  re- 
port shows  that  in  igo6,  out  of  a  total  141.241 
deaths  of  males  over  thirty-five  years  of  age.  12,695 
died  from  cancer;  and  out  of  a  total  of  140,607 
deaths  of  females  over  thirty-five  vears  of  age,  17,- 
671  died  from  cancer.  This  means  that  one  man  in 
eleven  over  thirty-five  years  of  age.  will  die  of  can- 
cer, and  that  one  woman  in  eight  over  ihirty-five 
years  of  age,  will  die  of  cancer.  In  England,  the 
cancer  death  rates  for  1905  are  for  each  100.000 
living  75.6  for  males  and  100.5  f*""  females ;  the 
corresponding  phthisis  rates  being,  for  males  134.7 
and  for  females  95.7.  The  meaning  being  that  more 
>vomen  die  of  cancer  than  of  tuberculosis. 

In  Nebraska,  a  population  of  young  ])eople,  tu- 
berculosis is  very  prevalent,  yet  even  there  cancer 
claims  its  many  victims.  Total  deaths  in  Nebraska 
from  tuberculosis  in  T007  were  589:  Men  303.  wo- 
men 286.  Total  deaths  from  cancer  (1907).  355; 
Men  166,  women  189.  Here  in  a  new  community 
representing  the  survival  of  the  fittest  from  older 
States,  more  than  half  as  main-  women  die  of  can- 
cer as  of  tuberculosis.  Aside  from  what  ma  .•  be 
one's  personal  belief  as  to  the  cause  of  cancer,  he 
should  be  modest  in  asserting  it,  when  so  ipanv 
brilliant  workers  are  at  sea  notwithstanding  their 
unusual  opportunities  for  investigation.  Dr.  Bash- 
ford,  general  superintendent  of  research  and  »li- 
rector  of  the  Laboratory  of  the  Imperial  Cancer 
Research  Fund,  says  {The  Lancet,  Xovember  21, 

Elliott  Publishing  Company. 


414 


SUMMERS:  CANCER  QUESTION. 


[New  York 
Medical  Journal. 


1908),  "The  successful  application  of  vhe  compara- 
tive and  experimental  methods  appears  to  be  great- 
ly narrowing  the  field  of  inquiry  and  dismissing 
many  explanations  of  cancer — previously  held  with 
good  reason  —  from  further  serious  consideration. 
Although  this  is  the  case  we  still  know  very  little  as 
to  its  ietiology  beyond  the  fact  that  it  manifests  it- 
self under  the  most  divergent  conditions  and  in 
such  a  way  that  we  may  have  to  entertain  the  pos- 
sibility of  several  aeliclogical  factors,  some  of  which 
are  external  and  some  internal  to  the  bod}'.  To 
these  factors  we  are  only  justified  at  present  in  as- 
signing an  indirect  and  mediate  aetiological  signifi- 
cance. The  most  satisfactory  explanation  of  the 
causation  of  cancer  will  probably  be  that  implied  by 
the  accurate  description  of  the  nature  of  the  trans- 
formation of  normal  into  cancer  cells  when  this  ad- 
vancement in  knowledge  shall  have  been  attained." 
This  sentiment  is  in  line  with  the  deductions  of 
Roger  Williams  as  stated  in  his  most  remarkable 
book  on  The  Natural  History  of  Cancer.  Wil- 
liams demonstrates  the  overwhelming  evidence  of 
the  heredity  of  cancer,  and  the  increase  of  the  dis- 
ease, but  believes  that  heredity  for  cancer  means  a 
lessened  resistance  to  the  cause.  The  increase  can 
best  be  explained  by  modes  of  modern  life,  and  ex- 
cess in  proteid  diet.  He  almost  ridicules  the  para- 
sitic theorv,  and  explains  away  the  "cancer  dis- 
tricts," "cancer  homes,"  etc.,  as  incidental.  In  strik- 
ing contrast  to  this,  Roswell  Park,  in  a  recent  ad- 
dress before  the  International  Society  of  Surgery, 
opening  the  ''symposium"  on  cancer,  comes  out 
boldly  for  the  parasitic  origin  of  cancer  and  in  a 
fascinating  and  convincing  way  pleads  for  the 
throwing  off  of  the  shackles  of  the  dead  house 
pathology  and  the  blind  following  of  so  called 
■  leaders."  Park  thinks  the  evidences  of  clinical  ob- 
servation and  experimental  research,  added  to  the 
analogy  that  cancer  bears  to  known  zymotic  dis- 
ease, admits  of  no  other  reasonable  explanation  than 
that  it  is  of  parasitic  origin. 

I  am  more  and  more  inclined  every  year  as  ni) 
clinical  experience  grows,  to  look  upon  cancer  as 
zymotic  in  origin.  In  my  judgment,  evidence  of  its 
infection  by  direct  contact  is  lacking,  it  may  be 
autoinoculable.  I  believe  the  germ  or  its  poison  to 
be  conveyed  through  the  medium  of  a  host  in  the 
same  way  as  yellow  fever  is  carried.  "Cancer  dis- 
tricts" exist,  this  is  known ;  what  other  explanation 
than  infection  through  some  intermediate  means  can 
explain  the  fact?  It  is  the  only  explanation  in  line 
with  what  we  really  know  about  infectious  dis- 
eases. There  is  probably,  I  think,  some  relation 
between  tuberculosis  and  cancer.  As  tuberculosis 
decreases  cancer  increases.  Cancer  is  prevalent  in 
tuberculous  families  and  prefers  to  select  for  its 
victims  those  members  of  the  family  who  have  sur- 
vived, unscathed,  the  tuberculous  age. 

During  the  past  two  or  three  years,  I  have  been 
more  than  commonly  impressed  by  the  number  of 
patients  with  advanced  cancer  of  the  uterus  and 
breast,  that  have  come  to  me  for  relief.  Some  of 
these  cases  were  clearly  inoperable,  and  others  al- 
most so.  C)n  the  other  hand,  with  the  exceptions 
of  cancer  of  the  mouth,  throat,  larynx,  and  oesopha- 
gus, I  have  seen  few  cases  of  late  cancer,  I  mean 


neglected  cancer,  on  the  surfaces  of  the  head,  face, 
neck,  and  body.  Particularly  must  it  be  emphasized 
that  nowadays  more  seldom  than  formerly,  we  meet 
with  unrecognized  malignant  diseases  of  the  ab- 
dominal viscera ;  this  is  due  to  the  phenomenal 
spreading  of  the  knowledge  of  diagnosis  in  all  ab- 
dominal affections.  When  we  stop  to  recall  that 
eighty  per  cent,  of  all  tumors  of  the  breast  are 
malignant,  and  that  every  malignant  tumor  unless 
removed,  sooner  or  later  kills,  the  great  responsibil- 
ity of  the  family  physician,  when  his  advice  is 
sought,  is  apparent.  Unfortunately,  human  nature 
is  still  as  of  y  ore,  and  education  is  slow  in  making- 
proper  progress.  Fads  and  fancies,  religious  and 
otherwise,  vain  hopes  and  graspings  after  straws, 
influence  too  many  to  put  off  an  operation.  The 
instinct  of  woman  to  conceal  the  existence  of  a 
tumor,  for  fear  it  may  be  pronounced  cancer,  can 
alone  be  overcome  by  the  medical  profession  spread- 
ing abroad  the  truth  that  eighty  per  cent,  of  all 
tumors  of  the  breast  are  cancer  or  become  so,  but 
that  the  operative  mortality  in  experienced  hands  is 
only  about  one  half  of  one  per  cent. 

Rodman  has  collected  2,133  operations  performed 
for  cancer  of  the  breast  since  1893,  twenty-one 
American  surgeons,  with  an  operative  mortality  of 
less  than  one  per  cent.  As  to  the  hope  of  cure, 
Bloodgood  (Aiuerican  Journal  of  the  Medical  Sci- 
ences, February,  1908)  says:  "The  statistics  in  Hal- 
sted's  clinic  up  to  the  present  time  show  that  among 
210  cases,  in  which  three  years  or  more  have  passed 
since  the  operation,  42  per  cent,  of  the  patients  are 
apparently  well.  If  we  consider  the  cases  in  which 
the  axillary  glands,  studied  microscopically,  showed 
no  evidence  of  metastasis,  sixty-one  patients,  or 
eighty-five  per  cent,  are  well.  In  cases  in  which 
the  axillary  glands  showed  metastasis  (no),  thirty 
per  cent,  of  the  patients  remained  free  from  recur- 
rence for  three  years.  When  the  glands  in  the  neck 
showed  metastasis  (forty  cases),  only  ten  per  cent, 
of  the  patients  remained  well  for  three  years.  In 
all  of  these  groups,  metastasis  has  been  observed 
after  an  interval  of  three  years  of  apparent  cure. 
Such  late  metastasis  may  take  place  up  to  eight 
years  after  operation.  Excluding  these  cases  of 
late  recurrence,  the  definitely  cured  in  these  three 
groups  is  reduced  to  seventy-five,  twenty-four,  and 
seven  per  cent,  respectively,  or  for  all  cases  to- 
gether, thirty-five  ])er  cent."  To  this  clinic,  464 
cases  of  primary  carcinoma  of  the  breast  have  been 
admitted.  In  ii  j  (^/-^  per  cent.)  the  disease  has 
been  inoperable. 

In  a  most  important  series  of  papers  read  at  the 
1907  meeting  of  the  Aiiierican  Surgical  Associa- 
tion, the  subject  of  the  End  Results  of  Primary  Op- 
erations for  Cancer  of  the  1>reast  was  the  chief 
topic  discussed.  There  was  practically  no  differ- 
ence in  the  results  at  the  hands  of  these  men,  all 
representatives  of  the  best  of  surgical  judgment  and 
skill  in  America.  I  have  taken  1  lalsled's  statistics 
as  an  example  because  we  are  nuich  indebted  to 
hiiu  for  the  principles  of  the  type  of  operation 
which  is  producing  the  best  results  in  the  ojjcrative 
treatment  of  cancer  of  the  breast.  In  addition  it 
can  be  stated  that  in  no  clinic  in  the  world,  are 
more  pains  takt  n  in  secure  accuracy  in  all  that  per- 


February  27,  1Q09.] 


SUMMERS:  CANCER  QUESTIOX. 


415 


tains  to  scientific  honest  work  and  reports,  than  at 
the  Johns  Hopkins  Hospital. 

Most  cases  of  cancer  of  the  breast  can  be  recog- 
nized by  every  physician  of  experience  or  proper  ed- 
ucation ;  because  a  tumor  may  have  existed  qui- 
escent for  months,  or  perhaps  years,  is  no  proof 
that  it  may  not  be  mahgnant.  Jacobson  (Annals  of 
Surgery,  July,  1907)  puts  it  very  nicely  when  he 
says,  "It  is  not  always  possible  to  determine  the 
period  of  duration  of  the  disease.  Inasmuch  as  in 
its  early  stages  carcinoma  is  entirely  devoid  of  pain, 
it  is  frequently  a  matter  of  accident  that  the  tumor 
is  discovered.  .  .  .  The  rapidity  with  which  the 
disease  progresses  is  of  paramount  importance,  I 
think  it  will  be  conceded  without  dispute  that  there 
is  as  much  difference  in  the  virulence  of  the  cases 
of  carcinoma  as  there  is  in  acute  infectious  fevers. 
In  some  instances  of  the  latter,  the  fever  will  pro- 
gress so  mildly  as  to  scarcely  disturb  the  patient, 
while  in  other  instances  it  will  overwhelm  the  in- 
dividual with  such  fury  as  to  be  fatal  within 
twenty-four  hovirs." 

Cases  of  the  acute  type  are  most  unfavorable  for 
operation — the  only  hope  of  these  patients  is  in 
early  recognition  and  immediate  operation.  Ques- 
tionable cases  may  be  submitted  to  exploratory  in- 
cisions. The  surgeon  should  be  better  equipped  to 
recognize  the  gross  pathology  presented.  Frozen 
sections  require  only  a  few  minutes  to  determine 
the  probable  character  of  a  tumor;  therefore  in 
some  hospitals  a  specimen  is  removed  at  an  explo- 
ratory incision,  and  frozen  sections  examined  in 
order  to  determine  the  true  nature  of  a  doubtful 
tumor.  This  practice  is  not  always  available,  but 
in  well  equipped  hospitals  it  should  be.  When  T 
am  in  doubt  as  to  the  nature  of  a  tumor  after  ex- 
ploration and  careful  inspection,  I  do  the  radical 
operation  and  have  the  pathologist  submit  his  re- 
port at  his  leisure.  This  practice  I  have  never  had 
to  regret,  tn  fact,  I  would  rather  trust  my  surgi- 
cal sense  after  a  careful  clinical  history  and  exam- 
ination, with  an  added  gross  inspection  of  a  tumor 
on  incision,  than  the  microscopical  findings  of  any 
pathologist.  One  would  be  a  fool  to  belittle  the 
value  of  the  microscope.  However,  from  the  same 
standpoint,  my  family  physician  must  be  the  man 
who,  in  a  case  of  strongly  suspected  diphtheria, 
gives  a  large  dose  of  antitoxme,  and  then  takes  a 
culture  and  awaits  the  bacteriological  report  with 
a  smile. 

In  spite  of  the  lack  of  positive  confirmation  by 
Wile  and  otherS;  of  the  work  of  Crile  in  his  study 
of  haemolysis  in  cancer,  I  feel  confident  that  Crile, 
a  known,  keen  clinician,  a  physiologist  and  original 
thinker,  is  in  a  better  position  to  scientifically  study 
cancer  in  man  than  his  colaborers,  the  bacteriolog- 
ists. His  technique  under  such  circumstances  can- 
not help  but  be  followed  by  more  uniform  results, 
hence  when  he  tells  of  the  eighty-five  per  cent,  posi- 
tive haemolysis  in  his  cancer  cases  (130  out  of 
153),  that  "the  cancer  patients  showing  no  haemoly- 
sis were  mostly  in  the  advanced  inoperable  stage. 
Only  an  occasional  early  case  failed  to  show 
haemolysis,"  we  must  recognize  that  a  great  stride 
has  been  made  toward  the  early  diagnosis  of  can  :er. 

It  is  to  be  hoped  that  a  reliable,  simple  technique 


may  be  worked  out  as  a  blood  test  for  cancer,  which' 
will  place  this  aid  to  diagnosis  where  it  can  be 
more  universally  applied  than  would  at  present  ap- 
pear. As  in  cancer  early  operation  offers  the  very 
best  and  reasonable  hope  of  cure,  we  should  do- 
our  duty  in  ever}^  legitimate  way  to  educate  the 
public  to  the  fact.  That  they  are  not  so  educated  is- 
evidenced  by  the  thrivings  of  charlatans  and  the  pro- 
prietors of  the  public  press.-  W.  D.  Haggard  remarks 
in  the  Journal  of  the  Am&rican  Medical  Association: 
"As  Rodman  says :  'It  is  more  important  to  make 
an  early  diagnosis  in  cancer  of  the  breast  than  it 
is  in  appendicitis.  .Some  of  these  patients  may,  and 
do,  get  well  without  operation,  whereas  neglected 
operation  in  breast  cancer  leads  inevitably  to  the 
most  loathsome  and  horrible  of  deaths.  Women 
with  lumps  in  their  breasts  do  not  understand  their 
danger.  They  are  afraid  of  operation  on  account 
of  ignorance  of  its  safety,  and  the  great  probability 
of  permanent  cure  in  the  early  stages,  because  of 
an  unfavorable  result  in  some  friend  who  was  prob- 
ably operated  upon  in  an  advanced  stage.'  "  At  least 
twenty  per  cent,  of  the  patients  with  cancer  of  the 
breast  in  advanced  stages,  who  have  come  to  me 
for  operation,  have  suffered  the  delay  because  of 
the  advice  of  their  physicians,  and  it  is  hard  to  put 
a  charitable  explanation  upon  such  advice.  Of 
course  there  are  frequent  instances  when  patients 
will  not  follow  the  family  physician's  advice  until 
it  is  too  late,  and  of  such  examples  I  have  had 
many  instances.  Particularly  among  the  relatively 
young  sufferers  from  cancer  should  we  be  over 
zealous  in  urging  early  operation — the  soil  is  fer- 
tile. Among  the  older  or  advanced  in  years,  the 
principle  of  recommendation  is  the  same,  yet  in 
truth,  in  them  cancer  often  has  long  periods  of 
quiescence.  In  the  presence  of  feebleness  or  the 
complications  of  age,  palliative  operations  only  are 
admissible,  and  in  some  instances  any  operation 
would  tend  to  bring  surgery  into  disrepute.  I  well 
recall  an  instance  of  an  old  lady  whose  breast  I 
amputated  (radical  operation).  It  was  as  the  re- 
sult of  heroic  efforts  that  she  survived  the  opera- 
tion. An  unexpected  weak  heart  only  needed  the 
shock  of  the  operation  to  almost  cause  it  to  cease 
to  beat.  Suddenly  about  tw'O  months  after  the 
operation,  the  poor,  tired  heart  stopped.  A  more 
careful  observation  prior  to  operation  ought  to  have 
discovered  the  weak  heart,  and  I  have  always  be- 
lieved that  my  operation  was  ill  advised.  So  let  us 
use  good  judgment  in  the  treatment  of  cancer,  as 
in  all  of  our  other  professional  duties. 

Since  I  have  been  doing  operative  surgery,  I 
know  of  no  surgical  disease  the  treatment  of  which 
has  advanced  so  much  in  the  saving  of  life,  as  that 
of  cancer  of  the  breast.  As  every  patient  with  can- 
cer of  the  breast  inevitably  dies  of  the  disease  un- 
less operated  upon  properly,  an  ability  upon  the 
part  of  the  operator  to  do  thorough  radical  work 
is  essential — a  knowledge  of  the  usual  and  unusual 
distribution  of  the  lymphatics  must  precede  the 
path  of  the  scalpel  and  scissors.  As  Mr.  Lockwood 
so  well  says,  "The  rapidity  with  which  cancer 
spreads  into  the  lymphatics  depends  to  a  large  ex- 
tent upon  the  position  of  the  primary  growth. 
When  that  is  situated  within  a  hollow  muscular 


4i6 


SUMMERS:   CANCER  QUESTION. 


[New  York 

MliillCAL  JoURNAT.. 


organ  such  as  the  urinary  bladder,  or  gallbladder, 
the  pause  may  be  a  long  one — months  or  even 
years.  But  wiien  the  growth  is  in  the  mammary 
g'land,  which  has  no  capsule,  or  the  tongue,  or  in 
the  pharynx,  there  is,  I  believe,  hardly  any  interval 
of  time  between  the  onset  of  the  growth  and  its 
spread  into  the  neighboring  lymphatics." 

The  first  amputation  of  the  breast  I  ever  wit- 
nessed was  in  the  fall  of  1879  Bellevue  Hospital, 
New  York,  and  the  operator  was  James  R.  Wood, 
a  most  skilful  man  in  operative  technique.  The 
breast  with  an  elliptical  covering  of  skin  was  re- 
moved. The  axilla  was  not  disturbed.  The  tech- 
nique did  not  vary  much  from  that  told  of  by  John 
Brown  in  his  pathetic  story  of  Rab  and  His 
Friends,  when  poor  Ailie  bared  her  breast  and  had 
it  removed.  Banks,  in  England,  the  younger  Gross 
and  Halsted.  in  America,  taught  us  the  principles 
of  thorough  radical  operation.  An  increasing 
knowledge  of  the  distribution  of  the  lymphatics 
has  added  greatly  to  our  end  results.  The  many 
men  who  have  of  late  tried  to  give  their  names  to 
special  operations  for  cancer  of  the  breast  are 
simply  artists  in  cosmetics — and  some  are  good 
ones,  too.  They  are  paraphrasers  of  the  writings 
of  Banks.  Gross,  Halsted,  and  their  students,  and 
their  work  is  useful  to  that  extent.  The  men  who 
have  the  best  results  in  the  treatment  of  cancer  are 
not  those  who  think  so  nuich  about  how  the  wound 
will  look  after  the  operation,  but  rather  how  they 
can  get  beyond  the  possible  extent  of  the  disease ; 
the  man  who  does  this  finds  some  way  to  close  the 
wound. 

Cancer  of  the  breast  in  men  is  rare.  I  have  only 
seen  three  patients,  upon  two  of  whom  I  operated. 
About  one  per  cent,  of  the  cases  of  cancer  of  the 
breast  occur  in  men.  In  the  Johns  Hopkins  Hos- 
pital, out  of  307  cases  of  cancer  of  the  breast,  only 
three  affected  the  male  breast. 

Age  is  no  protection  against  carcinoma  of  the 
breast.  ( )ne  case,  a  girl  (mulatto),  sixteen  years 
of  age.  was  operated  upon  by  me  in  the  Douglas 
County  Hospital,  and  Dr.  Lavender  pronounced 
the  tumor  a  typical  adenocarcinoma.  This  is  the 
youngest  case  of  my  experience.  I  have  among 
my  patients,  one  alive  and  well,  operated  upon 
twenty  years  ago.  A  patient  sent  by  Dr.  White, 
of  Bassett,  Neb.,  died  of  cancer  of  the  liver,  nine- 
teen years  after  I  had  removed  her  breast  for  can- 
cer— a  possible  late  metastasis.  I  have  a  few  other 
patients  living,  many  years  since  date  of  operation, 
but  among  a  large  number  operated  upon  since  the 
modern  operation  was  well  understood,  not  less 
than  fifty  per  cent,  have  been  cured — and  the  per- 
centage is  increasing — among  them  two  cases  of 
amputation  of  both  breasts.  One  case  is  extremely 
important :  A  surgeon  had  removed  a  neoi)lasm 
from  the  breast.  Some  months  later  when  I  saw 
the  woman  a  recurrence  had  taken  place ;  the  breast 
was  adherent  to  the  chest  wall,  and  the  axillary 
glands  were  much  involved.  A  thorough  opera- 
tion, including  the  removal  of  parts  of  two  ribs, 
was  carried  out.  To-day,  eleven  years  later,  the 
woman  is  well.  Certainly  such  a  result  is  a  credit 
to  surgery,  and  should  make  one  hopeful.  How- 
ever, I  must  confess  that  only  occasionally  have  I 


had  permanent  recovery  follow  operations  in  ad- 
vanced cancer,  wherever  situated.  Usually  such 
operations  are  only  palliative.  Fortunately,  many 
of  these  operated  sufferers  die  of  internal  metasta- 
sis. 

Another  question  of  importance,  viz.,  the  pres- 
ence of  a  cancer  in  the  breast  of  a  pregnant  or 
suckling  woman.  My  own  experience  is  that  three 
propositions  may  be  presented  for  decision:  i, 
cancer  recognized  developing  in  the  breast  of  a 
pregnant  woman  during  the  early  months  of  preg- 
nancy ;  2,  cancer  developing  in  the  breast  during 
the  later  months  of  pregnancy  ;  and  3,  cancer  de- 
veloping in  the  breast  during  the  early  active  pe- 
riods of  lactation.  It  is  known  that  pregnancy  and 
lactation  aft'ect  a  cancerous  breast  like  high  wind 
does  the  prairie  fire.  Little  advice  as  to  how  to  act 
is  found  in  our  American  textbooks.  There  is  the 
only  remedy,  the  knife — but  when  should  it  be  ap- 
plied ?  In  the  early  period  of  pregnancy,  the  sooner 
the  better.  In  the  later  period,  should  delay  be  per- 
mitted until  after  delivery?  Experience  has  shown 
that  it  is  hard  to  do  an  operation  at  this  time,  suf- 
ficiently radical  to  prevent  a  rapid  recurrence. 
There  are  said  to  be  special  dangers  to  the  mother; 
;he  mortaHty  is  high.  In  the  interests  of  the  child, 
would  delay  until  after  confinement  be  preferable? 
In  spite  of  the  gloomy  forebodings  of  some  Eng- 
lish surgeons,  my  experience  teaches  me  that  if  the 
case  is  an  operable  one  aside  from  the  complication 
of  pregnancy,  the  most  radical  operation  practic- 
able should  be  carried  out.  A  liberal  dose  of  mor- 
phine and  hyoscine  should  precede  the  anaesthetic, 
chloroform  by  preference.  Special  pains  should 
be  taken  to  guard  the  patient  from  shock  by  pro- 
tecting the  surfaces  of  the  body  and  wound  from 
cold  and  too  rapid  evaporation.  Pressure  upon  the 
abdomen  should  be  avoided.  Haemostasis  should 
be  accurate  as  the  operation  proceeds.  A  poky 
operator  should  turn  a  case  of  this  kind  over  to  a 
more  rapid  colleagtte.  The  morphine  and  hyoscine 
lessens  the  amount  of  the  anaesthetic  required  and 
is  followed  by  greater  repose,  thus  diminishing  the 
dangers  of  exciting  premature  labor.  I  have  had 
some  happy  experiences  following  this  practice. 
When  cancer  develops  in  a  suckling  woman,  the 
baby  should  be  weaned  immediately.  In  the  doing 
of  this  the  breast  should  not  be  wassa^^ed,  the 
breast  pump  should  be  tised  with  great  gentleness, 
and  not  too  often.  Nothing  should  be  done  to 
stimulate  the  fiow  of  cancer  cells  (germs)  from 
the  tumor  into  the  lymphatics  and  veins.  Camphor 
and  belladonna  given  internally,  and  moist  cold 
locally  with  the  breast  gently  and  equally  support- 
ed, will  bring  about  a  rapid  cessatifMi  of  the  func- 
tion of  lactation,  and  dimintition  in  the  general  full- 
ness of  the  breast.  Then  the  operation  may  be  car- 
ried out  with  a  fair  prognosis. 

After  every  breast  amputation  I  feel  confident 
that  the  x  ray  may  be  used  to  advantage ;  the  worse 
the  case,  particularlv  the  greater  the  skin  involve- 
ment, the  more  valuable  the  x  ra\ . 

Ilaldane's  explanation  of  the  spread  of  infection 
of  breast  cancer  is  a  valuable  consideration  along 
this  line. 

FlI-TMENTU  .\ND  DoOGK  S  l  RKK  IS. 


February  27.  iQoo  ] 


CARRIXGTOX:   U.  S.  MARINE   HOSPITAL  SAXATORIUM. 


417 


THE  U.  S.  MARINE  HOSPITAL  SAXATORIUM  FOR 
TUBERCULOSIS  AT  FORT  STAXTON,  X.  M.* 

By  p.  M.  Carrington,  M.  D., 
Fort  Stanton,  N.  M. 
Surgeon,  United  States  Public  Health  and  Marine  Hospital  Service. 

INTRODUCTORY  AND  HISTORICAL. 

The  Fort  Stanton  Sanatorium  being  one  of  the 
three  sanitoria  maintained  b\'  the  National  Govern- 
ment for  the  treatment  of  tuberculosis,  it  has  been 
thought  advisable  that  I  present  to  this  congress  a 
brief  account  of  the  work  of  the  sanitorium  from 
its  irxeption  in  1899  to  the  present  year. 

In  former  articles'  I  have  presented  to  the  pro- 
fession accounts  of  the  work  at  Fort  Stanton.  This 
article  includes  consolidated  statistics  from  the  open- 
ing of  the  sanatorium  in  November,  1899,  to  June 
30.  1908,  a  period  of  nearly  nine  years.  During  this 
period  we  have  treated  1,397  individuals  and,  in- 
cluding readmissions,  1,499  cases. 

Fort  Stanton  was  established  as  an  army  post  for 
the  control  of  the  Alescalero-Apache  Indians  in 
1855.  The  post  was  burned  and  abandoned  in  1861 
by  the  United  States  forces  upon  the  approach  of 
the  Texas  troops  under  General  Sibley.  In  the 
spring  of  1863,  after  the  defeat  and  withdrawal  of 
the  Confederate  troops,  it  was  reoccupied,  and  from 
1868  to  1 87 1  rebuilt.    Necessity  for  its  existence  as 


is  located  in  Lincoln  County,  in  south  central  New 
Mexico  in  33.5°  north  latitude  and  105.5°  longitude 
west  of  Greenwich.  Its  area  is  nearly  forty-five 
square  miles,  in  the  centre  of  which  on  the  south 
bank  of  the  Rio  Bonito  are  situated  the  sanatorium 
buildings.  This  large  area  was  necessary  and  has 
been  fenced  for  a  horse  and  cattle  range,  and  also 
to  prevent  the  too  nearby  settlement  of  undesirable 
neighbors. 

b.  Topographical. — The  reservation  is  situated  in 
the  foothills  of  the  White  Mountains  with  the  Rio 
Bonito  traversing  it  from  west  to  east  for  a  distance 
of  eight  miles.  Its  surface  includes  the  beautiful  val- 
ley of  the  Rio  Bonito.  hills  of  varying  altitude,  and 
broad  mesas  or  table  lands.  These  hills,  brown  and 
bare  during  the  greater  portion  of  the  year,  are,  dur- 
ing the  late  spring  and  early  summer  months, 
clothed  in  verdure  and  a  kaleidoscopic  array  of  wild 
flowers.  Along  the  Bonito  the  cotton  wood  trees, 
black  walnuts,  and  a  species  of  the  live  oak  grow 
in  profusion,  while  many  of  the  hills  are  covered 
with  pinon,  juniper,  and  cedar,  which  supplv  us  with 
fuel. 

The  sanatorium  buildings  are  surrounded  on  the 
north  and  south  by  hills  rising  from  300  to  600  feet 
above  them,  and  affording  protection  from  severe 
winds.  To  the  east  are  the  foothills  of  the  Capitan 
Mountains,  which  at  a  distance  of  ten  miles  rise  to 


I  iG.  1. — General  view  of  Marine  Hospital  Sanatorium,  Fort   Stanton.  New  Mexico. 


an  army  post  having  ceased,  it  was  abandoned  in 
August,  1896.  and  a  long  cherished  project  of  Sur- 
geon General  Wyman  was  consummated  when  on 
April  I,  1899,  President  McKinley  signed  an  execu- 
tive order  transferring  the  Fort  Stanton  Military 
Reservation  to  the  Treasury  Department  for  use  by 
the  then  Marine  Hospital  Service,  as  a  sanatorium 
tor  consumptives. 

The  reservation  with  its  thirty  odd  buildings  was 
received  by  Passed  Assistant  Surgeon  (now  Sur- 
geon) J.  d.  Cobb,  representing  the  Marine  Hospital 
Service,  shortly  after  the  date  of  the  executive 
order,  and  the  work  of  preparing  the  buildings  for 
occupancy  was  immediately  begim,  the  sanatorium 
being  actually  opened  by  the  reception  of  the  first 
patient  in  November,  1899. 

DESCRIPTIVE. 

a.  Geographical. — The  Fort.  Stanton  Sanatorium 

'Read  before  Section  VI  of  the  International  Congress  on  Tu- 
berculosis,  held   at  Washington. 

'Sanatorium  Treatment  of  Tuberculosis,  published  in  the  Journal 
of  the  .4merican  Medical  .Association.  December  i,  1902.  Further 
Observations  on  the  Treatment  of  Tuberculosis,  published  in  the 
Jiii.nial  of  the  .Association  of  Military  Surgeons,  1904. 


an  altitude  of  lo.ooo  feet.  To  the  westward  the  hills 
rise  tier  upon  tier  and  culminate,  twenty  miles  away, 
in  White  Mountain  Peak  12,000  feet  above  sea  level, 
snow  capped  during  the  greater  portion  of  the  3'ear, 
and  the  source  of  the  Rio  Bonito. 

The  Rio  Bonito  well  deserves  its  name,  for  it  is 
a  beautiful  stream,  traversing  a  lovely  and  fertile 
valley,  its  water  irrigates  productive  fields  and 
orchards.  Here  the  apple,  peach,  and  pear  grow  in 
all  their  perfection  and  beauty,  and  many  small 
fruits,  farm  and  garden  products  are  produced  in 
great  abundance. 

c.  Cliinaiological. — The  climate  of  Fort  Stanton 
is  in  general  terms  that  of  the  arid  Southwest,  but 
modified  by  differences  in  altitude,  latitude,  and 
topography.  Its  climate  is  characterized  by  small 
rain  fall,  low  relative  humidity,  large  percentage  of 
sunshine,  and  comparative  freedom  from  high 
winds,  with  cool  or  cold  nights  according  to  the  sea- 
son. The  topography  is  such  that  natural  drainage 
is  excellent.  The  soil  is  porous  and  dry,  and  evap- 
oration very  rapid.  \\'hile  there  is  a  wide  daily 
range  of  temperature,  the  low  temperatures  occur 


4i8 


CARRINGTON:   U.  S.  MARINE  HOSPITAL  SANATORIUM. 


[New  Vork 
Medical  Journal 


during  the  night,  and  even  on  the  coldest  days  out 
of  door  life  is  not  only  possible  but  pleasant,  on  ac- 
count of  the  warm  sunshine. 

We  claim  for  the  climate  of  Fort  Stanton  that  it 
permits  agreeable  out  of  door  life  almost  every  day 
in  the  year,  and  for  a  greater  number  of  hours  in  the 
day  than  is  possible  in  the  East.    Patients  more 


centage  suffered  from  grave  complications  of  stom- 
ach, liver,  kidneys,  and  other  organs. 

HOUSING. 

When  Fort  Stanton  was  transferred  to  the  Treas- 
ury Department  for  use  as  a  sanatorium,  the  old 
army  buildings,  consisting  of  officers'  quarters,  bar- 


FiG.  2. — Officers'  quarters,  Fort  Stanton,  New  Mexico. 


readily  obey  regulations  requiring  them  to  be  out 
of  doors  when  to  do  so  is  convenient  and  pleasant. 

The  altitude  of  about  6,200  feet  stimulates  res- 
piration, bringing  into  functional  activity  portions 
of  the  lungs  which  at  lower  altitudes  are  inactive. 
The  high  hills  surrounding  the  sanatorium  buildings 
give  protection  from  high  winds,  and  dust  storms 
so  prevalent  on  the  plains  and  table  lands  of  the 
Southwest  are  of  comparatively  infrequent  occur- 
rence. We  have  an  abundant  supply  of  pure  snow 
water  from  the  Rio  Bonito  during  a  greater  portion 
of  the  year,  and  when  the  stream  fails  a  deep  well 
furnishes  an  ample  supply  of  soft  and  remarkably 
pure  water. 

•  CHAR.\CTER  OF  CASES  ADMITTED. 

We  admit  to  the  Fort  Stanton  Sanatorium  cases 
of  tuberculosis  of  the  lungs  in  all  stages,  as  well  as 
tuberculosis  of  other  organs.  As  will  be  noted  from 
the  statistical  tables  there  is  a  great  preponderance 
of  moderately  and  far  advanced  cases.  Eliminating 
readmissions  we  have  treated  during  the  period  cov- 
ered by  this  report  1,339  cases  of  tuberculosis,  divid- 
ed as  follows : 

Incipient    80 

Moderately  advanced   492 

Far  advanced   765 

Tuberculosis  of  other  organs   2 

1339 

This  summary  does  not  include  consumptive  offi- 
cers and  employees  who  are  treated  of  under  a  sep- 
arate heading.  Tn  these  1.339  cases  nearly  half  were 
above  thirty-five  years  of  age  and  a  very  large  per- 


racks,  offices^  and  various  service  and  outbuildings, 
to  the  number  of  more  than  thirty,  were  found  to  be 
in  a  condition  of  deplorable  dilapidation,  but  the 
walls  at  least  were  all  good,  and  the  existence  of 
these  buildings  was  a  factor  of  weight  in  determin- 
ing the  selection  of  this  particular  location.  Nearly 
all  the  old  buildings  have  been  altered  and  repaired 
to  fit  them  for  their  new  uses.  Two  old  barracks 
buildings  were  fitted  up  as  dormitories,  and  when  in 
1905  the  old  army  hospital  was  destroyed  by  fire  one 
of  these  dormitories  was  hastily  prepared  for  use 
as  a  temporary  hospital ;  lacking  appropriation  for 
a  new  hospital  it  continues  to  be  used  for  this  pur- 
pose. These  dormitories  accommodate  about  sixty 
patients  each,  and  good  ventilation  is  had  by  means 
of  opposite  windows  and  doors,  and  also  by  means 
of  roof  ventilators.  They  are  supplied  with  ample 
toilet  and  bath  facilities,  but  we  find  in  experience 
'  that  most  of  our  patients  prefer  to  live  in  tents  or 
tent  houses  chiefly,  we  believe,  because  of  the  great- 
er privacy  obtaining  in  the  latter. 

Early  in  my  detail  at  Fort  Stanton  1  began  the  use 
of  tents.  We  at  first  pitched  an  ordinary  12  x  14 
tent,  placed  in  it  two  beds,  and  laid  a  few  boards 
on  the  ground  between  the  two  beds.  Even  this 
crude  tent  becaine  popular,  and  we  gradually  im- 
proved upon  it  until  we  now  have  such  a  tent  as 
that  shown  in  the  photograph. 

For  these  tents,  as  well  as  tent  houses  and  dormi- 
tories, a  certain  standard  of  opening  for  ventilation 
has  been  adopted,  and  the  officer  of  the  day  in  mak- 
ing his  inspections,  sees  to  it  that  this  standard  is 


February  27,  1909.] 


CARRINGTON:   U.  S.  MARINE  HOSPITAL  SANATORIUM. 


419 


maintained.  Our  tent  house,  of  which  a  photo  is 
shown,  we  regard  as  a  very  nearly  perfect  dwelling 
for  consumptive  patients.  It  is  now  built  14  feet 
square,  with  a  front  porch,  and  a  clothes  closet  in 
the  rear.  As  you  will  notice  the  openings  are  very 
ample,  being  formed  by  canvas  panels,  the  doors 
made  of  two  panels  of  the  pattern  known  as  the 
"Dutch  door,"  while  the  window  panels  are  hung  on 
weights,  and  readily  slide  up  and  down ;  they  may 
be  opened  from  the  outside  as  well  as  from  the  in- 
side. Each  tent  house  is  supplied  with  a  small  sheet 
iron  stove,  and  a  patient  may  close  all  the  openings, 
undress  and  retire  in  a  warm  room,  then  the  nurse 
may  come  around  and  open  up  the  tent  house  freely 
for  ventilation.  Each  tent  house,  and  tent  as  well, 
is  supplied  with  an  electric  light,  and  each  group 
of  a  dozen  tents,  or  tent  houses,  has  in  its  centre  a 
toilet  and  bath  house,  which  serves  the  patients  oc- 
cupying that  group. 

PREVENTION  OF  INFECTION. 

Our  efforts  to  prevent  the  infection  of  the  sana- 
torium have  met  with  apparently  perfect  results. 
The  principal  precaution,  of  course,  relates  to  the 
disposal  of  sputum.  W'e  use  at  Fort  Stanton  a  metal 
pocket  cup  and  a  bedside  cup  consisting  of  a  light 
metal  frame  and  a  paper  filler.    The  pocket  cups 


is  received  in  vessels  containing  a  solution  of  car- 
bolic acid  or  formalin,  and  of  course  stools  of  pa- 
tients with  tuberculous  enteritis  are  disinfected  be- 
fore being  disposed  of.  In  view  of  the  fact  that 
recent  observers  have  demonstrated  the  presence  of 
the  bacillus  in  the  dejecta  of  a  very  large  percentage 
of  all  consumptives,  it  may  seem  superfluous  to  dis- 
infect these  stools.  All  our  sewage  is  disposed  of  by 
the  irrigation  method  in  a  fenced  area  considerably 
larger  than  absolutely  necessary  but  we  feel  that  it 
is  wise  to  limit,  so  far  as  possible,  the  number  of 
bacteria  whose  destruction  we  must  depend  upon  by 
this  method.  Stringent  regulations,  regarding  spit- 
ting elsewhere  than  in  the  cups  provided,  are  en- 
forced. There  have  been  occasional  infractions  of 
the  spitting  ordinance  but  we  find  that  patients  be- 
come so  accustomed  to  the  use  of  spit  cups  that  the 
action  is  mechanical  and  automatic,  and  that  spitting 
elsewhere  than  m  the  cups  is  a  rare  exception.  The 
detection  of  any  one  spitting  elsewhere  than  in  his 
cup  is  always  followed  by  summary  dismissal,  and 
in  the  rare  instances  where  it  has  been  necessary, 
has  had  a  most  salutary  eflfect. 

DAILY  ROUTINE. 

With  a  daily  average  of  from  200  to  225  patients 
we  have  found  it  convenient  to  divide  the  work  into 


Fio.  3. — Type  of  tent  used  at  Fort  Stanton,  New  ilu.xicc 


are  disinfected  daily  by  steam  under  pressure  of 
two  atmospheres,  and  the  paper  fillers  are  burned  in 
crematories  especially  constructed  for  this  purpose. 

Urine  of  all  patients  in  the  hospital,  as  well  as  of 
other  cases  in  which  there  are  indications  therefor. 


various  departments  rather  than  to  assign  a  particu- 
lar number  of  patients  to  each  medical  officer.  The 
commanding  officer  devotes  him.self  chiefly  to  ad- 
ministrative details.  One  officer  has  charge  of  phy- 
sical examinations  and  another  has  the  laboratorv 


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Medical  Journal. 


work.  The  hospital  is  in  charge  of  another  officer, 
and  one  has  the  ambulant  sick  call,  while  another  has 
the  surgery,  and  still  another  the  nose  and  throat 
clinic.  Each  junior  medical  officer  serves  in  turn 
as  "officer  of  the  day"  for  a  period  of  twenty-four 
hours,  and  while  so  serving  it  is  his  duty  to  make  a 
morning  inspection  of  all  quarters  occupied  by  con- 


FiG.  4. — Library  and  Amusement  Hall.    Patients  in  foreground 
receiving  baseball  returns. 

sumptives,  baths,  toilets,  etc.  He  answers  emer- 
gency calls,  receives  arriving  patients,  and  between 
the  hours  of  9  p.  m.  and  midnight  makes  a  second 
general  inspection,  chiefly  with  a  view  to  ascertain- 
ing whether  or  not  good  order  and  discipline  pre- 
vail. Upon  going  off  duty  at  9  a.  m.  he  renders  a 
written  report,  on  a  blank  form  designed  for  the 
purpose,  of  the  occurrences  of  the  twenty-four 
hours.  Any  adverse  report  is  referred  by  the  com- 
manding officer  to  the  person  whose  duty  it  is  to 
correct  it.  Out  of  seven  medical  officers  two,  in- 
cluding myself,  are  recovered  consumptives,  and 
three  are  under  treatment  and  fast  recovering. 

Patients  upon  arrival  are  first  assigned  to  the  re- 
ceiving ward,  and  remain  at  rest  in  bed  for  at  least 
four  days,  in  the  meantime  being  taught  by  oral  in- 
structions and  frequent  perusals  of  a  leaflet  what 


I'lG.  5. — Ambulant  sick  call. 

manner  of  life  they  are  expected  to  live  in  the  sana- 
torium. On  the  fifth  day,  they  are,  if  able,  brought 
to  the  examining  room,  and  a  record  of  pulse,  tem- 
perature, etc.,  furnished  the  examining  officer. 
These  patients  are  then  transferred  to  one  of  the 
dormitories,  tents,  or  tent  houses,  as  their  condition 
may  justify.  Patients  unable  to  leave  the  receiving 
ward  are  examined  in  bed,  and  transferred  to  the 


hospital  ward  proper,  where  they  remain  in  bed  for 
as  long  as  may  be  necessary. 

Once  in  each  week  the  officer  in  charge  of  the 
ambulant  sick  call,  composed  of  more  than  two 
thirds  of  the  patients,  gives  a  lecture  at  his  regular 
morning  call  upon  the  subject  of  sputum  disposal, 
ordinary  hygiene,  and  other  matters  affecting  the 
daily  life  of  the  patients  under  his  charge.  He  fol- 
lows up  these  lectures  by  daily  visits  to  the  dwellings 
of  his  patients,  exercising  a  minute  supervision  over 
their  manner  of  life. 

REST  AND  EXERCISE. 

Not  the  least  of  our  remedial  agents  is  rest. 
Where  there  exists  a  doubt  the  consumptive  should 
rest  rather  than  exercise.  Even  the  best  cases  should 
take  their  exercise  with  proper  caution,  and  this  is 
especially  true  of  newly  arrived  cases,  who  have  not 
as  yet  become  readjusted  to  the  change  in  altitude 
from  sea  level  to  over  6,000  feet.  Patients  showing 
febrile  reaction  and  those  with  a  pulse  rate  of  100 
or  more  we  keep  at  absolute  rest.  Those  with  very 
limited  chest  expansion,  but  in  other  respects  cap- 
able of  taking:  a  certain  amount  of  exercise,  are  put 


Fig.  6. — latients  in  camp  on  trout  stream  near  Fort  Stanton 
New  Mexico. 

through  simple  breathing  exercises  daily  with  a  view 
to  increasing  their  chest  expansion.  The  officer  in 
charge  of  the  ambulant  sick  call  exercises  great  care 
and  personal  supervision  over  his  patients,  attempt- 
ing to  control  their  daily  habits,  particularly  with 
reference  to  the  amount  of  exercise  permitted,  indi- 
vidualizing as  far  as  possible  and  prescribing  rest 
and  exercise  in  appropriate  proportions  according  to 
the  requirements  of  each  individual  case. 

We  find  many  consumptives  either  desiring  or 
actually  coming  to  the  neighboring  towns  and 
ranches  with  a  view  to  earning  their  living  in  a 
rather  rough  way.  This  we  discourage  so  far  as 
lies  in  our  power,  believing  that  the  influence  of 
appropriate  climate  in  the  treatment  of  tuberculosis 
suffers  in  the  estimation  in  which  it  is  held  by  our 
eastern  brethren  because  of  failures  which  result 
from  the  class  of  ca.ses  referred  to,  who  come  to  the 
Southwest  without  means  and  actually  kill  them- 
selves as  a  result  of  their  efl'orts  to  be  self  sustaining. 

AMUSEMENTS. 

To  keep  our  patients  entertained,  amused,  and 
satisfied,  has  been  a  problem  which  we  have  not  al- 
ways solved  satisfactorily.  However  much  we  may 
disagree  as  to  the  admissability  of  various  forms  of 


February  27,  1909.]  CARRIXG FOX :   U.  S.  MARINE   HOSPITAL  SANATORIUM. 


421 


amusemen:  we  certainly  are  all  agreed  as  to  the 
necessity  of  entertaining  and  interesting  our  pa- 
tients. I  find  it  frequently  necessary  to  permit 
amusements  which  are  not  entirely  unobjectionable 
rather  than  by  their  interdiction  permit  patients 
to  brood  and  m.ope.  We  therefore  permit  croquet, 
cards,  walking,  shooting,  golf,  and  in  a  small  per- 
centage of  extra  good  cases,  horseback  exercise. 
The  stooping  required  in  playing  croquet,  the  ex- 
citement inevitable  in  card  playing,  and  other  ob- 
jectionable features  of  most  forms  of  amusement,  I 
consider  less  evil  than  absolute  inaction.  Of  course 
certain  patients  are  forbidden  any  form  of  exercise 
or  amusement,  and  many  require  absolute  rest.  We 
make  an  effort  to  individualize,  and  the  ofificer  in 
charge  of  the  ambulant  sick  call  spends  a  large  por- 
tion of  hi?  time  in  visiting  his  patients  in  their 
quarters  and  advising  them  with  regard  to  their  ex- 
ercise and  amusements.  \\'hen  in  any  doubt  as  to 
the  admissability  of  amusements  they  are  denied. 

STATISTICS  AND  COMMENTS  THEREOX. 

Gross  total  of  admissions  (exclusive  of  officers  and 

employees)    1441 

From  this  amount  should  be  deducted  the  readmis- 

sions,  amounting  to   102 

Which  leaves  the  number  of  individual  cases  treated. .  1339 
The  class  of  cases  composing  this  1339  is  as  follows : 

Tuberculosis  of  lungs   1337 

Tuberculosis  of  testicle   i 

Tuberculous  abscess,  psoas   i 

Total    1339 

The  results  obtained  in  the  1.337  patients  with 
tuberculosis  of  the  lungs,  were  as  follows : 
Incipients. 

Cured    O 

Apparently  cured   25 

Arrested    19 

Improved    19 

Unimproved    14 

Died   L   I 

Under  treatment  for  less  than  thirty  days  (still 

on  hand)    2 

  80 

Moderately  advanced. 

Cured    2 

Apparently  cured   63 

Arrested    81 

Improved    233 

Unimproved    34 

Died    73 

Under  treatment  for  less  than  thirty  days  (still 

on  hand)    6 

  492 

Far  advanced. 

Cured    2 

Apparently  cured   14 

Arrested    76 

Improved    209 

Unimproved    79 

Died    374 

Lnder  treatment  for  less  than  thirty  days  (still 

on  hand)    11 

  _765 

Total    1337 

Summary. 

Cured    4 

Apparently  cured   102 

Arrested    176 

Improved    461 

Unimproved    127 

Died    448 

Under  treatment  for  less  than  thirty  days  (still 

on  hand)   19 

Total    1337 


During  the  period  covered  by  this  report  we  have 
also  treated  in  addition  to  the  1,337  patients  with 
tubercttlosis  of  the  lungs  recorded  before,  fifty-eight 
consumptive  officers  and  employees.  In  these  pa- 
tients the  results  have  been  as  follows : 

Incipients. 

Cured   o 

Apparently  cured   7 

Arrested    3 

Improved    5 

Unimproved    i 

Died    O 

Under  treatment  for  less  than  thirty  days  (still 

on  hand)    i 

 17 

Moderately  advanced. 

Cured    1 

Apparently  cured   4 

Arrested    4 

Im.proved    5 

Unimproved    I 

Died    o 

Under  treatment  for  less  than  thirty  days  (still 

on  hand)    o 

  15 

Far  advanced. 

Cured    O 

Apparently  cured   3 

Arrested    4 

Improved    10 

Unimproved    7 

Died    2 

Under  treatment  for  less  than  thirty  days  (still 

on  hand)    o 

  26 

Total    58 

Summary. 

Cured    i 

Apparently  cured   14 

Arrested    il 

Improved    20 

Unimproved    9 

Died    2 

Under  treatment  for  less  than  thirty  days  (still 

on  hand)   I 

Total    58 

In  the  foregoing  statistics  I  have  treated  all  the 
cases  received  at  the  sanatorium  from  its  opening 
in  November.  1899,  to  and  including  June  30,  1908, 
as  though  the  sanatorium,  had  closed  on  the  last  day 
of  June.  Of  course  as  an  exhibition  of  our  results 
the  figures  as  given  above  are  somewhat  mislead- 
ing ;  therefore,  in  order  to  entirely  clarify  the  mat- 
ter, the  following  tables  are  added : 

As  heretofore  shown,  the  individual  cases  treated 
were  as  follows : 

Tuberculosis  of  the  lungs   1337 

Tuberculosis  of  testicle   i 

Tuberculous  abscess,  psoas    i 

1339 

Patients  treated  for  thirty  days  or  less : 

Discharged    115 

Still  under  treatment   19 

„    .         .   ■  ^34 

Patients  discharged,  treatment  being  terminated  : 

Tuberculosis  of  lungs   1033 

Tuberculosis  of  testicle   i 

Tuberculous  abscess   i 

Patients  still  under  treatment   170 

Total   1339 

The  following  results  were  obtained  in  the  1.033 
discharged  patients  in  whom  treatment  was  termi- 
nated, viz : 


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[Nf.vv  York 
Medical  Journal. 


Incipients. 

Cured   o 

Apparently  cured   25 

Arrested    IS 

Improved    15 

Unimproved    10 

Died    I 

  66 

Moderately  advanced. 

Cured    2 

Apparently  cured   63 

Arrested    51 

Improved    198 

Unimproved    24 

Died    73 

  411 

Far  advanced. 

Cured    2 

Apparently  cured   14 

Arrested    40 

Improved    151 

Unimproved    53 

Died    296 

  556 

Total    1033 

Summary. 

Cured    4 

Apparently  cured   102 

Arrested    106 

Improved    364 

Unimproved    87 

Died    370 

Total    1033 

Miscellaneous  statistics  of  the  1.337  cases  treated 
for  tuberculosis  of  the  lungs. 

Ages  of  patients  treated. 

Under  twenty-five  years   243 

Between  twenty-five  and  thirty- four  years   479 

Between  thirty-five  and  forty-four  years   384 

Between  forty-five  and  fifty- four  years   176 

Over  fifty-four  years   55 

Total    1337 

Heredity  in  patients  treated. 

History  of  tuberculosis  in  parents   199 

No  history  of  tuberculosis  in  parents   1109 

History  of  tuberculosis  in  parents,  doubtful   23 

History  of  tuberculosis  in  parents,  no  record   6 

Total    1337 

Tubercle  bacilli. 
Tubercle  bacilli  were  not  found  in  sputum  of     65  patients. 
Tubercle  bacilli  were  found  in  sputum  of . . . .  1250  patients. 
Tubercle  bacilli,  no  record   22  patients. 

Total    1337 

Record  of  pulmonary  hemorrhages  of  patients  treated. 

Before  arrival  only   241 

After  arrival  only   85 

Both  before  and  after  arrival   190 

Neither  before  nor  after   613 

Streaked  sputum   208 

Total    1337 

Length  of  lime  under  treatment  at  Sanatorium. 

Over  two  years   159 

Between  one  and  two  years   247 

Between  six  and  twelve  months  .•   311 

Between  three  and  six  months   274 

Between  three  and  one  month  ."   212 

One  month  or  less   134 

Total    1337 

It  will  be  noted,  and  attention  is  particularly  in- 
vited to  this  fact,  that  out  of  the  1,339  individual 
cases  treated,  only  eighty,  or  6  per  cent,  were  in- 
cipient, and  that  more  than  fifty  per  cent,  were  far 


advanced  cases.  If  we  eliminate  from  this  total  the 
cases  still  under  treatment,  and  cases  in  which  treat- 
ment was  terminated  within  thirty  days,  there  re- 
mains a  balance  of  1,033  cases  in  which  the  results 
are  shown  in  one  of  the  foregoing  tables  from 
which  it  will  apear  that  576  patients  or  considerably 
more  than  fifty  per  cent,  were  cured,  apparently 
cured,  arrested,  or  improved.    The  deaths  amounted 


-Sputum  crcmatorv. 


to  about  thirty-five  per  cent.,  and  the  unimproved 
to  less  than  ten  per  cent. 

Turning  next  10  the  tables  covering  fifty-three 
cases  of  consumption  among  officers  and  em- 
ployees, it  will  be  noted  that  the  percentage  of  cures, 
apparent  cures,  and  arrests  is  very  nujch  larger. 
This  I  attribute  largely  to  the  fact  that  the  patients 
included  in  this  list  are  of  a  generally  higher  grade 
of  intelligence,  education,  and  refinement  than  the 
average  of  the  class  included  in  the  larger  list,  and 
it  argues  that  the  intelligent  and  educated  consump- 
tive being  more  readily  convinced  of  the  necessity 
and  importance  of  the  regulations  made  for  his 


February  27,  1909.I 


CARRIXGTOX:  U.  S.  MARINE  HOSPITAL  SANATORIUM. 


423 


daily  guidance,  more  willingly  gives  heed  to  such 
instructions,  and  therefore  has  a  better  chance  of 
recovery  than  his  more  ignorant  and  less  tractable 
fellow  sufferer. 

INDUSTRIAL  FEATURES. 

In  establishing  the  sanatorium  at  Fort  Stanton 
it  was  the  desire  and  intention  of  the  surgeon  gen- 
eral that  the  sanatorium  should  eventually  become 
in  some  measure  self  supporting.  With  this  object 
in  view  we  secured  a  reservation  of  nearly  forty-five 
square  miles,  fenced  it,  and  stocked  it  with  beef  and 
dairy  cattle,  as  well  as  with  horses  for  breeding  pur- 
poses. We  have  always  produced  our  entire  milk 
supply  and  are  just  now  producing  all  the  beef  we 
can  consume.  We  maintain  a  truck  garden  of 
about  ten  acres,  producing  all  of  our  fresh  and  a 
large  part  of  our  winter  vegetables,  and  have  plant- 
ed an  orchard  which  will  shortly  supply  us  with  all 
of  our  fresh  fruit.  These  various  industries  pro- 
vide us  the  means  of  furnishing  employment  to 
many  of  our  recovered  patients  who  desire  to  con- 
tinue their  residence  in  the  region  where  they  have 
recovered.  Similarly  we  are  enabled  to  give  em- 
ployment to  and  actually  give  preference  to  con- 
sumptives seeking  employment  provided  their 
condition  will  permit  them  to  work  at  these  various 
employments.  In  addition  to  these  features  we 
maintain  a  farm  of  about  200  acres,  producing  our 
own  hay  and  a  portion  of  our  grain. 

In  our  plumbing,  painting,  and  carpentry  depart- 
ments we  frequently  find  it  possible  to  employ  con- 
sumptive worknien. 

A  considerable  number,  although  I  am  unable  to 
give  exact  figures,  of  our  apparently  cured,  ar- 
rested, and  improved  patients  have  taken  up  em- 
ployment in  nearby  localities.  Most  of  those  who 
were  apparently  cured  or  arrested  upon  dismissal 
have  progressed  to  recovery.  Some  of  them  con- 
tinue to  reside  in  this  region  because  of  having  be- 
come attached  to  the  locality  and  its  climate.  To 
mention  a  few  instances :  A  former  chaplain  dis- 
charged from  treatment  about  eighteen  months  ago, 
apparently  cured,  is  pastor  of  the  Presbyterian 
Church  at  Tucumcari  and  w-rites  me  that  his  health 
continues  robust.  Another  patient  was  at  last  ac- 
counts conducting  a  meat  market  and  restaurant  in 
the  growing  town  of  Carrizozo,  N.  M. ;  another 
conducts  a  small  general  store  which  gives  him  a 
clear  net  profit  of  S75  to  Sioo  per  month;  another,  a 
newspaper  man,  who  during  the  two  years  of  his 
employment  here  had  the  duty  of  daily  inspecting 
and  keeping  in  repair  our  principal  water  supply 
ditch,  was  discharged  apparently  cured  and  took  a 
position  on  a  Beaumont,  Texas,  paper,  later  going 
to  San  Antonio,  and  is  at  present  in  apparent  good 
health,  acting  as  city  editor  for  a  daily  newspaper 
in  St.  Joseph,  Mo.  Such  cases  might  be  multiplied 
indefinitely. 

MORTALITY  AND  EXPLANATION  THEREOF. 

We  receive  patients,  as  heretofore  stated,  in  every 
■possible  stage  of  disease,  and  their  ages  have  varied 
from  eighteen  to  eighty-four  years,  although  a  ma- 
jority are  under  forty  years  of  age.  I  will  not  at- 
tempt to  give  a  detailed  list  of  tuberculous  and 
nontuberculous  complications.    The  following  are 


.=;ome  of  the  most  frequent  complications  noted  as 
affecting  prognosis : 


Fistula  in  ano   26 

Intestinal  involvement   40 

Laryngitis    148 

Chronic  nephritis   loS 

.\sthina    14 

Aneurj'sm  of  aorta    5 

Diabetes  mellitus   5 

Involvement  of  lymphatic  glands   26 

Haemorrhoids    97 

Otitis  media   54 

Arteriosclerosis    15 

Valvular  disease  of  the  heart   115 

Degeneration  of  columns  of  cord   4 

Hemiplegia  and  other  paralysis   5 

Pneumothorax  and  hydrothorax   28 


A  very  large  percentage  of  our  patients  have 
been  addicted,  prior  to  their  reception  by  us,  to  the 
excessive  use  of  alcoholic  liquors,  and  nearly  all  of 
the  complications  referred  to  in  the  table  have  been 
in  existence  at  the  first  examination.  The  chronic 
alcoholic  is  not  only  apt  to  have  serious  degeneration 
of  the  liver,  but  such  patients  almost  invariably  have 
stomachs  the  functions  of  which  are  very  seriously 
impaired  and  thus  militate  against  recovery.  Out 
of  a  total  of  448  deaths,  seventy-eight  patients  have 
succumbed  to  the  disease  within  thirty  days  after 
arrival.  Given  an  advanced  stage  of  tuberculosis 
of  the  lungs  in  a  chronic  alcoholic  subject,  the  possi- 
bility of  recovery  or  even  improvement  is  reduced 
to  a  minimum.  Sixty  to  seventy-five  per  cent,  of 
our  patients  suffer  from  advanced  pyorrhoea  alveo- 
laris  and  dental  caries. 

TREATMENT  AND  CONCLUDING  REMARKS. 

The  only  treatment  upon  which  we  rely  with  any 
feeling  of  security  is  living  in  the  open  air  as  much 
of  the  time  as  possible ;  second,  a  dietary  as  com- 
plete and  satisfying  as  is  possible ;  and,  third,  but 
not  least,  rest  and  graduated  exercise  w-ith  that  gen- 
eral supervision  of  the  patient's  daily  life  and  con- 
duct, which  comprises  hygienic  treatment. 

We  maintain  our  own  dairy  herd,  producing  from 
eighty  to  one  himdred  and  fifty  gallons  of  milk  a 
day  according  to  the  season,  and  our  patients  are 
onlv  restricted  in  the  use  of  milk  by  the  quantity 
produced.  During  the  seasons  of  greater  plenty  we 
produce  often  as  much  as  500  to  600  pounds  of  but- 
ter monthly,  and  we  have  from  our  own  chicken 
yard  during  a  considerable  portion  of  the  year  suf- 
ficient newly  laid  eggs  to  supply  those  patients  who 
are  eating  them  raw.  We  have  found  no  medical 
treatment  which  offers  any  noticeable  betterment  of 
our  results.  We  have  recently  attempted  the  use 
of  mercury  succinnimide  by  deep  muscular  injec- 
tion. We  have  used  this  treatment  on  twenty-five 
or  thirty  patients  during  a  period  of  two  months  but 
have  been  unable  to  secure  any  results  even  re- 
motely approaching  those  published  by  Surgeon 
Wright,  of  the  navy.  For  haemorrhage  we  use 
amyl  nitrite,  the  recumbent  posture,  and  ice  bags, 
followed  by  the  use  of  sodium  nitrite.  Personally, 
I  have  very  little  faith  in  medicinal  treatment  for 
haemorrhage.  We  have  recently  been  using  tuber- 
culin for  diagnostic  purposes,  using  the  ophthalmic 
test.  This  has  been  valuable  in  diagnosis  of  obscure 
cases.    We  have  recently  begun  the  use  of  tubercu- 


424 


EI  SEN  BERG:  THORACIC  ANEURYSM. 


[New  York 
Medical  Journal. 


lin  by  mouth,  after  the  method  of  Arthur  Latham, 
of  London.  Our  cases  are  as  yet  few  and  have  been 
continued  for  too  short  a  time  to  warrant  any  posi- 
tive opinion  as  to  its  value,  but  it  has  seemed  to  be 
of  value  in  the  carefully  selected  cases  in  which  we 
have  used  it. 

I  am  more  and  more  convinced  of  the  necessity 
of  individualizing  in  the  treatment  of  tuberculosis, 
that  is,  that  each  patient  shall  be  carefully  studied 
by  the  officer  in  whose  immediate  care  he  is,  and 
then  his  daily  life,  particularly  as  to  food,  rest,  ex- 
ercise, and  the  like,  carefully  outlined  to  meet  his 
individual  needs,  and  this  we  attempt  to  do  so  nearly 
as  it  may  be  possible. 

There  is  another  matter  affecting  very  seriously 
our  statistics  which  1  will  ask  the  reader  to  remem- 
ber in  considering  this  paper,  namely,  that  although 
our  patients  are  sent  from  the  various  hospitals  of 
the  service,  absolutely  without  expense  to  them- 
selves, we  have  no  control  over  the  length  of  time 
they  may  he  willing  to  remain  under  treatment.  It 
consequently  happens  in  an  always  large  percentage 
of  patients  that  many  such  instead  of  being  recorded 
as  "improved"  or  "arrested"  would  with  just  a  little 
more  patience  have  been  recorded  "apparently 
cured." 

ADDENDA. 

Meteorological  Data  for  Fort  Stanton,  New  Mexico. 
Average  number  of  days. 

Clear    i6    14    13    15    16    13    10    11    13    20    16    16  173 

Partlycloudy  11    10    13    12    12    13    15    15    11      7      9    12  140 

Cloudy    445334656453  52 

With  precip- 
itation   ..4      5      5      3      4      71111      8     4     4     4  72 

ADDENDA. 

Average  monthly  relative  humidity,  for  twenty-eight  years. 
0.64  0.72  0.86  0.64  0.89   1.76  3.16  3.44  2.30  1.45  0.67  0.88,  17.41 

Average  monthly  relative  humidity  for  seven  years. 
60      55      47      37      34      41      55      57      59      56      59      61,  52 

Mean  maximum  temperature,  for  seven  years. 
47      52      56      65      72      81      83      80      74      66      55      49,  65 

Mean  minimum  temperature,  for  seven  years. 
21      27      29      36      44      50      56      54      48      37      28      24,  28 

Mean  temperature,  for  twenty-eight  years. 
3i      38      44      51      60      67      69      67      61       52      42      36,  52 

Highest  monthly  temperature. 
69     76     73     78     85     94     95     92     86     80     72     68,     (July)  95 

Lowest  monthly  temperature. 
— 6  — 3  6  14  29  34  46  44  31  22  7  — 18  — 18,  December  22,  1887 

Average  hourly  wind  velocity. 
8.0     9.2     8.4     8.2     7.5     6.0     4.5     4.7     4.4     5.2     6.1     6.8,  6.6 
Highest  velocity. 

51     54     60     60     63     42     44     36     30     42     44     so     63,  May 

Monthly  average  snowfall. 
1.6     2.1      8.2     T.     o.      o.      0.      o.      o.      T.     4.2     6.2,  22.3 

Average  date  of  last  killing  frost  in  spring  May  6th 

Average  date  of  first  killing  frost  in  autumn  October  5th 


REPORT  OF  C.^SE  OF  THORACIC  ANEURYSM, 

Involving  the  Transverse  Portion  of  the  Arch  of  the  Aorta, 
the  Innominate,  and  the  Right  Subclavian  Arteries. 
By  a.  D.  Eisenberg,  M.  D., 
Brooklyn,  N.  Y., 
Assistant   Surgeon,    New   Amsterdam   Eye  and   Ear  Hospital; 
Assistant  Surgeon,  Eye  Department,  Cornell  University. 

This  case  is  reported  chiefly  because  of  the  ex- 
tensive involvement  of  the  arterial  system  with  such 
apparent  little  inconvenience  to  the  patient,  his  gen- 
eral health  being  pretty  fair. 

Case. —  C.  E.  H.,  male,  five  feet  six  inches  tall, 
weight  130  pounds,  fairly  well  developed,  age  thirty 
year,  native  of  Maryland,  married  eight  years,  no 
children. 


Family  history.  The  patient's  mother  died  at  the 
age  of  sixty-one  years,  after  suffering  for  several 
years  from  a  tumor  of  the  stomach.  Otherwise 
family  history  was  negative. 

Previous  history.  The  patient  was  fairly  well  dur- 
ing early  life.  He  had  an  atack  of  rheumatism  at 
the  age  of  eighteen,  and  at  the  time  was  confined  in 
bed  for  several  weeks.  From  then  on  he  was  ap- 
parently well,  until  eighteen  months  ago,  when  an- 
other pretty  severe  attack  of  rheumatism  developed. 
He  was  then  laid  up  in  bed  for  three  months.  Since 
this  last  attack,  he  had  been  complaining  of  what  he 
calls  asthma.  He  did  not  drink  to  excess,  smokes 
moderately,  and  denied  all  venereal  diseases.  Up 
to  the  last  few  months  he  had  been  working  pretty 
hard  as  an  assistant  janitor  in  a  school  building. 

Present  history.  The  patient  came  to  the  hospital 
in  September,  1908,  complaining  of  a  sore  throat 
and  a  "lump  in  the  neck."     He  said  he  had  had 


Fig.  I. — Thoracic  aneurysm;  front  view. 


sharp  shooting  pains  in  the  upper  part  of  the  chest 
which  began  some  time  in  November.  1907,  and 
continued  steadily  until  a  few  months  ago,  when  it 
subsided,  except  for  an  occasional  attack  of  pain 
which  was  presumably  brought  on  by  overexertion. 
In  December,  1907,  he  noticed  a  small  mass  appear 
over  the  sternum,  this  gradually  increasing  until  it 
occupied  an  area  of  about  four  and  a  half  inches 
by  three  and  a  half  inches  square,  and  protruded 
quite  considerably  from  the  chest  (as  seen  in  tlie 
photographs).  He  complained  of  dyspnoea  only 
when  lying  on  his  back  or  right  side,  had  no  dys- 
phagia. For  the  last  few  weeks  he  had  become 
hoarse. 

Physical  examination.  Inspection  :  .\  pulsatins: 
tumor  (like  a  pear  in  form)  about  four  and  a  half 
inches  by  three  and  a  half  inches  square  was  seen 
occupying  the  upper  part  of  the  sternum  and  some- 
what to  the  right  side  of  the  neck.  The  skin  over 
the  tumor  appeared  normal.  The  right  clavicle 
moved  outward  with  each  heart  beat.    There  was  a 


February  27,  1909.] 


HARRIS:  IXJECTIONS  IN  CANCER. 


425 


visible  pulsation  in  all  the  large  arteries  of  the  ex- 
tremities. Both  pupils  were  equal.  \'ocal  cords 
were  congested.    No  paralysis. 

Palpation.    The  tumor  mass  felt  fairly  hard  and 


Fig.  2. — Thoracic  aneurysm;  view  from  left  side. 


expanded  with  each  heart  beat.  It  occupied  the 
upper  part  of  the  sternum  (which  had  been  de- 
stroyed) from  the  articulation  of  the  third  rib  up. 
The  sternoclavicular  articulation  on  the  right  side 
was  free,  and  the  clavicle  moved  freely  with  each 
expansion  and  contraction  of  the  tumor.  There  was 
a  swelling  felt  above  this  clavicle  which  also  pul- 
sated quite  distinctly.  The  apex  beat  was  felt  in 
the  sixth  space  about  two  inches  outside  the  nipple 
line. 

Percussion.    The  heart  dulness  was  increased  in 


Fig.  3. — Thoracic  aneurysm;  view  from  right  side. 


all  directions,  probably  due  to  cardiac  hypertrophy. 
The  tumor  percussed  flat.  There  was  some  tender- 
ness to  percussion  at  the  junction  of  the  right 
clavicle  with  the  sternum. 


Auscultation.  A  blowing  murmur  of  the  second 
sound  was  heard  at  the  apex.  At  the  aortic  valve 
and  over  the  tumor  the  second  sound  was  ac- 
centuated. With  each  third  or  fourth  beat  this 
sound  was  increased  as  if  the  sac  filled  up  at  once. 
The  pulses  of  both  radial  arteries  appeared  to  be 
normal  in  time  and  volume. 

Diagnosis.  It  is  my  belief  that  the  man  is  suf- 
fering from  an  aneurysm  of  the  transverse  por- 
tion of  the  arch  of  the  aorta  complicated  by  the 
aneurysm  of  the  innominate  and  right  subclavian, 
because  the  right  clavicle  appeared  to  be  lying  on  a 
tumor  which  pulsated  and  pushed  it  in  and  out  with 
each  heart  beat.  The  main  aetiological  factor  in  this 
case  appeared  to  be  the  second  attack  of  rheumatism 
the  man  had  suffered  from. 

89  IxDiA  Street. 


THE   TREATMENT   OF  MALIGX.WT  GROWTHS 
BY  IN'JECTIONS  OF  MERCURY,  ARSENIC, 
AND  IRON. 

By  L.  Harris,  M.  D., 

Providence.  R.  I., 
Surgeon  to  Saint  Joseph's  Hospital. 

.The  day  may  not  be  far  distant  when  we  shall  ar- 
rest the  advance  of  all  forms  of  disease,  as  we  now 
successfully  do  with  diphtheria,  by  a  serum  process, 
neutralizing  one  poison  by  another  and  fighting  the 
minute  organisms,  which  now  undo  us,  by  the 
weapon  which  Nature  has  provided  for  their  undo- 
ing. But  be  that  day  soon  or  late,  it  would  be  folly 
for  us  to  await  an  uncertainty,  and  meanwhile  to 
neglect  the  undoubted,  though  incomplete  discov- 
eries, which  the  science  and  practice  of  medicine 
have  achieved. 

Now  there  is  not  a  disease  in  the  long  list  of  hu- 
man infirmities  which  brings  more  terror  to  the  pa- 
tient, or  less  assurance  to  the  practitioner,  however 
skillful  he  may  be,  than  does  a  tumor  of  malignant 
type.  The  surgeon  does  his  part  as  radically  as 
may  be,  cuts  cleanly  away  every  evidence  of  the  dis- 
ease, but  usually  with  the  damning  sense  that  how- 
ever thorough  his  dissection,  or  comprehensive  the 
scope  of  his  operation,  nothing  will  save  the  patient 
from  a  recurrence  of  the  malady.  "It  will  come 
back"  he  tells  the  friends  of  the  sick  one,  "your 
friend  will  live  a  few  months  longer  as  a  result  of 
the  operation,  and  will  suffer  much  less,  but  I  can 
promise  nothing." 

I  wish  that  what  I  have  to  advance  now  had  the 
sanction  of  many  years  of  successful  trial,  instead 
of  the  three  or  four  at  the  most,  which  I  can  claim 
for  it.  Then  indeed  I  should  feel  that  what  I  now 
hold  tentatively  although  with  the  highest  hope,  had 
established  a  serious  claim  on  the  attention  of  the 
medical  fraternity  and  merited  to  be  considered  a 
real  contribution  to  the  study  of  the  treatment  of 
cancerous  growths ;  and  if  I  write  thus  frankly  of 
what  is  still  an  experiment  with  me,  it  is  in  the  hope 
that  something  which  I  will  have  said  may  interest 
some  to  join  with  me  in  putting  to  a  wider  range  of 
tests  than  I  can  hope  for,  a  treatment  which  so  far 
in  my  experience  has  given  some  remarkable  results. 

We  must  all  have  noticed  that  many  malignant 
growths  follow  prolonged  irritation.    The  continued 


426 


HARRIS:  INJECTIONS  IN  CANCER. 


[New  York 
Medical  Journal. 


irritation  of  a  sharped  edged  decaying  tooth,  causes 
a  chronic  induration  in  which  are  discovered  among 
other  inflammatory  processes,  a  round  cell  infiltra- 
tion. In  this  indurated  area  the  cell  proliferation 
characteristic  of  malignancy  begins.  Without  this 
indurated  area,  accompanied  by  round  cell  infiltra- 
tion, malignancy  would  in  all  probability  not  have 
occurred.  The  constantly  irritated  wound  of  the 
knuckle  finally  takes  on  the  characteristics  of  epi- 
thelioma. The  inflamed  breast  of  the  nursing  mother 
may  become  scirrhous.  The  prolonged  irritation 
caused  by  gallstones  may  produce  carcinoma  of  the 
gallbladder.  The  tear  in  the  os  uteri,  long  nothing 
more  or  less  than  an  indurated  ulcer,  becomes  a  car- 
cinoma of  the  cervix. 

Whatever  cancer  is,  be  it  a  germ  or  not,  it  seems  to 
find  a  soil  to  its  taste  in  inflammatory  tissue.  On  the 
edge  of  every  cancer  we  find  small  glands  possibly 
not  yet  carcinomatous,  but  merely  inflamed  with  in- 
creased blood  supply,  and  soon  a  round  cell  infiltra- 
tion. Is  it  not  fair  to  suppose  that  the  round  cell 
infiltration  is  necessary  for  the  growth  and  develop- 
ment of  the  cancer  ?  That  if  we  should  arrest  its 
growth  we  should  also  arrest  the  cancerous  growth  ? 
That  if,  once  the  cancerous  growth  is  removed,  we 
could  prevent  the  recurrence  of  this  glandular  con- 
dition, we  should  at  the  same  time  check  forever  the 
threatened  recurrence  of  the  cancer? 

Now  there  is  a  treatment  for  a  round  cell  infiltra- 
tion universally  recognized  and  known  to  every 
practitioner.  Who  does  not  know  what  wonders 
mercury  works  in  the  treatment  of  syphilis,  and  ter- 
tiary syphilis  causes  lesions  as  destructive  and  as 
loathsome  as  ever  cancer  does,  and  lesions,  be  it  re- 
marked, which  are  sometimes  difficult  to  distinguish 
from  cancerous  ones.  Yet  when  a  patient  is  so  far 
gone  from  a  gumma  of  the  brain  as  to  have  lost  con- 
sciousness from  the  pressure  of  this  round  cell  infil- 
tration, what  magician  could  work  more  instantly 
or  effectively  than  does  mercury  administered  sub- 
cutaneously?  What  does  it  do?  Does  it  kill  the 
germ  of  syphilis  ?  No ;  for  if  we  discontinue  its 
use,  after  a  time  the  syphilitic  symptoms  reappear. 
What  then  can  it  do  but  produce  such  changes  in  the 
tissues  of  the  body  as  make  them  unfruitful  soil  for 
the  syphilitic  germ?  The  germ  remains  quiescent, 
dormant,  because  the  field  in  which  it  flourished  has 
been  sterilized  by  mercury ;  the  round  cell  infiltra- 
tions have  disappeared  at  the  approach  of  the  metal, 
and  the  syphilitic  germ  is  consequently  paralyzed. 
But  suspend  the  use  of  mercury  for  six  months,  and 
what  is  the  result?  For  the  first  three  or  four 
months  the  patient  improves,  and  then  the  malady 
returns  in  all  its  virulence. 

Now,  mercury  we  know  has  been  found  in  the 
stools  four  months  after  the  cessation  of  its  use,  and 
it  is  fair  to  suppose  that  the  period  of  improvement 
noted  in  cases  after  the  discontinuance  of  its  use  co- 
incides with  the  survival  of  the  metal  in  the  system. 
Once  we  withdraw  the  mercury  from  the  system,  the 
germ  renews  its  activity  by  bringing  about  the  con- 
ditions coexistent  with  it,  viz.,  the  round  cell  infiltra- 
tion, and  soon  we  find  our  patient  in  his  original 
condition,  or  worse,  and  we  again  resort  to  the  only 
effective  antidote  that  medicine  knows  of,  which 
will  do  again  what  it  did  before,  remove  the  round 


cell  infiltration,  and  paralyze  the  syphilitic  germ.  If 
we  keep  at  it  long  enough,  and  maintain  the  use  of 
mercury  over  a  course  of  two  or  three  years,  we  will 
have  starved  the  germ  to  death  and  cured  our  pa- 
tient. If  this  reasoning  holds  together,  then  the 
same  treatment  must  be  beneficial  in  dealing  with 
other  diseases,  in  which  the  round  cell  infiltration 
accompanies  and  denotes  the  activity  of  disease 
germs. 

In  tuberculosis,  for  instance,  that  is  indeed  the 
claim  of  the  physicians  at  Fort  Lyons,  in  Colorado, 
who  have  had  excellent  opportunities  for  experi- 
menting with  the  remedy.  Quite  casually  during 
the  Spanish  American  war  their  attention  was  called 
to  the  remarkable  recoveries  of  soldiers  affected  both 
with  tuberculosis  and  with  syphilis,  and  whose  treat- 
ment had  consisted  of  subcutaneous  medication  with 
mercury.  Dr.  Bucher,  of  Fort  Lyons,  assures  me 
that  cases  of  tuberculous  laryngitis  frequently  clear 
up  in  from  seven  to  twelve  weeks  under  this  treat- 
ment. 

I  have  used  it  in  such  a  case,  and  can  report  that 
after  three  weeks'  treatment  w^ith  mercury  injec- 
tions, my  patient  showed  almost  complete  return  of 
voice  and  a  marked  improvement  in  the  appearance 
of  the  interlaryngeal  lesion. 

Incipient  cases,  where  the  apices  of  the  lungs  are 
involved,  are  benefited  wonderfully  by  such  treat- 
ment ;  the  symptoms  speedily  improve,  as  well  as  the 
bodily  appearance.  May  we  not  account  for  such 
results  on  the  supposition  that  mercury,  by  destroy- 
ing in  tuberculosis  as  in  syphilis,  the  round  cell  infil- 
tration has  starved  the  germ  of  disease,  and  thus 
aided  Nature  in  her  never  ending  struggle  to  main- 
tain the  life  of  the  human  organism  at  the  expense 
of  that  of  the  bacilli? 

On  this  theory,  then,  for  more  than  four  years 
I  have  been  using  mercury  hypodermically  in  my 
practice,  and  I  have  yet  to  meet  with  one  unfavor- 
able result  from  its  use.  The  one  case  of  saliva- 
tion that  I  found,  had  been  under  another  physi- 
cian's care  before  coming  to  me,  and  I  had  no 
means  of  knowing  what  quantities  of  mercury  had 
been  administered,  or  how. 

For  tW'O  and  one  half  years,  I  have  made  it  a 
practice  to  give  every  patient  I  operated  upon  for 
suspicious  or  malignant  growths,  a  course  of  injec- 
tions of  iron,  arsenic,  and  mercury.  I  have  had 
some  patients  who  have  refused  to  take  it,  and  in 
cases  far  advanced  I  did  not  urge  it.  I  have  always 
informed  them  of  the  experimental  treatment  I  was 
employing,  while  assuring  them  that  at  least  no 
harm  could  come  to  them  by  its  use. 

Breast  cases,  I  have  observed  have  done  particu- 
larly well.  In  one  case,  four  months  after  opera- 
tion for  scirrhus  of  the  breast,  two  supraclavicular 
glands  were  found  greatly  enlarged,  but  after  ten 
weeks'  treatment  with  these  injections,  the  enlarge- 
ment entirely  disappeared.  Another  patient  had 
enlarged  clavicular  glands  at  the  time  her  breast 
was  operated  on.  Her  axillary  glands  were  very 
extensively  involved,  and  she  was  so  enfeebled 
at  the  time  of  operation,  that  a  complete  rad- 
ical operation  could  not  be  performed,  but  since 
she  has  been  put  under  this  treatment,  she  looks 
like  a  new  woman.    Her  color  is  excellent,  she  has 


February  27,  1909.]         VOORHEES:  SUBMUCOUS  RESECTION  OF  NASAL  SA£PTUM. 


427 


gained  in  weight,  and  the  clavicular  glands  have 
entirely  disappeared.  Another  case  was  that  of  a 
woman,  who  had  a  suspicious  growth  on  the  floor 
of  the  mouth.  She  had  lost  one  sister  from  car- 
cinoma of  the  breast,  and  her  father  from  carcinoma 
of  the  prostate.  I  split  the  lower  jaw  in  the  me- 
dian line,  and  removed  freely  all  the  indurated  tis- 
sue, between  the  anterior  tonsillar  fold  and  the 
frenum  of  the  tongue.  There  were  two  small 
glands  immediately  over  the  upper  part  of  the  caro- 
tid sheath,  which  I  intended  to  remove  at  a  subse- 
quent operation.  I  began  the  day  after  operation, 
injections  of  iron,  arsenic,  and  mercury,  and  they 
slowly  disappeared.  I  am  sorry  to  say  that  the 
important  specimens  of  this  case  were  lost,  a  small 
portion  of  the  mucous  membrane  only  being  pre- 
served, but  it  was  some  distance  from  the  seat  of 
the  lesion,  and  its  examination  was  negative. 

I  can  only  account  for  the  speedy  recuperation  of 
these  patients  by  this  treatment.  I  would  not  be 
understood  as  asserting  to  have  found  a  cure  for 
this  terrible  scourge  of  mankind,  and  yet  I  feel  that 
it  is  a  rational  treatment  for  patients  that  have  been 
operated  upon  at  an  early  stage  of  the  disease,  and  in 
which  the  pathological  findings  have  shown  malig- 
nancy, at  least  I  feel  encouraged  to  think  so  by  my 
own  experience.  There  is  no  other  equally  malig- 
nant condition  where  the  round  cell  infiltration  does 
not  play  an  important  part  in  the  primary  stage, 
and  why  not  reduce  this  bed  of  disease,  by  the  only 
method  known  to  medicine,  and  employed  success- 
fully in  analagous  conditions? 

I  consider  that  the  treatment  should  extend  over 
two  or  three  years,  and  that  it  should  be  begun 
early,  the  earlier  the  better.  My  practice  has  been 
as  follows:  For  sixty  days  after  operation  to  inject 
daily  one  half  grain  of  a  soluble  iron  salt  and  one 
twenty- fourth  grain  of  arsenious  acid.  Every  ten 
days  to  give  two  and  one  half  grains  of  mercury 
salicvlate.  subcutaneously,  until  ten  grains  have 
been  administered,  then  one  half  or  one  grain  every 
fifteen  or  tw^enty  days  for  the  first  year. 

The  second  year  I  give  « a  series  of  one  grain 
doses  until  ten  grains  have  been  taken,  and  then 
one  half  grain  every  month.  Lately  I  have  been 
using  the  succinimide  of  mercury  in  one  fifth  grain 
doses,  subcutaneously.  This  is  put  up  in  sterile  so- 
lution for  me  by  the  druggist,  and  I  give  one  fifth 
grain,  every  five  or  ten  days  for  ten  doses,  then 
every  fifteen  or  twenty  days.  The  iron  and  arsenic 
injections  I  give  from  time  to  time,  and  so  invig- 
orating are  they  to  the  patient  that  often  they  return 
and  ask  for  them  of  their  own  accord. 

In  the  use  of  mercury  I  have  always  observed 
extreme  caution,  watching  each  case  carefully,  and 
lying  in  wait  for  the  premonitory  symptoms  of 
salivation.  I  have  desired  to  give  the  patient  as 
much  of  it  as  he  could  receive  into  his  system,  with- 
out producing  any  of  the  unfavorable  results  which 
have  usually  been  so  emphasized  in  the  exposition 
of  the  materia  medica,  as  to  have  relegated  this  gen- 
erally salutary  drug  to  the  treatment  of  only  one 
disease,  and  I  shall  continue  to  recommend  extreme 
caution  in  its  use  to  others,  if  others  there  be,  who 
may  wish  to  join  with  me  in  exploiting  its  use  for 
all  cases  in  which  a  round  cell  infiltration  plays  a 


leading  part.  In  no  case  would  I  administer  it  to 
an  anaemic  patient,  for  mercury,  while  in  some  way 
benefiting  nutrition,  has  a  tendency  when  given  too 
freely  to  make  the  blood  watery  and  to  impair  its 
power  of  coagulation.  Frequent  estimation  of  the 
haemoglobin  (and  also  red  cell  counts)  should  be 
made. 

I  consider  that  the  use  of  iron  and  arsenic,  as  has 
been  my  practice  in  conjunction  with  the  mercury, 
greatly  facilitates  the  salutary  efifects  of  the  latter. 

Till  now  I  have  not  spoken  generally  of  this  mat- 
ter, nor  am  I  aware  that  the  use  of  mercury  in  these 
cases  and  on  these  principles  has  been  advocated  or 
adopted  by  any  other  physician. 

The  curiosity  of  one  who  generally  meeting  with 
success  in  what  to  him  is  a  novelty,  and  who  is 
therefore  almost  suspicious  of  his  own  experiments, 
prompts  me  to  appeal  to  my  fellow  practitioners, 
and  to  ask  them  what  has  been  their  experience,  if 
any,  with  this  manner  of  treatment  of  malignant 
growths.  My  mind  is  quite  open.  I  make  no  as- 
sertions for  it  beyond  my  own  observation  and  the 
inherent  reasonableness  of  the  treatment.  What  I 
would  relish  would  be  to  interest  other  physicians 
to  work  along  these  lines  with  me ;  to  test,  as  I  am 
testing,  with  the  many  cases  which  come  before  me, 
and  to  report,  as  I  now  report,  so  that  whether  it  be 
of  value,  or  valueless,  we  may  know  for  a  certainty 
what  it  is,  and  what  part,  if  any,  it  can  play  in  deal- 
ing with  a  disease,  before  whose  ravages,  so  far,  the 
science  of  medicine  confesses  itself  to  be  peculiarly 
helpless  and  without  resource. 

Somebody  or  other  will  some  day  find  out  the 
cause  of  cancer,  and  discover  its  antidote,  but  till 
that  day  comes  we  are  not  justified  in  neglecting  to 
try  any  rational  method,  however  tentatively  ad- 
vanced, or  as  yet  unproved,  which  bids  fair  to  lessen 
the  grip  of  one  of  the  most  terrible  diseases  on  the 
vitals  of  mankind. 

532  Broad  Street. 


SUBMUCOUS  RESECTION  OF  THE  NASAL 
SEPTUM. 
An  Intensive  Study  of  Its  Technique. 
By  Irving  Wilson  Voorhees,  M.  S.,  M.  D., 
New  York, 

Assistant  in  Otology,   New  York  Eye  and  Ear  Infirmary;  Junior 
Surgeon,  Department  of  Rhinology,  Vanderbilt  Clinic. 

So  much  has  been  written  concerning  the  opera- 
tion for  the  submucous  resection  of  the  nasal  sasp- 
tum  that  any  further  contribution  to  the  subject 
seems  like  a  piling  up  of  Pelion  upon  Ossa,  yet  it 
is  doubtful  if  the  last  word  will  ever  be  said.  This 
operation,  like  that  of  appendicectomy,  admits  of  so 
many  variations  in  technique  and  such  great  play  of 
ingenuity  in  devising  new  details,  that  the  literature 
w^hich  describes  it  is  likely  to  become  quite  great  in 
volume.  This  essay  is  not  written  for  the  specialist 
who  already  has  developed  a  good  and  satisfactory 
technique  of  his  own,  but  for  the  physician  who  is 
interested  in  the  subject  because  of  its  newness  to 
him.  For  this  reason  many  details,  otherwise  un- 
necessary are  introduced. 


428 


VOORHEILS:  SUBMUCOUS  RESECTION  OF  NASAL  SEPTUM. 


[New  York 
Medical  Journal. 


Proper  Choice  of  Cases. 

To  begin  with  not  every  case  of  deviated  saeptum 
is  operable  either  of  necessity  or  choice.  In  study- 
ing the  sjeptum  only,  we  are  apt  to  neglect  the  con- 
dition of  the  external  nasal  wall  which  may  be  re- 
sponsible for  many  symptoms  of  obstruction.  The 
turbinals  may  be  waterlogged  from  some  constitu- 
tional disease  such  as  diabetes  in  which  condition 
local  treatment,  operative  or  other,  is  scarcely  so 
important  as  proper  general  management.  Again,  a 
change  of  climate  from  warm  to  cold  may  intensify 
the  symptoms  from  any  bony  irregularity  previous- 
ly unimportant.  This  seems  especially  true  of  pa- 
tients coming  to  this  zone  from  the  tropics.  Quite 
often  one  will  find  upon  examination  of  these  indi- 
viduals a  moderate  deviation  of  the  saeptum  with  a 
prominent  ridge  or  spur  which  produced  no  diffi- 
culty previous  to  coming  north.  They  declare  that 
^'catarrh"'  was  unknown  to  them  in  their  own  land. 

Young  children  are  not  good  subjects  for  the 
submucous  operation  owing  to  necessary  removal 
of  the  cartilaginous  and  ossific  centres.  In  clinical 
work  one  sees  daily  children  in  which  the  diagnosis 
of  adenoid  growth  has  been  made,  but  which  prove 
upon  examination  to  be  suffering  from  saeptal  devi- 
ation. x\  mother  recentlv  brought  to  the  \"ander- 
bilt  Clinic  her  three  children,  all  of  whom  had  ob- 
struction from  crooked  nasal  cartilages,  with  the 
story  that  this  condition  was  also  present  in  father 
and  grandfather.  It  is  a  problem  to  know  what  to 
do  with  such  cases. 

^ly  own  experience  leads  me  to  believe  that  the 
convexity  of  a  deviation  is  more  often  on  the  left 
than  upon  the  right  side  except  in  those  cases  of 
strictly  traumatic  origin.  This  is  also  true  of  spurs 
and  ridges  which  grow  out  from  lines  of  suture,  and 
are  likely  to  be  found  anteriorly  and  near  the  floor. 
A  spur  situated  far  posteriorly  is  a  troublesome  con- 
dition from  any  viewpoint.  Its  removal  is  attended 
with  difficulty  and  is  quite  likely  to  produce  a  tear 
in  the  overlying  flap,  from  which  postoperative  hem- 
orrhage may  occur. 

Cases  which  are  unfavorable  from  an  operative 
standpoint  are  not  common,  but  it  is  well  to  advise 
the  patient  before  the  operation  as  to  the  possibility 
of  a  poor  result.  There  are  individuals  with  mucous 
membranes  which  are  so  friable  that  they  almost 
crumble  away  at  the  slightest  touch  of  the  instru- 
ment. This  is  quite  likely  to  be  the  case  shortly  after 
puberty,  when  all  structures  of  the  body  are,  theo- 
retically at  least,  undergoing  transformation.  Syph- 
ilitic patients  too,  if  the  disease  is  still  active  at  the 
time  of  operation,  have  tissues  so  friable  and  which 
heal  so  slowly  that  this  disease  is  almost  a  contrain- 
dication to  the  operation. 

Haemophilia  would  certainly  forbid  operative  attack, 
since  bleeding  from  mucous  membranes  in  this  dis- 
ease is  so  difficult  to  check. 

On  account  of  the  dense  adhesions,  persons  who 
have  had  smallpox  offer  great  difficulty  in  the  ele- 
vation of  the  flaps.  I'itt! ng  often  takes  place  in  the 
nose  and  leaves  areas  of  fibrous  tissue  which  try  the 
operator's  skill  to  the  utmost. 

Old  fractures  which  have  depressed  the  extcrn-il 
nose  and  have  buckled  ti  e  saeptum  into  various  fan- 
tastic shapes  present  a  pro1)lem  that  cannot  be  solved 


without  lacerating  the  flaps.  However,  even  with  a 
perforation,  these  patients  often  experience  great  re- 
lief. A  previous  Asch  operation  in  which  the  de- 
formity was  not  corrected  or  recurred  after  a  time 
because  more  tissue  was  present  than  could  adapt 
itself  to  the  vertical  plane  offers  a  bad  outlook  for 
submucous  resection  of  the  saeptum. 

Preparation  of  the  Patient. 

As  in  any  other  operation  of  importance,  the  pa- 
tient should  be  prepared  with  some  care  if  the  best 
results  are  to  be  secured.  Consequently  the  general 
physical  condition  of  the  patient  becomes  a  matter 
of  inquiry.  If  there  is  anaemia  or  debility  following 
some  previous  disease,  the  proper  measures  will  sug- 
gest themselves  at  once.  If  the  bowels  are  consti- 
pated they  should  receive  appropriate  treatment  for 
at  least  two  days  beforehand.  All  this  may  seem 
like  mere  piffle  and  an  attempt  on  the  part  of  the 
rhinologist  to  magnify  the  seriousness  of  the  opera- 
tion, but  it  should  be  understood  that  the  conse- 
quences of  carelessness  as  ,to  detail  are  sometimes  as 
great  here  as  in  an  abdominal  operation. 

Relative  asepsis  of  the  nasal  cavities  should  be  se- 
cured by  irrigation  with  a  Bermingham  douche  used 
thrice  daily  for  two  days  prior  to  the  operative  at- 
tack. Between  times  a  small  piece  of  absorbent  cot- 
ton may  be  worn  in  each  nostril  to  filter  out  any  ex- 
cess of  dust  in  the  respired  air.  The  irrigation  should 
also  be  performed  immediately  preceding  operation. 
Clipping  the  hairs  in  the  nasal  orifice  is  an  impor- 
tant point  inasmuch  as  greater  cleanliness  is  thus 
assured  and  a  much  better  view  of  the  operative  field 
is  obtained. 

Hccniostasis  and  Ancesthesia. 

If  in  the  operator's  judgment  general  anaesthesia 
is  desirable  the  operation  may  be  performed  at  the 
patient's  bedside  quite  as  well  as  in  a  hospital,  with 
due  care,  of  course,  for  strict  surgical  cleanliness. 
A  hospital  is,  however,  always  to  be  preferred,  if  the 
case  is  likely  to  be  at  all  difficult  or  if  there  is  a  pos- 
sibility of  haemorrhage.  The  anaesthetic  may  be  ad- 
ministered through  a  tube  hooked  between  the  jaws. 
If  ether  is  used  the  containing  bottle  may  be  placed 
in  a  vessel  of  warm  water  at  the  bedside  and  the 
fumes  blown  over  by  means  of  an  ordinary  hand 
bulb.  Rectal  anaesthesia  is  excellent  if  one  is  accus- 
tomed to  its  use.  Besides  the  ordinary  equipment  to 
be  mentioned  later,  the  surgeon  will  need  a  good 
electric  headlight,  preferably  the  Kirstein  lamp  fixed 
to  a  suitable  reflector,  all  of  which  apparatus  should 
be  thoroughly  tested  before  use.  It  is  well  to  have 
a  duplicate  lamp  and  battery  at  hand  in  case  any- 
thing goes  wrong,  for  nothing  is  more  annoying  to 
every  one  concerned  than  to  have  the  operation  fail 
because  of  bad  illumination. 

The  majority  of  rhinologists  do  this  operation  in 
the  office,  hence  a  description  of  the  technique  neces- 
sary to  this  end  is  as  follows : 

Assuming  that  the  preparations  have  been  carried 
out  as  described,  the  patient  is  seated  in  the  chair 
and  is  given  a  drachm  of  aromatic  spirit  of  ammo- 
nia in  two  ounces  of  water.  This  diffusible  stimulant 
greatly  quiets  the  nervous  fears  of  the  patient  and 
forestalls  symptoms  of  cocaine  poisoning  by  its  par- 
tial antidotic  action.    The  nose  is  now  sprayed  mod- 


February  27,  1909  ]        VOORHEES:  SUBMUCOUS  RESECTIOX  OF  NASAL  SJEPTUM. 


erately  with  a  solution  composed  of  the  following 


drugs : 

I*    Cocaine  hydrochloride  gr.  x  ; 

Adrenalin  solution,  i  in  1000,   n\,xxx ; 

Elssence  of  wintergreen  q.  s. ; 

Pure  water  q.  5.  ad  ji. 

M. 


Pure  water  is  here  used  in  preference  to  distilled 
water,  because  it  is  much  less  irritating.  The  essence 
of  wintergreen  helps  to  prevent  the  solution  from 
quickly  becoming  stale  and  unfit  for  use,  and  affords 
a  pleasant  flavor. 

The  nose  is  then  packed  with  pledgets  of  cotton 
soaked  in 


R    Cocaine  hydrochloride  gr.  xhnii ; 

Adrenalin  solution,  i  in  1000,   TTtxxx; 

Essence  of  wintergreen  q.  s. ; 

Pure  water,   q.  s.  ad  3i- 

M. 


Care  should  be  taken  that  all  excess  is  squeezed 
from  the  pledgets,  as  it  is  undesirable  to  have  any 
of  the  solution  get  below  the  nasopharynx.  The 
pledgets  are  flattened  out  and  introduced  on  the 
point  of  an  applicator,  care  being  taken  to  see  that 
they  touch  the  saeptum  at  every  possible  point.  This 
packing  is  left  in  for  twenty  minutes  and  then  is  with- 
drawn.   The  saeptum  is  now  painted  with 

R    Cocaine  hydrochloride,  gr.  x; 

Adrenalin,  i  in  1000  to  saturation. 

M. 

Only  just  enough  adrenalin  should  be  used  to  dis- 
solve the  cocaine  crystals.  W"\t\\  a  cotton  wound 
applicator  dipped  in  this  solution  the  surgeon  should 
hunt  for  any  area  which  will  give  pain  when  touched, 
and  should  hold  his  applicator  against  this  area  until 
the  patient's  eyelids  cease  to  squeeze  together — an 
excellent  index  as  to  sufficient  anaesthesia. 

Equipment. 

Xext  to  a  proper  knowledge  of  the  principles  of 
technique,  a  complete  and  satisfactory  equipment  is 
the  most  essential  factor  to  a  successful  result.  The 
best  light  is  the  Coakley  electric  illuminator  fur- 
nished by  most  in.strument  houses,  a  description  of 
which  is  unnecessary,  suffice  it  to  say  that  it  gives  a 
brilliant  white  light  adjustable  to  all  the  conditions 
which  must  be  met.  The  ordinarv  Argand  burner 
with  a  ^lackenzie  condenser  gives  a  very  strong 
ligh.t.  but  there  is  a  preponderance  of  yellow  rays 
in  the  flame  to  which  one  must  become  accustomed 
before  the  best  work  is  possible.  A  head  mirror 
with  a  focus  of  fifteen  inches  is  desirable.  A  chair 
with  arms  upon  which  the  patient  can  lean  is  very 
serviceable.  The  operator's  stool  should  be  provided 
with  a  screw  which  permits  it  to  be  lowered  two 
inches  below  the  seat  level  of  the  patient's  chair. 

As  to  instruments,  very  few  are  required.  The 
knife  may  be  of  the  right  angled  variety  with  a  set 
screw  to  regulate  the  depth  of  incision,  but  this  I 
regard  as  an  unnecessary  refinement.  A  straight, 
narrow  bladed,  sharply  pointed  knife  fulfills  every 
requirement.  Three  elevators  should  be  at  hand — 
a  sharp  pointed,  curved  elevator  such  as  that  of 
Abraham,  a  straight,  blunted  elevator  such  as  that 
of  Hurd  or  Killian,  and  a^  hooked  elevator  shaped 
like  a  golf  stick  flattened  at  the  blade.  This  latter 
can  be  secured  from  any  dental  supply  house,  and 


is  invaluable  in  working  around  spurs.  For  removal 
of  cartilage  the  E5allenger  swivel  knife  is  useful,  but 
not  essential.  The  McCoy  forceps  is  an  excellent 
instrument  for  exsection  of  both  cartilage  and  bone, 
and  has  given  very  good  service  in  my  hands.  The 
thickened  nasal  crest  is  best  removed  by  the  Hurd 
forceps,  especially  designed  for  this  step  of  the  op- 
eration. It  is  far  superior  to  the  right  angled  chisel 
and  mallet.  In  some  cases  the  Roe  forceps  or  the 
Asch  forceps  is  useful  in  fracturing  an  extreme 
deviation  of  bone  situated  high  up  and  posteriorly, 
thus  enabling  remova'  of  the  redimdant  bone  after 
it  is  placed  in  the  median  line. 

Tlie  Pri))iary  Incision. 

When  all  is  ready  the  surgeon  cleanses  his  hands 
in  the  usual  surgical  manner  and  taking  up  the  knife 
makes  his  incision.  Ambidexterity  is  extremely  val- 
uable here,  inasmuch  as  it  enables  one  to  make  the 
incision  on  the  side  of  the  convexity,  whether  such 
be  right  or  left.  If  the  operator  is  right  handed 
only,  he  introduces  the  index  finger  of  his  left  hand 
into  the  patient's  right  nostril,  and  pushing  the  an- 
terior portion  of  the  saeptimi  toward  the  patient's 
left  makes  his  incision  without  the  aid  of  a  spec- 
ulum. If  the  obstruction  bulges  into  the  naris  the 
line  should  be  drawn  from  a  point  high  up.  should 
curve  forward  just  in  frotit  of  the  most  prominent 
part  of  the  bulge,  and  then  downward  to  the  ex- 
treme limit  of  the  floor.  Experience  only  will  teach 
the  operator  where  an  incision  gives  the  best  work- 
ing view.  One  must  be  careful  not  to  go  through 
to  the  opposite  side,  but  just  deep  enough  to  feel 
the  muffled  point  of  the  knife  beneath  the  index  fin- 
ger. The  beginner  does  better  to  limit  himself  to 
tracing  out  his  line  of  incision  several  times  imtil 
he  gets  down  to  cartilage,  but  not  through  it. 
Elevation  of  Mucopcrichondrinm  on  Convex  Side. 

A  suitable  nasal  specuhmi  is  now  introduced  and 
with  the  sharp,  curved  elevator  the  mucoperiosteal 
flap  is  dissected  free  of  cartilage  until  the  latter  is 
bared  for  one  quarter  inch  back  of  the  incision.  At 
this  point  the  dull  elevator  may  be  used  to  advan- 
tage. It  is  well  to  begin  the  separation  high  up 
toward  the  roof  as  it  is  m.ore  easily  carried  on  at 
this  point,  and  then  extend  it  as  far  as  is  necessary 
in  all  directions.  If  there  is  a  spur  or  ridge  near 
the  floor  trouble  is  sure  to  be  encountered,  and  the 
surgeon  must  work  cautiously  with  his  hooked  and 
blunt  elevators  imtil  the  obstacle  is  surmounted. 
One  must  make  sure  at  the  outset  that  he  is  separat- 
ing perichondrium,  from  cartilage  and  not  between 
perichondrium  and  mucous  membrane,  as  this  latter 
is  certain  to  end  in  disaster. 

Incision  of  tlie  Cartilage. 

When  one  side  of  the  saeptum  is  free  at  all  points 
the  incision  is  carried  through  cartilage  to  muco- 
perichondrium  of  the  opposite  side.  It  is  better  for 
the  uncertain  hand  to  go  slowl\',  feeling  the  way, 
and  thus  avoiding  blunders  which  may  subject  him 
to  criticism  at  the  hands  of  his  colleagues  later  on. 
EJez'ation  of  Mncoperichondrinm,  Concave  Side. 

Elevation  of  mncoperichondrinm  is  effected  in 
like  manner  on  this  side,  and  when  it  is  finished  the 
operator  has  a  saeptum  free  from  soft  tissue  at  all. 
the  points  to  be  resected. 


430 


VOORHEES:  SUBMUCOUS  RESECTION  OF  NASAL  SMPTUM.  [New  York 

Medical  Journai^ 


Removal  of  Cartilage  and  Bone. 
Removal  of  cartilage  and  bone  is  carried  out  by 
means  of  the  Ballenger  knife,  McCoy  forceps,  and 
Hurd  forceps,  biting  out  a  little  piece  at  a  time.  A 
most  important  step  is  examination  from  time  to 
time  with  a  probe  to  find  out  what  progress  is  being 
made  in  correcting  the  deformity.  If  the  flaps  are 
approximated  and  the  probe  applied  to  them  exter- 
nally, one  can  readily  determine  if  sufficient  deform- 
ity has  been  removed. 

Packing. 

The  packing  should  now  be  introduced.  A  very 
satisfactory  dressing  is  furnished  by  saturating 
plain  gauze  strips  in  fluid  petrolatum.  This  gauze 
can  be  obtained  three  quarters  of  an  inch  wide,  put 
up  in  glass  tubes.  The  fluid  petrolatum  is  simply 
poured  into  the  tube  in  sufficient  quantity  to  saturate 
the  contents ;  any  excess  is  poured  off  at  the  time 
of  use.  The  packing  should  be  carried  on  the  point 
of  an  applicator  high  up  and  far  back  on  the  side 
opposite  the  concavity,  and  sufficient  of  it  should  be 
used  to  cause  moderate  pressure  at  every  point. 
When  the  side  is  packed  which  holds  the  incision, 
care  must  be  taken  to  avoid  separating  the  flaps,  and 
for  this  purpose  a  long  bladed  speculum  is  useful  to 
keep  the  flaps  in  apposition.  The  packing  is  then 
pressed  in  place,  beginning  high  up  and  far  back,  as 
in  the  previous  instance,  and  carried  toward  the 
floor  and  anteriorly  to  the  limit  of  the  vestibule. 
When  all  is  finished  posterior  rhinoscopy  should  be 
done  to  determine  the  position  of  gauze,  and  pres- 
•ence  of  posterior  haemorrhage  if  any  exists.  In  case 
"the  gauze  protrudes  from  the  choanse,  a  finger 
should  be  introduced -into  the  nasopharynx  to  push 
it  into  place,  otherwise  reflex  coughing  and  gagging 
with  subsequent  haemorrhage  may  be  the  result. 
Postoperative  Treatment. 

Two  ounces  of  fluid  petrolatum  are  ordered  with 
a  glass  dropper,  and  the  patient  is  instructed  to  keep 
the  gauze  saturated  with  the  oil  until  packing  is  re- 
moved. He  is  given  morphine  sulphate,  grain  y^, 
No.  IV;  two  to  be  taken  as  soon  as  he  reaches 
^home,  and  two  more  one  hour  later  if  he  is  not  rest- 
ing quietly.  Absolute  rest  in  bed  for  twenty-four 
hours  should  be  the  rule,  with  applications  of  ice  to 
the  nose,  and  a  fluid  diet.  At  the  expiration  of 
from  twenty-four  to  thirty-six  hours,  depending 
upon  the  severity  of  the  case,  the  packing  is  re- 
moved. Removal  is  ordinarily  attended  with  only 
slight  pain,  but  haemorrhage  may  be  rather  marked 
for  a  few  minutes.  It  is  unwise  to  wipe  away  the 
clots  formed  at  this  time,  for  this  is  Nature's  first 
effort  at  healing.  Upon  the  following  day,  however, 
the  fossae  should  be  thoroughly  cleaned  and  in- 
spected. For  this  purpose  the  sprav  of  two  per  cent, 
cocaine  with  adrenalin  is  used,  followed  by  hydro- 
gen peroxide  and  water,  equal  parts. 

A  cleansing  douche  is  then  given,  and  a  pleasant 
antiseptic  oil  is  sprayed  into  the  anterior  nares  and 
oropharynx,  followed  by  a  piece  of  absorbent  cot- 
ion  in  each  vestibule,  which  is  left  in  while  the  pa- 
tient is  in  the  open  air.  At  this  visit  the  alkaline 
•wash  in  the  Bermingham  douche  is  again  ordered, 
and  the  patient  is  carefully  instructed  how  to  use 
them  in  order  to  cleanse  every  portion  of  the  nasal 
■cavity  without  filling  the  Eustachian  tubes.  The 


douche  is  half  filled  with  the  alkaline  wash  and  then 
very  hot  water  is  added  to  filling.  With  a  finger  on 
the  valve  the  nozzle  is  introduced  into  the  vestibule, 
and  the  head  thrown  back  with  mouth  wide  open. 
There  must  be  absolute  cessation  of  breathing.  The 
fluid  IS  now  allowed  to  flow,  and  when  the  chamber 
seems  filled  the  douche  is  removed,  the  fingers 
grasp  both  nostrils  and  the  head  is  held  forward  for 
a  few  seconds,  when  the  fluid  is  allowed  to  flow  out. 
I  am  satisfied  that  this  is  the  best  means  a  patient 
has  of  cleansing  the  nose,  and  that  all  adverse  criti- 
cism respecting  it  has  been  caused  by  improper  use. 
If  the  patient  refrains  from  blowing  the  nose  for 
ten  minutes  after  douching,  the  ears  will  never  get 
into  trouble. 

For  one  week  the  patient  makes  daily  visits  to  the 
physician,  at  which  times  the  nose  is  cleansed  and 
an  ointment  of  yellow  oxide  of  mercury,  five  per 
cent.,  with  sufficient  fluid  petrolatum  to  make  it 
quite  soft,  is  applied  to  all  abraded  surfaces.  The 
visits  should  be  continued  daily  during  the  first 
week,  then  once  a  week  for  six  weeks. 

Complications  and  Sequelce. 

Headache  for  two  or  three  days  may  be  expected 
from  the  trauma  and  packing.    It  is  seldom  severe. 

Haemorrhage  is  sometimes  very  annoving,  more 
because  it  frightens  the  patient  than  from  actual  loss 
of  blood.  It  is  due  to  inefficient  packing,  a  tear  sit- 
uated posteriorly,  reaction  from  adrenalin,  high 
arterial  tension  often  associated  with  insufficient 
elimination  of  waste,  unrecognized  haemophilia,  or 
interference  of  the  patient  with  the  packing. 

Loss  of  appetite  is  common  for  twenty-four  to 
forty-eight  hours. 

Nasal  occlusion  due  to  swelling  may  remain  for 
a  week  or  ten  days. 

Hasmatoma  between  the  flaps  with  infection  and 
abscess  formation  occasionally  occurs. 

A  mild  grade  of  conjunctivitis  is  common.  It 
disappears  in  a  few  hours.  Meningitis  is  a  very. rare 
complication. 

Synechia  ought  to  be  infrequent  if  due  care  has 
been  used  in  instrumentation.  However,  they  may 
occur  with  the  best  operators. 

Perforation  and  tears  are  sometimes  unavoidable. 
When  they  occur  effort  should  be  made  at  time  of 
operation  to  suture  them  with  fine  silk  or  horse  hair. 
If  this  is  done  healing  ordinarily  rapidly  ensues. 

Troublesome  crusts  are  likely  to  form  for  weeks 
after  operation.  They  should  be  removed  by  a 
hydrogen  peroxide  wash,  i  in  4,  followed  by  a  sirn- 
ple  alkaline  solution. 

While  the  packing  is  in  place  there  is  a  good 
deal  of  grayish  discharge  from  the  anterior  nares. 
The  upper  lip  should  be  kept  well  anointed  with  the 
five  per  cent,  mercurial  ointment  in  order  to  prevent 
excoriation  and  infection. 

Cocaine  poisoning  is  impossible  if  the  technique 
as  given  here  is  carried  out.  I  have  never  seen 
a  case  thus  affected  in  my  own  experience,  or  in  the 
experience  of  colleagues. 

The  end  result  of  operation  may  not  be  manifest 
for  six  or  eight  weeks,  but  in  skilled  hands  it  is 
likely  to  be  very  satisfactory  both  to  patient  and 
physician. 

3544  Broadway. 


February  2;,  1909,] 


SAJOUS:  AUTOFROTECTII'E  .MEtHAM:^.]!. 


IS    THE   HUMAN    BODY    SUPPLIED    WITH  AN 

AUTOPROTECTIVE  MECHANISM? 
A  neiu  theory  of  Immunity  based  on  the  Ductless  Glands.* 

By  Charles  E.  de  M.  Sajous,  M.  D., 
Philadelphia. 

{Concluded  from  page  368.) 
The  Governing  Centre  of  the  Thyreoparathy- 
REOiD  Glands. 

The  analysis  of  this  question  proved  to  have  been 
greatly  facilitated  by  the  previous  study  of  the  pitui- 
tary body  and  the  thyreoid  apparatus,  since  it  soon 
became  evident  that  the  latter,  as  in  the  case  of  the 
adrenals,  was  also  governed  by  a  centre  located  in 
the  pituitary.  This  conclusion  is  not  only  sustained 
by  what  evidence  there  is  on  the  subject,  but  also 
by  logical  reasoning,  since  the  two  centres  which 
regulate  oxygenation,  metabolism  and  nutrition, 
thus  conjoined,  are  placed  in  the  most  advantageous 
position  to  coordinate  these  all  important  functions. 

This  accounts  for  a  feature  already  emphasized 
in  the  preceding  pages — and  which,  therefore,  will 
only  be  summarily  dealt  with  here,  viz.,  that 

The  active  and  passive  phenomena  evoked  by  the 
pituitary  body  and  the  thyreoid  apparatus  shoiv  con- 
siderable parallelism. 

We  have  seen  that  removal  of  either  the  pituitary  or  the 
thyreoid  causes  a  steady  decline  of  the  temperature  with 
decreased  oxygen  intake  and  carbon  dioxide  output,  and 
also  weakness,  tetany,  and  even  epileptic  convulsions,  while 
conversely,  overactivity  of  either  organ  provokes  excesssive 
metabolism  with  increase  of  oxygen  intake  and  carbon 
dioxide  output,  and  glycosuria.  We  arrest  nutrition  by 
removing  either  the  pituitary  or  the  thyreoid,  just  as  de- 
generative changes  in  either  organ  entails  denutrition  laps- 
ing into  fatal  cachexia.  The  sthenic  stage  of  acromegaly 
and  gigantism  strikingly  illustrates  the  power  of  the  pitui- 
tan,'  to  incite  excessi^'c  nutrition  and  overgrowth ;  the 
rapid  growth  of  the  cretin  imder  the  influence  of  thyreoid 
extract  exemplifies  what  the  thyreoid  apparatus  can  do  in 
the  same  direction. 

The  simultaneous  presence  of  degeneration  of  the  pitui- 
tary and  myxoedema  in  cases  reported  by  Ponfick  (202), 
J.  Stewart,  Codd,  (203),  Sainton  and  Rathery  (204),  and 
others;  and  of  acromegaly  with  exophthalmic  goitre  by 
Murray  (205),  Lancereaux  (206),  and  others  (two  dis- 
eases which  as  emphasized  by  Lorand,  not  only  present 
many  characteristics  in  common,  but  which,  as  observed 
by  Magnus -Levy  (207)  are  attended  by  excessive  oxida- 
tion) clearly  suggest  functional  parallelism.  This  is  fur- 
ther emphasized  by  the  enlargement  of  both  organs  during 
pregnancy  indicated  by  the  labors  of  Comte  (208),  Lau- 
nois  and  Mulon  (209),  and  Lang  (210)  and  its  subsidence 
when,  after  parturition,  the  blood  no  longer  receives  the 
excess  of  wastes  that  the  presence  of  the  foetus  involved. 
On  the  whole  we  can  certainly  say  with  Thaon  (211)  that 
"between  the  pituitary  and  the  thyreoid  there  is  so  much 
analogy  that  the  one  cannot  be  studied  without  a  knowl- 
edge of  the  other." 

Zoology  affords  various  landmarks  in  the  same 
direction.  It  suggests,  in  fact,  when  its  teachings 
are  interpreted  from  my  viewpoint,  that 

The  pituitary  body  governs  o.vygenation,  metabol- 
ism, and  nutrition  in  all  animals  supplied  with  a  thy- 
reoid gland  and  adrenals. 

In  tunicata,  the  homologue  of  the  thyreoid,  according  to 
zoologists,  is  the  endostyle,  a  long  gland  at  the  base  of 
the  pharynx  closely  related  to  the  branchial  or  respiratory 
chambers.  The  adrenals,  in  these  invertebrates  are  repre- 
sented, as  personal  researches  have  suggested,  by  the  dor- 
sal tubercle ;  which  is  so  related  to  the  respiratory  cham- 
ber that  its  product,  which  corresponds  with  the  adrenal 
secretion,  can  be  secreted  into  the  blood  near  the  oral 
aperture,  the  inlet  for  the  water  which  supplies  the  animal 

*Read  by  invitation  before  the  Toronto  (Canada)  Academy  of 
Medicine,  January  5,  1909. 


with  oxygen.  Suggestive  in  the  light  of  the  views  I  have 
submitted  is  that  the  dorsal  tubercle — the  primitive  organ 

of  the  adrenals  from  my  viewpoint — is  connected  by  a 
delicate  duct  with  an  organ,  the  subneural  gland,  which 
Julin,  as  we  shall  see  presently,  has  identified  as  the 
hypophysis,  while  the  endostyle,  the  primitive  thyreoid, 
along  with  all  other  organs,  receives  nerve  fibres  from  a 
nerve  ganglion  attached  to  this  ancestral  pituitary. 

Two  important  facts  impose  themselves  in  this  connec- 
tion :  The  first  is  that,  as  stated  by  Jacques  Loeb  (212) 
in  reference  to  a  group  of  .these  invertebrates  ''the  cen- 
tral nervous  system  is  reduced  to  a  single  ganglion" ;  the 
second  is  that  this  single  ganglion  corresponds  with  the 
neural  or  posterior  lobe  of  the  pituitary.  Just  as  the  nerve 
ganglion  governs  the  functions  of  the  primitive  thyreoid 
and  adrenals,  that  is  to  say  the  respiratory  processes  in 
these  lowly  animals,  so  can  it  be  shown  to  do  at  every 
step  of  the  phylogenetic  scale  up  to  man,  since  it  preserves 
its  functional  importance  throughout.  The  snail,  for  ex- 
ample, is  supplied  with  both  a  cerebral  and  an  oesophageal 
ganglion ;  galvanic  excitation  of  the  cerebral  ganglion,  as 
shown  by  Vulpian,  produces  no  appreciable  effect;  but 
similar  excitation  of  the  lower  or  pharyngeal  ganglion,  the 
future  neural  lobe  of  the  pituitary,  provokes  violent  mus- 
cular movements.  Again,  removal  of  the  cerebral  gang- 
lion will  not  kill  the  animal,  but  it  will  remain  motionless. 
Extirpation  of  the  oesophageal  ganglion  on  the  other  hand, 
causes  its  death  in  less  than  twenty-four  hours.  All  this 
applies  as  well  to  other  invertebrates. 

We  can  assimilate  all  the  vertebrates  to  these  primitive 
forms  by  removing  the  brain.  That  the  respiratory  mech- 
anism or  the  processes  it  influences  are  not  in  the  least 
impaired  by  this  operation  was  shown  when  we  traced  the 
governing  centres  of  this  mechanism — to  which  the  thy- 
reoid belongs — to  the  pituitary.  The  well  known  Cornell 
frog  lived  several  years  after  its  brain  had  been  removed. 
The  decerebrated  pigeon  is  a  familiar  example  of  this 
kind.  Another  is  Goltz's  dog  which  lived  eighteen  months 
after  both  its  hemispheres  had  been  removed.  Conversely, 
we  have  seen  how  rapidly  extirpation  of  the  pituitary 
proves  fatal  in  the  higher  mammals,  just  as  it  does  in  the 
low  invertebrates  when  the  oesophageal  ganglion  is  ex- 
tirpated. We  found  that  all  the  lethal  phenomena  are  due 
to  arrest  of  respiration  and  oxidation,  both  of  which  pro- 
cesses are  carried  on  through  the  adrenals  and  the 
thyreoids. 

Additional  evidence  tends  also  to  indicate  that 
In  vertebrates  the  pituitary  body  is  connected 

with  the  thyreoparathyreoid  apparatus,  as  it  is  zvith 

the  adrenals,  by  direct  nerve  paths. 

The  thyreoid  apparatus,  as  all  textbooks  teach,  receives 
its  nerves  from  the  sympathetic  through  the  middle  and 
inferior  cervical  ganglia.  That  they  originate  in  the  pitui- 
tary is  shown  not  only  by  the  presence  of  typical  sympa- 
thetic fibres  between  the  pituitary  and  the  upper  connec- 
tions of  the  spinal  system  with  the  cervical  sympathetic, 
but  also  by  the  effects  of  electrical  excitation  of  the  ex- 
posed but  normal  pituitary. 

As  to  the  origin  of  the  nerves,  Cajal  (213),  Joris  (214), 
and  others,  we  have  seen,  traced  in  various  animals  fibres 
from  the  pituitary  to  a  nucleus  of  large  grey  cells  imme- 
diately above  the  infundibulum  in  the  anterior  portion  of 
the  third  ventricle,  which  nucleus  was  found  by  them  to 
project  nerves  over  the  ventricular  walls.  These  nerves 
are  also  described  by  Edinger  (215)  in  fishes,  reptiles  and 
birds,  as  "numerous  fine,  medullated  fibres" — the  charac- 
teristics of  sympathetic  nerves,  as  shown  by  Bidder  and 
Volkmann.  In  illustrations  of  sections  in  various  animals, 
Edinger  shows,  moreover,  that  several  bundles  of  these 
fibres  project  posteriorly  as  far  as  the  level  of  the  bulb 
whence,  as  is  well  known,  the  fibres  which  pass  over  to 
the  sympathetic  ganglia  begin  to  leave  the  spinal  system. 
As  the  ganglia  are  the  starting  points  of  sympathetic  nerves 
to  the  various  organs,  we  thus  have  through  these  ganglia, 
a  continuous  path  from  the  pituitary  of  these  organs.  This, 
we  have  seen,  is  sustained  by  physiology,  since  Cyon  and 
also  Masay  (216)  catised  an  immediate  rise  of  pressure  of 
over  100  mm.  Hg.  by  exciting  electrically  the  exposed 
pituitary.  As  the  vagi  were  cut  during  the  experiment,  and 
the  vasomotor  centre  is  independent  and  located  in  the 
bulb,  the  rise  of  pressure  could  only  be  due  to  general 
sympathetic   vasoconstriction.     I   have   shown  elsewhere 


432 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


[New  York 
Medical  Journal. 


(217)  by  data  which  would  take  up  too  much  space  here, 
that  the  pituitary  has  a  controlling  power  over  the  sym- 
pathetic system. 

When  the  influence  of  the  pituitary  over  the  adrenals 
was  studied,  it  was  possible  to  trace  step  by  step  along  the 
path  between  the  two  organs,  all  the  main  phenomena 
which  both  were  able  to  provoke.  In  the  case  of  the  thy- 
reoid we  are  deprived  of  this  valuable  testimony.  As 
Morat  (218)  in  his  review  of  the  sympathetic  system,  says, 
"the  thyreoid  gland  receives  its  vasomotor  fibres  from  the 
superior  portion  of  the  thoracic  chain  by  the  cervical  cord. 
Stimulation  of  the  thoracic  chain  causes  either  vasocon- 
striction or  vasodilatation  on  account  of  the  mixture  of  the 
two  orders  of  fibres."  In  other  words,  the  antagonistic 
nerves  which  control  the  functions  of  the  thyreoid  are 
so  conjoined  that  transaction  or  excitation  would  afford 
no  reliable  testimony. 

The  participation  of  the  thyreoid  in  the  phenomena 
awakened  by  the  pituitary  and  the  nerves  it  projects  pos- 
teriorly is  shown,  however,  by  the  intensity  of  these 
phenomena.  The  adrenal  secretion  alone,  as  represented 
by  its  extracts,  causes  a  rise  of  temperature  of  i  or  2°  F. 
How  account  for  the  rise  of  10°  F.  and  over  caused  by 
puncture  of  the  tuber  cinereum  (just  above  the  pituitary) 
by  Sakowitsch  (219)  ;  of  the  6°  F.  and  over  noted  by 
Briick  and  Giinther  (220)  on  puncturing  between  the 
pons  and  medulla ;  and  of  the  12.4°  F.  noted  by  Brodie 
(221)  after  an  injury  of  the  cervical  portion  of  the  spinal 
cord.  with,  impulses  to  the  adrenals  alone  to  account  for 
these  heat  phenomena?  They  obviously  fail  to  do  so.  On 
the  other  hand  they  are  readily  explained  by  simultaneous 
impulses  to  the  thyreoid  apparatus,  since  the  action  of  its 
secretion  upon  cellular  phosphorus,  we  have  seen,  provides 
an  active  source  of  heat  energy.  This  dual  action  not  only 
accounts  for  the  high  temperatures  obtained  by  irritation 
applied  all  along  the  path  from  the  pituitary  down  to 
where  the  nerves  to  the  adrenals  and  thyreoid  leave  the 
spinal  cord,  but  it  indicates  that  the  two  sets  of  thermo- 
genic nerves  follow  the  same  path,  down  to  this  region. 

All  the  data  and  deductions  submitted  so  far 
(pending  final  confirmatory  testimony  to  be  sub- 
mitted presently)  have  now  brought  us  to  the  cul- 
minating feature  of  this  address : 
The  Identity  of  the  Immunizing  Mechanism 
.-WD  ITS  Mode  of  Action. 

Of  fundamental  imtiortance  in  this  connection,  is 
that 

The  pituitary  body  of  all  animals  from  mollusks 
to  man  contains  a  sensory  organ  zvhich  structurally 
resembles  the  nasal  olfactory  membrane. 

Julin  (222)  urged  in  1881  that  in  ascidians,  the  sub- 
neural  gland  (conjoined  to  the  nerve  ganglion  which  I  as- 
simulate  to  the  posterior  or  neural  lobe)  was  the  ancestor 
of  the  pituitary  body  of  vertebrates.  Lloyd  Andriezen 
(223)  confirmed  this  view  after  a  comprehensive  study  of 
the  organ  from  amphioxus  to  man.  Personal  work  in  the 
same  line  led  to  a  similar  conclusion.  Now,  at  least  as 
low  down  as  mollusks  there  exists  in  the  corresponding 
location  a  patch  of  epithelium  which  Spengel  has  termed 
"the  olfactory  organ."  and  Lankester  (224)  the  "osphra- 
dium."  Unaware  of  the  connection  between  this  struc- 
ture in  ancestral  forms  and  the  pituitary,  Peremeschko 
(225),  Miiller  (226),  and  also  Cadiat  (227)  described  a 
cleft,  between  'he  two  lobes  of  the  latter  organ,  the  walls 
of  which  they  found  to  be  lined  with  epithelium.  The 
structure  of  this  epithelium  was  only  made  clear,  however, 
wluMi  the  Golgi  method  was  available.  Gentes  (228)  then 
found  that  it  was  merged  in  the  partition  (the  pars  inter- 
media) separating  the  two  lol)es,  and  that  it  contained 
elongated  nerve  cells  which  sent  their  neuraxons  into  the 
posterior  lobe,  and  thence  to  the  base  of  the  brain.  Ac- 
cording to  Gentes,  these  cells  recall  exactly  the  sensory 
elements  of  the  nasal  olfactory  membrane.  Caselli  also 
found  sensory  elements  in  the  pituitary  of  higher  animals, 
while  Boeke  (229),  and  Gemelli  (230)  discerned  them  in 
the  pituitary  of  fishes.  .\  personal  distinctive  study  of  this 
organ  from  the  true  olfactory  apparatus  has  shown  more- 
over, that  the  former  could  be  traced  down  to  lower  forms, 
gradually  receding  in  importance  until  the  patch  of  epithe- 


lium "supplied  with  a  special  nerve  and  ganglion"  as  Ray 
Lankester  describes  it  in  mollusks  is  reached. 

Suggestive  in  this  connection,  as  a  feature  of  the 
immunizing  process,  is  that 

In  ancestral  animals  the  "test  organ"  serves  to 
test  the  purity  of  the  sea  water  ingested  by  them. 

Spengel's  olfactory  organ,  Ray  Lankester's  osphradium, 
has  for  its  purpose,  according  to  zoologists,  to  test  the 
respiratory  fluid.  In  amphioxus,  the  lowest  of  vertebrates, 
similar  protection  is  aft'orded  by  what  Willey  (231)  de- 
scribes as  a  "vestibule  richly  provided  with  sensitive  cells," 
and  by  Andriezen  as  a  "nervous  organ"  which  "serves  to 
test  the  quality  of  the  water  which  passes  over  the  respira- 
tory organ." 

That  a  corresponding  autoprotective  function  exists  in 
the  higher  animals,  including  man,  is  not  only  sustained 
by  considerable  evidence,  but  as  a  solid  foundation  for 
the  whole  scheme  is  afforded  by  the  fact  that  the  blood 
of  these  higher  animals  is  the  physiological  and  qualitative 
homologue  of  sea  water.  Claude  Bernard  (232)  taught 
forty  years  ago,  that  "the  blood  is  an  internal  medium  in 
which  anatomical  elements  live  as  do  fishes  in  water." 
Rene  Quinton  (233)  showed  that  our  plasma  was  a  fluid 
which  chemically,  in  so  far  as  the  relative  proportion  of 
the  various  elements  was  concerned,  corresponded  with 
sea  water.  A.  B.  Macallum  (234)  also  holds  that  both 
animal  and  vegetable  protoplasm  derive  their  relations  to 
the  elements  sodium,  potassium,  calcium,  and  magnesium 
from  the  coinposition  of  sea  water  which  obtained  when 
all  forms  were  unicellular.  The  labors  of  Bunge  (235), 
Jacques  Loeb  (236),  Matthews,  Fisher,  Overton  (237), 
and  others  have  all  contributed  testimony  to  the  solidity 
of  this  view. 

Considered  in  the  light  of  the  anatomical  connec- 
tions of  the  pituitary  with  the  thyreoid  and  adre- 
nals, and  the  functions  I  have  ascribed  to  these 
organs,  the  conclusion  seems  warranted  that 

In  the  higher  animals,  including  man,  the  "test 
organ"  tests  the  purity  of  the  qualitative  homologue 
of  sea  water;  the  blood,  for  toxic  substances  and, 
ivhere  possible,  causes  destruction  of  these  sub- 
stances. 

We  have  only  to  analyze  the  pathogenesis  of  the  convul- 
sions that  follow  removal  of  the  pituitary  to  realize  that 
the  role  of  its  test  organ  is  also  to  prevent  general  in- 
toxication in  the  higher  animals,  including  man.  This 
procedure,  as  observed  by  Marinesco  (238),  Vassale  and 
Sacchi  (239),  Masay  (240),  and  others,  produces  as 
Schafer  (241)  expresses  it  "muscular  twitchings  and  tre- 
more.  developing  later  into  spasms."  This  exemplifies  the 
familiar  convulsions  caused  in  children  by  autointoxica- 
tion ;  those  engendered  by  tetanoxin ;  those  of  puerperal 
eclampsia  which  Williamson  (242),  G'randin  (243),  and 
others  ascribe  to  poisonous  substance  circulating  in  the 
blood:  those  provoked  in  animals  by  Herter  (244),  Krain- 
sky  (24s),  and  in  man  by  Ceni  (246)  with  hypertoxic  serum 
derived  from  epileptics,  a  fitting  corollar}^  for  Pierce 
Clark's  (247)  conclusion,  based  on  a  study  of  150,000  epil- 
eptic seizures,  that  "we  must  see  the  pathogenesis  in  an 
initial  toxinc  or  ;uitointo.\ication."  I  have  urged  in  this 
connection,  and  others  besides  myself  have  found,  that  in 
appropriate  cases  of  epilepsy  those  in  which  the  thyreoid 
is  inadequately  active  and  in  which  gliosis  has  not  been 
given  time  to  develop,  thyreoid  e.xtract  proves  effective 
in  arresting  the  paroxysms.  Need  I  refer  to  its  corres- 
ponding action  in  the  convulsions — of  both  tetanic  and 
epileptic  type — that  follow  extirpation  of  the  thyreoid 
parathyreoids  ?  Here  there  is  directly  introduced  into  the 
blood  the  agent  which  sensitizes  the  toxic  wastes  and  ren- 
ders them  vulnerable  to  the  destructive  action  of  the  other 
defensive  substances. 

If  all  this  is  true,  however,  the  introduction  of  a 
toxic  into  tlie  blood  should,  by  exciting  the  test  or- 
gan, awaken  the  defensive  resources  of  the  body  to 
action  through  the  intermediary  of  the  thyreoid  ap- 
paratus and  adrenals. 

Crucial  experiments  are  needed  to  meet  this  fea- 


3^ebruary  27,  1909.] 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


433 


ture  of  the  conception  as  a  whole.  It  does  not  suffice 
to  sax  that  the  test  organ  when  excited  by  a  poison 
stimulates  the  adrenals  and  the  thyreoid  apparatus 
and  thus  induces  destruction  of  that  poison  ;  it  must 
be  shown  that  when  the  test  organ  cannot  transmit 
its  impulses  to  the  adrenals  and  thyreoid  the  auto- 
protective  process  does  not  manifest  itself.  This 
requirement  is  met  by  a  series  of  experiments  in 
thirty-eight  dogs  by  Sawadowski  (248),  and  other 
investigations  reviewed  below.  They  indicate,  when 
explained  in  the  light  of  my  views,  that : 

Fever  is  the  physiological  expression  of  the  de- 
fensive mechanism',  z^'hcn  a  toxic  capable  of  exciting 
the  test  organ  is  present  in  the  blood. 

I  have  urged  that  the  pituitary  contained  the  heat  centre 
and  that  it  produced  a  rise  of  temperature  through  the 
intermediary  of  the  adrenals  and  thyreoid.  The  test  organ 
is  evidently  closely  connected  with  the  heat  centre  for  the 
protective  process  it  awakens,  when  certain  poisons  occur 
in  the  blood,  is  a  rise  of  temperature.  Now,  Sawadowski 
noted,  after  injecting  putrid  substances  into  the  blood, 
and  in  accordance  with  familiar  experience,  that  it  caused 
fever.  He  found,  moreover,  that  antipyrine  controlled  this 
fever.  But  his  experiments  revealed  an  important  fact, 
viz.,  that  section  through  the  optic  thalami  or  the  poster- 
ior edges  of  the  corpora  striata  (which  from  my  view- 
point also  severed  the  nerve  paths  from  the  test  organ  or 
heat  centre  to  the  adrenals  and  thyreoid)  prevented  these 
effects.  "After  these  sections,"  he  writes,  "neither  the 
putrid  materials  nor  the  antipyrine  exerted  any  influence 
upon  the  temperature.  The  sinking  of  the  temperature 
was  not  arrested  by  the  putrid  substances."  The  last 
statement  refers  to  tlie  fact  that  nothwithstanding  the  pres- 
ence of  putrid  substances  which  had  caused  fever,  the 
temperature  steadily  went  down — after  the  operation — 
from  38.1°  C.  in  the  colon  to  31.4°  C.  This  recalls  the 
steady  decline  that  occurs  after  removal  of  the  pituitary. 
Ott  and  Scott  ,(249)  also  found  that  the  marked  rise  of 
temperature  that  follows  the  intravenous  injection  of  beta- 
tetrahydronapthylamin  in  normal  rabbits  did  not  occur 
after  they  had  transsected  the  base  of  the  brain  behind 
the  tuber  cinereum. 

The  heat,  or  thermogenic,  centre  thus  influenced  cannot 
be  located  in  the  cerebrum,  for  we  have  seen  that  removal 
of  this  organ  does  not  aft'ect  the  temperature.  Xor  can 
it  be  located  in  the  optic  thalmus  or  the  corpus  stratium, 
for  Ott  and  Harris  (250)  provoked  the  typical  rise  of  tem- 
perature by  puncturing  with  a  needle,  through  the  mouth, 
"only  the  lower  surface  of  the  tuber."  Its  true  location 
is  shown  by  the  fact  that  Ott  found  a  thermogenic  centre 
in  the  anterior  portion  of  the  floor  of  the  third  ventricle, 
i.  e..  immediately  above  the  pituitary.  Moreover,  it  is  pre- 
cisely transversed  by  the  nerves  which  Andriezen,  Gentes, 
Joris,  and  others  traced  from  this  organ,  and  which  An- 
driezen followed  to  the  region  of  the  pons. 

Under  these  conditions,  however,  transsection  of  the 
pons  should  also  have  prevented  the  thermogenic  action 
of  putrid  materials  in  Sawadowski's  experiments.  Such 
proved  to  be  the  case.  Of  this  experiment,  carried  out 
with  the  aid  of  Pawlow,  Sawadowski  writes:  "Following 
out  Ischetschichin's  method,  a  diagonal  section  was  made 
through  the  pons  varolii.  When  the  section  was  complete, 
free  from  haemorrhage  or  of  any  condition  which  might 
excite  the  surface  of  the  cut  tissues,  a  gradual  diminution 
of  the  temperature  occurred  in  the  rectum  and  between 
the  toes.  In  one  experiment,  for  example,  in  which  the 
preoperative  temperature  was  38°  C.  in  the  rectum,  and 
34.5"  C.  on  the  skin,  nine  hours  after  the  operation  the 
first  had  fallen  to  27°  and  the  second  to  25°  C."  This 
applies  as  well  to  the  spinal  cord :  "when  the  section  was 
made,  quite  high  up,"  he  says,  "no  rise  of  temperature 
could  be  obtained  with  putrid  materials  nor  did  the  anti- 
pyrin  lower  it." 

In  the  portion  of  the  cervical  region,  however,  he  found 
that  transsection  of  the  spinal  cord  did  not  completely 
prevent  the  influence  of  either  the  putrid  materials  or  the 
antipyrine.  But  we  have  in  this  paradoxical  phenomenon 
only  confirmatory  testimony  to  the  presence  of  a  nervous 
connection  between  the  pituitary  and  the  thyreoid  appa- 
ratus, for  in  these  "low  sections"  as  he  terms  them,  he 


severed  the  cord  below  the  origin  of  the  nerves  to  the 
thyreoid,  thus  leaving  untouched  the  nerves  which  con- 
nected it  with  the  pituitary  and  its  test  organ,  though  sev- 
ering the  path  to  the  adrenals.  What  effects  were  obtained 
were  due  to  the  thyreoid  apparatus  which  remained  under 
the  influence  of  the  test  organ,  and  therefore  of  the  ther- 
mogenic poison  and  antipyretic. 


Fig.  I. — Immunizing  mechanism  (heavy  lines  and  shading:  semi- 
schematic),  a.  Pituitary  body,  containing  immunizing  centre;  b, 
thyreoid  gland;  c,  adrenals;  d,  d',  d",  nervepath  from  pituitary  to 
adrenals;  e,  nervepath  from  pituitary  to  thyreoid;  e',  terminals  of 
nerves  to  thyreoid;  f,  pons;  g,  medulla  oblongata  or  bulb;  h,  in- 
ferior vena  cava. 

These  experiments  speak  for  themselves — espe- 
cially in  view  of  the  fact  that  Sawadowski  mentions 
among  the  concomitant  effects  of  his  sections  '"dis- 
orders of  respiration  and  circulation,"  and  also  blue- 
ness  of  the  blood — obvious  evidences  of  defective 
oxygenation.  Added  to  the  foregoing  evidence,  the}' 
seem  to  me  to  warrant  the  following  general  deduc- 
tions : 

1.  Man,  in  keeping  unth  many  animals  lower  in 
the  phylogenetic  scale,  is  supplied  with  an  autopro- 
tective  mechanism. 

2.  This  mechanism  includes:  i,  the  immunising 
centre,  an  organ  of  special  sense  annexed  to  the  heat 
centre,  both  centres  being  located  in  the  pituitary 
body;  2,  the  thyreoparathyreoid  glands;  3,  the  adre- 


434 


SAJOUS:  AUTOPROTECTIVE  MECHANISM. 


[New  York 
Medical  Journm. 


nals;  and  4,  special  nerves  which  connect  the  im- 
munizing centre  {through  the  heat  centre)  with 
these  two  sets  of  organs. 

3.  The  immunizing  centre,  which  governs  the  aii- 
toprotective  mechanism,  is  the  developed  "osphra- 
dinm"  or  "test  organ"  described  by  zoologists  in 
mollusks  and  certain  ancestral  vertebrates. 

4.  While  the  osphradium  of  primitive  animals  tests 
their  respiratory  fluid,  sea  zuater,  its  prototype,  the 
immunizing  centre  of  higher  animals,  including  man, 
tests  the  blood,  also  a  respiratory  fluid  and  a  quali- 
tative homologue  of  sea  water. 

5.  When  the  functional  activity  of  the  immunis- 
ing centre  is  increased  through  the  presence  in  the 
blood  of  some  toxic,  i.  e.,  wastes,  toxines  or  endo- 
toxines,  mineral  and  vegetable  poisons,  certain  ven- 
oms, drugs,  etc.,  capable  of  exciting  this  centre,  it 
stimulates  correspondingly  the  heat  centre  and  thus 
awakens  the  immunizing  process. 

6.  Fever  indicates  that  the  autoprotective  mech- 
anism is  active.  The  rise  of  temperature  is  due  to  the 
increased  production  of  thyrcoparathyrcoid  and  adre- 
nal secretions,  and  the  resultant  increment  of  me- 
tabolic activity.  The  immunizing  process  is  a  con- 
sequence of  this  hypermetabolism,  all  the  immuniz- 
ing agents,  plasmatic  and  cellular,  being  produced  in 
greater  quantities. 

7.  Absence  of  fever  in  a  toxccmia  of  any  kind  is 
due  to  inability  of  the  immunizing  centre  to  react 
under  the  influence  of  the  toxic,  owing  to  deficient 
sensitiveness  {inherited  or  acquired)  of  this  centre, 
or  to  the  fact  that  the  toxic  is  itself  a  paralyzant  or 
anccstJietic  of  its  sensory  elements. 

8.  Excess  of  fever  {above  105.^°  F.)  is  due  to 
excessive  excitation  of  the  immunizing  centre  and  a 
corresponding  overproduction  of  defensive  bodies. 
This  condition  e.vposes  the  red  corpuscles  and  the 
endothelial  cells  to  proteolytic  destruction  {hcemo- 
lysis  and  autolysis)  along  with  the  pathogenic  sub- 
stances or  bacteria' 


FiG-  2- — Pituitary  body,  containing  immunizing  centre  (semi- 
schematic),  a,  anterior  lobe;  b,  arteries  and  d,  arterioles;  c, 
course  of  blood  diffused  through  sinusoidal  capillaries  of  epithelium; 
e,  cleft  into  which  contents  of  blood  cells  (colloid)  and  cellular 
detritus  are  driven,  and  whence  they  pass  into  lymphatics;  /,  sen- 
sory 'test  organ  (immunizing  centre)  excited  by  colloid  when  the 
blood  (and  therefore  the  colloid)  contains  certain  poisons;  g,  pos- 
terior pituitary  containing  origin  of  paths  to  adrenals  and  thyreoid; 
h,  tuber  cinereum,  showing  secretory  path  to  adrenals  and  thyreoid; 
»,  retrooptic  nucleus  which  transmits  sympathetic  vasoconstrictor 
nerves  to  various  organs,  including  the  thyreoid. 

This  leaves  unexplained  the  autoprotective  pro- 
cess itself.  I  must,  in  this  connection,  venture  the 
opinion  that  the  prevailing-  theories  of  immunity  are 

'The  placing  of  animals  in  the  heated  chamber  to  determine  the 
influence  of  high  temperatures  on  the  corpuscles  is  a  useless  and 
misleading  expcrimeiil,  since  the  proteolytic  ferment,  the  active  agent 
in  the  process,  is  not  increased.  S. 


not  proving  as  fruitful  in  the  practical  field  as  they 
would  if  they  were  less  complex  and  less  burdened 
with  problematic  factors.  We  need  a  simplified, 
clearly  defined,  process,  whose  agents  can  be  traced 
to  their  source,  and  whose  workings  can  readily  be 
discerned  and  governed  by  the  practitioner.  The 
researches  reviewed  herein,  embody,  it  seems  to  me, 
the  main  features  of  such  a  process,  while  bringing 
into  action  those  agents  which  the  painstaking  la- 
bors of  many  investigators  have  shown  actually  to 
take  part  in  the  defensive  function. 

As  a  summary  of  the  simplified  conception  I  sub- 
mit involves  factors  I  have  not  described  in  detail, 
I  will  merely  mention  them  here,  referring  you  to 
previous  writings  for  the  evidence.  In  brief,  these 
factors  are  i,  that  certain  leucocytes  (the  finely 
granular  oxyphiles)  secrete  in  the  blood  their  nu- 
cleoprotcid granulations,  the  phosphorus  of  which, 
when  oxidized,  liberates  heat ;  and  2,  that  the  final 
bacteriolytic  or  antitoxic  agent  (complement  or 
phagocytic  cytase)  is,  in  keeping  with  prevailing 
teachings,  a  trypsinlike  ferment  whose  activity  is 
increased  by  heat.  These  features  completing  the 
needs  of  the  defensive  process,  we  may  proceed  to 
summarize  it. 

A  Simplified  Theory  of  Immunity. 

There  occurs,  at  first,  what  might  be  termed  the 
"preparatory"  stage,  the  purpose  of  which  is  to 
increase  the  defensive  constituents  of  t^e  blood  and 
other  body  fluids.  This  is  brought  about  as  follows : 
The  toxic  (certain  toxines,  wastes,  drugs,  etc.) 
excites  the  immunizing  centre.  This  centre  in  turn 
stimulates  the  thyreoparathyreoid  glands  and  adre- 
nals, thus  causing  them  to  supply  the  blood  (and  to 
a  certain  extent  the  lymph  and  serous  fluids)  with 
an  excess  of  thyreoiodase  and  adrenoxidase.  Meta- 
bolism being  enhanced  in  all  tissues  by  these  sub- 
stances, the  pancreas  also  secretes  an  excess  of  tryp- 
sic ferment,''  while  the  leucocytogenic  tissues  (bone 
marrow,  lymph  glands,  etc.)  produce  an  increased 
number  of  leucocytes,  mainly  finely  granular  oxy- 
philes and  phagocytes.  The  blood  and  other  body 
fluids  being  now  provided  with  all  the  active  agents 
of  the  defensive  mechanism  the  process  itself  is 
started.    It  is  briefly,  as  follows : 

The  thyreoidase  {opsonin,  agglutinin)  sensitizes 
and  softens  the  pathogenic  agent  while  the  adrenox- 
idase {amboceptor)  oxidizes  the  phosphorus  of  the 
nucleoprotcid  granulations,  liberating  heat;  the  ac- 
tivity of  the  trypsic  ferments  {plasmatic  and  phago- 
cytic complement)  being  correspondingly  increased, 
the  pathogenic  agent  is  converted  into  benign  and 
eliminable  products. 

Concluding  Remarks. 

Such  are  the  facts  which  have  led  me  to  believe 
that  the  human  organism  is  supplied  with  an  auto- 
protective mechanism.  Its  functions,  I  may  add, 
harmonize  with  the  views  of  the  modern  biochemist 
who  has  found  that  increased  metabolism  is  a  char- 
acteristic of  the  febrile  process  ;  they  also  coincide 
with  the  observations  of  the  bacteriologist  that  while 
most  pathogenic  bacteria  thrive  at  the  normal  tcm- 

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


February  27,  1909.) 


SAj'oUS:  Ab'TOPROTECTIVE  MECHANISM. 


435 


perature  of  the  body,  they  promptly  die  when  it  is 
raised  several  degrees.  They  account  for  the  teach- 
ing of  clinical  experience  that  a  higher  mortality 
occurs  in  apyretic  cases  than  among  those  in  which 
the  febrile  process  had  been  active.  They  explain 
the  harmful  influence  of  hyperpyrexia,  since  excess- 
ive immunizing  activity  means  proteolytic  destruc- 
tions of  the  blood  cells  (haemolysis)  and  even  of 
tissue  cells  (autolysis)  besides  the  pathogenic  agents 
themselves. 

In  the  practical  field,  personal  experience  sus- 
tained by  that  of  colleagues  who  have  carefully  stud- 
ied my  doctrines,  has  shown  clearly  that  these  em- 
body the  lever  through  which  we  can  overcome  in- 
fections. We  need  only  analyze  the  beneficial  ac- 
tion of  vaccine  therapy,  of  antitoxine,  of  drugs  such 
as  mercury,  the  iodides  and  other  so  called  '"altera- 
tives" to  recognize  that  their  tendency,  in  therapeu- 
tic (nontoxic)  doses,  is  to  raise  the  temperature — 
proof  that  the  immunizing  process  is  active.  Here 
a  warning  imposes  itself,  however,  for,  as  stated 
above,  this  process  may  surpass  salutary  bounds,  and 
destroy  blood  and  tissue  cells.  This  affords  clues  to 
the  pathogenesis  of  many  admittedly  obscure  dis- 
eases. Trace  with  me,  if  you  please,  the  genesis 
of  arteriosclerosis,  endocarditis,  hepatic  cirrhosis, 
acute  yellow  atrophy  of  the  liver,  acute  chorea,  acute 
rheumatism,  and  many  other  disorders,  and  you 
will  clearly  discern  the  pernicious  influence  of  an 
•excessive  defensive  reaction.  Again,  the  W'idal  test, 
in  view  of  the  thyreoidal  origin  of  agglutinin,  finds 
its  normal  explanation ;  does  not  the  free  production 
of  antibodies  this  indicates,  account  for  the  relatively 
low  mortality  Tof  that  disease  ?  Does  it  not  explain 
also  the  serodiagnostic  and  seroprognostic  tests  of 
Arloing  and  Coumont  in  tuberculosis?  Agglutina- 
tion is  deemed  by  these  investigators  an  index  of  the 
defensive  power  of  the  organism  in  this  disease. 
Does  this  not  suggest — agglutinin  and  opsonin  be- 
ing identical — a  simpler  and  more  exact  opsonic 
index  than  that  now  available  for  all  diseases? 

These  are  but  a  few  of  the  many  instances  in 
which  the  elementary  conceptions  submitted  this 
evening  may,  it  seems  to  me,  prove  fruitful. 

Bibliography. 

T.  CEiivres  mcdkalcs  d'Hippocrate.  Ed.  Foes,  ii.  p.  195, 
1801. 

2.  Sajous.  The  Inteinal  Secretions  and  the  Principles 
of  Medicine,  i,  1903. 

3.  Paul  Bert.    C.  r.  de  I'Acad.  des  sci.,  October  28,  1878. 

4.  Setschenow  and  Holmgren,  cited  by  Ludwig.  Wiener 
med.  Jahrb.,  twenty-first  year,  i,  p.  145,  1865. 

5.  Ziintz.    Hermann's  Handbuch,  iv,  part  2,  p.  43,  1882. 

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19.  Aulde.    British  Medical  Journal,  May  4,  1894. 

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23.  Biedl.  Archiv  f.  d.  ges.  Physiol.,  Ixvii,  Part  9-10, 
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24.  Langlois.  Arch,  de  physiol.  norm,  et  pathol.,  ix,  p. 
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25.  Dreyer.  American  Journal  of  Physiology,  ii,  p.  203, 
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26.  Salvioli  and  Pizzolini.  Gazetta  degli  osped.,  March 
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27.  Gamgee.  Schafer's  Textbook  of  Physiology,  i,  p. 
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28.  Gamgee.    Ibid.,  p.  207,  1898. 

29.  Gamgee.    Ibid.,  p.  206,  1898. 

30.  Vulpian.  C.  r.  de  I'Acad.  des  sci.  de  Paris,  Septem- 
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31.  Gautier.    Chimie  biologique,  p.  355,  1892. 

32.  Moore.   Journal  of  Physiology,  xvii,  p.  xiv,  1894-95. 

33.  Moore  and  Purinton.  American  Journal  of  Physiol- 
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34.  Cybulski.    Gazeta  Lekarska,  March  23,  1895. 

35.  Moore.    Loc.  cif. 

36.  Mulon.    Personal  Communication. 

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38.  Schmiedeberg.  Archiv  f.  exper.  Path.  u.  Pharm.,  vi, 
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39.  Jaquet,  cited  by  Salkowski.  Archiv  f.  path.  Anat., 
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40.  Abelous  and  Biarnes.  Arch,  dc  physiol,  norm,  et 
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41.  Poehl.    Indian  Lancet,  May  22.  1904. 

42.  Jolles.  Miinch.  med.  H  Oih.,  November  22,  1904, 
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43.  Gamgee.   Loc.  cit,  i.,  p.  189,  1898. 

44.  Louis  Elsberg.  Annals  of  the  iV.  Y.  Acad,  of  Sci., 
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45.  Hirschfeld.  Virchow's  Archiv.,  clxvi,  part  2,  p.  195, 
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46.  Brockbank.   Med.  Chronicle,  March,  1908. 

47.  Determann.  Deut.  Archiv  f.  klin.  Med.,  Ixi,  part  4, 
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48.  Sajous.   Loc.  cit.,  i,  p.  715,  1903. 

49.  Litten.  Deut.  med.  IVoch..  November  2,  1899, 
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50.  Stengel,  White,  and  Pepper.  Amer.  Jour.  Med.  Sci., 
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51.  Quoted  by  L.  F.  Barker.  New  York  Medical  Jour- 
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52.  Leonard  Hill.    Textbook  of  Chemistry,  p.  374,  1903. 

53.  Chittenden  and  Albro.  Amer.  Jour,  of  Physiol,  ii, 
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54-  Morner,  Brandl,  and  L.  PfeifTer.  Cited  by  Ham- 
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55.  Mencki  and  Berdez.  Ibid. 

56.  Walter  Jones.    Amer.  Jour,  of  Physiol,  ii,  p.  380 

1899- 

57.  Abel  and  Davis.  Jour,  of  Exper.  Med.,  i,  p.  381, 
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58.  Boinet.    Marseille  med.,  April  15,  1896. 

59.  Miihlmann.    Deut.  med.  Woch.,  No.  26,  p.  409,  1896. 

60.  Oliver  and  Schafer.  Jour,  of  Physiol,  xviii,  p.  230, 
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61.  Reichert.    Univ.  of  Penna.  Med.  Bull,  April,  1901. 

62.  Morel.    Le  Progres  medical,  August  3,  1903. 

63.  Lepine.    La  Semaine  medicate,  February  18.  1903. 

64.  Sajous.    Loc.  cit..  ii,  p.  828,  1907. 

65.  Sajous.    Ihid,  p.  822. 

66.  Lazarus  Barlow.  Manual  of  General  Pathology, 
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436 


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[New  York 
Medical  Journau 


67.    Fredericq.   Arch,  dc  bioL,  iii,  p.  747,  1882. 

6S.    Corin  and  van  Beneden.    Ibid,  vii,  p.  265,  1889. 

69.  Pembrey.  Schafer's  Te.vtbook  of  Physiology,  i,  p. 
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70.  Goltz.   Arch.  f.  d.  ges.  Physiol,  li,  p.  570,  1892. 

71.  Schreiber.   Ibid.,  viii,  p.  576. 

72.  Reicliert.  Joiir.  Amer.  Med.  Assoc.,  January  18, 
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73.  Ott.    Therap.  Gas.,  June  15,  1903. 

74.  Tangl.    Cited  by  Ott.  Ibid. 

75.  Sakowitsch.    Neurol.  Centralbl.,  xvi,  p.  520,  1897. 

76.  Schafer.   Loc.  cit.,  ii,  p.  717. 

77.  Herring.  Quarterly  Jour,  of  Exp.  Physiol,  i,  No. 
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78.  Ramon  y  Cajal.  Anales  de  la  Soc.  espanola  de  hist, 
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79.  Joris.  Mem.  Couron.  de  I'Acad.  Roy.  de  Belgique, 
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80.  Gentes.    C.  r.  de  la  Soc.  de  bioL,  Iv,  p.  1560,  1903. 

81.  Andriezen.  British  Medical  Journal,  January  13, 
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82.  Schafer  and  Herring.  Philos.  Transactions,  cxcix, 
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83.  Marinesco.  Bull,  de  la  Soc.  de  bioL,  June  4,  1892, 
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84.  Vassale  and  Sacchi.  Arch.  ital.  de  bioL,  xxii,  p.  123, 
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85.  Masay.  Arch,  de  la  Soc.  roy.  de  sci.  med.  et  nat.  de 
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86.  Andriezen.    Loc.  cit. 

87.  Paulesco.  Jour,  de  physiol.  et  de  path,  gen..  No.  3, 
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88.  Pirrone.    Riforina  niedica,  February  25,  1903. 

89.  Thaon.    L'Hypophyse,  p.  90,  1907. 

90.  Caselli.  Studii  anat.  e  sperim.  sulla  fisio-pat.  della 
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91.  Pirrone.   Loc.  cit. 

92.  Masay.    Loc.  cit. 

93.  Fuchs.    Wiener  med.  Woch.,  February  8,  1903. 

94.  Harlow  Brooks.  Archives  of  Neurol,  and  Psychol., 
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95.  Cyon.    Arch,  de  physiol.,  x,  p.  618,  1898. 

96.  Masay.    Loc.  cit. 

97.  Langley.  Hill's  Recent  Advances  in  Physiology,  p. 
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98.  Schafer.    Textbook  of  Physioloby,  i,  p.  957,  1898. 

99.  Reid  Hunt.   Amer.  Jour,  of  Physiol.,  v,  p.  7,  1901. 

100.  Oliver  and  Schafer.  Jour,  of  Physiol.,  xvi,  p.  I, 
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lof.  Strehl  and  Weiss.  PAiiger's  Archiv,  Ixxxvi,  p.  107, 
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102.  Blum.  Deut.  Archiv.  f.  Med.,  Ixxi,  Nos.  2  u.  3,  p. 
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103.  Croftan.    American  Medicine,  January  18,  1902. 

104.  Metzger.   Miinch.  med.  Woch.,  xlix,  p.  478,  1902. 

105.  Herter  and  Wakeman.  Amer.  Jour.  Med.  Sci., 
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106.  Kauffmann.    Arch,  de  physiol.,  viii,  p.  150,  1896. 

107.  Loeb.    Centralbl.  f.  inn.  Med.,  September  3,  1898. 

108.  Borchardt.    Zeit.  f.  klin.  Med.,  Ixvi,  No.  4,  1908. 

109.  Sajous.   Loc.  cit.,  i,  p.  366,  1903. 

110.  Launoi?  and  Roy.    C.  r.  de  la  Soc.  de  biol.,  Iv,  p. 
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111.  Pavy.    Proc.  Royal  Soc.  of  London,  x,  p.  27,  1859. 

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113.  Ott  and  Scott.    Jour,  of  Exper.  Med.,  November, 
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114.  Caselli.   Loc.  cit. 

115.  Bruck  and  Giinther.    Arch.  f.  d.  gcs.  Physiol.  iii 
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116   Tscheschichin.     Arch.  f.  Anat.,  Physiol.  u.  wis- 
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122.  Langley.    Schafer's  Textbook  of  Physiology,  ii,  p. 
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123.  Bunch.    Jour,  of  Physiol.  xxiv,  p.  72,  1899. 


124.  Jacobi.  Arch.  f.  exper.  Path.  it.  Pharmakol,  xxix, 
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125.  Jacobi.  Ibid. 

126.  Goltz  and  Evvald.  Archiv  f.  d.  ges.  Physiol.  Ixiii, 
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127.  Ott.    Textbook  of  Physiology,  p.  348,  1904. 

128.  Biedl.  Arch.  f.  d.  ges.  Physiol,  Ixvii,  No.  9-10.  p. 
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129.  Dreycr.   Amer.  Jour,  of  Physiol,  ii,  p.  203,  1899. 

130.  Laffont.  Cited  by  Laulaine.  Elements  de  physi- 
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131.  Kauffmann.    C.  r.  de  la  Soc.  de  biol,  p.  284,  1894. 

132.  Mayer.   Arch.  gen.  de  med.,  July  17,  1906. 

133.  Rogowitsch.  Ziegler's  Beitrdgc  c.  pathol.  .Anat., 
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134.  Stieda.    Ibid.,  vii,  p.  537,  1890. 

135.  Schonemann.  Virchoiu's  Archiv,  cxxix,  p.  310,  1892. 

136.  Notkin.  Wiener  med.  Woch.,  xlv,  pp.  824  u.  872, 
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137.  White  and  Davis.  Cited  by  Halliburton.  Practi- 
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138.  Cited  by  Moriat  and  Doyon.  Traite  de  physiolo- 
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139.  Milroy  and  Malcolin.  Jour,  of  Physiol,  xxv,  p. 
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140.  Bail,  Stokes,  and  Wegefarth.  Bull  Johns  Hopkins 
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141.  Sangree.    Phila.  Med.  Jour.,  March  12,  1898. 

142.  Biondi.    Berl.  klin.  Woch..  xxv,  p.  954.  1888. 

143.  Zielinska.    Virchow's  Archiv,  cxxxvi,  p.  170,  1894. 

144.  Vassale  and  de  Brazza.  Arch.  ital.  di  biotogia, 
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145.  Welsh.    Jour,  of  Anat.  and  Physiol,  April,  1898. 

146.  Capobianco  and  Mazziato.  Giorn.  Int.  de  Science, 
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147.  Pembrey.  HiWs  Recent  Advances  in  Pliysiology, 
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148.  Gley.    La  Presse  medicate.  January  12,  1898. 

149.  Nothnagel  and  Rossbach.  Thira'peutique,  p.  261, 
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150.  Gley.    La  Seniaine  medicate,  May  25,  1898. 

151.  Bourcet.  Cited  by  Morat  and  Doyon.  Traite  de 
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152.  Justus.    Virchow's  Archiv.  clxxvi,  p.  i,  1904. 

153.  Nolf.  Annates  de  ITnst.  Pasteur,  xiv,  pp.  297,  492, 
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154.  Savtchenko.    Ibid.,  xvi,  p.  106,  1902. 

155.  Denys  and  Leclef.   La  Cellule,  xi,  p.  198,  1895. 

156.  Barratt.  Proc.  Royal  Soc.  of  I^ondon,  Ixxvi.  p. 
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157.  Briscoe.   London  Lancet,  September  7,  1907. 

158.  Fassin.  Cited  by  Marbe.  C.  r.  de  la  Soc.  de  biolo- 
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159.  Marbe.  Ibid. 

160.  Sajous.    Loc.  cit.,  ii.  pp.  1093,  1139,  1907. 

161.  Hektoen.    Jour,  of  Infect.  Dis.,  iii,  p.  438,  1906. 

162.  Hektoen.    Ibid.,  i,  p.  102.  1906. 

163.  Baldwin.    Nezv  York  Medical  Journal,  June  27, 
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164.  Bulloch  and  Atkins.    Proc.  Royal  Soc.  of  London, 
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165.  Wassermann.    Immune  Sera,  Bolduan's  Transla- 
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166.  chard  and  Bensaude.    C.  r.  de  I'Acad.  des  Sci., 
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167.  Widal  and  Sicard.    La  Semaine  medicate,  Septem- 
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16S.    Jemma.    Centralbl.  f.  inn.  Med.,  January  23,  1897. 

169.  Nolf.    Ann.  de  I'Inst.  Pasteur,  May,  T900. 

170.  Klein.    Wiener  klin.  Woch.,  April  17,  1902. 

17T.    Ruffcr  and  Crendiropoulo.    British  Medical  Jour- 
nal, April  5,  1902. 

172.  Ballet  and  F.nriquez.    Cited  by  Popoff.    Arch.  gen. 
de  wed..  October.  1899. 

173.  Rourneville.   Arch,  de  neural.  September,  1896. 

174.  Shattuck.    Boston  .Med.  and  Surtr.  Jour..  June  30, 
1904. 

175.  I.orand.    Lancet.  November  9,  1907. 

176.  Tliiele  and  Nchring.    Zeif.  f.  klin.  Med..  xxx.  p. 
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177.  Bouchard.    C.  r.  dc  la  Soc.  de  biol,  pp.  227,  237, 
'•^73- 

178.  TTenrijean  and  Corin.    Arch,  dc  pharmacodyn.,  U, 
1896. 


February  27,  1909.] 


HARROWER:  ROUTINE  URINARY  EXAMINATIONS. 


437 


179.    Wood.    ThcrafMs.  Thirteenth  Edition,  p.  499, 

'^80.    Cushny.    Pluirmacology  and  Therapeutics,  Fourth 

Edition,  p.  514.  1906-  ,  ...  . 

181.    Magnus-Levy.    Zcit  f.  klin.  Med.,  .xxxui,  p.  269, 

'^?82    Lorrain- Smith.   Jour,  of  Physiol.,  xvi,  p.  378,  1894- 
183    Rouxeau.   Arch,  de  physiol.  xxix,  p.  136,  1897- 

184.  Moussu.    C.  r.  de  la  Soc.  de  bid.,  p.  772,  1903. 

185.  JeandeHze.  Insiiifisancc  thyroidienne  et  parathy- 
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186.  Hirschlaff.    Zeit.  f.  klin.  Med.,  xxxvi,  No.  3-4.  S. 

200,    1898-99-  .       .        •,  O  Q 

187.  Notthaft.    Centralbl.  f.  inn.  Med.,  April  9.  1898. 
188    Telford  Smith.   Lancet,  October  7,  1897- 

189.    Henrijean  and  Corin.    Loc.  at. 

TOO    Handfield  Jones.   Cited  by  Wood.    Loc.  cit. 

Sfholtz.   Centralbl.  f.  inn.  Med.,  xvi,  pp.  1041,  1069, 

'^92.    Pouchet.   BulL  gen.  de  therap.,  September  15,  1905. 
193.    Chittenden.     Trans.   Congress  Amer.   Phys.  and 

^T£''  Coppe?'  d'Ophthal,  December  1900. 

195.    Cyon.    Arch,  de  physiol.,  X,  p.  618,  im ... 
i§>.    Schondorff.    Arch.  f.  d.  ges.  Physiol.,  Ixiii,  p.  423, 

1896;  Ixxii,  p.  395.  1897. 

197-  Justus.  Loc.  cit.  00- 
198.  Wilson.  Inorganic  Chemistry  p.  284,  i897- 
199    Roos.   Munch,  wed.  Woch.,  No.  47,  P-  "57,  1896. 

200.  Cited  by  Chittenden.    Loc.  cit.,  p.  98. 

201.  Chittenden.   Loc.  cit  p.  99-  ...  ,   ^  „ 

202.  Ponfick.    Zeit.  f.  klin.  Med.,  xxxviu,  Nos.  i,  2,  u. 

ioT*  Codd.   British  Medical  Journal,  May  5,  1895- 

204.  Sainton  and  Rathery.    C.  r.  de  la  Soc.  med.  des 

hopitaux.  May,  1908.  ,    ,^        ,    r         ;  Tr^K,-,,^,-^- 

205.  Murray.     Edinburgh  Medical  Journal,  February, 

^^206    Lancereau^x.   Lo  SmaiM^  m^diVa/f.  June  24  1896. 

207.  Magnus-Le^T•    British  Medical  Journal,  April  3, 

JQO3 

208.  Comte.    These  de  Lausanne,  1898.  „  ,  ... 

209.  Launois  and  Mulon.  Ann.  de  gynec.  et  dobstet., 
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210.  Lang.    Zeit.  f.  Geburts.  u.  Gynak.,  xl,  p.  34,  loog. 

211.  Thaon.   Loc.  cit.,  p.  li6.  ,         ■  ,       d  , 

212.  Jacques  Loeb.   Studies  in  General  Physwlogy,  Fart 

i,  p.  363,  1905- 

213.  Cajal.  Loc.  at. 

214.  Joris.    Loc.  cit. 

215.  Edinger.  Anatomy  of  the  Central  Nervous  System, 
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216.  Masay.  Ann.  de  la  Soc.  roy.  des  sci.  med  et  nat. 
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217.  Sajous.   Loc.  cit.,  ii,  p.  982,  1907. 

218.  Morat.  Physiology  of  the  Nervous  System,  byers  s 
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219.  Sakowitsch.    Loc.  cit. 

220.  Bruck  and  Giinther.    Loc.  cit. 

221.  Brodie,  Morat.  and  Doyon.  Loc.  cit.,  Article 
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222.  Julin.  Recherches  sur  I'organis.  des  ascides  sim- 
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223.  Lloyd  Andriezen.  British  Medical  Journal.  Jan- 
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224.  Ray  Lankester.  Article  Mollusca.  in  Encyclopccdia 
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225.  Peremeschko.  Virchow's  Archiv.  xxxviii,  p.  329, 
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226.  Miiller.  Jenaischc  Zeit.  f.  Naturn'..  vii,  p.  327, 
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227.  Cadiat.  Anatomie  ginerale.  cited  by  Guepin,  Tri- 
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228.  Gentes.   C.  r.  de  la  Soc.  de  biol..  Iv,  p.  100,  1903. 

229.  Boeke.    Auat.  Am.,  xx,  p.  17,  1902. 

230.  Gemelli.  Jour,  de  I'anat.  et  de  la  physiol. .  Fort>'- 
second  Year,  No.  i.  1906. 

231.  Willey.  Amphioxus  and  the  Ancestry  of  Verte- 
brates, p.  19,  1894. 

232.  Claude  Bernard.  Leqons  sur  les  proprietes  des  tis- 
SHS  rivants.  pp.  55-58,  1866. 


233.  Rene  Quinton.  Paris  Correspondent,  Lancet,  April 
16,  1904. 

234.  Macallum.  Trans.  Canadian  Institute,  p.  181, 
1903-4. 

235.  Bunge.  Physiological  and  Pathological  Chemistry, 
English  Translation  by  Starling,  pp,  loi,  102,  1902. 

236.  Loeb.    Pfliiger's  Archiv,  cvii,  p.  252,  1905. 

237.  Overton.   Ibid.,  cv,  p.  176,  1904. 

238.  Marinesco.   C.  r.  de  la  Soc.  de  biol.,  p.  509,  1892. 

239.  Vassale  and  Sacchi.    Arch.  ital.  di  biologia,  xxii,  p. 

133^  1895- 

240.  Masay.    Loc.  cit. 

241.  Schafer.    Textbook  of  Physiology,  i,  p.  946,  1898. 

242.  Williamson.    Obstetrics,  p.  703,  1903. 

243.  Grandin.  Grandin  and  Jarman's  Practical  Obstet- 
rics, p.  94,  Third  Edition,  1900. 

244.  Herter.  Jour,  of  Nerv.  and  Mental  Dis.,  February, 
1899. 

245.  Krainskj-.    Wiener  klin.  Woch.,  February  24,  1898. 

246.  Ceni.    Riv.  Sper.  di  Pren..  xxxi,  No.  ii,  1905. 

247.  Clark.    Med.  Nezis,  July  18,  1903. 

248.  Sawadowski.  Centralbl.  f.  d.  med.  Wissen.,  Twenty- 
sixth  Year,  No.  9,  p.  161,  1888. 

249.  Ott  and  Scott.  Jour,  of  Exper.  Med.,  November, 
1907. 

250.  Ott  and  Harris.    Therap.  Gaz.,  June  15,  1903. 
2043  W.xLNUT  Street. 


ROUTINE  URINARY  EXAMINATIONS. 
By  Hexrv  R.  Harrower,  M.  D., 
Chicago. 

That  the  examination  of  the  urine  is  a  procedure 
of  considerable  diagnostic  importance  cannot  be 
gainsaid.  The  physician  who  makes  it  a  regnlar 
practice  to  perform  a  complete  urinary  examination 
will  have  a  most  decided  advantage  over  his  profes- 
sional brother  who  is  readily  satisfied  with  just  the 
few  perfunctory  tests  performed  with  a  test  tube, 
some  nitric  acid,  and  Fehling's  solution. 

The  majority  of  the  medical  profession — the  aver- 
age general  practicians — are  rapidly  reaching  a  point 
in  their  experience  where  the  most  careful  and  com- 
plete diagnoses  are  absolutely  essential  to  their  pro- 
fessional success,  and  for  this  reason  I  believe  that 
the  rotitine  examination  of  the  urine  will  soon  be 
carried  out  by  every  progressive  practician,  no  mat- 
ter where  he  may  be  located,  whether  in  the  busy 
city  with  its  facilities  and  competition,  or  at  the 
country  crossroads  where  the  facilities  are  meagre 
and  there  is  little  competition,  or  none  at  all. 

In  this  particular  department  of  medicine — scien- 
tific laboratory  work — the  time  element  involved  un- 
doubtedly has  played  a  very  considerable  part  in 
preventing  the  average  man  from  carrying  out  these 
investigations  in  his  own  laboratory,  but  with  the 
progress  in  technique  and  the  simplification  of  the 
methods  in  vogue,  this  work  is  rapidly  becoming  a 
much  less  burdensome  matter  to  the  busy  man,  and 
the  time  now  required  for  the  complete  qualitative 
and  quantitative  urinary  examination  has  been  re- 
duced to  a  minimum. 

Of  course,  the  examiination  for  sugar  and  albumin 
will  always  hold  a  high  rank,  as  the  presence  of 
either  of  these  substances  in  the  urine  points  out 
definite  disturbances,  but  considerable  variation  is 
manifested  by  diflferent  laboratory  investigators  as 
to  the  relative  importance  of  the  various  quantitative 
estimations  of  the  normal  urinary  ingredients ;  at 
least  if  their  published  arguments  are  to  be  accept- 
ed. Thus,  some  men  think  that  the  estimation-  of 
the  urea  is  by  far  the  most  important  individual  test> 


438 


HARBRIDGE:  SUBSTITUTES  FOR  EYE  ENUCLEATIOX. 


[New  York 
AIedical  Journal. 


while  Others  place  much  confidence  in  the  estimation 
of  uric  acid.  Other  writers,  again,  hold  still  differ- 
ent notions. 

As  for  myself,  I  consider  the  accurate  estimation 
of  the  degree  of  urinary  acidity  of  paramount  im- 
portance, for,  so  far  as  my  experience  goes,  a  large 
proportion  of  disease  conditions,  both  organic  and 
functional,  are  always  associated  with  disturbance 
of  metabolic  processes  which  so  modify  the  clinical 
qualities  of  the  blood  that,  because  of  these  changes, 
the  urinary  acidity  is  markedly  increased. 

Unfortunately  this  test  is  rarely  carried  out  by  the 
majority  of  physicians.  A  perfunctory  test  with  the 
practically  useless  litmus  paper  is  about  as  far  as 
they  go,  and  it  must  be  admitted  that  the  value  of 
this  is  almost  nil. 

And,  yet,  the  quantitative  estimation  of  the  uri- 
nary acidity  is  a  comparatively  simple  matter  and 
gives  information  that  is  as  definite  as  it  is  valuable. 
The  variations  offer  a  very  good  guide  as  to  the 
metabolic  processes  in  the  individual. 

The  examination  of  a  large  number  of  specimens 
leads  me  to  believe  that  high  urinary  acidity  is  asso- 
ciated in  a  majority  of  cases  with  low  urea  output 
and  with  other  metabolic  disturbances,  possibly  of 
the  uric  acid  type,  but  not  necessarily  so. 

Again,  I  have  found  that  high  urinary  acidity  and 
indicanuria  quite  frequently  are  associated,  and  I  be- 
gin to  believe  that  this  high  acidity  is  due  to  the 
same  conditions  causing  the  presence  of  indican  and 
the  conjugate  sulphates.  At  all  events,  in  patients 
showing  excessively  acid  urine,  bacteriological  ex- 
amination of  the  faeces  in  a  majority  of  cases  dem- 
onstrates a  severe  infection  within  the  intestines  to- 
gether with  putrefaction  of  their  contents  and  the 
inevitably  resulting  autotoxaemia. 

Considerable  work  lias  been  done  during  the  last 
year  or  two  in  the  investigation  of  autointoxication 
as  to  its  cause  and  cure,  and  in  this  connection  Pro- 
fessor Eugene  S.  Talbot,  of  Chicago,  deserves  spe- 
cial mention.  Dr.  Talbot  has  definitely  proved  the 
relation  between  autointoxication  with  high  urinary 
acidity  and  certain  mouth  diseases — such  as  gingi- 
vitis with  pyorrhoea  alveolaris,  etc.,  and  his  method 
of  treating  these  conditions,  by  reducing  the  acidity 
of  the  blood,  if  I  may  so  call  it,  using  the  urinary 
acidity  as  the  index,  is  to  my  mind  a  decided  step 
along  the  line  of  progressive  medicine.  It  will  be 
found  that  those  remedies  that  reduce  urinary  acid- 
ity to  normal  distinctly  modify  many  aches,  pains, 
and  inconveniences  associated  with  a  high  degree  of 
acidity  of  the  body  fluids,  or,  more  correctly,  a  di- 
minution of  their  normal  alkalinity. 

Fortunately  the  quantitative  examination  of  the 
urine  as  to  the  amount  of  acid  present  has  been  made 
an  extremely  simple  matter,  requiring  as  it  does  only 
an  acidimeter  and  a  medicine  dropper  (see  my  de- 
scription of  A  Xcvv  Instrument  for  the  Estimation 
of  the  Urinary  Acidity  in  the  New  York  Medical 
Journal  of  January  2,  1909,  p.  24).  With  these  at 
hand  and  a  very  little  experience,  just  as  accurate 
work  may  be  done  by  any  careful  person  as  with  the 
burette  in  the  hands  of  an  expert. 

I  have  said  nothing  here  of  the  all  important  mi- 
croscopical examination,  which  should,  of  course,  be 
made  in  every  case. 

2806  North  Paulin.a  Street. 


THE  SUBSTITUTES  FOR  ENUCLEATION  OF 
THE  EYE.* 

By  D.  Forest  Harbridge,  M.  D., 
Philadelphia. 

What  I  have  to  say  this  afternoon,  in  regard  to 
various  operations,  for  the  production  of  a  suitable 
stump  for  giving  prominence  and  a  certain  amount 
of  movement  to  an  artificial  eye  is  merely  a  resume 
of  a  series  of  twelve  operations  which  I  have  per- 
formed and  in  ivhich  I  have  been  able  to  follow  up 
all  the  patients  to  the  present  time.  While,  of 
course,  my  experience  is  perhaps  limited  and  many 
of  the  gentlemen  present  have  had  a  more  ample 
opportunity  for  studying  the  merits  of  these  various 
procedures,  still  I  thought  the  recital  of  my  experi- 
ence might  prove  of  interest  and  the  discussion 
bring  out  an  answer  to  the  question :  Why  are  not 
these  operations  more  frequently  performed? 

I  am  aware  that  a  certain  number  of  eye  sur- 
geons look  upon  the  placing  of  a  gold  sphere  or  any 
foreign  substance  in  the  orbit  as  unsurgical.  This 
and  the  fact  that  the  last  report  of  this  hospital 
showed  only  four  such  operations  out  of  160  enucle- 
ations, suggested  to  me  the  following  questions : 

1.  Are  these  operations  desirable  for  cosmetic 
purposes  ? 

2.  Does  the  percentage  of  successes  warrant  the 
time,  patience,  and  skill  necessary  to  obtain  good  re- 
sults and  the  increased  loss  of  time  on  the  part  of 
the  patient? 

3.  Can  as  good  or  better  results  be  obtained  by 
some  more  simple  procedure? 

4.  Does  the  reform  eye  of  Snellen  secure  the  end 
sought  for  in  performing  one  of  the  substitutes  for 
enucleation  ? 

Replying  to  the  first  question,  it  is  my  opinion 
that  it  is  as  much  the  duty  of  the  eye  surgeon  to  give 
full  recognition  to  the  cosmetic  effects  of  an  opera- 
tion, so  prominent  and  disfiguring  as  the  enucleation 
of  an  eye,  as  is  given  to  the  necessity  requiring  the 
removal  of  this  organ ;  patients  generally  are  quite 
sensitive  as  to  their  personal  appearance  in  this  mat- 
ter. Some  form  of  operation  which  affords  a  stump 
giving  prominence  and  movement  to  an  artificial  eye 
does  not  only  improve  cosmetic  effects,  but  is  a  dis- 
tinct advantage  both  mentally  and  physically  to  the 
patient. 

To  the  second  question,  my  reply  is  most  em- 
phatically in  the  affirmative.  The  percentage  of  fail- 
ures to  retain  a  sphere  is  variously  given  from  eight 
to  seventeen  and  even  higher,  and  I  believe  Pro- 
fessor Haab  states  that  eventually  all  are  extruded. 
This  latter  statement  is  not  borne  out  by  my  per- 
sonal observation  of  cases  from  five  months'  to  four 
years'  duration ;  admitting  an  occasional  failure, 
nothing  is  lost,  but,  on  the  contrary,  a  distinct  ad- 
vantage is  gained,  for  the  sutured  muscles  and  tis- 
sues in  themselves  afford  a  very  admirable  stump,  as 
must  be  known  to  those  who  have  had  failure  of  re- 
tention of  the  sphere. 

To  the  third  question,  I  can  only  say,  my  personal 
experience  has  been  limited  to  the  use  of  a  gold 
sphere  in  Tenon's  capsule,  and  the  sclera  and  ab- 
scission of  the  cornea. 

To  the  fourth  question,  in  many  cases,  undoubt- 

•Read  at  a  meetings  of  the  Wills  Hospital  Oplitlialniological  Society. 


■February  27,  1909.] 


OUR  READERS'  DISCUSSIONS. 


439 


edly  the  reform  eye  of  Snellin  has  distinct  advan- 
tages in  giving  prominence,  but  yet  it  is  not  always 
as  complete  as  might  be  desired,  and  besides  it  is 
most  often  lacking  in  movement. 

I,  sometimes,  think  that  one  of  the  most  potent, 
deterring  factors  accounting  for  the  eye  surgeon  not 
using  one  of  these  various  operations  more  fre- 
quently is  largely  due  to  the  great  amount  of  time 
and  patience  necessary  in  the  details  of  such  opera- 
tions to  insure  success. 

Many  substances  have  been  suggested  and  used  by 
different  operators :  Dr.  Ramsey,  of  Glasgow,  at 
the  time  of  his  visit  to  this  hospital  described  in 
great  detail  a  method  for  using  paraffin  wax  as  a 
substitute  for  the  vitreous,  and  recently  a  French 
eye  surgeon  introduced  the  use  of  a  young  rabbit's 
eye,  importance  being  attached  to  placing  the  cornea 
posteriorly ;  others  endorsed  the  use  of  gold  and 
glass  spheres.  Paraffin  does  not  appeal  to  me,  ow- 
ing to  the  apparent  difficulty  in  handling  the  sub- 
stance and  perhaps  the  slight  possibility  of  embolism 
resulting.  As  for  the  use  of  a  rabbit's  eye,  not  only 
is  it  inconvenient  to  secure  a  fresh  eye  at  short  no- 
tice, but  I  doubt  whether  success  is  as  well  insured. 
My  own  experience  in  substituting  a  foreign  sub- 
stance for  the  vitreous  has  been  confined  solely  to 
the  use  of  gold  spheres,  which  I  have  found  ver\- 
satisfactory.  They  are  light,  durable,  and  not  affect- 
ed by  the  fluids  of  the  body,  can  be  rendered  abso- 
lutely sterile,  and  in  my  opinion  answer  every  indi- 
cation. What  I  believe  to  be  two  very  essential  fea- 
tures necessary  for  the  success  of  these  operations 
are  absolute  cleanliness  and  stopping  of  all  haemor- 
rhage. As  these  operations  are  only  applicable  in 
certain  cases,  particularly  if  one  desires  to  insure 
success,  it  requires  judgment  in  the  selection  of 
cases,  and  yet,  as  I  have  already  stated,  I  believe 
even  if  failure  ensues  the  resulting  stump  of  united 
muscles  and  tissue  is  better  than  a  simple  enuclea- 
tion. 

If  I  decide  upon  implanting  the  sphere  in  Tenon's 
capsule  I  first  dissect  the  conjunctiva  well  back  from 
the  limbus,  separating  the  recti  muscles,  one  after 
another,  from^  their  insertion  in  the  sclera,  and  pass 
a  suture  through  both  muscle  and  capsule.  •  I  then 
complete  the  enucleation,  following  which  I  am  most 
careful  in  stopping  all  haemorrhage  and  oozing.  In 
this  I  am  frequently  assisted  by  the  use  of  very  hot 
water.  When  perfectly  dry  the  sphere  is  inserted 
and  the  superior  and  inferior  suture  holding  muscle 
and  capsule  are  tied,  followed  by  the  external  and 
internal  muscles  and  capsule,  and  over  this  I  suture 
the  conjunctiva  in  the  horizontal  meridian.  By  most 
authors,  I  believe,  we  are  instructed  to  unite  oppos- 
ing muscles  first,  and  then  bring  the  capsule  and 
conjunctiva  over  in  front,  but  I  am  inclined  to  be- 
lieve this  not  only  makes  the  operation  a  little  more 
difficult,  but  also  affords  a  greater  tendency  for  the 
muscles  to  force  the  sphere  to  gravitate  to  one  or  the 
other  side.  If  I  was  asked  a  dogmatic  statement  as 
to  my  views  regarding  the  usefulness  of  a  Fox  con- 
former  in  preventing  this  occurrence,  I  would  give 
as  my  experience  that  it  is  of  doubtful  utility. 

If  I  decide  upon  implanting  the  sphere  in  the 
sclera  (Mules's  operation)  I  exercise  the  greatest 
care  and  patience  in  removing  every  vestige  of  the 
structures  within  the  scleral  cavity,  and  stopping  all 


haemorrhage ;  this  is  tedious,  takes  time,  and  cannot 
be  done  hastily,  but  I  believe  is  the  true  secret  of 
success.  Reaction  following  these  operations  has 
always  been  greatest  in  the  Mules  operation,  and 
when  marked  I  immediately  remove  the  dressings 
and  apply  ice  compresses  constantly. 

I  have  been  able  to  follow  twelve  cases,  ranging 
from  five  months  to  four  years  since  the  operation. 
They  are  as  follows :  Five  Mules  operations,  all 
with  good  results.  Two  cases  in  which  abscission 
of  the  cornea  was  done,  retaining  the  healthy  vitre- 
ous, one  with  good  results,  and  one  in  which  sym- 
pathetic irritation  developed  in  the  fellow  eye.  In 
this  case  I  promptly  enucleated  the  stump  and  treat- 
ed the  patient  with  salicylates  and  mercurial  inunc- 
tions. Five  cases  of  implantation  of  the  sphere,  in 
Tenon's  capsule,  with  three  successes  and  two  fail- 
ures, and  yet  these  failures  had  extenuating  circum- 
stances connected  with  them.  The  first,  a  colored 
man,  who  was  in  mortal  fear  of  a  hospital,  in  a 
semidelirious  or  devilish  moment  (I  suspect  the  lat- 
ter) removed  the  dressings  and  burrowed  his  head 
in  the  pillow,  forcing  the  sphere  out.  The  second 
case  I  attribute  to  especially  poor  judgment  in  the 
selection  of  the  case,  perhaps  due  to  a  too  zealous 
desire  for  a  good  cosmetic  effect.  It  was  a  case  of 
panophthalmitis  following  a  traumatism,  due  to  a 
piece  of  steel  in  the  vitreous ;  the  muscle  and  con- 
junctival stitches  sloughed,  and  the  sphere  extruded. 
258  South  Fifteenth  Street. 

 ^  


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion   in   this  department  are  an 
nounced  at  frequent   intervals.    So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXIII . — How  do  you  treat  acute  dysentery?  {Closed 
February  15,  1909.) 

LXXXIV. — How  do  you  use  alcohol  therapeutically? 
{Answers  due  not  later  than  March  15,  1909.) 

LXXXV. — Apart  from  an  operation,  how  do  you  treat 
disease  of  the  vermiform  appendix?  (Answers  due  not 
later  than  April  15,  1909.) 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  required)  that  the  anszvers  be  short;  if  practica- 
ble no  one  answer  to  contain  more  than  six  hundred 
words. 

All  persons  zirill  be  entitled  to  compete  for  the  prize, 
zvhether  subscribers  or  not.  This  prize  will  not  be  awarded 
to  any  one  person  more  than  once  within  one  year.  Every 
answer  must  be  accompanied  by  the  writer's  full  name  and 
address,  both  of  which  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal. 
Our  readers  are  asked  to  suggest  topics  for  discussion. 

The  prize  of  $2$  for  the  best  essay  submitted  in  answer 
to  question  LXXXII  has  been  awarded  to  Dr.  J.  Lytle 
Moore,  of  Toledo,  O.,  whose  article  appears  below. 


PRIZE  QUESTION  LXXXII. 
THE  TREATMENT  OF  CHRONIC  LEAD  POISON- 
ING. 

By  J.  Lytle  Moore,  M.  D., 
Toledo,  O. 

In  clinical  and  economical  importance,  chronic 
lead  poisoning  or  saturnism  overshadows  all  other 
chronic  intoxications,  except  that  due  to  alcohol. 


440 


OUR  READERS'  DISCUSSIONS. 


IXew  York 
M  EuiCAL  Journal. 


This  condition  was  known  to  some  of  the  earlier 
Greek,  Roman,  and  Arabian  writers. 

Chronic  lead  poisoning  results  from  the  slow  ab- 
sorption of  lead.  i\s  has  been  suggested,  it  takes 
place  in  one  of  three  ways :  Either  it  is  taken  inter- 
nally as  in  contaminated  water ;  or  it  is  absorbed 
through  the  skin — for  instance  from  pigments,  hair 
dyes,  or  surgical  dressings  containing  it ;  or  it  is 
inhaled  by  those  working  in  lead  plants,  painters, 
artists,  etc.  It  is  a  cumulative  poison,  but  accumu- 
lates slowly. 

The  treatment  of  lead  poisoning  naturally  divides 
itself  into  prophylaxis  and  the  treatment  of  the 
attack  after  it  has  developed. 

Prophylaxis.— "L^i  us  first  consider  those  who 
work  with  lead  in  some  way,  day  after  day.  Clean- 
liness is  by  far  the  most  important  point.  Work- 
ingmen  should  be  given  an  opportunity  to  keep 
themselves  clean,  and  then  required  to  do  so.  Many 
will  not  voluntarily  keep  themselves  clean.  Each 
man  should  take  a  bath  and  change  his  clothes  be- 
fore leaving  the  factory  at  night.  His  cleanliness 
ought  to  extend  even  to  his  finger  nails.  One  fac- 
tory where  the  danger  was  especially  great,  has 
eliminated  almost  all  cases  of  saturnism  by  facilities 
for  cleanliness,  and  giving  the  men  full  pay  for  the 
time  consumed  in  bathing. 

Laborers  should  occasionally  take  a  dose  of  mag- 
nesium sulphate  to  keep  the  bowels  open  and  to 
prevent  the  accumulation  of  lead  in  the  alimentary 
tract.  Sulphuric  acid  lemonade  is  highly  recom- 
mended as  a  preventative.  The  object  of  this  is  to 
form  an  insoluble  sulphate  of  lead.  The  laborers 
should  be  instructed  to  use  proteid  food  freely  at 
the  morning  and  noon  meals.  Milk  is  furnished 
free  in  some  factories.  This  also  acts  as  a  pre- 
ventative. 

Another  important  measure  is  exercise  in  the 
open  air.  This  increases  elimination  and  the  gen- 
eral resistance  of  the  body. 

People  handling  lead  should  take  special  precau- 
tions against  eating  in  the  workrooms,  and  they 
should  always  wash  their  hands  before  eating. 

Workers  should  be  transferred  from  time  to  time 
from  one  department  to  another,  and  from  inside  to 
outside  work  so  as'  to  equalize  the  exposure  to  the 
more  dangerous  parts  of  the  work. 

The  hygiene  and  construction  of  lead  plants 
should  be  regulated  by  law,  and  not  left  to  the 
philanthropy  and  knowledge  of  the  operator.  They 
should  have  efficient  forms  of  ventilation — high  ceil- 
ings, apparatus  for  the  exclusion  of  dust,  walls  and 
floors  should  be  of  such  construction  that  they  can 
be  easily  and  thoroughly  cleaned,  the  most  danger- 
ous parts  of  the  work  should  be  isolated,  there 
should  be  separate  eating  rooms,  exclusion  of 
women  and  children  from  the  more  dangerous  parts 
of  the  work,  etc.  T  might  mention  that  it  is  an 
advantage  for  men  to  wear  gloves,  and  a  moist 
towel  over  their  mouth  and  nose  when  at  work. 

When  poisoning  has  developed,  the  exclusion  of 
the  source  of  lead  is  the  most  imperative  necessity. 
If  the  individual  has  been  exposed  to  lead  by  his 
work,  a  change  of  occupation  must  be  insisted  upon. 
In  accidental  cases  it  is  often  a  very  difficult  and 
tedious  process  to  discover  the  source.    In  cases 


where  it  can  be  traced  to  the  using  of  water  which 
conies  through  lead  pipes,  the  water  should  be  al- 
lowed to  run  a  long  time  before  being  used — as  that 
which  stands  in  the  pipes  becomes  especially  laden 
— then  filtered  through  charcoal.  Or,  what  is  still 
better,  tlie  water  should  be  received  from  another 
source,  or  the  lead  pipes  replaced  by  others. 
_  Active  Treatment.— This  consists  in  the  elimina- 
tion of  the  lead  and  the  general  products  of  meta- 
bol  ism,  and  combating  the  general  and  local  symp- 
toms as  they  arise. 

Elimination. — The  first  thing  to  be  done  is  to  ex- 
pel the  contents  of  the  gastrointestinal  tract.  This 
is  best  done  by  means  of  saline  purges — those  which 
act  by  increasing  peristalsis  should  be  used  with 
caution.  In  addition  to  the  salines,  give  enemas 
containing  magnesium  su];)hate  and  glycerin.  Large 
oil  enemas  are  also  good.  In  severe  cases  it  is  ad- 
visable to  give  a  moderate  dose  of  morphine  before 
the  saline.  Witli  the  control  of  the  constipation,  the 
most  important  indication  for  treatment  is  met.  My 
aim  is  to  have  about  two  passages  a  day.  The  fol- 
lowing is  a  useful  prescription  : 

R    Magnesium  sulphate,   51; 

Diluted  sulpliuric  acid  5i; 

Water,  q.  s.  ad  Jiv. 

M.   Sig. :  A  tablespoonful  in  water. 

The  patient  should  drink  water  freely,  and  if 
there  is  insufficient  excretion  of  urine,  give  diu- 
retics. 

Potassium  iodide  is  the  drug  which  has  gained 
the  greatest  repute  in  these  cases.  It  increases  the 
general  elimination  by  its  alterative  efifect,  and 
forms  a  double  iodide  of  lead  and  potassium  with 
the  lead  in  the  tissues.  This  is  excreted  by  the 
kidneys.  This  should  not  be  given  during  the  very 
acute  stages,  as  the  liberation  of  lead  by  this  drug 
may  increase  the  symptoms,  so  its  effect  must  be 
watched  closely.  Five  to  ten  grains  should  be  given 
after  meals.  Hot  baths,  especially  sulphur  baths, 
are  a  very  material  aid  to  increase  the  elimination. 

Alum  given  in  doses  of  ten  to  twenty  grains  has 
had  a  reputation  of  having  a  curative  effect ;  I  do 
not  think  it  nearly  so  efficient  as  potassium  iodide. 

For  the  pain  use  hot  applications  to  the  abdomen, 
hot  baths,  and  hypodermics  of  atropine  or  pilocar- 
pine, avoiding  morphine  unless  the  pain  is  uncon- 
trollable by  these  methods,  as  it  reduces  the  elimina- 
tion of  the  lead  and  other  metabolic  products. 
Small  doses  of  chloroform  are  also  useful. 

The  cure  of  the  paralyses  takes  long  and  patient 
treatment.  It  comprises  the  general  principles  used 
in  managing  a  case  of  peripheral  neuritis.  The 
active  treatment  should  commence  only  after  the 
cessation  of  the  acute  process. 

Electrical  treatments  should  be  given  daily  for 
about  ten  or  fifteen  minutes.  The  positive  pole  of 
the  galvanic  current  is  connected  with  a  large 
sponge  electrode  placed  over  the  cervical  vertebrae, 
and  the  negative  sponge  is  applied  to  the  exterior 
muscles.  With  this  use  carefully  graduated  mas- 
sage and  passive  motion,  and  so  far  as  possible, 
slowly  increased  active  motion.  The  treatment 
must  not  be  discontinued  until  recovery,  or  all  im- 
provement has  stopped  for  a  couple  of  months. 

Cerebral  symptoms  must  be  handled  with  the  ut- 


February  27,  1909.] 


OUR  READERS'  DISCUSSIONS. 


441 


most  care.  Control  the  convulsions  and  delirium 
with  bromides,  chloral,  and  hyoscine,  using  mor- 
phine only  as  a  last  resort,  for  reasons  stated  be- 
fore. 

During  convalescence  insist  upon  plenty  of  fresh 
air,  sunshine,  and  a  generous  diet.  These  with 
bitter  tonics  are  usually  all  that  are  required. 

Arsenic  is  a  very  good  drug  in  the  anaemia — 
i/ioo  grain  after  meals,  continued  only  over  short 
periods. 

Alcohol  in  all  forms  ought  to  be  excluded  in  all 
cases,  both  during  the  prophylactic  and  active  treat- 
ment. 

235  Tenth  Street. 

Dr.  A.  F.  Stuart,  of  Portland,  Me.,  says: 

The  condition  arising  from  the  retention  and  dis- 
tribution of  lead  tipon  the  human  economy  demands 
from  every  practitioner  of  medicine  a  knowledge  of 
the  action  of  the  metal,  in  order  that  he  may  be  able 
to  combat  those  symptoms  which  arise  from  the 
mineral  during  its  deposition  in  the  body.  Lead  is 
a  cumulative  poison,  small  amounts  being  easily  ab- 
sorbed and  slowly  excreted.  Any  portion  of  the 
body  offers  it  an  avenue  of  admittance,  the  mucous 
membrane  of  the  digestive  tract,  so  closely  followed 
by  the  skin  being  its  chief  means  of  ingress.  Like 
many  other  substances  of  the  metal  kingdom  it  finds 
its  haven  of  rest  in  the  larger  organs,  whence  from 
it  gradually  ventures  to  mingle  with  the  cells  of  the 
muscle  and  nerve  tissue,  which,  under  its  action 
gradually  disintegrate,  giving  rise  to  that  condition 
known  as  chronic  plumbism  or  lead  poisoning. 

This  type  of  poison  is  characterized  by  a  gradual 
destruction  of  the  red  blood  cells,  and  a  resulting 
anaemia  profound  in  grade.  Gradually  the  lining  of 
the  vessel  walls  become  impregnated  with  the  me- 
tallic toxic  substance,  and  undergo  a  pathological 
change  eventually  resulting  in  fatty  degeneration  or 
else  in  arterial  fibrosis,  attended  by  increased  blood 
pressure.  Upon  the  nervous  tissue  the  metal  has 
an  affinity  for  the  periphreal  nerves,  although  the 
brain  centres  are  doubtless  involved.  This  affinity 
of  lead  for  the  peripheral  nerves  allows  of  the  con- 
dition so  commonly  seen  in  lead  colic  and  paralysis 
of  the  muscles ;  for  the  irritation  of  the  nerve  end- 
ings result  in  a  violent  contraction  of  the  muscle 
substance,  which  ultimately  become  paralyzed  and 
unable  to  respond  to  stimulation.  Outbursts  of  lead 
colic  are  no  doubt  due  to  an  increase  in  the  lead  ab- 
sorbed, and  agitating  to  increased  action  the  nerve 
endings  in  the  intestinal  muscles,  causing  a  violent 
contraction  of  the  same,  driving  the  blood  from  the 
vessels  controlled  by  the  splanchnics,  resulting  in 
the  higher  arterial  tension,  with  the  stronger  volume 
but  slower  pulse  so  characteristic  of  these  attacks, 
which  on  recovery  from,  leave  as  a  memento,  an  in- 
creased constipation  for  some  time  to  come. 

Turning  to  treatment  under  these  conditions  it  is 
readily  seen  that  the  methods  to  be  used  are  those 
which  include:  i,  Prophylactic  measure  ;  2,  the  elimi- 
nation of  the  toxic  material ;  3,  the  relief  of  pain  and 
other  symptoms,  due  to  the  agent ;  and  4,  last  but 
not  least  the  restoration  of  the  diseased  parts  to  their 
normal  tone  and  functions. 

Prophylactic  measure  constitutes  the  first  means 


to  be  employed  in  the  treatment  of  the  disease,  and 
the  patients  should  always  be  questioned  as  to  their 
occupation,  and  if  their  emplovment  is  one  that 
brings  them  in  contact  with  lead,  removal  from  its 
exposure  is  at  once  demanded.  Should  this  not  be 
the  case  then  the  interrogation  of  new  lead  water 
pipes,  of  cooking  dishes,  or  the  use  of  cosmetics  or 
hair  tonic  is  prompted,  and  their  use  discontinued  if 
found. 

Remedial  measures  consist  in  the  elimination  of 
the  metal  as  a  primary  treatment,  and  secondary  to 
this,  the  treatment  of  the  symptoms  as  seen  in  the 
anaemia  and  attending  constipation,  the  nephritis, 
and  the  local  manifestations  observed  in  the  colic, 
paralytic  affections,  and  athralgia. 

The  modes  of  elimination  that  I  have  found  most 
effective  are  the  use  of  the  hot  air  bath  and  the  in- 
testinal use  of  either  sodium  or  potassium  iodide, 
and  the  sulphate  of  sodium  or  magnesium.  The  ex- 
cretion of  lead  being  chiefly  through  the  alimentary 
tracts,  as  the  sulphates  serve  the  double  purpose 
of  converting  the  metal  into  one  of  its  most  in- 
soluble forms  that  of  a  sulphate,  and  at  the  samo 
time  relax  and  overcome  the  existing  constipation ; 
likewise  the  iodides  serve  a  double  duty,  as  the 
iodine  ion  acts  upon  the  bloodvessels  and  antag- 
onizes the  arteriosclerosis,  arresting  it  by  retarding 
the  development  of  the  increasing  fibrous  tissue. 
That  it  hastens  the  elimination  of  the  lead  may  be 
seen  by  an  analysis  of  the  urine,  but  increasing  doses 
are  needed,  as  it  seems  to  lose  its  efficiency  when 
given  for  a  material  time.  This  can  in  a  measure 
be  overcome  by  using  an  intravenous  injection,  us  ng 
one  of  the  veins  of  the  arm  under  aseptic  condi- 
tions. The  prescription  I  am  in  the  habit  of  using 
being, 

R     Sodium  iodide,   gr.  iii ; 

Water,   TIlxv. 

or 

R     Potassium  iodide,   gr.  iii; 

Water,   •  . . .  .TTl  xv. 

M. 

The  dose  being  much  smaller,  its  intensity  of  ac- 
tion greatly  increased  and  its  process  is  much  more 
decided.  Several  time  I  have  been  astonished  at 
its  value  ■jvhen  used  in  this  manner  after  witnessing 
its  decreasing  action  when  given  orally.  I  generally 
use  sodium  iodide,  but  sometimes  alternate  with  the 
potassium  salt.  The  iodide  should  be  given  in  small 
doses,  at  first,  three  grain  doses  in  a  glass  of  milk 
or  water  is  administered  on  an  empty  stomach, 
three  times  a  day,  to  be  followed  at  night  by  half  an 
ounce  to  one  ounce  doses  of  the  saturated  solution 
of  magnesium  or  sodium  sulphate  well  diluted.  I 
also  direct  that  large  quantities  of  milk  or  water  to 
be  taken  throughout  the  day,  as  they  serve  the  use- 
ful purpose  of  flushing  the  kidneys.  A  weekly 
urinary  analysis  is  imperative,  and  if  the  elimination 
of  the  toxic  material  decreases,  an  increase  is  made 
in  the  iodine  salt  given ;  and  I  have  frequently  ad- 
ministered as  high  as  sixty  grains  daily  by  the  ad- 
ministration of  small  increasing  doses,  in  the  treat- 
ment of  chronic  plumbism. 

The  anaemia  calls  for  iron,  and  I  generally  rely  on 
the  official  syrup  of  the  iodide,  believing  in  the  en- 
hanced value  of  the  iodide,  it  contains.  Tincture  of 
nux  vomica  or  ignatia  also  assume  an  important 


44-' 


CORRESPONDENCE. 


[New  York 
Medical  Journal. 


part  as  tonics  aside  from  their  afifect  on  the  nervous 
and  muscular  systems,  while  nutritious  foods  are 
quite  indispensable. 

The  colic  resultant  from  the  lead  poisoning  de- 
mands morphine,  no  other  agent  will  fill  its  place 
when  fully  developed,  and  as  the  causation  is  due 
to  an  increased  blood  pressure  in  the  area  con- 
trolled by  the  splanchnics,  the  action  of  this  drug 
is  rendered  greater  when  combined  with  atropine, 
which  has  direct  action  on  the  splanchnics,  and  ni- 
troglycerin, which  inhibits  the  increase  in  blood 
pressure.  T  know  of  no  method  which  will  so  surely 
relieve  lead  colic  as  the  administration  of  a  hypo- 
dermic injection  of  morphine  sulphate,  54  gr. ;  atro- 
pine, 1/50  gr. ;  and  nitroglycerin,  i/ioo  gr.,  at  the 
same  time,  making  use  of  a  hot  tub  bath  and  giving 
alum  by  the  mouth  in  30  grain  doses,  every  four 
hours.  The  constipation  is  best  met  by  salines,  al- 
though no  remedy  compares  with  alum  for  this  con- 
dition when  colic  is  present : 

R    Alum,   3ii; 

Diluted  sulphuric  acid,   3i; 

Distilled  water,   3ss; 

Syrup  of  orange  flowers,  3ss. 

M.  Sig:  A  dessertspoonful  (10  c.c.)  every  four  hours 
in  hot  water. 

Wrist  drop  or  other  local  manifestations  of  ner- 
vous involvement  as  seen  in  the  muscle  atrophy  de- 
mand the  use  of  strychnine  usually  given  in  fur- 
doses  and  injected  deeply  into  the  affected  muscles. 
I  usually  give  hypodermic  injections  of  1/48  of  a 
grain,  using  a  solution  of  i  grain  of  strychnine  to 
the  ounce  of  distilled  water,  10  minims  of  this  rep- 
resenting the  above  dose.  When  complete  contrac- 
tility is  absent  I  use. the  injection  daily.  Daily  mas- 
sage of  the  parts  form  an  essential  item  following 
which  I  strongly  urge  the  use  of  Bier's  method  of 
passive  hypera?mia  using  a  rubber  bandage,  ten  feet 
in  length,  and  applying  the  same  around  the  upper 
arm,  where  it  should  be  allowed  to  remain  at  least 
thirty  minutes,  after  removal  the  forearm  is  soaked 
in  hot  water,  it  is  then  ready  for  submission  to  elec- 
trical treatment  using  as  a  rule  a  galvanic  current 
of  from  five  to  fifteen  milliamperes  for  ten  minutes, 
the  flexor  muscles  being  strongly  flexed  backward 
to  place  the  diseased  muscles  at  rest,  application  be- 
ing made  with  the  cathode  over  the  atrophied  mus- 
cles and  the  anode  to  spine  or  sternum. 

Should  convulsions  arise  a  prompt  examination  of 
the  urine  is  at  once  instituted,  as  it  is  eminently  es- 
sential to  know  if  it  is  not  of  a  uraemic  nature  due 
to  cirrhoitic  kidneys,  if  this  is  the  case  I  believe  in 
active  purgation  and  diaphoresis,  relying  on  elatarin, 
gr.  %,  in  alcoholic  solution  by  the  mouth  for 
the  former,  while  hot  packs  and  pilocarpine,  grain 
guarded  by  nitroglycerin,  gr.  i/ioo,  every  four 
hours,  constitute  my  chief  means  of  diaphoresis. 

Chloral  hydrate,  oi ;  distilled  water,  to  fgvi  by 
rectal  enema,  often  give  marked  results  for  the  con- 
vulsions. Morphine  sulphate  in  this  condition  I  do 
not  use,  as  I  thoroughly  believe  it  locks  all  the  se- 
cretions, and  elimination  is  the  greatest  desire.  In- 
deed the  fundamental  treatment  of  uraeiriic  poison 
like  lead  pois(iiing,  is  the  protection  from,  and  the 
free  elimination  of  the  toxic  material,  through  all 
the  channels  of  the  body. 

{To  be  concluded.) 


LETTER  FROM  LONDON. 

Club   Practice. — Dr.   Elizabeth   Blackwell's   Birthday. — A 
Lecture  by  Sir  Patrick  Manson. 

London,  February  9,  /909, 

The  dififerences  between  medical  men  and  the 
clubs,  or  friendly  societies,  have  reached  an  acute 
stage.  The  usual  rate  of  payment  is  four  shillings 
a  member  per  annum,  which  includes  visiting,  if 
necessary,  and  all  medicines.  This,  medical  men 
contend,  is  wholly  inadequate,  and  in  places  where 
they  have  combined  and  made  a  stand  for  better 
terms  the  clubs  have  been  forced  to  yield. 

To  discuss  the  whole  question  of  the  relationship 
of  medical  men  with  the  clubs,  a  conference  was 
held  on  Saturday  at  the  Westminster  Hall,  arranged 
by  the  Charity  Organization  Society.  Sir  Alfred 
Lyall  presided,  and  among  those  present  were  sev- 
eral prominent  medical  men  and  also  representatives 
of  the  various  clubs. 

A  paper  was  read  by  Dr.  James  Pearse,  who  said 
that  in  the  medical  profession  all  over  the  countn,- 
there  was  a  chorus  of  complaint  against  the  present 
system  of  payment  for  medical  services  by  the 
friendly  societies.  Out  of  1,641  clubs,  76.5  per  cent, 
of  the  members  paid  less  than  five  shillings  a  year, 
and  for  this  a  doctor  must  attend  a  patient  and  also 
provide  the  necessary  drugs  and  dressings.  In  case 
of  protracted  illness  the  society  took  care  of  itself 
by  reducing  sick  pay,  but  it  ignored  the  injustice  of 
expecting  the  doctor  to  continue  attending  for  an 
indefinite  period.  He  knew  of  a  manufacturer  who 
was  paying  iioo  a  week  in  wages  and  who  as  a 
member  of  a  society  was  attended  by  a  doctor  at 
four  shillings  a  year.  He  died  worth  £10,000.  In 
another  case  a  member  of  a  society  who  was  receiv- 
ing medical  attention  at  a  similar  rate  died  worth 
£80,000.  Under  the  existing  system  medicine  was 
degraded  to  a  sordid  commercial  bargain.  The  doc- 
tor felt  that  he  was  being  sweated,  and  the  patient 
perhaps  felt  that  he  was  not  being  treated  as  a  pri- 
vate patient  would  be.  It  was  very  doubtful  whether 
medical  attendance  could  ever  be  satisfactorily  con- 
tracted for.  He  suggested  that  it  might  be  possi- 
ble to  pay  a  recognized  sum  for  each  item  of  work 
done.  Sir  Thomas  Smith  and  Sir  Thomas  Barlow 
also  spoke,  agreeing  to  these  remarks.  On  the  side 
of  the  friendly  societies  Mr.  Moflfrey  (Odd  Fel- 
lows) asserted  that  club  practice  was  as  important 
to  the  medical  profession  as  to  the  societies.  Many 
club  patients  would,  were  it  not  for  this  system,  go 
to  the  parish  or  hospital  and  so  be  treated  for  noth- 
ing. In  London,  moreover,  about  fifty  per  cent,  of 
the  members  lived  outside  the  radius  within  which 
the  doctors  were  obliged  to  give  their  services,  and 
they  paid  their  fee  and  got  nothing  in  return.  He 
considered  that  there  was  a  fair  bargain  between  the 
societies  and  the  doctors.  At  the  same  time  he  be- 
lieved that  if  a  consultation  took  place  between  the 
two  an  arrangement  satisfactory  to  both  sides  could 
be  concluded. 

England's  oldest  lady  doctor — the  first  woman  to 
take  a  medical  degree  and  to  be  placed  on  the  Eng- 
lish Medical  Register — celebrated  her  eighty-eighth 


February  27,  1909.] 


THERAPEUTICAL  NOTES. 


443 


birthday  on  Wednesday  last  at  Hastings,  where  she 
has  resided  for  thirty  years.  She  received  numer- 
ous congratulations  on  the  event  from  all  parts  of 
England  and  America.  Born  at  Bristol  on  Febru- 
ary 3,  1821,  Dr.  Elizabeth  Blackwell  has  epitomized 
in  her  life  the  whole  long  struggle  that  opened  a 
great  profession  to  women,  and,  although  in  these 
days  she  is  unequal  to  taking  any  active  part  in  out- 
side affairs,  all  will  unite  in  hoping  that  she  may  yet 
be  spared  to  see  the  further  developments  of  use- 
fulness that  are  being  found  by  medical  women  alike 
at  home  and  in  the  East. 

The  family  in  1832  went  to  America.  There  in 
due  course  she  became  a  school  teacher,  and  in  a 
book  she  wrote  about  fourteen  years  ago  she  has 
placed  on  record  how  the  idea  of  studying  medicine 
was  first  put  into  her  mind. 

A  great  friend  suffering  from  a  painful  malady 
said  to  her :  "You  are  fond  of  study,  and  have 
health  and  leisure.  Why  not  study  medicine?  If 
I  could  have  been  treated  by  a  lady  doctor  my  worst 
sufferings  would  have  been  spared  me."  But  Miss 
Blackwell  had  then  an  utter  distaste  for  anything 
connected  with  illness  or  the  physical  frame,  and  the 
suggestion  seemed  entirely  futile.  Still,  it  remained 
in  her  mind,  and  in  1845  she  had  gone  to  Asheville, 
North  Carolina,  to  begin  her  preliminary  studies. 
She  applied  to  various  medical  schools  in  America 
to  be  admitted,  and  after  several  refusals  she  was 
successful  in  obtaining  admission  to  the  school  at 
Geneva,  N.  Y.  Among  her  most  valued  possessions 
now  is  the  copy  of  the  resolutions  which  were  passed 
in  October,  1847,  when  it  was  unanimously  agreed 
"That  one  of  the  radical  principles  of  a  republican 
government  is  the  universal  education  of  both  sexes, 
that  in  every  branch  of  scientific  education  the  door 
should  be  open  equally  to  all,  that  the  application  of 
Elizabeth  Blackwell  to  become  a  member  of  our 
class  meets  our  entire  approbation,  and  in  extending 
our  unanimous  invitation  we  pledge  ourselves  that 
no  conduct  of  ours  shall  cause  her  to  regret  her  at- 
tendance at  this  institution."  She  duly  went  through 
the  course  and  went  through  the  ceremony  of  grad- 
uation on  January  25,  1849.  She  subsequently  went 
to  Philadelphia,  where  her  first  practice  was  in  the 
hospital  wards  of  the  Blockley  almshouse.  To  ex- 
tend her  experience.  Miss  Blackwell  spent  some 
months  in  La  Maternite  in  Paris  and  also  came  to 
London,  where  she  was  accorded  the  valued  privi- 
lege of  admission  to  St.  Bartholomew's  Hospital.  In 
1859,  when  the  first  British  Medical  Register  was 
published,  the  name  of  Miss  Blackwell  appeared 
— the  only  lady  on  the  register.  Soon  a  group 
of  other  ladies  joined  her  in  founding  the  Xew  Hos- 
pital for  Women.  In  its  earlier  days  she  was  con- 
sulting physician  to  this  hospital.  Miss  Blackwell 
is  at  present  engaged  in  writing  her  autobiography, 
for  which  she  has  accumulated  a  large  mass  of  ma- 
terial. 

Yesterday  a  distinguished  company  assembled  at 
the  Authors'  Club,  which  has  a  number  of  medical 
men  as  members,  to  entertain  Sir  Patrick  ^^lanson, 
K.  C.  M.  G.,  M.  D.,  F.  R.  S..  at  dinner.  Sir  Patrick 
gave  an  extremely  interesting  account  of  his  re- 
searches on  malarial  fever  and  other  mosquito  borne 
diseases.  After  giving  a  fascinating  account  of  his 
discovery  that  the  mosquito  was  the  host  of  the 
Filaria  sanguinis    hominis  he  dealt  with  his  re- 


searches on  malaria.  In  the  early  nineties,  when  the 
malarial  parasite  had  been  discovered  by  Laveran 
in  Algiers,  ]^Ianson  attempted  to  discover  the  pro- 
cess by  which  the  parasite  managed  to  pass  from  one 
human  body  to  another.  Many  conjectures  had  been 
made,  but  not  one  of  them  on  examination  was 
found  satisfactory.  In  1894  he  was  much  interested 
in  a  certain  phase  of  the  malarial  organism  which 
most  authorities  looked  upon  as  a  moribund  condi- 
tion of  the  parasite,  which  they  called  the  "agony" 
form.  This  peculiar  phenomenon  occurred  only 
when  the  parasite  was  withdrawn  from  the  human 
body,  and  Manson  did  not  agree  that  this  repre- 
sented a  dying  form  of  the  parasite.  He  reasoned 
thus :  The  malarial  parasite,  like  the  filaria,  to  pass 
from  man  to  man,  must  somehow  leave  the  human 
body.  It  is  incapable  of  doing  so  by  virtue  of  its 
own  effort,  because  it  is  inclosed  in  a  red  corpuscle 
of  the  blood.  Therefore  some  blood  sucking  ani- 
mal, probably  the  mosquito,  which  frequents  the 
haunts  of  malaria,  may  be  this  particular  agent,  and 
because  these  agony  forms — flagellated  bodies  they 
were  called — come  into  existence  only  when  the 
parasite  has  been  removed  from  the  human  body, 
they  must  be  the  earlist  form  of  the  extracorporeal 
phase  of  the  maiaria  parasite.  Being  in  England, 
he  was  unable,  for  want  of  material,  to  test  and 
work  upon  this  hypothesis,  but  he  wrote  a  paper  on 
the  subject  in  the  British  Medical  Journal.  About 
this  time  he  met  Professor  Ronald  Ross,  of  Liver- 
pool, and  discussed  the  matter  with  him.  Ross  went 
into  the  subject  thoroughly  and  proved  conclusively 
that  the  mosquito  was  the  intermediate  host  of  the 
malarial  parasite^  Sir  Patrick  concluded  by  ofiFer- 
ing  some  valuable  practical  suggestions.  The  dis- 
eases malaria  and  yellow  fever  are  still  geograph- 
ically limited,  but  the  opening  up  of  new  territory, 
the  increased  facility  for  travel,  implies  the  spread 
of  disease.  For  instance,  there  is  no  yellow  fever 
in  Asia  or  East  Africa.  As  regards  malaria,  it  does 
not  exist  in  many  of  the  Pacific  islands.  Fiji,  for 
one,  is  free.  Sir  Patrick  believed  that  if  precau- 
tions were  not  taken  in  time,  both  these  diseases 
would  extend  their  range,  that  with  the  opening  up 
of  the  Panama  Canal  and  by  the  repeated  passage 
of  rapid  steamers  across  the  Pacific,  yellow  fever 
would  be  introduced  into  the  Sandwich  Islands, 
Manila,  and  the  continent  of  Asia.  The  practical 
application  of  the  discovery  that  these  various  in- 
sects are  the  distributors  or  conveyors  of  disease 
germs  is  the  immediate  enforcement  of  measures 
which  will  tend  to  repress  these  germs ;  otherwise 
the  discovery  is  of  little  use.  At  the  conclusion  of 
the  lecture  there  was  prolonged  applause  and  he  was 
accorded  a  cordial  vote  of  thanks. 

 ^  


Test  for  Bile  in  Urine :    A  Correction. — In  the 

Xeiij  York  Medical  Journal  for  February  6th  a  for- 
mula was  published  for  the  detection  of  bile  in  urine 
which  was  obviously  incorrect  as  regards  the  amount 
of  sodium  chloride  prescribed,  1,100  grammes.  The 
volume  of  the  Wiener  klinische  Wochenschrift 
containing  the  original  formula  not  being  at 
present  accessible,  we  are  unable  to  compare  the 
formulas,  but  it  is  evident  that,  the  function  of  the 


444 


THERAPEUTICAL  NOTES.' 


[New  York 
Medical  Journal. 


sodium  chloride  in  the  formula  being  to  impart  den- 
sity to  the  solution,  no  great  exactness  in  the  amount 
used  is  necessary.  It  is  likely  that  no  grammes  was 
intended  instead  of  i,ioo  as  written. 

Chimaphila^  or  Prince's  Pine,  for  Diabetes. — In 

daily  doses  of  two  teaspoonfuls  of  the  fluid  extract, 
chimaphila  has  been  used  in  France  as  a  remedy  for 
diabetes.  In  conjunction  with  careful  dieting  a 
course  of  treatment  with  chimaphila  caused  the  dis- 
appearance of  glycosuria  in  the  personal  experience 
of  a  French  physician  {L' Union  pharmaceiitiqne) . 
After  sugar  is  no  longer  found  in  the  urine,  the  pa- 
tient is  put  on  arsenic  treatment,  continuing  the  chi- 
maphila meanwhile.  A  cure  is  looked  for  after  a 
two  months'  course  of  treatment. 

The  Treatment  of  Gout. — According  to  Pron 
{Foninilairc  syntlictiquc  dc  incdecine)  the  patient 
should,  during  an  attack  of  gout,  be  put  on  a  diet  of 
milk  and  Contrexeville,  Mttel,  or  Evian  water.  To 
induce  diuresis,  if  the  action  of  the  kidneys  is  less- 
ened, give  the  following : 

B     Theobromine  gr.  ix; 

Lithium  carbonate  gr.  ivss; 

Sodium  benzoate  gr.  iv. 

j\Iix  and  make  one  cachet.  One  such  to  be  taken  three  or 
four  times  daily. 

Locally,  hot  water  compresses  are  applied  and  fre- 
quently renewed,  or  compresses  soaked  in  a  hot  so- 
lution of  borax  are  applied  and  covered  with  cotton 
and  oiled  silk,  to  be  renewed  but  once  a  day. 

After  a  few  days  colchicum  is  prescribed,  sixty 
drops  of  tincture  of  colchicum  seed  being  given  in 
divided  doses  three  times  during  the  first  day.  On 
the  second  day  a  similar  dose,  or  one  slightly  re- 
duced, is  given,  according  to  the  effect  produced.  On 
the  third  and  fourth  days  forty  drops  of  the  tincture 
are  giyen  twice  a  day.  On  the  fifth  and  sixth  days 
twentv  drops  of  the  tincture  are  given  at  one  time, 
according  to  the  method  of  Lecorche,  or  the  follow- 


ing may  be  prescribed : 

R    Tincture  of  fresh  colchicum  flowers  5x  ; 

Tincture  of  ash  5iiiss  : 

Tincture  of  digitalis,   5iii ; 

Tincture  of  quinine,   5ii ; 

■  Tincture  of  belladonna,   5is5 ; 

Tincture  of  glycyrrhizin,   5v. 


M.  et.  Sig. :  Twenty  drops  five  times  daily. 
Or  wine  of  colchicum  may  be  prescribed  in  doses 
of  from  twenty-five  di"ops  to  one  drachm  three  or 
four  times  daily. 

If  the  colchicum  is  not  well  tolerated,  causing  di- 
arrhoea and  vomiting,  sodium  salicylate  may  be  given 
in  doses  of  ten  to  fifteen  grains  thrice  daily  to  begin 
with.  The  dose  is  increased  until  twenty-five  to 
thirty  grains  are  taken  at  a  time,  the  condition  of  the 
heart  and  kidneys  being  carefully  observed  mean- 
while. 

If  there  is  fever  give  quinine  sulphate  in  doses  of 
five  grains  twice  a  day.  Insomnia  may  be  overcome 
by  fifteen  grain  doses  of  sulphonal  or  trional,  but 
opium  should  not  be  given. 

The  Internal  Treatment  of  Syphilis  forms  the 
sul)ject  of  a  paper  by  E.  Rothschuh,  of  Aix-la-Cha- 
pelle,  in  the  January  number  of  the  /■'olia  Therapeti- 
tica.  In  an  introductory  paragraph  the  author  com- 
ments on  the  various  methods  of  treatment  followed 
in  (liffcrciit  (-"untries.     The  Englishman,  he  says. 


has  but  little  time  to  spare  from  business  or  recrea- 
tion, and  therefore  takes  his  medicine  in  the  form  of 
pills  or  powder ;  the  Frenchman  delights  in  the  ele- 
gance ofifered  by  the  silver  hypodermic  syringe ;  the 
German  and  northern  races,  seriously  minded  and 
systematic,  prefer  the  use  of  unguentum  cinereum 
according  to  certain  fixed  principles ;  the  American, 
in  deference  to  his  happy-go-lucky  disposition,  has 
no  particular  preference,  but  supplements  any  of  the 
above  mentioned  methods  by  the  liberal  use  of  sarsa- 
parilla.  He  goes  on  to  observe  that  the  internal 
method  of  treatment  is  one  of  the  oldest  forms.  The 
Mexican  and  Central  and  South  American  Indians, 
from  whom  European  syphilis  has  with  certainty 
been  acquired,  made  use  of  the  sarsaparilla  root, 
guaiacum  and  sassafras  woods,  and  other  drugs  of 
their  country,  with  or  without  the  concomitant  of 
vapor  baths,  in  precisely  the  same  manner  as  their 
descendants  do  to-day.  It  is  not  known  how  these 
drugs  act,  and  authorities  on  syphilis  deny  any  ac- 
tion to  them.  The  author  proposes  a  combination 
of  sarsaparilla,  sassafras,  guaiacum  and  cinchona 
bark  represented  by  the  following  formula : 


^    Fluidextract  sarsaparillae,  Honduras,  5' > 

Fluidextract  ligni  sassafras ; 

Fluidextract  ligni  guaiaci  aa  5iiss  ; 

Fluidextract  cort.  cinchonae  succirubrx,  ad  5x. 


M.  Two  to  four  tablespoonf nls  are  to  be  taken  daily  in 
hot  thermal  water  or  sudorific  draught. 

It  is  noted,  however,  that  mercury  remains  the 
sovereign  remedy.  The  hydrargyrum  cum  creta  of 
the  Pharmacopoeia  is  considered  the  most  constant 
and  least  changeable  of  all  the  preparations  of  me- 
tallic mercury  intended  for  internal  use.  The  com- 
bination of  iodine  with  mercury  has  a  favorable  ef- 
fect upon  certain  syphilitic  manifestations.  The 
use  of  the  monoiodide  of  mercury  is  common  in 
France  and  in  South  America,  and  Eastern  coun- 
tries. Good  results  are  yielded  by  Fournier's  pills 
of  the  following  composition  : 

B    Yellow  mercurous  iodide,   gr.  3/-;: 

Extract  of  opium,   gr.  1/(3. 

Ft.  pil.  One  to  be  taken  morning  and  night. 

The  red  mercuric  iodide  in  the  form  of  Gibert's 
syrup  is  used  in  practice  among  children ;  its  for- 


mula is  as  follows : 

B     Red  mercuric  iodide,   gr.  iii ; 

Potassium  iodide,   5iiss  ; 

•  Simple  syrup,   5xvss. 

Mix. 


This  is  said  to  be  well  tolerated,  and  is  suitable 
where  it  is  desired  to  combine  mercurial  action  with 
an  active  amount  of  iodine. 

The  author  speaks  favorably  of  mercuric  sozoio- 
dolate,  saying  that  it  deserves  a  more  extensive  use 
than'  it  has  been  hitherto  accorded.  It  produces 
stomatitis  less  readily  and  relapse  is  not  so  rapid. 

The  Treatment  of  Neurasthenia. — ]M\\g{Thera- 
peutisclic  M oiuitsheft)  employs  in  the  treatment  of 
neurasthenia  cannabis  indica  in  combination  with 
tonics,  as  in  the  following  formulas : 


B    Quinine  sulpliate,   gr.  xv; 

Arsenic  trioxide  '.  gr.  i.  to  gr.  iss  ; 

Extract  of  cannabis  indica  gr.  vii. 

Mix  and  divide  into  thirty  pills. 
B     Iron  lactate ; 

.Aqueous  extract  of  cinchona  aa  5i ; 

.Alcoholic  extract  of  nux  vomica,  gr.  .xv; 


I'xtract  of  gentian,  q.  s.  ft.  pil.  No.  100. 


February  27.  1909.] 


EDITORIAL  ARTICLES. 


445 


NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

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and  The  Medical  News. 

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NEW  YORK.  SATURDAY,  FEBRUARY"  27,  1909. 

SOME  PROBLEMS  IX  nOIUXITY. 
No  other  department  of  medical  science  offers  so 
fascinating  a  field  for  research  as  that  deahng  with 
the  immunity  to  infectious  diseases,  and  there  is  no 
other  branch  in  vvhich  so  much  progress  has  been 
made  in  the  past  ten  years.  Unfortunately  this  pro- 
gress has  not  contributed  materially  to  practical 
therapeutics.  As  far  back  as  in  1883  INIetchnikoff 
drew  attention  to  the  role  of  leucocytes  in  the  pro- 
duction of  immunity,  and  stibsequently,  in  a  num- 
ber of  able  papers,  this  brilliant  investigator  devel- 
oped what  became  known  as  the  phagocytic,  or  cellu- 
lar, theor}-  of  immunity.  With  von  Behring's  discov- 
ery of  diphtheria  antitoxine,  in  1892,  attention  was 
focused  on  the  blood  plasma  as  an  important  factor 
in  immunity.  In  fact,  attempts  were  everywhere 
made  to  produce  therapeutically  effective  sera  for  a 
great  variety  of  diseases.  As  those  who  have  fol- 
lowed the  subject  of  immunity  are  aware,  the  bril- 
liant series  of  studies  begun  by  Bordet  and  Ehrlich 
in  1899  showed  that  the  injection  of  cellular  ele- 
ments into  the  animal  body  was  followed  by  the 
production  in  the  animal's  serum  of  destructive  and 
dissolving  substances  directed  specifically  against 
these  cells.  These  substances  possess  a  complex 
constitution,  being  made  up  of  a  thermostable  im- 
mune body  .and  a  thermolabile  complement  (or 
alexin).  These  papers  aroused  tremendous  inter- 
est and  led  to  a  revival  of  serum  studies,  with  a  con- 
sequent neglect  of  Metchnikoff's  phagocytic  studies. 
Curiously,  the  fact  was  practically  lost  sight  of  that 
the  blood  plasma  was  not  an  ind^fterent  fluid,  like 
water,  but  was  the  representative  of  the  bodily  cells. 


Thanks  to  the  persevering  work  of  Wright,  we  seem 
now  to  be  ready  to  take  a  less  one  sided  view  of  the 
immunity  reaction,  and  to  recognize  the  role,  not 
only  of  the  blood  plasma,  but  of  the  leucocytes  as 
well 

The  study  of  immunity,  of  course,  concerns  itself 
not  merelv  with  the  defensive  mechanism  of  the 
body,  but  equally  also  with  the  aggressive  power  of 
the  invading  microorganisms.  It  is  easy  to  under- 
stand the  pathogenic  action  of  a  number  of  organ- 
isms, such  as  the  bacilli  of  diphtheria  or  of  tetanus, 
for  these,  we  know,  secrete  exceedingly  toxic  sub- 
stances even  when  grown  in  artificial  culture  media. 
Other  bacteria  give  off  substances  which  have  spe- 
cific Ivtic  properties,  and  almost  all  bacteria  excrete 
waste  products  having  a  more  or  less  toxic  action. 
Nevertheless,  it  early  became  apparent  that  the 
presence  of  these  substances  would  not  account  for 
the  specific  pathogenic  action  of  a  large  number  of 
bacteria,  such  as  the  cholera  spirillum,  the  typhoid 
bacillus,  the  streptococci,  etc.  It  was  to  account  for 
this  condition  that  Pfeiffer  formulated  his  endotox- 
ine  theory,  according  to  which  the  bacteria  possessed 
specific  toxic  substances  intimately  boimd  up  with 
their  protoplasm  and  inseparable  from  the  living, 
intact  bacterium.  These  toxic  substances,  it  was 
believed,  were  liberated  on  the  disintegration  of  the 
bacteria  through  the  action  of  specific  bacteriolytic 
substances.  As  a  matter  of  fact,  however,  the  pres- 
ence of  such  endotoxines  has  not  yet  been  conclu- 
sively demonstrated,  though  in  a  few  bacteria,  such 
as  those  of  cholera  and  dysentery,  their  existence  is 
very  probable.  It  is  interesting  to  note,  in  addition, 
that  animal  experiments  with  cholera  vibrios  and 
specific  cholera  immune  serum  have  shown  that  un- 
der certain  conditions  the  administration  of  the 
serum  may  even  have  a  disastrous  effect,  apparently 
because  the  serum  causes  a  too  rapid  liberation  of 
endotoxine.  It  is  possible  that  the  recent  studies 
concerning  the  phenomenon  known  as  anaphylaxis, 
or  allergic,  will  throw  some  light  on  the  pathogenic 
action  of  bacteria.  It  has  been  found,  for  exam- 
ple, that  the  injection  of  very  minute  quantities  of 
a  foreign  proteid  sensitizes  the  injected  animal  so 
that  a  subsequent  injection  of  the  same  proteid  may 
cause  pronounced  constitutional  disturbances  and 
even  the  death  of  the  animal. 

From  what  has  been  said  it  is  apparent  that  the 
problem  of  immunity  is  extremely  complex  and  in- 
volves the  study  of  a  large  number  of  different 
factors.  Attempts  to  find  therapeutically  effective 
sera  for  most  of  the  infectious  diseases  have  not 
been  successful.  In  view  of  the  fact  that  im- 
munization increases  only  the  immune  body  and  not 
the  complement,  it  has  been  supposed  that  the  fail- 
ures were  perhaps  due  to  a  lack  of  sufficient  com- 
plement.   A  number  of  investigators  have  therefore 


446 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal.. 


sought  to  devise  means  for  increasing  this  sub- 
stance, but  without  success.  The  discouraging  re- 
sults attending  all  efforts  to  secure  effective  sera 
for  passive  immunization  have  led  more  and  more 
to  the  practice  of  active  immunization  by  means  of 
bacterial  vaccines,  and  the  work  in  this  direction  has 
met  with  a  fair  degree  of  success. 

The  subject  has  recently  been  attacked  from  an- 
other side  by  Hiss  and  Zinsser,  and  the  results  of 
their  experiments,  as  reported  in  a  recent  lecture  be- 
fore the  Harvey  Society,  lead  to  the  hope  that  a 
distinct  therapeutic  advance  has  been  made.  These 
investigators  felt  that  too  little  attention  had  pre- 
viously been  paid  to  the  biochemistry  of  the  leu- 
cocytes, and  that  much  might  reasonably  be  expect- 
ed to  be  gained  by  a  closer  study  of  leucocyte  activ- 
ity. Previous  workers  had  already  tested  the  thera- 
peutic value  of  leucocytes  and  had  obtained  indiffer- 
ent results.  Jliss  and  Zinsser,  however,  experi- 
mented with  leucocyte  extracts,  and  this  appears  to 
have  been  an  important  change.  The  extracts  seem 
to  possess  an  antitoxic  action,  enabling  the  leuco- 
cytes in  the  infected  body  to  overcome  the  invading 
bacteria  readily.  In  a  number  of  the  cases  reported 
by  the  authors  there  was  a  rapid  drop  of  tempera- 
ture following  the  injection  of  the  leucocyte  extract. 
Whatever  the  mechanism  by  which  the  extract  in- 
fluences infection,  the  clinical  results  reported  by 
Hiss  and  Zinsser  demand  that  further  trials  be  made 
of  this  method.  It  is  very  possible  that  work  along 
these  lines  will  develop  a  successful  method  of  com- 
bating many  infections  which  we  now  are  practical- 
ly unable  to  influence. 


TETANY  AND  THE  PARATHYREOID 
BODIES. 

Between  the  years  1830  and  i860  frequent  men- 
tion was  made  of  tetany  in  French  literature,  but 
from  i860  to  1899  the  subject  was  seldom  referred 
to  (Dercum,  Keating's  Cyclopcedia,  Supplement). 
In  1889  Stewart  reported  a  case  at  the  meeting  of 
the  Association  of  American  Physicians,  and  in  the 
discussion  that  followed  the  report  \\'eir  Mitchell 
said  that  he  had  seen  but  two  cases,  and  Pepper 
said  that  he  knew  of  but  one. 

Cases  of  tetany  had  been  noted  accompanying 
severe  constitutional  diseases  and  following  removal 
of  the  thyreoid  body,  both  in  man  and  in  dogs.  In 
recent  years  the  relation  between  the  parathyreoid 
bodies  and  tetany  has  been  energetically  studied.  A 
review  of  the  work  done  at  the  Johns  Hopkins  Hos- 
pital was  published  in  the  Proceedings  of  the  Patho- 
logical Society  of  Philadelphia  in  May,  1908. 

MacCallum  and  Voegtlin  and  Halsted  continue 
their  interest  in  this  disea.se.  In  the  Journal  of  Ex- 
perimental Medicine  for  January,  the  former  au- 
thors describe  the  relation  of  tetany  to  the  para- 


thyreoid glands.  By  their  own  work  and  the  work 
of  others  the  intimate  relation  of  tetany  to  the  para- 
thyreoid bodies  is  shown,  the  convulsive  attacks  fol- 
lowing both  relative  and  absolute  deficiency  of  these 
structures.  The  active  principle  of  the  parathyreoid: 
glands  is  found  to  be  associated  with  a  nucleopro- 
tein.   But  the  substance  does  not  contain  iodine. 

Studies  of  the  metabolism  of  animals  after  re- 
moval of  the  parathyreoid  bodies  show  a  marked 
reduction  of  the  calcium  of  the  tissues,  an  increased 
calcium  excretion,  an  increased  nitrogen  excretion, 
an  increase  of  the  absolute  and  relative  ammonia 
excretion  in  the  urine,  and  an  increase  in  the  amount 
of  ammonia  in  the  blood.  This  is  quite  the  opposite 
of  the  metabolic  changes  following  thyreoidectom}', 
which  are  particularly  characterized  by  a  diminu- 
tion of  the  excretion  of  nitrogen.  The  injection  of 
a  calcium  salt  will  stop  the  convulsive  attacks  in  an 
animal  suffering  from  tetany.  ^lagnesium  salts 
may  have  the  same  effect,  but  their  toxic  action  is 
the  dominant  one.  Sodium  and  potassium  salts  tend' 
to  increase  the  tetanoid  attacks.  The  injection  of 
calcium  salts  in  cases  of  spontaneous  and  postopera- 
tive tetany  in  human  beings  is  an  important  thera- 
peutic procedure. 

Halsted  (Journal  of  Experimental  Medicine, 
January)  discusses  the  results  of  transplantation  of 
the  parathyreoids.  He  finds  that  there  must  be  a. 
deficiency  of  at  least  fifty  per  cent,  of  normal  para- 
thyreoid tissue  for  the  transplantation  to  be  success- 
ful. In  instances  in  which  the  deficiency  of  one  half 
has  existed  autotransplantation  has  been  successful 
in  sixty-one  per  cent.,  and  isotransplantation  in 
every  case  in  which  it  has  been  tried. 


THE  HEALTH  OF  SCHOOL  TEACHERS. 

This  is  the  subject  of  an  article  by  Dr.  R.  P. 
Williamson,  of  Manchester,  England,  lecturer  on 
school  h3-giene  in  the  Victoria  University,  which 
we  find  in  the  February  number  of  the  Medical 
Chronicle.  Though  he  thinks  that  the  professional 
work  of  the  school  teacher  often  especially  predis- 
poses to  certain  affections,  Dr.  Williamson  finds  that 
the  profession  is.  on  the  whole,  a  healthy  one,  the 
mortality  being  lower  than  that  of  any  other  pro- 
fession except  I  he  clerical,  and  in  England  and 
Wales  very  much  below  the  average  for  all  occu- 
pied and  retired  males.  Moreover,  it  has  declined 
steadily  and  decidedly  during  the  last  forty  years. 

But.  he  adds,  in  the  statistics  from  which  he 
draws  these  statements  the  occupation  group  of 
"schoolmasters  and  teachers"  includes  lecturers,, 
professors,  and  teachers  in  colleges  as  well  as  teach- 
ers in  elementary  schools,  and  he  gives  it  as  his 
opinion  that  statistics  relating  to  elementary  school 
teachers  alone  would  probably  not  be  so  favorable. 
He  thinks  there  can  be  no  doubt  that  school  teachers 


February  27,  1909.] 


EDITORIAL  ARTICLES. 


447 


very  frequently  suffer  from  preventable  illness  and 
diseases  which  are  produced,  directly  or  indirectly, 
by  their  professional  work.  With  regard  to  two 
causes  of  death — diabetes  and  suicide — schoolmas- 
ters and  teachers  oftener  fall  victims  to  them  than 
the  average  of  all  occupied  and  retired  males  in 
England  and  Wales,  but  less  frequently  than  physi- 
cians and  lawyers  and  than  men  of  many  other  oc- 
cupations. 

Pulmonary  consumption  is  the  most  frequent 
cause  of  death  among  schoolmasters  and  teachers ; 
their  mortality  from  that  disease  is  higher  than  that 
of  medical  men.  clergymen,  or  lawyers  (barristers 
and  solicitors),  but  lower  than  that  of  law  clerks 
and  lower  than  that  of  the  occupied  and  retired 
male  population  generally.  Other  frequent  causes 
of  death  among  school  teachers  are  diseases  of  the 
circulatory  system  and  diseases  of  the  nervous  sys- 
tem. Though  influenza  is  the  ailment  for  which 
teachers  most  commonly  claim  "breakdown  allow- 
ances," it  is  less  frequently  fatal  among  them  than 
among  clergymen,  and  their  mortality  from  it  is 
lower  than  that  for  the  average  of  all  occupied  and 
retired  male  persons.  Dr.  Williamson  says  that  it 
is  stated  by  several  observers  that  exophthalmic 
goitre,  "chiefly  in  a  mild  and  abortive  form,"  is  more 
common  among  teachers  than  among  other  persons. 
He  finds  that  there  is  a  great  prevalence  of  myopia 
among  teachers,  and  he  imputes  it  to  eye  strain  con- 
sequent on  the  book  work  incident  to  their  profes- 
sion. 

Much  of  the  impaired  health  met  with  among 
teachers.  Dr.  Williamson  thinks,  is  the  result  of 
overwork  during  their  preparation  for  the  profes- 
sion, and  especially  of  their  striving  for  scholarships 
and  special  prizes.  He  deprecates  the  spending  of 
great  sums  of  money  by  the  universities  on  scholar- 
ships and  prizes.  "It  should  be  remembered,"  he 
says,  "that  the  winners  of  such  scholarships  are  not 
always  the  best  men,  but  the  men  who  are  best  able, 
in  a  limited  time,  to  write  from  memory  the  largest 
number  of  facts  or  theories  relating  to  any  subject." 


DR.  WEIR  MITCHELL'S  BIRTHDAY. 
On  the  15th  of  February  Dr.  Silas  Weir  Mitchell, 
of  Philadelphia,  celebrated  his  eightieth  birthday. 
His  intellectual  activity  is  undiminished,  and  it  is 
to  be  hoped  that  the  "labor  and  sorrow"  which,  ac- 
cording to  the  psalmist,  are  the  portion  of  those 
men  who  by  virtue  of  their  strength  come  to  the  age 
of  four  score  may  long  be  spared  this  distinguished 
member  of  our  profession,  conspicuous  alike  in 
medicine  and  in  literature,  as  a  neurologist  and  as 
a  novelist.  For  what  he  has  done  for  mankind  we 
thank  him,  and  we  hope  that  he  will  be  with  us  for 
many  more  years  to  come. 


THE  MINERAL  SPRINGS  OF  SARATOGA. 
The  physicians  of  this  country  know  the  value  of 
the  medicinal  springs  of  Saratoga,  and  they  have 
little  if  any  doubt  that  the  waters  could  be  turned  to 
far  greater  account  than  they  have  ever  been,  pro- 
vided they  were  properly  protected  and  adequately 
managed.  It  is  a  matter  for  congratulation,  there- 
fore, that  steps  have  at  last  been  taken  in  the  legis- 
lature which  bid  fair  to  end  in  putting  the  manage- 
ment of  the  springs  on  a  proper  footing.  For  this 
we  have  largely  to  thank  the  people  of  Saratoga  it- 
self, who  have  acted  through  the  medium  of  their 
Business  Men's  Association  and  with  the  endorse- 
ment of  numerous  important  professional,  educa- 
tional, and  benevolent  organizations.  We  may  now 
look  to  see  the  medicinal  virtues  of  the  Saratoga 
waters  more  widely  recognized  and  the  springs  so 
cared  for  and  managed  as  to  put  them  on  a  par  with 
the  most  celebrated  spas  of  Europe. 


DR.  ELIZABETH  BLACKWELL. 

In  the  letter  which  we  publish  this  week  our  Lon- 
don correspondent  touches  upon  a  matter  that  is 
sure  to  awaken  the  interest  of  many  an  American 
physician  whose  memory  of  professional  affairs  goes 
back  for  a  few  decades,  especially  in  New  York.  We 
refer  to  what  the  letter  contains  with  regard  to  the 
venerable  Dr.  Elizabeth  Blackwell,  the  pioneer  fe- 
male physician  among  English  speaking  peoples. 
We  feel  that  the  lady  belongs  quite  as  much  to  us 
as  to  those  of  her  native  land,  England.  Though 
she  has  again  taken  up  her  residence  in  that  coun- 
try, she  is  still,  if  we  are  not  mistaken,  one  of  the 
consulting  physicians  of  the  New  York  Infirmar)- 
for  Women  and  Children,  a  beneficent  institution 
which  she  was  largely  instrumental  in  establishing. 
She  labored  in  New  York  for  many  years,  alleviat- 
ing sickness,  organizing  the  infirmary,  and  provid- 
ing for  the  training  of  voung  women  in  medicine 

We  are  glad  to  learn  that  Dr.  Blackwell  is  pre- 
paring an  autobiography.  It  is  sure  to  be  an  inter- 
esting and  instructive  book,  one  that  will  recall  to 
many  American  readers  the  author's  dignified  and 
benign  personality,  her  earnestness,  and  her  modesty. 
The  old  medical  school  in  Geneva,  in  the  State  of 
New  York,  where  she  obtained  her  degree  in  medi- 
cine, w^as  an  institution  of  no  little  merit,  and  not  the 
least  among  the  things  to  be  remembered  to  its  credit 
is  the  courage  which  it  showed  in  accepting  Miss 
Blackwell  as  a  pupil  after  she  had  been  refused  ad- 
mission into  several  other  medical  colleges,  and  that, 
too,  so  long  ago  as  to  admit  of  her  being  graduated 
in  Geneva  in  1849.  We  cordially  join  in  our  corre- 
spondent's hope  "that  she  may  yet  be  spared  to 
see  the  further  developments  of  usefulness  that  are 
being  found  by  medical  women." 


448 


OBITUARY. 


[New  York 
Medical  Journal. 


WILLIAM  TILLINGHAST  BULL,  M.  D. 

After  calmly  awaiting  the  inevitable  for  several 
months,  Dr.  Bull  died  on  Monday,  February  22d, 
in  the  sixtieth  year  of  his  age,  at  Savannah,  Ga., 
whither  he  had  but  recently  gone  for  the  sake  of 
profiting,  so  far  as  might  be,  by  a  mild  southern  cli- 
mate. It  had  been  well  known  among  his  profes- 
sional brethren  that  he  was  a  victim  of  malignant 
disease,  and  for  a  long  time  no  hope  of  his  recovery 
had  been  entertained,  but  his  bravery  in  holding  up 
against  the  grim  Destroyer  had  added  materially  to 
the  esteem  in  which  he  had  always  been  held. 

Dr.  Bull  came  of  an  old  Rhode  Island  family,  and 
land  in  Newport  is  still 
held  by  the  Bulls  after 
having  been  handed 
down  among  them  for 
more  than  250  years. 
He  received  his  aca- 
demic education  in  Har- 
vard University,  from 
which  institution  he  was 
graduated  in  1869.  He 
studied  medicine  under 
the  late  Dr.  Henry  B. 
Sands,  of  New  York, 
and  received  his  medi- 
cal degree  from  the  Col- 
lege of  Physicians  and 
Surgeons  (now  the 
School  of  xMedicine'  of 
Columbia  University) 
in  the  class  of  1872.  He 
served  the  full  term  on 
the  house  stafif  of  Bel- 
levue  Hospital  and  al- 
most immediately  enter- 
ed upon  a  distinguished 
service  in  various  New 
York  hospitals,  in  sev- 
eral of  which  he  was  a 
consulting  surgeon  at 
the  time  of  his  death. 
Early  in  his  active 
career  he  was  made  a 
professor,  of  surgery  in 
the  College  of  Physicians 

and  Surgeons,  and  in  that  capacity  he  was  rated  as 
a  very  successful  teacher.  He  was  not  a  copious 
contributor  to  medical  literature  under  his  own 
name,  but  he  inspired  many  a  younger  man's  contri- 
butions. So,  too,  he  was  seldom  conspicuous  in  so- 
ciety meetings,  but  what  he  occasionally  had  to  say 
at  them  .sank  into  his  hearers  with  exceptional 
weight. 

Dr.  Bull  began  as  a  general  practitioner,  and  he 
never  lost  his  interest  in  general  medicine.  That  he 
became  most  distinguished  in  surgery  was  not  due  to 
any  predetermined  desire  for  .specialism  on  his  part ; 
he  simply  worked  conspicuously  in  that  branch  for 
which  he  was  be.st  fitted.    He  was  an  excellent  diag- 


nostician and  a  cool  and  precise  operator.  It  was 
on  these  grounds  that  he  attained  to  distinction  as  a 
surgeon.  He  never  lost  sight  of  the  patient  in  the 
"case,"  and  he  consequently  came  to  be  known  as 
preeminently  the  patient's  friend.  Moreover,  he 
was  ever  mindful  of  the  comparative  inability  of 
many  patients  to  pay  the  full  fee,  and  he  worked  un- 
tiringly in  the  service  of  the  poor. 

Dr.  Bull  was  a  remarkably  handsome  man,  and 
his  benign  expression  was  a  real  key  to  his  inner 
feeling.  He  was  felt  to  be  great  in  the  sense  of  be- 
ing good  as  well  as  in  that  of  being  accomplished. 
He  was  every  inch  a  man,  and  so  he  was  rated  by 
everybody  who  knew  him,  whether  physician  or  lay- 
man. By  his  demise  the  profession  has  lost  one  of 
its  chief  ornaments,  and  the  community  a  sterling 
citizen. 


WILLIAM  TILLINGHAST  BULL,  M.  D. 


FREDERICK  IRVING 
KXIGHT,  M.  D.. 
of  Boston. 

The  death  of  Dr. 
Knight,  which  occurred 
at  his  home  in  Boston 
on  Februar\-  20th,  re- 
moves from  his  country 
a  pioneer  specialist  and 
from  the  world  at  large 
an  honored  member  of 
the  medical  profession. 
He  was  born  in  New- 
buryport,  Mass.,  in 
1841,  and  came  of  the 
best  New  England  par- 
entage. He  was  gradu- 
ated from  Yale  (A.  B.) 
in  1862  (A.  M.,  1865) 
and  from  the  Harvard 
Medical  School  in  1866. 
He  subsequently  studied 
in  \'ienna,  London,  and 
Berlin,  and  while  abroad, 
in  1872.  was  made  in- 
structor in  the  diagnosis 
of  diseases  of  the  chest 
and  in  laryngology  in 
the  Harvard  Medical 
School.  This  was  the 
first  clinic  of  its  kind  in 
New  England.  In  1886 
he  was  made  clinical  professor  of  laryngology,  which 
]:)osition  be  held  until  i8g2,  resigning  in  favor  of  the 
late  Dr.  Franklin  H.  Hooper. 

Dr.  Knight  was  one  of  the  founders  of  the  Ameri- 
can Laryngological  Association  and  one  of  its  early 
presidents.  He  was  also  president  of  the  American 
Climatological  Association, of  the  Boston  Society  for 
Medical  Ini])rovcmont,and  of  various  other  scientific 
bodies.  lie  was  consultant  to  the  IMassachusctts 
General  Hospital,  the  Sharon  Sanatorium,  and  the 
Free  Home  for  Consumptives.  In  the  movement 
against  tuberculosis  he  was  a  leader.  He  was  a  fre- 
quent and  able  contributor  to  the  literature  of  his 
(lepartmcnt,  a  practitioner  of  the  highest  distinction, 


F.ebruary  27,  1909  ] 


XEil  S  ITEMS. 


449 


and  one  who  devoted  himself  to  pubhc  philanthropy 
with  rare  self  denial  and  success. 

Personally  Dr.  Knight  ranked  among  the  most 
genial,  cultivated,  and  accomplished  men  of  his  time. 
His  worth  was  appreciated  by  the  most  high  minded 
of  those  around  him,  and  his  talents  were  freely  used 
bv  himself  and  bv  them  for  the  betterment  of  man- 
kind. '  D.  B.  D. 


Changes  of  Address.— Dr.  Anna  Wells  Bloomer,  to 
103  West  Seventieth  Street,  New  York. 

Epidemic  of  Scarlet  Fever  in  Buffalo. — It  is  said  that 
scarlet  fever  prevails  in  Buffalo  to  such  an  extent  that  the 
health  officials  have  turned  a  vacant  public  school  building 
inio  an  isolation  hospital  for  the  disease. 

The  Cholera  Situation  in  St.  Petersburg. — According 
to  press  dispatches,  cholera  has  been  epidemic  in  St.  Peters- 
burg for  one  hundred  and  sixty  days.  During  that  time 
10,000  cases  have  been  reported,  with  3,928  deaths.  The 
highest  number  of  cases  reported  in  one  day  was  +44. 

Women  Physicians  of  Pittsburgh  Organize. — The 
Woman's  Medical  Society  of  Pittsburgh  was  formed  re- 
cently, with  the  following  officers  for  the  first  year :  Dr. 
A.  yi.  Watson,  president;  Dr.  L.  R.  Goldsmith,  vice-presi- 
dent :  Dr.  Bertha  E.  Dornbush,  recording  secretary ;  Dr. 
Elizabeth  Martin,  corresponding  secretary ;  Dr.  Katherine 
Cook,  treasurer. 

Vacancies  in  the  House  Stciff  of  Beth  Israel  Hospital, 
New  York. — The  annual  examinations  for  appointments 
to  the  house  staff  of  the  hospital  will  be  held  on  NVednes- 
day,  March  31st,  and  Friday,  April  2d.  There  are  eight  ap- 
pointments to  be  made,  four  internes,  with  a  term  of  ser- 
vice of  two  years,  and  four  externes,  with  a  term  of  service 
of  one  year. 

Dr.  Jewett  to  Retire  from  Presidency  of  Bushwick 
Hospital. — Dr.  Charles  Jewett,  who  has  been  president  of 
Bushwick  Hospital  ever  since  its  incorporation,  is  about  to 
retire,  owing  to  the  increasing  demands  on  his  time  in 
other  lines  of  work.  His  resignation  has  been  in  the  hands 
of  the  secretary  for  some  months,  but  action  on  it  was  per- 
mitted to  await  the  completion  of  the  reorganization  of  the 
hospital. 

The  Genitourinary  Clinic  of  the  West  Side  Germarx 
Dispensary. — There  are  two  vacancies  to  be  tilled  in 
this  clinic,  and  applications  should  be  sent  at  once  to  Dr. 
Abraham  L.  Wolbarst,  105  East  Nineteenth  Street,  New 
York.  Tlie  clinics  are  held  on  Tuesdays,  Thursdays  and 
Saturdays  from  7:30  to  8:30  p.  m.  at  the  dispensary,  328 
West  Forty-second  Street,  and  present  splendid  opportuni- 
ties for  advanced  work,  as  the  service  is  large. 

To  Enlarge  the  State  Hospital  for  Tuberculosis  at 
Raybrook,  N.  Y. — A  bill  has  been  introduced  into  the  New 
York  Legislature  by  Senator  Allds,  providing  for  an  ap- 
propriation of  $175,000  for  improvements  at  the  State  Hos- 
pital for  the  Treatment  of  Incipient  Pulmonary  Tubercu- 
losis, at  Raybrook,  N.  Y.  The  bill  proposes  to  increase  the 
accommodations  and  equipment  of  the  hospital,  making  the 
minimum  capacity  about  three  hundred  patients. 

Personal. — Dr.  S.  Weir  Mitchell,  of  Philadelphia,  read 
a  paper  entitled  The  Chorea  of  Emotion  at  a  recent  meet- 
ing of  the  Philadelphia  Neurological  Society. 

Major  Jefferson  R.  Kean,  of  the  United  States  Army, 
who.  during  the  occupation  of  Cuba  by  our  forces,  was 
medical  adviser  to  the  provisional  governor,  has  been  as- 
signed to  temporary  duty  in  the  office  of  the  surgeon  gen- 
eral in  Washington,  D.  C.,  where  he  was  serving  before  he 
was  ordered  to  Cuba. 

Amalgamation  of  Medical  Societies. — An  agreement 
has  been  entered  into  by  the  Rochester  Pathological  Society 
and  the  Rochester  .\cademy  of  Medicine  by  which  the  two 
societies  agree  to  affiliate  on  certain  terms  and  conditions. 
The  Rochester  Pathological  Society  will  become  a  new 
section  of  the  Rochester  Academy  of  Medicine,  to  be 
known  as  Section  V.  Tlie  constitution  and  by-laws  of  the 
affiliated  societies  will  be  the  present  constitution  and  by- 
Ifiws  of  the  Rochester  Academy  of  Medicine,  with  some 
amendments.  The  question  of  the  amalgamation  was  dis- 
cussed at  a  special  meeting  of  the  academy  on  Wednesday 
evening,  February,-  24th. 


A  New  Building  for  the  New  York  State  Hospital 
for  the  Care  of  Crippled  and  Deformed  Children.— The 

managers  of  this  hospital  have  been  informed  officially  that 
tlie  present  site  of  the  hospital  at  West  Haverstraw,  N.  Y., 
has  the  entire  approval  of  the  State  Board  of  Charities, 
and  that  it  has  been  recommended  to  Governor  Hughes  and 
to  the  State  legislature  that  an  appropriation  of  $100,000  be 
made  for  the  erection  of  a  new  building  on  the  site. 

A  New  Society  for  the  Study  and  Advancement  of 
Psychiatry  has  been  organized  in  Philadelphia,  under 
the  name  of  the  Philadelphia  Psychiatric  Society.  The 
meetings  of  the  society  will  be  held  in  the  rooms  of  the 
College  of  Phvsicians,  on  the  second  Friday  in  November, 
Januarv,  March,  and  May.  The  officers  are :  President, 
Dr.  C.'W.  Burr:  vice-Presidents.  Dr.  .A..  B.  jMoulton  and 
Dr.  W.  W.  Richardson ;  secretary  and  treasurer,  Dr.  W. 
W.  Hawke ;  councilors.  Dr.  W.  H.  Hancker,  Dr.  John  K. 
Mitchell,  and  Dr   F.  X.  Dercum. 

The  West  End  Medical  Society,  New  York,  will  hold 
its  first  regular  meeting  for  1909  at  the  residence  of  Dr. 
Ward  B.  Hoag.  126  West  Eighty-first  Street,  on  Saturday 
evening,  February  27th,  at  8:15  o'clock.  Dr.  John  McCoy 
will  present  a  paper  entitled  New  Methods  of  Testing  the 
Internal  Ear,  Especially  the  Functionating  Condition  of 
the  .Semicircular  Canals,  and  the  Differential  Diagnostic 
Sxmptoms  of  Cerebellar  Abscess.  Dr.  Ernest  V.  Hulibard 
will  read  a  paper  on  the  Removal  of  the  Tonsils,  Partial 
and  Complete,  and  will  exhibit  some  new  instruments. 

Vital  Statistics  of  New  York  City. — During  the  week 
ending  February  13,  1909.  there  were  1,412  deaths  from 
all  causes  reported  to  the  Department  of  Health.  The 
annual  death  rate  in  a  thousand  population  was  16.14,  as 
against  a  death  rate  of  20.02  for  the  corresponding  period 
in  190S.  The  annual  death  rate  for  the  week  in  the  several 
boroughs  was  as  follows:  Manhattan,  16.11;  the  Bronx, 
19.04;  Brooklyn,  15.59:  Queens,  15.34;  and  Richmond, 
17.39.  The  total  number  of  deaths  of  children  under  five 
years  of  age  was  415,  of  which  238  were  under  one  year 
cf  age.  There  were  149  still  births.  Six  hundred  and 
eighty-eight  marriages  and  2,292  births  were  reported  dur- 
ing the  week. 

An  Esperanto  Association  for  Physicians. — Dr.  Ken- 
neth W.  Millican.  of  Chicago,  informs  us  that  at  the  last  Es- 
peranto Congress,  held  in  Dresden  last  summer,  there  was 
formed  an  association  of  physicians  interested  in  Esperanto, 
with  Professor  Dor,  of  Lyons,  as  president.  Representatives 
called'"consuls"  were  appoinited  for  various  countries,  among 
them  Dr.  Millican  for  the  United  States.  A  monthly  jour- 
nal, the  Vocho  dc  Kura<:istoj.  was  established,  and  it  will 
be  furnished  gratuitously  to  all  members  of  the  Tutmonda 
Esperanto  Kuracista  Asocio.  as  the  organization  is  called. 
The  subscription  ($1  annually)  may  be  sent  to  Dr.  Milli- 
can, 103  Dearborn  Avenue,  Chicago,  who  will  receive  and 
transmit  applications  for  membership. 

The  Pathology  of  Childhood.- -At  a  joint  meeting  of 
the  Philadelphia  Prediatric  Society  and  the  Pathological 
Societj-  of  Philadelphia  held  on  Thursdaj-  evening,  Febru- 
ary 25th,  the  evening  was  devoted  to  a  consideration  of 
the  subject  of  childhood  pathology.  A  splendid  exhibition 
of  pathological  specimens  was  inspected  by  both  members 
and  visitors  before  and  after  the  reading  of  the  papers. 
The  principal  paper  of  the  evening  was  read  by  Dr.  John 
Howland,  of  New  York,  entitled  A  Consideration  of  the 
Pathological  Anatomy  and  Pathogenesis  of  Status  Lymph- 
aticus  in  Children.  Other  papers  presented  were :  .Ante- 
natal Pathologj',  by  Dr.  Barton  Cooke  Hirst ;  Infections 
of  the  New  Horn,  by  Dr.  S.  McC.  Hamill ;  Tumor  Growth 
in  Childhood,  bv  Dr.  David  Riesman ;  The  Neuropathology 
of  Qiildhood,  by  Dr.  D.  J.  McCarthy. 

The  New  Psychiatric  Clinic  at  the  Johns  Hopkins 
Hospital. — Announcement  is  made  that  the  gift  of  Mr. 
Henry  Phipps,  of  New  York,  to  the  Johns  Hopkins  Hos- 
pital, for  the  establishment  of  a  psychiatric  clinic,  amounts 
to  over  $1,000,000.  As  originally  planned,  the  cost  of 
the  buildings  would  have  been  much  less,  but  after  a  care- 
ful study  of  the  construction  and  equipment  of  such  build- 
ings abroad,  it  was  decided  to  make  the  psychiatric  clinic 
at  Johns  Hopkins  the  best  in  this  country  and  one  of  the 
best  in  the  world.  Dr.  Adolph  Meyer,  of  New  York,  has 
been  selected  as  the  head  of  the  new  department.  The  an- 
nouncement was  made  by  Dr.  William  H.  Welch  at  the 
celebration  of  the  thirty-third  anniversary  of  the  founding 
of  the  university.  Dr.  .Arthur  Twining  Hadlej%  president 
of  Yale  Universit}',  made  the  principal  address. 


450 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


The  New  Department  of  Mechanicotherapy  at  Co- 
lumbia.— The  newly  established  department  of  mechan- 
icotherapy has  been  opened  at  the  Vanderbilt  Clinic  of  the 
College  of  Physicians  and  Surgeons.  The  equipment,  which 
was  the  gift  of  Mrs.  Ray  Matshak,  in  memory  of  her  late 
husband,  consists  of  thirty  steel  machines.  Dr.  Charles  H. 
Jaeger,  instructor  of  orthopaedic  surgery  in  Columbia  Uni- 
versity, will  be  in  charge  of  the  new  department.  These 
machines  were  first  made  and  used  in  Germany,  where  at 
the  present  time  265  general  hospitals,  33  military  hospitals, 
and  15  universities  are  using  them.  They  are  used  exten- 
sively in  hospitals  abroad,  and  it  is  said  that  America  is 
about  the  only  important  country  which  has  not  used  them 
in  hospitals.  It  is  said,  however,  that  Columbia  will  be  the 
first  university  to  instruct  her  students  in  this  branch  of 
therapeutics. 

Infectious  Diseases  in  New  York: 

We  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  fullovjing  statement  of  new 
cases  and  deaths  reported  for  the  two  weeks  ending  Feb- 
ruary 20,  iQog: 

^February  13— ^  ^February  20-^ 
Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis   pulmonalis    444  180         457  187 

Diphtheria    496  56         369  38 

Measles    499  13         608  20 

Scarlet  fever    367  18         388  16 

Smallpox   

Varicella    234  ..  210 

Typhoid  fever    25  9  20  s 

Whooping  cough   48  4  5^  5 

Cerebrospinal  meningitis    4  4  9  6 

Totals   2,117         284       2,113  277 

Scientific   Society   Meetings   in   Philadelphia   for  the 
Week  Ending  March  6,  1909. 

MoND.-w,  March  ist. — Philadelphia  Academy  of  Surgery; 
Biological  and  Microscopical  Section,  Academy  of  Nat- 
ural Sciences;  West  Philadelphia  Medical  Association; 
Northwestern  Medical  Society. 
Tuesday,  March  ^d. — Academy  of  Natural  Sciences ;  Phil- 
adelphia Medical  Examiners'  Association ;  Wills  Hos- 
pital Ophthalmic  Society. 
Wednesday,  March  3d. — College  of  Physicians. 
Thursday,    March    4th. — Obstetrical    Society ;  German- 
town  Branch,  Philadelphia  County  Medical  Society; 
Southwark  Medical  Society;  Section  Meeting,  Frank- 
lin Institute ;  Delaware  Valley  Ornithologists'  Club. 
Friday,  March  5th.- — American  Philosophical  Society ;  Ken- 
sington Branch,  Philadelphia  County  Medical  Society. 
A  State  Hospital  for  Advanced  Cases  of  Tuberculosis 
in  New  York. — A  bill  has  been  introduced  into  the  New 
York  State  Legislature  by  Senator  Schulz  providing  for 
the  establishment  of  a  State  hospital  for  the  care  and  treat- 
ment of  intermediate  and  advanced  cases  of  pulmonary 
tuberculosis.    At  the  State  Hospital  for  Tuberculosis  at 
Ray  Brook,  in  the  Adirondacks,  only  incipient  cases  are  re- 
ceived.   The  bill  provides  for  an  appropriation  of  $150,000 
for  the  purchase  of  a  site  and  the  erection  of  suitable 
buildings,  the  selection  of  the  site  to  be  subject  to  the  ap- 
proval of  the  State  Board  of  Health.    Provision  is  made 
for  the  appointment  of  five  trustees,  two  of  whom  must  be 
physicians,  who  will  have  the  supervision  of  the  hospital 
and  submit  annual  reports  to  the  State.    Indigent  patients 
will  be  given  the  preference  in  the  matter  of  accommoda- 
tion, but  when  there  is  sufficient  room  pay  patients  will  be 
received. 

Model  Tenements  for  the  Tuberculous. — Mrs.  William 
K.  Vanderbilt,  Sr.,  who  has  taken  an  active  interest  in  the 
tuberculosis  clinic  at  the  Presbyterian  Hospital  for  a  num- 
ber of  years,  has  given  $1,000,000  for  the  erection  of  four 
model  tenement  houses  in  East  Seventy-seventh  and  Sev- 
enty-eighth Streets,  between  Avenues  A  and  B,  New  York, 
where  tuberculous  patients  and  their  families  may  live  un- 
der conditions  similar  to  those  existing  in  sanatoria.  Dr. 
Henry  L.  Shively,  head  of  the  clinic,  has  worked  out  the 
plans  for  these  houses  in  connection  with  Mr.  Henry  At- 
terbnry  Smith,  the  architect.  The  buildings  will  be  called 
the  Shively  Sanitary  Tenements,  and  will  be  operated  un- 
der the  supervision  of  the  tuberculosis  clinic  of  the  Presby- 
terian Hospital.  There  will  be  accommodations  for  about 
four  hundred  families.  'I  he  apartments  will  consist  of  from 
two  to  five  rooms  each,  and  the  rents  will  compare  favor- 
ably with  the  prices  charged  for  the  poorest  tenements  on 
the  East  Side.   In  preparing  the  plans  special  care  has  been 


taken  to  secure  the  proper  ventilation  both  of  the  rooms 
and  the  courts.  AW  the  rooms  will  be  outside  rooms,  and  each 
apartment  will  be  provided  with  a  balcony,  with  windows 
reaching  from  the  floor  to  the  ceiling,  thus  making  sleeping  in 
the  open  air  both  possible  and  practicable.  The  roofs  will  be 
fitted  up  with  sun  parlors,  comfortable  chairs,  shrubbery 
and  flowers.  The  buildings  will  be  of  reinforced  concrete, 
steel  and  terra  cotta,  and  will  be  absolutely  fireproof.  In 
finding  tenants  for  the  buildings  care  will  be  taken  to  keep 
those  who  are  financially  able  to  afford  better  quarters  from 
crowding  out  the  really  poor.  It  is  said  that  the  Presby- 
terian tuberculosis  clinic  alone  has  about  a  thousand  fam- 
ilies in  its  care,  and  Dr.  Shively  thinks  that  the  apartments 
will  be  filled  at  once.  If  there  is  any  room  to  spare,  other 
tuberculosis  clinics  will  be  allowed  to  find  sanitary  quarters 
for  their  patients  and  their  families  in  these  tenements. 

The  Mortality  of  Chicago. — The  total  number  of 
deaths  from  all  causes  reported  to  the  Department  of 
Health  during  the  week  ending  February  13,  1909,  was  the 
same  as  for  the  preceding  week,  viz.,  592,  which  was  107 
less  than  in  the  corresponding  week  in  1908.  The  annual 
death  rate  in  a  thousand  population  was  13.88,  as  against  a 
death  rate  of  16.83  f'^''  the  corresponding  period  last  year. 
The  principal  causes  of  death  were :  Diphtheria,  13  deaths ; 
scarlet  fever,  6  deaths ;  measles,  3  deaths ;  influenza,  4 
deaths ;  typhoid  fever,  6  deaths ;  diarrhoeal  diseases,  38 
deaths,  of  which  29  were  under  two  years  of  age;  pneu- 
monia, 122  deaths ;  pulmonary  tuberculosis,  66  deaths ;  other 
forms  of  tuberculosis,  3  deaths ;  cancer,  36  deaths ;  nervous 
diseases,  18  deaths ;  heart  diseases,  49  deaths ;  apoplexy,  15 
deaths ;  bronchitis,  7  deaths ;  Bright's  disease,  42  deaths ; 
violence,  32  deaths,  of  which  5  were  suicides ;  all  othei 
causes,  138  deaths. 

The  Tristate  Medical  Association  of  Virginia  and 
the  Carolinas. — The  eleventh  annual  meeting  of  this  so- 
ciety, which  was  held  in  Charleston,  S.  C,  on  February 
i6th  and  i/th,  was  one  of  the  most  successful  in  the  history 
of  the  organization.    The  programme  included  a  long  list 
of  papers  by  prominent  members  of  the  medical  profession, 
and  the  discussions  were  particularly  interesting  and  in- 
structive.   Ample  entertainment  had  also  been  provided  for 
the  visitors.    Richmond,  Va.,  was  selected  as  the  next  place 
of  meeting,  and  the  following  officers  were  elected  for  the 
ensuing  year :  President,  Dr.  Le  Grand  Guerry,  of  Colum- 
bia, S.  C. ;  vice-oresidents.  Dr.  J.  W.  Jervey,  of  Greenville, 
S.  C. ;  Dr.  W.  W.  McKenzie,  of  Salisbury,  N.  C,  and  Dr. 
J.  W.  White,  of  Richmond,  Va. ;  secretary  and  treasurer, 
Dr.  J.  Howell  Way,  of  Waynesville,  N.  C. ;  executive  coun- 
cil, Dr.  R.  C.  Bryan,  of  Richmond.  Va. :  Dr.  J.  A.  Bur- 
roughs, of  Ashevjlle,  N.  C. ;  Dr.  C.  F.  Williams,  of  Colum- 
bia, S.  C. ;  Dr.  Stephen  Harnsberger,  of  Catlett,  Va. ;  Dr. 
David  T.  Tayloe,  of  Washin.gton,  N.  C. ;  Dr.  H.  E.  Mc- 
Connell,  of  Chester,  S.  C. ;  Dr.  J.  S.  Irvin,  of  Danville, 
Va. ;  Dr.  A.  J.  Crowell.  of  Charlotte,  N.  C. ;  and  Dr.  Archi- 
bald McEachern  Baker,  of  Charleston,  S.  C. 
Society  Meetings  for  the  Coming  Week: 
Monday,  Marcii  ist. — German  Medical  Society  of  the  City 
of  New  York;  Utica,  N.  Y..  Medical  Library  Associa- 
tion :  Niagara  Falls,  N.  Y.,  Academy  of  Medicine ; 
Practitioners'  Club,  Newark,  N.  J. :  Hartford,  Conn., 
Medical  Societj'. 
Tuesday,  March  2d. — New  York  Academy  of  Medicine 
(Section  in  Dermatology)  ;  New  YorJv  Neurological 
Society;  Buffalo  .Academy  of  Medicine   (Section  in 
Surgery)  ;  Ogdensburgh.  N.  Y.,  Medical  Association ; 
Syracuse,  N.  Y.,  Academy  of  Medicine;  Hudson  Coun- 
ty, N.  J.,  Medical  Association  (Jersey  City)  ;  Medical 
Association  of  Troy.  N.  Y.,  and  Vicinity ;  Hornells- 
ville,  N.  Y.,  Medical  and  Surgical  Association ;  Long 
Island,  N.  Y..  Medical   Society ;  Bridgeport,  Conn., 
Medical  Association. 
Wednesday,  March  3d. — Society  of  Alumni  of  Bellevue 
Hospital ;  Harlem  Medical  Association,  New  York ; 
Elmira,  N.  Y.,  Academy  of  Medicine;  Psychiatrical 
Society  of  New  York. 
Thursday.  March  4th. — New  York  Academy  of  Medicine; 

Dansville.  N.  Y.,  Medical  Association. 
Friday,  March  -ith. — New  York  Academy  of  Medicine 
(Section  in  Surgery)  :  New  York  Microscopical  So- 
ciety ;  Gynaecological  Society,  Brooklyn,  N.  Y. ;  Man- 
hattan Clinical  Society,  New  York ;  Practitioners'  So- 
ciety of  New  York 


February  27,  i9>^9  l 


PITH  OF  CURRENT  LITERATURE. 


451 


|itfe  at  ^Xixxm  f  iteramrt. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

February  i8,  1909. 

1.  The  Emamiel  Movement,     By  Charles  Dean  Young. 

2.  Mutual  Relations  of  Prosecuting  Officers  and  Medical 

Examiners,  By  Herbert  Parker. 

3.  Criminal  Abortion,  By  George  S.  Taft. 

4.  Fibroid  Phthisis  in  Childhood  with  Presentation  of  a 

Case,  By  Arthur  Willard  Fairbanks. 

5.  The  Aloin  or  Guaiac  Test  for  Blood  Depends  Solely 

upon  the  Iron  Contained  in  its  Haemoglobin, 

By  William  F.  Whitney. 

4.  Fibroid  Phthisis  in  Childhood. — Fairbanks 
reports  such  a  case  in  a  boy  of  ten  years  of  age.  He 
remarks  that  the  factor  that  makes  the  disease  a 
well  marked  chnical  entity  is  the  widespread  char- 
acter of  this  interstitial  proliferation.  Many  pro- 
cesses in  the  pulmonary  tissue  are  accompanied  or 
followed  by  circumscribed  increase  of  connective 
tissue,  but  this  disease  is  a  diffuse  proliferation  of 
this  tissue,  involving  one  entire  lobe  or  one  lung. 
The  process  is  almost  invariable  apparently  sec- 
ondary to  some  preceding  affection.  Among  these 
apparent  exciting  factors  are  antecedent  lobar  and 
lobular  pneumonia,  long  continued  bronchitis,  espe- 
cially that  accompanying,  measles,  pertussis,  and  in- 
fluenza, and  long  continued  pleurisies,  either  with 
or  without  exudate.  Many  theories  have  been 
evolved  to  explain  why  these  exceedingly  common 
conditions  should  in  one  instance  be  followed  by 
the  affection  under  consideration,  while  in  999 
others  no  such  result  ensues.  Of  the  theories 
evolved,  the  most  plausible  and,  at  the  same  time, 
the  most  difficult  one  to  prove  is  the  assumption  of 
an  individual  predisposition  to  excessive  interstitial 
connective  tissue  formation  in  the  exceptional  in- 
stances in  which  the  affection  occurs.  It  is  impos- 
sible to  forecast  the  prognosis  of  any  individual 
case  of  the  affection.  We  can  only  say  that  it  is 
extremdy  chronic  but  may  at  any  time  be  inter- 
rupted with  fatal  results  by  intercurrent  disease  or 
by  cardiac  failure.  That  its  course  may  be  extraor- 
dinarily chronic  is  evidenced  by  his  case,  which  has 
been  under  observation  six  years  and  probably 
dates  from  the  attack  of  pneumonia  two  years  pre- 
viously, which  gives  thus  far  a  duration  of  eight 
years.  It  teaches  us  that  we  should  not  be  hasty 
in  giving  a  hopelessly  unfavorable  prognosis  be- 
cause the  physical  signs  are  pronounced  early  in 
the  course  of  the  disease. 

5.  The  Aloin  or  Guaiac  Test  for  Blood. — Whit- 
ney reminds  us  that,  in  1861,  Van  Deen  first  called 
attention  to  the  fact  that  if  a  tincture  of  gum  guaiac 
is  mixed  with  a  solution  of  blood  coloring  matter 
and  then  a  fluid  carrying  loosely  combined  oxygen 
is  added,  a  deep  blue  color  is  at  once  developed, 
fading  away  after  a  short  time.  Aloin  is  another 
substance  which  gives  a  color  reaction  in  the  same 
way,  only  it  is  red  instead  of  blue.  This  was  first 
brought  into  notice  by  Klunge  about  twenty  years 
later.  Because  of  their  delicacy  and  ease  of  appH- 
cation,  these  two  tests  are  employed  in  the  prelimi- 
nary examination  of  suspected  blood  stains.  But 
their  real  value  is  chiefly  negative,  as  it  has  been 
found  that  there  are  many  other  substances  which 
give  the  same  reaction.    Therefore,  if  a  suspected 


stain  reacts  with  guaiac,  or  aloin,  further  tests 
must  be  made  to  prove  that  it  is  blood,  while  if  it 
does  not  react  it  can  be  surely  stated,  without  fur- 
ther testing,  that  it  is  not  blood,  at  least,  does  not 
contain  normal  blood  coloring  matter.  The  sub- 
stances which  have  been  found  to  react  are  iron  and 
many  of  its  salts,  manganese,  copper,  gold,  and 
platinum  salts,  extracts  of  some  plants,  watery  ex- 
tract from  leather  or  even  flannel,  and  some  kind 
of  filter  paper.  Of  these  iron  at  once  attracts  at- 
tention since  it  is  one  of  the  constituents  of  the 
normal  blood.  He  then  describes  experiments  with 
iron  and  its  salts,  and  with  haemoglobin,  and  comes 
to  the  conclusion  that  the  aloin  and  guaiac  tests 
are  not  tests  for  blood,  but  simply  for  its  iron  and 
are  utterly  valueless  for  suspected  stains  upon  any 
iron  article,  such  as  a  knife  blade,  hammer,  or  axe 
head.  It  enables  us  to  understand  better  why  their 
chief  value  is  a  negative  one  and  that  the  failure 
to  obtain  such  a  delicate  reaction  shows  the  absence 
of  any  normal  blood  coloring  matter  with  its  con- 
tained iron. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 
February  20,  1909. 

1.  Conclusions  from  1,087  Conjunctival  Tuberculin  Tests 

by  a  Uniform  Method,         By  Edward  R.  Baldwin. 

2.  The  Municipality  and  Its  Relation  to  Preventable  Dis- 

ease, By  J.  W.  Kerr. 

3.  Planning  and  Construction  of  Hospitals  for  Smaller 

Cities  and  Towns,  By  Meyer  J.  Sturm. 

4.  An  Epidemic  of  Acute  Anterior  Poliomyelitis,  Occur- 

ring in  Salem,  Va.,  and  Vicinity, 

By  R.  Minor  Wiley  and  J.  C.  Dardeen. 

5.  Mechanical  and  Dynamic  Obstruction  of  the  Bowels, 

By  J.  Sheldon  Horsley. 

6.  Theoretical  and  Practical  Considerations  Concerning  the 

Significance  of  the  Conjunctival  Reaction  (Ocular 
Tuberculin  Test),  By  A.  Wolff-Eisner. 

7.  The  Surgery  of  Syphilis,  By  G.  Frank  Lydston. 

8.  Relation  between  Pseudohaemisystole  and  Dropped  Beat, 

By  D.  Felderbaum  and  L.  J.  Pollock. 

9.  The  Medical  Society  and  the  Medjcal  Men  of  One  Hun- 

dred Years  ago.  By  Louis  W.  Flanders. 

I,  6.  Ocular  Tuberculin  Test. — Baldwin  re- 
marks that  the  conjunctival  tuberculin  test  per- 
formed with  weak  solutions  by  a  single  instillation 
has  some  value  in  confirming  the  presence  of  tuber- 
culosis in  the  early  stages.  It  has  little  value  in 
confirmation  when  the  symptoms  of  tuberculosis 
are  only  suspicious.  Its  value  in  distinguishing 
"active  latent"  from  healed  tuberculosis  in  appar- 
ently healthy  persons  has  not  yet  been  determined.. 
Repetition  of  the  test  in  the  same  eye  has  no  ad- 
vantage over  the  cutaneous  and  subcutaneous  tests 
in  the  percentage  of  reactions  produced  and 
may  be  misleading  and  dangerous.  Repetition  in 
the  other  eye  by  the  author's  method  offers  so 
little  advantage  that  it  cannot  be  recom- 
mended. The  conjunctival  reaction  is  unreliable 
for  prognosis.  Used  with  the  proper  precau- 
tions, danger  to  the  eye  is  slight  and  need  not  pre- 
clude the  test  when  other  methods  are  inapplicable, 
as  when  fever  is  present.  It  should  be  restricted  to 
adults,  since  the  cutaneous  test  has  been  found 
equally  valuable  for  children  and  is  harmless.  The 
cutaneous  test  by  the  simultaneous  use  of  dilute 
and  strong  tuberculin  offers  a  method  of  detecting 
at  once  or  excluding  tuberculous  infection  with  no 
danger  or  inconvenience.  Experience  is  needed  to 
show  the  value  of  this  method.    The  subcutaneous 


452 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


test  should  be  restricted  to  those  cases  in  which  a 
focal  reaction  at  the  site  of  the  disease  is  desired 
and  when  the  other  tests  result  negatively. — Wolff- 
Eisner  says  that  the  subcutaneous  and  the  cutaneous 
methods  are  specific  reaction  for  tuberculosis.  As 
they  both  demonstrate  active  and  latent  tuberculo- 
sis, their  use  is  extremely  limited  for  clinical  diag- 
nosis. The  positive  conjunctival  reaction  shows 
only  active  tuberculosis,  while  the  conjunctival  re- 
action in  clinically  healthy  individuals  makes  the 
suspicion  that  they  are  affected  particularly  strong. 
A  negative  result  in  those  manifestly  tuberculous 
justifies  a  bad  prognosis,  but  in  advancing  tuber- 
culous disease  negative  reactions  become  more  fre- 
quent. A  positive  conjunctival  reaction  does  not 
justify  a  good  prognosis,  but  this  is  the  case  only  in 
the  so  called  Daucrrcactioii  (continued  reaction)  a 
form  of  the  cutaneous  reaction.  It  is  possible  to 
create  receptors  in  tissues  that  are  indifferent  as 
regards  life,  such  as  connective  tissue,  these  recep- 
tors attracting  tuberculin  and  localizing  the  toxic 
action.    This  observation  is  of  therapeutic  value. 

2.  Municipality  and  Disease. — Kerr  observes 
that  the  government  of  the  United  States  is  unique 
in  that  it  blends  national  sovereignty  and  local  self 
government  in  such  manner  as  to  preser\e  the  in- 
tegrity-of  each.  While  police  powers  with  respect 
to  sanitation  within  the  States  have  been  reserved 
to  the  States  themselves,  the  national  government 
is  responsible  for  insanitary  conditions  affecting 
more  than  one  State  or  territory,  and  in  the  exer- 
cise of  its  authority  it  can  protect  and  aid  local  gov- 
ernments without  usurping  any  of  their  powers  or 
privileges.  The  cardinal  duties  of  the  federal  gov- 
ernment in  conserving  the  public  health  are,  first, 
the  prevention  of  the  introduction  of  contagious 
and  infectious  diseases  from  without  as  well  as 
their  spread  from  one  State  or  territory  to  another ; 
second,  the  investigation  of  communicable  diseases, 
the  conditions  favoring  their  spread,  and  the  meth- 
ods necessary  for  their  prevention  ;  third,  the  dis- 
semination of  sanitary  information  thus  acquired ; 
and,  fourth,  cooperation  with  State  and  municipal 
health  authorities  for  the  protection  of  life  and 
health.  All  these  measures  are  of  direct  interest  to 
municipalities,  and  their  enforcement  by  the  na- 
tional government  will  result  in  improved  municipal 
sanitation  throughout  the  country.  Provision  now 
exists  in  law  for  the  performance  of  certain  of 
these  duties,  but  additional  legislation  is  necessary 
to  enable  the  national  health  service  adequately  to 
meet  the  demands  made  on  it  in  the  interest  of  the 
public  health.  At  the  same  time  there  must  also  be 
granted  more  authority  to  State  and  municipal  au- 
thorities if  we  would  attain  the  standard  of  sanitary 
excellence  which  is  to  be  expected  of  us. 

4.  An  Epidemic  of  Acute  Anterior  Poliomye- 
litis.— Wiley  and  Dardeen  report  a  small  e])i- 
demic  of  anterior  poliomyelitis,  which  occurred  in 
Salem,  Va.  In  regard  to  the  treatment  our  author 
administered  salicylates  and  applied  counter  irrita- 
tion either  in  the  form  of  mustard  plasters  or  of 
tincture  of  iodine  to  the  spine  during  the  acute 
stage.  The  subsequent  treatment  consisted  of  as- 
cending doses  of  potassium  diodide  to  promote  ab- 
sorption in  the  inflammatory  area  in  the  cord,  and 


strychnine  in  increasing  doses  to  the  point  of  tol- 
eration for  its  tonic  effect.  They  also  employed 
massage,  warm  baths,  and  whenever  practicable  the 
galvanic  and  faradic  current.  In  none  of  these  pa- 
tients developed  deformities. 

7.  Surgery  of  Syphilis. — Lydston  says  that 
lesions  due  directly  or  indirectly  to  syphilis  should 
not  always  be  regarded  as  specific  from  the  stand- 
point of  treatment.  They  often  demand  surgical 
intervention,  based  on  the  merits  of  the  particular 
lesion,  and  more  or  less  independent  of  the  consti- 
tutional infection,  so  far  at  least  as  rational  treat- 
ment is  concerned.  Operations  on  syphilitic  pa- 
tients in  whom  the  constitutional  disease  is  under 
complete  or  fair  control  by  specific  medication  are 
likely  to  result  in  primary  union  of  the  wound  just 
as  though  syphilis  did  not  exist.  In  clean,  aseptic, 
incised  wounds  repair  will  often  occur  quite  as 
rapidly  as  in  nonsyphilitic  subjects.  In  open  wounds 
or  in  chronic  nonspecific  lesions  occurring  in  syph- 
ilitic subjects,  where  irritation  is  marked  and  per- 
sistent, the  syphilitic  constitution  unquestionably 
retards  repair.  Here  the  rational  employment  of 
mercury  and  iodides  is  an  indispensable  adjuvant  to 
the  knife.  Briefly,  it  might  be  said  that  in  chronic 
syphilitic  lesions  requiring  the  knife  surgery  is  the 
handmaiden  of  specific  therapy.  In  operations  on 
nonspecific  conditions  occurring  in  syphilitic  sub- 
jects the  importance  of  respective  roles  of  surgery 
and  therapeutics  is  reversed,  the  knife  playing  the 
principal  and  therapeutics  the  secondary  role. 

MEDICAL  RECORD. 

February  20,  igoQ. 

1.  Prostatectomy,  By  John  B.  De.wer. 

2.  A  Case  of  Acromegaly  with  Thrombophlebitis  of  the 

Superficial  Veins.  A  Study  of  the  Cardiovascular 
Changes  in  Acromegaly,  By  John  Phillips. 

3.  Free   Suppurative   Peritonitis.     Comments  on  Recent 

Discussions,  By  A.  E.  Isaacs. 

4.  Danger  Signals  in  Inflammation  of  the  Ear, 

By  Walter  ,A.  Wells 

5.  Paramyoclonus  Multiplex  (Friedreich).    Report  of  a 

Case,  with  Brief  Description  from  Oppenheim, 

By  E.  M.  Van  Buskirk  and  Alfred  Kane. 

6.  Treatment  of  Amoebic  Infection,     By  M.  B.  Saunders. 

I.  Prostatectomy. — Deaver  says  that  the  clin- 
ical distinction  between  carcinoma  and  hypertrophy 
of  the  prostate  is  far  from  being  eas)'.  Indeed, 
the  vast  majority  of  prostatic  carcinomata  are  not 
diagnosticated  before  operation.  A  tentative  diag- 
nosis of  a  prostatic  malignant  growth  is  warranted 
where  we  have  progressive  prostatic  enlargement 
in  a  man  rather  below  the  usual  age  for  prostatic 
hypertrophy  and  in  whom  the  local  symptoms  are 
rather  more  grave  than  would  seem  to  be  warranted 
by  the  condition  found  upon  examination.  The 
most  conspicuous  symptoms  are  sacral  and  perineal 
pain,  which  is  continuous  and  not  alone  associated 
with  mictin-ition.  The  pain  may  also  be  referred 
along  the  sciatic  and  anterior  crural  nerves.  Should 
the  prostate  be  extremely  firm  or  very  nodular  our 
suspicions  would  be  still  further  strengthened.  Per- 
haps the  most  reliable  sign  of  a  carcinomatous  in- 
volvement of  the  prostate  is  an  invasion  toward 
the  rectal  mucosa.  That  is  to  say,  in  prostatic  car- 
cinomata we  often  note  a  failure  of  the  rectal  wall 
to  slide  freely  over  the  prostate  gland.   There  is  no 


Kebruary  27,  1909.I 


PITH  OF  CURREXT  LITERATURE. 


453 


doubt  that  certain  chronic  cases  of  gonorrhoea  in 
which  the  prostate  is  greatly  involved  are  incurable 
as  long  as  the  prostate  remains.  W  hile  the  large 
majority  are  curable  by  prostatic  massage  and  other 
local  measures,  some  are  resistant  to  every  form 
of  treatment.  It  is,  however,  a  difficult  matter  to 
decide  when  to  advise  a  prostatectomy.  Most  men 
whom  we  see  with  this  condition  are  not  willing  to 
pay  such  a  price  for  the  cure  of  their  condition,  in- 
volving as  it  may  and  usually  does  interference 
with  normal  sexual  life.  So,  while  that  removal  of 
the  prostate  is  theoretically  desirable,  it  is  often  im- 
proper and  impracticable  to  advise  it.  Another 
prostatic  condition  should  be  noted  if  we  wish  to 
take  into  consideration  all  the  lesions  demanding 
prostatectomy.  This  is  tuberculosis  of  the  prostate. 
The  tuberculous  involvement  of  the  gland  is  rarely 
if  ever  an  independent  condition.  It  is  practically 
always  associated  with  tuberculosis  of  other  por- 
tions of  the  genitourinary  tract,  especially  the  epi- 
didymis and  bladder.  Before  undertaking  any  op- 
eration whatever  on  a  tuberculous  prostate  we 
should  be  sure  that  the  associated  organs  are  not 
so  involved  that  operation  w-ill  not  do  more  harm 
than  good,  and  that  the  patient  is  not  the  subject 
of  tuberculosis  elsewhere.  As  to  operation,  Deaver 
remarks  that  he  does  not  practise  the  Bottini  opera- 
tion any  more.  While  in  a  very  few  instances  it 
may  be  advisable,  he  considers  it  hazardous  and 
unsatisfactory.  The  improvements  in  the  technique 
of  prostatectomy  and  the  adaptation  of  various  op- 
erations to  the  needs  of  individual  patients  have 
rendered  the  operation  slightly,  if  at  all,  more  dan- 
gerous than  the  Bottini.  and  there  has  never  been 
any  question  concerning  the  relative  value  of  the 
two  methods  of  procedure  among  surgeons  who 
have  had  experience  wnth  both.  We  have  two  ap- 
proaches to  the  prostate,  the  suprapubic  and  the 
perineal  route.  The  suprapubic  route  has  very 
definite  advantages.  It  offers  a  free  exposure  of 
the  gland,  a  comparatively  large  working  area  and 
few  anatomical  difficulties.  It  is,  therefore,  the 
ideal  mode  of  approach  for  the  removal  of  large 
prostates  (soft  adenomatous).  There  is  a  larger 
working  space  and  we  are  not  compelled  to  remove 
the  gland  piecemeal.  We  know  also  that  as  a  gen- 
eral rule  haemorrhage  is  more  apt  to  occur  after 
the  removal  of  a  large  prostate,  which  leaves  a  deep 
bed  with  a  great  bleeding  surface.  If  the  bleeding 
is  excessive  it  is  very  easily  controlled  by  packing. 
Permanent  fistula  after  the  suprapubic  operation 
should  not  occur.  As  a  rule  the  patients  should  be 
well  in  from  four  to  six  weeks.  There  is  but  one 
serious  immediate  postoperative  complication,  and 
that  is  haemorrhage.  A  perineal  prostatectomy  he 
considers  the  operation  of  choice  in  all  small  and 
fibrous  prostates,  especially  those  situated  low  dow-n 
in  the  perinaeum.  There  are  several  reasons  for 
this  choice  of  approach.  In  the  first  place,  we  must 
traverse  much  less  space  to  reach  the  gland  itself. 
The  anatomy  is  somewhat  complex,  but  when  once 
mastered  it  presents,  even  when  pathologically 
altered,  no  very  grave  difficulties.  If  the  prostate 
is  very  adherent  to  its  outer  capsule,  removal  by 
the  suprapubic  method  may  be  impossible,  whereas 
by  the  perineal  it  may  be  accomplished.  Haemor- 


rhage after  a  properly  performed  perineal  opera- 
tion is  rare.  I'istulae  are  more  common  after  the 
perineal  than  after  the  suprapubic  operation,  and 
the  chances  of  an  operative  cure  are  even  less.  On 
the  other  hand,  they  are  probably  less  objectionable 
to  the  patient  than  the  suprapubic,  though  the  ex- 
istence of  either  variety  of  fistula  is  enough  to  pro- 
duce much  discomfort  to  the  sufferer. 

2.  Acromegaly.  —  Phillips  remarks  that  en- 
largement of  the  heart,  either  simple  or  associated 
with  a  myocarditis,  is  the  condition  usually  found  in 
acromegaly.  Sclerosis  of  the  arteries  and  degener- 
ative lesions  affecting  the  walls  of  the  veins,  with 
dilatation  and  subsequent  obliteration  of  their  lumen, 
are  constantly  present.  These  changes  in  the  heart 
and  vessels  should  be  considered  as  much  a  part  of 
the  clinical  picture  as  the  changes  in  the  bones,  and 
they  are  probably  due  to  the  prolonged  hyperten- 
sion of  the  vessels,  the  result  of  hypersecretion  of 
the  pituitary  body. 

6.  Treatment  of  Amoebic  Infection. — Saun- 
ders reminds  us  that  amoebic  infections  of  the  intes- 
tines are  very  resistant  to  treatment  and  prone  to 
relapses  after  either  long  or  short  intervals  of  time. 
The  cause  of  this  is  our  inability  to  get  our  medici- 
nal agent  in  contact  with  all  the  amoebae.  By  irri- 
gations we  are  powerless  to  kill  any  amoebae  lying 
deep  in  the  submucous  coat.  We  also  have  to  take 
into  consideration  that  many  amoebae  are  so  im- 
bedded in  mucus,  even  when  lying  superficially  in 
the  intestine,  that  the  solutions  wall  not  aft'ect  them. 
Also  that  amcebse  are  found  at  times  in  other  locali- 
ties of  the  body ;  the  well  known  tropical  abscess  of 
the  liver  is  by  far  the  most  common  secondary 
focus,  but  they  have  also  been  found  in  the  abdo- 
men, lung,  pleura!  and  pericardial  cavities,  etc.  In 
order  to  reach  these  deeply  seated  amoebae  the  most 
logical  method  is  systemic  treatment,  and  the  au- 
thor has  had  good  results  from  the  administration 
of  Chaparro  Amargoso.  He  favors  greatly  the  ad- 
ministration of  the  fluid  extract,  because  of  its  con- 
venience, in  drachm  doses  every  three  or  four  hours. 
Yet  he  has  had  patients  who  did  not  yield  to  this,, 
but  responded  to  infusion  of  the  bark  and  stems. 
The  drug  is  Chaparro  amargoso;  Castela  nicholsoni. 
Hook.  S  ynonyms  are:  Amargoso,  chaparro  bush, 
goat  bush.  Bark  of  stem  is  the  part  used.  Its  habitat 
is  Texas  and  Xorthern  jMexico.  The  U.  S.  Dispensa- 
tory (19th  Ed.)  has  the  following:  "Castela;  Cas- 
tela Nicholsoni,  Hook.  This  plant  is  reported  to 
have  antiseptic  properties,  probably  due  to  a  resin- 
ous principle  discovered  by  J.  L.  Putegnat  and 
named  by  him  amargosin."  This  amargosin  has  not 
been  fully  investigated;  and  the  ability  to  go  into 
the  open  market  and  get  the  drug  of  known  thera- 
peutic activity  has  been  unsatisfactory  with  our 
author.  The  natives  make  usually  an  infusion  of 
the  whole  plant.  This  is  a  bitter  mixture,  but  it  is 
as  good  medicinally  as  it  is  bad  in  taste  for  amoebic 
troubles.  The  infusion  is  drunk  freely  three  times 
a  day  before  meals,  the  treatment  usually  lasting 
from  three  to  twelve  months.  This  not  only  checks 
the  dysentery,  but  \\\\\  cause  small  hepatic  abscesses 
to  become  sterile,  and  under  continued  use  will  dis- 
appear. Large  abscesses  are,  of  course,  to  be  treat- 
ed surgically. 


454 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


BRITISH   MEDICAL  JOURNAL. 
February  6,  igoQ. 

1.  A  Lecture  on  Radium  in  Surgery,      By  Sir  F.  Treves. 

2.  Observations  on  Human  Glanders.    With  a  Study  of 

Six  Cases  and  a  Discussion  of  the  Methods  of  Diag- 
nosis, By  J.  M.  Bernstein  and  E.  R.  Carling. 

3.  Anaesthesia  in  the  Human  Subject  with  Known  Per- 

centages of  Chloroform  Vapor,      By  N.  H.  Alcock. 

4.  Atrophic  Rhinitis  Complicated  by  Mastoid  Abscess  and 

Extradural  Abscess,  By  F.  Stoker. 

5.  A  Case  of  CEdema  with  Resolution  by  Urinary  Crisis, 

By  H.  D.  RoLLESTON  and  F.  L.  Golla. 

I.  Radium  in  Surgery. — Treves  holds  that 
there  is  the  possibihty  of  a  great  ftiture  for  radium 
in  surgical  therapeutics.  Radium  will  cure  every 
form  of  nsevus,  including  "port  wine"  stains,  pig- 
mented moles,  and  hairy  moles.  It  cures  chronic 
local  eczemas,  especially  those  forms  associated  with 
itching.  It  causes  all  forms  of  keloid  to  vanish ; 
the  form  left  by  a  wound,  that  left  by  tuberculous 
glands,  and  that  obstinate  form  known  as  acne 
keloid.  Radium  will  cure  rodent  ulcers  which  have 
existed  for  many  years,  in  which  the  tissues  have 
become  adherent  to  the  bone,  or  apparently  to  the 
bone,  in  which  there  is  ulceration,  and  in  which  the 
X  rays,  the  Finsen  light,  and  cataphoresis  have  all 
been  tried  and  have  all  failed.  Such  cases  may  be 
cured  by  two  sittings  of  radium  lasting  one  hour 
each,  the  parts  being  finally  left  free  from  attach- 
ment to  the  deeper  parts,  the  skin  being  soft  and 
pliable.  It  has  been  said  that  radium  only  acts  by 
means  of  the  x  rays  which  are  part  of  its  radiation. 
But  here  are  cases  in  which  a  condition  is  cured 
which  has  refused  to  heal  after  persistent  treatment 
by  x  rays.  In  other  words,  radium  can  effect  a  cure 
where  x  rays  cannot;  Early  stages  of  epithelioma  of 
the  tongue  and  of  the  lip  are  cured  by  radium,  with 
apparently  permanent  results.  Radium's  main 
property  is  that  of  radioactivity — that  is,  it  gives  off 
rays  which  have  the  power  of  penetrating  solid  and 
opaque  substances,  of  affecting  a  photographic 
plate,  of  producing  fluorescence,  and  of  rendering 
air  or  other  gas  a  conductor  of  electricity.  These 
rays  are  of  three  kinds,  alpha,  beta,  and  gamma. 
The  alpha  and  beta  rays  are  composed  of  material 
particles  or  ions,  which  carry  a  charge  of  electricity. 
The  alpha  rays  carry  a  charge  of  positive  elec- 
tricity, have  a  relatively  slow  velocity,  and  little  pen- 
etrating power.  The  beta  rays  carry  a  charge  of 
negative  electricity,  move  with  a  high  velocity,  and 
have  great  penetrating  power.  The  gamma  rays 
are  of  a  different  type.  They  contain  no  ions; 
carry  no  electric  charge ;  have  enormous  penetrating 
power ;  and  move  with  about  the  same  velocity  as 
light.  The  beta  and  gamma  rays  are  inseparable. 
The  alpha  rays  are  supposed  to  give  off  the  heat, 
and  they  burn.  The  "cathode  rays"  of  the  x  rays 
correspond  to  the  beta  rays  of  radium.  As  regards 
the  application  of  radium  in  treatment,  the  main 
feature  is  surface.  The  strength  of  radium  is  esti- 
mated by  taking  uranium  as  a  unit.  Powdered  ra- 
dium is  placed  on  a  disc,  and  is  covered  with  a  very 
resistant  varnish ;  in  this  way  every  milligramme  is 
available.  Radium  must  be  ordered  by  a  definite 
prescription.  A  plate  of  a  certain  diameter  is  or- 
dered for  the  individual  case,  and  the  proportion  of 
alpha,  beta,  and  gamma  rays  stated.  The  distance 
should  be  stated ;  the  closer  the  plate  is  held  the 


more  intense  is  the  effect,  but  the  narrower  the  area 
of  action.  Radium  of  this  type  should  be  applied  an 
hour  at  a  time.  There  comes  off  from  radium  an 
emanation,  or  a  vapor,  which  renders  any  body  it 
touches  radioactive.  There  is  no  method  of  induc- 
ing radioactivity  except  by  the  emanation,  and  this 
emanation  leaves  on  any  surface  it  touches  an  active 
deposit — a  deposit  which  can  be  taken  off  and  re- 
moved. Further  investigation  along  the  following 
lines  is  required :  The  action  of  the  radium  rays  and 
of  their  emanation  on  bacteria  and  their  products ; 
the  selective  action  of  radium  on  certain  tissues,  as 
for  instance  on  vascular  tissue  as  in  the  case  of 
angiomata ;  the  effect  of  radium  in  large  amount ; 
the  effect  of  inhalation  of  the  emanation;  of  injec- 
tion into  the  diseased  parts  of  a  solution  of  the  ema- 
nation. 

2.  Glanders. — Bernstein  and  Carling  report 
six  cases  of  human  glanders,  three  of  which  proved 
fatal.  All  of  the  patients  gave  histories  of  occupations 
bringing  them  into  more  or  less  close  connection 
with  horses.  In  three  cases  diagnostic  injections  of 
mallein  were  given,  and  in  all  a  typical  reaction  fol- 
lowed. The  dose  used  was  ten  to  fifteen  minims. 
For  practical  purposes  animal  inoculation  was 
found  to  be  the  most  reliable  diagnostic  procedure. 
It  was  tried  in  four  cases  with  positive  results,  and 
in  one  afforded  the  only  means  of  arriving  at  a  posi- 
tive diagnosis.  An  emulsion  of  the  suspected  tissue 
should  be  inoculated  subcutaneously  into  the  abdo- 
men of  an  adult  male  guinea  pig.  If  inoculated  in- 
traperitoncally  the  contaminating  germs  may  cause 
death  from  peritonitis  before  the  characteristic  en- 
largement of  the  testes  with  acute  inflammation  and 
engorgement  of  the  timicse  vaginales  is  produced. 
The  reaction  is  noticeable  in  seven  to  ten  days  as  a 
rule,  but  may  be  delayed  for  several  weeks.  Bacte- 
rioscopical  diagnosis  from  smears  of  pus  is  often 
most  unsatisfactory,  the  bacilli  being  generally  very 
scanty.  But  the  cultural  characteristics  are  so  defi- 
nite and  so  constant  as  to  render  the  diagnosis  sim- 
ple. Smears  of  pus  on  glycerin  agar  produce  in 
twenty-four  hours  a  gelatinous  confluent  growth, 
and  on  potato  a  brownish  growth  in  forty-eight 
hours.  Histologically  there  is  only  one  feature  char- 
acteristic of  glandrous  lesions— the  peculiar  nuclear 
degeneration  known  as  chromatotaxis.  The  bacilli 
are  rarely  to  be  found  in  the  blood,  and  leucocytosis 
is  not  a  marked  feature. 

LANCET. 

February  6,  igog. 

1.  Certain  Forms  of  Jaundice  Capable  of  Relief  or  Cure 

by  Surgical  Treatment,  with  a  Consideration  of  the 
Operation  of  Choiecystenterostomy  Based  upon  an 
Experience  of  Sixty-four  Cases, 

By  A.  W.  M.  RoBsoN. 

2.  Early  Cardiac  Inadequacy,  By  L.  Williams. 

3.  Neurological  Fragments,  No.  XXI,    By  J.  H.  J.\ckson. 

4.  A  Case  of  Blood  Crisis  Occurring  in  Lardaceous  Dis- 

ease, By  T.  S.  Kerr  and  E.  I.  Spriggs. 

5.  The  Treatment  of  Empyemata,  with  Notes  from  Fifty- 

five  Consecutive  Cases,  By  G.  E.  Waugh. 

6.  Single  and  Successive  Extra  systoles.        By  T.  Lewis. 

7.  Two  Cases  of  Hypertrophic  Pulmonary  Osteoarthro- 

pathy, By  H.  E.  Svmes-Thompson. 

8.  A  Case  of  Excision  of   One  Kidney,  with  Quantitative 

Analysis  of  the  Urine, 
By  A.  P.  Dodds-Parker,  E.  P.  Poulton,  and  G.  H.  Hunt. 

9.  Shellfish  Typhoid  Fever,  By  H.  C.  Pattin. 


February  27,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


455 


10.  Some  Comparative  Measurements  of  the  Lives  of  Leu- 
cocytes when  the  Cells  are  Resting  in  the  Plasmata 
of  Different  Persons,  and  the  Possible  Application  of 
Such  ]\Ieasurements  as  an  Aid  to  Diagnosis  in  In- 
fective Disease,  By  H.  C.  Ross. 

2.  Early  Cardiac  Inadequacy. — Williams  states 
that  the  heart  may  be  described  as  inadequate, 
strictly  speaking,  whenever  any  of  Gaskell's  five 
essential  functions  become  impaired.  These  func- 
tions are  rhythmicity,  excitability,  conductivity,  con- 
tractility, and  tonicity.  The  first  result  of  impaired 
tonicity  is  dilatation,  so  that  it  is  by  the  signs  and 
symptoms  of  dilatation  that  we  have  to  recognize 
that  the  power  of  the  heart  is  no  longer  equal  to 
its  task  of  adeqtiately  maintaining  the  circulation. 
English  nomenclature  takes  no  cognizance  of  the 
various  degrees  of  dilatation;  in  France  they  dis-' 
tinguish  two  stages — the  first,  hyposystole,  and  the 
second,  asystole.  The  latter  is  faulty,  as  asystole, 
the  absence  of  systoles,  means  death.  A  better  term 
would  be  dyssystole.  But  the  author  concerns  him- 
self solely  with  the  signs  and  symptoms  of  hypo- 
systole  in  its  earliest  stages.  The  dyspnoea  of  hypo- 
systole  is  essentially  a  dyspnoea  of  effort.  When 
quiet  and  standing  or  sitting  up,  the  patient  expe- 
riences no  inconvenience.  But  when  the  muscles 
are  exercised  in  some  slight  exertion  he  becomes 
breathless.  This  is  especially  true  if  the  physical 
exertion  is  accompanied  by  mental  anxiety.  The 
two  cardiovascular  conditions  most  likely  to  cause 
dyspnrjea  are  ( i )  mitral  disease,  especially  mitral 
stenosis,  and  (2)  high  arterial  tension  or  hyper- 
piesis,  as  Albutt  terms  it.  Palpitation  or  faltering 
of  the  heart  is  a  signal  of  cardiac  distress.  The 
faltering  means,  in  all  probability,  a  temporary  loss 
of  tone,  a  slight  but  acute  dilatation  which  is  preg- 
nant with  hyposystolic  possibilities.  The  only  way 
to  arrive  at  a  just  conclusion  is  to  use  a  blood  pres- 
sure apparatus  ;  the  neglect  to  do  this  is  to  fail  in  an 
obvious  dtity.  A  form  of  cardiovascular  disturb- 
ance which  it  is  often  very  difficult  to  appraise  at  its 
true  value  is  tachycardia.  As  a  rule  heart  hurry 
is  more  often  due  to  arterial  causes  than  to  cardial. 
Marked  acceleration  of  the  pulse  beat  on  sitting  up 
usually  means  a  pronounced  loss  of  tone  in  the 
walls  of  the  systemic  arteries.  In  such  cases  albu- 
min is  often  found  in  the  urine,  and  may  lead  to 
an  unjustifiably .  alarming  prognosis.  But  tachy- 
cardia which  reveals  itself  only  or  more  especially 
in  the  recumbent  posture,  is  of  different  signifi- 
cance, and  is  often  cardiac  in  origin,  and  due  to 
hyposystole.  A  symptom  which  frequently  escapes 
the  attention  which  it  deserves  is  cedema  of  slight 
degree.  To  detect  it  in  its  earliest  stages  the  patient 
must  be  going  about  :  toward  the  end  of  the  day 
or  after  a  long  walk,  there  will  be  slight  but  definite 
pitting  over  the  tibia  just  above  the  ankles.  A 
marked  increase  in  the  amount  of  urine  during  the 
night — "nycturia"  as  it  is  called — and  a  decrease  in 
that  during  the  day  should  always  lead  one  to 
search  for  oedema  and  other  signs  of  commencing 
hyposystole.  QEdema  may  occur  in  very  inaccessi- 
ble places,  such  as  the  internal  organs.  When  this 
is  suspected,  careful  comparative  observations  of 
the  patient's  weight  will  be  of  value.  If  this  gradu- 
ally increases  while  the  amount  of  urine  lessens, 
oedema  is  probably  present.  The  influence  of  com- 
mon salt  in  the  production  of  oedema  must  be  borne 
in  mind.    In  a  person  who  takes  more  than  no 


grains  of  common  salt  a  day,  a  very  early  sign  of 
hyposystole  will  always  be  some  measure  of  oedema, 
and  the  treatment  should  always  include  restriction 
of  the  intake  of  chlorides.  In  the  examination  of 
the  heart,  the  question  of  its  size  is  of  the  greatest 
importance.  Where  the  blood  pressure  has  been 
high  for  months  a  normal  sized  left  ventricle  is  of 
bad  omen.  Of  sounds  other  than  murmurs,  the 
various  kinds  of  arrhythmia  are  of  the  greatest  im- 
portance. Other  symptoms  suggestive  of  hyposys- 
tole are :  Accentuation  of  the  second  sound  at  the 
aortic  cartilage ;  the  reduplicated  second  sound  at 
the  apex — the  "postman's  knock" ;  and,  finally,  the 
approximation  in  time  of  the  two  normal  sounds 
with  consequent  lengthening  of  the  refractory 
pause.  This  latter  phenomenon  is  common  after 
influenza. 

4.  Blood  Crisis. — Kerr  and  Spriggs  report  an 
instance  of  blood  crisis  occurring  in  a  man  aged 
thirty  years,  suffering  from  amyloid  disease.  The 
condition  was  characterized  by  the  appearance  of 
an  enormous  number  of  nucleated  red  cells  in  the 
blood — over  20,000  per  cubic  millimetre  on  one  oc- 
casion. The  red  cells  at  the  same  time  rapidly  in- 
creased in  number  and  the  amount  of  haemoglobin 
was  coincidently  increased.  From  these  facts  and 
from  the  improvement  in  the  patient's  general  con- 
dition, the  blood  crisis  may  be  regarded  as  a  regen- 
erative process.  Eight  days  after  the  crisis  the 
nucleated  red  cells  had  entirely  disappeared  from 
the  blood. 

ID.  Length  of  Leucocytic  Life  as  an  Aid  in 
Diagnosis.  —  Ross  summarizes  the  method  by 
which  he  endeavors  to  assist  in  a  diagnosis  in  a 
case  of  infective  disease,  as  follows :  A  small  quan- 
tity of  blood  from  a  patient  is  mixed  with  eight 
times  its  volume  of  the  citrated  plasma  of  other 
persons  who  are  known  to  be  suffering  from  cer- 
tain infective  diseases  and  also  with  the  citrated 
plasma  of  a  healthy  person.  Capillary  tubes  of  the 
various  mixtures  are  kept  in  a  revolving  apparatus 
for  fourteen  hours,  and  then  samples  of  their  con- 
tents are  examined  on  agar  films  prepared  from 
jelly  which  will  excite  movements  in  living  leuco- 
C3'tes.  The  number  of  living  and  dead  cells  are 
averaged,  and  the  difference  between  the  lengths  of 
the  lives  of  the  cells  when  resting  in  healthy  and  in- 
fected plasmata  are  determined.  When  an  infected 
plasma  is  found  which  will  not  comparatively  short- 
en the  lives  of  the  patient's  leucocytes,  it  seems 
probable  that  the  patient  is  suffering  from  the  same 
disease  as  the  person  from  whom  the  plasma  was 
taken.  This  procedure  can  then  be  confirmed  by 
reversing  the  process  and  trying  the  patient's  plas- 
ma on  the  leucocytes  of  other  persons  suffering 
from  the  disease  determined,  taking  care  to  make 
controls  in  both  cases  by  making  measurements 
with  healthy  plasma  and  with  the  plasma  of  persons 
suffering  from  other  diseases. 

LA  PRESSE  MEDICALE 

January  16.  igog. 

1.  Indications,  Technique,  and  Postoperative  Treatment  of 

Suprapubic  Prostatectomy,  By  G.  M.-^rion. 

2.  The  Growth  of  Pharmacodynamics, 

By  .Alfred  Martinet. 

3.  Spasmodic  Coryza  and  Autointo.xication,  By  P.  Cornet. 
4-    Tile  Action  of  the  Gonnococcic  Vaccine  upon  Gonor- 

rhseal  Joint  .Affections.  By  Carlos  M.mninl 


456 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Jourkau 


5.  Enormous  Invasion  of  the  Cerebrospinal  Fluid  by  the 

Microorganisms  and  Absence  of  Cellular  Reactions 
in  the  Course  of  Cerebrospinal  Meningitis, 

By  RiBADEAU-DuiiAS  and  R.  Debre. 

6.  The  Radium  Treatment  of  Cancer,  By  R.  Rom  me. 
2.    Growth   of  Pharmacodynamics. — Martinet 

describes  the  development  of  the  science  of  the 
action  of  drugs  which  he  divides  into  four  stages : 
The  first  wholly  empirical,  the  second  wholly  ana- 
lytical, in  which  the  active  principles  of  the  drugs 
v.^ere  chemically  isolated  and  the  pharmacodynar.iic 
action  was  considered  due  to  a  specific  molecule ; 
the  third  analyticosynthetic,  in  which  the  pharma- 
codynamic was  thought  to  depend  upon  a  molecular 
fragment,  an  atom  or  group  of  atoms,  and  fourth 
the  physicochemic,  in  which  the  pharmacodynamic 
properties  are  held  to  depend  not  upon  such  and 
such  an  atom  or  group  of  atoms,  but  upon  the  man- 
ner of  their  grouping. 

4.  Gonococcic  Vaccine  and  Gonorrhoeal  Joint 
Affections. — ^Mainini  alleges  that  the  gonococcic 
vaccine  exercises  a  very  pronounced  analgesic 
action  in  gonorrhoeal  arthritis,  that  its  action  is  in- 
dependent of  the  opsonic  index  and  perhaps  does 
not  exercise  any  influence  over  the  course  of  the 
disease,  and  that  possibly  its  analgesic  action  might 
be  utilized  for  the  purpose  of  diagnosis  in  doubtf al 
cases  of  rheumatism  of  one  or  more  joints. 

January  20,  1909. 

1.  The  Relative  Number  Normally  of  the  Clear  Hepatic 

Cells  and  their  Glycogenic  Function, 

By  A.  Gilbert  and  J.  Jomier. 

2.  Variations  and  Measurement  of  the  Muscular  Tonus  as 

Given  by  a  Myotonometer,  By  P.  Hartenberg. 

1.  The  Clear  Hepatic  Cells. — Gilbert  and  Jo- 
mier do  not  think  .that  the  clear  state  of  the  hepatic 
cell  is  necessarily  connected  with  the  glycogenic 
function.  The  results  of  their  experiments  lead 
them  to  conclusions  contrary  to  those  of  Bernard 
and  Loederich. 

2.  A  Myotonometer. — Hartenberg  describes  an 
instrument  he  has  devised  for  ascertaining  and 
measuring  the  muscular  tonus,  and  gives  some  of 
the  results  he  has  obtained.  Thus  he  finds  in  the 
physiological  condition  that  the  tonus  is  higher  in 
the  morning  than  at  night,  that  it  is  diminished  by 
general  fatigue,  that  it  is  increased  by  muscular 
work,  that  stretching  a  muscle  diminishes  its  tonus, 
that  faradization,  cold  baths,  and  such  rubstances 
as  strychnine  and  caffeine  increase  the  tonus,  and 
that  the  tonus  is  not  in  relation  to  the  dynamomet- 
ric  force.  In  pathological  conditions  the  tonus 
undergoes  considerable  variations,  increased  in 
some  diseases,  decreased  in  others. 

January  23,  iQog. 

1.  Comparative  Value  of  the  Different  Operations  of  He- 
botomy,  B3"  Jeannin. 

2.  The  Mental  State  Produced  by  the  Disaster  in  Sicily, 

By  Hartenberg. 

3.  Action  of  Sodium  Chloride  in  Impaired  Stomach  Di- 

gestion, By  Floresco. 

4.  Occlusion  of  the  Duodenum,  By  R.  Rom  me. 

I.  Hebotomy. — Jeannin  compares  the  various 
operations  which  have  been  advocated,  and  speaks 
in  favor  of  the  open  method  rather  than  one  that  is 
performed  either  wholly  or  partially  in  a  subcutane- 
ous manner.  Of  the  open  operations  he  prefers 
that  of  Calderini. 


3.  Action  of  Salt  in  Impaired  Gastric  Diges- 
tion.— Floresco  thinks  that  troubles  of  the  gas- 
tric digestion,  vomiting,  regurgitation  and  dyspep- 
sia, may  be  influenced  and  arrested  by  the  addition 
of  common  salt  to  the  food  through  the  productio.i 
of  the  gastric  juice  and  the  closure  of  the  cardiac 
orifice  by  reflex  action. 

LA  SEMAINE  MEDICALE. 

January  20,  igog. 
The  Splenohepatic  Syndrome  in  Acute  Malarial  Poisoning, 

By  M.  A.  Chauffard. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 

January  iS,  IQ09. 

1.  Origin,  Prevention,  and  Treatment  of  Tuberculosis  of 

the  Cervical  Glands,  By  A.  Most. 

2.  Autoserotherapy  in  Serofibrinous  Pleuritis, 

*  By  SCHNUTGEN. 

3.  Further  Results  from  the  Use  of  Atoxyl, 

By  Hans  Knopf  and  R.  Fabian. 

4.  Abscess  of  the  Spleen  after  Epityphlitis, 

By  Friedrich  Neugebauer. 

5.  Correlation  between  the  Sexual  Qiaracteristics  and 

the  Suprarenal  Capsules,         By  Leopold  Thumixl 

6.  The  Importance  of  Tuberculin  in  the  Struggle  against 

Tuberculosis,  By  Siegmund  Elkan. 

7.  Contribution  to  the  Emanation  Treatment, 

By  Anton  Bulling. 

8.  The  Sterilizing  Properties  of  Osmotic  Currents, 

By  F.  Holzinger. 

9.  A  New,  Simple,  Quantitative  Method  of  Estimating 

Sugar  with  the  "Glukosimeter," 

By  I.  Zeehandel.\ar  Jbz. 

10.  JMechanical  Death  from  Thymus,        By  F.  C.  Lund. 

11.  The  Epithelial  Corpuscles  and  their  Relations  to  the 

Pathogenesis  of  Tetany,        By  Bruno  Glaserfeld. 

1.  Tuberculosis  of  the  Cervical  Glands. — !vIost 
traces  the  infection  in  most  cases  of  tuberculosis 
of  the  cervical  glands  to  the  tonsils  as  the  place  of 
entrance,  and  in  other  cases  to  the  mucous  mem- 
branes of  the  nose,  mouth,  and  throat.  Prophylaxis 
consists  in  the  prevention  of  the  access  of  the  germs 
of  tuberculosis  to  these  points  of  entrance.  This 
includes  the  prevention  of  transmission  of  the  dis- 
ease from  one  human  being  to  another  and  also  of 
introduction  of  the  germs  in  cow's  milk.  If  the 
glands  continue  to  increase  in  size  tmder  conserva- 
tive treatment  they  should  be  extirpated  surgically. 

2.  Autoserotherapy  in  Serofibrinous  Pleuritis. 
— Schnlitgen  reports  fifteen  cases  in  which  this 
treatment  was  tried.  The  results  were  good  in 
fourteen. 

3.  Atoxyl. — Knopf  and  Fabian  report  twelve 
cases  of  different  diseases  treated  with  atoxyl,  and 
point  out  what  they  consider  an  indispensable  pre- 
caution to  take  when  this  drug  is  being  used ;  to 
maintain  a  constant  watch  over  the  field  of  vision  in 
order  to  avoid  the  induction  of  amblyopia. 

4.  Abscess  of  the  Spleen  after  Epityphlitis. — 
Neugebauer  reports  three  cases  of  this  nature  suc- 
cessfully treated  by  evacuation  of  the  abscess.  He 
speaks  at  some  length  on  the  technique  of  this 
operation  of  splenotoiny. 

5.  Correlation  between  the  Sexual  Character- 
istics and  the  Suprarenal  Capsules. — -Thumim  re- 
ports a  case  in  which  a  girl  with  atrophic  ovaries, 
but  otherwise  perfectly  feminine  genitals  developed, 
after  sudden  cessation  of  the  menses,  secondary 
masculine  characteristics  in  the  form  of  a  beard 
and  of  a  masculine  growth  of  hair  over  the  upper 


February  27,  1909. J  PROCEEDINGS  OF  SOCIETIES. 


part  of  the  body,  associated  with  a  great  enlarge- 
ment of  the  thyreoid  gland  and  an  enormous  hyper- 
plasia of  the  tissue  of  the  suprarenal  capsules. 

8.  Sterilizing  Properties  of  Osmotic  Currents. 
— Holzinger  finds  from  his  experiments  that  there 
is  no  proliferation  of  bacteria  in  a  nutritive  solu- 
tion free  from  albumin  through  which  osmotic  cur- 
rents pass,  and  that  by  the  action  of  osmotic  cur- 
rents .a  nutritive  solution  free  from  albumin  and 
containing  bacteria  is  sterilized  in  the  course  of 
forty-eight  hours,  and  remains  sterile  as  long  as  the 
osmosis  is  maintained  with  sufficient  intensity. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 
January  jg,  igOQ. 

1.  Constitutional  Eczema  of  Infants,  By  Peer. 

2.  Treatment  of  Placenta  Pravia  and  Eclampsia, 

By  Baisch. 

3.  The  Opthalmoreaction  and  Prognosis  in  Tuberculous 

Diseases  during  Pregnancy,  By  Martin. 

4.  The  Predisposition  of  the  Apices  of  the  Lungs  to 

Tuberculous  Pthisis  and  the  Law  of  Localization  of 
the  First  Tuberculous  Foci  in  the  Lungs. 

By  Hart. 

5.  The  Demonstration  of  Hsmoglobin  and  its  Derivatives 

through  Haemochromogen  Cr>-stals  and  the  Absorp- 
tion Bands  Lying  in  the  Violet  or  Ultra^-iolet  Por- 
tion of  the  Spectrum  of  this  Substance. 

By  BURKER. 

6.  Experimental  Studies  Concerning  the  Generation  of 

At\-pical  Proliferations  of  Epithelium,     By  Stober 

7.  Border's  Bacillus  of  Whooping  Cough,     By  Seiffert. 

8.  Two  Cases  of  Suture  of  the  Lung  on  Account  of 

Severe  Haemorrhage,  By  Lotsch. 

9.  Use  of  Camphor  in  the  Alimentary  Intoxication  of 

Infants,  By  Wurtz. 

10.  Experiences  with  Medina!  (Schering),      By  Ebsteix. 

11.  Almatein,  '  By  Werxdorff. 
\2.    Acute  Posttraumatic  Dupuytren's  Contracture  of  the 

Fingers,  By  Wyss. 

13.  Habitual  Icterus  Gravis  of  the  New  Bom,   By  Xahm. 

14.  Obituao'  of  Dr.  Adolf  Schmid.  By  M.A.-i-ER. 

2.  Placenta  Praevia  and  Eclampsia. — Baisch 
favors  anterior  hysterotomy  in  cases  of  this  nature. 

3.  The  Ophthalmoreaction  in  Tuberculosis 
during  Pregnancy. — Martin  thinks  that  the  reac- 
tion or  nonreaction  of  the  eye  to  Calmette's  test 
in  pregnant  women  suffering  from  tuberculosis  is 
of  prognostic  value.  A  positive  reaction  is  a  good 
sign,  a  negative  is  tmfavorable. 

4.  Predisposition  of  the  Apices  of  the  Lungs 
to  Tuberculous  Phthisis. — Hart  affirms  that  the 
stenosis  and  restriction  of  function  of  the  upper 
aperture  of  the  thorax  produces  in  the  apices  of  the 
lungs  an  individual  predisposition  to  aerogenous, 
h?ematogenous,  and  lymphogenous  tuberculous  in- 
fection. Xot  only  is  there  a  favorable  physical  op- 
portunity afforded  for  the  settlement  of  tubercle 
bacilli,  but  a  favorable  nutrient  medium  is  devel- 
oped with  the  injun-  of  the  tissues  in  which  the 
bacilli  multiplv  and  exert  their  activity. 

7.  Bordet's  Bacillus. — Seiffert  asserts  that  the 
bacillus  pertussis  of  Bordet  is  clearly  distinguish- 
able from  the  bacillus  of  influenza  and  other  simi- 
lar bacilli,  that  it  is  nearly  always  to  be  found  in 
the  fresh  sputum  of  patient  suffering  from  whoop- 
ing cough,  that  it  disappears  with  the  abatement  of 
the  disease,  and  that  it  produces  agglutination  of 
the  serum  of  these  patients. 

8.  Suture  of  the  Lung. — Lotsch  reports  two 
cases,  one  of  a  stab  wound,  the  other  of  a  shot 
wound  of  the  lung,  in  both  of  which  a  high  de- 
gree of  haemothorax  rapidly  developed  with  a  dan- 
gerous degree  of  anaemia.    Brauer's  apparatus  was 


used.  An  intercostal  incision  was  made  in  each 
patient  down  upon  the  lung,  the  wounds  in  which 
were  closed  by  sutures.  In  each  case  the  subse- 
quent course  was  complicated  by  an  empyema,  but 
both  patients  eventuallv  recovered. 

12.  Acute  Posttraumatic  Dupuytren's  Con- 
tracture of  the  Fingers. — ^^'yss  reports  a  case  of 
thi>  nature  that  he  met  with  in  a  boy,  fourteen 
years  old,  who  had  accidentally  received  a  shallow 
incised  wound  in  the  palm  of  the  hand,  8  cm.  long. 
The  wound  healed  without  stitures  under  an  anti- 
septic dressing.  After  fourteen  days  the  hand  ap- 
peared well,  and  the  boy  was  allowed  to  return  to 
work.  He  worked  two  days,  and  then  returned 
with  a  painful  flexure  of  the  fourth  finger.  It 
could  not  be  extended  voluntarily,  and  passive  ex- 
tension caused  great  pain.  Recovery  followed 
tmder  daily  treatment  with  massage  and  painting 
with  tincture  of  iodine. 



frocffbings  of  ^ecietits. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  PEXX- 
SYLVAXIA, 

Fifty-eighth  Annual  Meeting,  held  in  Cambridge  Sl^rings,. 
Septeuiber  15,  16,  and  17,  1908. 

{Continued  from  page  40^.) 

Sectiox  in  Surgery. 

Dr.  T.  B.  Appel,  of  Lancaster,  in  the  Chair. 
The  X  Ray  Diagnosis  of  Joint  Tuberculosis. — 
Dr.  Tames  K.  Young,  of  Philadelphia,  read  a  paper 
on  this  subject.  The  x  ray  picttire  of  tuberculous 
joint  disease,  he  said,  was  very  characteristic,  but 
should  always  be  verified  by  laboraton,-  findings, 
such  as  microscopical  examinations,  tuberculin  in- 
oculations, cultures,  and  animal  inoculations.  The 
diagnosis  in  children  was  less  difficult  than  in  adults, 
but  in  the  former  the  condition  could  be  studied 
to  better  advantage  by  progressive  plates,  since  the 
disease  was  more  rapid.  The  surgeon  himself  should 
make  the  diagnosis  from  his  study  of  the  plates, 
since  he  had  alsb  the  clinical  symptoms  to  aid  him, 
and  his  x  ray  findings  could  be  verified  by  the  other 
methods. 

Compound,  Comminuted  Fractures  of  the 
Tibia. — Dr.  W.  J.  Lowrv.  of  Carbondale,  said  in 
this  paper  that  in  treating  this  condition  he  smeared 
his  hands  and  the  tissues  about  the  wound  with  ster- 
ile petrolatum  and  filled  a  small  glass  syringe  with 
a  mixture  of  carbolic  acid.  95  per  cent.,  and  glycerin, 
5  per  cent.,  and  then  plugged  all  external  openings 
in  the  wound,  leaving  only  space  in  one  portion  to 
insert  the  tip  of  the  syringe.  He  now  forced  this 
carbolic  acid  solution  into  the  wound  with  sufficient 
pressure  to  reach  every  pocket  of  soft  and  bony  tis- 
sue. In  from  fifteen  to  thirty  seconds  this  solution 
was  followed  in  the  same  manner  with  about  five 
times  the  volume  of  alcohol. 

Fractures  of  the  Pelvis  with  Special  Relations 
to  Urethral  Injury. — Dr.  Fell  stated  that  in  frac- 
ture of  the  pelvis  all  the  bones  were  subject  to  in- 
jur}-, especially  in  the  ilium  and  the  os  pubis.  The 
urethra  might  be  injured  in  the  bulbar,  the  mem- 
branous, or  the  prostatic  portion,  but  in  the  mem- 
branous most  frequently.  It  was  impossible  to  de- 
termine the  amotmt  of  injur\-  without  thorough  ex- 
amination by  the  urethra  and  rectum  and,  in  the  fe- 


458 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal, 


male,  by  the  vagina.  The  most  valuable  informa- 
tion could  be  obtained  by  using  the  catheter.  If 
blood  was  present  in  the  urine  there  was  some  in- 
jury to  the  parts  above  the  prostatic  portion,  and  it 
might  be  to  the  kidney.  If  a  soft  catheter  would 
not  pass  and  became  clogged  with  blood,  or  if  blood 
was  passed  through  the  urethra,  there  was  probably 
some  injury  to  the  urethra.  Restoration  of  the 
urethra  could  generally  be  accomplished  by  repeated 
passing  of  sounds  gradually  increasing  in  size. 
Some  of  these  cases  were  not  seen  by  the  surgeon 
until  some  time  after  the  accident,  when  they 
showed  all  the  symptoms  of  peritonitis,  yet  with  im- 
mediate passing  of  a  stomach  tube  to  relieve  vomit- 
ing, the  continuous  drop  by  drop  enema  without 
pressure,  and  Fowler's  position  good  recoveries  had 
occurred. 

Dr.  W.  L.  EsTES,  of  South  Bethlehem,  believed 
that  the  fate  of  the  limb  in  compound  fracture  de- 
pended largely  upon  the  first  dressing.  A  first 
dressing  should  not  be  attempted  without  appliances 
for  thorough  asepsis,  and  digital  exploration  should 
never  be  made.  Reduction  should  never  be  attempt^ 
ed  at  the  first  dressing  unless  the  surroundings  per- 
mitted of  proper  disinfection.  The  speaker's  prac- 
tice was  to  chisel  oflf  the  ragged  ends  of  bones  so  as 
to  get  rid  of  infectious  material;  then,  after  proper 
disinfection,  the  bone  was  drawn  back  into  place. 

Dr.  W.  M.  RoDERTSON,  of  Warren,  did  not  believe 
the  surgeon  would  ever  see  a  case  of  compound 
fracture  that  had  not  already  been  reduced  by  some 
one.  In  his  experience  not  many  infections  had  re- 
sulted from  such  reduction.  Much  dependence  had 
to  be  placed  on  the  vital  resistance  of  the  patients  to 
take  care  of  sepsis. 

Dr.  LowKY  said  that  a  great  many  cases  of  com- 
pound fracture  of  the  tibia  become  infected.  Drain- 
age should  be  provided  at  the  first  dressing. 

Dr.  Fell  said  he  thought  the  first  dressing  was 
the  important  one.  For  getting  rid  of  pus,  he  used 
a  saturated  solution  of  potassium  permanganate,  fol- 
lowed by  corrosive  sublimate  as  high  as  i  to  500  in 
strength,  and  this  by  sterile  water.  ■ 

The  Operative  Treatment  of  Fistula  in  Ano. — 
Dr.  W.  M.  Beach,  of  Pittsburgh,  presented  this 
paper.  He  stated  that  the  history  of  the  case  and 
the  preparation  were  important.  The  examination 
and  diagnosis  were  sometimes  difficult.  As  regarded 
an  operation,  he  advocated  the  open  method  in  all 
cases.  The  importance  of  the  after  treatment  was 
emphasized.    Cases  were  reported  in  illustration. 

Dr.  J.  Coles  Brick,  of  Philadelphia,  said  that  free 
drainage  was  extremely  important.  He  called  atten- 
tion to  recent  statistics  which  showed  that  only  five 
per  cent,  of  patients  with  phthisis  had  fistula,  while 
twelve  per  cent,  of  those  with  fistula  had  phthisis. 
His  habit  had  been  to  refer  all  fistula  cases  for  a 
chest  examination.  The  after  treatment  should  be 
under  the  care  of  the  operator.  If  the  wound  did 
not  granulate  well,  the  administration  of  iodide,  run- 
ning up  to  large  doses,  was  serviceable. 

Dr.  John  H.  Gibbon,  of  Philadelphia,  said  that 
preparatory  treatment  should  continue  over  two 
nights  in  these  cases,  so  that  there  would  be  no  f?ecal 
matter  to  complicate  the  operation.  The  main  ob- 
ject in  the  after  treatment  was  to  keep  the  cut  edges 
of  the  fistula  from  uniting  until  the  tract  had  been 
filled  up  with  new  tissue.     For  this  purpose  pack- 


ing was  unsatisfactory,  and,  following  Kelsey's  ad- 
vice, he  ran  his  gloved  finger  through  the  tract  at 
the  daily  dressing.  This  gave  excellent  results  and 
was  more  comfortable  for  the  patient. 

Dr.  C.  P.  Noble,  of  Philadelphia,  said  that  the 
faihire  to  get  good-  results  was  due  largely  to  im- 
proper after  treatment. 

Dr.  W,  F,  Donaldson,  of  Pittsburgh,  reported 
good  results  from  the  injection  of  bismuth  paste, 
which  penetrated  to  all  parts  of  the  tract  and  would 
in  a  short  time  render  the  discharge  from  the  tract 
sterile.  It  also  afforded  a  foundation  for  connective 
tissue  to  build  upon,  and  this  promoted  healing.  It 
was  nonirritating  and  was  slowly  discharged  or  ab- 
sorbed. 

Dr.  Beach  said  that  he  had  found  the  iodides  very 
useful  in  tuberculous  and  syphilitic  conditions.  The 
operator  should  personally  carry  out  the  after  treat- 
ment. 

Some  of  the  Recent  Improvements  in  Opera- 
tions for  Tumors  of  the  Breast, — Dr.  Gibbox  said 
that  the  object  of  his  paper  was  to  popularize  the 
Collins  Warren  operation  for  cystic  disease  of  the 
breast,  the  plan  of  beginning  the  operation  for  can- 
cer with  the  dissection  of  the  axilla,  and  the  method 
of  dressing  the  wound  in  these  latter  cases  with  the 
arm  at  right  angles  to  the  chest.  He  believed  far 
safer,  more  satisfactory,  and  more  surgical  treat- 
ment was  that  of  making  the  semilunar  mcision  of 
Warren  along  the  lower  and  outer  periphery  of  the 
breast,  turning  the  breast  up  and  removing  the  cyst 
by  a  wedge  shaped  incision. 

Dr.  W.  L.  Rodman,  of  Philadelphia,  said  that  the 
breast  should  not  be  sacrificed  for  a  benign  cyst,  but 
the  gland  should  be  turned  up,  the  cyst  removed, 
and  the  breast  replaced.  As  the  incision  was  mac'e 
at  the  lower  border,  not  even  a  scar  was  visible.  In 
operating  for  cancer  the  incision  in  the  axilla  should 
be  made  early  in  the  operation,  so  that,  if  the  case 
should  prove  inoperable,  the  operation  could  be 
stopped  before  the  patient  had  been  subjected  to  ex- 
tensive cutting.  He  kept  the  arm  bound  down  to 
the  side  for  twenty-four  hours,  and  after  that  the 
patient  might  use  it  at  will. 

Dr.  NoRLE  said  that  after  a  breast  had  been  cut 
to  pieces  for  the  removal  of  multiple  cysts  it  was  of 
no  use  for  lactation,  and,  if  the  patient  should  have 
a  child,  abscesses  were  apt  to  occur  in  such  a 
breast.  Patients  with  multiple  cysts  should  have  the 
breast  removed. 

Dr.  Gibbon  said  that  the  function  of  a  breast 
might  be  preserved  after  the  removal  of  several 
small  cysts,  and  emphasized  the  importance  of  con- 
serving a  functionating  organ  wherever  possible. 

The  Importance  of  First  Aid  Dressings  in 
Wounds  of  Civil  Life, — Dr.  Guthrie,  of  Wilkes- 
Barrc,  cited  a  case  to  illustrate  the  total  lack  of  at- 
tention prevalent  in  the  care  and  treatment  of  in- 
juries at  the  time  of  their  reception.  All  facilities 
for- sterilization  should  exist  in  the  receiving  ward 
of  a  hospital.  He  stated  his  firm  belief  in  modern 
sterilization  and  asepsis  and  the  great  superiority  of 
such  methods  over  the  older  practice.  When  sepsis 
occurred,  very  frequently  the  avenue  of  entrance 
was  the  sterilizing  room. 

The  ini]->ortance  of  first  aid  to  injured  men  was 
indicated  by  the  fact  that  many  collieries  and  rail- 
road companies  and  other  corporations  who  em- 


February  27,  1909. 1 


PROCEEDINGS  OF  SOCIETIES. 


459 


ployed  large  bodies  of  men  organized  corps  of  men 
who  received  training  in  this  Hne  of  work  and  were 
supplied  with  the  facilities  and  materials  needed  in 
applying  this  instruction.  The  Pennsylvania  Rail- 
road had  taken  an  active  part  in  instructing  its  em- 
ployees how  to  place  injured  persons  on  stretchers 
and  how  to  carry  the  injured.  They  likewise  learned 
to  take  primary  care  of  fractures,  burns,  and  shock 
without  the  use  of  drugs  until  competent  medical 
aid  could  be  obtained.  The  lectures  were  simple 
and  could  be  comprehended  by  any  intelligent  lay- 
man. It  was  expected  through  this  plan  of  educa- 
tion eventually  to  reach  all  employees  who  might  be 
called  upon  to  give  first  aid.  Up  to  the  present  time 
about  25,000  men  had  received  instruction  in  first 
aid  to  the  injured. 

Report  of  200  Surgical  Cases  in  1907,  with  Spe- 
cial Reference  to  Accidents,  Errors,  and  Results. 
— Dr.  Charles  E.  Thoiisox,  of  Scranton,  read  this 
paper.    The  last  two  papers  were  discussed  jointly. 

Dr.  J.  M.  Wainwright,  of  Scranton,  stated  that 
in  certain  parts  of  the  State  a  great  many  wounded 
persons  died  because  they  had  had  improper  first  aid 
dressing  or  none.  Employees  everywhere  should  be 
instructed  to  get  the  patient  to  the  hospital  as  soon 
as  possible  and  how  to  avoid  hjemorrhage  and  sepsis, 
which  were  the  two  chief  dangers. 

Dr.  J.  K.  ^^'EAVER,  of  Norristown,  thought  that  if 
the  measures  of  first  aid  practised  in  the  National 
Guard  of  Pennsylvania  were  put  into  practice  in  the 
coal  regions  they  would  not  only  save  lives,  but 
would  make  the  men  very  comfortable. 

Dr.  A.  G.  Fell,  of  Wilkes-Barre,  said  that  in 
burns  he  used  a  one  per  cent,  solution  of  picric  acid 
in  alcohol.  With  this  treatment  the  scars  and  con- 
traction resulting"  from  other  treatment  were 
avoided. 

Dr.  E.  \'.  Swing,  of  Coatesville,  called  attention 
to  the  open  air  treatment  of  burns  as  introduced  by 
Dr.  Sneve,  of  Minnesota. 

Dr.  Guthrie  said  it  was  very  important  to  prop- 
erly support  a  fractured  limb  during  transportation 
of  the  patient ;  a  fracture  which  was  at  first  simple 
was  sometimes  rendered  compound  by  jolting  in  the 
ambulance  on  the  way  to  the  hospital.  The  simpler 
the  instruction  to  the  employees  the  better.  The 
mistake  they  made  was  in  attempting  to  do  too 
much. 

Spinal  Anaesthesia. —  Dr.  W.  Wayxe  Babcock. 
of  Philadelphia,  gave  the  results  of  a  clinical  study 
based  upon  796  operations  performed  under  spinal 
anaesthesia  upon  658  patients.  Of  the  operations, 
354  were  abdominal  sections  including  167  appen- 
dectomies ;  sixteen  operations  upon  the  stomach ; 
twenty-two  operations  upon  the  liver  and  biliarv  sys- 
tem ;  fifteen  upon  the  intestine ;  and  one  upon  the 
spleen.  There  were  112  kelotomies,  twenty  opera- 
tions upon  the  kidney,  one  upon  the  spleen.  147 
gynaecological  operations,  one  thoracotomy,  twenty- 
six  amputations,  117  operations  upon  the  rectum, 
anus,  and  lower  urinary  system,  and  seventy-eight 
upon  the  bones  and  joints.  Some  degree  of  anaes- 
thesia was  obtained  in  every  case  but  one,  and  the 
method  had  been  successfully  employed  at  all  ages 
between  nine  months  and  eighty-eight  years.  Two 
deaths  had  occurred  under  anaesthesia,  both  in  cases 
in  which  death  was  inevitable  irrespective  of  the 
anaesthesia  employed.     One  case  of  neuritis  of  the 


left  leg  with  temporary  palsy  had  followed  an  injec- 
tion into  one  of  the  lumbar  nerve  roots. 

The  strength  of  the  solution  employed,  as  a  rule, 
should  not  exceed  five  per  cent.,  tropacocaine,  and 
stovaine  being  the  preferred  anaesthetics.  In  nerv- 
ous patients  and  in  those  upon  whom  operations  in 
the  upper  abdomen  were  to  be  performed  the  gen- 
eral sensibility  should  previously  be  blunted  by  a 
hypodermic  administration  of  morphine  combined 
with  scopolamine  or  hyoscine.  In  forms  of  pulmon- 
ary, cardiac,  and  renal  disease,  and  in  conditions  as- 
sociated with  severe  forms  of  toxaemia,  spinal  anaes- 
thesia was  often  safer  than  ether  or  chloroform. 

Dr.  W.  A.  Steel,  of  Philadelphia,  strongly  advo- 
cated spinal  anaesthesia.  The  disagreeable  features 
resulted  from  unstable  drugs. 

Dr.  Babcock  said  that  in  the  first  case  he  attempt- 
ed, in  a  friend  of  his,  he  had  difficulty  in  getting  the 
needle  in  and  finally  gave  it  up,  but  since  then  had 
had  no  trouble. 

The  Scope  of  Local  Anaesthesia  in  General  Sur- 
gery.— Dr.  L.  J-  Ha^imoxd,  of  Philadelphia,  niai  i- 
tained  that  in  aged  people,  subjects  of  Bright's  dis- 
ease, radical  or  emergency  operations  for  hernia  lost 
most  of  their  risk  in  local  analgesia.  Gastrostomy 
for  cancer  of  the  oesophagus  and  perineal  prostatec- 
tomy, where  advanced  kidney  disease  existed,  will 
show  also  a  lowered  mortality  under  local  analgesia. 
The  risk  in  these  operations  was  practically  the  risk 
of  the  anaesthetic ;  therefore  when  local  analgesia 
was  employed  the  risk  was  removed.  The  effect  of 
local  analgesia  lasted  about  half  an  hour,  and  it  was 
much  more  promptly  and  completely  accomplished 
in  thin  persons  than  in  those  excessively  fat. 

Dr.  RoDMAX'  did  not  believe  the  dangers  of  gen- 
eral anaesthesia  so  great  that  local  anaesthesia  should 
be  given  the  preference  in  all  instances.  To  do 
kelotomy  under  local  anaesthesia  required  two  or 
three  times  as  long  as  when  general  anaesthesia  was 
used.  Local  anaesthesia  should  not  be  used  in  op- 
erations on  the  thyreoid  gland  unless  there  was  some 
excellent  reason  for  it. 

Dr.  Hammond  said  that  the  internal  anaesthetics, 
such  as  chloroform  and  ether,  could  not  at  present 
be  supplanted  by  any  other  agent. 

Color  Photography  by  the  Lumiere  Process. — 
Dr.  C.  B.  Longenecker,  of  Philadelphia,  presented 
this  contribution.  For  scientific  purposes,  he  said, 
the  value  of  the  photograph  was  vastly  increased  by 
the  correct  rendering  of  the  color.  A  diseased  part 
was  thus  brought  out  as  it  could  not  be  in  any  other 
way.  The  Lumiere  process  utilized  a  three  color 
screen.  All  of  the  picture  produced  by  first  devel- 
opment is  destroyed  chemically ;  the  remainder  was 
redeveloped  and  formed  the  picture,  serving  also  to 
cover  up  portions  of  the  color  screen  not  needed  and 
allowing  the  color  to  be  developed  and  afterward 
destroyed.  This  process  did  not  produce  color,  but 
utiHzed  the  color  of  the  screen  by  stopping  the  pas- 
sage of  all  that  was  not  wanted.  Thus  this  process 
combined  form  and  color  to  an  absolutely  accurate 
degree. 

Dr.  C.  A.  E.  CoDMAX,  of  Philadelphia,  said  that 
Dr.  Longenecker's  collection  of  photographs  by  the 
Lumiere  process  was  the  largest  in  existence.  The 
method  of  making  them  was  rather  simple  and  could 
be  carried  out  by  any  one  accomplished  in  amateur 
photography. 


460 


LETTERS  TO  THE  EDITOR.— NEW  INVENTIONS. 


[New  York 
Medical  Journal. 


Dr.  J.  K.  Young,  of  Philadelphia,  called  attention 
to  two  objections — the  cost  of  the  plates  and  the 
time  required  for  exposure. 

Dr.  Wendell  Reber,  of  Philadelphia,  said  that 
the  process  of  making  the  pictures  was  not  so  sim- 
ple as  Dr.  Codman  thought.  These  pictures  were  of 
great  value  for  purposes  of  illustration  and  teaching. 

Dr.  LoNGENECKER  agreed  with  Dr.  Reber  that 
the  process  was  not  a  simple  one.    It  required  much 
time  and  was  expensive.    However,  it  could  be  car- 
ried out  by  any  one  who  understood  photography. 
{To  he  continued.) 


fitters  t0  \\t  m\ax. 


MEDICAL   INVESTIGATION    AND  NEWSPAPER 
METHODS. 

Tufts  College  Medical  School, 
Department  of  Pathology  and  Bacteriology, 
Boston,  February  22,  igog. 

To  the  Editor: 

Your  telegram  was  probably  prompted  by  a  news- 
paper statement  emanating  from  the  Boston  Jour- 
nal.   The  facts  behind  the  statement  were  these : — 

We  have  been  working  with  vaccine  therapy  in 
this  laboratory  for  nearly  three  years.  Incidental  to 
this  work  we  have  had  some  rather  suggestive  re- 
sults in  pneumonia.  We  have  had  several  cases  in 
a  relatively  small  series  which  came  to  crisis  in  three 
days,  and  all  the  cases  in  this  series  have  terminated 
favorably  with  one  exception  (pneumonia  in  a  wo- 
man of  eighty  years). 

Realizing,  however,  that  in  a  self  limited  disease 
like  pneumonia  several  hundred  or,  better,  several 
thousand  observations  would  be  necessary  before 
conclusions  as  to  the  value  of  any  specific  treatment 
could  be  drawn,  we  have  not  even  published  our  re- 
sults. Recently  we  have  had  opportunity  to  follow 
the  treatment  of  some  cases  of  alcoholic  pneumonia. 
The  mortality  in  this  class  of  pneumonia  is  so  high 
that  we  have  felt  that  a  mtich  smaller  series  would 
justify  conclusions.  I  have  therefore  appealed  to 
several  groups  of  medical  men,  before  whom  I  have 
spoken,  to  furnish  us  cases  of  alcoholic  pneumonia 
for  treatment.  On  February  9th  I  made  such  an 
appeal  to  the  medical  examiners  of  the  Massachu- 
setts Catholic  Order  of  Foresters  at  their  annual 
dinner,  incidental  to  a  paper  on  Newer  Therapeutic 
Measures  of  Laboratory  Origin.  Two  days  later 
a  Boston  Jvurnal  reporter  called  on  me,  saying  that 
he  had  been  told  by  a  physician  of  the  work  we 
were  doing.  I  refused  to  talk  to  him,  on  the  ground 
that  what  we  had  to  say  we  should  say  in  medical 
journals  when  we  were  ready.  I  cited  a  previous 
experience  in  which  a  newspaper  man  came  to  me 
in  the  guise  of  a  brother  of  a  girl  suffering  from 
tuberculosis.  He  came  to  me  on  the  verbal  recom- 
mendation (he  said)  of  a  local  specialist  on  tuber- 
culosis, who  is  one  of  my  friends.  I  talked  with 
him  about  the  possibilities  of  vaccine  therapy  in  tu- 
berculosis, but  assured  him  that  nothing  had  as  yet 
been  proved.  At  the  end  of  the  interview  he  dis- 
closed the  fact  that  he  was  a  writer  on  a  local  paper 
and  asked  if  I  had  any  objection  to  a  publication  of 
the  methods  of  Wright,  which  were  new.  Since  he 
had  the  matter  and  there  was  no  means  of  getting 
it  back  from  him,  there  was  nothing  else  for  me  to 


do  but  stipulate  that  he  should  stick  to  the  known 
facts,  that  no  names  other  than  Wright's  should  be 
mentioned,  and  that  1  should  see  a  proof.  He 
agreed  to  these  stipulations  and  returned  in  a  week 
with  his  proof.  The  paper  started  oflf  with  the  claim 
that  tuberculosis  had  been  conquered,  that  this  new 
method  of  treatment  meant  the  death  knell  of  the 
tubercle  bacillus  and  of  other  bacteria  too  numer- 
ous to  mention.  He  put  these  statements  in  the  first 
person  singular  as  coming  from  my  mouth.  I  as- 
sured him  that  such  claims  were  absurd  and  blue 
pencilled  his  proof  so  that  there  was  left  only  about 
one  sixth  of  the  original.  He  was  contrite,  said  that 
he  had  misunderstood,  that  he  would  make  correc- 
tions and  show  me  a  second  proof.  In  spite  of  this 
the  Boston  Herald  published  the  matter  the  next 
mornmg  in  its  original  state  before  I  had  mutilated 
it.  The  result  of  this  publication  was  that  I  re- 
ceived scores  of  the  most  pitiful  letters  from  tuber- 
culous individuals  throughout  the  United  States.  I 
wrote  personal  letters  in  reply  stating  that  the  story 
was  a  pure  fake  and  recommending  that  the  writers 
stick  to  their  local  physicians.  It  was  apparent  in 
the  case  of  many  individuals,  however,  notably  those 
who  were  poor,  that  the  belief  still  existed  that  a 
panacea  for  tuberculosis  and  other  infections  had 
httn  discovered  in  Boston  and  that  only  their  pov- 
erty prevented  their  taking  advantage  of  it. 

After  reciting  this  experience  to  the  Journal  re- 
porter I  assured  him  that  when  we  had  anything  to 
say  through  the  newspapers,  he  would  be  notified. 
His  failure  to  obtain  any  facts  did  not  disturb  him, 
however,  and  the  next  morning  a  two  column  "in- 
terview" appeared.  He  was  careful  not  to  put  any 
claims  into  my  mouth,  but  the  insinuation  was  made 
on  the  authority  of  other  physicians  (unnamed)  that 
marvels  were  about  to  appear. 

The  actual  facts  are  that  we  are  working  on  alco- 
holic pneumonias  with  autogenous  vaccines,  and  in 
a  small  series,  so  far,  have  had  good  results.  We 
shall  not  publish  our  findings  until  we  have  treated 
a  much  larger  number  of  cases.  You  can  be  sure 
that  publication  will  be  made"  only  through  medical 
journals.  I  should  be  happy  to  furnish  your  jour- 
nal with  otir  facts  and  may  be  able  to  give  you  a  pa- 
per, with  cases,  within  a  few  weeks  or  at  most 
months. 

Timothy  Learv. 

 ^  


A  NEW  FRONTAL  SINUS  PUNCH. 
By  a.  M.  Anderson,  M.  D.. 
New  York. 

The  instrument  shown  in  the  accompanying  cut  is 
designed  for  the  purpose  of  enlarging  the  frontal 
sinus  duct  by  the  intranasal  route.  After  the  parts 
that  may  obstruct  the  lower  opening  of  the  duct  have 
been  removed  (preferably  with  a  Myles  punch  and  a 
snare)  and  the  opening  of  the  duct  is  located  with  a 
probe,  the  punch  is  opened  and  introduced.  The  in- 
troduction can  be  made  almost  as  easily  as  with  a 
probe  on  account  of  the  curve  of  the  instrument.  As 
the  cutting  and  pressure  are  forward  and  downward 
and  away  from  the  brain,  the  danger  of  injuring  that 
organ  is  almost  entirely  eliminated.    It  is  not  neces- 


Pcbruary  27,  1909.] 


BOOK  NOTICES. 


461 


sary  to  remove  the  instrument  from  the  nose  after 
each  bite,  as  the  parts  cut  are  pushed  downward 
from  the  field  of  operation.  Naturally  it  is  best  to 
use  the  smallest  instrument  first  and  a  larger  one  as 
the  opening  is  enlarged. 

I  have  used  this  instrument  successfully  in  about 
twenty  cases.    In  the  newer  model  the  blades  are 


longer,  which  makes  it  easier  to  see  the  male  blade 
as  it  enters  the  duct.    By  removing  one  screw  the 
blades  can  be  separated  and  easily  cleansed. 
15  West  Ninety-first  Street. 

 «>  

[We  publish  full  lists  of  hooks  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


Bacteriotherapie,  Vaccination,  Serotherapie,  par  les  Doc- 
teurs  MetchnikofFj  Sacquepee,  Remlinger,  Louis  Mar- 
tin, Vaillard,  Dopter,  Besredka,  Wassermann,  Leber, 
Dujardin-Beaumetz,  Salimbeni,  Cai.mette.  (Biblio- 
theque  de  therapeutique  Gilbert-Carnot).  Paris:  Bail- 
liere  et  fils,  1909.    Pp.  xii-400.    (Price,  8  fr.) 

This  volume  contains  an  amount  of  valuable  in- 
formation entirely  out  of  proportion  to  the  small 
size  and  low  price  of  the  book.  The  reviewer  has 
already  spent  several  pleasant  and  profitably  hours 
in  studying  the  various  articles,  and  promises  him- 
self man}'  more.  It  is  impossible,  in  a  short  review, 
to  mention  all  the  excellences  of  the  book,  but  a 
brief  sketch  of  the  article  on  diphtheria  and  its 


serum  treatment  will  show  the  thoroughness  with 
which  the  topics  are  discussed,  for  this  article  is 
typical  of  the  rest.  Serotherapie  antidipththerique 
is  discussed  by  Louis  Martin,  of  the  Pasteur  Insti- 
tute, and  opens  with  an  accurate  historical  account. 
Then  comes  a  discussion  of  diphtheria  cultures,  in- 
cluding a  detailed  description  of  the  preparation  of 
various  media.  Nine  pages  are  devoted  to  the 
methods  used  for  the  production  of  toxine,  and 
four  pages  to  the  properties  of  diphtheria  toxine. 
In  discussing  the  immunization  of  horses,  typical 
protocols  are  given,  and  special  mention  is  made  of 
the  method  of  Park,  in  which  partially  neutralized 
toxine  is  used  to  begin  the  immunization.  Fourteen 
pages  are  devoted  to  the  properties  of  diphtheria 
antitoxine,  and  this  includes  a  good  account  of  the 
measurement  of  the  antitoxic  power.  Under  the 
secondary  properties  of  the  serum  we  find  an  ac- 
count of  the  agglutinating  properties,  studies  on 
amboceptors,  the  bactericidal  power,  and  certain 
other  properties,  including  toxicity  of  the  serum. 
The  concentration  of  the  serum  is  described  in  full, 
especially  the  recent  method  of  Gibson.  The  presen- 
tation of  the  serum  therapy  of  diphtheria  is  very 
complete,  and  is  a  mine  of  information.  Twenty- 
five  pages  are  devoted  to  this  phase  of  the  subject. 
Then  follow  chapters  on  the  results  of  serum  thera- 
py, on  immunization,  and  finally  on  serum  acci- 
dents. Altogether,  the  article  on  diphtheria  occu- 
pies eighty  pages.  The  other  chapters  of  the  book 
are  equally  complete,  and  are  devoted  to  "intestinal 
bacteriotherapy"  (Metchnikofif),  smallpox  vaccina- 
tion, Pasteur's  rabies  treatment  (Remlinger,  fifty 
pages),  tetanus,  dysentery,  streptococcus,  and 
meningococcus'  serum  therapy,  the  vaccination  and 
serum  therapy  of  plague  and  cholera,  and  the  an- 
tivenomous  treatment  of  snake  bites.  The  authors 
and  editors  of  this  book  deserve  great  credit  for 
the  excellence  of  their  work. 

General  Pathology.  By  Dr.  Ernst  Ziegler,  Professor  of 
Pathological  Anatomy  and  of  General  Pathology  in  the 
University  of  Freiburg  im  Breisgau.  Translated  from 
the  Eleventh  Revised  German  Edition  (Gustav  Fischer, 
Jena,  1905).  Edited  and  Brought  up  to  Date  by  Aldred 
Scott  Warthin,  Ph.  D.,  M.  D.,  Professor  of  Pathology 
and  Director  of  the  Pathological  Laboratory  in  the  Uni- 
versity of  Michigan,  Ann  Arbor,  Michigan.  With  604 
Illustrations  in  Black  and  in  Colors.  New  York:  Wil- 
liam Wood  &  Co.,  1908.    Pp.  XX-781.    (Price,  $5.50.) 

This  translation  was  made  from  the  eleventh 
German  edition,  the  last  one  which  the  late  Pro- 
fessor Ziegler  attended  to  himself,  as  he  died  a  year 
after  its  publication,  November  30,  1905,  in  his 
fifty-seventh  year.  The  translation  is  very  good, 
and,  as  it  appears  three  years  after  the  original, 
Professor  Warthin  has  very  rightly  inserted  into 
the  book  the  results  of  recent  investigations  which 
have  proved  of  value  and  interest,  in  the  form  of 
additions  to  the  text  in  smaller  type.  Such  addi- 
tions include  observations  on  the  effect  of  Rontgen 
irradiation,  heredity,  phagocytosis,  opsonins,  regen- 
eration, tuberculosis,  syphilis,  etc.  Besides,  the 
bibliography  has  been  revised,  and  the  most  im- 
portant contributions  of  the  last  three  years  have 
been  included,  with  special  reference  to  American 
researches. 

Ziegler's  Pathology  has  been  for  nearly  twenty 
years  one  of  the  leading  standard  works  in  pathol- 


462 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


ogy,  and  the  translations  into  English,  French,  and 
Italian  have  all  been  so  perfectly  prepared  that  they 
are  of  equal  value  with  the  original.  The  book  is 
too  well  known  as  to  call  for  a  special  review,  but 
we  wish  to  call  attention  to  Ziegler's  views  on  tu- 
berculosis, a  question  which  at  the  present  time  is 
in  everybody's  mind :  "Koch's  view  as  to  the  differ- 
ence between  human  and  bovine  tuberculosis  is  ap- 
plicable only  in  so  far  as  certain  differences  in  the 
characteristics  of  the  two  strains  of  bacilli  are  con- 
cerned. For  all  these  differences,  it  is  true  that 
bovine  tuberculosis  is  communicable  to  man,  and 
the  domestic  animals  may  become  infected  from 
tuberculous  human  beings.  Von  Behring's  publi- 
cation that  infants  may  be  easily  infected  through 
milk  containing  tubercle  bacilli  has  only  confirmed 
well  known  views.  The  attempt  of  von  Behring  to 
refer  all  classes  of  tuberculosis  to  an  intestinal  infec- 
tion occurring  in  infancy  is  doubtless  an  error,  and 
is  not  likely  to  destroy  the  belief  that  tuberculosis  is 
most  frequently  an  air  borne  infection  and  enters 
primarily  through  the  lungs."  This  sentence  is 
characteristic  of  the  late  Professor  Ziegler,  who 
was  very  pronounced  in  his  own  views,  although  he 
always  gave  due  credit  in  his  textbook  to  the  opin- 
ions of  others. 

Diseases  of  the  Nervous  System.  For  the  General  Practi- 
tioner and  Student.  By  Alfred  Gordon,  A.  M.,  M.  D. 
(Paris),  Associate  in  Nervous  and  Mental  Diseases,  Jef- 
ferson Medical  College,  Philadelphia,  etc.  With  One 
Hundred  and  Thirty-six  Illustrations.  Philadelphia :  P. 
Blakiston's  Son  &  Co.,  1908.    Pp.  xii-487.    (Price,  $2.50.) 

As  its  title  implies,  this  is  a  textbook  for  students 
and,  we  may  add,  a  very  good  one.  The  various 
derangements  of  the  nervous  system  are  concisely 
and  yet  adequately  described,  and  the  same  may  be 
said  of  the  treatment  and  pathology.  An  excellent 
device  is  the  printing  of  the  more  distinctive  and 
important  symptoms  in  larger  type,  by  virtue  of 
which  a  conception  of  each  disease  may  be  easily 
and  quickly  formed. 

As  usual  in  books  of  the  sort,  there  is  an  anatom- 
ical and  physiological  introduction,  serving  at  once 
as  the  groundwork  for  the  rational  interpretation 
of  symptoms  and  the  localization  of  disease.  Not 
only  are  the  common  forms  of  nervous  disease  de- 
scribed, but  most  of  the  rarer  ones  are  also  in- 
cluded. A  rather  copious  index  adds  the  finishing 
touch  to  the  practical  scheme  of  the  author.  This 
is  not  a  book  of  reference,  but  it  should  do  good 
service  as  an  elementary  guide  for  both  students 
and  practitioners. 

A  Manual  of  Diseases  of  the  Nose  and  Throat.  By  Cor- 
nelius Godfrey  Coakley,  A.  M.,  M.  D.,  Professor  of 
Laryngology  in  the  University  and  Bellevue  Hospital 
Medical  College,  New  York,  etc.  Fourth  Edition,  Re- 
vised and  Enlarged.  Illustrated  with  126  Engravings  and 
7  Colored  Plates.  New  York  and  Philadelphia:  Lea  & 
Febiger,  igoS,    Pp.  604. 

In  the  fourth  edition  of  his  compact  and  prac- 
tical handbook  Dr.  Coakley  has  made  a  number  of 
slight  changes  and  minor  additions  which  add  to 
the  value  of  the  work,  both  for  practitioners  and 
for  students.  As  before,  he  has  applied  a  wise 
eclecticism  in  limiting  himself  to  one  of  a  number 
of  therapeutic  procedures,  medicinal  or  operative, 
and  explaining  this  one  in  detail.  A  special  chap- 
ter has  been  added  containing  a  classification  of 


drugs  and  a  goodly  number  of  prescriptions  ar- 
ranged under  the  headings  of  the  therapeutic  ac- 
tions which  may  be  expected  of  them.  The  consid- 
eration of  the  technique  of  the  radical  operations  in 
the  chapter  on  Chronic  Diseases  of  the  Accessory 
Sinuses  has  been  reyised  in  the  light  of  recent  stud- 
ies and  has  been  made  quite  complete. 

Anatomische  Verdnderungen  in  via-  ivegen  Drucksteigerung 
enuklcierten  Augen  mit  Netzliauthdmorrhagieen.  Von 
Ann.\  Dahlstroem.  Akademische  Abhandlung  zur  Er- 
langung  der  medizmischen  Doktor  Wiirde  der  Fakultat 
in  Upsala.    Leipzig:  Alexander  Edelman,  1908.    Pp.  148. 

This  inaugural  dissertation  presents  the  micro- 
scopical findings  in  four  cases  of  retinal  haemor- 
rhage leading  to  glaucoma  and  necessitating  enu- 
cleation. The  author  comes  to  conclusions  which 
agree  in  the  main  with  those  of  Wagenmann  and 
others,  that  both  glaucoma  and  hsemorrhages  are 
due  to  vascular  disease  of  the  uvea  and  secondarily 
of  the  retina,  the  increased  tension  being  caused  not 
so  much  by  intraocular  effusion  of  blood  as  by  a 
low  grade  chronic  indochorioiditis  due  to  vascular 
degeneration.  The  work  shows  thorough  study  of 
the  literature,  careful  pathological  work,  and  an  ex- 
ceedingly good  knowledge  of  the  theories  of  the 
pathogenesis  of  glaucoma. 

Klinische  Seiniotik.  Mit  besonderer  Beriicksichtigung  der 
gefahrdrohenden  Symptome  und  deren  Behandlung.  Von 
Dr.  Alois  Pick,  a.  o.  Universitatsprofessor,  k.  u.  k. 
Oberstabsarzt,  und  Dr.  Adolf  Hecht,  Kinderarzt.  Wien 
und  Leipzig:  Alfred  Holder,  1908.  Pp.  969.  (Price, 
21  marks.) 

This  encyclopaedic  work  of  nearly  a  thousand 
pages  occupies  a  unique  field  of  its  own.  No  similar 
book  with  which  we  are  familiar  treats  so  adequate- 
ly of  the  therapeutics  of  diseased  conditions  from 
the  standpoint  of  symptomatology,  which  after  all  is 
the  patient's  standpoint,  and  it  must  be  admitted 
often  necessarily  also  the  practising  physician's  in 
his  daily  task  of  relieving  suffering  and  averting 
dangers  to  life.  The  underlying  pathological  con- 
dition is  frequently  elusive  or  little  amenable  to  the 
resources  of  our  art ;  the  muddy  pool  of  metabolism 
and  physiological  chemistry,  in  which  the  patholo- 
gist and  laboratory  worker  of  to-day  are  so  deeply 
immersed,  is  slow  to  yield  up  secrets  directly  helpful 
to  the  patient.  Reference  to  this  practical  volume  wih 
make  nearly  any  physician  more  resourceful.  The 
atithors  have  anticipated  and  disarmed  criticism  by 
including  enough  of  aetiolog>%  pathology,  and  diag- 
nosis to  avoid  any  appearance  of  rule  of  thumb 
methods.  Familiarity  with  the  entire  field  of  the 
best  recent  literature  is  shown,  and  much  credit  is 
deserved  for  the  patience  and  industry  with  which 
the  wealth  of  therapeutic  detail  here  presented  has 
been  collected.  In  a  work  so  comprehensive  it  is 
surprising  that  the  omissions  are  so  few.  The  Amer- 
ican reader  will  regret  that  no  reference  is  made  in 
the  chapter  on  acute  infections  to  Flexner's  serum 
in  the  treatment  of  epidemic  cerebrospinal  meningi- 
tis. This  substantial  volume  may  be  commended  as 
sound  in  its  therapeutics  and  in  accord  with  the  best 
modern  teachmg,  whereas  works  on  therapeutics  are 
usually  novel  only  at  the  expense  of  Ijeing  erratic 
and  untrustworthy.  There  is  a  good  index  to  the 
volume,  and  for  ready  reference  there  are  marginal 
headings  which  will  be  appreciated  by  the  busy  prac- 
titioner. 


February  27,  1909.] 


OFFICIAL  NEIVS. 


463 


Ueber  den  Urs[<rung  des  mclanotischcn  Pigments  der  Haut 
und  des  Auges.  Von  Dr.  E.  Meierowsky,  Assistent  der 
Klinik.  Aus  der  Kcinigl.  Universitatsklinik  fiir  Haut- 
krankheiten  in  Breslau.  Leipzig:  Dr.  \V.  Klinkhardt, 
1908. 

This  monograph  will  be  especially  interesting  to 
dermatologists  and  opththalmologists.  as  the  ques- 
tion of  the  nature  of  the  pigment  in  melanosarcoma 
as  well  as  of  the  normal  pigment  of  the  cutis  and 
of  the  uveal  tract,  its  chemical  constitution,  his- 
tological origin,  and  biological  significance,  is  re- 
viewed in  the  light  of  the  author's  painstaking  and 
scientific  studies  in  clinic  and  laborator\-.  The  ques- 
tions of  the  influence  of  sunlight  and  of  the  Finsen 
ray,  the  development  of  pigment  in  the  embryonal 
skin,  the  cellular  nuclear  changes,  and  the  part 
played  by  chromatin,  are  among  a  number  of  in- 
teresting aspects  which  are  considered. 

Practical  Points  in  Anesthesia.  Bv  Fkederick  EiiiL  Xeef, 
B.  S.,  B.  L.,  M.  L.,  M.  D.,  New  York.  New  York :  Sur- 
gery Publishing  Company,  1908.  Pp.  46.  (Price,  60 
cents.) 

Dr.  Neef  presents  his  impressions  as  to  the  cor- 
rect use  of  chloroform,  ether,  ethyl  chloride,  and 
a  combination  of  the  three  in  molecular  propor- 
tions, called  anassthol.  .-\mong  the  subjects  treated 
are :  Indications  of  anaesthesia,  cardiac  and  respi- 
ratory collapse,  vomiting  during  aneesthesia,  ob- 
structed breathing,  the  influence  of  morphine  on 
narcosis,  postoperative  distress,  etc. 

 %  


I'laces. 


Date 


Cases.  Deaths. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports: 

The  following  cases  of  smallpox,  yellon'  fever,  cholera 
and  plague,  have  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  week  ending  February  19,  1909: 
Smallpox — United  States. 
Places.  Date.  Cases.  Deaths. 

California — Sacramento  Nov.   i-Dec.  31   24 

California — Los  Angeles  Jan. 

Illinois — Cairo  Jan. 

Illinois — Chicago  Jan. 

Illinois — Palmyra  Dec. 

Illinois — West  Frankfort  Dec. 

Indiana — Elkhart  Jan.   30-Feb.   6.T....  i 

Indiana — Evansville  Jan.   30-Feb.   6   i 

Indiana — Fort  Wayne  Jan. 

Indiana — Indianapolis  Jan. 

Indiana — Marion  Jan. 

Iowa — Uurlington  Jan. 

Kentucky — Covington  Jan. 

Kentucky — Le.xington  Jan. 

Louisiana — New  Orleans  Jan. 

Maryland — Baltimore  Jan. 

Massachusetts — New  Bedford  Jan- 
Missouri — Kansas  City  Jan. 

Missouri — St.  Louis  Jan. 

New  York — Rome  Jan. 

Ohio — Cincinnati  Jan 


23-30. 

30-Feb.   6   57 

30- Feb.  6   2 

25-Jan.  20   4 

i2-Feb.  13. 


Ohio — Dayton . 


3-Feb. 

3 1 -Feb.  7   I 

31-Feb.  7   5 

1-3 1   I  Imported 

30-Feb.    6   3 

6   3 

6   3 

6   I 

6   1 

6   2 

30-Feb.    6   3 

1-31   I 

29-Feb.  5. 


30-Feb. 
30-Feb. 
30-Feb. 
30-Feb. 
30-Feb. 


.Jan.  30-Feb.   6   I 


South  Dakota — Aberdeen  Dec.  14- Feb. 

Tennessee — Knoxville  Jan.  30-Feb.  6. 

Tennessee — Nashville  Jan.  30-Feb.  6. 

Texas — Denton  County  Jan.  i-Feb.  8.. 

Texas — San  Antonio  Jan.  30-Feb.  6. 

Vermont — White   River  Junction .  Jan.  2-Feb.  10. 

Virginia — Port   Royal  Dec.  27-Jan.  14 

Washington — Spokane  Jan.  16-30  


40 


West  Virginia — Weston  Feb 

Wisconsin — La  Crosse  Jan.  30-Feb 

Wisconsin — Milwaukee  Jan.  30-Feb. 

Smallpox — Insular. 
Philippine    Islands — Manila  Jan.  2-9.... 

Smallpox — Foreign. 

Brazil — Bahia  Dec.  5-26... 

Brazil — Pernambuco  Dec.  1-31... 

Canada — Halifax  Jan. 

Canada — Yarmouth  and  Vicinity.  .  .Jan. 

China — Shanghai.  Dec. 

Egypt— 'Alexandria  Dec. 

Egypt — Cairo  Dec. 

Formosa  Dec. 


2  Imported 
I   I  Imported 


23;30.  .  . 
I -Feb.  I 
19-26. . 
24-31 .  .  . 
31-Jan. 
12-26.  .  . 


4 

28 


16 
3 


Present 


Great  Britain — Bristol  Jan.    16-23   2  ! 

India — Bombay  Jan.    5-12   7 

India — Calcutta  Dec.   19-Jan.   2   61 

India — Rangoon  Dec.  26-Jaii.   2   1 

Indo-China — Saigon  Dec.    19-26   i  1 

Italy- — Cieneral  Jan.    18-24   47 

Italy — Calabria  Jan.  21   15 

Italy — Genoa  Jan.    1-13   2 

Italy — Naples  Jan.    18-24   20 

Java — Batavia  Dec.   26-Jan.   2   2 

Mexico — Mexico  City  Dec.    12-26   I3 

Mexico — Jlonterey  Jan.   24-31   5 

Newfoundland — St.   Johns  Jan.  31-Feb.  6   i 

Newfoundland — South  Coast  Feb.  6   Epidemic 

Peru — Lima  Dec.  31   6 

Portugal — Lisbon  Jan.    23-30   5 

Imported  i 

Russia — Moscow  Jan.    2-16   22  15 

Russia — Odessa  Jan.   2-16   6  r 

Russia — St.  Petersburg  Dec.  26-Jan.  9   13  > 

Russia — Warsaw  Dtc.   5-19   6 

South  .\frica — Capetown  Dec.   26-Jan.   2   4 

Spain — Barcelona  Dec.   19-jan.  9   4 

Jan.    16-Z3   I 

Spain — Valencia  Jan.    19-23   10 

Spain — Vigo  Jan.   9-16   1 

Turkey — Constantinople  Jan.    10-24   8 

Turkey — Smyrna  Oct.   5-Dec.   31   J3 

Yellow  Fever — Foreign. 

Brazil — Bahia  Dec.   5-Jan.  2   18  8 

Brazil — Para  Jan.    9-16   4  4 

Columbia — Cartagena  Jan.    7-14   i  1 

Ecuador — Guayaquil  Jan.    9-16   i 

.Mexico — -Mexcanu,  vicinity  Jan.    23-30   i 

Mexico — Merida  Jan.    23-30   i 

Mexico — Vera  Cruz  Jan.    23-30   i  i 

Trinidad  .Ian.    16-23   i  ' 

Cholera — Insular. 

Philippine  Islands — Manila  Dec.   19-Jan.  2   4  1 

Philippine  Islands — Provinces. ...  Dec.    19-Jan.  9  864  556 

Russia — General  Dec.   31-Jan.  7  iii  4; 

Jan.    12-24  342  1-5 

Russia — Helsingfors,  vicinity  Jan.   10   i 

Russia — St.  Petersburg  Dec.   3i-Jan.   7   96  40 

Straits  Settlements — Singapore. ..  .Dec.   5-12   11 

Plague — Foreign. 

Brazil — Bahia  Dec.   5-Jan.  2   9  5 

Brazjl — Pernambuco  Dec.    1-31   4 

Eg>pt — General  Jan.    14-21   3  2 

Formosa  Jan.    1-9  :   i  i 

India— General  Dec.   26-Jan.   2  i,793  >.43' 

India — Bombay  Jan.    5-12   9 

India— Calcutta  Dec.   i9  jan.  2   13 

India — Rangoon  Dec.  26-Jan.   2   1 

Indo-China — Saigon  Dec.    19-26   4  3 

Turkey — Bagdad  Jan.  2   3 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  fourteen  days  ending 
February  17,  1909: 

B-\HKENBURG,  L.  P.  H.,  Passcd  Assistant  Surgeon.  Grant- 
ed two  days'  leave  of  absence  from  January  jg,  1909, 
under  paragraph  191,  Service  Regulations. 

Br.axh.xm,  Hexry  G.,  Aczing  Assistant  Surgeon.  Granted 
three  days'  leave  of  absence  from  February  9,  1909, 
without  pay. 

CoLLixs,  G.  L.,  Passed  Assistant  Surgeon.  Granted  one 
day's  leave  of  absence.  February  4,  1909,  under  para- 
graph 169,  Service  Regulations. 

Dvx.^x,  XiCH0L.\s  J.,  Actmg  .Assistant  Surgeon.  Granted 
twenty-nine  days'  extension  of  annual  leave  on  account 
of  sickness  from  December  3,  1908,  and  a  further  ex- 
tension of  leave  on  account  of  sickness  for  thirty  days 
from  January  i,  1909. 

GoLDSBOROUGH.  B.  W.,  Acting  Assistant  Surgeon.  Granted 
thirty  days'  leave  of  absence  from  January  i,  1909, 
with  pay,  and  two  days'  leave  of  absence  from  Febru- 
ary I,  1909,  without  pay. 

Gustetter,  a.  L.,  Acting  Assistant  Surgeon.  Granted  . fif- 
teen days'  leave  of  absence  from  February  6.  1909. 

Herring,  R.  A.,  Assistant  Surgeon.  Granted  si.x  days' 
leave  of  absence  from  February  11,  1909,  under  para- 
graph 191,  Service  Regulations. 

M-\cC.^FFEV.  W.  B.,  Acthig  Assistant  Surgeon.  Granted 
two  days'  leave  of  absence  under  paragraph  191,  Ser- 
vice Regulations. 

Markoe.  W.  W.,  Acting  Assistant  Surgeon.  Granted 
thirty  days'  leave  of  absence  from  January  i,  1909. 

Ramus,  Carl,  Passed  Assistant  Surgeon.  Granted  one 
day's  leave  of  absence,  January  21,  1909,  under  para- 
graph 191,  Service  Regulations. 

Ramus,  Carl.  Passed  Assistant  Surgeon.  Granted  three 
days'  leave  of  absence  from  February  5,  1909,  on  ac- 
count of  sickness. 


464 


BIRTHS,  MARRIAGES,  A.\D  DEATHS. 


[New  York 
Medical  Jourxa:. 


Robertson,  H.  McG.,  Passed  Assistant  Surgeon.  Granted 
four  days'  leave  of  absence  from  February  23,  1909. 

Si-OUGH,  Charles,  Pharmacist.  Relieved  from  duty  at  San 
Francisco,  Cal.,  and  directed  to  proceed  to  Baltimore, 
I\ld.,  and  report  to  the  medical  officer  in  command  for 
duty  and  assignment  to  quarters,  February  8,  1909. 

Stiles,  Ch.  W.,  Chief  Division  Zoology,  Hygienic  Labor 
atory.    Granted  one  day's  leave  of  absence,  March  16, 
1909,  and  six  days'  leave  of  absence  from  April  5,  1909. 

Torres,  Julio  F.,  Acting  Assistant  Surgeon.  Granted  fif- 
teen days'  leave  of  absence  from  February  14,  1909. 

VoN  EzDOKF.  R.  H.,  Passed  Assistant  Surgeon.  Granted 
twenty-eight  days'  leave  of  absence  from  February  26, 
1909. 

Army  Intelligence: 

Official  list  (if  changes  in  the  stations  and  duties  of  offi- 
cers scri'ing  in  the  Medical  Corps  of  the  United  States 

Army  for  the  iccck  ending  February  20,  igog: 

B.\LL.'\Ri),  J.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  his  present  staliim,  and  ordered 
to  duty  in  the  Philippines  Division,  sailing  March  5th, 
from  San  Francisco,  Cal. 

B.WLEV,  E.  W.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  his  present  station,  and  ordered 
to  duty  in  the  Philippines  Division,  sailing  March  5th, 
from  San  Francisco,  Cal. 

Bowman.  M.  H.,  First  Lieutenant,  IMedical  Reserve  Corps. 
Arrived  at  San  Francisco,  Cal.,  on  the  Buford.  and  or- 
dered to  duty  at  the  Depot  of  Recruits  and  Casuals, 
Angel  Island,  Cal.  , 

Church,  J.  R.,  Major,  Medical  Corps.  Granted  an  exten- 
sion of  fourteen  days  to  his  leave  of  absence. 

Cole,  C.  L.,  Captain,  Medical  Corps.  When  relieved  from 
duty  at  Fort  Benjamin  Harrison,  Tnd.,  ordered  to  re- 
turn to  proper  station.  Fort  Thomas.  Ky. 

Dade,  W.  H..  First  Lieutenant,  Medical  Reserve  Corp.■^. 
Relieved  from  duty  at  his  present  station,  and  ordered 
to  duty  in  the  Philippines  Division,  sailing  March  5th, 
from  San  Francisco,  Cal. 

Hadra,  Frederick,  First  Lieutenant.  Medical  Reserve 
Corps.  Arrived  at  San  Francisco,  Cal..  on  the  Buford, 
and  ordered  home,  to  await  further  orders. 

Johnson.  C.  W.,  First  Lieutenant,  Medical  Reser\e 
Corps.    Granted  leave  of  absence  for  two  months. 

Love,  A.  G.,  Lieutenant,  Medical  Corps.  Arrived  at  San 
P'rancisco,  Cal.,  on  the  Buford  and  ordered  to  Colum- 
bus Barracks,  Ohio,  for  duty. 

Manly,  C.  J.,  Major,  Medical  Cor])s.  (Granted  leave  of 
absence  for  ten  days. 

Owen,  L.  J.,  Captain,  Medical  Corps.  When  relieved  from 
duty  at  Columbus  Barracks.  (31iio,  ordered  to  Fort 
Bejamin  Harrison,  Ind.,  for  duty. 

PiLLSiiURY.  H.  C,  Lieutenant.  Medical  Corps.  Relieved 
from  duty  on  the  transport  Buford  and  assigned  to 
duty  on  the  transport  Logan. 

Reynolds,  C.  R.,  Captain,  Medical  Corps.  Relieved  from 
duty  as  commanding  ofificer.  Company  C,  H.  C.  to  take 
effect  upon  the  departure  of  that  company  for  Fort 
Niagara.  N.  Y.,  about  March  15th,  and  assigned  to 
duly  at  the  Army  General  Hospital,  Washington.  D.  C. 

Schreiner.  E.  R.,  Major.  Medical  Corps.  Relieved  from 
duty. at  the  Army  General  Hospital,  San  Francisco, 
Cal.  and  ordered  to  I'"ort  Walla  Walla,  Wash.,  for 
duty. 

St.\llm.\.\',  G.  p.,  l'"irst  Lieutenant.  Medical  Reserve  Corps. 
Relieved  from  duty  in  the  Philippines  Division  ;  or- 
dered to  sail  .April  15th  lor  San  Francisco,  Cal.,  for 
orders. 

Steum  \N.  C.  J..  Captain.  Aledical  Corps.  ?Tonorably  dis- 
charged from  the  Army. 

Trurv.  W.  F..  Major.  Medical  Corps.  Order  for  duty  at 
Army  General  Hospital,  Fort  Bayard.  N.  M..  amended; 
will  proceed  to  Fort  Worden,  Wash.,  for  duty  upon 
return  from  Cuba. 

Veimier,  R.  B.,  Cant-'  u,  Medical  Corps.  Relieved  from 
duty  at  Fort  Walla  Valla.  Wash.,  and  ordered  to  Fort 
Stevens,  Oregon,  lor  duty. 

Navy  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  'i\.'eek  ending  f'chruary  20,  IQCX): 
Ralch.  \.  W.,  Passed   Assistant   .SurgeoiL  Resignation 
accepted  to  take  efTect  February  20,  1909. 


Stokes,  C.  F.,  Surgeon.  Detached  Irom  the  Bureau  of 
Medicine  and  Surgery,  Navy  Department,  and  ordered 
to  the  Naval  Academy,  Annapolis,  Md. 

 <^  


Married. 

IjALL.krd— Oli  HOF. — Tn  Lawrenceville,  Pennsylvania,  on 
Wednesday.  January  27th,  Dr.  Frederick  Clifton  Ballard 
ann  Miss  Jennie  Gretchen  Olthof. 

Ijisguic — Wilson. — In  Philadelphia,  on  Wednesday,  Feb- 
ruary 24th,  Dr.  Thomas  Lawrence  Disque,  of  Pittsburgh, 
and  Miss  Margaretta  Watt  Wilson. 

h'uLLER — Waukick. — In  Philadelphia,  on  Tuesday,  Feb- 
ruary 9th,  Dr.  Solomon  C.  Fuller,  of  West  Borough,  Mas- 
sachusetts, and  Miss  Meta  Vaux  Warrick. 

McCoRMKK — Con  VERY. — In  Newark,  New  Jersey,  on 
Wednesda}'.  February  i/tli.  Dr.  Daniel  L.  McCormick  and 
A'liss  Sara  A.  Convery. 

Pessacino — EvERLV. — In  Baltimore,  Maryland,  on  Thurs- 
day, February  iith.  Dr.  Eugene  L.  Pessagno  and  Miss 
Mary  L.  Eycrly. 

Wheeler — Flower. — In  Philadelphia,  on  Monday,  Janu- 
ary 25th,  ^Ir.  Fred  \\.  Wheeler,  of  Elmira,  N.  Y.,  and  Dr. 
Edith  Irene  Flower,  of  Mansheld,  Pennsylvania. 

Died. 

Beise. — In  Mankato,  Minnesota,  on  Tuesday.  Februarv 
9th.  Dr.  C.  J.  Beise. 

Brown. — In  Salem.  Massachusetts,  on  Tuesday,  Febru- 
ary 9th,  Dr.  Alden  W.  Brown,  aged  seventy  years. 

P)Kownlee. — In  Burnet,  Texas,  on  Monday,  February 
8th,  Dr.  J.  C.  Brovvnlee,  aged  fifty  years. 

Bruce. — In  Kingsboro,  (ieorgia,  on  Thursday,  February 
iith.  Dr.  W.  W.  Bruce,  aged  ninety-one  years. 

Bull. — In  Savannah,  Georgia,  on  Monday.  February 
22d,  Dr.  William  Tillingliast  Bull,  of  New  York,  aged 
fifty-nine  years. 

Cooper. —  In  Meachille,  Pennsylvania,  on  Thursday,  Feb- 
ruary nth.  Dr.  Joshua  M.  Cooper,  aged  sixty-four  years. 

Detrick. — In  Philadelphia,  on  Friday,  February  5th.  Dr. 
Henry  P.  Detrick,  of  Williamsburg,  aged  twenty-eight 
>-ears. 

Ensor. — In  Bristol,  Tennessee,  on  Friday,  February  latli, 
Dr.  John  J.  Ensor,  aged  eighty-four  years. 

Flagg. —  In  Rutherglen,  on  Wednesday,  February  loth, 
Dr.  William  C.  Flagg,  aged  fifty-four  years. 

Griffin. — In  Hiilsboro,  Texas,  on  Saturday,  February 
13th,  Dr.  J.  M.  Griffin,  aged  seventy-seven  years. 

Hamburg. — In  Rochester,  New  York,  on  Sunday,  Feb- 
ruary 7th,  Dr.  Eugene  Franklin  Hamburg. 

Harding. — In  Everett.  Massachusetts,  on  Tuesday.  Feb- 
ruary i6th.  Dr.  Walter  A.  Harding,  aged  thirty-five  years. 

Hill. — In  Denver.  Colorado,  on  Thursday,  February 
nth.  Dr.  O.  W.  Hill,  a.ged  twenty-three  years. 

Kemter. — In  Syracuse.  New  York,  on  Friday.  February 
I2th.  Dr.  T.  H.  Kemter,  aged  seventy-one  years. 

Knight. — In  Boston,  on  Saturday,  February  20tli.  Dr. 
Frederick  Ir\'ing  Knight,  aged  sixty-seven  years. 

McGrew. — In  Geneva.  Nebraska,  on  Thursday,  F"ebruary 
iith.  Dr.  .A.  G.  McGrew,  aged  seventy-two  years. 

Morgrid(;e. — In  Muscatine.  Iowa,  on  Friday.  February 
I2tli.  Dr.  G.  O.  Morgridge.  aged  sixty-nine  years. 

MuLi.iNs. —  In  Washington.  D.  C,  on  Thursday,  Febru- 
ary Iith,  Dr.  John  H.  Mullins,  aged  forty-two  years. 

Nock. — In  Brooklvn,  New  York,  on  Friday.  I'ebruarv 
19th.  Dr.  H.  Tilford  Nock. 

Price. — In  Bluefield.  West  Vir.gitiia.  on  Friday.  February 
T2th.  Dr.  Samuel  Davies  Price,  of  Montvale,  Virginia,  aged 
twenty-six  years. 

QuiGG. — In  Tomah,  Wisconsin,  on  Saturday,  February 
13th.  Dr.  Charles  E  Quigg. 

RoniiiNS. — In  Brooklyn.  New  ^'ork.  on  Tuesday.  Febru- 
ary T6th,  Dr.  Nathaniel  .\.  Robbins.  aged  seventy  years. 

Trti'pe. — In  .Atlanta.  Georgia,  on  Tuesday.  February  9tli. 
Dr.  R.  J.  Trippe.  of  Cartersville. 

\V.\Y. — In  Portland.  Maine,  on  I-'ridav.  Februarv  12th, 
Dr.  George  W.  Way. 

Wh.wne. — In  Pueblo,  Colorado,  on  Tuesday.  Fcbruani' 
gtb.  Dr.  W.  .A.  Whayne,  aged  forty-four  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  it  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J, 


Vol.  LXXXIX,  No.  10.  XEW  YORK.  MARCH  6,  1909.  Whole  No.  1579. 


OPrigiual  Conuminifation.s. 


SOME  AFFECTIONS  OF  THE  ORAL  AND  NASAL 
CAVITIES  WHICH  ARE  RELATED  TO 
SKIN  DISEASES.- 

By  John  A.  Fordyce,  M.  D., 
New  York, 

Professor   of   Dermatology   and    Syphilology   in    tlie   University  anil 
and  Bellevue  Hospital   .Medical  College. 

Before  an  association  of  specialists  the  con^^idera- 
tion  of  mucous  membrane  affections  in  relation  to 
skin  diseases  is  chiefly  one  of  diagnosis.  The  corre- 
lation of  the  two  structures  is  recognized  not  only 
in  jmrely  dermatological  cases,  where,  in  many  in- 
stances, we  rely  upon  mucous  membrane  lesions  to 
estal)]ish  a  diagnosis  in  obscure  diseases,  but  also 
in  general  ccmditions.  as  in  the  acute  contagious 
exanthemata,  where  we  attach  much  importance  to 
the  primary  Koplik  spots  on  the  buccal  and  labial 
mucosas  in  measFes,  the  vesicles  and  pustules  in  the 
mouth  and  pharynx  of  smallpox  and  varicella  pa- 
tients, and  some,  though  perhaps  less  significance, 
to  the  strawberry  tongue  and  pharyngitis  in  scarlet 
fever.  On  the  mucous  membranes,  however,  lesions 
present  peculiarities  which  are  not  seen  on  the 
skin,  and  consequently  the  question  of  diagnosis  is 
more  complicated.  For  example,  the  color  contrast 
is  less  owing  to  the  greater  transparency  of  the 
former  tissue  and  on  account  of  moisture  ajid 
maceration  primary  lesions  soon  undergo  modifica- 
tions or  lose  their  characteristics  by  secondary  in- 
fection. 

The  most  important  disease  of  the  skin — eczema 
— has  its  counterpart  in  catarrh  of  the  mucous 
membrane.  The  pathological  process  is  the  same 
in  both,  namely,  hyperjemia,  swelling,  exudation, 
and  epithelial  desquamation.  /Etiologically,  there 
is  a  further  relationship  in  that  local  irritants  or 
some  remote  factor,  as  inherent  vulnerability,  may 
be  oj)erative  in  both  conditions,  and,  among  the 
subjective  symptoms,  an  analogue  has  been  drawn 
between  the  pruritus  of  the  skin  and  the  cough- 
ing and  sneezing  following  catarrhs  of  the  respira- 
tory tract.  .Some  good  observers  have  noted  that 
catarrhal  inflammations  of  the  skin  may  alternate 
with  those  of  the  mucous  membranes,  the  one  being 
active  while  the  other  is  lield  in  abeyance.  This 
view  is  upheld  by  Brocq,  who  quotes  instances  of 
such  alternation,  and  it  may  be  due  to  the  same 
patliological  law  which  governs  the  subsidence  of 
an  inflammation  in  one  organ  while  it  is  active  in 

■*Read  before  the  .Section  in  Laryngologj-  and  Rliinology,  Xe.v 
Vork_  .\cadeniy  of  Medicine.    December  ^3.  1908. 


another.  I  cannot  substantiate  the  theory  of  the- 
alternation  of  cutaneous  and  mucous  membrane  af- 
fections, as  in  my  own  experience  I  have  not  been 
able  to  observe  this  phenomenon.  The  absence  of 
febrile  disturbances  in  cutaneous  catarrhs  has  been 
accounted  for  bv  the  heat  radiation  from  the  sur- 
face and  the  elimination  of  toxic  products  through 
the  excretions. 

In  dermatological  practice  it  is  quite  a  common; 
observation  to  find  a  catarrhal  condition  of  tlie  skin 
set  up  by  one  of  the  mucous  membranes  and  con- 
versely, the  mucous  membranes  may  be  involved  by 
autoinoculation  from  the  skin.  This  is  frequently 
illustrated  in  discharges  from  the  eye,  ear,  nose^ 
mouth,  or  genitals  producing  an  eczematoid  der- 
matitis of  the  contiguous  skin.  The  lesion,  which 
is  usually  staphylogenic  in  origin  and  vesicular  or 
erythematous,  soon  forms  eczematous  jjlaque.s- 
which  by  confluence  or  progression  involve  'arge 
areas,  or  by  autoinoculation  produce  new  ones. 
Engman  has  particularly  called  attention  to  cases 
of  this  kind  {American  ^fedicine,  1\\  N:i.  20. 
1902).  Eczema  of  the  cheeks  in  children  can  often 
be  traced  to  sleeping  with  the  mouth  open  and  the 
dribbling  saliva  in  subjects  of  adenoids.  The  con- 
nection between  the  mucosa  and  integument  is  fur- 
ther demonstrable  in  cases  of  refractory  sycosis  of 
the  lip  produced  by  pus  organisms  in  an  irritating- 
nasal  discharge;  in  facial  erysipelas  or  the  re- 
curring erysipelatoid  flush  of  the  face  from  picking 
the  nose.  Impetigo  contagiosa  also  attacks  the 
mucous  membrane  of  the  nose  and  mouth,  and  may 
;)recede.  accompanv,  or  follow  the  skin  eruption.  It 
is  seen  usually  as  isolated  vesicles  or  pustules  wliich 
become  encrusted.  More  rarely  a  papillom-tous 
condition  develops  and  an  adenitis  may  be  present. 
The  impetigo  of  l^iockhart  results  from  autoinocu- 
lation with  the  staphylococcus,  and  is  ])roduced  by 
scratching  in  pruritic  diseases.  The  lips  and  mouth 
are  eroded,  and  the  lesions  by  confluence  may  give 
rise  to  phlegmonous  areas.  In  a  case  of  fulminat- 
ing ecthyma  {ecthyma  tcrcbraiit) ,  which  I  reported 
several  years  ago  {Journal  of  Cutaneous  Diseases, 
xxi,  p.  549,  1903),  the  lesion  began  on  the  hand 
and  by  autoinfection  involved  the  face,  head, 
thighs,  mucous  surfaces  of  the  lips,  and  soft  palate 
and  nose,  where  numerous  pe^a  sized  superficial  ero- 
sions were  present,  accomf ..iiied  by  a  fcetid  .se^o- 
purulent  nasal  discharge.  Marked  septic  symptoms 
were  present,  and  the  case  had  a  fatal  issue.  .\t 
autopsy  the  entire  larynx  and  the  trachea  were  also 
found  ulcerated.  The  bacteriological  examination 
showed  staiiliylococci.  streptococci,  and  a  slender 
unclassified  bacillus. 


Copyright,  1909,  by  A.  R. 


Elliott  Publishing  Company. 


466 


FORDYCE:  ORAL  AXD  NASAL  CAVITIES  AXD     SKIX  DISEASES.  Vok-^ 

ilEDicAL  Journal. 


All  the  types  of  pemphigus  attack  the  mucous 
membranes,  that  of  the  mouth  most  frequently. 
They  may  be  involved  early  or  late  in  the  course  of 
the  disease,  often  preceding  the  skin  eruption  by 
months,  so  that  the  early  diagnosis  of.  pemphigus 
may  rest  with  the  specialist  in  nose  and  throat 
rather  than  with  the  dermatologist.  It  is  the  rule 
for  pemphigus  vegetans  to  primarily  involve  these 
structures,  while  pemphigus  vulgaris  and  pemphi- 
gus foliaceus  do  so  less  constantly.  Early  mani- 
festations in  the  mouth  and  larynx  are  not  uncom- 
mon, however,  and  the  presence  of  bullae  and  ero- 
sions in  the  oral  cavity  accompanied  by  constitu- 
tional disturbance  and  loss  of  weight  should  lead  to 
the  suspicion  of  a  beginning  pemphigus.  This  fact 
was  emphasized  recently  by  the  observation  of  a 
woman  who  consulted  me  for  erosions  of  the  throat, 
tongue,  mouth,  lips,  and  nasal  passages.  She  stated 
that  these  lesions  had  been  present  for  some 
months,  that  she  had  lost  at  least  thirty  pounds  in 
weight,  was  generally  weakened,  and  could  walk 
but  a  short  distance  without  being  exhausted.  She 
slept  poorly  and  was  much  disturbed  by  cough  at 
night.  The  constitutional  disturbance  increased, 
but  would  be  interrupted  by  periods  of  improve- 
ment when  the  lesions  would  apparently  heal.  Then 
without  warning  a  new  outbreak  would  take  place 
attended  by  great  prostration.  The  mouth  lesions 
were  observed  by  me  for  about  three  months  before 
vesicles  or  bullae  appeared  on  the  skin,  and  then  a 
few  were  noted  over  the  trunk.  Shortly  after  her 
entire  body  was  covered  with  bullae  and  large 
eroded  spots,  and  there  no  longer  remained  any 
question  as  to  the  diagnosis.  This  case  subsequent- 
ly came  under  the  observation  of  Dr.  Winfield,  of 
Brooklyn,  and  was  reported  with  others  in  the  Jour- 
nal of  Cutaneous  Diseases,  xxvi,  p.  566,  1908. 

Much  care,  however,  is  required  in  making  a  di- 
agnosis of  pemphigus  from  the  presence  of  bullous 
lesions  on  the  mucous  membranes  alone,  as  among 
the  diseases  of  which  they  are  symptomatic,  there 
are  certain  benign  recurring  afifections  of  the  mouth 
and  skin  which  come  and  go  for  years  without  in- 
fluencing the  general  health.  It  is  difficult  to  assign 
these  cases  to  any  known  nosological  group. 

Howe  has  reported  a  series  of  cases  of  bullous 
dermatitis  (Journal  of  Cutaneous  Diseases,  xxi. 
p.  254,  1903)  following  vaccination  in  adults,  in 
whom  the  mucous  membranes  of  the  mouth, 
pharynx,  and  trachea  were  involved  in  connection 
with  the  skin.  The  eruption  appeared  on  an  aver- 
age of  five  weeks  after  vaccination  as  grouped 
vesicles  and  bullae  on  the  trunk  and  extremities  with 
marked  constitutional  disturbance.  Its  duration 
was  about  six  weeks,  ending  in  recoverv  or  death. 
Of  ten  ca.ses,  si.x  proved  fatal,  one  of  them  after  a 
week.  The  infectious  element  was  not  determined. 
Pemphigus  of  the  skin  and  mucous  surfaces  noted 
in  butchers  and  after  wound  infections  is  probablv 
of  streptogenic  origin. 

Mouth  lesions  arc  at  times  an  extraordinary  ac- 
companiment in  dermatitis  herpetiformis  and  some- 
times antedate  those  of  the  skin  by  .several  months, 
showing  that  some  types  of  pemphigus  and  der- 
matitis herpetiformis  arc  closely  allied  conditions. 
The  pharynx  and  larynx  may  also  be  affected  and 


perhaps  the  mucosa  of  the  gastrointestinal  tract. 
Alorris  and  Whitfield  {  British  Journal  of  Derma- 
tology, ix,  p.  213,  1897)  reported  a  case  in  which 
the  disease  began  on  the  tongue ;  it  was  soon  fol- 
lowed by  an  outbreak  of  vesicles  on  the  face  and 
arms  and  later  by  a  more  general  distribution.  The 
patient  had  numerous  attacks  with  several  severe 
ones  of  the  mouth  and  tongue. 

As  the  result  of  a  pvogenic  infection  we  some- 
times have  the  development  of  a  vegetating  der- 
matitis secondary  to  dermatitis  herpetiformis,  and 
in  these  cases  it  is  not  uncommon  to  find  erosions 
and  ulcerations  about  the  mouth  and  lips.  I  have 
had  such  a  patient  under  my  observation  for  some 
time,  and  when  the  disease  was  at  its  height  in  ad- 
dition to  the  cutaneous  lesions,  he  exhibited  ero- 
sions, fissures,  and  ulcerations  on  his  palate  and 
lips,  and  had  partial  oral  atresia  from  the  inflam- 
matory infiltration  which  had  evidently  extended  to 
the  subcutaneous  muscular  tissue.  In  the  relapses 
which  he  has  had  during  the  course  of  his  malady 
the  lips  have  always  been  more  or  less  involved. 
{Journal  of  Cutaneous  Diseases,  xxiv,  p.  543, 
1906.) 

A  hereditary  tendency  to  bullous  formation  on  the 
application  of  slight  trauma  is  present  in  epidermo- 
lysis bullosa,  the  mucous  membranes  as  well  as  the 
skin  sufifering  from  this  inherent  weakness.  Bullje 
may  form  in  the  mouth  and  on  the  lips  and  pseudo- 
milia  or  subepidermic  corneous  cysts  mark  the  site 
of  a  previous  eruption. 

Herpes  zoster  exceptionally  implicates  the  mu- 
cous membranes  of  the  mouth.  When  the  disease 
mvades  that  part  of  the  ganglion  which  presides 
over  the  nutrition  of  the  second  division  of  the  fifth 
nerve  then  the  side  of  the  tongue,  inner  side  of  the 
cheek,  palate,  tonsil,  and  even  the  pharynx  and 
oesophagus  mav  be  the  seat  of  eruption.  Herpes 
simplex,  which  is  of  frequent  occurrence  on  the 
lips,  may  also  manifest  itself  on  the  oral,  pharyn- 
geal, and  laryngeal  mucosas.  It  is  usually  bilateral 
on  the  hard  palate,  and  is  not  due  to  ganglionic  in- 
volvement. Recurring  herpes  simplex  of  the  mouth 
and  throat  is  not  infrequently  encountered  in  syph- 
ilitic patients,  and  is  often  confounded  with  relaps- 
ing mucous  patches.  Herpes  and  aphthae  of  the 
mouth  and  throat  have  been  described  in  children 
who  contracted  them  by  drinking  milks  from  cows 
sufl'ering  from  foot  and  mouth  disease  (E.  F. 
Brush,  in  Journal  of  the  American  Medical  Asso- 
ciation, June  20,  1903). 

In  the  erythema  group  of  skin  diseases  and  cer- 
tain allied  conditions  as  urticaria,  angeioneurotio 
redema,  some  forms  of  purjnira,  and  certain  drug 
rashes,  the  mucous  membranes  of  the  mouth,  nose, 
respiratory  and  gastrointestinal  tract  may  partici- 
pate in  the  morbid  process.  Some  of  these  afifec- 
tions are  accompanied  by  organic  and  constitutional 
disturbance  ancl  are  of  grave  import.  Osier  has 
es])ccially  called  our  attention,  in  a  series  of  articles 
pul)lishe(l  in  the  American  Journal  of  the  Medical 
Sciences,  cx,  p.  620,  1895,  and  cxxvii,  p.  1.  i<X34.  to 
the  visceral  and  constitutional  manifestations  in  the 
ervthema  group  of  skin  diseases  attended  with  or 
without  haemorrhage  into  the  integunien  and  mu- 
cosa.    The  type  of  cases  described  by  him  is  sim- 


ilarcli  6.  /  915. 1 


FORDYCE:  ORAL  AND  NASAL  CAVITIES  AND  SKIN  DISEASES. 


467 


ilar  in  its  symptomatology  to  that  of  Henoch's  pur- 
pura. \\'e  know  there  is  a  very  close  relationship 
between  the  severer  forms  of  erythema  multiforme 
and  purpura,  the  severity  of  the  process  often  lead- 
ing to  extravasation  of  blood  cells  as  well  as  serum. 

In  erythema  multiforme  the  bullous  type  is  most 
frequently  encountered  on  the  mucous  surfaces.  In 
this  condition  we  have  a  toxaemia,  pf  metabolic, 
microbic,  or  other  origin,  frequently  arising  in  the 
intestinal  canal,  less  often  the  viscera,  or  occasion- 
ally from  some  other  source,  as  in  an  instance  in 
my  own  experience  where  the  absorption  of  a  bro- 
ken down  gumma  led  to  a  typical  erythema  multi- 
forme of  the  arms.  All  grades  of  the  infectious 
process  are  met  with,  and  the  disease  may  be 
ushered  in  by  a  severe  chill  followed  by  a  tempera- 
ture of  105°  or  106°  F.  with  almost  immediate  in- 
volvement of  the  mucous  membranes  of  the  mouth 
and  nose.  These  cases  excite  the  suspicion  that  we 
are  dealing  with  one  of  the  preliminary  rashes  of 
the  contagious  exanthemata,  and  it  may  be  neces- 
sary to  isolate  the  patient  for  a  few  days  until  the 
skin  manifestations  become  sufficiently  well  de- 
fined to  enable  us  to  make  the  diagnosis. 

The  absorption  of  a  local  irritant  from  the  skin  may 
act  on  the  vasomotor  centre  or  the  bloodvessels  and 
lead  to  an  oedematous  condition  of  the  mouth  and 
throat  resulting  in  serious  interference  with  breath- 
ing, as  in  a  case  observed  by  me  a  number  of  years 
ago  where  an  insect  bite  was  followed  by  enormous 
swelling  of  the  arm  and  urticarial  lesions  of  the 
entire  body  and  within  a  short  time  by  oedema  of  the 
glottis.  Similar -conditions  are  met  with  in  the 
mouth  and  throat  from  urticaria  from  any  cause. 
Following  serum  injections  the  reaction  mav  mani- 
fest itself  on  the  mucous  membrane  as  well'  as  the 
skin,  as  in  a  case  of  severe  oedema  of  the  face, 
pharynx,  and  larynx  seen  within  half  an  hour  after 
injection  of  a  prophylactic  dose  of  antitoxine  in  an 
adult  (Lewis,  Journal  of  Experimental  Medicine, 
x,  No.  5,  p.  608). 

Epistaxis  and  bleeding  from  the  mouth  and  throat 
followed  by  erosions  and  ulcerations  are  met  with 
in  the  severer  forms  of  purpura  which  constantly  in- 
volve the  mucous  membranes  and  form  a  part  of 
the  general  disease.  I  have  observed  a  case  in 
which  a  generalized  purpura  probablv  originated 
from  an  infectious  process  within  the  mouth.  In 
this  patient  a  bad  stomatitis,  the  result  of  neglect  of 
the  teeth  and  oral  hygiene  was"  followed  by  a  pur- 
puric eruption  which  disappeared  when  the  local 
condition  \vas  remedied. 

Among  the  drug  rashes  which  aft'ect  the  mucous 
membranes  in  conjunction  with  the  skin  are  those 
from  the  ingestion  of  the  iodides,  bromides,  mer- 
cury, belladonna,  quinine,  chloral,  arsenic,  the  coal 
tar  products,  and  the  balsams,  as  copaiba,  cubebs, 
and  turpentine.  I  have  seen  after  the  administra- 
tion of  the  iodides  a  generalized  macular  rash  ac- 
companied by  a  rise  of  temperature,  conjunctivitis, 
and  a  catarrhal  condition  of  the  throat.  It  simu- 
lated measles  very  closely  and  required  an  observ^a- 
tion  of  forty-eight  hours  before  the  correct  diag- 
nosis was  established.  The  balsams  also  give  rise 
to  an  erythema  of  the  palate  and  fauces  and  an 
elevation  of  temperature,  so  that  here  too  there  may 
be  danger  of  mistaking  it  for  a  contagious  exanthem. 


From  the  foregoing  it  is  seen  that  we  have  a  se- 
ries of  aflfections.  including  the  varieties  of  pemphi- 
gus, dermatitis  herpetiformis,  er\;thema  multiforme, 
and  kindred  conditions,  produced  by  some  irritant 
acting  simultaneously  on  a  skin  or  mucous  surface 
whose  resistance  has  been  temporarily  or  perma- 
nently lowered.  The  lesions  rupture  early  leaving 
erosions  which  become  encrusted,  especially  about 
the  orifices,  and  not  infrequently  lead  to  fissuring. 

In  dermatitis  exfoliativa  transitory  white  patches 
have  been  observed  on  the  tongue  and  oral  mucosa 
followed  by  increased  redness,  so  that  in  all  proba- 
bility here  too  e.xfoliation  takes  place. 

The  vermilion  borders  of  the  lips  may  be  the  seat 
of  an  eczema  which  has  spread  from  the  surround- 
ing skin,  or  they  may  be  the  only  regions  involved 
in  subjects  who^  are  lip  biters  or  are  susceptible  to 
cold  and  wind.  In  other  individuals  an  acid  secre- 
tion of  saliva  will  favor  its  production. 

Perleche,  a  parasitic  disease  of  the  lips,  occurs 
most  frequently  in  children  and  old  people  in  insti- 
tutions and  asylums.  It  affects  especially  the  com- 
missures with  fissuring  and  a  tendency  to  bleeding, 
and  simulates  quite  closely  mucous  patches. 

In  1896  I  called  attention  to  a  peculiar  affection 
involving  the  vermilion  border  of  the  lips  and  the 
mucous  membrane  of  the  mouthy  extending  along 
the  line  of  the  closed  teeth  from  the  angle  of  the 
mouth  to  a  point  opposite  the  last  molar  tooth. 
{Journal  of  Cutaneous  and  Genitourinary  Diseases, 
xiv,p.4i3, 1896.)  It  consists  of  white  or  yellowish  dis- 
crete bodies  embedded  in  the  mucous  membrane  and 
suggests  the  milia  met  with  on  the  face.  It  is  a  dis- 
puted question  still  as  to  how  these  bodies  originate 
or  whether  or  not  they  are  dependent  on  the  pres- 
ence of  sebaceous  glands  on  the  mucous  surfaces. 

True  psoriasis  of  the  mucous  membrane  is  such  a 
rarity  that  its  existence  is  denied  by  the  majority  of 
observers.  It  has  been  noted  on  the  genital  mucosa, 
and  I  have  seen  its  extension  from  the  integument 
of  the  chin  to  the  mucous  surface  of  the  lip,  but  it 
is  doubtful  if  independent  lesions  occur. 

Seborrhoeic  dermatitis  of  the  scalp  and  face  is 
sometimes  associated  with  lesions  of  the  mucous 
membranes.  Wandering  rash  of  the  tongue  and 
some  leucokeratoses,  when  accompanied  by  marked 
seborrhoeic  dermatitis  of  the  face  and  scalp,  have 
been  connected  setiologically  with  the  skin  affection. 

Lichenization,  a  chronic  inflammation  of  the  skin 
attended  by  itching  and  thickening,  is  the  result  of 
an  intoxication  or  develops  secondarily  to  other 
pruritic  diseases.  I  have  seen  this  condition  asso- 
ciated with  leucokeratosis  of  the  mouth,  a  relation- 
ship which  may  be  significant  in  determining  the 
pathogenesis  of  cases  of  leucokeratosis  when  to- 
bacco and  syphilis  cannot  be  invoked  as  causative 
factors. 

It  is  only  within  the  last  few  years  that  we  have 
recognized  such  affections  of  the  mucous  mem- 
branes as  lichen  planus,  although  the  condition  was 
described  as  far  back  as  1884  by  Thibierge.  The 
close  resemblance  of  these  lesions  of  the  mouth  to 
leucokeratosis  probably  accounts  for  the  fact  that 
they  were  not  interpreted  long  ago  as  a  distinct  dis- 
ease. On  the  skin  lichen  planus  presents  an  erup- 
tion consisting  of  a  few  papules  on  the  forearms  or 
legs  to  one  having  a  universal  distribution.    Not  in- 


468 


FORDYCE:  ORAL  AND  NASAL  CAVITIES  AND  SKIN  DISEASES.  [New  York 

Medical  Journal. 


frequently,  it  begins  on  the  genital  organs  simul- 
taneously with  lesions  in  the  mouth,  or  the  latter 
may  precede  or  follow  the  cutaneous  outbreak.  Oc- 
casionally, the  mucous  membrane  alone  is  involved. 
If  seen  in  the  early  stages  when  the  lesions  on  the 
mucosa  are  still  distinct,  the  initial  papule  is  the 
size  of  a  pin's  head  or  smaller,  hemispherical,  coni- 
cal, or  flattened,  hard  to  the  touch  and  arising  from 
a  sound  mucous  membrane.  Coalescence  soon  takes 
place,  however,  forming  plaques  of  various  sizes 
and  configuration,  appearing  round  or  oval,  or  as 
white  streaks  converging  to  give  stellate  figures,  or 
they  are  arranged  as  a  mosaic  or  arborescence.  The 
surface  of  these  patches  is  rough  and  irregular  to 
the  touch,  and  beyond  their  periphery  a  few  dis- 
crete papules-  usually  remain  which  assist  in  making 
a  diagnosis.  On  the  tongue  the  free  borders  are 
usually  affected ;  here  as  well  as  on'  the  dorsum  the 
characteristics  are  soon  lost,  while  on  the  under  sur- 
face the  lesions  retain  their  typical  form. 

On  the  mucous  surfaces  the  disease  is  very  re- 
fractory to  treatment,  often  persisting  for  years  or 
disappearing  and  relapsing,  the  relapses  usually 
taking  place  in  the  form  of  a  network.  In  addition 
to  the  mouth,  the  laryngeal,  urethral  and  vaginal 
mucosas  and  in  all  probability  that  of  the  gastro- 
intestinal tract  may  be  involved.  The  efflorescences 
in  the  mouth  and  on  the  penis  sometimes  precede 
those  of  the  skin  by  weeks  or  months,  and  in  the 
latter  situation  the  eruption  may  form  papular  or 
circinate  lesions.  The  grouping  and  distribution  on 
the  skin  with  pigmentary  changes,  efflorescences  in 
the  mouth,  on  the  palms,  and  soles,  with  swelling  of 
the  inguinal,  axillary,  or  cervical  lymph  nodes  and 
exceptionally  the  absence  of  pruritus,  give  a  picture 
not  easy  to  distinguish  from  syphilis. 

The  therapeutic  test  here  is  of  no  value,  as  the 
disease  is  also  favorably  influenced  by  mercury.  In 
one  of  my  patients  recently  the  lesions  began  on  the 
glans  penis  and  spread  to  the  abdomen  and  arms, 
accompanied  by  slight  itching.  On  his  tongue  were 
half  a  dozen  patches  of  leucokeratosis  not  distin- 
guishable from  postsyphilitic  leucokeratosis  and  on 
his  tongue  numerous  white  points  and  linear  lesions. 

In  making  a  distinctive  diagnosis  on  the  skin  we 
rely  on  the  presence  of  color,  the  polygonal  outlines, 
and  umbilication  of  individual  papules,  while  on  the 
mucous  surfaces  these  features  are  not  present. 
Here  search  should  be  made  for  pinhead  sized, 
white  topped  lesions  which  lie  in  the  neighborhood 
of  the  plaques,  or,  in  a  doubtful  case,  a  microscopi- 
cal examination  may  be  resorted  to,  the  histology 
being  identical  with  the  cutaneous  lesion.  Traut- 
mann  {  ZurDifferentialdiagiiosc  von  Dennatosen  iind 
Lues  bei  den  Schlehnhauterkrankiingen  der  Mnnd- 
hdltle  iDid  obercn  Luftivege)  has  pointed  out  as 
characteristics  of  lichen  planus  of  the  mucous  mem- 
branes that  the  patches  remain  constant  in  their  ap- 
pearance, the  mucous  membrane  itself  is  not  visibly 
infiltrated,  and  the  surrounding  tissue  is  unchanged, 
whereas  luetic  lesions  become  condylomatous  or  ul- 
cerative and  also  involve  the  surrounding  mucous 
membrane. 

Le])rosy,  in  a  large  number  of  ca.ses,  has  been  re- 
ported as  beginning  with  a  rhinitis,  and  it  may  be 
that  the  nasal  secretion  is  the  primary  carrier  of  the 


infection.  The  discharge  when  augmented  by  the 
production  of  a  coryza  with  potassium  iodide  and 
examined  for  lepra  bacilli,  has  established  a  diag- 
nosis in  some  cases  even  before  the  appearance  of 
the  cutaneous  lesions.  It  has  been  suggested  (Con- 
tribution a  I'etude  de  la  contagion  et  de  la  patho- 
genie  de  la  lepre.  Thiroux,  Lepra,  IV,  Fasc.  2,  p. 
117)  that  the  discrepancy  in  the  findings  of  the  or- 
ganism from  this  source  is  due  to  the  character  of 
the  lesion,  the  nodular  type  giving  a  larger  propor- 
tion of  positive  cases  than  the  trophoneurotic.  .  In 
glanders,  where  the  skin  and  mucous  membranes 
are  chiefly  affected,  the  characteristic  symptom  is 
the  nasal  discharge,  which  precedes  the  lesions  of 
the  integument  by  several  days  to  three  or  four 
weeks. 

The  organism  of  actinomycosis  usually  finds  its 
portal  of  entry  through  a  carious  tooth  or  other 
lesion  of  the  mucous  surfaces. 

In  systemic  blastomycosis  lesions  of  the  larynx, 
trachea,  and  bronchi  have  been  reported  by  Mont- 
gomery and  Ormsby  {Transactions  of  the  VI.  In- 
ternational Dermatological  Congress,  1907,  p.  365). 

Gangosa,  a  disease  of  the  tropics,  consists  of  an 
ulceration  of  the  nasopharynx  extending  from 
thence  to  the  skin  of  the  face  and  producing  great 
deformity.  It  is  met  with  in  natives  on  the  Island 
of  Guam,  Fiji,  British  Guiana,  and  in  all  probability 
in  the  West  Indies  and  Polynesia.  In  my  service  at 
the  City  Hospital  I  had  such  a  case  in  a  negro  from 
Jamaica,  which  Arnold  and  I  made  the  subject  of  a 
report  in  the  Journal  of  Cutaneous  Diseases,  xxiv. 
p.  I,  1906.  The  disease  in  this  patient  was  fully 
developed,  but  the  beginning  of  the  process  is  de- 
scribed by  Mink  and  McLean  {Journal  of  Cuta- 
neous Diseases,  xxv,  p.  503)  as  a  slight  pharyn- 
geal, tonsillar,  and  laryngeal  inflammation  over 
which  a  yellowish  gray  membrane  appears  in  a  few 
days,  and  within  twenty-four  hours  ulceration  is 
established.  The  ulcer  has  a  punched  out  appear- 
ance, undermined  edges,  and  a  deep,  uneven  floor : 
it  progresses  rapidly,  destroying  bony  and  soft  parts 
with  equal  ease.  Its  activity  may  continue  indefi- 
nitely or  become  arrested  at  any  time,  or  after  a 
period  of  quiescence  it  may  become  active  again. 
The  general  health  is  unaffected,  although  fulminat- 
ing cases  occur  in  children  .which  terminate  fatally 
in  forty-eight  hours.  The  disease  extends  from  tl'e 
nasal  and  oral  cavities  to  the  face,  destroying  the 
nose,  lips,  and  eyes-.  The  tongue  and  muscles  of 
deglutition  usually  escape.  The  aetiology  of  the  af- 
fection has  not  been  determined. 

Rhinoscleroma  generally  begins  in  the  mucous 
membrane  of  the  anterior  nares  and  the  adjacent 
skin,  or  the  saeptum  or  upper  lip  may  be  primarily 
involved,  the  larynx  and  pharynx  being  encroached 
upon  by  extension  of  the  process. 

Lupus  erythematosus  involves  the  mucous  mem- 
branes either  by  direct  extension  from  the  face  to 
the  lips,  or  it  occurs  in  the  mouth,  pharynx,  or  larynx 
independent  of  any  cutaneous  eruption.  In  my  ex- 
perience, after  the  lips,  it  has  been  met  with  more 
frequently  on  the  mucous  membranes  inside  of  the 
cheeks.  Plaques  on  the  tongue  resemble  leucokera 
tosis,  scars  from  early  syphilides,  lichen  plaiuis,  and 
other  aflfections.    W'lien  the  lips  arc  first  involved, 


March  6,  1909. 1 


FORDYCE:  ORAL  AND  NASAL  CAVITIES  AND    SKIN  DISEASES. 


469 


they  are  swollen,  purplish  red.  and  eroded,  but  later 
become  dry  and  seal)',  and  finally  show  an  atrophic 
grayish  white  centre  surrounded  by  a  hyperjemic 
zone  like  typical  lesions  on  the  face.  On  the  cheeks 
the  early  appearance  is  much  the  same,  but  later 
grayish  white  streaks  are  seen,  which  have  been 
likened  to  streaks  produced  by  brushing  the  surface 
with  silver  nitrate.  The  lesions  in  the  mouth  are 
sometimes  very  typical  and  help  to  clear  up  an  ob- 
scure skin  diagnosis. 

Owing  to  the  occurrence  in  a  large  percentage  of 
these  cases  of  a  h}pertrophic  or  atrophic  rhinitis, 
Wilfred  Warde  (British  Journal  of  Dermatology, 
xiv,  pp.  332  and  380,  1902)  inferred  that  the  morbid 
process  controlling  the  two  conditions  was  similar, 
consisting  of  an  inflammation  induced  by  vascular 
weakness  followed  by  local  oedema  and  atrophy. 
This  position,  however,  I  consider  untenable  on  both 
clinical  and  setiological  grounds,  as  in  the  one  we 
have  a  common  condition  dependent  on  a  local  hy- 
perplasia of  adenoid  tissue  and  in  the  other  a  disease 
sufficiently  rare  that  the  coexistence  with  hyper- 
trophic or  atrophic  rhinitis  may  be  looked  upon  as  a 
rare  coincidence.  Severe  constitutional  disturbance 
may  be  present  in  lupus  erythematosus,  as  in  the  dis- 
seminated form,  which  is  sometimes  accompanied  by 
a  general  toxsemia. 

Lupus  vulgaris  in  the  majority  of  cases  begins 
primarily  in  the  mucous  membrane  of  the  nose,  usu- 
ally at  the  edge  of  the  nostril,  and  by  extension  in- 
volves the  skin  of  the  face,  the  oral  and  laryngeal 
cavities.  It  is  estimated  that  seventy  per  cent,  of  all 
cases  of  lupus  show  mucous  membrane  involvement, 
and  perforation-  of  the  saeptum  is  not  uncommon. 
On  the  mucous  membranes  lupus  is  more  often  pa- 
pillomatous and  occurs  in  placards  on  the  gums,  the 
floor  of  the  mouth,  palate,  and  inner  surface  of  the 
cheeks.  In  the  nose  the  disease  produces  a  charac- 
teristic change  resulting  in  destruction  of  the  car- 
tilaginous tissue,  giving  rise  to  the  pointed  or  peaked 
nose  in  contradistinction  to  syphilis  where  the  bony 
portion  is  attacked  and  leads  to  a  flattened  or  de- 
pressed nose.  Lupus  of  the  mucous  membranes  pro- 
gresses much  more  slowly  than  luetic  lesions,  though 
on  account  of  the  anatomical  differences  of  the  tis- 
sues its  progress  is  more  rapid  than  on  the  skin.  Pri- 
mary tuberculosis  of  the  tongue  is  rare  and  is  gen- 
erally associated  with  an  active  tuberculosis  of  the 
lungs.  There  is  usually  a  traumatic  lesion  of  the 
tongue  following  irritation  from  a  ragged  tooth  on 
which  tubercle  bacilli  become  engrafted  and  produce 
an  ulcer  with  sharply  cut,  irregular  borders  sur- 
rounded by  miliary  tubercles. 

Pigmentation  of  the  mucosa,  especially  of  the 
cheeks,  is  seen  in  connection  with  Addison's  disease 
and  may  be  the  first  symptom  present ;  in  diabetic 
melanodermia,  xeroderma  pigmentosum,  vagabond's 
disease,  acarvis  infection,  and  from  the  use  of  arsenic 
and  silver  nitrate.  In  acanthosis  nigricans  the  mu- 
cous membranes  likewise  participate  in  the  general 
papillomatosis  and  hyperpigmentation. 

Touching  upon  other  conditions  which  also  occur 
on  the  mucous  membranes,  mention  might  be  made 
of  vitiligo,  which  is  sometimes  seen  on  the  cheeks 
conjointly  with  the  skin  changes ;  of  Darier's  dis- 
ease, lesions  on  the  lips,  tongue,  and  cheek  having 


been  reported ;  of  xanthoma,  which  involves  the  niu- 
cous  surface  of  the  lips,  tongue,  and  respiratory  and 
intestinal  canals ;  in  some  cases  only  a  solitary  lesion 
on  the  tongue  has  been  seen  in  children.  The  fungi 
of  ringworm  and  favus  have  in  a  few  cases  been 
known  to  invade  the  mucous  membranes,  and  among 
the  animal  parasites,  demodex  folliculorum  has  been 
found  in  conjunction  with  a  blepharitis.  In  a  few 
instances  of  von  Recklinghausen's  disease  tumors 
have  also  developed  on  the  lips,  gums,  and  hard 
palate,  and  in  a  case  which  came  to  autopsy  the  in- 
testine was  studded  with  small  fibromata. 

Much  confusion  exists  in  the  minds  of  physicians 
as  to  the  relationship  of  leucokeratosis  of  the  mu- 
cous membranes  and  an  antecedent  syphilis.  By 
many,  all  white  patches  met  with  in  the  mouth, 
whether  due  to  lichen  planus,  lupus  erythematosus, 
the  sequelae  of  syphilitic  lesions,  or  otherwise,  are 
grouped  together  under  the  heading  of  leucokera- 
tosis. 

I  might  summarize  my  impressions  of  this  condi- 
tion briefly  as  follows :  Alterations  of  the  surface 
epithelium  accompanied  by  a  certain  amount  of  un- 
derlying inflammation  may  be  produced  from  the 
irritation  of  tobacco  smoke  in  subjects  who  have 
never  had  syphilis,  the  amount  of  smoke  necessary 
to  produce  this  condition  being  altogeth^  an  indi- 
vidual matter  dependent  on  the  susceptibility  of  the 
mucous  surface.  We  get  similar  alterations  in  the 
superficial  epithelium  in  subjects  who  have  had  re- 
lapsing mucous  patches  of  these  regions,  which  al- 
teration is  more  frequent  if  the  syphilitic  lesions  are 
irritated  by  tobacco  smoke.  Analogous  changes  are 
met  with  where  there  is  a  deeply  seated  inflamma- 
tion, especially  of  the  tongue,  with  an  interstitial 
glossitis,  the  nutrition  of  the  surface  being  impaired 
by  the  underlying  inflammation.  The  question  of 
the  relationship  of  lichen  planus  lupus  erythemato- 
sus, seborrhoeic  dermatitis,  and  toxic  conditions 
which  affect  the  bloodvessels  of  the  skin  and  mucous 
membranes  has  already  been  referred  to.  In  sus- 
ceptible subjects  leucokeratosis  of  the  mucous  mem- 
branes might  be  produced  by  the  rough  edges  of  a 
tooth. 

Leucokeratosis  in  a  certain  percentage  of  cases  is 
attended  by  a  downgrowth  of  the  surface  epithelium 
and  epithelioma.  Growths  of  the  mucous  membrane 
are  usually  of  the  malignant  prickle  cell  type,  while 
in  the  skin  the  basal-cell  or  rodent  ulcer  variety  is  of 
more  frequent  occurrence.  I  have,  however,  seen 
several  instances  of  cylindroma  of  the  cheek  and 
palate,  which  are  really  basal  cell  tumors  analog'ous 
to  those  found  on  the  scalp,  and  in  another  case, 
that  of  a  woman,  a  growth  over  the  hard  palate 
which  closely  simulated  lupus  vulgaris  was  seen,  on 
microscopical  examination,  to  have  taken  its  origin 
from  the  basal  layer  of  the  epidermis.  At  the  pres- 
ent time  I  have  in  my  clinic  a  woman  with  rodent 
ulcer  of  the  vermilion  border  of  the  lips,  the  growth 
having  extended  from  the  skin  of  the  upper  lip. 
Epitheliomata  of  the  lips  and  tongue  are  not  com- 
monly met  with  in  women,  and  when  present  are 
very  frequently  secondary  to  some  other  change  of 
the  surface  epithelium,  a  specific  lesion,  or  some  irri- 
tation as  from  a  tooth  or  other  cause.  In  the  Third 
Scientific  Report  of  Investigation  of  the  Imperial 


PALMER:  MEDICAL  CENSORSHIP  OF  LAY  PRESS. 


[New  York 
Medical  Journal. 


Cancer  Research  Fund  attention  was  called  by  Dr. 
Bashford  to  the  occurrence  of  epithelioma  in  women 
in  India  who  chew  the  betel  nut  and  sleep  with  the 
plug  in  their  mouths,  cancer  developing  on  the  exact 
spot  where  the  plug  was  held.  This  observation 
emphasizes  the  importance  of  prolonged  irritation 
of  a  mild  grade  in  the  production  of  carcinomatous 
change. 

I  have  found  the  greatest  aid  in  making  a  diag- 
nosis of  mucous  membrane  lesions  in  excising  or  re- 
moving with  a  cutaneous  punch  a  small  piece  and 
submitting  it  to  microscopical  examination.  This  is 
especially  of  value  where  there  is  a  question  of  dis- 
tinctive diagnosis  between  syphilis  and  cancer  of  the 
tongue.  It  not  infrequently  happens  that  cancer  be- 
comes engrafted  on  a  syphilitic  base,  and  in  this  way 
it  is  possible  sometimes  to  detect  carcinoma  at  an 
early  stage.  A  good  many  surprises  are  met  with 
when  we  attempt  to  confirm  our  clinical  diagnoses 
by  the  microscope.  A  case  recently  presented  itself 
to  me  for  diagnosis  with  a  lesion  at  the  edge  of  the 
tongue  which  consisted  of  an  irregular  ulceration 
surrounded  by  a  considerable  degree  of  induration. 
A  biopsy  was  not  made,  but  the  patient  submitted 
himself  to  operation  for  a  partial  excision  of  the 
organ.  In  this  case  the  submaxillary  nodes  were 
not  enlarged,  but  those  along  the  carotid  were.  On 
microscopical  examination  the  lesion  was  found  to 
be  a  tuberculous  and  not  an  epitheliomatous  one.  A 
mistake  of  this  kind  could  hardly  have  been  fore- 
seen by  the  clinician,  as  tuberculosis  of  the  tongue 
is  an  exceedingly  rare  condition  and  does  not  often 
present  the  clinical  features  of  this  case.  Miliary 
tubercles  about  the  area  of  ulceration,  had  they  been 
present,  would  have  -given  a  clue  as  to  the  nature  of 
the  process. 

The  foregoing  article  is  not  meant  to  be  a  com- 
prehensive one,  but  merely  touches  upon  the  more 
usual  and  unusual  conditions  met  with  on  the  mu- 
cous surfaces  of  the  mouth,  nose,  throat,  and  larynx 
from  the  standpoint  of  the  dermatologist,  and  it  is 
hoped  at  least  that  they  may  be  suggestive  to  the 
specialist  whose  work  is  confined  to  these  regions. 
When  I  was  asked  to  discuss  the  lesions  of  the  mu- 
cous membranes,  I  was  requested  not  to  include  the 
syphilitic  ones.  As  these  comprise  a  large  majority 
of  the  affections  of  the  mucous  surfaces  and  often 
present  themselves  for  differential  diagnosis  with 
some  of  the  diseases  which  hav-e  been  mentioned,  it 
is  probable  that  they  may  have  been  reserved  for  a 
future  "symposium." 


CONCERNING  THE  NEED  FOR  MEDICAL  CEN- 
SORSHIP OF  THE  LAY  PRESS. 

By  W.  H.  Palmer,  M.  D., 
Providence,  R.  I. 

During  the  past  half  decade  much  has  been  ac- 
complished along  certain  lines  in  preventing  the 
dccejjtion  of  the  public  in  medical  matters  through 
the  agency  of  the  press.  Two  of  America's  fore- 
most publications.  Collier's  Weekly  and  The  Ladies' 
Home  Journal,  have  waged  relentless  battle  against 
the  insertion  of  medical  advertisements  in  news- 


papers and  periodicals.  This  campaign  has  yielded 
immeasurable  good,  but  a  matter  quite  as  impor- 
tant and  pernicious  has  received  little  or  no  atten- 
tion. I  refer  to  the  injudicious  publication  of  items 
referring-  to  things  medical. 

Manifold  are  the  ways  in  which  the  indiscrim- 
inate publication  of  medical  items  may  do  harm. 
Of  the  most  importance  is  the  premature  exploita- 
tion of  new  remedies  and  methods  of  treatment  for 
various  diseases,  particularly  for  chronic  and  in- 
curable maladies.  Of  less  importance  in  general  is 
the  disrepute  which  may  befall  a  reputable  and  con- 
scientious physician  through  distortion  of  fact  in 
quoting  his  utterances.  Thirdly,  pabulum  for  quacks 
is  furnished  by  the  glowing  reports  given  by  the 
press  of  methods  in  which  charlatans  quickly  in- 
terest themselves.  Lastly,  inaccurate  information 
about  anatomy,  physiology,  pathology,  etc.,  is  given 
to  many  people  for  whom  superficial  knowledge  is 
a  dangerous  asset.  The  difiierent  phases  of  the  sub- 
ject are  best  studied  separately. 

The  premature  announcement  of  remedies  and 
methods  of  therapeusis  before  they  have  stood  the 
test  of  time  can  be  of  no  possible  service  to  the 
public.  Every  reputable  physician  is  supposed  to 
keep  pace  with  the  progress  being  made  in  the  sci- 
ence of  medicine,  and  it  is  to  him  that  the  suffer- 
ing patient  should  go  for  advice,  and  not  seek  a 
relatively  untried  and  new  means  of  bettering  his 
condition,  sitch  as  is  offered  so  frequently  in  the 
columns  of  the  daily  press. 

The  public  readily  gives  more  credence  to  an  ap- 
parent statement  of  fact  than  to  an  advertisement, 
which  is,  prima  facie,  an  evidence  of  commercialism. 
Nostrum  venders  have  long  taken  advantage  of  this 
fact,  in  attempting  to  disguise  their  appeals  to  the 
laity  by  making  advertising  matter  simulate,  as 
nearly  as  possible,  the  appearance  of  an  ordinary 
news  item. 

Unfortunately,  the  great  majority  of  people  do 
not  consult  their  medical  advisers  before  taking  up 
a  newly  reported  cure ;  those  who  do  are  very  few. 
It  would  be  quite  impossible  to  gain  an  accurate 
idea  as  to  the  number  of  new  cures  brought  before 
the  public  in  a  single  year  through  the  agency  of 
the  press.  Cures  for  cancer,  chronic  rheumatism, 
locomotor  ataxia,  paresis,  eczema,  etc.,  are  con- 
stantly being  reported  in  the  columns  of  reputable 
publications.  My  morning  paper  is  before  me,  and 
a  perusal  of  the  first  page  reveals  two  rather  lengthy 
articles,  one  relating  to  the  marvelous  curative 
power  of  radium,  and  the  other  telling  of  a  new 
means  of  curing  tuberculosis. 

During  November,  1908,  three  of  my  patients 
asked  my  advice  regarding  a  trip  to  New  York  for 
the  purpose  of  seeing  a  physician  whose  newly  dis- 
covered treatment  for  a  common  chronic  ailment 
had  received  a  half  column  in  a  New  York  paper. 
I  know  of  at  least  one  patient  who  went  to  see  this 
])hysician  without  taking  the  precaution  to  ask  his 
medical  attendant  for  advice  relative  to  the  matter. 
I  Tow  many  sufferers  journeyed  to  see  this  man, 
whose  wonderful  treatment  was  made  to  appear 
infallible  after  it  had  been  copied  and  recopied 
throughout  the  land,  I  do  not  know.  Ai  any  rate, 
he  received  abundant  free  advertising  witliout  seri- 


March  6,  1909.] 


KARPAS:  GENERAL  PARALYSIS. 


ous  injury  to  his  professional  reputation.  Another 
example :  Two  years  ago,  while  I  was  doing  hos- 
pital work  in  mental  diseases,  the  relatives  of  sev- 
eral patients  under  my  care  sought  information 
about  taking  the  patients  in  whom  they  were  inter- 
ested to  see  a  physician  in  Ohio  who,  according  to 
press  statements,  had  recently  discovered  a  cure  for 
paresis.  It  took  much  argument  to  convince  them 
that  this  reported  cure  was  nothing  but  a  repetition 
of  what  had  occurred  thousands  of  times  in  the 
past,  and  was  bound  to  occur  again  in  the  future. 
I  might  quote  many  other  instances,  but  these  two 
examples,  I  think,  show  what  great  weight  press 
articles  of  this  sort  have  with  the  laity. 

Several  years  ago  a  sensational  New  York  news- 
paper sent  a  tuberculosis  patient  abroad  to  receive 
a  new  treatment  for  that  disease.  The  patient  re- 
turned much  benefited  b}^  the  sea  voyage  and  the 
care  he  had  received.  Whether  the  medical  side  of 
the  treatment  was  of  any  value  is  still  in  doubt.  This 
newspaper  gave  glowing  accounts  of  the  patient's 
returning  to  health,  furnished  the  prescriptions 
used,  and  certain  druggists  were  placed  in  a  posi- 
tion to  reap  a  harvest.  Aside  from  the  pecuniary 
betterment  of  the  pharmacists  who  handled  the 
remedy,  it  is  doubtful  whether  anybody  was  perma- 
nently benefited,  except  the  newspaper  in  question. 
How  can  we  expect  reform  along  these  lines  when 
one  of  our  most  powerful  newspapers  openly  and 
deliberately  lauds  a  practically  untried  therapeutic 
method,  with  no  end  in  view  save  increasing  its 
own  circulation  ?  The  value  of  a  drug  or  method 
cannot  be  determined  from  the  results  in  a  few 
cases — coincidence  is  too  great  a  factor.  Results 
have  to  be  achieved  by  the  thousand  in  medicine, 
not  by  the  dozen. 

Regarding  the  distortion  of  fact  in  publishing 
statements  of  a  medical  nature  given  out  by  medical 
men  little  need  be  said.  The  notable  example  of 
how  Dr.  Osier's  statements  about  euthanasia  were 
mutilated  is  still  fresh  in  our  memories.  Occur- 
rences of  this  sort  are  extremely  frequent.  During 
the  past  month  the  New  York  Medical  Journal  pub- 
lished an  editorial  entitled  Newspaper  Medicine, 
in  which  it  roundly  scored  the  New  York  Sun  for 
publishing  an  article  which  grossly  misquoted  Dr. 
R.  C.  Rosenberger,  of  Philadelphia.  While  I  was  an 
interne  in  Bellevue  Hospital,  I  was  astonished  one 
morning  in  July,  1903,  to  find  in  large  print  on  the 
front  page  of  one  of  the  sections  of  a  New  York 
paper  having  an  immense  circulation,  this  heading : 
"Dr.  Palmer,  of  Bellevue,  tells  how  to  prevent  the 
deadly  lockjaw."  The  article  had  been  copi'ed  al- 
most verbatim  from  an  encyclopjedia  by  some  re- 
porter in  need  of  a  few  dollars. 

Quacks  and  charlatans  take  advantage  of  the 
free  advertising  given  by  the  press  in  pressing  their 
occupation.  The  announceemnt  that  radium  pos- 
sessed wonderful  therapeutic  properties  led  to  all 
sorts  of  radium  cures,  among  which  was  the  noto- 
rious Radium  Radia,  a  preparation  directed  against 
chronic  diseases  in  general,  and  rheumatism  in  par- 
ticular. Another  example :  Dr.  H.  H.  Kane,  adver- 
tising specialist,  succeeded  in  extorting  $9,872 
from  a  patient  through  professing  to  be  able  to  cure 
nephritis  with  radium.  Following  the  discovery  of 
the  Rontgen  rays,  advertising  physicians  were  great- 


ly helped  by  frequent  press  notices  telling  of  this 
wonderful  panacea.  The  before  mentioned  are  only 
two  instances  of  how  quacks  keep  abreast  with  the 
times,  and  as  soon  as  the  press  extols  a  remedy 
make  use  of  it  to  extort  money  from  the  ignorant. 

Finally,  an  erroneous  conception  of  anatomy, 
physiology,  pathology,  and  allied  branches  is  given 
by  inaccurate  newspaper  descriptions.  Dmnng  the 
past  summer  a  striking  example  appeared  in  the 
columns  of  the  same  paper  that  interested  itself  in 
the  case  of  the  tuberculosis  patient  mentioned  in  a 
preceding  paragraph.  A  description  of  the  anatomy 
of  the  human  eye  was  given,  illustrated  by  dia- 
grams, which  was  as  woefully  inaccurate  as  Kip- 
ling's description  of  the  optic  nerve  in  The  Light 
that  Failed. 

Somebody,  I  think  it  was  Horace  Greeley,  used 
to  say  when  apprised  of  any  new  statement :  "Valu- 
able information — if  correct."  This  aphorism  ap- 
plies only  too  well  to  the  sort  of  information  being 
dispensed  by  some  of  our  most  reputable  papers. 
The  press  can  do  much  good  through  the  accurate 
promulgation  of  preventive  medicine  and  hygiene ; 
but  other  matters  of  a  medical  nature  had  better 
be  left  alone,  unless  a  competent  person  is  in  a 
position  to  draw  the  blue  pencil  through  obnoxious 
and  dangerous  information  before  it  reaches  the 
public.  All  of  our  great  newspapers  have  their 
sporting  and  financial  editors ;  why  not  a  medical 
editor,  whose  province  it  will  be,  not  to  have  a  par- 
ticular department  appearing  as  such  in  the  issues 
of  the  paper,  but  to  exercise  his  discrimination 
about  matters  such  as  this  article  deals  with? 

274  Broad  Street. 


GENERAL  PARALYSIS  OF  AN  UNUSUALLY  LONG 
DURATION  WITH  A  REPORT  OF  TWO 
CASES ;  ONE  WITH  NECROPSY.* 

By  Morris  J.  Karpas,  M.  D., 
New  York, 

Assistant  Physician.    Manhattan   State  Hospital;   Deputy  Assistant 
Neurologist,  New  York  Hospital  for  Nervous  Diseases. 

Introduction. 

It  is  generally  recognized  by  various  authorities 
that  the  life  history  of  general  paralysis  approxi- 
mates between  two  and  five  years.  Cases  in  which 
the  duration  is  eight  years  or  over  are  considered 
atypical  and  exceptionally  rare. 

The  literature  on  this  extremely  interesting  sub- 
ject is  meagre,  and  the  cases  which  have  been  so 
far  recorded  are  only  few  with  autopsies.  Of  Heil- 
bronner's  analysis  of  five  hundred  paretics,  five  were 
only  ten  years  and  one  eighteen  years  duration.  In 
Gaupp's  cases  of  paresis,  fifteen  per  cent,  of  the 
patients  died  in  the  sixth  year,  and  in  one  the  course 
was  ten  years.  Biswanger  declares  that  some  of 
his  paretics  lived  over  twenty  years.  Alzheimer 
knows  of  patients  in  whom  the  disease  process  re- 
mained without  progression  for  eleven  years.  Stolz- 
ner  reported  many  cases  of  paresis  whose  duration 
varied  from  eight  to  eleven  years,  and  in  one  clas- 
sical case  the  course  of  the  disease  extended  to  nine 
)'^ears. 

*Read  before  the  New  York  Neurological  Society,  February  2, 
1909. 


472 


KARPAS:  GENERAL  PARALYSIS. 


[New  York 
Medical  Journal. 


The  following  is  an  incomplete  list  of  isolated 
cases  which  were  recorded  in  the  literature : 

Observers.  Cases.  Duration. 

Brunet    i       Ten  years. 

Brunet    I       Twelve  years. 

Brunet    I       Twenty-two  years. 

Doutrebente  and  Marchand.          i       Twenty-one  years. 

Kundt   I       Nine  years. 

Lustig    2       Twenty  years. 

Lunier    i       Twenty-three  years. 

Mendel    i       Sixteen  years. 

Mendel    4       Eight  to  ten  years. 

Schiille   I       Twenty  years. 

Schaffer   I       Sixteen  years. 

VVickel    2       Twelve  years. 

Wickel    I        Sixteen  years. 

Arbriegia  and  Antonia   several    Fourteen  years. 

To  this  list  I  wish  to  add  Finck's'  two  clinical 
pictures,  simulating  general  paralysis  which  he 
terms  cerebral  syphilis ;  one  was  of  fifteen  years 
and  the  other  twenty-two  years  duration.  In  both 
of  them  somatic  features  and  mental  symptoms 
were  indicative  of  a  paretic  process,  and  a  diagnosis 
as  such  could  be  platisibly  made. 

Gaupp  has  recently  discussed  stationary  paralysis. 
He  made  an  exhaustive  study  of  the  material  from 
the  various  hospitals  in  Bavaria  and  Wurtemberg. 
In  twelve  out  of  twenty-five  of  those  hospitals  there 
were  nineteen  cases  of  general  paralysis  in  which 
the  course  of  the  disease  was  more  than  eight  years. 
Out  of  this  number  Gaupp  accepts  the  diagnosis  of 
general  paralysis  in  five  only.  One  of  these  five 
cases  was  a  woman  who  suffered  from  the  disease 
thirty-two  years  and  autopsy  confirmed  the  clinical 
diagnosis.  The  author  declares :  "The  classification 
of  stationary  paralysis  should  be  limited  to  such 
cases  in  which  the  -disease  has  progressively  devel- 
oped for  a  long  time  and  finally  clinically  terminated 
in  a  well  defined  stationary  state  (healing  of  the 
process — the  formation  of  cicatrization  termination 
in  a  permanent  stable  defective  state)  ;  however, 
the  material  at  hand  is  not  sufficient  to  establish 
with  certainty  stationary  paralysis.  On  the  con- 
trary it  cannot  be  disputed  that  the  disease  in  rare 
cases  is  insidiously  progressive  that  for  pure  clinical 
observation  it  appears  to  remain  temporarily  sta- 
tionary, while  tlie  slow  progress  of  the  pathological 
process  is  not  always  betrayed  in  the  clinical  symp- 
tomatology." 

In  my  exi)cricnce  with  general  paralysis  in  the 
female,  I  found  only  two  cases  in  which  the  dura- 
tion of  the  disease  was  unusually  long.  One  patient 
suffered- from  paresis  for  the  last  twelve  years,  and 
at  present  enjoys  very  good  health  :  the  other  one 
was  afflicted  with  the  malady  for  eighteen  years, 
and  her  death  was  due  to  the  interciUTency  of  an- 
other disease. 

C.\SE  I. — E.  K.,  without  autopsy.  Forty-seven  years  of 
age ;  nativity,  Switzerland ;  onset  rapid ;  married,  no  chil- 
dren ;  husband  died  from  general  paralysis ;  total  duration 
of  disease  was  twelve  years.  In  neither  case  could  the 
history  of  syphilis  be  determined. 

In  iRq6  patient  became  suddenly  excited,  screamed  "Fire, 
fire,  police !"  and  expressed  a  few  persecutory  ideas. 

Upon  admission  to  the  hospital  December  i6,  1896,  pa- 
tient was  confused,  rambling,  and  disconnected  in  her  con- 
versation. She  said  "the  man  that  lived  on  the  floor  below 
kept  an  electrical  machine  in  my  room  and  I  could  not 
work,  for  I  felt  the  electricity  going  through  me.  The 
court  kept  'tending  people  to  me  all  the  time.    The  court 

'Vide  author's  review  of  Finck's  article  in  Journal  for  Nervov.t 
a*id  yiruUit  Pi.rra^r.   .Aiic'i'-t.  1908. 


was  continually  in  session,  etc.,  etc.'"  It  is  lamentable  that 
at  that  time  no  neurological  status  was  taken.  Two  years 
later  patient  was  described  as  somewhat  quieter  but  talked 
in  a  peculiar  and  incoherent  manner.  She  stated  "I  must 
laugh,  I  don't  know  why,  I  won't  sing  any  more,  etc."  She 
uttered  a  few  persecutory  expressions  and  often  gesticulated 
and  laughed.  Her  mood  alternated  between  elation  and 
depression. 

Physical  status  revealed  exaggerated  knee  jerks,  unequal 
pupils  whose  reaction  to  light  and  accommodation  was  slug- 
gish. 

During  her  further  residence  in  the  hospital  she  gradu- 
ally and  progressively  declined  mentally. 

At  present  the  patient  is  quiet,  evinces  no  interest  in  the 
affairs  of  life,  but  bestows  proper  attention  upon  her  per- 
son, and  helps  with  light  work  on  the  ward.  She  mani- 
fests no  impulsive  or  assaultive  acts.  In  speech  she  is 
rambling,  makes  many  peculiar  remarks,  and  quite  often 
her  answers  are  irrelevant  and  show-  a  tendency  to  circum- 
stantiality. She  knows  where  she  is,  but  has  a  constricted 
conception  of  her  environment.  Her  memory  and  orienta- 
tion are  much  impaired.  Mood  is  that  of  silly  elation  and 
at  times  gives  way  to  crying.  No  delusions  of  grandeur  or 
well  defined  persecutory  ideas  can  be  satisfactorily  ascer- 
tained. 

Physical  Status :— Right  side  of  face  is  slightly  flattened 
out.  Both  grips  are  equal.  No  Babinski  or  Oppenheim 
phenomenon.  Active  knee  jerks,  but  unequal;  the  right 
responds  more  promptly  than  the  left  one.  Reflexes  of 
upper  extremities  are  normal.  Cutaneous  sensibility  is  di- 
minished. Pupils  are  irregular,  right  larger  than  the  left, 
and  both  do  not  react  to  light  but  the  accommodation  re- 
flex is  good.  Fundi  show  no  pathological  changes.  Tremor 
of  both  hands ;  writing  somewhat  tremulous  and  reveals 
many  elisions  of  syllables  and  letters.  There  is  no  ataxia 
in  gait  or  station.  Two  cytological  examinations  showed 
a  great  increase  of  lymphocytes  (about  50  cells  in  a  field 
under  the  i/i2th  power)  and  globulin  in  abundance. 

Case  II.— X.  L.,  with  autopsy.  Fifty-eight  years  of  age ; 
nativity  Canada ;  onset  gradual ;  total  duration  of  the  dis- 
ease was  eighteen  years. 

Family  history  was  negative  for  both  neurotic  and  ve- 
sanic  taint  in  the  collaterals. 

Personal  history:  Patient  was  born  in  Nova  Scotia,  Can- 
ada, in  1850.  She  received  a  fairly  good  education,  and 
came  from  an  intelligent  stock.  She  married  at  eighteen 
a  man  who  was  her  senior.  It  is  stated  that  she  indulged 
in  alcoholic  beverages  and  contracted  a  severe  form  of 
syphilis.  Three  years  after  marriage  the  husband,  by  rea- 
son of  jealousy,  made  an  abortive  attempt  to  shoot  her,  but 
succeeded  only  in  taking  his  own  life. 

In  1890  she  became  peculiar,  seclusive,  and  would  refuse 
to  be  interviewed.  At  times  she  made  the  impression  (if 
being  depressed. 

A  few  weeks  preceding  her  admission  to  a  private  hospital, 
she  stated  in  a  letter  to  her  daughter  that  she  was  not  feel- 
ing well,  and  a  week  later  she  called  her  landlady  and  told 
her  that  "drink  has  ruined  me,  and  I  have  drunk  more  or 
less."  She  was  then  melancholy,  and  on  several  occasions 
endeavored  to  commit  suicide. 

She  resided  in  a  private  hospital  from  March  31,  1892, 
to  December  5,  1892.  While  there  for  five  months,  patient 
was  in  a  state  of  agitation,  apprehension,  and  deep  depres- 
sion accompanied  by  frequent  restlessness.  She  declared 
that  she  was  a  wicked  woman,  and  that  she  had  ruined  the 
world.  '  She  besought  the  physician  not  to  put  her  in  the 
furnace.  Quite  often  she  would  express  few  ill  defined 
persecutory  ideas  against  her  environment.  In  September 
1892,  she  commenced  to  show  some  improvement.  She 
was  very  anxious  to  leave  the  hospital,  but  exhibited  no 
insight  into  her  morbid  condition.  On  December  5.  1892, 
she  was  discharged  as  "apparently  doing  well." 

She  remained  at  home  six  montl-.s,  and  during  that  time 
she  was  unnaturally  quiet,  manifested  no  initiative,  and 
later  it  was  necessary  to  send  her  to  a  private  sanatorium 
W'here  she  spent  six  months. 

In  1894,  she  became  again  abnormally  depressed  and  sui- 
cidal. She  was  admitted  to  another  hospital  for  insane. 
There  she  was  confused,  had  difllculty  to  express  her 
thoughts,  answered  only  few  simi)le  questions,  and  could 
not  be  engaged  in  conversation.  In  October,  1895.  she  was 
sent  to  a  private  hospital  for  insane.  Physical  examination 
showed  unequal  pupils  (left  larger  than  right"),  tremor  of 


March  6,  igog.j 


KARPAS:  GENERAL  PARALYSIS. 


473 


tongue,  ataxic  speech,  and  exaggerated  knee  jerks,  Men- 
tally she  was  quiet  and  passive.  On  the  night  of  her  ad- 
mission to  that  hospital,  patient  became  noisy,  voluble,  and 
maintained  an  elated  mood.  This  excitement  gradually 
increased  in  intensity.  She  tinally  grew  assaultive  and 
made  many  extravagant  statements.  For  instance,  she  de- 
manded that  the  hospital  be  built  of  gold  and  glass ;  she 
asserted  that  she  was  the  queen  of  the  world  and  king  of 
Venus,  and  made  indecent  proposals  to  the  physician.  She 
exclaimed  "1  am  glad  I  am  sane,  queen  of  all  the  world, 
and  today  you  give*the  world,  and  gold  and  get  a  statue  in 
and  make  me  queen  of  the  world."  Later  her  mood  fluctu- 
ated between  exhilaration  and  depression.  Six  weeks  after 
her  admission,  she  had  a  series  of  eight  convulsions  in  one 
day.  All  of  them  save  the  last  affected  the  right  side  of 
the  body;  the  last  one  was  general.  Soon  after  this  patient 
was  clearer  mentally,  and  her  ataxic  speech  greatly  dimin- 
ished. In  three  weeks  she  plunged  in  a  state  of  profound 
depression  and  one  month  later  became  subject  to  convul- 
sions which  recurred  at  intervals  of  once  a  month. 

In  the  spring  of  1S96  she  became  extremely  depressed, 
and  not  infrequently  reproached  herself  for  her  past  mis- 
takes and  sins.  In  three  weeks  her  anxiety  subsided;  she 
began  to  talk  rationally  and  employed  herself  at  sewing. 
'ro\\ard  the  end  of  1896  there  developed  mental  deteriora- 
tion with  evidences  of  impaired  memory. 

In  1897  she  displayed  emotional  variability  and  often 
reacted  to  hallucinations. 

In  May,  1898,  she  showed  temporary  inability  to  articu- 
late. Myotic  pupils  and  unsteady  gait  were  noticed  in  the 
same  year. 

From  1898  to  1907  patient's  psychosis  assumed  the  form 
of  quiet  dementia,  associated  with  mild  euphoria.  She  had 
major  convulsions  which  for  the  past  two  or  three  years 
grew  less  in  frequency,  but  attacks  resembling  petit  mal 
were  observed  daily. 

September  9,  1907,  patient  was  admitted  to  the  Manhat- 
tan State  Hospital.  Here  on  reception  physical  status  re- 
vealed the  following : — 

A  fairly  well- nourished  woman  with  few  unimportant  stig- 
mata. No  evidence  of  motor  paralysis.  Babinski  or  Oppen- 
heim  reflex  was  absent.  Abdominal  and  corneal  reflexes 
were  active.  Knee  jerks  were  exaggerated.  Triceps  and 
supinator  jerks  slightly  increased.  Cutaneous  sensibility 
was  normal.  Very  small  pupils,  unequal,  and  irregular  in 
outline ;  their  reaction  to  light  was  wanting,  but  accomo- 
dation response  was  good.  The  fundi  presented  no  patho- 
logical changes.  There  was  slight  tremor  of  tongue  but 
not  of  hands.  Writing  was  somewhat  tremulous  and  eli- 
sions of  syllables  were  demonstrable.  No  marked  ataxia  in 
gait  or  station  was  in  evidence.  Cytological  examination 
was  made  twice.  At  each  time  numerous  erythrocytes  with 
relative  increase  of  lymphocytes  were  found.  Albumin  was 
present.  .Speech  was  drawling,  and  test  phrases  were  not 
properly  articulated. 

Mental  status : — Patient  was  quiet,  good  humored,  com- 
plied with  ordinary  requests,  and  was  rather  indifferent  to 
questions.  Quite  often  she  would  give  stereotyped  answer 
"I  don't  know."  Her  memory,  orientation,  and  general 
grasp  were  very  poor.  No  ideas  of  grandeur  could  be 
elicited. 

During  her  residence  in  the  hospital,  patient  had  many 
general  convulsions. 

She  progressively  declined  both  physically  and  mentally, 
and  on  December  17,  1908,  she  succumbed  to  pulmonary 
oedema  and  bronchopneumonia. 

Necropsy  was  held  one  and  a  half  hours  after  death  by 
G.  Y.  Rusk,  to  whom  I  am  indebted  for  the  following  re- 
port : 

The  calvarum  was  symmetrical,  extremely  thickened, 
and  dense.  The  diploe  was  preserved  and  on  the  inner  sur- 
face of  the  frontal  bones  a  few  small  exostoses  were  seen. 
The  amount  of  cerebrospinal  fluid  was  increased.  The 
pia  showed  a  moderate  symmetrical  haziness  which  was 
most  marked  in  the  frontal  and  anterior  Syh'ian  fossa. 
Infiltration  was  well  marked  along  the  mesial  surface  of 
the  hemispheres  and  over  the  cerebellum.  In  the  floor  of 
the  fourth  ventricle  slight  irregularities  but  no  well  defined 
granulations  were  visible.  The  basal  vessels  showed  a  very 
slight  degree  of  atheroma.  The  frontal  and  temporal  tips 
were  adherent.  The  brain  as  a  whole  was  moderately 
atrophic  and  its  weight  was  1120  grams. 

Sections  from  right  first  and  second  frontal,  right  prje- 


frontal,  right  paracentral,  right  transverse  temporal,  right 
island  of  Reil,  right  calcarine,  right  gyrus  rectus,  right 
cornu  ammonis,  thalamus,  medulla,  and  cervical  cord,  were 
embedded,  and  stained  with  Toludine  blue. 

First  frontal  sections  showed  infiltration  of  the  pia  with 
plasma  cells,  the  lymphoid  elements  being  quite  scarce;  the 
layer  of  the  cortex  showed  a  glial  hyperplasia,  the  arch- 
ictectonics  appeared  fairly  well  preserved  except  for  occa- 
sional small  areas  where  there  appeared  a  dearth  of  nerve 
cells,  there  was  diffuse  glial  hyperplasia  of  moderate  in- 
tensity throughout  the  cortex,  both  numerical  and  in  tak- 
ing on  of  protoplasm  by  the  individual  cells,  with  the 
formation  of  spider  cells.  The  finer  blood  vessels  were 
probably  somewhat  increased,  and  scattered  sparsely  along 
the  walls  of  the  vessels  generally  were  found  plasma  cells 
together  with  an  occasional  mastzelle.  The  most  striking 
feature  of  the  vessels,  however,  was  the  marked  and  gen- 
eral endothelial  proliferation  leading  to  multiple  channel 
formation,  rod  cells  were  conspicuously  absent. 

The  same  cortical  area  stained  with  haematoxylin  and 
oesin  aside  from  emphasizing  the  glial  hyperplasia  in  the 
first  layer,  and  showing  its  adhesions  to  the  pia  brought 
out  no  important  facts. 

Sections  from  the  second  frontal,  stained  in  the  same 
manner  yielded  similar  results  to  those  detailed  in  the 
first  frontal  except  that  the  lesions  particularly  the  hyper- 
vascularity  appeared  much  less  marked. 

The  conditions  in  the  prsefrontal  region  were  again  of 
essentially  similar  nature  but  showed  a  somewhat  more 
marked  glial  reaction  with  considerable  irregularity  in  the 
archictectonics  of  the  cortex,  with  distinct  narrowing  of  it 
due  to  dropping  out  of  nervous  elements,  the  dropping 
out  affected  apparently  most  seriously  the  middle  layer  of 
the  cortex. 

Sections  from  the  paracentral  region  showed  a  thick- 
ened and  moderately  infiltrated  pia ;  the  Betz  cells  showed 
moderate  grade  of  pigmentation  ;  evidence  of  the  inflam- 
matory reaction  was  present  throughout  but  was  less 
marked  than  in  the  areas  previously  noted. 

The  transverse  temporal  region  again  showed  the  char- 
acteristic changes  present  but  again  they  were  slight ;  the 
glial  hyperplasia  of  the  first  layer  extending  into  the  sec- 
ond, a  less  marked  scanty  infiltration  with  plasma  cells, 
and  well  marked  endothelial  reaction  being  the  features. 

In  the  section  from  the  island  process  became  somewhat 
more  marked  in  severity,  being  comparable  to  the  condi- 
tion in  the  second  frontal. 

The  gyrus  rectus  showed  the  same  lesions  with  the  glial 
hyperplasia  and  the  endothelial  changes  paramount  but 
with  well  marked  dropping  out  of  nerve  cells  and  reduc- 
tion of  the  cortex  in  areas.  Similar  changes  were  seen 
about,  and  to  a  slight  extent  within  the  cross  section  of 
the  olfactory  tract. 

The  calcarine  cortex  in  all  respects  showed  less  change 
than  any  of  the  areas  examined  so  far ;  slight  infiltration 
and  thickening  of  the  pia,  scanty  infiltration  of  the  cor- 
tical vessels,  slight  glial  hyperplasia  in  the  first  layer,  and 
occasional  evidence  of  endothelial  activity  were  seen. 

The  cornu  ammonis  showed  the  typical  changes  of  mod- 
erate severity ;  the  occurrence  of  particularly  large  spider 
cells  might  be  seen ;  the  section  took  in  a  bit  of  the  ex- 
ternal geniculate  body,  the  cells  of  which  were  rather 
markedly  pigmented,  the  peripheral  glial  layer  was  hyper- 
trophic, the  overlying  pia  infiltrated,  but  no  plasma  cells 
happened  to  occur  about  the  vessels  in  the  depths  of  the 
tissue  itself. 

On  the  ependymal  surface  of  the  thalamus  definite  granu- 
lations were  wanting,  in  the  depths  of  the  tissue,  vessels 
showing  a  few  plasma  cells  were  occasionally  met  with." 

Sections  from  the  medulla  showed  -1  diffuse  ependymal 
hyperplasia  covering  the  floor  of  the  fourth  ventricle ;  the 
pia  showed  an  infiltration  of  the  usual  type  in  the  depths 
of  the  tissue. 

"Transverse  section  of  the  cervical  cord  again  showed 
the  same  infiltration  in  a  somewhat  thickened  pia,  the  layer 
of  superficial  glia  was  hypertrophic.  In  the  walls  of  sev- 
eral of  the  vessels  irregularly  distributed  in  the  cord, 
plasma  cells  were  seen,  no  particular  sclerosis  of  the  pos- 
terior column  region  is  observed." 

Post  mortem  examination  of  the  viscera  showed  pulmon* 
ary  cedema  and  bronchopneumonia  of  the  right  upper  an'! 
lower  lobes  and  left  upper  lobe ;  horse  shoe  kidney  without 


474 


CROFTAN:  ALIMENTARY  ALBUMINURIA. 


[New  York 
Medical  Journal. 


pathological  changes ;  slight  atheroma  of  the  first  portion 
of  the  aorta ;  moderate  mitral  thickening ;  and  chronic 
pelvic  inaflmmatory  disease. 

In  tJiis  case  the  histo pathological  picture  of  the 
cerebral  cortex  deviates  from  that  of  shorter  dura- 
tion by  the  scarcity  of  infiltration  and  relative  in- 
crease of  glial  proliferation  and  finer  blood  vessels 
which  show  marked  tendency  to  endothelial  pro- 
liferation. 

Comments. 

In  the  first  case  the  symptomatic  picture  from  the 
psychical  point  oi  view  presents  many  atypical 
features  which  are,  the  apparent  abrupt  develop- 
ment, long  period  of  excitement  without  fatal 
termination,  peculiar  behavior,  persecutory,  hallu- 
cinatory reaction,  and  moreover  the  present  general 
mental  dilapidation  partakes  of  many  characteristics 
of  dementia  precox.  However  the  striking  somatic 
signs  associated  with  a  very  marked  lymphocytosis 
and  writing  defect  can  only  be  explained  on  the 
grounds  of  a  paretic  process.  Indeed  the  diagnosis 
of  general  paralysis  cannot  be  questioned. 

While  in  the  second  case  the  onset,  the  various 
mental  phases  of  the  disease  picture,  and  the  well 
defined  physical  signs  were  decidedly  of  a  paretic 
reaction.  It  is  interesting  to  note  that  the  clinical 
phenomena  of  this  case  manifested  the  three  well 
known  forms  of  paresis — anxious,  grandiose,  and 
demented.   Each  of  which  ran  a  peculiar  course. 

It  is  worthy  of  emphasis  that  in  the  last  case 
especially  there  are  factors  which  doubtless  are 
detrimental  from  a  prognostic  standpoint.  And  to 
enumerate  them:  i,  Virulent  syphilitic  infection; 
2,  chronic  alcoholism;  3,  stress  of  life;  4,  emotional 
upset;  5,  early  appearance  of  convulsions;  6,  long 
standing  dementia ;  7,  progression  without  remis- 
sions ;  8,  the  form  of  paresis  was  cerebral.  Accord- 
ing to  various  observers  and  investigators  general 
paralysis  of  tabetic  type  has  relatively  a  much  better 
prognosis  than  that  of  the  cerebral  affection. 

In  spite  of  all  these  unfavorable  conditions  my 
patient  lived  eighteen  years,  and  the  cause  of  death 
was  precipitated  by  another  disease.  The  question 
may  be  asked :  How  are  we  to  explain  this  unusual 
longevity  of  such  a  grave  disease  in  presence  of  so 
many  deleterious  agents  ?  While  theoretically  many 
hypothetical  assumptions  can  be  advanced,  nothing 
is  more  plausible  and  forcible  than  to  accentuate 
the  important  fact  that  the  constitutional  coefficient 
of  the  individual  plays  an  important  role  in  the  pro- 
duction and  modification  of  a  psychosis,  be  it  func- 
tional or  organic. 

My  hearty  gratitude  is  due  to  Dr.  William  Mabon, 
superintendent  of  Manhattan  State  Hospital,  for 
the  kind  permission  he  has  given  me  to  report  these 
two  interesting  cases  of  paresis. 

References. 

Abregia  and  Antonia.    Quoted  by  Obersteiner. 
Alzheimer.   Quoted  by  Wickel. 

Bisvvanger.  Allgemeine  Zeitschrift  fiir  Psycliiatrie, 
1893- 

Brunct.    Annals  medico-psychologiques,  xix. 
Doutrebente  and  Marcband.    Ibidem,  xviii. 
Finckb.    Cciilralblatt  fiir  Nervenheilkunde  und  Psychia- 
tric, 1907. 

Gaupp.  Ibidem,  1903. 
Gaupp.    Ibidem,  1907. 

Heilbronner.    Inaugural  Dissertation,  1894. 

Kundt.    Quoted  by  Wickel. 

Kracplin.   Psycliiatrie,  seventh  edition. 


Lustig.    Allgemeine  Zeitschrift  fiir  Psychiatric,  1900. 
Lunier.    Quoted  by  Lustig. 
Mendell.  Paralyse. 

Oppenheim.    Lehrbuch  der  Nervenkrankheiten. 
Schiille.    Allgemeine  Zeitschrift  fiir  Psychiatric,  1872. 
Schaffer.    Ibidem,  1903. 
Stolzner    Quoted  by  Lustig. 

Wickel.  Centralblatt  fur  Nervenheilkunde  und  Psychia- 
tric, 1904. 

Zeihen.    Psychiatric.  , 

Ward's  Island. 


A  CLINICAL  NOTE  ON  ALIMENTARY  ALBU- 
MINURIA. 

By  Alfred  C.  Croftan,  M.  D., 
Chicago,  111. 

Scattered  through  the  literature  for  many  years 
back  will  be  found  isolated  reports  of  albuminuria 
following  the  ingestion  of  large  quantities  of  al- 
buminous food ;  but  it  was  not  until  specific  pre- 
cipitine  reactions  were  clinically  applied  that  these 
urinary  albumins  were  recognized  to  be  in  many 
cases  identical  with  native,  unchanged  food  al- 
bumin. 

In  view  of  the  belief  that  extensive  proteolysis  in 
the  intestiiie  must  always  precede  the  absorption  of 
albumin,  in  view  of  the  teaching  that  regeneration  of 
albumin  fragments  occurs  in  the  intestinal  wall  so 
that  a  reconstructed  albumin  enters  the  portal  cir- 
culation, the  postulate  that  albumin  can  pass  un- 
changed from  the  intestinal  lumen  through  the  in- 
testinal wall  into  the  circulation  and  thence  into  the 
urine  seemed  altogether  paradoxical  and  improb- 
able. 

Before  the  introduction  of  the  biological  method 
the  occurrence  of  albuminuria  following  the  inges- 
tion of  large  quantities  of  albuminous  food  was, 
therefore,  on  account  of  the  inadequacy  of  chemical 
and  physical  methods  to  identify  the  urinary  albumin 
as  food  albumin,  interpreted  to  signify  one  of  two 
things,  viz..  either  that  abnormal  degradation  or 
putrefaction  of  albumin  had  occurred  in  the  intes- 
tine causing  a  toxaemia  with  renal  irritation  and  al- 
buminuria, or,  more  vaguely,  that  certain  circulatory 
disturbances  in  the  splanchnic  area  followed  over- 
taxation of  the  intestinal  proteolytic  function,  with 
resulting  circulatory  changes  in  the  kidneys  and  al- 
buminuria. 

While  either  of  these  possibilities  must  be  taken 
into  consideration,  there  remains  a  form  of  alimen- 
tary albunlinuria,  corresponding  in  a  sense  to  ali- 
mentary glycosuria,  in  which  neither  of  these  factors 
is  operative  but  in  which  actually  the  albumin  of  the 
food  as  such  reappears  within  a  short  time  in  the 
urine. 

Clinically  this  form  of  albuminuria  is  very  inter- 
esting, for  it  seems  to  occur  (with  and  without 
nephritis)  when  albuminous  food  remains  in  con- 
tact with  the  otherwise  healthy  gastrointestinal  mu- 
cosa for  an  abnormally  long  time.  It  also  occurs 
when  food  albumin  passes  through  the  whole  length 
of  the  small  intestine  in  so  short  a  tempo  that  proper 
disassimilation  cannot  occur,  and  the  food  albumin 
consequently  roaches  the  large  intestine  unchanged. 
Alimentary  albuminuria  a  fortiori,  of  course,  also 
occurs  more  frequently  than  is  commonly  assumed, 
if  large  quantities  of  native  albumin  are  injected  di- 
rectly into  the  rectum  or  colon. 


March  6,  1909.) 


ZEMP:  ALCOHOL. 


475 


The  disorders,  therefore,  in  which  ahmentary  al- 
buminuria according  to  my  experience  is  most  apt 
to  occur  are. 

First,  motor  insufficiency  of  the  stomach  of  ad- 
vanced degree  particularly  if  combined  with  se- 
cretory depression  (hypochlorh\-dria  and  hypo- 
chylia).  In  achylia  gastrica  combined  with  motor 
insufficiency,  this  form  of  albuminuria  is  particular- 
ly common. 

Second,  in  diarrhceic  disorders  of  all  kinds  and 
particularly  in  cases  of  pancreatic  debility  with  ac- 
companying intestinal  dystrypsia. 

Third,  in  hepatic  insufficiency  of  various  origin. 

Fourth,  after  the  ingestion  of  abnormally  large 
quantities  of  albumin  (noted  especially  in  diabetics 
on  a  meat-fat  diet)  and  in  cases  in  which  large 
quantities  of  albuminous  food,  particularly  egg  al- 
bumen, are  injected  into  the  rectum  in  the  form  of 
nutritive  clysmata. 

The  treatment  of  this  form  of  albuminuria  is  ex- 
clusively causal,  i.  e.,  consists  in  the  correction  of 
the  above  indicated  morbid  states.  In  cases  of 
motor  insufficiency  with  hypochlorhydria  or  achylia 
gastrica,  the  supplying  of  a  sufficient  quantity  of 
hydrochloric  acid  and  all  measures  directed  toward 
overcoming  stagnation  of  stomach  contents,  as  a 
rule,  promptly  cause  a  disappearance  of  the  albumin 
from  the  urine.  Attention  directed  toward  the  cor- 
rection of  intestinal  dystrypsia  is  particularly  useful 
in  removing  this  particular  form  of  albuminuria, 
and  here  the  administration  of  large  quantities  of  an 
alkali  with  pancreatic  extracts  frequently  leads  to 
the  goal.  In  the  ,  case  of  alimentary  albuminuria 
following  rectal  feeding  with  large  quantities  of 
eggs,  the  addition  to  the  nutritive  enemata  of  con- 
siderable quantities  of  alkali  and  pancreas  again 
generally  causes  the  disappearance  of  the  albumin 
from  the  urine. 

\Miile  the  occixrence  of  small  quantities  of  albu- 
min in  the  urine  is  not  a  dangerous  phenomenon 
per  sc,  still  the  circulation  of  food  albumins,  that  is, 
of  albumins  foreign,  scil.  toxic,  to  the  human  organ- 
ism, distinctly  irritates  the  kidneys  and  produces 
changes  that  affect  chiefly  the  epithelia  of  the  con- 
voluted tubules.  Thus,  if  allowed  to  continue  for 
too  long  a  time,  an  alimentary  albuminuria  may  pro- 
duce a  true  nephritis  with  the  excretion  of  serum  al- 
bumin. The  appearance,  therefore,  of  alimentary 
albuminuria  in  the  various  digestive  disorders  be- 
fore enumerated  should  constitute  a  warning  signal 
of  impending  nephritis,  and  every  effort  should  be 
put  forward  to  cause  its  disappearance. 

In  cases  of  hepatic  insufficiency,  it  is  less  easy  to 
cause  a  disappearance  of  the  alimentary  albu- 
minuria. Treatment  here  is  exclusively  causal  and 
must  take  into  consideration  all  the  numerous  fac- 
tors that  contribute  to  produce  inadequacy  of  the 
hepatic  function.  (See  Croftan,  Hepatic  Insuffi- 
ciency. Medical  Record,  April,  1906.) 

In  the  animal  experiments  that  I  have  performed 
with  a  view  of  studying  the  path  traveled  by  in- 
gested food  albumins  that  pass  unchanged  through 
the  intestinal  filter,  the  interesting  discovery  was 
made  that  the  liver  (and  incidentally,  also  the  mus- 
cles) seems  to  possess  the  power  of  arresting  a  large 
proportion  of,  e.  g.,  egg  albumen  that  is  injected  di- 
rectly into  the  portal  circulation  ;  holding  the  latter 


for  long  periods  of  time,  causing  digestion  by  au- 
tolysis of  some  of  it  and  liberating  the  rest  so  slow- 
ly, that  it  enters  the  general  circulation  gradual- 
ly to  be  promptly  thereafter  excreted  in  the  urine. 
The  liver  here,  therefore,  seems  to  exercise  the  same 
protective  influence  against  egg  albumen,  which  is 
toxic,  when  it  reaches  it  in  the  portal  circulation,  as 
against  any  other  intestinal  poison,  immaterial  what 
its  chemical  character  or  constitution.  This  function 
also  accounts  for  the  fact  that  in  cases  of  alimentary 
albuminuria  the  albumin  excretion  in  the  urine  is  so 
slight  and  persists  for  so  many  days.  It  also  be- 
comes clear  that  the  conditions  that  favor  alimentary 
albuminuria  must  incidentally  also  be  included  in 
the  category  of  those  numerous  conditions  that  can 
produce  hepatic  insufficiency. 

The  comparative  frequency  of  this  form  of  albu- 
minuria should  be  appreciated.  The  identification 
of  the  albumin  as  food  albumin  should  be  attempted 
by  means  of  precipitine  tests  in  every  case  of  slight 
albuminuria  that  presents  itself.  It  is  unnecessary 
in  this  place  to  discuss  the  technique  of  identifying 
urinary  albumins  by  means  of  specific  precipitine 
tests ;  I  refer  for  this  technique  to  an  article  recent- 
ly published  by  me  in  the  Archives  of  Diagnosis. 
If  the  albumin  can  be  identified  as  food  albumin, 
then  proper  attention  directed  towards  the  under- 
lying digestive  disturbances,  as  indicated  above, 
will  often  produce  gratifying  results.  From  the  life 
insurance  standpoint,  this  is  particularly  important. 

It  is  essential,  then,  to  recognize  that  there  is  a 
form  of  albuminuria  of  rather  favorable  prognosis 
that  is  not  primarily  due  to  renal  debility,  nor  to 
nephritis,  nor  to  circulatory  disturbances  in  the  kid- 
neys as  a  part  phenomenon  of  general  cardiovascu- 
lar disease  (Briglit's  disease,  arteriosclerosis),  but 
that  is  enterogenous  in  type  and  primarily  and  ex- 
clusively a  gastrointestinal  and  hepatic  disorder. 

100  State  Street. 


ALCOHOL— PHYSIOLOGICAL  ACTION  AND 
THERAPEUTIC  INDICATIONS.* 

Bv  E.  R.  Ze.mp,  B.  S.,  M.  D., 

Knoxville,  Tenn., 

Professor  of  Materia  Medica,  Therapeutics,  Paediatrics,  and  Clinical 
Medicine,  Tennessee  Medical  College. 

Alcohol  is  a  narcotic  poison  obtained  by  the  dis- 
tillation of  fermented  grain  or  fruit.  Whiskey  and 
brandy,  the  two  most  commonly  used  preparations, 
contain  about  fifty  per  cent,  by  volume  of  absolute 
alcohol,  and  should  be  from  three  to  four  years  old. 
Age  not  only  destroys  certain  impurities,  such  as 
fusel  oil,  but  develops  ethers  upon  which  the  flavor 
of  the  liquor  depends.  Port  and  sherry  wines  con- 
tain about  twenty  per  cent,  absolute  alcohol,  while 
champagne  contains  about  ten  per  cent.  In  studying 
the  action  of  alcohol  it  is  best  to  take  up  the  vari- 
ous functions  of  the  body  separately,  and  analyze  its 
effect  upon  each  one,  for  alcohol  is  a  very  deceiving 
drug,  and  its  manifestations  upon  the  body  as  a 
whole  are  very  misleading. 

Horace,  the  Latin  poet,  pays  to  alcohol  the  fol- 
lowing tribute:  ''What  wonders  does  not  wine!  It 

*Read  before  a  meeting  of  the  East  Tennessee  Medical  Society, 
held  at  Newport,  Tenn.,  September  24  to  25,  1908. 


476 


ZEMP:  ALCOHOL. 


[New  York 
Medical  Journal. 


discloses  secrets ;  ratifies  and  confirms  our  hopes ; 
thrusts  the  coward  forth  to  battle ;  eases  the  anxious 
mind  of  its  burden ;  instructs  in  arts.  Whom  has 
not  a  cheerful  glass  made  eloquent !  Whom  not 
quite  free  and  easy  from  pinching  poverty !"  This 
would  seem  to  indicate  that  alcohol  is  a  most  de- 
sirable remedy,  but  when  we  analyze  its  action,  and 
in  the  cold,  grey  dawn  of  the  morning  after  view  the 
effect  immediately  following  in  the  wake  of  its 
earlier  manifestations,  we  are  forced  to  agree  with 
Solomon,  that  wine  is  a  mocker ;  that  strong  drink 
is  raging,  and  he  that  is  deceived  thereby  is  not 
wise. 

What,  then,  are  the  effects  of  alcohol  upon  the 
various  functions  of  the  body?  In  trying  to  solve 
this  problem  by  a  review  of  the  voluminous  litera- 
ture pertaining  to  this  subject  we  find  both  Horaces 
and  Solomons  galore.  Some  writers  condemn  it 
utterly.  Others  could  not  practise  medicine  without 
it.  The  conservative  physician  will  use  it  just  as 
he  should  use  anv  other  drug — with  a  full  knowl- 
edge of  its  usefulness  and  its  dangers. 

Locally,  alcohol  is  irritating.  If  this  effect  is  kept 
in  mind  many  of  the  ill  effects  of  this  drug,  when 
taken  internally,  can  be  accounted  for.  It  is  equal- 
ly true  that  many  of  its  beneficial  effects  are  directly 
due  to  the  same  cause.  Locally,  alcohol  coagulates 
proteids  by  abstracting  water  from  them.  This  re- 
sults in  irritation  and  inflammation  of  all  tissues 
with  which  it  comes  in  contact  in  sufficient  concen- 
tration. It  prevents  the  action  of  ferments  and  pro- 
hibits the  growth  of  bacteria.  This  last  statement 
should  be  slightly  modified  as  absolute  and  com- 
mercial alcohol  are  void  of  germicidal  power  if  the 
germs  are  dry.  A  forty  per  cent,  solution  of  alco- 
hol is  eflfective  in  five  minutes  against  nonsporulat- 
ing  bacteria.  Strongly  resisting  germs  require  about 
a  sixty  per  cent,  solution  to  destroy  them. 

Alcohol  is  depressing  to  all  cells  when  applied  in 
sufficient  concentration.  On  account  of  its  volatil- 
ity alcohol  penetrates  the  tissues  deeply  when  ap- 
plied to  the  skin  with  friction,  hence  it  is  a  most 
excellent  counterirritant.  On  open  wounds  it  pro- 
duces a  protective  film  of  coagulated  serum,  at  the 
same  time  increasing  cell  proliferation,  thus  hasten- 
ing the  healing  of  those  wounds  that  fail  to  unite 
bv  first  intention.  By  virtue  of  its  volatility  alco- 
hol abstracts  heat  from  the  body  when  applied  lo- 
cally, lowering  the  body  temperature  to  a  degree 
varying  with  the  mode  of  application.  Upon  nerves 
and'  museles  there  is  first  a  slight  stimulation  (in- 
crease in  function)  followed  by  a  marked  depression 
(loss  of  function),  so  that  injections  of  alcohol 
should' be  made  with  due  respect  for  the  location 
of  nerves,  as  such  injections  may  cause  paralysis. 
Sometimes  we  desire  to  obtain  just  such  a  result, 
hence  this  seemingly  ill  effect  is  put  to  a  useful  pur- 
pose. 

.Alcohol  is  irritating  to  all  mucous  membranes. 
By  this  means  we  may  obtain  certain  valuable  reflex 
actions  from  the  mouth  and  stomach — a  stimulation 
of  the  heart  and  respiration.  The  feeling  of  warmth 
that  is  experienced  in  the  gastric  region  after  a  glass 
of  whiskey  is  taken  is  due  to  this  local  irritation, 
and  if  the  dose  is  large  enough  vomiting  may  be 
produced.  The  continuous  application  of  alcohol 
to  the  gastric  mucous  membrane,  and  to  all  other 


membranes,  produces  certain  chronic  inflammatory 
changes  that  markedly  interfere  with  and  impair  nu- 
trition. During  the  absorption  and  elimination  of 
alcohol  the  liver  and  kidneys  bear  the  brunt  of  its 
local  irritating  ac.tion,  chiefly  on  account  of  their 
anatomical  positions. 

That  alcohol  is  a  splendid  solvent  for  many  drugs 
is  recognized  by  all.  It  is  because  of  this  power 
that  it  has  been  recommended  as  an  antidote  to  car- 
bolic acid.  No  chemical  action  takes  place  when 
these  two  drugs  are  brought  together.  The  carbolic 
acid  is  simply  diluted,  hence  its  caustic  power  is  di- 
minished. 

Absorption:  Alcohol  is  absorbed  very  rapidly 
from  the  stomach  and  intestines.  When  taken  by 
the  mouth  it  is  not  probable  that  very  much  of  the 
drug  reaches  the  intestinal  tract,  unless  it  is  taken 
in  very  large  quantities.  Intoxication  has  been  pro- 
duced in  animals  by  injecting  the  drug  into  the  rec- 
tum. It  is  absorbed  also  from  the  subcutaneous 
tissue  and  the  lungs.  Deep  anjEsthesia  has  been 
produced  by  inhalation. 

Elimination:  Alcohol  is  eliminated  by  the  lungs, 
skin,  and  kidneys,  but  a  large  portion  of  a  single 
dose  is  oxidized  within  the  body. 

General  Action:  The  general  action  of  alcohol  is 
only  too  well  known.  The  drunken  man  is  a  picture 
familiar  to  all.  There  are  certain  points,  however, 
that  I  wish  to  call  attention  to  that  illustrate  what  I 
mean  by  saying  that  alcohol  is  a  very  deceiving 
drug.  Alcoholic  intoxication  may  be  divided  into 
three  stages.  Excitement,  anaesthesia,  and  paralysis. 
It  is  the  first  stage  that  falsifies.  Apparently  it  is  a 
stage  of  stimulation.  The  heart  beats  faster,  respira- 
tion is  increased,  the  skin  is  warm  and  red,  and 
there  is  increased  action  and  speech.  The  speaker 
is  filled  with  an  inspired  brilliancy,  while  the  cow- 
ard is  thrusted  forth  to  battle.  None  of  these  symp- 
toms, however,  are  due  to  a  direct  stimulation  of 
nerve  centres.  They  are  the  "indirect  result  of  en- 
vironment, incoordination,  and  reflex  action."  The 
warmth  of  the  skin  is  due  to  vasomotor  depression. 
The  quickening  of  the  pulse  is  largely  due  to  the 
irritation  of  the  mucous  membrane  of  the  mouth 
and  stomach  and  to  the  vasomotor  depression,  by 
which  the  peripheral  resistance  is  removed.  The  in- 
crease in  respiration  is  largely  due  to  the  same 
cause  but  not  entirely.  The  apparent  brilliancy  of 
mind  is  due  not  to  a  stimulation  of  the  intellectual 
centres  but  to  a  depression  of  all  the  higher  mental 
faculties  which  permits  the  lower  centres  to  become 
more  prominent.  Thus  we  see  a  marked  depression 
in  judgment,  observation,  and  attention,  while  the 
imagination  almost  runs  riot.  .\11  those  faculties 
acquired  by  education  and  which  constitute  the  ele- 
ments of  restraint  are  depressed,  and  in  man  the 
animal  is  revealed.  Now  it  is  that  viciousness,  ob- 
scenity, and  lasciviousness  reigns  supreme.  Easily 
provoked  to  boisterous  laughter  man  is  just  as  easily 
and  suddenly  thrown  into  a  fit  of  maniacal  anger. 
Reason  is  dethroned.  Alcohol  never  increases  the 
physical  or  intellectual  power  of  man.  After  mod- 
erate doses  there  is  a  slight  increase  in  the  power  of 
voluntary  muscles,  but  within  a  half  hour  it  is 
markcdh  diminished.  The  increase  in  power  is  best 
seen  in  fatigue,  and  when  taken  under  these  circum- 
stances the  sense  of  comfort  that  is  experienced  is 


JIarch  6,  1 909. 1 


ZhMF:  ALCOHOL. 


A77 


not  due  to  stimulation  but  to  depression,  general  re- 
laxation being  the  result.  After  a  variable  period 
of  time,  depending  upon  the  dose,  the  stage  of  ap- 
parent stimulation  passes  gradually  over  into  the 
stage  of  anaesthesia  or  narcosis.  As  this  stage  ap- 
proaches the  activity  of  the  individual  is  markedly 
diminished.  There  is  lessened  mental  activity,  di- 
minished sensation  and  motion.  Speech  is  thick, 
gait  unsteady,  and  there  is  a  tendency  to  sleep.  Con- 
sciousness and  sensation  are  gradually  abolished, 
this  being  the  third  or  paralytic  stage.  Xow  the 
respiration  is  slow  and  stertorous,  pulse  weak,  skin 
cold  and  cyanotic,  pupils  dilated,  and  reflexes  abol- 
ished. When  death  occurs,  which  is  seldom  in  acute 
cases,  it  is  generally  from  respiratory  failure. 

Xervous  System:  Alcohol  affects  the  various 
nerve  centres  just  as  ether  does,  but  its  action  is 
more  prolonged.  In  the  early  stage  of  its  adminis- 
tration there  is  a  short  period  of  stimulation  prob- 
ablv  due  to  its  irritating  effect.  The  dominn.nt 
action  of  this  drug  is  that  of  a  depressant,  and  this 
is  readily  seen  on  the  brain,  spinal  cord,  motor  and 
sensory  nerves. 

Circulation:  The  effect  of  alcohol  upon  the  cir- 
culation depends  upon  the  size  of  the  dose.  INIe- 
dium  size  doses  do  not  raise  arterial  pressure,  or 
quicken  the  pulse  rate.  Large  doses  markedly  lower 
the  blood  pressure.  The  rate  of  flow  is  increased. 
That  is,  the  amount  of  blood  that  passes  a  given 
point  in  a  given  time  is  increased.  If  the  spinal 
cord  is  cut  high  up,  thus  removing  the  influence  of 
the  vasomotor  centre,  alcohol  is  capable  of  raising 
arterial  pressure.  Wood  asserts  that  a  drug  capa- 
ble of  producing  such  an  effect  must  stimulate  the 
heart  and  depress  the  vasomotor  centre.  With  the 
vasomotor  centre  intact  alcohol  is  incapable  of  rais- 
ing arterial  pressure.  In  fact,  the  tendency  is  to- 
ward lowering  of  the  blood  pressure,  but  the  rate 
of  flow  being  increased  there  is  a  more  equal  dis- 
tribution of  the  blood  over  the  entire  body.  The 
A-asodilating  effect  of  alcohol  is  most  marked  in  the 
vessels  of  the  skin  and  stomach.  Large  doses  of  al- 
cohol markedly  depress,  even  paralyze,  the  heart. 

Outside  of  the  body  alcohol  causes  a  coagulation 
of  the  blood  with  a  separation  of  its  haemoglobin, 
but  it  is  not  probable  that  such  an  action  takes 
place  within  the  body.  It  does,  however,  inhibit  the 
oxyhjemoglobin  from  readily  parting  with  its  oxy- 
gen, thus  lessening  oxidation.  Recent  investigation 
seems  to  show  that  alcohol  lowers  the  opsonic  in- 
dex and  markedly  interferes  with  phagocytosis. 

Temperature :  After  the  ingestion  of  alcohol  a 
feeling  of  warmth  is  felt  in  the  stomach  which  soon 
spreads  over  the  entire  body.  This  is  due  to  the 
local  irritating  eft'ect  upon  the  stomach  and  the  di- 
lating effect  upon  the  peripheral  vessels,  especially 
those  of  the  skin.  As  a  matter  of  fact  the  body 
temperature  is  not  raised  but  lowered,  especially  if 
the  dose  has  been  a  liberal  one.  This  is  due  to  in- 
creased heat  radiation,  so  that  one  who  is  under  the 
influence  of  alcohol  will  freeze  to  death  more  quick- 
ly and  surely  than  one  who  is  not.  The  experience 
of  all  arctic  explorers  confirms  the  statement  that 
alcohol  diminishes  the  body's  power  to  resist  cold. 

Nutrition:  Wood  states  that  alcohol  has  no  posi- 
tive influence  upon  the  processes  of  oxidation  or 
heat  production,  nor  has  it  any  direct  effect  upon 


nitrogenous  elimination.  In  moderate  amounts  it 
is  oxidized  within  the  system,  but  the  amount  that 
the  system  can  use  in  this  way  is  exceedingly  lim- 
ited. Adults  can  oxidize  about  an  ounce  and  a  half 
of  alcohol  a  day,  which  oxidation  produces  a  cer- 
tain amount  of  force  capable  of  being  utilized  by 
the  body.  Especially  is  this  true  in  marked  cases 
of  debility.  Alcohol  is  one  of  the  excretions  of  the 
body  being  found  in  the  urine  of  teetotalers.  Its 
source  of  origin  is  within  the  liver.  While  alcohol 
is  capable  of  being  oxidized  within  the  body  it  can- 
not be  considered  as  a  food,  for  it  is  capable  of  re- 
placing the  hydrocarbons  only  to  a  very  limited  ex- 
tent. In  fact,  alcohol  cannot  be  considered  as  a 
food.  The  following  parallel  drawn  by  Hall  is  cer- 
tainly convincing: 

Food.  Alcohol. 

1.  A  certain  quantity  will  i.  A  certain  quantity  will 
produce  a  certain  effect  at  produce  a  certain  effect  at 
first,  and  the  same  quantity  first,  but  it  requires  more 
will  always  produce  the  and  more  to  produce  the 
same  effect  in  the  healthy  sam.e  effect  when  the  drug 
body.  is  used  habitually. 

2.  The  habitual  use  of  2.  When  used  habitually 
food  never  induces  an  un-  it  is  likely  to  induce  an  un- 
controllable desire  for  it,  in  controllable  desire  for  more, 
ever  increasing  amounts.  in  ever  increasing  amounts. 

3.  After  its  habitual  use  a  3.  After  its  habitual  use 
sudden  total  abstinence  a  sudden  total  abstinence  is 
never  causes  any  derange-  likely  to  cause  a  serious  de- 
ment of  the  central  nervous  rangement  of  the  central 
system.  nervous  system. 

4.  Foods  are  oxidized  4.  Alcohol  is  oxidized 
slowly  in  the  body.  rapidly  in  the  body. 

5.  Foods  being  useful  are  5.  Alcohol,  not  being  use- 
stored  in  the  body.  ful,  is   not   stored  in  the 

body. 

6.  Foods  are  the  products  6.  Alcohol  is  a  product  of 
of  constructive  activity  of  decomposition  of  food  in 
protoplasm  in  the  presence  the  presence  of  a  scarcity  of 
of  abundant  oxygen.  oxygen. 

7.  Foods  (except  meats)  7.  Alcohol  is  formed  in 
are  formed  in  nature  for  nature  only  as  an  excretion, 
nourishment  of  living  or-  It  is,  therefore,  in  common 
ganisms  and  are,  therefore,  with  all  excretions,  poison- 
inherently  wholesome.  ous. 

8.  The_  regular  ingestion  8.  The  regular  ingestion 
of  food  is  beneficial  to  the  of  alcohol  is  deleterious  to 
healthy  body,  but  may  be  the  healthy  body,  but  may 
deleterious  to  the  sick.  be    beneficial    to    the  sick 

(through  its  drug  action.) 

9.  The  use  of  foods  is  fol-  9.  The  use  of  alcohol,  in 
lowed  by  no  reaction.  common   with  narcotics  in 

general,  is  followed  by  a  re- 
action. 

10.  The  use  of  food  is  fol-  10.  The  use  of  alcohol  is 
lowed  by  an  increased  activ-  followed  by  a  decrease  in 
ity  of  the  muscle  cells  and  the  activity  of  the  brain 
brain  cells.  cells  and  muscle  cells. 

11.  The  use  of  food  is  fol-        11.  The  use  of  alcohol  is 
lowed  by  an  increase  in  the      followed  by  a  decrease  in 
excretion  of  carbon  dioxide.      the  excretion  of  carbon  di- 
oxide. 

12.  The  use  of  food  may  12.  The  use  of  alcohol  is 
be  followed  by  accumulation  usually  followed  by  accumu- 
of  fat,  notwithstanding  in-  lation  of  fat  through  de- 
creased activity.  creased  activity. 

13.  The  use  of  food  is  fol-  13.  The  use  of  alcohol  is 
lowed  by  a  rise  in  body  followed  by  a  fall  in  body 
tem.perature.  temperature. 

14.  T  h  e  use  of  food  14.  The  use  of  alcohol 
strengthens  and  steadies  the  weakens  and  unsteadies  the 
muscles.  muscles. 

15.  The  use  of  food  makes  i.t.  The  use  of  alcohol 
the  brain  more  active  and  makes  the  brain  less  active 
accurate.  and  accurate. 

Digestion:  In  small  doses  alcohol  influences  di- 
gestion in  several  ways.     In  the  first  place,  if  not 


478 


ZEMP:  ALCOHOL. 


[New  York 
Medical  Journal. 


given  in  too  large  amount,  or  in  too  concentrated 
form,  it  increases  the  flow  of  both  saHva  and  gas- 
tric jnice.  It  also  increases  motor  function  of  the 
stomach  and  markedly  increases  the  rapidity  of  ab- 
sorption, all  of  which  is  brought  about  by  the  local 
action  of  alcohol  upon  the  stomach  wall  and  mucous 
membrane  of  the  mouth  and  throat.  Large  doses 
depress  the  digestive  functions  as  does  also  the  con- 
tinued use  of  this  drug. 

Therapeutics:  No  drug  in  the  materia  medica  has 
been  more  terribly  abused  than  alcohol.  Physicians 
have  an  idea  that  it  is  a  drug  full  of  virtue  and  con- 
taining no  evil.  It  should  ever  be  borne  in  mind 
that  alcohol  is  a  narcotic  poison  and  is  capable  of 
doing"  great  harm  when  unwisely  used.  In  the  first 
place  it  is  not  a  stimulant  as  commonly  accepted, 
and  although  when  administered  in  the  proper  man- 
ner it  manifests  some  of  the  properties  of  a  stimu- 
lant, the  promiscious  administration  of  alcohol  has 
undoubtedly  accomplished  more  harm  than  good. 
When  a  patient  is  cold  we  give  alcohol ;  when  the 
patient  has  fever  we  give  alcohol;  when  a  patient  is 
sick  from  any  cause  we  give  alcohol ;  and  when  he 
is  well  he  takes  it  himself.  What  a  wonderful 
drug ;  good  in  sickness  and  in  health ! 

When  we  come  to  explain  the  use  of  alcohol  in 
the  treatment  of  disease  we  find  that  its  so  called 
stimulating  effect  pales  into  insignificance  when 
compared  with  its  other  actions.  In  fatigue  alcohol  is 
of  value,  not  on  account  of  any  stimulating  action, 
but  because  it  is  depressing,  thereby  producing  re- 
laxation and  a  sense  of  comfort.  By  its  rapid  oxi- 
dation it  lends  to  the  muscles  a  new,  but  temporary 
energy,  which,  however,  never  reaches  the  height 
possessed  by  normal  muscle.  In  one  half  hour  after 
its  administration  the  power  of  the  muscle  is  mark- 
edly diminished.  Alcohol  undoubtedly  diminishes 
the  working  capacity  of  the  individual,  as  evidenced 
by  its  abandonment  by  the  world's  armies.  The 
time  to  take  it,  if  at  all,  is  after  the  day's  work  is 
done. 

In  digestive  troubles  where  the  secretions  of  the 
stomach  are  insufficient,  and  where  the  motor  func- 
tion of  the  stomach  is  incapacitated,  small  amounta 
of  alcohol  give  temporary  relief,  hence  in  the  bed 
ridden,  or  m  prolonged  convalescence  from  disease, 
alcohol,  by  creating  a  more  cheerful  state  of  mind, 
and  because  of  its  action  on  the  gastric  functions, 
is  of  much  value.  The  light  wines  possessing  a 
high  bouquet  are  preferable. 

In  prolonged  fevers  alcohol  is  of  benefit  when 
used  with  judgment.  Here  again  we  use  it  not  for 
its  stimulating  effect,  but  because  of  its  power  to 
dilate  the  peripheral  bloodvessels,  thus  restoring  the 
equilibrium  of  the  circulation ;  removing  the  re- 
sistance to  the  heart ;  increasing  the  dissipation  of 
heat ;  inducing  a  condition  of  quiet,  and  furnishing 
to  the  body  a  source  of  easily  utilizable  energy.  It 
should  be  borne  in  mind,  however,  that  the  amount 
of  alcohol  that  the  body  can  use  in  this  way  is  very 
limited.  All  over  this  indefinite  amount  is,  and  acts 
like,  a  narcotic  poison.  Each  case  is  a  law  unto  it- 
self. Only  the  ripe  judgment  of  an  accurate  clin- 
ical observer  can  be  a  true  guide  as  to  how  much  the 
patient  needs.  I  believe  it  to  be  true  that  many  pa- 
tients are  "stimulated"  to  death  by  the  injudicious 
u.se  of  alcohol  in  fevers.    Generally  the  time  to  be- 


gin their  use  is  when  the  patient  approaches  the 
typhoid  state,  so  well  known  by  its  classical  symp- 
toms. A  weak  heart,  per  se,  not  only  does  not  call 
for  the  use  of  alcohol  but  is  a  contraindication  to 
its  use. 

In  poisoned  wounds  alcohol  may  be  used  with 
benefit,  but  it  is  certainly  not  an  antidote  for  snake 
bite.  In  fact  the  body  succumbs  more  readily  to 
infection  under  the  influence  of  alcohol  than  with- 
out it.  A  certain  amount  by  benumbing  the  nerve 
centres  may  block  the  effect  of  the  infection  and 
thereby  modify  its  effect.  Locally  applied  to  the 
point  of  infection  it  is  of  value,  but  if  possible  suc- 
tion should  be  applied  first. 

Alcohol  is  of  value  in  preventing  the  "catching  of 
cold."  The  time  to  take  it  is  after,  not  before  or 
during,  the  exposure.  Under  these  circumstances 
the  peripheral  vessels  are  contracted  and  the  blood 
tends  to  stagnation  in  some  part  of  the  body.  The 
dilating  effect  of  alcohol  makes  the  blood  "move 
on"  like  a  faithful  policeman,  thus  internal  conges- 
tions are  relieved  before  inflammation  arises. 

In  shock  of  a  serious  nature  alcohol  may  be  used 
not  for  its  stimulating  effect  but  on  account  of  its 
benumbing  influence  upon  the  nerve  centres.  It 
is  in  this  condition  that  alcohol  has  been  used  for 
ages  with  the  idea  in  view  of  stimulating  the  pa- 
tient, whatever  that  may  mean.  As  a  matter  of  fact 
the  best  authorities  on  the  subject  of  shock  assert 
that  morphine  is  the  most  useful  drug,  verifying  the 
conclusion  that  alcohol  does  not  owe  its  successful 
use  in  this  condition  to  any  stimulating  properties 
it  is  imagined  to  possess.  In  cases  of  minor  shock 
with  temporary  inhibition  of  the  heart,  alcohol  if 
given  straight  (whiskey  or  brandy  undiluted)  will 
awaken  the  heart  to  its  duty  by  a  reflex  action  from 
the  stomach  and  mouth.  It  also,  by  dilating  the 
peripheral  vessels,  increases  the  amount  of  blood  in 
the  brain.  This  is  perhaps  the  most  useful  part  of 
its  action  in  these  cases  of  minor  shock,  for  it  is  a 
well  known  fact  that  if  patients  who  have  fainted 
are  placed  in  such  a  position  that  the  blood  will 
gravitate  to  the  brain,  they  soon  recover  without 
the  administration  of  any  drug. 

In  phthisis,  well  regulated  amounts  of  alcohol 
are  of  benefit.  The  more  cheerful  state  of  mind ; 
the  increase  in  gastric  function,  and  the  more  even 
distribution  of  the  blood  all  work  for  the  patient's 
good.  However,  the  abuse  of  alcohol  in  this  dis- 
ease markedly  hastens  the  end.  In  all  diseases  that 
tend  to  chronicity  the  strong  probability  of  the  pa- 
tient contracting  the  alcoholic  habit  should  ever  be 
kept  in  mind.  Physicians  have  blighted  many  a 
life,  and  ruined  many  happy  homes  by  the  careless 
prescribing  of  alcohol. 

Locally,  alcohol  is  a  most  useful  drug.  As  a  de- 
tergent it  is  unexcelled,  especially  if  a  little  sodium 
bicarbonate  is  added  to  the  solution.  As  an  evap- 
orating solution,  applied  to  the  body  generally,  as 
in  fevers,  or  used  on  local  areas  of  inflammation,  it 
is  gratifying  and  eft'ectivc.  The  cooling  effect  of 
these  alcoholic  lotions  can  be  markedly  increased  by 
the  addition  of  ammonium  chloride  and  vinegar,  as 
in  the  following :  .Mcohol,  60  parts ;  vinegar,  30 
parts ;  ammonium  chloride,  8  parts ;  water,  q.  s.  ad 
500.  Sprains  and  bruises  will  yield  to  this  as  read- 
ily as  they  will  to  complex  liniments.    To  prevent 


March  6,  1909.  J 


ZEMP:  ALCOHOL. 


479 


bed  sores  a  solution  of  alum  in  alcohol  is  often  ef- 
fective, the  skin  being  cleansed  and  toughened  at 
the  same  time.  A  hot  compress  of  alcohol  will  often 
relieve  neuralgia,  lumbago,  and  all  forms  of  myal- 
gia. Most  excellent  results  have  been  obtained  in 
the  treatment  of  erysipelas  by  the  local  application 
of  strong  alcohol.  Several  times  daily  the  afifected 
area  is  scrubbed  with  a  piece  of  cotton  dipped  in  a 
ninety-five  per  cent,  solution.  In  nineteen  reported 
cases  recovery  was  complete  in  five  days.  In  tuber- 
culous lesions  and  in  infected  lesions  of  all  kinds, 
compresses  of  alcohol  bring  about  a  most  marked 
change  for  the  better.  It  should  be  applied  on  lint 
or  gauze.  If  the  part  is  snugly  wrapped  and  cov- 
ered with  oiled  silk  we  have  a  most  excellent,  hot, 
antiseptic,  stimulating,  and  germicidal  dressing.  If 
the  part  is  wrapped  loosely  and  the  alcohol  per- 
mitted to  evaporate,  we  have  a  cold  dressmg  that 
will  benefit  those  cases  in  which  cold  is  indicated. 
Besides,  these  dressings  are  more  or  less  anjesthetic. 
They  are  useful  in  most  cases  of  granulating 
wounds,  especially  if  infection  is  present.  Ulcerat- 
ing surfaces  of  all  kinds  are  benefited  by  the  local 
application  of  strong  alcohol.  In  the  mouth  and 
throat,  weaker  solutions  have  to  be  used  unless  the 
ulcers  are  directly  treated.  A  twenty  per  cent,  solu- 
tion of  alcohol  makes  an  efficient  gargle,  and  readily 
relieves  stomatitis,  pharyngitis,  and  allied  condi- 
tions. Cracked  nipples  are  relieved  by  the  local  ap- 
plication of  alcohol,  but  it  is  more  efficient  when 
some  gum  resin  is  added,  tincture  of  benzoin  meet- 
ing the  indication  nicely.  In  colic  a  hot  compress  of 
whiskey  will  sometimes  relieve  at  once.  In  all  cases 
calling  for  counterirritation  alcohol  will  answer  well. 
Its  penetrating  powers  are  marked ;  it  stimulates  the 
cells,  benumbs  the  nerve  endings,  and  improves  the 
circulation. 

Interstitial  injections  of  alcohol  have  been  used 
by  Hasse  and  others  with  great  success  in  cases  of 
inoperable  cancer.  Hasse  reports  thirty-five  cases 
with  apparent  complete  recovery  after  twenty-five 
years.  In  cancer  of  the  breast  the  injections  are 
made  in  such  a  manner  as  to  shut  oflf  the  blood  sup- 
ply of  the  tumor  by  reason  of  the  hyperplasia  that 
follows  the  injection.  A  forty  per  cent,  solution  is 
used,  and  about  twenty  syringefuls  are  injected  all 
about  the  tumor  each  time.  This  is  repeated  in 
about  five  days.  If  the  case  progresses  favorably 
the  tumor  and  breast  will  gradually  get  smaller. 
About  three  months  is  required  to  complete  the  cure. 

In  trigeminal  neuralgia  alcohol  has  been  injected 
into  the  nen^e,  and  cures  efifected  when  all  other 
methods  had  failed.  In  fact,  Schlosser,  of  Munich, 
who  has  had  a  large  experience  in  the  treatment  of 
neuralgias  by  the  injection  of  alcohol,  gives  one 
hundred  per  cent,  of  cures.  The  technique,  how- 
ever, is  very  difficult  and  requires  the  master's  hand. 
In  other  forms  of  neuralgia,  such  as  sciatica,  the 
method  is  more  easily  applied. 

Alcohol  has  been  vaunted  to  the  skies  as  an  anti- 
dote to  carbolic  acid.  Practically  it  is  of  little,  if 
any,  value  at  all.  It  is  not  a  chemical  antidote  to 
this  drug,  but  simply  dilutes  it.  When  carbolic  acid 
is  taken  alcohol  might  modify  its  efTect  if  already  in 
the  stomach,  or  given  immediately  afterwards.  But 
where  some  time  must  elapse  between  the  taking  of 


the  acid  and  the  giving  of  the  alcohol  no  benefit  is 
derived.  The  only  sensible  way  to  use  alcohol  in 
these  cases  is  to  wash  the  stomach  out  with  a  solu- 
tion of  it.  Even  then  it  is  not  very  much  superior 
to  other  fluids  used  for  the  same  purpose,  or  to 
water.  Alcohol  may  actually,  and  probably  does, 
hasten  the  absorption  of  the  carbolic  acid,  hence  as 
an  antidote  to  carbolic  acid  it  is  not  to  be  recom- 
mended. Locally,  it  immediately  arrests  the  caustic 
action  of  this  drug  when  the  two  are  used  in  imme- 
diate succession,  but  carbolic  acid  on  the  skin  and 
carbolic  acid  in  the  stomach  are  two  very  dififerent 
conditions. 

In  all  cases  of  sickness'  in  which  profuse  sweating 
is  a  symptom  the  local  application  of  alcohol  (alco- 
hol baths)  are  of  benefit.  The  skin  is  condensed,  its 
tone  improved,  and  its  blood  supply  increased. 

In  chronic  bronchitis  inhalations  of  alcohol  are  of 
value.  If  used  in  the  atomizer  it  is  best  to  begin 
with  a  five  per  cent,  and  gradually  work  up  to  a  ten 
per  cent,  solution.  Or  the  alcohol  can  be  added  to  a 
vessel  of  boiling  water,  the  patient  inhaling  the 
fumes.  With  stronger  solutions  quite  a  stimulating 
effect  may  be  obtained  from  the  reflex  action  on 
heart  and  respiration.  This  is  sometimes  useful 
where  we  wish  to  rest  the  stomach  completely,  or 
for  any  reason  the  patient  is  unable  to  take  medi- 
cines by  the  mouth.  In  impending  death  from  anaes- 
thesia, especially  if  the  anaesthetic  is  ether,  the  hypo- 
dermic injection  of  alcohol  is  to  be  condemned  as 
being  irrational.  Alcohol  differs  from  ether  in  that 
its  action  is  more  prolonged. 

Coiichisioiis:  The  following  conclusions  have  been 
reached  after  a  careful  study  of  this  drug: 

Alcohol  is  a  narcotic  poison. 

It  is  not  a  stimulant  in  the  true  sense  of  the  word. 
It  is  not  a  food. 

It  is  a  useful  drug  when  properly  "used." 

It  is  a  drug  that  has  been  terribly  abused. 

Its  use  requires  as  much  intelligence  and  judg- 
ment as  does  the  use  of  any  other  drug. 

It  is  not  an  antidote  to  carbolic  acid. 

It  is  a  source,  in  proper  amounts,  of  easily  assim- 
ilated energy. 

In  small  quantities  it  aids  certain  forms  of  indi- 
gestion. 

Locally  it  possesses  values  often  overlooked. 

The  odor  of  alcohol  on  the  breath  is  no  criterion 
as  to  whether  the  patient  is  getting  too  much  or  not. 

In  the  usual  manner  of  administration  it  does 
more  harm  than  good. 

The  subjective  symptoms  of  the  patient  under  the 
influence  of  alcohol  no  more  indicate  his  true  con- 
dition than  do  those  from  morphine. 

The  drinking  of  whiskey  to  keep  from  "catching 
cold,"  or  to  prevent  serious  results  from  snake  bites, 
is  a  delusion  and  a  snare. 

When  sufficient  food  is  lacking,  alcohol  in  small 
amounts  will  prevent  body  waste,  by  conserving  the 
tissues. 

The  drinking  of  whiskey  in  health  is  a  pleasant, 
but  entirely  unnecessary  and  wasteful,  form  of 
amusement. 

The  habit  fixing  propensity  of  alcohol  should  al- 
ways be  kept  in  mind  by  those  who  prescribe  it. 


48o 


LAW  SON:  ALCOHOLISM. 


[New  York 
Medical  Journal. 


References. 

Tlie  following  works  have  been  freely  consnlted : 

Butler.    Textbook  of  Materia  Medica. 

Wood.  Therapeutics. 

Hare.    Practical  Therapeutics. 

Sollman.    Textbook  of  PJiarmacology. 

Wilcox.    Pharmacology  and  Therapeutics 

Shoemaker.    Materia  Medica  and  Therapeutics. 

Potter.    Materia  Medica,  Pharmacy,  and  Therapeutics. 

Sajou.    Analytical  Cyclopaedia. 

Foster.    Practical  Therapeutics. 

Gautier.    Diet  and  Dietetics. 

Benedict.    Golden  Rules  of  Dietetics. 

Journal  of  the  American  Medical  Association. 

A^eiv  York  Medical  Journal. 

Therapeutic  Gazette. 

Medical  Rericiu  of  Rez'ie-a's. 

International  Clinics. 

Practical  Medicine  Scries. 


A  STUDY  OF  ALCOHOLISM. 

By  George  B.  Lawson,  A.  M..  M.  D., 
Roanoke,  Va. 

(Published  by  permission  of  Dr.  A.  C.  Brush,  zisifing  neurologist 
of  the  Kings  County  Hospital,  Brooklyn,  N.  Y.) 

This  study  embraces  about  400  consecutive  cases 
admitted  to  the  alcoholic  ward  of  the  Kings  County 
Hospital,  Brooklyn.  N.  Y.,  besides  a  number  of  in- 
teresnng  cases  admitted  at  other  times  and  to  other 
wards  The  patients  were  studied  only  so  long  as 
thev  could  not  be  discharged  from  the  hospital. 
The  cases  with  delirium  occupy  most  of  the  study. 

Most  of  our  cases  of  delirium  tremens  were  from 
whiskey.  Only  one  case  was  from  beer  only.  Most 
of  the  cases  occurred  in  chronic  drinkers  after  ex- 
acerbation of  drinking.  .Some  cases  occurred  in 
chronic  drinkers  after  cessation  of  drinking.  One 
of  our  patients  had  never  drank  until  he  had  some 
domestic  trouble.  Ten  days  of  hard  drinking 
brought  on  one  of  the  most  severe  forms,  resulting 
in  death  in  twenty-four  hours  after  onset. 

From  our  study  the  cases  with  delirium  may  be 
classified  as  follows : 

I.  The  Ordinary  Form.  This  is  fainiliar  to  us  as 
a  delirium  with  marked  treinor  coming  on  after 
prolonged  alcoholism,  usually  starting  in  with 
tremor,  loss  of  appetite,  sleeplessness,  and  hallucina- 
tions of  hearing  and  sight.  The  delirium  may  be  of 
all  stages,  varying  from  only  a  few  hallucinations 
to  the  wildest  excitement.  In  the  milder  forms  the 
patierit  answers  questions  quite  readily  and  will  do 
what  he  is- told:  in  the  more  severe  forms  he  dis- 
regards his  surroundings  and  will  pay  no  attention 
to  questions  or  commands.  The  duration  of  the 
excitement  stage  usuallv  does  not  last  more  than 
three  or  four  days,  the  excitem.ent  gradually  be- 
coming less ;  usually  after  a  sleep  the  patient  will 
wake  mentally  clear.  The  delirium  is  usually  worse 
at  night ;  some  of  the  patients  that  have  been  in 
the  ward  several  days  and  are  apparently  normal 
mav  set  up  a  severe  delirium  at  night.  Some  of 
the  patients  that  are  recovering  and  are  apparently 
normal  during  the  day  set  up  a  mild  delirium  at 
night.  This  may  happen  over  a  period  of  two  or 
three  days.  The  textbooks  in  general  seem  to 
emphasize  too  much  the  hallucinations  of  seeing 
snakes  and  frightful  objects.  V'ery  many  of  the 
patients,  especially  in  early  stages.'  are  constantly 
picking  imaginary  things  from  bed,  walls,  etc. 
During  the  excitement  stage,  the  pulse  is  rapid  and 


in  most  cases  in  which  we  w'ere  able  to  take  blood 
pressure  readings,  the  tension  was  higher  than  nor- 
mal, say  160  to  170,  dropping  down  after  recovery 
to  from  120  to  130. 

Some  of  the  patients  were  delirious,  restless,  and 
excited  to  the  last  breath,  others  gradually  became 
quieter  until  recovery,  or  gradually  quieter  and 
weaker  until  death.  The  few  fatal  cases  that  we 
have  watched  during  the  final  outcoine  showed 
respiratory  failure  before  cardiac  failure ;  the  heart 
continued  to  beat  full  and  strong  for  some  time 
after  respiration  had  ceased. 

2.  Convulsive  Type.  Under  this  heading  we  do 
not  consider  epilepsy  with  its  accentuation  by  alco- 
hol, but  a  type  characterized  by  general  convulsions 
accompanied  in  the  intervals  by  delirium  or  coma. 
There  may  be  only  three  or  four  such  convulsions  in 
the  twenty-four  hours,  gradually  becoming  less  fre- 
quent and  less  severe  until  the  patient  clears  up. 
In  some  of  our  cases  the  convttlsions  occurred  three 
of  four  times  in  an  hour  with  death  in  eight  to  ten 
hours  after  admittance.  In  none  of  our  cases  did 
the  convulsions  last  longer  than  thirty-six  hours, 
the  result  being  recovery  or  death  in  less  than  that 
time.  As  a  rule  one  could  make  a  pretty  certain 
prognosis  at  the  end  of  twelve  hours.  One  of  our 
patients  had  almost  typical  strychnine  convulsions, 
the  attacks  coming  on  every  five  minutes.  This  pa- 
tient had  previously  had  no  strychnine  so  far  as 
could  be  ascertained.    This  patient  recovered. 

Percy  (1792)  (i)  described  a  form  of  convulsion 
after  drinking,  saying  that  excess  of  drinking  was 
apt  to  cause  convulsions  in  those  of  nervous  tem- 
perament. James  Bird  (2)  described  an  epileptic 
type  occurring  in  hot  countries  with  five  deaths  out 
of  seven  cases.  Later  writers  emphasize  the  ten- 
dency to  convulsions  after  the  use  of  absynth. 

3.  Wet  Brain  or  Serous  Meningitis.  One  sel- 
dom hears  of  this  form  outside  of  the  city  hospitals. 
It  was  first  described  by  Dana  (3),  and  his  descrip- 
tion is  an  excellent  one.  This  type  is  characterized 
by  low  muttering  delirium,  moving  constantl\  of 
the  arms  and  hands,  weakness,  and  irritability,  the 
patient  resisting  all  passive  motions,  especially  when 
made  quickly.  The  skin  looks  dry,  the  mouth  is 
usually  open  and  dry,  the  eyes  are  usually  slightly 
open  and  if  not  cared  for  closely  show  a  pus  dis- 
charge. The  patient  never  sleeps.  The  condition 
may  develop  graduall}-.  taking  three  to  ten  days  to 
develop,  or  it  may  follow  the  ordinary  excitable  de- 
lirium. The  pulse  is  usually  rapid,  the  temperature 
may  vary  a  little  above  normal,  gg°  to  101°  F.  As 
the  disease  becoines  more  pronounced  there  is 
marked  Kernig's  sign,  with  stiiTness  of  the  neck  mus- 
cles, or  even  some  retraction  of  head.  Dana  con- 
siders that  most  cases  that  show  retraction  of  head 
will  turn  out  fatally.  This  seems  to  be  true  of  the 
chronic  cases.  However,  a  few  patients  will  show 
retraction  of  the  head  for  only  a  part  of  a  day  and 
recover  rather  rapidly.  In  many  of  the  fatal  cases 
the  patients  never  show  retraction  of  the  head  or 
Kernig's  sign,  but  merely  become  weaker  and  die. 
The  delirium  is  of  the  so  called  typhoidal  type. 

The  patient  may  slowly  recover,  becoming  grad- 
ually brighter  mentally  and  stronger  physically. 
The  duration  is  sometimes  as  long  as  eight  weeks. 
Even  after  getting  out  of  bed.  the  patients  are  weak 
and  recover  slowly,  jusl  as   after  any  other  long 


March  6,  igog.] 


LAWSON:  ALCOHOLISM. 


sickness.  In  these  cases  that  turn  out  fatally  the 
patients  become  weaker,  until  death  is  reached.  In 
a  few  patients  the  hyperpyrexia  form  develops. 
One  of  the  patients  reached  a  temperature  of  109° 
F.  before  death  with  no  signs  of  pneumonia.  When 
the  disease  lasts  any  length  of  time  there  is  a  ten- 
dency to  bedsores  as  in  typhoid.  N6ne  of  the  pa- 
tients had  retention  of  urine.  Two  convalescents 
had  marked  faecal  impactions  which  caused  a  great 
deal  of  trouble.  In  none  of  our  patients  have  we 
found  hydrochloric  acid  present  using  milk  as  test 
meal.  The  coagulation  time  of  the  blood  was  taken 
by  means  of  Wright's  tubes  in  all  classes  of  alco- 
holic patients.  In  a  few  of  the  cases  of  wet  brain 
with  meningeal  symptoms  the  time  was  delat  ed  to 
from  seven  to  ten  minutes.  In  a  majority  of  the 
cases  there  was  no  delay.  We  may  illustrate  the 
changes  in  coagulation  time  by  one  case : 

Case. — Male,  age  forty-five,  admitted  November  i,  1906. 
Had  been  drinking  heavily  for  four  weeks,  eating  little. 
Patient  looked  quite  well  when  admitted  except  somewhat 
anaemic.  Heart  and  lungs  were  practically  normal.  Pa- 
tient became  irrational  on  evening  of  admission.  Tempera- 
ture 101°  F. 

November  2d. — Irrational,  coagulation  time  three  and 
one  half  minutes. 

November  3d. — Irrational  and  drowsy,  coagulation  time 
six  minutes. 

November  4th. — Irrational,  muscular  tremor  and  rigidity, 
pulse  tension  135,  coagulation  time  four  minutes. 

November  5th.- — Irrational,  tremor  of  hands ;  patient  re- 
sisted all  passive  motion,  pulse  tension  160,  coagulation 
time  nine  minutes. 

November  6th. — Irrational,  rigidity  of  muscles  of  neck, 
muscular  tremor,  pulse  tension  165,  coagulation  time  eight 
and  one  half  minutes. 

November  7th.— Patient  slept  some :  rigidity  of  neck 
muscles,  pulse  tension  160. :  10  p.  m..  temperature  105°  F., 
respirations  38  a  minute,  pulse  rate  130,  lungs  everwhere 
resonant  on  percussion. 

November  8th.— Death  at  5  145  a.  m. 

This  case  shows  nicely  the  high  pulse  tension  in 
delirium  and  changes  in  coagulation  time ;  however, 
the  wet  brain  cases  seldom  show  as  high  tension  as 
the  above  case.  These  peculiar  changes  in  coagula- 
tion time  occurred 'in  only  a  small  number  of  our 
cases.  None  of  our  patients  showed  any  noticeable 
tendency  to  haemorrhage  such  as  nose  bleed,  pur- 
pura, excessive  bleeding  of  wounds,  etc. 

4.  Delirium  with  Hyperpyrexia.  This  may  occur 
with  the  active  delirium,  thus  one  patient  who  was 
thought  to  be  in  quite  a  good  condition  showed  a 
temperature  of  105°  F.  In  two  hours  this  rose  to 
107°  F.,  followed  shortly  by  death.  Or  the  hyper- 
pyrexia may  occur  in  the  form  of  internal  conges- 
tion ;  the  patient  is  weak  and  semicomatose,  the 
pulse  is  weak,  the  body  feels  about  the  ordinary  tem- 
perature, but  the  hands  and  feet  are  cold.  Rectal 
temperature  mav  be  from  107  to  108.5°  F-  The  pa- 
tient may  last  ten  to  thirty-six  hours,  but  in  every 
case  the  final  outcome  is  death.  Two  of  our  patients 
with  hyperpyrexia  had  haemorrhage  from  the  bowel 
before  death.  At  post  mortem  examination  the  ves- 
sels of  the  intestines  were  found  to  be  very  much  dis- 
tended with  blood,  otherwise  the  post  mortem  exam- 
ination was  negative. 

It  is  very  seldom  that  one  sees  in  the  wards  a 
temperature  reaching  107°  F.  except  in  the  alcoholic 
and  cerebral  conditions.  Some  of  the  meningitis 
cases  reach  this  high  ;  in  one  postoperative  case  for 
broken  neck  the  temperature  ranged  around  107° 
F.  for  about  six  hours  before  death.    A  few  of  the 


patients  with  fractured  skulls  had  a  very  high  tem- 
perature. 

Mangan  in  Gazette  medicale  de  Paris,  1873,  spoke 
of  alcoholic  delirium  with  temperatitre  reaching  105° 
F.  and  higher,  but  considered  this  as  abnormal.  How- 
ever, if  this  is  true  one  can  not  well  understand  why 
it  would  not  occur  more  frequently  in  other  than 
cerebral  conditions. 

I  have  seen  only  one  patient  with  a  temperature  of 
105°  F.  who  recovered.  Lambert  (4)  brought  out 
this  point  in  his  studies  at  Bellevue. 

5.  Korsakow's  Psychosis.  Only  one  of  our  pa- 
tients showed  this  peculiar  condition  of  polyneuritis 
with  confusion  and  weakness  of  memory. 

The  most  common  complication  of  alcoholic  de- 
lirium is  pneumonia.  In  our  cases  pneumonia  was 
less  often  a  complication  than  reports  indicate  in 
other  hospitals.  In  many  of  our  cases  it  seemed  that 
the  chest  became  more  resonant  than  the  ordinary 
chest.  One  is  apt  to  overlook  pneumonia  in  deliri- 
um tremens. 

Traumatic  or  secondary  delirium  differs  little  from 
the  ordinary  except  that  it  is  more  fatal.  Most  of 
our  cases  resulted  from  fractures,  lacerations,  or 
local  infections.  ]\Iost  of  the  erysipelas  patients,  who 
had  drank  heavy,  became  delirious,  and  most  of  the 
deaths  from  erysipelas  occurred  in  heavy  drinkers. 
\'ery  many  of  the  severe  local  infections  in  the  sur- 
gical ward  were  in  chronic  drinkers.  One  of  the 
French  authors  has  well  brought  out  the  point  that 
chronic  alcoholics  are  more  prone  to  delirium  than 
are  other  patients. 

Diagnosis. — The  diagnosis  of  the  alcoholic  case 
is  usually  easy,  yet  one  is  apt  to  confound  any  case 
of  delirium  or  coma  with  one  of  alcoholism.  The 
patients  with  fractured  skulls  and  uraemia  were  par- 
ticularly liable  to  be  put  in  the  alcoholic  ward  until 
closer  study  revealed  the  difference.  One  patient 
with  typhoid  fever  was  admitted  to  the  alcoholic 
ward,  one  patient  with  acute  maniacal  delirium  was 
transferred  from  the  surgical  ward  as  an  alcoholic 
case. 

Some  patients  of  the  wet  brain  type  with  sliglit 
albumin  in  the  urine  were  extremely  interesting  in 
regard  to  diagnosis,  several  of  which  we  were  not 
able  to  decide.  One  such  patient  with  discharge 
from  the  ear  and  leucocytosis  was  operated  upon  for 
brain  abscess ;  however,  none  was  found.  A  post 
mortem  examination  was  not  obtained.  One  patient 
with  cerebral  irritation  after  basal  fracture  showed 
typical  alcoholic  delirium  for  weeks,  yet  there  was 
no  history  of  alcoholism.  One  occasionally  sees  the 
delirium  of  pneumonia  resemble  very  closely  that  of 
alcoholism. 

Under  the  head  of  treatment  of  alcoholic  delirium 
we  shall  discuss  somewhat  the  methods  at  present  in 
vogue  and  the  conclusions  drawn  from  our  cases. 
The  opinions  even  among  the  better  authorities  are 
frequently  contradictory  and  sometimes  confusing. 
Unfortunately  this  malady  seems  to  have  been  stud- 
ied so  little  from  a  clinical  standpoint.  Even  physi- 
cians seem  to  lay  most  stress  on  it  from  a  sociologi- 
cal standpoint.  Some  authorities  consider  the  mal- 
ady as  a  toxaemia,  others  as  a  vasomotor  paralysis 
either  with  or  without  cerebral  effusion ;  while  most 
of  the  textbooks  pass  by  this  point  altogether. 

In  the  treatment  of  most  diseases  the  first  indica- 
tion is  to  remove  the  cause,  and  probably  by  a  ma- 


482 


LAWSON:  ALCOHOLISM. 


[New  York 
Medical  Journal. 


jority  of  the  specialists  in  treatment  of  alcoholic  de- 
lirium this  is  done.  However,  at  present  it  some- 
times seems  doubtful  whether  this  is  best  or  not. 
We  know  that  a/«person  who  is  accustomed  to  drink- 
ing and  is  suddenly  stopped  feels  depressed.  It  is 
generally  acknowledged  that  a  few  alcoholic  patients 
when  suddenly  deprived  of  alcohol  become  delirious. 
With  morphine  and  other  drugs,  we  know  that  sud- 
den stoppage  causes  great  temporary  depression. 
We  see  a  few  patients  who  have  drank  heavy  over 
long  periods  of  time  come  in  the  ward  in  quite  a 
good  condition  and  fairly  rational,  become  weaker 
and  die  when  deprived  of  alcohol. 

Some  of  the  authors  speak  favorably  of  the  use 
of  alcohol : 

Cushny  (5)  :  "In  delirium  tremens  it  is  often  nec- 
essary, or  at  any  rate  advisable,  in  these  cases  to 
allow  small  quanties  of  alcohol,  as  the  sudden  with- 
drawal may  aggravate  the  condition." 

Shoemaker  (6)  :  "A  deprivation  of  the  accustomed 
stimulant  may  be  followed  by  an  outbreak." 

Hare  (7)  :  "As  a  rule  it  is  necessary  to  give  a  cer- 
tain amount  of  alcohol,  sometimes  it  must  be  given 
very  freely.  When  the  pulse  fails,  becomes  frequent 
and  weak,  and  the  skin  becomes  cold  and  clammy, 
alcohol  must  be  given  in  full  doses." 

If  alcohol  is  merely  a  toxic  body  it  should  be 
stopped ;  if  it  is  a  food  or  stimulant  to  which  the 
body  is  accustomed,  it  seems  rational  to  continue  the 
alcohol  in  small  doses.  Many  practitioners  use  al- 
cohol in  large  doses  in  pneumonia  and  other  infec- 
tions. The  work  of  Laitinen  (8)  is  interesting  in 
regard  to  this.  He  showed  that  chickens,  dogs, 
pigeons,  and  guinea  pigs  when  inoculated  with  the 
germ  of  anthrax,  diphtheria,  or  tuberculosis,  die 
sooner  when  fairly  large  doses  of  alcohol  are  used 
than  do  controls  without  the  alcohol.  In  only  a  few 
of  our  patients  was  alcohol  used. 

Treatment:  We  may  classify  treatment:  i,  To 
properly  feed  the  patient ;  2,  to  promote  the  action 
of  the  excretory  organs ;  3,  to  allay  excitement  and 
produce  sleep ;  and  4,  to  meet  certain  other  condi- 
tions not  included  in  the  above. 

Coues  (9),  in  1867,  was  probably  the  first  to  call 
attention  to  the  necessity  of  careful  feeding.  Col- 
lins (10)  has  especially  brought  out  the  point  of 
using  predigested  and  partly  digested  foods.  Croth- 
ers  (11)  advises  against  feeding  for  a  few  days  and 
insists  upon  solid  food.  In  most  of  the  city  hos- 
pitals there  is  an  idea  that  forced  feeding  is  a  very 
essential  point.  The  patients  usually  receive  milk 
and  raw  eggs.  The  ordinary  delirious  patient  usual- 
ly takes  liquid  nourishment  fairly  well  and  seldom 
vomits.  The  real  necessity  of  careful  feeding  comes 
in  in  the  treatment  of  the  weakness  following  the 
active  delirium  and  in  wet  brains. 

In  the  stomach  analysis  of  about  forty  cases, 
using  Ewald-l'oas  test  meal,  the  total  acidity  was 
decreased  in  every  case  except  one  patient  with  de- 
lirium from  beer;  this  was  normal.  In  probably 
half  of  the  cases  there  was  no  free  hydrochloric  acid 
present.  Chittenden  and  Mendel  (12)  have  shown 
that  alcohol  increases  the  secretory  activity  of  the 
stomach.  The  gastric  contents  of  a  few  of  our  pa- 
tients coming  in  merely  drunk  showed  no  hydro- 
chloric acid.  One  person  not  accustomed  to  alco- 
hol was  given  three  and  a  half  ounces  of  whiskey 


in  broken  doses  and  a  test  meal.  This  showed  de- 
creased hydrochloric  acid,  while  a  test  meal  made 
the  following  day  showed  the  normal  amount.  A 
stomach  analysis  of  a  few  cases  of  alcoholic  de- 
lirium showed  no  hydrochloric  acid  present  even 
three  to  four  days  after  recovery,  yet  there  was  no 
symptoms  of  f^astric  disorder. 

The  test  meal  seemed  to  disappear  quicker  from 
the  stomach  of  the  alcoholic  patient  than  from  the 
stomach  of  the  ordinary  patient.  One  of  our  pa- 
tients showed  markedly  the  depressant  action  of  the 
stomach  tube.  He  was  admitted  comatose  with  no 
history.  An  effort  was  made  to  wash  out  the  stom- 
ach and  put  in  some  hot  coffee,  but  the  introduction 
of  the  tube  caused  a  cessation  of  respiration,  which 
was  restored  with  difficulty.  About  ten  minutes 
later  a  second  attempt  was  made  to  introduce  the 
tube ;  this  caused  a  cessation  of  respiration,  which 
could  not  be  restored  again. 

On  looking  at  the  mouth  of  a  patient,  especially  of 
the  wet  brain  type,  one  sees  there  is  little  salivarv 
secretion,  and  as  our  analyses  showed  diminished 
hydrochloric  secretion,  one  might  conclude  that  the 
pancreatic  and  intestinal  secretory  activity  is  also 
diminished,  but  unfortunately  the  stools  were  not 
studied  as  to  whether  the  food  was  digested  or  not. 
On  the  basis  of  loss  of  secretory  activity  of  the 
stomach,  we  used  milk  in  combination  with  pepsin 
and  dilute  hydrochloric  acid  (two  drachms  of 
hydrochloric  acid  to  one  pint  of  milk),  and  in 
some  cases  combined  with  whiskey.  This  mixture, 
tried  on  two  wet  brain  cases,  in  which  the  patients 
had  previously  been  fed  on  milk  and  eggs,  gave 
quite  a  marked  temporary  improvement.  The  use 
of  hydrochloric  acid  seems  especially  good  because 
of  its  digestive  action,  and  because  it  has  been  shown 
by  Dolinsky  ( I3),using  dogs  with  pancreatic  fistula, 
to  be  an  extremely  good  pancreatic  stimulant  from 
its  action  on  the  duodenum.  This  is  also  true  of 
lemonade.  Crothers  emphasizes  the  good  results  of 
acid  drinks  in  many  cases  and  recommends  alkaline 
drinks  in  other  cases.  One  of  our  cases  set  up  a 
secondary  delirium  when  put  on  alkalies ;  however, 
three  other  cases  tried  in  similar  manner  showed 
no  such  results.  The  alkalies  were  shown  by 
Becker  (14)  to  diminish  gastric  activity. 

If  we  do  not  use  alcohol  in  our  feeding,  it  seems 
rational  to  use  foods  as  near  alcohol  as  possible, 
namely,  the  carbohydrates  and  fats.  The  older  the- 
ories were  that  alcohol  reduces  the  o.xidizing  power 
of  the  cell ;  if  this  is  true  we  should  recommend  the 
feeding  of  carbohydrates  and  fats  to  replace  a  part 
of  the  large  amounts  of  proteids  that  are  usually 
given.  The  work  of  Reid  Hunt  (15)  shows  that 
the  oxidizing  power  of  the  cell  is  increased  in  rela- 
tion to  certain  substances  and  he  thus  accounts  for 
the  increased  tolerance  for  alcohol  in  chronic 
drunkards. 

The  importance  of  food  is  shown  by  the  condi- 
tion;  if  the  patient  has  eaten  well  during  the  de- 
bauch, the  prognosis  is  very  good ;  whereas  if  he 
has  eaten  nothing  during  the  debauch  we  feel  very 
anxious  about  him,  even  though  he  is  not  delirious. 
One  writer  has  called  delirium  tremens  a  delirium 
of  starvation. 

To  pnimote  the  action  of  the  excretory  organs : 
Here  the  first  thought  is  for  free  catharsis  kept  up 


March  6,  1909.] 


LJJISOX:  ALCOHOLISM. 


483 


daily.  Some  think  that  calomel  and  gray  powder 
are  good  from  their  action  on  the  liver.  Magnesium 
sulphate  seems  to  he  one  of  the  best. 

In  igoi,  W'arbasse.  of  Brooklyn  (i6).  used  saline 
intravenously ;  since  that  time  this  method  has  been 
highly  recommended  by  certain  of  the  French  writ- 
ers. If  alcoholic  delirium  is  a  toxsmia  this  seems  a 
very  rational  procedure.  There  is  usually  a  good 
deal  of  trouble  in  giving  an  intravenous  injection  to 
this  class  of  patients,  and  as  routine  it  seems  hard- 
ly practical. 

One  of  our  patients  who  had  gradually  become 
weaker  and  who  had  every  appearance  of  rapidlv 
becoming  worse  drank  about  one  quart  of  water  and 
set  up  a  profuse  sweat.  The  condition  of  this  pa- 
tient improved  greatly  in  less  than  one  hour.  From 
this  time  on  our  endeavor  was  to  have  the  patient 
drink  as  much  water  as  possible.  The  large  amounts 
of  water  seemed  to  give  better  results  than  any 
other  method  of  treatment ;  especially  was  this  true 
if  there  was  any  fever.  Most  of  the  authors  speak 
of  using  the  eliminative  powers  of  the  body,  but  do 
not  emphasize  drinking  water  in  large  amounts. 
Collins  recommends  hot  packs,  trional,  and  copious 
drinks  of  hot  water  to  overcome  motor  unrest.  This 
seems  mostly  an  eliminative  measure.  Crothers 
speaks  very  highly  of  elimination.  The  interesting 
point  here  is  whether  the  intravenous  saline  injec- 
tions and  the  drinking  of  water  in  large  amounts 
will  increase  the  meningeal  effusions.  From  our 
cases  one  could  not  draw  such  a  conclusion.  There 
seems  to  have  been  no  bad  results  in  this  wa)-  from 
using  large  am'ounts  of  water  in  typhoid. 

Hot  packs  and  hot  baths  are  spoken  of  verv  high- 
ly by  many  authors.  This  method  of  treatment  was 
not  used  in  any  of  our  cases,  but  it  seems  a  very 
rational  method  of  treatment  if  there  is  not  too  much 
depression. 

To  allay  excitement  and  promote  sleep :  In  most 
of  our  cases  of  delirium  some  form  of  hypnotic  was 
used,  usually  morphine  hypodermically.  bromides, 
chloral,  paraldehyde,  and  occasionally  hyoscine. 
The  lack  of  sleep  is  such  an  important  symptom 
that  the  disease  was  at  one  time  called  delirium 
vigilans.  Ware  (17),  in  1838,  after  studying  only 
a  small  number  of  cases,  decided  that  the  disease 
usually  stopped  after  a  few  days  and  that  opium 
was  harmful  and  tended  to  prolong  the  delirium.  He 
decided  that  some  of  the  patients  die  even  after  they 
have  slept. 

In  looking  over  the  literature  one  finds  that  near- 
ly every,  drug  of  any  reputed  sedative  action  has 
been  highlv  recommended  :  even  chloroform  in  half 
ounce  doses  was  used.  In  our  own  cases  I  must  say 
I  do  not  know  whether  the  hypnotics  did  any  good 
or  not.  We  are  apt  to  draw  conclusions  from  too 
>mall  a  number  of  cases.  Thus,  at  one  time  we 
used  the  bromides  hypodermically  in  twenty-five 
])er  cent,  solutions.  The  first  few  cases  gave  won- 
derful results,  but  afterwards  even  doses  as  high  as 
sixty  grains  gave  no  results  except  abscess  forma- 
tion. It  is  interesting  here  to  note  that  in  no  other 
disease  showing  delirium  are  hypnotics  used  so  con- 
stantly as  in  delirium  tremens,  yet  the  conditions 
may  be  very  similar.  In  regard  to  the  amount  of 
hypnotics  to  be  used  opinions  vary.  Lambert  says 
'"small  dcses  of  hypnotics  are  worse  than  useless. 
They  are  ineft'ective,  and  the  patient  wears  himself 


out  by  incessant  thrashing."  Hare  says:  "If  sleej) 
is  difficult  to  obtain  it  is  better  to  tide  over  the  dif- 
ficulty by  moderate  doses  of  hypnotics  than  to  push 
excessively,  as  sleep  is  usually  induced  on  the  sec- 
ond or  third  rlay."  Crothers  considers  thf  use  of 
hypnotics  to  be  dangerous. 

Morphine  is  probably  the  most  commonly  used 
hypnotic  because  of  its  ease  in  administration.  It  is 
probable  that  the  hypnotics  when  given  by  mouth 
are  absorbed  very  slowly,  therefore  it  is  better  to 
use  them  hypodermically  if  possible. 

In  later  vears  hyoscine  has  come  markedly  into 
favor.  A  feeling  grew  in  our  hospital  among  the 
doctors  and  even  among  the  nurses  that  deaths  oc- 
curred after  hyoscine  which  were  due  to  the  hyo- 
scine. Lambert  says  that  hyoscine  seems  to  excite, 
especially  women.  Wagner  (18)  used  hyposcine 
in  chronic  alcoholics  and  concluded  that  it  had 
very  little  sleep  producing  qualities.  One  of  his  pa- 
tients was  thrown  into  maniacal  delirium  after  its 
use.  One  must  remember  that  morphine  some- 
times has  an  exciting  effect.  Thus  one  might  in- 
crease the  morphine  with  the  excitement  and  do  a 
great  deal  of  damage.  One  of  our  fatal  cases  seems 
suggestive  of  such  a  result. 

Chloral  hydrate  and  the  bromides  were  used  very 
frequently  in  our  cases.  The  chloral  was  given  some- 
times in  as  high  as  twenty  grain  doses  and  the  bro- 
mides in  as  high  as  sixty  grain  doses.  Neither  of 
these  seemed  to  exert  any  marked  effect  in  the  se- 
vere cases. 

Certain  conditions  to  he  met  z^'itli  not  iiiduded  in 
the  foregoing: 

Restraint.  Most  authors  advise  as  little  restraint 
as  possible,  using  even  a  padded  cell  if  necessary. 
With  our  patients  we  were  forced  to  fasten  hands  to 
the  side  of  the  bed.  and  feet  to  the  foot  of  bed.  We 
would  advise  complete  restraint  unless  a  reliable  at- 
tendant can  be  constantly  present.  Sometimes  the 
patient  when  apparently  quite  good  would  get  u]> 
and  start  to  wander  around  the  hospital.  One  such 
patient  fell  upon  the  floor,  striking  his  head.  Pneu- 
monia and  the  signs  of  fractured  skull  developed  in 
twenty-four  hours.  Operation  was  impossible.  ( )ne 
must  be  very  careful  with  restraint  used  about  the 
shoulders  for  fear  the  patient  may  strangle  himself 
in  twisting. 

Under  this  heading  we  may  put  the  so  called 
vasoconstrictors  such  as  digitalis  and  ergot.  One 
patient  drank  accidentally  a  half  ounce  of  tincture 
of  digitalis  and  recovered.  From  this  on  digitalis 
grew  into  favor  used  in  high  doses.  In  the  last  few 
years  it  has  tended  to  fall  into  distise,  especially  in 
the  very  large  doses. 

Ergot,  hypodermicallx .  was  brought  out  by  Liv- 
ingstone in  drug  addictions  and  alcohnlism.  Since 
then  Lambert  has  used  the  hypodermic  preparations 
quite  extensively. 

R    Extract  of  ergot  5i ; 

Water,     5! ; 

Chloroform  Til  iii. 

M. 

He  used  30  minims  of  the  mixture,  everv  two 
hours,  for  ten  days  without  abscess  formation.  He 
says  that  this  preparation  reduces  tremor  very  mark- 
edly. His  statistics  from  Bellevue  are  verv  interest- 
ing. Thus  8.099  cases  were  treated  without  ergot 
with  2.  7  per  cent,  mortality :  1.995  cases  were  treat- 


484 


KE.Y.VEDY 


CONSERVATISM  IN  ABDOMINAL  SURGERY. 


[New  York 
Medical  Journal, 


ed  with  ergot  with  1.5  per  cent.  mortaUty.  He  at- 
tributes this  difiference  in  mortahty  to  the  preven- 
tion of  wet  brains  by  the  use  of  ergot.  Its  use  was 
based  on  the  idea  of  dehrium  tremens  being  a  vaso- 
motor paralysis  with  cerebral  effusions  especially  in 
wet  brains.  One  can  hardly  regard  delirium  tre- 
mens as  a  vasomotor  paral\  sis  imless  in  some  way 
localized  to  the  cerebral  vessels  because  the  blood 
pressure  is  usually  higher  than  normal.  In  a  few 
cases  of  the  wet  brain  type  lumbar  puncture  was 
used.  The  pressure  of  the  spinal  fluid  was  not 
taken.  There  was  no  marked  benefit ;  however,  this 
method  was  used  only  in  extreme  cases.  Strychnine 
was  used  in  conditions  of  weakness. 

Conclusion:  One  may  summarize  the  conclusions 
as  to  treatment  as  follows : 

1.  Restraint  sufficient  to  prevent  patient  doing 
himself  injury. 

2.  Feeding  predigested  and  easily  digestible  foods, 
probably  best  in  combination  with  hydrochloric  acid. 

3.  Elimination  by  catharsis  and  intake  of  abund- 
ant fluids. 

4.  Certain  other  methods  of  treatment,  such  as  the 
use  of  hypnotics,  alcohol,  ergot,  digitalis,  and 
strychnine,  are  still  in  more  or  less  doubt  as  to  their 
value. 

I\Iy  thanks  are  due  to  Dr.  Barnet  Joseph,  of 
lirooklyn,  for  assistance  in  this  study. 

References. 

1.  Percy,  quoted  by  Rouzet,  Annalcs  clinique  de  la  So- 
cicte  dc  incdccinc  pratique  de  Moufpellier,  pp.  84  to  89. 

2.  London  Journal  of  Medicine,  1850. 

3.  Dana.    Medical  Record,  December  4,  1897. 

4.  Lambert.  Statistics  and  Studies  from  Alcoholic 
Wards  at  Bellevue.  Medical  and  Surgical  Reports  from 
Bellevue  Hospital,  1904  pp.  113  to  164. 

5.  Cushny.    Pharmacology  and  Therapeutics,  1906. 

6.  Shoemaker.    Medical  Bulletin.  July,  1904. 

7.  Hare.    System  of  Practical  Therapeutics. 

8.  Laitinen.  Zeitschrift  fiir  Hygiene  und  Infcctions- 
krankheitcn,  igoo. 

9.  Coue?.    The  Medical  and  Surgical  Reporter,  1867. 

10.  Collins.    Therapeutic  Gazette.  Aug.  15,  1904. 

11.  Crothers.  The  Virginia  Medical  Semi-Montlily, 
March  7,  1902. 

12.  '  Cliitenden  and  Mendel.  American  Journal  of  the 
Medical  Sciences,  1896. 

13.  Dolinsky.    Archives  des  sciences  biologiques.  1S95. 

14.  Becker.    Ibidem.  1893. 

15.  Hunt.  Studies  in  Jixperimental  Alcoholism.  Hygi- 
enic Laboratory  Bulletin,  No.  33.  1907. 

16.  Warbasse.    Medical  Nen'S.  March  2,  1901. 

17.  Ware.  Boston  Medical  and  Surgical  Journal.  1838. 

18.  Wagner.    Cleveland  Medical  Journal,  Jime,  1905! 

211  .Strickl.\nd  Building. 


ATTEMPT  AT  CONSICKVATISM  IN  ABDOMINAL 
SURGERY.* 

Bv  J.  W.  Ke.wedy,  M.  D., 
Philadelphia. 

(From  the  Clinic  of  Dr.  Jo.tefli  Price.) 

One  hesitates  to  make  a  plea  in  his  work,  which 
might  be  interpreted  as  being  unscientific.  .\  great 
deal  depends  upon  one's  idea  of  scientific  work  in 
medicine  and  surgery. 

Is  it  true  that  tlie  man  who  is  the  most  advanced 
in  the  skilled  use  of  the  microscope  and  exhaustive 
in  his  dicmical  analysis,  shall  dictate  to  the  veterans 

•Read  hrfore  th"  Somer-set  County  Medical  Society  of  New  Jei- 
Bcy,  Hccciiibcr  lo,  1908. 


whose  knowledge  of  physical  diagnosis  is  his  great- 
est resource? 

We  do  not  think  there  should  be  any  definite  line 
drawn  between  those  who  are  strong  advocates  of 
hands  on  the  patient  and  the  followers  of  biology 
and  chemistry.  Ever}'  means  of  diagnosis  must  be 
brought  into  play,  but  all  should  be  looked  upon  as 
mere  accessories  to  your  physical  signs  or  "hands 
on  the  patient."  We  believe  it  is  true  that  we  be- 
ginners, in  our  persistent  eft'orts  to  keep  pace  with 
the  progress  of  the  hour,  are  often  unmindful  of  the 
valuable  experience  of  our  fathers  in  the  profession. 
We  must  go  back  and  review  the  valuable  literature 
of  the  past  and  become  familiar  with  those  earnest 
men  who  knew  and  taught  so  much  from  their  edu- 
cated hand. 

Is  it  possible  that  we  are  permitting  artificial 
means  to  supplant  those  of  physical  diagnosis  which 
can  be  so  quickly  executed?  Without  in  any  way 
discouraging  biology  or  chemistry,  the  student  must 
be  taught  more  from  personal  contact  with  the  pa- 
tient. From  a  quite  extensive  experience  acquired 
from  hospital  and  dispensary  work,  I  find  the  coun- 
try practitioner  the  best  diagnostician  and  an  advo- 
cate of  early  operative  measures,  in  acute  and  dan- 
gerous lesions  of  the  abdomen. 

We  must  not  permit  chronic  means  of  diagnosis 
to  delay  acute  operative  work.  If  artificial  and 
physical  signs  cannot  be  early  reconciled,  certainly 
the  physical  means  of  diagnosis  should  be  given  the 
precedent. 

We  are  at  a  loss  to  know  why  it  is  that  in  the 
last  year  or  so,  there  has  been  so  many  disastrous 
attempts  at  conservative  surgery,  in  acute  and  dan- 
gerous lesions  of  the  abdomen.  ,  The  fruitless  at- 
tempts at  conservative  work,  based  upon  a  supposed 
legion,  where  true  pathological  condition  can  only 
be  revealed  by  exploration,  has  been  responsible  for 
numerous  deaths,  great  morbidity,  and  has  reaped 
anything  but  conservatism. 

We  are  not  using  the  knowledge  which  has  been 
acquired  through  thirty  years  of  antiseptic  or  aseptic 
surgery. 

We  are  being  taught  in  the  last  year  of  our  med- 
ical study  that  it  is  dangerous  to  open  the  abdomen 
in  acute  peritonitis  from  most  any  source,  and  even 
ectopic  gestation  fares  well  to  be  placed  on  the 
waiting  list.  Fortunately-  we  have  not  yet  been 
asked  to  wait  in  strangulated  hernia.  If  these  ad- 
vocates of  chronic  surgery  would  only  give  us 
something  tangible  in  the  way  of  signs  or  symptoms 
and  also  a  guarantee  that  the  acute  conditions  will 
become  chronic  before  post  mortem,  we  will  re- 
spect their  opinions  and  wait  for  subsidence  of 
angry  symptoms. 

Just  as  soon  as  the  general  practitioner  will  hold 
the  specialist  responsible  for  deaths  while  he  is  wait- 
ing for  his  walled  off  barriers  to  be  erected,  then 
and  not  until  then,  will  he  be  a  friend  to  you  in 
need.  The  specialist  must  be  whipped  into  the 
traces  or  acknowledge  he  is  picking  his  cases.  The 
selection  of  cases  in  peritonitis  or  ectopic  preg- 
nancy, is  beyond  human  skill. 

My  experience  with  Dr.  Price,  the  most  earnest 
advocate  of  early  and  completed  procedures  in  all 
acute  and  dangerous  conditions  of  the  abdonun. 
permits  me  the  opportunity  to  take  advanced  and 
positive  ground  in  these  conditions.    1  do  not  think 


March  6,  1909.] 


KENNEDY:  CONSERVATISM  IN  ABDOMINAL  SURGERY. 


485 


anything  could  be  more  unfortunate  than  an  attempt 
to  teach  the  profession  delay  in  appendicular  inflam- 
mation, pyosalpinx,  or  ectopic  pregnancy.  Dr. 
Price's  work  is  a  positive  denial  to  all  that  has  been 
recently  advocated  or  taught  in  regards  to  procras- 
tination in  these  rapidly  fatal  conditions.  For 
twenty-five  years  he  has  been  the  most  earnest  dis- 
ciple of  first  hour  operations  and  completed  toilets, 
at  anv  stage  in  peritonitis.  He  has  never  attempted 
to  draw  those  indefinite  lines  which  cannot  be  sub- 
stantiated by  definite  symptoms. 

The  advocates  of  delay  in  all  conditions  where 
there  is  a  marked  element  of  impending  danger 
ha\e  embarrassed  and  confused  the  general  pro- 
fession to  a  degree  which  has  resulted  in  disaster. 
Attempts  to  teach  the  profession  that  there  may  be 
some  late  period  in  an  acute  virulent  condition  in 
which  it  is  safe  to  operate,  at  the  same  time  not 
safeguarding  the  patient  through  the  active  stage, 
is  the  most  wanton  and  contradictory  attempt  for 
conservatism  of  which  we  have  any  knowledge. 
Men  are  not  stimulated  to  early  recognition  of  con- 
ditions when  you  attempt  to  apply  or  teach,  passive 
and  indifferent  surgery.  Can  anything  be  more  in- 
congruous than  an  ice  bag  on  a  perforated  bowel 
or  appendix?  Yet  the  specialist,  who  is  anything 
but  a  first  hour  operator  at  any  stage,  will  often  be 
brought  to  this  very  condition,  even  though  his  di- 
agnostic ability  is  the  most  skilled. 

It  is  not  my  purpose  in  this  paper  to  enter  any 
discussion  on  appendicular  inflammation ;  but  I  be- 
lieve in  the  retroca^cal  type  of  appendicular  inflam- 
mation in  many'cases.  the  first  symptom  the  patient 
has  is  a  perforation  of  a  gangrenous  appendix.  The 
patient  not  having  been  able  in  anv  way  to  recog- 
nize distress  until  perforation  has  taken  place.  This 
is  the  very  condition  in  which  the  advocate  of  delay 
is  apt  to  ask  for  extension  of  time  as  the  condition 
has  practicallv  been  a  painless  one. 

For  a  number  of  years  the  profession  was  well 
united  upon  the  early  operative  treatment  of  ectopic 
gestation,  but  at  present  we  have  a  number  of  advo- 
cates for  conservatism.  Mr.  Tait  was  probably  the 
first  to  call  attention  to  the  fact  that  the  ectopic  tube 
had  probably  been  a  pathological  one  prior  to  the 
ectopic  gestation.  Therefore  the  condition  in  its  in- 
cipiency  would  be  a  demand  for  early  operative 
measures.  There  seems  to  be  much  good  evidence 
that  Mr.  Tait's  idea  of  the  .-etiology  of  the  condition 
was  correct.  W  e  have  in  ectopic  gestation  an  in- 
aptitude to  conception  and  if  previously  confined,  a 
tardy  convalescence :  both  point  strongly  to  some 
pathological  condition  of  the  tube. 

The  general  symptomatology  of  ectopic  gestation 
I  shall  not  discuss ;  but  want  to  call  attention  to  one 
sign  which  has  not  been  brought  forth  conspicuous- 
ly, and  that  is,  a  markedly  sensitive  and  tender 
uterus.  I  have  always  found  this  symptom  present 
and  believe  there  is  no  inflammatory  condition  in 
the  pelvis  in  which  tenderness  of  the  uterus  is  so 
marked.  I  also  want  to  refer  as  a  symptom  of 
ectopic  gestation,  to  the  mental  aberration  of  the 
patient.  Dr.  Price  was  the  first,  to  my  knowledge, 
to  call  attention  to  this  peculiar  mental  condition  of 
the  ectopic  patient. 

When  shall  we  operate  in  ectopic  gestation?  We 


take  the  sarne  position  in  ectopic  gestation  that  we 
have  been  taught  to  take  in  all  the  acute  inflamma- 
tor\-  conditions  of  the  abdomen,  and  that  is,  the  first 
hour  at  any  stage.  We  are  at  a  loss  to  know  just 
why  some  operators  question  the  probability  of  a 
patient's  dying  of  acute  haemorrhage  in  ectopic  ges- 
tation, when  hundreds  have  been  found  post  mor- 
tem. Certainly  any  operator  with  a  considerable 
experience,  has  on  his  arrival,  found  the  patient 
dead  from  haemorrhage. 

It  seems  to  us  par  excellence  there  is  no  condition 
in  surgery  where  the  cause  is  such  a  definite  appeal, 
to  early  operative  measures.  You  may  discuss  the 
probabilities  oi;  possibilities  of  the  formation  of  a 
clot  and  you  can  place  the  nonoperative  mortalit}- 
as  low  as  you  please,  the  fact  remains,  if  there  is 
any  mortality  it  would  have  been  a  positive  indica- 
tion that  the  bleeding  vessel  should  have  been  tied 
at  the  earliest  possible  hour.  Even  if  you  were  posi- 
tive (and  you  never  are)  that  a  clot  had  formed, 
the  potential  tendency  of  that  ruptured  vessel  to 
bleed,  is  a  command  to  open  the  abdomen. 

Dr.  Price  is  fond  of  saying  that  the  inner  third 
of  the  tube  belongs  to  the  coroner,  and  the  outer 
two  thirds  belong  to  him.  In  other  words,  a  rup- 
ture at  inner  third  is  often  fatal  before  surgery  can 
intervene. 

This  may  simply  be  looked  upon  as  a  whip  to  the 
surgeon.  If  any  one  lesson  from  this  great  master 
can  be  more  appreciated  than  many  others,  it  is  the 
peace  of  mind  he  has  given  me  through  his  instruc- 
tion as  to  when  and  how  to  hit. 

The  appeal  for  conservatism  in  this  condition  is 
made  principally  in  those  cases  in  which  haemor- 
rhage has  been  extensive,  and  we  find  the  patient 
blanched,  pulseless,  and  shocked.  The  advocate  of 
delay  in  these  cases  takes  the  ground  that  the  addi- 
tional shock  incident  to  the  operation  is  the  cause  of 
the  high  operative  mortality.  We  have  seen  a  good 
number  of  these  bloodless  patients,  pulseless  at 
wrist  and  in  extreme  shock,  regain  their  pulse  un- 
der the  anaesthetic  and  leave  the  operating  table  in 
much  better  condition  than  before  the  operation. 

It  is  impossible  to  say  from  examination  of  the 
patient  just  how  much  blood  is  in  the  abdomen. 
The  pulseless  patient  does  not  necessarily  mean  she 
has  lost  a  great  quantity  of  blood. 

We  must  bear  in  mind  the  extravasated  blood  is 
a  foreign  body  in  the  abdomen  and  is  often  the 
cause  of  extreme  shock.  We  have  seen  the  reintro- 
duction  of  a  large  umbilical  hernia  acting  as  a  for- 
eign body,  profoundly  shocking  the  patient  and 
often  the  cause  of  death.  Especially  is  this  so  after 
the  hernia  has  been  out  for  a  number  of  years. 
Whether  your  patient  is  pulseless  from  loss  of 
blood  or  in  extreme  shock,  due  to  extravasation  of 
blood,  I  see  no  indication  for  delaw  I  am  con- 
vinced that  ether  carefully  given  is  a  stimulant. 
The  fact  that  I  have  seen  the  pulse  improve  in  these 
conditions,  would  lead  me  to  believe  that  the  anaes- 
thetic as  a  sedative  to  the  receptive  nervous  centres, 
had  counteracted  the  shock  from  trauma,  due  to  in- 
terabdominal  clot. 

An  attempt  to  tide  a  patient  over  from  condition 
of  shock  with  the  aetiological  factor  remaining,  has 
never  appealed  to  me.    It  is  too  much  like  waiting 


486  .  BASCH:   MINERAL  WATERS. 


for  an  indefinite  something  to  happen.  The  vir- 
tues of  surgery  and  its  indications,  are  too  mathe- 
matical in  precision  to  admit  of  any  such  skepti- 
cism. It  is  impossible  to  say  from  symptoms  the 
amount  of  bleeding  that  has  taken  place. 

I  have  seen  the  pulseless  patient  opened  with  very 
little  blood  in  the  abdomen,  yet  the  patient  pro- 
foundly shocked. 

The  removal  of  clot  as  foreign  body  is  certainly 
indicated.  Again  the  patient  may  be  distended  with 
products  of  ectopic  gestation  and  yet  show  little  ex- 
ternal evidence  of  hsemorrhage.  It  is  impossible  to 
say  just  how  nuich  fluid  in  the  abdomen  is  blood  as 
a  part  of  the  supposed  haemorrhage  may  be  serum 
incident  to  irritation  of  the  peritonaeum. 

Operators  argue  that  a  sudden  removal  of  a  large 
quantity  of  accumulated  fluid  in  the  abdomen,  be- 
fore the  other  vessels  have  had  time  to  adapt  them- 
selves to  the  altered  mechanical  conditions,  due  to 
the  release  of  pressure,  may  be  followed  by  sudden 
and  fatal  syncope.  We  would  answer  this  argu- 
ment in  this  way:  If  the  abdomen  is  flushed  by  sa- 
line solution  and  as  much  of  the  solution  as  pos- 
sible is  allowed  to  remain  and  then  a  good  tight 
bandage  applied,  it  would  be  hard  to  see  where  there 
would  be  much  difference  in  pressure  on  the  intra- 
abdominal vessels. 

We  are  at  a  loss  to  know  why  the  mortality  froiu 
twenty  prominent  clinics,  with  two  thousand  ectopic 
gestations,  should  be  eight  per  cent.  During  my  re- 
lation with  Dr.  Price  we  have  operated  for  ectopic 
gestation  on^  hundred  and  sixty-five  times,  with  one 
death.  This  list  includes  eight  suppurative  condi- 
tions. The  case  lost  was  a  suppurating  one,  of  five 
months"  standing.  This  work  has  been  done  during 
the  first  hour  the  patient  has  been  seen  in  every 
case,  irrespective  of  haimorrhage  or  shock. 

Dogmatic  rules  must  be  applied  to  treacherous 
conditions. 

Attempts  at  conservatism  for  incipient  cystic 
conditions  of  the  ovaries  or  unilateral  removal  of 
uterine  appendages  for  infectious  conditions,  cer- 
tainly has  been  anything  but  brilliant.  Some  few 
])atients  have  conceived  after  conservative  work  on 
the  uterine  appendages,  but  if  one  will  review  his 
work  in  those  cases  where  he  has  made  some  at- 
tcmi)t  to  save  ovaries  and  tube,  and  considers  the 
morbidity  of  such  patients,  and  the  very  great  num- 
ber who  return  for  second  or  third  operations,  he 
will  find  ' that  his  effort  has  been  a  miserable 
failure. 

We  feel  one  is  never  justified  in  removing  one 
pus  tube  and  permitting  the  supposed  good  side  to 
remain.  The  primary  source  of  infection  remains, 
the  remaining  tube  and  ovary  are  probably  already 
infected  and  the  patient  will  return  for  a  second  op- 
eration at  an  early  date. 

Seven  patients  in  one  week  reported  at  the  Phil- 
adelphia Dispensary  for  examination.  All  had  had 
within  three  months  operations  for  unilateral  re- 
moval of  tube  ovarian  suppuration.  Each  on  ex- 
amination revealed  tube  ovarian  abscess  of  the  re- 
maining side.  This  is  interesting  from  several 
standpoints.  It  shows  how  quickly  the  remaining 
side  became  involved.  .As  these  i)atients  came  from 
five  of  the  largest  clinics  of  the  city,  it  demon- 


[NeW  ^'ORK 

Medical  Journal. 

strated  that  ojjcrators  in  general  are  doing  unilateral 
work  in  the  midst  of  filth  and  infection. 

One  of  the  strongest  pleas  against  conservatism 
on  the  affected  appendages,  is  the  very  high  primary 
mortality  you  will  get  from  leaving  a  source  of  in- 
fection due  to  your  incomplete  work.  Early  and 
completed  operations  would  be  our  plea  for  all  in- 
fectious and  h?emorrhagic  conditions  of  the  al^- 
domen, 

1409  Spruch  Street. 


INDICATIONS  FOR  THE  DRINKING  OF  MINERAL 
WATERS  IN  GASTR0[NTP:STINAL  DISEASES.* 

By  Seymour  Basch,  M.  D., 
New  York, 

Attending  Physician   to  the  German   Poliklinik,   Department  of 
Gastrointestinal  Diseases. 

Mineral  waters  are  stronger  or  weaker  solutions 
of  salts,  gases,  and  probably,  also,  of  other,  hitherto 
unrecognized,  bodies  in  waters  of  varying  degrees 
of  temperature.  The  salts  present  usually  bear  but 
a  small  proportion  to  the  total  amount  of  water. 

Although  these  waters  are  amongst  our  oldest 
curative  measures,  there  is  much  concerning  their 
physiological  and  therapeutic  actions  that  still  needs 
clearing  up.  Thev  are  very  complicated  bodies,  and 
we  can,  therefore,  understand  the  difficulty  in  deter- 
mining the  really  active  factors.  This  difficulty  is 
enhanced  by  the  number  of  extraneous  elements 
that  are  associated  with  the  taking  of  a  course  of 
waters.  Despite  a  voluminous  literature  bearing 
upon  the  subject,  we  have  in  most  instances,  no  well 
defined  scientific  basis  of  procedure.  Within  recent 
years  von  Xoorden  (i).  Dapper  (2),  Lareche  (3), 
jaworski  (4),  Boas  (5),  Vincent  (6),  I.  Wolff' 
(7),  and  very  many  others  have  sought  to  determinj 
the  direct  local  and  systemic  eft'ects  of  mineral 
waters.  Their  results  thus  far  have  proved  contra- 
dictory, and  until  the  various  researches  have  been 
completed  and  the  conclusions  substantiated,  we 
must  continue  to  base  our  judgment  upon  empirical 
knowledge  in  conjunction  with  what  we  otherwise 
know  of  the  action  of  the  individual  ingredients. 

The  intrinsic  action  of  mineral  waters  is  not  con- 
fined to  their  mineral  substances,  but  is  due  in  part 
to  the  contained  gases  and  to  the  vehicle,  water. 
Chancellor  (8)  would  even  go  so  far  as  to  discard 
the  mmeral  ingredients  as  the  active  therapeutic 
factor,  and  ascribe  the  curative  jjroperties  to  the 
gases,  especially  the  newly  discovered  ones,  argon, 
helium,  xenon,  crypton,  etc.  He  would  "thus  explain 
the  surprising  results  from  world  renowned  indiftVr- 
ent  springs  as  Wildbad.  Cheltenham,  Ai.x  les  P)ains, 
Bcthesda.  lun-eka.  Clarendon,  etc.  Water,  per  si\ 
has  remarkable  pro])erties.  It  is  an  excellent  sol- 
vent, a  diluent,  a  diaphoretic,  and  an  enuretic. 
Taken  cold,  it  is  said  to  contract  the  gastric  vessels 
and  temporarily  and  locally,  at  least,  to  reduce  tem- 
perature. Warm  water  is  more  agreeable  to  the 
stomach,  whose  secretions  it  is  believed  to  stinuilate. 
and  it  also  acts  as  a  cleansing  agent  to  mucous 
membranes.    Taken  in  large  amounts,  water  is  said 

'Road  at  a  nucting  of  the  Ilarlcni  Medical  Association  of  New 
York  City,  held  on  December  2,  1908. 


March  6.  1 909.  | 


BASCH:    MINERAL  WATERS. 


487 


to  excite  the  heart's  action  and  to  temporarily  in- 
crease blood  pressure.  Thus,  it  not  only  assists  in 
the  digestion  of  food,  but  is  also  an  important  factor 
in  the  excretion  of  waste  products  from  the  body. 

The  therapeutic  application  of  mineral  waters  to 
irastrointestinal  diseases  may  be  conveniently  ar- 
ranged into:  (a>  The  drinking  of  waters;  (b)  gas- 
tric lavage:  (c)  their  administration  per  rectum; 
and  (d)  their  hvdriatic  or  external  application. 

These  various  methods  are  often  combined  with 
advantage.  In  the  present  writing  I  shall  confine 
myself  to  the  consideration  of  the  drinking  of  min- 
eral waters. 

In  no  class  of  diseases  has  their  internal  use 
gained  more  reputation  than  in  those  of  the  gastro- 
intestinal tract.  The  waters  may  be  administered 
in  s'ingle  dosage  to  overcome  an  acute  condition 
(e.  g.,  acute  intestinal  catarrh,  short  standing  con- 
stipation, so  called  ""bilious  attacks."  etc.).  or — and 
this  is  the  usual  mode  of  procedure — a  course  of 
waters  or  of  their  commercial  products  (salts,  arti- 
ficial waters,  etc. )  may  be  taken  at  the  spring  itself 
or  elsewhere.  In  all  but  the  severest  cases',  the 
best  results  are  obtained  where  the  waters  are  taken 
at  the  natural  source,  for  here  a  number  of  auxiliary 
factors  come  into  play. 

These  are  the  change  in  climate,  altitude,  and  sur- 
mundings.  outdoor  exercise,  amusements,  freedom 
from  business  routine  and  domestic  cares,  a  constant 
medical  surveillance,  regulation  of  diet  and  of  daily 
habits,  the  avoidance  of  excesses,  the  drinking  of  a 
large  amount  of  water,  and  the  additional  benefits 
derived  from  massage,  baths,  electricity,  etc. 

And  this  lead?  me  to  say  a  few  words  about  our 
native  resorts.  They  are  very  numerous,  can  be 
easily  reached,  and  their  natural  surroundings  are, 
as  a  rule,  idyllic.  \\'hile  a  large  number  of  them 
lack  recent  and  accurate  analyses,  their  waters,  in 
many  instances,  equal  or  excel  those  of  other  coun- 
tries in  potency  and  in  variety  of  mineral  ingredi- 
ents. It  is  unfortunate,  therefore,  that  they  have 
not  been  better  studied  and  are  not  more  scientifical- 
ly regulated.  As  far  as  the  waters  are  concerned, 
there  is  no  reason  whatever  why  the  large  majority 
of  our  patients  should  not  derive  as  much  benefit 
from  their  use  as  from  those  of  noted  European  re- 
sorts. As  matters  now  stand,  there  is  little  doubt 
but  that  the  average  invalid  who  visits  our  springs 
is  almost  as  often  harmed  as  benefited.  This  will 
necessarily  continue  until  existing  abuses  shall  have 
been  corrected.  If  we  would  make  the  most  of  our 
native  resorts.  ( and  it  is  a  business  as  well  as  a  sci- 
entific proposition),  then  we  must  first  of  all  have 
accurate  and  frequent  analvses  of  our  springs." 
Those  in  authority  at  the  resorts  should  provide 
facilities  for  the  proper  taking  of  the  waters  such  as 
exist  at  every  well  regulated  watering  place  abroad. 
These  include  specially  trained  physicians,  correct 
dietary  regulations  at  the  hotels,  quiet  but  pleasant 
recreation  for  the  patients,  sanatoria,  institutions 

'.'^evere  cases  require  bed  rest,  careful  nursing,  and  special!}'  in- 
dividualized methods  of  treatment.  They  are  best  cared  for,  there- 
for, at  home  or  in  sanatoria. 

-Crook  (Journal  of  rhc  American  Medical  Associaticn .  ilarch  14. 
100?)  discusses  the  inaccuracies  in  the  published  analyses  of  the 
An  erican  mineral  waters,  and  calls  attention  to  the  United  States 
Department  of  Agriculture's  recent  investigations  in  connection  with 
foity-two  of  our  prominent  springs. 


for  hydrotherapy  and  mechanicotherapy,  etc.  There 
should  also  be  a  cooperation  between  the  family 
physician  and  the  practitioner  at  the  springs.  W  ith 
the  installation  of  these  arrangements  will  follow 
the  education  of  the  general  public. 

Many  of  the  advantages  offered  by  a  course  of 
waters  at  the  springs  are  lacking  when  these  waters 
are  partaken  of  at  home.  It  is  difficult  for  a  patient 
at  home  to  break  away  from  his  routine  life,  and 
he  is  usually  surrounded  by  sympathetic  persons ; 
being  an  invalid  he  is  generally  spoiled,  and  too 
often  he  finds  the  temptation  for  dietary  and  other 
refractions  irresistible.  A  course  of  waters  at  home 
is.  therefore,  generally  improperly  carried  out,  and 
may  or  may  not  have  the  desired  results.  If  prop- 
erly carried  out,  the  same  beneficial  results  should 
obtain  as  when  taken  at  the  spring.  In  those  cases 
w  hich  have  had  initial  treatment  at  the  latter  place, 
the  course  at  home  is  most  apt  to  do  good. 

As  regards  evaporated  salts  and  artificial  com- 
binations of  mineral  ingredients,  they  may  have  the 
chief  action  of  the  original  waters  (laxative,  mucus 
solvents,  etc.),  but  cannot  compare  with  these  in 
general  usefulness.  For  while  these  artificial  prod- 
ucts are  in  the  main  correct,  they  take  no  account 
of  the  substances  present  iti  small  amounts,  wliich 
may  have  a  more  important  physiological  action 
than  we  generally  concede  to  them. 

Certain  contraindications  to  the  use  of  the  vari- 
ous classes  of  springs  in  gastrointestinal  troubles 
have  been  well  recognized  and  agreed  upon.  As  a 
fundamental  principle — indeed,  the  most  important 
rule  of  all — no  systematic  mineral  water  treatment 
in  gastrointestinal  disease  should  be  recommended 
until  a  diagnosis  or  at  least  careful  examinations, 
including  a  thorough  chemical  analysis  of  the  stom- 
ach contents,  and,  in  many  cases,  the  freces,  too, 
shall  have  been  made.  The  neglect  of  this  precau- 
tion can  lead  and  has  led  to  errors  in  therapy  with 
serious  consequences  to  both  patient  and  physician. 

The  following  named  conditions  of  the  gastroin- 
testinal .system  positively  interdict  the  drinking  of 
any  mineral  waters : 

I.  Gastric  motor  insufficiency  of  any  grade,  and 
from  an\-  cause  whatever.  It  is  well  known  that  n-) 
appreciable  amount  of  water  is  absorbed  from  the 
stomach,  and  that  saline  solutions  cause  a  transu- 
dation into  the  lumina  of  hollow  viscera ;  hence  the 
insufficiency  can  only  be  aggravated.  In  these  con- 
ditions there  is  the  further  danger  of  increased  dis- 
tension from  the  large  amount  of  free  carbonic  acid 
gas  usually  present  in  the  waters.  In  all  nonacute 
conditions  of  this  kind  gastric  lavage  with  a  mineral 
water  properly  adapted  to  the  chemistry  of  the 
stomach,  has  been  found  to  be  very  useful. 

II.  The  existence  or  the  probability  of  a  malig- 
nant growth. 

III.  Acute  hfemorrhagic  conditions. 
W .    Gastrointestinal  tuberculosis. 

\".  Intestinal  obstruction.  A  possible  exception 
in  this  instance  may  be  found  in  obstructions  due  to 
impacted  faeces. 

Y\.  In  acute  gastritis  they  are  apt  to  do  more 
harm  than  good. 

In  the  further  discussion  of  the  therapeutic  uses 


488 


BASCH:    MINERAL  WATERS. 


[New  York 
Medical  Journal. 


of  mineral  waters  I  shdll  make  no  reference  to  these 
conditions. 

The  waters  employed  in  gastrointestinal  diseases 
are  best  classified  according  to  their  most  prominent 
mineral  or  gaseous  constitutents.  This  is  some- 
times termed  the  "German  classification."  Where 
there  is  more  than  one  prominent  ingredient,  a  com- 
posite name  is  employed'.   Thus  arranged,  we  have : 

1.  Muriatcd  zvaters;  most  prominent  ingredient, 
sodium  chloride. 

2.  The  alkaline  zvaters,  subclassified  into : 

a.  Simple  alkaline  or  alkaline  carbonated ; 
most  prominent  ingredients,  sodium  bicar- 
bonate and  carbonic  acid  gas. 

b.  Alkaline  —  muriated  —  carbonated  ;  most 
prominent  ingredients,  sodium  bicarbonate 
and  chloride,  and  carbonic  acid  gas. 

3.  The  sulphated  ivaters,  consisting  of: 

a.  Sodium  sulphate,  or  alkaline  sulphate,  or 
Glauber  salt  waters,  and 

b.  INIagnesium  sulphate  or  the  "bitter  waters." 
Both  groups  of  this  class  of  waters  also  contain 

sodium  chloride  and  alkaline  carbonates  in 
active  amounts. 

4.  Calcareous  or  earthy  zvaters ;  most  prominent 
ingredients,  calcium  and  magnesium  carbonates  and 
sulphates. 

5.  Chalybeate  or  iron  zvaters;  most  prominent 
ingredients,  the  sulphates  and  carbonates  of  iron. 
With  this  class  are  often  associated  the  aluminous 
waters  as  well  as  those  containing  free  sulphuric 
acid. 

6.  Sulphureted  zvaters;  most  prominent  ingre- 
dient, sulphureted  hydrogen. 

7.  Acidulous  or  carbonated  zvaters,  which  con- 
tain a  large  amount  of  free  carbonic  acid  gas  and 
but  few  mineral  salts. 

I.  Muriated  waters.  Sodium  chloride  is  a  most 
important  constituent  of  the  body.  Of  late  the  ex- 
act local  and  systemic  action  has  been  much  dis- 
puted. Those  interested  will  find  detailed  discus- 
sions in  Dapper's  monograph  (9)  and  Wegele's  text- 
book (10).  The  generally  accepted  view  is  that  it 
stimulates  glandular  secretions,  causes  thirst  and 
improved  appetite,  increases  the  elimination  of  urea 
and  other  nitrogenous  products,  promotes  absorp- 
tion, causes  a  transudation  into  the  lumen  of  the 
digestive  organs,  and  dissolves  mucus.  In  large 
doses  it  has  a  laxative  action,  and  its  long  continued 
use  in  large  dosage  causes  loss  of  flesh.''  Small 
amounts  ( i  to  2  grammes)  have  been  found  to  ex- 
cite, and  large  amounts  (5  grammes  or  more)  to 
depress  gastric  secretion  and  digestion.  According 
to  Penzoldt  (11),  the  muriated  waters  are  unfit  for 
drinking  purposes  if  they  contain  more  than  fifteen 
grammes  of  sodium  chloride  to  the  litre. 

Among  the  most  prominent  muriated  drinking 
springs  are  Homburg  (Elizabethbrunnen).  Wies- 
baden (Kochhrunnen),  Kissingen  (Rakoczy), 
Nauheim  (Kurbrunnen).  Pyrmont  (Trinkquelle), 
Soden    (Milchbrunnen),    Asqui,    Bourbonne  les 

•Although  cla>isificd  according  to  their  prepondering  soluble  in- 
gredients, other  substances  are  frequently  present  in  sufficient 
amount  to  produce  definite  effects.  This  fact  must  always  be  given 
careful  consideration  in  prescribing  mineral  waters  for  any  patient. 

*Thus.  I  may  instance  a  patient  with  gastric  catarrh  to  whom  was 
prescribed  a  salted  dietary  regime  and  muriatcd  waters.  In  spite 
of  the  ingestion  of  large  amounts  of  nutritious  food  he  steadily  lost 
five  pounds  a  week. 


Bains,  and  Cestona.  abroad ;  and  Ballston  Spa 
(United  States  and  Sans  Souci  Springs),  Glen 
Springs  (Salubria  and  Deer  Lick  Springs),  She- 
boygan, and  some  of  the  Saratoga  waters,  especially 
the  Hathorn  and  Eureka,  in  this  country.  Less  gen- 
erally known  but  in  excellent  local  repute  are  the 
Louisville  Artesian  W'ell,  Ky. ;  Lodi  Artesian  Well, 
Ind. ;  Coronado  Springs,  Gal. ;  the  Sweet  Springs 
of  Missouri ;  the  Wasatko  Mineral  Springs  of  Utah  ; 
and  the  Caledonia  and  St.  Catharine  Springs  in  On- 
tario (Can.)'. 

From  what  has  been  said  regarding  the  action  of 
these  waters  we  can  understand  their  employment 
in  subacute  and  chronic  gastritis  w^ith  diminished  hy- 
drochloric acid,  in  gastric  achylia  of  nervous  origin, 
in  chronic  intestinal  catarrh  with  constipation,  in 
biliary  catarrh,  in  intestinal  atony  with  constipation, 
and  in  conditions,  in  general,  in  which  glandular 
stimulation  is  desirable,  as  well  as  their  contraindi- 
cation when  there  is  marked  loss  in  weight, 
and  in  affections  of  the  stomach  accompanied  by 
increased  acidity",  such  as  hyperchlorhydria,  ulcer, 
etc.,  and  in  those  of  the  intestines  accompanied  by 
diarrhoea  and  ulceration. 

2.  The  second  class  of  waters,  which  I  have  men- 
tioned, are  the  important  alkaline  waters.  Their 
characteristic  action  is  due  to  sodium  bicarbonate 
and  free  carbonic  acid.  Some  of  these  waters  con- 
tain also  sodium  chloride  in  varying  amounts.  The 
alkalies  and  their  carbonates  antagonize  acidity  and 
impede  normal  digestion.  Their  mucus  solvent  and 
bile  stimulating  properties  are  disputed  by  some  au- 
thorities. They  are  slightly  diuretic,  and  in  large 
doses,  laxative.  The  systemic  action  of  carbonic 
acid  is  still  in  doubt.  It  is  the  most  prominent  gase- 
ous ingredient  of  mineral  waters.  It  renders  water 
palatable  by  imparting  the  "sparkle"  and  a  slightly 
acidulous  taste ;  it  increases  the  appetite  ;  by  causing 
eructations  it  assists  in  expelling  any  gases  formed 
during  digestion,  and  in  overcoming  flatulence ;  it 
allays  nausea  and  thirst,  and  is  said  to  increase  gas- 
tric secretion  (12)  and  intestinal  peristalsis.  It 
combines  with  the  carbonates  to  form  the  bicarbon- 
ates  and  to  render  the  urine  less  acid.  I  would 
warn  against  the  rapid  and  excessive  drinking  of 
any  carbonated  waters  especially  in  persons  with 
cardiac  and  gastric  weaknesses.  Instances  are  not 
wanting  in  w'hich  such  indiscretions  have  been  fol- 
lowed by  serious  results. 

a.  The  simple  alkaline  waters  are  of  value  in  ex- 
cessive gastric  acidity,  in  mild  forms  of  chronic  gas- 
tric and  intestinal  catarrh,  and  in  moderately  severe 
constipation.  They  are  also  much  used  in  catarrhal 
jaundice.  They  are  contraindicated  in  conditions  of 
diminished  acidity  without  catarrh  and  in  diarrhoea 
except  that  associated  with  catarrhs  of  the  small  in- 
testines.    Owing  to  the  increased  soothing  effect, 

''The  analyses  of  the  foreign  springs  mentioned  in  the  present 
writing  are  given  in  the  Badcyoliiiaiiaclt .  published  by  Rudolnh 
Mo&sc,  of  Berlin,  and  those  of  the  domestic  in  Crook's  Mineral 
Waters  of  the  United  States,  and  (a  few)  in  Bulletin  gi.  Bureau  of 
Chemistry  of  the  United  States  Department  of  Agriculture,  issued 
in  1907. 

"In  many  patients  to  whom  he  gave  Kissingen  (Rakozcy)  or  Hom- 
burg (Elizabethbrunnen).  Dapper  (9)  noted  increased  acidity  in 
subacid  cases  and  diminished  in  superacid  (nervous)  cases.  lie 
explains  this  apparent  paradox  by  regarding  acidity  as  but  one  of 
many  factors  to  be  reckoned  with,  and  by  assuming  that  while  the 
role  played  by  the  mineral  waters  is  a  very  important  one,  much 
credit  must  be  given  to  the  individualized  (ovcrfatty)  diet,  the 
sanatorium  care,  and  the  special  therapeutics  employed. 


March  6.  igcg.] 


BASCH:    MIXERAL  HATERS. 


489 


the  thermal  waters  of  this  class  are  especially  indi- 
cated in  irritable  gastrointestinal  conditions. 

The  most  prominent  thermal  waters  of  this  class 
are :  \'ichy  and  La  Malon  in  France,  and  Xeuen- 
ahr  in  Germany.  In  the  United  States  they  appear 
10  be  mainh"  in  California.  Best  known  are  the 
Ukiah  Mchy.  Skagg's  Hot  Springs,  and  Excelsior 
(Howard)  Spring  of  California;  and  Canyon  City 
(Hot  Springs)  of  Colorado. 

Among  the  cold,  simple  alkaline  waters  we  have : 
\"als  in  France.  Fachingen,  Preblau,  and  Salzbrunn 
in  Germany,  and  Bilin  and  Giesshiibl  in  Bohemia. 
Of  the  domestic,  there  are  Bladon,  Ala. ;  Waukesha, 
Wis.;  Adams,  Aetna  Soda,  and  Seltzers  in  Califor- 
nia. 

b.  Some  of  the  alkaline  muriated  waters  contain 
a  considerable  quantity  of  sodium  chloride.  Their 
action  and  value  are  very  similar  to  the  simple  muri- 
ated waters  just  spoken  of.  If  the  alkalies  predom- 
inate, they  are  useful  as  mild  alkaline  waters.  These 
alkaline  muriated  waters  must  not  be  drunk  ad 
libitum,  as  the  amount  of  chlorides  they  contain  may 
further  weaken  debilitated  patients.  The  best 
known  foreign  waters  of  this  type  are,  ther}iial: 
Ems  ( Fiirstenbrunnen) .  Xeuenahr  (Augusta- 
quelle)  in  Germany,  and  Royat  and  Mont  Dore  in 
France  ;  cold:  Tonnistein,Gleichenberg  (Constantin- 
quelle) ,  Selters.and  Luhatschovitz  (\'incentzquelle) . 
In  the  United  States  we  have,  thermal:  Las  Vegas 
and  Ojo  Caliente,  in  Xew  jMexico,  Aguas,  Cal. ; 
and  the  Fountain  Ge^^ser  of  Yellowstone  National 
Park.  The  waters  of  these  domestic  springs  are 
used  mostly  for  bathing  purposes.  Cold  springs 
within  the  United  States  include  the  Manitou,  Col. ; 
Dixie.  Tenn. ;  Cressen  Magnesia,  Pa. :  Medical 
Lake.  Wash. :  Tolenas,  Litton  Seltzers,  Azule,  and 
Pacific  Congress  of  Cal. ;  Arrington  (spring  No.  i), 
Kas. ;  St.  Clair  and  Plymouth  Rock,  of  Michigan ; 
and  the  celebrated  Saratoga  Springs,  of  New 
York^ 

3.  Of  the  sulphated  waters  the  more  important 
group  is  that  of  the  Glauber's  salt  waters.  Admin- 
istered warm  or  hot,  they  at  first  increase,  but  later 
diminish  intestinal  peristalsis.  According  to  Ja- 
worski  (4) ,  very  small  quantities  of  the  hot  waters 
or  their  salts  stimulate,  and  large  amounts  diminish 
or  even  cause  a  total  cessation  of  the  gastric  juice. 
The  cold  waters  have  a  decided  purgative  action. 
These  waters  also  stimulate  biliary  secretion  and  ex- 
cite gastric  and  duodenal  peristalsis.  The  second- 
ary effects  are  seen  in  the  improvement  of  the  appe- 
tite and  of  the  general  metabolic  interchange.  Their 
continued  use  causes  a  diminution  in  body  weight. 

These  zcaters  contain  no  magnesium  sulphate. 
The  type  of  the  thermal  class  is  Carlsbad.  The  wa- 
ters of  its  numerous  springs  differ  mainly  in  tem- 
perature and  but  very  little  in  composition  ;  the  hot- 
ter waters  are  the  more  active.  A  milder  thermal 
water  of  the  same  type  as  Carlsbad  is  Bertrich.  In 
this  country  there  are  a  number  of  these  springs ; 
to  mention  a  few,  we  have  the  Arrow  Head,  San 

■I  include  the  Saratoga  waters  in  this  group  because,  in  addi- 
tion to  the  preponderance  of  sodium  chloride,  they  also  contain 
varying  amounts  of  alkaline  carbonates.  In  all,  there  are  over 
thirty  individual  springs  whose  sodium  chloride,  according  to  Ciook 
Ofineral  Waters  of  the  United  States)  varies  in  amount  from  1.S6 
gramme  per  litre  (Flat  Rock)  to  12.04  grammes  (Champion  Spout- 
ing). 


Bernardino,  and  the  Great  Paraiso  Hot  Springs  of 
California :  the  Pagosa.  ^liddle  Park,  and  most  of 
the  Hot  Sulphur  Springs  of  Colorado ;  Walley's 
Hot  Springs  and  Gibson's  Mineral  Wells,  Texas  ; 
the  Hot  Springs  of  Idaho ;  and  the  Ferris  Hot 
Springs  of  Montana. 

They  are  of  value  in  gastric  affections  accom- 
panied by  superacidity  and  not  of  nervous  origin 
(e.  g.,  in  chronic  ulcers  without  acute  symptoms,  in 
gastritis  acida  with  abnormal  secretion  of  mucus,  in 
gastrointestinal  conditions  secondary  to  affections  of 
the  liver,  and  in  constipation  of  short  duration)  ; 
also  in  gastritis  with  sliglitly  diminished  acidity,  in 
chronic  duodenal  ulcer  with  overacidity,  in  chronic 
dysentery,  and  in  subacute  and  chronic  catarrhs  of 
the  large  and  small  intestines  associated  zcith  diar- 
rhcca. 

They  are  contraindicated  in  any  condition  in 
which  there  is  a  total  absence  of  hydrochloric  acid, 
in  obstinate  chronic  cnnstihation,  in  all  forms  of 
nervous  gastrointestinal  affections,  and  in  debilitated 
conditions. 

The  cold  waters  include  Marienbad,  Tarasp, 
Franzensbad,Elster,and  Rohitsch  abroad,  and  Lower 
and  L'pper  Aquas  de  A'ida,  Cal. ;  Lineville  ^Mineral 
Springs,  la. ;  the  Porter  and  Rocky  Mountains 
Springs,  Col.,  etc.,  in  the  United  States.  They  are 
employed  in  catarrhs  ivitli  constipation,  in  intestinal 
atony,  in  hjemorrhoids,  and  in  abdominal  plethora. 

The  magnesium  sulphate  waters,  taken  hot  or 
cold,  act  as  a  purge.  They  are  said  to  cause  a 
transudation  of  fluid  into  the  intestinal  lumen.  In 
large  amounts  they  act  as  cellular  poisons  and  as 
irritants  to  the  mucous  membranes,  and  thus  may 
aggravate  an  already  existing  catarrh.  .  They  are 
depletents  of  the  abdom.inal  viscera,  and  are  suit- 
able for  single  dosage.  Only  the  very  mildest,  such 
as  the  Bedford  Springs.  Pa.,  are  to  be  recommended 
for  a  course  of  treatment.  They  can  only  relieve 
and  not  cure  a  chronic  constipation. 

Contraindications  :  Any  condition  in  which  an  irri- 
tant purge  is  harmful  is  a  contraindication ;  this  ap- 
plies especially  to  ulcers,  acute  inflammations  in  or 
about  the  stomach  and  bowel,  hsemorrhage,  and  ag- 
gravated catarrhal  conditions. 

yiost  foreign  bitter  waters  come  from  Hungai  y 
and  Bohemia;  they  include  Hunyadi,  Franz  Joseph- 
squelle,  Friedrichschalle,  Piilna.  and  Apenta.  Do- 
mestic waters  are  Crab  Orchard,  Harrodsburg,  and 
Estill  of  Kentuck}-;  Bedford  of  Pennsylvania;  the 
B.  B.  Mineral  Springs  of  "Missouri;  American 
Carlsbad,  of  Illinois;  Soda  and  Alleghany,  of  Vir- 
ginia ;  Mountvale,  of  Tennessee ;  Catoosa  of 
Georgia  ;.Gypsium  and  :Mineral  Park  Bitter  of  Ari- 
zona ;  Greenbrier  of  \\'est  \'irginia  ;  and  Seigler's  of 
California.  The  following  waters  of  this  group  are 
charged  with  sulphureted  hvdrogen :  French  Lick, 
Ind.;  Avon  and  Sharon,  N.  Y. ;  Salt  Sulphur,  W. 
Va. ;  and  Indian.  Ga. 

^^'aters  that  contain  calcium  and  magnesium  car- 
bonates, or  the  chalybeate  and  the  aluminum  salts,, 
as  well  as  those  with  free  sulphuric  acid,  tend  to  re- 
tard peristalsis  and  to  check  secretions.  In  addi- 
tion, i't  is  asserted  that  the  iron  waters  have  the  tonic 
virtues  of  that  drug. 

Well  known  foreign  calcareous  waters  are  Wil- 


490 


BASCH:    MINERAL  WATERS. 


I  New  York 
Medical  Journai.. 


(lungen.  Ra]:)]:)ol(ls\veiler,  Rcinerg-.  Cobursx,  Driburg. 
Lippspring^e,  and  Contrexeville.  In  the  United 
State?  they  are  very  numerous ;  to  mention  some, 
we  have  I'allston  Spa  (Sans  Souci)  ;  all  of  the  Sar- 
atoga Springs  and  Geneva  Lithia,  X.  Y . ;  Old  Sweet 
Springs.  W.  \'a. ;  Glenn.  S.  C.  ;  Soda  (Virginia  Hot 
Springs),  Tolenas,  Bartlett,  and  California  Seltzers, 
Cal. ;  Sweet  Springs.  INTontesano.  and  Akesion,  of 
Missouri:  Upper  and  Lower  Blue  Lick.  Ky. ;  Indian 
and  Kickapoo.  Lid. :  Sheboygan  and  Leslie,  and 
Michigan  Congress  of  Michigan  ;  W'aconda,  Tenn.. 
etc.  All  these  springs  also  contain  considerable 
amounts  of  magnesium  carbonate. 

These  waters  are  useful  in  checking  diarrhoeas, 
make  excellent  table  waters,  and  are  also  largely  em- 

1)  loyed  in  genitourinary  affections,  especially  those 
associated  with  catarrhal  and  gouty  and  lithjemic 
conditions. 

Foreign  carbonated  chal_\beates  of  repute  are 
Elster.  Pyrmont,  Franzensbad,  Cudowa,  Driburg, 
Reinerz,  and  Schwalbach ;  sulphated,  Brighton 
(Eng.),  Levico,  Ronccgno.  and  Guber.  There  are 
many  good  iron  springs  in  the  United  States.  Some 
of  the  carbonated  are  the  Columbia,  Eureka,  Hamil- 
ton, Putnam,  and  Excelsior,  of  .Saratoga;  Chitte- 
uango  Sulphur  and  Ballston  Spa,  all  of  Xew  York  ; 
Owas.sa,  Mich.;  Sparta  iNLneral  Wells,  Wis.:  Pa- 
cific Congress  and  Mono  Lake  of  California:  Fruit 
Port  Wells,  Mich. :  Wilhot's  Soda,  Ore. :  and  the 
Iowa  Sulphur  Springs  Examples  of  the  sulphated 
iron  waters  are  Oak  Orchard  Acid  Springs  (No. 

2)  .  X.  Y. :  Bath  Alum  (Xo.  2)  and  Iron  Lithia  and 
Bedford  .\luin  of  \'a. ;  .Austin's,  Tenn. ;  Intlian 
Springs,  Ind. ;  Matchless  3ilineral  Wells,  Ala.; 
Overall  ^Mineral  .Springs  and  the  Texas  Suur 
Springs  of  Texas ;  Wilbur's,  Cal. ;  etc.  A  number 
of  this  group  of  waters  contain  also  free  sulphuric 
acid  in  varving  amounts. 

The  iron  waters  are  emi)loyed  in  an;emic  condi- 
tions associated  with  gastric  and  intestinal  ulcers, 
dysentery,  and  chronic  diarrhoea. 

We  know  very  little  definitely  of  the  systemic  ac- 
tion of  sulphuretted  hydrogen.  It  is  said  to  stimu- 
I.ite  the  intestinal  glands,  augmenting  secretion,  and 
l)roducing  laxative  effects. 

The  hot  spring;s  contain  less  of  this  gas  than  the 
cold.  Xoted  European  springs  are  Leuk,  Naun- 
dorf,  Stachelberg,  Aix-la-Chapclle,  Challis,  and 
1  larrowsgate.  In  the  United  States  we  have  ver\ 
many  well  known  waters,  e.  g.,  Avon.  Sharon,  and 
Richfield,  in  'New  York;  Lower  Blue  Lick,  Ky. ; 
Green  Brier  and  Salt  Sulphur,  W.  \'a. :  Suwanee, 
Fla. ;  Blount,  Ala.;  French  Lick  (Proserpine),  Ind.. 
etc. 

Ewald  states  he  has  noted  ver\-  satisfactory  re- 
sults with  these  waters  in  abdominal  ])lcthora,  mu- 
cous discharges  from  the  bowel,  and  in  hepatic  af- 
fections. 

Owing  to  their  astringent  action,  waters  rich  in 
aluminum  salts  are  very  useful  in  conditions  asso- 
ciatcfl  with  excessive  intestinal  di.scharges.  W  ell 
known  di)mcstic  waters  of  this  tyi)e  are  liedford, 
I^ockbridge.  and  I'ulaski  .Mum  Springs,  of  \'ir- 
•■inia;  Ironclale  of  West  X'irginia  ;  Cooi)er's  Mineral 
"\\'ells.  Miss.;  and  tlie  Alum  Rock  Springs  of  Cali- 
fornia. 


Of  the  acidulous  or  carbonated  waters  I  need  only 
say  that  they  contain  large  amounts  of  carbonic  acid 
gas  and  few  or  no  salts ;  that  they  have  the  proper- 
ties of  carbonic  acid  gas,  already  stated,  and  that 
they  find  their  greatest  usage  as  table  waters.  A 
few  popular  ones  are  Apollinaris,  White  Rock,  Per- 
rier,  Rhens,  Selters,  Giesshiibl,  Waukesha,  Baden 
and  the  Sweet  Springs  of  West  X'irginia.  The 
question  of  the  advisability  or  not  of  drinking  wa- 
ters at  meals  is  one  that  cannot  here  be  entered  into, 
as  it  is  too  involved.  The  custom  is,  however,  well 
established  and  the  above  mentioned  waters  are 
those  mostly  indulged  in. 

In  this  survey  of  the  subject  I  have  endeavored 
to  point  out  the  most  important  therapeutic  proper- 
ties and  indications  for  the  use  of  some  classes  of 
mineral  waters.  It  will  be  noted  that  much  in  re- 
gard to  the  action  of  these  waters  is  purely  deduc- 
tive, or  at  least  empirical.  Further  scientific  studies 
are  very  much  needed.  The  gastrointestinal  af- 
fections mostly  benefited  are  chronic  catarrhal  and 
ulcerative  conditions,  diarrhoea,  haemorrhoids,  and 
chronic  habitual  and  atonic  as  well  as  acute  consti- 
pation. In  general,  the  more  severe  or  longer  the 
duration  of  the  affection,  the  I'ess  likelihood  is  there 
of  its  cure  through  mineral  waters.  This  rule  ap- 
plies not  only  to  hydrotherapy,  but  to  all  therapy.  L 
is  stated  that  the  severer  forms  are  never  benefited 
by  the  use  of  mineral  waters,  and  in  the  case  of  the 
milder  forms,  the  rest,  diet,  and  other  associated 
factors  are  the  real  curative  agents. 

This  contention  may  apply  to  the  indifferent  wa- 
ters, but  scarcely  to  the  more  active  ones  as  Carls- 
bad, Marienbad,  Kissingen,  X'icliy,  Saratoga,  Bed- 
ford Alum,  etc.  Xaturally,  other  therapeutic  pre- 
cautions must  be  always  observed.  However,  cen- 
turies of  experience — and  this  after  all  is  our  best 
teacher- — have  demonstrated  that  innumerable  cases 
of  gastrointestinal  diseases  resisting  all  other  forms 
of  treatment,  have  not  onl\-  been  temporarily  bene- 
fited, but  permanently  relieved  by  a  course  of  min- 
eral waters. 

BiP.LIOGR.M'HV. 

1.  v.  Noorden.  I'cber  dcu  EinAuss  dcr  sclmjachcn 
Koclisahquellcn  aiif  den  Stoif-wcchscl  dcs  Mciischcn. 
I'^rankfort  on  the  Main,  1894. 

2.  Dapper,  Carl.  Berliner  klinischc  Wochcnschrift. 
1899,  No.  .^9:  V vrhandlnu'^cn  dcs  Congresses  fi'tr  innerc 
Mediein.  i8gg. 

3.  Lareclie.    Rei'ue  dc  la  Suisse  romande.  1884,  No.  10. 

4.  Jaworski.  Deutsehcs  Arehiv  fiir  klinischc  Mediein. . 
xxxvii ;  ll'iener  inedicinisclic  IVochcnschrift,  1896,  No.  6. 

5.  Boas,  I.  Deutsche  mcdisinisclie  IVoehenschrifl.  1905, 
No.  20. 

6.  Vincent.    Soeictc  dc  biologic  (Paris),  1904.  Jan.  9. 

7.  Wolf.  I.    Zeitschriff  fiir  kliiiisclie  Mediziii.-  xvi. 

8.  Chancellor.    American  Medicine.  September  6.  1902. 

9.  Dapper,  C.  Sanimlung  kiinischcr  Abhandhtuficn 
iihcr  Pathologic  und  Therafie  dcr  StotfwechscI-  und  Er- 
ndhningsstorungen.    Heft  5.    Berlin,  1904. 

10.  Wegelc,  C.    Die  Therapie  dcr  Magen-  und  Darin 
krankhcilen.    Tliird  Edition.    Jena,  1905. 

1 1.  Penzoldl.    Handbueli  dcr  Therapie  inncrer  Krank- 
hcilen.   Third  edition.    IV,  p.  274. 

12.  Jaworski.    Zcitsehrifl  fiir  Biologic.    XX.  p.  232. 

14  Iv\ST  .SiXTIF.TII  SlRKF.T. 


March  (>,  1909.I 


UUK  REAU^.l<S^  DISCUSSIUXS. 


491 


(8ttr  gfaJjers'  iistussions. 

A  SERIES  OF  PRIZE  ESSAYS. 

Questions   for   discussion   in   this   department   are  an 
uounced  at  frequent   intervals.    So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follon's: 

LXXXIII. — How  do  you  treat  acute  dysentery?  {Closed 
Februarx  ij,  1909.) 

LXXXIV. — How  do  you  use  alcohol  therapeutically? 
(Anszvers  due  not  later  than  March  15,  1909.) 

LXXXV. — Apart  from  an  operation,  how  do  you  treat 
disease  of  the  vermiform  appendix?  (Answers  due  not 
later  than  April  15,  1909-) 

iVhoevcr  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  hts  advisers  zvill  re- 
ceive a  prize  of  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  required)  that  the  anszvers  be  short;  if  practica- 
ble no  one  ans-wer  to  contain  more  than  si.v  hundred 
words. 

All  persons  will  be  entitled  to  compete  for  the  prize, 
'whether  subscribers  or  not.  This  prize  will  not  be  awarded 
to  any  one  person  more  than  once  within  one  year.  Every 
anszver  must  be  accompanied  by  the  writer's  full  name  and 
address,  both  of  which  ive  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal. 
Our  readers  are  asked  to  suggest  topics  for  discussion. 

The  prize  of  $.25  for  the  best  essay  submitted  in  answer 
to  question  LXXXII  has  been  awarded  to  Dr.  J.  Lytle 
Moore,  of  Tolcd<\  O..  whose  article  appeared  on  page  439. 

PRIZE  QUESTION  LXXXII. 

THE  TREATMENT  OF  CHRONIC  LEAD  POISON- 
ING. 

{Concluded  from  f^a!:;c  f4^.) 

Dr.  Enr^eiic  W.  Loinax,  of  Blucficld,  W.  Fa.,  rc- 
iiiarJcs: 

The  effects  of  the  slow  absorption  of  lead  are 
chiefly  manifest  in  the  muscles,  peripheral  nerves, 
liver,  and  kidneys,  although  it  luay  be  evident  in 
other  organs,  chiefly  the  brain,  and  often  acts  as 
an  aetiological  factor  in  various  disorders. 

The  chief  points  to  be  considered  in  the  treatment 
of  chronic  lead  poisoning  are  the  removal  of  the 
cause,  the  elimination  of  the  poison,  the  elimination 
of  the  toxic  products  resulting  from  the  impairment 
of  function  of  the  various  organs  and  tissues,  tlie 
restoration  of  function  of  the  damaged  organs,  and 
treatment  of  the  various  lesions  and  tissue  changes 
resulting  from  the  presence  of  the  poison. 

The  principal  portals  of  elimination  are  the  kid- 
neys, intestines,  liver,  salivary  and  mammary  glands, 
and  glands  of  the  skin. 

The  general  treatment  includes  elimination  of  the 
])oison,  relief  of  the  pain  and  spasm,  the  restoration 
of  functions  of  the  damaged  organs,  treatment  of 
the  paralysis  and  cachexia,  and  supervision  of  the 
diet  and  general  hvgiene.  The  various  neuroses  and 
other  remote  etYects  of  the  irritant  may  require  spe- 
cial treatment. 

Magnesiimi  sulphate  is  effective  both  as  a  chem- 
ical antidote  and  intestinal  eliminant,  while  it  fre- 
quently relieves  the  attendant  colic.  Potassium 
iodide  in  doses  of  ten  to  twenty  grains,  well  diluted, 
three  times  a  day,  is  a  useful  drug,  and  in  nervous 
subjects  may  be  combined  with  potassium  bromide. 
For  relief  of  the  severe  abdominal  pains  enforce  ab- 
solute rest,  apply  hot  water  bags  to  the  abdomen, 
and  if  necessary  give  atropine,  gr.  1/60  to  gr.  i/i50- 
hypocfermically.  If  unrelieved  combine  with  mor- 
phine in  such  doses  as  the  condition  may  require. 


It  is  necessary  to  keep  the  secretions  and  excre- 
tions open,  hence  avoid  both  as  far  as  circumstances 
will  permit.  Basham's  mixture  in  tablespoonful 
doses  four  times  daily  will  tend  to  restore  the  im- 
paired function  of  the  kidneys  and  relieve  the  at- 
tendant cachexia,  which  is  first  due  to  vasomotor 
spasm,  later  to  increased  leucocytosis,  and  decrease 
in  the  number  of  red  cells.  Rectal  injections  of  nor- 
mal salt  solution  given  high  and  retained,  prove  use- 
ful as  a  diluent,  stimulant  to  the  function  of  the  kid- 
neys, bowels,  and  excretory  glands,  also  tending  to 
replenish  the  depleted  vessels.  Nitroglycerin,  gr. 
i/ioo,  lessens  arterial  tension  and  frequently  re- 
lieves or  prevents  the  colicky  pains  caused  by  vaso- 
motor spasm.  Hot  baths  given  daily  will  stimulate 
the  glands  of  the  skin  and  tend  to  prevent  occlusion 
of  their  ducts.  Strychnine  in  moderate  dose  is  use- 
ful in  the  paralyses  and  as  a  general  stimulant ;  but 
its  administration  should  be  guarded  in  the  event  of 
accentuated  arterial  tension.  If  the  process  of  de- 
generation has  not  advanced  too  far,  use  the  faradic 
current,  preferably  the  induced  current,  fifteen  to 
twenty  minutes  daily.  Otherwise  employ  the  gal- 
vanic current,  using  the  slow  interruptor  if  neces- 
sary. Employ  the  galvanic  until  the  tissues  respond 
to  faradism,  then  employ  the  latter.  Hydroelectric 
baths  and  massage  are  especially  useful  in  multiple 
neuritis.  Employ  the  sinusoidal  current,  the  second- 
ary faradic  current,  or  cata])horesis  in  case  of  severe 
localized  pain,  using  counterirritants  in  the  interim. 
Apply  ice  cap  to  head  and  counterirritants  to  the 
spine  and  neck  in  case  of  cerebritis. 

The  diet  should  be  to  a  great  extent  vegetable  and 
saccharin.  Lead  is  largely  absorbed  in  proteid  com- 
binations. Give  tomatoes,  spinach,  lettuce,  parsley- 
greens,  lentils,  and  other  vegetable  substances,  that 
leave  a  large  residue  in  the  intestinal  canal.  Syrups, 
green  and  dried  fruits,  and  honey  may  also  assist  in 
relieving  constipation. 

Cran  bread,  graham  bread,  corn  bread,  hominy, 
and  wheatena  are  permissible,  (live  lemonade  free- 
ly. Add  ten  to  twenty  drops  of  dilute  sulphuric  acid 
to  each  glass  taken  for  its  chemical  effect.  Give 
large  quantities  of  water  and  milk  for  their  nutri- 
tive, diluent,  diuretic,  and  laxative  actions. 
Dr.  M.  A.  Lainpcrt,  of  BrooJdyn.  X.  Y.,  observes: 

The  treatment  of  chronic  lead  poisoning  may  be 
divided  into  prophylactic  and  curative. 

FropJiylactic :  There  are  numerous  conditions 
which  tend  toward  the  introduction  of  lead  into  the 
body,  by  wav  of  the  gastrointestinal  tract  chiefly, 
then  through  the  skin  or  respiratory  passages.  Hav- 
ing found  the  source  of  the  poison,  it  is  the  duty  of 
the  physician  either  to  modify  the  conditions  or  re- 
move the  patient  from  exposure  to  the  poison.  If 
necessary,  the  artisan,  painter,  miner,  typesetter, 
tinner,  potter,  glassblower,  smelter,  or  stereotyper 
must  discontinue  his  occupation  and  if  needs  be. 
give  it  up  entirely.  If  the  patient  cannot  dispense 
with  that  work,  careful  instructions  must  be  given 
as  to  the  cleanliness  of  the  hands,  nails,  and  skin. 
The  drinking  of  sulphuric  acid  lemonade  renders 
the  lead  as  insoluble  as  possible  and  does  diminish 
the  number  of  cases.  Poisoning  occurs  from  drink- 
ing water  conducted  by  (new)  lead  pipes  or  water 
stored  in  lead  tanks,  such  necessary  precautions 
should  be  taken  to  do  away  with  these,  and  galvan- 
ized iron  substituted.    Old  lead  pipes  are  coated 


492 


THERAPEUTICAL  XOTES. 


[New  York 
Medilal  Journal. 


with  an  insoluble  lead  compound  which  renders 
them  less  injurious.  Utensils  made  of  lead,  or  food 
wrapped  in  foil  should  not  be  used.  As  to  the  respi- 
ratory tract,  should  it  be  known  that  poisoning 
takes  place  by  this  route,  special  devised  respirators 
worn  by  the  patient  and  thorough  ventilation  of  the 
premises  is  all  that  could  be  done.  Cosmetics  should 
not  be  used,  since  this  is  the  most  frequent  method 
of  intoxication  through  the  skin.  Do  away  with  all 
face  i^owder  and  hair  dye. 

There  are  some  who  are  predisposed  to  lead  poi- 
soning as,  females,  alcoholics,  and  anaemics,  and 
such  must  not  be  employed  as  lead  workers. 

Curative:  In  chronic  lead  poisoning  the  lead  is 
deposited  in  the  internal  organs  in  an  insoluble 
form ;  the  aim  of  treatment  is  to  eliminate  soluble 
lead.  Potassium  iodide,  beginning  with  small  doses, 
from  gr.  v  to  x,  t.  i.  d.,  forms  a  soluble  iodide, 
which  is  eliminated  from  the  intestines  and  kidneys. 
Sudden  and  too  large  doses  of  potassium  iodide 
cause  rapid  elimination  of  lead  and  thus  increase 
the  severity  of  original  symptoms.  To  facilitate  the 
action  of  the  potassium  iodide,  magnesium  sulphate, 
or  sodium  sulphite  may  be  given  as  a  morning 
purge  which  help  precipitation  of  the  lead  and  pre- 
vent reabsorption. 

Of  the  various  conditions  caused  by  chronic  lead 
poisoning,  each  must  be  treated  separately  in  con- 
junction with  elimination  of  the  lead.  Fresh  air, 
nonirritating  food,  tonics,  and  stimulants  are  all 
necessary  for  such  condition'.  Paralysis  is  treated 
by  potassium  iodide,  strychnine,  massage,  and  the 
faradic  current.  For  the  colic,  fomentations  and 
if  severe  a  hypodermic  injection  of  morphine  and 
atropine  should  be'  given.  Arterial  sclerosis,  gout, 
chronic  nephritis,  saturnine  mania,  epilepsy,  chronic 
poliomyelitis,  peripheral  neuritis  (wrist  drop  and 
optic  neuritis),  and  abortions  caused  by  lead  poi- 
soning must  all  be  treated  separately  in  conjunction 
with  the  treatment  of  lead  poisoning. 

Dr.    T.    E.    McMurray,    of    Wilkinsburg,  Pa., 
zvrites: 

The  treatment  of  chronic  lead  poisoning  com- 
prises two  essential  points  i.  e.  elimination  and 
repair ;  of  course  it  is  necessary  to  remove  the  pa- 
tient from  the  source  of  intoxication. 

We  have  one  drug  in  its  various  forms  which 
stands  foremost  as  an  aid  to  elimination :  Potassium 
iodide  in  lo  to  20  grain  doses,  three  times  daily, 
forms  an  iodide  of  lead,  which  may  be  excreted 
with  the  urine  and  faeces.  The  iodide  prescribed  in 
the  following  fashion  as  a  rule  does  not  interfere 
with  digestion  and  is  not  objectionable. 

R    Potassium  iodide,   f; 

Distilled  water  aa  £3. 

M.  Sig. :  Ten  to  twenty  drops  well  diluted,  one  hour  after 
meals,  three  times  a  day. 

Frequent  doses  of  Epsom  salts  hasten  elimination 
from  the  bowel  and  relieve  the  constipation,  a  con- 
dition which  is  usually  very  troublesome.  The 
epsom  salts  are  best  given  in  the  morning  before 
breakfast.  A  large  dose  may  be  given  in  the  morn- 
ing or  smaller  doses  two  or  three  times  daily.  I 
believe  3  ii  to  iv  in  a  glass  of  hot  water  an  hour 
before  breakfast  every  morning  answers  all  pur- 
poses :  of  course  the  size  of  the  dose  must  be  regu- 
lated by  the  condition  of  the  bowels  and  efTect  de- 
sired. 


The  patient  should  be  advised  to  drink  freely  of 
good,  pure  water  especially  between  meals  and  at 
bed  time ;  the  water  flushes  the  bowels  and  urinary 
tract. 

Frequent  bathing  must  be  insisted  upon ;  a  hot 
bath  followed  by  a  brisk  rub  every  night  before  re- 
tiring will  hasten  elimination  through  the  skin  and 
in  addition  will  have  a  quieting  effect  on  the  nerv- 
ous patient  and  allow  him  to  sleep.  Sulphur  may 
be  added  to  the  water  used  for  bathing  if  desired, 
but  the  skin  should  not  be  over  stimulated. 

Repair.  Strychnine  is  indicated  in  nearly,  every 
case ;  the  dose  to  be  eft'ective  should  be  large,  1/30 
to  1/20  of  a  grain  in  solution  before  each  meal, 
especially  when  there  is  paralysis  I  advise  the  use 
of  strychnine  in  solution  before  meals  because  there 
is  usually  an  atonic  condition  of  the  stomach  with 
loss  of  appetite. 

The  following  answers  all  indication- : 

R     Strychnine  sulphate,   gr.  1/20  to  1/30, 

Compound  tincture  of  gentian,   5j. 

M.  Sign. :  Tc  be  taken  diluted  in  water,  before  meals, 
three  times  daily. 

If  it  is  desired  to  administer  iron  which  is  usu- 
ally indicated  it  may  be  given  in  the  form  of  massa 
ferri  carbonates,  g.  v  after  meals,  three  times  a  day ; 
and  the  following  may  be  given  in  place  of  the  solu- 
tion of  str3-chnine : 

R    Mass  of  ferrous  carbonate,  gr.  v; 

Strychnine  sulphate,   gr.  1/20  to  1/30; 

Extract  of  gentian,   gr.  s,s ; 

Aloes  gr.  1/12. 

M.  Ft.  Pil.  I. 

Sig. :  One  pill  before  each  meal. 

Colic  is  best  treated  by  hot  applications  ;  but  wlu  n 
severe,  morphine  and  atropine  have  to  be  used. 

When  the  nervous  condition  is  severe,  rest  in  bed 
with  change  of  surroundings  should  be  insisted 
upon.  Usuall}^  small  doses  of  sodium  bromide  in 
conjunction  with  the  bathing  will  control  the  condi- 
tion as  a  rule.  Where  it  is  possible  it  is  better  to 
have  the  patient  do  some  light  work,  preferably  out 
doors.  Fresh  air  and  light  employment  work  won- 
ders with  most  patients. 

Unless  contraindicated  by  a  diseased  condition  of 
the  kidneys  or  digestive  organs  a  full  diet  should  be 
allowed. 

Anaemia,  is  best  treated  with  iron,  arsenic,  fresh 
air,  and  sunlight. 

In  paralysis  use  electricity,  massage,  and  str_ych- 
nine.  If  the  muscles  do  not  react  to  the  electric 
current  recovery  as  far  as  paralysis  is  concerned 
seldom  follows. 


Studies  in  the  Hormons.  —  In  Folia  Thcra- 
pentica  for  January,  IC)09,  T.  Brugsch  comments  on 
the  work  of  Zuelzer  on  the  stimulation  of  intestinal 
peristalsis  by  intravenous  injection  of  peristalsis 
hormon.  According  to  Starling  the  hormon.s,  in 
contrast  to  foodstuff's,  are  to  be  regarded  as  stimu- 
lating substances,  the  purpose  of  which  is  to  stim- 
ulate certain  cell  groups  to  certain  prescribed 
functions.  .\n  example  of  this  is  to  be  found  in  the 
mamma  hormon  discovered  by  Starling.  It  is 
known  that  from  the  very  commencement  of  preg- 
nancy there  occurs  a  constant  and  increasing 
growth  of  the  mammae,  which  continues  right  up  to 


March  6,  1909.1 


THERAPEUTICAL  NOTES. 


493 


term.  Starling  has  been  able  to  adduce  proof  that 
this  enlargement  is  caused  by  a  substance  produced 
in  the  growing  embryo,  as  by  means  of  the  injec- 
tion of  extracts  of  such  embryos  he  succeeded  in 
causing  enlargement  of  the  mammje  of  virgin  rab- 
bits such  as  would  correspond  to  the  early  stages 
of  gestation.  Zuelzer  now  infers  that  a  similar  spe- 
cific hormon  may  also  exist  for  the  function  of  in- 
testinal peristalsis — in  other  words  that  normal  per- 
istalsis is  set  up  by  a  special  hormon.  He  has  test- 
ed the  stomachs  of  various  animals — horse,  ox, 
rabbit,  pig,  and  dog — and  has  always  found  the  hor- 
mon. Brugsch  is  of  the  opinion  that  the  work  of 
Zuelzer  will  lead  to  fine  therapeutical  results  in  the 
treatment  of  constipation,  and  that  our  present 
teaching  on  the  subject  will  have  to  undergo  some 
modification  necessitated  by  the  discovery  of  the 
peristalsis  hormon. 

The  Medical  Treatment  of  Appendicitis. — A. 

Robin  {Bulletin  genera!  de  therapeutiqne,  January 
15,  1909)  prescribes  calomel  or  castor  oil  as  purga- 
tives, giving  the  former  in  a  dose  of  six  grains  di- 
vided into  four  parts  at  hourly  intervals.  Of  cas- 
tor oil  one  ounce  is  given,  one  to  two  drops  of 
tincture  of  opium,  or  one  sixth  of  a  grain  of  ex- 
tract of  belladonna  being  incorporated  with  the  oil 
by  vigorous  shaking,  so  as  to  overcome  any  grip- 
ing effect. 

After  purgation,  if  the  stomach  is  distended  and 
sensitive,  give  a  powder  composed  as  follows : 

^*    Magnesium  hydroxide  gr.  xxii ; 

Sodium  bicarbonate  gr.  xv; 

White  sugar,   gr.  xxx; 

Codeine,  .  .'.  gr.  1/8; 

Precipitated  chalk. 

Bismuth  subnitrate,   aa  gr.  xii. 

M.   Ft.  pulv.  No.  i.   Mitte  No.  x. 

Sig. :  One  powder  to  be  given  in  a  little  water  whenever 
pain  or  distension  is  felt. 

The  same  evening,  or  twelve  hours  after  the 
purgative  action  has  ceased,  give  an  intestinal  irri- 
gation consisting  of  one  quart  of  water  heated  to 
100°  F.  and  containing  two  or  three  tablespoonfuls 
of  olive  oil  and  from  five  to  ten  drops  of  tincture 
of  sage.  The  irrigation  should  be  made  without 
force,  and  very  gently,  the  container  being  held  only 
about  eighteen  inches  above  the  level  of  the  bed, 
and  a  long  rubber  catheter  being  used,  to  be  intro- 
duced slowly  and  as  far  up  as  possible. 

^^  hen  a  purgative  is  given  ice  should  not  be  ap- 
plied. Instead  the  following  ointment  should  be 
rubbed  into  the  tissues  in  the  region  of  the  vermi- 
form appendix,  after  the  purgative  effect  has 
ceased : 

R    Strong  ointment  of  mercurj',   3x; 

Extract  of  belladonna,   5iiss. 

M.  Ft.  unguentum. 

If  the  patient  suft'ers  much  pain  give  the  follow- 
ing pill: 

R    Codeine  gr.  1/3; 

Extract  of  gentian  gr.  iss. 

M.    Ft.  pil.  i.    Mitte  xxx. 

Sig. :  One  pill  two  or  three  times  a  day. 

After  the  inflammation  has  subsided  the  diet  of 
the  patient  should  be  gradually  augmented,  but 
milk,  or  preparations  of  which  milk  is  a  constituent, 
should  be  principally  employed ;  eggs,  vegetables, 
and  fruits  should,  of  course,  supplement  the  diet. 
After  a  week  or  two  the  diet  should  be  changed, 
according  to  taste.     On  rising,  and  at  4  o'clock  in 


the  afternoon,  one  pint  of  hot  milk  should  be  taken 
in  small  sips,  half  an  hour  being  taken  to  consume 
this  quantity. 

As  a  laxative  the  following  is  prescribed : 

R     Sodium  bicarbonate,   5ii ; 

Dried  sodium  sulphate. 

Dried  sodium  phosphate,   aa  5i. 

M.    Ft.  pulv.  i.    :Mitte  x. 

Sig. :  Dissolve  one  powder  in  two  pints  of  water  that  has 
been  boiled  and  cooled.  Take  three  to  four  ounces  of  the 
solution  three  times  a  day,  at  10  o'clock  a.  m.,  4  or  6  o'clock 
p.  m.,  and  at  9  or  10  o'clock  p.  m. 

The  Treatment  of  Haemorrhoids. — In  an  arti- 
cle by  G.  Sandberg  in  the  Klinisehe  tlierapeutischc 
IVochenschrift.  which  is  abstracted  in  the  Bulletin 
general  de  therapeutiqne  for  January  15,  1909,  it  is 
remarked  that  the  chronic  constipation  which  af- 
flicts sufferers  from  haemorrhoids  is  the  most  diffi- 
cult symptom  to  treat.  A  vegetable  diet  is  recom- 
mended. Breakfast  should  consist  of  tea  and  milk, 
and  white  bread  with  honey  or  jam.  Later,  at 
II  a.  m.,  from  one  half  to  one  pint  of  butter- 
milk may  be  taken.  For  luncheon  a  puree  of  green 
vegetables  is  prescribed,  together  with  stewed 
fruits.  In  the  afternoon  it  is  directed  to  drink  the 
same  quantity  of  buttermilk  as  in  the  forenoon. 
Vegetables  and  jellies  should  be  taken  for  dinner, 
and  three  small  wineglassfuls  of  a  mild  wine  or 
cider  may  be  permitted.  At  night  a  cold  compress 
should  be  applied  to  the  abdomen,  covered  with  a 
dry  compress.  In  the  morning  the  abdomen  is 
bathed  with  cold  water,  or  dry  friction  is  employed, 
followed  by  the  application  of  alcohol  well  rubbed 
in.  ^^'hen  the  constipation  is  of  long  standing  give 
a  purgative  of  the  following  composition : 

^    Potassium  bitartrate, 

Sublimed  sulphur  aa  5iis?  ; 

Pulverized  rhubarb,   gr.  Ixxv ; 

Pulverized  licorice,   5iv  ; 

Syrup  of  lemon,   3iss. 

M.  et  Sig. :  As  much  as  may  be  carried  on  the  point  of 
a  knife  to  be  taken  morning  and  evening. 

Enemas  and  drastic  purgatives  are  contraindi- 
cated  in  patients  stiffering  from  hjemorrhoids,  who 
should  be  instructed  to  take  physical  exercise 
(barring  horseback  riding  and  bicycling). 

Itching  and  fissures  are  best  treated  by  the  ap- 
plication of  a  tampon  bearing  an  ointment  of  boric 
acid ;  or  bromocoll,  cocaine,  or  Xoridal  supposi- 
tories, the  active  constituent  of  which  is  calcium 
chloride,  mav  be  used. 

H?emorrhage  is  best  treated  by  the  injection,  after 
the  intestine  has  been  evacuated,  of  five  drachms  of 
a  ten  per  cent,  solution  of  calcium  chloride  in  water, 
according  to  the  method  of  Boas.  This  treatment 
should  be  continued  for  several  weeks.  If.  however, 
the  haemorrhage  is  excessive  and  weakening  resort 
should  be  had  to  surgical  measures,  bv  total  ex- 
tirpation, or  by  the  injection  into  the  haemorrhoidal 
sacs,  by  means  of  a  very  fine  Pravaz  needle,  of  from 
two  to  five  drops  of  a  solution  of  one  part  of  phenol 
in  four  parts  of  glycerin. 

For  Insomnia  in  the  Aged. — To  overcome  the 
insomnia  in  cases  of  cerebral  ana?mia  following  arte- 
riosclerosis Lemoine  [Joiirjial  de  nicdecine  de  Paris. 
January  30,  1909)  prescribes  the  following: 

R    Cocaine  hydrochloride,   gr. 

Potassium  iodide,   gr.  xxx; 

Syrup  of  bitter  orange  peel  5v- 

M.  et.  Sig. :  One  tablespoonful  in  the  evening  and  during 
the  night. 


494 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


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NEW  YORK,  S.VTIJRDAY,  MARCH  6,  19.09. 


NEWSPAPER  TREATMENT  OF  MEDICAE 
^lATTERS. 

In  Dr.  W.  H.  Palmer's  article  entitled  Concern- 
ing the  Xeed  for  Medical  Censorship  of  the  Las- 
Press,  which  we  publish  in  this  issue,  the  author  deals 
with  matters  of  the  gravest  importance  to  the  com- 
munity. Almost  every  newspaper  article  on  a  med- 
ical subject  teems  with  errors, -and  many  of  them  are 
so  ridiculous  as  to  make  none  but  an  amusing  im- 
pression on  the  paper's  medical  readers — that  is, 
when  they  do  not  slander  some  practitioner  or  dis- 
credit him  in  the  eyes  of  his  professional  brethren. 
Too  often  they  have  the  latter  effect,  and  we  all  re- 
call with  indignation  the  atrocious  misrepresenti- 
tion  of  Dr.  Knopf  that  was  published  in  a  prominent 
Philadelphia  newspaper  two  years  ago  or  more. 
That  was  an  exceptional  case,  it  is  true,  and  the  of- 
fending paper  was  at  last  forced  to  make  .some  rep- 
aration of  the  injury  it  had  done,  but  usually  the 
manager  of  such  a  paper  continues  in  his  disgrace- 
ful course  with  im]:)unity,  as  shameless  as  anv 
haughty  driver  of  a  motor  car. 

Newspaper  errors  due  to  mere  ignorance  might 
generally  be  condoned,  for  the  better  papers  would 
probably  seek  to  retrieve  their  reputation  by  employ- 
ing a  competent  medical  man  to  correct  articles  deal- 
ing with  matters  covered  by  his  special  knowledge. 
Cut,  unfortunately,  it  is  not  in  ignorance  that  the 
worst  of  the  newspapers  offend  :  tliey  have  no  desirv,- 
to  tell  the  plain  truth,  for  thev  know  that  a  pack  of 
sensational  lies  will  better  tickle  the  popular  fancv 
and  enlarge  the  sale  of  their  sheets.    This  is  well 


known  among  persons  who  have  any  familiarity 
with  newspaper  methods.  If  an\body  doubts  it,  we 
would  direct  his  attention  to  the  letter  from  Dr. 
Leary.  of  Boston,  which  we  published  last  week.  So 
the  millennium  will  be  close  at  hand,  we  fear,  befopi 
the  newspapers  exert  themselves  to  tell  the  truth  : 
and  we  do  not  see  how  they  c-^n  be  compelled  to  do 
so  until  the  popular  fondness  for  humbug  undergoes 
an  abatement  of  which  t'  ere  is  now  no  indication. 

If  medical  men  and  n^edical  ])rogress  were  the 
sole  sufferers  from  the  disgraceful  newspaper  meth- 
ods of  the  present  time,  we  should  still  be  indignant, 
but  we  should  endeavor  to  preserve  our  patience. 
But  such  is  not  the  case.  The  chief  injury  falls  on 
the  poor  sufferers  from  incurable  disease.  The 
newspapers  delude  them  with  false  hopes,  and  what 
little  money  the  victims  can  raise  goes  into  the  pock- 
ets of  charlatans.  We  should  be  sorry  to  think  that 
the  newspapers  were  in  league  with  these  gentry, 
but  the  facts  too  often  lead  one  to  entertain  the  sup- 
position. So  far  as  we  can  see,  there  can  be  only 
one  cure  for  the  evils  of  newspaper  medicine,  and 
that  is  for  the  general  public,  who  support  the  pa- 
pers, to  give  the  journalists  to  understand  that  they 
will  withdraw  their  support  if  the  papers  do  not 
mend  their  ways.  But,  as  we  said  before,  we  fear 
that  the  time  is  far  di-stant  when  the  public  will  take 
up  the  cause  of  the  afflicted  in  any  such  practical 
wav. 


CARCINOMA  AND  THE  LEUCOCYTES. 

Macalister  and  Ross  ( Proceedings  of  the  Roya! 
Socicix  of  Medicine,  December)  have  devised  an 
ingenious  method  for  the  study  of  the  blood  of  pa- 
tients suffering  from  malignant  tumors.  The  cit- 
rated  blood  is  centrifugalized  and  the  citrated 
plasma  is  mixed  with  one  eighth  of  its  volume  of 
the  blood  of  a  healthy  person.  This  mixture  is 
kept  at  93.5°  F.  for  half  an  hour,  and  then  a  small 
drop  is  placed  on  a  slide,  covered,  and  examined  at 
a  constant  temperature  of  68°  V.  Within  half  an 
hour  of  its  removal  from  the  incubator  some  of  the 
leucocytes  show  remarkable  movements. 

It  had  been  previously  observed  by  Dr.  Ross  that 
alkaloids,  such  as  atropine  and  morphine,  acted  as 
excitants  to  the  movements  of  the  leucocytes,  caus- 
ing them  to  throw  out  unusually  long  and  active 
pseudopods.  The  blood  of  carcinomatous  patients 
had  the  same  effect,  and  the  authors  therefore  con- 
cluded that  such  blood  contained  substances  that 
were  excitants  to  the  leucocytes.  It  had  been  pre- 
viously shown  that  the  serum  of  carcinoma  patients 
did  not  shorten  tiie  lives  of  the  leucocytes  of  henlthy 
per.sons.  Conse{|uently  thev  concluded  that  car- 
cinoma was  not  an  infective  disease.  The  substance 
contained  in  the  blood  plasma  of  the  carcinoma  pa- 


March  6,  igog.  J 


EDITORIAL  ARTICLES. 


495 


tient  acted  like  an  alkaloid.  The  examination  of  the 
blood  serum  from  a  number  of  normal  persons  and 
persons  suffering  from  other ,  diseases  has  failed  to 
show  a  similar  effect  upon  tV/.-  leucocytes,  except  in 
the  cases  of  two  patients  \\v  i  malarial  disease  who 
were  taking  quinine.  In  '  lese  cases  the  alkaloid 
which  was  in  the  blood  pla?  na  was  thought  to  exert 
the  stimulating  effect  upor  the  leucocytes. 

The  haemolytic  tests  fl  r  the  presence  of  car- 
cinoma and  this  ingenious^  method  of  determining 
the  effect  of  carcinoma  serut»^  upon  healthy  leuco- 
cytes appear  to  us  important  ii]  the  study  of  malig- 
nant tumors.  Whether  these  properties  of  the 
blood  serum  are  the  causes  or  the  results  of  the  ma- 
lignant growth,  it  is  difficult  to  say.  In  all  proba- 
bility they  are  the  results  of  the  presence  of  the 
tumor. 


TRANSMISSIBLE  DISEASES. 

The  Philadelphia  newspapers  of  February  24th 
and  25th  were  enlivened  by  a  series  of  interviews 
with  the  chief  medical  inspector  of  the  Bureau  of 
Health  of  that  city.  The  purport  of  the  interviews 
was  that  the  inspector  accused  certain  physicians  of 
gross  carelessness  in  the  way  in  which  they  diag- 
nosticated and  managed  cases  of  infectious  diseases. 
Instances  were  given  in  which  patients  suffering 
from  mild  attacks  of  scarlet  fever  or  diphtheria  had 
been  allowed  to  pursue  their  usual  occupations  un- 
der a  mistaken  diagnosis.  In  one  instance  a  case 
of  typhoid  fever  was  said  to  have  been  treated  in 
the  family  dining  room,  from  which  room  the 
mother  often  went  to  the  kitchen  to  prepare  the 
meals  without  first  washing  her  hands.  Cases  of  this 
kind  are  extreme,  of  course,  but  we  do  not  doubt 
that  they  do  occur,  and  rather  frequently. 

The  average  citizen  objects  to  any  law  that  re- 
quires him  to  deny  himself  anvthing.  If  he  is  not 
actually  prostrated  by  a  disease,  he  considers  it  an 
abridgment  of  his  libertv  '\i  he  is  obliged  to  re- 
main in  one  room  in  order  to  prevent  the  spread  of 
a  contagious  disease.  Physicians  often  lend  the 
weight  of  their  approval  to  this  attitude.  As  a  mat- 
ter of  fact,  probablv  no  person  would  willingly 
spread  scarlet  fever  or  diphtheria  in  a  community. 
Consequently,  if  the  physician  in  charge  of  the  case 
would  stop  to  explain  to  a  patient  that  all  infective 
diseases  may  be  mild,  severe,  or  malignant,  and  that 
a  mild  case  in  one  individual  may  produce  a  malig- 
nant case  in  a  person  infected  from  him,  he  will 
usually  see  the  force  of  the  argument  and  consent 
to  the  definite  period  of  isolation.  If  such  argu- 
ment fails  to  convince  a  refractory  patient,  the 
weight  of  authority  must  be  used.  "A  physician  is 
the  teacher  of  his  patient,  not  his  patient's  servant." 

Concerning  defects  of  education  relating  to  the 


diagnosis  and  management  of  the  transmissible  dis- 
eases, we  think  they  are  only  tou  apparent.  More 
time  should  be  given  to  them  in  an  undergraduate 
course  than  to  some  more  recondite  subjects.  The 
teacher  should  always  bear  in  mind  that  the  .student 
is  learning  his  scientific  alphabet  and  his  medical 
multiplication  table.  He  is  not  able  to  follow  the 
teacher  into  the  advanced  fields  of  side  chain  theo- 
ries, metabolism  disputes,  and  technical  details. 
.Such  subjects  are  for  the  advanced  student,  the 
graduate. 

We  think  the  chief  medical  inspector  of  the  Phil- 
adelphia Bureau  of  Health  lays  too  much  stress  on 
the  possibility  of  a  physician's  carrying  infection  in 
his  clothing.  The  more  intimate  our  knowledge  of 
the  transmissible  diseases  the  less  importance  do  we 
attach  to  fomites  in  the  transmission.  The  use  of 
gowns  is  of  advantage  when  there  is  danger  of  hav- 
ing one's  clothes  soiled  by  infective  material  from 
the  unconscious  or  uncontrollable  patient.  We 
think,  however,  that  the  gown  is  not  a  necessary 
item  of  the  prophylactic  armamentarium.  Isolation 
of  the  patient,  after  a  proper  diagnosis,  with  clean- 
liness, and  destruction  of  infective  material  are  the 
essentials  in  prevention. 


••THC)R-RAD-X.' 

And  he  dreamed,  and  behold  a  ladder  set  up  on  the  earth, 
and  the  top  of  it  readied  to  heaven.    Gen  xxviii,  12. 

From  Chicago,  through  the  medium  of  the  dail\' 
press,  come  reports  of  the  discoverv  by  two  homcDeo- 
pathic  physicians  of  the  most  marvelous  cure-all  of 
the  age.  (Jf  such  transcendent  import  to  humanity 
is  this  discovery  that  one  of  its  sponsors  hesitates  to 
express  himself  adequately  lest  he  should  seem  to 
be  going  beyond  the  mark.  "In  fact,"  he  is  quoted 
as  saying,  "what  we  really  wonder  at  is  whether  any- 
thing exists  that  it  will  not  cure  once  we  have  thor- 
oughly mastered  handling  it."  Already,'  at  the  be- 
hest of  its  discoverers,  "tubercular  [^;V]  pleurisy  in 
an  advanced  stage  has  been  absolutely  cured  after 
three  applications  of  the  remedy,  senile  processes 
have  been  definitely  arrested,  and  locomotor  ataxia 
and  other  spinal  cord  scleroses  not  only  have  been 
arrested,  but  cured  by  its  use.  "  In  addition,  like 
one  of  these  ingenious  tools  that,  by  a  twist  of  tlie 
wrist,  instantly  may  be  transformed  from  a  monkey 
wrench  into  a  toothpick,  this  versatile  remedial  agent 
is  directly  useful  in  wireless  telegraphy,  entirely  do- 
ing away  with  batteries,  towers,  and  other  expensive 
paraphernalia,  for  "blue  flame  sparks  were  readily 

transmitted  through  a  brick  and  stone  wall  three 

»  .  r 
feet  thick  and  registered  on  a  glass  tube  held  by  an 

assistant." 

In  the  treatment  of  cutaneous  cancer,  lupus,  and 
the  like,  the  Finsen  light,  the  x  ray,  and  similar  well 


496 


EDITORIAL  ARTICLES. 


TNew  York 
Medical  Journal. 


proved  curative  agents  pale  into  utter  insignificance 
in  the  effulgence  of  "thor-rad-x  I"  The  name  given 
to  this  miracle-working  wonder  is  appropriate  as 
well  as  ingenious.  Thor,  the  god  of  thunder,  the 
son  of  Odin,  the  supreme  being,  and  of  Jordh,  the 
earth !  Thor.  the  champion  of  the  gods,  the  slayer 
of  evil  spirits  I  Descending  to  earth  from  the  aero- 
plane heights  of  fanciful  speculation,  we  learn  that 
radium,  as  was  to  be  expected,  is  the  basic  element 
of  this  new  discovery  and  that  Colorado  pitchblende 
is  the  source  from  which  it  is  obtained.  And  then 
our  sensibilities  and  hopes  are  jarred  acutely  when 
we  remember  that  the  properties  of  this  same  Colo- 
rado pitchblende  were  long  since  carefully  and  con- 
scientiously studied  by  at  least  a  score  of  investi- 
gators, each  of  whom  determined  that  its  chief  ther- 
apeutic constituent  was  impure  oxide  of  uranium  ; 
furthermore,  that  the  salt  existed  in  this  parent 
pitchblende  in  such  unstable  strength  and  in  such 
variable  quantity  that  its  radioactive  properties  were 
practically  nil. 

And  so  once  more  our  dreams  are  dissipated  on 
awakening  to  face  cold,  grim  facts.  "Thor-rad-x," 
say  the  press  dispatches,  "will  be  sold  to  surgeons 
and  physicians  and  even  to  laymen  through  a  cen- 
tral agency  to  be  established  in  Chicago.  The  cost 
will  be  merely  sufficient  to  defray  the  expense  in- 
volved in  manufacture."  Far  be  it  from  us  wit- 
tingly to  sow  the  seeds  of  incredulity  among  the 
ripening  stalks  of  honest  endeavor,  and  particularly 
w  hen  that  endeavor  has  for  its  object  the  ameliora- 
tion of  human  ills,  but  in  this  case  precedent  holds 
up  its  hands  and  purringly  whispers :  "Advertising 
pays,  and.  verily,  there  are  as  many  ways  to  adver  - 
tise as  there  are  to  skin  a  cat." 


PROFESSIOXAL  SECRECY  AND 
PROFESSIONAL  DUTY. 

An  editorial  article  in  the  St.  Louis  Medical  Re- 
7'iezv  for  February,  entitled  Moral  Obligation  rs. 
Legal  Restriction,  recounts  the  case  of  a  young  girh 
who  presented  herself  at  a  clinic  for  treatment  for 
acute  iritis.  "She  had,"  says  the  account,  "a  typi- 
cal, pronounced  secondary  syphilitic  eruption  with 
accompanying  sore  throat  and  mucous  patches. 
.She  admitted  knowledge  df  the  character  of  her 
affliction,  and  yet  persisted  in  retaining  her  posi- 
tion as  housemaid,  including  the  care  of  two  small 
children."  The  writer  of  the  article  bewails  the 
legal  inability  of  the  physician  to  warn  the  family 
in  which  this  young  woman  was  employed  of  the 
danger  incurred  by  them  in  continuing  her  in  her 
work. 

Now,  Mr.  Arthur  N.  I'aylur,  in  his  excellent 
bofjk  entitled  The  Larv  in  i(.<;  Relations  to  f^lixsi- 
eian.<;.  says :  "It  seems  well  settled  that  this  clause 


[that  'one  practising  medicine  and  surgery  shall  not 
be  permitted  to  disclose  "any  information  which  he 
acquired  in  attending  a  patient  in  a  professional 
capacity"  ']  in  the  statutes  includes  all  knowledge 
gained  in  the  professional  intercourse  of  a  physi- 
cian with  his  patient,  whether  obtained  from  state- 
ments made  to  him  by  the  patient  or  gained  from 
observing  and  examining  the  patient."  Mr.  Tay- 
lor undoubtedly  states  the  court  ruHngs  correctly, 
but  we  doubt  if  they  would  be  upheld  in  such  a 
case  as  our  St.  Louis  contemporary  depicts. 

We  must  assume  that  the  law^  aims  at  justice, 
but  where  is  the  justice  of  a  judicial  ruling  that  a 
certain  legislative  enactment  forbids  a  man  to  warn 
another  man  of  grave  danger  to  his  family  if  he 
continues  to  employ  a  conscienceless  servant  girl 
who  is  perfectly  willing  to  run  the  risk  of  giving 
syphilis  to  his  children?  We  doubt  if  any  jury 
would  fail  to  exonerate  a  medical  man  who  should 
give  such  warning,  statute  or  no  statute.  The 
matter  lies  at  the  base  of  our  social  institutions. 
As  well  might  physicians  be  forbidden  to  accuse  a 
certain  microbe  of  deleterious  operations.  Surely 
the  meaning  of  the  law  is  not  to  give  freedom  to 
the  scatterers  of  infective  disease.  If  it  is,  the 
sooner  we  know  it  the  better.  We  can  then  agitate 
for  a  highly  desirable  modification  of  the  statutes. 


THE  MAGNESIUM  TREATMENT  OF 
TETANUS. 

In  the  Bulletins  et  mcnioircs  dc  la  Socicte  medi- 
cale  dcs  Iwpitaux  de  Paris  for  February  4th  there  is 
an  account  by  Dr.  Robert  Debre  of  a  case  of  acute 
tetanus  in  a  little  girl,  eight  years  old,  in  which  two 
injections  of  magnesium  sulphate  (^each  of  two  cubic 
centimetres  of  a  warm  twenty-five  per  cent,  solu- 
tion, boiled  and  filtered)  into  the  rhachidian  canal, 
along  'with  the  subcutaneous  use  of  antitetanic 
serum  and  the  internal  administration  of  chloral 
hydrate,  were  followed  by  such  a  decided  ameliora- 
tion of  the  symptoms  as  to  amount  almost  to  their 
complete  subsidence.  The  good  effects  lasted  for 
about  thirty  hours,  but  then  the  terrible  disease  re- 
asserted itself  and  rapidly  proved  fatal. 
.  By  this  experience  and  by  a  digest  of  tlie  pub- 
lished reports  of  other  cases  M.  Debre  is  led  to  the 
conclusion  that  improvement  after  the  use  of  the 
magnesium  salt  should  not  be  interpreted  to  mean 
that  no  more  of  it  need  be  given,  but  rather  that  an 
additional  injection  should  be  employed.  It  is  well 
to  know,  he  says,  that  the  calmative  action  of  the 
drug  is  of  limited  duration,  and  tiiat  when  it  lias 
ceased  the  most  acute  manifestations  may  seize  upon 
the  patient  at  a  time  when  it  is  too  late  for  further 
intervention. 


JVIarch  6,  1909.] 


OBITUARY.     NEWS  ITEMS. 


497 


ROBERT  A.  MURRAY,  M.  D., 
of  New  York. 

Dr.  ■Murray  died  of  pneumonia  on  Saturday,  Feb- 
ruary 2yih.  at  his  home,  at  the  age  of  fifty-seven 
years.  He  was  a  graduate  of  the  Medical  Depart- 
ment of  the  University  of  the  City  of  Xew  York,  of 
the  class  of  1873.  He  was  particularly  well  known 
as  an  obstetrician,  and  his  professional  brethren  in 
New  York  had  for  many  years  recognized  him  as  a 
practitioner  of  exceptional  skill  in  obstetrics.  He 
was  a  member  of  the  New  York  Obstetrical  Society, 
of  the  American  Gynaecological  Society,  and  of  sev- 
eral other  medical  organizations.  He  was  an  ex- 
ceedingly modest  man  and  verv  attractive  person- 
ally. 


WILLIAM  McCOLLOM,  M.  D., 
of  Brooklyn. 

Dr.  IMcCollom  died  on  Tuesday,  February  23d,  of 
acute  bronchitis  and  pulmonary  cedema.  He  was 
born  in  Rochester,  Vt.,  in  1831,  and  was  graduated 
in  medicine  by  the  Castleton  INIedical  College,  in  the 
class  of  1853.  He  practised  medicine  in  Vermont 
until  1869,  when  he  moved  to  Brooklyn,  where  he 
continued  in  general  practice  and  made  an  enviable 
reputation.  He  was  an  honorary  member  of  the 
Medical  Society  of  the  State  of  Xew  York. 
-   ^  


Changes  of  Address. — Dr.  A.  L.  Benedict,  to  354 
Franklin  street,  Buffalo,  N.  Y. 

Dr.  Thomas  H.  O'Neill,  to  507  Fifth  avenue,  New  York. 

Dr.  Thomas  Luther  Coley,  to  3,?8  South  Twenty-tirst 
Street,  Philadelphia. 

The  Clinical  Significance  of  Blood  Pressure  in  In- 
surance Examinations  was  the  subject  of  an  address  de- 
li\ered  by  Dr.  Francis  Ashley  Faught  at  a  recent  meeting 
of  the  Philadelphia  Medical  E.xaminers'  Association. 

The  Obstetrical  Society  of  Cincinnati  elected  the  fol- 
lowing ofhcers  for  the  year  1909  at  a  recent  meeting:  Presi- 
dent, Dr.  L.  S.  Colter;  vice-president,  Dr.  J.  W.  Rowe ; 
recording  secretary,  Dr.  John  Landis :  corresponding  sec- 
retary, Dr.  E.  S.  McKee ;  treasurer.  Dr.  Ambrose  Johnson. 

X  Ray  in  the  Diagnosis  of  Tuberculosis. — Dr.  Lewis 
Gregory  Cole,  of  New  York,  will  read  a  paper  entitled  The 
Early  Diagnosis  of  Tuberculosis  by  the  Rontgen  Ray  at  a 
meeting  of  the  Pennsylvania  Society  of  Physicotherapy, 
which_  will  be  held  in  Philadelphia  on  Tuesday  evening, 
jMarcli  9th. 

The  Dr.  Andrew  J.  McCosh  Memorial.— The  E.xecu- 
tne  Committee  announce  that  the  fund  which  is  being  col- 
lected for  the  erection  of  a  suitable  memorial  to  the  late 
Dr.  Andrev,  J.  McCosh  now  amounts  to  $100,157.60,  of 
which  $93,362.60  has  been  received,  and  the  remainder 
promised. 

The  Last  Lecture  of  the  Harvey  Society  Course  will 
be  delivered  on  Saturday  evening,  March  6th,  at  8.30  p.  m., 
at  the  New  York  Academy  of  Medicine,  by  Dr.  C.  B. 
Davennort,  director  of  the  Station  for  Experimental  Evolu- 
tion, Cold  Spring  Harbor,  New  York.  The  subject  will  be 
Heredity  in  Man. 

A  Reception  to  Dr.  W.  W.  Keen,— The  Penn  Club, 
of  Philadelphia,  gave  a  reception  to  Dr.  W.  W.  Keen,  on 
the  evening  of  February  20th.  There  was  a  large  gather- 
ing of  men  prominent  in  the  social,  literary,  professional, 
scientific,  and  business  life  of  the  city,  who  tendered  con- 
gratulations to  the  guest  of  honor.  It  was  announced  that 
Dr.  Keen"s  medical  works  had  been  translated  into  the 
Spanish  language. 


Personal. — Dr.  Joseph  D.  Bryant,  of  New  York,  was 
robbed  of  his  watch  and  chain  and  a  gold  penknife,  valued 
at  $200,  while  he  was  directing  a  surgical  operation  re- 
cently in  St.  Vincent's  Hospital.  The  property  was  taken 
from  the  physicians'  dressing  room,  which  was  only  about 
fifty  feet  fronv  the  operating  room. 

The  Measles  Epidemic  in  the  District  of  Columbia. — 
According  to  the  report  of  the  Department  of  Health  for 
the  week  ending  February  20,  1909,  measles  is  still  epidemic 
in  Washington  and  vicinity.  During  the  week  684  new 
cases  were  reported,  312  patients  were  discharged  as  cured, 
and  one  death  was  reported,  which  left  at  the  end  of  the 
week  1,918  cases. 

Improvements  at  the  Metropolitan  Hospital. — Plans 
have  been  filed  for  remodeling  the  octagonal  cupola  of  the 
Metropolitan  Hospital,  Blackwell's  Island,  into  four  op- 
erating rooms.  These  alterations  will  cost  $12,000.  Tlie 
dining  rooms  and  kitchen  of  the  hospital  are  to  be  en- 
larged by  making  over  the  boiler  house  into  an  extension, 
at  an  additional  cost  of  $75,000. 

Lectures  on  Skin  Diseases. — The  governors  of  the 
New  York  Skin  and  Cancer  Hospital,  Second  Avenue,  cor- 
ner of  Nineteenth  Street,  announce  that  the  tenth  series  of 
clinical  lectures  on  diseases  of  the  skin  will  be  given  by  Dr. 
L.  Duncan  Bulkley  in  the  out  patient  hall  of  the  hospital, 
on  Wednesday  afternoons  at  4:15  o'clock,  beginning  March 
loth.    The  course  is  free  to  the  medical  profession. 

A  Hospital  for  Americans  in  Paris. — Press  despatches 
report  the  establishuient  of  a  hospital  in  Paris  to  be  de- 
voted to  the  needs  of  American  students,  business  men, 
tourists,  and  in  fact  any  American  who  falls  ill  in  Paris. 
It  is  a  model  institution,  well  equipped  with  all  modern  ap- 
pliances, and  its  establishment  fills  a  need  which  has  long 
been  felt  by  the  American  colony  in  Paris.  It  is  situated 
in  the  suburb  Neuilly. 

A  Free  Dispensary  for  Consumptives  in  Minneapo- 
lis.— Tlie  Board  of  Charities  and  Corrections  of  Minne- 
apolis has  announced  its  intention  of  establishing  in  connec- 
tion with  the  city  hospital  a  free  dispensary  for  the  tuber- 
culous. It  will  be  conducted  on  a  very  modest  basis  at 
first,  but  will  be  developed  as  rapidly  as  possible,  and  it  is 
hoped  will  ultimately  become  an  important  factor  in  the 
work  of  stamping  out  tuberculosis. 

Woman  at  Head  of  Williamsburg  Hospital. — Dr. 
Mary  Merritt  Crawford  began  her  duties  as  house  surgeon 
of  the  Williamsburg  Hospital,  Brooklyn,  on  Monday,  March 
1st.  It  is  said  that  Dr.  Crawford  is  the  first  woman  to  hold 
such  a  position  in  an  important  institution.  Dr.  Harold  L. 
Barnes,  the  retiring  surgeon,  was  given  a  banquet  by  the 
members  of  the  house  and  visiting  stafts,  who  also  pre- 
sented him  with  a  completely  equipped  operating  table. 

A  Concert  for  the  Benefit  of  the  Tuberculosis  Clinic 
of  the  New. York  Throat,  Nose,  and  Lung  Hospital  will  be 
given  on  Wednesday  evening,  March  24th,  at  the  residence 
of  Mr.  William  Salomon,  1020  Fifth  Avenue,  New  York. 
It  is  announced  that  Madame  Calve  and  other  noted  sing- 
ers will  take  part.  The  hospital  is  making  arrangements 
to  establish  an  open  air  camp  on  the  hospital  grounds, 
which  it  is  expected  will  be  ready  for  use  about  June  ist. 

The  Gibb  Operating  Pavilion  of  the  New  York  City 
Home  for  the  Aged  and  Infirm,  on  Blackwell's  Island,  was 
formally  opened  on  February  25th,  in  the  presence  of  a 
large  number  of  city  officials  and  other  persons  interested 
in  the  home.  The  building  was  named  in  honor  of  Dr.  W. 
Travis  Gibb,  of  42  West  Seventy-fifth  Street,  New  York, 
chief  surgeon  of  the  home.  It  is  a  one  story  structure, 
connected  with  the  medical  and  surgical  wards  by  glass 
enclosed  corridors,  and  consists  of  ten  rooms,  including  an 
X  ray  room,  a  laboratory,  and  a  sterilizing  room.  The  cost 
of  the  building  and  equipment  was  $24,000. 

The  Fiftieth  Anniversary  of  the  Alumni  Association 
of  the  College  of  Physicians  and  Surgeons  (Medical 
Department  of  Columbia  University),  was  celebrated  by  a 
dinner  at  Sherry's  on  the  evening  of  March  2d.  Several 
hundred  members  of  the  organization  were  present.  Dr. 
Samuel  W.  Lambert,  dean  of  the  faculty,  presided.  Among 
the  speakers  were  Dr.  Nicholas  Murray  Butler,  president 
of  Columbia  L-niversity;  the  Hon.  Seth  Low,  ex-Mayor  of 
New  York;  Dr.  H.  A.  Christian,  dean  of  Harvard  Medical 
School;  Dr.  Will  iam  M.  Polk,  dean  of  Cornell  Medical 
School,  and  Dr.  John  G.  Curtis,  of  the  College  of  Physi- 
cians and  Surgeons. 


498 


NEIVS  ITEMS. 


[Xfav  York 
Medical  Journal. 


A  Department  of  Medical  Research  at  the  University 
of  Pennsylvania. — AiinouuceiiK-'iU  is  made  of  a  gift  of 
S200,ooo  to  the  university  to  endow  a  chair  of  research 
medicine,  which,  it  is  reported,  will  be  called  the  John  H. 
Musser  Chair  of  Research  Medicine.  The  gift  came 
through  Dr.  Musser,  who  declined  to  give  the  name  of  the 
donor.  It  is  of  especial  value  to  the  university,  inasmuch 
as  the  institution  already  possesses  a  laboratory  for  re- 
search work,  which  is  the  gift  of  the  late  Dr.  William 
Pepper. 

Vital  Statistics  of  Minneapolis. — During  the  month  of 
January,  1909,  there  were  reported  to  the  Department  of 
Health  276  deaths  from  al!  causes,  which  corresponds  to 
an  annual  death  rate  of  8.86  in  a  thousand  population.  The 
annual  death  rate  for  the  year  1908  was  8.92  in  a  thousand 
population.  The  total  infant  mortality  for  the  month  was 
59;  38  under  one  year  of  age  and  21  between  one  and  five 
years  of  age.  There  were  20  still  births,  11  males  and  7 
females.  Two  hundred  and  twelve  marriages  and  262 
births  were  reported  during  the  month. 

Jewish  Sanatorium  for  Consumptives. — It  is  reported 
that  seventy  acres  of  ground  near  Eaglesmere,  Pa.,  liave 
been  purchased  by  an  association,  with  headquarters  m 
Philadelphia,  for  the  purpose  of  establishing  a  sanatorium 
for  Jewish  consumptives.  Mr.  S.  C.  Kraus  is  president  of 
the  organization,  the  corporate  title  of  which  is  not  pub- 
hshed ;  Dr.  Isaac  Leopold  and  Mr.  M.  J.  Speier  are  the 
vice-presidents;  Mr.  B.  F.  Miller  is  the  treasurer;  Dr.  A. 
J.  Cohen  is  the  secretary,  and  Samuel  Louchheim,  Esq.,  is 
the  solicitor.  The  board  of  managers  consists  of  thirty-five 
it/cmbers. 

Outdoor  Treatment  of  Mental  Diseases. — An  outdoor 
department  was  opened  some  months  ago  at  the  Vanderbilt 
Clinic  of  the  College  of  Physicians  and  Surgeons,  New 
York,  to  which  cases  of  incipient  insanity  or  borderland 
conditions  might  be  sent  for  examination  and  advice.  Sug- 
gestions regarding  diagnosis  and  treatment  will  be  fur- 
nished, if  desired,  to  physicians  who  refer  patients  to  this 
department.  These  clinics,  which  are  held  on  Tuesdays 
and  Fridays,  from  2  to  4  p.  m.,  are  in  charge  of  the  follow- 
ing well  known  neurologists  :  Dr.  Frederick  Peterson,  Dr 
M.  S.  Gregory.  Dr.  G.  Floyd  Haviland,  Dr.  A.  A.  Brill,  and 
Dr.  Robert  E.  Pou. 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  March  13,  1909: 

MON  DAY,  March  Sth. — Section  ni  General  Medicine,  Col- 
lege of  Physicians. 

TuESD.w,  March  gth. — Philadelphia  Pediatric  Society. 

VVediNESd.w,  March  /o^/;.— Philadelphia  County  Medical 
Society. 

Thursd-W,   March    nth. —  Pathological    Society;  Section 

Meeting;  Franklin  Institute. 
Frid.ay,  March  uth. — Northern  Medical  Association  ;  West 
Branch,  Philadelphia  County  Medical  Soeiety. 

A  Free  Dispensary  for  Nervous  and  Mental  Diseases 
iias  been  e>tal)li>licd  at  the  St.  Lawrence  State  Hospital,  at 
Ogdensburgii,  N.  Y.  Poor  and  indigent  persons  suffering 
from  incipient  nervous  and  mental  diseases  may  consult 
the  physicians  of  the  hospital  at  the  dispensary  and  receive 
advice.  They  will  not  receive  treatment,  but  will  be  re- 
ferred back  to  their  family  physician,  who  will  receive  a 
letter  containing  a  summary  of  the  findings  in  each  case 
and  suggestions  as  to  treatment.  No  fee  or  gratuity  of  any 
kind  will  be  accepted  and  no  medicines  will  be  dispensed  or 
sold.  The  dispensary  hours  will  be  from  10  a.  m.  to  3 
p.  m.  on  Saturdays  only. 

The  Charitable  Organizations  of  Italy. — The  recent 
earthquake  disaster  in  the  southern  portion  of  the  Italian 
mainland  and  the  adjacent  island  of  Sicily  has  drawn  at- 
tention to  Italian  affairs  from  all  parts  of  the  civilized 
world.  .A  pulilicalion  from  the  office  of  the  Minister  of 
the  Interior  of  Italy  will  be  of  interest  to  persons  who  are 
concerned  in  tiie  administration  of  charitable  institutions 
for  the  benefit  of  the  poor,  especially  of  the  sick  poor.  The 
report  shows  tliat  Italy  lias  an  equivalent  of  $466,029,976 
invested  in  eleemosynary  institutions  of  various  kinds.  In 
addition  to  the  forms  of  charity  familiar  to  Americans, 
■iuch  as  hospitals,  homes  for  the  aged  and  infirm,  homes 
(or  orphans,  institutions  for  the  blind,  etc.,  there  are  funds 
to  provide  dots  so  that  poor  girls  may  marry;  funds  for 
the  benefit  of  new  mothers;  free  kitchens,  and  free  hygienic 
lodging  houses. 


The  Umberto  I.  Prize  in  Orthopaedics. — Announce- 
ment has  been  made  by  the  Rizzoli  Institute  of  Ortho- 
paedics, Bologna,  that  the  second  competition  for  this  prize 
has  been  open  since  January  i,  1909.  and  will  remain  open 
until  the  end  of  the  year.  The  Umberto  I.  prize  is  a  quin- 
quennial prize,  of  the  value  of  £140  (3,500  lire),  which  is 
awarded  by  the  provincial  council  of  Bologna  to  the  med- 
ical practitioner  of  any  nationality  who  submits  the  best 
original  contribution  to  the  science  of  orthopredics.  The 
contribution  may  be  either  in  the  form  of  an  essay  or  a 
new  instrument  or  appliance.  The  rules  and  regulations 
governing  the  awarding  of  this  prize  will  be  sent  upon 
application  to  Dr.  Giuseppe  Bachelli,  president  of  the  Rizzoli 
Institute,  Bologna.  Italy. 

Infectious  Diseases  in  New  York: 

IVc  arc  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folloiving  statement  of  nciij 
cases  and  deaths  reported  for  the  tzco  zveeks  ending  Feb- 
ruary 2j.  igog: 

^February  20— >  ^February  27— ~ 
Cases.     Deaths.    Cases.  Deatl^s. 

Tuberculosis  |iulmonalis    457  187  377  167 

Diphtheria    369  38         3->6  4; 

Measles    608  20         635  27 

Scarlet  fever    388  16         373  29 

.Smallpox   .  .  I  I 

\'aricella    210  .  .  189 

Typhoid  fever    20  5  27  4 

Whooping  cough    52  5  47  7 

Cerebrospinal  meningitis    9  6  8  4 

Totals   2,113         277       ■•9S3  284 

Roosevelt  Hospital  Discontinues  Ambulance  Service. 

— In  order  to  reduce  the  expenses  of  the  institution,  the 
city  ambulance  service  at  Roosevelt  Hospital  was  discon- 
tinued on  March  ist,  by  vote  of  the  trustees.  The  district 
formerly  covered  by  this  hospital  will  be  included  in  the 
territories  of  the  J.  Hood  Wright  Memorial  Hospital, 
the  New  York  Hospital,  and  the  Flower  Hospital.  The 
National  Volunteer  Emergency  Service,  which  is  under  the 
supervision  of  Dr.  F.  Elbert  Davis,  of  50  Madison  .Avenue, 
New  York,  has  opened  ten  "first  aid"  stations  in  drug 
stores  on  the  upper  west  side,  and  the  four  ambulances  of 
the  service  have  been  transferred  from  241  West  Twenty- 
third  Street  to  Ninety-sixth  Street,  Ijetween  Columbus  and 
Amsterdam  Avenues.  Roosevelt  Hospital  has  no  idea  of 
curtailing  its  free  public  service,  however,  and  will  wel- 
come every  emergency  case  brought  to  it. 

The  Mortality  of  Chicago. — The  total  number  of 
deaths  reported  to  the  Department  of  Health  of  Chicago 
during  the  week  ending  February  20,  1909,  was  654,  as 
compared  with  592  for  the  preceding  week  and  616  for  the 
corresponding  period  in  igo8.  The  annual  death  rate  was 
15.33  in  a  thousand  population,  as  against  13.38  for  the  .pre- 
ceding week.  The  total  infant  mortality  was  iSg.  of  which 
138  were  under  one  year  of  age.  The  principal  causes  of 
death  were:  Diphtheria.  10  deaths;  scarlet  lever.  2  deaths; 
measles,  7  deaths ;  influenza,  5  deaths ;  typhoid  fever.  9 
deaths ;  diarrhoeal  diseases,  37  deaths,  of  which  31  were 
under  two  years  of  age;  pneumonia,  128  deaths;  pulmonary 
tuberculosis.  63  deaths ;  other  forms  of  tuberculosis,  9 
deaths ;  cancer,  27  deaths ;  nervous  diseases.  14  deaths ; 
heart  diseases,  77  deaths;  apoplexy,  g  deaths;  bronchitis, 
2  deaths;  Bright's  disease,  48  deaths;  violence,  41  deaths, 
of  which  7  were  suicides;  all  other  causes,  166. 

Popularizing  Pharmacopceial  and  National  Formulary 
Preparations.  —  .\  jmnt  meeting  of  the  Medical  Society 
of  the  County  of  Erie,  N.  Y..  the  Buttalo  .Academy  of 
Medicine,  and  the  Erie  County  Pharmaceutical  .Association, 
w  ill  l)e  held  in  the  rooms  of  the  Buffalo  Society  of  Natural 
Sciences,  Public  Library  Building,  liuffalo,  on  Tuesday 
evening,  March  gth,  at  8:30  o'clock,  for  the  purpose  of  dis 
cussing  the  propriety  of  popularizing  the  use  of  prepara- 
tions of  the  I'.  S.  Piiarmacopiria  and  the  National  Formu- 
lary, and  restricting  the  employment  of  patent  and  proprie- 
tary chemicals  and  pharmaceuticals.  Professor  William  C. 
Anderson,  of  the  Brooklyn  College  of  Pharmacy,  will  dc 
liver  the  principal  address.  .At  the  close  of  the  niccting  re- 
freshments will  be  served  informally,  the  physicians  beiiii.; 
the  guests  of  the  pharmacists.  Dr.  C.  .A  Wall  is  prcsideni 
of  the  Medical  Society  of  the  County  of  Erie;  Dr.  E.  .\. 
Bowerman  is  president  of  the  Buffalo  .\cademv  of  Medi- 
cine; and  .Mr.  H.  .A.  Scheck  is  president  of  the  Erie  County 
Pharmaceutical  .Association. 


March  6,  1909.] 


NEWS  ITEMS. 


499 


Vital  Statistics  of  New  York. — During  the  week  end- 
ing Februarv  20,  1909,  there  were  reported  to  the  Depart- 
ment of  fleaUh  of  the  City  of  New  York  1.505  deaths  from 
all  causes,  as  against  1,479  ^or  the  corresponding  period  ni 
1907.  The  annual  death  rate  in  1,000  of  population  was 
17.20  for  the  whole  city,  and  for  each  of  the  boroughs  it 
•was  as  follows:  Manhattan,  17.62;  the  Bronx,  19.79;  Brook- 
lyn, 15.97;  Queens,  14.91;  Richmond,  24.76.  The  total 
infant  mortality  was  476;  209  under  one  year  of  age  and 
267  between  one  and  five  years  of  age.  The  deaths  by  vio- 
lence numbered  62,  of  which  14  were  suicides.  There  were 
126  still  births.  Nine  hundred  and  fifty-two  marriages  and 
2,496  births  were  reported  during  the  week. 

The  Philadelphia  Neurological  Society. — The  pro- 
gramme for  the  regular  meeting  of  this  society,  which  was 
held  on  Friday  evening,  February  26th,  included  the  fol- 
lowing papers :  Cardiac  Crises  in  Tabes,  by  Dr.  S.  D.  Lud- 
lum;  A  Possible  Case  of  Landry's  Palsy,  presented  for 
diagnosis,  by  Dr.  John  H.  W.  Rhein  ;  A  Case  of  Cerebellar 
Meningocele,  by  Dr.  Theodore  H.  Weisenburg;  Poliomy- 
elitis in  an  Adult  following  a  Wound  in  the  Hand,  by  Dr. 
F.  X.  Dercum;  Chorea  of  Emotion,  by  Dr.  S.  Weir  Mitch- 
ell ;  The  Relation  of  Tabes  and  Aortic  Aneurysm,  by  Dr. 
Paul  H.  Bickle;  Meralgia  Paraesthetica  Recurring  with 
Repeated  Pregnancies,  and  Myopathy  of  Unusual  Distribu- 
tion, by  Dr.  George  E.  Price ;  Tuberculoma  of  the  Brain, 
by  Dr.'M.  D.  Bloomfield. 

Medical  Gymnastics  in  the  Treatment  of  Nervous 
Diseases  is  the  subject  chosen  for  discussion  at  the 
meeting  of  the  Section  in  Neurology  and  Psychiatry  of  the 
New  York  Academy  of  Medicine  to  be  held  on  Monday 
evening,  March  8th.  The  following  papers  will  be  pre- 
sented :  Exercise  in  the  Treatment  of  Neurasthenia  and 
Hysteria,  by  Dr.  Watson  L.  Savage ;  The  Value  of  Thera- 
peutic Gymnastics  in  Chorea  and  the  Ataxias  of  Childhood, 
by  Dr.  Hugh  C.  Thompson ;  Mechanical  Treatment  of 
Speech  Defects,  by  Dr.  E.  W.  Scripture ;  The  Mechanical 
Treatment  of  Locomotor  Ataxia  as  Practised  by  Dr. 
Frenkel  at  Heiden,  Germany,  by  Dr.  Ralph  Jacobi.  Among 
those  who  will  participate  in  the  discussion  are  Dr.  W.  H. 
Thomson,  Dr.  Charles  Gilmore  Kerley,  and  Dr.  J.  B.  Bis- 
sell. 

The  Second  Midyear  Meeting  of  the  American  Acad- 
emy of  Medicine,  which  will  be  held  in  Chicago  on 
March  25th,  will  consist  of  a  conference  of  medical  and 
academic  teachers.  The  meetings  of  the  conference  are 
all  open  to  the  public,  and  all  who  are  interested  are  in- 
vited. Especial  attention  is  called  to  the  evening  meeting, 
which  will  be  devoted  to  a  consideration  of  the  question  of 
what  constitutes  a  liberal  education  in  the  twentieth  cen- 
tury. Among  those  who  will  read  papers  at  the  conference 
are  the  following :  Dr.  William  McNab  Miller,  professor 
of  pathology  and  bacteriology  in  the  University  of  Mis- 
souri ;  Dr.  John  L.  Heffron,  dean  of  the  medical  faculty, 
Syracuse  University ;  Dr.  Charles  Mclntire,  of  Easton,  Pa. ; 
Dr.  Edward  Jackson,  of  Denver,  Colo. ;  Dr.  George  E. 
MacLean,  president  of  the  State  University  of  Iowa ;  Dr. 
Thomas  McClelland,  president  of  Knox  College,  Galesburg, 
111. ;  and  Dr.  Charles  F.  Thwing,  president  of  Western  Re- 
serve University,  Cleveland. 

The  London  X  Ray  Convention. — A  convention  will 
be  held  in  London  on  July  5  to  9,  1909,  for  the  purpose  of 
discussing  the  value  of  electricity  in  relation  to  the  prac- 
tice of  medicine.  Delegates  will  be  present  from  America 
and  the  Continent,  and  representatives  of  the  various  gov- 
ernments will  be  invited  to  take  part  in  a  discussion  as  to 
the  best  n/eans  of  providing  apparatus  and  training  for  the 
Army  and  Navy.  The  papers  and  debates  will  be  in  Eng- 
lish, but  papers  in  French  and  German  will  be  accepted, 
provided  a  resume  in  English  accompanies  them.  This  is 
the  first  English  speaking  x  ray  congress  ever  held  in  Eu- 
rope. In  connection  with  the  congress  will  be  held  an  ex- 
hibition of  all  kinds  of  electrical  and  physical  apparatus  for 
medical  treatment,  and  makers  and  inventors  of  x  ray  ap- 
paratus will  be  given  an  opportunity  of  demonstrating  their 
own  instruments.  Dr.  Lewis  Jones,  vice-president  of  the 
electrotherapeutical  section  of  the  Royal  Society  of  Medi- 
cine, is  president  of  the  congress ;  W.  Deane  Butcher,  M. 
R.  C.  S.,  president  of  the  Rontgen  Society,  is  vice-president 
of  the  congress ;  and  Dr.  Reginald  Morton  is  the  secretary 
and  treasurer.  Dr.  Qiarles  Lester  Leonard,  of  Philadel- 
phia, is  honorary  foreign  secretary  from  America.  All 
communications  relating  to  the  congress  should  be  ad- 
dressed to  Mr.  Ernest  Schofield,  Organizing  Secretary  of 
the  X  Ray  Convention,  11  Chandos  Street,  Cavendish 
Square,  London,  W. 


Contagious  Diseases  in  Chicago. — The  contagious 
disease  situation  in  Chicago  continues  to  improve,  on  the 
whole,  though  the  number  of  typhoid  fever  cases  reported 
during  the  week  ending  February  13,  1909,  was  90,  as 
against  35  during  the  preceding  week.  The  cases  reported 
were  as  follows:  Diphtheria,  145  cases;  scarlet  fever,  142 
cases ;  measles,  107  cases  ;  chickenpox,  90  cases ;  pneumonia, 
66  cases;  typhoid  fever,  90  cases  ;  whooping  cough,  30 cases; 
tuberculosis,  109  cases ;  diseases  of  minor  importance,  48 
cases ;  total,  827  cases.  During  the  week  ending  February 
20,  1909,  the  total  number  of  cases  of  contagious  diseases 
reported  was  703,  as  follows:  Diphtheria,  iii  ;  scarlet  fever, 
145;  measles.  124;  whooping  cough,  12;  tuberculosis,  78; 
pneumonia,  28;  typhoid  fever,  63;  chickenpox,  8;  mumps, 
42;  cerebrospinal  "fever,  i  ;  puerperal  fever,  r;  erysipelas,  11. 

Society  Meeting  for  the  Coming  Week: 

Monday,  March  8tlt. — New  York  Academy  of  Medicine 
(Section  in  Neurology  and  Psychiatry)  ;  Society  of 
Medical  Jurisprudence,  New  York;  New  York  Oph- 
thalmological  Society;  Corning,  N.  Y.,  Medical  Asso- 
ciation; Waterbury,  Conn.,  Medical  Association. 

Tuesday,  March  gth. — New  York  Academy  of  Medicine 
(Section  m  Public  Health)  :  New  York  Obstetrical 
Society;  Newburgh  Bay,  N.  Y.,  Medical  Society;  Buf- 
falo Academy  of  Medicine  (Section  in  Medicine)  ; 
Medical  Society  of  the  County  of  Rensselaer,  N.  Y. ; 
Practitioners'  Club  of  Jersey  City,  N.  J. ;  Medical  So- 
ciety of  the  County  of  Schenectady,  N.  Y. 

Wednesday,  March  loth. — New  York  Pathological  So- 
ciety ;  New  York  Surgical  Society ;  Medical  Society  of 
the  Borough  of  the  Bronx ;  Alumni  Association  of  the 
City  Hospital,  New  York ;  Brooklyn  Medical  and  Phar- 
maceutical Association ;  Medical  Society  of  the  County 
of  Richrr.ond,  N.  Y. 

Thursday,  March  nth. — New  York  Academy  of  Medicine 
(Section  in  Paediatrics)  ;  Brooklyn  Pathological  So- 
ciety ;  Blackwell  Medical  Society  of  Rochester,  N.  Y. ; 
Jenkins  Medical  Association,  Yonkers,  N.  Y. 

Friday,  March  I3th. — New  York  .A.cademy  of  Medicine 
(Section  in  Otology)  ;  New  York  Society  of  Derma- 
tology and  Genitourinary  Surgery;  Eastern  Medical 
Society  of  the  City  of  New  York ;  Saratoga  Springs, 
N.  Y.,  Medical  Society. 

Saturday,  March  13th. — Therapeutic  Club,  New  York. 

Charitable  Bequests. — By  the  will  of  Mrs.  David 
Dows,  the  Charity  Organization  Society,  New  York,  will 
receive  $10,000;  the  Children's  Aid  Society  will  receive 
$10,000  to  be  used  for  classes  for  crippled  children  ;  The 
New  York  Homoepathic  Medical  College  and  Hospital  will 
receive  $5,000  for  the  Nurses'  Training  School ;  the  Pres- 
byterian Hospital  will  receive  $5,000;  and  the  Daisy  Fields 
Home  and  Hospital  for  Crippled  Children  will  receive 
$5,000. 

By  the  will  of  Mrs.  Isabel  M.  Fowler,  who  died  in  Ja- 
maica Plain,  on  February  9th,  the  Pillsbury  Memorial  Hos- 
pital at  Concord,  N.  H.,  will  receive  $15,000  as  a  trust  fund, 
the  income  of  which  is  to  be  used  to  meet  the  expenses  of 
women  and  girls  who  may  not  otherwise  be  able  to  have 
the  benefit  of  hospital  treatment. 

By  the  will  of  Samuel  Parker,  the  Frederick  Douglass 
Memorial  Hospital  and  Training  School,  of  Philadelphia, 
receives  $1,000  and  the  Home  for  Aged  and  Infirm  Colored 
Persons,  of  Philadelphia,  receives  $500  as  contingent  be- 
quests. 

By  the  will  of  the  late  Emma  D.  Cummins,  of  New  York, 
the  pathological  laboratory  of  St.  Luke's  Hospital  receives 
$25,000 ;  the  Hahnemann  Hospital,  New  York,  receives 
$10,000:  the  Postgraduate  Hospital  receives  $10,000;  the 
New  York  Eye  and  E^ir  Infirmary  receives  $10,000;  the 
Home  for  Old  Men  and  Aged  Couples,  of  New  York,  re- 
ceives $10,000;  and  the  Home  for  the  Destitute  Blind  re- 
ceives $10,000. 

By  the  will  of  Ervin  Saunders,  of  Yonkers,  who  died  in 
New  York  on  February  17th,  the  Yonkers  Homoeopathic 
Hospital  and  Maternity  receives  $450,000. 

By  the  will  of  Marie  E.  Troutman,  the  Home  of  the 
Merciful  Savior  for  Crippled  Children  and  the  Woman's 
Hospital  of  Philadelphia  receive  $500  each. 

By  the  will  of  Margaretta  J.  B.  Drinkhouse,  the  Phila- 
delphia Home  for  Incurables  and  the  Sanitarium  for  Con- 
sumptives at  White  Haven,  Pa.,  become  provisional  bene- 
ficiaries. 

By  the  will  of  Henry  L.  Fell,  the  Philadelphia  Home 
for  Incurables  receives  $500. 


500 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


Jit|j[     Current  f  iteraturt. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 
February  25,  igog. 

1.  Cancer  of  the  Uterus.   A  Review  of  254  Cases  from  the 

Gj'nsecological  Service  of  the  Boston  City  Hospital, 
By  Ernest  Boven  Young  and  John  T.  Williams. 

2.  Anterior  Metatarsalgia.    Its  Causes  and  Its  Relief, 

By  Nathaniel  Allison. 

3.  Nerve  Strain  of  School  Children, 

By  Lx)uis  W.  Flanders. 

4.  Ethyl  Chloride  in  General  Anaethesia, 

By  Arthur  M.  Dodge. 

I.  Cancer  of  the  Uterus. — Young  and  Williams 
review  254  cases  of  cancer  of  the  uterus,  and 
make  the  following  rules  for  diagnosis :  Cancer  of 
the  uterus  should  be  suspected  whenever,  in  any 
woman  over  thirty,  there  is  an  increase  in  the 
quantity  of  the  regular  menstrual  flow ;  whenever 
there  is  the  slightest  bleeding  except  at  the  regular 
periods ;  and  whenever  there  is  the  onset  of  vaginal 
discharge  of  any  kind,  without  an  obvious  reason. 
The  possibility  of  its  presence  should  be  considered 
in  any  woman  of  this  age  in  whom  there  is  a  gradu- 
ally increasing  loss  of  flesh  and  strength  when  no 
cause  can  be  discovered  on  a  general  physical  ex- 
amination, even  in  the  absence  of  pelvic  symptoms. 
The  reappearance  of  flowing  after  the  menopause 
is  almost  pathognomonic.  These  symptoms  do  not 
necessarily  mean  that  the  patient  has  cancer,  but 
they  do  demand  immediate  investigation.  They 
may  be  symptoms  of  other  conditions  or  they  may 
be  manifestations  of  malignant  disease,  and  a  diag- 
nosis can  be  made  only  by  examination.  If  it  is 
found  that  the  patient  does  not  have  carcinoma,  no 
harm  has  been  done  by  an  examination  and,  if 
cancer  is  present,  it  must  be  recognized  early  if 
are  to  hope  for  a  cure.  It  is  usually  impossible  to 
distinguish  by  palpation  alone  between  a  beginning 
carcinoma  and  an  old  laceration  with  much  scar 
tissue.  Every  cervix  which  is  irregular,  hard,  and 
nodular  should  be  regarded  with  suspicion,  espe- 
cially if  it  bleeds  easily.  It  should  always  be  ex- 
posed and  carefully  inspected  for  an  eroded  or 
ulcerated  area.  If  this  is  found  a  snipping  should 
be  taken  for  microscopical  examination.  This 
should  be  made  in  the  form  of  a  wedge,  including 
both  the  ulcer  and  some  of  the  cervical  tissue  be- 
neath, in  order  that  invasion  of  the  muscle  by  epi- 
thelial elements  may  be  detected.  If  the  section 
does  not  show  malignancy,  the  cervix  should  be 
repaired  and  the  tissue  removed  in  the  denudation 
examined.  In  early  cancer  of  the  body  pelvic  ex- 
amination may  be  absolutely  negative  or  the  uterus 
may  be  a  little  large  and  soft  and  the  cervix  slightly 
patulous.  In  either  case  a  diagonsis  can  be  made 
only  by  a  curettage  and  examination  of  the  curet- 
tings.  If  one  examination  is  negative  and  the 
curettage  does  not  give  relief,  the  uteius  should  be 
explored  a  second,  third,  or  even  a  fourth  time,  for 
the  disease.  Better  results  in  the  treatment  of 
cancer  of  the  uterus  can  be  obtained  orly  by  earlier 
recognition.  This  can  be  accomplished,  in  the  first 
lOace,  by  dissemination  of  information  concerning 
it  among  the  laity ;  and.  in  the  second,  by  making 
the  thorough  examination  of  the  patient,  including 
the  use  of  the  microscope,  a  routine  procedure  in 
all  cases  which  present  suspicious  symptoms. 


4.    Ethyl  Chloride  in  General  Anaesthesia. — 

Dodge  observes  that  ethyl  chloride  is  probably  as 
safe  as  ether  but  not  as  safe  as  nitrous  oxide.  Seri- 
ous practical  objections  to  the  use  of  nitrous  oxide 
are  the  bulk  and  weight  of  the  apparatus  necessary 
in  administration  and  the  alarming  appearance  of 
such  paraphernalia,  to  many  patients,  especially 
when  they  are  children.  The  conclusion  reached  by 
the  writer  is  that  ethyl  chloride  has  sufficient  advan- 
tages and  points  in  its  favor  to  warrant  its  admin- 
istration in  the  majority  of  cases  where  an  anaes- 
thetic is  employed. 

JOURNAL  OF  THE  AMERICAN  M EDICAL  ASSOCIATION. 

February  27,  igog. 

1.  Frequency  of  Tuberculosis  in  Childhood, 

By  C.  VON  Pirquet. 

2.  The  Diseases  of  the  Cerebral  Arteries.    Their  Ef¥ects 

and  Treatment,  with  Special  Reference  to  Arterio- 
sclerosis, By  George  A.  Moleen. 

3.  The  Abuse  of  Surgery,  By  J.  L.  Wiggins. 

4.  Advantages  and  Difficulties  of  Publicity  in  Connection 

with  Municipal  Public  Health  Work, 

By  Ernest  C.  Lew. 

5.  Pleasures  and  Hopes  of  the  Health  Officer, 

By  Charles  V.  Chapin. 

6.  Food  Intoxication  in  Infancy,  By  Joseph  Brennemann. 

7.  Pharniocopoeial  Revision   Methods  of  Foreign  Coun- 

tries, By  H.  V.  Arny. 

8.  The  Diagnosis  of  Intestinal  Perforation  in  Typhoid 

Fever,  By  Alfred  Jerome  Brown. 

1.  Frequency  of  Tuberculosis  in  Childhood. — 

Von  Pirquet  makes  the  following  suggestions :  All 
children  are  submitted  to  the  cutaneous  test.  The 
following  day  they  are  inspected.  Those  showing  a 
positive  reaction  are  noted  as  belonging  in  the  group 
of  early  reactions.  A  week  later  those  who  showed 
no  reaction  are  again  tested  and  inspected  a  day 
later.  If  they  then  react,  they  are  grouped  in  the 
class  of  secondary  reactions.  Those  who  have  not 
reacted  on  either  occasion  can  be  considered  as  be- 
longing to  the  nonreacting  class.  This  method  of 
testing  requires  about  one  hour  for  a  hundred  chil- 
dren and  only  half  an  hour  is  consumed  in  the  in- 
specting process.  Medical  school  officers  could 
easily  accomplish  this  at  the  opening  of  the  schools 
in  autumn.  One  forenoon  would  be  sufficient  for  a 
school  of  from  400  to  600  children.  As  the  test  is 
absolutely  harmless,  there  can  be  no  objection  to 
carrying  out  such  valuable  investigations. 

2.  Diseases  of  the  Cerebral  Arteries. — Moleen 
says  that  the  all  important  factor  in  treating  dis- 
eases of  the  cerebral  arteries  is  rest  and  quiet  as 
soon  as  symptoms  of  a  definite  character  are  estab- 
lished. The  diet  should  be  carefully  guarded.  A 
constant  peculiarity  to  be  noted  in  most  cases  is  the 
abnormal  appetite ;  the  patients  veritably  eat  until 
they  can  not  walk,  and  to  keep  the  consumption  of 
food  down  will  be  no  little  task,  since  they  do  not 
seem  to  appreciate  the  amount  they  are  eating. 
While  the  patients  are  at  rest  the  diet  should  be 
light,  easily  digestible,  and  limited  in  quantity. 
Iodine,  notwithstanding  opinions  to  the  contrary,  in 
view  of  its  action  in  increasing  catabolism  and  its 
tendency  to  attack  those  tissues  most  recently 
formed,  is  obviously  of  value  here.  It  should  be 
borne  in  mind,  however,  that  since  increased  blood 
pressure  has  been  the  cause,  this  must  first  be  met 
if  the  most  pronounced  effect  of  the  medicament  is 
to  be  obtained.  The  results  with  potassium  iodide 
are  much  more  prompt  and  marked  if  absolute  rest 


March  6,  1909.! 


PITH  OF  CURRENf  LITERATURE. 


is  maintained  than  if  not.  Iodides  are  too  often  re- 
garded as  antisyphilitics  and  the  administration  of 
them  is  assumed  to  be  indicated  by  reason  of  syphi- 
litic disease.  This  is,  however,  not  the  case.  Iodine 
is  not  antagonistic  to  the  virus  of  the  disease  ;  it  is., 
or  should  be,  used  only  to  remove  the  results  of  the 
disease — hyperplasia,  granulomata,  etc. — and  is  in- 
dicated when  the  same  conditions  exist  as  a  result 
of  other  infections  as  well  as  those  of  syphilis.  The 
plan  which  he  employs  is  as  follows:  i.  Absolute 
rest  in  bed.  2.  Saline  catharsis  (preceded  by  calo- 
mel if  necessary)  ;  magnesium  sulphate  or  sodium 
phosphate  may  be  employed.  This  is  an  effective 
means  of  keeping  the  tension  moderate  or  low.  3. 
Potassium  iodide  beginning  with  ten  minims  and  in- 
creasing a  drop  each  day  of  the  saturated  solution 
imtil  fifty,  sixty,  or  seventy  drops,  three  times  daily, 
are  reached.  Should  iodism  be  manifested,  the  iodidt 
•may  be  stopped  for  twenty-four  hours  and  resumed 
where  it  was  left  off.  After  the  maximum  is  reached 
it  should  be  diminished  until  thirty  or  twenty  drops 
are  taken  and  then  discontinued.  A  tonic  may  then 
be  instituted,  such  as  strychnine,  beginning  w^ith 
1/30  grain  and  later  increasing  to  1/24  or  1/20  grain. 
It  is  best  given  in  the  compound  syrup  of  phosphates 
of  the  National  Formulary,  which  is  a  rich  phos- 
phatic  reconstructant.  If  the  hjemoglobin  is  low, 
iron  and  arsenic  may  be  alternated  with  the  above. 
If  syphilis  is  a  probability,  the  virus  should  be  com- 
bated with  mercury  alone,  as  soon  as  possible,  and 
followed  by  iodides  and  later  with  tonic  chalybeates. 
The  so  called  sera,  such  as  Poehl's  and  that  of 
Trunececk,  antiscFerosin,  and  the  like,  which  con- 
tain, in  the  main,  sodium  chloride,  sodium  sulphate, 
sodium  phosphate,  sodium  carbonate,  magnesium 
phosphate,  and  calcium  glycerophosphate,  are  advo- 
cated, and  some  good  results  are  asserted  for  them. 
They  are  best  given  after  the  more  acute  symptoms 
have  subsided,  such  as  twitching,  localized  weak- 
ness, numbness,  and  tingling.  Another  remedy  is 
deserving  of  more  attention  than  it  has  received, 
namely,  thiosinamine.  This  substance  was  first  in- 
troduced by  von  Hebra  in  1892,  who  found  it  of 
value  in  the  treatment  of  lupus  and  old  cicatrices. 
That  it  possesses  the  power  of  softenings  cicatricial 
tissue  such  as  strictures,  corneal  opacities,  and  ad- 
liesions  at  the  base  of  chronic  deafness  has  been  fre- 
quently observed.  It  is  given  in  substance  or  with 
milk  sugar  in  increasing  doses  of  from  ^  to  2  grains. 

6.  Food  Intoxication  in  Infancy.— Brennemann 
discusses  the  alimentary  intoxication  of  infants.  It  is 
a  metabolic  intoxication  caused  by  the  giving  of  food 
which  produces  toxic  products  of  an  inadequate  me- 
tabolism, which  may  lead  to  fatal  consequences,  but 
disappears  when  the  food  is  withheld.  Certain  foods, 
liowever,  give  rise  to  these  effects,  and  Brennemann 
insists  on  the  importance  of  the  fats  and  sugars  in 
the  infant's  food.  The  proteids  he  considers  com- 
paratively harmless.  The  exact  nature  of  the  tox- 
ines  is  unknown.  The  condition  is  probably  analo- 
gous to  an  acid  intoxication,  and  the  theory  that  it  is 
due  to  alimentary  rather  than  to  bacterial  toxines  is 
supported  by  the  absence  of  lesions  in  the  alimentary 
■canal,  the  absence  of  anv  microorganism  associated 
with  it,  the  ready  cure  by  withdrawal  of  food,  the 
■widely  dift'erent  conditions  with  which  it  is  associ- 
.ated.  and  the  lack  of  putrefactive  or  fermentative 


products  that  are  caused  by  bacterial  activity  within 
the  intestines.  The  treatment  is,  therefore,  indicated  : 
The  withdrawal  of  food  will  produce  a  normal  tem- 
perature and  absence  of  evident  intoxication  in  from 
24  to  72  hours.  The  child  can  be  given  plenty  of 
water,  sweetened  with  saccharin  one  grain  to  the 
quart ;  a  little  barley  water  is  harmless  or  weak  tea 
can  be  given,  as  is  done  so  much  in  German  clinics. 
When  the  baby  is  no  longer  toxic  we  can  give  a  lit- 
tle skim  milk — from  5  to  10  ounces  in  the  barley  wa- 
ter in  the  day's  food.  If  this  is  well  borne  for  a  day 
or  two  one  can  safely  add  a  small  amount  of  sugar 
and  gradually  increase  it  to  the  amount  for  a  normal 
healthy  child ;  but  only  after  weeks  or  months  can 
we  safely  begin  to  substitute  whole  milk  under  care- 
ful control  and  watched.  The  severer  the  case  the 
slower  must  be  the  progress. 

7.  The  Pharmacopoeial  Revision  Methods  of 
Foreign  Countries. — Arny  states  that  the  method 
of  selection  of  the  revision  committee  that  obtains 
in  this  country  is  completely  in  accord  with  the 
spirit  of  our  democratic  form  of  government,  and 
it  would  be  unfortunate,  indeed,  to  replace  our 
present  Pharmacopoeial  Convention,  with  its  dele- 
gates from  medical  and  pharmaceutical  societies, 
and  the  Committee  on  Revision  which  said  conven- 
tion elects,  by  a  commission  appointed  by  the  gov- 
ernment, like  those  which  prepare  the  foreign 
pharmacopoeias.  While  a  small  number,  for  in- 
stance, seven  members  as  in  Spain,  would  seem  to 
give  a  more  compact,  more  workable  body,  it  is 
significant  that  two  of  the  best  pharmacopoeias  of 
the  world — those  of  Germany  and  Switzerland — 
were  prepared  by  commissions  larger  than  our  last 
Committee  on  Revision.  That  a  goodly  proportion 
of  the  revisers  should  be  pharmacists,  since  a  large 
amount  of  revision  consists  merely  of  pharmaceu- 
tical and  chemical  details,  will  be  admitted  even  by 
physicians ;  but  whether  the  medical  representation 
should  be  as  scanty  as  prevailed  in  our  last  Com- 
mittee on  Revision  is  debatable.  As  to  frequency 
of  revision,  it  is  noticed  that  in  those  countries 
where  the  revision  committee  is  a  permanent  body, 
the  work  of  revision,  as  might  be  expected,  was 
accomplished  in  less  time  than  in  our  country, 
where  each  revision  is  taken  up  by  a  new  organiza- 
tion, hot  necessarily  containing  a  majority  of  the 
members  of  the  previous  committee.  The  fact  that 
the  last  German  pharmacopoeia  was  revised  in  one 
year  is  the  best  possible  argument  for  a  permanent 
committee.  Moreover,  the  permanent  existence  of 
the  committee  would  permit  the  publication  of  year- 
ly supplements,  a  step  that,  in  these  days,  is  highly 
advisable. 

8.  Diagnosis  of  Intestinal  Perforation  in  Ty- 
phoid Fever. — Brown  remarks  that  perforation 
occurs  as  a  rule  in  the  latter  part  of  the  second,  in 
the  third,  or  in  the  fourth  week  of  typhoid,  espe- 
cially in  ambulant  or  atypical  cases.  The  initial 
symptoms  are  sudden  severe  lancinating  pain  in  the 
lower  part  of  the  abdomen  and  generally  in  the 
right  iliac  fossa,  and  usually  tenderness,  there  may 
or  may  not  be  rigidity.  The  other  symptoms  usu- 
ally described  are  merely  confirmatory  if  present, 
and  the  majority  of  them  are  due  to  the  peritonitis 
following  the  perforation  and  not  to  the  perfora- 
tion itself.  Two  signs,  hitherto  undescribed,  appear 


502 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


to  him  to  be  valuable  as  confirmatory  evidence, 
namely,  the  one  which  he  designates  as  the  dipping 
crackle,  and  the  other  which  is  shown  by  tendency 
of  pain  and  tenderness  to  approach  on  the  side  that 
is  lowermost  if  the  patient  is  turned  on  this  side. 
In  the  management  of  a  case  of  typhoid  the  attend- 
ing physician  should  uncover  the  abdomen  at  least 
once  a  day  and  carefully  and  thoroughly  examine 
it.  In  the  light  of  recent  work,  blood  pressure 
should  be  taken  daily  if  possible.  Nurses  should 
be  impressed  with  the  extreme  importance  of  pain 
in  this  disease.  On  the  occurrence  of  a  severe 
sharp  pain  in  the  lower  part  of  the  abdomen,  and 
especially  in  the  right  iliac  fossa,  accompanied  by 
tenderness,  with  or  without  rigidity,  the  abdomen 
should  be  carefully  examined  and  the  limits  of  the 
tenderness  mapped  out.  The  patient  should  then 
be  turned  on  the  unaffected  side,  and  if  in  from 
fifteen  minutes  to  half  an  hour  the  tenderness  has 
moved  one  or  two  inches,  or  if  at  any  time  the 
tenderness  and  rigidity  become  marked,  immediate 
operation  is  indicated. 

MEDICAL  RECORD. 

February  27,  igog. 

1.  The  Claims  of  Water  as  a  Therapeutic  Agent, 

By  Simon  Baruch. 

2.  The  CoaguIabiHty  of  the  Blood  in  Pulmonary  Tuber- 

culosis— A  PreHminary  Investigation, 

By  Myer  Solis-Cohen. 

3.  The  Treatment  of  Patients  with  Hemiplegia  Resulting 

from  Cerebral  Apoplexy,    By  William  Leszynsky. 

4.  Tuberculosis  of  the  Breast,       By  Eugene  St.  Jacques. 

5.  Achylia  Gastrica  versus  Instifficientia  Pylori, 

By  Mark  I.  Knapp. 

I.    The  Claims  of  Water  as  a  Therapeutic 

Agent. — Baruch,  in  his  introductory  lecture  to 
the  course  on  hydrotherapy  at  Columbia  Uni- 
versity, New  York,  remarks  that  water  stands  easi- 
ly foremost  among  the  physiological  remedies.  He 
speaks  of  water  as  a  stimulant,  a  tonic,  a  diuretic, 
a  diaphoretic,  an  emetic,  a  purgative,  a  promotor 
of  metabolism,  an  antiseptic,  and  an  antipyretic.  He 
gives  a  very  good  condensed  review  of  the  history 
of  hydrotherapy  from  Hippocrates  to  our  times. 

3.  The  Treatment  of  Patients  with  Hemiple- 
gia Resulting  from  Cerebral  Apoplexy. — Leszyn 
sky  gives  the  following  grounds  for  predisposition 
to  cerebral  h.Tniorrhage,  as  some  families  exhibit 
such  a  predisposition,  but  this  is  usually  an  indirect 
result  of  the  inherited  tendency  to  arterial  degen- 
eration:  I.  From  the  history  of  a  previous  attack. 
2.  From  the  constitutional  state  which  induces  arte- 
rial degeneration,  i.  e.,  senility,  chronic  nephritis, 
rheumatism,  gout,  diabetes,  syphilis,  lead  poisoning, 
etc.  3.  From  the  i:)rescnce  of  arterial  degeneration 
itself,  as  manifested  in  the  radial  and  temporal  arte- 
ries by  their  rigidity  and  tortuosity.  This  evidence 
of  arteriosclerosis  is  extremely  suggestive,  but  is 
not  positive  proof  of  a  similar  condition  of  the  cere- 
bral vessels.  It  has  recently  been  stated  that  tor- 
tuosity and  prominence  of  the  temporal  arteries  are 
commonly  due  to  the  frequent  pressure  of  a  rigid 
hat  band.  As  a  matter  of  fact,  however,  many  cases 
are  on  record  in  which  post  mortem  examination 
and  careful  microscopical  investigation  have  shown 
normal  cerebral  vessels  coexisting  with  degenerated 
temporal  and  radial  arteries.  The  presence  of  reti- 
nal hjemorrhages  and  ophthalmoscopic  evidence  of 


arteriosclerosis  furnish  indications  of  considerable 
value.  They  are  extremely  significant,  inasmuch 
as  they  point  to  a  state  in  which  cerebral  haemor- 
rhage is  most  likely  to  occur.  4.  From  the  pres- 
ence of  continuous  high  blood  pressure  (as  deter- 
mined by  the  radial  pulse  and  the  sphygmomano- 
meter), chronic  interstitial  nephritis,  and  ventricu- 
lar hypertrophy.  These  are  matters  which  demand 
painstaking  investigation.  In  all  cases  of  cerebral 
apoplexy,  and  in  those  patients  with  a  manifest  ten- 
dency thereto,  the  condition  of  the  arterial  system  is 
a  factor  of  cardinal  importance.  Too  much  em- 
phasis cannot  be  laid  upon  this  point. 

4.  Tuberculosis  of  the  Breast. — St.  Jacques  re- 
marks that  there  are  three  ways  of  treating  this 
condition  at  our  disposal :  ( i )  To  treat  these  cold 
abscesses  of  the  breast  as  we  do  those  of  similar  na- 
ture elsewhere,  that  is,  evacuating  by  aspiration, 
with  the  strictest  of  aseptic  precautions,  and  then 
injecting  into  the  pouch  a  modifying  liquid  either 
iodoform-glycerin  or  ether,  or  one  of  Calot's  mix- 
tures, viz.,  iodoform  and  creosote  with  ether  and 
oil;  (2)  to  open,  cauterize,  and  drain;  (3)  or  else 
again — and  this  a  more  radical  treatment — to  excise 
the  whole  of  the  breast  and  clean  out  the  axilla. 
Da  Costa  and  Keen,  Kiimmel  and  von  Bergmann, 
von  Bruns,  Delbet,  all  advise  excision  in  toto,  alleg- 
ing from  experience  far  better  results  through 
this  radical  procedure.  Nevertheless  he  hesitates  to 
accept  such  a  radical  suggestion  for  all  cases.  For 
there  are  cases  in  which  the  patient  comes  to  us 
with  only  small  abscesses,  as  well  localized  as  super- 
ficial, subcutaneous  ones,  without  the  least  glandu- 
lar reaction,  where  to  excise  at  once  the  whole  or- 
gan seems  to  him  a  rather  hasty  procedure.  He  con- 
cludes that  if  excision  of  the  breast  and  cleansing  of 
the  axilla  is  the  treatment  of  choice  in  a  large  num- 
ber of  cases  of  tuberculosis  of  the  breast,  there  are 
also  cases  with  superficial  and  subcutaneous  local- 
ization but  no  lymphatic  reaction,  in  which  evacua- 
tion by  aspiration  and  injection  of  a  modifying 
fluid,  or  else  cauterization  with  the  thermocautery, 
ought  to  be  used,  before  making  the  more  radical 
operation  of  excision  of  the  breast. 

5.  Achylia  Gastrica. — Knapp  concludes  his  pa- 
per in  saying:  "Let  the  reader  bear  in  mind  the  ex- 
treme importance  of  the  diagnosis  of  insufiicientia 
pylori.  Let  the  reader  bear  in  mind  that  insufiicien- 
tia pylori  may  masquerade  as  tuberculosis,  as  a  can- 
cer hidden  somewhere,  as  neurasthenia,  etc.  Let  the 
reader  bear  in  mind  that  the  diagnosis  of  a  fatal 
disease  invariably  leads  to  a  fatal  prognosis  and  that 
this  again,  most  likely,  to  a  fatal  issue  because  of 
improper  medication.  Let  the  reader  bear  in  mind 
that  insufiicientia  pylori  is  the  natural  sequel  of 
chronic  pyloritis  (incorrectly  and  commonly  known 
as  chronic  gastritis).  Let  the  reader  bear  in  mind 
that,  as  such  natural  sequel,  insufiicientia  pylori  is 
one  of  the  mo';t  common  diseases.  Let  the  reader 
bear  in  mind  that  no  matter  how  long  the  patients 
sufi"ered,  the  patients  do  get  well  and  are  complete- 
ly cured  under  the  appropriate  treatment  for  insuf- 
ficientia  pylori  in  an  almost  miraculously  short  time. 
Let  the  reader  bear  in  mind  that  achylia  gastrica 
has  been  born  of  an  insufficient  conception.  Let  the 
reader  bear  in  mind  that  there  is  no  such  thing  as 
achylia  gastrica." 


March  6,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


503 


BRITISH  MEDICAL  JOURNAL. 

February  13,  igog. 

1.  The  Signs  of  Early  Disease  of  the  Thyreoid  Gland, 

By  G.  R.  Murray. 

2.  Remarks  on  the  Nature  and  Treatment  of  Parenchy- 

matous Goitre,  By  F.  L.  A.  Greaves. 

3.  Pulmonary  Tuberculosis  in  Children, 

By  M.  H.  Williams. 

4.  Iodine  in  Surgical  Tuberculous  Disease, 

By  W.  A.  Tatchell. 

5.  The  Control  of  Infectious  Diseases  In  and  Out  of  the 

•  Schools,  By  A.  D.  Edwards. 

6.  The  Medical  Aspect  of  Dentistry  and  the  Necessity  of 

Dental  Instruction  for  Medical  Students, 

By  H.  P.  Pickerill. 

7.  Feeding  Trial  in  Relation  to  "Epidemic  Enteritis," 

By  E.  P.  MiNETT. 

8.  Can  Opsonic  Estimations  be  Relied  on  in  Practice? 

By  E.  C.  Hart. 

I.  Early  Thyreoid  Disease. — 3iliirray  draws 
attention  to  some  of  the  signs  of  early  disease  of  the 
thyreoid  gland.  The  symptoms  may  be  local  and 
mechanical  from  simple  enlargement  of  the  thy- 
reoid, or  constitutional  from  variations  in  the  func- 
tional activity  of  the  gland  induced  by  the  structural 
changes  which  occur  in  it.  As  the  function  of  the 
thyreoid  gland  is  to  supply  an  internal  secretion 
which  escapes  by  way  of  the  lymphatics  into  the 
blood  stream,  by  which  it  is  distributed  to  all  parts 
of  the  body,  diseases  of  the  thyreoid  gland  may  be 
divided  into  three  classes,  according  to  the  manner 
in  which  this  function  of  the  gland  is  influenced  by 
them.  Class  i.  Diseases  having  no  appreciable  ef- 
fect upon  the  secretory  function  of  the  gland,  such 
as  uncomplicated  acute  thyreoiditis,  simple  paren- 
chymatous goitre,  and  adenomatous  or  cystic  goi- 
tre. Class  2.  Diseases  lowering  or  abolishing  the 
secretory  function  of  the  gland,  such  as  cretinism 
and  myxoedema.  Class  3.  Diseases  increasing  and 
possibly  perverting  the  secretory  function,  as  ex- 
ophthalmic goitre,  and  those  cases  of  goitre  with 
tachycardia.  Simple  enlargement  of  the  gland  is 
often  physiological  and  occurs  in  response  to  some 
temporarv  stimulus  or  demand  for  an  increased 
functional  activity.  But  in  many  cases  it  goes  on 
increasing  and  becomes  pathological.  It  is  a  sim- 
ple hypertrophy,  analogous  to  that  of  the  mammary 
gland  which  takes  place  during  pregnancy  and  lac- 
tation. The  treatment  consists  in  supplying  the  in- 
creased amount  of  thyreoid  secretion  required  from 
another  source.  When  this  is  done  the  gland  grad- 
ually diminishes  in  size.  As  a  rule  a  unilateral  goi- 
tre is  due  to  an  adenoma  or  cyst  in  one  lobe,  the 
size  of  which  wotild  not  be  affected  by  thyreoid  ex- 
tract. Three  to  five  grammes  of  dry  thyreoid  pow- 
der is  usually  a  sufficient  dose.  If  goitre  is  preva- 
lent in  the  district,  the  patient  should  drink  only 
boiled  or  distilled  water.  Myxoedema  results  from 
a  partial  fibrosis  of  the  gland,  and  occurs  in  women 
between  forty  and  fifty  years  of  age.  The  early 
symptoms  are  often  mistaken  for  those  of  the  meno- 
pause. There  is  a  gradual  loss  of  mental  and 
physical  energy,  with  defective  memory,  and  slight 
visual  hallucinations.  Cold  is  often  complained  of. 
The  face  becomes  rounded  and  fuller,  and  there  is 
slight  swelling  of  the  eyelids.  The  skin  is  dry  and 
smooth,  and  a  fine  desquamation  takes  place.  Care- 
ful examination  of  the  neck  may  show  that  the  thy- 
reoid gland  is  diminished  in  size.  When  the  ovaries 
atrophy  at  the  same  time,  the  symptoms  of  the  men- 


opause—flushes, sweats,  etc. — may  be  superadded. 
Certain  forms  of  lipomatosis  closely  resemble  mild 
forms  of  myxoedema,  but  thyreoid  extract  has  no 
eft'ect  upon  the  swellings.  Exophthalmic  goitre  is 
due  to  excessive  secretion  of  the  gland,  the  goitre, 
exophthalmos,  tachycardia,  tremor,  and  sweating 
making  up  a  readily  recognizable  clinical  picture. 
The  only  tenable  explanation  of  the  exophthalmos 
is  an  abundant  development  of  the  retrobulbar  fat 
in  the  orbit.  Where  the  exophthalmos  is  absent, 
there  may  be  a  staring  expression  and  an  absence  of 
winking.  The  tachycardia  is  the  most  constant 
symptom,  and  many  cases  are  described  as  paroxys- 
mal tachycardia.  This  should  only  be  done  if  it  is 
the  only  symptom  present,  and  the  gland  is  not  en- 
larged. The  enlargement  of  the  gland  is  usually  not 
great.  The  mental  condition  is  very  important,  it 
being  characterized  by  irritable  weakness  and  dis- 
proportionate fatigue.  The  fine  tremor  of  the  hand 
is  usually  present.  The  secondary  variety  of 
Graves's  disease  is  that  which  supervenes  in  a  goitre 
of  long  standing.  Excessive  and  long  continued 
use  of  thyreoid  extract  may  produce  many  of  the 
symptoms  of  exophthalmic  goitre. 

2.  Parenchymatous  Goitre. — Greaves  tells  us 
that  in  parenchymatous  goitre  there  is  glandtilar 
proliferation  which  results  in  the  production  of 
clusters  of  cells  or  of  glandlike  acini  lined  with 
epithelium,  which  may  be  somewhat  irregular  and 
flattened  compared  with  the  normal  gland.  The  en- 
largement is  at  first  symmetrical,  but  later  its  shape 
becomes  irregular,  due  to  the  formation  of  small 
cysts  or  the  growth  of  a  definite  encapsulated  ade- 
noma, which  in  its  turn  becomes  cystic.  Malignant 
new  growths  and  suppuration  are  other  causes  of 
asymmetry.  ^^lany  goitres,  besides  the  deformity 
and  slight  dyspnoea,  give  rise  to  no  other  symptoms. 
Dyspnoea,  however,  is  often  urgent,  and  depends  on 
several  factors,  among  them  being  direct  pressure 
on  the  sides  of  the  trachea,  impaction  of  an  en- 
larged lobe  or  lobes  behind  the  sternum,  pressure  on 
the  recurrent  laryngeal  nerve,  etc.  Dyspnoea  due  to 
penetration  of  the  trachea  may  be  due  to  malignant 
disease  or  rupture  of  a  suppurating  cyst.  Acute 
oedema  of  the  glottis  is  occasionally  seen,  especially 
in  malignant  cases.  Difficulty  in  swallowing  is  not 
a  common  symptom.  Pressure  on  the  cardiac  nerves 
and  on  the  large  bloodves.sels  may  cause  tachycar- 
dia, irregularity  of  the  heart,  and  oedema  of  the  head 
and  face.  These  are  the  mechanical  symptoms.  If 
the  gland  is  removed  or  atrophies,  the  symptoms  of 
myxoedema  supervene.  But  symptoms  of  hyper- 
thyreoidism  are  uncommon  in  simple  hypertrophied 
goitres.  The  amount  of  colloid  material  present  is 
no  indication  of  the  amount  of  active  internal  secre- 
tion. The  enormous  increase  of  colloid  in  these 
cases  is  probably  a  sign  of  gland  degeneration 
rather  than  of  increased  cell  activity.  But  the  col- 
loid is  probably  the  vehicle  which  contains  the  ac- 
tive internal  secretion.  The  immediate  results  of 
thyreoid  operations  are  excellent ;  healing  by  first 
intention  is  practically  always  obtained.  The  writer 
describes  his  method  of  operating,  but  gives  no  re- 
sults. 

3.  Pulmonary  Tuberculosis  in  Children. — M. 

H.  Williams  holds  the  view  that  pulmonary  tuber- 
culosis is  one  of  the  most  common  diseases  of  child- 


504 


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[New  York 
Medical  Journal. 


hood,  and  that  amongst  those  who  die  of  it  at  the 
ages  when  it  causes  the  highest  mortality,  the  ma- 
jority have  contracted  and  suffered  from  the  dis- 
ease in  childhood — that  is,  during  the  first  fifteen 
years  of  life.  The  common  route  of  infection  ap- 
years  to  be  the  intestinal  mucosa — not  the  stomach 
■ — by  way  of  the  lacteals  or  lymphatics  to  the  mesen- 
teric glands,  thence  (either  free  or  in  phagocytes) 
into  the  thoracic  duct,  to  the  venous  circulation,  and 
thence  to  the  lungs.  The  deep  cervical  glands 
share  in  this  infection. 

LANCET. 

February  13,  igog. 

1.  The  Psychology  and  Psychogenesis  of  Hysteria  and 

the  Role  of  the  Sympathetic  System, 

■By  T.  D.  Savill. 

2.  The  Clinical  Value  of  Hsemomanometer  Observations, 

By  W.  Russell. 

3.  An  Inquiry  Concerning  the  Etiology  of  Beriberi.  A 

Preliminary  Communication, 

By  H.  Fraser  and  A.  T.  Stanton. 

4.  An  Interesting  Case  of  Multiple  Retroperitoneal  Hy- 

datid Cysts,  By  F.  C.  Madden. 

5.  On  the  Anatomical  Varieties  and  their  Bearing  on  the 

Treatment  of  Pathological  Conditions  of  the  Palatine 
Tonsils,  By  G.  S.  Hett. 

6.  The  .ILtiologT.-  of  the  Psoriatic  and  Allied  Conditions, 

By  M.  J.  Chevers. 

7.  Transposition  of  the  Viscera  Occurring  in  Brothers, 

By  L.  LOWENTHAL. 

8.  Case  of  Spontaneous  Pulsating  Exophthalmos, 

By  B.  HiRD  and  W.  F.  Haslam. 

9.  An  Unusual  (  ?  Instructive)  Case  of  x^ppendicitis, 

By  F.  J.  Smith. 

10.  A  Note  on  a  Case  of  "Leather  Bottle"  Stomach, 

By  J.  L.  Stretton. 

11.  The  Food  of  Elementary  School  Children, 

By  A.  H.  Gerrard. 

2.  Blood  Pressure  Observations.  —  Russell 
states  that  in  the  examination  of  the  pulse  there  are 
two  important  factors :  ( i )  The  pressure  of  the 
blood  inside  the  vessel,  and  (2)  the  thickness  of  the 
vessel  wall.  The  blood  pressure  apparatus  or 
hpemonianometer  determines  the  pressure  of  the 
blood  inside  the  vessel,  plus  the  compressibility  of  the 
vessel  wall  itself.  When  the  vessel  walls  are  thick- 
ened the  internal  pressure  can  only  be  judged  by 
the  fingers.  The  limit  of  blood  pressure  is  known, 
so  that  whenever  there  is  a  reading  with  the  hsemo- 
manometer  above  that  limit  it  means  that  the  vessel 
wall  is  thickened.  This  thickening  may  be  due  to 
two  factors,  (a)  anatomical  and  pathological 
changes,  and  (b)  to  mtisclc  contraction  or  spasm 
of  the  muscular  coat.  The  arteries  contract  and 
relax  in  response  to  the  composition  of  the  blood. 
Waste  materials  retained  in  the  circulation  irritate 
the  vessel  wall  directly  and  lead  to  its  contraction ; 
simple  excess  of  the  nutritive  material  taken  up  from 
the  intestine  probably  has  this  effect.  The  same  is 
true  of  putrefactive  products  absorbed  from  the  in- 
testinal tract :  while  thickened  vessels  retain  their 
power  of  contracting  under  the  stimulus  of  sub- 
stances present  in  the  blood ;  and  it  requires 
greater  jiressure  to  obliterate  an  artery  the  lumen 
of  which  is  one  eighth  of  an  inch  than  one 
of  one  quarter  of  an  inch,  even  if  the  walls  are  of 
equal  thickness  in  both.  So  that  hsemomanometer 
reading  quite  within  the  limits  of  normal  blood 
pressure  may  not  indicate  a  normal  blood  pressure 
but  a  pressure   much  below  normal  inside  a  con- 


tracted artery.  The  writer  describes  the  following 
types  of  cases  in  which  observations  made  by  the 
finger  plus  the  ha;momanometer  become  of  impor- 
tant value.  N eurasthentic  tvpe.  Here  the  pressure 
is  normal  with  the  vessels  in  a  state  of  constant  con- 
traction due  to  autotoxaemia.  By  reducing  the  pres- 
sure, even  below  normal,  the  symptoms  are  relieved. 
Cardiac  type.  The  same  phenomena  are  observed 
in  cardiac  disease.  There  is  no  attack  of  angina 
pectoris  without  this  contraction  of  systemic  ves- 
sels. Digestive  type.  This  is  very  common,  the 
vessel  constriction  being  due  to  constipation  or  to 
some  particular  dietetic  substance.  In  some  cases 
the  sustained  or  repeated  contraction  causes  perma- 
nent structural  change.  Certain  things  must  be 
abandoned  by  certain  individuals — tobacco,  alcohol, 
free  proteid  feeding,  etc.  Asthmatic  type.  The 
arteries  tighten  up  during  the  asthmatic  attack  and 
relax  during  the  cessation  of  seizure.  The  pressure 
may  fall  40  mm.  Hg.  This  suggests  that  the  at- 
tacks are  due  to  spasm  of  the  pulmonary  vessels  and 
not  of  the  bronchi.  Renal  type.  Here  the  haemo- 
manometer  reading  is  very  variable,  such  variations 
occurring  in  the  vessel  wall  and  not  in  the  pressure 
itself.  A  sharp  rise  in  pressure  gives  warning  that 
an  attack  of  ursemia  is  impending.  Cerebral  type. 
This  is  most  important.  By  relaxing  the  contrac- 
tion of  the  vessel  walls,  and,  in  addition,  stimulating 
the  relatively  feeble  action  of  the  heart,  cerebral 
softening  can  often  be  prevented  and  hemiplegias 
rapidly  cured. 

3.  Beriberi. — Fraser  and  Stanton  have  studied 
the  occurrence  of  beriberi  among  parties  of  immi- 
grant laborers  on  the  Malay  peninsula,  it  being  possi- 
ble to  obtain  exact  information  as  to  their  dietary 
and  their  methods  of  preparing  the  same.  Twenty 
cases  of  beriberi  occurred  among  220  people  eating 
white  rice.  No  case  occurred  among  273  people  on 
parboiled  rice  and  under  similar  conditions  to  those 
which  obtained  in  the  white  rice  parties  at  the  time 
beriberi  was  prevalent  among  them.  Only  un- 
equivocal cases  of  the  disease  were  included,  and 
many  were  excluded  which  ordinarily  would  have 
been  considered  as  beriberi;  and  such  cases  oc- 
curred only  among  people  who  consumed  white 
rice.  No  case  of  beriberi  occurred  in  any  coolie 
who  had  been  on  white  rice  for  a  less  period  oi' 
eighty-seven  days.  Systematic  examinations  of  the 
blood  and  urine  of  the  patients  failed  to  show  any 
organisms  except  those  well  known  as  the  causative 
agents  of  other  diseases.  At  times  patients  in  vari- 
ous stages  of  beriberi  were  in  contact  with  men  on 
parboiled  rice.  No  cases  occurred  among  the  latter, 
showing  that  the  disease  is  not  a  directly  communi- 
cable one.  Removal  of  patients  suffering  from  beri- 
beri from  one  place  to  another  did  not  influence  the 
progress  of  the  disease,  and  removal  of  entire  par- 
ties from  the  place  where  the  disease  had  occurred 
did  not  influence  the  progress  of  the  outbreak  so 
long  as  they  continued  on  white  rice.  This  sug- 
gests, although  it  does  not  prove,  that  place  per  sc 
or  considered  as  a  nidus  of  infection  has  no  influ- 
ence upon  the  development  of  beriberi.  In  three  in- 
stances in  which  definite  outbreaks  of  beriberi  oc- 
curred among  parties  on  white  rice  substitution  of 
l^arboiled  rice  was  followed  by  a  cessation  of  the 


March  6.  1909.  | 


I'lTH  OF  CURRENT  LITERATURE. 


505 


outbreaks.  No  evidence  was  obtained  to  show  that 
any  article  of  food  other  than  rice  was  a  possible 
source  of  a  causative  agent  of  the  disease.  Ancylo- 
stomes  and  other  nematode  worms  were  not  found 
in  a  larger  proportion  of  patients  suffering  from 
beriberi  than  in  the  general  population  under  ob- 
servation. The  writers,  therefore,  conclude  that  the 
disease  beriberi  as  it  occurs  in  the  Malay  peninsula 
has,  if  not  its  origin  in,  at  least  an  intimate  relation- 
ship with  the  consumption  of  white  rice,  and  that 
further  research  along  these  lines  should  be  insti- 
tuted. 

LA  PRESSE  MEDICALE. 
January  2j,  i<)og. 

1.  Transplantation  of  a  \'ein  in  Plastic  Surgery  of  the 

Urethra,  By  T.  Tanton. 

2.  The  Ouloplasic  Action  of  High  Frequency  Currents, 

By  A.  ZiMMERX. 

3.  ^iitiologj'  and  Treatment  of  Functional  Spasm  (Writ- 

er's Cramp),  By  Laxel. 

1.  Plastic  Surgery  of  the  Urethra. — Tanton  re- 
ports a  case  in  which  he  successfully  treated  hypos- 
padia by  the  transplantation  of  a  portion  of  a  vein 
to  serve  as  a  urethra.  The  technique  of  the  opera- 
tion, which  is  rather  complex,  is  given  in  detail.  He 
considers  the  operation  one  to  be  done  preferably 
on  adults,  but  possible  in  young  persons.  The  same 
method  may  be  applicable  in  cases  of  epispadias. 

2.  High  Frequency  Currents. — Zimmern's  arti- 
cle is  an  essay  on  the  results  of  fulguration  in  which 
he  states  that  this  has  a  remarkable  property  of  ex- 
citing the  process  of  fibrosis  and  thereby  altering  the 
malignancy  of  a  tumor.  Thus  he  says  that  the  effect 
of  fulguration  is"  to  transform  a  virulent,  infective, 
extensive  cancer  into  a  new  tumor  of  the  scirrhus 
type,  that  is  into  one  which  is  relatively  benign,  not 
susceptible  of  metastasis,  of  slow  development  and 
may  not  be  the  direct  cause  of  death  in  the  patient, 
as  a  patient  may  live  very  long  with  a  cancer  of  this 
type. 

3.  Writer's  Cramp. — Lanel  recommends  me- 
thodical vibration  and  hot  air  in  these  cases. 

January  30,  iQOg. 

1.  Diseases  of  the  Tongue,  By  ^^Iaurice  Letulle. 

2.  Treatment  of  Comminuted  Fractures  of  the  Upper  End 

of  the  Bones  of  the  Leg,  By  P.  Alglave. 

3.  Regression  of  a  Sarcoma  of  the  Gums  through  Fibro- 

matous  Change  under  the  Influence  of  Ultra  Pene- 
trating Radium  Rays, 

By  DoMiNici  AXD  Faure-Ee.\ulieu. 

4.  Drainage   of  the   Cerebral   Ventricles   by   Means  of 

Transplanted  Veins.  By  R.  Rom  me. 

1.  Diseases  of  the  Tongue. — Letulle  presents 
the  microscopical  appearances  in  certain  diseases  of 
the  tongue  and  deals  with  their  recognition  in  the 
living  subject. 

2.  Comminuted  Fractures  of  the  Upper  End  of 
the  Bones  of  the  Leg. — Alglave  presents  photo- 
graphs and  radiographs  which  show  the  results  ob- 
tained in  a  case  of  this  nature  by  what  he  calls  "cer- 
clage central,"  cutting  down  upon  the  fragments 
and  securing  them  in  proper  position  by  means  of 
silver  wire.    The  result  was  very  gratifying. 

3.  Sarcoma  of  the  Gum  Changed  into  a  Fibro- 
ma by  Radium  Rays. — Dominici  and  Faure-Beau- 
lieu  give  a  very  complete  history  of  a  case  of  this 
nature  and  show  the  histological  appearances  pre- 
sented by  sections  of  the  growth  at  different  periods. 


They  assert  that  the  radium  rays  metamorphosed  a 
malignant  sarcoma  into  a  fibroma,  a  benign  tumor 
composed  of  fibrous  connective  tissue. 

LA  SEMAINE  MEDICALE. 
January  27,  igog. 
The  Impossibilit}-  of  Carrying  Tuberculosis  to  the  Lungs 
through  the  Lymphatics,  By  J.  Lhermitte. 

Impossibility  of  Carrying  Tuberculosis  to  the 
Lungs  through  the  Lymphatics.— Lhermitte  al- 
leges that  it  is  proved  both  clinically  and  by  path- 
ology that  the  tubercle  bacilli  are  not  carried  to  the 
lungs  by  the  lymphatics  unless  in  very  exceptional 
cases.  Conveyance  by  the  blood  is  contrary  to  clin- 
ical, anatomical,  and  experimental  evidence.  This 
leaves  but  one  method  of  approach,  through  the  air. 
He  considers  this  theory  the  oldest  in  date,  the 
most  logical,  and  the  least  contestable. 

February  3,  igog. 
The  Various  Types  of  Cardiac  Arhythmia  Observed  Clin- 
ically, By  L.  Bard. 

Cardiac  Arhythmia. — Bard  suggests  a  classifica- 
tion in  which  the  four  principal  groups  are  i,  inter- 
mittent; 2,  constant  irregular;  3,  quavering  {ca- 
uoicccs),  and  4,  cyclic.  Each  of  these  groups  has 
several  subdivisions. 

BERLINER  KLINISCHE  WOCH ENSCH Rl FT 
January  25,  igog. 

1.  Fatal  Haemoptysis  from  Bursting  of  Aneurysms  Orig- 

inating from  Nontuberculous  Bronchiectasies, 

By  H.  Chi.xri. 

2.  Further  Experiences  in  the  Treatment  of  Rhinoscler- 

oma  with  the  X  Rays, 

By  AxTox  R.  vox  Ruediger-Rydygier. 

3.  Contributions  to  Sigmoscopy,  By  H.  Strauss. 

4.  The  Practical  Importance  of  the  Serum  Diagnosis  in 

Syphilis,          By  C.  Bruxs  and  L.  Halberstadter. 
3.    The  Technique  of  the  Wassermann-Xeisser-Bruck  Re- 
action as  Proposed  by  Bauer,      By  E.  ]\Ieiro\vsky. 

6.  The  Treatment  of  Bad  Strictures  of  the  Urethra, 

By  J.  CoHX. 

7.  Improved  Method  for  the  Determination  of  the  Anti- 

tryptic  Power  of  the  Blood,  By  Marcus. 

8.  The  Transmissible  Leuchaemia  of  Hens. 

By  Hans  Hirschfeld  and  Jacoby. 
9-    Radium  Cataphoresis, 

By  F.  L.  Kohlrausch  and  Carl  Mayer. 

10.  The  Determination  of  the  Volume  of  the  Blood  Cor- 

puscles. Bv  M.  Hoxxiger. 

11.  Eulation  in  Pertussis,  By  Paul  Fr.^exkel. 

2.  Treatment  of  Rhinoscleroma  with  the  X 
Rays. — \'on  Ruediger-Rydygier  reports  the  re- 
sults obtained  in  fourteen  of  these  cases  and  remarks 
in  conclusion  that  the  subjective  improvement  of  the 
symptoms  appears  at  a  very  early  stage  of  the  treat- 
ment and  persists  for  a  long  time  even  when  the 
healing  is  incomplete.  This  is  not  wholly  an  advan- 
tage because  it  tends  to  incline  both  the  patients  and 
the  physician  to  discontinue  treatment  too  soon  and 
may  induce  neglect  when  recurrence  occurs. 

5.  Bauer's  Modification  of  the  Technique  of 
the  Wassermann  Reaction. — ^^leirowsky  appreci- 
ates the  need  for  a  simplification  of  the  technique  of 
obtaining  the  Wassermann-Xeisser-Bruck  reaction, 
but  after  a  test  of  the  modification  suggested  by 
Bauer  does  not  consider  it  satisfactory. 

6.  Urethral  Strictures. — Cohn  favors  the  grad- 
ual dilatation  of  urethral  structures  with  bougies  in 
most  cases.  His  experience  is  that  thiosiamin  and 
fibrolysin  exert  no  influence  upon  cicatrices  in  the 
urethra.    Adrenalin  can  be  used  with  advantage  in 


5o6 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


cases  of  urethral  stricture  associated  with  congest- 
ive conditions.  When  gradual  dilatation  is  impossi- 
ble or  impracticable  internal  urethrotomy  should  be 
performed.  External  urethrotomy  must  be  per- 
formed in  cases  in  which  a  filiform  bougie  cannot 
be  made  to  pass  the  stricture. 

9.  Radium  Cataphoresis.  —  Kohlrausch  and 
Mayer  raise  the  question  what  part  of  the  benefits 
obtained  b}'  radium  treatment  is  due  to  cataphoresis. 
They  find  that  after  a  radioactive  bath  without  cata- 
phoresis no  trace  of  emanation  can  be  found  in  the 
urine. 

MUNCHENER  MEDIZINISCHE  WOCH ENSCHRI FT. 
lanuary  26,  igog. 

1.  Rctroflection  of  the  Uterus  in  General  Practice, 

By  Henkel. 

2.  Treatment  of  Placenta  Praevia,  By  Fiessler. 

3.  Distinctive  Diagnosis  of  Leuchsemias,      By  Schultze. 

4.  Treatment  of  Superficial  Carcinoma  of  the  Skin, 

By  Rehn. 

5.  Change  of  the  Size  of  the  Heart  in  Hot  and  Cold  Baths, 

By  Beck  and  Dohan. 

6.  Further  Observations  in  the  Treatment  of  Tuberculo- 

sis with  Marmorek's  Serum,  By  Schenker. 

7.  Cure  of  Hyperidrosis  and  of  Seborrhoea  Oleasa  by  Means 

of  the  X  Ray,  By  Kromayer. 

8.  Treatment  of  Diphtheria  with  Pyocyanasis, 

By  Grasz  and  Barr. 

9.  Phtysoremid,  By  Kohler. 

10.  Treatment  of  Syphilis  with  Gray  Oil,  By  Geyer. 

11.  Endemic  Angina  Pneumococcica,  By  Schomerus. 

12.  A  Case  of  Embolism  of  the  Radial  and  Ulner  Arteries 

of  the  Left  Arm,  By  Hopffner. 

13.  Treatment  and  Prevention  of  Nontraumatic  Neurosis 

of  the  Kidney,  By  Beyer. 

14.  Report  Concerning  tiie  Capacity  of  the  Institution  for 

the  Care  of  Pulmonary  Diseases  of  the  Society  for 
the  Control  of  Tuberculosis  in  Munich,     By  Ranke. 

15.  A  Simple  Lens  Holder  for  Ophthalmological  Purposes, 

By  Kehr. 

16.  Clinical  Obstetric  Teaching,  with  Especial  Reference  to 

Antiseptic  Precautions,  By  Vogel. 

2.  Placenta  Prasvia. — Fiessler  gives  the  follow- 
ing statistics  of  iii  cases  of  placenta  praevia  seen 
in  the  Universitats-Frauenklinik  at  Tiibingen,  be- 
tween January  i  and  November  i,  1908.  Eight  of 
the  women  were  between  the  ages  of  twenty  and 
twenty-five,  twenty-four  between  twenty-six  and 
thirty,  twenty-six  between  thirty-one  and  thirty- 
five,  thirty-two  between  thirty-six  and  forty,  eigh- 
teen between  forty-one  and  forty-five.  The  ages  of 
two  patients  were  not  given.  The  labor  was  the 
first  in  eight  cases,  the  second  in  twelve,  the  third 
to  the  sixth  in  thirty-five,  the  seventh  to  the  tenth 
in  thirty-five,  the  tenth  to  the  fifteenth  in  seventeen, 
the  sixteenth  or  more  in  three.  Antecedent  patho- 
logical labors  had  taken  place  in  fifty-nine,  twenty- 
four  placental  complications  including  five  of  pla- 
centa praevia,  twenty-nine  abortions  or  miscar- 
riages. Anomalies  of  menstruation  were  present  in 
forty-five.  Gynaecological  operations  had  been  per- 
formed on  four.  Complications  during  the  preg- 
nancy under  consideration  were  heart  disease  in 
two  cases,  pulmonary  disease  in  two,  albuminuria 
in  four,  excessive  vomiting  in  two,  pain  and  spasms 
in  two,  struma  in  one,  psychic  trouble  in  one,  varix 
in  one,  hfemorrhages  in  the  beginning  of  pregnancy 
in  eleven.  H.-cmorrhages  began  before  the  twenty- 
fifth  week  in  eight  cases,  during  the  twenty-sixth 
and  twenty-seventh  weeks  in  fifteen,  during  the 
twenty-eighth  to  thirtieth  weeks  in  sixteen,  during 
the  thirty-first  and  thirty-second  weeks  in  sixteen. 


during  the  thirty-third  and  thirty-fourth  weeks  in 
nineteen,  during  the  thirty-fifth  and  thirty-sixth 
weeks  in  thirteen,  during  the  thirty-seventh  and 
thirty-eighth  weeks  in  thirteen,  during  the  thirty- 
ninth  and  fortieth  weeks  in  ten.  In  22.5  per  cent, 
of  the  cases  the  child  was  not  viable,  in  the  balance 
the  child  had  reached  a  viable  age.  The  duration 
of  the  haemorrhages  was  only  a  few  hours  in  three 
patients,  one  day  in  nineteen,  two  or  three  days  in 
seven,  four  to  seven  days  in  fourteen,  one  to  two 
weeks  in  nineteen,  three  to  four  weeks  in  eighteen, 
five  to  six  weeks  in  thirteen,  seven  to  eight  weeks 
in  ten,  nine  to  ten  weeks  in  four,  and  ten  to  fifteen 
weeks  in  three.  Duration  of  clinical  treatment  be- 
fore labor :  Immediate  delivery  in  five  cases,  deliv- 
ery after  a  few  hours  in  fifty-seven,  after  one  day 
in  fourteen,  after  two  days  in  three,  after  three 
days  in  seven,  after  four  days  in  five,  after  from 
five  to  seven  days  in  five,  after  one  to  two  weeks  in 
nine,  after  three  to  four  weeks  in  five.  Of  the 
sixty-two  delivered  immediately  or  within  a  few 
hours  twenty-two  had  been  tamponed  by  outside 
physicians,  six  had  been  tamponed  by  midwives,  and 
seven  had  been  examined  by  midwives.  Duration 
of  hospital  treatment :  Ten  to  fifteen  days  in  forty- 
three  cases,  sixteen  to  twenty  days  in  eighteen, 
twenty-one  to  twenty-five  days  in  fifteen,  twenty-six 
to  thirty  days  in  six,  thirty-one  to  thirty-five  days 
in  four,  thirty-six  to  forty  .days  in  four,  one  and  a 
half  to  four  months  in  eleven.  Eleven  patients  died. 
I'orty-nine  were  cases  of  central  placenta  praevia, 
thirty-six  of  lateral,  twenty-two  of  marginal,  four 
were  deep  seated.  Eighty-three  patients  were  de- 
livered by  version,  ten  by  vaginal  Caesarean  section, 
nine  by  extraperitoneal  section  of  the  uterus,  four 
■pontaneously,  eight  by  colpeurysis,  and  four  by  arti- 
licial  rupture  of  the  membranes.  Preliminary  tam- 
]ioning  was  practised  in  fifty  patients,  in  sixty  per 
cent,  of  whom  fever  developed,  while  only  in  thirty 
per  cent,  of  those  who  were  not  tamponed  fever  de- 
veloped. The  placenta  came  away  spontaneously  in 
twenty-one  patients,  and  had  to  be  expressed  in 
sixty-two,  usually  on  account  of  haemorrhage,  and 
removed  manually  in  eleven  because  of  adhesions,  in 
nine  cases  after  expression  had  failed.  After  labor 
the  genital  tract  was  tamponed  in  forty  patients,  in 
fifty-two  hot  intrauterine  douches  were  used  to 
check  haemorrhage,  in  three  the  uterus  was  removed 
because  of  the  danger  of  fatal  haemorrhage,  in  one 
because  of  infection.  In  nineteen  cases  the  women 
were  so  exsanguinated  that  salt  solutions  were  in- 
fused. 

4.  Superficial  Carcinoma  of  the  Skin. — Rehn 
does  not  find  the  x  ray  of  great  value  in  these  cases 
and  recommends  excision. 

5.  Change  of  the  Size  of  the  Heart  in  Hot  and 
Cold  Baths. — ^Beck  and  Dohan  report  their  obser- 
vations on  fourteen  patients  given  baths  of  differ- 
ent temperatures.  In  six  out  of  seven  given  hot 
baths,  from  40°  to  45°  C,  the  heart  was  diminished 
in  size  after  the  bath,  in  several  cases  very  mark- 
edly. After  a  cold  bath  the  heart  was  increased  in 
size  in  four  out  of  five  patients  and  remained  the 
same  in  only  one.  In  three  the  enlargement  was  re- 
markable. After  warm  baths  in  which  the  warmth 
did  not  exceed  the  body  temperature,  35°  C.  the 
size  of  the  heart  was  but  slightly  diminished. 


March  6,  igcQ.l 


PITH  OF  CURRENT  LITERATURE. 


507 


AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 
February,  ipog. 

1.  Gastric  Neuroses,  By  J.  B.  Deaver. 

2.  The  Treatment  of  Chronic  Bronchitis, 

By  F.  FORCHHEIMER. 

3.  Open  Air  and  Hypersemic  Treatment  as  Powerful 

Aids  in  the  Management  of  Complicated  Surgical 
Tuberculosis  in  Adults,  By  Willy  Meyer. 

4.  The  Heart  and  Pulmonary  Tuberculosis.    The  Heart 

Itself  Diseased,  By  L.  Brovvn. 

5.  Bacillus  Coli  Communis.    The  Cause  of  an  Infection 

Clinically  Identical  with  Typhoid  Fever, 

By  W.  Colemax  and  T.  W.  Hastings. 

6.  Acute  Syphilitic  Diseases  of  the  Spinal  Cord.    A  Dis- 

cussion of  Syphilitic  Paralysis, 

By  J.  Collins  and  C.  G.  Taylor. 

7.  Habitual  or  Recurrent  Anterior  Dislocation  of  the 

Shoulder.    Etiology  and  Pathology-. 

By  T.  T.  Thomas. 

8.  The  Clinical  Forms  of  Pyelonephritis, 

By  D.   X.  ElSENDR.\TH. 

9.  The  Operative  Treatment  of  Deflection  of  the  Nasal 

Sneptum,  By  C.  W.  Richardson. 

10.  The  Further  Report  of  a  Case  of  Tracheal  Scleroma, 

By  E.  Mayer. 

11.  The  Presence  of  Tubercle  Bacilli  in  the  Circulating 
Blood  in  Tuberculosis,  By'R.  C.  Rosenberger. 

I.  Gastric  Neuroses. — Deaver  thinks  there  is 
no  medical  term  whicli  hides  so  much  ignorance 
as  the  term  neurosis.  He  believes  there  are  certain 
morbid  gastric  conditions,  however,  which  may  be 
called  neuroses,  in  which  both  the  surgeon  and  the 
physician  are  called  upon  to  confirm  a  diagnosis  or 
suggest  a  treatment.  He  refers  particularly  to  the 
set  of  gastric  symptoms,  known  grossly  as  nervous 
dyspepsia.  These  exclude  an  organic  stomach  lesion, 
or  a  lesion  beyond  the  stomach  of  which  they  may  be 
reflexes  by  the  very  use  of  the  term  neurosis.  Funda- 
mentally a  gastric  neurosis  without  other  neuroses  or 
neurasthenic  conditions  is  a  great  rarity.  The  symp- 
toms to  which  reference  is  made  are  anorexia,  hyper- 
chlorhydria,  vomiting,  eructations,  colic,  atony,  and 
a  vague  combination  of  sensory,  motor,  and  secre- 
tory symptoms.  These  symptoms  must,  however, 
be  carefully  studied  and  considered,  and  they  will 
often  prove  that  the  various  organs  concerned  in 
digestion  form  a  system  correlated  in  every  part. 
It  will  not  infrequently  be  found  that  thev  are  the 
perceptible  manifestations  of  disease  in  the  liver, 
gall  bladder,  bile  ducts,  appendix,  or  kidney,  which 
will  demand  surgical  interference.  If,  however,  it 
becomes  plain  that  neuroses  of  the  stomach  actually 
exist  the  warning  is  reiterated  that  surgical  inter- 
ference is  not  indicated. 

3.  Open  Air  and  Hyperaemic  Treatment  as 
Powerful  Aids  in  the  Management  of  Compli- 
cated Surgical  Tuberculosis  in  Adults. — Meyer 
states  that  certain  forms  of  bone  tuberculosis  can- 
not be  cured  by  operation  alone.  Among  them  are 
tuberculosis  of  the  sacrum  and  the  pelvis,  compli- 
cated with  suppurating  coxitis.  Persistent  sinuses 
following  excision  of  the  hip  joint  often  seem  in- 
curable. Recurrent  cold  abscess  in  tuberculosis  of 
the  pelvis  is  always  a  grave  complication,  though 
it  may  sometimes  be  overcome  by  injection  of  iodo- 
form emulsion  and  persistent  hyperemia  for  the 
bone  or  joint.  The  cases  which  do  not  yield  to  such 
treatment  may  be  greatly  benefited  by  open  air 
treatment ;  indeed  it  may  mean  the  saving  of  life 
or  limb.  The  history  of  three  cases  which  yielded 
to  the  combined  effect  of  suction  treatment  and 


open  air  life  is  narrated,  and  a  plea  is  made  that 
in  all  country  sanatoria  for  consumptives  a  male 
and  a  female  ward  be  set  apart  for  surgical  cases, 
to  be  under  the  care  of  an  assistant  conversant  with 
Bier's  hvpersemic  treatment.  Eventually  philan- 
thropists or  the  State  should  erect  hospitals  exclu- 
sively for  this  class  of  patients,  for  in  the  majority 
of  them  there  are  no  complicating  tuberculous  af- 
fections of  the  lungs. 

4.  The  Heart  in  Pulmonary  Tuberculosis. — 
Brown  states  that  pulmonary  stenosis  is  always  the 
primary  heart  lesion  with  pulmonary  tuberculosis, 
mitral  insuflficiency  and  aortic  insufficiency  being 
usually  secondary.  The  most  frequent  secondary 
cardiac  lesion  in  patients  who  are  able  to  be  about 
is  mitral  stenosis.  Pulmonary  tuberculosis  occurs 
more  frequently  with  patients  who  have  pulmonary 
stenosis  than  in  any  other  form  of  cardiac  disease. 
Mitral  insufficiency  is  associated  with  pulmonary 
tuberculosis  more  frequently  than  any  other  form 
of  valvular  disease,  but  aortic  insufficiency  is  al- 
most as  frequent.  Aortic  stenosis  is  rarely  a  com- 
plication of  pulmonary  tuberculosis  and  involve- 
ment of  several  valves  simultaneously  rarely  oc- 
curs. The  treatment  is  the  same  which  would  be 
proper  if  tuberculosis  were  not  present.  An  eleva- 
tion of  more  than  2,000  feet  is  inadvisable,  unless 
the  heart  is  well  compensated.  Overexertion  must 
be  avoided,  arsenic,  strychnine,  ice  bags,  carbonic 
acid  baths,  massage,  rest  at  first  and  careful  exer- 
cise later  are  measures  that  will  be  found  useful. 

6.  Acute  Syphilitic  Disease  of  the  Spinal  Cord. 
— Collins  and  Taylor  note  the  fact  that  ye:'r  by 
year  it  becomes  more  firmly  established  that  syph- 
ilis is  the  chief  cause  of  acquired  disease  of  the 
nervous  system.  The  discovery  of  the  spirochseta 
and  the  determination  of  the  specificity  of  the 
serum  reaction  for  syphilis  have  given  firm  founda- 
tion to  what  v.as  previously  conjecture  and  pre- 
sumption concerning  the  dependence  of  certain 
diseases  of  the  nervous  system  upon  syphilis.  Thus 
tabes  and  general  paresis  give  a  specific  serum  di- 
agnostic reaction,  and  specific  antibodies  are  de- 
monstrable in  the  serum  or  cerebrospinal  fluid  by 
a  technique  which  is  still  very  complicated.  Nonne 
is  quoted  as  giving  the  following  anatomical  foun- 
dation for  syphilitic  spinal  paralysis:  i,  A  chronic 
punctate,  transverse  myelitis  with  ascending  and 
descending  degeneration ;  2,  a  similar  condition,  to- 
gether with  primary  degeneration  of  the  pyramidal 
tracts ;  3,  degeneration  of  the  pyramidal  tracts 
alone :  4,  degeneration  of  the  posterior  and  of  the 
lateral  columns,  a  combined  systemic  disease. 

9.  The  Operative  Treatment  of  Deflection  of 
the  Nasal  Sasptum. — Richardson  draws  the  fol- 
lowing conclusions:  i.  The  old  method  of  treat- 
ment gives  a  saeptum  maintaining  its  anatomical  in- 
tegrity. The  submucous  operation  gives  a  flaccid 
saeptum,  minus  certain  elements  formerly  consid- 
ered essential.  Renewal  of  cartilage  and  bone 
does  not  seem  to  affect  nasal  function.  2.  The  old 
operation  requires  about  ten  minutes ;  the  submu- 
cous about  half  an  hour.  3.  The  old  method  re- 
quires the  use  of  a  splint  for  a  week  or  ten  days, 
while  the  packing  in  the  submucous  operation  is 
removed  in  twenty-four  hours.   4.   The  old  method 


5o8 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


gives  rise  to  pain  and  discomfort  until  the  splint 
is  removed ;  in  the  submucous  there  is  no  post  oper- 
ative pain.  5.  By  the  old  method  the  patient  must 
remain  in  bed  several  days ;  by  the  new  one  he  is 
out  of  bed  and  well  in  forty-eight  hours.  6.  The  old 
method  is  rarely  attended  with  perforation,  but 
perforations  do  occur  with  the  new  one.  In  skill- 
ful hands,  however,  the  new  operation  is  greatly  to 
be  preferred. 

 <$,  


NEW  YORK  ACADEMY  OF  MEDICINE. 
Meeting  of  December  ij,  igo8. 
The  President,  Dr.  John  A.  Wyeth,  in  the  Chair. 

This  meeting  was  held  under  the  auspices  of  the 
Section  in  Genitourinary  Surgery.  It  was  devoted 
to  the  surgery  of  ureteral  calculi. 

The  Surgical  Anatomy  and  Pathology  of  Ure- 
teral Calculus  and  its  Operative  Indications. — 
Dr.  Benjamin  Merrill  Ricketts,  of  Cincinnati, 
divided  ureteral  anatomy  into  three  distinct  classi- 
fications— normal,  pathological,  and  anomalous. 
Normal  anatomy  was  that  based  upon  embryonic 
development  in  structure  and  relation.  Salbertus, 
in  1585,  described  the  normal  anatomical  structures  ; 
Dilthey,  in  1723,  described  the  valves  of  the  ureters; 
C.  Bell,  in  1812,  described  the  muscles  of  the  ure- 
ters. To-day  the  anatomy  of  the  ureter  was  as  well 
founded  as  that  of  any  other  animal  tissue.  The 
normal  ureter  was  divided  into  dilatations,  constric- 
tions, isthmuses,  reservoirs,  spindles,  ampullae,  and 
spirals,  each  of  which  might  vary  in  number  and  di- 
mensions. The  ureteral  isthmuses  were  three  in 
number — proximal,  middle,  and  distal.  The  first 
was  the  constriction  located  adjacent  to  the  distal 
renal  pole ;  the  second  was  at  the  point  where  the 
ureter  crossed  the  iliac  vessels ;  the  third  was  lo- 
cated in  the  wall  of  the  bladder  at  the  distal  end  of 
the  ureter.  Ureteral  dilatations  he  divided  into 
proximal  (calices  and  pelvis),  middle  (lumbar  spin- 
dle), and  distal  (pelvic  spindle).  They  were  reser- 
voirs and  werrf  due  to  obstruction  to  the  flow  of 
urine  through  the  ureteral  isthmuses  or  constric- 
tions. Spirility  was  a  common  property  of  the  ure- 
ter. Anomalous  anatomy  deviated  from  the  normal 
structure  and  relation  and  was  due  to  defective  em- 
bryonic development,  such  as  malformations  or  mal- 
positions. Each  kidney  might  have  one  or  two  ure- 
ters entering  the  bladder,  or  there  might  be  but  one 
ureter  connecting  both  kidneys  with  the  bladder. 
There  might  be  one  or  both  kidneys  without  any 
ureter  whatever.  Numerous  ureters  might  be  given 
oflF  from  one  or  more  kidneys,  each  to  open  inde- 
pendently into  the  bladder,  or  they  might  unite  to 
form  but  one  opening  into  the  bladder,  or  one  or 
more  openings  from  one  or  more  ureters  might  en- 
ter the  alimentary  canal  at  any  point,  the  vagina, 
uterus,  peritoneal  cavity,  or  abdominal  wall,  or  there 
might  be  an  entire  absence  of  ureteral  exit.  The 
point  of  entrance  in  the  bladder  might  be  anywhere 
above  the  internal  sphincter  of  the  urethra,  behind 
or  in  front  of  the  peritonaeum.  The  dimensions  of 
the  ureter  might  be  equally  varied.    The  length 


might  be  greater  or  less  than  the  normal,  and  their 
course  to  the  bladder  and  relations  to  the  surround- 
ing structures  might  be  absolutely  at  variance  with 
the  normal  type.  They  might  have  a  direct  or  cir- 
cuitous course  to  the  bladder,  behind  or  in  front  of 
the  peritonaeum.  They  might  be  straight,  spiral, 
curved,  or  angular,  and  the  circumference  might  be 
also  greater  or  less  than  normal  and  vary  consider- 
ably at  dif¥erent  points.  The  blood  and  nerve  sup- 
ply might  vary  from  the  normal  to  any  degree ;  the 
entire  absence  of  one  or  both  having  been  observed. 
Prolapse,  occlusion,  calculus,  cysts,  rupture,  fistulje, 
tuberculosis,  inflammation,  ulcer,  benign  and  ma- 
lignant neoplasms,  etc.,  were  the  abnormal  condi- 
tions other  than  causes  due  to  irregular  foetal  de- 
velopment, and  belonged  to  the  second  class,  patho- 
logical anatomy.  Prolapse  might  be  congenital  or 
acquired,  partial  or  complete.  Occlusion  represent- 
ed obstruction  due  to  any  cause,  at  any  point,  in  any 
degree,  due  to  injury  from  within  or  without  the 
ureter,  such  as  blows  or  surgical  operations.  Bands, 
ulcers,  and  cicatrices  were  prominent  factors  in  its 
causation.  Calculus  formed  primarily  in  the  ureter 
was  rare.  When  it  did  occur,  it  was  composed  of 
phosphatic  salts  deposited  above  a  stricture  or  upon 
an  ulcer  or  foreign  body  within  the  ureter.  Cysts 
might  be  multiple  or  single,  primary  or  secondary. 
Eve,  in  1889,  reported  a  case  of  cysts  of  both  ure- 
ters in  a  woman,  aged  fifty-one  years.  Rupture  was 
an  incident  and  seldom  involved  the  entire  circum- 
ference of  the  ureter.  Fistula  was  also  an  inci- 
dent. The  most  frequent  cause  was  surgical  op- 
eration for  the  removal  of  uterine  neoplasms  per 
vaginam.  Tuberculosis  was  common.  Bang  and 
Gemmell,  in  1886,  each  reported  a  case  of  primary 
tuberculosis  of  the  ureter.  Benign  neoplasms  were 
not  common,  but  were  of  sufficient  frequency  to  be 
given  due  consideration.  Lebert  described  a  poly- 
poid fibroma  and  Thornton  a  papillary  fibroma. 
Targett,  in  1891,  discovered  a  case  of  sarcoma  of  the 
ureter  with  the  pelvis  of  the  kidney  embedded  in  the 
growth.  Hektoen,  in  i8g6,  reported  a  case  of  pri- 
mary carcinoma  of  the  ureter.  Chian  recorded  one 
of  cholesteatoma,  Ribberta,  one  of  myosarcoma  of 
the  ureter,  and  Drew,  in  1897,  a  villous  carcinoma. 

Personal  Observations  upon  Ureteral  Calculi. 
— Dr.  Alexis  V.  Mo.schcowitz  said  that  in  text- 
books the  ureter  was  described  as  being  narrowed  at 
three  points,  namely,  at  or  about  the  junction  of  the 
ureter  and  the  pelvis  of  the  kidney,  at  the  vesical 
end,  and  at  the  point  where  the  ureter  crossed  the 
common  iliac  artery.  Between  these  points  the  ure- 
ter was  composed  of  spindle  shaped  segments. 
These  points  of  constriction  were  of  importance  be- 
cause they  were  the  sites  of  predilection  for  the  im- 
paction of  calculi.  In  addition  to  these  three  points, 
however,  he  was  able  to  say  from  his  own  experi- 
ence that  there  was  possibly  a  fourth  point,  one  that 
had  not  been  sufficiently  appreciated.  In  sixteen 
out  of  eighteen  of  his  cases  he  had  found  a  calculus 
impacted  at  a  point  between  the  vesical  end  of  the 
ureter  and  the  point  where  it  crossed  the  common 
iliac  artery.  This  point  of  constriction  was  due  to 
a  dense,  sharp  fascial  band  which  passed  horizontal- 
ly inward  from  the  lateral  pelvic  wall  to  the  median 
line.   As  this  band  occurred  in  both  sexes,  the  broad 


March  6,  1909. J 


PROCEEDINGS  OF  SOCIETIES. 


ligament  and  uterine  artery  could  not  be  looked 
upon  as  a  factor  in  its  production.  If  the  calculus 
was  quiescent,  the  only  symptoms  and  signs  were 
a  constant  and  fixed  pain,  with  a  point  of  tender- 
ness, either  in  the  back,  in  the  costovertebral  angle, 
or  in  front  on  the  lateral  abdominal  wall,  and  the 
presence  of  blood  in  the  urine.  In  the  later  stages 
there  were  added  to  these  symptoms  of  infection. 
If,  on  the  other  hand,  the  calculus  was  migrating, 
there  arose  all  the  classical  symptoms  of  renal  colic, 
with  the  hasmaturia  greatly  augmented,  etc.  It  was 
not  commonly  appreciated  that  a  calculus  in  the  ure- 
ter might  give  rise  to  symptoms  referable  to  the 
bladder;  this  only  occurred  when  the  calculus  was 
situated  near  the  vesical  end  of  the  ureter.  It  was 
a  peculiar  physiological  phenomenon  that  when  the 
ureter  was  the  seat  of  a  calculus  the  tenderness  was 
not  limited  to  the  site  of  the  calculus,  but  pervaded 
the  entire  extent  of  the  ureter.  Cystoscopic  inspec- 
tion of  the  bladder  was  of  comparatively  limited 
value  in  the  diagnosis.  The  cystoscopic  passing  of 
the  ureteral  catheter  afforded  better  knowledge,  but, 
after  all,  the  most  important  and  pathognomonic 
method  of  examination  was  with  the  x  ray,  and  for 
the  following  reasons:  i.  It  indicated  the  presence 
or  absence  of  a  calculus.  2.  It  showed  the  situa- 
tion of  the  calculus,  thus  indicating  with  great  pre- 
cision the  site  of  incision.  3.  It  showed  the  number 
of  calculi.  4.  It  showed  the  presence  or  absence  of 
an  associated  renal  calculus.  If  doubt  existed 
whether  a  given  shadow  proceeded  from  the  ureter 
or  not,  additional  evidence  might  be  obtained  by 
passing  a  styleted  ureteral  catheter  to  the  point  of 
obstruction  and  again  subjecting  the  patient  to  the 
X  rays.  This  would  show  whether  the  shadow  was 
extraneous  to  the  ureter.  Difficulty  was  also  en- 
countered when  one  was  dealing  with  a  uric  acid 
calculus,  which  was  less  impervious  to  the  x  rays 
than  calculi  of  other  composition.  No  calculus 
should  be  permitted  to  stay  indefinitely  in  the  ureter. 
He  made  it  a  rule  not  to  advise  an  operation  as  soon 
as  a  diagnosis  was  made,  but  to  observe  the  case 
for  a  short  time  in  order  to  allow  the  natural  forces 
full  scope  in  the  propulsion  of  the  concrement.  That 
this  course  was  the  proper  procedure  was  proved  by 
reported  cases.  In  the  female,  calculi  might  be  dis- 
lodged by  the  finger  within  the  urethra,  or  through 
a  perineol  boutonniere  in  the  male.  Calculi  situated 
in  the  intramural  part  of  the  ureter  required  for  ex- 
traction a  preliminary  suprapubic  cystotomy.  Then 
either  the  mouth  of  the  ureter  could  be  dilated  blunt- 
ly sufficiently  to  permit  the  extraction  of  the  stone, 
or  the  mouth  of  the  ureter  be  incised  if  neces- 
sary. This  method  was  perfectly  safe  for  a  distance 
of  I  cm. ;  beyond  this,  however,  there  was  danger 
of  wounding  the  peritonaeum.  Calculi  situated  in 
the  juxtavesical  portion  of  the  ureter  had  been  re- 
moved by  incision  through  the  vagina.  Calculi  in 
or  near  the  renal  portion  of  the  ureter  cotild  be 
best  reached  through  one  of  the  normal  kidney  in- 
cisions. For  calculi  impacted  in  the  pelvic  portion 
of  the  ureter  three  methods  of  attack  had  been  ad- 
vocated, by  an  intraperitoneal  incision,  by  an  extra- 
peritoneal incision,  and  by  a  combination  of  the  two. 
Personally,  he  believed  there  was  no  question  at  all 
that  the  possibility  of  peritoneal  infection  by  ex- 


travasated  urine  almost  forced  one  to  adopt  the  ex- 
traperitoneal method  as  the  method  of  choice,  even 
though  the  route  was  a  trifle  more  difificult  than  the 
intraperitoneal.  He  then  described  in  detail  the  pro- 
cedure he  followed.  Calculi  obstructing  the  ureter 
for  any  length  of  tim.e  would  sooner  or  later  be  fol- 
lowed by  an  infection  of  either  the  pelvis  or  paren- 
chyma of  the  kidney.  On  the  other  hand,  the  sur- 
gical removal  of  such  calculi  was  followed  by  al- 
most ideal  results.  The  mortality  in  experienced 
hands  was  practically  nil,  the  operation  was  com- 
paratively easy  of  execution,  the  period  of  conva- 
lescence was  rapid,  the  patient  was  immediately  re- 
lieved of  all  distressing  symptoms,  and  if  the  func- 
tion of  the  kidneys  had  not  been  seriously  interfered 
with  by  the  disease,  full  return  to  health  would  be 
probable,  and  the  danger  of  a  subsequent  hernia  was 
so  slight  that  it  did  not  merit  serious  consideration. 

The  Operative  Technique  of  Calculi  Impacted 
in  the  Lower  End  of  the  Ureter. — Dr.  C.  L.  Gib- 
son described  the  method  he  employed  to  approach 
the  lower  end  of  the  ureter  through  a  modified 
Stimson-Pfannenstiel  incision,  with  the  patient  in 
the  Trendelenburg  position.  By  this  incision  the 
ureter  was  more  readily  exposed  and  the  calculus 
more  easily  removed,  and  the  incision  in  the  ureter 
could  be  more  readily  closed. 

Cystoscopic  Aid  in  the  Diagnosis  and  Treat- 
ment of  Ureteral  Calculus. — Dr.  A.  T.  Osgood 
said  that  there  were  cases  in  which  it  was  unneces- 
sary to  resort  to  the  introduction  of  intravesical  in- 
struments ;  patients  in  whom  the  history,  physical 
signs,  urine  examination,  and  positive  radiographs 
pointed  in  a  classical  way  to  ureteral  calculus  of 
such  size  and  shape  that  experience  taught  might 
pass  by  physiological  methods  into  the  bladder  and 
be  expelled  from  that  viscus,  should  not  be  subject- 
ed to  the  discomfort  and  dangers  of  instrumental 
manipulation.  There  were  two  positive  means  for 
determining  the  position  of  a  calculus,  the  radio- 
graph and  ureteral  examination  by  the  cystoscope 
with  the  ureteral  bougie  or  catheter.  The  x  ray  would 
fail  in  the  case  of  pure  uric  acid  or  pure  urate  cal- 
culi. The  cystoscope  should  be  used  (i)  to  establish 
a  diagnosis  of  ureteral  calculus  and  to  determine 
its  situation;  (2)  in  all  cases  in  which  operative  re- 
lief was  in  question  because  no  diagnosis  was  com- 
plete and  the  preoperative  examination  of  every  case 
was  faulty  if  the  condition  of  the  other  kidney  was 
not  known  when  one  ureter  or  kidney  was  to  be 
dealt  with  surgically;  (3)  it  should  be  used  for 
therapeutic  purposes.  The  cystoscope  might  show 
the  calculus  fixed  in  the  ureter  mouth,  projecting 
into  the  bladder,  and  so  make  possible  its  removal. 
A  calculus  in  the  intramural  portion  of  the  ureter 
presented  the  appearance  of  a  rounded  elevation 
within  the  bladder,  which  might  be  the  seat  of  hy- 
perjemia  or  oedema  of  the  overlying  mucous  mem- 
brane. Congestion,  oedema,  submucous  extravasa- 
tion, or  prolapse  of  the  ureteral  mucous  membrane  in 
the  bladder  was  readily  visible  by  the  cystoscope, pro- 
ducing a  picture  not  pathognomonic  of  an  obstruct- 
ing body  within  the  ureter,  but  strongly  suggesting 
the  possibilty.  Complete  occlusion  of  a  ureter  by  a 
stone  occurred  at  times,  and  then  by  the  cystoscope 
no  fluid  was  seen  ejected  from  this  ureter  even  after 


PROCEEDINGS  OF  SOCIETIES. 


[New  York, 
Medical  Journal. 


hypodermic  injection  of  indigo-carmin.  The  ureter 
catheter  was  used  for  diagnosis  in  three  ways  :  ( i ) 
As  a  probe  or  bougie,  (2)  as  an  evacuating  tube,  and 
(3)  as  the  sheath  for  a  stylet.  In  the  great  ma- 
jority of  the  cases  of  ureteral  calculus  the  stone  pre- 
sented no  appreciable  obstruction  to  the  passage  of 
a  catheter  past  it.  In  some  cases  the  catheter  im- 
pinged directly  upon  the  calculus,  but  a  little  manip- 
ulation permitted  of  its  passage  beside  and  beyond 
it.  The  phonendophore,  or  ausculatory  bougie,  for 
the  ureter  was  one  of  the  most  valuable  of  instruments 
for  the  diagnosis  of  ureteral  calculi.  This  instru- 
ment was  not,  however,  an  infallible  guide.  The 
wax  tipped  catheter  method  devised  by  Dr.  Howard 
Kelly  was  one  of  the  best  means  for  obtaining  evi- 
dence of  calculus  when  employed  through  an  open 
tube  (like  a  urethroscope),  but  it  was  not  adaptable 
to  cystoscopes  because  of  the  liability  to  scratching 
the  wax  by  contact  with  parts  of  the  instrument. 
Having  been  passed  into  a  ureter  containing  a  cal- 
culus or  beyond  this  partial  obstruction,  the  catheter 
might  withdraw  the  secretion  of  the  kidney,  and  in 
this  fluid  might  be  found  the  morphological  elements 
denoting  haemorrhage  or  infection  or  both.  The  x 
ray  was  a  most  valuable  guide  in  the  diagnosis  of 
ureteral  calculi,  especially  in  conjunction  with  a  dem- 
onstration of  the  course  of  the  ureter  by  means  of 
the  shadow  of  a  stylet  which  lay  in  the  ureter. 

X  Ray  Aid  in  the  Diagnosis  of  Ureteral  Cal- 
culi.—Dr.  L.  Jaches  said  that  before  the  advent 
of  the  Rontgen  rays  a  diagnosis  of  ureteral  calculus 
could  not  be  made  with  any  degree  of  positiveness. 
The  Rontgen  rays  informed  the  surgeon  of  the  num- 
ber of  stones  present,  whether  unilateral  or  bilateral, 
whether  in  one  place  or  in  more,  whether  in  the  ure- 
ter alone  or  also  in  the  kidney  of  the  same  or  oppo- 
site side.  They  gave  the  surgeon  an  idea  of  the 
shape  and  size.  The  percentage  of  error  was  to-day 
very  small.  Pure  uric  acid  calculi  might  escape  de- 
tection, but  fortunately  they  were  rare,  the  majority 
being  made  up  of  the  combination  of  the  various  in- 
gredients. Experience  in  the  interpretation  of  radio- 
graphs would  enable  one  to  rule  out  most  of  the  non- 
calculous  shadows.  The  cleaner  the  intestinal  tract 
the  less  chance  for  doubt  and  the  less  occasion  for 
unnecessary  exposure  of  the  patient.  The  x  ray? 
were  but  one  more  means  that  made  the  diagnosis 
of  ureteral  calculus  possible,  but  it  should  be  borne 
in  mind  that  the  radiographer  was  as  much  interest- 
ed in  the  clinical  aspects  of  the  case  as  the  surgeon 
who  consulted  him.  Only  when  both  worked  liand 
in  hand  were  the  best  results  obtainable. 

Dr.  F.  TiLDEN  Brown  spoke  of  the  limitations  of 
these  methods  of  diagnosis.  Some  stones  gave  neg- 
ative X  ray  results. 

Dr.  Howard  Lilienthal  spoke  of  the  apparent 
relationship  that  existed  between  appendicitis  and 
ureteral  stone,  and  said  that  he  believed  many  ap- 
pendices were  removed  when  the  symptoms  were 
not  caused  by  conditions  in  them,  but  by  the  pres- 
ence of  ureteral  calculi.  Without  the  x  ray  it  was 
impossible  to  make  a  diagnosis  between  appendicitis 
and  impacted  ureteral  stone. 

Dr.  (iEORGic  WooLSEY  called  attention  to  the  fail- 
ure of  the  x  ray  to  aid  in  making  a  diagnosis  of  ure- 
teral calculi. 


COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA. 
Meeting  of  November  4,  1908. 
The  President,  Dr.  James  Tyson,  in  the  Chair. 

The  Results  of  an  Operation  for  Irreducible 
Congenital  Luxation  of  the  Hip  in  an  Adult. — ■ 

Dr.  GwiLYN  G.  Davis  showed  a  young  woman,  over 
twenty  years  of  age,  who^  was  almost  completely 
disabled  by  pain  in  walking.  His  colleague.  Dr.  W. 
J.  Taylor,  had  been  associated  with  him  in  the  case. 
The  joint  was  exposed  by  an  anterior  incision.  As 
it  was  impossible  to  bring  the  head  down  to  the 
acetabulum,  it  was  placed  in  a  depression  which 
was  cleared  just  above  the  acetabulum.  A  ridge  of 
bone  seemed  to  promise  support,  and  no  separate 
cavity  was  excavated  in  the  bone.  The  limb  was 
put  up  in  an  extreme  abducted  position.  Healing 
was  uneventful.  It  was  now  a  year  and  a  half  or 
more  after  the  operation.  The  shortening  was  com- 
pensated for  by  a  raised  heel.  Movements  of  the 
joint  were  quite  free  and  she  could  walk  consider- 
able distances  with  comfort.  She  limped  very  little 
and  considered  her  condition  as  being  markedly  im- 
proved. The  pessimistic  utterances  of  some  ortho- 
paedic surgeons  as  to  what  could  be  done  by  opera- 
tive means  to  relieve  these  distressing  cases  of  irre- 
ducible congenital  luxation  •  of  the  hip  had  caused 
this  method  of  treatment  to  fall  somewhat  into  dis- 
repute. 

The  Appearance  of  Pellagra  in  the  United 
States. — Dr.  Edward  J.  Wood,  of  Wilmington, 
N.  C,  presented  this  paper  and  referred  briefly  to 
the  appearance  of  pellagra  in  Europe  and  its  prev- 
alence in  Italy  and  Roumania.  Its  outbreak  in  the 
United  States  was  next  considered.  He  had  col- 
lected 196  cases  from  the  literature  and  personal 
letters.  Seventy  of  these  cases  had  been  found  in 
North  Carolina.  The  disease  occurred  in  two  va- 
rieties. The  more  common  in  the  southern  States 
was  the  acute,  fulminating,  or  "typhoid,"  which  ran 
a  course  from  a  few  weeks  to  three  months,  and 
the  patient  invariably  died  in  the  first  attack.  The 
symptorr\s  were  symmetrical  erythema,  especially  of 
the  uncovered  portions  of  the  body,  stomatitis  and 
often  salivation,  diarrhoea,  and  the  general  symp- 
toms of  a  profound  toxaemia.  Death  occurred  from 
exhaustion.  This  variety  was  unlike  anything  de- 
scribed by  the  Italians  and  was  virtually  a  new  dis- 
ease. The  chronic  variety  was  similar  to  that  de- 
scribed in  Italian  literature.,  but  ran  a  shorter 
course.  In  Italy  the  average  duration  was  five 
years.  In  the  speaker's  experience  the  longest 
course  was  three  years.  The  recurrences  occurred 
usually  every  spring.  One  case  was  cited  with  four 
attacks  (erythema,  stomatitis,  diarrhoea)  in  six  years 
and  another  case  with  an  attack  in  the  spring  and 
again  in  the  following  fall,  with  death  in  the  third 
attack.  The  nervous  and  mental  disturbances  sel- 
dom appeared  in  the  acute  cases  except  the  symp- 
toms of  a  profound  toxajmia.  In  chronic  cases  the 
manifestations  were  most  varied  and  often  indefi- 
nite, such  symptoms  as  parasthesias,  pain  in  the 
scapular  region,  and  a  burning  sensation  in  the  epi- 
gastrium, hands,  arms,  and  feet.  Cold  extremities 
and  vertigo  were  symptoms  frequently  noted. 
Among  the  mental   s\inptoms  were  slowness  of 


March  6,  igoo.  | 


PROCEEDINGS  OF  SOCIETIES. 


ideas,  irritable  depression,  disturbances  of  percep- 
tion, and  disturbances  of  judgment.  There  were 
often  present  delusions  of  fear  and  suspicion.  Sui- 
cidal tendencies  were  frequent.  The  tendon  re- 
flexes were  variable,  but  often  increased  even  up  to 
the  point  of  an  intense  clonic  contraction. 

"Pellagra  sine  pellagra,"  or  pellagra  without  skin 
lesions,  was  mentioned  at  some  length.  The  speaker 
thought  that  in  most  of  these  cases  there  was  an  in- 
conspicuous skin  lesion  present  at  some  stage  which 
might  easily  be  overlooked,  and  emphasized  the  fact 
that  the  erythema  was  by  no  means  an  index  to  the 
severity  of  the  affection. 

The  pathological  changes  were  chiefly  of  the 
nervous  system.  The  writer  mentioned  the  impor- 
tant fact  that  in  recent  cases  these  changes  did  not 
occur,  that  it  was  only  in  the  long  drawn  out, 
chronic  cases  that  degenerative  areas  were  discov- 
erable. The  posterior  and  lateral  coluir.ns  of  the 
spinal  cord  were  the  chief  seats  of  the  degenerative 
lesions.  When  the  lateral  columns  were  affected 
the  lesions  occurred  chiefly  in  the  dorsal  and  some- 
times in  the  cervical  regions.  The  brain  changes 
were  inconspicuous  save  for  occasional  fatty  degen- 
eration or  calcification  of  the  intima  of  the  small 
bloodvessels  and  pigmentation  of  the  adventitia. 

The  aetiology  was  briefly  discussed.  The  proba- 
bility that  corn  played  an  important  part  was  men- 
tioned. The  speaker  laid  stress  on  Lombroso's 
statement  that  sound  corn  was  as  often  diseased  as 
bad  corn.  He  thought  that  Tizzoni's  work  was  al- 
most conclusive.  Tizzoni  had  isolated  a  bacillus 
from  the  blood,  cerebrospinal  fluid,  organs,  and 
faeces  of  pellagrins-  and  also  from  samples  of  corn. 
He  had  produced  by  this  organism  the  disease  in 
rabbits  and  guinea  pigs.  The  post  mortem  lesions 
found  in  these  animals  were  very  similar  to  those 
found  in  the  human  victims  of  pellagra.  The 
speaker  had  been  able  in  several  instances  to  isolate 
an  organism  from  the  blood  of  pellagrins  which  was 
probably  Tizzoni's  bacillus.  It  was  questionable 
whether  or  not  this  organism  of  Tizzoni's  was  iden- 
tical with  the  Bacillus  viaidis  of  Peltauf  and  Heider. 
The  occurrence  of  acute  pellagra  with  its  short 
course  and  its  toxaemia  made  one  more  disposed 
than  ever  to  look  on  it  as  an  acute  infectious  dis- 
ease. 

The  treatment  in  the  acute  cases  was  shown  to  be 
of  little  avail.  The  use  of  atoxyl  in  rather  large 
doses  was  mentioned. 

The  hope  was  expressed  that  it  would  be  con- 
clusively proved  before  long  that  Tizzoni's  organism 
was  the  real  jetiological  factor,  and  as  it  had  already 
been  shown  that  the  disease  produced  an  antitoxine 
with  curative  properties,  and  as  the  horse  was  sus- 
ceptible to  it,  the  probabilities  of  the  early  produc- 
tion of  an  antitoxine  were  very  great.  The  speaker 
was  in  doubt  regarding  the  exact  role  of  the  corn, 
except  to  accept  the  theory  that  there  was  a  relation- 
ship. He  was  inore  disposed  to  believe  that  corn, 
good  or  bad,  was  a  suitable  medium,  when  damp,  for 
the  development  of  this  organism.  How  the  corn 
was  originally  infected  was  problematic,  but  it  was 
very  probable  that  good  corn,  kept  under  unfavor- 
able hygienic  conditions,  became  a  favorable  me- 
dium for  the  development  of  the  noxious  agent. 

The    Operative    Treatment   of  Papilloedema 


(Choked  Disc),  with  Special  Reference  to  De- 
compressing Trephining. — Dr.  George  E.  Dk 
ScHWEiNiTz  and  Dr.  T.  B.  Hollovvay,  after  a  dis- 
cussion of  the  pathogenesis  of  choked  disc,  the  oph- 
thalmoscopic appearances  of  the  nerve  head  which 
indicate  operative  interference,  the  methods  of  diag- 
nosis, the  ocular  lesions  in  their  early  stages,  the 
date  of  occurrence  and  the  character  of  the  nerve 
head  changes,  and  the  relation  of  the  refraction  of 
the  eye,  particularly  myopia,  to  the  development  of 
papilloedema,  presented  the  results  of  twenty-one 
cases  of  cerebellar  tumor  or  cyst,  nineteen  of  which 
had  been  operated  on  by  Dr.  Frazier  in  the  Univer- 
sity Hospital,  and  two  in  the  Orthopaedic  Hospital, 
one  by  Dr.  William  J.  Taylor  and  the  other  by  Dr. 
G.  G.  Davis,  and  twenty-two  cases  of  cerebral  tu- 
mor, cyst,  or  abscess,  twenty  of  which  were  oper- 
ated on  by  Dr.  Frazier  in  the  University  Hospital, 
and  two  in  the  Orthopaedic  Hospital  by  Dr.  Taylor. 

The  effect  of  decompressing  trephining  or  of  rad 
ical  operation  on  the  preservation  or  restoration  of 
eyesight  was  discussed  (o)  when  the  vision  was 
good  in  both  eyes  prior  to  the  operation;  (b)  when 
the  vision  was  good  in  one  eye  but  practically  lost  in 
the  other  eye  prior  to  operation;  and  (c)  when  the 
vision  was  defective,  that  is,  below  one  half  of  the 
normal,  in  both  eyes. 

Following  this,  the  paper  dealt  with  the  danger  of 
delay  in  resorting  to  operative  intervention  and  the 
rapidity  with  which  vision  might  deteriorate  in  cases 
of  papilloedema,  to  be  checked  by  suitable  operation 
provided  this  deterioration  had  not  passed  to  too 
late  a  stage.  The  authors  also  discussed  the  preser- 
vation, or  even  slight  improvement,  of  very  poor 
vision  existing  prior  to  the  operation,  and  what 
should  be  done  if  vision  had  been  reduced  to  light 
perception.  They  pointed  out  that  in  a  certain  num- 
ber of  these  cases  the  operation  was  rapidly  followed 
by  blindness,  and  utilized  them  to  emphasize  their 
contention  that,  if  the  operation  was  to  succeed  in 
preserving  sight,  it  should  be  performed  at  an  early 
stage  in  the  papilloedema,  but  they  also  thought  that 
such  poor  grades  of  vision  did  not  contraindicate  the 
operation  for  the  purpose  of  saving  sight,  inasmuch 
as  very  occasionally  it  was  followed  by  the  preser- 
vation of  what  small  vision  still  remained. 

They  also  pointed  out  the  occasional  unfortunate 
results  even  when  vision  was  good  prior  to  the  op- 
eration and  the  papilloedema  still  in  an  early  stage, 
and  described  the  various  theories  which  had  been 
invoked  to  explain  the  loss  of  vision  under  these  cir- 
cumstances. 

They  also  described  the  information  which  the 
disc  appearances  gave  as  to  the  size  and  situation  of 
the  growth,  whether  it  was  on  the  right  or  the  left 
side  of  the  brain,  and  thought  that  the  ophthalmo- 
scopic appearances  were  of  no  use  in  attempting  to 
determine  the  size  of  the  growth,  although  usually 
the  papilloedema  was  greater  on  the  side  of  the  tu- 
mor than  upon  the  opposite  side.  This  was  by  no 
means  an  invariable  rule,  however,  and  therefore  it 
could  not  be  urged  too  much  as  a  diagnostic  sign. 

They  agreed  with  Horsley,  Gushing,  and  others 
that  it  was  not  so  much  to  the  swelling  of  the  disc 
that  attention  should  be  paid  as  to  the  indications  as 
to  which  disc  had  been  longest  affected.  From  the«e 
data  evidence  of  distinct  value  in  localizing  the  posi- 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


tion  of  the  growth,  in  so  far  as  the  right  or  the  left 
side  of  the  brain  was  concerned,  could  be  obtained. 

Their  final  conclusions  were  as  follows :  i ,  The 
most  satisfactory  treatment  for  the  purpose  of  pre- 
serving vision  in  any  case  of  choked  disc,  or  papilloe- 
dema,  not  due  to  a  toxic  process  or  to  constitutional 
disease,  not  an  "infectious  optic  neuritis,"  but  de- 
pending upon  increased  intracranial  tension,  was  by 
decompressing  trephining,  with  removal  of  the 
growth  if  it  was  accessible.  2,  This  operation  should 
be  performed  early,  and  if  it  could  be  done  during 
the  first,  second,  or  even  third  stage  of  papilloedema, 
the  prognosis  as  to  sight  was  most  favorable.  3,  If 
for  any  reason  the  operation  was  postponed  until  the 
development  of  the  fourth  and  fifth  stages  of  papill- 
oedema, already  associated  with  marked  depreciation 
of  vision,  the  prognosis  as  to  sight  was  unfavorable, 
but  even  under  these  circumstances  the  operation 
should  be  performed,  because  it  sometimes  preserved 
such  vision  as  still  remained,  and  if  it  should  hap- 
pen to  be  followed  by  its  rapid  loss,  as,  unfortunate- 
ly, was  apt  to  occur,  it  at  least  had  given  the  patient 
a  chance,  because  without  it  he  was  doomed  to  abso- 
lute blindness.  4,  Time  spent  in  the  administration 
of  mercury,  iodides,  and  other  medicinal  agents  was 
time  wasted ;  after  the  operation  they  acted  much 
more  favorably  than  they  did  prior  to  its  perform- 
ance. 5,  The  eyes  should  be  examined,  not  only 
with  the  ophthalmoscope,  but  also  with  regard  to  the 
visual  acuteness,  the  visual  field,  the  color  percep- 
tion, the  light  sense,  the  size  of  the  blind  spot,  and 
the  signs  which  indicated  the  age  of  the  disc  changes. 
6,  Patients  with  papilloedema  dependent  upon  in- 
creased intracranial  tension  should  be  made  acquaint- 
ed with  the  unfavorable  results  of  the  operation,  but 
in  spite  of  them  it  should  be  urged,  because  in  its 
absence,  in  the  majority  of  cases,  blindness  was  sure 
to  occur. 

 <$>  

[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  zvhich  ive  think 
our  readers  are  likely  to  be  interested.} 


Expcrini-.'ulal  Researches  on  Specific  Therapeutics.  By 
Professor  Paul  Ehrlich,  Director  of  the  konigliches  In- 
stitut  fiir  experimentelle  Therapie  in  Frankfurt.  With  a 
frontispiece  of  the  author.  New  York :  Paul  B.  Hoeber. 
Pp.  vi-95.    (Price,  $1.) 

Ehrlich's  writings  are  always  a  source  of  inspira- 
tion. The  volume  before  us  is  no  exception,  and  is, 
in  fact,  one  of  the  most  stimulating  little  books  we 
have  encountered  in  many  a  day.  The  subject  is 
discussed  in  three  lectures.  The  first  deals  with  im- 
munity, especially  with  reference  to  the  relations  ex- 
isting between  the  distribution  and  the  action  of 
antigens;  the  second  with  atrepsy ;  and  the  third 
with  chemotherapeutical  studies  on  trypanosomes. 
The  style  is  simple  and  clear,  so  that  the  subject 
may  be  readily  followed  by  physicians  generally. 
The  book  deserves  to  be  widely  read. 

Tuber's  Pocket  Encyclopcedic  Medical  Dictionary.  Edited 
by  Clarence  W.  Taber,  Author  of  Taber's  Medical  Dic- 
tionary for  Nurses,  etc.  Associate  Editor,  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.  D.,  C.  M.  Chicago:  C.  W. 
Taber,  1908.   Pp.  x-13  to  418. 

This  seems  to  be  a  new  publication  of  one  of  the 
well  known  editions  of  Taber's  Encyclopccdic  Med- 


ical Dictionary  which  appear  adapted  «for  physicians 
or  nurses  or  the  family  use.  It  is  of  convenient 
size,  and  the  classification  of  information  and  sub- 
jects is  quite  complete.  Each  word  defined  is  pre- 
ceded by  a  number  which  runs  consecutively.  As 
an  addendum  is  given  a  cross  index,  which  treats 
alphabetically  of  the  subjects,  each  subject  con- 
taining numbers  referring  to  the  general  index, 
where  under  these  numbers  the  words  pertaining  to 
the  subject  are  to  be  found. 

As  associate  editor  is  still  mentioned  the  late 
Professor  Senn  without  indication  of  his  demise ; 
the  year  of  publication  is  nowhere  to  be  found.  The 
spelling  of  the  words  is  absolutely  unscientific,  and 
the  derivation  and  etymology  are  not  well  carried 
out. 

The  Heart  and  Sudden  Death.  By  Theodore  Fisher,  M. 
D.,  F.  R.  C.  P.,  Assistant  Physician  to  the  East  London 
Hospital  for  Children ;  Formerly  Honorary  Pathologist 
to  the  Bristol  Roj'al  Infirmary,  etc.  London:  The  Scien- 
tific Press,  1908. 

A  booklet  of  barely  fifty-three  pages  can  hardly 
be  expected  to  treat  of  this  important  topic  in  any- 
thing but  a  fragmentary  manner,  and  this  the  au- 
thor doubtless  has  realized.  This  one  is  made  up 
of  a  collection  of  scattered  notes,  put  into  book 
form  for  students,  illustrating  some  features  of  a 
hospital  experience  that  covered  2,500  autopsies. 
Briefly,  the  deductions  show  a  wider  acquaintance 
with  pathological  anatomy  than  with  pathology  or 
clinical  medicine.  For  example,  the  various  myo- 
cardial changes  that  are  now  known  to  be  the 
chief  immediate  causes  of  death  are  not  appreciated 
at  their  respective  values,  while  individual  opinions 
are  apt  to  be  backed  by  unconvincing  evidence.  On 
the  other  hand,  it  may  be  said  that  the  author  shows 
much  originality  and  throws  out  hints  that  may 
stimulate  others  to  complete  the  task  that  he  has 
outlined. 

The  various  sorts  of  heart  diseases  in  their  rela- 
tion to  sudden  death  have  never  yet  been  presented 
in  a  satisfactory  manner.  Their  great  importance 
is  evident.    Fourteen  photoplates  illustrate  the  text. 

The  Tra7isactions  of  the  Si.vth  International  Dermatological 
Congress.  Edited  by  Dr.  John  A.  Fordyce.  Secretar>' 
General.  New  York :  The  Knickerbocker  Press,  1908. 
Pp.  944. 

This  is  the  oi^icial  report  of  the  proceedings  of  the 
International  Dermatological  Congress  that  was 
held  in  New  York  from  the  9th  to  the  14th  of  Sep- 
tember, 1908.  It  contains  a  list  of  tb.c  nfticers  and 
members  of  the  congress,  all  the  papers  presented, 
with  stenographic  reports  of  the  discussions  of  them 
and  of  the  various  cx  tempore  addresses  delivered, 
together  with  lists  of  the  cases  shown  and  the  yiho- 
tographs  exhibited. 

An  idea  of  the  valuable  work  done  by  the  con- 
gress may  be  formed  by  noting  that  there  were 
about  a  hundred  papers  presented,  a  hundred  and 
twenty-eight  patients  shown,  and  hundreds  of  pho- 
tographs exhibited.  The  scope  of  the  work  is  siiown 
by  the  great  varieties  of  titles.  The  schemes  selected 
for  genera!  discussion  were  three,  namely:  i.  The 
astiological  relationship  of  the  organisms  found  in 
the  skin  in  the  exanthemata.  2.  Tropical  diseases 
of  the  skin.  3  (a).  The  possibility  of  immunization 
against  syphilis;  (b)  the  present  status  of  our 
knowledge  of  the  parasitology  of  syphilis. 


March  6,  1909.] 


BOOK  NOTICES. 


Besides  these  there  are  papers  on  bacterial  injec- 
tions in  diseases  of  the  skin ;  blastomycosis ;  derma- 
titis from  the  brown  tail  moth ;  dermatitis  cocci- 
dioides  ;  dermametropathism  ;  eczema  ;  elephantiasis  ; 
multiple  benign  cystic  epithelioma ;  erythema  multi- 
forme ;  filaria  ;  f  rambcesia  ;  gangosa  ;  gangraena  cutis 
hysterica  ;  hydroa  puerorum  ;  leprosy  ;  liquid  air  ; 
lupus  erythematosus  ;  lupus  vulgaris  ;  metabolism  of 
certain  skin  diseases ;  skin  diseases  in  the  negro ;  op- 
sonins ;  pityriasis  versicolor ;  psoriasis ;  radium  ; 
Rontgen  rays  ;  rosacea  ;  sarcoma  ;  syphilis  ( sixteen 
papers)  ;  tuberculosis  of  the  skin  :  urticaria;  verruca 
plantari? :  and  zoster  arsenicalis.  These  papers  are 
in  English,  French,  German,  and  Italian,  but  it  is 
not  necessary  to  be  a  polyglot  to  derive  a  great  deal 
of  information  from  the  book,  as  most  of  the  papers 
are  in  English. 

The  Transactions  are  issued  in  two  volumes,  print- 
ed on  the  finest  of  linen  paper,  so  that  for  their  size 
the  volumes  are  very  light  in  weight,  and  illustrated 
with  one  hundred  and  thirteen  beautiful  half  tones. 
The  editing  has  been  very  carefully  done,  so  that  the 
text  is  remarkably  free  from  typographical  errors. 
All  in  all,  the  books  are  a  credit  to  the  editor  and  to 
the  art  of  book  making  as  practised  in  this  country. 
All  the  members  of  the  congress  received  a  copy  of 
the  Transactions.  We  understand  that  copies  at 
cost  price  can  be  had  by  those  who  were  not  mem- 
bers. 

Report  from  the  Pathological  Department,  Central  Indiana 
Hospital  for  the  Insane.    1903-1906.    Indianapolis,  1908. 

The  staff  of  the  Central  Indiana  Hospital  for  the 
Insane  appear,  from  the  report  of  the  three  years' 
work  before  us,  to  be  energetic  and  more  impressed 
with  the  value  of  a  pathological  department  than 
alienists  usually  are.  In  three  years  they  have  had 
one  hundred  and  forty-seven  autopsies,  all  of  which 
appear  to  have  been  carefully  worked  up.  The 
pathological  department  w  orks  in  harmony  with  the 
clinical  staff,  the  pathologist  being  allowed  to  visit 
the  patients  while  they  are  alive,  thus  becoming 
familiar  with  the  clinical  manifestations  of  the  dis- 
ease. The  institution  acts  as  a  teaching  centre  for 
the  problems  of  insanity  in  the  neighborhood  in 
which  it  is  situated,  lectures  being  given  which  are 
attended  by  the  medical  men  of  the  vicinity.  A 
preliminary  chapter  by  Dr.  Edenharter,  the  super- 
intendent of  the  institution,  indicates  the  objects  of 
the  department,  its  past  activities,  and  its  future 
policy. 

Transactions  of  the  American  Surgical  Association.  Vol- 
ume XXVI.  Edited  by  Richard  H.  Harte,  M.  D.,  Re- 
corder of  the  Association.  Philadelphia :  Printed  for  the 
Association  by  William  J.  Dornan.  1908.    Pp.  xx.xiii-756. 

The  twenty-sixth  volume  of  these  transactions,  the 
first  of  which  appeared  in  1880.  contains  very  inter- 
esting papers  which  were  read  before  the  association 
at  its  meeting  of  May  4,  5.  and  6,  1908.  It  is  im- 
possible to  go  into  the  detail  of  reviewing  the  thirty- 
eight  essays,  introduced  by  the  address  of  the  presi- 
dent. The  Committee  of  Necrology  presents  short 
biographies  of  Francis  Hartman  ]y"larkoe,  of  Xew 
York,  John  Hill  Brinton,  of  Philadelphia.  Nicholas 
Senn,  of  Chicago,  Thomas  Annandale,  of  Edin- 
burgh, and  Friedrich  von  Esmarch,  of  Kiel.  The 
book  well  represents  the  progress  of  surgery. 


NEW  PUBLICATIONS. 
Ciiemisiry. 

Maly,  R. — Jahresbericht  iiber  die  Fortschritte  der  Tier- 
chemie  oder  der  physiologischen  und  pathologischen 
Chemie.  Bd.  xx.xvii,  iiber  das  Jahr,  1907.  Herausgegeben 
von  R.  Andreasche  und  Karl  Spiro.  Wiesbaden :  J.  F. 
Bergmann,  1908.    Pp.  1275. 

Botany. 

Recueil  des  traveaux  botaniques  neerlandais,  public  par  la 
Societe  botanique  neerlandaise,  sous  la  redaction  de  M.  IM. 
W.  Burck,  J.  W.  Moll,  E.  Verschaffelt,  Hugo  de  Vries  et 
F.  A.  F.  C.  Went.  Volume  iv.  Avec  17  planches.  (Price, 
12.50  f.) 

Anatomy,  Histology,  and  Microscopy. 

Peltrisot,  C.  N. — Etude  n.icrographique  des  poudres  medi- 
cinjles  d'origine  animale.  Avec  11  planches.  Paris:  Vigot 
freres.    (Price,  4  f.) 

Fritsch,  Gustav. — Ueber  Bau  und  Bedeutung  der  Area 
centralis  des  Menschen.  .Herausgegeben  mit  Unterstiitzung 
der  koniglichen  Akademie  der  Wissenschaften.  Volume 
viii.  Mit  10  Figuren  und  68  Tafeln.  Pp.  149.  Berlin :  G. 
Reimer,  1908. 

Guenther,  Konrad. — Vom  Urtier  zum  Menschen.  Ein  Bil- 
deratlas  zur  Abstammungs  und  Entwicklungsgeschichte  des 
Menschen.  2  Bde.  Stuttgart :  Deutsche  Verlags-Anstalt, 
1909.    Pp.  220. 

Strasburger,  Ediiard. — Histologische  Beitrage.  Heft  vii. 
Zeitpunkt  der  Bestimmung  des  Geschlechts,  Apogamie, 
Parthenogenesis  und  Reduktionsteilung.  Mit  drei  litho- 
graphischen  Tafeln.    (Price,  7.50  M. 

Von  Bardeleben.  Karl. — Handbuch  der  Anatomic  des 
Menschen  in  acht  Banden.  In  Verbindung  mit  Dr.  P.  Bar- 
tels  in  Berlin,  weiland  Prof.  Dr.  A.  von  Brunn  in  Rostock 
u.  s.  w.  Erster  Band:  Skeletlehre.  Mit  253  grosstenteiis 
mehrfarbigen  Abbildungen  im  Text.  (Preis  fiir  Abnehmer 
des  ganzen  Werkes,  21  M  ;  fiir  den  Einzelverkauf,  24.50  M. ) 
Physiology. 

Hcrtivig,  Oscar. — Der  Kampf  urn  Kernfragen  der  Enl- 
wicklungs-  und  Vercrbungslehre.  Pp.  122.  Jena :  G. 
Fischer,  1909. 

Ferrarini,  Guido. — Studi  e  ricerche  sperimentali  sulla 
fisiopatologia  del  cuore  di  mammifero  isolata  dall'organ- 
ismo.  Parte  3a — Azione  sul  cuore  di  alcune  tossine  e  an- 
titossine  batteriche.  (Communicazione  al  XXI  Congresso 
della  Societa  italiana  di  Chirur.gia-Roma,  27-29  Ottobre, 

1908.  )    Siena:  S.  Bernardino,  1908.    Pp.  56. 

Pathology. 

Gruner.  O.  C. — Studies  in  Puncture  Fluids.  A  Contribu- 
tion to  Clinical  Pathology.  Philadelphia :  P.  Blakiston's 
Son  &  Co..  1908.    Pp.  xviii-289.    (Price,  $2.00.) 

Zagari,  Giuseppe. — Cancro  n.assivo  del  fegato.  (Istituto 
di  clinica  medica  della  R.  Universita  di  Sassari.  )  Lezione 
clinica.    Napoli :  M.  Priore.    Pp.  12. 

Kahldcn. — Technik  der  histologischen  Untersuchung 
pathologisch-anatomischer  Praparate  von  Edgard  Gierke, 
viii.  umgearbeitete  Auflage.  Mit  Technik  der  Untersuch- 
ung des  Xervensystems  von  Spielmeyer.    Jena :  G.  Fischer, 

1909.  Pp.  220. 

Maas.  A. — Tuberkulose.  Krebs  und  ihnen  ahnliche  Seu- 
chen,  ihre  Entstehung,  Heilung  und  Prophylaxe.  Kolberg: 
Selbstverlag,  1908.    Pp.  104. 

Internal  Medicine. 

Bock.  H. — Vorlesnngen  iiber  Herzkrankheiten.  I.  Heft. 
Die  Erkrankungen  des  Herzmuskels.  Histologic,  patholo- 
gische  Anatomic,  Diagnose  und  Therapie.  Miinchen :  H. 
Thoma,  1908.    Pp.  iv-86.    (Price.  1.50  M.") 

Eulenhurg,  Albrecht. — Real  Enzyklopadie  der  gesamten 
Heilkunde.  iii.  umgearbeitete  Auflage.  fxxxiii  Bd. — En- 
c}-clopadische  Jahrbiicher  16  Bd.  Neue  Folge :  vii  Jahr- 
gang.)  Mit  66  Abbildungen  und  i  Tafe!.  Pp.  646.  Wien  : 
Urban  &  Schwarzenberg,  1909. 

Liebe.  Gcorg. — Vorlesnngen  iiber  Tuberkulose.  I.  Die 
mechanische  und  psychologische  Behandlungen  der  Tuber- 
kulosen  besonders  in  Heilstatten.  Pp.  267.  Miinchen :  J. 
F.  Lehrr.ann,  1909. 

Osborne,  Walter. — ^Ueber  Beri-Beri-artige  Erkrankungen 
r.us  -Afrika.  Ein  Beitrag  zur  Aetiologie  der  Segelschiflf- 
Beri-Beri.    Berlin  :  F.  Lcdermann.  1908. 

Malyniex.  J. — Ueber  die  Haufigkeit  der  postdiphtheri- 
tischen  Lahmungen  vor  und  nach  der  Serumbehandlung. 
Ziirich  :  E.  Speidel.  1908.    Pp.  58. 


514 


BOOK  NOTICES. 


[New  York 
Medical  Journal 


Loria,  Gmj(?/>/'^.— Tetania  e  malaria.  (Istituto  di  clin- 
ica  medica  della  R.  Universita  di  Sassari  diretto  dal  prof. 
Giuseppe  Zagari.)    Napoli :  Ruggiano  e  Figlie.    Pp.  12. 

Hughes,  Henry. — Atemkuren,  mit  115  Rezepten.  Wiirz- 
burg :  C.  Kabitzsch,  1909.    Pp.  58. 

Brandenburg,  K. — Medizinische  Klinik.  v.  Jahrgang 
1909.    Berlin :  Urban  &  Schwarzenberg. 

Naunyn,  B. — Notwendigste  Angaben  fiir  die  Kostenord- 
nung  Diabetischer,  fiir  Aerzte  zusammengestellt.  Jena ;  G. 
Fischer,  1908.    Pp.  18. 

Eiigelhardt,  R.  Baron. — Medizinische  Wissenschaft  und 
Praxis.    Riga :  G.  Lciffler,  1908.    Pp.  30. 

Marcndnzzo ,  L. — Sul  valore  pratico  del  metodo  di  Meu- 
nier  per  I'esame  del  succo  gastrico  senza  la  sonda.  Napoli : 
N.  Jovcne.    Pp.  5. 

Surgery. 

Fischer,  Herman. — Kriegschirurgische  Riick-  und  Aus- 
blicke  vom  asiatischen  Kriegsschauplatz.  Berlin :  A. 
Hirschwald,  1909.    Pp.  198. 

Conforti,  U.- — Su  tre  casi  di  tetano  tranmatico.  (Delirio 
posttetanico,  cura  alia  Baccelli,  Istituto  di  patologia  e  clin- 
ica  n.edica  dell'  Universita  di  Perugia  diretto  dal  prof.  P. 
Silvestrini.)    Roma:  Nazionale.  Pp.22. 

Maiocchi,  Andrea. — Considerazioni  sulla  prognosi  delle 
ferite  del  tubo  digerente.  Contributo  clinico  e  ricerche 
sperimentali.    Milano  :  Francesco  Vallardi.    Pp.  64. 

Brickner,  Walter,  and  Hays,  Harold  M. — Seven  Hundred 
Surgical  Suggestions.  Practical  Brevities  in  Diagnosis  and 
Treatment.  Third  Series.  New  York :  Surgery  Publish- 
ing Compan)',  1909.    Pp.  150.    (Price,  $1.50.) 

IVile,  Ira  S. — Blood  examination  in  Surgical  Diagnosis. 
A  Practical  Study  of  its  Scope  and  Technique.  New  York : 
Surgery  Publishing  Company,  1908.    Pp.  161.    (Price,  $2.) 

Douglas,  Richard. — Surgical  Diseases  of  the  Abdomen. 
With  Special  Reference  to  Diagnosis.  Illustrated  with  20 
Full  Page  Plates.  Second  Edition,  Revised  and  Enlarged. 
Edited  by  Richard  A.  Barr,  B.  A.,  M.  D.,  Professor  of  Ab- 
dominal Surgery,  Medical  Department,  Vanderbilt  Uni- 
versity. Philadelphia:  P.  Blakiston's  Son  &  Co.,  1909. 
Pp.  xii-897.    (Price,  $6.) 

Auvray,  M. — Maladies  du  crane  et  de  Tencephale.  Xiii. 
Avec  130  figures  intercalecs  dans  le  texte.  Paris :  J.  B. 
Baillere  et  fils,  1909.    Pp.  508. 

Chanipionnicrc ,  Just  Lucas. — Pratique  de  la  chirurgie 
antiseptiquc.  Legons  professees  a  I'Hotel  Dieu.  Avec  un 
portrait  de  Lord  Lister.  Paris :  G.  Steinheil,  1909.  Pp. 
ix-463. 

Obstetrics  and  Gynecology. 
Diihrssen.  A. — Gynakologisches  Vademecum  fiir  Studie- 
rende  und  Aerzte.  ix.  vermehrte  und  verbesserte  Auflage. 
Mit  138  Abbildimgen  und  11  Tafeln.    Berlin:  S.  Karger, 
1909.    Pp.  298. 

Zciller.  P.,  Sr. — Die  Entstehung,  Entwicklung  und  Ge- 
burt  des  Menschen,  in  den  einzelnen  Entwicklungsstadien 
allgemeinverstandlich  dargestellt.  Mit  280  Illustrationen. 
V.  Auflage.    Leipzig:  Ernst,  1900.    Pp.  270. 

Schultae.  Bernhard  Sigmund. — Lehrbuch  der  Hebammen- 
kunst.  Vierzehnte,  verbesserte  Auflage.  Mit  103  Abbil- 
dungen.  Leipzig:  Wilhelm  Engelmann,  1908.  Pp.  xxx- 
404.    (Price,  7  M.) 

Neurology  and  Psychiatry. 

fJoll.  M_. — Die  Inse!  des  Menschen-  und  Af¥enhirns  in 
ihrer  Bezielhungzum  Schlafenlappen.  Mit  5  Tafeln.  Wien  : 
A.  Holder,  1908.    Pp.  46. 

.Siemerling,  C. — Ueber  nervose  imd  psychische  Storungen 
der  Jugend.    Berlin  :  A.  Hirschwald,  1909.    Pp.  31. 

Yoshiinura.  Kisaku. — Ueber  den  Mendelscben  Fuss- 
briickcnreflex.    Wicn  :  J.  Safar,  1908.    Pp.  11. 

Ophthalmology. 

Shoemaker,  William  T.— Retinitis  Pigrnentosa.  With 
an  Analysis  of  Seventeen  Cases  Occurrin.g  in  Deaf  Mutes. 
Laboratory  Examinations  of  the  Blood  and  Urine  by  John 
M.  Swan,  M.  D.,  Philadelphia.  With  Illustrations  and 
Three  Colored  Plates.  Philadelphia :  J.  B.  Lippincott 
Company,  1909.    Pp.  iv-io6. 

Graefe  und  Saemisch. — Handbuch  der  gesamtcn  Augen- 
hcilkunde.  Hcrausgegeben  von  Professor  Dr.  Theodor 
Saemisch.  ii.  ncubearbeitetc  Auflage.  Leipzig:  W.  Engel- 
mann. 1908. 

Axenfeld.  Bach,  Bielschowsky. — Lehrbuch  der  Augen- 
heilkunde.  Hcrausgegeben  von  Theodor  Axenfeld.  Mit  10 
Farbcntafeln  wnA  455  teils  mehrfarbigen  Abbildungen. 
Jena :  G.  Fischer,  1909.    Pp.  679. 


Otology. 

Kahnt,  Karl. — Der  Mittelohrkanal  und  die  Schwerhorig- 
keit  und  ihre  Behandlung  nach  den  Grundsatzen  der  Natur- 
heilmethode  und  insbesonders  des  Pflanzenheilverfahrens, 
Berlin :  O.  Nahmamcher,  1908.    Pp.  53. 

Korner,  Otto. — Die  otitischen  Erkrankungen  des  Hirns, 
der  Hirnhaute  und  der  Blutleiter.  iv.  durch  Nachtrage 
erganzte  Ausgabe.  jilit  i  Abbildungen  und  5  Tafeln. 
Wiesbaden :  J.  F.  Bergemann,  1908.  • 

Laryngology  and  Rhinology. 

Rippich,  Gustav. — Wie  erhalte  ich  meine  Stimme  gesund  ? 
Ratschlage  fiir  alle  Bcrufsredner,  vornehmlich  fiir  Of- 
fiziere.    Berlin :  E.  S.  Mittler  &  Sohn,  1909.    Pp :  85. 

Conforti,  U. — L'Edema  sottoglottideo  della  malattia  da 
siero.  (Istituto  di  patologia  e  clinica  medica  diretto  dal 
prof.  R.  Silvestrini.)    Firenze :  Fiorentina. 

Rciss,  Carl. — Die  Krankheiten  der  Nase  und  ihre  Be- 
handlung.   Fiir  Aerzte  und  Laien.    iii.  vermehrte  und  ver- 
besserte Auflage.    Berlin :  H.  Steinitz,  1909.    Pp.  102. 
Dermatology. 

Bohm,  F.  L.  D. — Der  Haarausfall,  Haarschwund  sowie 
die  Heilung  aller  Haarkrankheiten.  Ursache,  Verhiitung 
und  Behandlung.  Mit  Anhaug:  Das  plotzliche  Ergrauen 
der  Haare  sowie  die  besten  Haarfarbemittel.  iii.  verbes- 
serte Auflage.  Leipzig:  Ernst,  1909.  Pp.  89  mit  Ab- 
bildungen. 

Venereal  and  Genitourinary  Diseases. 

Kannanmller,  Ludwig. — Caveant  moniti !  Ein  ofTenes 
Beherzigungswort  iiber  Masturbation  fiir  Gebildete  aller 
Stande.    Berlin  :  H.  Bermiihler,  1908.    Pp.  264. 

Jessner,  S. — Diagnose  und  Therapie  der  Syphilide. 
(Syphilis  der  Haut  und  Scheimhaut.)  I.  Teil :  Diagnose. 
Zweite  Auflage.  Wiirzburg:  Curt  Kabitzsch,  1909.  Pp. 
146.    (Price,  2.50  M.) 

Padia  tries. 

Escherich,  Theodor. — Die  Tetanic  der  Kinder.  Wien : 
A.  Holder,  1909.  Pp.  268,  mit  15  Abbildungen  und  2 
Tafeln. 

Hagenbach-Burckhardt,  E. — Ueber  offentliche  Fiirsorge 
fiir  kranke  Kinder.  Akademischer  Vortrag.  Basel :  Hel- 
bing  &  Lichtenhahn,  1909.    Pp.  40. 

FaiAinow,  C. — Kongenitale  Mitralstenose  (Duroziersche 
Krankheit),  Chlorose,  Lungentuberkulose  in  ihren  Bezie- 
hungen  zur  sc'hwachen  Konstitution  des  Organismus.  Ber- 
lin :  A.  Hirschwald,  1909.    Pp.  75. 

Hygiene  and  Public  Health. 

Jester.  Kurt. — Die  Ursachen  und  die  Verhiitung  der 
hohen  Sauglingssterblichkeit  und  die  Ernahrung  und  Pflege 
des  Sauglings.  Ein  volkstiimlicher  Vortrag.  Wiirzburg: 
C.  Kabitzsch,  1909.    Pp.  76. 

Krocker  und  Friedlicini. — Deutscher  militariirztlicher  Kal- 
ender  fiir  die  SanitatsofiRziere  der  Armee,  der  Marine  und 
der  Schutztruppen  (x.  Jahrgang),  herausgegeben  von  H. 
Friedheim,  1909.  Zwei  Telle  nebst  Vademecum.  Mit 
Schreibkalender  in  4  Heften.    Leipzig:  G.  Tbieme. 

Langlois,  J.  P. — Precis  d'hj'giene  pulilique  et  privee. 
Avec  79  figures.    Paris :  O.  Doin  et  fils.    Pp.  650. 

Bacteriology. 

Liepmann,  IV. — Tabcllen  zu  klinisch-bakteriologischen 
Untersuchungen  fiir  Chirurgen  und  Gynakologen,  nebst 
einer  kurzen  Anleitung  zur  Ausfiihrung  der  Dreitupfer- 
probe.    Berlin:  A.  Hirschwald,  1909.    Pp.  11. 

Saito,    K. — Untersuchungen    iiber   die  atmospharischeii 
Pilzkeime.    Berlin  :  R.  Friedliinder  &  Sohn,  1908.    Pp.  78. 
Therapeutics. 

Ehrlich,  Paul. — Experimental  Researches  on  Specific 
Therapeutics.  The  Harben  Lectures  for  1907  of  the  Royal 
Institute  of  Public  Health.  New  York :  Paul  Hoeber,  1909. 
Pp.  vi-95-    (Price,  $1.) 

Herschcll.  George. — Soured  Milk  and  Pure  Cultures  of 
Lactic  Acid  Bacilli  in  the  Treatment  of  Disease.  Second 
Impression,  Ninth  Thousand.  London:  J.  Glaisher ;  Chi- 
cago: W.  r.  Keener  &  Co.,  1909.    Pp.  32.    (Price,  is.  6d. ) 

Patec,  Alida  /^^n/Hfc^.— Practical  Dietetics.  With  Refer- 
ence to  Diet  in  Disease.  Fifth  Edition.  New  York :  A.  F. 
Patee,  i9aS.    Pp.  xvi-358. 

Manquat.  A. — Principes  de  therepeutique  raisonnec  et 
pratique.    Paris :  A.  Maloinc.    Pp.  368. 

Pcnzoldt.  Franz. — Lehrbuch  der  klinischen  Arzneibehand- 
Iting.  Chirurgische  Tcchnik  der  Arznciinwendung  von  M. 
von  Krygen.    Jena :  G.  Fischer,  1908.    Pp.  426. 


March  6,  1909. J 


OFFICIAL  NEWS. 


Onomatology. 

Zicglcr,  H.  £.— Zoologisches  Worterbuch.  Erklarung 
der  zoologischen  Fachiiusdriicke.  Zum  Gebrauch  beim 
SnuliuiT.'  zoologischcr,  entwicklungsgeschichtlicher  una 
naturphilosophischer  Werke  verfasst  von  E.  Bresslau,  Pri- 
vatdozent  ni  Strassburg  i.  E.,  Professor  Dr.  J.  Eichler  in 
Stuttgart,  Professor  Dr.  K.  Lambert  in  Stuttgart,  Dr.  Hein- 
ricii  Schmidt  in  Jena  und  Professor  Dr.  H.  E.  Ziegler  in 
Jena.    Lieferung  3.    (Price,  4  ^I.) 

Miscellaneous. 

Klcinschrod. — Die  Eigengesetzlichkeit  des  Lebens.  Eine 
neue  .  Lehre  vom  Leben  und  der  Krankheit.  Berlin :  O. 
Salle.    Pp.  108. 

Jarotzky,  Alexander. — Der  Idealismus  als  lebenerhalten- 
des  Prinzip.  Betrachtungen  eines  Arztes.  Wiesbaden :  J. 
F.  Bergmann,  1908.    Pp.  147. 

Leclair,  E. — Ce  qui  interesse  les  medecins  dans  le  codex 
franqais.    Edition  1908.    Paris:  Maloine.    (Price,  i  fr.) 

Ilberg,  Johannes,  und  IVellmann,  Max. — Zwei  Vortragc 
zur  Geschichte  der  antiken  Medizin.  Leipzig:  B.  G.  Teub- 
ner.  1909.    Pp.  38. 

Peters,  Otto. — Der  Wunderdoktor  und  seine  Mixturen 
im  XX.  Jahrhundert.  Ein  Beitrag  zur  Aufkarung  iiber 
das  Geheimmittelunwesen.  Worms :  H.  Krauter,  1909. 
Pp.  23. 

Holmes,  Christian  R. — Modern  Hospitals.  With  Special 
Reference  to  our  Xew  Municipal  Hospital  and  its  Rela- 
tion to  Medical  Education  in  Cincinnati.  An  Illustrated 
Lecture  Delivered  at  the  University  of  Cincinnati,  January 
9,  1908. 

Fort>--fourth  Annal  Report  of  the  Trustees  of  the  Boston 
City  Hospital.  Including  the  Report  of  the  Superintendent 
upon  the  Hospital  Proper,  the  South  Department  for  In- 
fectious Diseases,  the  Relief  Station  at  Haymarket  Square, 
the  Convalescent  Home  at  Milton  Lower  Mills,  and  also 
the  Medical  and  Surgical  Statistics.  House  Rules,  with 
Rules  for  Admission,  Discharge,  and  Government  of  Pa- 
tients, etc.  For  the  Forty-fourth  Year,  February  i,  1907,  to 
Januarv  31,  inclusive.  Boston :  Municipal  Printing  Office, 
1908.    Pp.  181. 

Stiles,  C.  IVardeir. — Index  Catalogue  of  Medical  and 
Veterinary  Zoolog}-.  Part  22.  ("Authors:  P.  to  Pfeil- 
sticker);  Part  23:  (Authors:  Pfender  to  Quortrup). 
Washington :  Governrr.ent  Printing  Office.  1909.    Pp.  1805. 

Merriam,  C.  Hart. — California  Ground  Squirrels.  Wash- 
ington :  Government  Printing  Office,  1909.    Pp.  8. 

IVells,  H.  G. — Tono-Bungay.  A  Novel.  New  York: 
Duffield  &  Co.,  1909.    Pp.  460. 

Bell.  Ralcy  Husted. — The  Changing  Values  of  English 
Speech.  Xew  York :  Hinds,  Noble,  &  Eldredge,  1909. 
Pp.  302. 

Publications  of  the  Massachusetts  General  Hospital,  Bos- 
ton. Volume  ii.  October,  1908.  Number  i.  Selected 
Papers  by  the  Staff.    Boston :  The  Barta  Press.    Pp.  393. 

First  Annual  Message  of  John  E.  Reyburn,  Mayor  of 
the  City  of  Philadelphia,  with  the  Annual  Reports  of  the 
Direcpr  of  the  Department  of  Public  Health  and  Qiari- 
ties  and  Chief  of  the  Bureau  of  Health,  for  the  Year  End- 
ing December  31.  1907.  Issued  by  the  City  of  Philadelphia. 
Philadelphia  :  Dunlap  Printing  Company,  1908.    Pp.  x-302. 

Transactions  of  the  American  Clim'atological  Associa- 
tion. For  the  Year  1908.  Volume  xxiv.  Philadelphia : 
Printed  for  the  Association.  1908.    Pp.  xxiii-290. 

Von  Bollinger.  O.— Wandluifgen  der  Medizin  und  des 
Aerztestandes  in  den  letzten  50  Jahren.  Miinchen :  J.  F. 
Lehmann,  1909.    Pp.  44.    (  Price,  i  M.) 


(Official  BfttJs. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports: 

1  he  following  cases  of  smallpox.  yellozL-  fever,  cholera 
and  plague  have  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  zceek  ending  February  26,  igog: 

Places.  Date.  Cases.  Death?:. 

SmaUpo.-e—-Vnited  States. 

.\labama — Mobile  Tan.   30-Feb.   6   i 

Arkansas — Magnolia  Jan.   5-Feb.   13   25 

Califorjiia — Los  -Angeles  J?.n.  30-Feb.  6   i 

California — San    Francisco  Feb.   7-13   2 

District  of  Columbia — VVashirgtonFeb.   6-13   3 


Date. 

6-  13..- 

7-  14.  . . 
6-13.. . 
6-I3..- 

17  

I-I5-  •  ■ 
6-13-.. 
30-Feb. 
6-13... 
6-13... 
30-Feb. 
30-Feb. 

6-13- ■■ 
6-13... 
1-31... 

5-  12.  .  . 

6-  13... 
I-31  ■  ■  • 
6-13... 
6-13... 
6-13... 


6-13. 
1-31  • 
4-17. 


Places. 

Illinois — Cairo  Feb. 

Illinois — Danville  F'eb. 

Illinois — Peoria  Feb. 

Indiana — Elkhart  Feb. 

Indiana — Evansville  Feb. 

Indiana — La  Fayette  Feb. 

Kansas — Kansas  City  Feb. 

Kansas — Topeka. ..."  Jan. 

Kentucky — Covington  Feb. 

Kentucky — Le.xington  Feb. 

Maine — \  an  Buren  Jan. 

Nebraska — South  Omaha  Tan. 

New  Vork — Niagara  Feb. 

New  Vork — Schenectady  Feb. 

North  Carolina — Charlotte  Jan. 

Ohio — Cincinnati  Feb. 

Ohio — Dayton  Feb. 

Oregon — Portland  Dec. 

Tennessee — Knoxville  Dec. 

Tennessee — Memphis  Dec. 

Tennessee — Nashville  Dec. 

Texas — Cotulla  Feb. 

Texas — San   Antonio  Feb. 

Utah — Salt  Lake  City  Jan. 

Virginia — Norfolk  Feb. 

Washington — Seattle  Jan. 

Washington — Spokane  Jan. 

Wisconsin — La  Crosse  Feb. 

^^'iscons^n — Manitowoc  Feb. 

Wisconsin — Milwaukee  Feb. 

Smallpox — Foreign 

.Arabia — Aden  Jan.  4-1! 

British  Honduras — Stann  Creek.  .  Feb.  11. 

Brazil — Rio  de  Janeiro  Dec. 

Brazil — Santos. ."  Dec. 

Canada — Halifax  Jan. 

Canada — Varmouth  Feb. 

China — .Shanghai  Dec. 

Kgypt — Cairo  Jan. 

German^' — Bremen  Jan. 

Guatemala — Guatemala  City  Feb. 

India — Bombay  Jan. 

India — Calcutta  Jan. 

India — Madras  Jan. 

India — Rangoon  Jan.   2-9. . . . 

Indo-China — Saigon  Dec.  26-Jan. 

Italy — General  Jan.  24-31.. 

Italy — Naples  .Jan.  24-31.. 

Malta  Jan.  16-23.. 

Mexico — Monterey  Jan.   31  -Feb. 

Peru — Lima  Jan. 

Russia — Moscow  Jan. 

Russia — Riga  Jan. 

Russia — St.  Petersburg  Jan. 

.Spain — Vigo  Jan. 

Straits  Settlements — Singapore...  Dec. 


Ca'es.  Deaths. 


1  Imported 

I 

1 

8 

3 


Presert 


From  vessel 


1-31  

30-Feb. 
6-13... 
6-13... 
6-13... 


27-Jan. 
13-20.  . 
30-Feb. 
13-20.  . 
26- Tan. 


Imported 
83 


7-14. . 
16-23. 


31 


)6 

Epidemi-: 


12-19. 
2-9. . . 
-S... 


3' 


3 
29 


16. 

16-23  

23-30  

9-16  

23-30  

26-Jan.  2.. 


Yellow  Fever — Foreign. 

Barbados  Jan.   24-Feb.   9   10 

Martinique — Fort  de  France  Jan.    16-30   3 

Mexico — Merid;   Jan.   30-Feb.  6  

Mexico — Ticul  Jan.  30-Feb.   6   i 

Cholera — Foieigr,. 

India — Bombay  Jan. 

India — Calcutta  Jan. 

India — Madras  Jan. 

India — Rangoon  Jan. 

Russia — General  Jan. 

Russia — Cronstadt  Jan. 

Russia — Moscow  Jan. 

Russia — St.  Petersburg  Jan. 

Jan. 

Straits  Settlements — Singapore...  Dec. 


2-9. 


2-9  

9-16  

9-16  

16-23  

g-i6  

-5-29  

21-Tan.   2.  . 


•135 


17   II 

9-23   8 

22-28   6 

2-i6  5.136 

12-19  

2-9  

2-9. 


46 
49 
41 

6 
3 


4,I4<> 
17 

12 

iS 
3 


Plague — Foreign. 

Brazil — Rio  de  Janeiro  Dec.  27-Jan. 

Chile — Iquique  Jan. 

Egypt — General  Jan. 

India — General  Jan. 

India — Bombay  Jan. 

India — Calcutta  Jan. 

India — Rangoon  Jan. 

Japan — Nishinomiya  Jan.    6   i 

Peru — General  Jan.    9-16   32 

Peru — Callao  Jan.    9-16   5 

Peru — Lima  Jan.    9-16   5  2 

Turkey — Tiddah  Jan.    22-24   3  3 

Public  Health  and  Marine  Hospital  Service : 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
February  24,  igog: 

BoGGESs,  JoHX  S.,  Passed  Assistant  Surgeon.  Relieved 
from  duty  on  Revenue  Cutter  Perry  and  directed  to 
proceed  to  Baltimore.  Md.,  and  report  to  the  com- 
manding officer  of  the  Revenue  Cutter  Tahoma  for 
duty. 

Parker.  Herman  B..  Passed  Assistant  Surgeon.  Granted 
one  day's  leave  of  absence,  February  20,  1909,  on  ac- 
count of  sickness. 


5i6 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journ.al. 


SiMONSON,  G.  T.,  Acting  Assistant  Surgeon.  Granted  five 
days'  leave  of  absence  from  February  23,  1909. 

Slough,  Chakles,  Pharmacist.  Granted  seven  days'  leave 
of  absence  cn  route  to  station  at  Baltirtiore,  ^Id. 

Smith,  F.  C,  Passed  Assistant  Surgeon.  Relieved  from 
ten.porary  duty  in  Hygienic  Laboratory  and  directed  to 
rejoin  station  at  Fort  Stanton,  N.  Al. 

Smith,  F.  C,  Passed  Assistant  Surgeon.  Granted  ten 
days'  leave  of  absence  cn  route  to  station  at  Fort  Stan- 
ton, N.  M. 

Ste.\rns,  H.  H.,  Acting  Assistant  Surgeon.  Granted  one 
day's  extension  of  annual  leave  on  account  of  sickness, 
February  5,  1909. 

Sterns,  C.  O.,  Pharmacist.  Granted  six  days'  leave  of  ab- 
sence fiom  February  20,  1909,  under  paragraph  210 
Service  Regulations. 

VON  EzDOKFF,  R.  H.,  Passed  Assistant  Surgeon.  Granted 
two  days'  leave  of  absence  from  February  2,  1909,  un- 
der paragraph  189  Service  Regulations. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  zveck  ending  February  27,  igog: 
Adair,  G.  W.,  Colonel,  Aledical  Corps.    Retired  from  ac- 
tive service,  on  account  of  physical  disability,  February 
25,  1909. 

AsHBURN,  P.  JkL,  Major,  Aledical  Corps.    Granted  leave 

of  absence  for  one  month. 
Chamberlain,  W.  P.,  Major.  Medical  Corps.    Detailed  to 

represent  the  Medical  Department  of  the  Army  at  the 

meeting  of  the  American  Society  of  Tropical  Medicine 

at  Washington,  D.  C,  April  10,  1909. 
Edie,  G.  L.,  Lieutenant  Colonel,  Medical  Corps.  Reliexed 

from  treatment  at  Hot  Springs,  Ark.,  and  ordered  to 

return  to  his  proper  station. 
Frick,  E.  B.,  Major,  Medical  Corps.    Granted  leave  of 

absence  for  ten  days. 
Hess,  L.  T.,  Major,  Medical  Corps.    Granted  leave  of  ab- 
sence for  three  months. 
Lameie,  J.  S.  Jr.,  Lieutenant,  Medical  Corps.  Ordered 

from  Fort  Alonroe,  Va.,  to  duty  at  camp  St.  Asaph's, 

Va. 

McIntvre,  H.  B.,  Lieutenant,  Medical  Corps.  Granted 
an  extension  of  one  month  to  his  leave  of  absence. 

Miller,  E.  W.,  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  two  nionths. 

Parkman,  'W.  E.,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  to  March  7,  1909. 

P.MTERSON,  E.  W.,  First  Lieutenant,  Medical  Reserve 
Corps.  Arrived  at  San  Francisco,  Cal.,  on  the  trans- 
port Buford;  and  ordered  to  Fort  Sain  Houston, 
Texas,  for  duty. 

Peck,  L.  B.,  First  Lieutenant,  Medical  Reserve  Corps.  Re- 
lieved from  duty  at  Fort  Andrews,  Mass.,  and  ordered 
to  Fort  Banks,  Alass. 

Reynolds,  F.  P.,  Major,  Medical  Corps.  Ordered  to  St. 
Paul,  Minn.,  for  temporary  duty  as  chief  surgeon. 

Sabix,  "W.  E.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  in  the  Philippines  Division ;  will 
proceed  on  first  available  transport  to  San  Francisco, 
Cal.,  for  orders. 

Truby,  W.  F.,  Major,  Medical  Corps.  Granted  lca\e  of 
absence  for  three  months. 

Tyler,  G.  T.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Porter,  N.  Y..  and  ordered 
to  Plattshurg  Barracks,  N.  Y.,  for  duty. 

Werrer,  H.  A.,  Major,  Medical  Corps.  Ordered  to  Fort 
Niagara,  N.  Y.,  for  duty  upon  relief  from  treatment  at 
Hot  Springs,  Ark. 

Wiieate,  J.  M.,  First  Lieutenant,  Medical  Reser\e  Corps. 
Ordered  to  Fort  Siielling,  Minn.,  for  temporary  duty. 

Navy  Intelligence : 

Official  list  of  changi's  in  flic  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  Slates 
Navy  for  the  iceck  ending  February  27,  igog: 

Bachus,  J.  VV.,  Passed  Assistant  Surgeon.  Ordered  to 
the  Naval  Hospital,  Narragansett  Bay,  R.  1. 

McDoNNOLD,  P.  E.,  Passed  Assistant  Surgeon.  Detached 
from  the  Connecticut  and  ordered  to  ten.porary  duty 
at  the  Naval  Training  Station.  Newport,  R.  I. 


Old,  E.  H.  H.,  Passed  Assistant  Surgeon.  Detached  from 
the  Navy  Yard,  Washington,  D.  C,  and  ordered  to 
temporary  duty  at  the  Naval  Training  Station,  New- 
port, R.  L 


iirt^g,  parnagts,  mi  feat^js. 

Born. 

Loving. — In   West   Point,   New   York,   on  Wednesda\-, 
Februar}'  17th,  to  Dr.  R.  Courtenay  Loving,  Medical  Corps, 
United  States  Army,  and  Mrs.  Loving,  a  daughter. 
Married. 

DiSQUE — Watt. — In  Germantown,  Pennsylvania,  on 
Thursday,  February  25th,  Dr.  Thomas  Lawrence  Disque, 
of  Pittsburgh,  and  Miss  Margaretta  Watt. 

O'Brien — Merrill. — In  Tulsa,  Oklahoma,  on  Wednes- 
day, February  loth,  Dr.  Leo  A.  O'Brien  and  Miss  Alice 
Walton  Merrill. 

Died. 

Atwood. — In   Fishkill-cn-Hudson,  New  York,  on  Sun 
day,  February  21st,  Dr.  John  W.  Atwood.  aged  forty-six 
years. 

Bigelow. — In  Washington,  D.  C,  on  Saturday.  February 
20th,  Dr  Horatio  Ripley  Bigelow. 

Brigham. — In  Fitchburg,  Alassachusetts,  on  Satiirda}-, 
February  20th,  Dr.  Hubbard  H.  Brigham,  aged  eighty-nine 
years. 

Brown. — In  Manchester,  New  Hampshire,  on  Monday, 
February  22nd,  Dr.  James  Scribner  Brow  n,  aged  tliirt;. - 
eight  years. 

Corson. — In  Plymouth  fleeting,  Pennsylvania,  on  Tues- 
day, February  23d,  Dr.  Carroll  Corson,  of  Duluth,  Minne- 
sota. 

CouLi'ER. — In  Philadelphia,  on  Monday,  February  22nd, 
Dr.  Charles  L.  Coulter,  aged  fifty-nine  years. 

Grimsley. — In  Nashville,  Tennessee,  on  Thursday,  Feb- 
ruary i8th,  Dr.  V.  H.  Grimsley,  of  Mt.  Carmel,  aged  thirty- 
five  years. 

HosKiNS. — In  Clevand,  Ohio,  on  Thursday,  February 
i8th,  Dr.  Frank  C.  Hoskins,  aged  thirty  years. 

Huber.- — In  New  Y'ork,  on  Sunday,  February  21st,  Dr. 
Joseph  Huber,  aged  fifty  years. 

Illing. — In  Little  Rock,  Arkansas,  on  Friday,  February 
19th,  Dr.  W.  P.  Illing,  aged  forty-two  years. 

Johnstone. — In  Savannah,  Georgia,  on  Monday,  Feb- 
ruary 15th,  Dr.  John  McArden  Johnstone,  aged  eighty  years. 

Longabough. — Tn  Camden,  New  Jersey,  on  Tuesday, 
February  i6th.  Dr.  N.  H.  Longabough,  of  Norristown, 
Pennsylvania,  aged  eighty-six  years. 

McBeth. — In  Galesburg,  Michigan,  on  Wednesday,  Feb- 
ruary 17th,  Dr.  WilliaiTi  L.  AIcBeth,  aged  sixty-eight  years. 

McCoLLOM. — In  Brooklyn,  on  Tuesday.  February  23d, 
Dr.  William  McCollom,  aged  seventy-six  years. 

NoRTHRip. — In  Stoutland,  Missouri,  on  Monday.  Febru- 
ary 15th,  Dr   B.  Northrip,  of  Springfield. 

Reynolds. — In  Potsdam,  New  York,  on  Saturday,  Feb- 
ruary 20th,  Dr.  Jesse  ReyiKjlds,  aged  eighty-five  years. 

Richmond. — In  Windsor,  Vermont,  on  Monday,  Febru- 
ary 1st,  Dr.  Deane  Richmond,  aged  forty-six  years. 

Santa  Maria. — On  board  steamship  Prin?.  August  Wil- 
helm,  on  Saturday,  February  20th,  Dr.  Ernesto  Estrado 
Santa  Maria,  of  Aledellin,  Colombia,  South  .America. 

Smith. — In  Lexington,  Alabama,  on  Tuesday,  February 
i6th.  Dr.  Alexander  H.  Smith,  aged  sixty-seven  years. 

Swigert. — In  Laramie,  Wyoming,  on  Friday,  I'ebruary 
19th,  Dr.  I.  R.  Swigert. 

Tripler. — In  Yokohama.  Japan,  on  Tuesday,  February 
2nd,  Dr.  Thomas  H.  Tripler,  aged  sixty-three  years. 

Trowbridge. — In  Muncie.  Indiana,  on  Monday.  February 
22nd,  Dr.  David  L.  Trowbridge,  aged  seventy-five  years. 

Waters. — In  Baltimore,  Maryland,  on  l-'riday,  February 
19th,  Dr.  EdiViund  George  Waters,  aged  sixty-nine  years. 

W^HEEi.EK. — In  .Augusta,  Maine,  on  Monday.  February 
15th,  Dr.  Ernest  Henry  Wheeler,  aged  forty  years. 

Winters. — In  Lancaster.  Pennsylvania,  on  Saturday,. 
Februarx-  13th,  l")r.  Daniel  Winters,  aged  sixty-one  years. 


New  York  Medical  Journal. 

INCORPORATING  THE 

Philadelphia  Medical  Journal  ^he  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  ii.       •   NEW  YORK,  MARCH  13,  1909.  Whole  No.  1580. 


^Briginal  Communitations. 

THE  LIFE  AND  WORK  OF  DARWIN.* 

By  Arthur  Erwin  Brown,  Sc.  D., 
Philadelphia. 

Before  I  enter  upon  an  informal  talk  on  the  sub- 
ject you  have  assigned  .to  me  I  wish  to  show 
you  that  we  of  Philadelphia  may  claim  an  especial 
privilege  in  marking  the  anniversary  of  Darwin's 
birth,  a  privilege  which  arises  from  the  undoubted 
fact  that  the  Academy  of  Natural  Sciences  of 
Philadelphia  was  the  first  institution  of  science  in 
the  world  to  share  its  honors  with  Darwin,  after  the 
publication  of  the  book  that  perhaps  more  pro- 
foundly influenced  the  course  of  human  thought 
than  any  other  ever  written.  The  Origin  of  Spe- 
cies was  first  published  in  London  on  November  24, 
1859.  On  March  27,  i860,  Darwin  was  elected  a 
corresponding  member  of  the  Academy,  and  a  few 
weeks  later  he  wrote  to  his  life  long  friend  Lyell, 
expressing  his  gratification  at  this  recognition  from 
a  foreign  city,  at  a  time  when  his  portion  in  his 
own  land  was  for  the  most  part  ridicule  and  abuse. 

I  think  it  was  Oliver  Wendell  Holmes  who  said 
that  if  you  would  know  thoroughly  a  man's  char- 
acter, you  must  go  back  half  a  dozen  generations  in 
his  ancestry.  And  if  we  study  Darwin  from  this 
standpoint  we  soon  find  where  he  got  his  supreme 
interest  in  biology,  for  in  the  three  centuries 
through  which  we  may  go  back,  we  find  more  than 
one  member  of  his  family  taking  interest  in  some 
branch  of  natural  history.  But  the  greater  part  of 
his  mental  make  up  he  seems  to  have  received  from 
his  grandfather,  Dr.  Erasmus  Darwin.  This  worthy 
gentleman  belonged  to  a  species  we  believe  to  have 
been  extinct  in  Europe  for  nearly  two  thousand 
years.  That  is,  he  was  an  evolutionist.  He  "ex- 
perienced," as  Heine  might  have  said,  a  ponderous 
poem.  The  Loves  of  the  Plants,  and  a  prose  vol- 
ume, Zoonomia,  published  shortly  after  his  death 
in  1802,  in  which  he  set  forth  his  views;  but  they 
were  obscure  and  ill  defined,  and  no  importance  be- 
longs to  them  except  that  due  to  kinship. 

Darwin's  father  was  a  physician  of  Shrewsbury ; 
a  man  of  some  note ;  a  fellow  of  the  Royal  Society ; 
much  given  to  detail,  but  lacking  in  imagination,  or 
ability  to  generalize. 

Charles  Darwin's  youth  was  much  like  that  of 
any  other  healthy,  vigorous  English  lad  of  his  gen- 
eration. Fond  of  out  door  life,  of  dogs,  guns,  and 
horses,  and,  much  to  his  father's  disgust,  addicted 
to  rat  catching. 

As  he  neared  the  age  when  his  future  must  be 

*An  address  delivered  before  the  Philadelphia  Pathological  So- 
ciety, February  ii,  1909. 


determined,  his  father  took  the  short  and  easy  path 

and  concluded  that  his  son  should  follow  his  own 
course.  So  Darwin  was  sent  to  the  University  of 
Edinburgh,  to  study  medicine.  But  the  attempt 
was  a  complete  failure.  He  found  the  lectures  on 
geology  so  dull  that  he  vowed  he  would  never  again 
open  a  geological  book.  This  from  the  man  whose 
geology  in  later  years  has  never  been  upset.  Anato- 
my bored  him  ;  the  hospitals  disgusted  him  ;  the  sight 
of  blood  made  him  sick ;  and  before  a  year  was  out 
it  was  decided  that  medicine  was  not  for  him. 

The  next  project  will  bring  a  smile  to  the  lips  of 
some  of  you,  as  an  instance  of  the  humorous  fancies 
that  human  destiny  sometimes  plays  with.  The 
man  who,  in  later  years,  was  more  abused  by 
churchmen  than  any  other  of  his  time,  was  intended 
for  holy  orders,  and,  just  as  he  was  sent  to  Edin- 
burgh to  learn  to  be  a  doctor,  so  he  was  sent  to 
Cambridge  to  learn  to  be  a  clergyman. 

On  the  surface,  this  experiment  seemed  to  be  no 
more  successful  than  the  other.  Darwin  himself 
says  that  all  he  learned  of  the  classics  was  when 
he  crammed  for  his  "little  go,"  and  he  early  con- 
cluded that  he  had  not  brains  enough  to  master 
mathematics.  Furthermore,  he  got  in  with  rather  a 
lively  set,  spent  more  money  than  his  father  thought 
proper,  and  the  conclusion  of  that  anxious  parent 
was  that  his  son  was  unlikely  ever  to  be  anything 
but  a  disgrace  to  his  family. 

But  all  the  while  that  which  was  in  the  man  was 
developing.  He  became  intimate  with  Sedgwick, 
professor  of  geology,  and  more  especially  with 
Henslow,  of  botany  and  zoology.  With  Henslow 
he  learned  something  of  both  great  branches  of 
biology,  got  some  knowledge  of  anatomy  and  dis- 
secting, and  learned  how  to  collect  with  system. 
From  Sedgwick  he  got  geology^  and  learned  his 
stratigraphy  in  the  most  practical  way  by  long 
walks  with  his  teacher  in  the  mountains  of  North 
Wales. 

It  does  not  seem  that  anybody,  at  any  definite 
moment,  put  an  end  to  the  clergyman  notion.  It 
simply  withered,  dried  up,  much  to  the  state  of 
what  Darwin  himself  would  have  called  a  "vestigial 
organ." 

In  his  third  year  at  Cambridge  the  chance  came 
that  sometimes  comes  to  those  who  know  its  face. 
The  British  admiralty  was  sending  out  the  brig  of 
war  Beagle,  to  make  a  survey  of  the  coast  of  South 
America,  and  then  to  carry  a  line  of  chronometric 
observations  around  the  world.  Fitzroy,  her  cap- 
tain, asked  that  a  naturalist  be  sent  with  him,  and 
through  the  efforts  of  Henslow  and  other  friends 
the  detail  was  offered  to  Darwin.  His  father,  with 
the  lack  of  imagination  we  have  noted  in  him,  bit- 
terly opposed  the  plan,  and  it  is  to  be  feared  that 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


5i8 


BROIVN:  LIFE  AXD  WORK  OF  DARWIN. 


[New  York 
Medical  Journal. 


his  final  consent  was  mainly  due  to  the  belief  that 
his  son  was  not  good  for  much  else,  and  that  he 
could  not  spend  as  much  money  in  the  gun  room  of 
the  ship  as  he  had  been  doing  at  Cambridge.  So, 
on  December  27.  183 1,  the  Beagle  sailed  from  Ply- 
mouth with  Darwin  on  board  as  naturalist. 

Now  I  want  to  fix  your  attention  for  a  moment 
on  that  voyage  of  the  Beagle.  The  sailing  of  a  lit- 
tle ten  gun  brig  was  of  no  great  historical  impor- 
tance. Probably  it  is  not  mentioned  by  any  con- 
temporary chronicler  of  British  history,  but  it  may 
fairly  be  doubted  if  any  ship  has  ever  sailed  from 
any  port,  bearing  within  itself  germs  whose  devel- 
opment was  to  so  deeply  affect  the  course  of  human 
thought. 

In  two  ways  the  whole  course  of  Darwin's  life 
was  influenced  by  that  cruise.  It  was  five  years  less 
two  months  when  the  Beagle  dropped  her  anchor 
in  Plymouth  harbor  on  her  return.  With  the  ex- 
ception of  occasional  short  trips  ashore,  these  were 
five  vears  of  unbroken  seasickness  for  I3arwin,  and 
in  later  years  his  physicians  agreed  in  ascribing  the 
beginnings  of  the  illness  that  filled  the  rest  of  his 
life,  to  the  miseries  he  imderwent  on  that  voyage. 
>nOw,  if  Darwin  had  returned  with  the  strength  and 
vigor  that  were  his  birthright  it  may  be  justifiable 
to  suppose  that  he  would  have  settled  himself  in 
London  and  taken  full  part  in  the  activities  of  the 
men  who  were  his  friends.  He  would  have  done 
great  things,  for  they  were  in  him  to  do.  But  it 
seems  improbable  that  he  would  have  had  time  or 
facilities  for  the  endless,  patient  experiments  in 
breeding  plants  and  animals,  and  inquiry  as  to  their 
habits,  with  which  he  passed  away  his  hours  of 
physical  weakness,  or  to  have  conducted  the  enor- 
mous correspondence  which  has  been  the  wonder 
of  ever\  one  who  has  read  the  four  volumes  of  it 
published  by  his  son.  If  we  may  suppose  this,  the 
colossal  foundation  upon  which  natural  selection 
was  built  might  not  have  been  laid.  At  least  by  the 
great  master  of  induction. 

Furthermore,  he  has  told  us  that  when  he  was 
about  fifteen  years  old  he  read  his  grandfather's 
Zooiioiiiia.  but  it  made  no  impression  on  his  mind. 
Later,  when  he  saw  the  gigantic  fossil  edentates 
scattered  over  the  plains  of  Argentina  and  north- 
ern Patagonia,  and  observed  that  so  large  a  propor- 
tion of  the  present  mammals  of  South  America  con- 
sists of  smaller  and  much  altered  members  of  the 
same  peculiar  group ;  and  when  he  saw  how  species 
replace  other  species  in  going  from  one  district  into 
another;  and.  further  still,  when  he  found  the  birds 
of  the  Galapagos  Islands  closely  allied,  but  always 
of  di liferent  species  from  those  of  the  mainland,  he 
reached  the  conclusion  that  only  some  process  of 
progressive  modification  could  give  the  explanation. 
And  this  thought  never  again  left  him. 

Darwin  returned  to  England  in  the  Beagle  in 
()ctoi)cr  1836.  and  set  to  work  in  London  and 
Cambridge,  writing  monographs  and  |)reparing-  his 
collections.  In  1839  he  married,  and  it  is  plcasanl 
to  know  that  to  this  great  and  simple  soul,  in  that 
act  lay  almost  the  whole  comfort  and  cheer  of  his 
later  life.  Steadily  his  health  grew  worse.  Soon 
he  abandoned  all  social  effort ;  then  it  became  im- 
possible to  attend  the  meetings  of  scientific  socie- 
ties; and  in  1842  he  and  his  wife  went  down  into 
tiiat  beautiful  county  of  Kent,  with  its  soft  and  even 


climate,  and  at  Down  they  established  a  home, 
which  thereafter  he  seldom  left,  especially  in  later 
years.  There  for  forty  years  he  patiently  investi- 
gated and  reasoned,  until  the  day  in  April  1882. 
when  he  went  to  join  the  company  of  great  men 
who  had  preceded  him  in  Westminster  Abbey — the 
grandest  monument  to  genius  upon  earth. 

Throughout  this  period  Darwin's  productiveness 
was  surprising.  Nearly  one  hundred  papers  in 
journals,  and  a  list  of  books,  some  of  which,  I  am 
sure,  will  be  new  to  you :  Narrative  of  the  Voyage 
of  the  Beagle  (1839);  Zoology  of  the  Beagle 
I  1839-40)  ;  Structure  and  Distribution  of  Coral 
Reefs  (1842)  ;  History  of  the  J'oyage  of  the  Beagle 
{  1845)  ;  Monograph  of  Recent  and  Fossil  Cirri- 
pedia  (1851);  Origin  of  Species  (1859);  Fertili- 
zation of  Orchids  (1862)  ;  Animals  and  Plants  un- 
der Domestication  (1868);  Descent  of  Man 
(1871)  ;  Expression  of  Emotions  in  Man  and  Ani- 
mals (1872);  Climbing  Plants  (1875);  Insectiv- 
orous Plants  (1875);  Cross  and  Self  Fertilization 
in  the  Vegetable  Kingdom  (1876)  ;  Different  Forms 
of  Flozvers  in  the  same  Species  (1877)  ;  Pozver  of 
Movement  in  Plants  (1880)  ;  Formation  of  Vege- 
table Mould  through  the  Action  of  IVorms.  unth 
Observations  on  their  Habits  (1881). 

Think  of  the  range  of  it,  you  gentlemen  who  are 
mostly  modern  specialists !  Geology,  botany,  zool- 
ogy, and  in  zoology  from  the  habits  of  earth  worms 
to  the  genesis  and  development  of  human  reason. 
And  this  was  the  output  of  a  man  tormented  for 
forty  years  with  daily  illness,  and  racked  with  al- 
most ceaseless  pain  ;  unable  to  wofk  continuouslv 
more  than  one,  or  at  most  two  hours ;  often  losing 
weeks  from  illness ;  once  seven  months.  That  was 
Darwin.  Time  lacks  to  speak  of  these  books, 
though  in  a  fuller  review  of  his  work  each  one 
should  be  examined,  for  each  puts  forth  original 
inductions  based  on  original  observations.  I  can 
at  most  speak  briefly  of  the  one  theory  with  which 
Darwin's  name  will  be  linked  as  long  as  men  rea- 
son and  remember. 

Of  course  you  all  know  the  thought  of  evolution 
was  not  new  in  Darwin's  time.  From  Thales  of 
Miletus,  in  the  sixth  century  before  our  era  down 
to  the  Roman  poet  Lucretius  in  the  first,  philos- 
ophers had  misty  dreams  of  the  coming  of  existing 
things  from  other  things  that  had  preceded  them, 
but  they  were  only  dreams,  in  no  way  correspond- 
ing to  present  conceptions,  and  except  as  historx 
they  are  not  of  interest. 

l"Vom  Lucretius  for  nearly  two  thousand  vears. 
if  men  had  thoughts  on  such  subjects  they  difl  n(  t 
,-peak  them,  for  those  were  the  days  of  Church  do- 
minion, and  the  hand  of  the  Church  was  heavy. 

The  great  Frenchman.  Lamarck,  broke  the  long 
silence  early  in  Darwin's  own  century.  I  cannot 
go  into  his  views.  They  were  largely  fanciful  and 
often  obscure,  attributing  evolution  to  the  eftVct.- 
of  use  and  disuse  of  organs,  and  the  action  of  ex- 
ternal conditions. 

1  lis  influence  in  his  own  time  was  not  great,  and 
lie  died,  like  Milton,  old,  blind,  and  near  to  pov- 
erty. In  1830,  the  year  after  his  death,  iiis  as.so- 
ciate  GcofFroy  St.  Ililaire  upheld  his  views  in  a 
memorable  debate  at  the  I'"rench  .\cademv  with 
Cuvier,  but  was  borne  down  and  discredited  b\  the 
eloquence  and  personality  of  that  great  naturalist. 


March  13,  1909.] 


BROWN:  LIFE  AND  WORK  OF  DARWIN. 


and  evolution  went  to  sleep  for  another  thirty 
years.    Then  Darwin  came,  and  brought  the  light. 

Darwin's  great  service  is  that  he  placed  the  fact 
of  evolution  so  far  beyond  dispute  that  men's  minds 
are  forever  freed  from  dogmatic  objections  to  it, 
and  since  his  work  was  done  every  investigator  in 
every  branch  of  human  research,  consciously  or  un- 
consciouslv,  works  according  to  its  methods.  He 
also,  in  natural  selection,  proposed  as  a  chief  factor 
in  the  course  of  evolution,  what  one  might  call  an 
ultimate  fact  in  organic  life — a  fact  of  daily  ob- 
servation, that  the  unfit  must  perish.  The  all  suf- 
ficiency of  the  service  of  natural  selection  to  modi- 
fication may  be  cjuestioned — indeed  Darwin  never 
claimed  it — but  the  fact  of  its  occurrence,  never. 
The  main  points  of  Darwin's  theory  are  familiar  to 
you.  He  founded  it  upon  overproduction  of  ofif- 
spring,  considerable  in  higher  vertebrates,  enor- 
mous in  the  lower  one? ;  upon  the  extinction  that 
results  in  the  relatively  small  totals  of  adult  life ; 
and  upon  the  presence  of  variation  in  the  individ- 
uals of  a  species.  Somewhere  within  these  oc- 
currences he  believed  the  key  to  modification  was 
to  be  found. 

In  the  year  after  his  return  to  England  he  opened 
a  notebook  for  the  reception  of  every  fact  and 
thought  bearing  upon  the  question.  The  following 
year,  1838,  he  read  Malthus's  famous  book,  and  the 
chapters  on  the  Checks  to  Increase  of  Population 
gave  him  the  clue.  Simple  enough — the  least  fit 
perish  in  the  recurring  strife  and  struggle  for  ex- 
istence, and  the  fit  survivors  bequeath  the  varia- 
tions that  saved  them,  to  their  offspring. 

For  twenty  years"  he  worked  silently,  publishing 
nothing  of  his  views,  mentioning  them  to  few. 
Then  from  beyond  the  southeastern  horizon  came 
a  small  cloud  that  overspread  the  whole  sky  to 
Darwin.  You  all  know  the  story.  How  Wallace, 
out  in  Ternate,  worked  out  an  almost  identical  ex- 
planation of  evolution  and — of  all  men  then  living 
— sent  it  to  Darwin  to  see  if  it  was  worth  publish- 
ing. You  all  know  how  by  advice  of  Hooker  and 
Lyell,  who  were  familiar  with  Darwin's  work,  a 
brief  abstract  of  his  twenty  years  labor  was  pre- 
pared and  presented  with  Wallace's  paper  to  the 
Linnaean  Society  on  ]\\\y  i,  1858.  You  all  know 
the  splendid  generosity  of  Wallace  in  disclaiming 
priority,  even  so  late  as  last  year,  and  the  equal 
willingness  of  Darwin  to  accord  it  to  him.  It  was 
the  triumph  of  great  souls  in  magnanimity. 

Few  of  those  present  are  old  enough  to  remem- 
ber the  storm  of  criticism  and  abuse  that  was 
poured  upon  Darwin  when  the  Origin  of  Species 
was  published  in  November  of  the  next  vear.  Tlie 
abuse  mostly  came  from  sentimentalists  who  could 
see  nothing  in  Darwinism  except  the  libelous  state- 
ment that  they  were  descended  from  monkeys,  and 
from  theologians  who  believed  their  cherished  dog- 
mas were  seriously  threatened.  We  need  spare 
no  time  for  objections  of  either  kind.  They  have 
been  with  us  from  the  beginning,  and  are  likely  to 
be  until  the  end,  and  serve  only  to  recall  the  poet's 
line,  "the  shallow  murmur  but  the  deep  are  dumb." 

Still  the  deep  did  have  something  to  say  about 
natural  selection,  and  even  Darwin  felt  the  se- 
riousness of  some  of  their  earlv  criticisms.  Chief 
among  these  was  the  difficulty  of  seeing  how  the 
minute  variations,  which  were  all  that  were  then 


believed  to  exist,  could  be  of  so  lifesaving  a  value 
in  the  struggle  for  existence,  as  to  permit  the  action 
of  natural  selection,  and  why,  as  it  was  then  be- 
lieved that  only  a  very  few  individuals  vary  in  a 
species,  the  favorable  variations  were  not  promptly- 
lost  in  the  free  breeding  of  all  its  members.  The 
later  practice  of  exact  measurement  of  all  organs 
in  large  numbers  of  individuals  in  a  species,  called 
"biometrics,"  has  partly  .solved  these  difiiculties, 
for  it  has  shown  that  variation  is  much  greater  int 
extent  than  was  supposed,  amounting  often  to 
twenty-five  per  cent,  of  the  average  of  a  character, 
and  that  practically  all  members  of  a  species  vary, 
and  that,  furthermore,  these  variations  follow  very 
closely  Ouetelet's  law  of  chance  in  being  massed 
thickly  about  the  mean  and  thinning  out  toward 
the  extremes.  Many  biologists,  however,  still  re- 
gard these  difificulties  as  serious. 

If  we  are  to  reach  a  conclusion  as  to  how  Dar- 
winism has  withstood  the  shocks  of  time.,  the  sup- 
plements and  alternatives  offered  by  the  past  gen- 
eration should  be  examined,  but  I  can  do  no  more 
than  refer  to  several  of  real  importance,  passing 
without  notice  the  larger  number  of  mere  logical 
systems  built  on  no  foundation  other  than  words. 
With  these  serious  science  has  no  concern.  Others 
reveal  on  the  part  of  their  authors  only  a  sort  of 
mental  strabismus  which  diverts  insight  from  Dar- 
win's real  meaning. 

Weismann's  theory  that  the  machinery  of  heretl- 
ity  consisted  of  an  unalterable  substance  called  by 
him  germ  plasm,  handed  down  from  parent  to  off- 
spring, and  incapable  of  being  acted  upon  bv  ex- 
ternal conditions,  if  true,  necessarily  disposed  of 
the  inheritance  of  acquired  characters,  a  factor 
which  was  in  a  measure  important  in  Darwin's 
scheme,  as  it  was  vitally  so  to  that  of  Lamarck. 

It  should  be  said,  however,  that  Weismann  has 
so  far  modified  his  construction  that  he  now  admits 
that  in  some  unknown  way  external  impressions 
may  reach  the  germinal  substance. 

Wallace  and  the  extreme  neo-Darwinians,  fol- 
lovving  the  original  method  of  Weismann,  there- 
fore attribute  progressive  modification  solely  to 
the  action  of  natural  selection  upon  variations  aris- 
ing only  within  the  substance  of  the  germ  plasm,, 
from  inner  causes. 

From  this  point  the  search  of  recent  years,  large- 
ly because  so  great  a  proportion  of  biologists  have 
become  cytologists  ancl  embryologists,  has  in  great 
measure  shifted  to  the  cause  of  variation. 

Many  palaeontologists  believe  that  in  phylogenv 
they  find  evidence  of  "determinate  variation,"  and 
still  more  that  evolution  has  been  in  determinate 
directions.    This  is  the  ortJiogeiiesis  of  Eimer. 

Of  recent  developments  of  evolutionary  thought. 
I  can  do  no  more  than  refer  hastily  to  three :  two 
of  them  additions  to  natural  selection,  the  third 
meant  to  entirely  displace  the  efificiency  of  Dar- 
winian variations. 

The  first  of  these  is  the  theory  of  isolation.  In 
its  most  usual  sense,  as  geographical  separation,, 
isolation  was  considered  by  Darwin,  but  later  on 
his  brilliant  associate.  Romanes,  and  another  stu- 
dent of  distribution,  the  Rev.  ]\Ir.  Gulick,  so  ex- 
tended its  scope  as  to  include  every  condition  in- 
ternal to  the  organism  or  external  to  it,  which  can 
result  in  the  establishment  of  a  bar  to  free  breed- 


520 


BROWN:  LIFE  AND  WORK  OF  DARWIN. 


[New  York 
Medical  Journal. 


in^  between  any  number  of  tbe  individuals  of  a 
s];ecies  and  the  rest  of  its  members.  Isolation  thus 
includes  geographical  separation,  differences  in 
station  resulting  from  change  of  habit  or  kind  of 
food,  alterations  in  the  reproduction  season,  and 
perhaps  sexual  selection  resulting  in  preference. 
As  a  result  the  varying  section  can  breed  within  its 
own  limits  and  carry  on  its  own  line  of  develop- 
ment. It  is  quite  certain  that  isolation  is  a  power- 
ful agency  in  divergence  of  character,  and  is  thor- 
oughly Darwinian,  being  no  more  than  an  extension 
of  a  factor  admitted  by  the  founder. 

Of  ovgonic  sclcdioit,  due  independently  to  the 
constructive  thought  of  three  men,  Osborn,  of  New 
York ;  Baldwin,  then  of  Princeton,  and  Lloyd  Mor- 
ji-an.  of  England,  it  is  impossible  to  treat  here  with 
fullness  proportioned  to  its  complexity.  It  proposes 
to  fix  the  ])lace  in  evolution  of  adaptive  structures 
without  requiring  use  inheritance :  to  show  how 
natural  selection  can  take  hold  of  slight  congenital 
variations ;  and  to  account  for  determinate  lines  of 
evolution.  Its  thought  is  that  all  the  individuals  of 
a  species  are  at  times  similarly  modified,  or  adapted, 
by  surrounding  conditions,  a  possibility  foreseen  by 
Darwin  himself.  These  ac(|uired  characters  are  not 
bequeathed  to  the  oft:'spring,  but  must  be  gained 
anew  by  each  generation.  Their  part  in  evolution 
is  simply  to  keep  the  species  in  fiuictional  relation 
to  its  environment,  and  so  to  keep  it  alive  until  in- 
heritable congenital  variations  occur,  directed  to  the 
same  end,  when  these  will  be  taken  hold  of  by  natur- 
al selection,  to  become  a  part  of  the  heritage  of  the 
race.  The  theory  is  comparativly  new  and  has  not 
yet  been  fullv  valued.  Doubt  may  fairly  arise,  how- 
ever, as  to  its  second  proposition,  for  it  is  not  easy 
to  see  that  the  slight  congenital  variations  could  be 
of  lifesaving  value  as  required  by  natural  selection, 
so  long  as  the  result  of  selection  is  already  attained 
through  the  larger  acquired  modifications  due  to  (li- 
rect  stress  from  without.  In  great  overbranching 
forests  little  underbrush  is  present,  it  is  shaded  out 
of  existence  by  the  giant  growth  above.  Such  would 
seem  to  be  the  probable  result  here.  It  seems  to  be 
true,  however,  that  some  of  what  we  call  species, 
and  many  subspecies,  remain  in  existence  just  as 
long  as  their  distinctive  characters  are  impressed 
similarly  on  the  individuals  of  each  generation  by 
an  unchanged  environtuent.  In  these  ontogenetic 
species  lies  a  fertile  field  for  the  ecologist  of  the 
future. 

The  one  remaining  theory  that  I  shall  speak  of  is 
the  mntation  theory  of  the  Dutch  botanist  De  Vries, 
which  is  believed  by  its  adherents  to  finally  dispose 
of  the  lesser,  or  Darwinian  sort  of  variation  as  a 
factor  in  evolution.  De  \'ries  found  that  new  char- 
acters, discontinuous  variations,  or  ''mutations,"  sud- 
denly occur  in  ])lants.  and  he  maintains  that  these 
being  inherited,  give  rise  at  once  to  new  species, 
but  that  the  lesser  variations,  which  he  calls  "fluc- 
tuations," can  never  do  so. 

Von  must  pardon  this  siunmary  statement  of  a 
most  elaborate  system.  It  will  serve  the  purpose  of 
the  moment.  Its  faults  briefly  are  these :  It  has  not 
been  C(  inclusively  shown  that  De  \  ries'  mutations 
arc  anything  more  than  Darwin's  sports;  it  is  not 
known  that  mutations  occur  frequently  in  wild  spe- 
cies, tile  experiments  of  De  \'ries  having  been  con- 
ducted on  garden  varieties  of  plants,  which  usually 


are  of  obscure  origin  ;  and  lastly,  the  evidence  of 
their  inheritance  so  far  is  confined  to  pedigree  cul- 
tures under  controlled  conditions.  Botanists  hold 
the  theory  in  more  repute  than  do  zoologists,  and  of 
these,  cytologists  are  more  tempted  by  it  than  field 
collectors  and  systematists.  Yet  if  mutations  are 
frequent  under  nature  these  last  should  have  some- 
thing to  say  as  to  their  potency.  Perhaps  no  zoolo- 
gist in  this  country  is  more  competent  to  form  an 
opinion  here  than  Dr.  C.  Hart  Merriam,  who  not 
long  since  announced  that  in  a  careful  examination 
of  more  than  one  thousand  species  and  subspecies  of 
North  American  mammals  and  birds,  he  foimd  no 
evidence  that  a  single  one  had  arisen  by  a  mutation. 
-A.  similar  examination  of  reptiles  was  undertaken 
by  me  shortly  afterward  with  a  like  result.  Muta- 
tions get  no  support  from  systematic  zoology.  Even 
were  it  otherwise  the  theory  could  dispute  only  that 
part  of  Darwinism  which  relates  to  the  progressive 
modification  of  small  variations.  Be  they  varia-, 
tions  or  mutations,  continous  or  discontinuous,  even 
though  they  may  occasionally  give  rise  to  new  spe- 
cies, natural  selection  must  still  determine  wdiether 
they  shall  die  or  live. 

You  will  want  to  know  something  of  the  present 
state  of  Darwinism.  You  will  get  many  answers 
from  many  men.  I  can  give  you  only  my  own.  Per- 
sonally, I  am  a  loyal  Darwinian  of  the  Darwin 
school,  not  of  his  later  day  followers.  To  use  his 
own  simple  statement  in  the  preface  to  the  sixth 
English  edition  of  the  Origin.  "I  believe  that  n^.tural 
selection  has  been  the  most  important,  though  not 
the  exclusive  means  of  modification."  I  believe  that 
variation  is  due  partly  to  imknown  causes  inherent 
in  the  germinal  substance,  but  more  to  the  stress  of 
external  conditions  upon  the  bodily  structure.  I 
do  not  believe  in  determinate  variation,  nor  in  deter- 
minate evolution,  except  in  the  sense  that  the  path 
followed  by  the  organism  is  determined  for  it  by 
its  environment,  through  which  it  can  follow  no 
other  path  and  live.  I  believe  that  new  species  have 
not  often  arisen  b\-  nuitation,  and  that  in  any  case 
their  permanency  must  be  determined  by  natural 
selection.  While  the  evidence  for  the  transmission 
of  acquired  characters  is  as  yet  slight,  I  am  near 
to  belief  that  it  will  some  day  be  proved  luider  at 
least  some  conditions.  Then  our  conceptions  of  the 
method  of  evolution  will  be  simpler  than  now.  That 
is  my  confession  of  faith  as  a  Darwinian. 

I  feel  that  I  cannot  conclude  this  inade(|uate  le- 
vicw  of  the  life  and  work  of  Darwin  better  tlrm  in 
the  words  spoken  a  few  days  after  his  death  by  an- 
other great  naturalist.  Sir  William  Henry  Flower, 
then  president  of  the  Zoological  Society  of  London. 
They  are  eloquent  of  the  noble  qualities  of  their  sub- 
ject, and  in  so  speaking  they  convey  a  message  to 
all  who  may  coiuprehend  :  "Tf  it  is  not  given  to  any 
of  us  to  emulate  him  in  brilliancy  of  scientific  induc- 
tion, or  to  light  upon  discoveries  that  will  change 
the  current  of  human  ideas,  we  can  at  lea.st  endeavor 
to  follow  the  example  he  has  set  us  of  patient  per- 
severance in  obseryation,  scru])ulous  accuracy  of 
statement,  deference  for  the  opinions  and  feelings  of 
others,  candor  toward  opponents,  and  of  the  invari- 
able modesty  and  gentleness  of  demeanor  which 
shed  such  a  charm  round  his  public  as  well  as  his 
private  life.  " 

1208  Locust  Stri:i:  r. 


March  13,  1909.] 


M'RAE:  PENETRATING  WOUNDS  OF  THE  ABDOMEN. 


521 


PENETRATING  WOUNDS   OF  THE  ABDOMEN.* 

Bv  Floyd  W.  McRae,  M.  D., 
Atlanta,  Ga. 

Mv  apology  for  again  bringing  this  subject  to  you 
for  discussion  is  that  it  is  full  of  dramatic  interest 
and  pathetic  tragedy.  When  the  history  of  gunshot 
wounds  of  the  abdomen  shall  have  been  written, 
chief  credit  must  be  given  to  southern  surgeons. 
Most  of  the  papers  on  this  subject  that  are  really 
worth  while  have  been  written  by  fellows  of  this 
association,  and  have  been  printed  in  its  transactions. 

We  of  the  South  are  brought  face  to  face  with 
gunshot  wounds  of  the  abdomen  far  more  frequently 
than  are  the  surgeons  of  any  other  section  or  coun- 
try. The  conditions  that  have  brought  us  these  op- 
portunities, with  their  care  and  great  responsibili- 
ties, still  obtain  to  a  considerable  degree.  With  our 
large  negro  population,  the  inherent  racial  antago- 
nism that  exists  between  the  lower  elements  of -both 
races  and  the  prevalent,  though  limited,  practice  of 
carrying  concealed  weapons,  we  must  for  an  indefi- 
nite period  of  time  continue  to  deal  with  these  emer- 
gencies. 

The  diagnosis  of  penetration  of  the  abdomen  in 
civil  practice  cannot  be  made  with  even  approximate 
accuracy  without  tracing  the  wound.  Attempts  to 
follow  wounds  with  the  finger  or  the  probe  frequent- 
ly eventuate  in  failure — neither  confirming  nor  dis- 
proving penetration.  These  are  dangerous  expedi- 
ents— universally  condemned  by  the  best  authorities. 

According  to  the  most  reliable  statistics  recorded, 
in  only  ten  per  cent,  of  the  cases  of  penetrating  ab- 
dominal wounds  do  the  hollow  and  solid  viscera 
escape  serious  injury.  There  is  but  one  positive  sign 
of  perforation-^seen  exceptionally — the  escape  of 
gas  or  faeces  externally.  Shock  is  a  very  variable 
symptom,  marked  in  nervous  individuals,  often  prac- 
tically absent  in  men  of  "iron  nerve"  in  spite  of 
grave  lesions.  When  pronounced  and  persistent,  it 
is  strong  presumptive  evidence  of  free  bleeding. 
Nausea,  vomiting,  and  muscular  tension  are  signs  of 
value.  (The  vomitus  should  be  examined  for  blood. 
Blood  in  the  stools  is  rarely  observed  early  enough 
to  be  of  diagnostic  value  as  indicating  perforation. 
The  Senn  hydrogen  gas  test  has  proved  unreliable 
and  dangerous;  it  is  conclusive,  not  exclusive.) 

Treatment  in  civil  life,  with  fair  hospital  facilities, 
aseptic  technique,  and  a  competent  surgeon  available, 
almost  every  penetrating  wound  of  the  abdomen  that 
does  not  prove  immediately  fatal  on  account  of 
shock  and  haemorrhage  should  be  dealt  with  by 
means  of  prompt  operation.  When  everything  is 
ready,  the  preparation  of  the  patient  should  be  made 
on  the  operating  table  during  the  administration  of 
the  anaesthetic ;  the  stomach  should  be  washed  out, 
and  the  field  of  operation  thoroughly  prepared.  If 
there  is  any  doubt  as. to  the  penetration  of  the  wound, 
it  should  be  traced.  By  tracing  is  meant  laying 
open  the  wound  of  entrance,  the  wound  of  exit,  and 
the  intervening  track  of  the  bullet.  Any  one,  or  all 
three,  may  be  necessary  to  prove  or  disprove  pene- 
tration of  the  peritoneal  cavity  beyond  equivocation. 

If  the  wound  is  penetrating,  the  operation  should 
be  so  extended  as  to  constitute  an  exploratory  coeli- 
otomy ;  and  if  visceral  damage  is  found,  immediate 

*Read  before  the  Southern  Surgical  and  Gynaecological  Associa- 
tion, at  a  meeting  held  in  December,  1908. 


repair  should  be  made.  Unless  very  inconveniently 
located,  the  wound  of  entrance  should  be  enlarged 
sufficiently  for  thorough  exploration.  (When  this 
is  not  advisable,  a  median  incision,  either  above  or 
below  the  umbilicus,  should  be  made.  The  location 
of  the  incision  should  be  determined  by  the  history 
of  the  case — the  position  of  the  patient  when  hit  by 
the  bullet,  the  angle  from  which  it  was  fired,  and 
its  probable  course.) 

On  opening  the  abdomen,  the  escape  of  gas  or 
fc-Eces  should  be  noted  and  immediate  search  be  made 
for  the  bleeding  vessel  or  vessels,  if  there  is  profuse 
haemorrhage.  Free  bleeding  should  be  arrested  at 
once,  and  if  essential  to  its  accomplishment  the  in- 
cision should  be  enlarged  and  the  patient  partially  or 
completely  eviscerated.  These  extreme  measures 
should  be  avoided,  if  possible.  Long  incisions,  evis- 
ceration, undue  exposure  of  intestines,  and  rough 
handling  greatly  increase  the  operative  mortality. 

The  first  portion  of  the  intestine  encountered 
should  be  brought  out  of  the  wound  and  a  tape  or  a 
strip  of  gauze  thrown  around  it  by  pushing  one  end 
through  the  mesentery,  between  vessels,  with  a  haem- 
ostat.  The  ends  of  the  tape  or  gauze  are  caught  and 
held  by  forceps ;  and  a  cross  nick  is  made  either 
above  or  below,  to  give  a  definite  point  of  departure. 
This  is  a  little  procedure  of  great  practical  value,  re- 
quiring only  a  few  seconds  of  time  in  its  accomplish- 
ment. To  look  for  the  ileocaecal  junction  or  some 
other  readily  recognizable  portion  of  the  intestinal 
tract  is  a  waste  of  time,  and  the  additional  handling 
tends  to  spread  infection  in  the  presence  of  perfora- 
tion with  leakage.  The  whole  intestinal  tract  should 
be  rapidly  examined,  first  above  and  next  below  the 
gauze.  Slits  in  the  mesentery  should  be  repaired, 
bleeding  be  arrested,  and  intestinal  perforations  be 
closed  as  found.  When  it  can  be  done  without  too 
much  contracture  of  the  lumen  of  the  gut,  the  per- 
foration should  be  closed  on  its  convex  surface  and 
in  its  longitudinal  axis.  Perforations  near  the  mes- 
enteric border  usually  can  be  closed  best  transverse- 
ly. Less  obstruction  is  of¥ered  to  the  faecal  flow  by 
a  longitudinal  seam  than  by  a  transverse  one,  and 
the  dangers  from  leakage  and  obstruction  are  con- 
sequently diminished.  Care  should  be  taken  to  see 
that  the  mesenteric  vessels  supplying  the  intestine 
are  not  interfered  with.  When  the  margins  of  the 
perforation  are  ragged  and  contused,  they  should  be 
trimmed  off.  When  the  wound  is  small  and  clean 
cut,  interrupted  Lembert  sutures  are  all  that  is  nec- 
essary. When  the  perforation  is  long  and  ragged,  a 
few  interrupted  Czerny  sutures  should  be  inserted ; 
over  these  Lembert  sutures  of  celluloid  linen  ( Pagen- 
stecher)  or  silk  should  be  placed  to  close  the  per- 
foration accurately — care  being  taken  not  to  infold 
too  much  tissue.  The  intestine  in  gunshot  perfora- 
tion is  often  in  a  state  of  spasmodic  contraction.  I 
have  found  this  condition  present  in  some  portion  of 
the  alimentary  canal  in  almost  every  case  of  gunshot 
wound  that  has  come  under  my  observation.  This 
contraction,  reducing  the  gut  much  below  its  normal 
calibre,  enhances  the  danger  of  infolding  too  much 
tissue,  the  bit  of  the  suture  being  six  to  eight  times 
deeper  than  it  would  have  been  had  the  gut  retained 
its  normal  degree  of  distention  and  relaxation. 

When  there  is  considerable  separation  of  the  gut 
from  its  mesentery,  resection  and  end  to  end  anasto- 
mosis should  be  done.    It  is  frequently  a  question  of 


522 


M'RAE:  PENETRATING  WOUNDS  OF  THE  ABDOMEN. 


[New  York 
Medical  Journal. 


judgment  as  to  whether  a  large  number  of  perfora- 
tions, close  together,  should  be  sutured  separately, 
or  a  resection  of  that  portion  of  the  intestine  be  re- 
sorted to.  The  latter  is  generally  considered  to  be 
the  better  procedure,  taking  less  time  and  diminish- 
mg  the  danger  of  obstruction.  (When  a  resection 
is  done,  the  intestine  should  be  cut  across  obliquely, 
so  as  to  be  sure  that  the  mesenteric  border  is  a  little 
longer  than  the  convex  border.  The  anastomosis 
can  best  be  accomplished  by  continuous  Czerny-Lem- 
bert  sutures  of  Pagenstecher  or  silk,  the  mesenteric 
borders  first  being  approximated  accurately  by  the 
Maunsell  mattress  mesenteric  suture.  The  approxi- 
mation of  the  cut  ends  is  facilitated  by  interrupted 
sutures  dividing  the  intestines  into  thirds,  as  sug- 
gested by  Connell.  Where  haste  is  essential,  the 
Murphy  button  may  be  used  instead  of  sutures.) 

The  intestine  should  be  cleansed  by  moist  spong- 
ing as  the  operation  proceeds.  If  it  is  necessary  to 
keep  any  considerable  portion  of  the  gut  outside  of 
the  abdominal  cavity  for  a  length  of  time,  it  should 
be  covered  by  pads  or  towels  wrung  out  of  warm 
normal  salt  solution,  and  it  should  be  kept  moist  and 
warm  by  frequently  wetting  the  gauze  with  warm 
salt  solution.  This  should  be  done  by  the  assistant 
or  the  nurse.  Under  ordinary  conditions,  only  a 
small  portion  of  the  intestine  need  be  withdrawn 
from  the  abdomen  at  a  time ;  as  the  surgeon  draws 
out  and  traces  the  intestine,  his  assistant  follows 
after  and  replaces  it  in  the  abdominal  cavity.  After 
examining  from  the  point  of  departure  upward  to 
the  end  of  the  gut,  or  vice  versa,  the  opposite  por- 
tion of  the  intestine  is  drawn  out  by  the  strip  of 
gauze  around  it,  and  followed  in  the  same  way  as 
above  described,  dealing  with  each  injury  seriatim. 
The  strip  of  gauze  around  the  intestine  is  next  re- 
moved, and  the  wound  in  the  mesentery  closed. 

Careful  handling  of  the  intestine  without  undue 
exposure  is  essential  in  order  to  secure  good  re- 
sults. Evisceration,  rough  handling,  and  the  long 
exposure  of  intestine  have  turned  the  scales  in 
many  of  these  abdominal  injuries,  and  led  to  a  fatal 
result.  (Many  of  the  deaths  occurring  seven  to 
ten  days  after  operation,  done  for  penetrating 
wounds  of  the  abdomen,  are  due  to  perforation 
caused  by  sloughing  of  the  intestine,  owing  to  sep- 
aration from  its  mesentery.  It  must  ever  be  borne 
in  mind  that  a  gut  separated  from  its  mesenteric 
blood  supply  cannot  live.) 

Note  should  always  be  taken  of  the  presence  or 
the  absence  of  urine  in  the  peritoneal  cavity,  and 
the  bladder  should  be  examined  for  injury.  If  the 
bladder  has  been  perforated,  it  should  be  sutured  ac- 
curately by  interrupted  sutures  of  catgut  which  em- 
brace all  the  coats  down  to  the  mucous  membrane. 
If  the  suture  line  cannot  be  tested  by  distending  the 
bladder,  a  catheter  should  be  introduced  or  drain- 
age be  obtained  through  a  perineal  incision.  I  pre- 
fer continuous  catheterization  through  the  urethra 
to  making  a  perineal  section.  In  these  days  of  clean 
surgery  and  skilful  nursing,  one  need  have  little  ap- 
prehension that  the  catheter,  when  properly  handled, 
will  cause  chills  or  produce  urethral  irritation. 

In  one  of  my  cases  the  bladder  was  tunneled  for 
two  inches,  but  other  than  the  time  required  in 
making  the  repair,  it  did  not  seem  to  complicate 


matters  in  the  least.  Two  of  the  fatal  cases  in  the 
Grady  Hospital  statistics  quoted  below  were  due  to 
failure  to  find  and  properly  deal  with  bladder  in- 
juries. 

Injuries  to  the  solid  viscera  other  than  the  kid- 
ney and  pancreas  are  dangerous  chiefly  on  account 
of  haemorrhage. 

Bleeding  from  the  liver  can  usually  be  controlled 
by  light  gauze  packing,  ^^''hen  this  does  not  suf- 
fice, deep  through  and  through,  heavy  catgut  su- 
tures, loosely  tied,  or  the  tape  suture  of  Tififany, 
may  be  necessary.  (Strips  of  gauze  packed  in  or 
about  bleeding  points  in  the  solid  viscera  should  be 
brought  out  through  the  abdominal  wound  for  drain- 
age.) 

Injuries  to  the  pancreas  are  very  difficult  to 
handle  properly,  and  consequently  they  are  peculiar- 
ly fatal.  When  the  pancreas  has  been  injured,  the 
wound  in  it  should  be  packed  and  both  anterior  and 
posterior  drainage  should  be  made  (through  and 
through  drainage). 

Superficial  injuries  to  the  cortical  substance  of 
the  kidney  should  be  drained  through  the  loin.  It 
is  dangerous  to  attempt  to  drain  a  kidney  trans- 
peritoneally.  When  there  is  extensive  laceration  of 
the  kidney  substance,  and  when  the  renal  vessels  are 
severed,  a  nephrectomy  should  be  done.  Tem- 
porizing with  a  kidney  thus  injured  will  usually  lead 
to  a  fatal  result.  It  has  been  advised  to  remove  the 
kidney  when  its  pelvis  is  torn.  As  a  rule,  it  is  safer 
to  suture  the  pelvis  with  chromic  catgut  and  to 
drain  through  the  loin.  A  secondary  nephrectomy 
may  be  required. 

Of  first  importance  in  the  after  treatment  of  pen- 
etrating wounds  of  the  abdomen  is  rest,  general  and 
alimentary.  W^hen  the  injury  is  in  the  upper  por- 
tion of  the  intestinal  tract,  nothing  should  be  al- 
lowed by  the  mouth  except  sterile  water  for  several 
days.  The  lower  bowel  should  be  kept  unloaded  by 
simple  enemata,  and  rectal  feeding  should  be  em- 
ployed. Purgatives  should  be  avoided.  A  little 
morphine  or  codeine  may  be  necessary  to  relieve 
great  pain  and  to  secure  proper  rest.  Opiates,  how- 
ever, should  be  given  very  guardedly.  Strychnine 
is  usually  indicated.  When  there  has  been  consid- 
erable haemorrhage,  if  practicable,  a  quantity  of 
normal  salt  solution  should  be  left  in  the  abdomen. 
(Normal  salt  solution  should  be  given  by  hypc- 
dermoclysis  or  by  intravenous  transfusion,  as  indi- 
cated. When  there  has  been  excessive  haemorrhage, 
lives  may  often  be  saved  by  the  free  use  of  normal 
salt  solution.  In  the  presence  of  injury  to  the  large 
bowel  it  is  best  to  give  simple  sterile  food  by  the 
mouth,  that  is  readily  absorbable  from  the  stomach, 
and  to  introduce  nothing  into  the  bowel  per  aiiiiin 
lest  the  wound  in  the  large  bowel  be  forced  open.) 
In  the  after  treatment  of  these  cases,  when  there  i> 
marked  gaseous  distention,  with  a  tendency  to  in- 
testinal paresis,  alum  enemata,  as  first  suggested  by 
the  late  Virgil  O.  Plardon.  of  Atlanta,  are  of  great 
value.  Sulphate  or  salicylate  of  eserin,  in  doses  of 
i/ioo  of  a  grain,  every  three  to  six  hours,  has 
seemed  to  have  a  salutary  effect.  I  absolutely  ex- 
clude milk  and  egg  diet  by  the  mouth  for  the  first 
five  to  eight  days.  Milk  and  eggs  tend  to  increase 
the  formation  of  gas  and  to  constipate  the  bowels. 


March  13,  1909.] 


M'RAE:  PENETRATING  WOUNDS  OF  THE  ABDOMEN. 


523 


Purgatives  should  be  employed  with  great  care, 
and  only  after  four  to  six  days  following  the  op- 
eration. 

It  is  unfair  to  quote  military  statistics  as  an 
argument  against  operations  in  civil  life.  The  con- 
ditions under  which  the  injuries  are  received  and 
the  character  of  the  injuries  are  so  different  as 
hardly  to  admit  of  just  comparison.  In  modern  mil- 
itary practice  the  abdominal  injuries  are  due  to 
small  calibre,  steel  jacketed  bullets  of  high  velocity, 
which  go  directly  through,  making  small,  clean  cut 
perforations  in  the  hollow,  as  well  as  the  solid,  vis- 
cera, from  which  there  is  very  little  leakage  or 
hremorrhage.  The  injuries  are  more  frequently 
than  otherwise  received  in  the  standing  posture, 
with  a  comparatively  empty  intestinal  tract,  bv  in- 
dividuals in  the  prime  of  life,  picked  specimens  of 
physical  manhood.  In  civil  practice  the  individuals 
are  more  frequently  than  otherwise  shot  in  drunken 
brawls,  when  the  alimentary  canal  is  filled  with  al- 
cohol and  with  all  sorts  of  irritating  and  even  infec- 
tious material.  The  wounds  are  made  by  infected 
bullets,  which  have  been  carried  around  in  the  hip 
pocket  by  "pistol  toters,"  of  large  calibre  and  lov>' 
A-elocity,  that  make  large,  ragged  perforations  in  the 
hollow  viscera,  and  jagged  wounds  in  the  mesentery 
and  solid  viscera  that  leak  freely  and  bleed  furious- 
ly. Other  things  being  equal,  the  surgeon  who 
opens  the  abdomen  the  earliest  after  the  injury  does 
his  work  rapidly  and  accurately,  and  who  closes  the 
abdomen  in  the  shortest  time,  will  get  the  best  re- 
sults as  to  mortality. 

The  prognosis  of  penetrating  gunshot  wounds 
made  by  large  calibre,  low  velocity  bullets,  without 
operation,  is  bad.  As  shown  by  the  statistics  of  the 
Crimean  war,  the  American  civil  war,  and  civil  hos- 
pitals, about  ninety  per  cent,  prove  fatal.  Stab 
wounds  and  wounds  made  by  small  shot,  or  small 
calibre,  steel  jacketed,  high  velocity  bullets  are  less 
fatal,  giving  a  mortality  of  from  fifty  to  seventy- 
five  p^r  cent.  Wounds  of  the  umbilical  and  hypo- 
gastric regions  are  peculiarly  dangerous.  In  these 
regions  the  small  intestines  rarely  escape  perfora- 
tion. 

The  contents  of  the  stomach  are  comparatively 
innocuous.  The  virulence  of  the  infection  contained 
in  the  alimentary  canal  progressively  increases  to 
the  ileocaecal  junction  ;  the  contents  of  the  large  in- 
testine are  less  infectious,  and  wounds  of  the  large 
intestine  are  less  fatal  than  are  those  of  the  small 
intestine. 

In  looking  over  the  statistics  of  the  Grady  Hos- 
pital, I  find  that  there  have  been  since  July,  1899, 
forty-seven  cases  of  penetrating  wounds  of  the  ab- 
domen. Thirty-one  of  these  patients  were  operated 
upon,  with  a  mortality  of  25.8  per  cent.  Thirteen 
patients  were  not  operated  upon,  with  a  mortality 
of  62.5  per  cent.  Not  a  single  death  could  have 
been  attributed  to  the  operation  pe?-  se.  In  one  fatal 
case,  a  perforation  of  the  gallbladder  was  over- 
looked. In  two  fatal  cases,  injuries  to  the  urinary 
bladder  were  overlooked.  In  two  patients  the  deaths 
were  evidently  due  to  kidney  injuries,  with  leakage 
of  urine  into  the  peritoneal  cavity,  which  were  over- 
looked. In  one  case  intestinal  perforations  were 
overlooked.  In  another  case  the  abdomen  was 
opened,  found  filled  with  blood,  the  blood  washed 
out,  and  the  abdomen  closed,  without  finding  the 


source  of  haemorrhage,  the  patient  subsequently 
dying  from  internal  hsemorrhage. 

These  thirty  operations  have  been  done  by  eight 
different  surgeons  and  three  house  surgeons,  this 
large  number  of  operators  giving  only  a  fair  aver- 
age of  surgical  skill.  In  spite  of  the  fatalities  due 
to  overlooked  injuries,  the  statistics  following  op- 
erations have  been  very  gratifying  and  have  con- 
stantly improved.  The  patients  not  operated  upon 
were  either  very  bad  ones  or  those  in  which  the 
wound  was  in  such  a  locality  as  to  indicate  no  in- 
jury to  important  viscera,  for  instance,  well  out  in 
the  lumbar  region,  high  up  in  the  hypochondriac  re- 
gion, or  in  the  epigastric  region.  The  average  of 
the  cases  operated  in  has  been  worse  than  those 
treated  expectantly. 

The  contraindications  to  operation  are  bad  sur- 
roundings, incompetent  help,  and  the  lapse  of  twelve 
hours  or  more  between  the  receipt  of  the  injury  and 
possible  surgical  aid.  Other  things  being  equal,  the 
mortality  is  in  direct  proportion  to  the  length  of  time 
elapsing  between  the  receipt  of  the  injury  and  sur- 
gical intervention.  After  eighteen  to  twenty-four 
hours,  the  mortality  is  so  great  that  operation 
should  be  undertaken  only  when  something  positive 
can  be  accomplished  by  it.  After  this  lapse  of  time. 
Xature  has  often  done  her  best  to  repair  the  dam- 
age, and  an  operation  increases  the  hazard. 

My  personal  experience  and  responsibility  cover 
but  fifteen  cases.  I  have,  however,  had  intimate 
knowledge  of  most  of  the  forty-six  Grady  Hospital 
cases  recorded  below,  and  have  assisted  in  or  been 
present  at  many  of  the  operations  done  by  other  sur- 
geons and  have  followed  up  their  patients  in  the 
wards.  I  have  been  forced  by  these  observations 
and  experience  from  an  attitude  of  passive  ex- 
pectancy to  a  position  of  earnest  advocacy  of  early 
operation  in  all  penetrating  wounds  of  the  abdo- 
men, unless  positively  contraindicated  by  the  indi- 
vidual's physical  condition  and  surroundings,  or  the 
absence  of  a  competent  abdominal  surgeon  and  as- 
sistants. Of  my  fifteen  cases,  nine  patients  had  the 
benefit  of  early  operation,  with  seven  recoveries. 
The  percentage  of  recoveries  was  77.7.  Seven  of 
the  nine  operations  were  for  rifle  or  pistol  shot 
wounds,  and  all  presented  grave  visceral  lesions. 
One  patient  had  an  extensive  laceration  of  the  liver 
with  excessive  haemorrhage,  was  exsanguinated  and 
pulseless  at  the  wrist.  Result,  recovery.  One  pa- 
tient had  three  perforations  in  the  stomach,  with 
leakage ;  recovery.  Three  patients  had  multiple  per- 
forations in  the  small  intestines,  with  leakage  in  all : 
two  recoveries,  one  death.  In  one  of  these  the 
bladder  was  also  injured ;  recovery.  Two  opera- 
tions were  done  for  stab  wounds  of  the  liver.  Free 
haemorrhage  in  both  cases  was  controlled  by  suture 
of  the  liver  wounds  and  gauze  packing.  Both  pa- 
tients recovered. 

I  have  treated  four  pistol  shot  wounds  of  the 
abdomen  expectantly,  with  three  deaths  and  one 
recovery.  One  man  with  a  stab  wound,  treated  ex- 
pectantly, died.  Five  cases,  four  deaths,  one  re- 
covery, a  mortality  of  eighty  per  cent.  I  have  done 
two  late  operations  for  complications  due  to  pene- 
trating wounds  that  might  have  been  prevented  by 
early  operation.  Both  died,  a  mortality  of  one  hun- 
dred per  cent. 

These  statistics,  my  personal  experience,  observa- 


524 


MORSE  AND  CROTHERS:  URINE  IN  DISEASES  OF  INFANCY. 


[New  York 
Medical  Jouknsl. 


tion  of  the  Grady  Hospital  cases,  and  a  careful  re- 
view of  the  literature  on  penetrating  wounds  of  the 
abdomen,  have  led  me  to  make  the  following  con- 
clusions as  to  civil  practice: 

1.  In  civil  practice  every  suspected  penetrating 
wound  of  the  abdomen,  under  favorable  conditions 

■  of  practice,  should  have  the  benefit  of  wound  trac- 
ing. 

2.  \Mien  the  wound  proves  to  be  penetrating,  an 
exploratory  laparotomy  should  be  done  at  once,  and 
visceral  damage  excluded  or  repaired  as  far  as  prac- 
ticable. 

3.  There  is  far  less  danger  from  wound  tracing 
than  from  probing  or  from  masterly  inactivity, 
while  awaiting  positive  evidence  of  visceral  damage 
requiring  operative  interference. 

4.  Local  toilet  with  moist  sponging  for  cleansing 
is  better  than  free  peritoneal  irrigation. 

5.  When  in  doubt  it  is  safer  to  drain. 

6.  Operations  done  within  two  hours  should  not 
give  a  mortality  over  twenty-five  to  thirty  per  cent., 
within  four  hours  over  forty  per  cent.,  within  six 
hours  over  fifty  per  cent.,  within  eight  hours  over 
sixty  per  cent.,  and  within  twelve  hours  over  sev- 
enty per  cent. 

7.  After  twelve  hours  expectant  treatment  is  best, 
unless  there  are  some  definite  indications  for  opera- 
tion. 

These  deductions  do  not  apply  to  militarv  prac- 
tice. Expectant  treatment  in  military  practice  has 
given  better  results  with  wounds  made  by  modern 
arms  than  has  operative  treatment.  It  seems,  how- 
ever, that  a  mortality  of  seventy-five  per  cent,  in  mil- 
itary practice,  under  the  expectant  plan  of  treat- 
ment, is  too  great,  and  ought  to  be  reduced  in  future 
warfare  by  thorough  organization  and  equipment  of 
the  medical  department,  prompt  ambulance  service, 
aseptic  first  aid,  well  appointed  field  hospitals  in 
charge  of  competent  abdominal  surgeons  and 
nurses,  and  a  proper  selection  of  cases  for  expectant 
treatment  and  for  laparotomy. 


THE  URINE  IN  THE  DISEASES  OF  INFANCY. 
An  Analysis  of  the  Results  of  the  Examination  of  the 
Urine  in  667  Cases. 
By  John  Lovett  Morse,  A.  M.,  M.  D., 
Boston, 

Assistant  P/ofessor  of  Paediatrics,  Harvard  Medical  School;  Asso- 
ciate Visiting  Physician  at  the  Children's  Hospital;  Assistant 
Physician  at  the  Infants'  Hospital;  Visiting  Physician 
at  the  Floating  Hospital, 

and 

Broxson  Crothers^  A.  B., 
Boston. 

Comparatively  little  has  been  written  concerning 
the  urine  and  the  kidneys  in  the  diseases  of  infants, 
that  is,  in  children  under  two  years  of  age.  What 
has  been  written,  moreover,  shows  much  diflference 
of  opinion  as  to  the  frequency  of  albtmiinuria  and 
renal  complications  in  these  diseases.  Carpenter, 
for  example,  examined  the  urine  of  sixty-two 
babies,  whose  age  ranged  from  three  weeks  to  eight 
months,  that  came  to  his  out  patient  department  for 
a  variety  of  ailments,  and  found  albumin  in  but  two. 
Knox  and  !Meakins  found  nothing  abnormal  in  the 
urine  of  nineteen  infants  ill  with  other  diseases  than 
those  of  the  ga><trocnteric  tract.    Bellico  found  evi- 


dence of  renal  complications  in  twenty-three  of 
seventy  infants  under  one  year  of  age  suffering 
from  various  complaints.  Albumin  and  casts  were 
found  in  fourteen,  albumin  alone  in  three,  casts 
alone  in  four,  and  red  and  white  cells  alone  in  two. 
Chapin  found  albumin  in  forty-nine,  and  casts  in 
thirty-two,  of  fifty-seven  children  with  various  pul- 
monary diseases.  Seventeen  of  these  died,  fifteen 
of  whom  showed  albuminuria,  and  ten  albumin  and 
casts.  He  also  found  albumin  in  thirty-one  of 
forty-five  others  suffering  with  various  general  dis- 
eases, and  albumin  and  casts  in  nine  of  eleven  cases 
of  cerebrospinal  meningitis.  Mendi  found  albumin, 
hyaline  and  epithelial  casts  in  all  of  seventeen  babies 
from  ten  to  forty  days  old  suffering  from  broncho- 
pneumonia, scleroderma,  and  convulsions.  Fry  and 
Alartin  examined  the  urine  of  one  hundred  infants 
under  three  months  of  age,  testing  the  urine  for 
albumin  by  cold  nitric  acid,  acetic  acid,  and  potas- 
sium ferrocyanide.  They  found  albumin  with  cold 
nitric  acid  in  nineteen.  They  found  casts  in  seven- 
teen of  these  and  also  in  fourteen  others.  They 
give  no  data  as  to  the  physical  condition  of  these 
babies,  but  as  nineteen  of  them  died  it  seems  as  if 
many  of  them  must  have  been  ill.  Goulkewitch 
found  evidences  of  nephritis  in  twenty-two  of  220 
autopsies  on  infants  from  two  to  nine  months  old. 
Renal  changes  were  found  more  often  with  pneu- 
monia than  with  any  other  disease,  occurring  next 
most  frequently  in  connection  with  tuberculosis  and 
the  diseases  of  the  gastroenteric  tract.  The  litera- 
ture on  the  renal  complications  in  these  diseases  is 
more  profuse  and  will  not  be  considered  here. 

The  667  babies  whose  urine  was  examined  were 
patients  on  Dr.  Morse's  services  at  the  Infants' 
Hospital  and  Floating  Hospital.  They  were  con- 
secutive except  that  in  many  cases,  especially  at  the 
Floating  Hospital,  the  urine  was.  for  one  reason  or 
another,  not  examined.  In  most  instances  but  one 
examination  was  made ;  in  many,  however,  espe- 
cially if  anything  was  found  wrong  at  the  first  ex- 
amination, repeated  tests  were  made.  The  exam- 
ination was  usually  made  within  the  first  forty-eight 
hours  after  entrance  into  the  hospital.  The  test  for 
albumin  was  made  either  with  cold  nitric  acid  or 
with  acetic  acid  and  heat,  sometimes  with  both.  The 
sediment  was  not  examined  unless  albumin  was 
found.  Unfortunately,  it  was  also  not  examined  in 
a  number  of  cases  in  which  there  was  albumin.  The 
writers  realize  that  examinations  made  in  this  rou- 
tine way,  and  not  repeated,  do  not  justify  very  defi- 
nite conclusions.  It  seemed  to  them,  however,  that 
on  account  of  the  large  number  of  cases  studied, 
even  such  incomplete  methods  ought  to  give  a  gen- 
eral idea  as  to  the  frequency  of  albuminuria  and 
renal  complications  in  the  various  diseases  in  in- 
fancy. 

Only  thirteen  of  the  667  babies  whose  urine  was 
examined  were  sulTering  from  diseases  of  the  uri- 
nary tract  not  connected  with  other  conditions.  One 
was  admitted  with  acute  nephritis  consecutive  to  a 
diphtheria  some  weeks  before.  One  had  a  simple 
bacteriuria,  and  eleven  infection  of  the  urinary  tract, 
as  shown  by  the  presence  of  bacteria,  pus,  various 
cells,  and  sometimes  a  few  casts  in  the  urine;  that 
is,  the  condition  commonly  known  as  pyelitis  or  pye- 
lonephritis. Three  hundred  had  diseases  of  the  gas- 
trointestinal tract,  and  354  other  diseases,  of  all  sorts. 


March  13.  >909.|  MORSE  AXD  CROTHERS:  CRIXE  IX  DISEASES  Oh  IXFAXCY. 


5^5 


Twentv-seven.  or  nine  per  cent.,  of  the  300  cases 
with  diseases  of  the  gastrointestinal  tract  and  forty- 
two,  or  about  twelve  per  cent.,  of  the  354  with  other 
diseases  showed  albumin,  giving  a  general  average 
for  the  654  cases  not  sutfering  exclusively  from  dis- 
eases of  the  urinary  tract  of  approximately  ten  per 
cent,  with  albuminuria.  This  proportion  is.  there- 
fore, more  consistent  with  the  findings  of  Carpenter 
than  with  those  of  most  of  the  other  writers.  The 
renal  complications  of  the  diseases  of  the  gastro- 
intestinal tract  will  not  be  considered  further  at  this 
time  but  will  be  spoken  of  later  in  another  paper; 
so  also  will  pyelitis  and  other  allied  conditions. 
Diseases  of  the  Respiratory  Tract. 

Xasopliaryngitis  and  Otitis  Media.  The  urine 
was  normal  in  fotir  cases  of  nasopharyngitis  and 
five  of  retropharyngeal  abscess.  It  was  normal  in 
all  but  one  of  twenty-one  of  otitis  media.  The  ex- 
amination in  these  cases  of  otitis  media  was  usually 
made  between  the  second  and  tenth  days,  but  in 
three  at  the  end  of  one.  two.  and  three  months  re- 
spectively. In  one  in  which  the  examination  was 
made  on  the  tenth  day,  the  urine  was  high,  clear, 
acid,  and  contained  a  slight  trace  of  albumin.  The 
sediment  showed  leucocytes,  squamous  epithelium, 
many  small  roimd  cells  and  a  few  hyaline,  fine 
granu.lar.  and  epithelial  casts.  It  was  unfortunately 
not  examined  again,  but  the  baby  was  discharged 
relieved.  The  temperature  in  these  cases  was  most 
irregular,  in  some  cases  being  high,  in  some  low. 
and  in  some  very  irregular. 

Bronchitis.  The  urine  was  normal  in  twenty-five 
and  abnormal  in  four  cases  of  bronchitis.  Xo  rela- 
tion between  the  presence  or  absence  of  albuminuria 
and  the  temperature  cotild  be  made  out.  albumin  be- 
ing both  present  and  absent  with  both  normal  and 
high  temperatures.  There  was.  however,  appar- 
ently some  relation  between  the  severity  of  the  ill- 
ness and  the  presence  of  albuminuria.  Only  a  trace 
of  albumin  was  fotmd  in  three  of  the  cases.  In 
these  the  sediment  was  unfortimately  not  examined. 
In  the  fourth  case  the  urine  was  high,  smoky,  acid, 
and  contained  a  ven,-  slight  trace  of  albimiin.  a  few 
casts,  and  some  blood.  Four  days  later  there  was 
still  a  little  blood  but  no  casts.  Two  of  the  first 
three  infants  recovered,  and  the  other  died  the  same 
day.  The  infant  in  whom  there  was  blood  in 
the  urine  was  discharged  against  advice  and  prob- 
ably died.  The  mortality  in  the  cases  without  albu- 
minuria was  sixteen  per  cent.,  that  in  the  cases  with 
albuminuria  fifty  per  cent. 

Bronclwpneii)iio)iia.  The  urine  was  normal  in 
fourteen  and  abnormal  in  one  case  of  bronchopneu- 
monia. It  was  examined  before  the  end  of  the  first 
week  in  four,  during  the  second  week  in  five,  and 
later  in  two  cases.  The  temperature  showed  all 
sorts  of  variations.  The  urine  showed  albumin  in 
but  one  case,  and  then  only  the  slightest  possible 
trace.  There  was  no  sediment  on  centrifugaliza- 
tion.  The  urine  in  this  case  was  examined  at  the 
end  of  two  weeks.    The  baby  died  two  days  later. 

Pnciiinoiiia.  The  urine  was  examined  in  sev- 
enty-seven cases  of  pneumonia,  albumin  being 
found  in  sixteen.  There  was  never  more  than  a 
slight  trace  in  six.  a  trace  in  six.  and  a  large  trace 
in  three.  In  one  there  there  was  0.5  per  cent.  The 
sediment  was  not  examined  in  three  cases,  showed 


nothing  abnormal  in  two  others,  and  only  lecuco- 
cytes  and  cells  in  four.  Hyaline  and  fine  granular 
casts  were  also  foimd  in  four,  while  in  three  there 
were  also  blood  and  blood  elements.  One  of  the 
patients  in  whom  blood  was  found  recovered,  the 
two  others  died.  In  one  of  these  the  nephritis  was 
the  direct  cause  of  death,  the  baby  having  recov- 
ered from  the  pneumonia  about  a  week  before.  In 
one  of  the  babies  with  only  a  trace  of  albumin,  a 
few  small  roimd  cells,  and  a  rare  hyaline  cast  in  the 
urine  oedema  developed  on  the  last  day  of  life. 
Secondary  examinations  of  the  urine  were  im for- 
tunately seldom  made  in  the  patients  who  recov- 
ered. In  one.  however,  the  urine  was  clear  in  ten 
days,  and  in  another  almost  clear  in  five  days.  The 
examinations  of  the  urine  were  made  at  alxwt  the 
same  relative  stages  of  the  disease  in  both  the  in- 
fants who  did  and  did  not  show  albumin.  Xo  rela- 
tion between  the  range  of  the  temperature  and  the 
presence  or  absence  of  albuminuria  could  be  made 
out.  The  percentage  of  deaths  was  slightly  greater 
in  the  cases  with  albimiintiria  than  in  those  without, 
being  25  per  cent,  in  the  former  and  17  per  cent, 
in  the  latter.  Death  occurred,  however,  no  sooner 
in  the  cases  with  albimiinuria  than  in  those  with- 
out it. 

Abscess  of  the  Lung.  Serous  and  Purulent  Pleu- 
risy. The  urine  was  normal  in  one  case  of  abscess, 
of  the  lung  at  the  end  of  two  weeks,  and  in  one 
case  of  serous  pleurisy  at  the  end  of  two  days. 
Albumin  was  found  in  only  one  of  four  cases  of 
purulent  pleurisy.  In  this  instance  there  was  a  vtrv 
slight  trace  of  albumin  and  a  few  cells  but  no  casts. 
This  baby  died  four  days  later  as  did  two  of  the 
three  which  did  not  have  albuminuria. 

Diseases  of  the  Xervous  System. 

There  was  no  albumin  in  one  case  of  cerebral 
paralysis,  four  of  tetany,  seven  of  eclampsia  from 
various  causes,  and  four  of  chronic  internal  hydro- 
cephalus. The  absence  of  albuminuria  in  the  cases 
of  eclampsia  is  worthy  of  notice.  A  slight  trace  of 
albumin  was  found  in  one  of  three  cases  of  idiocy. 
It  was  absent  at  many  other  examinations  in  this 
case,  however,  and  was  presumably  due  to  some 
transitory  condition. 

Cerebrospinal  Meningitis.  The  urine  was  ab- 
normal in  but  five  of  twenty-two  cases  of  cerebro- 
spinal meningitis,  some  of  which  were  acute  and 
some  chronic.  The  cases  with  albuminuria  were 
nearly  equally  divided  between  the  acute  and  sub- 
acute varieties.  Xo  relation  betw  een  the  presence 
or  absence  of  albuminuria  and  the  temperature 
could  be  made  out.  In  four  cases  there  was  only 
a  very  slight  trace  of  albumin.  In  these  the  sedi- 
ment was  not  examined.  In  the  other  case  there 
was  a  trace  of  albumin  in  the  urine,  which  was 
dark,  cloudy,  acid,  and  of  a  specific  gravitv  of  t.021. 
The  sediment  showed  leucocytes  and  blood,  numer- 
ous small  round,  caudate,  and  epithelial  cells,  brown 
granular  and  hyaline  casts,  and  casts  with  cells, 
blood,  and  fat  adherent.  All  but  one  of  the^e  in- 
fants died.  In  the  other  the  urine  was  clear  three 
days  after  the  first  examination.  The  mortalitv  in 
the  cases  without  albuminuria  was  twentv  per  cent. ; 
in  those  with  albuminuria,  eightv  per  cent. 

Tuberculous  Meningitis.    The  urine  was  exam- 


526 


MORSE  AXD  CROTHERS:  URINE  IN  DISEASES  OF  INFANCY. 


[New  York 
Meuical  Journal. 


int'd  in  thirteen  cases,  and  was  abnormal  in  five. 
The  examination  was  ahnost  always  made  within  a 
week  before  death.  In  two  instances  there  was  a 
slight  trace,  and  in  three  a  trace  of  albumin.  The 
sediment  was  not  examined  in  one,  and  contained 
only  cells  and  leucocytes  in  two,  suggesting  a  pye- 
litis or  cystitis  rather  than  an  involvement  of  the 
kidney.  In  one  of  them,  in  fact,  a  cystitis  was 
found  at  the  autops}-.  A  few  hxaline  and  fine  gran- 
ular casts  were  found  in  the  two  others. 

Diseases  oi"  Xutrition. 

Tlie  urine  was  normal  in  two  cases  of  starvation 
and  twx)  of  infantile  atrophy.  It  was  also  normal 
in  thirty-one  of  thirty-three  cases  of  malnutrition. 
The  urine  in  one  of  these  was  pale,  acid,  specific 
gravity  1.016,  and  contained  one  eighth  per  cent,  of 
albumin.  The  sediment  showed  only  a  few  small 
round  cells.  This  baby  died  ten  days  later.  In  the 
other  case  the  urine  was  high,  acid,  and  contained  a 
trace  of  albumin.  The  sediment  show^ed  a  few^  cells 
and  numerous  fine  granular  and  epithelial,  and  a  few 
hyaline  casts.  Four  days  later  the  urine  was  nor- 
mal in  every  way,  and  the  child  eventually  recov- 
ered. There  was  marked  oedema  in  one  case  in 
which  the  urine  was  normal. 

Racliitis.  The  lu-ine  was  always  normal  in 
twenty-five  cases  of  rickets.  There  was  marked 
ledema  in  one  case  in  which  repeated  examinations 
of  the  urine  showed  nothing  abnormal. 

Scurvy.  The  urine  was  normal  in  three  and  ab- 
normal in  two  cases  of  scurvy.  In  one  of  these 
the  urine  was  always  clear  and  never  contained 
albumin,  but  the  .sediment,  even  after  all  acute 
symptoms  had  disappeared,  contained  a  few  red 
blood  cells  and  an  occasional  leucocyte.  The  tem- 
perature in  this  infant  was  high  at  first  but  normal 
later.  In  the  other  case  the  urine  was  pale  brown 
^>nd  contained  a  sljght  trace  of  albumin.  The  cen- 
trifugalized  sediment  showed  much  normal  and  ab- 
normal blood,  an  excess  of  small  round  cells,  and 
an  occasional  hyaline,  fine  granular  and  brown 
granular  cast,  and  casts  w-ith  blood  adherent.  No 
further  examination  of  the  urine  was  made,  but  the 
baby  was  discharged  relieved  in  three  weeks. 

Severe  Anceniia.  One  of  seven  cases  of  severe 
anaemia  showed  the  slightest  possible  trace  of  albu- 
min in  the  urine,  with  a  few  leucocytes,  round  and 
s(iuamous  cells,  and  an  occasional  red  blood  cor- 
puscle, but  no  casts,  in  the  sediment. 

Tuberculosis.  The  urine  of  two  cases  of  local, 
seven  of  pulmonary,  and  nine  of  chronic  diffuse 
tuberculosis  was  examined.  One  infant  of  the  pul- 
monary cases  had  slight  oedema  of  the  feet,  and  the 
urine  contained  albumin,  varying  from  a  large  trace 
to  0.5  per  cent.  The  sediment  at  first  showed  a  few 
renal  cells  but  no  casts  or  blood ;  later  a  little  normal 
blood,  and  rarely  a  hyaline  cast  of  large  diameter. 

Coiii^cuital  .Syf'liilis.  The  urine  w^as  examined  in 
Init  three  cases,  in  one  of  which  it  was  high,  acid, 
and  contained  a  trace  of  albumin.  The  sediment 
showed  much  normal  blood,  an  occasional  leucocyte 
and  caudate  cell,  and  very  rarely  a  hyaline  cast. 
Death  occurred  four  days  later,  when  the  baby  was 
two  weeks  old.  The  autopsy  showed  general  atro- 
p)iy.  and  very  marked  uric  acid  infarction  of  the 
iciflneys. 


UNCLASSIFIED. 

The  urine  of  forty-eight  other  babies,  suffering 
from  all  sorts  of  acute  and  chronic  diseases,  w^as  ex- 
amined. Albumin  was  found  in  but  one  infant,  that 
had  an  abscess  of  the  neck.  The  urine  showed  a 
slight  trace  of  albumin  :  the  sediment  was  not  exam- 
ined. It  is  noteworthy  that  twelve  of  these  babies 
had  severe  eczema,  either  general  or  of  the  face. 
Two  had  marked  angioneurotic  oedema  without  al- 
biuninuria. 

SUMMARY. 

Analysis  of  these  cases  shoW'S  that,  putting  aside 
diseases  of  the  gastrointestinal  tract,  albuminuria  and 
casts  are  more  often  found  in  pneumonia  and  menin- 
gitis than  in  other  acute  diseases  in  infancy.  It  does 
not  corroborate  the  statements  of  Cassel  and  Sim- 
monds  as  to  the  importance  of  otitis  media  in  the 
aetiology  of  nephritis  in  infancy,  nor  those  of  many 
Italian  and  French  authors  as  to  the  frequency  of 
renal  complications  in  eczema.  It  shows  that  the 
kidneys  are  not,  as  a  rule,  affected  in  the  diseases  of 
nutrition,  although  in  scurvy  and  severe  anaemia  the 
urine  may  show  the  evidences  of  the  hjemorrhagic 
tendency  characteristic  of  these  diseases.  It  also 
shows  that  affections  of  the  kidneys  secondary  to 
other  diseases  in  infancy  do  not  usually  produce 
oedema,  and  conversely  that  oedema  in  infancy  is 
usually  due  to  some  other  cause  than  disease  of  the 
kidneys. 

The  study  of  these  cases  seems  to  justify  the  con- 
clusions that  the  presence  of  albumin  and  casts  in 
the  urine  in  the  acute  diseases  of  infancy  is  the  man- 
ifestation of  an  unusual  degree  of  toxaemia  and  is,  to 
a  slight  extent,  of  bad  prognostic  import.  This  con- 
clusion is  justified  only  in  a  very  general  way,  how- 
ever, as  many  infants  showing  albuminuria  and  casts 
recovered  and  man}-  others  in  which  the  urine  was 
normal  did  not.  There  was  nothing  about  these 
cases  to  show  that  the  renal  condition  had  any  direct 
influence  on  the  fatal  outcome.  It  was  merelx"  an 
index  of  the  toxaemia.  So  few^  pathological  exam- 
inations were  made  that  no  statement  is  justified  as 
to  the  pathological  changes  in  the  kidneys.  It  seems 
fair  to  assume  from  the  changes  in  the  urine,  how- 
ever, that  in  the  A'ast  majority  of  cases  the  patho- 
logical condition  did  not  go  beyond  an  acute  degen- 
erative nephritis  and  that  a  definite  parenchvmatous 
or  interstitial  nephritis  was  very  uncommon.  It 
seems  evident  from  the  study  of  these  cases  that  feb- 
rile albuminuria  and  acute  degenerative  nephritis  oc- 
cur in  the  same  conditions  and  at  least  as  frequently 
in  infancy  as  in  childhood  and  adult  life. 

Referexces. 

Bellico.  Rivista  di  clinica  f'cdialrica.  1905.  No.  10. 
(Quoted  by  Carpenter.) 

Carpenter.  British  Journal  of  Children's  Diseases,  iv,  p. 
421,  1907. 

Cassel.  Berliner  hiniische  H'oehenschrift,  .xxxvii,  p. 
21T,.  1900. 

Cliapin.    Archives  of  Pcediatrics,  xxiii;  p.  3.29.  1906. 

Fry  and  Martin.    Ibidem,  x.xi.  p.  19,  1904. 

(joulkcwitch.  Revue  inensuelle  des  maladies  de  I'enfance, 
xviii,  p.  308,  uxx). 

Knox  and  Meakins.  Arehizu's  of  Internal  .Medicine.  Oc- 
tober, i90iS. 

Mendi.  Ri'i  ista  di  cliniea  f^ediatriea,  1903,  p.  510.  (Quo- 
ted by  Carpenter.) 

Sinimonds.  Peutsehes  .\rehix-  fiir  klinische  .Mediein,  Ivi, 
p.  3S5.  1896. 

70  Bay  State  Road. 


March  13,  1909.  J 


SUPER:  GREEK  FOR  PHYSICIANS. 


GREEK  FOR  PHYSICIANS, 
By  Charles  W.  Super,  Ph.  D.,  LL.  D., 
Athens,  O. 

Some  time  ago  I  made  a  cursory  examination  of 
the  medical  terms  derived  from  the  Greek  and 
Latin  given  in  the  Century  Dictionary  and  found 
the  number  to  be  about  one  thousand.  It  is  impos- 
sible to  be  accurate,  for  the  reason  that  a  consider- 
able number  appears  in  two  or  more  forms ;  others 
again,  although  common  in  medicine,  are  also  em- 
ployed in  other  relations.  The  number  of  Greek 
terms  compared  with  the  Latin  is  about  four  to  one. 

Few  laymen  are  aware  or  even  suspect  that  such 
common  pathological  terms  as  diarrhoea,  dysentery, 
and  pneumonia  are  almost  pure  Greek.  This  long 
list  of  words  is  due  to  two  conditions,  one  is  the 
large  measure  of  attention  the  ancient  Greeks 
gave  to  the  healing  art  which  carried  their  phrase- 
ology into  the  Latin  also,  the  other  is  the  reputa- 
tion Greek  medical  practitioners  enjoyed  in  the 
ancient  world.  So  far  as  it  was  possible  with  the 
means  within  their  reach  they  endeavored  to  place 
the  aetiology  of  disease  and  medical  therapeutics 
upon  a  scientific  basis.  One  may  take  up  almost  any 
Greek  author  and  he  will  not  have  read  far  before 
he  is  impressed  with  the  important  and  honored 
place  Greek  physicians  held  not  only  among  their 
countrymen,  but  among  foreigners  likewise.  We 
need  not  wonder  at  this,  for  the  fact  is  that  until 
well  within  what  is  called  the  modern  era  medicine 
had  advanced  but  little  beyond  the  stage  to  which 
the  Greeks  of  antiquity  had  raised  it. 

It  would  seem,  therefore,  that  a  fair  knowledge 
of  the  language  in  which  they  wrote  must  be  an 
important  qualification  for  any  physician  who  is  in- 
terested in  the  history  of  his  profession.  The  prac- 
tical side  of  such  knowledge  is  the  ease  with  which 
so  man}'  medical  -terms  may  be  interpreted,  for 
Greek  is  still  the  inexhaustible  storehouse  from 
which  not  only  most  new  medical  terms  are  drawn, 
but  also  most  of  the  new  terms  called  for  in  general 
science. 

It  is  a  common  belief  that  Greek  is  an  exception- 
ally difficult  language.  To  a  certain  extent  this  be- 
lief is  well  founded.  If  one  intends  to  range  over 
the  whole  field  of  classical  Greek  he  should  be  able 
to  define  about  forty  thousand  words,  to  say  noth- 
ing of  the  many  different  forms  in  which  the  samfe 
word  may  appear.  Sometimes  it  is  easier  to  define 
half  a  dozen  words  than  to  give  the  various  mean- 
ings of  one.  A  person  may,  however,  know  the  lan- 
guage reasonably  well,  at  least  well  enough  for 
working  purposes,  without  trying  to  cover 
this  immense  field.  Moreover,  if  one  is 
fairly  familiar  with  the  etymological  and 
grammatical  structure  of  the  language  he 
will  be  able  to  derive  great  benefit  from  this 
knowledge  without  having  read  very  much.  I  do 
not  consider  Greek  more  difficult  than  modern  Ger- 
man or  Russian,  for  in  both  we  have  to  contend 
with  an  unfamiliar  alphabet.  Except  for  this  draw- 
back Greek  is  decidedly  less  difficult  than  Latin. 
All  evidence  is  against  Greek  being  a  hard  language 
to  learn.  Every  reader  of  history  knows  that,  dat- 
ing at  least  from  the  conquests  of  Alexander  the 
Great,  it  was  the  universal  language  of  the  ancient 
world.     All  persons  who  made  any  pretensions  to 


culture,  and  many  who  did  not,  spoke  Greek.  The 
Jews  felt  the  necessity  of  translating  their  sacred 
books  into  it,  since  with  each  succeeding  generation 
a  knowledge  of  the  Hebrew  became  less  general 
among  them.  The  New  Testament  was  written  in 
Greek ;  and,  strange  as  it  may  seem,  even  the  Epistle 
to  the  Romans  is  no  exception.  St.  Paul,  when  writ- 
ing to  the  Corinthians,  says:  "I  thank  God  that  I 
know  more  tongues  than  you  all."  If,  therefore, 
he  employed  the  Greek  when  writing  to  the  Romans 
it  must  have  been  because  it  was  better  adapted  to 
express  what  he  had  to  say  than  the  Latin,  or  be- 
cause he  knew  that  he  would  be  understood  by  a 
larger  number  of  those  addressed  than  if  he  used 
the  official  language  of  the  imperial  city.  Both  con- 
siderations doubtless  had  their  weight ;  why,  we 
need  not  stop  to  consider  here. 

The  ancients  did  not  learn  languages  from  books. 
There  were  no  grammars,  nor  dictionaries  in  classi- 
cal times  either  in  Greece  or  Rome.  The  first  Greek 
grammar  was  compiled  not  by  a  Greek  but  by  a 
Thracian  about  a  century  B.  C.  This  manual  is 
still,  to  a  considerable  extent,  made  the  basis  of  ele- 
mentary textbooks  on  the  subject. 

Whether  the  study  of  Greek  should  begin  with  its 
modern  form  or  with  the  classical  authors  I  do  not 
undertake  to  decide.  Few  persons  are,  however,  in 
position  to  learn  the  language  orally,  although  the 
number  of  Greeks  in  this  country  is  considerable. 
My  advice  would  be,  where  a  competent  teacher  of 
modern  Greek  is  accessible,  to  begin  with  the  lan- 
guage as  it  is  now  spoken  and  written.  When  such 
is  not  the  case  one  had  better  begin  with  the  lan- 
guage of  the  Nc-ii.'  Testament  or  of  Xenophon.  Few 
professional  men  are  so  situated  that  they  cannot 
acquire  sufficient  Greek  to  read  these  two  books, 
and  of  all  professional  men  such  knowledge  will  be 
of  most  service  to  the  physician.  The  accomplish- 
ment is  far  less  difficult  than  one  might  suppose. 
Let  us  look  at  it  in  the  light  of  facts.  Assuming 
that  the  intending  physician  has  no  time  or  no  in- 
clination or  no  opportunity  to  learn  Greek  until  he 
has  earned  his  medical  degree,  he  will  now  have  con- 
siderable leisure  on  his  hands.  Except  in  rare  cases 
his  actual  practice  for  the  first  few  years  will  not 
take  much  of  his  time.  Why  should  he  not  devote 
part  of  his  leisure,  stiy  one  or  two  hours  each  day, 
to  the  acquisition  of  Greek?  Having  already  had 
some  mental  training  and  having  acquired  the  power 
of  application  the  task  should  not  be  particularly 
difficult.  By  making  use  of  a  Greek  copy,  of  the 
New  Testament  he  could  manage  pretty  well  with- 
out any  other  help,  except  a  grammar  and  a  diction- 
ary. If  several  physicians  in  a  community  were 
to  meet  once  or  twice  a  week  for  combined  study 
and  for  comparing  notes  it  would  render  the  task 
easier  where  there  is  no  teacher.  But  there  are 
many  communities  where  it  is  easily  possible  to  get 
the  assistance  of  some  one  who  has  more  or  less  ac- 
quaintance with  the  language,  although  it  is  gen- 
erally less. 

I  doubt  whether  any  one  who  is  in  the  habit  of 
using  his  mind  rationally  is  ever  too  old  to  learn 
whatever  he  may  undertake.  I  am  aware  that  it  is 
almost  impossible  for  an  adult  to  acquire  the  cor- 
rect pronunciation  of  a  foreign  language ;  but  in 
this  case  pronunciation  is  of  little  importance.  It 
is  said  that  Dr.  Samuel  Johnson,  when  seventy  years 


528 


KIVLIN:  RADICAL  CURE  OF  HERNIA. 


[New  York 
Medical  Journal. 


old,  began  to  suspect  that  his  mental  powers  were 
failing.  To  test  the  matter  he  entered  upon  the 
study  of  the  Dutch,  and  to  his  great  delight  found 
his  selfimposed  task  not  especially  difficult.  It  is  a 
familiar  story  that  Cato  the  Censor,  after  devoting 
much  of  his  energy  to  opposing  the  spread  of  Greek 
thought  among  his  countrymen,  yielded  to  the  in- 
evitable and  acquired  a  knowledge  of  the  Greek  lan- 
guage in  extreme  old  age. 

It  stands  to  reason  that  the  method  followed  by 
the  mature  man  must  differ  from  that  of  the  boy. 
When  the  latter  undertakes  to  learn  anything  by 
heart  he  does  so  through  force  of  memory  and  will, 
the  amount  of  the  latter  needed  depending  upon  the 
strength  of  the  former.  On  the  other  hand,  the 
adult  has  already  in  mind  a  large  number  of  words 
and  facts  that  furnish  him  with  analogies  and  re- 
semblances or  contrasts  which,  by  the  principle  of 
mental  association,  he  can  employ  for  the  acquisi- 
tion of  new  vocables.  It  is  probable  that  a  mature 
man  would  experience  considerable  difficulty  in 
learning  Turkish  or  Japanese,  for  example ;  yet  the 
languages  of  this  class  are  so  symmetrically  con- 
structed that  the  difficulty  of  the  vocabulary  is  to 
a  considerable  extent  counterbalanced  by  the  sim- 
plicity of  their  structure.  We  may  say  that  the 
Turanian  languages  are  mechanical  or  artificial, 
while  Greek  and  Latin  are  artistic. 

Taken  all  in  all  classical  Greek  is  probably  the 
most  perfect  medium  for  the  accurate  expression  of 
thought  that  has  ever  been  devised  by  the  human  in- 
tellect, and  is  well  worth  study  for  its  own  sake. 
But  the  professional  man  cannot  be  expected  to 
scrutinize  its  niceties  or  unravel  its  intricacies.  The 
physician  will,  however,  find  that  it  will  repay  a 
considerable  degree  of  attention.  There  is,  more- 
over, a  wider  view  to  be  taken  than  that  of  mere 
unitarianism.  Every  professional  man  owes  it  to 
his  day  and  generation  to  do  something  to  promote 
its  general. culture.  It  is  to  be  said  that  in  this  do- 
main physicians  have  probably  contributed  more 
than  any  other  class  of  men  except  the  clergy.  Not 
a  few  have  also  been  eminent  in  other  scientific 
lines.  INIost  of  the  ancient  Greek  physicians  were 
likewise  philosophers.  The  connection  of  the  mind 
with  the  body  is  so  close  that  the  intimate  study  of 
the  one  leads  to  the  study  of  the  other.  The  physi- 
cian who  is  not  also  somewhat  of  a  psychologist  is 
seriously  handicapped  in  his  diagnosis  of  bodily 
disease. 

The  twentieth  century  is  beginning  to  recognize 
the  influence  of  the  mind  upon  the  physical  structure 
to  an  extent  that  not  many  years  ago  was  suspected 
by  few.  There  is  probably  a  great  deal  in  so  called 
mental  healing  that  is  merely  a  passing  delusion ; 
but  that  the  doctrine  contains  more  than  a  grain  of 
truth  few  persons  who  have  looked  into  the  matter 
carefully  will  deny.  It  is  probable  that  many  of  the 
mysterious  and  occult  phenomena  reported  in  the  lit- 
erature of  the  olden  time  could  be  explained  by 
hypnotism  or  some  similar  agency,  if  we  were  in 
possession  of  all  the  facts  of  the  case.  The  persons 
who  exercised  this  power  were  just  as  much  in  the 
dark  as  to  its  source  as  were  those  upon  whom  it 
was  exercised. 

"This  is  evident  to  me  that  the  primitive  substance 
is  great  and  potent,  eternal  and  immortal,  and  knows 
many  things." — Diogenes  of  Apollonia. 


A  NEW  METHOD  FOR  THE  RADICAL  CURE  OF 
INDIRECT  INGUINAL  HERNIA.* 

By  C.  F.  Kivlin,  M.  D., 
Troy,  N.  Y. 

In  presenting  the  paper  on  the  title  subject,  I 
know  that  I  have  a  great  deal  to  overcome ;  the 
prejudice  of  the  surgical  profession  that  the  Bassini 
operation  is  the  one  of  election,  and  that  it  has  sat- 


% 

Fig.  I. — Showing  the  sutures  in  place,  to  close  the  internal  ring  after 
the  sac  has  been  ligated  and  cut  away;  a,  sutures  in  place 
ready  to  be  tied;  b,  cord. 

isfied  those  who  have  come  to  know  the  operation 
and  its  results.  But  I  believe  my  method  of  deal- 
ing with  the  indirect  inguinal  hernia  is  a  better, 
safer,  and  stronger  cure  than  any  other  operation 
for  the  cure  of  this  condition,  and  it  is  for  that  rea- 
son that  I  offer  to  you  my  method  that  you  might  at 
this  time  point  out  to  me,  if  I  am  wrong  or  if  you 
think  the  operation  one  that  could  be  recommended. 
Try  it  for  yourself,  which  certainly  is  the  only  true 
way  in  which  a  man  could  demonstrate  satisfac- 
torily the  merit  the  operation  has  over  any  other 
operation  of  the  present  day.  The  question  might 
arise  in  your  mind,  why  has  he  changed  from  the 
Bassini  operation. 

■  It  is  a  rule  of  my  own  which  I  believe  to  be 
fundamental  of  a  surgeon  in  dealing  not  alone,  with 
hernia  but  any  surgical  procedure  to  leave  when  fin- 
ished as  near  a  perfect  work  of  Nature  as  the  par- 
ticular part  operated  on  is  natural.  Therefore,  I  be- 
lieve that  the  transplantation  of  the  cord  in  an  un- 
natural position  is  surgically  wrong,  also  that  the  re- 
section of  any  of  the  blood  supply  unless  for  path- 
ological reasons  is  wrong.  In  order  to  fully  under- 
stand the  method,  I  will  briefly  outline  the  essential 
anatomy  without  going  into  details.  The  anatomy 
of  the  inguinal  canal  is  an  imperfect  triangle  with 
an  external  and  internal  ring.  The  external  ring  is 
an  aperture  in  the  aponeurosis  of  the  external 
oblique.  The  internal  ring  is  an  aperture  in  the 
transversalis  fascia.  Arching  over  the  cord  in  front 
of  internal  ring  will  be  found  muscular  fibres  be- 
longing to  internal  oblique  and  transversalis  muscles 

•Read  at  a  meeting  of  the  Rcnnsclaer  County  Medical  Society, 
November  lo,  1908. 


March  :3,  igor.] 


KIVLIN:  RADICAL  CURE  OF  HERNIA. 


529 


for  a  distance  of  about  three  fourths  of  an  inch  from 
the  internal  ring  down.  These  fleshy  fibres  form 
the  anterior  wall  of  the  canal.  The  remainder  of 
the  distance  is  formed  by  the  aponeurosis  of  the  ex- 
ternal oblique.  The  roof  of  the  canal  is  principally 
formed  by  the  lower  border  of  the  internal  oblique 
and  transversalis  muscles,  its  floor  by  Poupart's 
ligament ;  its  posterior  boundary  and  its  upper  two 
thirds  is  formed  by  the  transversalis  fascia,  and  the 
lower  third  by  the  conjoined  tendon,  and  in  a  large 
percentage  of  cases  operated  in  for  hernia.  Noth- 
ing is  found  back  of  the  cord  but  transversalis  fascia 
throughout  the  entire  length  of  the  canal.  The  in- 
guinal canal  is  occupied  normally  by  the  spennatic 
cord  in  the  male  and  the  round  ligament  in  the 
female. 

Operation:  An  incision  is  made  through  the  skin 


■1 

Fig.  2. — Sutures  tied  showing  the  upper  margin  of  the  ring  drawn 
down  over  the  lower  margin  completely  obliterating  the  open- 
ing; a,  showing  suture  tied. 


of  an  inch  directly  below  the  outer  angle  of  the  in- 
ternal ring;  the  transversalis  fascia  is  pierced  with 
a  double  chromatized  twenty  day  suture  coming  out 
at  the  ring.  The  needle  is  grasped  by  a  needle 
holder  and  pulled  through.  The  sac  is  pulled  down 
and  reflected  over  the  lower  border  of  the  internal 
ring.  The  needle  now  passes  beneath  the  upper  edge 
of  the  internal  ring,  coming  out  at  a  point  about  one 
fourth  of  an  inch  above  the  edge  of  the  ring  in  the 
fascia.  Now  the  technique  is  reversed  but  the  s:ime 
as  before..  The  same  suture  pierces  the  fascia  for 
abovit  one  quarter  of  an  inch  internally  and  comes 
out  under  the  upper  edge  of  the  internal  ring.  The 
sac  again  is  reflected  about  the  upper  edge 
of  the  internal  ring,  and  the  suture  enters  under 
the  lower  edge  of  the  internal  ring,  coming  out  at 
a  point  in  the  fascia  of  one  fourth  of  an  inch  below 
the  edge  of  the  ring  but  inside  the  point  of  en- 
trance about  one  fourth  of  an  inch.  Another,  mat- 
tress suture  in  the  same  way  one  fourth  of  an 
inch  internally  to  this  is  placed  in  position ;  two 
sutures  are  all  that  are  necessary,  and  sometimes 
if  the  opening  is  small  one  is  sufficient.  The  ends 
of  the  suture  are  held  by  clamps,  the  sac  is  doubly 
ligated  at  its  neck  and  cut  away,  or  the  sac  can  first 
be  ligated  and  cut  away  before  the  sutures  to  close 
the  ring  are  introduced.  I  do  this  now  almost  in- 
variably except  when  I  want  to  show  the  technique 
of  the  operation  more  perfectly.  The  double  mat- 
tress sutures  are  now  picked  up  and  tied  singly  be- 
cause of  the  trouble  one  sometimes  has  when  a 
chromatized  double  knot  is  left.  After  the  two  su- 
tures are  tied  an  additional  suture  is  placed  in  the 
apron  which  is  formed  by  the  upper  edge  of  the  in- 
ternal ring  as  it  is  drawn  down  by  the  mattress 
suture.  This  is  a  single  chromatized  suture  piercing 
the  apron  going  down,  then  picking  up  the  portion 

\X  A. 


and  fatty  tissue  down  to  the  aponeurosis  of  the  ex- 
ternal oblique,  with  complete  arrest  of  any  bleed- 
ing point,  of  which  there  are  few.  Split  the  apo- 
neurosis of  the  external  oblique  directly  over  the 
canal  so  that  the  canal  can  be  observed  in  its  entire 
length.  Retract  the  internal  oblique  muscle  so  as 
to  expose  the  internal  ring.  Pick  up  the  sac  sepa- 
rate from  any  adhesions  which  may  have  formed. 
The  sac  should  now  be  separated  from  the  cord,  and 
it  is  well  to  start  the  separation  as  near  the  internal 
ring  as  is  possible,  as  it  makes  easier  work  and  as- 
sures you  of  less  danger  to  injury  of  the  cord.  Open 
the  sac,  and  free  it  from  any  and  all  its  contents. 
If  bowels  are  adherent  liberate  them,  if  omentum 
ligate  and  cut  off,  being  sure  that  you  leave  no 
bleeding  points  in  the  omentum.  The  sac  is  ex- 
posed, and  relieved  of  its  contents.  Now  comes  the 
important  step  in  the  operation.  The  assistant  holds 
the  sac  well  up  and  over  the  upper  edge  of  the  in- 
ternal ring,  beginnmg  at  a  point  about  one  quarter 


Fig.  3. — Showing  suture  in  the  apron  tied;  a,  showing  suture  tied. 

of  the  transversalis  fascia,  and  up  through  the  apron, 
when"  it  is  tied. 

The  operation.  I  believe,  if  left  alone  without  any 
additional  support  of  muscle  or  fascia  would  give  as 
good  as  statical  average,  if  not  better  than  any  op- 
eration which  the  profession  uses  at  the  present 


S30 


ROBIXSO\\-  URETERORENAL  SURGERY. 


[New  York 
Medical  Journ\l. 


time.  The  operation  is  completed  in  two  ways. 
The  normal  contents  of  the  canal  spermatic  cord, 
and  round  ligament  in  male  and  female  respectively 
are  left  in  their  natural  positions.  The  internal 
oblique  is  sutured  to  Poupart's  ligaments  with  in- 
terrupted sutures,  the  aponeurosis  of  the  external 


I'lG.  4. — Showing  the  continuous  suture  to  close  the  canal;  a,  shows 
end  of  continuous  suture  left  long  to  be  tied  later;  b,  shows 
the  same  suture  closing  the  aponeurosis;  c,  shows  the  same 
suture  uniting  the  muscle  to  the  shelving  portion  of  Poupart's 
ligament. 

oblique  by  continuous.  Or  as  is  my  custom  is  com- 
pleted with  a  double  continuous  suture,  which  starts 
from  above  in  the  inner  side  of  the  upper  angle  of 
the  divided  aponeurosis.  The  suture  left  long  is 
to  be  tied  later.  The  suture  then  goes  down,  picks 
up  a  portion  of  the  internal  oblique,  then  over  to  the 
shelving  portion  of  Poupart's  ligament,  crossed  and 
recrossed  down  to  the  lower  angle  of  the  cut  apo- 
neurosis when  the  ligature  is  looped  and  the  suture 
continued  from  the  inner  portion  of  the  split  apo- 
neurosis outward  up  to  and  on  the  opposite  side 
where  the  suture  started,  where  it  is  tied  in  single 
knots.  The  skin  is  closed  with  subcuticular  silk 
worm  gut. 

It  can  be  readily  seen  that  the  difference  between 
my  method  and  the  Bassini  operation  is  that  I  close 
the  0])cning  of  the  internal  ring  and  that  I  do  not 
transplant  the  cord ;  and  the  only  difference  between 
my  method  and  the  one  that  Colcy  has  done  a  num- 
ber of  times  is  I  close  the  ring  and  he  does  not. 

Tn  conclusion  the  only  real  difference  between  my 
method  and  the  P>assini  is  I  get  a  stronger  support 
at  the  weakest  point  in  the  whole  canal,  in  fact  I 
practically  obliterate  the  opening.  Without  an  open- 
ing there  can  be  no  hernia. 

1826  Fifth  Avenue. 


A  URETERORENAL  DECALOGUE, 
Ten  Consecutive  Ureterorenal  Surgical  Cases,  with  Resumi. 
By  Byron  Robinson,  B.  S.,  M.  D., 
Chicago, 

Professor  of  Gynecology  and  Diseases  of  the  Abdominal  Viscera  in 
the  Chicago  College  of  Medicine  and  Surgery,  in  affiliation 
with  Valparaiso  University;  Consulting  Surgeon 
to  Mary  Thompson  Hospital. 

Case  L- — Uropyoureter  (left).  Congenital  renal  cyst, 
with  giant  distal  renal  pole.  Recovery.  (See  Fig.  i.)  Re- 
ferred to  me  by  Dr.  L  B.  Washburn,  of  Rensselaer,  Indiana. 

The  patient  was  an  excessively  developed  child,  two  years 
of  age.  The  mother  had  noticed  that  the  child's  abdomen 
was  always  moderately  enlarged ;  suddenly  the  abdomen 
became  tender,  enlarged,  tympanic.  On  examination  I  found 
a  tympanitic  abdomen,  an  enormously  enlarged  left  kidney, 
rapid  pulse  and  respiration,  and  temperature  105°  F.  per 
rectum.  I  ordered  the  child  to  be  sent  to  Mary  Thompson 
Hospital  and  observed  it  for  three  days  during  preoperative 
preparation.  The  temperature  remained  102°  to  105°  F. 
with  corresponding  high  pulse  and  temperature.  The 
child's  urine  was  heavily  loaded  with  albumin  and  pus,  but 
no  blood. 

Operation:  Under  chloroform  I  made  an  abdominal  in- 
cision from  the  left  border  of  the  ribs  to  Poupart's  liga- 
ment, but  from  pathological  conditions  was  not  able  to  lib- 
erate the  kidney  without  penetrating  the  peritona?um.  The 
enormously  dimensioned  kidney,  irregular  in  contour,  al- 
most occupied  the  entire  abdominal  cavity.  The  kidney 
was  so  large  that  I  could  not  extirpate  it  without  incising 
the  peritonaeum- — it  was  a  peritonotomy.  The  kidney  proved 


Fig.  I. — Ventral  view  (left  kidney).  Boy,  two  years  old.  Enor- 
mous congenital  renal  cyst  on  proximal  renal  pole  with  giant  distal 
renal  pole.  Uropyoureter.  Nephrectomy  and  partial  ureterectomy; 
recovery. 

to  be  a  congenital  cystic  kidney  for  its  proximal  two-thirds, 
and  a  giant  distal  renal  pole  existed  with  the  ureteral  pelvis 
occupied  by  pus  (uropyyonreter).  1  enucleated  the  kidney 
from  its  adipose  and  iibrous  capsule,  punctured  the  congen- 
ital cystic  portion,  and  ligatcd  the  vasa  rcnalia  with  catgut. 
I  performed  a  nephrectomy,  leaving  in  situ  the  adipose  and 
fibrous  renal  capsule.    Considerable  peritoneum  (the  left 


March  13,  1909.J 


ROBINSON:  URETERORENAL  SURGERY. 


531 


mesocolon)  was  adherent  to  it.  Ureterectomy  was  per- 
formed, distal  to  the  proximal  ureteral  isthmus.  The  child 
made  an  uninterrupted  recovery. 

The  kidney  portion  of  interest  was  the  giant  distal  renal 
pole,  equal,  perhaps,  to  two  normal  renal  organs  of  a  two 
years  old  child.  The  cystic  portion,  the  proximal  renal 
two-thirds,  was  ten  times  the  size  of  a  normal  renal  organ. 
The  child  urinated  ample  quantities  previous  and  subse- 
quent to  the  operation.    This  subject,  a  two  years  old  child, 


Fig.  2. — Left  kidney.  Complete  calculous  occlusion  of  ureter  at 
proximal  ureteral  isthmus  (s)  and  resulting  proximalward  dilated 
uropyoureter.    Nephrectomy  and  partial  ureterectomy;  recovery. 

with  flowing  pus  in  the  ureteral  calyces  and  pelvis  pyoure- 
ter,  a  giant  distal  renal  pole,  an  enormous  congenital  renal 
cyst  located  at  the  proximal  renal  pole,  with  temperature 
from  103°  to  105°  F.  for  a  week,  pulse  120  to  140,  and 
respiration  36  to  48,  passed  through  a  nephrectomy  with  an 
uneventful  recovery  and  remained  well.  A  criticism  might 
be  offered  that  the  congenital  cyst  should  have  been  enu- 
cleated and  the  left  kidney  saved ;  however,  that  would  have 
jeopardized  excessively  the  child's  life  from  shock,  haemor- 
rhage, and  sepsis. 

Case  II. — Pyoureteritis  calculosa  (left),  due  to  me- 
chanical obstruction  at  proximal  ureteral  isthmus.  Ne- 
phrectomy; recovery.    (See  Fig.  2). 

This  subject  was  that  of  a  woman,  forty-five  years  old, 
mother  of  six  children,  who  became  ill  six  months  previous 
to  visiting  me.  She  presented  an  irregularly  spheroidal 
swelling  about  the  size  of  a  man's  head  in  the  left  proximal 
quadrant  of  the  abdomen.  It  was  tender  and  not  of  renal 
form.  X  ray  by  Dr.  Robert  Gregg  demonstrated  that  the 
tumor  was  a  continuation  proximalward  of  the  proximal 
renal  pole.  Albumin,  pus,  and  blood  existed  in  the  urine 
on  first  visit — a  month  before  the  operation.  The  abnor- 
mal urinal  contents  lessened  continually  until  the  operation, 
but  the  tumor  dimension  remained  the  same.  Cystoscopy 
presented  to  me  a  dark  excavation  for  the  left  ureteral  ori- 
fice, and  I  could  observe  no  functionation  in  it.  Ureteral 
catheterization  of  the  riglit  ureter  presented  urine  practi- 
cally free  from  pus  and  blood,  hence  pus  and  blood  arose 
from  the  left  ureter,  No  ureteral  peristalsis  could  be  ob- 
served in  the  left  ureter,  nor  any  fluids  from  it  oozed  or 
trickled  from  its  orifice.  Temperature,  99°  F.  per  rectum. 
Splenic  disease  was  excluded  because  the  blood  was  normal. 

Operation:  An  incision  was  made  in  the  linea  semilunaris 
sinistra,  where  the  enormous  tumor,  larger  than  a  man's 
head,  presented  itself.  It  proved  to  be  a  giant  cystic  kid- 
ney due  to  obstruction  of  a  calculus  in  the  proximal  ureteral 
isthmus.  The  renal  calculus  was  the  size  of  an  apple.  I 
reflected  the  left  colon  and  mesocolon  medianward,  incised 
and  cleaved  the  fibrous  renal  capsule  to  its  pedicle,  evacuated 


perhaps  four  pints  of  turbid  fluid,  ligated  the  renal  pedicle 
with  catgut  and  removed  the  kidney  with  three  inches  of  ure- 
ter. The  woman  presented  no  shock  for  six  hours,  seventy- 
two  hours  after  operation  she  had  a  pulse  of  150,  tempera- 
ture of  105°  F.  per  rectum,  and  respiration  of  forty  per 
minute.  These  abnormal  symptoms  appeared  to  be  from 
shock,  and  recovery  later  progressed  uneventfully.  I  tested 
the  presence  and  dimension  of  the  other  kidney  at  the  oper- 
ation by  palpation.  The  right  kidney  was  hypertrophied,  as 
it  had  probably  performed  the  chief  renal  labor  for  six 
months.  Her  urine  was  ample  in  quantity  following  the 
operation.  Shock  is  a  frequent  accompaniment  of  nephrec- 
tomy from  the  reason  that  considerable  trauma  on  the  ab- 
dominal brain  must  be  exercised  during  the  operation.  This 
woman  did  not  suffer  much  pain — she  was  simply  weak,  but 
performed  her  main  household  duties  until  the  operation. 
Subsequent  to  the  nephrectomy  (six  months)  she  rapidly 
gained  flesh  and  red  blood  and  performed  her  household 
duties. 

Case  III. — Uropyoureter  (rightl,  due  to  obstruction  at 
the  proximal  ureteral  isthmus.    (See  Fig.  3.) 

This  subject  was  a  woman,  forty-two  years  of  age,  who 
suffered  six  months  previous  to  her  visit  to  me.  The  urine 
was  loaded  with  pus,  blood,  and  albumin,  and  the  patho- 
logical urine  arose  from  the  right  kidney,  for  I  catheterized 
her  left  ureter  and  its  urine  was  normal.  The  kidney  on 
the  right  was  perhaps  four  times  its  normal  size,  slightly 
painful,  and  the  patient  felt  practically  well  a  week  previous 
to  the  operation.  During  the  first  two  months  of  the  six 
months  of  illness  she  had  considerable  pain  which  was 
diagnosticated  as  perityphlitis  by  the  attending  physician. 
The  x  ray  presented  no  calculus,  but  an  hypertrophied 
right  kidney. 

Operation:  After  three  days  of  careful  preoperative 
treatment  I  performed  nephrectomy  by  means  of  the  Hotz- 
Simon  incision.    The  kidney  was  enormously  cystic,  due  to 


Fig  3. — Ventral  view  (right  ureter).  Uropyoureter  due  to  patho- 
logical flexion  of  the  proximal  ureteral  isthmus  abetted  by  peri- 
ureteral adhesions,  the  compression  of  a  pair  of  renal  vessels,  and 
excessively  proximalward  insertion  of  the  proximal  ureteral  isthmus 
in  the  ureteral  pelvis  enhancing  the  potential,  physiological,  mechani- 
cal difficulties  in  ureteral  pelvic  evacuation.  Nephrectomy  and 
partial  ureterectomy;  recovery. 

a  pathological  flexion  at  the  junction  of  the  ureter  proper 
and  the  ureteral  pelvis,  i.  e.,  at  the  proximal  ureteral  isth- 
mus. The  renal  vessels  compressed  a  deep  groove  in  the 
extensively  dilated  ureteral  pelvis  and  ureter  proper,  which 
abetted  vigorously  the  pathological  flexion  of  the  ureter 
at  the  proximal  ureteral  isthmus.  I  incised  the  kidney  in 
Hyrtl's  exsanguinated  renal  zone  (see  Gray's  Anatomy, 
editions  of  1905  and  1908,  and  New  York  Medical  Journal, 
December  10,  1904),  i.  e.,  one-half  inch  dorsal  to  the  middle 
of  the  lateral  longitudinal  border  with  minimum  haemor- 
rhage, and  explored  the  enormously  dilated  calyces  and 


532 


ROBINSON:  URETERORENAL  SURGERY. 


[New  VoRK 
Medical  Journal. 


pelvis.  The  renal  parenchyma  was  so  necrosed  by  pressure 
that  I  concluded  nephrectomy  was  the  proper  method  and 
included  the  removal  of  the  proximal  three  inches  of  the 
ureter  proper.  In  many  places  the  renal  parenchyma  was 
practically  obliterated.  The  dilated  ureteral  calyces  and 
pelvis  contained  urine,  pus,  and  sufficient  blood  to  redden 
the  urine.  I  could  introduce  a  ureteral  catheter  through  the 
ureter  to  the  bladder,  demonstrating  that  the  ureteral  flex- 
ion at  the  proximal  ureteral  isthmus  was  of  potential  va- 
riety, depending  on  associated  environments.  (Proximal- 
ward  insertion  of  proximal  ureteral  isthmus  in  ureteral 
pelvis,  access  of  renal  and  periureteral  cicatricial  bands.) 
It  was  a  swanshaped,  ureteral  pelvis  with  distinct  potential 
pathological  flexion,  obstruction  to  urine  at  the  proximal 
ureteral  isthmus.   It  was  not  a  twelfth  of  an  inch  in  diam- 


Fic.  4. — Ventral  view  (right  ureter).  /,  Calyces,  and  ^  and  ^a. 
dilated  ureteral  pelvis  and  calyces;  3,  proximal  ureteral  isthmus; 
f  and  4a,  lumbar  ureteral  dilatations  (spindles) ;  5,  middle  ureteral 
isthmus;  6,  pelvic  ureteral  dilatation  (spindle);  7,  distal  ureteral 
isthmus  (right),  70  (left).  Observe  that  by  ureteral  contraction 
the  right  ureteral  vesicle  orifice  (7)  is  drawn  extensively  to  the 
right  (to  find  which  one  must  follow  the  interureteric  ligament), 
while  the  left  ureteral  orifice  (7a)  is  drawn  to  the  right  of  the 
middle  line  of  the  vesical  trigone  (B),  8,  vesical  urethral  orifice. 
AR,  Accessory  arteria  renalis  which  acutely  flexes  the  proximal 
ureteral  isthmus.  Periodic  uroureter  due  to  flexion  of  the  ureter 
at  the  distalward  located  supernuirerary  renal  vessel  at  j.  Re- 
covery by  nephrotomy,  severance,  and  ligature  of  the  accessory  renal 
vessel  and  adjusting  the  ureteral  pelvis  in  the  lumbar  wound  to 
facilitate  mechanicophysiological  evacuation.  The  vesicle  ureteral 
orifices  are  dislocated  to  the  right  side  of  the  trigone  by  cicatricial 
retraction  of  the  right  ureter. 

eter  and  was  distorted  until  obstruction  of  the  ureter  arose. 
It  resembled  the  potential  flexion  produced  in  a  rubber 
tube  by  being  flexed  while  hanging  across  a  wire.  The 


actual  cause  of  this  uroureter  (and  later  uropyoureter)  was 
not  fully  apparent.  Distinct  periuteral  adhesions  existed  at 
the  proximal  ureteral  isthmus  until  after  its  abdominal  ex- 
ploration.   The  patient  recovered  excellently.  • 

C.-\SE  IV.  Renal  carcinoma  (left).  Death  on  fifth 
day  from  embolus.  Referred  to  me  by  Dr.  Reflogle.  This 
subject,  a  woman,  some  sixty  years  of  age,  was  ill  for 
about  eight  months  when  she  consulted  me  for  pain  on  the 
left  side  and  urinary  disturbance.  Cystoscopic  examination 
in  association  with  Dr.  Gustav  Bergener  revealed  slight 
function  in  the  left  ureter  with  ample  function  in  her  right 
kidney.  The  left  kidney  was  increased  in  dimension  some 
fifty  per  cent.  After  careful  examination  I  extirpated  the 
left  kidney,  which  proved  to  be  afflicted  with  an  apple  sized 
carcinoma  in  the  distal  pole.  The  woman  progressed  un- 
eventful in  recovery  until  the  morning  of  the  fifth  day, 
when  she  suddenly  died  in  about  two  minutes  after  an  at- 
tack, which  I  diagnosticated  as  embolus. 

Case  V.  Uroureter  (right).  (See  Fig.  4),  due  to 
flexion  of  the  ureter  by  distalward  located  supernumary 
renal  vessels.  Referred  to  me  by  Dr.  Ray  Rice,  of  Dela- 
van,  Wisconsin. 

This  woman,  thirty-two  years  old,  had  been  ill  seven 
years  with  a  swelling  in  the  right  side.  For  this  trouble 
one  physician  extirpated  her  right  ovary.  The  swelling  in 
the  right  side  was  as  large  as  cacaonut.  Pus,  albumin,  and 
rare  red  blood  cells  were  found  in  the  urine,  but  when  I 
first  catheterized  the  left  ureter  I  found  the  urine  fron;  the 
left  kidney  normal,  hence  the  pus  and  blood  came  from  the 
right  kidney.  Before  the  operation  I  could  not  catheterize 
the  right  ureter  on  account  of  extensive  dislocation  (see 
Fig.  4),  subsequent  to  a  four  day  hospital  preparation.  On 
exposing  the  right  kidney  I  discovered  by  nephrotomy  that 
the  calyces  and  pelvis  of  the  ureter  were  dilated  as  large  as 
a  cacaonut,  and  was  due  to  flexion  of  the  ureter  over  a 
distalward  located  supernumerary  renal  vessel.  I  incised  the 
kidney  in  Hyrtl's  exsanguinated  renal  zone,  i.  e.,  one  half 
inch  dorsal  to  the  middle  of  the  lateral  longitudinal  renal 
border  (with  minimum  haemorrhage)  and  with  digital  ex- 
ploration no  calculus  or  neoplasm  were  found.  The  super- 
numerary renal  vessel  located  distal  to  the  main  one  was 
perhaps  two-thirds  normal  dimension.  It  penetrated  the 
distal  renal  pole  like  a  poniard  at  the  distal  angle  of  the 
renal  bilus.  It  was  located  dorsal  to  the  ureteral  pelvis,  and 
when  the  ureteral  calyces  and  pelvis  became  enormously 
distended  it  lay  exactly  dorsal  to  the  proximal  ureteral 
isthmus  vi'hich  it  flexed  at  an  acute  angle.  The  ureteral  wall 
at  the  ureteral  isthmus  (especially  at  the  proximal  ureteral 
isthmus)  is  relatively  thicker  and  firmer  than  at  other  ure- 
teral segments,  hence,  the  ureteral  isthmus  yields,  distends, 
with  much  less  facility  than  other  ureteral  segments,  especial- 
ly the  wall  of  the  ureteral  dilatations  or  spindles.  This  factor 
induces  what  I  termed  years  ago  the  "swan  shaped"  ureter 
(See  Figures  3  and  4).  I  severed  the  supernumerary  renal 
vessel  between  double  catgut  ligatures  and  placed  the  distal 
renal  pole  in  the  distal  angle  of  the  wound  which  enabled 
the  ureteral  pelvis  to  evacuate  itself  mechanically  with 
facility.  I  passed  the  catheter  from  the  calyces  through  the 
pelvis  into  the  ureter  proper  with  facility.  Though  the 
renal  gland  was  extensively  expanded  over  the  widely  dis- 
tended calyces  yet  considerable  localized  renal  parenchyma 
remained  intact — sufficient  for  considerable  urinal  secretion. 
She  recovered  from  the  nephrectomy  with  no  untoward 
events,  and  the  right  kidney  appeared  to  be  secreting  some 
ten  ounces  of  urine  per  diem  in  three  w-eeks  subsequent  to 
nephrectomy.  The  urine  from  the  kidney  discharged  per- 
haps equal  quantities  through  the  wound  and  through  the 
ureter  for  two  weeks,  whence  the  urinal  discharge  began  to 
increase  by  ureter. 

I  call  especial  attention  to  the  proper  mechanical  adjust- 
ment of  the  ureteral  pelvis  in  order  to  facilitate  its  physio- 
logicomechanical  evacuation.  The  forcible  location  and  fix- 
ation by  cicatrix  (not  ligature)  of  the  distal  renal  pole  in 
the  distal  angle  of  the  lumbar  incision  is  an  apt  method  to. 
aid  mechanical  and  physiological  evacuation  of  the  ureteral 
pelvis.  In  order  to  secure  ample  pelvic  ureteral  evacuation 
(of  a  once  distended  ureteral  pelvis)  the  distal  renal  pole 
must  be  controlled,  fixed.  Sutures  fail  too  frequently, 
hence  the  fixation  of  the  distal  renal  pole  in  the  lumbar  in- 
cision by  means  of  cicatrix  permanently  facilitates  the  me- 
chanical and  physiological  evacuation  of  the  ureteral  pelvis 
in  hydrouretcr.  The  loss  of  secreting  renal  parenchyma, 
from  obliteration  of  the  supcrnimierary  renal  vessel  by  liga- 
tion cannot  be  avoided  and  perhaps  may  be  compensated  by 


March  13^  1909.! 


ROBINSON:  URETERORENAL  SURGERY. 


533 


increased  flow  through  the  normal  renal  vessel.  Hydro- 
ureter  is  a  mechanicophysiological  condition  and  must  be 
treated  accordingly. 

In  association  with  Dr.  Gustav  Bergener  we  catheterized 
the  right  ureter  of  this  case  at  the  end  of  four  weeks 
(time  of  hospital  discharge).  The  right  vesical  ureteral 
orifice  was  dislocated  toward  the  right  from  diminished 
length,  contraction  of  the  ureter  due  to  ureteritis  and  peri- 
ureteritis. In  fact  the  dislocation  was  so  extreme  that  the 
left  vesicle  ureteral  orifice  was  drawn  to  the  right  of  the 
median  line  (see  Fig.  4.)  To  catheterize  this  subject  one 
had  to  follow  the  interureteric  bar  or  ridge  well  toward  the 
right. 

Case  VI.  Renal  carcinoma,  uropyoureter  (right).  Ne- 
phrectomy. Death.  Referred  to  me  by  Dr.  W.  Peck,  of 
Darlington,  Wisconsin. 

Woman,  thirty  years  old,  of  previous  favorable  health, 
complained  about  six  months  previously  of  pain  and  renal 
disturbance  with  impaired  health.  Physical  examination 
demonstrated  an  indurated  enlargement  in  the  region 
of  the  right  kidney.  In  association  with  Dr.  Gustav 
Bergener  cystoscopic  examination  with  the  adminis- 
tration of  methylene  blue  revealed  normal  left  urinal  pro- 
jection, but  the  right  vesical  ureteral  orifice  was  practically 
functionless,  idle — peristalsis,  minimum,  with  a  slow,  trick- 
ling, grayish  suppurative  fluid  flow.  It  resembled  the  pus 
stream  from  the  incision  in  an  abscess.  However,  the 
methyl  blue  test  was  sufficient  to  be  evident.  Urine  laden 
with  pus,  blood,  and  some  albumin.  Nephrectomy  (with 
partial  proximal  ureterectomy)  demonstrated  extensive 
carcinoma  of  the  right  kidney.  Death,  apparently  from 
shock,  ensued  within  fifty  hours. 

Case  VH.  Renal  cyst.  Renal  tuberculosis  (right).  Ne- 
phrectomy, with  partial  proximal  ureterectomy.  Recovery. 

Woman,  fift3--six  years  of  age,  suffered  violent  pain  for 
five  years  in  the  region  of  the  right  kidney.  I  attended 
her  at  different  times  for  five  years,  however,  she  refused 
operation.  She  was  afflicted  during  all  the  half  dozen  years 
with  intense  periodical  attacks  of  violent  pain.  Morphine 
alone  appeared  to  afford  relief.  The  last  two  years  the  right 
renal  swelling  waS  the  size  of  a  cacaonut  and  her  general 
health  was  unfavorable.  Functional  capacity  twenty-eight 
ounces  of  urine  which  was  increased  to  thirty-six  ounces 
by  visceral  drainage — i.  e.  ample  visceral  irrigation,  visceral 
elimination  through  liberal  quantities  of  water  at  regular 
intervals.  In  conjunction  with  Dr.  G.  Bergener  cystoscopic 
examination  revealed  right  ureter  idle,  functionless — no 
urine  projected  from  the  right  ureter. 

Operation.  Lumbar  nephrectomy  (with  partial  ureterec- 
tomy) demonstrated  an  enormous  renal  cyst  with  extensive 
renal  tuberculous  invasion.  The  renal  parenchyma  was 
almost  totally  destroyed  which  was  materially  aided  by  the 
fact  that  the  ureteral  calyces  and  ureteral  pelvis  seemed  to 
be  the  primary  tuberculous  seat  whence  the  ureter  became 
early  obstructed  ending  in  annihilation  of  function  of  renal 
parench>Tna.  Recovery  during  four  weeks  in  the  hospital, 
was  uneventful,  excellent,  and  progressive. 

Case  VIII. — Renal  and  ureteral  tuberculosis  (right). 
Nephrotomy  and  nephrectomy,  death.  Woman,  thirtj'-five, 
ill  about  eighteen  months,  came  to  the  hospital  verj'  ill  with 
continuous  high  temperature  and  rapid  pulse,  pus,  blood, 
and  albumin  in  the  urine.  She  was  so  septic  that  her  life 
was  completely  jeopardized.  Hence,  evacuation  of  a  peri- 
neal abscess  and  nephrotomy  was  the  procedure  employed. 
She  improved  remarkably  for  a  few  weeks  when  she  began 
to  become  increasingly  septic.  Nephrectomy  was  assayed, 
but  death  followed  in  about  a  week.  The  right  kidnej'  was 
almost  entirely  destroyed  by  tuberculosis.  The  calyces  and 
pelvis  were  almost  equally  destroyed,  and  the  ureter  proper 
was  a  rigid  nonflexible  tube  with  hjTJertrophic  walls  and 
diminished  lumen.  Slight  hope  could  be  expected  in  at- 
tempting to  save  a  patient  so  extensively  advanced  in 
renal  tuberculosis.  However,  the  duty  of  a  physician  is  to 
diagnosticate  and  treat  the  patient — not  to  prophesy. 

Case  IX. — Ureteral  calculus  (right).  Nephrotomy. 
Death.    (See  Fig.  5.) 

Woman,  forty-eight,  ill  for  several  years  with  pain  in  her 
right  side.  Two  months  before  consulting  me  she  went  to 
a  hospital,  where  she  had  ovariotomy  performed — a  hasty 
mistake  of  a  general  surgeon.  Subsequent  to  the  operation 
she  suffered  more  intensely.  On  arriving  at  the  Mary 
Thompson  Hospital  she  was  making  eight  ounces  of  urine 
tIaiVy.    We  placed  her  in  bed  and  gave  her  four  quarts  of 


water  daily,  and  in  ten  days  she  was  making  sixty  ounces 
a  day.  Pus,  blood,  casts,  albumin  in  the  urine.  She  was 
afflicted  with  parenchymatous  nephritis.  X  ray  demon- 
strated right  ureteral  calculus  which  practically  occupied 
the  ureteral  calyces  and  pelvis.  She  died  subsequent  to 
operation  (nephrotomy)  from  suppression  of  urine  and 
shock. 

Case  X. — Pyoureter  (left).  Nephrotomy,  recovery. 
(See  Fig.  6.) 

This  subject  was  a  woman,  thirty-eight  years  of  age. 
Two  years  previously  I  had  performed  a  Caesarean  section 
on  her  for  diminished  pelvic  capacity,  preventing  parturi- 
tion except  by  craniotomy  (in  three  parturitions).  Mother 
and  child  were  well  for  eighteen  months  when  the  mother 
began  to  be  ill.  She  suffered  pain  on  the  left  side  in  the 
region  of  the  kidney,  especially  pain  on  pressure.  She  be- 
came pale  and  anaemic,  and  cachectic.  Pus  and  albumin  in 
the  blood.  X  ray  presented  no  shadow.  The  cj'stoscope 
presented  normal  right  vesical  ureteral  orifice.  The  left 
ureteral  vesical  orifice  presented  a  patent  opening  with  slight 
ureteral  peristalsis,  and  cloudy  urine  trickled  into  the  blad- 
der from  it.  The  chief  work  was  performed  by  the  right  ure- 
ter. After  being  in  the  hospital  for  a  week's  observation 
she  suddenly  had  a  profound  chill,  at  a  temperature  of 


Fig.  5. — Dorsal  ^ew.  Practically  complete  obstruction  of  the 
ureter  hy  a  calculus  almost  completely  occupying  the  ureteral  calyces 
and  pelvis.  On  arriving  at  the  hospital  this  woman  was  urinating 
eight  ounces  daily.  • 

106°  F.  per  rectum,  rapid  respiration,  severe  pain  in  the 
left  lumbar  region.  Two  days  after  this  terrific  chill  I 
made  a  Simon-Hotz  incision  over  the  left  kidney  and  found 
a  kidney  of  about  double  normal  dimension.  The  increase 
in  dimension  was  practically  due  to  dilatation  of  the  ure- 
teral calyces  and  pelvis.  A  pair  of  vasa  renalia  presented 
a  deep  groove  on  the  ventral  surface  of  the  dilated  ureteral 
pelvis — in  fact  so  deep  an  impression  that  at  first  I  thought 
of  ligating  and  severing  the  vessels.  On  incision  in  Hyrtl's 
exsanguinated  renal  zone,  nephrotomy,  some  eight  ounces 
of  a  seropus  flowed  from  the  wound.  Digital  exploration 
discovered  no  calculus  or  neoplasm.  Recovery  was  rapid 
and  uneventful.  Five  weeks  subsequent  to  the  operation 
Dr.  Gustav  Bergener  and  I  catheterized  and  fdund  that  the 
left  kidney  was  performing  twenty-five  per  cent,  of  its  nor- 
mal duty.  Six  months  after  the  operation  she  continued  to 
improve. 

It  is  here  a  pleasant  duty  for  me  to  acknowledge 
my  indebtedness  to  Dr.  Gustav  Bergener  for  his  fa- 


534 


ROBINSON:  URETERORENAL  SURGERY. 


[New  York 
Medical  Journa'.. 


vors  to  me  in  urological  labors  during  the  past  five 
years. 

CONCLUSIONS  IN  REGARD  TO  RENAL  SURGERY. 

This  report  contains  ten  consecutive  patients  of 
renal  surgery,  no  selection  nor  limitation  occurred. 
The  patients  were  received  and  operated  upon  as 
they  appeared  in  order.  It  is  a  single  ureterorenal 
decalogue.  Sixty  per  cent,  recovered  and  forty  per 
cent.  died.  Thirty  per  cent,  of  the  disease  were  in 
the  left  renoureteral  tract  and  seventy  per  cent,  in 
that  of  the  right. 

Tzventy  per  cent,  of  the  cases  were  renal  carci- 
noma and  all  patients  died,  one  from  shock  due  to 
exhaustion  and  diminished  vitality,  and  one  from 
embolus  on  the  fifth  day. 

Sixty  per  cent,  of  the  cases  were  nropyoiireter.  Of 
the  five  subjects  of  uropyoureter,  one  was  due  to  an 
accessory,  distahvard  located  renal  vessel  (Fig.  4)  ; 
one  was  due  to  a  pathological  flexion  of  the  ureter 
at  the  proximal  ureteral  isthmus  (abetted  by  vasa 
renalia) — Fig.  3;  two  were  due  to  complete  ob- 


FiG.  6. — \'cntral  vie>v,  left  renourcter.  Practically  complete  ob- 
struction at  tlic-  pro-ximal  ureteral  isthmus  by  compression  of  renal 
vessels.  The  obstruction  is  at  the  ureterovascular  crossing.  The 
vasa  renalia  bifurcate  abnormally  adjacent  to  their  origin. 

This  patient  was  dangerously  ill  with  chills,  temj  erature  105°  and 
pulse  140  as  the  hydroureter  had  become  infected.  Nephrotomy 
was  performed,  and  since  no  other  cause  could  be  observed  than 
the  indicated  compression  of  the  ureterovascular  crossing  I  con- 
cluded that  it  was  a  case  of  hydroureter  of  the  calyces  and  pelvis 
due  to  renal  vascular  compression  of  the  proximal  ureteral  isthmus. 
Hydroureter  from  v^cular  renal  compression  at  the  ureterovascular 
crossing  may  be  decided  only  with  any  positive  degree  in  the  in- 
cipient stage.  The  patient  recovered,  and  six  months  subsequent 
to  the  operation  in  consultation  with  Dr.  Gustav  Bergener  we 
catheterized  the  ureters.  The  ureteritis  on  the  left  side  had  dislo- 
cated the  vesical  trigone  leftward  and  proximalward.  The  orifice  of 
the  left  ureter  was  potent.  The  left  ureter  was  defective  in  peri- 
stalsis, as  the  urine  trickled  from  it  lacking  the  rhythmical  projec- 
tion. The  left  kidney  was  performing  perhaps  sixty  per  cent,  ot 
its  normal  labor.  She  had  practically  no  pain  in  her  left  kidney 
and  ureter. 

At  present  (six  months  subsequent  to  operation)  she  has  pain 
in  the  right  side.  Cystoscopy  reveals  distorted  and  leftward  disloca- 
tion of  right  vesical  orifice  of  ureter,  and  ureteral  catheterization 
demonstrates  or  indicates  its  violent  ureteral  spasm,  for,  the  ureter 
grasps  the  catheter  with  brusque  vigor,  while  a  few  minutes  after 
withdrawal  of  the  ureteral  catheter  it  cannot  be  reintroduced  from 
violent  spasmodic  closure  of  the  ureteral  orifice.  She  is,  therefore, 
suffering  from  ureteritis  dextra.  However,  the  patient  has  gained 
in  red  blood  and  flesh  since  during  the  last  six  months.  This  is  the 
patient  on  whom  I  performed  a  Cscsarean  section  three  years  pre- 
viously. 

struction  of  the  ureter  at  the  proximal  ureteral 
isthmus  (by  calculus) — Fig.  2  and  Fig.  5;  one  was 
due  to  the  infection  of  a  congenital  renal  cyst 


(Fig.  i)  ;  one  was  due  to  an  undiscoverable  cause, 
however,  a  pair  of  renal  vessels  produced  a  deep 
groove  in  the  ventral  surface  of  the  distended 
ureteral  pelvis.  (The  ureter  was  patent  and  func- 
tionating previous  and  subsequent  to  operation — 
six  weeks  subsequent  to  operation  it  was  function- 
ating perhaps  twenty-five  per  cent. 

Twenty  per  cent,  of  the  cases  were  tuberculous, 
of  which  number  one  patient  died  and  one  recov- 
ered (nephrectomy). 

Twenty  per  cent,  of  uropyoureter  were  due  to  ure- 
teral calculus,  of  which  number  one  patient  died 
(nephrotorhy) . 

The  age  of  the  subjects  varied  from  two  years 
to  sixty  years. 

Every  subject  was  a  marked,  late  case,  repre- 
senting advanced  disease — practically  all  were  ad- 
vanced not  only  locally  but  invaded  in  the  general 
system. 

Twenty  per  cent,  of  the  subjects  had  experienced 
mistaken  diagnosis.  The  ovaries  had  been  removed 
on  the  side  of  the  renal  disease  in  two  subjects  by 
recognized  general  surgeons — hasty  mistakes. 

Nephrectomy  was  performed  seven  times  with 
three  deaths  (two  for  carcinoma,  and  one  for 
tuberculosis).  Nephrotomy  was  performed  four 
times  with  one  death  (one  nephrotomy  preceded  a 
nephrectomy  in  a  ureterorenal  tubercular  subject, 
Case  VIII).  The  death  in  nephrotomy  was  in  the 
subject  of  pyoureteritis  calculosa.  Case  IX. 

The  chief  aids  in  diagnosis  of  these  ten  subjects 
were  uranalysis,  ureteral  catheterization,  and  the 
x  ray. 

In  gynaecology  hydrosalpinx  supercedes  pyosal- 
pinx,  and  mainly  spontaneously  recovers.  In  urol- 
ogy hydroureter  proceeds  pyoureter  and  spontan- 
eous recovery  is  rather  rare.  Hydroureter  sooner 
or  later  becomes  infected. 

The  recovery  of  the  established  pyoureter  gener- 
ally demands  the  removal  of  a  distinct  cause,  e.  g., 
a  ureteral  calculus,  pathological  ureteral  flexion 
(from  accessory  renal  vessels,  periureteral  adhe- 
sions, mechanical  difliculties  in  ureteral  pelvic 
evacuation,  etc.). 

Renal  disease  requires  an  exacting  diagnosis  for 
renal  operations.  Renal  surgery  demands  cysto- 
scopy and  ureteral  catheterization  to  test  the  renal 
functions  and  to  locate  the  pathologic  conditions. 

Nephrectomy  demands  acknowledgement  of  the 
presence  of  another  kidney  with  sufficient  function 
to  maintain  life. 

Renal  operations  demand  careful  preoperative 
treatment  of  several  days  with  ample  ingestion  of 
fluids  at  regular  intervals,  six  pints  of  fluid  daily, 
i.  e.,  ample  visceral  drainage,  vigorous  visceral  irri- 
gation, maximum  visceral  elimination. 

Renal  operations  should  be  performed  as  rapidly 
and  skilfully  as  circumstances  permit  to  avoid  the 
frequent  subsequent  shock. 

Traction  on  the  kidney  pedicle  should  be  avoided 
as  it  traumatizes  the  closely  adjacent  abdominal 
brain — a  vital  vasomotor  centre,  the  seat  of  organic 
life. 

The  postoperative  treatment  should  include  proc- 
toclysis of  eight  ounces  of  cold  normal  salt  solution 
for  two  thirds  of  the  time.    The  proctoclytic  foun- 


March  13.  1909.J  JOHNSTON-SCHWARTZ:  METABOUSM  OF  SKIN  DISORDERS. 


535 


tain  should  be  one  foot  above  the  rectum  and  the 
rectal  tube  should  be  introduced  twelve  inches.  (In 
parenchymatous  nephritis  the  sodium  chloride 
should  be  omitted).  We  are  apt  to  perform  ex- 
cessive renal  surgery,  i.  e.,  especially  on  late  or  ad- 
vanced renal  subjects. 

Late  renal  surgery  is  excessively  fatal. 

The  amateur  as  a  rule  performs  excessive  renal 
surgery.  Frequently  if  a  patient  with  severe  renal 
lesion  is  medically  treated,  considerable  length  of 
life  would  be  granted,  however,  with  a  surgical 
operation,  life  may  be  rapidly  destroyed,  death  fol- 
lowing in  a  few  days.  Patients  with  renal  lesions 
that  appear  surgical,  improve  wonderfully  under 
anatomical  and  physiological  rest  with  visceral 
drainage,  i.  e.,  rest  in  bed,  appropriate  diet,  and 
ample  fluids  at  regular  intervals  for  visceral  drain- 
age— visceral  irrigation,  completion  of  vascular 
volume.  The  improvement  from  the  anatomical 
and  physiological  rest  is  so  pronounced  in  renal 
lesions  that  wise  surgeons  frequently  sheath  the 
scalpel — for  a  season. 

The  more  general  distribution  of  urological 
knowledge  will  enable  the  general  practitioner  to 
refer  the  patient  to  a  competent  urologist  suffi- 
ciently early  in  the  disease  to  conserve  health  and 
eradicate  disease. 

100  State  Street. 


STUDIES  IN  THE  METABOLISM  OF  CERTAIIm 
SKIN  DISORDERS. 

Bv  James  C.  Johnston,  M.  D., 
New  York, 

Assistant  Professor  of  Dermatology,  Cornell  University  Medical 
College, 

and  Hans  J.  Schwartz,  M.  D., 
New  York, 

Clinical  Instructor  in  Dermatology,  Cornell  University  Medical 
College. 

This  work  was  undertaken  in  the  hope  of  demon- 
strating, first,  a  connection  between  disordered  met- 
abolism and  a  number  of  inflammatory  dermatoses 
by  means  of  evidence  deduced  from  urine  examina- 
tion and,  second,  of  finding  some  rational  means  by 
which  relapses  in  those  inflammations  could  be  con- 
trolled. 

A  preliminary  communication  (i)  relating  to  auto- 
intoxication in  bullous  eruptions  alone  was  presented 
to  the  British  Medical  Association  in  1906.  Since 
then,  a  wider  line  of  investigations  with  improved 
methods  has  been  followed  into  other  classes,  ery- 
themas and  parakeratoses,  the  character  of  whose 
inflammatory  exudate  allies  them  to  the  bullous  dis- 
eases. These  three  groups  by  no  means  exhaust  the 
field  where  method  of  research  adopted  affords 
promise,  but  suitable  opportunity  for  the  study  of 
such  conditions  as  purpura,  pemphigus,  pompholyx, 
and  dermatitis  exfoliativa  has  not  presented  itself. 

We  have  attached  greatest  importance  to  the  re- 
sults of  the  study  of  urinary  nitrogenous  compounds 
following  numerous  suggestions  contained  in  recent 
literature.  We  shall  present  first,  in  order  that  there 
may  be  a  standard  for  comparison  with  disease,  a 
consideration  of  the  nitrogen  partition  of  normal 


metabolism  and  the  significance  of  the  compounds 
composing  it. 

THE  NITROGEN  PARTITION  OF  NORMAL  METABOLISM. 

The  table  given  below  has  been  condensed  from 
the  one  compiled  by  Ewing  and  Wolf  from  Folin's 
figures  based  upon  repeated  examinations  of  the 
urine  of  healthy  persons.  Each  of  the  percentages 
represents  the  results  of  urine  examination  of  ten 
individuals  for  the  space  of  three  days — that  is,  of 
thirty  twenty-four  hour  specimens — and  may  be  re- 
garded as  correct  for  all  purposes  of  comparison. 


3  63  6 

7  78.6 

II  83.0 

15  87.0 


12. 1 

s-s 

3-3 
3-3 


M  SZ 
J-  cj  . 

3-0 
2.3 
1-3 

1 .2 


.S  c3   .  a  . 

*-  cj  —  4>  -a 

"  o  4-»  u  cj 

v     *^  w  u 

V-  flj  c  1»  4)  O 

15-5  8.7 

8.4  6.6 

4.6  7.7 

4.1  4.7 


The  striking  differences  between  the  percentages 
in  low  and  high  total  nitrogen  output  renders  it  nec- 
essary to  keep  the  table  in  mind  in  order  to  interpret 
nitrogen  ratios  in  disease.  The  divergence  is  proba- 
bly due  to  the  close  approximation  to  constancy  of 
total  amount  for  the  individual  excreted  in  health 
of  all  the  constituents  except  urea.  The  importance 
of  these  figures  and  of  a  thorough  understanding  of 
them  is  illustrated  by  this  example :  Ten  per  cent,  of 
rest  nitrogen  is  high  for  a  urine  containing  thirteen 
grammes  of  nitrogen,  while  it  would  be  hardly  re- 
markable for  three  grammes.  Any  wide  variation 
from  these  standards  may  be  regarded  as  evidence 
of  disturbance  worthy  of  attention.  (For  elimina- 
tions intermediate  between  the  figures  of  the  table 
the  reader  is  referred  to  Ewing  and  Wolf's  (2) 
article,  or  he  may  take  the  mean  of  those  given  with- 
out fear  of  important  error. ) 

SIGNIFICANCE  OF  CHANGES  IN  THE  NITROGEN  PARTI- 
TION AND  OF  THE  PRESENCE  IN  DISEASE  OF 
CERTAIN  COMPOUNDS  NOT  CONSTITU- 
ENTS OF  NORMAL  URINE. 

Consideration  of  the  origin  of  the  urinary  com- 
pounds which  figure  in  our  reports  may  seem  a  little 
trite  at  this  late  day,  but  it  can  do  no  harm  to  refresh 
the  memory  of  the  casual  reader.  Deviations  from 
the  normal  while  still  under  discussion  are  suscepti- 
ble of  fairly  reasonable  interpretation  as  a  result  of 
recent  investigation. 

Urea  results  from  the  synthesis  in  the  liver  of 
ammonia  and  the  amino  acids,  basically,  according 
to  Hofmeister  (8)  an  oxidative  process.  Failure  in 
the  ureaforming  function,  therefore,  indicates  a  con- 
dition of  suboxidation.  Other  investigators  state  that 
proteid  metabolism  involves  other  processes  such  as 
hydrolysis  and  dehydration,  and  hold  that  the  the- 
ory of  deficient  oxidation  contains  only  a  part  of  the 
truth.  Ewing  and  W'oU  ( 10)  prefer  to  call  this  fail- 
ure to  remove  the  amino  group  and  convert  it  into 
urea  and  water  deficient  desamidation.  Low  urea 
may  result  from  a  nonnitrogenous  diet  and  in  itself 
does  not  indicate  deficient  metabolic  capacity.  It 
must  be  associated  with  an  increased  percentage  of 
ammonia  or  rest  nitrogen  or  in  both  in  order  that  no 
doubt  of  the  failure  of  the  synthetizing  process  may 
exist. 


536 


JOHNSTON-SCHWARTZ:  METABOLISM  Of  J)/v7.V  DISORDERS.  ,  [New  York 

Medical  Journal. 


The  rest  or  undetermined  nitrogen  fraction  con- 
sists principally  of  amino  acids,  but  contains  also 
peptone,  albumose,  and  the  xanthin  compounds.  Un- 
der ordinary  conditions,  amino  acids  are  largely  re- 
moved by  lytic  or  synthetic  processes ;  their  presence 
in  increased  ratio  is  an  indication  of  a  deficient 
desamidation.  Kreatinin,  according  to  Folin  (6)  is  an 
index  of  endogenous  metabolism,  the  result  of  the 
breaking  down  of  the  tissues.  Uric  acid  is  supposed 
to  indicate  in  the  same  way  the  eliminable  end  prod- 
uct of  purin  metabolism. 

Aside  from  the  compounds  constituting  the  nitro- 
gen partition,  there  are  others  not  present  or  present 
only  in  small  quantity  in  normal  urine  which  figure 
here.  In  the  first  class  are  kreatinin  and  the  acetone 
compounds ;  in  the  second,  indican.  Their  determi- 
nation is  an  essential  part  of  studies  in  metabolism. 
Indican  is  very  well  known  as  the  product  of  oxi- 
dation of  indol  and  a  symptom  in  the  urine  of  intes- 
tinal putrefaction.  The  acetone  compounds,  acetone, 
diacetic  aaid,  and  betaoxybutyric  acid  occur  in  the 
urine  of  diabetics,  in  starvation,  and  in  conditions 
of  enforced  abstention  from  food  as  persistent  vom- 
iting, and  in  anaesthesia,  and  are  regarded  as  unox- 
idized  byproducts  of  the  consumption  of  fat.  Kreatin 
is  an  urinary  abnormality  whose  origin  and  signifi- 
cance is  still  uncertain. 

METHODS    EMPLOYED,  CONTROLS,  AND    SOURCES  OF 
ERROR. 

The  analyses  were  done  in  the  laboratories  of 
chemistry,  experimental  pathology,  and  clinical 
pathology,  chiefly  in  the  last.  Kjeldahl's  was  the 
method  used  for  the  determination  of  total  nitrogen ; 
Folin's  for  urea  (3)",  ammonia  (4),  uric  acid  (5), 
kreatinin  and  kreatin  (6).  Walker  Hall's  purino- 
meter  was  used  in  the  clinical  laboratory.  Control 
by  examination  of  the  urine  of  healthy  persons  is  no 
longer  necessary  since  Folin  (3)  presented  the  re- 
sults of  his  elaborate  investigations.  We  have  nat- 
urally selected  the  groups  of  dermatoses  which 
promised  results,  but  the  individual  cases  were  used 
as  they  occurred  in  dispensary  or  private  practice, 
depending  only  on  the  patient's  willingness  to  co- 
operate. Certain  cases  of  pruritus,  ichthyosis,  and 
dermatitis  hiemalis  have  served  in  a  sense  as  con- 
trols, for  they  have  given  us  results  although  they 
might  be  expected  to  do  so.  We  have  omitted  these 
reports  except  in  one  instance  of  pityriasic  erythro- 
derma to  save  space.  Interval  analyses  will  be  found 
m  many  of  the  tables. 

The  total  urinary  nitrogen  varies  with  the  weight 
of  the  individual,  his  habits,  and  the  amount  of  pro- 
teid  intake,  but  the  error  here  is  eliminated  by  com- 
parison of  the  ratios  with  those  of  a  normal  person 
for  the  same  total  output.  Since  reliance  can  be 
placed  solely  on  variations  in  the  relative  propor- 
tions of  nitrogen  constituents  for  a  given  total,  in 
deciding  a  question  of  disturbed  metabolism  we  hav.e 
not  felt  it  necessary  to  weigh  the  food  taken  as  a 
routine  measure.  It  was  done  in  two  cases  (XI  and 
XXI).  In  general,  patients  have  been  placed  on  a 
restricted  purin  diet  and  directed  to  consume  as 
nearly  as  possible  the  same  amounts  of  the  same 
foods  on  the  day  preceding  and  that  in  which  the 
twenty-four  hour  specimen  was  collected.  Ammo- 
niacal  fermentation  was  excluded  by  adding  chloro- 


form to  the  first  portion  passed  and  shaking  the  bot- 
tle with  each  succeeding  addition.  The  specimens 
consisted  in  almost  every  instance  of  the  total  urine 
passed  in  twenty-four  hours.  We  have  followed  the 
cases  through  their  phases  whenever  possible  and  de- 
sirable ;  single  examinations  were  done  to  demon- 
strate a  particular  point. 

Urinary  changes  are  identical  or  nearly  so  in  met- 
abolism altered  by  bacterial  invasion  (pneumonia) 
and  by  changes  originating  within  the  body  (toxae- 
mia of  pregnancy).  Our  cases  are  sufficiently  re- 
moved from  the  possibility  of  bacterial  origin  to  re- 
lieve us  of  the  necessity  of  blood  culture  experi- 
ments. In  the  single  case  of  erythema  multiforme, 
the  absence  of  leucocytosis  precluded  the  likelihood 
of  the  presence  of  this  causative  factor.  We  have 
had  no  opportunity  to  study  purpura  or  pemphigus 
in  which  blood  culture  would  be  imperative. 

Error  in  the  making  of  chemical  tests  is  possible, 
to  say  nothing  of  the  calculations  involved.  It  is 
not  likely  to  be  very  great,  in  view  of  the  pains 
taken.  Rest  nitrogen  ratios  are  liable  to  slight  er- 
ror, particularly  in  females  from  the  presence  of  in- 
flammation in  the  genitourinary  tract  and  conse- 
quent addition  of  albuminous  compounds  to  its  quota, 
but  here  again  the  percentage  will  not  be  markedly 
aflfected. 

REVIEW  OF  THE  ANALYSES  IN  THESE  CASES. 

The  thesis  we  have  undertaken  is  susceptible  of 
proof  most  easily,  perhaps  only,  by  the  results  of 
urine  examination  measured  by  the  standards  of 
normal  metabolism.  Variation  in  specific  gravity  or 
in  the  total  weight  of  any  solid  constituent  or  con- 
stituents are  too  readily  produced  by  many  factors 
to  be  of  any  service  in  determining  the  presence  of 
disordered  metabolism.  In  order  to  stamp  a  urine 
analysis  as  showing  such  a  state,  it  must  exhibit  one 
or  all  of  three  characteristics  :  ( i )  The  presence  of 
compounds  not  found  in  normal  urine  such  as  albu- 
min, the  acetone  compounds,  and  kreatin;  (2)  the 
occurrence  in  increased  quantity  of  substances  like 
indican  which  ordinarily  appears  in  small  amount ; 
and  (3)  variations  in  the  proportions  of  normal  con- 
stituents wide  enough  to  be  recognized  as  departures 
from  the  standard. 

A  small  amount  of  albumin,  rarely  more  than  a 
trace  and  generally  of  serum  or  nucleoalbumin  was 
found  in  eight  of  the  twenty-one  cases.  It  occurred 
in  erythema  multiforme  as  part  of  an  acute  nephri- 
tis ;  but  generally  in  connection  with  chronic  dis- 
eases, in  one  case  of  chronic  urticaria,  in  two  of  five 
examples  of  dermatitis  herpetiformis,  in  one  of  three 
prurigos,  in  two  acute,  one  nephritic,  and  one  chronic 
eczema  among  seven.  Its  presence  may  be  account- 
ed for  in  certain  cases  by  inflammatory  exudate  from 
the  urogenital  mucosa.  When  the  cases  were  fol- 
lowed, it  disappeared  under  treatment,  although  it 
persisted  in  one  case  for  a  year  and  a  half  through 
all  the  fluctuations.  Acute  relapse  in  the  skin  seemed 
not  to  affect  the  amount  present.  In  two  cases  (I 
and  XIV)  where  albuminuria  reached  the  grade  of 
nephritis,  the  renal  change  had  no  apparent  effect  on 
the  nitrogen  partition. 

We  do  not  attach  the  importance  to  indicanuria  to 
which  other  observers  seem  inclined.  It  occurs  m 
patients  with  bullous  eruption  quite  constantly,  par- 


ilaich  13,  1909.  J 


JOHNSTON-SCHWARTZ:  METABOLISM  OF  SKIN  DISORDERS. 


537 


ticularly  dermatitis  herpetiformis,  as  Engmann  (9) 
has  pointed  out.  The  quantity,  too,  is  generally  con- 
siderable, but  it  may  be  absent,  as  in  Case  VI,  at  the 
height  of  an  attack.'  The  irregularity  of  its  behavior 
is  illustrated  in  the  prurigo  patients.  In  two  cases  it 
was  found  in  quantity  from  one  of  whom  it  had 
never  disappeared  in  spite  of  diet  and  medication ;  in 
the  third  it  was  absent  in  the  beginning,  to  appear 
later  coincidently  with  the  disappearance  of  the  al- 
bumin. The  urine  of  chronic  urticaria  and  rosacea 
with  gastrointestinal  disease  and  flatulence  failed  to 
show  it.  Acute  attacks  of  urticaria  and  eczema  are 
generally  marked  by  indicanuria,  but  it  is  often  ab- 
sent in  subacute  and  chronic  cases.  The  amount 
rarely  rises  so  high  in  eczema  and  urticaria  as  in  the 
bullous  group.  Eruptions  do  not  necessarily  im- 
prove with  its  disappearance  and  may  resolve  par- 
tially or  wholly  while  it  continues.  In  Case  XI, 
where  the  patient's  body  was  covered  with  prurigo, 
its  appearance  was  delayed  until  six  months  after 
treatment  was  begun.  No  nephritis  was  discovered 
in  the  individuals  in  whom  it  continued  longest  and 
occurred  in  greatest  amount. 

In  consideration  of  these  facts,  we  are  inclined  to 
attribute  slight,  certainly  not  aetiological,  importance 
to  indican,  while  there  can  be  no  reasonable  doubt 
that  circulating,  unoxidized  indol  may  contribute  ma- 
terially to  a  general  intoxication.  (Excessive 
amounts  of  indican  are  indicated  in  the  reports  by 
a  single  or  double  t  sign.) 

The  acetone  compounds  were  not  found  in  these 
analyses.  Kreatin  was  discovered  once  in  the  urine 
of  an  old  man  with  scrotal  eczema ;  it  disappeared 
before  the  next  report  although  the  disease  had 
spread  extensively. 

The  suggestion  was  offered  in  the  preliminary  re- 
port referred  to  that  the  most  striking  variations  in 
the  ratios  of  the  nitrogen  partition  may  be  expected 
in  the  prodromal  stage  of  an  acute  attack.  That 
point  has  been  demonstrated  convincingly,  we  think, 
by  these  reports,  not  only  in  bullous  disease  but  in 
erythematous,  and  scaling  disorders  and  in  the  first 
few  days  of  eruption  as  well  as  in  the  prodromal 
period.  In  general,  the  economy  soon  accommodates 
itself  to  the  disturbance  and  the  evidences  of  it  dis- 
appear from  the  urine.  At  times,  however,  partic- 
ularly when  the  rules  of  diet  are  not  rigidly  ob- 
served, the  derangement  persists. 

Relapse  in  the  course  of  chronic  disease  shows  ex- 
actly the  same  change  in  the  partition.  In  chronic 
disease  without  exacerbation,  the  urine  may  show  no 
radical  divergence  from  what  obtains  in  healthv  per- 
sons (Cases  IV,  VI,  XVI,  and  XVII),  even  when 
the  eruption  is  at  its  height,  covers  large  areas,  and 
has  existed  for  some  time.  This  rule  has  notable 
exceptions  in  cases  pursuing  an  uneventful  course 
(XI  and  XVIID.  Typically  chronic  inflammations, 
seborrhceic  eczema,  erythrodermie  pityriasique.  and 
psoriasis  exhibit  normal  partitions  in  spite  of  violent 
attacks  of  indigestion. 

The  disorder  of  metabolism  shown  in  our  cases 
almost  invariably  is  failure  of  urea  synthesis  or  de- 
fective desamidation,  consisting  in  a  decided  drop 
in  the  urea,  with  a  corresponding  rise  in  the  rest 
nitrogen  percentage,  or  in  the  latter  alone.  In  the 
prodromal  period  of  eczema  rest  nitrogen  reached 
1 1.9  per  cent.,  in  dermatitis  herpetiformis  11.4  per 


cent.,  in  prurigo  16.6  per  cent.,  in  urticaria  16.5  per 
cent. ;  corresponding  figures  for  urea  being  80 
per  cent.,  73.6  per  cent.,  71.2  per  cent.,  and 
71  per  cent.  In  Case  V  before  relapse  the 
urea  percentage  was  61.9,  rest  25.6  for  a 
total  nitrogen  output  of  9.46  grammes.  The 
figures  correspond  closely  in  the  prodromal  and 
onset  stage  of  a  first  attack,  after  complete  remis- 
sion, and  in  relapse  during  the  course  of  chronic 
disease.  Case  XIII  (beginning  eczema)  showed 
high  undetermined  nitrogen  11.9  per  cent.,  with 
normal  urea  80.2  per  cent.,  total  nitrogen  8.72 
grammes.  The  same  condition  occurred  in  prurigo. 
The  greatest  variation  observed  was  in  Case  XI  be- 
fore active  treatment  was  begun ;  urea  60.7  per 
cent., rest  28.1  per  cent.,  total  nitrogen  8.44  grammes. 
Besides  this  instance,  moderately  high  rest  nitrogen 
was  found  in  chronic  dermatitis  herpetiformis  and 
eczema  (Cases  VII  and  XVIII.)  Very  low  rest 
nitrogen  ratios  in  prurigo  and  erythrodermie,  0.3 
and  0.4  per  cent.,  may  be  the  result  of  error  in  analy- 
sis. They  have  not,  so  far  as  we  know,  been  seen 
before.  The  determinations  were  made  in  periods 
of  remission  in  the  prurigos  when  full  doses  of  thy- 
reoid were  being  given. 

An  increase  of  ammonia  nitrogen  was  sometimes 
associated  with  low  urea  and  high  rest  nitrogen,  but 
its  behavior  is  uncertain.  It  may  remain  low  with 
accompanying  evidence  of  deficient  desamidation,  or 
it  may  increase,  as  in  Case  XI,  as  relapse  subsides 
and  the  partition  is  returning  to  normal. 

Kreatinin  was  increased  in  amount  and  percentage 
in  psoriasis  associated  with  gastro-enteritis,  in  the 
prodromal  period  of  eczema  dependent  on  extensive 
visceral  lesions  (Case  XIV)  and  at  the  onset  of  der- 
matitis herpetiformis.  Its  highest  percentage,  9.7, 
occurred  with  suspiciously  low  rest  nitrogen  in  pru- 
rigo. In  the  remainder  of  the  cases,  the  change  is 
too  slight  to  be  worthy  of  notice.  Uric  acid  nitrogen 
varies  little  either  in  acute  or  chronic  disease. 

If  the  changes  in  the  nitrogen  partition  form  a  re- 
liable indication  of  metabolic  disturbance,  the  state 
of  aflfairs  met  with  in  Case  XV  requires  explanation. 
The  patient  was  a  robust  girl  of  ten,  subject  to  re- 
currences of  eczema  of  a  subacute  type.  During  a 
period  of  seven  days  preceding  and  following  opera- 
tion under  ether  anaesthesia  for  adenoids,  her  rest 
nitrogen  rose  from  5.1  per  cent,  to  20.9  per  cent., 
while  urea  sank  from  88.4  per  cent  to  70.2  per  cent. 
She  was  in  bed  and  on  a  fluid  diet  at  the  time.  No 
eruption  appeared  and  recovery  was  uninterrupted. 
The  only  reasonable  explanation  is  that,  although  the 
disturbance  of  metabolism  was  present,  the  usual 
toxines  failed  of  elaboration  or,  being  elaborated, 
failed  of  their  usual  effort  on  the  skin  as  in 
the  exthems  and  recurrent  erythemata  without  cu- 
taneous lesion. 

EFFECT  OF  TREATMENT  ON  THE  NITROGEN  RATIOS  IN 
DISORDERED  METABOLISM. 

Observations  in  this  connection  are  vitiated  by  the 
gradual  return  to  normal  after  the  stage  of  onset 
which  occurs  in  most  cases — though  not  by  any 
means  in  all — under  natural  conditions.  We  have 
found  occasionally  that  derangement  persisted  dur- 
ing elimination  treatment  when  diet  rules  were  not 
observed  (in  Cases  V  and  VII). 


JOHNSTON-SCHWARTZ:  METABOLISM  OF  SKIN  DISORDERS. 


[New  Yokk 
Medical  Journau 


Two  points  developed  during  medication  which  if 
confirmed  are  the  most  important  we  have  to  record. 
Seeing  the  result  in  Case  V  of  indulgence  in  exces- 
sive meat  eating,  we  induced  Cases  X  and  XII  to  in- 
crease their  proteid  food  to  rather  large  quantities 
twice  a  day.  In  both  instances,  after  a  lapse  of  ten 
and  in  the  second  of  thirteen  days,  the  experiment 
was  followed  by  eruption  which  was  preceded  by  a 
rapid  increase  in  rest  nitrogen  percentage.  The  con- 
junction of  the  two  symptoms  seems  rather  convinc- 
ing.  The  urea  percentage  showed  Httle  change. 

In  the  second  place,  under  injections  of  extract 
of  autolyzed  whole  sheep  thyroid,  in  Cases  XI  and 
XII,  the  same  phenomenon  occurred,  but  to  a  great- 
er degree.  In  Case  XI  the  high  figures  were  total 
nitrogen  13.77  grammes,  urea  nitrogen  71  per  cent., 
rest  nitrogen  16.5  per  cent.  The  urine  change  here 
was  unaccompanied  by  eruption  but,  there  can  be 
scarcely  any  doubt  of  the  connection  W'ith  thyreoid 
medication  since  the  same  process  was  repeated  when 
injections  were  renewed  after  a  period  of  withdrawal 
of  them.  The  partition  always  returned  to  normal 
while  they  were  continued. 

BLOOD  CHANGES. 

Importance  attaches  to  blood  examination  in  bul- 
lous and  scaling  eruptions  because  it  may  give  in 
relapse  a  fairly  reliable  indication  of  impending  out- 
break. Eosinophilia  was  exhibited  to  a  marked  de- 
gree among  bullous  eruptions.  In  one  case  of  pru- 
rigo it  receded  under  treatment  from  21  per  cent,  to 
2.6  per  cent.  It  begins  at  the  time  of  the  other  pro- 
dromal symptoms,  four  or  five  days  before  eruption. 
We  have  not  recorde.d  the  few  estimations  made, 
but  lymphocytosis  occurs  in  acute  scaling  disorders 
in  much  the  same  way.  Both  fall  to  normal  when 
improvement  becomes  pronounced,  often  before 
eruption  disappears. 

SIGNIFICANCE    IN    THE    DISORDERS    IN    URINE  AND 
BLOOD  AND  THEIR  RELATIONSHIP  TO 
CUTANEOUS  DISEASE. 

With  the  exception  of  indican  and  perhaps  certain 
amino  acids  contained  in  the  undetermined  nitrogen, 
it  can  not  be  said  that  any  of  the  urinary  compounds 
figuring  in  these  reports  are  themselves  toxic,  cer- 
tainly not  in  any  quantity  in  which  they  occur  in  the 
body.  Still  less  are  any  of  them,  including  the  two 
exceptions,  likely  to  be  specific  in  the  causation  of 
any  member  of  the  three  groups.  For  example,  in- 
dicanuria  or  increase  in  rest  nitrogen,  occurring  of- 
ten unassociated  with  skin  lesions  and  indifferently 
with  all  the  types  of  inflammation  included  here,  can 
hardly  stand  in  direct  aetiological  connection  or  in 
fact  do  no  more  than  contribute  to  general  depres- 
sion. 

Taking  into  consideration  the  facts  that  disturb- 
ance in  the  nitrogen  partition  is  most  common  and 
conspicuous  in  the  prodromal  period,  that  it  is  as- 
sociated with  other  symptoms  generally  recognized 
as  those  of  intoxication,  and  that  the  figures  return 
to  the  individual  normal  as  improvement  goes  on, 
the  conclusion  seems  justified  that  this  change  and 
the  skin  lesions  are  related  in  being  effects  of  the 
same  cause.  What  the  actual  exciting  agent  or 
agents  may  be  in  the  production  of  the  primary  er- 
ror of  metabolism  or  of  their  effect  on  the  skin 


there  is  no  way  at  present  of  finding  out.  When 
once  a  state  of  intoxication  is  estabhshed  it  is  not 
unlikely  that  byproducts  eliminable  through  the  kid- 
neys may  add  to  the  poisoning  of  already  altered  tis- 
sues. 

A  suggestion  may  be  offered  as  to  the  point  of  de- 
parture in  these  intoxications.  We  have  been  struck 
by  the  evidence  of  slight  change  in  nitrogen  ratios  in 
cases  of  severe  disease  referable  to  failure  in  pri- 
mary digestion  (Cases  IV  and  XXI)  and  the  wide 
variations  in  those  in  whom  no  such  disorder  could 
be  discovered.  These  observations  and  the  marked 
effect  of  thyreoid  medication  in  bullous  disease  ap- 
parently point  to  the  intermediary  metabolism  as  the 
primary  seat  of  disturbance. 

Eosinophilia  and  lymphocytosis  in  their  respective 
groups  must  be  regarded  with  skin  lesions  and  urine 
changes  as  part  of  the  symptom  complex,  additional 
evidence  of  systemic  poisoning,  their  regression  syn- 
chronizing with  abatement  of  other  symptoms. 

The  uniformity  of  the  character  of  the  change  in 
nitrogen  ratios  in  all  three  groups  suggests  that  their 
pathogenesis  is  the  same  and  that  an  outbreak  of 
eczema  or  dermatitis  herpetiformis  is  an  expression 
of  idiosyncrasy  {e.  g.,  the  multiformity  of  quinine 
rashes)  or  of  a  specificity  in  the  toxic  agent.  The 
individual  as  a  general  rule  shows  the  same  eruptive 
type  throughout  his  relapses ;  but  it  is  a  matter  of 
common  observation  that  types  approximate  closely 
and  even  merge  into  one  another.  Papular  urticaria 
may  become  frank  prurigo  in  time  ;  prurigo  in  re- 
gression exhibit  grouped  vesiculation ;  an  acute  ec- 
zema subside  into  inveterate  psoriasis.  With  succes- 
sive relapses  of  bullous  dermatitis  herpetiformis,  as 
severity  lessens  under  treatment,  the  lesion  reaches 
the  grade  of  erythema  only.  These  considerations, 
particularly  the  various  eruptions  produced  by  over- 
feeding with  proteids,  seem  to  warrant  the  deduction 
that  the  differences  between  the  members  of  the 
three  groups  are  those  of  degree,  cutaneous  expres- 
sion of  the  intoxication  being  determined  by  per- 
sonal reaction  and  to  some  degree  by  local  irritative 
factors.  It  may  become  possible  in  time  to  change 
the  character  of  the  eruption  by  therapeutic  meas- 
ures. 

TREATMENT. 

Therapeutics  suggested  by  this  work  do  not  differ 
essentially  from  the  line  followed  for  generations 
in  handling  most  of  the  members  of  these  groups. 
Regulation  of  diet,  always  of  first  importance,  should 
take  the  form,  except  in  cases  dependent  on  gastric 
hyperacidity,  of  limitation  of  proteid  intake,  to  the 
point  of  total  prohibition  for  a  time  in  acute  cases. 
In  practice,  individuals  accustomed  to  a  full  meat 
diet  do  not  accommodate  themselves  for  any  consid- 
erable period  to  a  regimen  of  fats  and  carbohydrates 
alone,  but,  as  Chittenden  has  pointed  out.  they  can 
do  well  on  much  less  than  appetite  suggests  to  the 
average  American.  They  should  reconcile  them- 
selves to  a  permanent  restriction  in  this  regard. 
Green  fruits  and  vegetables  are  pointedly  indicated. 
Medication  in  the  erythemata  and  scaling  disorders 
takes  the  form  of  elimination  alone  by  the  intestine, 
kidneys,  and  skin.  Diaphoresis  is  obviously  contra- 
indicated  in  acute  eczema ;  otherwise  it  seems  uni- 
versally applicable  and  is  better  secured  by  the  hot 


March  13,  1905.1 


JOHNSTON-SCHWARTZ:  METABOLISM  OF  SKIN  DISORDERS. 


539 


air  cabinet  than  by  pilocarpin.  Saline  cathartics  with 
occasional  doses  of  mercurials  give  better  results  in 
intestinal  putrefaction  than  antiseptics  and  are  suffi- 
cient aids  in  excretion.  (In  Case  XVIII  an  over- 
dose of  hydrargrum  cum  creta  permanently  removed 
an  introtrigenous  eczema  of  years'  standing.)  Elim- 
ination by  the  kidneys  may  need  no  further  aid  than 
quantities  (three  quarts  daily)  of  nonaerated  v^ater, 
but  saline  diuretics  were  generally  resorted  to  in 
addition. 

These  with  appropriate  local  measures  are  gener- 
ally sufficient  in  the  scaling  group  and  acute  urti- 
caria. Relapses,  even  of  dermatitis  herpetiformis, 
have  been  aborted  in  a  few  days  by  vigorous  elimi- 
native  treatment  along  these  lines.  The  chance  is 
greatly  improved  by  taking  the  attack  in  the  pro- 
dromal period,  whose  threatening  onset  the  patient 
learns  soon  enough  to  recognize.  It  was  found, 
however,  in  prurigo  and  the  general  run  of  derma- 
titis herpetiformis  that  treatment  by  diet  and  elimi- 
nation carried  the  patient  only  to  a  certain  point,  no 


Thyreoid  medication  is  not  useful  in  the  treatment 
of  chronic  urticaria.  In  general  or  local  idiopathic 
pruritus  in  certain  cases  it  does  influence  the  disease 
favorably  but  only  after  a  long  period  of  adminis- 
tration. Arsenic  in  dermatitis  herpetiformis  exer- 
cises some  control  over  both  eruption  and  nitrogen 
metabolism. 

GROUP  I.    ERYTHEMA  URTICARIA. 

Case  I. — Diagnosis:  Erythema  multiforme  gyratum. 

History  of  Present  Illness:  Eruption  appeared  about 
January  i,  1907,  on  legs  and  patches  appeared  daily  on 
trunk,  neck,  extremities.  Face  free.  Had  headache  and 
feverish  feelings  at  onset,  no  chill,  bowels  regular. 

Present  Condition :  Well  nourished,  mucous  membranes 
good  color,  tongue  coated.  General  lymphadenitis.  Heart, 
lungs,  and  liver  negative.  Temperature  100.6°  F.  Pulse 
118,  good  volume  and  tension.  Fauces  red  and  congested, 
redness  not  gyrate,  no  ulceration.  Spleen  distinctly  palpa- 
ble below  costal  margin.  Skin,  extensive  erythematous 
eruption  on  trunk,  neck,  and  extremities.  Eruption  con- 
sisted of  separate  rings ;  of  places  where  different  rings 
had  joined  and  edges  had  disappeared  so  forming  erythema 
gyratum.    In  other  places  erythema  iris  type  was  seen. 

Blood  Examination :  January  8,  1907,  Haemoglobin  loO 


Jan, 


Q 
1907. 


Jan.  12. 


Vol.  c.  c. 

5 

^0 

n 

V 

a 

Albumin 

Sugar. 

Acetone 
bodies. 

Indican. 

860 

1.025 

acid 

+  + 

0 

0 

+  + 

1 180 


i.oig 


acid  -|- 


N.  B. — Albumin  removed  before  N.  partition  was  done. 


1348 
16.5 

CASE  I. 


12-34 
91.50 

14-52 
88.0 


2  «^ 
0-37 


0-77 
4-7 


0.08 

0.6 


0.14 
0.9 


S  ti^ 

0.51 
3-8 

0.69 
4.2 


0.13 

0-  9 

0.31 

1-  9 


Hyaline  and 
granular 
casts. 
Hj'aline 
casts. 


matter  how  energetically  pursued.  We  began  then 
with  thyfeoid  administration  in  prurigo  in  the  hope 
of  controlling  to  some  extent  the  intermediary  pro- 
teid  reactions.  These  cases  after  the  preliminary 
period  of  intoxication  was  over  improved  under  tri- 
weekly or  daily  injections  of  2  to  5  c.  c.  of  aqueous 
extract  of  the  autolyzed  whole  sheep  gland.  We 
now  use,  except  in  emergency  as  in  the  beginning  of 
a  relapse  in  either  disease  or  the  exhibition  of  ten- 
dency to  standstill,  the  nucleoproteids  of  the  thy- 
reoid, gr.  1/200  in  milk  sugar  once,  twice,  or  three 
times  a  day.  Both  the  extract  and  the  nucleopro- 
teids are  prepared  by  Dr.  S.  P.  Beebe  of  the  Loomis 
Laboratory.  The  objections  to  the  use  of  the  ex- 
tract are  those  of  all  hypodermic  medications — a  lo- 


per  cent..    Red  blood  cells,  4,800,000.    White  blood  cells, 
10,000.    Red  cells,  normal.    Parasites,  none  found. 
Differential  count  of  300  white  cells  : 


Polynuclears    81.0 

Lymphocytes   lo.o 

Large  mononuclears    1.6 

Transitionals    7.0 

Eosinophiles    0.4 

Mast  cells    o 

Myelocytes    o 


Referred  to  Bellevue  Hospital  for  treatment. 

One  of  us  was  kindly  allowed  to  make  the  following 
notes  from  the  history  kept  in  Bellevue  Hospital : 

January  8th.  Temperature  varied  from  102°  F.  to  101°  F. 
Pulse  from  90-100.  Treatment:  calomel,  sod.  bicarb.,  at 
night.    Sal  Rochelle  in  morning.    Milk  diet. 

January  Qth.  Temperature  ioi°-i03°.  Pulse  92-120. 
Treatment :  Acid  salicyl.,  so.  bicarb.,  four  times  daily. 


0 

ctiol 

5 

(0 

c. 

60 

3 

X 

< 

VI 

008 

acid 

0 

0 

^Iz    ^Iz  li^i  ^iz 


C  >         X         X        <       m     <x>      a         i-'       ^'Zt^  'z.'tc^  «2j§  es&^ 

1907. 

May  5   1840       1.008       acid        000      ++       9.89         7.1  0.51  0.35         0.26         1.63  Squamous 

71-8  5-2  3.6  2.7         16.5  cells. 

CASE  II. 


a 

9.89 

7-1 

cal  reaction  at  times  pronounced  and  an  occasional 
general  intoxication  lasting  for  a  day  or  two  and 
due  to  the  presence  in  the  injection  of  poisonous 
products  of  autolysis.  Nucleoproteids  by  the  mouth, 
a  little  less  efficacious,  are  nontoxic.  (One  patient 
on  her  own  initiative  took  1/50  gr.  daily  without 
symptoms.)  Indications  for  increasing  or  lowering 
the  dose  are  obtained  from  the  progress  of  the  skin 
lesions  and  the  condition  of  the  pulse.  When  hard 
or  high  tension  pulses  present  in  a  great  majority  of 
cases  become  soft,  the  dose  is  sufficient. 


_  January  loth.  Temperature  101-102.8.  Pulse,  100-104.  Pa- 
tient feeling  comfortable,  sleeping  well.    Rash  fading. 

January  nth.  Temperature  102.8°  F.  in  morning.  Pulse 
96.  101.4°  F-  in  evening.  Pulse  100.  Doing  well — treat- 
ment continued. 

January  12th.  Temperature  102.8°  F.  in  morning.  Pulse 
90.  Temperature  101°  in  evening.  Pulse  102.  Treatment: 
sod.  bicarb.,  salol,  q1.  ricini,  four  times  daily. 

January  15th.  Patient  has  steadily  improved,  but  left 
hospital  today  before  complete  cure,  against  advice. 

Case  II. — Diagnosis:  Acute  urticaria. 

Duration:  Two  days.  Face  and  anal  region  especially 
affected.  Appetite  and  digestion  good.  Bowels  regular. 
Nothing  particularly  noteworthy  in  the  eruption. 


540 


PALIER:  APPENDICITIS. 


[New 
Medical 


York 
Journal. 


Case  III. — Diagnosis:  Chronic  urticaria. 

Duration  of  Disease:  Three  weeks.  Male.  Patient  is 
great  eater  of  salted  food,  pickles,  and  meat,  and  drinks  a 
great  deal  of  beer.  Appetite  and  digestion  good.  Bowels 
regular.  Constantly  recurring  outbreaks.  The  urine  ex- 
amination done  before  treatment  was  begun,  showed  only  a 
slight  increase  in  the  rest  nitrogen  percentage. 


areas  of  angeioneurotic  oedema  to  small  papules  and  patches 
of  erythema,  but  all  of  them  itched  furiously. 

After  a  thorough  trial  of  eliminative  measures  including 
pilocarpin  and  restriction  of  diet  without  success  daily  in- 
jections of  Beebe's  extract  of  the  whole  thyreoid  were  be- 
gun, an  initial  small  dose  increased  to  two  c.c.  a  day.  Pulse 
became  soft,  and  there  was  for  a  time  comparatively  little 


C 

0 

c 

o 

Reacti 

Ibun 

< 

1. 014 

acid 

0 

OS 


tn 

V 

B 

e 

c 

nj 

a 
ill 

1  6^ 

■  fj 

•3 

C 

H 

+  + 

16.02 

12.92 

0.8 

80.7 

50 

CASE 

III. 

.s£^ 

"^Ih    s&h  tsih 


>  OS       <      c«     <.o  H       D  blj^     z         P  fee?    i^^^  kSjs? 

0.3  0.64  !.29 

1.9  4.0  8.1  cells. 


1907. 

March   28   1806       1.014       acid        000       -|-+      16.02       12.92         0.8  0.3  0.64         1.29  Squamous 


Case  IV. — Diagnosis:  Chronic  urticaria.  Remains  of 
old  lichen  circinatus. 

Man,  aged  fifty.  Led  an  active  life ;  no  bad  habits.  Pres- 
ent illness  dated  from  May,  1906,  when  he  had  an  attack 
of  "ptomaine  poisoning"  from  spoiled  chicken.  Had  never 
been  free  from  urticaria  except  for  short  intervals  since. 
He  was  neurasthenic  with  poor  peripheral  circulation,  high 
tension  pulse,  and  headaches.  Small  eater,  but  ate  very  ir- 
regularly. Digestion  poor,  sensation  of  fullness  coming  on 
shortly  after  eating,  bowels  irregular,  tongue  coated,  flatu- 


itching,  good  sleep  ensuing.  The  injections  were  continued 
for  seventeen  days  and  then  abandoned  because  they  seemed 
to  exert  no  permanent  beneficial  influence.  On  one  oc- 
casion an  induration  was  left  at  the  side  of  injection,  there 
was  pain  in  bones,  joints,  and  head.  These  symptoms 
passed  off  in  twenty  hours.  After  an  ineffectual  trial  of 
calcium  lactate,  intestinal  antiseptics  and  astringents  were 
given  with  good  effect.  The  primary  seat  of  the  disturb- 
ance would  seem  to  be  in  the  intestinal  tract,  not  in  the 
intermediary  metabolism  as  was  at  first  supposed. 


u 

0 

c. 

Reaction. 

.Mbumin. 

Sugar. 

Acetone 
bodies. 

Indican. 

acid 

trace 

0 

0 

trace 

bo 


^1^-  .EE^i  ^isi  i 

^         SEh                   <|h  S&H  liH  B 

Q                >          'f!           c5         <                <^      ^          H         D  mES  S5           D  MiiS  K  Ml^  CS 

1907.                                                                                        10.10         8.18  0.54         0.13         0.46         0.79  Taken  before 

Feb.    13                645                     acid      trace      o         o      trace                   81.0          5.3           1.3          4.5          7.8  beginning 


CASE  IV. 


thyreoid 
injections. 


lence  marked.  Area  of  hepatic  dullness  extended  from 
sixth  interspace  to  below  border  of  ribs.  Skin  very  dry, 
never  sweat  even  in  Turkish  bath. 

The  amount  of  eruption  varied  during  the  day  and  was 
commonly  worse  late  in  the  afternoon  and  after  eating. 
The  face,  shoulders,  upper  arms,  flanks,  and  thighs  were 
generally  attacked.    The  lesions  ranged  in  type  from  large 


The  urine,  we  regret  to  state,  was  not  taken  during  the 
thyreoid  administration  because  the  patient  refused  to  col- 
lect it.  The  specimen  examined  showed  no  pathological 
variation  in  the  nitrogen  partition.  Treatment  by  diet  and 
intestinal  antiseptics  had  been  undertaken  a  month  previous 
to  the  examination. 

(To  be  continued.) 


SUCCESSFUL  MEDICAL  TREATMENT  OF  APPEN- 
DICITIS, WITH  A  REPORT  OF  CASES. 

By  E.  Palier,  M.  D., 
Nevir  York. 

Professor  A.  Robin  has  an  article  in  the  Bulletin 
general  de  therapeutiqtie,  January  30,  1907,  wherein 
he  reports  the  treatment  of  168  cases  of  appendicitis 
medically,  without  a  single  death.  In  all  those  cases 
an  operation  had  been  advised  by  other  physicians, 
but  Professor  Robin  took  the  responsibility  to  treat 
the  cases  medically.  In  addition  he  treated  other 
cases,  in  which  operation  was  not  insisted  upon  bv 
other  physicians,  with  excellent  results,  his  mortality 
being  in  a  scries  of  322  cases  1.17  per  cent.,  which 
is  a  better  result  than  that  obtained  by  surgeons. 

Emboldened  by  that  report,  the  writer  of  this  has 
tried  the  medical  treatment  in  cases  of  appendicitis  in 
which  an  operation  was  considered  urgent  by  other 
doctors,  with  astonishingly  good  results.  The  writ- 
er's cases  are  unfortunately  comparatively  few,  and 
by  themselves  they  might  not  be  very  convincing,  but 
having  the  large  statistics  of  Professor  Robin  as  a 
support  the  writer  considers  himself  ju.stified  to  re- 
port his  experience  and  to  draw  his  conclusions 
therefrom. 


The  following  two  cases  represent  the  affection  in 
question  in  both  the  acute  and  the  chronic  form. 

Case  I. — Miss  A.,  twenty-four  years  old,  born  in  Ger- 
many, saleswoinan  by  occupation,  came  to  the  writer's 
clinic  in  June,  1907.  The  family  history  of  this  patient  pre- 
sented nothing  of  interest.  The  patient  herself,  a  rather 
anaemic  girl,  had  been  in  good  health,  according  to  her 
statement,  up  to  four  weeks  previously  when  she  had  pain 
in  her  right  side,  some  vomiting  with  fever.  These  symp- 
toms had  continued  with  some  remissions  during  all  the 
time  since  the  onset  of  the  attack  till  the  time  she  came  to  the 
writer.  On  physical  examination  there  was  great  pain  in 
the  McBurney  point  on  pressure,  and  the  girl's  temperature 
one  time  was  104°  F.,  with  a  high  pulse.  The  patient  had 
also  tenderness  in  the  epigastric  region.  The  diagnosis  of 
appendicitis  in  this  case  had  been  made  by  other  physicians, 
and  by  the  patient  herself.  The  writer  himself  did  not  care 
to  treat  the  case  medically,  and  advised  the  patient  to  go 
to  a  hospital  to  be  operated  upon ;  but  as  the  patient  begged 
to  be  treated  without  an  operation,  the  w  riter  tried  medical 
treatment,  and  to  his  surprise  after  two  weeks  of  treatment 
all  the  signs  and  symptoms  of  appendicitis  disappeared. 
It  might  be  of  interest  to  mention  here  that  the  patient  also 
complained  of  gastric  trouble,  and  after  the  pain  in  the  ap- 
pendicular region  had  left  her  she  felt  her  gastric  discom- 
fort more  acutely.  .\n  examination  of  the  stomach  con- 
tents showed  that  the  patient  had  superacidity  with  over- 
secretion.  .After  some  treatment  directed  to  the  stomach 
there  was  a  great  improvement  in  this  organ  likewise. 

Case  II. — .\  school  girl,  aged  sixteen,  born  in  New  York. 
The  whole  family  of  this  patient  was  well  known  to  the 


March  13,  1909.  J 


PALIER:  APPENDICITIS. 


541 


writer.  The  mother  of  the  patient  had  been  suffering  from 
indigestion  for  many  years.  A  married  sister  of  this  patient 
was  suffering  from  hepaptosis  and  gastroptosis,  and  she 
had  had  a  number  of  attacks  of  pain  in  the  abdomen  com- 
ing on  usually  after  exertion.  A  physician  who  saw  this 
patient  in  one  of  these  attacks  thought  the  patient  had  a 
swollen  gallbladder  and  liver,  and  advised  an  operation.  It 
may  be  of  interest  to  remark  that  a  well  fitting  abdominal 
bandage  with  a  few  dietetic  and  hygienic  instructions  had 
relieved  the  patient  from  all  suffering,  and  she  had  not  had 
any  painful  attack  for  over  a  year,  whereas  before,  these 
attacks  had  occurred  once  or  twice  a  month,  and  lastly, 
that  is  before  the  patient  saw  the  writer,  they  came  on  even 
more  often.  The  young  girl  whose  case  interests  us  here 
had  been  suffering  from  indigestion  since  childhood,  other- 
wise she  had  had  no  serious  illness.  Her  appetite  had  been 
poor,  her  tongue  coated,  and  the  bowels  costive.  In  addi- 
tion, she  had  had  for  a  number  of  years  frequent  attacks 
of  pain  in  the  abdomen,  accompanied  occasionally  by  vomit- 
ing. The  last  five  weeks  before  the  patient  came  to  the 
writer  the  pain  which  was  located  in  the  right  side  of  the 
abdomen  as  the  patient  described  it,  became  constant,  and 
in  the  morning  it  was  very  severe  and  lasted  for  a  few 
hours,  when  a  slight  remission  would  set  in. 

A  physical  examination  of  the  patient  showed  extreme 
tenderness  in  the  McBurney  point,  with  muscular  rigidity 
on  this  side,  and  a  vague  mass  could  be  felt  in  the  right 
side  corresponding  to  the  McBurney  point.  What  this  mass 
was  could  not  be  told  with  certainty,  since  the  patient  was 
neither  operated  nor  autopsied.  In  all  probability  it  was 
nothing  else  than  a  faecal  or  mucous  mass,  and  not  a  sup- 
purative mass,  for  the  patient's  pulse  and  temperature  were 
not  high,  and  there  were  no  signs  of  sepsis. 

The  diagnosis  of  appendicitis  in  this  case  was  made  by 
the  family  itself,  and  a  physician  of  large  practice  whom 
the  patient  consulted  the  same  day  on  which  she  came  to 
me  for  her  trouble  in  question  refused  to  prescribe  any- 
thing for  her  and  urgently  advised  an  immediate  operation. 
Considering,  however,  that  the  patient's  pulse  and  tempera- 
ture were  not  alarming,  the  writer  advised  a  delay  of  two 
or  three  days,  to_  try  the  medical  treatment,  and  if  there 
was  no  improvement  then  an  operation  should  be  per- 
formed. To  the  writer's  great  surprise  all  the  signs  and 
symptoms  disappeared  on  the  third  day,  so  much  so  that 
the  mother  of  the  patient  thought  there  was  something 
wrong  about  the  matter,  as  she  could  not  believe  in  such 
a  quick  recovery  of  such  a  long  standing  affection.  The 
family  thought  that  there  was  magic  in  it,  or  some  char- 
latanism, or  the  patient  was  simulating  for  fear  of  an  op- 
eration in  saying  she  felt  well.  But  the  patient  had  abso- 
lutely no  more  sign  of  appendicitis,  and  the  bowels  which 
had  not  moved  before  without  a  laxative  began  to  move 
daily  by  themselves. 

Such  are  the  histories  of  the  two  cases  which  are 
selected  from  half  a  dozen  cases  treated  medically 
with  success. 

I  shall  now  briefly  describe  the  treatment :  The 
main  point  on  which  the  writer  relies  is  high  intes- 
tinal irrigation.  Many  physicians  unfortunately 
confound  an  enema  with  intestinal  irrigation,  and 
when  they  administer  an  enema  they  imagine  they 
did  an  intestinal  irrigation.  But  there  is  as  much 
likeness  between  the  two  as  there  is  between  an 
emetic  and  gastric  lavage.  The  intestines  should  be 
thoroughly  washed  out,  as  is  done  in  the  case  of  the 
stomach  when  lavage  of  this  organ  is  indicated,  and 
it  must  be  done  by  one  who  knows  how  to  do  it. 
otherwise  failure  will  result.  The  writer  uses  a  long 
rubber  tube,  not  too  hard,  so  as  not  to  cause  any  in- 
jury, and  not  too  soft  so  it  does  not  curl  on  itself. 
Either  a  funnel  or  rubber  ball  aspirator,  like  a  Polit- 
zer  bag,  can  be  used.  With  the  recurrent  catheter 
the  writer  has  no  experience.  The  patient  is  placed 
on  his  right  side,  with  the  buttocks  elevated,  and 
first  the  rectum  is  washed  out,  then  the  tube  is  grad- 
ually pushed  forward,  and  the  irrigation  continued 


till  the  water  comes  back  more  or  less  clear.  No 
great  pressure  should  be  used.  It  is  best  to  use 
some  alkaline  mixture,  of  which  there  are  many  on 
the  market.  The  water  must  be  warm.  In  addi- 
tion the  diet  should  be  strictly  lactoovovegetarian ; 
no  meats  are  to  be  allowed  during  the  disease  and 
some  time  afterwards.  The  writer  has  dealt  else- 
where with  the  effects  of  meat  enhancing  the_  viru- 
lence of  the  coli  bacilli  and  the  general  toxicity  of 
the  alimentary  canal."  Wet  warm  applications,  the 
so  called  Prisnitz  application,  to  the  abdomen  should 
also  be  used,  but  no  ice  bags.  In  view  of  the  suc- 
cessful Bier  treatment  it  is  understood  why  we 
should  use  warm  application  and  produce  hyperaernia 
of  the  affected  parts,  instead  of  anaemia  with  ice 
bags. 

As  to  medication,  appendicitis  is  usually  accom- 
panied by  superacidity  of  the  stomach.  In  hyper- 
chlorhydria  with  oversecretion  there  is  in  fact  gen- 
erally some  tenderness  in  the  appendicial  region, 
frequently  not  sufficiently  marked,  however,  to  diag- 
nosticate it  as  appendicitis.  When  in  a  case  of  ap- 
pendicitis one  finds  it  impossible  to  examine  the  stom- 
ach contents,  one  will  in  the  majority  of  cases  not 
go  astray  by  using  the  alkaline  treatment  as  an  ad- 
juvant. The  writer  usually  finds  the  following  pre- 
scription safe  and  grateful  to  the  patient : 

B    Codeine  sulph.,   gr.  1/6; 

Ext.  bellad.,  gr.  i/io; 

Magnesium  oxide,   ^ss. 

M.  S. :  For  one  powder. 

Such  a  powder  can  be  given  morning  and  even- 
ing, or  three  times  a  day,  as  the  case  may  require, 
for  a  few  days.  When  there  is  improvement  all 
medication  should  be  withdrawn,  except  for  a  short 
time  some  magnesia  ustae  in  the  morning  if  the 
bowels  are  costive.  The  washing  of  'the  intestines 
should  be  done  daily  till  improvement  sets  in.  The 
diet,  however,  should  be  so  regulated  that  the  pa- 
tient should  have  a  daily  evacuation  of  the  bowels 
without  any  medication  at  all.  If  the  stomach  is 
greatly  affected  it  should  receive  due  attention. 

This  is  briefly  the  medical  treatment  of  appen- 
dicitis, and  should  be  tried,  with  the  modifications, 
of  course,  that  each  case  may  require,  in  those  cases 
of  appendicitis  where  there  are  no  urgent  indica- 
tions for  an  immediate  operation,  beforfe  handing  the 
case  over  to  the  surgeon.  Some  enthusiastic  sur- 
geons state  that  it  is  criminal  not  to  urge  an  opera- 
tion for  appendicitis  as  soon  as  the  diagnosis  is 
made;  but  the  writer  of  this  makes  bold  enough  to 
revert  this  assertion,  namely,  that  it  is  criminal  to 
operate  before  rational  medical  treatment  has  been 
tried  and  has  failed,  excepting  those  cases,  of  course, 
where  delay  appears  to  be  dangerous,  and  an  imme- 
diate operation  seems  to  be  urgent,  when,  for  in- 
stance, the  onset  is  accompanied  by  alarming  symp- 
toms, or  there  is  an  abscess  formation.  If  the  physi- 
cian, however,  sees  the  case  early  and  institutes  the 
proper  treatment,  he  will  have  to  refer  to  the  sur- 
geon only  cases  of  the  first  category,  and  will  be 
able  to  avoid  many  complications  of  appendicitis. 
When  the  physician  understands  the  pathology  and 

'See  Intestinal  Bacteria,  Medical  Record,  January  s,  1907;  also 
Experimentelle  Untersuchungen  zur  Bestimmung  der  Toxicitat  des 
Mageninhalts,  der  Milchsaure  und  einiger  Speisen,  Archiv  fur 
Verdanungskrankheiten,  xiv.  No.  3. 


542 


EiJJOTT:  CLIMATES  FOR  CONSUMPTIVES. 


[New  York 
Medical  Journal. 


treatment  of  the  gastrointestinal  canal  he  will  find 
out  that  he  will  have  to  refer  very  few  cases  in  this 
field  to  the  surgeon.  It  is  owing  to  the  fact  that  up 
to  recently  the  physician  had  had  very  little  knowl- 
edge of  the  alimentary  canal  that  the  surgeon  has 
shown  in  it  such  great  activity. 
55  East  Ninety-third  Street. 


CLIMATES  FOR  CONSUMPTIVES. 
By  Edward  Everett  Elliott, 
Chicago. 

In  prescribing  medicines  for  various  diseases  the 
utmost  care  is  used  in  selecting  the  particular  rem- 
edy which  should  be  used  for  each  ailment  in  order 
to  obtain  the  best  and  quickest  result  in  each  indi- 
vidual case.  It  is  generally  admitted  that  for  want 
of  a  quicker  and  more  definite  cure  for  tuberculosis, 
fresh  air  is  the  best  medicine.  The  kind  of  fresh 
air  (medicine)  that  is  to  be  given  each  patient  is  not 
as  a  rule  given  sufificient  consideration  by  the  pro- 
fession at  large.  There  are  of  course  notable  excep- 
tions among  lung  and  throat  specialists  who  have 
made  careful  studies  of  climatic  conditions,  but  the 
great  majority  of  physicians  seem  to  consider  that 
any  kind  of  fresh  air,  if  taken  for  as  nearly  as  pos- 
sible twenty-four  hours  a  day,  is  sufficient  for  any 
patient  or  any  phase  of  the  disease. 

There  are  many  kinds  of  fresh  air,  and  each  of 
them  has  a  different  value  for  different  types  of  the 
disease  or  for  the  different  general  physical  condi- 
tions of  the  patients.  There  is  warm  fresh  air  and 
cold  fresh  air ;  dry  fresh  air  and  moist  fresh  air ; 
clean  fresh  air  and  dust  laden  fresh  air ;  fresh  air  of 
great  altitudes  and  fresh  air  of  the  valleys ;  fresh  air 
that  is  quiet  or  still  most  of  the  time,  and  fresh  air 
that  is  blown' about  in  gales  much  of  the  time.  Most 
of  these  conditions  may  be  helpful  to  some  patients 
and  positively  harmful  to  others ;  a  tuberculous  pa- 
tient may  do  well  in  some  of  these  conditions  and 
lose  ground  in  others.  The  placing  of  the  patient  in 
the  proper  atmosphere  for  his  particular  condition 
immediately  upon  the  discovery  of  the  disease  is  of 
the  very  utmost  importance,  and  yet  any  one  who 
has  personally  visited  or  lived  in  the  different  health 
resorts  or  sections  in  widely  different  parts  of  the 
country  cannot  but  be  surprised  and  frequently 
shocked  to  find  the  large  number  of  sufferers  from 
this  disease  who  are  improperly  placed  for  their 
particular  condition — who  are  not  doing  well  or  who 
are  actually  losing  ground,  largely  because  that  par- 
ticular situation,  that  kind  of  fresh  air,  is  not  suited 
to  their  phase  of  the  disease  or  their  general  physical 
or  mental  condition.  This  is  so  frequently  the  case 
that  one  is  forced  to  believe  that  it  is  due  either  to 
lack  of  information  regarding  climatic  conditions  or 
to  an  insufficient  study  of  the  individual  patient. 

In  most  affairs  of  life  the  average  man  is  com- 
petent to  make  independent  decisions  for  himself 
and  to  correct  his  errors  when  he  finds  himself  in 
the  wrong,  but  when  a  patient  has  once  been  placed 
by  his  physician  he  feels  powerless  to  move  even  if 
be  has  the  strongest  suspicion  that  he  is  not  placed 
to  the  best  advantage ;  and  the  cases  where  he  is  ad- 
vised by  the  local  physician  to  try  a  more  suitable 
climate  are  very  rare.  The  original  placing  of  the 
invalid  in  the  kind  of  fresh  air  that  his  particular 


condition  requires  is  therefore  of  the  greatest  im- 
portance. To  be  sure,  one  cannot  absolutely  know 
that  he  is  fitting  every  case  with  the  right  locality, 
but  there  should  be  sufficient  information  on  the 
part  of  the  physician  to  approximate  a  correct  de- 
cision. The  very  wide  divergence  of  climatic  condi- 
tions within  the  United  States  makes  it  possible  to 
place  almost  all  cases  of  pulmonary  tuberculosis  in 
the  right  kind  of  fresh  air  to  give  them  permanent 
benefit.  The  home  physician  should  insist  that  if 
the  patient  does  not  show  substantial  gains  within  a 
reasonable  length  of  time  he  should  be  given  a  rad- 
ical change  without  delay.  When  patients  are  prop- 
erly placed  in  climates  different  from  the  home  cli- 
mates they  usually  respond  very  quickly. 

The  Warm,  Dry  Air  of  the  Desert. — The  section 
of  the  Southwest  which  is  recognized  as  of  value 
from  a  health  standpoint  is  nearly  all  within  the 
boundaries  of  Arizona  and  New  Mexico.  (On  ac- 
count of  the  constant  agitation  against  tuberculosis 
people,  Texas  should  not  be  included.)  This  section 
should  be  divided  into  two  parts,  the  northern  por- 
tions of  both  Territories  being  mountainous  and  of 
varying  altitudes,  while  the  southern  portions  are 
of  low  altitudes  and,  mere  properly  speaking,  des- 
ert country.  It  is  of  this  southern  section  that  I 
speak  when  referring  to  the  Desert  of  the  Southwest. 

The  air  of  this  section,  during  that  portion  of  the 
\ear  that  is  not  too  hot  for  comfort — that  is,  from 
October  ist  to  June  ist — is  exceedingly  dry  and 
agreeably  warm.  There  are  few  cold  or  rainy  days, 
and  life  out  of  doors  is  decidedly  comfortable.  There 
are  a  few  frosts  every  winter,  but  no  ice  or  snow. 
The  sun  shines  a  large  part  if  not  all  of  every  day. 
It  is  in  this  section  that  people  who  for  various  rea- 
sons are  badly  run  down  in  strength  and  vitality 
make  the  quickest  gains.  The  very  minimum  of  re- 
sistance to  nature  is  required  to  live  comfortably. 
For  this  reason  patients  whose  condition  has  become 
low  through  sickness  preceding  tuberculosis,  for  in- 
stance, pneumonia,  or  by  overwork  or  nervous  strain 
usually  respond  very  quickly  in  .this  warm,  dry,  pure 
fresh  air.  It  is  no  hardship  to  live  out  of  doors  for 
practically  the  entire  twenty-four  hours.  The  great- 
est effort  required,  beyond  the  ordinary  requirements 
of  life,  is  to  keep  out  of  the  sunshine — to  keep  mov- 
into  the  shade.  It  is  possible  to  get  the  maximum 
of  fresh  air  with  the  minimum  of  effort  or  resistance 
to  nature.  There  is  seldom  any  excuse  for  closed 
windows  night  or  day,  as  one  quickly  becomes  ac- 
customed to  the  open  fresh  air,  and  a  closed  room 
becomes  distasteful.  Patients  living  in  this  climate 
are  therefore  more  nearly  sure  of  breathing  good  air 
twenty-four  hours  every  day  than  in  severer  cli- 
mates. There  is  also  the  least  danger  of  reinfection 
or  contamination,  for  there  is  no  occasion  for  hud- 
dling people  together  on  porches  or  in  closed  living 
rooms,  and  even  the  danger  of  boarding  house  life 
through  too  close  contact  can  be  avoided  by  the  use 
of  separate  tents  or  tent  cottages.  This  is  a  very 
frequent  and  usually  the  best  method  of  living. 

It  is  far  from  uncommon  for  patients  to  gain  rap- 
idly twenty-five,  thirty,  or  more  pounds  within  a 
comparatively  short  time.  The  effect  of  the  atmos- 
phere is  relaxing  and  not,  owing  to  its  dryness,  en- 
ervating ;  one  can  easily  become  lazy  while  still  per- 
fectly capable  of  effort. 


March  13,  1909.  J 


ELLIOTT:  CLIMATES  FOR  CONSUMPTIVES. 


543 


The  objection  to  this  region  is  the  dust,  but  this 
can  usually  be  avoided  by  using  care  in  the  selection 
of  the  locality  of  the  living  place.  Main  streets  and 
main  traveled  roads  are  apt  to  produce  much  dust  in 
dry  countries.  The  summer  months  in  this  region 
are  insupportable.  From  June  ist  to  October  ist 
the  heat  is  too  intense  for  health  or  comfort.  Dur- 
ing this  period  patients  should  go  to  higher  altitudes 
farther  north,  either  to  northern  Arizona,  northern 
New  Mexico,  Colorado,  or  of  course  to  their  homes 
if  the  physician  deems  it  best. 

This  climate  will  not  perform  miracles  any  more 
than  any  other — it  will  often  work  wonders,  how- 
ever. Patients  in  the  last  stages  of  the  disease 
should  not  be  sent  there  or  to  any  other  place  far 
from  home.  Also,  patients  whose  cases  are  clearly 
incipient  and  whose  strength,  weight,  and  vitality 
have  not  been  materially  reduced  do  not  require 
the  peculiar  benefits  of  this  atmosphere  and  can  often 
do  as  well  or  better  in  climates  more  rigorous,  more 
invigorating,  and  perhaps  more  like  their  home  con- 
ditions. 

The  clear,  clean  cold  air  of  the  mountains,  either 
in  the  West  or  especially  in  the  Adirondacks,  will 
often  act  as  quickly  and  possibly  more  thoroughly 
than  desert  air. 

The  Cold,  Pure  Air  of  the  Mountains. — The  win- 
ter months  in  the  mountains,  whether  of  very  high 
altitude  or  not,  are  necessarily  severe,  including  often 
intense  cold  with  much  snow  and  usually  frequent 
high  winds.  This  is  the  case  not  only  in  the  Rocky 
Mountain  section — northern  Arizona,  New  Mexico, 
and  Colorado — but  in  the  Adirondacks  as  well.  The 
weather  hovers  around  zero  (often  many  degrees 
below)  for  months  in  succession,  while  blizzards 
sometimes  lasting  for  days  are  not  infrequent.  This 
period  is  also  interrupted  more  or  less  frequently  by 
thaws  and  warm  rains  lasting  usually  but  a  short 
time,  but  bringing  great  changes  in  temperature  and 
atmospheric  conditions ;  changes  of  fifty,  sixty,  and 
even  more  degrees  in  from  twenty-four  to  thirty-six 
hours  are  not  unknown  every  year. 

Now,  it  must  be  granted  that  indoor  air  is  of 
pretty  much  the  same  value  whether  it  be  on  the 
desert  or  in  the  mountains.  Closed  windows  and 
doors  produce  the  same  quality  of  air  in  the  most 
favored  health  resort  as  in  New  York  City  or  Chi- 
cago. For  this  reason  the  tuberculous  patient  must 
keep  the  windows  of  his  room  open  constantly  (ex- 
cept when  bathing  or  dressing),  no  matter  what  the 
temperature  may  be ;  he  must  be  as  nearly  as  possi- 
ble in  the  open  air  for  twenty-four  hours  of  each  day, 
sleeping  or  waking,  no  matter  if  the  temperature  is 
forty  degrees  below  zero. 

For  patients  whose  strength,  weight,  and  vitality 
have  not  been  considerably  reduced,  living  under 
these  conditions  is  possible  without  injury  and  often 
with  positive  benefit.  Incipient  cases,  where  the  dis- 
ease has  been  detected  before  great  inroads  have 
been  made  on  the  resisting  power  or  cases  of  long 
standing,  where  the  conditions  of  the  patient  as  re- 
gards weight  and*  strength  have  been  raised  up  to 
or  beyond  normal  in  milder  climates,  are  often  com- 
pletely arrested  if  not  positively  cured  under  these 
climatic  conditions.  But  the  physical  and  mental 
condition  of  the  patient  must  be  equal  or  superior  to 
such  rigorous  treatment,  or  positive  injury  is  the  re- 


sult. The  healing  value  of  cold,  more  or  less  in- 
tense, can  only  demonstrate  itself  where  there  is 
force  enough  in  the  patient,  mentally  and  physically, 
to  rise  above  conditions  that  would  frighten  the  aver- 
age well  man.  Slight  elevations  of  temperature  are 
often  reduced  or  entirely  cease  amid  proper  condi- 
tions in  cold  weather,  but  with  high  fevers  in  weak- 
ened (bed)  patients  the  effect  is  usually  the  contrary. 
The  weak  patient  dreads  the  cold,  whether  dressed 
or  in  bed,  night  or  day.  The  necessary  discomfort 
at  times,  combined  with  the  nervous  tension  and  dis- 
tress, has  exactly  the  contrary  effect  to  that  intended 
by  the  physician  originally  handling  the  case.  If 
you  were  to  ask  one  of  your  healthy,  robust  friends 
to  sit  quietly  in  the  open  air  with  the  temperature 
around  zero  for  eight  or  ten  hours  a  day  and  sleep 
out  of  doors  or  with  open  windows,  so  that  every- 
thing in  the  room  would  freeze  solid  at  night,  what 
would  he  think  of  you?  Have  you  ever  tried  it 
yourself?  Of  course,  the  instruction  is  to  put  on 
clothing  or  blankets  enough  to  keep  one  warm,  but 
while  this  is  possible  for  strong,  full  blooded  people, 
it  is  often  not  successful  with  patients  whose  strength 
and  vitality  have  been  considerably  reduced  by  the 
disease.  The  frequent  result  is  that  such  invalids, 
contrary  to  instructions,  remain  in  warm,  closed 
rooms  as  much  as  possible.  This  is  controlled  in 
some  sanatoria,  but  the  number  of  people  so  gov- 
erned is  limited. 

In  other  words,  for  patients  whose  physical  condi- 
tion is  strong  enough  to  withstand  the  hardships  of 
intense  cold  weather  without  suffering  in  mind  or 
body,  the  bracing,  clear  pure  air  of  the  mountains 
(the  western  mountains  or  particularly  the  Adiron- 
dacks on  account  of  their  lower  altitude)  is  un- 
doubtedly beneficial.  One  cannot  but  be  surprised 
at  the  number  of  apparently  robust,  red  cheeked, 
sprightly  moving  patients  seen  constantly  in  these 
severe  climates.  They  often  look  the  picture  of 
health,  but  they  are  all  there  for  a  very  good  reason. 

But  for  patients  who  are  much  reduced  in  weight, 
strength,  and  vitality,  these  severe  climates  are  fre- 
quently harmful  or  fatal.  They  should  never  be  sent 
to  such  places,  or  if  they  have  been  sent,  the  error 
should  be  quickly  corrected.  There  are  hundreds  of 
patients  tucked  away  out  of  sight  during  very  cold 
weather  who  cringe  and  shiver  at  the  thought  of 
exposure  to  the  cold.  Careful  watching  would  dis- 
cover this  condition  before  it  is  too  late  to  make  a 
decided  change.  -The  physician  should  have  nerve 
and  independence  enough  to  compel  a  change  to  a 
milder  climate  at  the  first  appearance  of  such  a  men- 
tal state.  Many  lives  might  be  saved  or  pleasurable 
existence  prolonged  by  such  radical  treatment.  This 
does  not  apply,  of  course,  to  the  time  from  June  to 
October  in  most  mountain  sections  (provided  the 
altitude  is  not  too  high),  for  then  the  weather  con- 
ditions are  delightful  and  highly  beneficial. 

The  climate  of  California  has  ceased  to  be  gener- 
ally considered  as  beneficial  for  asthmatic,  bronchial, 
or  pulmonary  troubles.  The  fogs,  dust,  chill  winds, 
and  rainy  season,  which  among  them  cover  most  of 
the  year,  render  that  section  dangerous  for  any  but 
possibly  the  most  robust  patients. 

One  of  the  most  frequent  dangers  to  patients  who 
have  been  sent  to  sections  far  removed  from  their 
homes  is  their  impatience  to  return  (especially  if 


544 


CORRESPONDENCE. 


[New  York 
Medical  Journal. 


they  have  done  very  well)  as  soon  as  the  first  few 
days  of  hot  or  cold  weather  arrive.  In  the  South- 
west, when  the  weather  becomes  very  warm,  usually 
in  April,  they  insist  on  returning  to  the  raw  air  of 
the  North.  In  the  mountains  they  want  to  run  away 
with  the  first  evidence  of  snow  or  cold.  This  could 
often  be  obviated  if  the  home  physician  held  a 
stronger  control  over  the  patient  in  his  absence. 
They  will  not  heed  the  advice  of  the  local  physician, 
whose  control  over  them  is  not  so  strong  as  that  of 
their  home  adviser.  A  quick  gain,  a  quick  return  to 
their  homes,  and  a  quick  return  of  the  trouble  is  the 
frequent  history  of  this  disease. 

The  conclusions  arrived  at  herein  are  the  result  of 
long,  careful  study  of  the  various  sections  of  the 
country  to  which  tuberculous  people  are  consigned, 
and  are  entirely  unbiased  by  personal  reasons  or  re- 
sults. They  are  the  result  of  observations  made  of 
a  large  number  of  sufferers  in  various  conditions  and 
in  widely  different  climates.  Statistics  are  often 
very  deceptive;  unprejudiced  personal  observation  is 
often  more  trustworthy. 

 ^  


LETTER  FROM  LONDON. 

The  Huntcrian  Oration. — A  Large  Gift  to  the  London  Hos- 
pital.— The  Report  of  the  Poor  Law  Commission. — The 
Legal  Status  of  Anasthetizers. 

London,  February  23,  igog. 
February  15th  was  a  red  letter  day  in  the  annals 
of  the  Royal  College  of  Surgeons  of  England.  On 
that  day  their  Royal  Highnesses  the  Prince  and 
Princess  of  Wales  visited  the  college,  and  the  Prince 
was  elected  an  honorary  fellow.  He  was  handed  the 
diploma  by  the  president  and  duly  signed  the  roll. 
He  then,  with  the  Princess,  proceeded  to  the  theatre 
to  hear  the  Hunterian  oration  delivered  by  Mr. 
Henry  Morris,  the  president.  The  oration  was  en- 
titled John  Hunter  as  a  Philosopher,  and  this  was 
the  sixty-fifth  occasion  on  which  the  memory  of 
John  Hunter,  his  life  and  work  had  been  similarly 
honored. 

The  oration  was  of  extreme  interest.  Dealing 
with  Hunter's  method  of  inquiry,  Mr.  Morris  said 
that  he  combined  in  an  exceptional  degree  the  two 
philosophic  methods,  deduction  and  induction. 
Though  born  and  brought  up  in  Scotland,  where  in 
his  day  the  deductive  method  of  reasoning  prevailed, 
Hunter  very  largely  used  the  inductive  method, 
which  has  been  characteristic  of  English  thought 
since  Bacon.  His  employment  of  the  inductive 
method  is  illustrated  by  his  attempt  to  explain 
congenital  defects  by  a  reference  to  transitory 
structures  and  the  metamorphoses  of  foetal  life,  as 
in  the  case  of  congenital  hernia,  which  arises  from 
the  failure  of  the  peritoneal  process  to  become  shut 
off  from  the  peritoneal  cavity.  Other  instances  of 
his  use  of  induction  are  his  scheme  for  the  classifi- 
cation of  monstrosities,  based  on  the  disposition 
which  every  species  of  animal  and  every  part  of  the 
animal  body  has  to  deviate  from  nature  in  a  manner 
peculiar  to  itself;  his  instructions  to  Jenner  as  to 
how  he  should  ascertain  whether  color  blindness 
was  due  to  a  general  defect  or  to  a  failure  to  appre- 


ciate the  usual  impressions-  made  by  the  primary 
colors ;  his  patient  and  careful  dissection  of  so  many 
hundreds  of  different  species  of  animals  and  of  so 
many  animals  of  the  same  species ;  his  numerous  ob- 
servations of  plants ;  and  his  untiring  investigations 
of  the  diversities  of  structures  and  organs  in  order 
to  arrive  at  accurate  conclusions  as  to  what  struc- 
tures and  organs  are  necessary  for  the  performance 
of  different  functions.  As  a  result  of  these  dissec- 
tions and  observations  he  pointed  out  the  conditions 
which  characterized  groups  of  animals,  classifying 
them  according  to  their  hearts,  their  nervous  sys- 
tems, their  stomachs.  In  this  he  anticipated  Cuvier. 
Following  the  induction  method,  he  trusted  to  noth- 
ing but  his  own  observations  and  to  testing  his  ideas 
by  the  most  varied  and  exact  experiments.  His 
treatise  on  Bees  is  an  admirable  illustration  of  this. 
It  was  chiefly  by  induction  that  he  concentrated  the 
scattered  facts  of  comparative  anatomy  and  thereby 
advanced  the  progress  of  physiological  science. 
Hunter  was  at  once  a  collector  of  facts  and  an  in- 
terpreter of  them.  In  the  evening,  after  the  lecture, 
the  president  and  council  entertained  a  large  party 
of  friends  and  persons  of  distinction  at  the  Hun- 
terian Festival  Dinner. 

It  will  be  remembered  that  an  announcement  was 
recently  made  to  the  effect  that  an  anonymous  ben- 
efactor had  given  £20,000  to  the  London  Hospital, 
with  the  reservation  that  the  interest  of  this  sum 
should  be  solely  applied  to  the  advancement  of  med- 
ical research  at  that  institution.  This  munificent 
gift  has  now  been  placed  in  the  hands  of  the  trus- 
tees of  the  London  Hospital  Medical  College  En- 
dowment Fund,  Mr.  Douro  Hoare,  the  Hon.  Harry 
Lawson,  and  Sir  Frederick  Treves,  the  administer- 
ing trustees  being  the  Hon.  Sydney  Holland,  chair- 
man of  the  London  Hospital,  and  Dr.  Bertrand  Daw- 
son and  Dr.  Henry  Head,  physicians  to  the  hospital. 
It  has  been  stipulated  that  under  these  circum- 
stances the  money  should  not  be  used  for  routine 
teaching  in  the  medical  school.  In  connection  with 
the  administration  of  this  fund  the  London  Hospital 
Gazette  states  that  its  administrators  will  invite  ex- 
pressions of  opinion  from  the  various  heads  of  de- 
partments and  will  consider  the  claims  and  sug- 
gestions of  individuals.  The  gift  will  thus  form  the 
nucleus  of  the  endowment  fund  at  the  London  Hos- 
pital which  it  is  hoped  will  soon  be  raised  so  as 
to  place  medical  research  at  that  important  institu- 
tion on  a  satisfactory  financial  footing.  At  present, 
as  is  well  known,  many  able  young  men  cannot  af- 
ford to  spend  time  in  medical  research  after  they 
have  gained  their  qualifications  to  practise,  which  is 
of  course  the  primary  object  of  their  hospital  train- 
ing. By  providing  some  of  the  more  brilliant  of  the 
hospital  students  with  an  adequate  income  after 
qualification,  on  condition  that  they  devote  their 
time  to  the  furtherance  of  medical  knowledge,  the 
able  services  of  many  will  be  retained  at  the  hos- 
pital instead  of  being  lost  in  the  ranks  of  the  general 
practitioners,  who  of  course  have  little  time  for  re- 
search. The  total  sum  required  to  endow  the  Lon- 
don Flospital  Medical  College  completely  and  free 
it  from  debt  is  at  least  £150.000. 

A  very  important  document  has  just  been  pub- 
lished which  will  largely  affect  medical  men  in  Eng- 
land. This  is  the  report  of  the  Poor  Law  Commis- 
sion.   There  are  really  two  reports,  a  majority  and 


March  13.  I909-J 


THERAPEUTICAL  NOTES. 


545 


a  minority  report,  but  both  are  agreed  as  to  the  ne- 
cessity of  certain  drastic  changes  in  the  existing 
conditions.  Both  reports  recommend  the  aboHtion 
of  boards  of  guardians.  The  majority  proposes  to 
set  up  in  their  place  a  statutory  committee  of  the 
county  council  or  county  borough  council,  to  be 
called" the  Pubhc  Assistance  Authority,  consisting  as 
to  one  hali  of  members  of  the  council  and  as  to  the 
other  of  persons  experienced  in  the  local  system  of 
rehef  appointed  by  the  council  from  outside.  This 
authority  Ayould  set  up  and  supervise  public  assist- 
ance committees,  the  areas  of  which  \vould  at  first 
be  the  existing  union  areas.  The  recommendation 
of  the  minority  report  is  very  similar  and  proposes 
that  the  county  and  the  county  borough  councils, 
strengthened  in  numbers  for  their  enlarged  duties, 
should  replace  the  boards  of  guardians  and  become 
the  destitution  authorities  for  the  counties  and 
should  appoint  education,  health,  asylum,  and  pen- 
sion committees.  Both  the  majority  and  minority 
recognize  the  necessity  for  the  classification  of  per- 
sons, whether  children,  aged,  sick,  able  bodied, 
vagrant,  or  feebleminded,  and  that  to  make  indoor 
relief  effective  it  should  be  given  in  separate  insti- 
tutions to  the  various  classes.  One  of  the  principal 
points  of  difference  between  the  m.ajority  and  the 
minorit}-  reports  is  with  regard  to  medical  relief. 
The  majority  recom.mend  that  medical  assistance 
should  be  reorganized  on  a  provident  basis.  It 
would  be  the  duty  of  the  Public  Assistance  Author- 
ity to  coordinate  and  if  necessary  to  supplement  ex- 
isting medical  institutions  and  to  suggest  methods 
of  cooperating  with  the  sanitary  authorities  and 
with  voluntary  hospitals.  It  would  also  be  its  duty 
to  organize  an  outdoor  provident  medical  service 
easily  accessible  from  all  parts  of  the  county  or 
county  borough  and  to  include  the  provision  of 
competent  midwives ;  to  develop  a  nursing  service, 
preferably  in  connection  with  voluntary  nursing  as- 
sociations to  subscribe  towards  these  purposes,  and 
to  supervise  and  report  on  the  efficiency  and  ade- 
quacy of  the  medical  institutions  and  medical  ser- 
vice in  the  county  or  count)^  borough.  A  medical 
assistance  committee  would  be  appointed  from  the 
members  of  the  Public  Assistance  Authority,  with 
powers  to  cooperate  with  representatives  of  local 
hospitals,  nursing  associations,  dispensaries,  and 
registered  friendly  societies.  The  public  assistance 
authority,  acting  in  conjunction  with  the  local  medi- 
cal assistance  committee,  would  organize  medical 
relief  both  with  regard  to  in  patients  and  out  pa- 
tients. The  commissioners  recommend  that,  with  a 
view  of  enlisting  the  services  of  medical  practition- 
ers in  the  locality  of  a  provident  dispensary,  the 
British  INIedical  Association  should  be  requested  to 
suggest  a  general  scheme  or  scale  of  fees  and  wage 
limit  to  be  applied  by  its  local  divisions  as  local  cir- 
cumstances may  suggest.  The  minority,  however, 
condemn  this  provident  scheme  of  the  majority,  for 
the  reason,  they  say,  that  it  would  lead  to  an  ex- 
travagant expenditure  of  public  funds  without  ob- 
taining in  return  greater  regularity  of  life  or  more 
hygienic  habits  in  the  patients.  The  whole  report 
will  no  doubt  be  duly  considered  when  a  bill  is 
brought  into  Parliament,  and  the  suggestions  of  the 
commissioners  will  come  in  for  a  full  discussion. 

The  final  decision  of  the  London  anaesthetists  as 
to  the  proposed  alterations  in  the  existing  law  relat- 


ing to  the  administration  of  anaesthetics  has  at  last 
been  arrived  at  and  is  expressed  in  a  resolution 
passed  at  their  recent  meeting  to  the  effect  that  "the 
Council  of  the  Royal  Society  of  Medicine  be  in- 
formed that  the  section  of  anaesthetics  approves  of 
legislation  to  restrict  the  administration  of  anaes- 
thetics to  legally  quahfied  medical  practitioners." 
Such  legislation  would  obviously  exclude  dentists 
from  being  allowed  to  give  nitrous  oxide  gas.  It 
is  probable  that  the  representatives  of  the  dental 
profession  in  London  will  make  a  strong  protest 
against  such  a  course  of  events. 

 <^  


The  Therapeutics  of  Tincture  of  Veratrum 

Viride. — Attention  is  called  in  an  article  by  J.  S. 
Todd  {Therapeutic  Gazette,  February  15)  to  the 
neglect  into  which  veratrum  viride  has  fallen.  The 
author  refers  to  Norwood's  tincture,  the  tincture  of 
veratrum  viride  as  prepared  by  the  Shakers  at 
Mount  Lebanon,  N.  Y.,  according  to  the  formula 
given  by  Dr.  Norwood,  of  Cokesbury,  S.  C.  He 
speaks  of  the  drug  as  being  not  only  a  cardiac  de- 
pressant but  a  vasodilator,  and  says  it  is  best  admin- 
istered in  doses  of  13^  minims,  or  three  ordinary 
drops,  generally  at  three  hours  intervals.  Dr.  Todd 
says  it  is  important  to  bear  the  dose  in  mind,  as  the 
doses  directed  in  the  textbooks  are  from  five  min- 
ims (ten  drops)  to  thirty  minims  (sixty  drops). 
If  too  much  depression  is  caused  1/20  grain  of 
morphine,  three  minims  of  laudanum,  or  half  a 
drachm  of  paregoric  may  be  given  with  each  dose. 
As  regards  its  poisonous  action  and  the  antidote  to 
it,  he  says  that  but  one  antidote  is  needed,  and  that 
is  a  hypodermic  injection  of  morphine  which  will 
overcome  the  depressing  eft'ect  of  veratrum  viride 
almost  as  quickly  as  an  alkali  neutralizes  an  acid. 
It  is  obvious,  therefore,  that  veratrum  may  be  used 
as  an  antidote  in  the  treatment  of  opium  poisoning, 
as  the  author  has  previously  pointed  out  {American 
Journal  of  the  Medical  Sciences,  January.  1874). 
The  author  employs  veratrum  in  combination  with 
other  drugs  in  the  treatment  of  certain  heart  dis- 
eases, and  all  troubles  where  there  is  increased 
blood  pressure,  arteriosclerosis,  or  calcarious  de- 
generation of  the  arteries.    He  usually  employs  the 


following  prescription : 

I*    Tincture  of  veratrum  viride  (Norwood),.  ..  .TTtxlv ; 
Pulverized  digitalis, 

Pulverized  squill,   aa  5ss; 

Strychnine  nitrate  gr.  ss; 

Pulverized  ginger  3i. 

Mix  and  divide  into  thirty  capsules. 


Sig. :  One  every  four,  six,  eight,  or  twelve  hours,  as 
needed. 

Bonain's  Local  Anaesthetic. — The  formula  for 
this  compound  has  been  modified  by  Dr.  Bonain  so 


as  to  read  as  follows  : 

R    Carbolic  acid  crystals,   gr.  xv; 

Menthol,  gr.  xv; 

Cocaine  hydrochloride,   gr.  xv; 

Adrenine  hj-drochloride,   gr.  1/64. 


In  preparing  this  mixture  it  is  advised  to  first 
liquefy  the  carbolic  acid  and  menthol  in  a  porcelain 
capsule  by  the  heat  of  a  water  bath,  and  then  dis- 
solve in  this  liquid  the  cocaine  hydrochloride  and 
adrenaline  hydrochloride. 


546 


THERAPEUTICAL  NOTES. 


[New  York 
Medical  Journal. 


The  Treatment  of  Diabetes. — in  a  locture  by  O. 
Rozenraad  on  the  treatment  of  glycosuria  and  dia- 
betes at  the  London  Polydinic,  which  is  noticed  in 
folia  Therapeutica  for  January,  1909,  it  is  re- 
marked that  the  only  drugs  recommended  for  use 
in  the  treatment  of  diabetes  are  codeine  and  opium. 
The  question  of  proper  dieting  is  most  important, 
and  the  custom  has  lately  sprung  up  in  Germany 
of  treating  diabetes  in  nursing  homes.  For  the  first 
two  days  patients  are  kept  on  their  ordinary  diet,  to 
ascertain  the  amount  of  sugar  produced.  Then  the 
quantity  of  bread  for  the  next  two  or  three  days  is 
reduced  to  one  hundred  grammes,  and  the  propor- 
tion of  sugar  excreted  is  estimated.  If  it  is  found 
necessary  to  withdraw  all  starchy  food,  and  sugar 
still  persists,  the  prognosis  is  obviously  serious, 
but  it  is  bad  practice  to  withhold  for  any  length 
of  time  all  carbohydrates.  The  patient  should 
be  allowed  fifty  to  seventy  grammes  of  bread 
daily,  but  once  a  week  his  diet  should  con- 
sist exclusively  of  vegetables  and  eggs.  When 
a  patient  is  excreting  acetone  as  well  as  sugar, 
the  diet  should  be  arranged  as  follows :  Two 
days  "standard  diet,"  without  bread ;  two  days 
vegetables  with  eggs  only;  three  days  oatmeal,  250 
grammes,  with  200  grammes  of  butter ;  six  to  eight 
eggs  with  some  Burgundy  or  light  Moselle ;  two 
vegetable  days,  and  then  a  return  to  the  "standard 
diet."  The  following  is  the  ''standard  diet" :  At 
8  a.  m.  seven  ounces  of  coffee  or  tea,  with  two 
tablespoons  thick  cream,  five  ounces  meat,  with 
plenty  of  butter,  1%  ounces  bread;  10  o'clock  a  cup 
of  bouillon  or  a  glass  of  Burgundy  and  two  eggs. 
I  o'clock,  meat,  with  about  eight  ounces  vegetables 
such  as  spinach,  cauliflower,  or  asparagus,  with 
plenty  of  butter,  ounces  cheese,  one  glass  Mo- 
selle, and  ounces  wheat  bread.  At  5  o'clock, 
plain  cup  of  tea.  At  7  o'clock  cold  meat,  three  ounces 
salad  with  oil,  some  eggs,  and  one  glass  Moselle. 
If  diabetic  coma  has  supervened,  the  heart  must 
be  stimulated  by  whisky  or  champagne.  The  latter 
is  well  absorbed  by  the  gastric  mucous  membrane, 
and  large  amounts  of  sodium  bicarbonate  can  be 
put  into  it.  After  two  days  of  this  alkaline  treat- 
ment, levulose  should  be  given.  Rectal  injections 
are  most  efficient  for  this,  and  the  diet  should  con- 
sist of  milk,  bouillon,  or  oatmeal.  If  the  comatose 
stage  is  not  overcome  within  two  days,  the  case  is 
generally  fatal.  The  onset  of  diabetic  coma  is  often 
heralded  by  gastric  troubles,  with  an  unexplained 
feeling  of  restlessness  and  fatigue.  But  it  may 
come  on  with  absolute  suddenness. 

The  Proper  Method  of  Employing  Quinine. — 

In  cases  of  malaria  and  tertian  and  quartan  ague 
and  in  the  sHghter  cases  of  the  relapsing  pernicious 
form,  Professor  H.  Ziemannf  who  writes  in  Folia 
Therapeutica  for  January,  1909,  insists  upon  the 
necessity  of  energetic  and  speedy  treatment  by 
hypodermic  injection,  as  quinine  given  by  the  mouth 
is  nearly  always  rejected.  The  most  readily  soluble 
preparation  of  quinine,  such  as  the  carbamide  di- 
hydrochloride  (quinine  and  urea  hydrochloride) 
should  be  selected.  When  he  made  his  first  trials 
with  the  injection  of  a  solution  of  this  sort  in  1894 
he  injected  it  subcutaneously,  but  abandoned  this 


for  the  intramuscular  method  after  he  had  had 
some  disagreeable  experiences  connected  with  sores 
caused  by  the  needle.  Injecting  the  solution  intra- 
muscularly as  is  done  with  sublimate  in  the  Lewins 
injection  cure  he  has  had  the  most  splendid  success. 
His  method  of  operating  is  to  boil  a  Record  sy- 
ringe, capable  of  containing  four  cubic  centimetres, 
as  well  as  a  cannula  in  a  test  tube,  with  .the  open- 
ing directed  downward.  The  water  is  then  poured 
ofif,  the  syringe  is  removed  with  a  pair  of  sterile 
forceps,  and  the  cannula  is  fixed  on ;  then  a  sealed 
glass  tube  (ampoule)  containing  fifteen  grains  of 
the  carbamidated  quinine  dihydrochloride  in  fifteen 
minims  of  water  is  broken  at  the  apex,  and  the  con- 
tents sucked  up  by  the  cannula.  Then  three  cubic 
centimetres  of  sterile  water  are  sucked  up,  at  a 
temperature  of  about  40°  C,  by  the  syringe.  The 
sterile  solution  of  quinine  is  then  mixed  with  the 
sterile  water  by  raising  and  depressing  the  syringe, 
the  piston  is  pushed  in,  till  the  quinine  solution  be- 
gins to  issue  from  the  cannula,  and  the  whole  con- 
tents of  the  syringe  introduced  vertically  into  the 
middle  of  one  of  the  gluteus  maximus  muscles. 
Qnly  in  the  rarest  cases  did  he  find  a  slight  burning 
at  the  seat  of  injection.  The  action  of  quinine  in- 
troduced in  this  way  is  said  to  be  prompt  and  pow- 
erful, and  the  author  has  used  it  even  in  the  case 
of  little  children,  with  the  greatest  success. 

A  Hitherto  Unobserved  Effect  of  Cyanide 
Fumes. — In  a  communication  to  the  Therapeutic 
Gazette,  for  February  15,  J.  W.  Nolan,  a  physician 
of  a  mining  company,  calls  attention  to  the  circum- 
stance that  men  who  are  exposed  to  the  emana- 
tions from  potassium  cyanide  in  gold  reduction 
plants  never  suffer  from  cold,  coryza,  or  cough 
■from  any  cause.  Acting  upon  this  observation  he 
has  been  using  a  solution  of  cyanide  in  a  wide 
mouthed  jar,  placed  in  the  room  of  patients  suffer- 
ing with  cough  from  phthisis.  The  jar  is  left  un- 
corked and  the  patient  breathes  the  cyanide  charged 
air  "with  great  benefit." 

The  Therapeutic  Action  of  Calcium  Salts. — A 

note  in  Folia  Therapeutica  for  January,  1909,  di- 
rects attention  to  the  work  of  Sir  Almroth  Wright 
on  the  therapeutic  action  of  calcium  salts.  Accord- 
ing to  Wright's  observations  the  time  honored  milk 
diet  to  which  acute  invalids  are  submitted  as  a  mat- 
ter of  routine  is  a  direct  invitation  to  the  onset  of 
thrombosis,  owing  to  the  large  amount  of  calcium 
present  in  such  a  diet.  It  is  well  known  that  cal- 
cium salts  are  deeply  concerned  in  the  coagulation 
of  blood.  But  excessive  decalcification  is  also  at- 
tended by  evils.  Wright  himself  found  that  as  a 
boy  he  sulfered  from  aggravated  attacks  of  giant 
urticaria  when  he  partook  of  acid  fluids.  The  ex- 
planation was  that  the  coagulability  of  the  blood 
was  diminished,  and  as  a  consequence  serum  ex- 
uded from  the  blood  vessels  into  the  lymph  spaces. 
This  serous  exudation  is  held  to  account  for  urti- 
caria, chilblains,  functional  albuminuria,  angio- 
neurotic oedema,  and  certain  forms  of  headache. 
These  various  conditions  are,  therefore,  rationally 
treated  by  administering  such  a  salt  as  calcium  lac- 
tate in  doses  of  fifteen  grains  thrice  daily. 


March  13,  1900.] 


EDITORIAL  ARTICLES. 


547 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK,  SATURDAY,  MARCH  13,  1909. 


HEREDITY  IX  ^lAN. 

There  are  few  problems  so  fascinating  as  that  of 
heredity  in  man.  Tor  ages  men  have  applied  their 
knowledge  of  heredity  in  animals  to  improving  the 
breed  or  to  producing  strains  adapted  to  certain  par- 
ticular purposes.  Quite  empirically  man  has  ar- 
rived at  a  point  where  the  production  of  such  strains 
offers  no  great  difficulties.  The  case  is  well  illus- 
trated by  the  enormous  differences  between  the 
heavy  draught  horse  and  the  light  and  speedy  race 
horse.  It  is  not  to  be  wondered  at,  therefore,  that 
the  possibility  of  improving  the  human  race  by  the 
application  of  scientific  breeding  principles  should 
have  engaged  the  interest  and  serious  attention  of 
scientific  thinkers.  Nietzsche,  in  fact,  believes  that 
the  sole  function  of  man  is  the  creation  of  the  "su- 
perman," and  that  all  other  ends  should  be  subor- 
dinated to  this. 

In  a  recent  lecture  before  the  Harvey  Society,  Dr. 
C.  B.  Davenport,  of  the  Carnegie  Experiment  Sta- 
tion at  Cold  Spring,  gave  an  interesting  survey  of 
the  present  status  of  investigations  concerning  hered- 
ity in  man.  He  pointed  out,  among  other  things, 
how  valuable  it  would  be  to  have  data  concerning 
the  distribution  and  aggregate  amount  of  the  vari- 
ous qualities  of  the  human  intellect.  In  a  large  me- 
tropolis, like  New  York,  the  sum  total  and  variety 
of  such  qualities  must  be  exceedingly  large.  At  the 
present  time,  moreover,  these  qualities  are  not  scien- 
tifically made  use  of  in  securing  an  improvement  in 
the  human  breed.  According  to  Dr.  Davenport,  the 
main  reason  why  such  data  have  not  ^een  collected  is 


not  so  much  that  they  are  difiicult  to  obtain,  nor  yet 
that  no  one  is  sufficiently  interested  in  collecting 
them,  but  mainly  that,  even  if  they  should  be  ob- 
tained, we  are  not  yet  in  a  position  to  apply  them. 

It  is  well  known  that  when  both  parents,  for  ex- 
ample, are  congenitally  blind,  the  probability  is  great 
that  the  offspring  will  also  be  born  blind.  A  care- 
ful analysis  of  analogous  instances  has  shown  that 
when  a  unit  character  is  absent  in  the  germ  plasm 
of  both  parents,  it  will  be  absent  also  in  the  off- 
spring. In  applying  this  law,  however,  one  must  be 
sure  that  the  same  unit  character  is  involved.  Thus, 
the  defect  may  be  due  to  different  causes  in  the  two 
parents,  so  that,  between  them,  they  possess  all  the 
unit  characters.  Such  parents  would  be  able  to  pro- 
create normal  offspring.  Just  here  is  where  the  dan- 
ger of  consanguineous  marriages  becomes  very  ap- 
parent, because  it  is  readily  understood  that  the 
chances  of  the  parents'  lacking  the  same  unit  char- 
acter will  be  largely  increased  if  the  parents  are  re- 
lated by  blood. 

In  view  of  the  fact  that  the  family  physician  is 
often  consulted  concerning  the  advisability  of  cer- 
tain defectives'  marrying,  it  would  seem  well  for 
the  physician  to  know  something  about  heredity. 
On  the  other  hand,  it  is  doubtful  whether  at  present 
physicians  can  afford  to  devote  sufficient  time  to  the 
subject  to  make  their  opinion  of  much  value.  So 
far  as  applying  the  principles  of  heredity  to  human 
nature  is  concerned,  one  might  suppose  that  it  would 
at  least  be  possible  to  forbid  certain  defectives  and 
degenerates  to  marry.  When  we  remember  how 
little  has  been  accomplished  in  regulating  the  mar- 
riage of  syphilitics,  we  begin  to  realize  how  far  off 
the  time  still  is  when  such  a  prohibition  can  be  car- 
ried out.  It  seems  entirely  out  of  the  question  to 
apply  the  principles  of  heredity  to  attempts  at  breed- 
ing an  improved  human  race.  The  difficulties  to  be 
overcome  are  practically  insuperable.  The  length 
of  a  human  generation  and  the  fact  that  one  is  not 
dealing  with  passive  animals,  but  with  rational  hu- 
man beings,  at  once  make  any  comparison  with  the 
work  in  animals  impossible.  In  spite  of  this  dis- 
couraging outlook,  it  would  seem  advisable  to  col- 
lect accurate  data  concerning  the  unit  characters  of 
a  large  number  of  human  individuals,  and  thus  make 
possible,  in  isolated  instances,  the  application  of  sci- 
entific principles  in  human  mating. 


THE  OBSTETRICIAN. 
A  notable  meeting  held  in  New  York  on  Tues- 
day evening  of  this  week  was  the  first  meeting  of 
the  Alumni  Association  of  the  New  York  Lying-in 
Hospital,  an  institution  which,  under  the  masterly 
guidance  of  Dr.  James  W.  Markoe,  has  grown 
from  the  little  house  of  assistance  in  Broome  Street 
to  the  present  impressive  hospital  in  the  region  of 


548 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


Gramercy  Park.  And  it  is  not  this  material  growth 
alone  which  is  to  be  borne  in  mind ;  we  cannot  lose 
sight  of  the  fact  that  in  the  conduct  of  the  hos- 
pital, as  we  have  from  time  to  time  had  occasion  to 
chronicle,  many  an  improvement  in  obstetrical  prac- 
tice has  been  accomplished. 

At  the  meeting  alluded  to  a  distinguished  Phila- 
delphia obstetrician.  Dr.  Barton  Cooke  Hirst,  pre- 
sented a  paper  entitled  The  Scope  of  a  Maternity 
Hospital  and  of  Obstetrics  as  a  Surgical  Specialty. 
Dr.  Hirst  recounted  graphically  the  points  which 
make  obstetrics  prominent  in  the  healing  art.  In- 
deed, it  stands  out  as  a  preeminent  feature  of  that 
art,  and  as  that  it  is  now  everywhere  recognized. 
We  no  longer  meet  with  the  depreciatory  expres- 
sion "man  midwife" ;  rather  does  everybody  in  the 
medical  profession  realize  that  obstetrics  is  one  of 
the  chief  embodiments  of  both  medicine  and  sur- 
gery. It  is  all  very  well  to  say  that  parturition  is 
a  natural  process.  So  it  is,  but  it  is  a  process  often 
fraught  with  grave  peril,  and  the  fact  that  it  is  so 
commonly  gone  through  with  without  extinction  of 
the  life  of  mother  or  child  leads  us  to  join  in  the 
old  German  obstetrician's  exclamation,  Man  konne 
un  der  Gehiirt  die  Alhnacht  Gottes  erkennen! 

He  who  cares  for  a  women  through  her  preg- 
nancy and  her  delivery  must  be  a  master  in  both 
medicine  and  surgery.  He  must  know  how  to  cor- 
rect those  errors  of  her  functions  and  of  her  vis- 
ceral conditions  which  presage  disaster,  and  he 
must  be  ready,  at  a  moment's  warning,  to  show  his 
mastery  of  the  mechanical  problems  that  may  at 
any  time  arise  in  the  actual  process  of  parturition. 
Then,  too,  in  the  puerperal  period,  he  must  be  in- 
stant in  employing  those  measures  which  may  pre- 
vent infection  from  carrying  of¥  the  mother  of  a 
newly  born  child.  Surely  man  cannot  essay  a  more 
Godlike  function  than  that  of  guarding  aHke  the 
life  of  a  woman  who  is  pregnant  or  parturient  and 
that  of  her  tender  oi¥spring.  Bearing  these  con- 
siderations in  mind,  let  us  all  honor  the  obstetri- 
cian. 


A  STADIUM  FOR  COLUMBIA  UNIVERSITY. 

We  think  it  is  very  much  to  be  regretted  that  the 
removal  of  Columbia  University  to  Morningside 
Heights  was  not  preceded  by  the  acquisition  of  a 
far  greater  amount  of  land  than  that  now  available 
for  the  university's  needs.  When  the  removal  was 
decided  upon,  a  great  tract  of  land  could  have  been 
bought  on  the  heights  for  a  sum  of  money  which 
would  now  hardly  enable  the  institution  to  buy  a 
single  city  block  in  the  immediate  neighborhood. 
Consequently,  therefore,  the  purchase  of  much  more 
land  in  the  vicinity  appears  to  be  impracticable. 
Many  more  buildings  ought  to  be  erected  for  uni- 


versity purposes,  but  not  enough  space  is  available. 
This  limitation  has  had  its  effect  on  the  architecture 
of  most  of  the  present  buildings.  The  library  has  a 
scholastic  look,  and  so  in  a  lesser  degree  has  the 
chapel,  but  the  rest  of  the  buildings,  to  judge  from 
their  external  appearance,  might  have  been  put  up 
for  commercial  purposes.  Contrast  the  three  tower- 
ing monstrosities  that  have  lately  been  built  at  the 
Amsterdam  Avenue  end  of  the  South  Field  with  the 
really  collegiate  dormitories  of  the  University  of 
Pennsylvania,  for  example !  We  do  not  doubt  that 
the  Columbia  authorities  have  done  the  best  they 
could  do  with  the  resources  at  their  command ;  thev 
have  had  to  bujld  up  into  the  air,  and  the  elevator 
serves  perforce  as  the  gradus  ad  Parnassum. 

Then  there  is  the  regrettable  encroachment  that 
has  already  been  made  on  the  South  Field.  When 
that  addition  to  the  university  property  was  recently 
acquired,  at  very  great  cost,  it  was  the  general  un- 
derstanding that  it  was  to  be  wholly  devoted  to  pur- 
poses subsidiary  to  physical  culture,  a  feature  which 
is  now  made  prominent  in  the  training  of  youth  in 
all  great  educational  institutions ;  but  the  three  lofty 
buildings  that  have  been  put  up  at  the  Amsterdam 
Avenue  end  of  the  field  curtail  seriously  the  extent 
of  land  available  for  athletic  purposes.  It  is  to  be 
hoped,  therefore,  that  the  project  of  establishing  a 
stadium  on  what  remains  of  the  South  Field  will  be 
carried  out,  for  it  will  probably  check,  at  least  for 
some  years  to  come,  the  further  erection  of  great 
buildings  on  land  that  ought  to  be  wholly  devoted 
to  games  and  physical  contests.  The  undergradu- 
ates of  Columbia  have  a  right  to  ample  facilities  for 
outdoor  athletics,  and  too  long  now  has  the  univer- 
sity maintained  an  antiquated  stable  and  a  scrap 
heap  at  the  Broadway  end  of  the  South  Field.  That 
particular  part  of  the  field,  it  seems  to  us,  ought  to 
be  included  in  the  area  to  be  covered  by  the  stadi- 
um ;  thus  would  that  portion  abutting  on  New  York's 
greatest  thoroughfare  be  preserved  from  the  as- 
sumption of  a  commercial  aspect.  Surely  Columbia 
University  must  wish  to  conform  to  the  require- 
ments exacted  of  all  important  educational  institu- 
tions at  the  present  time,  and  certainly  it  must  rec- 
ognize that  prominent  among  those  requirements  is 
one  for  the  maintenance  of  abundant  facilities  for 
systematic  physical  exercise  in  the  open  air.  By  all 
means  let  Columbia  establish  a  stadium. 

THE  SURGERY  OF  THE  CHOLEDOCHUS 
AND  HEPATIC  DUCTS. 

This  important  subject  has  been  presented  recent- 
ly by  Kchr  at  the  Congress  of  the  International  So- 
ciety of  Surgery,  held  in  Brussels,  and  by  Delage- 
niere  and  Gosset  at  the  French  Surgical  Congress. 


March  13,  1909.I 


EDITORIAL  ARTICLES. 


549 


The  operative  indications  are  numerous.  We  have 
in  the  first  place  wounds  and  ruptures  of  the  ducts ; 
these  are  without  doubt  infrequent,  but  the  opinion 
is  unanimous  that  surgical  interference  should  be 
resorted  to  without  delay.  Without  referring  to  con- 
genital stricture  of  the  biliary  tract,  there  still  re- 
main two  indications  for  operation,  the  first  being 
lithiasis  and  the  second  tumors  of  the  biliary  tract. 
In  lithiasis,  admitting  that  infection  holds  the  pre- 
dominant place  in  its  aetiology,  when  should  one  op- 
erate? Kehr  states  that,  in  principle,  the  operation 
should  not  be  undertaken  early  in  the  process.  His 
statistics  are  sufficiently  conclusive,  because,  out  of 
4,000  cases,  only  1,309  were  submitted  to  surgical 
treatment.  In  other  words,  this  would  seem  to 
show  that  cholelithiasis  is  susceptible  of  being  ame- 
liorated or  even  cured  by  medical  treatment.  When 
after  the  symptoms  of  the  beginning  of  the  process, 
namely,  elevation  of  the  temperature,  chills,  and 
icterus,  decrease  and  tend  to  disappear,  there  is  what 
may  be  termed  a  "latency  of  the  calculus" ;  there  is 
no  vital  indication,  so  that  an  operation  may  be  post- 
poned. This  rule  applies  to  simple  cases ;  but  when 
medical  treatment  shows  itself  insufficient,  the  at- 
tacks of  pain  become  frequent,  and  there  is  a  rise  of 
temperature  often  indicating  a  suppurative  chole- 
cystitis, with  possibly  dilatation  or  empyema  of  the 
gallbladder,  no  hesitation  is  longer  permitted,  as  the 
indication  for  operation  is  distinct.  Such  is  the  opin- 
ion expressed  by  Kehr  and  Hartmann.  Other  sur- 
geons, among  whom  we  may  mention  Moynihan, 
Bruning,  and  Alessandri,  believe,  on  the  contrary, 
that  the  presence  of  calculi  in  the  gallbladder  is  more 
frequent  than  is  generally  believed ;  cholelithiasis 
may  often  be  mistaken  for  a  gastric,  an  intestinal, 
an  appendicular,  or  even  a  renal  affection. 

The  typical  operations  are  particularly  serious,  for 
the  patient  is  frequently  exposed  to  infection  or 
haemorrhage,  and  consequently  the  principal  thing  to 
combat  energetically  is  the  operative  shock.  The 
operations  on  the  choledochus  and  hepatic  ducts  for 
tumors  have  been  carefully  studied  by  Gosset,  who 
enumerates  the  various  forms  in  which  one  finds  can- 
cer of  the  hepatic  duct  or  at  the  junction  of  the  he- 
patic and  cystic  ducts,  cancer  of  the  choledochus, 
and  cancer  of  the  ampulla,  with  the  palliative  and 
curative  operations.  It  is  hardly  necessary  to  point 
out  that  the  results  obtained  in  cases  of  neoplasms 
cannot  be  compared  with  those  obtained  in  gall- 
stones. In  point  of  fact,  Gosset  found  a  mortality 
of  only  12.55  P^i"  cent,  out  of  about  1,124  operations 
for  calculi.  Besides  the  immediate  complications, 
there  are  those  which  occur  later  on,  such  as  biliary 
and  intestinal  fistulae,  postoperative  hernia,  and  often 
a  recurrence  of  the  lithiasis. 


THE  CHOLECYSTIC  AND  APPENDICULAR 
SYNDROMES. 

Both  the  appendicular  and  cholecystic  syndromes 
may  coexist  or  succeed  one  another  during  the  pro- 
gress of  the  same  morbid  state.  There  is  nothing 
surprising  in  this,  since  the  appendix  and  gallblad- 
der present  manifest  anatomical  connections  and 
are  submitted  to  the  same  pathological  causes  of 
disturbance.  Each  is  a  diverticulum  of  the  intes- 
tine and  forms  a  cul-de-sac,  covered  by  the  visceral 
layer  of  peritonaeum.  They  are  also  united  to  each 
other  anatomically  by  the  intestine,  to  the  peri- 
tonaeum by  the  lymphatics,  and  to  the  circulatory  ap- 
paratus, and  these  connections  explain  the  simulta- 
neous infection  of  both  organs. 

The  association  of  both  affections  may  be  pro- 
duced and  be  explained  in  two  ways.  Cholelithiasis 
and  appendicular  inflammation  are  both  dependent 
on  a  more  or  less  general  cause,  common  to  both 
organs,  or  else  the  lesion,  primarily  localized  in  one 
of  them,  reacts  on  the  other.  In  this  case  the  peri- 
tonaeum is  the  intermediary,  and  it  is  always  in- 
volved in  acute  or  subacute  inflammatory  pro- 
cesses, even  in  cases  of  simple  appendicular  or  bil- 
iary colic,  so  that  the  inflammation  extends  from 
one  organ  to  the  other. 

Thevenin  has  studied  another  category  of  facts 
in  which  there  is  also  an  association  of  the  two 
syndromes,  without  there  necessarily  being  any  or- 
ganic lesions  indispensable  for  their  production. 
Legendre  distinguishes  three  modes  of  association 
of  these  two  syndromes ;  sometimes  there  are  symp- 
toms arising  in  the  gallbladder,  which  first  appear 
very  distinctly  and  predominate,  followed  more  or 
less  tardily  by  manifestations  in  the  appendix.  In 
other  cases  there  is  a  simultaneous  appearance  of 
the  two  syndromes.  Lastly,  in  other  circumstances 
the  appendicular  symptoms  are  first  to  draw  atten- 
tion. What  characterizes  these  different  cases  is 
that  the  phenomena  of  appendicular  inflammation, 
no  matter  what  may  be  the  order  of  their  appear- 
ance, never  correspond  to  a  true  inflammation  of 
the  appendix,  but  rather  to  a  circumappendicular 
process.  The  gallbladder  is  the  origin  of  the  patho- 
logical process,  and  it  is  by  propagation  that  the 
inflammation  finally  extends  to  the  peritonaeum  of 
the  appendix. 

This  explanation  has  recently  been  put  forward 
by  Tripier  and  Paviot,  but  we  believe  that  it  is  pos- 
sible to  render  a  more  comprehensive  interpretation 
to  this  theory  and  one  which  in  no  way  underrates 
the  value  of  the  pathological  findings  collected  by 
competent  observers.  Generally  speaking,  all  these 
morbid  associations,  which  frequently  appear  very 


550 


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LNew  York 
Medical  Journal. 


mysterious  and  whose  pathogenesis  has  given  rise 
to  many  ingenious  theories,  in  reahty  are  derived 
from  a  generally  unknown  law,  viz.,  the  law  of  re- 
actionary synergy  of  all  the  various  visceral  ap- 
paratuses of  the  body.  There  is  no  reason  to  be 
astonished  a  priori  that  in  a  patient  presenting  pain- 
ful cholecystic  functional  disturbances  one  may 
simultaneously  observe  functional  disturbances,  also 
painful,  of  other  portions  of  the  digestive  apparatus, 
especially  of  the  c^cum  and  its  appendix.  A  me- 
thodical exploration  of  the  abdomen  will  remove 
all  doubts.  In  all  painful  abdominal  affections,  no 
matter  how  localized  they  may  be,  one  will  always 
find  undoubted  changes  in  the  shape  and  con- 
sistence of  the  digestive  organs.  Palpation  will 
very  frequently  give  rise  to  pain  along  the  colon 
when  the  patient  complains  of  no  spontaneous  pain 
which  may  call  the  attention  of  the  physician  to  it 
and  lead  him  to  believe  that  there  is  some  morbid 
process  in  the  large  intestine.  There  is  nothing 
surprising  in  the  fact  that,  if  these  functional  dis- 
turbances, accompanied  by  pain  on  palpation,  final- 
ly result  in  an  inflammatory  process,  they  have 
various  localizations  arising  simultaneously  or  in 
succession. 

 ^  

An  Appropriation  of  $10,000  for  the  Care  of  Tubercu- 
losis Patients  has  b'een  approved  hy  the  New  York 
Board  of  Aldermen.  The  money  will  be  used  to  fit  up  the 
old  ferryboats  Westfield  and  SoutJifield  so  that  they  may 
be  used  as  general  tuberculosis  hospitals. 

The  Archives  of  Otology. — The  editors,  Dr.  Herman 
Knapp  and  Dr.  Arnold  Knapp  announce  that  the  existence 
of  Archives  of  Otology  came  to  a  close  with  the  issue  for 
December,  1908,  which  completed  the  thirty-seventh  vol- 
ume of  the  periodical. 

Filipinos  Graduate  in  Medicine. — The  first  class  of 
Filipino  physicians  trained  under  the  American  rule  was 
graduated  from  the  Philippine  Medical  School,  Manila,  on 
February  27th.  Dr.  P.  C.  Freer,  dean  of  the  medical  fac- 
ulty of  the  school,  formerly  of  the  University  of  Michigan, 
presided  over  the  commencement  exercises. 

The  Need  for  a  Revision  of  the  National  Formulary 
was  discussed  at  a  meeting  of  the  City  of  Washington 
Branch  of  the  American  Pharmaceutical  Association,  held 
on  Tuesday  evening,  March  9th.  Papers  were  read  by  Dr. 
Lyman  F.  Kebler,  Mr.  Alexander  Muncaster,  and  Mr.  Sam- 
uel L.  Hilton,  followed  by  a  general  discussion. 

The  Superintendency  of  the  New  York  Hospital.— It 
is  reported  that  Dr.  Thomas  Howell,  superintendent  of  the 
Worcester,  Mass.,  Hospital,  has  resigned  his  position  to 
become  superintendent  of  the  New  York  Hospital  and  the 
House  of  Relief  (Hudson  Street  Hospital).  It  is  reported 
that  his  resignation  will  go  into  effect  on  April  30th. 

Chinese  Women  Become  Physicians. — Six  Chinese 
women  were  graduated  from  the  Woman's  Medical  School 
at  Shanghai,  China,  a  short  time  ago.  Each  of  the  six 
graduates  read  an  essay,  two  of  them  in  English.  This 
school  was  founded  about  three  years  ago  by  Li  Ping  Shu. 
and  the  prmcipal  is  a  Chinese  woman.  During  the  past 
year  there  were  thirt\-  students  at  the  school. 

A  Dinner  in  Honor  of  Dr.  Henry  W.  Frauenthal  and 
Dr.  Herman  C.  Frauenthal,  was  given  by  the  board  of 
managers  of  the  Hospital  for  Deformities  and  Joint  Dis- 
eases. New  York,  at  the  Hotel  Knickerbocker,  on  the  even- 
ing of  March  6th.  The  dinner  also  marked  the  completion 
of  the  second  year  of  the  work  of  the  hospital.  Silver  lov- 
ing cups  were  presented  to  each  of  the  doctors. 


The  Naval  Academy  Hospital,  at  Annapolis,  is  to 

have  a  new  general  ward  and  two  new  isolation  buildings. 
Plans  have  been  filed  for  the  buildings,  which  will  be 
29x55  feet,  one  story  in  height,  with  basement,  and  will  be 
constructed  of  reinforced  concrete.  The  general  ward  will 
be  50x52  feet.    The  improvements  will  cost  about  $83,000. 

The  Tuberculosis  Campaign  in  Wisconsin. — The  Wis- 
consin Antituberculosis  Association  announces  that  a  net 
profit  of  $8,754.88  was  realized  from  the  sale  of  the  Red 
Cross  Christmas  stamps.  The  money  is  to  be  devoted  to 
the  work  of  conducting  an  educational  campaign  through- 
out the  State,  by  means  of  traveling  exhibits,  the  organiza- 
tion of  societies,  etc. 

The  Shreve-Herbst  Bill,  which  provides  for  the  es- 
tablishment of  a  Board  of  Medical  Examiners  in  Pennsyl- 
vania, before  which  all  candidates  for  the  authority  to  prac- 
tise medicine  in  the  State  shall  appear,  was  given  a  public 
hearing  at  Harrisburg  on  Tuesday,  March  2d.  About  two 
hundred  physicians  from  Philadelphia  attended  the  hearing, 
and  many  from  other  parts  of  the  State  were  also  present. 

Tuberculosis  in  New  York  State. — During  the  year 
1908  the  mortality  from  pulmonary  tuberculosis  was  14,316; 
for  1907  it  was  14,431 ;  for  the  last  five  years  there  have 
been  something  over  14,000  deaths  each  year,  or  between 
ten  and  eleven  per  cent,  of  the  deaths  from  all  causes.  The 
mortality  from  other  forms  of  tuberculosis  for  the  year 
1908  was  2,205,  which  makes  a  total  of  16,521  deaths  from 
tuberculosis,  or  11.9  per  cent,  of  the  total  mortality. 

The  Lebanon  Hospital  Medical  Society,  of  Philadel- 
phia, whose  membership  consists  of  physicians  con- 
nected with  the  Lebanon  Hospital  and  Dispensary  who  are 
interested  in  medical  research,  meets  on  the  second  and 
fourth  Thursdays  at  the  hospital.  The  following  officers 
have  been  elected:  President,  Dr.  H.  Lowenburg;  vice- 
president,  Dr.  Aaron  Brav ;  secretary,  Dr.  A.  D.  Halpern ; 
and  treasurer,  Dr.  M.  Loeb. 

Open  Air  Schools  for  Tuberculous  Children  in  Bos- 
ton.— Since  the  establishment  of  this  school  in  Franklin 
Park  a  short  time  ago,  twenty-three  children  have  been 
dismissed  as  cured,  and  only  twenty  pupils  now  remain, 
and  they  are  all  making  rapid  progress  towards  recover}-. 
The  school  was  established  on  the  advice  of  Dr.  Thomas 
F.  Harrington,  medical  adviser  to  the  Boston  School  Board, 
who  feels  much  gratified  at  the  practical  results  obtained. 

Centenarians  in  Pennsylvania. — According  to  the  an- 
nual report  of  the  Bureau  of  Vital  Statistics  of  the  Depart- 
ment of  Health  of  Pennsylvania,  among  the  deaths  regis- 
tered during  the  year  1908  were  ten  over  one  hundred  years 
of  age.  One  of  these  was  one  hundred  and  fifteen  years 
of  age  and  one  between  one  hundred  and  ten  and  one  hun- 
dred and  fifteen  years  of  age.  Seven  of  the  ten  were  women. 
Four  were  natives  of  Pennsylvania,  three  of  Ireland,  one 
of  Scotland,  one  of  Hungary,  and  one,  a  negro,  of  Virginia. 

The  Transmission  of  Pathological  Specimens  by  Mail. 
— An  order  has  been  issued  by  the  Postmaster  General 
directing  that  specimens  of  communicable  and  infectious 
disease  tissues,  sent  for  bacteriological  examination  to 
State  and  county  laboratories,  will  be  refused  admission 
to  the  mails  unless  packed  in  accordance  with  postal  speci- 
fications. The  regulati  ons  require  that  specimens  of  dis- 
eased tissues  shall  be  carefully  sealed  in  a  strong  glass  vial 
or  test  tube  and  then  placed  in  a  circular  tin  box  before 
being  sent  through  the  mails. 

A  Tuberculosis  Hospital  for  Ontario  County,  N.  Y. — 
An  appropriation  of  $15,000  has  been  approved  by  the 
board  of  supervisors  for  the  establishment  of  a  tuberculo- 
sis hospital  and  sanatorium  in  Ontario  County.  A  com- 
mittee of  six  has  been  appointed  to  select  an  appropriate  site 
and  to  superintendent  the  erection  of  a  suitable  building. 
Dr.  A.  L.  Beahun,  of  Canandaigua ;  Dr.  C.  C.  Lytle.  of 
Geneva;  and  Dr.  S.  R.  Wheeler,  of  East  Bloomfield,  have 
been  appointed  members  of  the  committee,  the  other  three 
members  having  been  chosen  from  the  board  of  supervisors. 

Charitable  Bequests. — By  the  will  of  Mr.  Eugene 
Tompkins,  who  died  recently,  among  the  Boston  institutions 
which  received  legacies  are  the  followine: :  Boston  Chil- 
dren's Aid  Society,  $10,000;  Boston  City  Hospital.  $10,000; 
Boston  Dispensan.'.  $10,000;  Boston  Home  for  Incurables, 
$5,000:  Children's  Hospital.  Boston.  $10,000:  Carnev  Hos- 
pital of  Boston,  $10,000:  Home  for  .^ged  Couples.  Boston. 
$5,000:  Home  for  .\gcd  Men.  Boston,  $5,000:  Industrial 
School  for  Crippled  and  Deformed  Children.  Boston.  $10.- 
000;  New  England  Home  for  Little  Wanderers,  Boston. 
$25,000:  Massachusetts  General  Hospital.  $10,000. 


March  13,  1 909.  J 


NEIVS  ITEMS. 


A  Luncheon  to  Sir  James  Grant,  M.  D.,  of  Ottawa. — 

On  the  occasion  of  Sir  James  Grant's  recent  visit  to  New 
York,  a  luncheon  was  given  in  his  honor  in  the  rooms  of 
the  Century  Association  cn  Wednesday  afternoon,  March 
loth.  Among  those  present  at  the  luncheon,  in  addition  to 
the  guest  of  honor,  were  Dr.  J.  Leonard  Corning,  Dr. 
James  W.  Markoe,  Colonel  Charles  Richard,  of  the  Medi- 
cal Corps  of  the  United  States  Army,  Dr.  F.  T.  Haneman, 
and  Dr.  Frank  P.  Foster. 

The  Health  of  Pittsburgh. — During  the  week  ending 
February  13,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
22  cases,  I  death ;  typhoid  fever,  27  cases,  3  deaths ;  scarlet 
fever,  27  cases,  3  deaths;  diphtheria,  il  cases,  2  deaths; 
measles,  30  cases,  i  death ;  whooping  cough,  12  cases,  2 
deaths ;  pulmonary  tuberculosis,  36  cases,  13  deaths.  The 
total  deaths  for  the  week  numbered  164,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  15.9  in  1,000  of  population. 

Cutaneous  Tuberculosis. — At  a  stated  meeting  of  the 
New  York  Academy  of  Medicine,  to  be  held  on  Thursday 
evening,  April  ist,  the  programn»e  will  consist  of  a  "sym- 
posium" on  cutaneous  tuberculoses  and  tuberculides.  The 
following  papers  will  be  read:  The  Present  Status  of  the 
Subject,  by  Dr.  A.  R.  Robinson;  The  Diagnostic  Value  of 
the  Inunction  Tuberculin  Reaction  in  Cutaneous  Tubercu- 
losis, by  Dr.  William  B.  Trimble ;  The  Use  of  Tuberculin 
in  Certain  Diseases  of  the  Skin,  by  Dr.  A.  Schuyler  Clark ; 
Lantern  Slide  Exhibition  Illustrating  the  Clinical  and  His- 
torical Features  of  the  Tuberculoses  and  the  Tuberculides. 
There  will  be  a  general  discussion. 

Vital  Statistics  of  Greater  New  York. — During  the 
week  ending  February  27,  1909,  there  were  reported  to  the 
Department  of  Health  of  the  City  of  New  York  1,375 
deaths,  as  against  1,551  for  the  corresponding  period  in 
1908.  The  death  rate  for  the  week  was  15.71  for  the  whole 
city;  for  each  of  the  boroughs  it  was  as  follows:  Manhat- 
tan, 16.35;  the  Bronx,  18.74;  Brooklyn,  14.30;  Queens, 
13.84;  and  Richmond,  16.73.  The  total  number  of  deaths 
of  children  under  five  years  of  age  was  424,  of  which  247 
were  under  one  year'  of  age.  There  were  125  still  births. 
Nine  hundred  and  eighty-five  marriages  and  2,133  births 
were  reported  during  the  week. 

The  Alcohol  Problem. — In  response  to  an  invitation 
from  a  number  of  the  leading  men  of  Washington,  D.  C, 
the  American  Society  for  the  Study  of  Alcohol  and  Other 
Narcotics  will  hold  a  meeting  in  the  Hotel  Raleigh  on 
March  17th,  i8th,  and  19th.  There  will  be  two  sessions 
daily,  at  2  and  at  8  p.  m.  The  programme  includes  oxer 
thirty  papers  by  men  eminent  in  the  medical  profession 
who  will  deal  with  the  subject  of  alcohol  and  the  diseases 
following  its  use  from  a  scientific  point  of  view.  A  gen- 
eral invitation  is  extended  to  all  persons  who  are  interested. 
Programmes  and  full  details  regarding  the  meeting  may  be 
obtained  from  the  secretary  of  the  society,  Dr.  T.  D.  Croth- 
ers,  Hartford,  Conn. 

Another  Tuberculosis  Clinic  in  Brooklyn. — On  Mon- 
day evening,  March  8th,  a  tuberculosis  clinic  was  opened  at 
'he  Bay  Ridge  Hospital  and  Dispensary,  Sixtieth  Street  and 
Second  Avenue,  Brooklyn,  which  is  the  second  one  to  be 
established  in  that  borough,  the  other  being  maintained  by 
Hie  Department  of  Health  in  the  down  town  district.  Dr. 
S.  A.  Knopf,  of  Manhattan,  was  the  guest  of  the  evening. 
The  clinic,  which  is  thoroughly  up  to  date  in  every  particu- 
lar, was  litted  up  by  the  New  Utrecht  Red  Cross  Society 
''n  conjunction  with  the  Ladies'  Auxiliary  attached  to  the 
'■■ospital,  and  is  to  be  supported  by  private  means.  Dr.  Frank 
F.  Stoney,  Dr.  Robert  Coughlin,  and  Dr.  Rollin  Hills  con- 
stitute the  visiting  staff  of  the  clinic. 

The  Mortality  of  Chicago. — During  the  week  ending 
February  27,  1909,  the  total  number  of  deaths  from  all 
'■'■luses  was  659,  an  increase  of  live  over  the  preceding  week, 
hut  a  decrease  of  18  from  the  corresponding  week  last  year. 
The  annual  death  rate  in  a  thousand  population  was  15.45 
for  the  week,  as  against  a  death  rate  of  15.33  for  the  pre- 
ceding week.  The  principal  causes  of  death  were :  Dipli- 
theria,  18;  scarlet  fever,  11;  measles,  5;  whooping  cough. 
3;  influenza,  9:  typhoid  fever,  11;  diarrhoeal  diseases,  48,  of 
which  42  were  under  two  years  of  age ;  pneumonia,  132 ; 
pulmonary  tuberculosis,  54:  other  forms  of  tuberculosis, 
13;  cancer,  30;  nervous  diseases,  20;  heart  diseases,  59; 
apoplexy,  12;  bronchitis,  i;  Bright's  disease,  39;  violence, 
all  forms,  90,  of  which  So  were  due  to  accidents,  and  9  to 
suicides:  all  other  causes,  104. 


Personal. — Dr.  Abraham  L.  Wolbarst,  of  105  East 
Nineteenth  Street,  New  York,  has  been  appointed  genito- 
urinary consultant  to  the  Central  Islip  State  Hospital. 

Dr.  Alfred  Gordon,  of  Philadelphia,  has  been  elected  a 
member  of  the  Societe  medico-psychologique  de  Paris. 

Mr.  Henry  Bausch,  second  vice-president  of  the  Bausch 
&  Lomb  Optical  Company,  Rochester,  N.  Y.,  died  in  Au- 
gusta, Ga.,  on  March  2d,  aged  fifty  years. 

The  Annual  Meeting  of  the  Visiting  Nurses  Society 
of  Philadelphia  was  held  on  Friday,  March  5th.  This 
society  furnishes  district  nurses  to  the  poor  of  the  city, 
giving  those  who  cannot  afford  to  employ  a  nurse  con- 
stantly the  benefit  of  the  services  of  a  trained  attendant 
for  at  least  a  part  of  the  day.  The  society  has  branches  in 
Manayunk,  Kensington,  and  West  Philadelphia,  in  addition 
to  the  main  office  in  the  heart  of  the  city.  It  employed  nine- 
teen nurses,  who  made  51,181  visits  during  the  past  year. 
The  following  officers  were  elected :  President,  Mrs.  Henry 
C.  Lea ;  corresponding  secretary.  Miss  Lucy  Davis ;  record- 
ing secretary,  Mrs.  Morris  Jastrow;  treasurer,  Mrs.  Albert 
P.  Brubaker ;  superintendent,  Mrs.  L.  W.  Quintard. 
Infectious  Diseases  in  New  York: 

We  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  following  statement  of  new 
cases  and  deaths  reported  for  the  tzvo  weeks  ending  March 
6,  i()og: 

^February  27-^  ,  March  6  > 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  puhnonalis    377  167         464  163 

Diiihtheria    326  45         332  44 

Measles    635  27         642  20 

Scarlet  fever    373  29         352  23 

Smallpox    I  I 

Varicella    189  .  .  255 

Typhoid  fever    27  4  28  7 

Whooping  cough   47  7  62  3 

Cerebrospinal  meningitis    8  4  8  7 

Totals   1.983         284      2,143  267 

Scientific   Society   Meetings   in   Philadelphia  for  the 
Week  Ending  March  20,  1909: 

MoND.AY,  March  15th. — Medical  Society  of  the  Woman's 
Hospital. 

TuESD.w,  March  i6th. — Dermatological  Society ;  Academy 
of    Natural    Sciences ;    North    Branch,  Philadelphia 
County  Medical  Society. 
Wednesday,  March  17th. — Section  in  Otology  and  Laryn- 
gology, College  of  Physicians;  Franklin  Institute. 
Thursday,  March  i8th. — Section  in  Ophthalmology,  Col- 
lege of  Physicians ;  Section  Meeting,  Franklin  Insti- 
tute ;  Southwark  Medical  Society ;  Northeast  Branch, 
Philadelphia  County  Medical  Society ;  Delaware  Val- 
ley Ornithological  Club. 
Friday,  March  igth. — American  Philosophical  Society. 

Microscopy  Exhibition. — The  department  of  micro- 
scopy of  the  Brooklyn  Institute  of  Art  and  Sciences  will 
hold  its  twenty-second  annual  exhibition  of  microscopical 
objects,  preparations,  apparatus,  photomicrographs,  lantern 
slides,  etc.,  including  all  the  latest  developments  along  the 
lines  of  microscopy,  on  Saturday,  March  13th,  from  3  to 
6  and  8  to  11  p.  m.  An  interesting  feature  of  the  exhibi- 
tion will  be  the  showing  of  microscopes  of  the  -eighteenth 
century.  Exhibits  of  the  various  pathological  and  bacteri- 
ological phases  of  tuberculosis  will  be  shown  by  the  Hoag- 
land  Laboratory  and  the  Research  Laboratory  of  the  New 
York  Department  of  Health.  The  work  of  a  modern  well 
equipped  chemical  laboratory  will  be  shown  by  the  Polhe- 
mus  Memorial  Clinic  and  the  Randolph  Laboratory,  and  the 
suliject  of  hydrophobia  will  he  presented  by  the  Pasteur 
Institute. 

The  Birth  Rate  of  New  York  State.— According  to 
the  Twenty-ninth  Annual  Report  of  the  New  York  State 
Department  of  Health,  the  total  number  of  births  recorded 
as  occurring  in  igo8,  exclusive  of  still  births,  was  203,159. 
In  1907  the  number  was  195,735.  The  birth  rate  has  ac- 
cordingly increased  from  23.3  in  a  thousand  population  to 
23.8.  The  number  of  still  births  reported  during  the  year 
throughout  the  State  was  10,546.  The  number  of  males 
born  was  104,968,  and  of  females,  98,145.  The  addition  to 
the  white  population  was  200,551,  and  to  the  negro,  2,584. 
The  births  of  3  Chinese  and  21  Indians  were  reported  in 
tlie  State.  The  birth  rate  in  Greater  New  York  was  29.0, 
the  highest  rate  for  any  city  of  over  20,000  population, 
which  was  exceeded  in  the  whole  State  only  by  Dunkirk, 
which  had  a  birth  rate  of  36.6.  Troy  is  credited  with  the 
lowest  birth  rate  reported,  viz.,  11.6.  Other  cities  with  low 
birth  rates  were  Rensselaer,  11.7;  Watervliet,  12.6;  Middle- 
town,  1 1.8;  and  Albany,  12.5. 


552 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


Resolution  on  the  Death  of  Dr.  William  T.  Bull.— At 

a  recent  meeting  of  the  medical  board  of  the  General 
Memorial  Hospital,  the  following  resolution  was  adopted: 

Whereas,  In  the  recent  death  of  Dr.  William  Tillinghast 
Bull  the  General  Memorial  Hospital  has  lost  not  only  the 
most  distinguished  member  of  its  medical  staff,  but  also 
one  of  the  founders  of  the  hospital,  and,  since  that  time, 
one  of  the  most  loyal  and  earnest  members  of  its  Board 
of  Managers,  the  Medical  Board  desires  to  express  its 
deep  appreciation  of  this  double  service  so  long  and  so 
cheerfully  rendered. 

It  also  wishes  to  place  on  record  its  own  sense  of  great 
personal  grief  at  the  loss  not  merely  of  a  distinguished  col- 
league, but  a  warm  personal  friend  who,  in  the  midst  of 
the  urgent  demands  of  a  large  practice,  was  ever  ready 
to  respond  to  the  call  of  the  humblest,  and  whose  greatest 
reward  was  the  knowledge  that  his  efforts  had  brought 
relief  to  some  poor  sufferer. 

The  memory  of  his  remarkable  judgment  and  skill  as  a 
surgeon,  of  the  beauty  and  strength  of  his  character  will 
endure  as  long  as  the  hospital  exists  and  will  serve  as  a 
stimulus  to  the  generations  that  follow  him. 

The  Association  of  American  Medical  Colleges  will 

hold  its  nineteenth  annual  meeting  in  the  New  York  Acad- 
emy of  Medicine  on  Monday  and  Tuesday,  March  15th  and 
i6th.  On  Monday  afternoon  addresses  will  be  delivered  as 
follows:  Higher  Entrance  Requirements,  by  the  Hon.  Au- 
gustus S.  Downing,  First  Assistant  Commissioner  of  Edu- 
cation, Albany ;  The  Combined  Course,  by  Professor  Wil- 
liam H.  Carpenter,  of  Columbia  University;  The  Present 
Status  of  Medical  Eudcation,  by  Dr.  Frederick  C.  Zapffe, 
of  the  University  of  Illinois ;  The  Five  Year  Medical 
Course,  by  Dr.  John  Rogers,  of  Cornell  University  Medical 
College.  On  Monday  evening  the  association  will  meet  in 
Hosack  Hall,  under  the  auspices  of  the  New  York  Acad- 
emy of  Medicine.  Addresses  will  be  made  by  Dr.  John  A. 
Wyeth,  president  of  the  Academy ;  Dr.  Eli  H.  Long,  of  the 
University  of  Buffalo;  and  Henry  S.  Pritchett,  LL.  D., 
president  of  the  Carnegie  Foundation  for  the  Advancement 
of  Teaching,  who  will  speak  on  Standards  of  Medical  Ed- 
ucation. All  who  are  interested  in  medical  education  are 
invited  to  attend  and  fake  part  in  the  discussions. 

Foreign  Items  of  Interest. — Professor  Ramon  y  Cajal, 
of  Madrid,  has  been  created  a  senator  of  Spain. 

Professor  S.  Kitasato,  director  of  the  Institute  for  Infec- 
tious Diseases  at  Tokio,  Japan,  has  been  elected  an  honor- 
ary fellow  of  the  Royal  Society. 

Professor  Constantin  von  Monakow,  assistant  professor 
of  neurology  in  the  University  of  Zurich,  has  been  elected 
president  of  the  Swiss  Neurological  Society,  which  was 
organized  recently  in  Zurich. 

Dr.  C.  A.  Mercier,  professor  of  psychiatry  in  the  Charing 
Cross  Hospital  Medical  School,  London,  has  been  awarded 
the  Swiney  prize  of  $1,000  for  his  work  on  Criminal  Re- 
sponsibility. The  award  was  made  on  the  recommendation 
of  both  the  Royal  Society  of  Arts  and  the  Royal  College  of 
Physicians. 

.'\mong  the  fifty-one  physicians  who  lost  their  lives  in 
the  MessiiTa  disaster,  were  four  professors  and  five  lectur- 
ers of  the  medical  faculty  of  the  University  of  Messina, 
one  assistant  in  the  surgical  clinic  of  the  university,  and 
the  director  of  the  Pasteur  Institute. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing February  27,  1909,  the  following  cases  of  transmissible 
diseases  were  reported  to  the  Bureau  of  Health  of  Phila- 
delphia :  Typhoid  fever,  55  cases,  9  deaths ;  scarlet  fever, 
75  cases,  3  deaths ;  chicken  pox,  61  cases,  o  deaths ;  diph- 
theria, 80  cases,  8  deaths ;  cerebrospinal  meningitis,  i  case, 
I  death  ;  measles.  26  cases,  5  deaths ;  whooping  cough,  23 
cases,  4  deaths ;  tuberculosis  of  the  lungs,  152  cases,  79 
deaths;  pneumonia,  T03  cases,  85  deaths;  erysipelas,  15 
cases,  I  death ;  puerperal  fever,  4  cases,  3  deaths ;  mumps, 
33  cases,  0  deaths ;  cancer,  27  cases,  21  deaths ;  tetanus,  i 
case,  0  deaths.  Tlie  followimr  deaths  were  reported  from 
other  transrrissihle  diseases:  Tuberculosis,  other  than  tuber- 
culosis of  the  lungs,  7  deaths;  diarrha-a  and  enteritis,  under 
two  years  of  age,  10  deaths.  The  total  deaths  niunbered 
569  in  an  estimated  population  of  1,293,697,  corresponding 
to  an  annual  death  rate  of  18.81  in  a  thousand  population. 
The  total  infant  mortality  was  139;  ill  under  one  year  of 
age ;  28  between  one  and  two  years  of  age.  There  were  35 
still  liirths;  t6  males  and  19  females.  The  total  precipita- 
tion was  2.55  inches. 


The  Seventh  International  Congress  of  Applied 
Chemistry  will  meet  in  London  from  May  27  to  June  2, 
1909.  This  is  the  first  time  this  congress  has  ever  convened 
in  an  English  speaking  country.  It  is  to  be  held  under  the 
patronage  of  His  Majesty,  the  King,  and  the  vice-patronage 
of  His  Royal  Highness,  the  Prince  of  Wales.  The  Hon- 
orary President  is  Sir,  Henry  Roscoe,  and  the  active  presi- 
dent is  Sir  William  Ramsay.  Mr.  Wilham  McNab  is  the 
general  secretary,  and  Mr.  Thomas  Tyrer  and  Mr.  V. 
Wightman  are  the  treasurers.  Dr.  Harvey  W.  Wiley,  of 
Washington,  D.  C,  has  been  appointed  chairman  of  the 
American  Committee.  The  congress  has  been  divided  into 
the  following  eleven  sections :  Analytical  chemistry ;  in- 
organic chemistry  and  allied  industries ;  metallurgy  and 
mining;  organic  chemistry  and  allied  industries;  industry 
and  chemistry  of  sugar;  starch  industry ;  agricultural  chem- 
istry; hygiene,  medical  and  pharmaceutical  chemistry, 
bromatology ;  photographic  chemistry;  electrical  and  phy- 
sical chemistry ;  and  law,  political  economics  and  legislation 
with  reference  to  chen.'ical  industries.  Those  intending  to 
present  papers  should  write  to  the  chairman  of  the  section 
to  which  the  paper  belongs. 

Mortality  Statistics  of  the  State  of  New  York  for  the 
Year  1908  show  that  the  death  rate  for  the  year  was  the 
lowest  ever  recorded  in  the  State.  The  total  number  of 
deaths  recorded  was  138,441,  which,  in  an  estimated  popu- 
lation of  8,546,356,  corresponded  to  an  annual  death  rate  in 
a  thousand  population  of  16.2.  In  1907  the  death  rate  was 
17.5,  and  the  average  death  rate  for  the  past  five  years  was 
17.2.  In  Greater  New  York  the  mortality  was  6,130  less 
than  in  1907,  and  the  death  rate  was  reduced  from  18.5  to 
16.8.  There  were  26,503  deaths  of  children  under  one  year 
of  age,  and  11,364  of  children  between  one  and  five  years 
of  age.  Of  these  1,255  were  due  to  cholera  infantum  and 
7,844  to  diarrhoea  and  enteritis  in  children  under  two  years 
of  age.  The  average  annual  death  rate  in  the  cities  was 
16.5,  and  in  the  rural  districts  T5.4.  Of  the  cities  of  over 
100,000  population,  Rochester  had  the  lowest  death  rate — 
14.0.  Buffalo  had  a  death  rate  of  15.5.  In  the  smaller 
cities,  Schenectady  had  the  very  low  rate  of  13.3,  Yonkers's 
death  rate  was  only  15.3,  and  in  other  small  cities  the  fol- 
lowing exceptionally  low  death  rates  were  shown  in  the 
mortality  reports:  Jamestown,  11. 2;  Geneva,  11.4;  and  Lit- 
tle Falls,  1 1.9.  Troy  had  the  highest  death  rate,  20.1,  while 
Rome  came  next  with  a  death  rate  of  19.4,  Utica  following 
with  the  high  rate  of  19.0. 

Society  Meetings  for  the  Coming  Week: 

Monday,  March  15th. — New  York  Academy  of  Medicine 
(Section  in  Ophthalmology)  ;  Medical  Association  of 
the  Greater  City  of  New  York;  Hartford,  Conn.,  Med- 
ical Society. 

Tuesday,  March  i6th. — New  York  Academy  of  Medicine 
(Section  in  Medicine)  ;  Buffalo  Academy  of  Medicine 
(Section  in  Pathologj')  ;  Tri-Professional  Medical  So- 
ciety of  New  York ;  Medical  Society  of  the  County  of 
Kings,  N.  Y. ;  Binghamton.  N.  Y.,  Academy  of  Medi- 
cine;  Clinical  Society  of  Elizabeth,  N.  J.,  General  Hos- 
pital; Syracuse,  N.  Y.,  Academy  of  Medicine:  Ogdens- 
burgh,  N.  Y.,  Medical  Association ;  Medical  Society  of 
the  County  of  Westchester,  N.  Y. 

Wednesday,  March  i/th. — New  York  Academy  of  Medi- 
cine (Section  in  Genitourinary  Diseases)  ;  New  York 
Society  of  Dermatology  and  Genitourinary  Surgery; 
Woman's  Medical  Association  of  New  York  City  (New 
York  Academy  of  Medicine)  ;  Medicolegal  Society, 
New  York;  New  Jersey  Academy  of  Medicine  (Jersey 
City);  Buffalo  Medical  Club:  New  Haven,  Conn., 
Medical  Association ;  New  York  Society  of  Internal 
Medicine:  Northwestern  Medical  and  Surgical  Society 
of  New  York. 

Thursday,  March  i8th. — New  York  Academy  of  Medi- 
cine; German  Medical  Society.  Brooklyn;  Newark. 
N.  J.,  Medical  and  Surgical  Societv;  .^isculapian  Club 
of  Buffalo,  N.  Y. 

Friday,  March  roth.— 'New  York  Academy  of  Medicine 
(Section  in  Orthopaedic  Surgery)  :  Clinical  Society  of 
the  New  York  Postgraduate  Medical  School  and  Hos- 
pital ;  East  Side  Physicians'  Association  of  the  City  of 
New  York :  New  York  Microscopical  Society ;  Brook- 
lyn Medical  Society. 


March  13,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


553 


^xi\  fff  Cttmnt  f  ittratm. 


iOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 
March  4,  1909. 

1.  Some  Observations  on  Renal  Diagnosis, 

By  Charles  H.  Chetwood. 

2.  The  Principles  of  Mechanotherapy  with  Special  Refer- 

ence to  the  Treatment  of  Orthopaedic  Cases, 

By  C.  Hermann  Bucholz. 

3.  The  Newer  Silver  Salts  as  Compared  with  Silver  Ni- 

trate in  the  Treatment  of  Ophthalmia  Neonatorum-, 
By  Frederick  E.  Cheney. 

1.  Observations  on  Renal  Diagnosis. — Chet- 
wood observes  that  it  is  by  judicious  selection  and 
combination  of  the  various  available  tests  that  the 
best  results  are  obtained  and  the  most  satisfactory 
preliminary  diagnosis  accomplished  in  surgical  le- 
sions of  the  kidney.  It  is  impossible  and  superfluous 
to  resort  to  all  tests  in  every  instance.  Reliable  con- 
firmation is  what  is  sought  for,  as  regards,  first,  the 
kidney  in  which  the  lesion  is  existing,  and,  second, 
the  condition  of  the  remaining  kidney,  especially 
when  nephrectomy  is  a  possibility.  When  there  is 
an  obvious  variation  from  the  normal,  simple  cysto- 
scopical  examination  may  be  sufficient  to  determine 
in  which  kidney  the  lesion  is  located ;  and  the  indigo 
carmine  or  phloridzin  test,  accompanied  by  segrega- 
tion or  catheterization  of  one  ureter,  will  usually 
furnish  the  desired  information  as  to  the  condition 
of  the  other  kidney.  When  the  ureter  of  the  unsus- 
pected kidney  is  normal  in  appearance  and  the  quan- 
tity and  quality  of  the  urine  it  secretes  are  also  nor- 
mal, and  when  additional  evidence  is  afforded  by  the 
positive  result  obtained  with  phloridzin  or  indigo 
carmine,  there  need  be  no  indecision.  When  the  ure- 
teroscopical  picture  is  uncertain,  however,  and  when 
the  result  with  phloridzin  is  likewise  uncertain,  with 
a  possible  unfavorable  discrimination  as  regards  one 
kidney,  diagnosis  is  much  more  difficult,  and  it  be- 
comes necessary  to  resort  to  all  of  the  various  meth- 
ods until  a  net  result  is  sufficiently  decisive  to  war- 
rant conclusions.  In  reaching  a  decision  in  obscure 
cases,  it  should  be  remembered  that  a  diseased  kid- 
ney may  exert  restraint  upon  the  functional  capac- 
ity of  the  opposite  organ,  especially  in  the  case  of 
phloridzin  glycosuria,  when  by  means  of  the  other 
distinctive  tests  a  sufficiently  definite  net  result  must 
be  sought  to  justify  a  satisfactory  diagnosis  prepara- 
tory to  operation.  Inasmuch  as  the  progressive  de- 
velopment of  cystoscopical  and  functional  diagnosis 
represents  so  important  an  element  in  urological 
technique,  the  skillful  routine  employment  of  these 
means  is  essential  to  the  supremacy  of  the  genito- 
urinary surgeon  in  this  field  of  surgery. 

2.  The  Principles  of  Mechanotherapy  with 
Special  Reference  to  the  Treatment  of  Ortho- 
paedic Cases. — Bucholz  remarks  that  mecliano- 
therapy  must  be  considered  an  essential  factor  in  the 
treatment  of  many  orthopaedic  conditions.  The  re- 
sult obtained  from  it  will  depend  in  a  great  measure 
on  the  correct  use  of  the  methods  and  the  experience 
of  the  surgeon  and  his  assistants.  The  treatment 
must  be  elaborated  for  each  single  case  according  to 
the  anatomical,  physiological,  and  pathological  con- 
ditions. The  most  important  instrument  in  mechano- 


therapy used  in  orthopaedics  is  the  hand  of  the  sur- 
geon, but  for  several  conditions  apparatus  are  re- 
quired for  treatment.  For  a  hospital  with  a  large 
out  patient  department,  it  is  a  preeminent  advan- 
tage to  have  at  its  disposal  a  medicomechanical  de- 
partment fitted  with  apparatus  such  as  Zander's, 
where  the  treatment,  singly  or  in  classes,  and  under 
expert  direction,  may  be  carried  on  in  a  varied  way. 
These  treatments  always  require  considerable  time, 
and  in  many  cases  for  months,  even  for  years,  treat- 
ment must  be  continued.  Therefore,  not  only  the 
amount  of  time  requireid,  but  also  the  financial  cir- 
cumstances of  the  patients,  will  make  it  impossible 
for  medicomechanical  methods  to  be  applied  by  the 
physician  himself.  He  needs  assistants,  who  must 
be  carefully  trained"  to  carry  out  his  orders.  In  many 
cases  the  physician  needs  the  help  of  the  parents  or 
other  people  who  have  no  special  training,  especially 
in  those  cases  which  require  treatment  for  years,  as, 
for  instance,  in  lateral  curvature.  The  amount  of 
improvement  in  many  of  these  cases  will  depend 
upon  the  intelligence  and  energy  of  such  assistants. 
As  far  as  possible  the  physician  should  supervise 
the  treatment,  that  he  may  change  the  prescriptions. 
A  special  advantage  of  medicomechanical  or  gym- 
nastic institutes  is  that  certain  exercises  may  be  stud- 
ied, alone  or  in  classes,  by  the  patients  and  also  by 
those  who  help  them,  under  expert  direction.  In  a 
certain  number  of  cases,  however,  the  physician 
should  not  intrust  the  treatment  to  laymen,  as,  for 
instance,  fractures  before  bony  union  is  entirely  com- 
plete, or  joint  lesions  while  any  acute  symptoms  still 
persist. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 
March  6,  igog. 

1.  Diagnosis  in  Its  Relation  to  the  Laboratory  and  the 

Bedside,  By  W.  W.  Grant. 

2.  The  Treatment  of  Erysipelas  by  Inoculation  with  a 

Specific  Vaccine, 

By  George  W.  Ross  and  W.  J.  Johnson. 

3.  A  Milk  Borne  Outbreak  of  Typhoid  Fever  Traced  to 

Bacillus  Carrier, 

By  L.  L.  Lumsden  and  William  C.  Woodward. 

4.  The  Rate  of  Cooling  of  Several  Poultice  Masses, 

By  J.  D.  PiLCHER. 

5.  The  Symptomatology  of  Prostatitis, 

By  William  Cullen  Bryant. 

6.  Treatment  of  Tuberculous  Patients  in  Their  Homes 

and  in  Places  Other  Than  Sanatoria,  with  Special 
Reference  to  the  Psychic  Side  of  Their  Management, 

By  Charles  L.  Minor, 

7.  System  in  Recording  Cases,  By  Carl  E.  Black. 

2.  The  Treatment  of  Erysipelas  by  Inocula- 
tion w^ith  a  Specific  Vaccine. — -Ross  and  Johnson 
have  a  series  of  fifty  patients,  the  first  sixteen  of 
whom  were  treated  according  to  the  opsonic  princi- 
ples of  vaccine  therapy,  but  these  revealed  such  a 
uniformly  satisfactory  immunizing  response  and 
clinical  result  that  the  authors  felt  justified  in  at- 
tempting the  administration  of  the  erysipelas  vaccine 
without  the  usual  blood  examinations.  It  seems 
reasonably  certain  that  in  the  vast  majority  of  cases 
of  erysipelas  it  will  be  unnecessary  to  be  guided  by 
estimations  of  the  opsonic  content  of  the  blood  to 
determine  either  the  amount  of  the  vaccine  indicated 
or  the  appropriate  time  for  reinoculation.  They  are 
led  to  this  belief  because,  having  once  determined  a 


554 


PITH  OF  CURRENT  LITERATURE. 


INew  York 
Medical  Journal. 


satisfactory  method  of  administration  of  the  vaccine 
by  the  close  study  of  the  blood  in  sixteen  cases  they 
achieved  equally  successful  results  in  a  series  of 
thirty-four  cases  of  erysipelas,  many  of  which  were 
severe,  without  having  had  recourse  to  the  opsonic 
index  in  any  case.  But  in  certain  severe  cases  the 
usual  thorough  blood  investigation  may  be  required. 
If  they  are  right  in  their  conclusions  that  erysipelas 
vaccine  when  properly  administered  is  a  specific 
remedy  for  erysipelas,  then  the  importance  of  being 
able  to  omit  the  laborious  opsonic  investigations  be- 
comes exceedingly  great,  for  it  puts  into  the  hand 
of  every  practitioner  of  medicine  a  new  specific  for 
an  exceedingly  troublesome  affection  for  which  as 
yet  only  a  multitude  of  remedies  of  alleged  efficacy 
is  available.  It  is  entirely  unnecessary  to  prepare  a 
vaccine  for  each  case.  It  is,  however,  advisable  to 
*  have  a  composite  stock  vaccine  derived  from  several 
dififerent  strains,  from  as  many  different  cases.  It  is 
probable  that  the  more  virulent  the  case  of  erysipe- 
las the  more  valuable  will  its  streptococcus  be  as  a 
vaccine.  The  method  of  treatment  has  been,  in 
almost  every  case,  to  inoculate  with  10,000,000  of 
the  devitalized  streptococci  on  the  first  visit  if  the 
case  is  a  severe  one,  and  with  20,000,000  if  it  is  less 
severe.  On  the  second  day  in  the  severe  case  the 
patient  gets  10,000,000  more  if  there  are  signs  of 
improvement.  The  most  important  of  these  signs  is 
a  certain  clearing  of  the  intellect,  and  the  others  are 
a  lessened  intensity  of  the  local  condition — less  ten- 
derness and  pain.  The  temperature  is  not  so  satis- 
factory a  guide,  although  a  fall  of  two  or  three  de- 
grees on  the  morning  following  the  injection  is  a 
valuable  indication  for  a  second  inoculation.  If, 
however,  no  evidence  of  improvement  obtains  in  the 
very  severe  case  and  it  is  impossible  to  determine 
the  opsonic  power  of  the  blood,  then  5,000,000  only 
should  be  administered  on  the  second  day.  In  less 
severe  cases  improvement  is  almost  invariably  mani- 
fest on  the  day  succeeding  inoculation  and  the  pa- 
tient should  receive  half  the  first  dose  ;  that  is,  10,- 
000,000.  They  then  inoculate  with  5,000,000,  10,- 
000,000,  or  20,000,000  of  streptococci  on  every  sec- 
ond day  until  a  week  after  the  temperature  has 
reached  normal  and  the  erythema  has  subsided.  They 
are  guided  as  to  the  amount  of  the  dose  in  each  case 
(when  opsonic  investigations  are  impossible  or  un- 
necessary) by  its  severity  and  the  satisfactory  re- 
sults as  shown  by  clinical  observation.  The  rule  is : 
"The  rnore  severe  the  case  and  the  less  satisfactory 
the  clinical  response  the  smaller  the  dose."  The  site 
of  inoculation  chosen  has  always  been  away  from  the 
area  involved. 

4.  The  Rate  of  Cooling  of  Several  Poultice 
Masses. — Pilchcr  has  investigated  the  rate  of 
cooling  of  poultice  masses  composed  of  various  sub- 
stances under  conditions  approaching  as  nearly  as 
possible  those  under  which  they  are  used  in  medical 
practice.  He  concludes  that  while  the  rate  of  cool- 
ing is  not  conspicuously  different  for  the  cataplasma 
kaolini  and  the  linseed  poultice  mass,  the  difference 
is  constantly  in  favor  of  the  linseed  poultice  mass. 
Dry  kaolin  cools  appreciably  faster  than  the  cata- 
plasma, while  glycerin  cools  considerably  more  slow- 
ly. ( )thcr  poultice  masses,  viz.,  oatmeal,  bread,  and 
coriimcal.  apparently  retain  their  heat  even  some- 
what better  than  the  linseed  mass  :  on  the  otlicr  hand. 


water  cools  at  about  the  same  rate  as  cataplasma 
kaolini,  and  petrolatum  a  trifle  faster. 

5.  The  Symptomatology  of  Prostatitis.— Bry- 
ant remarks  that  while  the  classical  symptoms  of 
acute  prostatitis  are  so  apparent  in  every  case, 
chronic  prostatitis  presents  a  very  different  picture. 
In  order  to  arrive  intelligently  and  correctly  at  a 
diagnosis  it  is  necessary  to  have  a  classification  of 
the  symptoms  that  can  be  followed  as  a  routine 
measure.  Bryant  follows  the  classification  of  symp- 
toms as  suggested  by  Young:  i.  Urinary;  2,  sex- 
ual ;  and  3,  referred.  The  urinary  symptoms  may 
be  manifested  by  frequency,  often  more  noticeable 
at  night  than  during  the  day ;  pain  at  the  begin- 
ning, during,  or  at  the  end  of  urination  ;  slow  or 
difficult  urination  ;  hesitation  in  starting  the  stream  ; 
urgency  and  dribbling  at  the  end  of  urination.  These 
symptoms  depend  on  the  hypersensibility  of  the  ter- 
minal nerve  filaments  supplying  the  prostate,  the 
prostatic  urethra,  and  the  neck  of  the  bladder.  And 
as  a  result  the  sensory  stimuli  are  produced  in  such 
an  excess  above  the  normal  that  there  is  a  lack  of 
coordination  in  that  apparently  simple  and  yet  ex- 
ceedingly complex  act  of  urination,  the  phenomena 
of  which  we  do  not  yet  fully  understand.  The  sex- 
ual symptoms  are  usually  manifested  first  by  dis- 
turbing and  often  painful  erections  due  to  a  condi- 
tion of  erethism,  which  after  a  time  is  followed  by 
diminished  vigor  with  imperfect  erections,  prema- 
ture ejaculation,  frequent  nocturnal  emissions,  etc. 
These  patients  are  usually  neurasthenic.  The  basis 
for  these  symptoms  lies  in  the  pathological  con- 
dition which  is  the  result  of  chronic  inflammatory 
changes  affecting  the  terminal  filaments  of  the 
pudic  nerve  in  the  prostate.-  The  phenomena  of 
erection  is  not  fully  understood,  but  experiments  on 
dogs  have  shown  that  section  of  the  pudic  nerve 
completely  abolishes  it.  The  referred  symptoms  arc 
accounted  for  as  reflections  of  the  sensory  irritation? 
received  by  the  spinal  segments  supplying  the  pros- 
tate, and  are  ascribed  as  a  sort  of  overflow,  to  the 
nerves  reaching  those  same  segments  from  other 
parts.  Thus  we  can  readily  understand  the  mean- 
ing of  intense  pruritus  ani  through  the  inferior  hem- 
orrhoidal nerve,  the  pain  and  feeling  of  weight  in 
the  perinaeum  through  the  perineal  nerves.  Patients 
with  chronic  prostatitis  very  frequently  suft'er  with 
pains  in  the  back  and  down  the  legs,  which  is  often 
diagnosticated  as  lumbago  and  sciatica,  but  which  is. 
in  fact,  referred  pain  from  the  prostate  and  is  read- 
ily explained  by  the  intimate  relation  existing  be- 
tween the  roots  of  the  pudic  nerve  with  the  sacral 
and  lumbar  plexuses.  Residual  urine  is  another 
symptom.  In  most  cases  sufficient  symptoms  are 
present  to  direct  our  attention  to  the  prostate  at 
once.  There  are  some  cases,  however,  in  which  no 
definite  symptoms  are  present,  or  at  least  the  symp- 
toms are  so  slight  that  the  patient  is  entirely  una- 
ware that  he  is  suffering  from  any  prostatic  trouble. 
Rectal  examination  usually  shows  some  irregularity 
of  the  surface  of  the  gland,  slight  enlargement,  in- 
duration, nodulation,  or  excessive  sensitiveness. 
These  signs,  too,  may  also  be  lacking  in  some  cases. 
There  is  one  definite  positive  sign,  however,  which 
is  always  pathognomonic  of  chronic  prostatitis,  and 
that  is  the  presence  of  pus  cells  in  the  prostatic  se- 
cretion. 


March  13.  1909I 


PITH  OF  CURRENT  LITERATURE. 


555 


MEDICAL  RECORD. 
March  6,  1909- 

1.  The  Zoophil  Psychosis.    A  Modern  Malady;  with  Illus- 

trative Cases,  By  Charles  L.  Dana. 

2.  Dangers  Associated  with  the  Removal  of  the  Tonsils 

and  Adenoid  Growths,  By  F.  C.  Aru. 

3.  Thymus  Enlargement  Associated  with  Nervous  Symp- 

toms.   A  Preliminary  Communication, 

By  Otto  Lerch. 

4.  The  Prevention  of  Epidemics,    By  Martin  J.  Synnott. 

5.  Perithelioma  of  the  Carotid  Gland, 

By  John  Dougl.\s. 

6.  Transfusion  of  Blood  for  Pernicious  Anaemia, 

By  Robert  Lucv. 

I.  Zoophil  Psychosis. — Dana  says  that  the 
zoophil  psychosis  is  a  modern  type  of  mental  disor- 
der belonging  among  the  psychasthenic  or  obsessive 
insanities — though  really  not  an  "insanity"  in  the 
general  sense.  It  is  characterized  by  the  tormenting 
ideas  and  worrying  fears  of  this  psychosis,  but  it 
has  underlying  it  a  morbid  affective  state,  or  as  Ray- 
mond and'  Janet  call  it  an  invraisemhlahle  amour, 
toward  certain  persons  and  animals.  This  anomaly 
of  the  emotions  is  not  usually  referred  to  as  part 
of  ordinary  types  of  this  class  of  disorders ;  but  it  is 
a  most  important  feature ;  and  it  may  even  exist  as 
the  dominant  thing  in  the  psychosis.  So  far  as  the 
zoophil  psychosis  is  concerned,  it  shows  itself  both 
in  (i)  fixed  and  tormenting  ideas  and  (2)  an  emo- 
tional hypertrophy  which  carries  a  naturally  noble 
sentiment  to  the  point  of  disease.  With  l^oth  states 
there  are  morbid  fears  and  worries.  (  i  )  The  fixed 
idea  takes  usually  the  form  of  a  kind  of  quasidelu- 
sion  that  the  anfmal  world  is  constantly  sufifering 
from  or  in  danger  of  the  brutality  of  man.  To  an 
extent  this  is  true,  but  not  to  such  extent  as  to  lead 
an  individual  to  acts  of  oppression  and  feeling  of 
alarm.  (2)  The  hypertrophy  of  affection  leads  to  a 
continual  state  of  alarm,  jealousy, and  concern  for  the 
object  beloved,  whether  it  is  a  baby,  a  dog,  or  the 
cause  of  religion.  The  psychosis  is  really  the  ex- 
pression of  a  selfish  and  weak  nature.  It  happens 
that  many  people  cannot  nowadays  go  out  into  a 
city's  streets  and  not  be  distressed  continually  at  the 
sight  of  tired,  overworked,  and  badly  driven  horses ; 
or  over  some  very  thin  looking  and  ungroomed  dogs. 
They  are  so  eager  to  observe  the  unhappy  horse  that 
they  do  not  see  the  human  sufYering.  The  animal 
being  dumb  is  helpless,  but  so  is  the  baby ;  and  so 
practically  are  the  sick  poor,  while  the  defective 
child  is  vastly  more  the  slave  of  circumstance  than 
the  dog  or  cat,  which  have  chances  everywhere. 
Dana  pleads  for  sick  humanity,  and  against  the  ex- 
cesses in  such  sentiment  for  animals,  as  leads  to  self- 
ishness and  injustice  and  the  development  of  more 
psychopathic  states.  There  is  growing  up  an  enor- 
mous mass  of  artificially  cultivated  tenderness  to- 
wards a  suppositious  suffering. 

3.  Thymus  Enlargement  Associated  with  Ner- 
vous Symptoms. — Lerch  remarks  that  the  dis- 
tinctive diagnosis  is  not  difficult  to  make.  The  ever 
present  nervous  systems  and  the  area  of  dulness 
(trapezoid),  clearing  up  on  change  of  position, 
make  it  an  easy  task  to  diagnosticate  the  affection. 
The  action  of-  the  Rontgen  rays  and  especially  of 
the  high  frequency  current  causes  a  considerable 


contraction  of  the  gland.  After  an  application  of  a 
high  freciuency  current  for  five  minutes  a  large 
gland  will  diminish  considerably  around  the  margin. 
This  fact  will  distinguish  it  from  any  other  cause 
that  might  give  dulness  on  percussion  over  the  top 
and  to  the  side  of  the  sternum,  such  as  a  tumor  in 
the  mediastinum,  enlarged  glands,  aneurysm,  or  di- 
latation of  the  aorta.  The  application  of  this  form 
of  electricity  given  without  any  danger  will  prove 
one  of  the  most  valuable  means  of  treatment,  for  to 
some  extent  the  effect  is  permanent.  Specific  medi- 
cation on  the  lines  of  thyreoid  treatment  and  surgical 
interference  in  severe  cases  may  be  tried  and  rest 
and  hygienic  treatment  can  be  carried  out  to  good 
purpose.  He  believes  that  this  affection  is  an  entity 
for  which  he  proposes  the  name  "thymokesis"  (ab- 
normally large  thymus).  The  gland  can  be  distinct- 
ly and  sharply  outlined  by  percussion  in  adults  up  to 
extreme  old  age.  In  all  individuals  he  has  so 
far  examined,  the  size  of  the  organ  when  filled 
with  blood  and  lymph  varies  froin  2  to  3  cm. 
to  12  and  14  cm.  at  the  base,  corresponding  to  the 
level  of  the  sternoclavicular  joints  and  clavicles.  The 
apex  parallel  to  the  base  may  join  the  heart  dulness. 
The  area  of  dulness  is  represented  by  a  trapezoid, 
the  lateral  sides  of  which  are  slightly  curved,  and 
which  is  sometimes  not  larger  than  a  half  dollar. 
As  a  rule  one  side,  the  right  or  left,  of  the  sternum 
is  larger  than  the  other,  more  frequently  the  right, 
and  the  dulness  is  rarely  uniform  over  the  whole,  and 
varies  from  light  dulness  to  flatness  in  circumscribed 
spots.  To  percuss  the  gland  it  is  best  to  place  the 
patient  in  an  upright  position  with  the  head  thrown 
back ;  light  percussion  and  deep  perciission  may  be 
used ;  either  method  will  outline  the  organ  distinctly 
though  not  always  exactly  corresponding.  Palpat- 
ing percussion  may  be  used  for  control.  The  results 
obtained  by  percussion  may  be  verified  by  the  radio- 
graph and  fluoroscopic  examination.  Abnormal  at- 
rophy of  the  gland  has  been  found  associated  with 
progressive  and  fatal  marasmus,  and  the  enlarge- 
ment of  the  organ  is  due  to  congestion,  oedema,  and 
hyperplasia. 

5.  Perithelioma  of  the  Carotid  Gland. — Doug- 
las reviews  the  cases  which  so  far  have  been  re- 
ported and  states  that  it  appears  that  in  the  begin- 
ning these  tumors  are  benign  in  their  nature.  But 
the  history  of  the  appearance  of  rapid  increase  in  the 
rate  of  growth,  the  report  of  enlarged  glands  in  six 
cases,  and  of  recurrence  after  operation  in  six  cases, 
while  one  patient  died  of  malignancy  without  opera- 
tion, shows  that  a  considerable  number  of  these  cases 
become  malignant  that  were  apparently  benign  in 
the  beginning.  We  wait  to  operate  until  malignancy 
is  apparent  the  chance  of  recurrence  is  greater,  as 
well  as  the  difficulty  and  seriousness  of  the  opera- 
tion is  increased,  and  the  prospect  of  cure  is  certain- 
ly not  good.  In  but  few  of  the  cases  reported  was  a 
correct  diagnosis  made  before  operation,  and  it 
would  appear  that  by  calling  attention  to  the  exist- 
ence of  these  tumors,  an  opportunity  might  be  ob- 
tained of  operating  before  they  had  attained  a  great 
size,  and  the  operator  knowing  with  what  he  had  to 
deal  could  by  free  incision  and  careful  dissection, 
and  an  accurate  knowledge  of  the  anatomy  of  the 
region,  avoid  injury  to  the  nerves  which  in  several 


556 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


cases  has  been  one  of  the  causes  of  the  high  mortal- 
ity and  disagreeable  after  results  of  operation.  In 
view  of  these  facts,  while  recognizing  that  there  may 
be  a  certain  number  of  cases  where  a  large  but  slow- 
ly growing  tumor,  without  evidence  of  malignancy, 
exists  in  a  patient  whose  age  or  whose  general  or 
arterial  condition  would  make  the  danger  of  post- 
operative shock,  or  of  brain  disturbance  after  liga- 
tion of  the  carotids,  especially  great,  in  whom  oper- 
ation would  be  inadvisable ;  it  would  appear  to  the 
writer  that  instead  of  advising  against  operation  in 
all  cases  until  rapid  growth  or  malignancy  occurs, 
more  good  could  be  accomplished  by  an  effort  at 
early  diagnosis  and  removal  of  the  tumor  while  the 
risk  is  less,  and  the  prospect  of  lessened  mortality 
and  of  an  ultimate  cure  without  recurrence  greater. 

BRITISH  MEDICAL  JOURNAL. 
February  20,  1909. 

1.  John  Hunter  as  a  Philosopher  (Hunterian  Oration), 

By  H.  Morris. 

2.  The  Importance  of  Early  Diagnosis  with  a  View  to 

Successful  Treatment,        By  A.  W.  Mayo  Robson. 

3.  The  Pathology  of  Syphilis  of  the  Nervous  System  in 

the  Light  of  Modern  Research  (Morison  Lectures), 

By  F.  W.  MoTT. 

4.  On  the  Early  Diagnosis  of  Cancer  of  the  Tongue,  and 

on  the  Results  of  Operations  in  Such  Cases, 

By  H.  T.  BuTLiN. 

5.  Unna's  Method  of  Treating  Ulcers  of  the  Leg, 

By  G.  Pernet. 

3.  Syphilis. — Mott,  in  the  first  of  his  Morison 
lectures,  discusses  and  describes  the  newly  discov- 
ered aetiology  of  syphilis,  the  syphilis  spirochaeta, 
and  the  relation  between  syphilis,  sleeping  sickness, 
dourine,  and  other-  conditions.  The  morbid  tissue 
changes  in  syphilis  are  similar,  whether  the  lesion 
is  a  primary  sore  or  a  gumma  twenty  years  later. 
It  is  difficult  to  understand  how  the  spirochasta,  see- 
ing that  it  has  hardly  ever  been  found  in  ter- 
tiary lesions,  can  produce  the  same  specific  cell 
hyperplasia  so  long  after  the  primary  infection. 
The  following  hypotheses  may  be  put  forward  to 
explain  the  phenomena  of  a  gumma  appearing 
spontaneously  in  the  central  nervous  system  long 
after  the  primary  sore  and  apparent  cure  of  the  dis- 
ease. I.  The  spirochaeta,  or  some  modified  form  of 
it,  has  remained  latent  in  the  tissues  at  the  seat  of 
the  lesion,  and,  for  some  reason,  inherent  or  other- 
wise, the  resistance  of  the  tissues  at  that  particular 
spot  has  become  lowered,  and  the  organism  has 
again  exerted  its  specific  activity — possibly  in-  some 
not  yet  discovered  intracellular  form.  2.  The  spe- 
cific organism  has  remained  latent  in  some  other 
tissue — for  example,  the  bone  marrow,  the  spleen, 
or  glands — and  escaping  into  the  blood  or  lymph 
circulation,  has,  like  a  new  growth,  engendered  a 
metastasis,  which  has  developed  and  increased,  pro- 
ducing a  hyperplasia  of  the  fixed  tissue  cell  ele- 
ments, conjunctival  and  epithelial.  3.  There  may 
be  varieties  of  specific  spirochaetae,  one  of  which 
may  have  an  elective  affinity  for  the  central  nervous 
system,  just  as  the  Trypanosoma  gambiense  has. 
4.  The  invasion  of  the  body  by  the  spirochaetae  has 
altered  the  blood  and  lymph  biochemically,  so  that 
the  tissue  reactions  to  all  causes  which  would  lead 
to  injury  may  take  on  a  specific  character.    In  the 


second  lecture  he  discusses  the  Wassermann  and 
other  reactions  for  the  diagnosis  of  syphilis,  and 
summarizes  his  observations  as  follows:  The 
original  method  of  Wassermann  is  the  most  com- 
plicated but  the  most  specific  and  the  most  reliable. 
All  the  evidence  goes  to  prove:  i.  That  these 
methods  in  the  hands  of  competent  observers  af- 
ford a  valuable  means  of  diagnosis,  and  are  espe- 
cially useful  when  applied  to  the  cerebrospinal  fluid 
for  the  determination  of  the  existence  or  not  of 
general  paralysis.  2.  That  similar  substances, 
whether  antibodies  or  not,  occur  in  the  serum  of 
syphilitic  and  parasyphilitic  persons  in  such  quanti- 
ties as  are  not  found  in  the  serum  of  normal  per- 
sons or  in  the  sera  of  people  suffering  with  other 
diseases.  3.  That  similar  substances  are  found  in 
the  cerebrospinal  fluid  of  tabetics  and  general  par- 
alytics, and  the  amount  of  these  substances  which 
cause  a  deviation  of  the  complement  or  a  precipita- 
tion is  in  proportion  to  the  activity  and  length  of 
duration  of  the  disease ;  that  these  substances  are 
of  tissue  origin,  or  arise  from  tissue  destruction 
caused  in  some  way  by  the  action  past  or  present  of 
the  syphilitic  virus.  4.  It  is  probable  that  the  syph- 
ilitic virus  excites  an  increased  unloosening  of  com- 
plex lipoid  substances  containing  lecithin  and  cho- 
lesterin,  etc.,  from  the  red  corpuscles  and  cells  of 
the  body.  5,  That  this  prevails  through  life,  and  in- 
certain  cases  of  syphilitic  infection — namely,  gen- 
eral paralysis  and  tabes — ^the  central  nervous  sys- 
tem, which  under  ordinary  circumstances  is  pro- 
tected against  the  loss  of  its  lipoid  substances,  takes 
part  in  the  process,  and  this  is  manifested  by  the 
presence  of  lipoid  and  globulin  in  the  cerebrospinal 
fluid  which  acts  as  the  antibody  in  the  reaction. 
This  lipoid  complex,  as  well  as  globulin,  increases 
in  amount  as  the  process  of  neuronic  decay  pro- 
ceeds. It  is  probably  owing  to  the  presence  of 
these  substances  that  the  granulation  of  the  ven- 
tricles, so  characteristic  a  feature  of  general  par- 
alysis, arises  as  a  result  of  stimulation  to  prolifera- 
tive hyperplasia  of  the  ependymal  epithelium. 
Choline  may  also  be  present  owing  to  decomposition 
of  lecithin,  but  this  may  occur  in  any  active  degen- 
erative process  of  the  myelin,  and  is  not  path- 
ognomonic of  any  particular  disease. 

5.  Unna's  Treatment  of  Leg  Ulcers. — Pernet 
describes  the  method  of  treating  varicose  ulcers  of 
the  leg  according  to  Unna.  The  ulcer  is  first 
cleaned  up  with  a  i  in  2,000  bichloride  of  mercury 
solution,  and  its  floor  is  then  dusted  with  iodoform. 
Unna's  gelatin  paste  is  painted  on  the  parts  sur- 
rounding but  not  on  the  ulcer  itself.  Next  comes 
the  crux  of  the  whole  matter.  A  stout  two  headed 
three  inch  muslin  bandage  is  wrung  out  in  warm 
water,  and  the  middle  of  the  bandage  is  placed  on 
the  leg  opposite  the  ulcer,  and  the  first  turn  is  made 
with  pressure  vigorous  enough  to  reduce  the  diam- 
eter of  the  limb,  the  bandage  being  brought  well 
over  the  ulcer.  The  bandage  is  then  taken  around 
the  leg  with  firm  pressure,  especially  over  the  actual 
ulcer,  the  liquefied  Unna's  paste  being  painted  on 
the  wet  bandage  as  it  is  applied.  Two  or  three 
bandages  can  be  put  on  in  this  way.  The  result  is 
a  splint  which  allows  patients  to  go  about  their 
work  as  usual. 


March  13,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


557 


LANCET. 

February  20,  igog. 

1.  John  Hunter  as  a  Philosopher  (Hunterian  Oration), 

Bj-  H.  Morris. 

2.  Purulent  Encephalitis,  By  C.  E.  West. 

3.  Simple  Methods  of  Diagnosis  in  Diseases  of  the  Stom- 

ach, By  A.  E.  Barnes. 

4.  A  Case  of  Ship  Beriberi  Associated  with  an  Erythema- 

tous Eruption,  By  T.  K.  Monro. 

5.  Some  Notes  on  the  Interpelvic-Abdominal  Amputation, 

with  a  Report  of  Three  Cases,      By  J.  H.  Prixgle. 

6.  A  Historical  Instance  of  the  Adams-Stokes  Syndrome 

Due  to  Heartblock, 

By  G.  A.  Gibson  and  W.  T.  Ritchie. 

7.  Henoch's  Purpura  and  Intussusception,      By  H.  Lett. 

8.  Torsion  of  Pedicle  in  Two  Cases  of  Fibromyoma  of 

the  Blood  Ligament,  By  E.  C.  Be\-ers. 

9.  A  Case  of  Thrombosis  of  the  Cavernous  Sinus,  to- 

gether with  Brief  Pathological  and  Bacteriological 
Notes,  By  S.  Stephenson. 

10.  Motoring  Notes,  By  C.  T.  \V.  Hirsch. 

2.  Purulent  Encephalitis. — West  reports  a  case 
illustrating  the  condition  which  he  gives  the  name 
of  purulent  encephahtis  rather  than  cerebral  abscess, 
because,  \vhile  there  is  an  abscess  of  the  brain  in 
some  of  these  cases,  it  is  but  a  part  of  the  disease 
and  bears  the  same  relation  to  the  whole  as  the  small 
collection  of  pus  in  the  centre  of  an  area  of  cellulitis 
does  to  the  total  of  that  condition.  In  septic  infec- 
tions of  the  brain,  we  meet  with  two  classes  of  cases 
—  (a)  localized  and  clearly  delimited  abscesses,  of 
grave  risk  to  the  patient,  but  which,  if  correctly 
diagnosticated  and  operated  on,  leave  a  good  chance 
for  the  patient's  recovery;  and  (b)  conditions  of 
diffuse  infection  which  may  or  may  not  be  accom- 
panied by  the  formation  of  pus,  but  in  which  the 
opening  of  a  collection  of  pus,  if  such  is  present, 
affords  but  a  slight  degree  of  relief  and  has  little  or 
no  effect  on  the  ultimate  fate  of  the  patient.  The 
problem,  as  in  all  cases  of  spreading  infection,  is  to 
give  such  efficient  drainage  as  to  enable  the  process 
to  be  cut  short.  The  case  here  reported  presented 
a  picture  of  cerebral  compression  with  the  features 
of  an  ordinary  septic  illness.  The  commencement 
of  cerebral  compression  was  evidenced  by  the  slow- 
ing of  the  mental  processes.  Hardly  any  other  con- 
dition except  that  of  diffuse  cortical  meningitis  is 
accompanied  by  headache  of  such  intensity  as  that 
of  encephalitis.  At  the  operation,  after  opening  the 
skull  and  dura  mater,  the  brain  substance  was  boldly 
scooped  away  with  a  \*olkmann's  spoon  until  the 
sloughing  tissues  were  widely  exposed  and  in  large 
part  removed.  The  cavity  thus  formed  was  quickly 
filled  by  the  flowing-in  of  the  semifluid  brain.  No 
fear  was  felt  as  to  the  possibility  of  the  creation  of 
a  hernia  cerebri ;  it  is  only  when  there  is  increased 
intracranial  pressure,  from  inflammation,  or  from  in- 
crease of  the  bulk  of  the  contents  of  the  cranium 
by  some  cause,  that  the  protrusion  of  the  brain  takes 
place.  Xever  attempt  to  restrain  the  occurrence  of 
a  hernia  cerebri ;  seek  to  remove  its  cause.  No 
patient  ever  died  of  a  hernia  of  the  brain,  but  many 
have  died  from  want  of  one.  Though  the  operation 
was  a  severe  one,  there  was  practically  no  shock, 
and  three  days  later  the  patient  was  well  on  the  road 
toward  recovery.  The  widely  open  wound  behind 
and  above  the  ear  was  successfully  closed  by  means 
of  a  plastic  operation.  The  mental  condition  of  the 
patient  apparently  left  nothing  to  be  desired. 

3.  Diagnosis  in  Diseases  of  the  Stomach. — 
Barnes  describes  some  of  the  simple  methods  of 


diagnosis  in  diseases  of  the  stomach,  and  the  con- 
clusions to  be  drawn  from  the  results  obtained.  The 
condition  of  the  tongue  is  of  little  value  as  an  index 
to  the  condition  of  the  gastric  mucosa.  A  mucous 
pharyngitis,  however,  is  common  in  cases  of  mucous 
gastritis  and  the  treatment  of  the  pharynx  will  bene- 
fit the  gastric  condition.  A  narrow  waist  should 
always  lead  to  a  special  investigation  for  gastrop- 
tosis  and  pyloric  spasm.  In  most  cases  the  lower 
border  of  the  stomach  may  be  seen  as  a  faint  groove 
moving  down  the  abdomen  on  inspiration.  Visible 
gastric  peristalsis  is  of  great  importance,  as  it  is 
diagnostic  of  pyloric  obstruction,  whether  due  to 
spasm  or  to  organic  disease.  A  succussion  splash  is 
only  of  value  when  obtained  at  a  time  when  the 
stomach  should  be  empty,  or  over  an  area  not  nor- 
mally occupied  by  the  stomach.  The  diagnostic  fea- 
ture of  hypersecretion  of  the  stomach  is  the  vomit- 
ing of  large  quantities  of  acid  gastric  juice,  green- 
ish blue  in  color.  It  can  be  diagnosticated  by  finding  a 
large  amount  of  fluid  in  the  stomach,  usually  in  spite 
of  the  fact  that  large  quantities  have  been  vomited 
during  the  night.  Hypersecretion  occurs  as  a  sec- 
ondar}-  phenomenon  in  ulcer  and  dilatation  from  be- 
nign stenosis.  Hyperchlorhydria  is  a  more  common 
condition.  The  chief  features  are  the  character  of 
the  pain,  which  comes  on  at  the  height  of  digestion 
and  is  relieved  by  taking  more  food.  Ulcer  and 
dilatation  must  be  excluded.  Acute  gastritis  has 
chiefly  to  be  separated  from  surgical  abdominal 
catastrophes.  In  chronic  gastritis,  the  diagnostic 
feature  is  the  finding  of.  mucus  in  the  w^ash  water 
after  early  morning  laraye.  These  flakes  of  mucus 
sink  to  the  bottom.  The  acidity  is  diminished,  but 
.lactic  acid  is  not  present  as  the  motor  powers  are 
normal.  In  achylia  gastrica  there  may  be  very  few 
subjective  symptoms,  due  to  the  fact  that  the  stom- 
ach may  be  able  to  force  the  food  on  into  the  intes- 
tines which  can  do  the  work  of  both  organs.  The 
motor  powers  may  fail  or  a  chronic  enteritis  be  set 
up.  A  surgeon  should  be  called  in  in  the  following 
cases:  i.  Where  there  is  diminished  acidity  com- 
bined with  motor  insufficiency.  2.  Where  a  middle 
aged  person  begins  to  suffer  from  indigestion  with 
anorexia  and  loss  of  weight,  with  diminished  acidity. 
^Many  of  thes^  cases  are  due  to  cancer.  3.  All  cases 
nf  long  standing  ulcer  where  wasting  is  progressive ; 
where  there  is  rigidity  of  the  right  rectus  or  where 
occult  blood  persists  in  the  stools.  4.  All  cases  of 
pyloric  tumor  whether  palpable  or  only  inferred 
from  the  presence  of  exaggerated  peristalsis.  In 
cases  of  nervous  dyspepsia  the  only  abnormalities 
likely  to  be  found  are  visceroptosis  and  pyloric 
spasm,  with  a  certain  degree  of  hyperchlorhydria. 
Other  suggestive  features  are  the  lack  of  relation 
between  the  pain  and  meal  times,  the  sudden 
changes  in  the  symptoms,  the  good  general  nutri- 
tion, and  the  nervous  symptoms  apart  from  the 
stomach.  In  young  women  the  diagnosis  from 
ulcer  is  often  difficult.  Attempts  have  been  made 
by  several  investigators  to  diagnosticate  cancer  by 
means  of  the  "perceptive"'  reactions.  They  have  all 
failed  because  it  was  impossible  to  get  the  "cancer 
albumin"  free  from  the  other  normal  albumina  of 
the  animal  body. 

7.    Henoch's  Purpura  and  Intussusception. — 

Lett  considers  Henoch's  purpura  from  a  surgical 


558 

point  of  view,  and  discusses  the  distinctive  diagno- 
sis of  that  condition  and  intussusception,  and  also 
the  diagnosis  of  an  intussusception  occurring  dur- 
ing an  attack  of  Henoch's  purpura.  In  both  condi- 
tions the  pain  is  of  sudden  onset,  paroxysmal,  and 
severe.  The  joint  pains  of  pupura  are  as  a  rule  tem- 
porary, and  become  insignificant  when  the  abdom- 
inal symptoms  arise.  If  severe  vomiting  is  present 
from  the  beginning,  and  especially  if  the  vomit  con- 
tains blood,  the  probabilities  are  strongly  against 
the  case  being  one  of  intussusception.  In  purpura 
as  a  rule  the  abdomen  is  not  tender,  but  it  may  be 
distended  and  resistant.  In  intussusception  the 
abdomen  is  neither  distended  nor  tender  at  first, 
though  the  intussusception  itself  is  tender.  The 
crucial  test,  however,  is  the  presence  of  a  tumor. 
In  twenty-four  cases  of  intussusception  operated  on, 
a  tumor  was  felt  throtigh  the  abdominal  wall  or  by 
the  rectum,  in  all.  It  is  sausage  or  kidney  shaped, 
and  during  an  attack  of  pain  becomes  more  definite. 
It  is  freely  moveable  and  can  often  be  partially  re- 
duced by  manipulation. 

LA  PRESSE  MEDICALE. 

February  6,  igog. 

1.  Dietetic  Considerations  apropos  of  an  Obese  and  Ace- 

tonsemic  Diabetic,     By  L.  Landouzy  and  J.  Cottet. 

2.  The  Reaction  of  Cammidge  and  its  Relations  with  Pan- 

creatic Lesions,  By  H.  Labbe. 

J.    Tetany,   the   Tetanoid    State,   and   the  Parathyreoid 

Gland,  By  R.  Rom  me. 

4.    Practical  Apparatus  to  Determine  Nasal  Permeability, 

By  _R0BERT-F0Y. 

1.  Dietetic  Consideration  in  Diabetes. — Lan- 
douzy and  Cottet  report  a  case  in  which  an  obese 
man  suffering  from  diabetes  and  acetonjemia  had 
both  his  glycosuria  and  acetonuria  disappear  under 
the  influence  of  a  milk  diet. 

4.  Apparatus  to  Determine  Nasal  Permeability. 
— Robert-Foy  describes  an  apparatus  intended  to 
measure  the  vapor  function  of  nasal  respiration  by 
which  the  rhinologist  can  register  the  results  of  sur- 
gical treatment  and  observe  the  progress  of  treat- 
ment directed  to  reeducation  of  this  function. 

February  10,  igog. 

1.  A  New  Buccal  Streptococcus,   By  Professor  H.  Roger. 

2.  Alopecia  of  Dental  Origin,        By  Rousseau-Decellk. 

3.  Trepanation   and   Curettage   of   the   Maxillary  Sinus 

through  the  Nose,  By  Georges  Mahu. 

2.  Alopecia  of  Dental  Origin. —  Rousseau-De- 
celle  gives  the  following  characteristics  of  alopecia 
ascribed  first  by  Jacquet  to  dental  troubles.  It  often 
follows  a  painful  attack  of  trigeminal  neuralgia 
caused  by  the  teeth  (eighteen  out  of  twenty-five 
cases).  This  attack  may  precede  the  depilation  by 
two  or  three  months,  but  more  commonly  it  occurs 
in  the  preceding  month.  2.  It  occurs  on  the  same 
side  as  the  trigeminal  attack,  more  frequently  on 
the  left  side  because  dental  lesions  are  more  com- 
mon on  the  left  side.  3.  It  appears  by  preference 
in  certain  predisposed  zones  as  if  there  was  a  rela- 
tion between  the  seat  of  the  dental  irritation  and  the 
seat  of  the  initial  area  of  alopecia.  Thus  in  sixteen 
cases  of  trouble  with  the  lower  wisdom  tooth  the 
author  found  alopecia  localised  on  the  same  side  of 
the  nucha  in  fourteen.  4.  It  follows  alveolar  and 
gingival  irritation  rather  than  dental  irritation 
proper.  Thus  in  twenty-five  cases  of  dental  alope- 
cia the  author  traced  the  cause  in  three  cases  to  in- 


[New  York 
Medical  Jour}jai.^ 

flammation  of  the  dental  pulp,  in  the  remaining- 
twenty-two  to  troubles  outside  the  teeth.  These 
irritations  seem  to  act  differently  upon  the  trige- 
minus. 5.  It  is  accompanied  by  certain  phenomena, 
such  as  hypersesthesia,  erythrosis,  hyperthermia, 
adenopathy,  lymphangeitis,  and  oedema,  grouped 
by  Jacquet  under  the  name  of  the  dental  syndrome. 
6.  The  areas  are  generally  small  in  size  and  few  ia 
number.  7.  The  prognosis  is  good.  8.  The  cure 
is  rapid  and  often  immediate  after  dental  interven- 
tion alone. 

3.  Trepanation  and  Curettage  of  the  Maxillary 
Sinus  through  the  Nose. — Mahu  cuts  a  quadri- 
lateral opening  into  the  .sinus  through  the  wall  in 
the  inferior  meatus  of  the  nose,  and  through  this  is 
able  to  curette  the  cavity. 

LA  SEMAINE  MEDICALE. 
February  jo,  igog. 
Surgical  Treatment  of  Generalised  Purulent  Peritonitis. 
Its  Evolution  and  Present  Position,      By  F.  Moty. 

BERLINER  KLINISCHE  WOCHENSCHRIFT, 
February  i,  igog. 

1.  Psychic  Causes  of  Mental  Disturbances,    By  E.  Meyer. 

2.  Bilateral  Lesions  of  the  Optic  Nerve  in  Oxycephalus, 

By  J.  Hirschberg  and  E.  Grunmach. 

3.  Laparocolpohysterotomy    (a   Combination   of  Ritgen's 

Gastroelytrotomy  and  the  Vaginal  Csesarean  Section) 
as  a  New  Treatment  in  Cases  of  Narrow  Pelvis, 

By  A.  DiJHRSSEN. 

4.  The  Application  of  the  Vaginal  Csesarean  Section  in 

Narrow  Pelves  (Laparocolpohysterotomy), 

By  Ernst  Solms. 

5.  Treatment  with  Kuhn's  Lungs  Suction  Mask, 

By  F.  GuDSENT. 

6.  lodophilia  of  the  Leucocytes  in  Dermatological  Af- 

fections, By  STiJMPKE. 

7.  X  Ray  Measurement  in  Practice, 

By  Felix  Davidsohn. 

8.  The  Manual  Artificial  Respiration  of  Adults, 

By  LoEWY  and  Meyer. 

9.  A  Case  of  Arachnitis  Circumscripta  Syphilitica  of  the 

Posterior  Fossa  of  the  Skull  that  was  Operated  on, 

By  Ernst  Unger. 

10.  A  Special  Method  of  Investigation  of  the  Prevent 

ive  and  Curative  Values  of  Medicaments  in  Trypan- 
osomiasis, By  D.  Ottolenghi. 

11.  Medicolegal  Desires  for  the  Reform  of  the  Criminal 

Code,  By  F.  Strassmann. 

1.  Psychic  Causes  of  Mental  Disturbances.— 

Meyer  maintains  that  psychic  causes  play  a  greater 
part  in  the  origin  of  mental  diseases,  even  with 
hysteria  excluded,  than  is  usually  supposed. 

2.  Bilateral  Lesions  of  the  Optic  Nerve  in  Oxy- 
cephalus.— Hirschberg  reports  a  case  of  incom- 
plete atrophy  of  the  optic  nerves  of  inflammatory 
origin  in  a  girl,  eighteen  years  old,  who  had  oxyce- 
phalus. Grunmach  portrays  the  way  in  which  the 
conformation  of  the  skull  is  responsible  for  this 
condition  of  the  nerves,  and  finally  recommends  that 
on  account  of  the  danger  of  optic  atrophy  lumbar 
puncture  should  be  performed  in  these  cases  as  early 
as  possible  in  order  to  reduce  the  intracranial  pres- 
sure, and  if  this  proves  insufficient  to  trephine  the 
skull. 

3.  Laparocolpohysterotomy.  —  Diihrssen  con- 
cludes that  the  efforts  to  perform  both  the  vaginal 
and  the  ventral  Cresarcan  section  extraperitoneally 
are  to  be  commended,  but  that  the  methods  hitherto 
employed  are  imperfect  because  with  them  the  peri- 
tonaeum is  unintentionally  or  intentionally  opened. 
The  combination  of  Ritgen's  gastroelytrotomy  with 


PITH  OF  CURRENT  LITERATURE. 


March  13,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


559 


the  vaginal  Csesarean  section  gives  a  truly  extra- 
peritoneal method  which  the  author  terms  laparocol- 
pohysterotomy.  It  presents  also  the  following  ad- 
vantages :  It  does  not  require  elevation  of  the  pel- 
vis, whereby  the  danger  of  air  emboli  is  avoided 
and  the  p>erformance  of  the  operation  in  a  private 
house  is  rendered  possible.  It  allows  of  excellent 
drainage  from  the  vagina.  While  the  laparotomy 
wound  can  be  entirely  closed  and  the  integrity  of 
the  abdominal  wall  maintained  everything  else  can 
be  left  unsutured  in  septic  cases  and  open  wound 
treatment  instituted.  The  technique  of  the  vaginal 
Csesarean  section  is  simplified  by  the  combination. 
The  author  recommends  that  when  the  obstacles  are 
due  to  the  soft  parts  and  cannot  be  overcome  by 
milder  measures  to  perform  the  vaginal  Cjesarean 
section  alone,  but  when  the  obstacles  are  in  the  bony 
tissues  to  perform  laparocolpohysterotomy,  which 
he  believes  will  supplant  artificial  induction  of  pre- 
mature labor,  the  classical  Caesarean  section  even  in 
aseptic  cases,  hebosteotomy,  perforation  of  the  liv- 
ing child,  prophylactic  version,  and  the  high  for- 
ceps. 

4.  Vaginal  Caesarean  Section  in  Narrow  Pelves. 

— Solms  endorses  strongly  the  operation  of  lapa- 
rocolpohysterotomv  just  described  by  Diihrssen. 

5.  Treatment  with  Kuhn's  Lungs  Suction 
Mask. — Gudsent  presents  in  tabulated  form  the 
results  he  obtained  from  this  form  of  treatment  in 
seven  cases  of  anaemia  and  chlorosis.  Xone  of  the 
cases  presented  any  bad  after  etifects  and  none  grew 
worse  objectively.  Two  cases  may  be  looked  upon 
as  cured,  whether  permanently  or  not  remains  to 
be  seen.  In  three  cases  there  was  a  continuous 
objective  and  subjective  improvement  un(til  the 

treatment  was  discontinued.  In  two  cases  the  treat- 
ment was  continued  but  a  short  time,  one  for  six 
weeks,  when  an  objective  improvement  was  to  be 
observed,  the  other  only  eighteen  days,  too  short  a 
time  for  any  result  to  be  obtained. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 
February  2,  1909. 

1.  Partial  Functions  of  the  Cells,  By  Ehrlich. 

2.  The  Localization  of  the  Curvature  and  Other  Points  in 

the  Treatment  of  Scoliosis,  By  Fraenkel. 

3.  The  X  Rays  in  Therapeusis,  By  Muller. 

4.  Undesired  Results  after  Colpocoliotomy  and  Ale.xander 

Adams'  Operation.  By  Frel'xd. 

5    The  Methods  of  Practical  Disinfection  in  Cities, 

By  Tr.\utmann. 

6.    Checking  of  Haemorrhage  from  the  Cystic  Artery  by 
Ligation  of  the  Arteria  Hepatis  Propria,    By  Kehr. 

7-    1  lie"  Action  of  Pneumin,  a  Preparation  of  Creosote,  in 
Tuberculosis,  By  EscHBAUjr. 

8.    Treatment  with  Arsenic.  By  vox  der  Veldex. 

9    The  Use  of  Scarlet  Red  in  Affections  of  the  Eye, 

By  WoLFRUM  and  Cords. 

TO.  Preliminary    Communication    Concerning  Treatment 
with  "IK"  Immune  Bodies,  By  Herzberg. 

11.  Dental  Frontal  Headache,  By  Muller. 

12.  A  New  Dilator  of  the  Uterus,  By  Oberl.\xder. 
i.^.  The.  Use  of  Digestive  Means  in  Purulent  and  Tuber- 
culous Processes.  Bv  Mayer. 

14-  Pari  Ehrlich,  By  Wassermaxx. 

15.  A  Relief  Expedition  into  Calabria,  By  Hesse. 

3.  X  Rays  in  Therapeusis. — ^Miiller  presents  a 
glowing  account  of  the  benefits  obtained  from  the 
use  of  the  x  rays  in  various  forms  of  skin  diseases, 
tumors,  blood  diseases,  bronchial  asthma,  enlarge- 
ment of  the  thvreoid  gland,  and  diseases  of  the  pros- 
tate. 

4.  Undesired  Results  after  Operations.— Freund 


reports  ten  cases  in  which  the  uterus  was  fixed  in  a 
bad  position  by  cicatrices  after  colpocoliotomy,  or 
Alexander  Adams'  operation. 

6.  Checking  of  Haemorrhage  from  the  Cystic 
Artery  by  Ligation  of  the  Hepatic  Artery  Proper. 
— Kehr  reports  a  case  in  which  a  cystectomy  was  fol- 
lowed by  a  severe  haemorrhage  from  the  cystic  ar- 
tery, which  was  checked  by  ligation  of  the  hepatic 
artery  proper. 

9.  Scarlet  Red  in  Diseases  of  the  Eye. — Wolf- 
rum  and  Cords  show  by  their  experiments  on  the 
eyes  of  rabbits  that  it  is  probable  that  scarlet  red 
has  a  beneficial  influence  upon  ulcerative  processes 
in  the  cornea.  The  communication  is  of  a  prelimi- 
nary character. 

10.  Treatment  with  Immune  Bodies. — Herz- 
berg briefly  mentions  his  experiments  with  immune 
bodies  and  states  that  they  decidedly  act  sf>ecifically, 
that  they  heal  advanced  tuberculosis  of  the  lungs  in 
a  markedly  short  time,  and  that  they  produce  a  cure 
in  mild  and  moderately  severe  cases  of  pulmonary 
tuberculosis  without  exception. 

12.  A  New  Dilator  of  the  Uterus. — Oberlander 
describes  a  dilator  which  difTers  from  the  double  di- 
lator devised  by  Landau  only  in  that  the  ends  are  not 
cylindrical,  but  conical. 

AMERICAN  JOURNAL  OF  OBSTETRICS. 

February,  iQOg. 

1.  Evolution  in  the  History  and  Treatment  of  Uterine 

Fibroids,  By  A.  Vanderveer. 

2.  A  Plea  for  the  more  frequent  Performance  of  Caesar- 

ean Section,  By  L.  M.  Allex. 

3.  The  Best  Methods  of  promptly  terminating  the  First 

Stage  of  Labor  with  special  Reference  to  Vaginal 
Cesarean  Section,  By  H.  D.  Fry. 

4.  An  Analysis  of  Eighty  Consecutive  Cases  of  Ectopic 

Gestation,  By  R.  T.  Fraxk. 

5.  The  Prophylactic  Treatment  of  the  Psychical  Results 

of  Surgical  Diseases,  By  C.  M.  Rakestr.\u. 

6.  The   Causes   of  Death   of  the   Viable   Foetus  before 

Labor,  By  F.  A.  Dormax. 

7.  Foetal  Mortality  during  Labor,  its  Cause  and  Preven- 

tion (not  including  Pelvic  Deformity), 

By  S.  Marx. 

8.  Some  Unusual  Results  following  Cholecystotomv 

By  E.  W.  Hedges. 

9.  Abdominal  Surgery  in  the  Aged,     By  J.  G.  Sherrill. 

10.  Abdominal  Surgery  without  detached  Pads  or  Sponges, 

Bv  H.  S.  Crossex. 

11.  Infantile  Mortality  in  Early  Life.        By  A.  Brothers. 

12.  The  Relation  of  Cyclical  Vomiting  in  Children  to  Ap- 

pendicitis, By  C.  G.  CuMSTOX. 

2.  A  Plea  for  the  More  Frequent  Perform- 
ance of  Caesarean  Section. — Allen  concludes  that 
it  is  of  the  first  importance  to  determine  for  or 
against  Caesarean  section  in  advance  of  labor  in  as 
large  a  proportion  of  cases  as  possible.  The  prog- 
nosis of  natural  labor  depends  upon  the  capacity  of 
estimating  in  advance  the  obstacles  of  the  pelvis, 
the  characteristics  of  the  head,  and  the  maternal 
muscular  powers.  It  is  far  more  important  to  study 
the  relation  between  the  first  two  than  to  lay  so 
much  stress  upon  the  exact  measurements  of  either. 
The  fatal  cases  from  Caesarean  section  are  usually 
those  which  are  performed  late  in  labor  and  after 
infection  has  taken  place.  The  high  mortality  even 
with  hysterectomy  would  indicate  craniotomy  as  the 
proper  procedure.  In  the  clean  cases  there  is  little 
mortality  and  greater  improvement  is  probable. 
The  hope  for  the  future  is  that  the  general  prac- 
titioner will  seek  the  aid  of  the  specialist  when  he 
first  feels   anxiety  about   pregnancy  or   labor  and 


56o 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
MEDICAL  Journal. 


after  the  prospects  of  both  mother  and  child  have 
been  compromised  bv  exhaustion. 

3.  The  Best  Methods  of  Promptly  Terminating 
the  First  Stage  of  Labor,  with  Special  Reference 
to  Vaginal  Caesarean  Section. — Fry  makes  the 
following  deductions  as  the  result  of  his  studies:  i, 
Any  method  for  terminating  artificially  the  first 
stage  of  labor  should  be  selected  in  accordance  with 
the  condition  of  the  parts  to  be  dilated.  2,  Such 
conditions  pertain  to  the  opening  of  the  internal  os, 
canalization  of  the  cervix,  and  dilation  of  the  ex- 
ternal OS.  3,  The  indications  for  manual  dilatation 
and  cervical  incisions  should  be  restricted  to  those 
cases  in  which  the  cervix  is  efifaced  and  the  resist- 
ance of  the  external  os  only  is  to  be  overcome.  4, 
The  manual  method  will  meet  the  requirements  of 
a  large  percentage  of  the  cases,  cervical  incisions 
being  rarely  demanded  unless  there  is  some  patho- 
logical lesion  of  the  tissues.  5.  The  Bossi  dilator  is 
an  unnecessary  instrument.  The  principle  of  using 
a  steel  dilator  in  gynecology  is  correct,  but  the 
practice  cannot  safely  be  employed  in  obstetric 
work.  The  full  dilation  of  an  intact  cervix  by 
forcible  instrumental  stretching  is  bad  practice. 
Such  conditions  are  best  overcome  by  vaginal 
Csesarean  section. 

4.  An  Analysis  of  Eighty  Consecutive  Cases 
of  Ectopic  Gestation. — Frank  gives  the  following 
conclusions:  i,  The  diagnosis  must  first  be  as- 
sured. Patients  with  suspicious  symptoms,  spot- 
ting, cramps,  fainting,  collapse,  amenorrhoea,  ac- 
cessory symptoms  of  pregnancy,  insufficient  change 
in  the  shape  of  the  uterus,  assuming  pregnancy  to 
be  present,  or  a  mass  near  the  uterus,  should  be 
kept  under  close  observation  or  placed  in  a  hospital. 
2,  Forcible  examinations  should  not  be  made,  nor 
should  curettage  be  performed  until  every  possibil- 
ity of  ectopic  gestation  has  been  excluded.  3,  If  the 
condition  does  not  improve  in  two  or  three  days 
and  hsematocele  has  not  formed,  abdominal  section 
should  be  performed.  It  should  be  done  at  once  if 
fainting  or  collapse  occurs  during  the  period  of 
waiting.  In  well  defined  hsematocele  vaginal  sec- 
tion with  evacuation  and  drainage  may  suf¥ice.  4, 
If  a  patient  is  first  seen  in  collapse,  immediate  op- 
eration is  safer  than  waiting.  5,  If  in  extreme  col- 
lapse there  should  be  rapid  abdominal  section  fol- 
lowed by  measures  to  combat  both  haemorrhage  and 
shock.  It  is  better  to  interfere  unnecessarily  early 
than  too  late. 

ANNALS  OF  SURGERY. 
February,  1909. 

1.  Intestinal  Obstruction  due  to  Volvulus  or  Adhesions  of 

the  Sigmoid  Colon  with  a  Report  of  Five  Cases  and 
a  Study  of  the  Etiological  Factors, 

By  J.  C.  Bloodgood. 

2.  The  Value  of  the  Caminidge  Reaction  in  the  Diagnosis 

of  Pancreatic  Disease,  By  E.  H.  Goodman. 

3.  The    Prevention   of   Intestinal   Obstruction  following 

Operation  for  Appendicitis.  By  F.  Hawkes. 

4.  Accidents  in  Hernia  Operations.      By  J.  F.  Erdmann. 

5.  A  New  Cystfiscope  for  Catheterizing  the  Ureters  by  the 

Indirect  Method,  By  P.  M.  Piixher. 

6.  A  New  Indirect  Irrigating  Observation  and  Double 

Catheterizing  Cystoscope,  By  L.  Buerger. 

7.  Complete  Denudation  of  the  Penis,     By  C.  A.  Powers. 

8.  The  Operative  Technique  of  Carcinoma  of  the  Penis, 

By  J.  H.  NicoLL. 

9.  Carbolic  Acid  Gangrene  of  the  Finger, 

By  J.  A.  Kem.ev. 


I.  Intestinal  Obstruction  due  to  Volvulus  or 
Adhesions  of  the  Sigmoid  Colon. — Bloodgood  ad- 
mits that  his  study  of  volvulus  of  the  sigmoid  is  as 
yet  incomplete.  His  conclusions  from  present  ex- 
perience and  information  are  that  the  symptoms  of 
acute  or  subacute  volvulus  of  the  sigmoid  are  suffi- 
ciently evident  to  warrant  that  treatment  be  insti- 
tuted at  a  stage  in  which  the  prognosis  should  be 
uniformly  good.  The  attempts  qt  relief  with  the  rec- 
tal tube  and  enemata  should  be  continued  only  a  few 
hours.  During  this  time  the  patient  should  have  no 
food  and  no  cathartics.  Should  this  treatment  be 
unsuccessful  the  abdomen  should  be  opened  without 
further  delay.  When  this  has  been  done  resection 
is  indicated  only  in  the  presence  of  gangrene.  After 
untwisting  the  volvulus  the  bowel  should  be  evac- 
uated with  the  rectal  tube.  One  should  then  search 
in  the  region  of  the  mesentery  for  bands  or  adhe- 
sions which  should  be  relieved  and  the  raw  places 
covered  with  peritoneal  sutures.  After  recovery 
the  patient  should  be  very  careful  as  to  diet  and 
suitable  cathartics  should  be  given  to  prevent  con- 
stipation. If  the  symptoms  indicate  a  chronic  con- 
dition abdominal  section  should  be  performed  both 
to  relieve  symptoms  and  as  a  prophylactic  to  acute 
volvulus. 

3.  The  Prevention  of  Intestinal  Obstruction 
following  Operation  for  Appendicitis. — Hawkes 
thinks  that  this  complication  occurs  in  a  percentage 
of  cases  varying  from  a  fraction  of  one  to  ten  or 
more,  according  to  the  operator's  skill  and  exper- 
ience. The  obstruction  may  be  mechanical,  or  sep- 
tic, or  a  combination  of  both.  The  type  of  case 
which  seems  most  liable  to  mechanical  obstruction 
is  that  in  which  most  of  the  peritoneal  cavity  is  free 
from  adhesions  but  in  which  a  few  firm  adhesions 
are  developed  after  the  operation  between  the  caput 
coli  and  an  adjacent  loop  of  smail  intestine.  Pre- 
vention of  this  accident  may  be  best  effected  by:  a. 
Making  the  operative  incision  directly  over  the  caput 
coli ;  b,  drainage  to  the  outer  side  of  the  caput  coli ; 
c.  pelvic  drainage  to  the  outer  side  of  intestinal  coils 
if  necessary;  d.  protecting  coils  of  small  intestine  by 
an  omental  barrier.  Saeptic  obstruction  is  to  be  pre- 
vented by  means  suitable  for  the  prevention  of  fur- 
ther spreading  of  the  septic  peritonitis  e.xisting  at 
the  time  of  the  operation,  including:  a.  Quick  re- 
moval of  the  appendix ;  b,  free  drainage  of  the  sur- 
rounding inflammatory  area ;  c,  free  drainage  of  the 
])elvis;  cl,  great  rapidity  in  operative  measures;  e. 
Fowler's  position  after  the  operation :  f.  rectal 
enema  of  hot  saline  solution  after  the  operation  ;  g. 
intestinal  rest  by  withholding  food  and  medicine  by 
mouth  thirtv-six  to  forty-eight  hours :  h.  stimulation 
as  indicated;  i,  careful  postoperative  treatment;  j, 
ileostomy  in  case  of  emergency. 

5.  A  New  Cystoscope  for  Catheterizing  the 
Ureters  by  the  Indirect  Method. — Pilcher  main- 
tains that  his  instrument  has  the  following  advan- 
tages: I.  The  sheath  serves  the  purpose  of  a  cathe- 
ter for  washing  out  the  bladder.  2,  Its  small  caliber, 
its  roundness,  and  its  smoothness  at  beak  and  win- 
dow make  its  introduction  easy  and  diminish  the  pos- 
sibility of  injuring  the  deep  urethra.  3.  It  carrier 
larger  catheters  than  other  indirect  vision  cysto- 
scopes.  4,  Telescope  and  sheath  may  bo  removed, 
the  catheters  remaining  in  the  urethra.  Irriga- 
tion of  the  bladder  may  be  rapidly  effected  while 


March  13,  i9"9  l 


PROCEEDINGS  OF  SOCIETIES. 


catheterization  is  going  on.  6,  Grooved  beds  being 
used  the  catheters^  are  so  separated  that  friction  be- 
tween tliem  is  impossible.  7,  The  proximity  of  lamp 
and  objective  lens  give  the  best  illumination  for 
catheterizing  purposes.  8,  The  small  lamp  minmi- 
izes  the  chances  of  contact  with  the  bladder  wall. 
9,  The  construction  of  the  instrument  minimizes  the 
possibilitv  of  carrying  infection  into  the  ureters.  10, 
A  large  'telescope  for  indirect  or  retrograde  vision 
mav  be  used  in  the  same  sheath.  .11,  A  small  tele- 
scope leaves  room  for  the  introduction  of  various 
operating  instruments.  12,  A  correcting  prison 
added  to  the  ocular  gives  an  upright  picture  and  in- 
creases the  brilliancy  of  illumination. 


|m«i>mp  of  ^fltittiw. 


MEDICAL  ASSOCIATION  OF  THE  GREATER  CITY 
OF  NEW  YORK. 
Mcrtiiig  of  Xoicinbcr  j6.  IQ08. 
The  President,  Dr.  Robert  T.  jMokris.  in  the  Chair. 
Asiatic  Cholera. — Dr.  Willi.mm  H.  Thomson 
made  an  address  on  this  subject  (published  in  the 
Journal  for  January  2,  1909). 

Notes  on  the  Bacteriology  of  Cholera. — Dr. 
Edw.ard  K.  Dunh.vm  said  in  this  paper  that  he 
thought  it  would  be  of  most  interest  to  speak  of  the 
bacteriology  more  particularly  in  reference  to  the 
matter  of  diagnosis,  and  that  his  remarks  would  be 
based  on  his  own  personal  experience.  In  1886  and 
1887  he  was  studying  at  the  Hygienic  Institute  in 
Berlin,  under  Professor  Koch,  and  Koch  gave  him 
for  examination  cultures  from  reputed  cases  of  Asi- 
atic cholera  in  a  large  number  of  cities  in  different 
parts  of  Europe  and  South  America.  From  this 
study  he  found  that  the  cholera  bacillus  in  artificial 
culture  changed  its  characters  with  considerable  ra- 
pidity, and  that  the  older  the  culture  the  more  it  de- 
parted from  the  regular  type.  In  1893,  in  New 
York,  specimens  of  the  dejecta  of  cholera  patients 
were  submitted  to  him  for  investigation.  It  was 
rather  a  striking  fact  that,  unless  the  specimens  were 
absolutely  fresh,  a  direct  examination  would  not  re- 
veal the  presence  of  the  characteristic  bacteria,  yet 
if  the  dejecta  were  used  for  culture,  pure  cultures 
of  the  cholera  vibrio  could  always  be  obtained.  It 
was  therefore  evident  that  in  dejecta  which  were  not 
fresh  the  organism  was  present  in  a  different  form. 

As  to  the  method  of  investigating  the  dejecta,  a 
direct  plate  culture  might  be  made,  or  we  might 
make  use  of  a  culture  medium  which  favored  the 
development  of  the  cholera  organism.  Such  a  me- 
dium was  simple  peptone  salt  solution.  Having 
given  the  details  of  the  bacterial  investigation,  he 
remarked  that  there  were  other  organisms  which 
gave  the  same  reactions  as  the  cholera  vibrio,  but 
they  were  distinguished  from  this  by  the  fact  that 
the  reactions  were  not  so  promptly  given.  The  ra- 
pidity of  proliferation  in  the  case  of  the  cholera  or- 
ganism was  remarkable.  From  a  single  vibrio  six 
millions  might  be  developed  in  the  course  of  six 
hours.  At  the  time  he  made  his  investigations  the 
more  modern  methods  by  the  use  of  agglutination 
and  immune  sera,  obtained  from  animals  inoculated 
with  cholera,  had  not  come  into  vogue. 


At  the  conclusion  of  his  remarks  Dr.  Dunham 
showed  upon  the  screen  photographs  which  he  had 
taken  of  vibrios  isolated  and  in  small  groups,  of  col- 
onies, and  of  stab  cultures  in  various  stages  of  de- 
velopment. 

Cholera  in  its  Relations  to  Commerce.— Dr. 

William  T.  Jenkixs.  formerly  health  officer  of  the 
port,  read  this  paper  (published  in  the  Jourxal  for 
December  5,  1908). 

Dr.  John  B.  Huber  opened  the  discussion.  He 
said  he  remembered  being  very  much  struck  by  read- 
ing a  lecture  of  Tyndall's,  given  before  the  discov- 
eries of  Pasteur  liad  been  made  known,  in  which 
that  author  had  stated  that  he  could  easily  under- 
stand why  there  must  be  a  germ  for  the  dissemina- 
tion of  an  infectious  disease.     Such  a  disease,  he 
believed,  could  no  more  originate  without  a  specific 
setiological  organism  than  flfgs  would  come  from 
thistles  or  any  plant  grow  except  from  its  own  spe- 
cial seed.     Dr.  Huber  had  recently  had  occasion  to 
deliver  a  lecture  on  matters  of  public  health  at 
Whitehall,  in  this  State,  and  it  had  occurred  to  him 
that  it  might  serve  a  good  purpose  to  show  the  anal- 
ogy between  typhoid  fever  and  Asiatic  cholera  and 
between  existing  conditions  at  Whitehall  and  in  the 
city  of  St.  Petersburg.    It  was  true,  of  course,  that 
cholera  was  much  the  more  virulent,  but  the  two 
diseases  were  alike  in  being  water  borne  affections,, 
in  originating  solely  from  specific  organisms,  and  in 
certain  other  characteristics.    Every  spring  cholera 
broke  out  in  St.  Petersburg  from  the  use  of  the  con- 
taminated water  of  the  Dnieper,  and  every  spring 
typhoid  broke  out  in  Whitehall  from  the  use  of  the 
water  from  the  river  flowing  by  it,  which  was  pol- 
luted by  the  refuse  of  the  town  of  Granville,  a  short 
distance  farther  up.    Last  spring  there  were  fifty- 
one  cases  of  typhoid  at  Whitehall,  and  he  had  en- 
deavored to  point  out,  in  addition  to  the  needless 
suffering  and  mortality  resulting  from  such  a  state 
of  af¥airs,  how  great  the  economic  loss  was  that  w^as 
entailed  upon  the  community. 

Dr.  George  D.  N.ash  spoke  of  the  conditions  in 
Hamburg  and  the  measures  which  were  being  taken 
for  the  suppression  and  prevention  of  cholera  when 
he  was  sent  there,  in  1892,  by  Dr.  Jenkins.  He  said 
he  was  now  living  at  Hurley,  a  little  hamlet  in 
Ulster  County,  and  he  found  it  very  difficult  to  in- 
duce the  rustic  population  to  take  any  measures 
whatever  to  prevent  typhoid  and  other  diseases. 
The  people  always  alleged  that  what  was  good 
enough  for  their  fathers  was  good  enough  for  them, 
and  they  strenuously  objected  to  incurring  any  ex- 
pense whatever  for  the  improvement  of  sanitary 
conditions. 

Dr.  J.  Milton  jM.\bbott  said  it  seemed  to  be  a  fact 
that  vaccination  afforded  better  protection  against 
smallpox  than  a  prcA'ious  attack  of  the  disease,  and 
in  the  hospitals  where  smallpox  was  treated  the 
practice  of  having  nurses  who  had  had  smallpox 
had  now  been  abandoned.  All  that  was  required  of 
the  nurses  was  that  they  shall  be  efficiently  vaccin- 
ated. In  one  instance  some  time  ago  a  smallpox 
nurse  who  had  refused  vaccination  on  account  of 
having  had  the  smallpox  itself  died  of  the  disease. 

Dr.  Louis  L.  Se.\man  said  that  he  was  in  Paris 
in  1892,  when  there  was  such  a  severe  outbreak  of 
cholera  that  if  the  facts  had  been  generally  known 
there  would  have  been  a  tremendous  panic  in  the 


562 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


city.  These,  however,  were  carefully  suppressed. 
The  press  was  rigidly  censored,  and  all  that  ever 
came  out  in  the  papers  was  some  cursory  allusion 
to  the  presence  of  a  little  "cholerine."  Consequently 
the  public  mind  was  undisturbed  and  all  the  affairs 
of  life  went  on  as  usual.  Yet  he  had  known  as 
many  as  151  deaths  from  cholera  to  occur  in  a  single 
day,  and  in  some  of  the  cases  the  fatal  termination 
was  reached  in  an  almost  incredibly  short  time. 
Somewhat  over  a  month  ago  Dr.  Seaman  was  in 
St.  Petersburg,  and  it  seemed  to  him  that  the  out- 
break there  was  being  very  well  handled. 

Mr.  WoLeoTT  Beard,  who  was  a  commissioned 
officer  in  the  First  Regiment  of  Volunteer  Engi- 
neers during  the  Spanish-American  War  and  later 
was  appointed  executive  officer  of  a  large  province 
in  the  Philippines,  said  that  in  those  islands  he  had 
seen  a  great  many  cases  of  cholera — at  least  1,500 — 
and  he  was  told  that  every  twenty  years  they  had 
there  an  epidemic  of  the  disease  that  was  '"worth 
while."'  In  San  Carlo,  a  town  of  26,000  inhabi- 
tants, there  were  as  many  as  400  deaths  a  day  at 
one  time.  There  was  a  great  lack  of  physicians  as 
well  as  of  drugs  and  proper  facilities  for  treatment, 
and  a  certain  class  of  "witch  doctors''  in  the  com- 
munity did  all  they  could  to  thwart  the  ef¥orts  made 
to  suppress  the  outbreaks.  It  was  noticeable  that 
during  the  first  week  or  two  of  the  epidemic  the 
mortality  was  greater  than  at  any  other  period  of  its 
course.  After  that  the  percentage  of  deaths  grad- 
ually diminished,  until  finally  the  disease  practically 
disappeared.  Like  Dr.  Seaman,  he  had  remarked 
the  frightful  rapidity  with  which  death  ensued  in 
some  of  the  cases. 

Dr.  H.  Ernest  Gallant  said  that  it  was  now 
well  established  that  in  certain  instances  the  typhoid 
bacillus  remained  in  the  system  and  appeared  in  the 
urine  long  after  the  patient  had  recovered  from  the 
symptoms  of  the  disease,  and  he  would  like  to  in- 
quire whether  this  was  the  case  with  the  cholera 
vibrio  also. 

Dr.  Thomson  said  he  believed  that  the  spirillum 
had  been  detected  in  the  dejecta  of  patients  at  vary- 
ing periods  after  recovery  from  cholera  up  to  as 
long  as  forty-nine  days. 

Dr.  Dunham  said  that,  while  the  typhoid  bacillus 
entered  the  blood,  this  was  apparently  not  the  case 
with  the  cholera  spirillum  ;  so  that  it  was  not  likelv 
to  be  found  for  as  long  a  time  'as  the  typhoid 
organism. 


MED1C.A.L  SOCIETY  OF  THE  STATE  OF  PENN- 
SYLV.\NIA. 

fifty-eighth  Anniuil  Meeting,  held  in  Cambridge  Springs, 
Sefitcmber  /j,  16,  and  17,  igo8. 

{Continued  from  page  ^60.) 

Tumors  of  the  Salivary  Glands. — Dr.  John 
Si'iJcsK,  of  Philadelphia,  discussed  the  views  of  the 
origin  of  these  tumors,  and  gave  a  description  of 
their  pathological  characteristics,  He  also  described 
the  general  symptoms  of  benign  and  malignant 
growths,  the  clinical  course  of  such  tumors,  and  the 
operative  treatment,  and  reported  results  in  cases 
observed. 

The  Rontgen  Ray  Interpretation  of  Fractures. 

— Dr.  Stewart  L.  McCurdv,  of  Pittsburgh,  called 


attention  to  the  normal  skeleton  as  it  appears  in  a 
radiogram  and  compared  it  with  fractures  about  the 
joints  and  long  bones.  A  study  v^^as  made  of  the 
skeleton  in  perspective  and  topographically. 

The  following  officers  were  elected  for  the  ensu- 
ing year :  Chairman,  Dr.  George  W.  Guthrie,  of 
Wilkes-Barre  ;  secretary,  Dr.  J.  M.  Wainwright,  of 
Scranton. 

The  Surgery  of  the  Cervical  Triangles. — Dr. 

Ch.arles  H.  Frazier,  of  Philadelphia,  gave  the  ora- 
tion in  surgery.  He  said  that,  while  the  lesions  in 
the  cervical  region  of  surgical  interest  were  almost 
too  numerous  to  mention,  this  territory  was  one  to 
which  too  little  consideration  was  given  by  the  prac- 
tising surgeon.  The  refinements  of  technique,  upon 
which  so  much  stress  was  laid  in  other  special  re-- 
gions,  were  not  considered  so  essential  in  operations 
upon  the  neck.  This  was  probably  due  to  the  fact 
that  with  some  exception  the  mortality  w^as  so  low 
that  the  patient's  life  was  not  in  question.  The  head 
and  neck  were  coming  to  be  regarded  as  a  special 
field,  with  just  as  many  possibilities  and  necessities 
for  the  perfection  of  a  technique  as  had  long  been 
recognized  in  the  field  of  the  abdominal  or  genito- 
urinary surgeon. 

The  Thyreoid  Gland. 

The  Surgical  Treatment  of  Malignant  Goitre. 

—Dr.  Edw.\rd  Martin,  of  Philadelphia,  read  this 
paper.  In  recent  years  the  radical  cure  of  malignant 
goitre  had  appeared  to  be  distinctly  probable,  pro- 
vided an  early  diagnosis  was  made.  Early  diagnosis 
could  never  be  made  with  certainty ;  therefore  an 
operation,  if  done  early,  would  sometimes  be  done 
on  thyreoids  which  subsequent  microscopical  exam- 
ination would  show  to  be  benign.  This  was  not  to 
be  regretted,  for  such  an  operation  was  a  safe  one 
and  by  means  of  it  a  pathological  organ  would  have 
been  removed  which,  if  allowed  to  remain,  might  at 
some  time  undergo  malignant  change.  The  distinc- 
tion between  the  difl^erent  kinds  of  malignant  dis- 
ease could  not  be  made  clinically.  As  the  capsule  of 
the  gland  ofifered  considerable  resistance,  metastasis 
might  occur  early  by  the  blood  or  lymph  vessels, 
while  the  primary  tumor  was  still  intracapsular.  In 
advanced  cases  a  diagnosis  was  easily  made,  but  was 
futile.  An  operation  practised  early  was  compara- 
tively simple  and  had  a  mortality  so  low  as  to  give 
it  absolute  justification.  Even  after  metastasis  had 
occurred  it  might  be  possible  to  remove  the  gland  to- 
gether with  the  metastatic  focus.  With  involvement 
of  the  trachea  and  oesophagus  and  the  infiltration  of 
the  perithyreoid  tissues  radical  cure  became  at  best  a 
remote  possibility,  although  an  operation  in  accord- 
ance with  modern  principles,  complete  extirpation 
regardless  of  structure,  had  occasionally  given  good 
results. 

Personal  Experiences  in  the  Surgery  of  Simple 
Types  of  Goitre.— Dr.  Wainwright  said,  that 
while  statistics  based  on  an  enormous  number  of  op- 
erations were  very  interesting,  still  they  might  not 
be  of  as  much  value  to  the  general  surgeon  as  the 
experience  of  other  general  surgeons  who  were  do- 
ing a  smaller  number.  He  based  his  report  upon 
eighteen  cases,  thirteen  in  females  and  five  in 
males.  Ten  of  the  cases  occurred  in  people  born  in 
Wales  or  of  Welsh  parentage,  which  would  appar- 
ently show  that  the  Welsh  were  prone  to  this  dis- 


March  13,  1909.] 


LETTERS  TO   THE  EDITOR. 


563 


ease.  Seven  of  the  cases  were  simple  cysts,  two  were 
adenomata  with  cysts,  seven  were  enlargements  of 
the  parenchymatous  type,  one  was  of  the  exophthal- 
mic type,  and  one  was  a  carcinoma.  All  the  patients 
recovered  from  the  operation,  and  seventeen  were 
alive  and  well  to-day.  One  died  of  a  very  rapid  re- 
currence of  malignant  goitre  five  weeks  after  the  op- 
eration. There  were  no  accidents  due  to  the  anaes- 
thetic, which  was  ether.  Primary  union  was  ob- 
tained in  all  the  cases.  Tetany  was  not  observed. 
He  used  the  drop  method  of  ether  anaesthesia  in  all 
patients.  Atropine  was  always  given  before  the 
ether.  He  believed  that  all  patients  giving  symptoms 
of  pressure  and  all  showing  progressive  enlargement 
should  be  operated  upon  at  once.  As  to  the  amount 
removed,  he  followed  Crile's  rule  of  leaving  behind 
an  amount  of  thyreoid  tissue  about  equal  in  size  to 
the  normal  gland. 

{To  be  concluded.) 

 ^  

f  ettm  to  tlif  (gbitor. 


PROFESSIONAL  SECRECY  AND  PROFESSIONAL 
DUTY. 

1729  Chestnut  Street, 
Philadelphia,  March  8,  igog. 

To  tlie  Editor: 

I  sincerely  wish  to  endorse  your  editorial  on  Pro- 
fessional Secrecy  and  Professional  Duty  in  your  is- 
sue for  March  6th.  I  have  had  a  case  precisely  sim- 
ilar to  the  one  mentioned  in  the  St.  Louis  Medical 
Revieii.',  which  is  the  basis  of  your  editorial,  and  I 
promptly  informed  both  the  patient  and  her  em- 
ployer of  the  danger  to  his  children  of  contracting 
syphilis,  in  spite  of  the  fact  that  the  law  prohibited 
my  doing  so. 

I  am  verv  loth  to  advocate  plain  disobedience  to 
statute  law,  but  to  my  mind  the  moral  law  in  such 
a  case  is  much  higlier  and  more  imperative  than 
any  man  made  statute  law.  I  think  that  in  cases 
where  a  medical  man  knows  positively  of  the  dan- 
ger of  innocent  children  being  exposed  to  the  very 
probable  contagion  of  syphilis  from  a  nurse,  or  of  a 
pure  young  woman  being  certainly  exposed  to  such 
contagion  by  marriage  with  a  person  known  by  him 
to  be  a  syphilitic,  it  is  the  highest  moral  duty  to  the 
state,  to  the  innocent  individual,  and  to  our  own 
consciences  to  violate  this  iniquitous  law.  Of  course 
in  doing  so  we  ought  to  be  perfectly  willing  to  take 
the  legal  punishment,  but,  as  you  say,  I  think  in 
neither  of  the  cases  I  have  mentioned  any  decent 
jury  would  give  a  verdict  against  the  man  who  fol- 
lowed clearly  his  moral  duty. 

Let  each  man  ask  himself  the  simple  question 
"^^'hat  should  I  think  of  the  doctor  who  would  de- 
liberately conceal  the  facts  from  myself  in  the  case 
of  mv  own  child  ?*'  The  answer  would  not  be 
doubtful.  W.  W.  Keen. 


"LEST  WE  FORGET." 

23  West  Forty-sixth  Street, 
New  York,  March  3,  igoQ. 

To  the  Editor: 

In  the  Therapeutic  Notes  of  the  Journal  of  Feb- 
ruary 20th  "Heubner's  mustard  treatment  of  bron- 
chopneumonia in  children"'  is  described.    On  Feb- 


ruary 15.  1878,  I  read  a  paper  before  the  New 
York  Medical  Journal  Association  on  The  Thera- 
peutic A'alue  of  the  Hot  ^Mustard  Bath  in  Pneu- 
monia in  Children.  The  paper  was  published  in  the 
American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children  for  April,  1878,  and  abstracts 
of  it  appeared  in  various  medical  journals  here  and 
abroad.  In  that  paper  I  said  that  the  idea  of  em- 
ploying the  hot  mustard  bath  in  severe  cases  of 
pneumonia  and  capillary  bronchitis  of  children  oc- 
curred to  me  in  1869.  that  myself  and  other  practi- 
tioners on  my  advice  had  made  good  use  of  it.  par- 
ticularly in  desperate  cases  complicating  whooping 
cough  and  measles  which  were  almost  at  the  point 
of  asphyxia,  and  that  lives  had  been  saved  thereby. 
Seven  particularly  striking  cases  were  cited  and  the 
mode  of  procedure  given  as  follows  :  A  handful  or 
two  of  mustard  is  stirred  up  in  a  babytubful  of 
water  at  a  temperature  of  about  103'  to  105''.  the 
patient  immersed  and  brisk  friction  of  body  applied 
for  about  ten  minutes.  With  a  pitcherful  of  clear 
hot  water  the  child  is  showered  ot¥,  quickly  dried 
and  wrapped  in  a  couple  of  warm  blankets  and  left 
in  them  w  ith  wet  compress  over  forehead  until  free 
perspiration  has  taken  place,  then  rubbed  down  dry 
and  put  to  bed.  The  process  may  be  repeated  in 
the  twenty-four  hours,  if  necessary.  I  have  never 
seen  any  harm  from  it,  but  many  children  who  were 
almost  given  up  recovered  by  the  use  of  these  baths 
alone  and  without  further  administration  of  any 
drugs  whatever.  When  the  patient  comes  out  of 
the  bath  an  intense  active  hyperaemia  of  the  entire 
skin  is  noticed,  relief  is  brought  to  the  overbur- 
dened right  heart,  the  vasomotor  centre  is  stimu- 
lated, and  the  capillary  and  glandular  a,pparatus  of 
the  integinnents  will  also  assist  in  decarbonizing 
and  oxygenizing  the  blood. 

The  paper  referred  to  has  not  been  entireh'  for- 
gotten in  this  coimtry.  for  almost  every  year  in- 
quiries about  the  application  of  the  hot  mustard 
bath  in  pneinnonia  of  children  have  been  received 
by  me.  ]\Iay  this  communication  help  to  bring  the 
matter  again  before  the  practitioner?  at  large. 

Leonard  Weber. 


OPPORTUNITIES  FOR  THE  BOARD  OF  HEALTH. 

60  East  Fifty-eighth  Street. 
New  York,  February  11.  igog. 

To  the  Editor: 

The  present  crusade  against  spitting  inaugurated 
by  our  Department  of  Health  and  heralded  with  the 
usual  flourish  of  trumpets  and  exaggeration  of 
sensational  detail  by  the  press  must  impress  think- 
ing physicians  as  an  unfortunate  manifestation  of 
our  too  common  tendency  to  strain  at  a  gnat  and 
swallow  a  camel,  devising  nets  which  shall  catch 
the  srnall  fish  and  let  the  large  escape.  While  each 
and  every  sign  of  activity  in  the  prevention  of  the 
spread  of  contagious  disease  is  of  course  to  be  wel- 
comed, are  there  not  many  more  vital  and  immediate 
sources  of  danger  to  the  public  health  and  comfort 
than  that  of  spitting,  now  comparatively  infrequent  ? 
It  seems  strange  that  it  has  not  occurred  to  Dr. 
Bensel  or  to  any  of  his  predecessors  to  compel  re- 
forms in  the  closets  and  urinals  of  our  ferry  houses, 
in  the  dirty  surface  cars,  and  in  the  malodorous, 


5^4 


BOOK  NOTICES. 


[New  York 
Medical  Jourxai.. 


badly  ventilated  elevated  railroad  stations  with  their 
unsanitary  toilets  and  soft  wood  floors  absorbing 
filth  hourly,  daily,  weekly  and  cleaned  by  mop  and 
water.  The  city  itself  sends  about  open  carts  to 
collect  ashes  and  garbage,  and  in  the  high  winds 
which  prevail  here  in  so  large  a  part  of  the  entire 
^•ear,  much  of  this  stuff  is  caught  up  and  spread 
broadcast,  ruining  clothes  and  endangering  eyes, 
noses,  and  throats.  The  saying  De  minimis  non 
curat  lex  has  been  directly  reversed  by  our  health 
board,  which  seems  to  care  only  for  trifles. 

Percy  Fridenberg. 


ATROPINE  AS  A  H  F.MOSTATIC. 

1424  E.  Ravenswood  Park, 
Chicago,  March  2,  igog. 

To  the  Editor: 

I  am  collecting  material  for  a  paper  upon  atro- 
pine as  a  hiemostatic,  and  should  be  obliged  to  any 
of  )-our  readers  who  would  send  me  notes  of  their 
experience  with  this  remedy.  I  am  particularly 
anxious  to  receive  adverse  reports  as  well  as  those 
favoring  the  remedy.  \Villi.\m  F.  W.\ugh. 

 <i>  

§oflk  Botues. 

[We  publish  fiiU  lists  of  books  received,  but  z^'e  ackuoivl- 
edge  no  obligation  to  reiieiv  them  all.  Nevertheless,  so 
far  as  space  permits,  tee  reviciv  those  in  which  zve  think 
our  readers  are  likely  to  be  interested.] 


The  Bone  Marroiv;  .\  Cytological  Study,  Forming  an  In- 
troduction to  the  Normal  and  Pathological  Histology  of 
the  Tissue,  More  Especially  with  Regard  to  Blood  For- 
mation, Blood  Destruction,  etc  Together  with  a  Short 
Account  of  the  Reactions  and  Degenerations  of  the  Tis- 
sue in  Disease.  By  W.  E.  C.vrnegie  Dickson,  M.  D., 
B.  Sc.  Ediii,,  F.  R.  C.  P.,  Edin.,  Lecturer  on  Pathological 
Bacteriology  and  Senior  Assistant  to  the  Professor  of 
Pathology  in  the  University  of  Edinburgh;  Assistant 
Pathologist  to  the  Edinburgh  Royal  Infirmary.  With 
Colored  Plates  and  Microscopical  Photographs  by  Rich- 
AKD  MuiR.  London,  New  York,  Bombay,  and  Calcutta: 
Longmans,  Green,  &  Co.,  1908.    Pp.  ix-153. 

We  welcome  this  volume  on  the  histology  of  the 
bone  marrow,  which,  so  far  as  we  know,  is  the  first 
complete  monograph  to  be  issued  on  the  subject. 
Dr.  Dickson  was  the  Crichton  Research  Scholar 
in  I'athology  in  the  L^niversity  of  Edinburgh,  and 
it  was  during  his  tenure  of  this  position  that  he 
did  the  work  which  is  represented  in  the  volume 
imdcr  review.  Upon  its  merits  Dr.  Dickson  re- 
ceived his  degree  of  doctor  in  arte  medica  and  was 
awarded  a  gold  luedal.  The  work  begins  with  a 
general  introduction,  an  historical  resume,  and  a 
description  oi  the  material  and  methods  used  in  the 
piu-suit  of  the  work.  The  chapter  on  methods  is, 
if  anything,  too  short.  In  a  work  of  this  kind,  in 
which  a  subject  of  practically  new  import  is  being 
discussed,  it  i>;  important  that  a  minute  account  of 
all  the  technique  l)e  given.  Such  an  account  will 
save  the  man  who  wishes  to  apply  the  results  of 
original  observation  to  his  own  routine  much 
trouble   and   anxiety.    Si)ecific   directions   as  to 


methods,  furthermore,  make  for  uniformity  of  re- 
sults. 

The  chapter  on  methods  is  followed  by  a  chapter 
on  the  general  anatomy  and  histology  of  the  bone 
marrow.  Here  we  find  a  description  of  the  general 
architecture  of  this  tissue.  This  is  followed  by  a 
chapter  entitled  "varieties  of  bone  marrow,"  in 
which  the  description  of  normal  and  pathological 
bone  marrow  is  given.  The  normal  marrow  is 
divided  into  (i)  primitive,  or  embryonic,  marrow; 
(2)  red,  or  lymphoid,  marrow,  erythroblastic,  when 
it  is  engaged  in  the  production  of  erythrocytes,  and 
leucoblastic,  when  it  is  engaged  in  the  production 
of  leucocytes;  (3)  fatty,  or  yellow,  marrow.  The 
pathological  forms  of  marrow  may  be  fibroid  or 
gelatinous.  The  latter  form  may  be  acute  or 
chronic.  Gelatinous  change  in  the  marrow  is  con- 
sidered to  be  essentially  a  retrogressive  change  and 
to  follow  long  standing  septic  conditions,  such  as 
tuberculosis,  malignant  disease,  and  chronic  pois- 
oning with  lead,  mercury,  and  arsenic.  There  is  a 
progressive  diminution  in  the  blood  forming  con- 
stituents of  the  marrow  and  an  absorption  of  fat 
in  this  condition. 

The  reactions  of  the  bone  inarrow  in  diseases  are 
next  described.  The  reaction  which  results  in  an 
increased  production  of  red  blood  corpuscles  is 
known  as  erythroblastic ;  that  which  results  in  an 
increased  production  of  white  blood  corpuscles  is 
known  as  leucoblastic.  The  leucoblastic  reaction 
may  be  neutrophilic,  eosinophilic,  baseophilic,  or 
non-granular.  With  true  British  tenacity  the  author 
clings  to  the  term  "hyaline,"  a  term  which  is  not 
used  in  any  other  part  of  the  world.  The  erythro- 
blastic reaction  may  be  normoblastic  or  megalo- 
blastic. 

Of  course,  the  most  important  portion  of  the 
work  is  the  description  of  the  cytology  of  the  mar- 
row. Here  the  various  cells  found  in  the  normal 
bone  marrow  are  described.  In  this  chapter  the 
author  drops  the  term  hyaline  and  adopts  the  more 
universally  used  term  "nongranular"  for  those  cells 
having  neither  neutrophile,  eosinophilc,  nor  baseo- 
phile  granules  in  their  cytoplasiu.  In  this  chapter 
karyorrhexis  and  karyolysis  also  are  described.  In 
the  description  of  the  hsemoglobin  containing  cells 
of  the  marrow  the  author  discusses  the  method  of 
conversion  of  erythroblasts  into  erythrocytes. 
While  he  has  seen  the  extrusion  of  the  nucleus  in 
all  of  its  stages  in  smear  preparations,  he  has  never 
seen  it  in  sections  of  the  marrow.  As  the  result  of 
his  own  observations  he  believes  that  the  nucleus  of 
the  erythroblast  is  lost  by  a  combination  of  karyor- 
rhexis and  karyolysis. 

The  author  devotes  considerable  space  to  the  dis- 
cussion of  the  polykaryocytes  and  megakaryocytes 
fotmd  in  the  bone  marrow.  The  former  term  is  re- 
stricted to  the  multinucleated  Dhagocytic  cell,  or 
"osteoclast,"  found  especially  during  the  develop- 
ment of  bone.  The  latter  term  is  used  to  denote 
the  giant  cell  with  a  highly  complex  but  single  bas- 
ket nucleus.  The  former  cells  are  not  restricted 
to  the  bone  marrow :  the  latter  are  not  seen  in  the 
peripheral  blood.  Dickson  believes  that  the  poly- 
karyocyte is  derived  from  the  marrow  reticulinn, 
taking  the  view  held  by  Jackson  on  this  point.  The 


March  13.  1909.] 


BOOK  NOTICES. 


565 


pigmented  and  other  varieties  of  the  phagocytic  cell 
are  probably  derived  from  the  endothelial  cells  of 
the  marrow,  perhaps  from  the  cells  of  the  reticulum 
and  possibly  from  the  large  uninuclear  cells  of  the 
peripheral  blood.  The  question  of  the  origin  of  the 
megakaryocyte  he  leaves  undecided,  after  first  ar- 
riving at  the  conclusion  that  they  were  derived 
from  the  cells  of  the  reticulum  (page  68).  In  re- 
gard to  this  point,  we  see  a  rather  curious  result 
of  the  kind  of  work  done  by  Dr.  Dickson.  He  says 
that  at  first,  from  the  study  of  his  own  specimens, 
he  thought  that  the  megakaryocytes  were  derived 
from  the  reticulum  of  the  marrow,  but  that  after 
considering  the  careful  work  of  Goodall  on  the 
suljject  he  was  led  to  doubt  the  accuracy  of  his  ob- 
servations and  so  left  the  question  sub  judice.  We 
would  say  that  it  is  quite  likely  that  Dr.  Dickson's 
observations  were  as  accurate  as  those  of  Dr. 
Goodall.  and  we  should  consider  it  better  for  him 
to  have  let  his  first  opinion  stand,  unless  he  was 
a  thorough  convert  to  Goodall's  views.  Of  course, 
the  stand  might  be  taken  that  the  author  was  very 
honest  in  stating  the  doubt  about  his  own  accuracy 
and  leaving  the  question  open.  We  admit  this  argu- 
ment, and  we  admit  also  that  we  are  somewhat  in 
tlie  same  position  ourselves  when  we  say  that  we 
are  not  quite  sure  of  the  logic  of  our  stand  in  the 
matter.  But  at  present  we  feel  inclined  to  state 
that  in  a  matter  of  this  kind,  where  an  original 
study  leads  to  the  conclusion  that  a  certain  condi- 
tion exists,  it  would  be  better  to  let  that  opinion 
stand.  We  contend  that  in  matters  of  this  kind 
there  is  no  disgrace  in  changing  one  s  views  after 
further  study. 

The  monograph  is  illustrated  by  an  invaluable 
series  of  photomicrographs  and  colored  plates,  ex- 
cellently executed.  Doth  the  author  and  the  pub- 
lishers deserA^e  congratulations  on  the  appearance 
of  the  volume — the  former  for  the  ver\'  careful 
scientific  work  represented,  the  latter  for  the  ex- 
cellent mechanics  of  the  publication. 

The  Origin  of  Vertebrates.  Bv  \\'.\lter  Holbrook  Gas- 
KELL.  M.  A.,  M.  D.  ( Cantab,  "i.  LL.  D.  r  Edinburgh  and 
:McGill  University),  F.  R.  S..  Fellow  of  Trinity  Hall, 
and  University  Lecturer  in  Physiology-,  Cambridge.  Hon- 
orary Fellow  of  the  Royal  Medical  and  Cnirurgical  So- 
ciety. Corresponding  Member  of  the  Imperial  Military 
Academy  of  Medicine.  St.  Petersburg,  etc.  London,  Xew 
York,  Bombay,  and  Calcutta :  Longmans,  Green,  &  Co., 
1908. 

This  work  is  devoted  to  a  defense  of  the  thesis 
that  in  the  evolution  of  animal  species  from  inverte- 
Ijrate  to  vertebrate  the  central  nervous  system  of  the 
latter  animals  is  the  central  nervous  system  of  the 
former  combined  with  the  alimentar>  canal  of  the 
former.  According  to  the  theor\-  advocated,  the 
nervous  mass  of  the  vertebrate  central  nervotis  sys- 
tem corresponds  to  the  nervous  mass  of  the  inverte- 
brate central  nervous  system,  while  the  ventricles  of 
the  brain,  with  the  infundibtilum,  and  the  centra! 
canal  of  the  spinal  cord  correspond  to  the  alimentary 
canal  of  the  invertebrate.  The  alimentary  canal  of 
the  vertebrate,  according  to  this  hvpothesis.  is  an 
entirely  new  development  which  is  rendered  neces- 
sary on  account  of  the  narrowing  of  the  original  in- 
Aertebrate  alimentary  canal  by  the  presstire  of  the 
increasing  mass  of  nervous  material  in  the  region  of 


the  oesophageal  ring,  which  corresponds  to  the  in- 
fundibulum  of  the  vertebrate  brain.  The  ventricles 
of  the  brain  correspond  to  the  cephalic  stoinach  of 
the  appendiculate ;  the  central  canal  of  the  spinal 
cord  corresponds  to  the  long,  straight  intestine  which 
originally  led  to  the  anus  and  which  in  the  verte- 
brate embryo  still  ends  in  the  anus  (neurenteric 
canal). 

The  arthropod  subkingdom  is  composed  of  ani- 
mals that  have  been  evolved  from  coelenterates,  in 
which  the  central  nervous  system  forms  a  ring  sur- 
rounding the  mouth,  ^^'hen  radial  symmetry  was 
given  up  in  the  evolution  of  forms,  an  elongated  and 
segmented  fonn  was  developed  in  which  the  central 
nervous  system  became  elongated  and  segmented. 
On  account  of  the  derivation  of  this  system  from  an 
oral  ring,  however,  it  still  surrounded  the  moutli 
cavity  or  oesophagus,  and  in  the  highest  forms  be- 
came divided  into  a  supracesophageal  and  an  infra - 
oesophageal  nervous  mass.  Consequently,  in  the  in- 
vertebrate the  central  nervous  system  was  pierced 
by  the  alimentary  canal  so  that  the  greater  portion 
of  the  latter  lav  dorsal  to  the  former  system.  In  the 
vertebrate,  on  the  other  hand,  the  alimentary  canal 
is  entirely  ventral  to  the  central  nervotis  system.  In 
order  to  account  for  the  change  from  the  inverte- 
brate to  the  vertebrate  type  in  evolution,  one  theory 
supposes  that  the  invertebrate  turned  over  on  its 
back  and  swam  in  that  reversed  position,  so  that  the 
dorsal  surface  became  converted  into  the  ventral  sur- 
face, and  a  new  mouth  was  developed  in  the  new 
ventral  surface  of  the.  animal,  while  the  old  mouth 
was  obliterated.  Another  view  of  the  method  of 
evolution  supposes  that  bilaterally  symmetrical,  elon- 
gated, and  segmented  animals  were  formed  in  two 
ways — the  first,  already  mentioned,  in  which  the  di- 
gestive tube  pierced  the  central  nervous  system  :  the 
second  in  which  the  segmented  central  nervous  sys- 
tem was  situated  dorsally  to  the  alimentary  canal 
from  the  first  and  was  not  pierced  by  it.  The  first 
arrangement  led  to  the  evolution  of  the  arthropod ; 
the  second  to  the  evoltition  of  the  vertebrate. 

Xeither  of  these  views  is  convincing.  On  the 
other  hand,  at  first  sight  the  hypothesis  advanced  by 
Dr,  Gaskell  is  absurd.  But  as  one  follows  the  author 
through  his  arguments  one  becomes  impressed  with 
the  possibility  of  his  theory.  In  order  to  criticise 
his  statements  properly  one  should  be  an  expert  em- 
bryologist.  protozoologist.  zoologist,  and  anatomist. 
Such  a  combination  is  difficult  to  find.  The  reviewer 
found  that  in  reading  the  book  a  proposition  that 
originally  had  the  appearance  of  utter  impossibility 
became  gradually  more  plausible,  until,  at  the  end 
of  the  evidence  presented  from  all  points,  the  theory 
seemed,  to  say  the  least,  no  more  ridiculous  than  the 
theory  of  inverse  position  advocated  by  Geoffroy  St.- 
Hilaire. 

Many  revolutionary  statements  are  made  during 
the  development  of  the  argument,  one  of  the  most 
striking  of  which  is  that  which  leads  us  to  think  of 
giving  up  our  old  friend  the  amphioxus  as  the  type 
of  vertebrate  animal  and  substituting  for  it  Anitiw- 
ccctes  brancliialis.  the  larval  form  of  the  lamprev 
(Pteromyzon  Plaiieri),  an  animal  which  the  author 
inaintains  is  more  nearly  like  the  ancient  cephalas- 
pidian  fishes  than  any  other  living  vertebrate.  Again, 


566 


BOOK  NOTICES. 


[New  York 
Medical  Journal, 


it  is  a  good  deal  of  a  shock  to  be  told  that  the  noto- 
chord,  which  has  for  so  long  been  considered  to  be 
the  typical  feature  of  the  vertebrate  skeleton,  is  no 
longer  the  type,  but  that  the  cartilaginous  cranial 
and  branchial  skeleton  found  in  common  in  ammo- 
coetes  and  limulus  is  the  characteristic  feature  of 
that  skeleton. 

It  seems  to  us  that  the  weakest  part  of  the  au- 
thor's argument  is  in  his  failure  to  explain  satisfac- 
torily the  bearing  of  the  development  of  the  central 
nervous  system  in  the  vertebrate  embryo  upon  his 
hypothesis.  We  know  that  the  beginning  of  the 
nervous  system  in  vertebrates  is  a  thickening  and  a 
folding  of  the  ectoderm  in  the  axis  of  the  embryo, 
producing  the  medullary  folds  and  the  medullary 
groove,  and  that  these  folds  subsequently  unite  to 
form  the  neural  canal ;  that  the  cells  producing  the 
medullary  folds  and  the  walls  of  the  neural  canal 
become  differentiated  into  the  neurones,  the  neurog- 
lia cells,  and  the  ependyma  ;  and  that  the  neural  canal 
by  processes  of  unequal  growth  and  flexure  becomes 
the  ventricles  of  the  brain  and  the  central  canal  of 
the  spinal  cord.  If  the  author  can  trace  an  homol- 
ogy or  an  analogy  between  this  method  of  develop- 
ment and  the  development  of  the  alimentary  tract 
and  the  nervous  system  in  the  invertebrates,  he  will 
have  added  a  very  strong  link  to  his  chain  of  evi- 
dence. As  it  is  now,  we  think  this  is  the  weakest 
link,  at  least  from  the  viewpoint  of  human  anatomy 
and  embryology.  To  be  sure,  there  is  an  explana- 
tion offered  for  these  statements ;  but  at  present  it  is 
not  convincing. 

The  book  is  a  very  able  presentation  of  argu- 
ments in  favor  of  the  hypothesis.  The  author  com- 
plains that  his  theory,  which  was  originally  advanced 
in  1888,  has  been  neglected.  Such  treatment  is,  of 
course,  the  surest  method  of  overcoming  an  objec- 
tionable theory  ;  but  it  is  not  in  accord  with  the  tra- 
ditions of  science  to  starve  a  theory  to  death.  Those 
interested  in  the  problems  of  evolution  ought  by  all 
means  to  set  to  work  to  determine  the  tenability  of  a 
thesis  so  ably  defended. 

Einfache  Hiilfsmittel  zur  Aiisfiihrung  bakteriologischer 
JJniersuchuHgcn.  Von  Dr.  R.  Abel,  geheimer  Medizinal- 
rat  in  Berlin,  and  Dr.  M.  Ficker,  Professor  in  Berlin. 
2.  Auflage.  Wiirzburg:  A.  Stuber,  1908.  Pp.  57.  (Price, 
$1.20.) 

This  little  volume  is  designed  to  guide  the  prac- 
tising physician  who  wishes  to  carry  out  simple 
bacteriological  examinations  or  who  wishes  to 
equip  a  small  laboratory  for  this  purpose.  The  di- 
rections are  excellent  and  are  evidently  the  result 
of  considerable  experience.  We  heartily  commend 
this  book  to  all  who  desire  to  undertake  ordinary 
bacteriological  laboratory  work  on  their  own  ac- 
count. 

Transactions  of  the  Thirtieth  Annual  Meeting  of  the  Amer- 
ican Laryngological  Association,  Held  at  Montreal,  Can- 
ada, May  II,  12,  and  13,  1908.  New  York,  Published  by 
the  Association,  1908. 

The  Montreal  meeting  offered  an  unusually  in- 
teresting programme,  and  this  volume  brings  not 
only  the  papers  which  were  read,  but — what  is  so 
instructive  and  stimulating  to  those  who  attend  con- 
gresses— the  exchange  of  personal  experiences  and 
the  impressions  of  individual  character,  scientific, 


professional,  and  social,  which  form  part  of  the 
subsequent  discussions.  Among  the  topics  which 
were  considered  by  individual  writers,  or  in  collab- 
oration, we  may  mention  Points  in  the  Anatomy  of 
the  Pharynx  (Randall),  Rheumatism  through  Ton- 
sillar Infection  (Hope).  Adrenalin  in  the  Causa- 
tion of  Arteriosclerosis  (Hopkins),  Experiences  in 
Bronchoscopy  (Halstead),  a  series  of  papers  on 
Sinus  Diseases,  and  a  series  on  Recurrent  and  Ab- 
ductor Paralyses  of  the  Larynx,  by  Gleitsmann, 
Delavan,  Rice,  and  Casselberry. 

Das  Gehirn  und  die  Nebenhdlen  der  Nase.  Von  Dr.  A. 
Onodi,  a.  o.  Professor  der  Rhinolaryngologie  an  der 
Universitat  in  Budapest,  etc.  Mit  63  Tafetn  nach  photo- 
graphischen  Aufnahmen.  Wien  und  Leipzig :  Alfred 
Holder,  1908.    Pp.  13. 

This  atlas  shows  in  sixty-three  pictures  the  rela- 
tion of  the  brain  to  the  accessory  sinuses  of  the 
nose.  The  illustrations  are  all  of  normal  size ;  they 
are  fine  specimens  of  photographic  reproduction, 
and  demonstrate  clearly  the  study  of  brain  diseases 
arising  from  inflammation  originating  in  the  acces- 
sory nasal  cavities.  Some  of  the  illustrations  are 
Rontgen  ray  pictures,  while  others  depict  electrical 
illumination  of  the  frontal  cavities. 

The  exact  knowledge  of  these  topographical  ana- 
tomical conditions  of  the  accessory  cavities  of  the 
nose  and  the  cranial  cavity  are  of  great  importance 
for  the  rhinologist  in  the  treatment  of  diseases 
affecting  the  brain.  The  frontal  cavity  usually  cor- 
responds to  the  small  g\"rus  frontalis  superior  only, 
btit  may  also  take  in  the  gyrus  medius  and  the  gyrus 
inferior.  It  is  interesting  to  note  that  the  author 
has  found  that  the  frontal  cavities  are  missing  on 
both  sides  in  thirty  per  cent.,  on  one  side  in  about 
ten  per  cent.,  of  twelve  hundred  electrically  illum- 
inated skulls.  The  cavities  are  seldom  of  equal  size. 
The  ethmoidal  cells  usually  touch  the  lower  portion 
of  the  frontal  lobe,  the  region  of  the  gyrus  rectus 
and  gyrus  orbitalis.  The  book  will  be  of  great  inter- 
est to  the  rhinologist :  it  is  the  only  one  of  its  kind. 

Lehrbuch  und  Atlas  der  Zahnhcilkunde  mit  Einschluss  der 
Mundkrankhciten.  Von  Dr.  ined.  und  phil.  Gust.w 
Preiswerk,  Lektor  an  der  I'niversitat  Basel.  Zweite  ver- 
besserte  und  vermehrte  Auflage.  Mit  50  vielfarbigen 
Tafeln  und  141  Textabbildungen.  Miinchen  :  J.  F.  Leh- 
mann,  1908.    Pp.  xx-3gS. 

This  textbook  of  stomatology  is  very  carefully  pre- 
pared, and  gives  a  full  account  of  the  diseases  of 
the  mouth.  It  is  not  specifically  a  book  on  den- 
tistry, as  neither  operative  nor  prosthetic  dentistry 
is  con.sidered.  Like  the  thirty-six  other  medical  text- 
books, published  by  Lehmann.  of  Alunich.  it  is  a 
standard  work  the  text  of  which  is  greatly  enhanced 
by  well  executed  color  plates. 

The  author  reviews  the  anatomy,  embryology,  his- 
tology, physiology,  and  bacteriology  of  the  mouth 
and  the  sinuses  in  its  neighborhood.  The  pathology 
is  fully  gone  into,  and  the  fractures  and  dislocations 
of  the  maxill.ne  and  teeth  are  spoken  of.  together  with 
trigeminus  neuralgia  and  empyema  of  the  antrum  of 
Highmore.  Teeth  and  maxilla  anomalies  and  carie-^ 
of  the  teeth,  its  effects  and  prophylaxis,  arc  treated 
of.  Furthermore,  we  find  chapters  on  the  pathol- 
ogy, diagnosis,  and  treatment  of  affections  of  th'^ 
tooth  pulp  and  of  periodontitis.    The  index  of  au- 


;Marcli  13,  J909.J 


OFFICIAL  XEU'S. 


567 


thors  is  a  good  testimoii}  to  the  careful  readino;  of 
the  writer. 

The  chapter  on  diseases  of  the  mouth  proper  con- 
tains fifteen  subheadings.  To  mention  only  one,  we 
wish  to  call  attention  to  the  one  on  pyorrhoea  alveo- 
laris.  Thirty  authors  are  cited  in  regard  to  the 
treatment  of  this  malady,  and  our  author  takes  the 
view  that  pyorrhoea  alveolaris  is  a  constitutional  or 
a  local  disease — constitutional  as  one  of  the  main 
symptoms  of  gout,  diabetes,  tabes,  or  toxaemia,  and 
local  as  a  direct  production  of  deposits  on  teeth  and 
disturbed  articulation.  Both  causative  factors  may 
undoubtedly  be  combined,  and  the  treatment  must 
therefore  be  arranged  accordingly.  The  treatment 
of  stomatitis,  with  its  many  related  maladies,  should 
unquestionably  have  received  a  more  thorough  dis- 
cussion ;  its  constitutional  causative  factor  and  the 
logical  deduction  from  it  as  to  treatment  are  very 
poorly  considered. 

Fractures  of  the  lower  maxilla  are  of  great  vari- 
ety and  very  often  exasperating  to  the  surgeon,  who 
in  all  countries  will  mostly  turn  over  such  patients  to 
the  dentist.  This  should  not  be  the  case,  as  these 
fractures  surely  belong  to  the  domain  of  surgery, 
although  the  mechanical  part  ma\  belong  to  pros- 
thetic dentistry.  Our  author  should  have  gone  much 
more  into  detail  in  his  chapter  on  fractures  :  there 
are  many  better  forms  of  apparatus  than  he  men- 
tions, and  there  is  no  textbook  which  treats  of  these 
fractures  thoroughly.  But,  in  spite  of  these  criti- 
cisms, the  book  in  its  entirety  deserves  full  praise. 
 «>  


Mrial  |letos. 

Public   Health   and    Marine   Hospital  Service 
Health  Reports: 

The  folloiaing  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  U'cel;  ending  March  5,  igog: 

I'laces.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

California — Los  .\ngeles  Feb.   6-13   3 

District  of  Columbia — Washingfton .  Ff  b.    13-20   i 

Georgia — Cobb  County  Jan. 

Cieorgia — Paulding  County  Jan. 

Illinois — Danville  Feb. 

Illinois — (lalcsburg  Feb. 

Indiana — Elkhart.  Feb. 

Indiana — Evansville  Feb. 

Kansas — Kansas  City  Feb. 

Kansas — Topeka  Feb. 

Kansas — Vv'ichita  Feb. 

Kentucky — Covington  Feb. 

Kentucky — Lexington  Feb. 

Kentucky — Padncali  Jan. 

Louisiana — New  Orleans  Feb. 

Michigan — Grand  Rapids  Feb. 

Michigan — Saginaw  Jan.  30-Feb 

Feb.  13-20. 

Minnesota — ilinneapolis  Jan.    1-31 . . 

Missouri — Kansas  City  Feb.  13-20. 

Missouri— St.   Louis  Feb.  13-20. 

Montana- — Butte  Feb.  2-16.. 

Nebraska — Lincoln  Jan.  1-30. 


i6-Feb.   7   S 

15-  Feb.   7   15 

14-21   I 

13-20   ' 

13-20   1 

13-20   4 

13-20   6 

13-20   9 

13-20   1 

1320   I 

13-20   3 

16-  20   25 

13-20   4 

13-20 

6 


I'laces.  Date 

I'^rance — .Vlarseilles  |an. 

Great    Britain — Bristol  Jan. 

(ireat  Britain — London  Jan. 

India — Bombay  Jan. 

India — Calcutta  Jan. 

India — Madras  Jan. 

Indo-China — .Saigon  Jan. 

Italy — General  Jan. 

Italy — Naples  Jan. 

Japan — Formosa  Jan. 

Batavia — Java  Jan. 

Manchuria — 1  )alny  Jan. 

.Mexico — .Vcapulco  Jan. 

Mexico — (iuadalajara  Feb. 

Mexico — Mexico  City  Dec. 

Mexico — Monterey  Feb. 

Newfoundland — South   Coast  Jan. 

Norway — Bergen  Jan. 

Peru — Lima  Jan. 

Russia — Moscow  Ian. 

Russia — Odessa  Jan.  16-23 

Russia — St.   Petersburg  Jan.  16-23.. 

.Salvador — San   Salvador  'To  Feb.  6.. 

.Salvador — Santa  .\nna  To  Feb.  6.. 

-Spain — Madrid  Jan.    1-31 .  . . 

Spain — Valencia  Jan.  23-30.. 

Turkey — Constantinople  Jan.  24-Feb. 

Yellow  Fever — Foreign. 

Brazil — Bahia  Jan.  2-16... 

Brazil — Para  J?n.  16-30.. 

Dutch    Guiana — Paramaribo  Jan.  1-31... 

Ecuador — Guayaquil  Jan.  23-30.. 

West  Indies — Curacao  Jan.  8-15... 


16 


North   Carolina — Wilmington  March    i   3 

Ohio — Cincinnati  Feb. 

Ohio — Dayton  Feb. 

Tennessee — Memphis  Jan. 

Tennessee — Nashville  Feb. 

Texas — El   Paso  Feb. 

Texas — San  Antonio  Jan. 

Washington — Spokane  Feb. 

Wisconsin — La  Crosse  Feb. 

Wisconsin — Manitowoc  Feb. 


12-  19  , 

13-  20   I 

30-Feb.    13   53 

13-20   6 

923   3 

24-31   IS 

16-23   I  Imported 

13-20   7 

13-20   I 

Smallpox — Foreign. 

Brazil — Bahia  .Tan.    2-16   43  2 

British  Honduras — .Stann  Creek... Feb.   $-11   i  Imported 

Canada — Halifax  Feb.   6-J3   22 

Chile — Talcaguano  Jan.   23-30   Present 

Kgypt — Cairo  Jan.    14-21   62  18 


Case- 

1-  31  

30- Feb.  6   7 

30-  Feb.   6   I 

19-26  

9-16  117 

16-22  

2-  9   2 

3 1 -  Feb.   7   9 

3>-Feh-   7   25 

9-16   I 

2-9   4 

16-23   1 

18-24  

6-  1 1  

26-Jan.  2  

7-  14  

13  

23-30  

21   5 

23-30   19 

  3 

  9 

  3 

  40 


Deaths 


Ei)idemic 


T 

4 

2 
24 

Present 


32 


.217 
•273 


4 

15 


-79 
I  '  ( 


16 
18 
8 
49 
43 
24 
5 
3 


Cholera — Foreign. 

India — Bombay  Jan.  19-26.... 

India — Calcutta  Jan.  19-26.... 

India — Rangoon  Jan.  19-26.... 

Russia — General  Jan.  9-16  

Russia — St.   Petersburg  Jan.  16-23.... 

Plague — Foreign. 

lirazil — Bahia  Jan.  2-9   2 

Brazil — Para  Jan.  23-30   1 

Chile — Iquique  Jan.  26   ..  9 

Ecuador — Guayaquil   Jan.  23-30  

Egypt — General  Jan.  21-28   6 

r-gypt — .Alexandria  Jan.  21-28   1 

India — Bombay  Jan.  19-26  

India — Calcutta  Jan.  9-16  

India — Rangoon  Jan.  9-16  

Japan — Formosa  Jan.  9-23   21 

Mauritius  Nov.  1-30  

Peru — General  Jan.  23-30   57 

Peru — Callao  Jan.  23-30   7 

Peru — Lim?  Jan.  23-30   4 

Turkey — Bagdad  Jan.  9-16   5  2 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  coinntis- 
sioiied  and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Sei-iice  for  the  sczrn  days  ending 
March  3,  igog: 

Br.\xh.\m,  H.  M.,  .\cting  .A.ssistant  S'lr-^eon.  Granted 
thirty  days'  leave  of  absence,  from  February  23.  1909. 

BuLL.\RD,  John  T.,  Acting  Assistant  Surgeon.  Granted 
thirty  days'  leave  of  absence,  from  March  i,  1909. 

Eakins,  O.  M.,  Acting  .A.ssistant  Surgeon.  Granted  three 
months'  leave  of  absence,  from  January  21,  1909,  with- 
out pay. 

GoLDTHW.MTE,  Henrv,  Acting  Assistant  Surgeon.  Granted 
five  days'  leave  of  absence,  from  March  8,  1909. 

HoLSENDORF.  B.  E.,  Pharmacist.  Leave  granted  January 
22,  1909,  for  thirty  days,  from  February  17,  1909,  and 
seven  days,  from  March  18,  1909,  without  pay,  revoked. 

Kern.  W.  A.,  Passed  Assistant  Surgeon.  Granted  one 
month's  leave  of  absence  from  March  18,  1909,  with 
permission  to  go  beyond  the  seas. 

M.\cDo\VELL,  W.  F.,  Pharmacist.  Granted  two  days'  ex- 
tension of  annual  leave  on  account  of  sickness,  from 
February  16,  1909. 

McClin'tick,  Thom.\s  B.,  Passed  .Assistant  Surgeon.  Re- 
lieved froni'  duty  in  the  Philippine  Islands,  and  directed 
to  return  to  the  United  States. 

McK.w,  M.XLCOLM,  Pharmacist.  Granted  four  days'  leave 
of  absence,  from  February  22,  1909,  under  paragraph 
210,  Service  Regulations. 

P.XRKER.  Thom.xs  F..  Acting  Assistant  Surgeon.  Granted 
six  months'  leave  of  absence,  from  April  i,  1909.  with- 
out pay. 

TowNSEND.  F.,  Acting  Assistant  Surgeon.  Granted  four- 
teen days'  leave  of  absence,  from  February  23,  1909. 

W.\RD,  J.  L.^Bruce,  Acting  Assistant  Surgeon.  Granted 
five  days'  leave  of  absence,  from  March  3,  1909. 


568 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal. 


Promotions. 

Passed  Assistant  Surgeon  James  A.  Nydegger  commis- 
sioned a  surgeon,  to  rank  as  such  from  February  4,  1909. 

Assistant  Surgeon  Francis  H.  McKeon  commissioned  a 
passed  assistant  surgeon,  to  rank  as  such  from  November 
27,  igo8. 

Assistant  Surgeon  Joseph  Pettyjohn  commissioned  a 
passed  assistant  surgeon,  to  rank  as  such  from  October  20, 
1908. 

Assistant  Surgeon  Wade  H.  Frost  commissioned  a 
passed  assistant  surgeon,  to  rank  as  such  from  February 
3.  1909- 

Assistant  Surgeon  Eugene  H.  Mullan  commissioned  a 
passed  assistant  surgeon,  to  rank  as  such  from  February  2, 
1909. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  oM- 

cers  serving  in  the  Medical'  Corps  of  the  United  Stales 

Army  for  the  week  ending  March  6,  igog: 

Bartlett,  C.  J.  Captain,  Medical  Corps.  Granted  leave  of 
absence  for  ten  days. 

Dade,  W.  H.,  First  Lieutenant,  Medical  Reserve  Corps. 
Sailing  for  Philippine  service  deferred  to  April  5,  1909. 

Griswold,  W.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  three  months,  fifteen  days. 

Hadra,  F.,  First  Lieutenant,  Medical  Reserve  Corps.  Hon- 
orably discharged  from  the  service  of  the  United  States. 

Hanson,  L.  H.,  Lieutenant,  Medical  Corps.  Relieved  from 
duty  at  Fort  Sam  Houston,  Texas,  and  ordered  to  Hot 
Springs,  Ark.,  for  duty  at  the  Army  and  Navy  Gen- 
eral Hospital. 

Morris,  E.  R.,  Major,  Medical  Corps.  Having  been  found 
physically  disqualified,  retired  from  active  service  as  a 
lieutenant  colonel,  February  26,  1909. 

Mount,  J.  R.,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  one  month,  with  per- 
mission to  apply  for  an  extension  of  one  month. 

Patterson,  E.  W.,  First  Lieutenant,  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  one  month. 

QuiNTON,  W.  W.,  Captain,  Medical  Corps.  Having  been 
found  physically  disqualified,  ordered  to  his  home  to 
await  retirement. 

Thomason,  H.  D.,  Captain,  Medical  Corps.  Granted  an 
extension  of  ten  days  to  his  leave  of  absence. 

Navy  Intelligence: 

Official  list  of  changes  in  the  duties  and  stations  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  week  ending  March  6,  igog: 
Alexander,  C.   E.,   Pharmacist.    Ordered   to  temporary 
duty  in  the  Bureau  of  Medicine  and  Surgery,  Navy 
Department,  Washington,  D.  C. 
Douglass,  S.  W.,  Pharmacist.    Detached  from  the  Naval 
Magazine,  lona  Island,  N.  Y.,  and  ordered  to  the 
Naval  Hospital,  Mare  Island,  Cal. 
Ohnesorg,  K.,  Surgeon.    Detached  from'  the  New  Hamp- 
shire and  ordered  to  the  Naval  Medical  School  Hos- 
pital, Washington,  D.  C. 
Oman,  C.  M.,  Passed  Assistant  Surgeon.    Detached  from 

the  Illinois  and  ordered  to  the  Neiu  Hampshire. 
Rennie,  W.  H.,  Passed  Assistant  Surgeon.   Detached  from 

the  Kentucky  and  ordered  to  the  Illinois 
Richardson,  R.  R.,  Passed  Assistant  Surgeon.  Detached 

from  the  Albany  and  ordered  home  to  wait  orders. 
Stibbens,  F.  H.,  Assistant  Surgeon.    Detached  from  the 
Naval  Hospital,  Mare  Island,  Cal.,  and  ordered  to  the 
Albany. 

 <$>  

iirt^s,  Slarriagts,  ani  §tn\\$. 


Married. 

Hender-son — WisMER. — In  Philadelphia,  on  Wednesday, 
March  3d,  Dr.  Alfred  H.  Henderson  and  Miss  Harriet 
Wismer. 

McClary — Adams. — In  Philadelphia,  on  Friday,  Febru- 
ary 19th,  Dr.  Samuel  McClary  and  Miss  Elizabeth  Lucas 
Adams. 


McMukray— Bankhead.— In  Bullock  Creek,  South  Car- 
olina, on  Wednesday,  February  24th,  Dr.  W.  S.  McMurray 
and  Miss  Ola  May  Bankhead. 

Mabey— MacCall.— In  Newark,  New  Jersey,  on  Tues- 
day, March  2nd,  Dr.  Corwin  Mabey,  of  Montclair,  and  Miss 
Florence  May  MacCall. 

Manning — Campbell. — In  Brooklyn,  New  York,  on  Sat- 
urday, February  27th,  Dr.  Charles  E.  Manning  and  Miss 
Edith  Genevieve  Campbell. 

Died. 

Abricy. — In  Chicago,  Illinois,  on  Monday,  February  22nd, 
Dr.  Charles  D.  Abbey,  aged  six1:y-two  years. 

Barber. — In  Easton,  Maryland,  on  Monday,  March  ist. 
Dr.  Isaac  A.  Barber,  aged  fifty-seven  years. 

Bass. — In  Ashville,  Alabama,  on  Sunday,  February  28th, 
Dr.  John  B.  Bass,  aged  sixty-four  years. 

Brewer. — In  Vineland,  New  Jersey,  on  Wednesday, 
March  3d,  Dr.  Charles  Brewer,  aged  seventy-nine  years. 

Brooks. — In  Dixon,  Illinois,  on  Thursday,  February  25th, 
Dr.  J.  H.  Brooks,  aged  fifty-eight  years. 

Brower. — In  Chicago,  Illinois,  on  Monday,  March  ist, 
Dr.  Daniel  R.  Brower,  aged  seventy  years. 

Chenault. — In  Cleveland,  North  Carolina,  on  Wednes- 
day, February  24th,  Dr.  W.  F.  Chenault,  aged  forty-seven 
years. 

Cochran. — In  Tunnelhill,  Georgia,  on  Wednesday,  Feb- 
ruary 24th,  Dr.  E.  C.  Cochran,  aged  eighty-five  years. 

Cooper.— In  Meadville,  Pennsylvania,  on  Thursday,  Feb- 
ruary nth.  Dr.  Joshua  M.  Cooper,  aged  sixty-five  years. 

Dunn. — In  Selden,  Texas,  on  Friday,  February  26th,  Dr. 
A.  G.  B.  Dunn. 

Farley. — In  Glens  Falls,  New  York,  on  Tuesday,  Feb- 
ruary 23d,  Dr.  Charles  I.  Farley,  aged  seventy-nine  years. 

Farnsworth. — In  Clinton,  Iowa,  on  Sunday,  February 
14th,  Dr.  P.  J.  Farnsworth,  aged  seventy-nine  years. 

Fisher. — In  Port  Deposit,  Maryland,  on  Saturday,  Feb- 
ruary 20th,  Dr.  Samuel  G.  Fisher,  of  Chestertown,  aged 
seventy-seven  years. 

Friedlander. — In  Minneapolis,  Minnesota,  on  Sunday, 
February  21st,  Dr.  Samuel  Friedlander. 

Grimes. — In  South  Bend  Indiana,  on  Friday,  February 
26th,  Dr.  James  F.  Grimes,  aged  eighty-four  years. 

Lancaster.— In  Philadelphia,  on  Thursday,  February 
18th,  Dr.  Thomas  Lancaster,  aged  seventy-six  years. 

Long. — In  St.  Augustine,  Florida,  on  Tuesday,  February 
23d,  Dr.  H.  C.  Long,  of  Cleveland,  Ohio. 

LuNN. — In  Houston,  Texas,  on  Wednesday,  February 
24th,  Dr.  W.  W.  Lunn,  aged  sixty-three  years. 

Meyer. — In  New  York,  on  Tuesday,  March  2nd,  Dr.  Vic- 
tor Meyer,  aged  forty-five  years. 

Moore.— In  Easton,  Pennsylvania,  on  Sunday,  February 
28th,  Dr.  James  W.  Moore,  aged  sixty-five  years. 

Murray. — In  New  York,  on  Saturday,  February  27th, 
Dr.  R.  A.  Murray,  aged  fifty-seven  years. 

NiSBET. — In  Avon,  New  York,  on  Friday,  February  26th, 
Dr.  William  Nisbet,  aged  eighty-three  years. 

Palmer. — In  Monticello,  Florida,  on  Sunday,  February 
2ist,  Dr.  J.  Dabney  Palmer,  aged  sixty-eight  years. 

Perry. — In  Fairfield,  Connecticut,  on  Friday,  February 
26th,  Dr.  Nehemiah  Perry,  aged  eighty-two  years. 

Redd. — In  Crab  Orchard,  Kentucky,  on  Sunday,  February 
2ist,  Dr.  W.  G.  Redd,  aged  sixty-five  years. 

Seymour. — In  Brooklyn,  New  York,  on  Sunday,  Febru- 
ary 2Sth,  Dr.  Wilbur  Hall  Seymour,  aged  forty  years. 

Smith. — In  Mason  City,  Iowa,  on  Thursday,  February 
25th,  Dr.  Chauncey  H.  Smith. 

Thompson. — In  Grand  Rapids,  Michigan,  on  Thursday, 
February  25th,  Dr.  I.  A.  Thompson. 

Troy. — In  Worcester,  Massachusetts,  on  Friday,  Febru- 
ary 26th,  Dr.  Alice  G.  Troy. 

Walton. — In  Annapolis,  Maryland,  on  Tuesday,  March 
2nd,  Dr.  Thomas  Cameron  Walton,  aged  seventy  years. 

Wiley. — In  Des  Moines,  Iowa,  on  Sunday,  February 
28th,  Dr.  Edwin  D.  Wiley,  aged  sixty-three  years. 

WiLSON.^ — In  Lisbon  Falls,  Maine,  on  Wednesday,  Feb- 
ruary 24th,  Dr.  E.  L.  Wilson,  aged  forty-three  years. 

Wood. — In  Galesburg,  Illinois,  on  Thursday,  February 
25th,  Dr.  H.  C.  Wood,  aged  seventy-six  years. 


New  York  Medical  Journal. 

INCORPORATING  THE 

Philadelphia  Medical  Journal  T^t  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  12.  NEW  YORK,  MARCH  20,  1909.  Whole  No.  1581. 


^^riginal  ^ommrtnitations. 

PATHOLOGICAL  DISCOVERY  AND  ITS  BEARING 
UPON  PREVENTIVE  MEDICINE* 

By  J.  George  Adami,  M.  A.,  ls\.  D.,  F.  R.  S., 
Montreal,  Canada, 

Professor  of  Pathology,  McGill  University. 

It  mav  at  first  thought  seem  to  some  at  least  of 
you  that  I  have  been  asked  to  make  bricks  without 
straw.  Up  to  within  quite  recent  times  the  term 
pathology  has  commonly  been  regarded  as  synony- 
mous with  morbid  anatomy  and  histology,  the  study 
of  the  gross  and  microscopical  changes  in  diseased 
tissues.  There  may  be  those  here  present  who  still 
retain  this  conception.  It  would  be  difficult  to  dem- 
onstrate on  a  broad  scale  that  the  great  discoveries 
in  pathological  anatomy  had  been  of  direct  influence 
upon  the  problems  of  hygiene,  though  much  might 
be  said  regarding  their  indirect  influence.  Happily 
there  is  an  increasing  recognition  all  over  the  conti- 
nent, and  all  over  the  world,  that  pathology  is  very 
much  more  than  this,  that  it  includes  the  study  of 
disease  in  all  its  aspects,  that  it  is  the  science  of 
medicine,  or  all  of  that  science,  save  the  not  unim- 
portant portion  which  deals  with  treatment ;  that 
thus  it  is  the  exact  study  of  the  causes  of  disease, 
the  processes  of  disease,  the  results  of  disease.  And 
undoubtedly  it  is  the  last  thirty-five  years  that  have 
seen  the  great  medical  renaissance,  and  this  new 
birth  has  followed  upon  exact  observation  and  the 
employment  of  the  experimental  method.  Advance 
in  medicine  has  to  a  very  remarkable  degree  been 
the  outcome  of  exact  experimental  investigations 
conducted  in  the  laboratorv,  to  a  remarkably  slight 
extent  has  it  been  due  to  empiricism  or  the  employ- 
ment of  methods  of  treatment  upon  no  settled  plan 
but  on  the  chance  that  they  might  succeed.  It  mat- 
ters not  whether  these  investigations  have  been  con- 
ducted by  a  chemist,  like  Pasteur,  by  a  zoologist 
like  Metchnikoff.  by  country  practitioners,  like  Jen- 
ner  and  Koch,  by  army  surgeons  like  Laveran,  Ron- 
ald Ross,  Walter  Reed,  or  by  those  who  in  these 
later  years  have  devoted  their  lives  to  medical  re- 
search like  von  Behring  and  Roux  and  Flexner ;  all 
these  investigations  are  pathological. 

If  thus  it  can  be  shown  that  the  extraordinary  ad- 
vances made  in  medicine  within  the  last  generation 
are  essentially  based  upon  the  data  af¥orded  by  exact 
observation  and  pathological  research,  this  is  equal- 
ly the  case  with — indeed  it  is  true  to  an  even  greater 
extent  —  the  special  branch,  preventive  medicine. 
For-  if  we  seek  to  determine  wherein  pathological 

*An  address  delivered  at  the  College  of  Physicians  and  Surgeons, 
Columbia  University,   Xew   ^'nrk.    February  3,  1909. 


research  has  led  to  the  most  remarkable  discoveries,, 
and  medicine  has  undergone  the  greatest  revolution 
there  can  be  no  hesitation  in  deciding  that  it  is  in 
connection  with  infectious  diseases:  it  is  the  dis- 
covery of  the  causative  agents  of  so  many  diseases, 
of  the  mode  of  action  of  pathogenic  microbes  in  pro- 
ducing the  symptoms  of  disease,  and  the  conditions 
of  life  of  these  agents,  that  has  been  the  great  out- 
standing triumph  of  the  end  of  the  nineteenth  cen- 
turv.  Xovv  it  is  precisely  along  the  lines  of  con- 
trolling these  infectious  diseases  that  preventive 
medicine  has  its  dominant  activities — and  it,  there- 
fore, even  more  than  medicine  in  general,  has 
profited  from  these  discoveries.  Regarded  from 
this  point  of  view  it  is  self  evident  that  the 
great  pathological  discoveries  here  are  an  untold 
influence  upon  public  health  and  its  problems. 
I  fear  that  were  I  this  afternoon  merely  to  pass 
in  reviewing  these  discoveries — fascinating  as 
they  are — with  comments  upon  their  bearings  upon 
public  health  work,  I  should  not  tell  yon  any- 
thing of  which  you  were  not  already  convinced.  It 
would  be  a  work  of  supererogation.  It  will  be  of 
greater  service  if  I  attempt  to  trace  in  a  certain  num- 
ber of  instances  how  far  we  were  able  to  advance 
in  the  prevention  of  disease  under  general  hygienic 
principles,  and  what  has  been  our  advance  once  re- 
search has  afforded  us  a  certain  knowledge  of  caus- 
ative agents. 

As  a  preliminary  let  me  say  that  we  may  take  the 
period  1880  to  1887  as  that  in  which,  thanks  to  the 
work  of  those  great  founders  of  bacteriological  sci- 
ence, Pasteur  and  Koch,  the  principle  became  surelv 
established  and  accepted,  that  infectious  disease  is 
due  to  the  presence  and  growth  within  the  systtm  of 
pathogenic  microorganisms.  Some  were  discovered 
before  that  period,  others  since,  yet  others  have  still 
to  be  discovered;  but  by  the  year  1887  it  may  be 
laid  down  that  the  lay  world  had  come  to  accept  the 
new  doctrine,  so  that  from  now  on  legislation  and 
public  health  ordinances  based  upon  it  became  estab- 
lished and  began  to  bear  fruit. 

Let  me  begin,  therefore,  by  discussing  the  general 
decrease  in  the  death  rate  during  what,  as  regards 
statistics,  we  may  speak  of  as  historical  times,  dur- 
ing, that  is,  the  last  three  centuries. 

Finklenburg.  of  Bonn,  has  estimated  that  the  aver- 
age human  life  in  the  sixteenth  century  was  onlv 
eighteen  to  twenty  years.  In  the  middle  of  the  nine- 
teenth century  it  has  risen  to  over  thirty-seven  years, 
to-day  it  is  well  over  forty  years.  We  obtain  pos- 
sibly a  better  idea  of  the  improvement  in  hygiene 
by  a  study  of  the  mortality  tables  of  a  great  citv 
like  London.  There  from  1620  to  1643  the  mortal- 
ity has  been  estimated  as  serentx  in  a  thousand  ; 


("oiiyright.  igog.  by  A.  R.  Elliott  Publishing  Companv. 


570 


ADAMI:  PATHOLOGICAL  DISCOVERY   AXD  PREi'ENTll'E  MEDICINE.  „  [Ne.v  York 

Medical  Journal. 


from  1660  to  1679,  a  period  including  the  great 
plague,  it  rose  to  eighty  in  a  thousand.  After  the 
last  traces  of  the  oriental  plague  left  England,  the 
improved  hygiene  which  coping  with  the  same  had 
rendered  imperative  further  reduced  the  mortality 
so  that  this  in  the  period  of  1728  to  1757  fell  to 
Hfty-tzvo  in  a  thousand.  From  this  period  to  the 
end  of  the  eighteenth  century  it  progressively  rose, 
owing  largely,  it  would  seem,  to  the  continued  in- 
crease in  the  mortality  from  smallpox,  an  increase 
favored  instead  of  hindered  by  the  first  serious  at- 
tempt at  prevention  by  immunization,  by  the  exten- 
sion of  the  practice  of  inoculation  of  the  healthy 
with  material  from  those  sufifering  from  the  dis- 
ease. If  that  practice  afiforded  a  mild  disease  and 
subsequent  immunity  to  the  inoculated  one,  it  at  the 
same  time  spread  the  disease  among  his  entourage. 
The  inoculated  disease  was  so  mild  that  the  patient 
was  apt  to  take  no  precautions.  Thus  the  death 
rate  from  smallpox  rose  until  it  is  estimated  that 
3000  persons  in  each  million  died  annually  from  the 
disease.  It  is  in  1796  that  we  have  the  first  great 
practical  discovery  in  preventive  medicine,  that, 
namely,  of  vaccination  by  Jenner.  Here  let  me  be 
just.  Prior  to  that  date  it  was  a  popular  belief  in 
several  districts  that  cowpox  shielded  the  individual 
from  subsequent  smallpox,  and  there  is  clear  evi- 
dence that  others  had  performed  the  artificial  in- 
oculation for  preventive  purposes.  But  Jenner  it 
was  who  by  his  researches  proved  the  correctness 
of  this  belief  and  demonstrated  by  exact  experi- 
ment that  inoculation  with  matter  from  cowpox  pro- 
tected for  long  periods  from  smallpox.  And,  his 
observations  being  "exact  and  incontrovertible,  in  the 
first  years  of  the  nineteenth  century  vaccination  be- 
came widespread  in  London  with  as  a  result  a  rapid 
fall  in  the  death  rate  to  29.2  in  a  thousand.  Again 
there  came  a  period  of  latency  until  1835,  the  aver- 
age from  1813  to  1835  being  tivcnty-nine  in  a  thou- 
sand. From  now  on  the  British  Parliament  passed 
a  succession  of  acts  bearing  upon  municipal  admin- 
istration, child  labor,  ventilation  of  workshops,  arti- 
sans" dwellings,  etc.,  while  the  water  supply  and 
drainage  of  the  great  city  were  greatly  improved. 
.A.S  a  result  we  find  a  peri'od  of  steady  fall  inaugu- 
rated, with  death  rate  of  tivcnty-fiTC  in  a  thousand 
in  the  decade  from  1841  to  50,  a  little  over  tzueiity- 
foiir  during  the  score  of  years  1851  to  70,  22.5  in 
the  decade  1871  to  80. 

During  the  intermediate  period,  1880  to  1887,  al- 
ready noted,  the  death  rate  sank  to  20.4  and  in  the 
year  1887  the  first  time  fell  below  20  (19.5). 
Broadly  speaking,  we  may  say  that  in  eighty-seven 
years  it  fell  9.7  points  or  o.ii  per  annum.  Now 
during  the  last  twenty-one  years  it  has  fallen  an- 
other 5.2  points,  or  0.25  per  annum,  until  last  year 
it  stood  at  14.3  in  a  thousand.  In  other  words, 
since  the  discoveries  of  the  causative  agents  of  dis- 
ease, and  the  utilization  of  the  knowledge  thus 
gained  the  diminution  of  the  death  rate  in  London 
has  been  accelerated  more  than  twofold. 

W  eighing  everything  carefully,  it  is  impossible  to 
ascribe  this  greatly  accelerated  reduction  to  causes 
other  than  the  advance  in  public  and  personal 
hygiene  brought  alK)Ut  by  the  outburst  of  research 
JMid  discovery  regarding  the  causative  agents  of  in- 
fective (li.sease  during  the  late  seventies  and  early 
(iirhties  f)f  the  last  century,  and  the  increasing 


knowledge  of  the  modes  of  infection  and  of  preven- 
tion of  the  same  that  these  discoveries  brought  in 
their  train.  That  this  reduction  in  mortality  will 
continue  at  the  same  rate  is  not  possible.  Only  a 
certain  proportion  of  the  total  mortality  is  due  to 
the  infectious  diseases.  Could  we  wholly  banish 
these,  we  should  not  banish  death  from  our  midst ; 
the  individual  still  must  die  from  other  causes.  But 
these  same  considerations  render  the  figures  I  have 
given  all  the  more  remarkable.  As  we  reduce  the 
number  of  deaths  from  preventable  causes  each  re- 
duction of  one  in  a  thousand  means  a  greater  and 
greater  effort,  and,  notwithstanding  this,  the  reduc- 
tion has  during' the  last  twenty  years  continued  at 
twice  the  rate  of  that  occurring  during  the  previous 
eighty  years. 

I  have  taken  London  as  my  example,  because  it 
is  the  city  which  combines  greatest  population  with 
best  hygienic  conditions  and  lowest  mortality  dur- 
ing the  greater  part  of  the  last  hundred  years.  Had 
I  selected  New  York,  the  figures  would  have  been 
yet  more  striking.  Here  the  decrease  in  the  death 
rate  during  the  last  twenty-five  years  has  been  prac- 
tically six  in  a  thousand  (5.89).  But  at  the  same 
time  they  would  have  been  somewhat  exaggerated 
in  that  there  was  not  in  New  York  to  anything  like 
the  same  extent  that  preparatory  period  of  progres- 
sive reduction  in  mortality  due  to  an  enlightened  en- 
forcement of  legislation,  which,  while  primarily  di- 
rected to  secure  the  increased  well  being  of  the  in- 
dividual citizen,  simultaneously  reduced  his  liability 
to  infection. 

Tuberculosis. 

But  it  is  when  we  come  to  consider  individual  in- 
fectious diseases  and  the  means  now  being  taken  to 
arrest  them,  that  we  obtain  the  most  striking  dem- 
onstration of  the  beneficent  influence  of  the  great 
pathological  discoveries  of  the  nineteenth  century 
upon  preventive  medicine.  Naturally  the  first  of 
these  to  be  considered  is  that  which  among  us  stands 
preeminent  both  as  causing  disease  and  swelling 
the  death  rate.  It  is  a  matter  of  familiar  knowledge 
to  all  of  you  that  among  the  peoples  of  the  tem- 
perate zone  tuberculosis  stands  facile  princeps 
among  the  enemies  of  mankind,  causing  roughly 
one  seventh  of  the  deaths  from  all  causes.  It  is 
well  known  to  you  also  that  post  mortem  examina- 
tion reveals  naked  eye  evidence  of  either  active  or 
arrested  tuberculosis  in  the  majority  of  autopsies  at 
all  periods  of  life  and  in  those  who  have  died  from 
all  forms  of  disease,  the  frequenc}'  increasing  pro- 
gressively until  the  thirteenth  year  is  reached.  My 
own  series  of  autopsies  at  the  Royal  X'ictoria  Hos- 
l)ital  at  Montreal  upon  some  1,400  cases  has  yielded 
to  Dr.  Landrv  evidence  that  45.5  of  the  total,  af- 
ford such  niacrosco])ical  evidence  of  the  disease, 
or,  if  certain  doubtful  indications  are  also  included, 
a  little  over  51  per  cent.  Statistics  from  the  crowd- 
ed industrial  centres  in  the  old  world  give  yet 
higher  figures,  as  do  also  routine  microscopical  ex- 
aminations of  the  peribronchial,  peritracheal,  and 
mesenteric  Ivmph  glan<ls :  so  that  it  would  seem  thnt 
there  is  no  very  great  exaggeration  in  the  statenieni' 
that  every  one  has  his  bit  of  tuberculosis;  even  if 
fortunately  for  us  the  majority  arc  able  successfully 
to  hedge  in  that  bit  and  render  it  harmless. 

Lastly,  every  medical  student  knows  that  Koch 
announced  the  discovery  of  the  tubercle  bacillus  in 


March  20,  1909.] 


ADAMI:  PATHOLOGICAL  DISCOVERY  AXD  PRE]'EXJI\  E  MEDICIXE. 


March.  1882,  and  that  in  1884  he  pubHshed  the  ex- 
tended account  of  the  researches  which  led  up  to 
and  confirmed  that  discovery.  I  doubt  if  in  any  sci- 
ence there  exists  a  more  elaborate,  more  painstaking 
and  thorough  research  than  is  revealed  in  those 
pages  of  the  second  volume  of  the  Miffheilungeu 
aits  don  kaiserlicheii  Gcsiindheitsamte  with  their 
demonstrations  of  how  the  tubercle  bacillus  is  to 
be  detected  in  the  tissues,  how  the  germ  may  be 
grown  in  pure  culture,  and  the  record  of  the  hun- 
dreds and  hundreds  of  animals  of  different  species 
laboriously  studied,  both  for  the  presence  of  the  tu- 
bercle bacilli  in  their  tissues  and  for  the  results  of 
inoculation  of  pure  cultures  of  the  bacillus  in  set- 
ting up  the  disease. 

So  elaborate  and  so  thorough  a  research  it  was 
as  to  establish  instant  conviction.  From  1884  on- 
wards the  medical  world  was  forced  to  accept  the 
tubercle  bacillus. 

But  very  few  of  us  know,  and  still  fewer  realize 
nowadays  what  that  discoverv  has  meant  not  mere- 
ly for  the  medical  outlook  upon  phthisis  and  other 
forms  of  tuberculosis,  but  also  for  practice.  One 
has  not  to  be  very  old  to  be  able  to  remember  the 
medical  events  of  the  eighties,  but  I  take  it  that 
others  like  myself  have  the  impression  that  the  dis- 
covery came  naturally  enough  with  years  of  prepa- 
ration in  which  the  medical  profession  was  coming 
roinid  to  the  opinion  that  tuberculosis  is  an  infec- 
tious disease.  Secure  in  the  possession  of  this  exact 
knowledge  that  the  tubercle  bacillus  is  to  be  gained 
from  every  focus  of  active  tuberculosis,  we  are  only 
too  ready  to  admit  the  evidence  that  earlier  workers 
had  brought  forward  regarding  the  infectiousness 
of  the  disease.  We  cite  Isocrates,  Avicenna.  Fra- 
castorius,  Morgagni,  and  others  as  recognizing  the 
fact,  we  quote  the  disinfection  ordinances  of  Naples 
and  other  Italian  towns  in  the  eighteenth  century. 
We  adduce  Villemin's  masterly  experiments  of  1865 
upon  the  experimental  production  of  tuberculosis 
in  rabbits,  and  the  even  more  convincing  observa- 
tions of  Cohnheim  and  Salomonsen  in  1877, 
which,  placing  tuberculous  material  from  man  in  the 
anterior  chamber  of  the  rabbit's  eye,  they  were  able 
to  see  and  follow  the  development  of  tubercles  upon 
the  iris.  We  forget  that  all  these  observations  had 
practically  no  abiding  influence  upon  medical  ac- 
tion ;  that  accepted  by  some  they  nevertheless  did 
not  become  part  of  general  teaching  and  general 
belief ;  that  others  afforded  other  explanations ;  that 
as  regards  Villemin's  and  Cohnheim's  experiments 
Talma,  Aufrecht,  and  Lebert  in  Germany,  Empis 
and  Metzquer  in  France.  Burdon  Sanderson,  Wilson 
Fox,  and  Klein  in  England  brought  forward  such 
apparently  overwhelming  evidence  to  show  that  pus 
and  foreign  matter,  and  portions  of  healthy  and  dis- 
eased tissues  of  a  nontuberculous  nature  would  pro- 
duce identically  the  same  effects;  that  accurate  as 
we  now  know  these  experiments  to  have  been  they 
did  not  convince.  ^^"e  know  now  that  prior  to 
Koch,  Baumgarten  had  seen  the  tubercle  bacillus, 
but  he  had  not  isolated  and  grown  it  and  studied  its 
properties.  Xot  one  of  these  observers  had  afford- 
ed a  demonstration  absolutely  conclusive.  That  was 
left  to  Koch  and  his  must  be  the  credit. 

As  a  matter  of  curiosity  I  have  during  the  last 
few  days  glanced  through  a  series  of  the  more  pop- 
ular textbooks  of  medicine,  published  between  1845 


and  1882  to  recall  v.hat  was  the  ordinary  and  ac- 
cepted teaching  regarding  tuberculosis.  And  I  can 
say  that  until  one  does  this  it  is  impossible  for  any 
one  to  realize  the  revolution  that  Koch's  discovery 
has  brought  about.  \\'hether  it  be  in  regard  to 
aetiology,  to  the  morbid  anatomy  of  the  pro- 
cess, the  relationship  of  the  different  manifesta- 
tions of  the  disease,  or  the  treatment,  every- 
thing is  vague  and  hesitating,  where  it  is 
not,  as  we  now  know,  incorrect.  If  anything, 
there  is  increasing  vagueness  as  we  approach 
1882  and  that  largely  because  of  ^'irchow's  errone- 
ous teaching  regarding  the  nonidentity  of  caseous 
pneumonia  with  other  forms  of  tuberculosis  and  its 
intimate  relationship  to  catarrhal  pneumonia.  ( )ne 
and  all,  English  and  French  and  German  textbooks 
lay  stress  upon  hereditary  diathesis  and  the  strumous 
constitution  as  the  basis  of  the  disease.  Most  admit 
that  it  may  arise  de  novo  in  an  individual  showing- 
no  signs  of  the  diathesis,  and  then  in  consequence  of 
improper  nourishment,  impure  air,  unliealthy  occu- 
pations, low  temperature,  and  want  of  sunlight.  In 
the  very  year  of  Koch's  discovery.  Peters,  professor 
of  internal  pathology-  in  the  Paris  Faculty  and  mem- 
ber of  the  Academy  of  ^Medicine  (Leco;;^  de  clinique 
mcdicale,  second  edition,  II,  1882).  who  devotes 
some  600  pages  to  the  subject  of  tuberculosis  and 
more  than  200  to  its  aetiolog}',  denies  its  contagious 
nature,  regards  Mllemin's  conclusions  as  non- 
proved,  and  the  tubercle  as  an  evidence  of  a  vice  of 
nutrition  and  due  to  the  loss  of  vital  energy. 

It  is,  you  will  find,  always  the  case  that  when  the 
exciting  cause  of  a  disease  is  not  known,  teach- 
ers and  writers  dwell  with  emphasis  on  all  the  pre- 
disposing causes.  And  on  the  whole  these  writers 
of  the  first  three  quarters  of  the  nineteenth  century 
were  quite  accurate  in  their  enumeration  of  these 
predisposing  causes,  even  if  they  were  imcertain  as 
to  the  relationship  of  the  one  to  the  other  and  to 
the  actual  disease.  Nay.  more  in  these  latter  days 
from  the  attitude  naturally  assumed  after  the  first 
discovery  of  the  specific  pathogenic  microbes — the 
attitude  of  ascribing  everything  to  the  microbic  fac- 
tor— we  are  coming  round  to  realize  more  and  more 
that  it  is  the  summation  of  two  factors,  of  the  re- 
sisting powers  or  relative  susceptibility  of  the  or- 
ganism and  the  relative  virulence  of  the  microor- 
ganism, together  with  the  number  of  the  same 
gaining  entrance  into  a  particular  area  at  a  particu- 
lar time,  that  determines  whether  infection  is  light- 
ed up.  We  must  be  prepared  to  see.  therefore,  that 
progressive  improvement  in  general  hygiene  during 
the  nineteenth  century  had  a  definite  effect  upon  the 
mortality  from  tuberculosis.  Better  housing,  bet- 
ter conditions  of  work,  better  ventilation  of  house 
and  workshop,  better  wages  and  consequent  better 
nourishment  of  the  mass  of  the  people,  all  had  their 
effect  in  reducing  the  ravages  of  the  disease.  But 
think  what  it  has  meant  to  preventive  medicine  to 
know  with  absolute  certainty  that  the  disease  is  in- 
fectious ;  that  infection  is  conveyed  by  the  bacillus ; 
that  these  bacilli  cannot  thrive  and  multiply  at  the 
ordinar}-  temperature,  but  only  at  body  temperature 
or  thereabouts,  and  that  consequent! v  every  case  of 
the  disease  must  be  derived  directly  from  a  pre- 
vious case :  that  the  bacilli  are  discharged  in  enor- 
mous numbers  in  the  expectoration  of  phthisical  pa- 
tients and  may  be  found  in  teeming  millions  in  the 


572 


ADAMI:  PATHOLOGICAL  DISCOVERY  AND  PREl'ENTIVE  MEDICIXE.       [N.-;..v  \ork 

Medical  Journal. 


inilk  of  cattle  with  tuberculosis  of  the  udder;  and 
that,  consequently,  infection  is  from  man  to  man 
or  from  cattle  to  the  drinkers  of  raw  milk,  namely 
to  young  children  ;  that  the  bacilli  easily  killed  by 
sunlight  mav  persist  for  long  weeks  and  months 
in  a  virulent  state  in  dark  rooms.  These  facts  sup- 
\)\\  the  data  for  prevention  of  the  disease ;  they 
afford  the  data  for  the  solution  of  the  problem. 

We  see  here  the  same  process  at  work  as  was 
noted  in  connection  with  the  general  mortality 
rate,  ^'ou  must  forgive  me  if  as  a  British  subject 
I  tend  to  refer  to  British  statistics  best  known  to 
me.  With  imi>rove(l  general  hygienic  conditions  of 
the  mass  of  the  people,  even  before  anything  was 
known  regarding  the  tubercle  bacillus,  the  reduc- 
tion in  the  death  rate  from  phthisis  in  England  and 
Wales  was  very  remarkable :  that  dropped  from 
over  thirty-cU^ht  in  lo.ooo  living  in  1838  to  slightly 
over  ei'^htccn  in  1884.  Since  then  there  has  been 
a  distinct  acceleration  in  the  fall.  What  can  be  ac- 
complished is,  however,  best  shown  not  by  taking 
the  general  death  rate  but  by  employing  the  figures 
from  cities  in  which  the  disease  has  been  combatted 
systematically  by  measures  logically  deduced  from 
the  data  furnished  by  Koch's  discovery. 

You  all  know  New  York's  proud  showing  under 
the  firm  but  beneficent  mastery  of  your  Board  of 
Health  led  by  Dr.  Hermann  M.  Biggs,  and  how 
greatly  the  death  rate  for  tuberculosis  has  dropped 
during  the  last  ten  years.  But  even  more  striking 
figures  are  afforded  by  Edinburgh,  a  much  smaller 
city,  where  the  populace  is  more  homogeneous, 
more  docile,  and  more  intelligent  than  the  illiterate 
suarming  mixture  of  European  immigrants,  which 
crowding  into  the  -tenement  house  ((uarters  of  this 
city,  forms  so  hard  a  nut  for  your  health  officials  to 
crack.  To  Dr.  Philip  is  due  the  thorough  develop- 
ment of  the  Edinburgh  dispensary  .system,  which, 
acting  in  conjunction  with  the  city  health  authori- 
ties and  strengthened  by  compulsory  notification 
makes  it  possible  to  deal  with  every  recognized  case 
of  tuberculosis.  There  the  deaths  from  tuberculosis 
have  fallen  to  a  remarkable  extent.  As  Dr.  Philij) 
])oints  out,  we  may  divide  the  last  twenty  years— 
or  more  accurately  the  period  from  1886  to  1906 — 
into  two  equal  periods.  During  the  first  of  these 
necessarily  the  direction  of  antituberculosis  effort 
was  rather  indefinite.  Even  when,  as  in  Edinburgh, 
the  antituberculosis  effort  had  assumed  more  defi- 
nite shape,  time  was  needed  before  the  effect  of 
effnrt  be^an  to  register  itself  in  the  death  rate.  In 
brief,  whereas  from  1887  to  1896,  the  fall  in  10,000 
was  2.5  (from  19.5  to  seventeen  in  10,000).  from 
1897  to  1906  the  fall  in  10,000  was  from  nine- 
teen to  eleven.  The  percentage  reduction  in  the 
first  ten  years  was  12.82,  in  the  second  ten  years 
42.1.  These  are  remarkable  figures.  We  may  .sav 
that  in  the  last  ten  years  there  has  been  a  greater 
reduction  than  in  the  i)revious  fifty  years.  The  ef- 
fect of  exact  knowledge,  gained  by  experiment,  is 
indubitable. 

.M.\r..\Ri.\. 

The  other  great  scourge  of  mankind  affords  even 
more  striking  testimony  as  to  the  effect  upon  the 
j)ublic  health  of  |)athol()gical  discovery.  We  living 
in  the  tem])erate  zone  are  apt  to  forget  that 
there  is  a  disease  more  terrible  and  more  wide- 


spread than  tuberculosis.  It  has  been  said  that  one 
half  the  mortality  of  the  human  race  is  due  to 
malaria.  This,  I  am  inclined  to  think,  is  an  exag- 
geration, but  when,  as  Shiplev  ])oints  out,  in  1892 
out  of  a  total  population  of  India  of  217,255,655, 
the  deaths  from  all  causes  reached  the  figure  of 
6,980,785,  and  of  these  7,000,000  odd  5,000,000 
were  due  to  "fever,"  and  fever  in  the  tropics  is 
known  to  indicate  most  often  malaria,  the  state- 
ment is  perchance  not  so  very  far  from  the 
truth.  This  same  would  seem  true  of  China,  with 
its  innumerable  millions,  and  all  here  know  the 
ravages  of  the  disease  in  Central  and  South  Amer- 
ica. Nor  need  I  remind  you  as  next  door  neigh- 
bors of  Long  Island  and  New  Jersey  that  the  dis- 
ease is  not  confined  to  the  tropics.  What  is  of 
equal  importance  is  that  where  the  disease  is  not 
fatal  it  profoundly  affects  the  vitality  and  power  of 
the  individual  for  long  periods,  causing  listlessness 
and  incapacity  for  active  work.  Of  the  British 
soldiers  in  India  three  out  of  seven  suffer  from  an 
annual  attack  of  malaria ;  of  those  on  the  west 
coast  of  Africa  each  individual  suffers  on  the  aver- 
age from  two  attacks  each  year ;  the  loss  in  energy 
and  effectiveness  is  singularly  great.  A  recent 
writer'  has  brought  forward  a  considerable  bod\- 
of  evidence  from  classical  writers  that  more  par- 
ticularly the  decay  of  Greece  and  probably  als  )  th■^ 
decline  and  fall  of  the  Roman  Empire  coincided 
with  the  introduction  and  general  spread  of  malaria 
through  the  valleys  of  the  Grecian  peninsula  and 
through  the  hitherto  fertile  and  populous  Cam- 
pagna  around  Rome  and  other  low  Iving  regions  of 
Central  and  Southern  Italy.  The  striking  alteration 
in  the  character  of  the  inhabitants  of  the  Is- 
land of  Mauritius,  brought  about  by  the  introduc- 
tion and  universal  spread  of  malaria  since  the  year 
t866  strongly  supports  this  view. 

That  the  disease  especially  haunted  low  lying  and 
swampy  districts  had  been  known  for  centuries — 
as  also  that  it  was  particularly  dangerous  to  travel 
about  in  marshy  regions  after  nightfall.  .\s  the 
name  malaria  implies,  a  miasm  was  supposed  to  be 
exhaled  from  the  damp  ground  and  to  cause  the 
disease.  It  was  found  that  drainage  of  an  infected 
district  materially  reduced  the  incidence  of  the  dis- 
ease. When  I  was  an  undergraduate  at  Cambridge 
there  were  still  those  living  who  remembered  when 
it  was  dangerous  to  open  the  windows  at  night  in 
certain  parts  of  the  town  on  account  of  the  ague 
from  the  neighboring  fen  which  might  result.  That 
fen,  like  all  the  marshes  of  the  fen  country,  has 
long  been  drained  and  neither  in  that  district  nor 
in  any  other  part  of  England  has  there  been 
endemic  malaria  for  long  years.  Drainage  simi- 
larly and  occupation  of  land  has  banished  tiie  en- 
demic ague  from  regions  in  the  northern  States, 
like  that  around  Detroit,  where  within  living  mem- 
ory malaria  was  terribly  rife.  Procedures  of  this 
order  coujjled  with  the  proper  and  ade(|uate  use  of 
(|uinine  have  in  various  parts  of  the  world  mate- 
rially reduced  the  incidence  of  ague,  allhougli 
where  these  precautions  have  not  been  adojjfed  the 
disease  has  continued  its  depredations  with  undi- 
minished vigor.  Here  again  we  see  that  ])rior  to 
the  remarkable  series  of  discoveries  bearing  upon 

'Slolaria.  a  Scgl"cleH  Factor  in  the  History  of  Greece  ami  Home, 
hy  W.  II.  T.  Jones,  M.  A.  (Cambridge).    Maciiiillaii  &  Howes.  igo7. 


Ma.cii  ro.  .-909.]      ADAMl:  PATHOLOGICAL  DISCOl'EKY   AXD  PREI  EXTII  E  MEDICIXE. 


the  causative  agent  of  the  disease  preventive  meas- 
ures were  in  force  and  had  a  definite  effect.  The 
mere  discovery  by  Laveran  in  1880  of  the  hsema- 
nueba  in  the  blood  corpuscles,  important  as  it 
was.  had  Httle  effect,  save  to  aft'ord  indications 
for  treatment  of  the  individual  case ;  for  studying- 
the  cycle  of  forms  it  was  found  that  quinine  was 
ni(ist  eft'ective  upon  the  free  amneb?e  as  the\'  de- 
veloped from  the  liberated  spores.  That  discovery 
did  not  throw  light  upon  the  mode  of  infection. 
Xor  again,  deserving  it  is  of  remembrance,  did  the 
admirable  paper  of  Dr.  King,  of  Washington,  in 
1883.  in  which  he  showed  that  the  mosquito  must 
be  the  carrier  of  malarial  infection,  have  any  in- 
fluence upon  preventive  medicine,  save  as  preparing 
us  to  accept  the  absolute  demonstration  when  it 
came.  Only  in  1807  did  the  researches  of  Captain 
Ronald  Ross  solve  the  mystery  and  immediatelv 
demonstrate  how  the  disease  is  to  be  prevented. 
All  are  now  familiar  with  Ross's  work — how  first 
he  found  peculiar  acciunulations  of  parasitic  type 
in  the  v.alls  of  the  stomachs  of  mosquitoes  of  a  par- 
ticular species  that  had  fed  upon  the  blood  of  ma- 
larial patients ;  how  unable  to  procure  sufficient  hu- 
man n^.aterial  he  turned  his  attention  to  a  similar 
blood  parasite  in  birds  and  fotmd  here  that  another 
species  of  mosquito  acted  as  the  intermediate  host ; 
how  making  use  of  \\'.  G.  MacCalltun's  observa- 
tions upon  the  sexual  union  between  the  t^agella 
and  free  amoeboid  corpuscles  of  an  allied  parasite 
in  the  removed  blood  of  Canadian  crows  he  recog- 
nized the  existence  of  a  sexual  cycle  of  these  para- 
sites in  the  stomach  and  tissues  of  the  mosquito, 
and  concluded  that  a  similar  series  of  stages  occur 
with  the  malarial  organism  of  man  sucked  up  by 
the  anopheles ;  how,  in  short,  he  concluded  that  this 
mosquito  was  the  carrier  of  the  disease  from  indi- 
vidual to  individual ;  how  the  correctness  of  these 
conclusions  was  demonstrated  by  the  yoimger  Man- 
son,  who  in  malaria  free  London  became  infected  bv 
the  bites  of  mosquitoes  which  had  fed  upon  ague  pa- 
tients in  Rome,  and  h'ad  then  been  transported  for 
the  purposes  of  this  experiment ;  and  how  the  life 
liistory  of  the  human  malarial  parasite,  or  more  ac- 
curately, parasites,  was  worked  otit  along  the  same 
lines  by  Grassi,  Bastianelli,  and  Bignami.  in  Italy. 
Here  now,  at  last,  we  knew  how  malaria  was  ac- 
quired and  immediately  it  became  evident  how  it 
was  to  be  prevented — either  by  guarding  the  indi- 
vidual from  being  bitten  by  the  anopheles,  or  better 
by  preventing  the  anopheles  from  breeding,  and  so 
exterminating  these  mosquitoes. 

The  results  of  preventive  measures  adequately 
carried  out  have  been  extraordinary.  Take  for  ex- 
ample the  instance  of  Ismailia  in  Egypt.  This  is 
a  town  of  about  6,000  inhabitants,  principally  em- 
ployees of  the  Suez  Canal  Company,  founded  by 
Baron  de  Lesseps  in  1862.  In  1877  a  fresh  water 
canal  was  constructed  to  suppl\  the  town  with 
drinking  water,  and  with  that  an  ideal  breeding 
ground  for  mosquitoes  was  aft'orded.  Almost  at  once 
malaria  appeared  and  since  then  malaria  has  stead- 
ily increased  until  1902  when  the  mosquito  cam- 
])aign  was  inaugurated.  We  obtain  the  following 
figures : 

Year  ....  1898  1899  1900  1901  1902  1903  1904  1505 
Cases  -.  . .  1545    1784    2250    1900    154S     2  [4       go  37 

I-!  this  last  vear  Dr.  Pressat  the  official  medical 


officer  reported  that  there  were  no  new  cases  of  in- 
fection :  the  disease  was  killed  out,  and  that  by  one 
mosquito  brigade  consisting  of  four  men  acting 
under  the  medical  officer. 

In  Port  Swettenham,  in  the  ^lalay  States,  the 
same  brilliant  results  have  been  obtained.  Here  was 
a  new  tropical  settlement,  surrotnided  by  marshes  in 
which  the  anopheles  bred  abundantly,  and  having 
an  annual  rainfall  of  100  inches — a  swamp  of  the 
most  pernicious  order.  Within  two  months  of  the 
opening  of  the  port  in  IQ02  forty-one  out  of  the 
forty-nine  government  quarters  were  infected  and 
118  out  of  196  government  servants  were  ill.  Now, 
after  filling  up  all  pools  in  the  settlement  for  a 
space  of  440  yards  all  around,  and  clearing  the 
jungle,  no  single  officer  has  suffered  from  malaria 
since  1004,  and  the  number  of  cases  among  children 
fell  from  34.8  to  0.77  per  cent.  The  only  suft'erer 
at  the  present  time  is  the  enthusiastic  District  Sur- 
geon, Dr.  Malcolm  Watson,  whose  main  incmie 
gamed  from  attending  malarial  cases  has  dropped 
to  practically  zero. 

But  what  is  the  use  of  telling  to  an  American  au- 
dience what  drainage,  oiling  the  water,  and  the  us." 
of  mosquito  netting  has  brought  about?  You  all 
must  be  familiar  with  the  triumphant  work  of  the 
mosquito  brigade  at  Havana,  the  yet  greater  tri- 
umph if  possible — as  regards  malaria — of  Colonel 
Gorgas  and  his  corps  on  the  Panama  Canal.  It  was 
not  graft — bad  as  that  was — but  the  mosquito  that 
brought  ruin  to  the  French  project.  You  know 
that  long  as  is  the  national  purse  and  great  as  is 
the  national  pride  it  would  be  impossible  for  the 
States  to  carry  the  canal  through  the  Isthmus  but 
for  the  preventive  guard  of  the  medical  department, 
and  for  that  noble  army  of  trained  workers  who 
have  brought  it  to  pass  that  the  death  rate  in  the 
Canal  zone  is  now  less  than  that  of  the  city  of  Xew 
York.  That  the  daily  sick  rate  is  only  about  seven- 
teen in  a  thousand  has  been  obtained  almost  wholly 
through  mosquito  prophylaxis. 

Yellow  Fever. 

Speaking  of  mosquitoes  one  naturally  passes  to 
consider  that  other  scotirge  which  has  been  abso- 
lutely proved  to  be  conveyed  by  this  insect,  namely 
\  ellow  fever.  Here  again  the  facts  must  be  so  fa- 
miliar to  you  that  it  is  only  necessary  to  refer  to 
one  or  two  salient  points.  Once  more  w-e  see  that 
observation  led  thoughtful  members  of  the  profes- 
sion, like  Finlay,  to  recognize  the  mode  of  infection, 
but  that  it  was  well  conceived  experiments  and  the 
absolute  data  gained  therefrom  that  preceded  ad- 
vance. There  is  no  nobler  chapter  in  the  historx  of 
American  medicine,  no  more  triumphant  demon- 
stration of  the  beneficent  results  of  pathological 
discovery  than  the  history  of  the  suppression  of  vel- 
low  fever  in  Havana.  The  episodes  follow  one  an- 
other with  such  dramatic  rapidity  and  inevitable- 
ness :  First,  \\'alter  Reed's  deduction  that  matura- 
tion of  the  unknown  parasite  in  an  intermediate 
host  is  necessary  to  explain  the  delay  between  the 
first  and  subsequent  cases  of  the  fever  in  a  new 
locality ;  then  by  a  process  of  exclusion  the  nar- 
rowing down  of  the  probability  to  the  mosquito ; 
next  the  conclusive  experiments  'oy  Carroll,  Lazear, 
and  the  members  of  the  Cuban  commission  when, 
under  conditions  excluding  fallacy  of  observation, 
they  allowed  themselves  to  be  bitten  b}'  mosqui- 


574 


ADAMI:  PATHOLOGICAL  DISCOVERY    A\D  PREl'EXTiyE  MEDICIXE.         [Xew  York 

Medical  Journal. 


toes  (stegomyia) ,  which  days  before  had  bitten  yel- 
low fever  patients  ;  the  development  of  the  disease 
in  those  so  bitten  ;  the  death  of  Lazear :  the  estab- 
lishment of  the  mosquito  brigade  in  Havana  :  the 
immediate  fall  in  the  incidence  of  the  disease,  so 
that  whereas  in  1900  there  were  302  deaths  in  the 
city,  in  1901  there  were  onh-  five,  in  nunc. 
Never,  surely,  has  preventive  medicine  won  so  de- 
cisive a  victory,  a  victory,  let  me  repeat,  based  up  )n 
the  results  of  pathological  research. 

Other  Txfectioxs. 

In  this  way  I  might  continue  discussing  disease- 
after  disease  in  which  the  results  gained  by-  scien- 
tific investigation  have  led  to  the  adoption  of  ])rac- 
tical  means  of  orevention.  I  might,  for  example, 
discuss  the  extent  to  which  a  knowledge  of  the 
mode  of  life  of  the  typhoid  and  colon  bacilli  have 
influenced  the  problems  of  pure  water  supply  to 
great  cities  and  give  you  figures  showing  the  ef- 
fect of  filtration  and  what  bacteriological  studies 
have  accomplished  in  this  respect ;  might  turn  to 
the  prevention  of  infectious  disease  among  domes- 
tic animals  and  give  you  that  early  but  fascinating- 
story  of  how  Pasteur  and  the  P>ench  Commission 
by  studying  the  life  history  of  the  anthrax  bacillus, 
solved  the  mode  of  infection,  gained  a  means  of 
causing  immunity,  and  reduced  the  mortality  from 
this  disease  in  French  sheep  from  over  ten  to  under 
one  per  cent. ;  might  discuss  rabies  and  the  studies 
upon  preventive  inoculation  against  this  dread  dis- 
ease and  the  results  of  the  same ;  might  take  up 
Fourth  of  Jidy  tetanus  and  how  this  is  being  re- 
duced thanks  to. a  knowledge  and  employment  of 
methods  of  preventive  inoculation  gained  from  lab- 
oratorv  experiments;  and,  perhaps  of  wider  signifi- 
cance than  all  of  these,  might  dwell  upon  the  re- 
duction in  diphtheria  mortality  directly  due  to  the 
brilliant  researches  of  Behring  and  Roux  upon  diph- 
theria antitoxine.  But  after  this  recital  of  the  ef- 
fects of  pathological  discovery  as  applied  to  the 
extirpation  of  yellow  fever,  the  data  that  I  could 
give  you,  important  as  they  are,  would.  T  imagine, 
produce  somewhat  the  ffTects  of  an  anticlimax. 
Let  me.  instead,  in  conclusion  attempt  to  draw  to- 
gether the  reins  of  this  discourse. 

Conclusions. 

We  see  in  the  first  place  that  in  ignorance  of  the 
causative  agents  of  infective  diseases  earlier  gen- 
erations sought  after  the  predisposing  causes ;  that 
such  predisposing  causes  cannot  be  neglected  as  fac- 
tors determining  whether  the  individual  does  or 
does  not  succumb  to  infection :  and  that  as  a  result 
the  more  accurately  these  predisposing  causes  were 
determined  and  the  fuller  the  measures  taken  to 
guard  against  them,  the  greater  in  general  was  the 
lessening  of  the  death  rate. 

But.  in  the  second  place,  it  is  obvious  that  once 
through  exact  research  the  exciting  cause  of  a  dis- 
ease becomes  determined,  its  life  history  studied, 
and  mode  of  conveyance  from  individual  to  indi- 
vidual becomes  worked  out,  the  public  health  prob- 
lems in  connection  with  the  prevention  of  that  dis- 
ease assume  a  totally  new  aspect — vagueness  gives 
wav  to  clearness  of  vision  ;  direct  methods  become 
j)Ossible.  and  the  i)rcvious  slowly  progressive  dimi- 
nution of  incidence  and  mortality  have  given  place 


to  a  rapid  and  in  some  cases  dramatic  arrest  and 
extirpation  of  the  disease. 

Xext,  developing  out  of  this,  pathological  discov- 
ery has  taught  the  further  lesson,  that  while  certain 
general  principles  govern  the  incidence  of  all  in- 
fections and  so  certain  general  measures  must  tend 
to  lessen  the  incidence  of  infectious  disease  in  gen- 
eral, nevertheless,  the  more  exact  have  been  the 
studies  into  the  life  histories  of  pathogenic  organ- 
isms, the  more  surely  have  we  learned  that  each  spe- 
cific microorganism  has  characters  distinguishing  it 
from  all  the  rest,  and  as  a  result  that  each  disease 
induced  b}-  these  agencies  must  be  proceeded 
against  by  special  means ;  each  disease  brings  with 
it  particular  problems  to  be  solved.  It  is  these 
special  means  rather  than  broad  general  measures 
that  afford  the  ultimate  complete  triumph. 

Finally,  I  would  urge  that  there  is  a  danger  that 
must  be  guarded  against  in  a  recital  such  as  this: 
The  danger  of  satisfaction,  the  danger,  when  con- 
templating what  has  been  accomplished,  of  neglect- 
ing to  consider  the  abundance  of  what  is  still  to  be 
achieved.  To  you  at  Columbia  I  would  emphasize 
that  what  has  already  been  done  is  as  it  were  little 
more  than  the  fringe  of  what  is  still  to  be  done. 
Even  in  this  one  department  of  public  health  work 
— that  of  controlling  the  incidence  of  infectious  dis- 
ease— there  is  a  vast  achievement  still  possible.  In 
1907  (and  I  doubt  whether  1908  showed  any  very 
striking  dilTerences)  30,000  individuals  died  in  New 
York  from  preventable  causes.  It  is  not  too  late  for 
some  at  least  of  those  here  present  to  determine  to 
devote  themselves  not  to  the  treatment,  but  to  the 
prevention  of  disease,  confident  that  their  efforts, 
hy  research  and  by  the  application  of  the  results  of 
research  to  the  problems  of  public  health  they  can 
during  their  life  time  save  a  greater  number  of  lives 
by  following  the  profession  of  Preventive  Medi- 
cine than  they  could  by  direct  treatment  of  those 
already  the  victims  of  disease. 

Do  not  think  that  in  making  this  reference  to 
New  York  I  am  seeking  to  disparage  what  has  al- 
ready been  accomplished  in  this  city.  That  is  very 
far  from  being  my  ob j  ect.  The  work  accomplished  by 
Dr.  Hermann  M.  Biggs  and  his  coadjutors  during 
the  last  fifteen  years  is  in  every  respect  remarkable 
and  is  worthy  of,  and  is  receiving,  the  attention  and 
commendation  of  those  interested  in  public  lu-alth 
tliroughout  the  civilized  world.  But  let  me  impress 
upon  you  that  it  is  carried  out  under  most  unsatis- 
factory conditions.  These  conditions,  it  is  true, 
make  the  personal  triumph  of  your  health  i')flFicials 
all  the  greater.  With  problems  so  vast  to  be  tackled, 
you  in  this  city,  if  I  am  informed  aright,  do  not 
pav  a  single  one  of  the  heads  of  your  Health  De- 
partment sufficient  to  allow  him  to  devote  his  life 
and  energies  to  this  great  work.  On  the  contrary 
you  aflford  sti])ends  so  miserable  that  perf(^rce  those 
on  whom  you  depend  have  to  engage  in  private 
practice  to  keep  body  and  soul  together.  What  has 
l)een  accomplished  has  been  due  to  the  self  sacrific- 
ing enthusiasm  of  these  men.  Nay,  your  present 
]wlicy  absolutely  prevents  any  sane  man  undertak- 
ing preventive  medicine  as  his  life's  work.  W^ho 
wcnild  seriouslv  prepare  himself  to  make  preventive 
medicine  his  profession,  when  being  appointed  to 
office  his  continuance  in  the  same  is  dependent 


March  20.  1909.] 


D ALAND:  AXGIXA  PECTORIS 


AXD  OriSRI-EEDING. 


575 


upon  the  continuance  of  one  or  other  poHtical  party 
in  power.  These  matters,  I  hold,  must  be  taken 
out  of  tlie  field  of  party.  Permanency  of  position 
is  essential  for  the  development  of  a  properly  quali- 
fied body  of  health  officials  and,  for  the  good  of 
the  country  as  a  whole,  the  matter  should  not  be 
left  to  the  separate  States  but  should,  at  least,  be 
directed  and  controlled  by  the  federal  authorities." 

I  am  no  socialist,  but,  on  the  contrary,  appreciate 
that  point  of  view  which  leads  the  individual  to 
select  some  work  in  life  in  which  he  can  regard 
himself  as  his  own  master,  independent  of  trusts, 
and  can  strive  to  do  good  work  in  the  world  along 
his  own  lines.  I  have  little  sympathy  with  the  as- 
pirations of  those  who  would  see  the  state  becom- 
.  ing  the  monopolist  in  all  forms  of  industry  and  en- 
deavor. Nevertheless,  looking"  to  the  future,  I  can 
not  but  see  the  time  approaching,  and  approaching 
rapidly,  when  the  good  of  the  community  will  de- 
mand that  an  important  section  of  the  members  of 
our  profession  shall  be  servants  of  the  state,  their 
work  devoted,  not  to  the  cure,  but  to  the  preven- 
tion of  disease.  That  time  has  already  come  in 
Great  Britain,  where  since  1892,  there  has  been  de- 
veloped a  body  of  trained  and  certificated  special- 
ists, of  medical  men  whose  whole  time  is  devoted  to 
preventive  medicine. 

Despite  the  difificulties  imposed  by  State,  as  dis- 
tinct from  federal,  rights  and  privileges,  it  is  inevi- 
table that  a  like  development  shall  take  place  here 
in  America.  The  national  weal  demands  that  either 
the  States  combine  or  the  federal  authorities  impose 
common  action  and  a  common  system  in  dealing 
with  zymotic  diseases,  diseases  which  do  not  respect 
State  boundaries  and  State  prerogatives,  which, 
from  their  liability  to  become  widespread  are  mat- 
ters of  national  concern.  It  is,  for  example,  a  mat- 
ter of  national  and  not  of  State  concern  that  the 
plague  has  become  enzootic  in  certain  Californian 
rodents.  National  health  is  above  the  prerogatives 
of  the  individual  States.  And  as  the  control  and 
eradication  of  preventable  disease  becomes  more 
and  more  efTective,  so  will  the  duties  and  the  emolu- 
ments of  the  ordinary  medical  man  become  less  and 
less,  the  responsibilities  of  the  preventive  officer 
greater  and  greater.  There  will — there  must  al- 
ways— be  opportunities  for  independent  endeavor : 
The  general  practitioner,  like  the  poor,  must  always 
be  with  us ;  the  natural  multiplication  of  the  people ; 
accidents  calling  for  the  trained  surgeon  ;  diseases 
of  special  regions  demanding  the  care  of  the  special- 
ist :  the  common  neurasthenic ;  the  chronic  in- 
valid ;  m.ust  always  demand  individual  care.  But  as 
a  community,  we  shall  have  to  follow  the  Chinese 
fashion  to  a  very  definite  extent,  and  establish  an 
order  of  physicians  whose  remuneration  shall  be 
proportioned  to  their  success  in  keeping  us  from 
getting  ill. 

Nor,  when  we  com.e  to  consider  the  matter,  is  it 
one  whit  less  noble  or  less  satisfactory  to  become 
a  servant  of  the  public  than  it  is  to  be  an  inde- 
pendent professional  man.  In  the  first  place,  save 
as  a  mental  attitude,  the  independence  of  the  prac- 
titioner is  largely  a  fiction.  Proud  as  he  is  of  that 
independence,  in  reality  he  is  throughout  the  twen- 

■^1  liave  disci"ised  this  matter  of  the  State  and  federal  relation- 
shin  of  the  health  ofTicer  in  an  address  upon  The  Double  Allegiance 
delivered  at  the  Boston  meeting-  of  the  American  Public  Health 
Association  m  1905  (Public  Health,  xxxii). 


ty-four  hours  of  the  day,  the  servant  and,  indeed, 
the  slave  of  the  public.  No  one  more  so.  We  pro- 
fessors who  appear  to  have  greater  freedom  are 
servants  of  the  university,  and  after  long  years  of 
experience  find  that  that  service  is  not  irksome. 
Nay,  the  more  loyally  we  accept  the  yoke  the  greater 
do  we  find  our  freedom.  And  that  is  always  so. 
We  have  but  to  regard  the  attitude  and  the  standing 
of  those  foremost  servants  of  the  public,  the  offi- 
cers of  the  army  and  navy.  Where  could  we  find 
greater  selfrespect,  greater  respect  for  those  higher 
in  authority,  greater  delight  in  loyal  service  for  the 
good  of  the  community  than  in  those  two  services? 

There  is  thus  a  beneficent  future  before  the  Fed- 
eral Public  Health  Service.  I  would  urge  those  be- 
fore me  to  recognize  that  the  development  of  a  com- 
mon health  service  for  the  whole  Union  is  an  end 
that  all  should  work  earnestly  to  attain — a  service 
with  trained  officers  in  charge  of  every  city  and  dis- 
trict throughout  the  length  and  breadth  of  the  land ; 
a  service  independent  of  politics  ;  a  "third  service" 
with  ideals  everv  whit  as  noble,  if  not  nobler,  and 
aspirations  equally  lofty,  if  not  more  lofty,  than 
those  of  the  other  two — the  service  of  the  army  of 
the  common  weal. 

And  once  again  I  would  urge  some  at  least  of 
my  hearers  to  think  seriously  of  joining  the  stafif 
and  of  becoming  leaders  in  this  army ;  of  devoting 
their  energies,  their  talents,  and  their  lives  to  this 
great  and  beneficent  department  of  preventive 
medicine. 

331  Teel  Street.   

AXGIXA  PECTORIS  AXD  OVERFEEDING.* 
By  Judsox  Daland,  M.  D., 
Pliiladelphia, 

Professor  of   Clinical    Medicine   in  the   Medicochirurgical  College; 
and  Physician  to  the  Medicochirurgical  Hospital. 

The  liistory  of  the  patient  forming  the  basis  of  this  com- 
munication is  that  of  a  moderately  obese  male,  aged  sixty - 
six  (in  1903),  married,  a  native  of  Maryland  and  a  lawyer 
by  occupation.  He  was  first  seen  on  November  22,  1902, 
seeking  jrelief  from  (i)  occasional  sensations  of  heat  in  the 
chest  followed  by  substernal  pain  and  a  sense  of  oppres- 
sion ;  (2)  dyspnoea  on  exertion;  and  (3)  impairment  of 
hearing,  especially  for  low  tones. 

His  family  history  revealed  longevity  and  was  otherwise 
negative,  with  the  exception  that  one  brother  died  of  pul- 
monarj-  tuberculosis.  The  patient  had  the  ordinary  diseases 
of  childhood  with  the  exception  of  diphtheria,  and  at  the  age 
of  twelve  he  had  pleurisy.  While  in  college  he  was  un- 
usually active  and  strong  and  topk  part  successfully  in  ath- 
letic spores.  At  the  aged  of  twenty-four  (^larch,  i860), 
after  an  exposure  incident  to  a  trip  to  the  Far  West,  he  had 
rheumatism  affecting  the  arms,  legs,  and  shoulder,  lasting 
two  or  three  weeks.  The  following  year  it  recurred  con- 
fining him  to  bed  for  two  weeks,  and  a  third  attack  oc- 
curred si.x  years  later. 

Frequent  indiscretions  in  diet  occasioned  mild  attacks  of 
gastrointestinal  indigestion.  He  partook  freely  of  food 
rich  in  carbohydrates  and  proteids  and  while  at  the  table 
was  usually  buried  in  thought  and  unconsciously  bolted  his 
food.  He  drank  two  cups  of  strong  coffee  each  morning 
and  a  demi-tasse  in  the  evening:  tea  occasionally,  alcohol 
rarely,  and  had  abandoned  tobacco  during  the  past  thirty- 
four  years.  He  denied  venereal  disease.  Although  active 
in  college  athletics,  his  postgraduate  life  was  purely  seden- 
tary and  involved  excessive  mental  labor. 

After  exercising,  a  sensation  of  heat  beneath  the  sternum, 
snnilar  to  heart  burn  was  experienced,  lasting  a  few  min- 
utes and  was  then  replaced  by  substernal  pain  lasting  from 
three  to  thirty  minutes,  accompanied  by  numbness  and 
tingling  in  the  left  arm.  Sometimes  he  was  able  to  foretell 
the  coming  of  a  paroxysm  by  pain  in  the  left  arm.  The  first 
severe  attack  occurred  in  November,  1901,  at  the  age  of 

'Read  before  the  American  CHmatological  Association,  June,  1908. 


5/6 


DALAXD:  ASCI S A  PECTORiS     AXD  OI  ERI-EEUIXC. 


LNiav  V. 

.M  liUlCAL    J  "UUN  \L. 


sixty-live,  and  although  the  pain  was  quite  sharp  it  caused 
no  great  inconvenience.  One  week  later  another  paroxysm 
occurred,  so  severe  that  it  confined  him  to  bed  for  about 
twenty- four  hours.  He  remained  free  from  symptoms  until 
a  cold  day  in  December,  1901,  when,  while  walking  up  a 
moderate  ascent  he  was  suddenly  seized  with  intense  prse- 
cc^rdial  pain,  increasing  in  severity  until  he  was  compelled 
10  cease  walking  and  grasp  an  iron  railing  to  prevent  fall- 
mg.  The  pain  was  characteristic  of  angina  pectoris,  ex- 
tending down  the  left  arm,  which  was  the  seat  of  numbness, 
tmgling,  and  loss  of  power.  During  this  attack  he  felt  as 
though  he  would  die.  After  a  short  rest  he  was  able  to 
walk  across  the  street  to  a  tailoring  establishment,  where 
he  sat  for  an  hour  feeling  as  though  he  was  al)0ut  to  col- 
lapse. After  this  paroxysm  subsided  he  began  his  dail> 
work.  During  the  following  three  weeks  frequent  attacks 
occurred,  which  were  always  relieved  by  amyl  nitrite. 

After  January,  1902,  though  free  from  angina,  he  was 
conscious  that  he  could  not  exert  himself  as  violently  as 
formerly  because  of  the  severe  dyspn(ea  which  it  induced. 
This  dyspnuL-a  he  attributed  to  increasing  obesity.  Two 
weeks  prior  to  coming  under  observation,  November  11, 
1902,  he  was  awakened  from  sleep  by  a  sudden  attack  of 
prtecordial  pain,  which  was  promptly  relieved  by  amyl  nitrite, 
and  two  days  later,  while  working  at  his  desk  at  10:30 
p.  m.,  there  was  a  slight  recurrence,  which  speedily  disap- 
peared, but  on  his  way  to  bed  another  angenoid  attack  oc- 
curred lasting  about  half  an  hour,  b'our  days  after  this 
paroxysm,  while  walking  in  the  street,  he  suddenly  became 
dyspnceic,  but  quickly  recovered  after  resting.  Soon  after 
returning  home  pain  occurred  in  his  chest,  lower  down  than 
usual,  and  radiated  into  tlie  epigastrium  and  right  and  left 
hypochondriac  regions. 

During  the  past  year  he  had  had  difficulty  in  distinctly 
hearing  or  distinguishing  low  tones. 

Physical  examination  showed  a  well  marked  arcus  senilis  ; 
normal  pupillary  and  ocular  movements;  lips  slightly  cyan- 
otic; musculature  fairly  good  and  obesity  moderate.  There 
was  moderate  thickening  of  the  walls  of  the  radial  arteries. 
The  apex  beat  of  the  heart  was  in  the  fifth  interspace,  im- 
mediately below  the  left  nipple,  and  was  felt  with  great  dif- 
ficulty. The  left  border  of  cardiac  dulness  extended  to 
the  left  nipple  line,,  the  right  border  to  the  midsternal 
line.  Auscultation  over  the  apex  revealed  a  regular  action 
of  the  heart.  The  muscular  element  of  the  first  sound  was 
distinctly  feeble,  while  the  aortic  and  pulmonic  second 
■-ounds  were  accentuated.  No  nvurmur  was  audible  at  ain 
of  tile  cardiac  orifices,  either  before  or  after  exercise.  .After 
ten  bending  movements  the  apex  licat  was  distinctly  felt  in 
the  position  already  described  aiul  breathing  became  hur- 
ried. After  a  second  series  of  bending  mo\  cnicnts  the  heart 
rate  increased  to  iro  in  a  minute  and  became  slightly  irreg- 
ular in  rhythm.  The  muscular  element  of  the  first  sound 
did  not  increase  as  it  .should,  normally,  but  on  the  contrary 
became  more  feeble.  Dyspnoea  became  extreme,  and  a 
slight  moisture  appeared  on  the  forehead  and  the  umbilical 
region. 

There  was  only  a  moflcratc  aniount  of  subcutaneous  fat 
in  the  abdominal  walls,  the  enlargement  being  chiefly  due 
to  the  overdistension  of  the  gastrointestinal  tract  and  prob- 
ably also  to  the  deposit  o^  fat  in  the  omentum.  No  abnor- 
malities were  discoverable. 

Examination  of  the  blood  on  November  22.  1902,  showed 
erythrocytes  eighty-eight  per  cent.,  h,-emoglobin  eighty-si.x 
per  cent.,  and  leucocytes  8,400. 

Examination  of  urine  voided  on  the  evening  of  Novem- 
ber 21,  1902,  revealed  a  specific  gravity  of  1.027,  decidedly 
acid  reaction,  a  moderate  an.ount  of  bile,  a  trace  of  phos- 
phates, and  an  excess  of  acetone.  Glucose,  indican,  and  al- 
bumin were  absent.  Microscopically,  a  few  small  calcium 
oxalate  crystals  and  several  small  pale  uric  acid  crystals 
were  found.  Urine  passed  the  following  morning  gave 
similar  results,  with  the  exception  of  an  excess  of  indican. 

Between  November  21.  1902,  and  May  26.  1905,  thirty- 
tlirce  specimens  of  urine  were  examined  with  similar  re 
■■I'lts,  except  for  the  occasional  appe;irance  of  moderate 
amounts  of  indican,  a  few  cylindroids  ;ind  hyaline  cpst^. 
Between  \[ay  and  October.  1905.  while  abroad  and  feeling 
no  restrpint.  he  resumed  his  former  habits.  Urine  passed 
on  October  23,  1905,  showed  a  specific  gravity  of  1.032. 
faintly  acid  reaction,  faint  traces  of  acetone,  and  five  per 
cent,  of  glucose.  An  evening  urine  of  the  same  date  showed 
6.7  per  cent,  of  glucose,  On  October  24th  the  specific  grav- 
ity was  1.035.  aiifl  there  were  present  very  faint  traces  of 


acetone  and  albumin,  a  trace  of  indican,  and  8.9  per  cent, 
glucose. 

On  NoveiTiber  1,  1905,  the  morning"  urine  contained  0. 1 
per  cent,  glucose  and  the  evening  urine  0.9  per  cent,  glu- 
cose, and  each  urine  was  free  from  albumin.  On  December 
II,  1905,  but  0.08  per  cent,  glucose  was  found,  by  January 
17,  1906,  glucose  had  disappeared. 

Hyaline  casts  and  cylindroids  were  more  frequent,  how- 
ever, than  before  the  appearance  of  glucose.  Alluiinin  was 
found  but  once  prior  to  March  18.  1908,  when  a  faint  trace 
of  albumin  appeared  in  the  morning  and  exening  specimens, 
with  a  few  hyaline  casts. 

On  March  2t,  1908,  the  cystolic  pressure  was  uo  mm.  and 
the  diastolic  pressure  100  mm. 

It  is  evident  that  this  case  presents  the  sensory 
symptom  complex  known  as  angina  pectoris,  and  is 
especially  interesting  tetiologically  because  of  the 
absence  of  the  ordinary  catises  that  are  in  associa- 
tion with  this  symptom,  i.  e.,  no  evidence  of  syph- 
ilis, alcoholism,  nicotinism,  nor  excessive  inuscular 
exertion.  The  changes  in  the  walls  of  the  radial 
arteries  are  rather  less  than  would  be  expected  from 
the  age  of  the  patient,  and  the  amount  of  obesity  is 
btit  moderate.  In  addition  to  excessive  mental  toil 
and  excitement  dtie  to  his  occtipation  and  the  oc- 
currence of  rheumatism  nearly  half  a  century  ago, 
the  only  factor  of  importance  is  the  habitual  bolt- 
ing of  large  quantities  of  food,  rich  in  proteids  and 
carbohydrates,  producing  a  marked  disturbance  of 
metabolism,  as  evidenced  by  the  occurrence  of  indi- 
canuria,  acetonuria  and  intercurrent  glycosuria  in 
qttantities  as  great  as  eight  per  cent.,  which  re- 
turned a  few  days  ago  owing  to  disregard  of  advice 
regarding  excessive  work  and  care  in  diet.  It  would 
seem  but  reasonable,  therefore,  to  conclude  that  tlu 
symptoms  of  which  this  patient  complained,  mav  ))e 
ascribed  to  bolting  excessive  quantities  of  rich  food, 
with  the  consequent  pathological  changes  in  metab- 
olism, in  conjunction  with  excessive  mental  work, 
which  supposition  is  supported  by  the  disappearance 
of  angina  pectoris  for  more  than  five^years.  by  reg- 
ttlating  his  work  and  food  habits,  and  the  reappear- 
ance of  these  symptoms  when  in  the  beginning  he 
temporarily  disregarded  this  advice. 

From  the  I'ecent  recurrence  of  glycosuria  it  is 
probable  that  death  will  eventuallv  occur  from  this 
cause  and  not  from  angina  pectoris. 

When  first  examined.,  the  signs  and  symptoms 
were  consistent  with  the  diagnosis  of  dilatation  of 
the  right  and  left  heart  and  degeneration  of  the  mv- 
ocardium.  It  is  possible  that  certain  of  these  attacks 
of  angina  pectoris  are  best  explained  by  extreme 
overstretching  of  the  epicardium  from  acute  dilata- 
tion of  the  heart. 

Certain  authors  incline  to  reserve  the  term  angina 
])ectoris  for  cases  of  myocardial  degeneration  due 
to  sclerosis  of  the  coronary  arteries  and  terminating 
fatally  any  moment  prior  to  one.  two.  or  three  years, 
usually  in  less  than  a  year  or  two.  As  disease  of  the 
coronary  arteries  is  but  one  of  many  causes  of  fatal 
angina  pectoris,  and,  as  advanced  coronary  artery 
disease  and  myocardial  degeneration  may  exist 
without  angina  pectoris,  it  seems  desirable  titat  this 
term  should  be  retained  as  indicating  a  sensory 
synijitom  group,  until  further  experimental  patho- 
logical study  enables  us  to  grasp  the  many  unknown 
factors  necessary  for  a  complete  understanding  of 
this  interesting  symptom  group. 

Chronic  nicotinism  may  produce  angenoid  symp 
toms  iisnallv  classified  as  pscudoangina  pectoris,  and 


March  20,  igno.l 


FISCHER:   VON  PlROi'EJ'S  I'UBERCULIX  TEST. 


S77 


yet  death  during  a  paroxysm  has  occurred  from  this 
cause. 

In  conckisinn,  I  desire  to  again  call  attention  to 
the  importance  of  using  a  measured  amount  of  ex- 
ercise, as  the  ten  bending  movements,  for  example, 
to  determine  the  reaction  and  contractile  power  of 
the  myocardium.  When  this  patient  was  first  seen, 
these  movements  produced  an  appreciable  weaken- 
ing of  the  tone  of  the  first  sound  of  the  heart,  dem- 
onstrating conclusively  the  absolute  necessity  of  se- 
curing rest  for  this  organ. 

317  South  Eighteenth  Street. 


AN  AID  TO  THE  DIAGNOSIS  OF  TUBERCULOSIS 
IN  INFANCY  AND  CHILDHOOD 

By  means  of  the  Cutaneous  Inoculation  of  Diluted  Tuber- 
culin or  Pure  Tuberculin   (I 'on  Pirquet's  Method.)'' 

By  Louis  Fischer,  AI.  D., 
New  York, 

Atttiiiling  I'hysician  to  the  Children's  Department  of  the  .Syfkniiaiii 
Hospital  and  to  the  Riverside  and  Willard  Parker  Hospitals,  etc. 

The  diagnostic  value  of  the  cutaneous  inocula- 
tion with  pure  or  diluted  tuberculin  has  been  before 
the  profession  for  some  time.  As  an  aid  to  the  di- 
agnosis of  latent  tuberculosis  this  method,  so  sim- 
ple in  its  application,  has  many  advantages. 

The  absorption  of  the  tuberculin  gives  a  local  re- 
action— a  papule — a  slight  zone  of  inflammation 
about  ten  millimetres  in  width,  but  no  constitutional 
disturbance.  There  is  neither  fever,  nor  evidence 
of  general  disturbance,  nor  glandular  swelling. 
This  local  reaction  remains  several  weeks  in  older 
children — five  and  ten  days  in  young  infants. 

The  diagnosis  of  tuberculosis  in  infancy  and  early 
childhood  is  frequentlv  obscure.  Following  the 
acute  infectious  diseases,  notably  measles,  broncho- 
pneumonia, diphtheria,  and  pertussis  a  series  of 
pulmonary  symptoms  will  be  noted  in  which  tuber- 
culosis may  or  may  not  exist.  Cachexia  associated 
with  syphilis  frequently  suggests  tuberculosis.  Any 
aid  to  a  diagnosis  will  be  welcomed  provided  it  does 
not  subject  the  little  patient  to  an  additional  risk 
and  does  not  devitalize  the  already  weakened 
system. 

In  many  cases  progressive  emaciation  and  symp- 
toms resembling  marasmus  will  be  seen,  caused  by 
dyspeptic  or  intestinal  indigestion.  In  obscure  le- 
sions involving  the  lungs,  brain,  and  intestines, 
especially  in  the  earlv  manifestations,  the  diagnosis 
is  very  often  shrouded  in  mystery.  In  just  such 
cases  we  need  all  the  assistance  possible  to  arrive  at 
a  positive  conclusion. 

The  ocular  reaction  (Calmette)  is  not  devoid  of 
danger.  Although  before  the  profession  but  one 
year,  many  cases  are  recorded  in  which  serious  eye 
lesions  developed.  Marginal  ulceration  of  the 
cornea  has  been  seen  by  me.  and  was  also  noted  by 
other  observers  in  \'ew  York.  Barbier,  in  Paris, 
rejwrts  a  series  of  ulcerations  of  the  cornea  and 
pannus  seen  by  him  after  instilling  a  one  per  cent, 
diluted  tuberculin  solution.    So  also  Renon  reports 

*Read  before  the  Section  in  Diseases  of  Children  at  the  Inter- 
national Congress  on  Tuberculosis,  held  at  Washington,  September 
30.  1908. 


three  complications  in  a  series  of  twenty-eight  trials 
in  the  eye.  such,  for  example,  as  intense  conjunc- 
tivitis lasting  forty-five  days.  Another  patient, 
twenty  days  after  the  ocular  reaction,  showed  ex- 
tensive interstitial  keratitis  with  iritis.  Satterlee 
reports  a  serious  result  following  the  instillation  of 
a  one  per  cent,  tuberculin  solution  in  the  eye.  An 
editorial  in  the  Xcz^>  York  Medical  Journal  describes 
the  accidents  of  ocular  reaction  to  tuberculin. 

Method  of  iiwculatioii. — Scarify  three  small  areas 
of  skin,  but  not  enough  to  produce  a  bleeding  sur- 
face. Inoculate  a  small  drop  of  diluted  or  pure 
tuberculin  into  two  of  the  scarified  areas,  and  leave 
the  third  area  as  a  control  without  inoculating.  The 
method  pursued  should  be  similar  to  the  one  ordi- 
narily employed  in  vaccination. 

Solution  used : 

Koch's  old  tuberculin  i  part; 

Sterile  water  3  parts. 

Inoculate  two  of  the  scarified  areas,  leave  the 
third  area  as  a  control. 

\'on  Pirquet  uses  one  part  of  tuberculin  diluted 
with  one  part  of  a  five  per  cent,  carbolic  glycerin 
and  two  parts  of  a  physiological  salt  solution.  Of 
this  solution  the  same  method  of  inoculation  as  de- 
scribed before. 

During  this  last  summer.  1908,  while  making  the 
rounds  with  Dr.  C.  von  Pirquet  in  the  St.  Anna 
L  hildren's  Hospital  of  \  ienna  I  noted  that  instead 
of  diluted  tuberculin  being  used  the  pure  tuberculin 
(alt  tuberculin.  Koch)  is  used. 

I  have  inoculated  more  than  one  hundred  chil- 
dren and  have  not  seen  a  single  bad  result  from 
such  inoculation.  Neither  the  epitrochlear  nor  the 
axillary  glands  were  enlarged  at  any  time  following 
the  inoculation. 

The  following  series  of  cases  was  inoculated  dur- 
ing the  spring  and  summer  of  i()o8  in  my  service 
at  the  Sydt'i»ham  Hospital.  Children's  Ward. 


Name.  Age. 

Zelda  K   i.'-S  years 

I'auline  A   4  montlis 

Ida  W   2  months 

Sarah  S   2'/,  months 

Harry   F   5  years 

Lilly   L   5  weeks 

Katie  L   8  years 

("leorge  W   10  months 

Armelo  C   3  years 

Charles  S   .!  months 

Cathleen  W.   .  .  5  years 

(leorge  A   years 

.Antonette  D. . .  .  3  months 

liaby  P   3  days 

Harry  Z   o  moinlis 

.Abraham   B....  3  weeks 

-Michael  ^I   5  years 

Myrtle   d   6  months 

William   K   3  weeks 

Dora  G   2  years 

l'"rank  H   8  months 

Cathleen  R   16  months 

Salvatore,   .\  .  .  .  7  months 

Lillian  S   16  months 

Mary  1"   4  months 

Fannie   U   10  months 

Annie  B   2V2  years 

Lewis  R   8  years 

Jennie  P   i54  years 

Catherine   P....  14  years 

.Toe  .A   17  years 

Martha    F   g  years 

Minnie  Sipn. ...  6  weeks 

Margaret  S....  8  months 

.Sam  ]j   15  months 

'Proved  at  autopsy. 


Result  of  VOIl 
Pirquet's  te^t. 
negati\  e 
negative 


Clinical  dia;4M0sis. 
lobar  imeunionia 
narasmiis,  empyema 
congenital  deformation  01' 

ears  negative 
erythro  derma  desquama- 

tiva  negatuc 

tubercular  hip  positive 
bronchopneumonia,  m:i- 

rasmus'  negati\e 
catarrhal  a])pendicitis  negati\e 
lobar  pneumonia  negative 
tuberculous  osteomyelitis  positive 
luirulent  bronchitis  negative 
general  bronchitis  negative 
lobar  pneumonia  negative 
marasmus  negative 
normal  negative 
rachitis  negative- 
feeding  negative 
tuberculous  hip  positive 
marasmus  negative 
marasmus  negative 
bronchopneumonia  negative 
cervical  adenitis  negative 
hydrocephalus  negative 
broncho]  Ml  eumoni  a  negative 
bronchopneumonia  negative 
gastroenteritis  negative 
gastroenteritis  negative 
tuberculous  meningitis  positive 
sarcoma  of  kidney  negative 
cerebrospinal  meningitis  positive 
.•ipex  tuberculosis  po.sitive 
bone  tuberculosis  positive 
malnutrition  negative 
1)1  onchonneiimonia  negative 
miliary  tuberculosis  positive 
lobar  imeunionia  negative 


578 


FISCHER:   VON  PIRQUETS  TUBERCULIN  TEST. 


[New  York 
Medical  Journai.. 


Result  of  von 


Name. 

Age. 

Clinical  diagnosis.        Pirquet's  te.st. 

William  H 

4  years 

cerebrospinal  meningitis 

negative 

Clifford  W 

t>  months 

gastroenteritis 

positive 

Ray  E 

1 1  years 

gastroenteritis 

aoubtiul 

Tillie  W  

I  year 

bronchopneumonia 

negative 

Marv  B  

14  months 

lobar  pneumonia 

negative 

Morris  H  

18  months 

bronchopneumonia 

negative 

10  months 

hronchoimeumonia- 

negativ  e 

7  months 

bronchopneumonia 

negative 

7  months 

bronchopneumonia 

negative 

Rose  S      . . . . 

10  months 

bronchopneumonia 

positive 

14  months 

gastroenteritis 

negative 

Thomas  R.  < 

6  years 

lobar  pneumonia 

Tiprra  ti  VP 
ll^^d  Li  V  1^ 

10  years 

chorea 

negative 

20  months 

gastroenteritis 

negative 

Rosie  R  

4  months 

hydrocephalus 

negative 

6  years 

tuberculous  peritonitis' 

positive 

, ,    2^2  years 

gastroenteritis 

negative 

12  years 

typhoid 

negative 

.     20  months 

gastroenteritis,  bronchitis. 

otitis  media 

negative 

.    6  months 

gastroenteritis 

positive 

In  my  series  of  fifty-five  cases  here  reported  there 
were  three  autopsies.  In  the  one  case,  Margaret 
S.,  in  which  a  positive  reaction  occurred,  there  was 
a  general  mihary  tuberculosis  found.  In  a  second 
case  the  diagnosis  of  lobar  pneumonia  was  made 
intra  vitam.  We  there  had  a  negative  reaction.  The 
post  mortem  examination  showed  lobar  pneumonia 
and  no  evidence  of  tuberculosis.  In  a  third  case, 
Louisa  G.,  ten  months  old,  who  died  of  broncho- 
pneumonia, the  von  Pirquet  reaction  was  negative. 
The  post  mortem  examination  showed  no  evidence 
of  tuberculosis. 

In  this  last  group  of  cases  there  are  three  dis- 
tinct evidences  of  tuberculosis  in  the  family  history. 
Two  of  the  children  from  these  families  gave  a 
positive  cutaneous  reaction  and  the  third  was  a 
doubtful  reaction. 

Number  of  cases  of  each  disease. 

Lobar  pneumonia,  one  child  less  than  one  year 
old,  four  children  between  one  and  two  years,  one 
■cliild  at  six  years  of  age. 

Cerebrospinal  meningitis,  one  child  between  one 
and  two  years,  one  child  at  four  years  of  age. 

Gastroenteritis,  four  children  less  than  one  year 
old,  three  children  between  one  and  two  years,  one 
child  between  two  and  three  years,  one  child  at 
eleven  years  of  age. 

Bronchopneumonia,  seven  children  less  than  one 
year  old,  one  child  one  year  of  age,  one  child  at  two 
years  of  age,  two  children  between  one  and  two 
years. 

Chorea,  one  child  at  ten  years  of  age. 

Hydrocephalus,  one  child  less  than  one  year  old, 
one  child  between  one  and  two  years. 

Tuberculous  peritonitis,  one  child  at  six  years  of 
age. 

Typhoid,  one  child  at  twelve  years  of  age. 

Marasmus,  four  children  less  than  one  year  old. 

Congenital  deformation  of  ears,  one  child  less 
than  one  year  old. 

]"'rythrodermia  desquamativa,  one  child  less  than 
one  year  old. 

'i'uberculous  hip,  two  children  at  five  years  of  age. 

Catarrhal  appendicitis,  one  child  at  eight  years  of 

Tuberculous  osteomyelitis,  one  child  at  five  years 
of  age. 

General  bronchitis,  one  child  at  five  years  of  age. 

-Areas  of  consolidation  in  both  lungs  but  no  evidence  of  tubercle 
bacilli  shown  at  autopsy. 

'Tubercle  bacilli  found  at  laparotomy  with  excision  of  cheesy 
glands. 


Normal,  one  child  less  than  one  year  old. 

Rachitis,  one  child  less  than  one  year  old. 

Feeding,  one  child  less  than  one  year  old. 

Cervical  adenitis,  one  child  less  than  one  year  old. 

Tuberculous  meningitis,  one  child  between  one 
and  two  years. 

Sarcoma  of  kidney,  one  child  at  eight  years  of 
age. 

Apex  tuberculosis,  one  girl  at  fourteen  years  of 
age. 

Bone  tuberculosis,  one  boy  at  seventeen  years  of 
age. 

Malnutrition,  one  child  at  nine  years  of  age. 
Miliary  tuberculosis,  one  child  less  than  one  year 
old. 

Purulent  bronchitis,  one  child  less  than  one  year 
old. 

In  the  foregoing  group  of  cases  eight  children 
suffered  with  lobar  or  lobular  pneumonia  in  which  a 
positive  diagnosis  excluding  tuberculosis  was  hardly 
possible  intra  vitam.  With  the  aid  of  the  von  Pir- 
quet inoculation  a  negative  reaction  showed  the  prob- 
able absence  of  tuberculous  infection.  In  a  case  of 
coxitis  a  positive  reaction  strengthened  the  diagno- 
sis of  a  tuberculous  hip.  Another  positive  reaction 
was  found  in  a  case  of  osteomyelitis  of  the  foot. 

Value  of  the  reaction.  The  presence  of  a  positive 
reaction  means  that  we  are  dealing  with  a  probable 
tuberculosis.  Equally  important  therefore  is  the  ab- 
sence of  this  reaction,  so  called  "negative  reaction," 
by  which  we  can  exclude  tuberculosis.  In  some 
cases  a  reinoculation  is  indicated  because  some  chil- 
dren respond  slowly  and  give  tardy  reaction. 

Limitations.  The  younger  the  child,  especially  if 
it  is  between  infancy  and  its  third  year  of  age,  the 
more  valuable  and  the  more  reliance  should  be 
placed  upon  the  presence  or  absence  of  the  von  Pir- 
quet reaction.  We  must  not  expect  too  much  from 
the  inoculation  with  tuberculin,  and  no  one  should 
make  a  diagnosis  of  tuberculosis  based  on  a  positive 
cutaneous  reaction  alone.  When  symptoms  of  ma- 
laise and  general  breaking  down  are  noted  or  when 
symptons  of  malaria  exist  the  absence  of  the  Plas- 
modia in  the  blood  with  a  positive  von  Pirquet  re- 
action would  strongly  support  the  diagnosis  of  tu- 
berculosis and  exclude  malaria.  In  other  words,  no 
one  symptom  should  be  used  to  make  a  diagnosis 
unless  it  is  supported  by  systemic  manifestations 
in  which  tuberculous  suspicion  exists. 

The  presence  of  the  Klebs-Loefflcr  bacillus  in  the 
mouth  or  the  presence  of  the  pneumococcus  in  the 
throat  does  not  justify  the  diagnosis  of  diphtheria 
or  pneumonia  unless  accompanied  by  clinical  evi- 
dence of  each  distinct  disease.  In  like  manner  no 
one  should  isolate  a  patient  and  call  him  tubercu- 
lous, based  on  the  cutaneous  manifestation  alone 
without  supporting  evidence  of  organic  or  local  in- 
fection giving  distinct  suspicion  of  a  tuberculous 
process. 

I  have  previously  stated  that  this  reaction  is  not 
found  in  the  last  stages  of  miliary  tuberculosis  nor 
in  tuberculous  meningitis  because  at  such  times  the 
condition  of  the  system  is  so  transformed  that  there 
is  a  tolerance  of  the  maximum  doses  of  tuberculin 
without  apparent  effect.  In  some  children  it  is  wise 
if  the  first  inoculation  proves  negative  to  again  in- 
oculate after  one  or  two  weeks.     Von  Pirquet  re- 


March  20,  1909.] 


LYDSTON:  EXCISION  OF  CHA.XCRE. 


579 


ports,  in  his  series  of  cases,  a  first  inoculation  as 
negative  whereas  the  second  was  positive. 

Accidents  resulting  from  inoculation — In  my  own 
experience  in  the  hospital  and  cases  seen  in  private 
practice  there  has  never  been  an  accident  following 
the  inoculation  with  tuberculin.  This  same  absence 
of  bad  results  was  noted  by  me  while  studying  this 
method  in  several  hospitals  in  Berlin  and  \'ienna 
during  the  summer  of  1907  and  1908.  The  resident 
staff  of  the  Sydenham  Hospital  report  not  a  single 
accident  nor  infection  following  the  von  Pirquet 
method.  The  simplicity  of  the  method  and  the  ex- 
cellent after  effects  are  sufificient  in  themselves  to 
justify  a  more  general  acceptance  of  this  diagnostic 
aid. 

65  East  Xixetieth  Street. 


THE  EXCISION  0F  CHANCRE. 

By  G.  Fraxk  Lydstox,  D., 
Chicago, 

Professor    of    Genitourinary    Surgery.    Medical    Department,  .State 
University  of  Illinois. 

In  the  Journal  of  the  American  Medical  Associa- 
tion for  December  5,  1908,  appears  an  article  by  Dr. 
Harris  and  Dr.  Corbus  on  the  Spirochccta  pallida 
which  for  completeness  leaves  little  to  be  desired. 
It  is  an  excellent  up  to  date  exposition  of  the  chims 
for  the  spirochseta  as  the  fons  et  origo  of  syphilis. 
Incidentally,  the  article  appears  to  me  to  be  rather 
more  dogmatic  in  its  trend  than  is  warranted  by 
what  has  been  thus  far  proved  for  the  spirochaeta. 
I  am  willing  to  grant  at  the  outset  that,  from  the 
evidence  thus  far  offered,  the  spirochjeta  is  not  far 
from  fulfilling  the  demands  of  the  seekers  after  the 
specific  microorganism  of  lues.  I  do  not,  however, 
admit  that  the  evidence  is  yet  conclusive,  nor  do  1 
believe  that  it  will  be  until  much  more  experience 
has  been  had  or  the  supreme  test  of  specific  patho- 
geneses— culture  and  pure  culture  inoculation — with 
resultant  svphilis  has  been  made.  In  the  meantime 
I  th  ink  it  safer  to  regard  it  as  the  probable  .specific 
microorganism  of  syphilis  which  must  not  be  alone 
relied  upon  for  diagnosis. 

The  spirochceta  is  not  precisely  the  sort  of  organ 
ism  that  most  of  us  have  believed  would  eventuallv 
be  shown  to  be  the  specific  microbe  of  syphilis.  It 
does  not  comport  with  the  specific  microorganisms 
of  analogous  processes — of  tuberculous  lesions,  for 
example.  The  discovery  of  a  bacillus,  even  without 
the  final  proof  of  pure  culture  inoculation,  wouid 
have  been  far  more  reconcilable. 

It  must  not  be  forgotten  that  the  transformation 
or  other  and  apparently  harmless  spirochaetae  which 
are  quite  commonly  found  in  the  body  into  the  form 
which  Schaudinn  and  Hoffmann  assert  to  be  typic, 
is  not  impossible.  Such  harmless  spirochaetae  might 
find  in  syphilitic  lesions  a  soil  especially  favorable  to 
their  development  and  type  modification.  I  am  too 
faithful  an  evolutionist  to  overlook  this  possibility, 
remote  as  it  may  seem.  I,  of  course,  admit  that  if 
such  transformation  should  be  constant  in  s\philis, 
the  spirochaeta  would  be  of  great  diagnostic  value, 
independently  of  its  specificity.  Personally,  I  should 
not  yet  dare  to  rely  on  the  presence  or  absence  of 
the  spirochaeta  as  a  final  court  of  arbitration  in  the 
diagnosis,  although  the  proofs  thus  far  shown  are 


very  striking  and  suggestive.  Then,  too,  we  must 
take  into  consideration  the  fact  that  diagnoses  have 
been  and  will  continue  to  be  made  by  men  less  per- 
fect in  their  technique  than  the  authors  of  the  article 
to  which  I  have  referred.  I  have  several  times  been 
shown  typical  ( ?)  Spiroclicctcc  pallida:  under  the 
ordinary  1/12  objective  by  inadequate  daylight 
illumination — in  one  instance  on  a  cloudy  day,  at 
that ! 

I  trust  that  the  gentlemen  whose  excellent  work  I 
am  criticising  will  not  consider  me  a  hide  bound 
skeptic.  I  merely  am  not  yet  quite  convinced,  but  am 
perfectly  willing  to  be.  Incidentally  I  can  see  where 
reliance  on  the  spirochaeta  will  often  inevitably  lead 
to  egregious  error  and  a  lack  of  careful  and  critical 
study  of  venereal  sores. 

As  an  illustration  of  the  fallacies  into  which  the 
acceptance  of  the  spirochaeta  as  the  specific  micro- 
organism of  syphilis  may  lead  one.  I  think  that  Case 
XXVm  of  table  i  in  Harris  and  Corbus's  article  is- 
pertinent.  The  case  is  loosely  reported  in  that  the 
time  which  had  elapsed  since  the  diagnosis  is  not 
stated.  "The  wound  healed  by  primary  intention,, 
and  there  have  been  no  signs  or  symptoms  of  the 
disease  since."  This  is  indefitiite  and  misleading. 
Was  the  freedom  from  symptoms  due  to  the  fact 
that  sufficient  time  had  not  elapsed  for  them  to  de- 
velop, or  due  to  the  treatment?  If  to  the  latter, 
was  the  remarkable  result  due  to  the  medication,  tO' 
the  excision,  or  to  both  combined? 

Be  it  remarked  that:  i.  Even  in  untreated  cases,, 
observable  symptoms  may  not  develop  for  weeks,, 
months,  or  perhaps  many  years  after  the  initial 
lesion  ;  2,  no  system  of  medication  yet  devised  can 
be  relied  upon  to  altogether  prevent  secondary 
lesions ;  and  3,  excision  was  long  ago  tried  and 
found  wanting  in  the  prevention  of  secondarv 
lesions. 

Following  Auspitz,  and  under  the  inspiration  of 
the  enthusiasm  of  my  dear  old  master,  the  late  Fes- 
senden  N.  Otis,  I  began  testing  the  excision  method 
nearly  thirty  years  ago.  My  conclusions  were:  i, 
Excision  does  not  prevent  constitutional  syphilis ; 
and  2,  excision  sometimes  seems  to  modify  the  sub- 
sequent course  of  the  disease. 

With  increasing  experience  I  realized  the  fallacv 
of  observations  of  the  results  of  excision  where  med- 
ication was  also  employed.  Be  it  remarked  that  I 
did  not  dare  omit  medication  in  my  private  practice, 
and  the  unreliability  of  data  formulated  from  obser- 
vation of  hospital  and  dispensary  patients  was  even 
then  evident  to  me.  I  now  reserve  excision  for 
cases  in  which,  for  domestic  reasons,  it  is  impera- 
tively necessary  to  promptly  get  the  initial  lesion 
out  of  the  way.  One  of  the  clinical  facts  which  1 
noted  was  that,  in  a  certain  percentage  of  cases,  ex- 
cision, if  early  performed,  was  followed  by  recur- 
rent chancre  of  the  wound.'  The  diagnosis  of  the 
case  quoted  from  Harris  and  Corbus,  was  evidently 
made  solely  from  the  presence  of  the  spirochaeta. 
Upon  this  diagnosis  my  comment  would  be  "too 
early  in  the  history  of  spirochaeta,  not  quite  proved 
and  therefore  fallacious."  Xone  of  the  character- 
istic objective  signs  of  chancre  were  present  in  the 
case,  nor  was  there  any  ademopathy. 

'My  observations  and  deductions  along  this  line  were  published 
in  my  Lectures  oit  Sypliilis,  1885,  and  in  my  TextbooK,  1899. 


58o 


IVOLBARST:  CURABILITY  OF  GONORRH(EA. 


[New  York 
Medical  Journal. 


Referring  again  to  the  prevention  or  modification 
of  syphilis  by  removal  of  the  initial  lesion,  that  point 
was  so  thoroughly  threshed  out  many,  many  years 
ago  that  its  discussion  seems  like  invoking  a  ghost 
of  ancient  days.  De  \'igo,  in  15 14,  recommended 
immediate  "destruction"  of  the  lesion.  Petit  in  1774, 
Hunter  in  1810,  and  Kicord  in  1856  practised  ex- 
cision. It  was  abandoned  almost  altogether  till  re- 
vived by  Auspitz  in  1877.  A  few  years  later,  hav- 
ing as  before  been  tried  and  found  wanting,  it  was 
again  abandoned.  Berkeley  Hill  cauterized  a  rup- 
tured frenum  twelve  hours  after  exposure  to  infec- 
tion, and  Fournier  cauterized  a  chancre  six  hours 
after  its  first  manifestation  developed.  Syphilis  fol- 
lowed in  both  instances  in  due  course  of  time.  Early 
experiments  with  vaccinia  must  not  be  forgotten  in 
the  way  of  analogic  evidence. 

In  re  cauterization :  Admitting  that  the  presence 
of  the  spirochseta  absolutely  proves  a  given  lesion  to 
be  chancre,  the  discovery  of  the  organism  is  not  an 
indication  for  cauterization,  but,  per  contra,  is  an 
imperative  admonition  to  avoid  caustics  of  all  kinds. 
"Deep  cauterization"  of  chancre  as  recommended  by 
Harris  and  Corbus  is  a  practice  which,  I  think,  no 
syphilographer  of  wide  experience  will  endorse.  I 
have  under  my  care  at  present  a  young  man  with 
severe  secondary  syphilis  who  mourns  the  loss  of  a 
considerable  portion  of  the  glans  as  a  result  of  "deep 
cauterization"  of  chancre.  Incidentally,  I  am  free 
to  say  that  it  will  require  more  than  the  evidence 
thus  far  recorded  by  Dr.  Harris  and  Dr.  Corbus 
to  change  the  opinions  which  I  have  formed  from 
the  observation  of  several  hundred  cases  in  my  own 
experience.  I  note  with  some  interest  that  our  au- 
thors recommend  routine  excision  or  cauterization 
from  a  recorded  experience  of  tzvo  cases  of  excision 
and  no  cases  of  cauterisation. 

Apropos  of  early  treatment :  I  long  ago  con- 
tended that  on  the  whole  it  was  better  to  begin  con- 
stitutional treatment  as  soon  as  the  diagnosis  of 
syphilis  was  established,  simply  because  it  was  un- 
safe to  take  the  chances  of  precocious  syphilides  and 
of  even  the  ordinary  skin  lesions  which  he  who  ran 
might  read.''  I  stated,  however,  that  it  was  by  no 
means  positive  that  patients  on  the  average  did  so 
well  in  the  long  run  as  when  treatment  was  deferred 
until  the  active  period  had  begun.  I  fancy  there 
are  still  many  syphilographers  who  rather  incline  to 
the  view  that  they  do  not  do  so  well.  W'iih  myself, 
a  very  influential  factor  is  the  desirability  cf  prompt- 
ly curing  the  initial  lesion,  which  is  always  a  source 
of  danger  to  others,  and  the  clanger  of  a  precocious, 
malignant,  or  at  least,  a  disfiguring  syphilis. 

Our  authors  rather  dogmatically  state  that  "ade- 
quate antisyphilitic  treatment  presupposes  the  ab- 
sence of  all  syphilitic  lesions."  This  is  somewhat 
indefinite:  Of  course,  if  the  treatment  is  "ade- 
quate" there  can  be  no  lesions.  But  inadequate 
treatment  does  not  mean  unscientific  treatment  nor 
that  the  patient  has  not  had  all  the  medication  he 
can  tolerate.  Have  the  gentlemen  any  systciu  of 
treatment  that  can  be  relied  on  to  prevent  all  mani- 
festations of  the  disease  and  invariably  cure?  If  so, 
I  marvel  that  they  did  not  o|)pose  the  dictum  of  a 
distinguished  neurologist  who.  at  a  recent  sympo- 
sium  at  the  Chicago  Medical  Society,  made  the  false 

^Lectures  on  Syphilis.   1885.     Textbook,  iSgy. 


and  dogmatic  statement  that  the  patient  who  is  once 
a  syphilitic  is  "always  a  syphiUtic." 

In  re  the  inoculation  of  syphilis  in  monkeys  and 
apes,  it  is  interesting  to  note  that  the  earlier  inves- 
tigators are  being  ignored  altogether.  Depaul  many 
years  ago  alluded  to  a  "syphilitic  monkey."  Early 
in  the  eighties  Martineau  inoculated  the  penis  of  a 
monkey  with  "syphilitic  virus."  Chancre  developed. 
He  exhibited  the  animal  before  the  French  Acad- 
emy and  later  showed  it  with  secondary  lesions  be- 
fore that  same  learned  body.  Martineau  sufTered 
the  same  fate  as  did  many  other  early  pioneers  in 
medicine.  His  case  of  syphilis  in  the  monkey  was 
rejected  as  not  genuine.  I  recall  that  I  quoted  this 
case  in  my  Lectures  on  Syphilis  in  1885  as  having 
a  powerful  bearing  on  the  evolutionary  doctrine. 

100  State  Street. 


A  FURTHER  CONTRIBUTION  TO  THE  STUDY  OF 
THE  PROSTATE,  WITH  REFERENCE  TO 
THE  CURABILITY  OF  GONORRHCEA.* 

By  a.  L.  Wolbarst,  M.  D., 
New  York, 

Attending  Genitourinary   Surgeon,   Beth  Israel   Hospital  and  West 
Side  German  Dispensary;  Consulting  Genitourinary  Surgeon, 
Central  Islip  State  Hospital;   Professor  of  Genitourinary 
Diseases,  New  York  School  of  Clinical  Medicine. 

The  subject  that  I  have  selected  for  presentation 
to  your  society,  in  response  to  the  kind  invitation 
of  your  president,  is  one  that  appeals  to  me  very 
strongly,  not  only  because  of  its  very  great  impor- 
tance as  one  of  the  medical  problems  with  which  we 
are  constantly  engaged,  but  because  of  the  com- 
paratively meagre  general  knowledge  of  the  sub- 
ject. 

Extensive  researches  by  various  observers  have 
made  us  familiar  with  the  general  idea  that  gonor- 
rhoea of  the  prostate  is  a  condition  of  seriotis  im- 
port to  the  human  economy ;  that  it  is  the  most  fre- 
quent complication  or  extension  of  gonorrhoea^ 
urethritis ;  that  it  is  difficult  to  prevent  and  still 
more  difficult  to  cure,  and  that  its  tendency  to 
chronicity  is  one  of  its  prime  features.  Neverthe- 
less, in  spite  of  this  knowledge,  few  of  us  are  really 
aware  of  the  extensive  damage  which  this  disease 
is  capable  of  doing,  both  to  him  who  sufifers  from 
it,  and  to  those  with  whom  he  comes  in  contact. 

It  is  conceded  that  chronic  gonorrhoea  and 
chronic  gonorrhoea!  prostatitis  are  practically  syn- 
onymotis  terms.  I  do  not  remember  ever  having 
seen  a  rebellious,  intractable  gonorrhrea  in  the  male, 
in  the  absence  of  stricture,  in  which  it  was  not 
possible  to  find,  after  diligent  search,  a  more  or 
less  serious  involvement  of  the  prostate  and  its  an- 
nexa.  A  true  appreciation  of  this  fact  is,  in  fact, 
a  sine  qua  non  to  the  proper  diagnosis  and  treat- 
ment of  most  of  the  ills,  if  not  all,  that  follow  in 
the  wake  of  chronic  gonorrhoeal  inflammation 
These  ills  we  may  divide  into  two  broad  classes, 
viz.,  those  that  are  limited  in  their  action  and  se- 
quel?e  to  the  patient  alone,  and  those  whose  se- 
quela.* af¥ect  others  than  the  host  himself. 

Of  the  first  broad  class,  the  symptoms  are  well 
known  to  all,  and  scarcely  need  even  be  mentioned. 

*Read  by  invitation  at  the  annual  meeting  of  the  International 
.\rcdic;il  .\ssociation  of  Me.xico.  a    T.~.m|iico.  January  ji.  igoD. 


Maicli  JO,  1Q09.J 


WOLBARST:  CURABILITY  OF  GOXORRHCEA. 


581 


We  are  all  familiar  with  the  unabashed  and  ever 
present  goutte  inilitaire  or  morning  drop,  that  per- 
sists in  spite  of  wind  or  weather ;  likewise  with  the 
rest  of  the  tram  of  symptoms  that  go  to  make  up 
the  picture — frequent  outbreaks  of  the  old  dis- 
charge, increased  frequency  of  urination,  reflex 
pains  extending  to  various  parts  of  the  body,  invol- 
untary seminal  emissions  and  premature  ejacula- 
tion, and  the  multitudinous  forms  and  varieties  of 
symptoms  that  lie  on  the  borderland  of  true  neu- 
rasthenia. With  this  symptom  complex,  folio wmg 
chronic  gonorrhoea,  we  are  all  familiar,  but  few  of 
us  seem  to  realize  that  in  these  symptoms  we  see 
the  direct  result  of  inflammation  centered  in  the 
prostate  and  its  annexa.  If  this  fact  were  more 
widely  known  and  appreciated,  by  physicians  m 
general  practice,  the  treatment  of  this  class  of  cases 
would  be  far  more  successful  and  the  results  more 
satisfactory  than  they  have  been  heretofore. 

Apart  from  these  symptoms  and  their  sequelae, 
another  important  feature  of  chronic  gonorrhoea  of 
the  prostate  that  makes  this  subject  of  unusual  in- 
terest, is  to  be  foimd  in  the  consideration  of  impo- 
tence and  sterility  in  the  male.  That  gonorrhoea  is 
the  most  important  and  frequent  cause  of  sterility 
in  the  male  cannot  be  questioned.  It  is  stated  that 
in  cases  of  imfruitful  marriages,  the  husband  is  the 
sterile  member  in  about  one  case  in  six.  or  over  six- 
teen per  cent,  (i)  Brothers  (2)  examined  seventy- 
two  husbands  of  childless  women  and  found  fifty 
who  were  responsible  for  the  sterility.  He  believes 
that  one  out  of  every  five  husbands  is  responsible 
for  sterility.  In  practically  every  one  of  these  cases, 
with  very  few  exceptions,  the  source  of  the  trouble 
is  usually  found  in  an  old  double  epididymitis  or  an 
uncured  gonorrhoea  of  the  prostate.  In  some  cases 
the  epididymes  may  have  become  occluded,  thus 
preventing  the  passage  of  spermatozoa  from  the 
testes  into  the  prostatic  urethra ;  or,  and  this.  I 
think,  is  much  more  common  than  we  are  wont  to 
believe,  there  is  a  chronic  inflammation  of  the  pros- 
tate and  vesicles  leading  to  a  deteriorative  change 
in  the  constituent  characters  of  the  prostatic  and 
vesicular  secretions,  associated  with  partial  occlu- 
sion of  the  common  ejaculatory  ducts,  all  of  which 
tend  to  destroy  the  fectindating  power  of  the  sper- 
matozoa, if  not  their  very  life  itself.  In  the  latter 
type  of  cases,  we  are  apt  to  have  associated  with 
the  sterility  a  true  impotence — the  patient  suffer- 
ing from  feeble  or  utter  absence  of  erectile  power, 
or  from  premature  ejaculation  of  semen,  occurring 
either  before  or  immediately  after  introitus.  In 
either  event  the  patient  is  made  extremely  miser- 
able and  the  family  tie  is  imperilled.  Examination 
of  the  prostate  and  vesicles  of  these  men  invariablv 
shows  the  existence  of  a  long  standing,  chronic  in- 
flammation of  these  organs,  more  often  than  not,  of 
gonorrhoeal  origin.  Fortunately,  these  cases  are 
often  amenable  to  jjroper  treatment,  and  recovery 
with  a  fairly  good  approach  to  the  normal  may  re- 
ward our  efforts. 

I  need  only  mention  the  dire  results  of  gonor- 
rhoeal infection  in  women  to  bring  to  mind  another 
and  by  no  means  the  least  of  the  serious  conse- 
quences that  lie  in  the  wake  of  chronic  gonorrhoea 
of  the  prostate.  Xor  is  this  infection  necessarilv 
the  result  of  immoral  or  licentious  sexual  living. 


W'e  see  it  every  day  in  the  acute  inflammation  of 
the  young  bride,  home  from  her  wedding  journey,, 
and  but  recently  infected  by  the  happy  husband, 
who  has  believed  himself  cured  of  his  old  and  al- 
most forgotten  gonorrhcea ;  we  see  it  in  the  in- 
flamed pus  tube  of  long  standing,  the  cause  of  un- 
told agony  and  misery  to  the  faithful  wife — again 
the  innocent  victim  of  an  uncured  gonorrhoea  of  the 
prostate  in  the  husband! 

As  a  rule  men  do  not  marry  v/hile  their  gonor- 
rhoea is  in  the  acute  or  subacute  stage.  But  we 
know  that  very  few  men  go  to  the  trouble  of  hav- 
ing themselves  examined  for  the  purpose  of  de- 
termining whether  or  not  they  are  well  and  fit  to 
marry,  without  danger  of  infecting  their  wives. 
How  many  men  enter  the  married  life  while  en- 
joying the  constant  companionship  of  the  morning 
drop,  no  one  can  say.  but  the  number  must  be  very 
great.  We  can  easily  see  how  this  little  drop  of 
mucopus,  which  responds  so  readily  at  times  to  the 
simple  astringent  hand  injection,  may  be  the  means 
of  causing  life  long  misery  to  the  innocent  wife  if 
it  contains  gonococci.  This  drop,  or  the  few  "clap 
shreds"  in  the  morning  urine,  is  in  most  instances 
nothing  more  than  a  silent  yet  eloquent  witness  to 
the  existence  of  a  persistent,  tincured  gonorrhoea  of 
the  prostate. 

We  have,  therefore,  in  gynaecological  practice,  a 
constant  reminder,  if  one  were  needed,  of  the  im- 
portance of  prostatic  gonorrhoea.  We  are  told  (3)  that 
"in  1,000  abdominal  sections  for  pelvic  inflamma- 
tion, ninety-five  per  cent,  were  attributable  to  gon- 
orrhoea." Pozzi  and  Frederick  (4)  state  that  thei  - 
experience  puts  the  proportion  at  seventy-five  per 
cent.  How  much  of  this  extensive  morbidity  among 
women  is  directly  traceable  to  chronic  unctired 
gonorrhoea  in  the  prostate  cannot  be  stated  with 
certainty,  but  I  am  strongly  convinced  that  a  very 
large  proportion  is  directly  or  indirectly  due  to  this 
single  cause. 

We  may  go  a  step  further  and  dwell  for  a  mo- 
ment on  that  most  heart  breaking  of  human  trage- 
dies— blindness  in  the  newly  born,  as  a  result  of 
ophthalmia  neonatorum.  This  disease  occurs  in 
about  0.5  of  one  per  cent,  of  all  births — one  in  200. 
In  the  United  States  alone  there  are  living  between 
six  and  seven  thousand  persons  who  have  been  ren- 
dered blind  by  this  disease  (5).  Here,  too.  we  have 
an  indirect  yet  convincing  exhibition  of  the  perni- 
cious and  far  reaching  powers  of  uncured  male 
gonorrhoea. 

And  lastly,  in  this  brief  review,  we  have  to  con- 
sider the  relationship  between  chronic  gonorrhoea 
and  the  hypertrophy  of  the  prostate  seen  in  ad- 
vanced age.  There  seem  to  be  fairly  good  grounds 
for  believing  that  this  condition,  the  bane  and  curse 
of  old  age,  is  due  in  great  measure  at  least,  to  a 
chronic  inflammation  of  the  prostate.  Thi^  theory 
was  first  set  forth  by  Ciechanowsky  in  1896  (g). 
and  confirmed  bv  later  observers,  notablv  Crandon 
(6).  G  reene  and  Brooks  (7).  and  Rothschild  (8). 

In  his  paper.  Ciechanowsky  states  that  '"the  foun- 
dation for  hypertrophy  of  the  prostate  gland  and 
certain  forms  of  prostatic  atrophy,  in  my  cases  at 
least,  consisted  in  chronic  inflammatory  processes, 
the  getiological  relation  of  which  to  virulent  gonor- 
rhoea, is  not  sufficiently  proved  at  present.    Yet  the 


582 


iVOLBARST:  CURABILITY  OF  GONORRHCEA. 


[New  Vokk 
Medical  Journal. 


great  freejuency  of  chronic  prostatic  inflammation 
due  to  it  after  all  acute  inflammation  has  subsided, 
and  more  particularly  the  conspicuous  similarity  of 
my  observations  to  the  pathological  changes  found 
in  gonorrhLeal  prostatitis,  make  it  possible  that 
such  a  relation  exists."  He  also  adds:  "Whether 
gonorrhoea  really  is  the  most  frequent  and  im- 
portant cause  of  hypertrophy  of  the  prostate  gland, 
will  be  the  work  of  the  future  to  decide." 

Rothschild  (8)  confirms  this  testimony.  In  twenty- 
seven  out  of  thirty  examinations  on  the  cadavers 
of  patients  who  died  between  the  ages  of  thirty- 
four  and  fifty-two,  without  evidence  or  history  of 
disease  of  the  urinary  organs,  he  found  pathologi- 
cal changes  similar  to  those  described  by  Ciechan- 
owsky  in  hypertrophied  prostates,  and  by  Finger 
in  gonorrhoeal  prostates.  He  therefore  infers  that 
the  foundation  of  prostatic  hypertrophy  is  laid 
down  years  before  the  gland  actually  begins  to  en- 
large, and  that  gonorrhcea  is  at  least  the  usual 
cause  of  prostatic  hypertrophy  (9). 

Looking  at  the  subject  of  prostatic  gonorrhoea 
from  these  diverse  points  of  view,  we  can  readily 
see  how  important  it  is  to  determine  whether  or 
not  in  any  given  case,  gonococci  still  persist  in  the 
])rostatic  secretions,  and  to  discuss  the  methods  by 
Avhich  this  information  can  be  obtained. 

The  basis  of  our  study  is  to  be  found  in  the  fact 
that  the  gonococcus  may  lie  dormant  in  the  pros- 
tate without  causing  any  symptoms,  and  awaken 
months  or  years  after  the  initial  infection  as  the 
result  of  some  exciting  cause.  In  a  previous  paper 
( 10)  I  presented  a  series  of  fifty-five  cases  of  chronic 
gonorrhoea,  some  of  them  apparently  cured,  in 
which  a  studied  effort  was  made  to  determine  the 
presence  or  absence  of  gonococci  in  the  prostatic 
secretions,  as  brought  forth  by  massage  of  the 
gland. 

The  examinations  were  conducted  briefly  as  fol- 
lows :  The  patient  came  witli  a  full  bladder,  pre- 
ferably early  in  the  morning.  If  there  was  a  dis- 
charge at  the  meatus,  a  smear  was  taken  and  exam- 
ined microscopically.  The  anterior  urethra  was 
carefully  washed  out  with  plain  water  or  boric  acid 
solution  until  the  washings  came  out  perfectly 
clean.  The  writer's  test  for  the  determination  of 
pus  and  shreds  (11)  was  then  employed,  and  by  this 
means,  the  source  of  the  shreds  or  pus  was  determ- 
ined. The  inflammation  was  thus  localized.  The 
entire  urethral  tract  was  then  cleansed  with  the  so- 
lution, including  the  bladder ;  two  or  three  ounces 
of  the  solution  were  left  in  the  bladder.  The  pros- 
tate and  vesicles  were  now  carefully  yet  vigorously 
massaged  mitil  there  appeared  at  the  meatus  a  suf- 
ficient (|uantity  of  prostatic  fluid,  which  was  caught 
on  a  clean  glass  slide,  properly  fixed  and  stained 
and  examined  microscopically.  These  examinations 
were  repeated  at  frequent  intervals.  The  conclu- 
sions of  that  paper  may  be  quoted  here  appro- 
priately: 

i>.  Tlie  ^ocallcd  "iiicural  Ic"  and  "recurrent"  cases  of  gon- 
f)rrlifca  are  those  in  wliich  tlie  gonococci  remain  latent  in 
the  [)rr)state  and  anncxa. 

2.  F.vcry  case  of  chronic  gonorrhoea  in  the  male  should 
be  tlioroughly  exanpned  for  gonococci  in  the  prostate  and 
annexa. 

.V  The  morning  urine  passed  by  the  patient  may  or  may 
not  contain  gonococci :  the  massaged  urine  passed  imme- 
diately alter,  or,  better  still,  if  it  can  be  obtained,  the  ex- 


pressed secretion  of  the  prostate,  will  most  always  give  a 
positive  finding. 

4.  The  urine  passed  by  the  patient  may  be  clear  and 
sparkling;  yet  the  massaged  urine  may  be  full  of  pus  and 
epithelia  which  are  loaded  with  gonococci. 

5.  There  is  no  direct  relationship  between  the  urine  clear- 
ing up  and  the  disappearance  of  gonococci  from  the  pros- 
tate. 

6.  Five  exaniiiiations  of  the  massaged  urine  may  gi\  e  a 
negative  result.  The  si.xth  may  give  a  reverse  verdict. 
Here  persistence  is  a  cardinal  virfue. 

7.  Before  a  patient  can  be  declared  "cured"  and  marriage 
sanctioned,  he  should  be  put  on  the  customary  tests,  and  in 
addition,  the  massaged  prostatic  secretion  should  be  ex- 
amined at  weekly  intervals  until  at  least  six  consecutive 
negative  findings  result.  Thereafter  for  at  least  a  year,  a 
monthly  examination  of  the  same  kind  should  be  made,  so 
as  to  make  assurance  doubly  sure. 

Since  the  publication  of  that  paper,  I  have  per- 
sisted in  the  study  of  this  engrossing  subject,  and 
as  a  result  I  feel  that  at  least  two  of  the  "conclu- 
sions" require  amendment  and  further  study.  I 
refer  to  numbers  three  and  seven.  The  former 
says,  "the  massaged  urine  or,  better  still,  if  it  can 
be  obtained,  the  expressed  secretion  of  the  prostate, 
ivill  almost  alzvays'  give  a  positive  finding."  I  wish 
to  modify  the  last  few  words  to  read,  "the  ex- 
pressed secretion  of  the  prostate  zvill  sometimes 
give  a  positive  finding."  The  more  prostates  I  ex- 
amine, the  less  positive  I  am  that  the  deeply  seated 
gonococci  will  be  revealed  under  the  microscope. 

The  second  change,  in  conclusion  seven,  is  this. 
In  the  paper,  it  reads — "the  massaged  prostatic  se- 
cretion should  be  examined  at  weekly  intervals  un- 
til at  least  si.v^  consecutive  negative  findings  result." 
Here  again.  I  have  become  less  confident  and  more 
conservative.  I  am  not  satisfied  now  with  six  ex- 
aminations. I  am  strongly  inclined  to  double  and 
even  treble  the  number  of  examinations  required  to 
determine  the  point  to  my  personal  satisfaction. 
And  in  addition  I  must  add  a  qualification,  namely, 
that  the  massaged  secretion  should  be  examined 
from  time  to  time,  after  the  instillation  into  the 
deep  urethra  of  a  one  or  two  per  cent,  solution  of 
silver  nitrate. 

To  bring  out  these  points  more  clearly,  I  have 
selected  two  cases  from  private  practice,  which  I 
trust,  will  serve  as  an  illustration : 

Case  I. — F.  W.  C,  aged  forty-nine,  literary  man,  mar- 
ried thirty  years,  presented  himself  for  treatment  on  .'\prii 
8,  1908.  He  denied  all  venereal  history,  though  he  admitted 
straying  into  foreign  pastures  occasionally  since  his  mar- 
riage. 

Complaint :  A  feeling  of  dull  pain  in  the  perimcum  for 
the  past  two  years,  accompanied  by  an  increased  frequency 
in  urination,— every  hour  during  the  day,  once  or  twice  at 
night.  Occasionally  be  saw  a  sticky  discharge  at  the 
meatus,  but  more  frequently  it  was  watery.  There  was  also 
a  perceptible  leakage  of  a  fluid  that  resembled  urine,  from 
the  meatus,  barely  sufficient  in  amount  to  moisten  the  un- 
derclothing. A  plug  of  absorbent  cotton  inserted  into  the 
prajputial  cavity  became  soaking  wet  in  the  course  of  an 
hour  or  two.  General  health  excellent ;  sexual  appetite  and 
capacity  likewise. 

Exauiination :  The  first  urine  passed  by  the  patient  after 
washing  out  the  anterior  urethra  was  clear,  but  contained 
a  number  of  small  heavy  shreds.  The  prostate  was  found 
large  and  flabby,  and  the  vesicles  on  both  sides  distended. 
Slight  pressure  applied  to  the  prostate  brought  forth  a 
copious  flow  of  prostatic  fluid  at  the  meatus,  some  of  which 
was  caught  on  a  glass  slide  to  be  examined  microscopically. 
The  tirine  now  passed  was  very  cloudy  with  pus.  and  con- 
tained numeroi's  heavy  masses  of  detritus,  some  of  them 
more  than  an  inch  long:  the  last  drops  of  urine  brought 
with  them  a  free  flow  of  fresh  blood. 

'It.-ilics  not  in  original. 


March  20,  1909.] 


WOLBARST:  CURABIUI'Y  0¥  GONORRHCEA. 


583 


Suspecting  a  possible  prostatic  hypertrophy,  I  found  the 
urinary  length  eight  and  a  quarter  inches,  of  which  the 
posterior  urethra  measured  one  and  a  half  inches.  No 
residuum  by  catheter.  I,  therefore,  ruled  it  out  of  consider- 
ation. A  Thompson  searcher  failed  to  reveal  the  presence 
of  stone  or  tumor  in  the  bladder. 

1  therefore  made  a  tentative  diagnosis  of  chronic  gonor- 
rlKcal  prostatitis,  but  this  the  patient  could  not  accept  as 
being  possible,  in  view  of  his  positive  denial  of  any  venereal 
history.  On  close  questioning,  however,  he  recalled  that 
some  twenty  years  ago,  while  riding  horseback,  his  horse 
reared  and  almost  threw  him.  The  perinaeum  struck  the 
pommel  of  the  saddle  with  considerable  force,  causing 
great  pain.  This  was  followed  in  a  few  days  by  a  dis 
charge  from  the  urethra,  which  together  with  the  pain, 
subsided  after  a  few  days'  rest  and  treatment.  This  to  my 
mind,  confirmed  the  diagnosis  of  gonorrhoea.  I  considered 
the  horseback  accident  as  a  mere  coincidence  and  informed 
the  patient  that  I  believed  that  he  had  had  an  attack  of 
gonorrhcea  at  that  time. 

Microscopical  Examination  :  The  prostatic  secretion  was 
examined,  as  were  all  subsequent  specimens  in  this  series, 
at  the  Saxe  Laboratory,  and  the  tirst  report  read  as  fol- 
lows: "No  gonococci,  a  few  Gram  positive  diplococci,  a 
moderate  number  of  streptococci,  nvany  red  blood  cells,  and 
very  many  pus  cells ;  also  considerable  epithelia  from  the 
posterior  urethra  and  the  prostate."  In  spite  of  this  nega- 
tive report,  1  felt  that  the  diagnosis  was  correct  and  that 
subsequent  examinations  would  confirm  this  view.  The 
treatment  consisted  of  massage  of  the  prostate  every  other 
day,  followed  by  an  intravesical  irrigation  of  a  silver  nitrate 
solution  I  in  10,000,  alternating  with  a  protargol  solution  i  in 
500.  This  was  continued  for  seven  weeks,  and  during  this 
period  twelve  additional  microscopical  examinations  were 
made.  The  laboratory  reports  were  invariably  negative  as 
to  gonococci. 

The  patient,  however,  improved  considerably.  His  perin- 
eal pain  disappeared,  his  urination  became  less  frequent, 
and  the  dribbling  at  the  meatus  also  diminished  materially 
in  quantity.  The  absence  of  gonococci  in  the  prostatic  se- 
cretions did  not,  however,  weaken  my  view  that  the  trouble 
was  gonorrhceal  in  nature.  I  therefore  determined  to  force 
the  issue,  and  on  May  23rd,  instead  of  the  usual  massage 
and  bladder  irrigation,  1  gave  him  an  instillation  into  the 
deep  urethra  of  Tri_.\x  of  silver  nitrate  solution,  one  per 
cent,  strength.  On  the  following  day  I  massaged  the  pros- 
tate and  the  report  came  back  with  this  comment :  "No 
gonococci,  but  some  of  the  diplococci  observed  were  mor- 
phologically identical  with  the  gonococcus."  And  on  the 
next  day'  another  massaged  specimen  brought  forth  this 
report:  "Gonococci  many.  The  organisms  were  for  the 
rriost  part  e.Ktracellular,  but  several  intracellular  groups 
were  found."  Thus  were  patience  and  persistence  reward- 
ed. The  next  specimen  taken  four  days  later  showed  a 
"moderate  number  of  gonococci,"  and  this  was  followed  by 
si.x  consecutive  negative  reports.  On  June  8th,  si.xteen  days 
after  the  first  deep  instillation,  I  administered  another 
deep  instillation  of  the  same  strength,  and  the  report  again 
showed  the  presence  of  "many  gonococci."  A  smear  taken 
seven  days  later  proved  negative. 

The  patient  then  stopped  his  visits  for  about  a  month, 
feeling  very  well.  He  then  returned  one  day  for  an  exam- 
ination, and  this  again  proved  negative.  Since  that  time  I 
have  heard  from  him  several  times :  he  has  been  feeling 
very  well,  and  is  not  much  concerned  about  the  gonococci 
in  his  prostate  as  long  as  they  do  not  bother  him. 

This  case  illustrates  several  points  of  interest : 

1.  The  patient  went  along  for  about  eighteen 
years  without  any  symptoms  of  any  kind.  He  lived 
the  usual  married  life,  drank  alcoholics,  and  yet 
never  realized  that  he  harbored  gonococci  in  his 
prostate. 

2.  For  two  years  he  sttffered  from  a  severe 
chronic  prostatitis,  which  w^as  mistaken  for  simple 
cystitis  and  treated  as  such  without  benefit. 

3.  Twelve  microscopical  examinations  of  the 
massaged  prostatic  secretion  gave  negative  results 
as  to  the  presence  of  gonococci :  immediately  suc- 
ceeding the  deep  instillation  of  silver  nitrate,  how- 
ever, the  gonococci  were  found. 

4.  As  soon  as  the  effects  of  the  silver  nitrate 


passed  of¥,  the  gonococci  disappeared,  and  there 
were  five  successive  negative  reports,  until  the  sec- 
ond administration  of  the  silver  nitrate,  upon  which 
the  gonoccocci  appeared  for  the  second  time. 
Again  they  disappeared  as  soon  as  the  irritant  ef- 
fects of  the  silver  passed  off. 

Case  H. — B.  G.,  aged  thirty-one,  merchant.  Appeared 
for  the  first  time  September  9,  1908.  He  desired  to  marry, 
and  came  to  be  examined  to  determine  whether  he  was 
well. 

History:  Patient  had  the  first  attack  of  gonorrhoea  in 
1901,  and  had  three  or  four  recurrences  of  mild  type  at  in- 
tervals of  about  a  year.  For  the  last  four  years  he  had 
been  absolutely  well,  except  for  an  occasional  morning 
drop  after  coitus. 

Examination :  The  test  referred  to  before  demonstrated 
the  presence  of  a  chronic  prostatitis  ;  the  right  lobe  of  the 
prostate  was  slightly  enlarged  and  tender  to  the  touch,  the 
left  side  normal.  Seminal  vesicles  apparently  normal.  The 
urethra  easily  admitted  a  blunt  sound,  30  French,  down  to 
the  bladder.    Urine  clear. 

Microscopical  Tests :  The  microscopical  examination  of 
the  first  massaged  prostatic  secretion  was  negative  as  to 
gonococci ;  likewise  seven  successive  examinations,  made  at 
intervals  of  two  days.  At  this  time  a  deep  instillation  sim- 
ilar to  those  given  in  Case  I,  was  administered,  with  the 
result  that  the  next  report  of  the  series  showed  the  pres- 
ence of  "many  gonococci."  Treatment  was  instituted  and 
for  three  weeks  the  reports,  seven  in  number,  were  nega- 
tive as  to  gonococci.  Another  deep  instillation  broughf 
forth  another  positive  report. 

This  patient  is  still  under  treatment  for  chronic 
gonorrhcea  of  the  prostate.  His  marriage  has  been 
ordered  postponed  indefinitely.' 

In  closing  this  paper,  I  wish  to  offer  these  addi- 
tional conclusions,  which  I  think,  may  be  accepted 
as  proved  by  the  two  cases  herein  reported : 

1.  Clear  urine  and  absence  of  symptoms  do  not 
necessarily  mean  that  there  are  no  gonococci  in  the 
sexual  system. 

2.  The  gonococci  may  remain  latent  and  inac- 
tive for  many  years  (in  Case  I  they  were  quies- 
cent twenty  years  at  least,  possibly  more). 

3.  Doubtful  cases  resembling  simple  cystitis 
should  be  carefully  examined  for  a  possible  gonor- 
rhceal prostatitis. 

4.  The  massaged  secretion  of  the  prostate  may 
or  may  not  reveal  the  presence  of  gonococci ;  a  deep 
instillation  of  a  silver  nitrate  solution  will  help  to 
clear  up  the  diagnosis. 

5.  If  after  a  number  of  deep  instillations,  the  re- 
ports are  unexceptionally  negative  as  to  gonococci, 
the  probability  of  a  cure  is  reduced  to  a  moral  cer- 
tainty.   Cultures  may  remove  any  final  dotibts. 

References. 

1.  Hagner  and  Fuller,  Medical  Record,  August  10,  1907. 

2.  Brothers.  Paper  read  before  the  New  York  Post- 
graduate Clinical  Society,  January  4,  1901. 

3.  Johnson,  quoting  Price.  Journal  of  the  American 
Medical  Association,  August  10,  1907. 

4.  Loc.  cit. 

5.  Edgar.  Journal  of  the  American  Medical  Associa- 
tion, August  3,  1907. 

6.  Crandon.    Annals  of  Surgery,  xxxvi,  813,  1902. 

7.  Greene  and  Brooks.  Journal  of  the  American  Med- 
ical Association,  xxxviii,  p.  1051,  1902. 

8.  Rothschild.  Centralblatt  fiir  Krankheiten  der  Harn- 
itnd  Sexual-Organe,  xv,  p.  177,  1904. 

9.  Quoted  by  Keyes.  Journal  of  the  American  Medical 
Association.  July  16,  1904. 

10.  Wolbarst.  Neiv  York  Medical  Journal,  March  7, 
1908. 

11.  Wolbarst.    Medical  Record,  April  21,  1906. 

105  East  Nineteenth  Street. 

-The  patient  has  since  been  discharged  cured  and  has  now  been 
married  about  a  month  without  th'j  appearance  of  untoward  symp- 
toms. 


584 


SAMUELS:  URETHRAL  GONORRHCEA  LN  THE  FEMALE. 


[New  York 
Medical  Journal. 


GONORRHCEAL  URETHRITIS  IN  THE  FEMALE.* 

By  a.  Samuels,  M.  D., 
Baltimore,  Md., 

Associate  rrofessor  of  Gynaecology,  College  of  Physicians  and 
Surgeons. 

The  term  ''urethritis"  includes  all  forms  of  ure- 
thral inflammation.  By  far  the  most  common  of 
these  inflammations  is  the  gonorrhoeal.  Cases  of 
urethritis  originating  without  the  influence,  direct 
or  indirect,  of  the  gonorrhoeal  infection  are  rare. 
Other  forms  of  urethritis  arising  from  constitu- 
tional defects  or  from  mechanical  or  chemical  in- 
jury to  the  urethral  membrane  occur,  but  they  are 
chiefly  interesting  from  the  standpoint  of  aetiology, 
since  in  symptoms  and  treatment  they  coi^respond 
with  some  of  the  stages  of  the  more  common  dis- 
order. 

In  the  following  pages  the  subject  under  consid- 
eration is  gonorrhoeal  urethritis  in  the  female. 

Formerly  gonorrhoea  of  the  vagina  ranked  first 
in  importance  and  frequency,  but  recent  observa- 
tions and  studies  have  conclusively  proved  that  the 
virulent  suppuration  caused  by  the  gonococcus  is 
most  frequently  found  in  the  urethra  (Taylor). 
H.  Kelly  states :  "All  inflammations  of  the  urethra 
not  caused  by  a  foreign  body  are  due  to  the  gono- 
coccus." 

The  disease  is  more  common  between  the  ages  of 
puberty  and  the  menopause  and  rare  in  childhood 
and  old  age. 

Chronic  urethritis  is  the  lesion  most  frequently 
seen.  The  physician  in  many  instances  is  respon- 
sible for  this  condition  of  affairs.  Cases  of  gonor- 
rhoeal urethritis  are  diag'nosticated  symptomatically 
as  "cold  on  the  blad'der,"  "cystitis,"  or  "irritation  of 
the  bladder."  A  coexisting  vulvitis  is  frequently 
diagnosticated  as  leucorrhoea.  In  a  large  number 
of  cases  the  treatment  is  worse  than  the  diagnosis. 

Noeggerath  made  extensive  observations  in  New 
York  and  stated,  that  "eighty  per  cent,  of  married 
men  have  had  gonorrhoea  a*nd  that  ninety  per  cent, 
of  these  have  never  been  thoroughly  healed,  and 
that  of  five  married  women  three  have  gonorrhoeal 
urethritis"  (acute  or  chronic).  Zweifel  and  Sanger 
find  eighteen  per  cent,  of  women  with  gonorrhoeal 
urethritis.  In  353  cases  of  gonorrhoeal  infection 
Lasar  found  the  gonococcus  in  the  urethra  iii 
times;  seven  times  in  the  vagina  in  180  cases.  In 
four  fifths  of  the  in  cases  of  urethral  infection 
there  were  no  macroscopical  evidences  of  a  ureth- 
ritis. Palmer  Dudley  has  frequently  demonstrated 
the  gonococcus  in  the  urethra  when  there  were  no 
visible  secretions.  B.  Tarnovski,  in  750  cases,  found 
acute  and  chronic  urethritis  in  268  cases.  Stein- 
schneider,  in  a  study  as  to  the  localization  of  the 
gonorrhoeal  infection,  in  thirty-four  cases  (fresh), 
found  the  gonococci  in  the  urethra  in  them  all. 
Flora  Pollock  examined  ioqB  cases  in  the  Woman's 
Venereal  Department  at  the  Johns  Hopkins  Dis- 
pensary, both  subjectively  and  bacteriologically  for 
the  gonococcus.  it  was  found  that  out  of  668  cases, 
466,  or  sixty-eight  per  cent.,  had  urethritis;  173, 
or  twenty-five  per  cent.,  had  no  symptoms.  Two 
hundred  patients  from  private  practice  and  the 
Woman's  Department  at  the  City  Hospital  Dispen- 

•Read  before  The  Medical  Society  of  the  College  of  Physicians 
and  Surgeons,  at  P.altimorc. 


sary,  120,  or  60  per  cent.,  were  found  to  have  been 
infected  with  the  gonococcus.  Of  these  patients  all 
had  acute  or  chronic  urethritis.  Three  per  cent,  of 
these  cases  were  in  prostitutes.  In  Pollack's  series 
of  515  cases  Of  urethritis  seventy  per  cent,  showed 
typical  organisms,  and  29.9  per  cent,  showed  atyp- 
ical organisms.  It  is  interesting  to  note  that  the 
29.9  per  cent,  of  cases  that  showed  atypical  organ- 
isms complications  identical  with  those  of  true 
gonorrhoea  developed  in  16.75  P^'^  cent.  In  my 
series  of  cases  I  found  typical  organisms  in  sixty- 
five  per  cent. 

Gonorrhceal  urethritis  may  remain  localized  for 
years  unnoticed,  but  the  sequels  and  complications 
combined  make  it  more  to  be  feared  than  syphilis. 
The  anatomical  changes  in  the  urethra  are  those  of 
a  high  grade  inflammation.  During  the  height  of 
the  infectious  process  the  meatus  is  red  and  swollen 
and  covered  with  a  thin  mucopurulent  secretion.  In 
this  secretion  the  gonococci  may  be  found  in  vary- 
ing numbers. 

Often  the  dilated  orifices  of  the  glands  in  the 
anterior  part  of  the  urethra  can  be  seen  exuding 
minute  drops  of  pus.  This  condition  is  shown  by 
the  endoscope  to  extend  a  short  distance  back,  to  be 
less  intense  near  the  middle,  and  often  to  assume 
a  marked  intensity  near  the  internal  orifice  (H. 
Kelly).  About  the  tenth  day  the  inflammation  be- 
gins to  subside.  The  mucosa  looks  less  red  and  oede- 
matous,  the  pus  is  diminished,  and  the  number  of 
gonococci  decreased. 

Unless  proper  treatment  is  instituted  the  disease 
goes  on  to  the  chronic  stage.  This  stage  is  charac- 
terized by  small  elevated,  congested,  coneshaped 
areas,  which  are  sensitive  and  bleed  easily.  Here 
and  there  these  coneshaped  areas  have  undergone  a 
necrosis,  and  small  ulcers  have  formed.  The  ulcers 
secrete  a  thin,  mucopurulent  material  which  is  com- 
posed of  pus  cells,  epithelial  cells,  and  a  few  gono- 
cocci. These  ulcers  show  little  or  no  tendency  to 
heal  spontaneously,  and,  furthermore,  stubbornly 
resist  all  forms  of  treatment. 

The  glands  of  Skene  are  frequently  involved,  and 
here  the  disease  is  particularly  apt  to  linger  in  a 
chronic  form.  The  pus  can  be  milked  out  by  pres- 
sure from  above  downwards,  first  on  one  side  and 
then  on  the  other.  One  or  two  drops  of  thick  pus 
will  often  exude  from  the  orifice  from  the  duct  just 
inside  the  urethra,  giving  evidence  of  its  source  by 
adhering  more  to  the  side  from  which  it  was 
squeezed.  Long  after  a  gonorrhoea  is  apparently 
well  a  fresh  attack  may  start  up  by  autoinfection 
from  a  chronic  gonorrhoea  that  has  lingered  in  these 
glands. 

Under  the  name  of  "urethritis  externa"  Guerin 
has  described  a  localization  of  the  gonorrhoeal  pro- 
cess of  which  E.  Finger  (Die  Blenorrlioe  dcr  sex- 
ual Organe  niid  Hire  Complicationcn,  Leipzig  and 
Wien,  1893,  P-  300)  speaks  as  follows:  "The  gonor- 
rhoeal inflammation  of  the  follicles  at  the  orifice  is 
either  chronic  when  there  are  no  symptoms  and  a 
small  amount  of  pus.  or  acute  and  relapsing.  One 
or  the  other  follicle  swells,  giving  the  urethral  ori- 
fice an  asymmetrical  appearance,  and  the  mucous 
membrane  over  the  follicle  is  reddened.  Soon  a 
little  drop  of  pus  escapes,  and  the  follicle  closes.  In 
a  short  time  the  same  thing  occurs  again  in  the  .same 


March  20,  1909.  J 


SAMUELS:  URETHRAL  GONORRHCEA  IN  THE  FEMALE. 


585 


follicle  or  another  follicle,  and  so  it  continues  lor  a 
long  time." 

As  a  rule  the  invasion  of  the  urethra  in  the 
female  is  much  the  same  as  in  the  male.  There  is 
a  slight  tickling  and  burning  sensation  and  some 
seromucous  secretion  in  which  little  white  particles 
may  be  seen  suspended.  These  particles,  when 
microscopically  examined,  are  shown  to  be  epi- 
thelial cells  and  gonococci.  After  a  prodromal 
period  of  a  few  hours  or  a  day  or  two  the  acute 
stage  develops  with  more  or  less  severe  burning  in 
the  urethra,  rendered  worse  on  urination,  which 
soon  becomes  quite  frequent. 

Examination  of  the  parts  shows  the  urethral  ori- 
fice to  be  very  red  and  swollen,  with  perhaps  a 
pouting  prominence  of  the  lips.  A  greenish  yellow 
discharge  escapes  in  considerable  quantity,  and  may 
cause  redness  and  swelling  of  the  parts  around  and 
!)eneath.  By  inserting  the  finger  tip  in  the  vagina, 
the  urethra,  is  found  to  be  swollen  and  tender,  and 
pressure  from  behind  forwards  causes  pus  to  escape 
from  the  meatus.  The  local  suf¥erings  are  quite 
acute  and  usually  become  worse  when  the  bladder 
is  involved.  A  slight  rise  of  temperature  may  be 
noted.  Patients  will  often  hold  .their  urine  for  hours 
to  escape  the  burning  and  scalding. 

In  the  majority  of  cases  the  acute  stage  begins  to 
subside  in  from  six  to  ten  days.  The  burning  and 
scalding  become  less  and  less  severe,  the  tenesmus 
is  less  imperative,  and  the  urination  becomes  less 
frequent  and  painful.  The  redness  and  swelling  of 
the  meatus  subside  slowly,  and  the  pus  becomes 
whitish  and  mucoid.  In  this  way  matters  grow  pro- 
gressively better  until  the  chronic  stage  is  reached. 
Then  we  commonly  see  a  normal  or  only  a  slightly 
reddened  meatus,  from  which  by  intravaginal  pres- 
sure on  the  urethra,  a  drop  or  two  of  vesicomuco- 
pus  or  a  thinner  milky  looking  fluid  may  escape. 
In  this  condition  the  patient  may  sufifer  no  discom- 
fort whatever,  or  she  may  have  a  slight  smarting 
or  sense  of  heat  on  urination. 

Examination  of  the  urine  by  the  two  glass  test 
will  show  how  far  the  morbid  process  has  traveled. 
If  the  first  specimen  is  cloudy  and  the  second  clear, 
it  is  certain  that  the  bladder  is  not  involved.  If  the 
second  is  cloudy  or  turbid,  then  it  is  certain  the  blad- 
der has  been  infected.  When  the  bladder  has  re- 
mained intact  the  first  ounce  of  urine  will  contain 
f  lumps  and  filaments,  which  are  made  up  of  pus  and 
e  pithelial  cells,  and  may  contain  a  few  gonococci. 
Examination  of  the  pus  in  the  florid  stage  shows  pus 
cells  with  m.any  gonococci.  As  the  secretion  be- 
comes more  mucoid,  epithelial  cells  show  promi- 
nently in  the  field,  with  a  diminished  number  of 
gonococci.  In  the  chronic  stage  there  are  usually 
found  some  pus  cells,  epithelial  cells,  a  few  gono- 
cocci, and  the  usual  indiflferent  microorganisms. 

As  a  rule  the  diagnosis  is  easy.  The  history  of 
burning  and  scalding  urination,  a  reddened  and 
swollen  meatus,  covered  with  pus,  and  the  finding 
of  the  gonococci  put  the  question  beyond  a  doubt. 
In  subacute  or  chron  ic  cases  difificultv  mav  be  expe- 
i-ienced.  when  the  meatus  looks  normal  with  little 
or  no  secretion  or  if  the  patient  has  urinated  a  short 
time  previous  to  the  examination.  Under  this  con- 
dition tenderness  of  the  urethra  on  intravaginal 


pressure  is  quite  diagnostic  of  a  urethritis.  If  any 
doubt  exists  the  endoscope  will  reveal  the  small 
ulcers  or  congested  areas,  which  are  significant  of  a 
chronic  urethritis. 

In  the  treatment  of  this  disease  the  prime  essen- 
tials are  cleanliness,  intraurethral  injections,  and 
constant  care  as  to  details.  The  patient  should  be 
made  to  understand  clearly  the  gravity  of  the  dis- 
ease, the  sequels  and  compHcations  that  usually 
follow  neglected  cases,  and  she  should  be  urged  to 
continue  under  observation  until  pronounced  cured. 
It  is  the  duty  of  every  physician  to  make  a  thorough 
and  painstaking  examination  to  acquaint  himself 
with  the  full  extent  of  the  disease.  A  physician 
who  will  conscientiously  employ  the  proper  local 
treatment,  and  not  rely  on  the  advertised  quack  in- 
ternal remedies,  will  have  successful  results. 

In  the  acute  or  painful  stages  of  the  disease  no 
local  treatment  should  be  given.  The  external  geni- 
tals should  be  bathed  frequentlv  with  mild  antisep- 
tic solutions,  such  as  bichloride,  i  in  6,000,  or  a  sat- 
urated solution  of  boric  acid.  The  hot  sitzbath  may 
be  used.  Rest  in  bed  is  very  desirable.  The  diet 
should  be  light  and  nonstimulating  with  large  quan- 
tities of  such  diluent  drinks  as  flaxseed  tea.  The 
bowels  should  be  kept  loose  with  saline  purgatives. 
For  the  burning  and  scalding  urination  potassium 
acetate  in  from  ten  to  fifteen  grain  doses,  three  times 
daily,  usually  gives  the  greatest  amount  of  relief. 
If  tenesmus  is  present  tincture  of  hyoscyamus  in 
from  ten  to  fifteen  drop  doses  should  be  combined 
with  the  potassium  salt.  The  balsams  and  oils 
usually  employed  in  the  male  are  of  no  account  and 
have  a  strong  tendency  to  derange  the  digestive 
function.  As  soon  as  the  inflammation  in  the 
urethra  has  somewhat  subsided  from  the  use  of  the 
foregoing  measures  suitable  only  for  the  acute 
stage,  intraurethral  injections  of  protargol,  one  per 
cent.,  are  to  be  given  daily.  As  the  inflammation 
further  declines  the  strength  of  the  solution  is  to  be 
increased  gradually  up  to  two  or  three  per  cent. 
Generally  under  this  treatment  the  gonococci  rapid- 
ly disappear,  and  the  discharge  becomes  less.  After 
the  gonococci  have  disappeared  the  protargol  solu- 
tion should  be  discontinued.  The  process  of  heal- 
ing should  be  further  aided  by  injecting  a  mild  as- 
tringent solution  of  zinc  sulphate,  every  third  day. 
until  the  mucoid  discharge  ceases. 

Vaginal  douches  are  contraindicated,  as  they  de- 
feat the  purpose  for  which  they  are  intended  bv  re- 
moving the  protective  secretion  of  the  vagina.  At 
the  same  time  the  nozzle  of  the  syringe,  which  may 
have  been  lubricated  with  infectious  pus,  carries  and 
deposits  the  gonococci  high  up  in  the  genital  tract. 

The  chronic  stage  requires  a  difl:'erent  treatment. 
Injections  will  not  improve  the  condition.  The  only 
proper  and  satisfactory  method  is  to  expose  the 
ulcerated  or  congested  parts  by  means  of  an  endo- 
scope and  directly  apply  to  these  infected  parts  a 
solution  of  silver  nitrate,  twenty  grains  to  the  ounce, 
every  three  to  five  days  until  the  ulcers  have  healed. 
Skene's  glands  when  involved  should  be  emptied 
daily  by  pressure  from  above  downwards  on  each 
side  of  the  urethra.  If  there  is  a  chronic  diflfuse 
inflammation  about  these  tubules  they  should  be  laid 
open  in  the  direction  of  the  vagina  and  their  lining 


586 


KXOIVLES:   BROMIDE  ERUPTION  IN  CHILDHOOD. 


[New  York 
Medical  Journal. 


mucous  membrane  burned  with  either  a  silver  stick, 
carboHc  acid  followed  by  alcohol,  or  the  actual 
cautery. 

Conclusions. 

1.  All  cases  with  a  history  of  burning  and  scald- 
ing urination  should  be  thoroughly  examined  for  an 
existing  urethritis. 

2.  If  a  urethritis  is  found,  presume  it  is  of  a  gon- 
orrhoeal  origin,  if  no  foreign  body  is  present. 

3.  Institute  a  thorough  treatment  in  all  cases,  for 
if  a  cure  cannot  be  effected  complications  may  be 
prevented. 

4.  Emptoy  the  vaginal  douche  only  after  all  traces 
of  the  primary  infection  have  disappeared  and  never 
in  the  early  stages. 

2038  McCui.LOH  Street. 


UNUSUAL  CASES   OF  BROMIDE  ERUPTION  IN 
CHILDHOOD.* 

By  Frank  Crozer  Knowles,  M.  D., 
Philadelphia, 

Assistant    Dermatologist    to    the    Philadelphia    General  Hospital; 
Dermatologist  to  the  Northern  Dispensary,  the  Church  Home  for 
Children,  the  St.  Vincent's  Home;  Assistant  Dermatologist 
to  the  Dispensary  of  the  Children's  Hospital,  etc. 

The  original  idea  in  this  paper  was  to  give  a  com- 
plete statistical  review  of  bromide  eruption  in  child- 
hood, with  a  tabulation  of  all  reported  cases,  but 
the  literature  on  the  subject  was  found  to  be  so  ex- 
tensive that  it  was  decided  best  to  pick  out  only  those 
with  some  unusual  or  interesting  feature.  The  re- 
cognition of  the  many  forms  of  bromide  eruption  is 
of  extreme  importance  because  of  the  frequency 
that  the  .drug  is  administered  in  childhood.  In  sev- 
eral of  the  cases  reported  the  continued  administra- 
tion of  the  drug  after  the  appearance  of  the  erup- 
tion, because  of  the  erroneous  diagnosis  of  the 
cutaneous  condition,  has  lead  to  a  long  continued 
and  somewhat  malignant  outbreak.  The  subject 
will  be  discussed  under  the  headings  of  aetiology,  the 
dose  of  the  drug  and  the  length  of  time  required  to 
produce  the  eruption,  the  constitutional  involvement, 
the  production  of  the  eruption  by  bromine  transmit- 
ted by  the  mother's  milk,  the  various  forms  and  the 
distribution  of  the  eruption,  the  duration  of  the 
outbreak,  the  sequelae,  the  pathology,  the  prophy- 
laxis, and  the  treatment.  Thirty-seven  cases  are 
the  basis  for  the  study. 

JEtiology.  The  natural  answer  to  the  question  as  to 
the  cause  of  bromide  eruption  is,  that  it  is  due  to  the 
ingestion  of  a  bromide  compound ;  unfortunately, 
however,  the  exact  way  in  which  the  outbreak  is 
produced  is  still  unsettled.  It  has  been  suggested 
numerous  times  that  the  potassium  bromide,  and  not 
the  other  forms  of  the  drug,  was  alone  the  cause  of 
the  eruption.  In  the  case  in  this  series  reported  by 
Robison  the  sodium  bromide  was  administered,  and 
was  followed  by  a  severe  and  typical  outbreak;  in 
one  of  Elliot's  cases  also  the  eruption  was  first  pro- 
duced by  the  potassium  and  then  by  the  sodium  bro- 
mide. S.  Weir  Mitchell  produced  the  eruption  with 
the  ammonium,  the  lithium,  the  sodium,  and  the  po- 
tassium bromides,  each  having  been  administered 
•separately.  Three  principle  aetiological  theories  are 
suggested :  That  of  skin  elimination,  the  drug  acting 

•Read  before  the  Philadelphia  Pediatric  Society,  January  12,  1909. 


as  an  irritant  as  it  passes  through  the  cutaneous  tis- 
sues or  glands ;  increased  skin  elimination  due  to  the 
defective  condition  of  the  ordinary  eliminative  or- 
gans, particularly  the  kidneys.  The  neurotic  theory 
(Morrow)  is  the  suggestion  that  the  eruption  is 
due  to  the  influence  of  the  drug  upon  the  vasomotor 
centres,  the  peripheral  nerves,  or  else  purely  reflex- 
ly.  Personal  idiosyncrasy  or  susceptibility  to  drugs 
seems  in  some  unknown  way  to  be  causal  in  certain 
individuals  in  the  production  of  an  eruption.  Re- 
cently Engman  and  Mook  have  suggested  that  the 
eruption  is  produced  by  the  disturbance  of  the  gen- 
eral equilibrium  of  the  body,  the  drug  then  acting 
as  a  toxine  causes  an  inflammation  at  the  site  of 
the  past  and  present  local  disturbances,  such  as 
comedones,  acne  lesions,  seborrhoeic  lesions,  scars, 
traumata,  scratches,  etc.  Pasini  considers  the  out- 
break is  due  to  the  setting  free  of  the  bromine  from 
its  salts,  by  some  agency  in  the  blood,  and  he  sus- 
pects, on  the  bases  of  researches  made  by  Fere, 
Voisin,  and  others,  that  a  diminished  chloride  con- 
tent is  also  responsible. 

Age.  The  age  of  the  patient  does  not  seem  to 
predispose  to  the  eruption,  excepting  in  those  cases 
in  which  the  drug  had  been  improperly  adminis- 
istered ;  the  younger  the  child  the  greater  natural- 
ly is  the  susceptibility  to  the  bromide.  The  erup- 
tion appeared  in  twenty  of  these  cases  in  infants 
under  one  year  of  age ;  in  five  between  one  and  two 
years  ;  and  in  the  others  up  to  fifteen  years.  Thirteen 
of  the  cases  developed  in  the  female  sex.  ten  were 
noted  in  males,  and  in  the  others  the  sex  was  not 
specified. 

The  Quantity  of  the  Drug  and  the  Duration. 
The  quantity  of  the  .drug  and  the  length  of  time  re- 
quired to  produce  the  eruption  varied  considerably, 
probably  the  smallest  doses  and  the  least  time  elaps- 
ing before  the  appearance  of  the  outbreak,  was  in 
the  case  reported  by  Myers,  in  which  the  eruption 
appeared  in  two  days,  potassium  bromide  having 
been  given  in  two  grain  doses  every  three  hours. 
The  eruption  appeared  in  several  other  cases  in  a 
few  days  after  the  ingestion  of  small  doses  of  the 
bromide.  Myers  reported  a  case  in  which  the  erup- 
tion appeared  in  four  days,  potassium  bromide  hav- 
ing been  given  in  three  grain  doses  every  two 
hours.  In  Crocker's  case  the  outbreak  occurred  in 
two  weeks,  the  dose  of  potassium  bromide  being 
four  grains  three  times  daily.  Crocker  reported  an- 
other case  in  which  the  eruption  appeared  in  one 
month's  time,  ninety  grains  of  potassium  bromide 
having  been  administered  during  this  period.  Car- 
rington  recorded  a  case  in  which  the  eruption  ap- 
peared after  taking  the  drug  for  seven  weeks,  one 
grain  being  ingested  every  three  to  four  hours. 
The  dose  administered  in  Robison's  case  was  three 
to  five  grains  of  sodium  bromide  every  three  hours, 
the  drug  being  given  for  ten  days.  Parker's  pa- 
tient took  frequent  doses  of  two  grains  of  potassium 
bromide,  the  eruption  appeared  in  three  weeks. 
Lees's  patient  took  five  and  one  half  grains  of  po- 
tassium bromide  every  three  hours  for  two  weeks. 
In  Noyes's  case  bromides  were  given  fifteen  grains 
daily,  the  eruption  appearing  in  three  weeks.  In 
Tay  and  MacKenzie's  case  ninety  grains  of  the 
drug  was  administered,  the  outbreak  occurring  in 
ten  days.  Hutchinson  recorded  a  case  in  which 
potassium  bromide  was  given  in  two  to  si.x  grain 


March  20,  3909.] 


KNOWLES:   BROMIDE   ERUPTION  IN  CHILDHOOD. 


587 


doses  even-  four  hours,  the  eruption  being  noticed 
in  three  weeks.  Other  cases  are  recorded  in  which 
the  drug  was  administered  in  small  and  large  doses 
over  months  and  years.  In  Horrock's  case  potas- 
sium bromide  was  given  in  twenty-five  grain  doses 
twice  daily  for  six  months.  Cholmeley  reported  a 
case  in  which  potassium  bromide  was  given  in  doses 
of  eight  to  twenty-five  grains,  for  six  weeks.  In 
Xeum.ann's  case  the  eruption  appeared  in  two 
months,  potassium  bromide  having  been  given  in 
doses  of  two  to  ten  grains.  In  the  case  seen  by 
Elliot  the  eruption  appeared  in  four  months,  2,376 
grains  of  the  drug  having  been  administered.  Se- 
quin recorded  the  appearance  of  an  eruption  after 
potassium  bromide  had  been  given  in  three  to  four 
gramme  doses,  for  three  months.  In  Blackader's 
case  one  half  to  one  drachm  of  potassium  bromide 
was  given  daily  for  over  two  years.  In  the  case 
reported  by  Mitchell  potassium  bromide  was  given 
in  twenty  to  thirty  grain  doses,  three  times  daily, 
for  nine  months.  Several  other  cases  have  been 
mentioned  in  this  series  in  which  the  exact  dosage 
or  the  period  over  which  it  was  administered  were 
not  recorded  (Horrocks,  Colcott  Fox,  Harrison, 
Beevor,  Elliot,  Jackson,  Taylor,  Williams,  Graham, 
Sangster,  Amidon^. 

In  several  of  these  cases  the  drug  was  continued 
for  some  time  after  the  appearance  of  the  eruption, 
the  character  of  the  outbreak  not  being  recognized. 
In  Crocker's  case  the  bromide  was  administered 
after  the  development  of  the  eruption ;  in  the  case 
reported  by  Horrock  the  drug  was  continued  for 
three  weeks  after  the  onset  of  the  outbreak ;  in 
Lees's  case,  also,  the  medication  was  kept  up  for  a 
week  after  the  appearance  of  the  eruption. 

The  interesting  fact  was  discovered  in  a  few  of 
the  cases,  that  the  eruption  first  appeared  some 
days  or  weeks  after  the  bromide  compound  had 
been  discontinued.  Robison  recorded  an  instance 
in  which  the  outbreak  occurred  six  days  after  the 
drug  had  been  stopped ;  in  Jackson's  case  the  erup- 
tion developed  two  weeks  after  the  drug  had  been 
intermitted :  in  the  case  reported  by  Colcott  Fox  the 
exanthem  developed  two  weeks  after  the  interdic- 
tion of  the  bromide. 

Ingestion  of  a  bromide  compound  by  a  child  is 
not  the  only  cause  of  this  dermatitis  medicamen- 
tosa, the  eruption  may  be  produced  in  a  breast  fed 
infant  through  the  milk  of  the  mother;  the  mother 
eliminating  part  of  the  drug  in  this  way  to  the  det- 
riment of  the  child.  Five  cases  of  this  character 
will  be  mentioned : 

T.  Colcott  Fox  recorded  a  case  in  which  a  some- 
what generalized  eruption  developed  in  an  infant  of 
six  months,  the  cheeks,  the  arms  and  the  forearms, 
the  buttocks,  and  the  legs  were  attacked.  The  lesions 
were  from  pinhead  to  finger  nail  sized,  miliary 
pustular  on  a  solid  base,  with  some  tendency  to  con- 
fluence. Some  showed  a  papillary  hypertrophy  re- 
sembling condylomata,  others  were  somewhat  fun- 
gating  like  the  lesions  of  mycosis  fungoides,  a  few 
were  ecthymatous,  and  the  rest  ulcerative.  The 
baby  had  taken  no  medicine ;  the  mother,  however, 
had  ingested  twenty-five  grains  of  potassium  bro- 
mide daily,  for  three  months.  The  eruption  dis- 
appeared upon  stopping  the  mother's  medicine. 
Graham  Little  reported  an  eruption  in  an  infant 


of  nine  months,  the  entire  body  being  attacked  ex- 
cepting the  face,  the  legs  however  were  chiefly  in- 
volved. Large  framboesioid  tumors  were  present, 
two  and  one  half  inches  long  by  two  inches  wide, 
with  the  surface  one  quarter  inch  above  the  sur- 
rounding skin.  The  infant  had  been  given  no  med- 
icine, but  the  mother  had  taken  large  doses  of  po- 
tassium bromide  for  some  years. 

Shirley  F.  Murphy  recorded  a  bromide  eruption 
in  an  infant  of  seven  months,  the  forehead,  the 
scalp,  the  arms,  and  the  back  being  attacked.  The 
lesions  were  pinhead  to  dime  sized,  vesicular  and 
pustular  in  character.  The  infant  had  been  given 
no  medicine,  but  the  mother  had  been  taking,  inter- 
mittently, ten  grains  of  potassium  bromide  every 
three  hours.  The  eruption  disappeared  on  the  in- 
fant, during  the  intervals,  when  the  mother  was 
without  medicine. 

Tilbury  Fox  reported  an  eruption  in  an  infant  of 
three  months,  the  general  cutaneous  surface  was  in- 
volved, excepting  the  face  and  the  hands.  The  le- 
sions were  pinhead  to  almond  size,  dull  red,  and 
studded  with  minute  openings  beneath  a  superficial 
layer  of  cuticle.  Some  of  the  lesions  were  speckled 
from,  the  escape  of  milky  sebum.  The  baby  had  re- 
ceived no  medication,  the  mother  however  had 
taken  bromide  for  almost  two  years  for  epilepsy. 

The  case  recorded  by  Abraham  occurred  in  a 
nursing  infant,  no  age  being  given ;  the  distribution 
was  also  not  mentioned.  The  lesions  consisted  of 
multilocular  pustules  on  an  inflammatory  base,  re- 
sembling vaccine  vesicles,  some  were  of  large  size. 
The  infant  in  this  case  also  had  received  no  inter- 
nal treatment ;  the  mother,  however,  had  been  tak- 
ing bromides. 

Constitutional  involvement  resulting  from  the  in- 
gestion of  the  bromide  was  noticed  in  but  two 
cases ;  in  the  case  described  by  Graham  the  erup- 
tion was  preceded  by  fever ;  in  Cholmeley  case  there 
was  fever,  malaise,  pain  in  the  head  and  generally, 
and  the  patient  was  confined  to  bed.  The  skin  be- 
tween the  lesions  was  inflamed  and  tender. 

Various  Characteristics  of  tlic  Eruption.  The 
most  usual  type  of  eruption  is  the  acne  form  (Bed- 
ford Brown,  Pinsker,  Gowers),  this  form  is  no- 
ticed more  frequently  in  adults  than  in  children. 
Most  cases  consist  of  a  multiform  eruption  with  a 
predominance  of  one  type.  The  following  types  of 
eruption  have  been  reported:  The  varicellalike  CTay 
and  MacKenzie,  Myers,  Colcott  Fox,  Beevor,  Rob- 
ison, Cholmeley)  ;  the  ecthymatous  (Tay  and  Mac- 
Kenzie, Horrocks,  Myers,  Colcott  Fox,  Cholmeley, 
Lees,  Crocker,  Neumann.  Elliot,  Sangster)  ;  the 
erythema  nodosum  type  (Horrocks)  ;  the  rasp- 
berrylike (Myers,  Colcott  Fox,  Parker)  ;  the 
bullous  or  pemphigiislike  (Horrocks,  Graham,  Col- 
cott Fox)  ;  the  squamous  (Horrocks)  ;  the  papillo- 
matous (Colcott  Fox,  Parker,  Cholmeley,  Lees, 
Neumann,  Jackson,  Crocker,  Taylor,  Blackader. 
Noyes,  Graham,  .Sequin)  ;  the  anthracoid  and  the 
carbuncular  (Colcott  Fox,  Harrison)  ;  the  tuber- 
cular and  the  tuberose  forms  (Colcott  Fox,  Hutch- 
inson, Noyes)  ;  the  condylomalike  (Beevor)  ;  the 
confluent  acne  or  pustular  type  (Cholmeley,  Elliot, 
Myers,  Crocker)  ;  the  unbilicated  or  the  molluscum 
contagiosa  type  (Noyes,  Graham,  Jackson)  ;  the 
f ungating  and  the  mycosis  fungoides  type  (Noyes, 


588 


KNOWLES:    BROMIDE   ERUPTION  IN  CHILDHOOD. 


[New  York 
Medical  Journal. 


Elliot)  :  the  rupiallike  f  S.  Weir  Mitchell)  ;  and  the 
ulcerative  types,  including  the  ''ulcus  elevatum"  de- 
scribed by  Sequin  (S.  Weir  IMitchell,  Sequin,  Ami- 
don,  Jackson). 

Site  of  Eruption.  The  initial  site  of  the  eruption 
has  been  recorded  in  but  three  of  the  cases,  upon 
both  legs  in  one  case  (Horrocks),  on  the  right  leg 
in  another  case  (Horrocks),  and  on  the  vaccination 
scar  in  the  third  (Crocker). 

In  the  fully  developed  attack  the  lesions  were  dis- 
tributed generally,  on  the  legs,  the  arms,  the  trunk, 
and  the  head,  in  but  six  of  the  cases  (Colcott  Fox, 
Jackson,  Robison,  Elliot,  Crocker)  ;  the  distribution 
was  general  excepting  the  trunk  and  the  arms  in 
seven  cases  (Myers,  Carrington.  Cholmeley, 
Hutchinson,  Taylor,  Graham)  ;  the  face,  the  arms, 
and  the  legs  were  involved  in  three  cases  (Colcott 
Fox,  Elliot,  Neumann)  ;  the  arms  and  the  legs  were 
alone  attacked  in  six  cases  (Horrocks,  Noyes, 
Blackader,  Tay  and  MacKenzie)  ;  the  cheek,  the 
arm,  and  the  nates  were  attacked  in  one  case 
(Parker)  ;  the  legs  were  alone  involved  in  four 
cases  (Sequin,  Harrison,  Sangster,  Amidon)  ;  the 
face  alone  was  attacked  in  one  case  (Williams)  ; 
the  trunk  was  the  only  part  involved  in  another 
case  (Graham)  ;  the  face,  the  forearm,  and  the  neck 
were  attacked  also  in  another  case  (Lees).  The 
mucous  membrane  of  the  tongue  was  attacked  in 
one  case,  by  a  lesion  similar  to  those  on  the  cuta- 
neous surface  (Myers).  In  Crocker's  case  there 
was  a  tendency  to  a  symmetrical  arrangement  of  the 
lesions.  There  was  very  little  itching  or  other  sub- 
jective symptoms  in  the  cases. 

Duration  of  Eruption.  Before  taking  up  the 
duration  of  the  eruption,  the  interesting  fact  should 
be  mentioned  that  in  several  of  the  cases  the  erup- 
tion continued  to  appear  for  some  days  or  weeks 
after  the  drug  was  discontinued,  even  reaching  the 
height  after  the  stoppage  of  the  medication.  In 
Hutchinson's  case  the  lesions  appeared  for  some 
days  after  stopping  the  drug ;  in  the  one  reported  by 
Graham,  new  outbreaks  were  noted  for  a  week  after 
the  bromide  had  been  stopped ;  in  Tay  and  Mac- 
Kenzie's  case  fresh  lesions  appeared  for  two  weeks ; 
Horrocks  recorded  the  appearance  of  new  lesions 
for  some  time  after  the  bromide  had  been  discon- 
tinued ;  in  a  case  reported  by  Myers  the  eruption 
did  not  reach  its  height  until  eleven  days  after  the 
drug  had  been  stopped,  fresh  lesions  appeared  for 
four  weeks ;  Myers  recorded  another  case  in  which 
the  eruption  continued  to  appear  for  three  and  one 
half  months  after  stopping  the  drug;  Crocker  re- 
ported a  case  in  which  most  of  the  eruption  ap- 
peared after  the  drug  had  been  discontinued,  new 
lesions  appeared  for  several  months. 

Bromide  eruption  has  lasted  from  a  few  weeks 
to  many  months,  in  Tay  and  MacKenzie's  case  the 
duration  was  eight  weeks ;  in  Horrocks's  case  a  few 
weeks ;  in  one  of  Myers'  cases  ten  weeks,  and  in 
the  other  some  months ;  Carrington 's  case  persisted 
for  some  weeks ;  the  eruption  in  Cholmeley's  patient 
continued  for  seven  weeks;  one  of  Crocker's  cases 
lasted  for  some  months,  and  the  other  for  three 
months ;  the  outbreak  in  Neumann's  lasted  for  four 
weeks ;  Blackader's  had  a  duration  of  some  months ; 
Williams'  continued  for  six  weeks ;  Noyes's  lasted 


for  two  weeks ;  Graham's  two  cases  lasted  for  four 
and  ten  weeks  respectivelv. 

Seqnclcc.  .Sequelae  such  as  pigmentation,  scar- 
ring, and  desquamation  have  been  recorded  in  some 
of  the  cases.  Pigmentation  has  been  reported  in 
eight  of  the  cases  (Horrocks,  Myers,  Carrington, 
Parker,  Elliot,  Crocker,  Graham)  ;  scarring  was 
noted  in  two  cases  f  Taylor,  Blackader)  ;  desquam- 
ation in  one  case  (Horrocks). 

Pathology.  In  past  years  the  pathological  findings 
in  the  eruptions  caused  by  the  ingestion  of  bromide 
varied  considerably,  but  the  papers  recently  written 
on  this  subject  differ  in  only  minor  details.  Among 
the  older  writers  on  this  subject  are  Tay  and  Mac- 
Kenzie, Sequin,  and  Fox  and  Gibbes.  The  papers 
most  recently  written  are  by  Engman  and  Mook,. 
and  Pasini,  who  practically  agree  in  their  histopath- 
ological  examinations  of  the  various  lesions  of  bro- 
mide eruption.  According  to  Engman  and  Mook 
inflammatory  changes  first  occur  about  the  bloodves- 
sels and  in  the  connective  tissue,  and  secondarily  the 
glands  and  the  follicles  of  the  skin  are  involved  in 
the  pathological  changes.  The  gross  histological 
changes  in  the  skin  consist  in  different  degrees  of  in- 
flammation, from  slight  changes  about  the  vessels  to 
destructive  abscess  formation  and  progressive  death 
of  tissue.  The  minute  histological  changes  may  be 
classed  in  the  following  stages :  First,  increase  of 
connective  tissue  cells  about  the  vessels  ;  second,  ap- 
pearance of  lymphoidlike  cells  about  the  vessels : 
third,  addition  to  the  cells  of  trifold  leucocytes  with 
a  granular  appearance  of  collagen  and  vacuolation 
of  fixed  connective  tissue  cells ;  fourth,  local  increase 
of  all  of  these  phenomena  and  the  formation  of  an  ab- 
scess. Pasini  agrees  with  these  pathological  changes 
as  described  by  Engman  and  Mook,  he,  however, 
says  that  he  has  demonstrated  in  certain  of  the  con- 
nective tissue  cells  in  the  walls  of  the  capillaries, 
which  he  proposes  to  call  "ecumophagocytaires,"  in 
translation  of  " Schaumpliagocyten ,"  the  property  of 
ingesting  leucocytes  and  exerting  phagocytic  action, 
which  he  considers  as  so  far  pathognomonic  of  bro- 
mide eruption.  Guttmann  was  the  first  to  call  atten- 
tion to  the  fact  that  bromine  may  be  detected  in  the 
contents,  of  the  lesions  caused  by  the  ingestion  of  a 
bromide  compound.  Pasini  has  recently  been  un- 
able to  verify  this  finding,  he  demonstrated  by  a  lab- 
oratory test  that  bromine  enters  into  combination 
with  albumin  and  is  then  undetectable  by  the  ordi- 
nary methods  for  establishing  its  presence. 

Prophylaxis  and  Treatment.  Naturally  the  best 
way  to  prevent  an  eruption  is  to  administer  the  bro- 
mides in  as  small  doses  and  over  as  short  a  time  as 
is  possible  ;  in  certain  diseases,  however,  such  as  epi- 
lepsy the  drug  is  demanded  in  large  doses  over  long 
periods.  Even  the  short  administration  in  small 
doses  and  during  but  a  short  period  has  not  prevent- 
ed an  eruption,  in  those  who  are  susceptible  to  the 
drug.  Probably  the  best  prophylactic  measure  to  be 
carried  out,  with  those  who  are  compelled  to  take 
the  drug  over  long  periods,  is  the  adding  of  Fowl- 
er's solution  or  some  other  form  of  arsenic  to  the 
bromide  prescription.  A  few  cases  have  been  re- 
corded in  which  the  eruption  has  disappeared,  after 
adding  an  arsenical  preparation  to  the  previously 
used  bromide  mixture  (Horrocks).     Dr.  Hartzelt 


March  20,  3909.] 


KXOU  LES:    BROMIDE   ERUPTION  IN  CEIILDEIOOD. 


589 


and  I  had  an  almost  entire  disappearance  of  a  severe 
bromide  acne,  by  the  adding,  in  one  case,  of  Fowl- 
er's solution  to  a  bromide  mixture  that  an  epileptic 
was  compelled  to  take.  As  to  the  treatment  of  the 
eruption  itself,  any  mild  antiseptic  lotion  or  salve 
will  be  a  sufficient  local  precaution,  a  diuretic  such 
as  potassium  citrate  will  be  of  use,  but  first  and  fore- 
most stop,  if  possible,  the  bromide.  Several  cases 
have  been  reported  in  which  the  eruption  rapidly 
disappeared  imder  local  antiseptic  treatment  and  the 
administration  of  arsenic  internally  ( Gowers.  Sang- 
ster,  Carrington). 

During  the  last  two  years  it  has  been  my  good 
fortune  to  have  had  the  direct  or  indirect  care  of 
four  cases  of  bromide  eruption,  of  an  unusual  type. 
Two  of  these  cases  were  seen  in  the  dermatological 
clinic  of  the  Children's  Hospital :  one  in  the  derma- 
tological clinic  of  the  Pennsylvania  Hospital ;  and 
one  in  the  dermatological  clinic  of  the  Northern  Dis- 
pensary. 

Case  I. — The  first  patient  was  admitted  to  the  medical 
ward  of  the  Children's  Hospital  in  June  of  1906 :  the  pa- 
tient was  a  boy  of  three  years,  and  had  typhoid  fever. 
During  the  course  of  his  illness  potassium  bromide  was 
given  in  small  doses  and  for  only  a  few  days,  sixty  grains 
in  all  being  administered.  One  week  after  stopping  the 
drug  the  present  eruption  appeared,  fresh  outbreaks  oc- 
curring for  three  weeks.  The  lesions  were  chiefly  on  the 
legs  and  buttocks,  with  a  few  on  the  lower  portion  of  the 
iiack:  varicellalike  vesicles  first  appeared,  pinhead  in  size, 
which  enlarged  and  became  of  an  impetigenous  aspect. 
Some  of  the  lesions  were  sharply  defined,  flat,  hard,  and 
pustuliform.  with  a  central  cone  and  satellites  of  small 
pustules;  a  bloody  crust  formed  on  rupturing  the  lesions. 
The  lesions  were  pinhead.  pea.  and  dime  in  size.  The  case 
was  seen  on  several  occasions  in  the  skin  dispensan-  of 
the  Children's  Hospital,  the  child  made  an  uneventful  re- 
cover}" from  the  eruption,  pigmentation  remained,  how- 
ever, for  some  weeks  on  the  sites  of  the  former  lesions. 

Case  II. — The  second  patient  came  to  the  medical  dis- 
pensary of  the  Children's  Hospital  on  August  10,  1906, 
liie  patient  was  a  girl  of  five  years,  and  had  pertussis.  In 
the  medical  dispensary-,  the  tongue  was  found  to  be  coated, 
moist  rales  were  auscultated  in  both  lungs,  a  temperature 
of  100°  F.  was  discovered,  and  a  history  was  given  of 
persistent  cough  for  five  weeks,  and  of  whooping  for  two 
weeks.  The  patienr  was  given  a  prescription  of  five  grain? 
of  sodium  bromide  and  two  drops  of  tincture  of  bella- 
donna, to  he  given  three  or  four  times  daily;  on  the 
twenty-seventh  of  August  the  sodium  bromide  was  in- 
creased to  six  grains  at  a  dose,  and  this  dosage  was  ad- 
ministered imtil  the  eighth  of  October.  One  week  before 
the  drug  was  discontinued  the  eruption  appeared,  on  Oc- 
tober the  tenth  the  case  was  referred  to  the  skin  dispen- 
sarj-  of  the  Children's  Hospital.  There  were  about  three 
dozen  lesions  in  all,  and  the  legs  and  the  left  thigh  were 
the  parts  chiefly  attacked.  The  smallest  lesion  was  a  pin- 
head sized  pustule,  as  the  lesions  grew  larger  they  became 
•omewhat  tubercular,  pea  sized  and  larger,  multilocular, 
and  exuded  drops  of  a  smegmalike  substance.  The  largest 
lesion  was  one  half  dollar  in  size,  raised,  with  an  inflam- 
matory areolar,  it  was  composed  of  small  superficial  pus- 
tules, which  tended  to  break  open,  the.  surface  was  fungat- 
ir.g  in  character  and  covered  with  a  cheesy  excretion, 
slightly  tinged  with  blood.  There  was  a  quarter  dollar 
sized  lesion  on  the  left  upper  leg.  with  a  raised  and  sharply 
marginared  surface.  With  the  exception  of  these  two  large 
legions,  the  most  of  the  eruption  was  pea  size.  There  were 
lesions  also  on  the  right  wrist  and  on  the  vaccination  scar 
<in  the  left  upper  arm.  The  lesion  on  the  right  lower  leg 
had  a  crateriform.  center,  from  which  exuded  a  cheesy 
niaterial.  Most  of  the  lesions  had  numerous  minute  open- 
ings on  their  summit,  some  had  a  large  drop  of  cheesy  pus 
exuding  from  the  central  opening:  most  of  the  lesions  had 
an  infl.in.matory  areolar.  New  lesions  continued  to  appear 
for  a  week  after  the  bromide  had  been  stopped;  the  erup- 
tion disappeared  in  six  weeks  time ;  the  pigmentation  lasted 
for  some  time  longer. 


Case  HI. — The  third  patient  came  to  the  skin  dispen- 
sary of  the  Pennsylvania  Hospital,  in  January  1908,  the 
patient  was  a  girl,  thirteen  years  of  age,  and  she  had  been 
born  in  Russia,  of  Jewish  parents.  For  quite  a  number 
of  years  the  patient  had  had  frequent  epileptic  attacks,  fo' 
which  she  had  been  taking  the  present  drug,  with  some 
amelioration  in  the  severity  and  the  frequency  of  the  seiz- 
ures. The  history  was  unfortunately  exceedingly  hard  to 
obtain  because  of  the  dialect  of  the  parents  and  the  child, 
the  present  eruption  had  apparently  been  out  for  about  six 
months,  the  medicine  having  been  constantly  taken  during 
this  period.  The  lesions  were  limited  to  the  lower  part  o: 
the  legs,  the  ankles,  and  the  dorsal  surface  of  the  right 
foot ;  there  were  six  lesions  in  all  from  silver  dollar  to 
palm  sized.  On  the  anterior  surface  of  the  right  lower 
leg  there  was  a  palm  sized,  raised,  sharply  marginate. 
papillomatous,  reddish  brown  with  some  whitish  points, 
crusted  and  oozing  lesion,  with  numerous  miliary  abscess - 
like  openings  on  the  surface ;  a  cheesy,  smegmalike  material 
exuded  from  these  openings.  On  the  posterior  surface  of 
the  lower  leg  there  were  two  other  lesions,  silver  dollar 
in  size,  with  the  same  fungating,  cauliflowerlike,  appear- 
ance. On  the  inner  side  of  the  externa!  malleolus  of  the 
left  foot  there  was  another  silver  dollar  sized,  mycosis 
fungoidlike,  lesion.  Two  other  lesions  were  found  on 
the  anterior  surface  of  the  right  lower  leg  and  the  dorsal 
surface  of  the  right  foot,  of  the  same  size  and  with  the 
same  characteristics,  which  had  flattened  down  somewhat 
and  were  apparently  undergoing  involution.  Pigment 
marks  and  a  few  superficial  scars  were  found  on  these 
same  areas,  where  lesions  had  formerly  occurred.  The 
lesions  disappeared  on  stopping  the  drug,  but  reappeared 
when  it  was  again  given. 

Case  IV. — The  fourth  patient  came  to  the  skin  dispen- 
sarj-  of  the  Northern  Dispensary,  on  January  28.  1908 : 
the  patient  was  an  infant  of  five  months,  and  the  outbreak 
had  occurred  at  three  months  of  age.  The  infant  was  the 
first  child  of  a  j-oung  and  absolutely  inexperienced  mother, 
who  became  so  tired  of  hearing  the  constant  crying  of  th>. 
little  girl  that  she  began  to  give  anody-ne  treatment.  Prac- 
tically any  patent  medicine  with  an  advertised  soothing 
influence  was  administered,  this  form  of  treatment  being 
begun  when  the  infant  was  but  a  few  weeks  old.  After 
some  weeks  administration  of  these  various  "quack''  prep- 
arations, the  baby  became  very  irritable  and  peevish,  and 
the  present  eruption  appeared  ;  the  mother,  however,  con- 
tinued to  give  these  m.edicines  in  larger  doses  than  before 
because  of  the  peevishness  of  the  child.  The  eruption  became 
progressively  worse  and  after  two  months  of  inactivity- 
the  mother  finally  brought  the  baby  to  the  Northern  Dis- 
pensary. The  eruption  w-is  chiefly  noted  on  the  cheeks, 
although  discrete  lesions  were  also  found  on  the  forehead, 
the  scalp,  the  neck,  the  upper  arms,  and  a  few  on  the  trunk. 
The  outbreak  started  as  a  varicellalike  vesicle,  pinhead  in 
size,  which  tended  to  become  pea  sized,  the  contents  became 
cloudy,  large  patches  being  formed  by  a  confluence  of  these 
vesicopustules.  Some  of  the  lesions  had  a  typical  rasp- 
berrj-like  appearance,  some  were  multilocular.  with  the 
same  cheesy  excretion  as  in  the  other  cases,  they  were 
raised,  sharply  marginate,  and  some  had  an  inflammatory 
areolar.  Two  silver  dollar  sized  patches  were  noted  on  the 
cheeks,  caused  by  the  confluence  of  the  smaller  lesions, 
these  areas^  were  sharply  marginate,  with  a  papillomatous 
surface.  New  lesions  continued  to  appear  for  some  weeks 
after  the  stoppage  of  the  drug. 

Bromine  is  chiefly  eliminated  by  the  urinary  tract, 
in  Lees's  case  it  was  found  in  the  urine.  It  niay  also 
be  given  off  in  the  milk  of  the  nursing  mother,  as  in 
the  cases  cited  and  also  in  the  one  reported  by 
Thompson.  Bromine  has  also  been  found  in  the 
cerebral  tissue  of  an  epileptic,  who  died  seven  davs 
after  he  had  taken  the  last  dose  of  potassium  bro- 
mide (Echeverria).  MacDonald  has  detected  evi- 
dences of  bromine  in  the  urine  of  epileptics,  ten  and 
twelve  days  after  they  had  stopped  using  potassium 
bromide.  The  eliniination  is  more  active  in  the  urine 
secreted  after  meals  or  after  prolonged  e.xercise. 
Xamias  (Hale  and  Fishburn )  pointed  out  that  re- 
peated doses  of  the  bromides  delay  their  elimination 
greatly.     Simankowsky  found  traces  of  bromine  in 


590 


JOHNSTON-SCHWARTZ:  METABOLISM  OF  SKIN  DISORDERS. 


[New  York 
Medical  Journal. 


the  urine  of  a  dog,  four  months  after  fift^'-three 
grammes  of  sodium  bromide  had  been  given  in  di- 
vided doses.  Hale  and  Fishburn  gave  a  student  two 
grammes  of  sodium  bromide  in  one  dose,  traces  of 
bromine  -wtrt  found  in  the  urine  for  fifty-six  days ; 
only  39.7  per  cent,  of  the  drug  was  eliminated  by 
the  urine  during  this  period,  showing  the  large 
amount  stored  in  the  body  or  excreted  in  other  chan- 
nels. Other  forms  of  the  bromide  were  experiment- 
ally used  with  practically  the  same  result.  The  few 
articles  cited  prove  the  slow  elimination  of  bromine. 
An  interesting  point  to  be  emphasized  is,  that  the 
local  eruptive  phenomena  are  prone  to  occur  at  points 
of  previous  inflammation,  such  as  about  comedones, 
acne  lesions,  seborrhoeic  lesions,  scars,  traumata, 
scratches,  etc.  (Engman  and  Mook).  Vaccination 
scars  frequently  show  marked  involvement  as  in  the 
cases  reported  by  Parker,  and  myself ;  in  one  of 
Crocker's  cases  the  vaccination  scar  was  the  initial 
site  of  the  outbreak.  In  a  case  reported  by  Crocker 
a  lesion  formed  on  the  site  of  an  old  burn ;  in  Harri- 
son's case  a  lesion  developed  on  the  area  injured  by 
a  kick. 

Summary,  (i)  Bromide  eruption  may  occur  in 
those  who  are  susceptible,  independent  of  the  dose 
of  the  drug  or  the  length  of  the  administration.  The 
larger  the  dosage,  and  the  longer  the  ingestion,  the 
greater  is  the  chance  of  an  outbreak. 

(2)  There  are  practically  no  constitutional  or  sub- 
jective symptoms  in  most  cases. 

(3)  Because  of  the  slow  elimination,  the  eruption 
may  continue  to  appear  for  some  weeks  after  the 
drug  has  been  discontinued. 

(4)  Almost  any  type  of  eruption  may  be  present; 
in  childhood  the  lesions  are  usually  larger  and  more 
persistent  than  in  adult  life.  The  extremities  and 
the  face  are  the  parts  most  frequently  attacked ;  the 
most  extensive  eruption,  in  the  majority  of  the  cases, 
occurs  upon  the  legs. 

(5)  Lesions  have  a  great  tendency  to  occur  at 
points  of  previous  inflammation,  such  as  on  vaccina- 
tion scars,  injuries,  etc. 

In  closing  I  wish  to  express  my  thanks  to  Dr. 
Arthur  VanHarlingen,  for  the  privilege  of  reporting 
two  of  the  cases,  and  to  Dr.  Charles  N.  Davis  for  the 
courtesy  of  a  case. 

References. 

Abraham.  The  British  Journal  of  Dermatology,  igoz, 
p.  471. 

Amidon.    Medical  Record,  1886.  p.  469. 

Bedford  Brown.  The  Philadelphia  Medical  and  Surgical 
Reporter,  1873,  p.  iii. 

Beevor.    The  British  Medical  Journal.  1889,  p.  890. 

Blackader.    The  Medical  Nezv's,  1887,  i,  p.  221. 

Crocker.  Transactions  of  the  Pathological  Society  of 
London,  1878,  p.  252.  The  Illustrated  Medical  Neivs,  1889, 
ii,  p.  25. 

Carrington.  Abstract,  The  Journal  of  Cutaneous  and 
Venereal  Diseases,  1885,  p.  184. 

Cholmeley.  Transactions  of  the  Clinical  Society  of  Lon- 
don, 1870,  p.  38. 

Echeverria.   The  Medical  Times,  1872,  p.  115. 

Elliot.   Medical  Record.  1895,  P-  622. 

Engman  and  Mook.  The  Journal  of  Cutaneous  Diseases, 
1906,  p.  502. 

T.  Colcott  Fox.  The  British  Journal  of  Dermatology, 
1892,  p.  287. 

Tilbury  Fox.    The  Lancet,  1874,      P-  657. 

Fox  and  Gihlic;.  The  London  Medical  Society  Proceed- 
in  iss.  1S-S6,  p.  51. 

Gowers.   The  Lancet,  1878,  I,  p.  866. 


Guttman.  Virchozv's  Archiv,  LXXIV,  p.  541,  1878.  Vier- 
tcljahresschrift  fiir  Dcrmatologie  und  Syphilis,  1S79,  p.  369. 

Grahan;.    The  Canadian  Practitioner,  1889,  p.  407. 

Hale  and  Fishman.  The  American  Journal  of  Physiol- 
ogy, June,  1908,  p.  32. 

Harrison.  Ilie  British  Journal  of  Dermatology,  1901, 
p.  178. 

Hutchinson.  The  Medical  Press  and  Circular,  1894,  p. 
325- 

Horrocks.  Transactions  of  the  Pathological  Society  of 
London,  1883,  p.  272. 

Jackson.  The  Journal  of  Cutaneous  and  Genitourinary 
Diseases,  1895,  p.  462. 

Graham  Little.  The  British  Journal  of  Dermatology, 
1908,  p.  135. 

Lees.  Transactions  of  the  Pathological  Society  of  Lon- 
don, 1877,  p.  247.    The  Lancet,  1877,  I,  P-  839. 

Alurphy.  Transactions  of  the  Clinical  Society  of  Lon- 
don, 1888,  p.  293. 

Morrow.    Drug  Eruptions,  New  York.  1887,  p.  85. 

Myers.  The  Journal  of  Cutaneous  Diseases,  1904,  p.  231. 
Ibidem,  1906,  p.  271. 

S.  Weir  Mitchell.  American  Journal  of  the  Medical 
Sciences,  1870,  p.  440.  Transactions  of  the  College  of  Physi- 
cians of  Philadelphia,  1870,  p.  347. 

MacDonald.  Quoted  by  Echeverria,  The  Medical  Times. 
1872,  p.  115. 

Neumann.  _  Archiv  fiir  Dcrmatologie  and  Syphilis,  1873, 
5>  P-  555-    Virchow-Hirsch,  Jahresbericht,  1873,  p.  357. 

Noyes.    Australian  Medical  Journal.  1890,  p.  164" 

Namias.  Quoted  by  Hale  and  Fishman,  American  Jour- 
nal of  Physiology,  June,  1908,  p.  32. 

Pinsker.    The  London  Medical  Record,  1876.  p.  559. 

Pasini.  Annales  de  dcrmatologie  et  de  syphilographie, 
January,  1906,  p.  i. 

Parker.  Transactions  of  the  Clinical  Societv  of  London, 
1879,  p.  199. 

Robison.    The  Medical  Register,  1888.  p.  223. 

Simankowsky.    Quoted  by  Hale  and  Fishman. 

Sequin.    Archives  of  Medicine,  1882,  p.  149. 

Sangster.    The  Medical  Times  and  Gazette.  1885,  p.  312. 

Thompson.  Quoted  by  Abraham,  The  British  Journal  of 
Dermatology,  1902,  p.  471. 

Tay  and  MacKenzie.  Transactions  of  the  Pathological 
Society  of  London,  1884,  p.  400. 

Taylor.  The  Journal  of  Cutaneous  and  Genitourinary 
Diseases,  1891,  p.  441. 

Williams.  The  British  Journal  of  Dermatology,  1894, 
p.  251. 

•    332  South  Seventeenth  vStreet. 


STUDIES   IN   THE    METABOLISM   OF  CERTAIN 
SKIN  DISORDERS. 
By  James  C.  Johnstox,  M.  D., 
New  York, 

.Assistant  Professor  of  Dermatology,  Cornell  University  Medical 
College, 

and  Hans  J.  Schwartz.  M.  D., 
New  York, 

Clinical  Instructor  in  Dermati  lOgy,  Cornell  University  Medical 
Col!eRe. 

(Coiitiiiucci  from  page  ^40.) 
GROUP  XL 

BULLOUS  DISEASE. 

Case  V. — Diagnosis:  Dermatitis  lierpetiformis. 

Pas!  History:  Erysipelas  twelve  years  ago.  Gonorrhoea 
three  times.  Alcohol,  tobacco,  tea,  and  coffee  used  mod- 
erately. Never  any  eruption  on  body  before  present  ill- 
ness started.  No  headaches,  malaria,  or  rheumatism.  Ap- 
petite and  digestion  good.    Bowels  regular. 

History  of  Present  Illness:  In  past  year  patient  had  been 
subject  at  irregular  intervals  to  recurring  attacks  of  water 
blisters  seated  on  reddened  base,  preceded  and  accompanied 
by  severe  burning  and  itching.  Tlie  patches  came  out  here 
and  there  over  the  body,  so  that  he  had  never  been  entirely 
free  from  disease  since  it  started. 

Present  Condition:  Rather  poorly  nourished,  mucous 
membranes  a  little  pale,  tongue  clean.  Pulse  78,  regular, 
normal  volume  and  tension.    Heart,  lungs,  liver,  spleen, 


March  20,  .909.]  JOHXSTOX-SCHWARTZ:  METABOLISM  OF  SKIX  DISORDERS. 


and  abdomen  negative.  Skin :  Eruption  was  seen  on  dorsal 
surfaces  of  hands,  front  of  neck,  over  shoulders  and  scap- 
ula, over  sacrum,  anterior  surfaces  of  thighs  and  legs,  and 
inner  aspect  of  knees.  The  eruption  was  polymorphous, 
consisting  in  places  of  erythematous  patches,  in  others  of 
grouped  vesicles  on  erythematous  base,  and  here  and  there 
a  few  bean  sized  bullae,  especially  on  the  forearms.  In 
some  places  where  the  eruption  was  older  the  vesicles  had 
broken,  leaving  reddened  and  infiltrated  patches,  and  in 
still  other  places  pigmentation. 

Blood:  Hsemoglobin.  80  per  cent.  Red  blood  cells,  7.376,- 
000.  Index,  0.54.  White  blood  cells,  14,000.  Red  cells, 
normal.  Parasites,  none  found.  Blood  plates,  moderate 
number. 

Differential  count  of  300  white  cells : 

Polynuclears    74.6 

Lymphocytes    13.4 

Large  mononuclears    6.4 

Transitionals    0.4 

Eosinophiles    2.6 

Mast  cells    2.6 

^Myelocj'tes    o 

Patient  consented  to  bring  twenty-four  hour  specimen  of 
urine  for  examination  before  any  medication  was  given  and 
without  making  any  change  in  his  mode  of  living,  diet,  etc. 
The  results  of  the  examinations  of  these  specimens  follow, 
as  given  in  table : 

September  13,  1906.    Eruption  practically  unchanged. 


August  21,  1907.  Patient  was  not  seen  again  till  this  date 
when  he  came  in  response  to  a  note  sent  him.  He  reported 
that  since  his  last  visit  he  had  recurring  attacks  in  above 
localities  almost  every  day.  About  two  months  ago  he 
started  taking  arsenic  and  since  that  time  he  had  had  no 
new  outbreaks.  Appetite,  digestion,  and  bowels  normal. 
Skin  was  clear,  except  for  slight  scaling,  thickening,  and 
pigmentation  at  site  of  previous  eruptions.  The  urine  was 
examined  three  times  and  it  will  be  noted  that  the  partition 
had  returned  to  within  the  normal  limits. 

C\s^.Yl.— Diagnosis :  Dermatitis  herpetiformis.  Syphilis. 

A  woman,  aged  forty-tive,  occupation  chambermaid.  Had 
severe  headaches  and  sore  throat  fifteen  to  sixteen  years 
ago,  otherwise  has  always  been  in  fair  health.  Digestion 
always  good  till  two  years  ago ;  she  could  eat  anything 
without  discomfort.  Used  always  to  eat  sweet  things  and 
drank  tea  to  excess.  For  past  two  years  digestion  had  been 
very  poor  and  her  main  diet  had  been  bread,  coffee,  and  tea. 
Alcohol  used  in  moderation.  Bov.els  costive.  Menopause 
■oegan  June,  1907.  Patient  had  been  married,  had  one  full 
term  child  who  died  at  age  of  eight  from  scarlatina  and 
had  always  been  healthy  previously.  Xo  miscarriages. 
Patient  was  a  poorly  nourished  woman  of  neurotic  type, 
subcutaneous  tissue  scanty,  mucous  membranes  rather  pale, 
tongue  coated.  Heart,  lungs,  spleen,  liver,  and  abdomen 
negative. 

On  skm  an  eruption  was  seen  occupying  the  flexor  sur- 
face of  arms  and  elbows,  in  axillse.  over  sternum.  There 
was  an  extensive  confluent  area  covering  lower  abdomen. 


u 

Z  £Z 

z  t  ■ 

liiiii) 
anitn 
N. 

% 

■J 

z. 

^  ^ ,  • 

I  a;- 

—  X  =  S 

r. 

■r. 

Z  aS^ 

—  kE' 

«<     cc  V- 

1906. 

Sept.  6 

■ .  650 

1.02S 

acid 

0 

0 

0 

7.91 

6.15 

0.28 

0.1 1 

0.47 

0.84 

Few  squam- 

77P 

3.6 

6.0 

10.7 

ous  cells. 

1.02S 

acid 

0 

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9.62 

0.69 

0.30 

0.59 

l.IO 

Do. 

Sept.  >3  

77-9 

5-6 

2-5 

4.8 

8.9 

••  1340 

1.023 

acid 

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0 

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12.27 

0.59 

0-59 

0.25 

0.69 

i.i  I 

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acid 

9.46 

78., 

4.8 

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1.022 

0 

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0.48 

0.17 

0.50 

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Do. 

Oct.  I  

61. Q 

5-1 

1-9 

5-30 

25.6 

Cf.  history- 

. .  950 

1.020 

acid 

0 

0 

0 

7.6 

0.82 

0.12 

0.44 

0.94 

Do. 

Oct.  24 

69. 1 

10.8 

1.6 

3-8 

12.4 

..  IOI5 

1.024 

.'cid 

0 

0 

0 

-r  + 

9-9 

7.29 
73.7 

0-55 
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0.19 
1-95 

0.32 
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131 

Do. 

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. .  1300 

1.021 

acid 

0 

0 

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4- 

10.48 

7-97 
76.1 

0.52 
50 

0.23 

0.73 
7.0 

0.97 

9-3 

Aug.  26  

. .  1500 

1. 015 

acid 

0 

0 

0 

-j- 

10.75 

8.44 

0.81 

0.22 

0.62 

0.61 

78.6 

7.6 

2. 1 

5.S 

5.6 

-Sept.  3.".... 

. .  1240 

1.023 

acid 

0 

0 

0 

-1- 

C.\ 

1 1. 00 
SE  V. 

9.0 
81.9 

0.2S 
2.6 

0.22 
2.0 

0.64 
5-9 

0.81 
7-4 

Treatment  consisted  of  the  application  of  calamine  and 
zinc  oxide  locally :  internally,  sodium  phosphate,  i  drachm, 
every  morning :  restriction  of  proteid  diet,  and  the  follow- 
ing prescription : 

B     Sodium  salicylate  5vss; 

Pulverized  rhubarb  5j : 

Sodium  bicarbonate,   5iiss  ; 

Water,   ad.  3iv. 

^I.  S.    One  teaspoonful  three  times  a  day. 

September  17,  1906.  Old  lesions  drying  up  and  disap- 
pearing, practically  nothing  new  has  appeared.  Treatment 
continued. 

September,  20.  1906.    Improving.    Treatment  continued. 

September  24.  1906.  Quite  extensive  acute  erythemato- 
vesicular  eruption  on  the  scrotum — by  a  fortunate  coinci- 
dence patient  was  collecting  a  twenty-four  hour  specimen 
of  urine  just  at  time  this  new  eruption  was  developing  (see 
table).  Attention  may  be  called  to  the  ven.^  marked  rise 
in  the  rest  nitrogen,  both  relatively  and  absolutely.  From 
this  time  on,  patient  steadily  improved,  having  no  new  oitt- 
breaks  and  skin  being  clear  when  last  seen,  November  26, 
1906.    Treatment  as  outlined  was  continued  throughout. 

Two  more  analyses  of  urine  were  made  in  this  period. 
It  may  be  noted  that  both  before  and  after  the  acute  out- 
break cf  September  24th  the  rest  nitrogen  was  persistently 
at  01-  above  the  normal  high  limit  for  the  total  nitrogen 
excreted. 


sacrum,  buttocks,  and  groins,  extending  down  the  thighs- 
as  far  as  middle.  The  eruption  was  polymorphous  consist- 
ing in  part  of  grouped  vesicles  on  an  erythematous  base, 
partly  of  papules  and  bean  sized  tubercles  with  circiiiate 
outline.  In  many  places  the  horny  layer  had  been  removed 
by  scratching,  showing  the  mucous  layer  which  in  places 
was  exuding  a  clear  serous  fluid.  In  others  the  fluid  had 
dried  to  a  dark  yellow  crust.  In  older  areas  where  the 
acute  process  had  ceased  a  dark  brown  pigmentation  was 
left. 

This  condition  first  began  in  February.  1907,  and  was 
characterized  by  the  appearance  of  grouped  papules  and 
vesicles  on  an  erythematous  base  which  were  intensely  pru- 
ritic. The  condition  had  persisted  without  remission  since. 
Beside  this  eruption  there  was  also  to  be  seen  on  the  ulnar 
border  of  the  left  forearm  a  group  of  pea  sized  depressed 
.'■cars  surrounded  by  light  hrcwn  pigmentation  and  there 
was  evident  thickening  of  the  bone  beneath.  The  soft 
palate  and  fauces  were  also  much  scarred  as  a  result  of 
severe  ulceration  fifteen  to  sixteen  years  ago.  The  lesions 
on  the  forearm  and  throat  were  considered  to  be  undoubt- 
edly of  syphilitic  origin  and  at  first  there  was  srme  doubt 
as  to  whether  the  whole  eruption  was  not  of  svphilitic 
chnracter  also. 

B\i)od  (December  5.  1907")  :  Haemoglobin.  70  per  cent. 
Red  blood  cells.  5.840.000.  Wiite  blood  cells.  6.000.  Red 
cells  normal.  Parasites — none  found.  Plates — moderate 
number. 


502 


JOHXSTOX-SCHWARTZ:  METABOLISM  OF  SKIX  DISORDERS. 


[New  York 
Medical  Journal. 


Differential  count  of  300  w  hite  blood  cells : 

Polynuclears   70.0  per  cent. 

Lymphocytes    8.4  per  cent. 

Large  mononuclears   7.6  per  cent. 

Transitionals    4.0  per  cent. 

Eosinophiles    9.6  per  cent. 

Mast  cells   0.4  per  cent. 

Myelocytes    0.0  per  cent. 

Before  being  put  on  any  treatment  whatever  patient  was 
requested  to  bring  two  twenty-four  hour  specimens  of  urine 
at  a  few  days'  interval  (see  table). 

December  12th.  Specific  treatment  was  instituted  in  form 
of  inunctions  of  ung.  hg.,  and  pot.  iod.  was  given  internally 
in  doses  of  gr.  20  t.  i.  d.  The  only  marked  result  was  to 
increase  the  itching  and  cause  a  new  outbreak  of  distinctly 
grouped  vesicles  on  erythematous  base.  This  led  to  the 
opinion  that  the  whole  pruritic  eruption  was  of  metabolic 
origin,  probably  an  aberrant  form  of  dermatitis  herpeti- 
formis.    On   December  21.   1907.  specific  treatment  was 


sisted  of  grouped  vesicles  on  erj-thematous  base — in  other 
places  vesicles  had  been  destroyed  by  scratching  and  were 
capped  with  blood  crusts.  '  In  still  other  places  were  brown 
pigmented  areas  which  had  been  the  site  of  former  erup- 
tion. Pulse,  80,  soft,  rather  collapsing  in  character.  Ar-  . 
teries  not  palpable.  Spleen  distinctly  palpable  two  fingers' 
breadth  below  costal  margin.  Liver,  dulness  began  in 
mammary  line  at  sixth  rib  and  extended  to  two  fingers" 
breadth  below  costal  margin — not  palpable. 

Blood:  Haemoglobin,  75  per  cent.  Red  blood  cells, 
4,960,000:  pale  otherwise  normal.  No  plasmodia.  Wliite 
blood  cells  12,000. 

Differential  count  of  200  leucocytes : 

Polynuclears   81.0  per  cent. 

Lymphocytes    8.0  per  cent. 

Large  mononuclears  lo.o  per  cent. 

Eosinophiles    i.o  per  cent. 

Mast  cells   0.0  per  cent. 

Myelocytes    0.0  per  cent. 


1907. 
Dec.  7... 


640 


1.028 


Dec.  10   325 


acid 


acid 


faint 
t''ace 


(J 
E 

tr. 

*«  — 
0  c 

E 

0 

•£.9 

cetone 
idies. 

■5 

CO 

to 

'A 

z  Z  ■ 
1  £^ 

.  A.-N. 
ainnies 

i  .  IN . 

re  ^ 

z  2  • 
1  %^ 
1  ge- 

85 
p"E 

t»-Es 

es 

it 

0 

0 

5-r 

4-4  5 

0.29 

0.14 

0.31 

0.48 

Squam.  epith- 
much.  cal. 

-8.2 

2.5 

5-5 

8.5 

oxal. 

0 

0 

5-63 

4-35 

0.55 

0.15 

0.32 

0.2  1 

77-3 

9.8 

2.8 

5-8 

3-9 

CASE 

VI. 

Stopped  and  the  patient  was  given  the  Elix.  of  Fe,  strych- 
nine and  quinine  of  the  Xational  Formulary  in  drachm 
doses  three  times  daily  after  meals,  also  Sol.  Fowleri  be- 
ginning with  three  drops  t.  i.  a.  and  increasing  by  drop 
doses  The  result  was  a  distinct  change  for  the  better  in 
the  patient's  condition — no  new  eruption  appeared  after 
December  23,  1907 — and  by  January  7,  1908,  she  was  greatlj' 
improved  No  new  eruptions  had  appeared,  the  old  lesions 
were  drying  up,  the  thighs  and  buttocks  being  almost  clear 
of  acute  lesions.    The  itching  had  also  much  lessened. 

In  the  urine  examination  it  will  be  noted  that  the  nitro-- 
gen  partition  is  within  the  norinal  limits  which  we  have 
found  to  be  usually  the  case  at  the  height  of  an  acute  out- 
break— at  which  time  these  specimens  were  collected. 

C.\SE  VII. — Diagnosis :  Dermatitis  herpetiformis. 

Pasi  History:  Male,  aged  forty.  Scrofula  at  seven  years, 
otherwise  healthy.  Did  not  drink,  had  sinoked  ten  cigars 
daily  for  many  years.  Drank  five  or  six  cups  of  coffee 
daily.  Married  five  years — history  of  marked  sexual 
excess. 

History  of  Present  Illness:  Present  eruption  had  been 
present  practically  constantly  for  four  years — he  was  never 
entirely  free,  but  had  periods  of  exacerbation  and  improve- 


Ja-.uiary  26,  1906.    Condition  same. 

Treatment:  Mag.  sulph.  5ii.,  every  morning.  Acetate, 
bicarb.,  and  citrate  of  potassium,  aa  gr.  15,  four  times 
daily.  Lotion  of  magnesium,  zinc,  and  ichthyol  localh. 
Pilocarpin  gr.  1/60  by  mouth  three  times  daily. 

P'ebruary  27,  1906.  Patient  was  kept  on  this  treatment 
and  considerable  improvement  resulted. 

April  3,  1906.  Patient  had  neglected  treatment  since 
last  visit  and  was  distinctly  worse.  There  was  quite  an 
extensive  new  outbreak  and  severe  itching.  Treatment 
continued. 

May  I,  1906.  Constantly  new  outbreaks  since  last  note. 
Patient  had  continual  feeling  of  weariness. 

November  i,  1906.  Had  been  in  country  all  summer  and 
liad  had  no  treatment.  Eruption  had  been  appearing  in 
crops  right  along  and  the  skin  has  never  been  entirely  free. 
The  thighs  and  legs  were  now  inost  affected,  the  forearm.-; 
only  slightly.  Trunk  and  arms  were  practically  free  from 
eruption.  Bowels  had  been  regular,  digest-ion  good.  Had 
been  eating  meat  once  daily — drinking  five  to  si.x  cups  of 
coffee.    No  alcohol.    Tobacco  to  excess. 

.\ugust  15,  1907.    Not  seen  since  last  note. 

Tlic  urine  at  the  height  of  the  attack,  contrary  to  the 


to 

V 

c 

tn 

Date. 

u 

0 

■r. 

c 
o 

R 

c 

u> 
■r. 

Acetone 
bodies. 

c 
re 

Z 

Urea  N. 
grammes 
%  T.  N. 

Z'S^. 
1  =2 
•^c,  ■ 
re  * 

Z  fit? 

<  5 ' ' 

^.  re  ~ 

.s  s 

S  MiJ 

1906. 
Tan.  23  

1.025 

acid 

0 

0 

0 

-h-l- 

9-63 

•7-33 
76.2 

0.46 
4-8 

0.14 
'•5 

0.39 
4.1 

T'et).  15  

870 

1.026 

acid 

0 

0 

0 

0 

CASE 

8.09 
VII. 

6.26 
77-4 

0-34 
4-3 

0-38 
4-7 

0.14 
1.8 

re  ^ 

0  *■* 

0  tfl  X 

J=  re 

.a  n-^  = 

Si  5,^ 

0  re  u 

1.29 

No  casts. 

13-4 

Before  diet 

and  eliminn- 

tive  treat- 

ment. 

0-95 

After 

1 1.8 

treatment. 

nient.  Eruption  came  out  in  crops  as  grouped  vesicles  on 
an  erythematous  base,  and  was  accompanied  by  intense 
itching,  lassitude  and  licadache,  but  no  fever.  As  eruption 
faded  away  brown  areas  were  left.  Appetite  and  digestion 
good.    Bowels  regular.    No  urinary  symptoms. 

Present  Condition  (January  20,  1907)  :  Poorly  nourished; 
"uicous  membranes  rather  pale,  tongue  clean  :  hands  and 
feet  rather  clammy  and  cyanotic.  Sl-  in  oily,  relaxed  cheeks 
hollow.  General  lymphadenitis.  Extensive  eruption  on 
whole  extensor  surfaces  of  arms  and  forearms,  over 
'iacrum,  inside  of  thiglis,  and  round  knees.    Eruption  con- 


usttal  state,  shows  a  distinct  increase  in  the  rest-nitrogen 
fraction  which  was  very  little  modified  by  diet  and  purely 
eliminafive  treatment. 

Case  VI  IT. — Diagnosis:  Dermatitis  herpetiformis  of 
vesicular  type. 

Female,  nurse,  aged  twenty-three.  Health\  up  to  time 
of  entering  training  school  five  or  six  years  ago.  Tlie  at- 
tacks began  or  rather  had  been  coincident  with  periods  of 
overwork  and  menfl  stress.  Within  the  last  year  they 
had  come  apparently  withottt  discoverable  cause.  The  pa- 
tient \\.''s  otherwise  normal  with  110  personal  or  family  his- 


Mnrch  -»o,  19119.] 


JOHN  ST  ON -SCHWARTZ:  METABOLISM  OF  SKIX  DISORDERS. 


593 


tory  bearing  on  the  erupiion.  The  outbreaks  averaged 
three  or  four  a  year,  occurring  always  in  the  form  of 
grouped  vesicles  on  knees,  elbows,  sacrum,  and  about 
axillffi.  The  areas  burned  furiously  and  deep  pigmentation 
was  left  after  subsidence.  The  prodromal  symptoms  were 
very  marked  and  consisted  of  lassitude,  anorexia,  headache, 
joint  pains,  and  sometimes  chill  and  fever.  In  one  such 
period  eosinophilia  rose  to  eleven  per  cent.  Several  attacks 
had  been  aborted  by  the  use  of  vigorous  eliminative 
measures. 

With  a  practically  vegetarian  diet  and  constant  atten- 
tion to  eliminative  function,  the  attacks  subsided  during  the 
fall  of  1907,  into  abortive  outbreaks  with  much  less  pig- 
mentation preceding  occasionally  the  beginning  of  the  men- 


eating  increased  the  frequency  and  duration  of  the  attacks, 
and  so  for  the  past  two  years  she  had  eaten  it  only  once 
a  day.  Her  diet  consisted  now  mainly  of  vegetables  and 
fruit — she  drank  no  milk  and  ate  about  five  eggs  weekly. 
Drank  one  cup  of  cof¥ee  daily  and  only  about  two  glasses  of 
water.  Did  not  use  alcohol.  The  disease  from  which  she 
was  at  present  suffering  began  seven  years  ago  and  she  had 
been  troubled  with  it  every  summer  since.  The  eruption 
always  appeared  with  the  onset  of  warm  weather  and 
lasted  until  cool  weather  began,  when  it  would  disappear 
spontaneously.  The  face  and  extensor  surfaces  of  the 
arms,  forearms,  and  hands  had  been  the  parts  always  af- 
fected. Only  in  the  present  attack  had  the  eruption  ap- 
peared on  the  extensor  surfaces  of  the  legs. 


1907 

March   i   900 


•J: 

1.025 


acid 


Obscured 
by  drug 
reaction. 


10.43 


- .  - 

7.67 

73.6 


z  ?>  . 


2       :i!  £^ 


0.68 

6.6 


0.18 


0.65 
6.3 


OS  Ml- 

1. 18 
11.4 


Twentv-four  hour  specimen  taken  twelve  hours  before  eruption. 

CASE  VIII. 


strual  period.  She  has  recently  begun  to  take  thyreoid 
nucleoproteid  at  such  times  to  break  up  the  habit.  Her 
urine  taken  in  a  marked  prodromal  period  twelve  hours 
previous  to  the  appearance  of  any  lesion  showed  a  con- 
siderable increase  of  undetermined  nitrogen  with  corre- 
spondingly lowered  urea  percentages. 

C.\SE  IX. — Diagnosis :  Dermatitis  herpetiformis. 

Past  History:  Negative  except  that  patient  Iiad  been  a 
very  heavy  meat  eater  for  four  years.  No  venereal  his- 
tory, no  alcohol,  tobacco  used  moderately. 

History  of  Present  Illness:  For  six  months  had  been 
subject  to  crops  of  water  blisters  grouped  together  and  oc- 
curring irregularly  over  body.  H?.d  not  been  entirely  free 
since,  new  eruption  appearing  at  intervals  of  one  or  two 
days  and  always  accompanied  by  intense  burning  and 
itching. 

Present  Condition :  well  nourished,  muscles  well  devel- 
oped, tongue  clean.  Appetite  and  digestion  good,  bowels 
regular.  Skin,  irregular  areas  of  pigmentation  were  no- 
ticed on  extensor  surfaces  of  knees  and  elbows,  on  anterior 
axillary  folds,  over  shoulders  and  scapulae.  Two  large  pig- 
mented areas  on  each  side  over  great '  trochanters.  Pig- 
mentation was  evidently  the  remains  of  previous  eruption, 
as  patient  said  eruption  had  been  almost  entirely  confined  to 
above  mentioned  localities.  Only  a  few  vesicles  to  be  seen 
now,  occurring  two  or  three  together  on  erythematous  base. 

Treatment :  Ung.  menthol,  two  per  cent. 

April  2d.  Had  been  almost  entirely  free  from  eruption 
since  last  visit.  Both  examinations  showed  normal  condi- 
tions in  the  urine,  a  state  of  affairs  to  be  expected  in  a  case 
of  such  long  standing. 

May  26th.  About  same.  Treatment,  restriction  of  pro- 
teid  diet.    Calamin  and  zinc  locally. 


The  disease  was  characterized  by  the  constant  recurrence 
of  pin  head  sized  papules  deep  in  the  skin,  which  gradually 
approached  the  surface  until  they  could  be  distinctly  seen  and 
felt.  They  were  accompanied  by  intense  itching,  were  pale 
red  in  color,  discrete,  and  never  fused  into  plaques.  There 
had  never  been  any  surface  exudation  ;  after  regression  the 
papules  left  white  areas  surrounded  by  brownish  pigmen- 
tation. In  the  present  outbreak  the  face,  neck,  extensor 
surfaces  of  arms,  forearms,  and  hands,  and  extensor  sur- 
faces of  thighs  and  legs  were  affected  as  above  described. 
The  patient  otherwise  seemed  to  be  in  good  health,  was 
well  nourished,  mucous  membranes  of  good  color. 

Physical  examination  of  heart,  lungs,  and  abdomen  nega- 
tive. No  treatment  was  given  and  no  alteration  of  diet 
was  made,  but  patient  was  told  to  collect  a  twenty-four 
hour  specimen  of  urine  for  examination.  Urine  examina- 
tions of  August  igth  and  23  showed  condition  before  any 
treatment  was  inaugurated. 

On  August  23d  she  had  a  new  outbreak  on  face :  other- 
wise her  condition  was  the  same.  She  was  told  to  eat  meat 
twice  daily  as  an  experiment. 

August  28th.  Condition  about  the  same — urine  exam- 
ination of  that  showed,  however,  a  distinct  increase  in  the 
percentage  of  rest  nitrogen,  unaccompanied  by  increase  in 
the  eruption. 

September  7th.  Distinct  relapse  began  September  2 — 
extensive  new  outbreak  of  papules  accompanied  by  most 
intense  itching  (see  urine  table).  Treatment  was  now 
begun — she  was  given  a  saline  cathartic  every  morning  and 
alkaline  diuretics  during  the  day,  her  proteid  diet  was 
markedly  restricted,  and  she  was  told  to  drink  water  freely. 
She  was -kept  on  this  treatment  without  any  distinct  im- 
provement in  her  condition  until  October  22d,  when  she 


Date. 

\'ol.  c.  c. 

■A 

Reaction. 

.Mbumin. 

Sugar. 

Acetone 
bodies. 

Iniiican. 

U 

Urea  N. 
grammes 
%  T.  N. 

1907. 

March   24.  .  . 

. .  2240 

1. 01  I 

acid 

0 

0 

0 

-f 

15.20 

12. 3i 

81. 1 

1 .010 

acid 

0 

0 

0 

0 

T  2.76 

10.33 
Si.o 

CASE  I.\. 


i  =^ 

U.  A.-N. 
grammes 
%  T.  N. 

I  1^ 
3 

z  'C. 

1 

«  5ll°. 

1. 12 
7-1 
0-95 
7-5 

0.59 
3-9 
0.21 
1-7 

0.62 

4.1 

0.31 

-■  5 

0.48 
3-2 
0.91 

7-2 

>=:  X  c  S 

»^  O  C3 

Before  diet 
restriction. 

Few  squam- 
ous cells. 


Acetate,  bicarbonate,  and  citrate  of  potash,  gr.  15,  three 
times  daily. 

C.\SE  X. — Prurigo  of  Hebra. 

August  17,  1907.  Girl,  aged  twenty,  occupation  cigar 
maker.  Apart  from  present  illness  site  had  always  been  in 
good  health.  Appetite  always  good,  digestion  good.  Bow- 
els constipated.  Until  the  past  two  years  she  had  always 
been  a  very  heavy  meat  eater. — eating  meat  two  to  three 
times  daily.    She  gradually,  however,  learned  that  meat 


was  given  in  addition  one  capsule  of  the  nucleoproteid  of 
thyreoid  gland  (Beebe's).  Since  then  improvement  had 
been  taking  place  though  somewhat  slowly. 

December  28,  1908.    Patient  practically  well. 

Attention  should  be  given  to  the  fact  that  disturbance  in 
the  nitrogen  partition  following  five  days  of  proteid  feed- 
ing preceded  relapse  in  the  eruption  by  the  same  length  of 
time.  The  urine  of  September  i8th  indicated  the  pro- 
dromal period  of  another  attack. 


594 


JOHN  ST  ON -SCHWARTZ:  METABOLISM  OF  SKL\  DISORDERS. 


[New  York 
Medical  Journal. 


Case  XI. — Prurigo. 

Male,  aged  forty-six,  janitor  by  occupation,  born  in  the 
L'nitcd  States,  came  under  our  observation  December  23, 
1904,  suffering  from  a  \-ery  itchy  eruption  all  over  the  body. 

Past  History:  Fever  and  ague  as  a  youth;  otherwise  had 
always  been  healthy.  Has  used  alcohol  moderately ;  did  not 
smoke.  No  venereal  history.  Had  lived  in  Kansas,  Michi- 
gan, and  California.  He  went  to  Alaska  in  1900,  remained 
there  till  October,  1902,  when  he  returned  to  New  York 
State,  where  he  had  since  lived. 

History  of  Present  Ill>iess:  In  July.  1904,  he  first  noticed 
an  eruption  of  pin  head  sized,  very  itchy  papules  on  the  ex- 
tensor surfaces  of  the  right  fr)rearm.  On  scratching  a  clear 
watery  fluid  appeared.  The  eruption  gradually  spread  up 
the  arm  to  the  trunk,  neck,  face,  legs,  and  till  the  entire 
body  was  affected,  even  between  the  toes.  From  this  time 
on  he  was  never  entirely  free — he  would  have  outbreaks 
at  various  intervals  on  different  parts  of  the  body.  The 
first  thing  noticed  was  intense  burning  and  tingling,  then 
small,  hard  nodules  coidd  be  felt  deep  in  the  skin.  These 


Differential  count  of  300  white  cells; 


Polynuclears   64.0  per  cent. 

Lymphocytes    4.3  per  cent. 

Large  mononuclears   9.6  per  cent. 

Transitionals    i.o  per  cent. 

Eosinophiles   21.0  per  cent. 

Mast  cells   0.0  per  cent. 


Line  of  treatment  wa.s  instituted  February  8,  1906.  Re- 
duction of  proteid  diet,  cereals  and  vegetables  allowed, 
water  ad  libitum.  Sweat  bath  daily,  also  Scotch  douche. 
Pilocarpin  gr.  1/60,  increasing  gradually  to  an  amount  suf- 
ficient to  keep  skin  moist — reaching  eventually  a  dose  of 
gr.  1/30  five  times  daily.  Saline  cathartic  every  morning 
and  alkaline  diuretics  during  the  day.  Locallj',  soothing 
applications. 

At  this  time  for  a  period  of  two  months,  the  patient  kept 
an  accurate  record,  too  long  to  be  reproduced,  of  food 
taken,  weighing  every  ounce. 

Th-s  line  of  treatment  was  kept  up  till  October  11,  1906. 


"o 

■f. 

be 

■s. 

Acetone 
bodies. 

Indican. 

5. 

1e£^  ■ 

.  tr. 
f= ,  • 

". 

c  £ 

Rest— N. 
grammes 
%  T.  N. 

190,-. 
Aug.  19.... 

600 

1 .029 

acid 

0 

0 

0 

-F-f- 

8.63 

6.72 

77-9 

0.5 
5-9 

0.18 
2.0 

0.62 

-•3 

0.61 
7.1 

Aug. 

-3  ■  ■  ■  - 

68u 

1.028 

acid 

0 

0 

0 

-t- 

9.0 

80.4 

0.38 
4-3 

0.13 
1-5 

0.52 
5.8 

0.69 

Aug. 

28  

.  .   1 240 

1.025 

acid 

0 

0 

0 

[2.15 

9-54 
78.6 

0.49 
4-1 

0.24 
2.0 

0.54 
4-5 

1.28 
10.6 

Sept. 

< 

Sept. 

iS     ,  , 

840 
1280 

1. 021 
1 .02 1 

acid 
acid 

0 
0 

0 
0 

0 

0 

-1- 
0 

CASE 

6.35 
8.67 

X. 

5-0/ 
79-9 

6.61 
76.3 

0.46 

r-4 
0.36 

4-2 

0.14 
2.3 
0.21 
-•5 

0.36 
5-8 
0.46 
5-4 

0.27 
4.4 
0.97 
1 1-3 

S  £  n 
Squam. 
epith. -mu- 
cus: much 
cal.-oxal. 
Do.  Slight 
new  outbreak 
right  cheek. 
After  eating 
meat  b.  i.  d. 
for  5  days. 
Relapse 
since 
September  2d. 


would  graduallx'  approach  tl-.e  surface  and  there  appear  as 
pin  head,  whitish  or  pale  red  papules.  On  scratching  a 
profuse  watery  fluid  appeared,  so  profuse  at  times  that  it 
•could  be  scraped  off  with  a  knife.  Tliis  fluid  would  later 
dry  to  a  dark  crust.  The  skin  over  the  entire  body  grad- 
ually became  very  thick,  so  that  it  could  not  be  picked  up. 
It  also  gradually  became  much  darker  in  color. 

He  was  treated  at  first  for  chronic  eczema,  then  for  pre- 
mycosic  stage  of  mycosis  fungoides  by  x  ray  without  any 
material  improvement  in  his  condition.  Attacks  kept  re- 
currmg,  the  skin  did  not  lose  any  of  its  thickness  or  pig- 
mentation. It  was  not  till  February.  1906,  when  the  skin 
had  begun  to  clear  a  little,  that  the  true  nature  of  the  dis- 
ease w?s  recognized  and  another  line  of  treatment  insti- 
tuted.   At  that  time  his  condition  was  as  follows : 

Fairly  well  nourished  man,  mucous  membranes  good 
color,  tongue  clean.  Moderate  general  lymphadenitis. 
Heart,  lungs,  liver,  spleen,  and  abdomen  negative. 

It  IS  difficult  to  give  a  pen  picture  which  will  convey  an 
adequate  idea  of  the  condition  of  the  skin.  The  universal 
involvement,  consequent  absence  of  any  distinguishing 
lesion,  and  the  accidents  of  scratching,  made  a  diagnosis 
very  difficult.  Everywhere  but  on  the  palms  and  soles  the 
skin  showed  a  thickening  so  great  that  it  could  be  picked 
up  only  with  great  difficulty.  Its  thickness  was  increased  a 
dozen  times,  and  the  surface  marked  with  deepened  lines 
to  an  extent  sufficient  to  create  the  iitipression  of  ele- 
phantiasis. 

In  addition  to  lichenificatinn,  eczematization.  excoriation, 
pigmentation,  and  pustidation  were  generally  prominent. 
Ilrows  and  cheeks  were  thickened  and  lined  so  as  to  give 
a1mn«t  a  leonine  appearance.  The  scalp  was  covered  with 
a  fliffuse  infiltration.  There  was  a  deep  brown  pigmenta- 
tion practically  everywhere,  relieving  small  areas  of  leuco- 
denna,  depigmentation  resulting  from  localized  processes. 
Slight  branny  desquamation  was  universal  but  not  promi- 
nent. As  a  result  of  the  thickening  and  consequent  immo- 
bility of  the  skin  there  was  distinct  Assuring  in  the  neigh- 
boihood  of  the  joints.  The  hair  of  the  eyebrows,  mous- 
tarlic.  scalp,  and  pubic  region  was  very  scanty,  dry,  lustre- 
less, and  liroken  off. 

Blood:  Hjemoglobin,  90  per  cent.  Red  blood  cells,  .•?,8o8,- 
000.  normal  in  appe.irance,  no  malarial  parasites  found. 
White  blood  cells,  26,000. 


During  this  time  the  patient  improved  very  considerably. 
He  had  relapses  at  irregular  intervals,  but  each  relapse 
tended  to  be  shorter  in  duration,  less  in  extent,  and  less 
severe  than  the  preceding  one.  The  skin  became  progress- 
ively thinner  and  the  pigmentation  gradually  faded.  By 
October  the  only  parts  liable  to  be  affected  in  a  relapse 
were  the  forehead,  neck,  anterior  axillary  folds,  flexor 
surfaces  of  the  elbows,  and  the  sides  of  the  abdomen. 
These  places  still  remained  somewhat  thickened,  reddened, 
and  papules  could  always  be  felt  in  the  skin.  Over  the 
rest  of  the  body  the  skin  had  returned  almost  to  its  normal 
thickness,  it  could  be  picked  up  easily,  and  there  was  no 
longer  any  tendency  to  Assuring.  The  pigmentation  had 
faded  markedly  all  over  the  body.  Hair  began  to  grow- 
again. 

Blood  f  August  14,  1906)  :  Haemoglobin,  98  per  cent.  Red 
blood  cells,  6,112,000,  normal  in  appearance.    No  malarial 
parasites  found.    White  blood  cells,  21,000. 
Differential  count  of  300  white  cells: 

Polynuclears   70.7  per  cent. 

Lymphocytes   11.3  per  cent. 

Large  mononuclears   3.3  per  cent. 

Transitionals    5.7  per  cent. 

Eosinophiles    9.0  per  cent. 

Mast  cells   o 

Myelocytes    o 

Patient,  though  much  improved,  seemed  to  have  reached 
a  standstill:  therefore  on  October  11,  1906,  in  addition  to 
the  treatment  outlined  above  he  was  given  one  capsule  of 
nucleoproteid  of  thyreoid  ( gr.  1/200)  twice  dailv,  which 
was  gradually  increased  till  he  was  taking  five  daily.  This 
was  kept  up  till  November  13,  iqo(x  w  hen  the  capsules  were 
discontinued.  If  anything,  his  condition  had  become  worse, 
and  the  capsules  were  thought  not  to  agree  with  him. 
The  other  treatment  was  continued. 

From  November  13th  to  December  isth  he  remained  in 
very  good  condition,  having  no  new  outbreaks.  On  De- 
cember TSth,  howe\er,  a  distinct  relapse  occurred  affecting 
the  face,  flanks,  and  slightly  tiic  arms.  Tliis  relrinso  per- 
sisted until  January  15,  1907,  when  he  seemed  distinctly 
easier  and  the  eruption  seemed  to  be  lessening.  From  this 
time  fill  Fel)nnry  26t!i  he  kept  in  fairly  good  condition, 
though  a  few  papules  kept  appearing  every  few  days  on 
forehead,  neck,  and  flanks  especially.    Tlie  same  treatment 


.■^larch  20,  1909. 


JOHNSTON-SCHWARTZ:  METABOLISM  OF  SKIN  DISORDERS. 


595 


Q  '  > 

1 906. 

Feb.  6   1450 

Feb.    14   2060 

Feb.  20   1350 

Feb.  26   2070 

Marcli   27   1325 

Oct.    II   1620 

Oct.    23   1400 

-Nov.  8   2070 

Xov.  20   2300 

1907. 

Feb.  28   2300 

ilarcli    1   1780 

■Vlarch   2   1840 

March  4   2825 

March    5   1850 

Vlarch   6   2070 

ilarch   7   2680 

March   9   1620 

March    II   2860 

ilarch    12   2170 

March    13   2760 

Vlarch    15   2650 

March    18   2910 

March   20   1730 

March    2)2   1760 

March   26   199° 

April    1   1750 

April    5   2220 

April    8   2580 

April    12   1870 

April    16   1723 

April    19   1460 

April   23   2050 

April    26   2240 

May  7   2850 

May   in   1850 

May  17   1630 

May  21   i960 

May  24   1 200 

May  28   2100 

May  31   1930 

June  4   1710 

June  7   1710 

June  II   1530 


c 

d 
C/"; 

0 

i: 

Albumin. 

Sugar. 

Acetone 
bodies. 

Indican. 

T.  N.  gr: 

1. 01  5 

acid 

+ 

0 

0 

0 

8.44 

1.020 

acid 

+ 

0 

0 

0 

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acid 

+ 

0 

0 

0 

6.6s 

1 .0  I  2 

acid 

+ 

0 

0 

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9-!  5 

1. 01  7 

acid 

0 

0 

0 

9-9 

1. 018 

acid 

0 

0 

+ 

10.7 

I.OI7 

acid 

0 

0 

+ 

1 1 . 1 7 

1. 010 

acid 

0 

0 

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12.75 

1. 013 

acid 

+ 

0 

0 

+  + 

193 

1. 010 

acid 

+ 

0 

0 

0 

14.49 

1. 013 

acid 

+ 

0 

0 

0 

1 1 .9 1 

1.020 

acid 

+ 

0 

0 

0 

12.26 

1. 015 

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+ 

0 

0 

0 

13-77 

1. 018 

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+ 

0 

0 

0 

11.8 

I.O18 

acid 

0 

0 

0 

II. 8 

1. 012 

acid 

+ 

0 

0 

0 

13-4 

1. 015 

acid 

+ 

0 

0 

0 

II. S 

1.008 

acid 

+ 

0 

0 

0 

1 1.09 

1. 010 

acid 

+ 

0 

0 

0 

II. 48 

1. 010 

acid 

+ 

0 

0 

0 

12.26 

1. 010 

acid 

+ 

0 

0 

0 

1 1.42 

1.009 

acid 

0 

0 

0 

15-56 

1. 013 

acid 

+ 

0 

0 

0 

13-66 

i.o  1 4 

acid 

+ 

0 

0 

0 

12.8 

1. 013 

acid 

0 

0 

0 

12.6 

10.14 

acid 

+ 

0 

0 

0 

13-7 

1 .0 1 0 

acid 

+ 

0 

0 

0 

10.25 

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0 

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1. 010 

acid 

+ 

0 

0 

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1. 01 1 

acid 

0 

0 

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11.85 

1. 016 

acid 

+ 

0 

0 

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1. 010 

acid 

+ 

0 

0 

0 

12.68 

1. 015 

acid 

0 

0 

0 

13-67 

1. 010 

acid 

+ 

0 

0 

0 

12.68 

1. 016 

acid 

+ 

0 

0 

0 

12.8 

1. 010 

acid 

[ 

0 

0 

7-9 

1. 01 1 

acid 

+ 

0 

0 

0 

12.15 

1. 017 

acid 

+ 

0 

0 

0 

12.24 

1. 012 

acid 

+ 

0 

0 

0 

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1. 010 

acid 

+ 

0 

0 

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1. 01  5 

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+ 

0 

0 

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1.020 

acfd 

+ 

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0 

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20.4 

1. 013 

acid 

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11.66 

5 

5.12 
60.7 

6.97 
69.1 

436 
65.0 

6.1 
66.7 

7-32 
74.0 

8.05 
75-3 

9.09 
81.4 
10.74 
84-3 
1 6.4 
85.0 


86.8 


10.02 
84.2 

9-5 
77-5 

9-77 
71.0 

9.69 
82.2 
10.36 
87.8 

1 1. 61 
86.7 

9.88 
83.8 

8.65 


9-75 

84-  9 
10.44 
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1 1-77 

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II. 7 

85-  7 
10.26 
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8.59 
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10.56 
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10.52 
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9-78 
82.6 
10.16 
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70.5 

9-  45 
69.2 


8-9; 
70.6 


9.85 
77.0 

5-6 
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9-56 
78.7 
10.44 
85.3 

8.85 
77-0 

7-99 
72-7 
10.04 
85.1 

17.62 
86.4 
10.45 
89.7 


I  bz 

0.34 

3-9 

0.51 

5-1 

0.23 

3-  6 
0.48 
5-3 
0.51 
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1-34 

12.6 
0.46 
4.2 
0.57 

4-  5 
0.38 

z.o 
0.69 

4.8 


0.54 

4.6 

0.51 

4.2 

0.64 

4-7 

0-47 

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0.46 

3-9 


4-4 

0.48 

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1.42 
1 1.2 


1-35 
10.6 

1.0 

12.7 
0.59 
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0.36 
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0.81 
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0.2 
1-9 
0.25 
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0.42 
2.1 
0.16 
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0.23 

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0-33 

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0.27 
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0.32 

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0.36 

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0-35 

3-0 

0-37 

3-2 

0-45 

3-  4 
0.31 
2.7 
0.52 

4-  7 


0.51 
4-1 


0.39 

3-1 

0.36 

4.6 

0.38 

3-2 

0.25 

2. 1 

0.42 

3-7 

0.43 

4.0 

0.35 

3-1 

0.36 
1.8 
0.32 
2.8 


c  E 

S  tin 

0.34 

4.1 

0.41 

4.1 

0.27 

4.1 

0.37 

4-  1 
0.53 

5-  4 
0.51 
4.8 
0.55 
5.0 
0.7 
5-5 
0.69 

3-  6 

0-59 

4-  1 


0-54 

4-6 

0.49 

4.0 

0.49 

3-6 

0-37 

3-  2 
0.54 

4-  6 

0.4 

3-  0 
0.48 

4-  1 
0.52 
4-7 


1-47 
II. 6 


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it 

2.36 
28.1 

1.62 
16.I 

1.42 
21.5 

1.72 
18.8 

1.06 

10.8 
0.38 
3-6 

0-  7,5 
6.8 
0.2 1 

1-  7 
1-25 
6-5 

0. 14 
1.0 


0.42 

3-6 

1-33 

10.9 
2.27 

16.S 
0.87 
7-4 
0.04 
0.4 

0.29 

2.2 

0.59 

S-o 

0.99 

9-0 


0.49 

0.41 

0-37 

0.42 

4-3 

3-6 

3-3 

3-7 

0.66 

0.47 

0-5 

0.02 

5-4 

3-9 

4.1 

0.61 

0.45 

0.44 

i.ls 

5-4 

4.0 

3-9 

12. 1 

0-73 

0.52 

0.51 

1-97 

4-7 

3-4 

3-3 

12.7 

0.66 

0.31 

0-45 

0.49 

4-9 

2.3 

3-3 

3-6 

0.38 

0-33 

0.61 

1. 1 2 

3-0 

2.6 

4.8 

8.8 

0.51 

0.45 

0.64 

0.46 

4-1 

3-6 

5-1 

3-7 

0.69 

0-31 

0.64 

0-47 

5-1 

2.3 

4-7 

3-5 

0-55 

0.41 

0.46 

0.2 

5-4 

4.0 

4.5 

2.0 

0.81 

0.46 

0.56 

0.46 

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3-6 

4.4 

3-6 

0.9 

0.4  . 

0.48 

0-03 

7.3 

3-3 

3-9 

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0.69 

0.29 

0.55 

0.48 

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2-5 

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0.89 

0.32 

0.37 

1-33 

6.8 

2-5 

2-9 

10.2 

1.07 

0-35 

0.50 

1.76 

8.5 

2.8 

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13-9 

1-5 

0.42 

0.62 

1. 61 

1 1 .0 

3-1 

4.6 

II. 8 

0.31 

2-5 

0.6 
4-7 
0-54 
6.9 
1.0 
8.3 
0.57 
4.8 
0.82 
7-2 
1.72 
15-7 
0-5 

4-  3 

1.02 

5-  0 
•.I 
0.9 


No  casts. 
Few  squam. 
cells. 
Do. 

Do. 

Do. 


Injections 
begun  Feb. 
26, 

I — 2  tubes. 
S.T.F,.  daily. 


Injection 
stopped  Mar. 
6  (Rest?) 


Injections 
resumed 
Mar.  II,  I — 2 
tubes  S.  T.  E. 
daily. 


I — 2  tubes 
S.   T.   N.  V. 
daily. 


I — 2  tubes 
S.  T.  E.  daily. 


Rest? 


I — 2  tubes 
S.  T.   N.  P. 
daily. 


Recrudes- 
cence began 
April  25; 
change,  to 
S.   T.  E.  2 
daily. 
Recrudes- 
cence over 

and  pat. 
comfortable. 


Recrudes- 
cence. 
I — 2  tubes 
S.  T.  N.  P. 

daily. 
Well  again. 


596 


MAY:  J-'JXATION  AND  STAINING. 


[New  York 
Medical  Journal. 


Q 

1907. 


Ju.ic 


Vol.  c.  c. 

0 

Reaction. 

AlbuMiiii, 

Sugar. 

Acetone 
bodies. 

Indican. 

bo 

1350 

1. 018 

acid 

+ 

0 

0 

0 

12.47 

1.023 

acid 

+ 

0 

0 

0 

10.73 

1 240 

1. 016 

acid 

+ 

0 

0 

0 

10.83 

1500 

1  .020 

acid 

+ 

0 

0 

0 

I  5-54 

1770 

1.014 

acid 

+ 

0 

0 

0 

1710 

1. 010 

acid 

+ 

0 

0 

0 

1 1  86 

1 130 

1 .01 7 

acid 

+ 

0 

0 

0 

12. 14 

1210 

1. 017 

acid 

0 

0 

0 

+ 

135" 

1 .0  I  2 

acid 

0 

G 

0 

1050 

1. 019 

acid 

0 

0 

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9.67 

1 100 

1. 016 

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0 

0 

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10.07 

1770 

1. 010 

acid 

0 

0 

0 

956 

850 

1 .020 

acid 

0 

0 

0 

+ 

10.37 

2225 

1. 010 

acid 

0 

0 

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11.29 

1325 

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acid 

0 

0 

0 

+ 

10.5 

<«  p,  ■ 

D  &^ 

10.72 
86.0 

8.88 
82.8 

9.14 
84.4 
1327 
-  S5.4 

8.58 
78.7 
-10.16 
85.7 

9-77 
80.5 

9.07 
85.6 

6.64 
go.n 

8.24 
83.3 

8.27 
82.2 

7.87 
82.4 

8.82 
85.1 

9.72 

8fa.2 

9.04 


2s 


C.\SE  XI. 


0.22 

0.34 

0. 53 

0.61 

1.8 

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0. 1 6 

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0.26 

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5.7 

0.  57 

0.27 

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0.49 

0.45 

1 .0 

0.38 

4.4 

4.  J 

9- 1 

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0.59 

0.26 

0.6 

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0. 74 

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0.44 

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0.22 

0.  1 7 

0.63 

0.63 

2.7 

2. 1 

7-7 

7.6 

0.24 

0.2 

0.55 

0.41 

2-5 

5-7 

4-3 

0.25 

0.16 

0-57 

0.78 

2.5 

1.6 

5-7 

7.8 

0.27 

0.23 

0-73 

0.4 

2.9 

2-5 

7-7 

4-2 

0.2 

0.3 

0.59 

0.42 

2.0 

2.9 

5-7 

4.1 

0.2  I 

0.28 

0.79 

0.22 

1.9 

2.6 

7.0 

2.0 

■  ..J3 

(I.J  I 

0.65 

0.3B 

J.  1 

0.2 

3-1 

Slight  recru- 
descence. 


was  followed  throughout.  On  February  26th  in  addition  to 
his  ofher  treatment  he  was  given  an  injection  of  one  tube 
(2.5  c.c.)  of  extract  of  autolyzed  sheep's  thyreoid. 

Blood  (February  27,  1907)  :  Hemoglobin,  98  per  cent. 
Red  blood  cells  6,520,000,  normal  in  appearance.  White 
blood  cells  12,000. 

Difterential  count  of  300  white  cells  : 

Polynuclears   67.0  per  cent. 

Lymphocytes   22.0  per  cent. 

Large  mononuclears    4.0  per  cent. 

Transitionals    3.0  per  cent. 

Eosinophiles    2.6  per  cent. 

Mast  cells    1.4  per  cent. 

Myelocytes   •   0.0  per  cent. 

Examination  of  freces  for  ova  negative. 
This  injection  treatment  was  kept  until  November  20, 
1907 — the  patient  slowly  but  steadily  improving.    As  indi- 


cated on  the  urine  chart  he  received  daily  an  injection  of 
one  to  two  tubes  of  sheep's  thyreoid  extract  or  one  to  two 
tubes  of  sheep's  thyreoid  nucleoproteid.  The  dose  was 
regulated  by  the  condition  of  the  pulse  as  regards  fre- 
quency and  tension. 

On  November  12,  1907,  the  injections  were  stopped  and 
lie  was  given  one  capsule  daily  of  nucleoproteid  of  the 
thyreoid  as  prepared  by  Dr.  Beebe.  Improvement  under 
this  treatment  continued  and  at  the  present  writing  (April, 
1908,)  he  shows  no  lesions. 

The  urine  chart  is  too  elaborate  for  fin-ther  analysis 
than  the  numerous  references  in  the  general  discussion. 
We  believe  that  it  will  repay  the  interested  reader  for  some 
close  reading  and  would  like  to  direct  particular  attention 
to  the  changes  preceding  relapse  and  following  injection 
of  thyreoid  extract. 

(To  be  concluded.)  ^ 


AN  IMPROVED  METHOD  FOR  THE  FIXATION 

OF  TISSUES  AND  STAINING  OF  SECTIONS. 

Bv  James  V.  May,  M.  D., 
Binghamton,  N.  Y., 

Assistant   Physician,    Binghamton    State  Hospital. 

The  fluids  ordinarily  used  for  the  preservation, 
hardening,  and  fixing  of  tissues  preparatory  to  stain- 
ing sections  for  study  with  the  microscope  include 
alcohol,  Zenker's  fluid,  formalin,  corrosive  sublimate, 
Orth's  fluid,  Flemming's  solution,  Miillcr's  fluid, 
and  many  others.  For  routine  work,  the  nervous 
system  excepted,  ninety-five  per  cent,  alcohol  and 
Zenker's  fluid  are  generally  used.  For  nuclear  fig- 
ures, blood  cells,  protoplasin,  connective  tissue,  and 
general  histological  study,  Zenker's  fluid  is  unques- 
tionably the  best,  but  it  presents  serious  difiicultics 
in  staining.  The  eosin  and  methylene  blue  method 
is  usually  considered  as  giving  the  best  stain  for  sec- 
tions of  tissue  fixed  in  Zenker's  fluid.  It  is  neces- 
sary to  stain  in  eosin  first  as  methylene  blue  is  read- 
ily soluble  in  an  aqueous  solution  of  eosin,  while  on 
the  other  hand,  eosin  is  only  slightly  soluble  in 
methylene  blue.  After  staining  in  a  five  per  cent, 
solution  of  eosin  for  twenty  minutes  or  more  the 
sections  arc  placed  in  Unna's  alkaline  methylene 
blue  solution  (diluted)  for  ten  or  fifteen  minutes. 
They  are  then  difi^erentiated  in  ninety-five  per  cent, 
alcohol.  This  removes  the  methylene  blue  from 
everything  but  the  nuclei,  leaving  the  eosin  as  a 


contrast.  Only  one  section  should  be  differentiated 
at  a  time,  as  the  sections  must  be  kept  in  constant 
motion  in  the  alcohol.  If  the  sections  are  thin  (from 
six  to  nine  micra  in  thickness)  and  perfectly  uni- 
form, excellent  results  can  be  obtained,  but  great 
care  is  necessary.  It  will  often  be  found  that  the 
stain  is  not  uniform,  some  parts  of  the  sections 
staining  beautifully,  while  other  parts  are  all  blue, 
and  still  others  retain  the  eosin  only.  In  the  hands 
of  the  average  laboratory  worker  it  is  tmsatisfactory 
as  the  dififerentiation  is  not  uniform  and  is  difficult 
or  impossible  to  control.  A  successful  stain  by  this 
method  gives  a  beautiful  picture  but  often  fades  and 
does  not  keep  well. 

In  staining  alcohol  sections  the  nuclear  stain 
( haematoxylin)  can  be  carried  to  the  point  desired 
tinder  the  microscope.  Decolorization  is  then  done 
quickly  and  readily  by  acid  alcohol,  the  nuclei  only 
retaining  the  stain  and  standing  out  prominently. 
Unfortunately  this  cannot  be  done  with  the  Zenker 
sections.  The  excess  of  bichromate  obscures  the 
section  by  a  yellow  or  brownish  appearance  and  ren- 
ders it  difficult  to  tell  when  a  good  nuclear  stain  has 
been  obtained.  The  Lugol's  solution  used  in  remov- 
ing the  mercury  increases  this  difficulty.  Zenker 
sections  stain  at  best  very  slowly  in  hrcmato.xvlin. 
Decolorization  is  very  difficult  even  under  the  micro- 
scope, the  color  of  the  sections  being  obscured  by 
the  bichromate  and  any  iodine  which  may  be  left 
from  the  Lugol's  solution.     It  is  not  possible  to  get 


March  2»,  1909.] 


J  HERA  I't  U  TIC  A  L  XUTES. 


597 


a  satisfactory  idea  of  the  result  obtained  until  the 
section  has  been  placed  in  a  clearing  reagent.  All 
decolorizing  fluids  act  slowly  on  Zenker  sections. 

The  ideal  combination  would  be  Zenker  fixation 
with  a  stain  equal  and  similar  to  that  of  eosin  and 
methylene  blue  and  which  can  be  done  as  readily  as 
h?ematoxylin  and  eosin  after  alcohol.  To  do  this 
the  nuclear  stain  must  first  be  carried  to  the  desired 
point  under  the  microscope  and  a  contrast  stain 
which  will  not  dissolve  the  nuclear  stain  applied 
after  the  section  has  been  decolorized  until  the  nuclei 
stand  out  prominently  on  a  clear  background.  This 
can  be  done  by  a  modification  of  the  Zenker  method 
of  fixation.     The  formula  of  Zenker's  fluid  is  as 


follows : 

Potassium  bichromate,    2.5  parts ; 

Sodium  sulphate,    i  part : 

Corrosive  sublimate,    5  parts ; 

Glacial  acetic  acid,    5  parts ; 

Water,   ad.  100  parts. 


The  fi-xation  is  almost  if  not  entirely  due  to  the 
corrosive  sublimate.  The  peculiar  staining  property 
of  the  red  blood  cells  is  due  to  the  bichromate.  The 
sulphate  of  sodium  is  useless.  Experiments  have 
shown  that  the  staining  property  of  the  red  cells  can 
be  obtained  by  a  one  per  cent,  solution  of  bichromate 
as  well  as  by  a  two  and  a  half  per  cent,  solution.  B\ 
reducing  the  bichromate  to  one  per  cent,  the  yellow 
or  brownish  discoloration  of  the  sections  is  avoided. 
Corrosive  sublimate  is  best  used  in  a  physiological 
saline  solution  (sodium  chloride  0.75  per  cent.)  in 


which  it  is  readily  diffusible.  The  following  fixa- 
tion is  therefore  recommended : 

R     Corrosive  subliinate,    5  parts ; 

Potassium  bichromate   i  part : 

Sodium  chloride  solution  (0.75%),   100  parts. 


M.  S..  Add  5  c.c.  of  glacial  acetic  acid  to  each  100  c.c.  of 
the  fluid  at  the  time  of  using. 

The  fixation  is  exactly  the  same  as  that  obtained 
by  Zenker's  fluid,  and  any  staining  method  can  be 
used  which  is  used  after  Zenker.  The  advantage 
of  this  fixation  is  that  sections  can  be  stained  by 
hsematoxylin  and  eosin  as  readily  as  after  alcohol. 
It  is  used  in  the  same  way  as  Zenker,  i,  Fixation, 
twenty  four  hours  ;  2,  wash  in  running  water,  twent\  - 
four  hours ;  3,  alcohol,  eighty  per  cent.,  twenty-four 
hours ;  4,  alcohol,  ninety-five  per  cent.,  twenty-four 
hours;  5.  absolute  alcohol,  24  hours*.  Imbed  in  par- 
afiine  and  section  as  usual. 

Bichloride  and  bichromate  sections  are  best  fast- 
ened to  the  slide  by  using  a  twenty-five  per  cent, 
unfiltered  solution  of  white  of  egg  in  water.  The 
slides  are  thinly  and  evenly  spread  with  the  albu- 
men solution,  using  the  finger  to  spread  it,  and  then 
heated  to  70°  C.  in  the  incubator.  Shut  off  the 
heat  and  allow  the  incubator  to  cool  slowly.  Sec- 
tions when  cut  should  be  floated  in  warm  water  and 
then  taken  up  on  slides  albumenized  as  mentioned 
before,  after  which  they  are  adjusted  to  the  posi- 
tion desired  and  the  slide  heated  in  the  incubator 
to  a  point  just  below  the  melting  point  of  the 
paraffin  used.  When  cool  they  are  ready  to  stain. 
Sections  fastened  to  the  slide  in  this  manner  will 
not  be  loosened  by  any  staining  method.  The  or- 
dinary glycerin-albumen  method  of  fastening  sec- 
tions to  the  slide  is  unsatisfactory  for  tissue  fi.xed  in 
bichloride  or  bichromate  solutions. 


The  following  mixture  is  recommended  for  re- 
moving mercury  from  the  sections : 


R    Iodine,    i  part; 

Potassium  iodide,    2  parts ; 

Alcohol,  ninety-five  per  cent  100  parts. 

M. 


It  will  remove  the  mercury  in  a  few  minutes  and 
the  iodine  color  disappears  at  once  on  placing  the 
sections  in  ninety-five  per  cent,  alcohol.  It  is  much 
more  satisfactory  than  the  alcoholic  solution  of 
iodine  or  the  Ltigol  soltition  generally  used.  The 
mercury  should  not  be  removed  until  after  the  sec- 
tions are  cut,  as  iodine  interferes  with  the  staining 
properties  of  the  tissues  if  added  to  the  alcohol  be- 
fore imbedding  in  paraffin. 

For  general  work  the  hjematoxylin  and  eosin 
stain  is  recommended  for  use  after  the  fixation  sug- 
gested. The  best  results  are  obtained  by  using  a 
one  per  cent,  solution  of  hrematoxylin  in  a  saturated 
aqueous  solution  of  ammonia  alum.  Dissolve  one 
gramme  of  hsematoxylin  crystals  in  100  c.c.  of  the 
alum  solution  bv  the  aid  of  heat.  Ripen  artificially 
by  heating  with  a  small  amount  of  red  or  yellow 
mercuric  oxide  (two  to  three  grammes  to  the  100 
c.c.  of  stain),  until  it  changes  to  a  purple  color  and 
a  scum  of  a  metallic  appearance  forms  on  the  sur- 
face. Cool,  filter,  and  add  a  crystal  of  thymol  to 
preserve  it.    The  method  of  staining  is  as  follows: 

I,  Xylene;  2.  alcohol,  ninety-five  per  cent.;  3,  re- 
move mercury  by  the  iodine  solution  as  mentioned 
before,  three  minutes  usuallv  sufficient;  4,  alcohol, 
ninety-five  per  cent.,  tmtil  the  section  is  colorless, 
a  few  minutes  usuall}  sufficient ;  5,  stain  in  the  alum 
hasmatoxylin  solution  until  the  nuclei  are  clearly 
stained,  three  to  five  minutes  usually  sufficient,  a 
slightly  deeper  stain  is  necessary  than  after  alcohol 
fixation;  6,  decolorize  with  acid  alcohol  (hydro- 
chloric acid  one  per  cent,  in  seventy  per  cent,  alco- 
hol) ;  7,  wash  in  water  for  two  hours  at  least,  a 
longer  time  is  better;  8,  counter  stain  with  a  0.25 
per  cent,  aqueous  solution  of  eosin  for  five  or  six 
minutes;  0,  ninety-five  ])er  cent,  alcohol;  10,  abso- 
lute alcohol;  11,  xylene;  and.  12,  moimt  in  xylene 
balsam. 

After  a  little  experience  the  sections  will  be  equal 
to  any  eosin  and  methylene  blue  preparation  and 
will  not  fade.  The  technic]ue,  as  given,  should  be 
followed  closely. 

 ^  


The  Treatment  of  Rheumatic  Iritis. — The  fol- 
lowing mixture  is  prescribed  by  Brav  (Journal  de 
mcdcciiic  de  Paris.  February  6,  1909)  in  the  treat- 
ment of  iritis  of  rheumatic  origin  : 

B     Sodium  salicylate,   5iv  ; 

Potassium  iodide,   3iv; 

Compound  syrup  of  sarsaparilla,  jiii. 

M.  et  Sig. :  One  teaspoonful  to  be  taken  in  a  little  water 
four  times  a  day. 

The  Local  Treatment  of  Syphilitic  Lesions. — 

According  to  E.  Finger  (Rciue  dc  thcrapeutiquc, 
March  i.  1909)  the  treatment  of  syphilitic  lesions 
should  vary  with  the  condition  of  the  sore.  If  the 
suppuration  is  not  very  pronounced  the  application 


I 


598 


THERAPEUTICAL  NOTES. 


[New  York 
Medical  Journal. 


of  a  simple  astringent  will  suffice,  but  a  more  con- 
centrated astringent  is  necessary  where  there  is  any 
considerable  amount  of  pus.  Either  one  of  the  fol- 
lowing applications  should  be  used  : 


R    Copper  sulphate,   gr.  \Iv ; 

Distilled  water,   3'- 

M. 

R    Copper  sulphate,   gr.  x.xv; 

Petrolatum  3i. 


These  are  applied  on  aseptic  cotton  and  changed 
twice  daily.  It  is  also  recommended  to  wash  the 
parts  with  an  alcoholic  or  ethereal  solution  of  cor- 
rosive sublimate  of  the  strength  of  one  .n  one  thou- 
sand. 

If  the  destruction  of  tissue  is  very  great  recourse 
must  be  had  to  the  local  application  of  iodine  prepa- 
rations, as  the  following : 


R    Potassium  iodide  gr.  xv  ; 

Iodine  gr.  iss  ; 

Distilled  water,   Jiss. 

M. 


The  sore  may  also  be  painted  every  two  or  three 
hours  with  a  pure  tincture  of  iodine,  but  the  prepa- 
rations of  iodoform  are  best.  The  iodoform  may 
be  applied  pure  as  a  dry  powder,  or  mixed  with 
equal  parts  of  sugar  of  milk,  or  as  a  solution  of  the 
following  composition  : 


R     Iodoform  gr.  xv  ; 

Olive  oil,   5v. 

M. 

R    Iodoform,   gr.  xv  ; 

Ether, 

Olive  oil,   aa  3ii. 

M. 


The  iodoform  may  also  be  applied  as  a  spray,  one 
part  of  iodoform  being  dissolved  in  seven  parts  of 
ether.  The  ether  evaporates  and  leaves  a  thin  light 
adherent  coating  which  penetrates  to  all  parts  of  the 
ulcer.  The  application  need  not  be  repeated  oftener 
than  once  in  twenty-four  hours.  If  mercury  is  indi- 
cated or  the  specific  action  of  this  drug  is  deemed 
necessary,  some  one  of  the  following  formulas  may 


be  employed : 

R    Corrosive  sublimate,   gr.  iss; 

Distilled  water,   5'- 

M. 

R     Red  mercuric  oxide,   gr.  iss; 

Petrolatum,   5v. 

M. 

^    Mercurial  plaster. 

Soap  plaster,   aa  5iv. 


M.  Sig. :  Apply  as  a  plaster. 
The  mercury  in  contact  with  the  tissues  promotes 
cicatrization  and  by  absorption  softens  the  hardened 
tissue,  the  two  efifects  being  observed  to  take  place 
simultaneously. 

The  treatment  of  mucous  patches  should  consist 
principally  of  a  mouth  wa.sh  or  gargle  of  corrosive 
sublimate.  Once  a  day  the  patches  are  cauterized 
with  a  strong  solution  of  corrosive  sublimate  in  alco- 
hol, a  weaker  solution  being  used  at  other  times. 


The  strong  solution  consists  of : 

R    Corrosive  sublimate,  gr.  xv; 

Alcohol,   5v. 

M. 

The  mouth  wash  is  prescribed  as  follows : 

B    Corrosive  sublimate,  gr.  iss; 

Alcohol. 

Distilled  water  aa  3v. 


M.  et  Sig. :  One  teaspoon ful  in  a  glass  of  water  to  be  used 
aes  a  mouth  wash. 


Another  remedy  which  is  used  with  excellent  re- 
sults in  the  treatment  of  children  and  sensitive  per- 
sons is  the  glycerite  of  tannin.  The  author  einploys  a 
somewhat  weaker  preparation  than  that  of  the  Phar- 
macopo'ia,  it  being  a  ten  per  cent,  solution  of  tannic 
acid  in  glycerin  instead  of  twenty  per  cent.,  the  offi- 
cial strength. 

NEW  REMEDIES. 
Castoreum  Bromide  is  the  name  given  to  a 
granular  effervescent  preparation  which  is  stated  to 
have  the  following  composition :  Potassium  bro- 
mide, lo;  sodium  bromide,  lo;  ammonium  bromide, 
5 ;  extract  of  valerian,  15  ;  extract  of  castoreum,  7.5  ; 
effervescent  basis,  50.  As  an  antiepileptic,  nervine, 
and  sedative  it  is  given  in  doses  of  from  one  third  to 
one  teaspoonful. 

Cellasin. — A  patent  was  issued  by  the  United 
States  Government,  February  9th,  1909,  covering 
this  ferment.  According  to  the  printed  reports  of 
J.  E.  Teeple,  Ph.  D.,  S.  P.  Sadtler,  Ph.  D.,  LL.D., 
and  E.  H.  Hartley,  B.  S.,  M.  D.,  cellasin  is  a  cata- 
lyzer of  various  food  materials,  producing  lactic 
acid  from  carbohydrates,*  and  fatty  acid  from  fats. 
It  is  shown  that  it  acts  in  an  alkaline  medium,  thus 
representing  an  important  advance  over  ferments 
and  inicroorganisms  which  act  only  in  a  slightly 
acid  or  neutral  medium.  Cellasin  is  a  light  colored 
dry  powder  having  the  general  appearance  of  pan- 
creatin  or  other  enzymes.  It  is  described  to  be  a 
true  enzyme  which  is  not  permanently  affected  by 
hydrochloric  acid  or  by  other  enzymes,  and  that 
there  is  consequently  reason  to  believe  that  it 
reaches  the  cells  of  the  body  with  its  sugar  splitting 
qualities  vmimpaired.  A  considerable  part  of  Dr. 
Teeple's  tests  were  verified  by  Professor  W.  R. 
Orndorff,  of  Cornell  University.  Dr.  Sadtler  sums 
up  his  report  by  saying: — "These  experiments  show- 
conclusively  that  the  cellasin  operating  in  a  weak 
alkaline  or  neutral  solution  has  -  the  power  to  de- 
compose a  pure  sugar  solution  with  the  production 
of  lactic  acid,  alcohol,  and  carbon  dioxide,  and  that 
this  action  is  not  prevented  by  the  addition  of  the 
several  antiseptics,  with  the  exception  of  thymol.'" 
Dr.  Bartley  says :  "Cellasin  is  a  soluble  ferment, 
acting  in  an  alkaline  solution  and  possessing  great- 
er stability  and  a  greater  power  of  splitting  fats 
and  carbohydrates  (starch  and  sugar)  than  any 
ferment  with  which  I  am  acquainted." 

Cerolin,  a  substance  obtained  from  yeast,  has 
been  used  with  good  results  as  a  purgative,  pre- 
scribed in  pill  form.  It  also  finds  use  in  gynaecology 
in  the  form  of  bougies,  and  in  five  per  cent,  vaginal 
suppositories  in  the  treatment  of  leucorrhoea.  gonor- 
rhoeal  vaginitis,  dermatitis,  eczema,  and  pruritus. 

lodargyr  is  the  name  applied  to  an  organic 
iodine  and  mercury  compound  which  occurs  as  a 
yellow  powder  insoluble  in  water,  alcohol,  or  ether. 
It  is  intended  for  external  use  in  the  treatment  of 
wounds,  ulcers,  etc.,  but  may  also  be  given  inter- 
nally in  doses  of  one  to  two  grains  daily. 

lodoval  is  intended  for  use  as  a  substitute  for 
iodides.  Chemically  it  is  o-mono-iodo-iso-valerianyl- 
urea.  It  forms  white,  bitter,  needle  shaped  crvstals, 
almost  insoluble  in  cold  water.  It  is  prescribed  in 
doses  of  five  grains  three  times  daily. 


March  20,  1909.) 


EDITORIAL  ARTICLES. 


599 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK.  S.^TURDAY,  MARCH  20,  1909. 


MEDICAL  REPRESEXTATIOX  AT  THE 
PHARMACOPCEIAL  COX\  EXTIOX. 

A  call  will  soon  be  issued  for  the  ninth  decennial 
convention  for  the  revision  of  the  United  States 
Pharmacopoeia,  which  will  be  held  in  Washington 
on  May  lo,  1910.  The  United  States  Pharma- 
copoeial  Convention  is  a  body  incorporated  under 
the  laws  of  the  District  of  Columbia.  Its  constitu- 
tion provides  that  its  members  shall  be  "delegates 
elected  by  the  following  organizations  in  the  man- 
ner they  shall  respectively  provide :  Incorporated 
medical  colleges  and  universities ;  incorporated  col- 
leges of  pharmacy  and  pharmaceutical  schools  con- 
nected with  incorporated  universities ;  incorporated 
State  medical  associations ;  incorporated  pharma- 
ceutical associations ;  the  American  Medical  .Asso- 
ciation, the  American  Pharmaceutical  Association, 
and  the  American  Chemical  Society;  provided  that 
no  such  organization  shall  be  entitled  to  representa- 
tion unless  it  shall  have  been  incorporated  within, 
and  shall  have  been  in  continuous  operation  in,  the 
United  States  for  at  least  five  years  before  the  time 
fixed  for  the  decennial  meeting  of  this  corporation." 
The  membership  will  also  include  delegates  appoint- 
ed by  the  surgeon  general  of  the  United  States 
Army,  by  the  surgeon  general  of  the  United  States 
Navy,  by  the  surgeon  general  of  the  United  States 
Public  Health  and  Marine  Hospital  Service,  and  by 
the  organizations  not  previously  mentioned  which 
were  admitted  to  representation  in  the  convention 
of  1900.  Each  of  these  bodies  is  entitled  to  send 
three  delegates  to  the  meetings  of  the  corporation. 


The  medical  societies  and  institutions  which  are 
entitled  to  representation  in  this  convention  would 
do  well  to  give  the  matter  of  the  choice  of  delegates 
most  careful  consideration.  It  is  highly  important 
that  the  physicians  selected  to  participate  in  this 
work  shall  be  men  of  wide  experience  and  in  active 
practice.  There  has  been  a  tendency  to  select  as 
delegates  men  who  are  teachers  rather  than  practi- 
tioners of  medicine,  and  this  tendency  should  be  carc- 
fullv  guarded  against.  The  fact  that  the  United 
States  Pharmacopceia  has  now  become  a  legal  stand- 
ard adds  much  to  tlie  importance  of  the  work  and 
imposes  a  serious  obligation  upon  the  revisers.  The 
volume  is  intended  to  be  practically  useful,  and  care 
must  be  exercised  to  avoid  making  it  academic  in 
character.  The  best  way  to  insure  compliance  with 
these  requirements  is  to  place  its  revision  in  the 
hands  of  the  men  engaged  in  active  practice  both  in 
medicine  and  in  pharmacy.  Plans  are  now  on  foot 
for  the  meetings  of  several  medical  associations 
which  take  place  early  in  the  spring,  and  in  planning 
the  work  of  these  organizations  the  officers  and 
members  should  not  fail  to  give  due  attention  to  the 
very  important  duty  which  devolves  on  them  of  se- 
lecting delegates  to  the  Pharmacopoeial  convention 
who  will  bring  to  the  work  of  that  body  the  fruit  of 
wide,  active,  and  recent  experience  in  the  practice 
of  medicine.  Practitioners,  not  pedagogues  or  poli- 
ticians should  be  selected  as  delegates. 


THE  .^:TI0L0GY  of  rocky  MOUNT AIX 
FEVER. 

Rocky  Mountain  fever  has  long  been  an  a?tiologi- 
cal  conundrum.  ^lany  observers  have  believed  that 
it  was  typhoid  fever  modified  by  the  climatic  influ- 
ences of  the  Rocky  jMountain  region.  Others  have 
believed  it  to  be  a  modified  form  of  malarial  fever. 
Largely  through  the  work  of  King,  of  the  United 
States  Public  Health  and  Marine  Hospital  Service, 
this  disease  has  been  shown  to  be  transmitted  by  the 
tick,  Dcnnacenfor  occidentalis,  and  Wilson  and 
Chowning,  of  the  same  service,  had  previously 
shown  that  the  disease  was  neither  an  abnormal 
typhoid  infection  nor  an  abortive  form  of  malarial 
disease. 

Ricketts,  of  Chicago,  has  pttblished  numerotis  val- 
uable contribtitions  to  the  pathology  of  Rocky 
]Mountain  fever  and  has  been  successful  in  confirm- 
ing the  findings  of  King  concerning  the  method  of 
trasmission  of  the  virus.  In  his  latest  publication 
{Journal  of  the  American  Medical  Associatioji,  Jan- 
uary 30th)  Ricketts  describes  a  bacillus  that  resem- 
bles that  of  h;emorrhagic  septichasmia  which  he 
found  in  the  eggs  of  infected  ticks.  Similar  bodies 
were  found  in  the  blood  of  infected  guinea  pigs  and 
monkeys  and  occasionally  in  the  blood  of  man.  This 


EDITURIAL  ARTICLES. 


[Xew  York 
Meoical  Journal. 


organism  is  agglutinated  by  immune  guinea  pig 
serum.    It  has  not  been  cultivated. 

The  natural  history  of  Rocky  Mountain  fever 
points  to  a  protozoan  parasite  as  its  setiological  fac- 
tor. The  virus  evidently  undergoes  a  cycle  of  de- 
velopment in  the  body  of  the  tick,  as  indicated  by 
the  fact  that  it  can  be  transmitted  to  the  larvae  of 
the  insect.  The  symptomatology  also  points  to  a 
protozoan  origin  of  the  infection.  Before  it  is  defi- 
nitely concluded  that  the  bodies  described  by  Rick- 
clts  are  bacteria,  and  that  they  bear  an  astiological 
relation  to  Rocky  Mountain  fever,  the  experience  of 
other  observers  in  the  same  disease  should  b?  care- 
fully considered,  as  well  as  the  fate  of  the  numerous 
bacterial  agents  so  often  discovered  as  the  cause  of 
yellow  fever.  Piroplasma  houiinis  probably  does 
not  exist.  Cryptococcus  xanthogeniciis,  discovered 
b\  Domingos  Freire,  of  Rio  de  Janeiro,  in  1883  : 
Micrococcus  tctragciics.  isolated  by  Carmona  y 
Valle,  of  Mexico,  in  1885  ;  Bacillus  x,  described  by 
George  M.  Sternberg  in  1889;  and  Bacillus  ictcr- 
oidcs,  found  by  Sanarelli  in  1897.  have  all  been  dis- 
carded as  jetiological  factors  in  yellow  fever. 


CH.AXGIXG  FASHIONS  IN  THE  USE  OF 
MEDICAL  TITLES. 
Xot  many  years  ago  the  title  page  of  a  medical 
work  usually  introduced  the  learned  author  plas- 
tered with  decorations,  orders,  and  titles,  parch- 
ments and  beribboned  diplomas  in  each  hand,  and  a 
long  string  of  medals,  prizes,  and  degrees  trailing 
after.  In  all  countries  the  noblest  men  in  the  pro- 
fession have  not  been  above  the  weakness  of  freely 
indulging  in  this  ostentatious  farrago.  Thus,  the 
seventh  edition  of  Hyrtl's  scholarly  classic  on  anato- 
my, published  in  1884,  contains  no  fewer  than  sev- 
enty-five titles  following  the  name  of  the  distin- 
guished author,  which  in  four  point  type  occupy 
more  than  a  third  of  the  ample  octavo  title  page. 
'  For  some  time  there  has  been  evident  in  medical 
literature  a  wholesome  reaction  from  this  ludicrous 
display  of  numerous  titles,  and  there  is  now  to  be  de- 
tected a  tendency  to  the  opposite  extreme.  Instead 
of  appearing  in  all  his  ornamental  regalia,  there  is 
to-day,  in  some  quarters,  an  affectation  of  severe 
simplicity,  and  the  author  appears  before  his  read- 
ers with  scarcely  a  loin  cloth  to  cover  his  naked- 
ness. When  the  great  man  publishes  the  result  of 
his  researches,  it  is  likely  to  be  in  the  form  of  A 
Preliiiiiuary  Report  of  Observations  011  a  Xew  Cul- 
ture Medium  for  the  Hay  Bacillus,  by  Labki'cheii, 
or  The  Homologue  of  the  Pineal  Gland  in  the  Aut- 
phioxus,  by  Kadinsky.  One  often  looks  in  vain  f  ir 
the  writer's  first  name,  and  even  the  medical  de- 
gree is  frequently  omitted- -perhaps  in  some  cas.'S 
for  the  very  good  reason  that  the  writer  does  not 


possess  one,  for  it  is  a  somewhat  astonishing  fact 
that  there  is  an  ever  increasing  amount  of  medical 
literature  which  is  not  written  by  medical  men. 
Both  in  this  country  and  in  Europe  the  obscure  and 
rather  vague  subjects  of  metabolism,  pathological 
chemistry,  and  diet  reform,  to  say  nothing  of  such 
simple  matters  as  tuberculosis  and  cancer,  seem  to 
have  a  peculiar  charm  for  men  who  have  had  no  edu- 
cation or  training  in  medicine.  In  this  connection  ii 
is  worthy  of  note  that  a  recent  voluminous  System 
of  the  Practice  of  Medicine  is  remarkable  for  the 
number  of  articles  in  it  by  writers  who  do  not  hold 
a  medical  degree  and  who  could  not  legally  prac 
tise  medicine  in  any  civilized  country.  With  rare 
exceptions  the  most  valuable  literature  in  medicine 
has  been  produced  by  physicians,  and  usually  by 
physicians  who  have  themselves  practised  the  ar: 
in  which  they  assume  to  instruct  others.  There  are 
doubtless  good  reasons  for  the  disrepute  into  which 
the  ancient  appellations  "'Doc"  and  "Professor" 
have  fallen,  but  it  is  possible  that  we  may  go  too  far 
in  the  disuse  of  the  distinctive  and  honorable  med- 
ical degree.  For  ourselves,  we  confess  to  an  ol  1 
fashioned  liking  for  the  M.  D.  after  a  medical  writ- 
er's name. 


MEMORIALS  OF  MEDICAL  MEN. 

Very  satisfactory  progress  is  reported  in  the  col- 
lection of  a  fund  for  establishing  a  memorial  of  the 
late  Dr.  Andrew  J.  McCosh  in  connection  with  the 
new  buildings  of  the  Presbyterian  Hospital,  and  now 
it  is  very  properly  proposed  to  obtain  the  means  of 
creating  a  great  institution  for  surgical  research,  to 
be  connected  with  the  School  of  Medicine  of  Colum- 
bia University  (the  College  of  Physicians  and  Sur- 
geons), in  memory  of  the  late  Dr.  William  T.  Bull 
The  hospital  and  the  college  mentioned  arc  those  in 
which  the  respective  activities  of  Dr.  McCosh  and 
Dr.  Bull  were  largely  displayed,  and  there  can  bL> 
no  question  of  the  propriety  of  connecting  the  me- 
morials with  them. 

There  are  various  suitable  forms  of  memorials  of 
medical  men.  Among  them  is  the  statue,  but  the 
tendency  of  the  present  period  is  toward  other  and 
more  useful  means  of  perpetuating  the  memory  of  a 
distinguished  member  of  the  medical  profession. 
Hospital  wards  and  even  entire  hospitals  are  nan^ed 
for  deceased  physicians  and  surgeons  of  renown  ;  .<o 
also  are  medical  schools,  operating  theatres,  and  re- 
search laboratories.  The  statue  is  perishable,  and  in 
any  event  comes  before  many  years  to  have  little  if 
any  significance  for  the  great  multitude  of  those  who 
casually  view  it,  but  the  beneficent  work  of  a  hospi- 
tal, a  college,  or  a  laboratory  is  destined,  let  us  hope, 
to  be  more  lasting  and  by  its  name  to  perpctunte  a 
man's  memory  more  forcibly. 


March  20,  1909.] 


EDITORIAL  ARTICLES. 


60 1 


THE  DISPOSAL  OF  THE  DEAD  .\T  SEA. 

Interest  in  this  matter  has  of  late  been  revived, 
but  it  cannot  be  said  that  in  the  past  the  pubHc  have 
at  any  time  been  quite  apathetic,  and  on  occasions 
indignation  has  been  hot  at  the  imperious  deter- 
mination of  the  commanders  of  passengers  ships  to 
consign  the  dead  to  the  deep.  There  have  often,  in- 
deed generally,  been  circumstances  palliatory  of 
such  an  unwelcome  course,  but  the  present  resources 
of  the  great  vessels  engaged  in  passenger  transporta- 
tion do  not  longer  seem  to  warrant  it. 

Barring  sailors'  superstitions — and  they  ought  al- 
ways to  be  overruled — we  do  not  see  any  note- 
worthy impediment  to  such  efficient  embalming  as 
will  admit  of  the  conveyance  of  a  deceased  passen- 
ger's remains  to  the  ship's  destination,  whence  they 
mav  readily  be  transported  to  a  place  of  sepulture 
chosen  by  the  friends.  Then,  too,  the  modern  elec- 
tric furnace  may  undoubtedly  be  made  adequate  to 
the  satisfactory  accomplishment  of  cremation  with- 
out danger  to  the  vessel.  If  we  are  right  in  our 
supposition,  then,  the  friends  of  a  passenger  who 
dies  at  sea  ought  always  to  be  allowed  the  choice 
between  embalming  and  cremation  of  the  remains, 
the  expense,  of  course,  being  chargeable  to  them  or 
to  the  estate  of  the  deceased.  The  matter  of  re- 
sponsibility might  easily  be  arranged. 


SCOTTISH  NURSES  AND  HO^IE  RULE. 

It  seems  that  on  the  part  of  the  medical  profession 
of  Scotland — and  also  among  the  Scottish  nurses — 
there  is  considerable  dissent  from  the  provisions  of 
a  bill  which  has  passed  the  House  of  Lords  concern- 
ing the  registration  of  nurses.  The  question  is,  says 
the  Edijibiirgli  Medical  Journal  for  March,  Shall 
Scottish  nurses  have  home  rule?  Is  the  whole  pro- 
fession of  nursing  in  the  British  Islands,  asks  our 
contemporary,  to  be  regulated  by  a  council  in  Lon- 
don on  which  the  nurses  and  the  medical  profession 
of  Scotland  shall  each  have  one  member — "the  lat- 
ter, by  the  way,  nominated  by  the  British  iMedical 
Association,  a  body  not  greatly  in  favor  in  Scotland 
just  now" — or  shall  the  nurses,  in  conjunction  with 
the  medical  profession,  apply  to  the  legislature  to 
establish  an  independent  council  for  Scotland  ? 

Careful  consideration  of  the  bill  which  has  passed 
the  House  of  Lords  appears  to  have  led  those  most 
actively  interested  to  the  conclusion  that  the  latter 
alternative  is  to  be  preferred.  Meetings  of  the  med- 
ical and  nursing  superintendents  of  the  larger  Scot- 
tish hospitals  have  been  held,  and  a  bill  drafted  by 
them  has  been  published.  The  English  bill,  it  ap- 
pears, gives  to  the  proposed  council  the  conduct  of 
the  examinations  and  the  appointment  of  the  exam- 
iners, while  the  proposed  Scottish  bill  "only  takes 
power  to  regulate  and  supervise  by  means  of  the  ap- 
pointment of  inspectors." 


Our  contemporary  thinks  that  there  arc  one  or 
two  amendments  (which  it  does  not  specify)  that 
would  improve  the  Scottish  draft,  but  that,  on  the 
whole,  it  seems  reasonable  and  worthy  of  the  sup- 
port of  the  medical  profession,  for  it  appears  that  it 
more  adequately  recognizes  the  prime  importance  of 
training  and  the  essentially  ancillary  nature  of 
nurses,  while  the  English  bill  lays  most  stress  on 
examination  and  seems  to  tend  in  "the  undesirable 
direction  of  erecting  nursing  into  an  independent 
profession."'  Further,  the  fee  for  examination  and 
registration  proposed  in  the  English  bill  (five 
guineas)  is  regarded  in  Scotland  as  unnecessarily 
laree.  To  us  in  America  there  seem  to  be  substan- 
tial  prima  facie  foundations  for  the  Scottish  objec- 
tions to  the  English  bill,  though  we  cannot  profess 
to  know  the  ins  and  outs  of  the  questions  involved. 
In  particular,  we  cannot  pretend  to  estimate  the  im- 
portance of  the  lack  of  favor  with  v\-hich  the  British 
]Medical  Association  is  said  to  be  held  in  Scotland  at 
the  present  time. 


ESPERANTO  VERSUS  ILO. 
^Medical  men  seem  to  have  become  particularlv  in- 
terested in  artificial  languages,  especially  in  Espe- 
ranto, and  that  fact  is  our  reason  for  mentioning 
the  present  controversy  between  the  adherents  of 
Esperanto  and  the  advocates  of  Ilo.  Dr.  Max  Tal- 
mey,  of  New  York,  founder  and  first  president  of  the 
former  New  York  Esperanto  Society,  has  recentl\ 
published  a  pamphlet  from  which  we  gather  that  he 
has  abandoned  Esperanto  and  taken  up  Ilo.  It  ap- 
pears that  Ilo  is  an  offshoot  or  development  of 
Esperanto,  and  Dr.  Talmey  implies  that  it  is  an  im- 
provement on  the  parent  tongue.  We  know  but  lit- 
tle of  Esperanto,  and  we  know  less  of  Ilo,  but  our 
inclination  is  to  say,  with  Mercutio,  "a  plague  on 
both  your  houses !"  The  idea  of  a  universal  lan- 
guage made  to  order,  so  to  speak,  is  to  us  Utopian. 
It  may,  to  begin  with,  be  free  from  irregularities, 
bull  to  say  nothing  of  other  objections,  they  are 
sure  to  be  injected  into  it  by  the  illiterates  of  the 
period.  He  who  cannot  speak  his  mother  tongue 
correctly  is  absolutely  certain  to  corrupt  any  other 
language  which  he  may  suppose  himself  to  have 
learned,  particularly  an  artificial  one ;  and  those  who 
debase  their  own  language,  whatever  it  may  be.  are 
getting  to  be  more  and  more  numerous. 


ANNUAL  REPORT  OF  THE  BUREAU  OF 
ANIMAL  INDUSTRY. 
The  twenty-fourth  annual  report,  covering  the  op- 
erations for  the  year  1907,  was  issued  by  the  De- 
partment of  Agriculture  last  month.  It  is  an  octavo 
volume  of  nearly  500  pages.  Many  of  the  articles 
deal  with  subjects  quite  intimately  connected  with 


OBITUARY.— NEWS  ITEMS. 


[New  York 
Medical  Journai,. 


medicine  and  with  matters  of  public  health.  In  par- 
ticular, a  great  deal  of  space  is  devoted  to  the  milk 
industry  and  to  certain  diseases  of  the  domestic  ani- 
mals. It  is  not  to  dairymen  or  to  veterinarians  alone 
or  even  chiefly  that  these  writings  are  of  interest. 
They  are  closely  associated  with  many  of  the  great 
problems  of  public  and  individual  sanitation.  They 
w'ill  therefore  commend  themselves  especially  to 
physicians  and  to  sanitarians. 


THE  MASSACHUSETTS  GENERAL 
HOSPITAL. 
This  venerable  institution,  ever  memorable  as  the 
scene  of  the  first  public  surgical  operation  under 
ether  anaesthesia,  has  within  recent  years  shown  no- 
table development.  This  is  strikingly  shown  by  the 
plan  of  the  grounds,  which  serves  as  a  frontispiece 
to  the  ninety -fifth  annual  report,  for  the  year  1908, 
in  which  the  Bulfinch  Building  (practically  the 
whole  hospital  but  a  few  years  ago)  shows  as  rather 
a  minor  feature,  though  it  is  still  impressive  to  the 
actual  view.  We  note  that  Dr.  Reginald  H.  Fitz 
has  been  retired  as  a  visiting  physician,  by  reason  of 
having  reached  the  age  limit,  and  been  made  a  con- 
sulting physician. 

 ^  

THADDEUS  ASBURY  REAAIY,  M.  D.,  LL.  D., 
of  Cincinnati. 

Dr.  Reamy  died  on  Thursday,  March  nth,  at  the 
age  of  eighty  years.  He  was  a  Virginian  by  birth, 
but  he  received  his  medical  degree  from  the  Star- 
ling Medical  College,  of  Columbus,  O.,  in  1854, 
and  his  professional  life  was  led  in  Ohio — for  many 
of  his  later  years  in  Cincinnati.  For  many  years  he 
was  a  gynaecologist  of  note  and  an  active  member 
of  the  American  Gynjecological  Society,  of  which 
he  was  made  an  honorary  fellow  in  1907.  He  was 
a  man  of  great  physical  and  intellectual  power  and 
•of  attractive  personality. 

 ^  

|[tto5  Items.  • 


Changes  of  Address. — Dr.  Henry  F.  Waite,  to  1344 
Sprncc  Street,  Philadelphia. 

Hr.  I.  Stern,  to  128  East  Ninety-sixth  Street,  New  York. 

Dr.  H.  Apfel,  to  .133  Pennsylvania  Avenue,  Brooklyn. 

Dr.  William  Triiitt  Goclfrey,  house  surgeon  of  the  New 
^''|^k  Postgraduate  Hospital,  will  open  an  office  on  April 
1st.  at  32  South  Street,  Stamford,  Conn. 

A  Medical  College  at  Peking.  —  According  to  press 
despatches,  an  appeal  has  heen  issued  by  the  Chinese  Emer- 
gency .Appeal  Committee  for  $500,000  for  the  purpose  of 
establishing  a  medical  college  in  Peking,  and  three  medical 
schools  elsewhere.  The  object  is  to  provide  for  a  thorough 
merlical  training  on  modern  lines  for  the  Chinese. 

A  School  of  Applied  Science  in  Pittsburgh. — An- 
nf)iniccnu'nt  is  made  that  Mr.  Andrew  Carnegie  has  pre- 
sented to  the  Carnegie  Technical  Institution,  Pittsburgh,  a 
Si. 000.000  building  for  a  School  of  .Applied  Science.  An 
addition  to  the  new  school  is  being  erected,  at  a  cost  of 
another  million,  which,  it  is  said,  will  be  finished  within 
the  year. 


The  Section  in  Pathology  of  the  Buffalo  Academy  of 
Medicine  held  a  regular  meeting  on  Tuesday  evening, 
March  i6th.  The  programme  included  a  paper  entitled 
Hsemolytic  Reaction  in  Sarcoma,  by  Dr.  H.  G.  Sloan,  of 
Cleveland,  Ohio,  and  a  paper  on  Resuscitation  after  Ap- 
parent Death  from  An;csthesia,  by  Dr.  F.  C.  Busch  and  Dr. 
T.  H.  McKee. 

A  Dinner  in  Honor  of  Dr.  Rupert  Blue,  of  the  United 
States  Public  Health  and  Marine  Hospital  Service,  was 
given  at  the  Fairmont  Hotel,  San  Francisco,  on  Wednes 
day  evening,  March  17th,  as  a  testimonial  to  Dr.  Blue  for 
the  efficient  work  done  by  him  in  cleaning  up  the  city  a 
few  months  ago  when  it  was  threatened  with  an  epidemic 
of  bubonic  plague.  Five  hundred  of  the  most  prominent 
citizens  of  San  Francisco  attended  the  dinner  to  do  honor 
to  Dr.  Blue. 

Grateful  Patients  Seek  Souvenirs  of  Dr.  McCosh. — It 

is  reported  that  the  caretaker  of  the  house  which  was  occu- 
pied by  Dr.  McCosh  at  the  time  of  his  death  has  been  re- 
ceiving daily  for  a  number  of  weeks  requests  for  some 
small  article  as  a  souvenir  of  Dr.  McCosh.  A  pen  holder,  a 
pen  wiper,  or  even  a  pen  point  would  suffice,  and  one  man 
asked  for  even  a  small  slip  of  paper  that  had  been  touched 
by  the  hands  of  Dr.  McCosh.  The  caretaker  has  had  to  re- 
fuse all  such  requests. 

President  Taft's  Physicians. — Lieutenant  Colonel  Guy 
L.  Edie  and  Major  Matthew  A.  De  Lancy,  of  the  Medical 
Corps  of  the  Army,  have  been  appointed  physicians  to 
President  Taft  during  his  four  years'  term  of  office.  In 
addition  to  being  the  family  physicians  of  the  Taft  family, 
they  will  have  charge  of  the  hygiene  of  the  Wliite  House, 
succeeding  Dr.  P.  M.  Rixey,  Surgeon  General  of  the  United 
States  Navy,  who  was  physician  to  Mr.  Roosevelt  and  Mr. 
McKinley,  being  with  the  latter  when  he  died  in  Buffalo. 
Dr.  Edie  accompanied  the  Taft  party  which  went  to  the 
Philippines  in  1906. 

Fees  for  President  McKinley's  Physicians. — Accord- 
ing to  a  statement  which  has  just  been  issued  by  Treasury 
officials  covering  all  the  items  of  expenditure  incident  to 
the  last  illness  and  burial  of  President  McKinley,  the  fol- 
lowing fees  were  paid  to  physicians :  Dr.  M.  D.  Mann, 
$10,000;  Dr.  H.  Mynter,  $6,000;  Dr.  C.  McBurney,  $5,000; 
Dr.  Roswell  Park,  $5,000;  Dr.  C.  G.  Stockton,  $1,500;  Dr. 
E.  G.  Janewav,  $1,500;  Dr.  H.  G.  Matzinger,  $750;  Dr.  W. 
W.  Iohnston,'Dr.  E.  W.  Lee,  and  Dr.  H.  R.  Gaylord,  $500 
each ;  Dr.  N.  W.  Wilson,  $250 ;  and  Dr.  G.  McR.  Hall  and 
Dr.  E.  C.  Mann,  $200  each. 

The  American  Hospital  in  Paris  will  be  formally 
opened  in  May.  Through  the  generosity  of  members  of 
the  American  Colony  in  Paris  funds  have  been  raised  with 
wliich  two  adjoining  villas  at  Neuilly  have  been  purchased 
and  converted  into  a  fully  equipped  modern  hospital.  The 
hospital  contains  two  wards  of  seven  beds  each,  and  eleven 
private  roon/s.  There  is  also  a  free  consultation  room. 
The  grounds  in  the  rear  will  be  converted  into  a  delightful 
garden  and  two  pavilions  will  be  erected  there.  All  classes 
of  the  American  Colony  of  Paris  are  eligible  for  admission 
to  the  hospital — students,  artists,  merchants,  and  tourists. 

Sanatorium  for  Incipient  Tuberculosis. — The  atten- 
tion of  the  physicians  of  New  York  is  directed  to  the  facil- 
ities for  the  care  of  incipient  cases  and  early  second  stage 
cases  of  pulmonary  tuberculosis  now  available  at  the  Mu- 
nicipal Sanatorium  at  Otisville.  N.  Y.  This  institution  has 
at  present  over  two  hundred  beds,  and  the  number  is  being 
increased  as  rapidly  as  possible.  .Application  for  admission 
should  he  made  at  the  clinic  for  coir.municable  pulmonary 
diseases  of  the  Department  of  Health  of  the  City  of  New 
York,  at  Fifty-fifth  Street  and  Sixth  .Avenue.  Manhattan. 
Physicians  may  send  their  patients  directly  to  this  clinic  for 
examination,  with  card  or  letter. 

The  Woman's  Medical  Society  of  the  State  of  New 
York. — .\t  the  annual  meeting  of  this  organization, 
which  was  held  in  Rochester  on  Thursday,  March  nth,  the 
following  officers  were  elected:  President.  Dr.  F.liza  M. 
Mosher.  of  Brooklyn :  vice  president,  Dr.  Mary  B.  Jewett. 
of  New  York;  second  vice  president.  Dr.  Evelyn  Baldwin, 
of  Rochester;  third  vice  president.  Dr.  lane  VVall  Carroll, 
of  Buffalo;  secretary.  Dr.  Emelinc  P.  Ballantine.  of  Roches- 
ter; treasurer.  Dr.  Harriet  M.  Turner,  of  Rochester.  Dr. 
Sarah  R.  A.  Dollcy,  of  Rochester,  one  of  the  first  women 
to  practice  medicine  in  the  State,  celebrated  her  eightieth 
birthday  on  the  day  of  the  meeting. 


Maren  20,  1909.] 


NEWS  ITEMS. 


603 


Naming  London  Streets  after  Distinguished  Men  of 
Science. — The  British  Science  Guild  has  been  consider- 
ing the  question  of  naming  several  of  the  streets  of  London 
after  men  who  have  won  honors  in  the  world  of  science, 
and  recently  requested  the  members  of  the  executive  com- 
mittee of  the  guild  to  send  in  names  for  this  purpose.  The 
following  names  were  submitted :  Newton,  Darwin,  Har- 
vey, Jenner,  Huxley,  James  Watt,  Gilbert,  Kelvin,  Faraday, 
Joule,  James  Clerk  Maxwell,  Stokes,  Tyndall,  Captain 
Cook,  Livingstone,  Franklin,  Ross,  Bruce,  Mungo  Park, 
Cavendish,  Dalton,  Priestley,  Boyle,  Andrews,  Halley, 
Herschel,  Horrocks,  Adams,  Bradley,  Howard,  and  Pen- 
nington. 

A  Department  of  Naval  Hygiene  and  Physiology  at 
Annapolis. — The  recommendations  of  the  Surgeon  Gen- 
eral of  the  Navy,  the  Chief  of  the  Bureau  of  Navigation, 
and  the  former  Assistant  Secretary  of  the  Navy,  for  the  es- 
tablishment of  a  department  of  naval  hygiene  and  physiol- 
ogy at  the  Naval  Academy,  were  approved  just  before  the 
inauguration  of  President  Taft.  Surgeon  Charles  F. 
Stokes  will  organize  the  department,  and  the  senior  medical 
officer  on  duty  at  the  Academy  will  be  at  the  head.  It  is 
proposed  that  the  department  shall  provide  for  instruction 
in  physiology,  in  the  nature  and  effects  of  alcoholic  drinks 
and  narcotics,  and  in  all  matters  pertaining  to  naval  sanita- 
tion and  hygiene. 

The  Medical  Society  of  the  County  of  New  York  w  ill 
hold  a  stated  meeting  on  Monday  evening,  March  22d,  in 
Hosack  Hall,  New  York  Academy  of  Medicine,  at  8:15 
o'clock.  Dr.  George  Thomas  Jackson  will  read  a  paper  en- 
titled Freezing  as  a  Therapentic  Measure,  Liquid  Air  and 
Carbonic  Acid  Snow,  which  will  be  discussed  by  Dr. 
Charles  T.  Dade,  Dr.  H.  H.  Whitehouse.  Dr.  James  D. 
Gold,  and  Dr.  William  B.  Trimble.  Dr.  Russell  A.  Hibbs 
will  read  a  paper  describing  an  operation  for  congenital 
dislocation  of  the  hip.  He  will  also  present  patients  and 
exhibit  an  instrument  used  in  performing  the  operation. 
Dr.  Edward  A.  Scripture  will  read  a  paper  entitled  Pen- 
manship Stuttering,  which  will  be  discussed  by  Dr.  William 
S.  Thomas  and  Dr.  L.  Pierce  Clark.  The  next  meeting  of 
the  society  will  be  held  on  April  26th. 

The  Care  of  the  Crippled. — At  a  stated  meeting  of  the 
New  York  Academy  of  Medicine  held  on  Thursday  even- 
ing, March  i8th,  under  the  auspices  of  the  Section  in  Or- 
thopjedic  Surgery,  the  subject  chosen  for  discussion  was 
What  Becomes  of  Our  Cripples?  In  response  to  invita- 
tions Dr.  De  Forest  Willard,  of  Philadelphia,  read  a  paper 
entitled  Methods  of  the  Widener  Industrial  Training 
School  for  Crippled  On'ldren  in  Philadelphia,  and  F.  W. 
Persons,  Esq.,  of  the  Charity  Organization  Society  of  New 
York  read  a  paper  on  Opportunities  for  the  Employment  of 
Cripples.  Dr.  Oiarles  H.  Jaeger,  instructor  in  orthopaedic 
surgery  at  Columbia  University,  read  a  paper  on  the  Care 
of  the  Injured  and  Crippled  in  Germany.  Among  those 
who  participated  in  the  general  discussion  which  followed 
the  reading  of  the  papers  were  the  Hon.  Robert  W.  Heb- 
berd,  commissioner  of  charities  of  New  York;  Homer 
Folks,  Esq.,  of  the  State  Board  of  Charities ;  P.  Tecumseh 
Sherman,  Esq.,  ex-con,Tnissioner  of  labor  of  the  State  of 
New  York;  Dr.  Virgil  P.  Gibney;  Dr.  Newton  M.  Shaf- 
fer; and  Dr.  Theodore  C.  Janeway. 

A  Research  Laboratory  at  Columbia  as  a  Memorial 
to  Dr.  Bull. — As  a  fitting  memorial  to  the  life  antl  work 
of  Dr.  William  Tillinghast  Bull,  the  friends  and  medical 
associates  of  the  great  surgeon  are  planning  the  establish- 
ment of  an  institution  for  surgical  research  in  connection 
with  the  medical  department  of  Columbia  University.  At 
a  meeting  held  at  the  home  of  Dr.  Lemuel  B.  Bangs  a  short 
time  ago  for  the  purpose  pf  discussing  the  erection  of  a  suit- 
able memorial  to  Dr.  Bull,  an  executive  committee  was  ap- 
pointed to  further  the  work.  At  present  this  committee 
consists  of  the  following  members :  John  E.  Parsons,  Esq., 
ex-President  of  the  American  Bar  Association,  chairman: 
the  Hon.  Joseph  H.  Choate,  ex-Ambassador  to  England, 
who  is  also  an  ex-President  of  the  American  Bar  Associa- 
tion ;  Austen  G.  Fox,  Esq.,  Dr.  Clement  Cleveland,  Dr.  Vir- 
gil P.  Gibney.  professor  of  orthopaedic  surgery  in  the  Col- 
lege of  Physicians  and  Surgeons,  Dr.  Francis  P.  Kinnicutt, 
professor  of  clinical  medicine  in  the  College  of  Physicians 
and  Surgeons,  Dr.  Nathaniel  Bowditch  Potter,  also  a  pro- 
fessor in  the  College  of  Physicians  and  Surgeons,  Dr.  John 
B.  Walker,  the  intimate  friend  and  associate  of  Dr.  Bull, 
who  accompanied  Dr.  Bull  to  Savannah  on  his  last  illness, 
and  Dr.  Lemuel  B.  Bangs,  who  acted  as  secretary  pro  tem. 
of  the  meeting. 


A  Scientific  Dietist  Wanted  in  the  Philippine  Service, 

— The  United  States  Civil  Service  Commission  announces 
an  examination  on  April  14,  1909,  to  secure  eligibles  from 
which  to  make  certification  to  fill  a  vacancy  in  the  position 
of  scientific  dietist  for  duty  in  the  Philippines,  and  vacan- 
cies requiring  similar  qualifications  as  they  may  occur  there. 
The  salary  is  $900  per  annum,  with  board  and  quarters. 
Applicants  must  have  had  extended  experience  in  super- 
vising and  directing  the  formulating,  preparing,  and  serv- 
ing of  dietaries  suited  to  the  needs  of  invalids  and  con- 
valescents, such  experience  to  have  been  acquired  in  an  ex- 
ecutive capacity  in  hospitals  or  similar  institutions.  The 
examination  is  open  to  all  citizens  of  the  United  States, 
both  men  and  women  will  be  admitted  to  the  examination, 
and  the  age  limits  are  twenty  to  forty  years.  Applicants 
should  apply  at  once  to  the  United  States  Civil  Service 
Commission,  Washington,  D.  C,  for  application  Forms  2 
and  375. 

A  Testimonial  Dinner  to  Dr.  Mills. — One  hundred 
representative  physicians  tendered  a  testimonial  dinner  to 
Dr.  Charles  Karsner  Mills,  the  distinguished  neurologist 
of  Philadelphia,  on  the  evening  of  Monday,  March  15th.  in 
the  Clover  Room  of  the  Bellevue-Stratford.  The  occasion 
n.arked  the  fortieth  anniversary  of  Dr.  Mills's  graduation 
from  the  University  of  Pennsylvania.  On  behalf  of  those 
present,  Dr.  W.  Keen  presented  a  silver  loving  cup  to 
Dr.  Mills,  in  appreciation  of  the  invaluable  services  ren- 
dered by  him  in  the  advancement  of  medical  science.  Dr, 
George  E.  de  Schweinitz  acted  as  toast  master,  and  ad- 
dresses were  made  as  follows:  Dr.  S.  Weir  Mitchell,  Per- 
sonal Recollections  of  a  Friendship;  the  Rev.  Arthur  B. 
Conger,  Doctor  and  Parson;  Dr.  J.  J.  Putnam,  Reminis- 
cences of  the  Anierical  Neurological  Association ;  Provost 
C.  C.  Harrison,  Our  Guest  and  the  University  of  Penn- 
sylvania ;  Dr.  A.  Jacobi,  The  General  Practitioner ;  Dr. 
William  H.  Welch,  Relation  of  Neurology  to  Patholog)-; 
and  Dr.  Charles  L.  Dana,  The  Rolandic  Fissure. 

Personal. — Major  Charles  Lynch,  of  the  Medical  De- 
partment of  the  U.  S.  Army,  will,  on  March  31st,  become 
editor  of  The  Military  Surgeon  and  secretary  of  the  Asso- 
ciation of  Military  Surgeons  of  the  United  States,  to  take 
the  place  of  Major  James  Evelyn  Pilcher,  who  resigned 
recently. 

Dr.  James  C.  Hepburn,  of  East  Orange,  N.  J.,  who  is 
said  to  be  the  oldest  living  graduate  of  Princeton  Univer- 
sity, celebrated  his  ninety-fourth  birthday  on  Sunday, 
March  14th.  Dr.  Hepburn  spent  many  years  in  Japan, 
where  he  went  as  a  member  of  the  medical  staff  of  the 
Presbyterian  Board  of  Foreign  Missions,  and  in  recogni- 
tion of  his  services  in  that  country  the  Mikado  conferred 
special  honors  upon  him. 

Dr.  W.  W.  Cadbury,  of  Philadelphia,  will  start  for  Can- 
ton, China,  in  a  few  days,  for  the  purpose  of  beginning 
work  in  the  Medical  School  there,  whicli  is  conducted  un- 
der the  auspices  of  the  Christian  Association  of  the  Uni- 
versity of  Pennsylvania.  A  farewell  reception  was  gi\en 
to  Dr.  Cadbury  in  the  Friends'  Twelfth  Street  Meeting 
House  on  the  evening  of  i\Iarch  8th.  Miss  Mary  C.  Sales, 
a  graduate  of  the  Training  School  for  Nurses  of  the  Penn- 
sylvania Hospital,  will  also  go  to  Canton,  to  take  up  work 
in  the  hospital  there. 

Society  Meetings  for  the  Coming  Week: 

Monday,  March  22d. — Medical  Society  of  the  County  of 
New  York. 

TuESD.AY,  March  Jsd. — New  York  Otological  Society ;  New 
York  Medical  Union ;  New  York  Dermatological  So- 
ciety ;  Metropolitan  Medical  Society  of  New  York 
City;  Buffalo  Academy  of  Medicine  (Section  in  Ob- 
stetrics and  Gynaecology). 

Wednesd.av.  March  .-'4//;.— New  York  Academy  of  Medi- 
cine (Section  in  Laryngology  and  Rhinology)  ;  New 
York  Surgical  Society. 

Thursday,  March  25th. — New  York  Academy  of  Medicine 
(Section  in  Obstetrics  and  Gynaecology)  ;  Brooklyn 
Pathological  Society;  New  York  Celtic  Society;  Hos- 
pital Graduates'  Club,  New  York ;  Brooklyn  Society 
for  Neurologv". 

Friday.  March  26th. — New  York  Clinical  Society:  New- 
York  Society  of  German  Physicians ;  Academy  of 
Pathological  Science. 

Saturday,  March  2^th. — West  End  Medical  Society:  Nev<r 
York  Medical  and  Surgical  Society :  Harvard  Medical 
Society,  New  York;  Lenox  Medical  and  Surgical  So- 
ciety. 


NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


The  Health  of  Pittsburgh. — During  the  week  ending 
February  27,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  :  Chickenpox, 
9  cases,  o  deaths;  typhoid  fever,  13  cases,  6  deaths;  scarlet 
fever,  30  cases,  i  death;  diphtheria,  13  cases,  i  death; 
measles,  28  cases,  o  deaths ;  whooping  cough,  27  cases,  i 
death ;  pulmonary  tuberculosis,  32  cases,  13  deaths.  The 
total  deaths  for  the  week  numbered  161,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  14.80  in  a  thousand  of  population. 

Mortality  Statistics  of  Chicago.  —  During  the  week 
ending  March  6,  1909,  the  total  number  of  deaths  from  all 
causes  reported  to  the  Department  of  Health  of  the  City 
of  Qiicago  was  601,  a  decrease  of  68  from  the  number  re- 
ported during  the  corresponding  period  in  1908.  The  an- 
nual death  rate  for  the  week  was  14.09,  which  is  a  trifle 
lower  than  the  average  for  the  past  ten  years.  The  princi- 
pal causes  of  death  were:  Diphtheria,  16;  scarlet  fever,  6; 
measles,  2;  whooping  cough,  i;  influenza,  6;  typhoid  fever. 
9;  diarrhoeal  diseases,  37,  of  N^hich  34  were  under  two  years 
of  age;  pneumonia,  133;  pulmonary  tuberculosis,  60;  othei' 
forms  of  tuberculosis,  13;  cancer,  40;  nervous  diseases,  16; 
heart  diseases,  46;  apoplexy,  16;  bronchitis,  i;  Bright's  dis- 
ease, 33 :  A-iolence,  37,  of  which  9  were  suicides ;  all  other 
causes,  129. 

Infectious  Diseases  in  New  York: 

We  arc  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  following  statement  of  mw 
cases  and  deaths  reported  for  the  two  weeks  cndiv^  March 
T3,  1900: 


,  March  6  > 

, — March  13 — n 

Cases. 

Deaths. 

Cases. 

Deaths. 

  464 

163 

48s 

188 

  332 

44 

357 

46 

20 

829 

22 

  352 

23 

438 

46 

I 

  255 

246 

28 

7 

30 

"t 

62 

3 

83 

6 

8 

7 

1 1 

9 

 2,143 

267 

2,480 

323 

The  Mortality  of  San  Francisco. — During  the  month 
of  January,  1909,  there  were  reported  to  the  Department  of 
Public  Health  of  the  City  and  County  of  San  Francisco, 
Cal.,  553  deaths  from  all  causes,  in  an  estimated  population 
of  475,000,  corresponding  to  an  annual  death  rate  of  11.73 
in  a  thousand  population,  a  marked  decrease  from  the  death 
rate  for  each  month  during  the  past  year.  The  principal 
causes  of  death  were:  General  diseases,  151;  diseases  of 
the  nervous  system,  50;  diseases  of  the  circulatory  system, 
90;  diseases  of  the  respiratory  system,  66;  diseases  of  the 
digestive  system,  37;  diseases  of  the  genitourinary  system, 
58;  childbirth,  6;  diseases  of  the  skin,  i;  diseases  of  the 
locomotor  system,  i;  malformations,  4;  early  infancy,  30; 
old  age,  10;  violence,  46;  ill  defined  diseases,  3.  Of  the 
total  deaths  from  general  diseases,  64  were  due  to  pulmo- 
nary tuberculosis.  The  total  deaths  of  children  under  five 
years  of  age  was  90,  of  which  70  were  under  one  year  of 
age.    There  were  23  still  births  reported  during  the  month. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing March  6,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  of  P.hiladel- 
phia :  Typhoid  fever,  45  cases,  7  deaths  ;  scarlet  fever,  72 
cases,  4  deaths ;  chickenpox,  109  cases,  i  death ;  diphtheria, 
75  cases,  12  deaths ;  cerebrospinal  meningitis,  2  cases,  i 
death ;  measles,  207  cases,  4  deaths ;  whooping  cough.  32 
cases.  I  death;  tuberculosis  of  the  lungs,  136  cases,  55 
deaths;  pneumonia,  119  cases,  57  deaths;  erysipelas,  17 
cases,  2  (icaths  ;  puerperal  fever,  5  cases,  4  deaths ;  mumps, 
62  cases,  o  deaths  ;  cancer,  22  cases,  30  deaths ;  trachoma, 
I  case,  o  deaths.  The  followin.g  deaths  were  reported  from 
other  transmissible  diseases:  Tuberculosis,  other  than  tu- 
berculosis of  the  hings,  9  deaths;  diarrhoea  and  enteritis, 
under  two  years  of  age,  13  deaths.  The  total  deaths  nuin- 
bered  500  in  an  cstimatccl  population  of  1,565,569,  corre- 
sponding to  an  annual  death  rate  of  16.60  in  a  thousand 
population.  The  total  infant  n.ortality  was  96;  77  under 
one  \car  of  age,  19  between  one  and  two  years  of  age. 
There  were  47  still  births;  26  males  and  21  females.  The 
total  precipitation  was  0.76  inch. 


Vital  Statistics  of  New  York. — During  the  week  end- 
ing March  6,  1909,  the  total  number  of  deaths  reported  to 
the  Department  of  Health  of  the  City  of  New  York  was 
1,483,  in  an  estimated  population  of  4,564,792,  corresponding 
to  an  annual  death  rate  in  a  thousand  population  of  16.95. 
The  death  rate  in  Manhattati  was  17.02 ;  in  the  Bronx, 
20.39;  in  Brooklyn,  16.06;  in  Queens,  16.83;  and  in  Rich- 
mond, 17.29.  Of  the  total  number  of  deaths  94  were  from 
contagious  diseases,  163  from  pulmonary  tuberculosis,  84 
from  diarrhoeal  diseases,  of  which  39  were  under  five  years 
of  age,  135  from  pneumonia,  11 1  from  bronchopneumonia, 
27  from  suicide,  5  from  homicide,  and  66  from  accidents. 
There  were  in  still  births.  Seven  hundred  and  fifty-four 
marriages  and  2,549  births  were  reported  during  the  week. 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  March  27,  1909: 

Monday,  March  22d. — Mineralogical  and  Geological  Sec- 
tion, Academy  of  Natural  Sciences. 

Wednesday,  March  24th. — Philadelphia  County  Medical 
Society. 

Thltrsday,  March  2$th. — Pathological  Society ;  American 
Entomological  Society  and  the  Entomological  Section, 
Academy  of  Natural  Sciences ;  Section  Meeting ; 
Franklin  Institute;  Philadelphia  Botanical  Club;  Leb- 
anon Hospital  Medical  Society. 

Friday,  March  26th. — Philadelphia  Neurological  Society; 
Northern  Rtedical  Association ;  South  Branch,  Phila- 
delphia County  Medical  Society. 

Saturday,  March  27th. — Samaritan  Hospital  Medical  So- 
ciety. 

Resolutions  on  the  Death  of  Dr.  Bull. — At  a  regular 
meeting  of  the  New  York  Surgical  Society,  held  at  the 
New  York  Academy  of  Medicine  on  the  evening  of  March 
loth,  the  following  resolutions  were  unanimously  adopted 
by  the  Society : 

Wtiereas,  William  Tillinghast  Bull,  M.  D.,  was  removed  by- 
death  from  the  roll  of  the  society  on  February  twenty-second,  on'; 
thousand  nine  hundred  and  nine;  and 

Whereas,  By  his  death  not  only  the  New  York  Surgical  Society, 
but  the  community  and  the  world  at  large  have  suffered  a  great 
loss;  and 

Whereas,  The  New  York  Surgical  Society  desires  the  opportunity 
to  express  its  sorrow  and  its  appreciation  of  his  character  and  at- 
tainments; be  it 

Resolved,  That  the  society,  collectively  and  individually,  mourns 
the  loss  of  one  who,  by  his  sympathy,  geniality,  gentle  modest>' 
and  untiring  devotion,  was  endeared  to  all;  and  who.  by  his  wisdom, 
judgment  and  brilliant  execution,  occupied  the  foremost  rank  among 
the  surgeons  of  the  world;  and  further,  be  it 

Resolved,  That  these  resolutions  be  spread  upon  the  records  of 
this  society  and  a  copy  be  forwarded  to  his  bereaved  family  and  to 
the  medical  journals. 

George  Woolsev,         Samuel  Alexander, 
George  E.   Brewer,     .Toseph  A.  Blake, 

Clarence   A.  McWilliams, 

Secretar) . 

Resolutions  on  the  Death  of  Dr.  McCosh. — At  a  reg- 
ular meeting  of  the  New  York  Surgical  Society,  held  at  the 
New  York  Academy  of  Medicine  on  the  evening  of  March 
loth,  the  following  resolutions  were  unanimously  adopted 
by  the  society : 

Whereas,  Death  removed  from  the  roll  of  this  society,  on  De- 
,;ember  second,  one  thousand  nine  hundred  and  eight,  our  di.s- 
tinguished  colleague.  Dr.  Andrew  J.  McCosh;  and 

Whereas,  During  the  many  years  of  his  membership  in  this 
association.  Dr.  McCosh  has  been  an  active  worker,  an  ardent  and 
enthusiastic  supporter"  of  the  objects  which  called  the  society  into 
being;  and 

Whereas,  By  his  formal  communications  and  presentation  of  rare 
and  interesting  clinical  cases,  as  well  as  by  his  illuminating  dis- 
cussions, he  has  added  much  to  the  interest  of  our  meetings;  and 

Whereas,  During  the  entire  period  of  his  professional  activity. 
Dr.  McCosh  stood  for  the  highest  ideals,  and  has  ever  maintained 
the  loftiest  standards  of  professional  ethics;  be  it 

Resolved,  That  in  the  death  of  our  honored  colleague,  the  New 
York  .Surgical  Society  has  lost  one  of  its  most  valued  fellows,  who. 
by  reason  of  his  unusual  ability,  his  extraordinary  technical  skill, 
his  wise  and  conservative  judgment,  his  untiring  energy  and  his 
devotion  to  his  professional  work,  has  made  for  himself  a  con- 
spicuous position  in  the  foremost  ranks  of  the  world's  surgeons; 
and  who,  by  his  modesty,  his  professional  integrity,  his  kindliness, 
and  his  generous  treatment  of  the  poor  and  unfortunate  who  came 
under  his  care,  has  endeared  himself,  not  only  to  the  medical  pro- 
fession, but  to  the  entire  community  in  which  he  lived;  be  it 
/urther 

Resohed,  That  these  resolutions  be  spread  upon  the  minutes  o! 
this  society,  and  a  copy  be  transmitted  to  the  family  of  our  dt- 
ceased  colleague  and  to  the  weekly  medical  journals  of  this  city  for 
publication. 

George  E.  Brewer. 
•  Ellsworth  Eliot,  Jr., 

Clarence   A.  •  McWilliams, 

Secretary. 


March  20,  zgog.l 


PITH  OF  CURRENT  LITERATURE. 


605 


Jitt  si  Cttmnt  ^itmtmt. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

March  ji,  igog. 

I.    Tlie  Medical  Treatment. of  Malignant  Disease, 

By  George  W.  Gay. 
_'.    Early   Treatment    of    Some    Epitheliomata   by  Pure 
Radium  Salts,  By  Francis  H.  Williams. 

An  Accurate  Rapid  Method  for  the  Quantitative  Deter- 
mination of  Chlorine  in  the  Urine.  A  Short  Critical 
Study  of  the  Short  Methods  in  Vogue, 

By  Hexry  W.  Goodall. 
4.    Mysticism  and  Medicine.  By  Johx  E.  Fenley. 

1.  Malignant  Disease. — Gray  reminds  the  pro- 
fession and  the  pubHc  of  the  following  in  relation  to 
medical  treatment  of  malignant  disease :  Malignant 
disease  may  be  a  local  affection  in  its  early  stages 
and  if  thoroughly  removed  dtiring  that  period  will 
very  likely  result  in  a  permanent  cure.  Every  day's 
delay  in  ascertaining  the  character  of  a  growth  may 
diminish  by  so  much  the  chances  of  permanent  re- 
lief. \\'aiting  for  time  and  events  to  decide  the 
character  of  a  tumor  may  be  fatal  and  is  seldom  if 
ever  to  be  advised.  Prompt  and  thorough  removal 
of  tumors  by  operation  is  the  most  efficient  method 
of  treatment  known  at  the  present  time.  The  most 
favorable  time  for  the  removal  of  tumors  is  as  soon 
after  discovery  as  possible.  Malignant  growths 
should  be  removed  before  the  clinical  signs  of  ma- 
lignancy have  developed  to  any  extent.  Could  these 
facts  and  opinions  be  thorotighly  impressed  upon  the 
minds  of  the  family  physician  and  of  the  general 
public,  the  results  could  not  fail  to  be  beneficial  by 
preventing  sufTering  and  saving  or  prolonging  life. 

2.  Pure  Radium  Salts  in  the  Treatment  of 
Epithelioma. — ^^  illiams  remarks  that  fifty  milli- 
grammes of  pure  radivmi  bromide  are  desirable,  but 
this  is  difficult  to  obtain  and  is  very  expensive.  He 
was  fortunate  in  getting,  over  five  years  ago.  120 
milligrammes  of  pure  radium.  About  a  year  ago 
he  wrote  to  a  firm  which  has  been  interested  in  sell- 
ing this  salt  and  asked  the  price  of  pure  raditim  bro- 
mide. The  reply  was  that  they  had  none  of  the  pure 
salt  and  did  not  believe  it  existed,  but  they  had  some 
one  sixth  as  strong.  A  number  of  physicians  'are 
attempting  to  treat  patients  with  radium  too  weak 
in  quality  and  too  small  in  quantity  to  be  efficient, 
and  this  will  doubtless  tend  to  discredit  this  new 
therapeutic  agent.  The  raditun  should  be  placed  in 
a  capsule,  covered  with  lead  except  on  one  side, 
which  is  at  the  end  of  a  long  handle,  as  a  protection 
to  the  physician.  The  capsule,  over  which  a  clean 
rubber  cot,  for  each  patient  has  been  drawn  for  pur- 
poses for  cleanliness,  should  then  be  passed  slowly 
over  the  area  to  be  treated  or  held  over  the  special 
place  for  one  half  to  three  and  sometimes  four  min- 
utes. The  exposure  should  be  made  from  one  to 
three  times  a  week ;  less  often  after  healing  has  be- 
gun. The  remedy  must  be  used  with  sufficient  cour- 
age to  obtain  results,  but  with  care  to  avoid  harm, 

,for  a  remedy  that  is  of  any  value  is  a  two  edged 
sword  and  requires  judgment  and  experience  in  its 
use.  When  patients  learn  to  come  very  early  for 
treatment,  the  results  should  be  even  more  sat- 
isfactory than  those  obtained  during  the  past 
five  years.  During  this  time  patients  of  cases 
of   long   duration   and  considerable    extent  have 


done  \\ell,  but  obviously  we  may  fairly  ex- 
pect that  healing  will  be  more  prompt  and  take 
place  in  a  larger  proportion  of  patients,  when 
the  more  suitable,  especially  the  early  cases,  are 
submitted  to  this  treatment  and  operation  or  other 
treatment  advised  for  those  in  which  radium  is  un- 
suitable. He  has  compared  the  therapeutic  value  of 
the  X  rays  and  radium  and  shows  that  in  its  own 
particular  field  radium  has  an  advantage  over  the 
X  rays ;  on  the  other  hand,  radium  has  no  value  in 
diagnosis ;  but  lest  we  should  be  diverted  by  the  use 
of  the  X  rays  in  treatment  from  their  wider  useful- 
ness in  diagnosis,  we  should  remember  that  not  only 
for  surgical  but  more  emphatically  for  medical  diag- 
nosis, particularly  in  diseases  of  the  thorax,  the  x 
rays  are  of  great  value  and  importance. 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCiATlON. 
March  13,  1909. 

1.  The  Unity  of  the  Medical  Sciences, 

By  Algernon  T.  Bristow. 

2.  Nervous  Disorders  in  Women  Simulating  Pelvic  Dis- 

ease. An  Analysis  of  Five  Hundred  and  Xinety-onc 
Cases,  By  Claka  T.  Dercum. 

3.  Cancer  of  the  Uterus ;  Our  Present  Means  of  Lessen- 

ing Its  Mortality,  By  W.  Bean  Moulton. 

4.  The  Rontgen  Rays  as  an  Aid  in  the  Diagnosis  of  Cai- 

cinoma  of  the  Stomach,        By  George  E.  Pfahler. 

5.  A  Chapter  in  the  History  of  Quackery, 

By  James  J.  Walsh. 

6.  The  Treatment  of  Fractures :  Some  Practical  Points, . 

By  James  P.  Warbasse. 

7.  Bloodless  Hysterotomy  and  Preliminary  Ligation  as 

Aids  to  Conservative  Myomectomy, 

By  Arthur  E.  Hertzlek. 

2.  Nervous  Disorders  in  Women  Simulating 
Pelvic  Disease. — Clara  T.  Deroum  reviews  59; 
cases  of  the  g\  njecological  ward  of  the  Woman's 
Hospital  of  Philadelphia.  That  hysteria  and  neuras- 
thenia can  coe-xist  with  pelvic  disease  goes  with- 
out saying,  just  as  they  may  coexist  with  a  brain 
tumor  or  a  broken  leg.  The  author's  statistics  do 
not  show  that  neurasthenia  or  hysteria  exist  as  fre- 
quently in  pelvic  diseases  as  in  other  visceral  affec- 
tions. These  facts  seem  to  prove  that  operations 
on  the  pelvic  and  other  viscera  for  the  relief  of 
nervous  symptoms  have  no  justification.  It  is  clear 
that  no  operation  should  be  performed  which  has 
no  positive  surgical  indications.  W^hen  this  subject 
is  fully  understood  the  fastening  up  of  so  called 
loose  kidneys,  the  removal  of  normal  ovaries  and 
tubes,  of  normal  uteri,  of  normal  appendices,  of 
pieces  of  normal  coccygeal  bone,  will  cease,  as  will 
also  repair  of  trivial  cervical  lacerations.  A  careful 
examination  of  the  records  from  hospital  labora- 
tories will  abundantly  testify  to  this  assertion  of 
the  removal  of  normal  organs.  These  statistics 
show  also  that  there  are  more  retropositions  of  the 
uterus  withotit  nervous  symptoms  than  retroposi- 
tions existing  with  them.  It  is  the  same  when 
we  compare  the  anteflexions,  the  lacerations,  the 
splanchnoptoses,  and  malignant  disease.  Dysmen- 
orrhoea  is  most  striking  in  that  the  tables  show  in 
almost  every  case  symptoms  of  functional  nervous 
disorders  associated  with  it,  stiggesting  that  dys- 
menorrhcea  in  many  instances  is  but  one  of  the 
many  phenomena  of  these  nervous  affections.  This 
view  wotild  greatly  reduce  the  number  of  dilata- 
tions which  are  regarded  by  some  as  tiseless,  sense- 
less, and  cruel  except  for  diagnostic  purposes.  Un- 


6o6 


PITH  OF  CURRENT  LITERATURE. 


[New  Ysrk 
Meliical  Jolrn'al. 


complicated  retroversion  requires  no  surgical  or 
medical  interference  and  presents  practically  no 
symptoms.  Lucy  Waite  and  Byron  Robinson  of 
Chicago  experimented  on  the  cadaver  by  injecting 
air  into  the  bladder  and  rectum,  and  they  demon- 
strated an  extensive  deviation  on  variation  of  posi- 
tion regarding  the  uterus.  Anatomically  and  phy- 
siologically the  uterus  is  a  mobile  pelvic  organ  and 
not  an  abdominal  one,  and  to  force  it  upward  and 
forward,  to  stitch  it  to  the  abdominal  wall,  com- 
promises it  in  its  function,  circulation,  and  nerve 
supply,  su-bstituting  one  pathological  state  for  an- 
other. 

3.  Cancer  of  the  Uterus. — Aloulton  observes 
that  complete  surgical  extirpation  is  at  the  present 
time  our  only  method  for  the  cure  of  cancer  of  the 
uterus,  but  the  percentage  of  cures  is  much  below 
what  it  might  be  made.  Our  present  means  for 
lessening  the  mortality  lie  in  a  campaign  of  educa- 
tion, directed,  first,  to  the  general  public  by  the 
family  physician,  so  that  the  patient  will  not  neglect 
to  consult  him  on  the  occurrence  of  unusual  symp- 
toms, and.  second,  to  the  family  physician  himself, 
to  the  end  that  he  may  realize  that  every  case  of 
disturbance  of  the  vaginal  discharge  at  or  about 
the  time  of  the  menopause  is  most  significant  and 
suspicious.  We  should  emphasize  also  not  only  the 
necessity,  but  the  ease  of  obtaining  sufficient  tissue 
fot  a  microscopical  diagnosis  in  every  remotely  sus- 
picious case  at  the  time  of  the  first  consultation  and 
without  the  employment  of  any  anaesthetic. 

4.  The  Rontgen  Rays  as  an  Aid  in  the  Diag- 
nosis of  Carcinoma  of  the  Stomach. — Pfahler,  in 
speaking  of  the  technique  of  diagnosticating  gastric 
carcinoma  by  the  x  rays,  remarks  that  the  position 
of  the  patient  will  vary  much  with  the  individual 
patient,  and  several  positions  are  often  necessary  to 
confirm  or  to  demonstrate  more  clearly.  Generally 
the  standing  posture,  with  the  abdomen  against  the 
plate  or  screen,  will  give  the  most  evidence,  prob- 
ably because  in  this  position  the  stomach  is  more 
stretched  out,  and  because  we  can  best  watch  the 
passage  of  the  food,  which  is  conveyed  downward 
both  by  gravity  and  peristaltic  action.  A  position 
with  the  patient  lying  on  the  abdomen  for  postero- 
anterior  view  will  probably  be  the  next  most  valu- 
able. Then  one  can  easily,  with  the  patient  either 
in  the  erect  or  recumbent  posture,  change  to  the 
oblique  or  posterior  views.  At  the  beginning  of 
the  examination  it  is  usually  best  to  use  a  table- 
spoonful  of  a  mixture  of  bismuth  and  water.  This 
will  give  the  greatest  density  with  the  greatest  fluid- 
ity, and  it  can,  therefore,  be  best  followed  in  a 
tortuous  course  and  into  the  crevices ;  but  one  must 
not  use  too  much  of  this  mixture  for  fear  of  the 
water  becoming  absorbed  and  leaving  the  bismuth 
in  hard  masses.  For  general  use  and  for  further 
distention  of  the  stomach  he  has  found  a  mixture 
of  bismuth  and  kephir  (or  yolak),  to  be  most 
serviceable,  since  it  keeps  the  bismuth  in  almost 
perfect  suspension  and  is  easily  digested.  The  re- 
mainder of  the  technique  with  regard  to  the  man- 
agement of  the  tube,  the  apparatus,  the  dress  of  the 
patient,  the  patient,  and  the  plates,  are  similar  to 
that  used  in  other  abdominal  examinations.  Gas- 
tric carcinoma  is  demonstrable  when  it  changes  the 
course  of  the  food  through  the  stomach,  when  it 


decreases  the  volume,  interferes  with  peristaltic 
action,  fixes  or  displaces  the  stomach,  causes  an 
indentation  in  the  stomach  wall,  or  modifies  the  rate 
of  evacuation  of  the  gastric  contents.  But  with  this 
technique  a  diagnosis  can  be  made  earlier  than  has 
heretofore  been  possible.  As  a  rule  it  is  a  tedious 
and  expensive  study,  and  therefore  each  case  should 
be  studied  well  first  clinically.  Great  caution  and 
thoroughness  will  have  to  be  observed,  or  errors 
will  be  made,  and  this  valuable  method  of  investi- 
gation will  fall  into  discredit. 

6.  The  Treatment  of  Fractures;  Some  Practi- 
cal Points. — Warbasse  states  that  for  many  years  it 
has  been  his  teaching  and  practice  to  correct  de- 
formity and  permanently  immobilize  fresh  fractures 
of  the  tibia  and  fibula  as  soon  as  possible.  When 
the  fracture  is  seen  within  two  to  twelve  hours  after 
the  accident  there  is  usually  no  swelling  present. 
He  then  draws  a  long  white  cotton  stocking  over  the 
leg  and  applies  plaster  of  Paris  immediately  over 
this.  It  does  not  require  a  heavy  covering  with  the 
plaster  bandage  to  immobilize  the  fracture,  as  it  needs 
to  be  not  more  than  one  eighth  of  an  inch  thick.  It 
is  important  that  the  bandage  next  to  the  stocking 
is  applied  without  folds  and  with  the  most  perfect 
possible  evenness.  No  reverses  should  be  made. 
The  bandage  should  be  allowed  to  run  out  flatly,  and 
when  it  is  wished  to  change  its  course  it  should  be 
cut  and  started  in  the  direction  desired.  A  thin  cast 
applied  over  the  stocking  conforms  to  the  shape  of 
the  leg  and  allows  of  an  estimate  of  the  lines  and 
contour  which  can  be  compared  with  the  other  limb. 
A  good  plan  is  to  cut  through  this  cast  on  either  side 
so  as  to  divide  it  into  an  anterior  and  posterior  half. 
This  can  be  done  before  the  last  bandage  is  ap- 
plied, and  while  the  plaster  is  still  soft,  by  using  a 
sharp  scalpel  or  bandage  scissors.  Then  the  final 
bandage  is  put  on.  Later  when  the  cast  is  hard,  if 
it  is  desired  to  inspect  the  leg,  it  is  an  easy  matter 
to  cut  through  the  outer  bandage,  following  the  un- 
derlying crack,  and  lift  ofif  the  front  half  of  the 
splint.  This  operation  is  facilitated  by  employing 
two  stockings  instead  of  one,  and,  at  the  first  cast 
cutting  operation,  dividing  the  outer  stocking,  which 
is  adherent  to  the  cast,  and  leaving  the  under  stock- 
ing intact.  Putting  up  a  fracture  immediately  after 
its  occurrence  is  not  usually  regarded  as  good  sur- 
gery. It  is  not  good  surgerv  if  the  cast  is  not  put 
on  well.  But  if  it  is  smoothly  applied  and  the  ap- 
position is  good  there  will  be  no  further  swelling, 
provided  there  is  no  extraordinary  condition  pres- 
ent, such  as  imperfect  reduction,  rupture  of  large 
vessels,  or  venous  obstruction.  After  such  im- 
mobilization the  leg  should  be  free  from  pain.  There 
should  be  no  throbbing  or  discomfort ;  if  there  is, 
the  chances  are  that  the  reduction  is  not  good.  Such 
a  splint  should  never  be  left  on  in  the  presence  of 
pain.  It  is  very  rarely  that  pain  is  present  after  this 
treatment.  Another  matter  to  wliich  attenti(^n  may 
be  called  is  the  manner  of  extension  in  fractures  of 
the  thigh.  In  the  ordinary  fractures  about  the  mid- 
dle third  of  the  femur,  the  overriding  of  the  frag- 
ments is  considerable,  but  there  seems  to  be  little  ap- 
preciation of  the  great  amount  of  force  required  to 
overcome  the  muscular  contraction  and  bring  down 
the  fragments  into  place.  l^nder  the  best  condi- 
tions there  is  rarely  a  complete  correction  of  the 


3Iarch  20,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


607 


overriding.  Fortunately,  most  fractures  of  the 
shaft  of  the  femur  are  oblique  and  the  broken  bone 
surfaces  slide  over  one  another,  longitudinal  short- 
ening causing  but  little  lateral  displacement.  When 
the  fracture  is  transverse  the  overriding  produces 
lateral  displacement  equal  to  the  diameter  of  the 
bone,  often  interposes  more  or  less  soft  tissue  and 
becomes  a  more  serious  thing.  In  order  to  over- 
come these  longitudinal  displacements  in  a  man  an 
extension  which  is  more  than  the  patient  can  tolerate 
is  necessary.  If  the  fracture  is  oblique,  twenty  to 
forty  pounds  will  nearly  correct  the  overriding ;  if  it 
is  transverse,  that  amount  will  not  bring  the  bone 
ends  into  apposition  either  with  or  without  the  use 
of  a  general  anaesthetic. 

MEDICAL  RECORD 

March  13,  igog. 

1.  The  Principles  and  Technique  of  fiie  W'assermann  Re- 

action and  Its  Modifications,  By  Howard  Fox. 

2.  Nongastric  Malignant  Disease  and  the  Secretion  of  Gas- 

tric Juice,  By  Louis  A.  Levison. 

3.  The  Problem  of  Epilepsy,  By  Robert  H.  Porter. 

4.  Acute  Postoperative  Jaundice. 

By  Ch.arles  Green'e  Cumston. 

5.  A  Note  on  Poisoning  by  lElgg.        By  D.  J.  M.  Miller. 

I.  Principles  and  Technique  of  the  Wasser- 
mann  Reaction  and  its  Modifications. — Fox  men- 
tions, among  other  modifications.  Xoguchi's  method, 
which  is  now  accepted  as  an  improvement  on  W'as- 
strmann's  test.  The  order  of  the  steps  in  perform- 
ing the  test  is  as  follows :  i.  One  drop  from  a  capil- 
lary pipette  of  the  serum  of  the  patient  to  be  tested 
and  one  drop  for  the  control.  2.  One  square  of  pa- 
per representing  complement  or  if  preferred  0.04 
c.c.  of  fresh  guinea  pig  serum.  3.  One  c.c.  of  a  sus- 
pension of  human  corpuscles  in  the  proportion  of  r 
drop  of  blood  to  4  c.c.  of  physiological  salt  solution. 
4.  One  square  of  paper  representing  antigen,  after 
which  the  tubes  are  shaken  and  incubated  in  ther- 
mostat or  vest  pocket  for  a  half  hour.  5.  One  square 
of  paper  representing  the  haemolytic  amboceptor. 
The  tubes  are  then  incubated  again  for  two  hours 
after  which  the  results  are  recorded.  W  hen  exam- 
ined twenty-four  hours  later,  no  change  as  a  rule 
occurs.  The  controls  are  similar  to  those  used  in 
the  regular  Wassermann  reaction.  If  the  test  de- 
vised by  Xoguchi  were  merely  equal  in  accuracy  to 
the  regular  Wassermann  reaction,  its  simplicity 
would  mark  it  as  a  decided  advance  in  the  serum 
diagnosis  of  syphilis.  That  it  is  actuallv  more  deli- 
cate and  accurate  appears  from  the  results  obtained 
thus  far  by  its  author.  Some  rather  striking  difter- 
ences  in  favor  of  the  Xoguchi  test  have  been  ob- 
served among  the  cases  of  our  author.  Xoguchi 
does  not  depend  upon  the  patient's  serum  to  supply 
the  complement,  but  uses  guinea  pig  serum  for  com- 
plement. X'o  inactivation  of  the  patient's  serum  is 
necessary-  as  human  complement,  in  the  dose  used  in 
his  test  (one  capillary  drop),  is  not  active  against 
human  corpuscles,  when  2  units  of  amboceptor  are 
used.  Even  in  a  dosage  of  o.i  c.c.  it  remains  with- 
out any  action  at  all  in  the  presence  of  2  units  of 
amboceptor,  and  can  therefore  be  entirely  disre- 
garded. As  indicator,  the  corpuscles  of  the  patient 
to  be  tested  or  of  a  normal  person  are  used.  The 
suspension  of  corpuscles  is  obtained  from  the  finger 


or  ear  and  is  used  in  the  proportion  of  one  drop  to 
4  c.c.  of  physiological  salt  solution.  In  this  dilu- 
tion no  coagulation  of  the  blood  occurs.  A  suf- 
ficient amount  of  serum  can  be  obtained  from  a  half 
c.c.  of  blood  drawn  from  the  patient's  finger  or  ear. 
A  single  drop  only  from  a  capillary  pipette  (which 
can  be  easily  made  in  a  Bunsen  flame)  is  needed  for 
the  test  and  a  second  drop  for  the  control.  Finally 
the  antigen,  complement,  and  amboceptor  have  been 
concentrated,  dried,  and  impregnated  in  strips  of  pa- 
per, tiny  squares  of  which,  representing  measured 
amounts  of  the  impregnated  substances  are  used  for 
each  tube.  X^oguchi  has  even  found  it  possible  to 
dispense  with  an  incubator  by  keeping  the  little 
tubes  in  the  vest  pocket  and  allowing  the  bod\-  heat 
to  incubate  them.  In  this  way  he  has  succeeded  in 
devising  a  method  which  is  so  simple  that  it  can  be 
carried  out  by  any  physician  without  difficulty. 

3.  The  Problem  of  Epilepsy. — Porter  remarks 
that  epilepsy  can  be  better  appreciated  by  the  proper 
recognition  of  the  two  most  prominent  facts  in  the 
case :  First,  the  utter  hopelessness  in  the  present 
condition  of  the  epileptic.  And,  second,  the  uni- 
versal prevalence  of  the  disease — one  in  every  five 
hundred  of  the  population.  The  eft'ects  of  the  dis- 
ease are  deplorable  enough,  and  yet  the  seclusion  of 
the  epileptic  from  all  social  duties  and  business  life 
is  one  of  the  saddest  features,  and  this  no  doubt 
serves  to  intensify  the  morbid  condition,  for  the  pa- 
tient is  thus  debarred  from  all  normal  development. 
In  fact,  epilepsy  is  one  of  the  most  important  social 
tragedies  in  the  great  drama  of  life,  and  yet  there  is 
more  being  done  for  every  other  class  of  the  afflict- 
ed than  for  the  epileptic.  When  the  epileptic  patient 
comes  for  advice  and  treatment  there  is  often  a  super- 
ficial examination,  a  routine  prescription  of  the  bro- 
mides, a  few  suggestions  as  to  diet,  and  he  is  direct- 
ed to  call  again  in  a  week  or  two.  From  such  meas- 
ures the  physician  himself  expects  little  or  no  bene- 
fit, and  in  this  he  is  not  disappointed.  For  the  pa- 
tient the  result  is  well  nigh  disastrous,  for  there  has 
been  little  or  no  impression  made  on  either  the  fre- 
quency or  the  severity  of  the  attacks.  In  a  little 
while  he  becomes  impatient  or  discouraged  and  tries 
something  else,  going  from  one  thing  to  another, 
trying  everything  by  turns,  and  nothing  long.  Some 
patients  select  a  combination  of  remedies  that  seem 
to  give  the  most  benefit,  and  continue  the  same  in- 
definitely without  any  medical  supervision,  regard- 
ing a  continuation  of  the  disease  as  inevitable.  Clin- 
ical experience  has  many  times  demonstrated  the  fact 
that  remedial  measures  that  will  control  the  nocturnal 
chorea,  restrain  the  reddening  of  the  face  and  head, 
and  check  the  congestion  of  the  brain,  will  at  the 
same  time  arrest  and  control  the  threatened  epileptic 
convulsions.  The  demand  of  the  impaired  cells  for 
more  and  better  nourishment  causes  an  increased 
blood  supply.  Then  it  must  be  remembered  that  de- 
ficient nutrition  is  the  ordinary  cause  of  local  con- 
gestion ;  and  that  the  impaired  nutrition  of  the  brain 
cells  in  epilepsy  supplies  the  efficient  cause  for  this 
congestion  of  the  brain.  Owing  to  the  exhaustion 
of  the  brain  cells  from  impaired  or  perverted  nutri- 
tion they  are  oversensitive  and  easily  excited  by  this 
slight  congestion  into  perverted  action,  and  herein 
lies  the  essential  feature  of  every  epileptic  seizure ; 


6o8 


I'lTH  Uf  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


congestion  of  the  affected  regions  of  the  brain,  brain 
cells  with  perverted  nutrition  unduly  stimulated, 
causing  perverted  functional  activity.  The  dreadful 
convulsions  are  but  the  outward  manifestations  of 
the  tornadoes  that  are  sweeping  over  the  brain  cen- 
ters within.  If  these  are  the  external  expressions, 
one  can  easily  imagine  what  the  internal  commotion 
must  be. 

BRITISH  MEDICAL  JOURNAL. 
February  27,  igog. 

1.  Chronic  Spinal  Meningitis:   Its  Distinctive  Diagnosis 

and  Surgical  Treatment,  By  Sir  V.  Horsley. 

2.  Observations  on  the  Physiology  of  the  Female  Genital 

Organs  (Report  cxii  of  the  Science  Committee  of 
the  British  Medical  Association), 

By  W.  B.  Bell  and  P.  Hick. 

3.  On  Sleep  and  Want  of  Sleep,       By  R.  Farquharson. 

4.  The  Pathology  of  Syphilis  of  the  Nervous  System  in 

the  Light  of  Modern  Research  (Morison  Lectures, 
III),  By  F.  W.  MoTT. 

5.  A  Case  of  Acute  Ascending  Paralysis,    By  H.  J.  Dean. 

6.  Arterial  Blood  Pressure  Records  before  and  after  Mus- 

cular Exertion,  By  O.  K.  Williamson. 

7.  Tlie  Treatment  of  Chronic  Gonorrhoea  by  Antigonococ- 

cal  Vaccine,  By  A.  Loxton. 

I.  Chronic  Spinal  Meningitis. — liorsley  dis- 
cusses the  distinctive  diagnosis  and  surgical  treat- 
ment of  chronic  spinal  meningitis,  a  class  of  case 
presenting  the  same  symptoms — except  certain 
minutiae — as  tumor  of  the  spinal  cord.  The  cases 
occur  in  adults,  and  are  characterised  by  pain  and 
loss  of  power  in  the  legs,  with  it  may  be  also  slight 
kyphotic  curvature  of  the  spine,  and  the  ultimate 
development  of  a  progressive  paraplegia  running 
through  the  ordinary  course  and  terminating  fatal- 
ly. The  pain  is  felt  in  one  limb  to  begin  with,  and 
then  it  spreads  to  the  other  limb,  and  then  up  the 
back.  The  pain  is  generally  said  to  be  in  the  sub- 
stance of  the  limb,  and  feels  in  most  cases  Tike  a 
tightening  or  drawing  up.  The  typical  girdle  tight- 
ness, or  feeling  as  of  a  band  around  the  middle  of 
the  body,  is  sometimes  felt.  The  patients  become 
I)aralysed  by  a  general  sense  of  weakness  coming" 
on  in  the  whole  leg.  As  we  have  to  deal  with  a 
chronic  inflammatory  condition,  the  prognosis  sim- 
ply depends  upon  the  usual  rule,  that  if  a  patient 
is  below  middle  life  or  at  middle  life  recuperation 
is  apt  to  be  very  good;  if  beyond  middle  life,  it  is 
apt  to  be  very  poor.  The  treatment  of  the  condi- 
tion consists  in  simple  laminectomy,  opening  the 
theca,  and  washing  out  the  theca  with  a  mercurial 
lotion.  This  mode  of  treatment  is  paralleled  by  the 
well  known  surgical  procedure  of  opening  the  ab- 
domen to  cure  tuberculous  peritonitis.  There  is  no 
risk  in  using  strong  mercurial  solutions,  even  up  to 
<mt  to  500,  following  up  with  a  one  to  2,000  solu- 
tion, and  leaving  in  some  of  this  strength  when 
closing  up  the  wound,  which  should  be  completely 
closed  without  drainage.  It  is  not  necessary  to  sew 
up  the  theca ;  indeed  by  allowing  the  cerebrospinal 
fluid  to  drain  away  through  the  lymphatics  of  the 
walls  of  the  wouncl,  there  is  less  tendency  to  subse- 
f|uent  headache,  fever,  and  tachycardia.  After  the 
wound  is  completely  healed,  free  mercurial  inunc- 
tion of  the  spine  should  be  ordered.  es])ecially  over 
the  scar,  on  the  idea  that  having  arrested  tlie  dis- 
ease an  attempt  should  be  made  to  secure  active 
"absorption"  and  a  complete  restoration  to  health. 


5.  Acute  Ascending  Paralysis. — Dean  reports 
a  case  of  acute  ascending  paralysis  or  Landry's 
disease,  occurring  in  a  man  aged  twenty-four  years. 
The  chief  features  of  the  case,  apart  from  its  rapid 
progress,  were:  i.  No  obvious  cause,  beyond  get- 
ting wet.  2.  Absence  of  knee  jerks  from  the  onset, 
before  any  actual  paralysis  was  noticed.  3.  No  rise 
of  temperature  until  within  three  hours  of  death. 

4.  Sensation  unimpaired,  the  only  sensory  symp- 
toms being  numbness  and  vague  muscular  pains. 

5.  Perfect  consciousness  of  his  state  to  the  end. 

6.  Rapidity  with  which  the  paralysis  affected  the 
acts  of  coughing,  all  expiratory  efforts,  and  swal- 
lowing. 

6.  Blood  Pressure  Records. — W'iliiarnson  states 
that  expert  opinion  differs  as  to  whether  blood 
pressure  readings  represent  in  all  cases  the  true 
blood  pressure,  many  holding  that  where  the  read- 
mgs  are  above  200  millimetres  of  mercury,  some- 
thing beyond  the  pressure  of  the  blood  itself  is 
recorded.  Observations  taken  before  and  after 
violent  muscular  exercise  in  healthy  men,  should 
throw  light  on  the  question  for  the  reason  that  the 
influence  of  the  arterial  wall  can  be  excluded.  The 
vessels  are  in  a  state  of  vasodilatation,  and  the  sub- 
jects are  presumably  free  from  arteriosclerosis. 
The  writer  has  carried  out  such  observations  on 
Marathon  runners,  and  found  a  rise  of  from  20  to 
40  mm.  Hg,  corresponding  to  a  height  of  perhaps 
160  to  170  mm.  as  the  measurement  which  is  prob- 
ably near  the  limit  of  reserve  power  of  the  normal 
heart.  These  observations  throw  doubt  upon  read- 
ings in  the  neighborhood  of  300  mm.  Hg  represent- 
ing true  blood  pressure. 

7.  Antigonococcal  Vaccine. — Loxton  reports 
three  cases  of  chronic  gonorrhoea  successfully  treat- 
ed with  antigonococcal  vaccine.  They  show  that  in 
the  hypodermic  injection  of  sterile  dead  gonococci 
we  possess  a  curative  agent  of  marked  service  in 
the  treatment  of  gonorrhoea.  At  present  w-e  have 
no  other  means  of  attacking  the  gonococcus  direct- 
ly. Injections  and  drugs  only  act  indirectly;  but 
if  we  can  produce  in  the  juices  of  the  body  a  sub- 
stance which  is  a  poison  to  the  gonococcus,  then  we 
may  hope  that  the  disappearance  of  the  signs  of 
the  disease  thus  brought  about  means  that  the 
gonococci  are  killed,  and  not  merely  hidden  away 
in  a  quiescent  state,  read}''  to  light  up  again  when 
an  opportunity  presents  itself.  To  obtain  good  re- 
sults from'  inoculation  the  following  points  must  be 
attended  to:  (a)  The  gonococcus  should  be  demon- 
strated in  the  urethral  discharge.  It  is  obviously 
of  no  use  to  inject  antigonococcal  vaccine  if  the 
gonococcus  has  died  out  and  the  discharge  is  per- 
petuated by  other  forms  of  bacteria,  (b)  It  is  use- 
ful to  get  a  patient  into  a  good  state  of  health 
before  beginning  the  treatment.  A  holiday  may 
accomplish  this,  (c)  It  is  most  important  that  the 
dosage  be  carried  out  systematically.  The  best  re- 
sults are  obtained  by  commencing  with  small  doses 
— forty  or  fifty  millions  of  sterile  gonococci — and 
as  the  patient  becomes  accustomed  to  the  treatment, 
rapidly  to  increase  the  inoculation.  This  may  be 
done  in  two  ways — either  the  nrtmber  of  organisms 
may  be  increased  or  the  interval  between  the  doses 
may  be  shortened.  .\  judicious  combination  of  the 
two  gives  the  best  results. 


ilarcli  20,  1909.] 


FITH  Uf  CURRENT  LlTERAIURli. 


609 


LANCET. 

February  27,  igoQ. 

1.  The  Functions  of  the  Liver  in  Relation  to  the  Metabol- 

ism of  Fats.  By  J.  B.  Leathes. 

2.  Hernia  of  the  Iliopelvic  Colon,       By  H.  B.  RoBiNsn\-. 

3.  Anuria  with  Necrosis  of  the  Renal  Convoluted  Tubules, 

By  F.  P.  Weber. 

4.  Addisonism  as  a  Family  Disease,         By  D.  H.  Croom. 

5.  Injury  to  the  Semilunar  Cartilages  of  the  Knee, 

By  R.  MoRisoN. 

6.  Pancreatic  Secretion  in  the  Treatment  of  Diabetes, 

By  W.  M.  Crofton. 

7.  A  Case  of  Hepatic  Abscess  (  ?)  Treated  by  a  Vaccine; 

Recovery,  By  J.  H.  E.  Brock. 

I.  The  Liver  and  Fats. — Leathes  thinks  it  is 
a  fair  hypothesis  that  the  hver  stands  in  a  different 
relation  to  circulating  fat  from  the  other  organs  of 
die  body.  Its  work  is  to  take  up  this  fat  and  bring 
about  certain  changes  in  it,  the  result  of  which  is 
to  make  this  material  available  for  the  use  of  the 
organs  in  which  its  potential  energy  is  required.  It 
is  probable  that  this  change  consists,  at  any  rate 
in  part,  of  a  desaturation  of  the  fatty  acids.  But 
that  is  not  the  whole  of  the  change.  There  is  an- 
other difference  between  what  may  be  called  organ- 
ized fat — the  fat,  that  is,  in  the  cells  of  the  heart, 
muscles,  kidneys,  etc. — and  the  unorganized,  merely 
stored  fat  of  the  adipose  tissue.  The  latter  is  the 
unaltered  fat  of  the  individual's  food;  it  has  its 
iodine  value  determined  by  that  of  the  fat  which  has 
been  absorbed,  but  it  also  contains  no  phosphorus. 
The  fat  in  the  liver  and  the  other  organs  of  the 
body,  the  organized  fat,  is  very  largelv  composed 
of  phosphatide  lipoid  substances,  the  best  known  of 
which  is  lecithin.  Roughly  estimated  about  half 
of  the  organized  fat  is  lecithin.  The  fatty  acids 
which  can  be  obtained  by  saponification  of  lecithin 
■or  other  phosphatide  lipoid  substances  are  more  un- 
saturated than  those  from  adipose  tissue.  It  mav 
therefore  be  that  the  work  of  the  liver  consists  in 
the  conversion  of  food  fat  into  organized  fat,  and 
that  the  desaturation  of  fatt}-  acids  is  a  change 
which  occurs  after  that  conversion  has  taken  place. 
The  nature  of  this  change  is  unknown  ;  it  may  be 
brought  about  within  the  mysterious  circle  of  influ- 
ence of  the  phosphoric  acid  and  the  nitrogenous 
basic  constituents  of  the  more  complex  molecules. 
The  liver  has  work  to  do  in  preparing  fat  for  the 
metabolic  processes  in  which  fat  is  co^icerned  ;  but 
the  complete  oxidation  of  fat  liberates  so  much  en- 
ergy that  the  later  intensely  exothermic  stages  of 
the  breakdown  of  fat  are  likely  to  be  reserved  for 
organs  where  the  discharge  of  energy  is  conspicu- 
ous— e.  g.,  the  heart,  or  the  kidneys.  The  work  of 
the  liver  consists  in  an  operation  which  may  be 
compared  to  the  drying  of  gunpowder.  The  fats 
we  take  in  our  food  are  remarkably  unreactive  sub- 
stances, and  it  has  always  been  a  remarkable  chem- 
ical achievement  of  animal  cells  that  they  can  burn 
up  so  completely  and  cleanly  such  stable  structures 
as  saturated  fatty  acids  like  palmitic  or  stearic  acids. 
They  are  wet  gunpowder.  And  the  body  stores  its 
gunpowder  wet,  and  safely  removed  from  the  in- 
rtammatory  operations  of  busily  working  cells. 
When  the  orders  for  mobilization  are  issued  this 
wet  powder  is  conveyed  to  the  drying  chambers  in 
the  liver  and  from  there  distributed  to  the  fighting 
line  in  a  proper  condition  for  use.  There  are  times 
when  the  stress  of  this  work  is  manifestly  too  great. 


Too  active  a  mobilization  of  stored  fat,  or  too  lit- 
tle activity  in  dealing  with  it  on  the  part  of  the 
liver,  will  result  in  an  accumulation  of  the  unfin- 
ished product  in  that  organ.  A  fatty  liver  is  then 
the  result,  and  the  fatty  acids  which  it  contains  are 
found  to  have  a  low  iodine  value.  There  is  an  ac- 
cumulation of  wet  gunpowder.  The  most  marked 
changes  in  the  amount  of  fat  in  the  liver  are  due 
apparently  to  the  migration  of  fat  froin  the  adipose 
tissues  in  which  it  is  stored.  The  liver  seems  to 
be  the  organ  of  all  others  to  which  the  connective 
tissue  fat  can  most  certainly  be  traced.  And  yet 
when  this  importation  is  not  excessive  the  fatty 
acids  in  the  liver  are  like  those  in  the  other  work- 
ing organs  of  the  body  in  having  a  high  iodine 
value,  and  in  this  respect  unlike  those  in  the  stored 
fat  of  the  connective  tissues.  This  suggests  that 
the  fat  which  is  imparted  to  the  liver  is  tliere  nor- 
mallv  altered  so  as  to  acquire  a  higher  iodine  value. 
Such  a  desaturation  of  fatty  acids  must  occur 
somewhere,  since  the  fat  stored  away  and  not  in  use 
is  composed  of  acids  that  are  more  saturated  than 
the  fat  in  any  of  the  organs  in  which  fat  may  be 
oxidized. 

4.  Addison's  Disease. — Croom  reports  three 
cases  of  Addisonism  occurring  in  the  same  family, 
in  sisters  aged,  nine,  six,  and  three  and  a  half  years 
respectively.  The  father,  mother,  and  an  elder  sis- 
ter aged  nineteen  years,  were  all  healthy.  The  case 
of  the  girl  aged  nine  years  was  one  of  true  Addi- 
son's disease,  with  prostration,  asthenia,  typical  pig- 
mentation, low  blood  pressure,  and  occasional  vom- 
iting. The  other  two  cases  showed  only  the  typical 
pigmentation  and  low  blood  pressure.  Addison's 
disease  is  very  rare  in  children  under  thirteen  years 
of  age.  The  family  character  is  even  more  rare, 
only  one  instance  having  been  recorded. 

6.  Diabetes  and  Pancreatic  Extract. — Crofton 
holds  that  severe  glycosuria — that  is,  glycosuria 
produced  from  both  carbohydrates  and  proteins — is 
in  some  way  or  other  due  to  failure  in  the  pan- 
creatic functions  possibly  of  an  internal  secretion. 
This  failure  may  come  about  in  several  ways:  (a) 
The  chyme  entering  the  duodenum,  etc.,  might  not 
be  acid  enough  to  change  the  prosecretin  into  se- 
cretin, (b)  It  may  be  due  to  the  absence  of  se- 
cretin from  the  intestinal  mucosa,  (c)  It  may  be 
due  to  the  loss  of  function  of  the  cells  producing  the 
internal  secretion — that  is,  to  disease  of  the  pan- 
creas. The  pancreas  has  been  found  to  be  diseased 
in  a  large  number  of  cases — e.  g.,  intralobular  and 
interacinar  fibrosis  and  degeneration  of  the  cells  of 
the  islets  of  Langerhans.  In  treating  a  case  of  dia- 
betes the  first  step  must  be  to  remove  the  cause  of 
the  disability  of  the  pancreas.  If  it  is  due  to  the 
deficient  acidity  of  the  gastric  juice  leading  to  de- 
ficient conversion  of  prosecretin  into  secretin,  acids 
should  be  administered.  (It  is  possible  that  some 
cases  of  transient  glycosuria  may  be  due  to  this 
cause.)  If  it  is  due  to  the  absence  of  prosecretin 
give  secretin.  Since  it  is  difficult  with  our  present 
knowledge  to  remove  the  cause  of  the  pancreati : 
lesion,  the  next  best  thing  is  to  replace  the  secretion 
and  so  tide  over  an  acute  lesion  till  the  pancreas 
has  more  or  less  recovered  its  function,  or  in  the 
permament  sclerotic  cases  permanently  to  replace 
it,  just  as  thyreoid  extract  is  given  in  cases  where 


6io 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal 


there  is  loss  of  function  in  the  thyreoid.  The  writer 
reports  the  case  of  a  girl  aged  thirteen  years  suffer- 
ing from  severe  diabetes,  in  which  great  improve- 
ment was  brought  about  by  the  administration  of 
pancreatic  extract  and  secretin.  Although  the 
amount  of  urine  fell  under  the  influence  of  the  pan- 
creatic extract  which  was  at  first  given  alone,  yet 
the  percentage  of  sugar  remained  the  same.  The 
percentage  of  sugar  fell  when  the  pancreas  received 
the  additional  stimulus  of  the  secretin. 

LA  PRESSE  MEDICALE. 
February  13,  igog. 

1.  Operative  Indications  in  Uterine  Fibromata, 

By  J.  L.  Faure. 

2.  Hordenine  Sulphate  in  Therapeutics, 

By  J.  Sabrazes  and  C.  Guerive. 

3.  A  Tropical  Fever  not  hitherto  Described, 

By  Milton  Crendiropoulo. 

4.  The  New  Methods  of  Electrization  in  Muscular  Atro- 

phy of  Traumatic  Origin, 

By  Delherm  and  Laquerriere. 

5.  Argyrol  in  the  Treatment  of  Urethritis,  By  J.  De  Sard. 

6.  Typhomalaria  in  Palestine,  By  Emile  Arab. 

7.  Albuminuria  from  Lordosis,  By  R.  Romme. 

1.  Operative  Indications  in  Uterine  Fibro- 
mata.— -Faure  points  out  that  the  operative  indi- 
cations in  cases  of  this  nature  vary  infinitely,  but 
that  they  are  more  imperative  at  the  time  of  the 
menopause  than  in  young  women. 

2.  Hordenine  Sulphate. — Sabrazes  and  Guerive 
have  tried  the  sulphate  of  hordenine,  an  alkaloid 
with  the  composition  QoHi^NO,  in  intestinal  dis- 
eases, and  find  that  they  obtained  better  results  in 
adults  than  in  children,  particularly  in  simple  diar- 
rhoeas. 

4.  New^  Methods  of  Electrization. — Delherm 
and  Laquerriere  describe  the  modern  methods  of 
applying  electricity  in  the  treatment  of  muscular 
atrophies  of  different  degrees  due  to  traumatism. 

5.  Argyrol  in  Urethritis.  —  De  Sard  speaks 
highly  of  the  results  obtained  by  the  use  of  argyrol 
in  gonorrhoea  in  the  manner  he  describes.  The 
method  of  treatment  is  given  in  detail  for  the  pe- 
riod of  the  commencement  of  the  disease,  the  acute 
stage,  during  the  period  of  decline  and  in  accom- 
panying complications. 

February  17,  igo<). 

1.  Ichthyosis  and  the  Thyreoid  Gland, 

By  E.  Weill  and  G.  Mouriquand. 

2.  Difficulties  in  the  Diagnosis  of  Coxalgia  at  the  Begin- 

ning, By  Calve. 

I.  Ichthyosis  and  the  Thyreoid  Gland. — Weill 
and  Mouriquand  show  that  certain  cases  of  ich- 
thyosis coincide  either  with  thyreoid  lesions  or  with 
manifestations  of  dysthyreoidia,  and  state  that  it  is 
logical  to  attribute  the  cutaneous  troubles  to  these 
lesions  as  in  a  number  of  cases  treatment  directed 
to  the  thyreoid  has  caused  myxoedcma  and  ichthyo- 
sis to  disappear.  They  also  think  that  certain  cases 
attributed  to  hereditary  syphilis  should  be  referred 
to  thyreoid  lesions,  consecutive  or  not  upon  this 
disease.  It  is  universally  admitted  that  the  thyreoid 
gland  presides  over  the  nutrition  of  the  subcuta- 
neous cellular  tissue  and  of  the  skin,  and  therefore 
it  is  logical  to  admit  its  intervention  in  the  evolu- 
tion of  ichthyosis. 


LA.SEMAINE  MEDICALE. 

February  77,  igog. 

1.  The  Nasal  Crises  of  Tabes, 

By  M.  Klippel  and  J.  Lhermitte.. 

2.  Treatment  of  Stenoses  of  the  Larynx  by  Laryngostomy - 

with  Dilatation,  By  Professor  G.  Ruggi. 

I.  Nasal.  Crises  of  Tabes. — Klippel  and  Lher- 
mitte state  that  the  nasal  crises  of  tabes  can  be  di- 
vided into  three  principal  types,  the  sensory,  the- 
spasmodic,  and  the  secretory.  The  sensory  crisis 
appears  in  about  the  following  manner:  During 
digestion,  or  perhaps  without  appreciable  cause,  the 
patient  perceives  a  pricking  at  the  root  of  the  nose, 
a  disagreeable  tickling  of  the  mucous  membrane,, 
and  a  strong,  verj-  disagreeable  odor  which  they 
compare  to  that  of  rotten  fish  or  eggs.  These 
symptoms  may  appear  alone  or  they  may  be  accom- 
panied by  the  reflex  spasmodic  phenomena  which 
constitute  the  second,  spasmodic,  type.  The  latter- 
is  characterized  by  attacks  of  persistent  sneezing 
without  apparent  cause  associated  with  a  spasinodic 
cough,  scintillations  before  the  eyes,  and  buzzing 
in  the  ears.  This  spasmodic  nasal  crisis  may  be 
met  with  independently  of  the  others,  but  more  fre- 
quently it  is  associated  with  a  more  or  less  abun- 
dant flow  of  serous  fluid  from  the  nose,  which 
forms  the  third,  or  rhinorrhoeic  type.  This  like- 
wise may  be  met  with  dissociated  from  the  other 
types  and  may  be  accompanied  by  an  excitation  of 
the  secretion  from  the  conjunctiva  and  lachrymal 
gland.  The  diagnosis  of  the  tabetic  origin  of  the^e 
nasal  crises  depends  on  the  coincident  classical  signs 
of  the  presence  of  the  disease. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 

February  8,  iQog. 

1.  The  Combined  Treatment  of  Pellagra  with  Atoxyl  and 

Arsenic, 

By  V.  Babes,  A.  Vasiliu,  and  N.  Gheorghus. 

2.  Symptomatology  of  Tuberculosis  of  the  Ileosacral  Joint,. 

By  A.  Stieda. 

3.  Meningitis  Serosa  Acuta,  By  Georg  Axhausen. 

4.  Contribution  to  the  Study  of  Caisson  Myelitis, 

By  Wassermeyek. 

5.  Psychotherapy  and  Psychoanalysis, 

By  Otto  Juliusburgek. 

6.  Indications,  Modern  Methods,  and  Results  of  the  Or- 

thopaedic Treatment  of  Mouth  Breathing, 

By  A.  Peyser  and  Richard  Landsberger. 

7.  Contributions  to  Clinical  Microscopy  and  Micropboto- 

graphy.  By  C.  Posner  and  VV.  'Scheffer. 

8.  Epididymitis  Sympathica  (Porosz)   and  not  Epididy- 

mitis Erotica  (Walsch"),  By  Moriz  Porosz. 

9.  Injuries  which  show  the  Form  of  the  Injuring  Instru- 

ment, By  Marx. 

I.  Treatment  of  Pellagra  with  Atoxyl  and 
Arsenic. — Babes,  Vasiliu,  and  Gheorghus  report 
fourteen  cases  of  pellagra,  acute  and  chronic,  in 
adults  and  in  children,  which  were  all  cured  in  from 
six  to  twenty-eight  days  by  from  one  to  four  injec- 
tions of  atoxyl  together  with  the  internal  adminis- 
tration of  four  milligrammes  ol  arsenic  and  inunc- 
tions of  an  arsenical  ointment.  These  results  are 
the  more  marked  because  patients  frequently  suffer 
from  five  to  twentv  years  from  pellagra,  and  are 
transiently  improved  rather  than  healed  after  fre- 
quent and  long  continued  hospital  treatment.  Tliis 
treatment  acts  upon  all  tlie  symptoms  of  the  dis- 
ease ;  first  the  erythema  and  oedema  disappear,  then 
the  diarrhoea  is  arrested,  the  mental  hallucinations. 


"March  ;-o.  1909.] 


PITH  OF  CURRENT  LITERATURE. 


611 


melancholia,  and  asthenia  are  quickly  cured,  and  in 
each  case  the  weight  of  the  patient  rapidly  increased 
from  three  to  eight  pounds.  The  questions  now 
arise  whether  we  are  justified  in  urging  the  gen- 
eral systematic  treatment  of  pellagra  by  means  of 
this  or  of  a  similar  method,  and  also  whether  any 
conclusions  can  be  drawn  in  regard  to  the  aetiology 
of  the  disease  from  the  marked  reaction  to  prepara- 
tions of  arsenic.  The  first  question  the  authors 
answer  affirmatively,  in  regard  to  the  second  they 
say  that  the  almost  specific  action  of  the  atoxyl  and 
arsenic  renders  it  highly  probable  that  pellagra  is 
a  parasitic  disease. 

3.  Meningitis  Serosa  Acuta. — Axhausen  re- 
ports a  case  of  acute  serous  meningitis  in  an  eleven 
year  old  girl  which  was  very  severe  and  at  one 
time  threatened  immediate  death.  Two  opera- 
tions were  performed  at  different  times  to  evacuate 
some  of  the  cerebrospinal  fluid  and  relieve  the  pres- 
sure on  the  brain  with  the  excellent  result  that  the 
child  recovered  and  is  now  vigorous  and  intelligent. 

6.  Orthopaedic  Treatment  of  Mouth  Breath- 
ing.— Peyser  and  Landsberger  refer  in  this  arti- 
cle to  mouth  breathing  due  not  to  obstruction  in  the 
nose  but  to  malformations  or  defects  in  the  palate. 
To  correct  this  an  apparatus  has  been  devised  and 
is  described. 

7.  Clinical  Microscopy  and  Microphotography. 

— -Posner  presents  what  appears  to  be  the  first  arti- 
cle of  a  series  on  these  subjects  dealing  with  studies 
on  the  genital  secretions  of  man.  The  paper  is  illus- 
trated by  plates  showing  the  appearance  of  the  se- 
cretion in  chronic  prostatitis  in  various  lights,  of 
amylaceous  bodies,  and  of  cells  from  the  contents 
of  a  hydrocele,  in  various  lights  as  shown  by  mi- 
crophotography. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 
February  g,  igog. 

1.  The  Influence  of  Castration  and  Hysterectomy  upon 

the  Subsequent  Condition  of  the  Women  Operated 
upon,  By  Pankovv. 

2.  Protective  Work  in  the  Abdominal  Cavity  and  the 

I'unctional  Treatment  of  Persons  upon  whom  Lapa- 
rotomy has  been  Performed,  By  Witzel. 

3.  The  Early  Rising  of  Lying  in  Women,        By  Mayer. 

4.  Puncture  of  the  Brain,  By  Danielsen. 

5.  The  Unfolding  of  the  Stomach,  By  Brauning. 

6.  Kniematographic  X  Ray  Pictures  of  the  Human  Inter- 

nal Organs  (Biorontgenography), 

By  K.\STLE,  RiEDER,  and  Rosenthal. 

7.  The  Distinctive  Diagnosis  between  Diaphragmatic  Her- 

nia and  Monolateral  Idiopathic  High  Position  of  the 
Diaphragm  due  to  Diaphragmatic  Atrophy, 

By  KONIGER. 

8.  The  Plasticity  of  the  Substance  of  the  Liver, 

By  Flesch. 

9.  Fuetal  Typhoid  Infection,  By  Gahtgens. 

10.  Brief  Report  Concerning  Dental  Studies  in  the  Mission 

School  at  Bonaberi,  By  Hammer. 

11.  The  MalignaiiCy  of  Ovarian  Cystomata,         By  Kurz. 

12.  Elias  Metchnikofif,  By  Gruber. 

13.  The  Development  of  Ophthalmology  in  the  University 

at  Munich,  By  Eversbusch. 

I.    Influence  of  Castration  and  Hysterectomy. 

— Pankow  says  that  hysterectomy  with  one  or  both 
of  the  ovaries  I'eft  in  situ  does  not  induce  molimina 
menstrualia.  If  such  symptoms  do  exist  they  dis- 
appear either  immediately  after  the  operation  or 
gradually  in  the  course  of  six  months  or  a  year. 
An  increase  of  the  general  symptoms  of  molimina 
is  occasionally  observed  in  women  with  nervous 
■diseases.  Hysterectomy  is  accompanied  only  rarely 


by  a  pathological  obesity  and  not  at  all  by  atrophy 
of  the  genitals,  in  which  respects  the  results  are 
inarkedly  different  from  those  of  castration.  Yet 
in  a  certain  percentage  of  cases  symptoms  re- 
sembling those  following  castration  do  occur,  but 
chiefly  in  elderly  women,  and  they  usually  run  a 
very  mild  course.  They  are  not  due  to  atrophic 
changes  in  the  ovaries,  but  to  the  loss  of  the  uterus 
itself. 

3.  Early  Rising  of  Lying  in  Women. — Mayer 
protests  against  the  suggestion  made  by  Kiistner 
that  lying  in  women  should  be  allowed  to  rise 
earlier  than  is  the  usual  custom.  Among  the  dan- 
gers attendant  upon  such  early  rising  he  enumer- 
ates its  bad  influence  upon  the  involution  and  posi- 
tion of  the  sexual  organs,  as  well  as  upon  the  ab- 
dominal walls  and  the  pelvic  tissues,  the  causation 
of  thromboses  and  emboli,  and  the  eft'ect  upon  the 
general  condition,  particularly  upon  the  morbidity. 
These  dangers  he  illustrates  from  the  statistics  of 
200  cases  in  which  the  women  rose  on  the  third 
to  the  seventh  day  after  labor. 

4.  Puncture  of  the  Brain. — Danielsen  consid- 
ers puncture  of  the  brain  to  be  a  valuable  diagnos- 
tic aid  in  the  determination  of  the  kind  and  seat 
of  a  disease  of  the  brain.  The  procedure  is  not 
without  danger,  but  is  one  to  which  we  can  turn 
when  with  its  help  we  may  hope  to  save  a  human 
life. 

5.  The  Unfolding  of  the  Stomach. — Brauning 
describes  the  way  in  which  the  empty  stomach  be- 
comes distended  when  food  is  introduced  as  ob- 
served by  means  of  the  x  rays. 

6.  Biorontgenography.  —  Kiistle,  Rieder,  and 
Rosenthal  present  twenty-two  illustrations  to  show 
the  results  obtained  by  a  kinematographic  set  of 
X  ray  pictures,  called  by  them  biorontgenography. 
The  pictures  show  the  changes  in  the  silhouette  of 
the  heart  and  in  the  cupping  of  the  diaphragm 
during  respiration,  and  the  movements  of  the 
stomach. 

9.  Foetal  Typhoid  Infection. — Gahtgens  reports 
a  case  in  which  a  woman,  four  months  pregnant, 
had  an  attack  of  typhoid  fever.  Three  weeks  later 
she  aborted  and  investigation  of  the  foetus  discov- 
ered typhoid  bacilli  in  all  its  organs.  These  were 
particularly  marked  in  the  brain,  blood  of  the  heart, 
lungs,  liver,  bile,  spleen,  kidneys,  and  in  the  con- 
tents of  the  intestinal  tract.  No  anatomical  changes 
in  the  intestinal  tract  could  be  found.  No  macro- 
scopic changes  were  present  in  the  placental  and 
no  typhoid  bacilli  could  be  obtained  by  cultivation 
from  its  blood. 

ARCHIVES  OF  P>tDIATRICS 
February,  igog. 

1.  Fresh  Air  in  tlie  Treatment  of  Disease, 

By  E.  E.  Graham. 

2.  Fresh  Air  in  the  Treatment  of  Disease. 

By  W.  P.  Northrup.' 

3.  The  Restoration  of  Scoliosis  to  Symmetry, 

By  W.  G.  Elmer. 

4.  Scarlet  Fever  Carriers.  By  C.  Herrman. 

5.  Scarlet  Fever  with  Varicella  and  Whooping  Cough, 

By  H.  M.  McClanahan. 

6.  Scarlet  Fever  from  a  Wound  in  the  Foot, 

By  F.  Van  Der  Bogert. 

7.  A  Case  of  Scurvy  with  X  Ray  Plates, 

By  E.  A.  Riesekfei.d. 

8.  A  Case  of  Lead  Poisoning,  By  W.  H.  Wright. 

9.  Imperforate  Anus  with  Rectovesical  Fistula, 

By  E.  F.  KiSER. 


6l2 


PlIH  01'  CUKRENT  LITERATURE. 


Medical  Jovr.nal. 


I,  2.    Fresh  Air  in  the  Treatment  of  Disease. 
— Graham  began  his  fresh  air  treatment  of  infants 
and  yoimg  children  eight  years  ago.    In  hospital 
practice   the   cribs   were   moved   to  the  fire  es- 
cai)es  and  protected  by  wind  shields.     The  infant 
mortality  at  once  decfined,  the  patients  gained  m 
weight  and  health,  and  tiie  deaths  were  mamly  m 
pooVly  nourished  infants  under  three  months  of 
age.    In  his  service  in  the  new  Philadelphia  Hos- 
pital, with  large  airy  wards,  good  milk,  porches  on 
two 'sides,  and  fresh  air  day  and  night,  the  infants 
do  as  well  as  could  could  be  hoped.    Severe  cases 
of  pneumonia  in  children  of  all  ages  have  been 
treated  in  the  past  three  years  with  abundant  fresh 
air  and  have  given  favorable  results.    The  same  is 
true  of  typhoid  fever  and  tuberculosis  case.s.  In 
private  practice  fresh  air  is  insisted  upon  for  all 
infants  and  children,  sick  and  well.    In  both  pri- 
vate and  public  practice  a  room  temperature  of 
60°  r.  is  maintained  as  far  as  possible,  the  body 
heat  being  maintained  by  suf?icient  clothing,  hot 
water  bags,  etc.    The  advantages  of  high  altitude, 
seashore  air,  and  fresh  country  air  compared  with 
the  average  conditions  in  city*life  are  also  referr-ed 
to  as  most  important  conditions  for  the  reduction 
of   infantile   mortality   and   morbidity. — Northru]) 
considers  two  point.s',   (i)  the  class  of  cases  to 
which  this  treatment  is  especially  adapted,  and  in 
which  it  has  been  thoroughly  tried;  {2)  the  prac- 
tical application  of  the  method,  and  its  working 
out   in   detail    after   much   observation    and  ex- 
perience.   As  a  standardized  formula  for  the  L'. 
S.  P.  he  would  recommend,  "Open  air,  or  cold, 
fresh,  flowing  outdoor  air,  dosage   regulated  to 
individual  needs."  .AH  febrile  cases,  with  the  pos- 
sible exception  of  measles,  may  be  safely  and  atl- 
vantageously  treated  in  the  open  air,  the  comfort 
of  patient  and  nurse  being  at  all  times  considered. 
The  bed  must  be  carefully  prepared,  with  as  much 
clothing  below  as  above  the  patient.    The  patient 
should  have  a  complete  suit  of  flannel  next  to  the 
skin,  the  nurse  should  be  well  wrapped  up.  The 
author  concludes  that  he  has  no  percentages  and 
no  tabulations,  but  that  his  impressions  and  con- 
victions based  upon  his  experience  justify  the  state- 
ment that  open  air  treatment  has  killed  no  one, 
has  injured  no  one,  has  helped  every  one.  and  de- 
termined a  cure  in  a  few. 

4.  Scarlet  Fever  Carriers. — Herrnian  refers  to 
the  epidemic  of  scarlet  fever  in  New  York  city  in 
1908  as  the  most  severe  and  widespread  in  the  his- 
tory of  the  city.  The  mortality  was  5.4  per  cent., 
notwithstanding  the  most  extensive  sanitary  precau- 
tions. The  author  believes  there  must  have  been 
some  source  of  infection  which  had  been  overlooked 
or  which  had  not  received  due  consideration.  lie 
does  not  think  the  schools  were  at  fault  as  has  been 
the  case  in  some  epidemics.  As  to  the  question  of 
tran.smission  bv  dcsriuamated  scnles  of  epidermis  ar- 
gument is  brought  forward  to  show  that  this  is  at 
least  doubtful.  C  ited  cases  seem  to  point  to  saliva,  to 
the  walls  and  floors  of  the  sick  room  as  carriers  of 
the  infectious  material  whatever  it  may  be.  Mild 
cases  may  propagate  the  disease  as  effectively  as 
severe  ones,  and  any  one  with  a  scarlet  fever  throat 
mav  c^ive  the  disease  in  virulent  form  to  unpro- 
tected children.    A  discharge  from  the  nose  or  car 


may  bear  the  infective  material,  hence  the  greatest 
care  should  be  given  to  nasal  and  oral  hygiene. 
Open  wounds  should  be  protected  from  contact 
with  those  who  have  been  exposed  to  the  disease. 
Disinfection  may  be  unnecessary,  but  in  the  exist- 
ing uncertainty  as  to  the  medium  of  transmission 
such  a  procedure  cannot  be  dispensed  with. 

THE  PRACTITIONER. 

February,  igog. 

1.  The   Relation   of   some   Constitutional    Conditions  to 

Local  Lesions,  Traumatic  and  Otherwise 

By  SiK  W.  H.  Bexxetx. 

2.  Notes  from  a  Clinical  Lecture  on  .Addison's  Disease, 

By  W.  H.  White. 

3.  Fact  and  Fiction,  or  th.e  Prognosis  in  Cases  of  Frac- 

ture, By  W.  A.  L.\NE. 

4.  Myxicdenia.  By  G.  R.\nkin-. 

5.  Pulmonary  EnihoHsm  and  Thrombosis  after  Lapara- 

tomy,  By  L.  A.  Bidwell. 

6.  Orthopedic  Surgery,  By  A.  H.  Tubp.v. 

7.  Recent  Work  on  Anaesthetics,  By  J.  Bll-.mfelu. 

8.  The  Action  of  Drugs  on  Diseases  caused  by  Protozoa, 

By  W.  E.  Dixon. 

9.  Puerperal  Pxjemia.    Vaccine  Treatment. 

By  J.  T.  Hewetson. 

10.  Adulterations  of  Food.  By  W.  S.  Tebe. 

11.  Paroxysmal  Tach_\-cardia.    With  Notes  of  a  Case  oc- 

curring in  Alother  and  Daughter, 

By  A.  W.  F.XLCONEK. 

12.  Injuries  to  Hand  with  Relation  to  Insurance, 

By  J.  A.  M.ACKEXZFE. 

I.  The  Relation  of  Some  Constitutional  Con- 
ditions to  Local  Lesions. —  Dennett  thinks  that  in 
frec|uenc  cases  in  individuals  with  constitutional  de- 
fects, whether  already  known  or  ascertained  as  the 
result  of  bacteriological  or  other  examination,  any 
disease  or  departure  from  the  normal  course  in  re- 
covering from  an  injury  is  too  frequently  attributed 
to  the  constitutional  fault.  This  is  owing,  certainly 
in  part,  to  the  increasing  tendency  to  rely  too  much 
upon  bacteriological  and  other  laboratory  examina- 
tions, and  too  little  upon  careful  weighing  of  local 
manifestations  in  arriving  at  a  diagnosis.  Further- 
more, a  careful  investigation  of  the  patient's  family 
history  frequently  biases  the  physician  unduly  in 
making  his  diagnosis.  It  is  therefore  insi.sted  that 
in  ordinary  diagnosis  the  object  of  primary  import- 
ance is  the  local  condition  not  the  con.stitutional 
state.  It  does  not  follow  because  a  patient  has  a 
constitutional  defect  which  leads  to  the  development 
of  some  form  of  di.sease,  say  of  syphilis  or  malig- 
nant growth,  that  if  he  has  two  or  more  develop- 
ments of  disease  in  the  same  or  in  different  parts  of 
the  body  that  they  should  be  of  the  same  nature. 

3.  Fact  and  Fiction,  or  the  Prognosis  in  Cases 
of  Fracture.  —  Lane  has  excited  ()])position  by  his 
treatment  of  simple  fractures  by  o])crative  measures 
rather  than  bv  splints  and  niani]nilation.  The  ad- 
vantages of  operative  measures  are :  a.  They  relieve 
the  patient  from  the  pain  caused  by  the  movement 
of  the  fragments  upon  each  other :  h.  they  free  him 
from  the  tension  and  discomfort  of  blood  extrava- 
.sated  within  llie  tissues;  c.  they  shorten  the  period 
of  healing  and  so  of  absence  from  work,  for  union 
i---  practically  by  first  intention :  d,  they  leave  the 
skeletal  mechanics  in  the  condition  in  which  they 
were  before  the  injiuw  was  sustained.  The  conclu- 
sions which  he  reached  as  to  the  old  meth(xls  of 
treatment  are  as  follows:  i.  Anything  like  accurate 
apposition  of  displaced  fragments  in  a  fracture  is 
rarelv  obtained.     2,  The  old  fashioned  method  of 


March  20,  1909.J  FROCEEDIXGS  Of  SOCIETIES.  61 


treating  fractures  is  a  disgrace  to  surgical  practice, 
for  it  is  frequently  followed,  especially  in  the  leg 
by  enormous  physical  disability.  It  frequentl)' 
means  the  entire  destruction  of  the  patient's  wage 
earning  capacity. 

4.  Myxoedema. — Rankin  states  that  observa- 
tion and  experiment  have  now  conclusively  proved 
that  the  thyreoid  gland  supplies  to  the  economy  a 
secretion  essential  to  normal  metabolism,  and  that 
interference  with  this  secretion  from  atrophy  or 
destruction  of  the  gland  may  produce  cretinism  in 
children  or  myxtiedema  in  adults.  The  immediate 
exciting  cause  of  myxoedema  is  mechanical  removal 
of  or  morbid  change  in  the  thyreoid  gland,  but  the 
precise  nature  of  the  process  is  unknown  ;  it  may  be 
inflammatory  or  it  may  be  toxaemic.  The  onset  of 
the  disease  is  insidious,  but  when  fully  developed  it 
provinces  such  a  change  in  the  personal  appearance 
and  mental  activity  of  the  patient  that  its  facies  is 
])athognomonic.  The  only  diseases  with  which  it 
may  be  confounded  are  Bright's  disease  and  acrom- 
egaly. The  treatment  consists  in  the  internal  ad- 
ministration of  the  crushed  gland  or  its  extract. 
Such  treatment  is  curative  but  it  is  necessary  that 
it  be  continued  as  long  as  the  patient  lives. 

8.  The  Action  of  Drugs  on  Diseases  Caused  by 
Protozoa. — Dixon  thinks  it  is  impossible  to  de- 
stroy or  prevent  the  growth  of  the  bacilli  of  diph- 
theria, tetanus,  typhoid,  and  anthrax  within  the 
body  by  means  of  drugs,  since  the  latter  would  in- 
jure the  patient  before  they  killed  the  organisms. 
Protozoa  are  more  susceptible  to  the  action  of  drugs 
than  bacteria,  being  less  highly  organized.  Of  the 
specific  drugs  which  destroy  them  mention  is  made 
of  quinine,  mercur\ ,  arsenic,  antimony,  and  sal- 
icylates. The  diseases  for  which  these  substances 
are  undoubted  specifics  through  the  ef¥ect  which 
they  have  respectively  upon  the  protozoa  causing 
the  disease  are  malaria,  syphilis,  the  sleeping  sick- 
ness, and  acute  rheumatism.  The  organism  of  ma- 
laria is  definitely  determined.  That  of  syphilis  is 
determined  with  extreme  probability.  The  try- 
panosomes  of  the  sleeping  sickness  may  acquire  a 
tolerance  for  arsenic,  but  this  is  not  the  case  when 
antimony  is  used.  It  is  not  improbable  that  acute 
rheumatism  may  be  caused  by  protozoa,  but  the 
point  is  not  yet  decided. 

10.  Adulteration  of  Food. — Tebb  asserts  that 
adulteration  of  food  is  not  a  modern  art,  since  it 
has  come  to  us  from  antiquity.  There  is  everj'  rea- 
son to  believe  it  was  practised  long  before  anv 
means  were  used  for  its 'detection,  or  the  punish- 
ment of  of¥enders.  Pliny  refers  to  the  subject  and 
to  one  article  which  was  most  extensively  adul- 
terated in  his  time.  In  England  as  far  back  as  the 
eleventh  century  certain  drugs  and  several  articles 
of  food  were  adulterated.  The  greatest  offenders 
among  the  traders  of  early  times  were  the  vintners, 
brewers,  and  bakers.  Unsound  wine  is  referred  to 
in  the  annals  of  the  corporation  of  London  in  1364. 
English  ale  was  adulterated  with  cocculus  indicus  in 
the  tim.e  of  Queen  Anne.  Bakers  were  accu.'ed  of 
selling  bread  made  from  putrid  wheat  in  131 1,  and 
alum  was  used  in  the  bread  in  the  eighteenth  cen- 
tury. The  extent  to  which  adulteration  of  the 
necessaries  of  life  is  practised  at  the  present  time 
demands  legislation  of  a  very  drastic  character. 


Jrflfuiinp  at  ^uitim. 

XEW  YORK  ACADEMY  OF  MEDICINE. 
Meeting  of  January  7,  j^/og. 
The  President,  Dr.  Johx  A.  W'yETH,  in  the  Chair. 

A  Synopsis  of  Two  Years'  Work  of  the  Acad- 
emy.— Dr.  John  A.  Wvetu.  who  had  been  re- 
elected president,  in  a  report  of  the  scientific  work 
of  the  academy  for  the  last  two  years,  made  a  most 
gratifying  statement  as  to  the  condition  of  the 
academy,  both  financially  and  as  to  membership. 
The  waiting  list  of  the  academy  grew  to  such  an 
extent  that  it  became  necessary  to  amend  the  con- 
stitution raising  the  limit  of  membership  to  1,200 
instead  of  1,000.  The  number  of  fellows  on  the 
roll  on  December  29,  1908,  was  1,199. 

At  the  close  of  his  address  the  president  said : 
'■  L  deem  it  my  duty  to  refer  to  an  incident  which 
must  be  deplored  by  every  one  \yho  holds  that  the 
academy  should  represent  the  highest  ideals  in  med- 
icnie.  that  it  should  not  permit  its  privileges  to  be 
])rostituted  to  commercialism  nor  misleading  or  un- 
truthful reports  of  its  transactions  to  be  scattered 
far  and  wide  in  the  public  press. 

"In  commenting  upon  this  incident,  an  editorial 
writer  in  the  Nezv  York  Medical  Journal^  in  depre- 
cating the  laxity  shown  by  medical  societies  in  al- 
lowing undesirable  papers  to  be  presented  at  their 
meetings,  criticises  the  New  York  Academy  of 
Aledicine  when  it  gaye  an  individual  the  privilege 
of  exploiting-  a  matter  connected  with  the  treat- 
ment of  tabes  dorsalis  in  such  a  way  as  to  bring 
him  the  tremendous  advantage  of  newspaper  lau- 
dation. So  palpable  was  the  blunder  that  the  Xew 
York  Neurological  Society  very  promptly  signified 
its  disapproval. 

"AA'ith  a  knowledge  of  the  facts,  it  would  be  dif- 
ficult to  justify  this  criticism,  and  the  facts  could 
easily  have  been  obtained  from  the  Council  of  the 
academy.  The  paper  in  question  was  subjected  to 
the  same  careful  scrutiny  which  is  given  all  the  ma- 
terial oftered  to  the  academy.  It  is  held  that  every 
fellow  is  entitled  to  the  privilege  of  submitting  his 
views  upon  any  topic  in  medical  science,  proyided 
that  after  examination  they  shall  be  deemed  of  suf- 
ficient importance  to  justify  their  presentation  from 
the  platform  or  through  the  discussion. 

"In  this  particular  instance,  the  subject  was  loco- 
motor ataxia,  concerning  which  it  is  possible  that 
we  have  not  yet  reached  the  Ultima  Thule  of 
knowledge. 

"On  ^Nlay  16.  1907.  a  member  of  the  academy 
))resented  a  short  paper  entitled.  Locomotor  Ataxia, 
a  Xew  Theory  as  to  its  Cause.  The  theory  ad- 
vanced received  respectful  attention  and  excited, 
so  far  as  I  am  able  to  inform  myself,  no  comment 
or  criticism.  A  year  and  five  months  later  the 
same  fellow  requested  the  privilege  of  reporting  to 
the  academy  the  results  obtained  by  him  in  "the 
treatment  of  a  series  of  cases.  Before  permitting 
the  paper  to  be  listed,  by  consultation  with  a  mem- 
ber of  the  academy  and  another  physician,  not  a 
member,  both  gentlemen  of  high  standing  and  ex- 
perience in  neurology,  I  satisfied  myself  that  the 
paper  was  of  sufificient  importance  to  justify  its 


6i4 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


presentation.  On  October  i,  1908,  under  the  title 
of  Locomotor  Ataxia,  a  Report  of  Thirty  Cases,  it 
was  read  and  discussed  by  several  members  promi- 
nent in  neurology  and  general  medicine.  On  the 
day  following  and  thereafter  the  newspapers  of 
this  country  and  abroad  printed  dispatches  from 
the  Associated  and  the  United  Press,  two  organi- 
zations engaged  in  the  widespread  distribution  of 
news,  which  were  sensational,  distorted,  exagger- 
ated, and  in  large  measure  untruthful  accounts  of 
the  proceedings  of  the  academy,  to  which  was 
added  the  crowning  falsehood  that  the  claims  ad- 
vanced by  the  reader  were  endorsed  by  Dr.  John 
A.  Wyeth,  president  of  the  New  York  Academy 
of  Medicine.  Of  the  source  of  this  misinformation 
to  the  public  press  I  have  not  the  slightest  idea.  I 
am  not  willing  to  believe  that  any  member  of  the 
academy  would  consent  to,  let  alone  take  part  in,  a 
transaction  so  undignified  and  unprofessional." 


MEDICAL  SOCIETY  OF  THE  STATE  OF  PENN- 
SYLVANIA. 

Fifty-eighth  Annual  Meeting,  held  in  Cambridge  Springs, 
September  15.  16,  and  17,  1908. 

{Conthmcd  from  page  36^.) 

The  X  Ray  in  the  Treatment  of  Exophthalmic 
Goitre. — Dr.  J.  C.  Price,  of  Scrantoii,  advocated 
the  use  of  the  rays  in  selected  cases,  especially  in  the 
cases  the  surgeon  refused  to  operate  on  and  in  the 
class  of  cases  with  symptoms  not  sufficiently  severe 
to  send  the  patients  to  surgeons. 

Dr.  J.  H.  Gibbon,  of  Pliiladelphia,  said  there  was 
difficulty  in  selecting- the  cases  of  exophthalmic  goi- 
tre in  which  an  operation  should  be  done.  He  did 
not  believe  that  the  cure  of  this  condition  was  going 
to  be  a  surgical  one.  He  thought  much  help  would 
be  derived  from  serum  therapy.  Exophthalmic  goi- 
tre should  not  be  operated  on  in  the  early,  acute 
stages.  The  treatment  of  Beebe  and  Rogers  de- 
served a  trial  in  these  cases.  Patients  sometimes 
died  from  the  anc-esthetic,  but  the  pain  under  local 
anaesthesia  as  used  by  Kocher  was  so  terrific  that  in 
this  country  we  were  wise  in  selecting  a  general 
an?esthetic.  He  had  had  one  case  of  tetany  from  re- 
moval of  both  parathyrcoids. 

Dr.  George  C.  Johnston,  of  Pittsburgh,  did  not 
believe  exophthalmic  goitre  a  surgical  disease  at  all 
and  believed  Beebe's  serum  promised  good  results 
in  this  form.  In  malignant  cases  the  earlier  the  op- 
eration the  better.  He  believed  the  x  ray  was  of  value 
before  an  operation  in  surgical  goitre  because  it 
developed  a  thick  capsule  and  facilitated  an  opera- 
tion. 

Dr.  O.  C.  Gaub,  of  Pittsburgh,  .said  that  in  his 
experience  local  anaesthesia  had  given  very  satisfac- 
tory results  and  that  the  patient  sufl'ered  very  little 
under  it. 

Dr.  J.  A.  LiCHTY,  of  Pittsburgh,  said  he  had  seen 
a  hundred  cases  of  exophthalmic  goitre  in  the  last 
ten  years,  and  only  two  of  the  patients  had  died.  He 
had  used  Beebe's  fluid  on  six  patients,  of  whom  four 
were  well  and  two  others  improving. 

Pancreatitis.-r-Dr.  W.  L.  Rodman,  of  Pliiladel- 
phia, presented  this  subject.  The  principal  symp- 
toms of  chronic  pancreatitis,  he  said,  would  be  pro- 
gressive loss  of  flesh,  distaste  for  food,  especially 


meat,  and  imperfect  digestion  of  unstriated  mus^le 
fibre,  and  there  would  be  free  fat  in  the  faeces.  The 
skin  would  usually  be  muddy,  if  not  actually  jaim- 
diced.  The  urinary  was  the  most  important  of  all 
the  tests.  He  had  recently  had  a  case  with  Dr.  Mus- 
ser  in  which  the  diagnosis  was  actually  made  by  an 
examination  of  the  urine  without  any  history  at  all. 
From  that  fact  he  believed  that  the  Cammidge  test, 
which  had  been  discredited  in  many  parts  of  Amer- 
ica, was  a  most  valuable  test.  As  to  treatment,  he 
advocated  the  indirect  treatment  by  drainage.  The 
milder  cases  would  be  treated  medically  by  diet  and 
alkalis,  especially  by  mild  purgation,  which  was  an 
excellent  intestinal  antiseptic  and  relieved  gastric  or 
duodenal  catarrh,  which  was  often  the  cause  of  a 
chronic  interstitial  pancreatitis.  Of  the  surgical 
means,  practically  the  only  thing  we  could  do  was  to 
drain  the  gallbladder  first  by  cliolecvstostomy,  whi':h 
undoubtedl}-  would  relieve  the  mildest  cases,  which 
would  positively  not  require  drainage  more  than  a 
fortnight  or  three  or  four  weeks  or  possibly  a  shorter 
time.  If  there  was  an  extensive  infiltration  of  the 
pancreas,  or  it  was  thought  advisable  for  any  reason 
to  prolong  the  drainage,  undoubtedly  cholecystosto- 
my  should  be  preferred.  Mayo  Robson  preferred 
drainage  in  all  instances. 

Dr.  W.  L.  EsTES,  of  South  Bethlehem,  said  that 
he  had  seen  cases  of  supposed  carcinoma  of  the  head 
of  the  pancreas  turn  out  at  operation  to  be  chronic 
pancreatitis,  and  the  patient  make  entire  recovery 
after  an  operation. 

Dr.  E.  H.  GooDM.\N,  of  Philadelphia,  had  ap- 
plied the  Cammidge  test  in  twenty-five  or  thirty 
cases  of  pancreatitis  and  had  found  it  answer  in 
every  case.   In  cases  of  diabetes  it  had  failed. 

Dr.  JuDSON  Deland,  of  Philadelphia,  said  that 
what  was  needed  was  a  better  method  of  diagnosis. 
He  thought  pancreatic  disease  very  common,  but  the 
vast  majority  of  cases  were  not  recognized  and 
many  were  incapable  of  diagnosis.  If  the  Cam- 
midge test  proved  reliable  it  would  be  very  valuable. 

Dr.  Charles  E.  Thomson,  of  Scranton.  men- 
tioned one  patient  who  had  been  operated  upon 
twice,  each  time  with  a  diagnosis  of  cancer  of  the 
pancreas  and  an  unfavorable  prognosis ;  yet  the  pa- 
tient had  got  entirely  well. 

Dr.  Rodman  said  that  he  had  mistaken  chronic 
pancreatitis  for  carcinoma  in  the  case  mentioned  by 
Dr.  Thomson,  but  thought  that  with  the  Cammidge 
test  and  recognition  of  the  fact  that  in  carcinoma 
the  jaundice  was  deep  and  unvarying,  while  in  pan- 
creatitis it  was  less  ma?ked,  the  diagnosis  could 
readily  be  made. 

INTESTINAL  OBSTRUCTION. 

Redundant  Sigmoid.— Dr.  John  G.  Clark,  of 
Piiilaclclphia,  in  studying  the  embryology  of  the  in- 
testine to  account  for  redundant  sigmoid,  had 
found  that  at  birth  the  sigmoid  flexure  comprised 
one  half  of  the  large  intestine.  I'or  three  or  four 
months  subsequent  to  birth  it  remained  of  the  same 
length,  but  the  remainder  of  the  large  intestine  in- 
creased in  length  at  a  considerable  rate  of  growth. 
It  therefore  seemed  to  him  plausible  that  under 
similar  circumstances  the  growth  throughout  the 
entire  colon  might  occur  pari  passu,  thus  allowing 
the  sigmoid  to  increase  considerably,  and  conse- 
quently when  the  child  began  to  have  active  use  for 


March  20,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


615 


the  colon,  w  lien  solid  food  was  taken,  more  or  less 
constipation  was  noted. 

He  illustrated  his  remarks  with  the  histories  of 
four  cases,  one  in  a  boy,  four  years  of  age,  who  had 
suffered  with  recurring  attacks  of  intense  intestinal 
colic  finally  amounting  to  obstruction  so  excessive 
as  to  acquire  large  doses  of  purgatives  with  drastic 
enemata  to  effect  a  movement.  In  this  case  eighteen 
inches  of  the  sigmoid  flexure  were  removed  and 
end  to  end  anastomosis  done,  rendering  the  sigmoid 
of  normal  length.  Dr.  Clark  thought  it  quite  re- 
sonable  to  assume  that  had  this  redundancy  been 
less  extensive  it  would  not  have  fallen  into  the  class 
of  operative  cases,  which  had  been  designated  as 
Hirschsprung's  disease,  but  this  boy  would  have 
grown  up  always  suffering  with  intense  constipa- 
tion, and  probably  been  more  or  less  hindered  in  his 
growth  because  of  the  continued  autointoxication. 

Dr.  Clark  had  depended  upon  medical  measures 
for  the  larger  portion  of  these  cases.  In  others, 
where  the  redundancy  was  considerable,  the  sigmoid 
had  been  lightly  caught  by  either  the  epiploic  append- 
ages or  the  dorsum  and  held  by  one  or  two  stitches 
in  the  left  loin,  thus  preventing  the  sigmoid  from 
dropping  back  into  the  pelvis.  In  five  of  these  cases 
Dr.  Clark  had  done  resection  of  the  sigmoid,  and  in 
one  case,  anastomosis  between  the  dependent  loop 
and  the  lower  end  of  the  sigmoid  where  it  termin- 
ated in  the  rectum.  Upon  the  whole,  the  results  of 
these  cases  had  been  satisfactory. 

Acute  Intestinal  Obstruction. — Dr.  Luther  B. 
Klixe.  of  Catawissa,  said  that  the  abnormal  states 
or  conditions  acting  in  a  causative  relation  to  acute 
intestinal  obstruction  were  various.  The  aetiology 
bore  an  important  relation  to  the  symptoms,  diag- 
nosis, and  treatment  of  this  affection,  and  included 
strangulation,  intussusception,  volvulus,  foreign 
bodies,  and  hernia.  The  symptoms  were  abdominal 
pain  of  an  acute  character,  nausea,  vomiting,  tym- 
pany, and  increase  of  temperature.  The  diagnosis, 
in  consequence  of  the  sudden  onset  and  rapid  de- 
velopment of  the  disease,  was  most  important.  As 
there  were  many  of  the  same  symptoms  as  in  ap- 
pendicitis, careful  investigation  might  be  necessary 
to  discriminate  between  them.  The  treatment  w^as 
closely  associated  with  the  diagnosis  :  the  latter  being 
definitely  determined  in  favor  of  acute  obstruction, 
little  time  should  be  consumed  before  resorting  to 
surgical  interference. 

Intestinal  Obstruction  in  Connection  with  Tu- 
berculosis or  Tuberculous  Peritonitis.  —  Dr. 
Henry  Ne.ale,  of  Upper  Lehigh,  read  this 
paper.  Obstruction  of  the  bowels  due  to  tubercu- 
lous deposit,  he  said,  was  a  much  more  common 
condition  than  was  usually  supposed.  An  operation 
was  of  great  value  if  proper  discrimination  was 
made.  A  plea  was  made  for  exploratory  incision  in 
all  doubtful  cases  w'here  it  was  possible  and  at  the 
same  time  feasible  after  careful  consideration.  The 
author  reported  four  cases. 

Dr.  C.  H.  Miner,  of  Wilkes-Barre,  said  that  in 
tuberculosis  within  the  abdomen  there  were  many 
structures  from  which  it  might  arise,  hence  a  dis- 
tinction was  difficult.  Obstruction  of  the  intestine 
in  tuberculosis  might  be  due  to  a  healed  lesion  or  to 
thickening  of  the  intestinal  wall.  Dilatation  of  the 
intestine  above  the  obstruction  might  be  enormous, 
while  below  it  the  lumen  was  very  much  reduced. 


W  hile  an  exploratory  incision  was  always  justifi- 
able, it  was  true  that  sometimes  absorption  took 
place  with  relief  of  symptoms. 

G.  W.  Guthrie,  of  Wilkes-Barre.  said  that  in  all 
cases  of  intestinal  obstruction  the  treatment  was  to 
operate  early.  When  the  bowels  did  not  act,  the  ab- 
domen should  be  opened  and  the  cause  ascertained. 

The  Pathology,  Diagnosis,  and  Surgical  Treat- 
ment of  Gastroptosis. — Dr.  Ernest  Laplace,  of 
Philadelphila,  said  that  the  nutrition  of  tissue  form- 
ed the  basis  of  physiological  equilibrium.  Disturb- 
ance of  physiological  equilibrum  resulted  in  altered 
tissue  resistance.  Perfect  nutrition  maintained  the 
ligaments  in  proper  tonicity.  Imperfect  nutrition 
weakened  them  and  allowed  the  weight  to  stretch 
them  beyond  endurance.  He  thought  Beyea's  oper- 
ation of  shortening  the  ligaments  by  three  rows  of 
interrupted  sutures  a  good  one  in  immediate  re- 
sults, but  the  latter  effects  were  bad.  Dr.  Laplace 
had  therefore  devised  an  operation  to  suture  the 
gastrocolic  omentum  to  the  anterior  abdominal 
wall  by  means  of  a  continuous  catgut  suture  after 
gently  scarifying  the  surfaces  to  be  brought  in 
apposition.  IJy  this  means  the  stomach  was  sup- 
ported from  below,  relieving  the  weight  on  the 
shortened  ligaments  above  at  least  for  a  consider- 
able time  after  the  operation.  He  emphasized  the 
importance  of  his  operation  as  an  adjunct  to  Bey- 
ea's, allowing  it  to  furnish  the  maximum  relief,  but 
relieving  the  shortened  ligaments  of  their  work  as  ^ 
much  as  possible  during  the  period  following  the 
operation,  and  enabling  them  to  regain  as  speedily 
as  possible  the  unyielding  property  they  had  lost. 
He  reported  two  cases  where  there  was  complete 
relief  now  lasting  over  two  years  as  the  result  of  his 
operation. 

Dr.  Edw'ard  jNIartin,  of  Philadelphia,  said  that 
patients  were  usually  subjected  to  various  other 
operations  before  restitution  of  the  stomach  was  at- 
tempted. The  operation  was  indicated  only  when 
there  were  symptoms  of  stasis  in  the  stomach  com- 
bined with  neurasthenia,  which  was  always  toxic  in 
origin.  In  operating  Dr.  Martin  took  a  high  and  a 
low  grip  on  the  structures,  putting  the  sutures 
through  the  stomach  wall  itself  and  disregarding  the 
thinned  omentum.  In  his  five  cases  a  cure  had  re- 
sulted in  every  case. 

Exstrophy  of  the  Bladder  Treated  by  Extra- 
peritoneal Implantation  of  the  Ureters  into  the 
Rectum. — Dr.  Buchanan,  after  reviewing  the  his- 
tory of  the  efforts  to  relieve  exstrophy  of  the  blad- 
der, said  he  had  performed  the  Bergenhem  opera- 
tion in  two  cases,  one  in  a  girl  of  eighteen  months, 
and  the  IMaydl  operation  with  a  fatal  result  on  the 
fourth  day,  due  probably  to  the  eft'ect  of  the  ether 
on  the  lungs,  neither  peritonitis  nor  kidney  symp- 
toms being  present.  In  January,  1908,  he  operated 
upon  a  male  child,  seven  weeks  old,  with  exstrophy  of 
the  bladder,  with  marked  success.  Seven  months 
later  the  child  was  able  to  retain  urine  three  or  four 
hours  and  gave  no  indication  of  irritation  of  the 
bowel  by  the  urine  or  infection  of  the  kidneys.  He 
had  inquired  into  the  eft'ects  of  an  operation  in 
ninety-six  patients  surviving  it.  Only  eight  were 
known  to  have  had  subsequent  ascending  urinary 
infection,  and  in  these  it  might  have  existed  at  the 
time  of  the  operation.  The  mortality  of  Bergen- 
hem's  operation  in  the  cases  so  far  reported  was 


6i6 


PROCEEDINGS  OE  SOCIETIES. 


[New  York 
Medical  Journal. 


luit  Lltvfu  ])cr  cent.  It  converted  a  life  of  misery 
into  one  of  almost  perfect  comfort,  and  there  should 
be  no  hesitation  in  advising  its  performance. 

i)r.  Edward  IM.vrtin,  of  Philadelphia,  considered 
the  paper  of  Dr.  Buchanan  the  most  convincing  one 
yet  ])roduced  in  regard  to  the  late  results  of  implan- 
tation of  the  ureters.  These  were  difficult  cases, 
and  the  operation  was  usually  reluctantly  undertaken 
because  of  the  bad  final  results.  When  the  opera- 
tion for  the  closure  of  the  bladder  was  done,  the  im- 
mediate results  might  be  ver\  i)romising,  but  the 
ultimate  result  was  unsatisfactory.  Xo  operation 
gave  hope  except  this  one  of  implantation. 

Early  Signs  of  Ectopic  Gestation. — Dr.  Ra- 
leigh K.  HuGGiNS,  of  I'ittsburg,  read  this  paper. 
The  time  had  arrived,  he  said,  when  the  diagnosis  of 
ectopic  gestation  should  be  made  previous  to  the  time 
of  rupture  in  at  least  ninety  per  cent,  of  cases.  Unfor- 
tunately, physicians  were  not  always  called  until 
serious  symptoms  had  occurred.  One  of  the  most 
important  factors  in  its  early  recognition  was  a  care- 
ful study  of  the  patient's  history,  not  for  a  month 
but  for  a  number  of  years  previous  to  the  develop- 
ment of  symptoms  suspicious  in  character.  By  care- 
ful inquiry  a  history  suggestive  of  previous  tubal  in- 
fection would  be  found  in  the  great  majority  of 
cases. 

Ectopic  Gestation. — Dr.  Charles  Stillwagex, 
of  Pittsburgh,  reviewed  his  work  during  the  last 
year.  Included  in  his  report  of  cases  was  one  of 
secondary  abdominal  gestation  with  an  operation  at 
the  end  of  the  fourth  month. 

Dr.  G.  E.  Shoemaker,  of  Philadelphia,  said  the 
most  significant  thing  to  him  was  the  brown  vaginal 
discharge  which  was.  present  or  of  which  there  was 
a  history.  The  question  of  early  or  late  operation 
was  an  open  one,  but  the  author  inclined  to  an  opera- 
tion as  soon  as  the  diagnosis  had  been  made  and 
suitable  preparation  could  be  made. 

Dr.  J-  G.  Cl.\rk,  of  Philadelphia,  said  that  when 
the  patient  was  in  shock,  no  operation  should  be 
done  until  reaction  had  occurred.  By  operating 
when  there  were  air  hunger  and  pulselessness  death 
was  precipitated.  An  operation  without  proper  prep- 
aration could  only  do  harm.  Also,  when  a  ])atient 
was  slowly  rallying  from  shock,  it  was  a  bad  time  to 
operate.  It  was  best  to  consider  all  the  features  of 
the  case  and  take  a  middle  ground  in  reference  to 
operation,  neither  too  radical  nor  too  conservative. 

Dr.  E.  P.  D.WLS,  of  Philadelphia,  said  that  if  ecto- 
pic gestation  was  diagno.sticated  our  plain  duty  was 
to  remove  it.  In  case  of  tubal  abortion  an  operation 
should  also  be  done.  In  case  of  rupture,  if  condi- 
tions were  favorable  for  an  operation,  it  should  be 
carried  f)ut.  If  conditions  are  unfavorable,  delay 
should  be  exercised. 

Dr.  HfGGiN.s  said  that  with  careful  study  of  the 
history,  .symptoms,  and  signs  a  diagnosis  could  usu- 
ally be  made  before  rupture. 

Dr.  Stillw.vgen  said  that  in  twenty-eight  cases 
of  operation  by  him  there  had  not  been  recurrent 
h;emorrhage.  The  h;emorrhage  was  greater  in  tubal 
abortion  than  in  rupture. 

The  Question  of  Drainage  in  the  Surgery  of 
the  Pelvic  Organs. — Dr.  V.  Hlrst  Maier  slated 
in  this  paper  that  the  question  of  drainage  seemed 
>till  to  be  unsettled,  and  com]>ared  the  various  meth- 
ods of  treating  peritonitis  as  evidence.    lie  believed 


that  in  acute  general  peritonitis  the  method  of 
choice  should  be  that  of  Alurphy.  In  the  surgery  of 
the  pelvic  organs  he  contended  that  the  necessity  for 
radical  operations  in  the  acute  or  infectious  stages 
was  present  only  in  rare  instances.  This  eliminated 
largely  the  matter  of  drainage.  When  he  practised 
it  his  method  was  with  gauze  through  the  vaginal 
route,  as  his  purpose  was  not  .so  much  to  drain  off 
fluid  as  to  prevent  infection.  This  was  accomplished, 
first,  by  rendering  doubtful  areas  of  the  operative 
field  extraperitoneal ;  second,  by  keeping  the  intes- 
tines from  lying  in  contact  with  possibly  infected  or 
necrotic  areas ;  third,  by  the  prevention  of  dead 
spaces  and  fluid  accumulations  in  the  pelvic  fossa  ; 
and,  fourth,  by  anticipating  lack  of  primary  union 
in  injuries  of  the  bladder,  the  lower  part  of  the  de- 
scending colon,  or  the  rectum,  with  contamination 
with  urine  or  faecal  matter.  He  gave  four  groups 
of  indications  in  which  drainage  should  be  practised  : 
First,  those  cases  in  which  the  removal  of  disea-'^ed 
organs  was  complicated  by  denudation  of  large  areas 
of  peritoneeum,  especially  if  the  parts  involved  were 
the  lower  third  of  the  descending  colon  or  the  rec- 
tum ;  second,  in  the  presence  of  necrotic  tissue,  pyo- 
genic membrane,  the  remains  of  abscess  cavities, 
parts  of  cyst  walls,  and  extrauterine  gestation  sacs 
that  could  not  be  entirely  removed  ;  third,  injuries  of 
the  lower  parts  of  the  descending  colon,  rectum,  or 
bladder ;  fourth,  dermoid  and  infected  cysts  that  hnd 
ruptured  with  escape  of  their  contents  during  an  op- 
eration. 

Dr.  J.  G.  Clark,  of  Philadelphia,  said  that  it  was 
his  present  custom  to  use  drainage  hardly  ever,  but 
instead  to  use  extensive  irrigation  of  the  abdomen 
and  in  many  cases  to  practise  postural  drainage. 

Dr.  E.  A.  Weiss,  of  Pittsburgh,  said  that  in  cases 
of  pelvic  operation,  to  facilitate  the  introduction  of 
a  drain  through  the  posterior  vaginal  vault  at  the 
end  of  operation,  he  inserted,  before  the  operation,  a 
volsella  into  the  vagina  and  fastened  it  into  the  mu- 
cosa at  the  point  where  the  drain  was  to  be  brought 
through.  Then,  by  pushing  upon  the  forceps  at  tlie 
end  of  the  operation,  if  it  was  desired  to  insert  a 
drain,  the  point  at  which  the  incision  was  to  be  made 
was  easily  found,  and  valuable  time  was  saved. 

The  Prevention  of  Retroversion  of  the  Uterus 
after  Childbirth. — Dr.  Edward  P.  Davis,  of  Pliii- 
adelphia,  said  that  cases  of  congenital  retroversion 
and  those  arising  from  lack  of  development  were 
difficult  to  correct  after  childbirth.  It  was  impor- 
tant that  labor  be  so  conducted  that  overdistention 
of  the  ligaments  and  fasciae  which  maintained  the 
uterus  in  its  accustomed  position  be  avoided.  Deep 
lacerations  of  the  cervix  and  vagina  extending  into 
the  fasci.'e  should  be  immediately  repaired.  Lacera- 
tions near  the  utero.sacral  ligaments  were  especially 
important.  During  the  first  forty-eight  hours  after 
labor  the  uterus  should  be  maintained  in  position  by 
gauze  packing.  During  the  puerperal  period  the  pa- 
tient should  change  her  posture  frequently,  avoiding 
Iving  upon  the  back.  Patients  should  not  get  up  too 
early  after  childbirth.  After  the  lochial  discharge 
had  ceased,  the  knee-chest  posture,  night  and  morn- 
ing, would  greatly  aid  in  restoring  the  uterus  to  its 
jM  oper  position.  Where  there  was  a  disposition  to  re- 
troversion the  patient  should  wear  a  pessary  as  soon 
as  she  began  to  get  up.  Such  ca.ses  should  be  kept 
under  observation  for  several  months  at  least.  Where 


March  :;o,  1909.] 


BOOK  NOTICES. 


617 


the  uterus  did  not  assume  its  normal  position  and 
maintain  it,  intraperitoneal  shortening;  of  the  round 
ligaments  by  Gilliam's  method  should  be  performed. 

Dr.  R.  R.  HuGGixs,  of  Pittsburgh,  said  that  pa- 
tients should  be  under  the  care  of  the  physician  from 
the  beginning  of  pregnancy  to  the  end  of  the  puer- 
perium,  so  that  thev  might  always  be  kept  in  the 
l)est  of  condition. 

Malignant  Adenoma  of  the  Cervix  with  Vagi- 
nal Implantation  at  the  Point  of  Contact  Eleven 
Years  after  Operation.  —  Dr.  George  Eretv 
Snor.M  AKF.K.  of  Philadelphia,  presented  this  paper. 

Chromocystoscopy  in  Functional  Renal  Diag- 
nosis, Based  on  the  Employment  of  Indigocarmin. 
— Dr.  Bexj .vMix  A.  Thomas,  of  Philadelphia,  said 
that  normal  kidneys  in  ninety  per  cent,  of  cases  ex- 
creted indigocarmin  in  from  seven  to  fourteen  min- 
utes after  its  injection  intermuscularly  ;  in  only  ten  per 
cent,  was  the  excretion  suppressed  as  long  as  twenty 
minutes.  If  the  blue  coloration  appeared  later  than 
twenty  minutes  after  the  injection,  the  functional 
sufficiency  of  the  kidney  was  probably  impaired.  If 
the  excretion  failed  to  appear  at  all.  the  kidney  was 
the  seat  of  a  grave  pathological  process,  provided 
the  ureter  was  patulous.  The  intensity  of  color  of 
the  excretion  (light  blue  or  dark  blue)  depended 
upon  the  concentration  of  the  renal  secretion  and 
the  individual  excretory  power  of  the  organ.  .\ 
surgically  diseased  kidney  excreted  the  coloring 
matter  less  intensely  than  its  sister  organ  or  not  at 
all.  The  test  was  very  simple,  and  by  observation 
of  the  two  ureteral  orifices  dififerences  between  the 
two  kidneys  were  readily  and  speedily  noted. 
(To  he  continued.) 

 <$>  

§0»k  ptius. 

[Wc  publish  full  lists  of  books  received,  but  zt.'e  ackiiozcl- 
edge  no  obligation  to  revieiv  them  all.  Nevertheless,  so 
far  as  space  permits,  we  revieiv  those  in  tvhich  ive  think 
our  readers  are  likely  to  be  interested.] 

Applied  Surgical  Anatomy,  Regionally  Presented,  for  the 
Use  of  Students  and  Practitioners  of  Medicine.  By 
Georcf.  \VooLSE^•.  .A.  B..  M.  D.,  Professor  of  .Anatomy 
and  Clinical  Surgery  in  the  Cornell  University  Medical 
College.  Surgeon  to  Bellevue  Hospital,  etc.  Second  Edi- 
tion, Enlarged  and  Thoroughly  Revised.  With  Two 
Hundred  Illustrations,  Including  Fifty-nine  Plates, 
Mostly  Colored.  New  York  and  Philadelphia:  Lea  & 
Febiger,  1908.    Pp.  viii-601.    (Price,  $4.50.) 

Professor  Woolsey  pointed  out  in  the  introduc- 
tion to  the  first  edition  of  his  admirable  book  that 
the  study  of  anatomy  was  relieved  of  much  of  its 
difficulty  when  it  was  approached  from  the  prac- 
tical side.  And  he  has  followed  this  line  of  reason- 
ing which  he  has  laid  down,  which  fact  explains 
the  great  favor  the  book  has  found  with  the  stu- 
dent of  medicine  as  well  as  with  the  practitioner. 
It  is  in  fact  one  of  the  best  textbooks  of  surgical 
anatomy  and  anatomical  surger^•  that  we  possess. 
The  new  edition  has  fully  been  brought  up  to  date, 
so  the  sections  on  cerebral  localization,  craniocere- 
bral topography,  abdominal  viscera,  and  the  spinal 
cord  have  been  almost  entirely  rewritten.  The 
study  of  anatomy  is  very  dry.  but  it  is  the  basis 
for  our  knowledge  of  internal  medicine  and  to  a 
much  greater  extent  of  surgery.  Professor  Wool- 
sey has  the  ability  to  make  his  stibject  interesting, 
and  thus  he  captivates  the  reader. 


The  book  is  laid  out  in  the  usual  chapters  and 
contains  .seven  sections :  The  head  and  neck,  the 
upper  extremity,  the  thorax,  the  abdomen,  the  pel- 
vis and  perineum,  the  lower  extremity,  and  the 
spine.  The  illustrations,  of  which  there  are  a  great 
number,  are  well  selected  and  well  executed. 

Lchrbuch  der  pliysiologischen  Chcmic.  In  zweiunddreissig 
Vorlesungen.  Von  Emil  .\buerhalden,  a.  o.  Professor 
der  Physiologic  an  der  koniglichcn  tierarztlichen  Hoch- 
schule,  Berlin.  Zweite,  vollstiindig  un.gearbeitete  nnd 
erweiterte  Auflage.  Mit  19  Figuren.  Berlin  und  Wien  : 
Urban  &  Schwarzenberg,  1908.    Pp.  vii-984. 

A  period  of  a  little  over  two  years  has  elapsed 
since  the  appearance  of  the  first  edition  of  this 
splendid  work,  and  yet  within  that  time  so  much 
has  been  done  in  this  department  of  biology  that  a 
large  part  of  the  original  book  has  had  to  be  re- 
vised. This  is  particularly  true  of  the  pathology 
of  celltdar  metabolism,  which  has  been  carefully 
studied  in  recent  years.  The  arrangement  of  the 
book  is  such  that  each  food  stult  ( proteid,  carbo- 
hydrate, and  fat)  is  followed  in  its  course  through 
the  entire  organism,  and  this  gives  one  a  clearer 
insight  into  the  various  changes  than  is  obtained  by 
the  ctistomary  anatomical  arrangement.  The 
author's  style  is  pleasing  and  clear,  so  that  the 
reader  is  carried  along  without  ef¥ort.  The  two 
final  chapters  are  tmique,  indicating  as  they  do  the 
lines  of  future  work.  We  are  told  that  chemical 
investigations  in  the  domain  of  heredity  are  almost 
entirely  wanting,  and  that  this,  therefore,  consti- 
tutes one  of  the  most  promising  fields  of  research. 
\^'e  heartily  commend  this  book  for  its  clear  pres- 
entation of  difficult  subjects  and  especially  for  its 
many  stimulating  suggestions.  In  passing  we  may 
call  the  English  reader's  attention  to  the  translation 
recently  published  in  New  York.  This  is  practi- 
cally iclentical  with  the  second  German  edition,  hav- 
ing been  revised  by  the  author  in  igo8. 

.A  Textbook  of  Human  Physiology,  Theoretical  and  Practi- 
cal. By  George  V.  X.  Dearborn,  A.  ^I..  (Harv.).  Ph.  D.. 
M.  D.  (Col.),  Professor  of  Physiology  in  t'ne  Medical 
and  Dental  Schools  of  Tufts  College.  Boston,  etc.  Illus- 
trated with  300  Engravings  and  9  Plates. 

There  is  in  this  te.xtbook  of  Professor  Dearborn's 
a  freer  expression  of  the  personality  of  the  writer 
than  is  usually  found  in  scientific  and  medical 
treatises,  and  the  thought  is  sttggested  to  the  re- 
viewer that  impressed  on  his  pages  are  the  attri- 
butes of  the  successful  teacher,  fortunate  in  com- 
manding the  enthusiasm  and  af¥ection  of  his  stu- ' 
dents.  Throughout,  the  bald  facts  of  human 
physiology  are  illuminated  by  frequent  appropriate 
allusions  to  many  related  phenomena  in  biology, 
psychology,  and  practical  medicine,  with  the  vari- 
ous modern  phases  of  which  the  writer  shows  him- 
self to  be  sufficiently  familiar.  The  note  of  indi- 
viduality has  been  obtained  without  being  in  any 
way  bizarre  or  tuisound  in  teaching.  Especia'ly 
interesting  will  be  found  the  chapters  on  diet,  nutri- 
tion, and  mental  function.  The  author  does  not 
hesitate  to  condemn  many  of  the  prevalent  vagaries 
in  eating  which  have  received  quasi  scientific  en- 
dorsement, but  which  in  their  tiltimate  analysis  are 
not  far  removed  from  Christian  Science  and  other 
harmful  fads  and  humbugs.  A  strong  plea  is  made 
for  the  recognition  of  the  importance  of  good  cook- 
ing, which  is  defined  as  the  art  of  preparing  food 


6i8 


BOOK  NOTICES. 


[New  York 
Medical  Journai.. 


for  pleasurable  nourishment,  an  art  which  as  much 
as  any  other  thing  biologically  distinguishes  man 
from  his  "poor  relations,"  the  brutes.  Cold  stor- 
age, the  abuse  of  chemical  preservatives,  and  ready 
made  substitutes  for  real  food  receive  the  con- 
demnation they  deserve.  There  are  the  usual  chap- 
ters on  the  respiration,  circulation,  blood,  digestion, 
special  senses,  reproduction,  etc.,  to  produce  a  vol- 
ume satisfying-  to  the  most  critical  reader.  There 
is  one  conspicuous  omission,  however.  The  auri- 
culoventricular  bundle  of  His,  which  is  certainly 
the  most  important  physiological  discovery  in  re- 
cent years,  receives  no  adequate  treatment,  and  in- 
deed is  barely  mentioned. 

Retinitis  Pigmentosa.     With   an   Analysis   of  Seventeen 
Cases  Occurring  in  Deaf  Mutes.    By  William  T.  Shoe- 
maker, M.  D.,  Philadelphia.    Laboratory  Examinations 
of  the  Blood  and  Urine  by  John  M.  Swan,  M.  D.,  Phil- 
adelphia.   With  Illustrations  and  Three  Colored  Plates. 
Philadelphia:  J.  B.  Lippincott  Company.    Pp.  iv-io6. 
Shoemaker  has  made  an  interesting  study  of  this 
still  obscure  condition.    He  concludes  that  it  may 
well  be  looked  upon  as  a  stigma  of  degeneration, 
and  that  parental  consanguinity  is  of  importance 
only  in  connection  with  heredity  and  environment, 
while  impressionism  cannot  be  excluded  and  syph- 
ilis has  not  been  established  as  a  cause.  Careful 
laboratory  examination   of   the   blood,  urine,  and 
other  bodily  fluids  failed  to  throw  any  light  on  the 
nature  of  the  disease.    In  a  discussion  of  the  symp- 
toms attention  is  called  to  the  rarity  of  so  called 
ring  scotoma,  which  has  been  generally  accepted  as 
a  frequent  and  characteristic  manifestation  of  pig- 
mentary degeneration  of  the  retina. 

Orthopcedic  Surgery  -for  Practitioners.  By  Henry  Ling 
Taylor,  M.  D.,  Professor  of  Orthopedic  Surgery  and 
Attending  Orthopaedic  Surgeon,  New  York  Postgraduate 
Medical  School  and  Hospital.  Assisted  by  Charles 
Oglivy,  M.  D.,  Adjunct  Professor  of  Orthopedic  Sur- 
gerj',  New  York  Postgraduate  Medical  School  and  Hos- 
pital, and  Fred  H.  Albee,  M.  D.,  Instructor  in  Ortho- 
paedic Surgery,  New  York  Postgraduate  Medical  School 
and  Hospital.  With  254  Illustrations.  New  York  and 
London  :  D.  Appleton  &  Co.,  1009.    Pp.  xxiv-503. 

The  well  known  author  of  this  volume  has  made  a 
careful  study  of  the  many  subjects  which  are  com- 
monly included  in  a  treatise  on  orthopaedic  surgery. 
The  division  into  general,  special,  and  technical 
parts  is  novel,  but  convenient  and  useful  when  it  is 
understood.  The  opinions  expressed,  although 
positive,  are  free  from  the  appearance  of  dog- 
*  matism.  They  are  penned  in  a  hasty  mood,  and 
the  reader  feels  that  he  is  courteously  invited  either 
to  accept  them  as  they  stand,  to  modify  them  to  suit 
his  own  ideas,  or  else  to  pass  them  by.  He  is  thus 
agreeably  stimulated  to  independent  thought  and 
action.  One  is  reminded  of  the  writings  and  teach- 
ings of  the  author's  distinguished  father.  Impa- 
tience of  convention  has  gone,  but  independence  of 
thought  remains,  gracefully  aligned  with  the  chang- 
ing mental  attitude  of  the  times.  No  writer  may 
hope  to  present  much  that  is  new  in  the  field  of 
orthopredic  surgery,  where  so  many  new  things  have 
been  asserted,  Init  the  author  of  this  book  has 
ilhnninated  his  pages  with  not  a  few  side  lights  of 
real  and  lasting  practical  importance.  The  practi- 
tioner seeking  here  for  guidance  in  orthopaedic 
practice  will  find  diagnosis  and  treatment  discussed 


and  elaborated  in  a  manner  to  compel  him  to  select 
that  which  will  be  for  the  good  of  his  patient.  As 
a  suggestive,  practical,  and  reliable  guide  this  book 
has  very  exceptional  value. 

A  Manual  of  Bacteriology.  By  Herbert  U.  Williams. 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medical 
Department,  University  of  Buffalo.  Revised  by  B.  Meade 
Bolton,  M.  D.,  Washington,  D.  C,  One  Time  Associate 
in  Bacteriolog)-,  Johns  Hopkins  University,  etc.  With 
113  Illustrations.  Fifth  Edition,  Revised  and  Enlarged. 
Philadelphia :  P.  Blakiston's  Son  &  Co.,  1909. 

In  the  opinion  of  the  reviewer  no  other  students' 
manual  of  bacteriology  combines  so  many  excellent 
features  as  this  one.  It  is  particularly  well  ar- 
ranged, the  information  is  concise  and  accurate, 
and  there  is  a  great  deal  of  it  in  the  compass  of  a 
small  book.  The  inclusion  of  references  makes  it 
easy  for  any  one  who  desires  to  do  so  to  pursue  the 
subject  further.  The  reviewer  regrets  that  there 
is  evidence  of  careless  proof  reading.  In  order  to 
facilitate  the  correction  of  these  errors  in  the  next 
edition,  attention  is  called  to  foot  note,  page  267, 
last  line,  "spices"  instead  of  species ;  page  277,  "lep- 
tothric"  ;  page  295,  sixth  line,  "dextorse"  ;  page  302, 
"Loss  of  virulence  is  lost" ;  page  306,  "VVallstein," 
instead  of  Wollstein ;  page  311,  "The  trials  of  anti- 
sera  have  been  tried";  page  359,  foot  note,  "Reve- 
nel" ;  page  379,  foot  note,  italicize  Miinchener ; 
page  389,  second  paragraph,  "Jiirgens."  In  a 
number  of  places  the  author  has  made  use  of 
chenda.,  which  is  the  abbreviation  for  the  German 
cbendaselbst,  instead  of  the  abbreviation  Ibid. 

We  cordially  recommend  this  book  to  medical 
students,  physicians,  and  especially  teachers  of  bac- 
teriology. The  last  named  will  find  it  a  most  con- 
venient book  for  their  class  work. 

Seven  Hundred  Surgical  Suggestions.  Practical  Brevities 
in  Diagnosis  and  Treatment.  By  Walter  M.  Brick  xer. 
B.  S.,  M.  D.,  Assistant  Adjunct  Surgeon,  Mount  Sinai 
Hospital:  Eli  Moschcowitz,  A.  B.,  M.  D.,  Assistant  Phy- 
sician, Mount  Sinai  Hospital  Dispensary;  and  Harold 
M.  Hays,  A.  M.,  M.  D.  Third  Series.  New  York; 
Surgery  Publishing  Company,  1909.    Pp.  150.  (Price,  $1.) 

It  must  be  very  gratifying  to  the  authors  to  bo 
called  upon  for  the  second  time  in  two  years  to 
bring  out  a  new  and  revised  edition  of  their  very 
useful  surgical  hints.  The  title  has  been  changed, 
as  the  numbers  of  suggestions  have  been  increased 
from  500  to  700,  thus  necessitating  an  addition  of 
forty-two  pages.  Dr.  H.  M.  Hays,  of  New  York, 
has  been  added  to  make  the  editorial  staff  a  triiim- 
virate. 

A  Synopsis  of  Surgery.  By  Ernest  W.  Hey  Groves,  M.  S., 
M.  D.,  B.  Sc.  (Lond.),  F.  R.  C.  S.  (Eng.),  Assistant 
Surgeon  to  the  Bristol  General  Hospital.  New  York : 
William  Wood  &  Co.,  1908.    Pp.  viij-486. 

It  was  the  intention  of  the  author  to  compile  a 
book  which  should  be  useful  to  the  advanced  stu- 
dent as  well  as  to  the  practitioner  in  refreshing  the 
memory,  and  which  would  serve  in  the  place  of 
notes  made  during  the  perusal  of  voluminous  text- 
books. It  is  a  well  known  fact  that  the  average 
general  practitioner  cannot  find  time  to  study  the 
modern  large  textbooks,  but  a  short  compendium, 
which  gives  the  same  knowledge  in  condensed 
form,  will  easily  be  read  by  him. 

The  l)Ook  is  arranged  in  a  methodical  manner, 
and  is  divided  into  forty-nine  chapters,  the  first  and 


.March  20,  19C9.  | 


OFFICIAL  NEWS. 


619 


the  last  chapters  serving  as  introduction  and  epi- 
logue. The  diseases  are  described  in  a  certain 
routine  manner,  giving  the  definition,  cause,  path- 
ology, symptoms,  diagnosis,  prognosis,  and  treat- 
ment. This  last  part,  on  treatment,  should  not  have 
been  so  much  condensed,  and  could  have  been  en- 
larged without  much  increasing  the  size  of  the  oth- 
erwise very  handy  volume.  A  full  index,  such  as  is 
given  here,  is  of  great  value. 

Eine  neiie  Hypothese  iiber  Ursachen  uitd  IVesen  bosartigcr 
Gescln<.-iilsie.    Von  Dr.  phil.  et  nied.  Otto  Aichel,  a.  o. 
Professor  der  Gynakologie  an  der  Universitat  Santiago, 
friiherem  Privatdozenten  in  Erlangen.    Miinclien :  J.  F. 
Lehmann,  1908.    Pp.  36.    (Price,  1.50  M.) 
Professor  Aichel  reviews  the  hypotheses  devel- 
oped by  a  number  of  investigators  to  explain  the 
origin  of  malignant  growths,  and  comes  to  the  con- 
clusion that  none  of  these  theories  is  correct,  but,  in- 
stead, he  brings  forward  a  new  theory,  which  is  that 
the  sarcoma  cell  is  the  product  of  a  sexual  conjuga- 
tion of  a  normal  somatic  cell  with  a  leucocyte,  from 
which  a  sarcoma  cell  is  formed,  by  caryocinesis,  re- 
sulting in  a  malignant  timior. 

Lchrbuch  der  spesiiischen  Diagiiostik  uiid  TItcrafic  der 
Tubcrkulose :  Fiir  Aerzte  und  Stndierende.  Von  Dr. 
Bandelier,  Oberarzt  der  Dr.  Weicker'schen  Lnngenlieil- 
anstalten  in  Gorbersdorf.  und  Dr.  Roepke.  dirigierendem 
Arztc  der  Eisenbahnheilstatte  in  Melsiingen.  Zweite  ei- 
weiterte  und  verbessevte  .Auflage.  mit  19  Temperatur- 
kurven  auf  5  lithographischen  Tafehi,  i  farb.  lith.  Tafel 
.  und  4  Textabbildungen.  Wiirzburg:  Curt  Kabitzsch, 
1909.    Pp.  177.    (Price,  6  M.,  bound,  7  M.) 

Within  the  past  few  years  there  has  been  a  great 
advance  made  in  "the  use  of  tuberculin  both  as  a  di- 
agnostic, and  as  a  therapeutic  agent.  While  the 
subject  is  still  in  the  experimental  stage,  there  can 
be  no  doubt  about  certain  phases  of  the  question. 
A  concise  statement  of  fact  and  theory,  as  at  pres- 
ent understood,  should  therefore  be  welcome  to 
those  who  have  not  found  time  to  gather  from  the 
enormous  literature  of  the  subject  a  definite  com- 
prehension. The  book  under  review  gives  a  very 
fair  account  of  the  present  status  of  the  specific 
agents  made  use  of  in  tuberculosis.  The  four 
methods  of  applying  the  tuberculin  test.  viz. :  the 
cutaneous  test  of  von  Pirquet,  the  percutaneous,  or 
inunction,  test  of  Moro  and  Doganofif,  the  con- 
junctival test  of  Wolfif-Eisner  (or  Calmette).  and 
the  subcutaneous  test,  are  well  described  and  illus- 
trated. They  are  discussed  with  free  reference  to 
the  literature,  and  all  are  credited  with  certain  ad- 
vantages, although  the  limitations  and  disadvan- 
tages are  not  neglected.  The  authors  agree  with 
most  observers  that,  of  the  four,  the  old  injection 
method  is  by  far  the  most  reliable. 

The  second  part  of  the  book  is  devoted  to  a  con- 
sideration of  the  specific  therapy  of  tuberculosis, 
dealing  with  twelve  active  ancl  four  passive  im- 
munizing agents;  many  of  which  are  now  of  mere- 
ly historical  interest.  The  authors  conclude  that 
at  present  most  can  be  hoped  for  from  the  use  of  the 
actively  immunizing  substances,  of  which  Koch's 
preparations  represent  the  type.  The  technique  of 
administration  is  fully  described. 

The  book  is  a  convincing  brief  for  the  value  of 
the  proper  use  of  tuberculin,  and.  in  spite  of  the 
fact  that  the  subject  is  now  in  a  transition  stage,  an 
English  translation  would  no  doubt  find  wide  ap- 
preciation. 


(©mrial  Jehjs. 


23- 


Public   Health   and    Marine    Hospital  Service 
Health  Reports: 

The  following  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  zccek  ending  March  12,  igog: 

Places.  Uale.  Cases.  Deaths. 

Smallpox — United  States. 

California — Los  .\ngeles  Feb. 

California — San  Francisico  Feb. 

Illinois — Cairo  Feb. 

Illinois — Danville  Feb. 

Illinois — Galesburg  Feb. 

Illinois — Jacksonville  Feb. 

Illinois — Waukegon  Feb. 

Indiana — Indianapolis  Feb. 

Indiana — La  Fayette  Feb. 

Kansas — Kansas  City  Feb. 

Kentucky — Lexington  Feb. 

Kentucky — Paducah  Feb. 

Louisiana — New  Orleans  Feb. 

.Massachusetts — Xew   Bedford....  Feb. 

Missouri — Kansas  City  Feb. 

Missouri — St.  Louis  Feb. 

Xew  Jersey — Camden  Feb. 

New  Hampshire — Lebanon  Jan. 

New  York — Buffalo  Feb. 

Xorth  Carolina — Seven  Counties. . .Tan. 

Ohio — Cincinnati  F^eb. 

Tennessee — Knoxvi'.le  Feb. 

Tennessee — Nashville.  .  Feb. 

Te.xas — San  Antonio  Feb. 

Washington — Spokane  Feb. 

Wisconsin — La  Crosse  Feb. 

Wisconsin — Manitowoc  Feb. 

W  isconsin — Milwaukee  Feb. 

Smallpox — Insular. 
Philippine  Islands — Manila  Jan.  9-16... 

Smallpo.r — Foreign. 

.•\rabia — .\den  Jan.  i8-Feb. 

British  Honduras — Stann  Creek... To  Feb.  .35., 

Canada — Winnipeg  Feb.    13-20. . 

Chile — Valparaiso  Dec. 

Egypt — .Alexandria  Jan. 

Fgypt — Cairo  Jan. 

France — Paris  Jan. 

Breat  Britain — Bristol  Feb. 

India — Bombay  Jan. 

India — Madras  Jan. 

India — Rangoon  Jan. 

Italy — General  Feb. 

Italy — Naples  Feb. 

Java — Batavia  Jan. 

>Iexico — .\capulco  Jan. 

Me-xico — Guadalajara  Feb. 

Mexico — Monterey  Feb. 

Newfoundland — St.  Johns  Feb. 


13-20. . 
13-20.  . 
13-27.  . 

21-  28.  . 
20-27. . 
4-11 .  . . 
2-20.  .  . 

28.  . 

22-  Mar. 
20-27  •  ■ 
20-27  •  ■ 
20-27 .  . 
20-27 . . 
20-27. . 


-0-27.  . 
15-Feb. 
13-20.  . 
1-31  -  ■  - 

19-  26. . 

20-  27  •  • 
JO-27.  . 
6-27... 
13-20.  . 
20-27 .  . 


•3-2 


47 
13 


6 
18 


12-19 

7-14  

21-28   72 

30-Feb.    6   3 

6-  '3  

27-I'eb.  2  

23-29   2 

16-23   2 

7-  14   7 

7-I4----   7 

9-16   3 

23-31   2 


14-21  . 
6-13.. 


Portugal — Lisbon  Jan. 

Russia — Odessa  Jan. 

Russia — St.  Petersburg  Jan. 

Russia — Warsaw  Dec. 

Yellou  Fever. 


20- Feb.  13.  . 

30-Feb.   6   I 

23-30   10 

19-Jan.  2   13 

Foreign. 


From  vessel 
5 


Barbados  Feb.  15-16 

Brazil — Manaos  Jan.  23-30  

Brazil — Para  Jan.  30-Feb.   6   3 

Ecuador — Guayaquil  Jan.   30-Feb.  6  

Cholera — Insular. 
Philippine  Islands — Provinces  Jan.    9-16  245 

Cholera — Foreign. 

India — Bombay  Jan.  27-Feb.  2  

India — Rangoon  Jan.  16-23  

Russia — Jaroslav  Feb.    18   2 

Russia — Rubinsk  Feb.    18   22 

Russia — St.  Petersburg  Feb 

Straits  Settlements — .Singapore. .  .  .Jan. 

Plague — Foreign. 

Brazil — Para  Jan.   30-Feb.  6   1 

Ecuador — Guayaquil  .'.  To.   Jan.    28   26 

Jan.   30-Feb.  6  

Ecuador — Tolte  Dec. 

Egypt — General  Jan. 

India — Bombay  Jan. 

India — Rangoon  Jan. 

Indo-Chma — Saigon  Feb. 

Turkey — Jiddah  Jan. 


10-16  142 

9-23  •  •  • 


1908-Jan. 
i-Feb.  4.  . 
27-Feb.  2. 

16-23  

9-16  

30-Feb.  7. 


S 
43 


5 

27 


Public  Health  and  Marine  Hospital  Service : 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Scri-icc  for  the  seven  days  ending 
.Mirch  10,  igog: 

Delg.mx),  J.  M.,  Acting  Assistant  Surgeon.  Granted  one 
days'  leave  of  absence.  February  21,  1909,  under  para- 
graph 210,  Service  Regulations. 

F.^Bi.-\N,  J.\coB  J..  .Acting  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  February  20,  1909,  under 
paragraph  210,  Service  Regulations. 


620 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New 


York 

J  O  U  K  N  Ar„ 


Foster,  M.  H.,  Passed  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  March  i,  1909,  on  account 
of  sickness. 

Gibson,  R.  H.,  Pharmacist.  Granted  seven  days'  leave  of 
absence  from  March  i,  1909,  under  paragraph  210,  Ser- 
vice Regulations. 

Gibson,  R.  H.,  Pharmacist.  Granted  sixteen  days'  leave  of 
absence  from  March  8,  1909. 

Krulish,  Emil,  Assistant  Surgeon.  Granted  seven  days' 
leave  of  absence  from  March  2,  1909,  under  paragraph 
191,  Service  Regulations. 

Krulish,  Emil,  Assistant  Surgeon.  Granted  ten  days' 
leave  of  absence  from  March  9,  1909. 

Markoe,  W.  W.,  Acting  Assistant  Surgeon.  Granted  five 
days'  extension  of  annual  leave  from  January  31,  1909, 
on  account  of  sickness. 

McClintic,  T.  B.,  Passed  Assistant  Surgeon.  Granted  two 
n.onths'  leave  of  absence  en  route  to  the  United  States. 

McIntosh,  W.  P.,  Surgeon.  Directed  to  proceed  to  Cam- 
bridge, Md.,  upon  special  temporary  duty. 

Ryder,  L.  \V.,  Pharmacist.  Granted  two  days'  leave  of  ab- 
sence from  March  8,  1909,  under  paragraph  210,  Ser- 
vice Regulati.ons. 

Salmon,  Thomas  W.,  Passed  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  March  i,  1909. 

Stevenson,  J.  W.,  Acting  Assistant  Surgeon.  Granted  four 
days'  leave  of  absence  from  March  9,  1909. 

Wakefield,  H.  C.,  Acting  Assistant  Surgeon.  Granted  six 
days'  leave  of  absence  from  March  i,  1909,  under  para- 
graph 210,  Service  Regulations. 

Board  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital,  Baltimore,  Md.,  March  5,  1909,  for  the  purpose  of 
conducting  a  physical  examination  of  four  cadet  engineers 
of  the  U.  S.  Revenue  Cutter  Service.  Detail  for  the  board: 
Surgeon  W.  P.  Mcintosh,  chairn.an  ;  Passed  Assistant  Sur- 
geon M.  K.  Gwyn,  recorder. 

Army  Intelligence: 

Official  list  of  duinacs  in  the  stations  and  duties  of  officers 
serving  in  the  Medical  Corps  of  the  United  States  Army 
for  the  week  ending  March  is,  iQog: 

Banister,  W.  B.,  Major,  Medical  Corps.  Relieved  from 
duty  in  Philippines  Division ;  will  sail  May  15th  from' 
Manila,  P.  I.,  for  San  Francisco,  Cal,  for  orders. 

Brooke.  Roger,  Captain,  Medical  Corps.  Relieved  from 
duty  at  the  General  Hospital,  Fort  Bayard,  New  Mex- 
ico, and  ordered  to  duty  in  the  Philippines  Division  ; 
granted  leave  of  absence  for  four  months. 

Brown,  H.  L.,  Captain,  Medical  Corps.  Relieved  from 
duty  at  Fort  Riley,  Kans.,  and  ordered  to  Key  West 
Barracks,  Fla.,  for  duty. 

Chamberlain,  G.  E.,  First  Lieutenant,  IMedical  Reserve 
Corps.  Relieved  from  duty  at  Fort  Walla  Walla, 
Wash.,  and  ordered  to  his  home ;  granted  leave  of  ab- 
sence for  one  month,  and  then  relieved  from  active 
duty  in  the  Medical  Reserve  Corps. 

Cole,  C.  L.,  Captain,  Medical  Corps.  Relieved  from  duty 
at  Fort  Thomas,  Ky.,  and  ordered  to  Whipple  Barracks, 
Ariz.,  for  duty. 

Cr.mg,  C.  F.,  Captain,  Medical  Corps.  Relieved  from  duty 
at  Fort  Leavenworth,  Kans.,  and  ordered  to  New  York 
City  for  duty  as  attending  surgeon. 

Ford.  J.  H.,  Major,  Medical  Corps.  Relieved  from  duty  at 
Fort  William  Henry  Harrison,  Mont.,  and  ordered  to 
Fort  Riley,  Kans.,  for  duty. 

Gilchrist,  H.  L.,  Major,  Medical  Corps.  Granted  leave 
of  absence  for  one  month. 

Graves,  L.  K.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  Wliipple  Barracks,  Ariz.,  and 
ordered  to  his  home. 

Hevsingeu,  J.  D.,  Captain,  Medical  Corps.  Relieved  from' 
duty  at  Key  West  Barracks,  Fla.,  and  ordered  to  Fort 
Ethan  Allen,  Vt.,  for  duly. 

Jack.son,  T.  W.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  in  the  Philippines  Division,  and  or- 
dered to  San  Francisco.  Cal..  for  further  orders. 

Little.  W.  L.,  Captain,  Medical  Corps.  Relieved  from  duty 
with  Army  of  Cuban  Pacification;  will  proceed  to  Fort 
Adams,  R.  I.,  for  duty. 

Newton,  R.  W..  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Jay,  N.  Y..  and  ordered  to 
l-'ort  Revere,  Mass.,  for  duty. 


Patterson,  E.  W.,  First  Lieutenant,  Medical  Reserve 
Corps.  Relieved  from  duty  at  Fort  Sam  Houston, 
Tex.:  will  sail  April  5th  from  San  Francisco,  Cal.,  for 
duty  in  the  Philippines  Division. 

Pierson,  R.  H.,  Captain,  Medical  Corps.  ReHeved  from 
duty  at  Fort  Niagara,  N.  Y.,  and  ordered  to  Fort  Wil- 
liam Henry  Harrison,  Mont.,  for  duty. 

Schmitter,  Ferdinand,  Lieutenant,  Medical  Corps.  Re- 
lieved from  duty  at  Fort  Logan  H.  Roots,  Ark.,  and 
ordered  to  Jefferson  Barracks,  Mo.,  for  duty. 

Shillock,  Paul,  Major,  Medical  Corps.  Relieved  from 
duty  at  Fort  Robinson,  Nebr.,  and  ordered  to  Fort 
Sheridan,  III.,  for  duty. 

Stephenson,  Wm.,  Lieutenant  Colonel,  Medical  Corps.  Re- 
lieved from  duty  in  Philippines  Division;  will  sail  May 
15th  from  Manila,  P.  I.,  for  San  Francisco,  Cal.,  for 
orders. 

Stockard,  J.  K.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Revere,  Mass.,  and  ordered 
to  his  home. 

Winn,  R.  M.,  Major,  Medical  Corps.  Relieved  from'  duty 
at  Jefferson  Barracks.  Mo.,  and  ordered  to  Fort  Logart 
H.  Roots,  Ark.,  for  duty. 

Wren,  R.  J.,  First  Lieutenant.  Medical  Reserve  Corps.  Re- 
lieved from  duty  at  Fort  Slocum,  N.  Y.,  and  ordered  to 
proceed  to  his  home  and  report  for  further  orders; 
granted  leave  of  absence  for  ten  days. 

Navy  Intelligence: 

Official  list  of  changes  in  the  duties  and  stations  of  officers 
in  the  Medical  Corps  of  the  United  States  Navy  for  the 
zveek  ending  March  13,  jgog: 

De  Lancy,  C.  H.,  Passed  .\ssistant  Surgeon.  Placed  on 
the  retired  list  from  March  3,  1909,  under  the  provis- 
ions of  section  153,  revised  statutes. 

Ely,  C.  H.,  Passed  Assistant  Surgeon.  Detached  from  the 
Charleston  and  ordered  to  the  Naval  Station,  Olon- 
gapo,  P.  I. 

M.\Y,  H.  A.,  Passed  Assistant  Surgeon.  Ordered  to  the 
Charleston. 

Olson,  G.  M.,  Assistant  Surgeon.  Detached  from  the  Cul- 
goa  and  ordered  to  the  Naval  Recruiting  Station,  Pitts- 
burgh, Pa. 

Phillips,  E.  L.,  Acting  Assisting  SurgeoiL  Appointed  an 
acting  assistant  surgeon  from  March  2,  1909. 

PiCKKELL,  G.  Stu-geon.  Detached  from  command  of  the 
Naval  Hospital,  Annapolis,  Md.,  and  ordered  home  to 
await  orders. 

Ransdell,  R.  C,  .A.ssistant  Surgeon.  Detached  from  the 
Solace  and  ordered  to  the  Texas. 

Stoops,  R.  E.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  Pittsburgh,  Pa.,  and  or- 
dered to  the  Ciilgoa. 

—  ^  


Married. 

Sadler — Bosler. — In  Carlisle,  Pennsylvania,  on  Saturday, 
March  6th,  Dr.  Horace  T.  Sadler  and  Miss  Helen  Bosler. 
Died. 

.\llen. — In  St.  Joseph,  Missouri,  on  Wednesdav.  March 
3rd,  Dr.  H.  C.  Allen. 

Andrews. — In  Bergen.  New  York,  on  Wednesday,  Marclr 
loth.  Dr.  Robert  Andrews,  aged  seventy-two  years. 

Barton. — In  Boston,  Massachusetts,  on  Saturday,  March 
6th,  Dr.  Earl  J.  Barton,  aged  seventy-three  years. 

Caverlv. — In  Boston.  Massachusetts,  on  Saturday,  March 
6th,  Dr.  Charles  F.  Ca\erly. 

Cutler. — In  Boston,  Massachusetts,  on  Friday,  March  5th. 
Dr.  William  B.  Cutler,  aged  si.xty-two  years. 

Dalsen. — -In  Philadelphia,  on  Tuesday.  March  qth.  Dr. 
Charles  M.  Dalsen.  aged  eighty-two  years. 

Jones. — In  Oakland.  California,  on  Tuesday.  March  otli. 
Dr.  Henry  Isaac  Jones. 

Lange. — In  St.  Louis.  Missouri,  on  Friday.  March  5th, 
Dr.  .Mbcrt  F.  I^ange.  aged  forty-five  years. 

Luton. — In  Grand  Rapids,  Michigan,  on  Friday.  March 
5th,  Dr.  Albert  E.  Luton. 

Mattocks. — In  Cohoes.  New  York,  on  Monday.  March 
isl.  Dr.  James  E.  Mattocks,  aged  eighty-six  years. 

Reamy. — In  Cincinnati.  Ohio,  on  Thursday,  March  nth. 
Dr.  Thaddeus  Asbury  ReaiTiV,  aged  eighty  years. 

ScHMiTTLE. — In  New  Orleans.  Louisi.ina,  on  Friday, 
March  5th.  Dr.  Joseph  .Schmitfle.  aged  eighty  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  ilt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  13.  NEW  YORK,  MARCH  27,  1909.  Whole  No.  1582. 


frigiiial  ^Communications. 


ON  EXTERNAL  ROENTGEN  TREATMENT  OF  IN- 
TERNAL STRUCTURES  (EVENTRATION 
TREATMENT). 

By  Carl  Beck,  M.  D., 
New  York, 

Professor    of    Surgery    in    the    Postgraduate    Medical    School  and 
Hospital;  Visiting  Surgeon  to  the  St.  Clark's  Hospital 
and  the  German  Poliklinik. 

The  undeniable  fact  that  superficially  located  epi- 
theliomata  almost  universally  disappear  under 
proper  Rontgen  treatment  was  the  father  of  the  ob- 
vious thought  of  attacking  deep  seated  tumors  by 
the  same  method.  Numerous  attempts  were  made 
in  this  direction,  but  the  reports  did  not  prove  to  be 
encouraging.  A.  Dessauer,  the  ingenious  engineer, 
constructed  a  special  tube,  which,  as  he  asserted, 
permitted  of  intense  irradiation  in  deeper  seated  tis- 
sues, but  his  conclusions,  which  appeared  so  plausi- 
ble in  theory,  so  far  failed  to  show  success  in  prac- 
tice. 

Instead  of  trying  to  see  the  essential  factor  in  the 
construction  of  a  peculiar  type  of  a  Rontgen  tube, 
my  mind  concentrated  itself  more  on  the  biological 
relations  of  the  tissues.  As  the  mountain  does  not 
come  to  Mohammed,  Mohammed  must  go  to  the 
mountain.  In  other  words,  if  the  tubal  light  does 
not  reach  the  deep  seated  structure,  the  structures 
must  be  brought  to  the  tube.  This  consideration  in- 
duced me  to  use  the  following  modus  operandi  on 
December  5,  1906,  at  the  St.  Mark's  Hospital : 

Case  I. — Mr.  B.,  a  man,  forty  years  of  age,  whose  history 
revealed  that  two  of  his  brothers  had  died  from  cancer  of 
the  ston.'ach,  presented  a  fairly  large  carcinoma  of  the  py- 
lorus, which  was  slightly  movable.  Its  surface  showed 
several  nodules  of  an  annular  shape,  partially  attached  to 
the  vicinity  in  which  a  number  of  larger  and  smaller  glands 
could  be  recognized.  Instead  of  performing  a  risky  pylo- 
rectomy,  I  dissected  the  adherent  area  as  far  as  was  neces- 
sary to  permit  of  pulling  the  dissected  portion  into  the  ab- 
dominal wound,  suturing  its  outlines  to  the  abdominal  skin. 
There  was  no  reaction  after  this  operation.  Soon  there- 
after we  began  Rontgen  treatment,  in  daily  seances,  until  on 
the  ninth  day  an  erythematous  discoloration  began  in  the 
pyloric  portion.  The  integument  showed  no  reaction  at  this 
period.  The  treatment  was  stopped  then.  Five  days  later 
the  pyloric  portion  showed  a  pink  color,  which  became  more 
and  more  marked  while  the  induration  disappeared  gradu- 
ally. _  A  week  later  I  dissected  the  adhesions  with  the  abdom- 
inal integument  and  pushed  the  pyloric  portion  into  the 
abdomen.  Finally  the  abdomen  was  closed  again.  During 
treatment  the  patient  received  small  quantities  of  milk  by 
moufh  and  nutritious  enemata  besides.  The  general  reac- 
tion was  less  considerable  than  I  had  expected.  During 
the  first  week  vomiting  was  frequent.  Temporarily  it  would 
be  held  in  check  by  subcutaneous  injections  of  morphine. 
The  patient  complained  repeatedly  of  cramps  in  the  region 
of  the  wound,  which  did  not  disappear  until  three  weeks 
after  the  operation. 


The  patient  is  apparently  well  to-day.  He  has  gained  eigh- 
teen pounds.  No  resistance  can  be  palpated  in  the  abdomen. 
Me  was  irradiated  for  fifteen  months,  once  a  week,  without 
showing  any  effect.  (See  my  report  on  Combination  Treat- 
ment in  Malignant  Neoplasma  in  the  Berliner  klinische 
IVoclienschrift,  1907,  No.  42.) 

Case  II. — Mrs.  M.,  forty-three  years  of  age,  showing  a 
fair  family  history,  was  supposed  to  suffer  from  carcinoma 
at  the  large  curvature  on  account  of  the  presence  of  an  in- 
duration of  the  anterior  surface  of  the  stomach,  frequent 
haematemesis,  pain,  and  cachexia  being  also  observed.  Ex- 
ploratory laparotomy  performed  by  me  at  the  St.  Mark's 
Hospital  on  February  4,  1908,  revealed  a  large  ulcer  with 
indurated  margins.  Dermopexy  was  performed  in  the  same 
manner  as  in  Case  I.  Irradiation  was  started  on  the  third 
day.  After  four  weeks  the  patient  was  discharged  from  the 
hospital  and  has  reniained  well  ever  since.  She  gained 
twelve'pounds. 

Case  III. — This  patient  I  presented  to  the  International 
Dermatological  Congress,  held  in  New  York  City,  in  Sep- 
tember, 1907 :  Mr.  K.,  a  man  of  sixty-six  years  of 
age,  showed  signs  of  cachexia,  obstruction,  and  tender- 
ness in  the  right  iliac  region  at  the  early  part  of  the 
year  1907.  When  I  first  saw  the  patient  on  April  14th 
at  St.  Mark's  Hospital,  a  hard  mass  of  the  size  of  an 
outstretched  hand  could  be  palpated  in  that  region. 
On  April  15th  an  opening  of  the  abdomen  was 
made  above  the  tumor,  which  was  firmly  attached  to  the 
posterior  region  of  the  fossa.  It  was  hard,  showed  an  ir- 
regular (nodular)  surface,  and  was  diagnosticated  as  fi- 
brous carcinoma.  Extirpation  seemed  to  be  extremely  risky, 
wherefore  I  decided  to  give  my  patient  the  chance  of  the  ex- 
ternal Rontgen  treatment,  making  the  case  virtually  a  der- 
matological one  by  stitching  the  surface  to  the  peritonaeum, 
so  that  a  portion  of  the  extent  of  the  palm  of  a  man's  hand 
was  exposed.  One  day  after  this  operation  a  five  minute 
Rontgen  exposure  with  my  tubular  diaphragm  was  made, 
which  was  repeated  seven  days  in  succession,  then  only 
every  second  day:  Two  weeks  after  the  first  Rontgen  treat- 
ment a  slight  erythema  appeared,  wherefore  the  patient  was 
given  a  rest  of  two  weeks.  Then  irradiation  was  taken  up 
again  at  the  rale  of  every  third  day.  A  week  after  the  op- 
eration the  tinnor  could  not  be  palpated.  No  dissection 
from  the  abdominal  wall  was  attempted  in  this  case,  the 
entire  surface  of  the  large  wound  closing  by  contraction 
and  granulation.  Today  the  patient  is  apparently  well  and 
can  do  his  daily  work.  In  the  right  iliac  region  an  abdom- 
inal hernia  of  moderate  size  (Fig.  i)  is  recognized,  but 
no  induration  can  be  perceived.  (See  report  in  the  Trans- 
actions of  the  Sixth  International  Dermatological  Congress, 
i,  P-  453)- 

To  these  three  favorable  cases,  the  following 
four,  all  operated  on  in  St.  Mark's  Hospital,  con- 
trast : 

Case  IV. — 'Sirs.  L.,  fifty-two  years  of  age.  suffering  from 
a  large  inoperable  carcinoma  of  the  anterior  wall  of  the 
stomach,  submitted  to  extensive  exposure  and  dermopexy. 
May  30,  1907,  adhesions  with  the  left  lobe  of  the  liver  were 
noticed.  Disturbance  of  the  liver  circulation  was  evident 
by  the  presence  of  ascites.  Irradiation  was  begun  at  the 
second  day.  Pulse  and  general  condition  improved  remark- 
ably for  a  few  days,  until  ten  days  after  the  operation  sud- 
den death  occurred. 

Case  V. — Mr.  A.,  fifty  years  of  age,  practically  showed 
the  same  anatomical  conditions  as  Case  IV  dermopexy 
being  performed  on  September  8,  1908.  Irradiation  was 
begun  on  the  second  day  after  operation.    The  patient,  who 


Copyright,    1909,   by   A.  R. 


Elliott  Publishing  Company. 


622 


bECK:  ROENTGEN  TREATMENT  OF  INTERNAL  STRUCTURES. 


[New  York 
Medical  Journal. 


had  lost  forty-seven  pounds  since  the  beginning  of  his  mal- 
ady, gained  lour  pounds  during  the  following  three  weeks. 
After  five  weeks'  treatment  he  felt  so  well  that  he  insisted 
upon  returning  liome  in  a  neighboring  town,  from  where  he 
came  to  the  hospital  twice  a  week  for  Rontgen  treatment. 
His  fair  condition  remained  about  the  same  for  over  two 
months,  wlien  he  died  suddenly,  from  an  overdose  of  mor- 
phine, as  I  \\as  informed  by  his  family  physician.  The 


Fig.    I. — Case   III.     Showing   patient   seventeen   months  after 
operation.    Photograph  talcen  on  February  12,  1909. 

main  complaint  during  the  last  weeks  of  his  life  was  in- 
somnia.   (See  Fig.  2.) 

Case  VI.— Mrs.  W.,  forty-eight  years  of  age,  suffering 
from  a  large  inoperable  carcinoma  of  the  descending  colon 
and  omentum,  submitted  to  dcrmopexy  January  21,  1908. 
Irradiation  on  the  second  day.  Slight  improvement  was 
followed  by  continuous  exhaustion.  Exitus  on  the  fifth  day 
after  the  operation. 

Case  VII. — Mr.  H.,  thirty-eight  years  of  age,  suffering 
from  inoperable  carcinoma  of  stomach,  left  hepatic  lobe, 
and  omentum,  submitted  to  dermopexy  September  8,  1908, 
Considerable  fluid  escaped.  Irradiation  was  begun  on  sec- 
ond day.  The  extremely  weak  patient,  who  bad  lost  forty- 
four  pounds,  improved"  considerably  and  was  able  to  digest 
solid  food  from  the  eighth  day  after  operation.  After  a 
month's  treatment  he  had  gained  six  pounds.  Then  his 
condition  remained  stationary.  Three  months  after  the 
operation  he  showed  signs  of  indigestion  and  succumbed  to 
marasmus  a  few  days  later.  The  tumor  had  decreased  in 
size.  It  may  be  added  that  in  this  case  as  well  as  in  the 
other,  except  Case  I,  the  wound  was  allowed  to  heal  by 
granulation  and  contraction. 

I  report  these  cases  as  I  have  observed  them,  with- 
out an  attempt  at  generahzation.  Whether  the  pa- 
tients of  Cases  I  and  III  are  permanently  cured,  the 
future  only  will  be  able  to  prove.  Perhaps  they  were 
only  most  favorable  cases  for  this  mode  of  treat- 
ment, while  the  fatal  ones  were  received  in  a  very 
much  advanced  stage  and  might  have  been  more 
answerable  to  the  Rontgen  therapy  at  an  earlier 
period.  The  type  of  the  carcinoma  texture  must,  as 
we  know,  also  have  a  marked  influence.  It  is  my 
experience,  as  well  as  that  of  other  investigatois, 
that  in  some  neoplasms  the  process  of  destruction  is 
rather  accelerated  by  the  Rontgen  treatment  than 
prohibited-  If  we  could  define  the  exact  reasons  for 
this  strange  phenomenon  we  would  learn  more 
about  the  indication  and  the  eventual  prognosis  of 
this  kind  of  'therapy.  It  is  remarkable,  however, 
that  even  in  my  fatal  cases  a  short  improvement 
took  place. 

Some  may  say  that  the  good  results  obtained  in 
Cases  I  and  III  were  simply  accidental,  and  I  am 
unable  to  prove  the  contrary.  Still,  these  observa- 
tions revealed  to  me  so  much  of  importance  that  I  felt 
it  a  duty  to  publish  them  in  order  to  induce  others 
to  try  the  method  in  their  own  way.  No  doubt,  while 
thorough  extirpation  by  the  surgical  knife  is  to  be 


considered  first  of  all,  there  remains  a  certain  kind 
of  cases  in  which  dermopexy  may  at  least  be  tried 
as  a  last  resort.  Radium  treatment  has  about  the 
same  efifects.  It  will  be  noticed  that  none  of  the 
patients  died  from  the  immediate  elTects  of  the  oper- 
ation. 

While  this  article  was  being  printed  I  had  an  op- 
portunity to  try  the  eventration  principle  in  a  case 
of  chronic  progressive  peritonitis  followed  by  adhe- 
sion formation. 

Case  VIII. — The  patient,  a  man  of  forty-three  years,  re- 
ported that  about  nine  tnonths  ago  he  began  to  suffer  from 
indigestion,  and  considerable  pain  in  the  pyloric  region 
about  an  hour  after  meals,  his  abdomen  becoming  distended 
at  the  same  time.  He  was  admitted  to  a  hospital  of  this 
city  where  an  exploratory  laparotomy  revealed  the  presence 
of  bands  constricting  the  pylorus.  They  were  e.xtensively 
divided.  The  patient  made  a  splendid  recovery,  but  two 
months  after  the  operation  the  same  symptoms  of  obstruc- 
tion returned.  When  I  first  saw  the 'patient  two  months 
ago  I  found  a  rounded  abdomen,  appearing  tympanitic  and 
the  symptoms  classical  of  pyloric  stenosis.  The  stools  con- 
tained considerable  mucus.  No  resistance  could  be  pal- 
pated in  the  abdomen.  The  patient  complained  that  on  ac- 
count of  the  pain  he  was  unable  to  take  a  suflScient  amount 
of  nourishment,  and  stated  that  he  had  lost  over  twelve 
pounds  again.  By  the  courtesy  of  the  hospital  in  which 
laparotomy  was  perforined  first,  I  was  enabled  to  ascertain 
that  the  cause  of  the  stenosis  was  to  be  found  in  the  recur- 
rence of  the  adhesions,  wherefore  I  opened  the  abdomen 
again  at  the  Postgraduate  Hospital.  An  incision  made 
from  the  ensiform  process  down  to  the  umbilicus  revealed 
formations  of  fibrous  bands  between  part  of  the  anterior 
portion  of  the  stomach,  the  pylorus  and  part  of  the  duo- 
denum on  one  hand  and  the  lower  surface  of  the  left  lobe 
of  the  liver  on  the  other.  Thus  a  kink  was  caused  in  the 
pyloric  wall.  The  bands  were  extensively  severed,  a  pro- 
cess which  offered  some  technical  difficulties  during  the  sep- 
aration from  the  liver  tissue.  At  the  end  of  the  operation 
the  abdominal  organs  appeared  to  be  entirely  free,  but,  con- 
sidering the  fact  that  the  previous  operation  was  performed 
in  the  same  method  and  that  it  was  carried  out  by  a  mas- 
terly hand,  was  it  not  self  evident  that  the  recurrence  of  the 
bands  was  to  be  expected  ?  The  progressive  type  of  peri- 
tonitis, the  aetiological  factors  of  which  are  still  obscure, 
gives  a  poor  prognosis,  because  clinical  observation  shows 
that  it  alv/ays  returns.    I  calculated  therefore  that  the 


Fig.  2. — Case  V.    Showing  patient  two  months  after  operation,  with 
the  wound  still  granulating. 

shrinking  influence  of  the  Rontgen  rays  might  be  utilized 
in  this  case.  I  fastened  the  small  anterior  portion  of  the 
stomach  and  the  pyloric  region  in  the  wound  according  to 
the  principles  described  before  and  started  irradiation  a 
week  after  the  operation. 

So  far  the  patient  is  doing  extremely  well,  his  pyloric  re- 
gion still  being  reachable  from  without.  The  appetite  13 
very  good,  and  the  peristalsis  normal.  Of  course,  nothing 
definite  can  be  said  yet  as  to  the  influence  on  the  band  for- 
mation. / 

I  shall  give  an  additional  report  shortly. 


March  27,  1909.I 


DEAFER:  TRIGEMINAL  NEURALGIA. 


623 


THE  INTRACRANIAL  CAUSES  AND  OPERATIVE 
TREATMENT  OF  TRIGEMINAL  NEURALGIA* 

By  John  B.  Deaver,  M.  D.,  LL.  D., 
Philadelphia. 

Such  a  term  as  neuralgia  is  strongly  suggestive 
of  what  Oliver  Wendell  Holmes  called  "the  learned 
ignorance  of  a  nomenclature."  It  was  coined  in 
the  day  of  clinical  observation  which  always  has 
and,  doubtless,  always  will  precede  the  knowledge 
of  pathogenesis.  Meaning  as  it  does,  simply  a  pain- 
ful affection  of  nerves  and  knowing,  as  we  db,  that 
pain  is  the  chief  symptom  of  nerve  involvement  of 
various  kinds,  we  are  prepared  to  find  grouped  un- 
der this  caption  a  heterogeneous  collection  of  con- 
ditions which  manifest  themselves  chiefly  or  largely 
through  pain  somewhere  in  the  distribution  of  the 
fifth  cranial  nerve. 

The  intracranial  course  of  the  trigeminal  nerve 
takes  its  origin  from  a  long  nucleus  in  the  brain 
stem,  the  most  extensive  nucleus  of  any  of  the 
cranial  nerves,  reaching  in  a  long  cokimn  from  the 
mesencephalon  above  to  the  level  of  the  second  cer- 
vical nerve  below.  The  fibres  derived  from  these 
cells  are  gathered  together  in  two  roots,  a  large  af- 
ferent or  sensory  root  and  a  small  efferent  or  motor 
root,  which  emerge  from  the  side  of  the  pons  Va- 
rolii where  the  fibres  of  the  latter  are  converging 
to  form  the  middle  peduncle  of  the  cerebellum. 
Thence  the  roots  proceed  in  close  relation,  though 
not  incorporated  in  a  common  sheath,  in  a  forward 
and  outward  direction  to  a  depression  at  the  top 
of  the  petrous  portion  of  the  temporal  bone  where 
the  sensory  root  expands  into  the  large  crescentic 
Gasserian  ganglion  which  is  enclosed  in  a  recess  of 
dura  mater,  the  cave  of  Meckel,  and  lies  in  the 
depression  of  the  petrous  portion  of  the  temporal 
bone.  The  ganglion  now  gives  off  three  large  sen- 
sory roots,  named  respectively  from  above  down- 
ward, the  ophthalmic,  superior  maxillary,  and  in- 
ferior maxillary,  which  emerge  from  the  skull  after 
a  very  short  course  by  way  of  the  sphenoidal  fissure, 
the  foramen  rotundum  and  the  foramen  ovale.  The 
small  motor  root  crosses  from  within  outward  be- 
hind the  ganglion,  being  intimately  adherent  to  it, 
and,  passing  through  the  foramen  ovale  with  the 
inferior  maxillarv  nerve  is  at  once  incorporated 
in  its  trunk.  The  consideration  of  the  further 
course  of  the  nerve  with  its  peripheral  affections 
has  been  dwelt  upon  previously. 

Any  condition,  then,  which  affects  the  nerve  in 
any  part  of  this  course  from  the  nucleus  to  the  for- 
amina of  exit,  in  such  a  way  as  to  excite  painful 
sensations  will  be  productive  of  trigeminal  neural- 
gia, and  the  treatment  nnist  be  varied  according  to 
the  fetiology. 

It  is  necessary  to  mention  also  that  it  is  not  un- 
likely that  cerebral  disease  affecting  the  cortical 
neurone  may  in  rare  instances  register  as  a  neur- 
algic condition  of  the  trigeminus. 

There  is  a  considerable  list  of  predisposing  causes 
concerning  which  it  is  difficult  to  say  whether 
they  exert  their  influence  centrally  or  peripherally. 
Such  are  a  neuropathic  diathesis ,  exhausting  dis- 

*Rcad  at  a  meeting  of  the  Academy  of  Stomatology  of  Philadel- 
phia, February  19,  J909. 


eases,  the  loss  of  blood  or  tissue  juices,  anaemia, 
cachexia,  senescence,  and  arteriosclerosis. 

Certain  cases  indicate  the  influence  of  cold  and 
exposure,  overexertion  and  mental  strain. 

Many  poisons  play  a  part  in  the  aetiology.  Lead, 
mercury,  copper,  arsenic,  alcohol,  and  nicotin  are 
cited  as  more  or  less  direct  causes. 

Autogenic  or  metabolic  toxines  of  such  diseases 
as  diabetes,  gout,  Bright's  disease,  etc.,  are  occa- 
sional factors. 

Infectious  diseases,  whether  by  their  weakening 
effect  upon  the  system  or  by  their  toxic  products 
not  infrequently  set  up  a  neuralgia.  Such  are  ma- 
laria, typhoid,  influenza,  and  others  of  the  acute  and 
chronic  infections. 

A  fracture  of  the  base  of  the  skull  in  the  region 
of  the  roots  or  ganglion  of  the  trigeminus,  by 
reason  of  actual  trauma  or  the  subsequent  pressure 
of  exudate  or  callus  may  leave  a  residual  neuralgia 
with  or  without  motor  disturbances.  I  have  ob- 
served such  a  case  only  last  winter  in  which  a  man 
was  struck  violently  on  the  side  of  the  head  with  a 
wagon  tongue,  being  rendered  at  once  unconscious, 
with  a  discharge  of  blood  from  his  right  ear  and 
the  classical  picture  of  fracture  of  the  base.  Re- 
covering gradually  from  the  immediate  effect  of 
his  injury  it  was  found  that  he  had  lost  sensation 
to  a  large  degree  in  the  distribution  of  the  trigemi- 
nus on  the  right  side,  especially  in  the  first  division. 
So  marked  was  this  anaesthesia  that  he  fell  a  vic- 
tim to  the  panophthalmitis,  which  is  such  a  dreaded 
sequel  in  some  cases  of  removal  of  the  ganglion, 
and  the  eye  had  to  be  removed.  He  has  been  suf- 
fering since  with  a  pronounced  neuralgia  of  the 
lower  two  divisions  which  is  gradually  lessening  in 
severity. 

Periostitis  at  the  base  of  the  brain  may  commu- 
nicate a  neuritis  to  the  nerves  and  cause  pain.  The 
ganglionic  changes  which  give  rise  to  herpes  zoster, 
may  in  the  case  of  the  fifth  nerve,  as  elsewhere, 
leave  a  persistent  neuralgia,  the  so  called  postzoster 
neuralgia. 

An  abscess  along  the  course  of  the  nerve  may 
produce  a  condition  strongly  resembling  the  ordi- 
nary forms  of  neuralgia.  Walton,  in  International 
Clinics,  1895,  reports  a  case  of  abscess  of  the  pons 
involving  the  root  of  the  trigeminus,  which  simu- 
lated tic  douloureux  in  such  a  remarkable  manner, 
that  a  peripheral  operation  was  done,  of  cotirse, 
without  benefit. 

Aneurysm  of  the  internal  carotid  artery  can 
cause  excruciating  neuralgia. 

Tuberculous  and  syphlitic  granulomata  as  well  as 
other  forms  of  tumor  are  occasional  causes. 

There  is  an  interesting  group  of  tumors  of  the 
Gasserian  ganglion  to  which  Spiller  has  recently 
called  attention,  which  are  endotheliomatous  in  type 
and  are  characterized  by  severe  neuralgic  symp- 
toms with  general  motor  and  sensory  impairment 
and  offer  a  hopeless  prognosis  unless  operation  is 
done  very  early. 

Several  cases  of  cholesteatoma  in  the  neighbor- 
hood of  the  ganglion  have  been  reported  as  pro- 
ducing severe  neuralgic  symptoms. 

Among  intracranial  causes  of  neuralgia  must  be 
mentioned  those  cases  in  which  the  exciting  agent 


624 


DEAVER:  TRIGEMINAL  NEURALGIA. 


[New  York 
Medical  Journal. 


seems  to  have  been  almost  certainly  peripheral  but 
in  which  the  so  called  neuralgic  changes  of  Moebius 
have  proceeded  centralward  in  accordance  with  the 
rule,  until  the  intracranial  structures  are  involved. 
In  such  cases  the  central  elements  may  have  be- 
come so  diseased  as  to  render  a  peripheral  opera- 
tion valueless. 

Lastly,  there  is  the  group  of  cases  known  as  neu- 
ralgia major,  tic  douloureux,  epileptiform  neural- 
gia, etc.  Does  this  disease  come  within  my  prov- 
ince or  within  that  of  the  distinguished  gentleman 
who  has  discussed  the  peripheral  causes?  Here 
knowledge  fails  and  opinions  differ.  Its  clinical 
course  and  the  failure  to  demonstrate  extraneural 
cause  lead  us  to  believe  that  it  is  a  primary  disease 
of  the  nerves.  Whether  primarily  central  or  per- 
ipheral is  not  determined.  Examinations  of  ganglia 
and  nerves  by  the  most  expert  neuropathologists, 
such  as  Caminiti,  Spiller,  and  Barker,  have  failed  to 
demonstrate  constant  changes  which  might  clear  up 
the  point.  This  must  be  left  to  a  future  discov- 
erer. 

The  diagnosis  of  a  central  from  a  peripheral  le- 
sion may  afford  considerable  difficulty.  In  general, 
all  peripheral  causes  should  be  sought  and  excluded. 
This  does  not  mean  that  every  tooth  in  the  unfortu- 
nate victim's  head  should  be  pulled  in  order  to  dis- 
prove a  possible  dental  origin.  A  careful  considera- 
tion of  the  history  and  examination  will  obviate  that 
all  too  common  calamity.  It  is  necessary  to  remem- 
ber that  in  accordance  with  the  law  of  excentric 
phenomena,  any  irritation  along  the  course  of  the 
nerve  will  be  referred  to  the  terminals  of  the  fibres 
affected. 

If  a  patient  suffering  from  neuralgia  at  the  same 
time  gives  evidence  of  cerebral  disease  it  is  evidence 
presumptive  of  a  cerebral  origin  of  the  neuralgia. 

Wagner's  dictum  is:  "We  can  most  properly  as- 
sume that  a  neuralgia  is  of  cerebral  origin  if  several 
branches  only  and  not  the  entire  peripheral  distribu- 
tion, are  the  seat  of  neuralgia,  and  if  with  this  no 
peripheral  cause  can  be  ascertained,  and  if  the  pres- 
ence of  other  symptoms  of  cerebral  disease  is  af- 
forded in  cranial  nerves,  the  origin  of  which  is  not 
restricted  to  a  small  space,  but  is  convergent  from 
different  parts  of  the  brain." 

Concerning  tumors  of  the  ganglion  Spiller's  con- 
clusion is  that  "in  any  case  in  which  pain  is  felt  in 
all  three  of  the  branches  nearly  simultaneously  and 
some  loss  of  sensation  is  detected  in  the  distribu- 
tion of  the  same  nerve,  it  is  probable  that  the  lesion 
is  in  the  ganglion,  and  this  probability  is  increased 
if  paresis  of  the  motor  portion  of  the  root  occurs." 

The  history  is  available  for  differentiation  in 
cases  due  to  trauma,  herpes,  and  the  acute  and 
chronic  infections,  while  the  characteristic  course 
of  tic  douloureux  as  it  develops  is  sufficient  to  ren- 
der a  diagnosis  fairly  secure  to  one  familiar  with 
its  history. 

We  must  content  ourselves  with  these  brief  prin- 
ciples in  the  differential  diagnosis  and  hasten  on  to 
the  operative  treatment.  Having  come  to  a  con- 
clusion as  to  the  underlying  cause  of  the  neuralgia 
in  a  particular  case  we  are  in  a  position  to  recom- 
mend appropriate  treatment.  Striking  out  at  once 
cases  due  to  constitutional  disorders  which  should 


first  be  given  the  benefit  of  medical  treatment  and 
cases  in  their  nature  inoperable,  we  have  left  many 
cases  resistant  to  palliative  measures  and  progres- 
sive in  severity.  Generally  speaking,  neuralgia  due 
to  peripheral  cause  demonstrable  or  suspected 
should  be  given  the  benefit  of  the  peripheral  oper- 
ation under  the  principles  laid  down  by  Dr.  Brophy. 
If,  however,  peripheral  operations  have  not  afford- 
ed reHef  or  have  been  followed  by  severe  recur- 
rence ;  or  if  the  case  is  one  of  long  standing,  with 
great  intensity  and  wide  involvement,  or  if  we  have 
reason  to  believe  that  the  primary  cause  is  an  op- 
erable intracranial  condition,  we  should  not  hesitate 
to  cut  down  upon  the  ganglion. 

The  history  of  the  operation  of  extirpation  of  the 
Gasserian  ganglion  is  a  fascinating  chapter  in  sur- 
gery having  been  developed  in  so  few  years  that  the 
tremendous  value  of  experience,  method,  and  tech- 
nique in  the  saving  of  life  are  brought  out  in  vivid 
relief.  First  attempted  unsuccessfully  by  Horsley 
and  again  by  Macewen  it  was  first  successfully  ac- 
complished by  Rose  in  1890.  First  deserving  the 
title  of  a  "bloody,  difficult,  and  dangerous  opera- 
tion" with  hideous  deformity  in  case  of  recovery, 
to-day  it  has  cast  off  these  epithets  and  takes  its 
place  among  the  relatively  safe  operations  of  sur- 
gery, while  for  efficacy  there  are  few  superiors. 
The  operative  mortality  from  twenty  to  thirty  per 
cent,  has  been  reduced  to  less  than  five  per  cent. 
The  collective  statistics  of  Horsley,  Gushing, 
Hutchinson,  Lexer,  Lloyd,  Doellinger  and  Frazier, 
quoted  by  Frazier  in  Keen's  Surgery,  give  a  total 
of  230  cases  with  a  mortality  of  3.7  per  cent.  While 
I  have  not  operated  very  many  times  for  removal 
of  the  Gasserian  ganglion,  yet  I  have  done  a  num- 
ber of  cases,  but  my  mortality  has  been  higher  than 
3.7  per  cent.  In  this  connection  I  may  say  I  am 
not  usually  impressed  by  statistics. 

In  general  there  are  three  ways  of  approaching 
the  ganglion,  the  high  or  temporal  route  above  the 
zygoma ;  the  low  or  pterygomaxillary  route,  below 
the  zygoma ;  and  the  transzygomatic,  which  in- 
volves resection  of  the  zygomatic  arch.  The  first 
successful  operation  was  by  the  low  or  pterygo- 
maxillary route,  which  has  since  then  undergone 
considerable  alteration  and  improvement.  The  in- 
creased difficulties  and  subsequent  deformities  of 
this  operation,  however,  have  led  to  its  abandon- 
ment by  most  operators  in  favor  of  a  higher  ap- 
proach. 

The  majority  of  operators  now  favor  tempo- 
rary or  permanent  resection  of  the  zygoma.  The 
largest  number  of  operations,  however,  have  been 
done  by  the  suprazygomatic  or  temporal  route 
known  as  the  Hartley-Krause  operation  or  one  of 
its  modifications. 

Contrast  of  the  operative  results  of  the  modified 
Hartley-Krause  and  the  transzygomatic  operations 
in  the  hands  of  their  leading  exponents  indicate  that 
the  choice  of  the  operation  makes  little  dift'erence 
to  the  welfare  of  the  patient.  These  two  methods 
vary  so  little  in  the  truly  essential  features  of  the 
operation  that  different  surgeons  using  that  method 
with  which  they  are  perfectly  familiar  get  equally 
good  results.  Personally  I  do  not  find  it  necessary 
to  resect  the  zygoma. 


March  27,  1909.  J 


DEAI  ER:  TRIGEMINAL  XEURALGIA. 


625 


The  patient  is  best  placed  in  the  semierect  posture 
as  tending  to  obviate  troublesome  venous  oozing. 
The  curved  incision  above  the  zygoma  is  planned  to 
avoid  the  upper  branches  of  the  facial  nerve.  Di- 
vision of  these  nerves  is  serious  not  so  much  for 
cosmetic  reasons  as  because  the  development  of  a 
lagophthalmos  increases  greatly  the  risk  of  opthal- 
mia  attending  injury  and  drying  of  the  anaesthetic 
eye.  The  superficial  and  musculoaponeurotic  flap 
is  turned  downward  exposing  the  temporal  bone, 
which  is  trephined  above  the  posterior  extremity  of 
the  zygoma.  The  opening  is  enlarged  inward  to- 
ward the  ganglion  with  a  large  rongeur  or  bone 
forceps  working  cautiously  to  avoid  injury  to  the 
dura  or  the  middle  meningeal  artery,  which  enters 
the  cranial  cavity  through  the  foramen  spinosum 
just  lateral  to  the  foramen  ovale  and  breaks  up  into 
two  main  branches,  the  posterior  running  back- 
ward, the  anterior  running  forward  and  upward  in 
a  groove  on  the  inner  table  of  the  skull. 

Working  toward  the  ganglion  the  dura  is  now 
freed  from  the  skull  with  the  handle  of  a  scalpel 
gently  retracting  the  temporosphenoidal  lobe  up- 
ward. Great  care  should  be  exercised  in  this 
manoeuvre  as  it  is  easy  to  injure  the  brain  and  get 
unpleasant  paralysis  or  aphasia  as  a  result. 

In  the  exposure  of  the  ganglion  the  middle  men- 
ingeal artery  is  encountered  situated  slightly  in 
front  and  laterally  at  the  point  of  entrance  into  the 
cranial  cavity.  Usually  it  is  possible  to  push  it 
aside  and  preserve  it.  Occasionally  it  is  necessary 
to  ligate  it  to  secure  adequate  exposure  of  the 
ganglion.  In  any  case  it  should  be  treated  with 
great  respect,  as  injury  means  the  flooding  of  the 
field  with  blood  and  greatly  increased  operative  dif- 
ficulty. Should  such  an  accident  occur,  however, 
bleeding  may  be  controlled  by  passing  a  tenaculum 
through  the  foramen  spinosum  to  compress  the  ves- 
sel at  that  point.  The  danger  of  hsemorrhage  from 
an  arterial  source  is  increased  in  these  patients  since 
they  are,  as  a  rule,  past  middle  life  when  the  degen- 
eration of  the  arterial  wall  makes  them  more  brittle 
and  less  elastic. 

Having  the  ganglion  in  view,  its  dural  capsule  is 
incised  and  the  ganglion  gently  separated  by  blunt 
dissection.  Its  central  root  is  then  divided  or 
avulsed  and  the  ganglion  released  by  section  of  the 
primary  branches. 

It  is  well  to  remember  that  the  small  meningeal 
artery,  a  variable  vessel,  enters  the  skull  by  way  of 
the  foramen  ovale  with  the  third  division  of  the 
nerve.  Disagreeable  haemorrhage  may  follow  in- 
jury to  this  vessel.  In  a  deep  funnel  shaped  wound 
of  this  sort  haemorrhage  is  the  most  troublesome 
difficulty.  A'enous  oozing  is  often  very  free  and  ob- 
scures the  field  at  once.  In  fact  it  has  been  my  ex- 
perience that  there  is  more  trouble  in  controlling 
venous  than  arterial  bleeding.  In  such  case  it  is 
necessary  to  work  slowly,  using  small  compresses 
held  in  position  for  a  minute  or  so.  It  may  assist 
to  wring  them  out  of  almost  boiling  water.  If 
bleeding  is  profuse  and  is  not  very  readily  controlled 
time  should  not  be  lost  in  further  attempt,  but  the 
wound  should  be  packed  and  at  the  end  of  twenty- 
four  or  thirty-six  hours  the  operation  completed. 
Arterial  hemorrhage  may  be  controlled  by  ligation 


where  possible.  On  account  of  the  deep  situation 
of  the  arteries  likely  to  be  wounded  it  may  be  im- 
possible to  apply  a  ligature.  Recourse  must  then 
be  had  to  pressure  with  an  instrument,  or  by  sterile 
pegs  of  wood  or  absorbable  material,  or  by  gauze 
compress.  Intractable  oozing  may  make  it  neces- 
sary to  leave  drainage  in  the  wound. 

In  freeing  the  inner  aspect  of  the  ganglion  it  is 
necessary  to  remember  that  the  cavernous  sinus  is 
in  immediate  relation  and  gives  troublesome  haemor- 
rhage when  wounded.  That  portion  of  the  ganglion 
in  relation  to  the  cavernous  sinus  may  be  left,  but 
it  has  not  been  my  practice  to  do  so.  The  internal 
carotid  also  is  in  rather  close  relation,  but  ordinary 
care  should  be  sufficient  to  prevent  any  injury  to 
this  important  structure. 

The  manner  of  treatment  of  the  central  root  of 
the  ganglion  is  under  discussion  at  the  present  time. 
It  is  of  interest  to  note  that  the  first  intracranial  op- 
eration done  for  the  relief  of  this  condition,  by  Sir 
Victor  Horsley,  did  not  have  as  its  object  the  ex- 
tirpation of  the  ganglion  but  the  division  of  its 
sensory  root.  More  recently  it  has  been  suggested 
by  Spiller  that  it  is  sufficient  to  do  this  and  leave 
the  ganglion  in  situ.  This  procedure  is  based  on  the 
belief  of  neuropathologists  that  there  is  no  regen- 
eration of  the  axis  cylinder  of  the  central  neurone 
and  therefore  once  severed,  no  recurrence  can  ever 
occur.  Frazier  has  carried  out  this  procedure  with 
satisfactory  results,  having  secured  a  complete  and 
lasting  sensory  isolation  of  the  diseased  area,  and 
moreover  in  one  case  he  has  been  able  to  separate 
the  sensory  from  the  motor  root  and  preserve  the 
functions  of  the  muscles  of  mastication.  He  states, 
however,  that  it  is  very  rarely  possible  to  do  this, 
and  pending  absolute  certainty  of  the  impossibil- 
ity of  central  regeneration  and  recurrence  it  is  still 
his  practice  to  remove  at  least  a  part  of  the  gang- 
lion. 

A  word  should  be  given  to  a  distressing  compli- 
cation which  is  apt  to  follow  unless  carefully  guard- 
ed against,  namely,  panopthalmia.  This  is  most 
effectively  warded  off  by  care  against  any  possible 
trauma  or  irritation  to  the  eye.  I  have  had  excel- 
lent results  by  suturing  together  the  lids.  The 
same  object  may  be  secured  by  fixing  a  large  watch 
glass  over  the  eye  with  adhesive  plaster. 

I  have  made  no  mention  of  the  intracranial  re- 
section of  the  superior  and  inferior  maxillary 
nerves,  as  this  operation  is  not  any  more  curative 
than  the  peripheral  operations.  I  have  had  occa- 
sion to  remove  the  ganglion  after  this  operation  has 
been  practised,  and  it  can  readily  be  understood 
that  it  makes  the  ganglion  operation  more  difficult. 

To  those  who  have  not  had  the  opportunity  of 
observing  cases  of  major  neuralgia,  this  operation 
may  seem  somewhat  heroic  to  employ  for  the  reHef 
of  a  condition  characterized  by  pain  without  danger 
to  life.  By  those,  however,  who  have  seen  the 
abject  misery  it  can  cause,  leading  in  not  a  few  in- 
stances to  suicide-,  or  to  the  addiction  to  morphine, 
the  operative  treatment  with  its  comparatively  pres- 
ent low  mortality  and  not  very  great  deformity  will 
be  hailed  as  a  triumphal  offering  of  surgery  to  hu- 
manity. 

1634  Walxut  Street. 


626 


STEIXHARDT :  PAINFUL  HEELS. 


[New  York 

MeDUAL  JciURXAL. 


PAINFUL  HEELS. 

Bv  Ikving  D.  Steinhardt,  M.  D., 
New  York, 

Associate  Oitliopsedic  Surgeon,  Out  Patient  Department,  New  York 
Hospital:  Clinical  Assistant,  Departments  of  Orthopaedic 
Surgery  and  Pediatrics,  Vanderbilt  Clinic,  etc. 

Prologue. — It  has  no  doubt  been  a  source  of  mys- 
tery to  many  practitioners  as  to  why  many  patients 
who  have  come  under  their  professional  care  com- 
plaining of  severe  pain  and  tenderness  in  their  heels 
in  walking,  or  on  pressure,  have  failed  to  be  re- 


1. — .\  typical  case,  both  heels  involved. 


Heved  by  the  various  drugs  or  methods  prescribed 
for  their  benefit,  and  it  is  to  lift  this  curtain  of  mys- 
tery and  to  make  the  next  cases  easier  to  treat  prop- 
erly, and  therefore  to  effect  cures,  that  this  little 
article  is  offered  for  publication. 

A  most  frequent  cause  of  painful  heels  is  an  acute 
productive  inflammation  of  the  os  calcis,  sometimes 
spoken  of  as  exostosis  of  the  os  calcis.  exostosis  of 
'  the  heels,  os  calcis'  spurs,  and  infected  heels. 

At  the  present  time,  no  definite  statistics  can  be 
compiled  as  to  the  frequency  of  occurrence.  Per- 
sonally I  have  seen  in  conjunction  with  my  asso- 
ciates in  the  Orthopaedic  Department  of  the  Van- 


Fii-.   2. — S.imf   patient   as  in    Kig.    i.     .\   typical   case,  both  heels 
involved. 


derbilt  Clinic.  Dr.  Jaeger  (chief),  Dr.  Epstein,  and 
Dr.  Friedcr,  and  in  my  own  (Tthopaedic  service  in 
the  New  York  Hospital,  Out  Patitnt  Department, 
about  thirty  to  thirty-five  cases  in  the  past  two 
years. 

Allinlogy. — Usu'dh'  there  will   be   fnuufl  a  pre- 


vious history  of  gonorrhoea,  gonorrhoeal  rheuma- 
tism, clironic  gouty  rheumatic  diathesis,  and  trau- 
matism in  certain  long  standing  cases  of  weak  foot 
by  the  rubbing  and  impaction  of  ■  the  os  calsis 
against  the  external  malleolus.  So  far  as  ob- 
served, males  are  very  much  more  often  afi'ected 
than  females,  and  whites  more  than  negroes.  One 
or  both  heels  may  be  affected. 

Varieties. — Gonorrhoeal,  rheumatic,  traumatic, 
and  gouty  rheumatic. 

Age. — Those  of  the  gonorrhoeal  variety  occur 
usually  between  the  ages  of  eighteen  and  forty-five 
years,  those  of  the  gouty  and  gouty  rheumatic  va- 
riety occur  usually  from  forty  years  of  age  and  be- 
ond,  and  those  caused  by  weak  feet  can  occur  at 
any  age. 

Pathology. — Through  the  courtesy  of  Dr.  Charles 
H.  Jaeger  I  am  able  to  give  in  full,  the  report  of 
his  pathologist.  Dr.  Otto  Hensel,  on  a  case  of  the 
gonorrhoeal  variety,  in  which,  however,  the  tissue 
changes  are  about  typical  of  all  the  cases  no  matter 
to  which  class  they  belong: 

On  cutting  into  the  soft  part  of  the  heel,  which  in  ap- 
pearance and  on  palpation  did  not  exhibit  anything  abnor- 
mal, the  tissues  were  found  to  be  oedematous  and  the 
muscle  particularly  discolored.  In  the  region  of  the  tuber- 
cles on  the  inferior  surfaces  of  the  os  calcis,  the  bone  was 
considerably  more  prominent  than  normally  and  very 
rough.  The  bone  here  was  very  brittle  and  could  be  easily 
removed  with  a  sharp  spoon.  Pieces  of  this  bone  were  at 
once  dropped  into  a  rr.ixture  of  broth,  two  parts,  and  hu- 
man serum,  one  part,  which  had  been  kept  for  seventy-two 
hours  in  the  incubator,  to  insure  its  being  sterile.  All 
aseptic  precautions  were  observed.  After  twenty-four 
hours  the  fluid  was  found  turbid.  Microscopical  exam- 
ination revealed  many  short  Gram  positive  rods,  and  many 
distinctly  biscuit  shaped  diplococci,  which  reacted  negative 
to  the  Gram  stain.  Subcultures  on  serum  agar  gave  the 
same  pictures  on  ordinary  agar,  the  diplococci  did  not  grow 
but  the  bulla?  developed  abundantly.  These  were  most 
likely  a  contamination.  Pieces  of  bone  \\ere  decalcified  in 
nitric  acid  and  alcohol  and  finally  cut  in  paratfin.  They 
showed  a  dense  granulation  tissue,  consisting  chiefly  of 
spindle  cells.  The  tissues  were  infiltrated  in  all  directions 
by  broad  bands  of  well  developed  bone,  leaving  areas  of 
unaltered  connective  tissue  between  them.  The  few  blood 
vessels  present  showed  marked  engorgement.  Pathologi- 
cally, the  process  was  an  ossifying  periostitis.  The  germs 
present  were  undoubtedly  gonococci. 

Bacteriology. — In  the  gonorrhoeal  variety  the 
Xeisser  bacillus  has  been  positively  demonstrated 
and  it  is  from  this  fact  that  this  variety  takes  its 
name.  In  the  other  varieties  many  different  cocci 
have  been  found  including  the  streptococcus,  the 
staphylococcus.,  etc.  The  infection  is  probably  by 
way  of  the  blood  and  lymph  streams. 

Symptoms. — The  patient  usually  complains  at 
first  of  general  pain  in  the  toes  and  foot  which  after 
a  little  time  becomes  localized  in  the  heel  itself. 
Examination  of  the  heel  proper  shows  general  ten- 
derness with  a  point  of  exquisite  pain  on  pressure 
of  the  sole,  of  the  foot  immediately  in  contact  with 
the  tubercule  of  the  os  calcis.  This  pain  is  su~h 
that  ofttimes  the  fear  of  it  is  sufficient  to  prevent 
the  patient  from  putting  his  feet  to  the  ground  and 
he  uses  crutches  and  various  other  means  to  get 
about  without  having  to  i)ut  his  weight  upon  his 
feet. 

Diagnosis. — .\n  x  ray  picture  will  show  one  or 
more  small,  .'^harp  spicules  of  bone  protruding  from 
.the  OS  cTlcis  with  a  |)eristitis  of  the  surrounding 
bone  or  a  very  iinicii  enlarged  tubercle  of  the  os 


March  j;.  igog.l 


Rl^L  'i  EXIl'ALD:  DOUBLE  UTERINE  DILA'IOK. 


627 


calcis  with  a  surrounding  periostitis.  Where  the 
help  of  the  x  ray  is  not  to  be  had  conveniently,  the 
diagnosis  can  be  made  by  the  exquisite  pain  and  the 
localized  point  of  tenderness  caused  by  pressure 
over  the  tubercle  of  the  os  calcis  and  ofttimes  by 
being  actually  able  to  feel  the  exostosis  through  the 
heel  by  deep  pressure. 

Prognosis. — The  trouble  is  curable   by  proper 


Fig.  3. — A  typical  case;  both  heels  involved. 


treatment  and  where  the  exciting  cause  can  be  as- 
certained and  removed,  reoccurrence  will  not  take 
place.  In  the  series  of  cases  in  which  Dr.  Jaeger, 
Dr.  Epstein,  and  myself  have  been  interested,  there 
has  been  no  reoccurrence  to  date.  This  series  cov- 
ers a  period  of  almost  three  years. 

Prophylaxis. — The  abolition  of  the  very  per- 
nicious and  absolutely  wrong  idea  of  a  double 
standard  of  morals  will  prevent  gonorrhoea  and 
therefore  the  gonorrhoeal  variety  of  this  trouble. 
Also  the  proper  treatment  of  those  who  have  gon- 
orrhoea will  also  help  abolish  the  gonorrhoeal  va- 
riety. As  to  the  other  varieties,  except  the  trau- 
matic, thorough  medical  and  dietetic  treatment  in 
the  primary  and  subsequent  attacks  especially  as 


I'IG.  4, — Same  patient  as  in  Fig.   3,   showing  beginning  periostitis. 


to  keeping  the  body  fluids  alkaline  at  all  times  and 
seeing  that  there  is  a  proper  function  of  the  great 
excretory  organs  of  the  body.  The  traumatic  va- 
riety can  best  be  avoided  by  recognizing  cases  of 
weak  feet  early  and  then  instituting  the  proper 
treatment  at  once. 


Treatment. — There  is  only  one  proper  treatment 
and  that  is  removal  of  the  offending  exostosis  first 
and  then  postoperative  treatment  of  the  underlying 
cause. 

When  there  is  an  uncured  gonorrhoea,  the  usual 
antigonorrhceic  remedies  should  be  employed  lo- 
cally, alone,  or  in  conjunction  with  some  good 
preparation  of  antigonorrhceic  serum,  or  the  serum 
alone  may  be  used.  In  the  traumatic  variety 
caused  by  weak  feet,  treat  the  weak  feet  by  strap- 
pings until  they  are  ready  for  plates  and  then  make 
for  them  a  well  fitting  pair  of  Whitman  plates.  In 
the  other  varieties,  the  usual  antirheumatic  and 
antigouty  remedies  may  be  employed  in  conjunc- 
tion with  buttermilk,  which.  I  think,  is  best  pre- 
pared from  fresh  milk  and  from  any  of  the  lactic 
acid  ferments  on  sale  in  pharmacies,  rather  than 
purchased  from  more  or  less  clean  milk  stores,  as 
it  is  the  action  of  the  lactic  acid  bacilli  that  is  want- 
ed, and  not  merely  soured  milk  turned  so  by  the 
action  of  various  harmful  and  harmless  germs. 

The  technique  of  the  operative  part  of  the  treat- 
ment is  as  follows:  i.  Apply  Esmarch  bandage.  2. 
Usual  cleansing  of  entire  foot  for  operative  pro- 
cedure. 3.  Apply  tincture  of  iodine  to  line  of  in- 
cision. 4.  Make  an  incision  about  two  or  two  and 
one  half  inches  long  terminating  at  a  point  about 
one  half  inch  behind  the  tubercle  of  the  os  calcis. 
This  incision  should  be  right  down  to  the  bone  and 
in  the  middle  line.  5.  Insert  retractors  and  locate 
exostosis  at  bottom  of  wound.  6.  Chisel  away  ex- 
ostosis with  a  grooved  chisel  and  scrape  the  bone 
with  a  sharp  spoon  until  the  surface  is  smooth  and 
seems  healthy.  7.  Wash  out  with  sterile  normal 
salt  solution.  8.  Close  wound  without  drainage, 
with  interrupted  catgut  sutures.  The  patient 
should  rest  in  bed  for  about  three  days,  and  may 
then,  if  everything  is  going  along  smoothly,  be  al- 
lowed to  sit  up.  At  the  end  of  two  weeks,  the  feet 
may  be  put  to  the  ground,  and  after  twenty-one 
days,  the  patient  should  be  around  as  usual,  con- 
tinuing, if  still  necessary,  the  postoperative  treat- 
ment. 

160  West  One  Hundred  and  Sixth  Street. 


A  DOUBLE  DILATOR  FOR  USE  m  OBSTETRICS 
AND  GYNECOLOGY. 

By  J.  J.  Rectenwald,  M.  D., 
Pittsburgh,  Pa. 

The  instrument  herein  described  being  of  especial 
advantage  in  obstetrical  cases,  I  have  illustrated  its 
use  and  manipulation  with  reference  to  the  instances 
in  parturition  in  which  it  has  served  in  practice.  Its 
application  in  gynaecological  treatments  will  obvi- 
ously be  covered  to  the  satisfaction  of  the  interested 
reader. 

Often  while  attending  an  obstetrical  patient,  en- 
deavoring to  dilate  the  cervix  with  the  fingers — a 
method  frequently  unsatisfactory — I  have  felt  the 
necessity  of  an  instrument  by  which  the  practitioner 
rnight  safely  dilate,  slowly  or  rapidly  at  will,  to  fa- 
cilitate the  desired  manipulation  and  expulsion  of 
the  foetus. 

The  instrument  which  I  have  invented  will,  I 
think,  commend  itself  to  my  colleagues  as  a  distinct 


628 


RECTENWALD:  DOUBLE  UTERINE  DILATOR. 


[New  York 
i^Iedical  Journau 


Step  in  advance  of  the  mechanical  aids  thus  far  at 
the  command  of  obstetricians. 

In  this  double  dilator  the  blades  a  on  the  one  end 
are  fine,  similar  to  those  of  the  ordinary  dilator  of 


Fig.  I. — Illustrating  bladder;  b,  dilating  cervix  in  case  of  placenta 
pr.-Evia. 


common  practice,  and  of  such  proportions  as  to  per- 
mit insertion  into  the  smallest  opening.  With  these 
blades  in  use  dilation  can  be  carried  to  an  extent  of 
four  inches,  the  graduated  arc  c  permitting  the  op- 
erator to  see  positively  what  progress  is  being  made 
without  v/ithdrawing  the  instrument.  In  practice  I 
cover  the  fine  blades  by  slipping  sections  of  rubber 
tubing  about  three  inches  long  over  them,  thereby 
creating  a  cushioned  surface  less  liable  to  lacerate 
the  cervix.  On  the  other  end  the  blades  b  are  blunt 
and  are  intended  to  be  inserted  after  the  os  has  been 
sufficiently  dilated  to  permit  their  introduction. 
They  can  be  opened  to  six  and  a  half  inches. 

In  cases  of  eclam.psia  or  placenta  praevia  where 
speedy  delivery  is  essential  and  rapid  dilation  there- 
fore a  sine  qua  noii.  the  insertion  of  blades  b  will 
afford  opportunity  to  exert  any  desired  power  by 
gripping  blades  a.  In  cases  of  placenta  prasvia  the 
instrument  proves  to  be  one  of  extraordinary  util- 
ity, inasmuch  as  the  placing  of  a  rubber  hood  over 
the  blades  b  permits  dilation  to  proceed  while  the 
hood  in  question  diminishes  the  danger  attendant  to 
hjemorrhage  from  the  uterus.  The  effect  of  the 
hood  e  is  practically  speaking  "keeping  the  uterus 


closed  while  the  os  is  being  opened."  In  the  absence 
of  the  regular  hood  a  piece  of  ordinary  rubber  dam 
may  be  substituted  with  satisfactory  results. 

The  modus  operandi  of  placing  the  hood  or  rub- 
ber dam  is  to  double  the  centre  down  between  the 
blades  b  allowing  the  sides  of  hood  or  ends  of  rub- 
ber dam  to  extend  down  an  inch  or  more  on  the  out- 
side of  the  blades.  In  this  manner  sufficient  rub- 
ber material  is  at  hand  to  permit  all  necessary  travel 
of  the  blades  without  allowing  blood  to  escape,  or 
risking  the  rupturing  of  the  hood  or  dam. 

In  ordinary  cases  of  rigid  os,  I  have  used  the  in- 
strument very  successfully,  reducing  the  hours  of 
suffering  considerably  by  placing  rubber  bands  over 
the  ends  a  so  that  the  elastic  tractile  force  produced 
a  constant  gradual  dilation.  These  bands  are  shown 
in  position  at  d.  This  procedure  has  proved  of 
scarcely  any  inconvenience  to  the  patient. 

At  present  an  instrument  is  being  made  for  me  in 
which  by  the  use  of  a  screw  and  strong  spiral  spring 
the  same  results  can  be  obtained  without  recourse 
to  rubber  bands. 

In  cases  in  which  after  initial  dilation  it  may  be 
found  difficult  to  insert  the  blades  b,  or  where  there 
may  be  especial  reason  for  using  the  fingers,  I  have 
inserted  the  index  and  middle  fingers  and  then 
slipped  the  blades  a  between  the  said  fingers  adding 
power  to  them  by  gripping  the  blades  b.  This  fre- 
quently proves  a  highly  desirable  advantage.  (See 
Fig.  2.) 

My  very  first  case  in  which  this  instrument  was 


Fig.  2. — Reinforcing  the  finger  dilatation  with  the  blades  of  the 
dilator. 


used  was  one  of  ])lacenta  pr?evia.  The  uterus  was 
forcibly  dilated  in  the  manner  indicated  above,  the 
child  delivered  by  version  in  a  few  minutes.  Mother 
and  child  are  both  living.     Another  patient  had 


Marcli  27,  1909.] 


PIT  FIELD:  MEDICAL  MIND. 


629 


eclampsia  at  seven  months.  At  the  eighth  month 
albuminuric  retinitis  and  other  symptoms  of  kidney 
breakdown  developed.  A  catheter  introduced  into 
the  uterus  v^as  permitted  to  remain  for  twelve  hours 
without  having  produced  any  efifect.  Within  an 
hour  after  a  second  catheter  had  been  introduced, 
following  removal  of  the  first,  labor  began.  After 
the  patient  had  been  in  labor  five  hours,  I  was 
called  and  found  the  os  dilated  only  sufficiently  to 
admit  two  fingers.  With  the  aid  of  my  instrument 
the  delivery  was  concluded  in  one  and  three  quarter 
hours,  without  forceps,  mother  and  child  both  living. 

The  efficacy  of  the  device  manifested  itself  in  the 
case  of  a  mother  of  six  children.  Her  history  was 
to  the  efifect  that  each  labor  endured  more  than 
twenty-four  hours,  owing  to  slow  dilation  of  the  os 
and  its  obduracy  in  responding  to  usual  manipula- 
tion. At  the  time  I  arrived  she  had  been  in  labor 
about  three  hours.  In  view  of  the  history,  I  consid- 
ered the  opportunity  especially  good  for  making  a 
test  case,  and  immediately  proceeded.  After  initial 
dilation  with  blades  a  until  a  two  inch  opening  had 
been  secured,  I  introduced  blades  h  and  applied  the 
rubber  bands  over  blades  a,  refraining  from  apply- 
ing any  other  pressure  than  an  occasional  turn  of 
the  inner  set  screw  on  the  graduated  arc  c.  The 
accouchement  was  completed  in  one  and  one  half 
hours.  On  discharging  this  case,  I  was  deeply  grati- 
fied to  have  the  lady  express  her  appreciation  in  the 
following  words:  "That's  the  best  instrument  that 
ever  was.  I  certainly  expected  to  suffer  for  many 
more  hours  than  I  did." 

What  I  am  convinced  I  may  justly  assert  for  this 
instrument,  is :  - 

1,  With  reasonable  care  the  uterus  cannot  be  torn, 
because  the  conformation  of  the  blades  is  such  as 
to  reduce  the  possibility  to  an  infinitesimal  minimum. 

2,  By  the  blades  opening  transversely  injury  to 
bladder  and  rectum  is  prevented. 

3,  Liability  of  infection  is  greatly  reduced  by  re- 
moving the  necessity  of  frequent  introduction  of  the 
fiiigers  for  dilation. 

4,  In  obstetric  cases,  no  matter  how  small  the  cer- 
vix may  be,  it  is  always  possible  to  insert  blades  a 
and  secure  sufficient  dilation  for  the  introduction  of 
blades  h. 

5,  It  removes  for  the  general  practitioner  or  coun- 
try doctor  the  necessity  of  having  an  ordinary 
uterine  dilator,  because  the  set  screws  on  the  gradu- 
ated arc  c  enable  the  regulation  of  dilation  to  what- 
ever extent  desired  for  gynaecological  operations. 

6,  In  any  case  where  complications  may  render 
extreme  care  imperative,  the  set  screws  on  the  grad- 
uated arc  c  provide  a  means  to  gauge  accurately  the 
extent  of  travel  and  prohibit  any  inadvertent  ex- 
ceeding of  limitations. 

7,  It  will  be  found  a  great  aid  in  speedily  deliv- 
ering cases  of  eclampsia  and  placenta  praevia,  and 
will  materially  reduce  the  percentage  of  mortality  in 
these  most  dreaded  obstetrical  complications. 

8,  The  instrument  can  be  made  much  cheaper 
than  the  elaborate  four  bladed  dilator,  and  in  spite 
of  its  simplicity  will  insure  greater  flexibility  as  a 
mechanical  assistant  to  obstetricians  and  gynaecolo- 
gists. 

In  conclusion  I  might  say  that  the  instrument  can 
readily  be  inserted  by  first  introducing  a  vaginal 


speculum.  Furthermore,  it  is  relevant  to  remark 
that  in  the  use  of  this  double  dilator  less  pain  is 
caused,  than  where  one  must  depend  solely  upon 
uterine  contraction  for  dilation,  because  the  applica- 
tion of  pressure  is  confined  to  the  zone  of  the  cervix 
itself. 

808  Keenan  Building. 


THE  MEDICAL  MIND. 

By  Robert  L.  Pitfield,  M.  D., 
Philadelphia, 

Physician  to  St.  Timothy's  Hospital;  Pathologist  to  the  Germantown 
Hospital. 

Any  one  looking  for  the  first  time  at  a  Golgi  sil- 
ver preparation  of  the  cerebral  cortex  is  at  once 
amazed  and  charmed  at  the  bewildering  host  of 
pyramidal  cells,  with  their  far  reaching  axones  and 
dendrites  radiating  in  every  direction.  But  it  takes 
very  little  reflection  before  it  is  apparent  to  the  ob- 
server that,  after  all,  the  brain  cell  thus  portrayed 
represents  very  little.  Just  as  much  as  a  silhouette 
represents  the  true  countenance  of  a  friend  with 
smiling  eyes  and  ruddy  cheeks.  It  hardly  seems 
more  than  a  pyramidal  shaped  blot  of  ink  with  lines 
carelessly  run  off  from  it.  A  Nissl  preparation  is 
not  much  better.  Beyond  the  sheer  morphology, 
physiologA'  bridges  the  gap  over  to  psychology  in  a 
very  poor  way.  Crude,  cumbersome  methods  will 
never  unveil  the  very  highest  vital  phenomena  that 
God  ever  made.  As  well  pry  into  the  secrets  of  a 
polariscope  with  a  crowbar  as  to  investigate  cerebra- 
tion with  the  means  at  hand.  From  before  Aristotle 
mental  phenomena  have  been  studied  by  man,  with 
the  result  that  many  of  the  actions  of  the  brain  are 
accurately  described  and  recorded,  but  that  high 
divine  gift,  reasoning,  is  accomplished  by  the  cells 
and  other  brain  components — how  ?  It  matters  not, 
perhaps  the  thinker  pauses  in  his  work  and  wonders 
how  he  thinks.  His  field  of  consciousness  is  often 
overcrowded  with  ideas  like  the  characters  that 
teemed  in  the  brain  of  Balzac,  impatient  to  be  born. 
We  none  of  us  have  similar  mental  habits  and 
methods.  Mental  strength  varies  enormously.  The 
unborn  ideas  of  a  Young,  or  Helmholtz,  or  Kant 
of  a  single  day  perhaps  exceed  the  whole  cerebral 
output  for  a  lifetime  of  many  of  us,  printed  and 
bound  perchance  into  books  to  the  pleasure  and  de- 
lectation of  a  few  poor  souls.  But  every  man  has 
his  talents,  perhaps  one,  perhaps  ten ;  let  him  that 
hath  more  contribute  to  the  mental  coffers  of  those 
that  are  hvmgry. 

Insipid  and  colorless  would  the  political  world  be 
if  all  men  thought  alike. 

If  it  had  always  been  so  we  would  have  had  very 
little  history  and  no  historic  literature.  The  great 
dramas  and  epics  would  have  been  unconceived  and 
unborn.  Out  of  the  hordes  of  men  there  would 
have  been  no  heroes,  no  statesmen,  no  giant  fig- 
ures that,  like  great  peaks  rising  afar,  mark  the  his- 
toric plain.  Men's  thoughts  clashing  have  by  dif- 
ferences and  controversies  caused  wars  that  sepa- 
rated the  races  and  nations. 

Not  only  in  the  political  world,  but  also  in  the- 
theological,  opposite  opinions  and  judgments  have- 
caused  the  birth  of  divers  sects,  all  different,  and  in. 


630 


PIT  FIELD:  MEDICAL  MIND. 


[Xew  York 
Medical  Journal. 


the  battle  ground  of  beliefs  giant  figures  have 
arisen,  as  truly  heroic  as  the  political  ones.  Science, 
too,  has  had  her  heroes,  not  born  so  much  out  of 
controversies;  they  are  rather  the  ofifspring  of  great 
desires,  of  great  hungering  and  thirsting  for  knowl- 
edge. As  in  the  political  and  theological  worlds, 
so  in  the  scientific,  the  heroic  or  master  minds  have 
so  formulated  thought  and  rectified  it,  as  it  were, 
that  theories  and  facts  proved  and  accepted  have 
risen  into  structures  along  the  lines  of  which  men 
think  and  act ;  and  because  they  have  habitually 
thought  in  such  ways  we  speak  of  them  as  minds. 

We  are  familiar  with  the  legal,  with  the  artistic, 
and  the  theological  minds.  The  scientific  mind,  save 
in  psychology,  deals  not  with  the  emotions,  im- 
pulses, and  acts  of  the  intellect,  but  with  facts,  their 
relation  to  each  other  and  with  the  laws  that  gov- 
ern these  relations. 

Medicine,  the  knowledge  of  the  human  body  in 
health  and  disease,  "has  become  a  distinct  part  of 
science,  and  has  reared  for  itself  a  structure  of  its 
own.  Out  of  a  huge  mass  of  observations,  facts,  and 
theories  it  has  been  built,  at  a  cost  of  countless  lives 
to  the  race  and  with  infinite  labor,  and  what  we  now 
know  is  hard  won  and  exceedingly  precious. 

It  has  cost  as  much  to  learn  how  to  prevent  and 
cure  disease  by  the  use  of  common  things  around 
us,  such  as  the  application  of  heat,  light,  air,  rest, 
food,  as  it  cost  to  maintain  the  Roman  Empire 
against  all  the  enemies  that  it  ever  knew.  It  has 
cost  life,  this  medical  mind,  rich  in  experience,  now 
open  and  free  to  any  one  for  the  asking. 

Dearly  bought  to  the  human  race  is  the  knowl- 
edge of  some  of  the  very  simplest  of  the  modern 
agents  wherewith  we  fight  disease.  Men  have  not 
in  the  past  thought'  alike  in  medicine ;  there  have 
been  no  great  battles  resulting,  nor  any  great  di- 
vision; there  have  been  sects,  never  of  workers  or 
builders  of  this  intellectual  structure,  however.  The 
(lif¥erences  of  thought  have,  in  the  main,  been  caused 
by  great  desires  to  come  nearer  to  the  truth.  And 
this  structure  cost  more  to  build  and  represents 
more  than  did  ever  the  Roman  forum.  It  repre- 
sents human  liberties  dearly  bought  and  fought  for. 
To  develop  all  this  the  medical  mind  for  centuries 
has  advanced  slowly,  surely,  orderly,  weighing, 
measuring,  dissecting,  observing,  revising,  collect- 
ing, cataloguing,  and  publishing.  And  what  it  has 
is  thought  to  be  the  truth,  and,  out  of  the  sincerity 
i  f  the  medical  heart,  is  considered  truth  in  all  its 
proceedings. 

It  must  at  least  be  said  that  the  medical  mind  is 
intellectually  honest.  It  may  be  deceived,  and  there 
are  sad  records  of  deception,  but  no  archaic  theory, 
bitten  by  the  canker  of  a  superstitious  past,  is  for  a 
moment  part  of  our  structure.  To  erect  this  struct- 
ure of  medical  knowledge  we  have  had  to  have  the- 
ories, scafi'olds  i)erhaps  that  tumble  down  or  crum- 
ble at  the  first  fact  put  upon  them. 

How  convenient  it  is  to  think  along  the  lines  that 
the  theories  of  immunity  have  supported ;  how  eager 
are  we  to  build,  and  also  how  often  has  the  struct- 
ure tumbled,  only  to  be  rebuilt.  Many  other  cher- 
ished ideas,  like  beautiful  blocks  of  marble,  that  we 
must  use  facts  and  truths  that  arc  keystones,  corner 
stones,  buttress  stones,  that  by  their  shape  must  be 
given  position,  and  indicate  at  once  the  future  form 


of  some  great  arch  or  parapet.  What  a  useful  arch 
is  anaesthesia,  what  a  buttress  has  the  germ  theory 
proved,  how  it  has  supported  asepsis,  vaccination, 
and  serum  therapy.  As  paleontologists  reconstruct 
prehistoric  animals  from  a  single  bone  or  even  a 
tooth,  so  must  we  and  so  do  we  labor  day  and  night 
to  construct  whole  chambers  planned  upon  the  form 
of  a  newly  found  stone.  What  a  wonderful  stone 
th3Teoid  therapy  in  myxoedema  has  proved,  and  how 
awkward  a  one  as  yet  is  our  knowledge  of  the  func- 
tion of  the  parathyreoids. 

We  have  master  workmen,  and  we  use  ever)- 
tool  that  we  can  invent  or  borrow,  every  engine  to 
lift  the  crystalline  truths  out  of  the  mine,  and  every 
material,  every  kind  of  force.  Our  workmen  delve 
in  pestilential  swamps,  where  "million  murdering 
death"  threatens  on  every  hand ;  not  a  few  have 
been  crushed  in  the  endeavor  to  apply  some  marble 
truth  plumb  with  walls  below  it.  We  have  had  our 
Rosses,  Carrols,  Lazears,  and  Reeds.  We  honor 
them.  These  men  of  our  altruistic  masonic  order 
and  those  that  have  been  crushed  we  hope  to  raise 
that  which  they  endeavored  to  raise,  not  only  as  a 
part  of  the  structure,  but  as  a  monument,  forever  a 
buttress  against  the  wiles  of  the  antis,  and  memorial 
of  the  kindness  and  sacrifice  of  man  for  man. 

Such  is  this  entity  known  as  the  medical  mind, 
reared  on  ancient  and  tried  foundations,  roofless  as 
yet  in  parts,  unilluminated  in  many,  ugly  where  mud 
perchance  has  been  thrown  upon  it.  But  it  has 
domes  and  minarets,  built  by  the  Helmholtzes,  Pas- 
teurs,  and  Listers,  forever  solid,  forever  aplumb,  and 
beautiful  W'ithal.  The  genius  of  this  mind,  subtle, 
elusive,  brilliant,  has  yet  to  build  far,  far  beyond 
our  time. 

The  various  attributes  of  the  human  mind  have 
long  been  a  matter  of  study  by  philosophers  and 
psychologists.  And  they  have  been  discussed,  not 
only  from  the  physical,  but  the  metaphysical,  stand- 
points, from  the  days  of  Socrates,  but  the  mental  at- 
tributes of  the  medical  mind  have  never  been  stu- 
died, separately  and  apart.  The  mind  and  character 
of  the  doctor  differ  from  that  of  other  professional 
men.  We  can  with  perfect  propriety  and  truth 
speak  of  the  medical  mind  just  as  we  can  of  the 
artistic  and  legal  minds.  They  all  think  diflferently. 
using  different  type  and  formulae  of  thought. 

It  is  a  distinct  psychic  entity.  I  have  seen  it 
look  at  me  over  spectacles  as  if  it  were,  as  Emer- 
son says,  in  speaking  of  the  gaze  of  a  farmer,  "like 
a  blow  from  a  staff."  We  all  have  listened  to  its 
counsels  and  judgments  in  the  consulting  room,  and 
have  rejoiced  in  the  strength  of  its  wisdom  and  in- 
tegrity. We  have  seen  it  elucidate  theories  that  have 
won  Nobel  prizes  and  the  plaudits  of  the  world. 
We  have  hung  with  breathless  interest  as  it  has  de- 
livered truths  as  profound  as  the  theories  of  Coper- 
nicus, and  of  much  greater  import  to  the  welfare  of 
the  race  than  any  celestial  speculations.  It  preach.es. 
explores,  experiments,  and  prescribes ;  it  weighs  the 
strength  of  a  sick  man  with  the  surety  of  a  dynamo- 
meter and  with  a  subtility  far  exceeding  any  instru- 
ment of  precision.  It  ferrets  out  disease  with  an  art 
that  is  amazing.  Its  imagination  has  constructed 
out  of  the  bills  of  mosquitoes  and  the  slime  of  bac- 
teria theories,  more  precious  than  epics  or  sympho- 
nies.    And  it  has  a  singleness  of  purpose  in  the 


March  27,  1Q09.J 


PITFIELD:  MEDICAL  MIND. 


631 


search  for  truth  and  the  defense  of  it  that  is  un- 
rivalled by  any  other  of  the  learned  professions. 

The  medical  mind  is  the  only  mind  that  applies 
an  art  and  science  in  its  methods.  It  suffers,  often 
in  that  its  science,  to  fit  the  vagaries  of  the  human 
body,  is  often  inexact.  It  differs  in  each  individual 
according  to  the  man  and  the  branch  of  medicine 
that  he  has  taken  as  his  calling.  It  cannot  be  ex- 
pected that  the  perceptive  memory  and  reasoning 
powers  are  the  same  in  all  physicians.  The  all 
round  medical  mind,  awake  to  every  true  impulse 
and  perception,  giving  the  best  judgments  and  de- 
cisions, is  often  that  of  the  humble  general  practi- 
tioner. 

We  have  all  known  men  among  our  colleagues 
whose  greatest  mental  gift  is  a  marvelous  memory 
— a  memory  for  facts,  for  faces,  and  for  other  im- 
pressions. In  some  the  cerebral  apparatus  for  as- 
sociation of  ideas  is  so  exquisitely  and  acutely  active 
that  their  perceptions  are  also  marvelously  quick 
and  their  judgments  sound  and  reliable.  A  talk 
with  such  a  man  is  better  than  reading  a  book ;  he 
is  stored  with  facts  and  wise  aphorisms,  catalogued ; 
his  information  has  the  stamp  of  a  tried  and  varied 
experience ;  the  leaves  of  his  memory  are  as  green 
as  anv  in  all  of  that  curious  book — Bacon's  Novum 
Orga'num,  and  richer  by  far.  He  can  remember 
every  detail  of  a  patient's  illness,  and  can  relate  with 
stenographic  fidelity  how  the  whole  case  progressed, 
and  you  are  furnished  with  a  picture  of  the  diseased 
patient,  embellished  with  the  judgment  and  expe- 
rience that  are  most  valuable.  Medical  literature 
does  not  contain  anywhere  the  kind  of  information 
that  such  a  man  has  stored  in  his  mind,  practical, 
useful,  graphic,'  often  emphasized  by  a  dramatic 
illustration  or  sage  aphorism ;  his  talk  is  highly  in- 
structive. Medical  societies  at  times  hear  such  men 
speak.  They  are  at  their  best  in  their  back  office 
evenings  after  hours. 

Into  the  catalogued  storehouse  of  the  memory  is 
piled  the  fruits  of  experience,  and  great  is  the  man 
who  knows  how  to  use  it  with  profit,  how  to  draw 
on  it,  and  how  to  enrich  it.  A  man  with  common 
sense  is  one  who  depends  upon  his  experience. 

Various  thought  forms,  perhaps  not  cast  into 
verbal  tvpe,  are  used  by  the  medical  mind,  just  as 
intellectual  forms  are  used  by  the  legal  or  the  mu- 
sical mind.  The  power  to  weigh  a  scientific  fact 
and  to  test  it  if  it  be  true  or  counterfeit  becomes  a 
matter  almost  of  intuition.  The  memory  not  only 
stores  facts  and  pictures  of  things,  but  impressions 
of  things  brought  by  the  sense  of  touch  and  won- 
derfully developed  is  the  stereognostic  sense  of 
some  internists  and  obstetricians  ;  and  the  stereognos- 
tic memory  is  often  remarkable.  The  size  and  con- 
sistence of  an  abdominal  mass,  a  foetal  head,  or  in- 
fant's spleen  is  determined  and  remembered. 

In  the  intuitive  perceptive  abilities  of  the  medical 
mind  lies  the  art  of  medicine ;  the  lapidary  detects 
the  true  g'em  not  by  scientific  methods  so  much  as 
by  intuitive  ones.  Intuition,  that  fine  feminine  qual- 
ity, akin  almost  to  the  supernatural,  should  have  a 
great  place  in  the  mental  armamentarium  of  the 
practising  physician.  It  may  be  defined  as  the 
power  to  recognize  a  truth  that  cannot  be  acquired 
by  experience,  but  is  assumed  from  experience.  It 


is  scorned  at  by  the  scientist,  but  often  by  it  and  it 
alone  can  the  subtilties  of  other  minds  be  read  and 
understood,  and  in  the  practice  of  medicine  it  is  al- 
ways wise  to  try  to  know  about  what  a  patient 
thinks.  Like  an  aurora  borealis,  in  an  arctic  night, 
when  there  is  no  sunlight  wherewith  to  perceive 
facts,  this  subtile,  dancing,  ill  defined  light  illum- 
inates objects  for  the  mental  eye. 

Another  light  that  illuminates  the  mind,  and  the 
greater  the  mind  the  greater  the  illumination,  is  the 
faculty  of  imagination.  One  of  the  first  attributes 
of  genius,  the  imagination  is  the  flower  of  the  intel- 
lect in  its  greatest  perfection ;  by  it  in  the  nebulae 
of  knowledge  the  master  minds  of  science  have  per- 
ceived forms  where  none  apparently  existed. 

It  often  seems  to  be  a  racial  gift,  subtile,  delicate, 
soaring;  it  is  the  highest  intellectual  effort,  and  it 
is  dependent  upon  good  mental  health,  ablated  often 
by  ill  health,  fatigue,  and  exhaustion ;  it  flowers  best 
under  the  stimulus  of  other  minds.  To  the  investi- 
gator it  is  of  the  utmost  importance.  Fruits  of  the 
imagination  are  the  atomic  theory  of  Dalton,  the 
wave  theory  of  light  of  Young,  and  the  Hertzean 
theory  of  electric  waves.  Wonderful,  practical, 
beneficent  ideas  that  existed  in  the  minds  of  the  in- 
ventors as  mere  figments.  How  like  the  mycelial 
threads  of  a  mushroom  does  it  creep  along  the  dark 
soil,  springing  suddenly  into  light  and  bearing  fruit, 
fed  and  developed  by  the  soil  and  moisture  of  other 
mental  qualities. 

Men  who  never  accept  new  theories  rarely  have 
any  of  their  own,  and  are  always  men  devoid  of 
imagination.  Wonder  fills  the  mind  of  every  man 
before  he  can  invent ;  it  is  a  propelling  force,  what 
faith  is  to  a  fanatic ;  it  fairly  thrusts  the  mind  for- 
ward after  light. 

Carlyle,  in  his  Sartor  Resartiis,  says:  "The  man 
who  cannot  wonder,  who  does  not  habitually  won- 
der .  .  .  were  he  president  of  innumerable  royal 
societies,  and  carried  the  whole  mcchaiiiqiie  celeste 
and  Hegel's  philosophy  and  the  epitome  of  all  labor- 
atories and  observations  with  their  results  in  his  sin- 
gle head — is  but  a  pair  of  spectacles,  behind  which 
there  is  no  eye." 

Our  whole  knowledge  of  embryology  and  physi- 
ology were  discovered  out  of  sheer  wonder  for  the 
mysterious.  How  often  a  trifling  hint  to  a  man 
mentally  hungry  is  as  a  spore  sown  in  fertile  soil. 

Wonder  fills  the  mind  of  every  conscientious, 
searching  physician  ;  he  perpetually  wonders  at  the 
subtile  workings  of  the  body ;  particularly  does  he 
wonder  at  the  sphincter  mechanisms,  especially  that 
of  the  eye  and  pylorus  and  the  cardiac  cycle  of 
movements.  The  cerebral  reflexes,  the  medullar  ac- 
tions, awe  the  mind  of  any  one  who  merely  stops' 
and  thinks  with  a  transcending  wonder.  Who  is 
there  who  is  bold  enough  to  interfere  with  these 
mechanisms  needlessly  or  recklessly  with  drugs,  that 
may  be  powerful  levers  ?  Who  is  willing  to  attempt 
to  adjust  the  balance  wheel  of  a  watch  with  as 
clumsy  an  instrument  as  an  oyster  knife?  Just  as 
loathe  would  Rodin  be  to  touch  with  a  chisel  any 
work  of  Praxiteles  or  Michael  Angelo !  Wonder 
leads  to  worship,  and  little  is  he  indeed  who  can- 
not worship  with  scalpel  and  microscope. 

Wonder,  and  wonder  alone,  led  Pasteur  to  study 


632 


PIT  FIELD:  MEDICAL  MIND. 


[New  York 
Medical  Journal. 


the  crystallization  of  tartaric  acid,  and  this  was  the 
beginning  of  the  chain  of  mental  processes  and  ob- 
servations that  led  to  Listerism  and  aseptic  surgery. 

The  phagocytic  action  of  the  leucocytes  in  the 
blood  of  a  sand  flea  led  Metchnikof?  to  develop  his 
theory  of  immunity.  The  oservations  of  Hiss  on  the 
cardiac  impulses  of  a  tortoise  led  him  to  discover  the 
auriculoventricular  muscle  bundle  in  the  human  heart 
whereby  impulses  are  conveyed  from  one  chamber  to 
another.  The  blood  of  the  sand  flea  and  the  muscle 
bundles  of  the  tortoise's  heart  were  but  mycelial 
threads  in  the  mental  subsoil  in  the  brains  of  Metch- 
nikoft  and  Hiss :  lines  of  vital  thought  merely  ready 
to  crop  up  after  long  gropings  through  the  dark  into 
light  where  men  can  see  and  profit  by  the  fruit. 

The  constant  mental  attitude  of  all  medical  men 
should  be  to  wonder  not  only  at  the  phenomena  of 
the  human  body,  but  at  all  nature.  To  wonder  at 
the  migration  of  birds,  the  propagation  of  plants,  the 
fertilization  of  flowers,  the  embryology  of  the  chick. 
Country  roadsides  can  be  still  the  birthplace  of  new 
theories,  the  barnyard  may  yet  settle  the  cancer  ques- 
tion, the  hen  house  truly  hides  some  great  truth  yet 
unfolded.  Out  of  the  hen  house  and  cow  barn  comes 
our  modern  Cohnheim  theory  of  the  embryonal  ori- 
gin of  tumors.  Out  of  the  sheepfold  Koch  and 
Pasteur  evolved  the  theory  of  anthrax  infection  and 
vaccination. 

Out  of  the  wealth  of  your  imagination  develop  a 
new  theory  of  heredity,  and  then  proceed  like  the 
Silesian  priest,  IMendel,  to  prove  it  with  mice  and 
peas — no  laboratory  is  needed,  but  a  few;  square  feet 
of  dooryard  and  a  few  boxes. 

Theories  are  born  under  the  skies  and  finished  in 
laboratories.  Koch  in  a  recent  speech  in  Japan  said 
that  nature's  broad  field  was  the  true  place  to  make 
observations  and  not  laboratories.  Thinking,  brood- 
ing on  what  nature  has  to  show,  turning  over  stones, 
as  it  were,  the  vital  spores  may  lodge  in  any  one's 
brain,  ready  to  be  nourished  by  observation  and 
good  reading.  The  president  of  Haverford  College 
was  recently  in  Canada  on  a  vacation,  and  he  asked 
his  guide  what  he  did  in  winter  when  he  could  not 
hunt  or  fish.  "Well,"  said  the  guide,  "I  have  a  cow 
to  look  after.  I  don't  know  how  to  read,  so  some- 
times I  just  sets  and  thinks,  and  sometimes  I  just 
sets."  There  are  men  of  our  profession  in  every 
large  community  who  don't  read,  whose  profession 
is  a  cow  to  be  milked,  and  who  just  set.  There  is  no 
mental  embryology  in  such  minds ;  they  are  as  sterile 
as  an\-  teapot. 

The  perceptive  abilities  of  the  mind  vary  in  the 
case  of  the  medical  man  as  they  do  in  every  profes- 
sion or  calling,  but  medicine  is  more  apt  to  develop 
fine  qualities  of  apprehension  among  her  votaries 
than  is  law  or  theology.  Any  mind  coming  daily 
and  habitually  in  contact  with  Nature,  as  do  the 
minds  of  artists,  farmers,  sailors,  hunters,  natural- 
ists, or  physicians,  will  grow  in  its  perceptive  quali- 
ties more  than  one  that  deals  with  books  or  the  in- 
ventions and  actions  of  man ;  especially  will  the 
broader  observation  faculties  grow  and  develop. 

The  best  field  for  the  development  of  these  facul- 
ties of  perception  and  observation  is  under  the  sky. 
in  the  woofls,  on  the  water,  or  on  a  farm,  where  ac- 
curate ob.servatit>n  means  bread  and  butter,  where 
keen  perceptive  faculties  are  developed  in  hunting 


and  trapping  game,  or  in  tracking  lost  farm 
animals,  ferreting  out  hidden  watercourses,  in 
observing  the  efllects  of  chemical  fertilizers,  or 
the  cross  breeding  of  animals.  This  is  the  best 
school  to  nourish  these  fine  intellectual  qualities, 
and  most  master  minds  in  medicine  in  this  country 
have  come  from  the  farms,  the  lumber  camps,  and 
the  ranch,  leading  just  such  a  life  as  the  poet  Brown- 
ing describes  David  as  leading  in  his  poem  Saul,  ly- 
ing on  the  earth,  watching  his  sheep,  and  musing  on 
the  eagle  soaring  overhead,  and  influencing  the  sheep 
and  the  jerboa  by  various  strains  played  on  the  harp. 
From  out  under  the  stars  and  the  trees  rather  than 
from  the  city  streets  come  and  will  come  the  great 
minds  of  our  profession. 

By  long  use  the  sight  of  the  oculist  becomes  ex- 
quisitely sensitive  to  fine  shades  of  color,  to  subtile 
depths  of  focus,  imtil  he  can  detect  disease  red  hand- 
ed on  the  retinal  field,  see  the  pressure  of  a  grow- 
ing tumor  or  abscess,  the  pigmentation  of  chorioid- 
itis, or  the  degeneration  of  a  retinitis.  Just  so  a 
sailor  looks  at  the  sky  and  can  see  a  hurricane  in  a 
cloud  the  size  of  a  man's  hand,  or  on  the  horizon  can 
discern  land  where  all  is  haze  to  the  landlubber.  I 
know  a  gentleman  who  made  a  fortune  in  the  silk 
business  merely  by  his  faculty  of  feeling  a  piece  of 
silk  goods  and  instantly  estimating  its  value.  This 
ability  made  him  useful  to  a  large  manufacturer.  So 
the  touch,  the  hearing,  the  smell,  are  all  active  and 
valuable  servants  of  perception  to  the  doctor,  as  well 
as  the  sight.  There  was  a  man  who  had  remarkable 
abilities  of  perception ;  he  could  see  arrow  heads 
where  only  rubbish  could  be  found,  and  he  could 
smell  a  dwelling  house  when  he  passed  it  at  night.  . 

The  stereognostic  sense  of  some  internists  is  re- 
markable. Thickened  pylori,  gallbladders,  displaced 
organs,  sclerosed  arteries  are  palpated  with  exquisite 
and  consummate  skill,  and  recognized  at  once.  So 
the  fine  shadings  of  sound  in  lungs,  amphoric  whis- 
perings over  cavities,  crepitations,  murmurs,  bruits, 
all  are  instantly  recognized  and  a  diagnostic  or  prog- 
nostic value  put  upon  them.  Not  by  anything  but 
long  practice  can  these  various  clinical  entities  be 
recognized. 

Into  the  camera  obscura  of  the  mind  all  sorts  of 
sense  perceptions  and  thought  perceptions,  singly 
or  in  combination,  are  collected,  catalogued,  pictures 
of  rashes,  fundi  oculi,  false  membrane ;  the  feel  of 
tortuous  arteries,  softened  uterine  segments,  bruits 
of  aneurysms ;  the  odor  of  acetone  on  the  breath 
of  a  diabetic  or  septic  odor  on  a  dressing  or  diph- 
theritic membrane ;  all  collected,  recorded,  tagged 
with  associated  ideas  wherewith  to  remember  them, 
to  be  used  at  an  instant's  notice  at  the  critical  mo- 
ment. To  see  tuberculosis  lying  white  and  naked  in 
the  mesentery  folds,  to  detect  paresis  trembling  on 
the  lips  of  the  inebriate,  to  hear  the  ominous  clack 
of  an  impending  apoplexy  over  the  aortic  valves ;  all 
this  live,  virile,  mental  force,  enriched  and  enriching, 
grasping  for  more  pabulum,  spurning  the  luifit  and 
counterfeit  with  unerring  sense,  with  ever  search- 
ing, ever  feeling,  and  seeing  tentacles,  hungry  an- 
tenuic.  sensitive  end  organs,  hunting  for  knowledge. 
With  fingers  that  can  needle  a  lens,  deliver  a  baby, 
crush  a  stone,  detect  crepitus;  keen,  supple,  sensi- 
tive, palpating,  bold,  strong ;  throbbing  with  virile 
life,  feeling  degenerations  and  regenerations,  ex- 


March  27,  1909. J 


I 


PIT  FIELD:  MEDICAL  MIXD. 


633 


ploring  dark  blood  filled  cavities  with  the  skill  of  a 
divine  mechanism  and  the  nerve  of  a  David  before 
Goliath  ;  ever  alert,  masterful,  resourceful,  ingeni- 
ous, and  with  all  workmanlike.  Here  we  have  the 
medical  mind  brought  down  to  the  finger  tips,  feel- 
ing, cutting,  seeing,  sewing,  thinking,  draining,  with 
finish  and  skill.  The  art  of  medicine  here  exceeds 
the  science,  but  art  is  bold  alone  in  the  security  that 
science  gives  her- in  that  asepsis  makes  possible  many 
of  her  manoeuvres. 

Wonder  again  should  all  of  us  when  we  read  of 
hundreds  of  hysterectomies  performed  without  a 
death  :  of  gallbladder  operations,  exceedingly  well 
done,  with  a  very  small  death  rate. 

"Instantaneous  decision  of  unperverted  reason" 
is  Webster's  definition  of  common  sense. 

Two  judges  stand  perpetually  in  the  mind  of 
every  man  to  pass  upon  his  conduct :  one  is  his  con- 
science and  the  other  common  sense.  His  common 
sense  is  the  sense  of  that  which  is  reasonable,  just, 
and  proper,  judged  by  past  experiences  and  prece- 
dents.   It  is  like 

"The  compass  in  its  brazen  ring. 

Ever  level  and  true 

To  the  toil  or  task  zve  haz-e  to  do." 

It  is  that  association  of  judgment  and  reason  that 
'  makes  up  one  of  the  most  valuable  assets  that  any 
mind  can  possess. 

In  speaking  of  Benjamin  Franklin,  Weir  Mitchell 
says:  ''He  had  that  ////common  sense  called  com- 
mon sense."  Sheer  common  sense  is  the  best  intel- 
lectual qualit}-  that  any  medical  man  can  have  tran- 
scending the  memory,  the  imagination.  It  is  ex- 
ceded  only  by  the  will,  in  that  the  will  is  master  of 
it.  But  common  sense  alone  does  not  contribute  to 
the  storehouse  of  knowledge  :  it  is  at  best  a  conser- 
vator, a  holder  back,  as  it  were. 

Conscience  as  extremely  sensitive  to  influences 
as  a  d'Arsonval  galvanometer  and  plain,  rugged 
common  sense  are  prime  requisites  to  success.  They 
are  the  two  spheres  on  the  governor  of  our  mental 
actions.  The  erratic  man  is  often  thought  by  his 
fellows  to  lack  common  sense.  He  is  one  who  is 
fond  of  using  rare  and  untried  remedies  when  old 
and  trustworthy  ones  are  at  hand  and  can  be  used, 
or  of  giving  advice  to  patients  that  is  often  so  far 
from  that  which  is  apparently  sensible  as  to  be  con- 
sidered extraordinary.  Yet  these  same  erratic  fel- 
lows, by  reason  of  their  gyrations  out  of  the  axis  of 
common  sense,  sometimes  give  us  hints  and  ideas 
too  valuable  to  be  ignored.  In  no  other  branch  of 
medicine  does  common  sense  more  apply  than  in  the 
treatment  of  anything.  We  all  of  us  employ  em- 
pirical remedies  with  the  hope  that  they  may  do 
good.'and  therein  lies  again  the  art  of  medicine.  We 
are  beginning  to  see  why  mercury  is  valuable  in 
syphilis  and  why  quinine  cures  malaria  :  we  know 
that  hydrochloric  acid  cannot  be  displaced  in  the 
cure  of  disorders  of  digestion,  but  none  of  us  can 
tell  how  and  why  the.  iodides  act  or  why  colchicum 
is  good  for  gout. 

"Why  do  you  use  belladonna  in  whooping  cough?" 
asked  a  pathologist  of  a  clinician  recently.  'Tt  can 
do  no  possible  good ;  it  does  not  modify  the  infec- 
tion." The  answer  was  from  him  skilled  in  paedi- 
atrics :  "Because  it  diminishes  the  number  of  par- 
oxysms ;  being  an  antispasmodic  it  diminishes  the 


violence  of  the  outbursts,  and  somehow  makes  them 
more  comfortable."  I  have  heard  that  a  paroxysm  is 
caused  by  the  passage  of  a  ball  of  mucus  up  the 
trachea,  and  belladonna,  by  its  action  on  the  mucous 
membranes,  diminishes  the  secretion  of  mucus.  It  is 
therefore  useful  in  two  ways. 

It  is  well  also  to  treat  the  patient  as  well  as  the 
disease. 

We  are  always  open  to  the  accusation  of  using 
too  many  drugs.  Apart  from  the  value  of  quinine 
in  malaria  and  as  an  oxytoxic  agent  in  labor,  it  really 
has  very  little  place  in  the  treatment  of  disease,  and 
yet  tons  upon  tons  are  prescribed  and  ingested  year 
after  year  with  the  idea  that  it  does  some  good 
and  in  some  way.  The  largest  private  fortunes 
in  Philadelphia  are  largely  based  upon  the  useless 
employment  of  this  medicine  in  typhoid  fever  dur- 
ing the  civil  war. 

At  the  entrance  of  Xarragansett  Bay  there  is  in 
one  of  the  forts  a  mortar  pit  containing  twelve  ten 
inch  mortars,  each  capable  of  hurling  shells  over  a 
parabolic  course  until  they  fall  into  the  sea  from  an 
immense  height  at  least  five  miles  from  the  battery. 
The  whole  sea  for  miles  beyond  the  ba}-  is  marked  out 
in  squares,  and  when  an  enemy's  ship  enters  into  one 
of  these  squares  a  man  at  a  range  finder  at  once  no- 
tifies the  gunners,  and  instantly  the  whole  company 
of  mortars  hurl  shells  upon  that  square,  with  the 
hope,  and  a  very  good  one,  that  one  of  the  bombs 
will  strike  the  ship  and  sink  it.  There  are  not  a  few 
among  us  who  on  occasion,  especially  wdien  the  di- 
agnosis is  not  clear,  will  discharge  a  whole  battery 
of  drugs  on  the  body,  killing  not  only  the  enemy,  but 
disabling  the  kidneys,  the  ears,  the  stomach,  and  per- 
haps the  brain.  Only  lately  did  there  come  to  my 
notice  a  man  with  a  toxic  nephritis  caused  by  salol 
recklessly  given  for  a  long  time  for  flatus.  It  is 
most  commendable  to  hear  men  say  that  they  treated 
a  pneumonia  case  with  nothing  but  good  nursing 
and  a  cathartic,  or  to  boast  of  fifty  typhoid  patients 
who  got  well  on  cold  water  and  no  medicine. 

He  has  common  sense  who  sees  that  a  drug  is  the 
last  thing  to  be  considered  in  managing  a  case,  who 
does  not  always  see  digitalis  indicated  before  he  ex- 
amines a  heart,  or  takes  the  blood  pressure,  who 
does  not  prescribe  calomel  for  every  odorous  infant 
stool,  who  does  not  load  his  typhoid  and  tuberculous 
cases  with  drugs  and  patent  foods.  Great  is  he  in 
his  little  world  who  has  the  calmness  and  the  thera- 
peutic humbleness  to  say :  "I  can  modify  the  course 
of  any  disease  but  little.  I  can  watch  the  various 
organs  and  functions,  help  them  out,  and  kill  the 
enemy  if  he  shows  his  head  well  above  ground  with 
an  antiseptic  or  scalpel,  but  I  am  not  going  to  at- 
tempt a  cure  where  Xature  can  do  so  much  better," 
but  who  nevertheless  believes  in  a  faithful  remedy 
and  applies  it  fearlessly  and  vigorously  when  the 
indications  are  as  clear  as  a  semaphore  light  to  an  en- 
gineer. Why  any  one  wants  to  flood  a  system  al- 
ready intoxicated  with  subtile  poisons,  the  nature  of 
which  is  unknown  to  him,  with  drugs  that  sooner  or 
later  will  degenerate  renal  epithelium.  I  do  not  un- 
derstand. The  greater  percentage  of  typhoid  fever 
patients  get  w'e!l ;  a  hundred  and  fifty-six  in  a  large 
hospital  recently  recovered  and  two  only  died.  The 
treatment  was  good  nursing,  rest,  and  w^ater.  occa- 
sionally a  little  strychnine,  morphine,  or  urotropine 


634 


PJTFIELD:  MEDICAL  MIND. 


[New  York 
Medical  Journal. 


was  g^iven,  in  contrast  to  another  series  of  cases 
quite  disastrously  bad,  where  all  patients  received 
turpentine,  with  absolute  indifference  to  the  kidneys, 
already  about  to  degenerate  with  the  typhoid  poison. 

In  many  minds  there  is  a  woful  lack  of  perspec- 
tive. To  be  able  to  look  back  on  a  case  and  to  see 
how  useless  a  certain  treatment  was,  in  the  light  of 
subsequent  events  or  of  other  cases,  to  see  how,  in 
the  forward  vistas  of  a  case,  much  more  good  rest 
and  food  are  going  to  do  than  medicines ;  to  review 
a  case  of  typhoid,  and  see  that  the  calomel  and  salol 
and  turpentine  may  have  helped  some  tympany  or 
cleared  the  tongue  a  bit,  but  to  remember  that  the 
patient  recovered  because  Nature  provided  out  of 
the  patient's  own  blood  the  agents  that  killed  the 
bacilli  and  overcame  the  bacteriaemia,  neutralized 
and  eliminated  the  toxines  and  healed  the  ulcers,  in 
spite  of  the  turpentine  and  calomel,  is  the  kind  of 
greatness  that  is  altruistic  really  in  its  sheer  hum- 
bleness. Why  inflict  a  giant  egotism  on  a  system 
supine  with  a  terrible  disease?  Again,  the  sage  of 
Cheyne  Walk  speaks  plainly  of  such  individuals: 
"Strange  enough  how  creatures  of  the  human  kind 
can  shut  their  eyes  to  the  plainest  facts,  and  by  the 
inertia  of  oblivion  and  stupidity  live  in  ease  in  the 
midst  of  wonders  and  terrors." 

The  safest  and  best  man  in  medicine  is  the  man 
who  is  humble  enough  to  follow  the  masters  of 
medicine ;  if  in  doubt  he  tries  to  manage  a  case  as 
one  of  these  masters  would.  Why  not  follow  in  the 
footsteps  of  a  man  who  has  performed  two  thousand 
autopsies,  who  has  seen  disease  before  and  after 
death,  and  who  is  able  to  prove  to  himself,  as  did 
Nothnagel,  that  his  autopsies  showed  that  he  was 
right  in  but  sixty  per  cent,  of  his  cases. 

Thanks  to  an  abundant  literature,  fine  societies, 
and  the  very  latest  and  best  methods  merely  to  be 
had  from  a  profession  that  knows  no  secret.  Again, 
Carlyle  says  of  genius  that  it  is  "the  infinite  capacity 
for  taking  infinite  pains" ;  and  this  capacity  begins 
in  most  men,  not  in  the  medical  school  or  hospital, 
not  in  the  college  or  high  school,  but  in  the  home 
and  primary.  This  is  perhaps  one  secret  of  the 
success  of  the  Germans,  the  admirable  training  of 
the  young  to  take  pains.  "The  same  viscera,  tissues, 
livers,  lights,  and  other  life  tackle  [brains]  are 
there"  {Sartor  Resartus),  and  yet  they  exceed  most 
of  the  nations  in  the  science,  at  least  of  medicine. 

The  medical  mind  acquires  knowledge  in  many 
ways,  by  intercourse  with  its  fellow  minds  in 
medicine,  and  there  are  minds  in  medicines,  and,  sad 
to  relate,  there  are  some  skulls  in  medicine  in  which 
there  never  glimmers  one  precious  little  idea,  no 
ideas  above  gain,  "no  ray,  no  hope  into  that  cave 
profound  was  ever  shed." 

How  illuminating  it  is  to  sit  in  a  consulting  room, 
with  some  master  mind  in  medicine,  some  great 
worker  and  thinker,  and  discuss  the  case  under  con- 
sideration and  other  cases,  and  the  ideas  and  the 
ways  of  thinking  and  the  methods  of  arriving  at 
conclusions;  it  is  not  only  cold,  glittering,  precious 
facts,  methods,  and  treatments,  but  ways  of  think- 
ing and  the  approaching  of  the  problems. 

Large  cities,  with  their  clubs,  societies,  and  hos- 
pitals, where  men  meet,  offer  many  splendid  oppor- 
tunities to  him  who  would  merely  listen  to  the 
brilliant  talk  over  the  coft"ee  and  cigars,  perhaps, 
after  dinner.    This  is  what  the  solitary  practitioner 


of  the  village  misses ;  medical  association  and  fel- 
lowship, medical  comradeship,  to  be  told  that  his 
work  is  good  and  to  be  counselled  to  do  so  and  so, 
to  use  some  better  remedy  next  time,  to  have  some- 
body say,  "You  managed  that  head  beautifully  on 
the  perinseum,"  or  "Your  diagnosis  of  that  gallblad- 
der case  was  precisely  what  you  said  it  was."  Some 
friendly  shoulder  to  your  cart  wheel  stuck  fast  and 
hard  in  a  clay  road ;  some  steady,*  friendly  beacon 
over  a  troubled  sea,  marking  a  safe  course. 

Books,  of  course,  with  the  superb  mechanical  de- 
velopment, with  their  fine  engravings  and  litho- 
graphs, offer  a  splendid  source  of  information  to 
him  who  will  faithfully  use  them.  They  are,  as 
Channing  once  said,  "true  levellers."  A  friend  of 
mine  diagnosticated  a  case  of  chronic  meningitis  of 
the  cord  by  the  illustration  of  a  contracted  hand 
that  he  had  once  seen  in  Striimpell's  Practice.  By 
a  fine  colored  plate  in  Tuttle,  of  a  sentinel  pile,  I 
was  enabled  to  diagnosticate  syphilis  in  a  new  born 
infant. 

A  man  in  an  inland  city  had  treated  a  prominent 
man  in  the  community  for  years  for  heart  disease, 
when  his  real  malady  was  Graves's  disease  in  a 
typical  and  advanced  form.  When  the  correct  diag- 
nosis was  finally  made,  he  remarked  that  he  was  not 
altogether  to  blame,  because  he  had  never  seen  a 
case  of  this  disease.  The  mere  exophthalmos 
should  have  given  him  a  clue ;  any  textbook  with 
illustrations  should  have  given  him  at  least  a  hint. ' 
Even  the  advertising  prospectuses  of  books  often 
have  very  helpful  pictures.  INIedical  facts  can  some- 
times be  learned  from  the  daily  prints. 

To  see  a  master  of  obstetrics  deliver  in  a  difficult 
case,  to  see  a  neurologist  make  it  clear  that  a  sup- 
posed melancholia  is  in  reality  paresis,  or  to  see  an 
internist  diagnosticate  gastroptosis  where  chronic  in- 
digestion was  all  that  was  suspected,  should  impress 
the  memory  tablets  of  every  man  if  the  wax  of  his 
memory  tablets  is  soft  enough  to  receive  the  stylus 
marks. 

Good  work  is  rare  in  villages  or  remote  country 
towns,  but  it  should  be,  when  recognized,  commend- 
ed according  to  the  square  of  the  distance  that  the 
hamlet  is  from  the  medical  centres.  But  the  med- 
ical press,  like  firearms,  which,  according  to  Carlyle. 
made  all  men  tall  when  they  were  introduced,  in  a 
measure  annihilates  country  roads  and  prairies. 

But  sometimes  the  great  masters  and  teachers  in 
medicine  are  a  little  at  fault.  Their  writings  deal 
with  the  typical  and  the  commonest  and  most  com- 
plete forms  of  disease.  Atypical  pneumonias,  pare- 
sis cases,  skin  diseases,  or  rare  and  curious  com- 
bination of  disease  are  rarely  described  or  pictured. 
And  it  is  often  the  master  of  medicine  alone  who 
can  recognize  these  conditions.  What  surgery  is 
there  that  tells  how  to  amputate  a  leg  or  do  a 
tracheotomy,  without  even  an  old  housewife  to  hel]). 
or  how  to  remove  an  appendix  with  cowboys  as  as- 
sistants? And  yet  such  work  is  done,  and  has  to 
be  done,  and  there  are  good  men  who  do  these 
things  in  hay  lofts  and  cottages,  with  only  a  kitchen 
stove  and  a  dishpan  to  help  out. 

Some  of  the  master  minds  of  medicine  work 
alone,  hungry  for  information  and  recognition.  The 
heroes  of  medicine  are  not  always  those  of  the  mar- 
ble amphitheatre,  with  a  corps  of  trained  assistants, 
and  with  prestige  and  training  and  experience.  The 


March  27,  iso9'1 


PITFIELD:  MEDICAL  MIND. 


635 


heroic  mind  and  character  in  medicine  is  heroic  in 
the  cottage  and  lecture  hall,  and  is  often  in  the  ranks 
of  the  man  who  has  to  know  man}'  and  divers  things 
— a  real  heroic  "Jack  of  all  trades."  just  as  it  is 
heroic  when  blazoned  with  a  title  of  "Regius  Pro- 
fessor" or  "Herr  Geheimrath  Professor  Doctor." 

The  means  of  obtaining  information  are  pain- 
fully meagre  in  some  communities ;  there  are  no 
hospitals,  no  laboratories,  no  societies,  or  Hbraries ; 
practising  alone  in  such  districts,  with  no  kindred 
mind  to  talk  with,  consult  with,  no  x  rays  to  illu- 
minate diagnosis,  no  court  of  review  to  commend 
or  condemn  good  or  bad  work,  with  often  no  com- 
peting doctors  to  keep  work  up  to  higher  stand- 
ards ;  here  the  medical  mind  deteriorates,  the 
acumen  is  dulled,  enthusiasms  fade  and  vanish. 
I\Iedicine  here  becomes  a  mere  mode  of  making  a 
living. 

Of  a  high  grade  is  that  mind  that  clothes  not  its 
communications  with  big  words,  with  the  glamour  of 
pedantry,  often  using  pompous  technical  phrases  or 
terms,  but  speaks  in  the  mother  tongue  without  the 
heavy  term.  Our  medical  vocabulary  is  outrageous- 
ly turgid  with  cumbersome  words  of  Greek  and 
Latin  roots.  How  much  simpler  and  more  beauti- 
ful would  medical  English  be  if  a  leucocyte  was 
called  a  white  cell  or  a  many  nucleated  one,  and  not 
a  polymorphonuclear  neutrophile,  seventeen  letters 
for  twenty-eight,  two  Greek  roots  for  one.  \\'e  need 
clear,  limpid  simple  English,  readable  English  that 
will  charm  the  mind,  fatigued  perhaps  with  the 
harassments  of  an  arduous  practice.  Xature  ex- 
presses herself  simply  always.  Wh)'  cannot  we  who 
try  to  interpet  her  and  record  her  workings  copy 
her?  Complex  terms  are  convenient  thought  forms 
whereby  we  make  easy  our  thinking  and  our  means 
of  intercourse.  Big  words  are  always  considered 
the  refuge  of  the  ignoramus,  and  it  is  an  art  to 
know  how  to  avoid  using  them. 

The  various  handicrafts  of  medicine,  priceless  and 
indispensable,  like  the  various  handicrafts  of  the 
metal  workers,  the  soil  workers,  the  machine  build- 
ers, can  no  more  than  thev  be  kept  locked  up.  Dull 
is  he  in  medicine  who  tries  to  obscure  or  hide  the 
secrets  of  his  craft,  whether  it  be  in  surgery,  in  the 
technique  of  hydrotherapv,  or  in  the  use  of  medi- 
cines. The  very  antennae  of  his  conscience  are 
seared  and  hard  boiled,  the  quivering  nerve  stuff 
can  no  longer  feel  his  dendrites  throb  with  good 
impulses. 

Every  man  the  captain  of  h^s  own  career  should 
be  true  not  only  to  his  own  standards,  but  to  those 
long  set  before  him  by  the  hosts  of  splendid  men 
that  have  gone  before.  If  any  man  practise  in  a 
dog  cage  of  a  village,  with  no  one  to  criticise  or  en- 
courage him.  his  guiding  lights  should  be  kept  alive 
by  constant  self  examinations  and  reprovals. 

Perhaps  some  subtile  deftness  of  hand,  some  mas- 
terlv  technique,  sheer  mechanical  ability  lifts  a  man 
above  the  fellows  of  his  craft  in  medicine.  Let  him 
not  think  that  his  work  is  akin  to  the  greatness  »f 
mind  that  creates ;  he  can  but  rarely  pass  it  on  even 
to  his  own  son.  let  alone  the  generations  yet  to  be. 
Let  him  always  keep  in  mind  von  Graefe  and  Helm- 
holtz  if  his  work  is  ear  or  eye  surgery.  Ehrlich  and 
Ramon  y  Cajal  or  Koch  if  he  works  in  laboratories ; 
theirs  is  an  illuminating  technique :  that  like  the 
ophthalmoscope  of  Helmholtz  shines  brightly  in  the 


deepest  caverns.  Technique  is  often  worshipped  too 
much ;  it  is  glittering,  showy,  and  frequently  leads 
to  dramatic  crises,  like  the  operation  of  Lorenz.  In 
the  lives  of  the  great  mass  of  medical  men  comes 
very  little  opportunity  to  do  such  work ;  perhaps  a 
man  sees  but  one  case  of  congenital  hip  dislocation 
in  a  lifetime ;  there  are  very  few  incidents  of  a 
dramatic  nature  in  his  medical  life.  All  men  love 
to  say  to  their  patients :  "  You  were  ill ;  now  you  are 
instantly  well" ;  "you  were  blind,  now  you  see" ; 
"you  were  crippled,  now  you  walk" ;  "a  purulent  ap- 
pendix threatened  you.  and  out  of  great  jeopardy  I 
have  lifted  you." 

Xot  for  a  minute  do  I  mean  charlatanism,  mere- 
ly an  intense,  wholesome  desire  to  do  something  that 
is  set  for  a  while  on  a  hill,  to  lift  a  man  suddenly  out 
of  danger,  rather  than  drag  him  for  six  weeks  out  of 
a  sweating  mire  like  rheumatism.  All  that  people 
see  in  the  latter  disease  are  the  bottles  of  medicine, 
bed  pan  and  swollen  joints,  and  if  the  patient  is 
greatly  in  danger  of  dying  and  does  get  well  after 
the  exercise  of  much  care  and  judgment  the  physi- 
cian never  gets  the  credit  that  the  surgeon  does  who 
through  some  little  button  hole  snips  out  an  appen- 
dix with  a  few  adhesions  webbed  about  it,  with  the 
ease  and  nonchalance  of  one  who  pares  his  nails. 
This  the  countryman  misses  :  honest,  fearless,  per- 
haps diligent  with  his  books,  he  fails  to  get  a  little 
sweet  recognition  that  his  work  deserves. 

A  man  who  walks  the  wards  of  hospitals  all  winter 
and  sees  perhaps  a  hundred  cases  of  typhoid  fever,  is 
much  more  to  blame  if  he  misses  the  diagnosis  of  a 
case  of  typhoid  than  he  beside  the  duck  pond  of  a 
cross  roads  village  who  never  looked  for  spots  and 
tympany,  and  who  never  heard  of  a  W^idal  or  Dia- 
zo  reaction. 

The  hardest  thing  for  a  man  in  general  practice 
to  contend  with  is  diffuseness  of  effort ;  his  mind 
cannot  run  continuously  in  one  channel  of  thought 
for  a  long  time,  a  morning's  work  and  thought  is 
about  as  diverse  and  varied  as  can  be,  and  while  in 
a  great  measure  it  is  broadening  to  see  an  obstetric 
case,  an  infant  feeding  case,  a  broken  arm,  and  a 
psychopathic  case  all  in  a  few  hours,  it  is  hard  to 
concentrate  the  attention  sufficiently  to  become  pro- 
ficient in  any  one  branch. 

We  have  narrow  men  in  our  profession,  whose 
minds  work  only  in  confined  limits  like  the  leaves  of 
a  tree  in  the  following  story.  A  Japanese  coolie  in 
walking  through  a  forest  saw  a  huge  serpent  glide 
out  of  the  bushes  and  devour  another  coolie  who 
was  passing.  The  serpent  was  bulged  out  to  very 
uncomfortable  dimensions  by  his  dinner,  but  he  be- 
gan eating  the  leaves  of  a  bush  near  by  and  soon 
it  was  apparent  that  the  leaves  were  digesting  the 
man  and  the  snake  was  g-etting  thinner.  When  the 
serpent  had  disappeared  the  native  filled  a  bag  with 
the  digesting  leaves,  and  walking  into  the  nearest 
inn,  wagered  the  proprietor  that  he  could  eat  a  pile 
of  cakes  as  high  as  his  head.  The  inn  keeper  ac- 
cepted the  wager  and  the  coolie  began  eating  cakes 
and  leaves  alternately.  By  and  by  the  inn  keeper 
on  returning  to  the  barroom  found  only  a  pile  of 
cakes  ;  the  leaves  had  digested  the  man,  and  were  in- 
capable of  digesting  anything  else.  Some  minds  are 
isolytic,  content  with  digesting  over  and  over  the 
same  mental  pabulum. 

There  are  those  among  us  who  look  with  micro- 


636 


JOHXSTOX  AXD  SCHWARTZ:  METABOLISM  ()]■  SKIN  DISEASES.  [N^w  Vork 

MelICAL  loCRN.M.. 


scopes  at  blood  cells  and  tissue  sections,  who  never 
see  oedematous  feet,  or  enlarged  lymph  glands  that 
would  make  the  diagnosis  patent  to  the  sheerest 
tyro.  Thev  are  like  the  commandant  of  a  fort,  who, 
while  at  target  practice  on  Narragansett  Bay,  nar- 
rowly escaped  hitting  a  sailboat  filled  with  people. 
His  excuse  was  that  he  was  watching  his  target  so 
closely  with  his  telescope  that  he  did  not  see  the  in- 
tervention of  the  yacht  until  after  he  had  ordered 
the  shot  fired. 

A  crank  has  been  one  who  sees  a  thing  clearly 
enough,  but  not  in  its  true  relation.  The  thyreoid 
gland,  uric  acid,  arteriosclerosis,  have  been  fitted  to 
very  many  diverse  diseases  and  ascribed  as  the  cause 
of  manv  and  even  all  obscure  pathological  entities. 
Theories,  artificial  or  evanescent  as  can  be,  toxic 
mycelia  that  bud  and  bloom  in  the  shallow,  unculti- 
vated soil  of  a  gullible  public,  to  whom  pseudo- 
science  is  a  specious  food,  from  time  to  time  are  put 
forth,  never  to  stand  a  winter  of  criticism.  Puffed 
with  the  ideas  of  some  wind  blown  pregnancy  of  a 
theory,  their  success  is  but  the  morning  sickness  of 
conceit. 

Faddists  in  medicines  are  not  born  of  science, 
and  their  lives  are  soon  cut  off  and  forgotten.  We 
have  the  dietary  faddist,  the  water  faddists,  the 
osteopathy  faddists,  the  antidrug,  the  prodrug,  the 
surgical,  the  antisurgical,  the  antieverything  fad- 
dists, antieverything  that  science  cherishes,  time  has 
hallowed,  that  sane  men,  unselfish,  and  men,  geniuses 
in  their  day,  have  evolved  and  generated  after 
years  of  study  and  toil.  These  are  they  who  believe 
narrowly,  steadfastly,  doggedly  with  all  the  fervor 
of  a  fanatical  dervish  in  their  overdeveloped  theory. 
The\-  find  favor  with'  the  public  because  their  meth- 
ods are  easy  and  perhaps  soothing.  Never  have 
they  contributed  a  thing  to  the  world's  stock  of 
learning.  Their  workshops  grind  out  only  lucre. 
Even  in  other  lines  than  medicine  they  have  never 
contributed  anything,  no  book,  no  discovery,  where 
honestv  can  be  seen  and  truly  valued.  Carlyle  once 
took  a  long  walk  with  Bronson  Alcott,  who  was  a 
faddist.  They  talked  the  whole  round  of  creation. 
Finally,  on  the  way  home  after  Carlyle  had  become 
tired,  Alcott  talked  for  an  hour  on  vegetarianism 
and  its  great  worth.  This  was  more  than  the  old 
man  could  stand.  Stopping  for  a  moment  he 
pointed  with  his  cane  and  said :  "Yon's  Piccadilly, 
it's  been  there  a  thousand  years  before  your  damned 
potatoe  doctrine  was  enunciated,  and  it  will  be  there 
a  thousand  years  after  it  is  long  dead  and  for- 
gotten." 

The  health  and  salvation  of  the  race  do  not  de- 
pend upon  whole  wheat  flour,  prolonged  chewing, 
cold  baths,  proper  clothes,  or  circumcision,  but  on 
scientific  thought,  following  correct  ideas,  gestated 
for  the  full  term,  meditated  for  years,  and  based 
upon  the  observation  of  very  "kings  of  thought." 

Medicine  needs  seers.  Those  who  can  cast  the 
horoscope,  keeping  in  mind  the  tribulations  and 
triumphs  of  the  past,  who  can  look  into  a  sparkling 
drop  of  ether  quickly  evaporating  into  vapor,  seeing 
not  sulphuric  acid  and  alcohol  merely,  but  the  whole 
atomic  theorv.  the  genesis  of  chemistry  and  biology, 
the  triumph  of  force  over  matter,  of  mind  over 
bodv,  seeing  the  beneficent  action  of  the  happy  com- 
bination of  atoms  on  the  nerve  cells  of  the  nations 


surcharged  with  pain,  and  looking  into  the  future 
and  seeing  the  final  and  total  ablation  of  paifi  and 
suffering  at  the  hands  of  medical  men,  and  point  the 
way  and  the  means. 

Not  one  atom  of  the  ether  molecule  was  ever 
thought  of,  much  less  discovered,  by  any  of  the  so- 
called  schools  of  medicine,  the  sects,  the  iconoclasts, 
the  antis,  nor  can  any  one  point  to  an  instrument  or 
a  surgical  method,  a  single  pathological  discovery, 
no  operation,  no  book  great  in  its  usefulness,  not 
even  a  single  parasite  that  afflicts  man  or  indeed  any 
way  to  prevent  illnesses,  and  say  that  any  one  of 
these  heterodox  people  discovered  it,  for  they  never 
did  and  never  will. 

Finally  this  ancient  structure  of  knowledge,  this 
cathedral  of  high  and  honest  thought,  is  dominated 
by  a  will.  If  it  was  not  it  would  be  formless,  with- 
out force,  and  strength.  The  will  to  invent  and  to 
cure,  the  will  to  discover,  the  will  to  penetrate  the 
opaque  with  marvelous  rays,  the  will  to  prevent  dis- 
ease, the  will  to  annihilate  tuberculosis,  and  all  other 
infectious  diseases.  This  is  the  medical  will.  The 
will  to  limit  its  own  labor  by  stamping  out  disease, 
the  will  to  believe  and  trust  in  its  own  strength  and 
integrity,  the  will  to  eliminate  from  its  own  self  that 
which  is  sordid,  that  which  is  not  true,  thi.-  is  the 
will  of  this  Mind. 

521 1  W'avxe  Avenue. 


STUDIES    IN    THE  METABOLISM    OF  CERTAIN 
SKIN  DISORDERS. 

By  James  C.  Johnston,  M.  D., 
New  York, 

Assistant  Professor  of  Dermatology,  Cornell  University  Medical 
College, 

and  Hans  J.  Schwaktz,  M.  D.. 
New  York, 

Clinical  Instructor  in  Dermatology,  Cornell  Universit>  Medical 
College. 

(Concluded  from  f^agc  S9<5.) 
Case  XII. — Prurigo. 

History  of  Present  Illness:  Disease  began  sixteen  years 
ago,  since  when  patient  had  never  been  entirely  tree.  It 
appeared  first  on  genitals  with  intense  burning  and  itching, 
then  small  pinhead  sized  lumps  could  be  felt  deep  in  the 
skill.  These  gradually  approached  the  surface  and  formed 
small  papules — always  itching  intensely.  Never  any  exu- 
dation. For  all  these  sixteen  years  he  had  been  subject  to 
similar  frequently  recurring  attacks.  At  times  the  whole 
body  had  been  affected,  but  the  parts  most  frequently  at- 
tacked were  the  face,  especially  the  forehead  and  nose,  all 
round  the  neck,  flexor  surfaces  of  elbow,  flanks,  and  geni- 
tals. In  the  localities  inost  frequently  affected  the  skin 
gradually  became  and  remained  considerably  thickened  and 
pigmented  and  the  small  lumps  aforementioned  could  al- 
ways be  felt  in  it.  The  itching  had  been  so  intense  that 
tlie  patient  could  not  sleep  for  nights  at  a  time.  It  was  less 
in  cold  weather,  but  was  relieved  if  patient  got  into  a  pro- 
ftise  perspiration. 

Past  History:  No  skin  eruption  except  present  disease. 
No  malaria  or  rheumatism,  no  headaches — always  in  good 
health  except  for  present  illness.  Appetite  good,  digestion 
good,  bowels  always  very  constipated.  No  alcohol,  to- 
bjicco  moderately.  Had  always  been  a  very  heavy  meat 
eater — taking  regularly  about  i^-i  pounds  twice  daily.  He 
had  a  predilection  also  for  pastry. 

Present  Condition:  Well  nourished,  mucous  membranes 
good  color,  tongue  clean,  (lener.il  lymphadenitis.  Pulse 
80,  regular,  good  volume,  tension  increased.  Examination 
of  heart,  hmgs.  liver,  spleen,  and  abdomen  negative. 

Skin:  Pinhead  to  small  pea  sized  pale  papules  to  be  seen 
on  face,  especially  forehead,  on  anterior  surface?,  elbows. 


March  2-7.  jgog.l  JOHXSTOX  AXD  SCHWARTZ:  METABOLISM  OT  SKIX  DISEASES. 


637 


and  forearms,  internal  surfaces  of  thighs,  on  scrotum  and 
penis,  and  on  sides  of  abdomen.  In  some  places  papules 
had  fused  to  make  variously  sized  plaques  markedly  in- 
durated, reddened,  and  slightly  scaly  and  pigmented. 

The  initial  lesion  was  seen  especially  on  the  flanks  as  a 
pale  vesicopapule,  pinhead  in  size. 

Blood  (May  6,  1907)  :  Haemoglobin,  105  per  cent.  Red 
blood  cells.  5.936,000,  normal  in  appearance.  White  blood 
cells,  14,000.    Parasites  none  found.    Plates,  increased. 


May  10,  1907.  Condition  same  as  before,  itching  so  in- 
tense as  to  prevent  sleep.    Continue  treatment. 

May  13,  1907.  Condition  same  as  before — encouraged  to 
eat  more  meat  as  an  experiment. 

May  17,  1907.  Distinctly  worse  since  last  visit ;  consid- 
erable new  outbreak  of  papules  on  forehead,  neck,  and 
flanks  especially.    Itching  most  intense.    (See  urine  table.) 

Treatment :  Meat  and  eggs  cut  off  entirely.  Allowed 
one  quart  of  milk  daily,  vegetables  and  fruit.  Encouraged 


c  > 
190-. 

May   10   .  2800 

May   13   2090 

May    17   1530 

INIay  28   2025 

May  31   920 

Tune  7   880 

June  II   1350 

June  14   1530 

June  iS   1080 

Tune  21   1 1  70 

Tune  25   1300 

Tune  2>   1500 

July  2   1 190 

Tu!y  8   1 160 

July   12   2100 

July    16   1720 

July   19   1 120 

July   23   1340 

July   27   1260 

July  30   1460 

Aug.  2   950 

Au?.  6   1000 

Aug.  9   1450 

.\ug.  15   1990 

Aug.  20   1880 

Aug.  28   1850 

Sept.    5   1 120 

Sept.    20   870 


■f. 

< 

■J: 

<i 

014 

acid 

0 

0 

0 

+ 

17.32 

021 

acid 

0 

0 

0 

2  1.0 

024 

acid 

0 

0 

0 

+  + 

16.79 

1. 018 

1. 021 
1.025 

I  .022 
1.023 
1.021 
1.023 

1 .024 
1.019 
1.027 
1. 015 
1. 019 

1.022 
1. 021 
1.024 
1. 018 
1.018 


1 .020 
1. 010 
1. 018 

1 .0 1 6 
1. 018 
1. 016 
1. 013 
1.025 


acid 

acid 
acid 

acid 
acid 
acid 
acid 

acid 
acid 
acid 
acid 
acid 

acid 
acid 
acid 
acid 
acid 

acid 
acid 
acid 
acid 
acid 
acid 
acid 
acid 


-t--t- 


o  — 


-1-- 


+ 


o  — 


CASE  XII 


rt  ;z  . 
't  5- 
^  ME? 

12.33 

71.2 

15.26 

72.7 

14.0 

83.4 


15.67 
82.9 

9.64 

79.6 
1  1.27 
90.2 


52i 


z  it? 


3 


1. 21 

0.31 

0.55 

2.87 

7.0 

1.8 

3.2 

16.6 

1. 21 

0.37 

0.69 

3.47 

5.8 

1.8 

3.3 

16.5 

1.02 

0.3 

0.67 

0.75 

6.1 

1.8 

4.0 

4.5 

0.69 

0.37 

0.49 

1.58 

3.7 

2.0 

2.6 

8.4 

0.47 

0.22 

0.27 

1.50 

3.9 

'9 

2.3 

12-3 

0.25 

0. 16 

•  0.58 

0.23 

2.0 

1.2 

4.6 

1.8 

13-8 

1 1.32 

0.  52 

0.57 

0.34 

1.05 

82.1 

3.8 

4.2 

2.5 

7.6 

+ 

14.13 

12.05 

0.22 

0.35 

0.80 

0.65 

85.3 

1.6 

2.6 

5.7 

4.6 

+ 

1 1.99 

to.  I  5 

0.33 

0.17 

0.56 

0.71 

84.7 

2.8 

1-5 

4.7 

6.0 

+ 

10.28 

S.62 

0.2 

0.19 

0.6 

0.61 

83-9 

2.0 

1-9 

5.9 

6.0 

1 1.63 

10.21 

0.32 

0.22 

0.54 

0.30 

87.S 

2.8 

2.0 

4-7 

2.6 

14.7 

12.49 

0.07 

0.27 

0.66 

1. 13 

S3.0 

0.5 

1-9 

4-5 

7.7 

+  + 

10.89 

0.57 

0.13 

0.58 

1.49 

+  + 

79.4 

4.2 

1 .0 

4.3 

10.9 

9.19 

7.03 

0.47 

0.18 

0.54 

0.92 

76.6 

2.0 

5-9 

10. 1 

+  + 

13.8 

12.18 

0.16 

0.24 

0.82 

0.33 

88.3 

1.2 

1.8 

6.0 

2.4 

11.89 

9.45 

C.23 

0.26 

0.76 

1. 15 

79.3 

2.0 

2.2 

6.4 

9.7 

+  + 

9.28 

7.53 

0.13 

0.19 

0.58 

0.78 

10.36 

81.2 

2.2 

6.3 

8-5 

8.49 

0.20 

0.27 

0.70 

0.51 

82.5 

2.9 

2.4 

6.8 

5.0 

10.37 

8.49 

0.42 

o.iS 

0.62 

0.62 

S1.9 

4.' 

1.8 

6.0 

6.0 

+  -r 

11.44 

8  84 

0.5 

0.26 

0.76 

1.04 

77.3 

4-4 

2.3 

6.7 

9.1 

•~  c 

1% 


X  c  S 
o  n  i- 


Few  squam- 
ous cells. 
Do. 

Do.  After 
eating  more 
meat.  New 

outbreak. 
Do.  Relapse 
beginning 
May  26. 

Relapse 
continues. 
Relapse  con- 
tinues. Tune 
9.  2  tubes 
S.T.E.  daily. 
Much  easier. 


June  23,  3 
tubes  S.  T. 
N.   P.  daily. 


Relapse  be- 
ginning July 
1 1. 
3  tubes 
S.T.E.  daily. 


Distinctly 
better. 


July  31,  3 
tubes   S.  T.- 
N.    P.  daily. 


8.56 

7.1S 

0.3 

0.19 

0.83 

O.OI 

Rest  N.  P. 

839 

3.6 

2.3 

9.7 

0.2 

5-99 

4.41 

0.21 

O.II 

0.35 

0.84 

73-7 

3.6 

2.0 

5.9 

14.1 

Relapse. 

10.96 

8.93 

0.51 

0. 16 

0.56 

0.74 

81.5 

4.7 

1.5 

5.2 

6.8 

10.4 

7.49 

0.55 

0.26 

0.6 

1.5 

.\ug.    13.  2 

72. T 

5.3 

2.5 

5.8 

14.4 

tubes  S.T.  E. 

".5 

8.62 

0.4 

0.27 

0.71 

1.5 

Improving. 

74. Q 

3-5 

2.4 

6.2 

13.0 

S.18 

6.15 

0.51 

0.28 

0.48 

0.71 

Slight 

75.3 

6.3 

3-5 

5.9 

8.8 

recurrence. 

6.5? 

4.94 

0.43 

0.12 

0.46 

0.55 

75.5 

6.6 

1.9 

7-1 

*  5 

9.8 

7.97 

0.57 

0.14 

0.49 

0.57 

81.4 

5.9 

1-5 

5.0 

5-9 

Differential  count  of  300  white  cells : 

Polynuclears   74.0  per  cent. 

Lymphocytes   13.0  per  cen.t 

Large  mononuclears    2.0  per  cent. 

Transitionals   : .  . .  8.0  per  cent. 

Eosinophiles    3.0  per  cent. 

Mast  cells    o  per  cent. 

Myelocytes    o  per  cent. 

Treatment :  Ung.  carbol.,  5  per  cent,  e.xternally.  Given 
no  internal  treatment  and  no  change  made  in  diet.  Told 
to,  bring  twenty-four  hour  specimen  of  urine. 


to  drink  much  water.  Acetate,  bicarbonate,  and  citrate  of 
potassium,  gr.  15.  four  times  daily.  Mag.  sulp.  j  ss.  every 
morning.    Sweat  baths. 

May  24.  1907.  Stated  itching  was  considerably  less, 
seemed  easier. 

!May  28,  1907.  Distinct  recrudescence,  face,  neck,  and 
head,  for  two  days.    Treatment  continued. 

May  31.  1907.  Relapse  continued,  many  papules  felt  and 
seen  in  skin.    Itching  iiitense,  so  that  sleep  was  impossible. 

June  4,  1907.  Admitted  to  Bellevue  Hospital — suffering 
intensely.    Considerable  new  outbreak  of  papules,  especially 


638 


JOHNSTON  AND  SCHWARTZ:  METABOLISM  OF  SKIN  DISEASES. 


[New  York 
Medical  Journal. 


on  face,  neck,  head,  anterior  surface  elbows,  and  flanks. 
Face,  nose,  and  cheeks  red  and  angry  looking,  skin  infil- 
trated. Itching  excruciating,  so  that  patient  spent  most  of 
day  applying  various  lotions  without,  however,  gaining  any 
material  relief.  Same  treatment  was  continued,  but  the 
milk  was  cut  down  to  one  pint  daily.  He  was  also  ordered 
sweat  bath,  needle  and  Scotch  douche  daily  for  two  hours. 


while  under  injections  patient  at  times  seemed  to  get  an 
overdose,  as  he  would  complain  shortly  afterwards  of  hav- 
ing chilly  sensations,  violent  headache,  and  pains  all  over 
body,  and  general  malaise.  This  condition  would  gradually 
subsic^e  in  the  course  of  two  to  three  days.  The  symptoms 
were  probably  due  to  toxic  byproducts  of  the  process  of 
autolysis,  employed  in  the  preparation  of  the  gland  extract. 


Date. 

Vol.  c.  c. 

u 
a. 

Reaction. 

Albumin. 

Sugar. 

Acetone 
bodies. 

Indican. 

T.  N.  grai 

Urea  N. 
grammes 
%  T.  N. 

z  2  . 
1  £Z 
*^  5 » * 

U.  A.-N. 
grammes 
%  T.  N. 

Kreatinin 
N.  granim 
%  T.  N. 

Rest— N. 
grammes 
%  T.  N. 

1907. 

1.022 

acid 

+ 

0 

0 

8.72 

6.99 

0.18 

0.12 

0.36 

1.03 

80.2 

2. 1 

1-4 

4-2 

II. 9 

CASE  XIII. 


tn  C 


Few  squam- 
ous cells. 
Albumin 
removed  in 
N  partition. 


June  9,  1907.  Itching  somewhat  less,  slept  better  last 
night.  Beginning  today  received  injection  of  two  tubes  of 
extract  of  entire  sheep  thyreoid  as  prepared  by  Dr.  Beebe 
(See  Case  XI).    Other  treatment  continued. 

From  June  9th  to  June  23d  the  same  treatment  was  kept 
up,  and  patient  improved  very  markedly.  No  new  papules 
appeared,  skin  became  less  red  and  angry  looking,  and  be- 
came more  soft  and  pliable,  and  itching  lessened  very  much. 
After  June  12th  patient  slept  practically  without  any  dis- 
comfort all  night. 

June  23,  1907.  Patient  very  much  better.  Treatment 
continued.  Beginning  today,  received  daily  injection  of 
three  tubes  of  extract  of  nucleoproteids  of  thyreoid. 

June  28th.  Complained  of  slightly  more  itching,  espe- 
cially about  forehead.  Otherwise  in  very  good  condition. 
Treatment  continued. 

July  3d.  Patient  left  hospital  in  very  good  condition — 
itching  quite  bearable  and  slept  well.  Resumed  treatment 
at  the  Cornell  Dispensary  and  same  treatment  was  contin- 
ued, except  that  he  could  take  the  sweat  baths  only  three 
to  four  times  weekly. 

July  5th  to  loth.    Kept  in  good  condition. 

July  nth.  Patient  had  distinct  new  outbreak  of  papules 
on  face,  accompanied  by  severe  itching  (See  urine  table). 

July  isth.  Relapse  of  July  nth  continued,  new  outbreak 
on  forehead,  itching  severe. 

July  i6th.  Condition  same.  Treatment  continued,  ex- 
cept that  he  was  given  daily  injections  of  extract  of  whole 
thyreoid. 

July  i8th.  Itching  continued.  New  papules  on  face. 
Continued  treatment  and  injection  daily,  but  told  patient 
to  cut  off  milk  entirely  for  some  time  and  also  to  stop  oat- 
meal, of  which  he  had  been  eating  considerably. 

September  20,  1907.  Patient  had  been  on  same  treatment 
as  regards  diet,  cathartics,  diuretics,  etc.  The  application 
of  oleum  cadini  before  taking  his  sweat  bath  had  added 
materially  to  his  comfort.  The  injections  had  been  varied 
as  indicated  on  the  chart.  On  the  whole,  the  condition  had 
tended  to  improve,  but  not  altogether  satisfactorily.  We 
had  become  doubtful  as  to  whether  the  patient  adhered  to 
the  diet  ordered  him,  though  he  maintained  that  he  did. 

From  September  20  to  November  12,  1907,  same  treat- 
ment was  kept  up  with  a  certain  amount  of  steady  improve- 
ment.   On  November  12th  the  injections  were  stopped,  and 


The  interesting  relationship  of  urine  change  to  relapse  is 
clearly  brought  out  by  the  figures  of  the  accompanying 
chart,  also  the  marked  effect  of  injections  of  thyreoid  ex- 
tract on  the  ratios  of  urea  and  rest  nitrogen.  The  latter 
IS  particularly  noticeable  in  the  relapse  beginning  July  12, 
1907.  Rest  nitrogen  figures  never  reached  during  treatment 
those  taken  before  its  institution. 

GROUP  III. 

SCALING  DISE.\SES. 

Case  XIII. — Diagnosis :  Acute  erythematous  eczema. 

Duration,  four  days.  Face,  neck,  chest,  and  arms  mark- 
edly swollen,  red,  and  itchy.  Patient  had  similar  eruption 
twice  before. 

Urine  showed  a  considerable  quantity  of  indican  and,  as 
usual  at  the  beginning  of  an  attack,  rather  high  rest  nitro- 
gen. The  percentage  of  urea  was  normal,  and  ammonia 
was  slightly  reduced  for  the  total  nitrogen  eliminated.  The 
eruption  having  been  in  existence  for  four  days,  the  urine 
undoubtedly  showed  less  change  than  it  did  twenty-four 
hours  previous  to  the  outbreak.  The  case  pursued  the  usual 
course  of  vesiculation,  weeping,  and  final  scaling. 

Case  XIV. — Acute  vesicular  eczema. 

Woman,  aged  sixty-nine.  Deeply  alcoholic.  Suffered 
from  a  variety  of  ailments,  chiefly  bronchitis,  gastroenter- 
itis, arteriosclerosis,  nephritis,  and  cystitis.  Legs  oedema- 
tons,  fluid  in  peritoneal  and  pleural  cavities.  Had  been  on 
a  reduced  diet  for  weeks,  owing  to  anorexia,  and  lost  botli 
flesh  and  strength.  The  first  urine  examination,  which 
marked  the  time  of  admission  to  the  hospital,  showed  noth- 
ing beyond  the  evidences  of  nephritis.  The  nitrogen  parti- 
tion for  the  total  excreted  showed  no  marked  deviation 
from  normal.  Indican  occurred  in  very  small  amount.  The 
second,  taken  four  weeks  later,  antedated  the  eruption  of 
a  diffuse  vesicular  eczema  of  the  trunk  by  four  days.  The 
patient  had  improved  as  a  result  of  rest  and  feeding  and 
withholding  liquor.  The  amount  of  urine  tripled,  bin  on 
account  of  a  restricted,  almost  exclusively  milk  diet  the 
total  nitrogen  had  risen  very  little.  The  uric  acid  and 
rest  nitrogen  percentages  were  rather  high  ;  ammonia  and 
kreatinin  low,  while  the  nephritis  remained  imchanged.  The 
low  kreatinin  was_  probably  due  to  diminished  endogenous 
metabolism  following  complete  rest  and  restricted  diet.  The 


Date. 

u 
u 

u 

0 

ction. 

_c 
'5 
3 

u 

tone 
ies. 

Vol 

•J7 

tn 

Ji  ° 

1907. 

t.  18, ,  ,  , 

•  •  530 

1. 017 

acid 

trace 

0 

0 

1.015 

acid 

trace 

0 

0 

c 

rz 

Z  '£,  . 
1  =2 

=  E 

a 

CD 

to 

^  ez 

■5  a~ 

y 

•3 

H 

■.Szl-s 

+ 

2.99 

2.07 

0.14 

0.13 

0.31 

69-3 

4-9 

4.6 

10.5 

+ 

404 

2.9 

0.1 1 

0.29 

0.21 

72  s 

2.9 

7-2 

S-2 

0.31 
10.5 


0.47 
11.8 


CASE  XIV. 


Casts. 


Casts. 


capsules  of  nucleoproteid  of  thyreoid  was  substituted,  gr. 
1/200,  once  daily.  This  dose  had  been  increased  gradually 
till  at  the  present  writing  (January  11,  1907)  he  was  tend- 
ing steadily  towards  improvement.    It  may  be  stated  that 


urea  percentage  was  above  the  normal  for  the  total  nitro- 
gen excreted.  The  figures  were  not  indicative  of  a  failure 
of  urea  .synthesis,  although  there  was  defective  dcsann'da- 
tion. 


March  27.  1909-]  JOHNSTON  AND  SCHWARTZ:  METABOLISM  OF  SKIN  DISEASES. 


639 


Case  XV. — Diagnosis:  Subacute  scaling  eczema;  type 
continued  through  many  successive  outbreaks. 

Girl,  aged  eight,  robust  in  appearance,  but  subject  to 
sharp  attacks  of  illness.  Disease  had  continued  for  several 
years,  rarely  showing  any  lesional  variety  other  than  scaling. 


those  cases  which  Osier  calls  erythema  multiforme  without 
exanthem,  meaning  that  the  constitutional  disturbance  fails 
to  produce  its  cutaneous  effect. 

Case  XVI. — Diagnosis :  Erythematosquamous  eczema. 

A  subacute  type  involving  extensor  surfaces  which  had 


e 

K        <       <r.      <^     ^        H       t2  tiS^    t^lz;^     K  k 


Indican. 

T.  N.  gran 

Urea  N. 
grammes 
%  T.  N. 

1 

U.  A.-N. 
grammes 
%  T.  N. 

Kreatinin 
N.  gramme 
%  T.  N. 

Rest— N. 
grammes 
%  T.  N. 

+ 

5-42 

4-79 
88.4 

0.18 

3-5 

0.04 
0.9 

0.1 
1.9 

0.27 
5-1 

+ 

7.96 

5-58 
70.2 

0.32 
4.1 

0.19 

2-4 

0.17 
2.2 

1.66 
20.9 

1907. 

April   29   260        1.030        acid        000+         5-42         4.79         0.18         0.04         o.i  0.27        Taken  before 

operation. 
Part  lost. 

May  6   900       1.012       acid        000        +         7.96         5.58         0.32         0.19         0.17         1.66        Taken  after 


CASE  XV. 


operation. 


Spots  occurred  exclusively  on  neck  and  extensor  surfaces, 
appearance  clean,  border  shading  into  the  sufrounding  skin. 
In  one  attack  a  patch  covered  the  vulva,  but  there  was  no 
suspicion  of  a  seborrheic  element.  Outdoor  life,  diet,  and 
general  measures  failed  entirely  to  prevent  relapse.  It  was 
decided  to  operate  for  adenoids  in  April,  because  of  pro- 
nounced mouth  breathing,  and  in  hope  of  increasing  oxy- 
genation. A  twenty-four  hour  specimen  of  urine  was  taken 
several  days  previously,  but  part  of  it  was  lost.  As  the 
patient  had  had  several  slight  attacks  of  pyelitis,  the  find- 
ings were  regarded  as  suspicious  of  an  impending  attack 
because  the  total  amount  was  undoubtedly  small  and  the 


liad  no  very  acute  stage.  Such  a  condition  is  accompanied 
by  no  demonstrable  urine  changes.  The  case  is  introduced 
for  comparison. 

Case  XVII. — Diagnosis:  Chronic  eczema  of  scrotum, 
perinasum,  and  thiglis. 

Man,  aged  seventy-six.  Health  fairly  good  for  age. 
Little  arterial  tension,  no  sclerosis.  Habits  always  moder- 
ate, with  regard  to  alcohol,  tea,  and  tobacco.  Bowels  ir- 
regular. Considerable  flatulence,  fairly  constant.  Oc- 
casional mild  attacks  of  indigestion. 

Skin  of  penis,  scrotum,  perin?eum,  and  thighs  extremely 
thick,  fissured,  and  excoriated.    Paroxysms  of  itching  in- 


0 

cj 

0 

Reacti 

cc 

Q 

Vol 

■z 

1 907. 
April  16.  .  . 

..  1.930 

1. 010 

acid 

<2  = 


CASE  XVI. 


a 
u 
tm 

1  E^ 

'Z. 

Sin 

2  bis? 

7-83 

6.5 

0.5 

83.1 

6.4 

0.18 
2-3 


0.24 
31 


Ci  it? 


0.37 
4.8 


Squamous 
cells. 


specific  gravity  high ;  consequently  ether  was  used  instead 
of  chloroform.  A  few  days  after  the  operation,  May  6, 
1907,  a  second  specimen  was  taken,  in  which  the  percentage 
of  urea  was  considerably  lessened  and  that  of  rest  nitrogen 
enormously  increased.  The  low  specific  gravity  was  due 
to  an  almost  fluid  diet  which  was  also  in  exhibition  at  the 
time  the  specific  gravity  rose  before  operation  to  1.030,  a 
fact  only  explainable  on  the  ground  of  an  acute  suppres- 
sion in  the  latter  instance.  An  outbreak  of  eczema  was 
confidently  expected,  but  no  new  lesions  appeared,  and  the 
child  was  practically  well  on  May  20th.  The  reason  is  dif- 
ficult to  assign,  but  these  explanations  occur  to  us :  First, 


tense,  particularly  at  night.  Recovered  entirely  from  at- 
tack, which  had  continued  a  year. 

Acute  vesicular  outbreak  occurred  in  August,  1907,  and 
continued  to  October  21st,  brought  on  and  kept  up  by  diet- 
ary indiscretions.  Patient  was  held  strictly  to  milk  diet 
after  September  19th.  The  second  specimen  was  taken  a 
week  later,  eight  weeks  from  beginning  of  attack.  It  is 
practically  normal,  with  an  increased  volume  and  dimin- 
ished urea  output,  both  results  of  diet.  In  November  of 
same  year,  there  remained  only  occasional  attacks  of  pru- 
ritus scroti.  This  is  the  only  one  of  our  series  of  cases  in 
which  kreatin  was  found.    The  normal  state  of  the  nitro- 


j^i^-  11^  ^'i^ 


Q  >         -y:         ^        <      -A     <1     c.        H       t         2;  u^s      b         Q-litt^     a  S  Jb: 

1907. 

,T"ne  7   T180       1.027       acid     trace      o         o  13-33       11.05         0.3  0.23         0.46         1.21  Kreatin 

(nuc-  82.9  2.3  1.8  3.5  9.1  found, 

les)  Cylindroids. 

Oxalate  cal. 
crystals. 
Squamous 
epithelium. 

Sept.    26   189s        1.009       acid        o         o         0         -f-         7.75         6.31         0.27         0.12         0.38         0.67         No  kreatin. 

81.4  3.5  1.5  4.9  8.7  Milk  diet. 

Acute  attack. 

CASE  XVII. 


the  excess  of  rest  nitrogen  may  have  been  stored  in  the 
body  during  the  period  of  suppression,  being  poured  out 
when  it  ended ;  second,  the  failure  of  urea  synthesis  may 
ha\  e  been  the  result  of  the  anasthetic,  and  the  specific  poi- 
son may  not  have  been  elaborated;  third,  it  may  resemble 


gen  partition,  while  the  body  of  a  man  aged  seventy-six 
was  covered  with  weeping  eczema,  forcibly  indicates 
how  little  likely  the  urine  is  to  show  evidences  of  dis- 
turbed metabolism  after  the  state  is  thoroughly  estab- 
lished. 


640 


JOHNSTO.X  J.\D  SCHIJ'ARTZ:  METABOLISM  (>;•  SKIX  DISl-l.-ISJtS. 


[New  Vokk 
Mkdical  Journ  \).. 


Case  XVIII. — Diagnosis :  Chronic  eczema  of  vulva, 
perinaeum,  and  thighs.  Woman,  aged  seventy.  At  time  of 
birth  of  last  child,  thirty  years  ago,  sustained  severe  lacera- 
tion of  cervix  and  perinaeum,  which  was  never  repaired. 
As  a  result  there  has  been  profuse  leucorrhcea,  which  caused 
no  local  irritation  until  recent  years.  Three  years  ago, 
itching  became  annoying,  and  continued  until  time  of  urine 
examination.  Bowels  were  regular,  but  flatulence  was  com- 
mon. Moderate  eater,  something  of  a  tea  drinker,  but  not 
sufferer  from  indigestion.     Skin  red,  thickened,  fissured. 


sional  morning  nausea.     No  headaches.     Bowels  regular.. 

History  of  Present  Illness:  Eruption  first  appeared  De- 
cember 4,  1906,  on  arms,  two  or  three  days  later  it  came 
out  on  legs  and  trunk.  It  first  started  as  scattered  pea 
sized  pinkish  areas  with  scanty  dry  silvery  scaling.  The 
patches  gradually  increased  and  joined  with  neighboring 
ones,  forming  on  trunk  and  thighs  extensive  areas.  Dis- 
ease was  itchy,  especially  at  night. 

Present  Condition:  F"airly  well  nourished,  mucous  mem- 
branes good  color.    Had  Riggs's  disease  in  marked  degree. 


1907. 

April  19   860 


>  -T.  ^ 

1.023  acid 


Trace  of  urobilin. 


;-6 


C.\SF,  XVIII, 


2-;  Izi 

NH3— N. 
granunes 
%  T.  N. 

U.  A.-N. 
grammes 
%  T.  N. 

5.-8 
76. 1 

0.25 
3-3 

0.21 
2.8 

0,31 

4-2 

1 .02 

13-5 


Exception  to 
rule    of  nor- 
mal  N  parti- 
tion in 
chronic  cases. 


and  lichenified  in  eczematous  area.  Under  treatment,  the 
leuchorrhnea  lessened.  jMisimderstanding  directions,  she  took 
nine  grains  of  hydrargyrum  cum  creta,  and  had  eight  to  ten 
movements  next  day.  The  eczema  absolutely  disappeared 
within  the  following  ten  days  and  has  not  recurred  after  a 
year.  It  was  not  possible  to  obtain  another  specimen  of 
urine  because  she  left  town.  The  failure  of  urea  synthesis 
is  remarkable  in  degree  in  view  of  the  long  continuance 
of  the  eczematous  process. 

Case  XIX. — Diagnosis :  Seborrheic  eczema  and  rosacea. 


Conjunctivae  have  icteroid  tint.  Heart  and  lungs  negative. 
Liver,  dulness  begins  at  sixth  rib  in  mammary  line  and 
extends  downwards  for  eight  inches,  the  edge  being  dis- 
tinctly palpable,  smooth  and  rounded.  Spleen,  dulness  be- 
gins in  ninth  intercostal  space  in  the  midaxillar}-  line,  edge 
is  felt  one  and  a  half  inches  below  costal  margin.  Skin,  a 
diffuse  pinkish  eruption  was  scattered  practically  all  over 
the  body,  but  seen  most  abundantly  on  extensor  surfaces 
of  arms,  sides  of  trunk,  anterior  and  external  surfaces  of 
thighs,  and  on  penis.    The  early  lesion  seemed  to  be  a  pink- 


«              o  d  S        a  ^      tl  ^:  o«H  .  = 

a  >  w  c;        <  X     <j     «  H  imsS  ZtB^  t>  ti^  i=i2£?     e:  k 
1907. 

May  27   1700  1. 015  acid  trace  000  6.50  5.14  0.4  0.29  0.35         0.3  Few  cells. 


CASE  XIX. 


79-1  6.2  4.5  5.4  4.; 


Male,  age  fifty-two.  Weight,  one  hundred  and  twenty- 
seven  pounds.  Teacher.  Had  an  attack  of  acute  indiges- 
tion years  ago,  from  which  recovery  has  never  been  com- 
plete. Subject  to  neuralgia  and  fits  of  depression.  Dis- 
tress came  on  immediately,  or  an  hour  after  eating.  Flat- 
ulence constant.  Tongue  coated.  Bowels  constipated. 
Liver  tender  on  deep  palpation.  Eruption  limited  to  face 
and  head.  Erythematous  areas  of  rosacea  overlaid  with 
greasy  crust — scale  of  seborrhceic  eczema  which  extends 
also  over  bald  scalp.    There  are  on  face  small  scattered 


ish  pea  sized  spot  with  rather  indefinite  margin,  very  super- 
ficial and  covered  with  scanty  dry  powdery  scales.  On 
trunk  and  thighs  were  seen  large  confluent  areas  evidently 
formed  by  the  coalescing  of  small  patches.  None  of  the 
patches  showed  any  tendency  to  central  involution. 

Treatment :  Sod.  phosphate  3ss  morning  and  evening  in 
hot  water.    Ung.  resorcin  3  per  cent,  locally.    Milk  diet. 

Blood  (December  15,  1906)  :  Hremoglobin.  97  per  cent. 
Red  blood  cells,  6,160,000,  normal,  no  plasmodia  found. 
\'Vhite  blood  cells  18,000. 


u 

c 

c 

tj 

0 

u 

.0 

> 

0 

'X 

re 

< 

re 

zc 

•7. 

1906. 

18  .  . 

, .  880 

1.022 

acid 

0 

0 

0 

2  2  ■ 

•  75 

c  c 
|S2 

2  ■ 
1  1^ 

0.66 

0.2 

0.56 

0.08 

4,6 

1-4 

3-2 

0.6 

i  ^u-^  1I2  .£=2  :^.£ 
^  <SH  .bi 


CASE  XX. 


-|--|-       14-47        12.97         0.66         0.2  0.56         0.08  Mucous- 

90.1  4.6  1.4  3.2  0.6  s(iuamous 


cells.  Rcst-\ 
douhtfni. 


areas  showing  red,  denuded  nnicous  body,  finite  distinct 
from  the  papules  of  rosacea,  possibly  seborrh(cic  also.  The 
case  was  selected  as  a  control,  sliowing  a  normal  urine  with 
no  indican  and  a  serious  disturbance  of  digestion.. 

Case  XX. — Diagnosis :  Erythrodermie  pityriasiquc  en 
plaques  dissemines. 

Past  History:  Usual  children's  diseases.  Acute  rheuma- 
tism ten  years  ago.  No  venereal  history.  Used  alcohol 
and  tobacco  to  excess.  Operated  upon  for  piles  ten 
years  ago.    Appetite  good,  digestion  good,  but  had  occa- 


Differcutial  count  of  ,^oo  cells: 


I'olynuclcars   69.0  per  cent. 

Lymphocytes   22.6  per  cent. 

Large  mononuclears    0.8  per  cent. 

Transitionals    7.6  per  cent. 

I-'osinophiles    o  per  cent. 

Mast  cells    o  per  cent. 

Myelocytes    0  per  cent. 


Patient  improved  very  slightly  tuuler  treatment  and  dis' 
a])i)(';ircfl  from  view  December  20,  1906. 


March  r 


j  ooo.  J 


HOLLMAXX:  EUCALYPTUS  IX  LEPROSY. 


641 


Case  XXI. — Diagnosis :  Inveterate  psoriasis. 

Man,  aged  forty.  Sedentary  life,  but  had  no  habits  calcu- 
lated to  injure  health.  Had  "violent  indigestion"'  for  months 
at  a  time  in  spite  of  diet  and  outdoor  life.  During  those 
periods  nothing  seemed  to  be  digested.  Distress  came  on 
immediately  after  eating.  Not  infrequently  diarrhoea  ap- 
peared within  an  hour  after  meals.  Diet  had  never  been 
properly  regulated.  Stools  quite  foul.  No  hepatic  enlarge- 
ment can  be  made  out.  This  condition  resulted  in  consid- 
erable emaciation  after  a  lapse  of  several  years,  the  patient 
not  being  able  to  set  an  exact  date. 

Psoriasis  appeared  some  tin.e  after  the  digestive  disturi)- 
ance  began.  It  had  run  its  usual  course  of  remission  and 
•exacerbation,  but  the  body  had  never  been  entirely  free  in 
the  last  five  years.  It  existed  in  the  form  of  large  patches 
on  ilie  extensor  surfaces,  back  and  scalp,  which  were  very 


sis  was  gone,  a  depigmented  area  being  left  in  its  place"  in 
each  instance.  On  September  6th  there  appeared  on  the 
burned  areas  coinciding  exactly  with  the  previous  distribu- 
tion of  the  psoriasis  determined  by  the  lighter  color  an 
acute  vesiculation  and  weeping.  No  noticeable  increase  in 
gastrointestinal  symptoms  occurred  at  the  time.  Sponta- 
neous ulceration  appeared  over  both  elbows,  resembling 
exactly  the  original  burns.  The  remainder  of  the  eczema- 
toid  eruption  disappeared  under  appropriate  treatment,  but 
the  ulcers  show  no  tendency  to  heal  at  this  writing  (De- 
cember 1st)  and  are  exquisitely  painful.  Inside  the  left 
elbow  there  was  a  persistent  spot  of  psoriasis. 

Although  this  is  an  extreme  case  and  we  are  forced  to 
grant  that  the  gastrointestinal  disorder  and  the  skin  lesion 
may  be  coincident  and  not  casually  connected,  a  reasonable 
view  would  seem  10  be  that  the  very  slight  urine  changes 


u 
"c 

c 
_o 

c 

ZJi 

z  y  . 
1  =z 

IN 

•=  =^ 

ii 

X  — 

c 

> 

■f. 

■J. 

<!. 

£ 

t2z^ 

a:  bis? 

1907. 

• 

acid 

Sq.  epith.: 
few  leuco- 
cvtes:  mucus. 

Arril  16 

.  .  1500 

1. 01  5 

0 

0 

0 

12.75 

10.27 
80.6 

0.59 
4-7 

0.25 
2.0 

0.54 

4-3 

1.03 
8.1 

April  26 

. .  1580 

1. 013 

acid 

0 

0 

0 

-r  + 

9.18 

7-45 

0.54 

0.21 

O.S3 

0.41 

Do. 

8.1S 

81.2 

5-9 

^■3 

5-8 

4-5 

April  3C  

. ..  1720 

1. 012 

acid 

0 

0 

0 

-t--r 

6.78 
83.0 

0.41 
31 

0.22 
2.8 

0.48 
5-9 

0.23 
2.9 

Do. 

May  !0  

. .  1300 

1.013 

acid 

0 

0 

0 

8.73 

6.87 

0.47 

0.22 

0.51 

0.6 

Do. 

78.6 

5-4 

2.6 

5-9 

6.9 

CASE 

XXI. 

thick,  lichenified,  and  resistant  to  treatment.  They  yielded 
practically  only  to  x  rays,  although  a  lotion  of  eugallol  and 
acetone  benefited  the  scalp  recently. 

The  first  specimen  of  urine  taken  was  before  treatment 
was  begun,  the  others  afterward.  None  of  them  showed 
any  material  change,  including  the  last,  which  was  taken 
after  severe  x  ray  burns  on  both  elbows  and  exposure  of  a 
large  part  of  the  body  to  their  influence.  Kreatinin  per- 
-centages,  an  indication  of  tissue  change  according  to  Folin, 
remained  about  the  same,  increasing  slightly  after  limita- 
tion of  proteid  intake.  For  thirty-six  hours  preceding  the 
collection  of  the  last  three  samples  the  patient  consumed 
by  weight  the  same  amounts  of  the  same  foods  in  order  to 
eliminate  error  in  this  direction  as  far  as  possible.  It  was 
very  difficult  to  increase  the  amount  of  urine,  even  when 
large  quantities  of  water  were  taken.  A  curious  feature 
was  the  comparatively  small  amount  of  indican  occurring 
with  unmistakable  intestinal  fermentation,  and  increasing 
for  a  time  after  a  marked  change  for  the  better  took  place. 

The  x  ray  burns  referred  to  occurred  early  in  May,  1907, 
on  elbows  alone,  following  usual  exposure,  but  with  a  new 
tube.    They  had  almost  healed  by  June  loth  and  the  psoria- 


EUCALYPTUS  IN  LEPROSY. 

By  H.\rrv  T.  Hollmann,  M.  D., 
Kalaupapa.  Molokai.  Hawaiian  Territory, 

Assistant   Medical   Superintendent.    Leper   Settlement,  Molokai, 
Hawaii,  etc. 

Secoxd  Publication.' 

Many  diflPerent  remedies  at  different  times  have 
been  exploited  to  cure  or  ameliorate  leprosy.  How- 
ever we  rarely  see  a  second  publication  on  their 
value,  as  continued  use  has  proved  them  to  be  of 
little  service.  It  is,  therefore,  gratifving  that  we  have 
found  a  remedy  in  eucalyptus  which  continues  to 
effect  marked  ameliorations  in  the  clinical  manifes- 
tations of  leprosy. 

The  baths  and  internal  treatment  are  given  as  de- 
scribed before,  but  I  wish  to  briefly  summarize  my 
former  statement  as  follows: 

'See  Neiii  York  Medical  Journal,  Ixxxvi,    p.  773,  October  26,  1907. 


indicate  here  as  in  other  chronic  disorders  the  accommoda- 
tion of  the  detoxicating  functions  of  the  economy  to  condi- 
tions of  stress.    The  intractability  of  the  skin  lesion  would 
seem  to  indicate  a  persistence  of  causative  disturbance. 
References. 

1.  British  Medical  Journal,  ii,  839,  1906. 

2.  Ewing  and  W  olfe.  American  Journal  of  the  Medical 
Sciences,  cxxxi,  751,  1906. 

Folin.    American   Journal  of  Physiology,   xiii,  84, 

1905- 

4.  Folin.  Zeilschrift  fiir  physiologische  Cliemie,  xxxii, 
504,  1901:  xxxvi,  333..  1902. 

5.  Folin.  Zeitschrift  fiir  physiologische  Chemie,  xxxviii, 
i6i,  1902. 

6.  Folin  and  Shaffer.  Zeitschrift  fiir  physiologische 
Chemie,  xxxii.  552,  1901. 

7.  Folin.  Zeitschrift  fiir  physiologische  Chemie,  xli, 
223.  IQ04. 

8.  Hofmeister.  Archiz-  fiir  experimentelle  Pathologie 
iiud  Pharmalogie,  xxxvii.  426,  1886. 

9.  Engmann.  Jcurnal  of  Cutaneous  Diseases,  xxi,  216. 
1906. 


THE  COMPOUND  EUCALYPTUS  TRE.\TMENT. 

For  medicated  baths. 

Formula :  Take  of  thoroughly  cut  eucalyptus 
leaves.  54  lb;  of  Ohia  leaves  (mountain  apple — Jam- 
bos  malacccnsis).  %  lb.;  ground  haematoxylon 
bark,  and  ground  hemlock  bark,  each  i  ounce.  This 
is  tied  in  a  small  muslin  bag. 

Directions. — To  make  bath,  place  bag  in  5  gallons 
of  water  boil  for  one  hour,  of  this  take  2^  gallons 
and  add  to  the  daily  bath. 

EUCALYPTUS  DISTILLATE  TRE.A.TMENT. 

For  internal  use. 
Take  eucalyptus  leaves,  cut  up  thoroughly  and 
place  in  still,  cover  with  water,  and  place  on  fire. 
From  a  5  gallon  still  we  get  3  gallons  of  distilled 
eucalyptus. 

Directions  for  using  this  distillate. — Take  tea- 
spoonful  in  a  glass  of  sweetened  water  three  times  a 


642 


LE  ROY:  EPITHELIAL  CELLS  OF  SKIN  AND  KIDNEYS. 


[New  V'oiiic 
Medical  Journm.. 


day.  Gradually  increase  the  dose  until  the  patient  is 
taking  a  tablespoonful,  three  times  a  day. 

Results  obtained  after  two  years'  continued  use 
of  the  bath  and  internal  administration  of  euca- 
lyptus : 

1.  The  glands  of  the  skin  are  stimulated.  The 
skin  now  presents  a  much  clearer,  cleaner,  brighter, 
healthier  appearance. 

2.  It  softens  the  thickened,  indurated  skin  and 
underlying  integument.  The  skin  becomes  softer 
and  more  pliable.  '"Leonine"  facies  becomes  less 
marked.  The  two  cases,  one  reported  by  Dr.  Good- 
hue, and  the  other  by  me,  as  showing  marked  im- 
provement are  now  not  the  exception,  but  many 
more  lepers  show  this  decided  improvement. 

3.  Marked  improvement  in  leprous  neuritic  pains. 
This  pain  is  most  intractable  to  remedial  agents,  but 
under  baths  and  internal  eucalyptus  many  are  re- 
lieved to  a  great  extent.  The  numbness  of  the 
hands  land  feet,  (a  feeling  as  if  the  parts  were 
asleep)  becomes  less  marked  in  many  cases.  It  also 
relieves  the  coldness  of  these  parts. 

4.  Itch,  leprous  as  well  as  parasitic,  is  cured. 
Formerly  there  was  an  almost  constant  prevalence 
of  one  or  the  other  variety  of  itch.  To  those  who 
use  this  treatment,  itch  has  become  a  rare  disease 
or  symptom. 

5.  Many  cases  of  leprous  excoriations,  ulcera- 
tions, erosions,  and  abrasions  of  the  skin  and  mucous 
membranes  are  healed.  The  sores  of  whatever  va- 
riety except  where  the  bone  is  affected  are  stimu- 
lated, old  scabs  and  crusts  are  thrown  off,  and 
healthy  granulations  appear,  and  finally  healthv 
rosy  skin  covers  it  over. 

6.  Swollen  head  fever,  first  described  by  Dr. 
Goodhue  in  a  previous  report,  has  ceased  to  assume 
epidemic  proportions,  and  has,  in  fact,  largely  dis- 
appeared. There  have  been  no  attacks  in  those 
using  baths,  etc. 

7.  Leprous  fever,  produced  by  exacerbation  of 
the  disease,  or  perhaps  by  fresh  invasion  of  the 
germ  has  shown  a  decided  decrease  in  the  number 
of  patients.  Many  have  not  had  an  attack  since 
starting  treatment  two  years  ago. 

We  have  to  modify  our  previous  statement  that 
it  would  overcome  partially  contractured  fingers. 
It  has  not  permanently  done  so.  It  will  only  relieve 
the  stiffness  in  the  hands  and  fingers  of  those,  whose 
hands  and  fingers  were  stiff  from  leprous  hyper- 
trophic changes,  and  this  only  when  treatment  is 
continued  regularly. 

Furthermore,  we  cannot  substantiate  the  previous 
assertion  that  it  will  cause  leprous  tubercles  to  dis- 
appear. 

During  two  years  we  have  had  275  patients,  who 
have  taken  the  baths  more  or  less  continuously,  and 
have  taken  eucalyptus  internally  in  some  form  either 
distillate  or  the  oil,  with  strychnine.  Those  patients 
who  show  the  most  marked  improvement  have  fol- 
lowed the  bath  bv  an  inunction  of  a  salve  composed 
of: 

R    Oil  of  eucalyptus, 

Oil  of  chauimoogra,  equal  parts. 

M. 

Among  those  who  have  regularly  taken  the  baths, 
and  internally  eucalyptus  and  strychnine,  the  death 


rate  has  been  less  than  five  per  cent,  and  less  than 
two  per  cent,  due  to  leprosy. 

Eucalyptus  was  first  mentioned  in  connection 
with  leprosy  by  Dr.  Goodhue  in  the  Hazvaiian  Terri- 
tory Board  of  Health  Report  for  1903,  and  again 
in  the  Report  for  1907  and  190S,  while  I  read  a 
paper  on  it  before  the  Hawaiian  Territory  Medical 
Society  in  1906. 

We  do  not  assert  that  eucalyptus  is  a  cure  for 
leprosy,  for  we  have  not  cured  a  patient  with  it  so 
far,  nevertheless  we  feel  that  if  we  had  cases  in  the 
incipient  stage  of  the  disease,  ive  could  cure  the 
patients.  Every  one  of  our  275  patients  who  has 
been  improved,  has  had  the  disease  from  five  to 
twenty  vears. 


THE  SYMBIOTIC  ACTION  OF  THE  EPITHELIAL 
CELLS  OF  THE  SKIN  ON  THE  CELLS  OF 
THE  EPITHELIUM   OF  THE  KID- 
NEYS, WITH  CLINICAL  STUDY. 

By  Bernard  R.  Le  Roy,  M.  D., 
Athens,  Ohio. 

That  there  exists  a  peculiar  sympathetic  action, 
controlled  by  the  nervous  system,  between  the  cell 
action  of  the  skin  and  the  action  of  the  cells  of  ex- 
cretion in  the  kidneys,  is  well  known,  but  that  there 
also  exists  a  well  defined  action  between  the  cells 
of  the  integument  and  the  cells  of  the  kidneys, 
based  upon  the  results  of  a  physicochemical  action 
within  the  cells  of  the  skin,  is  but  little  known  or 
understood  by  even  the  more  advanced  members  of 
our  profession,  and  because  of  this  dearth  of  knowl- 
edge of  certain  physiological  laws,  the  writer 
wishes  to  present  the  following  observed  facts  with 
clinical  studies  of  the  same,  believing  that  if  this 
peculiar  action  was  more  fully  understood  it  would 
soon  prove  to  be  a  most  valuable  adjunct  in  clinical 
medicine. 

It  was  while  the  writer  was  making  his  earlier 
studies  of  the  epilepsies,  and  while  studying  the  ef- 
fects on  the  course  of  the  disease — of  an  earnest 
endeavor  to  render  and  to  keep  the  body  of  the  pa- 
tient, within  as  well  as  without,  as  nearl}-  surgically 
clean  as  it  was  possible — that  he  first  observed  the 
facts  given  below. 

Case  I. — The  first  case  was  a  youth  of  fourteen  years, 
epileptic  from  early  infancy,  had  been  petted  and  spoiled, 
overfed,  and  weighed  190  lbs.  He  was  cleansed,  carefully, 
within  and  without,  and  an  honest  endeavor  was  made  to 
keep  him  clean.  To  better  obtain  this  condition  we  were 
in  the  habit  of  making  use  of  an  acid  wash,  which  was 
carefully  used  externally  from  the  crown  of  his  head  to 
his  toes,  after  each  bath,  where  the  brush  and  soft  soap 
had  been  used  freely  and  vigorously:  it  was  also  my  habit 
to  make  daily  examinations  of  the  urine  and  of  the  saliva; 
an  examination  of  the  urine  made  previous  to  the  bath 
showed  strong  acidity,  but,  for  some  reason,  now  forgotten, 
a  specimen  of  his  urine  was  examined  \ery  soon  after  tlie 
batli  had  been  given  and  it  was  found  to  be  decidedly  al- 
kaline in  reaction.  Now,  why  this  sudden  change  in  the 
chemical  nature  of  this  secretion?  I  admit  that  I  did  not 
know,  but,  repeated  the  same  routine  day  after  day  in 
giving  the  baths,  and  the  same  results  in  the  reaction  of 
the  urine  was  noted  throughout  the  time  of  treatment. 
Many  other  resulting  effects  were  noted.  The  most  pro- 
nounced change  was  the  loss  in  bodily  weight  and  in  the 
disappearance  of  the  obesity,  the  boy  lost  that  barrellike 
shaped  abdomen  an.d  took  on  the  more  natural  form  of  a 
lad  of  his  own  age. 


March  27.  1909.] 


UUK  READERS'  DISCUSSIOXS. 


643 


After  about  three  months  of  .such  treatment,  the  epi- 
lepsy had  been  so  modified  that  he  was  having  only  three 
or  four  fits  a  month,  and  the  attacks  were  of  a  very  mild 
character,  where  before,  he  would  have  from  four,  to 
eighteen,  or  twenty  fits  each  day,  and  many  of  them, 
would  be  exceedingly  severe ;  his  mind  cleared  up  in  a 
way  that  was  very  pleasing.  This  boy  had  retrograded 
into  almost  a  moral  degenerate,  and  as  he  underwent  the 
treatment  his  mind  became  clearer  and  free  from  the  de- 
based thoughts,  taking  on  a  more  higher  moral  tone,  he 
often  told  me  that  he  was  conscious  of  the  demoralizing 
habits  but  that  he  "could  not  help  it."  Suffice  it  to  say 
that  this  boy  after  some  months  of  treatment  was  not  the 
same  natured  boy  that  he  had  been  before  he  was  given 
the  treatment. 

Xow,  it  was  thought  expedient  to  test  this 
new  action  where  an  acid  fluid  applied  to  the  sur- 
face of  the  body  would  cause  the  reaction  of  the 
urine  to  change,  if  it  was  acid  at  the  time,  to  be- 
come more  or  less  alkahne  in  reaction ;  it  was  soon 
demonstrated  that  this  was  a  fixed  fact,  and  also 
that  when  the  urine  was  alkahne  in  reaction  and 
an  alkahne  solution  used  after  the  bath,  that  the 
urine  would  change  over  to  an  acid  reaction,  but 
not  so  pronouncedly  as  when  the  acid  wash  was 
used,  that  is  the  reaction  would  be  more  pro- 
nounced after  the  acid  bath,  than  it  would  be  after 
the  use  of  the  alkahne  wa.sh. 

Because  of  the  reducing  power  on  the  obesity  of 
the  case  mentioned,  this  form  of  treatment  was 
made  use  of  in  a  case  of  ordinary  obesity,  testing 
the  reaction  of  the  urine  before  and  after  each 
bath,  and  regulating  the  reaction  of  the  "wash 
down"  accordingly,  and  in  this  manner  the  patient 
was  made  to  lose  rapidly  in  weight  and  to  take  on 
a  more  natural  form,  which  was  exceedingly  grati- 
fying to  the  one  experimented  upon. 

This  form  of  treatnient  was  given  a  number  of 
times,  and  in  each  case  it  produced  the  same  results, 
it  was  made  use  of  in  many  forms  of  diseased  con- 
ditions and  has  never  failed  to  produce  the  same 
change  in  the  reaction  of  the  urine  as  described  be- 
fore ;  to  illustrate  again  : 

Case  II. — 'SI.  M.,  aged  fifty-two,  last  stages  of  compli- 
cated chronic  nephritis,  had  been  sick  for  many  months, 
had  all  kinds  of  treatment,  yet.  he  steadily  filled  up  until 
he  measured  fifty-two  inches  around  the  waist,  medicines 
seemed  to  have  lost  their  power  to  act  upon  his  vital  or- 
,gans,  and  he  was  in  great  danger.  He  was  given  small 
hut  repeated  doses  of  the  old  fashioned  compound  jalap 
powder  with  no  effect  whatever,  on  the  eight  day  in  addi- 
tion to  the  powder  he  was  given  the  bath  as  described 
before  with  the  acid  "wash  down."  his  urine  being  highly 
acid;  and  within  twelve  hours  his  urine  increased  from  a 
teacupful  to  forty-two  ounces,  and  his  bowels  became  so 
loose  that  we  were  forced  to  modify  our  treatment  to  pre- 
vent exhausting  the  patient.  He  lost  eleven  inches  waist 
measure  in  ten  days. 

It  was  also  tried  in  more  ordinary  forms  of  com- 
plaints and  always  with  the  same  result,  whenever 
the  urine  was  acid  and  an  alkaline  urine  would  be 
of  advantage  the  "acid  wash"  was  made  use  of  with 
the  most  gratifying  results.  In  the  few  diseased 
conditions  where  we  are  troubled  with  alkaline 
urine,  and  it  is  desired  to  have  an  acid  urine,  the 
use  of  the  alkaline  bath  as  described  before  will  be 
a  wonderful  help  to  any  form  of  treatment.  Nor  is 
this  all,  even  in  health  will  this  reaction  be  noticed, 
if  followed  out  in  due  form,  with  the  same  changes 
noted  before,  and  may  be  tried  out  by  the  reader 
without  fearing  the  least  harm,  providing  that  he 
does  not  carry  it  to  too  great  a  length. 


The  acid  made  use  of  in  these  cases  was  the  bet- 
ter grade  of  sulphuric  acid  found  on  the  inarket, 
this  was  diluted  in  water  until  the  resulting  solu- 
tion was  of  suitable  strength  to  suit  the  individual 
case,  care  being  taken  not  to  have  the  percentage 
of  acid  so  great  as  to  cause  too  much  smarting,  but 
not  using  less  than  a  three  per  cent,  solution,  the 
primary  idea  was  to  kill  the  spore  bearing  micro- 
organisms found  on  the  body.  I  never  rinse 
off  the  patient  with  water  after  the  acid  bath,  but 
permit  him  to  enjoy  the  stimulating  effect  of  the 
acid,  for  it  is  the  chemical  action  which  goes  on 
within  the  cells  of  the  epidermis  that  produce 
changed  substances  which  are  soluble  in  the  body 
fluids  and  enter  the  circulation,  and  thus  reach  the 
kidney  cells  and  stimulate  them  into  new  form  of 
action ;  or  creates  the  substance  that  produces  the 
normal  action  in  these  eliminating  cells.  As  has 
been  said  before  nothing  much  is  known  of  this  cell 
power,  and  the  writer  has  never  seen  anything  in 
print  touching  upon  this  power  of  the  epidermal 
cells. 

There  were  changes  noticed  in  other  fluids  of  the 
body,  but  these  changes  are  being  studied,  the 
changes  being  more  delicate  in  reaction  and  much 
more  difficult  of  interpretation. 

 «>  — 

^ux  %td.hxs'  f  iscttssions. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  folloxt's: 

LXXXIV . — Hoiv  do  y  ou  use  alcohol  therapeutically? 
(Closed  March  jj,  7909.) 

LXXXV. — Apart  from  an  operation,  how  do  you  treat 
disease  of  the  vermiform  appendix?  {Answers  due  not 
later  than  April  jj.  7909.) 

LXXXV  I. — HolV  do  you  make  an  early  diagnosis  of  pul- 
monary tuberculous  disease.  (Ansn'crs  due  not  later  than 
May  75.  7909.) 

Whoever  anszcers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  azvard  zcill  be  based  solely 
on  the  value  of  the  substance  of  the  anszcer.  It  is  requested 
(but  not  required)  that  the  anszvers  be  short;  if  practica- 
ble no  one  anszver  to  contain  more  than  si.v  hundred 
zvords. 

All  persons  zi'ill  be  entitled  to  compete  for  the  prize, 
zvhether  subscribers  or  not.  This  prize  will  not  be  azvarded 
to  any  one  person  more  than  once  with  one  year.  Every 
anszi'er  must  be  accompanied  by  the  zvriter's  full  name  and 
address,  both  of  which  Zi'e  must  be  at  liberty  to  publish. 
All  papers  contributed  became  the  property  of  the  Journal. 
Our  re.vders  aue  .^sked  to  suggest  topics  for  discussion. 

The  prize  of  $2_^  for  the  best  essay  submitted  in  answer 
to  question  LXXXIII  has  been  azvarded  to  Dr.  Adrian  A. 
Landry,  of  Piaouemine.  La.,  ivhose  article  appears  below. 


PRIZE  QUESTION  LXXXIII. 
THE  TREATMENT  OF  ACUTE  DYSENTERY. 
By  Adrian  A.  Landry,  M.  D., 
Piaquemine,  La. 

By  acute  dysentery  we  mean  an  inflammation  of 
ten  to  fifteen  days'  duration,  located  in  the  lower 
bowel,  the  inflammatory  changes  involving  the  mu- 
cous membrane,  the  tubular  and  solitarv  glands, 
characterized  by  a  preliminary  diarrhoea,  fever,  pain 


644 


ULli  READlUiS'  DISCUSSIOXS. 


[New  Vokk 
Medical  Journal. 


in  abdomen,  slight  at  first,  later  colicky  and  grip- 
ing in  character,  with  frequent, small,  bloody,  mucous 
stools,  accompanied  by  tormina  and  tenesmus,  the 
astiological  factor  being  an  infection  from  a  bacillus. 
The  question  whether  the  disease  is  caused  only  bv 
the  Bacillus  dysenterice  discovered  by  Shiga  in  1838 
will  not  be  discussed  now. 

The  treatment  of  the  disease  consists  in  measures 
toward  the  relief  of  the  inflammation,  elimination  of 
causative  agency,  and  in  prolonged  cases,  sup- 
portive. 

Absolute  rest  in  bed  is  imperative.  I  insist  upon 
the  use  of  the  bed  pan.  The  diet  should  be  easily 
digestible,  bland,  and  nonirritating^  Broths,  gruels, 
and  milk  diluted  with  an  alkaline  water  or  pepton- 
ized are  indicated.  If  milk  disagrees  as  evidenced 
by  the  presence  of  curds  in  stools  it  is  eliminated 
from  the  diet.  Alcohol  is  used  only  when  absolutely 
indicated  in  cases  of  long  duration.  Cold  water  or 
preferably  crushed  ice  is  used  ad  libitum  if  it  occa- 
sions no  nausea.  Tea  and  coffee  are  allowed  to  those 
accustomed  to  their  use. 

Of  medicinal  agents  I  consider  the  salines,  mag- 
nesium or  sodium  sulphate,  the  magnesium  prefer- 
ably, as  particularly  efificient ;  especially  so  in  the 
early  stages  of  the  disease.  In  the  light  of  our  pres- 
ent knowledge  of  the  pathology  of  the  disease,  they 
come  nearer  meeting  all  indications  than  any  other 
drug,  their  hydragogue  action  producing  large  wa- 
tery evacuations  without  intestinal  irritation,  deplet- 
ing the  local  vascular  system  and  eliminating  the 
causative  factor,  the  bacilli. 

For  the  pain,  tormina,  and  tenesmus  I  have  no 
hesitancy  in  using  opium  in  the  form  of  the  deodor- 
ized tincture.  The  objection  to  opivmi,  that  it  locks 
up  secretions  and  excretions  and  the  elimination  of 
the  poisons,  is  negligible  in  view  of  the  action  of  the 
salines.  I  always  add  the  aromatic  sulphuric  acid 
for  its  astringent  action  upon  the  intestines. 

The  following  combination  is  the  one  used : 

R     Magnes.  sulpiiatis  5xi! ; 

,  Tinct.  opii.  deodor.. 

!  Acid  sulpliur.  .'ironiat  aa  5i ; 

Aquae  nieiitli.  pip.,  q.  s.,   ad.  3iv. 

M.  et  sig. :  One  tablespoonful  in  water  every  two  lioL'.r« 
until  stools  are  free  and  watery,  then  less  often. 

This  combination  with  rest  in  bed  and  diet  I  have 
found  to  seldom  fail  in  the  early  stages  of  the  dis- 
ease. Even  when  the  case  is  seen  late  after  ulcera- 
tion has  set  in,  as  evidenced  by  the  foul  stnelling 
stools  of  blood,  pus,  and  gangrenous  shreds  of  in- 
testinal mucous  lining,  marked  benefit  is  at  once  no- 
ticed from  its  use.  It  produces  free  watery  evacua- 
tions, relieves  pain  and  straining,  and  the  frequent 
desire  to  evacuate,  diminishes  congestion,  clears  out 
the  lower  bowel  of  the  poisons  and  decomposing  ex- 
foliations of  the  ulcerated  surfaces,  and  establishes 
a  condition  favorable  to  healing.  It  is  continued, 
diminishing  the  frequency  of  the  dose,  until  the 
stools  present  a  distinctly  faecal  character. 

In  the  event  of  the  failure  of  the  magnesium  mix- 
ture ipecac  is  the  next  drug  upon  which  I  rely.  If 
there  is  no  nausea,  a  single  dose  of  forty  to  sixty 
grains  a  day,  one  half  hour  after  a  twenty  drop  dose 
of  laudanum  and  the  application  of  a  mustard  plas- 
ter to  the  pit  of  the  stomach,  is  the  best  method  of 
administration.  This  is  repeated  for  three  or  four 
days,  after  which  time  a  f;ecal  character  may  be  de- 


tected in  the  stools.  The  action  of  ipecac  is  not 
clearly  understood.  It  is  supposed  to  exert  a  spe- 
cial action  on  the  intestinal  glands  and  liver,  stimu- 
lating the  secretion  and  flow  of  bile.  Bile  as  an 
antiseptic  may  exert  a  beneficial  action  upon  the  in- 
flamed and  ulcerated  lower  bowel.  Suffice  it  to  say 
that  tarry  and  bilious  stools  are  significant  of  im- 
provement. In  cases  of  nausea  where  a  single  large 
dose  cannot  be  retained  I  administer  small  and  re- 
peated doses,  one  to  five  grains  combined  with  pow- 
dered opium  every  four  hours.  This  method  is 
slower  and  less  efficient  than  the  single  dose. 

Enemata  of  starch,  silver  nitrate,  etc.,  solutions 
have  no  place  in  the  treatment  of  the  acute  disease, 
as  they  tend  to  increase  the  irritation.  Colonic 
flushing  with  normal  saline  solution  might  be  of 
some  help,  but  I  have  never  used  it,  having  as  a  rule 
obtained  the  desired  result  from  the  magnesium  sul- 
phate mixture. 

The  astringents  and  antiseptics,  bismuth,  salol, 
beta  naphthol,  etc,  I  have  little  occasion  to  use.  They 
are  indicated  after  the  use  of  the  salines  or  ipecac 
when  the  stools  have  a  faecal  character,  but  are  loose 
and  frequent  for  an  undue  length  of  time.  Other- 
wise I  seldom  use  them. 

In  the  acute  dysentery  of  young  children  calomel 
and  ipecac  compound  powder  in  small  doses  has 
proved  the  best  treatment  in  my  experience.  Milk, 
whether  breast  or  bottle,  is  stopped  until  the  charac- 
ter of  the  stools  changes,  to  be  tentatively  resumed, 
well  diluted  or  peptonized.  When  the  bowels  are 
loose  of  normal  color  with  no  straining  for  an  un- 
due length  of  time,  bismuth  subnitrate  in  ten  to 
twenty  grain  doses  is  given.  At  and  after  the  age  of 
five  I  do  not  hesitate  to  use  the  magnesium  sulphate 
mixture  in  appropriate  doses  in  preference  to  the 
calomel. 

As  to  prophylactic  treatment,  we  must  bear  in 
mind  that  the  disease  is  transmissible  in  like  man- 
ner to  typhoid  fever.  The  source  of  infection 
should  be  ascertained  and  removed.  Isolation  of  pa- 
tient, disinfection  of  stools  and  everything  that 
comes  in  contact  with  the  bedding  or  patient,  with 
as  absolute  cleanliness  as  possible  are  means  to  be 
instituted  at  the  very  incipiency  of  the  disease. 

Dr.  F.  J.  Riiiiyoii,  of  Clarksville,  Tenn.,  says: 

If  man  was  a  mere 'mechanical  machine  the  treat- 
ment of  his  ailments  would  be  greatly  simplified. 
As  it  is,  the  individuality  of  each  patient  must  be 
considered.  In  the  treatment  of  few  diseases  when 
severe  is  there  a  greater  call  for  discriminating  judg- 
ment. \Miile  the  average  case  untreated  will  term- 
inate spontaneously  about  the  eighth  day,  the  un- 
wise use  of  astringents  or  opiates  will, often  prolong 
these  cases;  the  severer  cases  are  not  self  limited 
and  require  careful  and  judicious  management. 

The  indications  to  be  met  according  to  the  se- 
verity of  the  case,  are:  i,  Elimination ;  2,  cleansing 
and  healing  injections  and  applications ;  3,  general 
measures — including  rest;  4,  internal  measures  in- 
cluding food. 

These  indications  merge  one  into  the  other  and 
so  are  not  sharply  defined.  Considering  these  meas- 
ures more  in  detail  1  adopt  the  following  plan :  The 
patient  should  be  put  to  bed  at  once  in  a  cool,  airy, 
comfortable  room  and  have  as  complete  mental  and 


iVlsrcii  -'7,  1909.] 


OUK  READERS'  DISCUSSIONS. 


045 


physical  rest  as  possible,  rising  even  for  stool  being- 
prohibited  during  the  acuteness  of  the  severer  cases. 

1.  The  whole  alimentary  tract  should  be  emptied 
with  castor  oil  (oSs)  or  salts  (gss),  Epsom  or  Ro- 
chelle.  This  removes  irritating  and  fermentating 
material,  the  pabulum  of  germs,  and  tends  to  deplete 
and  soothe  inflamed  parts. 

2.  As  enema  I  use  warm  normal  salt  solution,  and 
as  a  rule  give  it  low.  Have  the  patient  lie  either 
upon  the  back  or  left  side,  hips  elevated,  and  inject 
rci-y  slozdy  as  much  as  the  patient  can  stand  with- 
out causing  much  pain,  and  then  allow  the  injection 
to  be  immediately  returned.  This  is  in  rare  cases 
best  given  high,  and  in  either  case  may  be  preceded, 
if  tenesmus  is  great,  by  a  little  cocoaine  solution 
(with  or  without  adrenalin)  or  a  suppository  con- 
taining it.  This  is  seldom  necessary.  These  ene- 
mata  cleanse  the  bowel  or  stimulate  it  to  cleanse  it- 
self, have  a  soothing  influence  upon  the  bowel,  and 
increase  the  amount  of  urine,  thus  helping  to  relieve 
toxaemia.  Often  when  tenesmus  breaks  the  patient's 
rest  an  injection  will  bring  down  a  little  faecal  matter 
and  surprising  relief  follows.  It  is  strange  to  see  at 
times  how  a  little  faecal  matter  high  up  in  the  bowel 
increases  the  irritation  of  the  parts  below.  I  fol- 
low the  salt  water  enema  with  another  in  severe 
cases,  after  waiting  half  an  hour  to  an  hour,  com- 
posed of  iodoform  or  aristol,  5  grains ;  bismuth.  10 
grains ;  and  sweet  almond  oil,  oii  to  5iv ;  usuallv  in 
a  little  mucilage  of  acacia  and  hot  water,  the  whole 
amount  to  be  from  gss  to  -^i ;  the  latter  after  the 
retentive  power  of  the  bowel  is  much  improved.  I 
direct  that  this  injection  be  retained  as  long  as  pos- 
sible, and  though  it  is  often  expelled  at  once,  enough 
is  retained  to  diminish  irritation  and  consequently 
the  tenesmus  and  frequency  of  stool.  I  frequently 
add  a  little  cocaine  to  this  injection  instead  of  to  the 
salt  solution.  The  oil  in  the  second  injection  besides 
its  soothing  qualities  has  been  shown  to  stimulate 
the  liver  to  greater  bile  production  and  helps  to  ex- 
plain its  beneficent  action.  These  injections  should 
be  given  as  often  as  every  three  hours  in  severe 
cases,  and  are  given  less  and  less  frequently  as  the 
number  of  the  discharges  diminish  and  symptoms 
improve.  The  abdomen  should  be  kept  warm. 
Sometimes  a  hop  poultice  or  other  hot  application 
with  or  without  some  counterirritant,  as  turpentine, 
gives  marked  relief. 

3.  These  measures  tend  to  secure  the  desideratum 
in  all  acute  inflammations,  viz.,  rest.  How  to  se- 
cure it  for  the  inflamed  bowel  is  the  question.  Even 
in  cases  where  tormina  and  tenesmus  are  severe,  it 
is  surprising  to  see  how  soon  in  most  cases  the 
s}mptoms  are  under  control  simply  from  the  meas- 
ures here  advocated  and  the  necessary  intestinal 
"rest"  secured.  But  in  quite  a  proportion  of  cases 
it  seems  we  still  have  to  resort  to  what  has  been 
called  "the  splint  for  the  bowel,"  i.  e.,  opium  in 
some  form.  This  should  be  used  if  at  all.  in  as 
small  and  infrequent  doses  as  .possible,  especially  if 
the  fever  is  considerable,  or  if  it  causes  nausea  and 
vomiting,  or  if  the  patient  is  very  weak  and  the 
question  of  nourishment  is  very  important.  If  there 
is  a  tendency  to  much  fever,  special  pains  should  be 
taken  not  to  restrain  too  greatly  the  peristaltic  ac- 
tions. Eliminations  of  toxines  will  be  interfered 
with,  frequency  of  stools  may  be.  controlled  at  en- 


tirely too  much  cost,  systemic  poisoning  and  pros- 
tration. If  the  case  seems  critical,  to  abandon  the 
opium  will,  I  believe,  give  the  best  results  in  most 
if  not  in  all  cases.  I  would  certainly  give  this  plan 
the  preference.  So  also  if  the  opium  causes  nausea 
and  vomiting  it  is  necessary  for  us  to  choose  be- 
tween two  evils.  If  the  patient  is  very  weak,  drop 
opium  and  husband  the  stomach.  In  the  aged  or 
where  the  disease  is  very  severe  I  believe  it  is  best 
in  the  decided  majority  of  cases  not  to  resort  to 
opium  or  perhaps  give  it  tentatively.  While  omitting 
the  opium  results  in  an  increase  in  the  number  of 
stools,  it  has  been  my  experience  where  I  have  con- 
tinued to  withhold  opium  that  this  does  not  continue, 
the  bowels  gradually  checking  and  really  leaving  the 
patient  in  better  condition  for  continued  improve- 
ment. Should  opium  be  given,  it  is  usually  best 
given  hypodermically,  sometimes  though  by  the  old 
method  of  laudanum  and  starch,  after  the  salt  solu- 
tion. 

4.  This  brings  us  to  the  fourth  division  of  the  sub- 
ject. At  first  sterile  water,  hot  or  cold,  is  given  in 
just  as  small  amounts  as  the  comfort  of  the  patient 
will  allow.  This,  if  at  first  taken  freely  or  if  very 
cold,  is  liable  to  increase  peristaltic  unrest.  Of  med- 
icines a  combination  of  salol,  bismuth,  and  chalk 
mixture  has  given  me  the  best  results.  I  usually 
give  about  four  grains  of  salol  and  ten  of  bismuth 
in  two  drachms  of  the  chalk  mixture.  Usua'.lv  this 
in  addition  to  the  other  measures  mentioned  is  all 
that  is  necessary  during  the  height  of  the  inflamma- 
tion. But  other  antiferments  and  sedatives  some- 
times have  here  a  place.  It  is  of  course  better  to 
select  those  that  will  not  disturb  the  stomach  or  tend 
to  exacerbate  the  existing  inflammation.  To  allay 
nausea,  rest,  hot  water,  oxalate  of  cerium,  phenol, 
cocaine,  etc.,  may  be  used  as  in  other  afifections,  and 
so  also  where  heart  stimulants  are  needed  the  u-ual 
remedies  are  given.  So  alcohol,  strychnine,  spar- 
teine, etc.,  must  be  used  according  to  indications. 

Just  as  fuel  is  necessary  to  generate  steam,  so  food 
is  the  only  source  of  real  strength,  the  various  medi- 
cines serving  only  to  bridge  our  patients  over  dan- 
gerous ground.  Hence  alcohol,  strychnine,  etc., 
while  rightly  used,  and  serve  a  good  purpose  ( ex- 
cept for  the  slight  food  value  of  alcohol),  yet  their 
use  must  soon  be  supplemented  by  judicious  feeding. 
For  the  first  two  or  three  days,  unless  the  case  is 
very  mild  or  the  patient  very  weak,  it  is  best  to  give 
no  food  at  all ;  or  if  food  is  given  let  it  be  egg  water 
with  or  without  a  little  brandy  and  salt,  beef- juice, 
or  some  of  the  prepared  foods.  If  the  case  is  se- 
vere it  is  best  to  persist  with  these  till  after  the 
eighth  day.  In  mild  cases  no  such  rigid  restriction 
of  diet  is  necessary,  the  patient  being  permitted  to 
gradually  return  to  ordinary  diet.  But  nothing  but 
simple  food  should  still  be  allowed.  Personal!}-  I 
do  not  like  milk  in  these  cases. 

With  the  passing  of  the  eighth  day  the  disease,  as 
Flint  states,  in  many  cases  ends.  If  it  dots  not  the 
passing  of  that  day  should  n-iark  a  gradual  but  radi- 
cal change  of  treatment.  Tiie  indications  are  then 
as  follows:  i,  feeding;  2,  elimination;  3,  clean?ing 
and  medicated  injections  and  applications;  4,  adju- 
vant remedies. 

I.  Of  these  measures  first  and  foremost  is  food. 
The  patient  should  be  more  and  more  freely  fed  as 


646 


CORRESPONDENCE. 


LNew  York 
Medical  Journ\l. 


the  case  progresses  till  a  liberal  allowance  of  food 
is  given.  While  the  increase  is  gradual  this  is  ab- 
solutely essential  to  success.  As  a  rule  in  these  cases 
I  forbid  milk,  but  beef  juice,  egg  albumen,  etc., 
should  first  be  given  and  the  list  enlarged  gradually 
until  beefsteak,  chicken,  game,  eggs,  well  cooked 
rice,  beaten  biscuits,  etc.,  are  given  in  liberal  allowr 
ance.  Tea  is  allowable.  No  fried  dishes.  No 
sweets.  Not  an  overabundance  of  liquid  food.  I 
prefer  to  return  gradually  to  rather  a  semisolid  or 
dry  diet. 

2.  Elimination.  For  this  purpose  I  prefer  to  have 
my  patient  take  as  a  rule  every  morning  sufficient 
Epsom  salts  with  a  little  diluted  sulphuric  acid  to  act 
from  one  to  three  times.  The  patient  or  the  nurse 
should  ascertain  the  requisite  dose.  The  bowel 
should  be  kept  sufficient  empty  to  prevent  stools  be- 
coming very  offensive  and  to  prevent  formation  of 
scybalous  masses.  This  amounts  to  a  positive  indi- 
cation in  these  cases.  I  am  satisfied  salts  regularly 
repeated  after  the  eighth  day  tends  to  promote  the 
recovery  of  the  diseased  bowel. 

3.  Cleansing  and  medicated  injections  and  applica- 
tions. When  salts  is  given  every  morning,  and  this 
is  my  rule  in  subacute  cases,  I  usually  advise  in  ad- 
dition the  use  of  warm  normal  salt  solution  one  hour 
before  bedtime.  No  attempt  should  be  made  to  re- 
tain this.  One  hour  later,  just  before  retiring,  I  ad- 
vise a  medicated  injection,  most  often  employing  the 
one  formerly  mentioned  of  iodoform  ( or  aristol ) 
with  bismuth  and  sweet  almond  oil.  This  should, 
if  possible,  be  retained  all  night.  It  is  generally 
readily  retained  after  the  first  few  trials.  Some- 
times fluid  extract  of  hamamelis  or  fluid  hydrastis 
here  answers  a  good  purpose.  I  then  use  the  fluid 
extract  of  hamamelis",  a  drachm  or  two  to  the  pint 
of  water  instead  of  the  normal  salt  solution.  In 
other  cases  if  recovery  is  not  rapid  I  use  the  fluid 
h)'drastis  for  a  while  instead  of  the  oil  injection. 
In  such  a  case  I  use  a  tablespoonful  of  the  remedy 
to  a  half  teacupful  of  hot  water  and  advise  its  re- 
tention all  night. 

In  all  cases  of  subacute  dysentery  (or  diarrhoea) 
the  lower  bowel  should  be  made  the  subject  of  a 
careful  visual  examination.  Often  ulceration  is  vis- 
ible. It  is  beyond  the  limits  of  this  paper  to  take 
up  the  subject  of  rectal  ulceration,  but  I  will  add 
that  even  when  such  is  the  case  the  measures  al- 
ready advocated  are  generally  sufficient  to  effect  a 
cure  when  the  ulcer  is  of  the  simple  type,  and  it  is 
usually  of  this  type.  But  other  measures  may  here 
be  necessary.  If  so  the  topical  application  of  a  sil- 
ver salt  may  be  necessary,  and  I  use  the  nitrate  in 
the  strength  of  from  two  to  ten  grains  ( seldom 
more)  to  the  ounce  of  water.  This  may  be  applied 
two  or  three  times  a  week  and  followed  by  an 
unctuous  application  of  some  kind  or  a  suppository. 

Cases  of  subacute  dysentery  are  very  frequent  in 
cool  weather  and  it  is  important  that  the  body  and 
the  abdomen  in  particular  be  protected  from  chill. 
A  flannel  covering  is  often  advantageous  and  coun- 
teriritation  may  prove  helpful. 

4.  -Adjuvant  remedies.  Rest  in  bed  is  best  and 
generally  essential  when  the  symptoms  are  acute  and 
the  patient  weak.  In  many  subacute  cases  this  is 
not  a  necessity.  I'ut  if  improvement  is  not  soon 
manifest,  rest  in  bed  .should  be  enforced.  Suitable 


tonics  aid  materially  in  the  recovery  of  the  patient, 
but  nothing  should  be  given  which 'tends  to  irritate 
the  intestinal  tract  or  interferes  with  elimination. 
Hence  opium  is  positively  contraindicated.  Cold 
bathing  followed  by  friction  and  general  tonic  and 
corrective  measures  such  as'  those  prompting  nutri- 
tion and  improving,  digestion  have  here  their  place. 
I  believe  this  is  the  role  of  alcohol  in  such  cases. 
Dysentery  is  occasionally  either  of  malarial  origin  or 
is  complicated  by  it.  These  cases  are  not  common 
in  our  locality,  but  I  have  seen  some  cases  markedly 
benefited  by  quinine.  Usually  these  cases  are  ac- 
companied by  decided  fever  which  may  be  of  period- 
ical character. 

 ^  


LETTER  FROM  LONDON. 

Degrees  for  London  Students.— The  Washington  Tubercu- 
losis Congress. — The  Prevention  of  Deaths  under 
Ancesthesia. — A  Contested  Legacy  to  a  Physician. — The 
Radium  Institute. — The  Death  of  the  Editor  of  the 
Lancet. 

London,  March  g.  igog. 

Students  in  the  London  medical  schools  have 
long  felt  it  as  a  grievance  that  after  going  through 
a  full  course  of  study  in  London  which  would  en- 
able them  to  obtain  a  degree  .in  any  provincial  uni- 
versity thev  are  onlv  able  to  obtain  the  diploma  of 
the  Royal  Colleges,'  ^I.  R.  C.  S.  and  L.  R.  C.  P. 
The  work  required  for  a  London  degree  is  of  such 
nature  as  to  make  it  beyond  the  reach  of  the  aver- 
age student  who  wishes  to  qualify  in  the  minimum 
period  of  five  years.  In  order  to  remedy  this  ad- 
mitted grievance,  a  conference  has  been  held  of  del- 
egates from  the  Royal  Colleges  of  Physicians  and 
Surgeons  and  a  scheme  drafted  for  submission  to 
the  University  of  London.  Their  report  has  just 
been  issued.  The  delegates  are  of  the  opinion  that 
there  should  be  little  difficulty  in  arriving  at  an 
equitable  and  advantageous  solution  of  the  problem. 

The  scheme  suggested  is  to  allow  London  stu- 
dents who  pass  the  conjoint  examinations  to  receive 
also  the  degree  of  M.  B.  B.  S..  London,  the  present 
examination  for  the  degree  being  retained  as  an 
honors  degree.  This  arrangement  will  enable  the 
average  London  student  to  obtain  the  degree  of  doc- 
tor of  medicine,  medical  education  in  London  will 
be  more  systematized,  and  the  L'niversity  and  Royal 
Colleges,  acting  together  with  the  same  staff  and 
equipment,  will  be  able  to  reduce  the  expenditure 
on  examinations.  A  Rbyal  Commission  has  just 
been  appointed  to  consider  the  question  of  London 
University  education  in  general,  and  no  doubt  this 
scheme  will  be  duly  considered.  Should  it  he  ac- 
cepted, London  will  again  become  a  popular  centre 
for  medical  study  and  the  falling  off  in  the  number 
of  students  at  the  London  medical  schools  will  be 
checked. 

The  British  delegates  to  the  International  Con- 
gress on  Tuberculosis  held  last  autumn  at  Washing- 
ton have  just  presented  their  report  to  Parliament. 
After  giving  a  list  of  the  resolutions  unanimously 
adopted  at  the  closing  session  of  the  congress  the 
delegates  state  that  these  resolutions  were  passed 
without  a  dissentient  voice,  at  a  meeting  fully  rep- 


March  27,  1909.] 


CORRESPONDENCE. 


647 


resentative  of  the  best  knowledge  of  all  countries, 
concerning  the  means  practicable  for  the  diminution 
and  final  extermination  of  tuberculosis.  They  note 
with  satisfaction  the  general  testimony  that  objec- 
tions to  compulsory  notification  are  rapidly  disap- 
pearing. Experience  shows  that  both  in  this  coun- 
try and  in  the  United  States  notification  has  been 
valuable  to  the  patient  as  well  as  to  the  community. 
AMiile  it  has  enabled  each  sanitary  authority  to 
carry  out  the  simple  precautionary  measures  needed 
to  prevent  spread  of  infection,  it  has  brought  within 
reach  of  the  patient  valuable  official  and  private 
help;  it  has  taught  him  how  to  protect  himself  from 
reinfection  and  his  family  and  fellow  workers  from 
infection  ;  and  has  guided  him  in  obtaining  and  con- 
tinuing the  necessary  medical  help  and  in  securing 
sanatorium  treatment.  In  view  of  these  considera- 
tions the  delegates  regard  the  extension  of  compul- 
sory notification  in  the  United  Kingdom  as  an  in- 
dispensable step  in  the  institution  of  a  complete  and 
successful  organization  for  the  suppression  of  tu- 
berculosis bv  the  cooperation  of  voluntary  and  of- 
ficial agencies.  \\'\t\\  regard  to  treatment,  it  is 
stated  that  medical  experience  uniformly  supports 
the  conclusion  that  in  a  large  proportion  of  eases 
treated  in  sanatoria  permanent  improvement  is  se- 
cured. It  is  also  becoming  appreciated  that  sana- 
toria have  a  most  important  educative  influence,  an;l 
that,  if  the  number  of  beds  is  limited  or  patients 
cannot  consistently  with'  their  livelihood  make  a 
long  stay  in  the  sanatorium,  much  good  to  the  pub- 
lic can  be  accomplished  by  training  a  large  number 
of  patients  during  such  a  short  stay  in  habits  of  life 
which,  so  far  as-  their  means  permit,  they  will  con- 
tinue afterward.  Dealihg  with  the  educational  cam- 
paign against  the  disease  in  the  United  Kingdom, 
which  has  already  had  much  success,  the  delegates 
pay  a  tribute  to  the  good  work  which  is  being  done 
in  Ireland  under  the  auspices  of  Lady  Aberdeen  and 
the  Women's  National  Health  Association.  The 
awakening  of  the  Irish  people  to  the  necessity  of 
taking  action  was  one  of  the  features  revealed  at 
the  congress.  In  conclusion,  the  delegates  strongly 
commend  the  resolutions  of  the  congress  to  the  con- 
sideration of  his  ^Majesty's  government  and  that  of 
the  local  authorities  of  the  United  Kingdom. 

Dr.  F.  J.  Waldo,  the  coroner  for  the  City  of  Lon- 
don, in  his  annual  report  to  the  City  Corporation  for 
1908.  makes  several  recommendations  with  a  view 
of  lessening  the  numbers  of  what  he  regards  as  un- 
necessary deaths  under  anaesthesia.  The  principal 
are  the  following:  That  no  general  or  local  annss- 
thetic  shall  be  administered  by  any  but  a  duly  quali- 
fied medical  man.  That  full  details  be  reported  by 
the  anaesthetist  of  all  administrations  of  annssthetics, 
whether  in  hospital  or  in  private  practice.  That  as 
far  as  possible  special  skilled  anaesthetists  be  ap- 
pointed to  all  hospitals  and  infirmaries,  and  that 
resident  anjesthetists  be  provided  in  the  larger  insti- 
tutions. That  when  the  administration  of  an  anaes- 
thetic is  entrusted  to  a  junior  qualified  man.  he 
should  be  supevised  by  a  skilled  anaesthetist.  That 
notification  be  made  to  the  coroner  of  all  deaths  oc- 
curring at  anv  stage  of  general  anaesthesia.  Lastly, 
he  suggests  the  appointment  of  a  Royal  Comnv'ssion 
to  incjuire  into  the  present   facts  of  deaths  under 


anaesthesia,  together  with  the  official  machinery 
available  for  registration. 

An  interesting  legal  case  came  before  the  courts 
last  week,  involving  a  dispute  as  to  a  legacy  left  to 
a  medical  man  by  a  patient.  The  patient  was  a  lady 
living  apart  from  her  husband,  and  she  was  treated 
very  kindly  by  Dr.  Dunn,  for  whose  benefit  she 
made  more  than  one  will.  Undue  influence  was  al- 
leged by  the  husband  of  the  testatrix,  who  contested 
the  will.  It  was  shown  by  the  evidence  that  de- 
ceased came  to  Dr.  Dunn  in  great  poverty,  when  he 
attended  her  gratuitiusly  and  lent  her  money.  Af- 
ter this,  owing  to  the  death  of  a  sister,  she  succeed- 
ed to  certain  money  which  she  proceeded  to  deal 
with  in  wills  which  showed  her  intention  of  bene- 
fiting Dr.  Dtum.  The  case  was  decided  in  Dr. 
Dunn's  favor. 

It  is  officially  announced  that  the  King  has  been 
pleased  to  become  the  patron  of  the  Radium  Insti- 
tute, and  that  a  site  has  been  acquired  near  Port- 
land Place  upon  which  the  necessary  building  will 
be  erected  without  delay.  The  institute  will  be  con- 
ducted on  the  lines  of  the  Radium  Institute  in  Paris. 
The  institute  hopes  to  acquire  radium  to  the  amount 
of  five  grammes.  The  building  will  be  divided  into 
two  parts.  One  section  will  be  devoted  to  neces- 
sitous patients  and  the  other  to  the  well  to  do.  No 
patient  will  be  treated  except  at  the  request  of  a 
medical  man.  Dr.  Hay  ward  Pinch  has  been  ap- 
pointed director  of  the  institute,  and  there  will  also 
be  an  honorary  medical  and  surgical  staff'  (not  yet 
appointed) . 

I  regret  to  announce  the  death,  on  March  8th,  of 
Mr.  Thomas  Wakley,  L.  R.  C.  P.,  editor  of  the 
Lancet,  after  an  illness  lasting  two  months.  Mr. 
Wakley  was  fifty-seven  }  ears  of  age,  and  succeeded 
to  the  editorship  on  the  death  of  his  father,  less  than 
two  years  ago.  He  was  a  grandson  of  the  late 
Thomas  Wakley,  M.  P.,  the  founder  of  the  paper, 
and  was  educated  at  Trinity  College,  Cambridge,  re- 
ceiving his  medical  training  at  St.  Thomas's  Hos- 
pital. He  was  admitted  a  licentiate  of  the  Royal 
College  of  Physicians  in  1883  and  subsequentlv  be- 
came a  fellow  of  the  Royal  Society  of  Medicine.  He 
assisted  his  father  in  the  editorship  of  the  Lancet 
for  twenty  yeans. 


LETTER  FROM  WINNIPEG. 

Reciprocity  in  Licensing. — The  Canadian  Medical  Associa- 
tion.— The  Antituberculosis  Society  of  British  Coluiti- 
bia. — The  British  Columbia  Marine  Hospital. — The 
Saskatchewan  Medical  Journal. — Local  Medical  So- 
cieties. 

Winnipeg,  March  12,  igog. 
There  was  held  in  the  Medical  Library,  Winni- 
peg, on  March  6th  a  meeting  of  the  profession  in 
this  city  and  vicinity  to  discuss  the  question  of 
medical  reciprocity  among  the  four  provinces  in  the 
west,  Manitoba,  Saskatchewan,  Alberta,  and  British 
Columbia.  Dr.  R.  G.  Brett,  of  Banff,  Alberta,  was 
the  chief  speaker.  The  meeting  was  presided  over 
by  Dr.  J.  O.  Todd,  of  Winnipeg.  In  opening  the 
meeting  Dr.  Todd  pointed  out  that  the  province  of 
Nova  Scotia  had  already  made  the  first  advances  in 
the  direction  of  reciprocity  among  the  various  prov- 
inces of  Canada,  and  was  willing  to  admit  gradu- 


648 


THLRAPEUTICAL  NOTES. 


[New  York 
Medical  Journal. 


ates  of  Other  provinces  to  practise  in  that  province 
provided  the  same  privileges  were  extended  to  its 
own  graduates.  Dr.  Brett  pleaded  for  the  burial 
of  petty  jealousies  and  dissensions  among  the  mem- 
bers ot  the  profession  and  urged  the  establishment 
of  a  central  western  examining  board  which  would 
grant  a  license  to  graduates  of  the  various  provin- 
cial medical  colleges,  which  would  enable  them  to 
practise  at  will  in  any  of  the  provinces.  So  far  as 
Alberta  was  concerned,  they  in  that  province  were 
strongly  in  favor  of  such  federation  of  the  prov- 
inces for  the  purpose  of  giving  one  examination 
and  one  license.  He  deplored  the  fact  that  the  bill 
framed  by  Dr.  Roddick,  of  Montreal,  and  still 
standing  on  the  statute  books  of  Canada  as  the 
Canada  Medical  Act,  having  for  its  purpose  one 
examination  for  the  Dominion,  had  been  practically 
killed  through  opposition  from  Ontario  and  Quebec. 
He  said  it  was  embarrassing  to  have  to  answer  the 
question  often  put  by  the  laity  as  to  why  a  graduate 
of  one  provincial  college  could  not  practise  in  an- 
other province.  In  framing  a  scheme  as  proposed, 
the  most  difficult  detail  was  as  to  whether  the  effect 
of  the  examination  should  be  retroactive  or  not. 
Dr.  Chown.  dean  of  the  Manitoba  Medical  College, 
stated  that  for  a  long  time  the  medical  men  of 
Manitoba  were  unanimous  for  a  scheme  which 
would  open  the  portals  of  work  for  their  graduates 
in  the  widest  way  possible  throughout  the  Domin- 
ion. After  a  number  of  other  Winnipeg  men  had 
expressed  their  views  on  the  matter  it  was  decided 
to  appoint  delegates  to  tour  the  provinces  in  order 
to  gather  the  opinions  of  practitioners  on  the 
matter. 

The  forty-second  .annual  meeting  of  the  Cana- 
dian Medical  Association  will  be  held  in  this  city  on 
the  23d.  24t!i,  and  25th  of  August  next,  under  the 
presidenc}'  of  Dr.  R.  J.  Blanchard,  of  Winnipeg.  It 
is  rather  early  to  announce  anything  yet  in  connec- 
tion with  the  programme,  but  it  is  understood  that 
there  will  be  a  general  discussion  on  the  medical 
and  surgical  diseases  of  the  kidney.  Several  emi- 
nent medical  men  from  the  old  country  and  from 
the  United  States  are  expected  to  be  present  and 
take  part  in  the  proceedings ;  and,  as  the  meeting  is 
to  be  held  just  prior  to  the  meeting  of  the  British 
Association,  a  great  gathering  is  expected.  From 
the  office  of  the  general  secretary,  in  Toronto,  reply 
postal  cards  have  recently  been  sent  out,  asking  for 
expressions  of  opinion  as  to  the  scheme  for  the 
establishment  of  an  official  journal  for  the  associa- 
tion, as  well  as  that  for  the  incorporation  of  the 
association  by  act  of  Parliament.  Tt  is  understood 
that  railway  arrangements  are  pretty  well  com- 
pleted, and  that  from  the  east  a  single  fare  for  the 
round  trip  will  prevail.  An  endeavor  is  being  put 
forth  to  have  a  fine  pathological  and  x  rav  exhibi- 
tion. 

The  annual  meeting  of  the  subscribers  and  gov- 
ernors of  the  British  Columbia  Antituberculosis 
Society  was  held  recently  in  Victoria.  Dr.  R.  W. 
Irving,  the  medical  suncrintendent  of  the  Tran- 
quillc  Sanatorium  at  Kamlopps,  presented  the  an- 
nual report.  On  the  Tst  of  January.  TO08.  there 
were  sixteen  patients  at  Tranquille.  This  number 
taxed  the  accommodation  to  the  utmost,  and  just  as 
soon  as  conditions  permitted  six  cottages  were  built, 
which  afforded  accommodation  for  thirty  patients. 


During  lyoS,  forty-seven  were  admitted  to  the  insti- 
tution, and  those  remaining  less  than  one  month 
were  four.  Only  a  small  percentage  of  the  appli- 
cants during  the  past  year  could  be  accommodated, 
ihe  completion  of  the  new  building  in  course  of 
erection  will  overcome  that  difficulty  to  a  certain 
extent.  The  work ,  has  been  confined  to  the  resi- 
dents of  British  Columbia,  although  applications 
have  been  received  from  all  over  Canada  and  the 
northern  and  western  States. 

The  Federal  government  marine  hospital  at  Vic- 
toria is  said  to  be  poorly  provided.  There  is  scant 
equipment  and  meagre  allowance  for  the  institution. 
Recently  the  admittance  of  coasting  seamen  has 
been  barred,  and  the  expenditure  is  small  compared 
with  the  receipts  from  the  deep  sea  mariners.  An 
order  was  recently  sent  from  Ottawa  refusing  ad- 
mission to  seamen  from  the  coasting  steamers,  and 
this  has  been  adversely  criticised  by  shipping  men 
other  than  those  directly  interested.  The  patients 
will  hereafter  be  confined  to  seamen  from  those  ves- 
sels running  into  foreign  ports.  Last  year  there 
were  fewer  than  a  hundred  patients  in  the  institu- 
tion, and  a  very  few  of  them  were  sent  there  by  the 
deep  sea  steamers,  which  pay  the  bulk  of  the  sick 
mariners'  fund,  the  total  amount  collected  by  the 
government  being  many  times  the  amount  of  the 
cost  of  the  marine  hospital  to  that  government. 
The  hospital  is  said  to  be  so  poorly  equipped  that 
doctors  will  not  allow  serious  cases  to  be  handled 
there.  This  hospital  is  supplied  with  twenty  beds. 
There  is  an  operating  room,  but  it  is  not  supplied 
with  operating  instruments. 

The  Saskatchewan  Medical  Joiiiiia!  has  been 
launched,  the  object  of  it  being  to  publish  the  trans- 
actions of  the  Saskatchewan  !^Iedical  Association. 
It  has  not  yet  been  decided  wdiether  to  continue  it 
as  a  monthly  or  quarterly  or  simply  confine  it  to  an 
annual  volume  of  transactions.  Among  the  papers 
is  one  by  Dr.  George  A.  Bingham,  of  Toronto,  on 
Acute  Septic  Peritonitis. 

The  following  officers  have  recently  been  elected 
by  the  Winnipeg  Clincial  Society :  President.  Dr. 
W.  R.  Nicholls ;  vice-president.  Dr.  Charles  Hun- 
ter ;  secretary,  Dr.  J.  G.  Munro ;  treasurer.  Dr.  J.  E. 
Lehman ;  executive  committee.  Dr.  R.  W.  Kenny. 
Dr.  J.  H.  Bond,  and  Dr.  R.  Rorke.  The  present 
officers  of  the  Winnipeg  Medical  and  Surgical  Chi- 
rurgical  Society  are  as  follows  :  President,  Dr.  W.  J. 
McLean  ;  vice-president.  Dr.  J-  O.  Todd  :  secretarv. 
Dr.  C.  H.  \'rooman  ;  treasurer.  Dr.  Vrooman  ;  ex- 
ecutive committee.  Dr.  Smith,  Dr.  Hunter.  Dr.  Gal- 
loway, and  Dr.  Halpenny. 


f  herapttttital  ^otfs. 

The  Treatment  of  Typhoid  Fever  with  Calcium 
Creosote. — In  the  Monthly  Cyclo/^crdia  and  Med- 
ical Bulletin  for  February,  tqck),  an  interesting  and 
instructive  paper  bv  I,.  Kolipinski  is  published  on 
the  treatment  of  tvphoid  fever  with  solution  of  cal- 
cium creosote.  Wc  give  below  an  abstract  of  tlie 
author's  method  of  preparing  the  solution  of  cal- 
cium creosote,  merely  remarking  that  the  product 
must  be  of  rather  uncertain  composition : 

Freshly  slaked  lime,  made  by  the  addition  of  two 


March  -7.  1909.] 


THERAPEUTICAL  NOTES. 


649 


partj  of  water  to  one  part  of  calcium  oxide,  is 
allowed  to  cool,  and  the  product  is  then  passed 
througli  an  iron  wire  sieve  by  gentle  agitation.  The 
sifted  calcium  hydrate  (hydroxide)  is  placed  in  an 
appropriate  percolator  of  glass,  of  porcelain,  or  of 
earthenware.  One  made  ofifhand  with  a  large 
flower  pot  is  convenient.  Add  creosote  with  con- 
stant stirring.  [It  would  seem  necessary  to  specify 
here  that  only  pure  beechwood  creosote  must  be 
used.]  "It  is  best  to  use  an  excess  of  slaked  lime 
for  continuous  production,  and  the  original  quanti- 
ties should  be  three  pounds  of  calcium  hydroxide  to 
one  of  creosote,  the  gross  molecular  proportions  in 
which  these  bodies  combine  being  64  to  124.  The 
smooth,  white  substance  of  the  lime  becomes  gray 
and  granular,  and  heat  is  evolved."  When  the  re- 
action is  completed  water  is  added  in  sufficient 
quantity  to  produce  a  thin  magma.  The  mixture  is 
allowed  to  stand  one  day.  when  percolation  is  pro- 
ceeded with,  the  first  collection  of  percolate  being 
returned  for  repercolation.  The  specific  gravity  of 
the  liquid  for  use  should  be  1.010  to  1.012.  Where 
the  first  collection  is  below  thi.*  it  should  be  le- 
turned  for  repercolation.  One  pound  of  creosote 
yields  about  twenty  pints  of  the  preparation.  Ac- 
cording to  the  author  the  process  may  be  continued 
for  months  by  the  addition  of  more  creosote  to  the 
lime.  The  creosote  strength  of  the  preparation  is 
not  definite,  but  one  half  fluid  ounce  is  taken  to 
represent  from  ten  to  twelve  minims  of  creosote. 
As  to  dosage  the  calcium  creosote  must  be  given  in 
the  maximum  practical  doses.  These  are  for  a 
child  of  six  or  seven  years,  one  teaspoonful  every 
two  hours.  For  an  adult,  two  to  four  teaspoon fuls 
in  tlie  same  length  of  time.  The  solution  is  given 
day  and  night  for  the  greater  part  of  the  first  week 
until  falling  temperature,  normal  pulse,  normal  fac- 
ulties allow  the  discontinuance  of  the  night  doses. 
It  should  be  given  well  diluted  in  half  a  tumblerful 
of  water. 

The  Pharmacology  of  Job's  Tears. — Attention 
has  been  called,  says  The  Prescribcr  (February, 
1909),  to  the  seeds  known  as  Job's  Tears,  by  the 
publication  of  a  note  in  the  Dcnnatolo§;ische  Zcit- 
schrift.  The  plant,  remarkable  for  its  hard,  white, 
tear-shaped  seeds,  is  sometimes  cultivated  in  gardens 
in  Europe,  but  it  is  the  wild  form  alone  that  is  used 
medicinally.  In  the  East  it  is  cultivated  as  a  food 
stuff,  and  the  seeds  are  put  to  several  economic  uses 
besides  being  used  to  form  necklaces,  bracelets,  etc. 
\'edic  literature  refers  to  it  as  one  of  the  cereals  cul- 
tivated by  the  Aryans  on  the  hill  slopes  of  the  Him- 
alayas. 

Coix  Lacliryiua  Linn.,  or  Job's  tears  (so  called 
from  the  shape  of  the  seed),  is  a  grass  which  grows 
extensively  in  India,  Burma,  China,  Japan,  and  the 
East  generally.  It  is  known  by  dififerent  vernacular 
names,  according  to  the  district  in  which  it  is  found. 
It  has  become  naturalized  in  Spain  and  Portugal, 
and  has  been  introduced  into  Brazil.  The  name  coix 
originally  belongs  to  an  African  palm,  Hyphane 
coriacca,  and  its  application  to  this  grass  is  some- 
what obscure. 

The  seed  is  enclosed  in  a  hard,  white,  siliceous  in- 
volucre, about  the  size  of  a  small  cowrie  shell,  from 
the  apex  of  which  a  portion  of  the  female  flower 
protrudes.    In  the  cultivated  form  this  covering  is 


sometimes  quite  soft,  but  in  the  wild  plant  it  is  so 
hard  that  it  requires  some  force  to  break  it.  The 
seed  contained  within  this  involucre  is  edible,  con- 
taining proteins,  starch,  and  oil.  It  is  described  as 
tonic  and  diuretic,  being  given  in  the  form  of  decoc- 
tion. The  root  is  said  to  be  used  by  the  Santals  as 
a  remedy  for  strangury. 

The  author  of  the  article  in  the  Dcnnatologische 
Zcitschrift  states  that  he  has  found  Job's  tears  use- 
ful in  the  treatment  of  molluscum  contagiosum.  He 
employed  a  decoction  of  the  seeds,  prepared  by  boil- 
ing from  five  to  twenty-five  grammes  in  water  for 
several  hours,  and  straining.  The  decoction  was 
given  freely,  and  produced  no  unpleasant  effects  ex- 
cept a  slight  diarrhoea  observable  when  large  quan- 
tities were  administered.  The  treatment  was  suc- 
cessful in  nine  cases,  the  average  time  required  to 
effect  a  cure  being  a  fortnight,  by  which  time  the 
tumors  dried  up  and  finally  scaled  off.  He  recom- 
mends the  drug  as  a  harmless  remedy  for  women 
and  children.  The  use  of  the  seeds  in  medicine  ap- 
pears to  be  very  ancient.  The  authors  of  Pharina- 
cograpliia  Indica  state  that  Es-Saghani,  who  died 
about  the  year  1260,  mentions  them  in  the  Obdb  as 
a  well  known  strengthening  and  diuretic  medicine. 

The  Use  of  Mobile  Powders  (Pinkus  and  Unna  : 
Moiiatsheftc  fiir  PraktiscJic  Dcnnatologie,  October 
I,  1908).  The  mobile  properties  of  lycopodium 
may  be  imitated  to  some  extent  by  adding  to  potato 
starch  one  to  one  and  a  half  per  cent,  of  magnesium 
carbonate.  The  particles  of  magnesia,  by  attaching 
themselves  to  the  starch  granules,  isolate  the  latter 
and  prevent  agglutination.  Such  a  powder  fur- 
nishes a  uniform,  single,  but  firmly  adhering  coat- 
mg  to  the  skin,  and  is  not  disfiguring  like  ordinary 
cosmetic  powders.  The  following  is  a  useful  for- 
mula for  beautifying  the  skin  and  concealing  de- 


fects : 

R    Red  bole,   0.5  parts; 

White  bole,   2.5  parts; 

jMagnesium  carbonate  4.0  parts; 

Zinc  oxide  5.0  parts; 

Rice  starcii,   8.0  parts. 

M. 

or 

R    Zinc  oxide  5.0  parts; 

Lycopodium,   95.0  parts.' 


M.  and  add  solution  of  eosine  (i  per  cent.)  lo.o  parts. 

Precipitated  sulphur  (5  per  cent.)  or  ichthyol 
may  be  added  for  use  in  cases  of  acne. — The  Pre- 
scribcr, March,  1908. 

To  Allay  Vomiting  Associated  with  the  Cough 
of  Phthisis. — Renon  (Jonnial  dc  mcdccinc  dc  Paris, 
February  6,  1909)  directs  the  tuberculous  patient 
to  take  five  drops  of  the  following  mixture  in  a 
little  water  half  an  hour  before  each  meal  to  over- 
come the  tendency  to  vomiting : 

R    Tincture  of  hyoscyamus,   5iss; 

Tincture  of  belladonna,   3i; 

Tincture  of  stramonium  5i. 

M.  et.  Sig. :  Five  drops  in  a  little  water  half  an  hour  be- 
fore meals. 

Uranium  Wine  for  Diabetics. — The  following 

formula  has  been  proposed  : 


R    Uranium  nitrate,   gr.  xx ; 

Glycerin  Jiss; 

Red  wine,   q.  s.  ad.  Oil. 

M. 


650 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

Philadelphia  Medical  Journal 
and  The  Medical  News. 

A  Weekly  Review  of  Medicine. 

Edited  by 
FRANK  P.  FOSTER,  M.  D. 

Associate  Editor, 
John  M.  Swan,  M.  D., 
Philadelphia. 


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NEW  YORK,  SATURDAY,  MARCH  27,  1909. 

PREDICTION  IN  MEDICINE. 
It  was  Trousseau,  we  think,  who  rated  prognosis 
as  the  most  deHcate  test  of  the  physician's  skill,  and 
it  certainly  is  so  esteemed  by  the  laity.  How  often 
do  we  hear  men  declare  that  years  before  the  doc- 
tors had  told  them  that  they  could  not  live  six 
months !  These  declarations  arc  made  ciuite  as 
much  in  a  spirit  of  derogation  of  the  medical  pro- 
fession as  in  that  of  thankfulness  at  escape  from 
predicted  death.  It  is  hard  to  say  in  what  propor- 
tion of  instances  these  statements  are  out  and  out 
falsehoods  or  the  outcome  of  misunderstanding,  but, 
large  as  that  proportion  probably  is,  it  must  be  ad- 
mitted that  a  fatal  prognosis  does  at  times  turn  out 
to  have  been  a  mistaken  one.  It  is  seldom  or  never 
prudent  from  the  physician's  own  point  of  view,  and 
probably  not  very  often  justifiable  as  a  matter  of 
science,  to  give  an  absolutely  hopeless  prognosis. 
Moreover,  it  is  needlessly  and  cruelly  harrowing  to 
the  patient's  friends.  On  all  accounts  it  is  ever 
well  to  remember  that  there  is  much  truth  in  the  old 
adage  "As  long  as  there's  life  there's  hope,"  and  it 
may  not  disadvantageous^  be  borne  in  mind  that 
Fonssagrives's  "Docteur  Tant  Micux"  is  likely  to 
get  along  in  the  world  much  better,  on  the  whole, 
than  the  same  genial  if  optimistic  author's  "Docteur 
Tant  Pis." 

But  a  lucky  prediction  sometimes  brings  more  or 
less  undeserved  honor  to  the  practitioner.  Wo  re- 
call, for  example,  an  instance  in  which  a  man  who 
complained  of  neuralgia  in  the  side  of  the  chest  was 
told  by  his  physician,  a  comparative  youngster,  to 


be  on  the  lookout  for  patches  of  vesicles  reaching 
half  way  round  his  body.  It  was  not  many  hours 
before  typical  zoster  was  developed,  and  the  patient . 
thought  that  the  doctor  really  had  the  gift  of 
prophecy.  In  another  case  a  man  met  his  physician 
on  the  street,  near  his  place  of  business,  in  the  vicin- 
ity of  City  Hall,  New  York,  and  asked  him  to  pre- 
scribe a  purgative,  to  be  taken  at  once,  remarking 
that  it  must  be  one- that  would  not  operate  before  he 
could  reach  his  home,  in  Harlem.  It  was  in  the  old 
days  of  horse  cars,  and  the  journey  was  not  at  all 
sure  to  be  accomplished  on  schedule  time.  As  it 
happened,  the  medicine  took  ef¥ect  just  after  the 
man  had  gained  entrance  to  his  house.  He,  too, 
looked  upon  his  physician  as  a  wonder.  He  who 
can  foretell  an  attack  of  zoster  or  time  the  action  of 
a  cathartic  accurately  is  of  course  a  wonderful  fel- 
low in  the  eyes  of  those  who  do  not  know  to  what 
extent  guesswork  entered  into  the  achievement. 

Undeserved  blame  and  unmerited  praise  are 
about  equally  heaped  upon  practitioners  of  medicine, 
and  both  are  apt  to  hinge  on  some  matter  in  the  na- 
ture of  a  prediction,  but  one  must  be  as  careful  not 
to  give  a  favorable  prognosis  without  qualification 
as  not  to  foretell  certain  death,  for  it  is  almost  fatal 
to  one's  reputation  to  predict  recovery  and  find  the 
patient  dead  at  the  next  visit.  It  is  the  young  physi- 
cian particularly  who  needs  to  be  on  his  guard  in 
these  matters,  and  they  are  among  those  that  will 
largely  afifect  his  repute  as  a  practitioner. 


LEAD  POISONING. 

Glibert  {Bulletin  dc  I'Acadcmie  royale  de  mcdc- 
cine  de  Belgique,  xxii,  9,  10)  reports  the  results  of 
a  series  of  experiments  made  upon  guinea  pigs, 
under  the  direction  of  the  medical  service  of  the 
Inspection  da  travail  en  Belgique,  for  the  purpose 
of  determining  some  questions  concerning  the 
symptomatology,  pathogenesis,  and  pathology  of 
lead  poisoning". 

The  first  result  of  the  experiments  was  to  show 
the  great  variability  of  the  resistance  of  the  indi- 
vidual to  the  fatal  action  of  the  poison.  Some  ani- 
mals died  in  a  few  days,  while  others  resisted  the 
poisonous  action  of  the  lead  salts  for  more  than  a 
year.  The  diminution  in  the  percentage  of  haemo- 
globin is  a  constant  phenomenon.  The  greatest  re- 
duction is  seen  in  cases  of  chronic  poisoning.  In 
acute  lead  poisoning  the  fatal  termination  often  oc- 
curs before  there  is  much  change  in  the  haemoglobin 
percentage.  When  the  administration  of  lead  salts 
is  stopped  in  time,  the  loss  of  hjemoglobin  is 
promptly  restored.  The  number  of  erythrocytes  is. 
as  a  rule,  but  not  always,  diminished  in  proportion 
to  the  loss  of  haemoglobin. 


* 


March  27,  1909.] 

There  is  nothing  characteristic  in  the  resistance  of 
the  erythrocytes  to  hjemolysis,  so  that  that  phenom- 
enon is  of  no  value  in  the  diagnosis  of  the  poison- 
ing. The  ductiHty  of  the  red  blood  corpuscles,  how- 
ever, seems  to  be  definitely  diminished.  Basophilic 
degeneration  of  the  erythrocyte  is  common,  but  is 
not  specific.  The  loss  of  ductility  frequently  corre- 
sponds with  the  appearance  of  basophilic  degenera- 
tion, and  the  latter  is  almost  always  preceded  or 
accompanied  by  polychromatophilia.  All  the  exam- 
inations made  show  a  leucocytosis  following  the  be- 
ginning of  the  poisoning.  Histological  examina- 
tions show  that  the  lesions  produced  by  lead  are 
parenchymatous,  interstitial,  and  congestive.  The 
liver  and  the  kidneys  are  most  frequently  affected, 
then  the  respiratory  organs,  the  heart,  and  the 
spleen  in  the  order  mentioned.  Serious  lesions  of 
the  lungs  are  produced  by  small  and  moderate  doses 
of  lead  salts  acting  for  a  prolonged  period  of  time. 
This  fact  points  to  the  aetiological  relation  between 
lead  poisoning  and  pulmonary  sclerosis.  Animals 
that  have  had  epileptoid  attacks  following  lead  poi- 
soning frequently  show  no  histological  signs  of  the 
intoxication  upon  proper  examination. 


BACTERIOLOGICAL  VERSUS  CLINICAL 

DIAGNOSIS. 
The  success  which  has  attended  the  use  of  bac- 
terial vaccines  in  a  number  of  infections  brings 
prominently  forward  the  matter  of  bacteriological 
Z'ersits  clinical  diagnosis.  The  distinction  between 
these  is  well  brought  out  by  the  conditions  as  thev 
exist  in  typhoid  fever.  The  recognition  of  it  as  a 
distinct  disease  by  Louis  in  1829,  its  clear  distinc- 
tion from  typhus  fever  by  Gerhard  in  1837,  and  the 
discovery  of  the  typhoid  bacillus  by  Eberth  in  1880 
seemed  to  establish  typhoid  fever  as  a  distinct  entity. 
This  opinion  was  still  further  strengthened  b}-  the 
discovery  of  the  so  called  "Gruber-Widal"  reaction 
in  1896.  Shortly  after  this,  however,  a  number  of 
reliable  observers  began  to  report  instances  of  ty- 
phoid fever  in  which  a  positive  Widal  reaction  was 
absent  throughout  the  entire  course  of  the  disease, 
and  these  have  since  been  found  to  be  due  to  infec- 
tion with  bacilli  of  the  typhoid  colon  group.  By  far 
the  greater  proportion  of  these  cases  are  due  to  para- 
typhoid bacilli,  the  others  being  associated  with 
Bacillus  cnteritidis,  psittacosis,  and  the  colon  ba- 
cillus. 

\'arious  authors  have  mentioned  clinical  signs  and 
symptoms  by  which  they  think  they  have  distin- 
guished these  infections  from  typhoid  fever  due  to 
typhoid  bacilli,  but  these  differences  have  not  proved 
at  all  reliable.  There  is  not  a  single  clinical  sign  of 
typhoid  fever  which  these  infections  may  not  pre- 


651 

sent.  Course  of  temperature,  duration  of  illness, 
severity,  rose  spots,  enlarged  spleen,  tympanites, 
haemorrhages,  all  are  common  to  both  groups  of  in- 
fections. But  two  tests  remain  to  give  definite  in- 
formation concerning  the  nature  of  the  infection, 
namely,  serum  reactions  and  bacteriological  exam- 
inations. From  the  standpoint  of  public  health,  it 
is  of  course  not  only  unnecessary  to  carry  out  the 
distinctions  between  the  various  kinds  of  infection, 
but  rather  advantageous  to  have  these  infections  all 
regarded  as  clinically  typhoid  fever.  They  are  prob- 
ably just  as  infectious  and  just  as  apt  to  spread  lo 
others,  so  that  the  same  precautionary  measures  in- 
dicated in  typhoid  fever  should  be  insisted  on. 

With  the  more  extensive  application  of  bacterial 
vaccines,  however,  it  becomes  imperative  to  deter- 
mine definitely  the  nature  of  the  infecting  micro- 
organism. Of  the  two  methods  just  mentioned, 
serum  diagnosis  is  the  more  readily  carried  out, 
though  at  the  present  day  even  the  bacteriological 
examination  is  not  difficult  in  hospital  laboratories. 
In  applying  the  serum  diagnosis  a  great  deal  of  care 
is  required  in  interpreting  the  results,  for  group 
agglutinins  are  sometimes  very  decidedly  developed. 
The  infecting  organism  is  almost  alwa\  s  agglutin- 
ated in  higher  dilutions  than  one  of  an  allied  spe- 
cies, though  exceptions  to  this  have  been  reported. 
The  demonstration  of  an  increment  in  the  amount 
of  agglutinin  in  successive  examinations  is  strongly 
indicative  of  an  infection  by  that  organism,  though 
absorption  tests  are  the  only  conclusive  proofs  of 
such  an  infection. 

THE  USE  OF  THE  AMPOULE  FOR  THE 
PRESERVATION  OF  HYPODER^IIC 
SOLUTIONS. 
It  has  been  customary  among  the  physicians  of 
the  United  States  to  prepare  extemporaneously  such 
solutions  as  they  use  for  hypodermic  injection.  This 
task  has  been  rendered  a  simple  one  by  the  prepara-* 
tion  of  hypodermic  tablets,  each  of  which  contains 
one  dose  of  the  particular  medicament  desired. 
These  tablets,  when  properly  made,  dissolve  readily 
in  water,  enabling  the  physician  to  administer  the 
hypodermic  injection  with  but  little  waste  of  time 
or  effort  in  the  preparation  of  the  solution. 

The  introduction  of  gelatin  solutions  for  hypodermic 
medication  and  the  growing  use  of  preparations 
which  either  do  not  lend  themselves  to  dispensing 
in  tablet  form  or  which  decompose  readily  seem  to 
point  to  the  more  general  adoption  in  medical  prac- 
tice in  the  United  States  of  the  ampoule  as  a  means 
of  dispensing  sterile  hypodermic  solutions.  The 
only  medicines  which  have  thus  far  attained  any  de- 
gree of  popularity  in  this  country  in  this  form  are 


EDITORIAL  ARTICLES. 


652 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


preparations  of  ergot,  those  of  animal  extracts,  of 
enzymes,  and  one  or  two  French  proprietary  reme- 
dies, and  the  use  of  tliese  has  not  been  widespread. 
Quite  recently  ampoules  of  synthetic  suprarenin 
have  been  introduced,  and,  in  view  of  the  prone- 
ness  of  this  substance  to  decompose  under  ordinary 
conditions,  it  is  not  surprising  that  they  have  met 
W'ith  considerable  favor. 

In  an  address  on  the  subject  of  ampoules  deliv- 
ered before  the  Philadelphia  Collep-e  of  Pharmacy 
and  printed  in  the  American  Druggist,  for  Febru- 
ary 22d,  Mr.  Caswell  A.  Mayo  gives  an  interesting- 
account  of  the  various  methods  of  making,  filling, 
sterilizing,  and  sealing  ampoules,  and  points  out  the 
great  popularity  which  this  form  of  administering 
medicines  has  achieved  in  the  Latin  countries  of 
Europe.  In  France  and  Italy  the  hypodermic  tablet 
seems  to  have  gained  no  foothold,  but  the  lists  of 
filled  ampoules  furnished  by  the  manufacturing 
pharmacists  embrace  a  wide  range  of  medicaments 
many  of  which  are  rarely  administered  by  the 
American  practitioner  hypodermically.  One  Italian 
manufacturer  lists  127  different  kinds  of  filled  am- 
poules, embracing  the  following  medicaments, 
either  alone  or  in  combination : 

Carbolic  acid,  antipyrine,  apomorphine,  aristol, 
atoxyl,  atropine,  methylene  blue,  caffeine,  calomel, 
camphor,  quinine,  cocaine,  codeine,  creosote,  du- 
boisine,  ergotine,  heroin,  ether,  analgesine,  eucalyp- 
tol,  eugenol,  iron  arsenate,  citrate,  cacodylate, 
formate,  glycerophosphate,  methylarsenate,  and 
pyrophosphate ;  guaiacol,  iodine,  iodipin,  iodoform, 
Fowler's  solution,  menthol ;  mercury  cyanide,  bi- 
chloride, biniodide,  and  cacodylate ;  morphine,  paral- 
dehyde, pilocarpine,  piperazine,  scopolamine,  spar- 
teine, stypticin,  strychnine,  stovaine ;  and  sodium 
glycerophosphate,  iodide,  methylarsenate,  and  sal- 
icylate. 

The  use  of  the  ampoule  has  only  recently  attained 
.to  any  degree  of  popularity  in  Germany,  it  seems, 
and  its  introduction  has  been  deprecated  by  the 
German  pharmacist  as  tending  to  still  further  re- 
move the  preparation  of  medicaments  from  the 
harfds  of  the  individual  pharmacist  and  place  it  in 
the  hands  of  the  manufacturer.  One  or  two  Amer- 
ican manufacturers  have  already  announced  that 
they  are  prepared  to  furnish  solutions  for  hypo- 
dermic injections  put  up  in  sealed  ampoules. 

While  there  can  be  no  question  of  the  convenience 
of  having  a  reliable  sterile  solution  at  hand  ready 
for  dispensing,  it  is  questionable  whether  this  form 
of  medication  will  take  the  place  in  the  esteem  of 
the  American  physician  which  is  now  held  by  the 
hypodermic  tablet.  The  ampoules  are  fragile  and 
relatively  bulky  and  expensive.  The  physician  can 
carry  a  dozen  doses  of  half  a  dozen  different  medi- 


caments in  the  form  of  tablets  in  less  space  -nd 
more  safely  than  he  could'  carry  half  a  dozen  am- 
poules. As  a  matter  of  fact,  the  danger  of  infection 
in  hypodermic  injections  rests  largely  on  the  needle 
and  not  on  the  solution.  It  is  generally  through 
carelessness  in  cleansing  the  hypodermic  needle  or 
in  preparing  the  skin  at  the  point  of  injection  that 
infection  occurs ;  consequently  the  ampoule  does  not 
oft'er  great  additional  security  against  infection. 
The  principal  factor  which  may  lead  to  its  introduc- 
tion into  American  practice  is  the  growmg  use  for 
hypodermic  injection  of  medicaments  which  have 
heretofore  not  been  exhibited  hypodermically. 

We  regret  that  Mr.  Mayo  has  seen  fit  to  adopt  the 
"bobtailed"  spelling  of  the  word,  "ampul,"  for  the 
original  French  word  "ampoule"  is  a  much  better 
form  and  should  be  adopted  in  English,  unless  the 
Latin  ampulla  is  used. 


THE  CENSUS  OF  igio. 

At  the  present  writing  there  seems  to  be  some 
doubt  about  the  granting  of  an  appropriation  by 
Congress  to  meet  the  expenses  of  taking  the  next 
census.  There  ought  certainly  to  be  no  such  doubt. 
This  we  assert  positively  from  the  medical  point  of 
view.  Among  the  multifarious  data  incorporated 
in  the  census  returns  there  are  few  that  are  of  more 
importance  than  the  vital  statistics.  If  we  are  to 
progress  in  the  increase  of  population  of  native 
origin,  we  must  know  what  the  obstacles  are  to  such 
increase,  and  we  must  know  to  what  extent  each 
one  of  them  is  working  against  a  normal  increment 
of  native  American  population.  We  ought  to  know 
also  what  occupational  diseases  and  injuries  stand 
in  the  way  of  a  justly  expected  growth  of  our  peo- 
ple. We  ought  to  know,  furthermore,  in  what  di- 
rections medical  research  must  work  in  order  to 
mend  conditions  that  may  be  militating  against  the 
desired  end.  We  believe  that  Congress  cannot  long 
be  so  regardless  of  the  interests  of  the  country  as  to 
withhold  the  necessary  funds  for  taking  the  census. 


THE  LANCET'S  LATEST  BEREA\'EMENT. 

Within  less  than  two  }  ears  the  Lancet  has  twice 
been  deprived  by  death  of  its  editor  in  chief.  Mr. 
Thomas  Wakley,  the  successor  and  onh-  son  of  the 
late  Mr.  Thomas  Henry  Wakley,  has  now  followed 
his  father  to  the  grave,  if  that  statement  may  be 
made  of  one  whose  remains  were  incinerated.  He 
was  of  the  third  generation  of  those  Wakleys  known 
to  us  in  connection  with  the  Lancet,  which  was 
founded  by  his  renowned  grandfather  of  the  same 
name.  The  gentleman  who  has  recently  died  had 
passed  the  greater  part  of  his  life  as  a  bachelor,  and 
was  married  only  within  a  few  years  of  his  death, 


^larch  27,  1909.] 


OBITUARY.— NEWS  ITEMS. 


653 


and  we  do  not  know  whether  or  not  there  are  more 
of  the  Wakleys,  in  the  direct  hne  of  descent,  to  take 
up  the  reins  handled  for  so  many  years  by  one  after 
another  of  the  family.  It  is  to  be  hoped,  however, 
that  the  great  journal  which  has  now  for  near!\  a 
century  stood  as  a  monument  to  the  name  of  W'ak- 
ley  will  not  lack  an  editor  of  that  name. 



(flbituarij. 


HAMILTON  DOX  WEY,  M.  D., 
of  Elmira,  N.  Y. 

Dr.  Wey,  a  graduate  of  the  College  of  Physicians 
and  Surgeons,  of  New  York,  of  the  class  of  1878, 
and  a  son  of  a  very  distinguished  physician,  the  late 
Dr.  William  C.  Wey,  of  Elmira.  died  on  Wednes- 
day, jNlarch  17th,  in  Callao,  Peru,  where  he  had  ar- 
rived shortly  before  on  a  tour  which  had  been  un- 
dertaken for  the  benefit  of  his  health.  He  was  fifty- 
.  four  years  old,  and  had  long  been  a  prominent  physi- 
cian of  Elmira. 


Change  of  Address. — Dr.  L.  W.  \\'ittenberg,  to  423 
East  Eighty-fourth  Street,  New  York. 

Improvements  at  Mount  Sinai  Hospital,  New  York. 

— Plans  have  been  hied  for  a  two  story  extension  to  the 
administration  building  of  tb.is  hospital. 

A  Bronze  Bust  of  the  Late  Dr.  William  T.  Bull  has 
iieen  presented  to  the  New  York  Acadeni}-  of  Medicine  by 
Mrs.  Mary  Nevins-  Bull,  widow  of  Dr.  Bull.  It  is  given 
to  the  academy  in  the  name  of  Dr.  Bull's  son. 

Addition  to  St.  Luke's  Hospital,  Kansas  City,  Mo. — 
Announcement  is  made  by  tlie  board  of  directors  that  it 
has  been  decided  to  build  a  modern  fireproof  addition  to 
the  liospital,  to  cost  between  $25,000  and  $30,000. 

A  State  Sanatorium  for  Tuberculosis  in  South  Da- 
kota.— The  State  Legislature  of  South  Dakota  has  ap- 
propriated $10,000  for  the  erection  and  first  year's  main- 
tenance of  a  State  sanatorium  for  tuberculosis. 

A  Hospital  for  Freeport,  L.  I. — It  is  reported  that  a 
large  private  house  in  Freeport,  L.  I.,  has  been  leased  and 
arrangements  are  being  made  to  convert  it  into  a  hospital. 
There  will  be  accommodations  for  about  forty  patients. 

The  Geneva,  N.  Y.,  Medical  Society  will  hold  its  April 
meeting  on  Thursday,  April  ist,  at  8:30  p.  m.  The  pro- 
gramme will  include  a  paper  on  Organic  Heart  Troubles, 
by  Dr.  R.  D.  Knight,  of  Seneca  Falls,  and  one  entitled  The 
yEtiology-  of  Arteriosclerosis  by  Dr.  H.  M.  Eddy. 

The  Cancer  Problem. — At  a  meeting  of  the  Northern 
Medical  Association  of  Philadelphia,  held  on  Friday  even- 
ing, March  26th,  Dr.  John  A.  McGlinn  delivered  an  address 
dealing  with  the  cancer  problem.  A  general  discussion  fol- 
lowed, whicb  was  opened  by  Dr.  G.  Betton  Massey. 

A  State  School  of  Sanitary  Science  and  Public  Health 
at  Cornell. — A  bill  has  been  introduced  into  the  State 
Legislature  providing  for  the  establishment  of  a  State 
School  of  Sanitary  Science  and  Public  Health  to  be  con- 
ducted in  connection  with  Cornell  University. 

The  Annual  Dinner  of  the  Society  of  the  Alumni  of 
Bellevue  Hospital  was  held  on  the  evening  of  Tuesday', 
Alarch  23d,  at  Delmonico's.  Dr.  J.  H.  Woodward,  presi- 
dent of  the  society,  was  toastmaster.  and  Mayor  McClellan 
deli\-ered  the  principal  address.  .A.bout  one  hundred  and 
fift^■  members  were  present. 

Charitable  Bequests.— By  the  will  of  Dr.  M.  H.  Boye, 
who  died  in  Coopersburg.  Pa.,  on  ^larch  5th,  at  the  age  of 
ninety-seven  years,  the  University  of  Pennsylvania  Hos- 
pital receives  $12,000. 

By  the  will  of  the  late  Mrs.  John  Carter  Brown,  the 
Rhode  Island  Hospital  receives  $4,000,  to  found  a  bed  as 
a  memorial  to  her  sister.  Harriet  Adeline  Church. 

By  the  will  of  .Aaron  S.  Wingert,  the  Little  Sisters  of  the 
Poor,  of  Philadelphia,  receive  $500. 


A  Government  Tuberculosis  Sanatorium  in  Colorado. 

— A  bill  has  been  introduced  by  Representative  Sabath,  of 
Illinois,  providing  for  the  establishment  of  a  tuberculosis 
sanatorium  in  Colorado  by  the  Federal  Government.  The 
sum  of  $2,500,000  has  been  made  available  for  the  purpose. 

Insanity  in  Texas. — It  is  said  that  the  number  of  in- 
sane persons  in  Texas  is  increasing  at  a  rapid  rate.  Addi- 
tions to  the  three  hospitals  for  tlie  insane,  supplying  ac- 
commodations for  700  patients,  were  opened  recently  and 
rilled  immediately,  and  it  is  said  that  the  State  should  make 
provisions  at  once  for  1,500  additional  patients. 

A  Hospital  for  the  Tuberculous  at  Lawrence,  Mass. — 
Through  the  earnest  efforts  of  the  Lawrence  Antitubercu- 
losis League  a  tuberculosis  hospital  is  to  be  erected  in  Law- 
rence, and  an  appropriation  has  been  made  by  the  city  gov- 
ernment for  the  purpose.  A  suitable  site  has  already  been 
obtained,  and  the  work  will  be  carried  on  as  rapidly  as 
possible. 

The  Infant  Science  Academy  is  the  rather  inappro- 
priate name  given  to  an  institution  planned  by  the  recently 
organized  Infant  Science  Congress,  with  a  view  to  edu- 
cating women  in  the  duties  of  motherhood.  Tlie  movement 
originated  with  Mrs.  Gibson  Arnoldi,  who  has  enlisted  the 
cooperation  of  the  officers  of  many  of  the  woman's  clubs  of 
this  city. 

Work  for  Epileptics. — Dr.  ^Matthew  Woods,  of  Phila 
delphia,  is  endeavoring  to  organize  a  society  whose  object 
will  be  to  procure  employment  for  epileptics,  to  be  of  such 
a  character  that  the  patients  will  not  be  harmed  if  they  are 
seized  with  an  attack  while  at  work.  Dr.  Woods  protests 
against  the  popular  belief  that  the  epileptic  is  hopelessly 
incapable. 

Leprosy  in  Norway  is  the  title  of  a  paper  which  will 
be  read  by  Dr.  Henry  L.  Shively  at  a  meeting  of  the  West 
End  Aledical  Society,  to  be  held  on  Saturday  evening, 
March  27th,  at  the  residence  of  Dr.  Le  Roy  Broun,  70  West 
Eighty-second  Street,  New  York.  The  discussion  will  be 
opened  by  Dr.  Charles  A.  Kinch  and  Dr.  William  H.  Mor- 
rison. Dr.  Max  G.  Schlapp  will  exhibit  a  case  of  anaes- 
thetic leprosy. 

The  Tuberculosis  Commission  of  Pittsburgh,  which 
has  just  been  appointed,  consists  of  the  following  members: 
Dr.  J.  F.  Edwards,  director  of  the  Bureau  of  Health,  chair- 
man; Dr.  Joseph  Reiman,  secretary;  Dr.  William  C.White, 
Mr.  Otis  H.  Childs,  and  Dr.  Stanley  H.  Rhinehart.  The 
commission  will  take  entire  charge  of  the  campaign  against 
tuberculosis,  and  five  trained  nurses  have  been  engaged  to 
aid  in  the  work. 

Night  Camps  for  Tuberculosis  Patients  in  Boston. — 
Mr.  James  M.  Prendergast  has  donated  nineteen  acres  of 
land  in  West  Roxbury,  with  a  valuation  of  $16,000,  to  the 
Boston  Association  for  the  Relief  and  Control  of  Tuber- 
culosis. It  has  been  agreed  to  establish  night  camps  for 
men  who  are  still  able  to  work  and  day  camps  for  women 
suffering  from  tuberculosis.  A  small  fee  will  be  charged 
for  the  use  of  the  camps. 

The  Epileptic  Colony  in  Virginia. — The  State  Asylum 
Board  of  Virginia  has  purchased  a  site  for  the  proposed 
epileptic  colony,  the  establishment  of  which  has  been  under 
consideration  for  some  time  past.  The  property  is  situated 
in  Amherst  County,  near  Lynchburg,  and  comprises  1,000 
acres,  abundantly  watered,  and  well  timbered.  On  the  land 
there  are  thirty-five  cottages,  a  large  brick  house,  a  stable, 
and  an  orchard  of  750  fruit  trees.  There  is  a  river  front- 
age of  nearly  three  miles. 

The  John  Slade  Ely  Professorship  at  Yale. — The  cor- 
poration of  Yale  University  recently  received  an  anony- 
mous gift  of  $50,000,  with  which  to  establish  a  memorial  to 
the  late  Dr.  Johii  Slade  Ely,  who  occupied  the  chair  of  the 
theory  and  practice  of  medicine  in  the  medical  department 
of  the  university  from  1897  to  1906.  It  has  been  decided  to 
change  the  tide  of  the  professorship  so  long  held  by  Dr. 
Slade  to  the  John  Slade  Ely  Professorship  of  the  Theory 
and  Practice  of  Medicine. 

Prizes  for  Designs  for  a  Red  Cross  Christmas  Stamp. 
— It  is  announced  that  the  -American  Red  Cross  Society 
has  opened  a  competition  for  a  design  for  the  1909  Christ- 
mas stamp,  which  is  to  be  used  in  the  campaign  against 
tuberculosis.  Among  the  prizes  offered  are  cash  prizes 
ranging  from  $100  to  $10.  Designs  may  be  submitted  either 
to  the  secretary  of  the  American  Red  Cross  Society,  Wash- 
ington, D.  C,  or  to  the  secretaries  of  any  of  the  State 
branches  of  the  society.  The  New  York  "branch  has  its 
headquarters  at  500  Fifth  .Avenue.  Tlie  competition  closes 
on  May  15th,  at  6  p.  m. 


654 


NEWS  HEMS. 


[New  York 
JIedical  Journal. 


The  Medical  and  Chirurgical  Society  of  Maryland, 

Baltimore,  announces  that  the  library  will  be  closed 
from  j\larch  15th  to  April  19th,  in  order  to  facilitate  the 
removal  to  the  new  building,  and  during  that  time  only 
communications  by  mail  will  receive  attention.  After  April 
1st  the  address  of  the  library  will  be  121 1  Cathedral  Street, 
Baltimore. 

Society  Meetings  for  the  Coming  Week: 

TuuKSDAV,  April  jst. — New  York  Academy  of  Medicine; 
Dansville,  N.  Y.,  Medical  Association. 

Friday,  April  2d. — New  York  Academy  of  Medicine  (Sec- 
tion in  Surgery);  New  York  Microscopical  Society; 
Gynaecological  Society,  Brooklyn,  N.  Y. ;  Alanhattan 
Clinical  Society,  New  York;  Practitioners'  Society  of 
New  York. 

Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  April  3,  1909: 

Thursday,  April  isl. — Obstetrical  Society;  Germantown 
Branch,  Philadelphia  County  jMedical  Society;  South- 
wark  JMedical  Society ;  Section  Meeting,  Franklin  In- 
stitute; Delaware  Valley  Ornithologists'  Club. 
Friday,  April  2d. — American  Philosophical  Society;  Ken- 
sington Branch,  Philadelphia  County  Medical  Society. 

The  Health  of  Pittsburgh. — During  the  week  ending 
Marcli  13,  1909,  the  followmg  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
II  cases,  o  deaths;  typhoid  fever,  15  cases,  8  deaths;  scarlet 
fever,  16  cases,  o  deaths ;  diphtheria,  4  cases,  o  deaths ; 
measles,  45  cases,  o  deaths;  whooping  cough,  16  cases,  o 
deaths ;  pulmonary  tuberculosis,  36  cases,  14  deaths.  The 
total  deaths  for  the  week  numbered  163,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rale  of  15. oo  in  a  thousand  of  population. 

The  Authority  to  Locate  Tuberculosis  Hospitals  in 
the  State  of  New  York  is  placed  in  the  hands  of  the  health 
authorities  of  the  State  under  the  McGrath  bill,  which  has 
just  been  passed  by  the  legislature.  Under  the  amended 
bill  the  State  authorities  must  act  in  conjunction  with  the 
local  health  officer  after  a  hearing  is  given.  The  bill  is  in- 
tended to  do  away  with  the  difficulty  heretofore  experienced 
in  procuring  a  site  for  the  location  of  State  tuberculosis 
hospitals.  In  the  past  the  consent  of  the  local  boards  of 
supervisors  and  town  boards  has  been  necessary,  and  it  has 
frequently  been  impossible  to  obtain  this  on  account  of  local 
prejudice. 

Vital  Statistics  of  New  York. — The  total  number  of 
deaths  from  all  causes  reported  to  the  Department  of 
Health  of  the  City  of  New  York,  during  the  week  ending 
March  13,  1909,  was  1,484,  as  against  a  mortality  of  1,604 
for  the  corresponding  period  in  1908.  The  annual  death 
rate  in  a  thousand  population  was  16.96  for  the  whole  city, 
and  for  each  of  the  boroughs  it  was  as  follows  :  Manhattan, 
16.84;  the  Bronx,  19.64;  Brooklyn,  16.74;  Queens,  14.48; 
Richmond,  20.07.  rhe  total  infant  mortality  was  461 ;  283 
under  one  year  of  age,  91  between  one  and  two  years  of 
age,  and  87  between  two  and  five  years  of  age.  There  were 
148.  Seven  hundred  and  eighty  one  marriages  and  2,191 
liirths  were  reported  during  the  week. 

The  Registration  of  Vital  Statistics  in  Virginia. — At 
the  last  session  of  the  State  legislature  an  unsuccessful  at- 
tempt was  made  to  have  a  law  passed  providing  for  the 
registration  of  deaths  in  Virginia.  Another  effort  will  be 
made  at  the  next  session  of  the  legislature,  and  with  this 
object  in  view  a  joint  meeting  of  the  Richmond  Academy 
of  Medicine  and  Surgery  and  the  City  and  State  Depart- 
ments of  Health  was  held  on  Tuesday  evening,  March  23d, 
at  which  Dr.  Cressy  L.  Wilbur,  chief  statistician  of  the 
United  States  Census  Bureau,  delivered  an  address  on  the 
subject  Shall  Virginia  Register  its  Vital  Statistics?  The 
meeting,  which  was  open  to  the  general  public  as  well  as  to 
tlie  entire  medical  profession,  was  largely  attended. 

The  Health  of  the  Canal  Zone. — During  January, 
1909,  there  were  242  deaths  in  the  Canal  Zone,  in  a  popula- 
tion of  126,999,  corresponding  to  an  annual  death  rate  of 
22.86  in  a  thousand  population.  There  were  2  deaths  from 
typhoid  fever,  27  from  malarial  fever,  6  from  ?estivoau- 
tumnal  fever,  3  frr.m  h.Tinoglobinuric  fever,  i  from 
measles,  5  from  dysentery,  2  from  amoebic  dysentery.  1 
from  leprosy.  5  from  beril)eri,  i  from  purulent  infection 
and  septicemia,  22  from  puln.onary  tuberculosis,  2  from 
other  forms  of  tuberculosis,  3  from  cancer,  i  from  tetanus, 
6  from  bronchopneumonia,  23  from  pneumonia.  16  from 
diarrhnea  and  enteritis,  under  two  years  of  age,  and  2  from 
uncinariasis.  The  morbidity  rate  among  the  employees  of 
the  Canal  Commission  was  22.25  in  a  thousand. 


The   Pharmacopoeia   and   the    National  Formulary 

formed  the  topic  of  discussion  at  a  meeting  of  the  Phila- 
delphia County  Medical  Society  held  on  Wednesday  even- 
ing, March  24th.  Mr.  B.  Frank  Hays  read  a  paper  entitled 
Shall  Tablets  be  Recognized  by  the  United  States  Pharma- 
copojia?  Professor  Charles  H.  La  Wall  presented  Some 
Notes  Concerning  the  Revision  of  the  National  Formular\. 
The  Declaration  of  the  Prescription  was  the  title  of  a  paper 
read  by  Professor  1.  V.  Stanislaus,  and  The  Recapture  of 
the  Pharmacopoeia  by  the  Physicians  was  the  subject  of  a 
paper  read  by  Dr.  Henry  Leftman. 

Alumnae  Association  of  the  New  York  Medical  Col- 
lege and  Hospital  for  Women. — A  regular  meeting  of 
this  association  was  held  on  Wednesday  evening,  Marcn 
17th,  at  the  home  of  Dr.  Jennie  V.  H.  Baker,  of  Brooklyn. 
The  paper  of  the  evening  was  read  by  Dr.  Sophie  B.  Scheei, 
corresponding  secretary  of  the  association,  on  Foetal  Ab- 
normalities; Some  Possible  Causes.  The  subject  chosen 
for  general  consideration  was  What  shall  we  do  for  Dys- 
menorrhoea?  and  among  those  who  took  part  in  the  dis- 
cussion were  Dr.  Cornelia  Brant,  Dr.  Gudrun  Hohn,  Dr. 
Gertrude  Van  de  Mack,  Dr.  Lucy  O.  Wright,  Dr.  Addisone 
Boyce,  and  Dr.  Edwina  Freeh.  Dr.  Sara  D.  Smalley  is 
president  of  the  association. 

The  Mortality  of  Chicago. — During  the  week  ending 
March  13,  1909,  there  were  reported  to  the  Department  ot 
Plealth  654  deaths  from  all  causes,  in  an  estimated  popula- 
tion of  2,224,490,  corresponding  to  an  annual  death  rate  of 
15  33  in  a  thousand  population.  The  principal  causes  of 
death  were :  Diphtheria,  18  deaths ;  scarlet  fever,  7  deaths ; 
influenza,  6  deaths ;  typhoid  fever,  10  deaths ;  diarrhoeal  dis- 
eases, under  two  years  of  age,  29  deaths ;  over  two  years  of 
age,  6  deaths ;  pneumonia,  120  deaths ;  tuberculosis,  pul- 
monary, 77  deaths;  other  forms  of  tuberculosis,  11  deaths; 
cancer,  32  deaths ;  nervous  diseases,  16  deaths ;  heart  dis- 
eases, 67  deaths;  apoplexy,  13  deaths;  Bright's  disease,  45 
deaths ;  violence,  50  deaths,  of  which  10  were  from  suicide. 
Infectious  Diseases  in  New  York: 

We  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  following  statement  of  new 
cases  and  deaths  reported  for  the  tzco  weeks  ending  March 
20,  190Q: 

, — March  13 — v  , — March  20 — ■, 
Cases.    Deaths.    Cases.  Deatli~. 

Tuberculosis   pulmonalis    485  188         551  1S8 

l)i;ihthcria    357  46  372  52 

Measles    829  22         922  21 

Scarlet   fever    438  46         386  25 

Smallpo.x    I 

Varicella    246  ..  173 

Typhoid   fever    30  6  23  5 

Whooping  cough    83  6  117  8 

Cerebrospinal  meningitis    11  9  8  7 

Total   2,480         323       2,5,52  306 

Deaths  of  Eminent  Foreign  Medical  Men. — The  death 
is  announced  of  Professor  Victor  Egger,  professor  of  phil- 
osophy and  psychology  at  the  Sorbonne,  Paris.  He  was 
best  laiown  for  his  work  in  psychology. 

Dr.  Hermann  Ebbinghaus,  professor  of  philosophy  at  the 
University  of  Halle,  founder  and  editor  of  the  Zcitschrift 
fur  Psychologic,  has  died,  aged  fifty-nine  years. 

David  James  Hamilton,  M.  B.  Edin.,  F.  R.  C.  S.  Edin., 
LL.D.  Edin..  F.  R.  S.,  emeritus  professor  of  pathology  in 
the  University  of  AbcrdeLii,  died  on  February  19th,  aged 
si.xty  years. 

Dr.  Rudolf  von  Renvers  died  in  Berlin  on  March  22d. 
He  was  physician  to  the  late  Empress  Frederick  and  to 
Chancellor  von  Biilow. 

The  Annual  Dinner  of  the  Society  of  the  Alumni  of 
the  Medical  Department  of  the  University  of  Pennsyl- 
vania, which  has  heretofore  been  held  during  the  month 
of  February,  has  been  postponed  this  year  in  order  to  make 
it  one  of  the  features  of  the  "Home  Coming  Week."  It 
v\ill  be  held  at  the  Hotel  Bcllevue-Stratford  on  the  even- 
ing of  Wednesday,  April  14th,  at  seven  o'clock.  The  speak- 
I  's  chosen  for  the  occasion  are  the  Provost  of  the  Univer- 
sity of  Pennsylvania,  United  States  .Attorney  General 
George  W.  Wickersham,  Dr.  S.  Weir  Mitchell,  Dr.  James 
Tyson,  and  Dr.  Alonzo  E.  Taylor,  of  the  University  of  Cal- 
ifornia. Dr.  Goorgc  .\.  Piersol  will  act  as  toastmastcr. 
The  entertainment  committee  consists  of  the  following 
•iH'mlH'r< :  Dr.  Giarlcs  K.  Mills,  Dr.  Charles  H.  Frazier. 
Dr.  G.  E.  de  Schweinitz.  Dr.  J.  Alison  Scott.  Dr.  B.  Frank- 
lin Stahi,  Dr.  Herbert  B.  Carpenter,  and  Dr.  Samuel  M'  - 
Clintock  HanMll.  chairman. 


March  27,  1909.] 


NEl'VS  ITEMS. 


655 


The  Upper  Mississippi  Medical  Society  will  meet  at 
Staples,  Minn.,  on  April  6th.  The  afternoon  will  be  de- 
voted to  routine  business  and  the  reading  of  papers  on  sub- 
jects of  general  interest  to  the  medical  practitioner.  At 
six  o'clock  in  the  evening  a  banquet  will  be  held,  which  will 
be  followed  by  a  public  meeting,  at  which  addresses  will  be 
made  by  Dr.  F.  F.  Wesbrook,  dean  of  the  Medical  Depart- 
ment of  the  University  of  Minnesota ;  Dr.  H.  M.  Bracken, 
secretary  of  the  Minnesota  State  Board  of  Health,  and  Dr. 
W.  J.  Alarchcy,  superintendent  of  the  State  Sanitorium  for 
Consumptives. 

The  Harriet  Lane  Hospital  for  Children,  which  is  to 
be  erected  on  the  grounds  of  the  Johns  Hopkins  Hospital, 
Baltimore,  will  be  a  four  story  structure,  with  a  basement, 
and  will  cost  about  $200,000.  The  roof  will  be  equipped 
with  a  sun  parlor,  where  tuberculous  children  will  receive 
the  open  air  and  sun  bath  treatment.  There  will  be  accom- 
modations for  eighty  patients,  and  the  most  modern  meth- 
ods of  treatment  of  children's  diseases  will  be  employed, 
including  the  orthopaedic  methods  of  Dr.  Lorenz.  Dr.  C. 
von  Pirquet,  of  Vienna,  is  to  be  physician  in  chief  of  the 
new  hospital,  and  the  medical  staff  will  consist  of  six 
specialists  in  diseases  of  children,  and  a  corps  of  eighteen 
nurses.  The  work  on  the  hospital  will  be  started  this 
spring,  and  it  is  expected  that  it  will  be  ready  for  occupancy 
in  about  a  year. 

A  Year's  Fight  Against  Tuberculosis. — The  annual 
report  of  the  Tuberculosis  Committee  of  the  State  Chari- 
ties Aid  Association,  v.-hich  has  just  been  issued,  shows  that 
during  the  year  ending  March  16,  1909,  the  traveling  tuber- 
culosis exhibit  visited  Canandaigua,  Geneva,  Auburn,  Cort- 
land, Elmira,  Binghamton,  Oswego,  Cohoes,  and  Pough.- 
keepsie.  In  connection  with  the  exhibition,  108  public  meet- 
ings were  held,  and  over  300,000  pieces  of  literature  relating 
to  the  nature,  prevention,  and  cure  of  tuberculosis  were  dis- 
tributed. Special  exhibits  were  displayed  at  36  county 
fairs,  which  were  visited  by  more  than  a  million  people. 
As  a  result  of  the  campaign  in  the  State  hospitals  for  the 
care  of  advanced  •  cases  of  tuberculosis  will  be  built  in 
Oneida,  Elmira,  Ontario  County,  and  Rensselaer  County. 
Albany,  Schenectady,  and  Dobbs  Ferry  will  have  day  camps. 
Dispensaries  have  been  opened  in  Utica,  Rome,  Troy,  Al- 
bany, and  Schenectady,  and  visiting  nurses  have  been  pro- 
vided in  these  places.  These  hospitals  and  dispensaries  in- 
volve an  expenditure  of  over  $700,000  for  construction  and 
first  year's  maintenance.  No  definite  plans  for  the  current 
year  have  been  announced  by  the  committee,  but  the  good 
work  will  go  on.  Announcement  is  made  of  the  appoint- 
ment of  several  new  members  of  the  committee,  among 
them  being  Dr.  Jacob  Gould  Schurman,  president  of  Cor- 
nell University,  Ithaca. 

"Home  Coming  Week"  of  the  University  of  Pennsyl- 
vania.— The  first  annual  "home  coming  week"  of  the 
medical  department  of  the  University  of  Pennsylvania  will 
occupy  the  Easter  vacation  period,  April  12th  to  17th.  Ac- 
cording to  the  preliminary  announcement,  which  has  just 
been  received,  the  following  programme  has  been  arranged  : 
On  ^londay  morning  a  clinicopathological  demonstration  of 
tuberculosis  will  be  given  at  the  Phipps  Institute.  In  the 
mornings  and  afternoons  of  Tuesday,  Wednesday  and 
Thursday,  there  will  be  held  clinical  and  scientific  lectures 
and  demonstrations  in  the  hospitals  and  laboratories  of  the 
University  of  Pennsylvania  and  at  the  Philadelphia  General 
Hospital.  On  Tuesday  evening  the  Philadelphia  Alumni 
will  give  a  smoker  in  honor  of  the  graduates  who  are  m 
the  Army  and  Navy  Service.  The  medical  alumni  dinner 
will  be  held  on  Wednesday  evening.  On  Thursday  even- 
ing the  new  medical  amphitheatre  and  clinical  laboratory 
in  the  hospital  of  the  university  will  be  opened,  with  Dr. 
James  Tyson  presiding.  There  will  be  addresses  by  Dr. 
John  H.  Musser  and  Dr.  Alfred  Stengel,  and  an  oration  by 
Dr.  George  Dock,  of  Tulane  University,  New  Orleans.  On 
Friday  morning  and  afternoon  the  regular  class  exercises 
of  the  students  will  be  held,  and  Friday  evening  will  be 
"Progressive  Medical  Night."  Orations  will  be  delivered 
by  Dr.  M.  J.  Rosenau,  of  the  Public  Health  and  Marine 
Hospital  Service,  and  Professor  A.  E.  Taylor,  of  the  Uni- 
versity of  California,  and  a  reception  will-  be  held  after- 
wards. Saturday  morning  and  afternoon  will  be  devoted 
to  the  second  annual  meeting  of  the  combined  medical  so- 
cieties of  the  ^ledical  Department  of  the  University  of 
Pennsylvania,  and  on  Saturday  evening  the  annual  banquet 
of  the  combined  medical  societies  will  be  held. 


The  Fall  River,  Mass.,  Anti-Tuberculosis  Society  has 

started  an  active  crusade  against  the  great  white  plague. 
The  society  has  a  membership  of  about  two  hundred,  and 
its  object  is  to  help  those  who  are  too  poor  to  help  them- 
selves to  a  chance  to  get  well ;  to  know  every  one  in  Fall 
River  who  has  tuberculosis  and  to  help  him  in  every  possi- 
ble way;  to  teach  the  children  how  to  grow  strong;  to  im- 
prove home  conditions  of  the  poor ;  and  to  establish  a 
tuberculosis  class  where  the  poor  consumptive  can  get  ad- 
vice and  treatment.  About  $800  was  realized  from  the  sale 
of  the  Red  Cross  Christmas  stamps,  and  with  this  fund  the 
society  has  employed  a  nurse  who  will  investigate  all  cases 
reported  to  the  society. 

An  Open  Air  School  for  Tuberculous  Children  has 
been  established  on  the  old  ferryboat  South-field .  which  was 
recently  turned  into  a  day  camp  for  tuberculosis  patients 
by  Bellevue  Hospital.  These  special  classes  are  maintained 
by  the  Board  of  Education,  and  at  present  there  are  thirty^ 
five  pupils  in  attendance,  ranging  in  age  from  six  to  fifteen 
years.  The  children  are  carefully  protected  from  the  cold, 
and  work  at  their  desks  in  all  kinds  of  weather.  From  nine 
until  half  past  three  shifts  of  patients  take  their  seats-in  the 
ferryboat  school.  The  school  hours  are  short,  as  the  main 
object  is  to  make  the  children  well.  A  record  is  kept  every 
day  of  the  weight  and  temperature  of  the  children,  and 
milk  and  eggs  are  given  to  them  at  odd  intervals.  The 
improvement  in  some  of  the  children  has  been  remarkably 
rapid. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing Alarch  13,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  of  Philadel- 
phia :  Typhoid  fever,  27  cases,  5  deaths ;  scarlet  fever,  78 
cases,  2  deaths ;  chickenpo.x,  63  cases,  2  deaths ;  diphtheria, 
63  cases,  14  deaths ;  cerebrospinal  meningitis,  i  case,  o 
deaths;  measles,  173  cases,  7  deaths;  whooping  cough,  25 
cases,  3  deaths ;  tuberculosis  of  the  lungs.  162  cases,  68 
deaths ;  pneumonia,  78  cases,  62  deaths ;  erysipelas,  14  cases, 
6  deaths ;  mumps.  26  cases,  o  deaths.  The  following  deaths 
were  reported  from  other  transmissible  diseases :  Tubercu- 
losis, other  than  tuberculosis  of  the  lungs,  15  deaths ;  diar- 
rhoea and  enteritis,  under  two  years  of  age.  13  deaths; 
puerperal  fever,  3  deaths.  There  were  20  deaths  from  can- 
cer. The  total  deaths  numbered  555  in  an  estimated  popu- 
lation of  1,565,569,  corresponding  to  an  annual  death  rate 
<  f  18.40  in  a  thousand  population.  The  total  infant  mor- 
tality was  129;  99  under  one  year  of  age.  30  between  one 
and  two  years  of  age.  There  were  45  still  births ;  24  males 
and  21  females.    The  total  precipitation  was  0.69  inch. 

Personal. — Dr.  Wolff  Freudenthal,  1003  Aladison  Ave- 
nue, New  York,  has  been  appointed  a  corresponding  mem- 
ber of  the  Laryngological  Society  of  Berlin. 

Dr.  John  V.  Shoemaker,  of  Philadelphia,  who  has  been 
very  ill  for  several  weeks,  is  reported  to  be  improving.  He 
hopes  to  be  able  to  resume  his  practice  before  very  long. 

Dr.  R.  S.  Woodworth,  adjunct  professor  of  psychology 
in  Columbia  University,  has  been  promoted  to  a  professor- 
ship of  psychology-. 

Captain  Joseph  F.  Siler,  of  the  Medical  Corps  of  the 
United  States  Army,  will  represent  the  Medical  Depart- 
ment of  the  Army  at  the  meeting  of  the  American  Society 
of  Tropical  Aledicine,  to  be  held  in  Washington.  D.  C.  on 
April  loth. 

Dr.  Frederik  van  Eeden,  of  Amsterdam,  who  twenty 
years  ago  established  a  clinic  for  the  mental  treatment  of 
disease,  is  at  present  visiting  in  the  United  States. 

Dr.  A.  B.  Ancker,  who  has  been  superintendent  of  the 
St.  Paul,  Minn.,  City  and  County  Hospital  for  the  past 
twenty-six  years,  has  been  unanimously  reelected  to  that 
position  for  another  term  ot  four  years. 

The  appointment  of  Dr.  Richard  Leuschner  as  medical 
superintendent  of  the  Avery  Hotel,  ]\Iount  Clemens,  Mich., 
has  been  announced. 

At  a  recent  meeting  of  the  Board  of  Directors  of  the 
Chicago  Eye,  Ear,  Nose,  and  Throat  College,  Dr.  Joseph 
G.  Beck  was  elected  professor  of  otologj',  rhinology,  and 
laryngology.* 

Dr.  William  Henry  Wahl,  of  Philadelphia,  for  twenty- 
six  years  secretary  of  the  Franklin  Institute,  died  on  Tues- 
day, ]\Iarch  23d.  aged  sixty  years. 

.A.t  a  recent  meeting  of  the  Richmond,  Va.,  Academy  of 
Medicine  and  Surgery,  Dr.  Heinrich  Stern,  of  New  York, 
read  a  paper  entitled  Facts  and  Fallacies  Concerning  Al- 
buminuria. 


656 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


%\X\  0f  Cttrrtnt  f  ittrstttte. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

March  18,  igog. 

1.  Arteriosclerosis,  By  George  S.  C.  Badger. 

2.  Some  New  Applications  of  Electricity  and  Light  in 

Medicine,  By  H.  W.  Van  Allen. 

3.  A  Study  on  Hand  Sterilization, 

By  Charles  Greene  Cumston. 

1.  Arteriosclerosis. — Badger  remarks  that  the 
presence  of  arteriosclerosis  does  not  always  call  for 
treatment.  There  may  be  no  symptotns  attributable 
to  it.  The  damage  already  done  to  the  vessel  walls 
cannot  be  cured.  At  best  the  process  may  be  stayed 
or  hindered.  The  setiological  factors  iriust  be  taken 
into  consideration  in  planning  treatment.  Obviously 
immoderate  drinking,  overeating,  dissipation,  and 
excessive  muscular  effort  must  be  corrected.  The 
appropriate  treatment  in  cases  of  sclerosis  due  to  lead 
poisoning,  diabetes,  and  other  toxic  conditions  is  evi- 
dent, to  get  rid  of  the  underlying  condition.  The 
presence  of  high  blood  pressure  does  not  always  de- 
mand treatment,  as  in  some  cases  it  is  protective 
against  disaster.  A  falling  pressure  is  often  an  omi- 
nous sign.  When  symptoms  can  be  attributed  to 
high  pressure,  the  use  of  drugs  to  lower  it  is  indi- 
cated. Nitroglycerin,  the  nitrites,  aconite,  and  erv- 
throl  tetranitrate  may  be  used,  and  in  suitable  cases 
venesection.  The  iodides  are  very  useful  when  used 
over  long  periods  of  time.  They  lower  blood  pres- 
sure, possibly,  by  lessening  the  viscosity  of  the  blood. 
The  main  reliance  in  treatment  must  be  placed  on  the 
ability  to  properly  regulate  the  life  of  the  individual. 
An  intelligent  comprehension  on  the  patient's  part 
and  his  cooperatioii  are  essential  to  its  successful 
carrying  out. 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

March  20,  iQog. 

1.  Conservatism  in  Surgery,  By  James  E.  Moore. 

2.  Elective  Csesarean  Section,  By  Miles  F.  Porter. 

3.  The  Influence  on  the  Nose  of  Widening  the  Palatal 

.A.rch,  By  Lee  Wallace  Dean. 

4.  Relation  between  Deviation  of  Nasal  Sseptum  and  Ir- 

regularities of  Teeth  and  Jaw  from  a  Rhinologist's 
Standpoint,  By  Nelson  M.  Black. 

5.  Peripheral   and    Intracranial    Neurofibromatosis,  witii 

Report  of  a  Case,  By  William  Healv. 

6.  Ata.xic  Arsenical  Neuritis  with  Loss  of  Osseous  Sensi- 

bility, By  Charles  Metcalfe  Byrnes. 

7.  The  Rontgenologist  and  His  Specialty, 

By  Percy  Brown. 

8.  Fibromyoma  of  the  L'terus  Complicated  by  Cancer  or 

Sarcoma.    With  Report  of  Thirty-five  Cases, 

By  Ellice  McDonald. 
g.    Gastrointestinal  Disturbances  Due  to  Arteriosclerosis, 

By  John  J.  Gilbride. 
10.  Local  and  Systemic  Conditions  Due  to  Nasal  Obstruc- 
tion, By  Willis  S.  Anderson. 

2.  Elective  Cassarean  Section. — Porter  observes 
that  in  patients  with  contracted  pelves,  Caesarean  sec- 
tion should  supplant  the  obstetric  operations  in  many 
cases  and  practically  always  in  primaparje.  In  pla- 
centa pncvia  centralis  Csesarean  section  should  be 
the  operation  of  choice  if  the  child  is  viable.  In 
eclampsia  occurring  at  or  near  term  in  a  first  preg- 
nancy, Gesarean  section  is  the  best  method  of  deliv- 
ery, except  in  cases  where  the  child  is  relatively 
small,  or  the  vagina  and  pelvic  capacious,  when 
Diihrssen's  operation  might  be  given  the  preference. 
Wnnien  re<|uiring  abdominal  section  at  term  for  the 


removal  of  uterine  or  ovarian  tumors  should  be  de- 
livered by  Csesarean  section  immediately  before  or 
after  the  tumor  is  removed.  In  the  case  of  an  elder- 
1}-  primapara  at  term  with  a  vigorous  child,  with  a 
normal  pelvis,  but  with  rigid  soft  parts,  who  is  un- 
usually sensitive  to  pain,  whose  nervous  equilibrium 
is  unstable,  and  whose  physical  condition  is  below 
par,  Csesarean  section  done  before  labor  has  begun 
or  at  its  very  beginning  offers  a  better  chance  of  life 
and  health  to  both  mother  and  child  than  the  so 
called  conservative  operations.  It  is  not  to  be  for- 
gotten that  one  of  the  chief  arguments  in  favor  of 
Csesarean  section  as  against  other  operations  is  the 
fact  that  it  entails  no  risk  to  the  child ;  hence,  in  case 
of  a  dead  or  dying  child  this  argument  carries  no 
weight  and,  therefore,  it  will  not  infrequently  happen 
that  because  of  a  dead  or  dying  child  a  conservative 
method  will  be  better  in  a  case  which,  were  the  child 
vigorous  and  viable  and  the  other  conditions  the 
same,  Csesarean  section  would  be  the  better  method. 

4.  Saeptal  Deviations. — Black  remarks  that  the 
great  reason  why  saeptal  deformities  tend  to  return 
is,  in  the  first  place,  'the  difficulty  in  the  removal  of 
sufficient  tissue  to  prevent  backward  pressure  on  the 
saeptum  and  a  consequent  return  of  the  deflection.  If 
too  little  tissue  is  removed  the  result  is  unsatisfac- 
tory. In  the  second  place,  the  main  setiological  fac- 
tor— that  is,  some  dental  or  jaw  irregularity— is 
overlooked  and  goes  uncorrected.  The  main  factor 
in  the  production  of  the  deformity  remains  with  a 
lessened  resistance  in  the  deformed-part,  with  a  con- 
sequent tendency  to  return.  This  was  much  more 
frequently  the  case  in  the  days  before  submucous  re- 
section, but  to  a  certain  extent  still  holds  good.  Thus 
the  fact  is  being  forced  on  us  that  the  conditions, 
normal  or  abnormal,  of  one  portion  of  the  head  and 
face  are  dependent  on  the  condition  of  other  por- 
tions. The  result  is  the  relation  of  each  of  the  spe- 
cialties with  the  other  must  be  recognized,  and  spe- 
cialists, instead  of  drawing  imaginary  circles  around 
their  respective  provinces  and  saying  to  themselves, 
'"Thus  far  must  I  go  and  no  farther,"  and  to  their 
neighbors,  "Thus  far  may  you  come  and  no  farther." 
must  accept  the  results  of  the  study  and  clinical  ex- 
perience of  specialists  in  other  branches  and  cooper- 
ate with  them  for  the  good  of  the  patient.  The  time 
is  past  for  thinking  that  in  one  particular  field  of 
medicine  or  surgery  the  whole  cause  may  be  found ; 
on  the  contrary,  the  causative  factors  may  be  very 
complex. 

6.  Arsenical  Neuritis. — -Byrnes  reports  a  case 
of  this  disease  which  is  of  interest  on  account  of  its 
infrequency  and  also  because  of  its  pseudotabetic  fea- 
tures and  the  symptom  of  loss  or  osseous  sensibilitv 
which  has  been  hitherto  unreported  in  this  form  of 
neuritis,  though  common  in  other  forms  of  neuritis 
and  in  tabes.  The  cause  was  attributed  at  first  to 
exposure  to  fresh  paint  containing  white  lead  used  in 
house  painting,  but  it  was  afterward  ascertained  that 
it  was  due  to  arsenic  introduced  into  a  can  of  baking 
powder,  probably  with  criminal  intent.  The  loss  of 
the  vibratory  sense  or  os.seous  sensibility  is  specially 
noted  as  occurring  in  the  ataxic  form  of  neuritis.  It 
illustrates  a  resemblance  to  tabes.  In  reviewing  200 
cases  of  neuritis  from  various  causes  other  than  mul- 
tiple neuritis  Byrnes  has  not  found  one  case  in  which 
this  symptom  was  present. 


Maicil  27.  iQog.l 


PITH  OF  CURRENT  LITERATURE. 


657 


9.  Gastrointestinal  Disturbances  Due  to  Arte- 
riosclerosis.— (jilbride  says  tliat  gastrointestinal 
disturbances  dvie  to  arteriosclerosis  are  sometimes 
found  in  patients  who  have  a  generalized  arterio- 
sclerosis or  in  those  in  whom  the  splanchnic  arteries 
only  appear  to  be  diseased.  The  cases  that  come 
within. the  latter  group  are  perhaps  the  more  im- 
portant from  the  diagnostic  standpoint,  as  the  true 
cause  of  the  symptoms  may  be  overlooked.  The 
patients  are  usually  over  forty  years  of  age ;  indi- 
viduals between  forty  and  fifty  years  old  may  have 
symptoms  of  a  generalized  arterial  disease,  while 
some  patients  who  are  much  older  may  complain 
only  of  symptoms  of  a  localized  vascular  disease. 
Of  course  generalized  arteriosclerosis  is  more  com- 
mon in  elderly  people.  Abdominal  pain  is  a  promi- 
nent symptom.  At  first  it  is  paroxysmal,  lasting 
from  a  few  minutes  to  half  an  hour  and  recurring 
several  times  a  day ;  later  it  becomes  continuous  and 
the  patient  complains  of  a  dull  ache,  soreness  and 
throbbing  in  the  abdomen.  The  pain  is  localized  in 
the  epigastric  or  umbilical  regions,  less  commonly  in 
the  lower  abdomen.  It  is  increased  by  exertion  and 
in  some  instances  during  digestion.  Next  to  pain 
the  most  common  symptom  is  weakness,  and  not  a 
few  patients  lose  weight.  The  loss  of  weight  may 
be  moderate  and  gradual  or  rapid  and  considerable. 
A  loss  of  weight  is  ver_v  common  in  patients  with 
arteriosclerosis,  but  the  loss  of  weight  is  even 
greater  in  those  who  have  an  associated  dyspepsia. 
The  reduction  in  weight  is  due  in  part  to  the  vas- 
cular disease  and  in  part  to  the  dieting  which  is 
undertaken  in  an  effort  to  relieve  the  dyspeptic 
symptoms.  Abdominal  distension  and  belching  are 
frequently  present.  Therefore  the  association  of 
dyspeptic  symptoms  with  weakness  and  loss  of 
weight  in  persons  of  middle  or  advanced  age  is  apt 
to  arouse  some  apprehension.  There  may  be  ful- 
ness and  distress  after  eating,  nausea  at  times,  and 
regurgitation  of  sour  liquid  is  an  occasional  symp- 
tom. The  appetite  may  be  normal,  increased,  or 
diminished,  or  in  some  cases  lost.  The  bowels  are 
variable;  there  mly  be  constipation,  or  constipation 
alternating  with  attacks  of  diarrlirea.  or  the  move- 
ments may  occur  at  normal  intervals.  Some  pa- 
tients sufTer  from  attacks  of  vertigo,  and  a  few 
complain  of  disturbance  of  vision.  The  urine  is 
frequently  diminished  in  quantity  and  may  show 
signs  of  an  interstitial  nephritis.  Alany  such  pa- 
tients show  symptoms  of  autointoxication  at  times. 
The  radial  arteries  may  or  may  not  show  the  pres- 
ence of  sclerosis,  and  the  blood  pressure  may  be 
high.  low.  or  normal.  It  is  important  to  determine 
the  blood  pressure. 

10.  Nppal  Obstruction. — Anderson  points  out 
the  underlying  factors,  which  render  patients  par- 
ticularly susceptible  to  repeated  cold  and  suggests 
the  proper  line  of  treatment  for  their  permanent 
relief.  The  unsatisfactory  results  which  are  ob- 
tained in  the  treatment  of  catarrh  encourage  us  to 
search  more  carefully  for  the  reason  why  perma- 
nent relief  is  obtained  so  seldom  from  the  usual 
methods  of  treatment.  It  is  a  common  observation 
thaf  children  affected  with  adenoids  and  adults  with 
marked  nasal  obstruction  are  especially  susceptible 
to  colds,  and  also  sufifer  from  many  general  and 
local  symptoms.    This  fact  led  him  to  study  more 


closely  normal  nasal  respiration,  and  to  ascertain 
what  effect,  if  any,  a  moderate  degree  of  obstruc- 
tion has  on  the  resistance  of  the  patient,  and  also  to 
try  to  find  out  whether  or  not  there  is  any  relation 
between  diseases  of  the  respiratory  tract  and  im- 
proper breathing.  He  experimented  on  the  effects 
of  nasal  obstruction,  partial  or  total,  on  about 
seventy-five  animals,  guinea  pigs,  rabbits,  and  dogs. 
The  former  succumbed  to  complete  closing  in  from 
twenty-four  to  forty-eight  hours  and  to  partial 
closure  after  a  longer  period.  Rabbits  with  one 
nostril  closed  died  after  losing  about  one  half  their 
weight,  while  partial  closure  of  nostrils  of  dogs 
caused  symptoms  resembling  asthma  and  emphy- 
sema. The  younger  dogs  died  from  infection  and 
the  lungs  were  found  to  be  diseased  in  every  case. 
The  changes  in  the  hair  were  constant  and  peculiar. 
The  anatomical  differences  between  man  and  the 
lower  animals  must  be  considered,  but  he  is  con- 
vinced tliat  natural  breathing  should  be  through  the 
nose  and  that  even  a  small  amount  of  obstruction  is 
injurious.  As  conclusion  he  says  that  the  evidence 
derived  from  the  study  of  histology,  comparative 
anatom}',  experiments  on  animals,  and  clinical  ob- 
servations shows  that  the  nose  is  the  organ  through 
which  the  current  of  air  should  pass  in  normal 
breathing.  Nasal  obstruction  in  animals  is  fol- 
lowed by  dyspnoea,  lessened  resistance,  and  changes 
in  the  lungs.  Impaired  nasal  breathing,  even  of 
moderate  degree,  is  the  important  setiological  factor 
in  the  causation  of  catarrh.  Lowered  vitality,  ac- 
companied by  a  variety  of  general  symptoms,  is 
often  due  to  nasal  obstruction.  The  aim  of  treat- 
ment is  to  obtain  free  nasal  breathing.  This  can  be 
accomplished  in  the  majority  of  instances  only  by 
surgical  measures. 

MEDICAL  RECORD. 

March  20,  igog. 
r.    Some  Obser\'ations  on  Nephrectomy,  with  a  Report  of 
Fifty-three  Personal  Operations. 

By  George  Emerson  Brewer. 
2.    Cases  Illustrating  the  Results  of  the  So  Called  Heath 
Operations,  By  S.  Maccuen  Smith. 

The  Hygienic  and  Climatic  Prophylaxis  of  Tubercu- 
losis in  Childhood, 

By  Frederick  L.  Wachenheim. 

4.  Blocking  Stones  in  the  Lower  End  of  the  Ureter, 

By  J.  J.  Buchanan. 

5.  Rontgen  Diagnosis  of  Calculi,    By  Russell  H.  Boggs. 

6.  Medical  and  Sanitary  Inspection  of  Schools, 

By  Richard  Cole  Newton. 

7.  Purpura  Hjemorrhagica ;  Is  It  Caused  by  the  Colon 

Bacillus?  By  Stephen  J.  Mahek. 

2.  The  Heath  Operation. — Smitli  reports  five 
otological  cases  in  which  the  Heath  operation  was 
performed.  On  general  principles  it  is  difiicult  for 
one  to  accept  as  good  surgical  procedure  that  which 
advocates  the  nondisturbance  of  necrotic  tissues,  be 
it  either  diseased  ossicles  or  carious  bone  that  must 
necessarily  remain  in  the  narrow  space  connecting 
the  tympanic  cavity  with  the  mastoid  antrum,  and 
yet  this  is  precisely  what  is  said  for  the  Heath 
operation.  In  other  words,  the  aim  is  to  perform  a 
radical  operation,  which  includes  the  complete  ex- 
enteration of  the  cells  comprising  the  temporal 
bone,  with  the  exception  of  tlie  tympanic  ring  and 
the  fragment  of  ossicles  and  membrana  tympani 
which  are  left  undisturbed,  as  the  extent  of  their 


658 


RITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


necrotic  involvement  seems  to  make  but  little  differ- 
ence in  the  final  result.  The  operations,  performed 
by  Smith,  were  all  successful.  Our  author  concludes 
that,  generally  speaking,  the  operation  should  not  be 
performed  in  the  presence  of  suppurative  or  ne- 
crotic diseases  of  the  labyrinth,  where  cholesteato- 
mata  are  present  within  the  cavities  of  the  tympa- 
num or  antrum,  or  abscess  formations  involving  the 
interior  of  the  skull,  especially  if  the  infeciion  gains 
entrance  through  the  tegmen  tympani.  On  the 
other  hand,  he  advises  the  operation  in  appropriate 
cases,  from  the  fact  that  it  does  not  interfere  with 
the  membrana  tympani  and  ossicles,  thereby  not 
jeopardizing  the  power  of  hearing.  It  would  seem 
best,  as  a  rule,  for  this  reason,  that  the  operation 
be  performed  early,  before  the  disease  has  caused 
much  destruction  of  the  conducting  apparatus. 
Some  other  points  in  its  favor  are  that  the  danger 
of  injury  to  the  facial  nerve  is  very  much  reduced ; 
the  shock  from  the  surgical  procedure  is  consid- 
erably lessened,  and  the  recovery  is  notably  quick, 
while  at  the  same  time  it  corrects  the  pathological 
process  within  the  danger  zone,  the  antrum.  This 
procedure,  furthermore,  not  only  preserves  the 
hearing  present  at  the  time  of  operation,  but  actu- 
ally improves  it  to  a  noticeable  degree  in  the  major- 
ity of  cases.  Then,  again,  it  is  suitable  in  both  the 
acute  and  chronic  variety  of  cases,  and  will  prob- 
ably supplant  the  operation  known  as  ossiculectomy 
for  the  cure  of  an  otorrhoea. 

4.  Blocking  Stones  in  the  Lower  End  of  the 
Ureter. — Buchanan  gives  a  very  complete  review 
of  the  operative  treatment  for  the  removal  of  stones 
from  the  ureter.  Stones  have  been  removed  from 
the  ureter  by  opening  the  kidney  and  i?assing  for- 
ceps down  the  dilated  ureter  for  the  extraction  of 
the  stone.  The  kidney  has  been  removed,  to  stop 
its  secretion,  and  even  the  ureter  has  been  removed 
with  the  kidney  in  a  number  of  cases  to  do  away 
entirely  with  the  urinary  secretion  on  that  side  and 
to  remove  the  foreign  body.  The  kidney  has  been 
opened  and  the  stone  pushed  into  the  bladder  by 
sounds  passed  through  the  dilated  ureter.  The 
ureter  has  been  opened  through  a  suprapubic  cys- 
totomy, an  incision  being  made  also  through  the 
base  of  the  bladder,  when  the  stone  was  impacted 
at  the  very  end  of  the  ureter.  The  ureter  has  been 
opened  through  the  peritoneal  cavity,  by  making  an 
abdominal  section.  Stones  have  been  removed  from 
the  vesical  end  of  the  ureter  by  exposing  the 
ureteral  orifice,  through  the  cystoscope,  dilating  the 
orifice,  and  extracting  the  stone.  The  ureter  has 
been  opened  for  the  extraction  of  a  stone,  by  a 
vaginal  incision,  by  rectal  incision,  and  by  a  para- 
sacral incision.  Exposure  of  the  ureter  by  opening 
the  peritoneal  cavity  and  cutting  into  the  ureter 
through  the  peritonaeum  is  generally  considered  to 
be  a  dangerous  operation,  because  there  is  a  very 
large  probability  of  leakage  of  urine  through  the 
opening  left  by  the  extraction  of  the  stone,  and 
this  extravasation  of  urine,  if  it  passes  into  the 
peritoneal  cavity,  may  result  in  fatal  peritonitis. 
But  the  operation  of  choice  according  to  our  author 
is  the  extraperitoneal  ureterolithotomy.  This  op- 
eration is  made  by  carrying  the  incision  ])arallel 
with  the  fibres  of  the  external  oblique  muscle,  from 
a  position  somewhat  internal  to  the  anterior  supe- 


rior spinous  process,  extending  it  upward  or  down- 
ward, accordmg  to  the  location  of  the  stone,  carry- 
ing this  incision  through  the  muscular  tissues,  until 
the  peritonaeum  is  reached,  lifting  the  peritoneum 
from  the  structures  posteriorly,  until  the  vessels 
and  ureter  are  reached.  The  ureter  follows  the 
peritonaeum,  being  more  intimately  attached  to  it 
than  to  the  fascia  behind,  and  when  the  stone  is 
identified  it  is  an  easy  matter  to  follow  the  ureter 
to  the  point  of  constriction  and  impaction  of  the 
stone.  The  stone  is  then  coaxed  upward  from  its 
bed  into  the  dilated  ureter,  if  it  is  possible  so  to  do. 
An  incision  into  the  ureter  is  then  made  and  the 
stone  is  removed.  A  ureteral  bougie  is  then  passed 
downward  into  the  bladder  through  this  incision  to 
make  sure  that  the  passage  is  now  entirely  free. 
Ureteral  sutures  of  the  finest  silk  or,  preferably, 
of  fine  catgut  are  then  introduced,  a  drainage  tube 
is  inserted,  and  the  incision  is  closed.  Even  if  a 
large  amount  of  urine  is  extravasated,  it  is  always 
external  to  the  peritoneal  cavity,  and  it  escapes 
harmlessly  and  soon  ceases  to  be  discharged.  The 
conclusions  Buchanan  draws  are:  i.  The  diagnosis 
between  an  acute  attack  of  appendicitis  and  stone 
in  the  right  ureter  is  sometimes  impossible.  2.  If 
the  acuteness  of  the  attack  is  such  as  to  require 
an  immediate  operation,  in  case  the  condition  should 
turn  out  to  be  an  appendicitis,  the  immediate  re- 
moval of  the  appendix  is  indicated,  which  being 
under  these  circumstances  a  harmless  operation,  re- 
moves the  immediate  danger.  3.  The  diagnosis  by 
the  x  ray,  in  competent  hands,  is  accurate  and  satis- 
factory, and  every  doubtful  case  should  be  submit- 
ted to  this  test.  4.  Every  part  of  the  ureter  can  be 
exposed  by  the  extraperitoneal  operation,  which  in 
a  patient  in  an  ordinary  condition,  seems  to  be  prac- 
tically free  from  danger. 

7.  Is  Purpura  Hasmorrhagica  Caused  by  the 
Colon  Bacillus? — Maher  answers  this  question  in 
the  following  way,  having  recently  treated  such  a 
case:  i.  The  recently  extravasated  blood  of  this 
case  of  malignant  purpura  haemorrhagica  contained 
clumped  in  its  leucocytes  bacilli  having  the  cultural 
and  other  characters  usually  ascribed  to  the  colon 
bacillus.  2.  The  bacilli  isolated  either  from  the  fresh 
or  from  the  old  blood  had  the  power  on  intraperito- 
neal injected  into  guinea  pigs,  not  only  to  kill  the  ani- 
mals in  a  few  hours,  but  to  produce  on  the  wall  of 
the  animal's  intestines  and  stomach  purpuric  patches 
identical  in  appearance  with  those  that  characterized 
the  disease  in  the  human  body.  3.  This  power  to 
produce  purpuric  patches  on  the  walls  of  the  intes- 
tines of  the  injected  animal  was  striking  and  con- 
stant even  after  the  bacillus  had  passed  through  four 
series  of  guinea  pigs.  4.  This  power  was  diminished 
in  the  cultures  that  had  been  kept  for  eight  days  or 
more  in  the  incubator,  although  the  keeping  of  the 
cultures  fourteen  days  in  the  incubator  did  not  lessen 
the  pathogenicity  of  the  bacillus.  5.  A  white  rat, 
though  more  resistant  to  the  first  cultures  of  this  ba- 
cillus, succumbed  in  exactly  the  same  way  as  the 
guinea  pig  when  injected  with  the  bacillus  that  had 
been  through  four  guinea  pigs.  6.  The  colon  bacil- 
lus, although  usually  fatal  to  injected  guinea  pigs, 
does  not  kill  so  (|uickly  and  does  not  cause  the  ap- 
pearance of  purpuric  patches  on  the  intestinal  and 
stomach  walls  of  the  injected  animals. 


March  27,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


659 


BRITISH  MEDICAL  JOURNAL. 

March  6,  1909. 

1.  Some  Clinical  Facts  Regarding  Mammary  Cancer, 

By  Sir  H.  C.  Camerox. 

2.  The  Natural  Cure  of  Cancer,         By  \V.  S.  Handley. 

3.  The  Treatment  of  Cancer  by  the  Use  of  Potassium  Bi- 

chromate, By  J.  Fexvvick. 

4.  Observations  on  the  Physiology  of  the  Female  Genital 

Organs  (Report  CXII  of  the  Science  Committee  of 
the  British  Medical  Association), 

By  W.  B.  Bell  and  P.  Hick. 
^5.    Observations  on  Pleural  Pains  and  Adhesions, 

By  J.  T.  Maclachlan. 

I,  2,  and  3.  Cancer. — Cameron  stimmarizes  the 
present  clinical  teaching  in  regard  to  cancer  of  the 
breast,  as  follow  s :  It  is  a  disease  which  probably 
invades  the  body  from  without,  and  is  at  first  strict- 
ly of  local  character  and  of  local  consequence.  If 
removed  at  a  very  early  stage — that  is  when  the 
tumor  is  recent  and  still  small — by  an  extensive 
operation  definitely  planned  and  carried  out,  a  satis- 
factory cure  may  follow.  Should  no  return  of  the 
disease  occur  within  a  period  of  a  few  years — say 
three  to  five — this  result  may  be  considered  as  fair- 
ly assured.  But  our  most  favorable  results  are  not 
to  be  regarded  as  due  necessarily  and  always  to  the 
form  and  extent  of  the  operation  or  to  the  date  of 
interference  relatively  to  the  size  of  the  tumor. 
They  seem  due  rather  to  the  essential  character  of 
the  individual  tumor  and  the  degree  of  invasion  of 
the  lymphatic  system  of  the  part  in  each  individtial 
case.  If  the  upper  axilla  is  involved  as  well  as  the 
lower  the  prognosis  is  the  more  doubtful ;  if  there 
is  obvious  infection  of  the  skin,  especially  in  the 
form  of  detached  separate  nodules  near  the  seat  of 
the  disease,  the  prospect  of  long  immunity  from  re- 
currence is  very  slight,  however  large  an  area  of 
skin  be  sacrificed,  while  if  the  disease  is  apparent 
in  glands  above  the  clavicle,  the  writer  declines  to 
operate.  Still  the  extent  of  the  operation  is  a  cer- 
tain factor  in  the  results. — Handley  discusses  the 
natural  cure  of  cancer,  and  lays  down  this  hitherto 
unrecognized  law  of  cancer  growth :  Every  aggre- 
gation of  carcinoma  cells  has  a  definite  life  cycle, 
and,  after  increasing  in  size  for  a  varying  period 
and  at  a  varying  rate,  tends  spontaneously  to  un- 
dergo degenerative  and  fibrotic  changes.  These 
changes  extend  from  the  centre  of  the  mass  cen- 
trifugally  to  its  periphery,  lead  to  its  shrinkage,  and 
terminate  in  the  replacement  of  the  aggregation  of 
cancer  cells  by  a  fibrous  scar.  In  other  words,  the 
natural  history  of  a  cancer  is  one  of  centrifugal 
growth  followed  by  centrifugal  death.  The  natural 
cure  in  cancer  is  a  local  and  not  a  constitutional 
process,  and  as  a  rule  it  closely  follows  up,  without 
•overtaking,  the  centrifugal  spread  of  permeation, 
and  so  fails  to  arrest  the  march  of  the  disease.  In 
some  cases  its  vigor  is  sufificient  to  strangle  the 
growth  in  an  early  stage  or  to  reduce  it  to  impo- 
tence for  a  long  term  of  years,  but  as  a  rule  the 
natural  processes  of  cttre  go  on  contemporaneously 
with  the  active  advance  of  the  disease  in  other  parts 
of  the  body  further  removed  from  the  primary 
focus.  The  natural  local  cure  of  cancer  is  brought 
about  by  fibrotic  processes  which  cut  of?  the  cancer- 
ous epithelium  from  that  contact  with  connective 
tissue  cells  which  is  necessary  to  maintain  its  vital- 
ity.   This  process  presents  some  analogy  with  the 


natural  cure  of  tuberculosis,  which  also  takes  place 
by  a  process  of  fibrosis.  The  writer  suggests  that 
the  open  air  treatment,  which  has  proved  so  suc- 
cessful in  tuberculosis,  may  be  worthy  of  trial  in 
the  more  chronic  cases  of  inoperable  cancer.  The 
treatment  would  require  modification ;  for  example, 
the  carcinoma  patient,  as  contrasted  with  the  tuber- 
culosis patient,  would  probably  require  less  food 
and  more  exercise. — Fenwick  reports  twenty-two 
cases  of  cancer  treated  by  the  use  of  injections 
of  potassium  bichromate  into  the  substance  of  the 
tumor.  The  dose  used  was  from  seven  to  ten  min- 
ims of  a  sublimate  solution;  in  some  cases  fifteen 
minims  were  injected.  The  results  obtained  were 
excellent,  especially  in  cases  of  rodent  ulcer  and 
epithelioma.  The  method  is  simple  and  inex- 
pensive. Rodent  ulcers  can  be  removed  with  great 
ease,  without  the  patient's  losing  a  day's  work. 

4.  Menstruation. — Bell  and  Hick,  as  a  result 
of  their  studies  of  the  physiology  of  the  female 
genital  organs,  have  reached  the  following  conclu- 
sions regarding  menstruation;  i.  Menstruation  is  a 
periodical  function  only  in  so  far  as  the  calcium 
metabolism  is  in  harmony  with  this  periodicity^  and 
the  function  is  dependent  upon  the  calcium  meta- 
bolism in  all  its  ramifications.  2.  The  haemorrhage 
into  the  Graafian  follicle  may  be  coincidental,  and 
is  probably  the  result  of  the  lowered  coagulability 
of  the  blood  or  vasomotor  changes ;  but  rupture  of 
the  follicle  is  in  no  way  responsible  for  menstrua- 
tion. 3.  The  bleeding  from  the  uterus,  while  due 
to  the  lowered  coagulability  of  the  blood  in  part,  is 
also  dependent  on  the  local  changes  in  the  capil- 
laries from  which  the  diapedesis  of  leucocytes  and 
corpuscles  occurs ;  and  further,  these  leucocytes  are 
an  active  factor  in  the  conveyance  of  calcium  salts 
from  the  glands  to  the  exterior.  4.  The  uterine 
glands  excrete  calcium  and  mucin,  and  therefore 
the  uterus  is  a  "menstrual  organ."  5.  There  is  a 
correlation  between  the  ovaries  and  uterus  with 
reference  to  menstruation,  but  the  ovary  is  probably 
no  more  predominant  than  other  ductless  glands  in 
this  respect.  6.  Menstruation  per  se  is  not  a  neces- 
sary adjuvant  nor  concomitant  to  fertility  and  re- 
production. 

5.  Pleurisy  and  Tuberculosis.  —  Maclachlan 
states  that  the  importance  of  pleurisy  as  a  mode  of 
origin  of  pulmonary  tuberculosis  is  not  sufficiently 
appreciated.  Patients  often  complain  of  shooting 
or  darting  pains  in  the  chest  long  before  tubular 
breathing  or  expectoration  reveals  the  presence  of 
serious  mischief  in  the  lungs.  These  darting  pains 
are  too  often  ascribed  to  pleurodynia  or  neuralgia. 
But  the  writer  asserts  that  these  so  called  pleuro- 
dynias are  in  reality  localized  patches  of  pleurisy, 
and  they  are  mostly,  if  not  always,  of  tuberculous 
origin.  These  sharp  pains  come  on  suddenly  with- 
out reference  to  wind  or  weather ;  they  are  usually 
referred  to  certain  well  defined  regions,  namely, 
where  the  lungs  divide  into  their  lobes,  or  the  free 
margins  of  the  lungs.  The  involved  areas  may  be 
diagnosticated  by  very  delicate  percussion,  which 
may  be  called  tactile  percussion,  as  the  sense  of  re- 
sistance is  strongly  appealed  to.  The  ordinary  stroke 
in  percussion  strikes  through  these  areas  of  pleu- 
risy and  brings  out  lung  resonance.  Auscultation 


66o 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Tourxa:.. 


is  not  nearly  so  valuable  as  percussion.  If  the 
fibrinous  exudation  is  recent,  rubbing,  grating,  or 
squeaking  sounds  may  be  heard.  Inspection  in  well 
marked  cases  may  show  deficient  expansion  and 
contraction.  The  diagnosis  of  pleural  adhesions 
should  be  regarded  as  a  danger  signal  to  warn  the 
patient  to  take  all  precautions  in  his  mode  of  life, 
diet,  etc.,  to  ward  off  the  graver  manifestations  of 
tuberculosis  of  the  lungs. 

LANCET 

March  6,  igog. 

1.  The  Morpholog}-  and  Variation  of  the  Skull  (Hunterian 

Lectures,  I,  II,  and  III),  By  W.  Wright. 

2.  Four  Cases  of  Volvulus  Associated  with  Hernia, 

By  R.  L.  Knaggs. 

3.  Case  of  Volvulus  of  the  Entire  Small  Intestine,  Cjecum, 

and  Ascending  Colon ;  Operation  and  Recovery, 

By  W.  BiLLINGTON. 

4.  Two  Cases  of  Volvulus  Associated  with  Plernia, 

By  J.  F.  DoBSON. 

5.  A  Simple  Method  of  Estimating  the  Amount  of  Sugar 

in  Glycosuric  Urine,  By  T.  J.  Walker. 

6.  An  Investigation  into  the  Clinical  Significance  of  Al- 

bumosuria and  its  Value  in  Diagnosis  and  Prognosis, 

By  J.  Henderson. 

7.  Operations  for  Rectal  Cancer, 

By  W.  I.  DE  C.  Wheeler. 

8.  The  Advisability  of  Removing  the  Appendix  at  the 

Time  of  Opening  the  Appendicular  Abscess, 

By  H.  S.  Clogg. 

2  and  4.  Volvulus  and  Hernia. — Knaggs  re- 
ports four  cases  in  which  intestinal  obstruction  was 
produced  by  volvulus,  but  in  which  the  existence  of 
a  hernia  was  largely  instrumental  in  leading  to  the 
development  of  acute  symptoms.  Clinically  the 
large  majority  of  these  cases  are  regarded  as  strang- 
ulated hernia,  whilst  a  much  smaller  number  simu- 
late reduction  cii  masse.  There  are  four  well  marked 
groups,  as  follows: — i.  The  contents  of  the  hernia 
or  a  part  of  them  are  twisted,  the  neck  of  the  volvu- 
lus lying  either  within  the  hernial  sac  or  at  the  her- 
nial aperture.  2.  A  volvulus  is  present  and  its  neck 
and  some  of  the  alTected  coils  lie  within  the  ab- 
domen, but  a  loop  or  coil  belonging  to  the  twist  is 
engaged  in  the  hernia.  3.  A  volvulus  may  be  pro- 
duced within  the  abdomen  by  the  reduction  of  a  her- 
nia. 4.  Volvulus  may  occur  within  the  abdomen  from 
some  predisposing  condition  more  or  less  directly 
connected  with  a  hernia.  The  first  and  second 
groups  are  the  most  important  for  they  include  in 
all  probability  the  greatest  number  of  cases.  The 
four  cases  recorded  here  belong  to  the  second  cate- 
gory. All  four  patients  were  operated  upon,  and 
three  recovered. — Dobson  also  reports  two  cases  of 
volvulus  associated  with  hernia. 

6.  Albumosuria. — Henderson  states  that  per- 
manent and  abundant  albumosuria  of  the  Bence 
Jones  type  may  be  regarded  as  almost  pathogno- 
monic of  diffuse  sarcomatous  degeneration  of  bone 
marrow.  Albumosuria  has  been  found  chiefly  in 
suppurative  processes,  in  which  pus  is  retained  and 
disintegrated,  in  acute  infectious  diseases,  and  in 
acute  inflammations,  in  particular  in  pneumonia  and 
empyema,  or  large  abscess.  It  also  occurs  in  ne- 
phritis. The  writer  has  studied  its  occurrence  in  pneu- 
monia and  nephritis.  The  test  used  was  as  follows : 
Albiunin  was  tested  for.  and  if  present  removed  by 
precipitation  with  an  equal  volume  of  ten  per  cent, 
trichloracetic  acid,  boiling  until  concentrated,  and 
filtering.    The  filtrate  was  then  subjected  to  the 


biuret  test,  as  follows: — To  one  drop  of  two  per 
cent,  copper  sulphate  solution  and  five  o.c.  of 
urine,  add  five  c.c.  of  a  ten  per  cent,  solution  of 
sodium  hydrate — a  rose-pink  color  indicates  the 
presence  of  albumose.  Twenty-eight  out  of  seventy- 
eight  cases  of  pneumonia  showed  albumose  in  the 
urine.  Of  these  twelve  ended  fatally — a  mortality 
of  forty-two  per  cent.  The  chief  clinical  feature  of 
the  albumosuric  cases  was  the  severity  of  their  char- 
acter during  the  primary  fever,  usually  acconipanied 
by  higher  delirium.  The  presence  of  albumosuria 
in  pneumonia  must  therefore  be  regarded  as  un- 
favorable. In  eighty  cases  of  nephritis,  albumosuria 
was  present  in  forty-nine.  The  following  conclu- 
sions were  reached  regarding  nephritis:  i.  In  acute 
and  subacute  nephritis  albumose  is  rarely  present. 
When  present  it  may  be  associated  with  uraemia, 
and,  indeed,  may  herald  its  onset.  2.  Albumosuria 
seems  to  indicate  the  presence  of  a  chronic  condi- 
tion and  it  is  most  constantly  present  in  chronic 
parenchymatous  nephritis.  3.  The  presence  of  al- 
bumosuria is  often  in  such  cases  associated  with, 
though  it  does  not  necessarily  indicate,  an  early  fatal 
issue.  In  the  majority  of  cases  of  pneumonia  or 
nephritis,  the  origin  of  the  albumoses  is  probably 
pus  or  inflammatory  exudation.  Their  formation  is 
probably  due  to  the  digestive  action  of  the  invading 
microorganisms  on  the  rich  albuminous  fluids  and 
tissues  in  which  they  develop. 

8.  Removal  of  the  Appendix. — Clogg  discusses 
the  advisability  of  removing  the  appendix  at  the 
time  of  opening  the  appendicular  abscess.  He  holds 
that  the  danger  of  so  doing  is  more  theoretical  than 
real.  The  advantages  to  be  claimed  for  the  primary 
removal  of  the  appendix  are  as  follows; — i.  The 
time  of  the  healing  of  the  wound  is  lessened.  In 
calculating  this  due  allowance  is  made  for  the  size, 
situation,  and  depth  of  the  abscess.  2.  There  is  less 
tendency  to  imperfect  drainage,  which  is  at  times 
seen  during  the  course  of  the  healing  of  an  appen- 
dicular abscess.  This  is  so  partly  because  the  sup- 
ply of  infection  is  removed,  and  partly  on  account 
of  the  fact  that  the  abscess  cavity  is  so  thoroughly 
opened  that  it  may  be  drained  from  the  most  favor- 
able position.  3.  The  rare  complication  of  portal 
pysemia  following  a  persistent  sinus  ma\-  be  abol- 
ished. 4.  An  inflammation  spreading  up  the  right 
colon  to  the  subhepatic  or  subphrenic  regions  may 
lie  anticipated  and  cut  short  by  a  timely  lumbar 
drain.  5.  The  exploration  of  the  abscess  cavity  will 
enable  anv  concretions  which  have  escaped  from  the 
appendix  to  be  removed.  6.  The  persistent  sinus 
and  frequently  recurring  breaking  down  of  the  scar 
will  be  practically  abolished.  7.  The  risk  of  ventral 
hernia  is  by  no  means  increased  but  may  be  actually 
lessened.  Primary  removal  of  the  appendix  does 
not  necessarily  mean  a  longer  incision  through  the 
parietes.  nor  does  it  lessen  the  chance  in  any  way  of 
the  healing  of  the  wound  in  part  per  prinuiin.  8. 
The  permanent  changes  in  the  wall  leading  to  sten- 
osis of  the  appendix  and  the  very  frequent  pres- 
ence of  concretions  in  the  lumen  which  have  not 
escaped  into  the  abscess  cavity  are  most  p^)tent 
causes  of  recurrent  appendiceal  trouble.  But  the 
appendix  need  not  be  removed  in  all  cases  sup- 
puration. A  pelvic  abscess  which  can  be  easily  in- 
cised through  the  rectum  is  better  drained  through 


:Ma;cli  27,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


661 


this  route.  Age.  constitutional  .disease,  or  toxaemia 
■nay  make  it  advisable  to  treat  the  abscess  as  the 
primary  affection  in  order  to  curtail  the  time  of 
operation  as  much  as  possible. 

LA  PRESSE  MEDICALE. 

February  20,  igog. 

1.  The   Gastrointestinal   Troubles   at   the   Beginning  of 

Scarlet  Fever,      By  Charles  Lesieur  and  L.  Baur. 

2.  Triple  Venereal  Infection,  By  Professor  Dieulafoy. 
J.    Should  Persons  with  Uric  Acid  in  their  Urine  use  Tea, 

Coffee,  and  Chocolate?  By  Alfred  Martinet. 

4.    Salt.  Sugar,  and  Fever,  By  R.  Rom  me. 

1.  Gastrointestinal  Troubles  at  the  Beginning 
of  Scarlet  Fever. — Lesieur  and  Baur  consider 
separately  the  nausea,  the  vomiting,  and  the  diar- 
rhoea which  are  present  in  the  majority  of  cases  at 
the  beginning  of  an  attack  of  scarlet  fever.  They 
then  consider  the  relations  between  the  angina  and 
the  digestive  troubles,  the  relations  between  the 
eruption  and  the  digestive  troubles,  and  concktde 
with  an  essay  on  the  pathogeny  of  the  disease.  The 
gastrointestinal  troubles  were  present  in  sixty-seven 
of  one  hundred  cases  observed.  They  did  not  seem 
to  be  proportionately  severe  with  the  angina,  and 
were  present  in  the  six  cases  which  presented  no 
eruption. 

2.  Triple  Venereal  Infection. — Dieulafoy  re- 
ports the  case  of  a  man  who  contracted  from  one 
coitus  gonorrhoea,  chancroid,  and  syphilis. 

3.  Should  Persons  with  Uric  Acid  in  their 
Urine  use  Tea,  Cofifee,  and  Chocolate? — Martinet 
answers  this  question  in  the  negative,  particularly 
with  regard  to  those  persons  in  whose  urine  the  uric 
acid  precipitates  spontaneously. 

February  24,  iQOg. 
Unforefeen  Death  in  Scarlet  Fever, 

By  A.  GouGET  and  Mlle.  Dechaux. 

LA  SEMAINE  MEDICALE. 
February  24,  igog. 

1.  TIk-  post  Partum  Haemorrhages  of  Placenta  Praevia  and 

their  Haemostasis,  Bv  Professor  R.  de  Bovis 

2.  The  Machine  for  Detecting  Untruths,  By  Schlub. 

3.  Mvciplasty  for  Insufiiciency  of  the  Abdominal  Walls. 

1.  Post  Partum  Haemorrhages  of  Placenta 
Praevia. — De  Bovis  recommends  w-hen  the  hem- 
orrhages are  slight  to  give  ver}^  hot  injections; 
when  greater  to  compress  the  aorta,  and  to  sew  up 
any  large  lacerations  of  the  cervix.  If  this  does 
not  suffice  to  arrest  the  hseniorrhage  he  advises  to 
apply  two  haemostatic  forceps  of  a  certain  design, 
or  in  their  default  to  enclose  the  uterine  tissue  about 
the  base  of  the  large  ligament  in  a  submticous  liga- 
ture. The  compression  is  then  removed  from  the 
aorta.  If  there  is  no  bleeding  the  haemostasis  is  com- 
plete, if  there  is  the  ligatures  must  be  reapplied. 

2.  The  Machine  for  Detecting  Untruths. — 
Schlub  under  this  title  refers  to  the  apparatus  used 
in  measuring  the  psychogalvanic  reflexes,  or  the  gal- 
vanic iisychometer. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 

February  13,  igog. 

1.  Investigation  of  Injuries  of  the  Internal  Ear, 

By  B.  Heine. 

2.  Vi'^ceral  Ptosis  as  a  Constitutional  Anomaly, 

By  A.  Albu. 

3.  X  Ray  Carcinoma.  By  H.  Conen, 


4.  Iiiiplantation  Carcinoma  in  the  ^lucous  Membrane  of 

the  Urinary  Bladder,  By  Seizo  Suzckl 

5.  Experimental  Studies  of  the  Action  of  the  Collargol 

Upon  Leucocytes  and  Opsonins, 

By  C,  A.  Hoffmaxn. 

6.  Bismuth  Treatment  According  to  E.  Beck, 

By  F.  Rosexbach. 

7-    A  Case  of  Cholecystitis  Gangrjenosa  sine  Concremento, 

By  Carl  Guetig. 

8.    Puncture  of  the  Brain,  By  E.  Forstek. 

2.  Visceral  Ptosis  as  a  Constitutional  Anom- 
aly.— -Albu  has  studied  the  conditions  in  3400  pa- 
tients, nearly  equally  divided  in  regard  to  sex,  and 
found  visceral  ptosis  in  twenty-one  per  cent,  of  the 
men,  si.xty-eight  per  cent,  of  the  women.  A  floating 
tenth  rib  was  present  in  ten  per  cent,  of  the  men, 
fifty-seven  per  cent,  of  the  women  ;  right  nephropto- 
sis in  twenty-one  per  cent,  of  men,  sixty-eight  per 
cent  of  women  ;  left  nephroptosis  in  four  per  cent,  of 
men,  eleven  per  cent,  of  women  :  hepatoptosis  in  nine 
per  cent,  of  men,  seventeen  per  cent,  of  women ; 
splenoptosis  in  two  per  cent,  of  men,  six  per  cent,  of 
women  ;  and  gastroptosis  or  enteroptosis  in  nineteen 
per  cent,  of  men,  fifty-nine  per  cent,  of  women.  An- 
other study  of  ninety-four  infants,  from  one  to  ten 
days  old,  forty-five  male,  forty-nine  female,  gave 
visceral  ptosis  in  eleven  per  cent,  of  the  males,  forty- 
four'per  cent,  of  the  females.  Divided  in  the  same 
way  as  in  adults  a  floating  tenth  rib  was  present  in 
nine  per  cent,  of  the  males,  thirty-eight  per  cent,  of 
the  females,  right  nephroptosis  in  eleven  per  cent,  of 
the  males,  forty-four  per  cent,  of  the  females,  left 
nephroptosis  in  four  per  cent,  of  the  males,  twenty- 
seven  per  cent,  of  the  females,  hepatoptosis  in  five 
per  cent,  of  the  males,  nine  per  cent,  of  the  females, 
splenoptosis  in  three  per  cent,  of  the  males,  three  per 
cent,  of  the  females,  gastroptosis  or  enteroptosis  in 
eight  per  cent,  of  the  males,  fifteen  per  cent,  of  the 
females.  From  these  figures  he  concludes  that  vis- 
ceral ptosis  is  present  in  a  great  number  of  cases  at 
birth,  which  can  be  the  case  only  when  there  is  a  pre- 
disposition to  a  certain  form  of  body,  and  is  then  one 
of  the  symptoms  of  a  general  bodily  formation  which 
is  to  be  recognized  through  numerous  abnormalities 
in  the  bony  structure  and  in  the  development  of  the 
soft  parts. 

3.  X  Ray  Carcinoma. — Conen  reports  a  case 
of  carninoma  ascribed  to  the  influence  of  the  x  rays. 
It  was  met  with  in  the  finger  of  a  man,  forty-one 
years  of  age,  who  had  been  engaged  in  x  ray  work 
for  ten  years. 

4.  Implantation  Carcinoma  of  the  Bladder. — 
Suzuki  reports  the  case  of  a  man,  forty-three  years 
of  age,  who  died  with  the  clinical  diagnosis  of  tumor 
of  the  left  kidney.  On  autopsy  it  was  found  that  he 
had  a  neoplasm  of  the  left  suprarenal  gland  which 
had  penetrated  into  the  kidney  and  secondary  depos- 
its in  the  liver  and  in  the  mucous  membrane  of  the 
bladder. 

5.  Experimental  Studies  of  the  Action  of  Col- 
largol upon  Leucocytes  and  Opsonins. — Hoff- 
mann found  that  by  the  intravenous  injection  of  col- 
largol the  leucocytes  were  increased  in  number,  in 
six  of  the  experiments  more  bacteria  than  normal 
were  taken  up  by  them,  and  that  the  opsonic  index 
was  not  influenced. 


662 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT 

February  i6,  igog. 

1.  What  do  we  learn  through  Our  Clinical  Measurements 

of  the  Blood  Pressure  in  Man  ?  By  Moritz. 

2.  The  Way  in  which  Trichinae  spread,          By  Staubli. 

3.  The  Importance  of  Wassermann's  Serum  Reaction  in 

the  Distinctive  Diagnosis  of  Surgical  Syphilis, 

By  Batzner. 

4.  Demonstration  of  Cases  of  Congenital  Dislocation  of 
the  Hip  cured  with  Difficulty,  By  Bade. 

5.  The  Diseases  of  the  Musculature  of  the  Urinary  Blad- 

der, By  AscH. 

6.  The  Strauss-Leva  Motility  Test  of  the  Stomach  by 

Means  of  the  Fat  Zwieback  Breakfast, 

By  ScHENCK  and  Tecklenburg. 

7.  Congenital  Hernia  of  the  Umbilical  Cord.  Spontaneous 

Recovery,  By  Sittler. 

8.  A  Case  of  Traumatic  Gangrene  of  the  Gallbladder, 

By  SlEGEL. 

9.  An  Improved  Milk  Pump,  By  Kaupe. 

10.  The  Theory  and  Practice  of  the  Pressure  Difference 

Procedure,  By  Kuhn. 

11.  A  Special  Electroscope  for  Urethroscopy  and  Direct 

Cystoscopy,  By  Kaufmann. 

12.  Charles  Darwin,  By  Sobotta. 

13.  The  Development  of  Opthalmology  in  the  University 

at  Munich  {  Concluded) ,  By  Eversbusch. 

1.  Measurements  of   the   Blood   Pressure. — 

Moritz  says  that  the  hmits  within  which  the  meth- 
ods of  determining  the  blood  pressure  used  to-day 
are  of  value  are  still  comparatively  narrow,  but  that 
within  those  limits  the  measurement  of  the  blood 
pressure  has  great  diagnostic  and  prophylactic 
therapeutic  importance. 

2.  Trichinae.  —  Staubli  raises  tlie  question 
whether  certain  indeterminate  rheumatic  affections 
may  not  be  due  to  trichinosis.  He  declares  that  it 
is  scarcely  possible  to  detect  a  fresh  invasion  of  the 
trichinae  by  the  macroscopical  examination  of  a 
muscle,  even  with  a  practised  eye,  and  that  the  de- 
termination of  the'  real  prevalence  of  the  disease 
can  be  made  by  a  systematic  and  careful  micro- 
scopical examination  of  a  large  mass  of  cadaveric 
material.  He  refers  to  the  investigations  of  Wil- 
liams, published  in  the  Journal  of  Medical  Research 
in  igoi,  who  found  trichinosis  in  5.34  per  cent,  of 
505  cadavers  examined  microscopically,  in  only  two 
of  which  could  the  disease  be  detected  with  the 
naked  eye,  none  of  the  persons  had  died  frcm  the 
disease. 

3.  Wassermann's  Serum  Reaction  in  the  Dis- 
tinctive Diagnosis  of  Surgical  Syphilis. — Batz- 
ner states  that  when  the  clinical  symptomatology- 
indicates  the  presence  of  syphilis  the  serum  reaction 
is  a  very  valuable  confirmatory  symptom.  In  un- 
certain cases  in  which  the  positive  reaction  is  in 
unison  with  the  other  symptoms  it  tends  to  render 
the  diagnosis  positive.  A  negative  result  is  only  ex- 
ceptionally of  value,  except  as  confirmatory  of  a 
probably  negative  result  of  a  clinical  examination. 
The  method  has,  he  says,  sources  of  error.  Yet  he 
considers  it  of  great  scientific  interest  and  practical 
value. 

5.  Diseases  of  the  Musculature  of  the  Bladder. 

— Asch  has  met  with  eleven  cases,  four  in  men, 
seven  in  women,  in  which  the  musculature  of  the 
urinary  bladder  was  diseased  although  there  was 
present  no  stone,  stricture,  prostatic  hypertrophy, 
tabes,  or  other  disease  of  the  central  nervous  sys- 
tem. In  some  he  believes  the  atrophy  of  the  mus- 
cular tissue  is  primary.  The  principal  symptom  ap- 
pears to  be  retention. 


AMERICAN  JOURNAL  OF  SURGERY. 
March,  igog. 

1.  Intestinal  Resection ;  Preliminary  Report  of  a  Simpli- 

fied Method,  By  Howard  Lilienthal. 

2.  Sigmoiditis  and  Perisigmoiditis,    By  J.\mes  P.  Tuttle. 

3.  Sacral  Suspension  of  the  Uterus — A  New  Technique, 

By  John  Van  Doren  Young. 

4.  Cancer  of  the  Breast,  By  Willy  Meyer. 

5.  On  the  Surgery  of  Foreign  Bodies,  With  Especial  Ref- 

erence to  Those  Occurring  in  the  Skeletal  Tissues, 
including  the  Description  of  a  Localizing,  Method. 

By  Walter  M.  Brickner. 

6.  The  Operation  of  Direct  Blood  Transfusion;  Descrip- 

tion of  a  Simple  Method,      By  John  A.  Hartwell. 

7.  The  Avoidance  of  Hemolysis  in  Transfusion, 

By  Martin  Rehling  and  Richard  Weil. 

8.  Fibrosis  Uteri  and  Its  Surgical  Treatment  by  a  New- 

Method  of  Vaginal  Hysterectomy, 

By  Samuel  W.  Bandler. 

9.  Dislocation  of  Cervical  Vertebra, 

By  James  P.  Warbasse. 

10.  A  Plastic  Mastoid  Operation ;  A  New  Operation  for 

Acute  Mastoiditis,       By  Frank  Tucker  Hopkins. 

11.  A  A^odified  Operation  for  Inguinal  Hernia, 

By  .Albert  E.  Sellenings. 

12.  Surgery  of  the  Pericardium  and  Heart, 

By  H.  Beeckman  Delatour. 

I.  Intestinal  Resection. — Lilienthal  gives  a 
preliminary  report  of  a  simplified  method  in  intes- 
tinal resection.  He  uses  great  constricting  force  in 
ligating  the  stump  of  an  intestinal  organ.  He  re- 
ports six  cases,  in  which  his  methods  were  success- 
ful. The  important  point  is  to  tie  the  ligature  tight 
enough  to  crush  the  mucosa,  and  to  sterilize  the 
stump  with  pure  carbolic  acid,  not  followed  by  al- 
cohol. 

3.  Sacral  Suspension  of  the  Uterus. — Young 
describes  a  new  technique.  In  describing  the  liga- 
ments he  divides  them  into  three  parts :  First,  the 
sacral  or  fanlike  part,  is  fibrous  and  does  not 
stretch,  and  forms  the  sacral  attachment ;  second, 
the  middle  third,  is  the  weakest  portion  and  does 
stretch ;  third,  the  uterine  third,  where  most  of  the 
fibroelastic  and  muscular  tissues  are  found,  is  strong 
and  well  developed.  In  this  operation  the  stretched 
middle  third  is  eliminated,  and  the  uterine  portion 
is  attached  to  the  sacral  portion.  The  weak  middle 
third  is  used  to  strengthen  the  uterine  portion  and 
make  its  union  to  the  sacra!  third  more  complete. 
If  the  fundus  is  heavy  and  the  round  ligaments 
relaxed,  one  of  the  operations  to  shorten  this  liga- 
ment may  be  done  at  the  same  time,  either  the  op- 
eration of  Gilliam  or  that  of  Gill  Wylie.  The  points 
of  advantage  in  the  operation  are  given  by  Young 
as  follows :  The  supporting  of  the  uterus  in  its  nor- 
mal position  from  the  bony  structure  above ;  the 
body  and  especially  the  fundus  are  freely  movalilc 
for  all  the  functions  of  the  body :  it  does  not  dis- 
tort but  reproduces  the  curve  of  Carus.  There  arc- 
no  artificial  bands  through  which  intraabdominal 
hernia  may  occur.  In  the  event  of  pregnancy  there 
is  no  possibility  of  dystocia.  It  relieves  the  patient 
anatomically  and  symptomatically.  It  is  particular- 
ly indicated  in  retroversion  of  the  fundus  with  an- 
trosession  of  the  lower  segment  of  tlie  uterus,  or  the 
condition  of  beginning  prolapse. 

6.  The  Operation  of  Direct  Blood  Transfusion. 
— Hartwell  remarks  that  the  operation  of  direct 
blood  transfusion  as  practised  with  suture  and  can- 
nula shows  a  large  per  cent,  of  unsatisfactory  re- 
sults. It  requires  special  instruments  and  unusual 
.skill   for   its   successful   operation.     Our  author. 


JIarch  2-j.  IQ09.] 


PITH  OF  CURRENT  LITERATURE. 


663 


therefore,  endorses  the  direct  entrance  of  the  artery 
into  the  vein.  At  present  we  have  no  means  of  ob- 
taining accurate  knowledge  of  the  quantity  of  blood 
entering  the  vein.  The  changes  in  hiemoglobin,  red 
cell  count,  pulse  rate,  and  blood  pressure  must  all 
be  given  weight  in  estimating  this  quantity.  Actual 
weighing  of  the  donor  may  solve  the  problem.  The 
operation  is  not  without  danger  from  haemolysis, 
embolus,  or  overdistension  of  the  right  heart,  but 
with  proper  care  these  should  be  avoidable. 

AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 
March,  igog. 

1.  The  Dietetic  Treatment  of  Diabetes, 

By  T.  C.  Janeway. 

2.  Cardiac  Dangers  in  Great  Altitudes,  By  J.  N.  Hall, 
■>,.    Thrombosis  of  the  Inferior  Vena  Cava, 

By  E.  R.  Stillman  and  H.  W  Carey. 

4.  Complete    Aiiriculoventricular     Dissociation  without 

Syncopal  or  Epileptiform  Attacks, 

By  G.  B.\CHMANN. 

5.  The  Origin  of  the  "New  Leather"  and  "Dry  Friction" 

Sounds  heard  on  Auscultation,  By  H.  Sewall. 

6    Habitual   or   Recurrent   Anterior   Dislocation   of  the 
Shoulder,  By  T.  T.  Thomas. 

7.    A  Rontgenographic  Study  of  Peristalsis.    The  Relation 
of  Wave  Form  to  Functional  Activity, 

By  C.  L.  Leonard. 
,S    Intestinal  Sand.    The  Banana  One  of  its  Sources, 

By  J.  S.  Myer  and  J.  E.  Cook. 
g.    General  and  Specific  Resistance  to  Specific  Infection, 

By  K.  VoN  RuEK. 

10.  A  Clinical  Study  of  the  Effect  of  Tuberculin  Treatment 

on  the  Serum'  Agglutination  of  Tubercle  Bacilli, 

By  H.  M.  KiNGHOKN  and  D.  C.  Twichell. 

11.  The  Value  of  Rontgen  Ray  Examination  in  the  Diag- 

nosis of  Pulmonary  Tuberculosis,  especially  in  Refer- 
ence to  Early  Tuberculosis,  By  P.  Krause. 

12.  The  Treatment  of  Tinea  Tonsurans,     By  R.  L.  Sutton. 

1.  The  Dietetic  Treatment  of  Diabetes. — Jane- 
way  states  that  dietetic  treatment  in  this  disease 
is  our  mainstay.  Its  neglect  hastens  the  course 
of  the  disease  in  most  cases.  Loss  of  flesh 
and  strength  in  this  disease  are  due  to  inability  to 
use  the  carbohydrate  in  food,  the  problem  is  there- 
fore to  nourish  the  organism  with  little  or  no  car- 
bohydrate and  avoid  the  danger  of  acid  intoxica- 
tion which  is  imminent  in  the  absence  of  carbo- 
hydrate. A  correct  diagnosis  is  essential  and  means 
the  determination  (i)  of  the  degree  of  impair- 
ment of  carbohydrate  metabolism,  or  the  severity 
of  the  glycosuria  and  (2)  the  presence  of  the  de- 
gree of  the  secondary  disturbance  of  the  meta- 
bolism, or  the  severity  of  the  acidosis.  For  the 
first  point  the  patient  is  placed  i:pon  an  accurate 
test  diet  of  ample  food  value,  about  three  ounces 
of  white  bread  being  added.  In  the  milk  cases 
other  forms  of  carbohydrate  food  may  be  judi- 
ciously added.  For  the  second  point,  which  refers 
mainly  to  severe  cases,  the  acetone  bodies  must 
be  tested  for  in  the  urine  by  the  proper  methods. 
The  patient  must  be  thoroughly  examined,  the  case 
must  be  assigned  to  a  proper  category  and  accord- 
ing as  it  is  mild,  moderate,  or  severe  the  dietary 
must  be  arranged  first  to  prevent  or  minimize  hy- 
perglychjemia  and  second  to  act  similarly  upon  acid- 
osis. Instructive  tables  and  cases  illustrate  the  au- 
thor's ideas. 

2.  Cardiac  Dangers  in  Great  Altitudes. — Hall 
states  that  the  dangers  to  the  heart  in  great  al- 


titudes are  the  same  as  elsewhere,  but  are  sharp- 
1\-  exaggerated  in  certain  directions.  The  most 
common  and  serious  of  such  troubles  are  in  con- 
nection with  myocarditis  arteriosclerosis,  and  dila- 
tation of  the  heart.  The  fundamental  principle  is 
that  heart  and  lungs  have  an  increase  of  functional 
work  with  each  added  degree  of  elevation  and  the 
consequent  decrease  in  atmospheric  pressure.  To 
meet  the  increased  circulatory  demand  the  heart 
must  hypertrophy  if  the  usual  amount  of  exercise 
is  taken.  It  is  not  unusual  for  acute  dilatation  of  the 
heart  to  occur  after  slight  effort  in  those  whose  ar- 
teries have  begun  to  harden  and  who  have  long 
been  accustomed  to  sea  level  pressure.  Common 
experiences  with  those  who  suffer  in  great  altitudes, 
are  that  they  try  to  do  too  much  at  first,  being  "out 
of  training,"  but  feeling  invigorated  by  the  brac- 
ing atmosphere.  Even  an  ascent  in  a  railway  train 
may  be  fatal  to  those  who  have  but  a  narrow  mar- 
gin of  heart  strength,  or  the  slightest  exertion  at 
such  a  time  ma}'  produce  angina  pectoris.  This  is 
especially  the  case  with  those  whose  arteries  are 
atheromatous.  The  average  case  of  well  compen- 
sated valvular  disease  will  do  as  well  at  a  great  al- 
titude as  elsewhere,  when  proper  precautions  are 
observed,  and  he  is  less  susceptible  in  such  a  cli- 
mate to  acute  rheumatism. 

3.  Thrombosis  of  the  Inferior  Vena  Cava. — 
Stillman  and  Carey  report  two  cases  of  this  unu- 
sual condition.  Three  conditions  are  prominent  in 
connection  with  thrombosis  of  bloodvessels :  ( i ) 
Changes  in  the  chemistry  of  the  blood,  either  in 
proteins,  fibrin  ferment,  or  antiferment  whereby 
coagulability  is  increased.  (2)  Mechanical  factors, 
especially  with  weak  heart  muscle  and  sluggish  cir- 
culation. (3)  Injury  or  degenerative  change  in 
the  endothelium  of  the  vessel,  determining  the  for- 
mation of  a  coagulum  at  that  point.  Thrombosis 
of  the  inferior  vena  cava  is  usually  associated  with 
malignant  growths  of  the  abdomen,  with  infectious 
disease,  with  septic  conditions,  and  with  trauma. 
As  to  symptoms  the  cases  may  be  divided  into 
three  varieties  :  ( i )  Those  occurring  in  marantic 
and  cachectic  persons  in  whom  the  condition  is 
found  post  mortem,  but  in  whom  there  were  no 
symptoms  during  life.  (2)  Those  in  which  the 
condition  develops  slowly,  in  which  the  diagnosis 
is  made  by  the  establishment  of  collateral  circula- 
tion or  at  autopsy.  (3)  Those  in  which  there  is 
definite  evidence  of  obstruction,  the  diagnosis 
being  made  with  reasonable  confidence.  Pain  is  a 
constant  symptom.  CEdema  of  the  legs,  genitalia, 
etc.,  is  usually  present.  Ascites,  cyanosis,  and 
fever  are  frequently  noted.  The  liver  and  spleen 
may  be  enlarged,  and  there  may  be  diarrhoea  and 
albuminuria.  The  most  important  objective  symp- 
tom is  the  evidence  of  establishment  of  collateral 
circulation.    The  result  is  almost  invariably  fatal. 

II.  The  Value  of  Rontgen  Ray  Examinations 
in  the  Diagnosis  of  Pulmonary  Tuberculosis 
especially  in  Reference  to  Early  Tuberculosis. — 
Krause  states  that  in  adults  the  following  results 
are  noticeable :  ( i )  Infiltration  processes  at  the 
apex  recognizable  by  percussion  give  a  shadow 
with  the  fluroscope.  The  x  ray  examination  is 
superior   to   the   clinical.     (2)  Infiltrations  not 


664 


LETTERS  TO  THE  EDITOR. 


[New  York 
Medical  Journau 


clearly  demonstrable-  by  percussion  can  often  be 
demonstrated  with  the  fluoroscope  or  by  x  ray 
diaphragm  pictures.  They  may  also  determine  an 
advanced  stage  of  the  disease.  (3)  The  early 
stages  of  pure  catarrhal  processes  are  demonstrable 
neither  by  flouroscopy  nor  by  rontgenography. 
Diaphragm  photographs  of  the  apices  should  be 
obtained  in  such  cases.  (4)  The  height  of  the 
apices,  obtained  by  orthodrography  is  of  import- 
ance when  differences  of  i  to  1.5  cm.  exist.  The 
width  of  the  apices  of  the  lungs  has  not  yet  been 
accurately  studied  by  rontgenography.  Calcifica- 
tion of  the  first  rib  is  well  shown  and  is  of  diag- 
nostic importance.  In  children  and  young  people 
apical  findings  are  usually  wanting,  hence  the  im- 
portance of  recognition  of  shadow  variations  at  the 
hilum  which  are  due  to  enlarged  bronchial  glands 
and  infiltration  processes.  Cavities  may  be  readily 
diagnosticated  with  photographs  but  rarely  with  the 
fluoroscope. 

EDINBURGH  MEDICAL  JOURNAL. 
March,  igog. 

1.  The  Treatment  of  Varicose  Veins  of  the  Leg, 

By  J.  M.  COTTERILL. 

2.  Report  upon  the  Examination  of  the  Body  of  an  Acro- 

megalic Subject,  By  A.  Campbell  Geddes. 

3.  On  Stonemasons'  Phthisis,        By  G.  Lovell  Gulland. 

4.  Conservative  Surgery  of  fhe  Uterus  and  Ovaries :  Its 

Possibilities  from  the  Experimental  Standpoint, 

By  E.  ScoTT  Carmichael. 

I.  Varicose  Veins  of  the  Leg. — Cotterill  ob- 
serves that  if  local  treatment  by  bandaging  is  begun 
it  will  probably  be  necessary  to  continue  it  constant- 
ly afterwards.  Local  treatment  is  not  necessary,  or 
even  desirable,  unless  the  varix  is  getting  worse  or 
causing  troublesome  symptoms,  such  as  pain, 
cramps,  oedema,  eczema,  or  the  like.  While  some 
eighty  per  cent,  of  patients  begin  before  the 
age  of  twenty  -  five,  there  is  frequently  an  in- 
clination to  improvement,  or  at  least  to  the  con- 
dition remaining  stationary,  after  middle  life. 
The  treatment  to  be  adopted  in  suitable  cases  may 
be  considered  as  palliative,  or  radical  or  opera- 
tive. Having  applied  general  measures,  such  as 
rest,  tonics,  regulated  exercise,  cold  bathing,  and 
so  forth,  the  palliative  treatment  consists  in  the  ap- 
plication of  some  form  of  local  support  to  the  dis- 
tended veins.  Various  more  or  less  ingenious  de- 
vices, such  as  pads  applied  to  the  saphena  vein,  with 
the  object  of  supporting  the  column  of  blood,  may 
be  dismissed  without  further  notice,  for  they  have 
not  proved  successful.  On  the  whole,  a  carefully 
applied  Martin's  perforated  India  rubber  bandage 
seems  to  suit  the  majority  of  cases  best.  If,  in 
spite  of  palliative  treatment,  the  condition  becomes 
worse,  or  if  for  some  reason  a  bandage  or  stock- 
ing cannot  be  borne,  then  it  is  often  advisable  to 
operate.  The  indications  for  operation  (apart  from 
thrombosis  and  phlebitis)  are  as  follows:  i.  It  is 
most  satisfactory  to  operate  when  the  varix  afifects 
one  vein,  or  set  of  veins,  of  large  size,  rather  than 
when  the  smaller  veins  of  the  skin  are  chiefly  in- 
volved. 2.  Operation  should  not  be  undertaken,  as 
a  general  rule,  unless  the  varicose  condition  reaches 
fairly  well  up  in  the  thigh.  An  exception  to  this 
rule  should  be  made  where,  in  a  varix  restricted  to 
the  lower  leg,  recurrent  phlebitis,  ulcer,  or  the  dan- 
ger of  bleeding  from  a  thin  walled  pouched  varix 


is  present.  Trendelenburg's  operation  of  ligaturing 
the  vein  in  the  upper  part  of  the  thigh  is  not  enough. 
Gotterill  prefers  the  method  of  Phelps,  in  which  an 
inch  or  two  is  taken  out  of  the  saphena  high  up 
and  also  at  several  other  points  further  down  the 
limb,  specially  distended  portions  of  vein  being  dis- 
sected out.  The  collateral  circulation  in  the  veins 
of  the  leg  is  too  free  for  Trendelenburg's  operation 
to  suffice.  Owing  to  changes  in  the  vein  wall  and 
retardation  of  the  blood  current,  thrombosis  is  of 
frequent  occurrence  in  varicose  veins.  Thrombosis 
having  once  started  in  a  varix  may  spread  upward 
and  give  rise  to  serious  consequences — it  must  con- 
sequently be  regarded  as  an  important  matter  and 
dealt  with  most  carefully.  As  a  rule,  elevation  of 
the  limb  and  absolute  rest  in  bed  for  three  weeks 
or  more  is  the  best  course  to  pursue.  If  the  clot  is 
obviously  spreading  upward,  and  if  this  appears 
to  be  due  merely  to  centripetal  addition  to  the  throm- 
bus, brought  about  by  the  presence  of  the  clot  itself 
in  the  vein,  it  may  be  advisable  to  operate  by  liga- 
ture well  above  the  thrombus.  If  such  thrombosis 
occurs  in  a  varicose  vein  as  the  result  of  some  blood 
change,  such  as  may  occur  in  typhoid,  influenza, 
septichsemia  and  the  like,  the  ligature  may  do  no 
good,  and  may  do  harm.  A  local  thrombosis  in  a 
varicose  vein  may,  especially  in  later  life,  tend  to 
produce  a  spontaneous  cure  of  the  varix.  Phlebitis 
may  occur  in  two  forms.  In  simple  phlebitis  com- 
plicating varix  apply  soothing  applications,  such  as 
cold  or  sedative  fomentations,  elevate  the  limb,  and 
keep  the  patient  in  bed  till  all  signs  of  inflammation 
have  subsided.  If  pus  forms,  hgature  and  divide 
the  vein  well  above  the  inflamed  area,  and  thor- 
oughly clean  out  or  excise  the  inflamed  portion  of 
vein.  If  simple  phlebitis  recurs  frequently  in  a 
varix  it  may  call  for  operative  interference  by 
Phelps's  or  some  other  approved  method.  In  cases 
of  infective  phlebitis,  if  you  can  get  well  above  the 
inflamed  area,  cut  down  upon  the  vein  higher  up 
the  limb,  divide  and  ligature  it,  and  then  proceed 
to  clear  out  the  abscess,  excising  where  possible  the 
affected  portion  of  vein,  and  rendering  the  whole 
infected  area  as  aseptic  as  possible. 

 ^  

'gtWm  tfl  \\t  mux. 


UNIVERSAL  LANGUAGES. 
55  West  126th  Street,  New  York,  March  20,  1909. 
To  the  Editor: 

In  to-day's  issue  of  your  esteemed  journal  you 
mentioned  my  name  in  a  little  editorial  about  the 
Espcranto-Ilo  controversy.  You  did  not  announce 
to  your  readers  anything  else  about  me  except  that 
I  had  abandoned  Esperanto  and  taken  up  Ilo.  This 
is  of  very  little  interest  to  them  and  serves  rather  to 
discredit  me  in  their  opinion.  I  would  ask  you 
therefore  to  kindly  make  them  acquainted  with  this 
communication.  Its  main  point,  coinciding  almost 
entirely  with  your  views,  will  interest  your  readers 
a  little  and  will  restore  in  their  eyes  my  prestige, 
which,  I  think,  has  been  somewhat  lowered  through 
your  remarks.  This  point  is  that  after  many  years' 
study  of  and  experience  in  the  question  of  an  inter- 
national language  I  have  come  to  the  conclusion' 


March  27,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


665 


that  the  average  people  ought  not  to  be  seduced  into 
learning  any  international  language  whatsoever. 
They  would  do  better  to  devote  their  time  to  per- 
fecting themselves  in  their  respective  mother 
tongues.  This  applies  also  to  the  average  physi- 
cians, for  they,  too,  are  average  people.  When  I 
said  an  international  language  was  desirable  only 
for  scientists,  diplomats,  and  great  merchants,  I 
meant  for  people  having  frequently  international  re- 
lations, which  the  average  physician  has  not.  This 
shows  that  my  opinion  does  not  differ  very  much 
from  yours,  yet  from  your  editorial  it  would  appear 
that  in  the  p^nphlet  sent  you  I  was  advocating  an 
international  language  even  for  illiterates.  The 
pamphlet  demonstrates  the  defectiveness  of  Espe- 
ranto, but  does  not  praise  Ilo  beyond  stating  that  it 
is  far  superior  to  Esperanto  and  that  the  number  of 
its  adherents  is  much  larger  and  their  value  and  im- 
portance are  much  greater  than  the  fanatic  Espe- 
rantists  would  make  the  public  and  the  medical  pro- 
fession believe.  Max  Talmf.y. 

 ^  


MEDICAL  ASSOCIATION  OF  THE  GREATER  CITY 
OF  NEW  YORK. 

Special  Meeting,  Held  in  the  Borough  of  the  Bronx,  De- 
cember 7,  igo8. 
Dr.  N.  B.  Van  Ettex  in  the  Chair. 

Conclusions  in  Regard  to  the  Best  Surgical 
Treatment  of  Tic  Douloureux. — Dr.  Robert  Abbe 
referred  to  the  changing  attitude  of  the  profession  in 
relation  to  this  affection,  and  said  that  tic  doulour- 
eux must  be  regarded  as  something  quite  distinct 
from  the  ordinary  varieties  of  neuralgia.  It  might 
involve  any  or  all  of  the  three  branches  of  the  tri- 
geminal nerve,  and  the  seat  of  the  pain  varied  in 
different  instances,  occasionally  being  referred  to 
the  tongue  only.  Its  patholog)^  was  very  uncertain, 
and  np  to  the  present  time  nothing  regarding  it 
could  be  definitely  stated.  The  nerves,  and  especial- 
ly the  Gasserian  ganglion,  had  been  very  carefully 
examined  by  pathologists,  without  any  positive  re- 
sults. A  very  important  point  as  regarded  recur- 
rences and  the  matter  of  treatment  was  the  tendency 
to  repair  in  the  nerves  after  they  had  been  divided. 
It  was  found  that  within  two  weeks  after  such  sec- 
tion the  filamentous  nerve  ends  began  to  be  repaired, 
and  this  was  seen  not  only  in  the  proximal,  but  in 
the  distal  end  of  the  nerve.  It  was  not  in  the  pain- 
ful parts,  but  within  the  skull,  that  such  repair  was 
most  noticeable.  As  a  result  of  the  absence  of  the 
nerves  from  the  bony  foramina  in  consequence  of 
operations  for  the  relief  of  tic  douloureux,  it  was 
found  that  the  foramina  became  very  much  smaller 
than  normal.  This  he  had  personally  observed  in 
cases  in  which  he  had  operated  a  second  time  on 
account  of  recurrences,  at  periods  varying  from 
three  to  twelve  years.  The  foramina,  instead  of  be- 
ing openings  of  considerable  size,  had  shrunk  to 
needlelike  apertures,  but  through  these  there  passed 
a  few  little  nerve  filaments — two,  three,  four,  or 
hve,  as  the  case  might  be — and  it  was  to  these  fila- 
ments, the  result  of  the  reparative  process,  that  such 
recurrences  were  due. 


As  to  whai  surgical  means  had  been  employed  in 
the  treatment  of  tic  douloureux,  we  had  not  to  go 
back  very  far — perhaps  about  a  hundred  years.  At 
first  there  was  a  simple  section  of  the  affected  nerve, 
and  when  it  was  found  that  this  was  ineffectual  a 
resection  of  about  an  mch  of  the  nerve  was  tried. 
This  resulted  in  a  lengthening  of  the  time  of  re- 
currence. Then  followed  the  deeper  resection,  in- 
volving as  much  as  two  inches  and  a  half  of  the 
nerve,  known  as  Carnochan's  operation,  and  Dr. 
Abbe  said  that  he  had  himself  resorted  to  this  pro- 
cedure some  twenty  times.  The  next  step  was  the 
intracranial  operation,  in  which,  by  the  removal  of 
the  Gasserian  ganglion,  it  was  sought  to  cut  oft'  the 
nerve  connections  at  the  base ;  but,  as  this  opera- 
tion was  usually  performed,  its  results  as  regarded 
recurrences  were  no  better  than  those  of  the  extra- 
cranial operations.  It  was  most  grave  and  severe 
in  character,  and  it  was  extremely  difficult  to  re- 
move the  entire  ganglion.  A  modification  of  the 
extracranial  operation  was  the  plugging  up  of  the 
foramina  (the  foramen  ovale  or  the  foramen  ro- 
tundum,  as  the  case  might  be)  after  the  resection 
of  the  nerve,  in  order  to  prevent  the  entrance  into 
them  of  any  nerve  filaments  which  might  result 
from  the  process  of  repair.  Other  recent  procedures 
were  the  injection  of  osmic  acid  and  that  of  alcohol 
into  the  nerve  trunks.  Osmic  acid  was  no  doubt  of 
some  value,  but  it  was  not  a  very  powerful  agent 
for  the  destruction  of  nerve  tissue.  With  the  al- 
cohol injections  he  had  had  no  personal  experience, 
but  the  reports  concerning  them  were  very  favor- 
able, and  he  was  glad  that  Dr.  Kiliani,  who  had 
used  this  method  extensively,  was  present  to  give 
the  results  he  had  met  with. 

As  to  operations  of  the  grave  surgical  type,  he 
had  to  confess  that  he  had  never  yet  succeeded  in 
getting  the  ganglion  out  completely.  The  attempt 
to  extirpate  it  involved  the  risk  of  dangerous  hiem- 
orrhage  and  that  of  injury  to  other  parts,  as  well 
as  of  secondary  brain  lesions.  The  operation  con- 
sisted of  the  extraction  of  the  Gasserian  ganglion 
and  of  the  three  roots  of  the  fifth  nerve.  Krause 
and  Hartley  were  the  men  most  identified  with  this 
procedure.  In  Krause's  cases  a  number  of  recur- 
rences had  been  noted.  In  order  to  be  sure  that 
there  would  be  no  recurrence,  it  was  essential  that 
the  extirpation  should  be  complete,  and  unquestion- 
ably the  most  brilliant  results  with  this  measure  had 
been  accomplished  by  Hartley,  who  had  been  more 
successful  than  any  other  surgeon  in  getting  the 
gangHon  out.  Consequently  his  operations  had 
been  followed  by  hardly  any  recurrences.  Yet  even 
he  did  not  always  succeed  in  a  complete  removal. 
For  some  time  past  Dr.  Abbe  had  been  employing 
the  plan  of  inserting  rubber  tissue  between  the 
nerve  ends,  and  in  one  instance  the  patient  had  had 
twelve  years  of  absolute  health  after  this  was  done. 
At  the  expiration  of  this  time  there  was  a  recur- 
rence, and  on  opening  the  dura  he  found  that  nerve 
filaments  had  again  formed.  He  then  took  a  step 
further  and  plugged  up  the  foramen  with  gutta 
percha  tissue.  Altogether,  he  had  employed  it  in 
about  twenty  cases,  and  it  had  seemed  to  him  that 
this  procedure,  known  as  Mixter's  method,  was 
better,  as  regarded  the  prevention  of  recurrences, 
than  any  operation  except  the  complete  extirpation 
of  the  ganglion.    Among  his  own  cases  he  had  had 


666 


PROCEED! NCS  OF  SOCIETIES. 


[New  York 
Medical  Jouunai.. 


three  recurrences.  .  He  used  the  ordinary  gutta 
pei  cha,  w  hich  was  practically  sterile,  and  he  applied 
it,  after  warming,  ni  the  form  of  a  solid  plug.  He 
considered  this  as  the  safest  plan,  surgically,  at  our 
command.  There  was  practically  no  sliock,  and  the 
patients  vvere  generally  able  to  leave  the  hospital 
at  the  end  of  a  week  or  ten  days.  In  his  operations 
for  the  attempted  removal  of  the  ganglion  he  had 
had  one  fatal  case,  in  a  lady  of  very  advanced  age. 
In  the  injections  of  alcohol  about  a  thimbleful  of 
the  fluid  was  employed.  A  somewhat  heavy,  bev- 
eled needle  was  used,  and  the  Levine-Baudoine 
needle  was  .marked  in  such  a  way  that  by  inserting 
it  for  a  certain  number  of  centimetres  it  would  ex- 
actly reach  the  branch  of  the  nerve  that  it  was 
desired  to  inject. 

Dr.  Otto  G.  T.  Kiliani  said  there  was  no  ques- 
tion that  the  plan  of  alcohol  injections  was  alluring 
in  comparison  with  the  Krause-Hartley  operation, 
as  thus  far  it  had  been  attended  with  absolutely  no 
mortality.  The  most  plausible  explanation  of  the 
aetiology  of  tic  douloureux  seemed  to  him  to  be  the 
suggestion  of  Dana,  that  it  might  be  due  to  changes 
in  the  arterial  supply  in  the  nerve  sheath.  Spiller 
and  Gushing  had  given  elaborate  descriptions  of 
the  conditions  found  in  the  ganglion,  but  practically 
there  was  nothing  of  service  in  them.  The  exact 
origin  of  the  trouble  still  remained  undetermined, 
and  in  the  surgical  treatment  all  the  endeavors 
made  had  been  simply  in  the  direction  of  stopping 
the  pain  by  cutting  oi¥  the  nerve  conduction.  The 
alcohol  injection  method  was  devised  by  Schlesser, 
of  Munich,  some  six  years  ago,  but  as  its  publica- 
tion was  buried  in  the  archives  of  an  ophthalmo- 
logical  society  of  Southern  Germany,  it  had  escaped 
attention  for  a  time.  When  it  once  became  known 
it  was  very  extensively  employed,  and  more  than 
four  hundred  cases  had  now  been  reported.  Hav- 
ing given  some  details  regarding  its  use  and  re- 
ferred to  the  success  of  Patrick,  of  Ghicago,  and 
others  with  it,  the  speaker  said  he  thought  the 
method  should  be  practised  by  surgeons  only,  as  it 
demanded  a  thorough  knowledge  of  anatomy.  Dr. 
Kiliani  had  first  made  trial  of  it  about  two  years 
and  a  half  ago.  and  his  cases  now  amounted  to  137. 
In  most  of  these  the  peripheral  injections  had  been 
employed.  He  had  had  six  failures,  though  three 
of  these  ought  not  perhaps  to  be  coimted.  In  an 
afTection  like  tic  douloureux  we  had  to  take  the 
patient's  word  alone  as  to  the  pain  and  also  as  to 
relief  from  pain.  The  time  that  had  elapsed  was 
as  yet  too  short  to  permit  of  speaking  of  actual 
results,  but,  so  far  as  they  went,  the  results  were 
very  striking.  The  patients  were  rendered  not  only 
absolutely  free  from  Dain,  but  also  free  from  the 
anxietv  about  ))ain,  which  many  of  them  described 
as  finite  as  trying  as  the  pain  itself.  It  was  true 
that  be  had  had  quite  a  nimiber  of  recurrences  but 
in  sixty-four  per  cent,  of  the  cases  there  had  been 
no  recurrence  as  yet.  While  it  was  too  soon  to  de- 
termine the  permanent  value  of  this  treatment,  the 
results  already  accomplished  justified  its  further 
trial,  and  he  certainly  thought  it  ought  to  l)e  fol- 
lowed up. 

Dr.  Wi[.i.i.\M  M.  Lf.szvnskv  said  that  on  ac- 
coiuit  of  the  success  v^-hich  had  attended  the  method 
a  great  nianv  patients  now  preferred  the  alcohol 
injection  plan  to  medical  treatment.    He  did  not 


agree  with  Dr.  Kiliani  that  only  surgeons  should 
practise  it.  Any  one,  he  thought,  who  would  take 
the  trouble  to  study  up  the  anatomical  relations  of 
the  fifth  nerve  on  the  cadaver,  and  who  would  use 
strict  asepsis,  could  make  the  peripheral  injections 
by  the  Levine-Baudoine  method.  Schlesser's  tech- 
nique in  reaching  the  foramen  ovale,  however,  was 
very  difficult,  and  required  special  skill.  As  to  any 
clanger  attending  the  injections,  he  had  not  heard 
of  a  single  case  where  sepsis  had  resulted.  The 
only  trouble  that  he  himself  had  met  with  was  that 
occasionally  some  of  the  alcohol  got  into  the  nasal 
fossa;  but  it  did  no  harm  and  was  soqji  expelled  by 
the  patient.  It  had  been  alleged  that  it  was  essen- 
tial to  puncture  the  nerve  itself,  but  it  was  possible 
that  this  was  . really  not  the  case.  Dr.  Kiliani's  re- 
sults had  certainly  been  brilliant,  and  it  would  seem 
that  this  treatment  offered  much  hope  for  the 
future. 

Dr.  H.  J.  BoLDT  said  that  some  twenty  years  ago, 
when  he  was  in  general  practice,  he  had  made  a 
trial  of  osmic  acid  in  this  affection,  and  had  found 
it  entirely  valueless. 

The  Common  Forms  of  Gastroenteric  Neu- 
roses; their  .Etiology  and  Treatment. — This  pa- 
per was  by  Dr.  Anthony  Bassler  (published  in 
the  New  York  Medical  Journal  of  February  20, 
1909). 

Dr.  Louis  F.  Bishop  said  that  in  his  study  of 
heart  af¥ections  he  had  often  been  struck  with  the 
close  connection  between  gastroenteric  neuroses 
and  cardiac  neuroses.  He  had  observed  that  a  great 
many  patients  with  so  called  heart  trouble,  who  had 
no  organic  murmurs  and  yet  whose  hearts  were 
acting  irregularly,  showed  large  amounts  of  indican 
in  the  urine.  Indican  was  only  one  of  a  number 
of  waste  products,  such  as  skatol,  phenol,  etc., 
formed  in  the  intestinal  canal,  and  he  was  certain 
that  these  deleterious  agents  caused  kidney  and 
other  trouble,  leading  up  to  myocarditis  and  chronic 
Bright's  disease.  If  indicanuria  continued  for  any 
length  of  time,  traces  of  albumin  would  be  found 
in  the  urine.  In  this  connection  he  related  a  case 
of  unusual  interest  in  which  the  patient,  the  wife  of 
a  physician,  had  -for  some  weeks  shown  symptoms 
of  Graves's  disease.  Finally  the  heart  gave  out.  It 
had  become  dilated  and  was  beating  with  extreme 
rapidity.  In  addition,  there  were  ascites  and  a 
swollen  liver,  and  he  suggested  a  course  of  Nau- 
heim  treatment.  First,  however,  a  specimen  of  the 
urine  was  sent  for  examination,  and  the  report  was 
that  it  contained  a  larger  amount  of  indican  than 
any  other  urine  seen  in  the  laboratory  for  years. 
Dr.  Bishop  prescribed  two  grains  of  calomel  in 
divided  doses  of  t/to  of  a  grain,  and  the  effect  of 
this  was  to  produce  within  a  few  hours  an  intense 
general  dermatitis,  accompanied  by  a  temperature 
of  102°  to  103°  F..  after  which  the  skin  passed 
through  all  the  stages  of  desquamation.  One  ounce 
f)f  castor  oil  was  given  and,  later,  salines,  and  the 
bowels  were  also  washed  out.  He  believed  that  this 
patient's  symptoms  had  been  caused  by  the  absorp- 
tion of  indican.  and  as  a  result  of  this  cleaning  out 
treatment  they  all  began  at  once  to  improve.  She 
was  now  getting  well,  and  the  heart  beats,  which 
had  been  up  to  t6o  and  more,  had  come  down  to  80. 
The  dermatitis  caused  by  the  calomel  he  thought 
wa*^  due  to  the  fact  that  it  was  not  sufficient  to 


March  27,  1909.] 


BOOK  NOTICES. 


667 


carry  ofif  the  toxines  present  in  the  system  and 
served  only  to  stir  them  up,  as  it  were ;  giving  rise 
to  a  general  explosion,  which  had  its  outlet  through 
the  skin.  He  had  found  that  he  could  not  cure  his 
cases  of  functional  heart  trouble  until  he  had  got 
rid  of  the  indicanuria  present.  This  was  often  very 
persistent  and  it  was  a  problem  of  great  difficulty 
how  to  remedy  the  condition. 

Dr.  GusTAVE  H.  E.  Starke  spoke  of  the  psy- 
chical aspect  of  neuroses,  and  cited  cases  showing 
the  benefit  of  having  the  patient  in  an  easy  and 
contented  condition  of  mind.  He  also  spoke  of  the 
good  effect  of  the  administration  of  oils,  such  as 
olive  and  cottonseed  oils,  in  various  conditions  of 
the  stomach. 

Dr.  M.  C.  Rose  said  that  when  we  sent  our  pa- 
tients to  the  country,  we  should  always  take  care  to 
send  them  to  places  where,  in  addition  to  healthful 
air,  they  w-ould  be  sure  to  get  abundant  and  whole- 
some meals.  He  thought  it  would  be  a  good  idea 
for  physicians  when  on  their  vacations  to  look  up 
suitable  places  in  the  country  to  which  to  send  pa- 
tients. He  also  thought  it  very  desirable  when 
sending  patients  to  the  country  to  give  them  par- 
ticular directions  in  regard  to  exercise,  etc.  In  re- 
gard to  the  use  of  cof¥ee  and  tea,  he  had  found  that 
these  disagreed  with  many  persons  when  taken  with 
milk,  while  if  no  milk  was  used  they  were  harmless 
and  even  beneficial  if  taken  in  moderation.  In  his 
own  case,  coffee  with  milk  always  produced  dis- 
comfort. 

Dr.  A.  Ernest  Gallant  said  that  butter  fat  was 
the  hardest  of  all  fats  for  the  stomach  to  dispose  of. 
Thus,  if  the  stomach  contents  were  examined 
twenty-four  or  even  forty-eight  hours  after  but- 
tered toast  had  been  eaten,  the  butter  would  be 
found  to  be  still  present.  This,  he  thought,  ac- 
counted for  the  fact  that  coffee  or  tea  taken  with 
milk  or  cream  disagreed. 

Dr.  Bassler  said  that  indicanuria  was  a  result  of 
constipation.  He  had  never  yet  seen  a  case  in 
which,  if  the  constipation  present  was  properly 
treated,  the  indican  did  not  diminish  in  the  urine. 
Indican  was  not  formed  in  the  small  intestine,  and 
saUnes  were  of  great  benefit  because  they  acted  on 
the  lower  bowel.  The  formation  of  this  substance 
was  due  to  the  splitting  up  of  protein  molecules, 
and  it  took  place  especially  in  the  colon.  After  all, 
however,  calomel  was  the  best  drug  to  use,  and  it 
was  of  the  most  service  when  given  in  small  doses 
(i/io  to  1/6  of  a  grain)  three  times  a  day,  in  con- 
nection with  saline  cathartics.  If  the  stomach  was 
in  good  condition,  this  treatment  would  be  all  that 
was  required ;  but  in  many  of  these  cases  there  were 
present  faulty  gastric  conditions  which  demanded 
careful  attention.  He  had  .been  rather  astonished 
that  in  the  discussion  no  one  had  spoken  of  the 
benefits  to  be  derived  from  a  sojourn  at  some  of 
the  European  spas :  but  the  same  benefit  could  be 
had  at  institutions  in  this  country,  where  strict  rules 
as  to  the  dietary  and  manner  of  living  were  en- 
forced. In  all  such  places  the  psychical  part  of  the 
treatment  constituted  an  important  element  in  the 
results  accomplished. 

Some  Drugs  for  Gynaecological  Patients. — This 
paper,  by  Dr.  Herman  J.  Boldt,  has  been  pub- 
lished in  the  Xezv  York  Medical  Journal.  February 
20,  1909. 


ll'Ve  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  zve  think 
our  readers  are  likely  to  be  interested.] 

Bref  och  Skrifvelser.  Af  och  till  C.\rl  vox  Lixxe.  Forsia 
Afdelningen.  Del.  II.  Skrifvelser  och  Bref  till  K. 
Svenska  Vetenskaps-.\kaderr.ien  och  dess  Sekreterarc. 
Utgifna  och  med  Upplysande  Noter  Forsedda  af  Th.  M. 
Fries.    Stockholm:  Aktiebolaget  Ljus,  1908.    Pp.  ix-347. 

When  the  University  of  Upsala  celebrated  in 
1907  the  two  hundredth  anniversary  of  Linnaeus's 
birth,  it  was  decided  by  the  university  and  the 
Swedish  government  to  publish  the  correspondence 
of  this  brilliant  representative  of  Swedish  scholar- 
ship. During  1907  there  were  published  four  or 
five  volumes,  among  them  the  first  part  of  volume  i 
of  his  correspondence.  The  second  part  of  this 
volume  appears  now  (1908),  edited  by  Theodor 
Magnus  Fries,  lecturer  at  the  Royal  Agricultural 
Academy.  It  contains  thirteen  reproductions  of 
Linne's  seals  and  281  letters  (Xo.  177  to  458). 

Medizinische  Logik.  Kritik  der  iirztlichen  Erkenntnis. 
Von  Dr.  W.  Biegaxski.  Autorisierte  Uebersetzung  nacb 
der  zweiten  Originalauflage,  von  Dr.  A.  Fabiax.  Wurz- 
burg:  A.  Stuber,  1909.    Pp.  237.    (Price,  M.  4.50). 

Dr.  Fabian  has  seemingly  produced  a  very  good 
German  translation ;  we  do  not  know  the  original  by 
Bieganski.  The  Polish  (?)  author — his  name  is  not 
to  be  found  in  the  Index  Catalogue  or  in  Minerva 
— states  that  medical  logic  is  a  philosophical  theory 
of  m.edicine  which  as  such  comprises  all  the  medical 
sciences  as  well  as  the  practice  of  medicuie  and  the 
actions  (Tun)  of  the  physician. 

In  an  introduction  the  author  gives  us  a  full  re- 
view of  the  writers  on  this  stibject  and  their  views. 
He  divides  the  book  into  eleven  chapters :  Medicine 
and  medical  science;  observation;  anamnesis;  defi- 
nition, classification,  diagnosis  of  diseases ;  experi- 
mentation ;  theoretical  construction  of  the  medical 
sciences  ;  medical  statistics  ;  indications  for  and  con- 
sequences arrived  at  in  the  treatment ;  and  thera- 
peutical knowledge.  Like  most  books  on  philoso- 
phical subjects,  it  is  rather  heavy  reading,  and  one 
must  be  quite  conversant  with  the  langttage  to  en- 
joy the  great  knowledge  and  deep  thoughts  which 
we  find  expressed  in  this  well  rendered  translation. 

The  Arteries  of  the  Gastrointestinal  Tract,  zcith  Inoscula- 
tion Circle.  Anatomy  and  Physiology,  with  Application 
in  Treatment.  By  Bvrox  Robixsox,  B.  S..  M.  D.,  Pro- 
fessor of  GynEecoIogy  and  Diseases  of  the  Abdominal 
Viscera  in  the  Chicago  College  of  Medecine  and  Surgery, 
etc.  Chicago:  E,  H.  Colegrave,  1908.  Pp.  222.  (Price, 
$1.50.) 

Professor  Robinson  has  given  to  the  medical  pro- 
fession a  very  interestin,g  and  valuable  book.  He 
defines  an  inosculation  circle  as  a  circle  consisting 
anatomically  of  a  vascular  arc,  a  peripheral  viscus 
with  automatic  specialized  peripheral  ganglia,  stim- 
ulation of  which  initiates  and  sustains  common  vis- 
ceral function  (such  as  sensation,  absorption,  secre- 
tion, and  peristalsis),  and  special  function  if  it  is 
a  special  circle,  such  as  the  uteroovarian  circle 
(ovulation,  menstruation,  gestation).  "The  function 
of  the  inosculation  circle  is  to  congest  its  periph- 
eral viscus  and  to  transport  blood  volume  from  one 
viscus  to  another."  The  chief  rational  therapeutics 
for  the  inosculation  circle  is  visceral  drainage,  i.  e., 


668 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


the  administering  of  ample  fluids  at  regular  inter- 
vals, which  produces  maximum  visceral  hypersemia 
and  maximum  visceral  elimination. 

The  author  demonstrates  in  his  book  the  great 
utility  of  the  inosculation  circle  in  the  cure  and 
prophylaxis  of  disease,  for  blood  is  life  and  circulat- 
ing blood  cures  and  prevents  disease,  and  an  inos- 
culation circle  gives  the  blood  a  great  field  of  cir- 
culation. 

The  book  is  divided  into  five  sections  and  three 
chapters.  Section  I  contains  an  introduction  by  Dr. 
Thomas  G.  Atkinson;  Section  II  gives  an  abstract 
of  the  essential  views  contained  in  the  monograph ; 
Chapter  T  describes  the  cceliac  artery ;  Chapter  II 
the  proximal  mesenteric  artery ;  Chapter  III  the  dis- 
tal mesenteric  artery  ;  Section  III  contains  a  descrip- 
tion of  the  arterial  fields  of  the  abdomen ;  Section 
IV  of  the  applied  anatomy  and  physiology  of  the 
inosculation  circle ;  and  Section  V  of  the  manage- 
ment of  the  bloodvessels  during  intestinal  resection 
for  syphilitic,  carcinomatous,  or  other  obstruction  of 
the  intestinal  tract.  The  book  is  adorned  with  a 
great  number  of  very  instructive  illustrations. 

The  Future  of  Medicine.  By  Sydney  W.  Mac  Ilwaine, 
M.  R.  C.  S.,  L.  R.  C.  P.  London :  P.  S.  King  &  Son, 
1908.    (Price,  IS.) 

The  author  states  in  his  little  essay  that  there  is 
one  leading  question  which  physician  as  well  as 
patient  should  understand,  and  that  is.  What  is  the 
meaning  of  diseases  and  their  diagnosis?  While  it 
is  held  by  all  medical  authorities,  continues  the  au- 
thor, that  the  question  is  unanswered  and  unanswer- 
able, it  is  his  contention  that  we  are  now  in  a  posi- 
tion to  define  accurately  what  we  mean  by  disease 
and  so  to  fix  the  value  of  diagnosis.  He  then  comes 
to  the  conclusion-  that  the  whole  future  of  medicine 
turns  on  this  point.  He  remarks  that  when  Virchow 
swept  away  the  remains  of  the  humoral  pathology 
he  substituted  for  it  an  equally  false  theory  of  dis- 
ease in  saying  that  every  chronic  disease  had  its  root 
in  an  organ.  Pasteur's  genius  showed  us  the  right 
way,  and  with  the  knowledge  of  bacteriology  we 
can  now  properly  interpretate  Nature.  Was  it  not 
the  late  Otomar  Rosenbach  who  wrote  Physician 
versus  Bacteriologist?  What  would  his  answer 
have  been  to  this  statement? 

L'Eau  de  iiicr  en  injections  hypertoniques  dans  le  traite- 
ment  dcs  maladies  chroniques.  Par  le  Docteur  G.  Le 
MKHArxE.  medccin  principal  de  la  Marine  en  retraite, 
ancicn  professenr  a  I'Ecole  principale  du  service  de  Sante 
de  la  Marine.  Paris:  A.  Maloine,  1908.  Pp.  31.  (Price, 
I  fr.  so.) 

We  have  mentioned  Dr.  Carles's  method  of  the 
internal  use  of  sea  water  in  medicine  (See  New 
York  Medical  Journal,  Ixxxvii,  .p.  263).  This  form 
of  treatment  has  been  in  vogue  in  France  for  some 
time,  and  Dr.  Le  Mehaute's  brochure  is  a  very  time- 
ly review  of  the  subject.  He  states  that  he  has  used 
the  active  principles  of  sea  water  in  two  ways :  In- 
jecting small  quantities  of  the  sea  water  in  the  nat- 
ural state  hypodermically,  and  making  large  hypo- 
dermic injections  of  a  serum  prepared  from  diluted 
sea  water.  But  the  sea  water  treatment  should  be 
supported  with  drugs,  as,  for  example,  in  the  treat- 
ment of  syphilis  with  mercury,  when  the  unpleasant 
eflfects  of  the  drug  are  prevented,  so  that  it  may  be 
pushed  to  its  utmost  limitations ;  in  malarial  disease 
quinine  has  to  be  given  at  the  same  time  with  the 
sea  water. 


The  sea  water  obtained  from  a  considerable  depth 
and  at  quite  a  distance  from  the  shore  is  sterilized 
and  placed  in  small  tubes  to  which,  at  one  end,  a 
hypodermic  needle  may  be  attached,  while  a  rubber 
bulb  attached  to  the  other  end  will  convert  the  tube 
into  a  kind  of  hypodermic  syringe.  Dr.  Mehaute 
adds  to  the  marine  serum  phosphates,  arsenic,  mer- 
cury, and  iodine,  and  has  successfully  treated  with 
these  combinations  neurasthenia,  scrofula,  syphilis, 
arteriosclerosis,  etc. 

NEW  PUBLICATIONS. 

Chemistry. 

Hawk,  Philip  B. — Practical  Physiological  Chemistry.  A 
Book  Designed  for  Use  in  Courses  in  Practical  Physiolog- 
ical Chemistry  in  Schools  of  Medicine  and  of  Science. 
With  Two  Full  Page  Plates  of  Absorption  Spectra  in  Col- 
ors, Four  Additional  Full  Page  Color  Plates,  and  One 
Hundred  and  Twenty-six  Figures,  of  which  Twelve  are  in 
Colors.  Second  Edition,  Revised  and  Enlarged.  Philadel- 
phia:  P.  Blakiston's  Son  &  Co.,  1909.  Pp.  xvi-447.  (Price, 
$2.50.) 

Kiss,  Julius. — Das  periodisclie  System  der  Elemente  und 
die  Giftwirkung.  Beitrage  zur  physikalischen  Chemie  der 
Zelle.  Von  der  koniglichen  Gesellschaft  der  Aerzte  in 
Budapest  gekronte  Prei  sschrift.  Mit  6  Figuren.  Wien  und 
Leipzig:  Alfred  Holder,  1909.    Pp.  vi-182. 

Holland,  James  J'V.—A  Textbook  of  Medical  Chemistry 
and  Toxicology.  Fully  Illustrated.  Second  Edition,  Re- 
vised and  Enlarged.  Philadelphia  and  London:  W.  B. 
Saunders  Company,  1908.    Pp.  655. 

Anatomy,  Histology,  and  Microscopy. 

Meirowsky,  E. — Ueber  den  Ursprung  des  melanotischen 
Pigments  der  Haut  und  des  Auges.  Leipzig :  Dr.  Werner 
Klinkhardt,  1908.    Pp.  123. 

Merkel,  Friedrich,  und  Bonnet,  R. — Ergebnisse  der  Anat- 
omic und  Entwickelungsgeschichte.  xvii  Band.  A.u.d.T. : 
Anatomische  Hefte,  ii  Abteilung.  Mit  Abbildungen  und  7 
Tafeln.    Wiesbaden :  J.  F.  Bergmann,  1909.    Pp.  768. 

Qicain. — Elements  of  Anatomy.  Editors,  Edward  Albert 
Schafer,  LL.D.,  Sc.  D.,  F.  R.  S.,  Professor  of  Physiology 
and  Histology  in  the  University  of  Edinburgh ;  Johnson 
Symington,  M.  D.,  F.  R.  S.,  Professor  of  Anatomy  in 
Queen's  College,  Belfast ;  and  Thomas  Hastie  Bryce,  M.  A., 
M.  D.,  Lecturer  in  Anatomy,  University  of  Glasgow.  In 
Four  Volumes.  Volume  HL  Neurology.  By  E.  A.  Scha- 
fer and  J.  Symington.  Part  L  Containing  General  Struc- 
ture of  the  Nervous  System  and  the  Structure  of  the  Brain 
and  Spinal  Cord.  With  Numerous  Illustrations,  many  of 
which  are  Colored.  Eleventh  Edition.  London,  New  York, 
Bombay,  and  Calcutta :  Longmans,  Green,  &  Co.,  1909.  Pp. 
ix-421. 

Physiology. 

Mangold.  E.- — Unsere  Sinnesorgane  und  ihre  Funktion. 
Mit  Abbildungen.    Leipzig :  Quelle  &  Meyer.    Pp.  147. 

Crichton-Browne,  Sir  James. — Parsimony  in  Nutrition. 
London  and  New  York :  Funk  &  Wagnalls,  1909.  Pp.  vi- 
III. 

Hill,  Alexander. — The  Body  at  Work.  A  Treatise  on  the 
Principles  of  Physiology.  With  Forty-six  Illustrations. 
London :  Edward  Arnold,  1908.    Pp.  xi-448. 

Internal  Medicine. 

Koster,  Georg. — Fettresorption  im  Darm  und  Gallenab- 
sonderung  nach  Fettdarreichung.  Zugleich  ein  Vorschlag 
zur  Verbesserung  der  Oelkur.  Mit  6  Tafeln.  Leipzig:  Dr. 
Werner  Klinkhardt,  1908.    Pp.  98. 

Jehle,  Ludzifig.— Die  lordotische  Albuminuric  (orthosta- 
tische  Albuminuric),  ihr  Wesen  und  ihre  Therapie.  Mit  6 
Abbildungen  und  i  Tafeln.    Wien :  F.  Deuticke,  1909.  Pp. 

Sabourin,  Charles. — Traitement  rationnel  de  la  phtnisie. 
Troisieme  edition,  augmentee.  Paris :  Masson  et  cie.  Pp. 
318. 

Malynicz,  Jakob. — Ueber  die  Haufigkcit  der  postdipbther- 
ischen  Liihmungen  vor  und  nach  der  Serumbehandlung. 
Zurich:  F.  Speidel,  1908.  Pp.  58. 

Nauiiyn,  B. — Notwendigste  Angaben  fiir  die  Kostordnung 
Diabetischcr.  Zum'  Handgebrauch  der  .-^crzlc  zusammen- 
gcstellt.    Jena :  Gustav  Fischer,  1908.    Pp.  18. 

.Schott. — Acute  Ueberanstrengung  des  Herzens  und  deren 
Behandlung.    Mit  33  Abbildungen  im  Text,  2  Rontgenhil- 


March  27,  1909.] 


BOOK  NOTICES. 


669 


dern  auf  Tafel  i/ii  und  2  Radiogrammen  auf  Tafel  iii. 
Vierte  erweiterte  Auflage.  Wiesbaden:  J.  F.  Bergmann, 
1908.   Pp.  57. 

Hcraucourt,  Ferdinand. — Cholera  asiatica.  Geschichte, 
Aetiologie,  Wesen,  Erscheingungen,  Diagnose,  pathologische 
Anatomic,  Prognose,  Prophylaxe  und  Therapie,  zum  Teil 
auf  Grund  eigener  Beobachtung  geschildert,  nebst  einem 
Anhang:  Organisation  der  deutschen  Aerzte.  Leipzig:  G. 
Fock,  1909.   Pp.  73. 

Von  Miillcni,  Karl. — Grundriss  der  klinischen  Blutunter- 
suciiung.  Mit  5  Abbildungen,  6  fargiben  Tafeln  und  6 
Blatter  Erklarungen.    Wien :  F.  Deuticke,  1909.    Pp.  178. 

P'oii  Oldcnbarnevelt,  Jeanne. — Die  Atmungskunst  des 
Menschen  in  Verbindung  mit  Ton  und  Wort  im  Dienste 
der  Kunst  und  der  Wissenschaf t.  Vortrage  und  Demon- 
stration. Mit  2  Titelbildern,  30  Abbildungen,  i  Modell  und 
I  Uebungs-Tafel.  Dritte  erweiterte  Auflage.  Oranienburg: 
W.  Moller,  1909. 

Aschoff,  Albrecht. — Ueber  die  Entwicklungs-,  Wach- 
stums-  und  Alters- Vorgange  an  den  Gefassen  vom  elas- 
tischen  und  muskularen  Typus.  Mit  2  lithographischen 
Tafeln.   Jena :  G.  Fischer,  1908. 

Amrein,  O. — Hochgebirgsbehandlung  der  Lungentuberku- 
lose  mit  spezieller  Beriicksichtigung  fieberhafter  Falle.  Aus 
dem  Englischen.    Arosa :  F.  Junginger,  1909. 

Singer,  Gustav. — Die  atonische  und  die  spastische  Obsti- 
pation. Ihre  Differentialdiagnose  und  Behandlung.  Mit 
zwei  Abbildungen.  Halle  a.  S. :  Carl  Marhold,  1909. 
Pp.  46. 

Magnus-Levy.  A. — Das  Koma  diabeticum  und  seine  Be- 
handlung.  Halle  a.  S. :  Carl  Marhold,  1909.    Pp.  54. 
Surgery. 

Reclus,  Paul.- — Cliniques  de  la  Charite  sur  la  chirurgie 
jonrnaliere.    Paris:  Masson  et  cie.    Pp.  615. 

Von  Kuestcr,  Baron. — Bruchband  oder  Radikaloperation  ? 
Berlin  :  J.  Goldschmidt,  1909. 

Konig. — Lehrbuch  der  Chirurgie.  Vierter  Band.  Allge- 
meine  Chirurgie.  Von  Otto  Hildebrand.  Dritte  neubear- 
teitete  Auflage.  Mit  438  Abbildungen.  Berlin  :  A.  Hirsch- 
wald,  1909.   Pp.  96. 

Loan,  H. — Die  Krankenpflege  in  der  Chirurgie.  Aus  dem 
Hollandischen  von  Albert  Caan.  Mit  einem  Vorwort  von 
Arthur  Schlossmann.  ~ Leipzig:  F.  C.  W.  Vogel,  1909.  Mit 
^327  Abbildungen.    Pp.  300. 

Obstetrics  and  Gynecology. 

Gottschalk,  Sigmund. — Gynhkologie.  Mit  46  Abbildun- 
gen im  Text,  darunter  i  Farbendruck.  Wien  und  Leipzig: 
Alfred  Holder,  1908.    Pp.  355. 

Maygrier,  Charles,  et  Schwab. — Precis  d'obstetrique. 
Avec  326  figures.    Paris :  Doin  et  fils.    Pp.  324. 

Tzveedy,  Hastings,  and  Wrench. — Rotunda  Practical  Mid- 
wifery. London :  Oxford  University  Press  and  Hodder  ie 
Stoughton,  1908.    Pp.  xix-464. 

Neurology  and  Psychiatry. 

Sommer,  Robert. — Klmik  fiir  psychische  und  nervose 
Krankheiten.  Dritter  Band,  ii  und  iii  Heft.  Halle  a.  S. : 
Carl  Marhold,  1908. 

Edinger,  Ludivig. — Der  Anteil  der  Funktion  an  der  Ent- 
stehung  von  Nervenkrankheitem.  Mit  5  Abbildungen. 
Wiesbaden :  J.  F.  Bergmann,  1908.    Pp.  67. 

Serieu.v,  P.,  et  Capgras,  J.  Les  Folies  raisonmantes.  Le 
delire  d'interpretation.    Paris :  Felix  Alcan. 

Janet,  P. — Les  Nevroses.    Paris:  C.  Flammarion. 

Obcrsteiner,  Heinrich.- — Arbeiten  aus  dem  neurologischen 
Institute  an  der  Wiener  Universitat.  Band  xvii,  Heft  ii. 
Mit  33  Abbildungen  und  3  farbigen  Tafeln.  Wien :  F.  Deu- 
ticke, 1908.    Pp.  175-358. 

Stegerthal,  Armin. — Was  ist  Hysterie?  Eine  nosologiscTie 
Betrachtung.    Halle  a.  S. :  Carl  Marhold.    Pp.  79. 

Kotik.  Naum. — Die  Emanation  der  psychophysischen  En- 
ergie.  Eine  experimentelle  Untersuchung  iiber  die  unmit- 
telbare  Gedankeniibertragung  im  Zusammenhang  mit  der 
Frage  iiber  die  Radioaktivitat  des  Gehirns.  Wiesbaden : 
J.  F.  Bergmann,  1908.    Pp.  128. 

Waldstein,  Louis. — Das  unterbewusste  Ich  und  sein  Ver- 
haltnis  zur  Gesiindbeit  und  Erziehung.  Wiesbaden:  J.  F. 
Bergmann,  1908.    Pp.  71. 

Kolb,  G. — Vorschlage  fiir  die  Ausgestaltung  der  Irren- 
fiisorge  und  fiir  die  Organisation  der  Irrenanstalten.  Nach 
einem  Vortrage  im  Verein  bayrischer  Psychiater.  Halle 
a.  S. :  Carl  Marhold,  1908.    Pp.'  45. 

Bouquet,  Henri.- — L'Evolution  psychique  de  I'enfant. 
Paris:  Bloud  et  Cie,  1909.    Pp.  iv-ioo. 

Marie,  A.,  et  Martial,  7?.— Travail  et  folic.  Influences 


professionnelles  sur  I'etiologie  psychopathique.  Paris: 
Bloud  et  Cie,  1909.    Pp.  xi-iio. 

Meunier,  Raymond. — Les  Hachich.  Essai  sur  la  psy- 
chologic des  paradis  ephemeres.  Avec  trois  planches  hors 
texte.    Paris:  Bloud  et  Cie.,  1909.    Pp.  217. 

Ophthalmology. 

De  Ridder,  Paul. — La  Fonction  lombaire  dans  les  affec- 
tions oculaires.   Paris:  Stcinheil.    Pp.  120. 

Vossius,  A. — Sammlung  zwangloser  Abhandlungen  auf 
dem  Gebiete  der  Augenheilkunde.  Band  iv.  Halle  a.  S. : 
Carl  Marhold. 

Von  Haselberg. — Tafeln  zur  Entlarvung  der  Simulation 
einseitiger  Blindheit  und  Schwachsichtigkeit.  Zweite  ver- 
mehrte  Auflage.  Wiesbaden  :  J.  F.  Bergmann,  1908.  Pp.  22. 

Axenfeld,  Theodor. — Lehrbuch  der  Augenheilkunde, 
bearbcitet  von  mehreren  Fachgelehrten.  Mit  10  Farben- 
taf eln  und  455  zum  grossen  Teil  mehrfarbigen  Abbildungen 
im  Text.  Jena :  Gustav  Fischer,  1909.    Pp.  679. 

Deutschmann,  R. — Bcitrage  zur  Augenheilkunde,  im  Ge- 
meinschaft  mit  E.  Fuchs,  O.  Haab,  A.  Vossius.  Hamburg: 
L.  Voss,  1909. 

IVagenmann,  A. — Bericht  iiber  die  35.  Versammlung  der 
opthalmologischen  Gesellschaft,  Heidelberg,  1908.  Mit  17 
Abbildungen  und  22  Tafeln.  Wiesbaden :  J.  F.  Bergmann, 
1909.    Pp.  411. 

Otology. 

Rotser,  Franz  Xaz'ier. — Uebungsbuch  fiir  Schwerhorige 
und  Ertaubte.  Das  Ablesen  vom  Munde.  Mit  16  Lauttafeln. 
Miinchen  und  Berlin  :  R.  Oldenbourg,  1908. 

Laryngology  and  Rhinology. 

Lockard,  Lorenzo  B. — Tuberculosis  of  the  Nose  and 
Throat.  With  Eighty-five  Illustrations,  Sixty-four  of  them 
in  Colors.  St.  Louis :  C.  V.  Mosby  Medical  Book  and  Pub- 
lishing Co.,  1909.   Pp.  384. 

Hajek,  M. — Pathologic  und  Therapie  der  cntziindlichen 
Erkrankungen  der  Nebenhohlen  der  Nase.  Mit  150  Abbil- 
dungen und  2  Tafeln  in  Lichtdruck.  Dritte  vermehrte 
Auflage.    Wien  :  F.  Deuticke,  1909.    Pp.  443. 

Guisez,  J. — La  Pratique  oto-rhinolaryngologique.  Avec 
257  figures.    Paris :  Bailliere  et  fils,  1908.    Pp.  750. 

Castey,  A.,  et  Lubet-Barbon,  F. — Oto-rhinolaryngologie 
(Le  Dentu  et  Delbet,  Nouveau  traite  de  chirurgie,  fascicule 
xviii).    Avec  215  figures.    Paris:  Bailliere  et  fils.    Pp.  601. 

Burger,  H. — Was  leisten  die  Rontgenstrahlen  in  der 
Rhino-Laryngologie?  Mit  3  Abbildungen  im'  Text  und  8 
figuren  auf  den  Tafeln  i-v.  Wiesbaden :  J.  F.  Bergmann, 
1908.    Pp.  98. 

Dermatology. 

Lesser,  Edmund. — Lehrbuch  der  Haut-  und  Gcschlechts- 
Krankheiten,  fiir  Studierende  und  Aerzte.  Erster  Teil: 
Hautkrankheiten,  mit  einem  Anhang:  Die  Radiotherapie 
von  Dr.  Frank  Schultz,  Berlin.  Mit  58  Abbildungen  im 
Text  und  9  farbigen  Tafeln.  Zwolfte  erganzte  Auflage. 
Leipzig:  F.  C.  W.  Vogel,  1908.  Pp.461. 

Gilbert,  A.,  et  Thoinot,  L. — Nouveau  traite  de  medecine 
et  de  therapeutique.  XIV.  Maladies  de  la  peau,  par  E. 
Gaucher,  professeur  de  clinique  des  maladies  cutanees  et 
syphilitiques,  etc.  Avec  180  figures  intercalees  dans  le  tcxte. 
Paris:  J.  B.  Bailliere  et  fils,  1909.  Pp.  508.  (Price,  11 
fr.  SO.) 

Venereal  and  Genitourinary  Diseases. 

Winckler  und  A.vel. — Ueber  die  Behandlung  der  Syphilis. 
Erfahrungen  und  Ansichten  eines  Praktikers.  Halle  a.  S. : 
Carl  Marhold,  1908.    Pp.  26. 

Levy-Bing,  A. — Les  Injections  mercurielles  intramuscu- 
laires  dans  le  traitement  de  la  syphilis.  Paris :  Masson  et 
cie.    Pp.  44. 

Pcediatrics. 

Chapin,  Henry  Dwight. — The  Theory  and  Practice  of  In- 
fant Feeding.  With  Notes  on  Development.  Third  Editon, 
Revised.  With  Numerous  Illustrations.  New  York :  Wil- 
liam Wood  &  Co.,  1909.    Pp.  xiii-3S0. 

West,  Charles. — How  to  Nurse  Sick  Children.  With  a 
Preface  by  George  F.  Still,  M.  D.  New  Edition.  London, 
New  York,  Bombay,  and  Calcutta :  Longmans,  Green,  & 
Co.,  1908.    Pp.  ix-52. 

Monti,  Alois. — Kinderhe'lkunde  in  Einzeldarstellungen. 
Heft  xxviii.  Praktische  Anleitung  zur  Anwendung  der 
Serumtherapie  in  der  Kinderheilkunde.  Mit  10  Holzschnit- 
ten.  Berlin  und  Wien :  Urban  &  Schwarzenberg,  1908.  Pp. 
85- 

Hagenbach-Burckhardt.  E. — Ueber  offentliche  Fiirsorge 
fiir  kranke  Kinder.  Basel :  Helbing  &  Lichtenham,  1909. 
Pp.  39- 


670 


OFFICIAL  NEWS. 


[New 
Medical 


York 

JoURKAI.. 


Moll-JVeiss,  /iM;?.—L" Alimentation  de  I'enfant  de  2  a  6 
ans.    Paris :  G.  Steinheil.    Pp.  128. 

Hygiene  and  Public  Health. 

Report  upon  the  Physical  Condition  of  Children  Attend- 
ing the  Public  Schools  in  New  South  Wales  (With  Special 
Reference  to  Height,  Weight,  and  Vision).  Based  upon 
Statistics  Obtained  as  a  Result  of  the  Introduction  of  a 
Scheme  of  Medical  Inspection  of  Public  School  Children, 
1907-1908,  with  Anthropometric  Tables  and  Diagrams.  Is- 
sued by  Direction  of  the  Hon.  J.  A.  Hogue,  M.  L.  A.,  Min- 
ister of  Public  Instruction.  Sydney:  William  Applegate 
Gulick,  1908.    Pp.  66. 

Roth,  E. — Landliche  Hygiene.  Mit  2  Tafeln.  Jena :  G. 
Fischer,  1908.    Pp.  64. 

Sclince,  Wold. — Die  Kultur-  Training-  der  Hand.  I. 
Zur  Vervollkommung  der  Technik  fiir  Pianisten,  Violin- 
isten,  usw.  II.  Gesundheitspflege  und  Behandlungen  der 
erkranten  Hand,  einschlagig  Musiker-  und  Schreibkrampf. 
Dritte  vermehrte  Auflage.    Berlin  :  W.  Schnee,  1908.   Pp.  44. 

Heine,  Paid. — Leitfaden  der  Trichinenschau.  Dritte  stark 
vermehrte  Auflage.  Mit  Abbildungen.  Hannover:  M.  & 
H.  Schaper,  1909.    Pp.  67. 

Burckhardt ,  Albrecht. — Demographic  und  Epidemiologic 
der  Stadt  Basel  wahrend  der  letzten  drei  Jahrhunderte 
1601-1900.    Leipzig:  Carl  Beck,  1908.    Pp.  iii. 

Dornberger,  Eugen,  und  Grassmann,  Karl.  Unsere  Mit- 
telschiiler  zu  Hause.  Schulhygienische  Studie.  Miinclien : 
J.  F.  Lehmann,  1908.    Pp.  208. 

Bacteriology. 

Leopold,  G. — Vorschriften  der  Reinigung  (Desinfektions- 
Ordung)  fiir  die  Aerzte,  Hebammen  und  Hebammenschiil- 
erinnen  der  koniglichen  Frauenklinik  in  Dresden.  Sechste 
Auflage.    Dresden:  H.  Burdach,  1909.    Pp.  11. 

Therapeutics. 

Sutherland,  G.  A. — A  System  of  Dietetics.  London  :  Ox- 
ford University  Press  and  Hodder  &  Stoughton,  1908.  Pp. 
xiii-893.    (Price,  $10.50.) 

Butler,  George  F. — A  Textbook  of  Materia  Medica,  Phar- 
macology, and  Therapeutics.  Sixth  Edition,  Thoroughly 
Revised  and  Enlarged.  Philadelphia  and  London :  W.  B. 
Saunders  Company,  1908.    Pp.  708. 

New  and  Nonofficial  Remedies,  1909.  Containing  De- 
scriptions of  the  Articles  which  have  been  accepted  by  the 
Council  on  Pharmacy  and  Chemistry  of  the  American  Med- 
ical Association  prior  to  January  i,  1909.  Chicago :  Press 
of  the  American  Medical  Association,  1909.    Pp.  167. 

Gitillon,  A. —  Manuel  de  therapeutique  clinique  des  mala- 
des  tropicales.    Paris :  Doin  et  fils.    Pp.  400. 

Schnirer,  M.  T. — Taschenbuch  der  Therapie.  Fiinfte  ver- 
mehrte und  verbesserte  Auflage.  Wiirzburg :  A.  Stuber, 
1909.    Pp.  394- 

Roscnfcld,  Gcorg. — Das  Indikationsgebiet  des  Alkohols 
bei  der  Beliandlung  innerer  Krankheiten.  Halle  a.  S. : 
Carl  Marhold,  1908.    Pp.  48. 

Lcmanski. — L'Art  pratique  de  formuler.  Troisieme 
edition  refondue.    Paris  :  G.  Steinheil.    Pp.  302. 

Moncany,  Charles. — Nouveaux  emplois  therapeutique  du 
chlorure  de  calcium.    Paris  :  Steinheil.    Pp.  192. 

Morel,  Albert. — Precis  de  technique  chinvique  a  I'usage 
des  laboratoires  medicaux.  Avec  160  figures  et  2  planches. 
Paris :  Doin  et  fils.    Pp.  850. 

Electricity,  Rdntgcn  Rays,  and  Emanations. 

Snozii.  William  Benhani. — The  Therapeutics  of  Radiant 
Light  and  Heat  and  Convective  Heat.  New  York:  Scien- 
tific Authors'  Publishing  Co.,  1909.    Pp.  119. 

Miscellaneous. 

Hoche,  L.,  und  Hoche,  R. — Acrztliches  Rechtsbuch.  Er- 
ganzungsband  fiir  Norddeutschland.  Hamburg :  Gebr. 
Liideking,  1909.    Pp.  532. 

Schumacher,  E.  D. — Unfiille  durch  elektrische  Stark- 
strome.  Line  klinische  und  gerichtlich-medizinische  Studie. 
Wiesbaden:  J.  F.  Bergmann.  1908.    Pp.  83. 

Camac.  C.  N.  B. — Epoch  Making  Contributions  to  Medi- 
cine, Surgery,  and  the  Allied  Sciences.  Being  Reprints  of 
those  Communications  which  first  conveyed  Epoch  Making 
Observations  to  the  Scientific  World,  together  with  Bi- 
graphical  Sketches  of  the  Observers.  With  Portraits.  Phil- 
adelphia and  London :  W.  B.  Saunders  Company,  1909.  Pp. 
viii-4.35. 

Bulletin  of  the  Ayer  Clinical  Laboratory  of  the  Pennsyl- 
vania Hospital.  No.  V.  Issued  December,  1908.  Phila- 
delphia. 


Annual  Report  of  the  Board  of  Trustees  of  the  German 
Hospital  and  Dispensary  in  the  City  of  New  York.  For 
the  Year  1908. 

Remondino.  P.  C. — Some  Random  Thoughts  and  Reflec- 
tions on  the  Methods  and  Uses  of  State  Boards  of  Medical 
Examiners  and  their  Relations  to  Medical  Education  and 
Students  and  the  State  and  its  people.  Chapters  xvi  and 
xvii.    Pp.  247. 

Transactions  of-  the  Fourth  Annual  ■Meeting  of  the  Na- 
tional Association  for  the  Study  and  Prevention  of  Tuber- 
culosis, Chicago,  June  5  and  6,  1908.  Philadelphia  :  William 
F.  Fell  Company,  1908.    Pp.  352. 

 ^  


Public   Health   and   Marine   Hospital  Service 
Health  Reports : 

The  follozving  cases  of  smallpox,  yellozv  fever,  cholera, 

and  plague  have  been  reported  to  the  surgeon  general, 

United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  seven  days  ending  March  jg,  igog: 


Places. 

Smallpox— Xj 

-\rkansas — Bethal  

Arkansas — Jonesboro  

Arkansas — Paragould  

California — Oakland  

California — San  Francisco  

District  of  Columbia — Washington. 

Illinois — Benid  

Illinois — Chicago  

Illinois — Danville  

Illinois — Galesburg  

Indiana — Elkhart  

Indiana — La  Fayette  

Iowa — Council  Bluffs  


Kansas — Kansas  City  

Kansas — Topeka  

Kentucky — Covington  

Kentucky — Georgetown  

Kentucky — Paducah  

Louisiana — .-\lexandria  

Louisiana — New  Orleans... 

Michigan — Detroit  

Minnesota — Minneapolis.  .  . . 

Missouri — Kansas  City  

Missouri — St.  Louis  

Montana — Butte  

Nebraska — .Arlington  

Nebraska — South  Omaha... 

New  Jersey — Camden  

New  Jersey — Perth  Amboy. 

New  York — Buffalo  

New  York — New  York  

Ohio — Cincinnati  

Ohio — Cleveland  

Ohio — Columbus  

Pennsylvania — New  Castle., 
Pennsylvania — Prompton.  .  . 

Tennessee — Memphis  

Tennessee — Nashville  

Te-xas — El  Paso  

Texas — San  Antonio  

LUah — General  

N'irginia — Caroline  County. 

Washington — -Tacoma  

Wisconsin — La  Crosse  


Date. 
nited  States. 


Cases.  Deaths. 


Jan. 
T  an. 
"Feb. 
Tan. 
Feb. 
Feb. 
Feb. 
Feb. 
Mar. 
Feb. 
Feb. 
Mar. 
Jan. 
Feb. 
Feb. 
Feb. 
Feb. 
Dec. 
Mar. 
Feb. 
Feb. 
Feb. 
Feb. 
Feb. 
Feb. 
Feb. 
Jan. 
Feb. 
Feb. 
Mar. 
Feb. 
Feb. 
Feb. 
Feb. 
Feb. 
Feb. 
Feb. 
Tan. 
Feb. 
Feb. 
Feb. 
Ian. 
Mar. 
Feb. 
Feb. 


^5   3 

2o-Mar.  I   20 

i-Mar.  9   7 

1-31   4 

20-27   6 

20-27   • 


27-Mar.  6. 
1-7  

27-  Mar.  6. 

28-  Mar.  6. 


1-31   9 

1-  28   4 

27-Mar.  6   1 

20-27   6 

27-Mar.  6   3 

2-  Mar.   4   31 

1-7   2 

1-28   9 

29-Mar.  6   1 

20-Mar.  6.  .... .  2 

27-Mar.  6   II 

27-Mar.  6   2 

27-Mar.  6   2 

i6-Mar.  2   2 

25   I 

20-27   5 

27-  Mar.  6   J 

10   6 

28-  Mar.  6   I 

22-  27   • 

26-Mar.  5   9 

26-  Mar.  5   2 

28-Mar.  6   I 

1-  28   2 

2-  Mar.  4   8 

1-31   61 

25-Mar.  6   10 

23-  Mar.  2  

27-  Mar.  6   3 

1-3"  237 

9   I 

14-Mar.  7   8 

27-Mar.  6   2 


Imported 


Siuattpcr — Foreign. 

Algeria — .\lgiers  Jan. 

Canada — Halifax   Feb. 

China — Dalny  Ian. 

China — Tientsin  Jan. 

Egypt — Alexandria  Jan 


Egypt — Cairo  Jan. 

France — Paris  Feb. 

Germany — l^runswick  l-tb. 

Great  Britain — Bristol  Feb. 

India — Bombay  Feb. 

India — Calcutta  .Tan. 


India — Madras  Jan.  3o-I'eb.  5 

India — Rangoon  J^an. 

Italy — General  Feb. 

Italy — Naples  Feb. 

Italy — Paleimo  Jan. 

Tava — Batavia  .Ian. 

Malta  Feb. 

Mexico — Mexico  City  .'an. 

Mexico — Veracruz  I'eb. 

Persia — .\rabistan  Feb. 

Persia — Mechedisser  Feb. 

I'ersia — Mohammerah  Feb. 

Portugal — rjsbon  Feb. 

Russia— Moscow  Jan. 

Russia — St.  Petersburg  Jan. 


1-31  

20-27  .6 

23-30  

23-30   5 

1 -  3 1   8 

28-Feb.   4   33 

6-13   4 

13-20   I 

13-20   4 

2-  9  

16-^0 


i9 


23-30  

14-28  

"4-21  

23-30  

16-23  

23-^eb.   6]  . 

1-27  

3  

3  

3  

13-20  

30-Feb.  13. 
30-Feb.  6.. 


•5 


181 


19 


Present 
Present 
Present 


March  27,  1909.] 


OFFICIAL  NEV/S. 


671 


54 


26 


•  304 


.3.663 


15 


4 

Present 


16 


129 
60 
52 


Present 
14 

3.076 
28 
27 
2 1 


Places.  Date.  Cases.  Deaths. 

Russia — Warsaw  Jan.    2-9   i 

5pain — Almeria  Jan.    1-31   i 

.Spain — Barcelona  Jan.  23-Feb.  13. 

Spain — Valencia  Feb.  6-13  

Tripoli — Tripoli  Feb.  6-13  

Turkey — Constantinople  Feb.  7-21  

Turkey — Trebizond   Feb.  6-20  

Yellow  Fever — Foreign. 

Barbados — General  To  Feb.  27  

Feb.  27-Mar.  6.. 

Ecuador — Guayaquil  Feb.  6-13  

ilexico — Merida  Feb.  21-Mar.  6.. 

Mexico — Ticul  Feb.  2i-Mar.  6., 

Cholera — Foreign. 

India — Bombay  Feb.  2-9  

India — Calcutta  Jan.  16-30  

India — Madras  ..Jan.   30-Feb.  5.. 

India — Rangoon  Jan.  23-30  

Russia — General  Jan.  17-24  

Jan.   24-30  20  1 

Russia — St.  Petersburg  Jan.    24-30  193 

Feb.    12   43 

Plague — Foreign. 

China — Amoy  Mar.  16  

Ecuador — Guayaquil  Jan.  6-23  

Egypt — Suakim  Feb.    i   i 

India — General  Jan.  30-Feb. 

India — Bombay  Feb.  2-9  

India — Calcutta  Jan.  16-30... 

India — Rangoon  Jan.  23-30... 

Turkey — Bagdad  Jan.  16-23... 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
March  17,  igog: 

Anderson,  John  F.,  Passed  Assistant  Surgeon.  Directed 
to  proceed  to  Detroit,  Mich.,  upon  special  temporary- 
duty. 

AsHFORD,  Francis  A.,  Assistant  Surgeon.  Upon  the  ar- 
rival of  Assistant  Surgeon  R.  M.  Grimm,  directed  to 
proceed  to  Stapleton,  N.  Y.,  and  report  to  the  medical 
officer  in  command  for  duty  and  assignment  to  quar- 
ters. 

Cobb,  J.  O.,  Surgeon.  Granted  two  days'  leave  of  absence 
from  March  9,  1909,  on  account  of  sickness. 

Creel,  Richard  H.,  Passed  Assistant  Surgeon.  Relieved 
from  temporary  duty  at  the  Hygienic  Laboratory  and 
directed  to  proceed  to  Chicago,  III,  and  report  to  the 
medical  officer  in  command  for  duty  and  assignment  to 
quarters.  Granted  four  days'  leave  of  absence  en  route 
to  station. 

Fogarty,  J.  N.,  Acting  Assistant  Surgeon.  Granted  ten 
days"  leave  of  absence  from  March  16,  1909. 

Grimm,  R.  M.,  Assistant  Surgeon.  Upon  arrival  of  Passed 
Assistant  Surgeon  R.  H.  Creel,  directed  to  proceed  to 
San  Juan,  P.  R.,  and  report  to  the  commanding  officer 
of  the  U.  S.  Revenue  cutter  Algonquin. 

Lavinder,  C.  H.,  Passed  Assistant  Surgeon.  Detailed  to 
represent  the  Service  at  the  Sixth  Annual  Meeting  of 
the  American  Society  of  Tropical  Medicine,  to  be  held 
in  Wasliington,  D.  C.  April  10,  1909. 

McCoy,  George  W..  Passed  Assistant  Surgeon.  Directed 
to  proceed  to  Berkeley,  Cal.,  upon  special  temporary 
duty. 

Nydegger,  James  A.,  Surgeon.  Upon  the  arrival  of  Passed 
Assistant  Surgeon  Charles  W.  Vogel,  directed  to  pro- 
ceed to  Pittsburgh,  Pa.,  and  assume  charge  of  the 
Service. 

Ramus,  Carl,  Passed  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  March  4,  1909,  on  account 
of  sickness. 

Rosenau.  M.  J.,  Surgeon.  Directed  to  proceed  to  Phila- 
delphia, Pa.,  upon  special  temporary  duty. 

Ryder,  L.  W.,  Pharmacist.  Granted  one  day's  leave  of 
absence,  March  12,  1909,  under  paragraph  210,  Service 
Regulations. 

Vogel,  Charles  W.,  Passed  Assistant  Surgeon.  Relieved 
from  temporary  duty  at  the  Hygienic  Laboratory  and 
directed  to  proceed  to  Stapleton,  N.  Y.,  and  report  to 
the  medical  officer  in  command  for  duty  and  assign- 
ment to  quarters. 

Wertenbaker,  C.  p.,  Surgeon.  Directed  to  report  at  Bu- 
reau upon  special  temporary  duty,  and  upon  completion 
of  the  duty  to  rejoin  station. 

Young,  G.  B.,  Surgeon.  Detailed  to  represent  the  Service 
at  the  Fifth  Annual  Conference  of  the  Council  on 
Medical  Education  of  the  American  Medical  Associa- 
tion, to  be  held  in  Chicago,  III.,  April  5,  1909. 


Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 

Army  for  the  iveek  ending  March  20,  1909: 

Ashburn,  p.  M.,  Major,  Medical  Corps.  Relieved  from 
duty  at  Fort  Banks,  Mass.,  and  ordered  to  San  Fran 
Cisco,  Cal.,  for  duty  at  the  Army  General  Hospital. 

Baker,  F.  C.,  Captain,  Medical  Corps.  Ordered  to  Wash- 
ington, D.  C,  for  examination  for  promotion. 

Geddings,  B.  F.,  Captain,  Medical  Corps.  Ordered  to  Fort 
Howard,  Md.,  for  duty  upon  return  from  Cuba. 

K  iersted,  H.  S.,  Captain,  Medical  Corps.  Ordered  to  San 
Francisco.,  Cal.,  for  examination  for  promotion. 

Morse,  A.  W.,  Captain,  Medical  Corps.  Ordered  to  Wash- 
ington, D.  C,  for  examination  for  promotion. 

Reynolds,  C.  R.,  Captain,  Medical  Corps.  Ordered  to 
Washington,  D.  C,  for  examination  for  promotion. 

Roberts,  W.  M.,  Captain,  Medical  Corps.    Ordered,  in  ad 
dition  to  other  duties,  to  perform  duty  as  surgeon  at 
Sandy  Hook  Proving  Ground,  N.  J.;  granted  leave  of 
absence  for  one  month. 

Rockhill,  E.  p..  Captain,  Medical  Corps.  Ordered  to  San 
Francisco,  Cal.,  for  examination  for  promotion. 

Shimer,  L  a..  Major,  Medical  Corps.  Died  at  Camp  Over- 
ton, Mindanao,  P.  L,  March  13,  1909. 

Siler,  J.  F.,  Captain,  Medical  Corps.  Detailed  to  represent 
Medical  Department  of  the  Army  at  the  meeting  of  the 
American  Society  of  Tropical  Medicine,  Washington, 
D.  C,  April  10,  1909. 

Yos*,  J.  D.,  Captain,  Medical  Corps.  Ordered  to  San 
Francisco,  Cal.,  for  examination  for  promotion. 

Navy  Intelligence: 

Official  list  of  changes  in  the  duties  and  stations  of  offi- 
cers in  the  Medical  Corps  of  the  United  States  Navy  for 
the  week  ending  March  20,  jgog: 

Allen,  A.  H.,  Assistant  Surgeon.  Detached  from  duty  at 
the  Naval  Hospital,  Las  Animas,  Colo.,  and  ordered  to 
the  Naval  Recr  uiting  Station,  Oklahoma,  Okla. 

Ames,  M.  H.,  Assistant  Surgeon.  Detached  from  the  New 
Jersey  and  ordered  to  the  Southery. 

Asserson,  F.  a.,  Passed  Assistant  Surgeon.  Detached 
from  the  Kansas  and  ordered  to  the  Naval  Hospital 
Boston,  Mass. 

Backus,  J.  W.,  Passed  Assistant  Surgeon.  Detached  from 
duty  at  the  Naval  Hospital,  Naval  Training  Station, 
Newport,  R.  L,  and  ordered  to  the  Naval  Recruiting 
Station,  Detroit,  Mich. 

Bertolette,  D.  N.,  Medical  Director.  Detached  from  the 
Naval  Recruiting  Station,  Philadelphia,  Pa.,  and  or- 
dered to  command  the  Naval  Hospital,  Washington, 
D.  C. 

Curtis,  L.  W.,  Surgeon.  Detached  from  duty  as  fleet  sur- 
geon of  the  Atlantic  Fleet  and  ordered  to  the  Naval 
Torpedo  Station,  Newport,  R.  L 

DeLancy,  C.  H.,  Passed  Assistant  Surgeon.  Retired,  or- 
dered home,  when  discharged  from  treatment  at  the 
Naval  Medical  School  Hospital,  Washington,  D.  C. 

Edgar,  J.  M.,  Medical  Inspector.  Detached  from  the  Navy 
Yard,  Boston,  Mass.,  and  ordered  to  duty  on  board  the 
Connecticut  as  Fleet  Surgeon  of  the  Atlantic  Fleet. 

Farenholt,  a..  Surgeon.  Detached  from  the  Maryland 
and  ordered  to  the  West  Virginia. 

Farwell,  W.  G.,  Passed  Assistant  Surgeon.  Detached 
from  duty  at  the  Naval  Hospital,  Naval  Home,  Phila- 
delphia, Pa.,  March  22d,  and  ordered  to  the  Naval  Sta- 
tion, Guantanamo,  Cuba,  sailing  from  New  York  about 
March  26th. 

Fiske,  C.  N.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  Minneapolis,  Minn.,  and 
ordered  to  Washington,  D.  C.,  March  21st,  for  exam- 
ination for  promotion,  and  then  to  wait  orders. 

Flint,  J.,  Assistant  Surgeon.  Detached  from  the  Con- 
necticut and  ordered  to  the  Naval  Hospital,  Naval 
Home,  Philadelphia,  Pa. 

Gardner,  J.  E.,  Medical  Inspector.  Detached  from  the 
Naval  Recruiting  Station,  Boston,  Mass.,  and  ordered 
to  continue  duty  at  the  Marine  Recruiting  Station  at 
that  city. 

Geiger,  a.  J.,  Passed  Assistant  Surgeon.  Detached  from 
the  Supply  and  ordered  to  the  Naval  Hospital,  Mare 
Island,  Cal. 

Grow,  E.  J..  Surgeon.  Ordered  to  additional  duty  at  the 
Naval  Dispensary,  Naval  Medical  School  Hospital, 
Washington,  D.  C. 


672 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journai.. 


Haynes,  J.  p.,  Assistant  Surgeon.  Detached  from  the 
Virginia  and  ordered  to  the  Navy  Yard,  Norfolk,  Va., 
April  loth. 

Hayward,  a.  B.,  Assistant  Surgeon.  Detached  from  the 
Naval  Recruiting  Station,  Dallas,  Texas.,  and  ordered 
to  temporary  duty  on  board  the  Independence  and 
thence  to  the  Colorado. 

HOEN,  VV.  S.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  Oklahoma,  Okla.,  and 
ordered  to  duty  at  the  Naval  Hospital,  Las  Animas, 
Colo. 

KuDER,  W.  S.,  Assistant  Surgeon.  Detached  from  the  Min- 
nesota and  ordered  to  the  Navy  Yard,  Philadelphia,  Pa. 

Ledbetter,  R.  £.,  Surgeon.  Detached  from  the  Navy  Yard, 
Norfolk,  Va.,  and  ordered  to  the  Naval  Medical  School, 
Washington,  D.  C,  April  15th,  for  instruction. 

McDonald,  P.  E.,  Passed  Assistant  Surgeon.  Detached 
from  the  Naval  Training  Station,  Newport,  R.  I.,  and 
ordered  to  duty  at  the  Naval  Hospital,  New  York, 
N.  Y. 

MuNGER,  C.  B.,  Assistant  Surgeon.  Detached  from  the 
Naval  Proving  Ground,  Indian  Head,  Md.,  and  ordered 
to  the  Naval  Medical  School,  Washington,  D.  C,  April 
15th,  for  instruction. 

Murphy,  J.  F.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Station,  Culebra,  W.  I.,  and  ordered  to  the 
Naval  Medical  School,  Washington,  D.  C,  for  instruc- 
tion, April  istli. 

Nash,  F.  S.,  Surgeon.  Detached  from  the  Navy  Yard, 
Washington,  D.  C,  and  ordered  to  the  Naval  Recruit- 
ing Station,  Philadelphia,  Pa.  * 

Owens,  W.  D.,  Passed  Assistant  Surgeon.  Detached  from 
the  Southery  and  ordered  to  temporary  duty  on  board 
the  Buffalo  and  thence  to  duty  with  the  Marine  De- 
tachment, Legation  Guard,  Pekin,  Qiina. 

Peck,  A.  E.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Torpedo  Station,  Newport,  R.  L,  and  or- 
dered to  the  Naval  Medical  School,  Washington,  D.  C., 
for  instruction. 

Persons,  R.  C.,  Medical  Director.  Detached  from  com- 
mand of  the  Naval  Hospital,  Mare  Island,  Cal.,  and 
ordered  to  command  the  Naval  Hospital,  Naval  Home, 
Philadelphia,  Pa. 

Porter,  F.  E.,  Passe'd  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  Detroit,  Mich.,  and  or- 
dered to  the  Naval  Recruiting  Station,  Boston,  Mass. 

Raison,  T.  M.,  Assistant  Surgeon.  Detached  from  the 
West  Virginia  and  ordered  to  the  Maryland. 

Reed,  T.  W.,  Assistant  Surgeon.  Detached  from  the  Col- 
orado and  ordered  to  the  Navy  Yard,  Mare  Island,  Cal. 

RiGGS,  C.  E.,  Surgeon.  Detached  from  duty  with  the  Lega- 
tion Guard  at  Pekin,  China,  and  ordered  home  to  await 
orders. 

RiGGS,  R.  E.,  Passed  Assistant  Surgeon.  Detached  from  the 
Texas  and  ordered  to  duty  with  the  Marine  Detach- 
ment, Port  Royal,  S.  C. 

Rodman,  S.  S.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  Chicago,  111.,  and  ordered 
to  the  Naval  Medical  School,  Washington,  D.  C,  for 
instruction,  April. 

Simons,  M.  H.,  Medical  Director.  Detached  from  com- 
mand of  the  Naval  Hospital,  Philadelphia,  Pa.,  and  or- 
dered to  command  the  Naval  Hospital,  Mare  Island, 
Cal. 

Snyder,  J.  J.,  Surgeon.  Detached  from  duty  in  connection 
with  the  Marine  Detachment  at  Port  Royal,  S.  C,  and 
ordered  to  the  Rhode  Island. 

Spear,  R.,  Surgeon.  Detached  from  the  Rhode  Island  and 
ordered  to  the  Naval  Medical  School  Hospital,  Wash- 
ington. 

Stone,  E.  P.,  Surgeon.    Detached  from  the  Rhode  Island 

and  ordered  to  the  Navy  Yard,  Boston,  Mass. 
Thompson,  E.,  Surgeon.    Detached  from  the  Naval  Sta- 
tion, Guantanamo,  Cuba,  and  ordered  to  the  Naval  Sta- 
tion, Charleston,  S.  C. 
Winn,  C.  K.,  Assistant  Surgeon.    Detached  from  the  Mis- 
souri and  ordered  to  duty  at  the  Naval  Hospital,  Naval 
Training  Station,  Newport,  R.  I. 
The  following  officers  have  been  detached  from  instruc- 
tion at  the  Naval  Medical  School,  Washington,  D.  C. : 
Allen,  D.  G.,  Assistant  Surgeon.    To  3d  Squadron,  Pacific 
Fleet. 

Chambers,  W.,  Assistant  Surgeon.  To  the  Naval  Recruit- 
ing Station,  Dallas,  Texas. 


Dodge,  A.  H.,  Assistant  Surgeon.  To  Naval  Hospital,  Los 
Animas,  Colo. 

Henry,  R.  B.,  Assistant  Surgeon.    To  the  Naval  Magazine, 

lona  Island,  N.  Y. 
Johnson,  L.  W.,  Assistant  Surgeon.    To  the  Minnesota. 
Lane,  H.  H.,  Assistant  Surgeon.    To  the  Naval  Station, 

Hawaii. 

McDowell,  R.W.,  Assistant  Surgeon.    To  the  Connecticut. 

Mackenzie,  E.  G.,  Assistant  Surgeon.   To  the  Kansas. 

Noble,  D.  H.,  Assistant  Surgeon.  To  Naval  Hospital,  Las 
Animas,  Colo. 

Pollard,  J.  B.,  Assistant  Surgeon.    To  the  Missouri. 

Schmidt,  L.  M.,  Assistant  Surgeon.  To  the  Naval  Re- 
cruiting Station,  Chicago,  III. 

Shefard,  G.  W.,  Assistant  Surgeon.  To  the  Naval  Sta- 
tion, Culebra,  W.  I. 

Shippen,  L.  p.,  Assistant  Surgeon.  To  the  Naval  Recruit- 
ing Station,  Minneapolis,  Minn. 

Smith,  C.  W.,  Assistant  Surgeon.  To  Naval  Hospital, 
Naval  Home,  Philadelphia,  Pa. 

Stanley,  A.  C,  Assistant  Surgeon.    To  the  Virginia. 

Sterne,  C.  F.,  Assistant  Surgeon.  To  the  Naval  Recruit- 
ing Station,  St.  Louis,  Mo. 

Toulon,  A.  J.,  Assistant  Surgeon.    To  the  Supply. 

Whitmore,  G.  B.,  Assistant  Surgeon.  To  the  Naval  Prov- 
ing Ground,  Indian  Head,  Md. 

Whiteside,  L.  C.,  Assistant  Surgeon.    To  the  Nezf  Jersey. 

 #  


Born. 

Barney. — In  Fort  Bayard,  N.  M.,  on  Saturday,  March 
13th,  to  Captain  Charles  N.  Barney,  Medical  Corps,  United 
States  Army,  and  Mrs.  Barney,  a  daughter. 

Berkeley. — In  New  York,  on  Saturday,  March  20th,  to 
Dr.  William  N.  Berkeley  and  Mrs.  Berkeley,  a  son. 

Johnson. — In  Newport,  Rhode  Island,  on  Wednesday, 
March  17th,  to  Surgeon  Moulton  K.  Johnson,  United  States 
Navy,  and  Mrs.  Johnson,  a  daughter. 

Williams. — In  Philadelphia,  on  Sunday,  March  14th,  to 
Past  Assistant  Surgeon  Richard  B.  Williams,  United  States 
Navy,  and  Mrs.  Williams,  a  daughter. 

Married. 

Famous — Cope. — In  Philadelphia,  on  Tuesday,  March 
Qth,  Dr.  George  S.  Famous,  of  Berwyn,  Pennsylvania,  and 
Miss  J.  Gertrude  Cope. 

Hooker — Wilson. — In  Evansville,  Indiana,  on  Thursdaj, 
March  nth.  Dr.  Henry  J.  Hooker  and  Miss  Jennie  Wilson. 
Died. 

Adams. — In  Wilton,  Maine,  on  Wednesda3%  March  loth, 
Dr.  A.  B.  Adams,  aged  sixty-eight  years. 

Biddle. — In  Emporia,  Kansas,  on  S.aturday,  March  13th, 
Dr.  George  A.  Biddle,  aged  sixty-three  years. 

Brown. — In  New  York,  on  Tuesday,  March  i6th,  Dr. 
Dillon  Brown,  aged  forty-nine  years. 

Cleary. — In  Kenosha,  Wisconsin,  on  Friday,  March  12th, 
Dr.  John  L.  Cleary,  aged  sixty-two  years. 

CoRBus. — In  Mendota,  Illinois,  on  Thursday,  March  i8th, 
Dr.  J.  C.  Corbus,  aged  seventy-six  years. 

Gatewood.^ — In  Marion,  South  Carolina,  on  Sunday, 
March  7th,  Dr.  William  K.  Gatewood,  of  Westpoint,  Vir- 
ginia. 

Glasgow. — In  Welland,  Ontario,  on  Saturday,  March 
13th,  Dr.  S.  H.  Glasgow,  aged  fifty-four  years. 

Ham. — In  Richford,  Vermont,  on  Sunday,  March  14th, 
Dr.  James  W.  Ham,  aged  seventy-three  years. 

Harriman. — In  Hampton,  Iowa,  on  Wednesday,  March 
17th,  Dr.  W.  E.  Harriman,  of  Ames,  aged  forty  years. 

Jones. — In  Oakland,  California,  on  Tuesday,  March  9th, 
Dr.  Henry  Isaac  Jones. 

Kitchen. — In  Bnmifieldville.  Pennsylvania,  on  Saturday, 
March  13th,  Dr.  Elias  C.  Kitchen,  aged  eighty-three  years. 

Lawrence. — In  New  York,  on  Sunday,  March  14th,  Dr. 
J.  J.  Lawrence,  aged  seventy-three  years. 

MooRE. — In  Lakcport,  New  Hampshire,  on  Friday,  March 
19th,  Dr.  Joseph  Clifford  Moore,  aged  sixty-four  years. 

O'Connor. — In  ITolyoke,  Massachusetts,  on  Thursday, 
March  nth.  Dr.  J.  J.  O'Connor,  aged  forty-three  years. 

Pease. — In  Syracuse,  New  York,  on  Monday,  March  15th, 
Dr.  Henrv  H.  Pease. 

\VF.v._In  Callao.  Peru,  on  Tuesday.  March  i6th,  Dr. 
ITamillon  D.  Wey,  of  Elmira,  New  York. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  ^It  Medical  News 

A   Weekly  Review  of  Medicine,  Established  184J. 


\  0L.  LXXXIX,  Xo.  14.  XEW  YORK,  APRIL  3,  1909.  Whole  No.  1583. 


^^riginal  Communiratious. 


THEORIES  AND  PROBLEMS  OF  HEREDITY. 

Bv  JoxATH.xx  Wright,  M.  D., 
New  York. 

///.    The   AfUliation    of   Cancer   zvith    the  Fundamental 
Theories  of  Heredity. 

I  liave  forgotten  how  many  times  around  the 
world  the  energy  within  a  gramme  of  radium  would 
drive  a  railroad  train  if  economically  utilized.  At 
any  rate  LeBon  calculates'  that  a  rifle  ball,  to  attain 
the  velocity  of  a  corpuscle  torn  from  an  electrode  in 
a  Crookes  tube,  would  need  1.340.000  barrels  of 
pov.-der  exploded  behind  it.  I  have  forgotten  how 
great  a  mass  in  the  aggregate  it  has  been  calculated 
that  the  first  bit  of  the  tumor  taken  from  one  of 
Jenssen's  mice  has  now  reached.  It  is  of  the  same 
order  of  magnitude  as  that  of  atomic  energy,  and  is 
still  growing.  The  figures  are  unimportant  as  they 
convey  no  numerical  meaning  to  most  of  us.  How 
these  vague  but  stupendous  facts  came  to  be  con- 
nected in  my  mind  it  is  one  of  the  minor  objects  of 
this  paper  to  explain.  I  simply  mention  it  here  at 
the  start  to  economize  the  space  in  what  follows, 
which  ^\■ould  be  poorly  spent  in  any  very  great  elab- 
oration of  the  subject  in  a  study  of  the  aetiology-  of 
cancer. 

I  have  intimated  more  than  once,  as  have  many 
others,  and  now  it  has  become  a  pretty  well  estab- 
lished belief  that  the  road  which  leads  to  an  under- 
standing of  the  aetiology  of  cancer  is  traced  out 
through  the  widest  territory  of  the  domain  of  biol- 
ogy,— heredity.  Xaturally,  therefore,  we  must  busy 
ourselves  with  the  study  of  the  objective  appear- 
ances and  the  conclusions  to  be  drawn  from  the 
manifold  activities  of  the  nuclei  of  cells,  for  it  is 
chiefly  the  chromatin  in  them,  in  the  form  of  chromo- 
somes, that  is, — at  least  visibly. — continuous  from 
the  mother  cell  to  the  daughter  cells.  I  am  a  little 
chary  in  giving  an  objective  twist  to  the  expression 
of  this  fact  in  order  to  avoid  an  implication  ex- 
pressed in  the  terms  usually  employed.  '"The  chro- 
mosomes of  the  nucleus  are  the  bearers  of  heredity." 
I  should  prefer  to  put  it :  "In  the  act  of  the  trans- 
mission of  heredity  the  chromosomes  are  the  recog- 
nizable forms  of  matter  transferred."  This  leaves 
the  question  still  at  issue  open  and  without  preju- 
dice. 

In  the  two  previous  articles  of  this  series  (See 
Aril-  York  Medical  Journal.  January  g,  1909,  and 

' L'H;  otuticn  de  la  maticre. 


February  13,  1909)  I  have  endeavored  to  show  by 
a  very  general  discussion  of  the  fundamental  the- 
ories and  problems  of  heredity  that  we  must  view 
the  subject  in  a  light  to  be  derived  from  all  that  has 
hitherto  gone  on  in  biological  discussions,  but  at  the 
same  time  also  in  that  strong  illumination  reflected 
on  the  subject  from  the  field  of  molecular  physics, 
the  very  groundwork  of  all  our  superstructure  of 
the  knowledge  and  theory  of  cosmic  law.  In  other 
papers  I  have  attempted  to  illustrate  the  extent  to 
which  biologists  working  in  this  way  have  been  able 
to  apply  the  laws  which  govern  the  movements  of 
minute  bits  of  matter  to  the  problems  of  immunitv 
and  cell  division.  X'ecessarily  it  could  be  only  a 
mere  outline.  Since  they  were  published  the  work 
of  Gengou'  has  added  a  clearness  and  an  objective 
precision  of  demonstration  to  their  application  which 
is  very  instructive.  So  clearly  do  we  see  that  cer- 
tain functions  of  the  animal  cell,  which  we  are 
forced  to  call  characteristics  of  the  species  or  va- 
riety of  animal  with  which  we  are  dealing,  are  sim- 
ply the  regulated  molecular  activities  of  its  com- 
ponent elements  and  chemical  compounds,  that  we 
are  compelled,  as  I  have  intimated,  to  drop  the  ma- 
terial conceptions  of  \Veismann  and  others  and 
adapt  our  minds  to  a  purely  dynamic  conception  of 
heredity.  There  is  always  admissible  the  vitalistic 
influence  of  Driesch  and  others,  for  they  insist 
there  is  a  power  in  living  matter  which  is  metaphy- 
sical but  which  rules  physical  manifestations  of 
force ;  and  we  can  not  escape  its  exclusion  by  re- 
ducing matter  to  its  molecular  or  atomic  divisions, 
or,  so  far  as  that  is  concerned,  by  dematerializing 
energy  altogether.  Lehmann,  after  an  exhaustive 
study  of  his  so  called  '"apparently  living  crystals" 
and  a  consideration  of  the  forces  which  direct  the 
formation  of  solid  crystals,  remarks  that  these 
forces  in  living  matter  lie  would  call  the  "soul."  It 
seems  inconsistent,  in  view  of  the  fact  that  we  know 
nothing  of  any  line  separating  the  creation  of  the 
form  of  a  crystal  from  that  of  a  living  being,  to  be 
ready  to  attribute  a  metaphysical  term  to  one  ob- 
ject which  he  does  not  seem  ready  to  apply  to 
another,  ^^'e  meet  the  question  everywhere,  in  the 
inanimate  as  well  as  in  the  animate  world. 

^^llat  "entelechy"  governs  the  proliferation  of  the 
cancer  cell  I  cannot  say.  I  can  only  refer  the 
reader  to  Driesch's  latest  exposition  of  his  doctrine. 
Herbst  and  Driesch  admit,  it  is  only  fair  to  note, 
that  after  all  future  analysis  may  result  in  the  con- 
clusion that  "the  organism  might  prove  to  be  a  ma- 

-L'Adhesion  moleculaire  et  phenomenes  biologiques.  Archives 
inrcrationalcs  de  physiologic.  September  and  Xovember.  1908. 


Copjrright,   1909,  by  A.  R.   Elliott  Publishing  Company. 


6/4 


WRIGHT:  HEREDITY. 


[New  York 
Medical  Journal. 


chine  not  only  in.  its  functions  but  also  in  its 
origin.'" 

It  will  be  seen  that  I  propose  to  treat  of  cancer 
and  the  biological  activities  associated  with  it  in  a 
reciprocal  fashion,  for  just  as  biology  in  general  has 
its  lessons  for  cancer,  so  cancer  has  its  illumination 
for  the  subject  of  heredity.  I  have  adduced  some 
small  argument  and  I  have  cited  authority  of  more 
weight  to  support  the  view  that  the  somatic  cell  is 
governed,  mutatis  imitandis,  by  the  same  laws  of 
vital  activity  as  the  germ  cell,  i.  e.,  they  both  do 
best  and  easiest  that  which  they  have  been  used  to 
do.  I  desire  here  to  insist,  with  reference  to  what 
I  have  said  of  neovitalism,  that  no  view  of  hered- 
ity can  be  accepted  as  final  which  does  not  include 
the  explanation  of  the  structural  changes  of  the  tis- 
sues formed  by  the  somatic  cells  in  pathological 
aberrations  as  well  as  in  physiological  development. 
We  must  take  up  the  view  here  that  not  only  do  the 
somatic  cells  show  their  affiliation  with  the  germ 
cells  in  the  matter  of  use  and  disuse  in  the  meaning* 
I  have  just  given  those  terms,  but  they  do  so  in  the 
exhibition  of  the  occurrence  of  variation  and  muta- 
tion in  their  phylogeny.  Under  the  stimuli  of  use 
and  under  the  neglect  of  it,  disuse,  variations  are 
noted  in  their  morphology.  They  vary  to  meet  their 
functional  needs  even  of  repair  and  regeneration. 
We  who  are  not  ready  to  take  refuge  in  neovital- 
ism imagine  a  shift  of  some  kind  in  the  molecular 
arrangement  in  the  chemistry  of  the  cells  which 
does  this,  but  it  is  a  reversible  one,  a  thing  familiar 
enough  in  organic  chemistry.  In  the  language  of 
the  literature  of  mutation  when  it  is  more  or  less 
irreversible,  it  rolls  over  on  a  new  facet,  and  instead 
of  vacillating  back  and  forth  it  is  only  rarely,  per- 
haps it  is  never  -reversed.  Cancer  may  be  looked 
upon  as  such  a  mutation.  The  pendulumlike  swing 
of  the  molecules  is  not  stopped  but  the  pendulum 
swings  from  a  new  point  of  attachment.  There 
has  been  set  up  some  new  and  more  fundamental 
chemical  valence  for  the  molecules  in  the  chromo- 
somes, or  other  part  of  the  colloid  of  the  cell.  I 
am  putting  my  own  interpretation  on  the  revela- 
tions, in  the  first  place  of  Darwin'  but  brought  into 
much  greater  prominence  by  De  Vries, — indeed 
made  by  him  the  sole  way  in  which  evolution  fur- 
nishes material  for  natural  selection.  Now  there  is 
to  be  observed  here  in  the  cellular  problem  the  same 
question  as  in  the  question  of  individual  mutation. 
Does  it  dif¥er  toto  ccclo  from  variations?  That 
is  what  the  evidence  thus  far  adduced  under  Que- 
telet's  law  of  regression  seems  to  show.  But  here 
also  there  are  certain  phenomena  which  seem  to 
connect  the  two.  From  functional  variations  through 
inflammatory  growths  we  enter  the  domain  of  the 
benign  tumors.  It  would  be  a  joy  forever  to  the  his- 
tological diagnostician  if  some  kind  law  would  draw 
a  sharp  line  of  distinction  between  the  structure  of 
a  benign  and  a  malignant  adenoma.    Yet  we  can 

'Der  Vitalismus  als  Gcschichte  und  als  Lehre.  The  Science  and 
Philosophy  of  the  Organism.  Gifford  Lectures,  i,  1907;  Vol.  ii, 
1908,  by  Hans  Driesch.  I  refer  the  reader  tp  something  I  have 
pursued  in  various  languages,  but  which  I  frankly  admit  I  have 
failed  to  understand  in  al!  its  applications  or  in  any  of  its  limita- 
tions. 

*The  recent  admirable  paper  in  the  American  Naturalist,  Feb- 
ruary, 1909,  by  Professor  Charles  F.  Cox,  president  of  the  New 
York  .Academy  of  Sciences,  may  be  read  with  great  profit  in  the 
study  of  the  relation  of  Charles  Dai  win  to  the  mutation  theory. 


make  some  sort  of  a  definition  of  it  by  the  observa- 
tion that  in  the  benign  tumor  the  lawlessness  of 
growth  does  not  extend  markedly  to  the  intracellu- 
lar structure.  Ribbert  denies  this  also  to  beginning 
carcinoma,  but  I  am  not  disposed  to  think  this  is 
usually  the  case.  We  also  observe  that  what  we  shall 
afterward  have  occasion  to  refer  to  as  the  immor- 
tality of  the  caticer  cell  proliferation,  its  internal 
energy,  is  markedly  less  in  the  benign  tumor. 
While  it  proliferates  beyond  that  which  the  sym- 
metry of  form  and  function  demand,  it  still  has 
some  respect  for  the  synthesis  of  the  organism  as  a 
whole.  Even  taking  this  very  conservative  stand  as 
to  distinction,  I  think  it  will  be  apparent  that  here 
as  elsewhere  in  the  living  world,  it  is  impossible  to 
draw  sharp  lines  between  variation  and  mutation. 
In  admitting  at  the  start  that  such  is  the  case  as  be- 
tween  benign  and  malignant  tumor  and  the  tera- 
tomata,  I  only  echo  the  criticism  the  Darwinians, 
such  as  Wallace,  direct  against  the  mutationists.  It 
has  been  easy  to  suppose,  in  the  study  of  teratomata 
as  of  the  power  of  regeneration  in  the  lower  ani- 
mals, that  the  somatic  cells  may  contain  within 
themselves  some  stray  germ  plasm  or  some  of  Weis- 
mann's  determinants,  and  that  thus  we  may  explain 
the  occurrence  of  teratomata  entirely  unconnected 
with  the  ovary  or  the  testis,  as  for  instance  when 
they  are  found  within  the  brain  substance  where  it 
is  difficult  to  trace  any  embryogenetic  relationship  for 
the  foreign  tissue  forms.  This  supposition,  it  seems 
to  me,  is  much  more  a  forced  and  specious  pleading 
than  the  view  that  they  have  had  their  origin  in 
some  somatic  cell  through  its  atavistic  reversion  to 
the  germ  plasm  condition.  Johannes  Miiller  three 
generations  ago  pointed  out  the  affiliation  of  tera- 
tomata with  true  tumors,  and  in  spite  of  our  theories 
we  have  scarcely  got  further  along  than  dimly  to 
perceive  that  there  is  some  sort  of  affiliation  in  gen- 
esis between  processes  of  repair  and  regeneration, 
benign  tumors,  teratomata,  and  malignant  growths. 
What  we  seem  to  .see,  with  some  degree  of  clear- 
ness, is  the  evidence  furnished  by  these  physiologi- 
cal and  pathological  phenomena  that  there  is  a 
power  in  somatic  cells  akin  to  the  power 
usually  attributed  solely  to  the  germ  cells.  We 
see  that  cancer  as  a  mutation  is  in  a  certain  way 
moving  along  these  lines  of  vital  energ)'.  If  a  crab 
can  grow  his  claw  anew,  we  know  no  reason  wh\- 
an  epithelial  cell  may  not  grow  a  teratoma,  even 
containing  all  three  of  the  primitive  layers,  since  we 
recognize  that  the  flat  epithelium  is  that  form  of 
cell  most  closely  resembling  the  original  blastomere, 
and  we  shall  subsequently  see  there  is  evidence  of 
the  transformation  of  the  epithelial  into  a  connect- 
ive tissue  cell  type.  Even  Askanazy"  who  is  dis- 
posed to  cling  to  the  theory  of  the  integrity  of  the 
blastodermic  layers  in  somatic  development,  admits 
there  are  malignant  tumors  representing  two  layers. 
In  affiliating  teratomata  with  malignant  tumors  in 
their  genesis  we  must  remember  the  fundamental 
diff^erence  in  the  loss  of  control  of  the  primordial 
energy  of  growth  by  the  cancer.  The  teratoma  pro- 
duces more  or  less  perfect  tissue  form.  The  cancer 
df)es  nothing  of  the  sort.    Thus  early  it  is  well  to 

'•Verhandlungcn  der  dcutschen  pathologischcn  Gcscllscliaft ,  1907, 
published  in  1908,  p.  39. 


April  3,  1909.] 


WRIGHT:  HEREDITY. 


675 


point  out  the  presence  of  a  distinctive  formative  in- 
fluence in  the  one  case  and  its  absence  in  the  other, 
as  distinguished  from  the  common  energ}'  of 
growth  and  assimilation  present  in  both.  The 
marked  tendency  of  teratomata  to  malignant  degen- 
eration, the  myxomatous  reversion  of  connective 
tissue  tumors,  benign  and  malignant,  to  a  form  of 
embryonic  tissue  serves  to  preserve  our  belief  in  a 
sequence  of  events  which  ally  the  phenomena  one 
to  another.  As  an  example  of  the  difficulty  of  inter- 
pretation in  studying  the  teratomata,  the  case  noted 
by  Saxer  has  been  quoted  as  giving  strength  to  the 
Weismann  theory  of  determinants.  He  found  in  an 
ovarian  cvst.  as  the  sole  representative  of  a  tera- 
toma, a  tooth.  The  late  lamented  Professor  Al- 
brecht,  one  of  the  keenest  observers  and  one  of  the 
closest  and  most  original  reasoners  of  modern  Ger- 
man pathologists,  expressed  himself  as  believing 
that  fundamentally  no  line  of  distinction  could  be 
drawn  between  "the  foetus  in  foetu"  and  the  mixed 
and  simple  tumors.  With  him  as  with  many  of  us, 
it  naturally  follows  that  we  are  not  at  all  clear  as  to 
where  the  line  between  germ  plasm  and  soma  is  to 
be  foiind.  That  Weismann's  determinants  might 
temporarily  solve  some  of  the  difficulties  can  not 
be  denied  any  more  than  the  force  of  the  argument 
for  a  metaphysical  agent  wdiich  Driesch  might  bring 
to  bear  from  the  same  field ;  but  we  are  not  permit- 
ted to  solve  specific  difficulties  in  biology  with  gen- 
eral formulae  not  universally  applicable. 

I  must  revert  to  another  question  raised  in  mod- 
ern biolog}-  anew^  in  the  discussion  of  the  part 
mutations  or  discontinuous  variations  play  in  the 
evolution  of  new  species.  Darwin  when  he  consid- 
ered the  subject,  found  a  reason  for  disbelieving 
that  they  are  the  frequent  origin  of  new  species  in 
the  fact  of  their  isolated  occurrence.  Man,  of 
course,  by  interbreeding  the  same  kind  of  "sports" 
that  might  appear,  can  raise  from  them  a  new  race, 
if  the  male  and  female  form  can  be  united  through 
Mendelian  phenomena  or  otherwise,  but  in  nature 
unless  there  is  a  wade  jump  together  of  a  number 
of  individuals  at  once  the  mutation  w-ould  perish  if 
occurring  alone  in  a  sterile  form  as  concerned  con- 
jugation w'ith  its  stem  of  origin,  or  it  would  be 
swamped  by  the  general  heredity  of  the  stem  if  fer- 
tile with  it.  It  would  take  me  too  far  to  enter  into 
the  Mendelian  answer  to  this  objection.  In  another 
form  of  reply  I  wish  to  refer  to  the  fact  that,  under 
unknown  conditions  for  the  most  part,  especially  in 
the  plant  world,  a  number  of  mutations  of  a  stem  in 
a  certain  direction  have  been  observed  simulta- 
neously. Now  the  question  occurs  here,  does  can- 
cer arise  from  the  mutation  of  one  cell  or  from  a 
number  simultaneously?  The  question  is  not  a  vital 
one  for  the  conception  of  cancer  as  a  mutation,  be- 
cause we  may  look  upon  cell  segmentation  as  one  of 
parthenogenesis.  Nevertheless  it  is  an  interesting 
subject,  since  we  must  look  for  some  more  general 
biogenic  factor,  some  systemic  change,  if  we  are  to 
assume  that  cancer  is  not  always  a  local  growth.  Of 
course  the  clinical  phenomenon  of  general  carcino- 
matosis at  once  occurs  to  us  in  this  connection.  Into 
that  I  am  not  prepared  to  go,  though  perhaps  there 
also  we  might  derive  some  hint  of  the  influence  of 
environment  in  the  causation  of  varieties  or  muta- 


tions. I  desire  to  refer  to  a  note  I  have  made  of  a 
tumor  of  the  nasal  mucosa  of  the  anterior  end  of  the 
middle  turbinated  bone : 

Lab.  N'o.  3712 — CI.  No.  494251.  The  patient  was  a  Rus- 
sian Jew,  aged  forty-seven,  in  good  general  health,  who 
came  under  Dr.  McCullagh's  care  in  the  cHnic  of  Dr.  Cof- 
fin at  the  Manhattan  Eye,  Ear,  and  Throat  Hospital.  The 
whole  nasal  fossa  was  crowded  with  a  polypoid  mass  of 
unusual  shape  which  seemed  to  hang  from  the  middle  tur- 
binate as  a  curtain,  reaching  to  the  floor  of  the  nose.  The 
microscopic  structure  gave  rise  to  a  difference  of  opinion. 
One  competent  histologist  regarded  it  as  plainly  a  benign 
epithelial  growth,  and  another  of  great  experience  called  it 
a  typical  epithelion,a.  There  was  a  proliferation  of  the 
ciliated  columnar  epithelium  springing  from  the  surface, 
yet  partaking  of  the  character  of  the  gland  cells  somewhat 
in  its  structure.  At  many  plaxes  could  be  seen  the  close 
juxtaposition  of  the  normal  epithelium  and  the  abnormal 
cells  springing  apparently  directly  from  it  on  the  surface. 
There  w-as  plainly  not  only  a  metamorphosis  of  extracellu- 
lar structure,  but  of  intracellular  structure,  which  certainly 
removed  the  growth  from  the  ordinarj-  class  of  benign  hy- 
perplasias. Into  the  particulars  of  this  I  will  not  go.  Suf- 
fice it  to  say,  the  atypical  features  were  chiefly  noted  at  the 
anterior  end  or  at  that  portion  springing  from  the  forward 
tip  of  the  middle  turbinate,  most  exposed  to  irritations  of 
various  kinds.  Running  one's  eye  along  the  surface  of  the 
sections  made  in  a  vertical  anteroposterior  plane,  it  was 
seen  the  epithelial  infiltration  of  the  stroma  rapidly  dimin- 
ished from  before  backwards.  To  me  there  seemed  no  doubt 
that  in  the  limited  anterior  portion  of  the  growth  the  gen- 
eral character  was  that  of  which  we  are  accustomed  to 
postulate  malignancy.  But  at  the  middle  of  the  section  this 
infiltration  had  all  but  ceased,  while  the  posterior  part  of 
the  tumor  was  made  up  of  the  ordinary  cedematous  tissue 
of  the  nasal  polyp.  At  the  surface  the  morbid  epithelium  of 
the  anterior  portion  w-as  interrupted  in  the  middle  portion 
by  short  stretches  of  fairly  normal  epithelial  cells,  but 
along  this  border  budding  islands  of  the  abnormal  epithe- 
lium could  be  seen,  becoming  more  infrequent  in  passing 
backward.  The  sections  fell  in  such  a  way  and  were  ex- 
amined in  such  numbers,  (unfortunately  not  in  serial  sec- 
tions, however),  that  I  was  fairly  confident  there  was  no 
continuity  between  the  islands,  on  the  surface  or  beneath  it. 
The  impression  made  on  me  and  expressed  in  my  notes 
before  I  could  have  been  subjectively  moved  by  considera- 
tions of  a  theoretical  nature  expressed  in  what  has  pre- 
ceded, was  that  there  was  no  escape  from'  the  conviction 
that  this  cell  aberration  (and  for  our  purpose  here  the  sub- 
sequent fate  of  the  pat'ent  is  not  of  interest)  was.  springing 
simultaneously  though  progressively  from  a  number  of 
isolated  normal  cells,  subjected  anteriorly  to  the  stimulus 
which  decreased  in  intensity  and  corresponding  effect  as  the 
region  receded  into  the  depths  of  the  nasal  chamber." 

Hence,  so  far  as  this  case  is  concerned,  I  am  com- 
pelled to  accept  the  view  that  there  were  a  ntimber 
of  cell  mutations  of  a  cancerous*"  nature  springing 
simultaneously  from  cau.ses  more  or  less  identical 
both  systemically  and  locally.  Of  course  I  have 
seen  other  indications  of  the  same  phenomenon,  but 
none  to  which  I  could  not  apply  the  criticism  of  a 
possible  doubt  in  the  conclusions  or  a  possible  mis- 
take in  the  observation.  I  may  refer  to  observations 
pointing  to  the  same  multicellular  origin  of  carci- 
noma by  Ribbert.'  While  I  am  not  prepared  to 
subscribe  to  many  of  this  author's  well  know-n  views, 

"For  those  interested  in  the  subsequent  history  and  the  clinical 
diagnosis.  I  may  say  that  notwithstanding  the  plainly  cancerous 
structure  of  a  part  of  the  growth,  I  was  of  the  opinion  that  it 
would  not  recur  even  when  removed,  as  it  was,  by  the  ordinary 
snare  operation.  The  patient's  immediate  relief  from  discomfort 
would  have  induced  him  to  return  in  case  of  further  trouble.  As 
yet,  about  ten  months  since  the  growth  was  removed,  he  has  not 
again  applied  for  relief, — a  very  exceptional  thing  in  those  rare  cases 
of  nasal  epithelioma  that  have  come  under  my  observation.  The 
clinical  result,  however,  has  no  bearing  on  the  fact  that  this  was 
a  sudden  change  of  form  of  growth.  To  all  intents  and  purposes 
of  this  paper  it  was  a  mutation  as  clearly  as  though  it  was  surely 
malignant. 

^Beitrage  zur  Entstehung  der  Geschwiilste,  Dritte  Erganzung,  1908. 

Sechs  beginnende  Karzinome  der  Gesichtshaut  eines  Mannes. 


676 


IV RIGHT:  HEREDITY. 


[New  York 
Medical  Journal. 


he  has  presented  proof,  in  my  interpretation  of  the 
appearances,  that  the  cellular  mutation  to  cancer  has 
started  not  from  one  cell  but  more  or  less  simulta- 
neously from  several  in  the  same  locality.  It  seems 
also  quite  probable  in  his  cases  as  in  my  own,  that 
very  moderate  inflammatory  stimuli  have  pulled  the 
trigger  when  the  train  was  all  prepared  by  endoge- 
nic molecular  arrangements. 

If  we  are  to  consider  the  cancer  cell  a  mutation 
of  one  cell  or  of  a  number  in  the  same  locality  at 
once'  the  first  inquiry  must  be :  What  are  its  most 
striking  characteristics?  And  the  answer  must  be: 
Its  energy.  It  is  immortal,  under  proper  conditions 
of  course.  It  is  no  longer  a  somatic  cell  in  this  re- 
spect. Calkins'  has  pointed  out  the  significance  of 
the  continued  survival  of  the  transplanted  cancer 
cell  through  a  hundred  generations  (i.  e.  one  hun- 
dred individuals)  of  mice  from  the  first  original  in- 
oculation, as  evidence  that  the  cancer  cell  belongs 
to  the  same  order  of  mortality  or  immortality  as  the 
germ  cell.  Springing  originally  from  the  epithelial 
or  connective  tissue  cells  of  man  we  must  picture 
to  ourselves  that  this  is  an  atavistic  reassumption" 
of  the  characteristic  of  the  primitive  jjerm  cell  which 
of  all  things,  it  is  urged,  distinguishes  it  from  the 
somatic  cell.  Calkins"  seems  disposed  to  lay  stress 
upon  the  rhythms  of  growth  in  cancer,  occasionally 
noted  clinically  in  man.  as  indicative  of  a  strikeback 
to  a  similar  characteristic  noted  in  the  protozoa.  I 
doubt  if  this  idea  is  tenable.  Rhythms  of  molecular 
discharge  of  energy  may  be  traced  in  the  variations 
of  dailv  well  or  ill  feeling  of  man  himself.  It  is  prob- 
ably a  characteristic  of  all  living  matter.  Had  we 
the  proper  statistics  such  rhythms  could  probably 
be  traced  in  the  vigor  of  the  stirps  in  different  gen- 
erations of  many  animals.  The  protozoa  have  sim- 
ply presented  a  facility  of  observation  quite  impos- 
sible in  more  complex  animals.  Every  physician  ac- 
customed to  watch  the  physical  well  being  of  a 
chronic  invalid  knows  of  this  unaccountable  rhythm. 
It  only  needs  pointing  out  here  the  pressing  analogy 
of  similar  exhibitions  of  growth  in  the  protozoa. 
With  them  as  with  us  we  know  not  what  it  is  de- 
pendent on. 

Now  this  introduces  us  to  another  idea  that  has 
found  lodgment  in  the  minds  of  certain  acute  ob- 
servers. It  needs  only  a  mention  here  as  a  curiosity, 
though  it  may  be  helpful.  Butlin,  in  England,''  and 
Kelling.^'  in  Germany,  and  possibly  some  others, 
have  come  to  look  upon  the  cancer  cell  as  itself  a 
parasite.  In  the  sense  that  it  has  become  something 
foreign  to  the  organism,  partaking  no  longer  of  the 
altruistic  synthesis  of  the  organism,  I  suppose  there 
is  no  harm  in  regarding  it  as  such,  in  so  far  as  we 
are  not  compelled  to  postulate  its  origin  from  with- 
out, as  has  been  urged.    Naturally  it  then  falls  un- 

'Let  us  bear  in  mind  Driesch's  apothegm:  "The  prospective  fate 
of  a  cell  is  the  function  of  its  localization."  Perhaps  something  has 
gone  wrong  with  the  local  entelechy! 

"Rhythms  of  Growthl  Energy  in  Mouse  Cancer.  Juunial  of  Ex- 
perimental Medicine,  Mr.y  i,  IQ08. 

'"It  may  be  objected  that  I  am  confounding  atavistic  regression 
with  mutations  to  new  forms  of  growth.  1  cari  only  reply  thru 
such  distinctions  when  we  come  to  discuss  questions  of  molecular 
energy  are  merged  into  one  conception.  Tlic  cell  form  is  a  muta- 
tion, but  its  energy  may  be  traced  back  to  that  of  the  germ  cell. 
I  leave  it  to  others  to  wrestle  with  the  dialectics  that  may  be  waged 
about  this  point. 

"The  Protnzoa. 

"Butlin.    The  Lancet,  December  16,  1905. 

"Kelling.     Zcitschrifl  fi'ir  Krcbsfonchung,  iii,  part  2  el  alid. 


der  the  same  classification  of  idea  as  the  mutational 
one.  The  enthusiasm  with  which  large  numbers  of 
men  without  extensive  experience  of  the  histological 
examination  of  morbid  tissue  started  in  to  find  the 
organism  of  cancer,  was  due  to  the  microbian  rage 
which  had  seized  on  the  whole  medical  world.  Suf- 
fice it  to  say  that  it  is  subsiding  with  rapidity,  in- 
deed it  has  all  but  disappeared,  and  we  are  entering 
upon  that  broader  outlook  upon  etiology  whereb\- 
we  see  that  the  cancer  problem  is  ranging  itself  in 
line  with  other  problems  of  the  science  of  life  itself. 
In  passing  we  may  note  that  Calkins  suggests  that 
the  rhythm  of  the  cancer  cell  growth  as  noted  in 
the  difiFerent  generations  of  mice  may  not  be  due  to 
its  own  variation  of  internal  energy  but  to  the  varia- 
tion in  the  energy  of  some  invisible  and  unknown 
protozoan  organism  which  accompanies  it  and  fur- 
nishes the  stimulus  to  its  lawless  growth.  This 
seems  to  be  at  present  the  only  remnant  left  to  the 
arguments  which  have  been  urged  to  support  the 
idea  that  certain  cell  inclusions  and  cell  exudates 
are  cancer  organisms. 

Before  we  proceed  to  consider  the  normal  nu- 
clear phenomena  from  which  the  nuclear  and  cell 
phenomena  of  cancer  exhibit  so  marked  a  depart- 
ure, I  desire  now  to  revert  to  the  hint  expressed  in 
the  opening  paragraphs  of  this  article.  It  has  re- 
mained vaguely  defined  at  the  back  of  my  mind  for 
a  long  time,  and  perhaps  the  literature  emanating 
from  the  school  of  Driesch  has  had  something  to  do 
in  separating  the  idea  of  the  outburst  of  energy  ex- 
hibited in  the  cell  division  of  cancer  from  the  idea 
of  some  regulating  mechanism  or, — if  you  please, — 
entelechy  which  accompanies  the  normal  growth. 
After  all,  the  term  "normal"  is  entirely  an  anthro- 
pomorphical idea,  just  as  the  clinical  idea  of 
malignancy  is.  Cancer  kills  a  man  in  a  hundred 
ways.  When  a  man  chokes  to  death  from  laryn- 
geal cancer  or  starves  to  death  from  stomach  can- 
cer, the  result  has  nothing  to  do  with  the  vital  ac- 
tivities in  themselves,  except  to  stop  them.  A 
tracheotomy  or  a  gastrostomy  would  have  saved  the 
patient  and  continued  them  for  a  time.  The  central 
idea  is  that  of  the  boundless  energ\'  exhibited  and 
the  lack  of  control  it  shows.  Let  us  follow  out  the 
suggestion  of  separating  the  energy  of  growth  from 
its  limitations."  Let  us  waive  the  idea  of  control  and 
no  control  which  distinguishes  them  and  consider  the 
thing  the  cancer  cell  and  the  germ  cell  have  in  com- 
mon— boundless  energy.  Whence  comes  it  ?  The 
slow  step  of  time  soon  exhausts  it  in  the  somatic  cell 
of  man  as  we  pass  from  the  cradle  to  the  grave. 
Why  is  it  continually  unfolded  in  the  germ  cell  and 
the  cancer  cell  ?  I  presume  every  one  who  has  done 
me  the  compliment  to  follow  me  thus  far  will  see 
the  significance  of  coupling  together  the  enormous 
energy  of  the  flying  corpuscle  in  the  Crookes  tube 
and  the  stupendous  bulk  of  the  lordly  elephant  and 
the  giant  oak.  The  idea  of  atomic  disintegration  is 
also  affiliated  with  the  vision  of  that  agjjregate  mass 
referred  to  by  Calkins  growing  from  the  thousands 
of  mice  that  have  passed  through  the  hands  of  Bash- 

"Whether  or  not  there  is  such  a  separation  I  do  not  know,  h:it 
at  least  in  the  analysis  here  attempted  it  is  convenient  at  times  to 
assume  there  is  such  a  thing  as  an  entelechy  or  an  organelle  or  a 
formative  stimulus.  I  make  use  of  it  as  convenient  in  our  present 
st.-ite  of  ignorance,  but  I  am  very  far  from  asserting  its  reality. 


April  3,  1909.] 


WRIGHT:  HEREDITY. 


677 


ford,  of  Ehrlich  and  Apolant  and  their  followers. 
Perhaps  I  might  leave  the  matter  where  it  is  at  this 
point,  since  I  can  cite  no  "facts"  that  are  indispen- 
sable to  the  working  of  a  certain  order  of  mind ;  but 
after  all  it  may  be  worth  while  to  appeal  to  those 
fortunate  enough  to  be  endowed  with  imaginations 
they  are  not  ashamed  of.  First  let  me  refer  to 
the  careful  observations  of  Cluzet  and  Bassal"  who 
noted  the  action  of  the  x  rays  upon  the  evolution  of 
the  breast  during  pregnancy,  which  tends  to  limit  it 
or  arrest  it  by  causing  hypertrophy  of  the  nuclei  in 
the  epithelium  of  the  lacteal  canals.  Let  us  go  back 
to  the  observations  of  R.  Hertwig  and  his  cowork- 
ers, which  I  have  quoted  elsewhere.  Both  he  and 
Calkins  have  noted  that  the  functional  depression  of 
the  nucleus  aside  from  any  noticeable  change  in  ex- 
ternal conditions  coincides  with  relative  increase  of 
size."  Heiberg''  by  measurement  of  the  nuclei  of 
cancer  cells  has  shown  that  on  the  average  they  are 
materially  larger  than  normal.  It  is  possible  fur- 
ther investigation  will  find  in  this  observ-ation  and 
in  that  of  R.  Hertwig,  to  which  I  have  just  referred, 
a  significance  only  dimly  perceptible  at  present. 

Is  it  possible  that  the  x  ray  has  struck  a  quiver- 
ing particle  from  the  nucleus  as  it  does  from  the 
luminescent  screen?  Turning  to  plant  life,  we  find 
observations  on  the  profound  disturbance  of  growth 
induced  by  exposure  of  plants  to  radium  and  x 
rays."  We  can  scarcely  doubt  from  what  we  know 
of  the  nucleus  as  a  regulator  of  growth  that  it  is  the 
organ  of  the  cell  affected,  and  indeed  Professor  Ga- 
ger  has  shown  that  some  of  the  chromosomes  of  the 
nucleus  are  destroyed  by  the  x  rays  and  some  grow 
irregularly.  AIL  I  am  interested  in  here  is  in  sug- 
gesting the  readiness  with  which  atomic  disturbance 
is  set  up  in  the  nucleus  by  the  kind  of  influence  that 
sets  up  atomic  disturbance  in  the  diamond  and  the 
luminescent  screen ;  but  we  may  note  in  passing 
how  this  inequality  of  effect  on  the  chromosomes 
tells  for  that  individuality  ascribed  to  them  by  Bo- 
veri  and  Weismann.  In  the  act  of  copulation  of  the 
egg  cell  and  the  sperma.  or  in  parthogenesis,  do  we 
see  some  indication  that  certain  influences  strike  out 
from  protoplasm  the  energ\-  of  its  atoms? 

But  what  does  the  x  ray  do  to  the  somatic  cell? 
I  do  not  know  how.  from  the  evidence,  we  can  deny 
it  sometimes  produces  cancer  in  the  epithelial  layers, 
for  certain  it  is,  it  sets  up  various  forms  of  cell 
structure  which  resemble  the  cell  structure  of  can- 
cer.  Again  what  has  gone  wrong  with  the  nucleus  ? 

The  Finsen  light,  the  glare  of  the  tropic  sun,  vi- 
brations, all  of  them,  in  the  ether  do  certain  things 
easily  to  the  nuclei  of  cells  inaccessible  to  other  in- 
fluences. Dark  granules  gather  in  the  skin  layers 
and  we  have  a  tan  which  besmirches  the  face  of 
man,  and.  the  Lamarckians  say,  renders  his  de- 
scendants black  when  residence  is  continued  in  the 
tropics.  I  am  touching  on  grounds  of  controversy 
which  I  wish  to  avoid.  All  I  wish  to  insinuate  is 
that  the  influence  of  ordinary  light  rays  is  active  in 

^^Journal  de  I'anatomie,  No.  6,  igoS. 

"R.   Hertwig.     Ueber  neue  Problerae   der  Zellehre,   Archiv  fiir 
Zellenforschung,  I,  part  I,  1908. 
Calkins.    The  Protozoa. 

"Ueber  die  Erklarung  einer  Verschiedenheit  in  der  Krebszellen 
von  andern  Zellen,  Nordiskt  medicinskt  Arkir.  xli,  part  ii,  No.  4, 
August,  1908.     Ref.:  Biophysikal.  Ccniralbl.  iii,  Nos.  20-21,  1908. 

"Some  Physiological  Effects  of  Radium  Rays,  by  Charles  Stuart 
Gager,  The  American  Xaturalist,  December,  190S. 


the  evolutionary  processes  of  phylogeny  as  of  on- 
togeny. The  ethereal  vibrations  of  the  x  ray  we 
note  producing  change  in  the  chromosomes  of  the 
plant  nucleus  and  apparently  at  times  producing 
cancerous  mutations  in  the  cells  of  man.  Correlated 
with  the  experiments  and  observations  referred  to 
above,  it  seems  quite  possible  that  some  of  the  phe- 
nomena of  nuclear  activity  even  in  normal  processes 
may  be  due  to  an  energy  stored  within  the  atoms 
released  by  ethereal  vibrations  of  solar  energy  and 
regulated  by  that  mystery  we  call  heredity :  and 
Driesch  certainly  makes  it  no  clearer  by  calling  it 
"Entelechy."  The  formative  stimulus  of  \'irchow, 
the  normal  entelechy  of  Driesch  is  exchanged  in 
cancer  for  a  diastase  or  an  "organelle"  in  the  con- 
cept of  various  writers,  but  what  have  we  gained  by 
such  logomachy?  Certainly  nothing  definite  in  the 
way  of  knowledge,  but  yet  something  in  stating  the 
unsolved  problem  with  a  greater  precision  as  a  re- 
sult of  modern  cancer  research.  The  possibility  of 
explaining  the  source  of  cancer  energv  may  be  quite 
aside  from  explaining  the  direction  it  takes  in  de- 
velopment, but  I  am  by  no  means  convinced  that 
such  is  the  fact.  It  is  a  distinction  to  be  accepted 
for  convenience  of  discussion,  but  if  atomic  energy 
is  released  in  the  process  of  mitosis,  it  is  released 
as  the  result  of  the  impingement  of  other  energy 
and  it  is  merged  with  the  energy-  of  the  environment, 
the  resultant  being  manifested  by  the  course  of  the 
evolution  of  form. 

Here  it  may  profitably  be  considered  if  the  inertia 
of  inanimate  matter  is  not  at  one  with  the  heredity 
of  living  matter.  I  am  tempted  to  enter  into  the  dis- 
cussion of  this  question,  often  broached  in  the  bio- 
logical discussions  of  the  last  forty  years,  and  even 
before  the  birth  of  Darwinian  evolution,  but  it 
would  involve  too  many  considerations  aside  from 
the  subject.  It  still  remains  a  question  whether  this 
would  suffice  to  explain  the  continuity  of  form  and 
function  as  handed  from  one  bit  of  matter  to  another 
in  what  we  call  heredity.  The  arrangement  of 
molecules  in  such  a  train  that  from  it  the  inertia  of 
matter  in  motion  could  exhibit  the  persistence  of 
living  form  with  which  we  are  familiar  is  a  concep- 
tion too  bold  for  erection  into  a  theory  of  heredity 
at  present."  In  suggesting  that  the  source  of  en- 
ergy exhibited  by  germ  cells  and  by  cancer  cells 
may  be  intraatomic,  it  must  be  confessed  that  it  has 
not  been  demonstrated  in  anv  wav  that  it  is  impossi- 
ble for  all  of  the  energ}-  to  be  derived  from  without, 
and  in  so  far  as  that  may  be  possible  mv  suggestion 
may  be  superfluous.  However  that  may  be.  the 
cancer  cell  seems  endowed  with  an  energy  which 
separates  it  from  the  somatic  cells.  The  source  of 
it,  whether  from  within  its  com.ponent  atoms  or 
from  without,  seem.s  to  be  that  which  it  shares  in 
common  with  the  germ  cells.  In  separating  itself 
from  the  somatic  cells,  from  which  nearly  aH  those 
familiar  with  histological  observations  agree  it  does 
spring,  it  usually  does  so  by  a  visible  differentiation 
of  form  and  structure.  This  distinction  is  probably 
to  be  sought  for  in  the  same  field  with  that  in  which 
is  hidden  the  causes  of  the  distinction  of  species. — 

"It  has  been  attempted  by  D.  F.  Harris  in  his  brochure  recently 
published.  The  Functional  Inertia  of  Lining  Matter,  London,  1908, 
but  one  gains  the  impression  from  its  perusal  that  in  the  uni- 
versality of  the  application  the  author  makes  of  it,  he  weakens  some- 
what the  force  of  the  argument. 


678 


MciriLLIAMS:  EXOPHTHALMIC  GOITRE. 


[New  York 
Medical  Journal, 


the  nature  of  the  impulse,  I  mean,  which  gives  rise 
to  them.  The  visible  evidence  of  this,  aside  from 
the  loss  of  that  altruistic  regulation  which  leads  to 
the  death  of  the  organism  of  which  it  is  a  part,  is 
presented  by  the  lawlessness  of  intracellular  struct- 
ure and  of  extracellular  relationship.  These  are  fa- 
miliar enough,  or  may  be  found  in  textbook  litera- 
ture, but  they  have  not  yielded  us  much  informa- 
tion because  hitherto  they  have  not  found  their 
proper  place  in  general  biological  theory. 
44  X'V^EST  Forty-ninth  Street. 


EXOPHTHALMIC  GOITRE* 

By  Clarence  A.  McWilliams,  M.  D., 
New  York, 

Instructor  in  Surgery,  Columbia  University;  Assistant   Surgeon  to 
the  Presbyterian  Hospital;  Associate  Surgeon  to  the 
Woman's  Hospital. 

The  exact  aetiology  of  Graves's  disease  remains  a 
mystery.  We  may  attribute  the  changes  in  the 
gland  to  the  effects  of  some  metabolic,  chemical,  or 
extraorganismal  irritant.  Such  changes  have  beer 
readily  identified  and  have  been  put  on  a  rational 
basis  by  the  pathological  work  of  Wilson  (Amer- 
ican Journal  of  the  Medical  Sciences,  December, 
1908),  who  examined  294  thyreoid  glands  from 
patients  suffering  from  Graves's  disease,  which 
were  removed  by  Dr.  C.  H.  Mayo.  It  seems  well 
established  by  all  the  workers  in  this  field  that  the 
symptoms  are  due  to  an  increased  absorption  of  an 
increased  secretion  from  the  thyreoid  gland.  This 
increased  secretion  is  due  to  an  increase  in  the 
parenchyma  of  the  organ,  either  within  the  alveoli, 
or  there  is  an  increase  in  the  number  of  the  alveoli 
themselves.  The  larger  the  number  of  the  paren- 
chyma cells,  the  greater  is  the  amount  of  the  secre- 
tion, and  the  more  fluid  this  secretion  is,  the  more 
readily  will  it  be  absorbed.  The  parenchyma  in- 
crease is  in  direct  proportion  to  the  intensity  of  the 
symptoms.  The  severity  of  the  symptoms  will  de- 
pend, first,  upon  the  amount  of  the  absorbable  se- 
cretion, and,  secondly,  upon  the  patient's  ability  to 
neutralize  the  secretion.  It  must  not  be  forgotten 
that  Graves's  disease  may  be  grafted  on  to  an  old 
preexisting  colloid  goitre. 

Exophthalmic  goitre  is  rare  in  men.  It  mainly 
affects  women  between  the  ages  of  sixteen  and 
forty,  i.  e.,  at  the  period  of  sexual  vitality.  Its  com- 
parative frequency  of  occurrence  in  the  two  sexes 
is  about  twenty  women  to  one  man.  It  is  often  con- 
sequent upon  fright,  mental  strain,  shock,  or  worry, 
and  after  acute  illnesses. 

SVMl'TOMS  AND  DIAGNOSIS. 

'I'hc  disea.se  when  well  established  can  scarcely  be 
mistaken.  The  diagnosis  may  be  made  from  a 
group  of  four  symptoms,  namely,  cxophthalmus, 
tachycardia,  a  goitre,  and  a  fine  tremor.  The  two 
symptoms,  a  goitre  and  exophthalmus,  have  been 
rather  erroneously  considered  as  of  prime  impor- 
tance, prfibably  eighty  ])er  cent,  of  tlie  cases  pre- 
senting one  or  both  symptoms,  while  twenty  per 
cent,  might  show  neither  the  enlarged  thyreoid  nor 
the  exophthalmus.    Prior  to  the  appearance  of  these 

•Read  at  a  meeting  of  the  Lenox  Medical  and  Surgical  Society, 
February  27,  igog. 


symptoms,  the  patient  will  be  treated  for  heart  dis- 
ease, or  neurasthenia,  or  gastritis,  etc.  In  reality 
the  most  important  symptoms  are  those  referable  to 
the  vascular  system.  The  onset  is  usually  slow  and 
insidious. 

The  exophthalmus  is  bilateral  and  is  accompanied 
by  certain  inconstant  ocular  symptoms,  such  as  the 
Stellwag  symptom  (abnormal  wideness  of  the  pal- 
pebral opening  due  to  permanent  retraction  of  the 
lid),  the  Moebius  symptom  (a  lack  of  convergence 
of  the  two  eyes),  and  the  von  Graefe  symptom  (the 
upper  lid  does  not  follow  the  eyeball  when  it  is 
moved  down). 

The  tachycardia  varies  from  90  to  140.  beats  or 
higher  in  severe  cases,  and  there  may  be  a  systolic 
murmur  at  the  apex.  The  tremor  is  of  a  very  fine 
character,  best  seen  when  the  hands  and  tongue  are 
extended.  There  is  often  great  muscular  weakness. 
The  face  and  neck  are  flushed,  and  there  may  be 
frequent  attacks  of  profuse  sweating,  particularly 
of  the  extremities.  There  may  be  attacks  of  vomit- 
ing and  diarrhoea  as  well  as  of  palpitation  and  even 
angina  pectoris.  Tenderness  of  the  thyreoid  gland 
is  an  important  earl\-  symptom,,  particularly  in  the 
acute  stage  and  the  acute  exacerbations  of  the 
chronic  condition. 

The  blood  changes  may  be  of  great  assistance  in 
making  the  diagnosis  in  cases  with  atypical  symp- 
toms. Kocher  {Archiv  fiir  Klinische  Chiriirgie, 
Ixxxvii,  p.  132,  1908)  has  made  important  observa- 
tions in  106  cases  of  exophthalmic  goitre  with  re- 
spect to  the  blood  changes  with  fairly  uniform  re- 
sults. The  red  cells  are  normal,  but  there  is  a 
considerable  reduction  in  the  total  number  of  the 
white  cells.  Instead  of  the  normal  7,000,  they  are 
reduced  to  5,000  and  maybe  even  3,700.  More  im- 
portant, however,  is  the  number  of  the  various 
forms  of  the  white  cells.  The  reduction  in  the  num- 
ber of  the  white  corpuscles  seems  to  be  exclusively 
at  the  expense  of  the  neutrophile  polynuclear  leuco- 
cytes. Instead  of  the  normal  5,000,  or  seventy-five 
per  cent.,  the  leucocytes  are  reduced  to  as  low  as 
1,500,  or  thirty-five  per  cettt.  A  second  very  impor- 
tant change  in  the  white  cells  is  the  increase  in  the 
lymphocytes  from  the  normal  1,500,  or  twenty-five 
per  cent.,  to  as  high  as  5,800,  or  fifty-seven  per 
cent.  This  typical  hyperlymphocytosis  is  less  pro- 
nounced in  the  early  stages  of  the  disease  than  later 
on  at  its  height.  These  blood  changes  are  consid- 
erably influenced  by  operative  and  therapeutic 
measures.  Where  a  cure  has  been  effected,  the 
blood  constituents  return  to  the  normal.  Where 
this  does  not  occur,  as  after  an  operation,  sufficient 
of  the  gland  has  not  been  removed.  Thus  the  liga- 
ture of  the  isolated  arteries,  without  ligature  of  the 
veins,  increases  the  total  white  colls  and  also  the 
neutrophilcs  without  decreasing  the  total  numl)or 
of  the  lymphocytes.  We  thus  have  in  the  blood  pic- 
ture not  only  a  means  to  a  diagnosis  but  also' a  help 
to  determine  whether  a  given  case  is  a  severe  or  a 
light  mild  one  and  whether  operative  procedures 
are  necessary.  Kocher  in  the  light  of  these  blood 
changes  discusses  why  not  only  thyreoidectomy  but 
also  operations  on  other  organs  are  more  danger- 
ous in  this  disease.  The  task  of  rendering  innocu- 
ous the  consequences  of  acute  infections  devolves 
principally  on  the  neutrophilcs.    They  contain  for- 


April  3,  1909.] 


McWILLIAMS:  EXOPHTHALMIC  GOITRE. 


679 


ments  which  have  antitoxic,  peptic,  and  oxidating 
properties  and  they  possess  intense  chemotactic  ac- 
tion. The  reduction  in  the  number  of  neutrophils 
thus  partially  explains  the  lack  of  tolerance  for  op- 
erative intervention  in  exophthalmic  goitre.  The 
operations  cause  ferment  intoxications  by  effusion 
of  blood  and  toxic  influences  from  the  general  an- 
aesthesia, necrosis  of  tissue,  etc.  These  blood  find- 
ings have  been  confirmed  by  Gordon  and  Jagic 
{Miinchcucr  mcdizinische  IVochenschrift,  January 
12,  1909,  p.  64),  who  describe  experiments  proving 
the  existence  of  fat  splitting  ferments  in  the  lym- 
phocytes. According  to  Kocher,  lymphocytosis  is 
a  reaction  in  chronic  affections  whether  of  infec- 
tious or  metabolic,  toxic  aetiology. 

Caro  {Berliner  klinische  Wochenschrift,  xlv.  No. 
39,  p.  1755,  1908)  confirms  Kocher's  blood  findings 
in  fourteen  cases  of  Graves's  disease.  In  these  the 
lowest  polynuclear  leucocyte  count  was  fifty  per 
cent,  and  the  highest  lymphocyte  count  was  fifty 
per  cent.  Some  of  these  patients  were  placed  upon 
thyreoid  tablets  and  these  all  without  exception 
showed  an  increase  in  the  lymphocytes  at  the  ex- 
pense of  the  polynuclear  leucocytes.  He  argues 
then  that  a  lymphocytosis  may  lead  one  to  make  a 
diagnosis  of  thyreoid  toxic  heart  disturbance  in  the 
absence  of  any  other  cause  Hkely  to  produce  a  lym- 
phocytosis. 

The  changes  in  the  circulation  are  most  pro- 
nounced. There  is  a  tachycardia  which  varies  from 
90  to  140  beats,  or  even  higher  in  severe  cases.  The 
blood  pressure  is  increased.  The  large  vessels  pul- 
sate visibly,  and  this  may  extend  to  the  small  ones 
so  that  we  may-  have  a  capillary  pulse  as  well  as  pul- 
sation of  the  retinal  vessels  and  those  of  the  liver, 
kidney,  and  spleen.  The  thyreoid  gland  also  pul- 
sates. There  may  be  a  murmur  at  the  apex  of  the 
heart,  which  may  be  dilated.  A  murmur  may 
also  be  heard  over  the  gland  and  likewise  also 
at  times  over  the  small  vessels,  such  as  the 
volar  arch.  Moses  resected  a  part  of  the  supe- 
rior thyreoid  artery  in  a  case  of  exophthalmic 
goitre  in  order  to  examine  it  microscopically.  As 
is  the  case  in  the  majority  of  the  patients,  the 
artery  at  the  time  of  the  operation  was  very  much 
enlarged,  the  size  of  a  lead  pencil.  After  its  removal 
it  shrank  to  the  size  of  the  normal  vessel.  Micro- 
scopical examination  showed  that  it  could  not  be  told 
from  a  normal  vessel,  the  relations  of  the  elastic  ele- 
ments being  normal,  and  there  being  no  appearances 
of  degeneration.  The  greatest  complaint  of  patients 
affected  with  Graves's  disease  is  of  the  forcible 
throbbing  in  the  arteries,  often  accompanied  with 
unpleasant  flushes  of  heat  and  profuse  perspiration. 

Kocher  also  calls  attention  to  a  symptom  which 
appears  more  often  and  at  an  earlier  stage  than  the 
well  known  von  Graefe  symptom,  namely,  if  the 
hand  of  the  patient  is  held  on  a  level  with  his  eyes, 
and  is  suddenly  lifted  up  a  little  higher,  the  upper 
lid  springs  up  more  quickly  than  the  eyeball  follows. 

Kocher  also  discovered  that  the  coagulation  time 
of  the  blood  in  cases  of  Graves's  disease  is  de- 
creased, which  may  explain  why  these  patients 
seem  to  have  such  a  tendency  to  bleed  at  the  opera- 
tions. He  says  that  this  suggests  the  advisability  of 
administering  calcium  chloride  (better  calcium  lac- 
tate) before  operating  upon  these  patients. 


Friedrich  von  Miiller  says  that  according  to  his 
experience  a  third  of  all  cases  of  nervous  palpation 
belong  to  hyperthyreoidism.  A  positive  diagnosis  of 
hyperthyreoidism  can  be  made  if  the  thyreoid  is  en- 
larged. If  it  is  not  enlarged  the  right  diagnosis  can 
be  made  by  administering  iodine.  If  this  increases 
the  symptoms,  particularly  the  palpation  of  the  heart 
and  the  tremor,  then  we  are  dealing  with  a  case  of 
hyperthyreoidism. 

The  Mayos  group  the  cases  as  follows  with  re- 
gard to  the  symptoms:  Group  i.  Acute  cases;  a, 
mild,  b,  moderate,  c,  severe,  d,  very  severe.  Group 
2.  Cases  which  had  been  severe  but  which  at  the 
time  of  the  examination  showed  remission  of  the 
symptoms.  Group  3.  Cases  of  previously  severe 
hyperthyreoidism  but  with  symptoms  now  chiefly  of 
vital  organ  lesion  type  (heart,  nervous  system,  etc.) 
rather  than  hyperthyreoidism.  Group  4.  Mild, 
continuous  cases,  slowly  developing. 

In  the  late  stages  of  the  severe  type,  the  patient 
becomes  very  much  emaciated  and  weak  from  myas- 
thenia. The  pulse  is  irregular  and  there  is  low 
blood  pressure  and  cardiac  degeneration.  There  are 
palpitation  of  the  heart,  dyspnoea,  oedema  of  the 
lids,  ascites,  attacks  of  vomiting  and  diarrhoea,  and 
there  may  be  albumin  in  the  urine  and  enlargement 
and  fatty  degeneration  of  the  liver,  etc.  They  are  irri- 
table, nervous,  restless,  depressed,  and  tortured  by 
excessive  insomnia. 

An  important  complication  is  acute  mania,  in 
which  the  patients  may  die  in  a  few  days. 

There  does  not  seem  to  be  any  relation  between 
the  size  of  the  thyreoid  gland  and  the  severity  of 
the  symptoms,  but  during  an  acute  attack  the  gland 
is  more  tender,  larger,  and  softer  due  to  the  in- 
creased enlargement  of  the  vessels.  The  intensity 
of  the  vascular  symptoms  indicates  the  degree  of 
the  severity  of  the  disease.  If  the  disease  develops 
suddenly,  the  course  is  more  grave  and  the  prospect 
more  gloomy  than  when  the  disease  begins  slowly. 

TREATMENT. 

This  is  often  an  embarrassing  and  perplexing 
question  for  the  general  practitioner. 

In  general  there  are  the  medical  and  surgical 
plans  of  treatment,  and  these  should  be  judiciously 
combined  in  order  to  give  patients  with  this  com- 
plaint the  greatest  amount  of  relief.  Medical  meas- 
ures should  be  adopted  in  almost  all  cases  at  the  out- 
set in  order  to  ascertain  how  severe  the  lesions  are 
and  how  well  they  are  under  control.  This  is  par- 
ticularly true  of  the  fresh  acute  cases.  The  patient 
should  be  put  to  bed  and  removed  from  all  exciting 
influences,  and  a  diet  free  from  albuminous  food  is 
prescribed.  A  milk  diet  for  a  time  is  also  advan- 
tageous. Bromides  and  hypnotics  are  to  be  used 
when  necessary.  Ice  to  the  goitre,  ice  cold  half 
baths,  electricity  and  x  ray  treatments  to  the  goitre 
may  be  tried.  Of  drugs  to  reduce  the  rapidity  of 
the  heart,  the  best  are  belladonna  and  strophanthus. 
Iodine  preparations  and  thyreoid  tablets  make  the 
symptoms  in  true  Graves's  disease  worse.  Many 
drugs  have,  in  addition,  been  used  by  various 
authorities  thus,  iron,  arsenic,  digitalis,  convallaria, 
ergotin,  aconite,  intestinal  antiseptics,  veratrum 
viride,  sodium  phosphate,  etc.  Favorable  results 
have  been  reported  by  some  after  using  Moebius's 


68o 


MdVILLIAMS:  EXOPHTHALMIC  GOITRE. 


[liEW  VORK 

Medical  Journal. 


serum  which  is  the  blood  serum  of  sheep  after  the 
thyreoid  gland  has  been  removed,  sold  under  the 
name  of  antithyreoidine,  its  dose  being  five  min- 
ims after  each  meal.  Not  very  favorable  reports 
attend  the  use  of  the  milk  of  thyreoidectomized 
goats  which  is  sold  under  the  trade  name  of  roda- 
gen,  the  dose  being  a  drachm  three  times  a  day. 

In  my  opinion  almost  all  the  cases  of  Graves's 
disease  should  be  given  the  Rogers  and  Beebe  anti- 
serum before  operation  is  advised,  as  most  favorable 
results  are  often  obtained.  The  object  of  this  anti- 
serum is  to  bring  about  destructive  changes  in  the 
hypertrophied  thyreoid  by  a  process  of  cytolysis. 
The  nucleoproteids  and  globulins  from  the  human 
thyreoid  gland  are  injected  into  sheep  and  hares, 
and  from  these  the  serum  is  obtained  which  is  in 
turn  injected  into  the  patients  with  Graves's  disease. 

We  must  take  cognizance  of  the  social  position 
of  our  patients  in  considering  how  long  we  shall 
continue  medical  treatment  and  when  we  shall  re- 
sort to  surgery.  In  the  well  to  do  who  can  afiford 
all  the  time  necessary  to  effect  a  benefit,  we  may 
wait  longer  than  can  be  the  case  with  the  worker 
who  is  dependent  on  her  own  labor  for  a  living. 
Under  surgical  treatment,  there  is  an  unquestioned 
gain  in  time  for  the  patient  with  a  surer  hope  of  im- 
provement, if  not  cure.  Osier  says  that  if  after 
three  months  careful  medical  treatment,  the  patient 
is  not  better,  then  surgical  measures  should  be 
considered.  Progressing  changes  in  the  circulatory 
system  are  an  imperative  indication  for  surgical  in- 
tervention. 

In  considering  the  surgical  treatment  of  any  dis- 
order we  must  take  into  account,  first,  the  danger 
associated  with  such  operation,  and,  secondly,  the 
prospect  of  benefit  following  any  given  procedure. 
First,  with  regard  to  the  dangers  of  operations  for 
Graves's  disease.  I  quote  the  mortality  figures  of 
some  published  series  of  operations : 

Kocher,  first  series   167  cases  9  deaths 

second  series    153  cases  2  deaths 

Mayo    405  cases  19  deaths 

Klemm  (1908)    32  cases  o  death 

Garre  (by  Moses,  1908)   28  cases  i  death 

Riedel  (1908)    80  cases  7  deaths 

Krecke  (1909)    17  cases  i  death 

Crile  (1908)    41  cases  4  deaths 

Halsted  (1907)    90  cases  2  deaths 

Ferguson  (1909)    42  cases  3  deaths 

1,055  cases    48  deaths, 
or  four 
per  cent, 
mortality. 

In  the  hands  of  competent  surgeons,  then,  we 
find  that  the  mortality  of  four  per  cent,  is  not 
greater  than  in  the  majority  of  capital  operations. 
It  has  been  found  that  most  of  the  deaths  have  been 
in  those  in  whom  an  enlarged  thymus  gland  (status 
lymphaticus)  has  been  discovered  after  death.  Thus 
Capelle  (Miinchener  medisinische  Wochenschrift, 
XXXV,  No.  35,  September,  i,  1908)  has  had  four 
deaths  from  thymus  enlargement  following  opera- 
tions for  exophthalmic  goitre,  and  he  has  found 
records  of  sixty  cases  of  a  similar  kind  in  which 
autopsy  revealed  that  the  thymus  was  as  large  in 
proportion  as  at  the  height  of  its  development  in  in- 
fants. Before  deciding  on  operation,  every  diag- 
nostic means  should  be  exhausted   to  determine 


whether  or  not  the  thymus  is  enlarged.  Pre- 
sumptive evidence  of  enlarged  thymus  is  afforded 
by  finding  dulness  over  the  upper  sternum,  espe- 
cially when  a  tumor  can  be  felt  in  the  mediastinum 
during  inspiration,  and  when  the  Rontgen  rays  cast 
the  shadow  described  by  Hotz,  and  when  the  pale 
red  tonsils  are  enlarged  as  well  as  the  lymph  tissue 
at  the  base  of  the  tongue  and  the  lymphatic  glands. 
Such  cases  of  status  lymphaticus  should  not  be  oper- 
ated on  under  any  condition,  for  the  risk  is  too  great 
to  life.  If  such  patients  could  be  eliminated  from 
being  operated  upon,  the  mortality  figures  would  be 
trifling  indeed  in  competent  hands,  but  the  difficulty 
is  in  making  a  positive  diagnosis  of  enlarged  thymus 
in  many  cases. 

The  next  question  which  is  of  interest  is  to  in- 
quire what  benefit  is  a  patient  likely  to  receive  from 
operative  procedures.  What  do  we  mean  by  a  cure 
of  any  disease?  Comparatively  few  diseases  can  be 
so  influenced  by  therapeutic  measures  that  every 
pathological  trace  disappears.  Exception  to  this  is 
found  in  the  infectious  diseases  which  resolve  tnost 
frequently  without  any  after  effects.  In  Graves's 
cases  the  exophthalmus  is  the  most  obstinate  to  yield 
to  any  form  of  treatment,  if  it  has  been  pronounced 
and  of  long  standing  prior  to  operation.  Usually  it 
persists  to  some  extent,  due  to  the  fact  that  the  mus- 
cles of  the  eyes  are  so  stretched  as  to  be  unable  to 
contract  to  their  normal  length.  The  Mayos  recom- 
mend electricity  to  the  eyes  after  operations  on  the 
goitre,  with  the  hope  of  helping  the  muscles  to  con- 
tract. The  benefits  of  operation  are  seen  in  the  de- 
crease to  normal  of  the  rapid  heart  action,  the  men- 
tal and  physical  relief,  the  gain  in  weight,  and  the 
disappearance  of  the  nervous  symptoms. 

The  benefits  resulting  from  surgical  measures  are 
best  shown  in  the  statistics  of  various  operators : 
thus 

Mayo,  167  patients,  117  (70  per  cent.)  cured,  32 
(19  per  cent.)  improved,  10  (5.8  per  cent.)  slightly 
improved,  9  (5.2  per  cent.)  unimproved. 

Klemm,  27  patients,  25  (92  per  cent.)  cured,  i  (3 
per  cent.)  improved,  i  (3  per  cent.)  unimproved. 

Riedel  (1906),  50  patients,  36  (72  per  cent.) 
cured,  6  (12  per  cent.)  improved,  i  (2  per  cent.) 
unimproved. 

Kocher  (1907),  254  patients,  83  per  cent,  cured, 
9.2  per  cent,  improved,  none  unimproved,  6  per  cent, 
too  early  to  judge  results. 

Krecke  (1908),  16  patients,  7  (44  per  cent.)  cured, 
6  (38  per  cent.)  improved,  3  (17  per  cent.)  slightly 
improved. 

Totals,  514  patients  operated  upon,  72  per  cent, 
cured,  16  per  cent,  greatly  improved,  11  per  cent, 
slightly  improved,  3  per  cent,  unimproved. 

Surely  a  percentage  of  seventy-two  of  cures  in 
514  operated  patients  speaks  volumes  for  the  oper- 
ative treatment  of  Graves's  disease,  and  this  result 
is  all  the  more  gratifying  when  account  is  taken  of 
the  fact  that  probably  the  great  majority  of  these 
patients  operated  upon  had  all  imdergone  unavail- 
ingly  extended  medical  treatment.  It  must  also  be 
recognized  ( Mayo)  that  twenty-five  per  cent,  of  pa- 
tients aft'ected  with  Graves's  disease  would  recover 
with,  without,  or  in  spite  of  treatment,  while  from 
ten  to  twenty  per  cent,  would  die  despite  treatment. 

In  order  to  compare  the  results  obtained  by  med- 


April  3,  19D9.] 


McJVILLIAMS:  EXOPHTHALMIC  GOITRE. 


681 


ical  treatment  with  those  by  operative  measures,  Dr. 
Rogers  has  kindly  furnished  me  with  the  statistics 
of  about  300  patients  treated  by  means  of  the  Rogers 
and  Beebe  antiserum.  Of  these,  twenty  per  cent, 
were  cured,  sixty  per  cent,  were  improved,  ten  per 
cent,  were  unimproved,  while  ten  per  cent.  died. 

The  comparison  between  the  two  methods  of  treat- 
ment is  overwhelmingly  in  favor  of  operative  meas- 
ures, but  as  it  would  be  manifestly  unfair  to  subject 
a  patient  to  operation  who  could  be  cured  by  med- 
ical means,  unless  the  element  of  time  was  a  great 
desideratum,  the  wisest  course  seems  to  be  to  insti- 
tute the  antiserum  treatment  first,  and  then,  in  the 
event  of  no  cure,  to  supplement  this  by  operative 
measures,  preferably  tying  two  or  three  of  the  four 
sets  of  vessels  going  into  the  gland  in  stages,  and,  in 
addition,  it  may  be  necessary  to  remove  one  lobe  of 
the  thyreoid.  Operation  should  not  be  undertaken 
during  the  high  point  of  an  acute  attack,  but  should 
be  postponed  until  there  is  a  subsidence  of  the  acute 
symptoms. 

The  technique  of  operating  upon  these  patients, 
particularly  the  advantage  of  performing  the  opera- 
tions in  stages,  has  undergone  such  a  great  improve- 
ment of  late  that  the  mortality  rate  is  steadily  de- 
creasing. The  main  thing  seems  to  be  not  to  do  too 
much  at  one  sitting.  Kochar  asserts  that  the  danger 
of  the  operation  has  been  exaggerated,  as  surgeons 
have  allowed  themselves  to  be  persuaded  into  oper- 
ating in  advanced  stages  of  the  disease. 

The  problem  before  the  surgeon  is  to  decrease  the 
secreting  power  of  the  gland  to  a  point  where  the 
bodily  functions  are  brought  to  a  normal  activity. 
This  is  accomplished  by  tying  two  or  more  of  the 
vessels  going  into  the  gland,  or  the  removal  of  more 
or  less  of  the  gland  itself,  or  by  a  combination  of 
these  two  procedures.  The  safer  plan  of  operating 
seems  to  be  to  tie,  first,  one  set  of  superior  thyreoid 
vessels  under  local  anaesthesia.  This  in  itself  will  not 
make  much  change  in  the  patient's  condition.  At  a 
second  operation,  the  opposite  superior  thyreoids  may 
likewise  be  tied,  and  at  a  third,  one  inferior  thyreoid 
set  of  vessels  may  be  ligated.  This  often  brings 
about  great  improvement  both  in  the  subjective  and 
objective  symptoms,  and  at  times  exceptionally  a 
cure.  The  degree  of  benefit  may  be  ascertained  by 
the  relative  increase  toward  the  normal  of  the  neu- 
trophile  leucocytes  and  the  decrease  of  the  lympho- 
cytes, as  well  as  the  amount  of  decrease  of  the  pulse 
rate,  and  the  improvement  in  the  nervous  and  sub- 
jective symptoms.  In  some  cases,  these  relatively 
simple  operations  are  all  that  are  necessary.  In  other 
cases  where  the  improvement  is  not  great,  it  would 
be  necessary  to  remove  one  lobe  and  the  isthmus  of 
the  thyreoid.  The  preliminar}-  tying  of  the  thyreoid 
vessels  would  in  this  latter  contingency  so  improve 
the  general  condition  of  the  patient,  due  to  the  re- 
sulting decrease  in  the  thyreoid  secretion,  as  to  render 
the  thyreoidectomy  safe.  In  patients  in  whom,  at  the 
first  operation,  one  lobe  and  the  isthmus  had  been  re- 
moved and  in  whom  there  was  not  a  cure,  or  in 
whom  there  was  a  relapse,  the  opposite  superior  thyre- 
oid vessels  should  be  tied,  with  possibly  the  re- 
moval of  half  the  remaining  lobe  of  the  gland,  this 
latter  depending  on  the  degree  of  improvement  de- 
sired, as  judged  by  the  severity  of  the  symptoms  and 
the  blood  changes.   In  another  type  of  patient  it  was 


very  dangerous  to  do  a  radical  operation  such  as  the 
removal  of  a  lobe.  These  were  those  who  had  a 
degenerated  heart  muscle,  possibly  brown  atrophy 
with  soft  spleen,  fatty  degeneration  of  the  liver,  and 
nephritis.  If  under  local  anaesthesia,  ligation  of  first 
one  arter}-  and  its  vein  was  done,  and  then  the  other 
subsequently,  the  patient  would  improve.  Such  pa- 
tients, however,  could  never  recover  good  health 
since  the  disease  had  already  caused  permanent  ter- 
minal degenerations. 

A  few  suffer  from  hypothyreoidism,  or  m}Tcoe- 
dema,  due  to  an  insufficient  amount  of  thyreoid  se- 
cretion resulting  from  destruction  or  loss  of  secret- 
ing epithelium.  In  these  cases,  operation  is  only  in- 
dicated when  pressure  symptoms  are  to  be  relieved. 
Riedel  habitually  removes  about  nine  tenths  of  the 
total  thyreoid  gland.  Kocher  says  that  more  than 
half  the  gland  should  not  be  removed  except  in  rare 
cases  of  .very  large  glands. 

The  method  of  operating  will  depend  on  the  ex- 
perience of  the  individual  operator.  Opinions  differ 
as  to  the  advisability  of  using  local  anaesthesia  in 
preference  to  a  general  one.  The  superior  thyreoid 
vessels  are  easily  tied  by  the  use  of  a  local  anaes- 
thetic, and  a  general  one  is  entirely  unnecessary  in 
this  comparatively  simple  operation.  I  prefer  a  one 
half  per  cent,  solution  of  novocaine  combined  with 
adrenalin.  I  shall  not  go  into  a  discussion  of  whether 
local  or  general  anaesthesia  should  be  used  in  cases 
where  it  is  deemed  advisable  to  remove  a  lobe  and 
the  isthmus,  except  to  state  that  my  own  preference 
is  for  local  anaesthesia,  novocaine,  preceded  by  one 
or  two  injections  of  scopolamine  combined  with  mor- 
phine one  hour  before  the  operation.  With  a  proper 
technique  in  many  cases  the  operation  may  be  thus 
completed,  although  I  do  not  believe  that  it  can  be 
done  absolutely  painlessly  as  the  subjective  sensa- 
tions of  pain  are  always  increased  in  these  patients 
due  to  their  excessive  nervous  excitability.  On  the 
European  continent,  local  anaesthesia  is  much  more 
generally  used  for  these  thyreoidectomies  than  in 
America.  Thus  Kocher  uses  it  exclusively,  as  do 
also  Riedel,  Klemm,  Hildebrandt,  Socin,  Roux,  and 
others.  On  the  other  hand  we  find  that  general  an- 
aesthesia is  preferred  by  IVIoebius,  Garre,  Krecke, 
Crile,  von  Eiselsberg,  Dumont,  Braum,  and  the 
]Mayos. 

In  using  local  anaesthesia,  the  most  disagreeable 
feeling  to  the  patient  in  the  operation  is  the  sensa- 
tion of  asphyxiation  caused  by  the  dragging  on  the 
gland.  The  following  method,  as  I  have  seen  Rie- 
del perform  it,  is  very  successful.  A  long  needle  at- 
tached to  a  syphon  bottle  containing  500  c.c.  of  a  o.i 
per  cent,  solution  of  novocaine,  or  eucaine,  combined 
with  adrenalin,  is  inserted  into  the  subcutaneous  tis- 
sues at  the  lower  margin  of  one  sternomastoid,  and 
the  solution  is  allowed  to  run  in  until  there  is  a 
marked  swelling,  which  gradually  diffuses  itself  in 
all  directions.  The  needle  is  then  carried  deeper  un- 
der the  deep  cervical  fascia,  and  then  in  successive 
stages  is  advanced  while  the  solution  flows  into  the 
tissues  along  the  lower  part  of  the  neck  and  across  the 
front  of  the  goitre,  reaching  to  the  opposite  sterno- 
mastoid. In  this  way  the  whole  front  capsule  of 
the  thyreoid  is  bathed  in  the  solution.  In  addition 
the  cutaneous  cervical  nerves  are  rendered  insensi- 
tive.   The  skin  itself  may  be  infiltrated  with  a  hypo- 


682 


McWILLIAMS:  EXOPHTHALMIC  GOITRE. 


[New  York 
Medical  Journal. 


dermic  needle  along  the  line  of  the  incision  with  an 
one  half  per  cent,  solution.  The  thyreoid  is  then 
easily  exposed  without  any  pain  whatsoever.  The 
landmarks  are  obscured,  however,  to  some  extent  by 
the  gelatinous  condition  of  the  tissues,  but  this  soon 
disappears.  According  to  Lennander  the  thyreoid 
tissue  itself  possesses  no  sensation.  The  back  part 
of  the  capsule,  the  clamping  of  some  of  the  vessels, 
the  territory  of  the  trachea,  particularly  drawing  on 
it,  presumably  due  to  its  vagus  nerve  supply,  are  apt 
to  be  accompanied  by  some  pain.  It  may  then  be 
deemed  advisable  to  complete  the  removal  of  the 
lobe  with  the  minimum  amount  of  ether  by  the  drop 
method. 

Crile  {Annals  of  Surgery,  June,  igoS)  believes 
that  one  of  the  greatest  factors  in  the  surgical  risk 
is  mental  excitation.  He  advocates  a  plan  of  sur- 
gical treatment  which  is  intended  to  do  away  with 
this  by  performing  the  operation  without  the  pa- 
tient's knowledge.  The  patient  enters  the  hospital 
consenting  to  be  treated  either  medically  or  surgical- 
ly, as  thought  best,  without  further  discussion.  For 
a  varying  period  of  time,  depending  on  the  patient's 
symptoms,  a  nonoperative  routine  treatment,  con- 
sisting of  diet,  baths,  massage,  etc.,  is  employed.  In 
addition,  a  trained  anaesthetist,  who  is  gentle  and 
tactful,  goes  through  each  day  the  complete  form  of 
administering  anjesthesia  under  the  guise  of  inhala- 
tion treatment.  On  the  ether  mask  are  dropped  so- 
lutions of  volatile  oils.  At  a  time  when  the  patient 
is  in  a  suitable  condition  nervously,  the  operation  is 
decided  upon,  but  the  patient  is  not  informed.  The 
night  before  the  operation  bromides  are  given,  and 
before  the  operation. a  hypodermic  injection  of  mor- 
phine is  administered.  The  anaesthetist  then  begins 
the  inhalations  of  volatile  oils,  as  had  been  custom- 
ary, and  then  ether  is  added  drop  by  drop  until  the 
second  stage  of  anaesthesia  is  reached,  when  the  pa- 
tient is  taken  to  the  operating  room  and  the  opera- 
tion is  performed. 

Crile  makes  a  change  in  the  usual  technique  by  at 
once  securing  all  four  bloodvessels  by  means  of  a 
long  needle  threaded  with  catgut,  at  the  four  poles 
of  the  gland  tissue  near  the  posterior  capsule.  After 
tying  these  four  ligatures,  the  principal  blood  supply 
of  the  gland  is  controlled.  The  gland  tissue  is  then 
cut  away,  leaving  only  portions  of  each  lobe.  After 
this  the  raw  surface  is  treated  with  very  hot  water, 
almost  boiling,  to  control  and  destroy  the  superficial 
secretion-  and  minimize  oozing.  His  results  have 
been  visibly  improved  since  adopting  these  methods. 

It  may  be  noticed  that  I  have  said  nothing  as  yet 
regarding  those  interesting  bodies  called  the  para- 
thyreoids,  which  are  not  altered  in  Graves's  disease 
and  whose  functions  are  probably  quite  different 
from  those  of  the  thyreoid  gland,  for  removal  of 
them  produces  the  symptoms  of  tetany,  while  re- 
moval of  the  entire  thyreoid  gland  results  in  myxoe- 
dema.  No  fear  of  injury  or  removal  of  the  para- 
thyreoid  bodies  need  be  entertained  if  the  posterior 
part  of  the  capsule  of  the  thyreoid  is  left  in  the  op- 
eration, wiping  it  away  from  the  surface  of  the  gland 
by  gauze  as  Mayo  recommends.  To  avoid  tetany  it 
would  seem  wise  never  to  tie  more  than  three  of  the 
four  sets  of  thyreoid  vessels  for  fear  of  interfering 
with  the  blood  supply  of  the  parathyreoids.  How- 
ever, von  Mickulicz,  Crile,  and  von  Rydygier  have 


ligated  without  injury  all  four  sets  of  vessels,  like- 
wise Kocher,  though  in  two  stages  and  as  prepara- 
tory operations  to  strumectomy. 

Animal  experiments  have  shown  that  removal  of 
all  four  parathyreoids  produces  a  fatal  tetany.  Clin- 
ical observations  appear  to  confirm  the  truth  of  this 
phenomenon  in  man.  They  seem  to  possess  an  anti- 
toxic function,  preparing  the  toxic  products  of  me- 
tabolism for  rapid  excretion  through  the  kidneys. 
Their  fvmction  is  preserved  if  the  two  lower  para- 
thyreoid  glands  remain  intact,  while  the  removal  of 
all  but  one  lower  parath3'reoid  usually  leads  to  tet- 
any, which,  however,  is  not  fatal. 

As  illustrating  many  of  the  points  brought  out  in 
the  preceding,  I  desire  to  cite  the  following  case : 

A  girl  of  thirteen  years  of  age  was  seen  by  Dr.  Getty,  of 
Yonkers,  and  sent  into  the  Yonkers  Hospital  on  January 
22,  1908,  as  a  case  of  chorea.  She  had  had  a  previous  at- 
tack of  rheumatism  and  a  similar  attack  of  chorea  the  pre- 
ceding summer.  At  the  time  of  her  admission  to  the  hos- 
pital her  pulse  was  90  and  haemoglobin  eighty  per  cent. 
Three  weeks  later  her  pulse  ran  between  no  and  120,  and  it 
was  noticed  that  her  eyes  were  protruding  and  the  thyreoid 
gland  was  enlarged.  The  choreic  movements  were  ex- 
cessive. A  diagnosis  was  made  of  Graves's  disease,  and 
various  kinds  of  medical  treatments  were  used  with  no  less- 
ening of  the  symptoms.  On  April  iSth,  about  three  months 
after  her  admission,  her  neck  measured  33.05  cm.  She  was 
then  given  five  injections  of  the  Rogers  and  Beebe  auto- 
serum  at  three  day  intervals.  This  did  not  produce  the 
slightest  change  in  her  condition.  During  June,  July,  and 
August  her  pulse  ran  between  120  and  130  always.  I  saw 
her  on  August  4th,  seven  months  after  admission  to  the 
hospital.  The  girl  was  then  thin  and  very  emaciated,  and 
there  was  marked  symmetrical  exophthalmus  of  both  eyes. 
The  whole  thyreoid  gland  was  enlarged  and  soft,  and  very 
slightly  tender.  There  was  marked  visible  pulsations  of  the 
vessels  of  the  neck,  the  pulse  was  about  130,  and  there  was 
a  loud,  harsh,  systolic  murmur  at  the  apex  of  the  heart 
although  the  pulse  was  regular  in  force  and  frequency. 
There  were  present  very  severe  choreaic  movements  of 
various  parts  of  the  whole  body,  in  addition  to  which  she 
had  a  fine  tremor  of  the  tongue  and  extremities.  There 
were  insomnia  and  great  nervousness.  The  blood  examina- 
tion showed  the  characteristic  changes  of  Graves's  disease, 
according  to  Kocher.  The  polymorphonuclear  leucocytes 
were  forty-two  per  cent,  (the  normal  being  about  seventy- 
five  per  cent),  and  the  lymphocytes  were  fifty-si.x  per  cent, 
(the  normal  being  about  twenty-five  per  cent.),  The  blood 
pressure  was  about  134. 

The  only  treatment  in  August,  1908,  which  seemed  to 
offer  any  hope  for  the  girl  was  operation  but  it  seemed  to 
be  a  most  dangerous  proceeding,  in  view  of  her  poor  gen- 
eral condition,  to  attempt  to  do  in  one  sitting  the  classical 
partial  thyreoidectomy.  The  plan  advocated  by  Kocher  in 
the  severe  cases  was  adopted  of  doing  the  operation  in 
stages.  To  reduce  any  possible  psychic  excitement  the  pa- 
tient was  not  informed  of  the  operations  until  just  before 
the  procedures.  The  first  one  was  done  on  August  5th. 
The  right  superior  thyreoid  vessels  were  tied,  using  a  '/i, 
per  cent,  solution  of  novocaine  local  anaesthesia,  combined 
with  adrenalin  without  preliminary  morphine.  The  in- 
cision was  made  along  the  anterior  border  of  the  stcrno- 
mastoid  and  its  edge  was  retracted.  After  dividing  the 
deep  fascia  the  pulsating  superior  thyreoid  artery  was  felt 
going  into  the  upper  and  outer  part  of  the  right  lobe  of 
the  thyreoid  gland.  A  catgut  ligature  was  passed  beneath 
the  artery  and  vein,  and  the  vessels  tied  together  and  divided. 
No  haemostatic  forceps  was  required  to  be  used  at  any  time. 
There  was  a  slight  rise  of  temperature  after  this  operation, 
but  no  other  symptoms  from  it  were  observed.  It  pro- 
duced no  change  in  her  general  condition.  Nine  days  later, 
the  left  superior  vessels  were  tied  similarly  under  novocaine 
local  an.xsthcsia  without  the  slightest  difficulty.  For  two 
days  after  this  operation  the  temperature  ranged  about 
102°  F.,  but  the  patient  made  a  smooth  convalescence.  She 
immediately  began  to  improve  mentally  and  physically.  In 
seven  weeks  she  gained  sixteen  pounds,  the  exophthalmus 
was  less,  the  choreaic  movements  had  entirely  ceased,  she 
was  much  less  nervous,  the  goitre  was  smaller  but  still 


April  3,  1909.] 


PARRISH:  "THIRD  TONSIL." 


683 


present,  and  she  was  eating  and  sleeping  well.  The  im- 
provement after  eight  weeks  seemed,  however,  to  be  at  a 
standstill  for  the  heart's  action  ran  between  110  and  120. 

A  blood  count  might  have  helped  to  tell  the  grade  of  her 
improvement  as  Kocher  maintains.  A  progressing  increase 
in  the  polynuclears  with  a  corresponding  decrease  in  the 
lymphocytes  would  have  argued  for  a  policy  of  waiting 
until  the  blood  reached  a  stage  of  equilibrium  indicating  the 
end  of  the  improvement. 

The  patient  was  not,  however,  under  my  immediate  con- 
trol, being  in  a  hospital  in  a  neighboring  city,  Yonkers,  and 
as  the  patient  had  been  in  the  hospital  for  nearly  eight 
months,  the  parents  were  clamorous  for  immediate  results. 
Accordingly  on  October  7,  08,  forty-four  days  after  the 
second  operation,  both  sets  of  superior  thyreoid  vessels 
having  been  previously  tied,  the  right  lobe  of  the  thyreoid 
and  the  isthmus  were  removed,  using  novocaine  anaesthesia 
throughout,  preceded  by  a  preliminary  injection  of  mor- 
phine, gr.  J4-  There  was  some  pain  experienced  by  the  pa- 
tient when  the  gland  was  lifted  up  but  never  sufficient  to 
necessitate  the  use  of  ether.  In  my  next  case  I  shall  com- 
bine scopolamine  with  the  morphine  after  which  I  believe 
the  operation  can  be  done  almost  painlessly.  Kocher's  col- 
lar incision  was  used. 

The  convalescence  was  uneventful.  The  highest  tem- 
perature was  103°  F.,  and  was  normal  on  the  fifth  day  at 
which  time  the  pulse  had  dropped  to  74  and  the  blood  press- 
ure was  95.    The  wound  healed  by  primary  union. 

On  November  28th,  fifty-two  days  after  the  third  opera- 
tion, the  blood  examination  showed  almost  normal  rela- 
tions, the  polymorphonuclears  were  eighty-one  per  cent, 
and  the  lymphocytes  were  thirteen  per  cent.  Her  blood 
pressure  was  110. 

On  February  23,  1909,  four  months  after  the  third  opera- 
tion, her  condition  was  most  satisfactory.  The  blood  ex- 
amination showed  the  total  leucocytes  to  be  10,200,  the 
polynuclear  leucoc3'tes  were  seventy-four  per  cent.,  and  the 
lymphocytes  were  twenty-six  per  cent.  The  neck  measured 
30  cm.  (before  operation  34  cm.).  The  pulse  was  78  (be- 
fore operation  120  to  140).  There  was  no  pulsation  of  ves- 
sels of  the  neck  or  of  the  gland.  There  was  a  slight  sys- 
tolic murmur  in  cardiac  area.  The  eyes  had  a  very  slight 
bulging  and  there  was  slight  convergence.  There  was 
slight  Stellwagen  symptom  but  no  von  Graefe  symptom. 
She  was  not  at  all  nervous,  no  tremor  of  any  kind,  eats  and 
sleeps  well.  The  patient  showed  an  absolute  cure  of  the 
disease  after  extirpation  of  one  lobe  and  the  isthmus  of 
the  thyreoid  with  ligation  of  the  opposite  superior  thyreoid 
vessels. 

112  West  Fifty-fifth  Street. 


THE  "  THIRD  TONSIL."* 

By  Henry  Parrish,  M.  D., 
Philadelphia, 

Instructor  in  Diseases  of  the  Nose  and  Throat,  Polyclinic  Hospital; 
Clinical  Assistant  in  Department  of  Otolog>',  Medico-Chirurgical 
Hospital;  Attending  Physician  to  Baptist  Orphanage 
of  Philadelphia. 

The  third  tonsil,  Luschka's  tonsil,  or  the  pharyn- 
geal tonsil,  as  it  has  been  variously  named,  is  a 
physiological  structure  consisting  of  lymphoid  tis- 
sue, situated  in  the  roof  of  the  nasopharynx,  back 
of  the  sseptum  and  extending  downward  on  the  pos- 
terior wall.  Its  function  is  to  secrete  mucus  for 
the  lubrication  of  the  nasopharynx.  This  structure 
becomes  pathological  only  after  it  has  undergone 
hypertrophy  or  hyperplasia.  Attention  was  first 
called  to  this  structure  and  its  pathological  signifi- 
cance in  a  brilliant  paper  by  Meyer,  of  Copenhagen, 
in  1868.  He  termed  these  hypertrophied  lymphoid 
tissues  "adenoid  vegetations."  In  recent  years  they 
have  become  known  by  the  simple  name  of  ade- 
noids. These  growths  are  found  in  various  parts 
of  the  world  and  among  various  races  of  men. 
They  are  not  restricted  to  country,  climate,  condi- 

*Lecturc  delivered  at  the  Philadelphia  Polyclinic  and  College 
"for  Graduates  in  Medicine,  November  19,  1908. 


tion,  or  sex,  but  are  found  in  both  sexes,  in  all  cli- 
mates, and  in  the  various  nations  of  Europe,  Asia, 
and  America,  and  in  people  of  all  classes  and  con- 
ditions of  life. 

A  pathological  condition  which  is  so  common 
that  it  may  be  met  with  any  day,  in  any  family,  in 
any  part  of  the  country,  must  be  of  sufficient  im- 
portance to  merit  the  careful  consideration  of  the 
general  practitioner  of  medicine.  As  this  lecture 
is  not  intended  for  specialists  in  this  line  of  work, 
but  for  men  who  practise  general  medicine  and  sur- 
gery. I  shall  feel  free  to  go  somewhat  thoroughly 
into  the  subject,  detailing  the  aetiology,  symptoma- 
tology, and  effects  of  these  growths,  together  with 
the  treatment  indicated,  the  instruments  to  be  used 
for  their  removal,  and  the  after  effects  of  the  oper- 
ation. 

JEtiology  and  Occurrence. 
Tliev  are  most  common  in  those  between  the  ages 
of  three  and  fifteen  years,  although  it  is  by  no 
means  uncommon  to  find  them  in  persons  of  from 
fifteen  to  twenty  years  of  age.  The  growth  may 
be  congenital,  and  the  influence  of  heredity  is  in- 
sisted on  by  Meyer.  Stewart\  of  Michigan,  report- 
ed a  case  of  operation  for  adenoids  in  a  child, 
eleven  da3'S  old.  "The  child  snored  and  was  unable 
to  breathe  and  nurse  at  the  same  time.  Chloroform 
was  administered  and  a  Myles  ring  curette  was 
passed  into  the  nasopharynx  and  an  adenoid  mass 
measuring  three  eighths  of  an  inch  in  length  and 
one  quarter  of  an  inch  in  depth  was  removed.  Re- 
lief from  the  obstructive  symptoms  was  imme- 
diate." 

Other  aetiological  factors  which  have  been  enum- 
erated are  sex,  frequent  colds,  nasal  deformities, 
cleft  palate,  rheumatism,  scrofula,  acute  infectious 
fevers,  microbes,  and  climate,  a  cold  damp  climate 
being  more  favorable  to  their  growth  than  a  warm 
one.  While  sex  does  not  play  an  important  part 
in  the  aetiology  of  the  disease,  the  testimony  is  to 
the  effect  that  there  are  more  males  than  females 
affected  under  the  age  of  fifteen,  and  more  fe- 
males than  males  above  that  age. 

Symptomatology. 

The  most  characteristic  symptom,  because  the 
first  to  arrest  attention,  is  the  open  mouth.  We 
meet  with  children  afflicted  with  adenoids  who  are 
not  mouth  breathers,  but  these  are  the  exceptions. 
In  the  great  majority  of  cases  the  difficulty  of 
breathing  through  the  nose  is  so  great  that  the  child 
falls  into  the  habit  of  breathing  through  the  mouth, 
and  for  this  reason  the  mouth  is  always  open.  Dur- 
ing the  day  the  child  is  languid  and  irritated.  At 
night  he  does  not  sleep  soundly  and  his  breathing 
is  noisy,  his  loud  snoring  often  arousing  other 
members  of  the  family.  There  is  usually  a  dull, 
heav>'  look  around  the  eyes,  and  the  expression  of 
the  countenance  is  stupid  and  vacant,  in  some  cases 
appearing  alm^ost  idiotic.  A  persistent,  dry,  hack- 
ing cough  is  another  symptom  that  should  suggest 
the  existence  of  an  adenoid.  A  peculiar  muffling  of 
the  voice,  together  with  an  inability  to  pronounce 
the  nasal  consonants,  are  characteristic  symptoms 
of  these  growths.  In  most  adenoid  cases  there  is 
a  noticeable  impairment  of  the  hearing.  Whenever 

^Progressive  Medicine,  March,    1903.  242. 


684 


PARRISH:  "THIRD  TONSIL: 


[New  York 
Medical  Journal. 


we  find  pain  in  the  ear  of  a  child,  or  a  discharge 
from  the  ear  or  any  other  impairment  of  the  hear- 
ing, however  slight,  these  things  should  suggest  to 
us  the  possible  existence  of  adenoids.  Hypertrophy 
of  the  faucial  tonsil  is  a  frequent  accompaniment 
of  adenoid  growths  in  the  nasopharynx.  Farlow% 
has  pointed  out  that  a  sign  of  special  value  in  chil- 
dren over  five  or  six  years  of  age  is  "the  impossi- 
bility of  blowing  the  nose,"  the  posterior  nares  be- 
ing so  completely  blocked  up  by  the  adenoid  that 
the  child  cannot  force  air  from  the  throat  through 
the  nose. 

Diagnosis. 

With  a  group  of  symptoms  such  as  I  have  de- 
scribed there  should  be  no  difficulty  in  diagnosti- 
cating adenoids.  It  is,  however,  unwise  to  depend 
entirely  upon  objective  signs  and  symptoms  in 
making  a  diagnosis.  It  is  better  to  make  a  physical 
examination.  In  many  cases  this  can  be  done  by 
introducing  a  small  mirror  into  the  back  of  the 
throat,  at  the  same  time  holding  down  the  tongue 
with  the  tongue  depressor,  but  in  very  young  per- 
sons, or  where  the  opening  into  the  postnasal  cham- 
ber is  small  or  there  is  a  resistance  on  the  part  of 
the  patient,  an  examination  with  the  mirror  may  be 
impracticable.  There  still  remains,  however,  a 
method  of  examination  that  is  perfectly  easy  and 
absolutely  certain.  This  consists  of  passing  the 
forefinger  of  the  right  hand  behind  the  soft  palate 
into  the  nasopharynx  and  feeling  the  adenoid 
growth.  When  the  finger  is  withdrawn  the  end  of 
it  will  be  found  to  be  stained  with  blood,  as  these 
growths  are  very  vascular  and  bleed  at  the  slightest 
touch.  To  keep  the  jaws  open  during  this  exam- 
ination a  mouth  g^g  may  be  used,  or  a  napkin 
rolled  into  a  hard  knot  will  answer  the  purpose 
equally  well. 
Injurious  Effects  of  the  Presence  of  Adenoids. 
Children  who  are  afflicted  with  adenoids  usually 
exhibit  a  shallow  chest,  with  a  bulging  of  the  ster- 
num, resulting  in  so  called  pigeon  breast,  which  oc- 
curs in  rickety  children  and  in  mouth  breathers. 
There  is  also  a  lack  of  general  nutrition,  the  child 
not  being  able  to  inspire  sufficient  air  to  thor- 
oughly inflate  the  lungs,  the  blood  does  not  receive 
the  necessary  amount  of  oxygen  to  nourish  the  tis- 
sues. And  while  there  is  a  lack  of  oxygen  in  the 
blood,  there  is  an  excess  of  carbonic  acid,  and  the 
natural  and  inevitable  result  of  this  condition  is 
that  the  child  is  troubled  with  headache,  drowsi- 
ness, languor,  and  stupidity.  The  digestion  is  very 
apt  to  be  injuriously  affected.  The  child  does  not 
properly  masticate  his  food,  but  bolts  it,  in  order 
to  get  it  out  of  the  air  passage  as  speedily  as  pos- 
sible. 

It  has  already  been  remarked  that  ear  diseases 
very  generally  accompany  adenoid  growths.  They 
affect  the  organ  of  hearing  in  various  ways,  but 
mainly,  i,  by  preventing  the  free  circulation  of  air 
into  the  middle  ear;  2,  by  interference  with  the 
blood  supply ;  and  3,  by  infection. 

The  free  ventilation  of  the  tj'mpanic  cavity  is  of 
the  greatest  importance  to  the  healthfulness  of  all 
the  structures  that  enter  into  the  formation  of  the 
auditory  apparatus,  but  the  presence  of  adenoid 

^Boston  Medical  and  Surgical  Journal,  1888.  387. 


growths  in  the  nasopharynx  tends  to  prevent  this, 
1st,  by  occlusion  of  the  Eustachian  tubes,  2nd,  by 
obstructing  the  freedom  of  action  of  the  levator 
and  tensor  palati  muscles  in  the  acts  of  deglutition 
and  phonation.  The  natural  results  of  this  ob- 
struction are,  the  production  of  a  partial  vacuum 
in  the  middle  ear,  decreased  air  pressure,  depressed 
membrana  tympani;  congested  and  swollen  mucous 
membranes,  defective  nutrition,  partial  and  pro- 
gressive deafness,  and  a  well  prepared  field  for  the 
cultivation  and  development  of  disease  germs. 

That  ear  trouble  is  caused  by  adenoids,  in  very 
many  cases,  at  least,  there  can  be  no  doubt.  We 
meet  with  cases  where  the  adenoid  growth  is  con- 
fined to  one  side  only  of  the  postnasal  space  and  the 
other  side  is  entirely  free.  In  these  cases  the  hear- 
ing is  perfectly  good  on  the  clear  side,  while  on  the 
other  side,  although  the  drum  membrane  is  normal, 
the  hearing  is  defective.  This  would  seem  to  prove 
that  the  deafness  is  due  to  growths  in  the  naso- 
pharynx^ 

Dench*  states  that  pharyngeal  adenoids  '"are  re- 
sponsible for  more  than  half  the  pathological  con- 
ditions met  with  in  the  middle  ear."  Bosworth'' 
gives  it  as  his  opinion  "that  the  proportion  of  cases 
that  escape  ear  trouble  is  small."  Kyle^  affirms  that 
"ninety  per  cent,  of  cases  of  adenoid  growths  are 
accompanied  with  some  degree  of  deafness.  ' 

It  would  also  appear  that  adenoids  are  responsi- 
ble for  a  large  proportion  of  deafmutism.  This  af- 
fliction is  generally  due  to  nerve  involvement  or 
labyrinthine  disease  and  these  conditions  may  be 
brought  about  by  the  presence  of  adenoids.  Ex- 
amination of  deaf  mutes  in  different  parts  of 
Europe  and  America  have  revealed  the  fact  that  in 
from  fifty  to  seventy  per  cent,  of  the  cases  there 
was  an  abnormal  development  of  the  third  tonsil. 
Some  specialists  in  this  department  hold  the  opin- 
ion that  cases  of  congenital  deafmutism  are  com- 
paratively rare,  most  of  the  cases  having  been  ac- 
quired through  the  presence  of  adenoids  during  in- 
fancy. 

A  quite  frequent  result  of  the  impairment  of 
hearing,  due  to  adenoids,  is  a  deficiency  of  mental 
development.  It  is  easy  to  understand  how  this 
mental  deficiency  is  occasioned.  The  child  is  sub- 
ject to  headaches  and  other  mental  symptoms 
which  indispose  him  to  study.  When  in  school  he 
does  not  fully  understand  what  is  said,  and  failing 
to  get  clear  and  vivid  impressions  of  the  things 
taught,  he  is  unable  to  retain  them  in  his  memor}-. 
Consequently  he  loses  interest  in  his  studies  and 
makes  little  or  no  progress  in  learning.  He  fails 
to  win  the  admiration  of  his  friends  and  school- 
mates and  they  speak  of  him  as  dull  and. stupid,  or 
lazy.  This  tends  to  discourage  him,  so  that  he 
turns  with  disgust  and  loathing  from  all  attempts 
at  intellectual  advancement.  His  physical  condition 
is  below  par,  and,  lacking  the  vim  and  courage  and 
enthusiasm  which  come  from  abounding  health,  he 
lags  behind  in  the  race  of  the  intellectual  athletes 
and  becomes  mentally  stunted  and  dwarfed. 

Then  there  are  certain  conditions  usually  classed 

"See  Haight  on  .\denoid  and  Ear  Diseases,  Journal  of  the  .Ameri- 
can Medical  Association,  xxxiii,  p.  1597. 
*Discases  of  the  Ear,  First  Edition,  p.  629. 
'Diseases  of  the  Nose  and  Throat,  p.  302. 
"Kyle,  Diseases  of  the  Throat  and  Nose,  p.  361. 


April  1900.] 


PARRISH:  "THIRD  TONSIL." 


685 


as  neuroses  of  which  adenoids  are  supposed  to  be 
the  cause.  Neuralgia  and  chorea  are  often  due  to 
the  existence  of  adenoids.  There  is  no  doubt  that 
they  predispose  to  such  afi'ections  as  pertussis, 
asthma,  and  croup.  They  also  add  greatly  to  the 
person's  susceptibility  to  the  germs  of  tuberculosis. 
That  the  tubercle  bacillus  often  finds  access  to  the 
system  through  the  tonsillar  tissue  seems  to  be  a 
common  opinion  among  writers  on  this  subject. 
Grayson'  gives  an  epitome  of  a  case  originally  re- 
ported by  D.  M.  Barstow,  in  which  "there  had  been 
a  cough,  accompanied  by  pains  in  the  chest  and 
night  sweating,  extending  over  a  period  of  two 
years.  The  large  number  of  bacilli  found  in  the 
sputum  would  ordinarih'  have  indicated  a  fairly 
extensive  lung  lesion.  In  spite  of  most  careful  ex- 
aminations, however,  no  evidence  of  pulmonary  in- 
volvement could  be  discovered."  The  third  tonsil 
was  removed  and  all  symptoms  of  tuberculosis 
promptly  disappeared  and  the  bacilli  could  no 
longer  be  found  in  the  sputum.  Such  cases  as  this 
encourage  the  belief  that  tuberculosis  may  exist 
primarily  and  exclusively  in  the  pharyngeal  tonsil, 
and  that  by  the  removal  of  the  adenoid,  the  patient 
may  be  saved  from  the  threatened  development  of 
the  dreaded  disease.  It  is  worthy  of  remark  that 
the  adenoid  tissue,  after  removal,  is  frequently 
found  to  contain  tubercle  bacilli. 

Another  proof  that  the  tuberculous  infection  en- 
ters the  system  through  the  adenoid  is  found  in  the 
fact  that  the  glands  in  the  neck  which  become  en- 
larged in  adenoid  cases  are  frequently  found  to 
contain  the  germ  of  tuberculosis.  Edmunds,'  of 
London,  in  a  work  on  Glandular  Enlargement,  just 
issued  from  the  press,  asserts  that  the  removal  of 
tuberculous  glands  from  the  neck  is  utterly  useless 
unless  the  sources  of  infection,  which  are  common- 
ly tonsils  and  adenoid  vegetations,  are  first  re- 
moved. But  if  the  pharyngeal  tonsil  may  be  a  por- 
tal of  entry  for  the  tubercle  bacillus,  it  may  also 
be  the  avenue  through  which  the  germ  of  diphtheria 
and  other  infectious  diseases,  such  as  typhoid  fever, 
scarlet  fever,  measles,  tonsilitis,  and  influenza  may 
eain  access  to  the  system. 

Treat}nent. 

Do  these  cases  ever  clear  up  without  treatment? 
Some  doctors  answer  this  question  in  the  affirma- 
tive, and  in  justification  of  this  view,  point  to  many 
cases  which  have  ceased  to  be  troublesome  after 
the  patient  has  reached  a  certain  age.  It  is  un- 
doubtedly true  that  there  is  a  tendency  for  nasal 
respiration  to  improve  as  the  child  grows  older,  and 
that  improvement  in  ear  symptoms  often  takes 
place  as  the  patient  advances  toward  adult  life. 
This  is  due  to  an  enlargement  of  the  vault  of  the 
pharynx  and  the  partial  atrophy  of  the  adenoid  tis- 
sue. But  the  adenoid  still  remains  and  mav  do 
much  harm  to  the  auditory  apparatus  at  a  time 
when  its  existence  is  less  likely  to  be  detected  than 
during  the  period  of  childhood.  As  these  condi- 
tions do  not  tend  to  cure  themselves,  various  meth- 
ods of  treatment  have  been  suggested. 

Breathing  exercises,  for  the  cure  of  adenoids, 
were  quite  the  rage  for  awhile.    The  parents  were 


instructed  to  '"put  the  child  on  its  back  three  times 
a  day,  for  half  an  hour  at  a  time,  and  make  it 
breathe  in  and  out  as  deeply  as  possible,  through 
the  nose,  the  mouth  being  kept  shut.'"  Many  chil- 
dren were  apparently  greatly  benefited  by  this  treat- 
ment, but  they  were  doubtless  cases  in  which  the 
third  tonsil  was  temporarily  enlarged  as  the  result 
of  a  catarrhal  inflammation  and  where  there  was  no 
true  hypertrophy.  Medical  treatment  is  merely 
palliative,  but  has  a  good  effect  in  certain  cases. 
\\'here  there  is  great  objection  on  the  part  of  the 
parents  to  any  operation,  esnecially  if  the  growth  is 
not  large,  internal  medication  may  be  tried.  In 
such  cases,  Corwin"  recommends  the  administra- 
tion of  syrup  of  hydriodic  acid,  or  calcium  chloride. 
Under  this  treatment  the  glandular  tissue  may 
shrink  to  an  extent  that  will  give  considerable  re- 
lief to  the  patient.  Gleason'"  suggests  the  follow- 
ing course  of  treatment  when  the  growth  is  small : 
"Application  of  an  iodine  solution  should  be  made 
by  the  surgeon  two  or  three  times  a  week,  the  par- 
ents in  the  meantime  cleansing  the  nose  and  throat 
night  and  morning  with  the  spray  from  an  atomizer 
containing  an  alkaline  wash  and  afterwards  plac- 
ing in  each  of  the  child's  nostrils  a  mass  of  gallic 
acid  ointment,  the  size  of  a  pea.  The  child  should 
then  lie  on  its  back  for  a  few  moments  until  the 
ointment  melts  and  runs  into  the  nasopharynx.  The 
gallic  acid  ointment  should  be  of  the  strength  of  five 
to  ten  grains  to  one  ounce  of  petrolatum,  according 
to  the  age  of  the  child." 

But  all  are  agreed  that  when  the  hypertrophy  is 
considerable,  the  only  treatment  that  can  be  recom- 
mended is  the  removal  of  the  mass  by  means  of  a 
surgical  operation.  My  own  opinion  is  that  every 
case  of  mouth  breathing  or  of  impaired  hearing, 
due  to  adenoids,  is  a  case  for  operation. 

Shall  we  operate  with  or  without  a  general  anaes- 
thetic? There  would  be  some  advantages  in  oper- 
ating without  an  anaesthetic.  ]\Iany  parents  dread 
the  giving  of  an  anesthetic  to  their  children,  and 
the  operation  loses  much  of  its  terror  for  them  if 
the  anaesthetic  can  be  dispensed  with. 

But  the  objections  to  this  method  of  operation 
are  many  and  serious.  The  pain  which  is  inflicted 
by  this  method  is,  in  my  judgment,  not  inconsid- 
erable. Then  the  shock  to  the  nervous  system  may 
be  quite  serious  and  lasting.  The  terror  of  the  pa- 
tient when  no  anaesthetic  is  used,  the  consequent  re- 
sistance, the  difficulty  of  making  a  thorough  ex- 
amination of  the  nasopharynx,  the  fact  that  the 
struggles  of  the  child  may  cause  the  operator  to 
cut  and  injure  the  posterior  parts  of  the  turbinals 
or  the  Eustachian  tube  orifices,  and  the  hurried 
manner  in  which  the  work  must  necessarily  be 
done,  all  tend  to  render  the  operation  uncertain  as 
regards  its  thoroughness  and  the  after  results.  The 
operation  when  done  should  be  thorough  and  com- 
plete, and  to  do  this  in  the  case  of  young  children, 
it  is  necessary  to  use  a  general  anaesthetic.  Then 
the  question  arises  as  to  the  particular  anaesthetic 
to  be  used : 

Nitrous  oxide  gas  has  been  used  to  a  considerable 
extent  and  is  popular  with  some  operators  on  ac- 
count of  its  comparative  freedom  from  danger  and 


'Progressive  Medicine,  March,  1905.  p.  255. 

'Journal  of  the  American  Medical  Association,  li,  p.  1797. 


^Journal  of  the  American  Medical  Association,  xxx\-,  1343. 
'"Medical  Bulletin,  December,  1907. 


686 


HARRIS:    CESAREAN  OPERATION. 


[New  York 
Medical  Journal. 


injurious  after  ef¥ects,  but  while  it  may  be  all  right 
for  certain  operations  in  the  realm  of  general  sur- 
gery, it  cannot  be  recommended  for  operations  on 
adenoids  and  tonsils  for  the  following  reasons:  I. 
The  administration  of  nitrous  oxide  requires  an  ap- 
paratus that  is  both  cumbersome  and  expensive.  2. 
It  calls  for  the  service  of  a  larger  number  of  as- 
sistants than  is  necessary  in  the  giving  of  other 
anaesthetics.  3.  The  use  of  the  mask  renders  it  al- 
most impossible  to  get  any  satisfactory  view  of  the 
field  of  operation.  4.  The  effect  of  the  ansesthetic 
is  too  brief.  When  the  mask  is  removed  the  pa- 
tient revives  almost  immediately,  giving  little  op- 
portunity for  the  performance  of  an  operation. 
The  work  has  to  be  done  in  a  great  hurry,  and  it  is 
the  testirhony  of  universal  experience  that  things 
done  in  a  hurry  are  scarcely  ever  done  well.  Ethyl 
chloride  produces  quick  anaesthesia  and  is  free  from 
the  suffocating  effects  of  ether.  It  is  sometimes 
used  exclusively,  and  sometimes  preliminary  to 
ether,  but  as  a  number  of  accidents  and  some 
deaths  have  resulted  from  its  use,  many  are  afraid 
of  it  and  have  discontinued  its  use.  The  objections 
to  ethyl  chloride  are:  i.  That  it  stiffens  the  jaws, 
thus  making  it  difficult  to  use  a  mouth  gag.  2.  That 
its  anjesthetic  effect  is  of  such  short  duration.  3. 
That  it  is  too  unreliable  and  dangerous  to  be  de- 
pended upon.  Chloroform  is  in  favor  with  some, 
because  of  its  being  but  slightly  irritant  to  the 
respiratory  tract  and,  therefore,  more  pleasant  to 
take.  But  by  most  operators  it  is  considered  un- 
safe as  an  ansesthetic,  the  record  of  deaths  from  it 
being  somewhat  alarming.  Of  course,  there  are 
dangers  associated  with  the  use  of  ether  and  of 
every  other  anaesthetic,  but  in  the  judgment  of 
most  of  those  who  have  written  upon  the  subject, 
ether  necrosis  is  to  be  preferred  to  any  other  for 
operations  of  the  kind  we  have  under  discussion. 

As  to  the  position  of  the  patient  during  the  op- 
eration. .Some  men  prefer  a  sitting  posture.  Freer" 
gives  the  preference  to  "one  in  which  the  patient 
lies  on  his  side  and  chest,  close  to  the  edge  of  the 
table,  while  the  left  arm  is  placed  behind  the  back. 
The  face  looks  partly  down  toward  the  floor."  He 
asserts  that  with  his  patient  in  this  position  he  has 
never  had  any  trouble  from  vomiting  food  or  blood 
getting  into  the  trachea.  Many  prefer  to  have  the 
patient  lying  upon  the  back  with  the  head  slightly 
hanging  over  the  edge  of  the  table  and  supported 
by  the  hand  of  the  assistant.  This  position  enables 
the  operator  to  get  a  perfect  view  of  the  throat 
while  doing  his  work  and  gives  no  opportunity  for 
blood  getting  into  the  larynx.  I  have  witnessed  a 
great  number  of  operations  and  have  performed  not 
a  few  myself  witli  the  patient  in  this  position,  and 
have  never  seen  any  bad  result.  This,  therefore,  is 
the  position  of  preference  with  me. 

Concerning  instruments  to  be  used  for  this  op- 
eration, there  is  a  great  diversity  of  opinion  and  a 
wide  range  of  choice.  The  postnasal  forceps,  the 
sharp  spoon,  the  ring  curette,  the  snare,  the  finger 
nail,  and  various  other  instruments  have  their  ad- 
vocates, [""erhaps  the  instruments  in  most  general 
use  are  the  Gottstcin  curette,  in  various  sizes,  and 
the  Lowenberg  forceps. 

With  the  patient  thoroughly  anaesthetized  and  in 

"Journal  of  llic  American  .\tedical  Association,  xxxv,  p.  1341. 


proper  position,  a  gag  is  placed  in  the  mouth  and 
held  there  by  an  assistant.  The  operator  then 
passes  the  forefinger  of  his  left  hand  into  the  naso- 
pharynx and  with  the  right  hand  introduces  the 
forceps,  using  the  finger  as  a  guide,  and  being 
careful  to  begin  in  the  median  line,  he  grasps  and 
removes  the  central  mass.  A  smaller  pair  of  for- 
ceps may  be  used  to  clear  out  the  fossae  of  Rosen- 
miiller  and  the  region  around  about  the  Eustachian 
tubes.  The  Gottstein  curette  is  used  to  remove 
any  remaining  shreds  of  adenoid  tissue.  When  the 
adenoid  is  soft  and  centrally  located  the  Gottstein 
curette  will  remove  the  entire  mass  at  a  single 
sweep.  Great  care  must  be  exercised  to  avoid  in- 
juring the  uvula  and  the  Eustachian  orifices. 

The  after  results  of  these  operations  are  highly 
gratifying.  In  many  cases  the  hearing  is  found  to 
be  greatly  improved  immediately  after  the  removal 
of  the  adenoids.  The  snoring  and  mouth  breath- 
ing are  generally  corrected  at  once  and  without 
further  treatment.  The  patient  breathes  through 
the  nose,  and  the  vacant  expression  of  countenance 
soon  disappears,  the  tone  of  the  voice  is  improved 
and  defects  of  articulation  gradually  corrected.  As 
a  rule  there  is  a  rapid  increase  in  weight  and  a  very 
marked  improvement  in  the  health  and  spirits  of 
the  child.  Even  scrofulous  children  have  im- 
proved after  the  removal  of  the  third  tonsil,  as  they 
never  did  under  any  other  treatment. 

A  question  is  almost  sure  to  be  asked  concern- 
ing recurrence  of  these  growths.  They  do  some- 
times recur,  but  the  instances  are  so  rare  that  when 
the  operation  is  well  done  and  the  adenoid  tissue 
thoroughly  and  completely  removed,  we  do  not  ex- 
pect a  recurrence  of  the  trouble.  And  the  parents 
may  be  assured  that  while  a  regrowth  is  not  impos- 
sible, it  is  very  improbable. 

1422  South  Fifty-eighth  Street. 


CESAREAN  OPERATION.* 

By  William  L.  Harris,  M.  D., 

Providence,  R.  I., 
Surgeon  to  Saint  Joseph's  Hospital. 

The  operation  known  as  Cassarean  section  is  no 
novelty  in  the  medical  world.  It  is,  in  fact,  one  of 
the  oldest  operations  which  is  still  practised  by  sur- 
geons. 

Whether  it  derived  its  name  from  some  un- 
named Caesar,  or  whether  the  illustrious  Caesar  de- 
rived his  name  from  the  caesura,  or  cut,  through 
which  he  made  his  entrance  into  the  world,  is  a 
point  which  I  leave  to  the  historian  to  determine. 
But,  that  the  operation  has  been  performed  on  liv- 
ing and  on  dead  women  for  many  centuries,  is  un- 
deniable. That  circumstance  is,  indeed,  the  very 
reason  why  this  most  humane  and  life  saving  op- 
eration, as  it  is  performed  to-day,  has  yet  to  recom- 
mend itself  even  to  the  medical  fraternity.  For  the 
tradition  of  deadly  results  from  being  "ripped  from 
a  mother's  womb"  has  built  up  a  wall  of  prejudice 
against  the  Caesarean  operation,  which  it  is  difficult 
to  overthrow,  and  which  can  be  overthrown  only  by 
showing  that  the  past  and  present  processes  have 
scarcely  anything  in  common  but  the  name. 

•Read  before  the  Fall  River  Citv  Medical  Society,  January  13, 
1909. 


April  3,  1909.] 


HARRIS:    C.¥.SAREAN  OPERATION. 


687 


We  shudder  to  think  of  attempting  such  an  opera- 
tion now.  without  the  use  of  an  anesthetic,  and 
without  the  safeguard  of  aseptic  precautions.  But 
Nature,  which  never  shows  herself  more  defiant 
than  to  the  physician  who  is  prone  to  give  a  posi- 
tive diagnosis  or  more  benign,  than  to  him  who  has 
wisdom  enough  to  wait  and  see,  has  often  furriished 
examples  of  the  successful  performance  of  this  op- 
eration under  the  most  adverse  circumstances.  Wo- 
men, whose  uterus  have  been  gored  by  the  horns  of 
angry  cattle,  and  women  who  have  incised  their  own 
abdomen,  have  been  known  to  recover,  even  as  the 
rude  surgeons  of  the  African  jungles  are  said  to 
have  performed  this  operation  successfully. 

The  abundant  blood  supply  which  the  pregnant 
uterus  enjoys  has  undoubtedly  saved  lives  in  former 
times,- as  we  know  it  does  so  often  in  ours;  but  in 
spite  of  accidental  success  here  and  there,  the  op- 
eration, century  after  centur>',  established  its  repu- 
tation as  a  desperate  one  with  almost  certainly  fatal 
results.  For  a  hundred  years,  from  1700  to  1800, 
says  Dr.  Godson,  there  was  not  a  single  successful 
Csesarean  operation  in  either  Vienna  or  Paris,  and 
out  of  sixty-two  operations  in  Milan,  there  were  but 
three  recoveries,  according  to  Chiaria.  I  concern 
myself  but  little  with  how  these  statistics  were  gath- 
ered, or  whether  they  are  accurate  or  not ;  at  least, 
they  are  evidence  of  w'hat  scarcely  needs  to  be  dem- 
onstrated, that  Csesarean  section,  whether  deserved- 
ly or  undeservedly,  it  matters  not,  has  quite  uni- 
versally borne  a  bad  name,  and  even  now-  it  is  neg- 
lected when  it  should  be  practised,  and  when  none 
of  the  other  alternatives  to  which  the  surgeon  may 
resort,  can  promise  such  a  favorable  issue,  both  for 
the  mother  and  for  the  child. 

When  vou  meet  a  foetal  head  which  is  larger  than 
the  pelvic  outlet  through  which  Nature  intended  it 
should  pass,  you  are  put  in  the  position  of  one  who 
must  improve  on  Nature's  work  and  find  an  exit, 
although  the  way  is  blocked.  You  have  several. 
There  are  symphysiotomy,  pubeotomy.  craniotomy, 
the  induction  of  premature  labor,  and  Cjesarean  sec- 
tion. Now,  it  is  difficult  to  lay  down  the  measure- 
ments of  the  normal  pelvis,  but  it  may  be  said  with 
a  fair  degree  of  accuracy,  that  the  conjugate,  or 
anteroposterior  diameter  of  the  pelvis,  is  four  and 
one  fourth  inches,  and  the  transverse  diameter  is 
five  and  one  fourth  inches,  a  decrease  of  three 
fotirths  of  an  inch  in  the  anteroposterior  diameter 
means  therefore,  if  the  head  of  the  child  is  not  pro- 
portionately small,  that  the  uterus  cannot  be  emptied 
in  the  normal  way.  How  then  may  it  be  emptied? 
By  craniotomy?  Certainly  not,  unless  the  child  is 
dead,  or  we  desire  to  kill  it,  and,  in  fact,  since  it 
may  be  difficult  to  discover  whether  the  child  is 
alive  or  not,  craniotomy  requires  a  willingness  to 
perpetrate  infanticide.  How  then  may  we  pro- 
ceed ?  by  symphysiotomy  or  pubeotomy  ?  The  virtue 
of  these  operations  is  no 'longer  admitted;  we  have 
no  security  that,  when  our  outlet  is  thus  enlarged, 
we  may  not  have  to  resort  to  Csesarean  section,  and. 
w-ith  a  pelvis  whose  conjugate  is  less  than  three  and 
one  half  inches,  symphysiotomy  and  pubeotomy  are 
out  of  the  question ;  moreover,  they  are  fully  as  dif- 
ficult operations  as  Caesarean  section,  convalescence 
from  them  is  much  slower,  and  the  mortality  for 
mother  and  child  is  high.     Premature  labor  might 


solve  the  difficulty  if  we  could  be  sure  of  the  cor- 
rect time  to  precipitate  labor,  but,  if  brought  about 
too  soon  we  imperil  the  infant's  life,  if  too  late,  we 
have  to  face  the  original  danger  of  a  difficult  labor. 

Now,  Csesarean  section,  when  performed  in  time, 
presents  none  of  these  difficulties,  eliminates  anxiety, 
and  gives  almost  a  guarantee  of  safe  and  speedy  re- 
covery to  the  mother,  with  the  added  assurance  of  a 
living  child. 

The  secret  of  success  lies  in  operating  at  the  op- 
portune moment.  li  a  surgeon  delays  until  the 
use  of  high  forceps  has  been  proved  to  be  futile,  he 
has  to  deal  with  a  patient  who  is  exhausted,  and  who 
greatly  impedes  the  success  of  the  operation. 

The  application  of  high  forceps  results,  according 
to  reliable  authority,  in  a  mortality  of  from  one 
to  two  per  cent,  for  mothers,  and  thirty  per  cent 
for  the  infants,  and  Cassarean  section,  performed 
as  a  resort  after  ineffectual  attempts  at  delivery 
with  the  forceps,  must  face  the  possibility  of  such 
disasters,  which  are  wholly  independent  of  it,  along 
with  the  undeniable  but  negligible  risks  of  its  own. 

We  may  frankly  confront  statistics,  drawn  from 
here  and  there,  to  study  what  we  may  expect  from 
Cassarean  section  when  performed  by  competent 
surgeons.  Olshausen  reports  ninety-one  patients 
operated  upon  for  contracted  pelvis  with  nine 
deaths,  or  a  trifle  under  ten  per  cent. ;  Braun  sev- 
enty-four cases  with  a  mortality  of  eight  per  cent, 
while  Zweifel  reports  twenty-six  cases  with  only 
one  death,  and  that  patient  profoundly  septic  before 
the  operation  took  place. 

To  decide  when  this  operation  should  be  per- 
formed is,  of  course,  the  crux  of  the  question,  and 
is,  naturally,  not  without  its  difficulties. 

A  woman  in  bearing  her  first  child  may  have  a 
difficult  labor,  due  to  a  small  pelvis,  and  as  the  re- 
sult of  the  use  of  forceps  may  lose  the  child,  yet, 
ever  afterwards  bear  living  children  withou'.  any 
great  difficulty,  the  pelvis  seemingly  growing  more 
capacious.  But,  if  after  having  once  born  a  still- 
born child,  the  pelvic  measurements  still  show  con- 
traction, you  have  a  case  in  which  I  advise  the 
Cassarean  section  in  preference  to  taking  chances 
with  the  forceps. 

The  harm  wrought  by  the  forceps  is  beginning  to 
be  recognized.  I  think  that  the  laceration  of  the 
cervix,  the  vagina,  and  of  the  perinaeum,  which 
make  a  woman  a  chronic  invalid,  not  to  speak  of 
the  danger  of  puerperal  infection,  the  mortality 
from  which  is  so  fearfully  high,  have  done  as  much 
as  anything  else  to  discourage  child  bearing,  and  to 
encourage  race  suicide.  Caesarean  section  is  an  op- 
eration which  by  skilful  surgeons  can  be  performed 
in  from  ten  to  twenty  minutes,  and  which  with  or- 
dinary care,  has  practically  no  mortality,  and  from 
which  recovery  is  both  quick  and  complete. 

Now,  I  would  not  be  understood  as  advocating  its 
employment  where  there  is  a  chance  of  normal  de- 
livery, even  facilitated  by  the  moderate  use  of  in- 
struments ;  but  I  have  in  mind  the  horror  of  that 
sick  room,  where,  lying  on  a  bed  of  torture,  a  wo- 
man is  subjected  to  those  cruel,  however  kindly  in- 
tended ministrations,  which  so  often  result  either 
in  the  maiming  or  the  death  of  the  infant,  and  in 
the  utter  exhaustion  and  discouragement  of  the 
mother,  when  they  do  not  induce  her  death.  With 


688 


HARRIS:    CESAREAN  OPERATION. 


INevv  Vouk 
Medical  Journal. 


the  use  of  instruments  you  can  iiever  be  certain  of 
the  result  either  to  mother  or  child.  Sometimes, 
after  most  vigorous  application  of  the  forceps,  the 
child  comes  into  the  world  in  good  condition,  while, 
on  the  other  hand,  it  dies,  and  the  mother  is  badly 
torn  with  the  use  of  moderate  force. 

In  the  face  of  such  results  I  take  my  chances  with 
the  advocates  of  Csesarean  section,  and  I  lay  down 
as  proper  indications  for  the  operation  the  following 
conditions,  which  are,  I  believe,  accepted  by  the  best 
authorities : 

1.  When  the  conjugate  measurement  of  the  pelvis 
is  below  three  and  one  half  inches. 

2.  When  the  presence  of  a  pelvic,  cervical,  or 
vaginal  tumor  renders  delivery  impossible. 

3.  Central  placenta  prrr;via. 

4.  When  with  a  conjugate  measurement  below 
three  and  one  half  inches,  the  forceps  have  been  ap- 
plied and  no  advancement  can  be  detected  after  ten 
minutes. 

5.  When  a  w"oman  has  had  one  stillborn  child  of 
moderate  size  following  the  application  of  forceps. 

6.  When  a  woman  has  lost  two  or  three  children 
from  accidents  during  labor. 

7.  In  cases  o"f  puerperal  eclampsia  at  full  term, 
Csesarean  section  is  preferable  to  cervical  dilatation 
followed  by  version  or  high  forceps. 

8.  Several  cases  have  been  reported  where  the 
complications  following  ventral  fixation  have  made 
Csesarean  section  necessary. 

9.  The  following  pelvic  deformities,  Dwarf  pelvis, 
ankylosed  pelvis,  coxalgic  pelvis,  kyphotic  and 
oblique  pelvis,  require  the  Cassarean  operation. 

Dr.  Noble  reports  a  case  where  the  inflammatory 
exudate  so  blocked  the  pelvis  that  he  had  to  deliver 
by  Cesarean  section,  and  Dr.  Smith  reports  another 
which  required  it  because  of  the  cicatrical  contrac- 
tion of  an  extensive  wound  of  the  pelvic  outlet.  I 
have  recently  operated  in  a  case  in  which,  two 
weeks  before  full  term,  the  patient  had  a  pro- 
nounced apoplectic  attack  followed  by  hemiplegia ; 
her  condition  was  an  alarming  one,  but  the  child  was 
delivered  alive,  and  the  mother  made  a  slow  hut 
tmeventful  recovery. 

Time  for  operation  is  either  before  or  as  soon  as 
labor  begins.  Dilatation  of  the  cervix  can  be  pro- 
vided for  when  the  uterus  is  opened,  by  stretching 
the  internal  os  and  cervical  canal  with  fingers  of  the 
left  hand  and  if  thought  advisable  a  piece  of  gauze 
can  be  passed  through  the  cervical  canal  into  the 
vagina  for  drainage.  This  I  have  never  deemed 
necessary.  Some  operators  advise  postponing  the 
operation  until  the  os  has  dilated  to  the  size  of  a  sil- 
ver half  dollar.  I  have  followed  this  rule  in  the 
majority  of  my  cases  and  have  never  regretted  do- 
ing so. 

The  operation  is  best  done  in  a  well  equipped  op- 
erating room,  but,  if  such  is  not  available,  a  room 
in  the  patient's  house  can  be  prepared ;  carpets 
should  be  taken  up,  and  walls  and  ceilings  must  be 
thoroughly  cleaned.  The  temperature  of  the  room 
should  be 'about  78°  F. 

Preparation  of  patient :  For  two  or  three  days  pro- 
ceding  the  operation  she  is  given  a  hot  bath  where 
soap  is  used  freely.  Castor  oil,  in  one  ounce  doses 
is  given  twice  before  operation,  at  twenty-four 
hoiu-s'  intervals ;  and  in  the  morning  before  the  op- 


eration she  has  an  enema  of  soap  suds.  The  blad- 
der is  emptied  before  going  to  the  anaesthetizing 
room.  Twenty-four  hours  before  operation  the  ab- 
domen is  washed  well  with  soap  and  water  followed 
by  Harrington's  solution  No.  g  and  ether,  and  a 
large  dressing  soaked  with  equal  parts  of  alcohol 
and  bichloride  solution  ( i  in  4,000)  is  applied  and 
covered  with  oiled  silk.  This  dressing  is  changed 
the  morning  of  operation^,  and  no  further  prepara- 
tion is  necessary  when  the  patient  reaches  the  op- 
erating table. 

The  instruments  required  are  two  good  sized  scal- 
pels (one  used  in  opening  into  the  abdomen,  the 
second  in  opening  the  uterus),  one  half  dozen 
forceps,  two  small  tenacula  for  drawing  the  in- 
cision through  the  abdominal  wall  together  after  de- 
livering the  womb,  one  half  dozen  large  full  curved 
needles,  one  pair  of  scissors,  and  three  feet  of  large 
size  rubber  tubing  to  be  used  as  a  tourniquet  in 
case  one  is  required. 

The  operator  needs  two  assistants,  one  whose  sole 
duty  is  to  control  haemorrhage  by  digital  pressure 
upon  the  uterine  arteries,  and  the  second  handles 
sponges  and  instruments. 

1  have  always  opened  the  abdomen  by  an  incision 
through  either  rectus  muscle ;  care  should  be  taken 
not  to  open  the  bladder  by  carrying  the  incision  too 
far  down,  and,  as  with  the  first  incision  you  often 
cut  into  the  uterine  wall,  care  must  be  taken  to  avoid 
incising  a  loop  of  gut  that  may  be  prolapsed  be- 
tween the  belly  wall  and  uterus.  The  incision 
should  be  about  eight  inches  long.  Some  operators 
recommend  the  withdrawal  of  the  liquor  amnii 
through  the  vagina  before  opening  the  abdomen. 
This  certainly  saves  a  great  deal  of  soiling  of  the 
abdominal  contents,  but  I  have  never  considered  it 
necessary.  Some  favor  it  on  account  of  the  great 
reduction  in  the  size  of  the  uterus^  this  permitting 
its  withdrawal  through  a  much  smaller  wound.  Of 
late  I  have  opened  the  uterus  while  still  in  the  ab- 
dominal cavity.  First  packing  about  it  four  or 
five  large  elephant's  ear  marine  sponges,  as  the  fluid 
gushes  out  I  seize  the  first  lower  limb  of  the  child 
which  presents  itself  and  in  withdrawing  the  infant 
the  uterus  is  pulled  through  the  abdominal  wound 
to  the  outside  of  the  belly  wall,  and  in  this  wa>' 
the  greater  part  of  the  amniotic  fluid  is  discharged 
outside  of  the  abdominal  cavity.  When  the  uterus 
is  thus  withdrawn  I  approximate  the  upper  two 
thirds  of  the  incision  by  applying  two  or  three 
tenacula  to  the  two  sides  of  the  incision,  and  be- 
tween the  belly  w-all  and  the  posterior  surface  of 
the  uterus  is  placed  a  small  sheet  folded  in  two. 

If  there  is  much  haemorrhage  an  assistant  com- 
presses the  uterine  arteries  with  his  two  hands.  I 
have  used  the  clastic  ligature  two  or  three  times, 
but  have  discarded  it,  as  it  seemed  to  encourage 
subsequent  ha;morrhage  no  doubt  due  to  uterine 
paralysis.  No  steps  towards  the  control  of  haemor- 
rhage should  be  made  before  the  uterus  is  opened 
as  there  is  the  possibility  of  asphyxiating  the  child. 
The  absence  of  haemorrhage  I  have  often  remarked 
and  it  is  undoubtedly  due  to  uterine  contraction  fol- 
lowing its  exposure  to  the  air,  and  the  handling  it 
receives  at  the  time  of  incision,  and  when  the  child 
is  extracted.  On  several  occasions  I  have  found  h 
unnecessary  to  compress  the  uterine  arteries. 


April  3.  1909.] 


HARRIS:    CESAREAN  OPERATION. 


689 


The  incision  into  the  uterus  should  be  through  its 
upper  third  and  it  should  not  be  made  too  long.  If 
too  short  to  permit  of  ready  extraction  of  the  child, 
it  will  tear  easily,  as  the  body  is  withdrawn,  and 
there  is  less  hiemorrhage  from  a  tear  than  from  an 
incision  made  with  a  sharp  knife.  It  has  happened 
several  times  that  after  cutting  into  the  uterus  we 
find  an  anteriorly  attached  placenta,  this  is  a  rather 
startling  experience  and  calls  up  all  the  horrors  of 
placenta  prsevia.  Never  attempt  to  cut  into  it  or 
peel  it  off,  but  quickly  tear  through  it,  and  after 
seizing  a  limb  make  as  rapid  a  delivery  as  possible. 
The  more  rapidly  these  mentioned  steps  of  the  op- 
eration are  carried  out  the  better  the  results,  for  the 
haemorrhage  appears  to  be  in  inverse  proportion  to 
the  operator's  speed.  In  delivering  the  child,  the 
legs  should  be  sought  for^  as  in  delivering  by  that 
member  a  smaller  uterine  incision  is  required.  If 
the  child's  color  is  good  the  cord  is  at  once  divided 
between  two  artery  clamps,  and  the  child  turned 
over  to  an  assistant.  With  the  child's  withdrawal 
uterine  contraction  begins,  and  the  operator's  hand 
is  passed  into  the  uterus  in  order  to  peel  off  the 
placenta.  If,  at  this  stage  of  the  operation,  haemor- 
rhage is  profuse,  a  hypodermic  injection  of  ergot 
is  given  deep  into  the  buttock.  When  the  placenta 
is  removed,  I  pass  the  fingers  of  the  left  hand 
through  the  cervix  in  order  to  satisfy  myself  that 
there  is  sufficient  dilatation  to  afford  good  drain- 
age, and  then  I  wipe  out  the  uterine  cavity  with  a 
gauze  sponge. 

The  haemorrhage  from  the  uterine  incision  is  con- 
trolled by  the  heavy  silk  sutures  used  in  closing  the 
wound.  I  do  not  think  we  should  use  catgut  for 
this  purpose.  The  deep  sutures  are  placed  about 
five  eighths  of  an  inch  apart  and  I  always  use  for 
passing  them  the  dullest  needles  I  can  find.  A  new 
improved  Hagedorn  needle  should  never  be  used. 
The  sutures  should  begin  about  five  eighths  of  an 
inch  from  the  edge  of  the  incision,  and  should  pass 
down  to,  but  not  through  the  mucous  membrane.  In 
tying  them  the  serous  surface  of  each  side  of  the  in- 
cision should  be  turned  inwards,  so  that  the  two 
serous  surfaces  may  be  well  opposed.  In  the  in- 
tervals interrupted  Lembert  sutures  should  be  used. 
It  is  very  necessary  to  have  the  sutures  quite  close 
together  in  order  to  prevent  subsequent  adhesions 
between  the  uterus  and  the  omentum,  a  condition 
which  will  be  very  troublesome  to  the  operator  in 
the  event  of  a  second  operation. 

Before  closing  the  abdominal  incision  wipe  out 
Douglas's  pouch,  the  iliac  fossae,  and  the  vesicle 
space,  and  be  sure  to  count  sponges,  towels,  and  in- 
struments. Draw  the  omentum  down  over  the 
uterus  and  close  the  abdomen  with  interrupted  su- 
tures. A  well  fitting  many  tailed  bandage  should 
be  applied  over  a  moderate  size  dressing,  and  the 
patient  is  quickly  transferred  to  a  well  warmed  bed. 

Morphine  sulphate,  gr.  1/12,  should  be  given 
hypodermically  as  also  a  shock  enema  of  black  cof- 
fee and  brandy ;  water  may  be  given  freely  by 
mouth  if  thirst  is  excessive ;  but  rarely  will  it  be 
necessary  to  catheterize  your  patient.  Gas  is  best 
relieved  by  enema  of  turpentine,  glycerin,  and  water, 
or  milk  of  asafoetida,  and  at  the  end  of  the  third  day 
I  am  accustomed  to  giving  two  Hinkle  pills. 

The  child  is  put  to  the  breast  as  soon  as  the 
mother  has  recovered  from  the  effects  of  the  anaes- 


tlietic.  as  by  so  doing  you  encourage  uterine  con- 
traction. 

The  mother's  diet  should  be  quite  liberal  after  the 
first  twenty-four  hours.  Slight  rises  in  temperature 
are  not  uncommon  and  require  no  special  treatment. 

After  pains  I  have  found  very  rare  and  never  of 
any  consequence. 

A  bed  rest  is  allowed  at  the  end  of  the  second 
day. 

Dr.  King  says  that  the  mortality  from  this  opera- 
tion is  less  in  private  than  in  hospital  practice.  This, 
if  true,  is  probably  due  to  the  fact  that  the  worst 
cases  go  to  the  hospitals. 

I  have  done  this  operation  now  twenty-one  times, 
and  in  one  case  delivered  the  mother  of  twins.  Two 
patients  I  have  delivered  twice  by  Caesarean  sec- 
tion ;  all  of  the  mothers  are  living,  and  all  of  the 
children  but  three,  two  of  whom  died  a  few  min- 
utes after  birth,  and  one  a  few  days  later.  The 
twenty-one  mothers  had,  previous  to  their  opera- 
tions, lost  thirty-nine  children,  and  to-day  there  are 
in  this  State,  enjoying  good  health,  nineteen  boys 
and  girls  varying  in  age  from  three  months  to  six 
years,  who,  in  my  opinion,  owe  their  existence  to 
this  magnificent  operation.  Do  you  wonder  that 
I  appear  before  you  as  the  advocate  of  an  operation 
the  results  of  which  are  so  beneficent  and  the  value 
of  which  is  apparently  underestimated  ? 

The  surgeon,  no  doubt,  is  justly  criticised  for  his 
over  confidence  in  the  knife,  in  his  willingness  to 
assist  Nature,  which,  he  will  be  told,  is  abundantly 
able  to  take  care  of  herself,  and  does  so  many  times 
in  spite  of  his  efforts  to  undo  her.  But  I  face  a 
condition  and  not  a  theory. 

We  all  knew  what  terror  the  bearing  of  children 
brings  to  the  women  of  the  present  da\-,  even  to 
those  who  desire  to  be  mothers.  We  are  all  aware 
of  the  counsel  so  frequently  given  to  this  and  that 
woman  by  reputable  physicians,  that  they  must 
never  think  of  having  children,  that  death  will  in- 
evitably result  if  they  again  become  pregnant,  and 
the  consequent  fear  in  which  they  live,  not  unmixed 
with  the  qualms  of  conscience,  if,  as  frequently  hap- 
pens, they  are  women  of  strong  religious  belief. 
To  such  physicians  and  to  such  women  I  say,  are 
you  aware  that  there  is  a  way  to  live  out  your  life 
as  you  would  have  it? 

If  you  had  seen  as  I  have  the  looks  of  gratitude 
which  these  women  have  bestowed  on  me,  when 
they  discovered  that  the  tragedy  of  their  lives  was 
ended,  and  that  their  homes  might  be  blessed  with 
the  fragrance  of  childhood,  and  they  themselves 
far  from  being  disabled,  restored  in  a  few  days  to 
normal  health,  you  would  understand  why  I  wish  to 
do  my  part  in  levelling  the  wall  of  prejudice  which 
still  makes  this  operation,  even  to-day,  comparative- 
ly rare,  and  which  regards  it  as  a  last  resort,  and  to 
be  attempted  only  in  desperate  cases. 

That  antipathy  -must  disappear,  I  am  convinced, 
when  physicians  generally  discover  how  easy  of 
performance,  how  almost  sure  of  result,  and  how 
speedy  in  recovery  the  Caesarean  section,  as  per- 
formed to-day,  has  become,  and  I  shall  be  greatly 
gratified  if  my  words  direct  the  attention  of  any  of 
you  to  an  investigation  of  my  assertions  for  the 
consequence  of  which  I  have  no  fear. 

532  Bro.\d  Street. 


690 


VAN  SWERINGEN:  CESAREAN  SECTION. 


[New  York 
Medical  Journal. 


CESAREAN  SECTION* 

By  B.  Van  Sweringen,  M.  D., 
Fort  Wayne,  Ind., 
GjTijECologist  to  the  Lutheran  Hospital. 

Three  women  have  been  subjected  to  Cjesarean 
section  at  the  Fort  Wayne  Lutheran  Hospital  in  the 
last  ten  months  for  as  many  different  reasons. 

Case  I. — The  first  was  a  multipara  who  had  suffered  from 
a  gangrenous  appendicitis  at  the  sixth  month  of  uterogesta- 
tion  which  necessitated  drainage,  which  in  turn  was  fol- 
lowed by  adhesion  of  the  uterus  to  the  abdominal  wall. 
When  she  fell  m  labor  at  the  termination  of  her  pregnancy 
it  was  thought  safer  to  subject  her  to  the  Kaiserschnitt, 
separate  the  adhesions  under  view,  and  ligate  all  bleeding 
points  that  presented,  than  to  run  the  risk  of  allowing  the 
uterus  to  tear  itself  loose  producing  severe  abdominal 
haemorrhage,  or  failing  in  thus  freeing  itself  remain  so  di- 
lated as  to  permit  of  fatal  post  partum  bleeding. 

Accordingly  this  was  done  by  Dr.  H.  A.  Duemling.  The 
adhesions  were  separated  and  the  uterus  incised  within  the 
abdomen,  the  child  extracted,  and  the  incisions  closed.  The 
patient  made  an  uninterrupted  recovery. 

Case  II. — The  next  was  a  case  of  Dr.  L.  P.  Drayer's, 
whose  report  follows :  Mrs.  S.,  set.  twenty-eight,  married 
two  years ;  primipara.  Family  history  and  personal  history 
were  negative.  Pregnancy  had  been  absolutely  normal. 
The  labor  was  ushered  in  by  a  bloody  discharge  at  full 
term.  Pains  did  not  come  on,  but  the  bloody  discharge 
continued  and  at  times  was  copious.  This  continued  for 
twelve  hours,  when  digital  examination  revealed  a  dilated 
cervix  with  central  implantation  of  the  placenta.  She  was 
removed  to  the  hospital  where  the  haemorrhage  became 
alarming,  raising  the  pulse  to  no.  Csesarean  section  was 
advised,  after  consultation,  in  the  interest  of  both  mother 
and  child  and  was  accepted.  Accordingly  ether  was  admin- 
istered, a  midline  incision  made,  the  uterus  delivered,  the 
lower  segment  held  by  an  assistant,  the  child  delivered 
through  an  incision  in  the  uterus,  the  placenta  quickly 
extracted,  and  the  uterus  closed  with  three  tiers  of  catgut 
sutures.  The  abdominal  wound  was  closed  with  figure  of 
eight  silkworm  sutures.  The  loss  of  blood  was  estimated 
at  700  c.c.  The  patient  was  put  to  bed  with  a  pulse  of  140. 
Uneventful  recovery  followed  during  three  weeks.  The 
baby  had  a  convulsion  one  minute  after  delivery  and  a 
staphylococcic  ophthalmia  which  cleared  in  three  days.  Op- 
rator.  Dr.  M.  F.  Porter. 

Case  III.- — The  third  case  occurred  in  the  practice  of  Dr. 
L.  E.  Brown.  The  patient  was  a  primigravida,  twenty-one 
years  of  age,  who  fell  in  labor  at  term  on  September  i, 
1908,  in  the  evening.  Strong  contractions  came  on  during 
the  afternoon  of  the  second  and  continued  throughout  the 
night.  The  forceps  was  applied  by  Dr.  Brown  about  10 
o'clock  on  the  morning  of  the  third,  but  delivery  could  not 
be  effected.  The  patient  was  then  brought  to  the  Lutheran 
Hospital  where  the  following  measurements  were  taken : 
External  conjugate,  seven  inches;  crests,  nine  inches;  be- 
tween the  ischial  tuberosities,  two  and  a  quarter  inches; 
anteriorposterior  diameter  of  the  outlet,  three  and  a  half 
inches.  The  pubic  arch  was  very  sharp,  resembling  mark- 
edly the  male  pelvis. 

As  the  patient's  condition  was  fairly  good  at  the  time  I 
saw  her,  which  was  at  i  o'clock  in  the  afternoon  of  Sep- 
tember 3rd,  and  the  child  still  living,  our  choice  lay  be- 
tween symphysiotomy  and  one  of  the  Csesarean  operations, 
as  it  was  evident  that  the  forceps  must  fail  in  delivering  a 
full  term  child  through  the  diameters  of  the  outlet  without 
sacrificing  it.  We  chose  section,  as  the  bisischial  diameter 
present  was  too  small  to  admit  of  a  safe  delivery  even  after 
puhiotomy.  She  was  hastily  prepared,  the  abdominal  incision 
made,  the  uterus  brought  out,  incised,  the  left  occipitopos- 
tcrior  placenta  pierced  by  the  hand,  the  child  (which 
presented  m  the  position)  grasped  by  the  left  leg  and  de- 
livered, the  placenta  removed  and  hremorrhage  contro'lcd 
by  rubber  tubing.  All  incisions  were  then  closed,  and  the 
patient  returned  to  bed.  Her  condition  was  precarious  for 
two  days,  when  she  began  an  improvement  which  continued 
steadily  until  her  discharge  at  the  end  of  three  weeks. 

Tlie  baby's  occipitofrontal  diameter  was  4V2  inches;  oc- 
cipitomental, sVa  inches ;  biparietal.  4  inches ;  occipitobrcg- 
matic,  4i4  inches. 

-    'Read  before  the  Fort  Wayne  Medical  Society. 


The  type  of  pelvic  deformity  here  present  was  justo- 
minor  with  more  than  proportional  contraction  of  the  bi- 
sischial. That  is,  all  the  diameters  were  rather  regularly 
and  equally  contracted  except  the  bisischial,  which  was  re- 
duced 2  inches  from  the  average  normal  measurement.  The 
setiological  factor  in  the  production  of  this  deformity  in  the 
present  instance  was  an  inherited  luetic  infection,  for  the 
corneas  showed  evidence  of  early  interstitial  inflammation 
and  the  greater  part  of  the  shaft  of  the  right  radius  was 
missing.  There  were  present  also  scars  of  old  sinuses  on 
the  arm. 

These  tliree  cases  I  want  to  make  the  basis  of  a 
plea  for  the  more  frequent  employment  of  the  pro- 
cedure. The  babies  are  all  alive  and  well  at  this 
writing,  as  are  also  the  mothers. 

In  contradistinction  to  the  happy  outcome  of 
these  cases  is  the  outcome  familiar  to  you  all,  fre- 
quently seen  in  women  with  slight  degrees  of  justo- 
minor  pelves  in  labor  at  term  with  the  child  in  a 
posterior  position.  The  contraction  may  not  be 
great  enough  to  cause  one  any  uneasiness,  but  when 
a  large  head  and  a  posterior  position  are  added  the 
case  becomes  one  in  which  the  best  irtterests  of  both 
mother  and  child  will  be  better  conserved  by  Caesar- 
ean  section  than  by  any  other  operation. 

By  way  of  illustration  I  might  report  the  follow- 
ing case : 

Case  IV. — Mrs.  C,  a  young  primigravida,  healthy,  with 
an  apparently  normal  pelvis,  who  fell  in  labor  at  11  p.  m. 
October  4,  1908.  Labor  progressed  slowly  that  night  and 
all  the  next  day.  The  membranes  were  ruptured  at  9. p.  m. 
October  sth,  and  after  an  hour  of  unavailing  pains  forceps 
was  applied  to  the  head,  which  lay  in  the  left  posterior 
position.  It  could  not  be  made  to  descend  by  patient  in- 
termittent moderate  traction  persisted  in  for  half  an  hour. 
More  force  was  used  and  finally  descent  secured.  The 
head  rotated  to  the  anterior  position  at  the  outlet,  the  for- 
ceps was  removed,  and  the  delivery  accomplished  as  though 
unaided.  A  slight  perineal  tear  was  repaired  and  a  rather 
long  longitudinal  cut  along  the  upper  inner  surface  of  the 
left  labium  also.  The  mother  made  a  good  recovery.  The 
tragedy  comes  in  in  the  condition  of  the  baby.  One  blade 
of  the  forceps  had  impinged  on  the  right  mastoid  produc- 
ing right  facial  palsy.  On  the  left  side  of  the  frontal  bone 
was  a  short  though  deep  scalp  wound  which  was  dressed 
by  approximating  its  edges  with  plaster.  It  healed  nicely 
and  the  child  appeared  to  be  doing  as  well  as  we  could  ex- 
pect it  to  until  the  tenth  day  when  a  high  fever  developed, 
and  the  child  died  in  a  convulsion  from  meningitis  on  the 
eleventh  day,  the  point  of  infection  probably  being  the  scalp 
wound.  This  baby  was  a  strong  healthy  infant  weighing 
eleven  pounds  at  birth  and  -vould  have  been  alive  to-day  in 
all  probability  if  it  had  been  delivered  by  section,  for  in  that 
case  it  would  have  had  no  forceps  wounds  to  act  as  portals 
of  infection. 

The  situation  is  well  summed  up  by  Ross  in  Kelly 
and  Noble's  work,  as  follows.  Speaking  of  these 
borderline  cases  he  says : 

It  is  easy  to  sit  in  one's  armchair  and  argue;  it  is  more 
difficult  to  act  for  the  best  at  the  bedside.  The  patient  is  in 
labor,  the  cervix  dilates,  the  pelvic  measurements  show  a 
not  very  great  diminution  from  the  normal ;  the  child  does 
not  come  down,  and  we  naturally  proceed  to  assist  in  the 
delivery  by  a  forceps  operation.  When  the  forceps  is  placed 
it  is  necessarj'  that  it  be  pulled  down,  and  unless  it  is  pulled 
upon  vigorously,  we  might  better  have  left  it  unapplied. 
\Ve  are  now  enabled  to  determine  the  compressibility  of  the 
head,  and  from  a  slight  traction  we  proceed  to  apply  more 
force.  The  forceps  begins  to  slip  and  perspiration  to  bathe 
the  operator.  The  progress  n.ay  be  very  slow.  Finally 
when  the  forceps  fails  to  deliver,  a  consultation  is  called 
for.  I'nless  the  consultant  has  every  confidence  in  the  doc- 
tor in  charge,  he  may  desire  to  apply  the  forceps  himself 
and  make  his  own  attempt  to  deliver  the  patient.  Wlien 
he  has  done  so  the  patient  is,  in  all  probability,  much  ex- 
hausted, the  soft  parts  bruised,  and  the  fcrttis  dead.  If  the 
operator  is  certain  the  foetus  is  dead,  the  head  is  now  per- 
forated and  the  child  delivered,  and  he  feels  thankful  that 


April  3,  1909.] 


VAN  SWERINGEN:  CESAREAN  SECTION. 


691 


he  has  succeeded  in  saving  the  life  of  the  mother.  When 
we  look  back  over  such  a  case  we  naturally  ask  ourselves : 
At  what  point  should  pelvic  delivery  have  ceased  and 
Caesarean  section  (abdominal)  have  begun?  It  is  easy 
for  us  to  review  such  a  case  and  criticise,  but  the  ob- 
stetrician who  enters  a  gentleman's  house  and,  without 
making  an  effort  to  deliver  his  wife,  tells  him  that  she  must 
be  delivered  by  Cresarean  section,  is  liable  to  be  discharged 
unless  he  is  fortified  by  a  very  considerable  reputation  in 
this  particular  branch.  Pelvic  delivery  is  looked  upon  as  a 
natural  procedure,  Caesarean  section  as  an  unnatural  one. 
When  it  is  rendered  a  safe  method  of  delivery  and  the 
woman  is  able  to  escape  the  pangs  of  labor,  many  of  the 
difficulties  that  now  surround  the  attending  obstetrician 
will  disappear. 

But  no  matter  how  much  we  argue,  cases  such  as  the 
above  will  continue  to  be  treated  in  exactly  the  same  man- 
ner by  the  very  best  obstetricians. 

The  difficulty  in  laving  down  any  hard  and  fast 
rules  for  the  indications  for  Cesarean  section  lies 
in  the  fact  that  the  problem  is  a  continually  varying 
one.  Of  two  women  with  the  same  pelvic  measure- 
ments one  may  have  an  easy  labor  and  the  other  the 
reverse.  The  difference  is  accounted  for  by  the  dif- 
ference in  the  size  and  compressibility  of  the  child's 
head. 

Ross  says : 

"It  seems  rather  absurd  to  endeavor  to  settle 
these  questions  by  mere  measurements  of  inches  or 
centimetres"  on  this  account.  It  is  agreed  by  all 
writers,  however,  that  a  conjugata  vera  of  5  to  6 
cm.  constitutes  an  absolute  indication  for  section. 
That  is,  symphyseotomy  or  craniotomy  may  not  be 
substituted  for  it.  The  upper  limit  for  the  absolute 
indication  has  recently  been  raised  to  7.5  cm.  Seven 
and  a  half  centimetres  formerly  constituted  the  up- 
per limit  for  the  relative  indication  for  section,  but 
Williams  has  raised  this  limit  to  8.5  cm.  That  is,  in 
a  patient  with  this  diaineter  of  the  conjugate,  sec- 
tion may  be  done,  but  it  is  possible  to  effect  delivery 
by  pubiotomy  or  craniotomy. 

In  our  case  it  was  demonstrated  that  the  head  could 
be  made  to  engage  in  the  superior  strait  although 
the  external  conjugate  measured  but  7  inches, 
leaving  a  true  conjugate  (according  to  Litzmann's 
measurements  on  thirty  cases,  quoted  in  Edgar's 
Obstetrics)  of  3^  inches.  Inasmuch  as  the  short- 
est diameter  of  the  baby's  head  (the  biparietal)  was 
4  inches,  this  seems  improbable,  yet  Dr.  Brown  as- 
se'rts  that  the  head  could  be  brought  down  till  ob- 
structed by  the  bisischial  diameter,  showing  that 
considerable  compression  was  accomplished.  The 
marks  of  the  forceps  were  plainly  visible  on  the 
head  after  birth. 

A  bisischial  diameter  such  as  we  had,  i.  e.,  2^ 
inches,  is  an  absolute  indication  for  section,  and 
when  sought  for  and  found  one's  course  of  action 
is  plain.  It  is  the  borderline  cases  referred  to  in  the 
proceditres  that  are  difficult  to  treat  properly  in  the 
primipara.  When  one  has  the  history  of  one  or  two 
previous  severe  labors  terminated  by  forceps  and 
resulting  in  stillborn  babies  to  guide  him,  it  is  not 
so  hard  to  outline  a  proper  course  for  the  approach- 
ing accouchement.  We  have  here  to  choose  be- 
tween pubiotomy  followed  by  forceps,  and  section, 
if  the  pregnancy  has  gone  to  term,  and  taking  the 
interests  of  the  child  into  consideration  and  the 
present  low  mortality  from  Caesarean  section  under 
favorable  environment,  it  is  not  wise  to  bring  on 
premature  labor.    As  between  pubiotomy  and  sec- 


tion, under  equally  good  conditions,  it  seems  to  me 
that  the  choice  should  be  section.  The  convalescence 
is  shorter  and  the  danger  from  sepsis  distinctly  less. 
Then,  too,  there  is  no  discomfort  from  a  movable 
symphysis  possible. 

It  is  my  judgment  that  many  of  the  patients  with 
justominor  pelves  who  are  now  delivered  by  high 
forceps  would  do  better  under  section,  because  a 
live  baby  is  almost  invariably  delivered  and  the  ma- 
ternal trauma,  and  therefore  the  maternal  morbid- 
ity, not  so  great.  I  will  even  go  further  and  sa>- 
that  in  many  cases  where  the  conjugate  is  about 
normal  but  the  child  in  a  posterior  position  and  it  is 
deemed  advisable  to  do  a  high  forceps  operation, 
especially  in  primiparje,  section  should  be  very  care- 
fully considered  in  the  interest  of  both  mother  and 
child. 

Reynolds,  {Surgery,  Gynecology,  and  Obstetrics, 
May,  1908)  says  "the  maternal  mortality  of  high 
forceps  and  version  ...  is  probably  about  equiv- 
alent to  that  of  primary  Caesarean  section.  The 
foetal  mortality  of  these  operations  (high  forceps 
and  version)  is  .  .  .  placed  at  an  average  of  at 
least  from  twenty  to  twenty-five  per  cent.  By  "pri- 
mary Caesarean  section"  he  means  a  section  deter- 
mined upon  in  advance  of  the  onset  of  labor  and 
done  at  its  very  beginning  or  even  in  advance  of  the 
advent  of  pains.  The  prognosis  of  section  becomes 
progressively  more  grave  with  the  length  of  time 
labor  has  lasted  and  the  amount  of  intrapelvic  ma- 
nipulation and  trauma.  The  secondary  section,  that 
is,  the  section  performed  as  soon  as  possible  after 
the  test  of  labor  has  demonstrated  the  mother's  in- 
ability to  accomplish  a  spontaneous  delivery,  has. 
(Reynolds)  a  considerable  maternal  mortality  esti- 
mated at  from  two  to  four  per  cent. 

In  the  paper  already  referred  to  Reynolds  draws 
attention  to  some  types  of  primiparae  that  should 
receive  special  consideration  of  their  pelvic  diame- 
ters and  the  probability  of  spontaneous  delivery,  in 
the  following  words : 

All  primiparae  of  very  small  stature  should  have  a  deter- 
mination of  the  mechanical  conditions  during  pregnancy. 

All  priniipar;e  who  have  done  heavy  muscular  work  dur- 
ing the  period  of  development,  and  more  especially  all  of 
liiese  who  present  a  short,  squat,  short  legged  appearance 
should  "have  a  determination  of  the  mechanical  conditions 
during  pregnancy.  It  is  in  this  class  of  women  that  the  flat 
pelves  are  particularly  frequent. 

All  primiparae  with  the  narrow  hipped,  long,  straight 
legged,  flat  backed,  boyish  type  of  figure  should  have  a  de- 
termination of  the  meclianical  conditions  during  pregnancy. 
It  is  in  this  type  of  women  that  the  true  justominor  or  neu- 
tral type  of  pelvis  is  especially  frequent. 

All  primiparae  with  bandy  legs,  protuberant  buttocks, 
prominent  abdomen,  and  unusually  hollow  lumbar  region 
should  have  a  determination  of  the  mechanical  conditions 
during  pregnancy.  Such  women  are  often  rather  wide 
hipped,  markedly  feminine  in  figure,  and  at  first  sight  sug- 
gest favorable  labor ;  but  it  is  in  such  women  that  pelves 
witii  excessive  inclination  of  the  brim  and  exaggerated 
curvature  of  the  pelvic  axis  are  mostly  found.  This  pelvis 
has  attracted  no  attention  until  of  late  years.  It  is  fre- 
quently of  good  size  and  is  then  unimportant,  but  its  shape 
is  such  as  to  make  very  slight  diminutions  of  its  size  pro- 
ductive of  an  unexpected  difficulty  in  labor,  and  it  is  there- 
fore worthy  of  note.  These  pelves  are  the  more  important 
in  that  in  them  the  intrapelvic  operations  have  necessarily 
a  very  high  foetal  death  rate,  and  a  very  high  maternal 
morbidity  rate. 

All  prmiiparas  of  delicate  genera!  health  should  have  a 
determination  of  the  mechanical  and  constitutional  condi- 
tions during  pregnancy.    Many  of  these  women  have  easy 


692 


['AX  SirERLVGEX:  C^SAREAX  SECTION. 


[New  York 
Medical  Jourxal. 


labors,  but  in  them  even "  moderate  mechanical  difficulties 
assume  importance,  and,  moreover,  the  medical  oversight 
of  their  pregnancies  always  demands  great  care. 

Multiparse  who  have  had  easy  previous  labors  demand 
no  special  care,  but  all  n.ultiparje  who  have  had  even  one 
difficult  or  disastrous  labor  should  have  a  determination  of 
the  mechanical  conditions  during  pregiiancy. 

As  to  placenta  prsevia  as  an  indication  for  Cfe- 
sarean  section,  which  was  the  one  which  presented 
itself  in  Dr.  Draycr's  case,  the  majority  of  writers 
consulted  do  not  mention  it.  Olshausen  is  said  to 
look  upon  it  with  disfavor.  The  most  cogent  indi- 
cation for  it,  in  my  judgment,  lies  in  the  reluctance 
with  which  one  dooms  a  child  to  almost  certain 
sacrifice.  If  the  pregnancy  has  gone  to  term  then, 
without  a  dangerous  haemorrhage  occurring,  pre- 
senting an  undilated  cervix  and  a  living  child,  it 
seems  to  me,  in  view  of  the  infant  mortality  by  ver- 
sion and  delivery  through  the  placenta,  that  the  pro- 
cedure should  be  offered  to  the  patient  and  rela- 
tives as  no  more  dangerous  to  the  mother  and  very 
likely  to  save  the  child,  for  haemorrhage  from  the 
placental  site  can  be  more  safely  dealt  with  when 
doing  section  than  when  doing  version  and  the  risk 
of  sepsis  is  but  slightly,  if  at  all,  increased.  If  a 
dangerous  haemorrhage  has  already  occurred  one 
should  be  satisfied  that  the  child  is  living  and  ap- 
parently strong  before  advising  section,  even  if  the 
pregnancy  has  gone  to  term.  H.  S.  Crossen,  {Jour- 
nal of  the  American  Medical  Association.  May  2. 
1908)  says  that  the  death  of  many  infants  delivered 
of  mothers  the  subject  of  placenta  prasvia  in  which 
haemorrhage  has  occurred,  is  due  to  such  haemor- 
rhage and  that  in  those  who  are  born  alive  follow- 
ing severe  maternal  bleeding  their  chances  are  very 
much  reduced  by  it.  He  says,  'This  holds  true  even 
in  patients  who  have  been  subjected  to  Csesarean 
section.  In  twenty-five  cases  of  Caesarean  section 
for  this  condition,  sixteen  children  were  delivered 
alive,  but  seven  of  these  died  before  two  weeks  old 
— giving  a  foetal  and  infantile  mortality  of  sixty- 
four  per  cent." 

It  will  be  seen  then  that  of  these  twenty-five  cases 
of  Caesarean  section  in  nine  was  a  dead  foetus  ob- 
tained, a  circumstance  which  illustrates  failure  of 
the  prime  object  of  the  operation.  It  must  be  re- 
membered in  this  connection  that  only  about  forty 
per  cent,  of  these  patients  go  to  term  and  that  pre- 
maturity would  have  a  very  deleterious  influence  on 
the  infantile  mortality  rate. 

The  only  additional  indication  for  Caesarean  sec- 
tion in  these  cases  lies  in  the  necessity  for  the  con- 
trol of  haemorrhage.  I  can  not  imagine  a  case 
where  thorough  packing  would  not  suffice  unless 
it  should  occur  in  a  woman  in  whom  the  cervix  was 
not  effaced  and  it  was  impossible  to  pack  the  uterus 
up  against  the  presenting  part.  In  such  a  case  the 
infant  will  hardly  be  viable  and  need  have  but  scant 
consideration.  It  certainly  need  not  at  this  earlv 
date  cf)nslitutc  an  indication  for  Caesarean  section, 
and  therefore  this  haemorrhage  may  be  proceeded 
against  on  regulation  lines,  that  is,  the  cervix  quick- 
ly dilated  and  gauze  packed  up  into  the  canal  over 
the  bleeding  area  even  at  the  risk  of  dissecting  loose 
more  of  the  placenta  and  setting  up  premature 
labor. 

In  regard  to  the  fnetal  mortality  in  placenta  pne- 
via  when  delivery  is  accomplished  after  tamponade 


to  control  bleeding,  Hill,  in  the  Journal  of  the  Amer- 
ican Medical  Association,  January  4,  1908,  reports 
eight  cases  in  which  the  patients  were  delivered 
through  the  vagina,  resulting  in  five  living  babies. 
The  gestation  in  all  of  these  patients  was  far  ad- 
vanced, however,  and  in  only  one  was  the  implanta- 
tion central,  and  in  this  one  the  child  lived  only 
three  days. 

The  same  writer  says:  "We  will  find  the  statis- 
tics are  as  good  for  Caesarean  section  in  general  as 
for  placenta  prsevia  treated  by  other  methods.  The 
chances  for  the  mother  being  equal  under  the  two 
methods,  the  one  which  offers  the  best  chance  for 
the  child  must  undoubtedly  appeal  to  us.  The  foetal 
mortality  in  Caesarean  section  in  general  is  less  than 
in  placenta  praevia.  In  those  cases  of  placenta  prae- 
via,  which  we  would  probably  select  for  Caesarean 
section,  viz.,  patients  presenting  long,  rigid  cervices, 
especially  with  complete  placenta  praevia,  the  chance 
for  a  living  child  would  be  extremely  poor  under 
other  methods.  Therefore,  though  the  status  of 
Caesarean  section  for  placenta  praevia  can  hardly  be 
said  to  be  satisfactorily  established,  I  believe  it 
should  be  given  a  trial  in  the  interest  of  the  child." 

Crossen,  in  the  article  before  referred  to,  says : 
"It  is  only  in  those  execeptional  cases  in  which  a 
fairly  certain  diagnosis  of  placenta  praevia  centralis 
can  be  made  in  the  preliminary  examination,  that 
Caesarean  section  is  to  be  taken  into  consideration. 
In  regard  to  the  foetus,  the  chance  of  its  survival  is 
so  small  that  it  should  not  be  given  much  weight 
when  deciding  on  the  method  of  rescuing  the  pa- 
tient from  her  dangerous  situation.  On  account 
of  prematurity  and  debility  the  foetus  dies  in 
nearly  all  cases,  whatever  the  method  of  delivery. 
Under  ordinary  circumstances,  the  delivery  per  viam 
natnralem  is  so  far  superior  to  Caesarean  section 
that  the  latter  is  not  to  be  considered." 

In  the  case  herewith  reported,  it  seems  to  me 
that  the  question  of  treatment  should  have  been  and 
probably  was,  decided  on  the  probability  of  deliv- 
ering a  live  child  by  the  vagina.  The  fact  that  the 
pregnancy  had  gone  to  term  and  that  the  cervix 
was  dilated  would  seem  to  argue  in  favor  of  the  af- 
firmative. The  fact  that  the  patient  was  a  primi- 
para,  however,  with  a  central  implantation  which 
would  demand  version  and  delivery  through  the  pla- 
centa would  seem  to  argue  in  favor  of  the  negative. 
Certain  it  is  no  fault  can  be  found  with  the  result. 

The  indication  offered  in  the  first  case,  namely, 
adhesions  between  uterus  and  abdominal  wall  fol- 
lowing drainage  after  appendicular  inflammation,  is 
an  increasingly  common  one  and  is  not  universally 
accepted,  but  it  seems  to  me  good  surgical  practice 
to  separate  such  adhesions  under  the  eye,  and  once 
the  belly  is  opened  for  that  purpose  it  is  evident  the 
child  nuist  be  delivered,  either  by  incision  through 
the  uterus  or  by  forceps  by  the  vagina  because  one 
could  not  trust  suturing  of  the  abdominal  wall  how- 
ever well  done  to  withstand  the  strain  of  second 
stage  pains.  In  a  multipara  in  whom  no  possible 
obstacle  to  delivery  exists  one  might  apply  the  for- 
ceps while  the  belly  is  open  and  effect  the  delivery 
by  the  vagina,  thus  saving  the  uterine  incision.  In 
a  primipara  the  trauma  would  be  less  by  the  com- 
plete Caesarean  section. 

208' Washington  Building,  West. 


April  3,  1909.] 


RUCKER:  NEURASTHENIA. 


693 


SOME  OBSERVATIONS  OX  THE  NATURE  AND 
TREATMENT  OF  NEURASTHENIA.* 

By  S.  T.  RucKER,  M.  D.», 
Memphis,  Tenn. 

Definition  and  History. — The  word  neurasthenia 

derived  from  two  Greek  words  meaning  nervous 
debihty.  It  is  commonly  called  nervous  exhaustion, 
nervous  prostration,  or  simply  nervousness.  The 
name,  as  commonly  used,  is  too  comprehensive,  and 
admits  of  many  nervous  symptoms  and  phenomena, 
tliat  are  not  readily  understood,  being  classed  as 
neurasthenia.  Neurasthenia  has  been  classified  as 
a  psychosis,  a  neurosis,  and  more  recently  as  a 
psychoneurosis.  I  adhere  to  the  latter  term  as  be- 
ing more  suggestive  of  the  nature  of  the  disease. 
As  an  effort  towards  simplifying  classification,  I 
offer  the  following  definitions  : 

A  psychosis  is  a  functional  disease  of  the  cere- 
brum, an  example  is  mania  and  melancholia.  A 
neurosis  is  a  disease  of  the  nerves  leading  to  or 
from  the  cerebrum,  as  neuritis  and  tabes  dorsalis. 
A  psychoneurosis  is  a  disease  where  the  cerebro- 
spinal and  the  sympathetic  systems  are  involved,  as 
we  have  in  neurasthenia  and  hysteria.  Neuras- 
thenia is  sometimes  referred  to  as  "a  modern  dis- 
ease,'' or  the  '^\merican  disease,"  but  it  has  prob- 
ably existed  throughout  all  time.  Attention  was 
first  directed  to  it  in  1869  by  Dr.  Beard,  of  New 
York,  who  subsequently  published  a  book  entitled 
TJie  Nature  and  Diagnosis  of  Neurasthenia. 

Neurasthenia  is  a  functional  disorder  and  is 
characterized  by  a  neuromuscular  weakness,  with 
mental  instability  and  irritability.  The  thing  itself 
is  a  stern  reality  and  leads  to  untold  misery  for 
the  patient  and  those  associated  with  him.  The 
prevalence  of  neurasthenia  and  neurasthenics 
makes  it  of  immense  importance  to  medical  men. 

Etiology. — The  predisposing  causes  of  neuras- 
thenia are  heredity  or  a  neuropathic  family  history, 
and  the  mental  or  nervous  temperament.  Neuras- 
thenia is  essentially  a  disorder  of  an  active  brain 
and  nerves  of  refined  texture.  Neurasthenics  think 
too  much,  and  their  nerves  are  always  at  high  ten- 
sion. Negroes  and  phlegmatics  are  not  afflicted 
with  neurasthenia  and  the  "happy  go  lucky"  are 
immune.  Women  are  more  predisposed  to  it,  but 
men  are  somewhat  more  affected,  on  account  of 
their  occupations.  It  is  a  disease  of  adult  life, 
seldom  occurring  before  twenty  3-ears  of  age,  or 
after  fifty.  The  extensive  social  intercourse  of  the 
world,  the  increasing  wear  and  tear  of  earning  a 
livelihood,  the  hurry  and  worry  habits  of  business 
and  professional  men,  and  the  so  called  "strenuous 
life"  peculiar  to  Americans,  play  the  most  impor- 
tant role  in  its  aetiology. 

The  young  society  women  in  a  whirl  of  almost 
continuous  excitement  during  the  social  season, 
with  irregular  habits  and  insufficient  rest,  exhaust 
their  nervous  energies  and  often  suft'er  from  at- 
tacks of  neurasthenia.  jNIarital  unhappiness.  sexual 
excesses,  and  coition  with  sexual  disgust  in  the 
woman  are  frequent  offenders.  Other  inciting 
causes  are  worry,  anxiety,  anger,  mental  shock,  and 
overwork.     Any   stimulus   or   excitement  which 

*Read  before  the  second  annual  meeting  of  the  Southern  Medical 
Association,  held  at  Atlanta,  Ga.,  November  lo  to  12,  1908. 


drives  the  blood  too  fast  and  too  long  through  the 
brain  gives  insufficient  time  for  rest  and  repair ; 
thereby  exhausting  its  energy  and  causing  disturb- 
ance 0/  function.  Restrained  desire,  as  from  lack 
of  work,  will  produce  severe  forms  of  neurasthenia. 
For  instance,  the  ambitious  young  professional  man, 
anxious  to  succeed,  finds  patronage  painfully  slow 
in  coming.  He  chafes  and  frets  because  he  be- 
lieves he  is  competent  and  deserves  not  the  pittance 
he  receives. 

Many  cases  of  neurasthenia  occur  in  clever,  emo- 
tional, but  not  whimsical  women,  who  sincerely  long 
for  good  health.  Among  the  diseases  said  to  cause 
neurasthenia  are  influenza,  malaria,  phthisis,  and 
Bright's  disease.  Anremia  and  toxaemia  may  be 
primary  factors  in  causation.  The  first  by  depre- 
ciating the  integrity  of  the  blood,  the  latter  by  act- 
ing as  a  constant  nervous  irritation.  Anaemia  and 
toxaemia  may  also  be  secondary  and  incident  to 
neurasthenia.  It  is  sometimes  difficult  to  determine 
which  is  the  primary  affection.  Trauma,  specially 
when  due  to  accident  and  railway  injuries,  will  bring 
on  aggravated  cases  of  neurasthenia. 

Pathology. — Like  other  functional  diseases  of  the 
nervous  system,  no  pathological  lesion  has  yet  been 
demonstrated  in  neurasthenia.  It  is  known  that  the 
nervous  system  is  in  a  state  of  exhaustion,  the  sup- 
ply of  nerve  force  not  being  equal  to  the  demand. 
There  is  also  marked  instability  of  vascular  tone,  a 
nutritional  defect,  and  a  serious  disturbance  of 
metabolism.  The  nerve  cells  do  not  seem  to  have 
the  power  to  excrete  or  eliminate  its  own  debris. 
Beirnacki  says :  "The  blood  in  neurasthenia  coagu- 
lates slowly,  there  being  a  small  amount  of  fibrin 
present." 

Syniptovis. — The  symptoms  of  neurasthenia  are 
protean ;  so  numerous  and  varied  that  a  typical  case 
is  difficult  to  define.  For  convenience  the  s3'mptoms 
may  be  grouped  as  i,  psychic,  2,  motor,  3,  sensor}'-, 
4,  circulatory,  and  5,  visceral. 

Chief  among  the  psychic  disturbances  are,  an  irri- 
table weakness,  a  lack  of  energy,  a  sense  of  weari- 
ness, which  is  intensified  by  the  least  exertion,  and 
an  inability  to  sustain  continued  effort.  Protracted 
mental  effort  produces  so  much  fatigue  and  discom- 
fort that  it  must  be  discontinued.  The  will  is  en- 
feebled, and  there  is  an  inability  to  concentrate  the 
attention  to  details.  Confidence  and  courage  sub- 
side, and  the  patient  becomes  depressed  and  intro- 
spective. He  is  often  haunted  by  a  nervous  teas- 
ing and  unrest.  There  is  a  feeling  of  pessimism  and 
an  anxious  anticipation  of  some  impending  disaster. 
The  neurasthenia  patient  is  filled  with  doubts,  fears, 
and  morbid  apprehensions.  Not  infrequentlv  the 
borderland  of  insanity  is  approached,  when  there  is 
a  probability  of  its  merging  into  a  psychosis  like 
melancholia.  The  patients  of  these  borderland  cases 
are  extremely  anxious  and  may  live  in  a  dread  of 
becoming  a  victim  to  some  calamity,  as  of  being 
poisoned ;  assassinated ;  or  of  seeing  their  families 
suffer  from  the  pangs  of  poverty.  An  interesting 
symptom  in  many  cases  of  neurasthenia  is  the  im- 
perative idea  (or  concept)  ;  for  instance  the  patient 
sees  a  knife,  which  suggests  the  idea,  "Suppose  I 
was  to  stab  myself  with  this  knife."  He  stands  on 
the  bank  of  a  river,  the  thought  comes,  'T  believe 
I  will  jump  in  and  drown  myself."     When  in  a 


694 


RUCKER:  NEURASTHENIA. 


[New  York 
Medical  Journal. 


crowded  church  or  theatre  he  says  to  himself,  "Sup- 
pose I  was  to  scream  out,  my,  it  would  cause  a  great 
sensation."  The  mother  sees  her  child,  the  idea 
occurs,  "I  believe  I  will  grab  and  choke  it."  ^Then 
she  wonders  why  such  horrible  thoughts  come  to 
her.  While  these  imperative  ideas  may  come  quick 
and  strong,  they  will  almost  as  quickly  become 
ridiculous,  or  the  patient  will  shrink  with  fear  and 
get  away  lest  some  rash  deed  is  committed.  These 
imperative  ideas  are  seldom,  if  ever,  put  into  execu- 
tion. A  distinction  should  be  made  between  these 
imperative  ideas  and  the  imperative  impulses  of 
mania,  melancholia  and  paranoia,  in  that  they  are 
under  control  of  the  patient,  who  will  ridicule  and 
resist  them ;  while  the  imperative  impulse  of  mania 
and  melancholia  is  followed  by  quick  and  forceful 
action.  Insomnia  is  a  constant  and  annoying  symp- 
tom in  neurasthenia.  What  sleep  is  procured  is  not 
refreshing,  and  there  is  a  distressed  wide  awake 
feeling  following  sleep. 

Prominent  among  the  motor  symptoms  are  a  mus- 
cular weakness  and  lassitude,  the  patient  being  easi- 
ly fatigued  by  a  small  amount  of  exercise.  There 
are  also  muscular  tremors,  as  is  shown  by  shaking 
hands  and  trembling  knees. 

Sensory  symptoms  are  marked  in  all  patients ; 
headache  being  the  most  common.  In  some  in- 
stances it  is  slight  and  constant,  again  it  may  be 
what  is  described  as  the  bursting,  splitting  kind. 
Lumbar  pains,  pain  between  the  shoulders  and  down 
the  limbs  are  also  common.  Tender  and  painful 
spots  are  found  over  the  spine,  though  these  sensi- 
tive areas  are  seldom  sharply  defined  and  may  shift 
position,  or  vary  in  intensity.  AnjESthesia  never 
occurs  in  neurasthenia,  while  hyperjesthesia  is  not 
uncommon.  This  latter  condition  was  present  in  a 
woman  patient,  whose  skin  was  so.  sensitive  that  at 
times  she  could  hardly  bear  the  weight  of  her  cloth- 
ing. In  another  patient  there  was  cerebral  hyper- 
aesthesia  amounting  almost  to  explosions.  The  pa- 
tient said  at  times  she  had  the  greatest  desire  to 
scream  and  the  least  sound  was  horrifying.  These 
extreme  conditions  cause  intense  suffering  to  the  pa- 
tient and  they  deserve  our  profound  sympathy. 

There  is  always  more  or  less  disturbance  of  the 
circulation  in  neurasthenia.  The  pulse  rate,  as  a 
rule,  is  increased,  but  feeble.  Generally  the  circula- 
tion is  sluggish  and  deficient,  as  is  shown  by  the 
cold  and  clammy  extremities.  It  is  often  erratic 
and  irregular,  refusing  to  go  where  it  is  most  need- 
ed, and  lingering  where  it  is  not  wanted,  as  cerebral 
anaemia  when  the  patient  would  think  or  study,  and 
cerebral  hypersemia  when  he  wants  to  sleep.  Some- 
times it  gets  panical,  when  a  slight  exertion  or  ex- 
citement will  cause  a  rapid  and  tumultuous  heart 
action,  with  throbbing  arteries  and  precordial  dis- 
tress. Not  infrequently  there  occurs  a  vasomotor 
commotion,  with  hot  flushes  and  vertigo,  or  profuse 
perspiration.  Nervous  indigestion  and  general  atony 
of  the  gastrointestinal  tract  are  common  features  of 
neurasthenia.  This  causes  a  capricious  appetite ; 
the  patient  craving  a  certain  kind  of  food  and  hav- 
ing a  repugnance  for  another  kind. 

Obstinate  constipation  is  the  rule,  though  it  may 
alternate  with  a  mucous  diarrhoea.  Complicating 
this  gastrointestinal  disturbance  is  malassimilation, 
malnutrition,  and  a  loss  of  flesh.    Lessened  sexual 


desire  has  been  a  noticeable  symptom  in  all  cases 
that  I  have  treated.  In  women  the  sexual  desire  is 
absent. 

Diagnosis. — Usually  neurasthenia  is  easily  recog- 
nized. There  are  three  central  symptoms  of  neuras- 
thenia, around  which  all  others  revolve  with  varying 
constancy ;  the  irritable  weakness,  the  tendency  to 
fatigue,  and  an  inability  to  sustain  prolonged  effort. 
There  is  only  one  disorder  that  the  physician  is 
often  called  on  to  distinguish  from  neurasthenia, 
that  is  hysteria  with  neurasthenic  manifestations.  In 
the  hysterical  apepsia  of  young  girls  one  may  sus- 
pect neurasthenia,  but  on  close  examination  the 
hysterical  stigma  is  revealed.  Anaesthesias,  palsies, 
convulsions,  and  coma  vigils  are  ear  marks  of  hys- 
teria and  have  no  place  in  the  symptomatology  of 
neurasthenia.  The  borderland  cases  of  neurasthenia 
may  be  mistaken  for  melancholia,  though  when  the 
line  of  demarkation  is  passed  and  the  patient  is  no 
longer  anxious  or  apprehensive,  but  has  well  marked 
hallucinations,  then  a  psychosis  is  evident.  The 
phobias  of  neurasthenia  are  under  partial  control, 
and  the  patient  will  ridicule  an  imperative  idea  that 
may  pass  through  his  mind,  while  the  melancholia 
patient  is  a  victim  of  his  hallucination. 

Prognosis. — The  prognosis  in  neurasthenia  is  good 
as  regards  life,  and  a  recovery  may  be  expected  in 
the  majority  of  patients,  if  proper  treatment  can  be 
instituted  and  kept  up.  After  forty-five  years  of 
age  the  prognosis  is  less  favorable. 

Treatment. — Experience  has  taught  me  to  regard 
neurasthenia  as  a  serious  malady  and  one  that  is 
difficult  to  treat.  The  mistake  is  sometimes  made  of 
advising  a  patient,  who  is  in  a  state  of  nervous  ex- 
haustion to  travel.-  The  irritating  annoyances  inci- 
dent to  long  journeys  are  well  known  to  those  who 
have  traveled  much.  Many  people  who  enjoy  good 
health  are  fatigued  by  travel ;  the  neurasthenia  pa- 
tient craves  for  complete  rest  and  quiet.  Travel, 
especially  a  sea  voyage,  is  often  beneficial  after  the 
patient  is  convalescent.  An  occasional  tour  of  sight 
seeing  is  also  advisable  to  the  neurasthenic  business 
and  professional  man,  but  it  is  before  a  nervous 
breakdown  occurs. 

The  key  note  to  the  treatment  of  neurasthenia  is 
rest  in  bed,  augmented  by  diet,  hygiene,  medicines, 
and  suggestion.  In  this  way  the  expenditure  of 
energy  is  reduced  to  a  minimum,  lost  strength  is 
regained,  and  impaired  function  is  corrected.  Wo- 
men respond  more  favorably  to  the  complete  rest 
cure  than  men.  Separation  from  the  environments 
of  home  and  strictly  excluding  the  injurious  influ- 
ences of  relatives  and  friends,  are  large  factors  in 
treatment.  A  brief  of  my  plan  of  treatment  is  as 
follows : 

I  first  try  to  gain  the  confidence  of  the  patient, 
explain  the  causes  of  his  suffering  and  talk  encour- 
agingly over  the  outlook  for  his  recovery.  .\  tact- 
ful nurse  is  assigned  him,  and  complete  rest  in  bed 
is  enjoined.  I  select  a  diet  largely  of  milk.  eggs, 
and  fruits,  and  give  liberal  draughts  of  pure  water. 
Early  in  treatment  an  e.xtra  glass  of  milk  (prefer- 
ably buttermilk)  is  given  between  meals  and  at 
8 130  p.  m. 

Baths  are  extremely  valuable  when  properlv 
given.  A  prolonged  warm  bath  at  night,  followed 
by  a  glass  of  hot  milk  will  encourage  sleep.    .\  cold 


April  3,  1909.] 


GREEXE:  DIAGNOSIS  OF  KIDXEY  DISEASES. 


695 


shower  or  sponge  bath,  followed  by  light  brisk  mas- 
sage in  the  forenoon  will  stimulate  the  circulation 
and  increase  nervous  tone.  No  hot  bath  is  given 
during  the  day,  unless  followed  by  a  cold  douche. 
Frequent  lavage  of  the  colon  with  cool  water  is  ben- 
eficial. In  many  cases  the  electric  light  bath  given 
two  to  four  times  a  week  acts  favorably ;  it  equalizes 
the  circulation  and  stimulates  excretion  through  the 
skin  and  kidneys.  The  faradic  current  seems  to 
have  a  salutary  effect  and  impresses  the  patient  sug- 
gestively. Constipation  is  overcome  by  the  usual 
procedures.  In  some  cases  digestive  agents  must 
be  given  freely  to  relieve  dyspepsia,  and  as  the  pa- 
tient improves  the  gastrointestinal  atony  will  grad- 
ually disappear.  For  insomnia,  chloral,  trional  and 
hyoscine  may  be  given  until  normal  sleep  is  re- 
stored. Strychnine  is  highly  commended,  but  I 
never  prescribe  it  in  neurasthenia,  except  in  com- 
bination with  iron  and  quinine,  as  a  tonic.  Strych- 
nine to  exhausted  nerves  is  like  a  whip  to  the  al- 
ready jaded  energies.  I  find  codeine  phosphate  a 
superior  remedy  to  strychnine.  It  has  a  soothing 
and  tonic  eft'ect,  and  in  some  cases  acts  like  a  spe- 
cific. It  should  be  remembered,  however,  that  co- 
deine belongs  to  the  opium  family,  and  should  be 
given  guardedly  and  without  the  knowledge  of  the 
patient.    Alcohol  and  morphine  must  not  be  given. 

Psychotherapeutics  should  not  be  ignored  in 
treating  neurasthenia.  The  patient  is  depressed, 
discouraged,  and  filled  with  morbid  fears.  If  the 
physician  is  self  reliant,  sanguine,  and  cheerful,  he 
can  readily  arouse  a  like  condition  in  his  patient.  In 
fact  the  patient  will  soon  learn  to  look  forward  to 
the  doctor's  daily  visit  for  confirmation  of  the  hope 
that  his  condition  is  satisfactory.  Efforts  should  be 
made  to  convey  to  the  patient  a  rational  understand- 
ing of  his  condition,  and  that  he  is  gradually  re- 
sponding to  the  means  being  used  to  restore  his 
health.  He  must  be  taught  that  anger,  anxiety,  and 
fear  are  abnormal  psychic  states,  which  depress  and 
exhaust  vitality :  while  a  cheerful,  confident,  and 
optimistic  mental  attitude  increases  nervous  strength 
and  promotes  peace  of  mind. 


OBSERVATIONS  ON   DIAGNOSIS  OF  DISEASES 
OF  THE  KIDNEY.* 

By  Robert  Holmes  Greexe,  A.  M.,  'M.  D., 
New  York, 

Professor  of  Genitourinary  Surgery.  Medical  Department,  Fordham 
University;  Attending  Genitourinary  Surgeon,  City 
and  French  Hospitals. 

As  the  title  indicates  this  article  relates  to  observa- 
tion rather  than  theory.  If  any  apologies  are  need- 
ed for  writing  on  such  a  trite,  old  subject  as  any- 
thing concerning  the  diseases  of  the  kidney,  it  may 
be  excused  for  two  reasons :  One  is,  that  while  sta- 
tistics tend  to  show  the  death  rate  is  diminishing  in 
this  country  in  totality,  the  deaths  from  diseases  of 
the  kidney  are  increasing.  The  other  is,  that,  in  my 
opinion,  there  is  more  suffering  caused  to  individu- 
als from  mistaken  diagnosis  as  to  kidney  disease 
than  from  mistakes  in  the  diagnosis  of  the  diseases  of 
any  other  organ.  Thanks  to  the  work  of  such  men 
as  Dr.  Richard  Cabot,  of  Boston  (Clinical  Exam- 
ination of  Urine — A  Clinical   Study  of  Common 

*Read  before  the  Celtic  Medical  Society,  January  28,  1909. 


[Methods,  Richard  C.  Cabot,  Boston,  1908,  Journal 
of  the  America)i  Medical  Association  ) .  which  article 
will  be  referred  to  later,  it  has  been  demonstrated 
that  the  diagnosis  of  conditions  such  as  Bright's  dis- 
ease from  urinary  analysis,  as  has  been  taught  to 
such  a  great  extent  in  the  past  and  is  even  now  be- 
ing taught  to  a  considerable  degree,  is  almost  use- 
less. As  is  well  known  to  many  of  you  Dr.  Cabot 
carried  on  a  series  of  observations  of  histories  ex- 
tending over  many  years  (1893  to  1905)  in  the 
Massachusetts  General  Hospital,  Boston.  He  com- 
pared the  histories  of  the  cases  in  which  the  diag- 
nosis of  Bright's  disease  was  made  by  the  old 
routine  methods  of  urinary  examination,  with  the 
histories  of  the  autopsies  on  the  same  subject,  and 
he  found  great  disagreements  to  exist.  The  tone 
of  the  paper  read  by  him  at  the  Academy  of  Medi- 
cine in  this  city  recently,  which  doubtless  many  of 
you  listened  to,  was  decidedly  pessimistic  as  to  our 
ability  from  ordinary  urinary  examinations  to  diag- 
nosticate the  condition  of  the  kidney. 

Considering  our  subject  more  directly  let  us  re- 
view the  means  at  our  command  that  will  aid  us  in 
making  a  diagnosis  of  sick  kidneys.  Let  us  at  the 
outset  try  to  throw  away  any  old  ideas  of  the  kid- 
neys as  being  organs  of.  mystery,  and  try  to  look  at 
them  as  we  would  at  other  organs  of  the  body,  such 
as  the  ovaries  in  women,  the  spleen,  the  liver,  or  the 
prostate  in  men,  for  I  believe  that  too  much  stress  in 
the  past  on  the  usefulness  of  urinary  examination, 
has  tended  to  lead  us  away  from  giving  the  proper 
attention  to  the  study  of  individual  characteristics, 
and  to  careful  physical  examination  of  the  region 
of  the  kidney. 

As  regards  this  physical  examination  of  the  kid- 
ney, let  us  first  take  up  examinations  of  the  kid- 
ney by  means  of  the  x  ray.  If  x  ray  examinations 
are  carried  on  by  an  individual  well  versed  in  such 
work,  stone  if  of  a  sufficient  degree  of  hardness  can 
be  demonstrated  quite  accurately  to  be  present. 
This,  of  course,  is  known  to  you  all.  In  certain  very 
rare  cases  a  fairly  accurate  diagnosis  of  abscess  of 
the  kidney  can  be  made,  if  the  pus  is  impissated,  a 
clear  picture  is  presented. 

There  have  been  some  recent  advances  made  by 
x  ray  specialists  by  which  material  aid  is  furnished 
in  the  diagnosis  of  diseases  of  the  kidney.  Through 
shortening  the  exposure  and  other  refinements  of 
technique,  as  has  been  shown  by  Dr.  E.  W.  Cald- 
well, of  this  city,  it  is  now  possible  to  show  the  out- 
lines of  the  kidneys  on  the  plate,  and  any  consid- 
erable enlargement  can  be  made  out  thus,  such  as 
pyelonephritis.  This  ability  to  demonstrate  the  out- 
lines of  the  kidney  is  necessarily  of  aid  in  making 
a  diagnosis  in  misplaced  kidney,  although  the  posi- 
tion of  the  kidney  when  the  exposure  is  being  made 
is  generally  such  that  a  misplaced  kidney  is  liable 
to  return  to  a  normal  position.  A  stereoscope  has 
been  devised  by  Dr.  Caldwell  which  aids  materially 
in  showing  the  relationship  of  the  parts  when  a 
stone  is  discovered.  The  use  of  the  x  ray  combined 
with  the  metal  ureter  catheter,  while  not  such  a  re- 
cent discovery,  seems  to  be  coming  into  somewhat 
more  common  use. 

Concerning  the  direct  physical  examination  of  the 
kidney  through  percussion,  palpation,  and  balotte- 
ment,  palpation  is  the  only  method  from  which  the 


696 


GREENE:  DIAGNOSIS  OF  KIDNEY  DISEASES. 


[New  York 
Medical  Journal. 


writer  has  ever  derived  much  information.  As  re- 
gards the  position  of  the  patient,  the  simple  method 
of  the  patient  being-  allowed  to  recline  on  his  back 
with  the  thighs  flexed  and  shoulders  slightly  ele- 
vated, the  examination  being  made  with  one  hand 
on  the  abdomen  and  the  other  hand  pressing  be- 
tween the  crest  of  the  ilium  and  the  last  rib,  has 
been  found  to  be  the  most  useful  one.  Occasion- 
ally the  physical  examination  is  made  with  the  pa- 
tient bent  over  a  chair,  or  the  patient  lying  on  the 
side. 

There  are  two  things  I  may  specify  concerning 
the  physical  examination  that  I  wish  particularly  to 
call  attention  to:  One  is  that  the  physical  examina- 
tion should  be  made  in  the  manner  which  the  indi- 
vidual practitioner  finds  from  his  own  experience 
to  be  the  most  useful  for  him,  and  the  other  is  that 
in  cases  which  are  at  all  doubtful  the  examina- 
tions should  be  made  repeatedly.  In  one  doubt- 
ful case  the  writer  found  he  was  able  to  make  out 
an  enlargement  of  the  kidney  only  after  repeated 
physical  examinations,  and  on  operating  found  a 
very  large  pus  kidney  to  be  present.  In  another 
case  in  the  City  Hospital,  transferred  for  opera- 
tion, in  which  an  apparent  marked  enlargement  of 
the  kidney  existed  on  the  right  side,  and  which  was 
easily  made  out  by  the  observer  and  the  members  of 
the  house  staft',  on  later  examination,  this  could  not 
be  located,  nor  on  many  subsequent  examinations. 
The  result  was  that  the  proposed  operation  was 
postponed,  and  the  condition  of  the  patient,  a  wo- 
man, markedly  improved,  and  so  far  as  the  ob- 
server knows  no  subsequent  operation  was  ever  per- 
formed upon  her. 

Concerning  the  much  discussed  and  difficult  con- 
dition known  as  floating  kidney,  the  methods  of  di- 
agnosis already  mentioned,  physical  examination,  in- 
cluding the  X  ray,  and  the  use  of  the  ureter  metal 
catheter  combined  with  the  x  ray  are  the  best 
methods  to  be  employed.  Just  a  word  concerning 
these  floating  kidneys,  although  it  may  be  for- 
eign to  the  subject.  It  should  always  be  remem- 
bered when  in  making  a  diagnosis  of  floating  kid- 
ney we  are  not  necessarily  making  a  diagnosis  of 
any  disease,  for  the  kidney  may  not  be  in  the  ordi- 
nary position  and  still  the  individual  be  healthful, 
as  the  kidney  may  have  congenitally  a  longer  pedicle 
than  usual,  or  it  may  have  been  originally  displaced 
through  some  injury,  but  be  functionating  perfect- 
ly, although  situated  in  an  uncommon  position.  The 
displaceincnt  may  also  be  caused  by  the  absorption 
of  the  perirenal  fat. 

As  regards  tumors  of  the  kidney  physical  exam- 
ination is  necessarily  the  one  to  be  relied  upon.  As 
far  as  the  observation  of  the  writer  goes  ordinarily 
kidney  tumors  appear  to  be  higher,  as  would  natur- 
ally be  supposed,  than  tumors  of  the  uterus  and 
ovaries,  with  which  they  are  most  liable  to  be  con- 
founded. On  the  left  side  it  is  sometimes  extremely 
difficult  to  determine  whether  a  given  tumor  is  in 
the  kidney  or  in  the  spleen.  The  writer  had  one 
such  case  under  his  observation  at  the  City  Hos- 
pital, which  was  observed  at  one  time  and  another 
by  visiting  physicians,  both  medical  and  surgical, 
and  their  various  house  staflFs.  Opinions  were  about 
equally  divided  as  to  what  organ  was  affected.  To 
the  observer  it  seemed  as  if  it  was  kidney;  most  of 


the  medical  men  thought  it  was  spleen,  the  patient 
becoming  emaciated,  and  apparently  operation  was 
imperative.  Having  discovered  a  history  ot  syphi- 
lis before  operating,  and  from  former  experience 
with  syphilitic  kidneys,  the  observer  prescribed  a 
course  of  antisyphilitic  treatment  with  the  result 
that  in  a  short  time  the  tumor  entirely  disappeared, 
and  the  patient  regained  his  old  time  vigor  and  left 
the  hospital.  It  should  always  be  remembered  that 
gumma  of  the  kidney,  although  rare,  occasionally 
occurs,  and  may,  as  in  the  case  reported  by  the 
writer  several  years  ago,  give  rise  to  haemorrhage 
from  the  kidney.  Therefore,  unless  counter  indi- 
cations exist  before  operating  for  tumor  of  the  kid- 
ney, or  for  haemorrhage  of  the  kidney,  it  is  well  to 
previously  observe  the  effects  of  antisyphilitic  treat- 
ment. 

Cystic  tumors  of  the  kidney  the  writer  believes, 
judging  from  his  own  experience,  and  the  result  of 
autopsies  made  by  his  friend.  Dr.  Harlow  Brooks,- 
are  much  more  numerous  than  has  been  ordinarily 
supposed  to  be  the  case.  They  are  supposed  to  be 
somewhat  more  elastic  to  the  feel  than  other  forms 
of  tumor  of  the  kidney,  but  a  multilocular  cyst  to 
the  writer  on  palpation  exactly  resembles  a  nodu- 
lar malignant  growth.  Of  course,  in  very  doubtful 
cases  aspiration  may  be  performed,  and  if  the  fluid 
removed  is  found  to  contain  urea,  the  diagnosis  is 
positive. 

A  few  years  ago  at  the  City  Hospital  I  was  in- 
formed by  my  house  surgeon  that  a  certain  patient 
had  an  abscess  in  the  kidney.  I  inquired  as  to.  how 
they  had  come  to  that  conclusion.  I  was  told  that 
they  had  massaged  the  patient  along  the  course  of 
the  ureter  and  one  kidney ;  that  there  was  always 
some  pus  in  the  urine,  and  that  when  they  per- 
formed this  massage  on  the  left  side,  the  amount  of 
pus  was  increased,  whereas  if  they  performed  the 
massage  on  the  right  side  no  increase  in  the  pus  in 
the  urine  passed  could  be  noticed.  Finding  this  ob- 
servation to  be  correct,  I  operated  and  found  a  large 
abscess  in  the  back  of  the  kidney  diagnosticated  by 
them  as  the  diseased  one.  Very  recently  I  had  a 
case  of  cystitis  in  which  I  was  very  much  in  doubi: 
as  to  whether  a  pus  kidney  was  present  or  not.  1 
was  not  able  for  certain  reasons  to  satisfactorily 
catheterize  the  ureters.  I  had  massage  practised 
along  the  course  of  the  ureter  on  each  side  three 
different  times.  Twice  there  was  no  change  in  the 
amount  of  pus  noticed  in  the  urine ;  once  from  the 
right  side  there  seemed  to  be  a  considerable  in- 
crease, r  operated  on  that  side  and  found  a  kidney 
with  multiple  abscesses  to  be  present.  Therefore, 
from  these  two  cases  I  regard  the  squeezing  or 
massaging  of  the  kidney  region  starting  in  the  back 
and  coming  forward  and  running  down  the  course 
of  the  ureter,  and  observing  the  condition  of  the 
urine  following  such  massage,  as  an  extremely  prac- 
tical and  valuable  aid  in  making  diagnosis  where  it 
is  suspected  that  a  pus  kidney  exists.  But  just  as 
in  making  a  physical  examination  of  the  kidney  by 
palpation,  it  may  be  necessary  to  practise  this  pro- 
cedure not  once  but  on  several  diflferent  occasions, 
as  illustrated  in  the  history  of  the  last  case  de- 
scribed. 

There  is  no  assertion  made  for  originality  in  pre- 
senting this  simple  method  of  making  a  diagnosis  of 


April  3,  1909.] 


GREEXE:  DIACXOSIS  OF  KIDXEV  DISEASES. 


697 


pus  in  the  kidney.  The  only  hterature  on  the  subject 
obtainable  at  the  time  of  the  first  operation  was  per- 
formed by  me,  though  a  diagnosis  had  been  made  by 
this  method,  were  some  articles  by  Italian  surgeons. 
Recently  attention  has  been  called  to  this  procedure 
at  one  of  the  surgical  congresses  in  France,  and  un- 
doubtedly many  surgeons  are  familiar  with  the 
process. 

Space  will  not  permit  me  to  go  into  an  ex- 
haustive consideration  of  the  value  of  ureter  cathe- 
terization in  making  diagnosis  of  diseases  of  the 
kidney.  Unfortunately  not  infrequently  in  the  case 
where  we  are  most  anxious  to  catheterize  the  ureter 
we  may  be  unable  to  do  so  on  account  of  hcemor- 
rhage  or  contracted  bladder.  Concerning  the  vari- 
ous tests  for  demonstrating  the  permeability  of  the 
kidney  through  the  aid  of  methylene  blue  or  phlori- 
zin associated  with  ureter  catheterization,  the  ob- 
server's experience  is  such  as  to  convince  him  of 
their  usefulness  in  certain  cases.  From  personal 
observation  I  can  furnish  little  evidence  of  the  value 
of  the  indigocarmin  or  experimental  polyurea  test, 
but  would  refer  any  one  interested  in  a  description 
of  these  to  the  appropriate  article  in  the  book  pub- 
lished by  Dr.  Harlow  Brooks  and  myself  (Gc)iito- 
itriiiary  Diseases  and  Diseases  of  the  Kidney,  Phila- 
delphia. 1908,  second  edition). 

Concerning  the  value  of  urinary  examinations  as 
indicative  of  the  condition  of  the  kidney,  and  al- 
though such  examinations  are  able  to  tell  of  the 
presence  or  absence  of  Bright's  disease,  using  the 
term  in  a  general  way.  let  us  again  consider  the 
paper  of  Dr.  Richard  Cabot  previously  referred  to. 
with  whose  views  the  experience  of  the  writer  lead 
him  to  coincide.  Briefly  it  may  be  stated  that  hya- 
line casts  are  of  no  diagnostic  value,  and  that  gran- 
ular casts  mean  but  little  more.  Dr.  Cabot  quotes 
F.  C.  Shattuck  as  finding  in  two  thirds  of  health- 
ful patients  examined  who  were  over  fifty  years  of 
age,  albumin,  hyaline,  and  granular  casts.  In  only 
one  third  of  the  cases  shown  by  autopsy  to  be 
chronic  interstitial  nephritis  was  the  diagnosis  made 
before  death.  He  considers  the  increase  in  the 
relative  amount  of  nigth  urine,  in  his  experi- 
ence, one  of  the  most  reliable  manifestations  of  a 
chronic  nephritis,  especially  in  its  earlier  and  middle 
stages. 

Let  us  now  consider  the  information  to  be  de- 
rived from  the  presence  of  albumin.  My  friend  Dr. 
T.  Hastings  has  devoted  great  attention  to  the 
subject,  and  insists  strongly  that  distinction  should 
be  made  between  serum  albumin  and  nucleoalbu- 
min.  He  considers  the  neucleoalbumin  to  be  of  no 
pathological  interest.  Our  ordinary  tests  wnll  show 
either  form  of  albumin.  Whenever  there  is  a  large 
amount  of  albumin  present,  serum  albumin  is  sure 
to  be  found,  but  when  there  is  just  a  trace  it  may  be 
neucleoalbumin.  If  one  fifth  of  the  amount  in  vol- 
ume of  a  saturated  salt  solution,  thirty  grains  to  the 
ounce,  is  added  to  some  urine  in  a  test  tube,  the 
contents  of  the  tubes  acidified  with  two  or  three 
drops  of  diluted  acetic  acid,  any  albumin  found  to 
be  present  by  boiling  the  upper  portion  of  the  tube 
can  be  considered  serum  albumin.  ^^''hile  serum 
albumin  in  the  urine  does  not  necessarily  signify  anv 
disease  of  the  kidney,  it  does  signify  that  something 
abnormal  is  occurring  in  the  individual ;  maybe 
some  disease  of  the  heart  or  some  inflammatorv  con- 


dition existing  in  the  urinary  tract  lower  dowii  than 
the  kidney.  As  is  well  know-n  pus  will  give  rise  to 
albumin,  but  the  amount  of  albumin  is  not  neces- 
sarily a  measure  of  the  amount  of  pus. 

It  is  the  writer's  belief  concerning  the  examina- 
tion of  urine  in  chronic  kidney  disease  that  more 
value  is  furnished  by  the  observation  of  the  twenty- 
four  hour  urine  and  its  specific  gravity,  and  through 
that  estimating  the  amount  of  solids  present,  than 
by  any  other  measure.  If  the  urinary  solids  o?  an 
ordinary  healthy  individual  on  a  diet  which  is  not 
very  much  restricted  fall  continuously  below  seventy 
grammes  a  day,  it  is  an  indication  that  if  disease  of 
the  kidney  is  not  present  that  at  least  proper  metab- 
olism is  not  effected  and  that  disease  of  some  char- 
acter exists. 

Does  chfonic  Bright's  disease  affect  one  kidney 
more  than  the  other  or,  in  certain  cases,  confine  it- 
self to  one?  A  correct  answer  to  this  is  found  as 
the  result  of  post  mortem  examinations  although 
some  aid  may  be  furnished  through  the  results  ob- 
served from  ureter  catheterization.  It  can  be  stated 
that  generally  in  chronic  nephritis  both  kidneys  are* 
aflFected,  although  such  is  not  always  the  case,  and 
not  infrequently  one  kidney  is  affected  more  than 
the  other.  In  young  or  middle  aged  individuals 
with  chronic  Bright's  disease  where  one  kidney  is 
diseased  more  than  the  other,  the  more  healthful  one 
will  be  found  enlarged  throusrh  an  apparent  com- 
pensatory hypertrophy.  In  old  age  this  compensa- 
tory hypertrophy  will  not  take  place.  I  am  indebted 
to  my  colleague,  Dr.  Harlow  Brooks,  for  this  ob- 
servation which  I  consider  an  interesting  and  val- 
uable one,  as  well  as  for  some  other  suggestions  in 
this  paper. 

While  much  cannot  be  told  about  the  kidney  nec- 
essarily from  urinary  analysis,  we  should  not  after 
all  be  too  pessimistic  about  our  ability  to  diagnosti- 
cate diseases  of  the  kidney.     The  various  growths 
and  conditions  of  suppurative  inflammation  have  al- 
ready been  covered.     At  the  City  Hospital,  where 
opportunity  is  afforded  to  observe  the  post  mortem 
findings  in  case  of  death,  in  the  experience  of  the 
observer  almo.st  never  is  disease  of  the  kidnev  di- 
agnosticated during  life  that  it  is  not  demonstrated 
to  be  present  at  the  autopsy  table.    The  converse  of 
this  is  not  equally  true.    Occasionally  cases  of  dis- 
ease of  the  kidney  are  observed  on  autopsy  which 
we  were  not  able  to  diagnosticate.    Such  cases  are 
generally  found  to  be  complicated  with  other  patho- 
logical conditions.     Most  observers  at  the  present 
time,  when  making  a  diagnosis  in  such  conditions 
as  that  of  chronic  Bright's  disease,  are  coming  to 
put  more  and  more  stress  on  the  clinical  aspect  of 
the  patient,  and  consider  such  symptoms  as  dysp- 
noea, hazy  memory,  headache,  nausea,  and  the  verv 
valuable  aid  furnished  by  the  blood  pressure  ap- 
paratus, particularly  if  the   pressure  is  constantly 
above  200,  as  making  up  a  clinical  picture  indica- 
tive of  kidney  disease.    The  aids  furnished  by  such 
a  clinical  picture,  together  with  the  information  to 
be  obtained  by  the  physical  examination,  on  the 
value  of  which   I  have  endeavored   to  lay  much 
stress,  should   enable  us  in  the  vast  majority  of 
cases  to  make  an  accurate  diagnosis  of  diseases  of 
the  kidney — acute,  chronic,  suppurative,  or  of  tumor 
formation. 
78  East  Fifty-sixth  Street. 


WHITE:  UNUSUAL  CASES  OF  TYPHOID  FEVER.—OUR  READERS'  DISCUSSIONS.      [New  York 

Medical  Journal. 


TWO  UNUSUAL  CASES  OF  TYPHOID  FEVER. 

Parotid  Bubo  and   Other  Complications ;  Fatal  Hemor- 
rhagic Form. 
By  Fr.\ncis  W.  White,  M.  D., 
Philadelphia, 

Demonstrator  of  Clinical  Medicine,  Jefferson  Medical  College. 

That  parotiditis  developing-  during  the  course  of 
typhoid  fever  is  a  rare  and  dangerous  condition  may 
be  seen  from  the  following : 

Osier  in  829  cases  of  enteric  fever  reports  twelve 
cases  of  parotid  involvement  with  four  deaths,  and 
in  Liebermeister's  account  of  autopsy  findings,  in 
210  cases  of  typhoid  fever,  six  of  parotitis  are  men- 
tioned. Keen  reviewing  the  literature  upon  the  sub- 
ject noted  twenty-eight  cases  of  parotiditis,  with  a 
mortality  of  eight,  and  Hoffman  enuMierates  six- 
teen cases,  of  which  nine  were  fatal. 

C.\SE  1. — The  parotiditis  in  the  following  case  of  moder- 
ately severe  typhoid  fever  in  a  child  of  eleven  years,  de- 
veloped about  the  tenth  day.  The  gland  upon  the  right  side 
was  affected.  The  swelling  gradually  increased,  becoming 
hard  and  having  a  peculiar  brawny  feeling.  Four  days  after 
*  its  onset  the  patient  suddenly  became  worse,  and  within 
forty-eight  hours  there  was  a  marked  consolidation  at  the 
base  of  the  left  lung  posteriorly.  Pneumococci  were  pres- 
ent in  the  sputum  and  there  was  a  moderate  leucocytosis, 
which  lasted  until  convalescence  appeared.  The  pneumonic 
condition  ran  its  course  without  special  event.  During  this 
time  the  parotid  gland  remained  practically  the  same,  but 
about  the  tenth  day  of  its  enlargement,  softening  at  the 
centre  was  noted,  and  at  the  same  time  furuncles  made  their 
appearance  upon  the  chest  and  abdomen. 

Upon  routine  examination  of  the  heart  a  soft  systolic 
murmur  in  the  mitral  area  was  heard  which  lasted  about 
forty-eight  hours,  disappeared,  and  did  not  return.  A  puru- 
lent discharge  from'  the  right  ear  occurred  and  persisted 
for  two  days.  The  now  fluctuating  parotid  was  incised  and 
much  pus  allowed  to  escape.  Specimens  were  exam- 
ined microscopically,  also  cultures  made  upon  blood  agar 
and  ordinary  media.  Neither  tubercle  bacilli  nor  typhoid 
bacilli  were  found,  the  condition  being  a  staphylococcic  in- 
fection.-— Janowski  states  that  in  one  case  of  parotid  bubo 
a  pure  culture  of  typhoid  bacillus  was  obtained,  while  in  a 
number  of  cases  pyogenic  organisms  and  typhoid  bacilli 
were  found  by  Anton  and  Fiitterer, — With  relief  of  tension 
the  lower  jaw  could  be  more  freely  moved,  and  within 
twenty-four  hours  a  fairly  well  formed  cast  of  the  tongue 
was  expectorated,  leaving  a  dull  red,  beefy,  tender  mucous 
membrane  exposed.  At  the  height  of  the  parotid  condition 
llie  gland  of  the  opposite  side  became  painful  but  did  not 
enlarge.  The  case  went  on  to  complete  recovery,  the  in- 
cision healed  kindly,  and  no  salivary  fistula  occurred;  the 
corresponding  side  of  face  e\-en  after  six  or  eight  m'onths 
appearing  quite  normal,  both  upon  inspection  and  palpation. 
Xeither  localized  sweating  in  parotid  region  nor  palsy  of 
that  side  of  the  face  have  occurred. 

Virchow  contended  that  parotid  bubo  was  caused 
by  extension  through  Stenson's  duct  of  infectious 
processes  from  the  mouth.  That  this  is  so  can 
easily  be  imagined,  especially  when  typhoid  bacilli, 
cither  alone  or  in  association  with  other  organisms, 
as  has  been  demonstrated,  are  present.  It  is  also  a 
well  known  fact  that  the  parotids  are  more  often 
directly  af¥ected  by  the  typhoid  toxines  than  are 
any  other  organs,  thus  making  them  less  resistant  to 
any  form  of  bacterial  invasion.  For  this  reason  it 
is  also  very  plausible  that  the  gland  may  also  be 
involved  directly  from  the  blood  as  parotid  bubo 
has  been  associated  with  septichsemia.  In  the  above 
described  case  it  would  seem  that  both  avenues 
were  of  equally  easy  access,  there  being  areas  of 
suppuration,  furuncles,  and  a  purulent  otitis  media, 
and  in  the  moutli  a  local  condition,  a  gloss'tis,  all 
f)f  which  came  on  after  the  pneumonic  condition. 
Under  these  varied  circumstances  it  would  bi-  quite 


impossible  to  decide  definitely  the  route  of  infec- 
tion. 

The  important  data  of  the  second  case  are  as  fol- 
lows : 

Case  II. — The  patient,  a  female,  nineteen  years  of  age, 
had  been  in  this  country  but  three  months,  having  come 
directly  to  this  city  from  Ireland.  She  had  always  been 
delicate  and  shown  a  tendency  to  epistaxis  but  exhibited  no 
other  disposition  to  bleed  spontaneously.  Menstrual  func- 
tions started  when  she  was  fourteen  years  old  and  were 
painless  and  regular.  Her  temperament  was  of  the  highly 
nervous  type,  but  at  times  she  suffered  from  attacks  of 
melancholia.  These  periods  of  depression  started  about 
three  years  ago,  after  having  learned  that  she  was  born 
about  a  year  and  a  half  prior  to  the  marriage  of  her  pa- 
rents.    It  v^zs  on  this  account  that  she  left  home. 

About  the  end  of  the  second  week  of  a  mild  attack  of 
enteric  fever  there  suddenly  occurred  an  active  haemorrhage 
from'  the  nose,  which  ceased  after  ordinary  therapeutic 
measures  had  been  used.  A  few  hours  later,  however,  the 
condition  reappeared  but  responded  to  treatment  as  applied 
the  first  time.  Twelve  hours  later  a  discharge  from  the 
\  agina  similar  to  a  menstrual  flow  was  reported  and  con- 
tinued for  about  twenty-four  hours.  Shortly  after  its  ap- 
pearance there  was  bleeding  from  the  nose  again,  slight  in 
amount  and  ceasing  spontaneously.  This  was  followed  in 
a  few  hours  by  a  very  severe  hemorrhage  from  the  nose 
which  did  not  respond  to  measures  at  hand,  but  increased 
rather  than  diminished.  At  this  juncture  Dr.  J.  Leslie 
Davis  was  asked  to  treat  the  condition.  Local  applications, 
foiling,  packing  of  the  nostrils  was  resorted  to  but  even 
this  procedure  did  not  completely  control  the  now  serious 
hpemorrhage. 

The  patient  began  to  show  signs  and  symptoms  due  to 
the  loss  of  blood,  all  of  which  increased  alarmingly  after 
the  passage  of  a  large  quantity  of  bright  red  blood  from  the 
bowel.  Vomiting  of  blood  now  came  on,  although  at  least 
some  of  it,  had  been  swallowed.  All  methods  to  combat 
the  effects  of  the  haemorrhages  were  used  faithfully  but 
these  simply  put  off  for  a  few  hours  the  fatal  termination. 

There  were  no  hjemorrhagic  manifestations  in  the  skin ; 
bleeding  from  the  gums  did  not  occur,  nor  was  hematuria 
present.    Autopsy  was  not  performed. 

2025  Chestnut  Street. 

 «>  ■ 


A  SERIES  OF  PRIZE  ESSAYS. 

Question.':  for  discussion  in  this  departmcnl  are  nnnounee-l  at 
frequent  intervals.  So  far  as  they  haze  been  decided  ut^on,  the 
further  questions  are  as  follows: 

LXXXIV . — How  do  you  use  alcohol  therapeutically?  (.Closed 
March  1$,  iQog.) 

LXXXV. — .Apart  from  an  operation .  how  do  yott  treat  disease  of 
the  vermiform  appendix?  (Anszvers  due  not  later  than  April  ij. 
lOOQ.) 

LXXXyi. — Hoiv  do  you  make  an  early  diagnosis  of  pulmonary 
tuberculous  disease.     i.4us~cfers  due  not  later  than  .May  /5,  igog.) 

Whoever  answers  one  of  these  questions  in  the  manner  most  sat- 
isfactory to  the  editor  and  his  advisers  will  receive  a  prise  of 
No  importance  whatever  will  be  attached  to  literary  style,  but  the 
award  will  be  based  solely  on  the  zalue  of  the  substance  of  the 
answer.  It  is  requested  (.but  not  required)  that  the  answers  be 
short;  if  practicable  no  one  nnsrt'-'r  to  contain  more  than  sir  hun- 
dred words. 

.411  persons  will  be  ent'itlcd  to  compete  for  the  prise,  Zihether 
subscribers  or  not.  This  price  will  not  be  awa^-dcd  to  any  one  per- 
.fOH  more  than  once  within  one  year.  Every  answer  must  be  ac- 
companied by  the  writer's  full  name  and  address,  both  of  which 
we  must  he  at  liberty  to  publish.  All  papers  contributed  become  the 
property  of  the  Journ.m..    Our  RE.\nERs  are  asked  to  suggest  topics 

rOR  DISCUSSION. 

The  prise  of  $35  for  the  best  essay  submitted  in  answer  to  ques- 
tion LXXXIII  has  been  awarded  to  Dr.  Adrian  A.  Landry,  of 
Plaquemine,  La.,  whose  article  appeared  on  page  64-^. 

PRIZE  QUESTION  LXXXIII. 
THE  TREATMENT  OF  ACUTE  DYSENTERY. 

(Continued  from  f^as^e  646.) 

Dr.  St.  J.  B.  Graham,  of  FJIijay,  Georgia,  remarks: 
In  the  present  light  of  knowledge  at  least  two 
forms  of  acute  dysentery  are  to  be  distinguished 
and  discussed  under  this  heading,  the  liacillary  and 


April  3.  1909.  J 


OUR  READERS'  DISCUSSIONS. 


699 


the  amoebic.  The  presumption  is  fast  gaining 
ground  and  becoming  a  scientific  fact  that  wherever 
found,  in  what  clime  or  country,  bacillary  dysen- 
ter}-,  whether  endemic,  epidemic,  or  sporadic  is  due 
to  the  bacilUis  of  Shiga  (Japan),  Flexner  and 
Strong  (  PhilHpines),  Kruse  (Germany),  and  other 
competent  observers  in  South  Africa,  the  United 
States,  and  South  /America.  These  cases  differ  only 
on  account  of  the  potent  toxicity  of  the  schizomycete. 
their  weakened  virulence,  or  to  the  partial  immuni- 
ty or  vital  resistance  of  the  individual  it  gains  en- 
trance to.  A  protozoan  (animal)  parasite,  the  Amoeba 
ilxseiitcricc.  produces  and  reproduces  tropical  dysen- 
tery under  similar  conditions,  and  differs  from  the 
Ama'ba  coli.  which  does  not  produce  experimental 
dysentery.  This  digression  from  the  strict  essence 
of  the  subject  may  be  pardonable  and  is  made  to 
emphasize  the  value  and  important  bearing  it  has 
especially  on  preventive  treatment. 

Treatment  may  be  conveniently  divided  into  pro- 
phylactic, dietetic,  and  therapeutic.  The  patient's 
education,  mental  and  physical  condition,  and  en- 
vironment both  as  to  locality  and  habits  of  life,  are 
to  be  taken  into  consideration.  We  not  only  have  to 
treat  acute  dvsentery  but  an  individual  who  has  it. 
Methods  for  preventing  the  further  spread  of  the 
disease  should  be  promptly  inaugurated.  All  sus- 
picious sources  of  water  and  milk  supply  must  be 
strictly  looked  into  and  rigidly  handled.  All  scien- 
tific methods  known  to  be  of  value  should  be  used 
to  prevent  contamination,  drainage,  or  sewerage  of 
<iejecta,  wash  water,  or  anything  else  from  a  patient 
or  the  nurse  or  attendants  into  a  fresh  water  supply, 
more  particularly  should  this  be  in  the  vicinity  of 
surface  wells  or  springs.  If  suspicious  water  must 
be  used  it  should  be  boiled,  cooled  in  sterile  con- 
tainers, and  shaken  to  aerate  for  use.  Dipterous  in- 
sects, such  as  flies,  gnats.  &c.,  should  be  excluded 
by  screens  on  doors  and  windows.  As  far  as  safety 
<lemands  the  patient  should  be  in  a  sense  isolated. 
Hospital  treatment  where  it  can  be  had  is  prefer- 
able to  home  treatment.  Where  babies  or  young 
•children  are  the  patients  they  should  be  kept  from 
soiling  the  floors  with  dejecta,  and  their  diapers  dis- 
infected and  boiled.  Dejecta  should  be  treated  by  a 
potent  disinfectant  and  so  disposed  or  buried. 
Bedding  and  such  clothing  as  are  used  by  the  patient 
should  be  boiled.  Visiting  the  sick  should  be  dis- 
•couraged.  and  all  persons  handling  the  patient's 
clothing  or  bedding  should  be  instructed  regarding 
scrupulous  cleanliness  and  thorough  disinfection  of 
their  hands.  The  patient  should  be  confined  to  bed 
in  a  sunny  and  well  ventilated  room  with  an  average 
temperature  of  65°  or  70°  F.  in  winter  and  not  al- 
lowed to  get  up,  but  made  to  use  a  bed  pan.  The 
physician  should  examine  the  stools  as  often  as  he 
thinks  necessary. 

Diet. — Predigested  fluids  are  best  at  first.  Milk 
Avith  lime  water  or  Mchy  or  boiled  milk.  The  writer 
has  found  milk  oxygenated  by  pressure  of  oxygen 
gas  of  value.  Pressed  meat  juice,  whey,  egg  al- 
Ijiimen,  or  whole  raw  egg  beaten  with  a  little  milk 
and  sherry  wine  and  sprinkled  with  nutmeg.  Raw 
■scraped  beef  many  patients  do  well  on.  Buttermilk 
is  often  well  borne  and  distinctly  of  value  especially 
where  sweet  milk  is  not  well  digested,  as  is  too  often 
the  case.    Bouillon,  chicken  broth,  stewed  from  the 


whole  cleaned  chicken  bones  and  all  mashed  up. 
Light  soups,  arrowroot  milk,  corn  meal  gruel,  bar- 
ley water,  the  German  Schleim  soups  containing  gel- 
atinous materials,  gelatin,  ice  cream  if  pure  and  if 
it  does  not  bring  on  tormina  or  tenesmus.  Zwie- 
back, toasted  bread  or  milk  toast  may  be  given  as 
strength  improves.  Patients  in  the  early  stages 
should  be  fed  often  and  in  small  quantities.  Iced 
champagne  and  burned  brandy  are  the  best  stimu- 
lants.   The  diet  should  be  very  carefully  increased. 

As  convalescence  becomes  established  the  patient 
should  be  still  confined  to  foods  most  easily  digested 
and  leaving  but  little  waste  material.  Animal  foods 
are  thus  indicated,  rice  water  and  rice,  in. fluid  form, 
blancmange,  junket,  wine  jelly,  custard,  egg  nog. 
gradually  increasing  to  soft  boiled  eggs,  well  cooked 
rice,  roast  beef,  broiled  chicken,  toast,  and  milk 
toast.  All  fruits  and  vegetables  must  be  denied  till 
the  patient's  strength,  appetite  and  convalescence 
are  restored. 

In  infancy  breast  milk  alone  .should  be  given  even 
though  a  wet  nurse  should  have  to  be  resorted  to. 
fresh  goat's  milk  only  is  second  best.  Boiled,  cooled 
water  should  be  given  at  frequent  intervals.  In  older 
children,  beef  tea,  chicken  broth,  mutton  broth, 
pressed  beef  juice,  predigested.  Pasteurized  milk, 
buttermilk,  and  whey  are  indicated. 

Therapy. — External :  r)il  of  turpentine  stupes, 
hot  cloths,  cataplasms  soaked  in  brandy,  and  mus- 
tard poultices  to  the  abdomen  are  useful  and  grate- 
ful. Blisters  even  may  be  indicated  over  the  stom- 
ach. When  persistent  nausea  is  present  these  hot 
or  cold  applications  may  be  made  to  the  neck. 

Internal  medication  consists  of  the  proper  use  of 
saline  cathartics  such  as  magnesium  sulphate  or 
sodium  sulphate,  with  or  without  aromatic  sulphuric 
acid.  Pallor  and  weakness  contraindicates  salines. 
One  drachm  to  one  half  ounce  of  a  saturated  solu- 
tion of  Epsom  salts  with  ten  minims  of  aromatic 
sulphuric  acid,  in  water,  every  hour  till  the  char- 
acter of  stools  changes  or  other  benefits  are  shown. 
This  should  occur  in  twenty-four  hours.  Calomel  is 
of  great  value  in  small  doses  frequently  repeated  or 
occasionally  is  best  given  in  one  large  dose  of  from 
five  to  ten  grains  or  more  combined  with  powdered 
ginger  root  and  well  triturated  with  white  sugar, 
five  grains  each,  and  repeated  if  necessary.  The 
mouth  should  be  frequently  cleansed  with  dilute 
potassium  chlorate  or  a  potassium  permanganate 
solution.  [Morphine  and  atropine  hypodermically  are 
almost  indispensable.  Fluid  extract  of  ipecac,  three 
to  sixty  minim  doses  combined  with  paregoric  in  ten 
minim  to  one  drachm  doses  or  laudanum  five  to 
twenty  minims.  With  this  treatment  little  fluids 
should  be  allowed  and  mustard  plasters  applied  to 
neck  and  epigastrium.  Should  vomiting  occur  with- 
out too  much  prostration  the  dose  should  be  re- 
peated. The  dose  should  be  given  every  three 
or  four  hours,  unless  it  cannot  be  borne.  Five 
to  fifteen  grain  doses  of  Dover's  powder  combined 
with  bismuth  subnitrate.  ten  grains  to  thirtv  or  more 
grains,  is  efficacious.  ^  Bismuth  trinitrate  may  be 
used  instead  of  the  sub'nitrate ;  this  to  be  given  everv 
three  or  four  hours  as  indicated.  In  children  and 
infants  mercury  with  chalk  is  valuable. 

No  intestinal  antiseptic  the  writer  has  used  has 
any  advantages  over  calomel.    Cooked  starch  water 


JOO 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


enemata  in  small  quantities  with  laudanum  act  ad- 
mirably in  rectal  straining  and  irritation.  Supposi- 
tories of  opium,  belladonna,  and  camphor  are  valu- 
able also.  High  rectal  enemata  of  decinormal 
saline  solutions,  hot,  containing  also  one  half 
drachm  of  tannin  to  the  quart,  silver  nitrate,  five 
to  ten  grains  to  the  quart,  one  to  one  and  one  half 
quarts  may  be  used.  My  own  results  with  high 
rectal  enemata  have  not  proved  flattering,  and  for 
drugs  I  rely  on  salines,  ipecac,  opium  or  morphine, 
atropine,  mercury,  calomel. 

Examinations  of  the  blood  if  malarial  complica- 
tion is  suspected  should  not  be  forgotten,  then 
quinine  is  indicated. 

In  amnebic  dysentery  good  results  follow  the  use 
of  one  half  to  one  drachm  (to  the  quart  of  saline 
solution)  of  quinine  hydrochloride  by  high  enema. 
In  amoebic  dysentery  all  endeavors  should  be  made 
to  prevent  its  chronicity  and  consequent  complica- 
tion of  abscess  of  the  liver. 

Complications  are  to  be  treated  as  indicated  and 
as  they  arise.  The  patient's  strength  should  be  con- 
served, and  the  malady  cured  if  possible. 

In  bacillary  dysentery  the  writer  has  longed  for 
the  rational  serum  antitoxine  treatment,  which  will 
no  doubt  soon  be  obtainable  from  all  reports  of 
Shiga. 

In  late  convalescence  the  patient  should  be  sent 
to  milk  mountain  regions  or  to  a  balmy,  high,  j^ure 
atmosphere. 

Dr.  H.  L.  Baptist,  of  Ivy  Depot,  Va.,  states: 

The  treatment  described  below  is  intended  to  ap- 
ply chiefly  to  acute  catarrhal  dysentery  and  not  to 
tropical  or  bacillar-y  dysentery,  a  disease  rarely 
originating  in  this  latitude ;  although  it  may  be  emi- 
nently applicable  to  certain  types  of  this  form. 

When  called  to  a  case  of  dysentery  in  the  early 
stages,  I  usually  order  a  full  dose  of  Epsom  or  Ro- 
chelle  salts.  This  sweeps  out  the  intestinal  tube, 
cleansing  it  of  all  fermenting  and  irritating  mate- 
rial, and  at  the  same  time  depletes  the  intestinal  mu- 
cosa and  portal  circulation  with  a  minimum  of  irri- 
tation. After  the  full  effect  of  the  saline  has  sub- 
sided, the  use  of  aromatic  sulphuric  acid  is  begun  in 
fifteen  to  thirty  drop  doses  every  four  hours  well  di- 
luted. This  exercises  its  well  known  astringent  ef- 
fect on  the  mucous  membrane,  at  the  same  time  fur- 
nishing an  acid  medicine,  which  is  inimical  to  the 
growth  of  bacteria. 

For  it!;  sedative  and  mildly  antiseptic  action  bis- 
muth is  often  given  in  fifll  doses  every  three  or  four 
hours.  To  do  good  it  must  be  given  in  large  doses, 
from  thirty  to  sixty  grains  at  each  dose,  and  it  is 
more  applicable  to  the  latter  stages  of  the  disease, 
especially  if  it  shows  any  tendency  to  chronicity. 

For  the  pain  and  tenesmus,  nothing  can  take  the 
place  of  opium.  This  I  usually  give  in  the  form  of 
the  deodorized  tincture  in  fifteen  or  twenty  drop 
doses,  or  better  still  morphine  hypodermicall) .  Be- 
sides relieving  the  pain  it  helps  to  diminish  the  fre- 
quency of  the  discharges,  thereby  reducing  the  drain 
on  the  system  and  giving  the  patient  much  needed 
rest.  Hot  stupes  or  light  poultices  to  the  abdomen 
often  add  much  to  the  patient's  comfort  and  may  be 
used  as  the  occasion  requires.  As  a  valuable  supple- 
ment to  the  treatment,  I   usually  employ  copious 


clysters  of  normal  salt  solution  given  slowlv  from 
a  fountain  syringe  as  warm  as  can  be  comfortably 
borne  once  or  twice  daily.  This  I  consider  of  the 
uttermost  importance,  and  should  be  rigidlv  en- 
forced unless  the  bowel  proves  utterly  intolerant. 
Some  one  of  the  various  antiseptic  astringents  such 
as  zinc  phenolsulphonate  or  silver  nitrate  maybe  used 
instead  of  the  saline  solution.  .  Of  all,  silver  is  per- 
haps the  best,  but  is  more  beneficial  as  the  disease  is 
declining.  In  the  early  stage  the  bowel  is  usually 
too  irritable  to  bear  it  in  strength  sufficient  to  be  of 
much  benefit,  and  the  strong  solutions,  fifteen  grains 
to  the  pint,  are  always  very  painful.  In  general  I 
have  found  the  salt  solution  eflFective  and  it  is.  I 
think,  more  suitable  when  the  symptoms  are  acute. 
The  irrigation  may  be  preceded  by  an  injection  of  a 
four  per  cent,  solution  of  cocaine  or  a  ten  grain 
iodoform  suppositorv  where  the  rectum  is  verv  irri- 
table. 

The  patient  should  in  all  cases  be  confined  strictly 
to  bed,  and  his  diet  should  consist  of  the  simplest  and 
most  nourishing  liquids.  In  many  cases  milk  will  be 
found  to  do  harm  and  if  given  at  all,  should  be  used 
cautiously  and  well  diluted  with  some  effervescent 
alkaline  water.  Albumen  is  perhaps  one  of  the  best 
forms  of  nourishment  we  can  employ.  Fresh  but- 
termilk is  likewise  good,  as  well  as  barley  water, 
and  the  animal  broths  well  strained.  In  the  selec- 
tion of  any  food,  the  first  desideratum  is  that  it  shall 
be  nourishing  and  at  the  same  time  leave  little 
residue  to  irritate  the  inflamed  bowel.  Where  nau- 
sea and  vomiting  are  prominent  and  persistent  symp- 
toms, we  may  have  to  withhold  all  food  for  twenty- 
four  or  forty-eight  hours,  during  which  time  the  pa- 
tient may  be  allowed  small  quantities  of  iced  cham- 
pagne. 

In  many  instances  dysentery  seems  to  run  a  defi- 
nite course,  terminating  spontaneously  in  from  eight 
to  ten  days  in  mild  cases,  and  about  a  month  in  se- 
vere ones,  apparently  uninfluenced  by  treatment. 
Convalescence  should  be  carefully  guarded  by  a 
gradual  return  to  soft  and  semisolid  foods.  Re- 
lapses are  common  and  are  often  due  to  indiscretions 
in  diet. 

Dr.  Robert  E.  Ledhctter,  of  Norfolk,  Virginia,  ob- 
serves: 

For  treatment,  I  divide  acute  dysentery  into  two 
classes,  viz.,  amoebic  and  nonamoebic,  using  the  mi- 
croscope as  an  aid  to  diagnosis.  I  use  two  methods 
in  the  treatment  of  amoebic  dysentery.  The  ipecac 
method  and  the  injection  of  quinine  into  the  large 
bowel,  the  quinine  being  in  solution.  In  this  coun- 
try the  quinine  method  is  the  best,  while  in  the  trop- 
ics, the  ipecac  method  is  the  only  one  to  use.  In  the 
first  place,  in  all  cases  of  acute  dysentery,  irrespec- 
tive of  the  cause,  I  begin  by  giving  a  purge  of  castor 
oil,  one  ounce  with  fifteen  drops  of  laudanum,  which 
will  abort  the  condition  in  a  few  cases.  If  this  fails 
I  proceed  as  follows,  beginning  first  with  the  treat- 
ment of  amoebic  dysentery. 

Ipecac  method :  The  patient's  stomach  being 
empty,  I  first  give  him  thirty  drops  of  laudanum, 
wait  half  an  hour,  and  give  him  forty  grains  of  ipe- 
cac in  capsules  or  solution.  He  is  kept  as  quiet  as 
possible  for  five  or  six  hours,  moving  the  body  as 
little  as  possible,  and  ordered  to  fight  as  hard  as  he 


April  3,  1909.J  THERAPEUTICAL  XOTES. 


can  against  all  inclination  to  vomit.  If  the  drug 
cannot  be  retained  in  such  a  large  dose,  I  wait  for 
an  hour  after  vomiting  has  ceased  and  give  him 
thirty  grains,  which  will  usualK*  be  retained.  The 
drug  is  given  twice  a  day  for  a  week,  decreasing  the 
dose  four  or  five  grains  each  time  it  is  given.  Im- 
provement will  in  most  cases  be  noted  in  from  thirty- 
six  to  forty-eight  hours.  The  stools  will  become 
yellow  and  more  feculent  and  a  rapid  recovery  is 
the  rule. 

Quinine  method :  I  begin  with  a  solution  of  i  in 
10,000,  and  after  carefully  inserting  a  rectal  tube 
into  the  large  bowel,  the  hips  of  the  patient  being 
elevated,  I  allow  about  a  quart  of  the  solution  to  run 
gently  into  the  bowel.  The  tube  is  withdrawn,  and 
the  patient  is  requested  to  hold  the  solution  in  the 
bowel  as  long  as  possible,  which  w-ill  usually  be  from 
ten  to  thirt}^  minutes.  Two  injections  daily  are 
given,  increasing  the  strength  of  the  solution  at  each 
seance  until  it  is  of  the  strength  of  i  in  1,000.  The 
injections  are  kept  up  for  about  ten  days  and  in 
most  cases  do  great  good. 

Xonamoebic  dysentery :  This  is  best  treated  by 
giving  drachm  doses  of  sodium  sulphate  every  twen- 
ty minutes,  until  five  doses  have  been  taken,  waiting 
one  hour  and  giving  five  more  doses.  This  will  al- 
ways produce  free  purging  and  is  as  a  rule  followed 
by  rapid  convalescence.  Otherwise  repeat  the  treat- 
ment once  or  twice  more. 

In  all  cases  of  acute  dysentery  absolute  rest  in 
bed  must  be  insisted  upon  and  as  for  food  the  less 
given  the  better.  I  never  use  milk  until  conva- 
lescence is  well  established ;  it  does  not  give  good 
restilts.  I  prefer  egg  albumen,  beef  juiee,  and 
bouillon.  For  the  griping  and  tenesmus  I  apply  tur- 
pentine stupes  to  the  abdomen,  and,  if  severe,  I  con- 
trol it  with  minute  doses  of  morphine,  given  at  fre- 
quent intervals. 

{To  be  concluded.) 

 <^  


CberajJtutical  gotw. 


Tonic  Ferruginous  Pills  for  Asthenic  Gout. — 

Hiichard  (Journal  de  mcdecine  de  Paris)  pre- 
scribes the  follow'ing  pills,  two  of  which  are  directed 
to  be  taken  twice  daily  before  breakfast  and  dinner : 

B     Extract  of  cinchona,   \ 

Extract  of  gentian   f    aa  o"r  Ixxv  • 

Extract  of  rhubarb,    |         ^  "   '  ' 

Potassium  and  iron  tartrate,   ; 

Pulverized  nux  vomica,   gr.  viiss. 

;M.  ft.  pil.  No.  100. 

Pharmacomania. — Two  cases  of  pharmacoma- 
nia  are  reported  in  the  Gaczetta  de,£;li  ospcdali  e  delle 
clniichc.  and  noted  in  The  Prescriber  for  February. 
1909.  The  first  case  was  that  of  a  journalist,  fifty- 
six  years  of  age,  w^ho  at  the  age  of  forty  had  suf- 
fered from  severe  gastroenteritis  for  which  he  had 
begun  to  take  magnesium  sulphate  in  teaspoonful 
doses  every  other  day.  This  was  gradually  in- 
creased until  the  daily  dose  reached  50  grammes 
(about  2  ounces)  at  which  it  remained  for  five 
years;  later  it  was  increased  to  70,  90,  and  130 
grammes  daily.  It  was  theii  combined  with  mag- 
nesium carbonate  and  sodium  bicarbonate.  The 
patient  showed  no  sign  of  alkaline  cachexia ;  he  w^as 
capable  of  considerable  work,  had  a  good  appetite 


and  no  diarrhoea,  and  the  urine  was  normal  and 
strongly  acid.  The  second  case  was  that  of  a  wo- 
man of  sixty  years,  who  had  sixteen  years  previous- 
ly commenced  to  take  castor  oil  for  constipation. 
The  dose  was  gradually  increased  in  amount  and 
frequency  until  latterly  it  was  found  necessary  as  a 
tonic  and  digestive ;  the  system  having  become 
habituated  to  the  purgative  action  of  the  oil,  no  in- 
testinal irritation  was  observable,  and  tlie  patient 
enjoyed  good  health.  The  amount  of  oil  absorbed 
amounted  to  76  grammes  (about  2^  ounces)  daily. 

The  Treatment  of  Diphtheritic  Angina. — In  a 

note  in  the  Journal  de  mcdecine  de  Paris,  for  Feb- 
ruary 6,  1909,  Reymond  is  cited  as  favoring  the 
application  to  the  tonsils  of  a  tampon  of  cotton 
saturated  with  an  eighty  per  cent,  solution  of 
chromic  acid ;  he  sometimes  uses  a  small  crystal  of 
the  pure  acid,  applying  it  direct.  The  patient 
should  be  instructed  not  to  swallow  the  saliva  im- 
mediately after  the  application,  and  the  mouth 
should  be  washed  out  with  a  little  warm  water. 
The  author  says  he  has  seen  cases  of  diphtheria  in 
\vhich  the  progress  of  the  disease  was  arrested  by 
this  treatment.  He  fJrescribes  the  following  gargle 
for  hourly  use  following  the  application  of  the  acid : 
R     Sodium  salicylate  3iv  ; 

Sodium  bicarbonate  3iii ; 

Oil  of  peppermint,   gtt.  v ; 

Tincture  of  rhatanj-,   ttt  xlv  ; 

Tincture  of  guaiacum,   TTLxlv; 

Water,   ^vii. 

M.  et.  Sig.  One  tablespoonful  to  be  used  with  a  glass  of 
warm  water. 

Each  time  the  patient  is  visited  the  motith  should 
be  cleansed  by  the  application  of  the  following 
liquid  contained  in  a  syringe  having  a  long  cannula  : 

B     Ichthyol  gr.  Ixxv  ; 

Glycerin  51 ; 

Alcohol,   ^1 ; 

Water,   ; 

Tincture  of  iodine,  ni  xxx  ; 

Oil  of  peppermint,   gtt.  vi. 

A  teaspoonful  of  this  solution  is  added  to  a  glass- 
ful of  warm  water,  and  this  is  driven  from  the 
syringe  with  some  degree  of  force  against  the 
mucous  patches  and  false  membrane.  Before  the 
appHcation  of  the  chromic  acid  the  tonsils  should 
be  wiped  dry  with  a  tampon  of  absorbent  cotton. 

The  applications  of  chromic  acid  and  of  iodine 
should  not  be  repeated  every  day,  as  too  much  in- 
flammation would  thereby  be  set  up  in  the  throat- 
It  is  best  to  make  only  a  third  or  fourth  application 
on  the  fifth  or  seventh  day.  If  the  false  membrane 
persists  the  tonsils  and  mouth  should  be  cleansed 
daily  by  the  washes  and  gargles  prescribed  above. 
After  about  six  days  of  this  treatment  the  false 
membrane  usually  disappears. 

Toothache  Pellets. — In  a  recent  number  of 
Les  Xouveau.v  reinedes  the  following  formula  is 
given  for  a  pill  designed  for  introduction  into  a 
carious  cavity  for  the  relief  of  toothache : 

Menthol,   3ss ; 

Pellitorj-  root,   3ss  ; 

Guaiacum  resin,   3ss  ; 

Yellow  wax,   5i ; 

Eugenol,   gtt.  x  ; 

Extract  of  coffee,   gtt.  x. 

Mix  and  divide  into  pills  weighing  one  half  grain  each. 
Coat  with  pulverized  cloves. 


702 


EDITORIAL.  ARTICLES. 


[New  York 
Medical  Journal. 


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THE  SYMPATHETIC  NERVOUS  SYSTEM 
IN  PATHOLOGY. 

It  is  not  many  years  since  Professor  Osier,  in  a 
well  remembered  discussion  held  before  the  Ameri- 
can Netirological  Association  on  this  subject,  re- 
marked concerning  a  paper  which  had  been  read,  in 
which  the  author  referred  almost  all  the  unknown 
diseases  of  the  body  to  the  sympathetic,  that  he  was 
reminded  of  the  ancient  figure  of  the  snake  which 
held  its  tail  in  its  mouth.  Since  then  the  work  on 
the  sympathetic  has  been  very  actively  progressing 
and  before  a  recent  meeting  of  the  Verein  fiir  innere 
INIedizin.  in  Berlin,  Professor  Ziehen  gave  an  inter- 
esting and  suggestive  resume  of  our  present  knowl- 
edge of  the  subject. 

Not  only  was  the  general  subject  a  difficult  one, 
he  said,  but  by  reason  of  its  very  complexit}^  it  re- 
quired such  an  exhaustive  examination  that  few  stu- 
dents had  the  means,  the  patience,  or  the  facilities 
to  conquer  it.  The  practical  advances  that  had  been 
made  during  the  past  ten  years  were  largely  anat- 
omical ;  the  study  of  the  physiological  functions  had 
yielded  less,  while  from  the  pathological  side  still 
less  had  come  forth.  One  of  the  most  important 
anatomicophysiological  generalizations  that  had  been 
achieved  was  that  the  sympathetic  was  largely  a 
motor  apparatus,  which  fact  stood  in  direct  oppo- 
sition to  that  which  had  been  so  generally  held,  that 
its  functions  were  largely  sensory.  The  cervical 
sympathetic  contains  practically  no  sensory  fibres. 


while  only  ten  per  cent,  of  the  splanchnic  fibres  can 
be  held  to  have  sensory  functions. 

Ziehen  maintained  that  the  cells  of  origin  of  the 
sympathetic  apparatus  were  probably  situated  in  the 
mesial  horns  of  the  spinal  cord,  and  that  it  was  high- 
ly probable  that  sympathetic  ganglionic  centres  ex- 
isted in  the  thalamus  and  also  in  the  cortex.  Up  to 
the  present  time,  the  mapping  out  of  these  centres 
in  the  cord  has  not  been  completed,  but  it  seems  cer- 
tain that,  so  far  as  the  vasomotor  control  of  the 
arm  is  concerned,  the  sympathetic  is  in  close  rela- 
tions to  the  ulnar  centres  and  that  its  spinal  local- 
ization corresponds  with  that  of  the  ulnar  distribu- 
tion. 

Physiologically,  we  are  accustomed  to  ascribe 
vasodilatation,  vasoconstriction,  secretory  functions, 
pupillary  widening,  and  intestinal  movements  to  the 
action  of  the  sympathetic  system,  but  it  is  not  yet 
certain  just  how  far  such  opinions  are  correct.  The 
researches  with  nicotine  seem  to  indicate  that  an 
analysis  of  individual  neurone  action  is  feasible. 
True  sympathetic  tonus  and  sympathetic  reflexes, 
Ziehen  holds,  are  still  unproved.  Coordination  of 
clinical  symptoms  and  pathological  findings  leaves 
mtich  to  be  developed.  Apart  from  pupillary 
changes,  clinical  records  are  practically  silent  con- 
cerning the  sympathetic  symptoms.  It  is  desirable  to 
record  more  closely  the  symptoms  heretofore  care- 
lessly grouped  under  the  general  head  of  dermog- 
raphy,  and  the  speaker  suggested  that,  if  more  at- 
tention were  paid  to  local  skin  areas,  clues  to  sym- 
pathetic localization  might  be  obtained.  Further 
observations  of  the  secretion  of  the  sweat  glands, 
the  tear  secretions,  the  sebaceous  secretions,  and  the 
general  measurement  of  the  circulation  by  the 
jjlethysmograph,  as  had  been  done  by  Curschmann 
for  the  angioneuroscs,  were  desirable. 

From  the  anatomical  viewpoint  of  the  sympathetic 
as  a  marginal  system  in  the  mesial  horns  it  is  quite 
readily  understood  why  in  organic  disease  of  the 
spinal  cord  .symptoms  referable  to  the  sympathetic 
are  so  frequent.  These  consist  of  irritative  as  well 
as  paralytic  symptoms,  and  are  not  uncommon,  as 
is  fairly  well  known,  in  tabes,  in  cerebrospinal  syphi- 
lis, in  meningomyelitis,  in  syringomyelia,  in  tumor 
of  the  spinal  cord,  etc.  Further,  certain  structural 
anomalies  are  known  that  involve  the  sympathetic 
cells  of  the  cord,  and  familiar  types  of  sympathetic 
disease  have  been  recorded  by  Michel  and  others. 
Ziehen  is  of  the  opinion  that  migraine  is  a  specific 
sympathetic  afl'ection  accompanied  by  changes  in 
the  temperature  of  the  skin,  by  pupillary  phenom- 
ena, and  by  sensory  phenomena  largely  limited  to 
the  vasa  vasorum  and  vasa  nervorum.  Erythromel- 
algia  is  also  held  by  Ziehen  to  be  a  sympathetic  af- 
fection, limiting  the  disease  to  its  essential  rather 


April  3,  1909.] 


EDITORIAL  ARTICLES. 


70.5 


than  to  its  S3mptomatic  occurrence.  AcroparjES- 
thesia,  Raynaud's  disease,  and  probably  scleroder- 
mia  are  to  be  grouped  as  sympathetic  diseases. 
Tachycardia  is  apparently  a  pure  sympathetic  symp- 
tom, while  exophthalmic  goitre  as  well  as  idiopathic 
epilepsy  is  excluded  from  the  group. 


BEE  STIXGS  IX  THERAPEUTICS. 

There  have  of  late  been  several  indications  of  a 
disposition  on  the  part  of  some  physicians  to  look 
upon  the  sting  of  the  bee  as  affording  notable  alle- 
viation of  certain  painful  affections,  such  as  various 
forms  of  rheumatism  and  neuralgia.  Insects  now 
figure  so  largely  in  our  conceptions  of  the  spread  of 
serious  infective  diseases  that  perhaps  it  would  be 
nothing  more  than  poetic  justice  if  some  of  them 
were  to  furnish  us  with  efficient  therapeutic  re- 
sources. The  Spanish  fly  has,  to  be  sure,  long  been 
reckoned  as  of  importance  in  our  materia  medica, 
and  formic  acid,  which  occurs  naturally  in  the  venom 
of  ants,  has  been  thought  to  be  of  service  in  medi- 
cine. The  cockroach  also  has  been  used  as  a  rem- 
edy. However,  the  insect  world  still  seems  to  owe 
us  something,  and  perhaps  the  honey  bee  is  destined 
to  perform  a  part  in  the  wav  of  squaring  the  ac- 
count. 

We  do  not  know  who  it  was  that  was  first  moved 
to  resort  to  the  sting  of  the  bee  as  a  therapeutic 
measure,  but  Mr.  E.  T.  Burton,  of  Birmingham, 
England,  seems  to  have  made  rather  extensive  use 
of  it.  In  the  British  Medical  Journal  for  March 
20th  he  gives  notes  of  the  subsequent  progress  of 
four  patients  whose  cases  he  had  reported  in  the 
same  journal  for  December  5th  and  adds  brief  ac- 
counts of  four  more  cases.  In  addition,  ]Mr.  Burton 
reports  upon  his  own  case,  he  being  at  times  a  suf- 
ferer from  rheumatism.  Up  to  Januar)'^  22d,  he  had 
suffered  himself  to  be  stung  by  bees  271  times,  and 
since  that  date  he  has  applied  the  bees  to  himself 
freely  on  several  occasions  with  satisfactory  results. 

Mn  Burton  looks  upon  the  venom  of  the  bee  as 
"not  only  antitoxic,  but  also  counterirritant."  We 
can  well  imagine  its  acting  as  a  counterirritant,  but 
we  must  confess  that  we  are  somewhat  skeptical  as 
to  its  having  any  pronounced  antitoxic  effect,  and 
antitoxic  is  a  term  of  rather  wide  applicability.  He 
tells  us  that  the  pain  resulting  from  a  sting  grows 
less  in  duration  as  one  continues  to  subject  himself 
to  it,  at  last  enduring  no  longer  than  half  an  hour  at 
the  most,  though  the  sting  of  some  bees  seems  to 
cause  more  pain  than  that  of  others.  Sciatica  is  one 
of  the  painful  affections  in  which  he  has  found  the 
sting  of  the  bee  to  be  of  service,  but  he  hints  that  in 
cases  of  long  standing  the  treatment  has  to  be  some- 
what protracted. 


But  there  is  no  rose  without  its  thorn.  Several 
physicians  have  informed  Mr.  Burton  that  the  bee 
keepers  of  England  and  Scotland  refuse  to  take  bees 
from  their  hives  during  the  period  of  hibernation, 
so  that  the  bee  market  may  be  "cornered"  in  winter. 
However,  he  has  ascertained  that  if  the  bees  are  put 
into  a  properly  ventilated  box,  covered  with  cotton 
wool,  and  inclosed  in  a  second  box,  also  ventilated, 
they  will  stand  a  long  journey  by  post.  Then  they 
must  be  kept  warm  and  supplied  with  candy,  on 
which  a  few  drops  of  water  should  be  sprinkled 
every  day.  His  bees,  he  says,  are  quite  lively  at  the 
end  of  four  days.  ]\Ir.  Burton  hopes  that  before 
long  there  will  be  published  the  observations  of  an- 
other Birmingham  practitioner  who  tells  him  that  he 
has  found  great  relief  from  sciatica  of  long  standing 
under  the  bee  sting  treatment. 


ATHLETICS  AXD  ^lEXTALITY. 

There  appears  to  be  little  doubt  that  athletic  train- 
ing, when  pushed  beyond  certain  limits,  develops  the 
purely  physical  body  at  the  expense  of  the  mind. 
We  have  seen  a  '"strong  man"  kicking  his  hundred 
pound  dumbbells  about  the  floor  in  an  ecstasy  of  pro- 
fane rage  because  they  had  not  been  constructed 
strictly  according  to  specifications.  Childish  weep- 
ing by  a  loser  at  the  close  of  a  race  is  by  no  means 
an  uncommon  spectacle.  The  gossip  privately  re- 
tailed by  professional  athletes  concerning  one  an- 
other surpasses  that  of  a  small  country  village,  par- 
ticularly in  the  villainous  nature  of  its  accusations ; 
which  is  evidence  of  lack  of  mental  development. 
The  vanity  of  the  Paladins  is  common  to  all  who  are 
constantly  in  the  "spot  light."  It  might  be  just  as 
well  if  our  college  men  and  others  gave  a  little  more 
attention  to  mental  exercise ;  other  benefits  apart,  a 
well  stored  mind  is  a  treasure  for  old  age.  and  the 
elderly  scholar  is  more  interesting  to  himself  and  his 
friends  than  the  passe  gladiator  lumbering  about 
with  an  hypertrophied  heart  and  dubious  kidneys, 
bitter  alike  at  his  contemporaries  and  his  successors. 


ACTUAL  COMMAXD  FOR  MEDICAL 
OFFICERS. 

The  vexed  question  of  responsibility  for  sanitary 
conditions  was  settled  admirably  is  so  far  as  his  own 
command  was  concerned  in  an  order  issued  by  Lieu- 
tenant Colonel  Walter  L.  Finley,  of  the  Thirteenth 
United  States  Cavalry,  at  Fort  Sheridan,  Illinois,  in 
the  following  words :  "The  surgeon  is  chief  sanitary 
officer  of  the  post  and  reservation  ;  all  orders  given 
by  him  in  that  capacity  have  the  sanction  of  the  com- 
manding officer  and  must  be  obeyed  promptly." 
Tfiis  order  shows  a  realization  bv  Colonel  Finlev  of 


704  EDITORIAL 

the  grave  nature  of  the  task  confronting  the  chief 
medical  officer  of  his  command  and  of  the  need  for 
giving  that  official  full  authority  in  order  to  insure 
the  best  results  from  his  efiforts.  The  official  regu- 
lations will  probably  never  be  changed  so  as  to  be- 
stow actual  command  on  the  medical  officer,  though 
bills  proposing  such  a  change  have  been  introduced 
and  have  received  some  consideration  in  Congress. 
But  if  the  line  officers  can  be  brought  to  a  full  reali- 
zation of  the  dangers  incident  to  unsanitary  condi- 
tions it  is  not  unlikely  that  many  will  pursue  the 
method  of  Colonel  Finley  and  place  both  the  author- 
ity and  the  responsibility  with  their  medical  officers. 
Such  a  voluntary  delegation  of  authority  by  a  line 
officer  shows  a  most  commendable  breadth  of  view, 
and  it  is  to  be  hoped  that  other  commanding  officers 
may  note  Colonel  Finley's  admirable  example  and 
be  influenced  by  it.  Then  we  may  confidently  look 
for  an  improved  sanitary  condition  in  our  military 
camps  and  posts. 


AN  AUSTRALIAN  REPORT  ON 
PROPRIETARIES. 

Largely  because  of  the  publicity  attending  the  en- 
actment of  the  national  pure  food  and  drugs  law 
and  the  series  of  exposures  of  patent  medicine  frauds 
which  have  been  made  in  the  public  press,  most  of  us 
have  been  quite  convinced  that  in  no  other  country 
than  the  United  States  has  the  agitation  against  the 
use  of  secret  drugs  and  "cures"  been  prosecuted  vig- 
orously. But  there  has  just  come  to  this  office  a  most 
voluminous  report  of  a  Royal  Commission  which  in- 
vestigated in  the  Commonwealth  of  Australia  the 
manufacture  and  sale  of  all  kinds  of  patent  and  pro- 
prietary medicines  alleged  to  have  remedial  proper- 
ties. Of  folio  size,  the  volume  numbers  upward  of 
450  pages,  and  includes  reproductions  of  advertise- 
ments of  quack  preparations  and  notes  on  the  laws 
regulating  the  sale  of  medicines  in  different  coun- 
tries. There  is  not  a  good  word  said  for  any  of  the 
advertised  proprietary  remedies,  almost  every  line  of 
the  volume  constituting  a  sharp  arraignment  of  the 
advertised  "cures."  Our  Australian  cousins  have 
surely  done  their  work  thoroughly. 


WINTER  VOMITING. 
In  the  Prcssc  mcdicale  for  March  6th  Dr.  Michel 
de  Kervily  remarks  that  there  are  several  aflPections 
which  make  their  appearance  only  in  winter,  <;uch 
as  pruritus  hiemalis  and  winter  hsemoglobinuria. 
Winter  vomiting,  he  adds,  has  quite  recently  been 
described  by  a  Russian  physician,  Dr.  N.  KuuchefF 
{Praktitchcshy  I'ratch,  January  nth).  Kouchcff 


ARTICLES.  [New  Yokk 

Medical  Journal. 

has  observed  five  cases,  in  persons  of  either  sex  and 
between  the  ages  of  twenty-seven  and  sixty  years. 

For  years  in  succession,  as  soon  as  cold  weather 
appears,  the  patient  is  attacked  with  vomiting.  It 
often  occurs  several  times  a  day,  whether  the  af- 
fected individual  is  fasting  or  has  taken  food,  and  it 
seems  to  bear  no  relation  to  the  quality  or  the  quan- 
tity of  the  food.  There  is  never  haematemesis,  and 
pain  in  the  stomach  does  not  always  occur.  The 
vomiting  lasts  throughout  the  winter,  but  ceases  as 
soon  as  warm  weather  returns. 

It  cannot  be  maintained,  says  Koucheff,  that  the 
affection  is  a  chronic  gastritis  the  manifestations  of 
which  coincide  with  the  cold  season,  for  the  attacks 
are  too  numerous  to  be  looked  upon  as  coincidences ; 
one  patient,  for  example,  had  theni  during  ten  con- 
secutive winters.  Moreover,  the  vomiting  bears  no 
relation  to  the  quality  or  quantity  of  the  gastric 
juice;  in  two  cases  the  secretion  was  normal,  in  one 
case  there  was  a  deficiency  of  hydrochloric  acid,  and 
in  another  there  was  an  excessive  amount  of  that 
substance.  Winter  vomiting  seems  to  be  idiopathic 
and  to  be  due  to  a  reflex  taking  its  origin  from  the 
action  of  cold  on  the  skin. 


THE  JEFFERSON  MEDICAL  COLLEGE. 

As  may  be  gathered  from  our  news  columns,  a 
number  of  gentlemen  who  are  particularly  interest- 
ed in  this  great  institution  have  combined  to  present 
to  the  college  a  portrait  of  Dr.  James  W.  Holland, 
of  the  class  of  1868,  the  portrait  to  be  presented  by 
the  alumni.  In  addition,  suitable  letters  sent  to  the 
committee  will  be  bound  in  a  volume  for  presenta- 
tion to  Professor  Holland,  who  was  elected  to  the 
chair  of  chemistry  and  toxicology  in  1885  and  has 
for  twenty-one  years  been  the  dean  of  the  faculty. 
For  nearly  a  century  the  Jefiferson  Medical  College 
has  been  prominent,  not  only  as  a  Philadelphia  in- 
stitution, but  also  as  one  of  the  foremost  schools  of 
medical  learning  in  the  United  States.  Among  the 
famous  teachers  of  the  college  have  been  Dunglison, 
Da  Costa,  Pancoast,  Bartholow,  Brinton,  Parvin, 
Forbes,  the  two  Grosses  (father  and  son),  and 
Thomson.  Surely  no  medical  school  in  the  coun- 
try can  enumerate  many  more  great  names  among 
the  members  of  its  faculty. 


THE  TUBERCULOSIS  EXHIBITION. 
It  is  well  that  the  exhibition  which  formed  such  a 
conspicuous  feature  of  the  International  Congress 
on  Tuberculosis,  held  in  Washington  in  September 
and  October,  has  been  transported  to  other  cities, 
notably  New  York  and  Philadelphia.  Its  effect  on 
the  public  mind  cannot  have  been  other  than  pro- 


April  3.  iyog.] 


OBITUARY.— NEWS  ITEMS. 


motive  of  a  desire  to  aid  in  the  present  vigorous 
campaign  against  tuberculous  disease  and  of  a  re- 
solve on  the  part  of  the  pubHc  to  play  its  part,  so 
far  as  its  members  may  be  stricken,  in  the  restraint 
of  infection. 


i'HINEAS  SAXBORX  COXXER,  M.  D.,  LL.  D., 
of  Cincinnati. 

Dr.  Conner  died  at  his  home  suddenly,  of  cere- 
bral hfemorrhage,  on  jMarch  26th.  He  was  a  native 
of  Pennsylvania,  having  been  born  in  West  Chester 
on  August  23,  1839.  He  took  his  academic  degree 
at  Dartmouth  College,  and  his  degree  in  medicine 
at  the  Jefferson  Medical  College,  in  the  class  of 
1 86 1.  He  served  as  an  army  surgeon  throughout 
the  civil  war.  He  received  the  degree  of  LL.  D. 
from  Dartmouth  College  in  1885.  For  forty  years 
he  was  a  professor  in  the  ^^ledical  College  of  Ohio, 
and  for  twenty-four  years  in  the  [Medical  Depart- 
ment of  Dartmouth  College.  He  was  on  the  staff 
of  the  Good  Samaritan  Hospital  for  over  thirty-five 
3-ears,  and  on  that  of  the  Cincinnati  Hospital  for 
twenty-one  years.  He  was  a  member  of  the  Ohio 
Commandery  of  the  Loyal  Legion  and  of  the  Ohio 
Society  of  the  Sons  of  the  Revolution.  Only  four 
days  before  his  death  he  had  delivered  before  the 
Cincinnati  Academy  of  Medicine  an  address  on  his 
colleague  Dr.  Reamy,  a  notice  of  whose  death  we 
recently  published,  and  on  the  day  before  his  death 
he  went  to  ^liddletown,  Ohio,  where  he  delivered 
an  address  before  the  Butler  County  [Medical  Soci- 
ety. Dr.  Conner  was  not  only  a  distinguished  sur- 
geon, but  a  man  of  charming  personality.  . 


llttos  Items. 


A  Generous  Gift  to  the  Paterson,  N.  J.,  General  Hos- 
pital.— Mr.  Peter  Quackenbush  has  presented  to  this  hos- 
pital $40,000,  to  be  used  in  erecting  a  nurses'  home,  on  a  lot 
which  was  presented  to  the  hospital  by  Mr.  Quackenbush's 
late  wife. 

The  Naval  Medical  School. — Thirty-nine  assistant 
surgeons  w^ere  graduated  from  the  Xaval  Medical  School, 
Washington,  D.  C,  on  March  25th.  Mr.  George  V.  L. 
Meyer.  Secretary  of  the  Xavy,  delivered  the  address  and 
presented  the  diplomas  to  the  graduates. 

Gift  to  the  Episcopal  Hospital,  Philadelphia. — An- 
nouncement is  made  by  the  board  of  managers  that  $210,000 
has  been  received  as  the  lirst  instalment  of  the  bequest 
made  to  the  hospital  by  Mr.  Edwin  C.  Weaver,  who  died 
about  eighteen  months  ago.  The  total  bequest  is  expected 
to  reach  about  $350,000. 

Changes  of  Address. — Dr.  Harry  R.  Trick,  from  1195 
Main  Street,  to  605  Elmwood  Avenue.  Buffalo,  X.  Y. 

Dr.  Francis  R.  Packard,  to  304  South  Xineteenth  Street, 
Philadelphia. 

Dr.  Walter  J.  Henesey,  from  San  Francisco,  Cal.,  to  369 
Lexington  avenue.  Xew  York. 

The  Medical  Society  of  the  County  of  Ulster,  N.  Y., 
will  meet  in  Kingston,  on  Tuesday.  April  6th.  at  2  p.  m. 
The  programme  includes  a  paper  by  Dr.  George  F.  Chan- 
dler, of  Kingston,  entitled  Postural  Treatment  to  Avoid 
A'omiting  Follow  ing  Anaethesia.  and  a  paper  on  the  Use  of 
the  Microscope  in  General  Medicine,  by  Dr.  Gillette. 

Wholesale  Vaccination  at  Bellevue. — Acting  under 
orders  from  the  Board  of  Health,  all  tlie  doctors,  nurses, 
clerks,  and  patients  at  Bellevue  and  .\llied  Hospitals  were 
vaccinated  on  Sunday,  March  28th.  It  is  said  that  no  epi- 
demic of  smallpox  is  feared,  and  the  action  taken  by  the 
Board  of  Health  was  simply  for  the  sake  of  greater 
security. 


Bellevue's  New  Automobile  Ambulance  was  put  into 

service  on  Monday,  March  29th.  It  is  a  $4,000  car  of 
20  horse  power,  is  equipped  with  emergency  appliances  of 
all  kinds,  and  is  really  a  small  traveling  hospital.  The 
enclosed  part  is  lighted  by  electricity  and  heated  by  steam. 

The  Lincoln  Endowment  Fund. — It  is  announced  that 
$96,000  has  been  subscribed  of  the  $500,000  endowment 
fund  which  is  being  collected  to  make  the  Lincoln  Hospital 
and  Home  a  national  memorial  to  Abraham  Lincoln.  This 
hospital,  w'hich  is  situated  at  Southern  Boulevard  and  141st 
street,  Xew  York,  is  sixty-eight  years  old. 

Hereditary  Syphilis  and  Epilepsy. — Dr.  William  P. 
Spratling,  formerly  medical  superintendent  of  the  Craig 
Colony  for  Epileptics,  Sonyea,  N.  Y.,  now  professor  of 
nervous  diseases  and  physiology  in  the  College  of  Physi- 
cians and  Surgeons,  Baltimore,  would  like  to  receive  from 
physicians  reports  of  cases  of  epilepsy  in  which  the  causes 
are  thought  to  be  cerebral  syphilis  in  one  or  both  of  the 
parents.  Such  reports  will  be  greatly  appreciated  by  Dr. 
Spratling,  1 1 10  X'orth  Charles  street.  Baltimore,  jSId. 

In  Memory  of  Dr.  Robert  A.  Murray. — At  a  recent 
meeting  of  the  Xorthwestern  Medical  and  Surgical  Society, 
Xew  York,  a  resolution  on  the  death  of  Dr.  Robert  A. 
Murray  was  presented  by  Dr.  Ed\\ard  S.  Peck  and  Dr. 
Henry  Ling  Taylor  and  adopted  by  the  society,  expressing 
the  deep  sense  of  loss  felt  by  the  members  on  the  death  of 
Dr.  Murray,  which  took  place  on  February  27,  1909.  Dr. 
Murray  was  an  enthusiastic  member  of  the  society  for 
nineteen  years,  and  made  man\-  valuable  contributions  to 
scientific  medicine  and  surgery. 

The  Association  of  American  Physicians  will  hold  its 
twenty-fourth  annual  meeting  in  the  Xew-  Willard  Hotel, 
Washington,  D.  C,  !May  11  and  12,  1909,  under  the  presi- 
dency of  Dr.  Victor  C.  ^^aughan,  of  Ann  Arbor.  The  pre- 
liminar\-  programme,  which  has  just  been  received,  contains 
a  list  of  nearly  fifty  papers  by  leaders  in  the  profession 
from  all  parts  of  the'  United  States.  Papers  will  be  pre- 
sented only  in  abstract,  on  account  of  lack  of  time,  and 
members  are  requested  to  furnish  titles  and  abstracts  of 
their  conmumications  not  later  than  April  loth. 

The  Association  of  American  Medical  Colleges  held 
its  annual  meeting  at  the  Xew  York  Academy  of  Medicine 
on  March  i6th,  17th,  and  i8th,  with  some  sixty  members 
in  attendance.  Tlic  following  officers  were  elected  to  serve 
for  the  ensuing  year :  President,  Dr.  George  H.  Hoxie,  of 
the  University  of  Kansas  ;  vice-presidents.  Dr.  David  Street, 
of  the  Baltimore  Medical  College,  and  Dr.  J.  A.  Wither- 
spoon,  of  Vanderbilt  L'niversity ;  secretary  and  treasurer, 
Dr.  F.  C.  ZapfTe,  of  the  L'niversit\'  of  Illinois.  The  next 
meeting  of  the  association  will  be  held  in  Baltimore,  on 
March  21  and  22,  1910. 

The  Summer  Care  of  Babies. — The  campaign  for  re- 
ducing the  infant  mortality  in  Xew  York  during  the  sum- 
mer of  1909  will  be  started  on  Monday  evening,  April  5th, 
hy  a  conference  of  members  of  the  Department  of  Health 
with  over  fifty  representatives  of  private  agencies.  Mr. 
William  H.  Allen,  of  the  Bureau  of  Municipal  Research, 
has  been  appointed  chairman,  and  Dr.  J.  J.  Cronin.  of  the 
Department  of  Health,  secretary.  Dr.  S.  S.  Goldwater, 
president  of  the  Greater  New  York  Hospital  Conference, 
and  Dr.  Walter  Bensel,  of  the  Department  of  Health,  are 
members  of  the  executive  committee. 

A  Sanatorium  for  Children. — Announcement  is  made 
that  Mrs.  Elizabeth  ^lilbank  Anderson  is  the  donor  of  the 
$500,000  w  hich  was  presented  anonymously  to  the  Children's 
Aid  Society  of  New  York,  last  October.  Tlie  money  is  to  be 
used  for  the  establishment  of  a  sanatorium,  to  be  kept  open 
all  the  year  around,  for  sick  and  crippled  children,  and  the 
Chappaqua  Mountain  Institute  has  already  been  purchased 
by  the  society  for  the  purpose.  The  property  cost  $100,000, 
and  $50,000  will  be  expended  in  improvements.  The  income 
horn  the  remaining  $350,000,  which  has  already  been  in- 
vested so  as  to  yield  $14,000  a  year,  will  be  used  in  helping 
maintain  the  institution. 

Hospital  Benefits. — The  Flower  Hospital,  New-  York, 
gave  a  tea  and  linen  shower,  with  a  musical  programme, 
on  Monday,  jNIarch  29th,  which  was  very  successful.  The 
hospital  received  a  good  supply  of  linen,  and  a  sum  of 
money. 

Springfield,  Mass.,  Hospital  will  net  more  than  $7,000 
from  the  benefit  performance  given  at  the  Court  Street 
Theatre  on  Friday,  March  igth. 

Over  $3,000  was  the  amount  realized  from  the  concert 
held  recently  at  the  residence  of  Mr.  and  Mrs.  Salomon, 
Xew  York,  for  the  benefit  of  the  X^ew  York  Throat,  Nose 
and  Lung  Hospital. 


7o6 


NEWS  ITEMS. 


[New  \ork 
Medical  Jourmal^ 


The  Health  of  Pittsburgh. — During  the  week  ending 
Marcli  20,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
17  cases,  o  deaths;  typhoid  fever,  12  cases,  3  deaths; 
scarlet  fever,  18  cases,  0  deaths ;  diphtheria,  4  cases, 
I  death ;  measles,  40  cases,  o  deaths ;  whooping  cough,  20 
cases,  2  deaths ;  pulmonary  tuberculosis,  23  cases,  16  deaths. 
The  total  deaths  for  the  week  numbered  160,  in  an  esti- 
mated population  of  565,000,  corresponding  to  an  annvial 
death  rate  of  14.72  in  a  thousand  population. 

Blindness  of  the  New  Born  and  Its  Prophylaxis  is 
the  subject  chosen  for  discussion  at  the  meeting  of  the 
American  Society  of  Sanitary  and  Moral  Prophylaxis  to 
be  held  in  New  York  on  the  evening  of  April  8th.  Dr. 
Charles  Stedman  Bull  will  read  a  paper  treating  of  the 
subject  from  the  standpoint  of  the  eye  specialist,  and  Dr. 
James  Clifton  Edgar  will  deal  with  the  subject  from  the 
standpoint  of  the  obstetrician.  A  representative  of  the  De- 
partment of  Health  of  New  York  will  take  up  the  subject 
from  the  standpoint  of  sanitary  officials.  The  general  dis- 
cussion will  be  participated  in  by  prominent  members  of  the 
medical  profession  and  the  laity. 

Personal.— Dr.  Smith  Ely  Jeliffe,  of  New  York,  has 
been  made  an  honorary  life  member  of  the  Anglo-Ameri- 
can j\Iedical  Society,  of  Berlin. 

Dr.  Thomas  W.  Burnett,  a  surgeon  at  the  New  York 
Hospital,  was  seriously  injured  on  Saturday,  March  27th, 
by  the  collision  of  a  street  car  with  the  ambulance  in  which 
he  was  riding. 

Dr.  John  Steinwandel,  of  Philadelphia,  has  been  ap- 
pointed a  district  physician  by  Director  NefT,  of  the  Depart- 
ment of  Public  Health  and  Charities. 

Dr.  Charles  C.  Dreycr,  of  Toledo,  Ohio,  is  registered  at 
the  Philadelphia  Polyclinic  and  College  for  Graduates  in 
Medicine. 

Infectious  Diseases  in  New  York: 

IFe  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folloiving  statement  of  new 
cases  and  deatlis  reported  for  the  tivo  n'eeks  ending  March 
27,  igog: 

, — March  20 — v  , —  March  27 — \ 
Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis   i)ulmonalis    551  1S8         527  199 

Diphtheria   ,•   372  52         354  41 

Measles    922  21         913  27 

Scarlet  fever    3S6  25         415  17 

Smallpox   

Varicella    173  .  .  221 

Typhoid   fever    23  5  20  5 

\Vhooi)ir.g  cough    117  8  63  10 

Cerebrospinal    meningitis    8  7  g  8 

Total   2,552         306      2,522  307 

Charities  and  the  Commons. — With  the  April  3d  issue 
of  this  excellent  publication,  its  name  will  be  changed  to 
The  Survey.  The  publication  committee  and  the  editorial 
staff  have  long  considered  the  advisability  of  changing  the 
name  of  the  magazine  to  one  less  misleading,  as  the  word 
Charities  is  to  many  people  synonymous  with  almsgiving, 
and  consequently  conveys  a  wholly  wrong  impression  of 
the  contents  of  the  journal.  After  due  deliberation  the 
narne  The  Survey,  with  the  subtitle  Social — Charitable — 
Civic  was  chosen.  The  purpose  of  the  publication  is  to 
rnake  careful  examinations  into  living  and  working  condi- 
tions, on  which  will  be  based  recommendations  for  legisla- 
tion for  the  betterment  of  social  conditions.  The  editorial 
management  remains  in  the  hands  of  Dr.  Edward  T. 
Devine.  general  secretary  of  the  New  York  Charity  Or- 
ganization Society. 

To  Concentrate  Governmental  Health  Service  under 
One  Head. — It  is  reported  from  Washington  that  Presi- 
dent Taft  has  requested  Surgeon  General  Wyman  of  the 
Public  Health  and  Marine  Hospital  service  to  submit  a 
plan  for  the  concentration  under  one  bureau  of  all  the 
functions  of  the  government  bearing  on  public  health. 
These  functions  are  now  divided  among  four  executive 
departments,  as  follows :  The  Treasury  Department,  which 
has  the  supervision  of  the  bureau  of  the  Public  Health  and 
Marine  Hospital  Service;  the  Department  of  Commerce 
and  Labor,  which  has  the  supervision  of  the  isolation  of 
contagious  diseases  in  connection  with  immigration ;  the 
War  Department,  which  supervises  the  sanitary  bureaus  of 
Panama  and  the  Insular  possessions;  and  the  Department 
of  Agriculture,  which  has  control  of  the  Bureau  of  Chem- 
istry, which  is  charged  with  the  execution  of  the  food 
anfl  drugs  act. 


A  Spec/al  Meeting  of  the  Medical  Association  of  the 
Greater  City  of  New  York  will  be  held  in  the  Elks 
Building,  Long  Island  City,  Borough  of  Queens,  on  Mon- 
day evening,  April  5th,  at  8  :30  o'clock.  An  excellent  pro- 
gramme has  been  prepared,  which  includes  the  following 
papers :  Fibroid  Degeneration  of  the  Appendix,  by  the  pres- 
ident of  the  association.  Dr.  Robert  T.  Morris,  who  will 
present  a  series  of  typical  specimens;  A  Clinical  Talk  on 
Tabes,  by  Dr.  William  Broaddus  Pritchard ;  Idiopathic  Di- 
latation of  the  CEsophagus,  by  Dr.  Max  Einhorn.  There 
will  be  a  general  discussion  of  these  papers,  and  a  collation 
will  be  served  at  the  close  of  the  meeting. 
Scientific   Society   Meetings   in  Philadelphia  for  the 

Week  Ending  April  10,  1909: 
Monday,  April  jt!i. — Philadelphia  Academy  of  Surgery; 
Biological  and  Microscopical  Section,  Academy  of  Nat- 
ural Sciences ;  West  Philadelphia  Medical  Association ; 
Northwestern  Medical  Society ;  Wills  Hospital  Oph- 
thalmic Society. 
TuESD.w,  April  6th. — Academy  of  Natural  Sciences;  Phila- 
delphia Medical  Examiners'  Association. 
Wednesd.-w,  April  7th. — College  of  Physicians. 
Thursday,  April  8th. — Pathological  Society;  Section  Meet- 
ing, Franklin  Institute ;  Lebanon  Hospital  Medical  So- 
ciety. 

Friday,  April  gtli. — Northern  ]\Iedical  Association, 

Tuberculosis  Classes. — The  tuberculosis  clinic  of 
Bellevue  Hospital  has  started  a  series  of  classes  for  con- 
sumptives, which  will  meet  every  Monday  afternoon  on  the 
deck  of  the  old  ferryboat  Southfield.  which  is  the  tubercu- 
losis camp  of  the  hospital,  and  receive  instruction  regard- 
ing the  means  of  fighting  the  disease.  The  first  class  con- 
sists of  fifteen  patients,  some  of  whom  spend  their  days  at 
the  camp,  and  others  coming  to  the  Southfield  only  on  }iIon- 
day  afternoons  for  the  meeting.  Each  patient  is  required  to 
keep  his  own  chart,  taking  his  temperature  four  times  a 
day,  recording  the  amount  of  nourishment  taken,-  the  time 
spent  in  the  open  air,  etc.  Arrangements  have  been  made 
for  some  of  the  men  to  sleep  at  the  camp,  and  in  fact  every 
effort  is  being  made  to  bring  about  conditions  at  the  camp 
as  nearly  as  possible  like  those  e.xisting  at  sanatoria  for  the 
treatment  of  tuberculosis. 

A  Testimonial  to  Dr.  Jam.es  W.  Holland. — A  commit- 
tee has  been  appointed  by  the  alumni  of  Jefferson  Medical 
College  to. undertake  the  collection  of  voluntary  contribu- 
tions sufficient  to  secure  a  suitable  portrait  of  Dr.  Holland 
to  be  presented  to  the  college  by  the  alumni.  For  nearly 
a  quarter  of  a  century  Dr.  Holland  has  been  intimately 
identified  with  the  affairs  of  the  college,  for  twent\-one 
years  being  dean  of  the  faculty,  and  his  wise  counsel,  pro- 
ficient work,  and  tireless  industry  have  conduced  largely  to 
the  growth  of  the  institution.  It  is  to  the  end  that  a  fitting 
testimonial  of  his  long  and  faithful  service  may  grace  the 
walls  of  the  college  that  steps  are  being  taken  to  secure  the 
portrait.  In  addition,  suitable  letters  received  by  the  com- 
mittee will  be  bound  in  a  volume  for  presentation  to  Dr. 
Holland.  In  order  that  the  largest  number  may  participate 
in  this  testimonial  contributions  must  not  exceed  $5.  Checks 
should  be  made  out  to  the  order  of  Dr.  H.  Augustus  Wil- 
son, 161 1  Spruce  Street,  Philadelphia,  treasurer  of  the 
committee. 

The  Hamilton  Club  Dines  Doctors. — The  Hamilton 
Club,  of  Brooklyn,  gave  a  banquet  in  honor  of  the  medical 
profession  at  the  club  house  on  the  evening  of  March  29th. 
The  dinner  was  presided  over  by  the  president  of  the  club. 
Mr.  Sanford  H.  Steele.  Addresses  were  delivered  by  Dr. 
Rlaurice  H.  Richardson,  of  Plarvard,  Dr.  William  Hanna 
Thomson,  Dr.  John  A.  McCorkle,  Dr.  Joseph  D.  Bryant, 
and  Mr.  Robert  Hebberd,  Commissioner  of  Charitic- 
.About  one  hundred  were  in  attendance,  among  whom  were 
Dr.  A.  T.  Bristow,  Dr.  C.  Jcwett.  Dr.  J  C.  B'^ierworth,  Dr. 
J.  B.  Bogart,  Dr.  H.  B.  Delatour,  Dr.  C.  B.  Parker,  Dr. 
J.  M.  Van  Cott,  Dr.  Joseph  S.  Waterman.  Dr.  E.  H.  Green. 
Dr.  Philii)  Leach,  Dr.  .Archibald  Murrav.  Dr.  J.  B.  Thomas. 
Dr.  W.  B.  Brinsmade.  Dr.  O.  .-V.  Gordon,  Dr.  W.  F.  Camp- 
bell. Dr.  A.  R.  Jarratt,  Dr.  D.  D.  Roberts,  Dr.  J.  Sherman 
Wight,  Dr.  T.  R.  French,  Dr.  Frederick  Tilnev,  Dr.  T.  M. 
Lloyd.  Dr.  E.  H.  Squibb.  Dr.  Joseph  W.  Raymond.  Dr. 
J.  D.  Rushmore.  Dr.  Smith.  Dr  Birmingham.  Dr.  .Alex- 
ander Rae.  Dr.  W.  P.  Pool.  Dr.  F.  C.  Holdcii,  Dr.  Raphael. 
Dr.  Jacciues  Rushmore,  Dr.  Clark  Biirnham,  Dr.  W.  G. 
Wollev,  Dr.  F.  H.  Colton.  Dr.  H.  C.  Riggs,  Dr.  J.  G.  Tohn- 
son.  Dr.  F.  W.  Wunderlich.  Dr.  J.'  M.  Callender.  Dr. 
Mocser,  Dr.  J.  E.  Sheppard,  and  Dr.  C.  W.  Stickle. 


April  3,  1909.] 


NEIVS  ITEMS. 


The  Mortality  of  Chicago  for  the  week  ending  March 
20,  1909,  was  considerably  higher  than  for  the  preceding 
week.  The  total  number  of  deaths  reported  to  the  Depart- 
ment of  Health  during  the  week  was  711,  as  compared  with 
654  for  the  preceding  week  and  623  for  the  corresponding 
period  in  i^.  The  annual  death  rate  in  a  thousand  of 
population  was  16.66,  as  against  a  death  rate  of  15.33  for 
the  preceding  week.  The  principal  causes  of  death  were: 
Diphtheria,  19  deaths;  scarlet  fever,  11  deaths;  measles,  i 
death;  whooping  cough,  2  deaths;  influenza,  7  deaths;  ty- 
phoid fever,  8  deaths;  diarrhceal  diseases,  37  deaths,  of 
which  34  were  under  two  years  of  age;  pneumonia,  142 
deaths;  pulmonary  tuberculosis,  86  deaths;  other  forms  of 
tuberculosis,  12  deaths ;  cancer,  42  deaths ;  nervous  diseases, 
17  deaths ;  heart  diseases,  75  deaths ;  apoplexy,  14  deaths ; 
Bright's  disease,  53  deaths ;  violence,  36  deaths,  of  which  8 
were  suicides ;  all  other  causes,  149  deaths. 

Vital  Statistics  of  New  York. — During  the  week  end- 
ing March  20,  1909,  there  were  reported  to  the  Department 
of  Health  of  the  City  of  New  York,  1,581  deaths  from  all 
causes,  in  an  estimated  population  of  4,564,792,  correspond- 
ing to  an  annual  death  rate  in  a  thousand  of  population  of 
18.07,  as  against  a  death  rate  of  17.46  for  the  correspond- 
ing period  in  1908.  The  death  rate  in  each  of  the  bor- 
oughs for  the  week  was  as  follows :  Manhattan,  18.24 ;  the 
Bronx,  21.14;  Brooklyn,  17.49;  Queens,  13.63;  Richmond, 
24.76.  The  total  infant  mortality  was  464;  305  under  one 
j'car  of  age,  79  between  one  and  two  years  of  age,  and  80 
between  two  and  five  years  of  age.  There  were  128  still 
births.  Of  the  total  number  of  deaths,  103  were  due  to 
contagious  diseases,  188  to  pulmonary  tuberculosis,  92  from 
diarrhceal  diseases,  264  from  pneumonia,  174  from  organic 
heart  diseases,  132  from  Bright's  disease,  and  66  from  can- 
cer. There  were  78  deaths  by  violence,  of  which  19  were 
suicides. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing March  20,  1909,  the  following  cases  of  transmissible 
diseases  were  reported  to  the  Bureau  of  Health  of  Phila- 
delphia :  Typhoid  fever,  47  cases,  4  deaths ;  scarlet  fever, 
79  cases,  I  death ;  chickenpox,  63  cases,  o  deaths ;  diph- 
theria, 74  cases,  13  deaths;  measles,  224  cases,  9  deaths; 
whooping  cough,  27  cases,  3  deaths ;  tuberculosis  of  the 
lungs,  147  cases,  86  deaths ;  pneumonia,  76  cases,  55  deaths ; 
en,'sipelas,  15  cases,  2  deaths ;  mumps,  29  cases,  o  deaths ; 
trachoma,  2  cases,  o  deaths.  The  following  deaths  were 
reported  from  other  transmissible  diseases :  Tuberculosis, 
other  than  tuberculosis  of  the  lungs,  11  deaths;  diarrhoea 
and  enteritis,  under  two  years  of  age,  18  deaths ;  puerperal 
fever,  2  deaths.  The  total  deaths  numbered  545  in  an  esti- 
mated population  of  1,565,569,  corresponding  to  an  annual 
death  rate  of  18.10  in  a  thousand  population.  The  total 
infant  mortality  was  about  irS;  91  under  one  year  of  age, 
27  between  one  and  two  years  of  age.  There  were  29  still 
births ;  21  males  and  8  females.  The  total  precipitation 
was  0.13  inch. 

Society  Meetings  for  the  Coming  Week: 

Monday,  April  §th. — German  Medical  Society  of  the  City 
of  New  York  :  Utica,  N.  Y.,  Medical  Library  Associa- 
tion;  Niagara  Falls,  N.  Y.,  Academy  of  Medicine; 
Practitioners'  Club,  Newark,  N.  J. ;  Hartford,  Conn., 
Medical  Society. 

TuESD.w.  April  6th. — New  York  Academy  of  Medicine 
(Section  in  Dermatology)  ;  New  York  Neurological 
Society;  Buffalo  Academy  of  Medicine  (Section  in 
Surgery)  ;  Ogdensburgh,  N.  Y.,  Medical  Association ; 
Syracuse,  N.  Y.,  Academy  of  Medicine ;  Hudson  Coun- 
ty, N.  J.,  Medical  Association  (Jersey  City)  ;  Medical 
Association  of  Troy,  N.  Y.,  and  Vicinity ;  Hornellsville, 
N.  Y.,  Medical  and  Surgical  Association  (annual)  ; 
Long  Island,  N.  Y.,  Medical  Society ;  Bridgeport, 
Conn.,  Medical  Association. 

Wednesday.  April  yth. — Society  of  Alumni  of  Bellevue 
Hospital,  New  York ;  Harlem  Medical  Association, 
New  York:  Ehnira,  N.  Y.,  Academy  of  Medicine. 

Thursday,  April  8th. — New  York  Academy  of  Medicine 
(Section  in  Pjediatrics)  ;  Brooklyn  Pathological  So- 
ciety ;  Blackwell  Medical  Society  of  Rochester,  N.  Y ; 
Jenkins  Medical  Association,  Yonkers,  N.  Y. 

Friday,  April  gth. — New  York  Academy  of  Medicine  (Sec- 
tion in  Otolog>-)  ;  New  York  Society  of  Dermatology 
and  Genitourinary  Surgery ;  Eastern  Medical  Society 
of  the  City  of  New  York;  Saratoga  Springs,  N.  Y., 
Medical  Society. 

Saturday,  April  /of^!.— Therapeutic  Club.  New  York. 


Resolutions  on  the  Death  of  Dr.  Robert  A.  Murray.— 

At  a  regular  meeting  of  the  New  York  Medico-Surgical 
Society,  held  on  the  evening  of  March  20th,  the  following 
resolutions  were  presented  by  the  society  and  unanimously 
adopted : 

Whereas,  Death  has  removed  from  the  roll  of  this  society,  on 
February  27,  1909,  our  friend  and  colleague,  Dr.  Robert  A.  Mur- 
ray, and 

Whereas,  During  the  many  years  of  his  membership,  Dr.  Mur- 
ray has  been  a  most  active  and  enthusiastic  supporter  of  the  objects 
which  brought  about  the  organization  of  this  society;  and 

Whereas,  By  his  regular  attendance  and  active  participation  in 
discussions  on  all  subjects  coming  before  the  society,  as  well  as  by  his 
sociability,  he  has  added  much  to  the  interest  of  our  meetings,  be  it 

Resolved,  That  in  the  death  of  our  friend  and  fellow  member, 
the  New  York  Medico-Surgical  Society  has  sustained  a  great  loss  in 
one  who,  by  his  sympathy,  geniality  and  untiring  devotion,  was  en- 
deared to  all,  be  it  further 

Resolved,  That  these  resolutions  be  spread  ill  full  upon  the 
records  of  the  society,  a  copy  sent  to  the  medical  journals  for  pub- 
lication, and  an  engrossed  copy  transmitted  to  the  family  of  our 
deceased  colleague. 

J.  Arthur  Booth,  M.D.,  ) 

T.  K.   Tuthill,  M.D.,      \  Committee. 

John  A.  Bodine,  M.D.,  ) 

Foreign  Items  of  Interest. — The  German  Congress 
on  Internal  Medicine  will  hold  its  twenty-sixth  annual 
meeting  at  Wiesbaden  from  April  19th  to  22d. 

A  radium  institute  is  to  be  established  in  connection  with 
the  University  of  Heidelberg.  It  will  be  under  the  direc- 
tion of  Professor  Lenard,  who  has  done  valuable  work  in 
radiology. 

The  Eighth  International  Congress  of  Hydrology  and 
Climatology-,  which  includes  geology  and  physical  therapeu- 
tics, will  be  held  in  Algiers  from  April  4th  to  loth.  The 
general  secretary  of  the  congress  is  Dr.  L.  Raynaud,  7 
Place  de  la  Republique,  Algiers,  to  whom  all  communica- 
tions should  be  addressed.  The  usual  exhibition  will  be 
held  in  connection  with  the  congress. 

The  seventh  annual  meeting  of  the  South  African  Asso- 
ciation for  the  Advancement  of  Science  will  be  held  at 
Bloemfontein  in  September,  under  the  presidency  of  Sir 
Hamilton  J.  Goold-Adams. 

Dr.  Sven  Hedin,  the  eminent  Swedish  explorer,  who  is 
also  a  member  of  the  medical  faculty  of  the  University  of 
Upsala,  \\as  recently  awarded  the  Humboldt  medal  by  the 
Berlin  Geographical  Society. 

The  chair  of  pathology  in  Sheffield  University  is  to  be 
called  the  Joseph  Hunter  Chair  of  Pathology,  in  accord- 
ance v/ith  the  terms  of  the  will  of  the  late  Dr.  Julian  Hun- 
ter, who  bequeathed  £15,000  to  the  university  on  condition 
that  the  name  of  his  father,  Joseph  Hunter,  be  perpetuated 
at  the  university. 

It  is  announced  that  the  Prince  of  Wales  has  recently 
become  a  Fellow  of  the  Royal  College  of  Surgeons  of 
England.  His  Royal  Highness  has  been  a  Fellow  of  the 
Royal  College  of  Medicine  for  some  time. 

The  Control  of  Inebriety  in  New  York. — A  bill  has 
been  introduced  into  the  New  York  State  Legislature  by 
Assemblyman  Lindon  Bates,  Jr.,  providing  for  the  appoint- 
ment of  a  board  of  inebriety  for  the  city  of  New  York  and 
the  establishment  of  an  •inebriate  hospital,  with  an  indus- 
trial colony,  in  which  persons  arrested  for  intoxication  may 
be  detained  and  scientifically  treated.  The  measure  was 
framed  by  the  standing  committee  on  hospitals  of  the  State 
Qiarities  Aid  Association.  The  board  is  to  consist  of  five 
members,  to  be  named  by  the  Mayor,  who  will  serve  with- 
out pay  for  a  term  of  five  years.  Under  the  direction  of 
this  board  a  central  office  will  be  maintained,  at  which  will 
be  kept  the  records  of  all  persons  arrested  for  public  in- 
toxication, and  whenever  an  arrest  is  made  the  offender's 
previous  record  will  be  investigated.  The  hospital  and  in- 
dustrial colony  for  inebriates  which  it  is  proposed  to  es- 
tablish will  probably  be  situated  in  the  coimtry,  with  a  con- 
siderable area  of  land  attached  for  farm  and  garden  work, 
and  it  will  be  the  privilege  of  the  board  to  place  in  this  in- 
stitution any  patient  whom  they  think  will  be  benefited  by 
the  treatment.  The  board  will  be  authorized  to  make  ap- 
plication to  the  proper  court  authorities  for  a  commitment 
to  an  insane  hospital  of  any  person  committed  to  its  care 
who  is  shown  to  be  insane.  One  of  the  most  important  pro- 
visions of  the  measure  is  that  which  authorizes  the  com- 
mitment of  inebriates  to  the  custody  of  the  board  on  their 
own  petition,  or  that  of  relatives  or  friends,  if  two  physi- 
cians join  in  the  application,  such  commitment  to  be  made 
by  a  justice  of  a  court  of  record,  as  in  the  case  of  the  in- 
sane. The  trustees  of  Bellevue  and  AlHed  Hospitals  are 
to  have  similar  authorization  in  the  case  of  any  person 
treated  by  them  for  alcoholism. 


7o8 


PITH  OF  CURRENT  LITERATURE. 


[New  Vork 
Medical  Journal. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

March  25,  1909. 

1.  Surgery  of  the  Bile  Passages  with  Special  Reference 

to  the  End  Results,  By  John  C.  Munro. 

2.  The  Trend  of  the  Clinicians'  Concept  of  Hysteria, 

By  Tom  A.  Williams. 

3.  The  Calcaneolibular  Ligament  and  Its  Neighborhood 

Based  on  Dissections,  By  Edward  A.  Tracy. 

4.  A  Case  of  Pseudohermaphroditism, 

By  William  L.  Harris. 

5.  A  Study  of  Hand  Sterilization, 

By  Chari.es  Greene  Cumston. 

1.  Surgery  of  the  Bile  Passages. — Munro  ob- 
serves that  an  analysis  of  his  300  operations  dem- 
onstrates that  jaundice  is  present  in  a  majority  of 
all,  even  the  simple  gallbladder  cases  at  some  time ; 
that  a  very  large  majority  of  common  duct  cases 
has  jaundice.  The  pancreas  is  not  infrequently 
pathological,  as  determined  by  examination  of  the 
open  abdomen.  x\dhesions  are  present  in  a  large 
majority  of  cases,  and  may  be  the  direct  cause  of 
symptoms  rendering  all  medical  treatment  more 
than  futile.  Pulmonary  complications  must  be 
reckoned  with  in  prognosis,  but  they  are  less  fre- 
quent than  anticipated.  Cholecystostomy  is  nor- 
mally a  more  suitable  operation  than  cholecystec- 
tomy, unless  the  gallbladder  is  definitely  function- 
less.  Recurrence  of  symptoms  may  be  due  to  ad- 
hesions or  a  contracted  gallbladder  as  well  as  to 
overlooked  stones.  Toxaemic  cases  are  best  treated 
medically  until  the  acute  state  is  passed.  Fatal 
capillary  h3emorrhage  may  be  controlled  to  an  ex- 
tent not  yet  determined  by  the  use  of  fresh  animal 
serum. 

2.  Hysteria.  —  Williams  demonstrates  our 
knowledge  and  conception  of  hysteria  by  citing 
many  cases  from  the  literature.  In  the  introduc- 
tion to  his  very  interesting  paper  he  remarks  that 
with  regard  to  hysteria  the  medical  world  has  for 
many  years  been  utterly  dominated  by  the  sys- 
tematized conceptions  of  Charcot  and  his  collabo- 
rator, Janet,  to  the  exclusion  of  the  less  dramatic 
notions  of  Bernheim  and  the  Nancy  school  in  gen- 
eral. No  one  better  than  a  psychologist  knows  the 
difficulty  of  emancipation  from  the  ideas  of  a  dom- 
inating personality,  and  to  this  must  be  attributed 
the  delay  in  the  overthrow  of  the  almost  purely  fan- 
tastical clinical  picture  which  Charcot  believed  to 
characterize  hysteria.  For  the  proof  of  the  arti- 
ficial nature  of  the  famous  four  phases  of  hysterical 
seizure,  one  need  go  no  further  than  the  Sal- 
petriere  of  to-day.  There  one  sees  this  type  of  at- 
tack only  in  the  few  remaining  patients  of  Charcot. 
The  hysteric  of  to-day  either  has  no  attack  or  mere- 
ly goes  through  the  disorderly  contortions  of  the 
enraged  child,  which  are  no  longer  cultivated  to 
perpetuity  by  the  fostering  solicitude  of  an  admiring 
investigator.  They  are,  on  the  contrary,  quickly 
suppressed  by  the  stern  skill  which  holds  the  key 
to  their  mechanism.  The  evidence  is  now  pretty 
clear  that  the  so  called  stigmata  of  hysteria,  such  as 
hemianaesthcsia  and  contracted  visual  fields  are  gen- 
erally derived  from  suggestion  of  medical  origin, 
although  hemiangesthesia  is  sometimes  autochthon- 
ous by  imitation  of  hemiplegia. 


5.  Hand  Sterilization. — Cumston  says  that  the 
personal  prophylaxis  of  the  surgeon  and  his  assist- 
ants cannot  be  underrated,  and  they  should  care- 
fully avoid  autoinfection  in  every  possible  wa\-. 
One  should  never  allow  his  hands  to  come  in  con- 
tact with  pus  or  septic  wounds,  and  they  should 
also  be  protected  b}'  rubber  gloves  when  making 
rectal  or  vaginal  examinations  as  well  as  those  in 
the  mouth  and  nasal  cavities.  The  nails  and  skin 
should  be  kept  in  excellent  condition,  a  thing  which 
is  practically  impossible  when  the  routine  use  of 
sublimate  is  made.  Most  antiseptic  solutions  rap- 
idly deteriorate  the  skin  and  nails,  thus  rendering 
them  extremely  difficult  to  clean. 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

March  27,  1909. 

1.  Simple  Fracture.    Some  Points  on  Its  Diagnosis  and 

Operative  Treatment,  By  Lewis  A.  Stimson. 

2.  Intertransmissibility  of  Bovine  and  Human  Tubercle 

Bacilli.  Evidence  Oltered  by  Clinical  Administra- 
tion of  Tuberculins  ^lade  from  Bacilli  of  Human 
and  Bovine  Origin,  By  F.  M.  Pottengek. 

3.  The  Incidence  of  Tubercle  Bacilli  in  New  York  City 

Milk,  with  a  Study  of  Its  Effects  on  a  Series  of 
Children,  By  Alfred  H.  Hess. 

4.  A  Clinical  Study  of  the  Children  of  Tuberculous  Pa- 

rents, 

By  James  Alexander  Miller  and  I.  Ogden  Woodruff. 

5.  ^-Etiology  of  Face,  Nose  and  Jaw  Deformities, 

By  Eugene  S.  Talbot. 

6.  Bone  Pathology  and  Tooth  Movement, 

By  Eugene  S.  Talbot. 

7.  Readjustment  of  the  Superior  ]^Iaxillae  in  Treatment 

of  Hare  Lip  and  Cleft  Palate, 

By  George  V.  I.  Browx. 

2.  Intertransmissibility  of  Bovine  and  Human 
Tubercle  Bacilli. — Pottenger  remarks  that,  inter- 
preting laboratory  findings,  animal  experiments, 
clinical  observations,  and  the  diagnostic  and  thera- 
peutic use  of  tuberculins  made  from  bacilli  of  both 
human  and  bovine  varieties,  as  well  as  reasoning 
from  the  analogy  between  smallpox  and  cowpox, 
we  have  some  light  thrown  on  the  question  of  inter- 
transmissibility of  tubercle  bacilli  of  human  and 
bovine  origin  that  cannot  be  derived  from  the 
laboratory  and  animal  experiments  alone.  The  fol- 
lowing points  in  the  discussion  of  this  question 
seem  to  be  pretty  thoroughly  established,  according 
to  our  author :  Human  and  bovine  tubercle  bacilli 
are  different,  as  shown  in,  (a)  morphological  char- 
acteristics, (b)  cultural  characteristics,  (c)  viru- 
lence for  animals,  and  (d)  staining  characteristics 
(not  generally  confirmed).  Cattle  can  be  immun- 
ized against  bovine  bacilli  by  inoculation  with  mod- 
erate numbers  of  hinnan  bacilli.  The  resistance  of 
cattle  can  be  overcome  and  infection  brought  about 
by  inoculation  of  human  bacilli  in  large  numbers  or 
in  moderate  numbers  if  the  inoculations  are  kept  up 
for  a  prolonged  period  of  time.  Human  beings  are 
sometimes  infected  with  bacilli  of  bovine  type. 
Reasoning  from  the  data  obtained  from  the  diag- 
nostic and  therapeutic  use  of  tuberculins  made  from 
bacilli  of  bovine  and  human  types,  he  concludes 
that  bovine  and  human  l)acilli  arc  difi'erent  in  that 
their  toxines  are  different.  Judging  from  the  man- 
ner in  which  patients  suffering  from  tuberculosis 
react  toward  tuberculins  made  from  lumian  and 
bovine  bacilli,  it  should  be  concluded  that  both  vari- 
eties of  bacilli  are  able  to  produce  tuberculosis  in 
the  human  body,  but  that  the  localization  of  the 


April  3,  3900.] 


PITH  OF  CURRENT  LITERATURE. 


two  infections  is  more  or  less  constant.  He  has 
found  that  infections  of  the  lungs,  larynx,  and  in- 
testines, when  complicating  tuberculosis  of  the 
lungs,  are,  as  a  rule,  best  treated  by  tuberculins 
made  from  bovine  bacilli.  These  infections  are 
most  probably  produced  by  bacilli  of  human  origin. 
But  infections  of  the  bones,  glands  (as  a  rule), 
peritonaeum  (with  eft'usion),  ear,  and  genitourinary 
tract  are,  as  a  rule,  best  treated  by  tuberculins  made 
from  human  bacilli.  These  infections  are  most 
probably  produced  by  bacilli  of  bovine  origin.  Rea- 
soning from  the  analogy  furnished  by  smallpox, 
the  fact  that  human  bacilli  will  immunize  cattle 
against  infection  with  bovine  bacilli  would  suggest 
that  bovine  bacilli  might  immunize  human  beings 
against  hitman  bacilli;  and,  if  our  belief  that  tuber- 
culosis of  the  bones  is  of  bovine  origin  is  true,  and 
our  observation  that  persons  suffering  from  bone 
lesions  rarely  suffer  from  tuberculosis  of  the  lungs 
is  correct,  we  have  clinical  evidence  which  supports 
the  fact  that  immunity  in  human  beings  against 
human  bacilli  may  be  produced  by  infection  wnth 
bacilli  of  the  bovine  type. 

3.  Tubercle  Bacilli  in  New  York  City  Milk. — 
Hess  states  that  virulent  tubercle  bacilli  were  found 
in  seventeen  among  107  specimens,  that  is  in  sixteen 
per  cent,  of  the  milk  retailed  from  cans  in  Xew  York 
city.  These  bacilli  were  not  demonstrable  by  direct 
microscopical  examination,  but  were  proved  to  be 
present  by  means  of  animal  inoculation.  Cream  as 
well  as  sediment  was  found  to  harbor  these  organ- 
isms, so  that  in  all  experiments  of  this  nature  these 
two  parts  of  the  milk  should  be  used  in  making  in- 
oculations. Tubercle  bacilli  were  likewise  found  in 
a  specimen  of  "commercially  pasteurized"  milk, 
showing  that  this  method,  as  now  carried  out,  does 
not  insure  protection  in  this  particular.  It  is  sug- 
gested that,  as  this  name  is  misleading,  only  such 
milk  be  labeled  "pasteurized"'  as  has  been  heated  for 
a  length  of  time  and  to  a  degree  of  temperature  suf- 
ficient to  render  it  an  absolutely  safe  food.  When 
the  tubercle  bacilli  were  isolated  they  were  fotnid  to 
be  in  all  but  one  instance  bovine  in  type.  In  this  in- 
stance, however,  a  human  variety  was  distinguished, 
which  shows  that  milk  may  become  infected  from 
tuberculous  individuals  and  that  this  source  of  con- 
tamination should  be  guarded  against.  A  number  of 
infants  and  young  children  who  drank  milk  contain- 
ing tubercle  bacilli,  when  examined  one  year  later, 
seemed  to  be  in  average  health.  A  fourth  of  the 
number,  however,  reacted  to  tuberculin.  One  of 
these  subjects  was  in  poor  physical  condition  and 
had  suffered  from  a  recent  glandular  infection.  Al- 
though probably  over  90  per  cent,  of  tuberculosis  is 
due  to  infection  from  human  beings,  it  is  believed 
that  we  are  not,  therefore,  justified  in  neglecting  the 
danger  from  bovine  infection,  for  even  a  small  per- 
centage of  the  infections  in  the  United  States  means 
thousands  of  cases  of  tuberculosis.  As  an  immedi- 
ate safeguard,  milk  not  coming  from  tuberculin  test- 
ed cows  should  be  pasteurized  or  brought  to  a  boil. 
[Many  additional  inspectors  should  be  allowed  for 
examining  the  herds,  and,  finally,  all  cows  should  be 
tested  with  tuberculin,  and  animals  which  react 
should  be  condemned  or  isolated. 

4.  Children  of  Tuberculous  Parents. — Miller 
and  Woodruff"  have  examined  i^o  children  whose 


parents  were  under  treatment  for  pulmonary  tuber- 
culosis at  the  Bellevue  Hospital  tuberculosis  clinic. 
The  children  observed  lived  in  tenements,  in  most 
instances  under  insanitary  conditions  and  in  close 
association  with  their  parents,  the  majority  of  w-hom 
had  pulmonary  tuberculosis  in  an  advanced  stage. 
The}-  found  that  in  the  children  of  tuberculous  par- 
ents, who  lived  in  close  association  with  such  par- 
ents, a  large  proportion  (in  their  series  51  per  cent.) 
became  infected  wath  tuberculosis.  The  earliest 
manifestations  of  such  tuberculosis  were  not  found 
in  the  superficial  glands  or  in  the  bones  and  joints, 
but  in  the  lungs.  The  physical  signs  of  these  early 
pulmonary  lesions,  in  children  under  ten  years  of 
age,  were  very  rarely  those  usually  found  in  adults, 
but  consisted  more  often  in  the  presence  of  persist- 
ent fine  rales  just  without  the  midclavicular  Hne  in 
the  fifth  and  sixth  intercostal  spaces.  In  other  cases 
in  which  persistent  sibilant  rales  were  present  in 
varying  portions  of  the  chest,  the  diagnosis  was 
doubtful,  but  they  should  be  regarded  with  suspi- 
cion. The  tuberculin  tests  furnished  the  most  reli- 
able means  of  diagnosis  of  tuberculosis  in  children. 
Of  these  they  regard  the  hypodermic  test  in  doses 
up  to  five  milligrammes  as  positively  diagnostic.  Of 
the  local  tests  the  cutaneous  was  more  reliable  in  chil- 
dren than  the  ophthalmic  and  presented  none  of  its 
possible  dangers.  Moreover,  it  was  fully  corrobo- 
rated by  the  hypodermic  test,  and  in  consequence 
they  regard  it  as  a  reliable  and  safe  means  of  diag- 
nosis of  tuberculosis  in  children.  Examination  of 
the  sputum,  as  usually  practised,  was  of  almost  no 
aid  in  the  diagnosis  of  early  pulmonary  tuberculosis 
in  children.  As  a  routine  procedure  it  was  not  very 
feasible  in  dispensary  practice.  Alalnutrition  was 
sometimes  the  only  appreciable  evidence  of  tubercu- 
losis in  children.  The  presence  of  hypertrophied 
tonsils  and  adenoid  growths  in  any  child  did  not  ap- 
pear to  incline  the  balance  in  a  suspected  case  to- 
ward a  positive  diagnosis  of  tuberculosis.  In  view% 
however,  of  the  varying  opinions  held  on  this  sub- 
ject, further  investigations  along  the  lines  of  the 
bacteriology  and  pathology  of  this  subject  should  be 
made.  In  their  cases  the  evidence  that  the  enlarge- 
ment of  the  cervical  lymph  nodes  was  of  aid  as  a  de- 
termining factor  in  arriving  at  a  diagnosis  of  tuber- 
culosis in  children  w-as  not  conclusive. 

5.  Etiology  of  Face,  Nose,  and  Jaw  Deformi- 
ties.— Talbot  states  that  in  man's  evolution  cer- 
tain structures  develop  and  others  are  lost  for  the 
benefit  of  the  organism  as  a  whole.  Since  the  face, 
jaws,  and  teeth  are  undergoing  such  rapid  changes, 
these  are  structures  with  transitory  characteristics 
and  are  more  easily  involved  in  disease  than  any 
others  of  the  body.  In  the  development  of  man 
from  the  primitive  cell  periods  of  stress  due  to  read- 
justment to  environm.ent  occur.  Those  W'hich  occur 
during  development  are  called  periods  of  evolution 
and  those  after  maturity  periods  of  involution.  In 
man's  evolution  certain  parts  disappear  for  the  bene- 
fit of  the  organism  as  a  whole ;  in  the  evolution  of 
organisms  certain  organs  disappear.  Periods  of 
stress  occur  when  the  functions  of  some  organs  are 
lost  and  those  of  others  gained  by  development. 
The  law  of  economy  of  growth  centres  around  this 
struggle  of  organs  or  organisms  for  existence.  Be- 
cause of  this  fact  physiological  atrophies  and  hyper- 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


trophies  occur.  Whenever  arrest  of  the  develop- 
ment of  the  jaws  takes  place  there  is  also  nasal  sten- 
osis with  atrophies  or  hypertrophies  and  deformi- 
ties of  the  bones  of  the  nose  and  mucous  membrane. 
The  two  conditions  go  side  by  side.  Neither  is  de- 
pendent on  the  other  to  any  marked  degree  as  was 
formerly  supposed,  both  being  the  result  of  an  un- 
stable nervous  system.  The  successful  treatment  of 
one  must  exert  a  healthful  influence  on  the  other. 
The  perpendicular  line  is  the  dividing  line  between 
the  normal  and  abnormal  facial  angle.  Deformities 
of  the  face,  nose,  jaws,  and  teeth  rarely  require 
treatment  except  under  conditions  where  these 
structures  develop  inside  of  the  perpendicular  line 
drawn  at  right  angles  to  a  line  from  the  root  of  the 
nose  to  the  external  auditory  meatus. 

7.  Separation  of  the  Upper  Maxillae. — Brown 
concludes  that  in  otherwise  normal  cases  the  maxillae 
should  be  separated  to  improve  contracted  nasal 
conditions,  and  the  earlier  this  may  be  done  the  bet- 
ter the  result.  In  infants  with  hare  lip  and  cleft 
palate,  the  parts  should  be  readjusted  by  gradual 
methods,  care  being  used  not  to  disarrange  more 
than  may  be  absolutely  necessary  those  structures, 
which,  though  invisible,  are  nevertheless  in  course 
of  development.  In  cases  in  which  very  wide  fis- 
sure actually  exists  the  width  of  the  fissure  should 
be  reduced  and  the  form  of  the  palate  corrected  be- 
fore plastic  operation  for  closure  is  attempted.  It 
appears  to  be  quite  impossible  for  one  to  overes- 
timate the  benefit  to  the  general  health  and  develop- 
ment of  growing  children,  could  they  be  thus  cared 
for  at  a  sufficiently  early  date.  In  the  war  against 
tuberculosis,  treatment  of  this  character  is  imques- 
tionably  destined  to  be  a  factor  quite  worth  consid- 
eration. 

MEDICAL  RECORD. 

March  27,  1909. 

1.  Reports  of  300  Cases  Treated  with  a  Culture  of  Lactic 

Acid  Bacteria,  By  Charles  E.  North. 

2.  Direct  Blood  Transfusion — Its  Technique  and  the  Indi- 

cations for  Its  Use,  By  A.  A.  Berg. 

3.  The  Rontgen  Ray  and  the  Etiology  of  Cancer, 

Bv  William  H.  Dieffenbach. 

4.  Two  Unusual  Cases  of  Influenza  Pneumonia, 

By  RoLFE  Floyd. 

5.  Reduplication  of  the  Tibia,  By  J.  B.  Bissell. 

I.  Reports  of  300  Cases  Treated  with  a  Cul- 
ture of  Lactic  Acid  Bacteria. — North  adds  his 
new  results  to  his  experience  which  he  reported  in  a 
former  paper.  How  much  value,  he  remarks,  should 
be  attached  to  the  results  obtained  by  treatment 
with  the  culture  of  lactic  acid  bacilli  is  largely  a 
matter  of  individual  judgment.  It  is  possible  to  err 
on  the  side  of  enthusiasm,  on  the  one  hand,  and  on 
the  side  of  caution  and  timidity  on  the  other.  In  his 
opinion  the  treatment  of  some  inflammations  caused 
by  infectious  bacteria  which  can  be  reached  by  a 
spray  or  wash  of  the  culture  of  lactic  acid  bacteria 
used  in  this  research  has  considerable  value.  A  few 
things  have  been  learned  by  the  work  that  may  be 
even  more  positively  stated  :  The  bacillus  of  Mas- 
sol  can  be  grown  abimdantly  in  dextrose  bouillon 
by  the  addition  of  lumps  of  calcium  carbonate.  The 
use  of  the.se  cultures  as  a  wash  or  spray  on  inflamed 
surfaces  or  cavities  often  diminishes  the  discharge 
upon  such  surfaces  or  cavities.    The  use  of  these 


cultures  often  diminishes  odor  caused  by  putrefac- 
tion. The  treatment  sometimes  reduces  swelling, 
especially  in  the  erectile  tissues  of  the  nose.  Both 
acute  and  chronic  inflammations  caused  by  infec- 
tions sometimes  appear  to  be  checked  when  their  seat 
can  be  reached  by  an  injection  of  these  cultures. 
The  use  of  the  cixltures  seems  to  be  accompanied 
by  no  special  danger  and  they  cause  no  irritation. 
Further  study  of  the  treatment  seems  to  be  war- 
ranted from  the  results  obtained.  North  concludes 
that  if  this  treatment  becomes  established,  then  an- 
other weapon  will  have  been  placed  in  our  hands 
for  fighting  infections.  It  will  mean  fighting  bac- 
teria v\dth  their  own  weapons ;  literally,  "germ  fight 
germ."  The  success  of  one  species  of  bacteria  cul- 
tivated in  one  culture  medium  will  suggest  the  in- 
vestigation of  other  species  of  bacteria  and  other 
culture  media ;  and  among  these  may  perchance  be 
found  not  only  cultures  of  general  value,  but  some 
of  special  value  in  combating  particularly  infections 
of  one  sort  or  another.  It  may  be  that  bacteria 
cultivated  in  laboratory  media,  together  with  their 
products,  are  destined  to  play  an  essential  part  in 
the  warfare  against  infectious  disease. 

3.  Rontgen  Ray  and  the  .ffitiology  of  Cancer. 
— Diefiienbach  has  observed  three  lumdred  cases  of 
cancer  at  the  Flower  Hospital  and  in  private  prac- 
tice. Of  these  patients  60  per  cent,  were  women; 
married  women  in  great  majority.  The  greater 
number  of  patients  ranged  from  fifty  to  sixty-five 
years.  The  patients  were  in  fairly  good  health, 
excepting  in  cases  of  long  standing,  when  cachexia 
had  supervened.  Constipation  was  present  in  a 
large  percentage  of  cases.  Negative  history  of 
syphilis  in  nearly  all  the  cases.  Gonorrhoea  was  ad- 
mitted by  nearly  all  male  cases.  Vaccination  had 
been  performed  on  all  patients  questioned  on  this 
point.  The  infectiousness  of  cancer  from  contact 
or  otherwise  was  not  established,  and  the  bacterial 
or  parasitic  origin  of  cancer  receives  no  corrobora- 
tion or  encouragement  from  his  experience.  Hered- 
itary history  was  established  in  only  ten  per  cent, 
of  the  cases.  After  persistent  questioning,  history 
of  trauma  preceding  neoplasm  was  found  in  ninety 
per  cent,  of  the  cases.  Ofifhand  questioning  often 
resulted  in  negative  replies,  but  persistent  and  care- 
ful questions  as  regards  habits,  occupations,  etc., 
usually  elicited  some  kind  of  trauma  or  irritation  to 
which  the  patients  frequently  attached  no  impor- 
tance, but  which,  in  the  light  of  present  knowledge, 
when  oft  repeated,  are  a  menace  to  healthy  cell  de- 
velopment. He  concludes  that  neoplasms  are  due 
to  interference  with  normal  cell  reproduction  in- 
duced through  trauma,  pressiux.  severe  inflamma- 
tions, or  constant  irritation? ;  these  factors  act  noon 
cell  proliferation  by  producing  abnormal  cells  which 
in  turn,  if  the  original  irritating  status  is  main- 
tained, again  generate  cells  of  their  own  kind.  If 
trophic  nerve  impulses  are  not  interfered  with,  nor- 
mal conditions  may  supervene  when  the  irritation 
or  inflammation  subsides.  If  involvement  of  the 
trophic  nerve  takes  place  .so  that  efferent  and  affer- 
ent impulses  are  interfered  with  or  inhibited,  riot- 
ous devclf)pment  of  the  new  progeny  of  cells  will 
be  invited.  If  the  trophic  nerve  supplying  the  part 
is  severed  or  permanently  inhibited,  ulceration  will 
supervene. 


April  3,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


711 


BRITISH  MEDICAL  JOURNAL, 

March  13,  1909. 

1.  A  Case  of  Hernia  Strangulated  in  the  Foramen  of 

VVinslow,  and  the  Treatment  of  Greatly  Distended 
Small  Intestine,  By  C.  A.  Morton. 

2.  The  After  Results  in  a  Series  of  Operations  for  the 

Radical  Cure  of  Hernia,  By  R.  W.  Murray. 

3.  Strangulated  Hernia  through  the  Foramen  of  Wins- 

low  :  Operation :  Recovery,  By  T.  Sinclair. 

4.  A  Case  in  which  Enteros^sm  was  a  Pronounced  Fea- 

ture, Necessitating  Abdominal  Section  Four  Times 
within  Ten  Months,  By  C.  W.  Dean. 

5.  The  Diagnosis  and  Treatment  of  Chronic  Ulcer  of  the 

Stomach  and  Duodenum,  By  A.  Thomson. 

6.  Primary  Diffuse  Pneumococcic  Peritonitis :  Treatment 

by  Drainage  and  Pneumococcic  Vaccine :  Recovery, 

By  H.  B.  Robinson. 

7.  Incisions   for   Operations   on   the   Upper  Abdominal 

Organs,  By  A.  Don. 

8.  Intestinal    Obstruction   Produced   by   an  Enormously 

Distended  Stomach,  By  A.  E.  Maylard. 

9.  Observations  on  the  Physiology  of  the  Female  Genital 

Organs  (Part  III  of  Report  CXII  of  the  Science 
Committee  of  the  British  Medical  Association), 

By  W.  B.  Bell  and  P.  Hick, 

5.  Gastric  and  Duodenal  Ulcer. — Thom.son  re- 
ports a  consecutive  series  of  fifty  cases  in  which 
a  chronic  ulcer  of  the  stomach  or  duodenum  was  not 
onl}'  diagnosticated  by  clinical  methods,  but  was 
demonstrated  at  the  operation  undertaken  for  its 
relief.  Bearing  in  miijd  that  the  so  called  anterior 
wall  of  the  pylorus  and  duodenum  is  really  the  right 
lateral  wall,  and  that  with  which  the  acid  contents 
of  the  stomach  are  first  brought  into  contact,  it  is 
very  striking  that  it  is  almost  invariably  the  seat  of 
the  ulcer.  Even  though  ulcers  on  the  posterior  wall 
are  more  likely  to  escape  recognition,  yet  the  true 
proportion  of  anterior  ulcers  is  probably  about 
ninety-five  per  cent.  Sixty  per  cent,  of  the  total 
cases  occurred  in  men ;  the  duodenal  ulcers  occurred 
in  the  proportion  of  eighteen  men  to  four  women. 
The  age  varied  from  twenty-one  to  sixty-seven 
years,  the  average  being  forty-one  years.  The  duo- 
denal cases  alone  ranged  slightly  higher.  The  dura- 
tion of  the  ulcer  cannot  always  be  determined  with 
certainty,  because  of  the  long  remissions  which  oc- 
cur. In  only  six  per  cent,  of  the  cases  was  pain 
entirely  absent ;  in  all  the  ulcer  was  small,  with  no 
induration,  and  a  smooth  peritoneal  scar  on  the  sur- 
face. The  pain  is  almost  invariably  referred  to  the 
vicinity  of  the  middle  line,  and  frequently  passes 
through  to  the  back  between  the  shoulders.  In 
ulcer  of  the  lesser  curvature  the  pain  is  to  the 
left  of  the  xiphoid  or  below  or  over  the  right  costal 
margin.  In  ulcer  at  or  near  the  pyloric  ring  the 
pain  is  in  the  middle  line.  In  ulcer  of  the  duodenum 
the  pain  is  to  the  right  of  the  xiphoid  or  below  or 
over  the  right  costal  margin.  The  night  pain  in  duo- 
denal cases  is  a  variety  of  hunger  pain ;  in  the  py- 
loric cases  it  is  usually  associated  with  stenosis  and 
distension  of  the  stomach  and  the  accumulation  gnd 
decomposition  of  the  food  taken  during  the  day. 
Tenderness  in  the  epigastrium  was  present  in  about 
one  third  of  the  cases,  in  most  of  which  the  ulcer 
was  situated  near  the  pylorus  or  lesser  curvature, 
depending  on  the  greater  frequency  with  which  gas- 
tric ulcer,  in  contrast  with  duodenal  ulcer,  leads  to 
the  formation  of  adhesions.  The  writer  holds  that 
the  pain  of  ulcer  is  due,  not  to  hyperacidity  of  the 
gastric  contents,  but  to  interference  with  the  move- 
ments of  the  stomach  by  adhesions  which  have 


formed.  In  the  same  way  the  hunger  pain  of  duo- 
denal ulcer  is  probably  due  to  the  fact  that  when  the 
stomach  is  empty  it  tends  to  move  to  the  left,  thus 
putting  traction  on  the  duodenum.  Vomiting,  next 
to  pain,  is  the  most  constant  symptom  of  ulcer;  it 
attains  its  acme  in  ulcer  at  the  pylorus  with  narrow- 
ing of  the  outlet.  Vomiting  may  be  entirely  absent 
in  cases  of  uncomplicated  duodenal  ulcer.  Haemor- 
rhage occurs  in  about  one  half  the  cases ;  it  is  most 
frequent  in  ulcers  at  or  near  the  pylorus,  and  least 
so  in  ulcers  of  the  lesser  curvature.  Haemorrhages 
from  the  bowel  are  most  frequent  in  duodenal  ulcers. 
Constipation  is  almost  universal.  \'isible  peristalsis 
was  only  observed  in  five  cases,  and  is  a  favorable 
indication  from  an  operative  point  of  view,  as  the 
hypertrophy  of  the  muscular  coat  of  the  stomach 
enables  full  benefit  to  be  obtained  from  the  opera- 
tion of  gastroenterostomy.  Resection  of  the  stom- 
ach was  performed  in  three  cases  with  one  death; 
gastroenterostomy  in  forty-seven  cases  with  three 
deaths  at  operation.  Of  the  remaining  forty-four, 
thirty-eight  are  under  observation  and  all  greatly 
improved. 

7.  Incisions  for  the  Upper  Abdomen. — Don  rec- 
ommends the  following  incisions  for  operations  on 
the  upper  abdominal  organs.  They  are  anatomically 
correct,  give  ample  room,  and  when  healed,  produce 
a  firm  cicatrix.  The  blood  and  nerve  supply  is  in- 
tact, the  only  vessel  severed  being  the  deep  epigas- 
tric artery.  The  skin  and  anterior  sheath  of  the  rec- 
tus are  divided  a  finger  breadth  to  the  right  or  left 
of  the  middle  line  from  opposite  the  seventh  costo- 
chondral  junction  to  the  umbilicus.  The  sheadi  is 
dissected  off  the  muscle  on  the  inner  side,  and  the 
muscle  freed  from  its  inner  sheath  and  retracted 
outwards  as  far  as  possible.  The  posterior  sheath 
and  peritonaeum  are  then  incised  as  far  out  as  con- 
venient, and  parallel  to  the  whole  length  of  the  skin 
incision.  Through  this  opening  the  whole  of  the 
upper  abdomen  can  be  explored,  and  if  operation  on 
lateral  organs  is  deemed  advisable,  the  horizontal 
limb  is  then  added.  The  rectus  is  best  divided  at  its 
umbilical  intersection,  which  is  readily  exposed  by 
prolonging  the  vertical  incision,  and  from  the  lower 
end  of  this  a  curved  incision  is  made  upward  and 
outward  to  the  lowest  part  of  the  costal  margin. 
This  divides  skin  and  superficial  fascia  onlv.  The 
muscle  with  the  skin  and  anterior  sheath  is  now 
raised  up  with  the  left  hand,  and  the  whole  cut 
straight  outward  through  the  middle  of  the  fibrous 
intersection  till  the  whole  thickness  of  the  rectus  is 
divided.  The  posterior  sheath  is  divided  one  half 
inch  higher  up  for  ease  in  suturing  later. 

LANCET. 

March  13,  1909. 

1.  Disinfection  and  Disinfectants  (Milroy  Lectures,  I), 

By  R.  T.  Hewlett. 

2.  The  Mechanism  Underlying  the  Various  Methods  of 

Artificial  Respiration,  Practised  since  the  Founda- 
tion of  the  Royal  Humane  Society  in  1774  (Hunter- 
ian  Lectures,  I),  By  A.  Keith. 

3.  Tabes  Dorsalis  with   Unilateral   Anaesthesia;  a  Con- 

tribution to  the  Pathogenesis  of  the  Disease, 

By  H.  T.  Thompson. 

4.  Hydrochloric  Acid  in  the  Gastric  Contents  in  Cancer; 

a  Reply  to  Professor  B.  Moore, 

By  S.  M,  CoPEMAN  and  H.  W.  Hake. 

5.  Medical  Ionization  ;  Its  Uses  and  Possibilities, 

By  N.  S.  FiNzi. 


712 


PITH  or  CURRENT  LITERATURE. 


I  New  York 
Medical  Journal. 


6.  A  Case  of  Primary  Ovarian  Actinomycosis, 

By  F.  E.  Taylor  and  W.  E.  Fisher. 

7.  A  Method  of  Treating  Fracture  of  the  Clavicle, 

By  F.  RoMER. 

8.  A  Case  of  Oligohydramnios  with  Partial  Amputation 

of  a  Foot  Occurring  in  a  Uterus  Unicornis, 

By  L.  C.  Bl.\ckstone. 

I.  Disinfection.^ — ^  Hewlett,  in  the  first  of  his 
Milroy  lectures,  states  that  Nature's  methods  of  dis- 
infection— that  is,  the  removal  of  infective  power — 
only  partially  depend  on  the  killing  of  the  infecting 
organisms.  Outside  the  body  various  agencies  are 
always  at  work  tending  to  lessen  the  infecting  power 
of  microorganisms  to  such  an  extent  that  iiltimately 
infection  may  become  impossible.  Probably  in  all 
cases  a  certain  dose  of  the  organisms  is  necessary 
for  infection  to  occur,  and  thus  dilution  of  the  in- 
fective material  with  a  relatively  large  volume  of 
air,  or  in  some  instances  of  water,  may  so  reduce 
the  dose  of  infective  matter  which  can  be  admitted 
to  the  body  at  any  particular  time  that  infection  does 
not  take  place.  Such  dilution  with  air  plays  a  con- 
siderable part  in  preventing  the  spread  of  epidemic 
disease,  and  therefore  liberal  air  space  is  regarded 
as  essential  in  fever  hospitals.  In  the  air,  too,  the 
bactericidal  effect  of  sunlight  is  likely  to  exert  a 
maximum  effect.  Dessication,  though  to  some  ex- 
tent tending  to  promote  the  spread  of  infection  by 
favoring  the  formation  of  dust  and  so  serving  to 
disseminate  the  infecting  agent,  largely  acts  as  a 
disinfecting  agent  by  the  act  of  dessication  destroy- 
ing the  vitality  of  the  infecting  organisms.  The 
streets  of  large  towns  must  be  swarming  v>'ith  colon 
bacilli  from  the  excreta  of  domestic  animals,  yet  it 
is  exceptional  to  find  the  colon  bacillus  in  the  air  of 
cities.  Filtration  is  another  of  Nature's  methods 
of  disinfection  by  exrclusion.  Its  action  is  best  seen 
in  the  case  of  water,  which,  percolating  through  the 
soil  or  through  pervious  strata,  such  as  chalk,  be- 
comes purified  by  the  mechanical  removal  of  the 
microorganisms  it  contains.  In  man,  filtration  of 
the  air  through  the  channels  of  the  respiratory  tract 
almost  certainly  acts  as  a  protective  mechanism.  In 
ordinary  circumstances  the  respiratory  mucous 
membrane  below  the  larynx  is  practically  sterile. 
Light,  particularly  sunlight,  is  definitely  govraicidal 
and  acts  both  by  a  direct  action,  due  to  the  chemical 
rays  at  the  violet  end  of  the  spectrum,  and,  sec- 
ondarily, by  inducing  chemical  changes  in  the  sub- 
stratum whereby  germicidal  substances,  such  as 
ozone  and  hydrogen  peroxide,  are  generated.  In 
the  air  the  disinfecting  action  of  sunlight  plays  a 
considerable  role  in  the  destruction  of  infective  mat- 
ter. The  variations  in  virulence  of  pathogenic  mi- 
croorganisms which  are  well  known  to  occur  must 
to  some  extent  determine  the  occurrence  or  not  of 
infection.  Dessication,  light,  and  heat,  all  diminish 
virulence.  Symbiosis,  the  growing  together  of  va- 
rious species  of  microorganisms,  plays  a  large  part 
in  nature  in  the  destruction  of  infective  organisms. 
The  action  of  symbiosis  in  "crowding  out"'  patho- 
genic organisms  probably  largely  depends  on  the 
products  produced  by  the  symbiotic  organisms  hav- 
ing a  germicidal  effect  upon  the  pathogenic  organ- 
isms. Heat  is  by  far  the  most  important  and  most 
generally  used  disinfectant  agent.  It  may  be  em- 
jjloyed  in  the  form  of  fire  or  in  the  form  of  high 
temperature,  either  as  dry  or  moist  heat.     Fire  is 


the  most  efiicient,  and  one  form  of  it  should  be 
more  generally  used — torch  flames  generated  by  a 
cyclone  burner  burning  kerosene  oil  driven  by  a 
pump.  They  might  well  be  employed  for  the  dis- 
infection of  brick,  earth,  or  iron  surfaces  such  as 
stables,  pens,  yards,  etc.  Expert  operators  can 
treat  wooden  surfaces  without  burning  them.  Dry 
heat  has  been  largely  superseded  by  moist  heat  be- 
cause it  has  little  power  of  penetration,  and  relative- 
ly high  temperatures  are  required  —  almost  the 
scorching  point.  The  use  of  disinfectants  resolves 
itself  into  the  employment  of  germicidal  substances : 
(i)  In  the  treatment  of  wounds  and  local  infections, 
though  even  in  these  they  must  be  employed  with 
caution  and  discretion;  (2)  for  the  sterili.-^ation  of 
instruments  and  materials  used  in  surgical  and  med- 
ical practice;  (3)  for  the  prevention  of  the  bacterial 
infection  of  drugs — e.  g.,  antisera  and  solutions 
for  hypodermic  administration — and  for  the  preser- 
vation of  foods  and  other  substances;  and  (4)  for 
the  destruction  outside  the  body  of  infective  mat- 
ter emanating  from  infected  animals  and  plants. 
The  principal  disinfectants  comprise  manv  metallic 
salts,  in  particular  those  of  mercury,  the  mineral 
acids,  oxidizing  agents  such  as  hydrogen  peroxide 
and  carbolic  acid.  Many  other  substances — e.  g., 
boric  and  salicylic  acids,  alcohol,  etc. — are  used  as 
antiseptics,  but  have  little  germicidal  powei .  The 
disinfectants  very  frequently  form  compounds  with 
proteins,  and  on  this  power  their  germicidal  proper- 
ties may  largely  depend.  They  may  form  com- 
pounds with  the  bacterial  proteins  which  are  incom- 
patible with  the  life  of  the  bacterial  cells.  Perhaps 
all  germicides  have  this  power  of  combining  with 
proteins,  and  heat,  of  course,  causes  coagulation  of 
native  proteins.  The  following  conclusions  have 
followed  the  investigation  of  certain  of  the  best 
known  disinfectants:  i.  Antiseptic,  is  not  synony- 
mous with  disinfecting  power.  2.  The  effectual  dis- 
infectant operation  of  chlorine  and  potassium  per- 
manganate appears  to  depend  far  more  upon  the 
medium  in  which  the  infective  particles  are  distrib- 
uted than  on  the  specific  characters  of  the  particles 
themselves.  3.  No  virulent  liquid  can  be  consid- 
ered disinfected  by  carbolic  acid  unless  it  contains 
at  least  two  per  cent,  by  weight  of  the  pure  acid.  4. 
Aerial  disinfection  as  commonly  practised  in  the 
sick  room,  is  either  useless  or  positively  objection- 
able, owing  to  the  false  sense  of  security  it  is  apt  to 
produce.  5.  When  it  is  resorted  to  the  probability 
that  the  bacteria  are  shielded  by  an  envelope  of  dried 
albuminous  matter  should  always  be  borne  in  mind. 
6.  Dry  heat,  when  it  can  be  applied,  is  probably  the 
most  efficient  of  all  disinfectants.  The  require- 
ments for  an  ideal  chemical  disinfectant  may  be 
summarized  as  follows :  (a)  The  substance  must  be 
cheap,  (b)  It  should  be  relatively  nonpoisonous. 
(c)  It  should  have  no  corrosive  or  other  actions  on 
the  ordinary  metals  and  it  should  not  stain  linen, 
etc.  (d)  It  should  not  separate  into  layers  on 
standing,  and  should  run  freely  from  the  containing 
vessel  at  all  times,  (e)  It  should  possess  high  ger- 
micidal power,  .(f)  It  should  be  miscible  with  ordi- 
nary tap  water  in  all  proportions  to  form  a  stable 
solution  or  homogeneous  emulsion  which  should  not 
separate  appreciably  into  layers  on  standing,  (g) 
It  may  with  advantage  have  a  solvent  power  for 


April  3,  1909. 1 


I'lTH  OF  CURRENT  LITERATURE. 


713 


grease,  for  greasy  surfaces  have  often  to  be  disin- 
fected, (h)  Its  germicidal  power  should  not  be 
markedly  reduced  in  the  presence  of  organic  matter. 
( i)  Heating  to  a  moderate  temperature  should  not 
affect  it,  so  that  it  may  be  used  hot  if  desired. 

LA  PRESSE  MEDICALE. 
February  27,  igog. 

1.  History  of  a  Case  of  Atrophic  Myopathy  of  the  Facio- 

scapulohumeral Type  during  a  Period  of  Thirty 
Years,  By  L.  Landouzy  and  L.  Lortat-Jacob. 

2.  Treatment  of  Tuberculous  Lupus  of  the  Face, 

By  De  Beurmann  and  Degrais. 

3.  A  Case  of  Spontaneous  Rupture  of  the  Aorta.  By  J.  D. 

1.  History  of  a  Case  of  Atrophic  Myopathy. — 

Landouzy  and  Lortat-Jacob  present  the  history  of  a 
case  that  has  been  reported  several  times,  first  in 
1874,  from  the  first  observation  at  the  age  of  eight 
until  his  death  at  the  age  of  forty-five.  The  article 
is  illustrated  by  plates  that  show  the  deformations  of 
the  bones  and  the  atrophy  of  the  muscles  at  different 
ages.  The  patient  died  of  tuberculous  broncho- 
pneumonia, and  a  very  complete  autopsy  was  made. 
The  muscles  were  carefully  dissected  and  described 
and  the  nervous  system  examined  histologically. 
The  results  of  the  latter  were  negative. 

2.  Treatment  of  Tuberculous  Lupus  of  the 
Face.  —  De  Beurmann  and  Degrais  describe  a 
compressor  to  be  applied  to  the  diseased  tissues  in 
association  with  the  employment  of  the  penetrant 
rays  whether  x  rays,  radium  rays,  or  the  chemical 
rays  of  light.  They  assert  that  good  results  have 
been  obtained  in  secondarily  infected  ulcerous  lupus 
exedens,  lupus  vegetans,  and  lupus  non  exedens. 

3.  Spontaneous  Rupture  of  the  Aorta. — J.  D. 
reports  the  case  -of  a  man,  twenty-seven  years  of 
age,  who  while  engaged  in  his  ordinary  v/ork  as  a 
railroad  employee  was  suddenly  taken  ill  and  died 
in  eight  hours.  Autopsy  revealed  a  rupture  of  the 
posterior  wall  of  the  aorta  about  two  cm.  above  the 
level  of  the  sigmoid  valve.  Histological  examina- 
tion revealed  that  the  rupture  was  due  to  a  chronic 
atrophic  aortitis  caused  by  syphilis. 

March  3,  1909. 

1.  Aneurysm  of  the  Hepatic  Artery,  By  T.  Tuffier. 

2.  Clinical  Signs  of  Contusions  of  the  Abdomen  and  Dis- 

cussion of  the  Urgent  Indication  for  Operative  Inter- 
vention, By  Dehelly  and  Lagane. 

I.  Aneurysm  of  the  Hepatic  Artery. — Tuffier 
reports  the  case  of  a  man,  seventy-two  years  of 
age,  who  came  under  treatment  for  chronic  jaun- 
dice. Obstruction  of  the  ductus  choledochus  was 
complete,  and  cancer  of  the  pancreas  was  diagnosti- 
cated. On  operation  the  gallbladder  was  found  to 
be  absolutely  normal  in  form,  size,  and  coloration, 
but  adherent  on  the  left  side  to  a  tumor  which 
proved  to  be  an  aneurysm  of  the  hepatic  artery. 
The  pancreas  was  perfectly  free  and  was  not  the 
seat  of  any  abnormal  induration.  The  patient  died 
a  few  days  later,  and  autopsy  showed  that  the  rest 
of  the  arterial  system  was  normal. 

BERLINER  KLINISCHE  WOCH ENSCH Rl FT. 
February  22,  igog. 

1.  Experimental    Transplantation    of    Pieces    of  Living 

Tissue  into  Other  Hollow  Organs  of  the  Body, 

By  Alexander  Tietze. 

2.  The  Value  of  the  Pressure  Difference  Operation  in 

Surgery  of  the  Lungs  and  Pleura,  and  a  New 
Overpressure  Chamber,  By  F.  Karewski. 


.5.    Splanchnoptosis,  Bj'  L.  Landau. 

4.  Local  Cutaneous  Stimulation  and  Cutaneous  Reactions, 

By  KuLBS. 

5.  Carcinoma  of  the  Body  of  the  Uterus  in  Virgins, 

By  A.  HiRSCHBERG. 

6.  Processes  of  Healing  after  Amputation  of  a  Burst 

Sacral  Meningocele  with  Resection  of  the  Conus 
Terminalis,  By  F.  Goppert. 

7.  Recognition  and  Treatment  of  Pancreatitis, 

By  Johannes  Witte. 

8.  Diagnosis  of  Diseases  of  the  Pancreas, 

By  Felix  Eichler  and  Hans  Schirokauer. 

9.  Contributions  to  the  Diagnosis  of  Diseases  of  the  Pan- 

creas, By  L.  Caro  and  E.  Worner. 

10.  Contribution  to  the  Chemical  Demonstration  of  the 

Adrenalin  in  the  Blood  Serum, 

By  Giuseppe  Comessati. 

I.  Experimental  Transplantation  of  Pieces  of 
Living  Tissue  into  Other  Hollow  Organs  of  the 
Body. — Tietze  transplanted  pieces  of  the  femoral 
artery  into  the  ductus  choledochus  in  one,  and  into 
the  ureter  in  six  dogs.  In  the  first  case  one  of  the 
final  sutures  accidentally  made  a  longitudinal  tear  in 
the  wall  of  the  vessel,  and  the  dog  died  after  eight 
days  of  peritonitis.  There  was  a  perforation  at  the 
site  of  the  tear,  the  transplanted  vessels  could  be 
plainly  recognized,  its  wall  was  discolored,  though 
not  externally  necrotic,  and  only  a  slight  degree  of 
contraction  had  taken  place.  In  the  first  case  in  which 
the  ureter  was  replaced  by  a  piece  of  arterx-  the  dog 
died  at  the  end  of  five  days  of  peritonitis  and  retro- 
peritoneal phlegmon.  The  implanted  piece  of  ves- 
sel was  moderately  contracted,  no  perforation  was 
present,  the  ureter  was  permeable  to  the  sound,  and 
the  kidney  was  badly  infected.  The  remaining  dogs 
were  killed  at  the  end  of  from  eighteen  days  to  four 
weeks.  In  one  killed  at  the  end  on  three  and  a  half 
weeks  there'  was  a  slight  dilatation  of  the  upper  end 
of  the  ureter,  hydronephrosis,  stenosis  of  the  ureter, 
which  still  remained  permeable,  and  pus  in  the 
urine.  The  vessel  could  no  longer  be  recognized. 
In  another  killed  at  the  end  of  eighteen  days  the 
vessel  could  no  longer  be  recognized,  there  was 
stenosis  at  the  place  of  suture  though  still  per- 
meable, the  ureter  was  very  tortuous,  much  dilated 
above  the  suture,  and  there  was  hydronephrosis.  In 
the  next,  killed  at  the  end  of  nineteen  days,  the  con- 
dition was  the  same  as  in  the  last  except  that  pyo- 
nephrosis was  present.  In  the  next,  killed  at  the 
end  of  four  weeks,  there  was  no  peritonitis  and  a 
moderate  degree  of  pyonephrosis.  The  ureter  was 
very  tortuous  and  completely  stenosed  at  the  place 
of  suture.  In  the  last  dog,  killed  at  the  end  of  three 
weeks,  the  kidney  was  moderately  enlarged,  there 
was  no  marked  dilatation  of  its  pelvis,  the  contin- 
uity of  the  ureter  was  preserved,  though  it  did  not 
admit  a  probe.  The  result  shows  that  the  method 
employed  is  not  practically  useful,  particularly  as 
stenosis  of  the  ureter  follows  infection  of  the  kid- 
ney with  a  fair  degree  of  certainty  or  probability. 

5.  Carcinoma  of  the  Body  of  the  Uterus  in 
Virgins. — Hirschberg  reports  a  case  in  which  he 
met  with  a  carcinoma  of  the  body  of  the  uterus  in 
a  virgin,  sixty  years  old.  The  uterus  was  removed 
and  the  patient  recovered.  In  addition  to  the  rarity 
with  which  such  cases  are  met  with  it  is  noted  that 
the  uterus  felt  atrophic  and  small  instead  of  en- 
larged and  thickened  as  is  usual  when  carcinoma  of 
the  body  is  present. 


714 


PITH  OF  CURRENT  LITERATURE. 


7,  8,  and  g.  Diseases  of  the  Pancreas. — Witte 
furnishes  a  copious  abstract  of  the  Hterature  on 
this  subject,  Eichler  and  Schirokauer  an  experi- 
mental study  of  Cammidge's  reaction  on  dogs,  and 
Caro  and  Worner  a  cHnical  contribution.  The  lat- 
ter found  Cammidge's  reaction  positive  in  two 
marked  cases  of  pancreatic  disease  in  which  autopsy 
revealed  a  necrosis  of  the  fatty  tissue.  In  one  case 
the  melting  point  of  the  combination  of  phenylhy- 
drazin  and  parabromphenylhydrazin  showed  that 
glycuronic  acid  took  the  principal  part  in  the  posi- 
tive reaction,  and  it  is  suggested  that  in  all  cases  in 
which  the  pancreas  reaction  is  positive  the  para- 
bromphenylhydrazin combination  be  formed  and 
confirmation  made  through  its  melting  point  and  its 
strong  left  polarization.  Deucher's  observation 
that  in  pancreatic  diseases  the  lecithin  in  the  faeces  is 
increased  was  confirmed. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 

February  23,  jgog. 

1.  Pneiimotoccus  Influenza,  By  Curschmann. 

2.  Synergy  and  Asynergy  of  the  Auricle  of  the  Human 

Heart,  By  Rautenberg. 

3.  Pseudodysentery,  By  Barmann  and  Schuffnek. 

4.  Contribution  to  the  Treatment  of  Constitutional  Eczema 

of  Children,  By  Geissler. 

5.  The  Clinical  Demonstration  of  Blood  in  the  Faeces, 

By  Messerschmidt. 

6.  Extrauterine  Pregnancy,  By  Weissvvange. 

7.  Report  of  Some  Cases  of  Sickness  Induced  by  the 

Typhus  Bacilli  of  Mice,  By  Fleischanderl. 

8.  A  Case  of  Icterus  Gravis,  By  Huffel. 

9.  A  Case  of  Croupous  Laryngotracheitis  without  Loef- 

fler's  Bacilli,  By  Jacob. 

10.  A  Case  of  True  Cervical  Rib,  By  Lechleutner. 

11.  Report  of  the  Work  of  the  School  Physician  in  Munich 

during  the  Year  1908,  By  Gros. 

12.  Tuberculosis  as  a  Children's  Disease,  By  Schlossmann. 

13.  Medical  Notes  of  a  Journey  in  Japan  and  China, 

By  Frankel. 

1.  Pneumococcus  Influenza. — -Curschmann 
states  that  the  epidemic  in  Leipsic  in  1907-8  was  an 
example  of  pneumococcus  influenza  as  distinguished 
from  the  pandemic  of  1889  and  1893  in  which 
Pfeiffer's  bacillus  played  the  principal  part. 

2.  Synergy  and  Asynergy  of  the  Auricle. — 
Rautenberg  reports  some  interesting  observations, 
first  of  the  transmission  of  the  pulsations  of  both 
auricles  in  a  case  of  paralysis  of  both  auricles;  sec- 
ond of  permanent  paralysis  of  both  auricles :  and 
third  of  retrogressive  changes  in  a  paralytic  condi- 
tion of  one  or  both  auricles. 

3.  Pseudodysentery. — Barmann  and  Schiifif- 
ner  report  six  cases  met  with  in  Sumatra  of  dysen- 
tery with  bacilli  which  they  term  pseudodysentery 
bacilli. 

5.  Clinical  Demonstration  of  Blood  in  the 
Faeces.  —  Messerschmidt  asserts  that  the  usual 
guaiac  test  may  prove  negative  even  when  a  consid- 
erable amount  of  blood  is  present  in  the  fjeces,  par- 
ticularly in  old  people,  and  that  therefore  only  posi- 
tive results  of  the  test  arc  reliable.  He  recommends 
a  modification  of  the  benzidin  test  for  use  either  af- 
ter a  negative  result  has  been  obtained  by  the  guaiac 
test,  or  to  the  exclusion  of  the  latter. 

7.  Sickness  Induced  by  the  Typhus  Bacilli  of 
Mice. — incischandcrl  says  that  in  the  latter  part 


[New  York 
Medical  Journal. 

of  April,  1908,  he  had  under  his  care  six  cases 
of  disease  induced  by  the  typhus  bacilli  of  mice, 
three  of  which  were  severe  and  three  mild.  The 
symptoms  began  with  a  rapidly  increasing  abdomi- 
nal pain  followed  in  a  few  hours  by  diarrhoea.  There 
was  fever  and  a  general  bodily  weakness.  These 
symptoms  grew  worse  for  two  or  three  days,  tem- 
perature 30°  or  40°  C,  copious  diarrhoea,  vomiting 
in  one  case,  severe  abdominal  pain,  dizziness,  stag- 
gering attempts  to  walk,  a  moderate  degree  of  pros- 
tration. Later  a  rapid  dying  away  of  the  symptoms, 
leaving  only  a  great  weakness  for  several  days.  In 
one  case  convalescence  occupied  two  full  weeks.  In 
the  mild  cases  the  symptoms  were  the  same  except 
less  severe  and  persistent. 

8.  Icterus  Gravis. — Hiiffel  reports  the  clinical 
history  of  a  fatal  case  of  icterus  in  an  infant  to- 
gether with  the  findings  on  autopsy  and  the  results 
of  the  microscopical  examinations. 

10.  True  Cervical  Rib. — Lechleutner  reports  a 
case  of  true  cervical  rib  observed  in  a  woman  twen- 
ty-four years  of  age.  There  were  three  complete 
ribs  above  the  clavicle  on  the  right  side  arising  from 
the  seventh,  sixth,  and  fifth  cervical  vertabrae.  On 
the  left  side  the  upper  two  were  to  be  seen  less  clear- 
ly than  on  the  right,  and  the  uppermost  appeared  as 
though  broken.  All  the  ribs  were  completely 
formed,  there  were  no  rudiments. 

AMERICAN  JOURNAL  OF  OBSTETRICS. 

March,  1909. 

V.  Blood  Pressure,  Leucocyte  Count,  and  Ophthalmoscopic 
Examination  in  the  Diagnosis  of  Preeclamptic 
Toxaemia,  By  A.  J.  Skeel. 

2.  Decidual  Change  in  the  Endometrium  Due  to  Causes 

other  than  Pregnancy,  By  J.  R.  Goodall. 

3.  A    Variety    of    Chronic    Endometritis  Characterized 

Clinically  by  Profuse  Haemorrhages, 

By  C.  C.  NoRRis. 

4.  Observations  upon  the  Sarcomatous  Metaplasia  of  Cer- 

tain Uterine  Fibromata,  By  E.  A.  Schumann. 

5.  Ligation  of  Pelvic  Veins  for  Puerperal  Pyaemia.  Report 

of  a  Case,  By  H.  N.  Vineberg. 

6.  The  Protection  of  the  Accoucheur  and  His  Patient, 

By  D.  H.  Ste.vart. 

7.  Surgery   of   the    Spleen   with   Special    Reference  to 

Trauma,  a  Method  of  Encapsulation,  and  Reports  of 
Cases,  By  W.  C.  G.  Krichner. 

8.  Fibroid  Tumors  Complicating  Pregnancy, 

By  J.  H.  Carstens. 

g.    A  Month  at  Bumm's  Clinic  at  Berlin, 

By  C.  Macfarlane. 

10.  Fibroid  Tumor  of  the  Uterus  Simulating  Pregnancy, 

By  R.  B.  Hall. 

11.  Haemorrhage  at  the  Time  of  Delivery  an  Important 

Factor  in  the  Prevention  of  a  Full  Secretion  of 
Milk,  By  J.  G.  Drennan. 

12.  Acute   Gastric  and   Duodenal   Dilatation   Treated  by 

Gastrojejunostomy  with  Recovery,    By  G.  Tonance. 

13.  The  Case  of  the  Rheumatic  Child,  By  L.  Kerr. 
I.  Blood  Pressure,  Leucocyte  Count,  and  Oph- 
thalmoscopic Examination  in  the  Diagnosis  of 
Preeclamptic  Toxaemia. — Skeel  says  that  a  trace 
of  albumin  in  the  urine  is  of  no  value,  it  is  often 
present  in  normal  pregnancy.  If  in  large  and  in- 
creasing quantity  it  is  a  bad  indication.  Its  absence 
is  no  proof  that  the  patient  is  not  toxic.  Casts  and 
diminution  in  quantity  are  important  signs.  Specific 


April  3,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


gravity  is  important  if  the  total  for  twenty-four 
hours  is  known.  Blood  pressure  findings  by  the 
fingers  are  of  little  value.  There  is  a  rise  of  blood 
pressure  in  the  last  two  months  of  pregnancy,  but 
it  should  not  exceed  150  mm.  The  pressure  is  ele- 
vated and  variable  during  labor,  and  after  labor  it 
should  drop  to  normal.  In  eclampsia  the  pressure 
may  be  elevated  to  an  extreme  degree.  In  pre- 
eclamptic toxaemia  it  is  always  elevated.  With  in- 
creasing albumin  and  blood  pressure  in  pregnancy 
convulsions  are  imminent  whether  the  immediate 
cause  of  the  patient's  condition  is  distinguished  or 
not.  The  leucocyte  count  is  fifty  per  cent,  or  more 
above  normal  in  eclampsia  and  preeclamptic  tox- 
aemia. In  demonstrable  ocular  disturbances  of  early 
pregnancy  especially  with  ophthalmoscopic  lesions 
the  uterus  should  be  emptied.  In  the  last  two 
months  of  pregnancy  such  lesions  indicate  severe 
toxaemia  but  should  be  compared  with  other  findings 
to  decide  the  treatment. 

2.  Decidual  Changes  in  the  Endometrium  due 
to  Causes  other  than  Pregnancy. — Goodall  states 
that  the  finding  of  decidual  change  in  the  uterine 
mucous  membrane  is  usually  considered  positive 
proof  of  a  fertilized  ovum  or  of  a  recent  abortion. 
The  author  reports  four  cases,  however,  in  which 
there  was  typical,  widely  spread  decidual  change,  in- 
volving the  entire  endometrium  but  with  conditions 
which  absolutely  excluded  all  possibility  of  preg- 
nancy. These  cases  did  not  involve  a  question  of 
membranous  dysmenorrhoea  nor  of  the  slight  pseu- 
dodecidual  change  which  has  been  found  in  an 
uterus  in  which  rnenstruation  is  about  to  occur,  the 
latter  being  far  from  a  typical  decidual  change. 
From  these  cases  he  concludes  as  follows:  i.  That 
typical  decidual  tissue  involving  the  whole  endo- 
metrium and  indistinguishable  from  that  associated 
with  pregnancy  may  occur  without  the  presence  of 
a  fertilized  ovum.  2.  That  the  agents  concerned  in 
his  cases  seemed  to  be  a  combination  of  chronic 
pelvic  inflammatory  changes  acting  upon  a  suscep- 
tible patient. 

II.  Haemorrhage  at  the  Time  of  Delivery  an 
Important  Factor  in  the  Prevention  of  a  Full  Se- 
cretion of  Milk. — Drennan  states  that  menstrua- 
tion in  the  human  female  is  evidence  that  ovulation 
has  not  been  followed  by  impregnation.  In  ovula- 
tion, pregnancy,  and  lactation  there  is  hyperaemia  of 
the  organs  which  are  involved.  This  hypercemia 
progresses  in  a  cycle  from  one  organ  of  the  genera- 
tive system  to  the  other.  If  the  ovum  has  been  im- 
pregnated the  physiological  hyperaemia  of  the  uterus 
supplies  it  with  sufficient  blood  for  the  function  of 
pregnancy.  After  delivery  the  hyperaemia  is  trans- 
ferred to  the  mammary  glands  the  function  of  lac- 
tation now  assuming  its  proper  place.  The  present 
day  mode  of  life  predisposes  to  the  haemorrhage 
from  the  placental  site  at  the  time  of  delivery  and 
to  the  minor  losses  of  blood  from  the  lacerations  and 
abrasions  of  labor.  Normally  there  should  be  no 
haemorrhage  from  the  placental  site  after  delivery. 
Should  it  occur  it  must  interfere  with  the  normal 
hyperaemia  of  the  mammary  glands,  for  the  blood 
which  should  be  transferred  to  them  from  the  uterus 
is  insufficient  to  supply  their  demands.  The  deple- 
tion of  the  uterus  which  results  from  such  a  haemor- 
rhage should  be  accomplished  in  another  way  and 
not  by  loss  of  blood  from  the  entire  body. 


THE  PRACTITIONER. 

March,  igog. 

1.  Some  Points  in  the  Diagnosis  and  Treatment  of  "De- 

rangements" in  the  Knee  Joint,       By  A.  E.  Barker. 

2.  Dr.  Marshall  Hall  and  the  Decay  of  Bloodletting, 

By  D'Arcy  PowEfe. 

3.  Uterine  Haemorrhages,  By  F.  E.  Taylor. 

4.  Acute  Infection  of  the  Kidney  by  the  Bacillus  Coli 

Communis,  By  G.  Wright. 

5.  Injection  of  the  Broad  Ligaments  with  Quinine  for 

Prolapsus  Uteri,  By  J.  I.  Parsons. 

6.  Five  Cases  of  Resection  of  Large  Lengths  of  Small 

Intestines  for  Gangrene,  By  C.  P.  Childe. 

7.  The  Present  State  of  Our  Knowledge  of  Pemphigus, 

By  J.  M.  H.  Macleod. 

8.  Retrospect  of  Otology,  By  M.  Yearsley. 

9.  Appendicitis  in  General  Practice, 

By  G.  McKerron  and  J.  S.  Geikie. 

10.  The  Treatment  of  Relapsing,  Recurrent,  and  Chronic 

Appendicitis,  By  J.  Allan. 

I'l.  The  Principle  of  Proportional  Representation  in  Clin- 
ical Radiography,  By  W.  Cotton. 

12.  Hodgen's  Splint  in  Private  Practice, 

By  G.  C.  F.  Robinson. 

1.  Some  Points  in  the  Diagnosis  and  Treat- 
ment of  Derangements  in  the  Knee  Joint. — I'ar- 
ker  refers  to  displacement  of  the  semilunar  cartilage 
which  is  usually  due  to  some  sort  of  violence,  espe- 
cially in  athletic  games.  The  cartilage  may  be 
merely  loosened,  or  it  may  be  detached  in  its  entire 
periphery  and  held  only  at  one  or  both  cornua.  The 
resulting  disability  varies  from  a  slight  pinching  pain 
to  severe  agony  with  flexion  and  fixation  of  the 
joint.  Beside  the  displaced  cartilage  ther2  may  be 
true  loose  bodies  floating  in  the  joint  cavity,  or 
fringes  or  tags  of  hypertrophied  synovial  membrane, 
or  rheumatic  nodules  or  lips  on  the  borders  of  the 
bones.  The  symptoms  in  all  these  conditions  are 
pain, a  sense  of  insecurity, and  impaired  motionof  the 
joint.  No  operation  is  of  any  avail  for  the  rheu- 
matic condition,  the  others  may  be  relieved  by  re- 
moval of  the  loose  bodies,  of  the  fringe  or  tag,  or 
of  the  semilunar  cartilage  itself  according  as  either 
of  these  obstructions  is  present.  The  operation  is 
not  without  risk,  but  if  strictly  aseptic  conditions  are 
observed,  and  there  is  a  moderate  degree  of  skill,  an 
operation  is  not  only  justifiable  but  called  for. 

2.  Dr.  Marshall  Hall  and  the  Decay  of  Blood- 
letting.— Power  enumerates  various  important  re- 
forms which  are  attributable  to  Marshall  Hall,  not 
the  least  of  which  consisted  in  weaning  the  profes- 
sion from  the  excesses  in  blood  letting.  He  did  not 
doubt  its  efficacy  under  certain  conditions,  and  laid 
down  rules  for  its  rational  employment.  His  essay 
on  blood  letting  was  published  in  1825,  while  at  the 
same  time  he  was  doing  original  work  on  the  minute 
structure  of  the  capillaries,  on  the  hibernation  of 
animals,  and  on  the  physiology  of  respiration.  In 
his  article  on  Venesection  published  in  1833  he  says 
"General  blood  letting  is,  of  all  our  remedies,  the 
most  powerful ;  its  employment  requires  the  utmost 
consideration.  If  we  neglect  the  remedy  in  cases  in 
which  its  use  is  required,  we  allow  the  disease  to 
make  a  dangerous  progress."  He  published  a  table 
in  which  the  rules  for  bleeding  were  given  under 
the  heads  of  (i)  augmented  tolerance,  (2)  healthy 
tolerance,  (3)  diminished  tolerance.  The  various 
indications  and  quantities  to  be  drawn  were  noted 
under  these  headings.  He  died  in  1857  of  cancer 
of  the  oesophagus. 

3.  Uterine  Haemorrhages. — Taylor  considers 
haemorrhage  the  most  important  symptom  in  obstet- 


7i6 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


rical  and  gynaecological  cases.  Haemorrhage  during 
menstruation  is  said  to  be  produced  by  a  Oiapedesis 
of  red  corpuscles  through  the  walls  of  unruptured 
capillaries,  and  it  is  not  accompanied  by  shedding  of 
the  endometrium.  Metrostaxis  in  the  neAV  born  is 
usually  unimportant,  but  it  may  foreshadow  preco- 
cious menstruation.  The  haemorrhage  of  puberty 
has  no  universal  law  as  to  periodicity,  duration,  or 
quantity.  Menorrhagia  or  metrorrhagia  may  be  due 
to  general  diseases  which  cause  pelvic  congestion, 
such  as  heart  disease,  hepatic  cirrhosis,  etc,  and  de- 
mand a  general  medical  examination,  or  they  may 
or  may  not  be  associated  with  pregnancy.  Special 
attention  is  called  to  haemorrhage  from  adenomyoma 
and  chronic  metritis.  Climacteric  and  postclimac- 
teric haemorrhages  are  always  suggestive  of  malig- 
nant disease  and  imperatively  demand  an  immediate 
investigation.  The  early  discovery  of  cancer  of  the 
uterus  and  the  thorough  removal  of  the  organ  and 
its  adjacent  tissues  will  often  result  in  the  saving  of 
life. 

4.  Acute  Infection  of  the  Kidney  by  the  Ba- 
cillus Coli  Communis. — Wright  emphasizes  the 
importance  of  this  germ  in  infective  inflammations 
of  the  urinary  tract.  His  paper  refers  particularly 
to  acute  pyelonephritis.  It  often  occurs  in  pregnant 
females.  The  urine  is  usually  acid,  turbid,  and  con- 
tains an  excess  of  mucus.  There  is  usually  albumin, 
occasionally  haematuria,  and  the  microscope  will 
show  pus  cells  and  bacilli.  Agglutination  frequently 
occurs,  and  cultures  of  the  urine  will  yield  a  pure 
growth  of  the  bacillus  even  when  the'  microscope 
fails  to  reveal  its  presence.  Granular  casts  are  pres- 
ent in  severe  cases.  The  kidney  is  enlarged,  con- 
gested, and  there  .  are  often  submucous  haemor- 
rhages in  the  pelvis.  The  bacillus  coli  communis  is 
the  most  frequent  cause  of  this  condition,  but  it  may 
be  caused  by  other  organisms.  The  infection  is  usu- 
ally an  ascending  one,  and  not  one  which  is  derived 
from  the  blood.  There  is  a  tendency  to  spontaneous 
cure  but  should  the  evidence  indicate  that  this  is  not 
likely  to  occur  the  choice  of  operative  procedure 
would  lie  between  nephrotomy  and  drainage  and 
nephrectomy. 

6.  Five  Cases  of  Resection  of  Large  Lengths 
of  Small  Intestines  for  Gangrene. — Childe  states 
that  the  length  removed  varied  from  one  foot  five 
and  a  half  inches  to  nine  feet  six  inches.  Four 
patients  recovered,  none  being  under  fifty  years  of 
age,  the  oldest  was  sixty-five  years.  The  recoveries 
were  smooth,  without  high  temperature.  Three  of 
the  patients  did  well  subsequently,  the  fourth,  a 
woman,  fifty-nine  years  of  age,  from  whom  nine 
and  a  half  feet  of  intestine  were  removed  succumbed 
to  a  steadily  progressing  marasmus  after  seven 
months,  showing  that  at  that  age  the  removal  of  half 
the  small  intestine  is  unsafe.  The  operation  in  all 
but  one  of  the  cases  was  for  large  and  long  standing 
herniae.  It  was  concluded  that  whatever  ihc  length 
of  resected  intestine  might  be  the  anastomosis  must 
be  in  absolutely  healthy  tissue.  Lateral  anastomosis 
was  performed  in  all  but  one  of  the  cases,  and  should 
be  the  rule  whenever  it  is  practicable.  The  cases 
were  all  emergency  cases  and  could  not  have  elabo- 
rate preliminary  preparation,  and  in  only  one  case 
was  there  drainage. 


NEW  YORK  ACADEMY  OF  MEDICINE. 
Meeting  of  lanuary  21,  jgog. 
\  The  President,  Dr.  John  A.  Wyeth,  in  the  Chair. 

Cancer  of  the  Breast. — Dr.  W.  L.  Rodman,  of 
Philadelphia,  read  this  paper.  He  said  that  while 
much  had  been  written  during  the  past  year  tending 
to  show  the  parasitic  origin  of  cancer,  he  was  still 
of  the  opinion,  as  he  had  ever  been,  that  the  argu- 
ments of  those  who  could  see  nothing  in  carcinoma 
but  a  germ  disease  were,  to  say  the  least,  inconclu- 
sive. An  early  diagnosis,  when  the  disease  was  strict- 
ly local,  made  an  operative  cure  not  only  possible 
but  highly  probable,  whereas  a  tardy  recognition  of 
mammary  carcinoma  could  not  be  atoned  for  by  the 
most  extensive  and  brilliant  operative  procedure. 
That  the  transition  from  a  local,  discrete,  and  en- 
tirely operable  condition  to  a  general,  disseminated, 
and  inoperable  one  might  take  place  quickly  was 
demonstrated  by  the  most  elementary  anatomical 
and  pathological  investigations.  Cancer  began  as 
an  undue  proliferation  of  the  epithelial  cells  of  the 
mamma,  and  continued  to  be  a  strictly  local  neo- 
plasm and  therefore  easily  and  completely  remov- 
able if  attacked  before  metastases  had  occurred  in 
the  neighboring  or  distant  lymphatic  glands  and 
viscera.  An  early  operation  would  cure  eighty  per 
cent,  of  all  cases  without  glandular  involvement, 
while  infection  of  even  the  nearest  lymphatic  nodes, 
the  axillary,  permitted  of  an  abiding  result  in  only 
twenty-five  per  cent.  If  the  profession  would  teach 
the  laity  that  mammary  groyvths  were  ustially  ma- 
lignant and  should  be  considered  and  treated  as 
such  until  their  benignity  was  proved,  the  operative 
results  would  be  far  better.  If  the  disease  was  only 
as  painful  in  its  first  as  it  was  in  its  last  stages,  a 
much  larger  number  would  seek  early  relief.  But 
the  fact  was  that  all  the  laity  and  nearly  all  the 
profession  considered  a  tumor  that  was  not  painful 
benign.  Better  results  could  only  follow  an  early 
diagnosis.  Dr.  Rodman  reported  one  case  as  being 
the  only  one  he  had  ever  encountered  where  there 
were  both  sarcoma  and  carcinoma  undoubtedly 
present  in  the  same  specimen.  In  64  of  232  cases 
of  operation  in  the  Johns  Hopkins  Hospital,  where 
there  was  no  demonstrable  glandular  involvement, 
fifty-one,  or  eighty  per  cent,  of  the  patients  were 
free  from  recurrence  at  the  expiration  of  three 
years.  In  no  cases  with  demonstrable  axillary  in- 
volvement, only  24.5  per  cent,  of  the  patients  were 
free  from  recurrence  at  the  expiration  of  three 
years.  Of  236  patients  with  palpable  axillary  in- 
volvement operated  upon  in  the  Massachusetts  Gen- 
eral Hospital  during  the  deccnnium  1894  to  1904, 
only  twelve  per  cent,  were  cured  by  operation.  Of 
1 17  operated  upon  in  the  same  hospital,  in  whom  no 
glands  were  felt  in  the  axilla,  twenty-nine  per  cent, 
were  cured.  The  advantage  following  early  opera- 
tion, before  there  was  palpable  involvement  of  the 
axilla,  and  of  the  hazard  of  delay  until  axillary  in- 
volvement had  taken  place,  could  not  be  more  forci- 
bly shown  than  had  been  done  by  the  statistics  of 
two  such  large  and  representative  hospitals.  The 


April  3,  1909.  J 


PROCEEDINGS  OF  SOCIETIES. 


7^7 


experience  at  these  and  other  hospitals  demon- 
strated forcibly  that  where  axillary  involvement 
was  so  great  as  to  make  resection  of  the  axillary 
vein  necessary  the  operation  had  not  resulted  in  a 
single  cure.  It  was  never  safe  to  assume  that  en- 
larged axillary  glands  did  not  exist,  and  in  all  cases 
a  thorough  dissection  of  the  axilla  was  just  as  im- 
portant as  the  removal  of  the  breast  itself.  The  sta- 
tistics of  the  Massachusetts  General  Hospital  show- 
ed that  of  forty-five  per  cent,  of  cases  v.'ith  adhe- 
sion of  the  growth  to  neighboring  structures,  nota- 
bly the  skin  and  pectoral  wall,  five,  or  eleven  per 
cent.,  passed  the  three  year  limit  without  recur- 
rence;  of  194  cases  without  adhesions  to  the  chest 
wall,  there  were  forty-one  successful,  or  twenty-one 
per  cent. ;  of  262  cases  with  adherent  skin,  only 
forty-two,  or  sixteen  per  cent.  In  seventy-one 
cases  in  which  the  skin  was  not  adherent,  twenty- 
three,  or  thirty-seven  per  cent.,  were  cured.  There- 
fore this  complication  was  of  great  importance.  In 
forty  cases  with  palpable  neck  involvement,  two  pa- 
tients were  found  to  be  free  from  carcinomatous  in- 
volvement and  were  well  three  years  after  opera- 
tion. All  the  remaining  thirty-eight  cases  w^ere 
fatal.  Of  forty  operative  cases  at  the  Johns  Hop- 
kins Hospital  with  positive  involvement  of  the  neck 
and  axilla,  three,  or  7.5  per  cent.,  were  cured.  Re- 
cent anatomical  investigations  had  made  it  clear 
that  lymphatic  involvement  of  the  neck  might  oc- 
cur very-  early  in  the  history  of  cancerous  growths 
located  in  the  superior  hemisphere  of  the  breast,  as 
there  was  a  chain  of  lymphatics  which  passed  over 
the  clavicle  and  did  not  connect  with  the  axilla  at 
all.  Ulceration  of  the  skin  he  considered  one  of 
the  gravest  prognostic  signs  and  he  had  never 
known  a  case  to  be  cured  by  operation.  Cancer  of 
the  breast  was  necessarily  lethal  without  surgical 
intervention.  The  duration  of  life  rarely  exceeded 
thirty-six  months  from  the  inception  of  the  growth. 
The  more  abundant  the  cellular  and  the  less  pro- 
notmced  the  fibrous  element,  the  greater  w^culd  be 
its  deadliness.  Cancer  en  ctiirassc  was  invariably 
fatal  and  not  amenable  to  operative  procedure. 
Paget's  disease  of  the  nipple,  even  with  an  opera- 
tion, did  not  give  a  good  prognosis.  Cancer  of 
both  breasts  warranted  only  the  most  pessimistic 
opinion  as  to  its  future  course ;  nearly  all  such  pa- 
tients succumbed  quickly.  How  long  must  a  pa- 
tient go  without  recurrence  before  she  could  be 
considered  cured?  \'olkmann's  law  had  been  over- 
thrown. Dr.  Rodman  believed  that  the  three  year 
period  should  be  extended  to  five  years,  when  the 
patient  could  be  looked  upon  as  reasonablv  safe.  At 
the  present  time  it  was  not  alleging  too  much  to 
say  that  at  least  one  third  of  the  cases  of  mammary 
cancer  which  came  to  operation  should  be  cured, 
and  that  early  cases  should  give  a  much  better 
prognosis,  one  half  or  two  thirds  of  them  ending 
in  permanent  recovery.  When  the  disease  was 
strictly  local,  eighty  per  cent,  should  be  cured. 
There  was  but  one  treatment  for  cancer  of  the 
breast,  operation,  and  the  earlier  and  more  radical 
the  procedure  the  better.  The  advantages  of  first 
attacking  the  axilla  were  direct  and  manifest,  and 
should  be  more  generally  appreciated.  Tiiev  were, 
first,  the  axilla  might  be  so  hopelessly  involved  as 


to  make  an  attempt  at  removal  worse  thaji  fruitless. 
Hence  the  sooner  it  was  known  the  better.  Sec- 
ond, the  bloodvessels  could  be  reached  and  tied  at 
their  origin,  which  materially  lessened  both  haemor- 
rhage and  shock,  for  the  same  vessel  was  not  re- 
peatedly cut,  as  was  necessarily  done  in  working 
toward  instead  of  from  the  axilla.  Third,  the  ax- 
illary space  was  dissected  from  above  downward 
instead  of  from  below  upward,  because  it  was  both 
easier  from  a  surgical,  and  better  from  a  pathologi- 
cal viewpoint,  inasmuch  as  the  dissection  was  be- 
gim  beyond  the  encroachments  of  the  disease. 
Fourth,  one  avoided  largely,  if  not  wholly,  the  great 
danger  of  expressing  and  distributing  cancer  cells 
to  adjacent  tissueS  and  remote  organs  as  the  result 
of  manipulating  the  infected  mamma  and  lymph 
nodes.  This  was  a  considerable,  not  a  chimerical 
danger,  so  much  so  that  unnecessary  handling  of 
the  infected  tissues  should  be  avoided.  Fifth,  a  dis- 
section en  masse  was  sometimes  made  impossible  if 
the  work  was  begun  at  the  sternum,  as  the  hea\y 
mass  might  pull  upon  and  break  the  axillary  tail.  It 
certainly  would,  if  not  held  by  an  assistant,  during 
all  of  which  time  the  infected  mass  was  being  ma- 
nipulated. Sixth,  the  functional  use  of  the  arm 
would  be  better,  for  the  reason  that  in  beginning  at 
the  axilla  instead  of  ending  the  incision  at  this 
point,  greater  precision  was  assured.  The  incision 
should  not  extend  on  to  the  arm,  as  the  resulting 
cicatrix  in  such  cases  not  infrequently  restricted  the 
limb  in  its  future  movements. 

Dr.  Maurice  H.  Richardson,  of  Boston,  said 
that  the  treatment  of  cancer  of  the  breast  still  de- 
manded the  most  thorough  excision  possible,  and 
the  use  of  x  rays,  toxines,  ferments,  radium,  and 
similar  means  in  the  operable  cases  was.  in  his 
opinion,  w'holly  unjustifiable.  There  was  little  if 
any  encouragement  that  methods  would  soon  be 
found  of  sufficient  merit  to  replace  the  knife.  He 
had  seen  an  appalling  number  of  cases  of  hopeless 
cancer,  which  had  become  inoperable  under  methods 
with  some  scientific  basis,  to  be  sure,  but  quite  use- 
less. There  w'as  surely  a  sufficiently  wide  field  for 
the  trial  of  nonoperative  methods  without  taking  the 
easily  operable  cases.  The  layman,  however,  did 
not  know  this,  and  many  physicians  did  not.  Be- 
tween the  hopeful  layman  and  the  optimistic  physi- 
cian, the  period  favorable  to  operation  was  too  often 
passed,  and  the  unfortunate  patient  came  to  the  sur- 
geon too  iate.  The  watchword  of  our  profession 
had  of  late  years  been  early  operation,  earlier  oper- 
ation, earliest  possible  operation,  until  the  public 
was  weary. 

The  most  important  theme  for  discussion  at  the 
present  time  was  the  diagnosis  of  breast  tumors  ;  the 
most  conspicuous  subject  for  investigation  and 
study  was  the  cause  and  nature  of  cancer.  The 
treatment  of  all  descriptions  of  breast  tumors,  at  all 
ages,  was  by  excision,  for  excision  was  the  only 
treatment  which  would  obviate  the  awful  tragedies 
of  overlooked  malignancy.  The  great  majority  of 
patients  did  not  complain  of  pain ;  in  the  cases  in 
which  the  patients  did  complain  of  pain,  a  tumor 
had  usually  been  discovered.  Pain  as  a  diagnostic 
sign  should  have  but  little  weight ;  pain  as  an  indica- 
tion for  operation  should  have  only  weight  of  its 


7i8 


PROCEEDINGS  OF  SOCIETIES. 


[New  Yoek 
Medical  Journal. 


own  severity,  and  should  justify  operation,  in  the 
total  absence  of  breast  signs,  only  for  its  own  relief. 
He  was  forced  to  the  position  that  no  man's  experi- 
ence was  adequate  to  justify  the  neglect  of  surgical 
exploration,  when  the  signs  pointed,  at  the  earliest 
stages,  to  a  possible  diagnosis  of  cancer.  The  in- 
fluence of  heredity  on  a  doubtful  diagnosis  should  be 
great.  A  single  case  of  cancer,  even  under  the  para- 
sitic theory,  might  be  and  probably  was  sporadic ; 
but  two,  three,  four,  or  five  cases  in  a  family  meant 
more  than  the  accidental  infection  from  outside  the 
family  of  one  individual.  The  analogy  between  can- 
cer and  tuberculosis  was  striking.  Just  as  a  family 
history  might  be  riddled  with  tuberculosis,  so  might 
it  be  riddled  vi^ith  cancer.  As  a  rule,  cancer  in  both 
breasts,  occurring  independently,  was  extremely 
rare.  Nevertheless,  he  had  seen  this  often  enough 
to  mar  somewhat  the  positiveness  of  a  diagnosis 
based  upon  the  presence  of  double  breast  tumors. 
When  one  breast  had  a  tumor  which  seemed  to  be 
benign,  that  benignancy  was  rendered  more  proba- 
ble by  a  similar  tumor  in  the  other  breast.  Also, 
when  a  tumor  had  been  removed  from  one  breast, 
and  proved  to  be  benign,  the  later  occurrence  of  a 
similar  tumor  in  the  other  breast  favored  very 
strongly  a  similar  benignancy.  But  there  should  be 
no  rule  guiding  the  surgeon  in  such  cases,  unless  it 
was  the  only  safe  one  in  connection  with  breast 
tumors,  to  treat  them  as  malignant  until  they  had 
been  proved  benign.  The  examination  of  the  axilla 
was  prolific  in  important  evidence  for  or  against 
cancer,  and  especially  for  cancer.  There  was  a 
strange  variability  in  the  extent  of  axillary  involve- 
ment. As  a  rule,  the  presence  of  perceptible  axil- 
lary lymph  nodes  added  an  evil  significance.  Even 
more  serious  was  'the  presence  of  supraclavicular 
lymph  nodes.  Of  all  the  metastases,  the  most  malign 
were  those  of  involvement  of  the  cerebrospinal  axis. 
Any  persistent  cerebral  or  spinal  symptom  should 
excite  the  strongest  apprehension.  Spinal  symptoms 
that  were  marked  added  enough  to  the  contraindica- 
tions to  make  an  operation  unjustifiable.  A  persist- 
ent cough,  without  adequate  signs  in  the  lungs,  al- 
ways added  strength  to  the  diagnosis,  if  it  weakened 
the  indications  for  operation.  With  reference  to  the 
diagnosis  by  the  use  of  the  punch  or  the  knife  sec- 
tion, for  the  microscope,  he  believed  that  a  tumor 
doubtful  enough  to  justify  this  means  of  control 
should  per  se  be  immediately  extirpated,  for  he  was 
convinced  that  infection,  and  probably  not  only  in 
the  breast  cancer,  but  in  all  forms  of  malignancy, 
was  possible.  The  prognosis  in  cancer  not  operated 
on  was  as  bad  as  it  could  be.  But  the  prognosis 
was  measured  in  accordance  with  the  diagnosis. 
Every  case  in  which  there  was  the  slightest  doubt 
had  hope  in  the  possibilities  of  error,  hope  in  human 
frail ity.  This  hope,  when  an  experienced  surgeon 
made  a  diagnosis  of  cancer,  was  small,  but  there  was 
still  a  hope.  Statistics  based  upon  a  surgeon's  own 
experience  were  the  only  statistics  that  were  worth 
while  in  the  formation  of  his  own  prognosis.  Dr. 
Richardson  knew,  for  example,  the  cases  of  his  own 
in  which  there  was  no  hope  of  ultimate  cure,  and  he 
knew  the  cases  in  which  there  was  every  hope  of 
l)crmancnt  success.  When  there  was  a  mass  of  con- 
glomerated lymph  nodes  in  the  axilla,  even  if  there 


were  no  perceptible  ones  at  the  first  rib,  he  knew 
that  his  dissection  was  probably  too  late.  When  he 
found  but  one  or  two  nodes  in  the  centre  of  a  mass 
of  axillary  fat,  easily  separated  on  all  sides  by  an 
extensive  and  clean  dissection,  he  knew  that  the  case 
belonged  to  a  group  in  which  the  outlook  was  bright, 
in  which  the  percentage  of  cures  was  much  higher 
than  twenty-five  or  thirty  or  even  fifty  per  cent. 
Surgeons  probably  erred  most  frequently  in  giving 
a  too  favorable  prognosis,  but  occasionally  they  gave 
a  prognosis  that  was  worse  than  the  facts  justified. 
He  did  not  believe  there  was  any  limit  of  years 
after  which  a  patient  might  be  said  to  be  permanent- 
ly cured.  The  prognosis  as  to  recurrence  was  in- 
liuenced,  in  favorable  cases  especially,  by  the  thor- 
oughness of  extirpation.  The  advanced  cases  had 
really  very  little  prospect  of  cure,  but  that  depended 
entirely  upon  the  extent  and  thoroughness  of  ex- 
tirpation. Except  for  pain  and  annoying  dis- 
charges, the  prognosis  in  advanced  cases  of  mam- 
mary cancer  was  such  as  to  forbid  an  operation. 
From  what  he  had  said,  the  chief  indication  for 
operation  was  the  presence  of  a  tumor,  whether  in 
the  male  or  female.  Delay  in  extirpating  the  breast 
tumors  might  be  attended  by  appalling  conse- 
quences. The  only  exceptions  to  the  rule  of  uni- 
versal exploration  were  those  cases  of  multiple 
tumors  afi^ecting  both  breasts  which  were  so  unmis- 
takably retention  cysts.  Another  exception  was  a 
breast  tumor  which  appeared  after  the  removal  of 
a  benign  growth  or  simple  cyst.  Still  another  was 
the  appearance  in  the  other  breast  of  a  tumor  like  a 
benign  one  that  had  been  removed  from  the  first. 
But,  barring  such  contraindications  as  were  found 
in  the  various  organs  and  in  certain  constitutional 
diseases,  a  better  rule  was  that  of  the  removal  of 
every  tumor  of  the  breast,  of  whatever  nature,  at 
any  age.  Thus  only  could  we  avoid  those  errors 
which,  however  infrequent,  were  nevertheless,  when 
they  did  occur,  so  appalling  and  indefensible. 

Dr.  Willy  Meyer  said  that  the  insidious  and  dan- 
gerous character  of  the  disease  and  the  inevitable 
disfigurement  which  followed  an  operation  justly 
rendered  cancer  of  the  breast  the  dread  of  the  fe- 
male sex,  to  whose  members  it  was  almost  wholly 
confined.  An  early  operation  constituted  the  only 
weapon  of  defense  in  dealing  with  this  disease.  An 
early  operation  depended,  of  course,  upon  an  early 
diagnosis.  The  diagnosis  of  mammary  scirrhus  was 
comparatively  easy,  but  this  was  not  so  with  adeno- 
carcinoma. This  had  no  apparent  cft'ect  upon  the  nip- 
ple, its  growth  was  diffuse,  simulating  that  of  adeno- 
fibroma,  within  which  it  not  infrc(|ucntly  originated. 
Hence  it  certainly  was  not  easy  to  diagnosticate  ade- 
nocarcinoma in  its  incipiency.  To  confound  it  with 
the  so  called  diffvise  interstitial  fibroma  or  chronic 
mastitis  was  hardly  possible.  The  multiplicity  of  the 
tumors  in  the  latter,  the  small  size  of  the  axillary 
glands,  if  enlarged  at  all,  the  painful  development, 
and  the  fact  that  it  occurred  bilaterally  were  all  signs 
diametrically  opposite  to  those  seen  in  adenocarci- 
noma. The  diffuse  fibroma  belonged  to  the  border- 
land cases.  A  suspicious  adenofibroma,  however, 
needed  a  prompt  and  radical  operation.  He  said  he 
had  had  a  number  of  cases  of  chronic  mastitis  (sup- 
purative) showing  a  diffuse,  hard  swelling  which 


April  3,  1909.] 


LETTERS  TO  THE  EDITOR. 


719 


had  persisted  for  some  years.  Now  and  then  there 
was  pain,  usually  with  a  little  tenderness.  These 
patients  were  sent  to  him  for  operation  with  the  di- 
agnosis of  carcinoma.  However,  the  long  duration 
of  the  trouble,  its  diffuseness,  the  trace  of  the  finger 
tip  that  persisted  after  pressure,  and  the  fact  that 
the  aspirator  drew  pus,  a  fluid  which  carcinoma 
never  harbored,  made  him  hesitate  to  accept  the  di- 
agnosis. Simple  incision  effected  a  cure  in  these 
cases.  In  making  a  diagnosis  in  tumors  that  ad- 
mitted of  doubt  as  to  their  malignancy,  one  should 
never  forget  the  use  of  the  aspirator.  The  principal 
characteristics  of  his  operations  were  that  the  affect- 
ed breast,  together  with  the  two  pectoral  muscles  in 
their  entirety,  plus  axillary  as  well  as  subclavian 
glands  and  surrounding  fat,  was  lifted  out  in  one 
mass.  All  incisions  were  made  in  healthy  tissue  so 
far  as  feasible.  The  work  was  done  from  the  axilla 
toward  the  breast.  Bloodvessels,  arteries  as  well  as 
veins,  were  promptly  divided  at  their  exit  from  or 
entrance  into  the  axillary  vessels.  The  lymphatics 
were  also  first  cut  here,  before  the  seat  of  the  dis- 
ease was  approached.  As  the  tendon  of  the  pector- 
alis  major  was  primarily  divided  at  the  humerus,  it 
was  necessar}-  to  remove  the  whole  muscle,  the  cla- 
vicular portion  included.  The  operation  was  typ- 
ical, anatomical,  simple,  and  accomplished  with  a 
minimum  loss  of  blood.  In  1899  he  had  made  a 
slight  change  regarding  the  course  of  the  axillary 
part  of  the  skin  incision  which  permitted  of  a  more 
eft'ective  shifting  of  the  lower  flap  at  the  completion 
of  the  operation,  making  it  possible  to  cover  a 
greater  part  of  the  resulting  defect.  The  various 
operations  devised  by  others  within  the  last  fourteen 
years  were  all  based  on  the  principles  laid  down  in 
his  operation.  The  only  exception  was  the  opera- 
tion of  Halsted,  who  saved  the  clavicular  portion  of 
the  pectoralis  major  muscle  and  reunited  the  split 
halves  of  the  minor.  He  worked  from  the  sternum 
toward  the  axilla.  He  published  his  procedure  sim- 
ultaneously with  Dr.  Meyer's  in  1894.  From  his 
personal  experience  Dr.  Meyer  would  certainly  use 
the  hypersemic  treatment  with  the  suction  cup  as  an 
adjuvant  in  the  after  treatment  of  operative  fields 
that  could  not  be  cleared  of  the  disease  even  macro- 
scopically.  With  regard  to  the  so  called  borderland 
cases,  i.  e.,  fibroadenoma,  chronic  diffuse  mastitis, 
cysts,  etc.,  the  more  he  saw  of  this  class  of  cases  the 
more  he  felt  convinced  that  the  only  safe  plan  was 
to  operate  upon  every  patient  over  twent3'-five  or 
thirty  years  of  age,  and  not  allow  her  to  go  on  until 
unmistakable  signs  of  malignancy  had  become  ap- 
parent, when  it  might  be  too  late  to  help  her. 
■  ^  

fitters  to  U  mux. 


THE  INTERNATIONAL  LANGUAGE  IDEA. 

103  Dearborn  Avenue, 
Chicago,  March  27,  1909. 

To  the  Editor: 

In  the  editorial  comment,  Esperanto  vs.  Ilo,  in 
your  issue  of  March  20th,  are  you  not  a  little  "ofif" 
your  usual  critical  acumen?  You  say:  "It  (a  uni- 
versal language)  may.  to  begin  with,  be  free  from 
irregularities,  but,  to  say  nothing  of  other  objec- 


tions, they  are  sure  to  be  injected  into  it  by  the 
illiterates  of  the  period.  He  who  cannot  speak  his 
mother  tongue  correctly  is  absolutely  certain  to 
corrupt  any  other  language  .  .  .  and  those  who 
debase  their  own  language,  whatever  it  may  be,  are 
getting  to  be  more  and  more  numerous." 

Most  undeniably  and  regrettably  true !  But  the 
national  languages  still  manage  to  hold  their  own, 
I  observe,  debased  though  they  be  by  the  illiterates, 
as  a  medium  of  expression  of  thought  between 
compatriots.  Why,  then,  should  the  ultimate  de- 
basement from  its  pristine  purity  of  an  international 
language  place  any  greater  obstacle  in  the  way  of 
its  serving  its  essential  purpose — which  is  the  ex- 
pression of  thought  between  peoples  of  different 
countries — than  a  similar  debasement  does  with  re- 
gard to  national  languages  and  their  essential  pur- 
pose? Add  X  to  both  sides  of  an  equation  and  the 
result  remains  relatively  the  same.  Now,  this  ques- 
tion is  purely  a  relative  one.  The  debasement  of 
Esperanto  by  its  illiterate  speakers  and  writers  will, 
doubtless,  in  due  course  vex  the  soul  of  the  culti- 
vated Esperantist,  just  as  the  debasement  of  Eng- 
lish vexes  the  cultivated  English  speaking  person's 
soul — your  own  for  instance — and  it  w^ill  make  just 
as  little  difference  to  their  intelligibility.  For  the 
changes  will  occur  as  slowly  in  the  one  case  as  in 
the  other,  and  we  shall  all  keep  up  with  them  when 
we  are  widely  speaking,  and  far  more  widely  read- 
ing and  writing,  an  international  language,  just  as 
we  do  with  those  in  our  respective  mother  tongues. 
Surely  such  is  the  obvious  object  lesson  of  even  a 
moderate  acquaintance  with  comparative  philology. 

And,  then,  while  some  of  us  may  aspire  to  lite- 
rary excellence  in  Esperanto,  it  must  not  be  for- 
gotten that,  since  the  purpose  of  an  international 
tongue  is  to  facilitate  and  promote  intercourse  be- 
tween peoples  of  different  mother  tongues,  the 
changes — debasing  or  otherwise — will  necessarily 
be  Hmited  and  controlled  by  the  necessity  for  re- 
maining intelligible,  even  as  they  are  in  the  mother 
tongues. 

The  practical  experience  of  most  unprejudiced 
persons — and  not  a  few  prejudiced  ones,  quorum 
pars  magna  fui  about  a  year  ago — who  have  tried 
Esperanto,  for  instance,  disposes  of  the  many  per- 
sistently repeated  theoretical  objections  by  relegat- 
ing them  where  they  belong,  to  the  category  of 
things  that  "ought  to  be  so,  but  ain't." 

Kenneth  W.  Millica-n. 


PROFESSIONAL  SECRECY  AND  PROFESSIONAL 
DUTY. 

50  Broadway, 
New  York,  March  23,  iQog. 

To  the  Editor: 

In  your  editorial  Professional  Secrecy  and  Pro- 
fessional Duty,  published  on  March  6th,  you  make 
the  following  quotation  from  The  Law  in  its  Rela- 
tions to  Physicians:  'Tt  seems  well  settled  that  this 
clause  (that  'one  practising  medicine  and  surgery 
shall  not  be  permitted  to  disclose  "any  information 
which  he  acquired  in  attending  a  patient  in  a  pro- 
fessional capacity"  ')   in  the  statutes  includes  all 


720 


Ll-JTERS  TO  THE  EDITOR.  —BOOK  NOTICES. 


[New  Vork 
Medical  Journal. 


knowledge  gained  in' the  professional  intercourse  of 
a  physician  with  his  patient,  whether  obtained  from 
statements  made  to  him  by  the  patient  or  gained 
from  observing  and  examining  the  patient."  This 
quotation,  as  a  statement  of  law,  applies  to  the  right 
of  the  physician  to  disclose  information  in  a  court 
as  a  witness,  and  does  not  apply  to  such  a  situation 
as  that  referred  to  in  your  editorial. 

At  common  law  the  "privilege"  from  testifying 
was  recognized  betvi^een  attorney  and  client  only. 
The  statutes  of  about  two  thirds  of  the  States  have 
extended  this  privilege  to  information  obtained  by 
physicians  in  the  treatment  of  their  patients,  but  by 
the  express  terms  of  these  statutes  such  privilege  is 
from  testifying.  These  statutes  would  not  be  so 
construed  as  to  have  an  application  of  the  sort  now 
in  contemplation. 

Disregarding  the  statute,  which  has  been  shown 
not  to  apply,  it  would  seem  that  if  the  physician  im- 
properly makes  statements  regarding  his  patient,  the 
patient  would  have  the  right  to  elect  under  which 
of  two  forms  of  action  he  would  proceed  to  prose- 
cute the  physician.  The  election  would  be,  ist, 
slander,  or,  2nd,  breach  of  the  implied  contract  to 
treat  as  confidential  and  secret  all  information  ac- 
quired in  attending  the  patient.  In  an  action  for 
slander,  the  truth  of  the  words  spoken  is  a  defense ; 
therefore  the  physician  would  have  nothing  to  fear 
from  that  form  of  action.  If  the  action  were 
brought  on  the  theory  of  breach  of  contract,  I  am 
of  opinion  that  the  plaintiff  would  be  equally  unsuc- 
cessful, for  upon  the  facts  assumed  in  the  editorial 
I  am  satisfied  that  the  courts,  on  the  ground  of  pub- 
lic policy,  would  decline  to  admit  the  existence  of  an 
implied  contract  on  the  part  of  the  physician  not  to 
disclose  the  girl's  physical  condition  to  her  em- 
ployer. Arthur  N.  Taylor. 


GREEK  FOR  PHYSICIANS. 

126  East  Thirty-fourth  Street, 
New  York,  March  17,  igog. 

To  the  Editor: 

Permit  me  a  few  words  on  the  learned  and  highly 
interesting  article  of  Dr.  Charles  W.  Super,  of 
Athens,  O.  Dr.  Thomas  L.  Stedman  was  the  first 
to  call  our  attention  to  the  significance  of  living 
Greek  in  medicine.  I,  in  my  writings  on  this  sub- 
ject, have  shown  that  the  study  of  the  classical 
Greek  literature  will  not  enable  us  to  correct  the 
errors  in  medical  nomenclature  which  exist  and 
which  have  existed  for  centuries,  and  which  multi- 
ply with  the  increasing  necessity  of  forming  new 
names  for  new  conceptions.  None  of  our  profes- 
sors of  Greek,  except  he  is  a  medical  scholar  and 
knows  living  Greek,  can  give  us  aid  in  this  matter. 
Beautiful  and  elevating  to  the  mind  as  the  study 
of  Greek  classics  may  be,  it  cannot  be  expected  that 
physicians  should  devote  themselves  to  such  study, 
not  even  by  reading  Xenophon  or  the  New  Testa- 
ment, as  suggested  by  Dr.  Super.  Physicians  who 
wish  to  learn  Greek  for  practical  purposes  have  to 
commence  with  much  lighter  literature,  a  Greek 
translation  by  P.ikelas  of  Andersen's  Fairy  Talcs. 
for  instance.    The  last  fifty  years  under  the  influ- 


ence of  medical  and  natural  sciences  have  done 
more  for  mankind  than  all  the  scholasticism  of  cen- 
turies. At  the  same  time  it  is  more  than  ever  in 
the  interest  of  progress,  especially  in  medical  sci- 
ence, that  we  should  have  a  correct  nomenclature, 
and  this  we  can  obtain  only  by  aid  of  Greek  physi- 
cians of  the  present  time  and  their  literature.  There 
is  no  difficulty  in  learning  Greek  pronunciation  in 
any  large  city  of  America.  A.  Rose. 




[IVe  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  revieiu  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


Lehrbuch  der  Haut-und  Geschlechts-Krankheiten.  Heraus- 
gegeben  von  Prof.  Dr.  Erhard  Riecke,  in  Leipzig. 
Jena:  Gustav  Fischer,  1909.  Pp.  664.  (Price,  14.50  M., 
unbound,  16  M.,  bound.) 

This  book  has  three  features  that  distinguish  it 
from  others  of  its  class  as  published  in  Germany, 
namely:  i.  It  is  profusely  illustrated.  2.  It  has 
an  adequate  index.  3.  It  is  written  by  a  number 
of  physicians  of  high  standing. 

The  articles  on  the  anatomy  and  physiology  of 
the  skin  and  general  symptomatology  are  written 
by  Professor  Riehl.  To  Professor  Ehrmann  is 
given  the  very  important  chapter  on  eczema.  The 
editor  takes  for  himself  the  scaling  diseases  of  the 
skin,  the  lichens,  and  the  keratoses.  Professor  Bett- 
mann's  field  is  that  of  the  vesicular  and  bullous  dis- 
eases with  pruritus.  To  Professor  von  Zumbusch 
the  erythemas  with  the  drug  eruptions  are  assigned. 
Lupus  erythematosus  and  the  diseases  of  the  sweat 
and  fat  glands  and  the  hair  are  the  province  of  Pro- 
fessor Torok.  The  skin  diseases  due  to  the  inva- 
sion of  the  skin  by  bacilli  and  cocci  are  described 
by  Professor  Gouven.  Dr.  Tomasczewski  has  a  diffi- 
cult task,  as  he  unravels  the  atrophies  and  hyper- 
trophies of  the  skin  and  the  various  new  growths, 
both  benign  and  malignant.  The  parasitic  diseases 
are  treated  of  by  Professor  Jesionek.  Professor 
Bruhns's  sphere  is  gonorrhoea  and  the  chancroid, 
while  Professor  Buschke  writes  the  final  chapter, 
on  syphilis. 

In  consequence  of  this  arrangement  we  have  a 
somewhat  uneven  presentation  of  the  diseases,  but, 
all  in  all,  an  excellent  textbook.  It  is  almost  impos- 
sible for  any  one  man  to  cover  the  whole  subject 
of  dermatology  with  thoroughness,  for  no  one  can 
be  equally  well  versed  in  all  the  aspects  of  the  sub- 
jects. Systems  written  by  many  trained  observers 
are  prone  to  be  so  voluminous  as  to  be  too  costly 
for  many  doctors.  In  the  book  now  before  us  we 
have  the  merits  of  a  system  without  excessive  cost, 
with  the  added  advantage  that  it  can  be  readily 
handled.  Illustrations  of  the  anatomy  of  the  skin 
would  add  little  to  the  cost  of  the  book  and  much 
to  its  value.  Some  of  the  opinions  expressed  by 
the  authors  seem  to  us  inaccurate.  Thus,  dysidrosis. 
or,  rather,  pompholyx  of  the  hands  and  feet,  is  said 
by  Ehrmann  to  be  but  an  eczema.    Inasmucli  as  it 


April  i,  iC,oj.j 


BOOK  NOTICES. 


721 


occurs  and  recurs  on  the  hands  alone  without  any 
tendency  to  appear  as  eczema  elsewhere,  and  does 
not  itch  like  eczema,  it  seems  to  us  he  is  wrong. 
The  same  author  denies  the  right  of  pustular  eczema 
to  br  considered  as  a  form  of  that  disease,  regard- 
mg  it  as  a  pus  infection  of  another  form  of  eczema. 
Torok  will  have  nothing  of  seborrhoeal  eczema, 
teaching  that  that  term  has  been  used  to  include 
something  Duhring's  seborrhoea  corporis,  sometimes 
psoriasis,  or  a  scaly  erythroderm,  or  pityriasis  capi- 
tis et  barbae,  or  slight  hypersemias,  or  a  scaling  due 
to  slight  chemical  action,  or  an  intertriginous  ec- 
zema, or  a  streptococcic  infection.  Surely  this  is  a 
far  too  drastic  opinion.  Though  the  name  may  be 
badly  chosen,  most  dermatologists  have  accepted  in 
great  part  Unna's  teaching.  We  are  astounded  to 
find  on  page  416  Jesionek  stating:  "The  majority 
of  the  dermatologists  of  to-day  regard  pityriasis 
rosea  (Gibert)  as  related  to  the  maculosquamous 
form  of  herpes  tonsurans."  We  believe  that  the 
contrary  is  true,  and  that  only  a  few  of  the  adher- 
ents of  the  old  Vienna  school  hold  this  opinion. 
While  the  book  has  many  excellences,  and  is  one  to 
be  commended,  it  would  have  been  improved  by  the 
addition  of  synonyms.  As  it  is,  but  a  single  title  is 
given  in  most  cases.  The  sections  on  treatment 
are  not  so  full  as  they  might  be  to  advantage.  Even 
mention  of  x  rays  in  the  treatment  of  svcosis  is 
omitted  by  Torok. 

The  wealth  of  illustration  more  than  compensates 
for  the  few  defects  we  have  noted.  No  textbook 
on  dermatology  with  which  we  are  acquainted  is  so 
fully  illustrated  with  colored  plates  most  of  them 
true  to  life. 

A  Dictionary  of  Medical  Treatment  for  Students  and 
Junior  Practitioners.  Bv  Arthur  L.\th.\m,  M  A.  M 
D.  Oxon.,  M.  A.  Cantab.,  F.  R.  C.  P.  Lond.,  Physician 
and  Lecturer  on  Medicine  at  St.  George's  Hospital,  Lon- 
don, etc.  Philadelphia:  P.  Blakiston's  Son  &  Co.,  190S 
Pp.  vi-325.    (Price,  $2.) 

Dr.  Latham  has  compiled  a  very  handy  book.  Its 
aim  seems  to  be  to  give  a  definite  course  of  treat- 
ment for  any  disease  which  is  commonly  seen  in 
general  practice,  not  taking  into  consideration  ail- 
ments which  properly  belong  to  a  surgeon  or  a  spe- 
cialist. The  contents  of  the  book  are  alphabeticall> 
arranged,  and  the  diseases  are  mostly  treated  of 
under  their  scientific  names  with  cross  references 
from  the  English,  although  it  would  have  been  bet- 
ter to  adhere  strictly  to  this  rule. 

Textbook  of  Physiological  Chemistry.    In  Tliirty  Lectures. 
By  Emil  Abderhaldek,  o.  Professor  fiir  Phys'iologie  des 
physiologischen  Institut.=  der  tierarztlichen  Hochschule, 
Berhn,  und  Universitats-Professor.    Translated  by  Wil- 
LiA.M  T.  Hall,  Instructor  in  Chemistry,  Massachusetts 
Institute  of  Technology,   and    George   Defren.  New- 
York:  John  Wiley  &  Sons,  1908.  Pp.  xiii-722.  (Price,  $5.) 
Our  knowledge  of  the  chemical  process  which 
takes  place  in  animal  and  plant  organisms  is  con- 
stantly being  enlarged,  and  the  literature  of  the  sub- 
ject grows  day  by  day.    Professor  Abderhalden's 
work  in  the  domain  of  physiological  chemical  in- 
vestigation has  placed  him  m  the  front  rank  of 
physiological  chemists.    It  is  not  alone  in  the  ob- 
servation of  forms  in  the  animal  kingdom,  but  in 
the  study  of  plant  organs  and  in  the  relation  of 


pathological  processes  to  physiological  processes  as 
well,  that  modern  physiological  chemists  find  their 
chief  sphere  of  activity.  While  it  has  not  been  pos- 
sible to  state  all  the  results  of  latter  day  work  in 
physiological  chemistry  in  this  single  volume  of 
thirty  lectures,  the  German  edition  of  which  was 
noticed  in  our  issue  for  March  20th,  the  subject  is 
yet  very  comprehensively  treated,  and  no  one  can 
fail  to  obtain  from  a  study  of  it  a  very  clear  under- 
standing of  modern  developments  in  this  field  of 
chemical  research.  Of  special  value  are  the  refer- 
ences to  the  literature  of  the  subject,  which  show 
careful  discrimination  and  an  evident  desire  on  the 
part  of  the  author  to  stimulate  the  student  to  inde- 
pendent observation  and  further  investigations. 

On  Infantilism  from  Chronic  Intestinal  Infection.  Char- 
acterized by  the  Overgrowth  and  Persistence  of  Flora  of 
the  Nursing  Period.  A  Study  of  the  Clinical  Course, 
Bacteriology,  Chemistrj-,  and  Therapeutics  of  Arrested 
Development  in  Infancy.  By  C.  A.  Herter,  M.  D.,  Pro- 
fessor of  Pharmacology  and  Therapeutics,  Columbia  Uni- 
versity. New  York:  The  Macmillan  Company,  1908. 
Pp.  118.    (Price,  90  cents.) 

In  this  monograph  of  Professor  Herter's  a  new 
syndrome  peculiar  to  childhood  is  described  with 
great  accuracy  and  clearness.  Collaborating  with 
Holt  in  establishing  the  chemical  features  of  the 
pathological  state  here  treated  of,  the  author  recog- 
nizes a  condition'  characterized  by  retardation  of 
skeletal  growth,  anaemia,  bodily  and  mental  fatigue, 
abdominal  distention,  faulty  intestinal  digestion 
often  accompanied  by  diarrhoea,  excessive  appetite, 
nervous  irritability,  subnormal  temperature,  and  a 
tendency  to  rhachitic  symptoms.  The  urine  con- 
tains an  excess  of  indican,  phenol  compounds,  and 
at  times  indolactic  acid  and  aromatic  oxyacids.  The 
stools  are  marked  by  an  excess  of  fatty  acids,  soaps, 
and  neutral  fats.  The  child's  mental  development 
is  tisually  good  and  in  striking  contrast  to  his 
dwarfed  and  feeble  body.  The  true  pathological 
cause  of  this  condition  is  believed  to  be  a  persist- 
ence and  overgrowth  in  childhood  of  the  intestinal 
flora,  especially  the  Bacillus  bifid  us.  normally  pres- 
ent only  in  early  infancy.  The  treatment  is  chiefly 
dietetic  and  consists  briefly  in  the  restriction  of 
carbohydrates  and  fats,  the  use  of  milk  proteids  and 
gelatin,  and  the  gttarded  administration  of  alcohol 
in  small  amounts.  A  mild  climate  and  general  hygi- 
enic measures  are  important.  Of  drugs,  phosphoric 
acid  and  the  calcium  and  magnesium  salts  may  be 
ttseful.  In  his  carefully  wrought  otit,  painstaking 
study  Professor  Herter  has  made  a  stibstantial  con- 
tribution to  psediatric  knowledge. 

Ticks.  A  Monograph  of  the  Ixodoidea.  Part  I,  Argasidae. 
By  George  H.  F.  Nuttall.  M.  A.,  M.  D.,  Ph.  D.,  Sc.  D., 
F.  R.  S.,  Fellow  of  Magdalene  College,  Quick  Professor 
of  Biology  in  the  University  of  Cambridge ;  Cecil  War  ■ 
liURTON,  M.  A.,  F.  Z.  S..  Christ's  College  Zoologist  to  the 
Royal  Agricultural  Society;  W.  F.  Cooper,  B.  A.,  F.  Z. 
S',  F.  L.  S. ;  and  L.  E.  Robinsox.  .\.  R.  C.  Sc.  (Lond.), 
Cambridge :  University  Press :  London :  H.  K.  Lewis. 
Pp.  104.    (Price,  5s.) 

The  development  of  the  role  of  insects  in  the 
transmission  of  disease  has  shown  the  need  for  en- 
tomological knowledge  on  the  part  of  those  who 
would  practise  in  the  warmer  climates  of  the  world, 
particularly  if  they  are  to  accomplish  anything  in 


722 


OFFICIAL  NEWS. 


[New  York 
Medical  Journal. 


the  way  of  rendering  those  cHmates  more  salubri- 
ous for  the  white  man.  The  monographing  of  the 
various  families  of  disease  transmitting  insects  is 
an  important  work  that  is  as  yet  in  its  infancy. 
When  physicians,  entomologists,  and  zoologists  col- 
laborate in  the  task  the  result,  we  can  confidently 
predict,  will  be  of  great  advantage  to  the  cause  of 
scientific  medicine,  especially  to  that  branch  which 
deals  with  the  prophylaxis  of  disease.  It  is  of 
course  necessary  to  describe  the  characteristics  of 
the  nondisease  bearing  ticks,  as  well  as  of  those  that 
are  proved  disease  carriers.  The  first  part  of  the 
work,  on  the  Ixodoidea,  deals  with  the  classification, 
structure,  and  biology  of  the  family  Argasidce,  in- 
cluding the  genera  argas  and  oriiithodonis.  In 
these  genera  Oriiithodonis  iiioiibata  is  known  to  be 
the  intermediate  host  for  Spirochccta  Diittoni,  the 
organism  which  causes  African  tick  fever.  Argas 
persicus  is  known  to  be  the  intermediate  host  for 
spirochaetosis  in  fowls,  and  is  suspected  of  being 
the  intermediate  host  of  the  spirochosta  that  produces 
the  relapsing  fever  of  Persia,  or  "miana  fever," 
Argas  rcHexus  is  suspected  of  transmitting  Spiro- 
chccta Marclionxi.  Al  these  insects  inflict  a  trou- 
blesome bite  upon  man  should  they  happen  to  be- 
come imbedded  in  his  skin.  Ornithodorus  7noubata 
is  also  suspected  of  being  the  transmitting  agent  for 
spirochaetosis  of  fowls,  and  for  Filaria  perstans. 

One  of  the  most  important  features  of  such  a 
monograph  is  the  assembling  of  the  synonyms  for 
a  given  form,  so  that  one  may  be  sure  of  his  nomen- 
clature. In  the  work  under  review  this  is  admira- 
bly done.  The  mechanical  details  are  good,  and  the 
illustrations  are  well  reproduced.  There  is  a  new  de- 
parture in  the  manner  of  publishing  the  references 
to  the  literature ;  they  are  printed  on  thin  paper,  so 
that  they  may  be  cut  and  pasted  on  the  regular  size 
reference  cards. 

 ^>  


Affinal  llttos. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports: 

The  following  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  week  ending  March  26,  igog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

Alabama — Montgomery  Mar.  5-12   i 

California — .San   Francisco  Feb.  27-Mar.  6   i 

Kansas — Topeka  Feb.  27-Mar.  13   18 

Kentucky — Covington  Mar.  6-13   2 

Massachusetts — New  Bedford  Mar.  G-17   i 

Missouri — Liberty  Jan.  15-Mar.  11   20 

Montana — Butte  Jan.   2-9   2 

Mar.  2-9   I 

Nebraska — South  Omaha  Feb.   20-27   5 

Tennessee — Memphis  Feb.  27-Mar.  13   33  1 

Tennessee — Nashville  Mar.  6-13   2  , 

Texas — Kl  Paso  Mar.  2-9   2 

Texas — San  Antonio  Mar.  6-13   2 

Utah— Salt  Lake  City  Feb.    1-28   85 

Washington — Camas  Dec.  29-Mar.  8   18 

Wisconsin — Appleton  Mar.  1-13   i 

Smallpox — Insular. 

Philippine  Islands — Manila  Jan.   i6-Feb.  3   10  5 

Smallpox — Foreign. 

Africa — Tripoli  Feb.  13-Mar.  6   11  3 

Arabia — Aden  Feb.   i-is   7 

Brazil— Rahia  Jan.   i6-Feb.   13   53  5 

Brazil — Para  ;  Feb.   13-27   2  i 


Places. 

Brazil — Pernambuco  Jan. 

Brazil — Rio  de  Janeiro  Jan. 

Canada — Halifax  Feb. 

Canada — Vancouver  Feb. 

Canada — Yarmouth  Mar. 

China — Hongkong  Jan. 

Cuba — Cienfuegos  Feb. 

Ecuador — Guamonte  Feb. 

France — Nice  Jan. 

France — Paris  ■  Feb. 

Great  Britain — Bristol  Feb. 

India — Bombay  Feb. 

India — Calcutta  Jan. 

India — Madras  Feb. 

Indo-China — Saigon  Jan. 

Italy — Catania  Feb. 

Italy — Naples  Feb. 

Italy — Palermo  Jan. 

Japan — Kobe  Feb. 

Java — Batavia  Jan. 

Mexico — Guadalaj  ara  Feb. 

Mexico — ilonterey  Feb. 

Russia — Odessa  Oct. 

Russia — Reval  Jan. 

Russia — Riga  Feb. 

Russia— .St.  Petersburg  Feb. 

Russi  a — Warsaw  Jan. 

Yellow  Fe: 


Date. 


Cases.  Deaths. 


14. 
S-  ■ 


121 
6 
3 
28 


1-31  •  •  • 
iS-Feb. 
26-Mar. 

1-  28.  . . 
7-20.  . 

2-  2.5   3 

28-Mar.  fi   I 

15  

1-31   ' 

13-20   3 

20-  27   I 

9-16  

30-  Feb.  6  

6-12  

23-30   2 

2 1 -  Mar.  7   5 

21-28   20 

20-27   8 

6-13   4 

23-Feb.   6   7 

18-25  

28-Mar.  7  

31-  Feb.  13 

1-31  

13-20  

6-13  


3S 
82 


Present 


14 
202 
3 


37 


1 6- Feb.  13. 
30-Feb.  20 

6-27  

8- Feb.  6 .  . 
6-13  


9-16. 
3 1 -Feb.  6. 

6-12  

31-Feb.  6. 

I  

1-5  


:6 
5 


Present 
'9 


13 


45 
14 


9-16  

-Foreign. 

Barbados — General  Feb.  25-Mar.  5   2 

Barbados — Bridgetown  Feb.  25-Mar.  5   i 

Barbados — Sprightstown  Feb.  25-Mar.  5   i 

Brazil — Bahia  Jan.  i6-F>b.  13   51 

Brazil — Manaos  Jan. 

Brazil — Para  Feb. 

Ecuador — Guayaquil  Jan. 

Mexico — Merida,  vicinity  Mar, 

Cholera — Insular. 
Philippine  Islands — Provinces, ...  .Jan.   i6-Feb.   6  36 

Cholera — Foreign. 

China — Hongkong  Dec.   26-Jan.    16   2 

India — Bombay  Feb. 

India — Calcutta  Jan. 

India — Madras  Feb. 

India — Rangoon  Jan.   3i-I"eb.   6   13 

Russia — laroslav  Mar. 

Russia — St.   Petersburg  Mar.  1-5   50 

Plague — Foreign. 

Brazil — Bahia  Jan.    i6-Feb.    13   22 

Brazil — Rio  de  Janeiro  Jan.    17-Feb.    14   13 

China — Hongkong  Dec.   26-Jan.  2   i 

Chile — Iquique  Feb.  '   12 

Ecuador — I'.abahoyo  Feb.  15   3 

Ecuador — Guayaquil  Jan.   8-Feb.  6  

Ecuador — Milargo  Jan.   18   i 

Ecuador — Nisag  Feb.  15   7 

India — Bombay  Feb.  9-16  

India — Calcutta  Jan.   31-Feb.   6   10 

India — Rancoon  Jan.   31-Feb.  6  

Indo-Chiiia — Saigon  Jan.    23-30   2  2 

Peru — General  Jan.  2g-Feb.   6   66  18 

Peru — Callao  Jan.   29-Feb.   6   4  2 

Peru — Lima  Jan.  29-Feb.   6   5  .3 

Turkey  in  Asia — Jiddeh  Feb.    22-28   24  22 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
March  24,  1909: 

Amesse,  J.  W.,  Passed  Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence,  from  March  23,  1909. 

Blue,  Rupert,  Passed  Assistant  Surgeon.  Directed  to  re- 
port to  the  chairman  of  the  board  of  medical  examin- 
ers, to  determine  fitness  for  promotion  to  the  grade  of 
surgeon. 

BoGGESS.  J.  S.,  Passed  Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence,  from  March  21,  1909. 

Collins,  G.  L.,  Passed  Assistant  Surgeon.  Granted  three 
days'  leave  of  absence,  from  March  18,  1909,  under  par- 
agraph 189,  Service  Regulations. 

Frissell,  C.  M.,  Acting  Assistant  Surgeon.  Granted 
twenty-one  days'  leave  of  absence,  from  February  8, 
1909. 

G.\kdni;r,  Charles  II.,  Passed  Assistant  Surgeon.  Directed 
to  proceed  to  Washington,  D.  C,  and  report  to  the 
chairman  of  the  board  of  medical  examiners,  to  deter- 
mine fitness  for  promotion  to  the  grade  of  surgeon. 

Gibson,  R.  H.,  Pharmacist.  Leave  of  absence,  granted 
March  9,  1909,  for  sixteen  days,  from  March  8,  1909, 
amended  to  read  five  days,  from  March  8,  1909. 

Heiser,  Victor  G.,  Passed  Assistant  Surgeon.  Leave  of 
absence,  granted  October  12,  1908,  for  thirty  days, 
amended  to  read  seventeen  days  en  route  to  station. 


Ai  ril  3.  1909.  J 


OFFICIAL  XEWS. 


723 


Krulish,  Emil,  Assistant  Surgeon.  Granted  five  days" 
leave  of  absence,  from  March  19.  1909. 

Oakley,  J.  H.,  Passed  Assistant  Surgeon.  Directed  to  pro- 
ceed to  San  Francisco,  Cal.,  and  report  to  the  cliair- 
man  of  the  board  of  medical  examiners,  to  determine 
fitness  for  promotion  to  the  grade  of  surgeon. 

Porter,  J.  Y.,  Quarantine  Inspector.  Directed  to  proceed 
to  ^layport,  Fla.,  upon  special  temporary  duty. 

Reifel,  J.  W.,  Acting  Assistant  Surgeon.  Granted  seven 
days"  leave  of  absence,  from  March  2,  1909,  under  para- 
graph 191.  Service  Regulations. 

Roberts.  >sOK>i.\x,  Passed  Assistant  Surgeon.  Granted 
three  days"  leave  of  absence,  from  March  18,  1909,  un- 
der paragraph  191,  Service  Regulations. 

Roberts,  Xorm.\x,  Passed  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence,  from  March  21,  1909. 

Spragle.  Ezra  K.,  Passed  Assistant  Surgeon.  Directed  to 
proceed  to'Washington,  D.  C.,  and  report  to  the  chair- 
man of  the  board  of  medical  examiners,  to  determine 
fitness  for  promotion  to  the  grade  of  surgeon. 

Stiles,  Ch.xrles  W.\rdell,  Chief  Division  of  Zoolog>', 
Hygienic  Laboratory.  Granted  two  days'  leave  of  ab- 
sence, in  Januan,-,  1909.  and  one  day"s  leave  of  absence. 
Februao'  i,  1909,  under  paragraph  211,  Service  Regula- 
tions. 

Tarbell,  B.  C,  Acting  Assistant  Surgeon.    Granted  one 

day's  leave  of  absence,  March  28,  1909. 
\V.\SDix.  Ei'GEXE.  Surgeon.    Granted  one  month's  leave  of 

absence  from  March  22,  1909.  on  account  of  sickness. 
White,  J.  H.,  Surgeon.    Directed  to  proceed  to  Gulf  Quar- 
antine. Biloxi.  Miss.,  upon  special  temporary-  duty. 
WiGHT.MAX.  W.  M..  Passed  Assistant  Surgeon.  Granted 
twenty-five  days'  leave  of  absence,  from  January  23, 
1909,  on  account  of  sickness. 
Wollexberg.  R.  a.  C.,  Assistant  Surgeon.    Granted  two 
days'  leave  of  absence,  from  February  26,  1909,  on  ac- 
count of  sickness. 

Boards  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital,  San  Francisco,  Cal.,  April  5,  1909,  for  the  examin- 
ation of  certain  passed  assistant  surgeons  to  determine 
their  fitness  for  proinotion  to  the  grade  of  surgeon.  Detail 
for  tlie  board:  Surgeon  H.  W.  Austin,  chairman:  Surgeon 
S.  D.  Brooks ;  Passed  Assistant  Surgeon  W.  C.  Hobdy, 
recorder. 

Board  of  medical  officers  convened  to  meet  at  the  Bureau, 
Washington.  D.  C,  April  5,  1909,  for  the  examination  of 
certain  passed  assistant  surgeons  to  determine  their  fitness 
for  promotion  to  the  grade  of  surgeons.  Detail  for  the 
board :  Assistant  Surgeon  General  W.  J.  Pettus.  chairman : 
.Assistant  Surgeon  General  J.  M.  Eager ;  Assistant  Surgeon 
General  J.  W.  Kerr,  recorder. 

'  Boards  of  medical  officers  v  ere  convened  to  meet  on 
April  5,  1909,  for  the  purpose  of  making  physical  examina 
tions  of  applicants  for  the  position  of  cadet  in  the  Revenue 
Cutter  Service,  as  follows : 

Portland,  Me. :  Surgeon  P.  C.  Kalloch,  chairman :  Acting 
.Assistant  Surgeon  ,  recorder. 

Boston,  Mass. :  Surgeon  L.  L.  Williams,  chairman : 
Passed  Assistant  Surgeon  T.  W.  Salmon,  recorder. 

New  York.  X.  Y. :  Passed  Assistant  Surgeon  C.  W. 
Vogel,  chairman  :  Assistant  Surgeon  Lasher  Hart,  recorder. 

Philadelphia,  Pa. :  Surgeon  J.  ^M.  Gassawaj-,  chairman ; 
Acting  Assistant  Surgeon  H.  Horning,  recorder. 

Baltimore,  Md. :  Surgeon  W.  P.  Mcintosh,  chairman ; 
Passed  Assistant  Surgeon  M.  K.  Gwj-n,  recorder. 

Washington.  D.  C. :  Assistant  Surgeon  General  H.  D. 
Geddings.  chairman :  Passed  Assistant  Surgeon  J.  W. 
Trask.  recorder. 

Norfolk.  Va. :  Surgeon  C.  P.  Wertenbaker.  chairman : 
-Acting  Assistant  Surgeon  R.  W.  Browne,  recorder. 

Savannah.  Ga. :  Surgeon  F.  W.  Mead,  chairman :  Acting 
Assistant  Surgeon  A.  B.  Cleborne.  recorder. 

Mobile.  Ala. :  Surgeon  G.  M.  Guiteras.  chairman :  Acting 
.Assistant  Surgeon  J.  O.  Rush,  recorder. 

New  Orleans.  La. :  Sursreon  J.  H.  White,  chairman : 
Passed  Assistant  Surgeon  H.  W.  Wickes.  recorder. 

Galveston.  Tex. :  Passed  Assistant  Surgeon  G.  M.  Cor- 
put.  chairman:  Acting  Assistant  Surgeon  W.  H.  Gammon, 
recorder. 

Detroit.  Mich. :  Surgeon  R.  M.  Woodward,  chairman ; 
Passed  Assistant  Surgeon  M.  J.  White,  recorder. 
Chicago.  111. :  Stirgeon  G.  B.  Young,  chairman :  Passed 


A.^jisiant  Surgeon  R.  H.  Creel,  recorder. 

Seattle.  Wash. :  Passed  Assistant  Surgeon  M.  W.  Glover, 
chairman  :  Assistant  Surgeon  C.  W.  Chapin.  recorder. 

San  Francisco.  Cal. :  Passed  Assistant  Surgeon  W.  W. 
King,  chairman;  Passed  Assistant  Surgcin  J.  D.  Long, 
recorder. 

Army  Intelligence: 

OfRcial  list  of  changes  in  the  stations  and  duties  of  oM- 
ccrs  scriina  in  the  ^ledical  Corps  of  the  United  States 
Army  for  the  ncek  ending  March  27,  igog: 
Deax,  E.  A.,  Major,  Medical  Corps.    Relieved  from  duty 

in  the  Philippines  Division  :  will  sail  on  June  15th  from 

Manila,  P.  I.,  for  San  Francisco.  Cal.,  for  orders. 
Field.  P.  C,  Captain,  Medical  Corps.    Vv'hen  relieved  at 

Fort  Wayne,  Mich.,  ordered  to  Fort  Slocum.  N.  Y., 

for  duty. 

Kexxedy.  J.  S.,  First  Lieutenant.  Medical  Reserve  Corps. 
When  relieved  at  Fort  Omaha.  Neb.,  ordered  to  Fort 
Sam  Houston,  Tex.,  for  duty. 

Lewis,  W.  F.,  Major,  Medical  Corps.  Relieved  from  duty 
at  Fort  Thomas,  Ky. ;  will  sail  from  San  Francisco, 
Cal.,  June  5,  1909,  for  service  in  the  Philippines. 

Lord,  L.  W.,  First  Lieutenant,  Medical  Reserve  Corps.  Re- 
lieved from  durj-  at  Fort  Riley,  Kans..  April  13,  1909; 
ordered  to  his  home,  and  relieved  from  active  duty  in 
the  Medical  Reserve  Corps. 

Marrow,  C.  E.,  Major,  ^ledical  Corps.  Granted  leave  of 
absence  for  three  months,  with  permission  to  apply  for 
an  extension  of  one  month,  when  relieved  from  duty 
on  the  McClellan. 

Mas)X.  C.  F..  Major.  Medical  Corps.  Ordered  to  report 
at  Washington.  D.  C.  for  examination  for  promotion. 

Parkmax.  W.  E..  First  Lieutenant.  Medical  Reserve  Corps. 
Honorabh'  discharged  from  the  ser\-ice  of  the  L'nited 
States,  his  services  being  no  longer  required. 

Pattersox.  R.  U..  Captain.  Medical  Corps.  Ordered  to 
duty  with  Company  C.  Hospital  Corps,  at  the  Army- 
General  Hospital.  Washington.  D.  C.  upon  return  from 
Cuba. 

PiERSox.  R.  H..  Captain.  Medical  Corps.    Granted  leave  of 

absence  for  thirty  days. 
Porter,  R.  S.,  Captain,  Medical  Corps.    Relieved  from 

Awty  at  Fort  Huachuca.  Ariz.,  and  ordered  to  Fort 

Bayard.  N.  M..  for  duty  at  the  .Army  General  Hospital. 
Raxd.  I.  W.,  Major.  Medical  Corps.    When  relieved  at 

Fort  Du  Pont,  Del.,  ordered  to  Fort  Hancock.  N.  J., 

for  duty\ 

Reasoxer,  ^I.  a..  Lieutenant.  Medical  Corps.  Granted 
leave  of  absence  for  one  month. 

Rho.\ds.  T.  L..  Major.  .Medical  Corps.  Relieved  from  duty 
in  the  Philippines  Division ;  will  proceed  to  San  Fran- 
cisco. Cal..  for  orders. 

RiCHARDSOX.  R.  L..  Captain.  Medical  Corps.  Ordered  to 
duty  at  Fort  WajTie.  Mich.,  upon  return  from  Cuba. 

R  ir.ERTS.  W.  M..  Captain.  Aledical  Corps.  When  relieved 
at  Fort  Hancock.  N.  J.,  ordered  to  Fort  Thomas.  Ky., 
for  duty. 

Shiu.ock.  P.wl.  ^lajor.  Medical  Corps.  Granted  leave  of 
absence  for  ten  days :  ordered  to  report  at  Washington, 
D.  C.  for  examination  for  promotion. 

SiLER,  J.  F.,  Captain.  Medical  Corps.  Relieved  from  duty 
at  Fort  Jay,  N.  Y..  and  ordered  to  duty  at  the  ^Medical 
Supply  Depot,  New  York. 

Stoxe.  J.  H..  Major.  Medical  Corps.  Relieved  from  duty 
at  the  L'nited  States  Military  Prison.  Fort  Leaven- 
worth. Kans..  and  ordered  to  Fort  Sam  Houston.  Tex., 
for  duty. 

Usher.  F.  M.  C.  Major.  Medical  Corps.  Relieved  from 
duty  in  Philippines  Division :  will  sail  on  June  15th 
from  Manila.  P.  I.,  for  San  Francisco.  Cal..  for  orders. 

WiLLcox,  Charles.  Major,  Medical  Corps.  Ordered  to 
duty  at  Fort  Totten,  N.  Y.,  upon  return  from  Cuba. 

Woodruff,  C.  E..  Major.  Medical  Corps.  Ordered  to  re- 
port at  Washington.  D.  C.  for  examination  for  pro- 
motion. 

W  oopsox.  R.  S.,  ^lajor.  ^ledical  Corps.  Ordered,  upon  ar- 
rival at  San  Francisco,  Cal..  to  proceed  to  Fort  Dit 
Pont.  Del.,  for  duty. 

Wrex.  R.  J.,  First  Lieutenant,  Medical  Reserve  Corps, 
Honorably  discharged  on  March  23,  1909,  his  services 
being  no  longer  required. 


724 


HIRTH^.  MARRIAGES,  AND  DEATHS. 


[New  \ork 
Medical  Juurnal. 


Navy  Intelligence : 

Official  list  of  changes  in  the  statiniis  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  week  ending  March  27,  igog: 
BiELLo,  J.  A.,  Assistant  Surgeon.  Detached  from  the  Naval 

Hospital,  Mare  Island,  Cal.,  and  ordered  to  the  .\lary- 

land. 

De  Valin,  C.  M.,  Surgeon.  Detached  from  the  Washing- 
ton and  ordered  home  to  await  orders. 

Field,  J.  G.,  Surgeon.  Detached  from  Naval  Training 
Station,  San  Francisco,  Cal.,  and  ordered  to  the  Wash- 
ington. 

Grunwell,  a.  G.,  Surgeon.  Detached  from  the  Kentucky 
and  ordered  to  the  Kansas. 

HoLLOWAV,  J.  H.,  Passed  Assistant  Surgeon.  Detached 
from  the  Franlzlin  and  ordered  to  duty  on  the  Con- 
necticut. 

Jones,  E.  L.,  Assistant  Surgeon.  Detached  from  the  Mary- 
land and  ordered  to  duty  on  the  Independence. 

Kaufman,  J.  B.,  Assistant  Surgeon.  Detached  from  the 
Tennessee  and  ordered  to  the  Naval  Training  Station, 
San  Francisco,  Cal. 

Old,  E.  H.  H.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Training  Station,  Newport,  R.  L,  and  or- 
dered to  duty  at  the  Naval  Dispensary,  Washington, 
D.  C. 

Phillios,  E.  W.,  Acting  Assistant  Surgeon.    Ordered  to 

duty  at  the  Naval  Hospital,  New  York. 
Pickrell,  G.,  Surgeon.    Ordered  to  temporary  duty  in  the 

Bureau  of  Medicine  and  Surgery,  Navy  Department, 

in  connection  with  the  Solace. 
Rennie,  W.  H.,  Passed  Assistant  Surgeon.    Detached  from 

the  Illinois  and  ordered  to  the  Rhode  Island. 
Richards,  T.  W.,  Surgeon.    Detached  from  the  Kansas 

and  ordered  to  temporary  duty  in  the  Bureau  of  Medi- 
cine and  Surgery,  Navy  Department. 
Richardson,  R.  R.,  Passed  Assistant  Surgeon.    Ordered  to 

duty  at  Naval  Hospital,  Portsmouth,  N.  H. 
Stalnakek,  p.  R.,  Passed  Assistant  Surgeon.  Detached 

from  duty  at  the. Naval  Hospital,  Annapolis,  Md.,  ana 

ordered  to  the  Navy  Yard,  Washington,  D.  C. 
Stepp,  J.,  Passed  Assistant  Surgeon.    Ordered  to  Naval 

Training  Station,  Newport,  R.  I. 
Stuart,  A.,  Passed  Assistant  Surgeon.    Detached  from  the 

Yankton  and  ordered  to  the  A^ezu  Jersey. 
Whitmoke,  G.  B.,  Assistant  Surgeon.    Orders  of  March 

17th  modified;  ordered  to  Naval  Recruiting  Station, 

Baltimore,  Md. 
The  following  officers  have  been  detached  from  instruc- 
tions at  \aval  Medical  School,  Washington,  D.  C,  and 
ordered  to  duty  as  follows : 

Brown,  E.  W.,  Assistant  Surgeon.  To  the  Naval  Medical 
School,  Washington,  D.  C. 

Clifton,  A.  L.,  Assistant  Surgeon.  To  the  Naval  Hospital, 
Philadelphia,  Pa, 

Cottle,  G,  F".,  Assistant  Surgeon.  To  the  Naval  Hospital, 
Annapolis,  Md.  > 

Cuthp.ertson.  R..  Assistant  Surgeon.  To  the  Naval  Hos- 
pital, Mare  Island,  Cal. 

Giltner,-H.  a..  Assistant  Surgeon.  To  the  Naval  Training 
Station,  San  Francisco.  Cal. 

Mann,  W.  L.,  Assistant  Surgeon.  To  temporary  duty  on 
the  Independence :  thence  to  the  Tennessee. 

Moran,  C.  L.,  Assistant  Surgeon.  To  the  Navy  Yard,  Bos- 
ton, Mass. 

Phelps,  J.  R.,  Assistant  Surgeon.    To  the  Yankton. 

Sinclair.  J.  A.  B.,  Assistant  Surgeon.  To  the  Naval  Prov- 
ing Ground,  Indian  Head,  Md. 

Sutton,  D.  G.,  Assistant  Surgeon.  To  the  Naval  Acad- 
emy. 

Thomas,  G.  C,  Assistant  Surgeon.    To  the  Naval  Recruit- 
ing Station,  Omaha,  Neb. 
Turner,  H.  W.  B.,  .Assistant  Surgeon.    To  the  Naval  Med- 
ical School  Hospital  for  treatment. 
The  following  officers  have  been  detached  from  duty  at 
the  places  named,  and  have  been  ordered  to  instruction  at 
the  Naval  Medical  School,  Wasbington,  D.  C.  .April  15: 
Bi  ..NCKWoon,  N.  J.,  Surgeon.    I'rom  the  .Vrti*  Jersey. 
Bko')ks.  F,  H,.  .Assistant  Surgeon,    From  the  Naval  Re 
crniting  Station,  Baltimore,  Md. 


Corn,  I.  F.,  Assistant  Surgeon.  From  the  Naval  Hospital, 
Mare  Island,  Cal. 

Evtinge,  E.  O.  J.,  Assistant  Surgeon.  From  the  Naval 
Hospital,  New  York, 

Grayson,  C,  T.,  Passed  Assistant  Surgeon.  From  the  Na- 
val Dispensary,  Washington,  D.  C. 

Reed,  E.  U.,  Assistant  Surgeon.  From  the  Naval  Training 
Station,  San  Francisco,  Cal. 

Robnett,  a.  H.,  Assistant  Surgeon.  From  the  Recruiting 
Station,  Omaha,  Neb. 

Smith,  C.  G.,  Passed  Assistant  Surgeon.  From  the  Naval 
Hospital,  Portsmouth,  Va. 

Woods,  E.  L.,  Assistant  Surgeon.    From  the  Kearsargc. 




Born. 

Gkeenleaf. — In  Madison  Barracks,  New  York,  on  Tues- 
day, March  23d,  to  Major  H,  S.  Greenleaf,  Medical  Corps, 
United  States  Army,  and  Mrs.  Greenleaf,  a  son. 

Married. 

Giltner — Sullivan. — In  Washmgton,  D.  C,  on  Wednes- 
day, March  24th,  Assistant  Surgeon  Harry  A.  Giltner,  U. 
S.  N.,  and  Miss  Virginia  Eartlett  Sullivan. 

Keichline — Tho.mpson. — In  Petersburg,  Pennsylvania, 
on  Wednesday,  March  24th,  Dr.  John  Alaulfair  Keichline 
and  ]\liss  Martha  Jane  Ihompson. 

Sterne — Orndorff. — In  Washington,  D.  C,  on  Tliurs- 
day,  March  25th,  Assistant  Surgeon  Charles  F.  Sterne,  U. 
S.  N.,  and  Miss  Irene  OrndorfT. 

Died. 

Beatty. — In  Philadelphia,  on  Alonday,  March  22nd,  Dr. 
Thomas  J.  Beatty,  aged  iifty-two  years. 

Baker. — In  East  Bridgewater,  Massachusetts,  on  Friday, 
March  19th,  Dr,  George  Lorimer  Baker,  of  Dorchester, 
aged  thirty-five  years, 

Burwell, — In  Parkersburg,  West  Virginia,  on  ?^Ionday, 
March  22nd,  Dr,  W,  N,  Burwell,  aged  fifty-one  years. 

Butler. — In  Bangor,  Maine,  on  Tuesday,  March  23rd, 
Dr.  Harry  Butler,  aged  forty  years. 

Byers. — In  Independence,  Iowa,  on  Wednesday,  March 
17th,  Dr,  D,  S.  Byers.  of  New  Hampton,  aged  seventy-si.x 
years. 

Conner. — In  Cincinnati,  Ohio,  on  Friday,  March  26th, 
Dr.  Phineas  Sanborn  Conner,  aged  seventy  years. 

Davidson. — In  Perryopolis,  Pennsylvania,  on  Wednesday, 
March  17th,  Dr,  Jolm  H.  Davidson,  aged  sixty-three  years. 

FoRST. — In  Pitlsbm-gh,  Pennsylvania,  on  Wednesday, 
March  17th,  Dr.  A.  Forst,  aged  fifty-two  years. 

Fr.\ncis. — In  Brookline,  Massachusetts,  on  Saturday, 
March  20th,  Dr.  Tappan  E.  Francis,  aged  eighty-five  years. 

French. — In  El  I'aso,  Texas,  on  Tuesday,  March  23d, 
Dr.  Edwin  C.  French. 

Fulton. — In  Lyons,  New  York,  on  Monday,  March  22nd, 
Dr.  Cyril  Fulton,  aged  forty-one  years. 

II.\WKiNS. — In  Brunswick,  Ohio,  on  Thursday,  March 
iith.  Dr.  ^lorris  J.  Hawkins,  aged  seventy-two  years, 

Hoffman. — In  Clinton ville,  Pennsylvania,  on  Sunday, 
February  21st,  Dr.  K.  M.  IIolTman,  aged  seventy-five  years. 

HoTZ. —  In  Chicago,  Illinois,  on  Sunday,  March  21st,  Dr. 
Ferdinand  Carl  Hotz,  aged  sixty-six  years. 

McCabe. — In  Greenville,  New  York,  on  Tuesday,  March 
1 6th,  Dr.  B.  S.  McCabe,  aged  eighty-four  years. 

Reichard.— In  Paola,  Kansas,  on  Tuesday,  March  16th, 
Dr.  Albert  Reichard,  aged  fifty-seven  years. 

Revbuun. — In  Wasbington,  D.  C,  on  Friday.  March  26th. 
Dr.  Robert  Reyburn,  aged  seventy- six  years. 

Small.— In  Portland,  Maine,  on  Friday,  March  igtb.  Dr. 
Freeman  E.  Small,  aged  fifty-h\  e  years. 

T.\FT. — In  Longmont.  Colorado,  on  Friday,  March  5th, 
Dr.  l'>ed  P.  Taft,  aged  thirty-seven  years. 

Terry. — In  Dallas,  Texas,  on  Fridav,  March  26th.  Dr. 
II.  F.  Terry. 

VoN  Renvers. — In  Berlin,  GOrniany,  on  Monday,  M.nrch 
22ih1.  Dr,  Rudolf  von  Renvers. 

Wahl, — In  Philadelpbi,i,  on  Tuesday,  March  23d.  Dr. 
William  Henry  Wahl.  aged  <ixty-one  years. 

White. — In  Camden.  New  Jersey,  on  Tuesday.  Marcli 
23(1.  Dr.  J.  Orlando  White,  aged  sixty-two  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  rlt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


\  OL.  LXXXIX,  No.  15. 


XE\\'  YORK,  APRIL  10,  1909. 


Whole  No.  1584. 


(Original  Commanitations. 


-THE  COUNTY  MEDICAL  SOCIETY." 
Address  of  the  Retiring  President  of  the  Medical  Society 
of  the  County  of  New  York* 

By  J.  Riddle  Goffe,  M.  D., 
New  York. 

I  need  not  say  to  you,  Mr.  President,  how  much 
pleasure  it  gives  me  to  welcome  you  to  the  position 
of  honor  and  responsibility  which  you  are  about  to 
assume.  I  can  assure  you,  however,  that  with  what- 
ever feeling  you  assume  the  office  now,  you  will  re- 
linquish it  at  the  end  of  your  term  with  a  far  live- 
lier sense  of  its  dignity,  its  responsibility,  and  its 
honor.  I  am  speaking  now  from  my  own  personal 
experience.  You  will  perhaps  recall  the  fact  that 
previous  to  amalgamation  I  was  more  particularly 
identified  with  the  Medical  Association.  I  had  never 
taken  an  active  part  in  this  society  and  knew  noth- 
ing of  the  practical  workings  of  the  Comitia  Mi- 
nora, the  Board  of  Censors,  or  the  Milk  Committee. 
I  have  found  that  there  is  plenty  of  work  for  them 
all,  and  have  been  profoundly  impressed  with  the 
conscientious  devotion  of  the  members  of  these 
branches  of  the  executive  office,  and  the  efficiency 
with  which  the  business  is  transacted.  I  had  no 
conception  of  the  time  and  labor  these  committees 
required  of  their  members,  and  have  been  greatly 
inspired  by  the  promptness,  the  interest,  and  the 
thoughtful  judgment  that  each  and  every  man  on 
the  Board  of  Censors,  and  the  Comitia  Minora  de- 
votes to  his  duties.  I  am  convinced  that  the  mem- 
bers of  the  society  would  stand  amazed,  as  I  did,  at 
these  characteristics  as  they  gradually  revealed 
themselves  to  me  in  connection  with  my  official  du- 
ties. These  methods  and  these  traditions  can  only 
be  handed  down  by  the  system  of  organization 
which  carries  over  the  membership,  from  year  to 
year,  of  a  sufficient  number  of  the  older  members 
to  properly  leaven  the  new  organization.  Especially 
is  this  true  of  the  Board  of  Censors,  where  ques- 
tions of  the  most  delicate  character  are  constantly 
arismg,  and  necessarily  must  be  handled  with  the 
greatest  tact  and  discretion.  Owing  to  the  fortu- 
nate make  up  of  the  committees,  the  machinery  of 
the  society  during  the  past  year  has  run  with  the 
least  possible  friction,  and  with  the  greatest  har- 
mony, and  satisfaction. 

The  proceedings  of  the  Board  of  Censors,  like 

•Delivered  at  tlie  January  meeting  of  the  society. 


that  of  a  grand  jury,  are  necessarily  secret.  I  take 
this  occasion  to  assure  the  society,  that  so  far  as  my 
observation  and  participation  in  the  work  during 
the  past  year  has  gone,  the  most  perfect  impartiality 
in  dealing  with  the  members  of  the  society  for  minor 
breaches  of  professional  etiquette,  as  well  as  those 
of  a  grosser  nature  have  been  met  with  unflinching 
courage  and  diplomatic  tact.  I  know  of  nothing 
that  would  surprise  the  members  of  this  society 
more  than  for  me  to  reveal  the  prominent  men  of 
the  profession  that  have  been  before  the  censors  for 
little  slips  of  propriety,  most  of  them  innocently  and 
tmwittingly  committed,  as  well  as  those  who  have 
been  guilty  of  offenses  of  a  more  sordid  character, 
deliberately  prompted  by  selfishness  and  greed.  If 
there  is  one  word  of  caution  that  I  would  venture 
at  this  time  to  suggest,  it  is  that  you  guard  with 
jealous  eye  the  make  up  of  the  Board  of  Censors. 
Do  not  place  upon  it  any  man  who  \\ants  office  for 
the  sake  of  office.  On  the  contrary  see  to  it  that 
every  man  elected  to  this  important  trust  is  conspic- 
uous for  his  high  character,  rare  discretion,  and  ripe 
judgment. 

I  may  be  pardoned  perhaps  if  I  repeat  here  soine 
thoughts  I  have  expressed  on  a  previous  occasion. 
Society  throughout  the  world  in  its  political,  moral, 
and  social  organization  recognizes  the  family  as  the 
unit.  The  family  is  the  foundation  of  the  whole 
structure.  From  the  family  organization,  the  family 
relations,  emanate  the  virtues,  the  morals,  the  char- 
acter that  make  our  modern  civilization  possible. 
Upon  the  family  as  the  unit  the  whole  superstruct- 
ure depends.  So  in  our  medical  organization  the 
home  society,  the  county  organization,  is  the  unit 
upon  which  its  superstructure  rests.  When  the 
county  association  languishes,  the  district  branch 
and  the  State  body  languish,  and  when  the  county 
society  flourishes  the  impulse  there  engendered 
spreads  throughout  the  entire  system. 

The  intimate  relations  of  the  family  circle  culti- 
vate forbearance,  selfrestraint,  selfsacrifice,  love, 
and  charity,  as  well  as  an  intimate  knowledge  of 
each  other's  character,  and  these  in  turn  beget  unity, 
peace,  and  concord.  It  has  been  truly  said  that  in 
the  struggles,  the  misunderstandings,  the  reconcilia- 
tions, the  parental  discipline  of  a  large  family  of 
children  are  evolved  the  finest  characters  in  the 
world.  Selfishness,  imtruthfulness,  cunning,  and 
deceit  are  worked  out  of  each  other  by  the  ferment 
of  justice  and  right;  another's  privileges  are  re- 
spected ;  and  the  rights  of  all  are  on  a  common  plane. 

^[cml)ers  of  the  countv  society  are  but  children  of 


Copyrigl  t,  .509.  by  A.  R.  fillHott  Publisliing  Company. 


726 


GOFFE:  COUNTY  MEDICAL  SOCIETY. 


[Xeu-  Vork 
Medical  Journal. 


a  larger  growth  where  the  same  homely  virtues 
need  to  be  practised  and  cultivated.  The  county  so- 
ciety exists  primarily  for  the  cultivation  and  dis- 
semination of  medical  science  and  art.  but  the  value 
and  the  far  reaching  influence  of  experiences  there 
recorded  depends  largely  upon  the  careful  estimate 
of  the  narrator's  powers  of  observation,  the  accur- 
acy with  which  he  records  what  he  sees,  and  his 
natural  bias,  or  personal  equation.  This  can  only 
come  from  a  personal,  intimate  acquaintance  ob- 
tained by  more  or  less  familiar  intercourse.  The 
members  must  know  each  other,  not  as  bowing  ac- 
quaintances, but  in  that  intimate  wa\'  that  comes 
from  association  when  they  are  off  their  guard,  in 
affairs  of  nuitual  interest,  in  recreations  and  social 
functions.  This  is  obtained  in  the  social  intercourse 
that  attends  the  bouft"et  luncheons  at  the  close  of 
our  meetings. 

I  would  not  be  understood  as  maintaining  that  the 
local  society  exists  solely  for  the  cultivation  of  the 
urbanities  of  life  and  the  study  of  moral  character. 
The  scientific  work,  the  papers  and  the  discussion 
fix  the  intellectual  status  of  the  members.  From 
the  discussions  it  quickly  develops  who  has  the  ob- 
servant eye,  the  keen  ear,  the  delicate  fingers,  and 
the  educated  touch.  As  Osier  says  :  "The  well  con- 
ducted medical  society  represents  a  clearing  house 
in  which  every  physician  of  the  district  receives  his 
intellectual  rating,  and  in  which  he  finds  out  his 
professional  assets  and  liabilities." 

On  the  ed.ucational  value  of  the  local  medical  so- 
ciety we  need  not  dwell.  That  is  appreciated  by  all. 
The  aim  in  every  county  should  be,  moreover,  to 
see  to  it  that  every  respectable  practitioner  is  a  mem- 
ber of  the  local  society,  and  that  every  practitioner 
who  is  not  respectable  is  bounced  out  of  the 
profession. 

Let  us  not  deceive  ourselves,  however,  with  the 
idea  that  the  country  society  may  become  such  a 
postgraduate  school  of  instruction  that  it  will  make 
finished  scholars  out  of  all  its  members.  But  its  in- 
fluence is  always  for  the  good.  As  Lorimer  says  in 
his  letter  to  his  son  at  Harvard:  "College  doesn't 
make  bright  men,  it  developes  them;  it  doesn't  make 
fools,  it  developes  them.  A  fool  will  turn  out  a  fool 
whether  he  goes  to  college  or  not,  though  he  will 
probably  turn  out  a  different  sort  of  a  fool." 

But  the  homely  virtue  is  not  all.  The  stay  at 
home  man  may  cultivate  and  possess  the  elemental 
qualities  that,  as  we  have  said,  are  essential  to  the 
foundation  stone  of  our  superstructure,  but  the  man 
with  the  broader  outlook  must  go  afield  to  the  neigh- 
boring societies  and  the  State  organization  for  con- 
genial spirits  and  higher  mental  stimulus.  Then  it 
becomes  necessary  to  know  ''who  is  who"  and  have 
means  of  exchanging  ideas  and  securing  a  rating 
of  the  man  in  the  mccHcal  centres  and  the  distant 
parts  of  the  State.  Nothing  meets  these  require- 
ments so  completely  as  a  State  medical  directory, 
and  a  State  medical  journal.  Through  their  instru- 
mentality the  general  society  is  made  compact,  the 
mutual  interests  and  dependence  of  the  constituent 
societies  are  kept  alive  ami  responsive,  and  the  or- 
ganization as  a  whole  becomes  a  ready  instrument 
for  defensive  or  aggressive  action. 

I  trust  our  delegates  to  the  State  Society  next 


week  in  Albany  will  stand  solidly  in  support  of  the 
journal  and  the  directory. 

Malpractice  defense  is  a  pertinent  feature  of  a 
State  medical  society,  and  in  our  organization  it  is 
working  most  satisfactorily,  as.  shown  by  the  report 
of  our  counsel,  Mr.  Lewis.  The  effect  of  the  insur- 
ance companies  that  have  undertaken  such  work  is 
somewhat  questionable.  They  are  working  on  a 
strictly  business  basis  for  the  benefit  of  their  own 
pockets.  It  is  cheaper,  as  a  rule,  to  compromise 
than  it  is  to  fight.  The  ease  with  which  litigants 
thus  obtain  compensation  for  simple  or  fancied  mis- 
haps encourages  the  practice  of  suing  for  damages, 
and  the  doctor  becomes  a  marked  object  for  black- 
mail on  the  slightest  provocation. 

On  the  other  hand  a  determined  and  obstinate 
defense  through  the  medium  of  our  own  organiza- 
tion offers  a  real  protection.  I  am  credibly  informed 
that  the  counsel  for  the  State  Society,  Mr.  Lewis, 
has  never  lost  a  case  in  defending  members  against 
malpractice  prosecutions — and  better  still  has  so  suc- 
ceeded in  discouraging  threatening  prosecutions  that 
many  have  never  come  to  trial — and  that  too  without 
compromise  in  a  single  instance. 

And  now  for  the  future.  I  do  not  hesitate  to  say 
that  I  relinquish  the  presidential  chair  with  no  little 
regret,  for  I  have  enjoyed  to  the  fullest  extent  sit- 
ting in  it  and  administering  the  affairs  of  the  societv. 
This  pleasure  has  been  due  largely  to  the  fact  that 
I  felt  that  I  had  the  confidence,  support,  and  the  co- 
operation of  the  entire  society.  I  am  sure.  Sir,  that 
the  same  loyalty  will  attend  your  administration,  and 
that  it  will  be  crowned  with  a  similar  sense  of  grati- 
fication to  yourself. 

You  may  have  been  intere>ted  during  the  recent 
National  campaign  in  th£  various  articles  that  aj)- 
peared  in  the  press  from  the  two  candidates  for  the 
Presidential  office  and  others,  entitled :  My  \'ie\v 
of  the  Presidency.  The  discussion  centered  around 
the  question :  Is  the  constitution  of  the  L^nited 
States  a  series  of  inflexible  rules  which  can  be 
changed  only  by  the  methods  w  hich  those  rules  them- 
selves prescribe,  or  is  it  the  expression  of  certain 
great  political  principles  by  which  a  living  and 
growing  nation  has  resolved  to  guide  itself  in  its 
life  and  growth?  Is  it  an  anchor  which  fastens  th.e 
ship  of  state  in  one  place,  or  a  rudder  to  guide  it  on 
its  voyage?  President  Woodrow  Wilson,  of  Prince- 
ton University,  in  his  volume  on  Constitutional  Gov- 
enintcnt  in  the  United  States,  referring  especially  to 
the  Presidential  powers  applies  to  the  question 
what  might  be  called  the  Darwinian  view  of  evolu- 
tion and  declares  that  the  "President  is  at  liberty 
to  be  as  big  a  man  as  he  can,"  or  in  other  words, 
that  "the  persona!  force  of  the  President  is  perfect- 
ly constitutional  to  any  extent  to  which  he  chooses 
to  exercise  it."  Applying  this  constitutional  view 
of  presidential  prerogatives  to  yourself.  Sir,  there 
may  arise  before  your  vision  the  many  opportunities 
at  your  hand  for  lifting  the  status  of  our  County 
Society  to  vastlv  higher  levels  than  it  has  yet 
attained. 

There  seems  of  late  to  have  been  quite  a  stirring 
in  the  vitals  of  the  society.  The  secretary  informs 
me  that  the  past  vear  has  witnessed  a  greater  acces- 
sion of  new  members  than  any  year  in  the  history 


April  10,  1909.]  CARRINGTON:  ECONOMIC  HOUSING  OF  COXSUMFTI l  ES.  J27 


of  the  society,  that  the  monthly  attendance  has  been 
greater  than  any  record  sh5ws.  We  have  certainly 
been  favored  w^ith  peace  and  harmony,  and  they 
have  afforded  opportunity  for  a  more  Hvely  pursuit 
of  science.  And  it  is  with  a  feeling  of  great  satis- 
faction that  I  relinquish  the  mace  of  office,  and  pass 
it  on  to  your  keeping.  I  bespeak  for  your  admin- 
istration the  same  loyalty  and  cooperation  on  the 
part  of  the  members  that  has  characterized  the  past, 
and  predict  still  greater  achievement.  Our  heart 
and  our  hopes  are  with  you. 
616  Madison  Avenue. 


ECONOMIC  HOUSING  OF  CONSUMPTIVES,  WITH 
ESPECIAL  REFERENCE  TO  THE  SOUTHWEST.* 
By  p.  M.  Carrixgtox,  M.  D., 

Surgeon  in  the  Public  Health  and  Marine  Hospital  Service  of  the 
United  States. 

Fort  Stanton,  New  Mexico. 

Introductory. 

When  one  considers  the  appalling  number  of  con- 
sumptives in  the  United  States,  and  the  meagre 
arrangements  for  their  care,  one  is  naturally  led  to 
consider  ways  and  means  whereby,  with  the  limited 
appropriations  available,  provision  may  be  made  for 
a  greater  number.  The  cost  of  housing  consump- 
tives, according  to  usual  methods,  is  more  frequently 
above  than  below  one  thousand  dollars  per  indi- 
vidual. Expensive  buildings  of  brick  and  stone  are 
not  only  unnecessary,  but  actually  less  effective  than 
cheaper  structures,  and  it  is  proposed  in  this  article 
to  advocate  the  construction  of  sanatoria  with  less 
regatd  to  architectural  beauty  than  to  economy. 

The  Crowding  of  the  Cities  of  the  Southwest 
WITH  Consumptive  Visitors. 

By  reason  of  the  fame  which  has  been  acquired 
by  the  climate  of  the  arid  southwest,  in  the  effective 
treatment  of  tuberculosis,  great  numbers  of  persons 
afflicted  with  this  disease  resort  to  the  cities,  towns, 
and  even  the  country  districts  of  Colorado,  New 
Mexico,  Arizona,  and  southern  California.  While 
tuberculosis  is  no  respecter  of  persons,  attacking  the 
rich  and  the  poor  alike,  I  believe  that  it  is  an  un- 
questioned fact  that  a  majority  of  persons  attacked 
by  tuberculosis  are  of  moderate,  or  very  needy  finan- 
cial circumstances.  It  has,  therefore,  become  a 
problem  of  serious  import  to  the  residents  of  the 
southwest  to  make  proper  provision  for  the  care  of 
indigent  consumptives.  I  have  found  it  impossible 
to  obtain  data  regarding  the  number  of  consump- 
tives and  the  percentage  of  indigent  among  them 
who  resort  to  the  southwest  in  general,  but  in  the 
town  of  Deming,  with  a  population  of  only  1,500 
(Census  of  igoo  and  a  present  estimated  population 
of  2,500),  the  chairman  of  the  Village  Board  of 
Trustees  estimates  that  250  consumptives  resort  to 
the  town  annually.  About  ten  per  cent,  of  these  are 
indigent  and  five  per  cent,  become  public  charges. 
There  is  no  institution  in  the  town  where  they  may 
be  cared  for.    Most  of  them  find  homes  in  boarding 

*Read  before  Section  IT  of  the  International  Congress  on  Tuber- 
culosis, held  in  Washington. 


houses,  rent  cottages,  or  camp  out  in  very  primitive 
fashion. 

The  mayor  of  Las  Vegas,  a  town  of  about  5,000 
people,  estimates  that  250  consumptives  come  to  his 
town  annually,  and  that  at  least  50  per  cent,  of  them 
are  indigent.  There  are  ample  accommodations,  but 
the  expense  of  their  care  is  a  heavy  burden  on  so 
small  a  town. 

Dr.  Charles  T.  Race,  sanitary  inspector  in  the 
Health  Department  of  the  city  of  El  Paso,  Tex — a 
city  with  a  population  of  40,000 — informs  me  that 
the  city  has  about  1,500  consumptive  visitors.  More 
than  500  of  these  have  insufficient  means,  250  re- 
ceive partial  support,  and  150  are  wholly  destitute. 
There  are  no  free  tuberculosis  hospitals,  and  the 
destitute  are  sent  to  the  County  Hospital.  A  promi- 
nent clergyman  of  El  Paso  informs  me  that  fully 
sixty  per  cent,  of  all  requests  for  assistance  come 
from  consumptives,  and  that  three  fourths  of  these 
are  indigent. 

Letters  of  inquiry  were  addressed  to  a  number  of 
other  towns,  but  statistics  seem  to  be  unavailable, 
but  if  the  figures  relating  to  Deming,  Las  Vegas, 
and  El  Paso  may  be  taken  as  at  all  representative 
of  the  towns  of  the  southwest,  it  will  readily  be  seen 
that  the  problem  of  caring  for  visiting  consumptives 
must  be  one  of  great  magnitude.  It  may  be  re- 
marked en  passant  that  a  considerable  percentage  of 
the  active  professional  and  business  men  of  El  Paso 
first  came  there  as  health  seekers,  and  after  recovery 
have  established  themselves  in  the  town. 

In  the  beginning  there  was  great  difficulty  in  con- 
vincing the  people  of  the  communicability  of  tuber- 
culosis. This  led  perhaps  to  too  great  insistence 
upon  this  feature  of  the  disease ;  as  a  consequence 
there  has  developed  a  very  decided  phthisiophobia, 
which  has  produced  a  condition  of  affairs  in  the 
southwest  which  is  utterly  deplorable,  and  it  is  now 
extremely  difficult  for  avowed  consumptives  to 
secure  accommodations  in  the  hotels  and  boarding 
houses  in  the  southwestern  cities.  This  condition  of 
affairs  has  naturally  led  to  public  effort  looking  to 
the  establishment  of  special  institutions  in  which 
tuberculous  visitors  may  be  received  and  cared  for. 
T,  myself,  came  to  the  southwest  as  what  is  locally 
known  a  "health  seeker,"  and  I  can  but  feel  a 
warm  sympathy  for  my  fellow  consumptives  seeking 
climatic  relief,  who  now  arrive  in  the  towns  of  the 
southwest,  and,  applying  for  lodgings,  find  the  much 
too  familiar  sign,  "No^  consumptives  taken."  I, 
fortunately,  came  to  the  southwest  in  the  line  of 
duty,  and  while  still  sick  took  command  of  the  Fort 
Stanton  Sanatorium,  where  in  less  than  nine  months 
I  made  a  complete  recovery  and  have  remained  well 
for  nearly  seven  years,  but  my  sympathy  will  always 
go  out  to  those  poor  victims  of  tuberculosis  who 
come  to  the  southwest  with  barely  sufficient  funds 
to  reach  their  destination,  in  the  hope  of  finding 
"light  employment,"  which  will  maintain  them  while 
a  beneficent  and  Heaven  given  climate  effects  a 
cure.  We  need  now,  in  our  efforts  to  teach  the 
people  about  tuberculosis,  to  emphasize  the  fact  that 
while  the  ignorant,  careless,  or  vicious  consumptive 
is  dangerous,  the  educated,  careful,  and  conscien- 
tious consumptive  is  not  a  menace  to  the  health  of 
his  associates. 


728 


CARRINGTON :  ECONOMIC  HOUSING  OF  CONSUMF'J'irES. 


[Xt>v  York 
Medical  Jovrnat. 


The  Problem  of  Housing  Consumptive  Visitors 
AS  THE  Southwest  Is  Trying  to  Solve  It. 
Almost  every  city  of  any  size  in  the  southwest  has 
one  or  more  sanatoria  devoted  especially  to  the 
treatment  of  tuberculosis  (mostly  conducted  for 
profit}  and  the  cost  of  construction  of  the  various 


reduction  in  average  cost  of  construction  per  bed, 
and  such  an  increase  vVould  add  but  little  to  ex- 
penditures for  salaries  of  officers  and  employees.  In 
El  Paso,  Tex.,  cited  before  as  illustrative  of  how 
consumptives  are  crowding  into  the  southwest,  the 
situation  has  become  so  acute  as  to  enlist  the  svm- 


Vic    I. — Tent  liouse  in  summer. 


sanatoria  within  my  kncnvledge  varies  between  very 
wide  limits.  For  instance,  the  Albert  Baldwin  Sana- 
torium, at  El  Paso,  Tex.,  a  beautiful  stone  structure, 
cost  furnished  $115,000  and  accommodates  fifty 
people,  more  than  $2,000  per  caput,  while  the  Asso- 
ciation Health  l-~arm,  conducted  by  the  Young 
Men's  Christian  Association  at  Edgewater,  Col., 
and  accommodating  fifty-eight  men,  represents  a 
value  of  about  $50,000,  nearly  $1,000  per  caput. 
One  sanatorium  in  Alamogordo,  N.  M.,  cost  for 
buildings  only  $40,000,  with  $5,000  for  furnishing, 
and  has  a  capacity  for  seventy-five  patients,  or  $600 
[>er  caput  only.  At  Fort  Stanton,  N.  M.,  beginning 
with  a  collection  of  stone  and  adobe  buildings  con- 
structed for  the  use  of  the  army,  we  have  spent 
about  $250,000  to  care  for  250  to  300  patients.  This 
expenditure  includes  the  remodeling  of  the  old 
buildings  and  the  construction  of  nearly  one  hun- 
dred tents  and  tent  houses',  and  the  plant  as  it  stands 
is  worth  all  nf  a  half  million  dollars,  exclusive  of 
site.  It  sliould  be  here  stated  that  I'^ort  Stanton  has 
its  own  ice.  cold  storage  and  electric  light  plants : 
steam  laundry,  water  and  sewer  systems,  etc..  and 
that  the  present  executive  and  service  buildings, 
nfficers'  (|uarters.  etc.,  would  still  be  sufficient,  even 
though  the  capacity  of  the  sanatorium  were  in- 
creased fifty  tti  seventy-five  per  cent,  by  the  con- 
struction of  additional  tent  houses  and  consecpient 


patliy  and  et¥ort  of  the  charitably  disposed  citizens 
of  that  town,  and  there  is  now  on  foot  a  movement 
to  establish,  a  few  miles  out  of  town,  a  tent  city  for 
the  accommodation  of  consumptives  in  general  and 
indigent  consumptives  in  particular. 

At  Roswell.  Santa  Fe,  and  many  other  towns  in 
New  Mexico,  as  well  as  in  Arizona  and  Colorado, 
similar  tent  colonies  are  being  established.  Some  of 
these  have  their  distinctive  tent  dwellings,  usually 
accommodating  one  or  two  patients  each,  costing 
from  $85  to  $150  a  bed  unfurnished,  but  not  includ- 
ing administration  and  service  buildings.  Two  in- 
teresting specimens  of  this  class  of  sanatoria  are 
shown  in  photographs  of  the  New  Mexico  Cottage 
Sanatorium,  at  Silver  City,  where  the  total  cost  each 
bed  furnished  is  about  $800.  and  the  Nordrach 
Ranch  Sanatorium,  at  Colorado  Springs.  Col.,  where 
the  cost  a  bed  is  about  $700.  In  all  this  region 
labor,  lumber,  and  other  materials  of  construction 
are  very  dear. 

Hkstory  ok  THE  Tent  .\s  a  Consi^mptive  DwEi.r 
iNG  .\s  Developed  .\t  Fort  Stanton 
Sanatorium. 

.About  seven  years  ago  I  first  began  to  use  tents, 
pitching  four  or  five  of  them  in  the  shade  of  the 
Cottonwood  trees  near  the  hospital.  They  were  very 
primitive  affairs  and  are  illustrated  in  a  photograpli. 


April  10,  igog.  I 


C.iRRIXGTOX :  ECONOMIC  HOUSING  Of  CONSUM FTJ I  ES. 


Each  was  simply  a  i2x  14  feet  tent  provided  with 
two  hospital  beds,  with  three  12  inch  boards  laid 
on  the  ground  between  the  beds.  Later  we  added 
a  complete  floor,  with  sides  running  up  two  feet. 
Even  these  crude  tents  became  very  popular,  and  we 
gradually  began  to  take  more  care  in  their  con- 
struction. Our  present  tent  is  14  feet  square,  has  a 
flooring  of  matched  Te.xas  pine,  siding  about  4  feet 
high,  with  a  broad  shelf  on  each  side  as  a  con- 
venient place  for  keeping  various  articles.  It  is  sup- 
plied with  a  Dutch  door  in  front  and  a  glazed  sash 
in  the  rear.  The  canvas  sides  are  raised  and  low- 
ered by  series  of  ropes  and  pulleys.  This  tent  is 
heated  by  a  small  sheet  iron  stove  and  accommo- 
dates two  patients.  The  minimum  standard  of  ven- 
tilation required  is  maintained  by  keeping  the  entire 
front  and  rear  window  open  and  by  raising  at  least 
one  of  the  side  flaps.  In  case  of  rain  or  wind  that 
side  of  the  tent  to  the  windward  is  permitted  to  be 
closed.  On  one  occasion,  being  somewhat  crowded 
and  at  the  moment  without  additional  tents,  Mr. 
Thomas,  our  architect,  and  myself  devised  the 
structure,  a  photograph  of  which  is  shown  in  fig- 
ures I  and  2  and  which  we  call  a  tent  house. 

Each  tent  house  is  14  feet  square  and  is  intended 


necting  clothes  closet.  The  door  contains  a  glazed 
sash,  which  furnishes  light  when  the  tent  house  is 
closed.    The  stove  is  also  placed  near  this  rear  wall. 

The  front  wall  contains  three  canvas  covered 
Dutch  doors,  two  of  which  are  wide  enough  to 
allow  the  beds  to  be  rolled  through.  There  is  also 
a  rear  porch,  not  shown  in  the  photograph,  built  in 
the  same  manner  as  the  front  porch.  The  roof  has 
an  ample  overhang  and  a  good  slant.  The  slant 
should  always  be  in  the  direction  of  the  inclination 
of  the  surface  of  the  ground,  so  that  water  from  it 
will  drain  ofT  readily.  The  ventilation  is  good  and 
the  tent  house  will  be  open  so  much  of  the  time  that 
there  is  probably  no  objection  to  a  small  sheet  iron 
stove  as  a  means  of  heating,  it  being  both  cheap  and 
efficient.  But  one  of  the  Franklin  stoves,  of  which 
many  varieties  are  sold,  would  be  more  cheerful, 
and  assist  in  the  ventilation,  and  such  a  stove  is 
recommended.  A  lavatory  with  running  water 
would  also  be  very  desirable,  if  such  a  convenience 
is  practicable. 

A  tent  house  can  be  easily  screened  against  flies, 
etc.,  it  not  being  necessary  to  make  individual 
screens  for  window  openings,  but  simply  to  cover 
them  with  wire  cloth  from  a  roll  of  proper  width. 


Fig.  2. — Tent  house  in  winter. 


for  two  patients.  The  ceiling  is  about  9  feet  high, 
the  sides  being  closed  for  half  the  distance  up.  and 
the  remaining  portion  covered  with  sliding  canvas 
sashes,  provided  with  cords  and  weights,  as  are 
ordinary  glazed  sashes.  The  rear  is  boarded  to  the 
roof  and  has  a  door  opening  on  a  porch  and  a  con- 


securing  it  with  battens  screwed  on.  Of  course,  the 
doors  will  require  separate  screens,  with  frame. 

A  feature  especially  to  be  noted  is  the  small  ven- 
tilator in  the  roof.  There  are  a  good  many  kinds 
of  such  ventilators,  all  serving  to  convert  a  hori- 
zontal current  of  air  on  the  outside  of  the  buildings 


730 


CARRINGTON:  ECONOMIC  HOUSING  OF  CONSUMPTIVES. 


[New  York 

Medical  Julknai.. 


occupants  uncomfortable,  and  there  cannot  be  that 
degree  of  privacy  which  obtains  in  the  tent  house. 
In  my  experience  at  Fort  Stanton  patients  invariably 
prefer  the  tent  or  tent  house  to  the  dormitory.  They 
take  more  interest  in  its  care.  The  tent  house  pa- 
tient looks  upon  his  quarters  as  his  individual  home, 
and  the  home  idea  develops  to  the  satisfaction  and 
profit  of  all. 

First  Cost. — It  often  happens  that  those  contem- 
plating the  inauguration  of  a  sanatorium,  are  in  the 
outset  cramped  for  money,  and  find  it  difficult  to 
start  an  enterprise  which,  once  on  the  move,  and 
showing  results,  would  receive  ample  public  support. 
With  the  plan  which  we  submitted  after  having 
erected  and  equipped  the  kitchen  and  dining  room 
building,  the  construction  of  the  rest  of  the  hospital 
can  be  accomplished  as  necessity  arises.  For  in- 
stance, the  first  floor  of  the  administration  building 
could  be  first  erected,  and  the  second  floor  after- 
wards. Then  the  power  house,  dead  house,  and 
other  buildings,  according  to  the  exigencies  of  the 
various  stages  of  development  of  the  institution. 
Separate  quarters  for  the  surgeon  and  his  family, 
amusement  halls,  band  stands,  and  other  desirable 
but  not  absolutely  essential  features,  can  be  added  as 
its  resources  grow. 

The  small  fire  risk,  both  to  patients  and  to  build- 
ings, due  to  the  spaces  separating  the  latter,  is  also 
a  desideratum  to  be  considered. 

It  has  been  objected  by  some  that  our  tent  house 
would  be  objectionably  cold  in  some  latitudes,  but  at 
Fort  Stanton  we  have  experienced  temperatures  as 
low  as  15°  F.  below  zero,  and  at  no  time  have  the 
occupants  of  either  tents  or  tent  houses  experienced 
any  discomfort. 

Concluding  I  will  say  that  while  most  of  the 
towns  of  the  southwest  have  some  sort  of  provision 
for  caring  for  tuberculous  visitors,  very  few  have 
made  adequate  provision,  and  the  several  States  and 
Territories  none  at  all.  Private  charity  in  several 
localities  is  beginning  to  discuss  the  problem,  but 
these  projects  are  of  necessity  slow,  and  nearly  all 
the  sanatoria  now  conducted  in  the  southwest  are 
pay  institu.tions ;  in  the  meantime  and  until  private 


I'lr,.  4. — Sanr.torinm  at  Alamogordo,  New  Mexico.     Tlie  cost  of  construction  was  $600  «  bed 


mitting  patients  who  arc  personally  agreeable  to  one  and  public  charity  have  had  time  to  provide  sana- 
anothcr  to  live  together.  In  large  dormitories  one  toria  for  the  indigent  consumptives  our  brethren  of 
di.sagreeable  or  ofTensive  patient  may  render  all  the    the  cast  should  be  slow  to  advise  their  patients  to  ro- 


l  ii,.   3. —  Tuikt   and   l)atli  liuiisc   fui"  lent  dweller?. 


into  a  vertical  current  in  the  inside.  The  "star"  is  in 
use  at  the  Fort  Stanton  Sanatorium  and  is  very 
efficient. 

Some  of  the  Advantages  of  a  Sanatorium  Com- 
posed OF  Tents  and  Tent  FIouses  Grouped 

ABOUT  A  General  Service  Building. 
Last  year  our  architect,  Mr.  J.  Ross  Thomas,  and 
myself,  published  An  Economical  Plan  for  a  Con- 
sumptive Sanatorium,  floor  plans  of  which  were 
published  with  it.  Of  course  the  cost  of  construct- 
ing buildings  varies  greatly  in  different  localities, 
but  our  tent  house  accommodating  two  patients  has 
been  built  at  Fort  Stanton  (an  extraordinarily  dear 
market)  at  a  cost  varying  from  $185  to  $225,  and 
under  this  plan  I  believe  that  a  sanatorium  for  fifty 
patients,  with  all  necessary  service  buildings,  can  be 
constructed  at  a  cost  of  about  $750  a  bed,  and  upon 
increasing  its  capacity  to  one  hundred  or  one  hun- 
dred and  fifty,  the  cost  of  construction  would  be  re- 
duced to  about  $500  or  less  a  bed.  The  use  of  some 
tents  would  further  diminish  the  cost  per  bed. 

Convenience  of  i^rouping. — The  plan  permits  a 
ready  classication  of  cases  in  groups. 

Flexibility. — Other  groups  of  tent  houses  may  be 
added  as  the  sanatorium  expands  without  necessarily 
adding  to  service  buildings. 

Isolatio}:. --There  is  a  distinct  advantage  in  per- 


April  10.  1909.] 


FRICKS:  CLASSIFICATION  OF  CONSUMPTIVES. 


sort  to  the  southwest,  unless  such  patients  have  suffi- 
cient means  to  defray  their  own  expenses  without 
the  necessity  of  seeking  employment. 

It  is  to  be  remembered  that  tuberculosis  is  ex- 
tremely rare  in  our  resident  population  and  that 
nearly  all  the  consumptives  of  the  arid  southwest 
are  visitors ;  also  that  thirty-five  per  cent,  to  50  per 
cent,  of  them  are  indigent. 


A  SHORT  DISCUSSION  OF  THE  SCHEMA  FOR 
CLASSIFICATION  OF  PATIENTS  ON 
EXAMINATION. 

Especially  for  Admission  to  Sanatoria  as  Adopted  by 
the  National  Association  for  the  Study  and  Prevention  of 
Tuberculosis,  in  Washington,  May  18,  1905* 

By  L.  D.  Fricks,  M.  D., 
Fort  Stanton,  New  Mexico, 

Passed  Assistant  Surgeon,  United  States  Public  Health  and  Marine 
Hospital  Service. 

At  the  first  meeting  of  the  National  Association 
for  the  Study  and  Prevention  of  Tuberculosis,  held 
May  18,  1905,  the  Committee  on  Clinical  Nomen- 
clature, "after  long  continued  discussion  and  earnest 
endeavor,"  reported  a  scheme  for  the  classification 
of  tuberculous  patients,  based  upon  and  to  be  used 
in  connection  with  the  system  previously  advanced 
by  Turban,  in  1904.  In  the  report  of  the  third  meet- 
ing in  1907,  it  is  not  stated  that  the  classification  is 
to  be  used  in  connection  with  Turban's  scheme,  and 
from  this  it  would  seem  that  the  classification  adopt- 
ed by  the  National  Association  is  to  supplant  rather 
than  supplement  Turban's  scheme  as  was  at  first 
stated.  The  report  was  presented  only  after  mutual 
concessions  had  been  made,  and  the  committee  rec- 
ognized the  fact  that  it  was  not  necessarily  perfect, 
claiming  however,  that  it  was  a  good  working  basis 
which  time  would  prove  and,  perchance,  improve. 

There  can  be  no  question  whatever  as  to  the  abso- 
lute necessity  for  a  clearly  cut,  well  defined,  and 
comprehensive  scheme  of  classification  of  tubercu- 
lous cases  for  use  in  the  study  and  treatment  of  tu- 
berculous patients.  It  is  fundamental,  the  very  be- 
ginning. Without  it  no  true  progress  can  be  made 
in  the  study  of  the  disease,  no  statistics  worthy  of 
the  name  compiled,  no  comparison  of  treatment 
made.  It  is  of  as  much  importance  to  us  who  are 
undertaking  the  study  of  tuberculosis  as  were  the 
classifications  of  Linnaeus  to  the  students  of  botany 
in  the  beginning  of  the  nineteenth  century. 

But  why  the  scheme  adopted  by  the  American 
Association  in  preference  to  some  other?  That  of 
Petruschy,  for  instance;  who  divided  tuberculous 
disease  into:  Primary,  an  affection  of  the  lymph 
glands.  Secondary,  formation  of  tubercles  in  tis- 
sues.'   Tertiary,  stage  of  necrosis. 

Or  that  of  Brehmer:  i.  Infiltration.  2.  Cavities, 
large  or  small.    3.  CoUiquation. 

Or  that  of  Koniger:  i.  Slight  cases,  with  one 
apex  affected.  2.  Cases  of  medium  severity,  with 
one  or  both  apices  affected  to  a  greater  extent.  3. 
Severe  cases,  with  disease  of  one  or  more  whole 
lobes. 

Or  Turban's  classification  itself  without  modi- 

•Written  September,  1908. 


fication  or  elaboration:  I.  Disease  of  slight  severity, 
affecting  at  most  one  lobe  or  two  half  lobes.  2. 
Disease  of  slight  severity,  more  extensive  than  first, 
but  affecting  at  most  two  lobes ;  or  severe  and  af- 
fecting at  most  one  lobe.  3.  All  cases  of  greater 
extent  and  severity  than  second. 

Turban  explains  this  classification  as  follows: 
"By  disease  of  slight  severity  is  to  be  understood, 
disseminated  foci  manifested  clinically  by  slight  im- 
pairment of  resonance,  rough  or  weak  breathing, 
either  vesicular,  vesicobronchial  or  bronchovesicular, 
with  fine  and  medium  rales.  By  severe  disease ; 
compact  consolidation  and  cavities  recognized  by 
great  impairment  of  resonance,  tympanitic  note,  very 
weak  ("indeterminate")  bronchovesicular,  bron- 
chial, or  amphoric  breathing,  with  musical  or  tone- 
less rales,  either  medium  or  coarse.  The  extent  of 
one  lobe  is  always  to  be  taken  as  equivalent  to  that 
of  two  half  lobes,  and  so  on." 

CLASSIFICATION  ADOPTED  BY  THE  NATIONAL  ASSOCIA- 
TION. 

Incipient:  Slight  initial  lesion  in  the  form  of  in- 
filtration limited  to  the  apex  of  one  or  both  lungs  or 
a  small  part  of  one  lobe.  No  tuberculous  complica- 
tions. Slight  or  no  constitutional  symptoms,  par- 
ticularly including  gastric  or  intestinal  disturbance 
or  rapid  loss  of  weight.  Slight  or  no  elevation  of 
temperature,  or  acceleration  of  pulse  at  any  time 
during  the  twenty-four  hours,  especially  after  rest. 
Expectoration  usually  small  in  amount  or  absent. 
Tubercle  bacilli  may  be  present  or  absent. 

Moderately  Advanced:  No  marked  impairment 
of  functions,  either  local  or  constitutional.  Local- 
ized consolidation  moderate  in  extent  with  little  or 
no  evidence  of  destruction  of  tissue.  Or  d  ssemin- 
ated  fibroid  deposits.   No  serious  complications. 

Far  Advanced:  ^Marked  impairment  of  function, 
local  and  constitutional.  LocaHzed  consolidation  in- 
tense. Or  disseminated  areas  of  softening.  Or  seri- 
ous complications. 

Acute  Miliary  Tuberculosis:  Turban  considered 
Petruschy's  classification  excellent  from  a  scientific 
standpoint  but  difficult  to  carry  out  in  practice.  This 
seems  plain.  Brehmer's  classification,  according  to 
the  same  authority,  "pays  too  little  attention  to  the 
fact  that  the  severity  of  the  disease  depends  not  so 
much  on  the  presence  or  absence  of  a  cavity,  as  on 
the  actual  extent  of  the  morbid  process  in  the  lungs." 
Only  a  moderate  amount  of  experience  is  needed  to 
convince  one  of  the  truth  of  this  criticism.  Turban 
states,  on  the  other  hand,  that  in  the  classification  of 
Koniger,  which  approaches  nearest  to  his  own,  due 
regard  is  not  paid  to  the  intensity  of  the  disease  and 
that  too  much  latitude  is  left  for  the  "personal  equa- 
tion of  the  examiner  in  the  delimitation  of  the 
groups  themselves."  Objection  might  have  been 
made  to  Koniger's  limiting  his  first  and  second  de- 
gree cases  to  the  apices  altogether.  This  criticism, 
on  the  whole,  appears  to  be  just  and  the  same  objec- 
tion which  Turban  made  of  Koniger's  classification 
might  have  been  made  in  a  somewhat  less  degree  to 
his  own. 

Granting  that  Turban's  classification  was  the  best 
which  had  been  advanced  up  to  1905.  and  as  much 
seems  to  have  been  conceded,  both  in  Europe  where 
it  was  adopted  in  its  entirety,  and  also  in  the  United 


732 


PRICKS:   CLASSIFICATION  OF  CONSUMPTIVES. 


ilEDlCAL  TdL'RNAI.. 

[Neu  York 


States  where  it  has  been  used  as  a  basis  for  the 
classification  adopted  by  the  National  Association, 
the  question  naturally  arises  as  to  the  real  need  of 
modification  at  all.  Turban's  scheme  was  accepted 
by  England^,  France,  and  Germany  as  good  enough 
for  them,  and  the  idea  of  an  International  Nomen- 
clature was  one  of  the  reasons  given  bv  the  cr;m- 
mittee  for  its  use  as  a  basis  for  their  classification. 
But  why  not  accept  it  altogether  rather  than  in  part  ? 

The  reasons  given  in  the  report  of  the  committee 
are  that  in  Turban's  plan  the  divisions  i,  ii,  iii,  are 
"anatomical  only  and  do  not  seem  quite  comprehen- 
sive enough."  It  may  be  doubted  whether  Turban 
iias  ever  thanked  the  National  Association  for  foist- 
ing a  relationship  upon  his  scheme  based  on  such 
doubtful  ties  as  these. 

It  is  difficult  to  understand  how  a  classification  of 
a  morbid  process,  such  as  tuberculosis,  could  be 
made  except  upon  the  anatomical  lesion  present, 
unless  we  agree  to  open  wide  the  floodgates  to  par- 
tial resistance,  peculiar  susceptibility,  prognosis, 
and  other  equally  vague  and  untangible  phantasms 
which  the  examiner's  brain  may  hold  but  which  can 
hardly  be  charted  for  others'  use.  By  this  it  is  not 
meant  that  immunity,  susceptibility,  and  prognosis 
have  no  place  in  the  study  of  tuberculosis.  T^i<\\ 
have  a  place  and  an  important  one,  but  it  is  nol  in 
the  classification  of  cases  on  the  first  physical  exam- 
ination whether  for  admission  to  sanatorium  or  in 
general  practice. 

If  «c  are  to  be  absolutely  honest  with  ourselves 
arvl  our  coworkers  in  our  statistics — if  our  reports 
are  to  pass  current  throughout  the  world  as  goovl 
coin  of  the  realm.,  we  must  protect  them  from  our 
personal  vagaries  by  careful,  methodical  examina- 
tion, and  preserve  them  as.  plain,  lunimaginative 
facts. 

The  statement  that  Turban's  scheme  "is  not  com- 
prehensive enough,"  is  surely  erroneous,  as  it  in- 
cludes, without  doubt,  every  tuberculous  process  in 
the  lungs  which  is  capable  of  diagnosis  from  the 
slightest  infiltration  up  to  and  even  beyond  the 
"acute  miliary  tuberculosis"  added  by  the  National 
Association,  should  anything  be  discovered  hereafter 
of  greater  extent  or  severity  than  this.  It  is  cer- 
tairdy  more  comprehensive  and  comprehensible  than 
the  conglomeration  of  constitutional  symptoms,  con- 
stitutional impairment  of  function  and  complications 
with  the  pathological  lesion,  as  adopted  by  the  asso- 
ciation.- One  instance — It  is  more  comprehensive 
than  the  National  Association's  scheme  because 
there  is  no  place  in  the  latter  for  an  infiltration  more 
extensive  than  that  limited  to  the  apex  of  one  or 
both  lungs  or  a  small  part  of  one  lobe.  What  shall 
we  do  with  our  cases  in  which  the  infiltration  has 
extended  beyond  these  limited  parts,  unless  we  hold 
them  in  abeyance  until  consolidation  begins? 

Turban's  scheme  is  so  simple  that  a  wayfaring 
man  of  ordinary  intelligence  can  easily  find  his 
meaning,  whereas  there  is  a  haziness  about  the  other 
entirely  unbecoming  in  a  scientific  classification,  and 
it  would  rc(|uirc  one  of  the  very  elect  to  determine 
whether  the  divisions  "moderately  advanced"  and 
"far  advanced"  are  a  classification  of  function  or  of 
a  fliscased  process  in  the  lungs. 

Take  the  very  beginning,  for  instance,  "slight  in- 


itial lesion."  In  respect  that  "initial"  means  the 
beginning  of  the  tuberculous  process  in  the  lung,  it 
is  good,  but  in  respect  that  it  might  mean  the  begin- 
ning of  the  process  in  the  body,  some  of  our  best 
authorities  would  demur.  Petruschy,  as  noted  before, 
limited  his  primary  stage  to  a  process  altogether  out- 
side of  the  lungs. 

Again  we  have,  "no  tuberculous  complications" 
under  the  division  incipient,  while  under  ""nioder- 
ately  advanced"  and  "far  advanced"  we  have  "seri- 
ous complications"  given.  Do  these  last  mean  tu- 
berculous complications  or  such  accidental  compli- 
cations as  valvular  disease  of  the  heart? 

Under  the  division  "moderately  advanced"  we 
find  the  expression  "with  little  or  no  evidence  of  de- 
struction of  tissue",  while  under  "far  advanced"  the 
term  "disseminated  areas  of  softening"  is  used. 
What  relation  do  these  two  bear  to  each  other?  If 
they  are  synonymous,  as  some  might  suspect,  why 
not  say  so  in  a  scientific  classification?  If,  on  the 
other  hand,  "destruction  of  tissue"  means  less  than 
"area  of  softening"  the  National  Association  can 
surely  ill  afford  to  put  itself  on  record  as  doubting 
that  bacilli  and  elastic  fibres  in  the  sputum  are  suffi- 
cient evidence  of  destruction  of  tissue. 

Let  us  brush  away  some  of  the  clouds  which  are 
apt  to  obscure  our  vision  and  see  what  we  have  left 
in  this  classification  : 

Incipient. — Slight  initial  lesron  in  the  form  of  an 
infiltration  limited  to  the  apex  of  one  or  both  lungs 
or  a  small  part  of  one  lobe. 

Moderately  Adx'anced. — Localized  consolidation, 
moderate  in  extent,  with  little  or  no  evidence  of  de- 
struction of  tissue.  Disseminated  fibroid  deposits. 
No  serious  complications. 

Far  Advanced. — Localized  consolidation  intense. 
Disseminated  areas  of  softening.  Serious  compli- 
cations.   (This  last  may  appear  a  cloud  to  some.) 

Acute  Mili.^ry  Tuberculosis. 

Now  compare  this  again  with  Turban's  scheme  as 
given  in  the  preceding.  One  can  hardly  assert  that 
this  classification  is  as  comprehensive.  There  is  no 
place  for  an  infiltration  more  extensive  than  that 
specified  or  for  a  consolidation  other  than  localized. 
To  those  of  us  who  perform  from  sixty  to  seventy 
necropsies  a  year  on  tuberculous  bodies  this  sounds 
preposterous.  The  divisions  are  not  in  contiguity — 
the  hiatuses  are  obvious. 

Turban's  scheme  of  classification  is  sufficientlv 
comprehensive  to  include  all  cases  of  tuberculosis  of 
the  lungs,  and  I  am  persuaded  that  in  the  hands  of 
different  physical  examiners  equally  expert  almost 
one  hundred  per  cent,  of  all  cases  would  be  classified 
alike.  Hut  there's  the  rub!  This  is  the  "crux"  of 
the  entire  matter.  And  had  the  National  Associa- 
tion criticised  Turban  as  he  criticised  K()niger  on 
the  score  of  "personal  equation  of  the  examiner" 
their  work  would  have  been  constructive  and  to  the 
point.  Had  they  rai.sed  landmarks,  plain  and  true, 
for  the  less  experienced  examiner,  these  would  have 
remained  as  monuments  to  their  work. 

Unfortunately  we  cannot  all  expect  to  attain  lo 
the  same  degree  of  expertness  in  physical  diagno- 
sis ;  some  cannot  acquire  the  tactus  cruditiis  and 
others  have  not  the  oi)portunity.    "The  hand  of  lit- 


Ai'ri!  lo,  1909.] 


PRICKS:   CLASSIFICATION  OF  CONSUMPTIVES. 


733 


tie  employment  hath  the  daintier  sense"  may  be  a 
general  moral  truth,  but  it  has  no  place  on  the  wall 
of  an  examination  room. 

Here  nothing  is  worth  while  save  only  painstak- 
ing observations,  carefully  recorded  and  carefully 
considered  day  after  day.  Look,  thump,  listen, 
think  over  and  over  again  !  Only  those  who  have 
this  opportunity  aixl  grasp  it  can  expect  to  deter- 
mine with  exactness  the  many  phases  of  a  tubercu- 
lous process  in  the  lungs.  The  National  Association 
seems  to  have  had  this  idea  in  view,  but  it  is  not  re- 
ferred to  in  their  reports  and  the  indexes  to  the  mor- 
bid process  are  so  arranged  that  it  is  difficult  to  de- 
termine which  way  they  point. 

The  classification  adopted  by  the  National  Asso- 
ciation in  May,  1905,  has  been  followed  at  the 
United  States  Marine  Hospital  Sanatorium,  Fort 
Stanton,  New  Mexico,  since  July  1905,  with  vary- 
ing success.  Some  cases,  such  as  extensive  infiltra- 
tion, extensive  consolidation,  and  advanced  fibroid 
processes  have  been  classified  by  inference  alone, 
and  there  have  always  been  honest  dififerences  of 
opinion  among  the  medical  officers  regarding  the 
meaning  of  some  of  the  subdivisions  used.  The 
greatest  difficulty  was  encountered  when  in  Ma^' 
1907  a  brief  report  of  the  first  examination  of  each 
case  was  ordered  to  be  made  to  the  medical  officer 
who  had  transferred  the  patient  to  the  sanatorium. 
After  struggling  with  the  problem  for  some  months 
each  subdivision  was  lettered  as  follows :  Incipi- 
ent :  a,  b,  c,  d,  e.  Moderately  advanced :  a,  b,  c,  d. 
Far  advanced :  a,  b,  c,  d. 

Thus  a  case  reported  "moderately  advanced :  a, 
b,  d,"  would  mean  one  in  which  there  was  a  local- 
ized consolidation  without  marked  impairment  of 
function  or  serious  complications.  This  has  proved 
to  be  a  convenience,  but  in  no  way  remedies  the  de- 
fects in  the  classification. 

Why  not  return  then  to  Turban's  scheme  which  has 
met  the  demands  of  our  European  coworkers,  and 
erect  sign  posts  along  the  way  for  ourselves,  and  for 
the  occasional  examiner,  substituting,  however,  for 
bis  divisions  i,  ii,  iii,  "incipient",  "moderately  ad- 
vanced", and  "far  advanced"  because  they  are  more 
familiar  to  us  and  appear  to  mean  more ;  thus : 

Incipient. 

1.  Disease  of  slight  severity  affecting  at  most 
one  lobe  or  two  half  lobes. 

a.  With  slight  constitutional  symptoms,  such  as 
malaise,  variations  of  temperature,  or  acceleration 
of  pulse. 

b.  Without  marked  constitutional  symptoms, 
such  as  gastric  and  intestinal  disturbances,  high 
fever — 101.3°  F — or  rapid  loss  in  weight. 

c.  Without  noticeable  impairment  of  function. 

d.  With  or  without  expectoration  or  tubercle 
bacilli. 

Moderately  Advanced. 

2.  Disease  of  slight  severity,  more  extensive 
than  first,  but  affecting  at  most  two  lobes ;  or  severe 
and  affecting  at  most  one  lobe. 

e.  Without  cavity  formation. 

f.  With  marked  constitutional  symptoms. 

g.  Without  marked  impairment  of  function. 
Far  Advanced. 

3.  _  All  cases  of  greater  extent  and  severity  than 
second. 


h.  With  or  without  cavity  formation. 

i.  With  marked  constitutional  symptoms. 

j.  With  or  without  marked  impairment  of  func- 
tion. 

Tuberculous  complications  to  be  indicated  by  add- 
ing the  name  of  the  aft'ected  organ  as  proposed  by 
Turban. 

If,  however,  the  National  Association  believes 
that  Turban's  scheme  is  not  sufficiently  definite  in 
its  wording  of  the  stadia  ;  and  such  objection  might 
well  be  raised  inasmuch  as  infiltration,  consolida- 
tion, and  fibroid  processes  can  be  differentiated  in 
the  necropsy  room  and  should  be  in  the  examination 
room  ;  why  not  do  away  with  the  expressions  "dis- 
ease of  slight  severity",  and  "disease  of  greater  se- 
verity"? If,  in  their  opinion,  his  "infiltration  of  an 
entire  lobe"  constitutes  more  than  an  incipient  case, 
as  Koniger  thought,  why  not  make  a  classification 
something  like  the  following : 

PROPOSED  CLASSIFICATION. 

Incipient: 

1.  Infiltration  limited  to  one  or  both  apices  or  a 
small  part  of  one  lobe. 

(x)  a.  With  slight  constitutional  symptoms,  such 
as  malaise,  variations  of  temperature  or  acceleration 
of  pulse. 

b.  Without  marked  constitutional  svmptoms, 
such  as  gastric  and  intestinal  disturbances,  high 
fever — 101.3°  F — o'"  rapid  loss  in  weight. 

c.  Without  tuberculous  c6mplications. 

d.  Without  noticeable  impairment  of  function. 

e.  With  or  without  expectoration  or  tubercle 
bacilli. 

Moderately  Advanced: 

2.  Infiltration  involving  more  than  the  apices  or 
a  small  part  of  one  lobe  up  to  two  lobes. 

3.  Consolidation  limited  to  one  or  both  apices  or 
to  a  small  part  of  one  lobe  with  or  without  infiltra- 
tion up  to  two  half  lobes. 

4.  Disseminated  fibroid  deposits  with  evidence 
of  active  process. 

f.  Without  cavity  formation. 

(x)  g.    With  marked  constitutional  symptoms. 

h.  Without  serious  tuberculous  complications. 

i.  Without  marked  impairment  of  function. 
Far  Advanced: 

5.  Consolidation  or  infiltration  involving  more 
than  2  or  3. 

6.  Extensive  fibroid  process  with  evidence  of 
active  process. 

j.    With  or  without  cavity  formation, 
(x)  k.    With  marked  constitutional  symptom. 
1.    With  or  without  serious  tuberculous  compli- 
cation. 

m.  With  or  without  marked  impairment  of  func- 
tion. 

Acute  Miliary  Tuberculosis. 
(x)  Constitutional  symptoms  need  not  be  pres- 
ent at  time  of  examination.  Thus,  2,  f,  g,  i  would 
mean:  Moderately  advanced  case  with  infiltration 
involving  more  than  the  apices  or  a  small  part  of 
one  lobe  up  to  two  lobes  without  cavity  formation, 
with  marked  constitutional  symptom,  without 
marked  impairment  of  function.  While,  2  ivith  j 
and  1,  would  be:  Far  advanced  case  with  infiltra- 
tion involving  more  than  the  apices  or  a  small  part 
of  one  lobe  up  to  two  lobes,  with  cavity  formation 


734 


PECKHAM:  FLAT  FOOT. 


[New  York 
Medical  Journal. 


and  tuberculous  complication,  being  classed  as  "far 
advanced"  because  of  these. 

This  would  give  us  a  fairly  well  defined  classifi- 
cation as  comprehensive  as  Turban's  with  the  guides 
to  each  division  lettered  and  arranged  underneath, 
not  mingled  with  the  body  of  the  classification, 
where  they  are  both  out  of  place  and  confusing,  but 
yet  a  part  of  it  in  the  sense  that  they  point  to 
the  lesion  present  and  should  aid  the  examiner  in 
its  detection  and  proper  grouping. 

It  is  not  expected  that  the  boundaries  of  the  divi- 
sions as  given  will  meet  with  the  approval  of  the 
National  Association  altogether,  inasmuch  as  their 
delimitation  is  more  or  less  arbitrary  and  a  matter 
of  opinion  based  on  experience,  but  it  seems  plain 
that  this  classification  is  more  exact  and  more  com- 
prehensive than  the  one  in  present  use. 

As  this  scheme  is  an  elaboration  of  that  adopted 
by  the  association  it  is  only  just  that  the  reasons  for 
the  changes  proposed  be  given,  passing  without 
comment  those  parts  which  have  been  taken  over 
altogether. 

In  the  first  place  "slight  initial  lesion"  was  elim- 
inated because  it  has  not  yet  been  determined  that 
the  initial  lesion  is  in  the  lung. 

(a)  is  brought  in  for  the  purpose  of  excluding 
nontuberculous  diseases  with  physical  signs  in  the 
lungs,  and  because  it  is  believed  that  in  any  tuber- 
culous infiltration  capable  of  demonstration  in  the 
examining  room  these  slight  constitutional  symp- 
toms have  been  present  at  some  time  during  the 
course  of  the  disease. 

(b)  is  a  warning  to  move  on  and  suspect  a  lesion 
of  great'er  extent  than  that  detected. 

(c)  ,  (h),  and  (i)  refer  to  tuberculous  complica- 
tions which  might  very  well  be  left  out  of  the  classi- 
fication altogether  and  indicated  by  adding  the  name 
of  the  affected  organ  as  Turban  suggested.  The 
principal  reason  for  their  admission  is  the  grave 
bearing  which  some  of  them,  as  tuberculosis  of  the 
larynx  and  tuberculosis  of  the  intestines,  have  on 
the  prognosis  and  perhaps  indirectly  on  the  sta- 
tistics of  the  disease. 

(d)  has  no  great  importance  except  perhaps  in 
rare  cases.  It  was  retained  here  because  of  its  re- 
lation to  (i)  and  (m)  as  given  by  the  association 
under  the  two  following  divisions. 

(e)  is  practically  the  same  as  the  last  two  sub- 
heads of  the  National  Association  classification  in- 
cipient— a  warning  against  a  too  hasty  conclusion 
that  a  case  is  nontuberculous  because  tubercle  bacilli 
have  not  been  found  in  the  sputum. 

Under  "moderately  advanced",  (2)  is  inserted  be- 
cause there  is  no  place  for  an  extensive  infiltration 
in  the  National  Association  classification.  The  limi- 
tation to  two  lobes  conforms  with  Turban. 

(3)  is  substituted  because  "moderate  in  extent,"  is 
very  indefinite.  The  association  should  give  a  defi- 
nite limitation. 

(4)  is  elaborated  by  "with  evidence  of  an  active 
process"  because  "disseminated  fibroid  deposits" 
alone  without  active  process  would  be  discharged  as 
either  cured  or  apparently  cured  and  therefore  have 
no  place  in  the  classification. 

(f)  — in  excluding  cavity  formation  from  moder- 
ately advanced  cases  only  cavities  of  extent  sufficient 
to  give  physical  signs  are  contemplated.   In  this  it  is 


supposed  that  the  intent  of  the  National  Association 
classification  is  being  followed  but  the  wording  "cav- 
ity formation"  is  believed  to  be  less  ambiguous  than 
"evidence  of  destruction  of  tissue."  Personally  it 
is  believed  that  a  moderately  advanced  case  might 
still  be  so  with  a  cavity  of  this  extent  but  in  the 
hands  of  diftereht  examiners  the  statistics  will  be 
less  subject  to  error  if  cavity  formation  is  limited  to 
far  advanced  cases. 

(g)  and  (k)  are  retained  under  moderately  ad- 
vanced and  far  advanced  because  of  their  relation  to 
(a)  and  (b)  under  the  division  incipient,  which  are 
considered  particularly  important  in  the  limitation 
of  incipient  cases.  It  is  believed  that  they  have  been 
present  at  some  time  in  every  advanced  case  but  fre- 
quently after  the  body  has  partially  accommodated 
itself  to  the  invasion,  during  the  stage  of  quiescence, 
nothing  more  than  a  history  of  them  can  be  obtained. 

Under  "far  advanced"  (5)  is  suggested  in  place 
of  "localized  consolidation  intense,"  because  this  lat- 
ter covers  only  a  very  small  per  cent,  of  the  far  ad- 
vanced cases. 

(6)  is  added  because  we  have  such  cases  and  the 
extent  of  the  tissue  destruction  would  seem  to  war- 
rant their  being  placed  in  this  division. 

(j) — Cavity  formation  is  not  placed  in  the  body  of 
the  classification  but  is  used  only  as  a  guide  to  this 
division  "far  advanced"  for  the  reason  that  the 
functionating  lung  tissue  having  been  destroyed  it 
would  seem  to  make  no  great  difference  whether  its 
place  is  occupied  by  a  consolidated  mass  contain- 
ing minute,  poorly  drained  excavations  or  a  well  de- 
fined and  comparatively  clean  space. 

For  more  than  two  years  it  has  been  my  duty  to 
examine  and  report  tuberculous  patients  upon  their 
arrival  at  the  United  States  Marine  Hospital  Sana- 
torium at  Fort  Stanton,  New  Mexico.  This  paper 
is  based  upon  that  work  and  is  a  result  of  a  running 
discussion  of  the  National  Association  classification 
participated  in  by  the  different  medical  officers  who 
have  been  stationed  at  the  sanatorium.  In  its  prepa- 
ration Turban's  Ttiberciilosis  of  the  Lungs  and  the 
Reports  of  the  National  Association  have  been  freelv 
consulted. 

It  is  not  expected  that  the  classification  will  meet 
with  general  approval,  but  if  it  shall  be  the  means 
of  provoking  a  general  discussion  which  must  inevit- 
ably expose  the  defects  of  the  classification  in  pres- 
ent use,  its  object  will  have  been  accomplished. 


FLAT  FOOT. 

By  F.  E.  Peckham,  M.  D., 
Providence,  R.  I. 

The  term  flat  foot  is  used  here  as  the  general 
practitioner  uses  it  in  order  that  all  readers  may 
know  in  a  general  way  what  is  to  be  considered  in 
this  article. 

Some  years  ago  flat  foot  was  looked  upon  and 
spoken  of  as  a  breaking  down  of  the  arch  of  the 
foot,  and  tracings  or  impressions  of  the  soles  of 
the  feet  were  made  to  prove  or  disprove  such  a  con- 
dition. I  think  it  was  Dr.  Hoffman  who  first  demon- 
strated that  such  tracings  were  useless  and  that  feet 
might  be  so  pronated  as  to  give  the  impression 
which  would  correspond  to  a  flat  foot,  and  yet  the 


Aiiril  10,  iQuy.  I 


PECKHAM:  FLAT  FOOT. 


735 


foot  be  a  perfectly  strong  and  serviceable  one  and 
one  which  had  given  no  trouble  at  all.  This  he  did 
from  the  study  of  the  feet  of  people  inhabiting 
warm  climates  and  who,   naturally,  went  bave- 


FiG.  I. — Sliowing  the  shoe  and  support  recommended. 


footed.  He  also  demonstrated  that  some  of  these 
feet,  if  placed  in  our  shoes,  wovild  soon  go  to  pieces 
and  give  trouble.  Personally  I  was  very  much  in- 
terested in  observing  the  feet  of  some  native  Phil- 
ippinos.  The  feet  of  these  particular  individuals 
were  what  we  would  call  flat  if  they  had  come  into 
our  offices  complaining  of  any  symptoms,  but  here 
was  in  evidence,  feet  with  powerful  muscles  al- 
though quite  markedly  pronated  and  capable  of 
doing  any  work  which  might  be  put  on  them,  and 
yet  they  were  free  from  any  of  the  aches  and  pains 
with  which  we  are  all  so  familiar.  These  people 
were  living  an  out  of  door,  barefooted  life,  while 
the  people  whom  we  have  to  treat  for  foot  troubles 
live  an  indoor,  shoe  wearing,  and  very  artificial  ex- 
istence, and  it  is  this  which  must  make  all  the  dif- 
ference. In  both  cases  the  feet  are  or  may  be  the 
same  as  regards  pronation  and  flattening  of  the 
arches ;  the  one  is  entirely  free  from  symptoms,  and 
the  other  has  all  kinds  of  symptoms. 

These  feet  which  are  in  such  an  artificial  atmos- 
phere are  also  encased  in  shoes  which  vary  in  shape 
every  year,  forcing  the  feet  into  a  little  different 
shape  with  each  change  and  pressing  upon  the  feet 
at  different  corners  with  every  change.  The  shoes 
(commercially)  are  blocked  out  each  season  without 
any  thought  of  the  human  foot  but  with  the  sole  idea 
of  making  the  shoe  different  from  the  last  season's 
shape.  Without  going  into  the  anatomy  of  the 
foot,  it  is  well  known  that  in  general  there  are  two 
arches  in  the  foot,  the  longitudinal  and  the  trans- 
verse. The  transverse  arch  is  much  more  often  di- 
rectly flattened  or  "broken  down"  than  the  longi- 
tudinal, and  the  result  is  a  metatarsalgia.  This  par- 
ticular trouble  will  not  be  considered  in  this  paper 
as  it  does  not  come  strictly  under  what  is  meant  by 
flat  foot,  although  the  same  underlying  causes  exist 
and  the  same  general  treatment  would  benefit  both. 
In  the  case  of  trouble  with  the  longitudinal  arch, 
the  old  idea  was  that  it  was  "broken  down"  but, 


strange  to  say,  an  arch  that  is  really  '"broken  down" 
is  not  very  common.  A  foot  that  is  encased  in  a 
conventional  shoe  in  the  first  place,  is  so  held  that 
it  does  not  rest  upon  the  ground  or  floor  with  the 
lines  of  the  foot  in  normal  relation.  A  line  passing 
through  the  phalanges  of  the  great  toe  should,  if 
continued,  pass  directly  through  the  centre  of  the 
heel  as  described  by  Meyer,  while  in  a  shoe  as  de- 
scribed above,  this  line  is  distorted  the  great  toe 
being  usually  forced  outward.  Walking  is  a  purely 
mechanical  process.  As  one  foot  is  put  forward, 
landing  on  the  heel,  the  last  act  of  the  rear  foot  is 
to  push  forward  by  pressing  on  the  great  toe  joint 
as  the  foot  leaves  the  ground  or  floor.  It  is  at  this 
point  that  the  position  of  the  great  toe  is  so  im- 
portant, and  to  have  it  act  with  the  greatest  me- 
chanical efficiency  it  ought  to  be  in  the  correct  posi- 
tion of  Meyer's  line,  as  just  described.  With  this 
position  somewhat  distorted,  the  foot  is  thrown 
outward,  the  foot  being  rotated  outward  with  ref- 
erence to  the  long  axis  of  the  leg,  and  at  the  same 
time  the  ankle  tends  to  bulge  inward.  The  muscles 
and  tendons  which  support  the  foot  in  a  normal 
position  may  become  weakened  in  the  before  de- 
scribed faulty  position.  This  condition  may  result 
from  overuse,  from  using  too  soon  after  a  pro- 
longed illness,  from  using  in  a  more  or  less  continu- 
ously standing  occupation,  i.  e.,  clerks,  policemen, 
etc.,  and  from  a  disproportion  between  the  body 
weight  and  the  feet  and  ankles,  i.  e.,  overweight, 
etc.  This  distortion  of  the  foot,  i.  e.,-  foot  turning 
outward  and  ankle  bulging  inward,  at  first  may  be 
very  slight  and  is  only  noticeable  when  standing. 


Fig.  2.- — Showing  the  foot  exerciser  described  in  the  text. 

the  normal  lines  being  restored  when  the  body 
weight  is  removed,  as  in  sitting.  This  distortion 
or  deformity  slowly  becomes  more  pronounced  with 
the  cause  continuing  until  it  becomes  very  exagger- 
ated.   In  order  to  allow  this  development  of  de- 


736 


PECKHAM: 


FLAT  FOOT. 


[New  York 
Medical  Journal. 


fonnity,  there  must  come  a  gradual  loss  of  tone 
and  consequent  stretching  of  the  soft  structures, 
1.  e.,  muscles,  tendons,  and  ligaments.  After  these 
soft  parts  are  stretched  and  the  deformity  devel- 
oped the  bones  themselves  may  change  somewhat 
their  normal  relations,  and  the  pressure  between 
the  various  joint  surfaces  thus  becomes  somewhat 
shifted,  and  there  results,  in  extreme  cases,  a  low 
grade  inflammation  and  adhesions  form,  thus  pro- 
ducing the  rigid  type  of  flat  foot.  As  the  foot  is 
turned  outward  and  the  ankle  pushed  inward,  the 
tendo  Achillis  naturally  becomes  contracted  and 
hence  tends  to  perpetuate  the  deformity. 

As  these  different  stages  develop  the  clinical 
symptoms  are  also  sending  out  messages,  but  un- 
. fortunately  these  messages  are  usually  misinter- 


Fic 


-.Shduniy  i-lci  1  sli.mks.     The  cunventiuji jl  n;.r 
especially  wide  for  supporting  the  arch. 


and  tlic 


preted.  At  first  the  foot  may  only  ache  when  used 
up  to  the  point  of  easy  tolerance  or  there  may  be 
some  aching  or  real  pain  in  the  calf  muscles.  At  a 
later  stage  when  the  foot  is  sagging  still  more, 
there  may  be  real  pain  and  a  great  deal  of  aching  in 
the  region  of  the  longitudinal  arch  and  also  of  the 
dorsum  of  the  foot.  There  may  be  also  cramps  in 
the  calf  muscles  as  well  as  aching  and  pain.  At  a 
later  stage  the  flexibility  of  the  foot  and  ankle  be- 
comes interfered  with.  There  may  be  also  some 
limitation  of  motion  clue  to  muscular  rigidity,  con- 
tracted tendons,  and  formation  of  adhesions.  There 
is  very  apt  to  be  swelling  around  the  ankle  joint 
with  much  tenderness  both  on  pressure  and  on  mo- 
tion. In  some  cases  the  pain  extends  up  the  whole 
length  of  the  leg  and  even  backache  may  be  a 
lroul)lesome  symptom. 


From  all  this  explanation  it  will  be  readih'  seen 
that  the  important  tning  to  be  considered  is  not  that 
tne  loot  IS  flat  but  that  it  has  become  weakened  as 
described,  and  as  a  result  has  flattened.  Also  in 
consequence  of  this  we  now  hear  much  less  about 
flat  foot  but  more  about  weak  foot.  With  an  ankle 
that  is  limited  in  motion  from  muscular  rigidity  and 
adhesions,  it  may  be  due  to  the  later  conditions  of 
weak  foot  or  it  may  be  due  to  some  of  the  infec- 
tions which  have  very  improperly  been  called  rheu- 
matism. Perhaps  a  common  infection  in  the  ankle 
joint  is  that  of  gonorrhoea;  another  is  the  so  called 
rheumatoid  process,  while  any  infection  may  locate 
in  this  joint.  Let  us  hope  that  the  future  will  see 
the  word  rheumatism  dropped  and  the  disease  take 
its  place  with  the  group  of  infections  by  name  as 
it  is  now  in  reality.  In  two  or  three  per  cent,  of  all 
cases  of  gonorrhoea,  arthritis  develops  either  from, 
the  gonococcus  or  from  its  toxines.  If  the  gono- 
coccus  is  actually  present  suppuration  is  much  more 
apt  to  follow,  while  if  only  the  toxines  are  present, 
it  is  not  apt  to  suppurate,  and  theoretically  there 
should  be  no  suppurative  process.  The  knee  joints 
are  most  apt  to  be  involved  and  most  apt  to  su])- 
purate ;  while  the  ankle  joints  are  prone  to  be  in- 
volved they  are  more  apt  to  be  aflfected  by  the 
toxines  and  so  a  suppurative  condition  at  this  loca- 
tion is  not  so  common.  With  the  ankle  joints  thus 
affected  it  is  well  to  look  into  the  historv  very  care- 


l-lr 


-Sliouing  the  lateral  view  uf  steel   shank  in  shoe. 


fully  and  ascertain  not  only  if  there  is  an  actually 
present  gonorrhoea,  but  if  there  was  ever  an  old 
gonorrhoea,  because  it  is  now  a  well  established  fact 
that  practically  no  matter  how  many  years  ago 
there  may  have  been  a  specific  ur-ethritis  the  seminal 
vesicles  become  involved  in  many  of  the  cases  and 
retain  some  of  the  cocci  for  an  apparently  indefinite 
number  of  years,  and  any  sexual  excitement  might 
render  them  active  and  then  produce  a  so  called 
exacerbation  of  symptoms.  With  svich  an  infection 
in  the  acute  stage,  with  possibly  chills  and  some 
fever,  this  condition  would  be  readily  distinguished 
from  a  boggy  and  irritated  joint  of  so  called  flat 
foot,  but  in  the  chronic  stage  with  no  urethritis 
present,  it  might  be  overlooked  without  a  careful 
history  as  described. 

A  condition  which  is  much  more  like  that  of  flat 
foot  is  the  rheumatoid  process,  especially  when  it 
begins  in  the  ankle  joints.  Here  is  the  same  boggy 
joint  with  some  puffing  around  one  or  the  other  or 
both  malleoli,  the  tenderness  on  motion,  manipula- 
tion, and  weight  bearing.  If  there  is  no  villous  con- 
dition perceptible  and  if  there  is  absolutely  no  other 
j(Mnt  in  the  body  involved,  then  it  may  be  absolutely 
impossible  to  distinguish  it.  In  many  cases,  on  the 
other  hand,  there  may  be  slight  clues,  as  the  finger 
joints  or  some  (even  though  slight)  villous  condi- 
tion of  the  knee  joints :  while  in  other  cases,  other 
joints  will  be  so  evidently  involved  that  it  is  an  easy 
matter  to  diagnosticate.     In  the  cases  where  the- 


April  111.  igog.  I 


I'ELKHAM:  FLAT  FOOT. 


711 


diagnosis  is  impossible,  the  later  development  of  the 
process  will  have  to  be  awaited  before  one  can  be 
assured  of  the  exact  condition.  There  may  be  a 
pure  villous  condition  in  the  ankle  joints  varying 
irom  very  slight  to  very  pronounced.  With  the 
ankle  joint  grasped  firmly  between  the  thumb  and 
finger  the  grating  and  roughening  is  apparent  to  the 
feel  when  the  joint  is  moved.  There  is  a  group  of 
cases  which  seem  to  be  in  a  class  by  themselves  and 
that  is  in  children.  They  just  seem  to  be  born  and 
to  have  always  walked,  with  the  feet  markedly  pro- 
iiated  and  the  ankles  bulging  in.  This  happens  in 
children  of  slight  build  as  well  as  those  of  more 
stocky  mould.  The  ankles  seem  to  be  inherently 
weak.  This  condition  is  then  exaggerated  by  the 
conventional  shoe,  the  shoes  with  small,  high  heels 
being  especially  built  to  increase  such  a  tendenc)-. 
The  so  called  spring  heel  shoe  also  tends  to  assist 
any  lateral  dcformitv  from  the  very  fact  that  the 
highest  point  is  at  the  middle,  the  periphery  of  the 
heel  being  not  so  high.  Thus  the  foot  rolls  more 
easily  from  side  to  side,  and  any  tendency  of  the 
foot  to  pronate  would  be  materially  helped  along 
in  its  faulty  direction.  In  such  cases  there  is  usually 
entire  absence  of  pain  and  in  fact  of  all  symptoms. 
The  child  is  brought  to  the  surgeon  because  the 
feet  present  noticeable  deformity  and  the  shoes  arc 
worn  ofif  on  the  inside  and  the  counters  are  all 
turned  as  well.  In  other  words  the  shape  of  the 
shoe  is  so  deformed  that  the  parents  "take  notice." 

The  treatment  of  flat  foot  is  apparently  changing 
very  markedly  as  the  years  go  by.  In  the  beginning 
of  my  practice,  artificial  supports  were  used  to  the 
exclusion  of  almost  every  other  means,  and  steel 
1  lates  were  also  almost  exclusively  employed.  Plas- 
ter casts  of  individual  feet  were  made,  then  these 
casts  were  shaved  with  extreme  care,  thus  making 
an  artificial  arch.  This  arch  was  made  after  a  care- 
ful study  of  the  individual  foot  so  that  the  steel 
plate,  when  completed,  would  be  of  such  elevation 
as  the  surgeon  thought  the  foot  would  tolerate. 
These  plates  extended  up  the  inner  and.  to  a  lesser 
extent,  the  out^-  side  of  the  foot,  thus  giving  lateral 
support  as  well  as  support  underneath.  It  will  thus 
be  seen  that  instead  of  being  an  accurate  mechani- 
cal method  it  depended  entirely  on  the  judgment 
(an  educated  guess)  and  care  of  the  surgeon  in 
shaving  the  plaster  casts.  At  first  it  was  my  custom 
to  have  an  iron  foot  made  from  the  plaster  form 
and  then  a  steel  plate  fashioned  by  hammering  the 
red  hot  metal  over  the  iron  foot.  Later  my  me- 
chanic learned  to  shape  the  red  hot  steel  to  the 
plaster  form  without  the  use  of  the  iron  casting. 
In  my  own  experience  and  in  talking  with  other 
'urgeons,  I  found  it  was  also  their  experience  that 
it  was  at  times  a  difficult  thing  and,  in  a  few  cases, 
an  almost  impossible  thing  to  fit  a  hard  steel  plate 
to  the  human  foot.  It  was  a  very  easy  and  very 
simple  procedure  to  fit  a  steel  plate  to  a  plaster  foot, 
but  was  quite  a  different  proposition  to  fit  that 
identical  plate  to  the  human  foot,  and  still  more  dif- 
ficult to  fit  it  to  the  human  foot  \n  action.  For  ex- 
ample, a  plate  fitting  the  font  with  the  body  weight 
off  is  all  right.  When  the  patient  stands  and  at- 
tempts to  walk,  the  plate  might  hurt  on  the  bottom 
of  the  foot  or  on  either  side.  This  would  mean  that 
the  plate  must  be  immediately  lowered  or  bent  out 


on  either  side  at  the  point  of  too  great  pressure.  In 
a  tender  and  painful  foot,  especially  in  the  acute 
stages  the  plate  might  have  to  be  lowered  and 
widened  until  in  the  final  form  in  which  the  patient 
could  tolerate  it,  it  would  give  very  little,  if  any. 
support.  Then  too,  if  the  plate  was  so  fitted  that 
the  patients  could  walk  out  of  the  office  apparently 
free  from  any  undue  pressure,  the}'  were  some 
times  apt  to  return  in  a  few  days  with  the  plates 
in  their  hands,  being  unable  to  tolerate  them.  Then, 
as  we  were  obliged  to  change  these  plates  from  visit 
to  visit  to  improve  the  arch  of  the  foot,  it  meant 
heating  them  in  the  forge  each  time,  which  was 
more  or  less  of  a  nuisance  to  everybody  concerned. 

In  the  early  days,  in  addition  to  plates,  the  tip  toe 
exercises  were  used  to  a  certain  extent.  A  little 
later  efforts  began  to  be  made  with  regard  to 
having  a  shoe  manufactured,  the  shape  of  which 
would  be  at  least  some  improvement  over  the  con- 
ventional shoe.  Still  later  flat  feet  developed  in  the 
writer  himself  and  from  that  time  the  study  of  the 
problem  was  carried  on  a  little  more  intelligently. 
At  first  the  study  of  the  shoe  was  taken  up.  A  num- 


FiG  5. — Shoeing  the  deposition  01  lime  salts  at  the  insertion  of  tiu- 
tendon  on  the  os  calcis. 


ber  of  X  ray  pictures  were  made  of  feet,  both  with 
and  without  various  kinds  of  shoes.  This  work  ap- 
parently was  carried  on  at  about  the  same  time  Dr. 
Lovett,  of  Boston,  was  doing  identical  research.  I 
did  not  know  of  his  work,  however,  until  his  article 
appeared  in  the  Boston  Medical  and  Surgical 
.lonnial,  and  some  time  later  my  own  article  ap- 
peared in  the  Providence  Medical  Journal.  As  a 
result  of  these  studies  a  last  was  finally  evolved  and 
shoes  finally  manufactured  and  kept  on  sale  in  the 
shops.  I  was  guided  in  evolving  this  shoe  by  the 
conclusions  drawn  from  the  x  ray  studies,  men- 
tioned before,  and  by  fitting  the  shoe  to  my  own 
flat  feet.  W'wh  this  shoe  now  possible  for  both  men 
and  women,  my  results  in  treatment  were  im- 
mensely improved.  The  shoe  which  I  have  used  for 
a  number  of  years  is  illustrated  in  the  photograph. 
The  shank  is  twisted  slightly  inward  and  the  heel 
is  made  one  eighth  inch  higher  on  the  inside  than 
the  outer  side.  There  is  room  for  the  toes  with  a 
fair  breadth  at  the  ball  of  the  foot.  I  have  tried 
many,  if  not  all,  the  shoes  in  the  market,  and  this 
is  the  most  satisfactory  one.  and  the  results  have 
been  much  better  since  adopting  it. 

The  fitting  of  plates,  with  its  attendant  results 


738 


PECKHAM:  FLAT  FOOT. 


[New  York 
Medical  Journal. 


were  not  satisfactory  to  me,  and  patients  seen  by 
me,  fitted  with  steel  plates,  in  the  various  medical 
centres  of  the  country,  were  also  usually  unhappy 
over  the  results.  In  consequence  of  this  I  cast  about 
for  some  method  which  would  be  more  agreeable. 
There  is  nothing  new  in  this  support,  but  the  de- 
tails having  been  more  or  less  perfected,  there  has 
been  a  marked  improvement  in  ability  to  relieve 
and  that  without  so  much  discomfort  to  the  patient. 
A  pattern  of  the  sole  (inside)  of  the  shoe  is  made 
and  a  leather  insole  made  which  fits  the  shoe,  being 
a  little  wider  in  the  shank  than  the  shank  of  the 
shoe,  but  not  so  wide  that  the  steel  cuts  into  the 
leather  at  the  side  of  the  shoe.  There  is  a  pocket 
made  beginning  at  a  point  just  in  front  of  the 
weight  bearing  portion  of  the  heel  on  the  inner 
edge  of  the  insole  and  ending  at  a  point  just  back 
of  the  weight  bearing  portion  of  the  ball  of  the 
foot  back  of  the  great  toe  joint.    Then  a  curved 


Fig.  6. — Sliovving  Dr.  Nutt's  modification  of  a  Sliaffer  traction 
apparatus. 


pocket  is  formed  and  stitched  down  to  the  insole 
leaving  it  open  along  the  inner  edge  for  the  inser- 
tion of  felting.  The  orange  color  or  yellow  felting 
is  used,  and  first  a  single  thickness  is  inserted  in  the 
pocket.  Underneath  everything  is  a  piece  of  flat 
steel  to  preserve  the  curve  of  the  support.  It  will 
thus  be  seen  that  the  steel  is  entirely  away  from  the 
foot,  and  the  felting  being  compressible  flattens 
down  under  the  body  weight,  and  as  it  flattens  it 
shapes  itself  to  the  foot.  When  this  is  flattened  by 
wearing  two  weeks  or  so,  a  second  piece  can  be  in- 
serted and  later  the  steel  can  be  raised  to  about  one 
half  inch  elevation,  which  will  be  sufficient  for  most 
cases.  The  advantages  of  this  support,  it  seems  to 
me.  are  several.  It  does  not  present  a  hard,  un- 
yielding surface  to  the  already  usually  tender  and 
weak  foot,  but  on  the  contrary,  compared  to  a  piece 
of  steel,  it  is  soft  and  yielding.  It  is  made  low  at 
first  so  as  to  be  sure  it  does  not  hurt,  and  then  at 
subsequent  visits  it  is  gradually  raised  by  inserting 
more  felting,  and  lastly  by  raising  the  steel,  quite 
in  contrast  to  the  method  of  raising  necessary  in  a 
tempered  piece  of  solid  steel.  Then  this  softer  ma- 
terial is  better  suited  to  meet  the  foot  at  the  end  of 
its  downward  excursion  as  the  maximum  weight  is 


placed  on  it  in  the  act  of  walking  (resiliency  of  the 
human  foot.) 

Regarding  the  tip  toe  exercises,  I  found  when  I 
tried  them  on  myself  that  they  were  very  disagree- 
able when  the  foot  was  in  a  weakened,  tender,  and 
at  times,  painful  condition,  and  it  seemed  cruel  to 
advise  such  things,  for  patients  with  tired,  weak 
feet.  As  a  substitute  exercise,  which  I  found  to  be 
agreeable  rather  than  disagreeable,  was  to  have 
the  patient  in  the  sitting  position  with  legs  across 
a  chair  or  stool  with  the  feet  slightly  overhanging 
and  with  the  weight  thus  removed  to  make  the  four 
movements  of  dorsal  flexion,  plantar  flexion,  ad- 
duction, and  abduction.  These  movements  may  be 
repeated  at  first  a  few  times,  then  the  number 
gradually  increased,  never  going  beyond  the  point 
of  causing  muscle  tire.  This  proved  much  more 
satisfactory  as  an  exercise  and  has  since  accom- 
plished a  great  deal  of  good  in  weak  foot  conditions 
in  the  way  of  muscular  development.  It  is  difficult, 
however,  to  get  people  to  do  this  work  at  home. 
They  will  do  it  for  a  longer  or  a  shorter  time  and 
then  give  it  up  entirely.  Another  way  of  giving 
work  for  the  different  groups  of  muscles  is  by 
placing  the  feet  in  a  machine  which  oft'ers  resist- 
ance to  the  movements.  The  machine  which  I  have 
had  made  offers  the  resistance  through  friction. 

The  machine  is  seen  in  Fig.  2  on  page  735.  The 
figures  I  and  3  represent  the  shoes  into  which  the 
feet  are  placed  for  flexion  and  extension,  with  the 
amount  of  resistance  controlled  at  a  and  c;  2  is  the 
shoe  in  which  adduction  and  abduction  is  obtained 
with  resistance  offered  at  b.  If  a  patient  presents 
itself  with  the  feet  in  an  acute  condition,  hot  and 
cold  showering  or  plunging  followed  immediately 
by  massage  or  vibration,  will  usually  very  quickly 
afford  relief.  In  this  acute  condition,  a  few  days 
absolute  rest  from  being  on  the  feet  may  markedly 
hasten  the  recovery,  for  it  is  a  well  known  fact  that 
occasionally  a  patient  who  is  on  the  feet  all  day 
long  is  unable  to  continue  on  them  and  get  well.  A 
prolonged  rest  completely  off  the  feet  is  a  necessity 
for  such  a  patient.  This  happens  sometimes  to  a 
nurse  in  training.  The  feet  have  not  been  pre- 
viously employed  so  continuously  day  after  day, 
and  no  matter  what  is  done  the  feet  simply  refuse 
to  do  any  more  work  until  they  have  had  a  pro- 
longed rest.  On  the  other  hand,  it  is  in  the  majority 
of  just  such  cases  when  the  feet  have  given  out 
acutely  after  being  used  all  day,  day  after  day,  in 
an  unusual  (to  them)  manner,  that  hot  and  cold 
showering  or  plunging  followed  by  massage  or 
preferably,  vibration,  does  the  most  good.  It  goes 
without  saying  that  when  weight  bearing  duties  are 
resumed  that  a  proper  shoe  is  an  absolute  neces- 
sity for  future  comfort.  Just  what  a  proper  shoe 
consists  of  is  probably  not  yet  reduced  to  ultimate 
terms,  and  also  it  is  quite  evident  tliat  the  same 
shoe  as  regards  general  outline,  shape,  heel,  etc., 
cannot  be  used  in  every  patient  without  minor 
changes  for  the  individual  case.  The  changes,  how- 
ever, cannot  be  very  marked.  For  example,  in  ar- 
ranging the  so  called  Thomas  heel,  a  heel  which 
extends  a  little  further  forward  on  the  '-"side  than 
the  outer  and  also  the  inside  being  a  little  higher 
than  the  outer,  the  dimensions  wliicli  I  have  incor- 
porated in  the  stock  shoe  is  one  eighth  inch  higher 


April  10,  1909  1 


PECKHAM:  FLAT  FOOT. 


739 


than  the  outer  and  extends  one  eighth  inch  or  one 
quarter  inch  farther  forward.  Now,  in  exagger- 
ating these  heels  for  individual  cases,  too  great 
changes  cannot  be  made,  otherwise  the  counter  of 
the  shoe  becomes  pushed  over,  thus  rendering  the 
patient  uncomfortable.  If  any  change  is  called  for 
I  prefer  at  first  to  run  the  heel  three  eighths  inch  or 
occasionally  even  one  half  inch  farther  forward  and 
preserve  the  one  eighth  inch  elevation.  On  the  other 
hand,  if  the  heel  is  elevated  more  it  is  apt  to  be  run 
so  far  forward.  However,  there  are  occasional 
cases  when  both  dimensions  would  have  to  be  in- 
creased. Sometimes  also  in  an  exaggerated  case 
the  sole  of  the  shoe  might  have  to  be  elevated  on 
the  inside  to  correct  a  badly  pronated  foot.  In  a 
stock  shoe  these  before  mentioned  points  would  be 
the  only  ones  possible  to  change.  If  any  other 
changes  are  necessary,  the  measurements  of  the 
foot  must  be  taken  when  a  factory  made  shoe  can 
be  turned  out  in  accordance  with  such  measure- 
ments. 

In  treating  these  af¥ections  of  the  foot  each  case 
must  be  studied  for  the  different  points  presented 
and  the  characteristic  likes  and  dislikes  of  the  pa- 
tient have  also  very  much  to  be  taken  into  account. 
In  getting  up  a  combination  treatment  which  will 
get  all  of  these  conditions  into  a  harmonious  juxta- 
position and  adding  to  this  infinite  patience  on  the 
part  of  the  physician,  success  will  be  obtained  in 
the  majority  of  cases. 

In  considering  such  troubles  it  must  be  remem- 
bered that  there  are  various  stages  of  treatment 
through  which  the  patient  must  be  carefully  con- 
ducted and  the  portion  of  the  journey  selected  for 
the  individual  case  depends  upon  the  stage  of  the 
existing  trouble.  If  an  acute  condition  has  occurred 
in  which  the  foot  is  not  so  much  "broken  down," 
as  patients  express  it,  but,  rather  it  is  painful  and 
often  times  exquisitely  tender  to  the  touch.  The 
tendo  Achillis  is  extremely  tender  and  on  motion, 
very  painful,  the  foot  even  aching  when  not  being 
used.  Such  a  condition  of  acute  weak  foot,  as  it 
is  called,  is  best  treated  by  hot  air  baths  or  plunging 
alternately  in  hot  and  cold  water,  either,  to  be  im- 
mediately followed  by  massage  of  vibration.  The 
preferable  treatment  would  be  the  hot  air  and  vi- 
bration. These  treatments  every  day  with  the  pa- 
tient oflF  the  feet  for  a  very  few  days  will  usually 
suffice  to  give  entire  comfort  and  freedom  from 
pain.  Then  careful  regulation  of  the  shoe  as  before 
described,  may  be  sufficient  so  that  weight  bearing 
can  now  be  begun  and  continued  without  any  fur- 
ther trouble.  Such  a  foot,  however,  is  much  more 
liable  to  give  trouble  later,  unless  care  is  observed 
in  shoeing  and  attention  given  to  any  premonitory 
signs  of  trouble. 

Another  condition  which  may  present  itself  is 
where  there  has  been  pain,  usually  in  the  region  of 
the  instep  for  a  long  time,  sometimes  months  and 
sometimes  even  for  years.  The  foot  is  usuallv  very 
much  pronated,  probably  all  kinds  of  so  called  arch 
supporters  have  been  used.  In  such  a  case  the  tendo 
Achillis  is  also  very  apt  to  be  contracted  and  the 
calf  of  the  leg  tender  to  the  touch.  The  first  thing 
to  do  in  such  a  case  is  to  give  relief  and  this  is  ac- 
comnlis^Tcd  bv  shoes  and  sunports  as  described  in 
the  preceding.    The  supports  are  gradually  raised 


as  the  foot  tolerates  it,  and  relief  is  usually  quite 
prompt.  Relief,  however,  is  not  all  that  should  be 
attempted  if  the  patient  will  keep  on  and  do  more. 
Afcer  the  support  has  been  worn  for  a  longer  or 
shorter  time,  usually  a  few  months,  dependmg  on 
the  condition  of  the  foot  and  also  to  a  considerable 
extent  upon  the  weight  of  the  patient,  the  attempt 
should  be  made  to  diminish  the  amount  of  artificial 
support.  In  doing  away  with  the  brace  which  goes 
inside  the  shoe,  whether  it  be  plate  or  some  other  ' 
foi"m  of  support,  there  must  be  substituted  for  it, 
at  first  any  way,  either  more  changes  in  the  way  of 
exaggerating  the  Thomas  heel,  wider  steel  shank  in 
the  shoe,  or  both  combined.  Before  arriving  at  the 
time  when  this  change  should  be  made  there  should 
have  been  given  treatment  in  the  line  of  a  develop- 
ment of  the  foot,  provided  the  patient  would  con- 
sent to  do  it.  The  exercises  should  always  be 
stopped  short  of  producing  a  condition  of  muscle 
tire  and  immediately  followed  by  massage  or  vibra-^ 
tion.  At  the  same  time  this  treatment  is  carried 
on,  the  shortened  tendo  Achillis  must  be  stretched 
by  a  Shaffer  traction  apparatus. 

When  the  foot  has  been  supported  for  a  sufficient 
time  (this  time  varying  in  different  people),  usually 
months,  then  it  is  my  custom  to  gradually  give  the 
foot  less  and  less  support.  At  first  a  shoe  is  fitted 
to  the  foot  and  a  wide  steel  shank  inserted  in  the 
arch  of  the  shoe,  tempered  sufficiently  to  hold  the 
original  curve  of  the  shoe  so  that  it  will  not  sag  or 
yield  to  the  body  weight.  Normally  when  the  foot 
is  not  supporting  any  weight  there  is  a  certain 
curve  to  the  arch.  Now  when  it  supports  the  body 
weight  this  arch  is  lowered,  thus  in  the  act  of  walk- 
ing the  arch  moves  up  and  down  as  the  body  weight 
is  alternately  shifted.  This  might  be  called  the 
resiliency  of  the  human  foot,  and  this  resiliency 
must  be  reckoned  with  in  supporting  the  foot.  The 
arch  of  the  shoe  is  not  far  from  correct  and  that  is 
why  in  weakened  feet  that  a  new  pair  of  shoes  feels 
so  comfortable  when  they  are  new,  but  the  arch  in 
playing  up  and  down  in  walking,  presses  the  shoe 
down  until  it  no  longer  supports.  Now,  by  placing 
a  wide  steel  shank  as  shown  in  the  x  ray  plate,  this 
shoe  arch  is  preserved,  and  when  supports  are  first 
omitted  I  find  this  a  valuable  step  in  the  changes 
that  are  made  to  do  away  with  artificial  support. 
In  addition  to  the  steel  shank,  the  Thomas  heel  is 
made  with  a  somewhat  more  pronounced  tilt  in 
order  to  correct  any  pronation  which  may  exist. 
Thus  the  foot  is  now  supported  by  the  natural  curve 
of  the  shoe  alone,  held  in  place  by  a  steel  shank  and 
a  tilted  heel.  After  a  few  months  many  patients 
can  go  into  the  shoes  without  any  reinforcing  and 
thus  cure  be  completely  established.  Others  will 
have  to  continue  the  steel  shanks  and  still  a  few 
feel  that  they  cannot  get  along  with  perfect  free- 
dom from  trouble  without  the  supports  inside  the 
shoe. 

The  scope  of  this  paper  does  not  include  opera- 
tive work,  but  there  are  some  complications  which 
occur  and  which  are  obviated  by  mechanical,  not 
operative  treatment.  In  the  later  stages  of  these 
conditions,  usuallv  where  no  treatment  has  been 
instituted,  the  ankle  joint  may  become  rigid  from, 
adhesions  which  form  between  the  joint  surfaces.. 
If  the  joint  is  completely  rigid  and  stiff  it  must  be.- 


740 


PECKHAM:  FLAT  FOOT. 


[New  York 
MiDicAL  Journal. 


brukcn  up  under  ether  and  immediately  followed 
by  hot  an-  baths  and  manipulation  to  regam  tne 
motion.  If  the  motion  is  only  partially  hmited. 
hot  air  baths  followed  by  manipulation,  or  better, 
to  iecei\^?  rhythmical  movements  by  means  of  a 
pendulum  apparatus,  slowly  increasing  the  arc  of 
motion  irom  day  to  day  until  the  motion  has  been 
-  completely  restored. 

Some  of  these  patients  who  come  in  with  weak 
feet  complain  mostly  of  tender  heels,  and  some  of 
the  heels  are  exquisitely  tender.  Many  of  the  pa- 
tients are  relieved  by  supporting  the  longitudinal 
arch,  thus  shifting  some  of  the  weight  from  the 
heel.  Others  get  rid  of  the  pain  and  tenderness 
in  the  heels  after  a  few  hot  air  baths,  while  a  few 
have  only  been  relieved  by  potassium  iodide. 
Whether  this  was  due  to  some  periosteal  thicken- 
ing which  was  dissipated  by  the  drug  is  the  ques- 
tion. A  few  patients  have  had  beginning  deposi- 
tion of  lime  salts  in  the  plantar  ligament  beginning 
at  the  attachment  in  the  os  calcis,  as  shown  by  the 
X  ray,  this  seemingly  explaining  the  heel  pains.  In 
connection  with  tender  heels  on  account  of  deposi- 
tion of  salts  in  the  ligamentous  insertion,  this  also 
may  accompany  a  gonorrhoeal  infection,  and  a  gon- 
orrhceal  infection  of  the  ankle  joints  is  not  an  un- 
common thing  and  may  be  the  cause  of  discomfort 
and  pain  in  a  pronated  foot  which  otherwise  might 
not  give  any  symptoms  at  all.  If  a  gonorrhoeal  in- 
fection is  found  to  be  present  the  focus  must  be  at- 
tacked at  the  same  time  the  foot  symptoms  are 
treated.  If  an  arthritis  is  present  it  must  be  appro- 
priately treated.  If  the  seminal  vesicles  are  in- 
volved, and  if  a  large  prostate  is  present,  these 
must  also  be  attended  to  in  an  appropriate  manner. 

Three  patients,  two  adult  males,  and  another,  a 
boy,  have  presented  themselves  with  what  seemed 
to  be  flat  or  weak  feet  in  the  very  early  stages,  the 
S3'mpt()ms  especially  referred  to  feet  and  ankles. 
In  the  case  of  the  boy,  shoes  were  prescribed  and 
supports  worn  for  a  while  with  marked  improve- 
ment. Then  a  winter  spent  in  the  south  seemed  to 
make  everything  all  right  and  on  his  return  in  the 
spring,  the  feet  seemed  to  be  in  excellent  condition 
and  the  general  health,  .perfect.  In  the  next  few 
months,  however,  the  feet  became  troublesome 
again,  a  little  later  the  ankles  began  to  swell,  and 
slowly  all  of  the  joints  were  involved  including  the 
cervical  vertebrae.  In  other  words,  here  was  a  case 
of  rheumatoid  arthritis  beginning  with  the  joints 
of  the  feet  and  ankles  and  at  first  mistaken  for 
weak  feet. 

One  of  the  adult  male  ijatients  ])resented  himself 
complaining  of  pain  and  tenderness  in  the  feet  with 
stififness  of  the  ankle  joints.  Supports  were  ad- 
justed but  the  symptoms  increased  in  severity.  This 
patient  floated  from  city  to  city,  being  in  succession 
under  the  care  of  some  of  the  best  orthopaedic  sur- 
geons in  the  country.  All  without  exception  con- 
sidered it  a  case  of  flat  foot.  Each  in  succession 
made  and  fitted  his  own  style  of  foot  supports. 
The  patient  grew  very  much  worse,  returning  home 
where  '^till  another  surgeon  put  the  foot  and  legs  in 
plaster  of  Paris  in  an  attempt  to  relieve  him  by  fixa- 
tion. \\  about  this  time  the  disease  started  in  much 
more  seriously  and  rai)idly  and  involved  nearly  all 
the  joints  of  the  body.    .\"'"arently  it  was  an  infec- 


tious arthritis,  beginning  in  the  feet,  and  in  the 
early  stages  had  been  considered  and  treated  by  the 
best  men  in  the  country  as  an  aggravated  fiat  foot. 
The  other  adult  male  was  much  the  same  kind  of  a 
case.  Such  cases  keep  one  thinking  all  the  time,  as 
even  the  mildest  type  of  weak  foot  may  be  only  the 
lieginning  of  multiple  joint  trouble. 

Another  very  common  condition  in  these  cases, 
particularly  after  the  trouble  has  existed  for  some 
time,  is  a  contraction  of  the  tendo  Achillis.  This  is 
best  lengthened  by  stretching  in  a  Shaffer  traction 
apparatus,  the  modification  of  this  apparatus  by  Dr. 
Nutt  being  an  extremely  satisfactory  instrument. 
A  few  treatments,  especially  when  the  whole  calf 
of  the  leg  is  tender,  the  stretching  being  immedi- 
ately followed  by  vibration,  gives  a  great  deal  of 
relief,  and  walking  and  weight  bearing  becomes 
very  much  easier  almost  immediately.  In  later 
stages  when  the  irritation  from  faulty  position  is 
sufiicient,  adhesions  form  in  the  joint  and  the 
ankles  may  become  completely  ankylosed  if  allowed 
to  go  without  treatment.  Hot  air  baths  immedi- 
ately followed  by  manipulation  or  treated  in  a  pen- 
dulum apparatus  will  serve  to  break  up  the  mild 
adhesions.  If  the  joint  becomes  pretty  well  anky- 
losed, briseincnt  force,  is  necessary  and  then  fol- 
lowed by  hot  air,  manipulation,  or  preferably  pen- 
dulum apparatus  treatment. 

There  is  another  complication,  which  I  do  not  see 
much  in  writings  on  the  subject,  but  is  an  uncom- 
fortable one  and  in  some  patients  causes  the  most 
excruciating  pain.  I  refer  to  the  large  callous  places 
that  not  uncommonly  exist  on  the  ball  of  the  foot. 
The  chiropodist  pares  them  down  but,  in  many 
cases,  this  does  not  relieve  much  of  the  pain  and 
tenderness.  No  quick  way  has  yet  been  demon- 
strated to  get  rid  of  this  condition.  When  callosi- 
ties on  the  various  corners  of  the  feet  exist  they 
are  due  to  friction,  and  the  friction  is  due  to  a  badly 
fitting  shoe  or  a  shoe  which  may  be  too  tight  or  too 
loose.  Most  of  the  callosities  disappear  on  the  wear- 
ing of  a  proper  shoe.  But  these  very  tender  callous 
places  across  the  ball  of  the  foot  are  very  persis- 
tent. The  pressure  may  be  relieved  by  cutting  a 
piece  of  gummed  wdiite  felting  to  the  proper  shape 
and  size  and  then  cutting  out  a  hole  just  the  size 
and  shape  of  the  callous  place  and  moistening  the 
gummed  surface  and  sticking  it  on  the  skin  of  the 
foot,  thus  relieving  the  tender  area  from  such  di- 
rect pressure.  Also  I  have  found  it  of  great  value 
to  paint  the  callus  every  night  with  a  mixture  of 
salicylic  acid  in  collodion  in  the  strength  of  4 
grammes  to  30  c.c.  If  this  should  prove  occasionally 
to  be  too  strong  in  the  individual  case  and  causes 
tenderness,  it  may  be  omitted  for  a  week  or  two. 
when  it  may  be  continued  again.  Hence  it  is  seen 
that  the  treatment  of  what  was  formerly  called 
flat  foot,  but  now  in  all  but  the  later  stages,  is 
called  weak  foot,  has  changed  wonderfully  in  the 
last  few  years  and  instead  of  putting  braces  under 
the  feet  and  letting  it  go  at  that,  a  great  deal  is 
now  done  in  the  way  of  rendering  the  joints  more 
flexible,  or  developing  the  tone  and  muscular  and 
ligamentous  strength  1)\  i^hvsical  exercises  and  vi- 
bration, bv  breaking  up  adhesions,  by  hot  air  and 
maninulntion  and  Dendulum  apparatus  treatments 
and  briseincnt  force,  if  necessarv.  hv  regulating  the 


April  lo.  igoy.  I 


MEEKER:  ISTRAABDOMISAL  IXJECTIOX  OE  UXi  GEX 


various  points  about  the  shoes  that  tend  to  more 
correct  mechanical  walking,  by  using  supports  if 
necessary,  but  doing  away  with  them  as  soon  as 
may  be  advisable,  and  in  early  cases  doing  without 
them  anv  way. 

In  closing  it  is  hardly  necessary  to  emphasize  the 
fact  that  the  tendency  in  treatment  to-day.  is  to  re- 
duce artificial  supports  to  the  minimum  and  to  build 
up  the  natural  strength  of  the  feet  in  every  way 
possible  and  to  regulate  the  kind  of  shoes  worn  as 
much  as  possible. 

266  Bexekit  Street. 


THE  IXTRAABDO^nXAL  INJECTION  OF  ONYGEN 
AS  STUDIED  IN  ANIMALS. 
Rc{>ort  of  Cases  in  the  Human  Subject* 
By  Harold  Denman  Meeker,  M.  D., 
New  York, 

Instructor   in   Surgery,   New  York    Polyclinic   Medical   School  ami 
Hospital ;  Assistant  in  Gyn;ecolog>-,  College  of 
Physicians  and  Surgeons. 

Fourteen  months  ago  an  Italian  boy,  eleven  years  old, 
was  admitted  to  the  New  York  Polyclinic  Hospital.  He 
was  pale,  undersized,  very  poorly  nourished,  and  had  a 
markedly  protruding  abdomen. 

Physical  examination  justified  the  diagnosis  of  tuber- 
culous peritonitis  of  the  ascitic  type,  and  operation  was 
decided  upon.  Upon  opening  the  abdomen  the  peritonaeum 
was  found  thickly  sown  with  miliary  tubercles,  mostly  dis- 
crete, although  a  few  small  conglomerate  masses  were  in 
the  omentum,  mesentery,  and  upon  the  intestines.  A  few 
tubercles  were  felt  on  the  surface  of  the  liver.  The  peri- 
tonaeum was  congested  and  coated  with  a  thin  layer  of 
fibrin.  A  large  amount  of  olive  colored  serum  was  found 
free  in  the  peritoneal  cavity ;  no  sacculations  were  discov- 
ered Acting  upon  the  suggestion  of  Dr.  W.  S.  Bain- 
bridge  oxygen  was  injected  into  the  abdominal  cavity  after 
removal  of  the  ascitic  fluid.  The  incised  peritonaeum  was 
sutured,  leaving  an  opening  to  admit  a  small,  blunt,  glass 
lube.  A  purse  string  loop  held  the  tube  firmly  while 
warmed  oxygen  was  passed  through  it.  The  abdomen  was 
distended  until  the  wall  was  moderately  tense,  the  tub',' 
withdrawn,  and  the  wound  closed. 

The  anaesthetic  was  administered  by  an  expert.  Dr.  James 
T.  Gwathmey.  but  the  child  took  it  badly  from  the  start. 
Cyanosis  was  marked,  respirations  feeble,  the  pulse  rang- 
ing from  120  to  140.  Upon  the  introduction  of  oxygen  the 
cyanosis  was  replaced  by  a  healthy  pink  blush,  the  pulse 
quickh'  dropped  to  100,  and  the  patient  came  out  from 
under  the  influence  of  the  anaesthetic  almost  immediatelx'. 
Subsequent  nausea  and  pain  were  not  of  sufficient  moment 
to  demand  any  special  consideration.  The  bowels  moved 
spontaneously  on  the  second  day.  The  abdominal  girth 
became  progressively  smaller,  and  the  distended  veins  in 
the  abdominal  wall  less  conspicuous.  On  the  fifth  day  the 
abdomen  became  flat.  Pulse  and  temperature  were  normal 
from  the  first  day. 

The  mode  in  which  lap-irotomy  has  benefited  this 
type  of  tuberculous  peritonitis  has  been  attributed  to 
the  relief  of  tension,  the  admission  of  air  and  of 
light,  and  to  the  removal  of  the  exudation  with  its 
toxines.  Japanese  surgeons  have  made  use  of  direct 
sunrays.  It  has  been  abundantlv  proved  that  the 
removal  of  the  fluid  by  aspiration  is  not  sufficient, 
but  that  an  actual  incision  is  required. 

Other  cases  of  tuberculous  peritonitis  had  been 
operated  on  in  the  same  amphitheatre  by  simple  in- 
cision and  evacuation  of  the  fluid,  with  more  or  less 
permanent  benefit,  but  the  contrast  between  the  im- 
mediate results  in  cases  thus  treated  and  the  one  in 

*Read  before  the  Alumni  Society  of  the  City  (Charity)  Hospital. 
December  8,  1908. 


wh:ch  oxygen  was  used  was  so  marked  as  to  war- 
rant the  "inferencj  that  the  oxygen  was  probably 
the  active  agent. 

The  behavior  of  the  case  just  outlined,  together 
witli  others  previously  operated  in  by  Dr.  W.  S. 
Bainbridge,  led  to  the  conviction  that  the  intraab- 
dominal introduction  of  oxygen  was  entitled  to  a 
place  in  surgical  therapy.  In  order  to  determine  the 
value  of  the  procedure  and  establish  it  on  a  scientific 
basis,  a  series  of  animal  experiments  was  planned. 
The  object  of  the  experiments  was  to  stud>-  the 
beneficial  possibilities  of  oxygen  when  introduced 
into  the  abdominal  cavity  and  also  to  become  ac- 
quainted with  its  possible  dangers. 

Exi'i:kimexts  on  Axim.\ls. 

The  work  was  done  in  the  Physiological  Labcra- 
torv  of  the  College  of  Physicians  and  Surgeons, 
New  York,  through  the  courtesy  of  Professor  John 
G.  Curtis.  Credit  for  valuable  assistance  is  due  to 
Dr.  James  T.  Gwathmey,  who  anaesthetized  the  ani- 
mals. While  realizing  full  well  with  what  difficulty 
a  cat's  peritonaeum  is  infected,  nevertheless  all  oper- 
ations were  rendered  as  aseptic  as  possible. 

The  first  series  was  conducted  to  determine  the 
absorbability  of  oxygen  when  injected  into  the  ab- 
dominal cavity  of  the  cat.  The  following  technique 
was  employed:  A  cat  was  anaesthetized,  the  abdo- 
men shaved,  and  an  incision  made  down  to  the  peri- 
ton?eum.  A  small  cannula  was  introduced  through 
this  tissue  at  a  sharp  angle  whi.e  the  peritonaeum  was 
lifted  away  from  the  intestines.  The  cannula  was 
secured  bv  a  pursestring  suture  of  silk.  The  ar- 
rangement of  apparatus  made  it  possible  to  deter- 
mine the  ani"uiit.  temperature,  and  pressure  of  the 


I'ic.    1. —  S..c\M;.g    li.xygen    lank,    rubber   bag    14'".-   l.   c.    ca.  acity), 
thermometer  in  glass  Tube,  water  manomettr,  and  cannu'.i. 


oxygen  used.  The  gas  was  introduced  at  a  temper- 
ature of  38°  C  in  some  cases,  and  40°  C  ( 104°  F) 
in  others. 

Several  animals  were  distended  with  200  c.  c.  of 
oxygen  at  60  mm.  water  pressure  and  others  w'ith 
400  c.  c.  at  200  mm.  water  pressure.  After  with- 
drawal of  the  cannula  and  closure  of  the  wound  the 
cat  was  immersed  in  a  jar  of  water  to  determine 
possible  leakage.  The  animals  were  observed  at 
frequent  intervals  and  reduction  in  the  size  of  the 
abdomen  noted.  When  the  abdominal  girth  ap- 
proximated the  normal,  the  cat  was  again  anses- 


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LNew  York 
Medical  Jouknm.. 


Fir;.  2 — Introduction  of  oxygen  recorded  at  a  point  one  inch  from  left  margin;  upper  line  records  respiration;  the  middle  tracing, 
pulse  and  blood  pressure.  Figure  shows  slight  increase  in  pulse  and  respiration  and  slight  rise  of  blood  pressure  on  introduction  ot 
oxygen. 


thetized,  the  abdomen  punctured  under  water,  and 
any  gas  bubbles  expressed  were  collected  and 
measured.  No  chemical  test  of  the  gas  thus  col- 
lected was  made.  The  summary  of  this  series  was 
as  follows : 

1.  Oxygen  was  completelv  absorbed  in  all  cases 
left  undisturbed  seyenty-two  hours.  In  six:  cases  no 
trace  of  the  gas  could  be  found  after  twenty-four 
hours,  and  in  "two  cases,  none  after  eighteen  hours. 

2.  The  increased  -intraabdominal  pressure  had 
but  little  influence  in  hastening  the  process  of  ab- 
sorption. 

The  second  series  of  experiments  was  performed 
to  note  the  efifect  of  the  intraalxlominal  injection  of 
oxygen  on  blood  pressure,  pulse,  respiratioji.  its  in- 
fluence on  ihc  degree  of  onastJiesia,  and  the  time  of 


recovery  after  the  anaesthetic  had  been  discon- 
tinued. A  cat  was  anaesthetised,  a  carotid  artery 
exposed  and  connected  in  the  usual  manner,  with  a 
mercurial  manometer  and  kymograph.  The  oxygen 
was  introduced  into  the  abdomen  in  accordance  with 
the  technique  previously  described.  The  following 
observations  were  made: 

I.  A  slight  increase  in  the  pulse  rate.  This  was 
probably  due  to  a  certain  amount  of  the  oxygen 
reaching  the  heart  and  stimulating  that  process, 
which  causes  contraction  of  the  heart  muscle.  This 
theory  is  borne  out  by  the  studies  of  Oehrwall,  who 
found  that  a  volume  of  blood  sufificient  to  fill  a  frog's 
ventricle  would  maintain  contractions  for  hours, 
provided  the  heart  was  surrounded  by  an  atmos- 
j)here  of  oxygen.    .\  heart  brought  to  a  standstill 


Fig.  .3.- 


-Shows  regular  pulse  and  respiration  and  gradual   fall  in  lilood  pressure;   tracing  taken   three  minuto- 

oxygen  had  commenced. 


after   introduction  of 


April  lo,  1909.1 


MEEKER:  INTRAABDOMINAL  IXIECTIOX  OF  OXVGEX. 


743 


bv  a  lack  of  oxygen  could  be  made  to  beat  again 
after  an  arrest  of  twenty  minutes,  by  giving  it  a 
fresh  supply. 

2.  A  slight  increase  in  respiration.  This  was 
probably  due  to  a  stimulation  of  the  respiratory 
center,  dependent  upon  an  increased  production  of 
carbon  dioxide,  in  turn  a  result  of  more  active  oxi- 
dation. 

3.  There  was  a  slight  rise  in  blood  pressure, 
which  returned  to  normal  in  two  or  three  minutes. 
The  rise  Uvas  probably  due  to  pressure  on  the 
splanchnic  vessels,  thus  assisting  the  venous  flow  to 
the  right  ,heart,  while  obstructing  the  arterial  flow. 
The  return  to  normal  was  probably  due  to  a  com- 
pensatory dilatation  of  other  vessels  and  to  dimm- 
ished  diaphragmatic  excursions  which  would  cause 
a  lessened  amount  of  blood  to  flow  from  right  to  left 
heart  through  less  distended  lung  tissue. 

4.  In  all  cases  the  immediate  effect  upon  the  de- 
gree of  anaesthesia  was  marke;!,  tne  animal  showing  a 
tendency  to  come  out  from  under  the  influence  of 
the  anaesthestic  almost  immediately.  In  cases  where 
the  anaesthesia  was  profound,  reflexes  quickly  be- 
came active. 

5.  Animals  in  which  the  oxygen  had  been  intro- 
duced were  able  to  stand  up  in  from  two  to  ten 
minutes  after  the  discontinuance  of  the  anaesthetic. 

6.  All  reactions  were  more  prompt  when  tlie 
heated  oxygen  was  employed. 

In  the  third  series  of  experiments  a  number  of 
cats  were  distended  with  air,  the  same  technique, 
quantity,  pressure,  and  temperature  of  gas  being  used 
as  in  the  oxygen  e.xperiment.  The  object  of  this 
series  was  to  effect  a  contrast  with  the  previous  ex- 
periment.-;. The  effect  on  the  pulse  and  respiratory 
rate  was  even  less  marked,  the  blood  pressure 
showed  essentially  the  same  phenomena  as  previ- 
ously described.  The  influence  of  the  introduction 
of  air  upon  the  degree  of  anaesthesia  was  practically 
nil.  The  time  required  for  recovery  after  the  anaes- 
thetic had  been  stopped  was  from  fifteen  to  twenty- 
five  minutes. 

In  the  fourth  series  of  experiments,  several  ani- 
mals Avere  distended  with  oxygen  under  high  pres- 
sure to  determine  the  danger  point  of  intraabdom- 
inal pressure  as  manifested  by  a  fall  in  blood  pres- 
sure, respiratory  embarrassment,  and  cardiac  fail- 
ure. The  gas  was  introduced  in  the  same  manner 
as  in  the  previous  experiments,  but  the  pressure 
measured  by  a  mercurial  manometer. 

The  pressure  was  raised  to  the  equivalent  of  1800 
to  3000  mm.  of  water,  in  all  cases  the  abdomen  was 
exceedingly  tense  so  that  it  was  scarcely  possible  to 
make  any  indentation  with  the  finger  tip.  It  was  ob- 
seived  that  the  blood  pressure  rose  steadily  until 
the  intraabdominal  pressure  reached  a  point  varying 
between  1800  to  3000  mm.  of  water  when  it  sud- 
deniy  dropped.  The  heart  action  became  more 
rapid  and  less  regular  and  respiratory  embarrass- 
ment progressive  up  to  this  point,  when  respiratory 
embarrassment  primarily,  and  cardiac  failure  sec- 
ondarily, caused  death  in  a  short  time.  Autopsies 
revealed  no  microscopic  damage  to  the  viscera.  The 
effect  on  the  animal  of  the  high  intraabdominal  pres- 
sure demonstrated  that  the  danger  from  the  me- 
chanical pressure  of  the  gas  in  the  human  subject 


may  be  practically  disregarded.  There  was  but  a 
slight  rise  in  blood  pressure  and  no  marked  respira- 
tory or  cardiac  disturbance,  until  the  pressure  be- 
came extreme  i.  e.  reached  a  degree  far  in  excess 
of  that  to  which  any  human  abdomen  would  be  apt 
to  be  subjected  either  bv  accident  or  intent.  In  any 
case  the  respirator}  embarrassment  would  give 
warning  of  a  danger  point  approach. 

The  tifth  series  was  performed  to  determine  the 
eft"ect  of  the  intraabdominal  introduction  of  oxygen 
on  the  formatiun  of  adhesions. 

Abdominal  section  was  performed  on  a  number 
of  cats.  In  .some  the  parietal  and  visceral  perito- 
naeum was  scarified,  the  abdomen  moderately  dis- 
tended with  200  tc  300  c.  c.  of  oxygen,  according 
to  the  size  of  the  animal,  and  the  wound  closed.  In 
six  animals  air  was  used  instead  of  oxygen.  In 
others  the  same  operative  procedure  was  performed 
but  no  gas  introduced  into  the  abdomen.  In  still 
other  animals,  in  order  to  make  the  approximation 
of  the  scarified  surfaces  a  certainty^  a  portion  of 
small  intestine  three  inches  long  was  anchored  to 
the  transverse  colon  by  two  silk  sutures.  The  ap- 
proximated surfaces  between  the  sutures  were  gen- 
erously scarified,  the  abdominal  cavity  distended 
with  oxygen  in  one  series,  with  air  in  another,  and 
the  wound  closed.  This  procedure  was  repeated  on 
other  animals  and  the  wound  closed  but  without  the 
introduction  of  oxygen  or  air.  The  animals  used  in 
this  series  were  left  for  two,  four  and  seven  days 
respectively.  The  contrast  observed  on  autopsy  be- 
tween the  cats  in  which  oxygen  had  been  used  and 
those  in  which  no  gas  had  been  injected,  was  strik- 
ing. 

Of  the  twelve  cats  treated  with  o.xygen,  two  had 
a  few  cobweb  adfiiesions  close  to  the  anchoring  su- 
tures, one  had  a  few  fine  adhesions  between  appro.xi- 
mated  intestines  :  all  other  cats  were  free  from  ad- 
hesions of  any  sort.  Adhesion  formation  was  slight 
in  the  air  cases,  yet  decidedly  more  marked  than  in 
the  o.xygen  cases.  In  every  instance,  however,  when 
no  gas  was  employed,  abundant  adhesions  were 
found,  both  intervisceral  and  parietovisceral.  The 
difference  between  the  adhesions  found  in  the  ani- 
mals at  autopsy  on  the  fourth  and  those  at  autopsy 
on  the  seventh  day  was  one  of  density  rather  than 
of  number.  The  explanation  of  these  results  would 
seem  to  be  that : 

1.  Both  the  air  and  oxygen  mechanically  held 
the  scarified  surfaces  apart  until  new  cells  had  been 
produced. 

2.  The  oxygen  increased  the  activity  of  the  in- 
dividtial  cells,  thus  hastening  a  new  growth  of  epi- 
thelium to  replace  the  destroyed  peritoneal  cells  and 
thtis  cover  over  the  denuded  areas. 

3.  The  increased  intestinal  peristalsis  caused  bv 
the  oxAgen  was  tinfavorable  to  the  production  of 
adhesions. 

In  addition  to  the  observations  already  recorded, 
a  striking  change  in  the  color  of  the  blood  was 
noticed  upon  the  introductions  of  oxygen  into  the 
abdominal  cavity  of  cats  who  were  intentionallv 
put  into  a  condition  of  partial  asphyxia.  The  dark 
blood  quicklv  changed  to  scarlet.  It  was  also  ob- 
served that  the  intestinal  peristalsis  was  somewhat 
increased  by  an  atmosphere  of  oxygen.   In  no  case 


744 


MEEKER:  INTRAABDOMINAL  INJECTION  OF  OXYGEN. 


[New  York 
Medical  Journal. 


was  there  macroscopic  evidence  that  oxygen  was 
an  irritant  to  the  peritonaeum  or  any  of  the  abdom- 
inal viscera. 

A  study  of  these  experiments  on  the  intraabdom- 
inal introduction  of  oxygen  in  animals  permits  of 
the  following  conclusions : 

1.  Oxygen  is  completely  absorbed  from  within 
the  abdominal  cavity. 

2.  Oxygen  is  a  slight  respiratory  stimulant. 

3.  Oxygen  is  a  slight  cardiac  stimulant. 

4.  Oxygen  has  but  little  effect  on  blood  pressure 
when  the  pressure  of  the  gas  is  moderate. 

5.  Oxygen  tends  to  bring  an  animal  out  quickly 
from  deep  anaesthesia. 

6.  Oxygen  hastens  the  recovery  of  an  animal 
after  discontinuance  of  anaesthetic. 

7.  A  pressure  of  more  than  1800  mm.  of  water 
may  cause  collapse. 

8.  Oxygen  tends  to  prevent  the  formation  of 
adhesions.  It  does  so  more  efifectively  than  any 
inert  gas. 

9.  Oxygen  quickly  changes  a  dark  blood  to  scar- 
let in  cases  of  anoxaemia. 

10.  Oxygen  stimulates  intestinal  peristalsis. 

11.  Oxygen  is  not  an  irritant  to  the  peritonaeum 
or  abdominal  viscera. 

It  is  chiefly  to  the  active  properties  of  oxygen  that 
we  must  look  for  therapeutic  possibilities.  The  or- 
ganism may  be  regarded  as  an  aggregation  of  living 
cells,  each  of  which  during  life  consumes  oxygen 
and  gives  off  carbon  dioxide.  Activity  depends  es- 
sentially upon  oxidation,  consequently,  not  only  is 
oxidation  necessary  for  existence,  but  the  quantity 
of  oxygen  absorbed  must  bear  a  direct  relation  to 
the  degree  of  activity.'  Quinquaud^  has  demonstrated 
that  not  only  is  oxygen  absorbed  by  all  living  body 
tissue,  but  that  the  avidity  of  different  tissues  for 
oxygen  varies  greatly,  the  differences  doubtless 
being  expressive  of  the  relative  intensities  of  their 
respiratory  processes.  His  experiments  consisted 
of  exposing  one  hundred  grammes  of  tissue  for  three 
hours  in  an  atmosphere  of  oxygen  at  a  temperature 
of  38°  C.  The  quantity  of  carbon  dioxide  formed 
was  approximately  proportional  to  the  amount  of 
oxygen  absorbed. 

The  accuracy  of  these  observations  has  been  con- 
firmed by  others.  Inasmuch  as  oxygen  has  been 
proved  to  increase  cell  activity  in  all  body  tissues, 
is  it  not  reasonable  to  assume  that,  in  certain  abnor- 
mal conditions  this  fact  might  be  utilized  for  the 
benefit  of  the  individual?  The  mechanical  advan- 
tages of  the  intraabdominal  introduction  of  oxygen 
are  also  important.  The  bactericidal  properties  of 
oxygen  when  thus  emplo\ed  offer  an  alluring  field 
for  investigation,  this  phase  of  the  subject  has  been 
deferred  for  future  study. 

METHOD  OF  ADMI XISTR.-VTION   IN  THE  IIUM.\N 
SUBJECT. 

The  so  called  pure,  or  ninety-five  per  cent.,  oxy- 
gen should  be  used.  The  ox\  gen  is  warmed  to  a  tem- 
perature of  about  100°  F.  by  passing  it  from  the 
tank  in  which  it  is  compressed,  tlirougli  a  bottle  con- 
taining hot  water  and  then  through  a  tube,  prefer- 
ably of  metal,  which  is  submerged  in  hot  water.  The 
gas  enters  the  abdominal  cavity  through  a  rubber  or 

'Complcs  rcndus  de  la  SociHi-  de  biologie,  1890,  No,  9. 


blunt  glass  tube.  The  abdominal  wound  is  closed 
except  at  the  upper  or  lower  end,  where  the  tube 
is  left  partly  in  the  abdominal  cavity.  Interrupted 
stitches  are  placed  in  the  peritonjeum  at  this  point, 
but  not  tied,  and  a  pursestring  loop  is  passed  in  the 
peritonaeum  around  the  tube. 

The  other  layers  of  the  abdominal  wall  are  sutured 
in  the  usual  manner  excepting  those  around  the 
tube.  After  sufficient  oxygen  has  been  passed  into 
the  abdomen,  the  tube  is  withdrawn,  the  peritoneal 
stitches  quickly  tied,  and  the  succeeding  layers  su- 
tured. A  practical  rule  in  determining  the  proper 
amount  of  oxygen  to  be  used,  is  to  distend  the  abdo- 
men until  liver  dullness  is  obliterated,  having  previ- 
ously ascertained  that  the  liver  is  not  adherent  to 
the  abdominal  wall. 

A  few  cases  are  herewith  reported. 

Case  I. — M-s.  L.,  age  forty-three,  had  observed  a  rapidly 
growing  mass  in  her  abdomen  for  eight  months,  but  dread- 
ing an  operation  had  not  previously  sought  relief.  Ab- 
dominal palpation  revealed  a  rounded,  nonsensitive  tumor 
of  varying  density,  extending  an  inch  above  the  umbilicus. 
On  pelvic  examination  a  second  similar  mass  was  felt 
underlying  the  first.  There  was  considerable  fluid  in  the 
abdomen.  Operation  was  performed  at  the  New  York 
Polyclinic  Hospital  on  July  1st.  The  diagnosis  of  cystic 
carcinoma  of  the  ovaries  was  confirmed  by  the  report  of 
Dr.  F.  M.  Jeffries,  pathologist  to  the  hospital.  The  tumors 
were  removed  with  difficulty  on  account  of  the  many  dense 
adhesions  uniting  the  masses  to  intestines  and  to  parietal 
peritonaeum.  The  exceedingh-  friable  nature  of  the  tissue 
caused  troublesome  haemorrhage.  The  uterus  and  all  pal- 
pable pelvic  glands  were  also  removed.  The  patient,  who 
was  in  bad  condition  at  the  start,  was  in  a  state  of  pro- 
found shock  toward  the  end  of  the  operation.  The  abdo- 
men was  closed  with  all  possible  haste  after  warm  oxygen 
had  been  introduced.  The  effect  of  the  procedure  was 
striking.  The  pulse  became  stronger  and  less  rapid,  respir- 
ations deeper,  the  body  surface  became  warmer,  and  the 
ashy  pallor  disappeared.  There  was  but  a  moderate  amount 
of  postoperative  discomfort.  Recovery  was  uneventful. 
The  numerous  raw  surfaces  of  necessity  left  uncovered 
by  peritonaeum,  certainly  invited  abundant  adhesion  forma- 
tion. The  patient  has  been  kept  under  observation  and  as 
yet  has  given  no  symptoms  that  might  be  ascribed  to  the 
production  of  adhesions. 

Case  II. — Mrs.  E.  T.  referred  from  Connecticut  operated 
on  July  22,  1908.  The  pathological  condition  consisted  of 
a  right  tuboovarian  abscess  with  appendix  entangled  in  the 
mass,  left  hydrosalpynx  and  retroverted  uterus.  Abundant 
and  firm  adhesions  anchored  the  pelvic  organs  in  their 
abnormal  positions.  Operation :  Curettage,  appendectomy, 
right  salpingooophorectomy,  left  tube  resection,  freeing  ad- 
hesions and  a  Gilliam  operation.  In  spite  of  great  care 
about  a  drachm  of  pus  was  spilled  from  the  abscess  sac 
into  the  peritoneal  cavity.  This  was  gently  sponged,  warm 
oygen  introduced,  and  the  wound  closed  without  drainage. 
The  patient  had  taken  the  anaesthetic  badly,  and  was  in  a 
rather  alarming  state  of  shock  toward  the  close  of  the 
operation.  The  condition,  however,  was  largely  overcome 
by  the  introduction  of  the  oxygen.  One  hypodermic  in- 
jection of  morphine  was  given  to  control  restlessness.  Pain 
was  insignificant  bowels  moved  spontaneously  on  the  sec- 
ond day.    Recovery  was  uneventful. 

Case  III. — Mrs.  M.  J.,  age  thirty-three,  operated  upon  at 
the  New  York  Polyclinic  Hospital  June  27,  1908,  for  uter- 
ine filjroids.  Operation  :  Hysterectomy  and  appendectomy. 
Appendix  was  adherent  to  tiie  tumor.  Shock  was  at  no 
time  extreme  but  improvement  in  the  general  condition  was 
noticed  on  introduction  of  o.xygen ;  pulse  and  respirations 
stronger  and  blood  a  better  color.  Subsequent  pain  and 
nausea  were  less  than  usually  expected  after  such  an  oper- 
ation.   Recovery  was  uneventful. 

Case  IV. — Mrs.  E.  \V.  N.,  age  twenty-five,  operated 
upon  at  Rebeau  Sanatorium,  July  15,  1908.  Diagnosis, 
tuberculous  peritonitis,  ascitic  tyi)c.  Operation  :  Laparotomy, 
removal  of  fluid,  appendectomy,  right  salpingectomy  and  a 
Gilliam  operation.  Warm  oxygen  was  introduced  into  the 
al)dominal  cavity  and  the  wound  closed.    Many  tubercles 


April  10,  1909.] 


BENJAMIN:  DILATATION  AND  PROLAPSE  OF  STOMACH. 


745 


in  peritonaeum  of  right  tube  and  small  intestine.  Appendix 
adherent  to  the  right  tube,  contained  no  tubercles.  Recov- 
ery uneventful.  Up  to  date  there  has  been  no  reaccumula- 
tion  of  fluid,  no  recurrence  of  pain,  rise  of  temperature  or 
rapid  pulse.  Patient  feels  well,  has  gained  steadily  in 
weight. 

Case  V. — ^Irs.  K.,  operated  upon  at  St.  Elizabeth  Hos- 
pital, December  15,.  1908,  with  Dr.  A.  M.  Newman.  Patient 
had  been  ill  for  some  time,  and  was  in  poor  general  condi- 
tion. Pathological  condition,  left  pyosalpinx,  right  abscess 
sac  in  which  appendix,  small  intestine,  and  right  tube  and 
ovary  were  involved.  A  dense  mass  of  adhesions  in  the 
pelvis  and  lower  abdomen  were  firmly  fixed  to  adjacent 
organs.  About  eight  inches  from  the  ileocaecal  valve  was 
a  perforation  into  the  small  intestine  one  quarter  inch  in 
diameter,  communicating  with  abscess  sac.  Operation  :  Free- 
ing adhesions,  double  salpingectom}-,  right  oophorectomy, 
appendectomy,  resection  three  inches  of  small  gut.  Con- 
siderable pus  was  spilled  unavoidably  in  removing  abscess 
sac.  Patient  was  in  state  of  alarming  shock.  Abdominal 
ca\ity  was  distended  with  warm  oxygen  and  closed  with 
all  possible  haste.  Effect  of  oxygen  was  striking,  pulse 
improved,  respirations  became  deeper,  body  surface  became 
warm.  Condition  remained  good  for  forty-eight  hours, 
when  the  pulse  became  rapid  and  patient  became  weaker. 
Hot  saline  by  rectum  brought  a  quick  response,  and  re- 
covery was  uninterrupted. 

The  tendency  to  collapse  after  the  oxygen  has 
been  absorbed,  has  been  observed  in  a  number  of  pa- 
tients and  should  be  guarded  against.  This  may  oc- 
cur any  time  after  twenty-four  hours.  It  has  been 
seen  only  in  cases  in  which  the  condition  had  been 
extremely  bad.  The  writer  has  used  the  oxygen 
intraabdominally  in  several  other  cases,  no  harmful 
effect  has  yet  been  seen,  many  beneficial  results 
have  been  observed. 

A  study  of  the  animal  experiments  and  the  results 
witnessed  in  the  human  subject  would  seem  to 
justify  the  assumption  that  the  intraabdominal  use 
of  oxygen  is  entitled  to  a  place  in  surgical  therapy . 

166  West  Seventy-second  Street. 


CHRONIC  DILATATION  AND  PROLAPSE  OF  THE 
STOMACH.* 

By  a.  E.  Benjamin,  M.  D., 
Minneapolis. 

The  disease,  known  as  dilatation  of  the  stomach, 
is  now  engaging  the  attention  of  the  medical  and 
surgical  world.  The  association  and  relative  impor- 
tance of  stomach  prolapse  is  also  being  recognized. 
Recent  investigations  have  demonstrated  that  re- 
ported deaths  due  to  heart  failure,  gastralgia,  acute 
indigestion,  etc..  may  have  been  due  in  some  in- 
stances to  acute  dilatation  of  the  stomach. 

The  various  terms  applied  to  acute  dilatation  of 
the  stomach,  such  as  gastromesenteric  ileus,  post- 
operative gastric  paralysis,  etc.,  indicate  that  the 
patholog>%  aetiology,  and  modus  operandi  of  this 
form  of  dilatation  are  not  generally  or  thoroughly 
understood. 

From  personal  observations,  investigations  and 
study  of  the  subject  of  acute  dilatation  of  the  stom- 
ach the  writer  has  come  to  the  conclusion  that  there 
are  preexisting  conditions  to  be  reckoned  with  in 
tracing  out  the  true  causes  of  this  disease.  Impor- 
tant among  these  conditions  are  chronic  dilatation 
and  prolapse  of  the  stomach.    Judging  from  their 

*Read  before  the  Western  Surgical  and  Gynaecological  Association, 
held  at  Minneapolis,  December  29  and  30,  1907. 


writings  Kussmaul,  x\lbrecht,  and  others  are  also  of 
this  opinion. 

The  necessity  of  determining  the  existence  of  a 
chronic  prolapse  or  dilatation  or  both,  in  a  case  to 
be  operated  on,  should  be  apparent.  Where  both 
exist,  as  is  frequently  the  case,  it  is  often  impos- 
sible to  say  which  is  primary  and  which  is  second- 
ary. 

Cause. — In  many  instances  the  primary  cause  of 
chronic  dilatation  and  prolapse  are  the  same.  In 
some  cases  there  is  a  prolapse  followed  by  a  dilata- 
tion of  the  organs  due  to  kinking  at  the  pylorus,  or 
there  may  be  a  dilatation  due  to  frequent  overload- 
ing of  the  stomach  with  bulky  and  heavy  foods 
which  weigh  the  organ  down,  especially  in  standing, 
causing  a  stretching  of  the  gastrohepatic  ligament. 

Gastroptosis  itself  renders  difficult  and  delays  the 
expulsion  of  food,  hence  dilatation.  Gastroptosis  is 
often  present  without  dilatation  ;  especially  is  this  no- 
ticed in  some  yoimg  women  who  have  "laced."  It 
is  also  occasionally  noticeable  following  childbirth 
or  after  the  removal  of  any  large  abdominal  or  pel- 
vic growth,  owing  to  the  lack  of  abdominal  muscle 
support. 

The  cause  may  even  begin  in  childhood  where 
great  quantities  of  bulky  fermentable  food  and 
drink  are  habitually  allowed  children.  The  "pot 
belly"  is  often  seen  in  such  individuals,  especially  in 
anaemic  children  with  weak  abdominal  muscles.  A 
fermentation  of  food  with  gaseous  distention  of 
the  stomach  soon  leads  to  chronic  motor  insuffi- 
ciency and  atonic  dilatation  of  the  stomach,  espe- 
cially if  there  is  not  a  compensatory  muscle  hyper- 
trophy. 

Deficient  peristalsis  allows  a  stagnation  of  the 
food  which  may  remain  in  the  stomach  many  hours 
too  long  for  want  of  explusive  force.  The  pres- 
ence of  undigested  particles  of  food  results  in  de- 
composition, inflammation,  or  catarrh  of  the  stom- 
ach, which  produces  such  an  unhealthy  condition  of 
the  stomach  wall  that  may  lead  to  the  development, 
in  many  instances,  of  ulcers  or  even  cancer. 

The  diseased  state  of  the  stomach  may  be  a  de- 
generation of  the  muscle  fibre,  paresis  of  the  gastric 
nerves,  or  actual  organic  disease  of  the  muscles. 
At  any  rate  motor  insufficiency  is  more  marked  in 
the  diseased  state  and  necessarily  aggravates  all 
symptoms. 

A  chronic  dilatation  may  arise  from  obstruction 
at  the  pylorus  or  along  the  duodenum,  a  partial 
stenosis  from  healed  pyloric  ulcers,  constricting 
bands  of  adhesions  from  a  local  peritonitis,  gall- 
stones and  perigastric  inflammation. 

That  a  floating  right  kidney  can  and  does  pro- 
duce obstruction  in  some  cases  of  the  duodenum 
cannot  be  denied.  Bartels,  Bettman,  Litten,  Ewald. 
and  others  believe  this.  A  prolapsed  liver  may 
drag  the  stomach  down  or  a  heavy  transverse  colon 
as  noted  in  the  anatomical  type  of  Pancoast.  The 
mesenteric  vessels  may  constrict  the  duodenum,  re- 
sulting in  a  dilatation  of  its  proximal  portion  and 
secondarily  of  the  stomach. 

Kussmaul  called  attention  to  the  possibility  of  a 
chronically  dilated  stomach  passing  downward  and  a 
kinking  of  the  duodenum  at  the  point  where  the 
slightly  fixed  horizontal  part  joins  the  firmlv  fixed 
vertical  part.  The  injection  of  a  great  quantitv  of 


746 


BENJAMIN:  DILATATION  AND  PROLAPSE  OF  STOMACH. 


[New  York 
Medical  Journal. 


fluid  into  the  stomach  caused  kinking  of  this  point 
followed  by  great  dilatation  of  the  stomach  and  of 
the  duodenum  above  this  obstruction.  Albrecht 
thought  an  acute  dilatation  of  the  stomach  might  be 
engrafted  on  a  chronically  dilated  stomach  that 
suddenly  lacked  sufficient  muscle  tone  to  overcome 
the  obstruction  and  that  the  dilated  caecum  and 
ascending  colon  occasionally  found,  are  due  to 
kinks  made  by  the  dilated  stomach  pushing  down 
the  transverse  colon.  Kelling  says  there  must  be  a 
primar}'  overdistention  of  the  stomach  which  com- 
presses the  small  intestine  into  the  pelvis  and  calls 
the  condition  '"combination  ileus." 

Ptosis  of  the  abdominal  viscera  with  relaxation 
of  the  belly  walls  has  been  considered  a  causative 
factor  by  many  (Genard,  Robinson,  and  others). 
They  think  that  the  low  position  of  the  stomach 
favors  dilatation  and  a  pyloric  kinking,  and  the  re- 
laxed belly  walls  cause  a  prolapse  of  the  intestine 
into  the  true  pelvis  with  kinking  of  the  duodenum 
or  mesenteric  compression. 

Symptoms: — The  symptoms  of  chronic  dilatation 
or  prolapse  of  the  stomach  are  varied  according  to 
the  kind  or  degree  of  prolapse,  whether  dilatation  is 
also  present  or  not  or  obstruction  is  associated.  In 
mild  cases  symptoms  of  atonic  dyspepsia  are  no- 
ticed. 

A  fullness  and  uneasiness  two  or  more  hours  after 
meals  occurs,  not  commensurate  with  the  amount  of 
food  taken.  Hyperchlorhydria  is  noticed  and  a  sore- 
ness experienced  in  the  gastric  region,  when  the 
stomach  is  empty.  Hydrochloric  acid  may  be  ab- 
sent, diminished,  normal,  or  in  excess,  depending 
upon  the  cause  and  variety  of  the  dilatation,  or  pro- 
lapse. The  fermentation  produces  lactic  and  butyric 
and  possibly  acetic  acid,  and  various  gases.  Con- 
stipation, scanty  urine,  and  extreme  dryness  of  the 
skin  are  often  noticed.  The  patients  are  usually 
thin,  spare,  and  tall. 

Flatulency  and  eructation  of  gas  occurs.  Palpi- 
tation of  the  heart  owing  to  gaseous  pressure  is  of- 
ten experienced.  Reflex  nervous  disorders,  such  as 
hysteria,  neurasthenia,  melancholia,  etc.,  are  fre- 
quently observed.  The  constipation  may  later  be- 
come aggravated  owing  to  the  greater  prolapse  of 
the  stomach  and  the  consequent  kinking  of  the  hep- 
atic or  splenic  flexure  or  sagging  of  the  colon. 

Occasionally  symptoms  of  a  crisis  or  acute  dis- 
tension may  occur  with  cramp  like  pains,  owing  to 
the  muscular  contraction  of  the  stomach  endeavor- 
ing to  force  the  contents  onward  by  a  kink  or  ob- 
struction. The  symptoms  at  times  are  quite  alarm- 
ing and  can  be  mistaken  for  appendicitis,  peri- 
tonitis, cholelithiasis,  pancreatitis,  Dietl's  crisis,  etc. 

The  acute  symptoms  usually  subside  after  the 
obstruction  is  relieved  and  the  gas  finds  its  way 
along  the  intestinal  channel,  but  they  leave  the  pa- 
tient quite  weak.  These  attacks  may  come  on  ir- 
regularly. 

When  there  is  a  partial  obstruction  at  the  pylorus 
or  along  the  duodenum  distension  becomes  very 
marked  and  prolapse  quite  apparent.  The  patient 
becomes  weaker :  vomiting,  faintness,  and  emacia- 
tion quite  pronounced. 

I  have  observed  a  number  of  cases  in  which  post- 
operative vomiting,  constipation,  gaseous  disten- 


tion, and  distress  have  been  quite  marked,  owing  to 
an  aggravated  chronic  dilatation  or  prolapse. 

Diagnosis. — The  diagnosis  of  chronic  dilatation 
or  prolapse  of  the  stomach  at  the  present  time  can 
be  readily  made  out  by  various  known  methods. 
When  the  greater ,  curvature  is  found  to  have 
altered  its  level  as  on  a  line  with  the  navel  or  below 
it,  dilatation  of  the  stomach  may  generally  be 
assumed  to  exist.  Pacanowski  has  shown  that  the 
greatest  vertical  diameter  of  gastric  resonance  in 
the  normal  stomach  varies  from  ten  to  fourteen 
centimetres  in  the  male  and  is  about  ten  centimetres 
in  the  female.  Dilatation  with  gas  or  air  followed 
by  percussion  should  be  used,  but  the  giving  of 
bismuth  and  the  subsequent  taking  of  an  x  ray 
photograph  is  more  exact.  In  some  cases  the  abdo- 
men is  large  and  prominent  below  the  navel.  The 
outline  can  in  some  cases  be  plainly  seen  with  the 
small  curvature  below  the  ensiform  cartilage.  Ac- 
tual peristaltic  waves  may  be  seen  passing  from  left 
to  right,  where  there  is  much  obstruction  of  the 
pylorus,  in  individuals  with  thin  abdominal  walls. 
A  careful  history  of  the  case  will  reveal  much,  as 
symptoms  of  indigestion  extending  over  a  number 
of  years  and  other  symptoms  mentioned  before. 
Many  of  the  individuals  suffering  with  this  com- 
plaint are  hard  working  farmers'  wives  with  thin, 
relaxed,  abdominal  muscles  and  a  general  viscerop- 
tosis. 

Palpation  may  elicit  a  splashing  sound  which  can 
be  obtained  whenever  there  is  much  liquid  and  air 
in  the  organ,  three  or  more  hours  after  eating.  By' 
auscultation  a  sizzling  sound  is  present,  not  unlike 
that  heard  when  the  ear  is  placed  over  a  soda  water 
bottle  when  first  opened. 

Mensuration  may  be  used  by  passing  a  sound 
into  the  stomach  until  the  great  curvature  is 
reached.  Normally  it  rarely  passes  more  than  sixty 
centimetres,  measured  from  the  teeth,  but  in  cases 
of  dilatation  or  prolapse  it  ma)  pass  as  much  as 
seventy  centimetres. 

In  determining  whether  there  is  a  prolapse  or 
dilatation  of  the  stomach  it  is  quite  necessary  that 
we  should  have  a  clear  idea  of  what  the  terms  im- 
ply. W^ithout  question  a  number  of  individuals  go 
through  life  with  a  prolapsed  stomach  who  have 
few  or  no  symptoms.  We  should  also  have  some 
fixed  landmark  to  depend  upon  in  outlining  the  po- 
sition of  the  dift"erent  portions  of  the  stomach. 

Dr.  Henry  K.  Pancoast,  in  an  x  ray  study  of 
one  hundred  cases  of  gastroptosis  clears  up  a 
great  many  misunderstood  conditions,  and  his  arti- 
cle being  so  important,  I  take  the  liberty  of  quot- 
ing quite  extensively  from  it.  By  the  x  ray  he 
has  been  able  to  determine:  "i.  Abnormalities  in 
position,  such  as  ptosis.  2.  Abnormalities  in  size, 
such  as  contraction  or  dilatation.  3.  Abnormalities 
in  shape,  such  as  the  'hour  glass'  stomach.  4.  Ab- 
normalities in  motility.  5.  Retention."  He  says: 
"One  of  the  most  noticeable  features  of  ptosed 
stomachs  to  be  observed  when  making  a  collective 
radiographic  study  of  gastroptosis  is  the  tendency 
they  all  have  to  follow  certain  distinct  types." 

In  this  classification  five  distinct  types  of  gastrop- 
tosis are  recognized  and  for  convenience  he  added 
as  a  sixth  type  the  anatomically  normal  stomach : 


I.  The  normal  stomach.  2.  The  transitional  type  of  gas- 
troptosis.  3.  The  anatomical  type.  4.  The  tubular  type. 
5.  The  sagging  type.   6.  The  dilated  type. 

The  general  tendency  is  for  the  stomach  to  lie  obliquely 
and  nearer  to  a  horizontal  than  a  vertical  direction. 

The  normal  position  of  the  pylorus  may  vary  from  a 
point  somewhat  to  the  right  of  the  midline  to  as  much  as 
two  inches  to  the  right.  Its  normal  position  is  on  the  level 
with  the  first  lumbar  vertebrae. 

The  greater  curvature  is  found  to  lie  at  a  variable  dis- 
tance above  the  level  of  the  lower  border  of  the  third  lum- 
bar vertebra,  but  in  extreme  ptosis  it  may  drop  almost  to  a 
level  of  the  symphysis  pubis. 

Aside  from  its  cardiac  attachments,  the  main  support  of 
the  stomach  is  the  gastrohepatic  omentum.  Relaxation  or 
stretching  of  this  suspensory  ligament  is  one  of  the  most 
important  factors  m  the  mechanism  of  gastroptosis.  If 
this  structure  fails  in  its  mission,  the  performance  of  its 
duty  falls  upon  the  pyloric  attachments,  with  its  possible 
result  of  a  pyloric  "kink." 

In  the  transitional  type  the  very  earliest  stage  in  the  de- 
velopment of  gastroptosis  may  be  observed. 

The  sagging  type.  In  this  type  the  two  direct  primary 
factors  in  the  mechanism  of  ptosis  of  the  preceding  type 
are  also  operative,  but  they  are  reinforced  by  the  additional 
one  of  dilation,  which  through  a  stretching  and  weakening 
of  the  muscular  coat,  permits  the  stomach  to  sag  down- 
ward in  the  erect  posture  from  the  weight  of  its  contents 
in  the  most  dependent  portion.  Therefore  dilatation  is  al- 
ways present,  the  position  is  vertical.  The  amount  of  dis- 
placement of  the  pylorus  varies  greatly,  and  it  may  be 
found  e.xtremely  low.  Retention  is  favored,  and  the  py- 
loric "kink"  IS  likely  to  be  produced,  especially  when  the 
pylorus  is  relatively  high  compared  to  the  level  of  the  most 
dependent  portion  of  the  fundus.  A  relaxed  gastrohepatic 
ligament  is  particularly  to  be  inferred  in  the  presence  of  a 
kink.    Symptoms  are  always  prominent  and  severe. 

The  dilated  tj'pe.  In  this  type  dilatation  is  the  predom- 
inating feature.  Although  the  ptosis  may  still  conform  in 
some  respects  to  the  preceding  types,  still  the  dilatation 
may  be  so  extreme  as  to  destroy  all  resemblance  te  any  of 
them. 

Treatment. — This  divides  itself  into  the  medical 
and  the  surgical.  The  exact  location  and  position, 
form,  and  variety  of  prolapse  or  dilatation  should 
be  demonstrated  by  the  x  ray  or  gas  distension,  etc., 
in  order  to  formulate  the  treatment  to  fit  the  case 
if  possible. 

Atonic  dilatation  of  the  stomach  not  dependent 
upon  any  mechanical  obstruction  at  the  outlet. 
Cases  of  gastroptosis  with  no  particular  sagging  or 
kinking  or  pyloric  obstruction  or  when  the  convex 
border  in  the  sagging  variety  does  not  fall  below 
the  umbilicus  are.  as  a  rule,  subjects  for  medical  or 
mechanical  treatment,  e.  g.,  by  massage,  diet,  belts, 
electricity,  exercise,  and  position.  The  oblique  or 
tubular  type  needs  no  treatment. 

In  cases  with  relaxed  abdominal  muscles,  muscle 
exercise  especially  of  the  lower  portion  of  the  ab- 
domen for  the  purpose  of  strengthening  the  mus- 
cles and  elevating  the  abdoininal  contents  is  essen- 
tial. A  stomach  distended  with  gas  or  containing 
some  food  residue  may  be  made  to  empty  itself  into 
the  duodenum  by  such  exercise  if  assisted  bv  the 
knee  chest  and  recumbent  position.  This  takes  the 
weight  off  the  mesenteric  supports  and  the  relief 
may  be  immediately  noticed.  Such  a  stomach  may 
regain  a  great  deal  of  its  normal  tone  especially  if 
not  overdistended  with  food,  drink  or  gas.  A  long 
straight  front  corset  worn  in  these  cases  elevates 
the  abdominal  organs  and  especially  the  stomach, 
so  that  much  relief  is  thereby  experienced.  Stomach 
washings,  are  also  beneficial  in  individual  cases. 

A  stomach  prolapsed,  (except  the  oblique  type), 
two  or  more  inches  below  the  navel  in  a  person  past 


middle  lite  is  not  apt  to  regain  the  normal  position 
and  tone,  especially  if  there  is  a  long  history  of 
discomfort,  by  the  simpler  methods  of  treatment. 
Surgical  intervention  is  justifiable  and,  in  fact, 
offers  the  only  hope  of  marked  relief.  Where  there 
is  a  possible  pyloric  scar  or  kinking  or  obstruction 
an  operation  is  certainly  indicated. 

Surgical  Treatment. — Gastric  disturbance  with 
dilatation  may  be  dependent  upon  trouble  along  the 
intestinal  canal,  such  as  disease  of  the  appendix  or 
kinks  and  adhesions  around  the  colon.  A  careful 
search  should  be  made  at  the  time  of  operation  and 
all  these  conditions  corrected  if  possible. 

The  more  operative  conditions  to  be  met  in  ptosis 
of  the  stomach  are,  kinking  of  the  pylorus  and 
marked  dilatation. 

In  some  cases,  the  Beyea  operation  is  of  great 
value,  especially  if  there  is  no  associate  ptosis  of 
the  transverse ~ colon.  If  this  is  present  it  may  be 
necessary  after  shortening  the  supports  of  the 
stomach,  to  relieve  the  stomach  of  the  extra  weight 
of  the  transverse  colon  by  suspending  it  by  means 
of  the  omentum,  as  in  the  Coflfey  operation.  Dr. 
Cofifey,  however,  employs  this  operation  in  prolapse 
of  the  stomach  and  transverse  colon  as  well. 

Beyea's  operation  for  gastropexy  consists  in 
shortening  the  gastrohepatic  omentum  or  suspen- 
sory ligaments.  In  this  operation  the  mobility  of 
the  stomach  is  not  interfered  with.  I  usually  use 
chromic  catgut  sutures  instead  of  linen,  unless  the 
stomach  wall  is  included  for  cases  with  weak,  thin, 
and  friable  gastrohepatic  omental  tissue. 

The  operation  of  plication  for  dilatation  of  the 
stomach,  suggested  by  Bircher.  consists  in  folding 
inward  a  portion  of  the  stomach  wall  to  reduce  the 
size  of  the  much  dilated  organ.  A  scarification  of 
the  serosa  and  the  use  of  chromic  catgut  sutures 
has  been  very  satisfactory.  One  of  our  patients 
with  marked  dilatation  and  prolapse  of  the  stomach 
had  gallstones  and  a  benign  obstruction  of  the  py- 
lorus due  to  a  healed  ulcer.  \'omiting.  emaciation, 
and  absence  of  hydrochloric  acid  led  to  a  diagnosis 
of  malignancy  by  several  internists.  The  stones 
were  removed  and  a  gastroenterostomy  performed. 
A  gain  of  sixty-one  pounds  in  six  months  followed 
this  operation.  One  man  with  marked  stomach 
prolapse  had  a  diseased  appendix  removed  and  the 
stomach  elevated  by  shortening  the  gastrohepatic 
ligament.  Two  patients  suffering  from  general 
visceroptosis  with  relaxed  abdominal  walls  and  di- 
lated stomach  had  the  uterus  and  stomach  secured  in 
position  and  a  plication  operation  for  dilatation  and 
ini  overlapping  of  the  abdominal  muscles. 

In  simple  and  suitable  cases  the  Bircher  operation 
was  performed  for  the  dilatation  and  a  Beyea  op- 
eration was  performed  for  the  prolapse.  Occasion- 
ally a  few  adhesions  were  found  around  the  gall- 
bladder or  pylorus.  The  plication  operation  in  such 
cases  was  only  done,  after  removing  these  adhesions 
or  remedying  their  cause,  where  indications  pre- 
sented themselves.  In  each  case  the  individual 
gained  in  flesh,  digestion  was  improved,  the  distress 
usually  entirely  relieved,  and  the  physiological  ac- 
tivity of  the  stomach  more  perfect. 

These  operations  while  obiected  to  by  manv  have 
the  advantage  of  decreasine  the  stomach's  size  and 
elevating  it  so  that  the  food  does  not  become  stag- 


748 


CLOTHIER:  NEURORETINITIS  FROM  TYPHOID  FEVER. 


[New  York 
Medical  Journal. 


nant.  The  stomach  is  drained  and  fermentation  is 
less  possible  so  that  a  healthy  condition  of  the  stom- 
ach mucosa  recurs  and  a  better  muscle  tone  is  pro- 
cured. When  the  stomach  once  returns  to  this 
healthy  state  again  with  care  in  diet,  exercise,  etc., 
a  relapse  of  the  old  trouble  is  not  likely.  It  may 
be  necessary  in  some  cases  with  relaxed  abdominal 
walls,  as  in  women,  to  overlap  the  walls  to  make 
them  strong  enough  to  sustain  the  organs  within, 
this  operation  is  very  beneficial  in  women  who  have 
borne  several  children  with  no  abdominal  muscle 
tone  left. 

Conclusions.— 1.  Chronic  dilatation  and  prolapse 
of  the  stomach  are  often  interdependent  and  asso- 
ciated. 

2.  As  possible  antecedents  of  an  acute  dilatation 
they  must  be  recognized. 

3.  As  factors  in  the  causation  of  ulcers  or  cancer 
they  should  be  considered. 

4.  The  causes  for  dilatation  and  prolapse  may 
be  similar  and  primarily  are  often  due  to  indiscre- 
tion in  diet  followed  by  weakened  gastric  support, 
motor  insufficiency,  or  partial  obstruction. 

5.  The  exact  nature  and  variety  of  the  ptosis  or 
the  dilatation  should  be  determined  if  possible  by 
x  ray  and  other  means. 

6.  Symptoms  actually  due  to  chronic  dilatation 
or  prolapse  are  frequently  termed  hysteria,  neuras- 
thenia, or  nervous  dyspepsia. 

7.  Acute  upper  abdominal  pain  or  attacks  of 
vomiting  are  often  misinterpreted ;  they  are  fre- 
quently due  to  acute  pyloric  or  duodenal  obstruc- 
tion and  gastric  distension. 

8.  Hyperchlorhydria,  postoperative  vomiting,  and 
vomiting  of  pregn'ancy  may  be  dependent  much 
upon  the  presence  of  chronic  dilatation  or  prolapse 
of  the  stomach. 

9.  The  treatment  should  depend  upon  the  condi- 
tions found. 

10.  Simple  cases  are  often  amenable  to  medical 
and  mechanical  means  such  as,  diet,  exercise,  me- 
chanical support,  hygiene,  etc. 

11.  Certain  cases  should  be  operated  in  especially 
those  of  actual  pyloric  or  duodenal  obstruction  or 
of  the  sagging  type  and  other  aggravated  cases  not 
relieved  by  medical  means.  The  tubular  tvpe  of 
prolapse  needs  no  operation. 

12.  Some  cases  are  dependent  upon  an  associated 
visceroptosis  and  relaxed  abdominal  walls.  These 
should  be  properly  treated  to  bring  about  the  relief 
dependent  upon  such  a  general  pr^)lapse. 

13.  In  the  sagging  types  the  Beyea  operation 
either  alone,  or  supplemented  by  the  Coflfey  opera- 
tion, if  there  be  an  associated  sagging  of  the  trans- 
verse colon,  should  be  done. 

14.  Chronic  dilatation  of  the  stomach  not  de- 
pendent upon  obstruction  and  when  not  otherwise 
relieved  is  greatly  benefited  and  often  cured  by  the 
Rircher  operation  of  plication. 

15.  In  chronic  dilatation  dependent  upon  a  be- 
nign pyloric  obstruction  a  pyloroplasty  or  short 
loop  gastroenterostomy  should  be  performed. 

16.  Obstruction  or  dilatation  dependent  upon  a 
malignant  growth  may  call  for  a  pylorectomy. 

17.  In  operating  a  careful  search  should  be  made 
for  any  other  points  of  chronic  bowel  obstruction 
as  from  diseases  of  the  gallbladder,  appendix,  or 
from  a  kinking  colon,  etc.    These  conditions  may 

I 


add  to  digestive  disturbances  and  should  be  cor- 
rected at  the  same  time. 

18.  All  patients  operated  upon  should  be  fol- 
lowed for  some  time  and  the  subsequent  treatment 
carefully  managed. 

1020  Donaldson  Building. 


NEURORETINITIS  DUE  TO  TYPHOID  FEVER. 
Report  of  a  Case. 

By  Joseph  V.  Clothier.  M.  D., 
Philadelphia, 

Associate  in  Ophthalmology  in  the  Medical  Department,  Temple 
University. 

Kampherstein  (i)  in  the  study  of  the  causes  of 
200  cases  of  optic  neuritis  found  134  due  to  brain 
tumors  ;  twenty-seven  to  central  syphilis  ;  nine  to  tu- 
berculosis ;  seven  to  brain  abscess ;  three  each  due 
to  hydrocephalus,  nephritis,  and  cranial  deformity ; 
two  each  to  meningitis,  anaemia,  cysticercus,  and 
sinus  thrombosis ;  and  one  each  to  nephritis  from 
lead  poisoning,  and  cranial  exostosis.  Not  one  of 
the  200  cases  was  caused  by  typhoid  fever.  G.  Car- 
penter (2)  has  reported  two  cases  of  bilateral  mod- 
erate papillitis  occurring  with  typhoid  fever  in  girls 
aged  seven  and  eleven  years,  and  ending  in  recovery. 
Flatau  (3)  studied  the  condition  in  a  case  of  paraty- 
phoid. Reitter  and  Lauber  (4)  report  a  case  in  w-hich 
in  the  course  of  typhoid  fever  there  occurred  neu- 
ritis of  the  external  popliteal  nerve  and  shortly  af- 
terward neuritis  affecting  the  left  eye.  There  was 
swelling  of  the  papilla  and  retinal  haemorrhage  in 
this  case.  Recovery  occurred  in  three  weeks.  Sour- 
dille  (5)  has  observed  four  cases  of  visual  trouble 
complicating  typhoid.  In  three  there  was  evidence 
of  papillitis,  with  special  involvement  of  the  central 
vessels.  All  these  patients  recovered.  In  the  mi- 
croscopical examination  of  six  fatal  cases  of  ty- 
phoid, he  found  in  one  a  marked  chromatolysis  of 
the  ganglion  cells  of  the  retina,  while  the  optic 
nerve  was  normal.  In  the  others  the  retina  was 
normal  but  the  the  central  vessels  showed  hyaline 
degeneration  of  their  walls.  He  believes  the  visual 
disturbance  may  be  due  to  either  the  effect  of  tox- 
ines  upon  the  nervous  elements  or  to  vascular 
changes. 

Case. — Miss  F.  T.,  aged  sixteen  years.  Student.  Fam- 
ily history,  negative.  Previous  history,  good.  Patient  had 
had  measles  at  the  age  of  two  years.  Patient  was  first  seen 
by  me  October  21st,  when  she  came  complaining  of  poor 
vision  and  inability  to  see  the  blackboard  at  school.  Vision, 
O.  D.  5/12  ?;  O.  S.  5/12  ?  Opthalmoscopical  examination 
of  both  eyes  at  this  time  showed  media  dear,  discs  oval, 
,ixis  vertical,  outlines  fairly  well  defined,  vessels  of  normal 
calibre  and  appearance,  hmph  sheaths  full,  outlying  fundus 
normal.  Refraction  under  hvoscine  gave  R.  E.  -i-  2.00  c  105° 
=  5/6;  L.  E.  -I-  2.25  c  75°  ^  5/6.  Ordered  R  —  0.25  s.  -I- 
2.00  c  105;  L. — 0.25  s.  +  2.25  c  75.  These  glasses  were 
worn  with  perfect  satisfaction  until  the  patient  was  taken  ill 
with  typhoid  fever  in  December,  1908, 

Patient  wns  taken  ill  on  December  24tli,  but  did  not  take 
to  h.er  bed  imtil  January  ist.  Blood  examination  gave  posi- 
tive Widal  reaction.  Patient  had  t>-pical  typhoid  course 
imtil  January  6th,  when  she  complained  that  light  hurt  her 
eyes.  The  following  day  she  was  unable  to  recognize  her 
attending  physician  and  her  own  family.  She  could  recog- 
nize the  form  hut  not  the  face  or  color  of  the  individuals, 
and  complained  that  everything  looked  black  to  her.  Oph- 
thalmoscopical  examination  showed  bilateral  neuroretinitis. 
Papilla  was  swollen,  outline  obscured,  vessels  were  partly 
concealed  and  veins  full  and  somewhat  tortuous.  The 


April  lo,  1909.] 


ROSEN  HECK:  PARALYTIC  CONDITIONS  OF  CHILDHOOD. 


749 


macular  region  was  cloudy,  with  some  faint  radiating  striae 
to  disc  side  of  macula.  The  temperature  gradually  declined 
with  corresponding  subsidence  of  the  papillitis  and  im- 
provement of  vision.  On  January  21st  she  had  a  relapse 
of  the  febrile  condition,  but  the  vision  steadily  improved. 

The  patient  was  out  of  bed  about  February  i8th.  Re- 
peated uranalyses  showed  no  albumin,  and  only  a  slight 
trace  of  indican. 

Present  condition:  Vision  O.  D.  5/22,  O.  S.  s/15,  with 
old  correction  5/12,  and  5/9.  Ophthalmoscope  showed 
swelling  of  disc  had  subsided,  temporal  and  nasal  margin  of 
disc  was  fairly  well  defined,  superior  and  inferior  borders 
still  partly  obscured.  In  the  macula  were  some  faint  radi- 
ating strise  still  present.  Vessels  were  of  nearly  normal 
calibre. 

References. 

1.  Klinische  Monatschrift  fiir  Augenheilkunde ,  April, 
May,  and  June,  1905. 

2.  Opthalmoscope,  February,  1904. 

3.  Miinchener  medizinische  Wochenschrift,  July  12, 
1904. 

4.  La  Clinique  ophthalmologique,  August  25,  1907. 

5.  Ibidem,  August  10,  1903. 

1 2 12  Spruce  Street. 


THE  PARALYTIC  CONDITIONS  OF  CHILDHOOD.* 

By  Charles  Rosenheck,  M.  D., 
New  York, 

Neurologist  to  the  Hospital  for  Deformities  and  Joint  Diseases  and 
to  the  Harlem  Hospital,   Out  Patient  Department;  and 
Physician  to  the  Methodist  Episcopal  Dispensary. 

The  recognition  and  treatment  of  the  paralytic 
manifestations  of  childhood  are  of  such  importance 
that  its  reiteration  should  act  as  a  decided  stimulus 
to  practitioner  and  specialist  alike^ — the  former,  on 
the  alert  to  detect  paralytic  phenomena,  the  latter, 
to  institute  proper  measures  for  their  treatment.  In 
view  of  the  magnitude  of  the  subject  involved,  I 
shall  confine  my  remarks  to  the  diagnosis  only,  of 
the  various  paralytic  conditions,  the  distinction  be- 
tween paralysis  due  to  central  and  peripheral  causes 
and  to  the  paralytic  dystrophies,  wherein  the  path- 
ology seems  somewhat  obscure.  The  treatment  I 
shall  leave  to  the  gentlemen  present,  who,  no  doubt, 
can  enlighten  us  properly. 

In  the  paralytic  conditions  due  to  central  causes, 
we  find  that  the  cerebral  birth  palsies  occupy  an  im- 
portant place.  This  is  usually  of  congenital  origin 
due  to  the  mechanical  rupture  of  meningeal  vessels 
and  secondary  invasion  of  the  motor  zone  by  blood 
clot.  The  diagnosis  in  this  condition  presents  no 
difficulties.  There  is  usually  a  history  of  difficult 
labor.  After  a  variable  time,  it  is  noticed  that  the 
child's  extremities  are  rigidly  adducted,  and  when 
walking  is  attempted,  it  is  impossible  on  account  of 
the  adductor  spasm.  The  reflexes  are  markedly  ex- 
aggerated, the  lightest  tap  producing  a  violent  re- 
sponse. If  the  lateral  tracts  have  degenerated,  we 
may  get  a  marked  Babinski  and  ankle  clonus  refleX; 
The  electrical  reactions  are  normal,  and  there  is  no 
atrophy. 

There  is  another  type  of  cerebral  birth  palsy, 
which,  however,  is  due  to  cortical  agenesis  or  de- 
fective cortical  development.  This  condition,  which 
is  also  congenital,  is  characterized  by  a  flaccid  para- 
lysis on  account  of  the  maldevelopment  of  the  late- 
ral tracts.    The  reflexes  and  electrical  reactions  are 

*Rea_d  before  the  Qinical  Society  of  the  Hospital  for  Deformities 
and  Joint  Diseases,  Decerriber  30,  1908. 


as  a  rule  normal,  and  moderate  atrophy  may  be 
present. 

In  the  acquired  type  of  cerebral  palsies,  we  find 
hemiplegia  the  most  predominant.  This  usually  oc- 
curs in  childhood,  and  is  associated  with  cardiac 
conditions  or  supervenes  in  the  course  of  the  acute 
infectious  diseases.  It  may,  however,  develop  with- 
out any  definite  cause  being  assigned.  The  history 
of  the  case  and  the  lesion  glaringly  point  to  the 
correct  diagnosis.  The  reflexes  are  exaggerated, 
rigidity  is  present,  the  electrical  reactions  are  nor- 
mal, and  there  is  no  atrophy. 

Encephalitis  and  cerebrospinal  meningitis,  on  ac- 
count of  their  destructive  effects  on  the  motor  zone, 
occupy  a  prominent  place  as  the  causative  factors  of 
paralysis  in  childhood.  In  these  types  we  may  get 
either  a  paraplegia,  monoplegia,  hemiplegia,  or 
paralysis  in  combination.  There  is  usually  a  history 
of  an  acute  illness  of  long  duration,  with  all  its  at- 
tendant phenomena,  although  we  sometimes  see 
these  very  cases,  wherein  the  history  of  an  illness 
is  quite  meagre  and  indefinite.  The  paralysis  is  of 
the  flaccid  type  due  to  brain  and  cord  degeneration. 
Atrophy  is  moderate,  reflexes  may  be  present  or  ab- 
sent, and  the  electrical  reactions  are  normal. 

The  paralysis  due  to  spinal  cord  lesions,  the  most 
important  of  which  we  have  to  deal  with,  are  ante- 
rior poliomyelitis  and  compression  paraplegia. 

The  diagnosis  of  poliomyelitis  presents  little  or  no 
difficulties.  A  history  of  previous  well  being,  with 
a  sudden  onset  of  an  acute  illness,  in  either  a  mild 
of  acute  phase,  and  flaccid  paralysis  supervening 
early.  This,  in  the  mildest  type,  aflfects  a  group  of 
muscles  only,  or  in  the  severest,  all  extremities. 
Atrophy  is  an  early  condition  in  the  afifected  mus- 
cles. There  is  also  vasomotor  paresis,  giving  the 
limb  the  characteristic  bluish,  cold  appearance.  The 
reflexes  in  the  afifected  group  are  lost  early,  and  the 
reaction  of  degeneration  in  various  grades  com- 
pletes the  picture.  It  may  be  well  at  this  point  ta 
briefly  review  the  phenomena  of  electrical  reactions, 
in  general.  In  a  healthy  muscle  faradic  or  galvanic 
electrical  stimulation  produces  a  sharp  response.  A 
paretic  muscle  gradually  loses  that  irritability  to  re-, 
sponse,  so  that  very  strong  currents  are  necessary 
to  produce  contraction.  A  good  diagnostic  point  is 
the  feebleness  of  response  and  the  wormlike  char- 
acter of  the  contractions.  In  complete  reaction  of 
degeneration  the  muscles  will  not  react  to  the 
strongest  faradic  or  galvanic  current. 

The  compression  paraplegias  of  interest  to  us  are 
those  due  to  Pott's  disease.  Here  the  superincum- 
bent weight  of  several  spinal  segments  press  upon 
the  cord  and  interfere  with  its  functions.  Here 
we  have  a  history  pointing  to  the  spinal  affection, 
numbness,  and  shooting  pains  radiating  to  legs  or 
arms,  depending  upon  the  location  of  pressure, 
weakness,  ataxia,  and  finally,  paralysis.  The  re- 
flexes are'  exaggerated,  and  ankle  clonus  and  the 
Babinski  phenomenon  are  present.  In  compression 
of  the  lumbar  segments,  in  addition  to  the  para- 
plegia, we  get  involvement  of  the  sphincters.  The 
electrical  reactions  are  normal,  and  there  is  no 
atrophy. 

In  paralysis  due  to  peripheral  causes  we  find  that 
multiple  neuritis  takes  first  rank.  This  is  usually 
a  sequal  to  diphtheria,  but  may  be  caused  by  any  of 


OCR  READERS'  DISCUSSIONS. 


the  acute  infectious  diseases  of  childhood.  In  the 
majority  of  cases,  the  paralytic  phenomena  in  this 
condition  appear  slowly.  Sensory  symptoms  are 
distinguishing  features  and  consist  of  pain,  ten- 
derness, and  hyperaesthesia  along  the  course  of  the 
nerve  trunk.  Foot  and  wrist  drop  finally  appear 
and  clinch  the  diagnosis.  xA.trophy  and  the  reaction 
of  degeneration  appear  soon  after  the  paralysis.  In 
a  few  cases  of  multiple  neuritis  of  sudden  onset, 
with  little  or  no  sensory  symptoms,  the  condition 
may  be  mistaken  for  anterior  poliomyelitis,  and  a 
positive  distinction  between  both  conditions  may  be 
impossible.  The  course  of  the  disease  will  finally 
help  us.  A  history  of  diphtheria  or  exposure  to 
same  naturally  counts  in  favor  of  multiple  neuritis. 

My  concluding  remarks  bring  me  to  the  discus- 
sion of  the  muscular  dystrophies.  Most  important 
are  the  pseudomuscular  hypertrophies  and  the 
muscular  atrophies  of  Aran-Duchenne  and  Charcot 
— Tooth — Marie.  The  characteristics  of  the  hyper- 
trophies are  their  onset  in  early  childhood  and  dis- 
tinct hereditary  manifestation.  A  progressive  en- 
largement of  certain  muscular  structures,  notably 
the  thigh  and  calf,  and  a  corresponding  diminution 
in  their  motor  activity  until  total  helplessness  super- 
venes are  the  diagnostic  features.  The  reflexes  are 
retained,  and  the  electrical  reactions  are  diminished 
but  never  lost. 

In  the  muscular  atrophies  the  onset  of  gradual 
wasting  in  early  childhood  of  either  the  hands  or 
legs  distinguishes  this  type  of  disease.  The  reflexes 
disappear  when  atrophy  is  well  advanced,  and  the 
reaction  of  degeneration  is  present  in  the  affected 
muscles. 

247  West  One  Hu.\"drei)  and  Thirty-fifth 
Street. 

 ^  


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  iii  this  departmeni  are  announced  at 
frequent  intervals.  So  far  as  they  haze  been  decided  upon,  the 
further  questions  are  as  follows: 

LXXXIV. — How  do  you  use  alcohol  therapeutically?  {Closed 
March  75,  igog.) 

LXXXV. — .4part  from  an  operation,  how  do  you  treat  disease  of 
the  vermiform  appendix?  {Ansziers  due  not  later  than  April  15, 
/O09.) 

LXXXVI. — How  do  you  make  an  early  diagnosis  of  pulmonary 
tuberculous  disease.     {Answers  due  not  later  than  May  15,  iQog.) 

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FOR  DISCISSION. 

The  prize  of  $1$  for  the  best  essay  submitted  in  answer  to  ques- 
tion LXXXm  has  been  awarded  to  Dr.  Adrian  A.  Landry,  of 
Plaquemine,  La.,  whose  article  appeared  on  page  64^ 

PRIZE  QUESTION  LXXXIII. 
THE  TREATMENT  OF  ACUTE  DYSENTERY. 
(Coiirludcd  from  page  701.) 
Dr.  J.  E.  Klot::,  of  Lanark.  Out..  Canada.  7crifcs; 

The  patient  shduld  be  ])ut  immediately  into  a 
warm  bed — between  blankets — ami  a  hot  wntcr  bot- 
tle placc'l  nt  !n<=  fcrt  :  furtlior.  have  bim  lie  01  his 


[New  York 
Medical  Journal. 

back  with  a  large  bolster  under  his  knees;  this  im- 
proves the  circulation  in  the  lower  extremities  and 
relieves  the  abdominal  tension.  Follow  this  with  a 
hypodermic  injection  of  morphine,  ^  grain  ;  atro- 
pine, i/ioo  grain;  and  hyoscine,  i/ioo  grain.  Half 
an  hour  later  have  him  take  one  and  a  half  ounces 
of  castor  oil  in  three  half  ounce  doses  one  hour 
apart.  After  the  oil  has  operated  have  him  take  a 
dessert  spoonful  of  the  following  every  two  to  two 
and  a  half  hours  while  awake : 
R    Tr.  capsici,  5\  ; 

Tr.  opii.  deod.  5i3ii; 

Vin.  ipec,   5ii ; 

Bis,  subnit.,   ^ss; 

Muc.  acaciae  Jiss  : 

Sp.  vini  gallici  ad  ^vi. 

M. 

Intestinal  antiseptics  are  rarely  necessary,  though 
in  tedious  cases  are  often  invaluable ;  of  these  I  have 
found  zinc  phenolsulphonate  in  two  grain  doses,  and 
betanaphthol  in  four  grain  doses,  of  greatest  value, 
the  doses  repeated  every  three  hours  while  awake. 

Hot  water  flannel  cloths,  sprinkled  with  oil  of  tur- 
pentine, applied  to  the  abdomen,  alleviate  flatus  and 
pain;  cliange  them  every  twenty  minutes  to  half 
hour  till  the  skin  is  quite  pink ;  then  cover  the  abdo- 
men with  a  dry  warm  thick  flannel  cloth. 

If  there  is  much  prostration  or  collapse,  brandy 
well  diluted  with  carbonated  water  wall  revive  the 
patient  as  well  as  quench  the  coincident  thirst.  Clear 
black  tea,  iced,  although  less  stimulating,  is  very 
agreeable  to  most  patients,  acting  at  the  same  time 
as  a  mild  astringent.  In  severe  cases  it  may  be  nec- 
cessary  to  use  strychnine  in  small  divided  doses  as  a 
stimulant. 

If  the  bowel  fails  to  be  soothed  by  these  meas- 
ures and  continues  its  frequent  discharge  of  thick, 
tenacious,  irritating  mucous  stools,  which  may  be 
more  or  less  blood  tinged,  irrigation  of  the  large 
bowel  with  cold,  normal,  saline  solution  will  cleanse 
the  bowel,  reduce  the  inflammatory  congestion  of 
the  mucosa,  stimulate  the  circulation,  and  lessen  the 
thirst.  The  irrigation  of  the  bowel  with  normal  sa- 
line (two  or  three  quarts)  has  a  tendency,  likewise, 
to  quiet  gastric  disturbance,  which  may  consist  of 
nausea,  eructations,  or  actual  vomiting.  An  epigas- 
tric sinapism  should  not  be  omitted  when  there  is 
vomiting.  An  initial  hypodermic  injection  of  mor- 
phine is  at  times  productive  of  nausea  and  vomit- 
ing; but  this  action  is  only  very  temporary.  No 
food  or  internal  remedies  can  be  administered  till 
all  evidence  of  vomiting  has  passed ;  the  only  thing 
which  may  be  given  per  orem  for  gastric  disturb- 
ances is  cracked  ice. 

During  convalescence  the  patient  should  be  pro- 
tected from  damp  and  cold  exposure.  .A.  month's 
course  of  bismuth  subnitrate,  forty-five  grains  daily, 
is  advisable. 

During  the  attack  the  patient  should  be  regularly 
fed,  every  four  hours  while  awake,  on  eggnog,  lean 
broths,  buttermilk,  thin  and  thoroughly  boiled  rice 
and  tapioca — either  plain  or  with  custard.  To  drink 
he  may  have  carbonated  water,  iced  tea,  or  orange 
water.  During  convalescence  he  must  avoid  coarse 
vegetables,  hashed  meats,  rich  pasliry,  strong  alco- 
holics, copious  acid  drinks  and  unripe  fruits.  Mod- 
erate physical  exercise  and  jilenty  of  sleep  are  essen- 
tial to  complete  recovorx  anti  tut^ire  well  being.  Pre- 


April  10,  1909.] 


OUR  READERS'  DISCUSSIONS. 


751 


quent  warm  sponge  baths,  followed  by  a  brisk  towel- 
ing, are  to  be  recommended  during  convalescence. 

Dysentery  stools  should  always  be  covered  with 
a  solution  of  copper  sulphate  solution. 

Dr.  A.  A.  Young,  of  Nczvark,  N.  Y.,  states: 

It  is  the  consensus  of  opinion  that  the  condition 
known  as  acute  dysentery  is  produced  by  the  depo- 
sition of  a  specific  microorganism  within  the  colon 
which  organism  during  its  biological  changes  is  the 
-jetiological  factor  in  the  production  of  this  abnor- 
mality. The  colon  by  its  mechanical  construction 
forms  an  admirable  nidus  in  which  whole  colonies 
of  microorganisms  may  be  readily  generated.  It 
is  during  the  development  of  these  microorganisms 
that  pathological  conditions  are  produced.  Macro- 
scopically  the  pathological  conditions  dif¥er  in  dif- 
ferent individuals  and  at  different  stages  of  the  dis- 
ease. There  is  the  hypersemic  membrane  covered 
with  a  dirty  brown  tenacious  mucus ;  following  this 
there  may  be  deep  ulcerations  extending  entirely 
through  the  mucosa  and  coming  from  which  is  a 
purulent  or  mucopurulent  discharge  containing  ex- 
foliated necrotic  tissue.  The  solitary  glands  are 
enlarged  with  some  loss  of  functional  activity.  The 
submucous  tissue  is  also  swollen  and  thickened,  a 
condition  produced  by  the  infiltration  of  serum.  The 
liver  may,  and  probably  does,  become  involved,  and 
such  involvement  may  result  in  hepatic  abscess. 

Granted  then  that  there  is  a  dysenteric  organism ; 
that  this  organism  has  a  biological  life  history ; 
granted  that  during  its  development  it  produces 
pathological  conditions  in  the  mucosa  and  other  al- 
lied organs :  granted  that  systemic  disturbances 
are  Nature's  efforts  at  eliminating  the  organism  and 
its  products  from  the  intestinal  canal ;  then  along 
physiological  lines  there  appears  to  be  a  rational 
treatment.  This  treatment  has  for  its  object  the 
biological  destruction  and  the  elimination  of  the  or- 
ganism together  with  the  abnormal  products  pro- 
duced by  its  growth. 

The  suggested  treatment  resolves  itself  into  four 
parts,  viz.:  i.  Prophylactic:  2,  dietetic;  3,  medi- 
cinal ;  4,  mechanical. 

1.  The  prophylactic  treatment  consists  in  the  tak- 
ing of  proper  alimentation,  properly  prepared,  at 
proper  times,  and  suited  to  each  individual  person 
of  which  Nature's  suggestion  is  the  true  index. 

There  should  be  allowed  as  much  time  for  rest 
for  the  digestive  organs  as  work  is  required  of  them 
for  the  proper  digestion  of  food.  The  resisting 
powers,  bv  hygienic  living,  should  be  maintained 
at  their  maximum. 

Immediately  after  the  onset  of  dysentery  the  pa- 
tient should  be  placed  in  bed  and  perfect  rest  en- 
joined, rest  of  body  and  of  mind. 

2.  The  diet  should  be  as  the  patient  desires  which 
desire  is  usually  for  110  food,  so  nothing  should  be 
given  save  water  which  has  been  rendered  aseptic 
by  other  than  drug  agencies.  With  the  returning 
appetite  there  comes  a  desire  for  special  kinds  of 
food  which  should  be  supplied  in  moderation.  There 
is  no  universal  food  either  for  the  ill  or  for  the  con- 
valescent :  ^^'hat  is  meat  for  one  may  be  poison  for 
another ;  the  food  must  be  suited  to  the  individual 
and  not  the  individual  to  the  food. 

3.  Of  the  medicinal  treatment  its  object  is  two- 


fold :  a.  To  destroy  the  microorganisms  of  dysen- 
tery or  render  them  inert  or  inactive,  b.  To  cause 
their  expulsion  from  the  intestinal  tract,  together 
with  all  debris  and  toxines  produced  by  such  organic 
development.  Nature  then,  can  and  will  do  the  re- 
pair work,  a  work  that  medicaments  are  unable  to 
perform. 

At  the  oJiset  of  dysentery  antiseptic  or  germicidal 
treatment  approaches  the  ideal  one,  and  of  the  num- 
erous antiseptics  suggested  for  early  administration, 
iodine,  in  some  of  its  chemical  combinations,  is 
most  efficacious,  preferably  iodoform  is  selected. 
This  medicament  is  an  antiseptic  devoid  of  dele- 
terious action  upon  healthful  tissues ;  it  is  an  anaes- 
thetic quieting  undue  irritability  of  the  intestinal 
tract  without  retarding  normal  peristalsis ;  it  also 
appears  that  this  agent  has  but  little  deleterious  in- 
fluence over  the  activity  of  the  digestive  ferments. 
Such  antiseptic  approaches  the  ideal  one.  In  a  few 
cases  where  rapid  antisepsis  was  desired,  formal- 
dehyde, well  diluted  or  incorporated  with  egg  al- 
bumen, gave  pleasing  results.  Antiseptics  as  a  rule 
retard  or  destroy  the  activity  of  the  digestive  fer- 
ments, and  therefore  their  administration  should 
cover  but  a  short  period  of  time,  and  during  their 
administration  little  or  no  food  should  be  taken. 
With  the  destruction  or  marked  retardation  of  mi- 
croorganic  activity,  antiseptic  treatment  should  ter- 
minate and  eliminative  treatment  begin. 

4.  Eliminative  treatment  should  follow  in  the 
wake  of  any  antiseptic  treatment.  As  eliminants, 
cathartics  as  such  agents  are  contraindicated  and 
are  unqualifiedly  condemned  wiiich  condemnation 
appears  just,  when  the  pathological  condition  of  the 
mucosa  is  considered. 

There  is  an  eliminative  agent  that  possesses  in  a 
marked  degree  the  properties  of  antisepsis  without 
injury  to  the  digestive  ferments ;  it  is  a  stimulant 
of  peristalsis  without  irritation ;  it  is  a  solvent  of 
fascal  accumulations ;  it  is  a  haemostatic  by  virtue  of 
its  action  on  the  white,  muscular  fibres :  it  is  an  in- 
testinal digestant  that  exerts  a  beneficial  action  upon 
the  intestinal  mucosa ;  it  is  strictly  nontoxic  in  any 
desired  dosage ;  it  aids  in  changing  abnormal  hepatic 
excretions  into  more  normal  digestants.  Such  an 
agent  is  purified  aseptic  pig's  gall.  The  pig  is 
chosen  because  it  is  omnivorous  and  its  hepatic  pro- 
duct far  preferable  to  the  hepatic  product  of  the  ox. 
which  animal  is  herbivorous  and  a  ruminant  as  well. 

Coupled  with  pig's  gall,  lactose  and  mannite  aid 
materially  as  solvents,  not  alone  of  the  frecal  ac- 
cumulations, but  of  the  tenacious  mucoid  exudate 
as  well. 

5.  The  mechanical  treatment  is  largely  an  aid  to 
eliminative  methods  and  consists  in :  a.  The  dilata- 
tion of  the  sphincter  muscles  which  contract  on 
account  of  rectal  irritation,  dilatation  favors  elimi- 
nation, b.  High  colonal  flushing  tends  to  cleanse 
the  infected  pockets  of  the  colon  as  well  as  to  dis- 
tend the  contracted  organ.  Such  distention  causes 
normal  contracture  of  the  bowel  with  expulsion  of 
its  contents,  c.  Massage  increases  peristalsis  but 
should  be  allowed  only  when  the  stage  of  repair  is 
reached.  This  measure  may  be  classed  among  the 
prophylactic  agencies. 

Variation  from  any  method  of  treatment  may  be 
desirable  to  meet  v^arying  conditions,  but  there  must 


75^ 


CORRESPONDENCE. 


[New  York 
Medical  Journal. 


be  a  definite  object  in  view,  viz.:  Curative  and  not 
symptomatic  treatment,  a  course  of  treatment  often 
followed. 

Thus  I  have  described  a  method  of  treatment, 
with  some  reasons  for  its  adoption,  for  acute  dysen- 
tery, which  is  induced  by  other  than  malignant 
pathological  degenerations,  a  method  that  since  its 
adoption  has  yielded  uniformly  satisfactory  results. 

Dr.  W.  J.  Ryan,  of  East  Mauch  Chunk,  Pa.,  zvrites: 

As  we  are  dealing  with  a  disease  of  an  infectious 
nature,  attention  should  be  directed  to  the  proper 
isolation  of  the  patient  and  a  thorough  disinfection 
of  the  stools.  The  diet  should  receive  the  most 
careful  regulation,  lest  any  impure  or  otherwise  im- 
perfect food  should  favor  a  fatal  issue  or  prolonga- 
tion of  the  disease.  Liquid  diet  is  essential,  milk 
must  be  boiled  or  peptonized,  while  broths  and  beef 
juice  with  well  cooked  barley  and  rice  added  are  of 
service. 

Abdominal  pain,  tenesmus,  cramps  in  the  limbs, 
and  not  infrequently  nausea  and  vomiting  will  be 
found  to  be  the  distressing  features.  In  the  early 
stages  it  is  important  to  rid  the  intestinal  tract  of 
any  contained  faecal  matter,  this  might  be  best  ac- 
complished by  means  of  mild  cathartics,  as  castor 
oil  or  cascara,  to  which  we  might  add  ten  to  twenty 
drops  of  laudanum  to  control  the  pain.  Grain  doses 
of  opium  is  the  standard  remedy  for  the  relief  of 
pain  and  to  restrain  peristaltic  excitement,  in  many 
cases  where  pain  is  extreme  it  is  best  to  resort  to 
hypodermic  injection  of  morphine  ( i/8  to  1/9  grain) 
for  immediate  effect.  Camphor  mixtures  in  con- 
junction with  opium  have  been  popular  for,,prompt 
relief  but  it  is  not  the  proper  procedure  in  all  cases. 
As  opium  and  morphine  are  likely  to  cause  gastric 
disturbances,  in  some  cases  it  may  be  advisable  to 
use  codeine  in  i/io  grain  doses,  which  is  better 
tolerated.  Local  applications  to  the  abdomen  such 
as  stupes  of  oil  of  turpentine,  hot  fomentations,  or 
mustard  plaster  will  often  afiford  much  relief  from 
abdominal  pain,  while  the  cramped  limbs  w^ill  be 
benefited  by  massage.  A  powder  containing  bis- 
muth subnitrate  (ten  to  fifteen  grains)  and  salol 
(five  grains),  repeated  every  three  to  four  hours  will 
prove  very  efiicacious,  it  is  questionable  whether  or 
not  bismuth  exerts  any  influence  on  the  pain,  but 
in  this  form  will  act  in  a  soothing  and  antiseptic 
manner  throughout  the  diseased  tract.  We  might 
combine  the  bismuth  with  grain  doses  of  opium  or 
the  lead  acetate  in  one  to  two  grain  doses  to  gain 
its  astringent  effect  with  good  results. 

In  some  cases  where  there  is  much  irritation  in 
the  lower  intestine  or  painful  tenesmus  we  may  have 
to  resort  to  opium  suppositories  to  secure  results. 
Opium  in  any  of  its  forms  is  to  be  used  sparingly 
in  the  treatment  as  we  must  not  lose  sight  of  its  un- 
desired  effect  in  that  it  locks  the  bowels,  causes  gas- 
tric disturbances,  and  inhibits  intestimal  secretions 
that  are  essential. 

Saline  enemata  may  be  of  serivce  in  some  cases, 
in  early  stages  high  flushings  using  about  a  quart 
of  solution  (100°  F.)  will  serve  to  sooth  and  cleanse 
(he  lower  tract,  later  it  may  be  advisable  to  give 
small  amounts  frcf|ucntly  (two  to  four  ounces  every 
two  to  four  hours)  as  this  amount  is  less  likely  to 
cause  irritability  of  the  rectum,  which  would  contra- 
indicate  salines.  Should  we  have  to  deal  with  per- 
sistent nausea  and  vomiting  it  is  advisable  to  dis- 


continue all  food  by  mouth  for  the  time  being  al- 
lowing only  cracked  ice  in  small  quantities,  or 
drachm  doses  of  champagne,  and  mustard  plaster 
applied  to  the  epigastrium  will  often  give  desired 
relief.  If  this  fails  give  drop  doses  of  the  tincture 
of  aconite  every  one  half  hour  until  six  doses  are 
given,  then  discontinue,  this  treatment  is  very  re- 
liable in  cases  of  nausea  and  vomiting  of  reflex  ori- 
gin especially. 

Ipecac  has  found  favor  with  East  India  physi- 
cians who  state  it  to  be  especially  indicated  in  the 
amoebic  form  of  this  disease,  as  it  has  a  destructive 
tendency  on  the  amoebae  as  well  as  secretory  stimu- 
lant, increasing  the  flow  of  the  bile  which  in  itself 
is  a  material  intestinal  antiseptic,  also  acting  as  a 
muscular  sedative.  They  recommend  heroic  doses  of 
twenty  to  sixty  grains.  On  the  first  day,  no  food 
allowed  before  or  after  its  administration,  ice  only 
being  tolerated  to  allay  thirst,  smaller  doses  are 
given  on  second  day.  Ipecac  has  been  employed 
in  smaller  and  fractional  doses  with  good  success 
also. 

Mercuric  chloride  i/ioo  grain,  given  every  four 
hours  will  benefit  cases  where  there  is  marked  in- 
flammation and  excoriation  throughout  the  entire  in- 
testinal tract  as  will  be  shown  by  the  character  of 
the  stools. 

The  complications  of  dysentery  are  numerous  and 
of  grave  import,  and  it  is  important  to  recognize 
them  early,  as  surgical  interference  may  prove  use- 
ful. Febrile  condition  might  be  an  important  factor 
in  some  cases  and  can  be  met  with  antipyretic  meas- 
ures. We  are  not  to  lose  sight  of  the  exhaustion 
that  necessarily  attends  the  depletion  of  the  patient 
and  remedy  the  cause,  by  the  numerous  methods 
of  stimulation,  be  it  failing  heart  or  general  consti- 
tution. 

 <^  


LETTER  FROM  LONDON. 

King  Edivard's  Hosf>itaI  Fund.- — Discussion  ou  Asthma. — 
The  Medical  Services  of  the  Army  and  Navy. 

London,  March  23,  igog. 

The  annual  meeting  of  the  Council  of  King  Ed- 
ward's Hospital  Fund  for  London  was  held  last 
week,  the  president,  the  Prince  of  Wales,  in  the 
chair.  The  report  of  the  council  stated  that  the 
total  receipts  for  the  year  1908  were  £345,792.  The 
Prince  of  Wales,  in  moving  the  adoption  of  the  re- 
port, mentioned  that  the  negotiations  for  the  amal- 
gamation of  the  Hampstead  and  the  North  West 
London  Hospitals  were  completed.  He  also  stated 
the  new  buildings  of  the  Orthopaedic  Hospital  in 
Great  Portland  Street  would  be  ready  for  occupa- 
tion in  the  course  of  this  year.  Applications  from 
the  various  hospitals  and  institutions  for  grants 
were  invited. 

At  a  recent  meeting  of  the  Therapeutical  and 
Pharmacological  Section  of  the  Royal  Society  of 
Medicine  there  was  an  interesting  discussion  on  the 
treatment  of  spasmodic  asthma.  Dr.  Wall  opened 
the  discussion  and  pointed  out  the  various  theories 
held  as  to  the  nature  of  the  condition.  There  was 
marked  diifercnce  of  opinion  among  observers,  ex- 
cept on  the  one  point  that  during  the  attack  the 
bronchial  tubes  were  diminished  in  calibre,  and  this 


diminution  was  probably  effected  through  the  agency 
of  the  central  nervous  system. 

Prophylactic  treatment  was  directed  to  prevent 
the  occurrence  of  these  impulses  or  to  hinder  their 
passage  to  the  lungs.  Symptomatic  treatment  at- 
tempted to  lessen  the  turgescence  of  the  bronchial 
mucous  membrane  or  relax  the  tone  of  the  bronchial 
muscles  and  thus  widen  the  bronchioles. 

Dr.  Wall  pointed  out  the  influence  of  environ- 
ment, general  hygiene,  and  climate  in  preventing 
attacks.  Asthma  was  sometimes  associated  with 
nasal  abnormities.  In  twenty-three  cases  he  had 
noted  that  asthma  was  accompanied  by  nasal  defect, 
and  after  suitable  treatment  of  the  nose  there  was 
marked  improvement  in  fourteen  cases.  He  had 
found  the  most  useful  remedies  for  this  condition 
to  be  iodide  of  potassium,  arsenic,  and  stramonium. 
Of  the  last,  the  extract  was  better  than  the  tincture. 
The  nitrites,  atropine,  adrenalin,  and  acetone,  he 
had  found  of  benefit  in  some  cases.  Morphine  was 
very  valuable,  but  the  danger  of  establishing  the 
habit  forbade  its  too  frequent  use. 

Professor  Dixon  showed  tracings  indicating  the 
diminution  in  the  volume  of  the  lungs  which  fol- 
lowed upon  stimulation  of  the  vagus  of  a  cat.  A 
similar  change  followed  reflexly  from  stimulation  of 
the  nasal  mucous  membrane.  He  also  illustrated 
the  action  of  drugs  in  inhibiting  the  spasm.  For 
the  production  of  an  attack  of  asthma  two  things 
were  necessary,  a  ''neurotic"  medulla  and  a  periph- 
eral stimulus  as  the  exciting  cause. 

Dr.  Hertz  described  his  own  personal  experience 
of  asthma.  He  had  found  that  he  could  often  great- 
ly lessen  an  attack  if  he  resolutely  persisted  in  pur- 
suing some  mental  work  requiring  complete  con- 
centration of  mind.  If  an  attack  was  expected  by 
the  patient,  it  generally  came.  Those  subject  to 
asthma  must  avoid  the  places  in  which  experience 
taught  them  that  they  were  liable  to  attacks. 

Dr.  Spriggs  gave  details  of  forty  cases  of  asthma 
in  his  own  practice.  He  had  found  that  those  pa- 
tients who  were  entirely  free  from  symptoms  be- 
tween the  attacks  offered  a  prospect  of  successful 
treatment,  while  those  in  whom  the  severe  attacks 
subsided,  giving  place  to  a  chronic  dyspnceic  condi- 
tion, were  with  comparatively  few  exceptions  diffi- 
cult to  treat.  In  some  cases  surprising  benefit  fol- 
lowed attention  to  simple  hygienic  measures,  such 
as  the  digestion,  the  regular  action  of  the  bowels, 
and  the  avoidance  of  fatigue.  For  the  relief  of  se- 
vere attacks  he  had  had  good  results  with  the  injec- 
tion of  i-ioo  grain  of  atropine,  repeated  in  an  hour 
if  necessary.  Dr.  Carmall  Jones  said  that  he  had 
recently  isolated  a  microorganism  which  he  believed 
to  be  the  cause  of  certain  cases  of  asthma.  He  had 
prepared  a  vaccine,  and  in  many  cases  had  used  it 
with  success. 

Dr.  DuncansOn  stated  that  he  attached  great  im- 
portance, especially  in  the  young,  to  a  regular  course 
of  breathing  exercises. 

The  Xaval  Medical  Service  has  for  some  time 
been  rather  unpopular,  and  the  recruiting  has  been 
a  matter  of  anxiety  to  the  Admiralty.  Mr.  Mc- 
Kenna,  First  Lord  of  the  Admiralty,  has  appointed 
a  committee  to  inquire  into  the  Naval  IMedical  Ser- 
vice. The  board  hopes  that  this  committee  may 
help  to  put  the  service  upon  a  more  satisfactory  foot- 
ing.  The  Army  ■Medical  Service  was  also  discussed 


in  Parliament,  and  Mr.  Haldane  paid  a  tribute  to 
the  work  of  the  Army  Medical  Corps.  During  the 
last  six  or  seven  years  there  had  been  a  progressive 
improvement  in  the  health  of  the  troops.  The  work 
of  Colonel  Bruce  had  practically  caused  the  disap- 
pearance of  [Mediterranean  fever.  Preventive  in- 
oculations had  also  reduced  the  incidence  and  mor- 
tality of  enteric  fever. 

——^  


The  Treatment  of  Bronchitis  and  Broncho- 
pneumonia in  Children. — The  three  things  neces- 
sary to  attend  to  in  the  treatment  of  bronchitis  and 
bronchopneumonia  in  young  children  are,  according 
to  Marfan  (Gazette  medicale  dc  Paris,  IMarch  i, 
1909),  to  render  the  bronchial  tubes  aseptic,  to  fa- 
cilitate expectoration,  and  to  allay  the  cough.  In 
the  case  of  infants  they  should  be  kept  in  a  room 
where  a  uniform  temperature  of  62°  F.  is  main- 
tained ;  the  limbs  should  be  swathed  in  cotton  wad- 
ding, and  this  covered  with  oil  silk.  Twice  a  day 
apply  to  the  chest  liniment  of  turpentine,  or  a  mus- 
tard plaster,  allowing  the  latter  to  remain  two  or 
three  minutes,  or  a  sufficient  time  to  cause  a  redness 
of  the  skin,  the  application  of  the  plaster  to  be  re- 
peated two  or  three  times  a  day.  The  air  of  the 
room  in  which  the  patient  is  kept  should  be  charged 
with  the  vapors  arising  from  the  admixture  of  one 
teaspoonful  of  the  following  compound  with  eight 
ounces  of  boiling  water,  the  mixture  being  contained 
in  a  teapot  or  some  special  form  of  vaporizer : 

^    Wood  creosote  tt|.1xxv; 

Tincture  of  t)enzoin,   3iiss; 

Oil  of  turpentine,   

M. 

If  the  bronchial  symptoms  are  severe  and  the  child 
can  stand  it,  a  teaspoonful  of  syrup  of  ipecac  should 
be  administered  every  five  minutes  until  vomiting 
takes  place.  This  should  not  be  repeated,  however,  as 
it  causes  pain  and  may  provoke  enteritis.  If  diarrhoea 
ensues  on  the  fourth  or  fifth  day  of  the  attack  all 
medicine  should  be  stopped  and  the  infant  put  on  a 
diet  of  boiled  water  for  six  hours,  administering  at 
the  same  time,  every  two  hours,  a  powder  composed 
as  follows : 

R    Calomel,   gr.  ss  to  gr.  ^; 

Sugar  gr.  viiss. 

M.  et  divide  in  pulv.  No.  iii. 

Sig. :  One  powder  everj-  two  hours. 

The  diffusible  stimulants  are  fully  indicated  in  the 
benign  form  of  bronchitis,  since  they  act  also  as  ex- 
pectorants. In  place  of  alcohol  employ  ammonium 
acetate  as  in  the  following: 

.Ammonium  acetate,  gr.  viiss  to  gr.  xxx; 

Syrup  of  ether,   5iiss; 

Syrup  of  acacia,   

M. 

Lotion  for  Varicose  Veins. — Joly  is  cited  {La 
clinique,  January  29,  1909)  as  the  author  of  the 
following  lotion  for  application  to  varicose  veins: 


R     Tincture  of  lavender,   5xvi ; 

Tincture  of  nux  vomica,   3iiss; 

Tincture  of  arnica,   3iv; 

Tincture  of  conium,   31; 

Tincture  of  hamamelis,   3v. 


M.  ei.  Sig. :  Use  as  a  lotion  at  bedtime. 


754 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK,  SATURDAY,  APRIL  10,  1909. 


"FIXATIOX  ABSCESSES"  IN  THERA- 
PEUTICS. 

So  long  ago  as  in  1892  there  occurred  to  a  physi- 
cian of  Lyons,  M.  Fochier,  the  conception  of  a  ther- 
apeutic procedure  which  may  perhaps  be  looked 
upon  as  fighting  fire  with  fire.  It  consists  in  the 
deliberate  production  of  "fixation  abscesses"  {abces 
de  fixation),  the  idea  being  to  fix  the  pathogenic 
germs,  to  divert  them  from  the  system  at  large,  by 
means  of  localized  suppuration  produced  artificially 
in  cases  of  puerperal  septichsemia.  M.  Boissard  has 
recently  called  attention  anew  to  this  curious  pro- 
cedure (Obstctrique,  1908,  No.  6),  and  in  the  Pressc 
medicalc  for  March  20th  M.  Chirie  gives  an  inter- 
esting summary  of  the  treatment. 

Seeking  to  turn  to  account  the  recovery  of  certain 
patients  with  septichaemia  after  the  spontaneous  oc- 
currence of  localized  suppurations,  Fochier  under- 
took the  artificial  production  of  an  "abscess  of  fixa- 
tion" by  injecting  an  irritant,  oil  of  turpentine,  be- 
neath the  skin.  In  a  number  of  instances  of  grave 
puerperal  infection  he  had  the  satisfaction  of  seeing 
recovery  follow  recourse  to  this  practice,  and  at  the 
present  time,  we  are  told,  a  great  many  phy.sicians 
are  employing  it.  Theoretically,  the  injection  of  oil 
of  turpentine  acts  in  a  threefold  manner — by  often 
producing  an  abscess  at  the  point  of  injection,  by 
exercising  a  bactericidal  action  on  the  internal 
media,  and  by  stimulating  the  defensive  reactions  of 
the  system. 


According  to  Fochier's  method,  a  subcutaneous 
(not  intramuscular)  injection  of  from  three  to  five 
cubic  centimetres  (about  a  fluid  drachm )  of  oil  of 
turpentine  is  administered.  The  parts  preferred  for 
the  injection  are  the  forepart  of  the  thigh,  toward 
the  outer  border,  and  corresponding  situations  on 
the  thoracic  and  abdominal  walls.  It  is  said  that 
general  symptoms  are  not  usually  produced,  but 
there  is  always  pain  at  the  site  of  the  injection,  some- 
times so  severe  as  to  call  for  the  use  of  opium.  The 
skin  of  the  part  becomes  red,  and  oedematous  swell- 
ing of  the  region  occurs.  The  abscess  forms  about 
the  sixth  day  and  is  opened,  giving  exit  to  grumous 
pus  which  has  a  decided  terebinthinate  odor  and  is 
mingled  with  shreds  of  broken  down  cellular  tissue. 
After  it  is  opened,  the  abscess  is  treated  like  ab- 
scesses in  general. 

Boissard,  who  is  a  warm  advocate  of  the  turpen- 
tine treatment,  is  cited  as  having  observed  seven  re- 
coveries and  five  deaths  after  its  employment  in 
thirteen  grave  cases.  We  are  not  told  what  hap- 
pened to  the  thirteenth  patient.  He  thinks  that  there 
are  no  contraindications,  and  that  the  procedure 
should  be  resorted  to  in  all  cases  that  appear  to  be 
severe  from  the  clinical  point  of  view  and  in  which 
curetting  and  other  local  measures  have  not  resulted 
in  improvement.  If  the  pulse  remains  above  120,  if 
the  temperature  continues  to  fluctuate  in  the  neigh- 
borhood of  104°  F.,  or  if  the  patient  has  chills,  we 
should  not,  in  his  opinion,  hesitate  to  resort  to  the 
turpentine  injection. 


THE  ORDINARY  "COLD." 

It  might  be  worth  while  for  some  of  our  bacteri- 
ologists to  concentrate  their  attention  for  a  time  on 
the  plain,  every  day  "cold."  Coryza,  while  a  trivial 
disease,  produces,  in  the  aggregate,  a  vast  amount 
of  incapacity.  It  is  almost  the  only  disease  which 
occurs  frequently,  it  affects  some  persons  to  such  a 
degree  as  to  produce  more  or  less  incapacity  for  a 
good  share  of  the  winter  and  spring,  very  few  are 
immune,  and  there  is  no  season  in  which  it  does  not 
occur  to  some  extent. 

The  therapeutics  of  coryza  is  highly  unsatisfac- 
tory. Many  physicians  have  reached  a  point  of 
almost  complete  skepticism  regarding  general  meas- 
ures, or,  at  least,  have  come  to  share  the  lay  belief 
that  a  hot  sling  or  a  hot  bath  is  as  good  as  any  more 
elaborate  scheme  of  treatment.  Local  measures 
have  not  proved  absolutely  satisfactory.  Cocaine 
gives  almost  immediate  relief,  but  the  relief  is 
transient :  the  initial  constriction  of  the  arterioles 
is  followed  by  a  dilatation,  so  that  the  symptoms 
may  even  recur  in  exaggerated  degree,  and  the  dan- 
ger of  establishing  a  habit  is  almost  prohibitory. 


April  lo,  1909.] 


EDITORIAL  ARTICLES. 


755 


Analogous  drugs,  such  as  atropine,  are  open  to  sim- 
ilar objections,  besides  the  general  contraindication 
to  the  use  of  any  mydriatic  among  persons  com- 
pelled to  use  the  eyes  for  close  work.  Astringents 
are  also  apt  to  produce  unpleasant  after  effects. 
Alkaline  or  mineral  oil  sprays  are  soothing,  some- 
times one  sometimes  the  other  appearing  preferable, 
and  apparently  do  no  harm.  On  the  other  hand, 
they  do  not  bring  about  thoroughly  satisfactory 
results.  Antiseptics  of  various  kinds,  including  hy- 
drogen dioxide,  are  of  some  value,  but  not  of  such 
great  service  as  might  be  expected  from  one  view 
as  to  aetiology. 

Almost  any  one  of  the  aetiological  theories  is  cor- 
rect as  applied  to  certain  cases,  incorrect  if  applied 
to  all.  Under  conditions  of  hygienic,  open  air  life, 
all  sorts  of  exposures  to  cold  and  dampness  may 
fail  to  produce  a  coryza.  On  the  other  hand,  colds 
are  certainly  more  prevalent  in  cold,  damp  seasons, 
they  occur  without  obvious  sotirce  of  infection 
from  previous  cases,  among  persons  in  whom  close 
housing  due  to  the  weather  is  not  prominent,  and, 
while  dampness  may  be  considered  favorable  to  the 
development  of  germs  in  extracorporeal  media,  the 
associated  low  temperature  probably  inhibits  their 
growth  while  the  dampness  itself  prevents  the  dis- 
semination of  fomites  in  the  air.  In  many  epi- 
demics the  infectious  origin  is  obvious,  and  certain 
cases  can  even  be  traced  to  a  definite  source.  Pol- 
len coryzas,  more  or  less  asthmatic,  are  a  well  de- 
fined class,  distinct  from  the  ordinary  run  of  colds. 
Obstinate  hot  weather  colds,  occurring  without 
traceable  source  of  infection,  in  persons  not  ordi- 
narily subject  to  hay  fever,  rose  cold,  etc.,  are  diffi- 
cult to  explain.  The  very  fact  that  colds  are  plainly 
not  of  uniform  aetiology  shows  the  need  of  discrim- 
mation,  first,  as  to  cause,  secondly,  as  to  adaptation 
of  treatment  tio  actually  existing  processes. 

The  term  influenza,  or  grippe,  is  usually  applied 
without  bacteriological  investigation,  often  when 
the  presence  of  the  true  influenza  bacillus  is  alto- 
gether improbable.  Granting  that  one  group  of 
colds  is  infectious,  it  is  of  practical  importance  to 
know  whether,  as  is  commonly  held,  they  are  due 
to  a  miscellaneous  lot  of  germs.  If  it  is  true  that 
almost  any  of  the  ordinary  microorganisms  of  the 
air  or  mouth,  nose,  and  throat  can  produce  a  cold, 
the  bacteriological  theory  must  yield  first  place  to 
what,  under  this  theory,  have  been  considered  pre- 
disposing causes.  It  frequently  happens  that  cases 
of  coryza  appear  to  be  localizations  of  diphtheria, 
pneumonia,  rhevmiatism,  etc.  From  the  standpoint 
of  prophylaxis,  it  is  of  great  importance  to  know 
the  relative  frequency  of  such  cases  and  the  means 
of  detecting  them  promptly  and  easily. 

Pulmonary  consumption  often  appears  to  have  be- 
gtm  with  a  cold.    Is  this  history,  which  we  so  fre- 


quently obtain,  merely  coincidental,  or  is  the  cold 
unusually  favorable  to  the  effective  lodgment  of 
the  bacilli  ?  Is  the  cold  an  initial  tuberculous 
lesion  ?  It  may  be  that  a  serious  attempt  to  solve 
these  problems  will  show  that  they  have  been 
very  incorrectly  stated — in  other  words,  that  vari- 
ous ftmdamental  beliefs  are  fallacious.  But  the 
importance  of  the  general  problem  can  scarcely  be 
exaggerated.  There  can  be  no  question  that  a  fre- 
quent and  usually  frequently  repeated  inflammation, 
whether  strictly  infectious  or  not.  undermines  the 
general  health  and  predisposes  to  various  serious 
disorders.  Moreover,  an  ordinary  cold  is  often  the 
last  straw  in  overturning  the  balance  of  resistance 
in  the  aged  and  in  persons  with  widely  different 
diseases,  some  not  necessarily  fatal,  others  at  least 
admitting  of  being  long  delayed. 


DAXTE  AS  A  PHYSICIAX. 

A  very  interesting  pamphlet  on  this  subject  has 
appeared  only  lately,  entitled  Dante :  Physician,  writ- 
ten by  Dr.  A.  G.  Drury.  professor  of  hygiene  in  the 
^ledical  College  of  Ohio.  As  is  well  known,  the 
great  Italian  poet  was  born  in  Florence  in  1265  and 
died  in  Ravenna  in  1321.  He  received  a  good  edu- 
cation, such  as  was  customary  at  that  time  for  young 
men  of  his  position,  studying  at  several  universities. 
\Mien  he  settled  down  and  married  he  entered  the 
poHtical  arena  of  his  native  city.  To  do  so  it  was 
necessary  for  him  to  join  one  of  the  seven  guilds  of 
the  greater  arts,  and  he  chose  the  guild  of  physi- 
cians. He  soon  took  a  leading  part  in  politics  and 
was,  for  a  short  time  in  1300,  prior  of  his  guild.  But 
this  position  and  his  activity  were  the  cause  of  the 
miseries  and  misfortunes  of  his  later  life.  In  the 
political  fights  in  Florence  between  the  blacks  and 
whites,  he,  as  a  member  of  the  latter  and  as  an  office- 
holder, was.  in  1302,  expelled  from  Florence  and 
even  condemned  to  death.  Then  Dante  s  wander- 
ing began.  His  possessions  having  been  confiscated, 
he  had  in  the  real  sense  of  the  word  no  place  where 
to  rest  his  weary  body.  He  went  from  town  to  town 
— but  never,  as  has  been  said,  to  Oxford — often 
even  begging  and  living  on  the  charity  of  his 
friends.  The  ire  of  the  leader  of  the  blacks  was  so 
strong  that  Dante  was  never  included  in  any  of  the 
many  amnesties  which  were  granted  during  the  fol- 
lowing years.  Finally  he  found  an  asylum  in  Ra- 
venna, where  he  was  joined  by  his  family  and  where 
he  died,  making  it  a  point  in  his  will  that  his  body 
should  never  rest  in  his  ungrateful  native  city.  Such 
was  the  life  of  Dante. 

Although  he  was  a  member  of  the  guild  of  physi- 
cians, he  seems  never  to  have  practised  the  art  of 
healing.  We  even  do  not  know  whether  he  studied 
medicine.     Our  data  concerning  Dante's  life  are 


756 

very  meagre,  and  only  the  diligent  researches  of  the 
nineteenth  century  have  made  it  possible  for  us  to 
form  a  correct  idea  of  his  actions.  Commentators 
sprung  up  soon  after  his  death,  among  them  one  of 
his  sons ;  Italian  universities  founded  chairs  for  the 
interpretation  of  the  Divina  Commedia,  the  first  be- 
ing that  of  Florence,  in  1373,  where  Boccaccio  head- 
ed the  list  of  occupants ;  the  great  works  have  been 
translated  into  many  languages,  even  a  crowned 
head  of  Europe  contributing  under  the  name  of 
Philalethes  a  very  good  German  translation ;  but  the 
biographers  were  few  and  unreliable. 

Professor  Drury  gives  us  a  very  condensed  review 
of  Dante's  life ;  the  reader  who  does  not  know  much 
of  Dante  or  who  does  not  possess  a  good  biography 
would  miss  some  important  links  and  might  even  be 
led  to  misconceptions.  But  very  good  are  his  cita- 
tions from  Dante's  works,  showing  the  great  poet's 
knowledge  of  medicine  and  at  the  same  time  dem- 
onstrating Dr.  Drury's  great  knowledge  of  Dante's 
works.  The  essay  makes  very  interesting  reading 
and  will  certainly  be  a  source  of  recreation  after  a 
strenuous  day's  work  in  the  life  of  a  busy  practi- 
tioner. 


PELMC  DEFECTS  AND  THE  FIRST 
MENSTRUATION. 

In  the  enormous  number  of  more  than  thirty  thou- 
sand cases — to  be  exact,  31,659 — an  Italian  physi- 
cian. Dr.  Rossi-Doria  {Archiv  fiir  Gynakologie, 
Ixxxvi,  3;  Semaine  medicale,  March  24th),  has  re- 
corded the  ages  at  which  the  first  menstruation  oc- 
curred in  the  girls  of  his  country,  chiefly  those  of 
central  Italy,  though  the  girls  of  the  north  and  the 
girls  of  the  south,  those  living  in  the  rural  districts 
and  the  inhabitants  of  large  towns,  were  fully  repre- 
sented. As  a  result  of  this  inquiry  he  gives  the  aver- 
age age  at  which  the  first  menstruation  occurs  in 
Italian  girls  as  fourteen  years,  five  months,  and 
twenty-two  days.  Those  of  us  who  have  been  ac- 
customed.to  accepting  the  general  statements  of  the 
old  textbooks  might  perhaps  have  supposed  that  in 
Italy,  commonly  regarded  as  a  warm  country,  the 
menstrual  function  was  established  at  an  earlier  age. 

But  the  average  age  in  itself  is  of  minor  import- 
ance in  Dr.  Rossi-Doria's  investigation  ;  he  finds  that 
abnormities  of  pelvic  development  are  met  with  more 
commonly  in  women  whose  first  menstruation  took 
place  at  an  age  varying  widely  from  the  average 
than  in  those  who  first  menstruated  at  or  near  the 
average  age.  It  is  not  difficult  to  understand  that  an 
unusual  retardation  of  the  establishment  of  the  men- 
strual flow  should  in  some  way  be  connected  with 
causes  lying  at  the  bottom  of  defective  pelvic  devel- 
opment, but  it  is  not  so  easy  to  imagine  a  connection 
between  precocious  menstruation  and  lack  of  forma- 


[New  York 
Medical  Journal. 

tive  regularity  in  the  bones  of  the  pelvis.  Such  a 
connection,  however,  seems  to  be  deducible  from  Dr. 
Rossi-Doria's  observations.  Nevertheless,  delayed 
menstruation  does  seem  oftener  than  the  premature 
establishment  of  the:  function  to  go  hand  in  hand 
with  pelvic  deformity;  the  author  found  1S.18  per 
cent,  of  malformations  of  the  pelvis  in  women  who 
first  menstruated  at  the  age  of  nine  years,  8.31  in 
those  whose  first  menstruation  took  place  when  they 
were  thirteen,  8.64  in  those  in  whom  the  function 
was  initiated  at  fourteen,  and  39.21  in  those  who 
first  menstruated  at  the  age  of  twenty  or  over.  In 
those  whose  age  deviated  most  decidedly  from  the 
average  for  the  first  menstruation  the  pelvic  abnorm- 
ity was  found  most  pronounced  by  the  Italian  in- 
vestigator. 


THE  MAN  WITH  HIS  LIFE  INSURED. 

Dr.  Burnside  Foster,  of  St.  Paul,  the  editor  of  the 
St.  Paul  Medical  Journal,  visited  New  York  last 
week  and  presented  before  the  Association  of  Life 
Insurance  Presidents  a  communication  entitled  A 
Suggestion  Concerning  the  Increased  Longevity  of 
Life  Insurance  Policy  Holders.  Dr.  Foster's  sug- 
gestion was,  in  brief,  that  policy  holders  should  be 
invited  by  the  companies  to  avail  themselves  of 
periodical  examinations,  under  authority  of  the  in- 
suring companies,  for  the  purpose  of  ascertaining 
whether  or  not,  since  the  issue  of  their  policies,  the\- 
had  become  the  subjects  of  signs  or  symptoms  in- 
dicative of  serious  disease,  which  signs  or  symptoms 
might  not  otherwise  be  known  or  correctly  inter- 
preted by  them. 

Dr.  Foster's  idea,  of  course,  was  that  such  a 
course  as  he  recommended  would  in  many  instances 
lead  to  the  rescue  of  a  policy  holder  from  untimely 
death,  and  thus  benefit  the  insuring  company  by 
enabling  it  to  collect  premiums  for  a  longer  term 
than  it  would  otherwise  be  able  to  do.  The  associa- 
tion, however,  found  objections  to  the  scheme,  main- 
ly on  the  score  of  the  expense  of  the  necessary  ex- 
aminations. It  seems  to  us,  nevertheless,  that  the 
judicious  selection  of  cases  in  which  to  try  the  plan 
would  result  in  prolonging  the  lives  of  a  great  many 
individuals  and  in  increasing  the  income  of  the  com- 
panies. 


THE  NEW  YORK  ANTIVIVISECTIOX 

AGITATION. 
It  is  satisfactory  to  be  able  to  announce  that  the 
status  of  the  antivivisection  bills  that  have  been 
under  consideration  by  the  present  legislature  of  the 
State  of  New  York  is  more  satisfactory  to  the  medi- 
cal profession  than  the  disposition  of  similar  bills  in- 
troduced last  year  was  at  that  time.  On  March  24tli 
the  Assembly  committee  voted  not  to  report  either 


EDITORIAL  ARTICLES. 


April  10,  1909.] 


NEIVS  ITEMS. 


757 


bill.  The  Senate  committee  seems  to  have  taken  no 
action.  Thus  it  seems  that  both  bills  are  dead  so  far 
as  concerns  this  session  of  the  legislature.  At  the 
committee  hearings  the  preponderance  of  arguments 
was  decidedly  in  opposition  to  the  schemes  proposed 
in  the  bills  under  consideration.  Among  those  who 
appeared  in  opposition  to  the  bills  were  Bishop  Nel- 
son, of  Albany ;  Professor  George  W.  Kirchwey, 
dean  of  the  School  of  Law  of  Columbia  University ; 
President  Schurman,  of  Cornell  University ;  and  a 
number  of  eminent  medical  men. 

 ^  

Items. 


Changes  of  Address. — Dr.  Edgar  A.  Stein,  to  304 
South  Nineteenth  street,  Philadelphia. 

Dr.  George  Morrison  Coates,  Dr.  Ross  Hall  Skillern, 
and  Dr.  Francis  Brinton  Jacobs  have  moved  their  office 
and  residence  to  2032  Chestnut  street,  Philadelphia. 

A  Merger  of  the  Alumni  Associations  of  the  Miami 
and  the  Ohio  Medical  Colleges  has  been  effected,  and  at 
a  meeting  of  the  combined  associations,  held  on  April  ist. 
Dr.  William  H.  Campbell  was  elected  chairman,  and  Dr. 
Sidney  Lange,  secretary. 

Appropriation  Bills  Signed  by  Governor  Hughes.— 
Senator  Aids's  measure  appropriating  $295,000  for  the 
State  Tuberculosis  Hospital,  at  Raybrook,  in  the  Adiron- 
dacks,  and  Mr.  Edwards's  bill  appropriating  $168,000  for 
the  Rome  Custodian  Asylum,  have  been  signed  by  Gover- 
nor Hughes. 

The  Chemical  Basis  of  Pharmacology  was  the  subject 
of  a  lecture  delivered  by  Mr.  J.  L.  Turner  in  the  Chemistry 
Lecture  Hall  of  the,  Medico-Chirurgical  College,  Philadel- 
phia, on  Monday  evening,  March  29th.  Lantern  views  and 
appropriate  apparatus  were  used  to  demonstrate  the  theme. 
This  lecture  formed  a  part  of  the  winter  course  of  special 
lectures  upon  practical  chemistry  which  is  being  given  by 
the  college. 

-  New  Hospital  opened  in  Baltimore. — The  Sydenham 
Hospital  for  Minor  Infectious  Diseases,  Baltimore,  was 
formally  opened,  with  suitable  ceremonies,  on  April  3d, 
and  turned  over  to  the  city.  As  its  name  implies,  the  hos- 
pital is  for  the  treatment  of  the  minor  infectious  diseases, 
such  as  scarlet  fever,  diphtheria,  measles,  and  chickenpox, 
and  it  will  be  of  great  service  to  the  Health  Department  in 
preventing  epidemics  of  these  diseases.  There  are  accom- 
modations for  thirty-two  patients. 

The  Medical  Society  of  the  County  of  New  York  held 
a  joint  meeting  with  the  local  pharmaceutical  association 
at  the  antitoxine  farms  of  the  Lederle  Laboratories,  near 
Nanuet,  N.  Y.,  on  Wednesday,  April  7th.  Professor  Wil- 
liam C.  Ajiderson,  of  Brooklyn,  delivered  an  address  on  the 
Relations  between  Physicians  and  Pharmacists,  and  the 
methods  of  making  the  various  sera  were  demonstrated  and 
the  stables  and  laboratories  inspected.  The  members  were 
entertained  at  luncheon  by  the  Lederle  Laboratories. 

The  Long  Island  State  Hospital. — A  site  for  the  new 
Long  Island  State  Hospital  for  the  Insane  has  been  pur- 
chased at  Greenvale,  Nassau  County,  at  a  cost  of  $419,000, 
and  Dr.  Albert  W.  Ferris,  president  of  the  State  Commis- 
sion in  Lunacy,  announces  that  the  work  of  construction 
will  be  begun  at  once,  in  spite  of  vigorous  protests  made  by 
the  residents  in  the  vicinity  against  the  establishment  there 
of  the  new  buildings.  The  site  comprises  548  acres  of  land, 
about  seventy-five  per  cent,  of  which  is  tillable. 

The  East  Side  Physicians'  Association  of  the  City  of 
New  York  will  hold  a  meeting  on  Thursday,  April  22d, 
at  Scheffel  Hall,  194  Third  Avenue,  New  York.  Dr.  M. 
Girsdansky  will  read  a  paper  entitled  The  Myth  of  Puer- 
peral Septicaemia,  and  Dr.  Charles  Jewett  will  read  a 
paper  on  Puerperal  Sepsis.  Interesting  specimens  will  be 
presented  by  Dr.  Joseph  Wiener,  Jr..  and  the  general  dis- 
cussion will  be  opened  by  Dr.  Gustave  Seeligman.  At  the 
close  of  the  meeting  a  collation  will  be  served  to  both 
members  and  guests. 


The  Mortality  of  New  Orleans. — During  the  month 
of  February,  1909,  there  were  557  deaths  reported  to  the 
Board  of  Health,  352  white  and  205  colored,  in  an  esti- 
mated population  of  362,000;  265,000  white  and  97,000  col- 
ored. The  annual  death  rate  in  a  thousand  population  for 
the  month  was  15.94 -for  the  white  population,  25.36  for  the 
colored,  and  18.46  for  the  total  white  and  colored.  The 
total  infant  mortality  was  79;  64  under  one  year  of  age, 
and  15  between  one  and  two  years  of  age.  There  were  45 
still  births  during  the  month. 

The  Health  of  Pittsburgh. — During  the  week  ending 
March  27,  1909,  the  foUowmg  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
9  cases,  o  deaths ;  typhoid  fever,  12  cases,  3  deaths ;  scarlet 
fever,  30  cases,  2  deaths;  diphtheria,  13  cases,  i  death; 
measles,  28  cases,  o  deaths ;  whooping  cough,  26  cases,  0 
deaths ;  pulmonary  tuberculosis,  36  cases,  14  deaths.  The 
total  deaths  for  the  week  numbered  140,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  12.88  in  a  thousand  population. 

Diseases  of  the  Gall  Bladder  was  the  general  topic 
for  consideration  at  the  April  6th  meeting  of  the  Section 
in  Surgery  of  the  Buffalo  Academy  of  Medicine.  Dr. 
Allen  A.  Jones  read  a  paper  on  the  Gastric  Symptoms  and 
Comolications  of  Disease  of  the  Gall  Bladder.  Dr.  Ros- 
well  Park  read  a  paper  on  Complications  Arising  in  the 
Surgical  Treatment  of  Diseases  of  the  Gall  Bladder.  Dr. 
Martin  B.  Tinker,  lecturer  in  surgery  at  the  Cornell  Uni- 
versity Medical  College,  read  a  paper  entitled  The  Diag- 
nosis and  Surgical  Treatment  of  Diseases  of  the  Gall 
Bladder. 

The  Junior  Sea  Breeze  Hospital,  the  summer  hospital 
for  children,  at  Sixty-fourth  Street  and  East  River,  New- 
York,  which  was  built  by  Mr.  John  D.  Rockefeller  three 
years  ago,  will  be  opened  next  month  for  the  fourth  season 
by  the  New  York  Association  for  Improving  the  Condi- 
tion of  the  Poor,  under  the  auspices  of  which  the  hospital 
is  conducted.  The  work  carried  on  this  season  will  be 
more  extensive  than  ever  before,  as  additional  accommo- 
dations have  been  provided  for  sixty  babies,  and  the  staff" 
of  visiting  nurses  has  been  increased.  Day  classes  for 
mothers  will  also  be  held  at  the  hospital. 

Smallpox  in  New  Jersey. — It  is  reported  that  several 
cases  of  smallpox  have  been  discovered  in  Haddonfield 
and  Camden,  and  heroic  measures  are  being  adopted  to 
check  the  spread  of  the  disease.  In  Haddonfield  eight 
cases  have  been  reported,  and  the  health  authorities  burned 
to  the  ground  the  home  of  one  of  the  victims.  Eight  hun- 
dred pupils  in  the  public  schools  have  been  vaccinated.  In 
Camden  the  disease  has  been  practically  confined  to  the 
negrO'  population,  and  the  Board  of  Health  has  issued  or- 
ders that  every  negro  in  the  city  must  be  vaccinated.  The 
health  authorities  of  both  cities  feel  confident  that  the  dis- 
ease will  not  become  epidemic. 

The  Hygienic  Laboratory  of  the  U.  S.  Public  Health 
and  Marine  Hospital  Service. — The  addition  to  the  labor- 
atory, for  which  congress  appropriated  $75,000  some  time 
ago,  has  just  been  completed.  It  will  be  occupied  by  the 
divisions  of  zoology,  pharmacology,  and  chemistry,  and  the 
library,  the  original  building  being  devoted  entirely  to  the 
divisions  of  pathology  and  bacteriology.  One  of  the  most 
important  of  the  new  lines  of  work  recently  undertaken 
in  the  laboratory  is  the  preparation  of  a  digest  of  the  criti- 
cisms of  the  U.  S.  Pharmacopoeia  which  have  appeared 
since  the  publication  of  the  Eighth  Revision.  The  labora- 
tory has  also  undertaken  the  institution  of  the  treatment 
of  rabies  by  the  Pasteur  method. 

Individual  Drinking  Cups  for  the  Laclcawanna  Rail- 
road.— The  individual  paper  drinking  cup,  which  Dr. 
Thomas  C.  Darlington,  Commissioner  of  Health  of  New 
York,  has  been  testing  this  winter  at  department  head- 
quarters, has  been  adopted  by  the  Lackawanna  Railroad. 
Passengers  on  the  Lackawanna  Limited  have  commented 
on  a  small  nickel  plated  device  adjacent  to  the  water 
cooler.  Closely  nested  within  a  tube  are  a  hundred  or 
more  dainty  white  drinking  cups,  which  once  drawn  forth 
and  used  cannot  be  replaced  but  must  be  discarded  or 
carried  away.  These  cups,  which  are  in  the  e.xact  form  of 
a  drinking  glass,  are  stiffened  by  a  coating  of  paraffin  and, 
being  manufactured  automatically,  are  untouched  by  hands 
until  they  reach  those  of  the  drinker. 


758 


NEIVS  ITEMS. 


[New  York 
Medical  Jourxau 


Scientific   Society   Meetings  in.  Philadelphia   for  the 
Week  Ending  April  17,  1909: 

Monday,  'April  12th. — Section  in  General  Medicine,  College 

of  Physicians. 
Tuesday,  April  13! It. — Philadelphia  Psediatric  Society. 
Wednesday,   April    i4ih. — Philadelphia    County  Medical 

Society. 

Thursday,  April  15th. — Section  in  Ophthalmology,  College 
of   Physicians ;   Section  Meeting,  Franklin  Institute ; 
Southwark  Medical  Society ;  Northeast  Branch,  Phila- 
delphia   County   Medical    Society ;    Delaware  Valley 
Ornithologists'  Club. 
Friday,    April    i6th. — American    Philosophical  Society; 
West  Branch,  Philadelphia  County  Medical  Society. 
Changes  in  the  Medical  Faculty  of  Columbia. — Three 
important  additions  will  be  made  next  fall  to  the  faculty 
of  the  medical  department  of  Columbia  University  (Col- 
lege of  Physicians  and  Surgeons.)    That  of  Dr.  William 
G.  MacCallum,  who  comes  to  the  chair  of  pathology  from 
the  place  of  professor  of  pathological  physiology  ;;nd  lec 
turer  on  forensic  medicine  at  the  Johns  Hopkins  University, 
has  already  been  announced.    In  the  department  of  the 
practice  of  medicine  Dr.  Walter  B.  James,  at  his  own  re- 
quest has  been  transferred  from  the  Bard  professorship, 
which  involved  the  administration  of  the  department,  to  a 
professorship  of  clinical  medicine,  and  Dr.  Theodore  C. 
Janeway  and  Dr.  Evan  M.  Evans,  now  associates  in  medi- 
cine, have  been  promoted— Dr.  Janeway  to  the  Bard  pro- 
fessorship, and  Dr.  Evans  to  a  newly  created  professorship 
of  clinical   medicine.     Dr.  R.   Burton  Opitz,  adjunct  of 
physiology,  has  been  appointed  head  of  the  department  of 
physiology.  ! 

The  British  Association  for  the  Advancement  of 
Science  will  meet  in  Winnipeg,  Canada,  on  August  25, 
1909,  under  the  presidency  of  Sir  J.  J.  Thomson,  F.  R.  S. 
A  local  executive  committee  and  local  executive  officers 
have  been  appointed,  who  will  have  charge  of  all  local  ar- 
rangements. A  series  of  excursions  is  being  planned  for 
the  visiting  members  dunng  and  after  the  meeting,  which 
will  include  a  ten  days'  excursion  to  the  Pacific  Coast.  Ar- 
rangements are  also  being  made  for  a  party  of  mineral- 
ogists and  geologists  to  visit  the  Cobalt  district  en  route  to 
W  innipeg  before  the  meeting.  Full  information  regarding 
the  excursions  may  be  obtained  from  the  Local  Secretaries 
of  the  British  Association  for  the  Advancement  of  Science, 
University  of  Manitoba,  Winnipeg,  Canada.  A  list  of  the 
hotels  and  lodging  houses  will  be  issued  by  the  Winnipeg 
Executive  Officers,  to  whom  application  should  be  made 
early  in  July. 

Infectious  Diseases  in  New  York: 

IVe  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folloiving  statement  of  new 
cases  and  deaths  reported  for  the  tzvo  iveeks  ending  April 
2,  1909: 

.—March  27 — ,     ,  .Vpril  3  ^ 

_  ,        ,    .       ,  .  Cases.    Deaths.    Cases.  Deaths. 

luberculosis  piilmonalis    527         igg         ^^g  212 

Diphtheria    354  4,  32 

Scarlet  fever                                         4,5  ,7  373 

Smallpox    .  .  4  ' 

X'aricella                                                221  21^ 

Typhoid   fever                                         20  '5  26  '5 

Whooping  cough                                     63  10  62  8 

Cerebrospinal  meningitis                           g  8  jo  5 

"^"^^^   :i,i22         307       2.563  315 

Personal.— Dr.  Achilles  Rose,  of  New  York,  the  em- 
inent Greek  scholar,  has  retired  from  active  practice  and 
will  go  to  Athens,  Greece,  where  he  will  reside  in  future. 

Dr.  C.  .\.  Grofif.  of  Philadelphia,  has  been  appointed 
assistant  chief  medical  in.spector  in  the  Bureau  of  Health 
of  Philadelphia,  to  succeed  Dr.  Thomas  J.  Beattv,  deceased. 

Dr.  Paul  Bartholow,  of  New  York,  has  beeii  elected  to 
membership  in  the  New  York  Academy  of  Medicine. 

Major  Charle';  Lynch,  of  the  Medical  Corps  of  the  W  S 
Army,  delivered  a  lecture  before  the  Kansas  Citv  .\cademy 
of  Medicine  on  Saturday.  April  3d,  on  The  Medical  Service 
of  a  Modern  .'\rmy  as  Exemplified  by  the  Japanese  Army 
in  the  Russo-Japanese  War. 

Dr.  William  C.  Griswold.  of  the  Medical  Corps  of  the 
U.  S.  .'\rmy.  is  spending  a  three  months'  leave  of  absence 
in  taking  a  special  course  at  the  New  York  Postgraduate 
Medical  School  and  Hospital. 

Dr.  Frcderik  van  Eeden.  of  .\mstcrdam.  delivered  a 
lecture  on  March  24th  at  the  Universitv  of  Wisconsin  on 
The  Mind  in  Hfalth  and  Disease. 


"Symposium"    on   the    Status    Lymphaticus. — At  a 

stated  meetuig  of  the  New  York  Academy  of  Medicine, 
which  will  be  held  on  Thursday  evening,  April  15th,  under 
the  auspices  of  the  Section  in  Paediatrics,  the  programme 
will  consist  of  a  "symposium"  on  the  status  lymphaticus. 
Dr.  Alfred  Scott  Warthin,  of  the  University  of  Michigan, 
will  read  a  paper  on  the  Pathology  of  the  Status  Lymphati- 
cus, which  will  be  illustrated  with  lantern  slides.  Dr.  L. 
Emmet  Holt  will  discuss  the  clinical  features  of  the  sub- 
ject, and  Dr.  Joseph  A.  Blake  will  take  up  its  surgical  as- 
pect. The  general  discussion  will  be  opened  by  Dr.  John  A. 
VVyeth,  and  among  those  who  will  take  part  are  Dr.  James 
Ewing,  Dr.  John  Howland,  Dr.  Charles  Norris,  and  Dr. 
J.  P.  Crozer  Griffith,  of  Philadelphia. 

Vital  Statistics  of  New  York. — During  the  week  end- 
ing March  27,  1909,  there  were  reported  to  the  Department 
of  Health  of  the  City  of  New  York  1,619  deaths  from  all 
causes,  in  an  estimated  population  of  4,422,685.  correspond- 
ing to  an  annual  death  rate  of  18.50  in  a  thousand  popula- 
tion, a  trifle  lower  than  the  rate  for  the  corresponding 
period  in  1908.  The  rate  of  mortality  for  each  of  the  five 
boroughs  was  as  follows:  Manhattan,  19.19;  the  Bronx, 
21.44;  Brooklyn,  17.05;  Queens,  16.19;  Richmond,  20.74. 
There  were  199  deaths  from  pulmonary  tuberculosis  during 
the  week  and  329  from  pneumonia.  Other  important  causes 
of  death  were :  Heart  diseases,  144  deaths ;  bronchitis,  33 
deaths ;  diarrheal  diseases,  84  deaths,  of  which  39  were 
under  five  years  of  age ;  contagious  diseases,  90  deaths ; 
Bright's  disease,  132  deaths;  violent  deaths.  80,  of  which 
17  were  suicides.    There  were  136  still  births. 

College  of  Physicians  of  Philadelphia. — The  last  meet- 
ing of  the  season  of  the  Section  in  General  Medicine  will- 
be  held  on  Monday  evening,  April  12th.  The  following 
programme  has  been  arranged :  Dr.  Sherbourne  W.  Dough- 
erty— Report  of  a  Case  of  Sigmoid  Diverticulitis,  with 
Some  Observations  upon  the  Diagnosis  :  Dr.  David  Reis- 
man — Acute  Gout  (Podagra)  Occurring  in  a  Patient  with 
Bright's  Disease  while  upon  a  Greatly  Restricted  Diet ; 
Dr.  R.  S.  Lavenson — Observations  on  Gastric  Secretion  in 
a  Child  with  a  Gastric  Fistula,  with  Remarks  upon  the 
Recent  .A.dvances  in  the  Physiologj'  of  Gastric  Secretion 
and  Motility ;  Dr.  J.  C.  Gittings  and  Dr.  Ralph  Pemberton 
— Critical  Analysis  of  Typhoid  Fever  Cases  Occurring  at 
the  Presbyterian  Hosoital :  Dr.  John  H.  Musser — Report 
of  a  Case  of  Gastric  Carcinoma  with  LTnusua!  Symptoms. 

To  Reorganize  the  Ambulance  Service  in  New  York^ 
— At  a  conference  held  on  -April  6th.  it  was  decided  to  re- 
organize the  ambulance  service  of  Manhattan  and  Brooklyn 
in  accordance  with  the  provisions  of  the  Newcomb-Robin- 
son  bill  now  pending.  ."Kmong  those  present  at  the  confer- 
ence were  Mayor  McClellan.  Police  Commissioner  Bing- 
ham, Dr.  J.  W.  Brannan,  of  Bellevue.  Dr.  Walter  J.  Ben- 
sel,  of  the  Health  Department,  and  Mr.  Nathan  Bijur.  It 
was  decided  to  place  the  general  supervision  of  the  Brook- 
lyn ambulance  service  into  the  hands  of  the  Commissioner 
of  Charities,  and  in  Manhattan  to  give  to  Bellevue  Hospi- 
tal the  general  supervision  of  the  ambulance  service.  On 
account  of  Roosevelt  Hospital  recently  abandoning  its  am- 
bulance service,  it  was  decided  to  redistrict  the  city  and 
divide  the  work  among  the  other  hospitals.  .\  new  com- 
mission, with  supervisory  powers,  was  organized  with  of- 
ficers as  follows:  President.  Police  Commissioner  Bing- 
ham :  secretary,  the  Hon.  Robert  Hebbcrd.  commissioner 
of  charities;  voting  member.  Dp.  J.  W.  Brannan. 

Public  Health  Lectures  at  the  Postgraduate. — .A 
course  of  lectures  on  public  health  and  sanitation,  includ- 
ing school  inspection  and  school  hvgiene  lias  been  inaugu- 
rated at  the  New  York  Postgraduate  Medical  School  and 
Hospital.  The  first  lecture  in  the  course  was  delivered  on 
Friday  afternoon,  .April  gth.  before  the  students  of  the 
medical  school  and  a  number  of  physician-  who  are  inter- 
ested in  questions  relating  to  public  health.  The  subject 
v.-ns  The  Need  of  Doctors  of  Public  Health.  The  subject? 
chosen  for  subsenuciit  lectures  are  as  follows:  The  Reduc- 
tion of  Infant  Mortality:  The  Regulation  of  the  Practice 
of  Midwifery:  The  Sanitation  of  Schools.  Theatres,  and 
Other  Public  Buildings:  Milk  Production:  Sr.nitnrv  In- 
rnection  of  Offensive  Trades:  Child  Labor::  Laboratories 
and  Hospitals  for  the  Studv  of  Contncious  Diseases:  The 
Production  of  Sera  and  Vaccines :  The  Methods  of  Dis- 
trict TuMiection  of  Personal  Hygiene:  Disinfection  and 
Fumi.gation  ;  and  Vital  Statistics.  The  course  is  in  charge 
of  Dr.  John  J.  Cronin.  of  the  Department  of  Health  of 
the  City  of  New  York,  and  the  lectures  are  delivered  ore 
Mondav  and  Friday  .Tftornoon^.  at  4.30  o'clock. 


April  10,  1909. J 


NEWS  ITEMS. 


759 


The  American  Therapeutic  Society.— The  preliminary 
programme  of  the  tenth  annual  meeting  of  this  society, 
which  is  to  be  held  m  Lampson  Hall,  Yale  University, 
New  Haven,  Conn.,  on  May  6th,  7th,  and  8th,  has  just  been 
issued.  It  contains  a  list  of  the  papers  to  be  presented  at 
this  meeting  and  a  programme  of  the  entertainments  which 
have  been  planned  for  the  visiting  members  and  then- 
friends.  The  papers  are  all  on  subjects  of  practical  interest 
to  the  general  practitioner,  and  the  list  of  authors  includes 
leaders  in  the  profession  from  all  parts  of  the  country. 
Three  "symposia"  have  been  arranged;  one  on  Thursday 
afternoon  on  Diabetes,  one  on  Friday  morning  on  Diet, 
and  the  other  on  Friday  afternoon  on  Psychotherapy.  The 
subject  of  the  president's  address,  which  will  be  delivered 
on  Thursday  morning,  will  be  The  Therapeutic  Value  of 
Hypnotic  Suggestion.  The  officers  of  the  society  are: 
President,  Dr.  Frederic  H.  Gerrish,  of  Portland,  Me. ;  first 
vice  president,  Dr.  Alexander  D.  Blackader.  of  Montreal, 
Canada  ;  second  vice  president.  Dr.  Howard  Van  Rensselaer, 
of  Albany,  N.  Y. ;  third  vice  president,  Dr.  Robert  T. 
Morris,  of  New  York,  N.  Y. ;  secretary.  Dr.  Noble  *P. 
Barnes,  of  Washington,  D.  C. ;  treasurer.  Dr.  A.  Ernest 
Gallant,  of  New  York,  N.  Y. ;  chairman  of  committee  on 
arrangements.  Dr.  Oliver  T.  Osborne,  of  New  Haven, 
Conn. 

Charitable  Bequests. — By  the  will  of  William  Y. 
Meschter,  of  Norristown,  Pa.,  the  Mennonite  Home  for 
Aged  People,  Frederick,  Montgomery  County,  Pa.,  receives 
$300;  the  FrankHn  Reformatory  for  Inebriates,  Philadel- 
phia, receives  $200;  the  Pennsylvania  Society  to  Protect 
Children  from  Cruelty  receives  $200;  the  Pennsylvania  So- 
ciety for  the  Prevention  of  Tuberculosis  receives  $300;  the 
Medico-Chirurgical  Hospital,  of  Philadelphia,  receives 
$5,000  for  the  establishment  of  a  free  bed  in  memory  of  the 
testator's  father  and  mother,  the  Rev.  Jacob  Meschter  and 
Agnes  M.  Meschter;  the  Methodist  Episcopal  Hospital  and 
the  German  Hospital,  of  Philadelphia,  receive  $500  each. 

By  the  will  of  Ellen  Connell,  of  Maiden,  Mass.,  who  died 
on  March  25th,  the  following  Catholic  institutions  become 
beneficiaries :  The  Home  for  Destitute  Catholic  Children, 
Boston.  $100;  Little  Sisters  of  the  Poor,  Somerville,  $100; 
Free  Home  for  Consumptives,  Boston,  $100. 

By  the  will  of  Amelia  A.  Krause,  the  Bethesda  Chil- 
dren's Home,  at  Wyndmoor,  Pa.,  will  receive  $8oD.  The 
residual  estate  is  bequeathed  to  Christ  Church  Hospital. 

In  the  will  of  Nancy  Harding  Fordick,  of  Brookline, 
Mass.,  the  following  bequests  were  made :  $3,000  each  to 
the   Old  Ladies'   Home  of   Charlestown,   the  Children's 
Home  of  Charlestown,  the  Cullis  Consumptives'  Home  of 
Grove  Hall,  and  the  Old  Couple's  Home  of  Roxbury ; 
$S,ooo  each  to  the  Perkins  Institute  for  the  Blind,  South 
Boston;  the  Kindergarten  for  the  Blind,  Jamaica  Plain; 
and  the  Boston  Dispensary;  $3,000  each  to  the  Salvation 
.'Vrmy  fresh  air  fund  and  the  Boston  Floating  Hospital. 
Society  Meetings  for  the  Coming  Week: 
MoND.w,  April  I2th. — -New  York  Academy  of  Medicine 
(Section  in  Neurology  and  Psychiatry)  ;   Society  of 
Medical  Jurisprudence,  New  York;  New  York  Oph- 
thalmological  Society ;  Society  of  Alumni  of  St.  Mary's 
Hospital,  Brooklyn  ;  Corning,  N.  Y.,  Medical  Associa- 
tion ;  Waterbury,  Conn.,  Medical  Association. 
TuESD.w,  April  13th. — New  Y^ork  Academy  of  Medicine 
(Section  in  Public  Health)  ;  Medical  Society  of  the 
County  of  Schenectady,  N.  Y. ;  Practitioners'  Club  of 
Jersey  City,  N.  J. ;  Medical  Society  of  the  County  of 
Rensselaer,  N.  Y. ;  Buffalo  Academy  of  Medicine  (Sec- 
tion in  Medicine). 
Wedne.sdav.  April  14th. — New  York  Pathological  Society; 
New  York  Surgical  Society;  Medical  Society  of  the 
Borough  of  the  Bronx,  New  York ;  Alumni  Associa- 
tion of  the  City  Hospital,  New  York ;  Brooklyn  Med- 
ical and  Pharmaceutical  Association ;  Medical  Society 
of  the  County  of  Richmond,  N.  Y. 
Thursday,  April  r^fli. — New  Y^ork  Academy  of  Medicine; 
German  Medical  Society,  Brooklyn ;  Newark.  N.  J.. 
Medical  and  Surgical  Society;  ^sculapian  Club  of 
Buffalo.  N.  Y. 

Friday.  April  i6th. — New  York  Academy  of  Medicine 
(Section  in  Orthopaedic  Surgery)  :  Clinical  Society  of 
the  New  York  Postgraduate  Medical  School  and  Hos- 
pital:  East  Side  Phvsici.ins'  Association  of  the  City 
of  New  York:  New  York  Microscopical  Society; 
Brooklyn  Medical  Society. 


The  Bombay  Medical  Congress,  which  was  held  dur- 
ing the  week  of  February  22d,  under  the  presidency  of  His 
Excellency  Sir  George  Sydenham  Clark,  Governor  of 
Bombay,  was  most  successful.  It  brought  together  a  large 
number  of  workers  in  tropical  medicine,  who  carried  away 
with  them  new  knowledge  relating  to  the  many  branches 
of  tropical  medicine  and  surgery  and  fresh  inspiration  for 
their  work.  The  congress  was  divided  into  five  sections, 
and  the  papers  read  before  these  sections  during  the  four 
days  the  congress  was  in  session  represented  the  latest 
advances  in  tropical  medicine,  among  the  subjects  receiving 
special  attention  being  plague,  leprosy,  cholera,  dysentery, 
and  malaria.  After  the  section  meetings  an  importam 
exhibition  was  held  of  surgical  instruments,  aseptic  furni- 
ture, sanitary  appliances  and  models,  drugs,  foods,  etc. 
Great  interest  was  manifested  in  the  congress  by  the  gov- 
ernment and  the  public  at  large,  and  now  that  the  value 
of  scientific  research  has  been  recognized,  it  is  hoped  that 
the  congress  will  meet  again  in  three  or  four  years. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing March  27,  1909,  the  following  cases  of  transmissible 
diseases  were  reported  to  the  Bureau  of  Health  of  Phila- 
delphia :  Malarial  fever,  i  case,  0  deaths ;  typhoid  fever,  45 
cases,  7  deaths ;  scarlet  fever,  72  cases,  3  deaths ;  chicken- 
pox,  64  cases,  o  deaths;  diphtheria,  94  cases,  16  deaths; 
cerebrospinal  meningitis,  i  case,  o  deaths ;  measles,  188 
cases,  14  deaths ;  whooping  cough,  13  cases,  2  deaths ; 
tuberculosis  of  the  lungs,  189  cases,  76  deaths ;  pneumonia, 
46  cases,  64  deaths ;  erysipelas,  7  cases,  3  deaths ;  puerperal 
fever,  2  cases,  i  death ;  tetanus,  2  cases,  i  death ;  anthrax, 
I  case,  0  deaths ;  mumps,  20  cases,  o  deaths ;  trachoma,  i 
case,  0  deaths.  The  following  deaths  were  reported  from 
other  transmissible  diseases :  Tuberculosis,  other  than 
tuberculosis  of  the  lungs,  7  deaths ;  diarrhoea  and  enteritis, 
under  two  years  of  age,  15  deaths;  dysentery,  i  death. 
The  total  deaths  numbered  571  in  an  estimated  population 
of  1,565,569,  corresponding  to  an  annual  death  rate  of 
18.91  in  a  thousand  population.  The  total  infant  mortality 
was  108;  85  under  one  year  of  age,  23  between  one  and 
two  years  of  age.  There  were  31  still  births,  18  males  and 
13  females.    The  total  precipitation  was  0.23  inch. 

Race  Improvement  in  the  United  States. — The  thir- 
teenth annual  meeting  of  the  American  Academy  of  Polit- 
ical and  Social  Science  will  be  held  in  Witherspoon  Hall, 
Philadelphia,  on  Friday  and  Saturday,  April  16th  and  17th. 
The  general  topic  for  discussion  will  be  Race  Improve- 
ment in  the  United  States :  The  Development  of  Physical 
Welfare  Through  Social  Environment.  On  Friday  morn- 
ing there  will  be  a  special  exhibition  on  congestion  in  cities, 
at  which  Mr.  Benjamin  C.  Marsh,  of  New  York,  will  speak 
on  the  Dangers  of  Congestion  of  Population.  Dr.  Abra- 
ham Jacobi,  of  New  York,  will  preside  at  the  Friday  after- 
noon session,  and  the  subject  chosen  for  consideration  at 
this  session  is  the  Relative  Importance  of  Heredity  and 
Environment  in  Race  Improvement.  Papers  will  be  pre- 
sented by  Dr.  Carl  Kelsey,  professor  of  sociology  in  the 
University  of  Pennsylvania  ;  Dr.  Dudley  Allen  Sargent,  of 
Harvard  University ;  Dr.  Charles  B.  Davenport,  director 
of  the  station  for  experimental  evolution.  Cold  Spring 
Harbor,  N^  Y. ;  and  Mr.  Alexander  Johnson,  of  Fort 
Wayne,  Ind.  The  Influence  of  City  Environment  on 
National  Life  and  Vigor  is  the  topic  selected  for  discussion 
at  the  Friday  evening  session,  and  addresses  will  be  deliv- 
ered by  Dr.  Luther  H.  Gulick,  Dr.  Woods  Hutchinson,  and 
the  Hon.  Herbert  Parsons,  of  New  York.  The  Saturday 
morning  session  will  be  held  in  the  Psychological  Labora- 
tory of  the  University  of  Pennsylvania.  Dr.  Lightner  Wit- 
mer,  professor  of  psychology  at  the  university,  will  hold  a 
psychological  clinic,  and  there  will  be  a  general  discussion 
of  the  agencies  whose  cooperation  is  essential  for  the 
physical,  mental,  moral,  and  social  treatment  of  defective 
and  delinquent  children.  Obstacles  to  Race  Progress  in 
the  United  States  is  the  subject  for  the  Saturday  afternoon 
session,  and  papers  wnll  be  read  by  Dr.  Charles  L.  Dana, 
Mr.  Ray  Stannard  Baker,  Mr.  Champe  C.  Andrews,  Dr. 
J.  P.  Lichtenberger,  and  Mrs.  Florence  Kelley.  The  clos- 
ing session  w-ill  be  held  on  Saturday  evening,  at  8.30 
o'clock,  at  which  the  Hon.  William  P.  Dillingham,  United 
States  Senator  from  Vermont,  will  preside.  Addresses  will 
be  delivered  by  the  Hon.  Oscar  S.  Straus,  the  Hon. 
William  S.  Bennet,  Mr.  John  Mitchell,  and  Mr.  William  Z. 
Ripley. 


-(3c  PITH  OF  CURRENT  LITERATURE. 


|itt  at  €mm  f  itjramn. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

April  I,  1909. 

1.  Recent  Progress  in  the  Treatment  of  Various  Condi- 

tions Called  Rheumatism,        By  Robert  B.  Osgood. 

2.  Infection  with  ihe  Bacilkis  .A.erogenes  Capsulatus,  Fol- 

lowing Abortion.    A  Report  of  Two  Cases,  in  One 
of  which  the  Bacillus  was  Recovered  from  the  Cir- 
culating Blood  during  Life. 
By  Ernest  Boven  Young  and  Lawrence  J.  Rhe..\. 

3.  Tuberculous  Pericarditis,       By  Carleton  R.  Metcalf. 

4.  The  Wassermann  Reaction  in  Syphilis  and  Other  Dis- 

eases,    By  Robert  T.  Lee  and  Wyman  Whitemore. 

5.  Modern  Ideas  on  the  Teaching  of  Therapeutics  and 

Pharmacodynamics,       By  Maurice  Vegert  Tyrode. 

2.  Infection  with  the  Bacillus  Aerogenes  Cap- 
sulatus, Following  Abortion. — Young  and  Rhea 
describe  two  such  cases.  Both  the  gross  and  mi- 
croscopical findings  in  the  two  cases  were  typical  of 
those  produced  by  the  Bacillus  aerogenes  capsulatus. 
From  the  first  case  the  Bacillus  acrogeiies  capsu- 
latus, Bacillus  coli  coiiimuiiis.  and  Staphylococcus 
pyogenes  albus  were  recovered  from  a  swab  taken 
from  the  uterine  cavity  eighteen  hours  before  the 
patient  died.  A  cuUure  taken  at  the  same  time 
from  the  circulating  blood  showed  a  pure  culture  of 
the  Bacillus  aerogenes  capsulatus.  This  organism 
was  also  recovered  from  cultures  taken  from  vari- 
ous organs  at  the  autopsy.  The  uterine  cavity 
showed  the  Bacillus  aerogenes  cafysulatus.  Staphy- 
lococcus pyogenes  albus,  and  Bacillus  coli  coninut- 
nis.  In  the  second  case,  cultures  were  taken  at  au- 
topsy from  various  organs.  The  Bacillus  coli  coni- 
niunis  was  recovered  from  the  liver  ;  the  Bacillus 
aerogenes  capsulatus  was  not  obtained.  The  inabil- 
ity to  recover  the  Bacillus  acrogcnes  capsulatus  from 
this. case  may  be  accounted  for  from  the  fact  that 
the  body  had  been  kept  in  the  refrigerator  at  32°  F. 
for  twenty-four  hours. 

4.  The  Wassermann  Reaction  in  Syphilis  and 
Other  Diseases. — Lee  and  Whitemorc  have  made 
experiments  with  the  Wassermann  reaction.  They 
found  tliat  a  positive  serum  reaction  for  syphilis  is 
obtained  in  eighty-nine  per  cent,  of  all  cases  of  syph- 
ilis of  whatever  stage.  In  the  active  secondary  and 
tertiary  stage  a  positive  reaction  is  obtained  in 
ninety-five  per  cent,  to  one  hundred  per  cent. 
Known  normal  cases  seem  to  give  invariably  a  neg- 
ative reaction.  Some  chronic  diseases  accompanied 
by  marked  emaciation  near  death  may  give  positive 
reactions.  This  seems  especially  true  of  tuberculous 
cases.  In  such  cases  there  is  usually  no  question  of 
a  di.stinctive  diagnosis  of  syphilis.  In  other  disea.scs 
the  reactions  are  generally  negative.  The  few  posi- 
tive reactions  might  well  be  explained  by  tlie  possi- 
I)ility  of  the  incidence  of  a  latent  syphilis. 

MEDICAL  RECORD 

April  3,  igoQ. 

1.  ,\  .\ew  Method  of  Recognizing  Ulcers  of  the  Upper 

Digestive  Tract  and  of  Lf)ca]izing  'I  hem. 

By  Max  F.inhorn. 

2.  Postural  Lung  Dullness;  Its  Value  in  Diagnosis  and 

Treatment,  By  Albert  Abrams. 

-Anaphylaxis  and  bnmunity, 

By  Eugene  F.  Mc  Campbeli,. 


[Ne.\  ^■^KK 
MedIC.\U  Jia'KNAL. 

4.  Diagnosis  and  Treatment  of  Internal  Hsemorrhage  and 

of  Pulmonary  Haemorrhage,  as  a  Complication  of 
Tuberculosis,  By  Thomas  I-".  Smith. 

5.  Renal  Tuberculosis,  By  Edward  Quick. 

6.  Is  Gastrointestinal  Autointoxication  a  Disease  or  Only 

a  Symptom?  By  O.  L.  Mulit. 

1.  Diagnosis  of  Ulcer  of  the  Upper  Digestive 
Tract. — The  diagnosis  of  ulcer  of  the  stomach  is 
usually  connected  with  a  good  deal  of  difficultv. 
Even  in  the  presence  of  larger  cjuantities  of  blood  in 
the  vomited  matter  or  in  the  stool  no  positive  diag- 
nosis of  ulcer  of  the  stomach  can  be  made.  Einhorn 
follows  a  method  which  w'ill  make  it  possible  to  de- 
termine accurately  the  pressure  of  an  ulcer  and  at 
times  to  localize  it.  The  method  consists  in  the  fol- 
lowing :  The  patient  swallows  the  duodenal  bucket  in 
a  gelatin  capsule  about  9  p.  m.  The  thread  which  is 
of* braided  silk  (English.  No.  5)  is  attached  to  the 
shirt  in  stich  a  manner  that  it  can  pass  in  through 
the  digestive  tract  for  a  distance  of  75  cm.  from  the 
lips.  The  bucket  is  left  in  the  digestive  apparatus 
over  night  and  is  removed  about  7  or  8  a.  m.,  in  th^ 
fasting  condition.  At  the  pylorus  we  often  experi- 
ence a  slight  resistance  which  is  usually  easily  over- 
come ;  a  greater  resistance  is  offered  at  the  larynx  at 
the  entrance  of  the  oesophagus.  Here  the  patient 
mu.st  swallow,  and  while  the  larynx  moves  upward 
the  bucket  may  easily  be  drawn  out.  The  thread  is 
then  closely  inspected.  In  favorable  cases  of  ulcer, 
particularly  if  the  thread  has  come  into  intimate  con- 
tact with  the  surface  of  the  ulcer,  we  find  a  brown 
or  dirty  black  discoloration  of  the  thread  at  this 
point.  The  distance  of  this  brown  spot  from  the  lip.-; 
points  to  the  seat  of  the  ulcer.  A  blood  .stain  in  the 
neighborhood  of  40  cm.  points  to  an  ulcer  at  the 
cardia,  at  44  to  54  cm.  ulcer  of  the  lesser  curvature, 
56  to  58  cm.  ulcer  of  the  pylorus,  59  and  more  ulcer 
in  the  duodenum.  The  method  might  be  called  the 
"thread  impregnation  test."  LHcers  situated  in  the 
oesophagus,  cardia,  lesser  curvature,  pylorus,  and 
duodenum  can  best  be  recognized  by  this  method, 
whereas  ulcers  of  the  fundus  and  the  greater  curva- 
ture cannot  be  discovered  by  this  test.  Ten  cases 
without  ulcer  were  tested  with  the  thread  test  and  a 
negative  result  obtained.  In  as  far  as  it  appears  to 
be  advantageous  to  recognize  tilcers  also  in  regions 
that  are  not  accessible  to  the  throat  Einhorn  adopted 
the  following  method :  A  rubber  bag  is  introduced 
into  the  stomach,  which  bag  is  surrounded  with  silk 
gauze  which  is  inflated  and  left  for  a  half  hour  in 
tins  condition.  The  walls  of  the  stomach  are  thus  in 
close  contact  with  the  inflated  bag.  Finally  the  air 
is  allowed  to  escape  and  the  collapsed  balloon  is 
witlidrawn.  If  an  ulcerated  surface  is  present  in 
the  stomach  we  get  a  blood  spot  on  the  gauze  at  the 
corresponding  point.  The  instrument  could  prob- 
ably l>est  be  called  the  "gastric  stamper."  The  pa- 
tient must  have  an  empty  stomach,  otherwise  the 
organ  has  to  be  washed  out. 

5.  Renal  Tuberculosis. — Quick  observes  that 
there  are  but  three  ways  in  which  tubercle  bacilli 
can  reach  sucli  a  remote  organ  as  the  kidney,  viz., 
I,  by  the  blood;  2,  by  ascending  the  ureter:  3.  by 
direct  extension  from  coiUagious  organs.  The  ar- 
terial supply  is  such  that  the  kidney  structure  is  di- 
vided into  sharply  defined  sy.steius.  This  separation 
is  most  marked  between  the  anterior  and  posterior 
regions,  and  the  upper  and  lower  poles.    There  is 


A|  ril   I  o.  1  909. 1 


PITH  OF  CURRENT  LITERATURE. 


occasionally  seen  a  sharply  defined  tuberculosis  of 
one  pole  only.  It  is  conceded  by  all  that  tuberculosis 
once  started  finds  in  the  kidneys  so  favorable  a 
nidus  that  the  disease  becomes  always  progressive. 
Kidneys  removed  by  the  surgeon  often  show  a 
miliary  type  of  the  disease  which  is  not  part  of  a 
general  iniliarv  tuberculosis  and  which  infection 
"could  not  possibly  have  been  distributed  from  the 
ureter.  The  infection  corresponds  to  the  peculiar 
anatomy  of  the  kidney.  The  tubercles  are  most 
numerous  in  the  cortex  when  the  bacilli  have  be- 
come arrested  in  the  terminals  of  the  renal  arterv. 
The  question  whether  the  kidney  can  be  infected  by 
an  ascending  process  along  the  ureter  is  still  open. 
Direct  extension  from  contiguous  tissues  is  a  rare 
source  of  tuberculous  infection  of  the  kidney.  The 
conclusion  is  that  there  is  considerable  evidence  and 
a  very  wfdespread  clinical  notion  that  renal  tubercu- 
losis is  frequently,  if  not  usually,  a  primary  blood  in- 
fection, and  in  many  cases  unilateral.  However, 
primary  has  reference  particularly  to  the  genito- 
urinary system.  The  actual  atrium  of  infection 
must  be  sought  in  other  parts  of  the  body.  After  a 
tuberculous  infection  is  suspected,  the  hunt  for  the 
tubercle  bacillus  begins.  If  an  acid  resisting  bacil- 
lus is  found  in  the  mixed  urines,  we  must  determine 
whether  this  organism  is  the  smegma  bacillus  or  the 
tubercle  bacillus.  Both  organisms  are  acid  resist- 
ing, but  the  smegma  bacillus  is  destained  by  alcohol 
and  the  tubercle  bacillus  is  not.  It  is  often  useful 
to  use  the  Gram  stain,  as  the  tubercle  bacillus  stains 
by  the  Gram  method,  while  the  smegma  bacillus 
does  not.  So  far  as  possible  the  smegma  bacillus 
should  be  excludecl  by  the  use  of  catheterized  speci- 
mens from  the  bladder.  The  presence  of  tubercle 
bacilli  in  the  urine  is  of  the  highest  importance.  The 
absence  of  the  organisms  is  not  so  vital.  Their  pres- 
ence may  give  rise  to  great  difficulty  in  diagnosis, 
since  it  must  be  borne  in  mind  that  tubercle  bacilli 
as  well  as  many  other  organisms  may  pass  through 
the  kidneys  without  infecting  them.  If  both  kidneys 
are  infected  with  the  tubercle  bacillus  we  can  only 
wait  for  death  to  relieve  the  burden.  A  spontaneous 
cure  is  so  rare  that  Albarran  could  successfully  chal- 
lenge the  French  Surgical  Society  to  produce  an  in- 
dubitable instance.  Tuberculosis  of  the  kidney  as- 
sumes the  aspect  of  a  malignant  infection.  It  is  with 
the  rarest  exceptions  progressive.  To  attempt  a 
cure  by  climatic  and  hygienic  measures  is  time  lost. 
If  both  (irgans  are  involved,  of  course,  this  is  the 
only  method  available.  When  one  organ  is  infected, 
to  postpone  surgical  intervention  is  to  court  the  risk 
of  infection  of  the  bladder  and  sister  organ.  A 
seeming  cure  is  sometimes  obtained  by  the  process 
of  caseation  and  final  sequestration  through  oblitera- 
tion of  the  ureter. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 
April  3.  iqog. 

1.  Sanitation  of  the  Tropics  with   Special  Reference  to 

Malaria  and  Yellow  Fever, 

By  William  C.  Gorgas. 

2.  The  Functions  of  the  End  Organs  in  the  Vestibule  and 

Semicircular  Canals  and  the  Methods  for  Examining 
These  Canals  in  Practical  Diagnosis, 

By  George  E.  Shambaugh. 

3.  Intestinal  Localization,  Including  Surgery  and  Surgical 

Anatonn-  of  the  Small  Intestine, 

By  George  H.  Monks. 


4.  The  Repair  of  the  Internal  Ring  in  Oblique  Inguinal 

Hernia,  By  F.  Gregory  Connell. 

5.  The  Management  and  Treatment  of  a  Case  of  Infec- 

tion by  the  Bacillus  ty/'liosiis.  By  J.  P.  Roark. 

6.  Complement  Fixation  in  Malignant  Disease, 

By  Charles  E.  Simon. 

7.  Some  Facti  about  the  .-\rmy  Medical  Corps, 

By  Robert  M.  Culler. 

8.  Mild  Atypical  Typhoid  Fever  :  Result  with  Blood  Cul- 

tures, By  John  Pelham  Bates. 

9.  A  Study  of  the  .'\ction  of  Scopolamine  Morphine  on 

the  Heart,  Liver,  and  Kidneys.  Report  of  Six  Hun- 
dred and  Fifty  Cases  of  Scopolamine  Morphine  Ad- 
ministrations Preliminary  to  General  Anaesthesia, 

By  C.  M,  Nicholson. 

10.  The  Need  for  a  School  of  Tropical  Medicine  in  the 

United  States,  By  E.  N.  Tobey. 

2.  The  Functions  of  the  End  Organs  in  the 
Vestibule  and  Semicircular  Canals. — Shambaugh 
remarks  that  the  study  of  the  occurrence  of  vertigo 
and  nystagmus,  both  that  observed  in  disease  of  the 
labyrinth  and  that  brought  on  by  syringing  the  ear 
with  hot  and  cold  water,  has  established  the  follow- 
ing facts,  which  are  of  great  assistance  in  diagnosis 
not  only  of  the  labyrinth  but  of  the  cerebellum  as 
well.  If  the  semicircular  canals  are  normal  and  the 
ear  is  syringed  with  cold  water,  vertigo  will  result, 
and  there  will  be  set  up  a  nystagmus  increased  by 
directing  the  eyes  toward  the  opposite  side.  If  the 
ear  is  syringed  with  warm  water  the  same  symp- 
toms will  occur,  but  the  nystagmus  will  be  toward 
the  same  side.  Should  there  exist  an  irritation  of 
the  endings  of  the  vestibular  nerve  in  the  labyrinth, 
such  as  may  be  occasioned  by  a  circumscribed  sup- 
puration in  the  labyrinth,  there  will  be  spontaneous 
nystagmus  directed  toward  the  same  side.  Syring- 
ing the  ear  with  cold  water  will  produce  a  positive 
reaction.  If  there  occurs  a  sudden  destruction  of 
endings  of  the  vestibular  nerve,  such  as  would  be 
occasioned  by  a  diffuse  suppuration  in  the  labyrinth, 
there  will  be  set  up  a  spontaneous  nystagmus  di- 
rected toward  the  opposite  side,  but  lasting  only 
from  a  few  days  to  several  weeks.  This  nystagmus 
has  its  origin  in  the  opposite  normal  ear.  Syringing 
the  affected  ear  with  hot  and  cold  water  produces  no 
response.  In  case  of  long  standing  destruction  of 
the  nerve  endings  in  the  vestibular  nerve,  such  as 
occurs  in  chronic  diffuse  labyrinth  suppuration, 
there  will  be  no  spontaneous  nystagmus  and  no  re- 
action can  be  obtained  by  syringing,  the  ear  with  hot 
or  cold  water.  In  case  of  cerebellar  disease,  such 
as  cerebellar  tumor,  cerebellar  abscess,  or  a  menin- 
gitis in  this  locality,  there  will  occur  a  spontaneous 
nystagmus  directed  toward  the  affected  side.  It 
follows,  therefore,  that  in  case  there  exists  pro- 
nounced rotating  nystagmus,  and  the  membrana 
tympani  is  normal,  showing  an  absence  of  an  in- 
flammation in  the  middle  ear,  the  presence  of  a 
cerebellar  tumor  should  be  suspected.  On  the  other 
hand,  should  there  exist  pronounced  spontaneous 
rotating  nystagmus  in  a  case  of  suppurative  otitis 
media  without  fever,  but  with  severe  deafness,  and 
this  nystagmus  is  directed  toward  the  aft'ected  side, 
while  the  syringing  of  the  ear  with  cold  water  pro- 
duces no  response,  the  diagnosis  of  a  cerebellar  ab- 
scess is  the  probable  one.  Here  the  complete  de- 
struction of  the  hearing  in  the  affected  ear  would 
indicate  a  probable  diffuse  suppuration  of  the  laby- 
rinth.    The  failure  to  get  the  caloric  response  on 


762 


PITH  OF  CURRENT  LITERATURE. 


[Xew  York 
Medical  Journai. 


syringing  points  to  destruction  of  end  organs  in  the 
semicircular  canals.  The  only  spontaneous  nystag- 
mus which  this  lesion  could  produce  would  be  di- 
rected toward  the  opposite  side.  The  absence  of 
rise  of  temperature  would  in  most  cases  eliminate 
a  meningitis  as  the  source  of  the  nystagmus,  while 
a  cerebellar  abscess  pressing  on  the  vestibular  nerve 
could  produce  a  spontaneous  rotating  nystagmus, 
which  would  be  increased  by  directing  the  eyes  to- 
ward the  affected  side. 

3.  Intestinal  Localization. — Monks  observes 
that  the  surgeon  can,  approximately  at  least,  tell  to 
what  part  of  the  small  intestine  any  given  loop  be- 
longs. He  can  tell  the  real  direction  of  the  bowel 
in  that  loop,  provided  the  wound  is  large  enough 
to  allow  him  to  palpate  the  mesenteric  root ;  or,  af- 
ter the  bowels  and  the  abdominal  wall  have  been 
retracted,  to  see  it.  Intestinal  coils  outside  of  an  ab- 
dominal wound  can  be  efficiently  protected  between 
two  thin  sheets  of  rubber.  When  the  intestines  are 
enveloped  (in  the  sheets  of  rubber)  the  abdominal 
fossae  and  the  pelvis  may  be  inspected  much  more 
thoroughly  than  when  the  coils  of  intestine  are 
within  the  abdominal  cavity.  As  a  demonstration, 
the  mass  of  bowels,  comprising  nearly  the  whole  of 
the  small  intestine,  can  be  supported  well  above  an 
abdominal  wound  by  means  of  a  special  holder.  As 
a  demonstration,  the  intestine  and  mesentery  may 
be  satisfactorily  shown  at  the  same  time  by  gather- 
ing the  intestine  on  a  rod,  and  then  elevating  the 
rod  horizontally  above  the  abdominal  wound.  In 
order  properly  to  introduce  a  long  rigid  tube  into 
the  intestines  for  the  purpose  of  emptying  them,  the 
intestines  should  be.  drawn  over  the  end  of  the  tube, 
and  "gathered"  on  it  in  a  manner  similar  to  that  in 
which,  for  demonstration,  the  rod  was  used.  The 
base  of  the  pelvic  fold  of  the  mesentery  is  an  impor- 
tant landmark  in  the  lower  abdomen,  and  it  can 
usually  be  palpated  from  a  wound  in  that  part  of 
the  abdomen.  The  great  fossa  on  the  left  of  the 
abdomen  may  be  reached  from  a  wound  in  the 
lower  abdomen  by  carrying  the  tip  of  an  irrigating 
nozzle  well  around  the  pelvic  fold  of  the  mesentery, 
and  then  pushing  it  upward.  Finally,  the  lowest 
coil  of  the  ileum  can  be  picked  up  at  once  between 
the  surgeon's  thumb  and  finger  by  causing  them  to 
grasp  the  base  of  the  pelvic  fold  of  the  mesentery 
and  the  loop  of  bowel  which  is  attached  to  it. 

4.  Oblique  Inguinal  Hernia.  —  Connell  re- 
marks that  in  repairing  the  oblique  inguinal  hernia 
the  repair  of  the  internal  ring  by  suture  of  the 
transversalis  fascia  beneath  the  cord,  which  causes 
both  minimization  and  elevation  of  that  structure, 
with  the  attachment  of  the  internal  oblique  muscle 
to  the  outer  two  thirds  of  Poupart's  ligament,  so 
that  it  covers  and  protects  the  repaired  internal 
ring.  There  will  be  caused  a  relationship  which 
results  in  a  valvelike  formation  of  the  inguinal 
canal,  which  is  important  in  preventing  recurrence. 
These  steps  should  be  preceded  by  the  removal  of 
the  sac  at  its  neck,  with  the  redundant  parietal  peri- 
tonaeum, and  followed  by  the  reunion  of  the  divided 
external  oblique  aponeurosis,  and  the  formation  of 
a  suitable  external  ring. 

5.  Typhoid  Infection. — Roark  thinks  that  by 
lessening  tiie  toxjcmia,  which  is  the  only  cause  of 
the  rise  of  temperature,  the  temperature  can  be 
brought  to  normal  only  by  a  bath.    The  method  is 


this :  As  soon  as  a  diagnosis  is  made  with  reason- 
able certainty  a  calomel  purge  is  given  at  bedtime 
and  is  followed  with  a  saline  cathartic  next  morn- 
ing, not  with  the  idea  of  modifying  the  infection, 
but  for  the  purpose  of  clearing  the  intestinal  tract 
of  particles  of  undigested  and  fermented  food,  for 
during  the  prodrorhal  period  of  the  disease  most  of 
these  patients  eat  food  that  they  cannot  digest.  The 
baths  are  now  instituted  at  once  without  reference 
to  the  patient's  temperature.  The  bath  is  first  given 
at  7  a.  m.  and  repeated  regularly  every  two  hours 
during  the  day  until  9  p.  m.,  unless  the  patient  is 
restless,  when  the  last  bath  is  given  at  11  p.  m.  Im- 
mediately preceding  each  bath  the  patient  is  re- 
quired to  drink  from  four  to  eight  ounces  of  water, 
and  immediately  after  each  bath  he  is  required  to 
sip  slowly  from  two  to  six  ounces  of  milk,  the 
amount  depending  largely  on  the  appetite  of  the  pa- 
tient. The  technique  the  author  describes  thus: 
One  half  of  the  bed  is  covered  with  any  material 
(an  ordinary  quilt,  folded  once,  answers  the  pur- 
pose perfectly),  the  patient's  nightgown  is  removed, 
and  he  is  moved  on  to  the  covered  portion  of  the 
bed.  Two  large  bath  towels  are  then  saturated  in  a 
bowl  of  water  of  the  required  temperature ;  the  pa- 
tient is  told  to  extend  the  arms  parallel  with  the 
body,  and  the  anterior  surface  of  the  body  is  covered 
with  the  towels  that  have  been  slightly  squeezed — 
not  wrung — when  taken  from  the  water.  The  tow- 
els are  allowed  to  remain  for  three  minutes ;  then 
they  are  removed,  rewetted,  and  the  process  is  re- 
peated on  the  posterior  surface  of  the  body.  The 
patient's  body  should  be  entirely  covered  from  head 
to  heel,  the  towels  overlapping  somewhat  in  the 
middle  of  the  body.  The  whole  process,  including 
time  spent  in  giving  water  before  the  bath  and  milk 
afterward,  should  occupy  about  twelve  minutes.  If 
the  patient  complains  of  chilliness  following  the 
bath  he  may  have  a  hot  water  bottle  and  some  ex- 
tra cover  for  fifteen  or  twenty  minutes,  and  if  the 
chilliness  is  not  relieved  in  this  time  it  is  best  to 
raise  the  temperature  of  the  water  used  in  the  bath. 
These  baths  should  be  continued  in  this  manner  and 
time  until  the  patient  seems  on  the  point  of  achiev- 
ing his  immunity,  as  evidenced  by  a  marked  fall  in 
temperature,  an  ability  to  take  solid  food,  the  oc- 
currence of  a  formed  fiscal  movement,  a  normal 
tongue,  etc.  Then  they  should  be  given  every  three 
hours,  and  after  the  temperature  has  been  normal 
in  the  evening  for  two  or  three  days  they  may  be 
discontinued,  unless  the  disease  should  later  sliow 
signs  of  recrudescence,  when  they  should  promptly 
be  again  instituted.  The  only  contraindication  is 
the  occurrence  of  severe  intestinal  haemorrhage. 
The  baths  should  then  be  stopped  for  a  few  hours, 
until  it  appears  that  the  h3emorrhage  is  controlled, 
when  they  should  be  resumed.  The  temperature  of 
the  bath  for  a  robust  adult  should  be  about  60°  F.. 
and  for  most  women  and  all  children  from  twenty 
to  thirty  degrees  higher.  When  the  reaction  is  de- 
layed more  than  ten  minutes  it  is  too  cold  and  the 
temperature  should  be  raised. 

9.  The  Action  of  Scopolamine  Morphine  upon 
the  Heart,  Liver,  and  Kidneys. — Xieliolson  has 
experimented  on  animals  —  dogs,  rabbits,  cats, 
guinea  pigs — with  scopolamine  and  morphine  injec- 
tions. The  results  show  that  the  effects  of  the  in- 
jection of  scopolamine  anil  morphine  into  animals 


April  10,  1909.1 


PITH  OF  CURRENT  LITERATURE. 


763 


is  similar  to  that  of  morphine  when  given  alone, 
with  the  exception  of  the  injection  into  kittens,  in 
which  excitement  instead  of  sleep  was  produced. 
Continued  fepeated  daily  injections  produce  no  de- 
generation of  the  heart,  liver,  or  kidneys,  the  physi- 
cal condition  is  not  impaired  so  long  as  the  injec- 
tions are  given  at  such  intervals  as  not  to  interfere 
with  the  animal's  nutrition.  Daily  injections  of 
from  one  to  three  times  the  dose  given  to  patients 
produce  no  pathological  changes  in  animals.  The 
toxic  dose  of  scopolamine  and  morphine  in  his  ex- 
periments corresponded  very  closely  to  that  of  mor- 
phine alone  for  the  animals  used.  The  autopsy  find- 
ings in  animals  which  succumbed  to  a  toxic  dose 
were  the  same  as  those  for  morphine,  i.  e.,  conges- 
tion of  the  viscera.  The  animals  seemed  to  acquire 
a  tolerance  for  the  drugs  on  long  continued  daily 
administrations.  The  cause  of  death  in  patients  who 
have  died  after  operation  and  who  were  previously 
given  scopolamine  has  been  more  readily  explained 
as  due  to  great  loss  of  blood  during  or  before 
operation,  to  sepsis,  or  to  shock.  They  have  been 
desperate  cases  and  in  not  a  single  case  could  scopo- 
lamine be  said  to  have  produced  death.  Scopolamine 
by  itself  is  very  slightly  toxic  for  animals  and  cer- 
tainly does  not  produce  any  degeneration  of  the 
heart,  liver,  or  kidneys. 

BRITISH  MEDICAL  JOURNAL. 
March  20,  igog. 
r.    Some  Insufficiently  Recognized  Points  in  the  Diagnosis 
of  Disease,  By  Sir  D.  Duckworth. 

2.  The  Diagnosis  of  Fever  in  Patients  from  the  Tropics, 

By  Sir  P.  Manson. 

3.  Common  Mistakes  in  Ophthalmic  Practice, 

By  A.  C.  Roper. 

4.  The  Value  of  Some  Lactic  Acid  Ferment  Preparations 

for  Intestinal  Therapy, 

By  I.  W.  Hall  and  W.  A.  Smith. 

5.  Mining  Accidents :  With  an  Account  of  the  Use  of 

Oxygen  in  a  Coalpit  Accident,        By  J.  Robertson. 

6.  A   Simple   Method  of  Estimating  Ammonia  in  the 

Urine,  Suitable  for  Clinical  Purposes, 

By  G.  C.  Mathison. 

7.  Observations  on  the  Physiology  of  the  Female  Genital 

Organs  (Report  CXII  of  the  Science  Committee  of 
the  British  Medical  Association), 

By  W.  B.  Bell  and  P.  Hick. 

2.  Diagnosis  of  Tropical  Fevers. — Manson  first 
calls  attention  to  two  fallacies  which  must  be  avoid- 
ed. Because  a  fever  has  been  contracted  in  or  is  oc- 
curring in  a  patient  from  the  tropics  does  not  nec- 
essarily mean  that  it  is  a  tropical  fever,  symptomatic 
of  some  condition  peculiar  to  the  tropics.  Always 
think  first  of  and  test  for  the  great  pandemic  con- 
ditions— tuberculosis,  syphilis,  typhoid  fever,  can- 
cer, and  sepsis.  Next,  care  must  be  taken  not  to  be 
misled  by  the  diagnosis  of  malaria,  which  the  pa- 
tient is  almost  sure  to  volunteer.  Excluding  such 
acute  and  short  fevers  as  yellow  fever,  dengue,  etc., 
the  following  are  the  tropical  fevers  likely  to  be 
brought  to  England  or  America,  in  the  approximate 
order  of  their  frequency: — i.  Malaria.  2.  Hepatitis 
and  liver  abscess.  3.  Mediterranean  or  Malta  fever. 
4.  Kala-azar,  trypanosomiasis  and  sleeping  sickness, 
relapsing  fever,  elephantoid  fever,  and  other  infec- 
tions whose  nature  is  at  yet  unknown,  i.  Malaria. 
The  first  step  in  the  diagnosis  of  tropic  fevers,  is  to 
recognize  or  exclude  malaria.  The  most  important 
clinical  test  of  the  disease  is  its  periodicity.  Quotid- 
ian or  daily  periodicity,  however,  is  common  to 


many  diseases,  and  should  usually  be  ignored  as  an 
indication  of  malaria.  The  periodicity  characteristic 
and  absolutely  diagnostic  of  malaria  is  either  a  ter- 
tian or  a  quartan  periodicity.  Where  the  quotidian 
fever  sets  in  late  at  night,  however,  is  almost  pecul- 
iar to  malaria.  The  quinine  test  for  malaria  is  relia- 
ble if  properly  applied.  Ten  grains  two  or  three 
times  a  day  is  almost  sure  in  forty-eight  to  seventy- 
two  hours  to  tell  us  whether  we  are  dealing  with 
malaria  or  not.  But  the  quinine  should  be  given  in 
solution,  or,  in  highly  catarrhal  or  irritable  condi- 
tions of  the  stomach,  intramuscularly  in  doses  of 
seven  to  ten  grains.  The  microscopical  test  is  even 
more  reliable  than  the  two  before  mentioned  tests ; 
if  the  malarial  parasite  or  its  product — hjemozoin 
or  melanin — is  found  in  the  blood.  But  the  patient 
must  not  be  under  the  influence  of  quinine ;  even  a 
small  dose  may  cause  the  parasite  to  disappear  tem- 
porarily from  the  peripheral  circulation.  2.  Liver 
abscess.  Here  the  first  question  should  be,  has  the 
patient  had  dysentery  or  diarrhoea?  Among  the 
local  signs  are  enlargement  of  the  hepatic  area,  espe- 
cially upward,  local  pain,  oedema,  and  redness. 
Among  the  constitutional  indications  are  ansemia, 
progressive  emaciation,  and  irritability  and  depres- 
sion of  mind.  The  decubitus  is  dorsal,  there  is  pain 
in  the  shoulder,  and  finally  the  leucocytes  are  in- 
creased. 3  Mediterranean  fever.  Here  are  to  be 
noted  an  undulant  type  of  the  fever,  profuse  sweats, 
marked  rheumatic  pains,  orchitis,  and  the  absence  of 
indications  of  other  disease.  Otherwise  the  evidence 
is  principally  of  a  negative  nature.  The  serum 
test  is  not  always  reliable.  4.  Kala  azar.  Here  the 
patient  is  from  India,  China,  or  the  Soudan ;  he 
has  a  chronic  fever,  and  his  liver  and  spleen  are 
enormously  enlarged.  He  has  been  ill  for  men  hs, 
is  anaemic,  has  taken  pounds  of  quinine,  and  is  grad- 
ually growing  worse.  The  blood  shows  a  very 
marked  leucopenia,  or  poverty  in  white  corpuscles. 
There  are  usually  two  distinct  rises  of  temperature 
in  the  twenty-four  hours.  Leishman  bodies  can 
be  found  in  the  juice  obtained  by  puncture  of  the 
spleen  or  liver.  The  syringe  and  needle  used  must 
be  absolutely  dry,  otherwise  the  parasites  will  be 
so  distorted  by  endosmosis  as  to  be  unrecognizable. 
5.  Trypanosomiasis.  The  patient  comes  from  tropi- 
cal Africa,  and  complains  of  irregular  fever,  great 
lassitude,  and  tenderness  of  the  limbs.  The  skin 
shows  patches  of  ringed  erythema  and  there  is  a 
general  glandular  enlargement.  Examination  of 
the  blood  during  one  of  the  recurring  attacks  of 
fever  shows  the  trypanosome.  It  is  also  to  be 
found  in  puncture  fluid  from  an  enlarged  gland.  6. 
Relapsing  fever.  The  patient  comes  from  India, 
tropical  or  North  Africa,  or  Gibraltar.  There  are 
attacks  of  violent  fever  once  every  two  weeks,  last- 
ing from  three  to  six  days.  Examination  of  the 
blood  during  the  fever  paroxysm  shows  the  spiio- 
chset^  of  relapsing  fever.  7.  Elephantoid  fever. 
The  patient  has  attacks  of  violent  fever  at  irregu- 
lar intervals,  with  inflammation  and  cellulitis  of 
limb,  scrotum,  or  acute  lymphangitis. 

4.  Lactic  Acid  Treatment. — Hall  and  Smith 
have  studied  the  value  of  some  of  the  lactic  acid  fer- 
ment preparations  used  in  intestinal  therapy,  and 
find  that  even  the  best  present  commercial  prepara- 
tions are  not  sufficiently  and  regularly  active  for 


764 


PITH  OF  CURRENT  UTER.lTURIi. 


[New  York 
MoDiCAL  Journal. 


routine  use.  and  that  freshly  prepared  fluid  cultures 
should  be  employed  when  lactic  acid  therapy  is  in- 
dicated. The  activity  and  power  of  the  organisms 
in  producing-  acids  cannot  be  taken  as  an  index  of 
their  multiplication  and  inhibitory  action  upon  other 
organisms,  and  it  is  probable  that  no  one  organism 
can  be  regarded  as  efficacious  in  every  case.  When 
one  organism  fails  to  produce  the  desired  result,  cer- 
tain laboratory  tests  may  indicate  the  selection  of 
bacilli  possessing  other  characteristics.  It  should 
also  be  borne  in  mind  that  the  lactic  acid  therapy  is 
only  indicated  when  the  putrefactive  anaerobic  or- 
ganisms are  present  in  the  faeces  in  excess,  and  that 
without  such  a  guide  this  form  of  medication  ma}- 
aggravate  rather  than  ameliorate  the  intestinal  con- 
ditions. 

LANCET. 

Marc  1 1  20,  igog. 

\.    Uisiiiffction  and  Disinfectants  (Milroy  Lectures,  11). 

By  R.  T.  Hewlett. 

2.  X  Ray  Carcinoma  and  an  Experimental  Inquiry  into 

the  Conditions  Which  Precede  Its  Onset  (Hunterian 
Lecture).  By  C.  W.  Rowntree. 

3.  The  Mechanisni  Underlying  the  Various  Methods  of 

Artificial  Respiration  Practised  Since  the  Founda- 
tion of  the  Royal  Humane  Society  in  1774  (Hun- 
terian Lectures,  H),  By  A.  Keith. 

4.  An  Investigation  into  the  Leucocytosis  of  Epidemic 

Cerebrospinal  Meningitis.  By  W.  Dow. 

5.  A  Case  of  Intestinal  Pseudoparasitism  Due  to  Chilodon 

[  'lu-iiiafus  ( Blochmann), 

By  Sir  P.  Manson  and  L.  W.  S.\mbon. 

6.  .A  Note  on  the  Cultivation  of  Spirochccia  Duttoiii, 

By  C.  M.  Duval  and  J.  L.  Todd. 

7.  Urreniia  or  Meningitis?  By  A.  E.  Garrod. 

8.  A  Case  of  Malignant  Disease  of  the  Nasopharynx, 

By  W.  Stuart-Lovv. 
Q.    Problems  in  Mendelism  and  Some  Biological  Consid- 
erations: Human  Albinos,  By  G.  P.  Mi'dge. 

1.  Disinfection. — Hewlett,  in  the  second  of  his 
Milrov  lectures  on  disinfection  and  disinfectants, 
discusses  the  relative  merits  of  the  various  methods 
devised  for  the  determination  of  the  germicidal 
power  of  disinfectants.  The  Rideal-Walker  or  drop 
method  is  one  which  has  given  an  enormous  impetus 
to  the  standardization  of  disinfectants,  and  it  is  rel- 
atively simple  to  carry  out — a  very  desirable  condi- 
tion. With  the  emulsified  disinfectants  it  works 
well.  l)ut  with  disinfectants  like  mercuric  chloride, 
which  act  comparatively  slowly,  it  gives  too  low  a 
value.  It  is  lacking  in  that  in  its  original  form  it 
does  not  introduce  organic  matter  into  the  test,  a 
matter  of  considerable  importance.  This,  however, 
may  be  remedied  by  the  addition  of  faeces,  or  per- 
haps better  still,  of  gelatin  and  starch.  In  some  in- 
stances the  use  of  a  one  per  cent,  solution  which 
has  stood  for  twenty-four  hours  for  makii-i.g  the  test 
dilutions  is  desirable.  The  Chick-Martin  or  Lister 
Institute  nicthod  is  apjilicablc  ap])arently  to  all 
classes  of  flisinfectants  and  has  the  advantage  that 
but  a  single  variant  (that  of  concentration  of  disin- 
fectant) is  present,  and  not  two  variants — concen- 
tration and  time — as  in  the  Rideal-Walker  or  drop 
method.  The  method,  however,  is  not  nearly  so  sim- 
ple to  carry  out  as  the  Rideal-Walker  one.  The 
introduction  of  organic  matter  in  the  form  of  faeces 
marks  a  step  in  the  right  direction,  but  further  work 
is  necessary  to  determine  whether  this  is  the  best 
tnaterial  to  employ. 

2.  X  Ray  Cancer. — Rowntree,  in  his  Hunterian 
lecture,  states  that  ])rolonged  exposure  to  the  in- 


fluence of  the  X  rays  is  followed  by  injuries  which 
may  be  divided  into  two  classes: — (i)  more  or  less 
severe  burns  resulting  from  one  considerable  ex- 
posure ;  and  (2)  the  results  of  constant  exposure 
over  prolonged  periods  to  small  doses  of  the  rays. 
These  latter  changes  are  summed  up  under  the  con-i- 
prehensive  term  "x  ray  dermatitis."  It  is  now  a 
well  GStaJ^lished  fact  that  in  nuinerous  instances  the 
condition  ot  rS-diodermatitis  has  resulted  in  the 
formation  of  a '^lew.  growth,,  which  in  clinical  and 
microscopic  characters. is  squamous  celled  carcmo- 
ma.  An  imi^rtant  point  difiference  between  x  ray 
cancer  and  other  forms  of  malignant  growths,  -s 
that  in  the  former  the  lesions'v^re  very  often  mul- 
tiple. In  this,  as  in  many  other '"''f^P^^'^^'  '^"'^ 
dition  closely  resembles  xerodermia  pigmentosum. 
As  regards  treatment  of  x  ray  canc'r^'  ^'"''P'^- 
cision  of  the  growth  or  growths  may  carried  out 
in  many  instances,  because  the  degree  of  rJ'iaiignancx 
is  very  low.  The  evidence  is  conclusive  i^'^^t  t  le 
X  rays  in  a  moderately  large  dose  cause  reta^^  !^ 
of  cell  division  and  tissue  atrophy,  but  that  in'c^mali 
doses  the  opposite  efifect  of  stimulating  hyperai 
ity  of  cell  proliferation  is  brought  about.  ProbaT* 
there  are  two  essential  conditions  for  the  formatit?" 
of  a  squamous  celled  carcinoma:  (i)  The  presenc^ 
of  a  mass  of  epithelial  cells  which  are  capable  of 
multiplication;  and  (2)  a  surrounding  area  of  con- 
nective tissue  in  such  a  special  condition  as  to  ren- 
der it  vulnerable  to  epithelial  invasion.  The  con- 
nective tissues  in  advanced  x  ray  dermatitis  are  in 
almost  precisely  the  same  conditions  which  obtain  in 
precancerous  conditions.  It  is  also  a  feature  of  x 
ray  dermatitis  that  in  certain  stages  the  subepithelial 
tissue  shows  the  presence  of  masses  of  epithelial 
cells  which  are  more  or  less  con-ipletely  detached 
fron-i  the  surface  epithelium.  Such  a  mass  of  cells 
lying  isolated  in  a  favorable  stroma  of  altered  con- 
nective tissue,  ma\-,  as  the  result  of  the  stimulating 
efifects  of  constant  small  doses  of  the  rays  it  is  un- 
doubtedly receiving,  be  excited  to  grow,  and  as 
there  is  no  longer  any  normal  purpose  which  this 
isolated  mass  of  epithelium  can  fulfil  it  proliferates 
abnormally  and  invades  the  surrounding  parts. 
What  has  been  said  is  of  importance  in  connection 
with  the  X  ray  treatment  of  malignant  growths.  All 
observers  are  agreed  that  it  is  only  in  very  super- 
ficial conditions  that  amelioration  can  be  confidently 
anticipated.  Of  all  malignant  growths  rodent  can- 
cer is  the  most  superficial  and  it  is  the  only  variety 
in  which  really  good  results  have  been  obtainecl. 
I'ut  even  here  the  results  are  not  always  favorable. 
It  is  possible  that  in  certain  cases  the  dose  adminis- 
tered has  been  so  large  as  to  produce  a  condition 
analogous  to  x  ray  burn  ;  or  in  other  cases  it  is  prob- 
;ible  that  a  dose  just  sufficient  to  induce  retrogres- 
sion of  the  superficial  parts  of  a  growth  may.  in  the 
deeper  portions,  stinnilate  to  increased  activity. 

4.  Leucocytes  in  Meningitis. —  Dow  has  studietl 
the  leucocvtosis  which  is  a  constant  feature  of  epi- 
demic cerehr()S]>inal  meningitis,  and  reaches  the  fol- 
lowing conclusions: — i.  Cases  of  ei)idemic  cerebro- 
spinal meningitis  are  always  accompanied  by  a  leu- 
cocytosis, whether  the  attack  is  acute,  abortive,  mild, 
or  chronic.  2.  The  character  of  the  leuc(X"vtosis  is 
liractically  the  same  in  all  instances,  both  adults  and 
children,  and  is  the  result  mainly  of  an  increase  in 
the  number  of  the  ])olymorphonuclear  cells,   v  Xcv- 


April  10.  lyog.) 


PITH  OF  CURREXT  LITERATURE. 


ertheless  a  lymphocytosis  may  be  very  occasi  nally 
obstrved  in  intams  and  young  children.  4.  There 
is  a  relative  decrease  of  the  large  mononuclear  ele- 
ments alike  in  fatal  and  nonfatal  cases,  though  le.s 
marked  in  the  chronic  type.  5.  In  acute  cases  there 
is  sometimes  an  absolute  d-ecrease  of  the  large  mono- 
nuclear elements  and  occasionally  total  absence  of 
those  cells.  In  the  chronic  group,  absolute  decrease, 
like  relative  decrease,  is  little  marked.  6.  Eosino- 
phile  corpuscles  are  always  absent  in  acute  fatal 
cases,  though  present  in  varying  degree  in  all  others. 

LA  PRESSE  MEDICALE 

March  6,  1QO9. 

1.  The  Treatment  of  Cancer  by  Fulgiiration, 

By  Pierre  Fredet. 

2.  Technique  and  Operative  Indications  for  Drainage  of 

the  Hepatic  Canal.  By  Pierre  Sikor.\. 

3.  Wasserm.ann's  Reaction  in  Surgery.       By  R.  Rom  me. 

1.  Treatment  of   Cancer   by   Fulguration. — 

Fredet  describes  this  method  of  treatment  intro- 
duced by  Keating  Hart  in  1907  as  consisting  of  two 
parts,  the  surgical  removal  of  the  tumor  and  then 
the  projection  upon  the  wound  of  a  series  of  sparks 
obtained  from  an  alternating  current  of  high  fre- 
quencv  and  tension.  The  minimimi  of  the  surgical 
operation  is  the  complete  ablation  of  the  macro- 
scopic lesions,  the  object  of  the  fulguration  is  to  de- 
stroy the  remaining  neoplastic  particles.  After  a 
description  of  the  technique  the  author  mentions  the 
following  results  as  produced  by  fulguration.  It 
produces  an  nnmediate  arrest  of  hremorrhage  by 
vasoconstriction,  a  h.nemostasis  which  persists  thanks 
to  the  coagulation  of  the  blood  in  the  capillaries. 
Some  hours  after  the  fulguration  a  serous  exudate 
appears,  rich  in  polynucleated  cells  and  possessing 
toxic  and  perhaps  cytolytic  properties.  Retained 
in  a  wound  this  exudation  is  productive  of  intoxi- 
cation with  great  elevation  of  the  temperature  and 
may  even  cause  death.  The  fulguration  causes  a 
thin  eschar  of  the  tissues  which  comes  away  after  a 
few  days,  leaving  healthy  granulations.  Ful?,ura- 
tion  has  an  analgesic  effect  also.  The  indications 
for  this  treatment  may  be  said  to  be  confined  to  ex- 
ternal cancers,  such  as  of  the  breast  or  of  the  face. 
The  difficulties  of  access  to  visceral  cancers  seem 
to  present  an  insuperable  obstacle  to  its  employment 
in  such  cases. 

2.  Drainage  of  the  Hepatic  Canal. — Sikora  de- 
scribes in  detail  the  technique  of  this  procedure, 
which  he  seems  to  prefer  to  cholecystotoni}-. 

March  IS,  igcx). 

1.  Opening  Lecture  of  the  Surgical  Course  of  the  Faculte 

de  medecine  de  Paris,   By  Professor  H.  H.-\rtm.\n"n. 

2.  Diagnostic  Reaction  of  Tuberculin  on  the  Xasal  Mii- 

cous  Membrane.    The  Rhinorcaction, 

By  L.\FiTTE-DrP0XT  and  Molixiek. 

3.  The  Remote  Medical  Results  of  Contusions  of  the  Kid- 

ney. By  J.  SiMoxiN  and  Taxtox. 

4.  Apropos  of  Scoliosis  Following  Infantile  Paralysis, 

By  P.  Desfosses. 

2.  Diagnostic  Reaction  of  Tuberculin  on  the 
Nasal  Mucous  Membrane. — Lafitte-Dupont  and 
Molinier  apply  a  i  in  100  solution  of  dry  tuberculin, 
made  under  the  direction  and  in  the  manner  sug- 
gested by  Professor  Calmette.  on  a  pledget  of  cot- 
ton to  the  mucous  membrane  of  the  nose.  The 
patient  is  then  to  avoid  violent  respiration,  cough- 
ing, or  blowing  the  nose  for  six  minutes,  a  sufficient 
length  of  time  for  the  production  of  the  reaction. 


The  chaiactenstic  of  tiiis  rhinorcaction  is  the  ap- 
pearance of  an  exudate  at  the  point  of  application 
of  the  tuberculin,  preceded  by  a  more  or  less  in- 
tense congestion  01  the  mucous  membrane,  which 
also  persists  for  some  time  after  the  exudate  has 
become  dry  under  the  influence  of  the  respired  air. 
and  converted  into  a  thin  crust.  On  the  crusts  are 
often  found  little  hiematic  spots  due  to  extravasa- 
tion of  red  blood  globules.  The  crusts  are  adherent 
to  the  mucous  membrane,  and  their  removal  with  a 
probe  is  followed  by  a  slight  bloody  oozing.  Left 
to  themselves  they  become  detached  spontaneously. 
This  reaction  appears  in  from  eighteen  to  forty- 
eight  hours  after  the  application  of  the  tuberculin, 
but  its  complete  evolution  requires  seven  or  eight 
days,  exceptionally  ten  or  eleven  days.  The  nature 
of  the  exudate  and  the  predominance  in  it  of  poly- 
nucleosis is  in  accord  with  the  cytological  examina- 
tion of  cases  of  ophthalmoreaction.  They  believe 
the  rhinorcaction  to  be  as  reliable  as  the  ophthalmo 
or  the  cutaneous  reaction,  while  it  may  be  done 
without  the  knowledge  of  the  patient  and  is,  they 
assert,  absolutely  harmless. 

3.  Contusions  of  the  Kidney. — Simonin  and 
Tanton  report  two  cases  of  contusion  of  the  kidney 
on  which  they  based  a  study  of  the  remote  results 
on  the  functional  value  of  the  injured  organ,  and  of 
the  diminution  of  the  capacity  for  work  resulting 
from  the  injury  with  the  proper  claim  for  indem- 
nity. 

4.  Scoliosis  Following  Infantile  Paralysis. — 

Desfosses  asserts  that  infantile  paralysis  causes  a 
scoliosis  in  the  region  of  the  thorax  with  its  con- 
vexity directed  to  the  sound  side,  and  in  the  sacro- 
lumbar  region  a  scoliosis  with  its  convexity  directed 
toward  the  paralysed  side. 

LA  SEMAINE  MEDICALE. 
March  10.  igog. 

1.  Phlegmonous  Enteritis,  By  L.  Cheinisse. 

2.  The  Brachioocular  Syndrome  in  Cancer  of  the  Breast 

as  a  Contraindication  to  Surgical  Intervention. 

B\  I.  Kiproff. 

2.  The  Brachioocular  Syndrome  in  Cancer  of 
the  Breast  as  a  Contraindication  to  Surgical  In- 
tervention.— Kiprott  reports  a  case  of  cancer  of 
the  breast  in  which  the  patient  also  suft'ered  from 
paralysis  of  sensibility  along  the  course  of  the  ulnar 
nerve,  ptosis  of  the  upper  lid,  narrowing  of  the  pal- 
pebral fissure,  enophthalmos,  a  slight  vasodilatation 
of  the  conjunctival  vessels,  and  myosis.  The  exist- 
ence of  these  symptoms,  termed  the  brachioocular 
syndrome,  indicates  the  localization  of  a  metastasis 
at  the  level  of  the  last  cervical  vertebra,  and  forms  a 
contraindication  to  surgical  intervention  because  the 
latter  would  be  incomplete  without  the  extirpation 
of  this  metastasis, 

March  //.  /909. 
r.    Hepatocholangioenterostomy,  By  J.ejars. 

2.    Surgical  Treatment  of  Cerebral  Hremorrhage.' 

By  J.  LHERMITTfe. 

I.  Hepatocholangioenterostomy. — Lejars  de- 
scribes an  operation,  to  which  he  gives  this  name, 
that  he  performed  on  a  patient,  fifty-five  years  of 
age,  on  whom  cholecystectomy  had  been  performed 
several  years  before,  and  in  whom  the  bile  could 
not  be  drained  into  the  intestine  because  of  the  ab- 
sence of  the  gallbladder  and  of  the  common  bile- 
duct.  The  details  of  the  operation  should  be  read 
in  the  original. 


766 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 

March  2,  1909. 

1.  Diet  Poor  in  Salt  as  a  Remedy,  By  Mendel. 

2.  The  Processes  of  Cell  Degeneration,  Inflammation,  and 

New  Formation  in  the  Different  Varieties  of  Phos- 
phorus Poisoning,  By  Harn.\ck. 

3.  The  Behavior  of  the  Lungs  and  Heart  after  Operations 

on  the  Abdomen,  By  von  Lichtenberg. 

4.  The   Tubercle   Bacilli   Contained   in  Chesycretaceous 

Lymphatic  Glands,  By  Weiss. 

5.  Lymph  Follicles  in  the  Bone  Marrow  of  Children, 

By  Oehme. 

6.  The  Frequency  of  Tuberculosis  in  Children, 

By  Hamburger  and  Monti. 

7.  The  /Etiology  of  Appendicitis,  By  Klauber. 

8.  Bezold's  Functional  Test  of  the  Ears  and  Investigation 

of  Deafmutes,  By  Wanner. 

9.  Contribution  to  Hebeostomy,  By  Volker. 

10.  Acquired  Elephantiasis,  By  Tischler. 

11.  Oral  or  Nasal  Resection  of  the  Nasal  Saeptum.  A 

Reply,  By  Kretschmann. 

2.  Phosphorus  Poisoning. — Harnack  shows  by 
his  experiments  on  dogs  that  the  action  of  phos- 
phorus on  the  tissue  is  direct  and  local,  that  is,  not 
at  first  due  to  general  disturbances,  because  the  ac- 
tion is  the  more  intensive  the  more  concentrated  the 
phosphorus  is  at  the  place  affected. 

3.  Behavior  of  the  Lungs  and  Heart  after 
Operations  on  the  Abdomen. —  Von  Lichtenberg 
has  studied  this  subject  in  one  hundred  patients  oper- 
ated upon  in  the  surgical  clinic  at  Heidelberg.  The 
patients  were  fifty-two  men,  forty-eight  women,  ten 
in  the  second,  twenty-four  in  the  third,  twenty-nine 
in  the  fourth,  eighteen  in  the  fifth,  ten  in  the  sixth, 
eight  in  the  seventh,  and  one  in  the  eighth  decen- 
nium.  Thirty-five  of  the  operations  were  for  hernia, 
twenty-three  for  appendicitis,  ten  for  diseases  of 
the  stomach,  twenty  on-  the  biliary  passages,  and 
twelve  for  various  abdominal  conditions.  Chloro- 
form alone  was  used  in  fifteen,  ether  in  sixteen, 
mixed  chloroform  and  ether  in  thirty-six,  local 
anaesthesia  in  thirty-two,  and  lumbar  anaesthesia  in 
one.  The  conditions  found  on  physical  examina- 
tion after  the  operation  are  given  in  tabulated  form, 
and  the  following  conclusions  are  drawn:  i.  Post- 
operative complications  in  the  lungs  occur  much 
more  frequently  than  is  usually  supposed  because  in 
a  great  number  of  cases  they  run  their  course 
wholly  unmarked.  Slight,  temporary  rises  of  tem- 
perature in  the  days  immediately  after  an  aseptic 
operation  are  usually  caused  by  such  occult  compli- 
cations of  the  lungs.  2,  These  postoperative  changes 
in  the  lungs  cannot  be  termed  postoperative  pneu- 
monias in  the  usual  sense'.  Rather  they  form  the 
basis  for  the  development  of  such  complications, 
and  in  the  absence  of  favorable  conditions  can  retro- 
grade in  a  few  days  without  having  caused  much 
injury  to  the  persons  operated  upon.  3.  The  over- 
whelming majority  of  the  postoperative  pulmonary 
complications  appear  immediately  after  the  opera- 
tion and  arc  physically  demonstrable  on  the  second, 
third,  and  fourth  days.  The  method  of  an?esthetiza- 
tion  employed  exerts  no  influence  at  all  upon  the 
number  of  pulmonary  complications.  4.  Cases  of 
narcosis  pneumonia  occur  very  rarely.  In  the  great 
majority  of  cases  an  embolic  genesis  must  be  as- 
sumed, while  occasionally  hypostatic  forms  occur. 
5.  Extensive  heart  disease  appears  to  play  a  less  im- 


portant part  in  the  aetiology  than  changes  of  rela- 
tively less  degree  in  the  vascular  system  and  myo- 
cardium. 6.  The  presence  of  an  occult  pulmonary 
complication  may  be  inferred  from  the  restriction  of 
the  movability  of  the  borders  of  the  lungs  during 
the  days  immediately  after  the  operation.  7.  Con- 
clusions as  to  the  condition  of  the  circulatory  or- 
gans may  be  drawn  from  observation  of  the  pulse 
curve  in  any  particular  case  and  a  medicinal  sup- 
port of  these  organs  may  be  properly  instituted. 

5.  Lymph  Follicles  in  the  Bone  Marrow  of 
Children. — Oehme  says  that  lymph  follicles  with 
embryonic  centres,  formation  places  of  the  small 
lymphocytes,  are  to  be  found  in  the  otherwise  nor- 
mal red  marrow  of  the  long  bones  in  children,  with 
especial  frequency  in  children  suffering  from  rick- 
ets, either  with  or  without  general  lymphatic  hyper- 
plasia. This  probably  arises  as  a  local  hyperplasia 
from  the  normal,  adventitial,  lymphatic  cells  of  the 
vessels  of  the  medulla. 

7.  .ffitiology  of  Appendicitis. — Klauber  takes 
the  ground  that  appendicitis  is  caused  by  an  intes- 
tinal occlusion  located  in  the  appendix.  He  says 
that  simple  inflammation  of  the  intestine  never  pro- 
duces such  serious  injury  of  the  intestinal  wall  as 
to  result  in  peritonitis,  while  all  forms  of  mtestinal 
occlusion  are  productive  of  such  changes,  the  same 
as  those  that  take  place  in  appendicitis,  and  that  the 
acceptance  of  this  theory  explains  many  obscure 
points  in  the  pathology  of  the  disease. 

ANNALS  OF  SURGERY. 
March,  1909. 

1.  The  Intraabdominal  Administration  of  Oxygen, 

By  W.  S.  Bainbridge. 

2.  Plastic  Surgery  of  Bloodvessels  and  Direct  Transfusion 

of  Blood,  By  I.  Levin. 

3.  Nerve  Involvement  in  the  Ischaemic  Paralysis  and  Con- 

tracture of  Volkmann,  By  J.  J.  Thomas. 

4.  Operating  upon  the  Cranial  Vault,  By  H.  C.  Masland. 

5.  The  Surgical  Treatment  of  Internal  Hydrocephalus, 

By  R.  S.  Fowler. 

6.  Operations  Involving  Free  Opening  of  the  Thorax; 

Inflation  of  the  Collapsed  Lung  with  Oxygen  at  the 
Moment  of  Closing  the  Chest  Cavity  after  Operation, 

By  A.  E.  Rockey. 

7.  The  Value  of  the  Leucocyte  and  Distinctive  Counts  in 

Appendicitis,  By  G.  N.  Pease. 

8.  Typhoid  Fever  with  Multiple  Perforations.  Repeated 

Operations  Followed  by  Ultimate  Recovery, 

By  A.  j.  Roberts. 

9.  Angeiorrhaphy ;  Suture  of  a  Double  Stab  Wound  of 

the  Femoral  Artery  and  Vein,  By  F.  B.  Lund. 

10.  Perforating  Wound  of  the  Knee  Joint,  By  G.  Tonance, 

11.  An  Apparatus  for  the  Introduction  of  Salines  into  the 

Rectum,  By  G.  J.  Saxon. 

12.  The   Sitting  Posture.     Its   Postoperative   and  Other 

Uses,  By  W.  D.  Gatch. 

13.  A  Method  of  Splinting  Skin  Grafts.       By  J.  S.  D.wis. 

I.  The  Intraabdominal  Administration  of  Oxy- 
gen.— Bainbridge  lias  used  tliis  gas  clinically  dur- 
ing five  years,  as  follows :  i,  By  inhalation ;  2,  by  in- 
fusion into  the  pleural  cavity ;  3,  by  injection  into 
abscess  cavities,  carbuncles,  furuncles,  and  other 
acute  and  chronic  inflammations ;  4,  by  injection  into 
tuberculous  joints ;  5,  by  infusion  into  the  abdominal 
cavity,  the  gas  being  absorbed  in  a,  tuberculous  peri- 
tonitis with  ascites,  b,  after  removal  of  ascitic  fluid, 
c,  after  severe  abdominal  section  for  cnntrol  of 
shock,  hsemorrbage,  cyanosis,  nausea,  vomiting,  and 
the  prevention  of  adhesions.  The  indications  for 
which  it  is  now  used  within  the  abdomen  are  as  fol- 


April  10,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


767 


lows:  I.  To  lessen  shock,  haemorrhage,  nausea,  and 
vomiting.  2,  To  overcome  negative  intraabdominal 
pressure  after  removal  of  large  tumors.  3,  To 
prevent  the  formation  of  adhesions.  4.  To  produce 
favorable  results  in  tuberculous  peritonitis  of  certain 
tj^pes.  5,  To  destroy  pus  producing  organisms  and 
their  toxines.  The  pure  oxygen  gas  is  used.  It  is 
warmed  to  from  90°  to  100°  F.  The  abdominal 
wound  being  closed  except  at  the  lower  or  upper 
end  the  free  end  of  the  tube  conveying  the  oxygen 
is  introduced  within  the  abdominal  cavity.  The 
volume  of  oxygen  to  be  introduced  will  vary,  of 
course,  with  the  conditions  in  each  case,  care  being 
taken  always  to  avoid  undue  pressure  within  the 
abdomen. 

2.  Plastic  Surgery  of  Bloodvessels  and  Direct 
Transfusion  of  Blood. — Levin  defines  plastic  sur- 
gery of  blood  vessels  as  an  operative  procedure  in 
which  the  final  aim  is  not  to  arrest  the  bleeding  only, 
but  to  produce  a  free  circulation  through  the  im- 
paired vessels.  It  is  one  of  the  great  achievements 
of  modern  experimental  surgery.  In  repairing  a 
loss  of  continuity  of  a  bloodvessel  one  has  to  con- 
sider not  only  the  usual  aseptic  precautions,  but 
possible  secondary  haemorrhage,  and  the  formation 
of  thrombosis  with  subsequent  arrest  of  circulation 
and  possible  embolism  in  a  vital  organ.  This  form 
of  surgery  includes  lateral  suture  of  veins  and  ar- 
teries, circular  suture  of  veins  and  arteries,  arterio- 
venous anastomosis,  and  transplantation  of  arteries 
and  veins.  The  latter  may  be  incomplete  or  com- 
plete, according  to  the  extent  of  extirpation  of  the 
segment  before  the  anastomosis  is  performed.  The 
transplantation  "is  autoplastic  when  the  segment  is 
taken  from  the  same  animal,  homoplastic  when  taken 
from  another  animal  of  the  same  species,  and  hetero- 
plastic w^hen  taken  from  an  animal  of  another  spe- 
cies. The  author's  conclusion  from  results  thus  far 
achieved  is  that  the  therapeutic  value  of  plastic  vas- 
cular surgery  is  neither  as  troad  nor  as  general  as 
the  enthusiasts  believe. 

 ®   , 

Jmeebings  of  Sociftits. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  PENN- 
SYLVANIA. 

Fifty-eighth  Annual  Meeting,  held  in  Cambridge  Springs, 
September  15,  16,  and  17,  1908. 

{Continued  from  page  617.) 

Section  in  Medicine. 

A  tribute  was  paid  by  Dr.  Herbst  to  the  late  Dr. 
J.  Dutton  Steele,  who  had  been  elected  secretary  at 
the  previous  meeting. 

The  Nature  of  Carcinoma  in  General  and  the 
Early  Diagnosis  of  Gastric  Carcinoma. — In  this 
address,  the  oration  in  medicine,  Dr.  James  M. 
Anders,  of  Philadelphia,  gave  a  series  of  facts 
showing  that  the  disease  under  consideration  and 
microbic  diseases  as  a  class  were  identical  as  to 
f'ause  and  operation.  The  grouping  of  features 
rendering  a  given  case  suspicious  was  not  constant, 
and  the  closest  scrutiny  of  all  the  symptoms,  signs, 
and  laboratory  findings,  as  well  as  the  most  ju- 


dicious balancing  of  the  data  entering  into  the  pre- 
vious history  by  an  eminently  skillful  diagnosti- 
cian, was  an  absolute  necessity  before  a  probable 
diagnosis  could  be  reached.  The  general  practi- 
tioner, it  was  asserted,  who  failed  to  avail  himself 
of  an  expert  medical  opinion  in  the  most  slightly 
suspicious  case  was  scarcely  alive  to  his  profes- 
sional obligations.  The  paper  emphasized  the  im- 
portance of  the  recognition  of  carcinomatous  im- 
plantation upon  an  ulcer  and  urged  either  extirpa- 
tion or  gastroenterostomy  whenever  an  ulcer  proved 
rebellious  to  medical  treatment.  It  was  stated  that 
the  study  of  the  cases  must  be  conducted  upon 
broad  lines,  with  the  employment  of  the  various  re- 
fined diagnostic  methods. 

The  -Etiology  and  Pathogenesis  of  Gastric  Ul- 
cer.— Dr.  Warfield  T.  Loxgcope,  of  Philadel- 
phia, stated  that  circulatory  disturbances,  mechani- 
cal injuries,  and  chemical  injury  might,  each  and 
all,  cause  a  defect  in  the  gastric  mucous  mem- 
brane and  thus  lead  to  an  ulcer.  The  main  ques- 
tion at  issue  was,  why  the  healing  of  this  defect, 
which  took  place  so  readily  under  normal  circum- 
stances, was  so  difficult  to  effect  in  true  gastric 
ulcer.  Evidently  -there  was  some  other  factor  in- 
volved, and  at  the  present  moment  the  weight  of 
opinion  seemed  to  be  that  this  adjuvant  factor  was 
hyperchlorhydria. 

The  Medical  Treatment  of  Gastric  Ulcer  and 
its  Results. — Dr.  J.  A.  Lichty,  of  Pittsburgh, 
gave  the  results  of  the  treatment  of  140  cases.  The 
treatment  which  he  had  used  in  most  of  his  cases 
was  similar  to  that  which  had  first  been  described 
by  von  Leube  and  von  Ziemssen,  except  that  he 
had  used  a  more  mixed  diet  when  he  began  feed- 
ing by  the  mouth.  The  140  cases  were  divided  into 
three  classes,  according  to  treatment.  The  first 
class,  consisting  of  ninety-two  patients,  was  treated 
by  diet,  medication,  and  other  measures.  Of  these, 
three  were  unimproved,  fifty-two  had  improved, 
thirty-three  were  well,  and  four  had  died.  The 
second  class,  consisting  of  thirty-two  cases,  was 
treated  by  rectal  feeding.  Of  these  patients,  eight 
had  improved,  twenty-two  were  well,  and  two  had 
died.  The  third  class,  consisting  of  sixteen  patients, 
included  those  treated  surgically.  Of  these  patients, 
one  was  unimproved,  six  were  improved,  seven 
were  well,  and  two  had  died.  The  mortality  in  the 
140  cases  was  five  per  cent.  Four  of  the  eight 
patients  who  had  died  became  carcinomatous, 
and  three  had  died  of  perforation.  The  perfora- 
tions occurred  and  healed  several  years  before 
fatal  peritonitis  occurred.  The  number  of  cases 
which  Dr.  Lichty  had  studied  in  his  compilation, 
while  not  large  enough  to  furnish  conclusions, 
served  as  the  basis  for  the  following  observations : 

1,  The  140  cases  reported  occurred  among  about 
1,395  gastric  cases  which  were  included  in  over 
8,000  patients  which  made  up  a  general  practice. 

2,  The  mortality  need  not  be  high.  The  most  fre- 
quent cause  of  death  was  cancer ;  the  next  frequent 
was  perforation.  Death  from  haemorrhage  in  an 
uncomplicated  ulcer  did  not  occur  in  the  series.  3, 
The  medical  treatment  of  gastric  ulcer  gave  results 
which  showed  that  it  had  a  definite  place  in  the 
general  treatment  of  gastric  ulcer,  and  only  those 


768 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


cases  liaving  certain  complications  became  surgical. 

The  Surgical  Treatment  ot  Gastric  Ulcer.— -Dr. 
George  P.  Muller,  of  Philadelphia,  gave  the  indi- 
cations for  surgical  treatment  as  perforation,  re- 
peated hjemorrliage,  pyloric  stenosis,  perigastric 
adhesions,  dilatation,  and  hourglass  contraction. 
Symptoms  indicating  disturbance  in  secretory 
function  which  failed  to  respond  to  prolonged  med- 
ical treatment,  and  especially  when  motor  dis- 
turbances became  prominent,  should  lead  to  opera- 
tion. The  technique  of  the  various  operative  pro- 
cedures was  not  discussed  in  detail,  but  the  results 
were  presented,  as  was  also  the  physiology  of  gas- 
trojejunostomy. The  most  important  point  in  the 
surgical  treatment,  to  the  general  practitioner,  was 
the  after  history  of  patients  upon  whom  gastroje- 
junostomy had  been  performed,  and  in  this  connec- 
tion deductions  were  made  from  authoritative 
statistics. 

Dr.  JuDSON  Daland,  of  Philadelphia,  agreed 
with  Dr.  Longcope  that  the  excess  of  hydrochloric 
acid  was  a  contributing  cause  of  the  persistence  of 
these  gastric  ulcers.  The  summary  made  by  Dr. 
Aliiller  of  the  indications  for  operation  was  conser- 
vative, direct,  and  simple.  Gastric  ulcers  which 
under  treatment  recovered  sympto.matically  and 
later  recurred  formed  a  class  in  which  an  operation 
wa,>  urgently  required. 

Dr.  William  L.  Rodman  thought  that  practi- 
cally every  case  of  acute  ulcer  of  the  stomach  was 
amenable  to  medical  treatment.  He  was  equally 
clear  that  we  could  not  expect  to  cure  a  chronic 
gastric  or  an  indurated  ulcer  by  any  other  than  sur- 
gical means.  Undoubtedly  the  method  which  up 
to  the  present  time  had  been  most  popular  was  the 
simplest  of  all  operations  upon  the  stomach,  that  of 
gastroenterostomy.  It  was,  however,  becoming  less 
popular.  The  primary  mortality  following  gastro- 
jejunostomy as  done  at  the  present  time  was  al- 
most negligible.  We  should  bear  in  mind  the 
statement  of  the  facts  that  one  third  of  all  cancers 
in  the  body  originated  from  the  stomach,  and  that 
more  than  half  of  these  cancers  arose  from  neg- 
lected ulcers. 

Dr.  James  M.  Anders,  of  Philadelphia,  said  that 
in  the  present  state  of  our  knowledge  carcinoma  of 
the  stomach  became  largely  a  preventable  disease 
by  the  timely  removal  of  these  chronic  indurated 
ulcers.  \\'hether  a  radical  operation  should  be 
done  in  a-  given  case  was  a  (|uestion  to  be  studied 
carefully  by  clinicians  and  surgeons  together  if  pos- 
sible. The  presence  of  hyperchlorhydria  was  an 
indication  that  we  should  minimize  the  use  of  pro- 
teids  and  substitute  other  food  stufifs,  thereby  giv- 
ing the  stomach  physiological  rest. 

Dr.  Loxccoi'E  said  that  the  experiments  of  P)ol- 
ton  had  shown  that,  in  order  to  produce  gastric 
ulcers,  it  is  absolutely  necessary  to  have  acid  gas- 
tric juice  in  the  stomach.  If  he  washed  out  the 
stomach  with  alkaline  solutions,  there  was  no  ul- 
ceration whatever.  If  he  increased  the  acid,  the  ul- 
cers were  ])r(Kluced  more  readily. 

Indicanuria. — Charles  Re.\.  of  York,  gave  the 
definiti( 111.  history,  and  dififerent  sources  of  indi- 
canuria. The  principal  source  was  tlic  digestive 
tract  above  the  large  intestine.    The  method  of  de- 


tecting its  presence  was  given.  Its  common  com- 
plication of  acute  and  chronic  diseases  was  of 
much  clinical  significance,  but  was  probably  not 
generally  recognized  by  the  profession.  The  rela- 
tion of  microorganisms  of  the  digestive  tract  to 
indicanuria,  especially  lactic  bacteria,  was  consid- 
ered. The  conditions  favoring  its  production  were 
given.  The  treatment  consisted  of  diet,  antifer- 
mentative  drugs  and  digestants,  and  colonic 
flushings. 

A  New  Method  for  the  Quantitative  Estima- 
tion of  Albumin  in  the  Urine. — Dr.  Edward  H. 
Goodman,  of  Philadelphia,  discussed  briefly  the 
older  methods  of  quantitative  determination  of  al- 
bumin and  described  a  new  method  in  which  the 
solution  of  Tsuchiya  was  used  as  a  basis  for  a  ti- 
tration method. 

Dr.  Samuel  Wolfe,  of  Philadelphia,  believed 
that  indican  was  much  more  frequently  present 
than  was  generally  supposed,  and  said  that,  while  it 
was  an  undoubted  indication  of  absorption  from  the 
intestines,  the  putrefactive  processes  could  continue 
without  showing  indican  in  the  tirine.  The  pres- 
ence of  the  indican  and  the  absorption  of  delete- 
rious substances  from  the  intestinal  canal  showed 
that  the  mucosa  had  to  a  certain  extent  lost  its  de- 
fensive power.  Certain  slight  changes  would  favor 
absorption,  and  some  of  these  changes  might  be 
brought  about  by  nervous  disturbance. 

Dr.  JuDSON  Daland,  of  Philadelphia,  said  that 
the  subject  of  indican  was  of  paramount  import- 
ance to  a  very  close  observer  of  clinical  medicine 
and  had  a  wide  range  and  extraordinary  rela- 
tionship in  both  cause  and  efTect.  Among  the  other 
values  which  attached  themselves  to  the  presence 
of  indican,  there  was  the  additional  one  of  the  evi- 
dence of  the  existence  of  intestinal  toxaemia. 

Dr.  LiCHTV  asked  Dr.  Rea  whether  in  his  exami- 
nations he  depended  upon  the  twenty-four  hour 
specimen,  or  if  he  placed  reliance  upon  a  high  de- 
gree of  indican  found  at  one  examination. 

Dr.  L.  N.vpoLEON  Boston  felt  that  Dr.  Good- 
man had  given  in  his  paper  one  of  the  most  prac- 
tical tests  for  the  presence  of  albumin  in  the  urine 
and  one  which  required  less  time  than  any  hitherto 
presented. 

Dr.  Rea  appreciated  the  point  which  Dr.  Lichty 
had  raised.  Most  of  the  examinations  had  been 
made  from  the  twenty-four  hour  specimen.  In 
making  the  test  the  chloroform  must  be  allowed  to 
pass  slozvly  from  one  end  of  the  test  tube  to  the 
other  several  times,  or  the  chloroform  would  not 
take  up  the  indican.  Rapid  shaking  of  the  tube 
would  not  do  it,  and  he  had  known  instances  where 
large  amounts  of  indican  were  overlooked  for  this 
very  reason. 

Factors  Influencing  the  Clotting  Time  of  the 
Blood. — Dr.  MvER  Solis  Cohen,  of  Philadeli^hia, 
pointed  out  the  sources  of  error  in  the  methods 
most  frequently  employed  in  measuring  the  clotting 
time  of  the  blood.    His  own  method  was  cfesoribed. 

The  Relations  between  the  Blood  Diseases  and 
the  Digestive  Tract. — Dr.  R.\limi  S.  Lavexson. 
of  Pliiladelphia,  jiointed  out  that  lesions  of  the  di- 
gestive tract  might  be  ])rimary  or  secondary  to  dis- 
eases of  the  blood.   In  leuchajmia,  especially  in  the 


April  lo,  1909.1 


PROCEEDJXGS  Of  SOCIET/ES. 


769 


more  acute  forms  of  lymphatic  leuchjemia.  lesions  of 
the  digestive  tract  not  infrequently  occurred  second- 
arily to  the  leuchaemia.  The  commonest  of  these  le- 
sions was  ulceration  in  the  mouth  and  pharynx. 
The  significance  of  these  ulcerations  was  not  suf- 
ficiently appreciated  by  general  practitioners  and 
oral  surgeons,  to  whom  the  patients  frequently  first 
presented  themselves.  Progressive  pernicious 
anaemia  was  almost  invariably  associated  with  dis- 
ease of  some  portion  of  the  digestive  tract.  The 
most  frequent  of  these  conditions  were  carious 
teeth,  achylia  gastrica,  and  bacillary  infections  of 
the  large  bowel.  Whether  or  not  they  were  the 
cause  of  the  amemia.  energetic  treatment  directed 
against  these  faulty  features  resulted  in  great  bene- 
fit of  the  patient  s  condition  and  occasionally  in 
cure.  The  interpretation  by  earlier  clinicians  of  the 
association  of  chlorosis  with  gastric  ulcer  was  prob- 
ably erroneous.  Tlie  anaemia  in  these  cases  was 
usually  a  chlorana^mia.  the  result  of  faulty  diges- 
tion and  haemorrhage.  Cancer  of  the  stomach  at 
times  produced  an  anaemia  difficult  of  diagnosis 
from  progressive  pernicious  anaemia.  In  these 
cases  a  differential  white  count  was  frequently  of 
value.  In  pernicious  anaemia  a  leucopenia  with  a 
relative  lymphocytosis  was  amost  invariably  found, 
whereas  in  carcinoma  ventriculi  a  moderate  leuco- 
cytosis  with  a  slight  reduction  in  the  number  of 
Ivmphocytes  was  the  rule.  The  severe  degree  of 
anaemia  observed  in  gastric  carcinoma  was  not  the 
result  of  the  interference  with  the  processes  of  di- 
gestion alone,  but  probably  more  especially  the  re- 
sult of  toxic  substances  secreted  by  the  tumor. 
These  toxic  substances  were  apparently  of  the  na- 
ture of  lipoids. 

Dr.  A.  L.  KoTZ.  of  Easton,  said  that  the  prac- 
tical deductions  drawn  by  the  older  pathologists 
from  the  process  described  by  Dr.  Cohen  were  the 
number  of  times  the  patient  should  be  bled  and  the 
quantity  of  blood  abstracted.  The  knowledge  of 
the  clotting  time  of  the  blood  would  be  especially 
valuable  in  cases  of  small  persistent  haemorrhage 
and  in  all  diseases  prone  to  hyperinosis  and  hypi- 
nosis.  He  endorsed  what  Dr.  Lavenson  had  said 
in  his  paper,  and  believed  that  for  a  satisfactory  so- 
lution of  the  conditions  and  diseases  of  the  blood 
we  must  carry  our  investigations  along  the  line  of 
physiological  chemistry. 

Treatment  of  Alcoholism. — Dr.  Lowkll  M. 
Gates,  of  Scranton,  considered  the  importance  of 
the  subject  of  alcoholism  from  sociological,  eco- 
nomic, and  physical  standpoints.  Because  of  lack 
of  careful  and  systematic  consideration  by  the  lead- 
ers in  the  medical  profession  the  alcoholic  had  been 
driven  to  the  advertising  charlatan.  The  writer  be- 
lieved that  by  careful  attention  to  details  and  adapt- 
ing medicines  to  conditions  patients  could  be  re- 
lieved from  the  craving  for  drink.  The  perma- 
nent result,  however,  would  depend  largely  upon 
the  attitude  of  the  patient  and  his  willingness  to 
change  his  habits  and  environments.  Detention 
in  hospitals  was  needed  only  for  severe  cases  and 
nervous  wrecks.  The  cardinal  points  in  treatment 
were  the  immediate  withdrawal  of  alcohol,  elimina- 
tion of  the  poison  in  the  blood  and  bowels,  calming 
of  the  nerves,  and  restoration  of  diseased  organs 


to  normal  function.  The  patient  should  be  im- 
pressed with  the  facts  that  intoxicating  drinks  were 
used  solely  for  the  alcohol,  that  alcohol  was  not  a 
stimulant  but  a  narcotic  and  motor  depressant,  that 
it  was  poisonous  and  lowered  vitality  and  power  to 
resist  disease,  and  that  its  continued  use  would  in- 
jure the  vital  organs  permanently. 

Chronic  Appendicitis  Causing  Chronic  Diar- 
rhoea of  Several  Years'  Standing. — Dr.  Joseph 
Sailer,  of  Philadelphia,  and  Dr.  John  L.  Aulee, 
of  Lanca.ster,  presented  this  paper,  which  was  read 
by  Dr.  Sailer.  The  case  was  that  of  a  young  w^o- 
man  of  nineteen,  who  for  fifteen  months  had  had 
from  four  to  eight  loose  movements  daily,  usually 
liquid  or  mushy,  without  pain.  There  had  been  a 
slight  chronic  cough  without  expectoration,  rav- 
enous appetite,  and  occasionally  tympanites.  Ex- 
amination of  the  stools  gave  no  evidence  of  indi- 
gestion of  fats,  starches,  or  proteids.  Tubercle  ba- 
cilli and  amoebae  were  not  found  upon  repeated  ex- 
amination. The  Shiga  test  was  negative.  There 
was  no  reaction  to  tuberculin.  At  the  time  of  the 
first  visit  there  was  very  slight  tenderness  on  deep 
pressure  over  McBurney's  point.  Upon  operation, 
chronic  catarrhal  appendicitis  was  found.  The  di- 
arrhcea  stopped,  and  the  patient  had  remained  well 
for  eighteen  months  and  has  regained  all  the 
weight,  about  twenty  pounds,  lost  during  the  pe- 
riod of  diarrhoea. 

The  Symptomatology  of  Acute  Anterior  Polio- 
myelitis.—  Dr.  James  Heruekt  McKki:.  of  Pliila- 
delphia.  said  that  the  onus  of  the  future  clinical 
study  of  the  disease  under  consideration  must  rest 
largely  upon  the  shoulders  of  the  family  physician. 
While  it  was  true  that  anterior  poliomyelitis  occa- 
sionally appeared  after  one  or  other  of  the  infec- 
tious diseases  of  childhood,  it  was  a  prominent  fact 
that  the  disease  seldom  had  anything  behind  it. 
The  nervous  phenomena  are  viewed  from  the 
motor,  sensory,  vasomotor,  trophic,  and  cerebral 
standpoints,  and  the  writer  concluded  that  when  a 
young  child  was  suddenh'  seized  in  the  warm 
months  of  the  year  with  moderate  fever,  vomiting, 
constipation  or  diarrhoea,  pain  in  the  back  and  legs, 
some  stiffness  of  the  spine,  sweating,  and  possibly 
some  disturbances  of  the  consciousness,  the  attend- 
ing physician  should  give  anterior  poliomyelitis  a 
prominent  place  in  the  list  of  diagnostic  possibili- 
ties. Given  such  a  history  and  later  a  flaccid  pare- 
sis (of  parts  mentioned),  accompanied  by  mus- 
cular and  bone  atrophies,  absence  of  reflexes,  fail- 
ure of  response  to  faradic  currents,  coldness  and 
cyanosis  of  the  surface,  etc.,  there  was  little  diffi- 
culty in  diagnosticating  a  spinal  lesion  of  this 
nature.  There  remained  some  things  to  be  learned 
concerning  the  symptomatology  of  anterior  polio- 
myelitis in  its  earliest  stages.  This  additional 
knowledge  must  of  necessity  be  procured  by  the 
men  who  saw  the  patients  from  the  first. 

The  Epidemiology  of  Acute  Anterior  Polio- 
myelitis.—  Dr.  I-'kaxk  E.  Ukev.  of  Xew  Castle, 
observed  that  acute  anterior  poliomyelitis  occurred 
both  sporadically  and  epidemically,  and  that  some 
of  the  reported  epidemics  showed  plainly  a  con- 
tagious form.  While  the  clinical  history  strongly 
suggested  an  infection,  as  yet  the  organism  had 


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not  been  definitely  settled  upon.  The  mortality  was 
highest  in  the  epidemic  form,  reaching  from  six  to 
ten  per  cent,  in  some  epidemics. 

The  Treatment  of  Poliomyelitis. — Dr.  Theo- 
dore DiLLER,  of  Pittsburgh,  regarded  rest  as  by  far 
the  most  important  element  in  the  treatment  of  the 
acute  stage  of  the  disease.  The  afifected  limbs 
should  be  placed  upon  pillows  in  the  easiest  posi- 
tions, and  when  there  was  much  tenderness  it  was 
well  to  wrap  them  with  cotton.  Sand  bags  might 
be  placed  around  the  affected  members  to  keep 
them  in  position  and  to  retard  deformity.  The 
physician  should  from  the  beginning  be  on  the  out- 
look for  deformity  due  to  the  contraction  of  the 
unopposed  muscles.  This  should  be  combated  by 
the  use  of  padded  splints,  and  occasionally  elastic 
bands  would  be  found  a  valuable  help.  By  way  of 
medication,  a  purgative,  such  as  calomel  or  castor 
oil,  was  advised  at  the  outset,  and  later  an  alkaline 
diuretic  containing  a  moderate  dose  of  bromide. 
For  the  chronic  stage  electricity,  massage,  and 
orthopaedic  treatment  were  most  valuable.  Because 
of  the  pain  and  distress  produced  by  electricity  the 
author  seldom  used  it,  believing  that  the  same 
amount  of  good  might  be  derived  from  massage, 
gymnastics,  and  passive  movements.  Orthopaedic 
treatment  was  of  the  utmost  importance.  Little  or 
much  could  be  accomplished  in  almost  every  case. 
The  author  believed  that  definite  efforts  should  be 
made  by  philanthropic  individuals  and  societies  to 
secure  for  poor  children,  the  victims  of  poliomye- 
litis, the  benefits  of  modern  orthopaedic  treatment. 

Dr.  Charles  W.  Burr,  of  Philadelphia,  believed 
that  the  higher  apparent  death  rate  in  epidemics  of 
poliomyelitis  than  in  sporadic  cases  was  explained 
by  the  fact,  not  that  the  death  rate  was  smaller  in 
the  latter  cases,  but  that  the  men  who  made  hospital 
figures  saw  only  the  chronic  cases.  If  the  word 
poliomyelitis  was  confined  to  its  true  meaning,  dis- 
ease of  the  anterior  horns,  the  cases  showing  in- 
flammation throughout  the  spinal  cord,  inflamma- 
tion of  the  meninges  of  the  cord  and  of  the  brain, 
are  not  poliomyelitis  at  all.  This  led  to  the  theory 
that  poliomyelitis  was  due  to  some  sort  of  a  poison 
arising  from  within  or  without.  Whether  it  was 
a  bacterial  poison  or  an  organized  poison  from 
some  other  source  it  was  impossible  to  state. 

Dr.  Charles  K.  Mills,  of  Philadelphia,  had 
seen  more  than  the  usual  number  of  cases  of  polio- 
myelitis during  the  last  two  or  three  years.  No 
doubt  the  disease  was  a  special  infection.  The 
cases  which  were  called  poliomyelitis,  occurring 
after  the  ordinary  febrile  diseases,  were  not  of  the 
same  character,  though  some  of  them  closely  simu- 
lated poliomyelitis.  Regarding  symptomatology,  his 
own  view  was  that  the  disease  might  be  poliomye- 
litis and  yet  there  might  be  associated  with  a  true 
poliomyelitis  symptoms  indicative  of  the  occurrence 
of  a  root  neuritis  or  a  form  of  truncal  neuritis. 
Cerebral  symptoms  did  occur  in  these  cases  and 
were  due  to  an  associated  polioencephalitis.  If  any- 
thing should  be  emphasized  in  regard  to  treatment, 
it  was  conservatism  in  the  early  stages.  He  be- 
lieved in  rest  and  the  use  of  calomel  and  a  moderate 
use  of  salicylates  and  bromides.  Orthopaedic  treat- 
ment should  not  be  resorted  to  too  early,  but  sooner 
or  later  it  often  became  necessary.    One  did  not 


know  what  could  be  done  in  an  orthopaedic  way 
until  several  weeks  and  months  had  elapsed,  for 
he  did  not  know  what  the  residual  phenomena 
would  be.  Electrical  treatment  was  not  of  much 
value  unless  pursued  after  a  special  fashion.  Like 
the  orthopaedic  treatment,  it  also  should  be  post- 
poned for  a  few  weeks  or  months. 

The  Treatment  of  Tuberculosis  in  Rural  Dis- 
tricts.— Dr.  Walter  H.  Brown,  of  Richland- 
town,  said  that  in  rural  districts  few  tuberculous  pa- 
tients received  the  modern  treatment,  and  conse- 
quently they  nearly  all  died.  Physicians  were  held 
responsible  for  the  state  of  affairs.  The  remedy  was 
said  to  be  in  a  widespread  campaign  of  education. 
First,  the  family  physicians  must  be  converted  to  the 
belief  that  tuberculosis  could  be  cured  at  home.  Sec- 
ond, the  people  of  rural  communities  must  be  taught 
better  hygiene.  Third,  the  school  children  must  be 
better  instructed  in  the  principles  of  proper  living. 
When  these  objects  were  accomplished  the  campaign 
would  be  successful. 

Tuberculous  Phthisis:  Is  a  Second  Recovery 
Possible? — Dr.  W.  Forest  Dutton,  of  Walker's 
Mills,  in  a  paper  upon  this  subject  concluded  from 
his  experience  that  suft"erers  from  pulmonary  tuber- 
culosis might  recover  even  twice  or  thrice,  provided 
they  had  no  involvement  outside  a  moderately  ad- 
vanced tuberculous  focus  in  the  lung. 

The  Dispensary  System  of  the  Pennsylvania 
State  Department  of  Health. — Dr.  Thomas  H.  A. 
Stites,  medical  inspector  of  dispensaries  of  the  De- 
partment of  Health  of  Pennsylvania,  gave  a  sketch 
of  the  plan  of  organization  and  the  methods  em- 
ployed. Each  dispensary  was  in  charge  of  a  county 
medical  inspector  with  such  assistants  as  he  might 
require  or  be  able  to  secure.  A  declaration  of  ina- 
bility to  pay  for  attention  must  be  signed  by  each 
applicant.  The  use  of  drugs  was  discouraged  and 
patients  were  urged  to  take  rest  in  the  open  air.  Em- 
phatic warning  was  given  against  excesses  of  every 
sort,  and  the  importance  of  the  use  of  biological 
products  was  mentioned.  Classes  were  conducted 
wherever  conditions  warranted.  Instruction  was 
given  as  to  communicability  of  the  disease,  as  to 
precautionary  measures,  and  in  regard  to  fumigation 
after  death  or  removal.  The  obstacles  in  the  way 
of  the  successful  prosecution  of  the  work  were  enu- 
merated, and  the  necessity  for  cooperation  of  the 
profession  at  large,  without  which  good  results  were 
impossible,  was  pointed  out. 

Factors  in  the  Operative  Treatment  of  Pulmo- 
nary Tuberculosis. — Dr.  W.  Wayne  Babcock,  of 
Philadelphia,  maintained  that  operative  intervention 
in  the  condition  considered  was  not  of  universal  ap- 
plication, but  was  advised  only  in  certain  selected 
cases  where  local  lesions  were  beyond  medical  or 
hygienic  aid,  and  where  there  was  an  associated  fair 
degree  of  general  resistance.  Percentages  of  vari- 
ous types  of  cases  in  which  surgical  treatment  might 
be  considered  are  given.  The  influence  of  involve- 
ment of  both  lungs  and  of  other  organs  of  the  body 
was  considered.  The  maintenance  of  respiratory  ac- 
tion during  operative  procedures,  the  dangers  of 
pneumothorax  and  the  use  of  various  forms  of  posi- 
tive and  negative  pressure  devices,  the  control  of 
haemorrhage  from  the  lung  and  from  the  chest  wall, 
and  the  management  of  pleural  adhesions  were  some 


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771 


of  the  subjects  dealt  with.  Postoperative  treatment 
and  sequelae  were  also  fully  considered. 

Dr.  C.  H.  Miner,  of  Wilkes-Barre,  stated  that 
the  plan  of  the  commissioner  of  health  to  establish 
a  tuberculosis  dispensary  in  every  county  of  the 
State  had  proved  to  be  one  of  the  greatest  works  of 
philanthropy  ever  instituted  in  this  country.  Statis- 
tics of  the  dispensary  located  in  Wilkes-Barre 
showed  that  the  average  size  of  the  families  of  pa- 
tients treated  was  five,  and  that  the  average  income 
for  that  falnily  of  five  was  only  $26.36  per  month. 
This  showed  the  necessity  of  a  free  dispensary,  and 
showed  that  it  in  no  way  interfered  with  the  private 
practice  of  neighboring  physicians.  The  training  of 
one  or  more  of  the  patients  for  the  work  of  visiting 
nurse  was  regarded  as  an  excellent  plan.  The  coop- 
eration of  a  local  antituberculosis  society  would  be 
an  advantage  to  every  dispensary,  to  carry  on  an 
educational  campaign  and  to  supply  the  more  desti- 
tute patients  with  blankets,  cots,  tents,  reclining 
chairs,  and  special  nurses  for  the  dying.  A  feature 
of  the  work  in  the  dispensary  was  writing  upon  the 
blackboard  the  names  of  patients  making  the  great- 
est gains  during  the  preceding  two  weeks.  They 
were  taught  that  the  result  of  the  treatment  depend- 
ed largely  upon  their  own  courage,  patience,  and 
perseverance,  and  thus  a  rivalry  was  instituted.  The 
patients  who  received  a  digestive  tonic  gained  more 
rapidly  in  weight,  and  its  use  was  strongly  favored. 

Dr.  Edgar  M.  Green,  of  Easton,  emphasized  the 
importance  of  having  children  examined  in  families 
where  tuberculosis  occurred,  the  advantage  being 
not  only  the  gain  in  the  individual  case,  but  that  re- 
sulting from  finding  and  treating  incipient  cases 
among  the  other  members  of  the  same  household. 

Dr.  Arthur  A.  Watkins,  of  St.  Benedict,  said 
that  the  town  and  mines  of  St.  Benedict  had  been 
entirely  developed  within  the  past  six  years.  About 
half  the  inhabitants  are  of  the  Slavonic  race,  and  the 
"four  hundred"  of  the  town  were  composed  of  the 
clerks  of  the  company  store  and  office  with  the  mine 
foremen  and  engineers.  Naturally  any  reform  move- 
ment encountered  difficulty.  The  inhabitants  were 
certainly  changing  their  mistaken  ideas.  With  sixty 
cases  of  tuberculosis  they  had  the  treatment  con- 
stantly before  them.  Sixteen  patients  had  been  sent 
to  the  Johnstown  dispensary  for  free  milk  and  eggs. 
While  several  had  regained  their  health  as  the  result 
of  the  fund,  it  was  felt  that  more  good  had  been  ac- 
complished in  the  prevention  of  tuberculosis.  The 
crusade  forced  the  dairyman  to  have  his  herd  exam- 
ined with  tuberculin. 

Dr.  J.  K.  Roberts  reported  the  case  of  a  suspect- 
ed house  infection  in  Juniata  County.  There  was 
no  definite  history  of  tuberculosis,  although  there 
was  reported  one  suspicious  case,  that  of  a  negro 
who  underwent  amputation  of  one  leg  because  of 
"some  disease."  Of  one  family  who  moved  into  the 
house  in  1898,  six  members  died  of  tuberculosis 
within  six  years  and  two  of  the  living  were  infected. 
Of  a  famiiy  moving  into  the  house  in  1902,  three 
had  the  disease  and  died,  and  two  were  under  treat- 
ment. A  visitor  also  had  contracted  the  disease. 
Of  the  next  family,  one  died  of  tuberculosis,  three 
others  had  the  disease,  and  one  case  was  suspicious. 
The  house  was  at  present  occupied  by  a  family  of 
negroes,  all  apparently  healthy.    The  family  history 


in  the  majority  of  the  other  occupants  of  the  house 
was  negative.  The  location  of  the  house  was  ex- 
cellent. 

Dr.  J.  Wesley  Ellenberger,  of  Harrisburg, 
wished  to  emphasize  what  Dr.  Stites  had  said  upon 
the  great  importance  of  an  early  diagnosis,  first, 
for  the  sake  of  the  patient,  and,  second,  for  the 
benefit  of  those  coming  in  contact  with  him.  In 
proof  of  the  fact  that  all  physicians  did  not  recog- 
nize tuberculosis  early,  he  recalled  the  case  of  a 
young  woman  examined  by  a  rather  prominent  phy- 
sician in  a  large  town  who  said  in  writing  that  the 
case  was  an  incipient  one  with  good  chances  of  re- 
covery. She  died  three  weeks  after  the  opinion  had 
been  given.  One  thing  which  was  apt  to  mislead  in 
examination  was  that  the  avenue  of  infection  was 
often  through  the  tonsils  and  the  cervical  lymphatics 
down  to  the  bronchial  glands.  One  reason  for  the 
failure  of  physicians  to  make  an  early  diagnosis  was 
that  in  former  years  it  had  been  like  signing  the 
patient's  death  warrant  to  say  that  he  had  consump- 
tion, and  the  influence  of  that  early  condition  re- 
mained to-day. 

Dr.  William  B.  Stanton,  of  Philadelphia,  said 
that  to  make  an  early  diagnosis  of  tuberculosis  by 
the  physical  signs  required  much  and  constant  train- 
ing and  the  opportunity  of  seeing  a  large  number 
of  cases.  The  average  case  of  early  tuberculosis 
showed  a  temperature  of  about  99°,  and  in  taking 
it  the  work  should  be  done  over  a  oeriod  of  days,  at 
least  four  times  a  day,  and  the  thermometer  should 
be  kept  in  the  mouth  between  fifteen  and  twenty 
minutes. 

Dr.  David  S.  Funk,  of  Harrisburg,  recalled  a 
case  of  tuberculous  peritonitis  in  which  section  was 
done.  Miliary  deposits  were  found  in  both  the  par- 
ietal and  visceral  peritonjeum,  with  adhesions  so  ex- 
tensive that  it  was  impossible  to  separate  the  peri- 
tonaeum to  a  greater  extent  than  an  inch  and  a  half 
in  any  direction  from  the  line  of  incision.  To-day 
that  boy  was  well,  weighed  twenty  pounds  more 
than  ever  before,  and  was  earning  his  daily  wage. 

Gallstones :  A  Few  of  the  Factors  in  .flEtiol- 
ogy,  Diagnosis,  and  Medical  Treatment. — Dr.  H. 
C.  Hoffman,  of  Connellsville,  stated  that  the  de- 
velopment of  biliary  sediment  and  biliary  calculi 
was  not  an  acute  process,  but  always  the  result  of 
a  chronic  condition,  for  gallstones  are  results  and 
not  primary  formations  in  a  long  course  of  func- 
tional and  structural  changes.  The  author  believed 
with  Lorand  that  the  aetiology  of  gallstones  was 
closely  allied  to  diseases  of  nutrition,  such,  for  ex- 
ample, as  diabetes,  gout,  and  obesity,  and  that  these 
troubles  were  closely  connected  with  nervous  dis- 
orders ;  and  that  the  blood  glands  stood  in  close  re- 
lation to  one  another,  so  that  if  one  was  altered  the 
others  were  also  changed.  The  reason  of  gallstone 
frequently  following  pregnancy  seemed  not  well  un- 
derstood. By  far  the  most  difficult  distinction  in 
diagnosis  was  that  of  ulcer  of  the  duodenum  from 
gallstones.  In  treatment  too  often  did  the  physician 
feel  that  an  operation  was  the  only  means  of  relief. 
While  this  might  be  true  in  a  large  percentage  of 
cases,  the  author  believed  that  much  could  be  done 
for  the  relief  and  prevention  of  cholelithiasis  by 
carefully  and  well  selected  therapeutics,  diet,  and 
hygiene.    Treatment  must  necessarily  aim  at  the 


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Medical  Journal. 


restoration  of  a  normal  secretion  of  bile.  Treatment 
must  be  continued  for  years  and  must  unite  all 
remedial  measures  and  the  result  established  by  a 
well  regulated  and  hygienic  life.  Relief  of  the  con- 
dition would  depend  upon  the  physician's  ability  to 
recognize  the  signs  and  symptoms  of  the  earlier 
stages. 

Dr.  David  Riesm.vn,  of  Philadelphia,  said  that  in 
a  case  of  nervous  dyspepsia  with  clean  tongue 
which  did  not  yield  to  treatment,  if  there  was  in  the 
gallbladder  region  a  tender  point  discovered  upon 
palpation,  he  thought  it  proper  to  subject  the  patient 
to  an  operation  upon  a  provisional  diagnosis  of 
gallstones.  In  these  cases  diagnoses  of  gastric  ulcer 
and  appendicitis  were  sometimes  made.  Floating 
kidney  might  simulate  gallstones,  but  a  prop:r  ab- 
dominal support  relieved  the  symptoms.  He  had 
observed  during  an  attack  of  gallstone  colic  a  loud 
systolic  murmur.  While  this  might  be  attributed 
to  endocarditis,  it  was  usually  due  to  temporary  irri- 
tation. Medical  treatment  did  much.  He  was  in 
the  habit  of  employing  olive  oil,  giving  two  or  three 
teaspoonfuls  every  night,  di'Scontinuing  it  for  a  few 
days,  then  using  it  for  a  week.  Indications  for  sur- 
gical treatment  were  recurrence  of  pain  and  chronic 
jaundice.  He  had  recently  seen  gallstone  colic  re- 
turn within  three  or  four  years  after  an  operation 
for  gallstone. 

Dr.  William  E.  Robertson  thouoht  we  should 
bear  in  mind  the  intrathoracic  conditions  sometimes 
giving  rise  to  abdominal  pain,  and  remember  that 
this  pain  might  occur  in  any  section  of  the  abdo- 
men. 

Dr.  J.  H.  AluDGETT,  of  Philadelphia,  said  that, 
since  many  attacks  of  gallstone  colic  followed  the 
eating  of  a  full  meal,  he  would  advise  that  patients 
eat  a  little  at  a  time.  It  seemed  probable  that  the 
mucous  membrane  of  the  gallbladder  became  ac- 
customed to  the  gallstone  being  in  one  position,  and 
that  the  eating  of  a  full  meal  changed  the  position 
of  the  stone  with  the  resultant  contraction  of  the 
gallbladder  and  pain. 

Concerning  Bacterial  Vaccines,  with  some  Ref- 
erence to  the  Opsonic  Index. —  Dr.  .\.  Parkkk 
Hnc'iiENS,  of  (jlenolden,  I)elicved  that  apparently 
there  was  a  period  of  reaction  against  the  opsonic 
index  as  a  reliable  clinical  aid,  which,  however, 
would  be  succeeded  by  one  more  favorable.  He  felt 
that  practically  every  one  admitted  the  value  of 
vaccine  .treatment.  Diseases  to  be  treated  by  vac- 
cines would  ultimately  fall  into  two  classes :  i , 
Those  which  might  be  treated  by  the  general  prac- 
titioner, without  control  of  doses  by  opsonic  inde.x 
determinations.  2,  Those  requiring  the  .special 
knowledge  of  an  "immunizator"  and  control  of 
doses  by  the  opsonic  index. 

Dr.  Edward  J.  G.  Beardslev,  of  Philadelphia, 
said  that,  because  of  the  relatively  few  blood  counts 
made  by  the  ordinary  practitioner  and  the  length  of 
time  required  to  make  the  opsonic,  estimate,  the 
work  must  fall  ujjon  men  of  special  training.  It 
was  most  unfortunate  that  it  was  so.  If,  however, 
all  worked  with  the  enthusiasm  which  Dr.  Watkins 
had  shown  in  his  work  recently  discussed  in  tuber- 
culosis we  should  have  better  results.  The  method 
had  brought  our  knowledge  of  blood  serums  to  a 
much  greater  advance  than  attained  bef' re,  al- 
though there  was  much  yet   t(j  be  desired.  rhe 


usual  cases  treated  with  the  vaccine  therapy  by  the 
estimate  of  the  opsonic  index  were  those  m  which 
general  medical  treatment  had  failed. 

{To  be  continued.) 

 <$>  

■  THOR-R.\D-X." 

5899  Gates  Avenue, 
St.  Louis,  March  22,  k^oq. 

To  the  Editor-' 

A  recent  issue  of  the  Xcw  York  Medical  Journal 
contained  an  editorial  which  rather  facetiously  criti- 
cised "Thor-Rad-X."  The  criticisms  in  this  editorial 
were  just  and  timely,  but  they  were  almost  whoUv 
confined  to  di.screditing  "Thor-Rad-X"  as  an  exist- 
ing substance  and  to  disapproval  of  the  barbarism 
in  the  name.  The  person  who  coined  this  solecism 
had  evidently  heard  of  thorium,  radium,  and  thoriuni 
X,  and,  wishing  to  produce  something  sensational, 
created  "Thor-Rad-X." 

Thorium  and  radium  are  radioactive  elements 
(radioelements) ,  and  a  "period"  in  the  transforma- 
tion of  thorium — thorium  x — is  radioactive.  The 
radioelements  radium,  thorium,  and  actinium  emit  an 
inert  gas — the  emanation  ;  but  the  other  radioele- 
ments, uranium,  polonium,  and  radiolead.  do  not 
have  an  emanation.  There  are  many  ores  that  are 
radioactive — such,  for  example,  as  the  ores  carnotite 
and  roscoelite,  both  of  which  are  distributed  in  vary- 
ing quantities  over  the  earth  and  in  very  large  quan- 
tities in  Colorado,  and  the  ore  monazite,  which  is 
widely  distributed  in  the  Carolinas.  fVobably  every 
thing  in  nature  is  radioactive,  as  this  property  is  de- 
tected in  minerals,  in  vegetable  and  animal  tissues, 
and  in  the  air ;  but  this  activity  is  conferred  on  al- 
most everything,  and  is  not  an  inherent  property  of 
the  thing. 

The  newspaper  that  published  this  discovery  (  ?) 
referred  to  "Thor-Rad-X"  as  follows:  "The  min- 
eral is  yellow,  and  resembles  sulphur  when  ground 
up,"  "One  of  the  most  curious  experiments  with  the 
new  substance  was  the  taking  of  a  photogra])h."  and 
"It  is  found  in  Colorado  in  considerable  quantities." 
I  conclude  from  the  description  given  that  the  won- 
derful "substance"  referred  to  is  an  alleged  product 
of  carnotite,  as  carnotite  is  yellow  and  resembles 
sulphur  when  ground,  will  make  pictures  on  a  pho- 
tographic plate,  and  is  found  in  large  (|uantities  in 
Colorado.  The  best  grade  of  carnotite  is  canarv 
yellow,  and  the  color  is  due  to  the  uranium  oxide 
present  in  the  ore.  Uranium  oxide  is  radioactive, 
but  does  not  have  an  emanation. 

There  is  nothing  new  in  this  newspaper  re])ort 
that  this  substance  has  rays  that  will  make  ])hoto- 
graphs.  In  1903  .Mr.  .Adams,  a  resident  of  Tellu- 
ride,  Colorado,  sent  me  ])icturcs  of  a  key  and  other 
metal  articles  and  a  picture  of  a  Colorado  frog  that 
had  been  protogra])hed  with  carnotite.  \\".  D.  I'.ngle. 
professor  of  chemistry  in  the  I'niversity  of  Denver, 
has  also  demonstrated  the  photographic  pro])erties 
of  carnotite  and  other  radioactive  ores  of  Colorado. 

I  am  not  prepared  to  believe  that  carnotite  has 
thera])eutic  properties  or  that  such  ])roperties  are 
possessed  bv  anv  of  the  known  radioactive  ores  of 
Colorado.  In  1904  and  1905  I  experimented  with 
radioactive  ores  of  .America  and  foreign  cuunlries. 


A|]iil  10,  1909.  J 


LLTTERS  TO  THE  EDTTUR. 


777, 


Carnotite  was  used  on  guinea  pigs  for  the  purpose 
of  determining  its  action  on  living  tissues.  Finely 
pulverized  carnotite  was  mixed  with  a  thin  solution 
of  gum  arabic  and  applied  to  the  guinea  pig  just 
back  of  its  shoulders.  This  was  retained  in  position 
with  a  suitable  dressing  for  a  hundred  hours.  No 
noticeable  effect  had  been  produced  by  the  carnotite 
at  the  time  of  its  removal  from  the  pig,  and  there 
was  no  reaction  that  could  be  detected  within  three 
months  afterward.  A  portion  of  the  back  and  side 
of  another  pig  was  shaved,  and  upon  this  bare  sur- 
face carnotite  was  applied  and  retained  for  a  hun- 
dred hours.  This  treatment,  as  in  the  former  case, 
cUd  not  affect  the  tissues  of  the  pig  by  radiations 
from  carnotite.  Colorado  pitchblende  was  used  in 
precisely  the  same  manner  as  the  carnotite,  and  was 
found  to  be  equally  inactive,  but  pitchblende  from 
Bohemia,  when  used  under  like  conditions,  produced 
violent  inflammation. 

Carnotite  has  no  inherent  propert}-  whereby  it  can 
contribute  activity  to  other  substances  that  would 
cause  them  to  be  classed  as  medicinal,  and,  as  the 
direct  application  of  carnotite  to  naked  tissue  has  no 
appreciable  effect,  it  is  reasonable  to  conclude  that 
carnotite  is  devoid  of  curative  properties. 

Heber  Rob.arts. 


SUCCESSFUL    MEDICAL    TREATMENT    OF  AP- 
PENDICITIS. 

616  Madison  Avenue, 
New  York,  March  jg,  njog. 

To  the  Editor:  - 

In  the  issue  of  the  Jounuil  for  March  13th  I  find 
a  contribution  by  ]Dr.  E.  Palier  under  this  heading. 
"Dr.  Palier  describes  the  histories  of  two  patients 
of  his  own,  and  quotes  from  an  article  by  Professor 
A.  Robin  {Bulletin  general  de  thcrapeutiquc,  Janu- 
ary 30,  1907),  in  which  Robin  gives  a  list  of  168 
cases  of  appendicitis  treated  medically  without  a 
death,  after  other  physicians  had  advised  opera- 
tion. 

Abstractors  for  different  medical  journals  are 
now  giving  space  to  Dr.  Palier's  contribution,  and 
it  will  do  considerable  harm  among  physicians  who 
wish  to  do  the  right  thing  for  their  patients,  but 
who  are  too  busy  to  look  up  the  context  that  goes 
with  the  Robin  list. 

In  the  first  place,  allow  me  to  dispose  of  Dr. 
Palier's  two  appendicitis  patients  who  were  treated 
medically.  There  is  fair  presumptive  evidence, 
from  the  history  that  Miss  A.  really  did  have  an 
attack  of  appendicitis,  that  it  subsided  under  med- 
ical treatment  as  such  cases  commonly  do, — and 
that  she  may  expect  recurrence  of  the  trouble  at  no 
distant  day.  There  is  fair  presumptive  evidence 
that  the  second  patient  has  never  had  appendicitis, 
excepting  of  the  irritative  type  that  goes  with  loose 
kidney,  and  Dr.  Palier's  description  of  this  case  is 
about  as  clear  a  history  of  loose  kidney  as  one  could 
well  put  upon  paper. 

Now  for  the  Robin  list.  That  distinguished  author 
says  on  page  139  of  his  article:  "£n  somnie,  le 
viedicin  doit  garder  la  direction  du  traitement  de 
I'appcndicitc,  inais  savoir  faire  intervenir  le  chiriir- 
girn  d  son  heiire,  avec  de  precis  indications."  Few 
of  us  could  take  exception  to  that  statement.  In 
the  context  Robin  excluded  from  medical  treat- 


ment about  the  same  cases  that  I  would  exclude, 
and  he  chooses  for  medical  treatment  about  the 
same  cases  for  which  I  would  choose  medical  treat- 
ment. There  would  be  some  points  for  discussion 
between  us,  but  Robin's  entire  article  is  entitled  to 
respectful  consideration,  and  it  would  lead  no  one 
into  the  dangerous  territory  opened  by  the  abstrac- 
tors of  Dr.  Palier's  contribution.  The  fact  that 
operation  had  been  advised  by  other  physicians  in 
168  of  the  cases  quoted  by  Robin  is  a  matter  un- 
worthy of  comment,  unless  we  know  all  about  the 
physicians.  Very  few  days  pass  without  my  refus- 
ing to  operate  upon  some  patient  sent  in  for  opera- 
tion for  appendicitis.  These  are  mostly  cases  of 
fibroid  degeneration  of  the  appendix.  The  condi- 
tion is  one  in  which  I  believe  the  patient  to  be  pro- 
tected against  infective  appendicitis.  Improvement 
is  apt  to  follow  quickly  upon  proper  medical  treat- 
ment, and  the  cases  are  perhaps  on  the  whole  the 
most  common  of  those  in  which  the  appendix  comes 
into  question.  If  we  make  up  a  list  consisting  of 
cases  of  fibroid  degeneration  of  the  appendix,  con- 
gestion of  the  appendix  as  a  symptom  of  loose  kid- 
ney, and  lithaemic  irritation  of  the  lymphoid  layer 
of  the  appendix,  brilliant  results  might  be  reported 
after  nonoperative  treatment.  Let  us  take  an  en- 
tirely different  list — a  list  of  cases  in  which  infec- 
tive invasion  of  the  appendix  is  about  to  test  the 
protective  limitations  of  the  patients.  That  is  the 
field  in  which  the  right  kind  of  surgery  stands  tri- 
umphant today.  The  subject  of  appendicitis  is  one 
in  which  diagnosis  is  of  peculiar  importance,  and 
the  choice  of  surgeons  will  give  a  wide  range  in 
statistics,  because  the  highest  degree  of  technical 
skill  is  required  for  the  management  of  a  few  of 
the  cases.  Robert  T.  Morris. 


"AMPOULE"  OR  "AAIPUL":^ 

New  York,  March  31.  igog. 

To  the  Editor: 

While  I  thank  you  for  the  kind  reference  in  your 
issue  of  March  20th  to  my  paper  on  Ampuls  and 
their  use  in  the  Preservation  of  Hypodermic  Solu- 
tions, I  must  decline  to  accept  your  admonition  as 
to  the  method  of  spelling  the  word  "ampul." 

In  introducing  the  Latin  word  into  the  French 
language,  the  French  took  pains  to  change  it  so  as 
to  make  it  conform  to  Gallic  etymological  iisage. 
The  Italians  and  the  Spanish  also  adapt  the  word 
to  the  usage  of  the  respective  languages  and  give 
the  spelling  ampolla.  It  seems  to  me  that  we  may 
well  follow  the  example  of  these  three  Latin  na- 
tions and,  in  adopting  the  Latin  word,  adapt  am- 
poule to  the  spirit  of  modern  English,  simplifying 
and  abbreviating  as  much  as  is  consistent  with  clar- 
ity. The  Latin  ampulla  becomes  in  French  am- 
poule, in  Italian  and  Spanish  ampolla.  and  quite 
naturally  in  English  ampul.  Had  the  word  not 
already  found  lodgment  in  the  English  language, 
I  think  I  should  have  been  justified  in  proposing 
this  form  of  spelling.  As  a  matter  of  fact,  how- 
ever, it  was  not  necessary  for  me  to  do  more  than 
accept  the  precedent  set  in  Webster's  Dictionary 
and  in  the  Standard,  where  preference  is  given  to 
the  English  form  "ampul." 

Caswell  A.  Mayo. 
[Our  objection  was  that  the  form  "ampul"  might 
lead  to  the  mispronunciation  ample.] 


774 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


A  Textbook  of  Human  Physiology.  Including  a  Section 
on  Physiological  Apparatus.  By  Albert  P.  Brubakek, 
A.  M.,  M.  D.,  Professor  of  Physiology  and  Hygiene  in 
the  JefTerson  Medical  College ;  Professor  of  Physiology 
in  the  Pennsylvania  College  of  Dental  Surgery ;  Lecturer 
on  Physiology  and  Hygiene  in  the  Drexel  Institute  of 
Art,  Science,  and  Industry.  Third  Edition.  Revised  and 
Enlarged.  With  Colored  Plates  and  383  Illustrations. 
Philadelphia  :  P.  Blakiston's  Son  &  Co.  1908.  Pp.  752. 
(Price,  $3.) 

The  two  preceding  editions  of  Professor  Bru- 
baker's  admirable  textbook  have  already  been  fa- 
vorably reviewed  in  this  journal.  In  this,  the  third 
revised  and  enlarged  endition,  some  fifty  pages  of 
text  have  been  added  without  increasing  the  bulk 
of  the  volume.  The  most  noteworthy  changes  are 
naturally  to  be  found  in  those  subjects  in  which  the 
greatest  recent  advances  have  been  made,  and  in  the 
sections  dealing  with  the  ductless  glands  and  inter- 
nal secretion,  the  heart  muscle,  physiological  chemis- 
try, absorption,  the  specinl  senses,  and  the  central 
nervous  system  the  author  has  adequately  presented 
for  the  physician  and  student  the  latest  conclusions 
of  research  workers  and  authorities  on  the  physi- 
ology of  these  special  fields.  We  know  of  no  other 
textbook  which  treats  so  clearly  and  in  so  satisfac- 
tory a  manner  of  the  auriculoventricular  conduction 
fibres  of  the  cardiac  muscle.  The  important  work 
of  His,  Retzer,  Br&unig,  Tavars,  and  Erlanger  on 
this  interesting  subject  is  fully  reviewed.  In  the  ap- 
pendix is  given  an  excellent  description  of  modern 
apparatus  for  use  in  the  physiological  laboratory. 

A  Textbook  of  Genitourinary  Diseases.  Including  Func- 
tional Sexual  Disorders  in  Man.  By  Doctor  Leopold 
Casper,  Professor  in  the  University  of  Berlin.  Trans- 
lated and  Edited,  with  Additions,  by  Ch.vrles  W.  Bon- 
NEY,  B.  L.,  M.  D.,  Assistant  Demonstrator  of  Anatomy, 
Jefferson  Medical  College;  Formerly  Surgeon  to  the 
Southern  Dispensary.  Philadelphia,  etc.  Second  Edition. 
Revised  and  Enlarged.  With  230  Illustrations  and  24 
Full  Page  Plates,  of  which  8  are  in  Colors.  Philadel- 
phia: P.  Blakiston's  Son  &  Co.,  1909.  (Price,  $5.) 

The  second  edition  of  the  English  version  of  Pro- 
fessor Casper's  book  offers  a  marked  improvement 
over  the  first,  which  we  had  occasion  to  review  in 
these  columns  (Vol.  Ixxxiv,  p.  962).  In  our  review 
of  the  first  edition  we  complained  of  the  lack  of 
adaptation  of  the  book  to  American  ideas  and  meth- 
ods, and  of  certain  gaps  in  the  treatment  of  such 
practical  subjects  as  gonorrhoea,  circumcision,  etc. 
These  omissions  have  been  in  a  great  measure  filled 
in  the  present  edition  by  annotations  in  brackets  con- 
tributed by  Dr.  Bonney.  Thus,  a  number  of  Ameri- 
can cystoscopes  and  urethroscopes  have  been  de- 
scribed, the  chapter  on  gonorrhoea  has  been  revised, 
and  a  description  of  circumcision  has  been  inserted. 
Furthermore,  a  revision  of  several  other  chapters 
has  been  carried  out,  notably  that  of  the  chapter  on 
prostatectomy,  which  was  revised  by  Dr.  Casper 
personally. 

It  is  to  be  regretted  that  more  attention  was  not 
paid  to  those  features  of  genitourinary  technique, 
e.  g.,  of  intravesical  irrigations,  etc.,  which  are  im- 
portant to  the  general  practitioner,  and  that  the 


modern  treatment  of  gonorrhoea  was  not  more  ex- 
plicitly described.  There  is  also  a  noteworthy  lack 
of  detail  of  technique  in  the  clinical  laboratory  work 
which  is  so  essential  in  urolog}\  Possiblv  these  de- 
fects will  be  remedied  in  a  future  edition,  for  with 
these  exceptions  Casper's  book  in  its  present  Eng- 
lish dress  forms  an  attractive  and  useful  handbook 
of  genitourinary  diseases,  well  translated  and  well 
edited. 

Hints  to  Ships'  Surgeons.  By  J.  F.  Elliott,  L.  R.  C.  S., 
L.  R.  C.  P.  (Irel.).  London:  John  Bale,  Sons,  &  Dan- 
ielsson,  Ltd.,  1908.    Pp.  xii-64.    (Price,  2s.) 

In  this  handy  little  book  will  be  found  many  tise- 
ful  suggestions  for  the  intending  ship  surgeon,  on 
subjects  as  varied  as  the  method  of  obtaining  an  ap- 
pointment to  a  ship,  the  management  of  alcoholism 
and  lunacy,  nial  de  mer,  ship  hygiene,  and  the  doc- 
tor's duties  at  sea.  The  author  points  out  what  is 
little  short  of  a  crime  on  the  part  of  most  transporta- 
tion companies  in  their  failure  to  disinfect  state- 
rooms occupied  by  consumptives,  and  urge.s  the  ship 
surgeon  to  do  what  he  can  to  secure  a  much  needed 
reform  in  this  respect.  Not  only  will  the  practical 
points  presented  by  Mr.  Elliott  be  read  with  interest 
by  the  special  class  for  whom  they  are  designed,  but 
the\-  may  be  considered  to  advantage  by  all  physi- 
cians going  abroad. 

Gonorrhaa  in  Women.  By  Palmer  Findley,  M.  D.,  Pro- 
fessor of  Gynecology  in  the  College  of  Medicine  of  the 
University  of  Nebraska,  Omaha,  etc.,  St.  Louis:  C.  V. 
Mosby  Medical  Book  and  Publishing  Company,  1908. 

The  object  of  Dr.  Findley 's  book  is,  as  the  pre- 
face states,  "to  instruct  some  and  to  awaken  all  to 
the  greater  realization  of  the  supreme  importance  of 
the  stibject  of  gonorrhoea  in  women."  While  the 
book  does  not  present  anything  essentially  new,  and. 
is  largely  a  compilation  from  the  writings  of  various 
authorities  on  gonorrhoea,  it  will  doubtless  serve  its 
purpose  with  those  who  wish  to  have  such  a  collec- 
tion of  quotations  in  accessible  form.  It  is  to  be  re- 
gretted, however,  that  an  author  of  Dr.  Findley's 
standing  did  not  give  more  time  and  care  to  certain 
details  of  book  making.  The  present  volume  offers 
many  flagrant  examples  of  hasty  and  careless  edit- 
ing. 

We  are  not  speaking  of  the  subject  matter  of  the 
book,  but  are  referring  to  its  physical  form — to  the 
dress  of  stvle  and  spelling  which  it  has  received. 
There  are  numerous  misprints  in  the  text,  such  as 
"carbol-fuchskin,"  for  carbol-fuchsin ;  -'methyl- 
blue,"  for  methylene  blue ;  "Jadessohn"  and  in  an- 
other place  "Jodassohn,"  for  Jadassohn ;  "Seedhal- 
Green,"  for  Leedham-Green,  etc.  The  foreign  quo- 
tions  from  various  authors  ^re  translated  in  that 
bizarre  literal  style  which  we  know  so  well  in  the 
schoolboy's  "literal"  translations  of  C?esar,  Cicero, 
and  Nepos,  in  which  such  phrases  as  "The  Oration 
Into  Catiline"  abound.  No  one  could  mistake  some 
portions  of  the  translated  quotations  for  English 
without  a  stretch  of  the  imagination.  The  quota- 
tions from  English  and  American  authors  arc  in- 
serted in  scrapi)ook  style  without  any  attempts  to 
mingle  them  harmoniously  into  the  text  of  the  book. 
A  book  should  not  be  a  collection  of  clippings. 

But  the  worst  examples  of  carelessness  are  seen  in 
the  bibliography,  which  fairly  bristles  with  mis- 
prints. In  compiling  the  bibliography  it  is,  unfortu- 
nately, the  custom  with  some  writers  to  take  lists  of 


April  10,  1909. 1 


OFFICIAL  NEWS. 


77S 


references  from  other  authors  and  to  incorporate 
these  with  their  own  hst.  When  this  is  done  judi- 
ciously it  is  difficult  to  detect.  When  it  is  done  as  it 
has  been  done  in  this  book,  even  the  untrained  eye. 
can  detect  the  borrowed  titles.  Thus,  when  we  find 
such  titles  as  the  following,  it  is  easy  to  see  that  a 
German  writer  was  originally  responsible  for  the 
quotations :  ''Peterkin,  G.  S.,  Treatment  of  Chronic 
Urethritis.  Am.  Journ.  of  Urology,  1905,  part  10 
(Empfiehlt  Injektion  von  Hermophenyl  U.  4  u.  Ar- 
gyrol  2.  2.  auf  30  Glyzerin  u.  Mucilago  Caraghen)." 
More  care  in  editing  would  have  brought  the  book 
to  the  level  which  we  are  accustomed  to  see  in  the 
author's  other  writings. 

Maladies  des  reins.  Par  E.  Janselme,  Professeur  agrege 
a  la  Faculte  de  medecine  de  Paris,  etc.;  P.  Emile  Weil, 
ancien  interne  des  hopitaux  de  Paris ;  A.  Chauffard, 
professeur  agrege  a  la  Faculte  de  medecine  de  Paris  et 
L.  Laederich,  ancien  interne  (medaille  d'or)  des  hopi- 
taux de  Paris.  (Volume  xxi  du  Nouveau  traite  de 
medecine  et  therapeutique,  public  en  fascicules  sous  la 
direction  de  M.  M.  A.  Gilbert  et  L.  Thoinot.  professeurs 
a  la  Faculte  de  medecine  de  Paris.)  Paris:  J.  B.  Bail- 
-  Here  et  Fils,  1909. 

This  new  textbook  on  diseases  of  the  J<idneys, 
which  forms  a  part  of  the  great  System  of  Medicine 
edited  formerh*-  by  Brouardel  and  Gilbert,  and  now 
by  Gilbert  and  Thoinot,  forms  an  important  addition 
to  a  noteworthy  collection  of  monographs.  Clear 
and  concise  in  style,  thoroughly  modern  in  views, 
with  special  prominence  for  the  newer  experimental 
work  on  the  kidney,  this  volume  constitutes  a  most 
satisfactory  general  treatise  on  renal  disease.  It  is 
not  quite  so  elaborate  or  so  minute  in  detail  as  the 
well  known  book  of  Castaigne  and  Rotherv,  but  it  is 
perhaps  more  adapted  to  the  needs  of  the  practi- 
tioner than  that  book.  In  the  first  part,  by  Profes- 
sor Jeanselme  and  Dr.  Weil,  the  subject  of  urine 
analysis  is  briefly  covered  in  114  pages,  special  at- 
tention being  given  to  the  interpretation  of  findings 
and  but  little  attention  to  technical  methods.  The 
second  part,  by  Professor  Chauft'ard  and  Dr.  Laede- 
rich, deals  with  renal  diseases  proper,  and  covers  the 
congestions,  the  inflammations  (nephritides) ,  the 
degenerations,  and  the  infections,  and  parasitic  dis- 
eases of  the  kidneys.  Tumors,  stone,  movable  kid- 
ney, and  disturbances  due  to  renal  retention  are  con- 
sidered in  the  closing  pages.  xA.ttractively  printed 
and  illustrated  with  76  excellent  drawings,  this  book 
is  pleasing  to  the  eve  as  well  as  instructive  and  use- 
ful. 




Public   Health   and   Marine   Hospital  Service 
Health  Reports: 

The  foUozving  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  .States  Public  Health  and  Marine  Hospital  .Service, 
during  the  iveck  ending  April  2,  igog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

i-Mai'.  25   40 

7-Mar.  6   2 


A.rkansas — AUbrook  Jan. 

California — Los  Angeles  Feb. 

California — Oakland  Feb. 

California — Sacramento  Jan. 

Feb. 

Georgia — Macon   Mar. 

Illinois — Chicago  Mar. 

Illinois — Danville  Mar. 

Illinois — Galesburg  Mar. 

Illinois — Peoria  Feb. 


25-Mai'. 

I-3I   2^ 

1-28   7 

14-21   1 

13-  20   2 

14-  21   I 

6-13   I 

i3--;o   24 


1-22  

6-20  

20-Mar.  20. 

6-13  

6-20  

i-Mar.  24.  . 

13-20  

6-13  

6-13  

1-3"  

6-20  

5-  Mar.  20 .  . 

9-16  

1-21  

6-  20  


24  

6-20  

13-20  

5-  19  

26-Mar.  2 .  . 
2i-Mar.  21 . 

6-  20  

IS-31  

13-20  

9-16  

1-28  

5-  12  

28-Mar.  13. 

19  

13-20  

13-20  

6-  13  

24-Feb.   7 .  . 

7-  14  

13-20  

6-20.  .'  

28-Mar.  20. 


Places.  Dale. 

Indiana — La  Fayette  Mar.  8-22.. 

Kansas — Kansas  City  Mar.  6-20.. 

Kansas — Topeka  Mar.  13-20. 

Kansas — Wichita  Mar.  6-20.. 

Kentucky — Fulton  Feb. 

Kentucky — Lexington  Mar. 

Kentucky — Newport  Jan. 

Kentucky — Paducah  Mar. 

Louisiana — New  Orleans  Mar. 

Louisiana — Winnfield  and  Vicinity  .Jan. 

Massachusetts — Boston  Mar. 

Massachusetts — Lawrence  Mar. 

Minnesota — Minneapolis  Mar. 

Minnesota — St.  Paul  Jan. 

Missouri — Kansas   City  Mar. 

Missouri — Rich  Hill  Dec. 

Montana — Butte  Mar. 

Nebraska — Lincoln  Feb. 

New  Jersey — New  Brunswick ....  Mar. 

New  Jersey — Perth  Amboy  Mar. 

New  Jersey — Plainfield  Mar. 

New  York — Buffalo  Mar. 

Ohio — Cincinnati  Mar. 

Ohio — Columbus  Dec. 

South  Carolina — Winnsboro  Feb. 

Tennessee — Knoxville  Mar. 

Tennessee — Murf  reesboro  Mar. 

Tennessee — Nashville  Mar. 

Texas — El  Paso  Mar. 

Texas — Fort  Worth  Feb. 

Texas — Galveston  Mar. 

Texas — Houston  Feb. 

Texas — Laredo  Mar, 

Texas — San   Antonio  Mar. 

Virginia — Richmond  Mar. 

Washington — Spokane  Mar. 

Washington — Tacoma  Jan. 

Mar. 

Wisconsin — Appleton  Mar. 

Wisconsin — La  Crosse  Mar. 

Wisconsin — Milwaukee  Feb. 

Smallpox — Foreign. 

Algeria — Algiers  Feb.  1-28  

British  Honduras — Stann   Creek.. Mar.  4-11  

Canada — Halifax  Mar.  6-13  

Canada — Yarmouth  Mar.  21-27  

China — Tientsin  Jan.  16-23  

Egypt — .\lexandria   Jan.  14-28  

Lgypt — Cairo  Feb.  6-8  

France — Paris  Feb.  27-Mar.  6. 

Great    Britain — Bristol  Feb.  27-.Mar.  6. 

Greece — i\thens  Feb.  27-Mar.  6. 

India — Bombay.....  Feb.  16-23  

India — Calcutta  Feb.  6-13  

India — Madras  Feb.  13-19. 

India — Rangoon  Feb. 

Italy — General  Feb. 

Italy — Florence  Mar. 

Italy — Naples  Feb. 

Japan — Kobe  Feb. 

Java — Batavia  Feb.  6-13. 

Portugal — Lisbon  Mar.  6-13  

Russia — Moscow  Feb.  20-27  

Russia — Odessa  Feb.  27-Mar.  6.. 

Russia — St.    Petersburg  Feb.  13-20  

Siberia — Vladivostock  Feb.  4-14  

Spain — \'alencia  Feb.  19-26  

Turkey — Smyrna  Jan.  29-Feb.  26. 

Yellow  Fever — Foreign. 

Barbados  Mar.  14-20  

Mexico — Maxcanu,  Vicinity  Mar.  13-20  

Cholera — Foreign. 

India — Bombay  Feb.  16-23  

India — Calcutta  Feb.  6-13  

India — Rangoon  Feb.  6-13  

Russia — Charkov  Mar.  10  

Russia — Jaroslov  To   Mar.  7  

Russia — Roniano-Borissglabsk  Mar.  13  

Russia — St.    Petersburg  Mar.  6-11  

Plague — Foreign. 

.\zores — Fayal  Mar.  16  

Azores — Terceira  Feb.  1-28  

Chile — Iquique  Feb.  i5  

India — Bombay  Feb. 

India — Calcutta  Feb. 

India — Rangoon  Feb. 

I'eru — General  Feb. 

Peru — Callao  Feb. 

Peru — Lima  I' eh. 


Cases.  Deaths. 


34 


3  Imported 
33 


3 
37 
4 
5 


19 
14 

5 
5 


6-13. 
21-Mar.  7.  . 

3-10  

28-Mar.  6. 
13- 


3 
24 


4 
6 
68 
5 
5 


15 
4 
3 
6 

32 
6 
7 


4 

59 


2  + 
>7i 


5 
17 
7 

26 

Present 


10-23. 
6-13.. 
6-13.. 
13-20. 
13-20. 
13-20. 


Present 
15  S 
14 

In  Lazaretto 
94 

12 
14 
40 

3 
3 


80 
7 
5 


Public  Health  and  Marine  Hospital  Service: 

Official  Hst  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  tlie  seven  days  ending 
March  31,  igog :  • 

Anderson,  John  F.,  Passed  Assistant  Surgeon.  Detailed 
to  represent  the  Service  at  the  annual  meeting  of  the 
American  Association  of  Pathologists  and  Bacteriol- 
ogists to  be  held  in  Boston,  Mass.,  April  8,  1909. 


776 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal. 


BoGGF.ss,  J.  S.,  Passed  Assistant  Surgeon.  Granted  one 
day's  leave  of  absence,  March  28,  1909. 

CoKER,  L.  E.,  Passed  Assistant  Surgeon.  Relieved  from 
temporary  duty  at  Hygienic  Laboratory  and  directed  to 
proceed  to  Reedy  Island  Quarantine  Station  and  as- 
sume temporary  command. 

Creei,,  R.  H.,  Passed  Assistant  Surgeon.  Detailed  as  chair- 
man of  board  of  medical  officers  convened  under  Bu- 
reau order  of  March  23,  1909. 

Kim  MET,  William  A.,  Acting  Assistant  Surgeon.  Detailed 
as  recorder  of  board  of  medical  officers  convened  un- 
der Bureau  order  of  March  23,  1909. 

OxT,  C.  R.,  Pharmacist.  Leave  of  absence  granted  January 
25,  1909,  for  thirty  days  from  March  25,  1909,  amended 
to  read  thirty  days  from  March  23,  1909. 

Preule,  Paul,  Assistant  Surgeon.  Upon  arrival  of  Assist- 
ant Surgeon  F.  A.  Ashford,  directed  to  proceed  to 
Baltimore,  Md.,  and  report  to  the  medical  officer  in 
command  for  duty  and  assignment  to  quarters. 

Roberts,  Norman,  Passed  Assistant  Surgeon.  Granted 
four  days  leave  of  absence  from  March  28,  1909. 

Robertson,  Herman,  Acting  Assistant  Surgeon.  Granted 
twenty-three  days'  extension  of  leave  of  absence  from 
February  8,  1909,  on  account  of  sickness. 

Stewart,  W.  J.  S.,  Acting  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  March  26,  1909. 

Young,  G.  B.,  Surgeon.  Relieved  as  chairman  of  board  of 
medical  officers  convened  under  Bureau  order  of  March 
23,  1909. 

Board  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital,  Port  Townsend,  Wash.,  March  26,  1909,  for  the 
purpose  of  conducting  a  physical  examination  of  a  captain 
of  the  United  States  Revenue  Cutter  Service.  Detail  for 
the  board:  Surgeon  W.  G.  Stimpson,  chairman;  Passed 
Assistant  Surgeon  J.  H.  Oakley,  recorder. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  zveek  ending  April  3,  igog: 
Anderson,  E.  A.,  Fir»t  Lieutenant,  Medical  Reserve  Corps. 

When  relieved  at  Fort  Wingate,  N.  M.,  ordered  to  Ai- 

catraz  Island,  Cal.,  for  duty  at  the  Pacific  Branch,  U. 

S.  Military  Prison. 
BiSPHAM,  W.  N.,  Captain,  Medical  Corps.    Granted  leave 

of  absence  for  one  month. 
Brooks,  W.  H.,  Captain,  Medical  Corps.    Granted  sick 

leave  of  absence  for  one  month ;  relieved  from  duty 

at  Fort  Mackenzie,  Wyo.,  and  ordered  to  Presidio  of 

San  Francisco,  Cal.,  for  duty. 
Campbell,  G.  F.,  First  Lieutenant,  Medical  Reserve  Corps. 

Relieved  from  duty  at  the  Pacific  Branch,  U.  S.  Mili- 
tary Prison,  Alcatraz  Island,  Cal.,  and  ordered  to  Fort 

Wingate,  N.  M.,  for  duty. 
Duncan,  L.  C,  Captain,  Medical  Corps.    Relieved  from 

duty  at  Fort  Missoula,  Mont.,  and  ordered  to  sail  June 

5,  1909,  from  San  Francisco,  Cal.,  for  service  in  the 

Philippines  Division. 
Farr,  C.  W.,  Captain,  Medical  Corps.    Granted  sick  leave 

of  absence  to  June  i,  1909. 
HoPWOOD,  L.  L.,  First  Lieutenant,  Medical  Corps.  Granted 

leave  of  absence  for  one  month. 
KiERULFF,  H.  N.,  P'irst  Lieutenant,  Medical  Reserve  Corps. 

Relieved  from  duty  at  Fort  Apache,  Ariz.,  and  ordered 

to  Fort  Missoula,  Mont.,  for  duty. 
Lemmon,  Roi;ert,  First  Lieutenant,  Medical  Reserve  Corps. 

Ordered  from  Fort  Howard,  Md.,  to  Fort  Jay,  N.  Y., 

for  temporary  duty. 

McAndrew,  P.  H.,  Captain,  Medical  Corps.  Relieved  from 
duty  at  l<"ort  Slocum,  N.  Y.,  and  ordered  to  Fort  Mac- 
kenzie, Wyo.,  for  duty. 

Marrow,  C.  E.,  Major,  Medical  Corps.  Ordered  to  duty  at 
the  Presidio  of  San  Francisco,  Cal.,  at  the  expiration 
of  the  leave  of  absence  heretofore  granted  him. 

Mason,  C.  P.,  Major,  Medical  Corps.  Refieved  from  duty 
in  the  office  of  the  Surgeon  General  of  the  Army,  to 
take  effect  May  i,  1909,  and  ordered  to  duty  with  the 
Isthmian  Canal  Commi'Jsion. 

Miller,  E.  W.,  Captain,  Medical  Corps.  Ordered  to  duty 
at  Fort  Williams,  Mc,  upon  the  expiration  of  the  leave 
of  al)';enrf  heretofore  granted  him. 


Trotter-Tvler,  George,  First  Lieutenant,  Medical  Reserve 
Corps.  Ordered  from  Fort  Adams,  R.  I.,  to  Fort 
Howard,  Md.,  for  temporary  duty. 

Truby,  a.  E.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  two  months,  about  June  15,  1909. 

Wilson,  J.  S.,  Major,  Medical  Corps.  Granted  leave  of  ab- 
sence for  four  months,  when  relieved  from  duty  in  the 
Philippines  Division. 

Wilson,  W.  H.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  one  month,  twenty  days ;  relieved  from 
duty  at  Fort  Hamilton,  N.  Y.,  and  will  sail  from  San 
l'"rancisco,  Cal.,  June  5,  1909,  for  Philippine  service. 

Navy  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  ttie  week  ending  April  j,  igog: 

Abernathy,  R.  T.,  Pharmacist.    Appointed  a  pharmacist 

from  March  22,  1909,  and  ordered  to  the  Franklin 

March  20,  1909. 
Connor,  W.  H.,  Acting  Assistant  Surgeon.    Appointed  an 

acting  assistant  surgeon  from  March  24,  1909. 
Robbins,  I.  W.,  Acting  Assistant  SurgeoiL    Ordered  to 

duty  at  the  Naval  Hospital,  Mare  Island,  Cal. 

 ^>  

iirt^s,  Parriagts,  anb  i^atfes. 


Born. 

Rosenheck. — In  New  York,  on  Wednesday,  March  31st, 
to  Dr.  Charles  Rosenheck  and  Mrs.  Rosenheck.  a  daughter. 
Married. 

L.wvKENCE — Weber. — In  Reading,  Pennsylvania,  on  Fri- 
day, March  26th,  Dr.  Frank  H.  Lawrence  and  Miss  Maude 
Evangeline  Weber. 

Died. 

Albrecht. — In  Cincinnati,  Ohio,  on  Sunday,  March  28th, 
Dr.  Barbara  Albrecht,  aged  seventy-four  years. 

Burlingame. — In  Oakland  City,  Indiana,  on  Sunday, 
March  21st,  Dr.  E.  G.  Burlingame,  aged  forty-five  years. 

Butler. — In  Bangor,  Maine,  on  Tuesday,  March  23d,  Dr. 
Harry  Butler,  aged  forty  years. 

Chamberlin. — In  New  York,  on  Saturday,  April  4th, 
Mary  B.  Chamberlin,  wife  of  Dr.  Frank  W.  Chamberlin. 

DoRSCHUG. — In  Cincinnati,  Ohio,  on  Thursday,  March 
25th,  Dr.  F.  P.  Dorschug,  aged  forty-eight  years. 

Fessenden. — In  Salem,  Massachusetts,  on  Friday,  March 
26th,  Dr.  J.  P.  Fessenden,  aged  seventy-eight  years. 

Forman. — In  Freehold,  New  Jersey,  on  Monday,  March 
29th,  Dr.  D.  McLean  Forman,  aged  sixty-four  years. 

Harwood. — In  Worcester,  Massachusetts,  on  Friday, 
March  26th,  Dr.  Charles  W.  Harwood,  aged  fifty-two  years. 

Hews. — In  Chicago,  Illinois,  on  Thursday,  March  25th, 
Dr.  Charles  D.  Hews,  aged  sixty-five  years. 

Hogg. — In  Houston,  Texas,  on  Sunday,  March  21st,  Dr. 
Frank  Baylor  Hogg,  aged  thirty-seven  years. 

Hyser. — In  Plainfield,  Michigan,  on  Saturday,  March 
20th,  Dr.  William  Hjser,  aged  eighty-three  years. 

Kehm. — In  East  Berlin,  Pennsylvania,  on  Sunday,  March 
March  21st,  Dr.  Henry  Kehm,  aged  sixty-five  years. 

Kitchen. — In  Stayton,  Oregon,  on  Tuesday,  March  i6th. 
Dr.  John  M.  Kitchen,  aged  sixty-seven  years. 

Kline. — In  Catasauqua,  Pennsylvania,  on  Thursday, 
March  25th,  Dr.  Jonas  L.  Kline,  aged  seventy-three  years. 

Macomber. — In  Pasadena,  California,  on  Tuesday,  March 
23d,  Dr.  Henry  K.  Macomber,  aged  sixty-seven  years. 

Percy. — In  Washington,  D.  C.,  on  Wednesday,  March 
31st,  Dr.  Henry  T.  Percy,  of  the  Medical  Corps  of  the 
United  States  Navy,  aged  sixty  years. 

Pratt. — In  Elmira,  New  York,  on  Thursday,  March  25th, 
Dr.  Ray  B.  Pratt. 

Reed. — In  Massillon,  Ohio,  on  Sunday,  March  28th,  Dr. 
Thomas  J.  Reed,  aged  seventy-one  years. 

Seymour.— In  Warrenton,  'Texas,  on  Friday.  March  26th, 
Dr.  Robert  H.  Seymour. 

SoMERS — In  Atlantic  City,  New  Jersey,  on  Friday,  April 
jnd.  Dr.  ^L  LcRoy  Somers,  aged  twenty-eight  years. 

Tenney. — In  Kansas  City,  Kansas,  on  Saturday,  March 
20th,  Dr.  .\.  P.  Tenney,  aged  seventy-nine  years. 

TiNDALL. — In  Toledo.  Ohio,  on  Mondav.  March  22nd.  Dr. 
Ostar  N.  Tindall. 

White. — In  West  .\lexander.  Pennsylvania,  on  Friday, 
March  2fith.  Dr.  J.  W.  White,  aged  thirty-six  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal 


The  Medical  News 


A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  16. 


NEW  YORK,  APRIL  17,  1909. 


Whole  No.  1585. 


(Original  Commratations. 


THE    TECHNIQUE    OF    THE  WASSERMANN 
REACTION: 

Its   Practical  Application   ivith   Reference   to  Diagnosis, 
Prognosis,  and  Treatment  of  Nervous  Disease* 

By  E.  Castelli,  M.  D.. 
New  York, 

Consulting  Physician  at  the  Columbus  Hospital;  Instructor  of  Neu- 
rology at  the  New  York   Polyclinic;   Assistant  Neurologist 
at  the  German  Dispensary. 

PRINCIPLE  OF  THE  REACTION  AND  TECHNIQUE. 

The  principle  of  the  reaction  in  its  simplest  ex- 
pression is  the  following:  "Ttco  bodies  of  colloidal 
nature  having  the  property  of  binding  together,  have 
also  the  property  of  binding  a  third  element." 

In  the  Wassermann  reaction  we  have  in  each  re- 
agent tube  five  elements  which,  for  the  understand- 
ing of  the  reaction,  we  may  consider  divided  in 
three  groups :  First  group,  containing  as  element, 
(a)  syphilitic  serum,  and  (b)  syphilitic  extract; 
second  group,  containing  (a)  hgemolysin,  and  (b) 
blood ;  third  group,  containing  complement. 

If  the  complement  is  bound  by  the  first  group,  in 
the  second  group  deprived  of  complement  an  inhibi- 
tion to  the  dissolving  of  blood  will  occur.  Inhibi- 
tion means  positive  reaction.  The  reaction  may  be 
dififerent  in  intensity,  and  this  difference  can  only 
be  interpreted  as  a  difference  in  the  intensity  of  the 
infection.  Generally  in  a  patient  with  an  old  lues 
the  inhibition  is  not  so  intense  as  it  is  in  a  patient 
whose  infection  is  more  recent.  This  phenomenon 
corresponds  clinically  to  a  well  known  pathological 
axiom,  viz. :  "The  virulence  of  a  pathological  pro- 
cess is  in  inverse  proportion  to  its  duration."  So 
an  old  syphilitic  infection  will  give  a  weaker  reac- 
tion than  a  recent  one.  The  reagents  with  which 
we  have  to  deal,  being  organic  elements,  are  chem- 
ically unstable  and  so  not  always  reliable.  It  is  onlv 
a  long  and  tedious  training  in  the  use  of  the  ditfer- 
ent  organic  reagents  that  will  give  us  the  exact  un- 
derstanding and  the  logical  interpretation  of  the  re- 
action. Hsemolysin  and  extracts  for  reasons  some- 
times explainable  and  sometimes  unexplainable 
undergo  changes  which  will  alter  the  reaction.  I 
would  not  advise  anybody  to  carelessly  undertake 
the  use  of  the  reaction  for  serious  diagnostic  pur- 
poses, because  the  conclusive  statements  to  which 
the  results  of  a  reaction  bring,  have  a  too  vital  an 
importance  in  the  prognosis  oi  our  patient. 

*Read  before  the  New  York  Neurological  Society  on  October  6, 
1908. 

Copyright,  1909,  by  A.  R. 


REAGENTS  AND  ilETHOD  OF  OBTAINING  THEM. 

The  reagents  necessary  for  the  reaction  are  the 
following:  i.  Extracts  from  organs;  2,  sera  or  cere- 
brospinal fluid  from  syphilitic  and  nonsyphilitic  pa- 
tients ;  3,  complement,  generally  blood  serum  from 
the  guinea  pig ;  4,  hjemolysin,  inactive  serum  from 
rabbit  previously  treated  with  washed  sheep  blood 
corpuscles ;  and,  5,  blood  corpuscles  from  sheep. 

The  reaction  could  be  made  very  much  simpler 
if  instead  of  organic  extracts  we  could  use  more 
stable  elements.  Lecitin,  cholesterin,  and  petro- 
latum, used  by  Wassermann  and  others,  have  so  far 
proved  to  be  unsatisfactory  substitutes  for  organ 
extracts  and  unsuitable  for  obtaining  a  correct  re- 
action. Until  now  the  liver  of  a  syphilitic  foetus 
and  the  norma!  human  liver  have  been  used  re- 
spectively for  the  preparation  of  syphilitic  and  nor- 
mal extract.  Experiments  have  also  been  made 
with  extracts  obtained  from  the  heart  muscle  of  a 
guinea  pig  and  other  animals,  but  so  far  no  definite 
favorable  results  have  been  gathered.  To  come  to 
a  satisfactory  conclusion  a  great  many  examinations 
with  normal  organ  extract  must  be  made,  using  as 
control  a  syphilitic  extract  already  known. 

Extracts. — For  the  reaction  we  need  a  syphilitic 
and  a  normal  liver  extract.  We  procure  for  the 
purpose  the  liver  of  a  syphilitic  foetus  and  a  nor- 
mal liver  from  child  or  adult,  and  we  prepare  either 
a  watery  extract  or  an  alcoholic  one.  To  make 
the  watery  extract  we  weigh  a  determined  quantity 
of  liver  substance,  we  cut  it  into  small  pieces,  grind 
it  in  a  mortar,  and  when  it  is  all  reduced  to  a  pulp 
we  add  to  the  bulk  four  times  as  much  sterile  physi- 
ological solution  of  sodium  chloride,  to  which  we 
have  added  a  half  per  cent,  solution  of  carbolic  acid. 
Having  done  so  we  pour  the  mixture  into  a  dark 
bottle,  in  order  to  protect  the  extract  from  the 
eventual  possible  changes  that  the  action  of  light 
might  bring  in  its  composition,  and  shake  the  mix- 
ture in  a  rocker,  moved  either  by  water  or  elec- 
tricity, during  twenty-four  hours.  zAfter  the  twen- 
ty-four hours  the  extract  is  centrifuged  at  a  slow 
speed  during  ten  minutes,  the  liquid  part  taken  out, 
tested,  dosed,  and  used  as  syphilitic  or  normal  ex- 
tract at  the  established  dose. 

For  the  alcoholic  extracts  we  use  an  analogous 
method,  with  the  difference  that  we  substitute  alco- 
hol to  water,  and  we  filter  the  mixture  after  it  has 
been  in  the  shaker  twenty-four  hours.  The  most 
important  feature  in  the  preparation  of  the  extracts 
is  their  testing  and  dosing.  One  of  the  well  noted 
facts  is  that  not  all  syphilitic  livers  give  a  syphilitic 
reaction,  viz.:  not  every  syphilitic  extract' can  be 

Elliott  Publishing  Company. 


778 


CASTELLI:   WASSERMANN  REACTION. 


[New  Yokk 
Medical  Journal. 


used  for  the  reaction.  It  may  be  due  to  deficiency 
in  the  hver  of  syphilitic  virus,  or  to  some  errors  of 
technique.  What  I  have  observed  is  that,  when  a 
mixture  from  syphilitic  extract  undergoes  an  ex- 
cessive or  too  rapid  centrifugation  it  is  apt  to  give 
a  negative  reaction.  The  testing  and  dosing  of  ex- 
tracts is  obtained  by  a  control  method  in  which,  al- 
ready known,  respectively  normal  and  syphilitic  ex- 
tracts are  compared  with  the  unknown  extracts  to 
be  tested.  The  extracts  are  divided  in  fractional 
doses,  and  the  dose  selected  as  efficient  for  the  re- 
action is  the  one  that  gives,  with  syphilitic  serum, 
complete  inhibition  (Hemniung) ,  and  with  non- 
syphilitic  serum  complete  haemolysis  (Losung).  I 
selected  as  a  dose  0.075  grammes. 

The  extracts  are  very  unsteady  preparations.  It 
may  occur  that  an  extract  becomes  already  unfit  for 
use  after  a  few  davs,  and  in  other  cases  the  extract 
can  maintain  its  qualities  for  months.  This  fact 
makes  the  reaction  a  very  delicate  one  and  creates 
an  obstacle  to  the  reliability  of  observations  made 
by  amateur  investigators.  The  stability  of  the  alco- 
holic extracts  seems  greater  than  the  one  of  the 
watery  one,  but  their  efficiency  as  reagents  is  not 
considered  as  good  by  the  Wassermann  school. 

'  Other  organic  elements  have  been  substituted  for 
the  liver  extracts,  among  which  the  one  that  has 
proved  to  be  the  best  is  the  Hpoid  substance.  This 
name  lipoid  is  given  to  special  tissues  or  organs 
treated  with  ether,  and  they  are  formed  by  fats, 
phosphatides,  and  derivatives  from  cholesterin. 
Many  organs,  like  the  lungs  and  the  prostatic  gland, 
contain  lipoid  substance  in  a  large  quantity ;  other 
tissues,  like  the  bone  marrow,  contain  only  traces. 
According  to  Gerard  Lemoine  and  Lulier,  of  Lille, 
the  role  of  the  lipoids  in  the  organism  is  a  role  of 
defense,  and  they  seem  utilized  by  the  organism  in 
order  to  combat  against  intoxications.  For  these 
authors  the  lipoids  are  capable  of  eliminating  grad- 
ually the  tuberculous  bacillus  from  the  tuberculous 
foci.  The  same  writers  think  that  fatty  degenera- 
tion of  any  organ  is  not  a  real  degeneration  and  a 
sign  of  destruction  of  the  morphological  element  of 
an  organ,  but  is  a  real  defensive  mobilization  of  fat 
in  the  organ  invaded  by  a  toxic  substance.  The 
fact  that  the  lipoid  substance  may  give  the  same  re- 
action as  a  syphilitic  liver  extract  may  be  due  to 
the  occurrence  that  during  the  syphilitic  infection 
the  lipoid  substance  is  formed  in  the  liver  as  a  pro- 
duct of  defense,  and  constitutes,  together  with  other 
substances,  an  element  necessary  to  the  reaction. 

The  experiments  done  so  far  have  not  yet  estab- 
lished the  reliability  of  the  lipoid  substance  as  the 
proper  substitute  for  the  syphilitic  liver  extract  used 
until  now  in  the  Wassermann  reaction. 

Hcemolysin. — Hacmolysin  is  the  scrum  of  rabbit 
previously  treated  with  subcutaneous  or  subperi- 
toneal injections  of  blood  from  sheep.  Generally  the 
rabbit  is  injected  three  times,  each  injection  being 
given  five  days  apart,  with  one  cubic  centimetre  of 
sheep's  corpuscles  dissolved  in  equal  parts  of  physi- 
ological solution  of  sodium  chloride.  Five  days 
after  the  last  mjection  a  small  quantity  of  blood  is 
taken  and  its  serum  made  inactive  and  tested.  The 
hsemolytic  serum  is  considered  efficient  for  the  re- 
action when  in  the  quantity  of  o.ooi  together  with 


0.1  c.c.  of  complement  is  able  to  dissolve  in  about 
one  hour  i  c.c.  of  a  five  per  cent,  solution  of  sheep*s 
blood. 

The  dosing  of  hasmolysin  is  one  of  the  routine 
rules  to  be  followed  every  time  we  proceed  to  the 
examination  of  blood  for  the  serum  reaction.  The 
serum  taken  from  the  blood  is  made  inactive  by  leav- 
ing it  for  about  one-half  hour  in  the  water  bath  at 
the  temperature  of  56°  C.,  and  then  mixing  it  with 
one  c.c.  of  a  ten  per  cent,  solution  of  complement  and 
one  c.c.  of  a  five  per  cent,  solution  of  sheep's  cor- 
puscles. The  dose  selected  for  the  reaction  is  the 
dose  three  times  as  strong  of  haemolysin,  which  dis- 
solves completely  in  about  one  hour  blood  and  com- 
plement. 

Complement. — The  complement  used  for  the  serum 
reaction  is  the  fresh  serum  from  guinea  pig.  The 
extraction  is  accomplished  by  opening  the  carotid 
artery  and  gathering  the  blood  in  a  sterilized  reagent 
glass.  As  soon  as  the  blood  clot  is  formed  the  serum 
is  taken  from  the  tube  with  a  pipette  and  centri- 
fuged.  The  compliment  kept  in  the  ice  box  can  re- 
tain its  usefulness  for  about  three  days.  The  com- 
plement used  in  the  reaction  is  a  ten  per  cent,  solu- 
tion. 

Sheep's  blood. — The  blood  taken  from  the  vena 
jugularis  is  gathered  in  a  glass  jar  containing  small 
glass  balls,  shaken  thoroughly  in  order  to  separate 
the  fibrin.  The  defibrinated  blood  is  washed  three 
times  with  a  physiological  solution  of  sodium  chlo- 
ride, centrifuged,  and  used  for  the  reaction  in  a  five 
per  cent,  solution.  The  blood  kept  in  the  ice  box 
can  maintain  its  efficiency  as  reagent  for  about  one 
week.  The  decay  of  the  blood,  generally  through 
the  action  of  bacteria,  is  shown  by  the  fact  that  the 
blood  will  dissolve  in  the  physiological  solution  and 
assume  a  violet  color. 

Patient's  serum. — With  a  large  Pravaz  syringe 
properly  sterilized  we  take  from  the  vena  mediana 
5  c.c.  of  blood,  put  it  in  a  sterilized  reagent  glass, 
and  leave  it  twelve  hours  in  a  cool  place.  After 
twelve  hours  we  will  find  the  serum  separated  from 
the  blood  clot.  We  take  the  serum,  centrifuge  it  for 
five  minutes,  and  leave  it  in  a  water  bath  at  a  tem- 
perature of  56°  C.  for  half  an  hour  in  order  to  in- 
activate it. 

TECHNIQUE  OF  THE  WASSERMANN  REACTION. 

All  the  sera  and  extracts  used  for  the  reaction  are 
diluted  in  the  physiological  solution  of  sodium  chlo- 
ride in  such  way  that  the  dose  needed  for  each  re- 
agent is  always  contained  in  the  total  volume  of  i 
c.c.  The  first  phase  of  the  reaction  consists  in  the 
making  of  the  solution  of  the  sera  and  extracts,  add- 
ing to  them  complement.  The  second  phase  of  the 
reaction  consists  in  the  addition  of  hcnemolysin  and 
blood  corpuscles.  Each  reagent  tube  will  contain  five 
c.c.  of  solution.  The  tube  where  one  or  the  other 
substance  is  lacking  is  filled  up  with  equal  quantities 
of  physiological  solution  of  sodium  chloride. 

The  main  feature  of  the  technique  is  the  control 
system.  We  find  that  normal  scrum  plus  syphilitic 
extract  gives  a  complete  haemolysis,  and  syphilitic 
serum  plus  syphilitic  extract  gives  inhibition  (  Hem- 
niung). The  reaction  of  the  unknown  sera  that  we 
examine,  compared  with  the  reaction  of  controls, 


April  17,  1909.] 


CASIELLI:    WASSERMASX  REACTION. 


779 


and  their  bearing  either  as  the  control  for  the  nor- 
mal serum  or  as  the  control  for  the  syphilitic  serum, 
will  establish  the  diagnosis  of  syphilitic  or  normal 
reaction. 

VALUE  OF  THE  REACTIOX    W  ITH   REFERENCE  TO 
DIAGXOSI.S   AXD  THERAPEUTICS. 

Can  the  Wassermann  reaction  be  considered  spe- 
cific to  syphilis,  or  not  ?  ^^'assermann  declares  that 
a  positive  reaction  proves  a  syphilitic  infection,  but 
in  the  short  literature  already  existing  on  the  reic- 
tion  some  doubtful  cases  are  mentioned.  Dr.  Mi- 
chaelis,  in  over  1,000  control  cases  examined  of  sera 
and  cerebrospinal  fluid  of  people  in  which  syphilitic 
infection  was  denied,  found  only  three  cases  in  which 
the  Wassermann  reaction  proved  positive,  viz. :  in 
two  cases  of  typhoid  fever  and  one  of  malaria.  Hoff- 
mann and  Blumenthal  found  a  positive  reaction  in 
one  case  of  psoriasis  vulgaris  and  one  of  framboesia 
tropica.  This  last  case  created  at  the  time  the  sus- 
picion that  the  serum  diagnosis  was  probably  spe- 
cific of  pathological  conditions  created  by  protozoa. 

^ly  idea,  after  having  closely  w'atched  and  per- 
formed myself  the  serum  reaction,  is  that  the  cliffi- 
culty  and  delicacy  of  the  reaction  is  such  that  a 
doubt  on  the  real  value  of  these  few  and  isolated 
cases  is  justifiable,  especially  owing  to  the  fact  th-t 
such  results  were  obtained  principally  in  the  time  in 
which  the  Wassermann  reaction  was  at  its  inception, 
a  period  during  which  the  different  investigators  had 
probably  not  acquired  a  perfect  knowledge  of  the 
dosing  of  extracts  and  sera,  on  the  interpretation  of 
the  different  nuances  that  a  reaction,  although  posi- 
tive, would  show  in  the  reagent  glass,  to  the  fact 
also  that  many  of  these  investigators  have  used  alco- 
holic extracts  instead  of  the  more  reliable  watery 
ones.  We  cannot,  of  course,  discard  entirely  the 
possibility  that  these  few  cases  might  have  been  luet- 
ics, notwithstanding  the  iact  that  lues  had  been  de- 
nied. 

The  fact  that  Wassermann,  after  the  examination 
of  thousands  of  sera,  could  not  find  a  reaction  posi- 
tive in  other  diseases,  seems  to  me  a  suflficient  guar- 
antee that  the  reaction  is  specific  to  syphilis.  And, 
supposing  that  few  isolated  cases  nonsyphilitic  should 
have  given  a  positive  reaction,  could  that  fact  alone 
destroy  the  value  of  such  an  important  clinical 
achievement?  Admitting  that  the  Wassermann  re- 
action should  reach  in  its  unreliability  the  one  of  the 
Widal  reaction  in  typhoid  fever,  the  immense  impor- 
tance of  a  positive  reaction  could  not  be  compared  in 
its  value  to  the  importance  of  a  positive  reaction  in 
typhoid  fever.  When  a  Wassermann  reaction  is 
positive  we  change  entirely  the  prognosis  of  our  pa- 
tient, because  we  are  in  possession  of  a  specific  thera- 
peutic. When  we  have  a  positive  Widal  reaction  we 
have  a  clinical  fact  that  only  confirms  a  generally 
positive  diagnosis  of  typhoid  fever,  without  much 
help  as  to  treatment. 

Wiiat  more  do  we  want? 

One  of  the  principal  objections  to  the  reliability 
of  the  reaction  was  created  when  the  complement 
fixation  could  be  obtained  also  by  mixing  syphilitic 
sera  with  extracts  from  normal  organs.  But  such 
an  objection  could  not  have  sufficient  weight  to  de- 
strov  the  .specific  value  of  the  reaction.     It  was  true 


that  normal  extracts  could  give  a  positive  reaction, 
but  only  providing  that  the  sera  examinefl  were 
syphilitic.  .So  the  reaction,  while  less  relialile,  re- 
mained specific  for  .syphilis. 

Without  dift'ering  too  much  in  the  criticism  of  the 
reaction,  I  think  it  useful  to  give  a  few  of  the  results 
obtained  by  different  observers. 

In  the  clinic  for  medicine  in  the  Charite  Hospital 
of  Berlin,  of  25c)  patients  examined,  of  whom  193 
gave  sufficient  anamnestic  data  proving  a  previous 
syphilitic  infection,  the  result  was  that  seventy-two 
per  cent,  of  the  cases  gave  positive  reaction. 

Other  statistics  gathered  were  those  of  Fisher- 
Mayer,  in  which  eighty-three  per  cent,  of  cases 
proved  positive;  G.  ]\ layer,  in  which  eighty-one  per 
cent,  of  cases  proved  positive  ;  Blanschko-Citron.  in 
which  seventy-nine  per  cent,  of  cases  proved  po.-i- 
tive ;  Xoble  and  Artz,  in  which  eighty-one  per  cent, 
of  cases  proved  positive;  Miiller,  in  which  seventy- 
seven  per  cent,  of  cases  proved  positive ;  and  -Micae- 
lis-Lesser.  in  which  74.6  per  cent,  of  cases  proved 
positive.  These  are  statistics  of  cases  selected  tout 
ensemble,  without  special  consideration  being  paid 
to  the  period,  appearance,  and  stage  of  the  disease. 

Observations  made  taking  into  consideration  the 
stage  of  the  disease  and  its  treatment  have  given 
the  following  results : 

In  the  primary  stage  the  reaction  is  only  positive 
in  sixty-five  per  cent,  of  cases,  because  the  antibodies 
are  not  yet  completely  formed.  In  the  secondarv 
stage  (exantema)  the  reaction  is  positive  in  ninety- 
five  per  cent,  of  cases.  In  the  tertiary  stage,  with  evi- 
dent manifestations,  the  reaction  has  been  positive 
in  ninety-eight  to  one  hundred  per  cent,  of  cases,  ac- 
cording to  the  different  investigators. 

CEREBRAL  NERVOU.-^  .SYSTEM. 

In  paralysis  progressiva  the  reaction  has  been  pos- 
itive in  one  hundred  per  cent,  of  cases.  I  have  had 
the  opportunity  of  examining  personally  many  cases 
of  paralysis  in  the  psychiatric  department  of  the 
Charite  in  Berlin,  and  of  examining  not  only  the 
blood  by  the  Wassermann  method,  but  controlling 
the  method,  by  examining  the  cerebrospinal  fluid 
with  the  precipitation  method  and  with  the  \\'asser- 
mann  method,  obtaining  the  identical  results.  The 
fact  that  in  all  cases  of  dementia  paralytica,  without 
exception,  the  Wassermann  reaction  has  proved  pos- 
itive, would  resolve  the  long  discussed  argument 
over  the  aetiology  of  dementia  paralytica,  or  would 
establish  the  clinical  conception  that  dementia  para- 
lytica is  a  condition  of  deranged  metabolism  of  the 
nervous  system,  a  derangement  that  would  represent 
the  synthesis  of  long  exhaustion  created  either  by 
previous  inherited  conditions  or  by  accjuired  debili- 
tating conditions. 

If  such  should  be  the  case  syphilis  would  be  con- 
sidered as  an  infection  altering  the  functions  of  me- 
tabolism of  the  nervous  system,  altering  its  power 
of  resistance,  creating  a  condition  of  general  exhaus- 
tion, producing  in  a  relatively  short  period  the  same 
conditions  that  age  or  hereditary  weakness  produces 
slowly.  Is  not  perhaps  dementia  senilis  a  form  of 
dementia  paralytica  brought  on  by  the  natural  pro- 
cesses of  exhaustion  which  the  nervous  system,  lik  - 
any  other  system,  undergoes  when  life  has  been  t  o 
long? 


78o 


CASTELLI:   IFASSEmfANN  REACTION. 


[New  York 
Medical  Journal. 


Such  a  Statement  would  be  confirmed  by  the  sta- 
tistics gathered  in  the  Asile  d'Armentier,  where  the 
Wassermann  reaction  is  tried  systematically  on 
■every  patient  entering  the  institution.  Such  statis- 
tics prove  that  in  sixty  per  cent,  of  cases  of  dementia 
senilis  the  Wassermann  reaction  is  positive. 

I  watch  very  closely  and  attentively^  the  French 
investigators  because  of  their  tendency  to  embrace 
Avith  enthusiasm  every  new  idea  and  their  readiness 
to  analyze  its  real  value  by  testing  it  at  large  in  every 
clinical  case  indiscriminately.  It  is  in  this  way  that 
the  Clinic  of  the  Hotel  Dieu  at  the  time  of  the 
Widal  infatuation,  proved,  by  experimenting  the  ty- 
phoid  fever  reaction  on  every  case  in  which  hyper- 
thermia was  present,  that  the  reaction  when  positive 
Avould  constitute  only  one  datum  confirming  the  di- 
agnosis of  typhoid,  provided  that  all  the  other  symp- 
toms were  also  a  confirmation  to  the  diagnosis.  It 
is  in  the  same  way  that  the  Clinique  Baudelocque,  by 
adopting  as  a  routine  prophylactic  measure  the  in- 
jection of  antistreptococcic  serum  in  every  case  en- 
tering the  maternity  hospital,  came  to  the  conclusion 
that  without  any  doubt  the  puerperal  infections  were 
mainly  streptococcic  infections,  because  since  the 
adoption  of  the  prophylactic  injection  of  serum  in 
every  woman  entering  the  maternity  hospital  the  sta- 
tistics of  infectio  puerperalis  had  become  insignifi- 
cant. 

All  the  trials  made  with  the  Wassermann  reac- 
tion have  steadily  and  constantly  proved  its  positive- 
ness  in  all  syphilitic  cases. 

Wassermann  reaction  and  hereditary  syphilis.— 
The  last  results  obtained  are  those  published  by  the 
Asile  d'Armentier,  and  the  conclusions  to  which  the 
investigations  of  said  institutions  (Dr.  Raviart,  Dr. 
Breto,  Dr.  Petit,  Dr.  Cayet,  and  Dr.  Canac)  came 
are :  In  all  patients  presenting  the  stigmata  of  the 
hereditary  syphilis,  stigmata  very  well  defined  by 
Hutchinson  and  Fournier,  the  Wassermann  reaction 
was  positive. 

It  is  not  necessary  for  the  Hutchinson  triad  consti- 
tuted by  the  eyes,  ears,  and  teeth  stigmata  to  be  com- 
plete, in  order  to  have  a  positive  Wassermann  reac- 
tion. In  four  cases  presenting  as  stigmata  of  hered- 
itary syphilis,  the  Hutchinson  teeth,  in  four  cases 
presenting  cheratitis,  and  in  seven  cases  presenting 
■only  deafness,  the  Wassermann  reaction  was  posi- 
tive. 

Of  the  cases  examined,  presenting  the  stigmata 
of  hereditary  syphilis  established  by  Fournier,  the 
results  were  as  follows :  In  nineteen  cases  of  con- 
vergent strabismus,  in  eight  cases  of  divergent  stra- 
bismus, in  four  cases  of  saddle  nose,  in  forty-five 
•cases  of  malformation  of  the  skull,  in  twenty-four 
ca.ses  of  palatum  ovale,  and  in  thirty-one  cases  of 
malformation  of  the  ears,  the  Wassermann  reaction 
was  also  positive. 

We  must  then  acknowledge  that  Wasscrmann's 
reaction  and  stigmata  of  hereditary  syphilis  coexists 
in  the  same  patient.  The  authors  add  that  all  these 
subjects  except  one  presented  the  Argyll  Robertson 
sign. 

IVa.^scrmann's  reaction  in  other  forms  of  mental 
diseases. — (niided  by  the  idea  that  Huntington's 
chorea  is  caused  by  syphilis,  many  cases  were  exam- 
ined at  the  asylum  of'  Bailleul,  but  only  in  one  case 


the  spinal  fluid  gave  a  positive  reaction.  In  idiocy, 
forty  per  cent. ;  in  imbecility,  thirty  per  cent. ;  and  in 
dementia  prsecox,  26  per  cent,  of  cases  gave  positive 
reaction.  The  material  for  study  was  taken  from 
among  2,000  patients  belonging  to  the  insane  asy- 
lums of  Armentier  and  Bailleul,  and  constitute  so 
far  one  of  the  most  accurate  investigations  of  the 
Wassermann  reaction  ever  made. 

Professor  Kraepelin  in  Munich  has  adopted  sys- 
tematically the  serum  diagnosis,  and  I  am  sure  that 
this  will  furnish  us  with  one  of  the  most  com])lete 
statistics  on  the  reaction.  What  we  can  deduct  by 
the  results  so  far  obtained  is  the  indisputable  evi- 
dence of  the  specificity  of  the  Wassermann  reaction 
in  syphilis,  and  in  pathological  conditions  of  the 
nervous  system.  If  the  reaction  is  the  expression 
purely  of  a  latent  syphilitic  infection  or  the  reaction 
must  have  a  wider  interpretation,  and  be  considered 
as  the  expression  of  a  grave  disturbance  of  metabo- 
lism of  the  nervous  system,  and  syphilis  be  only  con- 
sidered one  of  the  most  prominent  aetiological  fac- 
tors in  causing  such  a  condition,  all  of  this  does 
not  change  the  importance  of  the  reaction ;  in  fact, 
in  my  opinion  it  increases  its  value,  in  as  much  as  it 
gives  us  the  possibility  of  weighing  and  measuring 
the  resistance  of  the  nervous  system  in  each  indi- 
vidium,  of  taking  prophylactic,  hygienic,  or  thera- 
peutic measures,  in  regard  to  the  person  showing 
what  I  would  call  a  dyscrasia  or  cachexia  nervosa. 

I  have  in  the  last  two  years  given  special  atten- 
tion to  the  therapeutics  of  the  nervous  system,  and 
in  my  trials  I  have  taken  as  a  foundation  the  con- 
viction that  in  order  to  improve  a  nervous  disease 
we  must  improve  the  nourishment  of  the  nervous 
element.  I  hope  to  be  able  to  present  results  in  the 
near  future. 

Reaction  dnring  treatment. — If  we  examine  pa- 
tients during  the  period  of  treatment  the  reaction  is 
always  negative.  Such  a  condition  would  show  that 
the  special  eft'ect  on  the  system  of  an  antiseptic 
such  as  mercury,  or  of  an  alterative  such  as  atoxile. 
is  to  alter  the  blood  crisis,  probably  diminishing  the 
amount  of  globulin  in  the  blood,  and  making  the  re- 
action negative,  because  of  the  chemical  irresponsive- 
ness  of  the  blood  serum  as  a  colloidal  substance.  In 
mv  opinion  the  therapeutic  elements  used  in  the 
treatment  of  syphilis  act  as  agents  of  elimination  of 
the  toxic  syphilitic  product,  and  not  as  agents  of 
neutralization.  The  fact  that  iodide  alone  can  pro- 
duce the  disappearance  of  the  syphilitic  manifesta- 
tions, and  that  arsenic,  or,  better,  its  derivative, 
atoxyl,  can  bring  about  the  same  results,  is  a  demon- 
stration that  that  alterative  and  drug  is  the  specific 
for  syphilis. 

I  want  a  propos  to  mention  the  existence  of  a 
very  old  watering  place  called  Salsomaggiore.  where 
the  cure  consists  in  the  administration  of  warm 
baths  in  which  iodine  develops  at  the  nascent  state. 
I  have  met  patients  sent  there  during  many  seasons 
beause  of  syphilitic  infection,  who  after  treatment 
never  suffered  from  any  other  syphilitic  manifesta- 
tion, notwithstanding  the  fact  that  mercury  was 
never  administered.  That  would  confirm  the  neces- 
sity of  alterative  treatment  in  syphilis.  If  during 
the  period  of  active  elimination  of  the  toxic  syphi- 
litic product  from  the  system  the  globulin  in  the 


April  17,  1909.] 


CASTELU:    WASSERM'ANN  REACTION. 


781 


blood  should  diminish,  it  would  be  natural  for  the 
reaction  to  be  negative.  I  do  not  know  of  any  spe- 
cial study  made  in  this  question,  but  I  think  it  is 
due  to  the  fact  that  until  now  the  knowledge  of  the 
changes  taking  place  in  the  colloidal  nature  of  the 
blood  have  not  had  the  importance  that  they  would 
have  had  now.  But  admitting  the  possible  hypoth- 
esis that  during  treatment  the  globulin  in  the  blood 
should  diminish,  it  would  be  natural  for  the  reaction 
to  be  negative,  but  as  soon  as  the  system  should  en- 
ter its  normal  phase  of  activity  the  syphilitic  toxic 
element  still  being  present,  the  reaction  would  be 
positive. 

Such  being  the  case  it  will  be  necessary  to  exam- 
ine the  blood  of  a  patient  who  has  undergone  treat- 
ment several  times  at  different  intervals,  and  only 
when  the  reaction  has  proved  repeatedly  negative 
we  will  establish  the  verdict  of  complete  clinical  re- 
covery. While  in  the  Charite  in  Berlin  in  the  clinic 
for  nervous  diseases,  I  have  several  times  examined 
blood  and  cerebrospinal  fluid  from  the  same  patient, 
and  found  that,  when  the  blood  gave  a  positive  Was- 
sermann  reaction,  the  spinal  fluid  gave  a  positive 
precipitation  and  also  a  Wassermann  reaction.  That 
would  make  plain  the  fact  that  the  increase  of  glob- 
ulin in  syphilitic  sera  and  the  increase  of  albumin  in 
the  spinal  fluid  are  parallel  conditions.  Citron  was 
the  first  to  draw  attention  to  the  influence  of  treat- 
ment on  the  reaction,  and  has  given  to  his  observa- 
tions the  form  of  laws  which  read  as  follows : 

(a)  The  longer  the  syphilitic  virus  has  had  its  ef- 
fect on  the  system  and  the  more  frequent  have  been 
the  relapses,  the  stronger  is  the  antibody  in  the 
serum. 

(b)  The  sooner  the  specific  treatment  is  started, 
the  longer  it  continues,  the  more  frequently  it  is  re- 
peated, the  smaller  is  the  quantity  of  antibodies  in 
the  serum. 

Fleishmann,  assistant  in  the  clinic  of  Professor 
Kraus  in  Berlin,  says  that  untreated  or  insufficiently 
treated  cases  give  positive  reaction  and  incline  to  re- 
lapses, while  well  treated  cases  show  an  easier  course 
and  are  free  from  relapses.  Many  authors  confirm 
the  ideas  of  Citron.  It  is  interesting  to  observe  that 
newly  infected  cases  react  more  promptly  and  act- 
ively than  old  ones.  It  is  the  repetition  of  an  ever- 
lasting pathological  axiom  that  the  more  acute  the 
process  the  more  active  the  process  of  repair,  be- 
cause of  the  high  vitality  of  the  tissues,  and  the  more 
chronic  the  process  the  more  sluggish  the  repair,  be- 
cause of  the  low  vitality  of  the  tissues.  Cases  have 
been  observed  in  which  a  patient  seems  for  a  long 
time  refractory  to  treatment,  viz. :  treatment  does 
not  bring  any  change  in  the  reaction.  Such  occur- 
rence is  especially  noticed  in  old  cases  treated  with 
gray  ointment. 

We  can  explain  the  phenomenon  by  making  two 
hypotheses,  equally  possible,  viz. :  either  that  the 
patient  has  become  mercury  immune,  or  that  the  low 
vitality  of  the  tissues  and  functions  is  such  that  the 
processes  of  absorption  are  diminished  or  nil.  I 
am_  more  inclined  to  embrace  the  last  hypothesis 
owing  to  the  observations  of  ]\Iichaelis  and  Lesser, 
who  noticed  that  these  apparently  refractory  cases, 
after  long,  repeated,  and  persistent  treatment,  gave 
finally  negative  reaction.    Citron  attributes  to  the 


ointment  treatment  more  influence  than  any  other 
treatment  on  the  change  of  the  reaction. 

At  any  rate,  the  shortness  of  time  during  which 
the  serum  diagnosis  has  been  tried  does  not  allow 
us  to  come  to  a  final  conclusion,  and  a  very  impor- 
tant warning  to  give  is,  that  all  observations  must 
be  taken  cum  graiio  salis.  Many  observations  are 
made  by  physicians  having  a  very  incomplete  knowl- 
edge of  the  reaction  and  of  the  changes  to  which 
the  dilYerent  reagents  employed  can  undergo.  At 
present  the  reagents  employed  are  known  for  their 
unreliability.  Atmospheric  changes,  as  much  as  the 
efifect  of  light  and  temperature,  can  alter  the  effi- 
ciency either  of  the  extracts  or  of  the  hjemolysin. 
Changes  may  take  place  in  them  within  twenty-four 
hours,  changes  that,  while  they  do  not  alter  the  ab- 
solute efficiency  of  the  extracts  and  haemolysin.  will 
compel  us  to  change  their  dose  in  order  to  obtain 
the  efficiency  of  the  reagent.  We  must  not  forget 
that  every  analysis  requires  a  long  preparatory,  tedi- 
ous, and  delicate  process,  viz.,  the  dosing  of  hjemo- 
lysin  and  extracts.  It  may  be  that  in  a  near  future, 
possibly  sufficiently  near,  we  may  be  able  to  reduce 
the  Wassermann  reaction  to  the  simplicity  of  an  or- 
dinary chemical  reaction. 

In  conclusion,  I  think  that  in  the  treat- 
ment of  patients,  the  system  adopted  by  Neis- 
ser,  the  so  called  chronic  intermittent  thera- 
peutic one,  is  the  one  more  in  harmony  with  our 
present  knowledge  of  the  reaction.  Neisser  treats 
the  patient  only  when  the  reaction  is  positive,  and 
he  examines  the  patient  every  three  months  regu- 
larly for  a  certain  length  of  time.  To  establish  how- 
many  times  this  examination  should  be  repeated  can 
only  be  suggested  to  us  by  the  age  and  intensity  of 
the  syphilitic  manifestations.  It  is  certainly  better 
to  exceed  in  the  repetitions  of  examinations  than  to 
have  them  insufficient. 

PROGNOSIS. 

A  positive  reaction  is  a  sure  evidence  of  a  syph- 
ilitic infection.  If,  in  my  estimation,  syphilis  is 
treated  before  the  virus  has  had  the  possibilitv  of 
creating  changes  of  functional  or  destructive  nature 
in  the  morphological  elements  of  the  nervous  sys- 
tem, the  parasyphilitic  affections, the  most  regrettable 
(principally  tabes  dorsalis  and  general  paralysis)^ 
and  those  pertaining  to  hereditary  syphilis,  will  nat- 
urally be  prevented  from  appearing. 

If  syphilis  is  detected  only  after  the  postinfectious, 
organic  and  morphological  lesions  of  the  nervous 
system  have  already  been  established,  the  knowledge 
of  the  existence  of  a  previous  syphilitic  infection 
will  allow  the  physician  to  retard  the  progressive 
course  of  the  disease  by  prescribing  an  appropriate 
tonic,  hygienic  and  specific  treatment. 

The  Wassermann  reaction  has  also  proved  that 
no  syphilitic  immunity  exists,  and  a  reinfection  is 
possible.  I  had  occasion  last  year  to  examine  a  pa- 
tient in  whom  a  new  syphilitic  manifestation  ap- 
peared twenty  years  after  the  previous  one.  Pro- 
fessor Fournier,  who  saw  the  patient,  acknowledged 
that  only  a  reinfection  could  explain  the  reappear- 
ing of  so  classic  a  manifestation.  He  declared  to 
the  patient  that  in  his  long  experience  he  had  occa- 
sion to  see  cases  of  that  kind  and  that  only  the  the- 


782 


KXOTT:  SPOXTAXEOUS  COMBUSTIOX. 


[New- 
Medical 


York 

JOURN'AL. 


i)\-y  of  reinfection  could  explain.  The  special  feat- 
ures in  the  patient's  manifestations  were  the  absolute 
irresponsiveness  to  treatment  and  the  persistence  of 
the  papulae  after  six  months  of  active  treatment. 
This  phenomenon  would  speak  in  favor  either  of 
mercury  immimity  or  of  defective  absorption.  The 
patient  is  at  present  in  Aix-la-Chapelle,  and  I  shall 
i)e  glad  to  report  on  the  case  to  those  interested  in 
it  as  soon  as  the  patient  returns  to  town. 

If  the  fact  exist  that  a  reinfection  is  possible,  we 
are  by  deduction  compelled  to  accept  as  an  axiom 
that  syphilis  is  curable.  In  this  way  we  have  reach- 
ed the  solution  of  one  of  the  most  discussed  prob- 
lems on  the  pathology  of  syphilis.  This  fact  alone 
would  be  sufficient  to  make  the  serum  diagnosis  of 
syphilis  one  of  the  most  valuable  discoveries  in  the 
history  of  medicine. 

CONCLUSIONS. 

1.  From  the  social  standpoint  the  serum  diagnosis 
of  syphilis  represents  one  of  the  greatest  achieve- 
ments attained  by  medicine  at  the  present  time.  The 
role  played  bv  syphilis  in  the  life  of  mankind  re- 
([uires  no  explanation.  The  highest  coefficient  to 
degeneracy  and  insanity  is  created  by  syphilis.  If 
we  are  now  in  a  position  to  tell  the  patient  coming 
for  advice  that,  notwithstanding  his  previous  syph- 
ilitic infection,  he  can  marry  and  create  a  healthful 
progeny  we  would  certainly  have  become  a  tremen- 
dous factor  for  tranquillizing  a  large  proportion  of 
our  human  fellows.  If  we  can  establish  the  fact 
that  syphilis  is  curable  and  does  not  hang  like  the 
sword  of  Damocles  over  a  man's  physical  and  men- 
tal future,  again  will  medicine  have  triumphed. 

2.  From  the  legal  standpoint,  the  fact  that  we  may 
be  able  to  aid,  either  the  prosecution  or  the  defense 
with  the  knowledge  that  the  criminal  has  a  claim 
on  the  court's  leniency,  by  reason  of  a  previous 
syphilitic  infection,  which  had  produced  a  derange- 
ment of  his  mental  poise,  we  become  useful  factors 
in  the  administration  of  justice. 

3.  The  serum  chagnosis  will  be  a  means  of  dif- 
ferential diagnosis  cluring  the  preparalytic  stage, 
when  the  general  symptoms  are  very  indefinite  and 
generally  masked  by  a  well  defined  neurasthenic 
syndrome.  The  differential  diagnosis  between  gen- 
eral paralysis  and  neurasthenia  during  this  period 
would  represent  the  real  prophylactic  warning. 
This  pcr.son  during  the  preparalytic  stage  is  already 
dangerous  to  himself,  his  family,  to  society  at  large, 
and  our  early  diagnosis  of  his  conditions  makes  pos- 
sible the  .safeguarding  of  the  patient  in  an  asylum 
before  the  dangerous  manifestations  of  the  disease 
has  resulted  in  injury  to  himself  and  others,  and 
compelled  society  to  take  protective  and  coercitive 
measures  against  him. 

4.  While  the  serum  diagnosis  of  syphilis  in  its 
present  condition  is  not  perfect,  and  owing  to  its 
complicated  technique  and  to  the  difficulty  of  pro- 
curing the  necessary  ingredients  remains  still  the 
privilege  of  few  scholars,  it  has  the  indisputable  ad- 
vantage of  furnishing  us  with  sUch  a  rich  amount  of 
sure  diagnostic  data  over  the  positivcness  oi  a  syph- 
ilitic infection,  and  I  consider  its  adoption  in  the 
different  hospitals  and  medical  institutions  not 
optional,  but  absolutely  necessary. 

'75  \Vi"ST  Si:v!:ntv-six"o.\d  Strkkt. 


SPONTANEOUS  COMBUSTION. 

By  John  Knott,  A.  M.,  M.  D.,  Ch.  B..  and  D.  P.  H.  (Univ. 
Dublin)  ;  M  R.  C.  P.  I.;  M.  R.  I.  A.,  etc, 
Dulilin.  Ireland. 

Recent  journalism  of  the  best  informed  general 
t\pe  of  "Daily"  has  called  attention  once  more  to 
the  popular  recognition  of  spontaneous  combustion 
of  the  human  body  as  one  of  the  calculable  assets 
of  scientific  pathology.  Examined  in  the  light  of 
its  past  history,  this  item  of  expert  scientific  opinion 
receives  an  additional  value  in  the  presence  of  our 
new  court  of  criminal  appeal.  For  one  of  the  most 
important  aspects  of  the  historic  faith  in  this  phe- 
nomenon is  that  of  its  skilful  employment  in  explain- 
ing away  what  would  otherwise  appear  to  be  con- 
vincing facts  of  circumstantial  evidence  in  cases  of 
accusation  of  murder.  And  the  glaring  fact  that 
this  same  "spontaneous  combustion"  is  still  accepted 
as  an  article  of  pathological  faith  by  our  recognized 
leaders  in  the  domain  of  medicolegal  opinion  and 
teaching,  and  taught  in  the  pages  of  our  most  com- 
prehensive treatises  on  medical  jurisprudence,  and 
treated  with  respect  by  the  leading  periodicals  of  our 
twentieth  century  medical  literature,  and  referred  to 
with  the  confidence  of  an  unquestioning  faith  in  the 
pages  and  columns  of  our  most  enlightened  general 
literature — all  combine  to  raise  some  serious  doubts 
in  the  minds  of  some  of  us  regarding  the  reality  of 
the  intellectual  progress  of  the  human  race,  as  a 
whole,  even  in  those  directions  in  which  its  paths 
had  been  made  most  conveniently  and  receptively 
straight  by  the  special  methods  and  results  of  agnos- 
ticism and  materialism  and  modernism.  Accord- 
ingly, I  think  that  a  stage  has  been  reached  at  which 
an  examination  of  the  scientific  status  of  spontane- 
ous combustion,  and  the  stated  facts  and  collected 
evidence  on  which  its  recognition  was  originally 
founded,  and  has  since  been  maintained,  may  not  be 
considered  unworthy  the  passing  attention  of  Eng- 
lish speaking  physicians  in  both  hemispheres. 

The  physical  facts  of  which  the  scientific  analogy 
would  appear  to  have  given  a  tinge  of  likelihood  to, 
as  well  as  a  fairly  plausible  explanation  for,  the  oc- 
currence of  such  an  aberrant  incident  of  natural  his- 
tory seem  to  be  the  following :  ( i )  The  known 
spontaneous  combustibility  of  certain  chemical  ele- 
ments and  compounds  at  comparatively  low  tem- 
peratures;  (2)  the  known  inflammability  of  the  in- 
testinal ga.ses  and  of  those  sometimes  produced  by 
decomposition  in  the  pleural  and  peritoneal  cavities, 
and  in  the  connective  tissue  spaces;  (3)  the  peculiar 
inflammability  of  alcohol,  ether,  and  some  other 
chemically  active  beverages  which  some  persons  un- 
wisely partake  of  in  large  quantities  :  (4)  the  great 
inflammability  of  fats,  oils,  etc.,  of  which  an  abnor- 
mal production  and  deposition  among  the  tissues  of 
the  human  body  is  a  not  infrequent  accompaniment 
of  the  cultivati(Mi  of  a  chronic  habit  of  overindul- 
gence in  the  highly  inflammable  beverages  referred 
to;  and  (5)  the  rejnUed  proneness  of  certain  animal 
pn^ducts,  and  many  vegetables — such  as  newly 
mown  grass — when  imperfectly  dried,  to  take  fire 
spontaneously  when  piled  up  in  large  quantity. 

Trobably  jM-eceding  all  (or  nearly  all)  these  items 
of  recorded  jihysical  observation,  and  surel\  tinging 


April  17,  1909.] 


KNOTT:  SPOXTAXEOUS  COMBUSTION. 


783 


the  atmosphere  of  popular  opinion  with  the  requisite 
hue  which  furnished  its  quality  of  easy  transmission 
of  irregular  flashes  of  misleading  illumination,  were 
the  occasional  reports  of  the  weird  phenomena  of 
electrification  and  phosphorescence ;  which  were,  of 
course,  utterly  inexplicable  in  the  light  of  the  sci- 
ence of  the  older  centuries.  Also  influencing  the 
direction  of  the  current  of  thought  in  this  channel 
came  the  discoveries  of  explosive  compounds  with 
the  spread  of  the  culture  of  alchymy,  and  the  transit 
of  the  same  into  the  more  exact  methods  and  modes 
of  modern  chemical  research — hit  upon,  as  those 
wonder  making  compounds  nearly  always  were,  hy 
the  merest  accident,  and  in  the  process  of  mechanic- 
ally mingling  two  or  more  specimen  items  of  ap- 
parently inert  matter.  The  medical  and  alchymical 
authorities  of  the  mediaeval  centuries  were  familiar 
with  ignes  lambentes,  but  had  no  knowledge  of  their 
why  or  wherefore ;  the  elevation  of  temperature,  the 
violent  effervescence,  the  spontaneous  combustion, 
or  even  destructively  violent  explosion,  produced  by 
the  mingling  of  two  liquids,  was  occasionally  placed 
on  record,  but  without  any  attempted  hypothesis  of 
the  molecular  rearrangements  which  were  account- 
able for  the  presentation  of  such  uncanny  phenomena. 
And  the  age  of  the  Renaissance  inevitably  bubbled, 
and  boiled  over,  with  such  items  of  scientific  know i- 
edge.  Igncs  lambentes  were  learnedly — if  not  quite 
scientifically — discussed  by  the  celebrated  Eusebius 
Nurembergius.  who  knew  that  they  were  developed 
by  friction  of  any  or  all  of  the  limbs  of  the  father  of 
the  emperor  Theodoric ;  and  the  famous  anatomist, 
Thomas  Bartholin,  recorded  a  corresponding  prop- 
erty of  the  cutaneous  surface  of  Carlo  Gonzaga,  duke 
of  Mantua.  The  critical  colossus  of  his  generation, 
Julius  Caesar  Scaliger,  knew  of  another  case  of  the 
same  kind.  The  alchymico-astrologico-medical  phi- 
losopher and  mystic,  Hieronimo  Cardan,  tells  his 
readers  of  a  Carmelite  monk,  whose  head  flashed 
forth  luniinous  sparks  whenever  he  tossed  his  cowl  on 
his  shoulders.  Ezekiel  a  Castro,  a  famous  Jew  and 
afterward  a  Christian."  wrote  a  thesis  on  the  same 
fascinating  subject  of  ignis  lamb  ens;  of  which  the 
text  had  been  furnished  by  the  case  of  the  countess 
Cassandra  Buri.  of  Verona,  who,  "when  she  rubb'd 
her  arms  with  a  cambric  handkerchief,  all  the  skin 
shined  with  a  very  bright  light."  The  description 
of  the  phenomenon  shows  an  exact  resemblance  to 
that  above  referred  to.  of  Maximus  Aquilanus,  as 
furnished  by  Eusebius  Nurembergius.  Fortunius 
Licetus,  that  living  encyclopaedia  of  monstrosities 
and  prodigies,  of  birth  and  of  growth,  informs  us 
that  he  knew  a  bookseller  of  Pisa,  by  name  Antonio 
Cianfio,  who,  "when  he  shifted,  shined  all  over  with 
great  brightness"  :  and  mentions  another  case,  that 
of  Francis  Guido,  a  civilian,  of  which  he  had  been 
told  by  his  father.  The  famous  Jesuit,  Athanasius 
Kircher,  has  transmitted  to  posterity  the  particulars 
of  his  visit  to  a  subterranean  grotto  at  Rome,  where 
he  saw  "sparkles  of  fire  evaporate  from  the  heads  of 
his  companions,  grown  warm  by  walking."  Father 
Alphonso  d'Ovale  communicated  to  his  contempo- 
raries a  description  of  analogous  phenomena,  which 
he  had  witnessed  on  the  summits  of  the  highest 
mountains  of  Peru  and  Chili,  where  he  had  noticed 
that  "both  men  and  beasts  there  seem  shining  with 
the  brightest  light  from  top  to  toe."     A  relatively 


ancient  item  of  transatlantic  record  in  this  depart- 
ment was  communicated  to  the  leaders  of  scientific 
light  of  the  mother  countr\-  at  an  early  stage  in  the 
existence  of  the  Royal  Society.  The  medium  was 
Robert  Boyle,  whose  Celtohibernian  enthusiasm  and 
conceptions,  often  visionary,  in  the  highest  (pro- 
phetic) sense  of  the  word,  made  him  the  worthy 
apostle  of  the  divinity  of  experimental  science,  which 
Francis  Bacon  had  so  ceremoniously  (  and  so  igno- 
rantly)  worshipped,  and  whose  birth  suggested,  by 
its  approximate  coincidence  of  date  with  that  of  the 
death  of  the  famous  lord  chancellor,  that  actual  me- 
tempsychosis— an  obvious  transmigration  of  genius 
— was  the  only  true  explanation  of  the  order  of 
events.  Boyle  had  received  from  a  Mr.  Clayton  a 
letter  which  had  been  forwarded  to  the  latter  by  a 
Colonel  Digges,  and  which  contained  an  account  of 
a  "strange  Accident."  The  document  reads  as  fol- 
lows : 

Maryland,  Anno.  1683. 
There  happened,  about  the  month  of  November,  to  one 
Mrs.  Susanna  Sewalt,  wife  to  Major  Nic.  Sewall  of  the 
province  aforesaid,  a  strange  flashing  of  sparks  (seem'd  to 
be  of  fire)  in  all  the  wearing  apparel  she  put  on,  and  so 
continued  till  Candlemas  .  And,  in  the  company  of  several, 
viz.,  Captain  John  Harris,  Mr.  Edward  Braines,  Captain 
Edward  Poulson,  etc.,  the  said  Susanna  did  send  several 
out  of  her  wearing  apparel ;  and  when  they  were  shaken,  it 
would  fly  out  in  sparks  and  make  a  noise  much  like  unto 
bay-leaves  when  flung  into  the  fire ;  and  one  spark  litt  on 
Major  Sewall's  thumb-nail,  and  there  continued  at  least  a 
minute  before  it  went  out,  without  any  heat :  All  of  which 
happened  in  the  company  of  Wm.  Digges. 

Mr.  Clayton  had  supplemented  the  information 
contained  in  this  letter  with  the  following  appendic- 
ular items : 

A'ly  Lady  Baltimore,  lier  mother-in-law.  for  some  time 
before  the  death  of  her  son.  Csecilius  Calvert,  had  the  like 
happen  to  her,  which  has  made  Madam  Sewall  much  trou- 
bled at  what  has  happened  to  her. 

They  caused  Mrs.  Susanna  Sewall  one  day  to  put  on  her 
sister  Diggcs's  petticoat,  which  they  had  tried  beforehand, 
and  would  not  sparkle ;  but  at  night,  when  Madam  Sewall 
put  it  off,  it  would  sparkle  as  the  rest  of  her  own  garments 
did. 

I  have  already  referred  to  a  case  which  was  pub- 
lished by  the  celebrated  Danish  anatomist,  Bartho- 
lin, of  the  University  of  Copenhagen.  That  very  in- 
teresting writer  quotes  a  number  of  other  published 
instances,  both  those  of  his  own  observation,  and 
those  derived  from  the  records — written  or  spoken 
— of  other  reliable  witnesses.  He  refers  to  the  case 
of  countess  Buri,  of  Verona,  on  whom  he  conferred 
the  distinctive  epithet  of  mulier  splendens;  and  he 
indicates  the  prominent  features  of  the  ver}'  peculiar 
phenomenon  which  he  presents  in  language  of  po- 
etic vividness:  "Ut  quotiens  levitcr  linteo  corpus 
tctigcrit;  scint'licc  ex  arbutis  copiosc  prosiliant. 
ciincfis  domesticis  coiispicuce,  non  secus  ac  si  e 
silice  excuterentur."  And  he  not  only  collected  a 
series  of  such  "natural  curiosities"  into  his  Anatom- 
ical Histories,  but  he  wrote  a  distinct  treatise  {De 
Luce  auimalium) ,  in  which  he  proved,  to  his  own 
apparent  satisfaction,  if  not  to  that  of  all  available 
readers,  that  "Light  is  connatural  or  innate  to  all.  as 
well  vegetables  as  animals."  In  the  year  1675  there 
was  published  by  a  Dr.  Simpson  a  Philosophical 
Discourse  of  Fermentation,  which  was  dedicated  by 
the  author  to  the  members  of  the  then  juvenile  Royal 
Society.  That  writer  there  discourses  at  length  on  the 


784 


KNOTT:  SPONTANEOUS  COMBUSTION. 


[New  Vork 
Medical  Jot  rn  al. 


phenomenon  of  light  reflected  by  animals  on  the 
"frication"  or  "pectation"  of  their  surfaces,  especial- 
ly of  the  more  hirsute  portions  of  the  same.  He  in- 
stances the  ''combing  of  a  woman's  head,"  the  "cur- 
rying of  a  horse,"  and  the  "frication  of  a  cat's  back." 
True  to  his  hobby  of  "fermentation,"  the  virtues  of 
which  he  had  undertaken  to  defend  against  all  chal- 
lenging opponents,  he  explained  all  such  luminous 
phenomena  by  its  principles  of  acidum  and  sulfur, 
which  were  the  fundamental  causes  of  all  those 
"lucid  effluvia  in  animals."  Some  ten  years  later, 
the  Rev.  Henry  ]Miles,  D.  D.,  F.  R.  S.,  made  a  com- 
munication to  the  Royal  Society,  containing  Obser- 
vations of  Luminous  Emanations  from  Human 
Bodies,  and  from  Brutes,  with  Some  Remarks  on 
Electricity.  This  scientist,  as  the  expert  reader  will 
probably  have  surmised  after  perusal  of  the  title, 
believed  himself  to  have  ridden  his  selected  hobby 
far  ahead  of  the  members  of  the  advance  guard  of 
his  generation  ;  his  electric  steed  appeared,  indeed, 
to  be  something  of  a  scientific  Pegasus,  by  the  prop- 
erties and  powers  of  which  he  could  explore  and  ex- 
plain all  such  mysterious  phenomena  of  luminosity. 

A  surmise  might  very  naturally  be  entertained  by 
the  ordinary  observer  that  if  such  flames  proved 
harmless  it  was  merely  for  want  of  the  appropriate 
fuel.  Peter  Bovistean  asserted  that  he  knew  of  a 
case  in  which  "such  sparkles  reduced  to  ashes  the 
hair  of  a  young  man."  Johannes  de  Viana  describes, 
in  a  treatise  De  Peste,  how  "the  wife  of  Dr.  Freilas, 
physician  to  Cardinal  de  Royas,  archbishop  of  To- 
ledo, sent  forth  naturally,  by  perspiration,  a  fiery 
matter  of  such  a  nature,  that  if  the  roller  that  she 
wore  over  her  shift  was  taken  from  her,  and  ex- 
posed to  the  cold  air,  it  immediately  was  kindled, 
and  shot  forth  like  grains  of  gunpowder."  Ezekiel 
a  Castro  (to  whose  treatise!)^  Igi"^  laifibente  I  have 
already  referred)  mentions  a  "famous  instance  of 
Alexandrinus  Megetius,  a  physician,  who,  from  the 
vertebra  of  the  coxa,  after  great  pain,  relates  how 
fire  came  out,  which  burned  the  eyes,  as  Simplicius 
and  Phileseus,  eye  witnesses,  did  attest."  In  his  very 
interesting  collection  of  Medical  Wonders.  Mar- 
cellus  Donatus  quotes  the  Saxon  history  of  Albertus 
Krantzius,  who  related  that,  "in  the  time  of  Godfrey 
of  Bologne,  his  Christian  war,  in  the  territory  of 
Niverva  or  Nivers,  people  were  burning  of  invisible 
fire  in  their  entrails,  and  some  had  a  foot  cut  off  or 
a  hand  where  the  burning  began,  that  it  should  not 
go  further."  This  strange  record  is,  of  course,  a 
fairly  representative  specimen  of  a  period  which, 
both  with  regard  to  public  events  and  private  indi- 
vidual existence,  proved  itself  peculiarly  fertile  in 
matters  of  mystery  or  miracle,  or  a  combination  of 
both.  From  the  critical  standpoint  it  is  most  noter 
worthy  to  find  the  famous  scientist,  Peter  Borelli, 
detailing  instances  in  which  the  "efiluvia"  which  em- 
anated from  the  (apparently  healthy)  human  body 
produced  not  merely  visible  light  but  actual  fire. 
One  of  his  Observations  informs  the  reader  "that 
there  was  a  certain  peasant,  whose  linen,  hempen 
thread,  etc.,  if  laid  up  in  boxes,  though  wet,  or  hung 
upon  sticks  in  the  air,  did  soon  take  fire ;  which  hath 
been  seen  by  a  great  number  of  spectators."  It  is 
less  surprising  to  those  who  have  some  critical 
knowledge  of  the  history  of  scientific  progress  to 
find  the  famous  Lord  Chancellor  Bacon  comment- 


ing, with  a  display  of  scientific  discrimination  char- 
acteristically his  very  own,  on  the  physical  fact  that 
he  had  himself  seen  "a  woman's  belly  sparkling  like 
fire"  ;  and  a  member  of  the  Royal  Society  assuring 
a  conclave  of  that  learned  body,  in  the  year  of  grace- 
1745,  that  "truly  such  flames  would  often  rise  in  us, 
if  the  natural  moisture  did  not  quench  them"^ — a  phil- 
osophic item  of  information  regarding  the  physiolog- 
ical physics  of  the  human  body  which  he  was  able,, 
most  happily  as  well  as  learnedly,  to  corroborate  by 
the  venerable  authority  of  Lucretius  himself : 

Poscimt  humorem,  glomerataqiie  multa  vaporis 
Corpora  quae  stomacho  prasbent  incendia  nostro 
Dissupat  adveniens  liquor,  ac  restinguit,  ut  ignem  : 
Urere  ne  possit  calor  amplius  aridus  artus. 

The  significance  of  such  observations  as  those 
above  referred  to  was  also  supposed  to  receive  fur- 
ther confirmation  from  another  case  reported  by 
Borelli,  in  which  he  gravely  informed  his  readers- 
that  he  had  seen  a  man  vomit  bile,  which,  after  its 
ejection,  "boiled  like  aqua  fortis" ;  in  which  connec- 
tion he  also  relates  that  he  "was  told  that  a  woman 
vomited  flames  in  the  point  of  death" ;  and  further 
quotes  Eusebius  Nierembergius,  who  had  related 
"how  fire  came  out  of  the  privy  parts  of  a  woman," 
and  goes  on  to  affirm  that  "such  accident  did  ofteri 
happen  in  great  drinkers  of  wine  and  brandy" — 
thus  almost  completely  formulating  the  fully  devel- 
oped "modern"  facts  of  "spontaneous  combustion." 
In  presence  of  such  a  series  of  items  of  scientific 
testimony  as  the  foregoing — all  of  the  individual 
.constituents  of  which  seem  to  have  been  allowed  to 
"pass  with  honor"  the  ordeal  of  the  critical  scrutiny 
of  the  acknowledged  judges  of  the  age — in  matters 
scientific  and  philosophic- — we  need  not  feel  the 
shock  of  a  new  surprise  when  we  find  Paul  Rolli,. 
F.  R.  S.,  stating  to  a  meeting  of  the  Royal  Society 
in  London,  on  June  20,  1745,  that:  "After  all  this 
I  say  that  a  feverish  fermentation,  or  a  very  strong^ 
motion  of  combustible  matters,  may  rise  in  the  womb 
of  a  woman,  with  an  igneous  strength  that  can  re- 
duce to  ashes  the  bones,  and  burn  the  flesh." 

Two  such  cases  were  referred  to  on  that  occa- 
sion as  already  known  to  the  inner  circle  of  the 
initiated ;  one  had  been  reported  in  the  Acta  inedica 
et  philosophica  hafniensia;  the  other  was  quoted  by 
Marcellus  Donatus  in  his  Mirabilia  medico.  (  I  have 
already  referred  to  each.) 

I  shall  now  proceed  to  consider  the  various  physi- 
cal, and  pathological — and  biographical  facts,  and 
associated  theories  and  fancies,  on  which  the  curi- 
ous superstructure  of  spontaneous  combustion  has 
been  gradually  founded,  and  raised  to  so  respectable 
an  eminence.  These  I  take  in  the  serial  order  indi- 
cated near  the  opening  of  the  present  communica- 
tion. 

I.  The  discovery  of  the  chemical  "element"  phos- 
phorus and  the  study  of  its  very  peculiar  properties, 
in  the  light  of  the  fact  that  its  earliest  experimental 
sources  were  human  urine  and  bone,  undoubtedly 
provided  the  original  data  for  an  attempt  at  the 
formation  of  a  physical  theory  of  the  spontaneous 
combustion  of  the  human  body.  The  unexampled 
facility  with  which  the  newly  found  form  of  mat- 
ter underwent  oxidation  at  even  moderate  tem- 
peratures, and  the  very  "spontaneous"  di'^play  of 
heat  and  flame  which  it  afTorded  in  the  process,  and 


April  17,  3909.] 


KNOTT:  SPONTAXEOUS  COMBUSTION. 


785 


the  still  very  obvious,  if  but  gradual,  transforma- 
tion into  a  form  of  "dust  and  ashes"  at  even  quite 
low  ones,  formed  a  very  effective  item  of  convinc- 
ing evidence — tending,  indeed,  to  remove  every 
shadow  of  doubt  as  to  the  possibility  of  the  "spon- 
taneous" destruction  of  the  human  body  by  flames 
generated  within  its  own  organs  and  tissues,  and 
without  the  application  of  an  external  agent.  Those 
who  are  familiar  with  the  effective  display  with 
which  a  chemical  conjurer  can  carry  out  the  labo- 
ratory experiment  of  the  genesis  of  phosphureted 
hydrogen,  and  have  watched  the  graduated  suc- 
cession of  explosions  with  which  its  bubbles  burst 
into  flame  as  they  escape  from  their  protective 
aqueous  investment,  and  form  a  truly  aesthetic  ex- 
hibition in  form  of  a  continued  series  of  successive 
white  "smoke"  rings  gradually  increasing  in  diam- 
eter as  they  ascend  towards  the  ceiling  with  a 
geometrical  regularity  suggestive  of  the  parallel 
sections  of  a  great  inverted  cone,  cannot  fail  to  ap- 
preciate the  effect  which  such  a  demonstration  of 
the  newlv  discovered  uncanny  powers  of  Nature 
must  have  had  on  the  minds  of  the  uninitiated  and 
unsophisticated  observers  of  the  older  centuries  in 
a  generation  in  which  faith  and  awe  were  immeas- 
urably more  abundant  than  they  are  in  our  own  ma- 
terialistic age.  The  phenomenon  of  the  "will-o'- 
the-wisp"  {ignis  fatJiiis)  of  marshy  regions,  is,  of 
course,  coeval  with  the  formation  of  the  earth's  sur- 
face crust — as  we  know  it ;  and  must,  necessarily, 
have  been  observed  bv  prehistoric  man.  That  of 
St.  Elmo's  fire  had  always  been  observed  by  those 
who  went  down  into  the  sea  in  ships.  (And  I  will 
just  observe,  parenthetically,  that  the  omens  which 
were  deduced  from  the  fact  of  the  appear- 
ance of  both  twin  brothers.  Castor  and  Pollux,  who 
were  supposed  to  control  the  theatrical  display  of 
such  electric  fireworks  at  the  masthead,  or  of  one 
only,  form  a  curious  and  interesting  illustration  of 
the  connecting  links  between  ancient  folk  lore 
superstition  and  modern  physical  science.) 

The  Bologna  stone  began  to  exercise  the  critical 
attention  of  the  curious  in  matter?  physical  about 
the  same  time  as  did  the  question  of  the  spontaneous 
combustibility  of  the  human  body,  and  the  very  inter- 
esting physical  peculiarity  displayed  in  the  "sponta- 
neous phosphorescence"  of  that  mineral,  and  of  the 
other  alkaline  earths,  has  not  ceased  to  engage  the 
inquiring  attention  of  the  most  advanced  physicists 
even  down  to  our  own  "radioactive"  generation. 
The  decidedly  uncannv  aspect  which  this  phenom- 
enon at  first  presents  to  the  eye  and  mind  of  the  un- 
sophisticated proved,  undoubtedly,  an  item  of 
strongly  corroborative  evidence  in  favor  of  the 
plausibility  of  the  idea  of  spontaneous  combustion. 

The  phosphorescence  of  the  sea  had,  of  course, 
been  always  known  to  those  who  went  down  in 
ships  to  that  mobile  medium  of  foreign  travel — to 
distances  of  sufficient  longitude ;  and  that  of  the 
natural  inhabitants  of  the  element  was  always  per- 
ceptible on  the  surfaces  of  the  fish  removed  there- 
from, and  must  have  impressed  the  inhabitants  of 
all  insular  territories  and  oceanic  borders,  from  the 
date  of  the  remotest  ichthyophagous  human  tastes. 

2.  Further  apparent  corroboration  of  the  belief 
in  the  actual  or  potential  spontaneous  inflamma- 
bititv  of  the  constituents  of  the  interior  of  the  hu- 


man body  was  furnished  by  the  discovery  of  the 
combustibility  of  the  gases  of  the  gastrointestinal 
canal,  which  was  made  and  announced  for  the  first 
time,  we  are  told,  by  Vulparius  in  1669,  who  was 
then  professor  of  anatomy  at  the  "premier"  Uni- 
versity of  Bologna.  The  original  description  of  his 
experiment  has  been  transmitted  to  us — in  the 
quaintly  luminous  English  version  of  the  period — 
as  follows : 

Tie  the  upper  orifice  of  the  stomach  of  an  animal  with  a 
string;  tie  also  its  lower  orifice;  then  cut  it  above  and  be- 
low the  ligatures,  and  press  it  with  both  hands,  so  that  it 
swells  up  on  one  side ;  which  done,  let  the  left  hand  keep  it 
so  that  the  swelled  part  may  not  subside ;  and,  with  the 
right,  having  first,  at  an  inch  distance,  placed  a  candle,  open 
it  quick  with  an  anatomic  knife,  and  you  will  see  a  flame 
there  conceived,  coming  out  in  a  few  seconds  of  time;  and 
such  a  flame  may,  by  the  curious,  be  perceived  not  only  in 
the  stomach,  but  also  in  the  intestines. 

Jan  Baptista  Van  Helmont  (1577-1644)  who  is 
regarded  by  many  experts  in  the  history  of  scientific 
progress  as  the  transitional  connecting  link  between 
the  mediaeval  alchymy  and  the  modern  chemistry, 
and  the  true  Joshua  of  the  long  sought  Terra 
Sancta  of  the  latter,  was  keenly  discriminating  in 
his  philosophical  and  physical  views  concerning 
Flatus's  or  Windy  Blasts  in  the  Body.  One  of  the 
items  of  his  published  information  reads  as  follows 
(in  the  English  version  of  J.  C,  1662)  : 

Belching,  or  a  flatus  originally  in  the  stomach,  even  as 
also  the  flatus  of  the  ileon,  do  extinguish  the  flame  of  a 
candle.  But  a  dung\-  flatus  which  if  formed  in  the  utmost 
bowels,  and  breaks  forth  through  the  fundament,  being  sent 
through  the  flame  of  a  candle,  is  enflamed  in  flying  through 
it,  and  expresseth  a  flame  of  divers  colours,  like  a  rain- 
bow. But  that  which  is  formed  in  the  ileon  or  slender 
bowels,  is  never  inflammable,  is  often  without  smell,  unless 
it  bring  down  the  mixture  of  another  with  it,  it  oft-times 
strikes  through,  being  tart,  sharp,  and  brackish  in  the  fun- 
dament. Therefore,  flatus's  or  windiness.  do  differ  in  us, 
in  their  matter,  form,  place,  ferment,  properties,  and  so  in 
their  whole  species.  Neither  have  flatus's  less,  in  their  own 
generic  and  specific  varieties,  than  the  bodies  from  whence 
they  proceed.    For  flatus's  are  in  nowise  air. 

Licetus  also  refers  to  the  combustibility  of  intes- 
tinal gas  in  a  way  which  shows  that  the  experiment 
to  which  \'an  Helmont  alludes  in  the  foregoing 
quotation  was  familiarly  known  in  his  own  genera- 
tion :  "Cum  chirnrgus  candenti  ferro  excrescentias 
carncas  adolescenti  succiiho  circa  nates  inureret. 
Hatiis  e.\  njio  in  ferniui  ignituin  irrumpens  Hani- 
viani  rcpcnte  concepit.  non  .nne  astantiuin  risu." 
And  that  author  refers  to  this  observed  fact,  and 
also  the  reported  experiment  of  \'ulparius  above 
cited,  as  items  of  evidence  which  were  definitely 
corroborative  of  the  popular  belief  in  the  existence 
of  lamps  whose  flame  never  went  out.  Such  "eter- 
nal" lights  were,  in  that  generation,  popularly  said 
to  exist  in  many  subterranean  vaults  and  grottoes, 
where  they  were  also  occasionally  reported  to  have 
been  accidentally  discovered.  The  relationship  be- 
tween the  mysterious  fulgiirations  of  the  thunder 
cloud  and  the 

Extreme  ructus  qui  venit  a  barathro 
of  Martial's  well  known  epigram,  formed  the  in- 
spiration of  a  learnedly  facetious  enigma  of  the  fa- 
mous Julius  Caesar  Scaliger : 

Ima  a  sede  mens,  cognatus  fulminis  alti, 
Summani  videor  rite  venire  manu. 

Vicini  fugiunt,  quatiuntur  tecta  cachinnis 
At  si  mutus  ero,  jurgia  snepe  cio. 


-86 


KNOTT:  SPONTANEOUS  COMBUSTION. 


[New  York 
Medical  Joirnal. 


Aureolus  Philippus  Theophrastus  Bombastus 
Paracelsus  Magnus  ab  Hohenheiin,  energetic,  self 
confident,  and  foul  mouthed,  made  out,  in  his  very 
original  scheme  of  reformed  physiology,  that  the 
stercoraceous  contents  of  the  intestine  consisted 
wholly  of  sulphur  and  \vind.  According  to  Johann 
Conrad  Peyer,  whose  name  has  become  immortal- 
ized by  its  permanent  association  with  the  patches  of 
agminate  glands  situated  in  the  nether  ileum  (which 
had  been  described  and  figured  just  a  short  time  be- 
fore by  the  English  Nehemiah  Grew,  the  discoverer 
of  Epsom  salt)  : 

Flatus  a  spiritii  nitro-aerio  derivari  posse  .  .  .  qui 
quatcmis  vi  expansiva  insigni  praeditus  cum  excrementorum 
particulis  sulphureo  salinis  impurioribus  ac  effetis  coeundo. 
illas  tamdiu  exagitat  donee  quoad  minima  contritre  &  reso- 
lutas  in  exhalationum  volumina  commigrent,  quae  inde  per 
anum  subinde  proruentia,  ob  particularum  sulphurearum  & 
iiitro-aerearum,  quoddam  vehit  torrente  erunipentium 
agmen  instar  pulveris  pyrii  admota  flanuua  celerrime 
deflagrat. 

The  occasional  luminosity  of  the  cutaneous  sur- 
face of  the  human  body  in  certain  morbid,  or  other- 
wise specially  peculiar,  conditions  had  been  noticed 
by  observers  from  time  to  time. 

The  almost  inspired  elevation  of  tone  and  concep- 
tion, and  photographic  accuracy  of  descriptive  de- 
lineation manifested  in  the  picture  of  the  horrors  of 
the  plague,  drawn  by  the  great  metrical  exponent 
of  the  Epicurean  philosophy,  did  not  fail  to  place 
in  the  most  striking  light  the  fearsome  phenomena 
of 

Sudoris  madens  per  cutem  splendidus  humor. 

3.  The  noncombustibility  of  the  ordinary  gases 
of  the  stomach  and' upper  part  of  the  intestinal  tube, 
contrasted  with  the  ready  inflammability  of  those  of 
the  lower  bowel,  left  scope  for  the  exercise  of  alco- 
holic inflammability  in  establishing  a  uniformity  of 
this  property  throughout  the  gaseous  contents  of 
the  digestive  tube,  in  its  entire  longitude.  Accord- 
ingly, we  find  this  development  attained  to  in  the 
clinical  experience  of  Sturmius,  who  informed  the 
medical  world  of  his  day  that :  "Often  in  the  north- 
most  countries,  flames  evaporate  from  the  stomachs 
of  those  who  drink  strong  liquors  plentifully."  And 
that  emphatic  clinical  observer  illustrated  this  state- 
ment by  adding  that:  "About  17  years  ago,  three 
noblemen  of  Curland.  whose  names,  for  decency 
sake,  I  will  not  publish,  drank,  by  emulation,  strong 
liquors ;  and  two  of  them  died  scorched  and  sufifo- 
cated  by  a  flame  forcing  itself  from  the  stomach." 
This  report  is  very  suggestive — and  probably  proved 
creatively  so  to  be — of  the  bulk  of  the  records  of 
individual  cases  of  spontaneous  combustion,  which 
have  dealt  almost  exclusively  with  persons  who  had 
been  in  the  habit  of  indulging  to  excess  in  the  use  of 
alcoholic  beverages.  The  extreme  inflammability  of 
that  very  deceptively  waterish-looking  liquid  went 
towards  furnishing  something  of  evidence  of  what 
might  be  regarded  as  a  prima  facie  possibility,  if  not 
probability,  to  the  statements  of  its  occurrence. 

4.  As  chemical  knowledge  waxed  in  stature  and 
in  wisdom,  the  constitution  of  fats  and  oils  became 
gradually  investigated,  and  the  relationships  of  the 
specimens  respectively  derived  from  the  animal  and 
vegetable  kingdoms  became  revealed  to  the  incjuir- 
ing  scientist.    The  relatively  higli  degree  of  inllam- 


mability  of  fatty  and  oily  substances  had,  of  course, 
been  familiar  to  humanity  ever  since  the  earliest 
attempt  to  construct  the  original  candle  or  lamp, 
and  was  signally  demonstrated  on  the  auspicious  oc- 
casion on  which  the  first  holocaust  was  offered  by 
a  priest  of  Baal.  And  the  high  class  logical  and 
scientific  reasoning  which,  in  the  year  of  grace  1745, 
was  based  upon  such  knowledge  and  received  in  evi- 
dence before  the  supreme  court  of  scientific  appeal 
in  Great  Britain,  is  forcibly  illustrated  by  the  re- 
marks of  Rolli,  made  in  this  connection,  at  the  meet- 
ing of  the  Royal  Society  above  referred  to : 

The  acid  particles  in  our  bodies  are  much  united  with  the 
fat  and  oily  parts ;  nay  all  our  limbs  abound  with  oil  and 
acid.  What  wonder  then  if  they  may  kindle  as  Mr.  Hom- 
berg  well  obser\  es  in  the  aforesaid  history,  .  .  .  where 
he  takes  notice  that  all  our  limbs  have  abundance  of 
fetid  oil  and  volatile  salt,  and  are  therefore  easily  com- 
bustible. We  ought  not  to  omit  how  the  teeth  are  formed 
by  so  many  short  tubes,  the  bones  by  long  ones,  and  easier 
therefore  to  be  set  on  fire.  Malpighi  observed  also  that 
the  bones  contain  a  fat,  oily  matter.  Besides  all  this,  we 
know  that  the  sebaceous  glands  are  spread  all  over  the 
body;  and  that  an  oily  moisture  with  now  and  then  a 
nitrous  sulfureous  smell  perspires  from  our  skin,  to  which 
Dr.  Blancard  ascribes  the  whole  circulation.  Abundance 
of  combustible  matter  shut  up  in  a  great  numter  of  cells 
lies  in  the  omentum.  There  is  further  to  be  considered 
the  vast  quantity  of  effluvia  that  emanates  from  our  bodies. 
.  .  .  On  this  supposition  I  say  that  the  effluvia  of  such 
an  insensible  transpiration  are  an  inflammable  mine  easily 
apt  to  kindle  whenever  a  friction,  be  it  ever  so  small,  puts 
them  in  quick  motion  and  increases  their  velocity. 

The  reference  made  in  this  quotation  to  Mr.  Rom- 
berg and  his  ideas  on  this  subject  of  combustion  of 
human  tissues  will  be  found  to  repay  the  trouble  of 
some  further  elucidation.  A  noted  experimentalist 
of  the  seventeenth  century,  Beccher  by  name  (  1635- 
1682),  had  startled  himself  and  astonished  the 
chemical  world  by  the  accidental  discovery  that  on 
adding  "oil  of  vitriol"  to  turpentine  the  mixture  in- 
stantly burst  into  flame — with  even  explosive  sud- 
denness. Borrichius  afterwards  reported  that  a  sim- 
ilar result  occurred  on  the  mingling  of  the  oil  of 
turpentine  with  aqua  fortis.  Tournefort  contributed 
to  the  growing  stock  of  explosive  experiment  the 
discovery  of  a  corresponding  effect  from  the  addi- 
tion of  "spirit  of  nitre"  to  oil  of  sassafras.  And  the 
famous  Romberg  (1652-1715),  who  is  referred  to 
in  the  above  quotation  from  Rolli,  still  further  ex- 
panded the  discoveries  of  his  precursors  in  this 
special  domain,  for  he  found  that  similar  processes 
of  sudden  and  violent  spontaneous  combustion  were 
developed  by  the  mingling  of  this  acid  "spirit"  with 
any  or  all  of  the  oils  or  quintessences  of  the  various 
aromatic  Indian  products  of  the  vegetable  kingdom. 

5.  Among  the  many  original  and  interesting  dis- 
coveries of  this  pioneer  of  modern  chemical  explora- 
tion was  that  of  his  pyropliorus,  a  description  of 
which  was  published  in  the  Mcmoircs  dc  1' Academic 
for  171 1.  The  production  of  this  sub.>^tance  was  a 
kind  of  rival  achievement  to  that  of  elemental  phos- 
plionis  itself,  which  had  recently  been  isolated  by 
llrandt  and  by  Kunkel.  lioniberg  blended  alum 
with  human  fjEces,  and  roasted  the  mixture  till  it 
was  reduced  to  the  state  of  a  moisture-free  powder. 
This  powder  was  then  exposed  in  a  matrass  to  a  red 
heat  till  every  trace  of  combustible  and  volatile  mat- 
ter was  got  rid  of.  When  a  little  of  the  powder  so 
elaborately  treated  was  then  pounvl  out  on  paper,  it 


April  !7.  1909. 1 


KNOTT:  SPONTANEOUS  COMBUSTION. 


7^7 


instantly  took  fire  and  ignited  the  latter.  And  Hom- 
berg  also  found,  in  continuing  his  experiments,  that 
other  organic  substances — or  matters  derived  from 
organic  sources — could  be  substituted  for  the  hu- 
man faeces ;  such  as  gum,  flour,  and  sugar.  Several 
generations  later  Sir  Humphry  Davy — for  the  first 
time — enlightened  the  chemical  world  by  the  expla- 
nation of  what  it  was  that  actually  happened  in  the 
process  of  the  spontaneous  combustion  of  Rom- 
berg's pyrophorus.  The  potash  of  the  alum  was  re- 
duced to  metallic  potassium ;  this  element  having 
an  intense  affinity  for  oxygen — which  is  at  its  acme 
of  activity  when  in  the  nascent  state — instantly  com- 
bines with  the  latter,  by  attracting  it  from  the  at- 
mosphere when  exposed  thereto ;  and  the  amount  of 
heat  which  is  generated  and  set  free  in  that  pro- 
cess of  oxidation  suffices  to  ignite  the  paper.  So 
that  there  is,  after  all,  a  close  cousingermanship  of 
relation  between  the  crudely  primitive  experiment 
of  Romberg,  and  the  characteristically  nineteenth- 
century  lecture-experiment  of  throwing  a  piece  of 
metallic  potassium  on  the  surface  of  a  broad  basin 
of  water. 

The  "doves'  dung"  of  scriptural  and  classical  (or 
postclassical)  celebrity  may  be  credited  with  a  very 
considerable  contribution  towards  the  development 
of  this  spontaneous  combustion  item  of  physical 
faith.  The  very  striking  reference  to  its  value— 
and  implied  efficacy — as  a  life  preserving  agent  in 
the  pages  of  Roly  ^^'rit  is  in  itself  an  interest- 
ing item  of  testimony  to  the  association  of  the  ideas 
of  heat  producing  and  life  preserving  substances  and 
agencies  in  the  popular  judgment  of  the  ancient  in- 
habitants of  the  Roly  Land. 

Indeed  Galen  himself,  the  immortal  philosophical 
physician  of  Pergamum,  the  St.  Paul  of  medical  in- 
spiration and  teaching,  states  that  he  had  himself 
seen  the  dung  of  doves  undergo  spontaneous  igni- 
tion after  having  become  rotten ;  and  emphasizes 
that  report  by  the  statement  that  the  dung  of  one  of 
those  birds  was  sufficient  to  set  fire  to  a  whole 
house.  And  we  have  a  Renaissance  reflex  of  this 
same  item  of  physical  belief  in  the  statement  made 
by  the  celebrated  Jesuit,  Father  Casati — in  a  tone, 
too.  of  apparently  unquestioning  credence — that  he 
had  "heard  a  worthy  gentleman  say.  that,  from 
great  quantities  of  the  dung  of  doves,  flights  of 
which  used,  for  many  years,  nay,  ages,  to  build 
under  the  roof  of  the  great  church  of  Pisa,  sprung 
originally  the  fire  which  consumed  the  old  church." 
It  is,  of  course,  a  fact  of  continuous  observation  in 
farm  yards  that  the  dung  of  some  animals  under- 
goes during  the  process  of  decomposition,  a  pro- 
nounced elevation  of  temperature ;  and  according  to 
popular  opinion  of  venerable  date,  the  greater  the 
tendency  to  "heating"  displayed,  the  more  efficacious 
and  valuable  were  its  fertilizing  properties.  On  this 
account,  horse  dung,  which  always  displayed  a 
great  tendency  to  active  fermentative  change,  with 
pronounced  evolution  of  heat,  was  vastly  more  con- 
ducive to  the  promotion  of  vegetable  growth  than 
tliat  of  horned  cattle,  which  "heated"  but  compara- 
tively little.  Indeed,  the  fertilizing  power,  or  the 
richness  in  stored  nutrient  material,  was  believed 
to  varv  directly  as  the  power  of  evolving  heat ;  and 
this  item  of  opinion  was,  of  course,  very  crreatlv 
corroborated  by  the  fact  that  by  the  possession  of 


this  mysterious  latent  property,  it  demonstrated  its 
relationship  to  the  highest  known  types  of  organic 
existence.  And  it  is  of  interest  to  note,  in  passing, 
that  this  heating  property  of  horse  dung  was  freely 
utilized  by  the  alchymists  and  pharmacists  of 
mediaeval  times ;  who,  as  we  learn  from  the  record^ 
of  the  period,  "in  ventro  equina  (scybalis  cqtiinis) 
digercre  sciiint  ziiro  inclusos  succos,  aquas,  ejusquc 
colore  stias  parare,  Essentias,  Elixiria  &  Tincturas. 
&c."  We  are  also  told  by  Bartholin  of  the  artificial 
mcubation  of  fowls'  eggs  by  the  same  agency:  In 
quovis  sterquilinio,  hybernis  etiam  mensibus,  pulli 
ex  ovis  excluduntur,  quod  in  palatio  Magnifici  Can- 
ccllarii  Regii  Dr.  Cliristiani  Thomcei  aliquoties  cum 
successu  fuit  tentatum. 

Very  closely  associated  in  the  cerebral  machinery 
of  the  rural  intellect  is  the  heating  process — so  in- 
dicative of  the  presence  of  future  vegetable  wealth 
— in  the  dunghill  with  that  which  develops  within 
the  newly  made  hayrick,  which  is  as  infallibly  in- 
dicative of  destruction  of  the  source  of  property 
on  which  the  very  staff  of  Hfe  depends.  But,  in 
each  of  these  cases,  and  the  fact  is  one  .  which 
seems  to  have  somehow  remained  undiscovered 
even  into  otir  own  luminous  twentieth  century,  the 
phenomenon  is  one  of  which  the  main  feature  does 
not  conform  to  the  venerable  household  adage,  for 
the  "smoke,"  which  is  so  ver}-  readily  and  copious- 
ly generated,  is  never  accompanied  by  fire.  In  the 
still  faintish  twilight  of  a  cool  autumn  morning — 
at  the  special  period  when  the  annual  manure  heap 
has  just  commenced  to  display  substantial  expan- 
sion, and  the  annual  hayrick  has  just  had  its  archi- 
tecture completed — the  condensation  of  the  ascend- 
ing water  vapor,  which  so  surely  tells  of  the  fer- 
mentative generation  of  underlying  "caloric,"  cre- 
ates a  misty  canopy  which  instantly  catches  the  eye 
of  the  anxiously  watchful  farmer  or  his  responsible 
representative.  The  development  of  the  phenom- 
enon is,  in  relation  to  the  former  position,  prophetic 
of  future  prosperity ;  in  association  with  the  latter 
of  immediate  destruction.  The  hay  which  has  un- 
dergone the  "heating"  process  is  permanently,  hope- 
lesslv,  spoiled  ;  its  odor  and  taste  instantly  betray  it, 
and  it  is  rejected  as  fodder  by  all  cattle.  Accord- 
ingly, it  has  actually  become  quite  as  useless  as  an 
article  of  food  as  if  it  had  been  reduced  to  ashes. 
But,  as  a  mere  matter  of  fact,  it  never  is.  Then  the 
alarm  with  which  the  discovery  of  a  heating  hay- 
rick causes  the  rousing  of  the  working  members 
of  a  farmer's  household  is  quite  comparable  to  that 
which  summons  the  assistance  of  a  fire  brigade  in 
a  crowded  city.  The  structure  is  immediately  re- 
duced to  a  chaotic  condition,  and  its  constituent  ele- 
ments are  spread  out  to  dry ;  not  exactly  to  cool, 
for  it  is  the  presence  of  an  undesirable  proportion 
of  the  vegetable  sap  which  determines  the  "heating" 
process — which,  accordingly,  never  develops  in  hay 
that  has  been  properly  "saved."  The  temperature, 
as  a  matter  of  fact,  is  never  very  high ;  and  the  idea 
of  spontaneous  ignition  is  purely  an  item  of  tradi- 
tional folklore — of  the  emotional  type.  And  such 
have  been  the  reports  of  a  corresponding  origin  of 
fire  in  barns,  paper  mills,  etc.,  which  have  been 
transmitted  from  hand  to  hand  for  centuries — with 
the  necessary  qualification,  or  discount,  that  they 
have  been  utilized  upon  occasion  for  the  purpose  of 


788 


CARR:  SURGICAL  TREATMENT  OF  EPILEPSY. 


[New  York 
Medical  Tourxal. 


veiling  negligence  or  malice  (or  for  improving  the 
golden  opportunity  of  bonded  relationship  with  an 
insurance  company).  But  the  unfortunate  farmer's 
"boy"  or  "herd,"  during  whose  period  of  responsi- 
ble charge  an  Irish  farmer's  hayrick  happened  acci- 
dentally to  catch  fire,  would  very  much  need  some 
such  excuse  before  he  faced  his  infuriated  em- 
ployer, and — he  always  found  it,  too! 

(To  be  Continued) 


THE  SURGICAL  TREATMENT  OF  EPILEPSY* 

By  W.  p.  Carr,  M.  D., 
Washington,  D.  C. 

There  seems  to  be  no  question  at  the  present  day 
that  cases  of  traumatic  epilepsy,  or  epilepsy  due  to 
any  demonstrable  localized  lesion  of  the  brain  or 
skull,  should  come  to  operation  as  soon  after  the  first 
seizure  as  possible ;  and  that  the  sooner  this  is  done, 
and  the  fewer  seizures  the  patient  has  had,  the  bet- 
ter are  his  chances  for  cure. 

Operation,  however,  in  the  so  called  idiopathic  or 
hereditary  cases,  and  in  all  cases  where  the  habit 
has  become  well  established,  is  generally  regarded  as 
useless,  and  has  been  practically  abandoned.  My 
own  experience,  though  limited,  has  led  me  to  be- 
lieve that  we  have  been  too  hasty  in  abandoning  sur- 
gery for  the  relief  of  this  class  of  unfortunates,  and 
that  they  have  been  given  up  on  theoretical  grounds 
rather  than  after  a  careful  systematic  trial  of  mod- 
ern surgical  measures. 

]Most  surgeons  have  trephined  a  few  cases,  mostly 
traumatic,  after  the  habit  was  well  established,  and 
have  had  only  slight  or  temporary  success. 

I  believe  that  in  very  few  of  the  so  called  idio- 
pathic cases  have  there  been  operations  since  mod- 
ern surgerv  has  made  the  operation  safe  and  easy ; 
and  yet  sporadic  cases  have  been  reported  from  the 
earliest  days  of  surgery,  of  cures  following  opera- 
tions, not  only  on  the  skull  or  its  contents,  but  op- 
erations for  the  relief  of  constant  sources  of  irrita- 
tion to  peripheral  nerves. 

Cures  of  epilepsies  and  allied  conditions  are  re- 
ported by  the  older  writers,  who  were  as  careful 
observers  as  any  we  have  today,  following  injuries 
to  the  head,  severe  illness,  tracheotomy,  operation 
for  phimosis,  and  even  the  removal  of  a  piece  of  the 
glutieus  maximus  muscle.  There  have  been  too 
many  such  cases  reported  to  be  explained  by  mer^ 
coincidence.  Many  of  these  patients  probably  re- 
lapsed after  a  longer  or  shorter  period ;  and  some  of 
them  were  unquestionably  due  to  the  mental  impres- 
sion, or  suggestion  of  the  operation. 

There  are  severe  intermittent  types  of  epilepsy 
that  suddenly  improve  and  remain  well,  or  nearly 
well,  for  long  periods,  without  apparent  cause.  Some 
of  the  cures  may  have  been  cases  of  this  kind,  that 
would  have  improved  as  much  without  interference. 
But  they  could  not  all  have  been  of  this  kind.  There 
are  at  least  four  factors  to  be  considered  in  this  con- 
nection :  h'irst,  the  removal  of  some  cerebral  condi- 
tion ;  second,  the  removal  of  some  peripheral  irritant ; 
third,  the  powerful  suggestion  of  an  operation,  espe- 
cially of  an  operation  upon  the  brain ;  and,  fourth, 

•Road  before  the  Southern  Surgical  and  Gyn.Tcological  Associa- 
tion, December  16  to  18,  1908. 


the  shock  or  illness  following  operation,  which  al- 
most invariably  arrests  the  habit  for  a  time,  just  as 
an  attack  of  typhoid  fever  does.  The  cerebral  con- 
dition removed  may  be  depressed  bone,  thickened 
dura,  a  tumor,  an  abscess,  serum  that  is  producing 
pressure  or  simply  waterlogging  the  brain,  or  toxic 
material  of  either  autogenous  or  bacterial  origin.  I 
have  reason  to  believe  that  one  of  my  cases  was  due 
to  an  oedematous  encephalitis  and  meningitis  caused 
by  the  germ  of  influenza,  and  that  operation  acted 
similarly  to  the  opening  of  the  abdomen  in  tubercu- 
lous peritonitis. 

This  has  suggested  to  me  a  similar  operation  in 
tuberculous  meningitis. 

There  seems  to  be  no  doubt  that  some  patients  with 
idiopathic  epilepsy  of  long  standing,  and  in  whom 
the  habit  was  well  established,  have  been  cured  by 
operation,  and  that  most  of  the  favorable  results  have 
followed  opening  and  draining  the  skull.  I  shall  not 
go  further  into  the  question  of  the  modus  operandi, 
at  present ;  but  I  believe  that  if  one  epileptic  in  a 
hundred  can  be  cured,  the  operation  is  perfectly  jus- 
tifiable. Personally,  I  have  operated  upon  twenty 
epileptics  during  the  past  ten  years.  Nearly  all  of 
long  duration,  with  the  habit  well  established,  and 
most  of  them  not  traumatic,  unless  we  consider  every 
case  traumatic  that  has  a  history  of  some  remote 
blow  on  the  head. 

The  results  have  been  most  encouraging.  Xcarly 
all  were  either  cured  or  temporarily  relieved  to  such 
an  extent  that  they  felt  repaid  for  undergoing  the 
operation.  Eight  have  remained  well  to  the  present 
time,  or  were  well  when  last  heard  from ;  one  after 
nine  years,  one  nine  and  a  half  years,  one  seven  and 
a  half  years,  one  four,  years,  one  three  and  a  half 
years,  one  for  one  year,  and  two  for  three  months. 

These  were  all,  except  one,  cases  of  long  stand- 
ing. Strange  to  say,  I  have  had  my  poorest  results 
in  the  cases  I  thought  most  favorable.  There  has 
been  much  discussion  and  dil¥erence  of  opinion 
among  alienists  as  to  when  a  case  should  be  called 
cured.  Some  have  said  after  one  year  of  freedom 
from  seizures,  others  five. 

Three  of  my  patients  have  been  well  for  seven 
3'ears  or  more.  If  we  take  three  years,  which  seems  a 
reasonable  period,  for  an  arbitrary  cure,  I  have  five 
cures  out  of  twenty  cases,  or  twenty-five  per  cent., 
and  a  probability  of  three  more,  or  forty  per  cent. 
Leaving  out  four  recent  cases  of  operation  in  less 
than  two  years  ago,  and  three  in  which  the  result  is 
unknown,  I  have  five  cures  in  thirteen  cases,  or 
thirty-nine  per  cent.  I  fully  believe  that  this  per- 
centage is  too  high,  and  that  a  larger  series  of  oper- 
ations will  show  fewer  cures,  and  I  expect  some  of 
these  cured  patients  to  relapse  even  yet,  but  I  feel 
that  they  have  fully  justified  the  twenty  operations. 

( )ne  patient  was  almost  imbecile  before  operation, 
and  continued  to  grow  worse  afterward,  finally  land- 
ing in  the  insane  a.sylum.  The  6peration  apparently 
hurried  him  along  a  little  faster.  This  is  the  only 
one  in  which  there  was  not  at  least  a  marked  tem- 
porary improvement.  Seven  of  those  not  cured  re- 
mained well  for  periods  of  from  two  to  seventeen 
months.  j\Iost  of  these  patients  expressed  them- 
selves as  not  sorry  they  had  undergone  the  opera- 
tion, and  twc)  wished  to  be  operated  upon  again. 

The  last  case  was  referred  by  Dr.  Henry  K.  Craig, 


April  ly,  1909.I 


CARR:  SURGICAL  TREATMEXT  OF  EPILEPSY. 


789 


who  has  written  me  an  extremel}-  interesting  history 
•of  it.    I  quote  from  him  as  follows: 

J.  H.,  aged  twenty-nine  years,  was  one  of  eleven  chil- 
Klren,  the  parents  of  whom  were  living  and  in  good  health. 
The  family  history  was  singularly  free  from  neurotic  dis- 
•orders  of  any  kind,  and  of  the  four  deceased  children, 
pneumonia  appeared  as  the  cause  of  death  in  two,  and 
typhoid  fever  and  cholera  infantum  as  the  cause  in  the 
other  two  instances.  At  the  age  of  five  years,  the  subject 
■of  this  paper  suffered  from  convulsions,  the  attacks,  judg- 
ing from  the  meager  details  at  hand,  being  doubtless  of  an 
■epileptic  character,  iiid  continued  until  about  the  age  of  ten, 
when  they  ceased.  During  period  of  infancy,  the  only  dis- 
■eases  noted  were  measles,  pertussis,  and  chickenpo.x. 

The  question  of  traumatic  injury  of  the  head  presents  in 
this  case  the  usual  misfortunes  incidental  to  the  early 
period  of  life.  At  the  age  of  eight  was  recorded  a  fall  on 
the  curbstone,  and  a  few  days  later  a  blow  over  the  eye 
from  a  stone,  but  at  no  time  were  any  untoward  symptoms 
manifested,  as  a  result  of  the  injuries  in  question.  By  one 
•of  the  immediate  family  it  was  related  that  tlie  patient  as  a 
.boy  had  frequently  been  struck  over  the  head  with  a  stick 
as  a  method  of  punishment,  but  careful  and  painstaking 
inquiry  failed  to  reveal  any  symptomatic  data  in  regard  to 
the  effect  of  this  disciplinary  measure.  During  the  period 
of  his  early  manhood,  the  history  of  this  patient  was  nega- 
tive, particularly  m  so  far  as  related  to  the  inevitable  re- 
-sults  of  a  deviation  from  the  straight  and  narrow  path  of 
moral  rectitude.  From  about  1889  to  1907,  a  period  of 
eighteen  years,  the  convulsive  seizures  ceased,  and  the  his- 
tory of  the  patient  during  that  period  presented  nothing  of 
interest. 

On  October  20,  1907,  the  patient  was  seized  with  a  typi- 
cal attack  of  epilepsy,  which  lasted  about  three  minutes. 
Half  an  hour  later  a  second  attack  appeared,  surpassing  in 
severity  the  previous  one.  and  a  week  later  a  third  attack 
was  noted.  On  the  i8th  of  December,  while  standing  in  his 
room,  he  suddenh-  turned  around  twice  toward  the  left  and 
fell  to  the  floor  with  an  attack  of  epilepsy,  twenty  minutes 
later  he  wa$.  the  victim  of  a  second  attack.  In  a  few  days 
the  patient  became  suddenly  possessed  of  the  idea  that  he 
■owed  large  sums  of  money,  and  that  unless  the  accounts 
were  speedily  settled,  the  suppositious  creditors  would  do 
him  bodily  harm.  He  refused  to  see  the  friends  who 
•called  upon  him  and  spent  the  day  in  devising  ways  and 
means  to  slip  out  the  back  way  at  night  and  settle  the  im- 
aginary obligations.  The  significance  of  the  approaching 
holiday  season  seemed  lost  to  hirr:;  violent  outbursts  of 
temper  appeared,  and  anything  placed  on  the  table  in  front 
of  him  was  at  once  tlirown  on  the  floor.  General  epileptic 
seizures,  about  ten  a  week,  now  appeared,  and  in  the  in- 
terim between  the  attacks  the  patient  was  stupid  and 
lethargic  in  the  extreme. 

About  ^May  i,  1908,  he  complained  that  his  left  arm  was 
stiff  and  cold,  this  condition  being  accompanied  by  a  severe 
attack  of  nausea.  During  the  night  he  suffered  from  an 
epileptic  convulsion.  Tlie  epileptic  attacks  continued  at  the 
rate  of  about  five  a  week  during  the  months  of  July  and 
.August,  and  now  the  patient  began  to  exhibit  distinct  signs 
•of  a  rapidly  failing  mentality.  Implements  of  trade  were 
supposed  to  be  missing  which  in  fact  were  at  the  moment 
under  his  eyes — implements  that  did  not  exist  were  de- 
scribed and  sought  for.  Smoking  pipes  and  various  instru- 
ments of  handicraft  which  had  been  laid  down  for  a  mo- 
ment suddenly  passed  from  his  mind,  and  in  the  vain  at- 
tempt to  describe  and  locate  the  same  words  failed  him — 
amnesic  aphasia  became  marked.  Finally,  the  sentences 
became  incomplete  and  incoherent,  and  he  would  sit  on  the 
floor  and  gaze  into  space.  During  the  month  of  August  the 
convulsive  seizures  became  more  marked  on  the  left  side, 
and  the  mental  deterioration  was  now  so  distinct  a  feature 
of  the  case  that  it  was  necessary  to  confine  him  to  his  room 
under  the  immediate  care  of  his  vafe. 

-About  the  loth  of  September  the  character  of  the  con- 
vulsive seizures  changed— the  loss  of  consciousness  being 
less  marked,  but  the  involvement  of  the  left  arm  and  leg 
in  a  severe  convulsive  movement  was  only  too  evident  in 
the  new-  order  of  affairs. 

On  September  12th,  while  standing  on  the  sidewalk,  the 
patient,  who  at  the  time  had  his  hand  at  his  mouth  to  re- 
move his  empty  pipe,  suddenly  dropped  his  left  arm  to  his 
side,  turned  completely  around  towards  the  left  three  times, 
and  was  about  to  fall  when  he  was  caught  and  placed  on  a 


bench.  This  attack  passed  away  in  about  two  minutes,  dur- 
ing which  time  the  patient  remained  fully  conscious  and 
soon  exclaimed,  'I  am  all  right' — then  followed  the  usual 
hallucinations  about  his  domestic  difficulties. 

On  the  i6th  of  September  a  sudden  and  serious  change 
for  the  worse  appeared — convulsion  after  convulsion  fol- 
lowing each  other  in  rapid  succession.  The  left  sided  char- 
acter of  the  seizures  was  more  marked  than  before,  and  at 
the  end  of  the  day  over  fifty  attacks  had  been  noted,  leav- 
ing the  patient  in  an  unconscious  and  exhausted  state. 

Beheving  there  was  soine  slowly  developing  le- 
sion of  the  right  cerebral  hemisphere,  probably  a 
cyst  or  cold  abscess,  and  regarding  the  case  as  ab- 
solutely hopeless  without  sttrgical  intervention,  I 
operated  upon  him  at  the  Emergency  Hospital,  Sep- 
tember 21,  1908.  A  large  osteoplastic  flap  was 
ttirned  down  from  the  right  temporoparietal  region, 
and  the  whole  Rolandic  area  exposed. 

To  my  surprise  the  brain  was  not  oedematous,  but 
the  tension  was  very  great,  and  no  pulsation  cotild 
be  felt  or  seen.  A  grooved  director  was  carefully 
introduced  in  half  a  dozen  ditterent  places  and  di- 
rections in  search  of  a  tmnor  or  cyst  or  abscess,  btit 
nothing  was  found.  I  was  so  sure  there  must  be 
some  growth  or  cyst  to  cause  the  great  amount  of 
tension  that  I  carefully  introduced  my  finger  into 
the  fissure  of  Sylvius  at  least  three  inches,  and  again 
into  the  stibstance  of  the  occipital  lobe,  palpating  the 
occipital  lobe  with  one  finger  in  the  centre  of  it  and 
one  on  the  surface.  But  nothing  w'as  found.  I 
replaced  the  flap,  still  feeling  that  there  must  be  a 
growth  in  the  brain,  but  not  feeling  justified  in  any 
further  exploration. 

I  gave  his  wife  a  gloomy  prognosis.  The  day  af-  ■ 
ter  the  operation  he  had  thirty-nine  convulsions,  on 
the  second  day  seven,  and  on  the  third  one.  Since 
then  he  has  had  none.  In  a  few  days  he  began  to 
improve  mentally,  leaving  the  hospital,  three  weeks 
after  the  operation,  considerably  improved. 

For  his  subsequetit  history  I  again  quote  Dr. 
Craig : 

The  rapid  disappearance  of  the  outward  manifestations 
of  the  malady  was  strongly  in  evidence  in  the  general  ap- 
pearance of  the  patient.  This  marked  improvement,  as  in- 
dicated in  the  animated  facial  expression,  was  in  striking 
contrast  with  the  stupid  and  inanimate  expression  which 
characterized  the  preoperative  state. 

In  the  place  of  a  distracted  intellect,  incapable  of  mani- 
festing anything  approaching  human  intelligence,  the  case 
now  attracts  unlimited  interest,  in  view  of  the  rapid  restor- 
ation of  the  psychological  faculties.  The  power  of  per- 
ception, once  obtunded  to  a  degree  approaching  imbecility, 
re?ppeared,  and  once  again  was  evidenced  by  the  interest 
the  patient  took  in  the  every  day  aff'airs  of  life.  Friends 
were  once  more  recognized,  photographs  were  handled  in 
a  spirit  of  recognition,  the  power  of  coherent  and  intelligi- 
ble speech  appeared.  As  if  by  magic  the  hallucinations  dis- 
appeared, and  not  for  a  moment  had  the  delusory  symp- 
toms which  but  a  few  weeks  ago  were  of  hourly  occurrence 
put  in  any  appearance.  Taking  an  interest  in  the  topics  of 
the  day,  he  was  able  to  discuss  fairly  well  the  patients  in 
the  hospital  ward,  recounting  the  names  of  the  patients,  and 
in  one  instance,  that  of  the  disease,  aneurysm,  he  frequently 
referred  to  the  'famous  heart  stitching  case,"  and  noted  the 
progress  of  the  same  in  the  daily  papers.  Tlie  names  of  the 
hospital  doctors  were  remembered — likewise  the  frequent 
visits  of  the  numerous  members  of  his  immediate  fafnily. 

Loss  of  memory  gave  place  to  a  retentive  state  of  mind, 
while  the  power  of  association  enabled  him  to  pursue  his 
daily  vocation,  that  of  janitor  and  general  utilitv  n.an  in  an 
apartment  house— without  forgetting  the  floor  he  was  on  or 
the  names  and  faces  of  the  occupants.  A  curious  feature 
of  the  case  was  found  in  the  fact  that  the  patient  was  able 
to  recall  the  hallucinations  from  which  he  had  suffered 
during  the  past  few  months,  describe  them  in  detail,  and 
note  the  marked  change  in  his  own  mental  condition. 


Ajiril  17,  1909.] 


CARR:  SURGICAL  TREATMEXT  OF  EPILEPSY. 


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f  For  a  few  days  after  the  return  from  the  hospital,  the 
f  patient  was  obliged  to  use  a  cane  in  walking,  owing  in  part 
i;  to  general  weakness  and  in  part  to  a  want  of  power  in  the 
I  muscles  of  the  left  leg,  but  these  symptoms  almost  entirely 
^  disappeared,  and  he  was  able  to  travel  without  difficulty 
at  any  time,  day  or  night. 

I  A  recent  note  from  Dr.  Craigr  tells  me  that  he  is 
i.  now  apparently  as  well,  mentally  and  physically,  as 
'2  ever,  and  that  he  has  been  on  top  of  a  high  steplad- 
~     der.  washing  windows,  and  doing  all  his  work  with- 

ont  difificnlty.  This  patient  might  have  got  well 
-  without  the  operation,  but  I  do  not  believe  it.  He 
■5     had  been  sick  too  long,  and  was  rapidly  progress- 

ing  from  bad  to  worse.  He  may  not  be  permanentlv 
i     cured,  but  there  had  been  sufficient  improvement, 

even  if  he  should  relapse  to-morrow,  to  more  than 
I     justify  the  operation. 

Z  As  I  have  said  before,  there  is  no  qtiestion  as  to 
J  the  propriety  of  operating  in  certain  cases  of  epi- 
t  lepsy,  but  my  results  have  been  so  encotiraging  that 
5  I  feel  that  they  justify  further  trial  in  case  of  idio- 
p  pathic  origin,  or  obscure  origin,  even  when  of  long 
«  standing.  Every  case  of  epilepsy  should  be  carefullv 
examined  for  sources  of  peripheral  irritation,  and 
A  especially  for  faulty  digestion  or  intestinal  diseases. 
=  If  no  peripheral  irritation  can  be  fotmd,  I  believe 
these  cases  should  be  operated  in  for  the  follow- 
■~     ing  reasons : 

First,  becatise  thev  are  otherwise  absolutely  hope- 
less, tmable  to  enjoy  life,  and  a  nuisance,  or  even  a 
menace  to  those  who  have  to  care  for  them,  for 
they  frequently  develop  attacks  of  homicidal  mania. 

Second,  because  some,  even  of  the  worst  cases, 
may  be  cured.  And  it  is  impossible  to  foretell  which 
can.  and  which  cannot,  be  ctired. 

Third,  because  those  patients  not  cured  are 
usually  benefited  temporarily  to  a  sufficient  extent 
to  make  them  glad  they  had  the  operation. 

Fourth,  because  there  is  so  little  danger  in  the 
operation.  All  my  patients  recovered  from  the 
operation,  and  all  that  I  know  of  personallv  have 
recovered.  Nothing  has  stirprised  me  more,  in  a 
long  experience  with  Emergency  Hospital  work, 
than  the  liberties  that  can  be  taken  with  the  brain 
without  any  bad  results,  and  the  apparent  great  re- 
sistance of  brain  tissue  to  infection  with  pus  pro- 
ducing organisms. 

Fifth,  the  lack  of  pain  and  discomfort  following 
operations  upon  the  brain. 

These  patients  make  more  rapid,  easy,  and  com- 
fortable recoveries  than  we  get  in  other  operations 
of  anything  like  equal  severity. 

The  best  method  of  operating.  I  think,  is  to  make 
a  large  osteoplastic  flap  over  the  region  to  which 
the  focal  symptoms  point,  or  if  there  are  none,  the 
flap  may  be  made  so  as  to  expose  the  Rolandic  area 
on  either  side.  This  can  be  rapidly  done  with  a 
good  de  ^■ilbiss  craniotome.  but  not  with  one  that 
has  been  bent  or  tw-isted  out  of  shape.  It  gives 
plenty  of  room  for  examining  nearly  the  whole 
hemisphere,  and  for  tying  such  bleeding  points  as 
are  bound  to  occur.  .\  large  crucial,  or  triangular, 
incision  should  be  made  in  the  dura,  and  a  careful 
examination  made  for  pachymeningitis,  depressed 
bone,  new  growths,  or  any  other  suspected  lesion. 
Any  offending  body  should  be  removed.  Xo  harm 
results  from  removal  of  a  large  amount  of  thick- 
ened dura  when  there  is  an  osteoplastic  flap  to  cover 


SMITH:  CEREBRAL  LESIONS  AS'D  OTITIS  MEDIA. 


[New  York 
Medical  Jolrxal. 


the  wound,  but  this  would  be  dangerous  where 
much  bone  had  been  removed  with  the  trephine  or 
rongeurs,  as  cerebral  hernia  would  be  likely  to  fol- 
low. CEdema  should  be  drained  by  the  careful  in- 
trtxluction  of  grooved  directors  into  the  brain  sub- 
stance. In  some  cases  serum  flows  in  streams, 
and  the  translucent  brain  may  be  seen  to  shrink 
and  become  opaque  in  a  few  moments.  Several 
<lirectors  may  be  introduced  at  once.  Of  course, 
no  lateral  movement  tearing  the  brain  should  ever 
be  made.  Exploring  needles  are  useless.  A  soft 
Tubl)er  drain  may  be  put  just  through  the  dura  and 
brought  out  through  one  of  the  small  trephine 
holes.  Sometimes  gauze  packing  may  be  used  in 
the  same  way  to  prevent  oozing ;  but  remember  that 
gauze  does  not  drain.  I  have  thought  it  possible 
that  my  good  results  were  due  to  the  large  open- 
ing, and  wide  inspection  of  the  brain,  and  that  the 
absence  of  bad  results,  particularly  cerebral  hernia, 
may  have  been  due  to  the  replacing  of  the  bone 
flap.  Certainl}-  the  patients  of  the  Cases  III,  Yl, 
\'I1,  VIII,  and  IX.  in  the  appended  table,  where  a 
•small  depressed  fracture  was  cut  out,  or  the  open- 
ing made  with  a  trephine,  did  not  do  so  well  as  in 
Cases  I,  II,  IV,  X,  XI,  and  X\'I.  where  the  more 
•extensive  operation  was  done.  And  yet  they  were 
apparently  more  favorable  cases. 

A  tabulated  report  of  all  my  cases  of  operation  for 
•epilepsy  has  been  included  in  this  paper. 

1418  L  Stref.t  Northwest. 


THE   IMPORTANCE   OF   CEREBRAL  LESIONS 
COMPLICATING  SUPPURATIVE  OTITIS 
MEDIA.* 
By  S.  MacCuen  Smith,  M.  D., 
Philadelphia. 

In  accepting  an  invitation  to  read  a  short  paper 
•on  brain  abscess  and  meningitis  complicating  aural 
•disease,  the  assumption  is  that  I  am  to  deal  solely 
■with  the  purulent  variety  of  the  latter.  I  will,  there- 
fore, confine  my  observations  to  a  consideration  of 
purulent  meningitis  and  temporosphenoidal  abscess. 

Cerebral  lesions  complicating  chronic  suppurative 
otitis  media  may  occur  at  any  time  during  the  course 
of  the  disease,  are  always  septic  in  character,  and 
can  only  be  relieved  by  surgical  intervention.  The 
infective  matter  enters  the  brain  tissue  or  its  cover- 
ings throCigh  the  lymphatics  or  bloodvessels,  or  di- 
rectly (and  this  is  the  usual  mode  of  infection)  l)y 
■carious  erosion  through  the  tegmen  tympani  or  teg- 
men  antri.  The  cerebral  fossa  is  also  invaded  at 
;times  by  way  of  the  labyrinth. 

In  my  experience  meningitis  comprises  the. most 
fre(|nent  intracranial  affection,  and  in  the  suppura- 
tive variety  the  most  fatal  lesion  complicating  aural 
'disease.  The  reason  for  the  latter  is  explained  in 
the  tact  that  the  underlying  or  primary  lesion,  sit- 
:iiated  in  the  car,  is  usually  overlooked  until  a  spon- 
taneous rupture  of  the  membrana  tympani  liberates 
a  (|uantity  of  pus  through  tlie  external  auditory 
canal,  which  frequently  is  the  first  intimation  that 
the  unsu.specting  physician  has  of  the  actual  cause 
of  his  patient's  illness.    This  diagnosis,  as  furnished 

*Ki-.i<l  at  a  meeting  of  the  Western  and  Middle  Sections  of  tlic 
American  LarynRoloBical,  Rhinological,  and  Otological  Society,  held 
aX.  C  hicago,  February  23,  1909. 


by  Nature,  however,  is  frequently  too  late  to  admit 
of  a  successful  attempt  to  save  the  patient,  for  if 
there  is  one  fatal  disease  more  deadly  than  another, 
it  is  an  infectious  meniagitis.  This  I  have  seen  oc- 
cur so  often  in  children  that  I  am  ready  to  believe 
that  the  setiological  factor  in  more  than  ninety  per 
cent,  of  all  cases  of  meningitis  in  infancy  is  an  over- 
looked or  never  suspected  aural  lesion. 

Although  the  diagnosis  of  an  uncomplicated  men- 
ingitis should  be  readily  made,  it  nevertheless  be- 
comes a  difficult  matter  to  differentiate  it  from  other 
intracranial  lesions  when  two  or  more  are  present. 
At  the  same  time,  an  early  diagnosis  is  of  vital  mo- 
ment, and  we  should  use  every  means  at  our  com- 
mand to  establish  the  same  in  its  incipiency,  if  we 
hope  to  meet  with  success  in  the  treatment. 

It  is  now  generally  recognized  that  the  circum- 
scribed variety  is  amenable  to  prompt  operative  in- 
tervention, but  I  wish  to  repeat  here  what  I  have 
declared  on  several  occasions,  that  I  believe  a  puru- 
lent diffuse  meningitis  is  positively  incurable.  This 
conviction  is  based  on  a  considerable  experience  and 
is  again  expressed  with  a  knowledge  that  such  cases 
have  been  reported  cured  by  surgical  means,  al- 
though the  probabilities  are  that  these  wc^e  of  the 
localized  rather  than  the  diffuse  form. 

Meningitis,  as  well  as  a  cerebellar  abscess  forma- 
tion, may  be  caused  by  a  labyrinthine  inflammation 
secondary  to  a  suppurative  otitis  media.  The  free 
intercommunication  of  the  cavities  of  the  labyrinth, 
as  provided  by  the  internal  auditory  canal  and  the 
aquaeductus  cochleae,  offers  an  easy  path  of  infection 
to  the  meninges  and  the  interior  of  the  skull  by  way 
of  the  subarachnoid  space  and  the  aqueductus  vesti- 
buli  into  the  saccus  endolymphaticus. 

In  a  case  presenting  violent  headache,  nausea,  and 
vomiting,  continued  temperature  without  marked 
remissions,  ranging  from  ioi°  to  103°  F.,  or  even 
higher  in  children,  the  p3'rexia  being  accompanied 
by  rigor,  rigidity  of  the  neck  muscles,  and  inability 
to  extend  the  leg  while  in  the  sitting  posture,  show- 
ing Kernig's  sign,  we  have  every  reason  to  feel 
that  we  are  dealing  with  an  advanced  case  of  men- 
ingitis. 

There  may  also  be  photophobia,  with  pupils  con- 
tracted and  responding  but  little  to  light,  and  optic 
neuritis.  Later  in  the  disease  the  pupils  become  di- 
lated and  often  unequal.  When  paralyses  occur 
and  there  is  optic  neuritis,  as  well  as  some  of  the 
other  symptoms,  the  diagnosis  is  assured. 

We  have  many  ocular  symptoms,  such  as  choked 
disc,  neuritis,  etc..  which  in  aural  disease  would  in- 
dicate the  presence  of  some  intracranial  lesion,  but 
they  are  of  absolutely  no  service  in  justifving  any 
conclusion  as  to  its  nature.  On  the  other  hand,  we 
do  have  many  intracranial  lesions  from  '.he  same 
origin  without  definite  ocular  symptoms.  This, 
again,  only  serves  to  show  our  inability  to  definitely 
locate  intracranial  implications.  If,  during  the 
course  of  an  otitis  media,  patients,  especially  chil- 
dren, prefer  to  be  in  a  dark  room,  I  believe  this 
should  be  regarded  as  an  early  sym])tom  of  some  in- 
tracranial complication.  Delirium  is  also  an  carlv 
manifestation  of  otitic  meningeal  disease  in  chil- 
dren. 

Although  we  have  lately  made  some  advances  in 
our  methods  of  brain  localization  in  intracranial 


April  17,  1909.] 


SMITH:  CEREBRAL  LESIONS  AND  OTITIS  MEDIA. 


793 


lesions  complicating  aural  disease,  the  confusion  is 
still  very  manifest  when  the  symptom  complex  is 
considered.  The  manifold  symptoms  generally  en- 
able us  to  determine  the  presence  or  absence  of  a 
brain  abscess ;  the  localization  of  it,  however,  is  still 
extremely  difficult.  The  indications  are  generally 
complex  and  confusing,  so  much  so,  indeed,  that  we 
are  compelled  at  times  to  arrive  at  a  diagnosis  by 
the  process  of  exclusion,  which,  I  wish  to  repeat,  is 
little  more  than  guesswork. 

From  the  fact  that  the  temporosphenoidal  region 
is  more  commonly  the  site  of  an  abscess  formation, 
we  are  justified,  in  the  absence  of  more  definite  lo- 
calizing manifestations,  in  assuming  that  the  lesion 
is  located  here.  \Wt  may,  for  the  same  reason,  feel 
that  a  meningitis  has  its  origin  through  the  tegmen 
tympani  or  tegmen  antri,  due  to  carious  erosion. 

Pressure  symptoms  are  made  evident  by  head- 
ache, nausea  and  vomiting",  vertigo  toward  the  dis- 
eased side,  mental  and  physical  depression,  marked 
stupor  that  may  be  attended  by  complete  loss  of 
consciousness,  choked  disc  and  neuritis,  as  well  as 
reduced  pulse  rate  and  temperature.  If  these  are 
sudden  in  development  and  follow  a  period  of  im- 
paired health,  we  may  be  assured  of  the  presence  of 
pus  in  some  part  of  the  brain,  but  in  the  absence  of 
focal  symptoms  we  cannot  always  be  certain  of  its 
location. 

Bruhl  says  that  in  a  lesion  of  the  third  frontal 
convolution  on  the  left  side,  we  find  agraphia  and 
alexia ;  in  lesions  of  the  first  temporal  convolution 
on  the  left,  word  deafness,  crossed  deafness,  and 
anosmia ;  of  the  occipital  lobe,  optic  aphasia  and 
hemiopia.  When  the  lesion  is  situated  around  the 
fissure  of  ilolando,  epileptiform  convulsions  and 
crossed  paralysis  of  the  extremities  are  present. 
Cerebral  abscess  of  otitic  origin  is  more  often  in  the 
temporosphenoidal  lobe  or  cerebellum.  A  great  ma- 
jority are  in  what  Barker  calls  "the  dangerous 
area."  This  is  within  a  circle  having  a  radius  of 
one  and  one  fourth  inches,  which  has  for  its  centre 
a  point  one  and  one  fourth  inches  above  and  behind 
the  external  auditory  meatus.  The  abscess  forma- 
tion is  often  found  not  in  direct  contact  with  its 
source  of  infection,  but  with  an  inch  or  so  of  healthy 
brain  tissue  intervening ;  this,  of  course,  occurring 
when  the  infection  is  carried  by  the  venous  system. 
Local  temperature  is  sometimes  higher,  directly  over 
the  seat  of  the  abscess,  even  if  the  body  temperature 
is  subnormal. 

A  point  of  greatest  value  and  one  that  explains  the 
fatal  termination  of  many  cases  that  succumb  after 
the  pus  has  been  evacuated,  is  the  development  of 
satellic  abscess  formations,  arising  from  the  parent 
abscess  cavity.  These  foci  are  usually  separated 
from  each  other  by  a  thin  wall  of  healthy  brain  tis- 
sue. Here  again,  accurate  localization  woukl  enable 
us  to  determine  definitely  the  situation  of  additional 
metastatic  pus  areas. 

If,  in  the  presence  of  suppurative  otitis  media, 
there  develop  certain  signs  of  intracranial  complica- 
tions, we  must  not  hesitate  to  advise  immediate  op- 
eration. On  the  other  hand,  we  should  just  as 
strongly  oppose  indiscriminate  surgical  intervention 
on  insufficient  evidence  of  the  existence  oi  such  le- 
sions. It  is  our  duty,  however,  to  give  a  patient 
the  benefit  of  an  early  operation  in  certain  doubtful 


contingencies,  as  the  risk  incident  thereto  is  practi- 
cally nil,  when  compared  with  the  certain  fatal  ter- 
mination that  must  be  the  reward  of  unwise  procras- 
tination. 

In  view  of  the  increasing  number  of  intracranial 
diseases  and  our  inability,  and  even  absolute  failure 
at  times,  to  dififerentiate  between  the  various  lesions, 
or  definitely  locate  an  endocranial  abscess  forma- 
tion, I  am  constrained  to  the  belief  that  we  are  still 
too  conservative  in  the  adoption  of  radical  measures 
for  the  cure  of  the  underlying  otorrhoea.  A  sup- 
purative otitis  is  always  curable  by  one  means  or  an- 
other, in  so  far  as  it  acts  as  a  causative  factor  in  in- 
tracranial complications,  and  why,  therefore,  should 
we  rest  content  and  bide  our  time  until  one  or  more 
of  these  grave  lesions  develop,  before  appreciating 
the  ever  increasing  danger  of  a  discharging  ear? 
Although  the  gravity  of  an  otorrhoea  cannot  always 
be  measured  by  its  chronicity,  nevertheless  he  is 
wisest  who  so  gauges  it  and  adopts  prompt  means- 
for  correcting  the  same.  The  safest  plan,  however, 
and  one  that  will  cover  all  classes  of  cases,  is  an  ac- 
ceptance of  the  assumption  that  all  suppurative  pro- 
cesses within  the  organ  of  hearing  are  hazardous 
and  act  as  a  dail}-  menace  to  health  and  even  life  so 
long  as  they  continue. 

Our  best  authorities,  even  in  this  present  day,  are 
still  as  doubtful  about  the  exact  nature  of  the  intra- 
cranial lesion,  as  well  as  its  location,  as  they  were 
some  )"ears  ago.  In  one  instance  the  diagnosis  lav 
between  a  meningitis  and  an  abscess  of  the  tem- 
poral region,  w'here  autopsy  showed  a  cerebellar  ab- 
scess formation.  In  another  case  where  all  the 
symptoms  indicated  a  temporal  lobe  abscess  of  the 
left  side,  the  autopsy  showed  a  diffuse  meningitis. 
Patients  have  been  operated  upon,  in  whom  the 
symptoms  positively  indicated  a  formation  in  the 
cerebrum,  the  autopsy  revealing  the  pus  in  the  cere- 
bellum of  the  opposite  side,  and  vice  versa. 

Where  a  patient  is  suffering  from  an  abscess  of 
the  brain  of  the  quiescent  or  latent  type,  the  diag- 
nosis many  times  is  impossible,  and  often  cannot  be 
made  until  the  collection  of  pus  has  reached  a  suf- 
ficient size  to  produce  mechanical  disturbance. 

In  septic  processes  the  examination  of  the  blood, 
especially  the  differential  leucocyte  count,  should 
not  be  overlooked  as  an  important  point  in  the  group- 
of  symptoms  which  indicates  the  form  of  treatment 
best  adapted  to  a  particular  patient.  In  fact,  such 
an  examination  often  forms  the  dividing  line  be- 
tween conservative  and  radical  treatment,  and  in 
finely  drawn  cases  not  infrequently  decides  which 
of  the  two  is  indicated. 

Before  considering  the  findings  in  differential  leu- 
cocyte counts  which  guide  one  to  the  proper  reme- 
dial measure,  it  is  well  to  briefly  review  the  normal 
proportions  of  white  cells.  At  birth  the  leucocytes 
range  from  12,000  to  25,000,  and  after  a  few  days- 
of  independent  life  the  number  drops  to  from  9,000' 
to  14,000.  During  the  period  of  childhood  the 
average  count  is  from  6,000  to  12,000,  which  de- 
creases as  the  individual  grows  older  to  from  6,000 
to  10,000  at  adolescence  and  remains  at  this  average 
throughout  adult  life. 

The  polynuclear  leucocytes  in  infancy  bear  a  rela- 
tive proportion  of  twenty  per  cent,  to  forty  per  cent, 
to  the  whole  number  of  white  cells,  but  in  adult  life 


794 


SMlill:  LEKEBtiAL  LESIONS  JXU  OTITIS  MEDIA. 


(.Is'jEW  VuKK 

Medical  Jolrnal. 


this  increases  to  from  fifty-nine  to  sixty-eigb.t  per 
cent. 

We  feel  that  a  hyperleucocytosis  (an  increase  to 
15.000  or  more)  does  not  indicate  the  severity  of 
the  septic  condition,  but  rather  the  individual's  abil- 
ity to  combat  the  attack.  Some  very  virulent  forms 
of  microbic  infection  are  accompanied  by  a  leuco- 
penia,  or  at  least  by  no  increase  in  the  number  of 
leucocytes,  and  therefore  the  presence  or  absence  of 
a  hyperleucocytosis  cannot  be  accepted  as  an  indi- 
cation for  operative  interference  on  the  one  hand, 
or  conservatism  on  the  other. 

With  the  relative  polynuclear  percentage  it  is 
quite  different,  and  we  have  in  this  a  fairly  reliable 
inde.x.  In  adults  we  seldom  find  pus  with  this  per- 
centage below  eighty,  though  in  children  the  maxi- 
mum percentage  without  pus  is  placed  at  about  sev- 
enty-three. An  increase  above  these  two  points  in 
adults  and  children  respectively  is  in  direct  propor- 
tion to  the  degree  of  the  infective  process,  and  the 
higher  the  proportion  the  more  urgent  is  the  need 
for  promi)t  intervention. 

Lumbar  puncture,  in  my  opinion,  is  of  value 
chiefly  as  an  aid  to  diagnosis,  although  good  results 
are  obtained  from  this  procedure  when  cerebral 
pressure  is  due  to  an  increase  of  cerebrospinal  fluid. 
The  value  of  this  procedure  as  an  indication  for  or 
against  operative  interference  is  variable.  A  clear 
fluid  does  not  always  exclude  the  presence  of  a 
meningitis,  as  this  condition  may  be  localized.  One 
observer,  Braunstein,  believes  in  drawing  oft'  suf- 
ficient fluid  to  be  sure  it  comes  from  the  interior  of 
the  skull,  and  if  it  is  clear,  concludes  there  is  no 
purulent  infection  of  the  meninges.  Quincke,  how- 
ever, believes  this  test  not  to  be  infallible,  and  also 
that  such  a  procedure  is  not  justifiable  from  the  fact 
that  it  may  spread  an  otherwise  circumscribed  area 
of  sepsis. 

A  cloudy  fluid  shows  without  doubt  the  i)resence 
of  a  purulent  meningitis,  and  while  ordinarily  this 
is  not  considered  a  hoi)eful  case  for  operation,  it 
would  seem  worth  while  to  give  the  meninges  of  the 
brain  and  cord  an  opportunity  for  the  estaljHshment 
of  resolution  and  repair  by  removing  the  necrotic 
bone  which  was  the  original  source  of  the  infection 
and  draining  the  site  of  the  initial  attack  upon  the 
dura. 

.\llhough  of  considerable  importance  lor  diag- 
nostic purposes,  lumbar  puncture  is  frequently  un- 
satisfactory and  nuist  be  viewed  as  a  procedure  pos- 
sessing more  or  less  danger,  this  in  spite  of  the  fact 
that  cases  reported  as  resulting  fatally  from  this  op- 
eration are  possibly  attributable  to  the  underlving 
disease. 

If.  during  the  mastoid  operation,  carious  bone  is 
found  in  the  tegmen  tymjjani  or  the  tegnien  antri. 
this  should  all  be  removed,  the  dura  being  freclv  ex- 
posed, even  though  no  symptoms  of  meningitis  or 
brain  abscess  are  present.  It  frequently  happens 
that  pus  will  be  seen  in  this  vicinity,  and  the  ex- 
poscfl  dura  may  be  even  bathed  in  pus.  In  some 
cases  as  soon  as  the  necrotic  bone  is  removed  a  gush 
of  pus  will  cscaj)c  through  the  dura,  owing  to  its 
origin  in  the  tcmporosj)Iunoi(hl  lobe.  IVrs ouTlly  I 
iiave  never  scm  a  case  of  this  character  prove  fatal, 
they  having  tuiifnrmly  recovered,  in  my  experience, 
on  account  of  the  natur.iliv  good  drainage. 


Although  it  may  be  unwise  to  incise  the  dura,  in 
the  presence  of  an  infection,  unless  there  is  suf- 
ficient evidence  of  disease  to  warrant  the  same,  yet 
I  have  incised  it  where  only  slight  evidence  of  dis- 
ease was  present,  and  by  doing  so  evacuated  pus 
from  the  interior  of  the  skull.  In  cases  of  this  char- 
acter I  have  not  felt  it  either  wise  or  necessary  to 
make  a  counter  opening  above  the  ear. 

From  the  fact  that  a  large  majority  of  abscess 
formations  involving  the  interior  of  the  skull  enter 
through  carious  erosion  of  the  tegmen  tympani  or 
tegmen  antri,  we  should  always  carefully  examine 
these  regions  during  the  course  of  a  mastoid  opera- 
tion. In  about  one  half  of  such  cases  the  dura  is 
noticeably  diseased,  and  will  be  found  firmly  ad- 
herent to  the  brain,  these  adhesions  frequently  act- 
ing as  a  barrier  against  the  further  development  of 
a  localized  meningitis. 

Not  long  since  we  looked  for  abscess  of  the  brain 
complicating  the  chronic  form  of  suppurative  otitis 
media  almost  exclusivel}-,  but  in  recent  \ears  our 
observations  have  taught  us  that  the  acute  type  is 
also  productive  of  many  such  cases,  thus  clearly 
demonstrating  the  value  of  prophylaxis  as  furnished 
by  early  operative  intervention. 

In  considering  the  time  when  surgical  measures 
should  be  instituted  for  the  relief  of  intracranial  le- 
sions, we  must  keep  in  mind  the  important  fact  that 
pressure  symptoms  and  other  recognized  signs  of 
brain  abscess  frequently  usher  in  the  terminal  state, 
or  in  other  words,  mark  the  beginning  of  the  end, 
in  which  event  it  is  usually  too  late  to  expect  to  meet 
with  success  even  though  radical  measures  are  re- 
sorted to. 

After  the  radical  mastoid  operation  has  been  per- 
formed, and  the  dura  gives  evidence  of  even  slight 
involvement,  the  adjacent  necrotic  bone  must  all  be 
removed  and  the  abscess  formation  evacuated 
tiirough  the  place  from  which  it  enters,  which  is  in- 
dicated by  either  a  visibly  diseased  or  bulging  dura 
in  the  tympanic  or  antral  roof. 

It  sometimes  happens  that  an  extradural  abscess 
in  this  vicinity  will  be  the  cause  of  dangerous  symp- 
toms. It  may  be  wise,  therefore,  in  some  cases,  to 
postpone  o])eniiig  the  dura  for  a  day  or  two,  unless 
:i  .smrdl  opening  already  exists  there  or  the  condi- 
tion of  the  same  is  such  as  to  demand  prompt  in- 
cision. 

The  use  of  Whiting's  encephaloscope  is  not  onlv 
valuable  as  a  means  of  evacuating  pus,  but  is  most 
serviceable  for  washing  out  the  cavity,  if  wisdom 
.so  dictates,  and  also  for  packing  the  same  or  the  in- 
troduction of  a  wick  of  iodoform  gauze  or  a  drain- 
age tube.  It  is  usually  inadvisable  to  use  irrigation 
in  acute  abscesses,  whereas  in  chronic  formations 
such  measures  are  u.seful  and  should  be  employed, 
especially  when  the  pus  is  thick  and  foul  smelling. 

The  (juestion  may  arise  as  to  the  advisability  of  a 
counter  oi)ening  one  and  one  quarter  inches  above 
the  middle  of  the  external  auditory  canal.  As  stated 
before,  I  have  never  yet  found  this  necessary,  as 
all  my  uncomplicated  cases  of  temporo.sphenoidal 
abscess  that  have  been  given  ample  drainage  through 
the  middle  ear  recovered. 

However,  in  the  absence  of  sufficient  evidence  of 
di.sease  either  of  the  tegmen  antri  or  tegmen  tym- 
pani  to  warrant  operative  interference  in  this  local 


April  J  7,  1 909.  J 


NASCHER:  LONGEVITY  AND  REJUVENESCENCE. 


795 


ity,  the  usual  operation  through  the  squamous  por- 
tion of  the  temporal  bone  should  be  performed. 
When  serious  doubt  as  to  the  actual  location  of  the 
abscess  exists,  it  may  be  best  to  follow  Percy  Dean'r 
suggestion  and  trephine  one  inch  behind  and  a  quar- 
ter of  an  inch  above  the  external  auditory  canal, 
which  enables  us  to  explore  both  the  tempcrosphe- 
noidal  and  cerebellar  lobes. 

The  treatment  of  suppurative  meningitis  is  neces- 
sarily surgical,  and  although  we  can  only  hope  tor 
success  in  the  circumscribed  variety,  yet  from  the 
fact  that  it  is  almost  impossible  to  recognize  when  a 
case  has  extended  beyond  this  point,  I  believe  w-e 
are  always  justified  in  operating  in  all  cases  of  in- 
fectious meningitis  complicating  aural  disease  un- 
less already  in  a  moribund  state.  Counter  openings 
are  here  also  advised  and  should  be  employed  in 
suitable  cases. 

1429  Spruce  Street. 


LONGEVITY  AND  REJUVEXESCENXE. 

By  J.  L.  Xascher,  M.  D., 
New  York. 

The  folly  of  the  ancients  is  the  wisdom  of  to-day. 
The  alchemist  who  sought  for  the  philosopher's 
stone,  the  alkahest,  and  the  panacea,  was  a  visionary 
attempting  the  impossible.  To-day  the  scientist  is 
still  seeking  the  philosopher's  stone,  that  something 
by  which  he  can  convert  one  element  into  another, 
and  believes  he  has  found  it  in  radium.  The  chem- 
ist is  still  endeavoring  to  produce  the  universal  sol- 
vent. The  physician  is  still  trying  to  find  the  pan- 
acea, the  elixir  vitae,  which,  if  it  will  not  cure  all  ills 
and  confer  immortality,  will  prolong  life  and  re- 
juvenate the  aged. 

When  Brown-Sequard  announced  his  faith  in  the 
efficacy  of  testicular  extract  in  senility  about  twenty 
years  ago  he  revived  the  belief  in  the  panacea.  The 
unfortunate  results  with  his  extract  in  Shamokin  in 
August,  1889.  destroyed  faith  in  his  discovery  but 
not  in  the  belief  that  it  is  possible  to  make  an  old 
man  feel  young  and  make  his  s\  stem  harmonize  with 
his  sensations. 

We  have  seen  men  old  in  years  who  felt  young, 
and  looked  far  younger  and  acted  younger  than  is 
customary  at  their  age,  and  we  have  seen  young 
men  who  looked  old,  felt  old,  and  acted  like  old  men. 
Most  of  us  probably  know  men  who  feel  ten  or 
twenty  years  younger  than  they  did  a  year  or  two 
ago.  What  had  occurred  in  the  physical  and  mental 
condition  of  the  individual  to  account  for  the  re- 
juvenation ?  Let  us  first  see  what  occurs  in  gro\y- 
ing  old.  We  divide  the  periods  of  life  into  infancy, 
childhood,  youth,  early  manhood,  middle  age,  old 
age,  and  senility,  terms  expressive  of  years  of  life, 
approximate  until  early  manhood  and  indefinite 
thereafter.  There  are  no  terms  expressing  the  ex- 
act mental  and  physical  condition  of  an  individual 
except  the  ordinary  measurements,  height,  weight, 
etc.,  and  the  obvious  physiological  features,  number 
of  respirations,  pulse,  quantity  of  urine,  etc.  Even 
these  definite  figures  give  us  only  a  comparative 
conception.  There  is  no  absolute  standard  of  physi- 
cal or  mental  capacity,  size,  or  function.  All  are 
based  upon  averages.    Normal  means  average  based 


upon  several  hundred  or  many  thousand  examina- 
tions. The  only  exact  terms  indicating  the  physi- 
cal and  mental  conditions  are  the  period  of  develop- 
ment, the  period  of  maturity,  and  the  period  of  de- 
cline. These  periods  are  definite  as  applied  to  the 
individual,  but  are  indefinite  when  applied  to  the 
mass  of  mankind,  and  when  so  applied  are  based 
upon  averages.  Thus  most  men  reach  their  limit  of 
height  at  about  the  twentv-second  year,  but  the  aver- 
age height  varies  with  nationality,  climate,  and  race. 
There  is  no  uniformity  in  rate  of  development,  no 
fixed  proportion  between  the  development  of  the 
mind  and  the  body,  none  between  portions  of  the 
body,  none  between  mental  capacities  (intellect, 
sensation,  and  will).  During  the  active  period  of 
development  before  puberty,  from  the  sixth  to  the 
fourteenth  year,  the  legs  increase  proportionately 
more  than  the  trunk,  the  width  of  the  head  increases 
about  one  millimetre,  while  the  height  of  the  face 
increases  one  centimetre  and  a  half.  In  many  men 
and  women  the  greatest  increase  in  circumference 
of  the  abdomen  occurs  between  the  thirty-fifth  and 
fiftieth  year,  years  after  all  other  proportions  have 
become  fixed  in  the  period  of  maturity.  Physical 
capacity,  strength,  and  activity,  reach  maturity  from 
the  twenty-fifth  to  the  thirtieth  year,  remain  station- 
ary for  a  few  years,  the  period  depending  upon  the 
mode  of  life,  then  decline. 

Mental  development  presents  marked  irregulari- 
ties. Some  individuals  exhibit  a  determined  will 
almost  from  birth  and  maintain  it  throitghout  a  long- 
life.  Some  are  plastic  and  pliant,  show  little  of  the 
energy  dependent  upon  deliberate  thought  and  mo- 
tive, but  are  swayed  by  impulse,  habit,  association,, 
emotion,  or  instinct.  Occasionallv  a  determined  will 
is  quickly  developed  or  broken.  This  factor  of  the 
mind  is  iminfiuencedbyage.  Sensation  is  another  per- 
manent factor  which  is  uninfluenced  by  age  unless 
the  sensory  organs  themselves  are  affected.  Some  be- 
come inured  to  disagreeable  sensations  to  such  ex- 
tent that  pain  and  hardship  are  borne  with  but  little 
distress,  while  others  become  more  sensitive  with 
age.  It  may  be  pointed  out  that  in  old  persons  the 
special  senses  are  usually  weakened.  It  can  be 
shown  on  the  other  hand,  that  among  savages  whose 
lives  are  uninfluenced  by  the  concomitants  of  civili- 
zation, the  senses  are  normally  acute  to  a  very  old 
age. 

The  intellect,  the  conscious  controlling  force  of 
the  mind,  governing  the  will,  interpreting  sensation 
and  senses,  and  directing  the  will  and  voluntary  ac- 
tion is  influenced  bv  age.  Its  various  faculties  have, 
however,  different  periods  and  varying  degrees  of 
development  and  are  differently  affected  by  age. 
^Memory,  the  conservative  faculty,  is  found  in  the  in- 
fant and  persists  through  life.  In  some  cases  fail- 
ing memory  is  the  first  sign  of  mental  decline,  in 
others  memory  remains  after  the  reasoning  faculty 
is  gone.  The  cognitive  faculty  of  immediate  knowl- 
edge generally  persists  through  life.  It  is  the  hu- 
man development  of  animal  instinct  requiring  no 
thought,  memory,  or  reason,  and  depends  upon  the 
impressions  produced  upon  the  special  senses.  Some 
of  these  impressions  are  deluding  and  must  be  cor- 
rected by  other  faculties  as  the  appearance  of  the 
new  moon,  the  sound  of  thunder,  and  errors  of  sen- 
sation. 


796 


X.ISCIIER:  LOXGEr/TY  AND  REJUrEXESCEXCE. 


LXe'.v  York 
MiiuicAL  Journal. 


The  comparative  and  constructive  faculties  which 
inckide  thought,  reason,  and  imagination,  the  pure- 
ly human  mental  faculties,  are  the  last  to  he  de- 
veloped, dominate  the  others,  and  exhibit  marked 
vagaries  in  their  development,  permanence,  and  de- 
cline. 

There  is  a  norma!  mean  in  phvsical  development 
at  different  ages  with  comi)aratively  slight  varia- 
tions from  the  norm.  Any  ver}-  marked  departure 
from  the  normal  can  be  looked  upon  as  pathological. 
There  is  no  norm  or  standard  of  intellect  or  in- 
telligence and  no  means  of  establishing  one.  At 
the  one  extreme  is  the  idiot  who  has  no  mental  fac- 
ulties whatever  and  lacks  even  the  primary  animal 
instinct  of  self  preservation.  There  is  no  known  op- 
posite extreme.  There  have  been  precocious  chil- 
dren, geniuses,  and  prodigies  who  surpassed  their 
fellows  in  one  or  niore  faculties,  but  we  cannot  de- 
termine by  figiHTS  or  b}-  any  other  standard  how 
much  they  differed  from  the  zero  of  the  absolute 
idiot  in  amount  or  degree  of  intelligence  or  intellect. 

The  progressive  teachings  in  school  furnish  an 
apparent  standard  of  mental  capacity  at  various 
ages,  since  children  of  approximately  the  same  age 
are  taught  the  same  subjects.  The  ever  changing 
school  curriculums,  and  the  antagonistic  views  of 
paedagogists,  the  widely  differing  mental  capacities 
of  children,  and  the  different  degrees  of  prepared- 
ness shown  by  graduates  to  enter  the  struggle  for 
existence  emphasize  the  imperfect  if  not  irrational 
development  of  the  mental  powers  when  conducted 
according  to  the  present  artificial  standard  I)ased 
upon  age.  W'liile  education  rouses  and  develops 
these  powers,  the  faculties  have  inherent  capacities 
and  activities  which  can  be  roused  but  not  exceeded 
by  educational  eft'orts.  Before  the  age  of  puberty 
the  cognitive  and  conservative  faculties  are  most 
active :  afterwards  the  comparative  and  constructive 
faculties  are  roused  to  action,  and  they  do  not  reach 
their  maximum  capacity  until  middle  age.  Many 
great  thinkers  did  their  best  work  at  what  we  would 
call  old  age,  while  others  never  equalled  the  reason- 
ing powers  of  their  youth. 

In  savage  life,  where  physical  prowess  confers 
superiority,  the  tendency  is  to  increase  strength  and 
physical  development.  In  civilization  mental  rather 
than  physical  superioritv  is  sought,  and  the  mind  is 
cultivated  to  surpass  its  previous  development.  The 
tendency  of  the  present  day.  however,  is  not  alone 
to  increase  mental  and  physical  capacity,  but  to 
■hasten  development.  Active  exercise,  athletics,  and 
gymnastics  are  taken  up  early  and  sy.stematically,  tn 
develop  the  bodv  to  the  highest  degree  possible  and 
in  the  shortest  time.  The  school  studies  are  in- 
creased, the  mental  faculties  are  rou.sed  and  brought 
into  action  at  a  much  earlier  age  thun  formerlv,  anrl 
we  frequently  find  children  grappling  with  mathe- 
matical problems  and  abstract  sciences  which  would 
puzzle  mature  min<ls.  As  kn<iwledge  increases  in 
all  directions  more  and  more  is  imparted  to  the 
growing  mind  producing  a  greater  strain  upon  it. 

The  period  of  maturity  (Icpends  mainly  upon  the 
mode  (if  life  of  the  individual.  A  man  does  not 
think  of  his  physical  or  mental  condition  until  some 
abnormal  conditifui  or  sensation  attracts  his  atten- 
tion. He  gives  no  thontiiit  Id  his  back  until  he  has  a 
backache.      lie   is  unconscious   of   the  metabolic 


changes  going  on  in  his  system  during  the  period 
when  the  constructive  and  destructive  processes  are 
balanced,  and  not  until  the  destructive  processes 
surpass  the  other  does  he  note  the  change  in  his  con- 
dition. The  greater  his  mental  and  physical  activity 
and  the  less  time  he  gives  to  recreation,  the  sooner 
does  the  period  of  decline  set  in.  While  the  period 
of  development  is  intentionally  shortened,  the  period 
of  maturity  is  unconsciouslv  shortened  through 
those  acts  which  quicken  metabolic  activity. 

In  ordinary  physiological  life,  unbroken  by  acci- 
dent or  avoidable  disease,  during  the  period  of  de- 
velopment the  constructive  metabolic  processes  are 
more  active  than  those  causing  destruction  of  tissue, 
and  organic  matter  is  readily  assimilated.  During 
the  period  of  maturity  the  two  processes  counterbal- 
ance each  other,  there  is  a  constant  battle  for  the 
mastery  until  some  feature  of  the  individual's  con- 
stitution or  mode  of  life  causes  the  destructive 
changes  to  overcome  the  constructive  processes  and 
decline  begins.  The  most  important  change  at  this 
period  is  in  the  assimilative  powers.  While  during 
the  developing  period  the  gain  is  mainly  organic, 
during  the  period  of  decline  the  body  assimilates  less 
organic  matter  and  destroys  less  inorganic  matter, 
there  is  a  waste  of  tissue  and  an  increase  of  salts. 
The  waste  occasioned  in  those  muscles  which  are 
most  frequently  employed  is  not  repaired  as  fast  as 
it  occurs  and  as  a  result  there  is  loss  of  strength  in 
the  limbs,  the  waste  in  the  muscles  of  the  face  gives 
the  appearance  of  age.  The  deposit  of  lime  salts 
in  the  ligaments  causes  stiffness,  in  the  bones  brittle- 
ness.  There  is  a  deposit  in  the  arterial  walls  causing 
arteriosclerosis.  In  his  studies  upon  the  aged  De- 
mange  found  atheroma  in  every  one  of  five  hun- 
dred autopsies  on  old  people  and  also  in  aged 
animals.  He  ascribes  the  decline  in  old  age  to 
a  change  in  the  quantity  and  quality  of  the  inter- 
stitial nutritive  material,  caused  by  an  alteration  in 
the  conditions  of  the  circulation  induced  by  the 
atheromatous  process.  The  origin  of  the  atheroma 
can  be  found  in  the  friction  of  the  blood  witli  the 
lining  membrane  of  the  vessels  producing  an  endo- 
carditis in  the  vasa  vasorum  later  extending  to  the 
larger  vessels  through  a  necrobiotic  infarct  in  their 
walls.  We  know  that  the  blood  changes  in  acute  in- 
fectious diseases,  in  lead  and  mercurv  poisoning,  in 
alcoholism,  gout,  rheumatism,  diabetes,  syphilis,  etc., 
may  produce  atheroma  and  the  consequences  of  this 
atheroma  are  the  same  as  when  due  to  o'd  age. 

The  decline  due  to  old  age  is  not  a  retrogression 
of  development.  Xot  a  single  organ  or  function  re- 
verts to  an  infantile  or  youthful  type.  Instead,  there 
is  a  change  in  the  character  or  composition  of  the 
organ,  which  impairs  its  action  or  causes  abnormal 
action  gradually  more  pronounced.  The  change  is 
not  sudden.  Pathological  symptoms  of  senility  do 
not  appear  imtil  the  destructive  processes  have  been 
actively  at  work  for  years,  and  then  they  can  be 
found  in  everv  organ  and  tissue  of  the  body.  The 
atheroma  of  the  vasa  vasorum  of  the  coronary  arte- 
ries produces  arteriosclerosis  in  these  arteries,  which 
in  turn  affects  the  nutrition  of  the  heart.  This  re- 
sults in  degeneration  of  the  endocardium,  extending 
later  to  the  deeper  layers  of  the  heart  tissue  and 
the  valves.  This  condition  produces  impairment  of 
the    circulation  with    consequent    malnutrition  of 


April  17,  1909.] 


NASCHER:  LONGEVITY  AND  REJUVENESCENCE. 


797 


every  organ  and  tissue.  In  the  heart  itself  there  is 
fatty  degeneration,  thickening  of  the  valves  fol- 
lowed by  valvular  rigidity  with  irregular  heart  ac- 
tion. 

The  respiratory  organs  become  afifected  in  several 
ways.  Through  the  deposit  of  lime  salts  the  ster- 
num becomes  ankylosed,  the  costal  cartilages,  the 
cartilages  of  the  larynx  and  trachea  become  ossified, 
the  ribs  become  less  resilient,  and  the  whole  chest 
loses  its  elasticity  and  mobilitv,  further  increased  by 
the  wasting  of  the  muscles  of  the  chest.  Faulty 
circulation  produces  atrophy  of  the  lung  tissue.  We 
have  then  diminished  capacity,  elasticity,  and  mobil- 
ity of  the  chest,  wasting  of  lung  tissue  and  imper- 
fect circulation,  with  a  consequent  imperfect  aera- 
aon  to  account  for  the  greater  liability  to  inflamma- 
tion and  hypostatic  congestion. 

The  most  marked  changes  in  the  digestive  organs 
are  the  direct  results  of  atheroma,  and  wasting  of 
the  muscular  coats  of  the  stomach  and  .intestines. 
There  is  atrophy  of  the  glands  while  the  organs  are 
subject  to  venous  engorgement  due  to  cardiac  weak- 
ness. The  liver,  spleen,  pancreas,  and  lymphatics 
become  atrophied  and  hardened,  and  finally  degen- 
erate. The  same  causes  afl:"ect  the  kidneys  and  uri- 
nary organs.  The  kidney  becomes  contracted,  the 
capsule  thickened,  the  parenchyma  hardened  ;  there 
is  sclerosis  of  the  connective  tissue  compressing  the 
tubules  and  glomeruli. 

The  wasting  of  muscular  fibres  in  the  bladder 
causes  loss  of  contractile  power  and  consequent  dis- 
tention by  urine.  There  is  dilatation,  sometimes 
hypertrophy  of  the  bladder  with  retention  of  urine, 
then  weakening  of  the  sphincter  with  the  consequent 
dribbling  or  incontinence  of  urine. 

The  changes  in  the  brain  and  spinal  cord  are  sim- 
ilar to  the  changes  in  other  organs.  These  are 
? trophy,  sclerosis,  and  degeneration  due  to  circu- 
latory disturbances.  There  are  many  minor  changes 
such  as  ossification  of  the  Pacchionian  bodies,  os- 
seous plates  in  the  arachnoid  and  pia  mater,  miliary 
aneurysms,  etc.  The  atrophic  changes  in  the  cord 
resemble  the  changes  in  progressive  muscular  atro- 
phy. The  changes  in  the  nerves  are  similar  to  those 
in  the  brain,  the  motor  functions  being  first  affected. 
T^ater  on  the  general  sensibility  and  the  special 
senses  generally  become  impaired. 

Natural  death  or  death  from  old  age  results  from 
the  decay  of  all  the  organs,  accompanied  by  a  dimin- 
ishing nervous  force  to  the  point  of  cessation  of 
nervous  activity. 

While  mental  activity  has  an  influence  upon  me- 
tabolism, absolute  idiots  have  become  old,  showing 
that  mental  activity  is  not  necessary  for  longevity. 
The  mental  powers  are  weakened  with  age,  the  ex- 
tent of  such  weakness  bearing  no  relation  to  the  ex- 
tent of  the  physical  decline.  The  various  mental 
faculties  themselves  differ  in  their  rate  and  method 
of  decline,  but  it  is  usually  memory  that  first  ex- 
hibits signs  of  weakness  due  to  age.  In  persons  ac- 
customed to  mental  activity  and  who  have  not 
abused  their  mental  faculties  by  excessive  strain 
these  faculties  often  remain  unimpaired  until  the 
end,  when  the  physical  powers  have  lost  the  power 
to  perform  the  functions  of  life.  They  may  require 
longer  periods  of  rest  than  formerly,  but  the  quality 


of  their  work  remains.  While  with  the  decline  due 
to  age  the  physical  powers  are  weakened  and  longer 
periods  of  rest  from  physical  activity  are  necessary 
this  decline  does  not  necessarily  weaken  the  mental 
powers,  but  it  prevents  long  continued  mental  strain. 
Mental  fatigue  requires  rest  and  recreation,  and  as 
the  old  man  does  less  mental  work  than  during  ma- 
turity there  is  less  necessity  for  the  complete  cessa- 
tion of  mental  activity  in  sleep  than  in  any  other 
period  of  life. 

The  tendency  of  the  present  day  is  to  shorten  the 
period  of  development  and  increase  the  mental  and 
physical  capacities,  pass  over  the  period  of  maturity 
with  indift'erence,  and  endeavor  to  lengthen  the  pe- 
riod of  decline.  We  ignore  the  mode  of  living  of 
those  who  lead  a  natural  life  terminating  in  a  nat- 
ural death.  We  all  want  to  live  long,  yet  we  adopt 
the  mode  of  life  which  shortens  the  periods  of  de- 
velopment and  maturity,  and  then  try  to  retard  the 
last  or  declining  period. 

In  natural  life  uninfluenced  by  the  complex  re- 
quirements of  civilization,  we  find  these  three  peri- 
ods of  about  equal  duration.  We  find  this  not  on\\ 
in  the  savage  but  in  the  peasant,  and  even  in  enlight- 
ened life  we  find  the  men  brought  up  in  the  country 
reach  maturity  later  and  become  senile  later  than 
those  brought  up  in  the  city.  In  other  words,  forced 
development  shortens  life.  In  our  schools  children 
are  urged  to  learn  more  and  faster,  the  curriculum 
is  constantly  enlarged  necessitating  greater  mental 
exertion.  Teachers  say  their  charges  are  bright  and 
their  minds  are  receptive  and  retentive  during  the 
first  hour  or  two.  but  during  the  third  hour  they  be- 
come restless  and  inattentive.  This  is  not  due  to 
hunger  but  to  brain  fag.  Whatever  the  nature  of 
one's  work  may  be,  mental  or  physical,  there  comes 
a  time  of  fatigue  which,  prolonged,  ends  in  complete 
exhaustion.  Exhaustion  demands  complete  mental 
and  physical  rest,  while  fatigue  requires  reaction  or 
rest  from  the  fatiguing  task  while  some  other  organ 
or  faculty  is  pleasurably  employed.  Moderate  phys- 
ical activity  stimulates  muscular  development  in  the 
part  implicated  in  the  work  or  exercise,  but  when 
carried  beyond  the  point  of  fatigue  the  development 
is  inhibited  and  the  tissue  either  degenerates  or 
wastes.  The  same  applies  to  mental  activity.  If 
activity  is  forced  beyond  its  capacity  the  mental  fac- 
ulties become  weakened  or  perverted. 

Reconstruction  is  most  active  during  sleep,  and 
Nature  provides  sufficient  sleep  to  the  healthy  or- 
ganism to  repair  the  previous  waste,  while  the  tissue 
waste  during  sleep  is  at  the  minimum.  Since  the 
mental  and  physical  activities  are  most  marked  dur- 
ing the  developmental  period,  this  period  demands 
the  most  recreation  and  rest.  In  the  hurry  and  activity 
of  present  day  city  life  the  rest  is  not  commensurate 
with  the  work  which  necessitates  it,  while  recreation 
itself  is  intensified  until  it  becomes  exhausting  work. 
Instead  of  mild  physical  exercise  like  simple  gym- 
nastics, as  recreation  for  mental  work,  school  chil- 
dren take  up  strenuous  athletics  like  running  and 
football.  Instead  of  simple  reading  and  light  plays 
for  physical  labors,  we  take  up  educational  lectures 
and  scientific  reading.  The  greater  the  antithesis 
between  the  character  of  the  work  and  the  character 
of  the  recreation  the  more  benefit  will  redound  to 


798 


X.-ISCHER:  LONGEVITY  AND  REJU]' ENESCENCE. 


[New  York 
Medical  Journal. 


the  individual.  Tins  docs  not  mean  that  exhausting 
labor  requires  exhausting  recreation,  vet  that  is  what 
we  are  doing  in  the  period  of  development. 

Mens  Sana  in  corporc  sano  does  not  mean  cram- 
ming the  mind  to  its  capacity  and  developing  the 
body  into  an  athlete,  neither  does  intense  application 
to  study,  slich  as  is  required  by  the  present  school 
curriculum,  conduce  to  a  sound  mind,  nor  violent 
athletics  to  a  sound  body. 

Instead  of  trying  to  shorten  the  period  of  devel- 
opment we  should  endeavor  to  lengthen  it.  ^letital 
and  physical  tasks  should  not  be  carried  to  the  point 
of  fatigue.  When  they  begin  to  strain  they  should 
be  dropped  at  once  for  some  recreation,  the  form 
depending  upon  the  character  of  the  task  performed. 
Short  recreation  periods  between  each  subject  taken 
up  in  schools  should  be  introduced.  At  present  it  is 
customary  to  devote  an  hour  to  each  subject,  and 
while  the  mind  is  still  engaged  with  that  subject  the 
next  is  taken  up.  Compel  a  writer  whose  mind  is 
engrossed  with  one  story  to  stop  and  take  up  an- 
other story  or  another  subject  without  a  moment's 
intermission  and  his  mind  will  become  confused.  It 
is  the  same  with  the  child.  In  some  classes  the 
teacher  will  give  the  children  a  few  minutes'  rest 
between  subjects,  but  this  does  not  relieve  the  child's 
mind.  Recreation  demands  some  other  occupation  to 
take  the  place  of  the  task,  and  the  best  occupation  at 
such  a  time  is  play.  A  few  minutes'  play  after  each 
subject  will  relieve  the  mental  strain.  Too  many 
subjects  are  taught  at  present,  and  the  child  leaves 
the  school  with  a  smattering  of  many  useless  sub- 
jects, some  of  which  will  be  forgotten  immediately 
after  the  examination.  The  subjects  requiring  the 
reasoning  faculties  should  not  be  taken  up  until  the 
constructive  and  comparative  faculties  are  prepared 
to  take  them  up,  generally  about  the  time  of  puberty. 
The  age  of  admission  to  high  schools  and  colleges 
should  be  raisetl,  and  owing  to  the  multiplicitv  of 
subjects  branches  should  be  specialized.  The  mental 
faculties  should  be  developed  slowly  until  they  have 
reached  their  maturity. 

Physical  development  like  mental  development  is 
now  hurried,  and  the  period  shortened  through  vio- 
lent means.  \'iolent  exercise  is  always  dangerous 
and  if  persisted  in  it  is  always  harmful.  The  boxer 
trains  for  months  to  get  in  condition,  yet  we  see 
school  boys  run  races,  make  long  and  high  jumps, 
wrestle,  and  play  foot  ball  with  little  or  no  prepara- 
tion. 

Physical  development  should  be  slow,  steady,  and 
if  increased  artificially,  such  increase  should  be  svs- 
tematic.  We  do  not  know  how  far  osseous  devel- 
opment is  influenced  by  exercise,  but  we  know  that 
muscular  development  can  be  increased  and  adipose 
deposits  decreased  thereby.  Gymnastics  and  mild 
exercises  like  walking  and  skating  will  bring  this 
about  as  well  as  the  more  vigorous  sports.  The  ob- 
ject of  such  artificial  aids  to  physical  development 
should  be  to  increase  capacity,  not  to  reach  the  max- 
imum at  the  earliest  moment 

The  amount  of  absolute  rest  in  sleep  should  be 
measured  by  the  individual's  natural  requirements, 
not  by  the  exigency  of  his  vocation.  The  natural  re- 
f|uirenient  is  determinc<l  by  his  inclination  to  sleep. 
The  child  sleeps  naturally  as  long  as  the  system  finds 
it  necessary,  it  awakes,  plays,  learns,  and  when  over- 
come by  mental  or  physical  fatigue  it  falls  asleep 


again.  Alan  fixes  his  period  of  sleep  irrespective  of 
the  requirements  of  his  system,  and  habituates  him- 
self to  a  certain  number  of  hours  or  a  certain  hour 
of  arising.  While  the  system  will  accommodate  it- 
self to  the  habit,  after  exhausting  labor  the  individ- 
ual will  oversleep  himself.  Few  are  so  situated  that 
they  can  sleep  when  they  feel  so  inclined  and  as  louij 
as  the  system  demands.  In  the  normal  individual 
the  amount  of  sleep  required  depends  upon  the 
amount  of  mental  and  physical  strain  or  activity  un- 
dergone, and  it  should  not  be  broken  until  the  sys- 
tem has  entirelv  recovered  from  the  strain.  When 
this  occurs  the  individual  awakes  naturally.  Insuffi- 
cient sleep  causes  insufficient  reconstruction,  and  the 
body  does  not  develop  to  the  full  extent.  The 
amount  of  sleep  during  the  period  of  development 
should  not  be  fixed  by  a  certain  number  of  hours 
but  by  the  demands  of  the  system  as  indicated  by 
the  length  of  time  the  person  would  sleep  if  not  dis- 
turbed. These  are  the  main  factors  to  be  consid- 
ered in  prolonging  the  period  of  development.  In- 
cidental thereto  are  diet,  habits  (sedentary  or  act- 
ive), heredity,  social  conditions,  etc. 

Diet  plays  an  important  part  in  development.  A 
meat  diet  imparts  vigor,  energy,  activity,  and  irrita- 
bility. The  boxer  during  his  period  of  training  lives 
upon  a  meat  diet  from  which  every  fat  forming  sub- 
stance is  excluded.  On  the  other  hand  a  vegetarian 
diet  produces  the  best  built  individuals  and  conduces 
to  longevity.  The  Hindus  are  as  a  rule  finely  formed 
men,  but  they  lack  stamina  and  vigor,  although  they 
maintain  maturity  much  longer  than  meat  eaters. 
The  German  peasant  who  has  meat  but  once  a  week 
is  as  a  rule  strong  and  well  built,  lacking,  however, 
energy.  W^e  find  the  same  difiference  here  between 
the  city  boy  who  has  meat  once  or  twice  a  day  and 
the  back  country  lad  who  has  meat  two  or  three 
times  a  week.  This  was  shown  during  the  civil  war 
when  the  city  regiments  endured  hardships  better 
than  the  regiments  raised  in  country  districts,  al- 
though the  physical  development  of  the  latter  was 
better.  In  considering  longevity,  however,  we  must 
exclude  such  factors  as  extraordinary  hardships  and 
hazardous  vocations.  We  must  remember  that  ac- 
tivity increases  waste,  and  that  meat  increases  phys- 
ical activity.  Since  mental  rather  than  physical  vigor 
is  necessary  in  the  battle  of  life,  meat  should  be  used 
sparingly  and  cereals  freely  during  the'  develop- 
mental period.  It  is  hardly  necessary  to  refer  to 
alcohol,  tobacco,  and  sexual  excesses  during  this  pe- 
riod. 

The  period  of  maturity  is  passed  over  with  indif- 
ference by  most  individuals.  The  man  feels  well  and 
strong  physically  and  bright  mentally,  and  until  de- 
cline sets  in  he  does  nothing  to  prolong  this  period 
while  he  does  much  unconsciously  to  shorten  it.  Ex- 
cesses of  all  kinds  weaken  nutrition,  prevent  recon- 
struction, and  increase  waste.  The  city  man  lives 
too  fast.  He  does  not  sleep  enough,  he  eats  too 
much,  he  works  too  hard  mentally  and  physicallv, 
he  drinks  and  smokes  to  excess,  he  is  irrational  in 
his  recreations,  he  does  not  believe  in  sexual  conti- 
nence. As  long  as  he 'does  not  feel  the  harm,  he 
will  not  believe  in  its  existence.  It  is  only  when 
some  excess  leads  to  a  pathological  condition  which 
produces  the  discomfiture  of  disease  can  he  be  made 
to  realize  that  his  mode  of  living  will  shorten  his 
life.   Sleep  should  be  regulated  by  nature  according 


April  17,  J  909.] 


A'ASCHER:  LOXGEl'lTY  AND  REJUVENESCEXCE. 


799 


to  the  work,  not  by  the  clock.  Hunger  and  not  the 
taste  of  the  viands  should  regulate  the  amount  and 
frequency  of  his  meals.  The  sense  of  mental  and 
physical  fatigue  should  control  the  amount  of  his 
w  ork.  In  his  recreations  he  should  be  regulated  by 
the  principle  that  the  greater  the  antithesis  between 
his  work  and  his  recreation  the  greater  the  benefit. 
]\Iental  labor  requires  physical  recreation  and  vice 
versa.  Dancing  may  be  a  diversion,  but  it  is  no 
recreation  to  the  manual  laborer,  while  chess  playing 
will  not  relieve  the  mental  strain  of  the  civil  engi- 
neer. This  is  a  subject  on  which  the  physician  is 
rarely  called  upon  for  advice,  yet  it  is  important  in 
its  bearing  upon  health  as  excesses  and  perversions. 

Alcohol,  tobacco,  and  sexual  .excesses  as  agents 
predisposing  to  early  decline  are  too  well  known  to 
need  elaboration. 

It  is  during  the  period  of  maturity  that  the  arterial 
degenerations  begin  w^hich  cause  degeneration  of 
other  organs  and  general  decline.  During  maturity 
normal  waste  is  counterbalanced  by  normal  assimi- 
lation and  the  degenerative  processes  progress  slow- 
ly. Causes  which  produce  increased,  waste  as  alco- 
hol, fast  life,  overwork,  sexual  and  mental  excesses, 
rich  food :  or  which  prevent  complete  reconstruction 
as  insufficient  sleep,  improper  recreation,  sedentary 
habits ;  or  which  irritate  the  vascular  system,  hasten 
the  fibrous,  calcareous,  and  fatty  changes  in  the  arte- 
rial walls.  To  prolong  the  period  of  maturity  we 
must  avoid  those  causes  favoring  arterial  degenera- 
tion. 

Our  efiforts  toward  longevity  have  in  practice  been 
confined  to  the  period  of  decline,  and  then  it  was 
rather  to  prolong  the  closing  hours  or  to  brace  up 
some  decaying  organ  than  to  prolong  the  whole  pe- 
riod. We  are  called  upon  to  improve  the  senile 
tremor,  the  senile  weakness,  senile  dementia,  waning 
sexual  powers,  weakened  senses,  etc.,  but  we  are 
never  called  upon  to  prepare  the  system  to  withstand 
the  general  decav  w^hich  ends  in  death.  The  treat- 
ment of  senility  should  not  be  confined  to  one  organ 
which  appears  to  be  on  the  point  of  breaking  down, 
but  should  take  in  the  system  as  a  whole  and  inci- 
dentally that  organ  or  those  organs  which  appear  to 
be  most  affected.  We  cannot  do  anything  to  restore 
degenerated  organs,  but  we  can  do  something  to 
prevent  the  increased  waste,  to  increase  assimilation 
especially  of  organic  substances,  and  we  can  employ 
psychic  measures  to  restore  mental  activity  and  even 
phvsical  vigor. 

We  all  know  the  restorative  ettect  of  a  vacation 
upon  the  tired  mind  and  body.  The  city  man  goes 
to  the  country,  the  mountains,  the  seashore,  or  makes 
an  ocean  trip,  while  the  man  from  the  country 
comes  to  the  city  to  spend  his  vacation.  It  is  not 
alone  the  rest  and  recreation,  the  changed  air  and 
surroundings,  but  also  the  mental  eftect  produced 
by  the  knowledge  of  freedom  from  work  and  re- 
straint that  brings  about  the  sense  of  exhilaration 
and  the  general  improvement  in  mind  and  body. 
The  workman  who  spends  his  vacation  in  his  home 
where  he  may  have  better  food,  a  better  room,  even 
more  air  and  freedom  from  restraint  than  in  the 
country  will  probably  have  rested  more  than  in  the 
country,  but  he  will  not  have  had  the  same  mental 
stimulus  and  exhilaration.  He  will  not  have  the 
same  vigor,  the  same  desire  to  work  as  if  he  had 
been  in  the  country.    He  ma\'  want  to  return  to 


work  to  break  the  strain  of  doing  nothing,  but  there 
is  lacking  the  ambition,  energy,  and  vigor  which  fol- 
lows change  of  scene,  change  of  occupation,  and 
mode  of  living.  A  long  continued  routine  or  occu- 
pation becomes  monotonous  and  finally  occasions 
mental  and  often  physical  fatigue  though  the  occu- 
pation is  ordinarily  a  recreation  or  pastime.  The 
professional  ball  player,  chess  player,  gambler,  find 
no  recreation  in  their  vocations.  They  demand 
change  of  occupation  or  scene  to  recuperate.  The 
eft'ect  upon  the  mind  by  an\"  agreeable  change  is 
stimulating  and  rejuvenating.  The  housewife 
changes  the  position  of  the  furniture  in  the  room 
occasionally  when  she  is  "tired  looking  at  the  same 
thing  all  the  time."  The  workman  changes  his  po- 
sition and  he  works  with  more  ambition  in  his  new 
place  though  the  work  be  harder.  Gloving  into  a 
new  home  after  years  in  the  old  one  has  an  exhil- 
arating eft'ect  upon  the  mind  reflected  upon  the  body 
which  exhibits  greater  ph\  sical  activity. 

The  most  powerful  rejuvenating  eft'ect  upon  an 
old  man  is  produced  by  a  young  wife.  Men  who 
have  been  impotent  for  years  have  regained  their 
sexual  power  under  this  stimulus,  and  not  only  sex- 
ual power  but  mental  and  physical  vigor  as  well. 
The  impotent  married  man  has  been  known  to  re- 
gain sexual  vigor  after  a  single  '"change,"  showing 
the  mental  influence  over  the  system. 

Rejuvenescence  depends  primarilv  upon  increased 
mental  activity,  which  in  turn  stimulates  physical 
activity  and  vigor.  The  most  potent  of  the  mental 
stimulants  are  psychic,  a  young  wife,  change  of 
scene  and  residence,  complete  change  of  mode  of 
living.  The  joke  alDOut  the  bald  heads  in  the  front 
rows  of  the  theatre  where  there  are  pretty  chorus 
girls  in  the  cast  has  a  psychological  basis.  Alental 
activity  is  aroused,  and  the  old  men  feel  young  again. 

Of  drugs  phosphorus  is  the  only  one  which  pro- 
duces a  lasting  mental  stimulation  without  a  de- 
pressant reaction.  Alcohol  favors  atheromatous  de- 
posits, and  its  action  is  evanescent :  cannabis  indica. 
morphine,  and  cocaine  in  minute  doses  increase 
mental  acti^'ity,  but  in  senility  the  S}  stem  becomes 
soon  habituated  to  them.  A  physician  who  at  sixty- 
five  began  to  take  one  twentieth  grain  of  morphine 
occasionally  for  its  stimulating  eft'ect,  in  six  months 
took  one  sixth  grain  twice  daily,  and  six  months 
later  he  was  taking  one  third  grain  three  times  a 
day.  Shortly  afterward  he  died,  after  taking  one 
half  grain  of  the  drug.  He  was  at  one  time  a  bril- 
liant speaker  in  societies,  but  his  powers  waned  un- 
til, shortly  before  he  began  to  take  the  drug,  he 
could  not  make  a  sensible  cx  tempore  speech.  He 
regained  his  old  time  force  and  mental  activity  after 
taking  the  drug. 

In  many  cases  the  feeling  of  being  old  is  either 
psychic  or  the  result  of  illness.  \\'hen  due  to  the 
latter  cause  restoration  of  health  carries  with  it 
restoration  of  mental  and  physical  activity.  Changed 
surroundings,  a  sea  voyage,  or  a  stay  in  the  country 
hastens  such  restoration,  the  main  factor  in  such  re- 
covery being  the  eft'ect  upon  the  mind. 

There  are  many  psychic  causes  for  quick  aging. 
The  moment  a  man  is  a  grandfather,  though  he  be 
but  forty  years  of  age,  he  suddenly  feels  old.  Many 
men  when  they  are  placed  in  a  responsible  position 
involving  life,  lose  their  former  buoyanc}'  and  light- 
ness.   Impending  death,  a  secret  fear,  a  great  loss. 


8oo 


ROBIXSON:  LOXG  LIFE  AND  HOT  CLIMATES. 


[New  York 
Medical  Journal. 


a  sudden  fright  have  all  produced  sudden  and  per- 
manent aging  of  the  individual.  A  more  important 
mental  factor  in  creating  the  feeling  of  age  is 
enforced  seriousness  and  dignity,  which  become  in 
time  habitual  and  restrain  the  person  from  such 
recreations  which  would  best  overcome  the  mental 
and  physical  fatigue  of  their  vocations.  An  elderly 
physician  went  to  a  masked  ball  disguised  as  a 
school  boy.  He  played  marbles,  spun  a  top,  and 
played  with  others  similarly  masked.  For  weeks 
afterwards  he  was  in  a  joyous  humor,  more  active 
and  brighter  than  he  had  been  in  years.  We  decry 
the  old  maid  who  dresses  as  a  young  girl  and  seeks 
her  companions  among  the  young.  One  of  them 
said  she  felt  young  because  she  tried  to  feel  young 
by  dressing  and  acting  as  a  young  person.  She 
knew  the  secret  of  rejuvenescence. 

Rejuvenescence  in  the  aged  is,  however,  only  a 
temporary  condition.  The  increased  physical  activ- 
ity stimulates  the  anabolic  processes,  and  unless  the 
catabolic  changes  can  be  stimulated  as  well  the  indi- 
vidual hastens  the  inevitable  end.  A  powerful  men- 
tal stimulus  without  deleterious  effects  is  association 
with  the  young.  The  lessened  assimilation  in  the 
aged  is  due  partly  to  the  senile  changes  in  the  diges- 
tive organs,  partly  to  altered  metabolism  caused  by 
altered  physical  condition  and  functions  of  all  the 
organs  due  to  altered  nutrition  in  atheroma. 

Owing  to  the  changes  in  the  digestive  organs  the 
sense  of  hunger  and  thirst  is  obtunded.  The  dulled 
mental  faculties  do  not  realize  the  system's  need  for 
reconstructives  to  supply  the  waste.  As  a  result  the 
aged  eat  less  and  drink  less  and  their  food  is  not 
especially  adapted  to  the  changed  conditions. 

\\'hile  the  condition  of  the  digestive  organs  can 
be  generally  improved  and  proper  diet  supplied,  it 
is  impossible  to  change  the  degenerative  processes, 
and  the  best  that  we  can  hope  for  is  to  retard  their 
progress.  The  ordinary  measures  to  accomplish 
this  are  hygienic,  fresh  air,  proper  diet,  sufficient 
sleep,  rest  periods,  mild  exercise,  and  methodical 
life,  changing  these  requirements  as  the  progressive 
changes  of  the  system  call  for.  Fresh  air  as  cool  as 
the  individual  can  stand  without  bundling  himself 
up  in  an  overcoat  is  necessary.  Proper  diet  is  the 
most  important  factor  in  the  period  of  decline.  The 
food  should  be  free  as  far  as  possible  from  non- 
digestible  and  nonnutritious  elements  and  lime  salts. 
Some  articles  of  food  often  given  to  the  aged  on 
account  of  their  digestibility  have  little  nutritive 
value ;  such  are  jellies,  gelatin,  broths,  green  vege- 
tables, stewed  fruit.  The  staple  articles  of  diet 
should  be  vegetables  except  greens,  cereals,  soft 
boiled  eggs,  white  meats,  fish,  well  baked  stale  bread 
or  zwieback  or  toast,  milk,  weak  coffee,  cocoa.  In- 
dividual predilection  and  digestibility  may  be  taken 
as  a  guide.  When  digestion  fails  or  when  owing  to 
bad  teeth  the  food  cannot  be  properly  masticated  we 
must  rely  upon  predigestcd  or  partly  digested  foods, 
malt  extract,  meat  juice,  milk,  and  soft  boiled  eggs. 
.As  the  sensation  of  hunger  becomes  blunted  we 
should  give  food  at  regular  intervals,  not  hearty 
meals,  but  frequent,  without  regard  to  the  sensation 
of  hunger. 

The  best  form  f>f  exercise  is  walking  up  a  mod- 
erate incline  with  frc(|ucn*  rests.  This  should  never 
be  carried  to  the  extent  of  fatigue,  and  the  strain 
upon  the  legs  should  be  relieved  and  distributed  to 


the  arms  by  the  use  of  a  cane.  Rubber  heels  make 
walking  easier.  The  Xauheim  system  of  saline 
baths  with  moderate  exercise  and  massage  is  bene- 
ficial. 

The  aged  apparently  do  not  require  as  much 
sleep  as  in  the  earlier  periods  of  life,  but  they  do 
require  frequent  periods  of  rest.  Slight  fatigue  is 
quickly  overcome  by  rest,  but  exhaustion  in  the  aged 
is  more  serious  and  takes  much  longer  for  recovery 
than  at  any  other  period  of  life. 

In  giving  drugs  in  old  age  we  must  always  bear 
in  mind  the  atheromatous  condition  of  the  arteries 
with  the  resultant  degeneration  of  the  organs,  the 
impaired  circulation,  and  the  changed  power  of  as- 
similation. As  a  general  tonic  phosphorus  is  the 
only  one  that  can  be  given  to  the  aged  indefinitely 
without  creating  a  habit  or  aggravating  existing 
conditions.  Digestive  stimulants  such  as  the  simple 
bitters,  cinchona,  and  nux  vomica  may  be  given,  also 
digestive  aids,  antifermentives,  and  agents  to  relieve 
constipation.  For  the  last  indication  calomel  is 
best. 

I  have  not  touched  upon  the  new  theory  that  pre- 
cocious senility  is  due  to  poisoning  of  the  tissues 
caused  mainly  by  the  intestinal  microbes  and  that  an 
agent  arresting  intestinal  putrefaction  will  postpone 
old  age.  It  seems  more  rational  to  give  autointoxi- 
cation through  intestinal  putrefaction  a  place  as  one 
of  the  contributing  causes  of  premature  age,  and  to 
give  "fast"  living  as  the  main  cause,  and  to  ascribe 
longevity  to  natural  living  and  rational  hygiene 
rather  than  to  the  use  of  a  single  drug  or  article 
of  food. 

The  whole  question  of  longevity  hinges  upon  the 
mode  of  living.  If  we  favor  the  unnatural  pre- 
cocious development  of  youth  and  maintain  indilfer- 
ence  during  the  period  of  maturity,  thus  shortening 
both  periods,  we  will  have  an  early  and  short  period 
of  decline.  If  we  prolong  the  period  of  develop- 
ment, and  prolong  the  period  of  maturity  preparin^;' 
for  the  succeeding  period  we  will  have  a  late  and 
long  period  of  decline.  It  is  all  a  question  of  ra- 
tional and  natural  living. 

73  E.\ST  Eighty-second  Street. 


LONG  LIFE  AND  HOT  CLIMATES. 
By  W.  F.  Robinson,  M.  D., 
Palm  Beach,  Fla. 

One  of  the  most  interesting  questions  of  the  day 
is  the  prolongation  of  life.  In  this  connection  there 
are  two  questions  of  vital  importance,  viz.,  the 
question  of  struggle  and  the  question  of  rest.  It 
may  be  put  down  as  certain  that  too  much  and  too 
fierce  a  struggle  inevitably  shortens  life.  The  des- 
perate fight  to  get  rich  quick  which  is  so  popular  in 
America  to-day  sends  many  a  man  to  his  grave  be- 
fore his  time.  On  the  other  hand  too  much  rest 
is  also  bad  for  the  system  because  the  vital  ma- 
chinery if  not  used  will  decay,  and,  therefore,  lazy 
and  idle  persons  who  for  any  reason  have  no  need 
to  work  or  struggle  are  also  very  apt  to  go  before 
their  allotted  time.  It  is  the  man  or  woman  who 
learns  to  work  and  rest  in  proper  proportions  that 
has  the  best  chance  of  a  long  life. 

The  natural  time  for  struggle  is  youth  and  man- 
hood when  the  system  is  strong  and  the  powers  of 


April  17,  1909.] 


FAIRCHILD:  POSTOPERATIVE  STOMACH  DILATATION. 


8oi 


body  and  mind  are  at  their  best.  As  old  age  ap- 
proaches and  the  powers  of  the  body  begin  to  fail, 
work  and  effort  become  harder  and  harder,  and 
what  was  a  pleasure  and  a  benefit  in  earlier  years 
becomes  a  wearisome  and  fatiguing  task.  At  the 
same  time  the  force  of  habit  is  very  strong  and 
many  a  man  who  can  well  afford  to  retire  and  take 
his  ease  is  driven  on  by  this  same  force  to  continued 
effort  which  becomes  harder  and  harder  as  the  sys- 
tem becomes  weaker.  There  are  two  other  causes 
which  contribute  to  this  result.  One  is  the  stim- 
ulating eft'ect  of  the  northern  climate  and  the  other 
is  that  all  of  his  companions  are  working  as  hard 
as  he  is. 

Thus  with  the  three  elements  of  habit,  climate, 
and  association,  all  working  together  to  the  same 
end,  it  is  evident  that  rest  is  almost  if  not  entirely 
out  of  the  C[uestion.  The  struggle  goes  on  year 
after  year  until  our  man  suddenly  breaks  down  and 
has  a  complete  collapse.  A  doctor  is  summoned 
who  declares  that  the  patient  must  give  up  all  work 
and  responsibility,  and  take  a  sea  voyage  or  a  long 
trip  of  some  kind.  It  is  very  possible,  however, 
that  the  thing  has  gone  too  far  and  that  the  broken 
down  system,  worn  out  by  overwork,  cannot  re- 
cover itself.  If  such  is  the  case  the  patient  may 
drag  out  a  year  or  two  of  hopeless  invalidism  and 
then  drop  into  the  grave  long  before  his  allotted 
time. 

Let  us  now  look  at  the  other  side  of  the  picture. 
Suppose  this  man  anywhere  between  the  ages  of 
fifty  and  fifty-five,  had  formed  the  habit  of  leaving 
his  business  for  three  months  every  winter  and 
coming  south. .  The  conditions  are  now  all  changed. 
For  a  stimulating  climate  he  has  substituted  a  mild 
and  soothing  one.  Instead  of  his  hard  working 
friends  at  home  he  is  surrounded  by  a  lot  of  men 
as  idle  as  himself.  Lastly  he  has  effectually  broken 
the  habit  of  work  by  leaving  it  and  going  away 
where  he  cannot  do  it. 

The  result  is  easy  to  predict.  Being  unable  to 
work  he  soon  loses  that  fierce  impelling  desire  for 
work,  which  had  possession  of  him  in  the  north. 
Surrounded  as  he  is  by  the  idle  he  soon  learns  to 
take  an  interest  in  the  idler's  affairs,  such  as  fishing, 
golf,  shooting,  etc.  He  soon  finds  himself  a  new 
man  in  many  ways.  He  has  lost  the  nervousness 
and  restlessness  which  were  his  at  home.  He  eats 
and  sleeps  better,  enjoys  life  more,  and  feels  alto- 
gether twenty  years  younger. 

He  enjoys  his  winter  so  much  that  he  comes 
again  the  next,  the  next,  and  finally  becomes  like 
thousands  of  Americans  to-day,  a  permanent  win- 
ter southern  tourist.  Again  let  us  look  at  the  re- 
sult. Instead  of  dying  a  broken  down  wreck  around 
the  age  of  sixty  he  will  live  on  five,  ten,  or  even  fif- 
teen years,  and  at  the  same  time  enjoy  a  fair  meas- 
ure of  health,  and  happiness. 

Just  here  the  writer  wishes  to  state  the  fact  that 
he  practised  a  number  of  years  in  the  north,  where 
he  lost  his  health.  He  immediately  came  south, 
where  his  health  was  rapidly  restored  and  where  he 
now  practises.  On  account  of  this  double  practice 
he  feels  himself  specially  qualified  to  compare  the 
effects  of  the  two  climates  upon  the  northern  man. 
The  writer  has  always  been  deeply  interested  in  the 
subject  and  has  made  a  careful  study  of  it  not  only 


since  he  has  been  in  the  south  but  even  before, 
when  he  was  still  in  the  north.  As  a  result  of  his 
studies  and  observations  the  writer  wishes  to  make 
the  following  assertion  which  he  firmly  and  hon- 
estly believes  to  be  conservative : 

The  average  successful  American  man,  either 
business  or  professional,  who  forms  the  habit  at  the 
age  of  fifty  or  thereabouts  of  coming  south  for  three 
months  every  winter,  the  period  being  so  arranged 
that  he  will  avoid  the  worst  of  the  terrible  northern 
spring  of  his  home  climate,  will  almost  certainly 
prolong  his  life  ten  years  as  well  as  greatly  increase 
the  enjoyment  of  his  declining  years.  The  latter 
part  of  this  statement  requires  a  little  explanation. 
The  most  trying  time  in  all  northern  climates  is  the 
early  spring.  It  is  trying  to  the  system  which  has 
been  depleted  by  the  rigors  of  the  winter  and  equal- 
ly so  to  that  one  which  has  been  relaxed  by  a  three 
months'  stay  in  a  hot  climate.  This  dangerous  pe- 
riod differs  in  different  climates,  growing  later  as 
a  matter  of  course  as  one  goes  farther  north.  For 
example,  people  living  in  New  York  city  who  have 
spent  the  winter  in  the  south,  should  arrange  to  get 
home  not  sooner  than  May  ist,  as  the  month  of 
April  in  that  city  is  raw  and  cold,  and  a  delicate 
elderly  person  coming  from  the  south  during  this 
month,  would  be  very  apt  to  catch  a  severe  cold  and 
perhaps  undo  all  the  good  of  the  southern  trip. 


ACUTE  POSTOPERATIVE  DILATATION  OF  THE 
STOMACH.* 

By  D.  S.  Fairchild,  M.  D., 
Des  Aloines,  Iowa, 

Professor  of  Surgery,   Drake  University  College  of  Medicine; 
Surgeon  to  Agatha  and  Mercy  Hospitals. 

Case. — Mrs.  A.  came  under  my  observation  at  Agatha 
Hospital  on  December  26,  1906.  She  had  been  operated 
upon  by  Dr.  D.  S.  Fairchild,  Jr.,  eight  days  before  for  a 
large  ovarian  tumor.  Mrs.  A.  was  a  rather  frail  woman, 
forty  years  of  age,  had  enjoyed  fairly  good  health  until  a 
few  months  before  the  operation  when  the  presence  of  the 
tumor  began  to  cause  her  trouble  on  account  of  its  size. 
She  had  for  years  been  annoyed  by  "stomach  trouble,"  but 
not  of  a  serious  nature,  nothing  to  suggest  the  later  devel- 
opments. There  were  no  operative  dii^iculties.  The  tumor 
while  large  was  not  adherent ;  convalescence  was  unevent- 
ful until  seven  days  after  the  operation.  On  the  evening 
of  the  seventh  day,  she  had  some  rise  of  teniperature,  dis- 
tention of  the  stomach,  and  some  unsuccessful  efforts  at 
vomiting.  She  suffered  so  much  distress  that  the  stomach 
tube  was  used  and  a  large  amount  of  dark  offensive'  fluid 
removed,  followed  by  very  decided  relief  for  a  few  hours, 
when  all  the  distressing  symptoms  returned. 

I  saw  her  on  the  following  morning.  At  that  time  the 
lower  part  of  the  abdomen  was  flat,  but  in  the  epigastric 
region  there  was  a  great  distention,  corresponding  exactly 
to  the  position  of  a  much  distended  stomach.  This  was  at 
once  recognized  as  an  acute  dilatation  of  that  organ.  The 
temperature  was  102°  F.,  pulse  124,  and  she  was  much 
prostrated.  I  was  informed  that  the  condition  appeared 
without  any  marked  premonitory  symptoms  and  the  tem- 
perature and  pulse  record  showed  a  suddenly  developing 
toxajmia.  I  had  no  previous  experience  with  a  similar  con- 
dition, but  I  recalled  some  cases  recorded  in  medical  liter- 
ature and  particularly  the  chapter  on  acute  dilatation  of  the 
stomach  in  Mayo  Robson's  and  Moynihan's  book  published 
in  1901.  Most  of  the  cases  reported  up  to  that  time  had 
proved  fatal,  and  the  condition  of  our  patient  indicated 
very  strongly  that  a  similar  result  would  follow.  The 
stomach  tube  was  again  used,  and  a  large  quantity  of  dark 
offensive  fluid  removed  with  great  relief  to  the  patient. 

■•Read  before  the  W^estern  Surgical  and  Gyniecological  Associa- 
tion, December  29,  1908. 


r.llRCHlLL):  POSTOPERATIVE  STOMACH  DILATATIOX. 


[New  Vork 
Medical  Journal. 


Tlie  tcir.perature  dropped  to  lOo'F.  and  the  pulse  to  io6. 
Incjuiry  was  made  to  discover,  if  possible,  whether  there 
was  any  pyloric  or  other  obstruction  in  any  part  of  the  in- 
testinal tract.  Her  bowels  had  moved  even  that  very  morn- 
ing. Her  appetite  had  been  fairly  good,  and  up  to  the 
beginning  of  the  present  symptoms  the  food  had  been  di- 
gested well  and  had  escaped  freely  through  the  pylorus. 
There  w  as  also  no  distention  of  the  bowels,  nor  was  there 
at  any  time  during  her  sickness.  The  success  of  the  stom- 
ach lavage  gave  a  hope  of  a  recovery.  In  about  four  hours 
the  symptoms  as  before  related  returned  and  were  again 
relieved  by  the  stomach  tube.  Each  time  before  the  tube 
was  introduced,  there  was  a  rise  of  temperature  followed 
by  a  fall  soon  after  the  stomach  was  washed  out. 

The  woman  died  forty-eight  hours  after  the  symptoms 
first  appeared.  Gastroenterostorr.y  was  apparently  the 
proper  treatment,  but  before  her  friends  could  reach  her 
.^he  was  so  much  prostrated  that  any  operative  treatment 
could  not  be  considered.  The  cause  of  the  acute  dilatation 
of  the  stomach  in  this  case  was  regarded  as  some  form  of 
to.\£emia  e.xercising  a  neuroparalytic  influence  on  the  stom- 
ach.   Xo  post  mortem  examination  could  be  secured. 

The  interest  e.xcited  by  this  case  led  to  a  careful 
examination  of  the  literature  at  hand  on  acute  di- 
latation of  the  stomach,  and  neither  at  the  time  or 
since  have  I  entertained  the  belief  that  any  form  of 
obstruction  was  an  aetiological  factor. 

The  recent  papers  by  Joseph  C.  Bloodgood  {An- 
iials  of  Suri^cry,  Xovember,  1907)  and  Walter  B. 
Letfer  {A}iiials  of  Siiiiicry.  March,  1908)  would 
at  least  suggest  that  several  causes  may  be  produc- 
tive of  this  condition.  It  appears  that  Dr.  Fagg  was 
the  first  to  describe  acute  dilatation  of  the  st(Mnach. 
His  paper  was  based  on  two  cases  in  his  own  prac- 
tice which  proved  fatal.  Several  papers  followed 
Dr.  Fagg's  communication.  In  Alayo  Robson's  and 
]\Ioynihan"s  book  on  the  stomach  published  in  1901, 
it  is  stated  that  four  cases  of  acute  dilatation  of  the 
st(/mach  occurred  in  t-he  Leeds  Infirmary.  It  ap- 
pears that  all  these  cases  followed  operations  and 
rapidly  proved  fatal.  The  cause  was  regarded  as 
a  toxic  neuroparesis.  INIore  recent  papers,  how- 
ever, appear  to  show  that  a  wider  range  of  cases 
has  been  included  so  as  to  embrace  a  class  follow- 
ing operations,  designated  postoperative  acute  dila- 
tation of  the  stomach  apparently  due  to  different 
causes,  in  many  cases  to  some  mechanical  obstruc- 
tion in  the  upper  intestine. 

The  earlier  cases  were  regarded  as  a  neuroparesis. 
J'epper  and  Stengel  suggested  that  the  immediate 
cause  is  a  neuroparesis  of  the  stomach  probably  as- 
sociated with  a  spasm  of  the  pylorus.  Later  writers 
have  added  other  factors  in  producing  acute  dilata- 
tion of  the  stomach,  as  arteriomesenteric  ileus,  gas- 
tromcsentei'ic  incarceration  and  other  conditions 
more  or  less  nearly  allied,  which  in  many  instances 
are  related  to  postoperative  cases  but  not  limited 
to  this  class  but  also  included  others  not  following 
surgical  operations,  a^  for  instance  Glenard  in  1885 
<lcscribed  mesenteric  ileus  when  the  empty  small 
intestines  ])rolapsed  into  the  pelvis  and  exerted  a 
pull  on  the  root  of  the  mesentery. 

The  ])articular  and  close  relation  of  the  symp- 
tonis  of  acute  dilatation  of  the  stomach  to  abdominal 
o()cration'^  very  naturally  leads  to  tiie  h\  pothesis  of 
obstructive  lesions  in  the  u|)pcr  intestines,  and  it 
is  probably  true  that  many  arc  of  this  nature.  But 
other  factors  must  be  taken  into  account  as  in  our 
case  and  in  otlicrs  like  it.  The  symptoms  are  too 
acute  from  the  fir'^t.  and  the  rapid  prostration  and 
<lcath  f|uite  clearly  indicate-  the  difference. 


The  cases  referred  to  in  Dr.  Bloodgood's  paper 
illustrate  both  a  toxic  cause  and  an  obstruction.  A 
case  referred  to  by  Dr.  Bloodgood  as  coming  under 
his  observation  in  j\larch.  1904.  following  an  opera- 
tion for  appendicitis  presents  a  clinical  picture  of  a 
neurotoxic  cause.  Another  case  by  the  same  ob- 
server diagnosticated  as  primary  gastromesenteric 
ileus  upon  which  a  jejunostomy  and  the  passing  of 
a  tube  into  the  duodenum  was  done.  The  patient 
died  two  hours  later.  Post  mortem  exammatio.i 
failed  to  show  any  changes  from  the  normal.  It 
would  seem  from  the  reading  that  the  acute  dila- 
tation of  the  stomach  and  duodenum  involved  a 
neurotoxic  influence  tipon  the  duodenojejunal  jiuic- 
tion.  The  third  case  in  Dr.  Bloodgood's  paper 
seems  to  have  been  practically  of  the  same  charac- 
ter. Three  cases  were  therefore  of  the  nature  of  a 
primary  acute  dilatation  following  operations,  while 
the  remainder  were  secondary  to  obstructive  condi- 
tions in  the  upper  intestinal  tract,  mostly  gastro- 
mesenteric ileus. 

Dr.  Leffer  reports  in  his  paper  four  cases  of  his 
own,  of  which  three  patients  died.  The  first  case 
followed  a  normal  confinement  the  first  symptoms 
appearing  an  hour  after  the  child  was  born.  The 
second  case  followed  an  infection  of  the  antrum  of 
Highmore.  The  third  case  followed  an  operation 
for  an  acute  appendicitis.  The  history  in  this  case 
seems  to  indicate  that  the  dilatation  was  secondary 
to  a  peritonitis,  this  patient  recovered  as  soon  as  the 
pus  passed  freely.  The  fourth  case,  a  cystitis  and 
pyelitis  following  the  use  of  a  catheter  in  a  paraly- 
tic, death  resulting  in  twenty-four  hours  after  the 
first  appearance  of  the  dilatation  of  the  stomach. 

It  appears  from  the  observations  thus  far  made 
that  acute  dilatation  of  the  stomach  may  hi  desig- 
nated postoperative  or  otherwise,  according  to  its 
relations  to  surgical  operations,  and  may  fairly  be 
divided  into  three  groups,  r,  toxic  neuroparalytic: 
2,  gastromesenteric  ileus  ;  3,  from  peritonitis.  The 
first  group  may  be  regarded  as  primary  and  the  sec- 
ond and  third  groups  as  secondary  acute  dilatation. 

The  mortality  from  the  first  group  is  very  high. 
According  to  Kayser,  eliminating  all  cases  of  gas- 
tromesenteric ileus  and  all  cases  of  mild  peritonitis, 
the  death  rate  is  seventy-one  per  cent. 

The  treatment  of  postoperative  acute  dilatation  of 
the  stomach  will  depend  tipon  the  pathological  fac- 
tors involved.  Bloodgood's  observations  on  opera- 
tive treatment  were  not  at  all  encouraging,  of  the 
ten  patients  operated  upon  eight  died  and  two  re- 
covered. He  admits  that  the  obstructive  factor  is 
not  an  entirely  satisfactory  aetiology  of  the  cor.di- 
tion,  and  that  the  true  cause  cannot  be  said  to  be 
established. 

The  gastromesenteric  ileus  cases  are  better 
treated  by  the  exaggerated  Trendelenburg  position 
than  by  operation,  and  the  neuro])aralytic  cases  bet- 
ter by  tlie  stomach  tube  than  by  the  gastroenter- 
ostomy. 

If  the  diagnosis  between  the  two  conditions  can- 
not be  made,  the  trcament  may  be  conducted  by 
both  position  and  the  stomach  tube.  Seelig  in  the 
Interstate  Medical  Journal  mentions  a  case  in  which 
the  stomach  tube  gave  temporary  relief,  but  onlv 
after  placing  the  patient  in  the  exaggerated  Trendel- 
enburg position  did  the  symptoms  satisfactorilv  im- 


April  17,  J  909.  J 


MILLER:  HERNIA. 


803 


prove.  This  was  probably  a  case  of  gastromesen- 
teric  ileus,  in  which,  position  overcame  the  twist, 
Dr.  Leffer  in  his  first  case  placed  his  patient  in  the 
Trendelenburg  position  for  other  reasons  without 
benefit.  This  may  be  assumed  to  have  been  a  case 
of  neuroparesis. 

Beck's  observations  demonstrated  that  in  addi- 
tion to  gastric  paralysis  there  is  another  factor  to  be 
taken  into  account,  viz. :  a  hypersecretion  indicated 
by  the  large  amount  of  material  removed  by  the 
stomach  tube.  In  a  case  of  his  own,  although  the 
patient  had  had  no  food,  from  one  to  two  quarts 
was  removed  every  twenty-four  hours  for  four 
days,  the  patient  recovering.  In  our  case,  the  same 
observation  was  made  only  that  the  quantity  was 
much  in  excess  of  the  quantity  mentioned  before, 
nearly  as  much  was  remo^'ed  every  three  or  four 
hours.  I  take  it  Beck's  observations  have  been  re- 
peated in  nearly  all  of  this  class  of  cases. 


A  CORRECT  DEFINITIOX  FOR  ABDOMINAL 
HERNIA  ILLUSTRATED  BY  TWO  CASES. 

I,  Strangulated  Hernia  through  Linea  Semilunaris,  and  2, 
Intraabdominal  Incarcerated  Hernia* 
By  George  1.  Miller.  M.  D., 
Brooklyn,  N.  Y., 

Instructor  in  Operative  Surgery.  Postgraduate  Medical  School  and 
Hospital;  Surgeon  to  St.  Mark's  and  People's  Hospitals; 
Associate  Surgeon,  Jewish  Hospital,  Brooklyn. 

When  we  meet  a  rare  form  of  hernia  such  as  an 
intraabdominal,  properitoneal,  or  ileocolic  hernia  the 
usual  definition  given  to  denote  the  existence  of  a 
hernia  is  not  'correct. 

Authors  of  reputation  and  experience  define  her- 
nia as  a  protrusion  from  a  cavity,  of  any  of  its  nat- 
ural contents ;  as  hernia  of  the  brain  from  the  cra- 
nial cavity,  of  the  lung  from  the  cavity  of  the  chest, 
or  of  any  of  the  inclosed  viscera  of  the  abdominal 
cavity. 

It  is  asserted  that  abdominal  hernia  occurs  at 
some  point  in  the  muscular  wall  that  is  weakened 
by  the  transmission  of  nerves  and  blood  vessels,  or 
at  muscular  parts  that  have  been  stabbed,  incised, 
or  lacerated,  or  at  points  congenitally  defective  or 
acquired  paralysis  of  the  resisting  muscles. 

The  gradual  stretching  of  tissue  and  the  escape 
of  the  abdominal  contents  in  a  congenital  or  ac- 
quired sac  from  the  peritonaeum  constitute  the  usual 
hernia. 

In  a  rare  form  of  hernia  which  I  cite  below  there 
existed  either  a  congenital  or  acquired  pouch  from 
the  peritonaeum  within  the  abdominal  cavity.  The 
muscular  fibres  and  usual  weak  spots  of  the  abdomi- 
nal wall  had  of¥ered  sufficient  resistance  from  al- 
lowing the  hernial  mass  to  pass  through  with  the 
result  of  the  formation  of  a  hernia  within  the  ab- 
dominal cavity.  A  correct  definition  for  abdominal 
hernia  would,  therefore,  be  the  escape  of  the  ab- 
dominal contents  in  a  congenital  or  acquired  sac  of 
peritonaeum  which  is  within  the  abdominal  cavity 
or  has  passed  through  some  point  of  its  muscular 
wall. 

A  definition  which  covers  very  clearly  the  possible 
existence  of  a  nonprotruding  abdominal  hernia  will 
bring  to  students  and  operators  true  interpretation 

"Cases  reported  at  the  meeting  of  the  Surgical  Society  of  Brook- 
lyn. N.  Y.,  on  January  7,  1909. 


of  certain  subjective  symptoms  such  as  an  impulse 
during  coughing  or  sneezing  at  definite  points  of  the 
abdominal  wall,  when  no  bulging  of  the  part  is 
visible. 

The  first  case  is  a  report  of  a  strangulated  hernia 
through  the  linea  semilunaris  to  which  the  book 
definition  for  hernia  is  applicable,  while  the  second 
case  being  one  of  incarcerated  intraabdominal  her- 
nia suggests  a  complete  definition  for  all  forms  of 
abdominal  hernia. 

Case  I. — Mrs.  H.,  sixty-two  years  of  age,  white,  house- 
wife, previously  healthy,  was  admitted  to  the  Jewish  Hos- 
pital on  November  21,  1908.  She  stated  that  she  had  recui- 
ring  abdominal  pain,  vomiting  and  obstinate  constipation. 

Previous  history:  She  had  always  been  in  good  health. 
Had  given  birth  to  eleven  children.  ^Menopause  set  in 
eleven  years  ago. 

For  the  last  fourteen  years  she  felt  a  mass  in  her  abdo- 
men, at  a  point  about  the  middle  third  and  outer  border  of 
the  right  rectus  muscle.  At  times  this  mass  was  smaller, 
and  on  several  occasions  it  almost  entirely  disappeared  after 
twenty-four  hours  of  rest  in  bed,  together  with  applications 
of  hot  water  bottles.    Her  general  health  remained  good. 

Three  days  before  entering  the  hospital  she  became  nau- 
seated and  vomited  a  few  times.  Her  bowels  did  not  move, 
and  she  had  some  pain  over  the  tuinor.  Several  physicians 
were  called  in,  who,  after  trying  taxis  without  success  pro- 
nounced the  case  one  of  fatty  growth.  The  following  day 
she  vomited  again,  and  the  pain  in  the  mass  became  more 
severe  and  the  distention  also  increased.  When  admitted 
to  the  hospital  the  bowels  acted  as  a  result  of  a  high  enema 
of  soap  suds,  the  pain  diminished,  and  she  felt  much  re- 
lieved. She  had  not  voirnted  twenty-four  hours  before  ad- 
mission. 

I  saw  her  half  an  hour  before  the  operation,  for  the  first 
time.  She  appeared  to  rest  in  bed  very  comfortable,  tem- 
perature, 99°  F. ;  pulse,  86;  respiration,  20.  Urine  nega- 
ti\e;  blood  exainination  leucocytosis  15400;  polymorpho- 
leucocytes,  71  ;  small  monoleucocytes,  29. 

The  abdomen  was  somewhat  uniformly  distended,  pendu- 
lous, and  loaded  with  fat,  rendering  accurate  palpation  very 
difficult.  A  mass  about  the  si;^e  of  an  orange  could  be 
made  out  in  the  middle  third  of  the  linea  seir.ilunaris  on  the 
ri.ght  side.  This  mass  was  soft,  not  movable,  somewhat 
painful.    Diagnosis  :  Strangulated  hernia. 

Operation  :  The  abdomen  was  opened  by  a  three  inch  in- 
cision directly  over  the  tumor.  The  omentum  appeared  as 
an  irregular  lobulated  mass  somewhat  congested  and  formed 
the  greatest  part  of  the  bulging.  On  opening  the  same  I 
found  a  knuckle  of  small  intestine  quite  dark  in  color,  but 
it  had  not  lost  its  hrstre  and  improved  on  washing  with 
warm  salt  solution,  after  a  division  of  the  constriction.  The 
ring  through  which  the  loop  of  gut  passed  was  about  the 
size  of  a  ten  cent  piece.  I  iignted  and  excised  the  sac  and 
omentum,  after  reducing  the  protruded  coil,  and  closed  the 
abdominal  wall  with  three  layers  of  sutures.  The  patient 
made  an  uneventful  recovery. 

Remarks. — Hern  ia  in  the  linea  semilunaris  does 
not  always  penetrate  the  abdominal  wall  and  often 
forms  no  manifest  swelling.  The  majority  of  these 
hernias  are  close  to  the  ptibes  and  are  termed  direct 
hernije.  Protrusion  up  to  or  through  the  skin 
above  the  level  of  a  direct  hernia  is  not  frequent. 

Macready  in  his  treatise  on  ruptures  states  that 
out  of  twenty  -  three  cases  of  hernia  in  the  linea 
semilunaris  only  four  were  observed  above  the  level 
of  the  umbilicus.  Both  sexes  are  afifected  nearlv 
equally,  and  on  the  left  side  more  commonly  than 
on  the  right. 

When,  as  in  my  case,  no  definite  cause  for  its  ex- 
istence can  be  found,  such  as  injury  or  suppuration, 
we  must  conclude  that  it  is  the  result  of  some  con- 
genital defect  or  acquired  paralysis  of  that  region. 

Case  II.— On  August  i.  1908,  I  was  called  by  a  phvsician 
to  see  his  father  in  law.  whom  I  was  told  was  suffering 
from  an  attack  of  appendicitis. 

The  patient,  J.  W.,  was  fifty-five  years  old.  well  preserved 


8o4 


THLRAPEUIICAL  NOTES. 


LNnv  York 
Medical  Journal^ 


and  weighed  220  pounds.  While  attending  his  business  as 
woul  merchant  lour  days  prior  to  the  date  of  my  visit,  he 
experienced  a  severe  pain  iii  the  right  ihac  region,  particu- 
larly in  the  region  oi  the  appendix.  1  he  pain  was  very 
>evere  so  that  he  was  obliged  to  be  in  bed  and  keep  the 
right  leg  drawn  up.  He  vomited  several  times  and  was  con- 
>tipate(J. 

i^revious  History.— For  the  last  ten  years,  he  had  sul- 
fered  from  some  discomfort  in  the  abdomen.  Three  years 
ago  the  discomfort  increased  with  occasional  attacks  of 
pain  m  the  lower  right  quadrant  of  the  abdomen.  He  fol- 
lowed advice  given  to  him  at  the  tirr.e  and  put  on  a  truss 
which  he  wore  ever  since. 

During  one  of  his  uncomfortable  attacks  about  six 
months  ago  he  called  at  my  office,  and  requested  me  to  ex- 
amnie  him  and  tell  him,  whether  or  not  he  had  a  rupture. 
After  a  most  careful  examination  I  failed  to  lind  evidences 
of  an  existing  hernia.  There  was  no  bulging  of  any  part 
of  the  abdomen.  The  external  ring  was  not  abnormally 
enlarged.  His  statement  of  an  impulse  in  the  right  in- 
guinal region  during  coughing  and  sneezing  was  considered 
a  weakened  abdominal  resistance.  He  had  no  other  sensa- 
tions, no  digestive  disturbances.  Regular  movements  of 
the  bowels. 

When  I  saw  him  this  time  he  w  as  in  bed,  complained  of  pam 
in  the  right  iliac  region  and  a  feling  of  fulness  in  the  ab- 
domen. On  inspection  1  found  the  abdomen  very  much 
distended,  innumerable  small  dilated  veins  beneath  the  skin 
gave  the  whole  surface  a  bluish  tinge.  There  were  marked 
tenderness  and  more  or  less  rigidity  of  the  muscles  in  the 
region  of  the  appendix  and  downwards  to  the  pubic  bone. 
I'y  the  rectum  I  felt  a  resisting  mass.  The  liver  dullness 
extended  about  an  inch  and  a  half  below  the  ribs. 

He  had  a  chronic  bronchitis.  I  advised  the  patient  to  go 
to  the  hospital,  but  he  positively  refused.  Two  days  after 
this  I  was  again  called  and  found  that  the  pain  and  tender- 
ness in  the  right  iliac  region  had  increased.  By  this  time  I 
could  feel  a  mass  or  swelling  of  some  kind  about  the  head 
of  the  C£ecum.  The  report  of  his  blood  count  made  in  a 
laboratory  stated  15,200  leucocytes.  Next  day,  August  4, 
igo8,  the  patient  was  admitted  to  the  Jewish  Hospital  of 
Brooklyn,  temperature,  loi"  F. ;  pulse,  88;  respiration,  24. 
1  le  complained  of  pain  in  the  back  and  a  cold  on  the  chest. 
I'rine:  specific  gravity  i.o:?8,  and  a  trace  of  albumin.  Blood 
examination:  Leucocytes,  13,800;  Polymorphonuclear  leu- 
cocytes. 79  per  cent. ;  Large  monophiles,  5  per  cent. ;  small 
monophiles,  15  per  cent  :  eosinophiles,  i  per  cent.  An 
enema  was  gi\en  with  a  good  fluid  result. 

Operation. — The  abdomen  was  opened  by  an  oblique  in- 
cision over  the  appendix  region.  After  the  peritonaeum' 
was  well  opened  there  was  a  thin  transparent  additional 
layer  of  peritonseum  covering  which  proved  to  be  the  caecum, 
the  lower  part  of  the  ileum  and  beginning  of  the  ascend- 
ing colon  all  of  it  well  distended  and  markedly  congested. 
The  entire  mass  was  adherent  to  the  sac.  I  slowly  sep- 
arated all  adhesions  and  lifted  out  the  mass  which  was 
about  the  size  of  a  fatal  head.  The  appendix  was  not 
\  isible.  The  color  of  the  sac  was  grayish  and  of  a  fibrous 
nature.  Certain  regions  showed  grayish  black  points  indi- 
cating old  haemorrhages.  The  outer  surface  of  the  sac  was 
blended  by  adhesions  to  the  posterior  and  lower  wall  of 
the  abdominal  cavity.  The  hernia  with  its  covering  was 
immovable  in  its  fixed  position.  Upon  withdrawing  the 
contained  intestines  the  pouch  tapered  downward  and  in- 
ward to  the  right  external  ring.  I  closed  the  opening  with 
3  catgut  sutures  and  replaced  the  mass  without  doing  any- 
thing. The  abdominal  wall  was  closed  with  separate  lay- 
ers after  inserting  a  cigarette  drain.  The  wound  healed  by 
primary  union.  There  developed,  however,  an  ether  pneu- 
monia five  hours  after  the  operation  and  the  patient  was 
sren  by  Dr.  L.  Louno  and  Dr.  FL  Koplik,  of  New  York, 
during  the  week  and  in  spite  of  every  efTort  to  save  him  he 
died  on  the  eighth  day.  His  temperature  ranged  frorr; 
103  to  105'  P.,  pulse  108  to  130,  respiration  30  to  84  per 
minute.    No  autopsy  was  allowed. 

In  a  limited  survey  of  the  literature  I  have  been 
unable  to  discover  any  report  of  such  a  ca.<;e  and  I 
tlierefnre  concluded  that  this  case  was  of  such  raritv 
as  well  mie^ht  merit  its  being  reported  to  this  so- 
ciety for  discussion. 

700  St.  Marks  Avenue. 


A  Soothing  and  Tonic  Mixture. — Strzyzowski 
prescribes  a  mixture  of  iron  phosphate,  quinine  hy- 
drochloride, and  sodium  bromide  combined  in  the 
following  manner  {Therapeutische  Monatslieftc, 
through    Bulletin    general    de    thcrapciitique  for 


March  23,  1909  )  : 

R    Sodium  bromide,   5ii ; 

Distilled  water,   5x;. 

Syrup  of  bitter  orange  peel,   5v ; 

Alcohol,  5iiss; 

Mix  and  add,  shaking  the  solution  meanwhile : 

Quinine  hydrochloride,   gr.  .xv  ; 

Distilled  water,   5x  ; 

Syrup  of  bitter  orange  peel,   5v ; 

To  this  add  in  turn  a  solution  of: 

Iron  pyrophosphate,   5i ; 

Ammonium  citrate,   5i : 

Distilled  water,   5x  ; 

Dissolve  with  a  slight  degree  of  heat  and  add : 

Syrup  of  bitter  orange  peel,   5x. 


M.  et  Sig. :  One  teaspoonful,  or  half  a  tablespoonful,  to 
be  taken  in  water  before  meals. 

The  author  says  that  this  mixture  is  not  disagree- 
able to  take  and  is  well  tolerated.  In  the  case  of 
nervous,  anaemic  females  it  stimulates  the  appetite 
and  improves  the  general  condition. 

The  Treatment  of  Inguinal  Intertrigo. — In  an 

article  in  which  the  aetiology  of  the  affection  is  fully 
described,  Sabouraud  gives,  in  La  clinique  for  Jan- 
uary 22,  1909.  a  series  of  formulas  for  use  in  the 
treatment  of  this  annoying  complaint.  The  treat- 
ment is  purely  local  and  it  varies  with  the  surface 
indications.  Acute  cases  must  be  treated  like  an 
eczema.  Where  the  surface  is  inflamed  and  the 
epidermis  moist  and  sore  it  is  best  to  apply  a  weak 
solution  of  silver  nitrate,  of  three  and  one  half  per 
cent,  strength,  or,  if  a  stronger  solution  is  indicated, 
one  of  ten  per  cent.,  the  strength  being  determined 


by  the  sensitiveness  of  the  tissues.  A  very  moist^ 
oozing  intertrigo  is  treated  each  day  with  a  lotion 
composed  of : 

^     Silver  nitrate  5i ; 

Distilled  water,   Jin. 

M. 

The  use  of  ichthyol  is  indicated  where  the  oozing 


is  not  excessive  and  the  lesion  is  red.  and  but 
slightly  moist.  A  weak  solution  of  ichthyol  is  used 
as  in  the  following  prescription : 


R    Ichthyol,   5i; 

Resorcin,   gr.  xv; 

Distilled  water,   j'ii- 

M. 


A  stronger  solution  contains  double  the  quantities 
of  ichthyoi  and  resorcin.  These  topical  applications 
are  best  made  with  a  wad  of  absorbent  cotton. 


To  Expel  Thread  Worms.  —  Raudnitz  (Corrc- 
spondcuz-Blatt  fiir  Schu-eiccr  Aerztc)  has  seen  per- 
manent cures  result  from  the  use  of  the  following : 

H    Naphthalene,   gr.  xxiii; 

Thymol,   gr.  Ixxii; 

Santonin  gr.  vi. 

M.  et  divide  in  doses  No.  viii. 


In  addition  to  this  podophyllin  is  prescribed,  and  a 
suppository  containing  one  and  one  half  grain  each 
of  iodoform  and  naphthalene  is  administered. 


April  17,  1909.] 

NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

Philadelphia  Medical  Journal 
and  The  Medical  News. 

A  Weekly  Rcvieiv  of  Medicine. 

Edited  by 
FRANK  P.  FOSTER,  M.  D. 

Associate  Editor, 
John  M.  Swan,  M.  D., 
Philadelphia. 


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NEW  YORK,  SATURDAY,  APRII  17,  1909- 

NATIONAL  HEALTH  LEGISLATION. 

The  report  that  President  Taft  has  requested  Sur- 
geon General-Wyman  to  draw  up  plans  for  the  con- 
sohdation  of  the  various  agencies  having  to  do  with 
puhHc  health  is  exciting  much  favorable  comment. 
We  also  are  much  pleased  and  hope  that  this  work 
will  result  in  something  more  than  a  mere  dream. 
Meanw^hile  it  is  well  to  consider  the  actual  state  of 
affairs  as  relates  to  General  \\'yman's  own  bureau, 
by  far  the  most  important  of  the  present  public 
health  agencies.  There  is  urgent  need  for  more 
physicians  in  the  Public  Health  Service.  An  exam- 
ination was  recently  held  to  fill  vacancies ;  we  are 
informed  that  very  few  candidates  presented  them- 
.-^elves  and  that  not  one  of  them  met  the  require- 
ments. Older  men  are  being  placed  on  waiting 
orders  and  younger  men  are  being  tempted  to  leave 
the  service  for  better  positions  elsewhere.  Thus  the 
corps,  instead  of  growing  to  meet  the  increased 
needs,  is  actually  becoming  smaller. 

It  is  also  reported  that  Dr.  J.  H.  Kastle,  chief  of 
the  Division  of  Chemistry  in  the  Hygienic  Labora- 
tory, has  resigned  to  accept  a  professorship  in  a 
southern  university.  The  enlargement,  a  few  years 
ago,  of  the  Hygienic  Laboratory,  with  the  establish- 
ment of  three  new  divisions — those  of  chemistry, 
zoology,  and  pharmacology — was  one  of  the  first 
signs  that  the  old  jNIanne  Hospital  Service  would 
grow  into  a  Public  Health  Bureau  with  broad  func- 
tions relating  to  internal  health  matters.  Within  a 
few  weeks  after  this  enlargement  the  chief  of  the 


805 

Division  of  Zoology.  Dr  Stiles,  made  the  important 
discovery  of  the  occurrence  of  the  hook  worm  dis- 
ease in  this  country.  The  importance  of  this  dis- 
covery is  being  more  and  more  recognized :  a  south- 
ern physician,  thoroughly  conversant  with  the  facts, 
recently  compared  this  problem  to  that  of  yellow 
fever  in  Cuba  and  on  the  Isthmus  which  the  ]\Iedical 
Corps  of  the  Army  had  to  meet.  The  Division  of 
Pharmacology  has  recently  undertaken  work  in  con- 
nection with  the  United  States  Pharmacopana  which 
promises  to  be  of  great  importance  to  the  entire 
medical  and  pharmaceutical  professions.  Dr.  Kastle, 
the  former  chief  of  the  Division  of  Chemistry,  was 
a  member  of  the  board  which  has  been  issuing  such 
valuable  reports  on  the  occurrence  of  tvphoid  fever 
in  Washington :  he  also  made  important  contribu- 
tions to  the  Report  on  Milk  recently  prepared  by  a 
number  of  government  officials.  It  is  not  an  en- 
couraging sign  to  see  a  man  leave  one  of  the  most 
important  positions  in  the  Hygienic  Laboratory  for 
a  professorship  in  one  of  the  smaller  universities. 

Why  is  it  that,  with  the  increased  interest  being 
taken  in  public  health  matters,  the  present  Public 
Health  Service  is  unable  to  maintain  even  its  pres- 
ent efficiency  as  regards  its  personnel  ?  The  answer 
is  simple ;  it  cannot,  under  present  conditions,  com- 
pete wth  the  sister  medical  services  of  the  army  and 
navy  or  with  the  universities.  The  attractiveness  of 
the  other  medical  services  has  recently  been  greatly 
increased  by  legislation,  and  that  of  university  pro- 
fessorships by  the  Carnegie  Foundation.  Under  the 
latter  a  university  professor  is  assured  of  a  liberal 
pension  in  case  of  accident  or  disability  :  he  may  also 
retire  on  liberal  pay  at  a  given  age  or  after  a  certain 
number  of  years  of  service ;  and  in  case  of  his  death 
his  widow  receives  a  pension.  College  men  estimate 
that  for  a  professor  in  middle  life  these  privileges 
are  equivalent  to  an  increase  of  twelve  hundred  dol- 
lars in  the  annual  salary.  When  the.  position  of  a 
professor  in  even  the  smaller  colleges  is  contrasted 
with  that  of  a  chief  of  a  division  in  the  Hygienic 
Laboratory,  it  is  not  strange  that  the  Public  Health 
Service  cannot  compete  with  the  colleges. 

The  Senate  last  year  passed  a  bill  which  would 
have  placed  the  commissioned  officers  of  the  Public 
Health  Service  on  the  same  basis  as  that  of  the 
Medical  Corps  of  the  Army  and  Navv  and  the  chiefs 
of  divisions  in  the  laboratory  on  that  of  professors 
at  ^^'est  Point.  The  House  committee  reported  a 
bill  containing  somewhat  similar  provisions  with  re- 
gard to  the  commissioned  officers,  but  the  measure 
was  not  allowed  to  come  to  a  vote.  The  Senate  also 
passed  a  bill  enlarging  considerably  the  functions  of 
the  Public  Health  Service;  a  similar  bill  was  re- 
ported to  the  House,  but  was  not  acted  upon. 

In  view  of  the  large  deficit  and  the  financial  un- 
certainties attendant  upon  a  new  taritf ,  there  is  little 


EDITORIAL  ARTICLES. 


8o6 


EDITORIAL  ARTICLES. 


LNeu"  York 
Medical  Jocrxal. 


probability  that  any  comprehensive  public  health  bill 
will  pass  in  the  near  future.  ]\Iean\vhile,  why  should 
not  those  who  profess  interest  in  the  public  health 
unite  their  efforts  and  urge  Congress  to  pass  the  two 
Senate  bills  or  bills  closely  similar  to  them?  Such 
legislation  would  enable  the  present  Public  Health 
Service,  including  the  Hygienic  Laboratory,  to  hold 
its  own  and  to  prevent  further  resignations  of  men 
whose  places  will  be  difficult  to  fill.  Then  later, 
when  conditions  are  more  auspicious  for  expansion, 
the  chief  unit  in  a  larger  organization  will  at  least 
not  be  in  a  disabled  condition. 


THE  STRAUS  MILK  SCHE^IE  AXD  THE 
MEDICAL  PROFESSIOX. 
The  Xew  York  newspapers  for  April  13th  con- 
tained accounts  of  a  fervid  appeal  by  ]Mr.  Nathan 
Straus,  before  the  Aldermanic  Committee  on  Laws 
and  Legislation,  in  favor  of  an  ordinance  requiring 
all  milk  brought  to  the  city  of  New  York  to  be  cer- 
tified as  the  product  of  cows  shown  by  the  tuber- 
culin test  to  be  free  from  tuberculous  disease,  or 
else  to  be  pasteurized.  Mr.  Straus,  as  is  well  known, 
is  an  ardent  advocate  of  the  pasteurization  of  milk. 
He  is  a  worthy  citizen  and  doubtless  sincere  in  his 
expressions  concerning  this  matter,  and  he  is  quite 
entitled  10  lay  his  views  before  the  community.  He 
is  not,  however,  entitled  to  misrepresent  the  medical 
profession. 

"Pasteurization."  said  Mr.  Straus,  according  to 
the  Timcs's  report,  ''is  advocated  by  all  scientific 
men  who  have  studied  the  question  as  the  only 
method  of  securing  safe  milk."  We  make  bold  to 
deny  the  accuracy  of  this  statement.  Medical  men 
generally  concede  the  value  of  the  proper  pasteur- 
ization of  milk  under  certain  circumstances,  but  they 
are  certainly  divided,  to  say  the  least,  as  to  what  it 
is  that  constitutes  those  circumstances.  We  do  not 
all  admit  that  the  tuberculin  test  of  cows,  satisfac- 
tory as  it  may  be  theoretically,  is  in  all  instances 
convincing ;  we  think  there  are  vitiating  defects  in 
the  ])ractical  application  of  the  test. 

But  Mr.  Straus  is  reported  to  have  gone  on  to 
say :  "There  are  paid  advocates  here  to  oppose  me. 
I  am  opposed  by  doctors — the  passage  of  this  ordin- 
ance would  put  them  out  of  business.  But  I  will 
fight  every  man  who  opposes  me,  and  may  the  Lord 
have  mercy  on  him !"  While  we  are  ready  to  make 
due  allowance  for  all  statements  made  under  ex- 
citement, we  prefer  to  take  it  for  granted  that  as  to 
this  particular  Mr.  Straus  has  been  misreported. 
No  laynian  of  this  community  knows  better  than  he 
the  utter  forgetfulness  of  self  interest  with  which 
physicians  take  part  in  the  consideration  of  prob- 
lems relating  to  the  public  health,  and  we  are  sure 
that  .Mr.  Straus  would  admit  his  conviction  to  that 


effect.  The  history  of  medicine  for  much  more 
than  the  last  century  shows  that  physicians  welcome 
rather  than  oppose  all  measures  that  promise  to  ef- 
fect an  improvement  in  the  chances  of  the  general 
population  for  freedom  from  physical  suffering  and 
for  the  postponement  of  deatli.  There  is  nothing  to 
which  the  medical  profession  can  point  with  greater 
pride  than  to  its  unvary  ing  cooperation — and  .gen- 
erally its  leadership — in  all  measures  looking  to  im- 
provement of  the  public  liealth. 


IMMUNIZATION  WITH  LIVING  BACTERIA. 

At  the  Sixth  International  Congress  on  Tubercu- 
losis, held  in  Washington  last  autumn,  one  of  the 
papers  that  attracted  a  great  deal  of  attention  was 
that  by  Dr.  Gerald  B.  Webb  and  Dr.  William  ^\'hit- 
ridge  Williams,  of  Colorado  Springs,  and  Professor 
M.  A.  Barber,  of  the  University  of  Kansas.  The 
authors  described  a  method  of  producing  immunity 
to  tuberculosis  and  other  microbic  infections  by  the 
injection  of  living  bacteria,  beginning  with  one  bac- 
terium and  gradualh'  increasing  the  number  of  or- 
ganisms used  in  the  immunizing  injections.  We 
gave  an  abstract  of  the  paper  in  our  columns  de- 
voted to  the  report  of  the  meeting  (Nezv  York  Med- 
ical Journal,  November  14.  1908).  We  take  this 
opportunity,  however,  of  calling  the  attention  of  our 
readers  to  the  publication  of  the  complete  paper, 
which  appeared  in  the  Journal  for  Medical  Research 
for  Januarw  The  contribution  opens  with  a  resume 
of  the  literature  on  the  production  of  artificial  active 
immunity.  Then  the  experimental  technique  is  de- 
scribed, although  the  method  of  isolating  one  micro- 
organism is  not  described,  reference  being  made  to 
the  description  already  published  by  Professor  Bar- 
ber in  the  Kansas  University  Science  Bulletin. 
March,  1907.  Professor  Koch,  when  he  first  heard 
of  the  method,  said  that  the  isolation  of  one  bac-  • 
terium  and  its  injection  could  not  possibly  be  ac- 
complished. The  authors  of  the  paper,  however, 
demonstrated  their  technique  to  Professor  Koch, 
and  he  then  said  that  iie  was  convinced  that  one 
bacterium  could  be  picked  out  of  an  emulsion  and 
injected  into  an  animal. 

The  paper  under  discussion  gives  the  results  of 
the  inoculation  of  five  tuberculous  men  with  living 
tubercle  bacilli.  The  first  patient  received  one  tu- 
bercle bacillus ;  sixty  days  later  there  was  no  mark 
at  the  site  of  the  inoculation.  The  second  patient 
received  one  tubercle  bacillus,  and  six  days  later  he 
received  five  tubercle  bacilli ;  sixty  days  later  there 
was  no  mark  at  the  site  of  the  inoculations.  The 
third  patient  had  extensive  and  advanced  pulmonary 
tuberculous  di.'^ease.  He  received  one  tubercle  ba- 
cillus, and  at  intervals  of  from  four  to  seven  days 
he  received  bacilli  gradually  increased  in  number 


April  17,  1909.1 


EDITORIAL  ARTICLES. 


807 


from  five  to  500.  Following  the  ninth  dose,  his 
temperature  fell  to  normal  and  remained  there.  At 
the  time  the  paper  was  written  he  was  up  and  about, 
and  walked  to  the  laboratory  to  receive  his  inocula- 
tions. There  had  never  been  the  least  reaction. 
Tubercle  bacilli  were  still  present  in  the  patient's 
sputum.  The  fourth  case  was  one  of  acute  pulmon- 
ar\'  tuberculous  disease.  The  first  inoculation  was 
made  with  fifty  tubercle  bacilli,  and  subsequent  in- 
oculations were  made  at  intervals  of  from  four  to 
seven  days  with  bacilli  gradually  increased  in  num- 
ber to  500.  After  the  sixth  inoculation  all  fever  dis- 
appeared, the  cough  was  much  improved,  weight 
was  being  gained,  and  in  seven  weeks  the  patient 
was  able  to  do  light  work.  He  was  subsequently 
discharged,  cured,  after  twelve  further  inoculations 
with  500  bacilli.  The  fifth  case  was  one  of  extensive 
pulmonary  tuberculous  disease  of  ten  years'  dura- 
tion. The  inoculations  were  begun  with  one  tuber- 
cle bacillus,  and  were  continued  at  intervals  of  from 
foin-  to  seven  days  as  above  indicated.  There  was 
no  demonstrable  improvement  in  this  patient,  al- 
though he  felt  generally  better.  There  were  no  local 
or  general  reactions,  and  there  was  no  lesion  of  any 
kind  at  the  site  of  the  inoculation.  This  method  is 
a  most  ingenious  one,  and  its  adoption  was  most 
coiirageous.  It  is  not  a  method  to  be  adopted  by 
every  one.  however.  Only  the  most  painstaking  and 
conscientious  operators  should  use  it.  Living  micro- 
organisms are  dangerous  things  to  play  with.  The 
recent  experience  of  Mr.  Hafifkine  in  India,  with  a 
careless  worker  using  the  plague  prophylactic,  is 
an  instance  in  point. 


:measles  axd  disixfectiox. 

Several  of  our  French  exchanges  have  given  more 
or  less  prominence  in  their  recent  issues  to  a  vigor- 
ous denunciation  of  the  sanitary  officials  of  Paris 
for  some  of  the  features  of  their  disinfection  service 
as  applied  to  households  in  which  cases  of  communi- 
cable disease  have  occurred.  The  Abuses  of  Disin- 
fection in  Paris  is  the  title  (translated)  of  a  paper 
on  the  subject  by  Dr.  J-  Comby,  published  in  the 
Bulletins  et  memoircs  de  la  Socicte  mcdicalc  dcs 
hopitaux  de  Paris  for  March  25th.  It  was  appar- 
entlv  under  the  influence  of  emotion  that  'SI.  Comby 
resolved  to  bring  the  matter  to  the  societv's  atten- 
tion, for  he  tells  us  that  he  was  not  a  little  moved 
by  reading  the  following  letter  from  a  lady : 

I  am  ready  to  hope  that  the  year  will  pass  peacefully  for 
us,  for  it  has  begun  somewhat  ill ;  I  have  had  a  good  deal 
of  annoyance  with  this  measles ;  it  does  not  pass  off  so 
dimply  in  Paris  as  in  the  country :  I  find  that  disinfection 
!5  a  good  thing,  but  it  is  very  upsetting.  They  have  come 
iwice  to  sluice  the  walls  and  the  floor,  and  it  has  been  a 
real  rough-housing  for  me ;  there  is  nothing  but  the  crock- 


ery that  has  not  been  sprinkled.  The  children  and  I  my- 
self have  had  to  pull  up  our  skirts  to  take  the  spray.  Since 
then  two  inspectors  have  been  here  to  ascertain  if  the 
work  had  been  well  done.  Then,  too,  they  took  away  the 
bedclothes,  blankets  and  sheets,  that  had  served  for  the 
little  girl.  The  physicians  of  the  prefecture  came  several 
times  to  observe  if  it  was  really  the  measles  that  the  little 
girl  had.  I  do  not  understand  this  at  all.  for  we  had  a 
physician  of  the  neighborhood  who  came  every  other  day 
(Dr.  M.).  I  wondered  every  day  whom  I  should  have  to 
open  the  door  to  next.  At  last  it  is  over,  but  I  tremble  at 
the  thought  that  it  may  possibly  be  repeated,  etc. 

M.  Comby  denies  emphatically  that  disinfection 
is  of  any  tise  in  cases  of  measles,  and  he  eloquently 
portrays  its  annoying  features  as  carried  out  by  the 
sanitary  officials  of  Paris.  He  reminds  tis  that,  so 
long  ago  as  in  1882.  Beclere  showed  conclusively 
that  measles  was  contagious  only  dtiring  the  periods 
of  invasion  and  eruption,  that  is  to  say.  for  eight 
days  at  the  most.  After  this,  he  declares,  one  may 
sleep  with  a  desquamating  patient  without  running 
the  risk  of  contracting  the  disease.  It  is  absolutely 
certain,  he  continues,  that  the  pathogenic  organism 
of  measles  has  only  an  ephemeral  existence  outside 
the  human  system.  He  cites  Grancher.  Sevestre, 
and  others  as  having  demonstrated  this.  The  con- 
tagion, he  says,  is  propagated  directly  from  child  to 
child  at  short  range  by  the  projection  of  virulent 
secretions  from  the  throat  or  the  nose.  He  quotes 
Fiessinger  as  saying  sententiousl\-  that  the  danger 
is  in  the  throat  or  the  nasal  passage?,  but  they  dis- 
infect the  furniture ! 

]M.  Comby  was  well  stipported  in  the  meeting  at 
which  his  paper  was  read,  and  not  a  voice  appears 
to  have  been  raised  in  opposition  to  his  contention. 
He  is  opposed  to  continuing  measles  on  the  list  of 
diseases  to  be  reported  under  comptilsion.  though  of 
course  he  does  not  object  to  its  being  reported  for 
statistical  purposes.  We  believe  that  there  is  mtich 
tn;th  in  what  M.  Comby  said,  and  we  feel  stire  that 
the  disinfection  of  Paris  apartments  in  which 
measles  has  occurred  is  carried  otit  with  more  re- 
gard for  official  authority  than  for  well  conceived 
propliylaxis.  Let  us  hope  that  Parisian  methods  in 
this  matter  will  never  be  tolerated  in  an  American' 
communitv. 


A  XOVEL  OX  A  PROPRIETARY  MEDICIXE. 

Tono-Bnngay  is  the  title  of  a  novel  by  H.  G. 
Wells  (Xew  York:  Dtiffield  &  Co..  1909)  which 
will  be  of  great  interest  to  the  physician.  It  is  the 
story  of  an  apothecary  who  makes  a  large  fortune 
by  the  sale  of  a  proprietary  medicine,  although  he 
later  loses  by  reason  of  his  own  dishonesty,  not 
only  his  acquired  millions,  but  also  his  good  name, 
and  dies  a  fugitive  from  justice,  a  poor  man  in  a 
foreign  country.    The  novel  is  well  built  up.  being 


8o8 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


written  in  the  form  of  a  narrative  by  the  promoter's 
nephew,  who  acts  as  his  assistant  and  who  tells  us 
in  a  monologue  of  his  life's  experience.  The  book 
is  thus  written  in  the  speech  of  the  day.  The  author 
is  a  good  narrator,  a  vivid  caiiscur.  and  fascinates 
the  reader  from  beginnmg  to  end,  although  there  is 
really  no  bcgiiniing  or  end — the  story  begins  and 
ends  abruptly:  "We  are  all  things  that  make  and 
pass  striving  upon  a  hidden  mission  out  to  the  open 
sea." 


Slttoi  Items. 


Changes  of  Address. — Dr.  Louis  Fischer,  to  162  West 
Eiglity-s<.  Ncnth  Street,  New  York. 

Dr.  Joliii  Stroiher  Gaines,  to  the  Sherman  Square  Hotel, 
Seventy-first  Street  and  Broadway.  New  York. 

Dr.  Maximilian  Lewson,  to  S5  \\  e?t  Ninth  Street,  New 
York. 

Dr.  Willard  H.  Kinney,  to  1941  North  1  welflh  Street, 
Philadelphia. 

Dr.  Sidney  .A.  Chalfant.  to  the  Westinghouse  Building, 
Penn  Avcnr.e  and  Nintli  Street.  Philadelphia. 

The  Editorship  of  The  Lancet. — Dr.  Squire  Sprigge, 
who  has  been  chief  of  the  editorial  staff  of  The  Lancet. 
London,  for  fifteen  years,  has  heen  formally  appointed 
editor. 

The  Public  School  and  Its  Influence  upon  the  Health 
of  Pupils  was  the  title  of  a  pai)cr  read  by  Dr.  A.  W. 
.\rinstrong,  at  a  recent  meeting  of  ihe  Society  of  Physi- 
cians of  C;.!iandaigua.  \.  Y. 

A  Reception  to  Dr.  Joseph  S.  Neff,  of  Philadelphia, 
Director  of  Public  Health  and  Charities,  was  given  at  the 
Hotel  Bellcvue-Stratford  on  Friday  evening.  April  i6th,  by 
the  Medical  Club  of  Philadelphia. 

The  Society  of  Medical  Jurisprudence,  New  York, 
held  its  22i't  regular  meeting  in  the  New  York  .Academy 
f>f  Medicine  on  Monday  evening.  April  12th.  Dr.  Heinrich 
Stern  read  the  paper  of  the  evening  on  The  Decay  of  Na- 
tions. 

Saratoga  Springs  to  be  Purchased  by  the  State. — The 

Brackett  bill  providing  for  the  appointment  of  a  commis- 
sion to  purchase  the  springs  at  Saratoga  for  a  State  reser- 
vation ha?  been  passed  by  the  Senate.  The  bill  carries  an 
appropriation  of  $600,000. 

The  Medical  Society  of  the  State  of  California  will 
hold  its  thirt} -liintli  annual  meeting  at  tiie  Hotel  \'endome, 
San  Jose,  on  .April  20th,  21  st,  and  22d.  -A  splendid  pro- 
gramme of  papers  has  been  prepared,  and  the  usual  com- 
mercial exhibit  will  be  held. 

The  Preparation  of  Cotton  Fibre  for  Surgical  Pur- 
poses was  ihe  subject  of  lecture  delivered  i)y  F.  B.  Kilmer, 
Ph.  D.,  on  Monday  evening,  April  12th.  in  the  Chemistry 
Lecture  Hall  of  the  Medico-Chirurgical  College,  Phila- 
delphia. Lantern  slides  and  appropriate  apparatus  were 
u-cfl  to  illustrate  the  address. 

Protest  against  Site  Selected  for  the  Long  Island 
State  Hospital. — .A  petition  with  one  thousand  signa- 
tures has  been  presented  to  the  Senate  finance  committee 
in  opposition  to  the  bill  appropriating  $175,000  for  the  site 
of  the  Long  Island  State  Hospital  for  the  Insane  at  Green- 
vale.  The  matter  has  been  referred  to  Governor  Hughes, 
who  has  approved  of  the  site  selected. 

The  Need  of  Additional  Red  Cross  Nurses.— At  a 
meeting  of  the  New  York  State  Branch  of  the  .American 
Red  Crocs  Society,  which  was  held  in  New  York  on 
Tuesday  aftcrnf>on,  .April  13th.  an  appeal  was  made  for 
more  nurses  to  take  up  Red  Cross  Work.  Major  Charles 
Lynch,  of  the  medical  corps  of  the  L'niled  States  .Army, 
delivered  the  principal  address  on  The  Relation  of  Red 
Cross  Nurses  to  the  .Army,  in  which  he  spoke  of  the  neces- 
sity for  preparation,  so  as  to  be  in  readiness  for  any 
emergency  requiring  trained  nurses,  whetiier  a  war  or  a 
■calamity. 


The  Frederick  Douglass  Memorial  Hospital,  Phila- 
delphia, which  is  for  the  exclusive  use  of  the  colored  popu- 
lation of  the  city,  has  been  completed,  and  will  be  dedi- 
cated with  suitable  ceremonies  on  April  22d.  A  training 
school  for  nurses  will  be  conducted  in  connection  with  the 
hospital,  which  is  well  equipped  and  thoroughly  up  to  date 
in  every  particular. 

In  Memory  of  Dr.  Phineas  Sanborn  Conner.— A  spe- 
cial meeting  of  the  Cincinnati  .Academy  of  Medicine_  wa~ 
held  on  April  ist,  to  do  honor  to  the  memory  of  Dr.  Phinea- 
Sanborn  Connor,  who  died  in  that  city  recently.  There 
was  a  very  large  attendance,  and  many  addresses  were  de- 
livered, in  which  tribute  was  paid  to  the  sterling  qualities 
of  Dr.  Conner  by  his  colleagues. 

Cholera  in  St.  Petersburg. — No  new  cases  of  cholera 
were  reported  in  St.  Petersburg  on  April  2d,  for  the  first 
time  since  September  8,  1908.  when  it  was  officially  admit- 
ted that  the  disease  was  present  in  the  city.  Since  the 
outbreak  of  the  epidemic  10,283  cases  were  reported,  with 
4,002  death.  On  .April  2d  there  were  fifty-one  cholera 
patients  in  the  hospitals. 

In  Memory  of  the  Late  Dr.  Senn. — At  a  meeting  ot 
the  Senn  Club,  held  in  Chicago  on  March  26th,  it  was  de- 
cided to  undertake  a  systematic  campaign  of  education, 
among  both  physicians  and  the  general  public,  as  to  the 
value  of  the  great  services  rendered  to  medicine  by  the 
late  Dr.  Senn.  Dr.  .Alexander  Hugh  Ferguson  was  unani- 
mously elected  oresident  of  the  club,  and  Dr.  Arthur  Mac- 
Neal  was  reelected  secretary. 

The  Medical  Society  of  the  County  of  Ontario,  N.  Y., 
held  its  quarterly  nieeting  at  Clifton  Springs  on  April  13th. 
The  programme  included  the  following  papers:  The  Func- 
tion of  the  Great  Omentum,  by  Dr.  H.  J.  Knickerbockei , 
of  Geneva ;  Ontario  County's  Tuberculosis  Problem,  b} 
Dr.  A.  L.  Beahan,  of  Canandaigua ;  Some  Observations  011 
Postoperative  Treatment  of  Surgical  Cases,  by  Dr.  J.  H. 
Jewett,  of  Canandaigua. 

The  Sixteenth  International  Medical  Congress. — .An 
nouncemcnt  is  made  by  the  secretary  general  of  the  con- 
gress that  all  communications  which  are  to  be  presented  at 
this  congress  should  be  sent  in  on  or  before  May  15th.  but 
in  case  authors  have  been  unable  to  prepare  their  papers 
prior  to  this  date,  they  may  present  them  at  the  congress, 
and  such  communications  will  be  published  in  the  second 
volume  of  the  transactions  of  the  congress. 

The  Oliver  Wendell  Holmes  Centenary. — The  one 
hundredth  anniversary  of  the  liirth  of  Dr.  Oliver  Wendell 
Holmes  will  be  celebrated  on  .April  27th  at  Harvard  Uni- 
versity, where  he  held  the  chair  of  anatomy  and  physiology 
from  1847  to  1882.  Dr.  Charles  W.  Eliot,  former  president 
of  Harvard,  will  preside,  and  addresses  will  be  delivered 
by  Dr.  Edward  Waldo  Emerson,  Dr.  David  Williams  Chee- 
ver.  Colonel  Thomas  Wentworth  Higginson.  and  the  Rev. 
Samuel  M.  Crothcrs. 

Pott's  Disease  was  the  subject  discussed  at  the  .April 
T3th  meeting  of  the  Philadelphia  P?ediatric  Society.  Dr. 
J.  K.  Young  presented  two  patients :  one  showing  the  de- 
formity present  in  Pott's  disease  without  treatment,  and 
the  other  showing  the  absence  of  deformity  in  Pott's  dis- 
ease as  the  result  of  treatment.  Dr.  J.  M.  Spellissy  demon- 
strated a  new  bed  frame.  The  paper  of  the  evening  was 
read  by  Dr.  Compton  Riley,  of  Baltimore,  on  the  Early 
Diagnosis  and  Treatment  of  Pott's  Disease. 

A  Request  for  Papers  Pertaining  to  Internal  Medi- 
cine.— I'lbstcin's  annual  report  of  internal  medicine  is 
now  being  edited  by  Dr.  Werner  Klinkhardt.  of  Leipsic. 
The  first  volume  (1901)  has  been  completed,  and  volume 
II,  representing  the  years  1902  and  1903,  will  be  ready  this 
spring.  The  volume  for  1908  will  follow  and  will  be  suc- 
ceeded atinually  by  new  reports.  Authors  are  asked  to 
send  reprints  of  papers  pertaining  to  internal  medicine  to 
Oberiirzt  Dr.  Schreiber.  i  Beaumontstrasse,  Magdeburg. 
Germany. 

American  Association  of  Pathologists  and  Bacteriol- 
ogists.— The  ninth  annual  meeting  ol"  this  ;issoeiation 
was  held  in  Boston  on  .April  8th.  glh,  and  loth.  .About 
three  hundred  members  were  in  attendance,  and  many 
papers  wei^e  read  by  eminent  scientists  from  various  parts 
of  the  United  States.  Ofiicers  for  the  ensuing  vear  were 
elected  as  follows:  President.  Dr.  Frank  B.  Mallorv.  of 
Boston:  vice  president.  Dr.  P.  H.  Hiss,  of  New  York: 
secretary.  Dr.  H.  C.  Ernst,  of  Boston:  treasurer.  Dr.  H.  U. 
Williams,  of  Buffalo. 


April  17,  1909.] 


NEIVS  ITEMS. 


809 


The  Buffalo  Academy  of  Medicine. — At  a  meeting  of 
the  Section  m  ?>Iedicine,  which  was  held  on  April  13th,  the 
following  programme  was  presented:  The  report  of  two 
cases  of  brain  tumor,  with  the  exhibition  of  specimens,  by 
Dr.  Henry  P.  Frost,  assistant  superintendent,  Buffalo  State 
Hospital :'  the  report  of  three  cases  of  pyloric  stenosis  in 
infants,  by  Dr.  Irving  M.  Snow;  a  paper  on  Pneumoperi- 
cardium with  report  of  a  case,  by  Dr.  Joseph  Burke ;  a 
paper  entitled  Medical  Work  in  Paris  Hospitals,  by  Dr. 
A.  L.  Benedict. 

Women  Nurses  in  the  Navy. — The  next  draft  of 
female  nurses  in  the  Naval  Service  will  be  sent  to  the  hos- 
pital at  Norfolk,  and  they  will  probably  be  taken  from  the 
second  class  that  recently  passed  the  examination  and 
received  appointments.  Women  nurses  have  now  been 
furnished  to  the  hospitals  in  New  York,  Annapolis,  and 
Washington,  and  after  the  hospitals  at  Norfolk  and  Mare 
Island  have  been  supplied  with  nurses  there  will  still  be  a 
sufficient  number  available  to  furnish  the  hospitals  at  Yoko- 
hama and  Canacao. 

The  Health  of  Pittsburgh. — During  the  week  ending 
April  3,  1909,  the  following  cases  of  transmissible  diseases 
were  reported  to  the  Bureau  of  Health :  Chickenpox,  7 
cases,  o  deaths;  typhoid  fever,  13  cases,  o  deaths;  scarlet 
fever,  21  cases.  4  deaths;  diphtheria,  5  cases,  i  deaths; 
measles,  23  cases,  o  deaths ;  whooping  cough.  16  cases,  2 
■deaths;  pulmonary  tuberculosis,  41  cases,  11  deaths.  The 
total  deaths  for  the  week  numbered  151,  in  an  esti- 
mated population  of  565,000,  corresponding  to  an  annual 
death  rate  of  13.89  in  a  thousand  population. 

City  Nurses  to  Visit  the  Homes  of  Newborn  Babies. 
— On  April  15th  the  Bureau  of  Child  Hygiene  of  the  De- 
partment of  Health  of  New  York  City  inaugurated  its 
plan  of  sending  a  nurse,  on  receipt  of  a  birth  certificate,  to 
the  home  of  each  newborn  baby.  There  are  one  hundred 
and  forty  nurses  on  the  staff  at  present,  and  the  number 
will  be  increased  as  soon  as  possible.  For  a  time  prece- 
dence will  be  given  to  the  homes  where  the  birth  certifi- 
cates are  sent  in  by  midwives,  which  constitute  about  45  per 
cent,  of  the  total  number,  but  later  on  the  cases  sent  in  by 
physician'^  will  be  attended  to. 

The  International  Congress  of  Hygiene  and  Demo- 
graphy, whicli  held  its  fourteenth  session  in  Berlin  in 
1907,  will  hold  its  next  meeting  in  Washington  in  1910. 
The  members  of  the  executive  committee  are  as  follows : 
Dr.  S.  N.  D.  North,  director  of  the  Bureau  of  the  Census  : 
Dr.  John  S.  Billings.  U.  S.  N..  retired,  of  New  York:  Dr. 
Henry  G.  Bever,  U.  S.  N. :  Colonel  Walter  D.  McGraw, 
U.  S.  A. :  Dr.  William  H.  Welch,  of  Johns  Hopkins  Uni- 
versity;  Surgeon  General  Walter  Wyman,  Public  Health 
and  Marine  Hospital  Service :  Dr.  Hermann  Biggs,  of  the 
Department  of  Health  of  the  City  of  New  York :  and  Dr. 
Abraham  Tacobi,  of  New  York. 

Tulane  Medical  Department  Extension  Lectures. — ■ 
Dr.  F.  Creighton  Weliman,  of  Washington,  D.  C,  who  was 
for  many  years  Health  Officer  of  Portuguese  East  Africa, 
delivered  a  series  of  lectures  on  tropical  medicine  and  nat- 
ural history  in  the  Hutchinson  Alemorial,  during  the  week 
of  April  I2th,  which  formed  a  part  of  the  extension  course 
of  lectures  arranged  by  the  Medical  Department  of  Tulane 
University.  There  were  six  lectures  in  the  series,  on  the 
following  subjects:  Insects  and  Human  Diseases:  Diseases 
of  West  Africa:  Why  the  Physician  in  Temperate  Cli- 
mates should  Study  Tropical  Diseases:  General  Biological 
Conditions  in  \\>st  Africa;  Anthropological  Notes  ]\Iade 
in  W^est  Africa. 

A  Central  Purchasing  Agency  for  New  York  Hos- 
pitals.— Forty-five  privately  endowed  hospitals  in  New 
York  are  considering  the  advisability  of  establishing  a 
joint  central  purchasing  agency,  based  on  the  plan  of  the 
purchasing  department  of  the  Harriman  railroads.  Tlie 
plan  was  suggested  at  a  meeting  of  the  Hospital  Confer- 
ence, held  in  the  New  York  Academy  of  ^Medicine  on  Fri- 
d'^y  evening,  hy  Mr.  W.  V.  S.  Thorne,  treasurer  of  the 
Presbyterian  Hospital,  who  was  at  one  time  purchasing 
agent  for  the  Southern  Pacific  and  the  Union  Pacific  lines. 
The  plan  was  received  with  favor  and  a  resolution  was 
passed  recommending  its  adoption.  It  does  not  include  the 
city  hospitals,  as  they  have  their  own  means  of  purchasing 
supplies,  but  in  the  forty-five  hospitals  included  in  the  plan, 
it  is  thought  that  over  $150,000  each  year  will  be  saved  in 
the  purchasing  of  supplies. 


The  Medical  Association  of  the  Greater  City  of  New 
York  will  hold  a  stated  meeting  on  Monday  evening. 
April  19th,  at  8:30  o'clock,  in  Du  Bois  Hall,  New  York 
Academy  of  Medicine,  The  following  papers  have  been 
promised  for  this  meeting;  Cerebral  Affections  of  Nasal 
Origin,  by  Dr.  Wolff  Freudenthal ;  Some  Technical  Diffi- 
culties in  the  Treatment  of  Hypospadias,  by  Dr.  Carl  Beck ; 
Ten  Consecutive  Cases  Illustrating  the  New  Point  in  Ap- 
pendix Diagnosis,  by  Dr.  Robert  T.  Morris.  Among  those 
who  will  take  part  in  the  discussion  are  Dr.  Robert  C. 
Myles,  Dr.  Lewis  A.  Coffin,  Dr.  W.  Sohier  Bryant,  Dr. 
Samuel  Lloyd,  Dr.  Pollen  Cabot,  and  Dr.  Edward  W. 
Peterson.  A  collation  will  be  served  at  the  close  of  the 
meeting. 

Medical  Ethics  and  the  Physician's  Income  was  the 

subject  discussed  at  the  April  14th  meeting  of  the  Central 
Branch  of  the  Philadelphia  County  Medical  Society.  The 
following  papers  were  read :  Why  Train  the  Undergradu- 
ate in  the  Financial  Side  of  Practice?  by  Dr.  I.  N.  Snively; 
A  Course  in  Ethics  and  Business  Methods  Required  for 
Undergraduates,  by  Dr.  Henry  Leffmann ;  Ethical  and 
Business  Training  of  the  Prospective  Physician  at  the 
Medico-Chirurgical  College,  by  Dr.  James  M.  Anders;  In- 
struction in  Medical  Ethics  and  Income  at  the  University 
of  Pennsylvania,  by  Dr.  Charles  H.  Frazier ;  A  Practical 
Course  in  Professional  Success  given  in  Past  Years  to 
Senior  Students,  by  Dr.  G.  iV'l.  Christine:  The  Possibility 
of  and  Suggestions  for  a  Mutual  Business  Bureau  for 
Practitioners,  by  Dr.  A.  B.  Hirsch. 
Infectious  Diseases  in  New  York: 

We  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folUnaing  statement  of  new 
cases  and  deaths  reported  for  the  two  zveeks  ending  April 
10,  iQog: 

,  .\pril  3  V  I  April  10  , 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    478         212         683  196 

Diphtheria    320  32         309  49 

-Measles   1,077  34         953  32 

Scarlet  fever    373  19         353  23 

Smallpox    4 

Varicella    213  ..  119 

Typhoid  fever    26  5  15 

Whooping  cough    62  8  42  6 

Cerebrospinal  meningitis    10  5  8  8 

Total   2.563         315       2,482  314 

Charitable  Bequests. — By  the  will  of  Mr.  Joseph  A. 
Wright,  charitable  institutions  in  Worcester,  Mass.,  will 
receive  about  $100,000,  those  receiving  the  largest  gifts 
being  the  Home  for  Aged  Women,  the  Children's  Friend 
Society,  the  Associated  Qiarities  and  the  Memorial  Hos- 
pital, which,  it  is  expected,  will  receive  $15,000  each. 

By  the  will  of  W.  P.  Henszey  the  following  Philadelphia 
institutions  receive  $10,000  each :  Hospital  of  the  Good 
Shepherd,  Children's  Hotnocopathic  Hospital,  Homoeopathic 
Hospital  of  Philadelphia,  Episcopal  Hospital,  University 
Hospital,  Philadelphia  Orthopaedic  Hospital  and  Infirmary, 
Presbyterian  Hospital,  Women's  Hospital,  Home  for  Aged 
Couples,  Friends'  Home  for  Children,  Friends'  Charity 
Fuel  Association,  Sheltering  Arms  for  Infants,  Society  for 
the  Prevention  of  Cruelty  to  Animals,  Medico-Chirurgical 
Hospital,  Society  to  Protect  Children  from  Cruelty,  Cath- 
cart  Home  for  Incurables,  Wills  Ej-e  Hospital,  and  White 
Haven  Sanitarium. 

Personal. — Major  Charles  F.  Mason,  of  the  Medical 
Corps  of  the  United  States  Army,  will  sail  on  May  3d  for 
Panama,  where  he  will  go  on  duty  with  the  Canal  Commis- 
sion. Lieutenant  Jefferson  R.  Kean  will  succeed  him  in 
the  sanitary  division  of  the  Surgeon  General's  office. 

Dr.  J.  H.  Kastle,  of  the  Hygienic  Laboratory.  Washing- 
ton, D._  C,  lias  been  appointed  professor  of  chemistry  in 
the  University  of  Virginia. 

M.  Perrot,  of  the  Observatory  at  Meudon,  has  been  ap- 
pointed professor  cf  physics  in  the  Paris  Polytechnic 
School,  to  succeed  M.  Becquerel. 

Dr.  Edward  Guion,  vice-president  of  the  New  Jersey 
Sanitary  Association,  has  been  appointed  health  officer  of 
.Atlantic  City,  to  succeed  Dr.  M.  L.  Somers,  recently  de- 
ceased. 

Dr.  Hastings  H.  Hart,  superintendent  for  many  years  of 
the  Illinois  Children's  Home  and  Aid  Society,  Chicago,  has 
been  appointed  head  of  the  children's  department  of  the 
Russell  Sage  Foundation,  New  York,  and  will  begin  his 
new  duties  on  Mav  ist. 


8io 


NEWS  ITEMS. 


[New  York 
Medical  Iolrnal. 


The  Twelfth  Annual  Meeting  of  the  Medical  Library 
Association  will  be  held  in  Washington  and  Baltimore 
on  May  I2th  and  13th.  The  first  day's  sessions  will  be 
held  in  W  ashington,  in  the  Surgeon  General's  Office,  and 
on  May  13th  the  members  of  the  association  will  go  to  Bal- 
timore to  be  present  at  the  dedication  of  the  new  library 
building  of  the  Medical  and  Chirurgical  Faculty  of  Mary- 
land, when  Dr.  Osier  will  deliver  the  oration.  The  offi- 
cers of  the  association  are :  f^resident.  Dr.  George  Dock,  of 
New  Orleans ;  vice-president.  Dr.  John  H.  Musser,  of  Phil- 
adelphia; secretary,  Ada  Bunnell,  of  tlie  State  Library.  Al- 
bany ;  treasurer,  Dr.  George  D.  Hersev,  of  Providence, 

R.  i. 

Civil  Service  Examinations. — .^mong  the  positions 
for  which  the  Xew  York  State  Civil  Service  Commission 
will  hold  examinations  on  May  i,  1909,  arc  the  following  : 
Assistant  bacteriologist  to  the  New  Vork  State  Department 
of  Health,  with  a  salary  of  $1,500  a  year;  assistant  physi- 
cian to  the  Rome  State  Custodial  Asylum,  with  a  salary  of 
$600  and  maintenance :  and  inspector  to  the  State  Board  of 
Charities,  salary  $900  to  $1,200.  The  last  day  for  filing  ap- 
plications for  these  positions  is  April  24th.  Full  informa- 
tion and  application  form  for  any  of  these  examinations 
may  be  obtained  from  the  State  Civil  Service  Commission, 
Albany,  and  the  request  is  made  that  postal  cards  be  used 
in  applying  for  forms. 

The  Mortality  of  Chicago. — During  the  week  ending 
March  27,  iqoy,  there  were  reported  to  the  Department  of 
Health  of  the  City  of  Chicago  722  deaths  from  all  causes, 
as  compared  with  711  for  the  preceding  week  and  660  for 
the  corresponding  period  in  1908.  The  annual  death  rate 
in  a  thousand  population  was  16.92.  The  principal  causes 
of  death  were :  Diphtheria.  21  deaths ;  scarlet  fever,  8 
deaths;  measles,  i  death:  whooping  cough,  r  death;  influ- 
enza. 12  deaths:  typhoid  fever,  7  deaths;  diarrhceal  dis- 
eases. 41  deaths,  of  which  33  were  under  two  years  of  age ; 
pneumonia.  140  deaths:  pulmonary  tuberculosis,  89  deaths; 
other  forms  of  tuberculosis.  12  deaths:  cancer.  29  deaths; 
nervous  diseases,  21  deaths;  heart  diseases.  73  deaths:  apo- 
plexy, 19  deaths;  Bright's  disease,  57  deaths;  violence.  55 
deaths,  of  which  15  were  suicides;  all  other  causes,  136 
deaths. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing April  3.  1909.  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  of  Philadel- 
phia: Typhoid  fever.  35  cases.  10  deaths;  scarlet  fever,  46 
cases,  2  deaths;  chickenpox,  56  cases,  o  deaths;  diphtheria, 
Si  cases,  17  deaths ;  cerebrospinal  meningitis,  i  case,  o 
deaths ;  measles,  204  cases,  10  deaths ;  whooping  cough.  24 
cases,  5  deaths;  tuberculosis  of  the  lungs.  127  cases,  59 
deaths ;  pneumonia.  68  cases,  60  deaths  ;  erysipelas,  15  cases, 
3  deaths;  puerperal  fever,  i  case,  3  deaths;  mumps.  23 
cases,  o  deaths ;  tetanus,  i  case,  i  death  ;  trachoma,  i  case, 
o  deaths.  The  following  deaths  were  reported  from  other 
transmissible  diseases:  Tuberculosis,  other  than  tubercu- 
losis of  the  lungs,  8  deaths ;  diarrhoea  and  enteritis,  under 
two  years  of  age.  13  deaths;  malarial  fever,  i  death.  The 
total  deaths  numbered  523  in  an  estimated  population  of 
.'.565-569<  corresponding  to  an  annual  death  rate  of  17.31 
in  a  thousand  population.  The  total  infant  mortality  was 
108,  81  under  one  year  of  age,  27  between  one  and  two 
years  of  age.  There  were  40  still  births,  25  males  and  15 
females.    The  total  precipitation  was  0.66  inch. 

The  New  Pennsylvania  Medical  Bill. — By  a  vote  of 
thirty-one  to  one  the  Senate  on  .\pril  8th  passed  the  Herbst 
single  hoard  medical  bill,  with  certain  amendments.  .\s  the 
bill  now  stands  it  provides  for  the  creation  of  a  State 
Board  of  Medical  Examiners,  to  be  composed  of  nine  mem- 
bers, one  of  whom  shall  be  the  State  Superintendent  of 
Public  Instruction,  the  other  eight  members  to  he  appointed 
by  the  Governor,  three  to  be  chosen  from  among  the  mem- 
bers of  the  Medical  Society  of  Pennsylvania:  three  from 
the  Homoeopathic  Medical  Society  of'  Pennsylvania,  and 
two  from  the  Eclectic  Society  of  Pennsylvania.  To  be 
eligible  to  become  a  member  of  the  board  a  physician  must 
be  at  least  thirty-five  years  of  age  and  have  been  engaged 
in  active  practice  in  the  State  for  ten  years.  No  teacher 
or  instructor  in  :'ny  medical  school  shall  be  eligible  for 
appointment.  The  l>oard  is  to  be  empowered  to  revoke 
licenses  or  to  suspend  the  right  to  practise  medicine  pend- 
ing the  invc^tigatiiin  f)f  any  physician.  The  several  schools 
of  medicine  unanimously  agreed  to  the  insertion  of  a 
clause  in  thf  bill  providing  for  the  requirement  of  higher 
stanflartls  of  preliminary  education  in  ajiplicants  for  licenses 
to  practise. 


Vital  Statistics  of  New  York.-  During  tlie  week  end- 
ing April  3,  1909,  there  were  reported  to  the  Department  of 
Health  ot  the  City  of  New  'iork  1,710  deaths  from  all 
causes,  in  an  estimated  population  of  4,564.792,  correspond- 
ing to  an  annual  death  rate  of  19.53,  as  against  a  death 
rate  of  17. 00  for  the  corresponding  period  of  1908.  The 
death  rate  for  each  of  the  five  boroughs  was  as  follows : 
Manhattan,  20.74;  I'le  Bronx,  22.19;  Brooklyn,  17.02; 
Queens.  19.81 :  Richmond.  20.74.  There  were  212  deaths 
from  pulmonary  tuberculosis,  31  from  other  forms  of  tuber- 
culosis. 37  from  acute  bronchitis.  379  from  pneumonia,  16 
from  diphtheria,  and  32  from  diphtheria  and  croup.  There 
were  148  still  births.  Nine  hundred  and  twelve  marriages 
and  2,436  births  were  reported  during  the  week. 
Scientific   Society   Meetings   in   Philadelphia  for  the 

Week  Ending  April  24,  1909: 
MoxD.w,    April    jytli. — Medical    Jurisprudence  Society; 

Medical  Society  of  the  Woman's  Hospital. 
TuESD.w,  April  20th. — Dermatoiogical   Society;  Academy 
of    Natural    Sciences ;    North    Branch,  Philadelphia 
County  ^ledical  Society. 
Wednesday.  April  21st. — Philadelphia  County  Medical  So- 
ciety   (business    meeting,    open    to    members   only;  ,. 
Section  in  Otology  and  Laryngology,  College  of  Phy- 
sicians; Franklin  Institute. 
THfRSD.w,   April   22d. — Pathological    Society;  American 
Entomological  Society  and  the  Entomological  Section 
of  the  Academy  of  Natural  Sciences;  Section  Meeting, 
Franklin  Institute;  Philadelphia  Botanical  Club;  Leb- 
anon Hospital  Medical  Society. 
Fkid.\v,    April   2sd. — Philadelphia    Neurological  Society; 
Northern  Medical  As-^ociation. 
The  American  Gastroenterological  Association  will 
hold   its  twelfth  annvial  meeting  at  tlie  Hotel  Windsor. 
Atlantic  City,  N.  J.,  on  June  7th  and  8th.    The  preliminary 
programme,  which  has  just  been  issued,  includes  a  "sym- 
posium" on  gastroenterostomy,  and  among  those  who  will 
pre.=ent  papers  on  the  subject  are  Dr.  W.  B.  Cannon,  ci 
Boston ;  Dr.  F.  T.  Murphy,  of  Boston ;  Dr.  H.  W.  Bett- 
mann,  of  Cincinnati :  Dr.  F.  W.  White,  of  Boston ;  Dr. 
J.  M.  T.  Finney,  of  Baltimore:  Dr.  Ludwig  Kast.  of  New 
York ;  Dr.  Morris  Manges,  of  New  York :  Dr.  Jesse  S. 
Myer,  of  St.  Louis :  Dr.  H.  Adler,  of  Baltimore :  Dr.  A.  L. 
Benedict,  01  Buftalo,  and  Dr.  J.  C.  Johnson,  of  Atlanta. 
Other  papers  on  the  programme  are :  The  Development  of 
Gastroenterology  in  America,  by  Dr.  Julius  Friedenwald. 
of  Baltimore:  Duodenal  Ulcers,  by  Dr.  Max  Einhorn,  o; 
New  York;  Disturbances  of  the  Chemical  Coordinations 
of  the  Organism,  by  Dr.  John  C.  Hemmeter.  or  Baltimore  : 
and  Patho.genesis  of  Gastric  Tetany,  by  Dr.  W.  G.  Mac- 
Callum.  of  Baltimore. 

Society  Meetings  for  the  Coming  Week: 

.AIoxD.w.  April  /(;//;.— New  York  .Academy  of  Medicine 
(Section  in  Ophthalmology);  Medical  .Association  of 
the  Greater  City  of  New  York;  Hartford.  Conn.,  Med- 
ical Society. 

TuESD.w.  April  20th.—y.t\\  York  Academy  of  Medicine 
(Section  in  Medicine);  Buffalo  Academy  of  Medicine 
(Section  in  Pathology");  Triprofessional  Medical  S 
ciety  of  New  York;  Medical  Socictv  of  the  Countv  of 
Kings,  N.  Y. ;  Binghamton,  N.  Y.,  Academy  of  Medi- 
cine; Clinical  Society  of  the  Elizabeth.  N.  J..  General 
Hospital ;  Syracuse.  N.  Y.,  .-Vcademy  of  Medicine ;  O.q- 
densburg  N.  Y.,  Medical  Association. 

Wedxesd.vv.  April  2jst.—\e\\  York  Acadeiny  of  Medicine 
(Section  in  Genitourinary  Diseases')  ;  New  York  So- 
ciety of  Dermatolog^■  and  Genitourinary  Surgery;  Wo- 
rnan's  ^ledical  Association  of  New  'V'ork  City  (New 
York  Academy  of  Medicine);  Medicolegal  Societ v. 
New  York;  New  Jersey  .■\cademv  of  Medicine  (Tei- 
sey  City);  Buffalo  Medical  Club;  New  Haven,  Conn., 
Medical  Association ;  New  York  Society  of  Internal 
IMedicine;  Northwestern  Medical  and  Surgical  Societv 
of  New  York. 

Thursd.w.  April  .'.'rf.— New  York  Academy  of  Medicine 
(Sect  ion  in  Obstetrics  and  Gynrecologv )  ;  Brooklyn 
Pathological  Society :  Hospital  Graduates'  Club.  New 
York :  New  York  Celtic  Soeietv. 

¥R\l^^\.  April  23d.—'Si:w  York  Clinical  Society:  New  York 
Society  of  German  Physicians;  Acadeniv  of  Patho- 
logical Science.  New  York. 

Satikd.vv.  April  West  End  Medical  Society.  New 

York;  New  York  Medical  and  Surgical  Society;  Har- 
vard Medical  Society.  New  York;  Lenox  Medical  and 
Surgical  Society,  New  York. 


April  17,  1909] 


I'lTH  Ul-  CURREXl  LITERATURE. 


8n 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL 

Apnl  8,  lyog. 

1.  'I'he  Examination  of  the  Fjeces  for  the  Study  of  the 

Functional  Condition  of  the  Alimentary  Tract  111 
Clinical  Work,  By  Henry  F.  Hewes. 

2.  The  Municipal  Hospital   for  Advanced  Consumptives 

in  Boston,     By  Edwix  A.  Locke  and  Simon  F.  Cox. 
J.    A  Cursory  Review  of  Surgical  Methods  for  the  Ex- 
tirpation of  Haemorrlioids, 

By  T.  Chittenden  Hill. 

I.  Examination  of  the  Faeces.  —  Hewes  re 
marks  that  there  are  two  general  methods  of  ex- 
amination of  the  special  test  diet  fsces  for  deter- 
mining the  condition  of  the  function  of  the  body  for 
the  digestion  and  absorption  of  food  products ( i  ) 
The  chemical  analysis  for  the  determination  of  the 
content  in  various  food  products,  proteid.  carbohy- 
drates, fat,  neutral  fat. 'soap,  etc.;  (2)  the  macro- 
scopical  and  microscopical  study  of  the  fsces  for  the 
observation  of  the  visible  food  elements  present, 
muscle  fibre,  starch,  and  fat  in  its  various  forms — 
neutral  fat,  soap,  fatty  acid.  Of  these  two  methods 
the  first  is  so  difficult  of  accomplishment,  its  em- 
ployment necessitating  a  great  expenditure  of  labor 
and  a  considerable  knowledge  of  chemical  technique, 
that  its  general  use  in  the  routine  practice  of  clinical 
medicine  is  impracticable.  We  are,  therefore, 
forced  in  our  investigation  to  depend,  as  a  rule, 
upon  the  macroscopical  and  microscopical  study  of 
the  visible  and  recognizable  food  elements.  The  prin- 
ciple of  this  method  consists  in  the  comparison  of 
the  character  of  the  food  findings  of  our  test  case 
upon  a  definite-  diet  with  that  of  the  fjeces  of  normal 
individuals  upon  a  similar  diet.  This  method  of  de- 
termining the  extent  of  the  utilization  of  fat  in  the 
alimentary  tract  by  the  character  of  the  microscop- 
ical fat  finding  is  a  reliable  and  useful  method  to 
this  extent,  that  wherever  the  microscopical  fat  find- 
ing is  marked,  the  character  of  this  finding  is  a  re- 
liable index  of  the  extent  of  fat  utilization,  the  quan- 
tity and  quality  of  the  fat  remains  varying  in  ac- 
cordance with  the  total  quantity  of  fat  present.  The 
student  is,  therefore,  justified  in  concluding  wher- 
ever bv  this  method  of  observation  the  microscopical 
fat  finding  shows  a  definite  variation  from  the  nor- 
mal finding  that  an  abnormal  condition  of  fat  utili- 
zation is  present.'  The  presence  of  a  normal  micro- 
scopical fat  finding  does  not.  however,  necessarilx 
indicate  the  existence  of  a  normal  utilization  of  fat. 
This  method  does  not,  therefore,  serve  as  a  reliable 
means  of  determining  the  normalitv  or  abnornialitv 
of  the  function  of  fat  utilization  for  all  cases.  It 
does  serve,  however,  for  the  determination  of  the 
existence  of  an  abnormal  condition  of  function  in 
many  cases.  And  as  according  to  the  experience  of 
the  author  an  abnormal  microscopical  fat  findin<i  is 
present  in  a  majority  of  the  cases  where  the  total 
quantity  of  fat  exceeds  the  normal,  the  method  is  of 
much  service  in  the  study  of  the  condition  of  fat 
utilization  in  practical  work.  In  addition  to  the 
knowledge  of  the  total  ouantity  of  fat  in  the  tpst  diet 
Lneces,  whether  or  not  this  quantitv  is  normal  or  in- 
creased, a  knowledge  of  the  proportions  of  the  vari- 
ous fat  siibstinces  which  make  up  this  total  fat  con- 


tent, neutral  fat,  fatty  acids,  and  soaps,  ma}-  be  of 
value  in  connection  with  the  study  of  any  case  with 
disturbance  of  function  for  fat  utlization. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

April  10,  igoQ. 

1.  The  Suppression  of  a  Cholera  Epidemic  in  Manila, 

By  Allan  McLaughlin. 

2.  Syphilis  of  the  Stomach,  By  Arthur  Curtis. 

3.  Partial  Myxoedema,       By  John  Benjamin  Nichols. 

4.  The  Diagnostic  Value  of  Ureteral  Catheterization, 

By  Simon  L.  Elsner. 

5.  Systematized  Technique  of  Suprapubic  Prostatectomy, 

By  G.  Kolischer. 

6.  Ignorance  or  Malpractice?    Financial  and  Climatic  Con- 

ditions in  the   Treatment  of  Tuberculosis, 

By  W.  Warner  VVatkins. 

7.  Spelling  as  an  Index  to  the  Preparation  of  the  Medical 

Student,  By  George  Dock. 

2.  Syphilis  of  the  Stomach. — Curtis  states  that 
syphilis  of  the  stomach  is  of  considerable  patho- 
logical interest  because  it  is  rarely  diagnosticated. 
Althougli  the  affection  is  infrequent,  the  value  of 
recognizing  its  presence  is  enhanced  for  clinicians 
by  the  fact  that  serious  complications,  amenable  to 
treatment,  have  arisen  in  two  out  of  sixteen  cases 
thus  far  reported.  A  summary  of  the  literature  with 
synopsis  ot  cases  to  date  shows  four  important  fac- 
tors which  play  a  part  in  the  anatomical  diagnosis : 
I.  Location  of  changes.  The  seat  of  primary  in- 
volvement is,  as  a  rule,  the  submucosa,  the  gum- 
matous tissue  invading  other  coats  secondarily.  2. 
Miliary  gummata.  sometimes  with  giant  cells  of  the 
Langhans  type.  3.  Spirocluctcc  pal  lid  cc.  These  are 
not  to  be  depended  on,  according  to  the  views  of 
both  Koch  and  of  Schmorl.  They  are  often  not 
present  in  undoubted  syphilis  ;  on  the  other  hand, 
Koch,  using  the  Levaditi  stain,  found,  in  cases  of 
undoubted  carcinomata  of  the  lung,  organisms  of 
the  typical  appearance  of  Spirochccta  pallida.  4. 
Peculiar  vascular  changes  of  high  grade,  resulting 
in  partial  occlusion  or  obliteration  of  vessels.  Cel- 
lular accumulations  are  found  about  the  vessels. 
The  latter  may  become  thickened  from  cell  in- 
crease, thus  beginning  from  without,  or  stxbendo- 
thelial  change  may  be  the  prominent  feature.  The 
process  tends  to  spare  many  vessels  entirely,  while 
others  are  thickened  to  the  point  of  occlusion.  The 
author  describes  a  case  which  he  observed.  The 
patient  was  operated  upon  and  gastrectotny  was 
performed,  the  resected  portion  extending  from  the 
middle  of  the  stomach  almost  to  the  pylorus.  In 
the  stomach,  anteriorly,  not  far  from  the  pylorus, 
and  posteriorly  near  the  head  of  the  pancreas,  were 
tough,  fiat,  tumorlike  thickenings  of  the  wall.  P'ol- 
lowing  the  operation  the  patient  went  on  to  une- 
ventful recovery.  Tuberculin  skin  and  conjunctival 
tests,  which  were  made  during  convalescence  be- 
cause of  the  untisual  appearance  of  the  excised 
tissue,  failed  to  give  the  tuberculin  reaction.  Was- 
sermann's  test  was  also  unsatisfactory. 

3.  Partial  Myxoedema. — Xichols  remarks  that 
the  specific  treatment  of  partial  myxoedema  in  all 
its  forms  consists  in  the  administration,  by  mouth, 
of  preparations  of  the  thyreoid  gland.  The  daily 
dose  is  from  i  to  12  grains  of  the  desiccated  gland 
substance  (from  sheep),  equivalent  to  five  times  as 
much  of  the  fresh  thyreoid.  The  administration  of 
thyreoid  substance  reqtiires  caution  and  close  ob- 


8l2 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


servation  until  the  proper  dosage  for  each  patient 
is  determined  by  individual  trial.  Given  in  exces- 
sive doses  thyreoid  causes  unpleasant  and  even  dan- 
gerous effects,  those  of  hyperthyreoidism,  such  as 
undue  acceleration  of  the  pulse,  great  prostration, 
headaches,  sweating,  restlessness.  Special  care  is 
necessary  in  giving  the  drug  to  patients  with  arte- 
rial or  cardiac  disease,  as  death  has  occurred  dur- 
ing treatment  in  such  cases.  At  first  the  treatment 
is  vigorously  pushed,  but  after  the  symptoms  sub- 
side only  sufficient  thyreoid  need  be  given  to  main- 
tain the  patient  in  the  best  condition.  The  treat- 
ment is  highly  efficient,  and  there  is  a  prompt  and 
marked  subsidence  of  the  abnormal  manifestations. 
The  excessive  weight  is  rapidly  reduced,  the 
strength  is  increased,  the  nutrition  of  the  skin  and 
hair  improves,  the  pains,  constipation,  and  dyspnoea 
diminish,  mental  and  physical  development  is  ad- 
vanced. Complete  recovery,  or  at  least  great  and 
highly  gratifying  improvement,  can  be  confidently 
expected,  though  in  some  cases  absolute  restoration 
to  normal  is  not  attainable,  and  vestiges  of  the 
trouble  may  persistently  continue. 

6.  Ignorance  or  Malpractice? — Watkins  ob- 
jects to  the  custom  of  physicians  to  send  their  tu- 
berculous patients  far  away  from  home  without  tak- 
ing into  consideration  the  financial  means  of  the 
sufferers.  The  patients,  Dr.  Watkins  speaks  about, 
are  those  w-ho  have  reached  an  advanced  stage  of 
phthisis  and  in  whom  the  disease  is  making  steady 
progress,  insidious  or  rapid  as  the  case  may  be ; 
whose  financial  means  are  small  and  who  can  not, 
under  the  most  favorable  surroundings,  provide 
themselves  with  more  than  the  necessities  of  life  or 
who  perhaps  are  the  actual  wards  of  charity.  The 
custom  is  that,  in  t-he  face  of  all  known  teachings 
concerning  the  disease  and  in  the  face  of  common 
sense  and  humanity,  physicians  will  persist  in  send- 
ing this  class  of  patients  away  from  home,  family, 
and  friends  to  die  in  a  strange  land,  by  holding  out 
to  them  the  fatuous  hope  of  recovery  in  a  "change 
of  climate."  Phcenix  is  one  of  the  best  known  health 
resorts  in  the  country  for  pulmonary  tuberculosis. 
Patients  go  there  and  have  to  be  taken  from  the 
train  by  strangers,  by  representatives  of  charity,  or 
by  the  civil  authorities.  The  point  in  the  doctor's 
protest  is  this :  That  reputable  physicians  in  every 
section  of  the  country  are  responsible ;  they  have 
urged  the  patient  to  leave  his  home  where  he  could 
at  least  have  died  comfortably ;  have  placed  him  on 
the  train  at  his  home  town  with  no  means  save  his 
railroad  fare,  and  with  the  delusive  advice  that  he 
could  doubtless  find  some  light  work  at  the  destina- 
tion at  which  he  could  make  a  living,  and  the  climate 
would  do  the  rest.  The  effort  to  find  that  work  al- 
most invariably  adds  the  finishing  touches  to  that 
physician's  culpability.  Each  winter  the  Associated 
Charities  of  Phoenix  is  swamped  with  such  a  class 
'of  patients  and  the  county  hospital  is  filled  with 
them,  and  potter's  field  is  a  veritable  monument  to 
the  guilt  of  all  practitioners  who  are  guilty  of  such 
malpractice.  Our  author  concludes :  "The  eastern 
physician  will  naturally  ask  what  is  to  be  done  for 
liis  patients  in  advanced  stages  if  he  can  not  order 
a  change  of  climate.  Each  community  must  solve 
tliis  fjuestion  for  itself,  and  many  of  them  arc  doing 


so,  but  the  duty  of  the  physician  in  charge  of  such 
a  case  is  plain.  He  should  carefully  acquaint  him- 
self with  the  stage  and  probable  course  of  the  dis- 
ease, and  in  prognosticating  the  outcome  he  should 
never  lose  sight  of  the  social  and  financial  condition 
of  the  patient ;  before  sending  a  patient  into  a  new 
community  he  should  know  how  he  is  to  be  received 
there ;  under  what  social  conditions  he  is  to  live ; 
how  the  requirements  as  regards  rest  and  food 
can  be  and  will  be  carried  out ;  and  if  all  these 
are  not  in  the  highest  degree  favorable  a  change 
of  climate  —  which  is  a  minor  consideration — 
should  never  be  recommended.  The  doctor 
should  honestly,  firmly,  and  courageously  meet 
the  conditions  as  they  exist.  If  these  are  hope- 
less he  should  gently  ease  his  patient's  pathway  into 
the  grave  and  not  deliberately  shirk  his  duty  by 
shipping  the  patient  across  the  continent  to  die  away 
from  the  solicitous  care  of  friends  and  loving  minis- 
trations of  a  family." 

7.  Spelling  of  Medical  Students. — Dock  speaks 
of  the  preliminary  education  of  medical  students. 
He  finds  that  a  large  proportion  of  students  is  not 
properly  educated  for  the  study  of  medicine.  The 
causes  of  this  condition,  he  thinks,  are  chiefly  the 
following :  ( i )  Imperfect  training  -in  the  precolle- 
giate  or  preuniversity  years ;  ( 2  j  imperfect  scru- 
tiny of  candidates  for  admission  to  the  medical 
school;  (3)  looseness  with  reference  to  scholarly 
fitness  all  through  the  medical  course.  It  is  not 
enough  to  dismiss  the  first  reason,  poor  primary  and 
secondary  education,  as  is  often  done.  If  all  uni- 
versity departments  insisted  on  better  preparation, 
the  standards  in  the  lower  schools  would  rapidly  be 
raised. 

MEDICAL  RECORD. 

April  10,  J909. 

1.  The  Cammidge  Reaction  in  Diseases  of  the  Pancreas, 

By  Francis  P.  Kinnicutt. 

2.  The  Rational  Treatment  of  Tabes  Dorsalis  in  Relation 

to  Its  Pathogenesis,  By  Tom  A.  Williams. 

3.  The  Three  Ureteral  Isthmuses,     By  Bvron  Robinson. 

4.  The    Proper    Teaching   of    Therapeutics    in  Medical 

Schools,  By  George  F.  Butlek. 

5.  Diagnosis  and  Treatment  of  Diabetes  Mellitus, 

By  John  Dunham. 

6.  The  History  of  Tuberculosis, 

By  George  Frederick  Laidlaw. 

7.  A  Tray  for  Holding  Instruments  during  Surgical  Op- 

erations, By  B.  F.  Jen  NESS. 

8.  A  Forceps  for  the  Removal  of  Tags,  etc.,  on  the  Pos- 

terior Pharyngeal  Wall  after  ,\denoid  Operations, 

By  .\lfred  VN'ienek. 
g.    An  Improved  Hysterectomy  Clamp, 

By  Howard  Coutcher. 

I.  The  Cammidge  Reaction  in  Diseases  of  the 
Pancreas. — Kinnicutt  has  applied  tlie  Cammidge 
pancreatic  test  to  thirty-eight  individuals,  four  of 
whom  were  supposed  to  be  healthy,  thirty-four  were 
cases  of  suspected  pancreatic  disease,  cholelithiasis, 
cholecystitis,  and  diabetes.  As  is  well  known.  Cam- 
midge states  that  in  inflammatory  lesions  of  the  pan- 
creas a  substance  is  excreted  by  the  kidneys  which, 
on  hydrolysis,  yields  a  body  giving  the  reactions  of 
a  pentose,  and  that  such  a  substance  is,  as  a  rule, 
not  found  in  lesions  of  other  organs.  The  pentosa- 
zone  precipitate  which  he  obtains  by  a  somewhat 
elaborate,  though  easily  mastered,  technique,  con- 


April  17,  1 909. J 


PITH  OF  CURRENT  LITERATURE. 


813 


sists  of  golden  yellow  crystals,  exceedingly  fine  and 
hairlike  in  form,  arranged  in  sheaves  and  rosettes. 
Thev  are  to  be  distinguished  from  glucosazone  crys- 
tals by  their  appearance  under  the  microscope,  their 
ready  solubility  in  thirty-three  per  cent,  sulphuric 
acid  and  their  melting  point,  about  160°  C.  To  them 
Cammidge  has  given  the  name  of  "pancreatic  reac- 
tion crystals,'"  and  he  believes  that  their  presence  in 
the  urine,  i.e.,  a  positive  "pancreatic  reaction,"  is 
"strongly  suggestive  of  inflammatory  disease  of  the 
pancreas."  After  reviewing  the  literature,  Kinni- 
cutt  remarks  that  to  the  present  date,  the  studies 
of  the  uriye  both  in  clinical  and  experimental  pan- 
creatic disease,  indicate  that,  while  the  "pancreatic 
reaction"  is  not  pathognomonic  of,  it  is  strongly 
suggestive  of  inflammatory  and  destructive  lesions 
of  the  pancreas,  and  is  of  much  assistance  in  diag- 
nosis in  association  with  other  clinical  evidence  of 
disease  of  this  organ. 

2.  Rational  Treatment  of  Tabes  Dorsalis. — 
Williams  states  that  "as  the  syphilitic  nature  of  the 
tabetic  process  is  beyond  question  therapeutists  are 
again  inquiring  why  mercury  failed  in  the  past,  and 
whether  it  cannot  succeed  in  the  present  and  fu- 
ture." Williams  believes  that  mercury  is  the  speci- 
fic drug,  but  it  should  be  inserted  directly  into  the 
body  in  known  quantities  so  that  we  can  commen- 
surately  antidote  the  injury  of  syphilis  with  the  min- 
imum of  injury  to  the  patient's  tissues.  Hence,  it 
is  only  by  this  method  that  it  is  fair  to  judge  the 
specific  therapy  of  tabes  and  paresis ;  and  recent  re- 
sults have  justified  the  hopefulness  of  the  scientific 
pharmacologist  with  respect  to  this,  for  numerous 
cases  and  cures  are  being  reported.  But  an  early 
diagnosis  is  absolutely  imperative,  and  the  Wasser- 
mann  reaction  will  be  of  great  help,  then  the  direct 
introduction  of  mercury  will  remove  from  the  radi- 
cular nerves  the  infiltrations  and  exudates  caused  by 
lues.  If  intravention  is  early,  absorption  occurs 
without  cicatrix:  and  the  lost  conductivity  of  the 
nerve  fibres,  which  always  precedes  destruction,  is 
quickly  restored.  The  invasion  of  other  regions  is 
forestalled,  and  the  general  health  of  the  patient  is 
improved.  The  accessory  treatment  consists  in  hy- 
giene and  diet. 

3.  Three  Ureteral  Isthmuses. — Robinson  re- 
marks that  there  exist  practically  three  constant 
ureteral  isthmuses,  which  are  due  to  the  erect  atti- 
tude and  consequent  flexion,  angulation  of  the  ure- 
ters by  adjacent  structures  (distal  renal  pole,  iliac 
vessels,  and  bladder  wall — sphincter).  They  consti- 
tute the  most  important  ureteral  landmarks  (a  land- 
mark is  a  point  for  consideration,  anatomical,  phy- 
siological, pathological),  and  are  points  where  spe- 
cial ureteral  pathology  prevails,  e.g..  ureteral  flexion, 
torsion,  hydroureter,  obstruction  by  calculus,  ure- 
teral stricture,  ureteritis,  catarrh,  hypertrophy  of 
ureteral  mucosa,  tuberculosis,  malignancv,  obstruc- 
tion by  debris,  or  blood  clot.  Because  of  the  pres- 
ence of  an  abundant  amount  of  connective  tissue  and 
lack  of  muscular  tissue,  they  dilate  less  in  proportion 
than  the  other  ureteral  segments  in  ureteral  expan- 
sion. The  ureteral  isthmuses  are  practically  ureteral 
sphincters,  and  are  significant  in  ureteral  pathology 
being  the  greatest  of  ureteral  landmarks ;  they  are 
therefore  significant  in  ureteral  diagnosis.    In  ure- 


teritis the  ureteral  isthmuses  represent  the  tender 
points  of  the  ureter  on  pressure.  They  are  also  the 
points  where  the  introduced  catheter  is  obstructed. 
]n  the  operation  for  removing  a  calculus  which  is 
lodged  at  any  one  of  the  ureteral  isthmuses,  the 
stone  should  be  pushed  forward  until  it  enters  one 
of  the  ureteral  dilatations  where  the  lumen  is  suffi- 
ciently wide  to  allow  for  surgical  manipulation  and 
for  coaptation. 

BRITISH  MEDICAL  JOURNAL. 

March  27,  igoQ. 

1.  An  Address  of  the  Natural  History  of  Ulcerative  Coli- 

tis and  Its  Bearing  on  Treatment, 

B}'  Herbert  P.  H.\wkins. 

2.  A  Case  of  Amoebic  Djsentery  with  Abscess  of  the 

Liver  in  a  Patient  who  had  never  been  out  of  Eng- 
land. By  Robert  S.^undby. 

3.  Bilharziosis  of  Women  and  Girls  in  Egypt  in  the  Light 

of  the  "Skin  Infection  Theory,"  By  A.  Looss. 

The  Science  Committee  of  the  British  Medical  Asso- 
ciation.   Report  CXII : 

4.  Observations  on  the  Physiology  of  the  Female  Genital 

Organs,  By  W.  Bl.\ir  Bell. 

The  Therapeutic  Committee  of  the  British  Medical 
Association  : 

5.  Report   on   the  Local   Anaesthetics   Recommended  as 

Substitutes  for  Cocaine,  By  C.  N.  Le  Brocq. 

I.  The  Natural  History  of  Ulcerative  Colitis 
and  Its  Bearing  on  Treatment. — Hawkins  says 
that  the  proof  value  of  serum  treatment  in  tropical 
bacillary  dysentery  makes  it  important  that  the  ac- 
tive bacterial  agents  in  ulcerative  colitis  should  be 
known.  It  is  the  very  type  of  disease  which  should 
yield  to  serum  or  vaccine  treatment.  The  site  of 
infection  is  localized,  there  is  no  general  infection, 
and  the  symptoms  are  mainly  local  and  exhaustive, 
though  partly  toxsemic.  If  it  is  not  cured  in  an 
early  stage,  nothing  remains  as  a  rule  but  such  crude 
measures  as  colostomy  and  ileosigmoidostomy.  The 
necessity  for  bacterial  treatment  holds  good,  whether 
the  primary  organism  concerned  should  ultimately 
prove  to  belong  to  the  dysenteric,  paratyphoid,  coli, 
or  pyogenic  group.  Nothing  can  be  done  until  the 
natural  history  of  the  disease  is  understood.  The 
pedigree  of  the  disease  can  be  traced  back  for  nearly 
300  years.  It  was  then  called  dysentery,  or  blondy 
flux.  In  the  seventeenth  century  epidemics  were 
common  in  England.  There  were  sometimes  4,000 
deaths  a  }ear  from  bloody  flux.  At  the  pres- 
ent time  small  outbreaks  still  occur  in  asylums. 
Thev  still  occur  also  on  a  small  scale  in  the 
open,  and  the  evidence  is  almost  conclusive 
that  both  in  these  small  epidemics  and  in  asvlum 
outbreaks  the  disease  is  spread  by  direct  transference 
of  infected  material  from  person  to  person.  This 
disease  comes  before  us  in  varying  guise,  as  a  short, 
severe  illness,  and  as  a  long  illness  continuous  or 
intermittent.  To  these  three  fonns  must  be  added 
a  simple  nonnecrotic  diarrhciea.  often  the  precursor 
of  a  more  severe  attack.  The  diiYerence  between 
these  various  forms  is  not  a  matter  of  symptoms  and 
physical  signs.  These  are  constant.  The  difference 
rests  mainly  on  the  duration  of  illness  and  partly  on 
the  mode  of  onset,  and  in  both  these  respects  this 
disease  presents  greater  variation  than  does  bacillary 
dysentery.  Between  the  temporary  diarrhoea  with 
or  without  bleeding,  the  short  fatal  illness,  and  the 
long  recurring  illness,  clinical  evidence  shows  no 


8i4 


PITH  OF  CURRENT  LITERATURE. 


M  EPICAL  Journal. 


distinguishing  feature  except  the  mere  duration. 
They  cannot  be  separated  into  two  or  more  groups. 
There  is  a  perfect  gradation  from  the  illness  of 
thirty  days  to  the  long  illness  of  many  years,  and 
there  is  no  break.  At  any  time  in  the  long  illness 
there  may  supervene  an  acute  attack  which  may 
rapidly  prove  fatal.  The  early  attacks  in  the  long 
cases  are  often  severe  enough  in  themselves.  Thev 
differ  in  no  particular  from  the  short  single  attack 
which  proves  fatal  except  in  their  lesser  severity, 
and  in  any  one  of  them  with  a  little  less  luck  the  pa- 
tient might  have  died,  and  so  have  converted  a  po- 
tential long  illness  into  an  actual  short  fatal  attack. 
The  author  has  a  series  of  eighty-five  cases,  of  these 
eighty-five  patients  forty-one  died.  Of  the  forty- 
four  survivors,  many  improved,  but  only  eight  of 
them  were  cured.  These  figures,  being  drawn  from 
hospital  and  consulting  work,  naturally  only  in- 
clude the  severe  and  chronic  cases.  In  all  the  fatal 
cases  the  colon  was  examined  after  death,  and  in 
all  these,  except  one,  the  colon  was  extensively  ul- 
cerated, such  ulceration  not  being  due  to  typhoid 
fever,  tuberculosis,  or  other  recognized  cause.  Un- 
til specific  treatment  can  be  provided  no  dogmatic 
rules  of  treatment  can  be  produced. 

3.  Bilharziosis  of  Women  and  Girls  in  Egypt 
in  the  Light  of  the  "Skin  Infection  Theory." — 
Looss  remarks  that  any  theory  about  the  mode  of 
infection  with  bilharziosis,  in  order  to  be  at  all  ac- 
ceptable, must  (a)  account  for  the  passages  of  the 
miracidium  both  from  man  to  water  and  from  water 
back  to  man;  it  must  (b)  duly  consider  both  the 
habits  of  the  host  and  the  biological  peculiarities 
of  the  parasite.  The. theory  of  the  infection  taking 
place  by  the  mouth  (along  with  food  and  drink) 
must  be  refuted,  because  it  is  irreconcilable  (a  )  with 
certain  biological  peculiarities  of  the  miracidium. 
{h)  with  the  general  distribution  of  the  disease 
among  the  population  of  Egypt.  The  theory  of  in- 
fection by  the  miracidium  entering  the  urethra  or 
the  anus  is  (a)  utterly  improbable  for  general  par- 
asitological  reasons;  {b)  in  contradiction  with  a 
number  of  biological  and  anatomical  pathological 
facts  (for  exam.plc,  the  incapability  on  the  part  of 
the  miracidium  to  resist  the  action  of  acids,  even  if 
very  diluted ;  the  part  played  in  the  infection  by  the 
liver,  etc.).  The  theory  of  infection  by  the  skin 
is  in  accordance  with  all  the  facts  thus  far  known 
(a)  of  the  biology  of  the  parasite,  {b)  of  the  dis- 
tribution of  the  disease  among  the  population  (na- 
tive and  foreign,  town  or  rural)  of  Egypt.  It  shows 
(r)  how  the  chief  suflfercrs — the  children  in  town, 
the  adult  males  in  the  country — live  under  condi- 
tions which,  from  the  ejiidemiological  point  of  view, 
are  essentially  the  same,  and  give  the  miracidia  id) 
tlu  opportunity  of  passing,  within  the  .short  time  of 
their  life,  from  man  to  water  and  from  water  back 
to  man. 

5.  Report  on  Local  Anaesthetics  Recommend- 
ed as  Substitutes  for  Cocaine. — Le  Rrocq  states 
that  the  points  to  which  special  attention  has  been 
paid  arc  those  laid  down  l)y  Professor  Rraim  ns  es- 
sential in  estimating  a  local  an.Tstlietic  action.  They 
are:  r.  A  lower  degree  f)f  toxicity  than  cocaine  in 
proportion  to  its  local  an;csthetic  power.  2.  Suflfi- 
cient  solubilitv  in  water.      The  solution  should  be 


stable,  that  is,  they  sliould  keep  without  deteriora- 
tion and  be  capable  of  sterilization  by  boiling.  3. 
.Absence  of  any  sign  of  irritation.  There  should 
be  no  injury  to  the  tissues:  the  local  ansesthetic 
should  be  easily  absorbed  without  causing  any  after 
effects,  such  as  hyperaemia.  inflammation,  infiltra- 
tions, or  necroses.  4.  Compatibility  with  adrenalin. 
5.  Rapid  penetration  of  the  mucous  membrane,  and 
suitability  for  medullary  an;esthesia.  In  determin- 
mg  which  of  these  four  drugs  is  the  most  suitable 
substitute  for  cocaine,  it  is  necessary  to  compare 
them  with  one  another.  The  only  drugs  which  com- 
ply with  the  first  two  conditions  were  sttivaine.  no- 
vocain, tropacocaine,  and  betaeucaine  lactate.  With 
I'hese  four  drugs  further  experiments  •  were  per- 
formed to  discover  how  they  fulfill  the  other  con- 
ditions laid  down  for  the  perfect  local  anaesthetic.  If 
novocain  and  tropacocaine  are  first  compared,  their 
toxicity  and  anaesthetic  properties  are  equal,  but  the 
irritant  action  of  tropacocaine  is  far  greater  than  that 
of  novocain  ;  in  other  respects  their  actions  are  simi- 
lar, therefore  novocain  is  a  more  suitable  drug  than 
tropacocaine.  On  comparing  novocain  with  betaeu- 
caine lactate  it  is  seen  that  while  the  an.nesthetic  value 
is  roughly  about  equal,  the  toxicity  of  betaeucaine 
lactate  is  slightly  less  than  that  of  novocain,  but  the 
irritant  action  of  betaeucaine  lactate  is  far  greater 
than  that  of  novocain.  It  appears,  then,  that  while 
betaeucaine  lactate  has  only  a  slighter  degree  of  tox- 
icity to  recommend  it  in  preference  to  novocain,  its 
irritant  action  far  and  away  overshadows  any  such 
slight  advantage,  and  novocain  is  recognized  as  un- 
doubtedly the  better  drug  of  the  two.  Finallw  it 
only  remains  to  compare  novocain  with  stovaine. 
The  former  drug  is  less  to.xic  and  much  less  irritant ; 
indeed,  its  specific  action  on  nerve  fibres  is  so  great 
that  it  has  practically  no  destructive  effect  on  the 
other  tissues ;  stovaine  is  more  toxic  and  consider- 
ably more  irritant.  The  one  definite  advantage 
which  stovaine  possesses  over  all  the  other  local 
anaesthetics  is  its  greater  injurious  action  on  nerve 
fibres,  as  shown  by  anaesthesia.  Nevertheless,  the 
specific  action  of  stovaine  on  nerve  fibres  is  less 
than  that  of  novocain,  since  stovaine  destroys  other 
tissues  besides  nerve  fibres.  He  comes  to  the  con- 
clusion that  of  the  drugs  investigated,  novocain  is 
most  satisfactory  for  general  use.  Its  anaesthetic 
action  is  equal  to  that  of  cocaine,  and  its  toxicity  and 
general  destructive  power  on  the  tissues  are  very 
much  less. 

LANCET. 

March  2/,  igOQ. 

1.  Disinfection  and  Disinfectants. 

By  R.  Tanner  Hewlett. 

2.  Mechanism  Underlying  the  Various  Methods  of  Artifi- 

cial Respiration  Practised  since  the  Fonndation  of 
the  Royal  Humane  Society  in  1774, 

By  Arthur  Keith. 

,3.    Tuniorlike  Formations  of  Fat  in  Man  and  the  Lower 
.Animals.  By  S.  G.  Sh.\ttock. 

4.  Some  -Abnormalities  of  Ocular  Movements,  with  Par- 

ticular Reference  to  "Erroneous  Projection"  in  Cases 
of  Paralysis  of  Muscles  of  the  Eye  Ball,  especially  in 
Cases  of  Paralysis  of  an  External  Rectus — Outgoing 
( Centroperipheral)  Ingoing  ( Peripherocentral) 
Currents,  By  J.  Hughlinos  J.ack.son. 

5.  Some  Points  ii.  the  I're.Mtment  "f  Nervous  Diseases, 

By  James  Taylor. 


April  17,  .909-J  I'lTH  OF  CURRENT  LITERATURE. 


6.  Direct  OEsophagoscopy ;  A  Unique  Experience, 

Bv    HerBEUI'  TlLLEV. 

7.  .Motoring  Notes,  By'C.  T.  W.  Hiksch. 
2.  Mechanism  Underlying  the  Various  Meth- 
ods of  Artificial  Respiration. — Keith  in  his  third 
Hunterian  Lecture  remarks  that  it  is  only  one  case 
in  twenty  or  thirty  which  is  recovered  by  aid  of 
artificial  respiration,  but  that  twentieth  case  cannot 
be  recognized  at  sight,  therefore  it  is  necessary  to 
perform  respiration  in  every  one;  if  properly  per- 
formed it  can  do  no  harm;  if  improperly  performed 
it  may  destroy  the  possibility  of  recovery.  As  to 
the  method  he  says  that  the  Silvester  method 
should  be  properly  carried  out.  If  that  condition 
cannot  be  guaranteed,  the  Schafer  method  should 
be  used,  for  although  it  is  less  affected  it  is  also 
simpler,  and  in  one  sense,  that  of  obstructing  from 
falling  back  of  the  tongue  less  dangerous  than  the 
Silvester  method.  In  every  case  of  drowning  he 
advises  to  follow  the  custom  of  first  turning  the. 
patient  prone  and  compressing  the  thorax  to  empty 
the  main  respiratory  passage.  The  Howard  meth- 
od is  said  to  be  dangerous  on  account  of  rupturing 
the  engorged  liver.  A  very  good  method  is  the 
ancient  method  of  mouth  to  mouth  insufflation  with 
expiratory  compression  of  the  chest.  With  the  pa- 
tient in  the  prone  position  the  operator  will  have 
great  difficulty  in  knowing  whether  or  not  air  is 
entering  and  leaving  the  lungs  freely ;  with  direct 
inflation  one  knows  the  effect  immediately  by  plac- 
ing the  hand  on  the  epigastrium ;  the  hand  is  also 
needed  there  to  produce  expiration. 

5.  Some  Points  in  the  Treatment  of  Nervous 
Diseases. — Taylor  observes  that  in  many  diseases 
which  are  called  nervotis  the  disease  is  not  primar- 
ily in  the  nervotis  system  itself.  The  functions  of 
that  system  may  be  interfered  with  because  the  nu- 
trition of  nervous  elements  is  impaired  in  conse- 
quence of  the  derangement  of  some  other  tissue  or 
organ.  Thus,  in  the  condition  which  we  know  as 
hemiplegia,  in  which  one  half  of  the  body  is  para- 
lyzed, this  paralysis  is  the  result  not  of  any  inherent 
primary  defect  in  the  nervous  system  itself  but  of  an 
interference  with  the  nutrition  of  a  part  of  the 
nervous  system  due  to  an  interruption  of  its  vas- 
cular supply.  In  other  words,  hemiplegia  really  de- 
pends upon  a  diseased  or  defective  condition  of  the 
vascular  system,  leading  to  impaired  function  of 
the  nervous  system.  This  impairment  may  be  of 
varying  degree,  and  according  to  the  degree  and 
e.xtent  of  impairment  so  is  the  character — severe 
or  slight,  restricted  or  widespread — of  the  paraly- 
sis. The  author  then  mentions  the  causes  and 
treatment  of  hemiplegia,  disseminated  sclerosis,  the 
types  of  tabes,  paralysis  agitans,  infantile  paralysis, 
anrl  the  treatment  of  epilepsy.  Hemiplegia  may  be 
the  result  of  rupture  of  a  bloodvessel,  resulting  in 
a  cutting  off  of  the  blood  supply  of  a  part  of  the 
nervous  system  and  consequent  impairment  of  the 
function  of  that  part :  there  may  also  be  a  tearing 
up  of  the  nerve  fibres  and  pressure  on  the  neighbor- 
ing parts,  the  result  of  the  blood  clog :  or  it  may  be 
the  result  of  thrombosis  in  a  bloodvessel  leading 
to  abolition  of  the  function  of  the  part  of  the  brain 
supplied  by  this  vessel.  The  treatment  will  have 
to  consider  the  cause  of  hemiplegia.  Of  dissemi- 
nated sclerosis  he  says  we  are  justified  in  regarding 


81.S 

it  as  a  disease  in  which  improvement  may  take 
place  and  in  which  therapeutic  measures  may  at 
least  be  helpful.  The  best  treatment  for  such  a 
condition,  as  soon  as  it  is  recognized  is  complete 
rest.  Tabes  is  a  disease  of  many  types,  and  it  is 
surprising  how  frequently  is  seen  a  gradual  and 
steady  improvement.  Aspirin  will  relieve  the  pain, 
belladonna  the  bladder  symptoms,  and  exercise  may 
ameliorate  the  ataxy.  Paralysis  agitans  is  one  of 
the  most  distressing  diseases  of  the  degenerative 
type  with  which  we  have  to  deal. .  It  is  idle  to  hope 
that  we  shall  ever  be  able  to  cure  such  a  disease, 
but  we  may  relieve  some  of  the  troubles  and  symp- 
toms by  hyoscine  or  hydrobromide.  Another  most 
tragic  disease  is  infantile  paralysis  and  here  mas- 
sage and  electricity  may  be  of  value.  The  author 
finally  speaks  of  epilepsy. 

LA  PRESSE  MEDICALE. 

March  17,  igog. 

Opening  Lecture  of  the  Surgical  Clinic  at  the  Necker  Hos- 
pital, By  Pierre  Delbet. 

March  20,  1909. 
Opening  Lecture  of  the  Course  on  the  History  of  Medicine 
and  Surgery  of  the  Faculte  de  medecine  de  Paris. 

By  .\.  Chauffard. 

LA  SEMAINE  MEDICALE. 

March  24,  igog. 

Pathological  Physiology  of  Traumatic  Pleural  Hsematoma. 
The  Local  Haemolytic  Formation  of  Biliary  Pig- 
ment,        By  Georges  Guillaix  and  Je-»iN  Troiser. 

Traumatic  Pleural  Hasmatoma. — (iuillain  and 
Troiser  report  the  case  of  a  man.  thirty-two  years  of 
age,  who  suffered  from  a  haematoma  in  the  pleura 
as  the  result  of  a  traumatism  received  in  the  pos- 
terior region  of  the  thora.x.  The  bloody  fiuid  with- 
drawn by  thoracentesis  was  found  to  contain  biliary 
pigment.  There  was  no  morbid  condition  of  the 
liver  and  the  existence  of  the  biliary  pigment  in 
this,  and  in  a  similar  briefly  mentioned  case,  is  held 
to  be  due  to  the  local  hjemolysis. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 

March  8,  igog. 

1.  Resection  of  the  Tuberculous  Hip  Joint.     By  Ko.nig 

2.  Contributions  to  Brain  Surgery,  By  Otfried  Forster. 
^.    Idiosyncrasy  to  the  X  Rays,  By  Hermann  Gocht. 

4.  Demonstrations  from  the  Field  of  Operative  Accident 

Surgerj-,  By  Richard  Muhsam. 

5.  Studies  Concerning  the  Antitryptic  Index  of  the  Blood 

with  Malignant  Tumors  and  Septic  Diseases, 

By  Felix  Landois. 

6.  The  Use  of  Serum  Diagnosis  in  Practical  Surgery, 

By  Georg  Wolfsohn. 

7.  .\nother  Contribution  to  the  Laying  Bare  of  the  Hypo- 

physis, By  Loewe. 

S.    A  Precision  Pipette  for  the  Counting  of  Red  Blood 

Corpuscles,  Bj-  Hans  Hirschfeld. 

9.    The  Modern   Methods   of  Treatment  of  Gonorrhoeal 

Epididymitis  and  ?  Personal  Experiment  with  the 

Puncture  Treatment,  By  Ernst. 

I.    Resection  of  the  Tuberculous  Hip  Joint. — 

Konig  reports  568  cases  of  tuberculous  hip  joint 
disease ;  294  received  conservative  treatment,  in  274 
the  joint  was  resected.  Of  the  294  patients  treated 
conservatively  information  as  to  the  final  result  was 
wanting  in  ninety-two.  Fifty-five  patients  died  while 
under  observation;  114  recovered  so  as  to  be  able 
to  go  about  without  assistance,  in  thirty-three  of 
these  the  mobility  and  use  of  the  joint  became  nor- 


8i6 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


mal  or  nearly  so ;  ninety  had  more  or  less  movable 
joints.  Aside  from  the  114  good  recoveries  thirty- 
five  patients  became  able  to  go  about  with  a  cane  or 
crutches,  three  of  those  with  great  difficulty.  Fis- 
tulae  persisted  in  thirteen  patients.  Of  the  274  pa- 
tients upon  whom  resection  was  performed  informa- 
tion as  to  the  final  result  was  wanting  in  sixty.  109 
patients  died  while  under  observation  ;  sixteen  re- 
covered and  were  able  to  go  about  without  assist- 
ance and  had  no  fistulae ;  in  sixteen  the  result  w^as 
excellent,  the  patients  were  able  to  take  long  walks, 
do  hard  work,  and  could  dance.  Forty-three  were 
able  to  go  about  with  a  cane,  the  remainder  with 
crutches,  but  the  condition  of  five  of  these  was  piti- 
able. Fistuhe  persisted  after  the  operation  in  thirty- 
five.  He  says  that  it  is  not  surprising  that  the  final 
results  in  the  cases  not  operated  in  were  better  than 
those  where  the  operation  was  performed.  One 
reason  is  that  in  the  cases  operated  in  the  disease 
was  more  severe,  for  he  usually  operated  only  upon 
patients  in  whom  the  severity  was  such  that  there 
was  little  hope  for  recovery  without  intervention. 
Another  reason  is  the  danger  of  the  operation. 
Double  the  number  of  patients  died  under  observa- 
tion that  were  operated  upon.  Nine  of  these  died 
from  collapse,  two  from  haemorrhage,  seven  from 
sepsis,  and  two  from  embolism.  General  acute  tuber- 
culosis carried  oft"  fourteen  of  those  conserv^atively 
treated,  twenty-four  of  those  operated  upon.  But  it 
is  noteworthy  that  of  these  bad  cases  operated  in  so 
large  a  number  made  good  recoveries. 

5.  The  Antitryptic  Index  of  the  Blood  with 
Malignant  Tumors  and  Septic  Diseases. — Lan- 
dois  sa\s  that  in  .carcinomatous  patients  there  is 
usually  a  slight  rise  of  the  antitryptic  index,  and 
that  the  cachexia  of  carcinoma  is  the  imprint  of  a 
ferment  reaction  of  white  blood  corpuscles  conse- 
quent upon  secondary  ulceration  of  the  tumor  which 
reacts  upon  the  body  with  the  formation  of  anti fer- 
ment. In  septic  diseases  he  finds  that  as  soon  as 
the  suppuration  begins  the  antiferment  circulating 
in  the  blood  is  reduced  and  the  antitryptic  index 
lowered.  This  happens  in  the  very  early  days  of  the 
case,  usually  before  the  patient  comes  under  obser- 
vation. An  increase  of  the  antiferment  immediately 
follows  with  increase  of  the  quantity  of  proteolytic 
ferment,  as  has  been  shown  by  Wiens.  The  bodv 
thus  makes  an  attempt  to  stop  the  rapid  breaking 
down  of  albumin  by  the  increase  of  antiferment. 
The  direct  antiferment  treatment  of  suppurating 
wounds  is  based  on  this  principle.  If  the  body  over- 
comes the  suppuration  the  antitryptic  index  of  the 
blood  gradually  sinks  and  returns  to  normal,  but  if 
the  body  is  overborne  the  inhibitory  power  of  the 
blood  rapidly  increases.  This  is  a  fact  that  is  hard  to 
explain  theoretically.  Either  the  addition  of  ferment 
to  the  circulation  ceases  and  the  quantity  of  antifer- 
ment increa.ses,  or  it  may  be  that  the  formation  of 
antiferment  in  the  blood  is  primarily  stimulated. 
This  can  be  determined  only  by  a  systematic  com- 
parison of  the  quantities  of  ferment  and  antiferment 
in  one  and  the  same  patient.  When  the  infection  is 
at  its  heiglit  and  the  destruction  of  leucocytes  great- 
est the  antitryptic  power  of  the  blood  is  also  great- 
est. .\s  the  temperature  declines  and  the  destruc- 
tion of  tissue  becomes  less  the  antitryptic  inde.\ 


sinks.  This  reaction  can  scarcely  be  of  value  prog- 
nostically  in  suppurations,  but  it  is  in  acute  infec- 
tious diseases.  Finally  he  declares  that  the  raising 
of  the  antitryptic  index  in  both  carcinoma  and 
chronic  septic  processes  is  due  to  a  single  cause,  the 
great  destruction  of  leucocytes  and  the  setting  free 
of  the  ferment. 

6.  Use  of  Serum  Diagnosis  in  Practical  Sur- 
gery.— W'olfsohn  declares  that  most  of  the  sero- 
diagnostic  reactions  recently  described  are  of  no 
practical  use  in  surgery.  He  makes  three  excep- 
tions only,  Wassermann's  syphilis  reaction,  von  Pir- 
quet's  cutaneous  tuberculin  reaction,  and  Calmette's 
conjunctival  reaction. 

MUNCHENER  MEOIZINISCHE  WOCHENSCHRIFT 

March  9,  /pop. 

1.  Digestive  Disturbances  and  Psychoneuroses, 

By  Fleiner. 

2.  The  Mechanism  of  Glycosuria  Due  to  Adrenalin, 

By  Straub. 

3.  A  Practicable  Method  for  the  Serum  Diagnosis  of 

Syphilis,  By  Noguchi. 

4.  Common  Salt  and  Uraemia,  By  Ceconi. 

5.  Lumbar  Anaesthesia  with  Novocain  in  Gynaecology, 

By  SlEBER. 

6.  Physiological    and    Anatomical    Studies    of  Lumbar 

Anaesthesia  and  of  the  Question  of  Its  Clinical  Value, 

By  Klose  and  V'ogt. 

7.  Streptococci  in  the  Genital  Secretion  of  Pregnant  and 

Lying  in  Women,  By  From  me. 

8.  Contribution  to  the  Treatment  of  Carriers  of  Typhus 

Bacilli,  By  Liefmann. 

9.  Another  Contribution  to  Injuries  of  the  Eye  by  Light- 

ning. By  Hessberg. 

10.  Explanation  of  the  Rachitic  Residua  in  the  Thorax  in 

Adults,  By  ScHURiG. 

11.  A  New  Method  for  the  Production  of  Stimulation  of 

the  Skin,  By  Plate. 

12.  Puerperal  Fever,  By  Deipser. 

13.  Diet  Poor  in  Salt  as  a  Remedy  {Concluded) . 

By  Mendel. 

14.  The  Division  of  Fatal  Diseases  According  to  Age. 

By  VON  der  Veldex. 

I.  Digestive  Disturbances  and  Psychoneu- 
roses. — Fleiner  makes  the  statement  that  there  is 
no  primary  nervous  dyspepsia,  only  functional  stom- 
achic and  intestinal  disturbance  of  psychic  origin 

3.  Serum  Diagnosis  of  Syphilis. — Noguchi  de- 
scribes a  method  that  he  has  devised  by  means  of 
which  he  states  that  any  practitioner  may  be  able  to 
test  the  serum  of  his  patient  for  syphilis  wathout 
the  aid  of  a  laboratory.  The  results  obtained  bv 
this  method  compare  favorably  with  those  obtained 
by  Wassermann's  method. 

4.  Comon  Salt  and  Uraemia. — Ceconi  seems  to 
think  that  uraemia  is  caused  not  by  the  presence  of 
an  excess  of  salt,  but  by  the  absence  or  deficiency 
of  other  salts  which  exert  a  neutralizing  influence. 

6.  Lumbar  Anaesthesia. —  Klose  and  \'ogt 
found  that  lumbar  anajsthesia  in  animals  produced 
.serious  changes  in  the  cells,  though  they  were  for 
the  most  part  of  a  reparable  nature.  How  far  the 
results  can  be  applied  to  man  is  a  very  important 
question,  though  one  not  easily  answered  as  yet. 
The  topography  of  the  spinal  canal,  the  absolute  and 
relative  quantity  of  thiid,  and  perhaps  also  the  cur- 
rents, are  conditions  which  arc  not  directly  analo- 
gous in  man  to  those  in  the  lower  animals. 

7.  Streptococci  in  the  Genital  Secretions  of 
Pregnant  and  Lying  in  Women. —  l"ronime  finds 


April  17,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


817 


that  haemolytic  streptococci  are  present  in  a  certain 
percentage  of  pregnant  and  lying  in  women  without 
inducing  sickness  of  the  affected  women,  and  he 
makes  a  distinction  between  the  mechanical  bacte- 
rijemia,  in  which  the  prognosis  may  be  good,  and 
the  true  bacteriaemia  that  is  present  in  puerperal 
fever. 

8.  Treatment  of  Carriers  of  Typhoid  Bacilli. — 

Liefmann  reports  that  in  two  cases  in  which  the  ex- 
amination of  the  stools  of  the  patients  revealed  the 
presence  of  typhoid  bacilli,  treatment  with  the  Bul- 
garian sour  milk  called  Yoghurt  was  followed  by 
the  disappearance  of  the  bacilli  from  the  stools. 

9.  Injuries  of  the  Eye  due  to  Lightning. — 
Hessberg  reports  three  cases,  two  of  cataract  and 
one  of  optic  neuritis  with  partial  iridoplegia  and 
horizontal  nystagmus.  The  cataracts  were  of  the 
form  designated  by  Prauns  contusion  cataract,  and 
were  successfully  extracted.  In  the  third  case  the 
optic  neuritis  recovered  completely,  the  partial  iri- 
doplegia gradually  improved,  but  the  nystagmus  be- 
came permanent. 

13.  Diet  Poor  in  Salt. — Mendel  thinks  that  a 
diet  poor  in  salt  .is  an  excellent  remedy  in  many 
forms  of  diseases. 

GLASGOW  MEDICAL  JOURNAL, 
March,  igog. 

1.  Recent  Methods  of  Examination  of  the   Nose  and 

Throat,  By  John  Macintyre. 

2.  A  Case  of  Hodgkin's  Disease, 

By  R.  Barcl.^y  Ness  and  John  H.  Teacher. 
,3.    Treatment  of  Hypertrichosis  by  X  Rays, 

By  John  Don.m,d. 

4.    The  History  of  Botany  in  Glasgow  University  and 
some  Personal  Reminiscences, 

I.  Recent  Methods  of  Examination  of  the  Nose 
and  Throat.  —  Macintyre  describes  the  recent 
methods  of  diagnosis  of  diseases  of  the  nose  and 
throat,  including  for  the  most  part  what  has  taken 
place  since  1895,  as  contrasted  with  what  took  place 
after  the  introduction  of  the  laryngoscope  by  Garcia 
and  before  that  year,  that  is  the  methods  of  direct 
inspection  of  the  cavities  and  passages,  their  trans- 
illumination ;  and  the  use  of  the  x  rays,  whether  by 
means  of  the  radiogram  or  fluorescent  screen.  Xot 
only  has  anatomy  gained  much,  and  may  gain  more, 
but  much  will  be  done  to  facilitate  the  study  of 
physiology  and  pathology. 

3.  Treatment  of  Hypertrichosis  by  X  Rays. — 
Donald  speaks  of  the  technique  and  dangers  to  be 
avoided  in  the  treatment  of  hypertrichosis  by  x  rays. 
His  conclusions  are  as  follows :  Never  treat  more 
than  four  square  inches  in  one  area  at  a  time.  Too 
many  different  areas  at  a  time  should  not  be  under- 
taken, as  it  will  bring  discredit.  Some  part  will  get 
too  little  treatment  and  the  hair  will  return.  Do 
not  be  influenced  by  the  patient  tempting  you  to  do 
the  work  faster  than  you  deem  it  safe;  a  wound 
would  likely  result.  Never  treat  at  the  same  time 
two  areas  which  are  very  near  each  other,  lest  a 
flushing  of  the  whole  face  should  occur.  Always 
give  about  ten  sittings  after  the  hair  has  disappear- 
ed, to  make  sure  of  the  roots  being  destroyed. 
These  sittings  need  not  be  oftener  than  three  times 
weekly.  An  area  should  not  be  considered  thor- 
oughly finished  until  the  hair  has  remained  absent 
for  three  months. 


AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 

April,  Jpop. 

1.  Surgical  Anaemia  and  Resuscitation, 

By  George  W.  Crile. 

2.  Tlie  Influence  of  Emotional  States  on  the  Functions  of 

the  Alimentary  Canal,  By  W.  B.  Cannon. 

3.  The  Meaning  of  Haematemesis, 

By  William  Fitch  Cheney. 

4.  Concerning  Diseases  that  Depend  on  Disturbances  oi 

Internal  Secretion,  By  Wilhelm  Falta. 

5.  The   Treatment   of   Acute    Infectious    Diseases  'with 

Extracts  of  Leucocytes  (Hiss), 

By  Samuel  W.  Lambert. 

6.  The  Rontgen  Rays  in  the  Treatment  of  Deep  Seated 

Malignant  Disease,  By  George  E.  Pfahlek. 

7.  Is  Percussion  as  a  Method  of  Testing  the  Lungs  De- 

serving of  Greater  Attention?       By  C.  E.  Waller. 

8.  Specific  Aids  in  the  Diagnosis  and  Prognosis  of  Tuber- 

culosis, By  Silvio  von  Ruck. 

9.  Some  Aspects  of  Calculous  Anuria, 

By  Francis  S.  Watson. 
ID.  The  Importance  of  Modifications  of  the  Sensibility  in 
the  Diagnosis  of  Disease,      By  Tom  A.  Williams. 

11.  Cysts  of  the  Common  Bileduct,       By  R.  S.  Lavenson. 

12.  Some  Cases  of  ^lultiple  Infection, 

By  William  Royal  Stokes  and  Thomas  M.  Wright. 

13.  Diaphragmatic  Hernia,  By  E.  T.  Bell. 

I.  Surgical  Anaemia  and  Resuscitation. — Crile 
observes  that  tissues  and  organs  of  low  specializa- 
tion endure  total  anaemia  better  than  tissues  and 
organs  of  high  specialization.  In  the  central  nerv- 
ous system  the  component  parts  endure  anaemia 
according  to  their  phylogeny ;  the  nerve  tissue  pre- 
siding over  the  basal  functions  of  life  endures 
anaemia  better  than  the  nerve  tissue  which  by  the 
process  of  evolution  distinguishes  the  higher  ani- 
mals from  the  lower.  The  weakest  link  in  the  en- 
tire vital  chain  in  the  central  nervous  system  is  that 
which  presides  over  conscious  life  and  its  special 
manifestations.  The  higher  the  development  of 
the  tissue  the  more  sharply  is  the  period  of  endur- 
ance to  anaemia  marked.  While  the  vasomotor  and 
the  respiratory  centres  may  show  very  considerable 
variation  in  their  resistance  to  anaemia,  the  cere- 
brum varies  but  slightly.  The  observation  the 
author  has  made  in  attempts  at  resuscitation  of  the 
human  being  have  impressed  him  with  two  main 
facts :  The  human  heart  seems  to  respond  even 
more  readily  than  the  heart  of  a  dog;  and  the  possi- 
bility of  drilling  an  operative  staff  so  that  the  tech- 
nique may  be  begun  within  two  minutes. 

3.  Haematemesis. — Cheney  gives  seven  causes 
for  haematemesis:  i,  Cirrhosis  of  the  liver;  this 
haematemesis  of  cirrhosis  is  usually  early,  copious, 
and  followed  by  no  further  bleeding  for  months  or 
years,  if  at  all.  But  here,  as  elsewhere,  there  are 
exceptions.  2,  Gastric  ulcer ;  the  bleeding  from  a 
gastric  ulcer  that  leads  to  haematemesis  is  usually 
from  a  good  sized  vessel  opened  in  its  base ;  a  con- 
siderable amount  of  blood  is  poured  out  quickly, 
so  that  vomiting  of  bright  red  blood  occurs,  as  it  is 
not  detained  in  the  stomach  long  enough  to  be 
altered  by  acid  secretions.  3,  Gastric  cancer  is  the 
condition  above  all  others  that  gives  rise  to  the 
small,  frequently  repeated  haematemesis,  the  blood 
being  dark,  altered  by  gastric  juice,  forming  the 
classical  "coffee  ground"  vomitus.  These  three  are 
the  great  causes  of  haematemesis.  all  the  others  be- 
come unusual  and  infrequent  by  comparison.  4, 
Splenic  anaemia;  5,  acute  pancreatitis;  6,  uraemia; 
and  7,  toxic  gastritis. 


8i8 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


5.  Treatment  of  Acute  Infectious  Disease. — 
Lambert  states  that  we  have  a  new  remedy  repre- 
senting a  new  point  of  view  in  the  study  of  im- 
munity, proving  an  endoceUular  immunity  in  addi- 
tion to  the  accepted  types  of  serum  immunity  and 
of  phagocytosis.  This  remedy  is  appUcable  to  ob- 
scure cases  of  unknown  bacterial  cause,  to  cases  of 
disease  with  unknown  or  unapproachable  lesions. 
The  remedy  influences  the  toxaemia  of  the  disease 
and  gives  an  opportunity  to  the  body  cells  to  over- 
come the  infection  by  removing  from  them  the 
necessity  of  immediately  attacking  the  endotoxines 
of  the  bacteria.  It  is  by  no  means  a  "cure  all."  It 
does  not  cure  every  case  and  it  produces  no  mira- 
cles. It  will  not  remove  death  from  the  world.  In 
application  it  is  painful  locally,  but  it  has  caused  no 
other  local  complication,  and  the  urticaria  so  often 
seen  in  the  use  of  serum  has  been  conspicuous  b}' 
its  absence.  This  new  method  of  treatment  has 
been  developed  by  Professor  Hiss,  who  approached 
his  subject  entirely  from  the  theoretical  and  labora"- 
tory  side,  and  worked  out  his  method  upon  the 
basis  of  animal  experimentation.  The  laboratory 
development  has,  therefore,  reached  a  higher  plane 
than  has  its  application  to  the  diseases  of  man.  In 
general,  the  method  consists  of  the  subcutaneous 
injection  of  an  aqueous  extract  of  dead  leucocytes 
taken  from  rabbits.  The  leucocytes  are  secured  in 
a  bacteria  free  condition  from  the  ])leural  cavities 
of  the  animal  under  the  stimulus  of  the  injection 
of  aleuronat.  These  exudates  are  centrifugalized 
and  washed  free  from  sertmi  with  saline  solution 
and  then  extracted  with  an  amount  of  distilled 
water  equal  in  bulk  to  the  original  amount  of  the 
exudate. 

6.  Rontgen   Rays   in   Malignant   Disease. — 

Pfahler  states  that  cases  that  are  operable  should 
be  operated  upon,  and  this  should  be  followed  by 
early  and  thorough  postoperative  Rontgen  ray 
treatment.  Sarcomata  yield  better  to  the  x  rays 
than  carcinomata.  In  sarcoma  it  seems  from  the 
foregoing  results  that  we  may  hope  for  fifty  per 
cent,  of  recoveries.  In  the  series  reported  sixty- 
five  per  cent,  have  recovered.  Localized  recurrent 
carcinoma  will  usually  yield  to  the  Rontgen  rays, 
unless  the  mucous  membrane  is  involved.  Occa- 
sionally good  results  are  obtained  even  in  advanced 
cases  of  carcinoma,  but  generally  one  can  hope  only 
for  ])alIiation  or  prolongation  of  life.  Good  results 
will  depend  very  much  upon  good  technique. 

7.  Percussion. — Waller  says  that  by  noticing 
the  varying  character  of  the  nontympanitic  sound 
upon  different  .strengths  of  percussion,  dulness  can 
be  detecterl  and  its  degree  established  with  greater 
certaintv  and  quite  independently  of  the  symme- 
trical comparative  percussion  method,  which  as  usu- 
ally applied  is  inadequate  and  misleading  for  the 
determination  of  the  presence  and  the  degree  of 
dulness ;  it  should,  therefore,  he  dislodged  from  the 
prominent  position  it  now  occupies. 

II.  Cysts  of  the  Common  Bileduct. — Lavcn- 
son  rejjorts  such  a  case  in  a  girl,  c  ght  years  of  a<^c. 
who  was  operated  upon,  and  succumbed  three  d-^ys 
after  operation.  The  autojjsy  showed  a  cyst  of  the 
common  fluct,  15x8x7  cm.  The  author  has  col- 
lected twenty-eiglit  cases  of  rcteiUion  cysts  of  th- 


common  duct.  Of  the  nineteen  instances  in  which 
the  sex  is  mentioned,  seventeen  occurred  in  females. 
Such  a  preponderance  of  one  sex  is  indeed  striking, 
and  yet  an  analysis  of  the  cases  throws  no  light 
upon  the  significance  of  this  relative  frequency  of 
the  condition  in  females.  The  features  which  tend 
toward  the  greater  frequency  of  other  diseases  of 
the  biliary  passages,  especially  gallstones,  in  females 
are  certainly  not  concerned  in  the  production  of 
cysts  of  the  bile  ducts,  for  these  features  are,  for 
the  most  part,  dependent  upon  modes  of  dress  or 
functions  peculiar  to  the  female  sex,  possible  only 
in  adult  life;  and  the  majority  of  cases  of  cysts 
have  occurred  in  the  young.  Of  the  twenty-two 
cases  in  which  the  age  was  mentioned,  the  average 
was  fifteen  years  and  eight  months ;  two  were  under 
one  year  of  age ;  seven  were  between  one  and  ten 
years  of  age;  six  between  ten  and  twenty  years  of 
age ;  four  between  twenty  and  thirty ;  one  between 
thirty  and  forty ;  and  two  between  forty  and  fifty 
years.  It  can  be  readily  appreciated  that  surgery 
oflfers  the  only  possibility  of  cure.  Of  the  twenty- 
one  cases  in  which  more  or  less  extensive  surgical 
procedures  were  adopted,  simple  puncture  of  the 
cyst  was  performed  in  three  cases,  all  of  which 
resulted  in  death.  Incision  and  drainage  was  per- 
formed in  fourteen  cases,  with  thirteen  deaths. 
Cholecystenterostomy  was  performed  in  four  cases, 
with  three  recoveries.  The  latter  operation  thus 
seems  to  ofifer  the  best  chances  of  cure. 

ANNALS  OF  SURGERY. 

April,  loog. 

r.    An  Analytical  and  Statistical  Review  of  One  Thousand 
Cases  of  Head  Injury.  By  Charles  Phelps. 

2.  The  Rational  Treatment  of  Xonmalignant  and  Border- 

line Tumors  of  the  Breast, 

By  Charles  Langdon  Gibson. 

3.  Mesocolic  or  Retrogastric  Hernia, 

By  William  J.  Mayo. 

4.  Inguinal  Hernia  of  the  Cjecum, 

By  John  Berton  Carnett. 

5.  Hernia  of  the  Vermiform  Appendix,  with  an  .Account 

of  Four  Cases,  By  John  A.  Macewen. 

6.  Cystic  Dilatation  of  the  Vermiform  Appendix, 

By  James  A.  Kelly. 

7.  Prostatic  Abscess ;   Observations  upon  the  Pathology 

and  Operative  Treatment.     By  Samuel  Alexander. 

2.  Borderline  Tumors  of  the  Breast. — Gib- 
son remarks  that  small  stationary  tumors  which  do 
not  cause  mental  or  physical  disturbances  in  young- 
er individuals  up  to  thirty  years  of  age  may.  as  a, 
rule,  be  disregarded,  particularly  so  if  occurring  in 
yoimg  unmarried  women  and  those  whose  social 
status  and  habits  render  active  interference  unde- 
sirable. Generally  speaking,  the  more  intelligent 
and  receptive  to  advice  and  caution  the  individual, 
tlie  more  may  she  be  "trusted"  with  her  tumor.  In 
the  less  favored  class  of  society,  those  \vho  may 
never  seek  or  have  occasion  to  receive  further  ad- 
vice, we  ought  to  shoulder  the  responsibility  for 
them.  If  any  of  these  tumors  at  any  age  or  stage 
grows  ra])idly  or  (|uite  steadily  it  ought  to  be  re- 
moved if  for  no  other  reason  than  the  necessity  of 
anticipating  severer  operati(Mis  proportionate  to  an 
increasing  bulk.  lU-tween  thirty  and  thirtv-five  a 
definite  lump  will  be  better  removed, — it  represents 
flistinctly  morbid  process  and  everv  vear  brings 
the  individual  nearer  to  the  time  when  she  must 


April  i-.  .909.J  FROCEEDIXGS  OF  SOCIETIES.  8ig 


not  have  abnormal  processes  in  her  breast.  Past 
thirty-five  no  exceptions  should  be  made,  except  for 
very  definite  reasons  and  assuredly  never  in  any 
process  which  was  increasing  steadily.  The  opera- 
tion performed  according  to  Professor  Warren's 
admirable  technique  should  leave  only  a  very  fine 
scar,  well  hidden  in  the  fold  which  the  lower  half 
of  the  breast  makes  with  the  chest  wall, — that  is. 
no  visible  scar  under  ordinary  conditions.  Small 
tumors  or  diseased  areas  may  be  exsected  without 
material  change  in  the  contour  of  the  gland  and 
even  the  removal  of  considerable  portions  may  re- 
sult in  a  minimum  of  disfigurement,  if  one  skilfully 
"reconstructs"  the  organ  according  to  Dr.  Warren's 
directions. 

5.  Hernia  of  the  "Vermiform  Appendix. — ^lac- 
ewen  reminds  us  that  in  hernia  of  the  vermiform 
appendix  the  appendix  may  either  descend  into  the 
scrotum  or  it  may  simply  accompany  the  caecum. 
Where  the  appendix  is  present  alone  in  the  scro- 
tum, it  may  give  rise  to  a  characteristic  condition. 
Examination  at  the  neck  of  the  scrotum  reveals 
either  the  presence  of  what  appears  to  be  a  thick- 
ened cord,  or  even  a  double  cord ;  while  the  ex- 
tremity of  the  appendix  lying  curled  up  above  the 
upper  extremity  of  the  testicle,  together  with  its 
thickened  mesentery,  may  simulate  a  second  testi- 
cle. A  much  thickened  and  fat  laden  condition  of 
the  mesentery  of  the  appendix,  when  present  in 
hernia,  is  said  to  be  characteristic.  It  has  been  said 
that  the  tubernaculum  testis  is  sometimes  attached 
above  to  the  caecum  and  vermiform  appendix,  and 
it  is  reasonable  to  suppose  that  such  an  attachment 
would  tend  to  produce  an  inguinal  hernia  of  the 
appendix.  Probably  also  in  these  cases  the  meso- 
caecum  has  been  unduly  lax,  while  a  mesocolon  may 
also  have  existed,  thereby  giving  the  large  bowel  a 
much  greater  range  of  movement  than  it  normally 
possesses.  In  all  of  the  cases  reported  the  patients 
were  of  the  male  sex,  and  in  three  of  these  the  con- 
dition was  certainly  present  at  or  soon  after  birth, 
while  in  the  fourth  case  the  early  history  is  quite 
indefinite.  In  all,  likewise,  the  hernia  was  of  the 
right  inguinal  variety. 

6.  Cystic  Dilatation  of  the  Appendix. — Kelly 
has  collected  sixty-eight  cases  of  cystic  dilatation  of 
the  appendix  in  the  literature.  He  finds  that  33  were 
observed  at  the  operating  table.  18  were  found  at 
autopsy,  and  in  17  the  method  of  observation  is  not 
recorded.  Of  the  33  cases  observed  at  the  operat- 
ing table  there  were  symptoms  of  appendicitis  in  20. 
In  13  cases  the  cyst  of  the  appendix  was  found  dur- 
ing the  course  of  operations  upon  other  structures. 
Of  these  13  cases,  4  were  present  in  hernial  sacs, 
and  2  were  associated  with  ovarian  cysts.  Of  the 
68  cases,  9  were  found  in  males.  8  in  females,  and  in 
51  the  sex  is  not  recorded.  The  cyst  included  the 
entire  appendix  in  1 1  cases,  it  was  localized  to  a  por- 
tion of  the  organ  in  20',  and  in  37  no  note,  was  made 
as  to  whether  it  was  general  or  local.  Of  the  32 
cases  in  which  the  age  is  recorded  it  is  given  as  fol- 
lows :  Between  i  and  10  years,  one  case ;  between  1 1 
and  20  years,  two  cases;  between  21  and  30  vears. 
seven  cases;  between  31  and  40  years,  eight  cases: 
lietween  41  and  50  years,  seven  cases  ;  and  between 
51  and  60  years,  seven  cases. 


IroceeDmgs  o(  ^ocietits. 


NEW  YORK  NEUROLOGICAL  SOCIETY. 
Meeting  of  October  6  1908. 
The  President,  Dr.  B.  S.^chs,  in  the  Chair. 

Tne  Seat  of  Consciousness. —  Dr.  pREPtiacK 
Petersox^  in  this  paper,  said  that  consciousness  was 
a  word  in  everybody's  mouth.  \\'e  used  it  gl  bly, 
as  if  we  knew  all  about  it.  Psychologists,  meta- 
physicians, physiologists,  and  physicians  had  all 
written  a  great  deal  concerning  it.  but  if  they  had 
said  anything  of  any  great  significance,  it  had  eluded 
liis  observation.  The  most  tangible  thing  that  he 
had  been  able  to  grasp  in  reading  their  works  was 
that  consciousness  was  a  stream,  a  flow,  a  flight, 
a  current,  a  thread,  an  "'orderly  succession  of 
changes."  He  took  it  for  granted  that,  whatever 
consciousness  might  be,  it  had  a  seat.  It  w^as  as- 
sumed that,  if  parts  of  the  body  were  removed, 
first  the  legs  and  the  arms  and  then  the  trunk  as 
far  as  the  base  of  the  skull,  consciousness,  if  the 
circulation  and  oxygenation  were  kept  up.  still  per- 
sisted in  the  head,  and  that  its  seat  was  in  the  brain. 
Such  an  experiment,  in  eflfect.  had  often  b:en  per- 
formed for  us  in  broken  necks  and  other  spinal  cord 
lesions.  Those  w^ho  had  dared  to  sunnise  further 
had  intimated  that  consciousness  was  diffused 
throughout  the  brain,  or  that  it  was  an  attribute  of 
the  cortex  of  the  brain  alone. 

With  this  preliminary  statement.  Dr.  Peterson 
said,  he  would  take  a  plunge  at  once  into  a  subject 
that  he  knew  as  little  about  as  any  one,  not  so 
much  with  the  hope  of  establishing  any  new  fact 
as  for  the  purpose  of  provoking  a  discussion  that 
might  lead  to  some  light  in  so  much  obscurity.  In 
his  opinion,  the  seat  of  that  power  which  produced 
the  manifestations  of  consciousness  was  in  the  basal 
ganglia  (probably  the  corpora  striata),  and  consci- 
ousness was  a  peculiar  siunmation  of  energy  at  that 
point,  capable  of  being  directed  like  the  rays  of  a 
searchlight  into  this  or  that  portion  of  the  brain. 

In  pointing  out  the  lines  of  reasoning  which  had 
led  him  to  this  conclusion,  the  speaker  first  referred 
to  the  daily  physiological  variation  of  consciousness 
in  the  condition  of  sleep,  which  was  certainly  a 
reduction  in  consciousness  from  the  highest  summa- 
tion of  energies  to  some  lower  level.  Sleeping  and 
waking  were  to  be  observed  in  a  vast  group  of 
animals  that  had  little  or  no  cerebral  development. 
Furthermore,  the  phenomena  of  sleep  w'ere  observed 
in  newly  bom  infants,  despite  the  fact  that  the  cere- 
brum was  quite  empty  of  experiences  and  anatomic- 
ally still  much  undeveloped  as  to  its  connections 
with  the  rest  of  the  brain.  They  were  also  observed 
in  children  born  without  a  cerebrum,  and  even  in 
dogs  deprived  of  their  hemispheres.  In  innumer- 
able cases  of  extensive  loss  of  cerebral  substance, 
of  a  hemisphere,  as  in  infantile  cerebral  palsies,  a 
frontal  lobe  in  the  crowbar  case,  etc.,  consciousness 
itself  seemed  unimpaired  throughout  life.  These 
observations  seemed  to  show  that  consciousness,  at 
least  as  regarded  its  variations  in  the  condition  of 
sleep,  did  not  reside  in  the  cerebrum.  Another  argu- 
ment of  a  similar  bearing  was  the  fact  that  every  in- 


820 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


dividual  with  a  brain  stored  full  of  all  the  experi- 
ences of  a  lifetime  was  only  actually  awake  at  any 
one  time  around  some  particular  small  group  of 
functions  or  ideas  that  occupied  consciousness. 

To  pass  now  to  another  series  of  pathological  con- 
ditions, the  one  disorder  which  had  led  him  to  think 
much  of  this  subject  was  epilepsy,  in  which  disease 
loss  of  consciousness  was  the  most  extraordinary  and 
often  the  only  symptom.  He  alluded  chiefly  to  such 
remarkable  conditions  as  the  tic  de  salaam  and  other 
forms  of  petit  uial,  in  which  the  patient  dropped 
suddenly  to  the  floor  with  loss  of  consciousness,  and 
quite  as  suddenly  rose  again  in  full  possession  of 
his  faculties.  The  loss  of  consciousness  was  com- 
plete and  often  lasted  but  a  fraction  of  a  second. 
How  could  we  account  for  such  a  phenomenon? 
If  consciousness  was  a  diffused  attribute  of  the 
whole  brain,  what  spasm  of  bloodvessels  or  other 
physical  process  familiar  to  vis  could  act  and  be  re- 
adjusted with  such  speed? 

The  question  now  arose,  What  portion  of  the 
brain  was  so  constructed  as  to  be,  apparently,  in  in- 
timate connection  with  every  other?  The  corpora 
striata.  There  was  no  part  of  the  brain  that  we 
knew  so  little  of.  As  Edinger  said,  here  we  had  "a 
mighty  portion  of  the  brain  that  must  be  of 
enormous  significance ;  otherwise  it  would  not  be 
always  present,  from  the  fish  up  to  the  man." 

Mr.  Henry  Rutgers  Marshall  said  that  a  few 
years  ago  it  would  have  been  a  matter  of  surprise 
to  find  such  a  subject  presented  for  discussion  be- 
fore a  body  of  neurologists,  as  it  would  have  been 
considered  to  belong  more  particularly  to  the  field 
of  psychology.  The  speaker  thought  the  thesis  pre- 
sented by  Dr.  Peterson  open  to  discussion,  in  that 
it  attempted  to  describe  consciousness  in  terms  of 
energy.  We  had  become  more  or  less  accustomed 
to  similar  descriptions  since  the  appearance  of  Ost- 
wald's  work,  in  which  he  had  attempted  to  define 
consciousness  in  terms  of  energy,  but  since  the 
publication  of  that  work  psychologists  and  philoso- 
phers had  been  endeavoring  to  bring  meaning  into 
his  statement,  but  without  success. 

There  was  one  interesting  point  to  which  he  de- 
sired to  call  attention.  The  word  consciousness,  as 
commonly  employed,  had  two  diverse  meanings. 
For  instance,  when  we  referred  to  the  conscious- 
ness of  plants,  of  which  Darwin  had  lately  spoken, 
we  referred  to  psycliic  existence  as  such.  \Mien. 
on  the  other  hand,  we  stated,  for  instance,  that  we 
had  gone  to  the  theatre  and  met  an  old  friend  who 
so  engrossed  our  attention  that  we  were  not  con- 
scious of  the  play,  we  used  the  word  consciousness 
with  an  entirely  different  meaning.  We  here  re- 
ferred to  a  state  of  "awareness,"  and  that  was  en- 
tirely different  from  '"psychic  existence  as  such." 
When  we  spoke  of  the  seat  of  consciousness  we 
might  mean  eitiier  the  seat  of  psychic  sense  in  man 
or  the  seat  of  "awareness."  This  latter  was  prob- 
ably the  form  of  consciousness  to  which  Dr.  Peter- 
son referred.  When  we  inquired  as  to  the  seat  of 
consciousness  as  psychic  existence  as  such,  we  dealt 
with  quite  a  different  question.  The  evidence  at 
our  command  at  present  favored  a  very  broid  and 
exceedingly  general  seat  of  consciousness,  as  thus 
considered.  In  the  case  of  the  epileptic,  to  whose 
sudden  loss  of  consciousness  Dr.  Peterson  had  re- 


ferred, there  was  also  a  momentary  paralysis — a 
sudden  cessation  of  activities.  That  distinction  was 
important,  because  it  brought  into  relation  with 
our  states  of  clear  consciousness  all  those  states 
of  what  were  commonly  called  our  "subconscious" 
mental  life ;  those  states  which  might  better  be  called 
"subattentive  consciousness." 

Mr.  Marshall  said  that,  under  the  view  he  held, 
waking  and  sleeping  were  objective  signs  of  the 
same  conditions  which  from  another  point  of  view 
were  described  respectively  as  clear  consciousness 
and  the  lack  of  clear  consciousness. 

Dr.  Frederic  S.  Lee  said  that,  while  Dr.  Peter- 
son had  presented  a  very  interesting  idea,  his  paper 
gave  rise  to  a  considerable  number  of  important 
questions — first,  as  to  the  nature  of  consciousness 
itself,  whether,  for  example,  it  represented  a  spe- 
cial form  of  energy  or  not.  The  speaker  thought 
that  most  physiologists  would  hardly  agree  to  the 
idea  that  consciousness  represented  energy.  It  had 
seemed  to  him  that  the  best  working  hypothesis  for 
the  physiologist  was  that  consciousness  was  some- 
thing of  unknown  nature  which  merely  accom- 
panied the  activity  of  certain  brain  structures.  He 
did  not  like  the  term  "epiphenomenon"  to  express 
that  idea,  but,  since  that  was  the  common  and  ac- 
cepted term,  he  would  use  it.  Consciousness,  then, 
was  an  epiphenomenon  accompanying  the  activity 
of  certain  brain  structures ;  or,  rather,  it  was  one 
of  the  modes  of  manifestation  of  their  activity, 
just  as  chemical,  thermal,  and  electrical  phenomena 
were  other  modes.  Consciousness  could  not  put 
the  brain  structures  into  activity.  He  would  not 
necessarily  confine  consciousness  to  the  activity  of 
the  cerebral  cortex  alone,  although  he  was  inclined 
to  believe  that  consciousness  was  more  particularly 
associated  with  the  working  of  cortical  cells.  Bech- 
terew  maintained  that  in  early  life  certain  parts  of 
the  brain  below  the  cortex  acted  consciously,  and 
that  as  the  tracts  between  these  and  the  cortex  be- 
came myelinized  and  functional  conscious  activity 
came  to  be  preeminently  associated  with  cortical 
activity.  He  asked  Dr.  Peterson  how,  on  the  theory 
that  the  corpus  striatum  worked  through  the  medi- 
ation of  the  cortex,  he  would  interpret  the  behavior 
of  one  of  Goltz's  dogs  from  which  the  cortex  had 
been  entirely  removed? 

Dr.  Adolf  Meyer  said  that  the  thesis  of  Dr. 
Peterson  brought  back  to  us  the  proposition  which 
Dr.  P.  Carus  advanced  about  thirteen  years  ago  in 
the  Journal  of  Comparative  Neurology,  which  was 
based  largely  on  the  argument  that  the  corpora 
striata  formed  a  large,  bulky  part  of  the  brain  to 
which  at  the  present  time  no  other  function  could 
be  assigned.  Gaul  in  turn  assigned  the  function  to 
the  optic  thalamus. 

Ignoring  entirely  the  question  of  what  we  meant 
by  "consciousness"  as  a  positive  function,  it  seemed 
that  the  evidence  that  Dr.  Peterson  had  brought 
forth  could  best  be  summed  up  as  evidence  of 
vulnerability  of  mechanism  of  consciousness  by  a 
lesion  in  the  basal  region.  It  was  evidence  in  favor 
of  the  possibility  of  localizing  the  lesions  in  some 
tvpes  of  unconsciousness.  As  soon  as  we  tried  to 
make  positive  inferences,  e.  g..  as  to  the  "seat  of 
consciousness,"  we  were  sure  to  meet  with  auite 
a  number  of  difficulties,  and  one  of  them  was  this 


April  17.  1909.] 


PROCEEDIXGS  OF  SOCIETIES. 


821 


— contrary  to  Dr.  Peterson's  assumption,  the  cor- 
pora striata  had  relatively  a  very  obscure  connec- 
tion with  the  rest  of  the  brain.  This  was  one  of 
the  greatest  stumbhng  blocks  to  the  theory  ad- 
vanced that  the  corpora  striata  should  be  of  such 
fundamental  importance.  So  far  as  we  knew,  their 
connections  with  the  cortex  were  extremely  scanty, 
and  with  the  rest  of  the  base  their  connections  were 
essentially  those  with  the  hypothalamus.  On  ana- 
tomical grounds  alone  it  would  be  very  difficult  to 
explain  any  connection  between  the  corpora  striata 
and  the  "seat  of  consciousness,''  not  to  speak  of  the 
question  of  whether  the  "seat  of  consciousness" 
could  be  a  safe  problem  today. 

Dr.  Smith  Ely  Jelliffe  said  that,  in  very  gen- 
eral terms,  consciousness  might  be  regarded  as  the 
streaming  in  of  all  the  sensory  functions,  and  with 
the  cutting  off  of  the  sensory  or  perceptive  func- 
tions a  loss  of  consciousness  followed.  To  illus- 
trate that  point  we  need  not  consider  the  efifect  of 
an  anaesthetic,  because  in  alcohol  we  had  an  agent 
par  excellence  which  cut  of¥,  one  by  one,  the  dif- 
ferent sensory  perceptive  functions  little  by  little 
until  we  had  a  nonconscious  residuum.  So  far  as 
the  seat  of  consciousness  was  concerned,  in  his 
opinion,  the  corpora  striata  simply  acted  in  the 
capacity  of  a  cut  off  by  reason  of  the  anatomical 
distribution  of  the  fibres  in  that  region.  Instead  of 
being  the  seat  of  consciousness,  he  looked  upon  it 
as  a  gateway  through  which  the  fibres  passed,  and 
any  injury  in  that  area  would  be  apt,  therefore,  to 
have  a  widespread  effect. 

The  Serum  Diagnosis  of  Syphilis  ix  Its  Rela- 
tion TO  Nervous  Disease. 

The  Development  and  Character  of  the  Was- 
sermann  Test. — Dr.  C.  F.  Bolduan,  after  a  brief 
review  of  Ehrlich's  theory  of  antitoxine  produc- 
tion and  cytolysis,  described  the  Wassermann  test, 
which  was  now  being  extensively  employed  in  the 
serum  diagnosis  of  syphilis.  The  Wassermann  re- 
action, briefly  outlined,  was  as  follows :  Two  tubes 
were  prepared  with  the  following  contents  :  Tube 

1.  — Extract  of  the  liver  and  spleen  of  a  syphilitic 
foetus,  representing  the  syphilitic  organism  (or 
antigen),  plus  serum  to  be  tested.  Tube  2. — Red 
blood  cells  of  a  sheep  or  other  animal,  suspended 
in  normal  saline  solution,  plus  serum  of  a  rabbit 
which  had  been  immunized  to  the  particular  red 
blood  cells  used.  Complement  (  a  substance  neces- 
sary to  all  immune  reactions,  which  existed  in  the 
fresh  serum  of  all  animals)  in  the  shape  of  fresh 
normal  guinea  pig  serum,  was  now  added  to  tube  i 
and  allowed  to  stand.  At  the  end  of  half  an  hour 
the  contents  of  tube  i  were  added  to  those  of  tube 

2.  If  the  serum  in  tube  i  had  come  from  a  syphi- 
litic individual,  its  relation  to  the  extract  of  anti- 
gen was  a  specific  one,  and  the  complement  would 
be  absorbed  thereby ;  so  that,  when  the  contents  of 
tubes  I  and  2  were  joined,  no  haemolysis  of  the  red 
blood  cells  in  tube  2  would  take  place.  If  the 
serum  was  not  from  a  syphilitic,  the  complement 
would  not  be  absorbed,  but  would  remain  active  to 
cause  haemolysis  in  tube  2.  Haemolysis  was  ob- 
served in  the  test  tube  as  a  tingeing  of  the  whole 
field  with  a  transparent  red  color.    The  red  cor- 


puscles had  been  disintegrated  and  the  haemoglobin 
liberated.  In  the  absence  of  haemolysis  the  solution 
of  red  cells  remained  turbulent  and  opaque.  The 
test,  of  course,  involved  numerous  controls  and  a 
careful  standardizing  of  the  hsemolytic  serum  and 
of  the  syphilitic  extract. 

The  Technique  of  the  Wassermann  Reactions 
Its  Practical  Application  with  Reference  to  the 
Diagnosis,  Prognosis,  and  Treatment  of  Nervous 
Disease. — Dr.  E.  Castelli  read  this  paper.  (  See 
page  777  of  this  issue.) 

A  Demonstration  of  the  Wassermann  Reaction. 
Dr.  NoGUCHi,  of  the  Rockefeller  Institute,  after 
demonstrating  the  Wassermann  reaction,  showed 
briefly  a  reaction  evolved  by  him  during  some  ex- 
perimentation with  the  various  albumin  reactions 
in  the  spinal  fluids  of  general  paralysis  and  other 
disorders.  This  was  obtained  as  follows:  o.i  c.c. 
of  the  spinal  fluid  to  be  tested  was  placed  in  a  test 
tube  whose  diameter  was  i  cm.  or  less.  To  this 
was  added  0.5  c.c.  of  a  ten  per  cent,  solution  of 
butyric  acid.  The  tube  was  now  heated  until  the 
fluid  was  bubbling,  and  while  it  was  still  hot  o.i  c.c. 
of  a  normal  four  per  c^nt.  solution  of  sodium 
hydrate  w-as  added.  In  nearly  all  spinal  fluids  an 
opalescence  occurred,  but  in  the  spinal  fluid  of 
general  paralysis  the  cloud  soon  separated  into  a 
definite  flocculence  which  was  characteristic.  The 
flocculence  usually  appeared  in  a  few  moments — 
rarely  requiring  more  than  twenty  minutes. 

The  reaction  shown  by  Dr.  Xoguchi  had  the  ad- 
vantage of  being  positive  in  a  quantity  of  o.i  c.c. 
or  less  and  of  being  a  qualitative  as  well  as  a  quan- 
titative test.  What  the  flocculence  might  mean  was 
not  known,  but  it  might  consist  of  some  globulin 
fraction  which  was  found  only  in  syphilitic  or  meta- 
syphilitic  disorders  of  the  nervous  svstem.  That 
the  reaction  was  not  entirely  quantitative  was 
shown  by  the  fact  that  many  fluids  from  nonpara- 
lytic cases  gave  much  richer  clouds  than  those  from 
paresis,  but  the  clouds  did  not  flocculate. 

Dr.  J.  W.  Moore,  of  the  State  Pathological  In- 
stitute, Ward's  Island,  said  that  they  had  tested 
thus  far  eighty  cases  by  the  Xoguchi  method.  Fifty 
undoubted  cases  of  paresis  gave  forty-eight  positive 
results.  The  two  negative  cases  did  not  seem  pe- 
culiar in  any  way.  Of  three  cases  of  cerebral  svph- 
ilis,  two  gave  positive  reactions.  Of  the  nonpar- 
alytic cases  tested.,  five  were  alcoholic  psychoses, 
two  manic-depressive  cases,  one  a  paranoic  state, 
one  in  an  imbecile,  and  one  which  was  diagnosticated 
as  Karsakow's  delirium,  but  which  proved  at 
autopsy  to  be  due  to  a  fractured  skull  with  extensive 
dift'use  dural  haematoma.  Only  one  of  the  nonpar- 
alytic cases  gave  a  postive  reaction.  This  was  a 
case,  diagnosticated  as  dementia  praecox,  in  which 
the  patient  had,  however,  increased  knee  jerks  and 
speech  defect.  Five  doubtful  cases  gave  two  posi- 
tive results  and  three  negative. 

In  the  majority  of  cases  of  paresis  the  W^asser- 
mann  reaction  was  also  carried  out.  Four  cases 
of  general  paralysis  which  were  negative  to  the 
Wassermann  test  were  positive  to  the  other.  Four 
gave  the  Wassermann  raction  much  less  definitely 
than  the  Xoguchi  reaction.  In  no  case  was  the 
Wassermann  test  the  more  conclusive  of  the  two. 


822 


MUl'  I.\  I  EXTIOXS. 


[New  York 
Medical  Journal. 


In  two  ot  the  cerebral  syphilis  cases  in  which  the 
Wassermatin  reaction  was  tried  it  <jave  a  uegati\e 
result. 

Dr.  B.  Onuf  said  that  Dr.  Castelli  had  made  the 
statement  that  in  a  large  percentage  of  cases  of 
general  paresis — seventy  or  eight}- — the  W'asser- 
mann  reaction  was  positive,  and  also  in  about  sixt\- 
per  cent,  of  cases  of  senile  dementia.  Could  we  con- 
clude from  that  that  senile  dementia  was  simply  a  late 
form  of  general  paresis :  that  syphilis  produced  a 
rather  rapid  exhaustion  of  the  nervous  system,  w'hile 
in  senile  dementia  identical  changes  occurred  in 
a  longer  course  of  time?  Did  he  mean  to  identify 
senile  dementia  with  general  paresis? 

The  PREsu)EyT  said  that,  while  the  W'assermann 
test  could  not  be  applied  at  the  bedside,  its  technique 
was  not  difficult  and  could  easily  be  acquired.  For 
the  present,  of  course,  this  test,  like  many  others, 
would  be  restricted  to  the  laborator\-  and  had  to 
be  made  by  persons  who  were  specially  qualified 
along  those  lines.  Thus  far,  the  reaction  had  been 
practically  limited  to  cases  of  suspected  tabes  or 
general  paresis,  but  at  the  Mt.  Sinai  Hospital  an 
effort  was  being  made  to  employ  it  in  other  doubt- 
ful spinal  or  cerebral  cas'es  where  syphilis  was  sus- 
pected. 


COLLEGE  OF  PHVSICL\NS  OF  PHILADELPHIA. 
Meeting  of  December  2.  igoS. 
Tlie  Pre-iident,  Dr.  James  Tyson,  in  the  Chair. 

Circumscribed  Serous  Spinal  Meningitis. —  Dr. 
\\'iLi.i.\.\t  U.  Si'ir.i.ER  mentioned  that  the  case  de- 
scribed by  Dr.  Musser.  Dr.  Martin,  and  himself  in 
1903.  of  circumscribed  serous  spinal  meningitis, 
was  the  only  case  reported  in  this  country  and  the 
first  case  in  which  an  operation  was  done  in  any 
coimtry.  Their  patient  had  recently  been  reexam- 
ined. She  was  in  excellent  health  and  had  no  longer 
any  symptoms  of  spinal  compression.  Xo  other 
case  in  which  recovery  had  persisted  so  long  as  six 
years  and  five  months  was  on  record. 

The  pathology  of  these  collections  of  fluid  in  the 
piaarachnoid,  causing  the  symptoms  of  tumor,  was 
not  understood.  W  ith  the  exception  of  the  case 
of  .Spiller.  Musser.  and  Martin,  all  the  cases  were 
recorded  in  (jerman  literature.  Nothing  was  to  be 
found  as  yet  C(jncerning  the  condition  in  the  Eng- 
lish or  French  literature,  but  it  was  probably  much 
more  common  than  the  paucity  of  reported  cases 
would  indicate.  Dr.  Spiller  expressed  the  hope 
that  attention  might  be  directed  to  this  disorder,  as 
he  felt  convinced  that  the  reported  cases  would 
soon  be  numerous.  The  lesion  found  was  a  collec- 
tion of  clear  fluid  in  the  piaarachnoid,  causing  the 
signs  of  compression  of  the  spinal  cord. 

Rontgenographic  Studies  of  Peristalsis.— Dr. 
Ch.\i<i,i;>  Lkster  Li-:ox.\ru  exhibited  a  series  of 
slides  illustrating  the  various  forms  of  peristaltic 
wave>  in  the  stomach  and  intestines.  He  also 
showed  the  difference  between  the  passage  of  bo- 
luses of  bread  and  milk  and  of  kumyss  through  the 
oesophagus.  His  pajjer  was  confined  to  the  studv 
of  variation^  in  the  form  of  peristaltic  waves  in 
their  relation  to  normal  and  |)athological  functional 
activity  in  the  •stomach  and  intestines.  He  showed 
that  by  thi*  mean-  tin-  Rontgen  method  of  diag- 


nosis could  distinguish  between  sthenic  and  asthenic 
forms  of  gastrectasis,  as  well  as  show  the  presence 
of  deficient  gastric  motility.  This  had  been  made 
possible  by  recent  advances  in  technique  which  per- 
mitted Rontgenograms  of  the  stomach  and  intes- 
tines to  be  made  with  exposures  of  from  half  a 
second  to  a  second.  These  studies  showed  that 
there  was  a  constant  gelation  between  the  form  and 
amplitude  of  peristaltic  waves  and  the  work  to  be 
accomplished.  These  waves  varied  with  the  posi- 
tion of  the  patient  and  the  amount  and  character 
of  the  food  ingested.  One  form  of  waves  varied 
in  sthenic  and  asthenic  conditions  sufficiently  to 
assist  in  distinguishing  between  such  pathological 
conditions.  He  showed  also  that  the  stomach  elon- 
gated with  every  expiratory  movement  of  the  dia- 
phragm, adding  an  additional  force  to  the  peri- 
staltic waves  in  emptying  the  stomach.  He  showed 
differences  in  the  peristalsis  of  the  small  and  large 
mtestines  and  demonstrated  that  marked  peristalsis 
was  present  in  the  descending  colon. 

The  Cammidge  Reaction  in  Experimental  Pan- 
creatitis.— Dr.  John  Speese  and  Dr.  Edward  H. 
Goodman  presented  this  paper.  They  had  exam- 
ined the  urine  of  dog  before  and  after  the  produc- 
tion of  an  acute  necrosis  of  the  pancreas.  In  four 
of  the  five  dogs  they  found  that  the  Cammidge  re- 
action appeared  in  from  four  to  eight  hours  after 
necrosis  was  induced.  In  the  fifth  case  there  was 
no  reaction,  and  in  this  instance  a  microscopical 
examination  of  the  pancreas  showed  that  it  was  not 
involved.  In  three  cases  they  endeavored  to  pro- 
duce a  nonacute  pancreatitis  by  ligation  of  the  pan- 
creatic duct,  and  found  in  the  first  case  that  the 
reaction  appeared  on  the  second  day  and  remained 
for  five  days.  In  the  second  animal  the  reaction 
appeared  on  the  first  day  after  the  operation.  The 
dog  was  killed  on  the  second  day.  Both  these 
rases  showed  a  subacute  pancreatitis  on  micro- 
scopical examination.  A  third  operation  gave  a 
positive  reaction  on  the  fifth  day  after  the  opera- 
tion. An  attempt  to  open  the  pancreatic  duct  was 
unsuccessful,  and  after  this  attempt  a  failure  of 
reaction  appeared  in  the  urine,  and  this  \vas  fol- 
lowed by  a  positive  reaction. 



leto  litbcntiffiis. 


A  PHARYNGOSCOPE. 

.Vc'ic  Electrical  Instrument  for  Direct  Examination  of 
the  Nasopharynx  and  Adjacent  Parts. 
By  H.\rold  H.\ys.  .\.  M..  M.  D., 
New  York. 

On  account  of  the  impossibility  of  making  a  care- 
ful study  of  the  pathological  conditions  of  the  naso- 
pharyn.x.  Eustachian  tubes,  and  posterior  nares  by 
means  of  the  p(\stnasal  mirror,  the  writer  wishes  to 
introduce  the  instrument  here  described  : 

The  instrument  is  made  on  the  principle  of  the 
cvstosco])c.  The  horizontal  part  which  is  about 
eight  inclies  long  is  joined  about  three  inches  from 
its  outer  extremity  by  a  perpendicular  shaft  so  that 
the  whole  instrument  can  be  used  as  a  tongue  de- 
jiressor  (see  cu\) .    The  jiart  1)cyond  the  handle 


April  17.  1909.] 


BOOK  XOTICES. 


823 


which  contain.i  tiic  wires)  is  made  up  of  three  com- 
ponents arranged  ->ide  by  side.  The  central  part  is 
a  tube,  one  quarter  inch  in  diameter  on  either  side 
of  which  are  the  two  electric  light  attachments,  and 
at  the  extreme  end  the  two  electric  lights  themselves. 
This  makes  more  or  less  of  a  flat  surface  for  de- 
pressing the  tongue.  Through  the  central  tube  runs 
a  telescope  made  on  the  same  principle  as  the  cysto- 
scope  except  that  the  lens  has  a  focal  distance  of 
about  one  inch.  The  telescope  can  be  inserted  into 
the  instrument  to  any  distance  desired  and  the  lens 
can  be  rotated  in  any  direction  by  revolving  the  e>  e 
piece,  the  position  of  the  lens  always  being  ascer- 
tained by  the  steel  ball  on'the  eye  piece.  The  instru- 
ment can  be  attached  to  any  rheostat. 

Method  of  Insertion. — After  the  instrument  is  at- 
tached to  the  rheostat,  the  lights  are  turned  up  until 
the  illumination  is  great  enough  to  bring  all  parts 
distinctly  into  view.  The  amount  of  light  needed 
can  be  ascertained  by  placing  the  lens  in  the  palm 
of  the  loosely  closed  hand  and  noting  the  distinctness 
of  the  palmar  lines.  A  strong  light  is  not  needed. 
Before  inserting  into  the  patient's  mouth,  the  instru- 
ment should  be  warmed  by  running  warm  water 


Hays's  pliiiryngoscoptr ;  .'.  wire  carriers  for  lamps;  3.  lamp  sockets: 
5.  ball  to  indicate  position  of  lens;  4,  handle  carrying  wires  to 
be  used  to  depress  tongue;  3.  rods  for  attachment  of  wires  to 
rheostat:  6,  rheostat:  a,  lens;  b,  lamp;  c,  telesco|>c;  d,  rheostat. 


over  it.  This  pnx^erlure  diminishes  the  subsequent 
condensation  on  the  lanips  and  lens. 

The  patient  is  told  to  open  his  mouth  wide  and  to 
')reathe  quietly.  The  telescope  is  pushed  into  the 
instrument  as  far  as  possible.  The  horizontal  part 
is  placed  on  the  tongue  firmly  until  the  extreme  end 
of  the  telescope  almost  touches  the  pharyngeal  wall 
(about  one  .sixteenth  of  an  inch  away).  The  patient 
:s  then  told  to  close  his  lips  firmly  oz'er  the  instrn- 
nient.  A  sufficient  hold  is  taken  of  the  handle.  By 
looking  through  the  eye  piece  of  the  instrument  a 
complete  view  of  the  nasopharynx  can  be  obtained. 
No  gagging  or  retching  takes  place  unless  the  in- 
strument is  moved. 

\\'hen  the  len>  points  upward,  the  vault  of  the 
pharynx  is  plainly  seen.  Adenoids  are  visible  and 
can  be  closely  studied.  If  the  instrument  is  tipped 
uf)  slightly  and  the  lens  rotated  to  either  side,  the 
Eustachian  tubes  are  brought  into  view.  Rands, 
hypertrophied  lymphoid  tissue,  adenoids,  etc..  on  the 
Eustachian  prominence  are  readily  appreciated.  By 
placing  the  lens  downward,  the  epiglottis,  base  of 
the  tongue.  lingual  tonsil,  and  the  larynx  come  into 
view. 


The  instrument  cannot  be  boiled.  It  must  be  ster- 
ilized like  the  cystoscope  in  formalin  fumes  and  then 
rinsed  ofi  with  warm  water.  . 

A  modification  for  direct  catheterism  of  the  Eus- 
tachian tubes  through  the  mouth  is  now  being  made. 
Small  tubes  are  to  be  fitted  between  the  lamp  car- 
riers (Xo.  I  in  figure),  and  into  the  tubes  are  to 
be  inserted  silk  woven  Eustachian  catheters  some- 
what like  ureteral  catheters.  If  the  Eustachian 
tubes  can  be  entered  in  this  way,  the  inconvenience 
to  the  patient  will  be  much  less,  traumatism  to  the 
Eustachian  orifices  will  be  lessened,  and  the  whole 
procedure  will  be  performed  under  the  direct  inspec- 
tion of  the  eye. 

Mv  thanks  are  due  to  INIr.  R.  Wappler.  of  the 
American  Cy.stoscope  Makers.  Inc..  for  the  mani- 
fest interest  he  has  shown  in  perfecting  the  instru 
ment  and  in  suggesting  technical  details. 

II  West  Xixetv-first  Street. 

 <^  

§00)1  ^fltues. 

[We  publish  full  lists  of  books  received,  but  ue  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


1  he  Psychological  Phenomena  of  Christianity.  By  George 
B.ARTux  CuTTEX,  Ph.  D.  (Yale),  Author  of  The  Psychol- 
f^'Sy  '-'f  Alcoholism.  New  York;  Charles  Scribner's  Sons, 
igo8. 

The  antagonism  between  science  and  theology 
seems  in  a  fair  way  to  be  much  less  active  than  it 
has  been  in  the  past  where  books  with  the  title  of 
the  one  under  review  are  sent  to  scientific  journals 
for  the  criticism  of  scientific. men.  The  opposition 
of  the  two  methods  of  thought,  the  scientific  and 
the  religious,  is  easily  understood  by  one  who  stops 
to  consider  it.  Science  is  mobile,  receptive  of  new 
ideas,  and  tolerant  of  new  views  ;  religion  is  fixed, 
exclusive  of  new  ideas,  and  intolerant  of  new  views. 
The  boy.  brought  tip  in  an  orthodox  religious  at- 
mosphere, who  begins  the  study  of  scientific  sub- 
jects is  soon  much  at  a  loss  to  correlate  his  ideas  of 
natural  phenomena  obtained  through  religious  in- 
struction and  his  increasing  knowledge  of  these 
phenomena  which  scientific  research  brings.  The 
tendency  on  the  part  of  theologians  to  hold  to  their 
dogmas  in  spite  of  the  advances  in  the  tmderstand- 
ing  of  natural  phenomena  of  all  kinds  is  the  corner- 
stone of  the  differences  between  the  two  groups  of 
men. 

The  advent  of  a  book  written  by  a  clergyman 
from  a  scientific  viewpoint  is  an  event  to  be  noted. 
In  Dr.  Cutten's  work  the  various  phenomena  asso- 
ciated witli  religious  manifestations  are  analyzed 
from  the  viewpoint  of  psychology. 

Dr.  Cutten  subdivides  his  subject  into  mysticism, 
ecstasy,  glossolalia.  visions,  dreams,  stigmatizatioti. 
witchcraft,  demoniacal  possession,  monasticism  and 
asceticism,  religious  epidemics,  contagious  phenom- 
ena, revivals,  faith  cure.  Christian  Science,  the 
miracles,  conversion,  age.  sex.  intellect,  knowledge, 
imagination,  inspiration,  will,  emotions,  worship, 
prayer,  sexuality,  denominationalism,  immortalit\'. 
and  preaching. 

The  reviewer  has  read  nearlv  everv  word  of  the 


824 


BOOK  NOTICES. 


[New  York 
Medical  Jolk.\'aL_ 


book  with  a  great  deal  of  pleasure.  The  subject  is 
treated  in  a  sane  manner  without  emotionalism  and 
without  sensationalism.  It  may  be  read  with  profit 
by  any  physician  who  cares  to  get  an  idea  of  the 
mental  attitude  of  those  who  pass  through  violent 
religious  experiences  and  of  those  who  fail  to  have 
such  experiences. 

The  Xczi'  Standard  Foniiulary.  Volume  I.  Pharmaceutical 
Preparations.  Comprising  all  Preparations  Official  or 
Included  in  the  Pharmacopoeias,  Dispensatories,  or  For- 
mularies of  the  World,  together  with  a  Vast  Collection 
from  Other  Sources,  the  Whole  Embracing  the  Entire 
Field  of  Pharmaceutical  Preparations  as  related  to  all 
Schools  of  Medical  Practice.  By  A.  Emil  Hiss,  Ph.  G., 
and  .Albert  E.  Ebekt,  Ph.  M.,  Ph.  D.  Chicago :  G.  P. 
Engelhard  &  Co..  1908.    Pp.  576. 

The  Standard  Formulary  belongs  to  a  rather 
numerous  class  of  recipe  books  in  use  by  pharma- 
cists. pul)lished  in  one  volume.  In  the  enlargement 
of  the  formulary  it  is  intended  to  spread  the  matter 
over  a  series  of  six  volumes,  of  which  the  book  be- 
fore us  is  No.  I.  As  explained  in  the  title,  the  ob- 
ject of  the  compilers  has  been  to  bring  together  a 
collection  of  the  official  preparations  of  all  pharma- 
copoeias and  dispensatories  w'ithout  distinction  as 
to  schools  of  inedical  practice.  The  arrangement  is 
alphabetical  for  the  most  part.  liniments  being 
grouped  by  themselves,  and  powders,  etc.,  the  same, 
though  without  any  chapter  division.  The  collec- 
tion of  formulas  is  a  somewhat  miscellaneous  one, 
and  the  book  has  a  somewhat  hodge-podge  appear- 
ance. It  is  not  a  work  w'hich  is  calculated  to  be  of 
much  value  to  medical  men  who  may  possess  a  copy 
of  one  of  the  dispensatories,  but  pharmacists  are 
likely  to  find  it  useful  in  many  ways.  The  book  is 
provided  with  a  good  index,  but  it  is  marred  by  the 
appearance  of  so  called  reform  spelling  in  which 
liberties  are  taken  with  pharmacopoeial  nomencla- 
ture to  the  confusion  of  the  reader. 

A  Textbook  of  Medical  Chemistry  and  Toxicology.  By 
By  J.\MES  W.  Holland,  A.  M.,  M.  D.,  Professor  of  Med- 
ical Chemistry  and  Toxicology,  and  Dean,  Jefferson  Med- 
ical College,  Philadelphia.  Fully  Illustrated.  Second 
Edition,  Revised  and  Enlarged.  Philadelphia  and  Lon- 
don :  W.  B.  Saunders  Company,  1908.    Pp.  655. 

In  looking  through  the  second  edition  of  this 
work  we  note  that  the  volume  is  in  accord  with  the 
latest  revision  of  the  United  States  Pharmacopoeia 
and  otherwise  brought  abreast  of  recent  advances 
in  medicine,  pharmacy,  and  chemistry.  In  the 
monographs  pertaining  to  physiological  chemistry 
the  subject  of  the  chemistry  of  foods  and  their 
changes  in  the  body  is  included,  in,  of  course,  a  con- 
densed form.  Xote  is  made  of  recent  improvements 
in  urinary  tests,  and  the  chapter  in  which  the  subject 
is  treated  is  illustrated  with  handsome  colored  plates 
showing  the  appearance  of  urinary  sedimentation, 
the  phloridzin  reaction,  etc.  The  equivalents  of 
doses  in  the  metric  and  the  apothecaries  systems  as 
given  by  the  author  are  not  always  in  agreement, 
and  in  some  places  he  takes  too  much  pains  to  give 
the  exact  ef|uivalents  in  minute  fractions  and  deci- 
mals. Under  vn\<:fitra  crctcc,  page  240,  the  dose  is 
stated  as  follows:  "Dose:  f.  dr.  (7.39  C.  C.)."  As 
four  fluid  drachms — if  this  is  what  is  meant  by  the 
abbreviation  —  represent  approximately  15.5  c.c, 
and  7.39  c.c.  is  nearly  the  exact  equivalent  of  two 
fluid  drachms,  the  error  is  plain. 


The  toxicological  notes  interspersed  throughout 
the  text  are  accurate  and  trustworthy  in  the  main. 
With  regard  to  the  antidote  for  carbolic  acid,  we 
concur  ui  the  author's  statement  that  dependence 
should  not  be  placed  on  alcohol,  but  it  is  question- 
able whether  the  best  results  in  the  antidoting  of 
phenol  are  to  be  obtained  by  washing  out  the  stom- 
ach with  a  solution  of  sodiuin  sulphate  alone.  Lime 
has  a  ready  affinity  for  carbolic  acid  and  has  the. ad- 
vantage of  producing  an  insoluble  compound,  which 
cannot  be  said  of  sodium  sulphate.  We  should  be 
disposed  to  place  rather  more  dependence  on  a  solu- 
tion of  saccharated  lime,  for  example,  than  on  a 
solution  of  sodium  sulphate,  since,  in  the  chemical 
antidoting  of  poisons,  the  aim  should  be  to  turn  a 
soluble  poison  into  an  insoluble  compound. 

The  author  gives  "Preston  salts"  as  a  synonym 
for  ammonium  carbonate,  but  this  is  scarcely  accu- 
rate. The  name  Pre.'^ton  salt  was  originally  applied 
to  a  squat,  large  mouthed  bottle  filled  with  a  mix- 
ture of  ammonium  carbonate,  stronger  ammonia 
water,  and  various  odoriferous  essences,  among 
which  oil  of  lavender  and  essence  of  musk  predom- 
inated. This  is  what  an  apothecary  would  be  likely 
to  dispense  on  a  prescription  for  Preston  salts. 

Studies  in  Paranoia.  Periodic  Paranoia  and  the  Origin  of 
Paranoid  Delusions.  By  Dr.  Nikolaus  Gierlich.  Wies-  ■ 
baden ;  and  Contributions  to  tlie  Study  of  Paranoia.  By 
Dr.  M.  Friedmaxx,  Mannheim.  Translated  and  Edited 
by  Smith  Ely  Jelliffe,  M.  D.  New  York:  Journal  of 
Nervous  and  Mental  Disease  Publishing  Company.  1908. 
Pp.  790. 

The  two  papers  incorporated  in  this  pamphlet  are 
of  distinct  value  to  the  student  of  morbid  mental 
phenomena,  and  the  translator  is  entitled  to  thanks 
for  bringing  them  within  the  ken  of  the  English 
reading  scholar.  As  Dr.  Jelliffe  remarks  in  his  in- 
troduction, "It  is  clearly  realized  by  all  students  that 
many  recoverable  conditions  often  show  in  certain 
phases  of  their  evolution  the  true  paranoid  coloring ; 
this  is  eminently  true  for  certain  alcoholic  psychotic 
states  and  for  the  Kraepelinian  group  of  manic  de- 
pressions, but  both  Gierlich  and  Friedmann  bring 
into  prominence  the  fact  that  certain  diseased  men- 
tal reactions  which  have  heretofore  been  regarded 
as  bearing  the  stamp  of  chronicity  are  not  infre- 
quently recoverable,  and  although  thought  of  as  in 
the  category  of  true  paranoia,  they  may  be  consid- 
ered as  mild  and  for  all  practical  purposes  curable." 

Dr.  Jelliffe  has  done  his  w'ork  with  conscientious 
care ;  and,  so  far  as  we  have  noticed,  there  are  few 
if  any  rough  places  in  this  work. 

NEW  PUBLICATIONS. 
Anatomy,  Histology,  and  Microscopy. 
Bailey.  Frederick  Randolph,  and  Miller,  Adam  Marion. — 
Textbook  of  Embryology.  With  Five  Hundred  and  Fifteen 
Illustrations.    New  York:  William  Wood  &  Co.,  1909.  Pp. 
xiv-672.    (Price,  $4.50.) 

Frost.  Rudolf. — Die  Grundziige  der  Zellmechanik  und  dcr 
normalen  Zcllentwicklung.  Wiesbaden :  J.  F.  Bergmann, 
1 909.    Pp.  I  1 2. 

Ballovjitc,  E. — Morpliologische  .\rbeiten  aus  dem  anato- 
mischen  und  zootomischcn  Institut  der  kijniglichen  Uni- 
versitat  Munster  i.  W.  Zweiter  Band.  Heft  i.  Mit  12S 
Abbildungen  und  5  Tafeln.  Leipzig:  W.  Engelmann.  1909. 
Pp.  128. 

Sissl,  Franc,  nnd  .Alzheimer,  Alois. — Histologische  und 
histopathologische  .Arln-iten.  iibe.r  die  Grosshirnrinde.  mil 
besonderer  Beriicksichtigung  der  pathologischen  Anatomic 


-April  17,  1909.] 


BOOK  NOTICES. 


82s 


•der  Geisteskrankheiten.    Dritter  Band,  i.  Heft.    Mit  6  Ab- 
bildungen  und  15  Tafeln.    Jena :  G.  Fischer,  1909.    Pp.  198. 
Physiology. 

Bcctcrcw,  W. — Les  Fonctions  bulbomedullaires.  Avec 
14  figures.    Paris :  Doin  et  fils.    Pp.  400. 

Hcrtzi-ig,  Oskar. — Die  Entwickelung  der  Biologic  im 
neunzehnten  Jaiirhundert.  Vortrag  gehalten  auf  der  Ver- 
sammlung  deutscher  Naturforscher  zu  Aachen  am  17  Sep- 
tember. 1900.  Zweite  erweiterte  Auflage  mit  einem  Zusatz : 
Ueber  den  gegenwartigen  Stand  des  Darwinismus.  Jena : 
Giistav  Fischer,  1908.    Pp.  46. 

Starling,  Ernest  H. — The  Herter  Lectures  (New  York, 
1908)  on  the  Fluids  of  the  Body.  Chicago  :-W.  T.  Keener 
&  Co.,  1909.    Pp.  viii-186. 

Kiss.  Julius. — Das  periodische  System  der  Elemente  und 
die  Gifcvvirkung.  Beitrage  zur  physikalischen  Chemie  der 
Zelle.  Mit  6  Fi.guren.  Wien  und  Leipzig :  Alfred  Holder, 
1909.    Pp.  vi-182. 

Internal  Medicine. 
Sokolozi'sky.     R. — Larynxtuberkulose     und  Graviditat. 
Halle  a.S. :  Carl  Marhold,  1908.    Pp.  28. 

Von  Noorden,  Carl. — Sammlung  klinisclier  Abhandlungen 
iiber  Pathologic  und  Therapie  der  Stoffwechsel-  und  Er- 
nahrungstorungen,  vii  und  viii  Heft.  Ueber  die  Behandlung 
einigcr  wichtiger  Stoff wechselstorungen  ( Hungerzustand, 
Mastkuren,  Entfettungskuren,  Gicht).  Berlin:  August 
Hirschwald,  1909.    Pp.  viii-106. 

Wolff-Eisner,  A. — Friihdiagnose  und  Tuberkulosc-Im- 
munitat.  L'nter  Beriicksichtigung  der  neuesten  Forschun- 
gen :  Konjunktival-  und  Cutan-Reaktion.  Opsonine,  etc., 
speziell  der  Therapie  und  Prognose  der  Tuberkulose.  Ein 
Lehrbuch  fiir  Aerzte  und  Studierende.  Mit  einem  Vorvvort 
von  Professor  Dr.  H.  Senator  und  Professor  Dr.  A.  Was- 
sermann.  Mit  7  farbigen  lithographischcn  Tafeln,  i 
shwarzen  Tafel,  14  Kurventafeln,  zahlreichen  Abbildungen 
und  Kurven  im  Text.  Zweite  vermehrte  Auflage.  Wiirz- 
iDurg:  Curt  Kabitzsch,  1909.    Pp.  x-378. 

ScJiwalbc.  J. — Lehrbuch  der  Greisenkrankheiten.  Stutt- 
gart :  F.  Enke,  1909.    Pp.  914. 

Jehlc,  Ludvjig. — Die  lordotische  Albuminuric  (ortlio- 
statische  Albuminuric).  Ihr  Wesen  und  ihre  Therapie. 
Mit  6  Textabbildungen  und  einer  Tafel.  Leipzig  und 
Wien  :  Franz  Deutickc.  1909.    Pp.  114. 

I'Vinckler,  A.vel.—V ehtr  die  Behandlung  der  Gicht  mit 
Schlammbadern.  Zweite  Auflage.  Miinchen :  Vcrlag  der 
arztlichen  Rundschau.  1908.    Pp.  19. 

Bach,  H. — Vorksungen  fiber  Herzkrankheiten.  Erstes 
Heft :  Die  Erkrankung  des  Herzmuskels,  Histologic,  path- 
ologische  Anatomic,  Diagnose  und  Therapie.  Mit  Abbil- 
dungen.   Miinchen  :  J.  J.  Lentner,  1908.    Pp.  86. 

Bhintschli,  H. — Die  Bedeutung  der  Leibesiibungen  fiir  die 
gesunde  Entwicklung  des  Korpers.  Anatomische  Betrachi- 
gung  in  gcmeinverstandlicher  Darstellung.  Mit  25  Abbil- 
dungen.   Miinchen:  E.  Reinhardt,  1909.    Pp.  86. 

Madcr.  M. — Behandlung  und  Hcilung  der  Tuberkulose 
(Lungenschwindsucht),  gemeinfasslich  dargestellt.  Mit 
Abbildungen.    Graz :  Styria,  1909.    Pp.  26. 

MathicH.  Albrecht,  et  Rou.v,  J.  C/iar/c^.— Pathologic  gas- 
trointestinal clinique  et  therapeutique.  Paris :  Doin  et 
file.    Pp.  524. 

Surgery. 

Orth.  J. — Ueber  die  Krebsgcschwulst  des  Menschen. 
Berlin  :  G.  Reimer,  1909.    Pp.  125. 

Rose.  C. — Ueber  die  Wirkungsweise  der  Gaumen-  und 
Schhmdmuskulatur  bei  angeborener  Gaumenspalte.  Mit 
Abbildungen.    Berlin:  J.  Springer,  1909.    Pp.  26. 

Congres  de  chirurgie,  2ime  session  dc  I'Association  fran- 
gaise  de  chirurgie.  Avec  170  figures  et  planches.  Paris: 
Felix  Alcan.    Pp.  1043. 

Biiinic.  John  Fairbairn.—Mamm]  of  Operative  Surgerv. 
Volume  I.  Operations  on  the  Head,  Neck.  Nerves.  Trunk, 
Genitourinary  System.  Fourth  Edition,  Revised  and  En- 
larged, with  713  Illustrations,  a  Number  of  which  are 
printed  m  Colors.  Philadelphia :  P.  B!akiston"s  Son  &  Co  . 
1909-    Pp.  xi-832.    (Price,  $3.50.) 

Cntc.  George  fF.— Haemorrhage  and  Transfusion.  An 
Experimental  and  Clinical  Research.  New  York  and  Lon- 
don :  D.  Appleton  &  Co.,  1909.    Pp.  xiii-550. 

Rlcdingcr,  F..  und  Bayer,  if.— Ueber  die  Wirkung  mod- 
erner  Projektile.  Festrede  zur  Feier  des  59.  Stiftungs- 
festes  der  physikalisch-medizinischcn  Gesellschaft  zu  Wurz- 
burg.  :Mit  neun  Rontgen-  und  drei  Geschosstafeln.  Wiirz- 
burg:  Curt  Kabitsch.  1909.    Pp.  30. 


Obstetrics  and  Gyncecology. 

Baum,  P.,  und  Graefe,  M. — Beitrage  zu  neueren  thera- 
peutischen  Massnahmen  in  der  Geburtshilfe.  Ueber  Para- 
metritis posterior  und  ilire  Behandlung.  Halle  a.S.:  Carl 
Marhold,  1909.    Pp.  55. 

Hdlzl,  Marie. — Die  Mutter.  Ein  Gelcitbuch  fiir  die  junge 
Frau.  Neu  bearbeitet  von  Therese  Danner.  Sechste  ver- 
besserte  Auflage.    Miinchen:  E.  Reinhardt,  1909.    Pp.  122. 

Arendt. — Die  klimaktcrischcn  Beschwerden  und  ihre 
physikalisch-diatetische  Behandlung.  Vortrag.  Berlin : 
J.  Goldschmidt,  1909.    Pp.  12. 

Abraham,  Otto. — Verhaltungsmassregeln  fiir  Schwanger- 
schaft,    Entbindung    und    Wochenbett,    fiir    Mutter  und 
Pflegerinnen.    Mit  i  Figuren.    Berlin :  L.  Simion  Nach- 
.  folger,  1909.    Pp.  25. 

Kilstner,  Otto. — Kaiserschnitt.  Riickblicke  und  Ausblicke. 
Stuttgart :  F.  Enke,  1909.    Pp.  77. 

Neurology  and  Psychiatry. 

Handbook  for  Attendants  on  the  Insane.  Fifth  Edition. 
Revised  and  Enlarged.  Thirtj'-third  Thousand.  Published 
by  the  Authority  of  the  ^ledicopsychological  Association. 
Chicago :  W.  T.  Keener  &  Co.,  1909.  Pp.  xvi-390'.  ( Price, 
$1.00.) 

Savjyer,  H.  C. — The  ^Matter  with  Nervousness.  San 
Francisco  and  Los  Angeles  :  Cunningham,  Curtiss,  &  \\'elch, 
1909.  Pp.  X-210. 

Hesnard,  A. — Les  Troubles  de  la  personalite  dans  les 
etats  d'asthenie  psychique.    Paris :  F.  Alcan. 

Cesbron,  Henri. — Histoire  critique  de  I'hysterie.  Paris: 
Asselin  et  Houzcau.    Pp.  340. 

Taillens. — Les  Causes  des  maladies  nerveuses.  Lausanne 
et  Paris :  Theodor  Sack-Rcymond.    Pp.  43. 

Grasset,  J. — Le  Tabes,  maladie  de  la  sensibilite  profonde. 
Lecons  cliniques,  publiees  par  L.  Rimbaud.  MontpelHcr : 
Coulct  et  fils.    (Paris:  Masson  et  cie.)    Pp.  124. 

Falkenberg.  WilheUn. — Die  Pflege  Geisteskranker.  An- 
leitung  zum  Krankendienst  fiir  Pfleger  und  Pflegerinnen. 
Zweite  neubearbeitetc  Auflage.  Leipzig:  G.  Thieme,  1909. 
Pp.  48. 

Sidxs,  Boris. — Psychopatliological  Researches.  Studies  in 
^lental  Dissociation.  With  figures  and  Ten  Plates.  Lon- 
don :  W.  Rider   Pp.  352. 

Laqucr,  L. — Die  arztlichc  Fcststellung  der  verscbiedenen 
Formen  des  Schwachsinns  in  den  ersten  Schuljahren. 
Zweite  verbesserte  Auflage.  Miinchen :  Vcrlag  der  arzt- 
lichc Rundschau,  1909.    Pp.  37. 

Opthahiiology. 

Stilling,  J. — Pseudoisochromatische  Tafeln  zur  Priifung 
des  Farbensinnes.  Zwolfte  Ausgabe.  Mit  14  farbigen 
Tafeln.    Leipzig:  G.  Thieme,  1909. 

Roth,  A. — Sehproben,  nach  Snellens  Prinzip  entworfen. 
Zweite  Auflage.  Erster  Teil,  5  Tafeln  mit  4  Text-Bei- 
lagen.    Zweiter  Teil,  2  Tafeln.    Leipzig:  G.  Thieme,  1909. 

Wilbrand,  H.,  und  Saenger,  A. — Die  Neurologic  des 
Auges.  Ein  Handbuch  fiir  Nerven-  und  Augenarzte.  Vier- 
ter  Band,  i  Halfte.  Die  Pathologic  der  Netzhaut.  Mit 
zahlreichen  Textabbildungen.  Wiesbaden  :  J.  F.  Bergmann, 
1909.    Pp.  463. 

Hoor,  Karl. — Die  parenchmyatose  Hornhautenziindung. 
Halle  a.S.:  Carl  Marhold,  1909.    Pp.  124. 

Dermatology. 

Darier,  J. — Precis  de  dermatologic.     Avec  122  figures. 
Paris :  Masson  et  fils.    Pp.  707. 

Third  Annual  Report  of  the  St.  Louis  Skin  and  Cancer 
Hospital,  1908.    Pp.  42. 

Venereal  and  Genitourinary  Diseases. 

Deguy,  M. — Therapeutique  venerienne.    Avec  24  figures. 
Paris :  G.  Steinheil.    Pp.  280. 

Emmel,  Eduard. — Die  Hcilung  der  Sj-pbilis  durch  die 
physikalisch-diatetische  Hcilmethode  ohne  Quccksilber. 
Leipzig:  M.  Spohr,  1909.    Pp.  27. 

Luys.  Georges. — Exploration  de  I'appareil  urinairc, 
Deuxieme  edition,  augmentee.  Avec  226  figures  et  6 
planches  colore.    Paris :  Masson  et  cie.    Pp.  610. 

Pcediatrics. 

Schlesinger,  Eugene. — Moderne  Sauglingsfiirsorge.  Die 
Bekiimpfung  der  grossen  Kindcrstcrbliclikeit  in  Deutsch- 
land  durch  Vereine,  stadtische  und  staatliche  Behorden. 
Strassburg:  Schleiser  &  Schweighardt,  1909.    Pp.  150. 

Pazvlinozu,  C. — Kongenitale  Mitralstenose  (Durozier'sche 
Krankhcit),  Chlorose.  Lungentuberkulose,  in  ihren  Bezie- 
hungen  zur  schwachen  Konstitution  des  Organismus.  Ber- 
lin: August  Hirschwald,  1909.    Pp.  75. 


826 


MISCELLANY. 


|Ne  V  York 
Medical  Journal. 


Cci-niy,  Adolf,  und  Keller,  A. —  Des  Kindes  lirnahruiig, 
Ernahrungsstorungcn  und  lirniihriiiigslherapie.  Ein  Hand- 
buch  fiir  Aerzte.  7  Ablciluiig.  Zwc-iter  Band.  Alit  Ab- 
bildungen.    Wien :  F.  Deuticke,  1909.    Pp.  256. 

Ascliaffcnburg,  G. — Dc-  Sclilaf  im  Kindesalter  und 
seine  Storungen.  Mit  4  Abbildungen.  Wiesbaden :  J,  F. 
Bergniann,  1909.    Pp.  2,3. 

Hygiene  and  Public  Health. 

Kot>p.  Carl. — Das  Geschlechtliche  in  der  Jugenderzie- 
luing.  Zvveite  unveranderte  Auflage.  Leipzig :  Johann 
Ambrose  Earth,  1908.    Pp.  20. 

Jaffc,  K. — Ueber  den  gegenwiirtigen  Stand  der  Frage  der 
sexuellen  Jugcndbelehrung.  Leipzig :  Johann  Ambrose 
Earth,  1909.    Pp.  20. 

Hoffmann,  IV.  Experimentelles  iiber  das  Warmelei- 
tungsvermogen  des  Linoleums  im  Vergleich  zu  Holzfuss- 
Ijoden.  Mit  4  Abbildungen.  Charlottenburg :  P.  J.  Mul- 
len 1908. 

Heymann,  Bruno. — Der  praktisclic  Desinfektor.  xii 
Heftc.  i  Heft,  mit  i  Abbildungen.  Berlin :  Deutscher 
Verlag  fiir  Volksvvohlfahrt.    Jahrgang,  1909. 

Blcivergiftungen  in  hiittenmannischen  und  gevyerblichen 
Eetrieben,  Ursachen  und  Eekampiung.  Herausgegeben 
vom  k.  k.  arbcitsstatisiischcn  Amt  im  Handelsministerinm. 
vii  Teil.  Bericht  und  Protokoll  iiber  die  Erhebungen  in 
Buch-.  Steindruckereinen  usw.  und  in  Scliriftgiessereien. 
W' ien  :  A.  Holder,  1909.    Pp.  78. 

Therapeutics. 

Edmunds.  Charles  Wallis.  and  Hale.  Worth. — The  Phy 
siological  Standardization  of  Digitalis.    Bulletin  No.  48  of 
the   Hygienic   Laboratory   of   the   United    States  Public 
Health  and  Marine  Hospital  Service.    Washington:  Gov- 
ernment Printing  Office,  1909.    Pp.  61. 

Bon  jour,  J. — La  Suggestion  hypnotique  et  la  pyscho- 
therapie  actuellc.  Lausanne  et  Paris :  Theodor  Sack-Rey- 
mond,  1908.    Pp.  III. 

Bachem,  C. — Unsere  Schlafmittel  mit  besonderer  Be- 
riicksichtigung  der  neueren.  Mit  i  Kurve'im  Text.  Ber- 
lin :  August  Hirschvvald,  1909.    Pp.  88. 

Grassct. — L'Hypnotisme  et  la  suggestion.  Troisieme 
edition.    Avec  figures.    Paris :  Doin  et  fils.    Pp.  500. 

Pcnzoldt,  P.,  und  Stintaing.  K. — Handbuch  der  gesamten 
Therapie  in  sieben  Banden.    Vierte  Auflage  des  Handbuchs 
der  Therapie  innerer  Krankheiten.    Band  i,  init  3  Abbil 
dungen.    Jena :  G.  Fischer,  1909.    Pp.  80. 

Electricity,  Rontgen  Rays,  and  Emanations. 

Raffety,  Charles  IV. — An  Introduction  to  the  Science  of 
Radioactivity.  With  Illustrations.  London,  New  York, 
Bombay,  and  Calcutta :  Longmans,  Green,  &  Co.,  1909. 
Pp.  xii-208. 

Miscellaneous. 

Sudnoff,  A'aW.— Studien  zur  Geschiclite  der  Medezin,  he- 
rausgegeben von  der  Puschmann-Stiftung  an  der  Universi- 
tat  Leipzig.   Leipzig:  J.  A.  Barth. 

Edcl,  Ma.v. — Festschrift  zum  40  jiihrigen  Bestehen  der 
Edel'sclien  Heilanstak  fiir  Gemiits-  und  Ncrvenkranke  zu 
Charlottenburg,  1869-1909.  Mit  Vorwort  von  Wilhelm 
Sander.  Mit  i  Portrait,  4  Tafeln,  Abbildungen  und 
Planchen.    Berlin  :  A.  Hirschvvald,  1909.    Pp.  155. 

Hocrnes,  M.— Natur-  und  Urgeschichte  des  Menschen. 
In  zwei  Banden.  Mit  7  Karten  und  iiber  500  Abbildungen. 
In  25  Licferungen.  i  Lieferung,  mit  i  Tafeln.  Wien:  A. 
Hartleben,  1909. 

Slurmer,  Julius  IFiV/w/;;.— Rudiments  of  Latin.  With 
Special  Reference  to  the  Nomenclature  of  the  U.  S.  Phar- 
macopoeia, the  National  Formulary,  and  the  Textbooks  in 
Materia  Mcdica  and  Botany.  Including  also  Prescription 
Writing  and  Notes  on  the  Nomenclature  of  the  German 
Pharmacopeia.  Lafayette,  Ind. :  Published  bv  the  author 
Pp.  92.    (Price,  $1.) 

Report  of  the  Commissioner  of  Education  for  the  Year 
Ended  June  30.  igaS.  Volume  I.  Washington:  Govern- 
ment Printing  Office,  igaS.    Pp  vi-382. 

Transactions  of  the  College  of  Physicians  of  Philadel- 
phia. Third  Scries.  Volume  XHI,  Philadelphia:  Printed 
for  the  college,  1908.    Pp.  lii-256. 

Annual  Report  of  tlie  Library  .Conimitee  of  the  College 
of  Physicians  of  Philadelphia  for  the  Year  1908.  Reprinted 
from  the  Transactions,  Third  Series,  XXX,  1908. 

Thirty-seventh  .Annual  Report  of  the  Roosevelt  Hospital, 
New  York.  From  January  r,  1908,  to  December  ?i  igoS' 
Pp  146. 


Annual  Report  of  the  Surgeon  General  of  the  Public 
Health  and  Marine  Hospital  Service  of  the  United  States 
for  the  Fiscal  Year  1908.  Washington:  Government  Print- 
ing Office,  1909.    Pp.  220. 

An  Analytical  Index  to  Volumes  I  to  X  of  the  Medical 
Review,  and  a  Digest  of  the  Facts  Important  to  the  Prac- 
titioner in  the  Medical  Periodicals  of  the  World.  1898- 
1907.    London:  The  Medical  Review,  1908.    Pp.  201. 

Brenning,  M„  und  Opfenheiiner,  E.  H. — Der  Schiffsarzt. 
Leitfaden  fiir  Aerzte  und  Kandidaten  der  Medezin.  Mit 
Angabe  der  Rcedereien,  ihrer  Linien  und  Anstellungs- 
Bedingungen  und  Beriicksichtigung  aller  einschlagigen 
Fragen.  Mit  ^  Textfiguren.  Berlin  :  August  Hirschwald, 
1909.    Pp.  vi-79. 


Piifcllaiiii. 


Mastoiditis. — In  our  issue  for  February  13th  we 
]niblishcd  an  article  entitled  Results  in  Four  Hun- 
dred Operative  Cases  of  Mastoiditis,  by  Dr.  F. 
Phiniz}-  Calhoun,  of  Atlanta.  Dr.  Calhoun  now 
writes  to  us  that  by  an  o^•ersight  he  did  not  men- 
tion that  the  case  histories  were  taken  froin  the 
records  of  the  New  York  Eye  and  Ear  Infirmary, 
where  they  were  treated  during  his  interneship  by 
Dr.  Bacon,  Dr.  Dench,  Dr.  McKenion.  Dr.  Adams, 
Dr.  Whiting,  and  Dr.  Lewis. 

Resolutions  on  the  Death  of  Robert  Alexander 
Murray. — The  Society  of  the  Alumni  of  Bellevue 
Hospital  at  its  last  meeting  adopted  the  following- 
resolution  : 

It  becomes  the  painful  duty  of  your  committee  to  record 
the  death  of  our  colleague.  Dr.  Robert  A.  Murray,  on 
February  27,  1909. 

Robert  Alexander  Murray  was  burn,  of  Scotch  ancestry, 
in  this  city,  fifty-seven  years  ago  last  January.  He  took 
the  degree  of  bachelor  of  science-  at  the  College  of  the 
City  of  New  York  in  1871  and  that  ui  doctor  of  medicine 
in  the  New  York  University  Medical  College  in  1873,  and 
in  the  same  year  became  an  interne  in  Bellevue  Hospital, 
serving  on  the  second  medical  division.  He  was  visiting 
physician-  to  the  Northwestern  Dispensary,  diseases  of 
women,  1876-1883;  visiting  physician  to  the  Workhouse 
and  Almshouse  Hospitals  1880-1884;  visiting  obstetrician 
to  the  Maternity  Hospital,  Blackwell's  Island,  1884-1895; 
assistant  professor  of  obstetrics.  New  York  University 
Medical  College,  1876- 1886.  At  the  time  of  his  death  he 
was  associate  obstetrician  to  the  French  Hospital  and  as- 
sistant visiting  surgeon  to  the  Wonian's  Hospital. 

He  was  a  member  of  the  American  Medical  Association: 
the  Congress  of  American  Physicians  and  Surgeons :  the 
American  Gynaecological  Society  a>  well  as  many  local 
medical  societies.  He  had  been  president  of  the  Obstet- 
rical, Medicosurgical,  and  Northwestern  Medical  and  Sur- 
gical S(.)cieties:  chairman  of  the  section  in  obstetrics  of  the 
Academy  of  Medicine :  a  \  ice  president  and  acting  presi- 
dent of  the  County  Medical  Society :  and  at  the  time  of 
his  death  he  was  president  of  the  Society  of  Medical 
Jurisprudence  for  1909.  * 

As  a  regular  attendant  at  our  meetings  the  wide  range 
of  his  professional  experience  ga\e  dignity  tc  his  participa- 
tion in  discussion,  while  his  happv  disposition  endeared  him 
to  all. 

Above  all  he  belonged  to  the  t\pe  physician  fast  dis-  • 
appearing,  the  "'family  doctor,""  and  a-  the  "'family  doctor" 
he  became  a  martyr  to  his  conscientK'H-  regard  for  his 
professional  dutv.  Stricken  with  pleurc>pneiini()nia.  he  was 
fifteen  hours  later  forcibly  taken  from  the  bedside  of  a 
toxa?mic  woman  to  his  home  and  to  the  bed  from  which  he 
never  arose.  Thus  he  was  faithful  to  the  end.  for  saith 
the  Divine  Physician  :  "Greater  love  hath  no  man  than  this, 
that  he  lay  down  his  life  for  his  friend." 

Your  Committee  also  present-  the  following  preamble 
and  resolutions  : 

Wherkvs  it  has  pleased  .Mmiphty  God  I0  remove  from 


April  17,  1909.] 


OFFICIAL  NEWS. 


827 


the  sphere  of  his  earthly  usefulness  our  colleague,  Dr. 
Robert  Alexander  Murray ;  therefore 

Resolved,  that  we  note  our  sincere  sorrow  for  the  great 
loss  we  have  sustained,  that  we  appreciate  fully  his  genial 
and  attractive  personality  and  his  high  and  conscientious 
character. 

Resolved,  that  we  extend  to  the  members  of  his  family 
our  heartfelt  sympathy  and  sincere  condolences  in  this 
their  hour  of  grief  and  sorrow. 

Resolved,  that  this  memorial,  and  this  preamble  and 
resolutions  be  spread  in  full  upon  the  minutes  of  this 
societj',  that  a  copy  be  sent  to  each  of  the  two  local  medical 
journals  for  publication,  and  to  the  family  of  our  deceased 
colleague. 

(Signed)  Richard  Kalish, 

Edward  D.  Fisher, 

Committee. 

 ^  


Public   Health   and   Marine    Hospital  Service 
Health  Reports: 

The  follozving  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  week  ending  April  9,  igog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 
California — Oakland  Jan.  7-31. 


Feb. 

California — San  Francisco  Mar. 

District  of  Columbia — Washington.  Mar. 

Illinois — Danville  Mar. 

Illinois — Springfield  :  Mar. 

Indiana — La  Fayette  Mar. 

Indiana — South  Bend  Mar. 

Kansas — Kansas   City  Mar. 

Kentucky — Covington  Mar. 

Kentucky — Lexington  Mar. 


-Mar.   21   3 

13-20   ' 

20-  27   I 

21-  28   7 

19-  26   3 

22-  29   2 

20-  27   I 

20-27   4 

20-27   5 

20-27   3 


20-27   ' 

13-27   3 

20-27   2 

20-27   2 

16-23   3 

20-27   1 

20-27   2 

19-  26   I 

i-Mar.  2. 

20-  Mar.  27 
20-27  

19-  26  

20-  27  

20-27 


200 
53 


Kentucky — Paducah  Mar.  20-27   ' 

Michigan^ — Detroit".  Mar. 

Michigan — Saginaw  Mar. 

Missouri — Kansas  City  Mar. 

Missouri — St.  Louis  Mar. 

Montana — Butte  Mar. 

Nebraska — South  Omaha  Mar. 

Xew  Jersey — New  Brunswick  Mar. 

Ohio — Cleveland  Mar. 

Tennessee — Fayette  County  Dec. 

Tennessee — Memphis  Feb. 

Tennessee — Nashville  Mar. 

Texas — Galveston  Mar. 

Texas — Houston  ilar. 

Texas — San  Antonio  Mar. 

Washington — Bellingham  Jan.  20-Mar.  20   3 

Washington — Spokane  Mar.  13-20 

Wisconsin — La  Crosse  Mar.  20-27 

Wisconsin — Racine  Mar.  20-27 

Smallpox — Insular. 
Philippine  Islands — Manila  Feb.  5-20. 

Smallpox — Foreign . 

Arabia — Aden  Feb. 

Brazil — Rio  de  Janeiro  Feb. 

Canada — Halifax  Mar. 

France — Paris  Jan. 

Great  Britain — Bristol  Mar. 

India — Bombay  Feb. 

India — Calcutta  Feb. 

India — Madras  Feb. 

India — Rangoon  Feb. 

Italy — General  Mar. 

Italy — Naples  Mar. 


33 


14-22 . 
14-28. 

13-20   6 

23-30   6 

6-  13   2 

23-Mar.  2  

13-20  

20-26  

13-20  

7-  14   5 

6-13   26 


27-Mar. 
27-Mar. 
6-27... 
14-21 .  . 
6-20.  . . 
6-13.  . . 


1-31  

1 4- Mar. 


Japan — Kobe  Feb.  27-Mar.  6. 

Martinique — Fort  de  France  Feb.  27-Mar.  6. 

Mexico — Mexico  City  Feb. 

Mexico — Monterey  Mar. 

Mexico — Veracruz  Mar. 

Netherlands — Rotterdam  Mar. 

Southeast  Africa — Lourenco  Mar- 

quez  Jan. 

Spain — Barcelona  Feb. 

Spain — Valencia  Feb.  27-Mar.  12   9 

Spain — Vigo  Mar.  6-13  

Straits  Settlements — Singapore ...  .Jan.  23-Feb.  13  

Turkey — Bassorah  Feb.  27-Mar.  6  

Turkey — Constantinople  Feb.  28-Mar.  14  

Yellow  Fever — Foreign. 

Barbados  Mar.  6-27   10 

Brazil — Manaos  Feb.  20-27  

Brazil — Para  Feb.  27-Mar.  6  

Cholera — Insular. 
Philippine  Islands — Provinces  Feb.   6-20  271 


16 

146 
4 

3 


34 
3 


Present 
6 


178 


Places. 


Brazil — Rio  de  Janeiro 

Chile — Arica  

Chile — -Antofagasta  

Chile — Iquique  


Date. 

Cholera — Foreign. 

 Feb.  13-28 

 Mar.   9.  . . 

 Feb.  28... 

,  Mar.  7-14. 


Cases.  Deaths. 


Egypt — Bombay  

Egypt — General  

German     East     .\frica — Dar 

Salaam   

India — Calcutta  

India — General  

India — Madras  

India — Rangoon  

Japan — Kobe  

Peru — Callao  

Peru — General  

Peru — Lima  Department  

Russia — Jaroslov  

Russia — Rubinsk  

Russia — St.  Petersburg  


.Feb.  24-Mar. 
.Mar.  11-18... 


Present 

15 

32 

In  Lazaretto 
153 


.  Oct.   lo-Jan.   7   7 

.Feb.  13-20  

Feb.   6-13  3-803 

Feb.  20-26  

Feb.  13-20  

.  Feb.  20-Mar.  6   2 

.Mar.  1-14   2 

.Feb.  28-Mar.  13  65 

.  Mar.  1-14   13 


.Mar. 
.Mar. 


28 
3,162 
I 
16 


33 
3 


.Mar.  12-19   41 


Public  Health  and  Marine  Hospital  Service: 

Oificial  list  of  changes  of  stations  and  duties  of  comnits- 
sioned  and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
April  7,  jgog: 

Brooks,,  S.  D.,  Surgeon.  Granted  two  days'  leave  of  ab- 
sence en  route  to  station. 

FoGARTY,  J.  N.,  Acting  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  March  26,  1909. 

Foster,  S.  B.,  Acting  Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence  from  April  19,  1909. 

Grace,  John  J.,  Acting  Assistant  Surgeon.  Granted  two 
months  and  twentj'-one  days'  extension  of  leave  of  ab- 
sence, without  pay,  from  April  10,  1909. 

Graham,  K.  H.,  Pharmacist.  Relieved  from  duty  at  Bal- 
timore, Md.,  and  directed  to  proceed  to  the  Savannah 
Quarantine  Station  and  report  to  the  Medical  Officer 
in  Command  for  temporary  duty. 

Herrixg,  R.  A.,  Assistant  Surgeon.  Granted  one  day's 
leave  of  absence  in  March,  1909,  under  paragraph  191, 
Service  Regulations. 

Hough,  J.  S.,  Acting  Assistant  Surgeon.  Granted  thirty 
days'  extension  of  annual  leave  on  account  of  sickness 
from  February  i,  1909. 

Hough,  J.  S.,  Acting  Assistant  Surgeon.  Granted  thirty 
days'  leave  of  absence  from  March  3,  1909,  and  four 
months'  leave  of  absence,  without  pay,  from  April  3, 
1909.  • 

McBride.  C.  R.,  Pharmacist.  Granted  nine  days'  leave  of 
absence  from  April  15,  1909. 

MacCaffev,  \V.  B.,  Acting  Assistant  Surgeon.  Granted 
one  day's  leave  of  absence  in  March,  1909,  under  para- 
graph 191,  Service  Regulations. 

MooRE,  Dunlop,  Passed  Assistant  Surgeon.  Granted  thirty 
days'  leave  of  absence  from  April  3,  1909. 

Salmon,  Thomas  W.,  Passed  Assistant  Surgeon.  Granted 
two  days'  leave  of  absence  from  March  8,  1909. 

Smith,  W.  S.,  Acting  Assistant  Surgeon.  Granted  an  in- 
definite leave  of  absence  without  pay. 

Spaxgler,  L.  C,  Pharmacist.  Upon  arrival  of  Pharmacist 
K.  H.  Graham,  directed  to  proceed  to  the  South  At- 
lantic Quarantine  Station  and  report  to  the  Medical 
Officer  in  Command  for  temporary  duty. 

Wetmore.  W.  O.,  Acting  Assistant  Surgeon.  Granted 
one  day's  leave  of  absence,  March  17,  1909. 

Wetmore,  W.  O.,  Acting  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  March  22,  1909,  un- 
der paragraph  210,  Service  Regulations. 

Boards  Convened. 
Boards  of  medical  officers  were  convened  to  meet  »on 

.April  5.  1909.  for  the  purpose  of  making  physical  examina- 
tions of  applicants  for  the  position  of  cadet  in  the  Revenue 

Cutter  Service,  as  follows : 

Milwaukee.  Wis. :  Surgeon  J.  O.  Cobb,  chairman ;  Act- 
ing Assistant  Surgeon  W.  E.  Fox.  recorder. 

Wilmington,  X.  C. :  Acting  Assistant  Surgeon  Thomas 

,\r.   Green,  chairman ;   Acting  Assistant  Surgeon  W.  D. 

MacMillen.  recorder. 

Boards  of  medical  officers  convened  to  meet  on  April 

15,  1909.  for  the  purpose  of  making  physical  examinations 

of  officers  of  the  Revenue  Cutter  Service  for  promotion,  as 

follows  : 


828 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal. 


New  York,  N.  Y. :  Passed  Assistant  Surgeon  C.  W. 
Vogel,  chairman;  Assistant  Surgeon  F.  A.  Ashford,  re- 
corder. 

Norfolk,  Va. :  Surgeon  C.  P.  Wertenbaker,  chairman ; 
Acting  Assistant  Surgeon  R.  W.  Browne,  recorder. 

Newbern,  N.  C. :  Acting  Assistant  Surgeon  t.  Duffy, 
chairman ;  Acting  Assistant  Surgeon  R.  S.  Primrose,  re- 
corder. 

San  Juan,  P.  R. :  Passed  Assistant  Surgeon  S.  B.  Grubbs, 
chairman;  Acting  Assistant  Surgeon  P.  del  V.  Atilles,  re- 
corder. 

Boston,  Mass.:  Surgeon  L.  L.  Williams,  chairman; 
Passed  Assistant  Surgeon  T.  W.  Salmon,  recorder. 

Port  Townsend,  Wash.:  Surgeon  W.  G.  Stimpson, 
chairman:  Acting  Assistant  Surgeon  L.  T.  Seavey,  re- 
corder. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Arnty  for  the  week  ending  April  lo,  1909. 
AsHBURN,  p.  M.,  Major,  Medical  Corps.     Assigned  to 

temporary  duty  in  the  office  of  the  Surgeon  General. 
Carter,  E.  C,  Lieutenant  Colonel,  Medical  Corps.  Granted 

leave  of  absence  for  fifteen  days. 
CuTUFFE,  W.  O.,  First  Lieutenant,  Medical  Reserve  Corps. 

Granted  leave  of  absence  for  two  months. 
GiLCHKi.ST,  H.  L.,  Major,  Medical  Corps.    Granted  an  ex- 
tension of  ten  days  to  leave  of  absence. 
Heysinger,  J.  D.,  Captain,  Medical  Corps.    Granted  leave 

of  absence  for  twenty-one  days. 
HoFF,  J.  V.  R.,  Colonel,  Medical  Corps.    Ordered  to  Fort 
Wayne,  Mich.,  Fort  Thomas,  Ky.,  and  Fort  Benjamin 
Harrison,  Ind.,  on  business  pertaining  to  the  Medical 
Department. 

McAndrew,  p.  H.,  Captain,  Medical  Corps.    Granted  leave 

of  absence  for  two  months. 
McCuLLocH,  C.  C,  Jr.,  Major,  Medical  Corps.  Relieved 

from  duty  with  the  Isthmian  Canal  Commission,  and 

ordered  to  duty  in  the  Philippines. 
MuRR.-w,  Alexander,  Captain,  Medical  Corps.    Ordered  to 

San  Francisco,  Cal.,  to  sail  May  5th,  for  service  in  the 

Philippines. 

Nichols,  H.  J.,  First  "Lieutenant,  Medical  Corps.  Relief 
from  duty  in  the  Philippines  Division  deferred  for 
three  months. 

Reno.  W.  W..  Captain,  Medical  Corps.  Relieved  from  duty 
in  the  Philippines  Division  and  assigned  to  duty  as 
Surgeon  of  the  transport  Kilpdtrick. 

RiCH.ARDS,  R.  L.,  Captain,  Medical  Corps.  Granted  leave 
of  absence  for  ten  days. 

Stockard,  J.  K.,  First  Lieutenant,  Medical  Reserve  Corps. 
Honorably  discharged  from  the  service  of  the  United 
States,  his  services  being  no  longer  required. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  iti  the  Medical  Corps  of  the  United  States 
Naty  for  the  zveek  ending  April  Jo,  igog: 
Clark,  G.  F.,  Acting  Assistant  Surgeon,    Detached  from 
instruction  at  the  Naval  Medical  School,  Washington, 
D.  C.  and  ordered  to  the  Naval  Hospital,  Narragan- 
sett  Bay,  R.  L 
Cole.  H.  W..  Assistant  Surgeon.    Detached  from  the  Navy 
Yard,  Charleston,  .S.  C,  and  ordered  to  the  Yankton. 
Foster,  T.  G.,  Assistant  Surgeon.    Detached  from  duty  at 
the  Naval  Hospital,  Narrangansetl  Bay,  R.  L,  and  or- 
dered  to   instruction   at  the   Naval   ^Icdical  School. 
Washington.  D.  C. 
Harlan.  T.,  Acting  Assistant  Surgeon.    Detached  from 
instructif)n  at  the  Naval  Medical  School,  Washington, 
D.  C,  and  ordered  to  the  Naval  Recruiting  Station, 
Pittsburgh,  Pa. 
Kerr.  W.  M.,  Acting  .Assistant  Surgeon,    Detached  from 
instruction  at  the  Naval  Medical  School,  Washington, 
D.  C,  and  ordered  to  the  Naval  Training  Station,  Nar- 
ragansolt  Bay,  R.  1. 
Ol.son.  (i.   M.,   Assistant   Surgeon.     Detached   from  the 
Naval  Recruiting  Station,  Pittsbtngh,  Pa.,  and  ordered 
to  instruction  at  the  Naval  Medical  School,  Washing- 
ington,  D.  C. 

Phelps,  J.  R..  Assistant  Surgeon.  Detached  from  the 
Yankton  and  ordered  to  the  .VcTt'  York  when  commis- 
sioned. 


Pickrell,  G.,  Surgeon.  Detached  from  the  Bureau  of 
Medicine  and  Surgery,  Navy  Department,  and  ordered 
to  duty  in  connection  with  the  fitting  out  of  the  Solace. 

RiKER.  G.  A.,  Acting  Assistant  Surgeon.  Detached  from 
instruction  at  the  Naval  Medicali  School,  Washington, 
D.  C,  and  ordered  to  the  Franklin. 

Scott,  T.  W.,  Pharmacist.  Detached  from  duty  at  the 
Naval  Hospital,  Annapolis,  Md.,  and  ordered  to  duly 
in  connection  with  the  fitting  out  of  the  Solace. 

Smith,  C.  W.,  Assistant  Surgeon.  Detached  from  duty  at 
the  Naval  Hospital,  Philadelphia,  Pa.,  and  ordered  to 
the  Naval  Hospital,  Norfolk,  Va. 

Strite,  C.  E.,  Assistant  Surgeon.  Detached  from  the  Na- 
val Hospital,  Norfolk,  Va.,  and  ordered  to  instruction 
at  the  Naval  Medical  School,  Washington,  D.  C. 

Ta\lor.  J.  S.,  Surgeon.  Detached  from  the  Naval  Hos- 
pital, New  York,  N.  Y.,  and  ordered  to  the  Ncia  York 
when  commissioned. 

Wheeler,  L.  H.,  Passed  Assistant  Surgeon.  Detached 
from  duty  at  the  Naval  Training  Station,  Narragansett 
Bay,  R.  L,  and  ordered  to  instruction  at  the  Naval 
Medical  School,  Washington,  D.  C, 

ZiEGLER.  J.  G.,  Acting  Assistant  Surgeon.  Detached  from 
instruction  at  the  Naval  Medical  School,  Washington, 
D.  C,  and  ordered  to  dut)-  at  the  Naval  Hospital, 
Pensacoia,  Fla. 

 <f>  


Born. 

Blaxchard. — In  Fort  Sheridan,  Illinois,  on  Saturday, 
.\pril  3d,  to  Captain  R.  M.  Blanchard,  Medical  Corps, 
United  States  Army,  and  Mrs.  Blanchard,  a  son. 

Stibbens, — In  Mare  Island,  California  on  Saturday,  Feb- 
ruary 27th,  to  Assistant  Surgeon  F.  H.  Stibbens,  United 
States  Navy,  and  Mrs.  Stibbens,  a  daughter. 

Married. 

Gordon — Wood. — In  New  York,  on  Saturday.  March 
20th,  Dr.  John  Kyle  Gordon  and  Miss  Eleanor  Wharton 
Wood. 

Died. 

Barclay. — In  Philadelphia,  on  Saturday,  April  3d,  Dr. 
George  O.  Barclay,  aged  thirty-three  years. 

De  Ver. — In  Waterbury,  Connecticut  on  Friday,  April 
gth.  Dr.  Hugh  J.  De  Ver.  aged  sixty  years. 

DoANE. — In  New  York,  on  Sunday,  April  4th,  Dr.  Luigi 
Galvani  Doane.  aged  fifty-nine  years. 

Fairweather. — In  Troy.  New  York,  on  Thursday,  April 
8th,  Dr.  H.  O.  Fairweather. 

Hagen. — In  Newark,  New  Jersey,  on  Monday.  April  5th, 
Dr.  Charles  W.  Hagen,  aged  eighty  years. 

Hahn.— In  Boston,  on  Tuesday,  March  30th.  Dr.  .Ammi 
R.  Hahn,  aged  sixty-seven  years. 

Hessert. — In  Chicago,  on  Sunday,  April  4th.  Dr.  Gustav 
Hessert.  aged  seventy-four  years. 

Hildreth. — In  New  York,  on  Thursday,  March  25th,  Dr. 
Henry  A.  Hildreth,  of  Bethlehem.  New  Hampshire,  aged 
fifty-nine  years, 

Lancaster. — In  Brunswick,  Maine,  on  Monday,  April 
5th,  Dr.  Charles  E.  Lancaster,  aged  forty-six  years. 

Le  Claire. — In  Daniclson,  Connecticut,  on  Thursday, 
April  1st,  Dr.  C.  J.  Le  Claire,  aged  forty-five  years. 

Miesse. — In  Chillicothe,  Ohio,  on  Saturday.  April  3d, 
Dr.  B.  F.  Miesse,  aged  sixty-eight  years. 

Newberry. — In  Wliitcmarsh.  Pennsylvania,  on  Sunday, 
April  4th.  Dr.  Milton  Newberry,  aged  seventy-nine  years. 

Peaslee. — In  Randolph.  New  York,  on  Tuesday. ' March 
30th,  Dr.  Joseph  Pcaslce,  aged  twenty-seven  years. 

Rankin, —  In  Kalamazoo.  Michigan,  on  Sunday,  March 
28th,  Dr.  John  M,  Rankin,  aged  seventy-six  years. 

Slettengren,— In  Boston."  on  Monday.  April  5th.  Dr. 
Oscar  W.  Slettengren,  aged  sixty-one  years. 

Thoaip.son.— In  Middietown.  New  York,  on  Saturday, 
.April  3d.  Dr  John  H.  Thompson,  of  Goshen,  aged  eighty- 
two  years. 

White. — In  Wtiodland.  Marvland  on  Mondav.  .April  sth 
Dr.  John  K.  White. 

Wilson, — In  Pontiac.  Michigan,  on  Friday.  March  26th. 
Dr,  John  P.  Wilson,  aged  eighty-five  years. 

Wolfe.— In  Mnuckport.  Indiana,  on  Tuesdav.  March 
30th.  Dr.  L.  O.  P,  Wolfe. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  rlt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  17.  NEW  YORK,  APRIL  24,  1909.  Whole  No.  1586. 


Original  Cflmnmniraticns. 

THEORIES  AND  PROBLEMS  OF  HEREDITY. 
By  Jonathan  Wright,  M.  D., 
New  York. 

IV.  The  Affiliation  of  the  Specific  Problems  of 
Cancer  zvith  the  Specific  Problems  of  Heredity. 
I  discussed  in  the  last  article  the  affiliation  the 
problem  of  cancer  has  for  the  fundamental  theories 
of  heredity.  I  shall  try  to  confine  myself  in  this  to  the 
specific  questions  of  cancer  which  have  a  bearinsf 
on  some  of  the  specific  problems  of  heredity,  but  it 
is  impossible  to  avoid  repetition,  and  still  more  it  is 
impossible  in  such  a  publication  as  this  to  avoid  wide 
gaps  in  our  consideration  of  such  a  theme  as  hered- 
ity. We  have  considered  the  cancer  cell  as  a  muta- 
tion, or  as  in  some  respects  an  atavistic  reversion  to 
the  germ  cell.  Clinically  we  find  this  taking  place 
at  a  time  when  the  somatic  cells  of  man  have  long 
since  begun  to  flag  in  the  exhibition  of  that  energy 
they  have  derived  from  the  germ  cell.  In  other  ar- 
ticles we  have  seen  that  Hertwig  and  his  followers 
have  shown  that  as  the  relative  size  of  the  chromo- 
somes in  the  nuclei  of  the  cells  in  the  low  forms  of 
life  decreases,  as  compared  to  the  amount  of  the 
cytoplasm  of  the  cell  body,  the  time  of  division  is 
longer.  The  spring  of  life  is  wound  up  as  the 
somatic  cell  forges  away  from  the  germ  plasm, 
wherein  it  remains  ever  tense,  and  the  advance  of 
age  means  the  reduction  of  the  energy  no  longer 
supplied  anew  from  an  apparently  inexhaustible 
source.  It  sinks  so  low  after  forty  that  its  momen- 
tum, its  inertia  is  largely  lost.  We  have  an  exhibi- 
tion in  the  frequency  of  cancer  at  this  time  of  a  ten- 
dency to  regain  energy  in  the  reversion  of  the  type 
of  cell.  Like  the  Wandering  Jew  the  cancer  cell 
gains  a  miserable  immortality  and  loses  touch  with 
its  fellow  cells.  Its  form  is  less  regulated  by  far 
than  that  of  the  teratoma  and  the  normal  embryo, 
and  its  energy  has  not  that  selflimitation  which  is 
necessary  for  the  perpetuation  of  life  as  a  whole  in 
the  metazoa. 

We  have  thus  far  pursued  the  assumption  that 
the  energy  of  the  cell  is  largely  endogenous,  at  least 
for  functions  of  form  and  procreation.  Abandon- 
ing the  concept  of  a  directive  force,  we  have  found 
perhaps  a  sorry  place  of  refuge  for  the  direction  of 
heredity  in  the  inertia  of  living  matter.  Such  as  it 
is,  however,  it  may  answer,  if  we  seek  elsewhere 
for  those  auxiliary  directive  forces  in  the  environ- 
ment. 

There  is  nothing  which  the  study  of  cytology 
has  so  plainly  shown  in  the  last  few  years  as  the  in- 


terchange of  matter  constantlv  going  on  between 
karyoplasm  and  cytoplasm.  It  has  scarcely  needed 
the  demonstration  of  Godlewski,'  of  Heidenhain,'  of 
Ruzicka,^  of  Tellyesniczy,''  and  a  horde  of  others  to 
convince  us  that  the  growth  of  matter  in  the  bulk  of 
the  chromosome  is  derived  from  without.  That 
seems  a  selfevident  proposition.  We  have  imagined 
the  endogenous  origin  of  nuclear  energy  due  to 
atomic  disintegration,  but  as  rash  as  this  may  seem, 
I  have  never  heard  of  anv  one  so  foolhardy  as  to 
suppose  that  the  nucleus  evolves  matter  out  of  the 
ether.  Even  LeBon  does  not  suggest  that.  The 
ability  to  segment  means  the  ability  to  attract.  The 
material  attracted  contains  certain  potentialities- 
within  itself,  and  to  suppose  that  they  as  foreigners- 
have  no  effect  upon  the  potentialities  of  the  chromo- 
somes is  to  lay  aside  all  we  know  of  cosmic  law. 
If  we  must  suppose  the  chromosomes  or  the  chro- 
matin of  the  nucleus,  out  of  which  they  are  shaped 
along  the  lines  of  force,  have  derived  their  material 
from  the  cytoplasm,  the  proposition  is  also  self-evi- 
dent that  the  cytoplasm  is  in  its  turn  dependent  for 
material  on  its  environment.  This  is  moulded  of 
course  into  acceptable  molecular  configuration,  and 
it  is  again  put  in  more  perfect  shape  for  the  nucleus 
by  the  cell  body,  but  undeniably  it  is  derived  from 
the  vegetables  and  meat  and  oxygen  of  the  environ- 
ment of  man.  In  many  species  bits  of  chromatin.' 
from  the  nucleus  have  been  seen  in  the  cytoplasm 
during  the  vegetative  or  resting  stage  of  the  cell. 
In  the  cancer  cell  these  chromatin  bits  are  more  fre- 
quently and  widely  distributed  throughout  the  cyto- 
plasm, which  in  addition  frequently  contains  the 
naked  nuclei  of  leucocytes  derived  from  without  the 
cell.  Evidently  the  surface  tension  of  the  cancer  cell 
has  been  modified  in  such  a  way  that  it  sucks  within 
its  lawless  grasp  the  law  abiding  protoplasm  of 
other  cells.  In  the  normal  cell  of  certain  lowly  spe- 
cies of  life  bits  of  the  chromatin  from  the  nucleus- 
wandering  in  the  cytoplasm  apparently  are  rein- 
volved  in  the  burst  of  energy  which  starts  the  pro- 
cess of  cell  division.  For  in  some  they  are  seen  tO' 
be  gathered  into  an  accessory  or  micronucleus.  In 
others  again  they  are  dissolved  in  the  cytoplasm.  In- 
fact  we  find  protoplasm  with  which  we  associate  the- 
notion  of  life  to  present  a  diversity  of  chemical 
structure  and  physical  action  in  its  most  concrete- 
forms,  such  as  the  germ  cells,  the  protozoa  and  the 
bacteria,  which  abolishes  any  idea  of  the  unity  of 

'Godlewski.  Archiv  fiir  Entwickelungsinechanik  der  Organismen, 
xxvi,  p.  277,  1908. 

-Heidenhain.    Plasma  und  Zelle. 

'Ruzicka.  Struktur  und  Plasma.  Ergebnisse  der  Anatomic  und 
Entwickelungsgeschichte,  xvi,  1906. 

-■Tellyesniczy.    Die  Eiitstelnir.g  der  Chromosomen,  1907. 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


830 


WRIGHT:  HEREDITY. 


[New  York 
Medical  Journal. 


the  essence  of  vitality.  It  is  vain  to  attempt  to  iden- 
tify bacteria  as  nuclear  material,  or  to  entertain  the 
idea  that  the  chromatin  of  one  nucleus  is  made  up  of 
matter  in  the  same  state  as  the  chromatin  of  another 
nucleus.  It  seems  to  me  quite  clear  that  all  this 
tells  conclusively  against  the  idea  that  the  chromo- 
somes are  sharply  dififerentiated  parts  of  the  proto- 
plasm. 

Weismann  and  Boveri  hold  to  the  doctrine  of  the 
preservation  of  the  identity  of  the  chromosomes  in 
cell  division,  but  it  is  difficult  to  find  a  proper  basis 
for  the  term  "identity."  Certainly,  as  we  have  seen, 
we  can  hardly  speak  of  the  identity  of  the  molecules 
and  atoms  in  them  in  the  face  of  the  phenomena  of 
intracellular  and  even  intranuclear  currents.  But  I 
suppose  it  is  not  fair  to  visit  upon  the  objective 
demonstrations  of  Boveri  the  blighting  conception 
of  Weissmannism.  It  seems  likely*  that  in  the  sense 
of  coagulated  bits  of  albumin,  Boveri  never  regard- 
ed the  chromosomes.  In  the  colloid  state,  dependent 
as  it  is  on  the  dynamic  relationship  of  the  com- 
ponent molecules  or  groups  of  molecules,  it  is 
■difficult  to  understand  how  their  identity  can  be  sup- 
posed to  exist  for  any  great  length  of  time  in  the 
resting  stage  of  the  cell,  but  it  becomes  quite  in- 
comprehensible, in  this  sense,  when  they  segment 
and  are  transferred  to  another  or  daughter  cell,  be- 
cause their  segmentation  means  the  previous  attrac- 
tion of  new  stuff.  The  conception  of  an  identity  of 
dynamic  arrangement,  by  virtue  of  which  the  mole- 
cules and  masses  are  grouped  in  certain  lines  and 
figures,  it  is  more  difficult  to  deny  to  the  theory.  It 
may  be  urged  that  the  dematerialization  of  our  con- 
ceptions of  the  essence  of  heredity  is  impossible. 
Yet  the  demonstrations  of  Thomson'  have  compelled 
us  to  dematerialize  our  conceptions  of  the  atom.  ■  I 
see  no  escape  for  it  in  discussing  the  problems  of 
heredity.  The  only  thing  that  is  inconceivable,  short 
of  divine  interposition,  is  that  of  a  force  uninflu- 
enced by  the  impingement  of  another  force,  which  is 
essentially  the  position  of  ultra  neo-Darwinism. 

There  is  no  one  phenomenon  of  the  cancer  cell 
which  is  characteristic  by  itself  of  malignancy,  but 
one  of  the  appearances  which  forms  its  composite 
picture  is  the  inequality  in  the  mitotic  picture,  as  von 
Hansemann'  pointed  out.  If  we  are  to  look  upon 
the  chrom.osomes  and  the  figures  they  form  as  the  sole 
basis  of  the  visible  evidences  of  heredity  there  can  be 
no  ([uestion  that  this  is  an  important  consideration 
in  drawing  an  analogy  between  the  mutations  of  in- 
dividuals and  the  mutation  of  the  somatic  cell,  as 
representing  our  conception  of  the  origin  of  cancer. 
Even  if  we  are  inclined  to  refuse  acquiescence  in  the 
usually  accepted  interpretation  of  the  identity  of  the 
chromosomes  from  one  period  of  mitotic  activity  to 
another  in  the  germ  cell,  we  can  not  even  in  the  so- 
matic cell  refuse  an  acquiescence  to  the  view  of  their 
fundamental  importance  in  the  process  of  division. 
I  am  not  prepared  to  believe  that  even  in  the  germ 
cell  the  chromosome  or  the  mitotic  figures  lie  at  the 
basis  of  the  question  of  heredity.  It  seems  to  me 
that  we  have  insufficient  evidence  that  a  distinction 
in  form  and  function  can  be  traced  to  a  distinction 
in  the  form  and  number  of  the  chromosomes  in  the 

*I  confess  I  have  not  read  all  the  Zellenstudien  of  Boveri,  though 
I  am  familiar  with  his  latest  hrochiirc.  No.  6,  1907. 
'The  Corpuscular  7  hcory  of  Mailer. 

"Die  mikroskctische  Diagnose  der  b'osarligen  Ceschwutste,  1897. 


visible  phenomena  of  the  mitotic  figure  though  work 
is  being  done  to  investigate  this  point.  It  seems  to 
me  it  will  fundamentally  come  down  to  the  kind  of 
dynamic  charge  with  which  the  molecules  or  their 
unit  masses  in  the  colloid,  constituting  the  chromo- 
somes, are  loaded. 

Notwithstanding  various  acts  of  violence  done  to 
the  eggs  of  frogs  after  fertilization,  such  as  centri- 
fuging  and  separating  from  one  another  the  constit- 
uents of  different  specific  gravity,  such  as  various 
experiments  of  destruction  wrought  upon  one  or 
more  of  the  primary  blastomeres,  such  as  the  placing 
of  the  developing  eggs  between  glass  plates  in  the 
early  stages, — it  has  been  noted  subsequently  per- 
fect animals  have  been  formed.  Driesch  and  the 
neovitalists  point  to  these  observations  as  indicative 
of  the  overruling  influence  of  a  directive  force. 
When  in  the  cancer  cell  we  see  that  the  spindles  and 
the  chromatin  threads  are  atypical,  it  has  seemed 
necessary,  as  I  have  pointed  out,  to  search  for  an 
organism  or  an  organelle  to  explain  it.  I  can  not 
see,  if  we  are  to  avoid  the  invention  of  this  dens  in 
machina  any  avenue  of  escape  but  the  view  to  which 
1  have  just  alluded,  viz.,  the  molecular  nature 
of  heredity.  The  observations  and  deductions  of 
Heidenhain'  on  muscle  fibre  are  in  line  with 
this  molecular  view,  since  the  repeated  application 
of  higher  and  higher  objective  powers  of  the  micro- 
scope to  the  subdivisions  of  the  fibrillae,  until  the 
limit  of  artificial  vision  is  reached,  simply  results  in 
the  revelation  of  continued  subdivisions  between 
which  in  the  function  of  contraction  we  must  imag- 
ine the  interplay  of  electromagnetic  forces.  His  con- 
clusion that  the  ultimate  structure  of  the  striped 
muscle  cell  is  one  of  a  fibril  made  from  a  string  of 
molecules  may  be  unwarranted,  but  the  indications 
of  something  approaching  it,  even  when  applied  to 
the  strings  of  chromatin  granules  in  the  germ  cells, 
called  the  chromosomes,  is  obvious.  As  a  prelimi- 
nary, however,  we  must  get  rid  of  the  cell  as  the 
unit  of  life.  Whatever  may  be  true  of  the  germ 
cell,  it  is  clear  that  nuclear  material  extruded  in 
the  cytoplasm  has  been  traced  in  the  excretions  of 
the  somatic  cell  itself.  To  deprive  them  of  life  when 
they  are  thus  extruded  is  again  doing  unnecessary 
violence  to  the  conception  of  the  absolute  continuity 
of  cosmic  phenomena.  We  may  indeed  accept  a 
modification  of  the  apothegm  of  Driesch  without  its 
metaphysical  implication.  The  prospective  fate  of 
any  part  of  the  substance  of  the  karyoplasm  of  the 
cell  is  a  function  of  its  position.  The  granula  of 
the  gland  cell,  as  demonstrated  by  Heidenhain,  is 
alive  within  the  cell  body,  and  under  certain  condi- 
tions it  remains  alive  outside  of  it,  if  we  remember 
how  some  of  these  things  attract  and  assimilate,  in 
the  process  of  growth,  material  to  themselves  inside 
the  cancer  cell  and  outside  of  other  cells,  even  when 
there  is  no  question  of  clinical  malignancy.  Hyaline 
granules  grow  by  virtue  of  this  assimilation  in  the 
stroma  of  adenomata  of  the  stomach,  and  I  have 
demonstrated'  them  in  the  stroma  of  benign  nasal 
adenomata.  To  ascribe  life  to  bits  of  the  karyoplasm 
within  the  nucleus  and  to  avoid  it  when  they  are 
present  in  the  cytoplasm,  to  draw  a  line  between 

'Loco  citato. 

'The  So  Called  Hyaline  Bodies  and  Other  Cellular  Degenerations 
in  Nasal  Polypi,  The  American  Journal  of  the  Medical  Sciences, 
October,  1898. 


April  24,  1909.] 


WRIGHT:  HEREDITY. 


831 


their  intracellular  and  their  extracellular  growth,  is 
an  entirely  arbitrary  procedure. 

I  have  insisted  on  this  from  so  many  points  of 
view,  there  has  been  so  much  assertion  of  the  gen- 
eral principle  and  so  much  evidence  advanced  to 
support  it  by  others,  that  it  will  be  understood  that 
I  refrain  from  dilating  here  upon  it  not  from  any 
lack  of  argument  but  from  its  profusion."  I  con- 
tent myself  with  having  drawn  attention  to  an  old 
observation  of  mv  own  which  many  years  ago 
helped  to  raise  the  question  in  my  mind  of  the  non- 
existence of  a  line  between  the  living  and  the  non- 
living. This  question  is  by  no  means  out  of  place 
here.  It  can  not  be  doubted  that  a  large  share  of 
the  difificulty  of  interpretation  in  the  study  of  in- 
tracellular activity  is  due  to  the  intrusion  of  the 
question  as  to  whether  this  or  that  bit  of  matter  is 
alive  or  dead.  This  is  illustrated  by  the  hesitation 
of  many  biologists  in  the  acceptation  of  the  view 
that  the  inorganic  environment  has  its  full  effect 
upon  the  so  called  organic.  It  is  inherent  in  the 
view  they  are  things  apart.  It  may  be  traced  in  the 
hesitation  with  which,  for  instance,  Ruzicka"  and 
others  accept  the  accuracy  of  the  observation  which 
goes  to  show  that  the  nuclear  substance,  which  we 
must  believe  to  be  "alive,"  can  possibly  enter  into 
the  excretion  or  secretion  of  the  cell,  which  we  are 
accustomed  to  think  of  as  not  alive.  Suffice  it  to 
say  that  in  raising  the  question  as  to  the  vitality  of 
some  of  the  cell  inclusions  of  cancer  we  meet  with 
the  same  embarrassment.  We  have  every  reason  to 
believe  that  the  spider  in  very  fact  spins  its  web  in 
part  at  least  out  of  what  was  once  the  chromatin 
material,  the  .'"hereditary  bearing"  stuff  of  the  nu- 
cleus itself.  The  mother's  milk  we  recognize  as 
possessing  a  certain  "life"  not  inherent  in  the  boiled 
stuff  of  the  sterilization  bottles.  In  ridding  it  of 
foreign  "life"  we  deprive  it  of  intrinsic  "life,"  we 
may  say,  but  this  in  no  way  expresses  the  real 
change,  that  from  a  higher  colloid  synthesis  to  a 
lower  condition  of  fatty  emulsion,  a  miserable  sub- 
stitute after  all  for  the  very  juice  of  life.  It  will 
be  immensely  helpful  to  progress  if  we  succeed  in 
abolishing  this  aloofness  of  life  from  its  environ- 
ment. The  part  which  the  material  of  the  nucleus 
takes  in  the  nutritive  life  of  the  cell,  the  generative 
matter  mixed  with  the  vegetative  matter,  is  but  an 
illustration  of  the  fact  that  "any  part  of  the  activi- 
ties going  on  within  the  colloid  of  cells  must  bear 
intimate  relations  to  other  intracellular  activities." 
During  the  resting  nutritive  stage  of  the  cell,  which 
is  by  far  the  most  frequent  and  prolonged  condition 
of  the  somatic  cells,  we  have  evidences  of  osmosis 
back  and  forth,  the  orfsorption  and  the  rejection,  the 
a&sorption  and  the  excretion  of  material,  the  con- 
stant interchange  of  it  between  nucleus  and  cyto- 
plasm, between  cell  and  cell.  In  the  nutrition  and 
growth  of  the  germ  cell  there  is  abundant  evidence 
of  the  same  state  of  affairs,  and  when  the  somatic 
cell  reverts  to  the  germ'^cell  state  of  immortality  in 
cancer,  there  is  no  radical  change  in  this  respect. 
We  find  the  detritus  of  the  badly  and  furiously 

J'As  I  write  I  note  the  reference  to  the  work  of  Kourilof  (Revue 
scientitigue,  January  16,  1909,  quoting  from  Bulletin  de  la  Societc, 
chimique,  December  5,  ipo8.  Original  in  Journal  de  la  Socicte 
chimique  de  Russe,  xxxviii)  who  in  advancing  evidence  of  this  con- 
tinuity in  another  field  shows  how  there  are  transitions  in  the  state 
of  matter  between  crystalloid  and  colloid  solutions. 

^"Loco  citato. 


working  cell  organism  revealed  to  us  in  various  cell 
inclusions,  which  are  capable  of  independent  growth 
both  in  and  outside  of  the  cell  body.  I  have  noted" 
the  avidity  of  the  normal  nucleus  for  fatlike  globules 
absorbed  from  mucous  surfaces.  Fatlike  (lipoid) 
globules  are  demonstrable  in  the  nuclei  of  many 
cells.  I  have  no  reason  for  believing  that  this  lipoid 
material  is  exclusively  di;e  to  metamorphosis  of  the 
nuclear  protoplasm,  as  seems  to  be  the  tendency  with 
a  growing  number  of  histologists.''  Some  of  it  at 
least  certainly  seems  absorbed  from  the  environ- 
ment, not  only  extracellular  into  the  cytoplasm,  but 
from  the  extranuclear  environment  into  the  karyo- 
plasm.  I  have  already  made  some  reference  to  the 
evidence  of  the  constant  interchange  of  matter,  of 
molecules  and  atoms  between  the  nuclear  chromatin 
and  its  environment :  and  I  have  intimated  the  im- 
portant bearing  this  has  on  the  usual  acceptation  of 
the  doctrine  of  the  identity  of  the  chromosomes  as 
urged  by  Boveri.  Obviously  it  also  has  a  very  dis- 
tinct critical  bearing  on  the  dictum  of  Weismann 
that  his  "determinants  in  the  germ  are  not  hypo- 
thetical, but  something  real,  just  as  certain  as  though 
we  could  see  them  with  our  eyes  and  follow  their 
development."  Evidently  the  accuracy  of  this  con- 
ception depends  upon  the  definition  of  reality. 

By  the  evidence  which  Ruzicka"  has  collected 
from  literature  and  by  the  demonstrations  which 
Tellyesniczy"  has  submitted,  we  must  be  influenced 
to  believe,  in  spite  of  proof  to  the  contrary  in  cer- 
tain instances,  that  the  nucleus,  for  the  most  part  in- 
visible in  life,  in  some  species  of  cells  at  certain 
times  and  under  certain  conditions  loses  itself  in  the 
cytoplasm.  In  these  cases  it  seems  impossible  to 
demonstrate  it.  Ruzicka  seems  to  be  enamored  of 
his  term  "morphological  metabolism."  I  must  con- 
fess that  if  the  nucleus  at  one  time  is  in  such  a  phys- 
icochcmical  state  as  to  be  visible  by  post  mortem  or 
vital  staining  and  at  another  in  such  a  state  as  not  to 
be  visible  by  such  methods  of  demonstration,  I  for  one 
am  forced  to  the  conclusion  that  the  chromosomes, 
the  bearers  of  heredity,  have  undergone  a  modifica- 
tion and  at  one  time  no  longer  represent  what  they 
do  at  another.  How  this  can  be  reconciled  with  their 
identity  I  do  not  know.  The  nucleus  as  a  nucleus 
has  disappeared.  Something  of  this  kind  is  seen  in 
the  nerve  cells  of  hibernating  animals,  and  still  more 
in  the  observations  of  Lillie.  It  has  been  observed 
in  the  somatic  cells  of  pluricellular  organisms,  but 
what  is  of  more  significance,  it  has  been  observed  in 
unicellular  organisms  and  in  the  germ  cells  of  others. 
Apart  from  this  somewhat  controversial  subject,  it 
has  been  established  by  observations  on  various  spe- 
cies that  the  spindle  and  the  centrosome  represent- 
formations  from  cytoplasm  as  well  as  from  the  nu- 
clear material.  We  have  Boveri's  word  for  it  that 
in  the  normal  process  "the  nucleus  does  not  divide 
itself,  on  the  contrary,  it  suft'ers  division"  from  with- 
out, but  in  parthenogenesis  and  in  bacterial  fission 
we  have  to  modify  the  conception  in  such  a  manner 
that  we  allow  it  is  a  very  universal  agent,  so  non- 
specific as  heat,  moisture,  food,  etc.,  which  pulls  the 

^^Nezv  York  Medical  Journal,  December  15,  1906. 

^^Most  recently  I  note  the  report  of  Brandts  before  one  of  the 
German  societies.  Ref. :  Centralblatt  fiir  allgcmeine  Pathologie,  etc., 
xix.  No.  22. 

^'Loco  citato. 

'^*Loco  citato. 


832 


WRIGHT:  HEREDITY. 


[New  York 
Medical  Journal. 


trig-ger.  So  that  when  we  come  to  apply  this  say- 
ing of  Boveri  to  the  birth  of  the  first  cancer  cell 
from  a  normal  somatic  cell  it  is  no  argument  at  all 
for  what  is  commonly  meant  by  the  extrinsic  origin 
of  cancer.  It  would  seem  that  the  only  way  to  rec- 
oncile so  many  apparently  contradictory  observa- 
tions as  to  the  origin  of  the  cell  form  in  heredity,  is 
to  suppose  that  in  the  physicochemical  composition 
of  the  colloid  protoplasm  there  is  an  arrangement  of 
the  molecules  of  such  a  nature  that  when  it  receives 
the  proper  d}namic  influence  from  without,  more 
and  more  specific  as  we  rise  in  the  scale  of  differen- 
tiation, adsorption  forces  are  developed  which  string 
together  the  thickened  plasma  ( which  we  call  chro- 
matin because  of  its  color  absorbing  properties)  into 
shapes  identical  with  those  of  the  species ;  but  it  is 
said  this  constancy  of  normal  form  is  necessary  for 
the  existence  of  the  organism  as  a  whole ;  yet  the 
disorder  of  the  cancer  cell  teaches  us  that  the  power 
to  segment  lies  back  of  the  chromosomes  in  the  mole- 
cular arrangement. 

In  the  changed  cancer  state  we  note  the  increase 
in  the  number  of  mitotic  figures  in  the  morbid  tis- 
sue. The  proliferation  of  cells  is  enormously  in- 
creased. In  normal  germ  cell  mitosis, — as  studied 
in  the  simpler  and  more  resistant  form  of  the  plasma 
of  the  lower  animals  and  in  the  protozoa, — we  see 
streams  of  matter  flowing  along  lines  of  force, 
more  or  less  symmetrically  and  regularly  arranged, 
in  definite  order  and  number  for  each  species.  This 
mitosis  may  be  started  by  a  spermatozoon  or  bv 
some  other  influence  putting  the  molecules  in  the 
certain  constant  order  of  arrangement  necessary. 
The  tendency  to  parthenogenesis,  once  chiefly 
noted  in  the  bacterial  microorganisms,  where  a  very 
simple  arrangement,  for  which  heat,  moisture  and 
food  suffice  as  agents,  has  of  late  been  noted  even  in 
the  eggs  of  birds,  where  L.ecaillon''  has  given  it  the 
name  of  partial  natural  parthenogenesis  to  remind 
us  that  in  the  sea  urchin's  egg  it  is  easily  made  com- 
plete. The  molecular  arrangement  awaits  the  stimu- 
lus to  normal  segmentation.  What  influence,  other 
than  endogenic,  there  may  be  which  starts  up  the  ab- 
normal mitosis  of  the  cancer  cell  with  its  irregular 
arrangement  of  the  chromosome,  we  do  not  know. 
Here,  however,  we  must  receive  again  the  intima- 
tion that  irregular  karyokinesis  is  not  the  essential 
thing  in  the  manifestation  of  change.  Our  knowl- 
edge of  mitotic  changes  in  cancer  is  still  very  incom- 
plete. We  do  know,  or  wc  have  reason  to  believe, 
that  the  unbridled  energy  of  the  cancer  cell  can  flow 
along  the  regular  channels  of  the  mitotic  figure,  as 
will  a])])ear  in  the  next  article.  W^e  know  that  irreg- 
ular karyokinesis  occurs  in  cells  entirely  unconnect- 
ed with  cancer.  Whatever  it  is  that  throws  the 
mechanism  out  of  gear  so  frec|uently  in  cancer,  so 
far  as  the  chromosomes  are  concerned,  it  is  not  spe- 
cific. The  specificity,  as  I  have  insisted,  nnist  be 
molecular.  In  sea  urchins'  eggs  ISoveri'"  has  shown 
that  in  dispcrmia  or  jwlyspermia,  i.  e.,  when  an  egg 
is  fertilized  l)y  two  or  more  s])ermatozoa,  there  is  a 
deformation  of  the  mitotic  figure.  This  is  a  disar- 
rangement which  is  herital)le  but  which  soon  leads 
to  the  death  of  the  cells  which  inherit  it.     In  these 

'^Rcriif  fcicnlifiauc,  January  i6,  1909. 
"ZcllensliiJicn,  No.  6,  1907. 


cases  on  the  completion  of  the  four  cell  stage  divi- 
sion of  the  blastomere,  in  the  abnormal  tetraster  seg- 
mentation (i.  e.,  the  undisturbed  sequence  of  the 
aster  formation  resulting  from  the  intrusion  of  two 
spermatozoa  into  the  egg)  the  az'erage  number  of 
the  chromosomes  in  each  of  the  four  cells  was  one 
quarter  less  than  the  normal  number,  but  the  actual 
number  in  each  was  more  or  less  fortuitous, 
and  the  greater  the  departure  from  the  normal 
number  the  greater  was  the  so  called  pathological 
state  of  the  cell.  Subsequent  observation  of  the 
fission  of  each  one  of  these  quadruplet  cells  showed 
that  the  number  of  chromosomes  present  at  that 
stage,  whatever  the  number  was,  was  inherited  bv 
the  cells  springing  from  that  one.  Naturally  it 
would  seem,  in  the  synthesis  of  a  pluricellular  being, 
such  an  upset  of  the  equilibrium  at  the  start  inevita- 
bly resulted  in  the  death  of  the  organism.  Normal- 
ly at  the  four  cell  blastomere  stage  each  one  of  the 
four  parts  when  separated  from  its  fellows  seems 
able  to  develop  a  s}-mmetrical  larva,  but  these  ab- 
normal polyspermia  cells  perish  at  different  stages 
of  the  subsequent  segmentation.  When  McDougal 
injected  magnesium  chloride  solution  into  the  ovar- 
ies of  plants  he  obtained  a  viable  mutation  of  the 
plant.  What  the  condition  of  the  chromosomes 
was  I  do  not  know,  but  in  cancer  the  dividing- 
cell  in  the  so  called  pathological  state  of  ir- 
regular chromosomes  is  not  only  viable  but  im- 
mortal, as  the  mice  experiments  show.  We  may  be 
allovyed  to  conjecture  then,  that  the  basis  of  the 
change,  which  is  viable,  is  a  molecular  one  and  not 
a  chromosome  one,  and  I  do  not  believe  that  it  is  in 
the  relationship  of  one  chromosome  to  another  as  a 
whole,  that  we  shall  find  an  explanation  for  varia- 
tion or  mutation  in  species.  Yet  no  statement  of 
ibis  kind  must  be  exclusive,  for  a  section  of  a  ma- 
chine may  be  out  of  order  as  well  as  one  or  more  of 
its  component  parts.  In  cancer  the  trouble  is  more 
primordial  than  chromosome  formation,  and  though 
I  am  also  very  sure  that  it  is  not  chiefly  chromosome 
formation  but  molecular  formation  which  lies  at  the 
basis  of  most  of  the  normal  changes  in  heredity,  I 
can  not  even  here  afford  to  let  it  be  supposed  that  I 
leave  out  of  view  such  evidence  as  exists  to  the  con- 
trary. Such  chromosome  formation  as  is  visible 
has  been  seen  to  have  something  to  do  with  somatic 
cell  form  and  function. 

I  have  referred  to  the  karyokinetic  irregularities 
in  the  cancer  cell  and  I  have  to  note  that  in  the  adult 
being,  as  has  been  most  recently  urged  by  Wilson.'' 
certain  changes  of  characteristics  are  coincident  with 
the  physical  aspect  and  even, — possibly, — with  the 
number  of  the  chromosomes  in  the  nucleus  of  germ 
cells.  At  least  it  seems  likely  that  in  some  species 
the  extra  or  odd  chromosome  has  some  relation  with 
the  determination  of  sex.  P)Ut  we  may  see  in  the 
ap])arent  disorder  of  the  chromosomes  in  cancer  mi- 
tosis, in  the  entire  lawlessness  of  the  cytoplasmic 
contents  of  the  cancer  cell  that  the  tendency  to  pro- 
liferation,— the  specific  cell  energy, — is  not  depend- 
ent upon  the  regularity  of  the  visible  morphological 
characters  of  any  part  of  the  cell. 

It  will  remain  for  me  to  develop  in  another  arti- 

''Scieiiic,  January  9,  1909.  See  also  the  remarks  of  I'rofessor 
T.  n.  Morgan  on  Sex  Determination,  etc..  Science,  l-'cbruary  5, 
I  yo9. 


April  24,  1 909.  J 


WILLIAMS:  IXEBRIETY. 


833 


cle  the  argument,  from  the  diversity  and  variation 
of  cancer  form  and  energy,  that  tissue  structure  is 
frequently  not  a  guide  either  for  diagnosis  or  prog- 
nosis. Fundamentally  this  arises  from  the  point 
which  I  have  wished  to  establish  in  this  article,  viz. : 
that  visible  pathological  morphology  in  cancer,  like 
physiological  morphology  in  heredity,  is  dependent 
primordially  on  forces  which  influence  molecular 
rather  than  molar  arrangement. 
44  West  Forty-ninth  Street. 


THE   PSYCHOLOGICAL   BASIS    OF  INEBRIETY: 
Its  Etiological  and  Social  Factors;  Remedies* 
By  Tom  A.  Williams,  M.  B.,  C.  M.,  Ediu., 
Washington,  D.  C. 

Why  should  an  individual  be  compelled  to  period- 
ically debauch  himself  with  a  narcotic,  in  spite  of  a 
repeated,  firm  intention  to  never  again  even  taste  the 
poison?  The  author's  enquiry  during  a  temporary 
residence  at  an  inebriate's  home  in  England  showed 
that  a  great  majority  of  the  fifty  inmates  broke  their 
resolves  through  inability  to  overcome  the  impulse. 

What  is  the  nature  of  this  impulse,  what  is  its 
origin,  why  is  it  so  irresistible ;  finally  can  it  be 
overcome  in  those  in  whom  it  occurs,  and  how  mav 
its  occurrance  be  prevented  in  others?  If  these  ques- 
tions can  be  answered  satisfactorily  there  need  be 
no  prohibition  remedy. 

That  the  longing  is  a  state  of  feeling  needs  no 
argument.  It  is  the  call  of  the  unsatisfied,  of  the 
miserable,  of  the  depressed.  It  finds  many  answers, 
as  that  of  Janet's  patient  ( i )  who  solaced  her  un- 
speakable anguish  by  dropping  boiling  water  upon 
her  naked  feet ;  or  as  that  other  extreme  case,  the 
Oriental  mystics,  the  dervishes,  who  gash  them- 
selves with  knives,  although  in  both  these  and  the 
Christian  mystics  who  mortify  the  flesh  in  other 
ways,  there  is  a  definite  religious  purpose  in  the 
deed  which  they  use  to  assuage  their  yearning. 
Their  emotional  longing  is  essentially  the  same  as 
that  of  the  drunkard :  both  seek  intoxication.  But 
m  the  mystic,  the  means  are  mainly  psychic  ;  in  the 
narcomanic.  they  are  a  drug. 

This  feeling  of  intolerable  longing  and  consequent 
discontent  is  the  imfortunate  appanage  of  certain 
individuals ;  but  in  most  cases  it  has  arisen  from  ig- 
norance, and  has  been  fostered  by  mismanagement. 

The  mother  who  seeks  out  every  caprice  of  her 
child  to  satisfy  it  is  laying  the  train  for  future  ex- 
plosions of  uncontrolled  impulse.  The  mother  who 
neglects  her  child  to  the  point  of  compelling  him  to 
seek  amusement  at  all  costs  from  any  passer  by, 
hence  to  discard  everything  which  does  not  imme- 
diately please,  is  incurring  many  chances  of  her  boy 
developing  a  habit  of  immediate  satisfaction  at  all 
costs.  Again,  the  parent  who  allows  doctrinaire 
rigidity  to  alienate  him  from  the  sympathetic  under- 
standing of  his  child's  innocent  and  harmless  tur- 
bulence is  driving  him  to  seek  elsewhere  the  modi- 
cum of  solace  which  at  least  every  child  at  times  re- 
quires.   A  frequent  outcome  of  this  is  the  alterna- 

*Read  by  invitation  before  the  National  Society  for  the  Study 
of  .'\lcohol  and  Qther  Drug  Narcotics,  held  in  Washington,  ^larrh 
17  and  18,  TQog. 


tion  of  stoical  self-suppression  and  outbursts  of  in- 
dulgence in  what  is  believed  to  be  wrong. 

Whether  the  indulgences  of  states  of  feeling  find 
their  accentuation  in  alcohol  or  whether  they  use 
some  other  aid  is  a  mere  accident  of  environment. 
This  accidental  nature  of  the  response  to  longing  is 
shown  by  the  experiments  of  Pawlow  with  dogs  (2). 
Thus,  by  association  of  ideas,  ringing  of  a  bell  could 
determine  gastric  flow,  which  could  be  again  in- 
hibited by  the  showing  of  a  whip :  and  in  turn  any 
impression  could  be  substituted  for  these  and  pro- 
duce pleasurable  or  painful  emotions  as  well  as  in- 
crease or  decrease  in  the  secretions.  In  another 
case,  of  Fere,  (3)  the  attempt  to  force  out  of  the 
house  a  dog  suffering  from  agoraphobia  caused  such 
terror  that  the  evacuations  escaped  involuntarily. 
The  feeing  of  terror  is  a  painful  one  :  but  with  pleas- 
urable sensations,  the  principle  of  substitution  for 
their  excitation  is  equally  clear,  and  is  most  con- 
spicuously shown  in  cases  of  fetishism,  which  illus- 
trate this  law.  Thus.  Stcherbak  (4)  reports  a  case 
of  a  man  in  whom  an  orgasm  was  produced  only 
when  he  held  upon  his  knees  the  feet  of  a  woman 
clothed  in  elegant  shoes.  The  cause  of  this  "condi- 
tioned reflex"  was  his  early  association  of  sexual  de- 
sire with  the  elegant  ladies  he  saw  in  the  street  when 
a  boy.  More  normally,  the  response  to  lissatisfied 
mental  states  may  be  directed  toward  the  opposite 
sex ;  but  accident  or  defective  instruction  may  per- 
vert this  to  homosexuality  or  onanism. 

Longing  may  find  satisfaction  in  religious  search- 
mgs.  taking  the  form  of  a  desire  for  completeness 
'ind  perfection.  The  brooding  may  eventuate  in  ec- 
stasy, produced  expressly  and  preceded  by  orison, 
so  well  described  by  [Madame  Guyon  (21)  and  St. 
Theresa  (22).  An  analogous  phenomenon  among 
the  Wesieyans  was  called  "the  power."  It  was  very 
puzzling  to  their  founder,  who.  however,  discour- 
aged its  manifestations. 

Though  these  phenomena  often  arose  from,  and 
were  fortified  by.  suggestions  from  without  in  the 
nature  of  religious  rites  or  personal  exhortations,  yet 
they  responded  to  a  need  of  certain  organizations, 
and  betrayed  a  lowered  psychological  tension  pro- 
ceeding from  physical  nerve  inadequacy. 

This  state  is  shown  also,  and  more  familiarly,  by 
worry,  despondency,  bad  temper,  lack  of  decision 
in  small  matters,  morbid  introspection,  overcon- 
sciousness,  increased  susceptibility  to  temptation  of 
appetite,  which  more  often  are  at  the  root  of  the 
addictions  to  drugs  for  the  purpose  of  uplifting  the 
depressed  feeling. 

In  general,  a  habit  reflex  forms,  and  the  early  in- 
dulgences are  those  which  persist ;  but  it  must  be 
remembered  how  much  greater  is  a  desire  for  spir- 
itual sustenance  and  comfort  when  the  stress  of  in- 
dependent industrial  life  combines  with  the  decline 
of  youthfulness.  Hence  the  pathological  indulgence 
of  feeling  in  hurtful  acts  may  be  postponed  quit? 
late,  although  the  pathological  feelings  had  hitherto 
been  there  though  restrained  by  self  respect,  re- 
ligion, the  sake  of  decency,  or  fear  of  the  criminal 
law. 

Of  the  feelings,  it  is  preeminently  true  that  appe- 
tite grows  by  what  it  feeds  on.  The  indulgence  of 
the  sickly  sentimentality  of  what  Nietsche  describes 


834 


WILLIAMS:  INEBRIETY. 


[New  York 
Medical  Journal. 


as  "slave  and  woman  morality,"  fostered  by  fond 
petting  in  childhood,  is  readily  replaced  later  by 
the  maudlm  self  satisfaction  of  the  sot;  the  riotous 
self  indulgence  of  the  untramelled  child,  unconscious 
of  the  very  real  limitations  set  him  by  an  arduous 
world,  finds  its  counierparc  in  adult  age  in  the  il- 
lusory happiness  of  alcoholic  vain  glory.  The  poet 
Burns  knew  this  in  saymg 

"Kings  may  be  blessed,  but  Tarn  was  glorious 

O'er  a'  the  ills  o'  life  victorious"; 
as  indeed  he  was  where  his  immediate  feelings  were 
concerned. 

Psychological  experiment  shows  how  persons  dif- 
fer from  day  to  day  in  mental  capacity.  Physiologi- 
cal experiment  exhibits  the  difference  in  bodily  se- 
cretions and  in  activity.  Such  oscillations  are  as 
true  of  the  feelings,  depending  as  these  do  upon 
bodily  changes  and  mental  impressions.  Nearly  all 
of  us  then  must  necessarily  encounter  phases  dur- 
ing which  our  feeling  is  one  of  incapacity,  even  of 
inaptitude,  discontent,  dislike  of  our  surroundings, 
anxiety,  etc.  To  support  these  unpleasant  states,  a 
certain  fortitude  is  required,  unless  one  chooses  to 
put  an  end  to  the  state  of  feeling  by  some  stimulus. 
The  outcome  of  this  course  is  the  need  for  a  ver}' 
large  stimulus  to  do  away  with  a  quite  trifling  feel- 
ing; for  the  power  of  resistance  progressively  de- 
creases by  nonuse,  especially  when  a  ready  satisfac- 
tion is  within  reach.  The  immediate  satisfaction  of 
desire  at  all  cost  is  a  habit  which  can  be  made  or 
unmade  at  the  will  of  the  educator ;  and  it  is  toward 
this  factor  that  the  prevention  of  inebriety  must  be 
directed. 

The  remedy  is  the  teaching  of  mothers  to  form 
healthy  emotional  habits  in  their  children.  The 
happy-go-lucky  absolutism  which  so  often  asserts 
itself  as  capacity  is  sadly  defective  as  such  a  guide 
for  hesitating  childhood.  The  mind,  the  emotions, 
and  their  management  into  a  morality  constitute  the 
most  difficult  study  and  art.  Woman's  sphere  is 
here,  and  is  indeed  a  noble  one ;  but  instinctive 
motherhood  has  had  its  day.  The  women  who  as- 
pire to  bring  up  leaders  of  men  in  a  nation  which 
aims  at  future  greatness  must  cease  striving  for 
vain  things  and  no  longer  confine  their  attention  to 
superficialities ;  but  do  as  their  grandmothers  did  ; 
and  buckle  to,  modestly,  earnestly,  thoroughly  to 
an  understanding  of  tlrat  fascinating  complexity,  the 
heart  and  mind  of  the  child. 

Even  persons  emotionally  unstable  may  be  read- 
ily taught  to  provide  against  the  extra  load  this 
might  mean.  Simple  faith  has  in  the  past  been  effi- 
cacious in  this  respect,  at  least  among  the  unin- 
structed  mass.  Endeavors  have  recently  been  made 
to  restore  this  function  to  religion  by  claiming  a 
combination  with  the  science  of  the  mind.  I  need 
not  particularize ;  for  in  essence  none  of  the  meth- 
ods so  far  differ  in  principle  from  that  employed 
by  the  priests  and  necromancers  of  what  we  now 
agree  to  be  superstitions.  In  all.  the  means  (5) 
consist  of  a  rousing  of  the  attention  by  rhythmic 
sounds,  a  succession  of  images  and,  especially 
among  the  more  barbaric,  ordered  movements,  more 
or  less  varied  spontaneously.  Tn  this  respect,  the 
ancient  religions  showed  themselves  empirically 
more  efficacious;  for  the  reinforcing  effect  of  active 
movement  upon  our  tlinu<r|it  i^;  now  an  established 


fact.  Will  is  nothing  more  than  the  balance  of  the 
concomitant  stresses  toward  movement ;  and  peda- 
gogy has  (6)  taught  us  that  present  methods  lack 
wofully  that  dymogeny  without  which  education  is 
a  mere  name.  In  this  respect,  the  modern  world 
lias  been  injuriously  dominated  by  the  arm  chair 
philosophers,  who  have  neglected  the  facts  of  life, 
and  above  all  the  genetic  factor.  The  notions  of 
experimental  science  have  not  yet  sufficiently  pene- 
trated the  teaching  of  ethics.  This  has  been  left 
almost  entirely  in  the  hands  of  persons  whose  point 
of  view  is  hopelessly  vitiated  by  the  artificialities  of 
outworn  conceptions  of  the  universe  and  of  the 
mind  of  man,  which  are  maintained  by  the  tradi- 
tions of  popular  literature,  academic  philosophy, 
and  ecclesiastical  dogmata  and  ritual  whose  nature 
precludes  adjustment. 

The  philosophers  of  the  past  have  seen  the  need 
of,  and  have  tried  to  enunciate  laws  for  the  mastery 
of  the  passions  and  moods.  Their  efforts  were  nul- 
lified by  too  exclusive  a  reliance  upon  introspection 
and  by  their  referring  to  extraneous  agencies  such 
as  ghosts  and  good  and  evil  spirits,  the  more  marked 
manifestations  of  disordered  affectivity.  It  is  to  the 
study  of  this  in  our  day  by  Cartesian  methods  that 
we  owe  the  genetic  point  of  view  which  I  will  briefly 
indicate. 

Moods  and  emotions,  as  Spencer  (7)  long  ago 
showed,  are  the  determinants  of  conduct.  The  di- 
rect power  of  idea  and  reason  in  modifying  behavior 
has  strict  limits.  However,  the  indirect  effect  is  tre- 
mendous. Prevision,  however,  is  the  essential  ele- 
ment of  this  control ;  and  this  prevision  must  occur 
before  the  formation  of  emotional  habit.  It  is  the 
very  early  years  which  form  these  habits.  The  per- 
version of  infancy  and  childhood  through  the  neg- 
lect by  parents  of  the  knowledge  we  have  for  guid- 
ing the  disposition  of  a  child  is  most  reprehensible. 
The  overthrow  of  the  method  of  obedience  to  the 
arbitrary  desires  of  a  parent  ignorant  of  the  evolu- 
tion of  the  child's  mind  has  been  followed  by  the 
equally  obnoxious  "laisscz  fa  ire"  methods,  conspicu- 
ously shown  in  the  United  States,  where  the  emo- 
tions and  behavior  at  least  are  concerned.  The  abo- 
lition of  obedience  as  such  has  enthroned  the  imme- 
diate impulse  as  the  ruling  factor.  Our  next  advance 
must  transfer,  from  the  world  of  commerce,  finance, 
and  even  science  to  the  field  of  social  relation  and 
ethics  and  even  religion,  the  powers  civilized  man 
has  cultivated^  for  receiving  wide,  deep  and  subtle 
impressions,  collating  these  accurately  and  judicious- 
ly, and  of  acting,  not  upon  the  impulse  of  the  mo- 
ment, but  as  the  result  of  the  total  impressions  stored 
in  his  mind.  Unless  education  in  ethics  becomes 
as  kinetic  when  applied  to  normality  as  it  now  is 
with  regard  to  business  and  the  law,  it  will  continue 
sterile.  To  do  this,  we  must  order  the  consequences 
of  our  children's  acts  in  conformity  with  their  pow- 
ers of  observation  and  inference.  The  surest  fore- 
runner of  unreasoning  conduct  in  an  adult  is  a  child- 
hood which  is  taught  to  act  without  understanding 
and  to  understand  without  acting.  It  is  because  of 
this  that  wisdom  has  fallen  behind  knowledge,  and 
that  where  manners  and  morals  are  concerned,  peo- 
ple act  indiscriminately,  conventionally,  impulsively, 
or  indifferently,  thanks  to  the  apology  for  training 
they  have  received  in  childhood.    It  is  significant 


April  24,  1909.] 


HILLIAMS:  INEBRIETY. 


835 


that  whereas  they  are  not  so  trained  in  the  arts  and 
sciences,  it  is  in  these  wherein  so  much  progress  has 
been  made. 

The  constant  attempt  to  arrest  the  mental  activi- 
ties of  the  child  by  thwarting  even  his  healthy  im- 
pulses deprives  him  of  initiative,  and  he  becomes 
discontented  unless  entertained  by  others.  This  want 
of  resourcefulness  is  a  sure  forerunner  of  ennui,  of 
the  loafing  habit,  of  the  need  of  something  to  pass 
the  time,  so  prolific  a  source  of  drug  habits.  To 
prevent  this,  method,  as  in  the  universities,  is  more 
important  than  results.  Didactically  memorized  pre- 
cepts have  no  meaning  to  the  childish  intelligence  ; 
whereas  education  by  deeds  is  pregnant  with  results. 
The  events  upon  which  the  child  has  to  base  his  in- 
ductions must  be  carefully  chosen  by  the  parent  to 
conform  to  the  limits  of  his  intelligence,  and  of 
course  must  not  be  at  variance  with  natural  law  ; 
for  example,  when  he  shows  cruelty  to  an  animal, 
there  is  no  real  efficacy  in  telling  him  he  is  a  naughty 
bov,  but  a  great  deal  in  presenting  him  with  a  pet 
able  to  resent  and  produce  discomfort.  Again,  if  he 
shows  fear  of  an  animal,  exhortation  meets  no  stored 
memories  upon  which  to  bear  ;  but  the  familiarity 
gained  by  fondling  an  animal  which  does  not  hurt 
soon  substitutes  a  new  emotional  complex  for  that 
of  fear. 

We  expend  millions  of  money,  incalculable 
thought,  and  the  health  and  lives  of  innumerable 
teachers  upon  the  instruction  of  the  intellect  of  the 
young  by  a  curriculum  artificially  graded  to  meet 
the  fancied  needs  of  each  period  of  childhood.  The 
child  is  given  meaningless  problems  in  arithmetic  to 
teach  him  to  calculate ;  corollaries  and  inductions  in 
mathematics  -  to  teach  him  to  reason ;  dates  and 
events  in  history  and  geographical  details  to  teach 
him  to  remember  ;  drawing,  clay  modeling,  and  man- 
ual training  in  general  to  teach  him  muscular  con- 
trol. Something  is  taught  of  the  arts  of  music, 
sculpture,  and  painting  to  teach  him  aesthetic  appre- 
ciation, and  even  the  sciences  are  touched  upon  to 
give  him  a  notion  of  the  world  in  which  we  live. 
But  the  object  of  all  these,  the  first,  intermediate, 
and  last  art,  that  of  living  in  relation  to  others,  is 
taught  only  in  the  most  haphazard  or  arbitrary  way 
or  entirely  neglected.  Is  it  not  reasonable,  there- 
fore, to  demand  for  this  at  least  the  beginning  of  a 
graded  curriculum,  in  which  examples  must  be 
worked  out  by  the  student  and  in  which  he  is  taught 
"rule"  by  "practice"?  The  ethics  which  is  taught 
in  the  rule  of  thumb  way  of  the  average  family  is 
still  that  of  rudimentary  survivals.  It  is  conspicu- 
ous for  its  poverty  in  such  criteria  of  modern  civili- 
zation as  justice,  liberty,  courtesy,  altruistic  sym- 
pathy. The  natural  good  impulses  of  the  child  are 
even  artificially  checked  and  twisted ;  his  reasoning 
from  cause  to  effect  where  conduct  is  concerned  is 
neglected  or  obstructed ;  he  is  thus  confused,  and 
finally  discouraged  into  sadness  or  indiflference,  and 
is  bred  into  a  despondent  or  happy-go-lucky  man, 
ethically  speaking.  Even  if  knowledge  and  freedom 
are  ultimately  attained,  it  remains  difficult  to  throw 
off  the  aifective  accompaniments  of  conduct  first 
practised  under  such  brutish  auspices  (8). 

The  responsibility  for  the  different  attitude  which 
the  child  observes  in  his  parents  toward  moral  ques- 
tions as  against  others  must  be  laid  to  the  door  of 


religion ;  for  the  sacrosanct  connotations  of  super- 
naturalism  which  pervaded  morality  in  days  of  ig- 
norance and  repression  have  still  survived,  on  ac- 
count of  the  want  of  its  scientific  study  and  prac- 
tice. On  the  one  hand,  we  find  a  perpetuation  into 
adult  mental  life  of  the  helplessness  and  irrational- 
ity of  the  child :  and  at  the  other  extreme  is  taught 
the  inherent  damnableness  of  human  nature  unless 
justified  by  Faith.  Need  one  insist  upon  the  effect 
of  either  of  these  artificial  attitudes,  upon  the  culti- 
vation of  the  power  of  observation,  inference,  and 
of  reasoning  in  general  ? 

Its  effect  upon  the  sentiments  has  been  even 
worse ;  for  in  the  child  of  careless  or  indifferent 
mind,  these  qualities  have  been  perpetuated  by  the 
attenuation  of  their  results  into  a  state  of  happy  ex- 
pectancy that  the  Lord  will  take  care  of  his  own. 
The  second  extreme  will  fall  most  heavily  upon  the 
child  who  is  inclined  toward  overconscientiousness. 
The  neurologist  almost  daily  is  presented  with  ex- 
amples where  this  morbid  trend  has  been  cultivated 
to  excess  by  the  religious  atmosphere  legated  by  the 
apostle  of  Geneva.  » 

As  Tollner  said :  "Play  of  whatever  sort  should 
be  forbidden  in  all  Evangelical  schools" :  but 
Frobel  has  said  "play  is  not  trivial.  It  is  highly 
serious  and  of  deep  significance.  The  play  instinct 
affords  the  teacher  and  parent  a  ready  opportunity 
of  training  the  child  into  right  ways  of  living." 

Now  the  cultivation  of  either  the  happy-go-lucky 
disposition  or  that  of  hyperconscientiousness  is  bad 
for  that  intellectual  and  affective  poise  which  is  the 
best  safeguard  against  the  psychological  state  favor- 
ing inebriety.  A  disposition  toward  carelessness  is 
fortified  by  the  constant  leaning  upon  others ;  the 
scrupulous  disposition  is  fostered  by  misplaced  reli- 
ance upon  the  so  called  intellectual  determinants  of 
conduct.  To  the  child,  these  are  meaningless ;  be- 
cause they  are  mere  symbols  of  something  he  can- 
not understand  owing  to  want  of  motor  experience. 
That  which  makes  a  concept  effective  is  its  motor 
element ;  w-ithout  this  it  is  quite  incomplete.  It  might 
nearly  be  said  that  an  idea  which  has  never  been 
kinetic  is  impossible,  that  indeed  the  notion  is  not 
in  consciousness ;  all  that  is  there  is  the  simulacrum 
constituted  by  the  verbal  image.  A  familiar  exam- 
ple is  the  child's  "chart  in  heaven"  which  shows 
how  little  he  was  conscious  of  the  real  meaning  of 
the  Lord's  prayer. 

The  truth  of  this  is  implied  in  the  old  proverb 
"example  is  better  than  precept"  ;  but  the  implica- 
tion depends  upon  the  fact  that  this  example  can  be 
understood  and  hence  rendered  kinetic  by  imita- 
tion, while  precept  conveys  comparatively  small 
meaning.  Consider  the  concept  of  a  dog.  The  real 
properties  of  this  creature  come  only  from  personal 
contact.  The  child  by  mere  gazing  and  hearing  can 
gain  no  knowledge  of  the  dog's  weight,  roughness 
in  gamboling,  painfulness  of  claws  and  teeth,  the 
difference  between  long  hair  and  short,  and  so  on. 

The  kinetic  element  is  more  important  still  in 
the  acquisition  of  an  art,  such  as  the  working  of 
wood  or  metal.  "0»  devient  forgeron  en  forgeant" 
and  only  so :  But  these  experiences  must  not  be 
forced  at  undue  age,  or  the  painfulness  of  their  ac- 
quisition will  bring  disgust  instead  of  pleasure.  As 
accomplishment  is  learned,  the  kinesthetic  element 


836 


WILLIAMS:  INEBRIETY. 


[New  York 
Medical  Journal. 


tends  to  fall  more  and  more  into  the  background, 
and  to  be  represented  visually  and  auditorily  :  but  it 
is  nevertheless  present,  and  once  more  emerges  dur- 
ing states  of  mental  dissolution.  It  is  the  real  basis 
of  knowledge ;  and  the  neural  stresses  entailed  by 
its  inhibition  from  activity  have  important  functions 
in  the  associational  processes.  Examples  abound. 
Isaac  Newton  was  at  the  foot  of  his  grade  at  twelve. 
He  showed  neither  ability  nor  industry.  Charles 
Darwin  was  not  at  all  a  studious  boy.  He  writes : 
"To  my  deep  mortification,  my  father  once  said  to 
me,  'You  care  for  nothing  but  shooting,  dogs,  and 
rat  catching.'  "  Rosa  Bonheur  in  her  eleventh  year 
generally  contrived  to  avoid  the  schoolroom,  and 
spent  most  of  her  time  in  the  woods.  When  placed 
with  a  seamstress  in  order  to  learn  to  sew,  she  im- 
plored her  father  to  take  her  away,  which  he  did, 
and  much  perplexed  left  her  entirely  to  herself ;  and 
Rosa,  full  of  unacknowledged  remorse  for  her  in- 
capacity and  uselessness,  sought  refuge  from  her 
uncomfortable  thoughts  in  his  studio,  where  she 
learnt  her  art  as  a  solace,  in  play. 

A  vast  majority  of  parents  and  teachers  do  not 
appreciate  the  tremendous  possibility  of  character 
building  through  play  ;  and  they  try  to  subdue  it  in 
the  child,  thinking  it  is  something  he  should  over- 
come, forgetting  that  when  the  time  comes,  it  will 
pass  out  of  his  life;  and  it  will  do  so  as  ;naturallv 
and  readily  as  the  tail  of  the  tadpole  is  absorbed 
when  there  is  need  of  the  legs  of  the  frog.  The  hi- 
larious enthusiasm  of  childhood  and  youth  will  in 
time  develop  into  the  eager  earnestness  of  the  busi- 
ness man,  the  soldier,  etc.  As  said  Stanly  Hall  (9)  : 
"There  is  a  sense  in  which  all  good  conduct  and 
morality  may  be  defined  as  right  muscle  habits.  As 
these  grow  weak  and  flabby,  the  chasm  between 
knowing  the  right  and  doing  it  yawns  wide  and 
deep."  As  F.  W.  Robertson  said:  "Doing  is  the 
best  organ  of  knowing."  This  must  become  the 
dominant  note  in  the  pulpit  itself  as  soon  as  the 
preacher  seeks  to  know  what  the  soul  really  is. 

That  this  is  being  realized  is  shown  by  the  play- 
grounds movement,  which  in  Germany  are  used  as 
developer  of  the  inventive  and  creative  instincts,  and 
for  the  growth  of  muscle,  mind,  and  morals.  In 
England,  this  is  done  in  the  national  games,  which 
arc  a  part  of  the  curriculum  in  the  better  secondary 
schools.  In  these  games,  the  masters  themselves 
not  only  supervise,  but  participate  ;  and  in  this  wav 
encourage  fortitude  and  the  spirit  of  fair  play,  and 
restrain,  or  at  least  guide,  the  exuberance  and  nat- 
ural brutality  of  the  boy.  As  a  matter  of  fact,  phy- 
logeny  shows  us  that  the  most  valuable  lessons  of 
life  should  be  taught  in  play.  For  instance,  in  the 
gambols  of  young  rabbits,  it  is  the  mother  who 
teaches  them  to  enter  and  leave  their  burrows  quick- 
ly. In  the  menagerie,  one  may  see  the  parent  lion 
or  tiger  teaching  its  cub  to  leap  from  ambush.  W. 
J.  Long  believes  that  the  old  beavers  set  the  young 
ones  to  work  building  dams  in  summer  so  that  they 
will  have  learnt  to  do  so  when  required,  and  all  this 
is  done  in  and  as  play.  ' 

I'ut  educators,  unfortunately,  think  that  they  have 
discovered  a  better  way  than  the  natural  one ;  and 
our  little  children  were,  and  still  are,  forced,  against 
all  the  instincts  of  life,  away  from  their  plav  into 
schools,  where  in  many  cases  play  is  rarely  permit- 


ted. As  a  result,  they  are  suffering  from  arrested 
development  of  the  will,  as  well  as  of  the  emotions 
and  the  intellect.  No  wonder  Frobel  insisted, 
"Wouldst  thou  lead  the  child  in  this  matter,  observe 
him.  He  will  shew  thee  what  to  do."  The  child 
in  a  palatial  nursery  may  lead  a  life  even  less  desira- 
ble than  that  of  those  in  shops  and  factories.  He 
too  may  miss  the  stages  of  distinction  only  possible 
with  constant  reactions  to  healthy  environment. 
Even  though  not  stunted  physically,  he  is  certain  to 
be  so  mentally  and  morally ;  for  as  James  has  said : 
"The  boy  who  lives  alone  at  the  age  of  games  and 
sports  will  usually  shrink  in  later  life  from  the 
effort  of  undergoing  that  which  in  youth  would 
have  been  a  delight."  And  so  with  traits  of  charac- 
ter, they  must  become  reflexes  in  childhood  and 
youth,  or  the  opportunity  for  their  development  will 
have  passed.  Otherwise  we  shall  crush  out  character- 
istics upon  which  future  strength  depends,  and  force 
the  growth  of  untimely  virtues,  which  will  never 
become  mature.  Take  pugnacity  for  instance  ;  it  is 
generally  suppressed,  in  modern  education,  which 
forgets  that  the  "good  man  is  not  the  man  who  never 
fights,  but  rather  the  one  who  does,  and  fights  for 
the  right  and  in  defense  of  the  down  trodden."  Sim- 
ilar arguments  may  be  used  with  regard  to  selfish- 
ness, anger,  cruelty,  rude  humor,  venturesomeness, 
and  other  so  called  evils.  As  a  matter  of  fact,  the 
boy  who  cannot  play,  if  he  has  had  the  opportunity, 
is  not  capable  of  work  ;  for  both  work  and  play  are 
merely  the  use  of  the  surplus  of  energy  after  breath- 
ing, digestion,  and  circulation  of  the  blood  have 
been  accomplished. 

The  superiority  of  play  as  against  work  in  the  de- 
velopment of  a  child's  character  is  due  to  the  inter- 
est it  gives.  This  stimulates  effort,  without  which 
development  will  be  imperfect.  Indeed  activity  made 
without  effort  conduces  to  bad  habits  of  action, 
slovenliness,  and  lack  of  will  power — the  w"ant  of 
forcefulness. 

Regarding  altruism,  play  is  again  the  best  devel- 
oper. The  small  child  cannot  but  be  selfish  ;  he  can- 
not see  the  need  of  cooperation.  Group  games  will 
gradually  teach  this ;  for  instance,  little  bo\'S  have 
no  acknowledged  captain ;  but  later,  the  efforts  to 
play  well  and  for  the  team  to  win  make  necessarv 
the  subordination  of  certain  individuals  for  the  good 
of  the  whole ;  and  so  first  a  temporary  and  later  a 
permanent  captain  must  be  selected.  From  this  de- 
velops a  respect  for  law  and  order,  the  will  to  sub- 
mit to  discipline,  and  amenability  to  the  results  of 
its  infraction.  The  unselfishness  thus  derived  is  an 
active  force  in  the  future  man's  life :  it  is  kinetic. 
Hence  we  may  no  longer  say  that  knowledge  alone 
is  power ;  and  we  may  say,  again  with  Frobel :  ".\ 
comparison  of  the  relative  gains  through  play  of 
the  mental  and  physical  ])owers  would  scarcely  yield 
the  palm  to  the  body.  Justice  is  taught,  and  mod- 
eration ;  self  control,  truthfulness,  loyalty,  brotherlv 
love,  courage,  perseverance,  prudence,  together  with 
the  severe  elimination  of  indolent  indulgence." 

Premature  attention  to  the  inhibition  of  motor 
activities  in  the  development  of  man  prevents  the 
development  of  the  psychological  systems  without 
which  capacity  cannot  be  attained.  Resolution  be- 
comes permanently  "sicklied  o'er  with  the  pale  ca.>;t 
of  thought"  ;  and  moreover,  not  only  are  the  activi- 


April  24,  1909.] 


WILLIAMS:  INEBRIETY. 


837 


ties  incomplete,  but  those  which  develop  are  incom- 
moded by  the  constant  fear  brought  by  an  over  act- 
ive conscience.  As  James  ( 10)  has  asked  :  "How 
can  social  intercourse  occur  in  the  sea  of  responsi- 
bilities and  inhibitions  due  to  the  self  centered  hor- 
ror of  saying  something  too  trivial  and  obvious  or 
insincere  or  unworthv  of  the  company  or  inadequate 
to  the  occasion  ?" 

Now,  the  tremendous  friction  of  a  life  of  restraint 
upon  normal  activity  causes  nervous  exhaustion ; 
and  this  feeling  is  so  painful  that  one  readily  flies  to 
what  removes  it.    Hence  inebriety. 

On  the  other  hand,  there  is  danger  in  the  noncul- 
tivation  of  inhibition  ;  for  impulsiveness  then  rules  ; 
and  this  meets  with  innumerable  inducements  to  in- 
temperance of  all  kinds.  But  its  cultivation  must 
not  conflict  with  ontogeny  and  above  all  must  be 
kinetic. 

It  is  from  these  two  extreme  types  that  are  main- 
1}-  recruited  the  intemperate. 

As  may  be  readily  perceived,  the  treatment  differs 
radically  in  the  two  types,  the  latter  of  which  mav 
be  called  the  hysterical,  the  former  the  psychas- 
thenic. The  words  are  used  in  the  sense  given  them 
by  the  modern  French  psychoneurologists,  repre- 
sented respectively  by  the  schools  of  Babinski  (11) 
and  Pierre  Janet  (12).  A  few  words  must  be  said 
of  the  two  diseased  conditions  connoted  by  these 
terms.  z\s  I  have  remarked  elsewhere  (13),  "the 
very  important  diagnosis  between  hysteria  and 
psychasthenia  depends  upon  the  following:  First, 
as  to  fixed  ideas,  their  duration  in  hysteria  tends  to 
be  long;  for  though  the\"  are  easily  buried  and  for- 
gotten, they  ^re  resuscitated  with  great  ease  and  in- 
fallibility ;  whereas  in  the  psychasthenic  the  fixed 
ideas  are  very  mobile,  but  keep  recurring  voluntarih' 
and  indeed  become  cherished  parts  of  the  individual, 
and  are  far  more  difficult  to  eradicate  than  those  of 
the  hysteric.  Secondly,  hysterical  ideas  are  evoked 
by  well  defined  and  not  numerous  associations,  "sug- 
gestions'" ;  in  the  psychasthenic  they  are  often  evoked 
by  apparentl}-  irrelevant  associations,  which  are 
searched  for  by  the  patient;  thus  the  points  de  repcrc 
are  very  numerous,  cannot  be  predicted  with  cer- 
tainty, and  are  often  mere  excuses  for  crises  of  ru- 
mination or  tic.  Thirdly,  in  the  hysteric,  the  ideas 
tend  to  become  kinetical.  whereas  the  psychasthen- 
ic's  constant  state  of  uncertainty  causes  him  to  oscil- 
late between  T  would'  and  T  would  not.'  Inhibition 
is  too  strong  to  allow  an  act,  but  not  strong  enough 
to  dismiss  the  obsession." 

Psychasthenics  are  naturally  fitful  eaters ;  and 
every  heavy  meal  will  cause  an  intoxicative  metab- 
olic upset,  which  will  produce  the  conditions  for  an 
exacerbation  of  psychasthenia,  which  in  turn  read- 
ily induces  inebriety.  If  in  the  treatment,  attention 
is  drawn  to  this,  food  and  appetite  scruples  may  be 
produced  and  hence  undernutrition  and  even  hypo- 
chondria. Therefore  it  is  best  to  dose  the  repasts 
while  training  the  judgment,  and  not  to  tell  the  pa- 
tient until  his  critical  impersonality  is  better  culti- 
vated. 

Another  cause  of  psychic  perturbations  which  call 
for  extraneous  stimulus  is  illustrated  by  the  case 
(14)  of  the  woman  who  had  been  prescribed  three 
grains  of  cafi:'eine  each  day.  x\fter  eight  months  of 
frequent  attacks  of  angoissc  she  gave  it  up ;  where- 


upon the  attack  ceased.  She,  however,  resumed  the 
drug ;  but  the  attacks  recurred  and  she  relapsed 
again  and  again,  until  finally  she  ceased  the  caf- 
feine. When  one  remembers  that  this  is  only  the 
quantity  contained  in  one  and  a  half  cups  of  coffee 
of  average  size  and  strength,  or  in  about  three  cups 
of  tea,  a  frequent  and  insidious  cause  of  nervous 
depression  is  strikingly  revealed. 

Psychasthenic  needs  and  insufficiencies  may  be 
imitated  by  suggestion  (15)  ;  e.  g.,  when  vacuity  of 
mind  occurs,  attention  naturally  concentrates  on  the 
desirability  of  something  to  remove  it.  The  first 
thing  thought  of  constitutes  the  suggestion.  It  may 
be  mischief,  as  in  a  crowd  of  hooligans  and  school- 
boys ;  it  may  be  an  impulsion  to  move,  as  of  horses  in 
d  field,  the  rapid  contagiousness  of  such  movements 
being  there  well  seen.  The  stampeding  of  military 
horses  is  a  well  known  example.  Accustomedness 
and  training  turn  these  vacuous  trends  toward  work 
or  profitable  amusement  like  the  arts  of  music,  paint- 
ing, and  sculpture,  and  other  interests.  Hence  the 
vahie  to  most  people  of  a  hobby.  The  vacuousness, 
boredom,  is  worse  at  night,  in  some  persons.  Sus- 
picions may  form  ;  and  such  ideas,  easy  during  de- 
jection, have  often  been  reinforced  by  the  supersti- 
tion that  they  are  instinctive,  e.  g.,  it  has  been  be- 
lieved that  Alohammedans  detest  pork  by  nature, 
whereas  they  really  do  so  from  suggestion  and  imi- 
tation in  childhood.  Similarly,  fear  of  the  dark  is 
inculcated,  and  not  merely  instinctive  as  the  study 
of  pjedology  shows.  A  striking  instance  has  recent- 
ly come  to  my  attention  where  entire  fearlessness  in 
the  dark  marks  the  three  girls  of  a  mother  whose 
life  was  a  burden  to  her  on  account  of  the  terrors 
learnt  from  superstitious  negroes,  although  she  no 
longer  believed  them. 

It  is  essential  to  supply  occupation  of  vacant  mo- 
ments for  suggestible  persons  failing  strength  of 
psychic  constitution  or  its  substitute  in  philosophy 
or  moral  training. 

Again,  intemperance  in  eating  (due  to  bad  child- 
hood habits,  eating  being  a  very  strong  instinct 
then)  lowers  feeling  of  wellness;  and  this  leads  to 
want  of  stimulus  ;  hence  desire  for  an  uplift,  such 
as  alcohol  when  used  to  it,  tobacco,  etc. 

Another  cause  conducing  to  a  psychic  state  favor- 
ing inebriety  is  the  impelling,  by  an  ambitious  or  art 
loving  desire,  beyond  one's  endurance,  which  en- 
tails consequent  loss  of  sleep,  hasty  meals,  unsettled- 
ness,  and  anxiety  often  justified  b}'  business  oscil- 
lations. I  recollect  a  letter  sorter  who  broke  down 
on  account  of  the  added  stress  caused  when  he  wrote 
novels,  and  poor  things  they  were.  Foolish  ambi- 
tions are  most  rife  in  suggestible  people,  whose  crit- 
ical power  is  low.  They  make  misfits ;  and  consti- 
tute the  windbags  so  rife  in  public  and  official  life. 
These  are  the  penalty  of  all  government.  Lack  of 
ability  must  be  compensated  by  extra  work.  Manv 
a  broken  down  professional  man  is  a  spoilt  barber 
or  ploughman.  The  effects  of  these  extra  loads  de- 
press the  psyche,  and  lead  to  desire  for  stimulus  and 
hence  to  inebriety. 

A  form  of  ilddictive  tendency,  unfortunately  too 
common,  is  that  induced  by  the  reaction  of  the  pa- 
tient against  some  disappointment,  disgrace,  or  other 
psychic  trauma.  In  its  essence  this  is  what  psychol- 
ogists call  a  defense  reaction,  and  further  analyzed 


838 


WILLIAMS:  INEBRIETY. 


[New  York 
Medical  Journal. 


is  one  of  the  varieties  of  \vhat  Dupre  (17)  has 
termed  mythomania.  The  appetite  for  distinction, 
the  disHke  of  neglect,  determined  to  be  fed  and  hav- 
ing no  means  for  satisfaction  through  exhibition  of 
t'llent  or  capacity  to  perform  in  some  useful  way  or 
from  indolence  or  cowardice  of  disposition,  resorts 
to  the  extortion  of  sympathy  by  its  perseverance  in 
a  suffering  in  which  the  patient  indeed  comes  to 
believe. 

Sympathy  and  praise  removes  depression  or  vacu- 
ity of  mind,  titillates  the  psyche.  A  child  who  has 
learnt  to  lean  upon  others  is  a  candidate  for  false 
neurasthenia  of  this  type,  when  later  in  life  some 
business  or  social  project  miscarries.  When  a  per- 
son is  ruined  or  slighted  or  when  ambition  fails, 
neurasthenia  is  often  diagnosticated  and  a  rest  cure 
imposed,  or  drink  flows  to  terminate  the  suffering. 

A  remarkable  case  has  just  come  to  the  writer's 
attention  (18).  It  was  that  of  a  naval  yeoman,  who 
after  rapid  promotion,  of  which  he  had  reason  to 
be  proud,  utterly  broke  down  on  account  of  the  ex- 
actions and  irritability  of  a  new  commander  whom 
he  could  not  please.  His  state  of  health  eventuated 
in  his  desertion,  although  this  stigma  was  later  re- 
moved from  his  record.  His  symptoms  were  moros- 
ity  and  loss  of  interest  and  stamina,  impotence,  and 
overpowering  desire  to  get  away  from  his  distress- 
ing environment,  and  to  go  to  his  mother.  He  also 
seriously  thought  of  committing  suicide.  He  be- 
came suspicious  to  the  point  of  believing  that  the 
object  of  his  persecution  was  to  promote  over  his 
head  his  clerk,  who  had  been  longer  in  the  service 
and  was  more  efficient  than  himself,  though  too  un- 
reliable for  the  chief  post.  As  soon  as  he  felt  that 
he  was  in  an  asylum  and  free  from  the  risk  of  hav- 
ing to  return  to  an  environment  he  could  not  stand, 
he  began  to  improve  and  recovered  within  three 
months.  All  the  time,  he  was  glad  to  believe  him- 
self insane ;  and  indeed  while  under  treatment  be- 
fore going  to  the  asylum  had  run  away  from  home 
with  the  vague  idea  of  finding  employment.  Al- 
though well  in  other  respects,  he  still  interpreted 
his  experience  as  an  attempt  by  the  commander  to 
supplant  him. 

The  state  of  mind  from  which  this  man  suffered 
is  very  common  as  a  consequence  of  failures  of  am- 
bition, disgrace  in  business,  politics,  etc.  The  reac- 
tion depends  upon  the  psychic  make  up  of  the  pa- 
tient. The  mental  alienation  by  no  means  invaria- 
bly tends  toward  suicide,  it  may  take  the  form  of 
religious  remorse ;  and  very  commonly  consists  of 
resort  to  so  called  stimulants ;  in  such  a  state  drunk- 
enness is  easily  acquired.  Early  schooling  in  buoy- 
ancy under  adverse  contingencies  not  only  tends  to 
prevent  the  development  of  the  paranoid  state  shown 
in  this  patient,  but  makes  the  reaction  to  the  para- 
noid syndrome  less  unhealthy  than  suicide,  drunken- 
ness, or  even  general  suspiciousness. 

A  fourth  type  of  inebriate  differs  from  the  three 
foregoing  in  not  being  a  psychopathic ;  it  is  repre- 
sented by  the  man  who  drinks  to  excess  (without 
very  obvious  detriment  to  his  efficiency)  on  account 
of  the  habits  pertaining  to  his  environment.  A  dray- 
man, commercial  traveler,  or  our  "three  bottle"  an- 
cestors are  examples  of  this  type.  Such  people  have 
not  taken  to  alcohol  on  account  of  mental  depres- 
sion or  through  want  of  will  or  even  from  pleasure^ 


of  the  palate  or  general  feeling.  They  are  not  ine- 
briates until  their  will  is  destroyed  by  years  of  in- 
toxication ;  their  psychic  degeneracy  is  acquired,  not 
inherent.  The  number  of  this  class  is  rapidly  di- 
minishing with  the  spread  of  knowledge  of  hygiene 
with  regard  to  intoxicants.  To  the  intemperate  ad- 
vocates of  the  temperance  movement  is  perhaps  due 
some  credit  for  this  improvement :  their  agitation 
has  at  least  kept  the  subject  in  the  foreground,  and 
thus  directed  toward  it  the  scientific  research  of 
which  our  present  knowledge  is  the  fruit.  An  ex- 
ample is  that  of  the  poor  lad  who  consulted  me  for 
nervous  breakdown  due  to  alcohol  which  he  had 
first  learnt  to  take  because  at  the  age  of  thirteen  he 
looked  upon  the  big  boys  who  did  so  as  heroes. 

I  have  purposely  refrained  from  speaking  of  the 
psychological  effects  of  alcohol ;  this  problem  of 
physiological  experiment  has  been  clearly  solved  by 
the  researches  of  Horsley  (19)  and  of  Kraepelin 
and  his  followers  (20).  There  is  no  longer  any 
dispute  about  alcohol's  paralysing  eft'ect  upon  neu- 
ronic activity  as  measured  psychometrically.  The 
more  complex  is  the  neural  process,  the  more  detri- 
mental is  the  intoxicant. 

But  the  problem  we  have  to  face  now  is  the 
means  of  preventing  these  injurious  effects,  by 
studying  the  factors  which  lead  individuals  to  in- 
cur them.  I  am  well  aware  that  the  psychological 
factor  is  onlv  one  of  these ;  and  I  have  accordingly 
emphasized  its  relation  to  the  pedagogical.  Econ- 
omists, sociologists,  criminologists,  and  legislators 
may  occupy  themselves  with  the  various  factors  of 
the  problems  which  pertain  to  their  respective 
sciences ;  but  without  a  precise  determination  of 
that  psychological  character  of  the  individual 
against  which  they  must  direct  their  efforts,  their 
labours  must  be  sterile,  even  if  not  injurious. 
Hence  it  is  upon  the  student  of  morbid  psychology 
that  each  and  all  must  found  their  procedures  if 
they  wish  to  build  rather  on  rock  than  on  sand  and 
to  hew  a  step  more  in  the  advance  of  humanity  to- 
wards the  perfection  it  seeks. 

Again,  when  a  tendency  to  inebriety  recurs,  when 
founded  upon  one  of  the  psychic  perturbations  indi- 
cated, it  is  to  the  student  of  morbid  psychology  that 
recourse  must  be  had.  The  developments  of  psychic 
therapy  in  our  day  are  greater  than  I  can  even 
attempt  to  outline,  so  complex  are  their  ramifica- 
tions. Suffice  it  to  say  that  in  them  we  find  an  an- 
swer to  the  despairing  query  of  Hamlet,  "But  who 
can  minister  to  a  mind  diseased?" 

References. 

1.  Janet.  Les  Oscillations  du  niveau  mental.  Cougrcs 
international  de  Rome,  1904. 

2.  Pawlow.  Huxley  Lecture.  British  Medical  lournal. 
1906. 

3.  Fere.    Revue  d'hypnoiism.  1802. 
Stcherbak.   Archives  de  veurofogie,  1907. 

5.  Leuba.  American  Journal  of  Religious  Psychology, 
1906. 

6.  O'Shea.  Dynamic  Factors  in  Education.  London  and 
New  York,  1906. 

7.  Spencer.    Principles  of  Psychology. 

8.  Friedmann  and  Gierlich.  Studies  of  Paranoia, 
Translated  in  Nervous  and  Mental  Monographs.  1908. 

9.  Stanley  Hall.  Adolescence,  New  York.  1904. 

10.  James.    Essays,  1904. 

11.  Babinski.  Ma  Conception  de  I'hystcrie.  Paris,  1906. 
Williams.  Status  of  Hysteria.  Neiv  York  Medtcai 
Journal,  January  9,  IQ08. 


April  24,  1909. J 


KRAUSS: 


SUPPURATIVE  ETHMOIDiriS. 


839 


12.  Raymond  et  Janet.  Les  .  Obsessions  et  la  psychasthenie. 
Paris,  1903.  . 

13.  Williams.    International  Clinics.    Vol.  iii,  1908. 
Also  The  Trend  of  the  Clinician's  Concept  of  Hys- 
teria.   Boston  Medical  and  Surgical  Journal,  March 
25,  1909. 

14.  Archives  dc  niedccine  provinciale ,  1899. 

15.  Williams.  Differential  Diagnosis  Between  Neuras- 
thenia and  some  Affections  of  the  Nervous  System  for 
which  it  is  often  Mistaken.    Archives  of  Diagnosis,  1909. 

Also  The  Importance  of  Distinguishing  Types  among 
the  Psychoneuroses.  Journal  of  Abnormal  Psychol- 
ogy, March-April,  1909. 

See  also  Spencer.  Education,  Physical,  Intellectual, 
Moral. 

Oilman.    Concerning  Children,  New  York. 

Gould.    Will  Women  Help? 

Swift.    Mind  in  the  Making.    New  York,  1908. 

16.  Hickniet.  Congrcs  international  dc  I'hypnotisnie. 
Paris,  1900. 

17.  Diipres.    La  Mythomanie.    Paris,  1905. 

18.  White.  Washington  Society  of  Nervous  and  Mental 
Disease.  1908. 

19.  Horsley.   Alcohol.    London,  1906. 

20.  Kraepelin.    Arbeiten,  1889. 

21.  Moycn  court  ct  facile  de  faire  oraison. 

22.  Le  Chateau  intcrieur. 

21 18  Wyoming  Avenue. 


TWO  CASES  OF  ACUTE  SUPPURATIVE  (PHLEG- 
J^IONOUS)  ETHMOIDITIS  IN  CHILDREN 
RESULTING  IN  DEATH.* 

By  Frederick  Krauss,  M.  D., 
Philadelphia. 

Acute  ethmoiditis  may  be  divided  into  three  types  : 
r.  Acute  serous  ethmoiditis,  a  rather  common  af- 
fection resulting  from  mild  inflammation  of  the  mid- 
dle turbinate  bones,  as  in  severe  colds  in  th<.-  head, 
etc. 

2.  Acute  suppurative  ethmoiditis,  which  is  asso- 
ciated with  severe  pain  about  the  eye,  oedema  and 
redness  on  the  affected  side  of  the  nose  and  orbit, 
including  the  lids,  and  frequently  resembling  dacryo- 
cystitis. It  is  often  cured  by  the  evacuation  of  pus 
through  the  natural  openings  in  the  nose.  If  not 
thus  relieved,  it  breaks  usually  through  .the  thin 
plate  of  the  os  plenum  and  forms  an  abscess  below 
the  periosteum.  The  orbit  may  be  invaded,  and 
other  complications  ensue. 

3.  When  the  process  is  exceedingly  acute,  espe- 
cially in  children,  the  purulent  inflammation  extends 
rapidly  between  the  bony  sutures,  and  involves  the 
vascular  supply,  emptying  into  both  the  general  and 
the  cerebral  circulations,  whereby  rapid  death  en- 
sues from  toxaemia,  thrombosis  of  the  cavernous 
sinuses,  pyaemia,  meningitis,  brain  abscess,  etc.  On 
account  of  the  rapidity  of  its  progress,  the  name, 
phlegmonous  ethmoiditis,  seems  not  to  be  out  of 
place.  These  patients  appear  to  have  no  resistance, 
and  the  disease  spreads  with  startling  rapidity. 
Very  few  days  are  taken  in  the  whole  process.  Death 
from  acute  suppurative  ethmoiditis  is  perhaps  much 
less  uncommon  than  is  believed. 

The  reason  for  this  statement  is  that  the  process 
in  many  ways  resembles  erysipelas,  orbital  abscess, 
etc.,  and  might  readily  be  falsely  diagnosticated.  If 
the  possibility  of  acute  suppurative  ethmoiditis  is 

*Read  before  the  Section  in  Ophthalmology  of  the  College  of 
Physicians,  February  18,  1009. 


kept  in  mind,  and  excluded  in  all  orbital  inflamma- 
tions, much  will  be  accomplished. 

Peters  (i)  states  that  every  disease  of  the  orbit 
requires  an  exact  examination  of  the  accessory  nasal 
sinuses  and  that  according  to  the  latest  statistics 
about  sixty  per  cent,  of  all  cases  of  orbital  disease 
are  due  to  disease  of  the  nasal  sinuses.  This  per- 
centage is  perhaps  too  small  because  many  of  the 
sinus  diseases  become  latent  or  heal  more  quickly 
than  the  orbital  complication. 

The  resemblance  between  acute  suppurative  eth- 
moiditis and  erysipelas  should  be  dwelt  upon  so  fre- 
quently that  the  practitioner  will  be  on  the  alert  to 
make  the  diagnosis  in  nearly  every  case. 

Leber  (2)  recites  a  case  in  which  he  states  that  an 
orbital  phlegmon  followed  a  low  grade  of  erysipe- 
las in  a  twenty-five  year  old  man : 

The  patient  had  a  severe  cold  in  the  head,  with  erysipela- 
tous swelling  of  the  left  side  of  the  face.  Two  days  later 
there  was  developed  a  severe  pain  in  the  left  eye,  temple, 
and  forehead,  disturbing  his  rest  at  night.  The  following  day, 
exophthalmos  and  chemosis  of  the  conjunctiva  were  added. 
The  pupils  were  contracted  and  inactive  to  light.  The  pa- 
tient had  no  fever,  and  his  senses  had  been  clear,  though  by 
the  evening  of  this  day  he  was  delirious.  On  the  following 
morning  his  senses  were  again  clear,  but  there  was  exten- 
sion of  the  swelling  of  the  lid,  chemosis,  and  exophthalmos 
of  the  opposite  eye.  The  temperature  was  39°  C.  The 
symptoms  increased,  the  patient  became  comatose  and  died 
the  following  day.  Post  mortem  examination  disclosed  pus 
in  the  orbit,  and  in  the  orbital  veins,  suppurative  throm- 
bosis of  the  cavernous  and  inferior  petrosal  sinuses,  pachy- 
meningitis, and  multiple  infarcts  of  the  lung.  In  this  case, 
suppurative  ethmoiditis  was  probably  the  original  source  of 
trouble  instead  of  erysipelas. 

Several  other  cases  supposedly  due  to  erysipelas 
are  cited  by  Leber  in  which  the  history  and  progress 
of  the  patient  strongly  indicate  sinusitis.  It  is,  how- 
ever, only  in  the  last  twelve  years  that  attention  has 
been  thoroughly  brought  to  the  accessory  nasal  sinus 
as  a  possible  source  of  intracranial  complications. 
It  was  formerly  thought  that  orbital  abscess  was 
due  to  an  idiopathic  periostitis  of  the  walls  of  the 
orbit,  the  most  favorable  outcome  of  which  would 
be  rupture  into  one  of  the  nasal  sinuses  with  exit  of 
the  pus.  Otherwise  intracranial  complications  could 
ensue.  The  possibility  of  the  pus  originating  in  the 
sinuses  was  not  considered. 

In  Graefe-Saemisch  Handbuch,  first  edition,  Ber- 
lin (3)  states  that  caries  orbitaire  primitive,  as  it 
was  called,  is  accompanied  by  strabismus,  double 
vision,  difficult  movement  of  the  eye,  lessened  vision, 
more  or  less  exophthalmos,  inflammation  of  the 
globe,  with  cloudiness  of  the  cornea,  perforation, 
and  loss  of  the  eye.  One  of  the  predisposing  causes 
of  this  disease,  he  believes,  is  childhood,  especially 
the  scrofulous. 

In  the  cases  reported  in  the  following,  it  is  be- 
lieved that  the  rapid  absorption  of  virulent  toxines 
into  the  circulation  caused  violent  toxaemia,  an  ex- 
cessive increase  in  temperature,  coma,  and  death, 
with  but  slight  post  mortem  changes,  belonging  to 
the  class  of  cases  mentioned  by  St.  Clair  Thompson 
(4)  as  meningeal  septicaemia  with  slight  or  no  ana- 
tomical changes. 

Case  I. — Female,  age  thirteen,  came  to  St.  Christopher's 
Hospital  eye  dispensary  on  December  9,  1908,  with  the  his- 
tory of  having  had  a  toothache  in  the  lower  jaw  of  the  left 
side  four  days  before.  Two  days  before  coming  to  the  clinic 
the  left  nostril  had  discharged  watery  fluid  and  became  red 


840 


KKAUSS: 


SUPPURATIVE  ETHMOIDITIS. 


[New  .York 
Medical  Journal. 


and  tender  on  its  tip.  The  redness  and  swelling  increased 
the  following  day.  When  she  appeared  at  the  clinic  on 
December  9th  the  tip  of  the  nose  was  red  and  thickened, 
especially  on  the  left  side,  the  redness  and  swelling  extend- 
ing beyond  the  base  of  the  nose. 

The  region  directly  above  the  nose  on  the  forehead  was 
greatly  cheinosed  and  reddened,  but  had  no  indurated  edges 
nor  bullre.  The  chemosis,  involving  both  lids  of  the  left 
eye,  was  very  great,  permitting  a  view  of  the  globe  only 
after  their  forcible  separation.  The  chemosis  of  the  fore- 
head was  reddened,  but  that  of  the  lids  was  pallid.  The 
eyeball  was  normal  in  appearance  and  movements.  No 
proptosis  was  present.  The  eye  ground  e.xamination  dis- 
closed a  normal  fundus  in  each  eye.  The  septum,  the  in- 
ferior and  middle  turbinates  were  red  and  chemotic  tilling 
the  left  nares  completely.  The  pus  was  flaky  in  character 
but  adherent  sloughlike.  The  examination  of  the  nose  was 
difficult  on  account  of  its  tenderness.  There  was  great  ten- 
derness over  the  left  side  of  the  whole  nose  and  the  inner 
surface  of  the  orbit.  The  frontal  region  was  not  so  tender. 
There  was  no  tumor  formation.  As  it  was  found  impossi- 
ble to  enter  the  patient  into  the  hospital  on  account  of  the 
quarantine  against  diphtheria,  and  as  the  patient  appeared 
to  be  bright  and  in  good  condition,  the  temperature  being 
100"  F.,  she  was  told  to  go  to  bed,  a  Dobell  solution  was 
prescribed,  as  a  douche,  and  hot  compresses  were  to  be  ap- 
plied locally.  Frequently  repeated  doses  of  two  grains  of 
quinine  were  ordered.  If  no  improvement  was  noted  the 
next  day,  the  mother  was  warned  to  send  an  immediate  re- 
port, and  the  girl  was  to  be  operated  upon. 

No  word  was  received  until  two  days  later,  on  December 
II,  1908,  when  it  was  stated  that  the  patient  was  uncon- 
scious, and  had  at  times  been  delirious  the  previous  day. 
When  seen  by  my  assistant,  Dr.  Bachman,  the  temperature 
was  103°  F.,  the  pulse  was  thready  and  counted  with  diffi- 
culty. The  patient  was  comatose  and  had  had  an  involun- 
tary bowel  movement.  There  was  no  rigidity  of  the  mus- 
cles of  the  neck,  nor  was  there  any  retraction  of  the  head. 

I  saw  the  patient  shortly  afterward,  finding  her  uncon- 
scious, the  temperature  at  105°  F.  The  chemosis  had 
spread  greatly  and  now  involved  the  right  side  of  the  face 
and  both  lids.  It  was  of  a  dark  red  color  in  spots,  but  had 
no  indurated  edges  nor  biills.  In  both  eyes  the  chemosis  of 
the  lids  was  so  great  the  forcible  separation  was  needed  to 
disclose  the  eyeball.  The  right  eye  was  slightly  proptosed 
but  movable,  the  bulbar  conjunctiva  greatly  chemosed. 
The  left  eye  was  tremendously  proptosed,  and  fi.xed  down 
and  out,  with  marked  conjunctival  chemosis.  Both  pupils 
were  3  mm.  in  diameter  and  immovable.  No  attempts  to 
make  an  ophthalmoscopic  examination  were  made,  on  ac- 
count of  the  seriousness  of  the  patient's  condition. 

She  was  admitted  to  the  w  ards  of  the  How  ard  Hospital 
at  once.  She  was  seen  immediately  upon  admission  and 
was  operated  upon  practically  without  an  anaesthetic,  a  few 
whiffs  of  ether  being  given  for  its  stimulant  efYects.  She 
was  given  several  hypodermics  of  strychnine  and  digitalin. 
When  the  curved  incision  was  completed  to  the  periosteum, 
as  in  the  Killian  operation,  a  few  larger  flakes  of  pus  ap- 
peared, apparently  from  the  suture  between  the  nasal  and 
lachrimal  bones.  No  pus  was  found  in  the  orbit-.  The  os 
planum  was  very  thin  and  was  readily  perforated  by  the 
ordinary  blunt  probe.  This  opening  was  enlarged  by  a 
bone  curette  until  a  large  opening  into  the  nose  was  made. 
From  this  opening  the  posterior  ethmoidal  cells  were  thor- 
oughly opened,  after  which  a  large  opening  was  made  into 
the  sphenoid.  Pus  was  found  in  the  anterior  and  posterior 
ethihoidal  cells.  Pus  of  a  flaky  character  was  found  com- 
pletely covering  and  adherent  to  the  anterior  end  of  the 
middle  turbinate  bone,  which  latter  was  removed  and  the 
anterior  cells  broken  up  with  a  curette  from  the  nasal 
side.  The  wound  and  the  nose  were  thoroughly  washed 
with  a  weak  l)ich]f)ride  solutior>,  and  a  rubber  drainage  tube 
inserted  into  the  nose  frorr.'  the  orbit. 

The  patient  r<illied,  but  a  few  hours  later  hydrostatic  con- 
gestion of  the  lungs  developed,  and  she  died,  fifty  hours 
after  lier  first  appearance  in  the  eye  clinic.  No  autopsy  was 
permitted. 

Ca.se  it. — The  second  case  was  mentioned  in  a  previous 
paper  read  before  this  .section.  In  this  instance  the  patient 
was  first  seen  when  the  disease  was  fully  developed.  Tlic 
I)atient,  who  was  nine  years  old.  was  attacked  with  a  cold 
which  was  followed  by  swelling  about  the  left  eye  four  days 
later.    The  physician  called  in  an  opthalmologist  who  diag 


nosticated  the  condition  as  acute  dacryocystitis.  As  the 
condition  became  worse  the  patient  became  comatose,  and 
an  involvement  of  the  right  e\'e  developed,  when  she  was 
brought  to  St.  Christopher's  Hospital.  When  first  seen, 
therefore,  she  was  unconscious,  with  a  temperature  of  106° 
F.,  pulse  excessively  rapid  and  feeble.  Both  eyes  were 
greatly  proptosed  and  dislocated  down  and  out  and  immov- 
able. The  lids  and  root  of  ncse  were  greatly  chemosed  and 
reddened. 

The  irides  were  semidilated  and  did  not  respond  to  light 
stimulus.  The  ears  were  normal.  There  was  no  retraction 
of  the  head  or  other  sign  of  meningitis. 

As  the  left  eye  was  slightly  more  proptosed  than  the 
right,  and  as  the  history  indicated  primary  involvement  of 
the  left  eye,  a  curved  incision  as  in  Killian  operation  was 
made  to  the  periosteum.  A  few  flakes  of  pus  were  found 
near  tlie  frontonasal  suture.  No  carious  areas  of  bone 
were  found,  and  no  further  pus  was  found  in  the  orbit.  A 
free  opening  was  made  into  the  nose  and  through  drainag-.; 
established.  The  patient  rallied  from  the  operation,  but 
the  temperature  and  toxaemic  state  continued  until  her 
death,  ten  hours  later. 

During  my  absence  from  the  city  a  post  mortem  exannn- 
ation,  kindly  made  on  the  following  day  by  Dr.  Charles  ^Ic- 
Creight,  who  had  assisted  me  at  the  operation,  showed  no 
purulent  secretion  in  the  brain  or  meninges,  no  signs  of 
meningitis  nor  other  causes  of  death,  indicating  that  death 
had  been  due  to  septicemia,  w  ith  no  post  mortem  changes. 
The  proptosis  had  disappeared. 

I  regret  that  in  both  cases  the  bacteriological  ex- 
aminations made  by  the  resident  physicians  were  re- 
ported negative,  or  at  least  tinsatisfactory. 

The  freqtiency  of  intracranial  inflammation  fol- 
lowing disease  of  the  accessory  sintises  is  a  dif- 
ficult matter  to  estimate.  Pitt  (6)  fotind  in 
9000  post  mortem  sections  at  Guy's  Hospital  be- 
tween 1869  and  1888  only  a  single  case  of  cere- 
bral inflammation  of  rhinological  origin  compared 
with  57  of  otologic  jetiology.  Treitel  (7).  in 
6000  sections  for  the  Berlin  Institute,  found  two 
cases  of  cerebral  abscess  and  one  of  extradural 
abscess  combined  with  meningitis,  and  in  142  cases 
of  brain  abscess  Gowers  (8)  found  six  of  rhino- 
logical  origin.  Wertheim  (9)  found  127  cases  of 
intracranial  suppuration  in  10,394  post  mortem  sec- 
tions at  the  Breslau  Pathological  Institute,  of  which 
six  were  caused  by  accessory  nasal  sinus  disease, 
with  an  additional  eight  cases  in  dotibt. 

It  is  thus  seen  that  intracranial  complications  are 
much  rarer  following  accessory "  nasal  sinuses  dis- 
ease than  otitis  media. 

Dreyfuss  (5)  collected  nine  cases  of  death  result- 
ing from  ethmoiditis.  of  which  five  cases  were  acute, 
two  chronic,  and  two  syphilitic.  The  ages  varied 
from  very  young  (one  case)  to  forty-five  years,  five 
males  and  three  females.  Xone  of  these  resemble 
the  author's  cases,  and  some  of  the  reports  are  unsat- 
isfactory. Of  these  cases  the  one  by  Ogston  is  espe- 
cially interesting : 

.\  girl  nine  years  of  age  felt  unwell  for  several  days,  when 
headache  and  nausea  developed.  On  the  third  day  she  had 
pains  in  her  eyes  and  headache,  and  died  suddenly.  The 
coroner's  examination  showed  a  gelatinous  semifluid  sub- 
stance in  the  subarachmoid  space.  The  dura  mater  on  the 
convex  surface  was  normal,  as  was  the  basal  dura  except- 
ing a  small  area  on  the  left  orbital  roof.  Here  it  was  thick- 
ened, rough  on  the  outer  side,  and  covered  with  exudate  on 
the  inner  surface.  On  the  corresponding  area  of  the  op- 
posite side  there  was  a  slight  redness  and  roughness.  The 
ethmoid  cells  were  full  of  pus. 

IVcysing  (  10)  reports  a  case  of  suppurative  eth- 
moiditis following  scarlet  fever,  resulting  in  orbital 
abscess,  phlebitis  of  the  sinus  cavernosa,  and  septico- 


April  24,  1909.] 


KRAUSS:  SUPPURATIVE  ETHMOIDITIS. 


841 


pyaemia.  The  patient  was  five  years  old  and  died  in 
spite  of  operation  and  evacuation  of  the  pus. 

Paunz  (11)  reports  an  additional  case  of  brain 
abscess  resultin^j.  from  acute  suppuration  of  the  left 
ethmoidal  cells.  The  lamina  cribrosa  was  thin.  Gut- 
man  (12),  in  the  January,  1909,  number  of  the  Zcit- 
schrift  fiir  Augenhcilkiinde  reports  another  case  oc- 
curring in  a  twenty-nine  year  old  man. 

Adding  these  cases  to  the  two  reported  by  the  au- 
thor we  find  ten  fatal  cases  due  to  acute  ethmoiditis, 
and  four  to  chronic  ethmoiditis  or  accepting  Zar- 
niko's  estimate  of  Dreyfuss's  cases  (5)  as  five  acute 
and  one  chronic,  and  adding  the  five  additional  acute 
cases,  we  find  a  great  preponderance  of  acute  eth- 
moiditis as  a  cause  of  intracranial  complications  and 
death,  namely  ten  cases  of  acute  to  one  of  chronic 
disease.  This  is  just  opposite  to  the  findings  in  the 
other  forms  of  sinusitis  according  to  the  investiga- 
tions of  Dreyfuss. 

Ufifenorde  (14)  after  a  careful  consideration  of 
diseases  of  the  ethmoid  bone  decides  that  intracra- 
nial complications  are  not  so  rare  as  the  reports  in 
literature  would  suggest. 

Intracranial  suppuration  and  death  due  to  disease 
of  the  sphenoidal,  antra!  and  frontal  sinuses  have 
been  described  more  frequentl}'. 

St.  Clair  Thompson  (4)  recently  gathered  a  series 
of  forty-two  cases  of  cerebral  and  ophthalmic  com- 
plications of  sphenoidal  sinusitis  resulting  fatally. 
Of  these  forty-two  cases,  seventeen  died  of  menin- 
gitis from  thrombosis,  thirteen  of  thrombosis  and 
meningitis,  one  of  intracranial  abscess,  two  of  men- 
ingeal septicjemia  with  slight  or  no  anatomical 
changes.  There  was  one  case  each  of  encysted  ab- 
scess, hasmorrhagic  encephalitis,  phlebitis  of  the 
cavernous  sinus  giving  rise  to  pysemia,  intracranial 
haemorrhage,  and  suppurative  encephalitis. 

In  the  symptomatology  of  acute  suppuration  or 
phlegmonous  ethmoiditis  there  is  usually  a  history 
of  a  cold  in  the  head  and  more  or  less  intense  neu- 
ralgia for  several  days.  This  is  marked  by  swelling 
of  an  erysipelatous  type  along  the  nose  to  its  root 
and  above  it  on  the  forehead.  The  intense  cedema 
of  the  lids  of  the  affected  side,  together  with  great 
tenderness  and  oedema  of  the  whole  inner  wall  of 
the  orbit,  is  ver}-  suggestive.  In  a  patient  who  has 
had  only  a  slight  rise  of  temperature  later  a  raging- 
fever  develops  with  its  accompanying  symptoms. 
Extension  has  ensued.  Soon  the  oedema  affects  the 
loose  tissue  of  the  orbit,  causing  intense  exophthal- 
mos with  an  immovable  globe,  chemosis  of  the  con- 
junctiva, and  an  immobile  iris.  The  pupils  may  be 
contracted  or  dilated.  Usually  after  intracranial  in- 
fection the  opposite  eye  becomes  similarly  affected. 
The  cfidema  rapidly  assumes  a  darker  hue,  the  ten- 
derness to  touch  on  the  orbital  or  nasal  wall  becomes 
very  acute.  The  patient  is  delirious,  later  comatose. 
At  first  in  the  night  only,  but  usually  the  following 
day  coma  increases,  finally  resulting  in  death.  Pre- 
vious to  death  the  temperature  rises  to  a  great 
height.  In  children  the  affection  seems  to  be  more 
acute  and  rapidly  fatal,  three  to  five  days  being  the 
usual  course  of  the  disease. 

The  nasal  examination  is  difficult  on  account  of 
the  great  swelling  about  the  vestibule,  making  the 
nasal  orifice  narrow  and  very  tender.  With  care,  an 
ear  speculum  can  be  introduced  into  the  nose,  dis- 
closing intense  swelling  of  all  the  mucous  membrane 
of  the  nose  completely  filling  the  nasal  spaces.  Be- 


low the  middle  turbinate  in  anterior  ethmoiditis  and 
above  it  posterior  ethmoiditis  the  few  flakes  of  tena- 
cious pus,  often  removed  with  difficulty,  are  sug- 
gestive of  sloughing  tissue. 

A  striking  feature  in  this  disease  is  the  exoph- 
thalmos, which  is  apt  to  become  extreme.  In  spite 
of  this  extreme  degree  of  proptosis,  the  lids  cover  the 
eyeball,  requiring  forcible  separation  usually.  This 
is  due  to  great  serous  swelling  or  cedema  of  the 
neighboring  parts,  which  Hajek  believes  to  be  char- 
acteristic of  acute  inflammation  of  the  ethmoidal 
cells.  Also  in  part  to  thrombosis  of  the  cavernous 
sinus  and  its  consequent  venous  stasis. 

The  spreading  of  this  process  through  the  circular 
sinus  to  the  opposite  sinus  is  the  probable  cause  of 
the  involvement  of  the  opposite  eye.  Therefore 
marked  exophthalmos  of  the  opposite  eye  is  a  serious 
symptom,  necessitating  a  grave  prognosis.  The 
cedema  and  exophthalmos  frequently  disappear  com- 
pletely after  death. 

The  high  temperature  and  the  weak  rapid  pulse 
developing  so  quickly  with  fatal  results  indicate  an 
acute  toxaemia,  which  is  easily  accounted  for  by  the 
profuse  blood  and  lymph  supply  of  the  nose,  its  ac- 
cessory sinuses  and  the  intimate  connection  with  the 
vascular  supply  of  the  brain  and  meninges. 

The  seriousness  of  acute  suppurative  ethmoiditis 
should  be  recognized  especially  in  children,  and  im- 
mediate operative  interference  advised  as  soon  as 
symptoms  of'  extension  become  manifest.  The  pa- 
tient should  be  closely  guarded  with  a  trained  nurse 
in  charge  to  watch  the  symptoms.  In  the  earlv 
stages  efforts  at  reduction  of  the  nasal  disease  should 
be  made  by  applications  of  cocaine  and  adrenalin  to 
the  turbinate  bones,  and  mild  cleansing  lotions.  In 
the  earliest  stages  atropine  sulphate  solutions,  gr.  i 
to  5ii,  two  drops  instilled  into  the  eye  three  times 
daily  is  of  great  value.  Ice  compresses  in  the  early 
stages  and  heat  in  the  later  stages  are  applied  locally. 

Extension  is  indicated  by  sudden  increase  in  the 
temperature  above  103.5°  ^■■^  with  more  or  less  de- 
lirium, marked  chemosis,  a  dusky  appearance  of  the 
skin  about  the  root  of  the  nose.  This,  with  the  ap- 
pearance of  a  tender  swelling  in  the  upper  inner  part 
of  the  orbit,  and  exophthalmos  even  of  slight  degree, 
should,  I  believe,  be  an  indication  for  immediate  op- 
eration. Delay  may  result  disastrously  as  in  the 
cases  I  reported,  while  patients  operated  upon  at  an 
earlier  stage  invariably  recover. 

Operation  may  be  performed  when  bilateral  ex- 
ophthalmos has  developed,  but  if  there  is  additional 
toxaemia  present  the  effort  is  usually  useless  and 
death  ensues.  In  a  third  case  of  acute  suppurative 
ethmoiditis  in  which  the  symptoms  indicated  a  tend- 
ency to  rapid  progress,  an  immediate  operation  re- 
sulted in  a  cure.  Pus  was  absent  in  this  case  at  the 
time  of  the  operation,  but  on  the  following  day  it 
was  very  profuse,  and  of  the  same  flaky  character 
as  in  the  fatal  cases  reported. 

In  operating  on  these  cases  it  is  my  practice  to 
make  deep  incision  to  the  bone  directly  on  the  lower 
edge  of  the  shaved  eyebrow,  as  in  Killian's  opera- 
tion. The  periosteum  is  carefully  separated  so  that 
the  whole  contents  of  the  orbit  can  be  displaced.  A 
careful  search  is  made  for  carious  spots  of  bone  with 
a  blunt  probe.  The  os  planum  is  usually  very  thin 
in  these  cases,  and  the  slightest  pressure  suffices  to 
force  the  probe  or  blunt  curette  into  the  nose,  should 
no  carious  areas  be  found.     This  opening  can  then 


842 


KNOTT:  SPONTANEOUS  COMBUSTION. 


[New  York 
JIedical  Journal. 


be  enlarged  with  a  curette,  care  being  taken  not  to 
work  higlier  tlian  the  level  of  the  ethmoidal  vessels. 
After  the  mouth  gag  is  in  place  the  finger  is  placed 
in  the  posterior  choana,  from  behind  the  palate, 
whereby  the  curette  is  located.  Unless  a  very  large 
section  of  bone  is  resected,  it  is  difficult  to  see  from 
above,  and  I  find  the  sense  of  touch  very  valuable  to 
keep  my  bearings.  In  this  way  the  posterior  cells 
can  be  broken  up  and  an  entrance  gained  into  the 
sphenoid.  It  is  surprising  how  little  bleeding  ensues 
in  these  acute  suppurative  processes  in  comparison 
with  wounds  of  the  normal  turbinate  which  bleed 
very  freely.  After  the  cells  are  thoroughly  opened 
a  notched  rubber  tube  is  introduced  into  the  nose 
and  the  periosteum  carefully  stitched  into  place.  This 
can  be  done  by  using  deep  sutures,  including  all  of 
the  stiuctures,  using  especial  care  to  catch  the  peri- 
osteum. The  wound  is  covered  with  gauze  wet  with 
a  I  in  3000  bichloride  of  mercury  solution,  and  the 
tube  kept  clean  by  frequent  syringing  with  either  a 
weak  bichloride  or  a  saturated  boric  acid  solution. 
If  the  operation  has  been  done  in  an  early  stage,  it 
is  possible  to  remove  the  tube  on  the  third  day — 
washing  through  the  sinus  left  by  it  until  the  latter 
closes,  usually  in  a  few  days.  The  rest  of  the  treat- 
ment is  carried  on  through  the  nose.  The  scar  on 
the  face  is  practically  invisible. 

Briefly  summing  up  the  salient  points,  it  is  be- 
lieved that : 

1 —  There  is  an  increasing  conviction  that  acute 
suppurative  ethmoiditis  causing  orbital  and  cerebral 
symptoms  is  not  as  rare'  a  condition  as  has  been 
thought. 

2 —  It  is  often  rapidly  fatal,  especially  in  the 
young. 

3 —  Indications  for  operation  in  acute  ethmoiditis 
are  sudden  increase  in  temperature,  delirium  at 
night,  tumor  formation  in  the  inner  wall  of  the  orbit, 
the  slightest  exophthalmos.  Operation  should  not 
be  delayed  too  long.  As  in  appendicitis,  early  oper- 
ation is  a  harmless  procedure,  late  operation  gener- 
ally useless. 

4 —  When  there  is  bilateral  exophthalmos,  opera- 
tion is  usually  useless,  as  the  disease  has  probably 
extended  through  the  cavernous  and  circular  sinuses, 
causing  a  general  toxaemia  and  pyaemia,  or  fatal 
brain  lesion. 

References. 

1.  Peters,  A.   Axenfeld's  Augcnheilkunde,  1909. 

2.  Leber,  Th.    Archiv  fur  Angenheilkundc,  xxvi,  No.  3. 

3.  Graefe  and  Sacmisch.  Handbuch  fiir  'Angenheil- 
kundc, first  edition.  1880,  vi. 

4.  St.  Clair  Thompson.  Transactions  of  the  Medical 
Society  of  London,  1906, 

5.  Dreyfus';.  I>ie  Erkrankungen  des  Gchirns  in  seinen 
Adnexa  im  Gefolge  von  Naseneiterungen. 

6.  Pitt.    British  Medical  Journal,  1890. 

7.  Treitel.  Ueber  Hirn-Erkrankungen  und  Naseneiter- 
ungen. 

8.  Govvers.  Handbuch  der  N ervenkrankheiten ,  ii,  Bonn, 
1892. 

g.    Wcrtheim.    Archiv  fiir  Laryngologic,  1901,  No.  11. 
ID.  Preysing.    Zcitschrift  fiir  Ohrcuhcilkunde ,  xxxii. 
Ti.  Paunz.    Archil'  fiir  Laryngologic.  xiii,  1903. 

12.  Gntman.  Zcitschrift  fiir  Augenheilkunde,  xxi,  No.  I, 
January,  1909. 

13.  Zarniko.  Die  Krankheiten  der  Nasc  und  des  Nas- 
cnrachcns. 

14.  Uffenorde.    Die  Erkrankungen  des  Siebbeins. 
1701  Chest.xut  Stref.t. 


SPONTANEOUS  COMBUSTION. 

By  John  Knott,  A.  M.,  M.  D.,  Ch.  B.,  and  D.  P.  H.  (Univ. 
Dublin);  M.  R.  C.  P.  I.:  M.  R.  I.  A.,  etc. 
Dublin,  Ireland 

{Continued  from  page  jS8.) 

The  apparently  spontaneous  origin  of  some  cases 
of  vast  conflagrations,  in  remote  forests  and  in  un- 
tenanted territories  of  combustible  grasses,  contrib- 
uted to  the  maintenance  of  the  general  belief  in  the 
occasional  occurrence  of  an  allied  phenomenon  in 
the  animal  kingdom.  The  primitive  method,  of 
which  the  practice  has  always  been  so  widely  dis- 
seminated in  savage  life,  of  raising  a  fire  by  pro- 
ducing the  ignition  of  wood  by  friction,  also  yielded 
its  item  of  plausibility  to  the  conception ;  so  did 
even  the  latent  (inorganic)  existence  of  the  spark  of 
which  the  possibilities  were  so  readily  demonstrable 
— and  so  continually  utilized — on  the  abrupt  contact 
of  mineral  flint  and  (somewhat  artificial)  steel.  Of 
the  sacred  flame  of  the  altar  of  A'esta,  we  are  told 
by  Festus  Pompeius  that:  "Siquando  interstinctus 
esset,  virgines  verberibus  afficiebantur  a  Pontifice, 
quibus  mos  erat,  tabulam  felicis  materiae  tam  diu 
terebrare,  quousque  exceptum  Ignem  cribro  seneo 
virgoinaedem  ferret."  The  remarks  of  the  elder  Pliny 
upon  the  combustibility  of  wood  are  quaintly  inter- 
esting ;  as,  indeed,  are  most  of  the  remarks  and 
comment  of  the  same  writer  on  the  innumerable 
arcana  of  natural  history  with  which  he  concerned 
himself : 

The  wood  of  the  Linden  tree  seems  of  all  other  to  bee 
most  soft,  and  hotest  withal ;  for  proofe  whereof,  this  rea- 
son doe  men  alleadge,  because  it  soonest  turnes  and  dulles 
the  axe  edge.  Of  a  bote  nature  also  are  the  Mulberne 
tree,  the  Lawrell,  and  the  Yvie,  and  in  one  word,  all  those 
that  serue  to  strike  fire  with.  This  experiment  was  first 
found  out  by  spies,  that  goe  between  camp  and  camp,  by 
sheepheards  also  in  tlie  field ;  for  hauing  not  flint  euermore 
readie  at  hand  to  smite  and  kindle  fire  withall,  they  make 
shift  for  to  rub  and  grate  one  wood  against  another,  and 
by  this  attrition  there  fly  out  sparkles,  which  lighting  vpon 
some  tinder,  made  either  of  drie  rotten  touch-wood,  or  of 
bunts  and  withered  leaues,  very  quickly  catch  fire,  and 
burne  not  out.  And  for  this  intent,  there  is  nothing  better 
than  to  strike  the  Yvlewood  with  the  Bay.  In  this  case 
also  the  wilde  Vine  (I  mean  not  Labrusca)  is  much  com- 
mended ;  and  it  climbeth  and  runneth  upon  trees  in  manner 
of  Yuie. 

The  classical  writers,  both  Greek  and  Roman, 
refer  to  the  recognized  fact  of  occasional  origin  of 
fires  in  deep  forests,  ferocientc  aiistrina  tentpestate; 
and  the  ready  explanation  afforded  by  the  violent 
collision  of  the  trees  (ascripserunt  id  etiam  cacu- 
minum  arborum  a  vento  agitatorum  collisioni,  per 
quam  ignis  elicitur  non  aliter,  ut  e  Canna  Inclica 
scintillas  excitari  vulgo  innotuit).  The  highly  re- 
spectable authority  of  Thucydides  himself  is  com- 
mitted to  the  same  itenr  of  (in  this  instance  "Nat- 
ural" )  history.  The  phenomenon  has  been  cele- 
brated in  dignified  (philosophical)  hexameters  by 
the  Epicurean  Lucretius,  the  almost  divinely  in- 
spired exponent  of  the  atomic  theory : 

.At  saepe  in  magnis  fit  montibus,  inquis,  ut  altis 
Arboribus  vicina  cacumina  summa  terantur. 
Inter  se  validis  facere  id  conantibus  austris. 
Donee  fulserunt,  flammae  flore  coorto. 

And  the  more  geometrical  Manilius  descends 
from  his  sidereal  pathway  of  exploration  and  con- 


April  24,  1909. 1 


KXOJT:  SPONTANEOUS  COMBUSTION. 


843 


templation  to  indicate  this  same  terrestrial  source  of 
the  more  naturally  celestial  "element"  of  "fire" : 

Sunt  autem  cunctis  permisti  partibus  ignes, 
Ac  silice  in  dura  viridique  in  cortice  sedem 
Inveniunt,  turn  Sylva  sibi  collisa  crematur. 
The  remarkable  property  of  inflammabilit}-  which 
is  possessed  by  alcohol,  a  liquid  which  in  its  purer 
specimens  looks  to  the  unsuspecting  eye  so  exactly 
like  water,  would  prepare  not  only  the  uneducated, 
but  even  the  representatively  scientific,  minds  of  the 
more  crudely  scientific  ages  to  receive  and  assimi- 
late fanciful  stories  of  the  effects  of  its  prolonged 
and  continuous  influence  on  living  tissues.  One  of 
the  most  definite,  and  even  emphatically  expressed, 
of  the  early  reports  of  spontaneous  combustion — 
one  of  the  few  which  was  ushered  into  the  world 
with  the  auspiciously  patronizing  guarantee  of  high 
medical  authority — is  that  (already  referred  to) 
which  was  published  by  the  celebrated  physician  and 
anatomist,  Thomas  Bartholin.  The  version  of  this 
report  which  was  brought  under  the  notice  of  the 
then  junior  Royal  Society  informed  the  members  of 
that  critically  scientific  body  that :  ''A  poor  woman 
at  Paris  used  to  drink  spirit  of  wine  plentifully  for 
the  space  of  three  years,  so  as  to  take  nothing  else. 
Her  body  contracted  such  a  combustible  disposition 
that  one  night  she,  lying  down  on  a  straw  couch, 
was  all  burned  to  ashes  and  smoke,  except  the  scull 
and  the 'extremities  of  her  fingers." 

Another  uncompromising  report  is  mentioned  by 
Cohausen  {Lumen  novum  Phosphoris  accensiim; 
Amsterdam,  1717),  in  which  we  are  told  that  "A 
Polish  gentleman,  in  the  time  of  the  Queen  Bona 
Sforza,  having  drank  two  dishes  of  a  liquor  called 
brandy  wine,  vomited  flames  and  was  burnt  by 
them.'" 

The  first  case  of  this  kind  which  appears  to  have 
been  brought  under  the  notice  of  the  Royal  Society 
of  London  was  reported  "in  a  letter  from  Mr.  R. 
Love  to  his  brother,  j\Ir.  George  Love,  apothecar\- 
of  Westminster,  dated  Ipswich,  June  28,  1744,  which 
was  lain  before  the  society  by  the  president  on  No- 
vember 8."    That  letter  stated  : 

That  it  appeared,  upon  the  coroner's  inquest  concerning 
the  death  of  this  woman  (at  which  he  attended),  that  she 
having  gone  upstairs  with  her  daughter  to  bed,  went  down 
again  from  her,  half  undressed,  and  that  the  next  morning 
early,  her  body  was  found  quite  burnt,  lying  upon  the  brick 
hearth  in  the  kitchen,  where  no  fire  had  been,  with  the  can- 
dlestick standing  by  her,  and  the  candle  burnt  out,  with 
which  she  had  lighted  herself  down,  and  that  the  daughter 
could  assign  no  reason  for  her  going  down,  unless  it  were 
to  smoak  a  pipe:  but  said  she  was  not  addicted  to  drink  gin. 
The  jury  brought  it  in  accidental  death. 

A  week  after  the  above  date  (15  November, 
1744),  Dr.  Lobb  comminiicated  two  letters  concern- 
ing the  same  case :  "One  from  the  Reverend  ^Ir. 
Notcutt,  of  Ipswich,  to  the  Reverend  Mr.  Gibbons ; 
this  dated  July  25.  1744.  and  the  other  from  the  said 
Mr.  Gibbons  to  a  friend,  dated  September  2,  fol- 
lowing." The  extract  from  the  "minutes"  which 
was  published  in  connection  with  the  report  of  the 
case  states  that : 

They  both  agree  in  all  the  material  circumstances  relat- 
ing to  the  fact ;  both  giving  their  relations  from  the  mouths 
of  the  eye  witnesses,  who  viewed  the  body  when  it  was  first 
found  burning;  particularly  Mr.  Gibbons,  from  the 
woman's  own  daughter,  and  from  two  other  persons  living 
in  the  same  house,  whose  names  are  Boyden.  The  case 
was  this :  One  Grace  Pett.  a  fisherman's  wife,  of  the  parish 
of  St.  Clement's,  in  Ipswich,  aged  about  60,  had  a  custom, 


for  several  years  past,  of  going  down  stairs  every  night, 
after  she  was  half  undressed,  to  smoak  a  pipe,  or  on  some 
other  private  occasion.  The  daughter,  who  lay  with  her, 
fell  asleep,  and  did  not  miss  her  mother,  till  she  awaked 
early  in  the  morning,  April  10,  1744,  when  dressing  herself, 
and  going  down  stairs,  she  found  her  mother's  body  lying 
on  the  right  side,  with  her  head  against  the  grate,  and  ex- 
tended over  the  hearth,  with  her  legs  on  the  deal  floor,  and 
appearing  like  a  block  of  wood  burning  with  a  glowing  fire 
without  flame ;  upon  which  quenching  it  with  two  bowls  of 
water,  the  smother  and  stench  thereof  almost  stifled  the 
neighbours,  whom  her  cries  had  brought  in  :  the  trunk  of 
the  body  was  in  a  manner  burnt  to  ashes  and  appeared  like 
an  heap  of  charcoal,  covered  with  white  ashes ;  the  head, 
arms,  legs  and  thighs  were  also  very  much  burnt. 

It  was  said  that  the  woman  had  drank  very  plentifully  of 
gin  over  night,  on  the  occasion  of  a  merry-making,  on  ac- 
count of  a  daughter  who  was  lately  come  home  from  Gibral- 
tar. But  the  difficulty  is  to  account  for  the  fire  with  which 
she  was  burnt ;  since  there  was  none  in  the  grate,  and  the 
candle  was  burnt  out  in  the  socket  of  the  candlestick,  which 
stood  by  her;  and  a  child's  cloaths  on  one  side  of  her,  and 
a  paper  screen  on  the  other,  were  both  untouched.  And 
although  the  melting  of  the  grease  had  so  penetrated  into 
the  hearth,  as  not  to  be  scoured  out,  yet  they  observed  that 
the  deal  floor  was  neither  singed  nor  discolored ;  and  the 
manner  of  the  fire  burning  in  her  body  is  described  as  the 
working  of  some  inward  cause,  and  not  from  the  burning 
of  her  cloaths,  which  were  only  a  cotton  gown  and  upper 
petticoat. 

With  the  exception  of  a  single  case  published  in 
a  posthumous  work  of  Lecat,  and  which  does  not 
appear  to  have  had  the  supporting  testimony  of  any 
reliable  vouchers,  the  above  appears  to  be  the  only 
instance  of  spontaneous  combustion  that  had  been 
definitely  brought  under  the  notice  of  the  scientific 
world  before  the  epoch  making  communication 
made  to  the  Royal  Society  of  London  on  June  20, 
1745.  This  communication  was  made  in  form  of 
"an  extract  by  Mr.  Paul  Rolli,  F.  R.  S.,  of  an  Ital- 
ian treatise,  written  by  the  Reverend  Joseph  Bian- 
chini,  a  prebend  in  the  city  of  \'erona  ;  upon  the 
death  of  the  Countess  Cornelia  Zangari  and  Bandi, 
of  Cesena,  to  which  are  subjoined  accounts  of  the 
death  of  lo.  Hitchell,  who  was  burned  to  death  by 
lightning ;  and  of  Grace  Pett  at  Ipswich,  whose  body 
was  consumed  to  a  coal."  The  account  of  the  last 
is  that  which  I  have  just  quoted.  The  Italian  state- 
ment of  the  circumstances  of  the  death  of  the 
countess  dated  from  April  4,  1731.  The  version 
placed  before  the  Royal  Society  deserves  our  full 
attention  in  this  connection,  as  this  communication 
it  was  that  first  established  the  position  of  sponta- 
neous combustion  before  the  English  speaking  world 
of  science.  I  therefore  take  the  opportunity  of  re- 
producing it  in  full : 

The  Countess  Cornelia  Bandi,  in  the  sixty-second  year 
of  her  age,  was  al!  day  as  well  as  she  used  to  be;  but  at 
night  was  observed,  when  at  supper,  dull  and  heavy.  She 
retired,  was  put  to  bed,  where  she  passed  three  hours  or 
more  in  familiar  discourses  with  her  maid,  and  in  some 
prayers;  at  last,  falling  asleep,  the  door  was  shut.  In  the 
morning,  the  maid,  taking  notice  that  her  mistress  did  not 
awake  at  the  usual  hour,  went  into  the  bed-chamber,  and 
called  her,  but  not  being  answer'd,  doubting  of  some  ill 
accident,  open'd  the  window,  and  saw  the  corpse  of  her 
mistress  in  this  deplorable  condition. 

Four  feet  distance  from  the  bed  there  was  a  heap  of 
ashes,  two  legs  untouch'd,  from  the  foot  to  the  knee,  with 
their  stockings  on;  between  them  was  the  ladv's  head; 
whose  brains,  half  of  the  back  part  of  the  scull  and  the 
whole  chin,  were  burnt  to  ashes ;  amongst  which  were 
found  three  fingers  blacken'd.  All  the  rest  was  ashes,  which 
had  this  particular  quality,  that  they  left  in  the  hand,  when 
taken  up,  a  greasy  and  stinking  moisture. 

The  air  in  the  room  was  also  observed  cumber'd  with 
soot  floating  in  it.    A  small  oil  lamp  on  the  floor  was  cov- 


844 


KNOTT:  SPONTANEOUS  COMBUSTION. 


[New  York 
Medical  Journal. 


er'd  with  ashes,  but  no  oil  in  it.  Two  candles  in  candle- 
sticks upon  a  table  stood  upright ;  the  cotton  was  left  in 
both,  but  the  tallow  was  gone  and  vanished.  Somewhat  of 
moisture  was  about  the  feet  of  the  candlesticks.  The  bed 
receiv'd  no  damage ;  the  blankets  and  sheets  were  only 
raised  on  one  side,  as  when  a  person  rises  up  from  it  or 
goes  in.  The  whole  furniture,  as  well  as  the  bed,  were 
spread  over  with  moist  and  ash-color  soot,  which  had  pen- 
etrated into  the  chest-of-drawcrs.  even  to  foul  the  linnens  : 
nay  the  soot  was  also  gone  into  a  neighbouring  kitchen,  and 
hung  on  the  walls,  moveables,  and  utensils  of  it.  From  the 
pantry  a  piece  of  bread  cover'd  with  that  soot,  and  grown 
black,  was  given  to  several  dogs,  all  which  refused  to  eat  it. 
In  the  room  above  it  was  moreover  taken  notice,  that  from 
the  lower  part  of  the  windows  trickled  down  a  greasy, 
loathsome,  yellowish  liquor ;  and  thereabout  they  smelt  a 
stink,  without  knowing  of  what ;  and  saw  the  soot  fly 
around. 

It  was  remarkable  that  the  floor  of  the  chamber  was  so 
thick  smear"d  with  a  gluish  moisture,  that  it  could  not  be 
taken  off ;  and  the  stink  spread  more  and  more  through  the 
other  chambers. 

And  the  "remarks"  appended  to  the  original 
"narration"  by  the  reverend  author  were  as  follows: 

It  is  impossible  that,  by  any  accident,  the  lamp  should 
have  caused  such  a  conflagration. 

There  is  no  room  to  suppose  any  supernatural  cause. 

The  likeliest  cause,  then,  is  a  flash  of  lightning,  which, 
according  to  the  most  common  opinion,  Ijcing  but  a  sul- 
phureous and  nitrous  exhalation  from  the  earth,  1ia\  ing  been 
kindled  in  the  air.  did  penetrate  either  thro'  the  chimney 
or  thro'  the  chinks  of  the  window,  and  did  the  operation. 
All  the  above-mentioned  effects  prove  the  assertion ;  for 
those  remaining  foul  particles  are  the  grossest  parts  of  the 
Fulmen,  either  burnt  to  ashes  or  thickened  to  a  viscous 
bituminous  matter.  And  no  wonder  the  dogs  would  not  eat 
of  the  bread,  because  of  the  bitterness  of  the  soot,  and  stink 
of  the  sulfur  that  lodged  on  it.  The  impalpable  ashes  of 
the  lady's  corpse  are  also  a  demonstration ;  for  nothing  but 
a  Fulmen  could  produce  such  an  ef¥ect. 

They  say  that  there  was  not  any  noise ;  but  may  be  there 
was,  and  they  lieard  it  not.  being  in  a  sound  sleep.  Be- 
sides, there  have  been  seen  lightnings  and  fulmina  without 
noise,  as  one  may  very  often  observe. 

Other  items  demonstrative  of  the  profundity  of 
the  scientific  discrimination  of  the  first  half  of  the 
eighteenth  century  are  also  furnished : 

It  seems,  also,  that  it  was  not  what  is  commonly  taken  as 
a  Fulmen.  for  there  was  not  left  in  any  place  any  sulfure- 
ous  and  nitrous  smell.  There  did  not  appear  any  blackish 
tracks  on  the  walls ;  all  signs  of  the  Fulmina,  .  .  .  , 
and  the  opinion  of  an  academician  at  Ravenna,  who  in- 
sisted that  underneath  that  chamlier  must  be  a  sulfureous 
mine,  which  opinion  he  founds  on  this  :  That  in  the  very 
house,  in  a  room  near  that  the  lady  was  burnt  in,  there  was 
set  on  fire  a  good  quantity  of  hemp,  and  couldn't  be  found 
out  by  w  hom  ;  as,  also,  that  all  of  a  sudden  part  of  the 
palace  had  fallen,  and  not  by  an  earthquake,  so  that  one 
might  conjecture  all  this  to  be  the  effects  of  the  sulfureous 
mine  underground,  which  is  not  proved  by  those  assertions. 
Nay,  on  the  contrary,  if  there  was  a  mine  of  sulfur,  one 
could  smell  the  stink  of  it  in  those  dull  days,  when  the 
nauseous  south  wind  blows,  the  sulfur  mines  then  stinking 
a  great  distance.  Besides,  the  effects  of  sulfur  are  not  to 
reduce  a  body  into  impalpable  ashes. 

And  then  "the  author's  opinion"  is  definitely  enun- 
ci'^tcfl  in  the  following  grave  sentences : 

The  fire  was  caused  in  the  entrails  of  the  body  by  in- 
flamed effluvia  of  her  lilood,  by  juices  and  fermentations  in 
the  stomach,  by  the  many  combustible  matters  which  arc 
abundant  in  living  l)()dics  for  the  uses  of  life;  and,  finally, 
by  the  licry  cvapf)rations  which  exhale  frnm  the  settlings  of 
spirit  of  wine,  lirandics,  and  other  hot  liquors  in  the  tunica 
villosa  of  the  stomach,  and  other  adipose  or  fat  membranes ; 
within  which  (ns  chemists  observe)  those  spirits  engender 
a  kind  of  camphire;  which,  in  the  night  time,  in  sleep,  by  a 
full  breathing  nnd  respir.-ilion.  are  i)ut  in  a  stronger  motion, 
and,  consequently,  more  apt  to  be  set  afire. 

A  series  of  "proofs"  is  then  drawn  out  in  long 
array,  and  facts  arc  arranged  so  as  to  form  outposts 


and  buttresses  for  the  defense  and  support  of  the 
opinion  thus  expressed.  They  are  mostly  derived 
from  the  materials  which  I  have  already  laid  before 
the  reader.  The  results  of  the  investigations  of  Sanc- 
torius  regarding  the  cutaneous  excretions  then  oc- 
cupied a  prominent  position  in  the  collective  intel- 
lect of  the  scientific  oligarchy  of  Europe.  And  they 
evidently  subscribed  to  the  "opinion"  of  the  Rev. 
Joseph  Bianchini : 

After  all  these  instances,  what  wonder  is  there  in  the 
case  of  our  old  lady?  Her  dulness  before  going  to  bed 
was  an  effect  of  too  much  heat  concentrated  in  her  breast, 
which  hindered  her  perspiration  through  the  pores  of  her 
body ;  which  is  calculated  to  about  40  ounces  per  night. 
Her  ashes,  found  at  about  four  feet  distance  from  the  bed, 
are  a  plain  argument  that  she,  by  natural  instinct,  rose  up 
to  cool  her  heat,  and  perhaps  w'as  going  to  open  a  window. 

As  I  have  already  indicated,  the  preparation  of 
elemental — spontaneously  combustible — phosphorus 
from  the  human  urine  by  Brandt,  that  of  pyrophorus 
from  human  faeces  by  Homberg,  and  the  statement 
on  the  infallible  authority  of  Galen  of  the  sponta- 
neous inflammability  of  doves'  dung,  all  forcibly 
combined  to  give  an  air  of  extreme  probabilitv  to 
the  belief  in  the  spontaneous  ignition  of  some  of  the 
excrementitious  products  of  the  animal  (more  espe- 
cially the  human)  body.  And  throughout  all  the 
prescientific  centuries  of  learning  and  dogma,  the 
very  idea  of  life  was  closely  associated  with  the  idea 
of  the  phenomena  of  light  and  heat,  and  the  ph}  s- 
ical  properties  thereof.  The  first  cominand  pro- 
nounced by  the  omnipotent  Creator  was:  Fiat  lux. 
Some  of  the  most  subtly  thoughtful  of  philosophers 
have  enunciated  the  belief  that  the  human  soul  itself 
was,  in  each  individual  instance,  formed  by  a  distinct 
scintilla  of  the  lux  iiiimortalis — a  view  which  has  bt  en 
poetically  embalmed  for  modern  English  readers 
by  Alexander  Pope,  in  a  single  line  of  pregnant  full- 
ness of  inspiring  thought  and  meaning,  which  seems 
to  be  proportionally  as  rarely  understood  as  it  has 
been  frequently  read,  and  copied,  and  quoted : 

Vital  spark  of  hcaz'ciily  flame. 
And,  of  course,  even  in  brutes  the  principle  of  life 
must  have  had  a  similar  origin,  as  was  shown  so 
conclusively  by  the  phosphorescence  sometimes  ob- 
servable in  dead  bodies — especially  in  those  under- 
going slow  decomposition.  The  original  source  of 
the  internal  heat  of  warm  blooded  animals  could  also 
be  accounted  for  in  this  way,  and  in  no  other.  The 
"divine"  I'lato  himself — who,  contrary  to  what  most 
people  in  the  ])resent  day  seem  to  think  of  the  physio- 
logical knowledge  of  those  remote  pagan  centuries, 
had  fairly  well  defined  ideas  of  the  circulation  of  the 
blood — was  apparently  of  this  way  of  thinking.  We 
find  his  i!J.<fur<rj  Oiji'id'^  perpetually  burning — a 
rrra  tlamma — in  the  left  ventricle  of  the  heart.  .-\nd 
the  other  highest  and  noblest  members  of  the  intel- 
lectual and  scientific  aristocracy  of  those  ages  of  tin- 
snij)assed  mental  subtlety  and  tndy  philo.sophical 
illumination,  Hippocr.ates,  Ari.stotle,  dalen,  etc..  all 
appear  to  have  entertained  somewhat  cognate  opin- 
ions. It  was  even  noted,  in  this  connection,  that  al- 
though burning  was  the  usually  characteristic  acci- 
dent of  fire,  it  was  not  of  the  essence  of  that  "ele- 
ment" :  witness  the  facts,  that  lightning  sometimes 
killed  without  .scorching;  that  the  flame  yielded  bv 
the  "spirit  of  wine"  is  relatively  feeble  in  luminosity 
and  in  consinning  destnictiveness  ;  and  that  the  calor 


April  24,  1909.] 


KXOTT:  SPOXTAXEOUS  COMBUSTIOX. 


845 


aiiiinaliiiiii  was  discoverable  by  touch,  but  uot  by 
sight.  Accordingly,  it  was  not,  after  all,  difficult  to 
comprehend  that  the  '/''^yji  became  overheated  by 
disease,  and  took  its  part  in  the  display  of  the  phe- 
nomena of  fever.  And  we  find  that  in  the  imagina- 
tion of  the  celebrated  reformer.  Melanchthon  (at 
whose  intellectual  focus  the  respective  bisectors  of 
the  angular  Renaissance  domains  of  pagan  philoso- 
phy, and  Christian  theology,  and  dovetailed — old  and 
new — physiology,  appeared  to  meet  in  a  single  point ) 
the  spiritiis  vita'Us.  on  whose  presence  and  functional 
activity  life  and  animal  heat  depended,  was  gener- 
ated within  the  heart,  and  from  the  purest  blood — 
and  thus  necessarily,  of  course,  in  the  left  side  of 
that  organ. 

There  were  various  qualities  or  features — and 
those  of  the  most  distinctive  importance — which  were 
common  to  the  heat  of  ordinary  combustion  and  that 
of  the  animal  body  ;  both  were  continuous,  with  su- 
perficial variations  ;  both  were  influenced  by  the  qual- 
ities of  the  surrounding  atmosphere  :  both  required 
a  periodic  supply  of  nourishing  fuel ;  both  were  ex- 
tinguishable — very  easily  so,  if  not  on  a  large  scale  : 
when  once  extinguished,  no  trace  of  survival  re- 
mained in  either  case  ;  both  yielded  to  water,  a  sub- 
stance of  the  mildest  physical  qualities  ;  both  required 
free  ventilation ;  each  favored  a  special  focus  or 
hearth  ;  and  each  manifested  itself  in  warmth,  and — 
in  certain  instances  and  special  circumstances — in 
light.  We  find  the  very  learned  Tidicseus  comparing 
this  focus  of  the  vital  principle  to  the  unfading  fire 
of  Vesta.  When  the  "three  principles"  of  Basil  \'al- 
entine  and  Paracelsus  reigned,  the  sulphur  regulated, 
as  a  matter  of  colirse,  all  the  phenomena  connected 
with  the  production  and  elimination  of  heat.  And 
it  is  refreshing  to  our  intellectual  pigmies  of  the  pres- 
ent generation  to  find  Kepler,  the  pioneer  colossus  of 
modern  astronomy,  stating — with  a  convincing  air 
of  the  most  fully  selfsatisfied  scientific  deliberation : 
In  arterias  ex  corde  venit,  in  corde  vero.  non  vereor 
.  .  .  flamman  vero  perennem  .  .  .  Cordis  late- 
brosa  lampas.  sanguis  ex  ipso  cavae  venae  caudice  per 
canalem  peculiarem  in  cor  traductus,  ad  instar  olei. 
unde  vivat  h?ec  flamma. 

Those  who  adopted  the  sulphur  theory  of  the  ori- 
gin of  animal  heat  usually,  however,  if  not  always, 
regarded  the  internal  "flame"  as  "potential."  not 
"actual."  The  fantastic  \'an  Helmont,  the  "Father 
of  Alodern  Chemistry,"  divided  the  various  forms  of 
animal  (light  and)  heat  into  tw^o  classes,  solar  and 
lunar.  This  arrangement  depended  upon  manifesta- 
tion of  physical  characters — which,  necesarily.  de- 
pended on  the  source.  That  of  fish,  being  cold  and 
moist,  was,  in  the  very  nature  of  things,  referable  to 
the  moon.  And  any  and  all  phosphorescent  phenom- 
ena displayed  by  warm  blooded  animals  would  be 
unhesitatingly  attributed  to  solar  influence.  And 
here  in  our  own  twentieth  century,  with  its  accumu- 
lated experience  and  concentrated  luminosity  of 
physical  theory  and  capitalized  store  of  fact,  the  most 
"modern"  and  materialistic  science  is  obliged  to  ac- 
cept the  solar  control  of  life  and  heat  on  the  surface 
of  our  globe,  as  unquestionably  as  it  does  that  of  its 
light!  And  has  not  the  mathematical  calculation 
which  had  been  so  confidently  carried  out  of  the 
allotted  date  of  the  coming  period  of  extinction  of 
all  life,  light,  heat,  and  movement  on  the  face  of 
this    planet    been    falsified    only    by    the  recent 


discovery  of  the  phenomena  of  radioactivity? 
— which  physical  entity  has,  in  turn,  furnish- 
ed the  nearest  approach  to  a  basis  of  act- 
uality for  the  imaginary  displays  of  spontaneous 
combustion.  And  in  this  connection  it  is  also  in- 
teresting to  note  that  the  phenomenon  of  the  phos- 
phorescence of  the  "Bologna  stone,"  which  furnished 
the  fruitful  text  for  copious  discussion  in  his  day, 
was  referred,  as  well  as  that  of  sea  water,  by  the 
illustrious  Robert  Boyle  to  a — necessarily — solar  ori- 
gin ;  not  lunar,  which  would  be  more  in  accordance 
with  the  theoretic  classification  of  \'an  Helmont. 

If  we  wish  to  be  at  all  genuinely  just  in  our  criti- 
cisms, we  should  not  enunciate  our  notions  of  the 
scientific  acquirements  of  the  older  centuries  with 
too  robust  a  confidence,  for  we  surely  can  but  seldom 
define,  with  even  a  tolerable  approximation  to  ac- 
curacy, what  the  limits  of  their  attainments  actually 
were.  We  of  the  present  democratic  generation  are 
conspicuously  prone  to  take  an  emancipated,  edu- 
cated, intelligent  public  into  our  scientific,  philo- 
sophic, and  moral  confidence.  But  in  the  centuries 
which  witnessed  the  slow  and  painful  evolution  of 
the  early  stages  of  modern  science,  the  members  of 
the  learned  oligarchy  of  the  commonwealth  of  in- 
tellect were  usually  of  the  opinion  that  they  their 
"own  gained  knowledge  should  profane"  by  its  most 
casual  and  limited  exhibition  to  the  scrutiny  of  the 
untrained  gaze  of  the  uninitiated  "multi-capitate." 
What  "secrets"  they  did  transmit  to  writing  were 
ver\-  generally  veiled  in  enigmatic  diction — in  a  lan- 
guage which  could  be  translated  only  by  those  who 
were  privileged  to  possess  a  cipher-key.  And  the 
subjects  of  fire  and  light  were  so  mysteriously  im- 
portant, so  thoroughly  emblematic  of  the  highest 
conceivable  sources  and  seats  of  power,  so  obvious- 
ly and  inextricably  associated  with  the  existence — 
the  growth,  development,  and  whole  life  history — 
of  all  forms  of  organic  life,  that  they  were  always 
among  those  which  were  most  impregnablv  fenced 
around  with  the  most  impressive  paraphernalia  of 
mystery  and  adoration.  The  cave  of  Methra  and 
the  altar  of  Vesta  are  correspondingly  imposing  items 
of  testimony  to  the  distribution  of  this  sentiment 
throughout  the  ancient  pagan  world,  as  the  Hat  lux 
of  the  Jewish  cosmogony  became  its  special  watch- 
word in  the  Christian.  Of  the  four  elements  of  the 
time  honored  theory  of  matter  w^hich  was  accepted 
by  Galen  himself,  fire  occupied  the  highest  place. 
\'ery  naturally,  too,  as  it  was  the  only  recognizable 
entity  of  which  the  tendency  was  invariabh'  up- 
ward. Necessarily  then,  the  soul,  as  the  principle 
of  life,  must  be  a  derivative  thereof.  Thus  we  have 
the  profoundly  speculative  Patricius  declaring  that 
all  life  was  derived  from  spirit  and  fire  {spirit n 
igiicque).  Thus  even  the  aniiua  microcosmi  was 
of  the  nature  of  fire ;  hence  the  horror  with  which 
the  quenching  of  a  fire  was  regarded:  "apiid 
ictcrcs  igiicm  e.vtiiiguere.  nou  minor  crat  religio. 
quain  hoiniiicin  occidcrc.''  And  as  the  human  mi- 
crocosm was  but  a  picture  in  little  of  the  universal 
megacosm,  the  auinia  luuiidi  was,  of  course,  wdiollv 
constituted  of  matter  derived  from  the  same  elemen- 
tal source.  The  luminosity  of  the  human  soul  was 
made  professedly  demonstrable  by  some  representa- 
tives of  the  vagaries  of  the  Alanichasan  (or  allied 
contemporary)  doctrines:  the  Sun  was  the  taber- 
nacle of  the  Redeemer,  and  the  transitory  abode, 


846 


KNOTT:  SPONTANEOUS  COMBUSTION. 


[New  York 
Medical  Journal. 


during-  the  process  of  purification,  of  all  redeemed 
souls — and  thus  was  its  perennial  luminosity  se- 
cured ;  while  the  ascending  soul  always  rested  tem- 
porarily on  the  moon  in  its  journey,  from  which 
there  was  a  monthly  discharge  to  its  eternal  home  in 
the  hi.r  zodiaca.  Hence  the  succession  of  the  moon's 
phases ! 

The  attitude  of  the  popular  mind,  in  all  ages  of 
human  history,  towards  the  "divine  effulgence" — 
and  its  ever  recurring  conception  of  the  nature 
of  the  latter,  is  shown  in  the  account  of  the 
episode  of  the  shining  of  Moses's  face  on  his  de- 
scent from  the  mount ;  similarly,  by  the  sparkles 
which  emanated  from  the  head  of  the  infant 
jEsculapius,  and  indicated  the  special  powers  of  the 
coming  divine  healer  of  the  pagan  world ;  by  the 
"golden"  halo  which  Homer  used  to  decorate  the 
head  of  the  hero  of  his  Iliad ;  by  the  more  "will-o'- 
the-wisp"  like  effulgence  with  which  Virgil  con- 
secrated the  youthful  Ascanius  ;  by  the  flashes  which 
radiated  from  the  head  of  Alexander  the  Great  dur- 
ing the  battle  of  the  Indus ;  by  the  corresponding 
emanations  from  the  head  of  Hasdrubal  under  cor- 
responding circumstances ;  and  by  those  observed  to 
escape  even  from  the  person  of  Alasanissa,  King  of 
the  Xumidians : 

Carpenti  somnos  subitus  rutilante  corusca 
Vertice  fulsit  apex :  crispamque  involvere  visa  est 
Mitis  flamma  comam  atque  hirta  se  spargere  fronte. 

One  of  the  strangest  of  the  examples  of  the  Old 
World  fusion  of  the  ideas  of  fire  and  life  with  those 
of  the  divine  paternity  and  virginal  conception  of  a 
future  redeemer  of  his  people,  is  to  be  found  in  the 
traditional  account  of  the  generation  of  Servius 
Tullius,  the  liberator  of  the  Roman  people.  It  is 
thus  furnished  by  the  elder  Pliny — in  the  quaint 
version  of  Philemon  Holland,  Doctor  of  Physicke : 

But  before  I  make  an  end  of  fire,  and  the  hearth  where 
it  burneth,  I  will  not  passe  one  admirable  example  com- 
mended unto  us  by  the  Roman  Chronicles :  in  which  we 
reade,  That  during  the  reign  of  Tarquinius  Priscus,  King 
of  Rome,  there  appeared  all  on  the  sudden  vpon  the  hearth 
where  hee  kept  fire,  out  of  the  very  ashes,  the  genital  mem- 
ber of  a  man,  by  verlue  whereof  a  wench  belonging  vnto 
Tanaquil  the  queen,  as  she  sate  before  the  said  fire,  con- 
ceived and  arose  from  the  fire  with  childe ;  and  of  this 
conception  came  Servius  Tullius  who  succeeded  Tarquin 
in  the  kingdome.  And  afterwards,  while  hee  was  a  yong 
childe,  and  lay  asleep  within  the  court,  his  head  was  seen  as 
a  light  fire ;  whereupon  he  was  taken  to  be  the  son  of  the 
domestical  spirits  of  the  chimney. 

Divine  halos,  apostolic  fiery  tongues,  and  saintly 
corona,  conspired  with  less  conspicuous  items  of 
celestial  symbolism  to  maintain — in  script,  and 
sculpture,  and  architecture  and  painting — the  mys- 
terious reverence  always  associated  in  the  emotion- 
ally religious  mind  with  the  inexplicable  properties 
and  powers  of  light  and  fire,  down  through  the  long 
lapse  of  ages  that  preceded  the  dawn  of  modern  sci- 
ence. So  did  the  weird  phenomena  of  comets  and 
meteors,  and  the  deadly  powers  of  the  more  nearly 
familiar  lightning.  And  the  history  of  the  growth 
and  development  of  the  tradition  of  the  spontaneous 
combustion  of  the  human  body  well  shows  that  dis- 
cussion alone — logical  and  illogical,  inductive  and 
deductive — was  the  weapon  methodically  employed 
in  establishing  the  "authority"  of  the  "scientific" 
facts  which  were  brought  under  its  notice,  in  the 
exercise  of  its  "Royal"  function,  by  the  learned 
"Society"  which  was  so  auspiciously  organized  and 
chartered  in  London  "for  improving  natural  knowl- 


edge." It  was  almost  a  century  after  the  sprouting 
of  the  original  germs  of  the  Royal  Society  that  the 
communication  of  Paul  RoUi,  F.  R.  S.,  on  the  novel 
scientific  conception  of  the  spontaneous  combustion 
of  the  human  body  came  to  receive  the  impr'unatnr 
of  the  august  council  of  that  most  learned  of  scien- 
tific bodies.  The  fact  of  its  publication  in  their 
Transactions  assured,  its  acceptance  as  an  inspired 
chapter  in  the  progressive  gospel  of  modern  science. 
Few  outsiders  could  possibly  possess  either  the 
knowledge,  or  the  ability,  or  the  time,  or  even  the 
mclination  requisite  to  the  preparation  of  an  attack 
on  a  scientific  position  thus  captured  and  fortified. 

And  if  an  exceptional  individual  happened  to  be 
equipped  with  every  one  of  those  requisites,  he 
would,  most  assuredly,  on  making  the  effort,  have 
found  himself  doomed  to  reap  a  reward  of  irritation 
and  disappointment.  The  whole  tone  of  Rolli's 
epoch  making  communication  combines  with  its  ac- 
ceptance for  the  position — which  it  has  ever  since  so 
firmly  occupied — of  foundation  stone  of  the  scien- 
tific recognition  of  the  physical  entity  of  spontaneous 
combustion,  to  demonstrate  the  fact  that  the  Royal 
Society  of  1745  retained  the  original  complexion  of 
1660,  when  its  widely  experienced  and  observant 
(even  if  somewhat  frivolous)  patron,  Charles  II, 
nonplussed  its  collected  members  by  propounding  the 
problem :  Why  is  it  that  a  dead  fish,  when  intro- 
duced into  a  vessel  full  of  water,  will  cause  it  to 
overflow,  whereas  a  live  one  will  not?  The  cynical 
gossips  of  the  court  of  the  merry  monarch  actually 
went  so  far  as  to  circulate  the  report  that  this  query, 
after  very  prolonged,  and  even  at  times  acrimonious, 
discussion,  was  about  to  be  shelved  .as  insoluble  in 
the  existing  state  of  knowledge,  when  one  of  the 
menials  employed  at  a  symposium. of  the  society  con- 
ceived— and  carried  out — by  means  of  a  couple  of 
fish  and  a  vessel  of  water,  the  experimental  move- 
ments necessary  to  decide  whether  the  hypothesis 
which  was  confidently  assumed  in  the  enunciation  of 
the  problem  was  really  based  on  matter  of  fact ! 

The  foundation  of  the  orthodoxy  of  spontaneous 
combustion  having  been  thus  firmly  imbedded  in  the 
petrifying  cement  of  the  Transactions  of  the  Royal 
Society,  future  contributors  to  the  discussion  of  this 
article  of  the  scientific  creed  sought  rather  to  ac- 
count for  its  existence  than  to  question  its  possibil- 
ity. The  general  love  of  the  marvelous  and  admira- 
tion for  the  incomprehensible,  on  which  the  mal<ers' 
of  new  faith  and  shoddy  miracle  have  always  relied 
for  professional  prosperity,  were  cultivated  in  this 
connection — with  a  very  fair  proportion  of  success 
indeed.  The  hankering  after  notoriety — which  is 
never  a  negligible  quantity  in  the  collective  cerebral 
panoply  of  the  leading  phalanx  of  the  scientists  and 
physicians  of  any  generation-^would  appear  to  have 
been  accountable  for  the  genesis  of  some  of  the  suc- 
cessive contributions  to  the  subsequent  literature  of 
the  subject.  "Philosophic  doubt"  has  never  been  a 
welcome  guest  in  the  halls  of  learned  institutions ; 
and  the  charge  of  heresy  has  always  been  as  serious, 
and  as  deadly  in  its  course  and  consequences,  in  sci- 
ence as  in  theology,  so  far  as  the  power  of  punish- 
ment and  of  permanent  extinction  of  the  culprit  is 
permissible  or  attainable.  So  spontaneous  combus- 
tion continued  to  germinate,  and  cast  forth  fruitful 
branches;  and  Frank,  in  1843,  was  able  to  arrange 
and  analyze  the  records  of  42  cases.   Then  Tourdes, 


April  24,  1909.] 


KNOTT:  SPONTANEOUS  COMBUSTION. 


847 


writing  in  1876,  stated  that :  "on  pent  evaluer  a  45 
oil  48  le  nombre  total  des  faits  qui,  pendant  deux 
cents  ans,  de  1672  a  notre  epoqre.  ont  etc  consideres 
comma  appartenant  a  la  combustion  spontanee.'"  So 
that  the  supply  had,  very  evidently,  been  on  the  de- 
cline for  the  preceding  third  of  a  century  or  so ! 

Precisely  in  the  middle  of  the  last  century  a  new 
era  opened  in  the  history  of  spontaneous  combus- 
tion. Down  to  that  period,  hardly  a  voice  of  scien- 
tific authority  had  been  raised  lo  dispute  its  credi- 
bility or  possibility — with  the  solitary,  and  very  con- 
spicuous, exception  of  the  great  French  surgeon, 
Dupuytren,  whose  powers  of  penetrating  observation 
and  strong  common  sense  had  illuminated  so  many 
of  the  previously  dark  places  of  the  theory  and  prac- 
tice of  surgery.  This  original  thinker  and  fearless 
speaker  vigorously  attacked  the  traditions,  and  the 
theories,  and  the  evidence  of  spontaneous  combus- 
tion, and  explained  the  deaths  of  the  drunkards — as 
they  practically  all  were — which  had  been  attributed 
to  its  occurrence,  by  ordinary  and  rationally  ( and 
scientifically)  explicable  causes.  But  even  his  voice, 
great  and  widespread  as  was  his  influence  in  the 
professional  world,  remained  for  years  that  of  a  sci- 
entific John  the  Baptist.  The  most  highly  placed  and 
generally  accepted  medicolegal  authorities  have  ac- 
^  cepted  the  authenticity  of  spontaneous  combustion  ; , 
men  of  the  acknowledged  rank  and  attainments  of 
Fodere,  Marc,  Braeschet,  Devergie,  and  Friedreich 
had  discussed  all  the  reported  details  with  respectful 
seriousness,  and  seemed  to  be  anxious  but  for  the 
formulation  of  a  satisfactory  theory.  The  forthcom- 
ing explanations  were  divisible  into  two  groups,  one 
w^as  that  the  combustion  originated  in  alcoholic  (or 
allied)  vapor;  the  other  that  it  owed  its  onset  to  the 
copious  development  of  highly  inflammable  gases  in^ 
the  interior  of  the  human  body  itself.  Under  the 
first  group  may  be  included  that  of  Fontenelle,  who, 
after  having  pointed  out  that  even  on  the  ignition  of 
the  "preserving"  alcohol  in  which  specimens  of  (ana- 
tomical or  pathological)  human  tissues  have  been  im- 
mersed, the  combustion  goes  on  to  spontaneous  ex- 
tinction— on  exhaustion  of  the  whole  of  the  inflam- 
mable liquid — with  little  or  no  injury  to  the  struc- 
tures which  it  had  bathed,  proceeded  with  a  perverse 
ingenuity  to  persist  in  the  suggestion  that  the  eflfects 
of  chronic  alcoholism  on  the  living  body  might  re- 
sult in  the  production  of  a  degree  of  inflammability 
which  would  account  for  ayd  explain  the  phenome- 
non of  "spontaneous  combustion." 

The  new  era  in  the  somewhat  weirdly  interesting 
history  of  spontaneous  combustion  was  ushered  in 
by  the  investigation  of  the  case  of  the  Countess  of 
Goerlitz.  On  June  13,  1847,  the  body  of  that  noble- 
woman was  found  in  her  chamber  at  Darmstadt.  The 
head  was  completely  charred,  the  whole  circumfer- 
ence of  the  neck  deeply  burned,  and  the  upper  limbs 
had  been  almost  entirely  consumed.  The  lower  part 
of  the  thorax  had  also  suffered  deeply  in  the  process 
of  combustion  ;  but  even  the  clothes  which  covered 
the  lower  part  of  the  trunk  and  the  inferior  extremi- 
ties had  escaped.  The  body  had  been  found  in  the 
midst  of  a  large  quantity  of  combustible  furniture, 
of  which  the  destruction  had  been  correspondingly 
and  inexplicably  limited.  The  limitations  of  the  ac- 
tion of  the  fire  seemed  to  be  somewhat  peculiar  ;  and 
although  the  projection  of  the  tongue  which  was  no- 
ticed was  suggestive  of  strangulation,  the  idea  of 


spontaneous  combustion  appears  to  have  suggested 
itself  at  once  to  the  first  expert  summoned.  The 
most  skilled  scientific  evidence  then  available  was 
utilized  in  the  investigation  of  the  case ;  and  elicited, 
among  other  results,  an  absolute  denial  of  the  phys- 
ical possibility  of  spontaneous  combustion  from  Lie- 
big,  Bischoff,  and  some  others — whose  testimony  and 
arguments  carried  all  the  experts  engaged,  with  a 
single  exception.  Liebig  afterwards  published  a 
pamphlet  on  the  subject,  utilizing  this  case  as  his 
text,  and  discussed  the  existing  records  and  theories 
therewith  connected  with  an  absolute  thoroughness 
and  undeniable  mastery  of  all  its  aspects,  which 
should  surely  have  settled  the  solution  of  the  prob- 
lem for  all  time.  The  culprit  afterwards  confessed 
that  the  lady  had  been  strangled ;  the  furniture  had 
then  been  piled  up  around  the  body  ;  and  special  at- 
tention was  paid  to  the  burning  of  the  upper  por- 
tion, for  the  purpose  of  absolute  destruction  of 
all  marks  of  the  external  violence  which  had  been 
applied.  Xevertheless,  so  much  pleasanter — and 
sometimes  more  profitable — is  the  production,  as  well 
as  the  perusal,  of  fiction  than  of  fact,  that  there  was 
published  in  the  Ga.7ettc  des  tribnnaux  of  February 
25,  1850 — during  the  period  when  the  Goerlitz  case 
was  still  the  subject  of  unsettled  discussion — the  fol- 
lowing : 

Un  ouvrier  que  Ton  nomine,  dont  I'lntemperance  etait 
connue,  occupe  a  boire  dans  un  cabaret  de  la  barriere  de 
I'etoile.  s'introduit  dans  la  bouche  une  cbandelle  enflammee ; 
aussitot  on  voit  errer  sur  les  levres  une  flamme  bleuatre ; 
I'incendie  est  interieur  et  en  moins  d'une  deini-heure  la 
tete  et  le  thorax  sont  carbonises ;  deux  medecins  constatent 
la  combustion  spontanee,  M.  Regnault  et  Pelouze  sont 
aussitot  consultes  sur  ce  fait. 

It  is  a  significant  fact  that  of  the  total  number  of 
cases  of  alleged  spontaneous  combustion  that  have 
been  floated  on  the  literature  of  the  profession,  near- 
ly half  have  been  reported  from  the  neurotic  land  of 
France.  Caspar  attributes  this  high  ratio  to  the 
greater  credulity  of  the  people  of  that  nation  ;  per- 
haps excitability — accompanied  by  an  inordinate  ap- 
petite for  its  gratification — would  represent  a  more 
accurate  presentation  of  the  cause.  But  what  can  be 
said  in  scientific  seriousness  of  the  faith  of  a  practical 
Anglo-Saxon  "authority"  on  forensic  medicine,  who 
gravely  enunciates  his  belief  that  spontaneous  com- 
bustion of  the  human  body  can  originate  post  mor- 
tem?— W'ith  the  solemnly  formulated  addendum  that : 
"I  think  also  that  it  occurs  in  a  fat,  flabby,  drunken 
person,  who  has  been  in  a  drunken  slumber,  in  whom 
the  cessation  of  life  has  been  due  to  a  fatty  heart,  the 
whole  circumstances  being  favorable  to  the  growth 
of  a  microbe  which  brews  combustible  gas  or  alco- 
hol." (  !)  Cannot  even  the  most  injured  enemy  of 
the  mischievous  microbe  afford  to  forgive — almost 
to  pity,  even — that  agent  of  evil  when  he  finds  the 
"fact  "  of  spontaneous  combustion  laid  at  his  door? 
Cannot  we  now  anticipate  that  the  final  conflagra-  1 
tion  of  the  universe  will  be  credited  to  the  omnipo- 
tent microbe — if  there  remain  any  human  (scien- 
tific) survivors  to  record  their  testimony?  More 
than  likely  ;  for  the  authority  just  quoted  fortifies  his 
faith  in  the  occurrence  of  spontaneous  combustion 
in  defunct  animal  bodies  by  an  announcement  asso- 
ciated with  the  inanimate  domain  of  organic  life : 
"It  is  well  known  everywhere  that  if  grass  be  cut  wet 
and  stacked  wet  the  hayrick  is  very  likely  to  ignite." 
I  will  now  close  this  rather  tediously  prolonged  com- 


848 


PROESCHER:  SPIROCH^TA  LYMPHATICA. 


\_tiEw  York 
Medical  Journal. 


munication  by  assuring  my  readers  that  such  hayrick 
has  never  yet  done  anything  of  the  kind !  And  as 
the  myth  of  spontaneous  combustion  of  the  human 
body  has  been  thoroughly  exploded  and  exposed, 
more  than  half  a  century  ago,  in  Germany  and  in 
France,  it  is  hardly  encouraging  to  patriotic  British 
citizens,  who  are  in  touch  with  the  present  data  of 
scientific  research,  to  find  it  still  taught  in  our  best 
medicolegal  manuals  as  a  scientific  fact,  and  glibly 
referred  to  as  such  in  our  best  periodical  literature 
of  the  "general"  class. 
34  York  Street. 


FURTHER  INVESTIGATION  OF  THE  SPIRO- 

CH/ETA  LYMPHATICA. 
Experimental  Inoculations  on  Monkeys  and  Rats. 
By  Frederick  Proescher,  M.  D., 

Pittsburgh,  Pa. 
Pathologist,  Allegheny  Genersl  Hospital. 

The  following  article  is  a  brief  report  of  the  lab- 
oratory investigation  of  the  Spirochceta  lymphatica, 
first  described  by  White  and  Proescher  in  the  Jour- 
nal of  the  American  Medical  Association:'' 

On  account  of  the  immense  amount  of  work  and 
the  numerous  technical  difficulties  a  detailed  de- 
scription and  complete  autopsy  reports  can  not  be 
given  at  this  time.   A  full  report  will  follow  later. 

In  previous  articles  it  was  stated  that  the  Spiro- 
chceta  lymphatica  had  been  found  in  both  sections 
and  smears  made  from  lymphatic  leuchasmia  and 
lymphosarcoma.  The  spirochaetae  were  found  also 
in  the  lymph  glands  of  the  guinea  pigs  which  had 
been  inoculated  with  lymphosarcoma.  The  subse- 
quent investigations  have  been  limited  exclusively  to 


I'IG.  1. — .Male  inuiikey,  showing  nodules  in  the  abdominal  wall  five 
months  after  inoculation  with  tumor  tissue  from  lymphocytoma. 
Inguinal  glands  enlarged. 

^Journal  of  the  American  Medical  Association,  August  31,  Sep- 
tember 28,  and  December  14,  1907. 


Fig.  2. — Intraperitoneal  growth  following  intraperitoneal  implanta- 
tion of  an  enlarged  lymphatic  gland  taken  from  male  monkey. 
Died  two  months  after  inoculation. 

the  so  called  lymphosarcoma,  several  patients  suf- 
fering with  this  disease  having  been  available. 

A  brief  discussion  of  the  pathological  anatomy  of 
the  primary  diseases  of  the  lymphatic  glands  will 
perhaps  not  be  amiss  at  this  point.  The  histological 
dififerentiation  of  the  diseases  of  the  lymph  glands 
are,  despite  the  fact  that  a  large  amount  of  work  has 
been  done  along  this  line,  still  a  subject  of  great 
controversy,  and  a  study  of  the  literature  shows 
great  confusion  in  their  nomenclature  and  classifica- 
tion. Numerous  investigators,  as  Paltauf,  Kundrat, 
Beuda,  Sternberg,  and  Longcope,  have  tried  to 
bring  some  order  out  of  chaos,  but  with  little  suc- 
cess. The  solution  of  the  question  seems  to  lie  en- 
tirely in  the  aetiology  of  these  affections,  the  differ- 
ent clinical  pictures  being  possible  individual  ex- 
pressions of  the  same  infection. 

In  the  different  leuch;emias  and  ])scucloleuchae- 
mias  we  find  varied  clinical  and  blood  pictures.  In 
some  a  leucocytosis  with  definite  blood  changes,  in 
others  no  leucoc}  tosis  and  no  definite  blood  changes, 
and  at  present  we  have  no  adequate  explanation  for 
these  various  manifestations. 

According  to  our  present  conception  the  diseases 
of  the  lymph  gland  may  be  classified  as  follows : 

1.  The  acute  and  chronic  lymphadenitis  (includ- 
ing lues  and  tuberculosis'). 

2.  Leuchitmic  and  alcucha'inic  lymphomata 
(pseudolcucluemia,  granulomatous  and  hyper] )lastic 
forms  with  or  without  blootl  changes).  The  patho- 
logical anatomy  in  the  leuchaemic  and  aleuchasmic 
varieties  is  practically  the  same  and  consists  either 


April  24,  1909.] 


PROESCHER:  SPIROCH^TA  LYMPHATICA. 


849 


Fig.  3. — Specimen  of  rat's  blood  stained  with  Giemsa  solution,  show- 
ing spirochaetoe  (x).     Zeitz  ocular  4.     Objecti\e  7.  70oX- 

of  a  pure  lymphatic  hyperplasia  or,  as  is  occasion- 
ally seen  in  one  form  of  pseudoleuchsemia,  a  granu- 
lomatous hyperplasia. 

3.      Primary  sarcoma  of  the  lymph  glands  (ex- 
cluding sarcoma  which  develops  from  the  connective 
tissue  stroma)  or  lymphosarcoma  which  preserves 
more  or  less  the  character  of  the  lymphatic  tissue 
and  which  might  be  better 
named  lymphocytoma  (Rib- 
bert)   or  granulolymphocy- 
toina,  or  malignant  granu- 
loma (Reuda),  also  the  leu- 
cosarcoma     described     b  y 
Sternberg  and  accompanied 
by  a  characteristic  blood  pic- 
ture, and  finally  the  chlor- 
oma  which  resembles  mor- 
..^j^  phologically  the  lymphosar- 

FiG.  4— Spleen  ot  monkey  coma  but  differs  in  the  pro- 
shown  in  Fig.  I   showing  duction  of  a  greenish  color- 

lympnadenoid  nodules.  ■ 

mg  matter. 

I  believe  that  the  commonly  called  lymphosar- 
coma is  closely  related  to  the  aleuchaemic  tumors 
and  represents  a  lymphatic  hyperplasia  with  polv- 
morphic  cell  masses  and  marked  infiltrations  of  the 
surrounding  tissues.  The  diagnosis  is  verv  difficult 
in  some  cases  between  round  cell  sarcoma  and  ma- 
lignant lymphocytoma.  The  lat- 
ter, in  some  cases,  remains  local 
and  shows  no  tendency  to  infiltrate 
the  surrounding  structures,  in 
other  cases  this  tendency  is  well 
marked  and  in  addition  gives  rise 
to  metastatic  deposits.  When  sar- 
coma metastasizes  it  forms  dis- 
crete nodules,  when  lymphocy- 
toma metastasizes  no  nodules  are 
seen  but  merely  a  more  or  less  dif- 
fuse  infiltration   of  the  affected 

Fig.     5.  —  Liver     of  ficcnps 
monkey    shown  in 

Fig    I,   showirg      The  singular  form  of  tnberculo- 

lymphademoid    nod-     .        .     ,  ^  ,  . 

iiies.  Sis  01  the  lymphatic  system  de- 


scribed by  Sternberg  is  not  unlike  the  picture  seen 
in  pseudoleuchsemia.  The  enlarged  lymph  glands 
very  frequently  show  yellowish  caseated  masses.  It 
resembles  somewhat  lymphosarcoma  macroscopical- 
ly,  but  dift'ers  from  the  latter  by  reason  of  the  large 
variety  of  cell  formations  round  and  epitheloid  cells, 
fibroblasts,  and  giant  cells.  In  certain  cases,  how- 
ever, the  glands  do  not  show  tuberculous  infection, 
and  it  is  possible  that  those  cases  which  do  show 
tuberculosis  were  secondarily  infected. 

We  venture  to  suggest  that  the  spirochsetse  were 
possibly  the  primary  infecting  agent  in  these  cases 
described  by  Sternberg,  though  as  yet  no  oppor- 
tunity has  presented  itself  to  prove  this  by  experi- 
ment. 

I  have  observed  two  cases  in  which  tuberculosis 
attacked  a  previously  existing  lymphocytoma  limited 
to  the  cervical  glands.  It  is  not  unlikely  when  we 
consider  the  widespread  prevalence  of  tuberculosis, 
that  it  should  attack  an  organism  weakened  by  a 
spirochseta  infection,  especially  since  both  show  a 
preference  for  lymphatic  tissues. 

An  attempt  will  be  made  later  on  to  show  that  this 
hypothesis  can  be  proved  by  experiments  on  ani- 
mals. » 

The  supposition  that  attenuated  tubercle  bacilli 
can  produce  an  universal  lymphomatosis  is  probably 
incorrect.  It  is  more  than  likely  that  the  tuberculous 
infection  is  a  secondary  one.  Before  reporting  the 
results  of  the  inoculation  on  rats  and  monkevs  a 
short  description  of  the  staining  methods  will  be 


Fig.  6. — Guinea  pig  inoculated  with  spirochaetae.  showing  enormous 
spleen,  weighing  eighteen  grammes. 


850 


PRCESCHER: 


SPIROCH^TA  LYMPHATICA. 


[New  York  " 
Medical  Journal. 


given  and  also  the  detection  of  the  living  organism 
by  means  of  the  dark  ground  illuminator. 

In  the  previous  report'  a  detailed  description  was 
given  of  the  staining  method  with  the  old  Loeffler's 
mordant  followed  by  eosin-methelene  blue  and  to- 
luidin  blue.  The  chief  advantage  of  this  method  is 
its  rapidity,  but  as  it  also  produces  many  artifacts 
it  is  rather  unsatisfactory.  An  attempt  was  there- 
fore made  to  stain   the  specimens  with  eosin  and 


w  ■ 


Fig.  7. — Lungitudinal  section  of  botli  femora  and  right  humerus 
from  female  monkey  inoculated  subcutaneously  with  enlarged 
lymph  gland  from  male  monkey  in  Fig.  i.  Cavities  filled  witli 
myelomata. 

methylene  azure  without  a  mordant.  The  Giemsa 
solution  worked  best  when  the  specimens  were 
stained  for  twenty-four  hours.  The  fresh  tissue  and 
blood  smears  were  placed  for  five  minutes  in  methyl 
alcohol,  then  in  Giemsa  solution  diluted  with  dis- 
tilled water  (i  drop  of  stain  to  i  c.c.  of  water). 
The  spirocha-ta  stains  of  a  reddish  blue  or  violet 
color  and  appears  as  slender  straight,  curved,  or 
wavy  filaments.    Its  length  varies  from  10  to  20 

'New  York  Medical  Journal,  1907. 


mikra.  In  the  later  specimens  which  have  been  ex- 
amined the  long  spirochcCtae  which  were  seen  in 
slides  prepared  from  a  case  of  pseudoleuchsemia 
have  not  been  found. 

They  are  rather  difficult  to  find  in  smears  from 
the  organs  or  lymph  glands  unless  the  smear  is 
very  thin  and  contains  a  small  amount  of  tissue 
juice,  as  the  coagulation  precipitations  due  to  the 
fixing  fluids  make  their  recognition  almost  impossi- 
ble. It  was  on  this  account  that  I  was  unable  to 
find  them  when  using  the  Giemsa  stain  alone. 
Their  exact  morphology  was  only  recognized  when 
fresh  tissue  scrapings  were  examined  with  the  dark 
ground  illuminator.  When  examined  this  way  they 
show  very  active  vermicular  movements,  sometimes 
nearly  straight,  sometimes  curved  upon  themselves. 
When  the  ordinary  silver  stains  are  used  it  is  often 
necessary  to  prepare  several  blocks  of  tissue  in 
order  to  get  a  satisfactory  result  on  account  of  pre- 
cipitation, incomplete  impregnations,  and  the  insta- 


i-'rc.  8. — Jlicroscopic.Tl  section  of  myeloma  found  in  medullary 
cavity  (lymphocytic  myeloma).  Zeitz  ocular  4.  Objective  6. 
460X. 


bility  of  all  metallic  staining  methods.  The  spiro- 
chcTtje  when  stained  with  silver  ap])ear  thicker  than 
when  stained  with  Giemsa  and  are  rarely  found  alone 
and  under  low  magnification  usuallv  occur  in 
clumps,  but  with  higher  power  the  individual  spiro- 
chasta  can  be  recognized.  The  spirochjeta  in  tissue 
can  also  be  stained  with  iron  hrematoxylin  but 
the  results  are  not  constant.  So  far  we  have  been 
unable  to  grow  the  spirocha-ta  on  any  known  cul- 
ture medium. 

The  spirocha:tje  were  successfully  inoculated  in 
guinea  pigs,  monkeys  (Maccasiis  Rclisiis),  and 
gray  house  rats.  The  guinea  i)igs  died  in  three  or 
four  months  with  a  general  enlargement  of  all  the 
lymphatic  glands  and  the  spleen,  in  some  cases  this 
enlargement  was  extreme.  In  one  case  the  spleen 
weighed  eighteen  grammes,  in  another  twenty- 
seven  grammes,  the  normal  weight  of  a  guinea  pig 
spleen  being  0.4  to  0.5  grammes.  The  body  weight 
of  the  guinea  i)igs  used  was  about  400  to  500 
grammes. 

A  series  of   guinea   pigs  were   inoculated  with 


J\pTll    24,    IpOf).  I 


PROESCHER:  SPIROCHMTA  LYMPHAl ICA. 


Tig.  9. — Microscopical  iection  of  spleen  shown  in  Fig.  4.  Lymph- 
adenoid  hyperplasia  of  a  follicle  (Malpighian  body).  Zeitz 
ocular  4.    Objective  4.  160X. 


pieces  of  tissue  taken  from  two  cases  of  malignant 
lymphocytoma.  Some  of  the  guinea  pigs  died  of 
a  mixed  infection  of  spirocha?ta  and  tuberculosis, 
and  the  others  of  pure  spirochasta  infection.  Micro- 
scopic sections  of  the  lymph  glands  taken  from  the 
guinea  pigs  dying  of  spirochaeta  infection  show 
hyperplastic  changes  with  necrotic  areas  and  some 
fibrous  induration  similar  to  the  histological  picture 
seen  in  the  lymph  glands  of  persons  suffering  with 
-chronic  lymphomatosis.  The  liver  and  spleen  show 
lymph  adenoid  infiltration.  The  spirochfetas  are 
rarely  found  in  the  blood.  Frequently  they  can  b^ 
found  shortly  before  death. 

Two  monkeys  were  inoculated  with  pieces  of  tis- 
sue taken  from  a  patient  suffering  with  a  large 
lymphocytoma  of  the  neck.  Before  the  patient  was 
operated  upon  he  was  tested  with  tuberculin,  with 
negative  result.    Pieces  of  the  lymphocytoma  about 


Fig.  10. — Microscopical  section  of  the  tumor  mass  found  in  the 
abdomen  of  Ihe  male  monkey  (Fig.  2).  Zeitz  ocular  4.  Ob- 
jective 4.  160X. 


the  size  of  a  cherry  were  implanted  in  skin  pockets 
on  the  abdominal  wall  of  two  monkeys,  male  and 
female.  Bacteriological  examination  of  the  im- 
planted tissue  failed  to  show  the  growth  of  any  mi- 
croorganism. After  implantation  the  tumor  tissue 
was  apparently  completely  absorbed  and  the  wound 
healed  by  first  intention.  Six  weeks  later  at  the 
site  of  implantation  a  mass,  the  size  of  a  walnut, 
appeared  and  the  inguinal  lymph  glands  became  en- 
larged. The  overlying  skin  quickly  ulcerated,  and 
the  monkeys  died  about  eight  months  later.  At  the 
autopsy  there  was  found  general  hyperplasia  of  the 
whole  lymphatic  system  with  nodules  in  the  liver 
and  the  spleen.  The  male  monkey  became  sec- 
ondarily infected  with  tuberculosis  during  the  pe- 
riod of  observation,  possibly  through  milk  feeding. 
The  female  monkey  was  kept  in  a  separate  cage  and 
remained  free  from  tuberculous  infection.  The 
lymph  adenoid  hyperplasia  was  especially  marked 
in  the  male  monkey,  and  the  miisculature  and  sub- 
cutaneous tissue  contained  large  numbers  of  lentil 


Fii:.  II. — Microscopical  section  of  lymphocytoma  removed  from  neck 
of  a  woman,  showing  numerous  s  irochsetae  stained  with  silver. 
Zeitz  ocular  4.    Objective  4.  180X. 


sized,  yellowish  white  nodules.  Smears  made  from 
the  nodules  showed  great  numbers  of  tubercle  ba- 
cilli. The  female  monkey  did  not  show  any  lymph 
adenoid  nodules  in  the  muscular  and  subcutaneous 
tissue.  In  the  pelvis  of  both  monkeys  on  the  left 
side  was  found  a  tumor  the  size  of  an  egg,  extra- 
peritoneal, of  a  yellowish  white  color,  necrotic  in  its 
centre,  and  showing  on  microscopical  section  a 
lymph  adenoid  tissue.  Spirochjetse  were  found  in 
all  the  lymph  adenoid  tissues  examined  even  in 
those  showing  tubercle  bacilli.  The  marrow  of  the 
long  bones  all  showed  myelomata  which  on  micro- 
scopical examination  proved  to  be  lymphocytic 
myelomata. 

Three  months  before  the  male  monkey  died  one 
of  the  enlarged  inguinal  glands  was  extirpated  and 
pieces  of  it  implanted  in  two  other  monkeys  of  the 
same  species,  one  intraperitoneal,  the  other  subcu- 
taneously.  The  monkey  with  the  intraperitoneal 
implantation  died  two  months  later,  and  at  the 
autopsy  the  abdominal  cavity  was  found  to  be  filled 


852 


Fig.  12. — Microscopical  section  of  spleen  of  guinea  pig  shown  in 
Fig.  6.  Several  spiroch^Ets"  (x)  are  shown,  stained  with  iron 
hsematoxylia.    Zeitz  ocular  4.    Objective  7.  700X. 


with  an  immense  tumor  mass.  The  bone  marrow 
showed  a  few  circumscribed  myelomatous  masses. 
The  monkey  with  the  subcutaneous  implantation 
died  three  months  later  with  a  general  hyperplasia 
of  the  lymphatic  tissues  and  enormous  myelomatous 
masses  in  all  the  long  bones  completely  fillino-  up 
the  medullary  cavity.  The  blood  findings  will  be 
given  later.  All  monkeys  showed  a  marked  anaemia. 


Kic.  13. — Microscopical  section  of  intraperitoneal  tumor  found  in 
male  monkey  shown  in  Kig.  2.  The  darker  areas  arc  clumps 
of  sjiirochartar  stained  with  silver.  Zeitz  ocular  4.  Objective  4. 
180X. 


Tn  conclusion  wc  will  briefly  report  some  experi- 
ments made  on  gray  house  rats.  Twenty-five  rats 
were  inoculated  intraperitnneally  with  tumor  tissue 
taken  from  enlarged  lymph  glands  of  guinea  pigs. 
Two  died  at  the  end  of  four  days.  Numerous 
spirochjetse  were  found  in  a  specimen  of  blood  ex- 
amined before  rlcath  by  means  of  a  dark  field  il- 
luminator.   Further  experiments  arc  being  made. 

100  TO  no  East  Stockton  Avenue. 


[New  York 
Medical  Journ.^l. 

BILATERAL  UNUNITED  FRACTURE  OF  PA- 
TELL.E  WITH  GOOD  FUNCTIONAL 
RESULT. 

By  Sidney  Lange,  M.  D., 
Cincinnati. 

Mr.  H.  G.  aged  50  years,  was  admitted  to  the  Cincinnati 
Hospital  for  the  treatment  of  a  fistula  in  ano.  The  fistula 
was  injected  with  bismuth  paste  and  the  patient  was  re- 
ferred to  the  Rontgen  ray  laboratory   for  a  skiagrani, 


Fig.   I. — Right  patella  broken  into  three  fragments  which  are 
widely  separated. 

where  it  was  accidentally  discovered  that  both  patellre  were 
fractured. 

The  accompanying  skiagram  reveals  the  condition  found. 
The  right  patella  is  broken  into  three  small  fragments,  the 
upper  and  lower  being  separated  four  inches.  The  left 
patella  is  broken  into  two  fragments,  almost  in  contact  at 
their  posterior  margins  but  gaping  over  an  inch  at  their 
anterior  margins. 

The  patient  gave  the  following  history.  The  right  pa- 
tella was  broken  thirty  years  ago  by  a  fall  from  a  train. 


LANGE:  UNUNITED  FRACTURES  CI'  PATELL/h. 


April  24.  1909  ] 


GRACE:  HIGH  BLOOD  PRESSURE. 


853 


After  some  weeks  in  bed  with  the  leg  on  a  splint  he  was 
able  to  get  about  with  little  discomfort.  A  month  later  the 
patient  slipped  while  walking  and  the  fragments  of  the 
injured  kneecap  separated  again.  A  brief  rest  in  bed,  how- 
over,  enabled  him  to  again  use  the  leg. 

The  left  patella  was  fractured  twenty-five  years  ago  by 
a  misstep  in  alighting  from  a  street  car.  Simple  extension 
gave  him  good  functional  result. 

Since  these  accidents,  dating  back  thirty  years,  the  pa- 
tient had  been  constantly  doing  hard  work.    He  had  been 


Fic.  2. — Left  patella  fractured  transversely. 


employed  at  loading  and  unloading  sand  barges  and  at 
doing  heavy  teamster  work.  More  recently  he  was  en- 
gaged in  delivering  ice  and  asserted  to  be  able  to  lift  the 
large  blocks  of  ice  from  the  wagon  to  the  sidewalk  and  I0 
be  able  to  mount  and  dismount  from  the  wagon  without 
discomfort. 

The  patient  walked  with  a  firm  step,  ascending  and  de- 
scending stairs  with  ease.    He  weighed  about  180  pounds. 

22  West  Seventh  Street. 


THE  SIGNIFICANCE  OF  HIGH  BLOOD  PRESSURE 
IN  LIFE  INSURANCE  EXAMINATIONS. 

By  Ralph  Grace,  M.  D., 
New  York, 

Assistant  Attencing  Physician  to   the   Lincoln  Hospital. 

In  the  examination  of  an  applicant  for  life  insur- 
ance, every  means  should  be  used  to  determine  the 
exact  physical  condition,  and  in  no  other  wav  can 
we  obtain  so  important  evidence  as  by  the  use  of  the 
sphygmomanometer.  Blood  pressure,  as  is  well 
known,  is  estimated  by  the  force  necessary  to  com- 


press the  artery  and  obliterate  the  pulse  wave  be- 
yond the  point  of  compression.  This  force  is  meas- 
ured in  millimetres  of  mercury. 

Two  factors  enter  into  the  reading  obtained  by 
the  sphygmomanometer.  The  actual  pressure  of  the 
blood  flowing  in  the  artery,  and  the  resistance  of  the 
arterial  wall  are  so  slight  in  a  normal  vessel  as  to  be 
negative  factors,  and  the  reading  gives  the  actual 
blood  pressure;  but  when  we  have  a  high  reading, 
that  is  a  reading  over  160.  we  may  be  confronted 
with  a  condition  of  serious  import  to  life  expectancy, 
and  a  proper  interpretation  of  the  reading  is  inost 
important. 

In  arteriosclerosis  we  have  a  condition  in  the  ves- 
sel wall  which  is  best  described  as  diffuse  perma- 
nent thickening,  or  a  hypertrophy  of  the  muscular 
elements  of  the  artery.  There  may  be  a  thickening 
of  the  external  coat  or  of  the  media,  and  should  be 
distinguished  from  atheroma  which  is  a  focal  affec- 
tion of  the  arterial  wall  affecting  separate  limited 
areas,  probably  of  microorganic  origin  and  usually  a 
disease  of  the  aged.  In  simple  arteriosclerosis  the 
blood  pressure  is  not  greatly  raised  as  the  increased 
resistance  of  the  thickened  vessel  wall  is  not  so  great, 
but  that  the  additional  pressure  of  comparatively 
few  millimetres  of  mercury  is  sufficient  to  obliterate 
the  pulse  wave,  and  simple  arteriosclerosis  need  not 
materially  shorten  life  and  the  fear  of  cerebral 
haemorrhage  later  in  life  may  be  groundless,  but  in 
arteriosclerosis  with  a  coexistent  hypertonus.  the 
real  cause  of  our  high  readings,  we  have  a  condi- 
tion of  grave  importance  in  the  life  expectancy  of 
the  applicant.  The  diagnostic  value  of  the  sphyg- 
momanometer then  is  not  so  great  in  uncompli- 
cated arteriosclerosis,  and  we  must  depend  upon  our 
tactile  sense  in  outlining  the  thickened  artery,  which 
may  be  quite  difficult  as  the  elasticity  of  the  artery 
is  not  greatly  destroyed  and  in  the  absence  of  hvper- 
tonus  do  not  become  rigid. 

The  high  readings  that  are  obtained  in  a  hyper- 
tonic contracted  vessel  that  may  or  may  not  be 
sclerosed  is  due  to  the  thickening  of  the  vessel  zvalt 
and  the  narrowing  of  its  lumen.  This  hypertonia  is 
brought  about  in  two  ways,  through  the  influence  of 
the  nervous  system  and  by  substances  circulating  in 
the  blood.  The  effect  of  the  emotions  upon  the  cir- 
culatory system  through  the  vasomotor  centre  in  the 
medulla  is  well  known,  and  the  effect  of  active  busi- 
ness life  in  modem  times  with  the  necessity  of  close 
application  and  the  constant  irritation  through  the 
nervous  system  is  a  great  and  important  factor  pro- 
ducing this  hypertonus  and  increasing  the  danger  of 
cerebral  haemorrhage  even  in  the  comparatively 
yotmg. 

It  is  well  known  that  the  substances  in  the  blood 
stream  act  directly  upon  the  coats  of  the  vessel  with- 
out the  medium  of  the  nervous  system  causing  con- 
traction of  the  muscular  coat.  The  source  of  these 
substances  that  even  in  small  quantities  cause  ar- 
terial contraction  and  raising  of  the  blood  pressure 
is  through  the  alimentary  tract,  particularly  intes- 
tinal. As  a  result  of  these  disorders  of  alimentation, 
toxic  substances  are  developed  and  absorbed  into  the 
blood  which  act  directly  on  the  vessel  wall,  causing 
this  dangerous  hypertonicity  which  should  be  an  ele- 
ment of  concern  to  the  examiner. 

This  hypertonicity  that  exists  either  in  the 
sclerosed  vessel  or  the  sclerosed  atheromatous  ves- 


?54 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


sel  or  in  the  healthy  vessel  and  gives  us  the  high 
readings,  can  be  relieved  by  proper  hygiene,  diet,  etc., 
and  we  may  remove  this  so  called  high  blood  press- 
ure and  find  an  apphcant  to  be  a  risk  of  the  first  class 
rather  than  one  to  be  refused  on  account  of  danger- 
ous disease.  The  very  high  readings  that  are  ob- 
tained in  cases  of  interstitial  nephritis  are  caused  bv 
the  pathological  changes  in  the  arteries  that  are  in- 
variably met  with  in  that  disease,  and  cannot  be  ma- 
terially' aft'ected  by  treatment ;  but  high  readings  do 
not  necessarily  mean  either  arterial  or  kidney  dis- 
ease ;  we  must  recognize  this  hypertonic  contraction 
of  the  vessels  as  a  factor  in  high  sphygmomanometer 
readings  and  depend  greatly  upon  the  microscopical 
findings  of  the  urinary  analysis  for  our  diagnosis  of 
kidney  affections. 

54  ^^'EST  FiFTV- FIFTH  StREET. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  interi'als.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follozi's: 

LXXXV. — Apart  from  an  operation,  hovj  do  you  treat 
disease  of  the  icrmiform   appendix?    (Closed  April  13, 

LXXXri. — Hocu  do  you  make  an  early  diagnosis  of  pul- 
monary tuberculous  disease?  (Ansti'crs  due  not  later  than 
May  75,  /pop.) 

LXXXl'lI. — How  do  you  treat  supraorbital  neuralgia? 
(AnsZ'.'ers  due  not  later  than  June  13,  igOQ.) 

Whoever  anszji'ers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  zvill  re- 
ceive a  prize  of  $25.  No.  importance  zchatever  zvill  be  at- 
tached to  literary  style,  but  the  azi^ard  zvill  be  based  soleiy 
on  the  value  of  the  substance  of  the  anszcer.  It  is  requested 
(but  not  REQUIRED)  that  the  anszvers  be  short;  if  practica- 
ble no  one  answer  to  contain  more  than  six  hundred 
words. 

All  persons  zvill  be  entitled  to  compete  for  the  price, 
zvhcthcr  subscribers  or  not.  This  prize  zvill  not  be  azvarded 
to  any  one  person  more  than  once  zvithin  one  year.  Every 
anszver  must  be  accompanied  by  the  zvriter's  full  name  and 
address,  both  of  which  zve  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journ.\l. 

OUK  RF..\DERS  .\RE  .\SKED  TO  .SUGGEST  TOPU  S  F  "R  DISCUSSION. 

The  prize  of  $25  for  the  best  essay  submitted  in  anszver 
to  question  LXXXIV  has  been  azvarded  to  Dr.  Joseph  R. 
U'isrman,  of  Syracuse,  N'.  Y.,  zvhose  article  appears  belozju. 


PRIZE  QUESTION  LXXXIV. 

THE  THERAPEUTIC  USE   OF  ALCOHOL. 

By  Joseph  R.  \Visem.\n.  M.  D., 
Syracuse,  N.  Y. 

The  pharmacopteia  contains  no  drug  whose  action 
has  been  the  subject  of  more  dispute,  or  whose  em- 
ployment has  been  the  occasion  of  more  abuse  than 
that  of  alcohol.  Its  manifold  activities  are  still  being 
scientifically  investigated  and  its  effects  may  not  as 
yet  be  fully  understood,  but  most  pharmacologists 
agree  fairly  well  on  certain  points. 

I'pon  the  nervous  system  its  dominant  action  is 
that  of  a  depressant.  There  may  be  at  first  an  ap- 
parent stimulation,  best  explained  by  an  inhibition 
of  the  higher  mental  faculties,  but  this  is  rapidlv 
snccfcdcd  by  a  period  of  actual  depression  in  which 


muscular  power,  brain  activity,  and  mental  accuracy 
are  definitely  impaired. 

Alcohol  has  no  direct  stimulating  effect  on  the 
cardiac  muscle  or  its  nerves,  but  it  dilates  the  super- 
ficial bloodvessels  and  increases  the  output  of  blood 
from  the  heart,  thereby  increasing  the  general  rate 
of  flew  and  activity  of  the  circulation  without  ap- 
preciably altering  blood  pressure.  By  thus  produc- 
ing a  readjustment  of  the  circulation,  favorable 
therapeutic  results  may  be  produced. 

Upon  the  respiration  it  seems  to  have  somewhat 
of  a  stimulating  effect,  and  it  undergoes  combustion 
in  the  body  thereby  furnishing  food  energy.  It 
tends  to  lower  bodily  temperature  and  is  an  irritant 
to  the  kidneys. 

A  new  drug  whose  pharmacological  possibilities 
were  no  more  attractive  than  those  of  alcohol,  could 
hardly  be  expected  to  gain  an  extensive  foothold  in 
the  practice  of  medicine ;  nevertheless  years  of  ob- 
servation by  numerous  careful  clinicians  have  dem- 
onstrated many  of  the  good  and  bad  qualities  of  the 
drug,  and  after  all,  with  due  limitations,  "an  ounce 
of  practice  is  worth  a  pound  of  theory." 

Cushney  says :  "The  indications  for  the  internal 
use  of  alcohol  are  ill  defined,  and  cases  which  one 
physician  would  treat  with  alcohol,  often  seem  to 
progress  as  favorably  without  it  in  the  hands  of  an- 
other." Much  of  this  misapprehension  arises  from 
actual  ignorance  of  its  proper  therapeutic  uses,  from 
the  great  variation  in  individual  susceptibility,  and 
from  the  use  of  impure  preparations.  A  dose  of 
alcohol  which  in  one  patient  will  produce  a  pleasant 
feeling  of  exhilaration,  in  another  may  cause  a  real 
toxic  depression.  In  some  hospitals  the  use  of  large 
quantities  of  impure  whiskey  and  brandy  containing 
higher  alcohols,  aldehydes,  and  other  irritants,  in  the 
treatment  of  infectious  diseases,  is  an  undoubted 
factor  in  the  production  of  the  cardiac  failure,  al- 
buminuria, and  great  depression  often  seen  at  the 
height  of  these  diseases. 

In  acute  infections  as  pneumonia,  diphtheria,  ty- 
phoid fever,  sepsis,  etc.,  alcohol  should  never  be 
given  from  the  first  unless  the  onset  is  accompanied 
by  great  prostration.  The  system  rapidly  becomes 
accustomed  to  its  use,  and  when  a  critical  point  is 
reached  we  find  we  have  been  robbed  of  its  power. 
In  heart  failure  or  in  the  "right  heart  misery"  of 
Dueumonia  with  pallor,  small  feeble  pulse,  and  em- 
barrassed breathing  alcohol  should  be  given  freely. 
In  the  critical  stages  of  diphtheria  or  sepsis  large 
quantities  may  be  needed.  Under  these  conditions 
alcohol  seems  to  act  as  a  temporary  imparter  of 
power  to  help  us  bridge  over  a  period  of  danger. 
iDut  its  effects  should  be  carefully  watched  and  the 
drug  discontinued  when  unfavorable  evidences  ap- 
pear, such  as  sharp,  angry  pulse,  increased  restless- 
ness, delirium,  or  depression.  In  a  typhoid  or  ady- 
namic state,  especially  in  the  aged,  when  the  vital 
powers  are  at  a  low  ebb,  alcohol  furnishes  consider- 
able food  energy,  allays  the  nervous  excitability,  and 
although  it  does  not  actually  stimulate  tends  to  re- 
-store  the  equilibrium  of  the  circulation  much  as  does 
a  cold  bath  in  typhoid  fever.  Given  as  milk  punch, 
by  its  stinnilating  action  on  digestion,  it  furnishes 
us  nearly  a  perfect  food.  In  the  late  stages  of  ty- 
I)hoi(!  fever  with  a  marked  asthenia,  weak  heart 


April  24,  1909.] 


OUR  READERS'  DISCUSSIONS. 


«55 


sounds  and  emaciation,  even  though  the  tempera- 
ture be  high,  alcohol  is  of  great  value.  From  one 
half  to  two  ounces  every  four  hours  is  average  adult 
dosage  in  acute  fevers. 

In  convalescence  from  acute  disease  or  in  condi- 
tions of  wasting  or  malnutrition,  alcohol  in  moder- 
ate quantities  is  often  of  signal  benefit.  It  stimu- 
lates digestion,  absorption,  and  peristalsis,  and  has 
undoubted  fuel  value.  Repeated  experiments  have 
demonstrated  that  alcohol  is  absorbed  mainly  from 
the  stomach,  practically  without  digestion,  that  it 
requires  less  energy  for  combustion  than  does  sugar, 
and  that  it  can  take  the  place  of  fats  and  carbohv- 
drates  thus  acting  as  a  tissue  sparer.  When  moder- 
ate amounts  are  taken  over  ninety  per  cent,  is  com- 
pletely utilized,  leaving  but  a  small  percentage  for 
excretion.  One  should  nevertheless  not  lose  sight 
of  the  fact  that  there  may  be  engrafted  upon  the 
patient  a  habit  far  more  disastrous  than  the  condi- 
tion it  was  intended  to  relieve. 

In  shock,  the  results  of  Crile's  animal  experiment- 
ation to  the  contrary,  alcohol  seems  to  be  of  some 
benefit  by  its  benumbing  action  on  the  central  nerv- 
ous system  and  through  reflex  stimulation  from  its 
local  effect.  , 

The  external  use  of  alcohol  seems  to  have  been  as 
much  neglected  as  its  internal  use  has  been  abused. 
The  experiments  of  Harrington  and  Walker  have 
demonstrated  that  in  strengths  of  sixty  to  seventy 
per  cent,  alcohol  is  an  excellent  antiseptic  for  wide 
general  use.  It  makes  a  clean  dressing  for  dirty 
wounds,  acts  as  an  astringent,  and  promotes  cell 
activity  and  healing.  It  is  an  important  constituent 
of  Loeffler's  solution  for  local  throat  application,  and 
in  ten  to  twenty  per  cent,  solution,  used  hot,  it  makes 
an  excellent  gargle.  Alcohol  has  considerable  value 
as  an  evaporating  lotion,  and  an  alcohol  and  water 
sponge  bath  gives  us  means  of  reducing  fever,  very 
grateful  to  the  patient. 

In  conclusion  let  us  not  forget  that  alcohol  is  es- 
sentially a  depressant  to  all  the  cells  of  the  bodv, 
and  that  we  have  other  well  known  drugs,  equally 
eflfective  in  most  instances,  and  devoid  of  its  peculiar 
dangers.  If  physicians  instead  of  turning  first  to 
alcohol,  a  habit  made  only  too  easy  by  necessary 
familiarity  with  it  in  daily  life,  would  hold  it  in  re- 
serve until  a  condition  of  pressing  need  arose,  they 
would  probably  find  increasingly  less  use  for  it  as 
time  went  on. 

705  East  Genesee  Street. 

Dr.  WiUiam  Brady,  of  Elmira,  K.  Y..  zvrites: 

Alcohol  is  a  useful  agent  but  a  dangerous  one  in 
therapeutics.  It  will  meet  certain  indications  that 
no  other  drug  can  meet.  Xevertheless,  there  is 
such  a  pronounced  tendency  toward  habituation  to 
its  use  particularly  among  those  neurotics  and  in- 
competents who  seem  most  commonly  to  require  it. 
that  we  as  physicians  should  prescribe  it  with  the 
same  caution  we  employ  in  prescribing  opiates  ;  in 
other  words.  Tir  should  disgiiise  the  alcohol,  when- 
ever possible,  so  that  the  patient  may  not  be  aware 
of  the  nature  of  his  medicine.  This  we  <;an  readily 
do.  (a)  by  sfiving  it  with  liquid  food;  (b)  by  com- 
bining it  with  a  simple  bitter,  a  flavoring,  or  a  col- 
oring agent ;  or  (c)  by  prescribing  it  in  the  form  of 
one  of  the  "medicinal  foods"  of  the  market,  most 


of  which  contain  about  the  same  proportion  of  al- 
cohol as  does  wine.  The  latter  plan,  of  course,  is 
expensive,  but  this  is  offset  by  the  fact  that  we  rare- 
ly need  continue  its  use  longer  than  a  few  days. 

As  to  its  indications,  these,  to  my  mind,  are  as 
certain  and  as  clearl}-  defined  as  those  of  any  known 
therapeutic  agent;  they  are  based  on  scientifically 
demonstrated  physiological  action,  and  that  alone. 
Why  physicians  persist  in  the  improper  use  of  a 
measure  handed  down  "by  our  forefathers  who  de- 
pended entirely  on  empiricism — a  measure  repudi- 
ated by  physiological  experiment — is  a  myster}-  that 
defies  solution'!  One  prominent  author  of  a  work  on 
therapeutics  gives  a  very  fair  description  of  the  phy- 
siological action  of  alcohol — insists  that  it  acts  under 
all  conditions  as  a  depressant  to  brain,  nerves,  heart 
and  temoerature — then  proceeds  to  advise  its  use 
in  cardiac  failure,  shock,  fainting,  pneumonia,  and 
tvphoid !  Urged  to  reconcile  this  wavering  of  opin- 
ion he  replied :  "Tt  is  quite  conceivable  that  alcohol 
may  act  as  a  stimulant  on  other  functions  of  which, 
as  yet  we  know  very  little,  as,  for  example,  the  abil- 
ity of  the  body  to  resist  infection."  This  statement 
was  made  in  a  personal  communication — not  in  the 
textbook — and  is  given  here  for  what  it  may  be 
worth. 

Externally,  alcohol  is  useful,  (i)  as  a  cooling  lo- 
tion for  bathmg  in  febrile  states,  for  rubbing  the 
back  of  bedridden  patients,  and  as  a  substitute  for 
the  old  "lead  and  laudanum"  as  an  application  to 
sprains,  bruises,  and  beginning  inflammations : 

B    Morphinse  acetatis  0.65  gramme; 

Liq.  plumbi  subacetatis,   30  c.c. ; 

Alcoholis  qs.  ad.  120  c.c. 

M.  Sig.  Apply  on  one  layer  of  muslin  or  cotton  and  al- 
low to  evaporate. 

This  is  clean  and  efTective. 

(2)  As  a  coinplete  antidote  to  carbolic  acid  burns 
alcohol  needs  no  commendation.  I  have  washed  my 
hands  in  pure  carbolic  acid,  followed  by  alcohol — 
the  skin  was  left  soft  and  natural. 

Internally,  there  are  but  fi.ve  indications  for  al- 
cohol, that  justify  its  use  under  our  present  knowl- 
edge. 

(i.)  As  an  ajitidotc  to  carbolic  acid — only  when 
it  can  be  administered  shortly — within  one  or  one 
and  a  half  hours — following  the  poison.  I  have  seen 
life  saved  in  two  instances  by  this  measure.  It  is  a 
chemicophysical  antidote,  not  a  physiological  anti- 
dote. The  treatment  of  the  collapse  symptoms  of 
carbolic  acid  poisoning  require  not  a  narcotic  but 
heroic  stimulation.  Diluted  alcohol  (fifty  per  cent.) 
is  better  than  brandy  and  whiskey. 

(2)  As  a  fuel,  in  fevers,  exhausted  states  of  the 
body,  and  marasmus  of  infants.  Here  our  purpose 
must  be  to  give  only  a  quantity  that  the  patient  can 
metabolize  or  oxidize  and  derive  therefrom  energy ; 
our  guide  to  the  dose  is  the  odor  of  the  breath — 
when  we  can  detect  alcohol  on  the  breath,  the  dose 
must  be  decreased.  An  average  dose  of  alcohol 
for  this  purpose  is  2  c.c.  to  4  c.c.  (4  to  8  c.c.  whis- 
key; 30  c.c.  or  less  of  wine  according  to  varietv ;  10 
to  3c  c.c.  of  any  of  the  "medicinal"  proprietary 
foods),  given  every  four  to  six  hours,  with  or  fol- 
lowing other  food,  preferably. 

(3.)  For  the  chill  of  febrile  states — such  as  pneu- 
monia, malaria,  .septich?emia — here,  alcohol  in  medi- 
cinal dose  (e.  g.  15  c.c.  or  more  of  whiskey),  (a) 


856 


CORRESPONDENCE. 


[New  York 
Medical  Journal. 


opens  the  surface  capillaries  that  are  contracted  in 
chill  and  so  gives  a  sense  of  warmth  to  the  patient, 
(b)  lowers  the  fever,  and  (c)  through  cerebral  de- 
pression blunts  the  patient's  mental  anguish.  Of 
course  the  chill  of  haemorrhage,  shock,  or  other  con- 
dition not  accompanied  with  fever  contraindicates 
alcohol  for  obvious  reasons. 

(4.)  To  reduce  fever.  In  some,  not  all,  cases  of 
tvphoid,  where  the  plunge  or  sponge  bath  fails  to 
lower  an  excessive  temperature,  30  c.c.  of  brandy 
immediately  preceding  the  bath  will  insure  a  nota- 
ble reduction,  by  driving  the  warm  blopd  to  the  sur- 
face to  be  returned  cooled  to  the  internal  organs. 
Good  judgment  must  be  applied  to  determine 
whether  the  blood  pressure  and  heart  action  are  such 
as  to  safely  withstand  such  a  depressant  as  alcohol, 
however.  In  the  presence  of  a  low  arterial  tension 
or  a  very  weak  heart  muscle  this  use  of  alcohol 
would  be  hardly  justified. 

(5.)  As  a  narcotic,  in  many  persons  of  advanced 
years  and  a  few  with  earlier  arteriosclerosis  who  are 
apt  to  suffer  from  insomnia,  a  "night  cap"  of  brandy 
in  the  form  of  a  "sling"  will  act  favorably  and  is 
free  from  the  unpleasant  symptoms  that  often  fol- 
low the  use  of  the  old  or  new  hypnotics.  Fear  of 
habit,  in  this  instance,  need  hardly  be  considered. 
Prescribing  alcohol  to  enable  a  patient  to  withstand 
the  strain  of  having  a  tooth  extracted,  an  abscess 
opened,  or  a  wound  sutured,  on  the  other  hand,  is 
crude  therapeutics ;  of  course,  it  will  diminish  worry 
or  fear,  but  a  dose  of  morphine  could  surely  be 
smuggled  into  such  a  patient's  stomach  with  better 
effect  and  little  danger  of  the  patient  resorting  to 
the  subtle  aid  of  the  narcotic  for  future  strains  of 
the  strenuous  life. 

We  have  covered  every  rational  indication  for  al- 
cohol. Possibly  some  of  these  indications  could  be 
met  without  it— we  only  wish  they  could.  Physi- 
cians owe  it  to  the  public  to  discountenance  the  tenn 
"stimulants"  when  referring  to  alcohol — clinical 
charts  and  molly  coddle  doctors  who  employ  this 
term  should  be  "revised  and  enlarged" — not  to  say 
"corrected."  Those  who  persist  in  looking  upon  al- 
cohol as  a  "stimulant"  belong  to  either  of  two 
classes :  They  are  too  lazy  to  study  the  question  for 
themselves  or  they  prefer  to  ally  themselves  to  that 
pitiable  group  who  "throw  physiological  action  to 
the  dogs." 

Dr.  Alexander  Marchisio,  of  Neiu  York,  says: 

Physiology  says  that  alcohol  is  locally  an  irritant. 
Ingested  it  is  easily  absorbed  but  nevertheless  a  por- 
tion of  it  passes  into  the  intestines  where  it  promotes 
the  intestinal  peristalsis  by  its  irritating  action.  Its 
irritative  action  upon  the  gastric  mucous  membrane 
exites  the  secretions  of  the  gastric  juices  thus  favor- 
ing digestion,  but  in  solution  superior  to  \  in  lO 
inhibits  the  power  of  the  digestive  ferments.  Once 
in  the  blood  it  diminishes  its  ability  to  produce  oxy- 
gen in  presence  of  a  reducing  agent  thus  hindering 
the  chemical  interchanges  of  the  tissues  and  hence- 
forth the  niUrition.  In  moderate  doses  alcohol  has 
a  slight  stimulating  influence  upon  the  cardiac 
muscle  at  the  same  time  producing  a  dilatation  of 
the  bloodvessels  of  the  skin  so  that  a  slight  rise  of 
pressure  may  ensue.  Large  doses  depress  the  heart. 
There  is  no  evidence  that  alcohol  in  anv  dose  has  a 
stimulating  effect  on  the  brain.    Small  doses  pro- 


duce a  small  increase  in  temperature,  large  doses 
a  downfall.  Respiration  is  stimulated  by  small 
doses.  Dr.  Wood  in  his  book  Principles  and  Prac- 
tice of  Therapeutics  states  that  alcohol  from  ninety- 
five  to  ninety-nine  per  cent,  is  oxidized  into  the  or- 
ganism in  carbonic  acid  and  water  producing  useful 
energy,  lessening  the  oxidation  of  the  body  tissues, 
and  thus  diminishing  the  amount  of  hydrocarbon- 
necessary  to  maintain  nutritive  equilibrium,  and  is 
consequently,  in  a  certain  sense,  a  food  which  can 
be  used  for  this  purpose.  But  he  states  also  that  the 
experience  of  arctic  explorers  has  clearly  shown  that 
alcohol  has  no  heat  producing  power,  that  the  free 
use  of  spirits  far  from  enabling  a  man  to  withstand 
habitual  exposure  to  intense  cold  very  materially 
lessens  his  power  of  resistence. 

Experience  has  shown  that  alcohol  is  to  be  avoid- 
ed always  when  our  forces  are  put  to  great  strain, 
thus  demonstrating  that  alcohol  is  more  apt  to  con- 
sume than  to  produce  energy. 

Experiments  made  to  demonstrate  whether  alcohol 
diminishes  or  increases  the  power  of  the  system  to 
resist  infections  seem  to  point  rather  to  the  first. 
From  what  precedes  it  seems  clearly  shown  that  the 
only  beneficial  influences  of  alcohol  are  its  slight 
stimulating  action  upon  the  heart  and  upon  the  di- 
gestive function,  this  depending  by  its  ifritating  ac- 
tion upon  the  gastric  and  intestinal  mucous  mem- 
branes. 

For  this  reason  we  hold  that  the  use  of  alcohol 
is  absolutely  unwarranted  when  employed  to  lower 
the  temperature  as  this  is  due  to  its  depressing  and 
intoxicating  action ;  to  stimulate  the  nervous  sys- 
tem, as  such  stimulating  power  does  not  exist ;  to 
aid  nutrition  as  nutrition  is  more  hindered  than 
favored  ;  and  to  increase  the  resistance  of  the  organ- 
ism as  experience  and  experiments  have  shown  that 
the  resistance  of  the  organism  is  lessened  by  it.  In 
typhoid  fever  we  must  add  to  all  these  considera- 
tions, the  irritative  action  upon  the  gastrointestinal 
mucous  membrane. 

Therefore  we  hold  that  the  use  of  alcohol  is  only 
advisable  when  we  want  to  temporarily  stimulate 
the  cardiac  muscle  as  in  fainting,  pain,  heat  exhaus- 
tion, loss  of  blood,  asphyxia,  snake  poisoning,  and 
poisoning  by  all  paralyzing  drugs ;  and  when  we 
need  to  stimulate  digestion  if  there  is  no  danger  of 
irritating  the  gastric  mucous  membrane  and  no 
other  contraindications  to  its  use  as  there  are  in 
acute  infective  diseases. 

Externally  alcohol  may  be  used  to  stimulate  the 
function  of  the  skin,  to  warm  a  benumbed  extremity 
and  to  stimulate  the  nervous  system  reflexedly. 
{To  he  continued.) 
 <$>  

Cffrrfspnbtntt. 


LETTER  FROM  LONDON. 
An  Interesting  Legal  Case. — Women  and  the  Royal  Col- 
leges.— Pernicious  Vomiting  of  Pregnancy  Diagnosti- 
cated Post  Mortem. 

London,  April  6,  igog. 
A  unique  case  came  before  the  courts  last  week. 
The  plaintiff  was  a  medical  practitioner  who  was 
admitted  into  .St.  Bartholomew's  Hospital  in  March, 
1907.  in  order  that  he  might  be  ^amined  under  an 


April  24,  1909.] 


THERAPEUTICAL  NOTES. 


857 


anaesthetic.  It  was  alleged  that  the  plaintiff  was 
placed  upon  the  operating  table  in  such  a  position 
that  his  arms  were  allowed  to  hang  over  his  sides, 
that  his  left  ann  was  in  contact  with  a  hot  water  tin 
projecting  from  beneath  the  table,  that  the  inner 
part  of  his  right  arm  was  bruised  by  the  operator  or 
some  other  person  pressing  against  it  during  the 
operation,  and  that  the  results  of  these  injuries  were 
traumatic  neuritis  and  paralysis  of  both  arms,  so 
that  he  had  ever  since  been  unable  to  exercise  his 
profession. 

The  defendants  were  the  governors  of  the  hos- 
pital. They  denied  the  alleged  negligence  and 
pleaded  that  if  they  owed  any  duty  to  the  plaintiff 
it  was  to  exercise  reasonable  care  in  the  selection 
of  the  hospital  staff,  in  which  duty  they  had  not 
failed.  After  the  plaintiff's  case  had  been  opened  it 
was  submitted  on  the  part  of  the  defendants  that  no 
action  could  lie  against  the  defendants,  being  gov- 
ernors of  a  charitable  institution.  Sir  Isambard 
Ov^ren  and  Dr.  Risien  Russel  gave  testimony  for  the 
plaintiff',  stating  that  his  injuries  were  due  to  the 
burn  by  the  hot  water  tin.  The  plaintiff  said  that 
on  the  day  after  the  operation  the  warden  and  the 
house  surgeon  told  him  that  his  arms  had  not  been 
supported  while  he  was  under  the  anaesthetic  and 
they  could  not  account  for  the  burn  on  the  arm  un- 
less it  had  come  in  contact  with  a  hot  bottle  or  some 
hot  apparatus.  Mr.  Justice  Grantham,  in  giving 
judgment  for  the  defendants,  stated  that  he  con- 
sidered it  would  be  a  fatal  policy  to  allow  such  a 
case  to  go  to  the  jury  under  these  circumstances, 
because  if  he  did  so,  everybody  who  happened  to 
have  a  grievance  against  the  hospitals  would  be 
bringing  an  action  "on  spec"  and  raising  all  sorts  of 
Cjuestions,  which  would  be  disastrous  to  those  who 
controlled  these  institutions.  This  is  the  first  case 
of  the  kind  heard  in  England. 

At  the  forthcoming  April  meeting  of  the  Council 
of  the  Royal  College  of  Surgeons  the  new  by  law 
regulating  the  admission  of  women  to  the  examina- 
tions of  the  college  will  come  up  for  final  discussion. 
If  it  is  approved  the  July  examinations  will  be  the 
earliest  that  women  will  be  able  to  enter  for.  Under 
the  provisions  of  this  by  law  women  wall  be  eligible 
for  the  highest  surgical  distinction  we  have,  namely, 
the  Fellowship  of  the  Royal  College  of  Surgeons, 
also  for  the  conjoint  diploma  of  the  college  given 
in  conjunction  with  the  Royal  College  of  Physi- 
cians. Women  will  also  be  eligible  for  the  L.  D.  S., 
tlie  dental  license  of  the  college,  but  under  no  cir- 
cumstances will  be  given  a  voice  in  the  government 
of  the  college  or  be  eligible  as  examiners  of  the 
college,  even  should  they  become  possessed  of  the 
highest  diploma. 

At  a  recent  meeting  of  the  Gynaecological  Section 
of  the  Royal  Society  of  ^ledicine.  Dr.  Drummond 
Maxwell  gave  an  account  of  a  fatal  case  of  perni- 
cious vomiting  of  pregnancy  in  a  primigravida  aged 
twenty-six.  The  diagnosis  was  difficult,  as  the  pa- 
tient, after  admission  to  the  hospital,  ceased  vomit- 
ing and  there  w-as  only  the  historv'  of  severe  vomit- 
ing at  home,  unassociated.  however,  with  marked 
wasting.  There  was  no  characteristic  alteration  of 
the  urine.  The  only  ominous  signs  on  her  admis- 
sion were  drowsiness  and  a  very  rapid,  weak  pulse. 


There  was  no  jaundice.  The  patient  passed  success- 
ively through  stages  of  restlessness,  delirium,  mania, 
and  final  coma.  The  autopsy  revealed  hyaline  de- 
generation and  necrosis  of  the  central  cells  of  the 
hepatic  lobules,  the  kidneys  also  showing  a  severe 
parenchymatous  inflammation.  The  diagnosis,  un- 
certain during  life,  was  based  finally  on  the  post 
mortem  appearances. 

 <t>  


In  the  Subacute  Stage  of  Influenza. — D.  W. 

\\'augh,  of  Brooklyn,  has  had  remarkably  good  re- 
sults with  the  following  treatment.  The  patient  is 
first  ordered  to  take  a  hot  mustard  foot  bath  and  go 
to  bed.  mixture  is  then  prescribed  for  internal 
use,  a  teaspoonful  of  which  is  to  be  taken  hourly. 


The  prescription  reads : 

R    Ammonium  benzoate,   5i; 

Ammonium  salicj-late.   5i ; 

Aromatic  spirit  of  ammonia  5iss  ; 

Spirit  of  nitrous  ether,   Jiss. 


M.  et  Sig. :  One  teaspoonful,  well  diluted,  everj-  hour. 
In  the  evening  the  nasal  passages  are  thoroughly 
cleansed  by  means  of  a  spray  of  some  saline  solu- 
tion, preferably  Seller's,  and  after  the  patient  is  able 
to  breathe  freely  through  the  nostrils  one  or  two 
drops  of  a  twenty-five  per  cent,  aqueous  solution  of 
argyrol  are  inserted  far  back  in  each  nostril  by 
means  of  a  medicine  dropper,  the  patient  being  in- 
structed to  draw  the  solution  into  his  throat  by  a 
deep  nasal  inspiration.  As  a  rule  this  treatment  is 
effective  in  twenty-four  hours.  It  is  often  advisable 
to  spray  the  nasal  passages  with  a  solution  of  ad- 
renalin of  the  strength  of  i  in  3,000  before  applying 
the  argyrol. 

Insufflations  for  Chronic  Rhinitis. — In  the  Ga- 
zette medicale  de  Paris  for  March  i,  1909,  the  fol- 
lowing formulas  are  given  for  insufflations  used  in 


the  treatment  of  chronic  rhinitis : 

(1)  R    Boric  acid,   5v; 

Menthol,   gr.  iss. 

M. 

The  amount  of  menthol  rnay  be  increased  progres- 
sively to  about  seven  or  eight  grains. 

(2)  R    Boric  acid,   gr.  v; 

Camphor,   gr.  xv. 

M. 

(3)  R    Sublimed  sulphur  3iL 

M. 

Only  one  insufflation  a  day  should  be  taken  to 
commence  with. 

(4)  3    Sodium  salicylate,   5ii; 

Sodium  borate,   3ii. 

M. 

The  foregoing  is  intended  for  use  in  the  treat- 
ment of  rhinitis  of  rheumatic  origin. 

(5)  R    Sodium  hyposulphite,   gr.  Ixxv: 

Sodium  borate,   Siisa 


It  is  understoood  that  all  of  the  powders  employed 
must  be  in  a  state  of  the  finest  subdivision.  Cocaine 
is  not  prescribed  in  combination  with  these  ingredi- 
ents on  account  of  the  danger  of  patients  acquiring 
the  habit. 


858 


EDITORIAL  ARTICLES. 


[New  Vork 
Medical  Journal. 


NEW  YORK  MEDICAL  JOURNAL 

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Philadelphia  Medical  Journal 
and  The  Medical  News. 

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Philadelphia. 


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NEW  YORK,  S.-\TURDAY,  APRIL  24,  1909. 


PENNSYLVANIA'S  "HOME  COMING 
WEEK." 

The  Medical  Department  of  the  University  of 
Pennsylvania  devoted  last  week  to  a  fnnction  which 
was  called  "Home  Comine  Week."    The  alumni 


dedication  of  the  new  Medical  Amphitheatre  and 
Clinical  Laboratory.  This  building  forms  one  unit 
of  what  is  planned  to  be  a  complete  chain  of  build- 
ings to  replace  the  present  University  Hospital.  The 
unit  in  question  is  built  in  the  customary  substantial 
manner  of  all  the  buildings  recently  erected  by  the 
university  trustees,  and  on  the  same  satisfactory  and 
artistic  architectural  plan.  The  building  is  planned 
to  accommodate  all  the  medical  teaching  in  the  uni- 
versity, except  the  bedside  work  in  the  wards.  There 
are  rooms  devoted  to  general  medicine,  neurology, 
paediatrics,  and  similar  subdivisions ;  a  lecture  room ; 
and  a  laboratory  of  clinical  pathology. 

The  address  made  upon  the  occasion  of  the  dedi- 
cation of  this  addition  to  the  teaching  plant  of  the 
Medical  School  of  the  University  of  Pennsylvania 
was  prepared  by  Dr.  George  Dock,  professor  of 
medicine  in  Tulane  University,  of  New  Orleans.  The 
theme  of  Dr.  Dock's  address  was  the  particular 
value  of  the  clinical  laboratory  to  the  general  prac- 
titioner. He  showed  that  the  methods  of  exact  diag- 
nosis were  not  alone  for  those  who  lived  in  medical 
centres,  but  of  the  most  practical  importance  to  the 
physician  in  any  community.  The  student,  in  order 
that  he  may  realize  the  value  of  the  procedures  in- 
cluded by  the  term  laboratory  methods,  should  be 
taught  them  thoroughly  in  his  undergraduate  days. 
The  things  to  be  done  in  the  accurate  diagnosis  of 
cases  of  disease  depend  for  their  value  upon  the 


The  New  Hospital  Buildings  of  the  University  of  Pennsylvania. 


from  all  parts  of  the  country  were  invited  to  return 
to  the  Alma  Mater  while  the  undergraduate  course 
was  in  full  swing,  so  as  to  see  the  changes  and  the 
imj)rovements  that  had  been  made  in  the  curriculum 
since  the  time  of  their  graduation.  A  special  roster 
of  medical  and  surgical  clinics,  demonstrations,  and 
lectures  was  prepared  which  filled  the  days  with  op- 
portunities for  rapid  reviews  of  the  advances  in  all 
the  main  and  the  subsidiary  features  of  the  under- 
graduate course.  The  local  alumni  arranged  special 
entertainments  for  the  evenings,  and  the  undergrad- 
uate medicai  societies  held  their  annual  congress, 
fallowed  by  a  dinner. 
The  main  feature  of  the  week,  however,  was  the 


quickness,  the  .Tccuracy,  and  the  certainty  of  their 
performance.  Furthermore,  when  the  young  man 
is  properly  trained  in  the  methods  he  will  find  that 
he  easily  has  time  for  all  those  details  which  seem 
insurmountable  obstacles  to  a  man  improperly 
trained.  The  speaker  pointed  out  the  necessity  for 
every  modern  hospital  to  operate  a  well  equipped 
laboratory  for  the  purposes  of  diagnosis,  and  he  re- 
ferred with  well  deserved  sarcasm  to  those  institu- 
tions that  tried  to  get  along  with  a  couple  of  micro- 
scopes and  test  tubes  and  an  occasional  search  for 
tubercle  bacilli  or  casts,  made  l)y  an  uninterested  and 
unwilling  interne,  without  training  or  scientific  en- 
thusiasm. 


April  24,  1909.] 


EDITORIAL  ARTICLES. 


859 


The  Medical  Department  of  the  University  of 
Pennsylvania  is  to  be  congratulated  upon  the  com- 
pletion of  such  a  building  for  its  hospital  system.  It 
is  earnestly  to  be  hoped  that  other  institutions  will 
fall  into  line,  and  if  they  cannot  afford  to  erect  a  new 
building  for  the  purpose,  that  they  will  at  least  fol- 
low the  good  example  set  by  this  and  other  colleges 
and  so  train  their  undergraduates  that  when  they 
take  up  the  duties  of  hospital  interne  they  shall  not 
require  an  expenditure  of  valuable  time  for  the  ac- 
quisition of  a  technique  that  they  should  have  mas- 
tared  before  the  diploma  was  passed  to  them. 


one  that  calls  for  eternal  vigilance  and  unceasing 
activity,  but  it  is  one  that  must  be  prosecuted  ener- 
getically, and  not  in  San  Francisco  alone,  for  a 
high  officer  among  those  on  duty  with  others  of  the 
Public  Health  and  ^larine  Hospital  Service  in  San 
Francisco  writes  to  us  that  the  pandemic  of  plague  is 
encroaching  slowly  but  surely  upon  our  Gulf  and 
Atlantic  seaboards.  Mr.  Todd  gives  excellent  ad- 
vice for  the  extermination  of  rats  in  hoitseholds, 
and  on  that  account  alone,  if  for  no  other  reason, 
the  book  which  he  has  produced  ought  to  be  widely 
studied  by  our  citizens. 


THE  PLAGUE  IN.  SAN  FRANCISCO. 

No  longer  playing  at  cross  purposes,  the  medical 
officers  of  the  United  States  Public  Health  and 
Marine  Hospital  Service,  the  State  and  city  boards 
of  health,  and  the  Citizens'  Health  Committee  have 
of  late  been  doing  exceedingly  good  work  in  erad- 
icating the  Oriental  plague  from  San  Francisco, 
which  is  now  described  as  one  of  the  healthiest 
cities  in  the  world.  Air.  Frank  Morton  Todd,  the 
Citizens'  Health  Committee's  historian,  has  recently 
issued  an  exceedingly  interesting  account  of  the 
work  done  and  the  methods  employed,  making  a 
volume  of  more  than  300  pages. 

Naturally,  the  wholesale  destruction  of  rats  has 
played  an  important  part  in  the  work.  Mr.  Todd 
gives  a  graphic  story  of  the  role  of  the  rat  in  the 
propagation  of  the  disease.  When  the  plague  has 
ceased  its  devastation  in  the  past,  he  'remarks,  the 
cessation  may  have  been  due  to  the  immunization 
of  individual  rats  by  their  having  had  the  disease, 
or  to  the  propagation  and  survival  of  resistant  indi- 
viduals only,  or  to  weakening  of  the  virulence  of 
the  bacilli,  or  to  all  these  causes ;  and  fresh  out- 
breaks may  have  been  owing  to  new  migrations  of 
rats  from  established  foci. 

It  seems  that  rats,  when  they  are  very  hungry, 
often  eat  other  rats,  and  male  rats  eat  their  young, 
"but  not  enough."  "The  natural  enemy  of  the  rat," 
says  Mr.  Todd,  "is  the  homeless  and  hungry  cat — 
not  the  sleek  and  pampered  cup  winning  house  pet, 
with  a  ribbon  and  bell,  but  the  mean  and  scrawny 
brute  that  yowls  at  night  and  can't  be  petted  and 
has  to  get  its  living  where  it  can."  The  services  of 
such  felines  in  harrying  rats  away  from  food,  in 
breaking  up  rat  families,  in  disturbing  their  breed- 
ing places,  and  in  preventing  overground  migra- 
tions, he  thinks,  are  probably  valuable  beyond  esti- 
mate. Dogs  do  more  harm  than  good,  because, 
though  they  are  good  harriers  of  rats,  they  inter- 
fere with  the  more  efficient  cats.  'Tt  is  thought," 
he  says,  "that  cat  fleas  will  not  carry  plague,  but 
this  point  has  not  been  fully  settled." 
.  The  work  of  eradicating  rats  is  a  difficult  task, 


THE  PROBLEAI  OF  INEBRIETY. 

How  shall  w^e  deal  with  the  man  who  shows  him- 
self publicly  in  a  state  of  drunkenness?  He  has  not 
necessarily  committed  an  oflfense.  In  the  great  ma- 
jority of  instances,  at  least  among  those  who  are 
only  sporadically  found  drunk  on  the  streets,  there 
has  been  no  intention  of  offending  even  against  the 
proprieties ;  the  individual  has  simply,  in  a  spirit  of 
conviviality,  overestimated  his  ability  to  withstand 
the  effects  of  alcohol,  or  possibly,  as  the  effects  of 
the  drug  crept  over  him,  he  has  lost  sight  of  the  ne- 
cessity of  declining  to  take  an  overdose.  Surely  we' 
ought  not  to  class  such  a  man  as  an  offender  against 
the  law ;  we  ought  not  to  imprison  him,  or  fine  him, 
or  even  arrest  him.  It  is. probable  that  in  a  high  pro- 
portion of  instances  his  remorse  is  a  sufficient  cor- 
rective ;  he  blames  himself  for  yielding  to  tempta- 
tion, and  his  contrition  often  serves  for  him  as  a 
perpetual  safeguard  against  further  undue  indul- 
gence. Least  of  all  should  we  ascribe  a  man's  insanity 
to  drink,  for  it  is  probable  that  immoderate  tippling 
is  oftener  one  of  the  results  of  incipient  mental  im- 
pairment than  its  cause. 

Still,  we  must  do  something  to  curb  the  tendency 
to  drunkenness,  to  restrain  the  wage  earner  from 
squandering  on  drink  the  wages  that  ought  to  go  to 
the  support  of  his  family.  But  to  bring  him  up  for 
sentence  to  fine  or  imprisonment  is  detrimental  both 
fo  him  and  to  the  public  welfare.  The  disgrace  dis- 
courages him  and  sometimes  makes  him  desperate, 
and  the  result  is  not  of  advantage  to  his  family  or 
to  the  community ;  too  often  it  is  disastrous. 

The  "rounder,"  however,  must  be  corrected  or 
punished  by  law,  and  far  preferable  will  it  be  if  he 
can  be  corrected.  An  excellent  plan  for  accomplish- 
ing both  correction  and  punishment  appears  to  have 
been  elaborated  by  the  Standing  Committee  on  Hos- 
pitals of  the  State  Charities  Aid  Association  of  New 
York.  The  scheme  contemplates  the  establishment 
of  a  Board  of  Inebriety  vested  with  power  to  grade 
the  correction  of  inebriates  according  to  the  circum- 
stances of  individual  cases,  and  it  includes  the  crea- 
tion of  State  sanatoria  for  the  treatment  of  victims 


86o 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


of  the  drink  habit.  A  prominent  feature  of  the  plan 
— a  most  estimable  one,  it  seems  to  us — is  the  un- 
conditional release  of  first  offenders.  This  has  been 
tried  in  Massachusetts  and  has  seemed  to  work  well. 
It  is  easy  to  imagine  why  it  should  be  so. 


"PARISIANOAIANIE." 
This  fanciful  name,  quite  analogous  to  Dr.  Gird- 
ner's  "Newyorkitis"  of  the  last  decade,  is  employed 
by  M.  Rene  Cruchet  {Pr ogres  medical.  March 
20th)  to  denote  what  he  humorously  treats  of  as  a 
disease — the  propensity  to  look  upon  Paris  as  con- 
stituting the  whole  of  France.  He  describes  an 
aggravated  case,  that  of  a  Parisian  singer  of  dis- 
tinction who,  finding  herself  in  Bordeaux,  was  as- 
tonished to  perceive  that  the  buildings,  the  streets, 
the  men  and  women,  the  horses,  and  the  dogs  of 
that  city  were  not  greatly  different  in  appearance 
from  those  of  Paris.  After  looking  at  a  display  of 
bronzes  and  marbles  she  exclaimed :  "Ah,  this  is 
pretty !  I  thought  such  things  existed  only  in 
France!"  Another  instance,  and  probably  the  one 
that  really  evoked  the"  article,  was  the  recent  an- 
nouncement of  the  constitution  of  a  so  called 
French  Committee  of  Organization  of  the  Buda- 
pest Congress  consisting  of  seventy-eight  Parisians 
and  only  six  residents  of  other  places  than  Paris. 


HEXAMETHYLENAMINE  AND 
MENINGITIS. 
In  some  experiments  made  in  the  Flunterian  Lab- 
oratory of  Experimental  Medicine  {  Johns  Hopkins 
Hospital  Bulletin,  xix,  p.  109},  Crowe  showed  that 
after  the  administration  of  hexamethylenamine  by 
the  mouth  it  appeared  in  the  bile  and  in  the  pan- 
creatic juice.  During  the  course  of  these  experi- 
ments it  was  accidentally  discovered  that  the  drug 
was  also  eliminated  in  the  cerebrospinal  fluid.  Con- 
sequently other  experiments  were  undertaken  to  de- 
termine the  conditions  under  which  this  elimination 
took  place  {Johns  Hopkins  Hospital  Bulletin, 
April).  It  was  found  that  when  hexamethylenamine 
was  administered  by  the  mouth  it  invariably  made 
its  appearance  in  the  cerebrospinal  fluid  within  an 
hour,  and  in  some  instances  within  thirty  minutes. 
The  elimination  of  this  drug  in  the  cerebrospinal 
fluid  was  found  to  be  sufficient  to  inhibit  the  growth 
of  microorganisms  in  that  fluid  when  the  organisms 
were  inoculated  after  the  removal  of  the  fluid  from 
the  body.  In  dogs  and  rabbits  it  was  found  that  if 
streptococci  were  inoculated  into  the  pia-arachnoid, 
the  administration  of  from  sixty  to  eighty  grains  of 
hexamethylenamine  daily  would  decidedly  defer  the 
onset  of  a  fatal  meningitis  in  the  animals.  In  the 
first  article  referred  to  the  administration  of  hexa- 
incthylonaminc  to  a  patient  suffering  from  an  in- 


fected cerebrospinal  fistula,  which  followed  a  suboc- 
cipital operation  for  cerebellar  tumor,  was  said  to 
have  resulted  in  the  closing  of  the  fistula  within  three 
weeks.  The  prompt  administration  of  hexamethyl- 
enamine is  advised  in  all  cases  in  which  meningitis 
is  probable  or  a  threatened  complication,  or  in  which 
meningeal  infection  has  developed. 


RUEDIGER'S  ANTISERUM  FOR  RINDER- 
PEST. 

An  antiserum  for  rinderpest  was  discovered  by 
Koch  more  than  ten  years  ago,  and  has  been  used 
successfully  in  Africa  and  in  the  Philippine  Islands. 
The  antiserum  is  produced  by  bleeding  an  infected 
bullock  to  death  and  injecting  this  virulent  blood 
into  other  animals  for  immunizing  purposes.  By 
this  technique  the  virulent  blood  is  very  expensive, 
each  quart  costing  about  $5.  Ruediger  {Philippine 
Journal  of  Science,  November,  1908)  has  recently 
shown  that  artificial  peritoneal  exudate  is  highly 
virulent  and  that  it  can  be  used  for  the  production 
of  an  antiserum. 

Five  quarts  of  a  0.5  per  cent,  solution  of  potas- 
sium citrate  were  injected  into  the  peritoneal  cavity 
of  a  sick  bullock,  and  an  hour  later  the  animal  was 
bled  to  death  and  the  peritoneal  fluid  was  collected 
and  used  for  immunizing  purposes.  The  antiserum 
produced  by  animals  immunized  with  the  peritoneal 
exudate  was  of  higher  potency  than  that  produced 
by  animals  immunized  with  virulent  blood.  By  the 
method  of  using  the  peritoneal  exudate  from  in- 
fected animals  the  quantity  of  virulent  material 
available  for  immunizing  purposes  may  be  doubled, 
so  that  the  virulent  material  costs  only  $2.50  a 
quart. 


INTESTINAL    PARASITES    IN  THE 

PHILIPPINES. 
As  a  result  of  the  study  of  the  faeces  of  three 
hundred  patients  admitted  into  the  United  States 
Naval  Hospital  at  Cafiacao,  Philippine  Islands.  Hovt 
{Philippine  Journal  of  Sciences,  November,  1908) 
found  motile  amoebae  in  34.6  per  cent. ;  motile  fla- 
gellates in  15.3  per  cent.;  ova  of  Ascaris  lumbri- 
coides  in  10  per  cent. ;  ova  of  Trichocephalus  trichi- 
uris  in  6.6  per  cent.;  and  ova  of  Ankylostoina  duo- 
denale  in  3.3  per  cent.  The  patients  had  been  ad- 
mitted for  the  general  run  of  diseases  found  in  the 
personnel  of  a  naval  station.  Only  twenty  were 
admitted  with  clinical  dysentery.  The  author  is  6i 
the  opinion  that  Entainccba  histolytica  cannot  be 
distinguished  from  Amoeba  coli  by  morphology 
alone  in  smears  of  faeces.  Simultaneous  examina- 
tions of  the  blood  showed  an  increase  of  eosino- 
philcs  in  about  40  per  cent,  of  the  patients  harbor- 
ing amoebae. 


April  24,  1909.] 


NEM'S  ITEMS. 


Freeport  Hospital  Opened. — ^The  Southside  Hospital, 
recently  established  in  Freeport,  L.  I.,  was  opened  for  the 
reception  of  patients  on  April  19th. 

A  Children's  Hospital  in  Augusta,  Ga.,  is  to  be  erect- 
ed by  Mrs.  G.  F.  W.  Duff,  of  New  York,  in  memory  of  her 
husband,  who  died  in  Augusta  recently.  The  building  will 
cost  approximately  $20,000. 

The  St.  Louis  Medical  Library  Association  will  hold 
its  annual  meeting  in  the  Medical  Librar\-  Building,  on 
Wednesday.  April  28th.  The  meeting  is  of  special  impor- 
tance as  it  is  the  tenth  anniversary  of  the  founding  of  the 
organization. 

State  Ownership  of  Saratoga  Springs. — ^The  Assemb- 
bly  has  passed  the  Brackett  bill  providing  for  a  commis- 
sion and  appropriating  $600,000  for  the  acquisition  of  cer- 
tain lands  and  springs  at  Saratoga  for  a  State  reservation. 
The  bill  has  already  passed  the  Senate  and  now  will  go  to 
the  Governor  for  final  action. 

Dr.  Adami  in  Philadelphia. — Dr.  J.  George  Adami,  of 
McGill  University,  Montreal,  delivered  an  address  at  the 
annual  conversational  meeting  of  the  Pathological  Society 
of  Philadelphia  on  Thursday  evening,  April  22d.  His  sub- 
ject was  Certain  Fundamental  Conceptions  Regarding  the 
Nature  of  the  .\rteriosclerotic  Process. 

Mr.  Martin's  Tuberculosis  Fund. — Mr.  Frederick 
Townsend  Martin,  of  Xew  York,  has  turned  over  to  Dr. 
Nicholas  Murray  Butler,  president  of  Columbia  University, 
the  sum  of  $10,000,  which  he  personally  collected  to  be 
used  in  the  campaign  against  tuberculosis  in  New  York. 
The  money  was  accompanied  by  the  names  and  addresses 
of  those  who  contributed  to  the  fund. 

Sea  View  Hospital,  Staten  Island. — The  Board  of 
Estimate  and  Apportionment  of  Xew  York  has  authorized 
the  issue  of  $1,350,000  in  corporation  stock  to  provide  for 
the  erection  and  completion  of  the  Sea  View  Hospital,  on 
Staten  Island.  It  is  said  that  the  new  building  will  be 
ready  for  occupancy  in  about  two  years,  and  will  be  fur- 
nished with  one  thousand  beds. 

American  Medical  Editors'  Association. — The  coming 
meeting  of  this  association,  to  be  held  at  the  Marlborough- 
Blenheim  Hotel,  Atlantic  City,  N.  J.,  June  5th  to  7th,  cele- 
brates its  fortieth  anniversary,  and  an  unusual  programme 
has  been  prepared  for  the  occasion.  It  is  expected  that 
delegates  from  the  foreign  medical  press  will  be  present 
and  every  medical  editor  should  make  an  effort  to  attend 
the  meeting. 

Scientific   Society   Meetings   in  Philadelphia  for  the 
Week  Ending  May  i,  1909: 

MoxD.Wj  April  26th. — Mineralogical  and  Geological  Sec- 
tion, Academy  of  Natural  Sciences. 

Wedxesd.^y.  April  28th. — Philadelphia  County  Medical  So- 
ciety. 

Frid.w.  April  23d. — South  Branch.  Philadelphia  County 
Medical  Society. 

A  Neurological  Institute  in  New  York. — It  is  report- 
ed that  a  hospital  for  the  treatment  of  nen-ous  diseases  is 
soon  to  be  established  in  New  York.  A  clinic  for  the 
study  and  observation  of  nervous  and  mental  diseases  and 
a  training  school  for  nurses  and  specialists  in  this  branch 
of  medicine  will  be  conducted  in  connection  with  the  hos- 
pital, and  a  sanatorium  will  be  built  in  the  country.  Among 
the  members  of  the  Board  of  Directors  of  the  institute  are 
Dr.  Joseph  Collins  and  Dr.  Joseph  Fraenkel. 

The  Regulation  of  Medical  Expert  Testimony. — The 
bill  introduced  by  Assemblyman  Fowler,  of  Ulster  County, 
dealing  with  the  question  of  medical  expert  testimony,  was 
passed  in  the  Assembly  by  a  vote  of  91  to  16.  It  provides 
that  the  Appellate  Division  in  each  district  may  select  from 
ten  to  sixty  members  of  the  medical  profession,  from 
arnong  whom  medical  experts  may  be  drafted  as  need  may 
arise.  They  shall  be  paid  by  the  county  in  which  the  action 
is  tried,  and  by  no  other  person,  the  judge  determining  the 
amount  of  their  compensation.  They  shall  have  had  at 
least  five  years'  experience  in  the  practice  of  medicine,  and 
will  be  subject  to  call  by  the  court  or  by  either  party  to  a 
ci\nl  or  criminal  action.  The  bill  has  been  endorsed  by  the 
State  Bar  Association  and  the  medicolegal  societies,  as  well 
as  by  the  courts. 


Physician  Wanted  at  Gouverneur  Hospital. — An- 
nouncement is  made  that  an  attending  physician  is  wanted 
in  the  outpatient  department  of  Gouverneur  Hospital,  with 
which  position  is  associated  the  position  of  assistant  attend- 
ing physician  to  the  hospital  proper.  Applications  for  ap- 
pointment to  this  position  may  be  sent  to  Dr.  John  H. 
Huddleston,  secretary  of  the  Medical  Board  of  Gouverneur 
Hospital,  Gouverneur  and  Front  streets.  New  York. 

Society  Meetings  for  the  Coming  Week: 

MoND.w,  April  26th. — Medical  Society  of  the  County  of 
New  York. 

TuESD.w,  April  2jth. — New  York  Medical  Union :  New 
York  Dermatological  Society;  Metropolitan  Medical 
Society  of  the  City  of  New  York ;  Buffalo  Academy  of 
Medicine  (Section  in  Obstetrics  and  Gynaecolog>0 • 

\\"edxesday,  April  28th. — New  York  Academy  of  Medicine 
(Section  in  LaiTngology  and  Rhinology)  ;  New  York 
Surgical  Society. 

Thursday,  'April  ^p/Zr.— Brooklyn  Society  for  Neurology. 

Promotions  and  Appointments  at  the  Rockefeller  In- 
stitute for  Medical  Research. — At  a  meeting  of  the 
Board  of  Directors  of  the  Rockefeller  Institute  held  on 
April  loth,  the  following  promotions  and  appointments 
were  made :  Associate  Members — Dr.  John  Auer,  physiol- 
ogy; Dr.  Hideyo  Noguchi,  pathology;  Dr.  Alexis  Carrell, 
surgerj-.  Associate — Dr.  George  W.  Heimrod,  chemistry. 
Assistants — Dr.  Martha  Wollstein,  pathology;  Dr.  Richard 
V.  Lamar,  pathologj-;  Dr.  A.  O.  Shaklee,  physiologv-;  Dr. 
Gustave  M.  Meyer,  chemistry.  Fellows — Dr.  M.  T.  Bur- 
rows, pathologj- ;  Dr.  Paul  F.  Clark,  bacteriology-. 

The  Medical  Society  of  the  County  of  New  York  will 

hold  a  stated  meeting  on  ^Monday,  April  26th,  at  8:15  p.  m., 
in  Hosack  Hall,  New  York  Academy  of  Medicine.  Tlie 
programme  will  consist  of  a  "symposium"  on  Military 
Medicine,  and  papers  will  be  read  by  Major  Jefferson  R. 
Kean,  U.  S.  Army,  Washington,  D.  C. ;  Captain  Charles  F. 
Stokes,  U.  S.  Navy,  Washington,  D.  C. ;  Lieutenant  Colonel 
William  G.  Le  Boutillier,  National  Guard,  New  York ;  Cap- 
tain Harlow  Brooks,  Seventh  Regiment  Infantry,  National 
Guard,  New  York ;  and  Dr.  Edmund  Price  Fowler,  Seventh 
Regiment  Infantry,  National  Guard,  New  York.  There 
will  be  a  general  discussion  which  will  be  participated  in 
by  prominent  members  of  the  medical  profession. 

Ambulance  Service  in  New  York. — T)he  bill  intro- 
duced by  Mr.  Hoey  providing  for  the  appointment  of  a 
Board  of  Ambulance  Service  for  New  York  City,  has  been 
passed  by  the  Assembly  and  handed  down  to  the  Senate. 
As  originally  drafted  the  bill  provided  that  the  board 
should  consist  of  the  Commissioner  of  Police,  the  Commis- 
sioner of  Charities,  and  the  president  of  the  board  of  trus- 
tees of  Bellevue  and  Allied  Hospitals,  with  the  Commis- 
sioner of  Police  at  the  head.  The  Senate  committee,  how- 
ever, will  amend  the  bill  to  provide  two  places  on  the  board 
to  be  filled  by  private  citizens  who  will  be  appointed  by  the 
maj'or.  Under  the  Hoey  bill  the  Board  of  Ambulance  Ser- 
vice will  be  given  general  control  over,  and  will  establish 
rules  and  regulations  governing  all  ambulance  service  in 
the  city  of  New  York,  except  such  as  shall  be  maintained 
by  the  Board  of  Health  for  contagious  and  infectious  dis- 
eases. 

The  Centennial  of  McDowell's  Operation  was  cele- 
brated at  the  thirty-fourth  annual  meeting  of  the  American 
Gynaecological  Society',  which  was  held  in  New  York  on 
Tuesday.  Wednesday,  and  Thursday,  April  20th.  21st,  and 
22d.  There  were  forty-six  papers  on  the  programme,  all 
by  well  known  specialists  in  gynaecology,  a  special  feature 
being  a  "symposium"  on  Caesarean  Section.  In  addition 
to  the  splendid  scientific  programme  presented,  ample  enter- 
tainment was  provided  for  the  visiting  members  and  their 
friends.  The  McDowell  Centennial  Banquet,  which  was 
given  at  the  Waldorf-Astoria  on  Thursday  evening  by  the 
New  York  and  Brooklyn  Fellows  of  the  society,  was  the 
special  event  in  the  commemoration  of  McDowell's  opera- 
tion. The  following  officers  were  elected  to  serve  for  the 
ensuing  year :  President,  Dr.  Edward  P.  Davis,  of  Phila- 
delphia ;  first  vice-president,  Dr.  S.  C.  Gordon,  of  Portland, 
Me. ;  second  vice-president.  Dr.  Edward  Reynolds,  of  Bos- 
ton; secretary.  Dr.  Le  Roy  Broun,  of  New  York;  treasurer. 
Dr.  J.  Wesley  Bovee.  of  Washington.  D.  C.  The  next 
meeting  of  the  society  will  be  held  in  Washington,  D.  C,  in 
May,  1910. 


862 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


Insanity  as  a  Defence  was  the  topic  discussed  at  the 
April  igth  meeting  of  the  ]\Iedical  Jurisprudence  Society 
of  Philadelphia.     Mr.  George  A.   Drovin,  of  the  Phila-  ■ 
delphia  Bar,  delivered  an  address  on  the  subject,  and  a 
general  discussion  followed. 

The  Fresh  Air  Excursions  to  Sea  Breeze  Hospital, 
Conej'  Island,  will  begin  on  May  igth.  Dr.  Edward  O. 
Park,  of  the  New  York  Foundling  Hospital,  has  been  ap- 
pointed attending  physician  to  the  fresh  air  department  of 
the  New  York  Association  for  Improving  the  Condition 
of  the  Poor,  and  he  will  examine  all  children  who  take  the 
trips  to  Sea  Breeze  this  summer,  to  guard  against  the 
spread  of  contagious  diseases. 

The  Pennsylvania  Society  for  the  Prevention  of 
Tuberculosis  elected  the  following  directors  at  the  an- 
nual meeting  held  on  April  14th :  Dr.  H.  S.  Anders,  Dr. 
F.  A.  Craig,  Dr.  J.  Clinton  Foltz,  Dr.  A.  P.  Francine,  Dr. 
C.  Lincoln  Furbush,  Dr.  C.  H.  Miner,  Mr.  R.  L.  Mont- 
gomery, Mr.  L.  J.  Palmer,  Dr.  W.  D.  Robinson,  Mr.  Sam- 
uel Scoville,  Jr.,  Dr.  William  C.  White.  Dr.  T.  Melor 
Tyson,  Dr.  J.  Willoughby  Irwin,  Dr.  H.  D.  Jump,  and  Dr. 
J.  G.  Taylor. 

The  Health  of  Pittsburgh. — During  the  week  ending 
April  10,  1909.  the  following  cases  of  transmissible  diseases 
were  reported  to  the  Bureau  of  Health :  Chickenpox,  8 
cases,  o  deaths ;  typhoid  fever,  10  cases,  4  deaths :  scarlet 
fever.  15  cases,  3  deaths;  diphtheria.  2  cases,  o  deaths; 
measles,  14  cases,  2  deaths ;  whooping  cough.  35  cases,  i 
death ;  pulmonary  tuberculosis,  52  cases.  8  deaths.  The 
total  deaths  for  the  week  numbered  160,  in  an  estimated 
population  of  565.000,  corresponding  to  an  annual  death 
rate  of  14.72  in  a  thousand  population. 

Officers  of  the  Alumni  Association  of  the  University 
of  Pennsylvania. — .\t  a  meeting  of  the  association  held 
last  week,  the  following  officers  were  elected:  President, 
Dr.  Richard  C.  Norris ;  honorary  vice-president.  Mr. 
Charles  C.  Harrison  ;  vice-presidents.  Dr.  George  C.  Stout, 
Dr.  Lewis  H.  Adler,  and  Dr.  Clarence  P.  Franklin ;  re- 
cording secretary.  Dr.  William  S.  Wray ;  corresponding 
secretary.  Dr.  B.  Franklin  Stahl ;  treasurer.  Dr.  Herbert  B. 
Carpenter ;  executive  committee.  Dr.  George  D.  Morton, 
Dr.  George  P.  Miller,  Dr.  William  McKeage,  and  Dr.  ^ohn 
J.  Gilbride. 

Practitioner's  Week  at  the  New  York  Homoeopathic 
Medical  College. — The  faculty  of  the  New  York  Homoe- 
opathic Medical  College  and  Flower  Hospital  have  decided 
to  devote  the  week  beginning  ]\L-iy  loth  to  a  practitioner's 
course  in  medicine  and  surgery,  to  which  all  homoeopathic 
physicians  are  invited.  The  course  will  be  given  gratui- 
tously, and  four  hours  each  day  will  be  devoted  to  the  dem- 
onstration of  the  latest  methods  of  medical  diagnosis  and 
surgical  technique.  The  regular  alumni  day  exercises  will 
be  held  on  Thursday,  and  the  programme  provided  includes 
lectures  and  clinics.  Dr.  Royal  S.  Copeland  is  dean  and  Dr. 
J.  W.  Dow  ling  is  secretarv  of  the  faculty-. 

The  Site  for  the  Long  Island  State  Hospital.~The 
discussion  of  the  bill  appropriating  money  for  the  purchase 
of  the  Greenvalc  site  for  the  Long  Island  State  Hospital  for 
the  Insane  brought  out  so  many  protests  against  the  es- 
tablishment of  the  institution  at  that  place  that  the  bill 
has  been  laid  aside.  Dr.  .Mbert  Warren  Ferris,  president 
of  the  State  Commission  in  Lunacy,  is  reported  to  have 
said  that  if  a  situation  as  advantageous  as  the  Greenvale 
site  could  he  found,  and  if  the  State  could  be  indemnified 
for  the  ten  per  cent,  of  the  purchase  money  which  had  been 
paid  to  bind  the  option  on  the  latter,  the  establishment  of 
the  asylum  at  Greenvale  might  be  averted.  The  Greenvale 
site  had  been  selected  at  the  solicitation  of  the  Board  of 
Managers  of  the  hnsnital. 

An  Association  of  Tuberculosis  Clinics  in  Brooklyn. 
— Steps  arc  being  taken  in  Brooklyn  toward  getting  the 
tuberculosis  situation  in  that  borough  under  control.  .A. 
permanent  organization  of  tuberculosis  clinics  has  been 
formed,  w  ith  the  following  officers :  President.  Dr.  John 
Raker;  vice-president,  Dr.  E.  H.  Stoiiey;  secretary.  Mr. 
James  Jenkins,  of  the  Department  of  Charities.  .-Kccording 
to  the  plans  of  the  organizers,  the  borough  will  be  divided 
into  districts,  in  which  will  be  special  clinics  and  dispen- 
saries for  tuberculosis  patients,  with  trained  nurses  to  visit 
each  case  reported.  A  systematic  campaign  is  being 
planned,  nnd  the  greatest  good  is  expected  to  come  from 
the  csi.nblishmenl  of  the  .Association  of  Tuberculosis  Clin- 
ics, which  will  work  in  cooperation  with  the  Department 
of  Health. 


The  Mortality  of  San  Francisco. — During  the  month 
of  February,  1909,  there  were  reported  to  the  City  and 
County  of  San  Francisco,  Cal.,  531  deaths  from  all  causes, 
339  males  and  IQ-  females,  in  an  estimated  population  of 
475,000,  corresponding  to  an  annual  death  rate  of  11.38. 
There  were  36  still  births,  23  males  and  13  females.  The 
principal  causes  of  death  were :  General  diseases,  143 
deaths;  diseases  of  thq  nervous  system,  46  deaths;  dis- 
eases of  the  circulatory  system,  92  deaths ;  diseases  of  th-j 
respiratory  system,  59  deaths;  diseases  of  the  digestive 
system,  37  deaths ;  dis';ases  of  the  genitourinary  system,  50 
deaths :  childbirth,  6  deaths ;  diseases  of  the  skin,  i  death ; 
malformations,  i  death;  early  infancy,  29  deaths;  old  age, 
16  deaths;  violence,  51  deaths,  of  which  20  were  suicides. 
Infectious  Diseases  in  New  York: 

U'c  arc  indcbicd  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  follozving  statement  of  new 
cases  and  deaths  reported  for  the  tivo  u'ceks  ending  April 
17,  1909: 

,  .\pril  10  V  ,  .\pril  17  , 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    683  196         601  201 

Diphtheria    309  49         316  41 

Measles    953  32       1.224  45 

Scarlet  fever    353  23         379  23 

Smallpox   

Varicella    119  ..  [47 

Typhoid  fever    15  ..  17  3 

Whooping  cough    42  6  63  8 

Cerebrospinal  meningitis    8  8  11  10 

Total   2,482         314       2.758  331 

Janeway  Hall  Opened  at  the  City  Hospital. — The 

new  four  story  building,  which  will  be  the  home  of  the 
physicians  connected  with  the  City  Hospital  on  Blackwell's 
Island,  was  formally  opened  on  April  15th.  The  building, 
which  was  named  in  honor  of  Dr.  Edward  G.  Janeway,  has 
accommodations  for  twenty-six  doctors,  is  equipped  with  a 
library,  a  staff  room,  and  a  large  dining  room,  and  is  con- 
sidered one  of  the  finest  staff  iiouses  of  any  hospital  in  the 
city.  It  is  75  X  35  feet  and  cost  $75,000.  \  tablet  in  front 
of  the  building  bears  the  following  inscription:  "Named  to 
commemorate  the  distinguished  public  service,  particularly 
to  the  City  Hospital,  of  Dr.  Edward  G.  Janeway,  and  his 
achie\ement  in  promoting  the  establishment  in  .\merica  of 
the  scientific  practice  of  medicine  based  on  objective  patho- 
logical experiments.'' 

State  Care  of  Inebriates. — In  connection  with  the 
plans  for  more  adequate  treatment  of  public  intoxication 
and  inebriety  in  New  York  City,  now  pending  before  the 
State  Legislature,  it  is  interesting  to  note  that  a  bill  has 
pa-sed  the  State  Legislature  of  Pennsylvania  providing  for 
a  State  hospital  for  the  treatment  of  the  habitual  drunkard. 
The  plan  now  before  the  State  Legislature  at  .\lbany  con- 
templates such  an  institution,  together  with  additional  fea- 
tures which  provide  for  more  extended  probation  work  in 
connection  with  habitual  drunkenness.  The  problem  is  one 
for  both  social  and  medical  experts  and  both  of  these  agree 
that  an  institution  in  which  the  habitual  drunkard  can  be 
surrounded  with  an  abundance  of  light,  air.  and  outdoor 
work,  and  where  he  can  be  kept  from  alcoholic  liquors  for 
a  somewhat  extended  period  of  time,  offers  the  only  nos- 
sible  means  of  reformation  for  this  class  of  persons.  The 
.\gnew-Bates  bill  providing  these  features  is  receiving  the 
imanimous  support  of  authorities  dealing  with  this  prob- 
lem both  in  New  York  City  and  throughout  the  Stnte. 

Medical  Internes  wanted  in  the  Government  Hosnital 
for  the  Insane. — The  United  States  Civil  Service  f^om- 
mission  announces  that  an  examination  w-ill  be  held  on 
June  16th  to  secure  eligibles  from  which  to  make  certifica- 
tion to  fill  at  least  two  vacancies  in  the  position  of  medical 
interne  (male')  in  the  Government  Hosnital  for  the  Insane, 
Washington.  D.  C.,  at  $600  a  vear.  with  maintenance,  and 
vacancies  requiring  similar  qualifications  as  they  may  occur 
at  the  hospital.  From  the  grade  of  medical  interne  the 
hospital  makes  promotions  to  the  next  higher  positions  in 
the  medical  staff  as  vacancies  occur.-  .\s  considerable  diffi- 
culty has  been  experienced  in  filling  vacancies  in  the  posi- 
tion of  medical  interne  in  the  hosnital  service  during  the 
past  several  years,  owing  to  th'-  limited  number  of  eligibles 
available,  aualified  persons  are  urged  to  enter  this  examina- 
tion. .Applicants  nmst  be  citizens  of  the  I'nitC'I  States, 
must  be  graduated  from  a  reputable  medical  college  not 
more  than  two  vears  prior  to  date  of  examination,  must  be 
twenty  vears  of  age,  or  over  and  unni.Trricd.  .Application 
should  be  made  at  once  to  the  Ignited  .Sfate«  Civil  Service 
Commission.  Washineton.  D.  C.  for  application  Form  1312. 


-April  24,  1909.] 


XEIVS  ITEMS. 


863 


The  Mortality  of  Chicago. — During  the  week  ending 
April  10,  1909.  the  total  number  of  deaths  from  all  causes 
reported  to  the  Departemnt  of  Health  was  667,  as  com- 
pared with  699  for  the  preceding  week  and  600  for  the 
corresponding  period  in  1908.  The  annual  death  rate  in  a 
thousand  population  was  15.60.  as  against  a  death  rate  of 
14.06  for  the  corresponding  week  last  year.  Of  the  total 
number  of  deaths  reported  143  were  from  pneumonia,  83 
from  tuberculosis.  77  from  heart  diseases,  48  from  Bright's 
disease,  46  from  diarrhoeal  diseases,  44  from  violence,  32 
from  cancer  and  20  from  nervous  diseases.  Other  impor- 
tant causes  of  death  were :  Diphtheria,  20  deaths ;  scarlet 
fever,  3  deaths ;  measles,  2  deaths ;  whooping  cough,  3 
deaths ;  influenza,  9  deaths ;  typhoid  fever.  8  deaths ;  apo- 
plexy, II  deaths:  all  other  causes.  118  deaths. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing April  10,  1909,  the  following  cases  of  transmissible 
diseases  were  reported  to  the  Bureau  of  Health  of  Phila- 
delphia :  Typhoid  fever.  29  cases,  3  deaths ;  scarlet  fever, 
70  cases,  3  deaths  :  chickenpox.  66  cases,  o  deaths ;  diph- 
theria, 74  cases,  16  deaths ;  cerebrospinal  meningitis,  i  case, 
I  death ;  measles,  173  cases,  19  deaths ;  whooping  cough, 
17  cases.  4  deaths :  tuberculosis  of  the  lungs,  125  cases, 
64  deaths ;  pneumonia,  52  cases,  75  deaths ;  erysipelas,  16 
■cases,  3  deaths ;  mumps,  31  cases,  o  deaths.  The  following 
deaths  were  reported  from  other  transmissible  diseases : 
Tuberculosis,  other  than  tuberculosis  of  the  lungs.  6 
deaths :  diarrhoea  and  enteritis,  under  two  years  of  age, 
23  deaths :  puerperal  fever.  4  deaths.  The  total  deaths 
numbered  553,  in  an  estimated  population  of  1,565.569,  cor- 
responding to  an  annual  death  rate  of  18.37  in  a  thousand 
population.  The  total  infant  mortality  was  118  :  91  under 
one  year  of  age.  and  27  between  one  and  two  years  of  age. 
There  were  41  still  births;  17  males  and  24  females.  There 
was  only  a  trace  of  precipitation. 

International  Congress  on  Alcoholism. — The  twelfth 
international  congress  for  the  study  of  alcohol  and  its  in- 
fluence on  the  public  health  will  be  held  in  London,  from 
July  iSth  to  24th.  in  the  Imperial  Institute.  This  congress, 
which  consisted  originally  of  a  few  philanthropists  and 
reformers  who  met  occasionally  to  discuss  the  moral  side 
of  the  alcohol  question,  has  now  become  a  scientific  gather- 
ing of  medical  men.  teachers,  and  statesmen,  under  official 
direction.  Two  years  ago  the  congress  was  held  under  the 
direction  of  the  Swedish  Government,  and  this  year  the 
English  Government  has  undertaken  the  official  direction  of 
the  congress.  The  Duke  of  Connaught.  brother  of  King 
Edward,  who  is  honorary  president,  will  preside.  Invita- 
tions have  been  sent  to  all  the  Governments  of  Europe  and 
America  to  send  delegates  to  the  meeting.  The  con- 
gress has  been  divided  into  five  sections,  and  many 
eminent  men  will  take  part  in  the  proceedings,  either  read 
ing  papers  or  taking  part  in  the  discussions.  Dr.  T.  D. 
Crothers.  of  Hartford.  Conn.,  who  is  an  honorary  vice 
president  of  the  congress,  will  be  glad  to  furnish  informa- 
tion to  any  one  interested  in  the  forthcoming  meeting. 

The  National  Association  for  the  Study  and  Preven- 
tion of  Tuberculosis. — The  preliminary  programme  of 
the  fifth  annual  meeting  of  this  association,  which  will  be 
lield  in  Washington.  D.  C,  on  May  13th.  14th.  and  15th. 
has  just  been  issued.  .\11  the  sessions  will  be  held  in  the 
Xew  Willard  Hotel.  The  general  programme  is  as  follows  : 
On  Thursday,  May  13th.  at  11.30  a.  m.,  there  will  be  a 
general  meeting,  at  which  an  address  will  be  delivered  by 
the  vice-president.  Mr.  Homer  Folks,  of  Xew  York,  and 
general  routine  business  transacted :  at  2  p.  m..  there  will 
he  a  meeting  of  the  Surgical  Section:  at  4  p.  m.,  a  meeting 
of  the  Clinical  Section  :  and  at  8  p.  m.,  a  meeting  of  the 
advisory  council.  On  Fridav.  May  14th,  at  9.30  a.  m..  the 
Section  in  Tuberculosis  in  Children  will  meet:  at  11  a.  m.. 
there  will  be  a  meeting  of  the  Pathological  Section :  at 
12.30  p.  m.,  there  will  be  a  business  meeting:  at  2.30  p.  m.. 
the  Sociological  Section  will  meet,  and  the  Clinical  Section 
will  meet  at  4  p.  m.  Two  sessions  will  be  held  on  Satur- 
day. May  i;th.  one  of  the  Sociological  Section,  at  9.30  a.  m., 
and  the  other  at  11.30  a.  m..  of  the  Pathological  Section. 
An  excellent  programme  of  papers  has  been  provided,  and 
the  meeting  promises  to  be  one  of  special  interest.  The 
officers  of  the  association  are:  President,  Dr.  Vincent  Y. 
Bowditch :  honorary-  vice-presidents,  Ex-President  Roose- 
velt and  Dr.  William  Osier:  vice-presidents.  Mr.  Homer 
Folks  and  Dr.  Charles  L.  Minor:  treasurer.  General  George 
M.  Sternberg;  secretary.  Dr.  Henn,-  Barton  Jacobs,  11 
Mount  Vernon  Place,  Baltimore,  Md. 


The  Springfield,  Mass.,  Academy  of  Medicine  held  its 
third  annual  meetmg  recently  and  elected  the  following 
officers :  President,  Dr.  Cobb ;  first  vice-president,  Dr.  Rob- 
erts ;  second  vice-president.  Dr.  Seelye ;  secretary,  Dr.  But- 
ler ;  treasurer.  Dr.  Martin ;  censor,  Dr.  Cummings ;  director 
for  five  years,  in  place  of  Dr.  Cobb,  Dr.  W.  A.  Smith. 
About  fifty  members  were  present  at  the  meeting,  and  the 
question  of  providing  certified  milk  for  Springfield  was 
discussed.  Professor  James  O.  Jordan,  of  Boston,  read  a 
paper  entitled  The  Organization  of  a  Municipal  yh\k  Com- 
mission, in  which  he  urged  upon  the  physicians  present  the 
duty  of  educating  public  opinion  in  favor  of  the  certified 
milk  commission. 

Tuberculosis  Legislation  in  Puerto  Rico. — The  Legis- 
lative Assembly  of  Puerto  Rico  recently  passed  three  laws 
relating  to  the  prevention  of  the  spread  of  tuberculosis  in 
the  island,  and  the  care  and  treatment  of  tuberculosis  pa- 
tients. One  of  the  laws  provided  for  an  appropriation  of 
$22,800,  which  is  to  be  expended  under  the  direction  of 
the  departments  of  health,  charities  and  corrections ;  $13,800 
to  be  devoted  to  the  treatment  of  indigent  cases,  and  the 
remaining  $9,000  to  be  used  for  the  establishment  and 
maintenance  of  seven  State  tuberculosis  dispensaries  in  the 
largest  cities  in  the  island.  The  second  act  provides  for  the 
establishment  of  a  tropical  and  transmissible  disease  service, 
which  bureau  is  to  conduct  an  educational  campaign  against 
communicable  diseases,  particularly  tuberculosis  and  unci- 
nariasis (tropical  anamiaj.  By  the  third  act  the  commis- 
sioner of  education  is  instructed  to  provide  material  for 
teaching  in  the  public  school  the  best  means  of  preventing 
tuberculosis  and  uncinariasis. 

Personal. — Dr.  William  A.  Evans,  health  commis- 
sioner of  Chicago,  has  been  appointed  the  first  director  of 
the  new  municipal  tuberculosis  sanatorium. 

Dr.  William  Osier,  regius  professor  of  medicine  at  Ox- 
ford L'niversity.  sailed  for  the  United  States  on  April  14th, 
to  be  present  at  the  dedication  of  the  new  library  building 
of  the  Medical  and  Chirurgical  Faculty  of  Maryland.  Balti- 
more, which  will  take  place  on  May  13th. 

Dr.  B.  Grady  has  been  appointed  superintendent  of 
Grady  Hospital,  Atlanta,  Ga. 

Dr.  G.  P.  Barth  has  been  appointed  school  physician  of 
Milwaukee,  Wis. 

Dr.  William  Jones,  the  well  known  anthropologist,  who 
had  been  conducting  scientific  research  in  the  Philippines 
for  the  past  few  years,  was  murdered  by  the  Filipinos  re- 
cently. Dr.  Jones  was  sent  out  by  the  Field  Museum  of 
Xatural  Historj-  of  Chicago. 

Dr.  Rufus  I.  Cole,  associate  professor  of  medicine  in  the 
Johns  Hopkins  Medical  School,  has  been  appointed  di- 
rector of  the  new  hospital  to  be  established  in  connection 
with  the  Rockefeller  Institute  in  Xew  York. 

Gifts  and  Bequests  to  Charitable  Institutions. — By  the 
will  of  Anna  G.  Ludlow,  of  Richmond.  \'a..  the  Oswego, 
X.  Y.,  Hospital  receives  Si. 000. 

By  the  will  of  Xancy  Harding  Fosdick,  who  died  recently 
in  Brookline.  Mass.,  the  entire  estate  is  left  to  her  sister, 
.A.nn  Maria  Fosdick.  for  life,  after  which  public  and  chari- 
table institutions  are  to  receive  bequests  as  follows :  $3,000 
each  to  the  Old  Ladies'  Home  at  Charlestown,  Children's 
Home  at  Charlestown,  Cullis  Home  for  Consumptives,  Old 
Couples'  Home  at  Roxbury,  Salvation  Army  Fresh  Air 
Fund,  and  the  Floating  Hospital,  and  $5,000  each  to  the 
Boston  Dispensary,  Perkins  Kindergarten  for  the  Blind  at 
Jamaica  Plain,  and  the  Perkins  Blind  Asylum  at  South 
Boston. 

The  Children's  Free  Hospital.  Milwaukee,  Wis.,  recently 
received,  from  Mr.  Daniel  W.  X'orris,  a  gift  of  $4,000  to  be 
used  for  the  erection  of  a  detention  ward  and  a  gymnasium 
at  the  hospital. 

Wesley  Hospital.  Chicago,  has  been  offered  a  gift  of 
$55,000  by  'Mr.  William  Deering.  on  condition  that  a  similar 
sum  is  raised  by  the  board  of  directors  of  the  hospital, 
the  entire  Si  10.000  to  be  used  in  completing  the  building  in 
accordance  with  the  original  plans. 

By  the  will  of  Mr.  Frank  W.  Hoyt,  Philadelphia  char- 
ities become  conditional  legatees,  as  follows :  Samaritan 
Hospital,  $10,000;  Children's  Hospital,  $5,000 ;  Homceopathic 
Hospital,  $5,000;  Free  Hospital  for  Poor  Consumptives, 
$5,000. 

^liss  Alice  Seward,  of  X^ew  York,  has  given  to  the 
Geneva,  X'.  Y..  Hospital  the  sum  of  $5,000,  to  be  used  to 
endow  a  bed  in  the  hospital,  in  memory  of  her  mother, 
Mrs.  Clarence  Seward. 


864 


PITH  OP  CURRENT  LITERATURE. 


[New 

ilEDICAL 


York 
Journal. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

.]/>;■)/  If,,  jgoij. 

1.  Some  Truths  about  Hydrotherapy,    By  Simon  B.xkuch. 

2.  The  Personal  IClcment  in  Prescribing  Hydrotherapy, 

By  Henry  C.  B.\ld\vin. 
V    The  Treatment  of  Filirinous  and  Serofibrinous  Pleuritis, 

By  Frederick  T.  Lord. 

4.  Xoma;  Seven  Cases;  Two  Recoveries;  Forty  Infected, 

By  L.  R.  G.  Crandon,  I^dwin  H.  Plac  e,  and  Wil- 
liam J.  Brown. 

5.  Tlie  Consumption  of  Alcohol  and  of  Other  Medicines 

at  the  Massachusetts  General  Hospital, 

By  Richard  C.  Cabot. 

6.  The  Therapeutic  Action  of  Rattlesnake  Venom  in  Pul- 

monary Consumption,  in  Acute  and  Chronic  Bron- 
chitis, Asthma,  etc.,  and  in  some  Well  Recognized 
Neuroses.    A  Prcliminarv  Paper, 

By  Thomas  J.  Mays. 

3.  Fibrinous  and  Serofibrinous  Pleuritis. — Lord 
has  collected  a  series  of  500  cases  with  sero- 
fibrinous effusion,  in  which  sudden  death  before 
tapping  occurred  in  three  patients.  Autopsy  showed 
the  cause  of  death  to  be  pulmonary  embolism  in 
two,  of  whom  one  had  a  double  effusion,  the  second 
a  large  unilateral  accumulation.  In  the  third  case, 
one  of  double  eft'usion.  no  other  cause  than  pulmon- 
ary oedema  was  found.  The  frequency  with  which 
effusions  may  be  complicated  by  venous  thrombosis 
is  suggested'by  the  occurrence  of  fatal  pulmonary 
infarction  in  five  of  fourteen  cases  coming  to  au- 
topsy in  this  series.  The  removal  of  fluid  and  the 
consequent  change  in  intrathoracic  pressure  may 
dislodge  a  thrombus  and  thus  cause  the  infarction. 
It  seems  reasonable  to  assume,  however,  that 
venous  stasis  is  in  part  responsible  for  venous 
thrombosis  and  also  for  sudden  death  in  the  numer- 
ous instances  in  which  autopsy  fails  to  disclose  defi- 
nite lesions,  and  it  may  thus  be  a  question  whether 
earlier  removal  would  not  have  been  life  saving. 
While  the  operation  of  thoracic  puncture  is  itself 
not  entirely  devoid  of  danger,  yet  it  seems  probable 
that  many  more  lives  are  sacrificed  by  hesitation 
and  delay.  In  si)ite  of  tlie  infrequency  of  acci- 
dents and  the  security  which  many  operators  feel 
from  large  series  of  successful  tappings,  the  un- 
fortunate experience  of  a  few  suggests  greater 
caution  in  the  selection  of  cases.  In  primary  and 
uncomplicated  pleurisy  with  effusion,  in  young 
subjects,  witli  symptoms  of  only  one,  two,  or  three 
weeks,  the  evacuation  of  fluid  which  flows  in  re- 
si)onse  to  sjight  negative  pressure  may  apparently 
be  safely  continued  until  the  first  moment  of  cough, 
])ain,  dyspncea,  pressure,  or  other  discomfort.  In 
cases  of  longer  duration,  however,  or  those  with 
complicating  cardiac,  pulmonary,  or  mediastinal 
disease,  and  in  patients  past  middle  life,  the  first 
operation  may  well  be  regarded  as  an  experiment, 
in  whicli,  to  be  sure,  unfortunate  accidents  are  ex- 
tremely uncommon  and  not  wholly  avoidable.  They 
are  less  likely  to  occur  if  only  a  small  amount  of 
fluid  is  slowly  witlidrawn  without  forcible  asi)ira- 
tion. 

4.  Noma. — Crandon.  Place,  and  lirowii  studied 
an  outbreak  of  noma  occurring  in  a  crowded  insti- 
tiUion.  .\n  epidemic  of  measles  liad  appeared  in 
a  ward  and  forty-six  children  showed  gangrenous 


stomatitis,  with  foul  lireath,  and  of  them  .six  showed 
definite  gangrene  of  the  lip  or  cheek.  The  authors 
conclude  that  noma  is  not  proved  to  be  a  contagious 
disease,  and  patients  need  not  be  isolated.  Any 
uncared  for  mouth,  particularly  in  a  sick  child,  and 
especially  after  measles,  may  contain  Bacillus  fusi- 
formis  and  Spiroclucta  gracilis.  In  such  a  mouth 
these  organisms  may  be  found  without  ulceration 
or  in  the  lesions  which  have  been  described  as 
stomatitis  gangrenosa,  \'incent's  angina,  and  noma. 
The  lesions,  in  other  words,  may  be  only  round  the 
roots  of  teeth,  on  tonsils  and  pillars,  on  inner  sides 
of  cheek,  in  nasal  fossae,  on  the  external  ear,  and 
about  the  genitals.  Any  of  these  conditions,  in- 
cluding the  extensive  gangrene  and  sloughing  of 
so  called  noma,  may  be  different  stages  of  the  same 
disease,  which  may  be.  therefore,  considered  as  not 
necessarily  a  specific  disease,  but  the  successful  in- 
gress of  mouth  bacteria  into  tissues  rendered  non- 
resistant  by  uncleanliness  and  preceding  disease. 

5.  The  Consumption  of  Alcohol  and  of  Other 
Medicines  in  the  Massachusettts  General  Hospi- 
tal.— Cabot  gives  interesting  data  referring  to  the 
consumption  of  alcohol  and  of  other  medicines  in 
the  Massachusetts  General  Hospital  during  the 
period  from  1898  to  1907.  In  1898  there  were 
5,005  patients,  in  1907,  5.966 ;  the  expenses  for  alco- 
holic beverages  in  1898  were,  ale  and  beer,  $759; 
wine  and  liquors,  $1,563;  total  $2,322.  In  1907, 
$203  and  $610,  total  $813.  For  medicine  the  ex- 
penses were  in  1898,  $8,424,  and  in  1907.  $5,492. 
The  cost  of  alcohol  for  each  patient  decreased  from 
$0.46  in  1898  to  $0.13  in  1907,  and  for  medicine 
from  $1.68  to  $0.92.  He  concludes  that  since  there 
has  been  no  fall  in  the  price  of  stimulants  or  medi- 
cine, the  diminished  expenditure  corresponds  to  a 
diminution  in  the  numl^er  of  doses  of  medicine  and 
stimulants,  and  indicates  a  rapid  and  striking 
cliange  of  view  among  the  members  of  the  staff'  of 
the  hospital,  especially  in  the  past  five  years,  when 
it  has  become  generally  known  that  alcohol  is  not  a 
stimulant  but  a  narcotic,  and  that  drugs  can  cure 
only  about  half  a  dozen  of  the  diseases  against 
which  we  are  contending.  There  has  been  during 
this  period  no  increase  in  the  proportion  of  surgical 
cases  among  the  whole  number  treated,  so  that  the 
decreased  use  of  medicines  and  alcoliolic  beverages 
lias  not  resulted  from  an  increased  resort  to  sur- 
gical remedies.  On  the  other  hand,  there  has  been 
a  great  increase  in  the  utilization  of  baths  (hydro- 
therapeutics),  of  massage,  of  mechanical  treatment, 
and  of  psychic  treatment,  all  of  which  accounts  no 
doubt  for  jiart  of  the  falling  off'  in  the  use  of  alco- 
hol and  drugs. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

.Ipril  ij.  iQog. 

1.  Sanitary  Protection  of  Tidal  Waters. 

By  Georce  a.  Soper. 

2.  The  Results  of  Drug  Treatment  in  Five  Hundred  Cases 

of  Delirium  Tremens,  By  S.  Walter  Ransom. 

T,.    Tuberculosis.  By  B.vrton  Lisle  Wright. 

4.    Medical  Education.     .A  Plea  for  the  Development  of 

Leaders.  By  Gr.>ham  Lusk. 

•,.    .\  Study  of  the  Blood  after  Splenectomy.  Following  a 

Stellate  Rupture  of  that  Organ. 

By  Jerome  Myers. 


April  24,  1909. J 


PITH  OF  CURRENT  LITERATURE. 


865 


6.  Complemental  Opposition,  By  C.  F.  Hoover. 

7.  Carcinomatous  Polyposis  of  the  Colon,  with  Report  01 

an  Interesting  Case. 
By  EnMuxD  A.  Babler,  H.  J.  Niebruegge  and  Carl  Fisch. 

8.  Paralytic  Ileus,  with  Report  of  Two  Cases  in  which  Op- 

eration and  Treatment  was  Successfully  Performed, 

By  C.  H.  :McKexxa. 
0.    The  Pollution  of  Streams  by  Distillery  Waste.  With 
Special  Reference  to  Leptomitus  Lacteus, 
By  .Marshall  Laxgdon  Price  and  \\'illl\m  Roval 

Stokes. 

I.  The  Discharge  of  Sewage  into  Tidal  Waters. 

— Soper  remarks  that  contrar\-  to  wliat  might  be  ex- 
pected, there  is  Httle  statistical  evidence  to  show  that 
a  large  amount  of  sickness  is  produced  by  polluted 
harbors.  Repeated  attempts  to  collect  such  evidence 
have  been  made,  btit  without  sticcess.  \\'hen  the 
river  Thames  at  London  was  giving  off  its  most 
abominable  stenches,  prior  to  the  constrtiction  of  the 
present  sewage  disposal  system,  the  vital  statistics  of 
the  city  showed  no  increase  in  the  prevalence  of  any 
disease  v>hich  the  sanitarians  of  that  day  could  as- 
cribe to  the  odors.  Inquiries  into  the  health  of 
wharfmen  and  boatmen  indicated  that  their  health 
was  not  visibly  affected.  \\'hen  the  river  Lift'ey 
was  being  described  as  the  most  abominable  nuisance 
in  Ireland,  efforts  were  made  to  ascertain  the 
amotint  ot  sickness  near  the  waterfront  of  Dublin, 
but  no  excess  of  illness  could  be  found.  ^luch  of 
the  argument  which  for  centuries  taught  that  epi- 
demic diseases  were  produced  by  vapors  arising 
from  ill  smelling  substances  has  been  shown  by  the 
cold  light  of  modern  science  to  have  been  founded 
on  imperfectlv  observed  facts.  Offensive  odors  may 
aggravate,  if  _not  predispose  to  infectious  disease, 
but  they  do  not  produce  them.  Failure  to  discover 
an  increase  in  specific  disease  does  not  prove  that 
liarm  is  not  done  to  public  health  by  the  existence 
of  insanitary  conditions.  The  methods  of  inquiry 
employed  in  such  investigations  are  too  crtide  to 
detect  the  whole  extent  of  the  injury  even  if  consid- 
erable harm  is  done.  Only  the  most  conspicuous 
evils,  such  as  cases  of  specific  intestinal  diseases,  are 
generally  accepted  as  indicating  the  extent  of  the 
consequences.  The  more  stibtile  eft'ects.  stich  as 
those  which  are  produced  by  insufficient  air.  food, 
sunlight,  exercise,  and  rest,  can  not  so  readily  be 
detected,  measured,  and  traced.  The  most  convinc- 
ing proof  of  a  connection  between  polluted  harbors 
and  specific  disease  lies  in  the  results  of  eating  shell 
fish.  There  have  been  more  than  enough  cases  of 
typhoid  fever  and  gastroenteritis  reliably  ascribed  to 
the  eating  of  oysters,  clams,  and  other  shell  fish  de- 
rived from  polluted  waters  to  show  the  danger  in 
this  direction.  Shell  fish  taken  from  sewage  polluted 
water  are  polluted  themselves.  The\'  are  likely  to 
cause  typhoid  fever  if  eaten  raw.  Cases  have  been 
known  to  arise  merely  from  handling  the  shells.  The 
total  amount  of  sickness  caused  by  impure  shell  fish 
is  not  even  approximately  known.  Only  some  of 
tlie  most  striking  and  most  obvious  cases  are  likely 
to  be  traced.  The  form  of  sanitary  jurisdiction 
which  should  be  exercised  over  a  tidal  harbor  must 
depend  on  the  local  circumstances.  Tn  America, 
where  there  is  no  central  liealth  authority,  the  pro- 
tection of  the  watercourses  is  left  to  the  care  of  the 
individual  States.    Some  States  require  that  all  plans 


for  sewerage,  as  well  as  sewage  purification,  shall  be 
passed  on  by  the  State  board  of  health  before  they 
are  carried  out.  American  harbors  are  protected, 
where  any  protection  exists,  chiefly  throtigh  works 
constructed  by  sanitary  atithorities,  such  as  sewerage 
commissions,  which  have  no  jurisdiction  over  the 
matters  of  pubhc  health.  The  need  and  nature  of 
such  work  are  often  determined  by  a  special  board 
of  commissioners.  The  preparatory  investigation 
now  being  made  to  determine  how  best  to  protect  the 
sanitary  condition  of  Xew  York  harbor  has  been 
placed  by  the  State  of  Xew  "^'ork  in  the  hands  of  a 
commission. 

2.  Delirium  Tremens. — Ranson  has  observed 
five  hundred  patients  with  delirium  tremens.  He 
remarks  that  in  incipient  cases  the  patients  respond 
readily  to  treatment  with  chloral,  ergot,  bromides, 
and  whiskey,  tlie  drtigs  being  mentioned  in  the 
order  of  their  valtie.  Delirious  patients  are  very 
resistant  to  treatment.  In  the  cases  studied  the 
administration  of  tlie  sedative  drtigs  increased  the 
mortality.  This  was  most  evident  when  scopola- 
mine was  used,  that  drug  increasing  the  mortality 
thirteen  per  cent.  These  unsatisfactory  results  with 
the  sedative  drugs  were  due  to  the  large  doses  used. 
Small  quantities,  for  example,  fifteen  to  thirty 
grains  of  chloral  in  twenty-four  hours,  may  be  giv- 
en with  good  results,  but  that  when  larger  quan- 
tities are  given  the  death  rate  increases  with  the 
amount  of  sedative  administered.  The  only  drug 
which  reduced  the  mortality  was  ergot:  By  its  use 
the  death  rate  was  decreased  21.6  per  cent.  W  hen 
whiskey  was  given  the  mortality  was  increased  1.8 
per  cent.  The  atithor  emphasizes  the  importance 
of  proper  methods  of  restraint,  frequent  adminis- 
tration of  liquids,  and  the  use  of  sedative  bath. 
Drugs  are  not  of  such  value  that  other  therapeutic 
measures  can  be  neglected. 

3.  Tuberculosis. — Wright  reports  his  results 
with  mercury  in  the  treatment  of  tuberculosis, 
which  drug  has  been  administered  in  gradually  in- 
creasing doses  until  the  therapeutic  limit  is  reached ; 
after  the  maximum  dose  is  established  it  is  then 
divided  by  two  and  the  injections  are  continued  on 
this  dose.  During  the  intervals  between  injections 
the  use  of  potassium  iodide  has  been  discontinued. 
This  procedure  has  increased  the  efficiency  of  the 
treatment  in  ,a  decided  manner.  The  author  be- 
lieves in  the  specific  nature  of  mercury  in  relation 
to  tuberculosis. 

5.  Blood  after  Splenectomy. — Meyers  has  ob- 
served a  boy  upon  whom  splenectomy  was  per- 
formed. The  subjective  eff'ect  of  the  operation  was 
nil,  the.  boy  is, as  lively  and  as  healthy  in  appear- 
ance as  any  other  boy  of  his  age.  Objectively  two 
interesting  results  were  shown  in  the  blood  exam- 
ination :  In  the  first  place  the  picture  of  the  red 
blood  corpuscles  which  showed  a  most  amazing 
variability,  while  their  haemoglobin  content  was 
normal  or  above  normal  and  the  microscopical  ap- 
pearance shov.ed  no  sign  of  even  a  moderate  anae- 
mia. In  the  next  place,  a  hyperh'mphocytosis  was 
recognized,  but  here,  in  the  face  of  an  ordinary  in- 
flammation, calling  forth  normally  a  polynticlear 
neutrophilic  hyperleucocytosis,  a  persistently  grow- 
ing hyperlymphocytosis  appeared. 


866  PiTH  OF  CURRENT  LITERATURE. 


MEDICAL  RECORD. 

April  17,  1909. 

1.  Freezing  as  a  Therapeutic  Measure;  Liquid  Air  and 

Carbonic  Acid  Snow, 

By  George  T.  Jackson  and  S.  Dana  Hubbard. 

2.  The  Early  Diagnosis  of  SyphiUs  and  the  Technique  of 

Examination  for  the  Spirochseta  Pallida, 

By  WiLLARD  J.  Stone. 

3.  Why  Mastoiditis  is  Sometimes  Misunderstood, 

By  Emil  Amberg. 

4.  Report  of  Two  Unusual  Cases  of  Appendicitis, 

By  Alexander  Nicoll. 

5.  Gonorrhoeal  Conditions  in  Women, 

By  Andrew  J.  Love. 

6.  Two  Interesting  Cases.    Extensive  Peritonitis ;  Perfo- 

ration of  the  Rectum.  By  James  H.  Stevens. 

I.  Freezing  as  a  Therapeutic  Measure. — Jack- 
son and  iliibbard  remark  that  freezing  is  used  for 
the  most  part  as  a  destructive  agent.  Dr.  White 
used  liqiiid  air  for  the  stimulation  of  ulcers,  and  for 
producing  anaesthesia  for  surgical  purposes.  For  the 
latter  purpo.se  it  acts  quicker  than  ethyl  chloride.  It 
is  .sufficient  to  produce  only  a  superficial  freezing. 
Some  have  used  this  an.Testhetic  action  to  quiet  the 
pain  of  zoster.  Here  the  cold  is  applied  to  the  spine. 
He  advocated  its  use  for  the  treatment  of  boils  and 
carbuncles,  and  applied  liquid  air  for  this  purpose 
m  the  form  of  a  spray  from  a  bottle  with  a  cork  per- 
forated to  let  tv/o  glass  tubes  pass  through.  When 
the  finger  was  placed  over  the  shorter  tube,  the  air 
came  in  a  fine  stream  of  spray  from  the  other  tube 
that  went  down  into  the  liquid.  In  this  way  the  air 
was  forced  into  the  openings  of  the  carbuncle  or 
boil,  and  the  surface  was  slightly  frozen.  As  many 
of  Dr.  White's  early  experiments  were  made  at  the 
\'anderbilt  Clinic,  and  as  freezing  in  one  form  or 
another  has  been  employed  there  ever  since,  it  is 
probable  that  the  experience  of  this  dispensary  has 
been  greater  than  that  of  any  other  clinic.  Unfor- 
tunately, only  very  incomplete  records  of  the  hun- 
dreds of  cases  treated  have  been  kept.  The  authors 
emphasize  certain  conclusions :  The  best  treatment 
for  lupus  erythematosus  is  freezing.  Every  case  of 
this  most  intractable  disease  has  been  cured  when 
the  patient  has  submitted  to  complete  treatment. 
The  disease  is  capricious,  and  recent  cases  often 
yield  to  other  remedies  and  disappear  without  a  scar. 
It  is  best  then  to  try  other  simpler  remedies  in  re- 
cent cases.  But  in  chronic  patches,  where  there  has 
been  more  or  less  deep  destruction  of  tissue,  freezing 
is  the  remedy  of  choice.  Of  course,  it  does  scar, 
but  the  scar  is  soft  and  pliable,  and  the  disease  is 
sure  to  scar  of  itself.  They  have  seen  many  patches 
heal  with  a  single  freezing.  In  this  disease  it  is  not 
neces.<;ary  to  freeze  deeply.  When  the  cone  is  dipped 
in  ether,  fifteen  seconds  is  usually  enough.  Pigmen- 
tary nrevi  are  easily  removed.  Hairy  n.nevi  also  must 
be  frozen  deeply,  using  firm  pressure  for  one  or  two 
minutes,  so  as  to  destroy  the  hair  follicles.  Though 
they  may  have  to  be  frozen  several  times,  at  last 
the  result  is  a  brilliant  one.  Epithcliomata  especially 
of  the  rodent  ulcer  type  are  more  rapidly  cured  by 
freezing  than  by  any  other  form  of  caustic,  and  with 
less  pain,  and  the  scar  is  of  the  best.  In  them  the 
pressure  must  be  firm,  and  the  time  of  freezing  from 
half  a  minute  to  a  minute  and  a  half,  depending  upon 
the  depth  of  the  ulcer  and  the  thickness  of  its  walls. 
Other  forms  of  the  disease  may  be  cured  by  it,  and 
in  inoperable  cases  it  should  always  be  tried.  Kera- 


[Nevv  York 
Medical  Journ.'VL^ 

tosis  senilis  is  readilv  removed  by  freezing.  Warts, 
papillomata,  tatoo  marks,  powder  stains,  hypertro- 
phied  scars,  keloid,  tuberculosis  verrucosa  cutis, 
chloasma,  and  scrofuloderma  have  all  yielded  to 
freezing.  The  authors  believe  that  Dr.  White's  ap- 
plication of  freezing  with  liquid  air  as  a  therapeutic 
agent  is  one  of  the  most  important  of  our  time. 

3.  Why  Mastoiditis  is  Sometimes  Misunder- 
stood.— Amberg  says  that  at  tiie  present  time  it 
is  impossible  to  reach  an  absolutely  certain  decision 
regarding  the  necessity  of  surgical  interference  in 
some  cases  of  affection  of  the  temporal  bone.  In 
most  cases  the  groups  of  symptoms,  and  in  many 
cases  the  presence  of  one  or  two  marked  symptoms, 
make  surgical  iiiterference  appear  imperative.  The 
danger  of  general  inhalation  anaesthesia  in  any  oper- 
ation, especially  in  persons  suffering  from  tuberculo- 
sis, should  not  be  forgotten.  The  employment  of 
local  anaesthesia  might  be  more  thoroughly  tested  in 
cases  in  which  the  general  anaesthesia  is  contrain- 
dicated.  The  temporal  bone  contains  numerous 
groups  of  cells  which  may  come  into  consideration 
in  an  affection  of  the  same,  and  therefore  the  term 
"temporitis"  may  be  a  better  name  than  "mastoid- 
itis," which  is  sometimes  misleading.  The  construc- 
tion of  the  temporal  bone  is  such  that  a  process  can 
go  on  in  the  depth  without  betraying  itself  by  very 
plain  symptoms ;  marked  symptoms  may  appear  sud- 
denly, and  in  some  instances,  they  pronounce  the 
death  sentence  of  the  patient. 

BRITISH  MEDICAL  JOURNAL. 

April  3,  1909. 

1.  Remarks  on  the  Treatment  of  Gastric  Ulcer  by  Imme- 

diate Feeding.  By  Edmund  I.  Spriggs. 

2.  The  Early  Diagnosis  and  Treatment  of  Cancer  of  the 

Stomach,  By  W.  Hale  White, 

3.  The  Early  Diagnosis  and  Treatment  of  Cancer  of  the 

Stomach.  By  B.  G.  A.  Movnihan. 

4.  On  the  Surgical  Treatment  of  Gastric  Ulcer,  Its  Com- 

plications and  Sequelae,  By  John  M.\rnoch. 

5.  Intussusception  containing  a  Sarcoma  of  the  Intestinal 

Wall ;  Enterectomy  ;  Recovery, 

By  C.  A.  Scott  Ridout  and  J.  Ford  Falser. 

6.  A  Note  upon  the  Embryological  and  Pathological  Sig- 

nificance of  Certain  Folds  in  the  Anal  Canal, 

By  J.  Bernard  Dawson. 

I.  Treatment  of  Gastric  Ulcer  by  Immediate 
Feeding. — Spriggs  speaks  of  the  Lenhartz  treat- 
ment of  gastric  ulcers.  Before  attempting  a  new 
method  it  is  necessary  to  ask  whether  the  old  is  un- 
satisfactory. There  is  no  doubt  that  the  recognized 
method  of  treatment  is  in  many  cases  extremely 
successful.  It  has.  however,  some  serious  disadvan- 
tages. In  the  first  place,  severe  cases  are  subjected 
to  a  considerable  period  of  starvation  or  semistarva- 
tion,  and  the  less  successful  the  treatment  is  the 
longer  is  the  starvation  period  extended.  The  rou- 
tine when  fully  carried  out  is  extremely  tedious.  The 
essential  features  of  Professor  Lenhartz's  treatment 
are:  (i)  Complete  rest  in  bed  for  four  weeks;  (2) 
feeding  the  patient  from  the  beginning  of  the  at- 
tack with  small  quantities  of  beaten  up  egg  and 
milk,  the  quantities  being  increased  daily:  (3)  the 
application  of  an  icebag  to  the  epigastrium  :  (4)  add- 
ing to  the  dietary  boiled  rice,  mince,  and  other  semi- 
solid and  solid  foods  after  the  first  week:  (5)  the 
administration  of  bismuth  and  iron  in  suitable  fonn. 
Of  these,  the  complete  rest  in  bed.  the  bismuth  and 
iron,  and  the  icebag  are  commonly  advised  by  phy- 


April  24,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


867 


sicians ;  but  the  plan  of  allowing  food  to  be  put  into 
the  ulcerated  stomach  at  the  beginning  of  treatment 
is  contrary  to  the  usual  practice.  The  method  is 
founded  on  the  view  that  acid  gastric  juice  delays 
the  healing  of  an  ulcer,  even  when  no  food  at  all 
is  given  by  the  mouth :  and  that  the  reparative  pro- 
cess cannot  proceed  satisfactorily  in  an  ill  nourished 
and  anjemic  person,  such  as  the  subject  of  this 
malady  commonly  is.  Experimental  researches  are 
quoted  in  support  of  each  of  these  propositions. 
Spriggs  based  his  paper  upon  thirty-five  cases 
treated  by  the  Lenhartz  method,  and  thirty-four 
treated  by  the  ordinary  methods.  He  concludes  that 
the  Lenhartz  method  of  treatment  is  not  more  dan- 
gerous than  treatment  by  nutrient  and  saline  enemata 
followed  by  a  graduated  milk  diet.  In  these  partic- 
ular cases  the  recurrence  of  haemorrhage  was  less 
frequent  and  there  were  no  deaths.  The  pain  suf- 
fered by  the  patient  in  the  course  of  treatment  is 
less  on  the  Lenhartz  diet.  The  diet  gives  far  more 
nourishment  than  can  be  introduced  into  the  body 
by  nutrient  enemata.  and  is.  therefore,  more  desir- 
able in  patients  who  have  frequently  been  for  a  long 
time  in  a  state  of  semistarvation,  or  have  suflFered 
a  loss  of  blood,  or  both.  In  cases  treated  by  this 
method  rectal  injections  may  be  entirely  avoided. 
This  is  an  advantage  in  a  hospital,  and  a  still  greater 
advantage  in  treating  patients  at  their  homes,  where 
rectal  injections  are  not  only  regarded  as  extremely 
unpleasant,  but  are  seldom  efficiently  administered. 

3.  Early  Diagnosis  and  Treatment  of  Cancer 
of  the  Stomach. — Moynihan  remarks  that  cases 
of  cancer  of  the  stomach  when  examined  in  regard 
to  their  previous  history  may  be  divided  into  three 
groups :  (a)  Cases,  generally  acute,  in  which  the 
symptoms  appear  suddenly  and  progress  rapidly : 
the  whole  history  may  be  confined  within  a  space  of 
four  to  nine  months,  (b)  Cases  in  which  there  is  a 
history  of  one  ancient  attack,  or  of  repeated  attacks, 
due  undoubtedly  to  the  presence  of  a  chronic  gastric 
ulcer,  (c)  Cases  in  which  there  is  no  previous  his- 
tory of  gastric  ulcer  :  in  some  of  them  a  condition  of 
'"ulcus  carcinomatosum"  may  be  found.  The  acute 
cases  are  not  seldom  ushered  in  by  an  attack  of 
severe  h?ematemesis,  with  or  without  meljena.  It 
is  possible  that  such  copious  bleeding  is  dependent 
upon  multiple  hieniorrhagic  erosions.  The  import- 
ance of  a  history  of  repeated  attacks  of  indigestion, 
alike  in  their  origin,  course,  and  termination,  cannot 
be  exaggerated.  Such  attacks  are  due  to  a  chronic 
gastric  ulcer,  which  at  last  becomes  malignant.  Can- 
cer of  the  stomach,  in  so  far  as  it  depends  upon  a 
chronic  ulcer  for  its  origin,  is  a  preventable  dis- 
order. It  is  probable  that  two  thirds  of  the  whole 
number  of  cases  may  be  so  classed.  The  final  attack 
is  distinguished  from  former  attacks  by  its  lingering 
character,  its  rebellion  against  the  treatment,  dietetic 
and  medicinal,  which  has  proved  helpful  before,  but 
chiefly  by  the  presence  of  a  profound  distaste  for 
food,  anremia.  and  a  progressive  loss  of  weight.  The 
chemical  examination  of  stomach  contents  is  of  little 
or  no  value  in  so  far  as  early  diagnosis  of  carcinoma 
of  the  stomach  is  concerned.  In  the  later  cases, 
when  a  possible  diagnosis  of  malignancy  is  made  on 
the  clinical  evidence,  the  results  of  repeated  chemical 
analyses  of  the  stomach  contents  afford  additional 
evidence  of  considerable  value.    Surgical  treatment 


should  be  advised  in  all  cases  of  stomach  disorder 
where  there  is  obstruction,  stasis,  or  tumor,  and  in 
all  cases  of  chronic  ulcer ;  in  this  way  early  cases 
of  carcinoma  will  be  found,  and  radical  treatment 
will  be  possible.  There  are  no  symptoms,  and  there 
are  no  signs  which,  individually  or  collectively,  per- 
mit of  an  assured  diagnosis  of  cancer  of  the  stomach 
in  an  early  stage.  In  cases  where  there  is  grave 
suspicion  an  exploratory  operation  should  be  ad- 
vised. Such  operations  should  be  practised  to  ena- 
ble a  diagnosis  to  be  made  in  an  early  stage,  not  to 
confirm  an  almost  certain  diagnosis  in  a  hopeless 
stage. 

LANCET. 
April  3,  1909. 

1.  Some  Disorders  of  the  Cerebral  Circulation  and  Their 

Clinical  Manifestations  (Goulstonian  Lecture), 

By  Alfred  E.  Rl'SSExl. 

2.  Modern  ^lethods  of  Treatment  of  Some  Common  Skin 

Diseases,  By  J.  L.  Buxch. 

3.  A  Preliminary-  Note  on  the  Clinical  \"alue  of  the  Anti- 

tryptic  Index  of  the  Blood  in  Tuberculosis. 

By  F.  L.  GoLL.A. 

4.  Spontaneous  Cure  of  Thoracic  Aneurysm. 

By  Sir  Thomas  Oliver. 

5.  A  Case  of  Amputation  through  the  Hip  Joint  in  \Miich 

the  Haemorrhage  was  controlled  by  Intraperitoneal 
Compression  of  the  Common  Iliac  Artery. 

By  E.  \V.  RouGHTON. 

6.  The  Use  of  Intraperitoneal  Compression  of  the  Com- 

mon Iliac  Artery  during  Amputation  through  the 
Hip  Joint.  By  T.  P.  Legg. 

7.  Notes  on  a  Case  of  Pemphigus  in  a  Xonogenarian ;  Re- 

covery, By  J.\MEs  Grev  Glover. 

8.  Juxtaepiphyseal  Inflammation  of  the  Upper  End  of  the 

Humerus.  By  Arthur  F.  Messiter. 

9.  Graduated  Rest  in  the  Treatment  of  Pulmonary  Tuber- 

culosis, By  Edward  E.  Prest. 

I.  Some  Disorders  of  the  Cerebral  Circula- 
tion and  Their  Clinical  Manifestations. — Russell 
remarks  that  there  is  no  doubt  that  in  epilepsy  the 
vasomotor  system  is  unstable.  He  has  been  repeat- 
edly struck  by  the  pulse  irregularities  in  epileptic 
patients.  In  some  the  pulse  rate  is  very  consider- 
ably increased,  and  yet  on  other  less  frequent  occa- 
sions is  abnormally  slow.  Not  only  that,  but  the 
ptxlse  frequently  shows  wide  variations  in  the 
course  of  a  few  minutes.  In  two  patients  he  had 
seen  time  after  time  the  pulse  so  feeble  and  small 
that  they  might,  on  the  evidence  of  the  pulse  alone, 
have  been  in  a  state  of  severe  collapse.  The  volume 
and  pressure  also  vary  very  considerably.  The  rapid 
rise  in  blood  pressure  postulated  by  Hare  as  pre- 
ceding vagus  inhibition  in  the  epileptic  fit  might  be 
very  transient,  and.  unless  the  blood  pressure  was 
under  observation  at  the  moment  preceding  the  on- 
set of  the  fit,  wotild  be  most  difficult  of  demonstra- 
tion and  even  of  observation.  The  sensation  of 
chilliness  which  sometimes  precedes  a  fit  is  prestun- 
abl)'^  to  be  attributed  to  cutaneous  vasoconstriction. 
If.  however,  constriction  should  occur  in  other  re- 
gions— the  splanchnic  area,  for^  instance,  or  in  a 
large  muscular  area — the  result  would  be  the  same 
— viz..  either  a  compensating  vasodilatation  else- 
where or  of  necessity  a  rise  in  the  general  blood 
presstire.  If.  instead  of  the  heart  responding  to 
this  rise  in  blood  pressure  by  the  customary  in- 
creased force  of  beat,  its  vagus  mechanism  is  too 
sensitive,  or  its  protecting  depressor  nerve  mechan- 
ism at  fault,  the  result  might  be  cardiac  inhibition 
with  resulting  cessation  of  the  heart,  or  a  marked 


S6S  PITH  OF  CURRENT  LITERATURE. 


(.nfeeblement  short  of  actual  cessation,  followed  by 
unconsciousness,  and,  if  of  more  tiian  the  most 
transient  duration,  would  result  in  the  production 
of  convulsions — i.  e.,  .an  epileptic  fit.  It  is  unfor- 
tunate that  so  few  observations  of  these  vascular 
changes  in  epilepsy  are  on  record.  Unless  the  heart 
or  pulse  happens  to  be  under  examination  at  the 
moment  of  onset  of  a  fit  the  opportunity  does  not 
occur,  the  failure  of  the  circulation  is  very  transient 
and  the  muscular  spasms  render  any  examination 
of  the  heart  and  pulse  a  matter  of  great  difficulty. 
It  is  maintained  in  these  lectures  that  the  funda- 
mental factor  underlying  both  the  ordinary  faint 
and  the  epileptic  fit  is  cerebral  anaemia.  It  follows 
further  that  the  diiTerence  between  the  two  is  one 
of  degree  rather  than  of  kind.  We  have  some  clin- 
ical evidence  of  this  in  the  suddenness  of  some 
faints,  and  in  the  conversion  of  faints  into  fits.  The 
dif¥erence  our  author  thinks  to  be  due  to  the  differ- 
ence in  the  rate  of  development  of  the  cerebral 
ana;mia.  In  the  ordinary  faint  the  cerebral  circula- 
tion slowly  diminishes  pari  passu  with  the  falling- 
blood  pressure.  In  the  fit  there  is  a  sudden  cessation 
of  the  circulation.  Similarly  the  circulation  slowly 
improves  in  the  faint ;  in  the  fit  it  probably  returns 
with  greater  rapidity. 

4.  Spontaneous  Cure  of  Thoracic  Aneurysm. 
— ( )liver  reports  such  a  case  and  remarks  that 
whatever  may  be  our  opinion  in  regard  to  the  grav- 
ity of  thoracic  aneurysm  it  is  within  the  experience 
of  physicians  that  patients  who  are  the  subjects  of 
this  affection  may  not  only  live  a  considerable  time 
after  their  malady  has  been  detected  but  that  even 
alarming  and  distressing  symptoms  may  tempo- 
rarily subside  or  even  entirely  disappear.  Death 
does  not  always  come  by  rupture  of  the  sac,  threat- 
ening at  times  as  this  may  seem.  Where  improve- 
ment has  taken  place  for  a  period  and  the  patient 
has  subsequently  succumbed  to  an  intercurrent  mal- 
ady, the  aneurysm  at  the  necropsy  is  frequently 
found  to  have  been  undergoing  a  process  of  cure. 
Nature's  method  of  accomplishing  this  being  the 
strengthening  of  the  walls  of  the  sac  by  the  internal 
deposition  of  layer  after  layer  of  clot  which  dimin- 
ishes the  shock  imparted  to  the  sac  by  each  systole 
of  the  left  ventricle.  While  such  a  deposition  of 
fibrin  occurs  in  aneurysms  situated  at  some  distance 
from  the  heart  and  occasionally  leads  to  sponta- 
neous cure,  it  is^  maintained  by  some  pathologists 
that  tlie  conditions  of  quietude,  lowered  arterial 
tension,  arirl  slowing  of  the  circulation,  which  are 
essential  to  the  formation  of  clot  within  an  aneurys- 
mal sac  are  almost  impossible  when  the  aneurysm 
is  near  the  heart ;  for  example,  on  the  ascending 
portion  of  the  arch  of  the  aorta.  Notwithstanding 
all  these  it  is  yet  a  fact  that  in  a  large  number  of 
cases  of  thoracic  aneurysm,  especially  of  the  saccu- 
lated type,  clot  is  found  in  the  interior,  indicating 
an  effort  on  the  p^t  of  Nature  to  establish  a  cnrc. 
The  presence  or  absence  of  coexisting  aortic  regur- 
gitation is  not  without  importance  in  regard  to  the 
dc])osition  of  fibrin  in  thoracic  aneurysm.  If  there 
is  aortic  incompetence  of  any  severitv  there  can 
liardlv  be  in  the  interior  of  a  thoracic  aneurysmal 
sac  the  same  favoral)lc  conditions  for  clotting  likely 
to  apiH-rtain  where  tliere  is  no  aortic  reflux,  for  in 
uncnmiilicatcd  cases  of  thoracic  aneurysm  the  left 
ventricle  of  the  heart  is  usually  not  hypertrophicd 


[New  York 
Medic.\l  Journal. 

to  any  extent,  if  at  all,  while  it  is  enlarged  in  aortic 
regurgitation.  The  fact  that  patients  occasionally 
live  for  several  years  after  their  thoracic  aneurysm 
has  been  detected  can  only  be  explained  by  the 
presence  of  the  firm  clot  in  the  interior  of  the  sac 
observed  after  death. 

9.  Graduated  Rest  in  the  Treatment  of  Pul- 
monary Tuberculosis.  —  forest  says  that  rest 
should  be  the  most  important  item  in  the  treatment 
of  pulmonary  tuberculosis.  If  rest  of  a  graduated 
kind  together  with  good  food,  are  the  chief  means 
we  possess  for  bringing  about  a  cure,  the  precise 
climate  in  which  a  sanatorium  is  erected  will  be  a 
matter  of  comparative  unimportance.  It  will,  how- 
ever, be  found  that  if  extensive  disease  has  been  al- 
lowed to  develop  or  a  patient  has  bronchitis  or  laryn- 
geal disease,  especially  if  a  mouth  breather,  that  is 
to  say,  where  the  lesions  speedily  come  into  contact 
with  freshly  indrawn  air,  that  wintering  abroad  in 
some  comparatively  mild  and  moist  climate  will 
greatly  benefit  the  condition,  and  by  allaying  the 
cough  may  promote  healing.  The  only  way  that 
such  a  climate  can  be  produced  in  England  on 
certain  winter  days  is  by  means  of  a  fire  which  does 
not  unduly  dry  the  air.  together,  if  necessary,  by 
preventing  too  large  an  entrance  of  the  outside 
atmosphere.  The  sending  of  phthisical  patients 
abroad  should  never  be  encouraged,  without  very 
careful  consideration,  and  when  one  hears  of  a  pa- 
tient going  to  Egypt  for  treatment,  one  is  scarcely 
surprised  to  hear  of  his  premature  death  in  South 
Africa  some  months  later.  Rest  at  home  should  be 
the  rule. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 
March  if,.  IQ09. 

1.  Venous  Anaesthesia,  By  August  Biek. 

2.  Hematoma  Vulv;e  as  a  Hindrance  to  Labor, 

By  W.  LiEPM.\N.\. 

3.  Early  Rising  after  Laparotomy.  By  C.  H.artog. 

4.  Treatment  of  Placenta  Prsevia.  By  G.  Binder. 

5.  Method  of  Action  of  Atoxyl.  By  W.  Rohl. 

6.  Some  Thoughts   Concerning  Bauer's   Modification  of 

Wassermann's  Reaction.  By  Carl  Ster.x. 

7.  lodomenin,  a  New  Preparation  of  Iodine  for  General 

Practice,  By  R.  Fried m.\nn. 

8.  Modern  Methods  of  Treatment  of  Gonorrhceal  Epididy- 

mitis, together  with  a  Personal  Experiment  with 
Treatment  by  Puncture  (Concluded),       By  Ernst. 

I.  Venous  Anaesthesia. — Bier  suggests  a  man- 
ner of  producing  dec])  local  anaesthesia  of  the  ex- 
tremities by  the  injection  of  a  0.5  per  cent,  solution 
of  novocain  into  the  veins.  The  novocain  is  dis- 
solved in  physiological  salt  solution,  and  is  injected 
by  means  of  a  specially  prepared  syringe.  .\  band 
is  placed  about  the  limb  above  the  field  of  opera- 
tion and  an  Esmarch  bandage  is  then  applied  from 
the  periphery  so  as  to  overfill  the  veins  and  make 
them  visible  through  the  skin.  It  is  recommended 
that  beginners  dissect  down  upon  the  vein  before 
they  attempt  to  make  the  injection.  The  anaesthesia 
l)roduced  by  the  novocain  between  the  two  band- 
ages is  immediate  and  direct,  while  an  indirect 
anaesthesia  appears  somewhat  later  below  the  Es- 
march bandage  in  the  bloodless  portion.  The  in- 
jection may  be  made  centrally  or  peripherally  to 
the  valves  in  the  veins,  but  he  prefers  as  a  rule  to 
make  it  peripherally,  particularly  as  the  central  in- 
jection does  not  seem  to  be  free  from  danger.  The 
largest  dose  for  an  adult  is  usually  80  c.c.  of  a 
0.5  per  cent,  solution,  but  100  c.c.  or  more  mav  be 


April  24,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


869 


given.  Smaller  doses  suffice  for  the  anaesthetization 
of  an  entire  limb.  Six  minutes  after  the  injection 
the  section  of  the  limb  below  the  lower  bandage  is 
completely  aniesthetic  and  after  another  minute 
there  is  motor  paralysis  and  loss  of  the  sense  of 
position,  and  the  limb  is  insensitive  to  any  required 
operation  from  the  upper  bandage  to  tiie  tips  of 
the  fingers  or  toes.  I  he  author  then  discusses  the 
relative  advantages  of  direct  and  indirect  anaes- 
thesia in  operations  on  the  thigh,  resection  of  the 
knee  joint,  and  in  operations  on  the  leg.  foot,  and 
arm.  He  then  considers  its  use  in  amputations, 
extirpation  of  varices,  and  operations  On  account  of 
serious  septic  diseases.  \'enous  anaesthesia  is  indi- 
cated only  in  cases  beyond  the  reach  of  the  usual 
methods  of  producing  local  anaesthesia,  i.  e.,  only  in 
cases  of  major  operations  on  the  extremities.  In 
such  cases  he  thinks  it  better  than  lumbar  and  pre- 
fers it  to  general  anaesthesia.  He  has  not  met  w  ith 
trouble,  except  in  cases  of  senile  and  diabetic  gan- 
grene, diseases  in  which  he  considers  the  method 
contraindicated,  but  would  not  recommend  it  in 
very  nervous  children.  The  results  reported  in  134 
cases  of  operations  of  various  kinds  are  good  in 
115.  satisfactory  in  fourteen,  unsatisfactory  in  five. 
In  these  five  cases  the  operations  had  to  be  finished 
under  ether. 

2.  Hasmatoma  Vulvae. — Liepmann  reports  four 
cases  in  which  a  hematoma  of  the  vulva  appeared 
during  the  early  stages  of  labor  and  formed  an 
obstacle  to  delivery.  The  child  was  delivered  with 
forceps  in  each  case.  The  causes  of  the  formation 
of  such  a  haematoma  he  considers  to  be  four:  i. 
The  venous  stasis  produced  by  the  long  continued 
pressure  of  an  advancing  large,  hard  skull ;  2. 
Faulty  collateral  circulation  for  the  removal  of  the 
engorged  blood ;  3.  The  greater  liability  of  periph- 
eral veins  to  laceration  and  therefore  the  place  of 
predilection  in  the  veins  of  the  labia  majora ;  4.  The 
loose,  little  resistent  position  of  the  veins  in  the 
subcutaneous  fatty  tissue  of  the  labia  majora.  He 
has  never  met  with  a  case  of  arterial  haemorrhage, 
but  one  such  case  has  been  reported.  If  the  obstet- 
rician is  present  when  the  accident  happens  the  child 
may  be  delivered  at  once  without  injury  to  the 
mother,  otherwise  forceps  must  be  used.  It  is  un- 
necessary to  incise  and  empty  the  haematoma.  The 
prognosis  is  good,  and  the  blood  will  become  ab- 
sorbed. 

3.  Early  Rising  after  Laparotomy. — Hartog 
does  not  believe  in  keeping  patients  upon  whom 
laparotomy  has  been  performed  several  weeks  in 
bed.  On  the  contrary  if  there  are  no  indications 
of  fever  he  is  inclined  to  let  them  get  up  after  a  few 
days,  dependent  greatly  on  the  patient's  own  desire. 
But  when  there  is  fever  the  patients  are  kept  in  bed. 
as  he  believes  that  early  rising  may  do  harm  in 
such  cases.  The  objections  usually  urged,  dangers 
of  secondary  haemorrhage,  breaking  open  of  the 
wound,  and  embolism,  he  considers  theoretical 
rather  than  practical. 

8.  Puncture  Treatment  of  Epididymitis. — 
Ernst  states  that  the  puncture  treatment  of  epididy- 
mitis is  to  be  strongly  recommended,  at  any  rate 
for  hospital  treatment.  It  acts  favorably  on  the 
fever,  quickly  removes  spontaneous  pain,  rapidly 
alleviates  the  tenderness,  and  in  most  of  his  cases 
shortened  the  course  of  healing. 


MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 
March  16.  i</og. 

I.  Paro.xysmal  Haemoglobinuria  and  Hsemolysis  in  \'itro. 

By  MoRo,  XoDA.  and  Bex.t.\min. 
_'.    The  Influence  of  Alcohol  upon  the  Hungry  Organism, 

By  KOCHMAXN. 

3.  The  Serum  Diagnosis  of  Syphilis,  By  BECKERb. 

4.  Bradycardia  and  the   Stokes-Adams   Symptom  Com- 

plex, By  Hlismaxxs. 

5.  The  Question  of  Acute  Dilatation  of  the  Heart  from 

Overexertion,  By  Raab. 

6.  An    Unrecognized    Form   of    Mechanically  Produced 

Amennorrhcca  and  its  Operative  Treatment, 

By  RiECK. 

7.  Experiences  in  the  Treatment  of  Diseases  of  the  Throat, 

Nose,  and  Ear  with  Pyocyanasis,      By  Trautmaxx. 

8.  An  Apparatus  for  the  Graphic  Determination  of  the 

Blood  Pressure.  By  Stursberg. 

9.  The  Alternating  Heart,  By  Galli. 

10.  Alternating  Mitral   Insufficiency   and  the  Alternating 

Heart,  By  Herixg. 

II.  Concernmg  the  Dosage  of  my  Polyvalent  Serum  in 

Both  General  and  Eye  Diseases,  • 

By  Deutschmaxx. 

ij.  The  Peristaltic  Function  of  the  Stomach  in  the  X  Ray 
Picture,  By  Grodel. 

13.  Reform  of  the  Rural  District  Health  Insurance. 

By  Jaks. 

1.  Paroxysmal  Haemoglobinuria  and  Haemo- 
lysis in  Vitro. — More.  Xoda.  and  Uenjamin  con- 
firm by  their  serological  investigations  the  findings 
of  Donath  and  Landsteiner  in  all  important  points. 
They  find  that  the  union  of  haemolytic  intermediate 
bodies  and  the  erythrocytes  produced  by  cold  is 
completely  broken  up  by  a  temperature  of  37°  C.  in 
a  water  bath  and  consider  that  the  rapid  disassocia- 
tion  of  the  intermediate  bodies  from  the  erythro- 
cvtes  bv  warmth  explains  the  relatively  transient 
intravascular  haemolysis  produced  by  cold  in  the  liv- 
ing:. Their  studies  of  .the  haemolvtic  intermediate 
bodies  in  the  serum  of  persons  with  haemoglobinuria 
and  of  Wassermann's  reaction  lead  them  to  the  con- 
clusion that  the  unknown  material  in  the  serum 
which  takes  part  in  the  syphilis  reaction  has  nothing 
to  do  with  the  haemolytic  intermediate  bodies  in  the 
serum.  One  experiment  gave  them  the  following 
facts.  While  the  serum  before  the  experiment  was 
poor  or  wanting  in  complement  its  complement  in- 
creased a  short  time,  fifteen  minutes,  after  a  cold 
bath,  but  this  was  demonstrable  for  only  a  few  min- 
utes, within  an  hour  the  serum  was  again  free  from 
complement.  The  consequence  was  that  a  moderate 
intravascular  haemolysis  caused  a  clear,  reddish 
staining  of  the  serum  which  was  demonstrable  for 
about  forty  minutes.  The  body  temperature  rose 
after  the  bath,  reached  its  maximum  in  about  two 
hours,  and  then  sank  again  to  normal. 

2.  Influence  of  Alcohol  upon  the  Hungry  Or- 
ganism.— Kochmann  finds  by  experiment  that  it 
is  possible  to  prolong  the  life  of  starving  rabbits  bv 
the  subcutaneous  injection  of  suitable  doses  of  alco- 
hol, that  larger  quantities  of  alcohol  hasten  the  death 
of  the  animals.  The  favorable  action  of  the  alcohol 
is  to  be  ascribed  in  part  to.  its  saving  eflfect  on  albu- 
min and  the  better  preservation  of  the  watery  con- 
stituents of  the  organism.  Another  part  of  the  fa- 
vorable action  is  due  to  the  fact  that  under  the  in- 
fluence of  alcohol  the  albuminous  constituents  of 
vital  organs  are  preserved  at  the  expense  of  other 
tissue  less  important  for  the  preservation  of  life. 
The  acceleration  of  death  under  the  influence  of 
larger  quantities  of  alcohol  is  to  be  explained  nat- 
urally by  the  increased  destruction  of  albumin.  The 


'8/0 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


metabolic  action  of  alcohol  in  starving  rabbits  is 
shown  in  the  behavior  of  the  body  weight.  A  diu- 
retic action  was  produced  only  by  the  administra- 
tion of  larger  quantities  of  alcohol,  smaller  quanti- 
ties had  an  opposite  effect.  From  these  results  he 
concludes  that  alcohol  in  suitable  doses,  which  ex- 
cludes toxic  action,  is  very  valuable  in  many  ways, 
both  in  the  treatment  of  ill  nourished  patients,  and 
from  a  military  point  of  view,  because  it  is  able  to 
prolong  life  in  the  entire  absence  of  food. 

6.  Mechanically  Produced  Amenorrhoea.  — 
Rieck  reports  two  cases  in  which  amenorrhoea  was 
due  to  pressure  upon  the  uterus,  in  one  case  by  a 
cyst,  in  the  other  by  a  haematosalpinx.  Removal  of 
these  obstructions  was  followed  by  regular  menstru- 
ation. 

7.  Pyocyanasis. — Trautmann  says  that  acute 
inflammations  of  the  nose  and  throat  and  acute 
purulent  inflammation  of  the  antrum  of  Highmore 
have  their  recovery  hastened  by  the  use  of  pyocya- 
nasis, while  in  chronic  inflammations,  especially  of 
the  middle  ear,  it  is  powerless. 

ARCHIVES  OF  P/£DIATRICS 

March,  igog. 

1.  Congenital  ^lalformations  of  the  QEsophagus, 

By  J.  P.  C.  Griffith  and  R.  S.  Lavenson. 

2.  Spasmodic  Stricture  of  the  GEsophagus, 

B\'  S.  S.  Ad.\ms. 

3.  Transmission  of  Tuberculosis  through  Family  Associa- 

tion, By  C.  Floyd  and  H.  I.  Bowditch. 

4.  Artificial  Feeding  of  Infants,  By  J.  Levy. 

5.  Leucocytes  in  Pulmonary  Diseases  of  Children, 

By  L  S.  Wile. 

6.  Abscess  of  Lung  due  to  Wire  Nail, 

By  F.  HuBER  and  H.  M.  Silver. 

7.  Pyelitis  terminating  in  Suppurative  Nephritis, 

By  J.  P.  West 

8.  Charts  of  Three  Cases  of  Pyelitis,     By  C.  G.  Kerley. 

9.  Miliary  Tuberculosis  diagnosticated  by  finding  Tubercle 

Bacilli  in  the  Blood.  By  A.  F.  Hess. 

10.  Case  of  Tuberculous  Meningitis, 

By  E.  M.  Buckingham. 

11.  Infiucnza  with  Unusual  Aspects,       By  J.  Hemenwav. 

I.  Congenital  Malformations  of  the  Oesopha- 
gus.— Griffith  and  Lavenson  classify  such  mal- 
formations as  follows:  i,  Total  absence  of  the  duct. 
2,  Partial  or  complete  doubling  of  the  duct.  3, 
Tracheooesaphageal  fistula  without  other  lesions  of 
the  duct.  4,  Stenosis.  5,  Congenital  dilatation. 
6.  Obliteration  of  the  oesophagus  in  only  a  portion 
of  its  extent,  unaccompanied  by  fistula.  7,  Obliter- 
ation of  a  portion  of  the  oesophagus  with  tracheo- 
oesophageal  or  bronchooesophageal  fistula.  The 
pathological  explanation  of  these  deformities  is  un- 
certain and  unsatisfactory.  The  symptoms  of  sten- 
osis in  infancy  are  similar  to  those  which  are  ob- 
served in  later  life,  the  same  being  true  of  dilata- 
tion. Death  usually  takes  place  in  the  first  week 
from  asthenia,  from  lack  of  food,  and  from  the 
drying  of  the  tissues  due  to  lack  of  water.  The 
treatment  is  discouraging,  all  cases  in  which  there  is 
complete  obstruction  have  died.  Gastrostomy  offers 
the  only  hope  and  that  a  feeble  one.  If  it  should 
avail  an  operation  to  repair  the  defect  may  be  tried 
later. 

3.  Transmission  of  Tuberculosis  through 
Family  Association. — Floyd  and  Bowditch  in 
their  investigations  at  the  clinic  of  the  Boston  Con- 


sumptives Hospital  found  that  the  effect  of  the  dis- 
ease on  the  mortality  of  early  years  is  greatest  dur- 
ing infancy,  decreasing  slowly  with  age.  The  influ- 
ence of  the  exanthemata  predisposes  to  the  disease. 
The  great  paths  of  infection  are  ingestion  and  in- 
halation, the  respiratory  tract  not  being  the  only 
vulnerable  point  of  attack.  The  early  detection  of 
intrathoracic  tuberculosis  in  the  infant  or  child  is 
often  very  difficult.  Surgical  tuberculosis  is  usually 
of  the  bovine  type  and  this  type  and  human  infec- 
tion do  not  often  occur  in  the  same  case.  Protective 
measures  which  are  recommended  are:  i.  Early 
notification  of  all  births.  2,  Better  inspection  and 
control  of  the  milk  supply.  3,  Systematic  school  in- 
spection. 4,  Housing  reform.  5,  Segregation  of 
advanced  cases.  6.  Required  notification  of  the  dis- 
ease. 7,  Provision  for  the  care  of  pulmonary  tuber- 
culosis in  children.  8,  Education  of  all  school  chil- 
dren on  matters  of  general  hygiene. 

4.  Artificial  Feeding  of  Infants. — Levy's  con- 
clusions are  the  following:  I,  Infants  should  not  re- 
ceive less  than  the  minimum  proteid  requirement. 
2,  Neither  should  the  maximum  caloric  requirement 
be  exceeded.  3,  Enough  fat  should  be  given  to  make 
up  the  necessary  calories,  but  seldoin  more  than  3 
per  cent.  4,  Most  of  the  disturbances  of  nutrition 
in  the  second  half  year  are  due  to  overfeeding.  5, 
Cow's  milk  should  be  modified  in  accordance  with 
the  proteid  and  caloric  requirements  of  the  infant's 
metabolism.  6,  To  find  the  minimum  percentage  of 
proteids  required  we  should  know  the  infant's 
weight  and  the  total  quantity  of  food  to  be  fed  in 
twenty-four  hours.  7,  To  find  the  percentage  of  fat 
required  we  first  determine  the  total  caloric  require- 
ments and  subtract  from  this  the  number  of  calories 
supplied  by  proteid  and  carbohydrate.  8,  By  this 
method  top  milks  are  rarely  indicated.  9,  A  method 
which  justifies  the  dilution  of  whole  milk  is  valuable 
because  adapted  to  home  modification. 

AMERICAN  JOURNAL  OF  OBSTETRICS. 
April,  1909. 

1.  Hernias  through  the  Pelvic  Floor,    By  C.  W.  Barrett. 

2.  Amputation  of  the  LTterus  in  the  Corpus  to  preserve  the 

Menstrual  Function,  By  H.  Kelly. 

3.  The  Origin  of  Certain  Types  of  Monsters, 

By  C.  R.  Stockari>. 

4.  A  Preliminary  Report  on  the  Use  of  Bacterial  Vaccines 

in  the  Treatment  of  Septic  Infections, 

By  F.  R.  Oastler. 

5.  Three  Rare  Surgical  Complications  of  Pregnancy, 

By  J.  F.  W.  Ross. 

6.  Endometritis,  By  J.  J.  Mundell. 

7.  Floating  Kidney  in  its  Relation  to  Pelvic  Disease, 

By  A.  H.  Ely. 

8.  Treatment  of  Movable  Kidney,  By  L.  G.  Baldwin. 
g.    Gangrene  of  a  Pedunculated  Subserous  Uterine  Myoma 

with  Twisted  Pedicle,  By  R.  T.  Gillmore. 

10.  Lesions  of  tlic  Cornea  in  Gonorrhoeal  Opthalmia  and 

Phlyctenular  Keratitis,  By  C.  W.  Cutter. 

11.  The  Importance  of  Dental  Orthopaedics  in  the  Normal 

Development  of  the  Child,  By  F.  A.  Gough. 

I.  Hernias  through  the  Pelvic  Floor. — Bar- 
rett desires  to  emphasize  the  following  points:  i. 
The  pelvic  floor  is  an  important  factor  in  abdominal 
support,  but  not  a  direct  support  to  the  uterus.  2, 
The  importance  of  the  levator  ani  as  a  means  of  sup- 
port has  been  abundantly  demonstrated.  3,  The  pel- 
vic  floor   support   is   weakened   by   the  passage 


April  24,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


871 


through  it  of  certain  canals  or  "faults."  4,  The 
vagina  sometimes  becomes  a  hernial  canal.  5,  Ten- 
dency to  the  latter  (4)  is  increased  by  traumatism 
and  by  congenital  defects.  6,  It  is  also  increased 
by  increased  intraabdominal  pressure,  by  a  displaced 
uterus,  and  by  a  vertical  vagina.  7,  Incipient  hernias 
should  be  treated  by  rest,  lessening  the  intraabdom- 
inal pressure,  reducing  fat,  curing  cough,  the  use 
of  knee  chest  position,  tampons,  pessaries,  etc.  8, 
If  the  hernia  is  extensive  the  pelvic  floor  should  be 
repaired,  the  cystocele  reduced,  the  vagina  made  less 
vertical,  and  the  uterus  properly  treated.  9,  With 
hysterectomy  the  stumps  of  ligaments  should  be 
united  to  tlie  upper  part  of  the  vagina.  10,  The 
levator  muscle  should  be  reunited.  Superficial  vul- 
var structures  should  be  allowed  to  remain  open  by 
making  a  U  shaped  incision  at  the  lower  end  of  the 
vagina  instead  of  the  usual  incision  in  the  labia 
majora. 

4.  The  Use  of  Bacterial  Vaccines. — Oastler's 
summary  is  as  follows:  i,  Apparently  favorable  clin- 
ical results  have  been  obtained  from  vaccines  of 
streptococcus,  staphylococcus,  B.  coli,  B.  mucosus, 
and  gonococcus.  2,  All  but  gonococcus  vaccine 
should  be  autogenous.  3,  Vaccines  aid  in  combating 
the  septic  process,  the  effect  being  gradual  and  pro- 
gressive. 4,  They  are  especially  useful  when  the 
blood  shows  poor  resistance.  5,  In  violent  cases  of 
acute  sepsis  no  resistance  can  be  created  and  no 
eft'ect  obtained.  6,  The  negative  phase  is  rarely  ob- 
tained. 7,  The  positive  phase  is  more  often  ob- 
tained. 8,  Blood  cultures  are  generally  negative.  9, 
Wound  discharge  increases  soon  after  injections. 
10,  Good  results  were  obtained  with  all  the  organ- 
isms tried,  but  the  least  satisfactory  were  with  the 
Streptococcus  lo)igus.  li,  The  pulse  may  remain 
rapid  after  the  temperature  falls.  12,  As  yet  no  bad 
effects  have  followed  injections.  13,  The  dose  is 
experimental,  the  same  is  true  as  to  the  site  and  fre- 
quency. Small  dosage  is  usually  preferable.  14. 
The  injection  should  be  repeated  every  fourth  day. 
15,  If  a  negative  phase  appears  the  injection  should 
be  delayed  and  the  dosage  reduced.  16,  The  opsonic 
index  is  uncertain.  Leucocyte  count  with  polymor- 
phonuclear count  gives  the  best  indication  of  the 
resistance  of  the  patient. 

6.  Endometritis. — ]\Iundell  quotes  Kelly  as 
finding  true  endometritis  in  only  two  per  cent,  of 
cases  curetted  for  that  supposed  condition.  Confu- 
sion as  to  varieties  is  due  to  the  following:  i,  The 
structure  and  relations  of  the  endometrium  are  lost 
sight  of.  2,  Age  in  the  patient  should  not  be  a  dis- 
tinction. 3,  Classification  according  to  aetiology  is 
bad,  as  there  may  not  be  a  relation  between  cause 
and  anatomical  changes.  4.,  Classification  according 
to  symptoms  leads  to  confusion  and  unlimited  varie- 
ties. 5,  The  same  is  true  of  classification  in  accord- 
ance with  pathological  changes.  The  author  con  - 
eludes:  i.  The  classification  of  endometritis  should 
be  acute  and  chronic.  Further  subdivision  is  con- 
fusing and  does  not  aid  the  clinician.  2,  Uncom- 
plicated cases  are  infrequent  and  an  uncomplicated 
chronic  case  is  a  great  rarity.  3,  Normally  the 
endometrium  is  free  from  bacteria.  4,  Successful 
treatment  of  chronic  endometritis  implies  suitable 
treatment  of  the  associated  conditions. 


ANNALS  OF  OPHTHALMOLOGY. 
April,  igog. 

1.  Influence  of  the  Eye  on  the  Ear  under  Normal  and 

Pathological  Conditions,  By  Marcel  Rollet. 

2.  Size  versus  Distance  in  Test  Types, 

By  Carl  Schulin. 

3.  Herpes  Zoster  Ophthalmicus  with  Involvement  of  the 

Cornea  and  with  Oculomotor  Paralysis, 

By  BuRTOX  Chance. 

4.  Atropine ;  Its  Use  and  Limitations  in  the  Correction 

of  Heterophoria.  By  Gilbert  D.  Murray. 

5.  Opticociliary  Vessels ;  Report  of  a  Case. 

By  William  T.  Shoemaker. 

6.  Hereditary  Blindness  and  its  Prevention. 

By  Clarence  Loeb. 

I.  Influence  of  the  Eye  on  the  Ear. — Rollet 
has  collated  a  number  of  cases  in  which  the  influ- 
ences exerted  by  general  maladies  or  diatheses  were 
eliminated  and  tinnitus  or  deafness  was  produced 
in  a  reflex  manner  by  ocular  troubles.  He  classifies 
the  catises  in  the  eye  which  may  produce  a  disturb- 
ance in  the  ear  in  three  groups:  i,  An  inflamma- 
tion ;  2,  a  muscular  contraction  or  a  static  disturb- 
ance ;  3,  a  luminous  impression.  In  the  first  group 
three  cases  of  injury  to  the  eye  are  described,  each 
of  which  caused  symptoms  of  sympathetic  irritation 
in  the  other  eye  together  with  auditory  hyperaesthe- 
sia,  diminution  of  hearing,  tinnitus,  and  vertigo.  In 
each  the  aural  symptoms  were  relieved  immediately 
by  enucleation  of  the  injured  eye.  The  fourth  case 
was  that  of  a  scrofulous  child,  eight  years  old,  with 
diffuse  keratitis  and  synechias  in  both  eyes  who  had 
been  deaf  since  two  years  of  age.  Double  iridec- 
tomy enabled  the  child  to  both  see  and  hear  better. 
A  man  who  had  lost  the  sight  of  one  eye  and  had 
recurrent  attacks  of  inflammation  in  the  other,  not 
sympathetic,  frequently  remarked  that  when  his  eyes 
were  relatively  well  he  could  hear  better,  but  that 
when  they  were  acutely  inflamed  his  hearing  was 
worse.  A  journalist,  fifty-six  years  old,  had  been 
deaf  since  his  eighth  year.  After  an  operation  for 
entropion,  which  had  caused  frequent  inflammations 
of  the  eye,  he  stated  that  he  could  hear  perfectly 
well.  An  officer  in  Garibaldi's  army  was  struck  in 
the  eye  by  a  spent  ball.  The  eye  was  functionally 
destroyed  by  the  contusion  and  the  corresponding 
ear  became  almost  totally  deaf.  The  second  group 
of  cases  includes  those  in  which  aural  symptoms, 
generally  tinnitus,  were  caused  by  contractions  of  the 
orbicularis,  of  the  orbital  muscles,  including  perhaps 
the  ciliary,  and  by  a  disparity  in  the  muscular  bal- 
ance. These  seem  to  be  due  to  a  synergic  contrac- 
tion of  the  stapedius  muscle  excited  by  the  contrac- 
tion of  the  muscles  of  the  eye,  and  in  one  case  relief 
was  given  by  tenotomy  of  the  stapedius.  The  third 
group  includes  cases  in  which  the  ear  reacts  to  ah 
impression  of  light.  D'Arsonval  himself  noticed 
that  if  he  looked  intently  at  an  arc  light  for  several 
seconds  he  became  deaf  for  an  hour  or  more ;  once 
he  remained  deaf  for  seventeen  days.  Other  similar 
cases  are  noted,  one  by  the  author  in  which  tinnitus 
was-  caused  by  an  ophthalmoscopic  examination  ; 
the  tinnitus  ceased  as  soon  as  the  examination  was 
discontinued  and  recurred  each  time  it  was  tried. 
In  these  cases  the  phenomena  seem  to  be  of  a  char- 
acter analogous  to  those  of  color  audition.  The 
nervous  track  followed  by  the  reflexes  in  the  pro- 
duction of  aural  svmptoms  as  the  result  of  eye  affec- 
tions is  discussed  at  some  length. 


872 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


AMERICAN  JOURNAL  OF  SURGERY. 

April,  igog. 

I.    The  Lingual  Tonsil,  By  F.  C.  Raynor. 

J.    Early  Diagnosis  of  Carcinoma  of  the  Uterus, 

By  Isaac  L.  Watkins. 
.3.    The  Value  of  Vaginal  Fixation  in  Procidentia, 

By  S.  S.  Graber. 

4.  Therapy  of  the  Prostate,  By  Charles  S.  Stern. 

5.  Remarks  on  Cystitis,  By  Nathaniel  P.  Rathbun. 
0.    A  Case  of  Laryngeal  Stenosis  in  the  Adult  Successfully 

Treated  by  Intubation ;  Continuous  Wearing  of  the 
Tube  for  Four  Years,        By  William  K.  Simpson. 

7.  Report  of  a  Case  in  which  205  Gallstones  were  Re- 

moved Simultaneoush'  with  Operations  on  Cervix 
Uteri  and  Uterine  Annexa,  By  A.  Brothers. 

8.  Thrombosis  of  the  Popliteal  E;nd  Anterior  and  Pos- 

terior Tibial  Arteries  Complicating  an  Appendicular 
Abscess.  By  James  L.  Campbell. 

9.  Report  of  an  Accident  to  an  Infant,  Seventeen  Months 

Old,  with  Extensive  Injury  to  the  Abdominal  Wall 
and  Evisceration  of  All  of  the  Small  Intestines ;  Re- 
covery, By  RuFus  B.  Hall. 

I.  l^ingual  TonsiL — Raynor  says  that  the  first 
mention  in  literature  concerning  the  Ungual  tonsil 
was  by  Heymann  in  1877,  in  the  Berliner  klinischc 
W ochenschvift ,  and  the  first  paper  in  the  United 
States  was  by  H.  Holbrook  Curtis  in  1884,  pub- 
lished in  the  Ncn'  York  Medical  Journal.  The  col- 
lection of  lymphoid  tissue  situated  at  the  base  of 
the  tongue  between  it  and  the  epiglottis,  to  which 
the  name  lingual  tonsil  has  been  applied,  consists 
of  a  flattened  mass,  often  divided  by  a  median  de- 
pression, giving  it  the  appearance  of  two  glands. 
In  amount  it  varies  widely  in  health,  and  its  dis- 
eases, contrary  to  those  of  the  pharyngeal  and  fau- 
cial  tonsils,  are  mostly  of  adult  life,  although  a  case 
has  been  recorded  of  a  child  of  two  years  dying  of 
asphyxia  from  enlargement  of  this  gland.  It  tends 
to  increase  rather  than  diminish  after  puberty.  In 
structure  it  corresponds  to  the  other  tonsils  and  is 
>ubject  to  the  same  disease,  e.  g.,  acute  catarrhal, 
lacunar,  and  phlegmonous  inflammations,  mycosis, 
tuberculous  and  syphilitic  involvement,  and  hyper- 
trophic changes.  It  may  also  be  the  seat  of  tumors. 
It  may  be  involved  with  other  disorders  of  the 
throat,  but  is  often  independently  affected.  The 
author  speaks  of  the  treatment  and  cites  five  cases. 
He  also  describes  two  new  instruments  for  the  re- 
moval of  the  lingual  tonsil,  which  singly  or  com- 
bined are  adapted  to  the  ablation  of  any  growth. 
The  curette  is  a  curved  "hoe  shaped"  instrument, 
with  a  sharp  cutting  edge,  and  is  introduced  be- 
yond the  hypertrophied  tissue,  and  with  a  combined 
])ulling  and  lateral  movement  the  growth  is  severed, 
either  entirely,  or  in  some  situations  the  removal  is 
com])leted  by  the  forceps.  This  forceps  has  the  usual 
lingual  curve,  and  has  rounded  cup  shaped  blades 
extending  ])elow  the  general  plane  of  the  instru- 
ment, which  cut  from  the  point  to  the  junction  with 
the  shaft.  The  blades  are  so  ground  as  to  force 
them  into  the  growth,  and  they  do  not  slip  off  as 
does  the  ordinary  lingual  scissors  or  guillotine. 
The  instruments  arc  readily  sterilized. 

6.  Laryngeal  Stenosis. — Simpson  reports  such 
a  case.  The  exact  time  of  the  intul)ating  ]-)eriod 
from  the  date  of  the  first  introduction  was  four 
years  and  twenty-five  days,  and  with  the  exception 
of  a  few  days  tlie  tube  remained  in  continuously. 
The  author  emphasizes  the  following  points  :  The 
tolerance  of  the  larynx  to  long  continued  pressure. 
The  superiority  of  continuous  pressure  in  causing 


absorption  over  the  older  methods  of  the  tempo- 
rary introduction  of  dilating  instruments.  The 
comparative  comfort  with  which  an  intubation  tube 
may  be  indefinitely  worn.  The  improved  general 
condition  of  the  patient  while  wearing  the  intuba- 
tion tube  in  contrast  to  the  debilitating  influence 
and  local  annoyance-  of  the  tracheotomy  cannula. 
The  superiority  of  the  hard  rubber  over  the  metal 
tube  in  forming  less  amount  of  calcareous  deposit, 
thus  lessening  the  danger  of  ulceration  and  forma- 
tion of  exuberant  granulation  tissue. 

 ^  


MEDICAL  ASSOCIATION  OF  THE  GREATER  CITY 
OF  NEV/  YORK. 

Meeting  of  Deeember  ^i,  igo8. 
The  President,  Dr.  Robert  T.  Morris,  in  the  Chair. 

Gastric  Neuroses. — This  paper  was  by  Dr. 
John  B.  De.wer,  of  Philadelphia.  He  said  that  the 
very  complexity  of  the  classification  and  description 
of  gastric  neuroses  in  the  books,  the  diversity  of 
opinion  concerning  their  causation,  and  the  innum- 
erable modes  of  treatment  suggested  by  various 
authors  lead  us  at  once  to  question  the  supposed 
facts  concerning  them.  It  was  his  purpose  to  con- 
sider these  so  called  gastric  neuroses  especially  in 
so  far  as  they  concerned  the  surgeon,  dealing  par- 
ticularly with  that  set  of  gastric  symptoms  classed 
grossly  as  "nervous  dyspepsia."  It  was  true  beyond 
a  doubt  that  there  were  certain  disturbances  in  the 
stomach  functions,  motor,  secretory,  and  sensory, 
for  which  we  could,  even  by  the  minutest  examina- 
tion, find  no  organic  basis.  Besides  grouping  them 
into  these  three  classes,  we  might  also  classify 
them  as  conditions  of  irritation  or  depression.  When 
we  spoke  of  any  one  or  more  of  them  as  a  neurosis 
we  excluded  also  the  existence  of  a  lesion  outside 
the  stomach  which  might  give  rise  to  them  reflexly. 
Accepting  them,  then,  as  neuroses,  what  was  their 
frequency  of  occurrence,  how  might  they  be  cor- 
rectly diagnosticated  and  treated,  and  in  what  way 
did  they  reach  the  border  line  of  surgical  practice  ? 

As  a  fundamental  principle,  it  could  be  safely 
stated  that  a  gastric  neurosis  without  other  neuroses 
or  neurasthenic  conditions  was  a  most  rare  thing. 
In  practically  every  case  in  which  we  finally  con- 
cluded th.at  the  condition  was  a  true  neurosis  it 
would  be  found  that  it  was  but  one  of  a  train  of 
neuroses  afl^ecting  the  most  diverse  functions  and 
widely  separated  organs.  Of  the  sensory  disturb- 
ances, anorexia,  or  at  least  capriciousness  of  appe- 
tite, was  the  most  universally  ])resent ;  but,  as  this 
was  a  constant  symptom  in  all  stomach  diseases, 
both  organic  and  functional,  it  was  of  little  diagnos- 
tic value.  True  gastralgia  he  had  found  very  rare. 
Of  the  secretory  disturbances,  hyi>erchlorhydria  was 
by  far  the  most  important,  l)ut  immediately  there 
arose  the  question  as  to  our  ability  to  correctly  diag- 
nc)sticate  such  a  condition.  His  own  experience 
with  ga.stric  analyses  had  been  most  unsatisfactory. 
Where  once  he  had  IiojumI  that  these  would  lead  us 
to  the  possibility  of  definite  diagnoses  of  ulcer,  car- 
cinoma, and  secretory  disturbances,  unaccompanied 
l)y  or.ganic  lesions,  he  now  had  almost  come  to  the 


April  24,  1909.] 


PROCEEDIXGS  OF  SOCIETIES. 


873 


conclusion  that  a  gastric  analysis  was  too  often  of 
but  little  help  to  a  diagnosis.  Yet  extreme  cases  of 
hyperchlorhydria  could  be  so  diagnosticated,  and  did 
at  times  occur  in  the  absence  of  anything  that  would 
seem  to  account  for  the  condition. 

As  we  extended  the  field  of  motor  disturbances  we 
approached  the  scope  of  surgical  treatment  as  well 
as  diagnosis.  \'omiting.  eructations  and  colic  were 
as  a  rule  but  symptomatic.  There  might  be  fre- 
quently repeated  attacks  of  vomiting,  and  an  opera- 
tion or  autopsy  would  fail  entirely  to  give  even  a 
clue  to  the  causation,  and  a  prominent  surgeon  had 
recently  reported  excellent  results  in  such  cases 
from  exploratory  operations :  though  these  were 
made  upon  false  diagnoses.  He  even  went  so  far  as 
to  recommend  an  operation  for  the  cure  of  such  a 
neurosis — an  extremely  radical  and,  to  Dr.  Deaver's 
niind,  untenable  position.  Atony  of  the  stomach 
also  could  not  at  times  be  considered  as  anything 
but  a  neurosis,  and  its  treatment  fell  fully  as  much 
within  the  province  of  the  surgeon  as  of  the  intern- 
ist. Finally,  we  had  that  vague  group  of  symptoms, 
sensory,  motor,  and  secretory  combined,  which,  in 
the  absence  of  any  definite  or  tangible  demarcation, 
had  been  called  "nervous  dyspepsia."  Having  de- 
scribed its  prominent  characteristics,  he  said  that 
usually  this  condition  was  not  a  neurosis,  but.  grant- 
ing even  that  it  might  be  such,  the  name  nervous 
dyspepsia  had  been  overworked  almost  more  than 
any  other.  The  diagnosis  of  a  gastric  neurosis  was 
probably  the  most  difficult  of  all  to  make.  The  most 
important  feature  of  this  was  to  solicit  a  careful  his- 
tory, which  would  show  the  general  neurasthenic 
condition  of  the  patient.  His  ocular  or  cardiac 
symptoms  might  give  us  a  clue.  The  variability  in 
gastric  symptoms  would,  again,  point  to  a  neurosis. 
Some  cases  of  ulcer,  however,  were  very  obscure, 
and  even  more  frequently  the  symptoms  of  duodenal 
ulcer  failed  of  recognition.  Carcinoma  in  its  early 
stages  was  much  more  frequently  considered  as  a 
gastric  catarrh  or  nervous  dyspepsia  than  it  was 
reco.gnized.  Furthermore,  recent  clinical  manifesta- 
tions had  directed  attention  to  that  condition  of 
puncture  ulceration  of  the  gastric  mucosa,  with 
small,  early  bleeding  points,  which  might  involve 
almost  all  if  not  its  entire  extent.  In  the  absence  of 
the  classical  signs  of  ulcer  often  met  with  in  this 
condition,  the  hyperchlorhydria  present  had  fre- 
quentlv  been  mistaken  for  the  main  trouble. 

Ulcer  and  carcinoma,  again,  might  lead  to  a  simu- 
lation of  the  motor  manifestations  of  gastric  neuro- 
ses, as  well  as  of  the  secretory  and  sensory  ones. 
It  had  always  been  the  speaker's  opinion  that  in 
very  many  of  the  cases  of  vomiting  regarded  as  pri- 
mary neuroses  v.-e  had  really  a  symptom  of  some  un- 
determined lesion  in  or  outside  the  stomach. 
\'omiting  as  a  pure  motor  neurosis  was  at  present 
regarded  as  of  far  less  frequency  than  was  the  case 
thirty  years  ago :  nevertheless,  it  could  not  be  de- 
nied that  it  was  occasionally  met  with.  The  impos- 
sibility of  diagnosticating  a  nervous  dyspepsia  with 
some  slight  gastritis  was  manifest.  It  could  be 
safely  asserted  that,  while  all  sufferers  from  neu- 
rasthenia did  not  have  gastric  symptoms,  all  suf- 
ferers from  chronic  dyspeptic  symptoms,  from  what- 
ever cause,  soon  became  neurasthenics. 

Hitherto  he  had  spoken  only  of  the  resemblance  be- 


tween so  called  gastric  neuroses  and  organic  gastric 
lesions.  It  would  be  evident,  he  said,  how  often  we 
must  be  deceived  in  diagnosticating  the  presence  of 
a  neurosis,  in  how  many  instances  there  was  in  a 
supposed  neurosis  but  the  beginning  of  a  serious  or- 
ganic disease.  Yet.  not  only  in  the  stomach  did  we 
find  conditions,  often  unrecognized,  to  the  symptoms 
of  which  the  older  clinicians  often  applied  the  term 
neurosis,  but  there  were  numerous  lesions  of  other 
abdominal  viscera  which  deceived  us  in  the  same 
way.  Thus,  a  patient  who  suffered  from  gallstones 
with  stomach  pains  of  an  atypical  variety  would 
furnish  the  exact  picture  of  so  called  idiopathic" 
gastralgia.  All  the  other  symptoms  of  gallstone 
disease  might  be  absent,  and  the  pain  attributed  to  a 
stomach  neurosis,  when  it  really  had  a  basis  in  the 
very  solid  fact  of  biliary  calculi.  We  were  coming 
to  recognize  more  clearly  every  year  that  the  vari- 
ous organs  concerned  in  digestion  formed  a^system 
correlated  in  every  part.  Having  spoken  aV  some 
length  of  the  biliary  system  in  this  connection,  he 
said  that  Moynahan.  of  Leeds,  had  aptly  cited  the 
term  "gallbladder  dyspepsia"  as  accurately  describ- 
ing the  digestive  symptoms  which  preceded  by 
months  or  years  the  late,  or  so  called  "classical." 
signs  of  gallstones.  Again,  when  the  perichole- 
cvstic  adhesions  very  commonly  found  in  association 
with  bileduct  lesions  of  long  standing  encroached 
upon  the  stomach  or  duodenum,  they  often  caused 
symptoms  entirely  gastric.  Turning  to  the  appen- 
dix, it  v.as  found  that  chronic  inflammation  of  this 
organ  caused  many  cases  of  chronic  dyspepsia. 
Only  within  the  last  few  days  Dr.  Deaver  had  per- 
formed two  appendectomies  for  marked  chronic  ap- 
pendicitis in  patients  in  whom  the  entire  pain  and 
distress  were  located  in  the  epigastrium — typical 
instances  of  pylorospasm.  Our  internists  and  gas- 
troenterologists  diagnosticated  many  cases  of  gas- 
tric, intestinal,  and  nervous  dyspepsia.  Hereafter 
they  might  save  their  patients  much  suffering  and 
themselves  much  chagrin  by  more  frequent  diag- 
noses of  gallbladder,  duodenal  and  appendicular 
dyspepsia,  with  the  recommendation  for  prompt  sur- 
gical intervention. 

Having  referred  to  the  neuroses  of  various  forms 
caused  reflexly  by  renal  lesions,  such  as  movable 
kidney,  and  lesions  of  the  male  or  female  genital 
organs,  he  went  on  to  say  that  it  had  to  be  admitted 
that  there  were  certain  cases  for  which  the  term 
"nervous  dyspepsia"  must  suffice  as  a  diagnosis. 
The  surgeon's  principal  duty,  as  regarded  the  true 
neuroses  of  the  stomach,  was  to  recognize  them,  to 
separate  them  from  secondary  dyspeptic  conditions 
due  to  lesions  which  perhaps  it  was  within  his  prov- 
ince to  treat.  He  regarded  the  proposition  to 
operate  in  such  cases  for  the  mental  effect  upon  the 
general  neurasthenic  or  hysterical  condition  as  un- 
safe, illogical,  and  setting  a  most  dangerous  prece- 
dent. These  cases  belonged  to  the  internist  and 
neurologist,  and  whether  the  neurasthenia  was  pri- 
mary or  secondary-  to  the  stomach  lesion,  the  same 
treatment  was  called  for.  There  was  no  exception 
perhaps  to  the  general  statement  that  gastric  neuro- 
ses per  sc  were  not  within  the  province  of  the  sur- 
geon. If.  however,  we  considered  gastric  atony  and 
ptosis  as  really  neuroses  when  they  were  apparently 
primary,  they  constituted    the    exception.  There 


8/4 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


were  certain  of  these  cases  in  which  all  medical  and 
general  treatment  was  unavailing,  while  a  gastro- 
enterostomy promptly  gave  recovery  by  furnishing 
the  stomach  with  drainage,  which  by  its  own  force 
it  was  unable  to  secure.  In  ptosis  he  believed  that 
this  operation  was  the  only  logical  procedure,  and 
this  was  true  even  in  some  instances  where  the 
pylorus  was  entirely  patulous. 

Indications  for  Surgery  in  Gastric  Disease. 
— In  this  paper  Dr.  Anthony  Basslek  said  it 
was  to  be  remembered  that  to  be  too  conservative 
and  drift  aimlessly  along  until  conditions  had  passed 
beyond  the  hope  of  surgical  cure  before  the  patient 
was  given  the  benefit  of  surgical  treatment  was 
quite  as  bad  practice  as  engaging  in  hazardous  oper- 
ative exploitation  without  previously  knowing  just 
why  or  estimating  the  loss  and  uncertain  gain.  Each 
case  must  be  a  law  unto  itself,  and  some  cases  from 
their  onset,  and  often  afterward,  rightly  belonged 
to  the  ^iiedicosurgical  class  rather  than  to  the  med- 
ical or  the  surgical  class  alone.  It  was  possible,  of 
course,  to  give  only  general  rules  as  to  deciding 
when  surgical  procedures  should  be  resorted  to.  but 
in  those  he  would  mention  the  speaker  had  found 
them  of  service  in  his  own  experience. 

Cancer  was  a  surgical  condition,  and  in  its  be- 
ginning it  was  susceptible  of  absolute  cure  when  the 
growth  was  completely  excised.  Any  case  of  sus- 
pected cancer  became  surgical  after  the  following 
findings  had  been  obtained :  The  securing  of  a 
piece  of  carcinomatous  tissue  ;  a  short  upward  move, 
followed  by  a  steady  fall  or  just  a  fall  of  from  i° 
to  4°  of  hydrochloric  acid  a  week,  with  a  corre- 
sponding rise  in  the  amounts  of  the  organic  acids ; 
when  test  meals,  carefully  removed,  usually  con- 
tained blood  in  small  quantities ;  when  an  increased 
bacterial  flora  of  streptococci,  staphylococci,  or  dip- 
lococci  was  present  in  test  meals ;  when  the  same 
type  of  organism  was  always  found  in  large 
amounts,  and  these  were  apparently  not  from  the 
saliva  or  sputum ;  when  pus  cells  were  always,  pres- 
ent in  the  empty  stomach  and  sarcinas  were  not 
found  in  the  test  meals ;  when  there  were  slight  evi- 
dences of  gastric  retardation  and  fermentation ;  and 
when  the  patient  showed  a  steady  loss  of  weight. 
In  cases  of  early  surgical  interference  the  mortality 
was  only  between  one  and  ten  per  cent.  In  the 
class  of  cases  ushered  in  by  fulminating  haemor- 
rhage, however,  few  patients  survived  an  operation, 
and  the  rate  of  mortality  under  medical  treatment 
was,  indeed,  better  than  under  surgical.  The  bleed- 
ing was  not  always  from  a  large  vessel  which  could 
easily  be  found,  but  might  come  from  many  insig- 
nificant erosions  and  be  almost  impossible  to  control. 
Still,  in  such  instances  the  flow  might  suddenly  stop, 
but  later  come  on  again,  and  here  surgery  might  be 
of  signal  help. 

Perforation  into  the  general  peritoneal  cavity  was 
found  in  about  one  in  twelve  of  all  cases  of  true 
gastric  ulcer  which  came  under  observation,  and 
when  the  condition  was  diagnosticated  an  operation 
should  always  be  resorted  to  at  once.  Success,  of 
course,  hinged  upon  an  early  diagnosis,  and  every 
hour  of  delay  lessened  the  chances  for  recovery. 
When  the  opening  into  the  peritoneal  cavity  was 
large  and  free,  there  were  the  general  symptoms  of 
shock,  but  sometimes  the  diagnosis  could  not  be 


made  early,  as  these  were  absent,  and  even  the  char- 
acteristic intense  local  pain  and  tenderness  might  be 
more  or  less  wanting.  When  a  more  diffuse  pain 
than  had  previously  been  present  developed,  it  sig- 
nified the  onset  of  localized  peritonitis,  and  was 
usually  followed  in  from  one  to  twelve  hours  by 
rigidity  of  the  whole  abdomen.  As  the  latter  sub- 
sided, there  generally  occurred  a  gradual  tumefac- 
tion of  the  abdomen,  due  to  paralytic  distention  of 
the  intestines  and  the  escape  of  gas  into  the  general 
peritoneal  cavity.  The  outcome  of  an  operation 
now  became  very  doubtful,  but  nevertheless  it  should 
be  performed,  as  offering  the  only  possible  means 
of  saving  the  patient's  life.  It  was  apparent  that  if 
more  gastric  ulcers  were  treated  properly  in  the 
first  instance,  there  would  be  fewer  baneful  results 
from  the  ulcers  and  fewer  cases  calling  for  surgical 
interference.  One  should  always  be  guarded  in  pro- 
nouncing an  ulcer  cured  until  several  years  had 
elapsed,  and  it  was  advisable  that  all  cases  which 
had  apparently  yielded  satisfactorily  to  treatment, 
should  be  kept  under  observation  and  the  patients 
carefully  examined  from  time  to  time.  After  de- 
scribing the  healing  of  ulcers,  the  speaker  said  that 
if  after  an  acute  case  had  been  suitably  treated  a 
sufficient  length  of  time  there  was  constant  gastric 
pain,  which  was  made  worse  by  the  injection  of 
coarse  foods,  an  unhealed  ulcer  or  an  irritable  scar 
was  to  be  suspected.  Even  more  significant  was  a 
history  of  more  or  less  vomiting,  though  in  such 
cases  the  vomitus  did  not  usually  contain  blood.  He 
advised,  however,  as  a  routine  in  all  post  ulcer  cases 
that  the  stools  should  be  examined  from  time  to 
time  for  occult  blood. 

Dr.  Bassler  next  described  the  class  of  "chronic 
dyspeptics,"  those  who  never  seemed  to  get  well  un- 
der any  form  of  treatment,  and  said  that  when  after 
an  ulcer  a  chronic  dyspeptic  condition  began,  or  be- 
came much  worse,  and  kept  up  continuously,  an  un- 
healed ulcer  or  an  irritable  scar  should  be  thought 
of ;  in  both  of  which  recourse  to  surgery  might  give 
good  results.  In  the  majority  of  cases  of  this  kind, 
however,  it  had  been  his  practice,  when  the  condi- 
tions were  such  as  to  afford  a  fair  chance  of  success, 
to  recommend  first  another  course  of  strict  ulcer 
treatment  in  bed  or  a  prolonged  rest  in  a  well  or- 
dered sanatorium,  or  possibly  a  sojourn  at  one  of 
the  foreign  spas,  such  as  Kissengen.  When  an  ulcer 
had  once  filled  in  with  scar  tissue,  provided  this  was 
tmiformly  intact,  it  was  really  no  longer  an  ulcer 
in  the  proper  acceptation  of  the  word,  ^^'hat  he 
would  designate  as  a  chronic  ulcer  was  rather  the 
slower  form  of  ulcer  seen  in  those  past  middle  life, 
which  was  commonly  of  two  varieties.  In  the  first 
but  little  organization  of  new  growth  tissue  had 
taken  place  and  the  stomach  walls  were  soft  an.d  flat, 
while  in  the  second  a  conglomerate  mass  under  the 
ulcer  might  form  a  considerable  tumefaction  in  the 
stomach  wall,  rendering  it  stiff  at  this  point  and 
sometimes  for  a  distance  around.  In  these  condi- 
tions little  was  to  be  expected  from  medical  treat- 
ment, and  on  this  account,  as  well  as  their  morbid 
nature,  the  resulting  cachexia,  and  the  time  of  life 
of  the  patient  (at  which  there  was  always  a  ten- 
dency to  carcinomatous  degeneration),  surgical  in- 
tervention was  to  be  recommended.  Gastroenter- 
ostomv  was  often  curative,  but  excision  forms  of 


April  24,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


875 


operation  would  give  the  best  final  results  in  the 
majority  of  instances.  In  many  patients  with 
chronic  ulcer,  and  even  some  of  those  whose  ulcers 
had  healed,  a  carcinoma  was  apt  to  develop,  and  it 
was  well  to  remember  in  this  connection  that  it  was 
often  impossible  to  diagnosticate  the  ulcus  carcino- 
inatosum  in  ihe  beginning,  and  sometimes  even  late 
in  its  course  when  it  was  encapsulated  in  structure 
and  formed  outside  the  free  surface  of  the  stomach. 
Thus  it  was  that  a  rather  liberal  leaning  toward  the 
surgeon  was  generally  necessary  to  assist  in  making 
an  early  diagnosis.  About  ten  per  cent,  of  pyloric 
stenoses  followed  gastric  ulcer.  \\'hen  the  stenosis 
v^as  benign  in  nature  and  slight  in  extant,  much  in 
the  way  of  satisfactory  relief  could  be  accomplished 
bv  medical  treatment ;  when  it  was  moderate,  by  the 
strictest  care  such  patients  could  be  kept  comfort- 
able ;  but  when  the  stenosis  was  such  that  distinct 
stagnation  and  fermentation  of  food  resulted,  the 
case  was  decidedly  surgical.  Having  referred  to 
cicatricial  contractions,  not  near  the  pylorus,  caused 
bv  ulcers,  and  their  general  management,  he  re- 
marked that  those  cases  with  distinct  collective 
vomiting,  intense  thirst,  diminution  of  urine,  tetany, 
and  marked  fermentation  were  all  instances  of  more 
or  less  complete  stenosis,  for  which  the  excisions, 
pyloric  plastic  operations  for  adhesions,  or  gastro- 
enterostomy might  be  resorted  to.  The  last  class 
of  cases  in  which  operations  were  indicated  were 
those  showing  the  presence  of  benign  growths.  In 
this  were  also  included  the  congenital  stenoses  and 
cases  of  foreign  bodies  in  the  stomacli.  To-day.  he 
said  in  conclusion,  mistakes  on  both  the  medical  and 
surgical  side  were  gradually  disappearing,  and 
knowledge  and  understanding  were  growing  toward 
perfection  in  this  field  of  medicine. 

Dr.  George  E.  Brewer  said  that  he  was  espe- 
cially interested  in  Dr.  Deaver's  paper  because  he 
had  made  more  mistakes  regarding  gastric  neuroses 
than  in  any  other  line  of  gastric  or  intestinal  work. 
It  seemed  to  him  that  internalists  saw  so  many  more 
cases  of  this  character  that  they  were  apt  to  think 
many  cases  involving  the  stomach  were  not  surgical 
which  really  did  belong  to  the  surgeon.  On  the 
other  hand,  on  account  of  the  brilliant  results  which 
had  of  late  been  accomplished  by  operative  meas- 
ures, surgeons  were  too  much  inclined  to  regard  as 
surgical  many  cases  which  were  not  suitable  for 
•operation.  He  could  recall  at  least  five  cases  in  his 
own  experience  in  which  he  had  operated  with  no 
benefit  to  the  patient  and  in  which  no  anatomical 
lesion  was  discovered  when  gastroenterostomy  was 
performed.  These  proved  to  be  pure  cases  of  neu- 
rosis, in  which  the  gastric  afYection  was  the  only 
form  of  neurasthenia  manifest.  He  cited  one  of  the 
cases  in  which  there  was  a  point  of  decided  tender- 
ness in  the  epigastric  region :  yet,  on  operation,  the 
stomach  and  duodenum  were  found  to  be  entirely 
normal.  As  a  result  of  the  operation  the  condition 
of  the  patient  was  made  much  worse,  and  finally  a 
generalized  neurasthenia  showed  itself.  Here  the 
gastric  symptoms  noted,  therefore,  were  simply 
among  the  manifestations  of  neurasthenia  affecting 
the  whole  system.  In  another  case  he  mentioned, 
in  which  there  was  supposed  to  be  an  organic  lesion 
of  the  stomach,  there  was  simply  a  general  neuras- 
thenia, and  as  a  result  of  the  operation  there  was 


added  traumatic  neurasthenia.  Instances  like  these 
had  led  him  to  adopt  the  rule  not  to  operate  unless 
some  sign  really  indicating  surgical  interference 
were  present.  In  regard  to  malignant  disease  of  the 
stomach,  so  much  progress  had  been  made  in  the 
last  ten  or  fifteen  years  that  some  surgeons  reported 
as  good  results  in  gastric  carcinoma  as  in  cancer  of 
the  breast.  This  was  hardly  to  be  expected,  how- 
ever, as  all  the  cases  came  to  the  surgeon  at  a  later 
date  than  those  of  mammary  cancer.  If  results  at 
all  satisfactory  were  to  be  attained,  it  was  essential 
that  an  exploratory  incision  should  be  made  early. 
If  in  any  case  there  was  one  chance  in  ten  that  the 
condition  present  was  malignant,  he  thought  that 
such  an  incision  should  be  made,  but  that  it  should 
be  left  to  the  patient  to  decide  for  himself  whether 
the  exploratory  operation  should  be  done. 

Dr.  IMax  Eixhorx  said  he  was  glad  that  neither 
Dr.  Deaver  nor  Dr.  Brewer  was  in  favor  of  opera- 
tion in  cases  of  neuroses.  Because  our  patients  did 
not  do  well  we  should  not  necessarily  think  of  re- 
sorting to  operative  procedures.  Before  we  decided 
to  do  this  we  must  be  reasonably  sure  that  some- 
thing could  be  accomplished  by  the  operation.  As 
to  gastroptosis,  he  could  not  agree  that  gastroen- 
terostomy was  the  right  treatment.  The  correction 
of  this  condition  required,  first,  support  by  a  proper 
bandage  (though  this  might  not  be  essential),  and, 
second,  and  most  important,  the  building  up  of  the 
patient  by  good  nutrition.  No  operation  whatever 
was  demanded.  He  did  not  believe  that  gastrop- 
tosis ever  gave  rise  to  dilatation  of  the  stomach  and 
pyloric  obstruction.  When  these  conditions  were 
present,  operative  interference  was  called  for  gen- 
erally, though  not  in  all  cases.  If  the  stenosis  was 
not  of  a  high  degree,  it  would  often  be  found  that 
the  patient  picked  up  after  a  few  weeks  of  suitable 
treatment,  and  he  had  known  them  to  live  for  years. 
Even  when  there  were  recurrences,  not  infrequently 
a  cure  could  be  eflfected  by  medical  treatment  alone. 
If  the  operation  of  gastroenterostomy  was  entirely 
without  mortality,  he  would  certainly  advise  it  in 
all  such  cases ;  but,  unfortvmately,  this  was  not  the 
case,  and  he  did  not  think  it  justifiable  to  subject  the 
patient  to  the  risk  unless  the  indications  for  the  pro- 
cedure were  very  clear.  y\.s  to  cases  in  w^hich  there 
was  a  possibility  of  the  presence  of  cancer,  he  could 
not  agree  with  Dr.  Brewer  to  ask  the  patient  to  sub- 
mit to  an  exploratory  incision  if  the  chances  were 
ten  to  one  against  cancer.  He  would  prefer  to  wait 
for  further  developments  in  the  case.  If  the  explo- 
ration was  made  and  no  cancer  found,  the  patient 
might  com.e  back  after  a  time  with  symptoms  sug- 
gesting the  possibility  of  cancer,  and  then  another 
operation  would  have  to  be  performed  to  find  out 
the  condition.  He  did  not  believe  in  operating  as 
a  rule  unless  there  was  something  positive  to  go  by. 
If,  however,  after  a  thorough  examination,  it  was 
found  that  the  chances  were  about  even  as  to  the 
presence  of  cancer  (not  one  in  ten),  an  exploratory 
incision  might  be  justifiable.  Even  if.  on  making 
the  incision,  nothing  could  be  felt,  could  we  be  cer- 
tain that  no  cancer  existed  ?  The  incision  alone  was 
not  always  a  safeguard,  since  the  growth  must  be 
of  a  certain  size  to  be  appreciated  by  the  touch.  It 
was  therefore  necessarv  to  study  these  doubtful 
cases  from  all  points  of  view.    He  did  not  believe  in 


87b 


LETTERS  TO  THE  EDITOR. 


[New  York 
Medical  Journal. 


calling  some  cases  surgical  and  others  medical.  The 
profession  of  medicine  was  one,  and  the  physician 
and  the  surgeon  should  work  harmoniously  together, 
so  that  our  patients  might  receive  every  help  that  it 
was  possible  to  give. 

Dr.  RoBF.RT  CoLF.MAN  Kkmi'  thought  that  fre- 
quent analyses  of  the  stomach  contents  and  the 
stools  for  the  presence  of  occult  blood  were  of  great 
service  in  the  matter  of  diagnosis,  especially  when 
the  patient  had  been  instructed  to  refrain  from  eat- 
ing meat  for  five  days  previous  to  each  examination. 
Very  often  also  the  diagnosis  could  be  arrived  at  by 
a  process  of  exclusion.  He  had  found  that  the  en- 
grafting of  cancer  upon  a  gastric  ulcer  was  a  very 
common  occurrence.  He  did  not  agree  with  Dr. 
Einhorn  in  regard  to  exploratory  incisions.  He 
would  go  even  further  than  Dr.  Brewer  and  say 
that,  if  there  was  one  chance  in  twenty  that  cancer 
existed,  the  incision  should  be  advised.  As  to  atonic 
dilatation  and  stenotic  dilatation  of  the  stomach,  the 
symi)toms  of  the  two  conditions  were  entirely  dif- 
ferent. In  his  service  at  the  Manhattan  State  Hos- 
pital no  fewer  than  from  ninety-five  to  ninety-eight 
per  cent,  of  the  patients  had  atonic  dilatation.  A 
large  proportion  of  them,  never  vomited,  but  they 
suffered  from  all  the  different  types  of  toxjemia. 
After  speaking  of  the  success  he  had  met  with  in 
warding  off  the  convulsive  seizures  in  epileptics  by 
means  of  lavage  and  other  treatment  directed 
against  autointoxication,  the  speaker  said  that  cases 
of  stenotic  dilatation  were  characterized  by  persis- 
tent vomiting  and  peristaltic  unrest,  and  that  here 
medical  treatment  did  no  good  whatever.  An  oper- 
ation alone  was  of  service,  and  after  it  the  patient 
was  often  restored  to  .perfect  health.  Referring  to 
gastric  jjtosis,  he  said  we  must  remember  that  this 
was  onl\  part  of  a  general  condition,  a  relaxation  of 
all  the  organs,  with  -, aiious  torsions  apt  to  occur  in 
consequence.  Therefore  a  gastroenterostomy  was 
not  likely  to  be  of  service.  What  was  required  was 
the  increase  of  abdominal  pressure  by  the  putting 
on  of  ta1  and  the  use  c^'  appropriate  abdominal  sup- 
l)ori.,  sue):  as  was  afloided  by  Gallant's  corset  or 
Rnse'.i  bandage.  Xearo;  all  cases  could  be  success- 
fully treated  in  this  way.  If  an  operation  was  called 
toi,  it  was  one  which  "hitched  up"  all  the  abdominal 
organs,  such  as  Morris's  operation  on  the  recti  mus- 
cles. The  result  of  a  gastroenterostomy  was  to 
afford  support  simply  to  the  .stomach,  while  it  left 
the  general  condition  unchanged. 

Dr.  R.\.\SK()KD  E.  V.\N  GiKsiix,  having  remarked 
that  the  stomach  was  a  storm  centre  for  all  .sorts  of 
neuro.ses,  related  the  case  of  a  young  girl  who  suf- 
fered from  persistent  vomiting,  with  some  pain.  It 
was  found  that  whatever  course  of  treatment  was 
adoi)ted  which  was  first  discussed  in  the  i)resencc  of 
the  patient  did  good  for  a  time,  but  she  finally  died 
of  inanition.  Ga.stric  neuroses  were  frc(|ucntly  re- 
flex manifestations  of  sources  of  irritation  in  other 
organs,  and  in  order  to  effect  a  cure  it  was  requisite 
to  seek  these  out  and  correct  them.  In  cases  of  per- 
foration from  gastric  ulcer  the  fatal  result  often  oc- 
curred so  rapidly  that  there  was  no  time  to  do  any- 
thing. Some  time  ago  he  had  presented  the  .speci- 
men from  a  case  of  this  kind  at  the  Pathological 
Socitty.   When  he  reached  the  i)atient,  collapse  had 


already  set  in.  He  disagreed  with  Dr.  Deaver  as  to 
gastric  symptoms  being  caused  by  the  presence  of 
gallstones.  In  his  own  cases  the  patients  were  en- 
tirely free  from  such  symptoms  in  the  intervals  be- 
tween the  attacks,  and  nearly  all  of  them  had  had 
perfect  digestion.  He  thought  Dr.  Kemp  was  en- 
tirely right  in  the  matter  of  gastroptosis,  and  said 
that  in  his  own  experience  his  results  with  the  use 
of  Rose's  bandage  could  be  described  as  nothing  less 
than  marvellous. 

The  Pre.sidext  said  he  would  like  to  ask  the 
opinion  of  Dr.  Deaver  in  regard  to  two  points  which 
seemed  to  him  of  very  great  importance.  One  was 
as  to  the  value  of  microscopical  examination  of 
frozen  sections  made  at  the  bedside  at  the  time  of 
operating,  and  the  other,  as  to  the  agency  of  eye- 
strain in  causing  gastric  disturbance.  Many  eye 
specialists  were  incapable  of  determining  the  exact 
condition.  When  a  proper  examination  was  made, 
however,  by  a  proper  ophthalmologist,  he  believed 
that  in  very  many  instances  it  would  be  found  that 
the  gastric  condition  was  dependent  upon  errors  of 
refraction. 

Dr.  De.wer  said  he  agreed  thoroughly  with  Dr. 
Alorris  as  to  the  importance  of  both  these  points. 
As  to  gastroptosis,  he  seemed  to  have  been  some- 
what misunderstood.  (Jccasionally  he  did  see  cases 
where  the  stomach  alone  was  down,  and  in  such  he 
had  found  gastroenterostomy  entirely  effective.  He 
could  not  agree  with  Dr.  Einhorn  in  advising  delay- 
in  making  an  exploratory  incision  in  cases  of  possi- 
ble cancer,  and  could  not  but  think  that  such  teach- 
ing would  have  a  bad  influence. 

Dr.  Bassler  said  he  believed  that  the  early  diag- 
nosis of  cancer  could  not  be  made  by  the  clinical 
signs,  but  only  from  the  laboratory  side,  absolutely. 
We  could  not  depend  upon  any  symptom.  When 
we  found  in  any  case  that  cancer  possibly  existed, 
he  believed  that  we  should  tell  the  patient  frankly 
that  such  was  the  case.  Another  point  worth  noting 
was  that  ulceration  was  commonly  present  in  early 
cancer.  An  exploratory  incision  was  a  compara- 
tively simple  matter,  and  could  be  done  with  the 
local  use  of  a  one  per  cent,  cocaine  solution,  thus 
avoiding  the  employment  of  general  ansesthesia. 

 ®  

fetters  to  the  (tbitor. 


THI-    SriNG  OF  BEES  AS   .-\   CURE  FOR 
RHEUM.^TISiM. 

Ex.\MINING   PhVSICI.\n's  OfFKE. 

Foot  of  E.\st  Twextv-sixth  Street, 
April  13,  1909. 

To  the  Editor: 

The  old  adage  "there  is  nothing  new  under  the 
sun"  holds  true  about  this  new  (  ?)  cure  for  rheuma- 
tism. It  is  certainly  not  a  recent  discovery.  The 
honey  bee  iiullifica)   has  for  many,  many 

years  been  recognized  in  the  homcEopathic  ])harma- 
copoeia  and  practice,  the  tincture  being  considered 
the  most  reliable  remedy  for  rheumatism,  especially 
in  the  acute  forms  accompanied  by  swellings.  It  is 
also  considered  best  for  (tdema  of  the  eyelids  ( non- 
surgical) and  for  facial  erysipelas. 


April  24.  1909.) 


BOOK  NOTICES. 


877 


Bees  are  so  intimately  related  to  the  study  of  bot- 
any that  most  botanists  know  of  this  "rheumatism 
cure,"  while  to  farmers  and  apiarians  the  remedy  is 
almost  as  old  as  the  hills.  Formic  acid  is  the  active 
principle  in  the  salivary  secretion  of  the  bee.  To  the 
bee  it  is  indispensable,  for  it  is  the  means  of  preserv- 
ing the  honey  against  the  processes  of  fermentation 
or  of  changing  into  sucrose.  The  bee  instils  it  into 
the  nectar  (gathered  from  the  flowers)  during  the 
interesting  labor  of  transforming  it  into  honey. 

In  regard  to  the  degree  of  pain  caused  by  the 
sting  of  the  different  bees,  it  might  be  added  that 
the  sting  of  the  Syrian  bee  is  most  painful,  that  of 
the  Italian  bee  less  so,  and  that  of  the  small  black 
honey  bee  least  in  the  severity  and  duration  of  pain. 
Any  one  desinng  to  make  use  of  the  direct  method 
of  application  can  easily  obtain  the  kind  of  bees  he 
wants  at  any  season  of  the  year.  The  dealer  will 
transmit  them  by  mail.  F.  M.  Bauer. 


VWe  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.^ 


Taschcnbncli  dcr  Thcrapic  mit  Ijesonderer  Beriicksichtigung 
der  Therapie  an  den  berliner,  wiener,  u.  a.  deutschen 
Kliniken.  Herausgegeben  von  Dr.  M.  T.  Schnirer,  Re- 
dakteur  der  Klinisc/i-thcrapcutischcn  IV  ochcnschrift. 
Fiinfte.  vermehrte  und  verliesserte  Ausgalie.  Wiirzburg: 
A.  Stubei's  Verlag  (C.  Kabitzscb),  1909.  Pp.  394 
(Price,  2  M.J 

This  little  therapeutical  vade  mecum  appears  for 
the  fifth  time,  taking  into  consideration  the  pharma- 
copoeia of  the  German  language,  so  to  say,  with 
special  reference  to  prescriptions  issued  at  German 
and  Austrian  clinics.  It  contains,  besides,  an  index 
of  official  and  nonofficial  drugs,  alphabetically  ar- 
ranged, with  references  to  pages  where  they  are 
mentioned ;  a  second  list  of  these  drugs  with  the 
doses,  price  in  Austrian  and  German  money,  etc. ; 
a  third  list  of  the  maximum  doses  ;  and  an  alpha- 
betical hst  of  maladies  designated  by  their  Latin 
names  with  the  proper  treatment.  This  list  would 
be  greatly  improved  if  the  pages  were  interleaved 
with  blank  pages  for  the  reader  to  make  his  notes. 
This  is  the  main  part  of  the  manual,  in  which  also 
will  be  found  separate  chapters  on  cosmetics,  sera, 
first  aid,  normal  dentition,  dietetics,  a  list  of  spas, 
etc. 

Noiivcau  traitc  dc  chirurgic.  Publie  sous  la  direction  de 
A.  Le  Dentu  et  Pierre  Delbet.  Volume  XVIII.  Oto- 
rhino-laryngologie.  Par  Andre  Castex,  charge  du  cours 
d'oto-rhino-larj-ngologie  a  la  Faculte  de  medecine  de 
Paris,  et  F.  Lubet-Barbon,  ancien  interne  des  hopitaux 
de  Paris.  Avec  215  figures  intercal'ees  dans  le  texte. 
Paris:  J.  B.  Bailliere  et  fils,  1909.    Pp.  601. 

This  rather  formidable  volume  is  a  "fascicule," 
of  the  new  Traitc  dc  cJiirnrgie  published  under  the 
direction  of  Le  Dentu  and  Delbet,  of  the  faculty  of 
Paris.  While  complete,  in  the  sense  of  dealing  with 
practically  all  the  disease  conditions  known,  it  is 
hardly  sufficiently  detailed  on  some  points.  This 
disproportion  is  particularly  striking  in  the  few  lines 


devoted  to  the  submucous  operations  for  deviation 
of  the  nasal  septum  and  the  paragraph  or  so  on  the 
Stacke  radical  mastoid  operation.  The  illustrations 
are  similarly  uneven.  Many,  notably  the  half  tone 
reproductions  of  instruments  and  disease  conditions, 
are  excellent.  They  are,  however,  all  too  few,  while 
the  more  numerous  woodcuts  are  unsatisfactory 
from  the  artistic  standpoint  as  well  as  that  of  clin- 
ical teaching.  There  is  a  lack  of  descriptive  explan- 
atory text  in  reference  to  the  cuts  of  many  instru- 
ments and  of  some  operations.  This  applies  above 
all  to  the  major  operations  on  the  ear.  The  exposi- 
tion of  functional  tests,  clinical  examinations,  and 
technique  of  treatment  is  uniformly  good. 

Gyndkologic.  Von  Professor  Dr.  Sigmund  Gottschalk 
in  Berlin.  Mit  46  Abbildungen  im  Text,  darunter  i  Far- 
bendruck.  Wien  und  Leipzig :  Alfred  Holder,  1909.  Pp. 
>:iv-355- 

This  is  volume  xviii  of  the  MediziniscJie  Hand- 
bibliotheli  edited  by  Dr.  F.  Luithlen,  of  Vienna. 
Like  the  other  volumes  of  this  encyclopaedic  work, 
it  is  meant  to  be  a  manual  for  the  general  practi- 
tioner; it  is  therefore  a  practical  book,  and  refers 
to  anatomy,  anatomical  pathology,  and  histology 
only  so  far  as  these  branches  are  necessary  for  an 
understanding  of  the  symptoms  ;  it  is  a  product  of 
an  experience  of  nearly  twenty-five  years. 

It  treats  gynaecology  in  sixteen  chapters,  the  first 
two  chapters  being  an  introduction  to  diagnosis,  and 
the  last  two  an  appendix  reviewing  the  sterility  of. 
married  women  and  the  climacteric.  Chapter  III 
treats  of  the  diseases  of  the  vulva,  Chapter  IV  of 
the  vagina,  and  Chapter  V  of  the  uterus.  Chapter 
\  I  speaks  of  the  menstrual  disturbances,  and  Chap- 
ter VII  of  versions  of  the  uterus.  In  Chapter  VIII 
we  find  the  consideration  of  tumors  of  the  uterus. 
Chapter  IX  gives  diseases  of  the  oviduct,  and  Chap- 
ter X  those  of  the  ovaries.  Chapters  XI  and  XII 
deal  with  parametritis,  perimetritis,  and  pelvic  peri- 
tonitis. Chapter  XIII  takes  into  consideration  the 
diseases  of  the  round  ligaments,  and  Chapter  XIV" 
tumors  of  the  pelvic  connective  tissue. 

Dcr  mciischlichc  Korpcr  in  Sage,  Branch  und  Sprichwort. 
Von  Professor  Karl  Knortz,  North  Tarrytown,  N.  Y. 
Wiirzburg:  A.  Stuber,  1909.    Pp.  240. 

This  book  is  a  very  well  compiled  collection  of 
proverbs  and  sayings,  usage  and  tradition,  in  which 
the  human  body  plays  a  role.  It  makes  interesting 
reading,  combining  education  with  pleasure,  such  as 
the  tired  physician  will  greatly  appreciate  after  a 
strenuous  day's  work. 

Surgical  Diseases  of  the  Abdomen,  with  Special  Reference 
to  Diagnosis.  By  Richard  Douglas.  M.  D..  etc.  Illus- 
trated by  20  Full  Page  Plates.  Second  Edition.  Revised 
and  Enlarged.  Edited  by  Richard  A.  Barr.  A.  B.,  M.  D., 
etc.  Philadelphia,  P.  Blakiston's  Son,  &  Co.,  1909.  Pp. 
xi-897. 

The  editor,  taking  up  the  work  of  the  late  Dr. 
Doiiglas,  states  that  he  has  made  few  changes  in  the 
original  edition  except  such  as  were  necessitated  by 
the  progress  which  has  been  made  since  it  was  pub- 
lished, and  that  in  these  changes  he  has  endeavored 
to  follow  out  the  ideas  of  his  predecessor.  Dr. 
Douglas  was  not  only  a  man  of  very  considerable 
experience  as  an  abdominal  surgeon  and  gynaecolo- 
gist, but  a  trained  student  in  pathology  and  a  clear 


878 


MISCELLANY. 


[New  York 
Medical  Journal- 


and  virile  writer.  Consequently  the  editor  of  this 
posthumous  work  has  necessarily  found  very  little 
that  he  could  change  to  advantage. 

The  work  will  repay  the  student  of  abdominal 
surgery  for  careful  reading,  and  will  prove  a  good 
friend  for  consultation  in  the  wide  variety  of  sub- 
jects which  it  discusses,  wider  than  any  similar  work 
on  this  subject  with  which  we  are  familiar.  It  pur- 
ports to  be  principally  a  work  on  diagnosis.  It 
would  be  equally  fair  and  just  to  say  that  it  was 
quite  efficiently  devoted  to  aetiology  and  clinical 
pathology. 

The  last  130  pages  are  especially  devoted  to  gyn- 
aecological subjects,  and  Dr.  Douglas  has  treated 
these  with  conspicuous  ability,  for  this  was  his  par- 
ticular field.  There  is  no  better  or  more  satisfac- 
tory consideration  of  them  in  the  many  books  on 
gynx'cology  which  have  been  issued  in  the  past  ten 
years. 

Throughout  the  book  one  is  impressed  with  the 
magisterial  tone  of  the  trained  clinical  teacher,  and 
it  is  a  great  pleasure  to  follow  him  from  subject  to 
subject.  It  is  far  better  to  treat  a  broad  subject  like 
this  in  one  volume  of  moderate  size  than  to  expand, 
after  the  common  fashion  of  the  day,  into  five  or  six 
volumes,  burdensome  alike  to  the  pocket  and  the 
time  of  the  physician.  Why  will  not  the  influential 
voices  of  the  profession  cry  aloud  against  these 
plethoric  systems  and  series  :  costly,  unhandy,  and 
quickly  out  of  date. 

Diagnosis  und  Therapie  des  Eksems.    Von  Dr.  S.  Jessnek, 
Zweite  Auflage.    Wiirzburg:  C.  Kabitzsch,  1908.    Pp.  96. 

This  is  the  latest  of  the  series  of  excellent  and 
eminently  practical  monographs  upon  dermatologi- 
cal  subjects  by  the  same  author,  many  of  which  have 
deservedly  gone  into  several  editions.  Its  subject 
matter  is  divided  into  two  parts:  i.  The  diagnosis 
of  eczema.  2.  The  treatment  of  eczema.  Both  gen- 
eral and  regional  eczemas  are  considered,  and  the 
treatment  for  both  is  appropriately  given.  It  is  writ- 
ten largely  from  the  standpoint  of  the  author's  per- 
sonal experience  in  clear  and  simple  German.  Its 
usefulness  would  be  greatly  enhanced  if  it  was  fur- 
nished with  an  index.  It  is  a  good  and  safe  guide  to 
the  treatment  of  the  disease  of  which  it  treats. 
Would  that  such  monographs  could  be  produced  in 
this  country  at  the  same  small  price  of  about  sixty 
cents.  So  small  a  book  can  be  carried  in  the  pocket 
and  read  while  one  is  going  his  rounds. 

Practical  Bacteriology,  Blood  Work,  and  Animal  Parasitol- 
ogy, including  Bacteriological  Keys,  Zoological  Tables, 
and  Explanatory  Clinical  Notes.  By  E.  R.  Stitt,  A.  B., 
Ph.  G.,  M.  D.,  Surgeon,  U.  S.  Navy ;  Graduate,  London 
School  of  Tropical  Medicine;  Instructor  in  Bacteriology- 
and  Tropical  Medicine,  U.  S.  Naval  Medical  School ;  Lec- 
turer in  Tropical  Medicine,  Jefferson  Medical  College. 
With  86  illustrations.  Philadelphia:  P.  Blakiston's  Son, 
&  Co.    Pp.  294. 

We  have  been  astonished  at  the  large  amount  of 
accui-atc  information  contained  in  this  book.  As  can 
be  seen  from  the  title,  the  author  covers  a  great  deal 
of  ground  ;  in  fact,  so  far  as  the  reviewer  now  re- 
calls, there  is  no  other  single  book  which  takes  up 
all  the  various  subjects  here  presented.  It  will  be 
readily  understood,  therefore,  that  the  book  is  not 
a  textbook  from  which  one  absolutely  unacquainted 
with  the  subject  could  learn  to  carry  out  the  exam- 


inations described.  The  book  will  be  invaluable  to 
those  who  have  once  mastered  the  subject  and  wish 
to  refresh  their  memor}'  on  some  forgotten  point  of 
technique  or  of  laboratory  diagnosis.  We  heartily 
commend  this  work  as  a  convenient  guide  in  labora- 
tory examinations. 

The  Urine  and  Clinical  Chemistry  of  the  Gastric  Contents, 
the  Common  Poisons,  and  Milk.  By  J.  W.  Holl.-\nd, 
M.  D.,  Professor  of  Medical  Chemistry  and  Toxicology, 
Jefferson  Medical  College  of  Philadelphia.  Forty  Illus- 
trations. Eighth  Edition.  Revised  and  Enlarged.  Phila- 
delphia:  P.  Blakiston's  Son  &  Co.,  1908.  Pp.  viii-i6o. 
(Price,  $1.) 

Holland's  tiranalysis,  as  this  convenient  sized 
manual  of  clinical  chemistry  is  generally  known  to 
sttidents,  is  now  in  its  eighth  edition.  By  judicious 
pruning"  in  some  parts  the  publishers  have  been 
enabled  to  add  much  new  matter  and  bring  the  book 
well  abreast  of  recent  work  in  the  stibjects  of  which 
it  treats.  A  system  of  interleaving  makes  it  easy  for 
the  student  or  laboratory  worker  to  record  inde- 
pendent observations  and  experiments.  Our  favor- 
able opinion  of  the  earlier  editions  of  Holland's  book 
is  enhanced  by  the  new  revised  edition. 



Pistcllann. 


The  Health  of  the  Canal  Zone. — Col.  William 
C.  Gorgas,  2\Ied.  Corps,  U.  S.  A.,  Chief  Sanitary 
Officer  of  the  Canal  Zone,  in  his  report  to  the 
commission  for  the  calendar  year  of  1908,  notes 
that  the  death  rate  among  the  employees  is  the 
lowest  yet  recorded,  being  only  13.01  per  thou- 
sand. In  1906  the  rate  was  41.37,  and  in  1907 
18.77.  Among  the  blacks  the  ratejias  fallen  more 
sharply.  In  1906  it  was  47.24,  in  1907  33.28,  and 
in  1908  only  12.76.  This  is  the  first  year  that  the 
black  death  rate  has  been  lower  than  the  white  rate. 
These  figures  are  for  employees  only.  For  the  gen- 
eral population  of  the  Zone,  Colon  and  Panama,  the 
death  rate  has  fallen  per  thousand  from  65.41  in 
1905  to  24.83  last  year.  There  has  been  a  marked 
falling  off  in  deaths  from  dysentery,  inalaria,-  ty- 
phoid, and  pneumonia.  The  best  measure  of  the 
sanitary  work  done  on  the  Zone  Colonel  Gorgas 
considers  the  malaria  cases.  In  1906  out  of  every 
thousand  employes,  there  were  admitted  to  the 
liospitals  from  malaria  821  ;  in  1907  the  number  fell-' 
to  424,  and  in  1908  to  282.  That  is,  there  is  only 
abotit  one  third  the  amoimt  of  malaria  among  the 
employees  that  existed  three  years  ago.  Beriberi 
has  fallen  from  68  deaths  in  1906  to  38  in  1908.  It 
has  been  more  than  three  years  since  a  case  of  yel- 
low fever  developed  on  the  Isthmus.  The  last  case 
was  in  November,  1905.  The  last  case  of  plague 
was  in  August.  1905.  No  case  of  smallpox  devel- 
oped in  1908.  The  report  for  1908  on  the  whole 
sliows  far  better  conditions  than  have  prevailed  in 
an)'  previous  year  since  the  Americans  have  been  in 
charge  on  the  Isthmus,  and  the  death  and  sick  rates 
among  the  employees  will  compare  favorably  with 
those  of  most  parts  of  the  United  States.  We 
should,  while  doing  full  credit  to  the  splendid  work 
of  Colonel  Gorgas  and  his  assistants,  not  forget 
what  Lieut.  Col.  Goethals.  chief  engineer  of  the 


April  24,  1909.] 


OFFICIAL  NEWS. 


879 


canal,  calls  attention  to  in  his  brochure,  The  Isth- 
mian Canal,  which  is  just  off  the  press  of  the  Gov- 
ernment Printing  Office,  Washington:  "According 
to  the  statistics  of  the  health  department,"  he  says, 
"based  on  the  death  rate,  the  Canal  Zone  is  one  of 
the  healthiest  communities  in  the  world,  but  it  must 
be  remembered  that  our  population  consists  of  men 
and  women  in  the  prime  of  life,  with  but  few  if 
any  of  the  aged,  and  that  a  number  of  the  sick  are 
returned  to  the  United  States  before  death  over- 
takes them."  Colonel  Goethals  goes  on  to  say  that 
"too  much  credit  cannot  be  given  to  the  department 
of  sanitation,  which,  in  conjunction  with  the  divi- 
sion of  municipal  engineering,  has  wrought  such  a 
change  in  the  conditions  as  they  existed  in  1904  as 
to  make  the  construction  of  the  canal  possible. 
— Anny  and  Xavy  Journal.  April  10.  1909. 


Official  lletos. 


2  6- April  2  

20-27   I 

20-27   I 

20-27   I 

27-  ApriI  3   I 

28-  Aiiril  4   2 

-Mar.    1   50 

27-April  3   I 


Public   Health   and    Marine    Hospital  Service 
Health  Reports : 

The  folloz^ing  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Pubfic  Health  and  Marine  Hospital  Service, 
during  the  week  ending  April  16,  igog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

Alabama — Antaugua  County  To  April  5   11 

Alabama — Pottsville  Feb.  7-April 

Alabama — Montgomery  Mar. 

•California — Los  Angeles  Mar. 

■California — Sacramento  Mar. 

•California — San  Francisco  Mar. 

District  of  Columbia — Washington.  Mar. 

Georgia — Macon  Mar. 

Illinois — Canton..."  Jan. 

Illinois — Chicago  Mar. 

Illinois — Danville  Mar.  zS-April  4   7 

Illinois — Fulton  County,  general. .  Jan.    i-Mar.    i   Present 

Illinois — Peoria  Mar.  27--\pril  3   12 

Indiana — Kokomo  Jan.  20-Mar.  7   14  S 

Indiana — Muncie  Mar.  27-April  3   i 

Indiana — South  Bend  Mar.  27-April  3   i 

Iowa — Cedar  Rapids  Mar.  1-31   13 

Kansas — Kansas  City  Mar.  27-April  3   i 

Kansas — Topeka  Mar.  20-27   15 

Kansas — Wichita  Mar.  27-.\pril  3   i 

Kentucky — Berea  Feb.    i-April   5   20 

Kentucky — Covington  ilar.  27-April  3   8 

Louisiana— Xew  Orleans  Mar.  27-April  3   2 

Minnesota — Minneapolis  Mar.   13-27   5 

Missouri — St.  Louis  Mar.  27-April  3   2 

New  Jersey — Camden  Mar.  27-.\pril  3   3 

New  jersey — Hightstown  Mar.  3   i  Imported 

New  Jersey — Xew  Brunswick  .Mar.  27-April  3   3 

New  jersey — Paterson  Mar.  6-April  5   8 

New  Jersey — Plainfield  Mar.  29-April  5   i 

New  Jersey — Woodbridge  ilar.    6   i 

New   Vork — Xew  York  Mar.  27-April  3   4 

Ohio — Cincinnati  Mar.  ig-April  2   10 

Ohio — Cleveland  Mar.  26-April  2   i 

Tennessee — Kno.xville  JIar.  2S-April  3   3 

Texas — Corpus  Christi  April  2   Present 

Texas — Fort  Worth  Mar.  1-31   10 

Te.xas — San  Antonio  Mar.  27-April  3   4 

■Wisconsin — La  Crosse  Mar.  27-April  3   2 

Smallpox — In  sular. 
Philippine  Islands — Manila  Feb.   20  27   5 

Smallpox — Foreign. 

Brazil — Bahia  Feb.    13-27   15  i 

Brazil — •Pernambuco   Feb.   1-15   11 

Canada — Halifax  Feb.    13-27   5 

China — Hongkong  Feb.    13-27   4 

China — Shanghai  Feb.  28-Mar.  6   i 

China — Tientsin  Feb.   20-27   i 

Eg>'Pt — Alexandria  Feb.    18-25   i 

Egypt — Cairo  Feb.   18-25   27  17 

France — Paris  Mar.  6-20   6 

•Great  Britain — Bristol  Mar.  13-20   i  i 

India — Bombay  Mar.  2-9.  . . 

India — Calcutta  Feb.  20-27. 

India — Madras  Feb.  27-Mar 

India — Rangoon  Feb.  20-27. 

Indo-China — Saigon  Feb.  6-13.. 

Italy — General  Mar.  13-21. 

Italy — Catania  Mar.  6-20.. 

Italy— Genoa  Feb.  1-28.. 

5  caly — Naples  Mar.  14-21. 


19 

332 


14 


Places.  Date.  Cases.  Deaths. 

Italy — Palermo  Feb.  23-Mar.  6   2 

Japan — Formosa  Feb.  13-Mar.  13   9 

Jaiian — Kobe  Mar.   6   i  ' 

Java — Batavia  Feb.    13-20   5  ' 

Malta  Feb.    13-20   ' 

Mexico — Guadalajara  Mar.  18-25   5 

Mexico — Monterey  Mar.  21-28   4 

Mexico — \'era  Cruz  Mar.  21-27   i  ' 

Netherlands — The  Rotterdam  Mar.  20-27   ' 

Newfoundland — St.  John's  Mar.  13-20   i 

Russia — Moscow  ilar.  6-20   54  I7 

Russia — Odessa  Mar.  6-13   i 

Russia — Riga  Mar.  6-20   6 

Russia — St.  Petersburg  Feb.  20-Mar.  6   23  ; 

Spain — -Almeria  Feb.    1-28   2 

Spain — Barcelona  Mar.  8-22   7 

Spain — Valencia  Mar.  12-19   ' 

Straits  Settlements — Singapore...  Feb.    13-20   i 

Uruguay — Montevideo  Jan.    1-31   ' 

Yellow  Fever — Foreign. 

Barbados — General  Mar.  22-27   3 

Brazil — Bahia  Feb.    13-27   14  6 

Brazil— Para  Mar.  6-13   5 

Brazil — Pernambuco  Feb.    1-15   1 

Ecuador — Guayaquil  Mai.  6-13   10 

Cholera — Insular. 

Philippine  Islands — Provinces....  Feb.  20-27   28  34 

Cholera — Foreign. 

India— Calcutta  Feb.   20-27   4° 

India — Madras  Feb.  27->lar.  5   2 

India — Rangoon  Feb.   20-27   / 

Russia — Saratov  Mar.    21   i 

Russia — St.  Petersburg  Mar.   19-26   19  4 

Straits  Settlements — Penang  Feb.   20-27   i 

Straits  Settlements — Singapore  ...Feb.    13-27   3 

Plague — Foreign. 

Brazil — Bahia  Feb.    13-27   6  2 

Chile — Magillones  Mar.    10   Epidemic 

China — Hongkong  Feb.  6-27   6  5 

Ecuador — Guayaquil                         Mar.   6-13   5 

India — General  Feb.    20-27  4.71/  3.75>3 

India — Bombay  Mar.  2-9   197 

India — Calcutta  Feb.  20-27   36 

India — Rangoon  Feb.  20-27   17 

Japan — Formosa  Jan.  23-Mar.  13   223  187 

Tapan — Kobe                                     Feb.   27-Mar.   6   i 

Turkey — Jiddali  Mar.  15-21   16  iC 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
April  14,  1909: 

Bl.axchard,  J.   F.,   Acting  Assistant  Surgeon.  Granted 

three  days'  leave  ot  absence  from  April  13.  1909. 
Collins.  G.  L..  Passed  Assistant  Surgeon.    Detailed  as 

chairman  of  board  of  medical  officers  convened  under 

Bureau  order  of  April  5,  1909. 
Ebersole,  R.  E.,  Passed  Assistant  Surgeon.    Granted  seven 

days"  leave  of  absence  from  February  27.  1909,  under 

paragraph  191,  Service  Regulations. 
G.ARDXER.  C.  H.,  Passed  Assistant  Surgeon.    Granted  three 

days'  leave  of  absence  from  April  8.  1909. 
GoLDBERGER,  JoSEPH.  Passed  .'\ssistant  Surgeon.  Directed 

to  proceed  to  Richmond,  Va.,  upon  special  temporary 

duty. 

Grah.\m,  K.  H.,  Pharmacist.  Granted  one  day's  leave  of 
absence  en  route  to  station. 

HoBDV.  ^VILLI.^M  C.,  Passed  Assistant  Surgeon.  Upon 
being  relieved  by  Passed  Assistant  Surgeon  Frederick 
E.  Trotter,  directed  to  proceed  to  Honolulu,  T.  H..  and 
assume  command. 

Irwin,  Fairf.ax,  Surgeon.  Relieved  from  duty  on  the  Rev- 
enue Cutter  Snohomish  and  directed  to  report  to  the 
commanding  officer  of  the  Revenue  Cutter  Rush  for 
duty. 

Kastle.  Joseph  H..  Chief  Division  of  Chemistry,  Hygienic 
Laboratory.  Granted  two  days'  leave  of  absence  in 
March,  1909,  under  paragraph  211,  Service  Regulations. 

King.  Walter  W..  Passed  .\ssistant  Surgeon.  Relieved 
from  duty  at  the  Marine  Hospital,  San  Francisco,  Cal., 
and  detailed  for  duty  in  the  examination  of  arriving 
aliens  at  San  Francisco,  Cal. 

Onuf,  B.,  Acting  Assistant  Surgeon.  Granted  seven  days' 
extension  of  annual  leave,  on  account  of  sickness,  from 
March  29,  1909. 

Ott.  C.  R..  Pharmacist.  Relieved  from  dut}^  at  Fort  Stan- 
ton, N.  M.,  and  directed  to  proceed  to  Memphis,  Tenn., 
and  report  to  the  Medical  Officer  in  command  for  duty 
and  assignm.ent  to  quarters. 

Sprague.  E.  K..  Passed  Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence  from  April  8,  1909. 


88o 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal, 


Stiles,  Charles  Wardeli.,  Chief  Division  of  Zoology, 
Hygienic  Laboratory.  Granted  one  day's  leave  of  ab- 
sence in  March,  1909,  under  paragraph  211,  Service 
Regulations. 

Tappan,  J.  W.,  Acting  Assistant  Surgeon.  Granted  five 
days'  extension  of  annual  leave  on  account  of  sicknesb 
from  March  11,  1909. 

Trotter,  Frederick  E.,  Passed  Assistant  Surgeon.  Upon 
being  relieved  by  Passed  Assistant  Surgeon  Walter  W. 
King,  ordered  to  assume  command  of  the  San  Fran- 
cisco Quarantine  Station,  Angel  Island,  Cal. 

Wertenbaker,  C.  p.,  Surgeon.  Relieved  as  chairman  of 
medical  officers  convened  under  bureau  order  of  April 
5,  1909- 

Appointment. 

Dr.  Samuel  C.  Hotchkiss  commissioned  as  an  assistant 
surgeon  in  the  Public  Health  and  Marine  Hospital  Service. 

Resignation. 

Pharmacist  C.  R.  McBride  resigned,  to  take  effect  April 
23,  1009. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers seri'ing  in  the  Medical  Corps  of  the  United  States 
Army  for  the  week  ending  April  ij,  igog: 
Baily,  M.  H.,  Captain,  Medical  Corps.    Ordered  to  accom- 
pany Company  F,  Engineers,  from  Washington  Bar- 
racks, D.  C.,  to  Vancouver  Barracks,  Wash.,  and  then 
return  to  station.  Fort  Myer,  Va. 
Brown,  H.  L.,  Captain,  Medical  Corps.    Granted  leave  of 

absence  for  six  days. 
Freeman,  C.  E.,  First  Lieutenant,  Medical  Corps.  Ordered 
to  report  at  San  Francisco,  Cal.,  for  examination  for 
promotion. 

Hanson,  L.  H.,  First  Lieutenant,  Medical  Corps.  Ordered 
to  report  at  Wasliington,  D.  C,  for  examination  for 
promotion. 

Hart,  W.  L.)  First  Lieutenant,  Medical  Corps.  Ordered 
to  accompany  Company  G,  Engineers,  to  San  Francisco, 
Cal. ;  then  to  return  to  Washington  Barracks,  D.  C. 

Hewitt,  J.  M.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  duty  with  troops  in  the  Yosemite  National 
Park. 

HopwooD,  L.  L.,  First  Lieutenant,  Medical  Corps.  Or- 
dered to  report  at  San  Francisco,  Cal.,  for  examination 
for  promotion. 

Hughes.  L.  S.,  First  Lieutenant,  Medical  Reserve  Corps. 

Ordered  from  Fort  McDowell,  Cal.,  to  temporary  duty 

at  the  Department  Rifle  Range,  Point  Bonita,  Cal. 
Jones,  H.  W.,  First  Lieutenant,  Aledical  Corps.  Ordered 

to  report  at  Washington,  D.  C,  for  examination  for 

promotion. 

Kress,  C.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Bliss,  Texas,  in  time  to 
proceed  to  San  Francisco,  Cal.,  and  sail  June  5th  for 
service  in  the  Philippines. 

Love,  A.  G.,  First  Lieutenant,  Medical  Corps.  Ordered  to 
report  at  Washington,  D.  C,  for  examination  for  pro- 
motion. 

McIntvre,  H.  B.,  First  Lieutenant,  Medical  Corps.  Or- 
dered to  report  at  San  Francisco,  Cal.,  for  examination 
for  promotion. 

Mc  Millan,  C.  W.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  duty  at  target  range  near  Ashland,  Nebr., 
during  the  target  practice  season. 

MuNSON,  E.  L.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  two  months,  ten  days,  about  June  5th. 

PiNKSTON,  O.  W.,  First  Lieutenant,  Medical  Corps.  Or- 
dered to  report  at  Washington,  D.  C,  for  examination 
for  promotion. 

Raymond.  T.  U.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  one  month. 

Reasoner.  M.  a.,  First  Lieutenant,  Medicf.l  Corps.  Or- 
dered to  report  at  Washintrton,  D.  C,  for  examination 
for  promotion. 

SrHMiTTF.R,  F.,  First  Lieutenant,  Medical  Corps.  Ordered 
to  report  at  Washington,  D.  C,  for  examination  for 
promotion. 

Sparrenuergep,  F.  II.,  First  Lieutenant,  Medical  Reserve 

Corps.    Granted  an  extension  of  twenty  days  to  his 

leave  of  absence. 
Woodson.  R.  S.,  Major,  Medical  Corps.    Ordered  to  Fort 

Hamilton,  N.  Y.,  for  duty,  instead  of  Fort  Du  Pont, 

Dtl. 


Navy  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  wee  ft  ending  April  //,  igog: 
Bki.l,  W.  H.,  Surgeon.    Detached  from  the  Bureau  of  Med- 
icine and  Surgery,  Navy  Department,  and  ordered  to 
instruction  at  the  Naval  Medical  School,  Washington, 
D.  C. 

Biello,  J.  A.,  Assistant'  Surgeon.  Detached  from  duty  at 
the  Naval  Hospital,  Mare  Island,  Cal.,  and  ordered  to 
the  Vicksburg  vvhen  commissioned. 

Chambers,  W.,  Assistant  Surgeon.  Detached  from  the 
Naval  Recruiting  Station,  Dallas,  Texas,  and  ordered 
to  the  Maryland. 

Connor,  W.  H.,  Acting  Assistant  Surgeon.  Ordered  to 
duty  at  the  Naval  Hospital,  Norfolk,  Va. 

Curl,  H.  C.,  Surgeon.  Detached  from  duty  at  the  Naval 
Medical  School  Hospital,  Washington,  D.  C,  April 
24th,  and  ordered  to  duty  at  the  Naval  Hospital,  Cana- 
cao,  P.  I.,  via  the  Buffalo. 

FxSKE,  C.  N.,  Passed  Assistant  Surgeon.  Ordered  to  spe- 
cial temporary  duty  in  the  Bureau  of  Medicine  and 
Surgery,  Navy  Department. 

Heiner,  R.  G.,  Passed  Assistant  Surgeon.  Detached  from 
the  Pennsylvania  and  ordered  to  the  Albany. 

Jones,  E.  L.,  Assistant  Surgeon.  Detached  from  the  Mary- 
land and  ordered  to  the  Naval  Recruiting  Station,  Dal- 
las, Texas. 

Kennedy,  R.  M.,  Surgeon.  Detached  from  the  Bureau  of 
Medicine  and  Surgery,  Navy  Department,  and  ordered 
to  instruction  at  the  Naval  Medical  School,  Washing- 
ton, D.  C. 

Reed,  T.  W.,  Assistant  Surgeon.  Orders  of  March  17th 
modified ;  detached  from  the  Colorado  and  ordered  to 
the  Marine  Recruiting  Station,  San  Francisco,  Cal.,  and 
to  duty  in  attendance  upon  officers  and  families  not 
otherwise  provided  Vi'ith  medical  service. 

Stibbens,  F.  H.,  Assistant  Surgeon.  Detached  from  the 
Albany  and  ordered  to  the  Pennsylvania. 

Stokes,  C.  F.,  Surgeon.  Detached  from  the  Naval  Acad- 
emy and  ordered  to  the  Naval  Medical  School  Hospi- 
tal, Washington,  D.  C,  for  duty. 

Wilson,  H.  D.,  Surgeon.  Ordered  to  additional  duty  in 
charge  of  the  medical  departments  of  the  Indiana,  Ken- 
tucky and  Illinois. 

 ^  


M  arried. 

Gannon — Lambert. — In  W^ashington,  D.  C,  on  Wednes- 
day, April  14th,  Dr.  James  A.  Gannon  and  Miss  Mildred' 
Benedicta  Lambert. 

Halsey — Bates. — In  New  York,  on  Wednesday,  April: 
14th,  Dr.  R.  H.  Halsey  and  Miss  Edith  Bates. 

Jones — Clark. — In  Stockbridge,  Massachusetts,  on 
Thursday,  April  8th,  Dr.  Joseph  Jones  and  Mrs.  Emily  M. 
Clark. 

Died. 

Bone. — In  Arlington,  Tennessee,  on  Sunday,  April  nth,. 
Dr.  J.  P.  Bone,  aged  seventy-seven  years.' 

Brooke. — In  Newark,  Ohio,  on  Fridav,  April  2nd.  Dr. 
J.  H.  Brooke. 

Duke. — In  Cumberland,  Maryland,  on  Tuesday,  .April' 
13th,  Dr.  Edgar  T.  Duke,  aged  forty-two  years. 

Hazen.^ — In  Sharon,  Pennsylvania,  on  Tluirsday,  .\pril 
8th,  Dr.  Samuel  A.  Ha7.en,  aged  sixty-five  years. 

Jolly. — In  Dixon,  Nebraska,  on  Friday,  April  2nd,  Dr. 
J.  O.  Jolly. 

Neufield. — In  New  York,  on  Sundav,  April  nth.  Dr. 
Albert  W.  Neufield. 

Radford. — In  Kansas  City,  Missouri,  on  Saturday,  April 
loth,  Dr.  Thomas  W.  Radford,  aged  eighty  years. 

Smith. — In  Louisville,  Kentucky,  on  Wednesday,  April 
"th.  Dr.  Letchworth  Smith,  aged  thirty-nine  years. 

Stark. — In  Little  Rock,  .Arkansas,  on  Friday,  April  9th, 
Dr.  R.  L.  Stark,  aged  sixty-eight  years. 

Stern. — In  .San  Francisco,  California,  on  'Wednesday, 
.April  7th,  Dr.  Louis  Stern,  aged  fifty-six  years. 

Tytlf.r. — In  New  York,  on  Tluirsday,  April  15th.  Dr. 
George  E.  Tytlcr,  aged  sixty  years. 

Whitney. — In  Big  Rapids,  Michigan,  on  Saturday,  April' 
3d,  Dr.  Willard  Southard  Whitney,  aged  ninety  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  tH  Medical  News 


A   Weekly  Review  of  Medicine,  Established  184J. 


V'ML.  LXXXIX,  Xo.  iS.  XEW  YORK.  .MAY  i.  1909.  Whole  Xo.  1587. 


THE  DOCTOR  AXD  THE  NURSE* 

Bv  Charles  P.  Noble.  M.  D.. 
Philadelphia. 

It  has  once  more  become  my  duty,  as  represent- 
ins^  the  stafif  of  the  hospital,  to  deliver  the  annual 
address  to  the  graduating  class.  During  the  course 
of  your  training  you  have  received  instructions  upon 
principles  which  are  the  basis  of  your  work  as 
nurses  and  have  also  received  instruction  as  to  the 
natu:-e  of  your  responsibilities  and  more  particularly 
as  to  the  trust  relations  which  exist  between  each 
of  you  as  a  nurse  to  the  physician  and  to  the  patient 
who  employs  vou.  Perhaps  you  feel  that  these  in- 
structions have  been  not  only  ample,  but  more  than 
ample.  Hence  I  shall  not  enlarge  upon  these  ques- 
tions this  evening,  but  will  discuss  instead  the  nature 
of  the  life  of  the-doctor  and  of  the  nurse. 

As  vour  career  as  nurses  so  far  has  been  spent 
in  a  hospital  we  will  select  the  hospital  doctor  and 
the  hospital  nurse  as  types  for  discussion.  It  may 
be  that  the  nature  of  their  relation  to  the  institution 
with  which  they  are  connected  and  the  patients 
whom  they  serve  has  not  fully  impressed  itself  upon 
you . 

The  doctor  occupies  a  dual  relation  in  his  work 
as  a  hospital  surgeon  or  physician.  First,  there  is 
the  trust  relation  between  the  doctor  and  the  hos- 
pital, and.  second,  that  between  the  doctor  and  his 
patient.  Xow  what  is  the  nature  of  the  hospital  ? 
It  is  an  institution  founded  by  the  charitable,  or  the 
philanthropic,  to  restore  to  health  or  to  ameliorate 
the  sufferings  of  the  poor  and  the  lowly  who  have 
been  overtaken  by  disease.  It  is  true  that  in  the 
mcKlern  hospital  those  that  are  not  poor  are  also 
treated.  But  this  is  a  secondary  matter  and  is  ar- 
ranged merely  for  the  convenience  of  the  public  and 
for  the  convenience  of  the  medical  stait.  The  prim- 
ary purpose  of  the  hospital  is  to  care  for  the  poor. 

It  ma>-  interest  you  to  know  that  hospitals  are  a 
comparatively  modern  institution  and  that  they  are 
the  outgrowth  of  the  spirit  of  Christianity.  Prior 
to  the  Christian  era  there  were  no  hospitals  and  the 
philosophical  reason  for  this  is  apparent. 

The  basic  teaching  of  the  Christian  religion  is 
charitv.  which  is  love,  and  from  this  principle,  in 
ihought.  is  born  altruism,  and  in  practice,  philan- 

*Addre5s  delivered  at  the  Annual  Commencement  of  the  Training 
School  for  Nurses  at  the  Kensington  Hospital  for  Women.  Phila- 
delphia. Janiiar}'   14,  1909. 


thropv.  Prior  to  the  Christian  era  men  were  con- 
trolled by  the  primar\-  law  of  creation,  which  is  self 
preservation.  The  fit  survived  and  the  unfit  per- 
ished in  the  battle  between  the  strong  and  the  weak. 
Xo  man  was  his  brother's  keeper,  but  each  man 
fought  for  himself  as  do  the  beasts  of  the  field.  This 
was  the  old.  or  so  called  Jewish,  dispensation :  then 
Christianity  was  introduced  into  the  world  to  change 
this,  by  the  introduction  of  the  principle  of  charity 
which  shall  influence  the  minds  and  the  hearts  of 
men.  and  so  cause  them  to  be  less  selfish  and  to  be 
more  thoughtful  of  others. 

Every  philosophical  writer,  whether  himself  a 
Christian  or  not.  has  recognized  the  truth  that  the 
world  has  been  different  since  the  year  i,  A.  D.. 
and  that  the  difference  consists  in  the  effect  upon 
the  acts  of  mankind  of  the  principle  of  charity. 

It  will  be  unnecessary  to  enlarge  upon  the  nature 
of  the  trust  relation  between  the  hospital  doctor  and 
the  institution  which  he  serves.  Suffice  to  sav  that 
it  is  his  dut}'  to  carry  into  practical  eft'ect  the  pur- 
poses of  the  hospital,  to  cure  their  diseases,  or  to 
relieve  the  suft'erings  of  the  patients  committed  to 
his  charge. 

In  his  relation  to  his  patient  the  conditions  are 
dift'erent.  As  hospitals  exist  for  the  care  of  the 
poor  it  is  but  natural  that  the  great  majority  of  their 
patients  are  poor  and  unfortunate,  and  therefore  it 
becomes  the  duty  of  the  doctor  to  serve  them  with- 
out price  because  otherwise  they  must  go  without 
service. 

Xow  what  is  the  nature  of  this  service  and  of  this 
relation  ?  In  order  to  do  his  duty  the  surgeon  must 
know  his  business.  He  must  be  a  man  of  education 
in  a  general  sense,  and  in  a  special  sense  he  must  be 
instructed  in  the  principles  and  practice  of  medicine 
and  in  addition  in  the  special  principles  and  practice 
of  surgery.  'If  he  has  charge  of  a  service  for  the 
diseases  of  women,  in  addition  he  must  understand 
the  nature  of  women  as  distinguished  from  men.  be- 
cause if  he  does  not  understand  this  he  will  fail  to 
deal  wisely,  that  is  successfully,  with  the  patients 
committed  to  his  charge. 

Women  are  dift'erent  from  men.  Their  special 
senses  are  more  highly  developed.  They  are  more 
under  the  influence  of  their  feelings  and  their  emo- 
tions. Xhey  are  dominated  by  their  affections  both 
negatively  and  positively ;  all  of  which  is  another 
way  of  saying  that  their  nervous  systems  are  more 
delicately  organized  than  is  true  of  men.  Hence 
they  are  more  liable  to  the  functional  nervous  dis- 
eases than  are  men  and  their  bodies  are  more  con- 


Copyright.  1909.  by  .\.  R.  Elliott  Publishing  Company. 


882 


NOBLE:  DOCTOR  AND  NURSE. 


LXew  York 
Medical  Jovrnm.. 


trolled,  or  at  least  influenced,  by  their  thoughts  than 
is  true  of  men.  Therefore  the  woman's  doctor  must 
be  also  a  neurologist  and  a  practical  psychologist  in 
order  to  understand  his  patients  and  their  diseases 
and  the  causes  of  the  various  symptoms  of  which 
tiiey  complain. 

Like  every  surgeon  he  must  be  a  craftsman,  that 
is  he  must  have  learned  by  practice  the  art  of  sur- 
gery as  an  apprentice,  in  order  to  do  his  work  rapid- 
ly, accurately,  and  well,  hence  much  is  required  of 
him  in  order  that  he  may  do  his  duty. 

If  he  is  an  honest  man  and  has  what  is  called  a 
sense  of  duty,  he  feels  the  necessity  of  learning  all 
that  a  man  can  learn  about  his  profession  in  order 
that  his  patients  may  receive  from  him  the  best  that 
can  be  given,  and  as  such  a  man  always  knows  his 
own  limitations,  his  sense  of  duty  is  a  constant  spur 
to  make  him  do  his  best. 

In  the  wards  of  a  hospital  where  the  patients  are 
received  his  relations  to  his  patients  are  those  of  the 
trained  scientist  who  is  seeking  the  truth,  guided  by 
the  knowledge  of  his  profession  and  helped  in  the 
solution  of  the  particular  problems  by  his  practical 
training  in  his  calling,  which  is  called  making  a 
diagnosis.  Here  he  must  also  create  the  normal  re- 
lation between  doctor  and  patient — that  is,  he  must 
cause  the  patient  to  put  her  trust  in  him  in  order 
that  her  mind  may  be  at  ease  and  that  she  may  be 
willing  to  accept  the  advice  which  is  necessary  for 
a  cure.  More  especially  with  the  poor  this  must  be 
accomplished  through  kindliness  of  manner  because 
the  poor  and  the  ignorant  are  not  intelligent  and 
therefore  one  cannot  appeal  to  their  reason.  Hence 
in  the  ward  the  personality  of  the  doctor  is  a  very 
large  factor  in  the  success  or  the  failure  of  his  work, 
which  is  but  another  way  of  saying  of  the  work  of 
the  hospital. 

In  the  operating  room  personality  is  lost  sight  of. 
The  particular  problem  is  to  perform  the  operation 
or  operations  in  such  a  manner  as  best  to  insure  the 
recovery  of  the  patient.  Here  everything  must  bend 
to  securing  this  one  result.  The  surgeon  becomes  a 
craftsman,  though  he  remains  the  engineer,  for  his 
■knowledge  of  theory  guides  his  fingers  and  also 
•obliges  hmi  to  maintain  military  discipline,  because 
Tthe  chain  is  no  stronger  than  its  weakest  link,  and 
he  must  work  not  only  himself,  but  through  as- 
sistants, and  the  failure  of  any  one  of  these  to  per- 
form his  or  her  part  correctly  may  mar  the  whole 
plan  and  result  in  the  injury  or  the  death  of  the  pa- 
tient. Hence  this  is  a  trying  part  of  the  surgeon's 
life,,  for  ho  is  responsible  to  his  patient  not  only  for 
his  ov.'n  acts,  but  also  for  those  of  all  who  assist  him. 

In  a  busy  hospital  tljere  is  necessarily  always  a 
"busy  operating  room,  and  the  operations  must  be 
performed  in  series  and  the  series  is  arranged  not 
iiI)on  personal  grounds,  but  according  to  the  nature 
of  the  disease.  This  is  done  in  order  that  one  pa- 
tient may  not  be  infected  from  septic  matter  which 
may  be  contained  in  the  body  of  another.  In  the 
modern  hospital  where  both  the  poor  and  those  who 
are  not  poor  arc  treated,  it  thus  comes  about  that 
the  poor  often  come  before  the  rich  in  the  arrange- 
ment of  the  operating  room  schedule ;  because  to  the 
true  surgeon  all  are  human  beings  and  each  deserves 
the  same  consideration  at  his  hands.    There  is  no 


thought  of  busmess  or  of  price  in  the  operating 
room ;  its  work  is  controlled  in  so  far  as  may  be 
by  the  laws  of  pure  science,  that  is  that  portion  of 
universal  truth  which  is  called  the  principles  of 
medicine. 

When  the  patient  is  returned  to  the  wards  for 
postoperative  care,  it  is  still  the  principles  of  medi- 
cine which  direct  the  treatment,  but  once  more  the 
personality  of  the  doctor  as  well  as  that  of  the  nurse 
becomes  the  dominant  factor  in  promoting  the  peace 
of  mind  and,  therefore,  the  recovery  of  the  patient. 
This  is  the  psychological  factor  in  practice,  and  de- 
pending upon  the  spirit  with  which  it  is  exercised 
there  results  the  atmosphere  of  the  hospital,  which 
may  be  either  kindly  and  helpful  or  rigid  and  insti- 
tutional ;  the  one  being  the  right  spirit  and  the  other 
being  the  harsh  one. 

Thus  the  entire  relation  of  the  doctor  to  the  pa- 
tient is  one  of  service,  but  service  guided  and  con- 
trolled by  knowledge,  and  hence  the  doctor's  acts 
are  controlled  by  sentiment  rather  than  by  senti- 
mentality. 

The  relations  of  the  nurse  to  the  patient  and  to 
the  doctor  are  quite  similar  in  their  nature.  She  is 
the  doctor's  assistant  and  much  of  his  treatment 
that  is  psychological  must  be  carried  into  practical 
effect  by  her.  Thus  she  can  do  much  either  to  make 
or  mar  the  success  of  his  efforts,  and  the  good  nurse 
who  is  faithful,  intelligent,  and  efficient,  is  of  the 
utmost  value,  indeed  a  prime  necessity  in  enabling 
him  to  cure  or  to  relieve  his  patients. 

Like  the  doctor  she  must  be  instructed  in  the  prin- 
ciples which  underlie  her  practical  duties  in  order 
that  she  may  understand  the  reason  why  she  does 
what  she  is  called  upon  to  do  and  thus  be  not  a  mere 
machine.  In  addition  she  must  be  a  craftsman  and 
learn  the  technique,  that  is  the  way  of  doing  the 
various  things  that  she  is  called  upon  to  perform. 
She  must  serve  her  apprenticeship,  and  it  is  for  this 
that  she  serves  the  hospital  during  the  period  of 
probation,  her  pupilage.    This  you  have  all  done. 

The  nurse  comes  into  much  more  intimate  rela- 
tion with  the  patient  than  does  the  physician,  and 
hence  in  the  psychological  management  of  the  pa- 
tient may  be  of  equal  or  even  more  value  than  the 
doctor.  It  is  true  that  the  doctor  directs  or  wishes 
for  the  right  atmosphere  to  surround  his  patient,  but 
the  nurse  becomes  the  environment  of  the  patient, 
and  it  depends  upon  her  as  to  whether  the  patient 
receives  it,  that  is  lives  in  the  right  atmosphere. 
Thus  the  personality  of  the  nurse  is  a  most'  import- 
ant factor  in  the  successful  management  of  sick  per- 
sons. What  is  called  a  good  heart,  that  is  right 
principles  and  unselfishness,  is  a  factor  of  primary 
importance  in  constituting  a  good  nurse. 

Nature  points  out  why  this  is  true.  The  first 
mother  who  suckled  her  children  and  tended  them 
in  health  and  in  sickness,  was  the  first  nurse,  and 
so  nursing  is  as  old  as  the  race ;  and  as  the  spirit  of 
unselfishness  is  that  which  above  all  others  char- 
acterizes the  mother,  so  it  is  this  spirit  which  above 
ail  others  should  characterize  the  nurse  whether  she 
nurse  her  own  people  or  "the  stranger  within  the 
gates." 

X'ot  only  must  the  nurse  have  a  kind  heart,  but 
she  must  also  have  intelligence ;  for  with  the  Ijest 


May  I,  1909. J 


ELLIOTT:   TONSILLAR  TOXIN ES. 


883 


intentions,  without  intelligence  and  without  knowl- 
edge, her  efforts  may  be  not  only  unavailing,  but 
even  positively  harmful.  Also  to  promote  the  recov- 
ery of  her  patient  she  must  know  her  business ;  that 
is,  she  must  be  skillful  in  the  performance  of  her 
various  duties.  This  she  acquires  by  training,  and 
it  is  only  by  training  that  she  can  become  skillful. 
Thus,  as  is  true  of  the  doctor,  that  is  the  typical 
doctor  or  the  ideal  doctor — so  it  is  true  of  the  nurse, 
that  is,  of  the  real  nurse — her  life  is  one  of  service ; 
and  so  in  the  hospital  it  is  the  patients,  the  poor  and 
the  unfortunate  whom  she  serves. 

Now,  is  this  scientific?  Yes,  because  science  is 
truth  and  one  truth  is  just  as  true  as  another  truth; 
and  while  the  truths  of  medicine  must  guide  the 
doctor  and  the  nurse  in  the  performance  of  their  re- 
spective duties,  it  is  none  the  less  true  that  the  truth 
which  is  called  charity,  when  it  dominates  their  ac- 
tions, creates  the  atmosphere  which  is  needed  to 
promote  in  the  highest  degree  the  recovery  of  their 
patients. 

Now,  who  is  the  model,  or  the  arch  type,  who  set 
the  example  for  the  physician  and  the  nurse  to  fol- 
low? It  was  the  Great  Physician,  who  healed  not 
only  the  diseases  of  the  body,  but  also  those  of  the 
souls  of  his  patients ;  and  this  is  the  spirit  which 
should  both  animate  and  dominate  the  physician  and 
the  nurse  in  the  performance  of  their  duties. 

This  is  now  the  twentieth  year  of  my  connection 
with  this  institution,  during  all  of  which  time  I  have 
been  a  member  of  its  Board  of  Directors  and  of  its 
Executive  Committee,  upon  whose  respective  mem- 
bers falls  the  duty  of  conducting  its  affairs.  The 
board  has  always  desired  that  this  work  shall  be 
conducted  upon  the  best  possible  lines  and  it  has 
been  not  only  the  purpose,  but  also  the  care  of  the 
Executive  Committee  that  this  object  shall  be  ac- 
complished. The  question  has  always  been,  not, 
"how  little  can  be  done  for  our  patients  or  our  em- 
ployees or  for  the  medical  staff  or  for  the  nurses." 
but  "what  ought  to  be  done,"  and  to  the  best  of  their 
ability  this  has  been  carried  into  effect. 

Two  of  the  members  of  this  committee  are  with 
us,  and  so  nothing  need  be  said  of  them,  but  one  who 
served  the  hospital  for  twenty  years,  has  passed  to 
his  reward,  and  a  few  words  concerning  his  service 
are  appropriate.  I  served  with  him  upon  the  Ex- 
ecutive Committee  for  sixteen  years  and  met  him 
every  week,  and  in  the  settlement  or  adjustment  of 
all  the  many  problems  which  came  before  the  com- 
mittee during  that  long  period,  I  never  heard  him 
say  an  vmkind  word,  or  express  an  unkind  or  an  un- 
charitable thought.  He  not  only  continued  faithful 
to  the  duties  of  his  position,  but  made  it  his  dutv.  as 
well  as  his  pleasure,  to  visit  every  employee  of  the 
institution  and  to  greet  each  with  a  pleasant  word, 
so  that  everyone  loved  him.  His  presence  and  his 
personality  went  far  to  create  the  right  atmosphere, 
which  should  prevail  in  every  charitable  institution, 
so  that  its  work  may  be  done  in  the  spirit  which 
brought  about  its  foundation.  Who  can  estimate 
the  good  which  this  loving  service  performed  so 
cheerfully  and  unostentatiously,  has  done  in  this 
community? 

So  long  as  I  was  personally  able  to  do  all  the 
l)rofessional  work  of  the  hospital  it  was  the  daily 
habit,  for  the  lesson  which  it  taught,  in  making  the 


usual  rounds,  to  visit  first  the  ward  patients — the 
private  patients  were  visited  later.  The  hospital  ex- 
ists primarily  for  the  care  of  the  poor,  and  therefore 
they  should  be  the  first  care  of  the  surgeon  as  well 
as  of  the  nurses.  The  idea  of  institutionalism  was 
never  permitted  to  gain  a  foothold  in  this  hospital 
and  I  trust  that  in  the  future,  as  in  the  past,  this 
same  policy  will  be  pursued. 

I  have  referred  to  the  great  example,  the  arch 
type,  the  Great  Physician.  Now  what  was  his  life? 
VVas  it  a  selfish  one,  and  was  it  self  seeking?  Or 
was  it  devoted  to  the  service  of  others?  All  men 
know  the  answer.  He  served  not  only  his  fellows, 
but  all  men.  By  precept  he  taught  the  duty  and 
the  beauty  of  service,  and  he  .said  "that  greater  love 
hath  no  man  than  this,  lhat  he  lay  down  his  life  for 
his  friend,"  and  by  example  He  laid  down  His  owil 
life  for  mankind.  And  this  is  the  thought  which 
should  be  uppermost  in  our  minds  when  we  read  of 
the  doctor  and  of  the  nurse  who,  in  fulfilling  the  du- 
ties of  their  calling,  whether  in  the  performance  of  a 
surgical  operation  upon  a  septic  patient,  in  combat- 
ting the  ravages  of  an  epidemic  of  contagious  dis- 
ease, have  fallen  victims  to  the  particular  disease 
themselves,  and  so  have  sacrificed  their  own  lives  in 
an  effort  to  save  others. 

Now  let  us  hope  that  you  who  have  completed 
your  training  in  this  institution  and  wdll  now  go 
forth  into  the  world  to  practise  your  vocation  shall 
have  caught  this  spirit,  if  you  did  not  bring  it  with 
you,  and  shall  take  it  with  you  and  practise  it  in 
your  lives. 

1509  Loci'ST  Street. 



(Original  ^ommiiniciitions. 


THE  TOXIC  SECONDARIES  OF  CHRONIC  TON 
SILLAR  DISEASE.* 

By  Arthur  R.  Elliott,  M.  D., 
Chicago. 

We  have  little  knowledge  regarding  the  physio- 
logical function  of  the  tonsil.  The  tonsillar  epithe- 
lium allows  the  free  passage  of  leucocytes  outward, 
the  testimony  pointing  to  a  current  of  lymph  flcAV - 
ing  outward,  an  emigrating  stream  of  leucocytes. 
It  has  been  stated  that  these  l}'mphocytes  possess 
and  exert  phagocytic  power  and  thereby  endow  the 
tonsil  with  a  function  of  protective  character.  The 
proofs  direct  or  comparative  for  such  a  theory 
form  too  slim  a  basis  for  serious  consideration. 
\\''hatever  function  the  normal  tonsil  may  primarily 
exert  it  probably  has  fulfilled  its  physiological  des- 
tiny early  in  life,  for  it  is  rare  that  a  normal  tonsil 
is  met  with  after  the  age  of  childhood.  The  situa- 
tion of  the  tonsils  in  the  throat  exposes  them  to 
constant  trauma,  irritation,  and  infection.  More- 
over, their  crypts  and  fissures  form  traps  for  in- 
fecting microorganisms  and  places  of  lodgment  for 
foreign  material  and  retained  secretions,  while  the 
peculiar  structure  of  the  epithelium  opens  the  gates 
to  infections  of  their  substance.  It  is  not  difficult 
to  understand  therefore  why  the  tonsils,  especially 

*Read  by  invitation  before  the  Chicago  Laryngological  Socitl^, 
March  9,  1909. 


884 


ELLIOTT 


TONSILLAR  TOXLWES. 


[New  Vurk 
Medical  Journal. 


if  their  vitality  and  resisting  power  is  from  any 
cause  lowered,  become  so  frequently  the  seat  of 
infections.  Once  invaded  by  morbific  agents  the 
rich  lymphatic  and  vascular  supply  of  the  tonsil 
favors  the  dissemination  to  the  system  of  the 
products  of  infection. 

There  is  reason  to  believe  that  many  grave  and 
fatal  infections  occur  through  this  portal  of  entry, 
such  for  example  as  tuberculosis,  acute  rheumatism, 
endocarditis,  scarlet  fever,  septichsemia,  etc.  Not 
only  may  we  have  specific  bacteriaemias  such  as  the 
foregoing  originating  from  the  tonsil  but  other  less 
virulent  and  nonspecific  bacterial  processes  may  be- 
come established  there  and  poison  the  organism 
with  their  toxic  products. 

It  is  a  fact  that  there  are  elaborated  at  the  seat 
of  infection  within  any  organ  which  harbors  active 
germ  colonies,  especially  when  drainage  is  defec- 
tive, certain  toxines  or  toxalbumins  that  are  very 
diffusible  and  quickly  pass  into  the  general  circula- 
tion constituting  a  toxaemia  of  more  or  less  sever- 
ity. The  marked  systemic  depression  and  constitu- 
tional disturbance  attending  acute  follicular  amyg- 
dalitis is  an  instance  in  point,  and  the  same  must 
ensue  in  varying  degree  with  every  lesion  of  the 
tonsils  dependent  on  bacteria.  In  view  of  the  great 
frequency  of  infective  tonsillar  processes,  a  tox- 
lemia  originating  at  this  seat  must  be  a  common 
enough  condition.  The  examination  of  removed 
tonsils  frequently  reveals  latent  abscesses  at  the 
deeper  points  and  collections  of  retained  secretions 
and  fermenting  food  particles  in  the  fossae  and 
crypts.  That  such  conditions  are  not  more  gener- 
ally recognized  as  a  source  of  low  grade  systemic 
toxaemia  seems  surprising,  to  say  the  least. 

Similar  condition.s"  in  other  organs  are  not  so 
lightly  passed  over.  Attention  has  been  directed  to 
the  lymphoid  structure  of  the  appendix,  its  similar- 
ity to  the  tonsil  in  this  respect  giving  it  the  name 
of  the  "abdominal  tonsil."  Chronic  catarrhal  ap- 
pendicitis is  a  condition  not  dissimilar  to.  a  chronic 
follicular  amygdalitis,  yet  the  reputation  of  the 
former  lesion  as  a  dangerous  toxine  generator 
ofifers  a  strong  contrast  to  the  indifiference  with 
which  tonsil  infection  is  regarded  by  the  internist. 
The  prostate  and  seminal  vesicles  offer  conditions 
which  furnish  a  somewhat  similar  although  less 
striking  analogy.  Any  mucous  surface  may  serve 
as  a  toxine  filter  provided  there  is  contact  with  toxi- 
genic material  and  natural  drainage  or  cleansing  be 
interfered  with.  The  gallbladder,  the  accessory 
sinuses  of  the  nose,  the  renal  pelvis,  the  appendix, 
are  each  well  known  to  originate  chronic  intoxica- 
tions. Even  open  mucous  surfaces  may  act  in  this 
way  under  conditions  of  imperfect  drainage,  as  for 
in>;tance  the  nasal  mucosa  in  fcctid  atrophic  rhinitis 
witli  crust  formation.  The  peculiar  anatomical 
arrangement  of  the  tonsil  renders  it  es])ccially  liable 
to  act  as  a  seat  of  toxine  generation  and  absorption. 
The  fact  that  tonsillectomy  often  brings  about  a 
marked  all  round  improvement  in  the  patient's 
liealth  or  may  prove  to  be  the  factor  that  deter- 
mines the  arrest  or  disappearance  of  some  chronic 
nutritive  disturbance  need  therefore  occasion  no 
surprise. 

Once  toxines  gain  access  to  the  general  circula- 


tion they  exert  certain  catalytic  and  haemolytic 
effects  which  if  the  toxaemia  is  long  continued  may 
eventuate  in  organic  degenerative  changes  or  ab- 
normal blood  states. 

The  most  common  secondary  which  may  result 
from  chronic  tonsillar  toxaemia  is  anaemia.  It  is  well 
known  that  bacterial  toxines  can  produce  haemo- 
lysis. This  has  been  shown  to  be  true  of  the  strep- 
tococcus, staphylococcus,  and  many  other  forms  of 
bacteria.  No  definite  relation  can  be  shown  to  ex- 
ist between  the  virulence  of  a  bacterium  and  the 
haemolytic  power  of  its  toxine,  indeed  the  strongest 
bacterial  haemolysin  observed  was  found  in  a  sapro- 
phyte {Bacterium  mcgathcriiiui) .  Welsh  suggests 
that  some  obscure  anaemias,  not  of  infectious  origin, 
may  be  associated  with  the  growth  of  certain  haemo- 
lysin producing  saprophytes  in  the  tissues.  Apply- 
ing this  idea  to  tonsillar  disease  it  would  appear  that 
it  is  not  even  necessary  for  the  tonsil  to  be  the  seat 
of  pathogenic  germ  engraftment  to  cause  intoxica- 
tion of  the  system,  but  that  saprophytic  growth  in 
retained  secretions  or  food  particles  in  the  crypts 
and  fossae  may  prove  sufficient  to  originate  toxic 
secondaries  in  the  blood. 

The  form  of  anaemia  ordinarily  associated  with 
chronic  tonsillar  disease  is  the  simple  or  so  called 
symptomatic  type.  These  patients  usually  give  a 
history  of  repeated  attacks  of  amygdalitis  and  in 
childhood  may  have  had  adenoids  and  hypertrophied 
tonsils.  They  complain  of  a  lack  of  vitality,  a  sense 
of  languor  and  fatigue  on  slight  exertion.  They 
catch  cold  readily,  the  throat  usually  sharing  in  the 
symptoms.  They  may  be  subject  to  obscure  slight 
febrile  attacks  characterized  by  muscular  or  arthri- 
tic pains.  In  young  females  there  may  be  slight 
soreness  of  the  throat  at  the  menstrual  periods. 
One  type  of  case  presents  the  usual  indications  of 
slight  anaemia  with  an  afternoon  rise  of  0.5  to  i 
degree  of  fever  for  which  careful  general  physical 
examination  fails  to  accoimt.  Careful  examination 
of  the  throat  may  reveal  tonsils  which  are  partially 
submerged,  somewhat  tender  to  pressure,  and  when 
massaged  yield  a  cheesy  looking  sometimes  foul 
smelling  material.  In  every  case  of  obscure  anaemia 
the  tonsils  should  be  examined,  for  not  only  may 
they  be  distributing  poisonous  material  to  the  blood 
but  the  swallowing  of  diseased  tonsillar  secretions 
may  have  a  bad  effect  on  digestion  and  assimila'tion 
as  in  oral  sepsis. 

Another  condition  which  is  frequently  associated 
with  diseased  tonsils  is  a  subtoxic  state  closely  allied 
in  its  sym])toms  with  rheumatism.  In  children  we 
observe  periodic  slight  febrile  attacks  with  malaise 
and  aching  in  the  limbs  and  back.  The  tonsils  are 
h}  ])erplasic  and  the  upper  cervical  glands  may  be 
indurated.  In  adults  chronic  fibroid  degeneration 
of  the  tonsils  is  especially  associated  with  the  so 
called  rheumatic  or  gouty  diathesis.  It  is  well  to 
remember  in  the  present  connection  that  the  chronic 
rheumatic,  rheumatoid,  or  gouty  state  is  nothing 
more  than  chronic  tox.xmia  resulting  from  either 
metabolic  or  infective  to.xines.  Muck  regarding 
the  tonsil  as  responsible  for  recurrences  of  arthritic 
attacks  devised  a  simple  aspirating  contrivance  for 
evacuating  the  crypts  of  the  tonsil  thereby  kecinng 
them  free  from  accumulation,  and  had  the  satisfac- 


Jlay  I,  1909.] 


ROBIXSOX:    TREATMENT   OF  APPEXDICITIS. 


885 


tion  of  observing  recurring  articular  rheumatism 
vanish  completely  and  permanently  under  its  use. 
The  same  result  has  been  accomplished  by  tonsil- 
lectomy. Chronic  gouty  and  rheumatoid  conditions 
may  own  a  similar  aetiology  and  yield  to  the  same 
treatment.  More  interesting  still  is  the  fact  that  the 
pains  and  stiffness  of  the  finger  joints  have  com- 
pletely disappeared,  the  arthritic  process  being  ap- 
parently under  control. 

This  occurred  recently  in  my  own  experience  in  the  case 
of  a  woman  who  had  been  under  my  occasional  profes- 
sional care  for  the  rehef  of  ansemia  covering  a  period  of 
ten  years.  About  a  year  ago  she  began  to  experience  stitl- 
ness  and  pains  in  the  digital  joints,  and  examination 
showed  terminal  phalangeal  joint  changes  of  the  gouty 
type.  Her  previous  history  included  many  attacks  of  ton- 
sillitis, the  last  one  being  apparently  associated  with  the 
advent  of  the  arthritic  symptoms.  The  tonsils  were  the  seat 
of  fibroid  degenerative  changes.  Double  tonsillectomy  was 
performed,  and  during  the  first  six  months  after  operation 
there  was  a  very  marked  improvement  in  the  general 
health  with  a  gain  of  fifteen  pounds  in  weight. 

The  idea  that  slow  progressive  rheumatoid  arthritis 
is  a  secondary  to.xaemia  is  of  course  no  novelty,  but 
the  tonsils  have  not  been  considered  as  a  prominent 
toxigenetic  source  in  this  aft'ection.  In  the  forego- 
ing briefly  related  case  there  could  be  no  doubt  that 
the  long  continued  low  grade  ana;mia  and  the  arthri- 
tis were  dependent  on  the  tonsil  condition.  Rlieu- 
matic  arthritis  of  much  more  acute  type  may  appar- 
ently be  associated  with  tonsil  infections  as  in  the 
following  case : 

This  patient  was  a  young  Irish  woman  who  for  two 
months  previous  to  consultation  had  been  under  unavailing 
medical  treatment  for  an  arthritis  mvolving  both  knees  and 
ankle  joints.  The  only  deformity  of  the  joints  to  be  made 
out  was  a  slight  swelling  of  the  right  knee  joint.  There 
was  no  tenderness  on  palpation  but  a  good  deal  of  stiff- 
ness and  pain  on  movement  and  manipulation.  There  was 
no  febrile  reaction  and  except  for  a  slight  degree  of 
anaemia  no  impairment  of  the  general  health.  Examination 
of  the  mouth  and  throat  revealed  pyorrhoea  alveolaris  and 
chronic  amygdalitis.  After  unsuccessful  treatment  by  diet, 
general  hygiene,  and  antirheumatic  medication  for  one 
month  all  medication  was  discontinued  and  attention  was 
concentrated  on  the  mouth  and  throat  condition  with  the 
result  that  the  arthritis  so  improved  that  within  a  month 
she  was  able  to  resume  her  occupation  as  a  waitress. 

It  would  be  well  if  in  cases  of  obscure  slowly 
progressive  rheumatic  states  we  would  consider  the 
tonsils  as  a  possible  to.xigenic  source. 

Absorption  of  septic  toxines  from  the  tonsils  may 
so  lower  the  vital  resistance  to  infections  as  to 
render  the  individual  liable  to  certain  minor  infec- 
tive developments  such  as  styes,  furuncles,  and 
acne.  Erythema  and  herpes  have  been  observed  in 
association  with  tonsil  infections. 

I  have  for  some  years  been  in  close  touch  with  a  patient 
who  has  partially  submerged  tender  tonsils  that  when 
■'stripped"  by  pressure  yield  almost  invariably  a  cheesy 
looking  material.  This  patient  had  had  during  the  ten 
years  of  my  observation  a  number  of  times  each  year,  usu- 
ally following  exhaustion  from  overwork,  or  chilling  of 
the  surface  or  at  the  menstrual  periods,  an  attack  of  herpes 
involving  the  skin  of  the  face,  neck,  or  upper  chest.  Usu- 
ally the  attacks  were  afebrile,  but  were  invariably  asso- 
ciated with  a  feeling  of  stiffness,  malaise,  backache,  and 
discomfort  in  the  throat.  This  patient  was  taught  to  empty 
the  crypts  of  the  tonsil  by  massage  and  was  instructed  to 
carry  out  this  procedure  daily.  Since  adopting  this  prac- 
tice, now  covering  a  period  of  eighteen  months,  she  has 
not  had  a  single  attack  of  herpes.  That  this  is  an  effect 
and  not  a  coincidence  seems  a  justifiable  inference  in  view 
of  the  fact  that  for  a  period  of  fully  fifteen  years  previous 


to  adopimg  this  treatment  of  the  tonsil  she  was  a  niartvr 
to  herpetic  eruptions.  It  would  be  interesting  to  know  if 
the  herpes  in  this  case  were  an  avirulent  pneumococcus  in- 
fection from  the  tonsil. 

Although  there  is  no  striking  proof  forthcoming 
it  seems  probable  that  mild  types  of  chorea  in  chil- 
dren may  come  from  the  throat.  The  connection 
between  tonsillitis  and  acute  rheumatism  is  well 
known.  As  high  ratios  as  from  thirty  to  eighty  per 
cent,  of  amygdalitis  are  recorded  in  the  rheumatism 
of  childhood.  The  aetiological  unity  of  chorea  and 
acute  rheumatism  being  accepted  it  is  not  unreason- 
able to  assume  that  the  tonsils  may  originate  the 
toxines  causing  chorea.  The  throat  should  be  in- 
vestigated in  every  case  of  chorea. 

It  has  been  urged  that  the  toxines  of  disease  act 
similarly  to  enzymes  and  produce  their  effects  in 
similar  catalytic  manner.  However  this  may  be 
there  can  be  no  doubt  regarding  the  degenerative 
influence  exerted  by  disease  to.xines  on  the  tissues 
of  the  body.  As  a  general  thing  chronic  Bright  s 
disease,  diabetes,  arteriosclerosis,  myocarditis  are 
toxic  secondaries  produced  by  long  continued  low 
grade  toxaemia.  This  effect  is  brought  about  not 
only  by  the  so  called  metabolic  to.xines  but  may 
equally  well  be  the  result  of  to.xines  of  exogenous 
or  infective  origin.  As  an  example,  long  continued 
poisoning  of  the  system  with  pus  to.xines  may  beget 
a  weak,  degenerated  myocardium  or  cause  a  clironic 
nephritis.  It  is  not  an  infrequent  clinical  experi- 
ence to  encounter  chronic  myocarditis  manifested 
by  dyspnoea  on  eff'ort.  tachycardia,  palpitation,  and 
other  indications  pointing  to  cardiac  insufficiency  as 
a  consequence  of  long  standing  gallblader  or  ap- 
pendix infections.  Infection  of  any  of  the  mucous 
cavities  may  produce  degenerative  secondaries  such 
as  those  enumerated,  and  while  I  have  no  conchi- 
sive  proof  to  offer  that  tonsillar  infections  mav 
bring  about  such  effects.  I  have  on  the  other  hand 
no  reason  to  believe  that  a  chronic  closed  infection 
of  the  tonsil  is  necessarily  less  no.xious  to  the  organ- 
ism at  large  than  similar  processes  elsewhere. 

103  St.ate  Street. 


TREATMENT  OF  APPEXDICITIS. 

Bv  Beverlev  Robixsox,  M.  D.. 
Xew  York. 

In  order  to  treat  appendicitis  with  wisdoin.  it  is 
essential  first  to  make  an  accurate  diagnosis.  I  state 
to-day.  that  it  is  most  difficult  at  tinies,  not  to  say 
impossible,  to  distinguish  accurately  and  positively, 
between  appendicitis  and  colitis.  '  In  some  case's. 
^IcBurney's  point,  rigidity,  blood  count,  sympto- 
matic antecedents,  are  similar.  When  all  these  are 
identical  one  or  other  disease  may  exist  alone :  what 
is  frequently  the  case  here,  as  elsev.here,  two  dis- 
eases, so  far  as  the  mere  organ  is  concerned,  inav 
exist  together  just  as  we  find  elsewhere  quite  often 
— notably,  in  uterus  and  ovaries :  in  larvnx  and 
trachea. 

-\dmitting  the  truth  of  the  foregoing,  to  be  wise 
and  prudent,  we  should  treat  patient  medicallv,  in 
u  hat  seems  best  way  to  accomplish  a  cure  and  with 
sliofhtest  risk  in  the  great  majoritv  of  these  cases. 
This  treatment  should  be : 


886 


h' ISC  HER:  DIAGNOSIS  OF  APPENDICITIS. 


[New  York 
Medical  Journal. 


1.  Rest  in  bed,  and  with  rest  in  bed,  I  mean 
little  or  no  voluntary  movement  while  pains  are 
acute,  temperature  elevated,  and  other  general 
symptoms  threatening,  or  grave. 

2.  Ice  bag,  or  preferably,  as  I  believe,  hot  water 
bag,  or  poultices,  or  stupes  with  hot  water  and  oil 
of  turpentine  and  soap  liniment;  flannel  covered,  or 
not,  with  impermeable  i.  e.  oil  silk,  or  rubber  tissue. 

3.  Laxative  enema  with  castor  oil  and  oxgall, 
sometimes  a  little  glycerine  being  added.  Flaxseed 
tea  should  preferably  be  the  menstruum  of  the 
enema. 

4.  A  moderate  amount  of  codeine  every  hour  or 
two,  by  mouth,  if  pains  seem  to  require  it,  from  1-20 
to  i-io  or  1-5  grain. 

5.  In  rare  instances  only  are  hypodermic  injec- 
tions of  morphine  to  be  given  and  then  only  for 
excessive  pain  not  otherwise  relieved. 

This  treatment  will  help  relieve  many  instances 
of  acute  appendicitis.  If  to  this  treatment,  when- 
ever the  stomach  tolerates  it,  ten  grains  of  salicin  in 
cachets,  be  added,  every  two  to  four  hours,  we 
shall  have  a  practical,  rational,  effective  treatment 
of  appendicitis. 

During  acute  stage  only  liquid  food  in  small 
quantities  and  properly  selected,  should  be  per- 
mitted. Whenever  an  abscess  is  well  defined,  it 
should  be  opened  and  drained.  In  this  connection, 
it  should  be  remembered  that  very  many  perforated 
cases  of  appendicitis,  cause  an  abscess  limited  by 
protective  false  membrane,  if  not  operated  on  too 
soon  or  ill  advisedly.  Treves  and  Richardson  are 
surgeons  whose  conduct  and  example  inspire  me 
with  great  admiration. 

Of  course,  in  a  small  proportion  of  the  total  num- 
ber of  cases,  despite  this,  or  any  medical  treatment, 
now  known  perforation  may  occur.  Under  these 
circumstances,  prompt  operation  is  practically  the 
only  hope  of  the  patient.  Even  if  perforation  is 
imminent,  it  is  far  wiser,  provided  such  a  diagnosis 
can  be  surely  made,  to  operate  rather  than  to  wait 
and  risk  life,  probably.  But  up  to  date,  this  diag- 
nosis is  only  probable,  never  certain,  and  at  most, 
such  instances  are  relatively  infrequent  (two  per 
cent.)  in  the  large  number  of  cases  of  appendicitis, 
and  it  seems  that  in  view  of  this,  we  might  wait 
until  it  occurs,  only  then  to  be  prepared  to  operate 
immediately,  .\bout  this  standpoint,  I  grant  there 
may  be  two  views — good  and  well  balanced,  both. 
If  people  generally,  would  lead  rational  lives  as  to 
food,  work,  exercise,  and  other  habits  also,  there 
would  be  relatively  few  cases  of  appendicitis.  If 
the  underlying,  so-called  rheumatic  or  gouty  ten- 
dency, were  also  treated  properly  in  advance  and  at 
the  right  time,  with  a  few  well  known,  time  honored 
remedies,  there  would  be  still  fewer  cases. 

If  after  a  primary  attack,  recovered  from  without 
operation,  these  lines  of  conduct  were  closely  fol- 
lowed, there  would  be  very  few  sccondarv  or  re- 
peated attacks. 

A  dose  of  castor  oil  and  blue  mass,  taken  in  time 
for  adults  and  children — and  sweets  and  alcohol  cut 
off  for  a  while,  from  daily  use — w'ould  save  manv 
a  patient  from  operation  and  from  abdominal  pain 
and  distress. 

42  West  Tiiirtv-Skventii  Street. 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS  OF 
APPENDICITIS.* 

By  Hermann  Fischer,  M.  D., 
New  York, 

Adjunct  Surgeon,   German  Hospital. 

Of  all  the  diseases  which  occur  in  the  abdomen, 
the  inflammation  of  the  vermiform  appendix  plays 
the  most  important  role.  We  may  justly  say  that 
this  disease  taxes  frequently  to  an  extreme  degree 
the  diagnostician's  skill.  The  pathological  process 
with  its  complications  is  not  confined  to  the  lower 
part  of  the  abdomen  alone.  It  may  spread  and  be 
disseminated  over  the  entire  peritoneal  cavity,  or 
complicating  inflammatory  conditions  may  arise  at 
some  distance  from  the  original  site  of  the  trouble, 
in  the  subphrenic  space  or  even  in  the  pleural  cav- 
ity. On  account  of  the  varied  picture  which  the 
disease  may  present  and  on  account  of  its  very  com- 
plicated pathology,  it  is  a  rather  difficult  task  for 
ine  to  exhaust  the  subject  in  the  short  time  allotted 
to  me.  I  shall,  however,  try  to  bring  out  the  more 
important  diagnostic  and  differential  diagnostic 
points,  and  shall  dwell  especially  on  those  phenom- 
ena which  deserve  the  greatest  attention  from  the 
standpoint  of  the  general  practitioner. 

For  this  reason  I  shall  divide  the  clinical  forms 
of  appendicitis  into  three  chief  groups  and  propose 
to  deal  with  each  of  them  separately:  i,  Acute  sup- 
purative appendicitis ;  2,  acute  catarrhal  appendi- 
citis ;  and  3,  chronic  catarrhal  appendicitis. 

I.    The  Acute  Suppurative  Appendicitis. 

The  onset  is  usually  abrupt  without  any  prelimin- 
ary symptoms.  The  patient  suddenly  experiences 
severe  abdominal  pain.  This  often  comes  on  dur- 
ing the  night.  In  the  beginning  these  pains  may  be 
felt  anywhere  in  the  abdomen,  in  the  epigastrium, 
around  the  umbilicus,  or  in  the  left  iliac  region,  most 
frequently,  however,  they  are  localized  from  the 
start  in  the  right  iliac  region.  If  the  pain  and  dis- 
comfort were  felt  in  other  parts  of  the  abdomen, 
they  usually  travel  to  the  right  side  after  some 
hours,  and  if  the  attack  is  a  severe  one,  these  pains 
may  become  very  pronounced.  In  the  mean  time, 
often  with  the  beginning  of  the  abdominal  discom- 
fort, the  patient  feels  nauseated  and  vomits  once  or 
repeatedly.  If  food  was  taken  shortly  before  the 
beginning  of  the  symptoms,  this  will  be  vomited,  if 
the  stomach  was  empty,  the  vomitus  will  consist 
of  bile  stained  mucus.  The  vomiting  is  caused  by 
the  peritoneal  irritation,  resulting  from  the  inflamed 
appendix.  Very  soon  the  intestines  will  become 
more  or  less  paralyzed,  which  is  shown  by  a  slight 
distention  of  the  abdomen  and  the  impossibility  to 
expel  gas.  These  are,  for  the  main  part,  the  sub- 
jective symptoms. 

Upon  physical  examination,  we  note  the  follow- 
ing: The  skin  is  warm  and  moist.  The  face  is 
flushed.  The  pulse  varies  from  90  to  110  and  more 
in  a  minute.  Temperature  ranges  between  100.5° 
and  102°  F.  by  the  rectum.  On  palpation  the  ab- 
domen is  distinctly  sensitive.  This  sensitiveness  may 
be  localized  in  the  right  iliac  region  or  may  be  dif- 
fused over  the  whole  abdomen.  The  point  of  great- 

'Rcad  before  the  German  Medical  Society  of  New  York,  Novem- 
ber 2,  1908. 


May  I,  1909.] 


FISCHER:  DIAGNOSIS  OF  APPENDICITIS. 


887 


est  tenderness,  however,  is  over  the  well  known 
McBurney's  point,  the  importance  of  which  I  will 
dwell  upon  later.  The  abdominal  muscles  are  mod- 
erately rigid,  especially  on  the  right  side,  where  the 
rigidity  of  the  right  rectus  muscle  is  especially  evi- 
dent, the  defense  musculaire  of  the  French.  In  the 
ileocaecal  region  one  feels  a  more  or  less  distinctly 
palpable  tumor  of  varying  size,  or  only  a  slight  in- 
distinct resistance.  Upon  examination  by  the  rec- 
tum, which  must  never  be  omitted  in  cases  suspici- 
ous of  appendicitis,  there  is  tenderness  on  the  right 
side  of  the  pelvis,  an  indistinct  doughy  feeling  or  a 
distinct  mass  in  Douglas's  pouch.  In  these  cases 
with  a  pelvic  exudate,  the  patient  frequently  com- 
plains of  bladder  symptoms.  The  percussion  of  the 
abdomen  is  dull  over  the  tumor  and  exudate,  dull 
tympanitic,  if  there  are  coils  of  intestines  interposed 
between  the  site  of  inflammation  and  the  abdominal 
wall.  This  dull  tympanitic  percussion  note  is  best 
brought  out  by  very  light  percussion.  Another 
symptom  that  may  be  helpful  is  that  on  sudden  with- 
drawal of  the  palpating  hand,  the  tenderness  of  the 
abdomen  is  augmented.  Blumberg  was  the  first  to 
draw  attention  to  this  phenomenon.  According  to 
this  author  this  symptom  is  brought  about  by  the 
sudden  jarring  of  the  abdominal  wall,  the  peri- 
tonjeum  and  intestines,  in  consequence  of  the  sud- 
den cessation  of  the  pressure  of  the  palpating  hand. 

He  thinks  it  valuable  as  an  early  warning  of  the 
process  spreading  to  the  peritonaeum,  and  therefore 
the  presence  of  this  symptom  is  an  indication  for 
early  operative  interference.  In  some  cases  it  is 
observed  that  the  pain  is  increased  by  forced  ex- 
tension of  the  thigh.  This  symptom  is  especially 
found  in  those  cases  in  which  the  appendix  lies  upon 
the  ilium  or  retrocaecally.  Here  the  inflammatory 
process  has  implicated  the  fascia  of  the  psoas  muscle 
and  has  caused  an  inflammatory  oedema  of  the  mus- 
cle itself.  To  look  upon  this  symptom  as  pathogno- 
monic of  appendicitis  especially  in  the  chronic  form, 
as  Illoway  has  stated,  seems  to  me  unwarranted,  for 
this  augmentation  of  pain  can  also  be  elicited  in  a 
good  many  other  diseases,  in  which  a  complicating 
inflammatory  condition  of  this  muscle  is  possible, 
as  for  instance  in  tuberculosis  and  actinomycosis  of 
the  caecum,  osteomyelitis  of  the  ilium,  ureteritis  and 
periureteritis,  stone  in  the  ureter,  cold  abscesses 
from  Pott's  disease,  etc. 

In  the  foregoing  I  have  spoken  of  the  main  and 
most  important  symptoms  of  an  attack  of  appendi- 
citis of  median  severity  in  which  an  inflammatory 
exudate  of  smaller  and  larger  magnitude  has  been 
formed.  Of  the  haematological  examination  which 
interests  us  so  much  nowadays,  I  shall  speak  later. 
These  symptoms  may  last  from  several  days  to  one 
and  one  half  weeks  or  longer,  and  finally  disappear 
gradually.  At  first  the  pain  becomes  less,  the  ab- 
domen gets  softer  and  defaecation  becomes  normal. 
The  swelling  or  resistance  in  the  right  ileocaecal  re- 
gion becomes  less  sensitive,  decreases  in  size  and 
sometimes  is  completely  absorbed.  This  complete 
absorption  with  return  of  the  tissues  to  the  normal, 
however,  takes  place  only  in  a  very  few  cases  and 
it  is  impossible  to  foretell  in  the  individual  case 
whether  or  not  this  will  occur.  In  the  majority  of 
cases  a  recurrence  of  the  trouble  will  take  place 


sooner  or  later,  and  the  development  of  a  new  at- 
tack will  be  so  sudden  and  unexpected  or  so  severe 
that  only  a  quickly  performed  operation  will  save 
the  life  of  the  patient.  In  cases  in  which  the  process 
does  not  resorb  a  perityphilitic  abscess  may  develop, 
or,  if  the  plastic  tendency  of  the  peritonaeum  was 
deficient,  a  sudden  perforation  of  the  appendix  may 
take  place  with  development  of  a  general  peritonitis. 

Should  an  abscess  form,  the  temperature  will  rise 
or  remain  high  from  103°  to  104°  F.  The  pulse 
ranges  between  120  and  130.  The  pains  become 
more  violent.  The  face  assumes  a  look  of  distress. 
The  rigidity  of  the  right  rectus  muscle  and  the  sen- 
sitiveness to  touch  are  augmented.  On  palpation  a 
tumor  is  felt  which  extends  more  or  less  towards 
the  median  line  or  even  beyond  it.  If  the  abscess 
descends  into  the  pelvis,  it  may  fill  Douglas's  cul- 
de-sac  and  find  its  way  again  upwards  into  the  left 
iliac  fossa.  If  such  is  the  case  a  mass  will  appear 
above  Poupart's  ligament  on  the  left  side.  On  rec- 
tal examination  the  palpating  finger  will  feel  a  pro- 
jection of  the  anterior  wall  of  the  rectum,  which  is 
sensitive  to  the  touch.  In  these  cases  the  patient 
will  also  often  complain  of  pain  and  frequency  of 
urination  caused  partly  by  the  pressure  of  the  exu- 
date, partly  by  the  inflammation  involving  the  wall 
of  the  bladder.  These  abscesses  may  empty  them- 
selves spontaneously  into  the  rectum  and  bladder. 
The  wall  of  the  rectum  also  becomes  inflamed  so 
that  the  patient  suffers  from  severe  tenesmus  ac- 
companied by  mucous  discharges. 

If  the  appendix  lies  retrocaecally,  an  abscess  may 
develop  in  the  lumbar  region,  which  sometimes 
reaches  up  to  the  lower  pole  of  the  kidney  or  the 
hilus  of  the  liver.  This  condition  can  often  be  rec- 
ognized by  protrusion  or  resistance  in  the  loin,  just 
above  the  iliac  crest.  This  spot  is  also  the  main 
seat  of  pain  upon  pressure.  After  Mangoldt  there 
is  heard  upon  percussion  over  the  caecum  a  bruit  de 
pot  fele,  he  thinks  this  to  be  an  important  sign  of  a 
retrocaecal  abscess.  If  the  process  has  reached  the 
right  kidney  and  has  infected  the  pararenal  fat,  a 
paranephritic  abscess  is  the  consequence,  or,  if  the 
abscess  .extends  upwards  toward  the  posterior  sur- 
face of  the  liver,  the  much  dreaded  subphrenic  ab- 
scess may  be  the  result.  The  diagnosis  of  the  latter 
condition  is  often  very  difficult,  in  as  much  as  local 
symptoms  may  be  entirely  wanting.  Sometimes 
only  the  temperature  remains  high,  or,  if  the  tem- 
perature reaches  normal  after  the  operation,  it  rises 
again  after  a  few  days  or  a  week.  In  some  of  these 
cases  a  peculiar  form  of  vomiting  is  seen,  the  so 
called  "projectile  vomiting"  which  appears  very 
suddenly  without  any  retching.  The  diaphragm  on 
the  right  side  does  not  take  part  in  the  respiratory 
movements.  Over  the  right  lower  lobe  of  the  lung 
behind  there  is  heard  here  and  there  a  few  pleuritic 
friction  sounds,  or  a  pleuritic  effusion  can  be  de- 
tected. The  area  of  liver  dullness  may  also  extend 
abnormally  high  in  front.  Suspicion  of  a  subphrenic 
suppuration  having  arisen,  it  is  imperative  to  try  and 
find  the  focus  of  pus  by  exploratory  puncture.  It 
is  necessary  to  use  long- needles  of  large  calibre,  and 
one  should  not  be  satisfied  with  a  single  puncture. 
In  one  of  the  author's  cases  only  the  sixth  attempt 
revealed  the  location  of  the  abscess. 


888 


FISCHER:  DIAGNOSIS  OF  APPENDICITIS. 


[New  York 
Medical  Journal. 


2.    Tlic  Acute  Catarrhal  Appendicitis. 

This  type  distinguishes  itself  from  the  acute  sup- 
purative appendicitis  only  by  its  lesser  severity  and 
:ts  lower  grade  of  inflammatory  reaction.  The  onset 
is  often  sudden,  but  pain,  rise  of  temperature,  and 
acceleration  of  the  pulse  are  less  pronounced.  The 
general  condition  of  the  patient  may  be  little  altered. 
The  temperature  rarely  exceeds  101.5°  F.,  the  pulse 
rate  often  remains  normal  or  is  only  a  trifle  accel- 
erated. Severe  and  repeated  vomiting  does  not  oc- 
cur, but  the  patient  may  complain  of  a  nauseous  feel- 
ing. The  pain  is  mostly  localized  in  the  right  iliac 
fossa.  The  function  of  the  intestines  is  little  inter- 
fered with.  The  abdomen  is  soft.  In  the  region 
of  iMcBurney's  point  there  is  some  tenderness.  The 
pain  often  disappears  after  a  day  or  two  and  may 
even  last  only  a  few  hours.  In  some  cases  the  symp- 
toms are  so  slight  that  the  patient  frequently  does 
not  consult  a  physician,  thinking  his  discomfort  due 
to  some  indiscretion  of  diet.  Such  an  attack,  how- 
ever, may  at  any  time  develop  into  a  severe  purulent 
inflammation.  Just  these  cases  often  turn  out  to  be 
most  dangerous  to  the  life  of  the  patient,  either 
through  a  sudden  perforation  of  the  organ,  with 
consequent  general  peritonitis,  or  through  the  form- 
ation of  a  localized  abscess.  It  is  in  these  cases 
where  one's  diagnostic  acumen  is  most  satisfactorily 
rewarded.  An  early  operation  rids  the  patient  in 
the  shortest  possible  time  with  a  minimum  of  danger 
to  life,  of  a  treacherous  foe  who  without  warning 
may  bring  him  near  death's  door. 

Let  us  now  consider  our  last  and  third  type : 

3.    The  Chronic  Catarrhal  Appendicitis. 

This  type  of  the  disease  may  develop  after  an 
acute  attack  of  catarrhal  appendicitis  or  may  de- 
velop independently  as  such.  A  patient  gets  an  at- 
tack as  just  described  which  subsides  after  a  short 
time.  After  a  longer  or  shorter  interval,  however, 
he  notices  that  something  is  wrong  with  his  ab- 
domen. He  has  attacks  of  slight  pain,  colicky  in 
character  which  are  mostly  confined  to  the  right 
side  of  the  abdomen.  At  the  same  time  he  experi- 
ences vague  stomach  and  intestinal  discomfort. 
Symptoms  of  chronic  colitis,  sometimes  of  the  mem- 
branaceous type,  may  be  present.  After  an  indis- 
cretion in  diet  these  patients  often  experience  ab- 
dominal discomfort.  They  have  constipation  alter- 
nating with  diarrh<ea.  The  patient  is  usually  up 
and  about,  for  his  general  condition  is  not  much  dis- 
turbed. This  state  of  affai  rs  mav  last  a  consider- 
able length  of  time.  In  some  cases  the  pain  is  con- 
stant, in  others  the  pain  comes  on  in  attacks  with 
free  intervals  that  may  last  weeks  and  months.  If 
such  a  patient  is  examined  one  finds  a  soft  abdomen 
which  is  not  sensitive  with  the  exception  of  the  ilco- 
cjecal  region.  Occasionally  a  local  tympanitic  con- 
dition of  the  caput  coli  is  found,  the  so  called  "air 
ifushion"  symptom.  If  the  vermiform  appendix  is 
situated  favorably,  one  may  be  able  to  palpate  a 
goo.se  quill  like  band  which  may  be  painful  on  pres- 
sure. This  is  especially  the  case,  if  the  appendix  lies 
obliquely  across  the  psoas  muscle,  with  the  tip 
directed  towards  the  i)elvis.  In  ])alpating  this  re- 
gion, the  caput  coli  is  very  often  mistaken  for  the 
ap])endix,  especially  in  such  cases  the  colon  con- 
tracts upon  the  irritation  i)roduced  by  the  pressure 


of  the  examining  fingers.  One  can  avoid  this  mis- 
take by  carefully  palpating  this  sausagelike  body 
and  following  it  upwards,  where  one  will  notice  that 
it  corresponds  to  the  site  of  the  colon,  ascendens 
which  gradually  becomes  less  distinct  toward  the 
right  hypochondrium. 

I  wish  now  to  touch  upon  an  important  question 
which  is  still  held  sub  judice  by  a  good  many  sur- 
geons. Is  the  normal  appendix  palpable  and  pain- 
fid  on  pressure  or  is  the  palpability  and  scnsitii  c- 
ness  a  sign  of  pathological  changes,  i.  e.,  can  palpa- 
tion alone  be  depended  upon  to  diagnosticate  a 
case  of  chronic  appendicitis f  Whereas  most  au- 
thors deem  it  impossible  to  palpate  the  normal  ap- 
pendix, Jaworski  and  Lepinski  were  successful  in 
palpating  51.5  per  cent,  of  the  appendices  in  eight 
hundred  normal  individuals  whom  they  examined 
carefully.  To  obtain  these  results,  however,  the  fol- 
lowing conditions  must  be  present:  i.  The  appendix 
must  lie  upon  the  aponeurosis  of  the  psoas  muscle 
and  must  run  obliquely  ])arallel  to  the  same,  other- 
wise it  will  in  most  cases  be  covered  by  the  caecum. 
2.  The  abdominal  walls  must  not  be  so  massive  and 
rigid.  3.  The  psoas  muscle  must  be  relaxed  by  fix- 
ing the  thigh.  4.  The  right  index  finger  must  be 
held  transversely  to  the  course  of  the  psoas  muscle, 
until  one  feels  its  sharp  and  rigid  edge.  By  a  slight 
to  and  fro  movement  the  appendix  will  roll  under 
the  finger.  Of  the  412  palpable  appendices  270  were 
sensitive  to  touch,  of  these  twenty-three  even  were 
decidedly  painful.  Jaworski  and  Lepinski  there- 
fore conclude,  that  it  is  impossible  to  draw  any  con- 
clusions from  the  thickness  or  the  sensitiveness  of 
the  appendix  as  to  its  being  diseased.  McBurnev's 
point  was  sensitive  in  26.5  per  cent,  of  cases  ex- 
amined ;  but  this  sensitiveness  does  not  coincide  with 
that  of  the  appendix.  We  therefore  see  that  these 
two  clinical  findings,  palpability  and  sensitiveness 
upon  pressure  of  the  ap,pendix  and  pain  over  Mc- 
Burney's  point  alone  may  lead  in  many  cases  to 
diagnostic  mistakes,  a  misfortune  from  which  hard- 
ly any  physician  who  has  seen  many  cases  has 
escaped. 

This  local  pain  may  also  be  found  upon  the  left 
side.  The  reasons  for  this  may  be  manifold  :  There 
may  be  present  a  situs  inversus  viscerum,  a  concom- 
itant enteritis  or  colitis  with  lymphangitis,  and 
lymphadenitis  of  the  mesenteric  and  retroperitoneal 
lymph  vessels  and  lymph  glands,  acute  and  chronic 
sigmoiditis,  reflex  pain  radiating  toward  the  left 
side,  refle.x  irritation  on  symmetrical  nerves  of  the 
same  .spinal  cord  segment,  inflammatory  conditions 
upon  the  left  side  which  have  traveled  over  from  the 
right,  localized  pus  collections  after  general  puru- 
lent peritonitis,  salpingitis,  etc. 

I  wish  h.crc  to  say  a  few  words  about  the  signifi- 
cance of  McRurney's  point,  which  has  played  and 
still  plays  such  an  important  role  in  the  diagnosis 
of  our  affection.  As  you  all  know,  this  point  is  sit- 
uated in  the  right  iliac  fos.sa,  two  inches  mesial  from 
the  anterior  superior  iliac  spine,  upon  an  imaginary 
line  drawn  from  this  i)oint  toward  the  umbilicus. 
Mcl'urney  has  identified  tliis  jioint  with  the  anatom- 
ical situation  of  the  base  of  the  appendi.x.  a  su])i)nsi- 
tion,  which  holds  good  only  in  a  comparatively  small 
number  of  cases.  Lanz  reinvestigated  these  condi- 
tions and  found,  that  the  base  of  the  appendix  cor- 


May  I,  1909.] 


FISCHER:  DIAGNOSIS  OF  APPENDICITIS. 


889 


responds  to  the  so  called  Lanz's  point,  as  he  pointed 
■out  ten  years  ago.  This  point  is  found  by  connecting 
the  two  superior  anterior  iliac  spines  and  dividing 
this  line  into  three  equal  parts.  The  first  point  of 
division  corresponds  approximately  to  the  base  of 
the  appendix.  He  therefore  draws  the  following 
conclusions:  i.  The  situation  of  the  appendix — as 
far  as  its  point  of  junction  with  the  caecum  is  con- 
cerned— is  much  more  constant  as  it  was  hitherto 
thought  to  be.  2.  McBurney's  point  does  not  cor- 
respond to  the  situation  of  the  appendix.  3.  Mc- 
Burney's point  corresponds' to  the  mesical  side  of 
I. he  colon  ascendens  at  a  point  five  centimetres  above 
tiie  base  of  the  appendix.  4.  Lanz's  point  on  the 
interspinal  line  is  of  greater  importance  to  the  de- 
termination of  the  vermiform  appendix  than  Mc- 
Burney's point.  Notwithstanding  Lanz's  conclu- 
sions. I  believe  that  sensitiveness  over  McBurney's 
point  is  of  great  clinical  significance. 

Another  symptom  to  which  T.  Rovsing  has  lately 
drawn  our  attention  consists  in  pain  in  the  appen- 
<ltcal  region  elicited  by  pressure  upon  the  left  side. 
Rovsing  describes  the  procedure  of  examination  as 
follows :  "The  fingers  of  the  left  hand  are  put  flatly 
upon  the  abdomen  and  are  pressed  slowly  down  by 
the  right  hand  along  the  brim  of  the  pelvis  into  the 
left  iliac  fossa,  so  that  the  coils  of  the  ileum  are 
j)ushed  inward,  out  of  the  way  and  the  fingers  press 
the  colon  descendens  firmly  against  the  posterior 
abdominal  wall.  The  fingers  that  firmly  compress 
the  colon,  ascendens  are  now  slowly  moved  upward 
toward  the  splenic  flexure."  By  this  manipulation 
the  contents  of  the  gut  are  put  under  high  enough 
tension  to  ef¥ect  a  back  pressure  upon  the  caecum. 
By  this  pressure  a  severe  lightninglike  pain  is  pro- 
duced in  the  ileocrecum  region.  Rovsing  thinks  this 
symptom  verv  important  as  a  dififerential  diagnostic 
point  because  it  is  only  present  in  cases  of  diseases 
of  the  appendix  and  caecum,  and  is  not  met  with  in 
kidney  diseases,  ureteritis,  stones  in  the  ureter,  and 
salpingitis. 

Besides  these  points  of  sensitiveness,  quite  a  num- 
ber of  other  places  of  tenderness  have  been  de- 
scribed which  in  certain  cases  may  be  helpful  to 
make  the  diagnosis  of  chronic  appendicitis.  R.  T. 
Morris  mentions  the  hyperjesthesia  of  the  lumbar 
nerve  plexus  upon  deep  pressure  on  either  side  of 
the  umbilicus.  Hoenk,  who  attributes  to  the  sym- 
pathetic nervous  system  an  important  role  in  inflam- 
matory conditions  of  the  vermiform  appendix,  found 
a  number  of  points  which  are  painful  upon  pressure 
in  chronic  appendicitis.  .Ml  these  need  not  be  pres- 
ent in  a  single  given  case.  On  the  abdomen  there 
is  always  found  a  sensitive  spot  above  the  umbilicus, 
in  most  instances  in  the  middle,  a  little  toward  the 
right.  The  location  of  this  point  corresponds  to  the 
body  of  the  second  and  third  lumbar  vertebra.  The 
body  of  the  last  lumbar  vertebra  is  also  said  to  be 
regularly  sensitive,  if  the  palpation  of  the  lumbar 
spine  is  at  all  possible.  On  the  back  he  found  the 
following  points :  The  first  spinal  process  of  the 
sacrum,  the  spinal  process  of  the  fifth  lumbar  verte- 
bra, the  angle  between  the  sacrum  and  crest  of  the 
ilium  on  the  right  side,  the  right  and  left  costospinal 
angle,  and  two  spots  between  spinal  column  and  the 
angle  of  the  scapula. 

Thus  we  see  from  the  multiplicity  of  symptoms. 


how  variable  the  clinical  picture  of  the  chronic  form 
of  our  disease  may  be,  and  how  easily  the  physician 
may  be  deceived,  if  he  is  not  careful  in  analyzing  the 
different  symptoms  as  to  their  respective  value  in 
the  individual  case. 

In  the  foregoing  I  have  attempted  to  picture  to 
you  the  most  important  diagnostical  points  of  the 
inflammation  of  the  vermiform  appendix  as  shortly 
as  was  compatible,  with  the  importance  of  the  sub- 
ject. 

In  conclusion  I  would  like  to  say  a  few  words  in 
regard  to  the  differential  diagnosiii.  In  this  I  shall 
confine  myself  entirely  to  those  diseases  which  might 
be  mistaken  for  the  acute  form  of  our  disease.  In 
the  first  place  I  must  mention  here  the  inflammatory 
conditions  of  the  female  genitals.  The  acute  sal- 
pingo-oophoritis  on  the  right  side,  or  the  chronic 
gonorrhoeal  salpingitis  with  acute  febrile  recru- 
descences may  be  confounded  with  an  attack  of  acute 
appendicitis.  In  these  cases  a  good  anamnesis  and 
thorough  bimanual  examination  if  necessary  under 
narcosis,  will  clear  up  the. diagnosis.  In  affections 
of  the  tubes,  the  point  of  greatest  sensitiveness  lies 
usually  below  the  inters]jinal  line,  the  rigidit}^  of  the 
abdominal  muscles  is  also  not  so  pronounced.  Ber- 
thonier  has  recently '  pointed  out  that  the  examina- 
tion in  the  left  lateral  position  produces  severe  pain 
over  McBurney's  point  in  appendicitis,  even  in  cases 
where  this  is  not  found  with  the  patient  upon  his 
back.  In  .salpingitis,  however,  McBurney's  point 
is  free  from  pain  upon  pressure,  if  the  patient  is 
put  upon  the  left  side.  In  acute  cholecystitis,  empy- 
ema of  the  gallbladder  and  cholelithiasis  with  infec- 
tion of  the  bileducts  the  greatest  intensity  of  pain 
is  in  the  upper  region  of  the  abdomen.  If  there  is 
a  tumor  present  which  seems  to  be  in  connection 
with  the  liver  it  will  follow  the  respiratory  excur- 
sions of  the  diaphragm.  Pain  radiating  into  the 
right  shoulder,  slight  icterus  in  former  attacks  must 
lead  to  the  right  diagnosis.  Nephrolithiasis  with 
consecutive  infection  of  the  kidney  may  be  a  cause 
of  error.  A  careful  urananalysis  will  clear  our 
doubts. 

Other  affections  that  might  be  mistaken  for  ap- 
pendicitis are :  Carcinoma  of  the  colon,  tuberculosis 
of  the  caecum,  intestinal  obstruction  from  various 
causes  with  beginning  general  peritonitis,  inflamma- 
tion of  a  Meckel's  diverticulum,  extrauterine  preg- 
nancy, typhoid  fever,  acute  pancreatitis,  lead  colic, 
acute  enterocolitis,  etc.  The  time  allotted  to  my 
paper  does  not  permit  me  to  go  into  further  details. 
The  brief  allusion  to  these  conditions  must  therefore 
sufiice. 

In  conclusion  let  me  say  a  few  words  on  the  value 
of  the  leucocyte  count  in  acute  appendicitis.  I  per- 
sonally have  never  attached  too  much  importance  to 
the  blood  examination  and  was  never,  as  regards 
diagnosis  or  operative  interference,  guided  bv  the 
blood  count  alone,  because  in  my  experience  we  are 
liable  to  draw  false  inferences.  Still  the  differential 
leucocyte  count  may  become  of  importance  if  stud- 
ied in  conjunction  with  all  the  other  symptoms,  but 
more  from  the  prognostic  standpoint.  According  to 
Kote,  a  temperature  of  37.9°  C,  pulse  96,  14,000 
leucocytes  speak  for  a  catarrhal  appendicitis.  Aug- 
mentation of  clinical  symptoms  with  temperature 
38.2°  C,  pulse  116,  leucocytes  20,000  means  severe 


890 


COOKE:  APPENDICITIS  AND  PREGNANCY. 


[New  York 
Medical  Journal. 


pathological  changes  of  the  appendix,  however  us- 
ually localized.  Temperature  38.5°  C,  pulse  126, 
leucocytes  30,000  denotes  a  more  or  less  progressive 
peritonitis.  Are  pulse  and  temperature  high,  leu- 
cocytosis,  however,  low  (18,000),  a  general  peri- 
tonitis with  doubtful  prognosis  may  be  considered. 

As  a  means  of  differential  diagnosis  the  leucocyte 
count  is  of  little  value  in  inflammatory  afTections  of 
the  female  annexa.  It  is,  however,  important  to 
note,  that  leucocytosis  is  generally  low  in  cholelithi- 
asis and  cholecystitis ;  in  typhoid  fever  the  leu- 
cocytes are  diminished,  in  lead  colic  not  increased. 
In  ileus  of  mechanical  origin  and  in  acute  pancreati- 
tis the  leucocyte  count  is  usually  low. 

130  E.\ST  Seventy-si  .\Tn  Street. 


APPENDICITIS  COMPLICATING  PREGNANCY 
WITH  REPORT  OF  FOUR  CASES.* 
By  Charles  O.  Cooke,  A.  M.,  M.  D., 
Providence,  R.  I. 

It  is  universally  recognized  that  appendicitis  is 
one  of  the  most  dangerous  complications  of  preg- 
nancy. In  view  of  the  importance  of  the  subject 
and  the  high  mortality  of  the  complication,  it  is  sur- 
prising to  see  how  little  space  is  devoted  to  it  in  re- 
cent books  on  surgery  and  obstetrics.  Kelly  in  his 
monograph  on  appendicitis  has  an  excellent  chapter 
on  the  subject. 

HISTORICAL  notes. 

Hancock,  in  the  Lancet  1848,  page  380,  reports 
the  first  case  of  appendicitis  complicating  pregnancy. 
Ten  days  after  a  premature  delivery,  Hiincock  in- 
cised an  appendicular  abscess.  Fifteen  days  after  the 
operation,  two  fascal.  concretions  were  discharged 
from  the  wound,  verifying  the  diagnosis.  The  on- 
set of  disease  was  four  days  before  delivery.  The 
patient  recovered  although  in  extremis  at  time  of 
operation. 

In  1885  Korn  and  in  1888  Miiller  reported  a  case 
in  which  the  autopsy  showed  death  due  to  a  per- 
forated appendix.  The  first  case  in  which  the  diag- 
nosis was  made  and  operation  advised  was  reported 
by  F.  H.  Wiggin  in  the  Medical  Record  (January 
23,  1892).  He  reported  a  case  of  perforative  appen- 
dicitis complicated  by  pregnancy  of  three  months. 
Operation  was  advised  but  refused.  General  peri- 
tonitis developed,  and  the  patient  died  on  July  31, 
1889.  Autopsy  showed  a  perforated  appendi.x 
which  contained  a  faecal  concretion  the  size  of  a 
hazel  nut.-  The  first  case,  in  which  the  diagnosis 
was  made  and  operation  performed,  was  reported 
by  Munde  in  the  Medical  Record,  December  i, 
1894,  in  an  article  entitled.  The  Premature  Delivery 
of  a  Dead  Child  Induced  by  Acute  Appendicitis, 
with  Remarks  on  Appendicitis  in  Women.  An  ap- 
pendicular abscess  was  opened  six  days  after  deliv- 
ery, and  the  patient  recovered. 

In  the  same  year  B.  C.  Hirst  (Medical  News, 
December  15,  1894)  reported  a  case  of  diffuse  un- 
limited suppurative  peritonitis  in  a  woman,  four  and 
one-half  months  pregnant.  Operation  was  per- 
formed, recovery  took  place,  and  the  patient  went 
on  to  full  term  and  was  delivered  of  a  living  child. 
Two  years  later  a  most  excellent  paper  was  read  by 

'Read  at  a  meetinf;  of  the  Providence  Medical  Association,  held 
on  February  i,  1909. 


Abrahams  entitled.  Appendicitis  Complicating  Preg- 
nancy. This  paper  was  published  in  the  American 
Journal  of  Obstetrics  for  February,  1897,  and  it  is 
universally  quoted  to-day.  In  this  paper  he  col- 
lected from  the  literature  to  date  seventeen  cases. 
The  diagnosis  was  verified  in  twelve  cases  by  opera- 
tion, of  which  number  seven  patients  died.  Five  pa- 
tients recovered  after  operation,  and  five  milder 
cases  recovered  without  operation. 

Boije  in  a  review  of  the  literature  up  to  1901  col- 
lected only  seventy  cases.  V'ineberg  in  1907  col- 
lected ninety-three  more  and  reported  six  cases  him- 
self, bringing  the  total  to  169.  Babler  in  a  recent 
article  has  collected  a  total  of  241  cases  of  appendi- 
citis complicating  pregnancy,  labor,  and  the  puer- 
perium.  Of  the  212  cases  occurring  during  preg- 
nancy, 106  were  of  the  perforative  or  gangrenous 
type  and  106  of  the  nonperforative  type.  He  has 
collected  twenty-eight  cases  complicating  the  puer- 
perium. 

Renvall  has  prepared  a  very  complete  monograph 
on  this  subject  with  a  full  table  of  references  and 
condensed  reports  of  over  250  cases,  divided  into 
subseries.  Extrauterine  gestation  cases  are  ex- 
cluded. The  first  subdivision  includes  all  cases 
where  the  complication  was  registered  as  simple  ap- 
pendicitis, one  hundred  in  all,  no  operation  in  preg- 
nancy, fifty ;  in  the  puerperium,  seven ;  operation  in 
pregnancy,  thirty-eight ;  in  the  puerperium,  five. 
The  second  series  is  much  the  larger,  including  cases 
where  appendicitis  was  associated  with  free  or  en- 
capsulated peritonitis.  No  operation  in  pregnancv, 
twenty-two ;  puerperium,  eleven ;  operation  in  preg- 
nancy, 108;  puerperium,  twelve.  Renvall  adds 
twenty-five  from  the  hospital  practice  of  Professor 
Engstrom. 

Jones,  in  Northwest  Medicine,  January.  1909,  re- 
ports three  cases :  One  was  a  subacute  recurrent 
case  operated  on  in  third  month,  followed  by  recov- 
ery and  labor  at  full  term.  The  second  was  an  acute 
suppurative  case  with  a  well  walled  off  abscess,  oc- 
curring during  the  fourth  month  of  pregnancy ; 
operation  was  followed  by  recovery  and  delivery  at 
full  term.  The  third  was  an  acute  perforative  gan- 
grenous appendicitis  in  a  young  woman  seven 
months  pregnant ;  operation  was  followed  by  prema- 
ture labor,  birth  of  a  dead  child,  and  death  of  the 
patient  by  general  peritonitis. 

frequency. 

The  frequency  of  the  complication  is  hard  to  es- 
timate. Doubtless  many  mild  cases  during  preg- 
nancy are  overlooked  and  many  serious  ones  occur- 
ring after  delivery  are  erroneously  regarded  as  puer- 
peral sepsis.  Some  authorities  assert  that  since  there 
is  a  greater  tendency  to  intestinal  toxaemia  during 
pregnancy,  there  is  every  reason  to  expect  appendi- 
cular complications.  Statistics,  however,  do  not  bear 
out  this  hypothesis. 

Treves  in  an  article,  entitled  The  Prospects  and 
\' icissitudes  of  .Appendicitis  After  Operation 
{British  Medical  Journal,  March  4,  1905.  p.  457). 
reports  1,000  cases  of  operation  for  appendicitis,  at 
the  London  Hospital,  from  July  i,  1900.  to  August 
15,  1904.  Of  these  1,000  cases,  319  were  women. 
Six  women  were  pregnant.  Ochsner  in  his  report 
of  1,000  cases  {Journal  of  Medicine  and  Suri^cry, 


May  I,  igoq.l 


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891 


Chattanooga,  November,  1904),  and  J.  B.  Murphy 
{The  American  Journal  of  the  Medical  Sciences, 
August,  1904),  2,000  cases,  do  not  mention  the  com- 
plication. 

In  the  entire  surgical  service  of  Mount  Sinai  Hos- 
pital from  1898  to  1907  there  were  2,003  cases  of 
appendicitis,  of  which  731  occurred  in  the  female 
sex.  The  association  of  pregnancy  occurred  in  only 
nine  cases,  two  of  these  were  not  operated  on. 
There  were,  therefore,  only  seven  undoubted  cases. 
In  both  gynaecological  services  there  was  not  a 
single  case.  From  these  figures,*it  would  seem  that 
one  third  of  all  the  cases  of  appendicitis  occur  in 
women.  Of  this  number  only  a  small  percentage  are 
at  the  same  time  pregnant. 

Frankel  met  with  only  four  cases  of  acute  appen- 
dicitis in  pregnancy  in  40,000  obstetrical  and  gyn- 
jecological  cases.  Lobenstine  states  that  in  the  last 
30,000  cases  under  the  care  of  the  New  York  Lying 
In  Hospital  there  have  been  but  five  cases  of  acute 
gangrenous  appendicitis.  Two  patients  recovered 
and  three  died  after  operation. 

AETIOLOGY. 

The  aetiology  of  appendicitis  complicating  preg- 
nancy is  the  same  as  in  the  nonpregnant  state. 
Where  it  has  previously  existed  there  is  a  great 
tendency  to  recurrence.  This  is  probably  due  to  the 
stretching  or  breaking  up  of  old  inflammatory  adhe- 
sions as  the  uterus  enlarges  and  rises  out  of  the 
pelvis.  Most  of  the  reported  cases  give  a  history  of 
long  continued  constipation,  and  in  many  there  is 
evidence  of  one  or  more  attacks  previous  to  the 
pregnancy.  The  pregnant  state  itself  does  not  pre- 
dispose to  the  development  of  acute  appendicitis. 

PATHOLOGY. 

The  pathology  of  the  disease  is  too  well  known 
to  require  more  than  a  passing  notice.  After  the 
third  month  the  uterus  forms  the  inner  wall  of  the 
abscess  in  those  cases  that  progress  to  suppuration. 
As  the  uterus  rises  from  the  pelvis  it  pushes  the 
caecum  upwards,  hence  the  appendix  may  be  found 
far  above  its  usual  position.  Fiith  has  called  atten- 
tion to  the  fact  that  in  early  pregnancy  the  uterus 
fills  the  pelvis  and  hence  pus  forming  from  a  dis- 
eased appendix  would  not  work  its  way  downward 
into  the  pelvis  so  readily  as  in  the  nonpregnant  con- 
dition. A  similar  condition  is  found  in  the  puer- 
peral state.  It  should  be  remembered  that  an  acute 
suppurative  inflammation  of  the  uterus  and  tubes 
may  be  set  up  bv  direct  extension  from  an  acutely 
diseased  appendix. 

S  V  J  r  PTO  M  ATOLOG  Y. 

The  attack  may  occur  at  any  stage  of  the  preg- 
nancy. One  of  my  cases  occurred  at  the  end  of  the 
tenth  week,  one  at  six  months,  and  two  at  the 
eighth  month.  The  attack  may  be  mild  or  severe. 
It  may  be  a  primary  attack,  but  often  a  history  of 
previous  attacks  may  be  obtained.  Owing  to  the 
increased  blood  supply  and  to  the  congestion  of  tho 
parts  due  to  pressure  of  the  enlarging  uterus,  apjicn- 
dicitis  in  pregnancy  runs  a  rapid  course.  Though 
some  subside,  the  majority  of  acute  cases  go  on  to 
suppuration.  The  pain  is  often  spasmodic  and  peri- 
odical in  character  resembling  labor  pains.  In  a 
case  occurring  in  my  practice,  the  patient  insisted 
that  she  was  starting  in  labor  and  the  pains  were 


apparently  typical  labor  pains.  The  vomiting,  which 
almost  always  follows  the  pain  at  the  onset  of  an  at- 
tack, may  be  confounded  with  the  vomiting  of  preg- 
nancy in  the  mild  attacks.  In  cases  occurring  early 
in  pregnancy,  the  pain  and  tenderness  are  usually 
localized  over  McBurney's  point.  In  those  cases  oc- 
curring late  in  pregnancy,  the  pain  and  tenderness 
are  often  localized  high  up  in  the  region  of  the  liver 
or  even  on  the  left  side  of  the  abdomen  as  it  was  in 
the  fourth  case  reported  by  ine. 

DIAGNOSIS. 

The  diagnosis  is  not  easy.  In  the  early  months 
with  the  classical  history  of  sudden  onset  of  general 
abdominal  pain  localizing  in  the  right  iliac  fossa, 
vomiting,  rise  in  temperature,  and  acceleration  of 
pulse,  leucocytosis  with  an  increased  percentage  of 
polynuclear  cells,  the  clinical  picture  is  complete 
when  we  find  rigidity  of  the  right  rectus  muscle  and 
tenderness  over  McBurney's  point  and  a  negative 
vaginal  examination.  But  how  seldom  it  is  that  we 
find  the  classical  case.  As  the  uterus  enlarges,  how- 
ever, the  diagnosis  becomes  more  difficult  for  the 
following  reasons  :  ( i )  The  presence  of  a  uterine 
tumor  small  or  large  filling  the  pelvic  or  abdominal 
cavity.  (2)  The  fact  that  the  abdominal  walls  are 
on  the  stretch  lacking  softness  and  pliability  so  es- 
sential in  the  examination  of  the  abdomen.  (3)  The 
fact  that  as  the  uterus  rises  from  the  pelvis  it  pushes 
the  caecum  upward  toward  the  liver.  Hence  the  pain 
may  be  referred  high  up. 

Frankel  has  suggested  as  an  aid  in  differentiating 
an  appendiceal  exudate  from  the  uterus,  that  the 
patient  be  turned  on  the  left  side  when  the  uterus 
sinks  in  that  direction  and  the  mass  is  more  easily 
palpated.  A  most  valuable  aid  to  diagnosis  is  the 
leiTcocyte  count  and  the  percentage  of  polynuclear 
cells  as  I  have  pointed  out  in  a  previous  paper  ( Yale 
Medical  Journal,  November,  1907).  The  diagnosis 
is  especially  difficult  after  labor,  in  which  case  the 
symptoms  may  simulate  puerperal  infection. 

DIFFERENTIAL  DIAGNOSIS. 

In  making  a  diagnosis  the  following  diseases  must 
always  be  borne  in  mind  and  ruled  out.  I  have 
briefly  indicated  under  each  one  the  most  important 
symptons  in  the  diagnosis.  Pain  in  the  right  side 
may  be  due  to  the  following  conditions  : 

1,  Myalgia  due  to  stretching  of  muscles  of  an- 
terior abdominal  parietes. 

2,  Ectopic  gestation  with  rupture ;  a,  temperature 
may  be  high  but  usually  subnormal  at  onset ;  b,  pain 
is  more  paroxysmal  and  severe ;  c,  rigidity  and  ten- 
derness over  McBurney's  point  not  marked ;  d, 
usually  bloody  flow  from  vagina  intermittent  in 
character;  e,  bimanual  examination  usually  shows 
mass  on  side  of  uterus ;  f,  symptoms  of  internal 
haemorrhage. 

_  3,  Pyelitis ;  a.  Onset  with  chill ;  b,  temperature 
high,  104°  to  105°  F.,  while  pulse  may  be  low;  c, 
bladder  symptoms,  frequent  and  painful  micturi- 
tion ;  d,  thickening  of  ureter  as  it  courses  anterior 
vaginal  well ;  e,  pus  in  urine  which  is  acid ;  f ,  ten- 
derness over  ureter  may  be  misleading  if  it  is  near 
McBurney's  point. 

4,  Typhoid  Fever,  Widal  test. 

5,  Diseases  of  Right  Adnexa;  a,  pain  frequently 
radiates  down  the  thigh ;  b,  history  of  gonorrhceal 


COOKE:    APPEXDICITIS  AND  PREGNANCY. 


[Xew  York 
ilEDiCAL  Journal. 


infection  soon  after  marriage ;  c,  local  examination  ; 
d.  a  differential  diagnosis  is  often  impossible  in 
those  cases  in  which  the  appendix  is  adherent  to  the 
right  annexa. 

6,  Ureteral  calculus ;  under  this  head  I  would  call 
attention  to  the  fact  that  blood  in  the  urine  may  be 
associated  with  an  inflamed  appendix  in  close  rela- 
tion with  the  ureter. 

7,  Gallstones. 

8,  Ovarian  cyst  with  twisted  pedicle ;  pain  par- 
oxysmal, severe,  often  out  of  proportion  to  the  con- 
stitutional symptoms. 

9,  Floating  kidney  ;  with  J:orsion  or  kinking  of 
ureter.  It  should  be  remembered  that  appendicitis 
may  occur  coincidently  with  any  or  all  of  these  con- 
ditions. 

10,  Perforated  gastric  or  duodenal  ulcer. 

11,  Perforation  of  large  intestine. 

PROGNOSIS. 

The  prognosis  in  the  acute  catarrhal  and  chronic 
recurrent  types  is  no  more  nor  no  less  dangerous 
than  in  the  nonpregnant  state.  The  mortality  is 
practically  nil.  The  vast  majority  of  these  patients 
recover  after  operation,  and  the  pregnancy  as  a 
rule  is  undisturbed.  The  prognosis  in  the  acute 
gangrenous,  perforative,  and  abscess  type  is  ex- 
tremely grave.  The  disease  runs  a  rapid  course. 
The  further  advanced  the  pregnancy,  the  worse  is 
the  prognosis,  particularly  if  pus  has  formed.  When 
pus  forms  in  the  later  months  of  pregnancy,  mis- 
carriage usually  takes  place  whether  operation  is 
l^erformed  or  not  because  the  pregnant  uterus  forms 
part  of  the  abscess  wall.  When  the  uterus  is  thus 
suddenly  emptied,  the  danger  of  general  suppura- 
tive peritonitis  is  extremely  grave,  for  limiting  ad- 
hesions are  broken  down  and  the  peritonaeum  flood- 
ed with  pus.  Septic  salpingitis  and  endometritis 
may  be  set  up  by  direct  extension.  The  mortality 
of  this  type  of  cases  with  operation  is  nearly  fifty 
per  cent.  Without  operation  is  nearly  one  hun- 
dred per  cent.  When  general  suppurative  peritoni- 
tis already  exists  at  the  time  of  operation,  whether 
miscarriage  has  already  taken  place  or  not,  the 
jjrognosis  is  almost  hopeless.  Abortion  or  prema- 
ture delivery  occurs  in  about  eighty  per  cent,  of  the 
acute  gangrenous,  perforative,  and  abscess  cases. 
The  prognosis  improves  the  earlier  such  cases  are 
operated  in  and  with  the  length  of  time  elapsing 
between  operation  and  miscarriage.  The  figures 
speak  for  themselves  and  show  the  urgent  need  of 
early  operation  before  perforation  has  taken  place 
or  an  abscess  has  formed. 

TRE.\TMENT. 

operation  should  be  performed  in  every  case  as 
soon  as  the  diagnosis  is  established,  without  wait- 
ing for  the  attack  to  subside  or  until  pus  has 
formed.  The  danger  at  this  time  is  very  slight,  the 
abdomen  can  be  closed  without  drainage,  and  there 
is  much  less  danger  of  miscarriage.  A  fatal  com- 
l^lication  sometimes  develops  in  patients  improving 
and  on  the  road  to  recovery,  and  patients  apparently 
dying  sometimes  get  well  by  aid  of  a  timely  oiiera- 
tion.  It  should  be  borne  in  mind  that  occasionally 
the  severest  types  of  a])pcn(licitis  present  the  mild- 
est symptoms.  In  ca.se  of  doubt  operation  is  sifer 
than  waiting.    Operation  is  to  be  advised  in  those 


cases  of  chronic  recurrent  appendicitis  when  the 
clinical  symptoms  are  of  a  mild  character  because 
a  fatal  attack  is  liable  at  any  time  to  light  up.  In 
the  abscess  cases  incision  and  drainage  should  be 
performed  at  the  earliest  possible  moment.  The 
appendix  should  be  removed  if  it  can  be  safely  done 
without  breaking  up  protective  adhesions.  There 
should  be  as  little  clisturbances  of  the  abscess  wall 
as  possible.  The  uterus  should  not  be  emptied 
either  before  or  after  the  operation,  inasmuch  as  it 
forms  the  inner  wall  of  the  abscess  cavity,  and  there . 
would  be  danger  of  setting  up  a  general  suppurative 
peritonitis.  Inasmuch  as  the  prognosis  in  those 
cases  of  general  diffuse  suppurative  peritonitis  is 
almost  invariably  fatal,  it  has  been  advised  by  some 
writers  that  the  uterus  be  emptied  in  those  cases  oc- 
curring at  the  end  of  pregnancy  with  the  hope  of 
getting  a  living  child  and  to  secure  better  drainage 
of  the  peritoneal  cavity.  The  most  favorable  time 
for  operation  in  all  of  these  types  of  appendicitis, 
especially  of  the  gangrenous,  perforative,  and  ab- 
scess type  is  within  twenty-four  hours  of  the  onset 
of  the  attack ;  when  the  disease  is  confined  to  the 
appendix  itself  and  the  incision  can  be  closed  with- 
out drainage,  and  there  is  less  danger  of  abortion 
and  miscarriage. 

I  have  four  cases  to  report.  Three  of  these  were 
operated  in  by  me  during  my  service  as  house  sur- 
geon at  the  Rhode  Island  Hospital  through  the 
kindness  of  Dr.  Churchill  and  Dr.  E.  B.  Smith.  It 
is  through  their  courtesy  that  I  report  these  cases. 
The  fourth  case  occurred  in  my  own  practice.  Thre," 
patients  recovered,  in  the  fourth  patient  scarlet 
fever  developed,  and  the  patient  left  the  hospital 
against  advice  and  subsequently  died. 

Case  I. — Diagnosis,  acute  perforative  appendicitis  witli 
abscess ;  two  and  a  half  months  pregnant. 

M.  B.,  age  si.xteen ;  married  ;  born  in  Buenos  Ayres :  mill- 
hand ;  entered  Rhode  Island  Hospital  October  23,  1906. 

Present  history :  Onset  two  days  ago,  preceded  by  two 
days'  constipation,  early  in  the  morning  with  pain  in  epi- 
gastriuni.  Four  or  five  hours  later  pain  localized  in  right 
lower  quadrant  of  abdomen,  and  patient  vomited.  Pain 
continued  in  this  location  up  to  time  of  entrance.  Patient 
was  two  and  one  half  months  pregnant.  Heart  and  lungs 
clear. 

Inspection  :  Abdomen  looked  tense  and  was  slightly  dis- 
tended and  there  was  a  slight  bulging  in  right  lower  quad- 
rant. 

Palpation  :  Whole  abdomen  w  as  rigid  and  tender,  whicli 
symptoms  were  more  marked  in  right  lower  quadrant. 
There  was  dullness  in  right  flank  and  right  lower  quadrant. 
Vaginal  examination  showed  cer\ix  soft  and  broad,  other- 
wise negative.  Uterus  mapped  out  with  difficulty  owing  to 
rigidity. 

Operation  :  Under  nitrous  o.xide  and  ether,  appendecto- 
my, dramage  of  abscess,  and  removal  of  right  lube.  Mc- 
Burney  incision.  Upon  nicking  the  peritonwum  a  small 
loop  of  snrall  intestine  protrudeci  into  wound.  This  was  re- 
placed and  followed  by  escape  of  thin  yellow  pus  with  a 
colon  odor.  The  appendix  was  felt  at  the  bottom  of  the 
abscess  cavity  curled  upward  and  outward  toward  the 
caecuni.  The  tip  was  seized  and  drawn  upward,  but  the  ap- 
pendix was  friable  and  tore  off.  The  proximal  portion  was 
again  seized  with  forceps  but  tore  again.  The  base  was  m 
the  well  of  the  abscess  cavity  and  coilld  not  safely  Jje  re- 
moved. The  right  tube  was  swollen  and  injected  and  evi- 
dently infected  and  was  removed.  Three  cigarette  drains 
were  inserted,  one  leading  to  stump  of  tube,  one  to  stump 
of  appendix,  and  a  third  to  tlic  bottom  of  abscess  cavity. 
Incision  closed  above  and  below  the  drains. 

October  25th.  Patient  miscarried.  Temperature  and 
pulse  remained  elevated. 

November  3rd.    Typical  scarlet  fever  rash  developed  and 


May  1.  1909.] 


COOKE:  APPENDICITIS  AND  PREGNANCY 


893 


patient  was  removed  trom  the  hospital  by  her  husband 
against  advice  and  subsequent!}-  died. 

Case  II.— Diagnosis,  acute  appendicitis  ;  pregnancy  eighth 
month ;  recovery. 

.Mrs.  O'R. ;  married,  aged  thirty-nine ;  born  in  Canada ; 
entered  Rhode  Island  Hospital  on  Noven.ber  18,  1906. 

Present  history :  Onset  two  days  ago  with  sharp  pain  in 
region  of  umbilicus,  nausea,  and  vomited  off  and  on  all 
jiight.  Vomited  constantly  yesterday.  This  morning  pam 
increased  in  severity  and  patient  vomited  constantly. 

Past  history:  Two  similar  attacks  in  June  and  August  of 
present  year. 

Exammation :  Abdomen,  size  eight  months'  pregnancy, 
\  cry  tender  to  palpation  over  whole  lower  half,  especially 
right  side  and  around  umbilicus.  Other  physical  signs  ob 
scured  by  pregnancy. 

Temperature  oii  admission  99,8''  F.,  pulse  100,  respiration 
54.    White  count  24,600. 

November  19th.  Temperature  normal,  pulse  92.  White 
blood  corpuscles  in  forenoon,  17,800;  in  afternoon,  21,200. 

November  20th.  Still  having  pain  in  lower  abdomen, 
whicli  was  very  tender.  Area  of  dullness  in  appendix  re- 
gion, a  mass  was  made  out  indefinitely  on  palpation.  White 
blood  corpuscles  count,  18,400. 

November  22nd.  Less  abdominal  rigidity  and  tenderness 
over  appendix. 

November  24th.  Only  slight  tenderness  and  rigidity 
over  appendix. 

November  28th.  Steady  improvement.  White  blood 
corpuscles  count,  13,200.    No  abdominal  symptoms. 

November  29lh.  White  blood  corpuscles  count,  14,600. 
Patient  sat  up  in  a  chair. 

December  2i)d.  Patient  had  been  up  and  about  for  four 
flays,  some  tenderness  on  deep  palpation  over  appendix. 
Patient  discharged  as  improved. 

Patient  reentered  the  hospital  on  December  7,  1906. 
Three  days  ago  (two  days  after  leaving  hospital)  patient 
gave  birth  to  a  four  -ind  a  half  pound  baby.  Five  hours' 
following  delivery  patient  was  seized  with  sharp  abdominal 
pain  in  the  lower  abdomen,  had  a  chill  and  vomited.  She 
vomited  several  times  yesterday  and  bowels  moved  several 
times.    Pain  continued  off  and  on  up  to  time  of  admission. 

Examination ;  There  was  tenderness  over  the  whole  ab- 
domen, more  marked  in  right  lower  quadrant.  Area  of 
dulness.  size  of  hand  over  appendi.x  region,  evidently  an 
appendiceal  abscess.  White  blood  corpuscles  count,  15,200. 
Operation  under  nitrou';  oxide  and  ether.  Drainage  of  ap- 
pendiceal abscess  and  removal  of  right  tube.  McBurney 
incision.  Deeper  layers  oedematous.  Upon  nicking  the  peri- 
tcnteuin  a  walled  off  abscess  was  opened,  containing  nearly 
■\  pint  of  foul  smelling  pus.  Above  was  cjecum  and  to  in- 
ner side  small  intestine  and  the  uterus.  The  right  tube  was 
at  the  bottom  of  the  abscess  cavity  which  was  lined  by  a 
thick  exogenic  membrane  and  which  easily  peeled  off,  leav- 
ing a  red,  inflamed  surface.  The  appendix  was  not  felt. 
The  right  tube  was  swollen,  oedematous,  and  friable,  and 
was  removed.  Three  cigarette  drains  were  inserted  and  in- 
cision closed  above  and  below  the  drains.  Patient  made  an 
uninterrupted  convalescence  and  was  discharged  cured  on 
January  2,  1907. 

C.\SE  III. — Diagnosis,  acute  gangrenous  appendicitis,  with 
pregnancy  six  months,  recovery. 

A.  C,  age  forty  ;  married  :  waitress  ;  entered  Rhode  Island 
Hospital  on  February  21,  1907,  about  4  p.  m. 

Family  history  negative. 

Patient  had  been  troubled  at  times  with  a  great  deal  of 
indigestion.  Onset  of  present  illness  two  days  ago  with 
pain  and  vorriiting  in  lower  abdomen  around  umbilicus. 
Patient  was  six  months  pregnant  and  was  sent  in  under 
diagnosis  of  "threatened  abortion,"  and  was  having  spas- 
modic pains  at  intervals  of  about  seven  minutes  and  some 
watery  discharge  from  the  vagina. 

Examination  showed  an  abdomen,  size  six  months'  preg- 
nancy. Marked  tenderness  over  appendicular  region.  No 
<l''illness  anywhere  on  oercussion.  No  free  fluid  in  flanks. 
F'ritient  looked  sick.  Wliite  blood  corpuscles  count  12,600. 
riift'erential  count  showed  polyiuiclears  ninety  per  cent. 
Temperature  99. 4'  F.,  pulse  104.  respiration  24. 

Diagnosis  of  gangreno'is  aopendicitis  was  made,  but  it 
was  decided  to  watch  patient  a  few  hours,  as  the  case  was 
not  absolutely  clear  and  operation  was  to  be  avoided  if 
possible.    White  blood  corpuscles  count  fell  to  11,000  six 


hours  later.  Spasmodic  pain  ceased,  but  exquisite  tendei- 
ness  persisted  over  McBurney's  point  and  signs  of  tree 
fluid  in  belly  were  present  where  they  were  absent  six  hours 
before.  Patient  was  sent  at  once  to  the  operating  room 
and  an  appendix  was  removed  that  was  gangrenous  from 
base  to  tip.  Free  fluid  was  present  and  the  intestines  cov- 
ered with  plastic  exudate.  The  belly  was  closed  without 
drainage,  and  patient  made  an  uninterrupted  convalescence 
except  for  a  mural  abscess,  and  did  not  n.iscarry. 

C.\SE  IV. — Diagnosis,  acute  gangrenous  appendic.tis ; 
pregnancy  eighth  month ;  recovery. 

This  case  has  been  reported  in  detail  in  the  Providence 
Medical  Journal  for  January,  1908.    I  will  briefly  report  it. 

The  patient  was  a  woman  thirty  y^ars  of  age,  married 
ten  years,  and  had  had  four  children,  ages  nine,  six,  four, 
and  sixteen  months.  Had  one  instrun.ental  delivery.  Fol- 
lowing birth  of  second  child,  patient  was  ill  about  six 
months  with  septichiemia,  abscesses  in  right  shoulder  and 
"milk  leg."  Since  that  time,  patient  had  had  pain  above 
and  to  the  left  of  umbilicus.  For  the  past  thirteen  years 
patient  had  attacks  of  acute  indigestion  at  intervals  of  two 
to  three  months.  These  attacks  were  characterized  by  se- 
\ere  pain  in  the  epigastrium  and  were  accompanied  by  vom- 
iting and  diarrhoea.  The  pain  never  localized  on  the  riglu 
side.  Patient  had  never  had  pelvic  trouble,  never  had  fre- 
quent nor  burning  micturition.  Last  menstruation  occurred 
on  Februray,  28,  1907,  and  according  to  her  own  calculation 
she  expected  to  be  confined  the  last  part  of  November. 
She  had  morning  sickness  throughout  pregnancy. 

I'he  patient  was  seen  by  me  for  the  first  time  on  October 
17,  1907,  having  been  seized  the  preceding  night  with  a  se- 
vere attack  of  indigestion  with .  distress  in  epigastrium. 
There  was  no  nausea  and  no  vomiting.  Bowels  had  been 
regular  and  had  moved  that  morning.  She  had  periodical 
pains  starting  in  back  and  running  through  to  the  front,  so 
much  like  labor  pains  that  patient  believed  herself  starting 
in  labor  and  thought  best  to  consult  a  physician. 

Abdomen  size  of  eight  months'  pregnancy.  Vertex  pre- 
sentation with  head  engaged.  Back  of  fretus  on  left  side. 
Foetal  heart  heard  on  left  side,  and  beating  140  a  minute. 
Abdomen  soft,  no  muscular  spasm  nor  nuiscular  rigidity. 
No  tenderness  over  appendi.x.  Slight  tenderness  in  epigas- 
trium.   No  free  fluid  in  flanks. 

Vaginal  examination  :  Os  patulous,  admitting  tip  of  in- 
dex finger ;  head  very  low  ;  no  exudate  in  pelvis.  Tempera- 
ture 100.4°  F- ;  pulse  96. 

During  the  night  patient  suffered  excruciating  pain  run- 
ning through  from  l)ack  to  front  and  felt  as  if  membranes 
were  going  to  rupture. 

October  i8th.  Patient  still  suffering  severe  pain.  Ten.- 
perature  100°,  pulse  96.  There  was  localized  tenderness 
over  left  lower  abdomen  in  the  left  iliac  fossa.  No  tender- 
ness whatsoever  over  appendiceal  area.  Foetal  head  was  not 
engaged,  and  fundus  of  uterus  was  higher  up.  Pelvic  ex 
amination  showed  os  patulous  but  not  dilated.  The  pain 
was  periodical  and  shooting  from  back  to  front  of  abdo- 
men, and  patient  stated  they  resembled  labor  pains. 

October  19th.  Patient  suffered  acutely  all  night.  Ex- 
pression that  morning  was  drawn  and  anxious.  Tongue 
was  dry  and  thickly  coated,  and  lips  were  dry.  Tempera- 
ture 100°  F..  pulse  96.  Heart  and  lungs  normal.  Pelvic 
examination  negative,  and  os  was  not  dilated.  On  this  day 
for  the  first  time  there  was  sharply  localized  tenderness 
over  McBurney's  point  and  an  area  of  dulness  size  of  palm 
of  hand  in  that  region.  No  free  fluid  in  flanks.  Blood  ex- 
amination showed  leucocytes  19.000.  and  a  differential  count 
of  500  cells  showed  polynuclears,  ninety  per  cent.,  mononu- 
clears ten  per  cent. 

Under  ethylchloride  and  ether  an?esthesia  the  abdomen 
was  opened  by  a  three  inch  muscle  splitting  incision  over 
IMcBurney's  point.  Upon  nicking  the  peritonjenm  free  fluid 
was  present.  Upon  inspection  of  the  peritoneal  cavity  noth- 
ing could  be  seen  but  the  uterus.  The  intestines  were 
nowhere  apparent.  The  incision  was  enlarged  upward  by 
cutting  across  the  fibres  of  the  internal  oblique  muscle. 
The  Falloonian  tube  was  free  and  covered  with  plastic  ex- 
udate. Half  way  upward  toward  the  liver,  the  appendix 
was  found  buried  beneath  the  caecum.  The  tip  of  the  ap- 
pendix for  a  distance  of  one  and  one  quarter  inches  wa« 
swollen  and  gangrenous.  The  mesoaopendix  was  tied  off 
with  No.  2  plain  gut.  The  base  of  the  appendix  was  tied 
off  with  chromicized  gut  No.  2.    The  appendix  was  cut 


894 


WARREN: 


EXTRAUTERINE  GESTATION. 


[Niw  York 
Medical  Journal. 


away,  and  the  stump  cauterized  with  pure  carbohc  acid.  A 
cigarette  drain  was  placed  at  the  upper  angle  of  the  wound 
leading  down  to  the  stump  of  the  appendix. 

The  incision  was  then  closed  below  the  drain  as  follows : 
Plain  gut  No.  2  continuous  suture  for  the  peritonseurn.  In- 
terrupted chromatized  suture  for  the  muscle ;  continuous 
chromic  gut  No.  2  suture  for  the  aponeurosis,  and  inter- 
rupted silk  worm  sutures  for  the  skin.  The  patient  stood 
the  operation  well,  pulse  at  no  time  being  higher  than 
T08,  and  she  made  an  excellent  recovery  from  the  anaes- 
thetic. 

Patient  miscarried  suddenly  on  the  fourth  day  following 
operation,  the  baby  being  born  with  membranes  unrup- 
tured. The  child  weighed  four  pounds  and  thirteen  ounces, 
and  was  born  alive.  From  now  on  improvement  was  rapid. 
The  patient  sat  up  in  bed  with  a  backrest  on  November 
6th,  and  was  out  of  bed  for  the  first  time  on  November  12th. 
SUMMARY. 

In  conclusion  I  wish  to  emphasize  the  following 
points : 

(1)  Appendicitis  should  be  suspected  in  all  cases 
of  right  sided  pain  occurring  during  pregnancy. 

(2)  Inasmuch  as  constipation  is  an  important  fac- 
tor in  the  aetiology  of  the  disease,  the  physician 
should  see  that  the  bowels  are  kept  free  throughout 
the  pregnant  state. 

(3)  The  symptoms  are  often  misleading. 

(4)  The  diagnosis  is  not  easy. 

(5)  The  prognosis  is  good  in  the  acute  catarrhal 
and  chronic  recurrent  types,  but  extremely  grave  in 
the  gangrenous,  perforative,  and  abscess  type. 

(6)  The  treatment  is  operation  in  every  case  as 
soon  as  the  diagnosis  is  established.  In  cases  of 
doubt  operation  is  safer  than  waiting. 

(7)  The  mortality  of  appendicitis  compHcating 
pregnancy  is  the  mortality  of  delay. 

(8)  Appendicitis  during  pregnancy  is  more  dan- 
gerous than  in  the  nonpregnant  state. 

(9)  The  true  prophylaxis  in  a  child  bearing  wo- 
man who  has  had  a  well  marked  attack  of  appendi- 
citis is  an  interval  operation. 

(10)  The  possibility  of  appendicitis  after  labor 
in  predisposed  patients  should  be  borne  in  mind  in 
order  not  to  mistake  such  for  puerperal  sepsis. 

(11)  In  the  perforative  cases  with  general  dif- 
fuse suppurative  peritonitis,  occurring  at  the  end 
of  pregnancy  accouchement  force  is  indicated  fol- 
lowed by  incision  and  drainage  of  the  peritoneal 
cavity. 

References. 

Abrahams.    American  Journal  of  Obstetrics,  1897,  p.  .305. 

Babler.  Journal  vf  the  American  Medical  Association, 
October  17,  1908. 

Baker  and  Smith.  American  Journal  of  Obstetrics,  Au- 
gust, 1905.. 

Boije.  Mitteilungen  aus  der  gyndkologischen  Klinik  des 
Professor  Engstrotn,  1903. 

Coe.  Journal  of  Surgery,  Gynecology,  and  Obstetrics, 
P-  53,  1905- 

Davenport.    Providence  Medical  Journal,  July  i,  1900. 

Davis.    American  Journal  of  Obstetrics,  xliii,  p.  351. 

Deaver.    A  Treatise  on  Appendicitis. 

Docgc.    Mikvauhce  Medical  Journal,  July,  1905. 

Gcrstcr.    Philadelphia  Monthly  Medical  Journal. 

Hancock.    Lancet,  p.  380.  1S48. 

Heaton.    British  Medical  Journal.  March  4,  1905. 

Hilton.    Western  Medical  Review,  November,  1907. 

Hirst.    Medical  News,  December  15,  1894. 

Keen.  Surgery. 

Kclley.    The  Fermiform  Appendi.v  and  Its  Diseases. 

Lobenstinc.  Bulletin  of  the  Lying  In  Hospital  of  New 
York,  September,  190S. 

Mapuire.  Mobile  Medical  and  Surgical  Journal.  1907,  p. 
205. 

Mtiiulc.    Medical  Record,  December  i,  1894. 


Murphy.  American  Journal  of  the  Medical  Sciences, 
August,  1904. 

Myer.    American  Journal  of  Obstetrics,  p.  358,  1906. 

Renvall.  Mitteilungen  aus  der  gyndkologischen  Klinik 
des  Professor  Engstrom.  vii.  Part  3,  igoS.  British  Medical 
Journal,  December  15,  igo8. 

Treves.    British  Medical  Journal,  March  4,  1905. 

Vineberg.    New  York  Medical  Journal,  11,  1907. 

Webster.  Journal  of  Surgery,  Gyncccology,  and  Obstet- 
rics, p.  27,  1905. 

Wiggin.    Medical  Record,  January  23,  1892. 

Williams.  Obstetrics. 

251  Broad  Street. 


EXTRAUTERINE  GESTATION.* 

Report  of  a  Case  zvith  Delivery  of  a  Viable  Child. 

By  J.  N.  Warren,  M.  D., 
Sioux  City,  Iowa. 

Extrauterine  gestation  is  quite  frequently  met  ' 
with.  There  is  abundant  literature  covering  the 
history  and  treatment  of  such  cases.  Only  those 
completing  the  term  of  pregnancy  will  be  discussed 
in  this  paper.  It  is  possible  for  a  case  of  tubal 
gestation  to  abort  or  suffer  rupture  of  the  tube 
without  separation  of  the  placenta  with  continuance 
of  the  gestation.  This  is  rare,  but  it  is  more  sel- 
dom to  have  the  patient  delivered  of  a  viable  child 
at  or  near  the  completion  of  the  term  of  pregnancy. 
While  the  ectopic  foetus  is  placed  in  dangerous  sur- 
roundings, a  sufficient  number  of  cases  have  been 
reported  where  the  foetus  has  attained  a  viable  age, 
so  that  these  cases  are  not  extremely  rare. 

Kelley  reports  seventy-seven  cases  collected  from 
1809  to  1899,  which  he  divides  into  two  groups. 
First  group  fro  in  1809  to  1889,  thirty-seven  cases 
with  seven  recoveries,  18.9  per  cent,  a  maternal 
mortality  of  75.6  per  cent.  The  second  group,  from 
1889  to  1899,  containing  forty  cases,  with  twenty- 
seven  recoveries,  or  67.5  per  cent.,  a  mortality  of 
32.5  per  cent.,  an  improvement  of  fifty  per  cent,  in 
mortality  rate  under  improved  technique  and  asep- 
sis. Sittern  has-  recently  reported  147  cases  in 
which  a  viable  foetus  has  been  delivered  by  means 
of  operation.  Dr.  Werder  reports  three  cases  with 
one  death.  Dr.  Blesh  and  Dr.  Reed  report  a  case, 
mother  and  child  both  living  several  months  after 
operation.  The  child  mortality  is  very  high.  In 
the  first  group  reported  by  Kelley,  it  was  82.9  per 
cent. ;  in  the  second  group,  seventy-five  per  cent. 
There  are  many  reasons  to  account  for  the  large 
death  rate.  The  child  is  apt  to  be  poorly  developed 
and  badly  nourished,  hence  it  succumbs  to  slight 
causes. 

Sittern  states  that  more  than  half  of  the  children 
survived  the  first  month.  He  advises  operation 
some  weeks  prior  to  completion  of  the  term,  on  ac- 
count of  spurious  labor  causing  death  of  the  child. 
Werder  states  that  it  is  better  to  wait  till  comple- 
tion of  the  term,  because  the  children  are  weak,  and 
the  death  rate  will  be  increased  by  premature  opera- 
tion. I  am  of  the  opinion  that  Dr.  Werder's  advice 
should  be  adopted. 

The  following  case  is  believed  to  be  of  sufficient 

interest  to  be  worthy  of  record : 

Case. — Mrs.  W.,  aged  thirty-four,  married  at  twenty; 

•Read  before  the  Western  SiirRical  and  Gynjecological  Associa- 
tion, at  a  meeting  held  in  December,  1908. 


May  I,  1909.] 


PEDERSEN:  ERRORS  IN  URETHRA  AND  BLADDER  TREATMENT. 


895 


first  child  born  seven  years  after  marriage,  labor  normal. 
Not  again  pregnant  till  this  pregnancy.  Last  menstruation 
September  23,  1907.  On  September  15th  she  had  an  attack 
of  pain  in  the  right  iliac  region,  lasting  several  days.  Abour 
every  two  weeks  she  had  attacks  of  pain  in  the  right  side. 
From  November  12th  to  26th  she  was  in  bed  on  account  of 
this  pain  in  the  right  side. 

On  December  ist,  she  had  a  very  severe  attack  of  pain  in 
lower  abdomen,  more  marked  on  the  right  side  and  was 
confined  to  her  bed  until  February  15,  1908.  Diagnosis: 
Appendicitis.  It  is  probable  that  she  suffered  a  rupture  of 
the  tube  at  this  time.  From  the  latter  date  she  was  in  fan- 
health  until  June  26th,  when  she  had  a  spurious  labor. 
Some  watery  discharge  took  place,  followed  by  a  bloody  dis- 
charge. She  had  labor  pains  for  some  hours,  when  they 
ceased.  On  August  12th,  she  had  a  recurrence  of  pain,  and 
was  examined  by  the  attending  physician.  On  August  13th 
she  was  given  an  anaesthetic,  but  no  definite  diagnosis  was 
arrived  at. 

Un  August  i4ih  she  was  brought  to  the  Samaritan  Hos- 
pital, and  upon  examination  I  found  the  foetus  extrauterine, 
ihe  head  presented  in  the  pelvis,  back  of  the  uterus;  the 
body  of  the  foetus  lay  in  the  left  side  of  the  abdominal 
cavity,  back  against  the  parietal  wall.  The  placental  souf- 
fle could  be  made  out  upon  the  right  sijde,  extending  from 
the  umbilicus  down  to  Poupart's  ligament.  No  foetal  heart 
sound  could  be  made  out.  Patient  was  anaesthetized  and 
proper  preparation  made  for  abdominal  section.  An  incis- 
ion extendmg  from  the  umbilicus  down  to  the  pubis  was 
made.  The  membranous  sac  presented  upon  the  left  side, 
attached  to  the  intestines,  and  left  side  of  the  uterus.  The 
light  side  was  covered  in  by  the  omentum,  much  thickened 
and  firmly  adherent  along  the  right  margin  of  the  uterus 
down  to  the  pelvic  brim.  I  commenced 'separating  the  sac, 
which  was  very  thin,  from  the  intestines  and  left  margin 
of  the  uterus.  After  separating  the  sac  for  about  four 
inches,  it  ruptured,  with  a  discharge  of  some  amniotic  fluid, 
and  the  right  arm  was  expelled.  The  child  was  now  rapid- 
ly delivered,  the  cord  ligated,  and  the  child  passed  to  Dr. 
A.  M.  Warren,  who,  after  some  time,  succeeded  in  resus- 
citating it.  Notwithstanding  the  unfavorable  surroundings 
of  the  child,  no  deformity  was  present.  It  weighed  about 
seven  pounds.  A  careful  exammation  was  made  to  know 
whether  it  was  possible  to  remove  the  sac  and  placenta.  It 
was  impossible  to  reach  the  arteries  supplying  the  placenta, 
which  was  attached  upon  the  right  side,  extending  from  the 
pelvis  upward  for  several  inches,  and  was  attached  to  the 
uterus  and  omentum  overlying  it.  During  the  manipulation 
some  hremorrhage  occurred  and  further  efforts  were  aban- 
doned. A  portion  of  the  sac  was  separated  from  the  intes- 
tines and  the  excess  removed.  The  cord  was  ligated  and 
cut  short.  The  sac  was  now  sutured  to  the  lower  part  of 
the  abdominal  incision  and  packed  with  sterile  gauze. 

Each  day  some  haemorrhage  occurred  and  the  patient  be- 
gan to  be  somewhat  anaemic.  On  the  sixteenth  day  after 
the  operation  I  attempted  to  remove  the  placenta,  but  on 
account  of  free  h;i?morrhage  I  found  it  impossible  to  do  so. 
The  sac  was  firmly  packed,  and  two  hsemostats  were  placed 
at  the  upper  portion  to  completely  control  the  haemorrhage, 
and  were  allowed  to  remain  in  place  for  forty-eight  hours. 
During  the  fifth  week  the  sac  and  a  portion  of  the  placenta 
were  discharged.  Some  days  following  this  infection  took 
place,  attended  with  a  free  dicsharge  of  pus,  the  tempera- 
ture ranging  from  100°  to  103°  F.  for  ten  days.  With  the 
patient  profoundly  anaemic  and  now  septic,  it  seemd  almost 
impossible  for  her  to  recover.  However,  with  free  stimu- 
lation and  feeding  she  began  to  rally.  During  the  first 
week  she  had  marked  distention  of  the  stomach,  which  re- 
quired stomach  lavage  once  or  twice  daily. 

After  a  tedious  and  stormy  convalescence,  she  left  the 
hospital  November  5,  1908,  and  has  gained  steadily  in 
strength  and  flesh.  The  child  lived  about  ten  hours,  when 
it  suddenly  expired. 

The  history  of  these  cases  shows  a  large  mortal- 
ity. The  frightful  h?ernorrhage  caused  b'^'  efforts  to 
remove  the  placenta  has  determined  the  cause. 
When  possible  to  separate  the  adhesions  and  secure 
the  ovarian  artery  and  the  branches  of  th*"  uterine 
it  may  be  safely  removed.  I  am  of  the  ooinii^n  that 
many  cases  would  be  saved  by  allowing  the  placenta 
to  remain  for  subsequent  delivery.  It  is  tru?  that 
later  hremorrhage  might  occur,  threatening  the  life 


of  the  patient ;  also,  we  have  the  danger  of  infection. 
With  pressure  or  clamping  of  the  abdominal  aorta, 
the  haemorrhage  may  be  controlled,  but  unless  it  is 
plainly  possible  to  completely  remove  the  placenta, 
it  had  best  not  be  resorted  to,  for  when  the  pressure 
is  removed  a  fatal  hjemorrage  will  take  place. 

When  the  diagnosis  has  been  made  of  an  abdo  n- 
inal  gestation  existing,  it  is  usually  after  the  middle 
of  the  term.  Hence,  I  believe  it  better  to  wait  until 
the  completion  of  the  term  before  operating.  The 
danger  to  the  mother  will  not  be  increase  ',  and  th^ 
possibility  of  the  delivery  of  a  viable  child  is  as- 
sured. Should  a  diagnosis  be  made  at  the  time  of 
the  rupture  of  the  tube,  it  would  probably  be  better 
to  advise  operation. 

Again,  it  is  a  mooted  question  as  to  whether  an 
immediate  operation  should  be  done.  In  my  case, 
it  was  not  suspected  that  the  pregnancy  was  other 
than  normal.  This  case  demonstrates  the  possibility 
of  delivering  a  viable  child  some  time  after  the  com- 
pletion of  term,  and  spurious  labor  has  taken  place. 
In  this  case  spurious  labor  occurred  June  26th,  and 
the  operation  took  place  August  14th,  a  period  of 
forty-nine  days.  It  is  probable  that  the  complication 
of  appendicitis  may  account  for  the  dense  adhesions 
existing  at  the  location  of  the  placental  attachment. 
The  right  tube  was  the  seat  of  primary  implantation 
of  the  ovum. 

Sittern  advises  complete  removal  of  the  placenta, 
stating  that  the  death  rate  is  18.8  per  cent.  When 
the  placenta,  is  allowed  to  remain,  the  mortality  is 
54.4  per  cent.  These  statistics  are  so  pronounced  in 
favor  of  complete  removal  of  the  placenta  that, 
when  possible,  it  should  be  done.  However,  I  am 
convinced  that  some  lives  have  been  lost  on  account 
of  uncontrollable  haemorrhage  caused  by  persistent 
efforts  to  remove  the  placenta.  The  history  of  a 
number  of  cases  proves  that  it  can  be  safely  done 
when  properly  managed.  Dr.  Blesh  and  Dr.  Reed 
allowed  their  patient  to  leave  the  hospital  at  the  end 
of  four  weeks.  Four  weeks  following,  or  eight 
weeks  from  the  time  of  operation,  their  patient  re- 
turned to  the  hospital,  when  the  placenta  was  easily 
and  safely  removed. 

Corner  Fifth  and  J.xckson  Streets.  ; 

COMMON  ERRORS  IN  THE  TREATMENT  OF  THE 
URETHRA  AND  BLADDER,* 

By  J.\MEs  Pedersen,  M.  D., 
New  York. 

Excluding  cases  marred  by  errors  of  judgment, 
mistakes  in  diagnosis,  and  the  accidents  of  instru- 
mentation, to  all  of  which  a  liability  must  necessarily 
exist,  there  remains  a  fair  percentage  of  urethral 
and  bladder  cases  which  have  been  overtreated  or 
erroneously  treated  by  a  conscientious  physician  or 
surgeon  while  striving  to  do  his  patient  ftill  justice. 
This  may  happen  by  reason  of  a  failure  to  appreciate 
certain  general  conditions  that  influence  the  local; 
by  reason  of  overzealous  treatment  in  the  anxiety 
to  get  the  patient  well  quickly ;  through  lack  of  spe- 
cial knowledge  or  training;  and,  finally,  through 
want  of  skill  in  instrumentation. 

*Read  before  the  American   Association   of   Genitourinary  Sur- 
geons at  its  annual  meeting,  May,  1908. 


S96 


PEDERSEX:  ERRORS  JX  URETHRA  AXD  BLADDER  TREATMENT.  I-^'e-v  Vork 

Medical  Journal. 


The  urethra  and  bladder  seem  especially  exposed 
to  errors  in  treatment,  apparently  because  many  of 
the  symptoms  they  give  rise  to — perhaps  because 
some  of  the  diseases  they  are  exposed  to — are  not 
taken  seriously  by  the  majority.  The  few  illustra- 
tions here  brought  together  are  random  examples 
of  cases  seen  in  consultation  or  referred  for  treat- 
ment. They  are  offered  as  evidence  in  favor  of  care- 
ful discriminations  in  the  search  for  a  solution  of 
the  problems  presented  by  many  of  the  urethral  and 
;bladder  conditions  that  come  under  observation. 

The  use  of  the  sound  indiscriminately, — some- 
times with  violence. — for  diagnostic  or  exploratory 
]iurposes,  is  a  common  error.  Often  it  amounts  to 
overtreatment  in  tlie  sense  of  meddlesome  treatment. 
Every  now  and  then  it  would  seem  that  the  sound 
liad  been  used  because  no  indication  for  any  other 
treatment  had  been  recognized.  Possibly  sometimes 
there  had  lieen  a  failure  to  recognize  the  coiitm'm- 
(Hcations  to  that  form  of  treatment. 

C-\SE  I. — A  young  man,  accustomed  to  moderate  coitus 
v.-ith  his  mistress,  noticed,  on  a  certain  day,  a  slight  dis- 
charge from  his  urethra.  He  consulted  his  physi- 
cian, who  promptly  pronounced  it  "no  infection,"  and 
at  once  passed  a  full  sized  sound.  This  gave  the  patient 
considerable  pain  and  produced  some  bleeding.  The  fol- 
lowing day  he  had  a  chill  and  rise  of  temperature,  and 
there  developed  an  increasing  frequency  of  urination  with 
a  progressive  sense  of  obstruction.  A  few  days  thereafter 
he  had  to  take  to  his  bed.  Twenty  days  after  the  unwar- 
rantable instrumentation,  complete  retention  occurred,  and 
for  one  week  he  was  catheterized  once  daily.  The  urine 
was  described  as  having  contained  blood  and  pus.  He  now 
came  under  my  obser\  ation.  A  soft  rubber  catheter  passed 
without  difficulty,  and  drew  twenty-four  ounces  of  chocolate 
colored  urine  from  the  overdistended  atonic  bladder.  Forty- 
eight  hours  later,  the  prostatic  abscess  was  evacuated 
through  a  perineal  incision.  After  one  more  catheteriza- 
tion, nine  hours  after  the'  operation,  he  began  to  urinate 
spontaneously.  His  recovery  from  then  on  was  rapid  and 
uneventful. 

In  this  case  there  was,  apparently,  a  failure  to 
recognize  the  cardinal  rule  that  instrumentation  of 
the  urethra  should  not  be  performed  in  the  presence 
of  a  urethral  discharge,  unless  the  discharge  have  a 
history  of  chronicity,  and  only  then  if  the  patient 
declare  no  recent  illicit  coitus.  To  this  rule  there 
are.  I  believe,  only  two  exceptions — retention  of 
urine,  and  extremely  severe  acute  posterior  urethri- 
tis, not  yielding  to  palliative  measures.  A  criticism 
may  furthermore  be  entered  against  the  use  of  so 
large  a  sound,  and  with  such  evident  violence.  As 
it  is  not  known  whether  the  sound  was  passed  to  ex- 
plore for  strictures  or  to  dilate  any  that  might  exist, 
the  question  whether  a  further  error  was  made  in 
not  choosing  a  bougie  a  boitle  instead  of  a  sound, 
cannot  be  discussed. 

C.\SF.  II. — A  similar  case.  A  middle  aged  man  on  wliom 
a  sound  had  been  passed  and  bladder  irrigations  given  b> 
catheter  because  lie  complained  of  painless  frequency  of 
urination,  .^ftcr  the  second  irrigation  the  patient  complained 
of  still  greater  frec|uency  and  of  slight  pain.  To  relieve  this 
pain,  he  had  been  directed  to  drink  large  quantities  of  wa- 
ter. During  the  evening  before  he  consulted  me,  he  had 
drunk  a  quart ;  during  that  night  he  had  risen  ten  times, 
•  ncc  every  liour,  tn  \oid  about  six  ounces  each  time. 

An  analysis  of  his  history  readily  disclosed  the  fact  that 
the  patient  was  neurotic  and  came  of  a  neurotic  family,  that 
his  original  frequency  of  urination  dated  back  thirty  years, 
to  the  days  of  his  yor.th.  and  was  due  to  a  polyuria  of  neu- 
rotic origm,  and  that  iiis  present  frequency  was  partly  that 
<if  vfilume  and  partly  that  of  irritation.  Subsequent  de\cl- 
f'pments  under  the  sedative  treatment  instituted  proved 
these  deductions  to  be  correct.     The  errors  in  this  case 


were  the  omission  to  get  a  detailed  history  of  the  patient 
and,  secondly,  to  note  that  there  existed  no  indication  for 
bladder  irrigations. 

Overfreqtient  instrumentation, — usually  with  the 
sound, — in  the  treatment  of  urethritis,  is  perhaps  the 
next  most  common  error. 

C.vsF,  III. — A  case  in  point  is  that  of  a  young  man  with 
a  history  of  three  attacks  of  urethritis.  The  first  ran 
a  mild  course  of  seven  weeks.  The  second  (si.x  years  later) 
ran  a  course  of  nine  months  under  irrigations  of  potassium 
permanganate  and  silver  nitrate,  supplemented  by  sound 
32  F  for  "slight  stricture."  The  third  (again  six  years 
later)  was  treated  for  eleven  months  with  a  variety  of  in- 
ternal medication.  Thereafter,  for  six  weeks  before  he 
came  under  my  observation,  sounds  from  30  to  36  French 
were  passed  "every  few  days." 

In  addition  to  two  strictured  zones  and  the  characteristic 
endoscopic  picture  of  a  chronically  inflamed  urethra,  he  pre- 
sented a  chronic  prostatitis  and  right  seminal  vesiculitis.  A 
moderated  treatment  of  the  urethra  plus  massage  of  the 
prostate  and  affected  seminal  vesicle,  cleared  up  the  con- 
dition in  seven  weeks.  Not  only  had  there  been  overtreat- 
ment  of  the  urethra,  but  also  neglect  of  the  prostatitis  and 
vesiculitis. 

Case  IV. — Somewhat  in  line  with  the  foregoing  case,  at 
the  same  time  furnishing  an  introduction  to  a  class  that  is 
to  follow,  is  that  of  an  anaemic,  poorly  nourished  man,  thir- 
ty years  old,  whose  antecedent  history  is  pointedly  marked 
by  two  operations  for  osteomyelitis,  eight  years  apart. 
His  previous  venereal  history  includes  a  great  deal  of  un- 
gratified  sexual  excitement,  and  one  attack  of  urethritis  of 
short  duration,  one  year  before.  The  urethritis  of  which 
he  complained  at  the  time  he  came  in  consultation,  had  been 
in  existence  three  months.  His  symptoms  were,  a  scanty 
urethral  discharge,  some  frequency  day  and  night,  marked 
urgency,  pain  in  and  tenderness  of  certain  joints  and  bones, 
loss  of  appetite,  and  general  absence  of  well  being.  Early 
in  the  course  of  the  urethritis  he  had  been  treated  with  in- 
travesical irrigations  for  tiiree  weeks.  Sounds  had  been 
^passed  every  third  daj',  a  stricture  having  been  discovered. 
No  progress  toward  recovery  having  resulted,  he  became  so 
discouraged  and  run  down  that  he  abandoned  all  treatment 
and  went  away  for  three  weeks.  He  returned  greatly  im- 
proved in  every  particular.  Attention  having  become  cen- 
tered on  the  insignificant  stricture,  to  the  total  exclusion  of 
tiie  significant  cautionary  signals,  dilatation  had  been  re- 
sumed and  more  frequently  than  before.  As  a  result,  the 
frequency  and  urgency  of  urination  had  returned. 

The  following  case  may  further  illustrate  not  only 
the  ease  and  frequency  with  which  the  general  con- 
dition of  the  patient  is  overlooked,  if  not  neglected, 
but  also  the  futility  of  urethral  irrigations  as  a  rou- 
tine measure  in  acute  specific  urethritis,  and  the 
traitmatism  they  are  capable  of  effecting  even  in 
experienced  hands. 

C.-VSK  V. — The  patient  was  a  spare,  poorly  nourished, 
anremic  man.  Both  sides  of  his  neck  bore  the  legible,  path- 
ognomonic scars  of  extensive  dissections.  With  evident 
conviction  and  without  qualification,  he  stated  that  he  had 
had  a  great  deal  of  sickness  in  his  life.  Certainly  his  looks 
did  not  belie  him.  He  had  every  appearance  of  a  man  re- 
quiring supportive  treatment.  During  the  first  four  days  of 
his  urethritis  he  had  allowed  the  disease  to  take  its  course 
and  was  fairly  comfortable.  He  then  consulted  a  well 
known  advocate  of  the  so  called  irrigation  treatment,  who 
promptly  instituted  urethral  irrigations  and  two  days  there- 
after essayed  an  intravesical  irrigation.  It  was  not  very 
successful.  The  reason  given  was  the  fact  that  the  pa- 
tient was  "very  sore  and  sensitive,  and  not  used  to  it.'" 
This  was  preeminently  the  fact ;  it  was  the  patient's  first 
urethritis.  That  evening,  the  iiatient  had  terminal  bleed- 
ing and  noticeable  frequency  of  urination  developed.  The 
second  intravesical  irrigation  was  undertaken  the  following 
day,  with  the  san^e  consequences  and  results.  The  treat- 
ment was  then  reduced  to  anterior  irrigations. 

He  presented  a  profuse,  dark  yellow  disciiargc.  marked 
inflammatory  swelling  of  the  urethra,  and  considerable  en- 
gorgement of  the  whole  penis.  There  were  slight  frc- 
cpiency.  urgency,  and  tenesnuis.  Under  treatment  that  made 
general  measures  as  important  as  the  local  means,  the  gros.? 
inflammatory  signs  entirely  disappeared  before  the  eleventh 


:^Iay  1,  1909.]  FEDERSEN:  ERRORS  /.V  URETHRA  AXD  BLADDER  TREATMEXT. 


897 


day;  the  discharge  almost  ceased — was  sometimes  absent 
altogether;  his  rest  was  broken  bj-  only  one  nocturnal  uri- 
nation ;  his  diurnal  freqnency  became  normal ;  and  only  a 
small  numbtr  of  gonococci  could  be  found  in  the  scanty 
smears.  Several  days  prior  to  this,  his  appetite  and  gen- 
eral wellbcing  had  returned.  He  had  not  lost  a  day  from 
his  office. 

Case  VI. — A  second  illustration  in  the  same  class  is  fur- 
nished by  a  hearty,  vigorous,  well  nourished  man, — physical- 
ly tlie  direct  opposite  of  the  patient  in  the  preceding  case. 
Comparison  is  further  favored  by  the  fact  that  both  infec 
tions  were  virulently  specific.  His  treatment  had  been 
begun  with  a  potassium  permanganate  irrigation  of  the  an- 
terior urethra  three  times  daily.  Xo  improxement  result- 
ing, a  change  had  been  made  to  a  i  in  6000  solution  of 
mercuric  iodide,  'litis  scalded  intensely,  and  at  once  fre 
quency,  urgency,  and  severe  tenesmus  developed,  with  fee- 
bleness of  the  stream  and  terminal  bleeding.  The  symp- 
toms had  almost  reached  those  of  strangury.  Thereupon 
the  potassium  permanganate  irrigation  had  been  resumed, 
and  hand  injections  of  weak  solutions  of  argyrol  added. 
The  prostatitis  had  culminated  in  an  abscess.  It  had  al- 
ready ruptured  into  the  urethra  when  he  came  under  my  ob- 
servation, eight  weeks  after  the  onset  of  his  symptoms. 

Notwithstanding  his  history  of  a  previous  severe,  prob- 
ably specific  urethritis,  ^vith  a  sharp  involvement  of  the  pos- 
terior urethra,  and  notwithstanding  his  inability  to  take 
any  rest  during  the  present  attack,  as  also  during  the  pre- 
ceding one,  it  IS  fair  to  assume  that  potent  but  less  violent 
local  treaenieni,  with  a  hand  injection  of  one  of  the  silver 
albuminoid  salts,  for  example,  would  have  saved  him  a 
great  deal  of  \aluable  time  and  an  amount  of  suffering  that 
is  unpleasant  to  contempiate.  Largely,  if  not  wholly,  be- 
cause of  the  complications  he  had  sufYered,  his  course  to- 
ward recovery  was  slow,  though  progressive. 

The  in.stillation  of  a  strong  silver  nitrate  soltition 
into  the  urethra  or  bladder  is  a  not  uncommon  error. 

Case  VII. — A  young  man  had  apparently  recovered  from 
a  second  urethritis  of  si.x  montiis"  duration.  Five  months 
later  a  frequency  of  urination  developed,  undoubtedly  in 
consequence  of  the  effect  of  beer  drinking  and  excessive 
use  of  tobacco  and  coffee  on  a  chronically  inflamed,  imper- 
fectly treated  urethra.  Probably  his  physical  and  mental 
fatigue  were  contributing  causes.  After  the  frequency  had 
persisted  for  about  a  month,  he  noticed  a  redness  around 
tlie  meatus.  Soon  thereafter  a  urethral  discharge  appeared 
and  gradually  increased  until,  at  the  end  of  a  week,  it  was 
profuse  and  greenish  yellow.  By  the  end  of  another  week 
be  was  having  very  frequent  and  painful  erections.  When 
giving  me  this  history,  he  voluntarily  summed  up  his  condi- 
tion as  it  then  was  by  calling  it  a  worse  attack  than  the  one 
of  si.x  mouths'  duration  from  which  he  had  completely  recov- 
ered, as  he  thought,  five  months  before.  Overlooking  the  pa- 
tient's faulty  mode  of  life,  the  attempt  had  been  made  to 
cure  the  urethritis  by  irrigations  alone.  The  discharge, 
being  a  secondary  one,  so  to  speak,  was  promptly  checked 
by  the  effect  of  the  daily  irrigations  on  the  inflamed  mucous 
membrane,  but  they  failed  to  clear  up  the  mucoid  morning 
drop,  though  continued  daily  for  two  months.  Apparently 
in  his  zeal  to  cure  his  patient,  the  physician  then  instilled 
into  the  urethra  a  ten  per  cent,  solution  of  silver  nitrate. 
The  immediate  effect  need  not  be  described.  When  he  was 
brought  in  consultation  four  days  later,  the  discharge  was 
again  moderate,  thin,  and  purulent,  the  inflammatory  signs 
were  conspicuous,  and  both  urines  were  almost  equally 
cloudy.    Gonococci  were  absent. 

C.\SE  VIII. — An  elderly  prostatic  patient,  seen  in  con- 
sultation, illustrates  still  another  common  error,  and  also 
one  similar  to  the  foregoing.  To  relieve  his  first 
complete  retention,  the  phxsician  had  properly  passed  a 
catheter,  but  had  suddenly  drawn  off  the  total  quantity  con- 
tained in  the  over  distended  bladder,  without  injecting  a 
compensating  volume  of  fluid.  Finding  that  the  supervened 
cystitis  was  not  being  alleviated  by  a  daily  lavage,  he  finally 
injected  into  the  bladder  a  solution  of  silver  nitrate,  gr.  ii 
in  oz.  i.  This  excited  so  much  tenesmus  that  further  cath- 
eterization was  withheld,  under  the  erroneous  assumption 
that  the  catheter  was  to  blame.  The  bladder  soon  became 
overdistended  again,  and  added  the  pain  of  its  expulsive 
efforts  to  the  sharp  irritation  caused  by  the  silver  nitrate 
solution. 

Examination  showed  an  enlarged  prostate,  now  greatly 
swollen  by  congestion,  and  a  tender  bladder  overdistended 


with  bloody  urine.  A  greatly  moderated  line  of  treatment 
on  a  systematic  plan  was  advised  and  followed.  Three  days 
later  the  patient  was  able  to  go  out  driving  as  formerly. 

Tlie  experience  of  the  patient  in  this,  the  final 
case,  inckides  both  overtreatment  and  uncertainty  in 
treatment.  In  the  latter  may  be  found  a  significant 
commentary  on  the  still  unsettled  conception  of  the 
histology  and  pathology  of  the  urethra. 

Case  IX. — A  middle  aged  man,  decidedly  neurasthenic 
from  protracted  business  cares,  had  a  slight  urethral 
discharge  soon  after  he  had  established  a  mistre>>.  The 
discharge,  scanty  at  first,  had  gradually  increased.  Xo  effort 
had  been  made  toward  stopping  his  se.xual  indulgence, 
which  had  become  excessive,  nor  toward  modifying  his 
mode  of  life  in  any  way.  At  the  outset,  no  gonococci  had 
been  discovered.  Three  months  later,  with  the  more  abun- 
dant discharge,  gonococci  were  reported. 

He  came  under  observation  six  months  after  the  devel- 
opment of  the  discharge.  The  treatment  given  him  during 
those  six  months  included  methylene  blue,  salol,  and  sodium 
bicarbonate;  ten  injections  of  argyrol;  irrigations  of  bi- 
chloride, in  strength  from  1  in  6000  up  to  i  in  4000;  irri- 
gations of  potassium  permanganate  i  in  4000;  instillations 
of  silver  nitrate  i  in  20  (five  per  cent.);  irrigations  of 
protargol  solutions  from  i  in  500  up  to  i  in  200;  and,  final- 
ly, an  injection  of  resorcin  (4  per  cent.).  Some  of  these 
means  had  been  used  conjointly,  notably  the  five  per  cent, 
instillations  of  silver  nitrate,  followed  by  the  i  in  500  pro- 
targol irrigation,  and  that  by  the  4  per  cent,  resorcin  in- 
jection. The  combination  in  use  when  he  came  under  my 
observation  was  a  daily  irrigation  with  a  i  in  4000  potas- 
sium permanganate  solution,  followed  by  the  four  per  cent, 
resorcin  injection.  It  is  interesting  to  note  that  under  this 
coiHf'aratively  simple  combination  the  first  appreciable  im- 
provement in  his  symptoms  had  taken  place,  .\side  from 
stopping  his  alcoholics  as  soon  as  the  gonococci  had  l.een 
reported,  no  general  treatment  had  been  given.  He  had 
continued  his  se.xual  excess  and  his  very  liberal  use  of 
tobacco. 

After  two  weeks  of  absolute  sexual  rest  and  the  use  of 
a  very  mild  hand  injection  at  lengthening  intervals,  he  was 
able  to  report :  "Xo  drop  of  pus  has  appeared,  and  really 
no  true  drop  of  mucuslike  fluid." 

The  common  errors  in  the  treatment  of  the  ure- 
thra and  bladder,  may  be  stimmed  up  as  errors  of 
omission  and  errors  of  cominission.  Under  errors 
of  omission,  may  be  grouped :  Xeglect  of  a  prosta- 
titis or  seminal  vesiculitis,  or  both  ;  neglect  of  the 
patient's  general  condition ;  failure  to  insist  upon 
sexual  hygiene :  failure  to  regulate  his  habits  as  to 
alcoholics,  tobacco,  and  coffee ;  inattention  to  the 
dietary  and  the  quantity  of  water  drunk. 

Under  errors  of  commission  may  be  placed :  The 
use  of  the  sound  in  the  face  of  contraindications ; 
overfrequent  dilatation  and  overdilatation :  the  un- 
scientific use  of  urethral  irrigations  in  general  (in 
particular,  the  use  of  intravesical  irrigations  before 
the  chronic  stage  of  a  tirethritis)  ;  the  use  of  strong, 
i.  e..  caustic,  in  jections  and  instillations ;  the  sudden 
emptying  of  a  chronically  overdistended  bladder ; 
the  administration  of  methylene  blue  except  at  a 
placebo:  and.  finally,  the  use  of  undistilled  water  in 
making  up  a  solution  of  silver  nitrate. 

I  have  ventured  thus  to  indicate  the  common 
caitse  of  our  failures  in  the  ordinary  cases  in  this 
sphere  of  practice  hoping  to_  aid  in  urging  a  more 
careful  analysis  of  them,  to  the  end  tliat  our  failures 
may  be  diminished  and  our  successes  multiplied.  It 
is  admitted  that  many  cases  are  complex,  but  a  de- 
tailed history  will  often  simplify  them.  and.  when 
supplemented  by  a  proper  physical  examination  as  a 
working  basis,  will  usually  direct  the  treatment 
aright. 

20  E.\ST  FORTV-SIXTH  StREET. 


898 


EARP:   TREATMEXT  OF  ACUTE  RHEUMATISM. 


[New-  York 
Medical  Journal. 


BEDSIDE   CLINIC  SUMMARY   OF   THE  TREAT- 
MEXT OF  ACUTE  RHEUMATISM  AT  THE 
INDIANAPOLIS  CITY  HOSPITAL.* 

Bv  Samuel  E.  E.vkp,  M.  S.,  M.  D., 
Indianapolis. 

During-  some  portion  of  the  past  tliirty-six  days 
you  have  on  alternate  days  watched  the  course  of 
twelve  patients  with  acute  articular  rheumatism  and 
each  one  was  relieved  of  pain  within  forty-eight 
hours  without  the  use  of  any  form  of  opium.  K 
summary  will  be  of  interest. 

The  highest  temperature  was  105°  F..  the  high- 
est pulse  rate  160;  one  patient  was  admitted  to  the 
hospital  with  acute  pericarditis,  one  with  acute 
myocarditis,  and  one  with  acute  delirium.  A\\  other 
patients  were  free  from  any  heart  lesion.  All  were 
males  and  none  was  confined  to  bed  more  than  ten 
days.  Two  were  able  to  occupy  a  chair  in  the  ward 
on  the  second  day.  Four  gave  a  history  of  rheuma- 
tism, one,  of  syphilis.  Ten  gave  a  history  of  amyg- 
dalitis preceding  the  attack  of  rheumatism,  and  all 
were  typical  cases  if  we  include  those  with  the 
complications  mentioned.  The  joint  affections  were 
multiple.  Two  patients  failed  to  follow  instruc- 
tions after  leaving  the  hospital  and  have  returned. 
The  one  now  in  the  hospital  has  been  here  thirty 
days,  which  is  due  to  a  complication  present  when 
admitted ;  and  he  will  be  dismissed  within  a  few 
days.    There  have  been  no  deaths. 

The  remedial  agent  is  not  a  new  one  and  if  others 
fail  to  get  such  results  as  you  have  witnessed  there  is 
something  wrong  in  the  method.  It  is  quite  possible 
that  the  doses  are  too  small.  Let  us  review  the  rou- 
tine treatment.  The  use  of  calomel  is  followed  by  Dor- 
sey's  magnesia  mixture'  until  the  bowels  are  freely 
open,  then  keep  them  so.  The  patient  should  drink 
plenty  of  water.  Thirty  grains  of  sodium  salicylate 
should  be  given  each  three  hours  until  pa  n  is  relieved 
or  there  are  unpleasant  head  symptoms.  Then  drop 
the  dose  to  twenty  grains,  and  when  the  joints  can  be 
used  freely  without  pain  or  stiffness  continue  fifteen 
grains  four  times  a  day  for  one  week.  When  the 
patient  considers  himself  well  then  use  ten  grains 
three  times  a  day  for  two  weeks.  Oil  of  winter- 
green  was  applied  to  the  joints  twice  a  day.  and  they 
were  dressed  in  cotton  and  oiled  silk  or  rul)ber 
sheeting.  There  has  been  some  slight  deviation  from 
this  rule.  For  instance,  sodium  bromide  in  one  case 
was  used  to  produce  quietude.  In  one  case  of  tachy- 
cardia the  ice  bag  was  used.  One  patient  with  a 
syphilitic  •  history  was  given  potassium  iodide,  but 
sodium  salicylate  was  not  aljandoned.  One  patient 
with  a  subnormal  pulse  and  lowered  temperature 
was  given  1/30  of  a  grain  of  strychnine  each  four 
hours.  In  order  to  lie  precise  we  should  call  to  mind 
that  the  patient  admitted  with  acute  pericarditis  did 
not  have  active  manifestations  of  rheumatism,  but 
sodium  salicylate  was  the  agent  u.sed  and  was  re- 
sponsible for  the  cure. 

•Held  before  a  section  of  tlie  Senior  Class  of  Indiana  University 
School  of  Medicine. 

'This  ni.iirnisia  mixliire  i<  composed  of  a  saturated  solution  of 
Kpsoni  salt  and  one  draclim  of  aromatic'  sulphuric  acid  to  the  ounce. 
Tliis  is  also  known  by  the  name  of  Dorsey's  inasnesia  mixture.  The 
composition  jjiven  is  that  of  the  ori(;ina!  Dorsev's  mixture,  and  if 
large  closes  are  used  the  acidity  is  too  Rreat.  Far  this  reason  the 
Indianapolis  City  Hospital  now  uses  this  formula:  Kpsoni  salt-, 
eight  pounds;  granulated  sugar,  three  pounds:  citric  acid,  one  pound 
and  a  half:  aromatic  sulphuric  acid,  eight  ounces;  water,  two  gal- 
lon».    This  modification  is  superior  to  the  original. 


In  no  case  was  there  an  untoward  influence  on 
the  heart  by  the  use  of  the  remedy.  Ice  in  the 
mouth,  sodium  chloride  on  the  tongue,  and  milk  as 
a  vehicle  was  necessary  in  three  instances  only,  to 
overcome  a  rebellious  stomach.  If  the  stomach  can- 
not be  controlled  I  have  in  several  instances  used 
sixt}'  grains  by  the  rectum.  If  the  rectum  is  sensi- 
tive and  the  fluid  is  not  retained  apply  two  inches 
above  the  sphincter  muscle  a  two  per  cent,  solution 
of  cocaine. 

In  private  practice  you  may  follow  the  right  tech- 
nique and  yet  very  frequently  you  may  not  get  such 
favorable  results  as  seen  in  hospital  treatment. 
Here,  patients  come  mostly  from  the  working  classes 
who  have  lived  on  a  wholesome  diet.  Their  stom- 
achs are  less  sensitive  and  fastidious.  There  are  less 
stomach  lesions.  There  are  fewer  neurotics.  Last- 
ly the  patient  has  a  definite  purpose  and  implicitly 
obeys  instructions. 

24"/$  Kkntucky  Avenue. 

A  CLINICAL  STUDY  OF  HYPERNEPHROMA  OF 
THE  KIDNEY,  WITH  A  REPORT  OF 
TWO  CASES.* 

By  Warren  L.  Duffield,  M.  D., 
Brooklyn,  N.  Y., 

Attending  Surgeon,  Jewish  Hospital;  Assistant  Surgeon,  St.  John's 
Hospital. 

In  1883  Grawitz  (i)  called  attention  to  the  fact 
that  those  tumors  which  were  then  described  as  renal 
lipomata  were  of  suprarenal  origin  and  contained 
the  elements  of  the  adrenal  gland,  but  it  was  not 
until  1896  that  they  were  given  the  name  of  hyper- 
nephroma by  Birch-Hirschfeld  (2).  Prior  to  thi.; 
time  they  were  designated  by  a  variety  of  names,  as 
myxoma,  adenoma,  lipoma,  sarcoma,  angeioma,  an- 
geiosarcoma,  adenocarcinoma,  and  endothelioma. 
The  use  of  the  term  hypernephroma  is  now  properly 
restricted  to  those  tumors  having  their  origin  from 
adrenal  cells  whether  the  growth  be  adenoma,  carci- 
noma, or  sarcoma  in  type,  and  irrespective  of  its  aris- 
ing from  the  adrenals  normallv  situated  or  from  aber- 
rant adrenals  or  "rests."  The  latter  occur  in  a  variety 
of  places,  and  according  to  Keen  (3)  have  been 
found  in  the  solar  and  renal  plexus,  under  the  cap- 
sule or  in  the  substance  of  the  kidney,  or  in  the  pcri- 
nephritic  tissue,  in  the  broad  ligament,  along  the 
spermatic  vessels,  in  the  testicle  and  ovary,  in  the 
liver,  the  mesentery,  and  the  inguinal  canal. 

Hypernephroma  are  the  most  common  of  all  ma- 
lignant growths  of  the  kidney,  according  to  Bevan 
and  Israel,  and  Eisendrath  (4)  states  that  the  ma- 
jority of  renal  tumors  in  adults  are  hypernephroma 
or  sarcoma.  Of  twenty-five  cases  of  renal  neoplasm 
treated  in  Mount  Sinai  I  lospital.  twenty-one  or 
cighty-.seven  and  a  half  per  cent,  were  hypernephro- 
ma, and  Albrecht  (5)  reports  a  series  of  twenty- 
eight  out  of  thirty-two  cases  as  being  hypernephro- 
ma. Although  these  tumors  form  such  an  important 
group,  our  textbooks  make  but  sligiit  mention  of 
them,  and  though  the  literature  dealing  with  them 
is  voluminous  it  is  mainly  devoted  to  their  histolog- 
ical characteristics,  and  little  effort  is  made  to  class- 
ify their  clinical  symptoms. 

•Read  before  the  Medical  Association  of  the  Greater  City  of  New 
York,  February  i,  iQOQ- 


yiay  I,  1909.] 


DUFFIELD:  HYPERNEPHROMA. 


899 


Their  malignancy  varies  greatly,  some  never  man- 
ifesting any  malignant  tendencies  and  only  being 
discovered  at  autopsy,  while  others  are  extremely 
malignant.  In  size  they  vary  from  that  of  a  pea  to 
that  of  a  child's  head.  Cheesman  (6)  reports  the 
successful  removal  of  a  hypernephroma  weighing 
four  and  one  quarter  pounds  from  an  infant  twenty 
months  old.  Ramsay's  (7)  statistics  show  that  the 
average  duration  from  the  onset  of  the  first  symp- 
tom until  death  was  from  6.7  months  to  10.6  months, 
the  shortest  duration  being  six  weeks  and  the  long- 
est three  years.  Malignancy  is  manifested  by  local 
extensive  invasion  of  kidney  and  neighboring  or- 
gans and  by  metastases,  the  latter  probabh'  not  un- 
commonly occurs  by  reason  of  the  invasion  of  the 
renal  vein  by  such  tumors  (Kellv  and  Bierring  (8) 
Albrecht  (9)).  Metastases  usually  occur  by  way  of 
the  blood  stream  and  seldom  by  the  lymphatics, 
(Blackburn  ( 10) )  and  are  particularly  prone  to  give 
rise  to  secondary  growths  in  the  lungs,  liver,  long 
bones,  and  bronchial  glands.  So  frequently  do  me- 
tastatic growths  appear  in  the  bones  that  Hoffman 
(11)  suggests  the  importance  of  bearing  in  mind 
the  possibility  of  hypernephroma  when  consulted  on 
account  of  a  tumor,  especially  a  bone  tumor  in  a  pa- 
tient past  fifty,  even  when  no  local  or  remote  symp- 
toms point  to  a  kidney  tumor,  and  Scudder  (12) 
states  that  the  kidney  region  should  be  palpated  with 
great  care  in  every  case  of  tumor  of  bone  particu- 
larly as  a  primary  bone  tumor  in  middle  aged  or 
elderly  people  is  rare,  and  further  that  a  bone  me- 
tastasis may  be  the  first  sign  of  a  hypernephroma 
and  may  be  the  only  metastasis.  In  four  of  Al- 
brecht's  twenty-eight  cases  tumors  of  the  bones  were 
the  first  lesions- noted.  Pulsating  bone  tumors  should 
arouse  suspicion  of  metastasis  from  either  adrenal 
or  thyreoid  (13),  Eshner  (14)  reporting  a  case  of 
metastatic  hypernephroma  of  the  manubrium  sterni ; 
the  size  of  a  clenched  fist,  in  a  woman  sixty  years 
of  age.  Under  treatment  with  ointments  it  dimin- 
ished in  size,  and  at  the  expiration  of  a  year  it  again 
increased  to  become  smaller  once  more.  There  was 
present  a  pulsation  synchronous  with  that  of  the 
heart  and  having  an  expansile  character.  No  thrill 
was  palpable,  but  a  loud  systolic  murmur  was  audi- 
ble on  auscultation  over  the  mass  together  with  the 
second  sound  of  the  heart.  This  tumor  closely  sim- 
ulated an  aneurysm,  but  an  autopsv  revealed  the 
mass  to  be  a  hypernephroma  with  other  deposits  in 
the  kidneys,  lungs,  and  uterus.  Von  Bergman  (17) 
also  reports  a  pulsating  metastatic  growth  of  the 
tibia.  Among  the  more  infrequent  metastatic  sites 
may  be  mentioned  the  case  of  Chance  (15)  of  a  sec- 
ondary hypernephroma  of  the  iris  and  ciliary  body, 
and  that  of  Grafenberg  (16)  of  a  hypernephroma  of 
the  vulva  as  the  only  metastasis  of  malignant  hypei"- 
nephroma.  Metastatic  growths  may  attain  a  size 
considerably  greater  than  the  primary  growth. 

Metastases  as  a  rule  do  not  take  place  until  late, 
probably  due  to  the  fact  that  hypernephromata  are 
usually  capsulated,  an  excellent  reason,  if  such  a 
reason  was  necessary,  for  an  early  diagnosis  and 
proper  treatment.  Clairmont  (18)  reports  a  case 
in  which,  almost  ten  years  after  surgical  removal  of 
a  tumor  of  the  kidney,  a  hypernephroma  developed 
at  the  bifurcation  of  the  trachea,  and  several  writers, 
Eshner  (14)  among  them,  mention  a  single  metas- 
tasis as  a  peculiarity  of  hypernephroma.    On  this 


basis  it  has  been  advised  to  remove  the  primary  and. 
secondary  growth,  hoping  thereby  to  eradicate  the- 
disease.  It  would  seem  to  the  writer,  however,  fronr 
the  reports  he  has  been  able  to  collect,  that  multiple- 
metastases  are  not  at  all  infrequent. 

Among  the  rarer  manifestations  of  tumors  of  the 
adrenals  as  observed  by  ]\Ioffitt  (13)  are  trophic 
changes,  such  as  abnormal  development  of  genitalia,, 
or  of  general  overgrowth,  and  hypertrichosis  has 
been  observed  in  both  children  and  adults. 

In  color  the  tumors  are  usually  grayish  red  or 
yellow,  the  latter  predominating,  but  they  frequent- 
ly contain  dark  areas  due  to  haemorrhages  into  their 
substance. 

They  are  of  most  frequent  occurrence  in  the  male 
adult,  Keen  (3)  states  the  age  as  fifty-two,  and  all 
of  Berg's  (5)  twenty-one  cases  were  "between  the 
second  and  fifth  decennials  of  life." 

The  statistics  of  Ellis  (ig)  would  seem  to  indi- 
cate that  the  kidney  was  the  most  frequent  seat  of 
the  growth,  for  out  of  one  hundred  and  sixty-three 
cases  reported  by  him,  one  hundred  and  fifty-seven 
were  in  the  kidney,  three  in  the  adrenals,  two  in  the 
liver,  and  one  in  the  uterus. 

Of  the  general  symptoms,  marked  asthenia,  lan- 
guor, depression,  and  emaciation  seem  to  be  com- 
mon. In  both  the  cases  which  I  have  seen  a  marked 
lethargy  amounting  almost  to  a  stupor,  a  condition 
similar  to  that  seen  in  cholaemia  only  deeper,  has 
been  present  and  in  one  case  reported  there  is  men- 
tion made  of  a  typhoid  state.  Though  most  writers 
contend  that  there  is  no  discoloration  of  the  skin 
Watson  (20)  reports  a  case  of  hypernephroma 
with  skin  showing  similar  discoloration  to  that  seen 
in  Addison's  disease,  which  gradually  disappeared 
following  nephrectomy,  and  Thorndike  and  Cun- 
ningham (21 )  in  reporting  a  series  of  cases  men- 
tion one  patient  as  having  a  dark  skin  and  the  other 
as  dark  but  anjemic.  In  one  of  the  writer's  cases 
the  skin  was  decidedly  pigmented  and  in  the  other 
it  was  dark  but  anjemic. 

The  urine,  except  for  the  hasmaturia  which 
may  be  present,  is  of  little- diagnostic  aid,  it  usually 
contains  a  slight  amount  of  albumin. 

The  blood  picture  is  that  of  an  anjemia  in  i)art 
due  to  the  haematuria :  haemoglobin  low,  red  cells 
reduced  about  one  third,  with  the  white  cells  normal 
or  slightly  increased  but  with  a  normal  differential 
count. 

Enlarged  veins  are  frequently  found  over  the 
abdomen. 

Gastrointestinal  symptoms  are  quite  common, 
comprising  a  feeling  of  fullness  and  oppression  in 
the  epigastrium  after  eating,  nausea,  vomiting, 
alternating  diarrhoea  and  constipation.  These 
symptoms  may  in  part  be  due  to  the  proximity  and 
pressure  of  the  tumor  on  the  duodenum. 

The  symptoms  which  will  aid  us  most  in  miking 
a  diagnosis  and  which  fortunately  are  almost  always 
present  during  some  part  of  the  disease  are  pain, 
k-ematuria,  and  the  detection  of  a  tumor. 

The  pain  in  these  cases  is  not  characteristic  ex- 
cept that  when  it  is  the  first  symptom  it  will  usually 
exist  for  a  considerable  period,  months  perhaps,  be- 
fore the  appearance  of  other  symptoms.  Albrecht 
and  Israel  both  consider  that  the  long  duration  of 
pain  prior  to  the  onset  of  haematuria  or  to  the  pal- 
pable presence  of  a  tumor  as  indicating  hyperne- 


900 


DUFFIELD:  HYPERNEPHROMA. 


[New  York 
Medical  Journal. 


phroma  rather  than  other  maUgnant  kidney  tumors. 
The  pain  has  been  attributed  to  pressure  upon  the 
renal  plexus  and  to  increased  tumor  tension  due  to 
haemorrhages.  The  pain  is  usually  described  as  a 
dull  aching  or  dragging  sensation  in  the  loin  at 
times  radiating  to  the  right  shoulder.  In  other  cases 
it  assumes  the  type  of  renal  colic  radiating  to  the 
testicles  or  penis  and  is  due  to  the  passage  of  clots. 
In  Albarran's  series  pain  was  the  first  symptom 
complained  of  in  twenty  out  of  sixty-three  patients. 

On  the  question  of  hsematuria  in  hypernephroma 
there  exists  a  great  difiference  of  opinion,  most  writ- 
ers agreeing  that  it  is  not  only  a  constant  symptom 
but  usually  an  early  symptom,  thus  Pf abler  (3) 
states  that  it  is  not  only  the  most  common  symptom 
but  usually  the  first.  Albarran  (22)  found  it  to  be 
the  first  complaint  in  thirty-six  out  of  sixt3'-three 
cases.  Mofifitt  (13)  also  mentions  it  as  the  most 
common  symptom.  On  the  other  hand  both  Berg 
(5)  and  Eschner  {14)  assert  that  it  is  less  common 
than  in  other  malignant  tumors  of  the  kidney.  Not- 
withstanding the  existing  confusion  as  to  its  being 
a  constant  symptom  there  is  a  unanimity  of  opinion 
that  when  present  it  has  certain  well  marked  char- 
acteristics, usually  appearing  without  any  apprecia- 
ble cause  as  when  the  patient  is  in  bed  and  asleep, 
thus  differing  from  the  hasmaturia  of  calculus,  and 
secondly  that  its  appearance  is  as  a  rule  markedly 
intermittent,  the  intermissions  usually  being  long 
measured  by  months  or  years.  Thorndike  and  Cun- 
ningham (21)  call  attention  to  the  fact  that  these 
cases  dififer  from  renal  stone  in  that  an  attack  of 
hsematuria  causes  a  relief  of  pain  both  in  the  region 
of  the  kidney  and  of  a  colicky  character,  the  pain  of 
calculus  being  coincident  with  the  blood  which  the 
calculus  causes.  They  also  mention  the  alternation  of 
periods  of  haemorrhage  and  frequency  of  urination, 
with  periods  of  absence  of  hremorrhage  and  absence 
of  frequent  urination  but  with  marked  pain  in  the 
back  which  they  attribute  to  blockage  of  the  ureter 
and  consequent  retention  of  blood  and  urine. 

The  severity  of  the  hsematuria  is  variable,  in  some 
there  will  be  microscopic  blood  in  the  urine  for  some 
time  prior  to  a  macroscopic  hsematuria,  and  in  others 
the  amount  of  blood  lost  will  be  considerable,  caus- 
ing an  ansemia,  and  accompanied  by  the  passage  of 
ureteral  casts  causing  colic.  It  is  rare  that  hsema- 
turia is  absent  during  the  entire  course  of  the  dis- 
ease, but  it  may  be  in  those  cases  where  the  kidney 
is  not  involved  in  the  growth  or,  according  to  Berg 
(5)  where  the  entire  secreting  structure  is  destroyed 
and  the  pelvis  filled  with  tumor  masses. 

An  abdominal  tumor  or  tumor  in  the  loin  may  be 
the  first  thing  to  attract  the  patient's  attention,  but 
this  is  not  the  rule,  and  several  years  may  elapse 
between  the  appearance  of  pain  and  ha;maturia  and 
the  discovery  of  a  tumor.  The  affected  kidney  may 
not  be  nuich  increased  in  size,  but  is  generally  quite 
large.  The  general  outline  of  the  organ  is  usuallv 
retained  and  the  surface  is  almost  always  nodular. 
Carcinoma  and  sarcoma  usually  cause  a  uniform  en- 
largement, whereas  in  hypernephroma  only  that  part 
containing  the  adrenal  rest  is  enlarged,  the  remain- 
der of  the  kidney  maintaining  its  normal  outline. 

Although  in  the  reports  of  individual  cases,  men- 
tion is  made  of  the  elevation  and  irregularities  in 
temperature  it  docs  not  seem  to  thr  writer  that  this 
has  been  sufficiently  emphasized.    Berg  (5)  cites 


ten  cases  with  temperatures  varying  from  99°  to 
100°  F.  prior  to  operation  and  two  in  which  it 
reached  102°  F.  He  mentions  the  occurrence  of 
irregular  temperature  elevations  as  one  of  the  diag- 
nostic points.  Thorndike  and  Cunningham  (21) 
quote  one  case  in  which  the  temperature  gradually 
climbed  to  101.2°  F.  without  apparent  cause  or 
change  in  the  patient's  condition.  Eisendrath  (4) 
says  a  renal  tumor  is  occasionally  accompanied  by 
quite  marked  elevations  of  temperature.  Weil  (23), 
Striibing  (24),  Peck  (25),  and  Keene  (3)  all  refer 
to  cases  with  moderate  irregular  temperatures.  That 
this  is  even  more  common  than  the  reports  would 
indicate,  is  the  writer's  opinion,  for,  as  before  stated, 
the  articles  published  deal  largely  with  the  histology 
of  the  tumors.  In  both  of  the  cases  seen  by  the 
writer  there  was  a  very  irregular  temperature,  vari- 
ation ranging  at  times  over  eight  degrees,  accompa- 
nied by  severe  chills  and  very  profuse  sweating,  thus 
very  closely  simulating  intermittent  malarial  fever. 
In  fact  one  of  the  patients  was  treated  by  several 
different  physicians  over  a  period  of  a  number  of 
weeks  for  malaria. 

A  point  of  considerable  interest  and  to  which 
very  little  attention  has  been  paid  is  that  of  increased 
arterial  tension.  Beilby  (26)  states  that  it  is  logical 
to  suppose  that,  with  an  increase  of  adrenal  tissue, 
we  may  have  an  excess  of  adrenal  secretion,  which 
would  result  in  a  rise  of  blood  pressure,  and  Ochs- 
ner  (27)  states  that  hypernephromata  cause  severe 
systemic  disturbances  the  principal  symptoms  being 
greatly  increased  arterial  pressure.  The  only  refer- 
ence to  this  condition  which  I  have  been  able  to  find 
is  among  the  cases  reported  by  Thorndike  and  Cun- 
ningham (21).  In  one  case  the  pulse  is  spoken  of 
as  fair  in  volume  and  tension  and  in  two  other  cases 
as  of  good  volume  and  tension. 

An  X  ray  examination  may  be  of  value  in  distin- 
guishing the  hsematuria  of  stone,  but  we  must  not 
forget  that  stones  not  infrequently  elude  even  these 
searching  rays,  and  in  a  case  of  Keen's  (3)  the  x 
ray  showed  a  movable  kidney  with  suspicion  of 
three  stones. 

Cystoscopy  will  aid  us  in  determining  absolutely 
from  which  kidney  the  blood  is  coming,  will  aid  i-i 
eliminating  tuberculosis  by  the  absence  of  bladder 
ulcerations  and  the  characteristic  appearance  of  the 
ureteral  openings  in  tuberculosis. 

As  points  of  distinctive  diagnosis  may  be  men- 
tioned that  the  hsematuria  of  calculus  is  increased  or 
caused  by  exercise  and  is  not  as  a  rule  so  profuse. 
In  tuberculosis  the  hsematuria  is  small  in  amount,  is 
not  influenced  by  exercise,  and  is  accompanied  by 
pus  and  tubercle  bacilli  in  the  urine.  Thompson 
(28)  in  speaking  of  liver  abscess  says: — 'Tn  disease 
of  other  organs  I  have  only  once  met  pus  simulating 
that  found  in  liver  abscess.  This  case  presented 
symptoms  of  liver  abscess,  was  aspirated  in  the 
tenth  space  midaxillary  line,  and  chocolate  colored 
fluid  exactly  like  liver  pus  was  withdrawn.  Opera- 
tion revealed  a  normal  liver  but  a  cyst  the  size  of 
small  orange  at  upper  end  of  right  kidney,  a  cystic 
hypernephroma." 

The  diagnostic  points  to  which  I  would  call  atten- 
tion are: — i,  The  relative  frequency  of  this  form  of 
renal  tumor :  2.  pain  persisting  for  long  intervals 
before  the  onset  of  other  symptoms ;  or  3,  the  long 


May  I,  1 909. J 


DUF FIELD:  HYPERNEPHROMA. 


901 


interval  between  the  initial  symptoms,  haematuria, 
pain,  etc..  and  the  time  of  seeking  medical  advice 
favoring  hypernephroma  rather  than  carcinoma  or 
sarcoma ;  4,  haematuria  without  any  appreciable 
cause  and  occurring  at  rather  long  intervals ;  5,  the 
great  frequency  of  bone  metastases ;  6,  the  irregular 
temperature  simulating  malaria,  not  responding  to 
antimalarial  treatment  and  with  a  normal  leucocyte 
count ;  and  7,  possibly  increased  arterial  tension. 

In  addition  to  these  points  I  would  draw  the  fol- 
lowing conclusions:  i,  That  they  are  the  most  fre- 
quent malignant  growth  of  the  kidney  and  are  not 
rare  but  are  rarely  recognized ;  and  2,  that  they  may 
produce  marked  toxic  symptoms  simulating  sepsis 
or  malaria. 

The  treatment  is  purely  surgical,  and  wherever 


1908.  His  mother  died  at  sixty-nine  years  of  cancer  of  the 
breast,  the  family  history  was  otherwise  negative. 

He  had  suffered  from  most  of  the  diseases  common  to 
childhood,  grippe  fifteen  years  ago,  and  denied  venereal 
history.  He  was  a  moderate  drinker;  suffered  at  times 
with  sick  headaches  until  forty  years  of  age,  but  had  since 
been  free  from  them.  In  April  of  1907  he  contracted  ma- 
laria! fever  lasting  until  July,  1907,  during  which  time  he 
had  several  chills,  headaches,  pains  in  legs,  and  a  general 
feeling  of  malaise.  This  feeling  would  at  times  appear  in 
early  afternoon  compelling  him  to  stop  work  and  go  home 
to  bed.  Twice  these  symptoms  were  followed  by  severe 
chills,  extreme  drowsiness,  and  profuse  sweating,  the  latter 
usually  taking  place  in  the  early  morning.  Later  patient 
went  to  Poughkeepsie.  where  chills  became  more  frequent 
but  irregular,  but  headaches  and  malaise  would  appear 
every  evening.  On  September  i,  1907,  his  condition  became 
so  bad  that  he  was  compelled  to  go  to  bed  and  was  treated 
for  malaria.  While  in  bed  he  suffered  with  a  sudden  attack 
of  severe  pain  in  both  flanks,  radiating  to  both  testicles. 


possible  an  exact  diagnosis  should  be  made  before 
operation,  for  due  to  the  frequency  of  extension  of 
the  growth  into  the  renal  vein  even  the  slightest 
manipulation  of  the  kidney  may  cause  a  portion  of 
this  to  become  separated  causing  metastatic 
growths.  The  operation  of  choice  is  to  first  ligate 
the  renal  vein  through  an  abdominal  incision  and 
then  proceed  to  a  nephrectomy  with  a  counter  open- 
ing in  the  loin  for  drainage,  if  indicated,  or  to  close 
the  abdominal  incision  and  perform  a  nephrectomy 
through  a  second  lumbar  incision.  Growths  with 
extensive  adhesions  and  invasions  of  the  surround- 
ing structures  are  best  left  untouched,  for  the  mor- 
tality in  these  patients  is  particularly  high  and  death 
usually  follows  promptly. 

For  the  notes  and  temperature  charts  of  the  fol- 
lowing case  I  am  indebted  to  Dr.  Charles  G.  Stock- 
ton, under  whose  care  the  patient  was  in  the  Buf- 
falo General  Hospital. 

Case  I :  T.  S.  W.,  fifty-three  years  of  age,  male,  married, 
toolmaker.  He  was  admitted  to  the  Buffalo  General  Hos- 
pital on  February  3,  igoS,  and  left  there  unadvised  April  8, 


Pain  started  at  midnight,  lasted  four  or  five  hours,  and  was 
relieved  by  heat.  In  January,  1908,  he  suffered  with  an  at- 
tack similar  to  the  one  described. 

Blood  examination,  February  4,  1908,  showed,  haemo- 
globin forty  per  cent,  index  0.6 ;  erythrocytes  3.30D.000 : 
leucocytes  5.400.  Iodine  reaction  was  negative.  No  ma- 
larial organisms.  His  physical  examination  revealed  a  liver 
slightly  enlarged ;  and  a  faint  systolic  murmur  at  the  apex 
of  the  heart.  Examination  was  otherwise  negative.  Urine 
contained  a  faint  trace  of  albumin.  On  February  nth  blood 
was  found  in  the  urine,  and  on  the  15th  it  was  noted  that 
he  was  tender  at  the  right  costovertebral  angle.  On  Feb- 
ruary 14th  and  15th  he  suffered  with  two  very  sharp  attacks 
of  pain  in  the  right  lumbar  region  radiating  to  his  testicles, 
followed  for  several  days  by  pain  and  tenderness  in  right 
lumbar  region. 

On  February  21st,  Dr.  Roswell  Park  removed  his  right 
kidney,  containing  a  large  hard  tumor  mass  resembling  a 
hypernephroma,  confirmed  by  examination.  From  the  op- 
eration on  February  21st  until  March  loth  his  temperature 
remained  about  normal  and  he  felt  comparatively  well,  but 
on  the  loth  of  March  the  daily  elevations  of  temperature 
began  again.  On  April  10,  1908,  he  came  under  my  care. 
At  this  time  be  was  able  to  be  up,  dressed,  and  able  "to  take 
a  short  walk  in  the  morning.  As  he  expressed  it,  he  was  a 
well  man  every  morning  but  a  sick  man  at  night.  He  com- 
plained of  a  dull  pain  in  the  right  lumbar  region  and  had 


902 


DUfflELD:  HYPERNEPHROMA. 


[New  York 
Medical  Journal. 


daily  elevations  of  temperature,  chills,  and  very  profuse 
sweats,  also  complained  of  great  inability  to  keep  awake 
and  would  sleep  the  greater  part  of  twenty-four  hours.  He 
died  in  St.  John's  Hospital,  Brooklyn,  on  May  21,  1908. 


cavities  contained  no  fluid.  On  opening  the  pericardial  sac, 
a  serohbrinous  peridicarditis  was  found  to  be  present:  the 
sac  contained  about  one  ounce  of  cloudy,  yellowish  serum 
containing  flocculi  of  fibrin,  and  the  parietal  pericardium 


Dr.  A.  Murray  performed  an  autopsy  upon  this 
case  and  kindly  furnished  me  with  the  records  of 
autopsy  and  microscopical  examination : 

Record  of  autopsy  upon  T.  S.  W.,  died  at  St.  John's  Hos- 
pital, Brooklyn,  May  21,  1908.    Autopsy  May  22,  1908. 

Body  poorly  nourished  and  rigor  mortis  poorly  marked. 
No  marks  of  violence.  Skeletal  muscles  pale  and  scanty. 
Sternum  normal.  Diaphragm  at  fifth  space  on  left  and 
fifth  rib  on  right.  The  anterior  mediastinum  was  filled  with 
an  irregular,  nodular  mass  of  glands  the  size  of  a  small 
lemon.     The  lungs  were  nornia!  in  size  and  crepitate  on 


and  epicardium  were  covered  with  irregular  patches  of  soft 
fibrin. 

The  heart  was  moderately  hypertrophied.  The  left 
auriculoventricular  orifice  admitted  two  fingers,  the  right, 
three  fingers.  The  wall  of  the  left  ventricle  was  somewhat 
thicker  than  normal :  wall  of  the  right  ve^ntricle  apparently 
normal.  Myocardium  normal  in  color  and  consistency. 
Heart  cavities  apparently  normal.  The  anterior  flap  of 
mitral  valve  and  the  openings  of  the  coronary  arteries 
showed  a  moderate  amount  of  atheroma.  Other  valves  and 
aorta  were  normal.  Spleen  was  normal  in  size  and  color 
but  much  firmer  than  normal.    On  its  outer  surface  was 


pressure.  The  visceral  pleura'  were  studded  with  hundreds 
of  small,  whiti,sh  nodules  varying  in  size  from  a  pinhead  to 
that  of  a  dime.  On  section,  the  same  nodules  were  seen  to 
be  scattered  throughout  the  lung  tissue,  which  otherwise 
was  normal.  The  parietal  pleurs  showed  a  moderate  num- 
ber of  nodules  scattered  ovei  their  surface.    The  pleural 


seen  a  small  nodule,  loosely  attached,  about  the  size  of  a 
wheat  grain. 

The  liver  was  about  one  tliird  larger  than  normal  and 
extended  one  and  one  half  inches  below  the  free  borders 
of  the  ribs.  On  section,  color  and  consistency  were  found 
to  be  normal  and  no  metastatic  nodules  were  found.  Gall- 


May  1,  1909.] 


DUF FIELD:  HYPERNEPHROMA. 


903 


bladder  normal  in  size,  full  of  bile,  no  calculi.  T^'he 
left  kidney  was  twice  the  norma!  size  and  very  pale. 
Consistency  was  increased.  Cortex  much  wider  than  nor 
mal.  One  's:mall  nodule  was  seen  in  the  cortex.  Left  supra- 
renal body  normal  in  size  and  appearance.  The  entire  right 
renal  region  \vas  occupied  by  an  irregular,  nodular  mass  the 
size  of  two  fists,  extending  ever  the  spinal  column  and  also 
intilirating  the  right  psoas  muscle.  The  stomach  was  di- 
lated, the  walls  thin,  and  the  mucosa  showed  a  few  petech- 
ial hasmorrhages.    The  intestines  were  normal.    The  entire 


The  histological  structure  of  the  tumor  corresponded 
in  a  general  way  to  that  of  the  adrenal  cortex.  In  tlie 
metastases  the  type  of  cell  and  general  arrangement  were 
the  same  as  in  the  primary  tumor. 

The  myocardium  was  normal.  In  the  lungs  the  haemato- 
genous  origin  of  the  metastases  could  be  plainly  seen,  the 
cells  springing  from  the  alveolar  capillaries  and  growing 
into  the  alveoli. 

The  left  kidney  was  markedly  oedematous,  the  tubules 
distended,  and  the  epithelium  flattened.  A  moderate  amount 


niL-sentcry  of  the  intestines  were  studded  wifh  small  me- 
tastic  nodules.  The  appendix  was  normal.  On  the  free 
anterior  border  of  the  ileum,  about  eighteen  inches  from 
the  ileocascal  valve  was  found  a  diverticulum  one  and  one 
half  inches  long  and  of  the  same  diameter  as  the  ileum. 
The  wall  of  the  peritoneal  cavity  contained  many  nodules 
varying  in  size  from  a  pinhead  to  that  of  a  walnut.  The 
lumbar  IjTnphglands  were  much  enlarged  and  invaded  by 
the  growth.    The  bladder  was  normal. 

Microscopical  Examination. — Microscopically  the  tumor 
mass  itself  was  made  up  of  numerous,  thin  filaments  of 
comiective  tissue,  in  the  centre  of  each  of  which  was  a 


of  am^'loid  degeneration  was  seen  in  the  glomeruli.  Tiie 
small  nodule  noticed  in  the  cortex  proved  to  be  a  cystic 
tubule.  No  adrenal  "rests"  were  found  in  the  kidney  or  its 
capsule.  The  left  adrenal  was  apparently  normal.  The 
liver  and  spleen  both  showed  moderate  amyloid  degenera- 
tion but  no  metastases  were  found.  The  pancreas  was 
normal. 

I  regret  to  state  that  due  to  a  recent  change  in 
the  filing  system  at  St.  John's  Hospital  the  tempera- 
ture charts  of  this  case  have  been  misplaced  and  I 
am  unable  to  present  them.    His  temoeraturc  while 


capillary  bloodvessel  and  resting  on  these  vascular  fingers 
were  rows  of  large,  irregularly  shaped  epithelial  cells. 
Owing  to  the  irregular  course  of  the  capillaries  numerous 
oval  and  elongated  spaces  were  formed  which  were  filled 
with  cells.  In  some  places  a  tubulelike  arrangement  was 
seen,  while  in  others  the  appearance  was  that  of  a  papillary 
Cyst  adenoma. 

The  prevailing  type  of  cell  was  large,  round,  or  oval  with 
a  distinct  nucleus  and  nucleolus.  The  protoplasm  was  pale 
and  contained  numerous  vacuoles.  Many  of  the  cells  were 
simply  thin  walled,  clear  globules  with  an  eccentric.  pal« 
staining  nucleus. 


there  was  in  every  way  similar  to  that  shown  on  the 
accompanying  chart  from  the  Buf¥alo  General  Hos- 
pital, which  I  have  reduced. 

The  second  case  came  under  my  care  at  the  Jew- 
ish Hospital  two  days  before  the  termination  of  my 
service  and  it  is  through  the  courtesy  of  Dr.  \W\- 
liam  Linder  that  I  am  enabled  to  report  it. 

C.JvSE  II— The  history  is  as  follows:  Mrs.  A.  Z.,  fifty- 
seven  years,  born  in  Russia,  was  admitted  November  28: 
1908.    Four  years  ago  she  began  to  experience  a  dull  pain 


904 


ATTIX:  POISONS. 


[New  York 
Medical  Journal. 


in  right  iiypochondriac  region  after  meals.  One  year  ago 
she  was  seized  with  sharp  pain  over  this  region  preceded 
bv  a  chill  and  followed  by  fever  and  sweat.  Pain  radiated 
upward  to  right  shoulder.  No  history  of  jaundice,  clay  or 
tarry  stools.  Five  weeks  before  admission  she  noticed 
blood  in  the  urine,  and  urination  was  accompanied  by  sharp 
pain  in  bladder,  this  condition  had  continued.  Mental  con- 
dition was  very  dull,  she  slept  most  of  the  time.  Cysto 
scopic  examination  by  Dr.  Pentlarge  revealed  blood  tinged 
urine  issuing  from  right  ureter  and  an  examination  of 
specimens  obtained  by  ureteral  cathertization  was  as  fol- 
lows : 

Right  Kidney.  Left  Kidney. 

Innumerable  red  blood  M  o  d  e  r  a  t  e  number  red 
cells,  tryosin  crystals,  nu-  cells.  Few  white  blood  cells, 
merous  epithelia  from  pelvis  Crystals  of  acid  sodium 
and  from  kidney.  Many  iirate,  numerous  ureteral, 
white  blood  cells.  No  tu-  few  renal.  Occasional  poly- 
bercle  bacilli,  l  nicknulied.  nuclear  cells.  No  tubercle 
Gram  positive,  diplococcus.  bacillus.  Gram  positive,  and 
No  colon  bacillus.  negative  large  spore  bearing 

bacilli,  sugar  fermenting. 

On  examination  patient  was  tender  in  the  right  lumbar 
region  w'ith  a  sense  of  increased  resistance  over  kidney,  but 
kidney  could  not  be  palpated. 

On  December  2,  1908,  Dr.  Linder  removed  the  right 
kidney  through  a  lumbar  incision,  and  on  section  the  upper 
pole  was  found  to  contain  a  large  tumor  mass,  which  on 
examination  proved  to  be  a  hypernephroma. 

From  time  of  operation  until  January  3,  1909,  when  she 
left  to  return  home  she  suffered  frequently  from  severe 
chills,  elevations  of  temperature,  and  profuse  sweating. 

On  December  26,  1908,  a-  tumor  round  in  outline,  soft 
but  not  fluctuating,  about  one  and  a  half  inches  long  and 
half  as  wide  made  its  appearance  at  the  inner  side  of  the 
left  biceps  slightly  below  the  insertion  of  the  pectoralis 
major.  This  tumor  apparently  arose  from  the  soft  parts 
and  not  from  the  bone. 

A  small  section  of  this  obtained  with  an  aspirating 
needle  determined  it  to  be  a  hypernephroma. 

Bibliography  of  Hvperxephkom.\. 

1.  VirchoTxfs  Archiv, •y.cm,_  p.  39. 

2.  Lehrbiich  dcr  palhologischen  AtiatODiic,  5th  Edition. 
I,  p.  262. 

3.  Transactions  of  the  College  of  Physicians  of  Phila- 
delphia, xxvi,  p.  251. 

4.  Eisendrath.    Surgical  Diagnosis.  1907. 

5.  Berg.    Mt.  Sinai  Hospital  Reports,  v.  p.  169. 

6.  Annals  of  Surgery,  xlv,  p.  91. 

7.  Quoted  from  Transactions  of  the  College  of  Physi- 
cians of  Philadelphia,  xxv. 

8.  NeiL'  York  Medical  Journal,  July  30,  and  August  6, 
190S. 

9.  Journal  of  the  American  Medical  Association,  July 
23,  1904= 

10.  New  York  Medical  Journal,  August  17,  1907. 

11.  Deutsche  inedisinische  W ochenschrift,  xxxiii.  No.  7. 

12.  Annals  of  Surgery,  xliv,  p.  856. 

13.  Boston  Medical  and  Surgical  Journal,  October  8, 
igoS. 

14.  Journal  of  the  American  Medical  Association,  Alay 
30,  1908. 

15.  Ibidem,  xlviii..  p.  475. 

16.  Virchozv's  Archiv,  October,  igo8. 

17.  l^crhandlungen  der  deufschen  Gesellschaft  fiir  klin- 
ische  Chirurgie,  xvi,  Congress,  1887,  p.  30. 

18.  Archiv  fiir  klinische  Chirurgie,  Ixxiii,  p.  620,  1894. 

19.  Quoted  from  Keen's  Surgery,  iv,  p.  245. 

20.  Annals  of  .Surgery.  December,  1904. 

21.  Boston  Medical  and  Surgical  Journal,  cxlix.  No.  23. 

22.  Les  Tunieurs  du  rein.  Paris,  1903. 

23.  Annals  of  Surgery,  xlvi,  p.  421. 

24.  Dculschcs  Archiv  fiir  klinische  Medicin,  1888. 

25.  Annals  of  Surgery,  xlv,  p.  617. 

26.  Surgery,  Gynaecology,  and  Obstetrics,  vii,  p.  287. 

J27.  Journal  of  the  American  Medical  Association, 
^  larch  17.  1900. 

28.  Proceedings  of  the  Pathological  Society  of  Phila- 
delphia, June,  1902. 

119  Berkeley  Place. 


A  CONSIDERATION  OF  POISONS. 

With  Special  Reference  to  Poisoning  by  Potassium  Per- 
manganate and  a  Report  of  Tzvo  Cases. 
By  J.  C.  Attix,  M.  S.,  D.  D.  S.,  U.  D., 
Philadelphia, 

Professor  of  Chemistry  and  Toxicology,  Medical  and  PliannaceuticaJ 
Departments,  Temple  University. 

The  subject  of  poisons  is  as  old  as  the  hills,  and 
while  we  all  have  in  our  minds  a  sort  of  home  made 
conception  of  what  a  poison  is  and  means  it  is  very 
difficult  indeed  to  frame  a  definition  which  will 
cover  every  detail  and  hold  water  at  the  same  time. 

This  is  not  surprising,  since  there  are  almost  as 
many  definitions  for  a  poison  as  there  are  works  on 
the  subject.  In  its  broadest  sense  a  poison  is  any 
substance  which,  when  taken  into  the  body,  applied 
to  it,  or  generated  within  it,  is  capable  of  producing 
disease  or  death. 

It  will  be  seen  at  a  glance  under  this  definition 
that  many  substances  which  are  daily  used  and  in- 
gested would  be  classed  as  poisons,  since  no  amount 
of  the  substance  is  specified.  A  person  might  swal- 
low such  a  quantity  of  water  for  instance  which 
would  drown  him,  yet  no  one  would  think  of  class- 
ing even  that  from  the  Schuylkill  as  a  poison,  and 
many  other  substances  used  daily  as  articles  of  food, 
such  as  vinegar,  pepper,  salt,  mustard,  and  the  like, 
are  much  more  poisonous  than  sodium  hyposulphite, 
for  instance,  which  the  law  declares  is  a  poison  and 
prohibits  its  use  as  a  preservative  for  foodstufifs. 

Attempts  have  been  made  to  designate  as  poisons 
such  substances  as  are  capable  of  producing  harm- 
ful effects  in  quantities  of  a  drachm  or  less,  and  as 
you  well  know  a  drachm  of  many  of  our  poisons 
would  be  sufficient  to  poison  a  regiment. 

Still  later  it  has  been  proposed  to  classify  as  poi- 
sons those  substances  which  in  amounts  of  five 
grains,  or  less,  are  capable  of  producing  disease  or 
death.  This  is  still  wonderfully  deficient  also.  Five 
grains  of  a  number  of  the  poisons  are  sufficiently 
potent  to  wipe  out  of  existence  the  entire  North 
Western  Medical  Society,  whereby  Philadelphia  anf! 
the  world  at  large  would  suffer  an  irreparable  loss. 

The  legal  definitions  of  poisons  differ  greatly  and 
are  in  fact  distinct  from  the  scientific  aspect.  Un- 
der some  of  the  laws  it  is  stated  that  whoever  shall 
administer,  or  cause  to  be  administered,  to  take  or 
cause  to  be  taken,  any  poison,  or  destructive  thing, 
with  intent  to  murder  or  commit  suicide  shall  be 
guilty  of  felony.  This  includes  practically  every- 
thing on  the  face  of  the  earth,  so  long  as  it  is  ad- 
ministered or  taken  with  felonious  intent.  Thu.<;  it 
cannot  be  defined  from  the  legal  side  alone. 

Blyth  defines  a  poison  as  a  substance  of  definite 
chemical  comjiosition,  whether  organic  or  inorganic, 
which  when  taken  into  the  bod\-  is  capable  by  means 
of  its  own  inherent  chemical  nature  of  producing 
impairment  or  destruction  of  function. 

This  falls  far  short  in  a  number  of  ways  of  an 
ample  exposition  of  the  subject.  For  instance,  there 
are  many  substances,  such  as  snake  venoms,  numer- 
ous ptomaines,  the  toxincs  of  many  of  the  bacterial 
disea.ses,  such  as  antiirax,  pneumonia,  diphtheria, 
etc.,  whose  definite  chemical  compositions  arc  not 
known,  and  if  they  were  their  toxic  effects  miglit 
not  be  due  to  this  alone  but  to  what  was  wont  to  be 


May  I,  1 909. J 


OUR  READERS'  DISCUSSlOX S. 


ruf erred  to  years  ago  by  both  the  physiologists  and 
the  chemists  as  the  vital  act. 

By  the  Blyth  definition  such  substances  as  broken 
glass,  pins,  needles,  tacks,  musket  balls,  etc.,  which 
are  not  capable  by  their  own  chemical  composition, 
and  even  incapable  of  absorption,  can  yet  produce 
disease  or  death  indirectly  do  not  come  under  this 
classification. 

Thus  it  is  seen  that  a  poison  cannot  be  defined 
from  a  purely  legal,  chemical,  physiological,  or 
therapeutic  standpoint. 

To  my  mind  the  best  restricted  definition  of  a  poi- 
son is  that  it  is  any  substance  which,  when  taken 
into,  applied  to,  or  generated  within  the  body  in  any 
considerable  amount  above  the  ordinarily  prescribed 
or  body  resistant  dose,  is  capable  of  producing  dis- 
ease or  death. 

All  attempts  to  classify  or  group  poisons  have 
failed  likewise  in  that  no  fixed  or  fast  line  can  be 
drawn,  since  they  are  either  deficient  or  redundant. 

The  poison  which  I  desire  especially  to  call  atten- 
tion to  may  be  classed  under  several  groups  or 
heads,  escharotic,  depressant,  mineral,  or  inorganic. 
I  have  not  as  yet  been  able  to  find  a  reported  case 
of  poisoning  by  potassium  permanganate  and  conse- 
quently no  antidote  for  it  in  any  of  the  works  on 
toxicology  consulted.  The  reason  for  its  apparent 
increased  frecjuency  as  a  poison  is  probably  due  to 
the  fact  that  it  is  becoming  more  widely  used  by  the 
ptiblic  as  an  antiseptic,  especially  in  gonorrhoeal  in- 
fections, and,  of  course,  is  easily  obtained.  The  two 
cases  seen  were  treated  entirely  upon  the  chemical 
indications : 

Case  I. — M.  C. ;  age,  lorty-eight  years ;  colored ;  was 
given  a  dozen -five  grain  compressed  tablets  of  potassium 
permanganate  and  instructed  to  dissolve  one  tablet  in  a 
quart  of  hot  water  and  use  as  a  vaginal  douche  twice  a 
day.  Almost  immediately  after  arriving  home  she  swal- 
lowed six  of  these — iust  why  no  one  know'S,  but  she  de- 
clared most  vigorously  that  she  could  not  read  and  bad 
misunderstood  the  orders. 

She  w^as  seized  at  once  with  a  violent  burning  pain  in  the 
throat,  oesophagus  and  stomach,  with  considerable  shock, 
rapidly  followed  by  unconsciousness. 

Case  II. — Mrs.  B.,  an  actress,  becoming  despondent  at 
one  of  the  hotels  poured  some  water  upon  what  was  ap- 
parently one  half  ounce  of  the  ordinary  crystals  of  potas- 
sium permanganate  and  swallowed  nearly  all  of  the  sat- 
urated solution.  She  at  once  was  seized  with  burning  pains 
of  the  throat,  oesophagus,  and  stomach  and  rang  for  the 
bell  boy,  to  whom  she  had  barely  time  to  state  that  she  had 
taken  poison  and  then  collapsed. 

The  pain  from  the  burning  and  escharotic  effects  of  the 
compound  seems  to  be  severe,  as  in  both  cases  the  collapse 
and  unconsciousness  came  on  very  rapidlj",  before  sufficient 
time  had  elapsed  for  absorption  and  general  constitutional 
effects  from  that  source.  The  first  patient  described  the 
sensation  as  if  she  had  been  swallowing  coals  of  fire  and 
the  other  patient  described  it  as  a  very  hot,  burning,  and 
painful  sensation. 

In  both  cases  dilute  vinegar  was  administered  first,  since 
the  salt  is  quite  strongly  alkaline  in  its  reaction.  In  Case 
I  the  stomach  tube  was  resorted  to,  since  the  compressed 
tablets  dissolve  slowly,  and  dilute  ferrous  sulphate  solution 
and  water  were  used  alternately  to  wash  and  siphon  out  the 
stomach.  This  was  continued  until  no  color  was  imparted 
to  the  water  washings,  which  took  more  than  an  hour.  The 
second  patient,  after  receiving  the  vinegar,  was  given  sod- 
ium hyposulphite  solution.  The  two  together  produced 
vomiting  and  no  other  treatment  was  resorted  to  until  the 
hospital  was  reached.  Then  one  drachm  doses  of  sulphurous 
acid,  well  diluted,  were  administered  at  frequent  intervals 
for  several  hours,  and  then  the  same  amount  given  three  or 
four  times  daily  for  four  days. 

No  other  treatment  was  used  in  either  case  and  both  pa- 


tients recovered  rapidly.  The  first  one  was  at  work  in 
three  days,  and  the  second  was  able  to  leave  the  hospital  in 
four  days  and  on  the  fifth  day  returned  to  New  York. 

There  are  several  antidotes  which  can  be  used 
with  equally  good  results,  as  follows :  Weak  ferrous 
sulphate,  sodium  sulphite,  sodium  hyposulphite, 
oxalic  acid,  sulphurous  acid.  OxaHc  acid  should  not 
be  tised  unless  it  is  definitely  known  how  mtich  per- 
manganate has  been  taken  and  the  exact  molecular 
proportion  of  it  is  then  to  be  giveUj  as  che  oxalic 
acid  is  as  poisonous,  if  not  more  so,  than  potassium 
permanganate.  Consequently  no  excess  should  be 
given.  The  antidote  indicated  is  sulphurous  acid  if 
it  can  be  obtained,  and  for  the  following  reasons : 
I,  Potassium  permanganate  is  alkaline — sulphurous 
acid  is,  of  course,  acid.  2,  Potassium  permanganate 
is  an  oxidizing  agent — sulphurous  acid  is  a  powerful 
reducing  agent.  3,  Sulphurous  acid  is  not  poisonous 
and  an  excess  will  do  no  harm  and  it  acts  very 
rapidly. 

2355  XoRTH  Thirteexth  Street. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  tliis  department  arc  an- 
nounced at  frequent  intervals.  So  jar  as  they  have  been 
decided  upon,  the  further  questions  are  as  folloius: 

LXXXV. — Apart  from  an  operation,  how  do  you  treat 
disease  of  the  vermiform  appendix?  {Closed  April  15, 
/pop.) 

LXXXVI. — Hoiv  do  you  make  an  early  diagnosis  of  pul- 
monary tuberculous  disease?  C^nsvL'Crs  due  not  later  than 
May  I  J,  1909.) 

LXXXVII. — How  do  you  treat  supraorbital  neuralgia? 
(Anszi'ers  due  not  later  than  June  13,  igog.) 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  zvill  re- 
ceive a  prize  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solety 
on  the  value  of  the  substance  of  the  ans-wer.  It  is  requested 
(but  not  required)  that  the  anszvers  be  short;  if  practica- 
ble no  one  answer  to  contain  more  than  six  hundred 
zi'ords. 

All  persons  will  be  entitled  to  compete  for  the  prise, 
idicther  subscribers  or  not.  This  prise  w^ll  not  be  awarded 
to  any  one  person  more  than  once  within  one  year.  Every 
anszver  must  be  accompanied  by  the  writer's  full  name  and 
address,  both  of  which  zve  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Journal. 
Our  readers  are  asked  to  suggest  topics  for  discussion. 

The  prise  of  $25  for  the  best  essay  submitted  in  answer 
Wiseman,  of  Syracuse.  X.  Y..  whose  article  appeared  on 
page  834. 

PRIZE  QUESTION  LXXXIV. 
THE  THERAPEUTIC  USE  OF  ALCOHOL. 
(Continued  from  page  8^6.) 
Dr.  L.  Slicddan,  of  Kiioxi  iilc,  Tenn.,  remarks: 

Therapeutically  alcohol  is  used  much  less  fre- 
quently than  in  former  years.  In  replying  to  this 
question  I  will  first  state  some  conditions  in  which 
I  consider  it  contraindicated. 

Alcohol  should  not  be  used  in  large  quantities  as 
a  stimulant,  as  it  will  not  act  as  such,  and  rarely  so 
in  small  quantities  for  any  length  of  time.  Its  use 
cannot  be  too  severely  condemned  in  severe  injuries 
and  in  surgical  shock. 

I  use  it  quite  frequently  as  a  sedative  in  some 


9o6 


OUR  READERS'  DISCUSSIONS. 


[Nevv  Vork 
Mi£DicAL  Journal. 


cases  of  insomnia,  and  in  tlie  extreme  nervous  man- 
ifestations so  often  accompanying  some  of  the  acute 
specific  diseases.  In  delayed  eruptions  in  the  ex- 
anthematous  diseases  a  dose  of  hot  whiskey  will  fre- 
quently hasten  its  appearance. 

In  the  incipient  stage  of  acute  catarrhal  inflamma- 
tions of  the  uppei  air  passages,  such  as  coryza,  laryn- 
gitis, pharyngitis,  tracheitis,  bronchitis,  etc.,  alcohol, 
judiciously  given,  is  one  of  the  very  best  therapeu- 
tic agents  we  have.  Alcohol  also  has  a  very  salutary 
influence  over  the  catarrhal  and  myalgic  forms  of 
influenza.  To  be  efi.'ective,  however,  in  these  con- 
ditions, it  must  be  given  in  the  very  incipiency  of 
the  disease,  and  the  patient  put  to  bed.  If  the  pa- 
.  tient  is  allowed  to  expose  himself  to  chilling  influ- 
ences his  condition  will  be  made  worse.  On  the 
otlier  hand,  a  good,  stiff  drink  of  whiskey,  followed 
by  small  dcse  every  three  or  four  hours,  and  a  stay 
in  bed  for  twenty-four  hours,  the  condition,  as  a 
rule,  w^ill  be  very  much,  if  not  entirely,  relieved. 

It  acts  by  dilating  the  superficial  capillaries,  and 
relieving  the  congested  conditions  of  the  mucous 
membranes,  and  establishing  the  equilibrium  of  the 
circulation ;  and  by  its  sedative  action  it  quiets 
the  restless  nervous  condition  and,  to  a  great  extent, 
relieves  the  myalgic  pains.  Some  laxative,  c'lch  as 
small  doses  of  calomel  or  salines,  should  be  used  in 
conjunction  with  the  alcohol. 

A  small  dose  of  alcohol  at  bedtime  will  frequently 
induce  sleep  in  certain  cases  of  insomnia.  However, 
it  should  be  watched  and  the  patient  not  allowed  to 
continue  it  for  any  great  length  of  time,  as  there  is 
great  danger  in  this  class  of  patients  forming  the 
drug  habit. 

The  one  condition,  above  all  others,  in  which  al- 
cohol is  especially  efiFicacious  is  the  extreme  nervous 
condition  met  with  in  acute  lobar  pneumonia,  where 
there  is  wild  delirium  with  complete  insomnia.  Noth- 
ing in  the  whole  pharmacopoeia  will  so  efifectually 
meet  the  indications  in  this  condition  as  pure  corn 
whiskey.  It  must,  however,  be  given  in  large  quan- 
tities to  produce  the  desired  ef¥ect.  I  have  found  it 
next  to  impossible  to  produce  the  constitutional  ef- 
fect of  alcohol  upon  this  class  of  patients. 

I  have  given  a  pint  of  whiskey  to  a  girl  of  seven, 
and  a  quart  to  an  adult  in  twelve  hours  without  pro- 
ducing symptoms  of  alcoholism.  These  extreme 
doses  will  only  be  necessary  in  those  cases  where 
the  delirium  and  nervous  symptoms  are  very  pro- 
nounced. 

I  have  never  seen  one  of  these  cases,  where  this 
remedy  could  be  taken,  which  did  not  yield  to  it  if 
pushed  far  enough.  I  do  not  consider  it  a  stimulant, 
and  do  not  give  it  as  such  in  this  condition,  but  as  a 
sedative  and  an  antitoxine.  There  must  be  some 
loxine  produced  in  the  course  of  the  pneumonic  in- 
.  fection  which  produces  these  symptoms  by  its  efifect 
upon  the  nervous  centres.  These  toxincs  and  the 
whiskey  must  have  some  neutralizing  efifect  upon 
each  other,  as  it  is  practically  impossible  to  produce 
the  constitutional  efifect  of  alcohol  in  these  patients. 
Then  again  if  enough  whiskey  is  given  these  nerv- 
ous phenomena  subside,  and  the  patient  will  fre- 
quently fall  into  a  f|uiet.  natural  sleep.  I  have  seen 
this  efifect  so  often  that  I  am  convinced  that  the 
whiskey  in  some  way  neutralizes  these  toxines. 
No  definite  dose  can  be  put  down.    The  whiskey 


must  be  given  in  large  doses  often  repeated  until  the 
desired  efl:'ect  is  produced.  The  efifect  must  be  the 
index  to  the  amount  given  and  not  so  many  cubic 
centimetres  nor  ounces.  When  the  nervous  symp- 
toms subside  and  the  patient  becomes  quiet  the 
amount  of  whiskey  may  be  diminished,  or  stopped, 
as  indicated. 

It  does  not  matter  in  what  form  the  alcohol  is 
given  but  pure  corn  whiskey  straight,  in  toddy,  milk 
punch,  egg  nog.  or  any  way  it  can  best  be  tolerated 
has  been  my  method  of  giving  this  remedy.  Just  so 
the  patient  gets  enough  is  the  most  important  point. 
1  am  not  discussing  the  treatment  of  pneumonia  in 
general,  but  the  therapeutic  application  of  alcohol  to 
meet  certain  indications  in  pneumonia. 

The  conditions  I  have  mentioned  are  about  the 
only  ones  in  which  I  have  found  alcohol  to  be  the 
besi  remedy  with  which  to  combat  them.  In  the 
delirious  conditions  met  with  in  other  acute  infec- 
tious diseases  especially  if  of  the  low  muttering  type 
alcohol  will  have  a  certain  sedative  efifect  but  not  so 
decidedly  so  as  in  lobar  pneumonia. 

Dr.  J.  E.  Klotc,  of  Lanark,  Out.,  states: 

The  nature  of  the  question  dispenses  with  an  ex- 
planation of  the  physiological  action  of  alcohol  in 
a  more  or  less  diluted  form  :  I  shall  therefore  en- 
deavor to  outline  its  uses,  in  its  various  forms,  as  a 
stimulant,  diuretic,  diaphoretic,  food — so  called — ■ 
also  as  a  refrigerant,  appetizer,  promoter  of  diges- 
tion, astringent,  and  bitter  tonic. 

Under  true  cardiovascular  stimulants  may  be 
classed : — Rye,  Scotch  and  Irish  whiskeys,  gin.  rum, 
brandy,  and  various  liqueurs ;  these  are  useful  in 
doses  of  from  three  to  sixteen  ounces  daily,  in  the 
depression  stage  of  eruptive  fevers,  typhoid,  diph- 
theria, pneumonia,  acute  cerebrospinal  disease,  de- 
lirium tremens,  septicha;mia,  erysipelas,  tetanus, 
dysentery,  cholera,  acute  neuralgia,  influenza,  quin- 
sy, pemphigus,  acute  podagra,  acute  empyema,  sun- 
stroke, malaria,  and  yellow  fever. 

E.xternally  alcohol,  proof  and  rectified  spirits, 
pure  or  dilute — are  of  value  to  prevent  bed  sores, 
as  a  skin  refrigerant,  to  destroy  "pily"  diseases  of 
the  external  auditory  meatus  and  of  other  parts  of 
the  body,  and  as  a  rubefacient,  antiseptic,  and  dis- 
infectant. 

Alcoholic  beverages  of  a  marked  diuretic  power 
include  dilute  gin,  light  beers,  and  light  acid  white 
wines.  As  diaphoretics  may  be  mentioned  all  the 
strong  alcoholic  drinks.  When  taken  liberally  or 
when  taken  dilute,  hot  and  in  moderation :  hot  rum 
is  a  noted  diaphoretic.  The  stronger  aromatic  wines 
taken  hot  have  a  like  efifect.  Bitters  and  other  car- 
minatives added  to  strong  alcoholics  increase  their 
diaphoretic  influence.  .All  alcoholic  beverages  take, 
to  a  certain  extent,  the  place  of  foods  when  taken 
in  moderation  :  but  the  stronger  liquors  assume  this 
value  only  through  their  power  to  save  the  oxyda- 
tion  of  the  proteid  cells  of  the  body,  being  them- 
selves converted  into  carbon  dioxide  and  water. 

The  beverages  containing  true  food  properties  are 
heavy  ales,  egg  flips,  milk  punches,  porters,  malt 
extracts,  stout,  and  rich  red  wines.  The  ales, 
porters,  and  malt  e.xtracts  are  likewise  splendid  bit- 
ter tonics  taken  before  or  with  meals :  at  the  same 
time  many  patients  arc  unable  to  take  ale  and  porter. 


May  1,  igog. ] 


OUR  READERS'  DISCUSSIONS. 


90;/ 


•complaining  that  they  cause  an  unusual  acidity  of 
the  stomach,  as  well  as  sensations  of  lethargy. 

Among  "appetizers"  and  promoters  of  digestion 
may  be  enumerated  sherry,  mild  cordials,  dilute 
liqueurs,  dry  aromatic  red  wines  if  not  acid,  various 
cocktails,  and  porter,  ale,  or  stout  in  very  small 
quantities. 

Of  refrigerants  we  have  sauterne,  Roman  punch. 
Moselle,  some  Rhine  wines,  white  Burgundy,  light 
white  champagnes,  and  light  claret,  all  taken  iced. 

The  astringent  wines  useful  in  dysenteries  and 
diarrhoeas  are  few ;  among  them  the  Bordeaux,  the 
dark  Burgundy,  good  brandies,  and  black  currant 
wine. 

For  a  tedious  convalescence,  of  whatever  kind, 
nothing  answers  so  well  as  a  rich  port  wine  of 
twelve  per  cent,  alcohol  or  less.  A  rich  Madeira  or 
Catawba  answer  as  well  where  the  stimulant  effect 
of  the  inherent  alcohol  is  of  less  importance.  Next 
in  value  may  be  mentioned  the  li(|uid  malt  extract 
which  is  generally  better  tolerated  by  the  stomach 
than  ales  or  porter. 

In  the  various  cachexias,  the  malt  extracts  are 
very  useful  as  well  as  egg  flips  of  food  brandy,  rich 
ales,  stout,  and  porter,  and  some  red,  unfermented 
grape  wines.  • 

Stout,  porter,  ale,  malt  extracts,  unfermented  and 
fermented  rich  sweet  wines,  have  a  marked  food 
value  through  their  sugar,  peptone,  and  albumose 
content. 

Champagne  through  its  efitervescence  is  a  gastric 
sedative  as;  well  as  a  refrigerant  and  diuretic — much 
in  vogue  on  high  rolling  seas. 

Vermouth  is  to  be  avoided  on  account  of  its 
marked  drug  depressant  effect  following  a  very 
noticeable,  unusual,  and  undesirable  exhilaration. 

Plain  water  or  carbonated  water  is  the  best  dilu- 
ent for  any  kind  of  beverage. 

Kumyss,  containing  one  to  three  per  cent,  alcohol, 
is  exceedingly  valuable  in  chronic  kidney  disease 
and  phthisis. 

Whiskeys,  brandies,  and  wines  are  best  not  mixed 
with  milk,  unless  merely  as  a  flavoring.  All  bever- 
ages must  be  used  in  moderation  at  meals ;  the  old 
time  dinner  with  three  to  six  wine  courses  is  to  be 
deprecated. 

Strong  liquors  much  diluted  are  useful  in  reduc- 
ing high  fevers,  though  now  seldom  used  for  that 
purpose ;  but  where  there  is  any  gastric  intolerance 
they  must  be  omitted  entirely.  Hot  milk  poured 
into  an  equal  quantity  of  good  ale  or  beer  makes  an 
e.xcellent  going  to  bed  drink  and  food  for  puny, 
restless  and  scrofulous  children. 

Dr.  G.  W.  Loiii^ciiccker,  of  Elsviorc,  Kansas,  ob- 
serves: 

The  effect  produced  by  alcohol  when  taken  into 
the  system  is  an  old  subject ;  almost  as  old  as  man 
himself.  But  of  all  that  has  been  said  and  written 
on  this  important  subject,  comparatively  little  has 
appeared  in  regard  to  its  therapeutic  usefulness. 

There  can  be  no  doubt  that  much  harm  follows 
the  indiscriminate  and  immoderate  use  of  alcohol. 
But  Rosemann.  Rosefeld,  and  others  have  conclu- 
sively proved  that  when  taken  in  moderate  quanti- 
ties, it  is  oxidized  in  the  body  liberating  heat  and 


energy.  If  taken  in  comparatively  large  quantities, 
the  greater  part  is  excreted  unchanged. 

Alcohol  is  not  to  be  recommended  for  its  food 
value  but  in  properly  selected  cases  may  do  much 
good  as  a  food  and  general  stimulant.  It  is  often 
prescribed  unjustifiably.  But  in  cases  of  general 
weakness  or  collapse,  when  the  heart  is  weak  and 
respiration  poor,  nothing  will  take  its  place.  In 
fevers  or  exhaustion  of  nerve  centres  with  inability 
to  digest,  it  may,  when  judiciously^  used,  be  em- 
ployed as  a  food — replacing  the  carbohydrates  and 
fats  and  saving  the  proteids.  It  supports  the  devel- 
opment of  immunity  against  infection,  stimulates 
the  heari  and  respiration,  and  corrects  the  danger- 
ous distribution  of  blood.  It  assists  in  covering  the 
expenditure  of  energy  of  the  diseased  body  and  pro- 
tects its  tissues  from  breaking  down. 

Pneumonia  is  one  of  the  diseases  where  it  is  often 
most  useful.  But  all  cases  of  pneumonia  do  not  re- 
quire alcohol.  The  best  guide  as  to  its  use  in  these 
cases  is  the  pulse.  When  it  becomes  small  and  com- 
pressible, reaching  from  no  to  120  a  minute,  it  calls 
for  alcohol.  The  more  rapidly  this  condition  de- 
velops, the  more  alcohol  is  needed.  Other  disturb- 
ances which  are  common  during  an  attack  of  pneu- 
monia are  also  much  benefited  by  its  use.  Sleep- 
lessness, with  low  muttering  delirium,  and  the  dry 
mouth  and  parched  tongue  that  accompany  it,  are 
often  much  relieved  by  a  full  dose  given  at  bed  time. 
It  should  be  continued  through  the  exhausting  per- 
iod of  the  crisis  until  recuperation  has  set  in.  This 
is  usually  three  to  seven  days.  When  properly  ad- 
ministered it  materially  aids  the  patient  in  combat- 
ing the  infection. 

Alcohol  is  useful  in  all  acute  fevers  where  there 
is  feeble  circulation  with  the  alarming,  symptoms 
ihat  accompany  it.  More  reliance  can  be  placed 
upon  it  than  any  other  stimulant.  One  great  ad- 
vantage is  its  quick  action.  When  alcohol  is  given 
the  effect  produced  must  govern  the  amount  admin- 
istered. Its  use  should  not  be  a  mere  matter  of  rou- 
tine, but  it  should  be  given  where  the  conditions  call 
for  it.  It  should  not  be  given  where  nephritis,  liver 
disease,  myocarditis,  endocarditis,  or  pericarditis  is 
present.  It  is  usually  best  administered  in  the  form 
of  good  brandy,  whiskey,  or  some  of  the  wines, 
whichever  is  best  suited  to  the  case. 

Many  cases  of  persistent  vomiting  can  be  relieved 
by  small  doses  of  brandy  on  cracked  ice. 

Alcohol  is  in  some  measure  antidotal  to  the  poison 
of  the  tubercle  bacillus.  Tuberculous  patients  can 
often  take  relatively  large  quantities  without  show- 
ing symptoms  of  intoxication. 

In  measles,  when  the  eruption  turns  dark  or 
haemorrhagic,  alcohol  in  full  doses  and  at  slxDrt  in- 
tervals is  beneficial. 

In  infectious  dyspepsia  and  many  bowel  disorders, 
both  in  children  and  adults,  alcohol  in  the  form  of 
good  brandy  will  often  give  much  relief. 

Its  administration  will  also  be  found  advantage- 
ous in  cases  of  septic  poisoning — sapraemia  and  sep- 
tichasmia.  It  is  also  useful  in  cases  of  poisoning 
from  snake  bite.  It  is  not.  however,  an  antidote,  as 
is  usually  supposed  by  the  laity ;  but  is  useful  prin- 
cipally as  a  stimulant — keeping  the  circulation  up 
until  the  system  can  eliminate  the  poison. 


9c8 


CORRESFONDENCE. 


1'Sl^\   \  ork 
Medical  Journal. 


Manv  local  inHammatiohs  are  much  relieved  by 
the  external  application  of  alcohol.  In  some  cases 
of  buboes  it  seems  to  act  almost  as  a  specific.  In- 
flamed joints,  bruises,  wounds  of  a  contused  char- 
acter, carbuncles,  furuncles,  herpes  zoster,  and 
peripheral  neuritis  show  marked  improvement  under 
this  treatment.  In  all  of  these  conditions  it  is  best 
applied  in  the  form  of  a  compress.  A  pad  of  gauze 
should  be  moistened  with  th.e  alcohol  and  placed 
over  the  afifected  part  and  this  covered  with  rubber 
tissue.  Alcoh*ol  poured  or  rubbed  on  the  skin  gives 
little  chance  for  absorption,  whereas  a  moist  com- 
press gives  opportunity  for  greater  penetration. 
Some  physicians  assert  to  have  had  good  results 
from  these  applications  in  peritonitis.  The  useful- 
ness of  these  dressings  is  from  the  antiseptic  effect 
and  from  their  power  to  dilate  the  blood  vessels, 
thereby  relieving  congestion.  A  sponge  bath  with 
diluted  alcohol  is  useful  for  its  cooling  and  soothing 
effect  upon  the  fever  patient. 

Levy  and  Boudouin  report  good  results  in  the 
treatment  of  facial  neuralgia  by  injections  of  alcohol 
into  or  around  the  nerve  trunks  at  their  basal  fora- 
menal  exits  of  the  skull.  Ostwalt  reports  more  than 
250  injections  with  good  results  and  without  an  ac- 
cident of  any  kind.  Bodine  and  Keller  report  fifteen 
cases  treated  in  this  manner  with  a  cure  or  improve- 
ment in  every  case. 

Another  of  the  valuable  uses  of  alcohol  which 
must  not  be  forgotten,  is  in  the  treatment  of  car- 
bolic acid  poisoning,  and  the  burns  from  carbolic 
acid. 

In  the  use  of  alcohol,  as  with  any  other  powerful 
drug,  the  physician  must  be  watchful  and  be  gov- 
erned by  the  effect  produced  upon  the  patient. 
{To  be  concluded.) 

 ^  

Correspfluknct. 


LETTER  FROM  TORONTO. 

The  Hospitals  of  Ontario. — The  Canadian  Nurse. — Medical 
Inspection  of  Schools.— The  Milk  Question.— The  On- 
tario Medical  Association. 

ToRO.NTO,  April  19,  igog. 
The  thirty-ninth  annual  report  of  the  public  hos- 
pitals, charities,  refuges,  and  orphanages  of  Ontario 
for  the  year  ending  the  30th  of  September,  1908, 
has  just  been  issued.  Ontario  now  has  sixty-nine 
hospitals,  thirty-four  refuges,  thirty  orphanages, 
three  homes  for  incurables,  two  convalescent  homes, 
two  Magdalen  asylums,  and  twenty-eight  county 
houses  of  refuge  receiving  governmental  aid  and 
under  governmental  insi)ection.  ( )n  the  ist  of  Oc- 
tober. 1907,  there  were  2,935  ])atients  in  the  hos- 
pitals of  Ontario,  and  there  were  admitted  during 
the  year  4I.(j96  patients.  The  number  of  births  in 
these  hospitals  during  the  year  was  2,340.  These 
figures,  of  course,  do  not  refer  to  those  who  received 
treatment  in  the  out  door  departments  of  these  in- 
stitutions. The  numi)er  of  deaths  during  the  year 
was  2.748.  a  percentage  of  5.85.  The  provincial 
grant  to  the  hospitals  during  the  year  amounted  to 
Si 46.268.08.  and  the  amount  received  from  all 
sources  was  $1,278,000.16.  The  total  exjjcnditure 
for  tile  hospitals  was  $2,721,524.28,  the  average  cost 
of  each  patient  j)er  diem  being  $1.21.    In  a  decade 


in  Ontario  the  number  of  hospital  patients  has 
doubled,  while  the  maintenance  account  is  about  five 
times  what  it  was  then.  A  provincial  grant  is  made 
to  all  hospitals  during  the  first  ten  years  of  their 
existence  at  the  rate  of  twenty  cents  a  day  for  each 
patient.  After  ten  years  the  grant  is  paid  only  for 
patients  for  whose  maintenance  $4.90  a  week  or  less 
is  contributed.  In  all  cases  the  limit  is  120  days. 
The  grant  to  sanatoria  for  consumptives  will  for  the 
coming  year  be  $3  a  week  for  all  patients  for  whose 
maintenance  $4.90  a  week  or  less  is  contributed. 
During  the  past  year  871  patients  were  admitted  to 
the  special  hospitals  or  sanatoria  established  for  the- 
treatment  and  care  of  consumptives  in  Ontario, 
which  is  a  small  percentage  of  the  number  of  tuber- 
culous patients.  In  order  to  facilitate  the  establish- 
ment of  country  or  municipal  sanatoria  for  con- 
sumptives, the  Ontario  government  now  gives  a 
grant  of  $4,000  for  the  establishment  of  these  insti- 
tutions, and  the  liberal  contribution  toward  each  pa- 
tient's maintenance  as  aforesaid. 

The  number  of  patients  under  treatment  in  all 
departments  of  the  Toronto  General  Hospital  on  the 
30th  of  September.  1907,  was  322 ;  admitted  during 
1908,  4,005  ;  births  in  the  hospital,  263 ;  total,  4,590. 
The  discharges,  including  those  of  infants,  were 
4,005 ;  died,  305 ;  under  treatment  30th  of  Septem- 
ber, 1908,  280.  Of  the  4,590  persons  treated  during 
the  year,  274  males  and  144  females  were  inmates 
of  the  Andrew  Mercer  Eye  and  Ear  Infirmary,  and 
572  in  the  Burnside  Lying-in  branch.  Of  all  the 
patients  treated,  2.498  were  males  and  2,092  females. 
The  total  revenue  for  the  }-ear  was  $150,273.04,  of 
which  private  and  other  paying  patients  contributed 
$68,007.60. 

The  third  annual  meeting  of  the  Canadian  Hos- 
pital Association  \\as  held  in  Toronto  on  the  12th 
and  13th  of  April,  under  the  presidency  of  Dr.  W. . 
J.  Dobbie,  superintendent  of  the  Weston  Sanatorium 
for  Consumptives.  Dr.  J.  N.  E.  Brown,  superin- 
tendent of  the  Toronto  General  Hospital,  acted  as 
the  secretary.  Mr.  E.  F.  Stevens,  hospital  architect, 
of  Boston,  was  present  and  in  speaking  before  the 
meeting  paid  a  tribute  to  the  Canadian  nurse.  He 
said  that  the  United  States  owed  much  to  the  Cana- 
dian nurse,  that  one  could  scarcely  visit  a  hospital 
from  Maine  to  California  without  finding  Canadian 
nurses,  often  in  charge  of  the  hospitals.  It  appears 
that  about  ninety  per  cent,  of  the  nurses  are  Cana- 
dians. He  also  advocated  the  treatment  of  private 
patients  in  a  separate  building  from  free  patients. 
Dr.  C.  Campbell  Me}-ers,  of  Toronto,  gave  a  paper 
upon  neuropathic  wards  in  general  hospitals,  refer- 
ring particularly  to  the  work  done  in  connection 
with  the  Toronto  General  Hospital  in  this  respect. 
He  said  it  was  possible  to  effect  a  cure  and  prevent 
insanity  if  the  subject  was  treated  before  the  border 
line  was  reached.  The  following  officers  were 
elected:  President.  iMr.  H.  E.  Webster,  of  Montreal; 
vice-presidents.  Dr.  D.  Robertson,  of  Ottawa;  Dr. 
W.  J.  Dobbie,  of  Toronto:  Mr.  W.  W.  Kenny,  of 
Halifax:  Miss  Green,  of  Belleville;  and  Dr.  E.  W. 
Fiyan,  of  Kingston.  Dr.  J.  N.  E.  Brown,  of  To- 
ronto, was  reelected  .secretary. 

At  the  annua]  meeting  of  the  Ontario  Teachers" 
Association.  heKl  in  Toronto  during  the  week  end- 
ing on  the  17th  of  Auril.  a  branch  of  the  Interna- 
tional Con.gress  en  School  Hygiene  was  organized. 


May  1,  1909.] 


THERAPEUTICAL  XOTES. 


It  will  have  for  its  patron  Earl  Grey,  the  Governor 
General.  Sir  James  Grant.  M.  D.,  of  Ottawa,  was 
elected  the  first  president,  and  Dr.  Helen  MacMur- 
chy,  of  Toronto,  secretary  and  treasurer.  Before 
the  organization  of  the  branch.  Sir  James  delivered 
an  address  on  the  subject  of  the  life  of  our  young 
nation,  advocating  especially  the  medical  inspection 
of  schools,  and  citing  Germany,  where  they  now  had 
676  regularly  appointed  school  doctors.  ^ledical  in- 
spection of  schools  had  not  yet  become  an  accom- 
plished fact  in  Canada,  but  it  had  been  under  con- 
sideration for  some  time  past,  and  some  cities  had 
even  begun  the  good  work.  Another  paper  which 
attracted  a  good  deal  of  attention  was  that  of  Dr. 
Charles  C.  J.  O.  Hastings,  who  took  for  his  subject 
the  danger  of  children  contracting  tuberculosis  from 
milk.  As  Dr.  Hastings  is  chairman  of  the  Milk 
Commission  of  the  Canadian  Medical  Association, 
and  is  doing  a  good  work  in  getting  the  question  of 
clean  milk  before  the  medical  profession,  health  de- 
partments, 'and  the  community  at  large,  this  paper 
was  listened  to  with  marked  attention. 

The  annual  meeting  of  the  Ontario  Medical  As- 
sociation will  be  held  in  Toronto  on  the  ist,  2nd, 
and  3d  of  June,  under  the  presidency  of  Dr.  H.  J. 
Hamilton,  of  Toronto,  Dr.  E.  Stanley  Ryerson,  of 
Toronto,  being  the  secretary.  Among  other  United 
States  physicians  and  surgeons  who  will  be  present 
and  take  part  in  the  meeting  are  Dr.  John  B. 
Deaver.  of  Philadelphia,  who  will  read  a  paper  on 
acute  septic  peritonitis;  Dr.  W.  P.  Manton,  of  De- 
troit; who  will  read  a  paper  on  the  ultimate  end  of 
surgery,  with  special  reference  to  the  surgery  of  the 
pelvic  organs,  in  women ;  Dr.  L.  Emmett  Holt  and 
Dr.  J.  Adler,  of  New  York.  There  is  to  be  a  "sym- 
posium" on  Present  Day  Therapeutics,  opened  by 
Dr.  J.  T.  Fotheringham,  and  continued  by  Dr.  John 
Ferguson,  Dr.  J.  H.  Elliott,  and  Dr.  S.  H.  West- 
man,  all  of  Toronto.  There  will  also  be  another 
"symposium"  on  Slight  Contractions  of  the  Pelvis 
in  Pregnancy  and  Labor. 

 ^  


Treatment  of  Eczema.— Dr.  J.  L.  Bunch  while 
speaking  on  the  modern  methods  of  treatment  of 
skin  diseases  (The  Lancet.  April  3,  1909)  says  that 
in  acute  papular  eczema  he  always  uses  powders, 
pastes,  or  lead  lotion  applications;  in  vesicular  ec- 
zema, especially  when  the  vesicles  are  tending  to  be- 
come confluent,  the  powders  are  definitely  indicated, 
and  external  irritations  such  as  the  effect  of  sun, 
wmd._  excessive  heat,  the  friction  of  clothing,  the 
use  of  nater,  and  especially  soap,  are  to  be  avoided. 
Thus  boric  acid  fomentations  applied  cold  prove  of 
the  greatest  service,  if  care  is  taken  that  their  macer- 
atmg  effect  shall  be  confined  to  the  discharging  le- 
sions. These  are  to  be  applied  only  until  the*dis- 
charge  diminishes,  and  then  either  powders  or  Las- 
sar's  paste  containing  5  minims  of  thiol  to  the  ounce. 

For  old  chronic,  thickened  eczema  plaques,  chry- 
sarobin  or  pyrogallol  should  be  used  in  from  one  to 
ten  per  cent,  ointments  made  up  with  petrolatum  and 
painted  on.  followed  by  the  application  of  zinc  and 
starch  powder.   When  the  patches  are  greativ  thick- 


ened they  may  be  softened  by  the  painting  on  of 
fifty  per  cent,  solution  of  potassium  hydroxide,  then 
applying  fifty  per  cent,  silver  nitrate  solution,  and 
covering  with  sterile  gauze  for  one  or  two  weeks 
until  healed.  The  scab  is  then  removed  by  treating 
with  boric  ointment. 

The  especially  rebellious  eczemata  of  the  scrotum, 
anus,  and  vulva  arc  best  treated  by  the  Paquelin 
cautery  under  general  or  local  anjesthesia  and  the 
subsequent  application  of  a  five  per  cent,  solution  of 
borax  compresses.  Light  treatment  has  given  good 
results  in  some  cases,  especially  in  localized  eczema- 
tous  plaques,  and  in  certain  cases  applications  of 
radium.  But  it  is  important  in  both  cases  to  give 
only  minimal  doses  and  to  avoid  any  possible  over 
excitation  of  the  inflamed  skin.  The  irritability  of 
the  skin  can  also  he  diminished  by  applications  of 
blue  light  by  means  of  the  blue  quartz  lamp  or  the 
uviol  lamp.  High  frequency  currents  have  also  been 
recommended. 

One  of  the  most  troublesome  symptoms  of  eczema 
is  unquestionably  the  itching,  and,  although  this 
diminishes  as  the  inflammator}'  hyperaemia  lessens, 
we  often  need  some  more  rapid  means  of  checking 
it..  Cold  water  compresses  are  often  of  service,  and 
any  harmful  effects  of  the  water  can  be  minimised 
by  subsequent  applications  of  drying  powders,  but 
menthol  suits  some  cases  even  better.  Two  to  ten 
per  cent,  solutions  in  alcohol  or  oil  are  the  best 
means  of  applying  it,  but  the  resulting  sensation  of 
cold  is  sometimes  felt  to  be  worse  than  the  itching. 
Then  one  or  two  per  cent,  solutions  of  salic\-lic  acid 
in  alcohol  may  be  tried,  or  carbolic  glycerin  made 


up  as  follows : 

B     Carbolic  acid  *..gr.  iv; 

Glycerin,   -. .  ntxl ; 

Alcohol,   ji- 

M. 


In  cases  where  the  coagulation  time  of  the  blood 
is  delayed  calcium  salts  should  be  ordered  and  food 
containing  vegetable  acids  such  as  tomatoes  and 
rhubarb  forbidden.  Arsenic  has,  of  course,  a  con- 
siderable reputation,  but  it  should  only  be  given  in 
chronic  cases  and  then  for  a  period  of  a  month  in 
increasing  doses  up  to  thirty  minims  a  day  and  then 
diminished  during  the  succeeding  fortnight,  at  the 
end  of  which  it  should  be  stopped  for  a  time. 

To  Relieve  Gastric  Irritation. — Delancy  Roch- 
ester {Nciu  York  State  Journal  of  Medicine,  April. 
1908;  through  Jonrnal  of  the  American  Medical 
Association,  February  20,  1909)  relieves  gastric 
irritation,  flatulence,  and  pain  with  the  following 


prescription : 

R     Strontium  bromide,   5iss  ; 

Sodium  bicarbonate,   5x  ; 

Wood  charcoal,   3v  ; 

Bismuth  subcarbonate,   3v; 

Milk  of  magnesia,   ^vi- 


M.  et  Sig. :  Two  teaspoonfuls,  in  water,  three  times  a 
day,  after  meals. 

If  between  meals  there  is  burning  or  pain  in  the 
stomach  due  to  hyperchlorhydria,  it  is  recommend- 
ed to  give  the  following  gastric  sedative : 


R     Cerium  oxalate  3iiss  ; 

Bismuth  subcarbonate,   3v; 

Magnesium  oxide,   3x. 

M.  et  fac  pulverem. 


Sig. :  A  teaspoonful  stirred  in  water,  and  repeat  in  an 
hour  if  needed. 


EDI  TORI  A  L  A  KTICLES. 


[Xevv  York 
Medical  Journal. 


NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

Philadelphia  Medical  Journal 
and  The  Medical  News. 

A  Weekly  Kcviciv  of  Medicine. 

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NEW  YORK.  SATURD.VY,   M.\^■   i,  1909. 

MILITARY  MEDICINE  AS  A  CAREER. 

It  was  a  happy  thoiig:ht  on  the  part  of  Dr.  Ed- 
mund Prince  Fowler,  for  we  understand  that  to 
hiin  the  credit  is  due,  to  arrange  for  a  number  of 
communications  on  military  medicine  to  be  present- 
ed before  the  Medical  Society  of  the  County  of  New 
York  last  ^.londay  evening,  and  the  idea  was  ad- 
mirably executed.  Acting  under  orders  from  the 
Secretary  of  War  and  the  Secretary  of  the  Navy. 
Lieutenant  Colonel  Jefferson  R.  Kean.  of  the  Medi- 
cal Corps  of  the  Army,  and  Surgeon  Charles  1". 
."^tokes,  of  the  Medical  Corps  of  the  Navy,  attended 
tile  meeting  and  presented  interesting  papers  deal- 
ing with  the  qualificaticns  required,  the  obligations 
impo:-ed,  and  the  status  and  remuneration  gained  in 
the  medical  service  of  thd  army  and  navy.  The  pro- 
gramme was  further  elaborated  by  papers  from 
medical  and  line  officers  in  the  National  Guard, 
showing  the  relations  of  the  medical  officer  to  the 
guard  and  the  duties  imposed  by  accepting  service 
in  that  organization.  The  medical  ofificer  in  the  Na- 
tional Guard  is  in  a  jiosition  to  render  material  ser- 
vice to  society  generally  as  well  as  to  the  guard  bv 
carefully  instructing  the  men  and  officers  in  ])crsonaI 
hygiene,  as  well  as  in  the  hygiene  of  the  camp.  The 
guard  may,  and  in  fact  should,  be  a  valuable  school 
of  sanitation  for  the  citizen. 

'i'lic  ])apers  and  discussion  brought  out  tlie  fact 
that  the  remuneration  and  the  social  position  af- 
fordefj  the  beginner  in  medical  i)ractiee  by  a  com- 
mission in  the  Medical  Corps  of  the  .Army  were  de- 


cidedly better  than  the  average  young  practitioner 
could  hope  to  obtain  in  private  practice.  The  growth 
of  specialization  in  medicine  is  being  recognized 
in  the  army,  and  an\'  officer  who  shows  special  ap- 
titude or  capacity  for  particular  lines  of  original 
research  will  generally  find  an  opening  for  the  dis- 
pla}^  of  this  capacity.  Officers  of  the  medical  corps 
have  been  detailed  for  courses  of  instruction  at  the 
Schools  of  Tropical  Medicine  in  England,  one  lec- 
tures on  tropical  medicine  in  New  York,  several  are 
connected  with  the  School  of  Tropical  Medicine  in 
Manila,  several  members  of  the  corps  under  Colonel 
Gorgas  have  won  golden  opinions  for  their  services 
at  Panama,  Colonel  Kean  himself  has  but  just  re- 
turned from  a  two  years'  tour  of  duty  as  medical 
adviser  to  the  Provisional  Governor  of  Cuba,  and 
another  medical  officer  is  now  in  the  heart  of  Africa 
with  ex-President  Roosevelt.  It  will  be  seen  that 
the  service  offers  not  only  substantial  rewards,  but 
possibilities  of  pleasing  variety. 

Unfortunately  Congress  does  not  seem  to  appre- 
ciate the  importance  of  military  training  for  medical 
officers,  and  the  intimate  history  of  the  wars  of  the 
Cnited  States  shows  that  at  no  time  has  the  medical 
department  been  properly  prepared  for  war  at  its 
outbreak.  Ten  days  after  the  second  battle  of  Bull 
Run  the  surgeon  general  of  the  army  wrote  a  letter 
to  the  Secretary  of  War,  INIr.  Stanton,  stating  that 
iliere  were  still  on  the  field  600  wounded,  many  of 
whom  would  die  before  they  could  be  relieved  with 
the  facilities  and  under  the  regulations  provided, 
while  already  many  of  the  wounded  had  actually  died 
of  starvation  lying  on  the  field  of  battle  where  they 
had  been  struck  down.  This  is  a  picture  of  what  has 
happened  as  the  result  of  unprcparedness  for  war 
in  the  medical  corps.  Colonel  Kean  assured  the 
meeting  that,  even  were  all  the  hundred  vacancies 
now  existing  in  the  corps  filled,  the  medical  depart- 
ment w  ould  be  relatively  less  well  prepared  for  war 
now  than  it  was  at  the  beginning  of  hostilities  in 
any  of  our  wars  of  the  past,  in  so  far  as  the  pro- 
ijortion  of  medical  officers  to  the  total  force  is  con- 
cerned. 

With  such  a  gniesc)me  history  to  guide  us.  it  is 
almost  incomprehensible  that  public  opinion  will  per- 
mit a  Congress  which  squanders  money  so  lavishly 
on  unnavigable  streams,  on  palatial  marble  offices 
for  the  use  of  its  members,  and  in  the  payment  of 
age  pensions,  to  save  a  few  thousand  dollars  annual- 
ly bv  cutting  down  the  appropriation  for  the  medical 
department  of  the  army  when  this  appropriation, 
properly  expended  now.  will  enable  us.  by  having 
adequately  prepared  for  war.  to  save  thousands  of 
lives,  untold  suffering,  and  millions  in  pensions 
which  will  undoubtedly  be  .sacrificed  through  the  un- 
preparerlness  of  oiu'  medical  department  when  the 
next  war  comes. 


May  1,  1909.1 


EDITORIAL  ARTICLES. 


9x1 


THE  Mcdowell  cextexxl\l. 

A  notable  feature  of  the  annual  meeting  of  the 
American  GynsecologicaL Society,  held  in  New  York 
last  week,  was  the  celebration  of  the  hundredth  an- 
niversary of  Ephraim  iMcDowell's  first  ovariotomy. 
It  was  doubtless  largely  owing  to  their  desire  to 
take  part  in  such  an  interesting  commemoration  that 
such  eminent  European  g\nascologists  as  Mr.  Her- 
bert P.  Spencer  and  ]\Ir.  Alban  Doran,  of  London, 
Hofrat  Professor  Hofmeier,  of  Wiirzburg,  and  Pro- 
fesseur  Agrege  Pozzi,  of  Paris,  all  busy  men,  took 
the  time  to  come  to  New  York  for  the  meeting,  be- 
fore which  they  presented  valuable  papers.  It  was 
an  honor  which  American  physicians  will  not  read- 
ily forget. 

It  was  particularly  graceful  on  the  part  of  ]\Ir. 
Doran  to  entitle  his  paper  .A.  Sequel  to  ^McDowell's 
Triumph,  being  a  Sketch  of  the  Rise  and  Progress 
of  the  Samaritan  Free  Hospital,  and  the  title  should 
wipe  out  any  little  trace  of  bitter  recollection  among 
us  of  the  comment  on  the  story  of  AIcDowell's 
achievement  when  it  reached  him  "from  the  wilds  of 
America,"  as  he  contemptuously  remarked,  made  by 
the  editor  of  the  Mcdico-Chirnrgical  Reviezc — Cre- 
dat  Jndccus,  non  ego!  It  is  our  belief,  however,  that 
the  last  vestige  of  any  such  bitterness  disappeared 
long  ago,  to  be  succeeded  by  admiration  of  the  work 
of  such  British  surgeons  as  Sir  Spencer  Wells,  Mr. 
Keith,  and  Mr.  Tait. 

The  special  event  in  the  commemoration  last  week 
was  the  bancjuet,  held  on  Thursday  evening,  and  it 
was  a  happy  thought  to  arrange  that  Dr.  Mc^Iur- 
try's  address  should  be  given  after  the  dinner,  at  a 
time  when  it  naturally  led  to  sympathetic  remarks 
by  other  distinguished  men.  The  choice  of  Dr. 
Lewis  S.  McMurtry,  the  eminent  Louisville  gynae- 
cologist, to  speak  in  commemoration  of  the  pioneer 
ovariotomist,  also  a  Kentuckian,  was  peculiarly  ap- 
propriate. Nobody  could  utter  more  telling  or  more 
graceful  sentences  concerning  McDowell  than  those 
that  came  from  Dr.  McAIurtry.  We  shall  soon 
publish  Dr.  McMurtry's  address  in  full. 

Few  achievements  in  surgery — perhaps  none  at 
all — have  had  more  beneficent  results  than  have  fol- 
lowed Ephraim  ^IcDowell's  early  ovariotomies.  Sir 
Spencer  Wells's  work  in  demonstrating  the  tremen- 
dous saving  of  life  by  ovariotomy  is  one  of  the  most 
convincing  testimonies  to  the  great  advantage  which 
humanity  has  drawn  from  the  activities  of  the  med- 
ical profession,  and  a  work  of  w^hich  we  are  all 
proud.  It  stands  almost  on  a  par  with  the  record 
of  Listerism.  It  was  indeed  well  that  the  .Amer- 
ican Gynaecological  Society  should  have  made 
a  special  point,  at  its  thirty-fourth  annual  meet- 
mg,,  of  celebrating  the  centennial  of  McDowell's 
triumiph. 


THE  CORRELATION  OF  SPECIALTIES. 

We  have  often  alluded  to  the  advantages  to  be 
derived  by  practitioners  in  a  certain  specialty 
from  the  adaptation  to  their  own  line  of  work  of 
therapeutical  methods  found  efficacious  in  other 
fields  of  practice.  But  the  correlation  of  specialties 
may  profitably  be  carried  further,  as  was  shown  by 
Dr.  Edward  Reynolds  and  Dr.  R.  W.  Lovett,  of 
F)OSton,  at  the  recent  meeting  of  the  American 
Gynaecological  Society.  Dr.  Reynolds  presented  a 
paper  entitled  The  Influence  of  Corsets  and  .High 
Heeled  Shoes  on  the  Symptoms  of  Pelvic  and  Static 
Disorders.  He  did  not  read  it  in  its  entirety,  but 
occupied  the  attention  of  the  meeting  mostly  with 
explanations  of  diagrams  and  views  of  the  human 
figure  in  the  upright  and  other  postures  as  influ- 
enced by  changes  in  the  situation  of  a  vertical  line 
passing  through  the  centre  of  gravity  of  the  body, 
referring  to  brief  histories  of  cases  showing  the 
effects  of  such  changes  on  symptoms  like  "static 
backache,"  for  example.  Dr.  Lovett  followed  with 
an  exposition  of  the  orthopaedic  elements  in  such 
cases. 

It  had  been  found  in  a  number  of  instances  that 
orthopaedic  treatment  alone  had  failed  to  give  relief 
from  such  symptoms  as  backache,  and  so.  too,  had 
the  correction  of  intrapelvic  abnormities  failed,  but 
the  subsequent  conjunction  of  orthopaedic  and  gynae- 
cological treatment  had  proved  efifective.  This 
shows,  of  course,  the  need  of  always  bearing  in  mind 
the  possibility  that  a  given  patient  may  be  suffering 
at  one  and  the  same  time  from  pathological  condi- 
tions calling  for  treatment  from  more  than  the  point 
of  view  natural  to  the  specialist  in  any  one  field ;  it 
shows  the  occasional  need  of  concerted  action  by 
practitioners  in  different  specialties.  It  was  an- 
nounced by  Dr.  Reynolds  and  Dr.  Lovett  that  the 
observations  made  by  them  thus  far,  though  extend- 
ing over  a  period  of  about  three  years  and  a  half, 
had  led  them  to  an  incomplete  and  merely  prelimin- 
ary report,  and  so  we  may  expect  them  to  report 
upon  additional  work  in  the  future. 

The  authors  insisted  on  the  exceeding  difficulty 
of  the  exact  experimental  investigation  of  balance 
in  the  erect  posture,  but  said  that  the  keynote  to  its 
comprehension  was  to  be  found  by  studying  the  re- 
lation of  the  centre  of  gravity  to  the  several  por- 
tions of  the  skeleton.  Certain  individuals,  they  had 
remarked,  possessed  a  stable  figure  and  were  free 
from  ptoses  and  static  ailments.  Such  persons  were 
but  little  affected  by  corsets  and  shoes  of  various 
types.  Those  of  unstable  figure,  however,  were 
greatly  affected,  beneficially  ok  injuriously,  by  these 
articles  of  apparel.  As  regarded  corsets,  some  were 
always  productive  of  harm,  while  others  were  harm- 
less and  might  often  be  of  benefit. 


912 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journa:,. 


THE  PROFESSIONAL  ANAESTHETIST. 

Within  the  last  few  years  there  has  been  shown 
in  this  country  a  decided  increase  of  attention  to  the 
details  of  anesthetization.  This  was  strikingly  mani- 
fested by  the  fact  that  at  the  recent  meeting  of  the 
American  Gynaecological  Society  an  entire  afternoon 
was  devoted  to  the  subject.  Papers  were  presented 
by  Dr.  J.  Montgomery  Baldy  and  Dr.  Charles  P. 
Noble,  of  Philadelphia;  Dr.  H.  J.  Boldt  and  Dr. 
James  T.  Gwathmey,  of  New  York;  Dr.  Robert  L. 
Dickinson,  of  Brooklyn ;  Dr.  J.  Clarence  Webster, 
of  Chicago :  Dr.  J.  Wesley  Bovee,  of  Washington ; 
Dr.  Hunter  Robb,  of  Cleveland ;  Dr.  F.  F.  Simpson, 
of  Pittsburgh  :  Dr.  Reuben  Peterson,  of  Ann  Arbor ; 
and  Dr.  S.  C.  Gordon,  of  Portland,  Me. 

Prominent  among  the  matters  discussed  was  the 
question  of  the  employment  of  professional  anaes- 
thetists in  hospitals  and  in  private  practice.  In  the 
United  States  the  specialist  in  anassthetization  has 
until  very  recently  had  no  existence.  This  state  of 
things  has  excited  some  astonishment  among  Euro- 
pean surgeons,  especially  among  our  British  breth- 
ren, for  almost  ever  since  the  introduction  of  anaes- 
thesia its  conduct  in  Great  Britain  has  been  largely 
in  the  hands  of  the  professional  anaesthetizer.  It  is 
not  difficult  to  find  a  plausible  reason  for  the  differ- 
ence of  practice ;  in  the  United  Kingdom  chloro- 
form, a  highly  dangerous  drug,  has  been  the  anaes- 
thetic preferred,  while  with  us  the  employment  of 
ether,  a  far  safer  agent,,  has  predominated.  The  use 
of  chloroform  called  for  far  greater  skill  in  admin- 
istration than  was  required  in  that  of  ether. 

Of  late  years,  however,  since  certain  refinements 
in  the  administration  of  anaesthetics  have  been 
shown  to  possess  distinct  advantages,  the  profession- 
al anaesthetizer  has  come  into  vogue  in  our  larger 
cities,  and  doubtless  his  function  is  destined  to  be 
more  and  more  widely  recognized.  Some  of  our 
hospitals  have  been  furnished  with  trained  anaes- 
thetists, and  in  private  practice  they  are  getting  to 
figure  largely.  It  is  easy  to  see  that  the  day  is  not 
far  off  when  every  considerable  hospital  will  have 
its  specialist  in  anaesthetization.  In  making  the 
change,  however,  let  us  not  lose  sight  of  one  thing 
that  may  happen — the  gradual  loss  of  what  little 
skill  the  average  practitioner  may  now  possess  in 
the  administration  of  anaesthetics. 

We  arc  convinced  that  it  would  be  most  unwise 
for  any  hospital  to  take  the  mask  altogether  out  of 
the  hands  of  the  members  of  the  house  staff  and  give 
it  into  the  sole  keeping  of  the  professed  anaesthetist. 
Anjcsthctization  is  one  of  the  things,  and  a  highlv 
important  one,  which  the  house  officer  has  a  right  to 
be  well  instructed  in ;  it  must  be  assured  that  the 
paid  an.Tsthctisl  will  teach  the  young  men,  and  not 
by  precept  alone,  but  also  by  superintending  their 


own  administration  of  anaesthetics.  And  not  only 
hospital  men,  but  undergraduates  as  well,  must  be 
thoroughly  taught  the  art  of  administering  anaes- 
thetics, including  its  niceties  and  its  special  means 
of  making  anaesthesia  as  safe  as  it  can  be  made. 


THE  ULTRAMICROSCOPE. 

The  ordinary  combination  of  lenses  and  illumin- 
ating apparatus  with  which  modern  compound 
microscopes  are  equipped  has  the  power  of  resolv- 
ing structural  elements  of  a  given  body  down  to  a 
fineness  of  one  quarter  of  a  micron.  Below  this  it 
is  impossible  to  resolve  the  details  of  structure  with 
the  optical  apparatus  now  generally  used.  Sieden- 
topf  {Journal  of  the  Royal  Microscopical  Society. 
October,  1903)  showed  by  experiments  with  gold 
ruby  glass  that  it  was  possible  to  demonstrate  de- 
tails of  structure  in  bodies  otherwise  apparently 
structureless,  provided  the  average  of  the  single 
particles  was  no  smaller  than  half  a  wave  length. 
Such  particles  were  termed  "ultramicroscopic." 

For  the  purpose  of  rendering  these  ultramicroscopic 
objects  visible,  a  method  of  dark  ground  illumination 
has  been  devised  by  which  the  axis  of  the  illumin- 
ating rays  of  light  is  at  right  angles  to  the  axis  of 
the  rays  dift'racted  upward  into  the  microscope. 
Furthermore,  the  cones  of  light  must  be  of  such  di- 
mensions that  no  part  of  the  one  overlies  any  part 
of  the  other.  In  that  manner  all  reflections  in  the 
condenser  are  made  harmless  and  no  stray  light  en- 
ters the  objective.  With  this  apparatus  particles 
have  been  demonstrated  in  all  turbid  or  colloidal 
solutions,  fixed  or  fluid,  and  in  gold,  silver,  and 
copper. 

For  the  purpose  of  bringing  bacteria  which  had 
formerly  resisted  all  attempts  at  direct  examination 
into  view,  a  black  spot  was  placed  on  the  anterior 
surface  of  the  front  lens  of  the  ordinary  objective, 
after  it  had  been  ground  flat.  By  this  device  the 
cones  of  light  do  not  need  to  be  at  right  angles  to 
each  other,  but  preparations  of  bacteria  may  be 
mounted  in  the  ordinary  way  for  examination. 
Siedentopf  subsequently  devised  a  paraboloid  con- 
denser, which  takes  the  place  of  the  regular  Abbe 
condenser  in  the  substage  apparatus  of  the  micro- 
scope, and  allows  of  the  examination  of  ultramicro- 
scopic particles  with  a  minimum  of  apparatus  and 
inconvenience.  It  is  necessary  to  employ  an  incan- 
descent gas  light,  an  arc  light,  or  the  direct  rays  of 
the  sun  for  illumination  of  the  objects  examined. 
In  medicine  the  specific  use  of  dark  ground  illumin- 
ation is  for  the  examination  of  the  Treponema  pal- 
lidum and  other  spirochnetes  and  in  the  search  for 
the  microorganismal  causes  of  diseases  of  unknown 
aetiology. 


^lay  I,  1909.] 


XEIVS  ITEMS. 


dittos  Ittms. 

Changes  of  Address. — Dr.  Carl  Beck,  to  37  East  Sixty- 
first  Street,  New  York. 

Dr.  Adolph  Goldhammer,  to  208  West  I22d  Street,  New- 
York. 

Dr.  C.  C.  Page,  to  122  Waverly  Place.  Xew  York. 

Dr.  L.  M.  Kommel,  to  717  Union  Avenue,  Xew  York. 

Dr.  Gerard  Kasper,  to  714  Macon  Street.  Brooklyn.  N.  Y. 

The  Annual  Banquet  of  the  Northern  Medical  Asso- 
ciation of  Philadelphia  was  held  on  Thursday  evening, 
April  29th,  at  the  Hotel  Walton.  The  guests  of  honor  were 
Dr.  Henry  W.  Rihl,  Dr.  Thomas  Shriner,  and  Dr.  Charles 
K.  Mills,  ex-presidents  of  the  association. 

Hookworm  Disease. — Dr.  Charles  \Vardell  Stiles,  of 
the  United  States  Public  Health  and  Marine  Hospital  Ser- 
vice, delivered  a  lecture  on  the  Biolog>%  Treatment,  and 
Prevention  of  Hookworm  Disease  at  a  meeting  of  the 
Richmond.  Va..  Academy  of  [Medicine  and  Surgery  held  on 
Tuesday,  April  27th. 

Vacancy  in  the  West  Side  German  Dispensary. — The 
position  of  fir^^t  assistant  and  chief  of  clinic  at  the  night 
genitourinary  clinic  of  the  West  Side  German  Dispensary, 
328  West  Forty-second  Street.  Xew  York,  is  now  vacant. 
Applications  should  be  sent  at  once  to  Dr.  A.  L.  ^^'olbarst, 
105  East  Xineteenth  Street.  Xew  York. 

The  Necessity  of  Teaching  Legal  Matters  in  Medical 
Colleges  was  the  topic  chosen  for  discussion  at  the  April 
27th  meeting  of  the  ^ledicolegal  Society  of  Philadelphia. 
Dr.  D.  J.  McCarthv  read  a  paper  on  the  subject,  and  a 
general  discussion  followed  which  was  participated  in  by 
prominent  members  of  the  medical  and  legal  professions. 

The  Glover  C.  Arnold  Surgery  Prize. — Announcement 
is  made  that  the  widow  and  daughters  of  the  late  Dr. 
Glover  C.  Arnold  have  made  a  gift  of  S2.000  to  the  Uni- 
versitj-  and  Bellevue  Medical  College,  the  annual  income 
of  which  js  to  constitute  a  prize  to  be  awarded  to  the  mem- 
ber of  the  graduating  class  who  stands  highest  in  surgery. 

The  University  of  Pennsylvania  Alumni  Association 
of  the  Juniata  Valley  held  its  annual  reunion  at  Altoona, 
Pa.,  on  Thursday.  April  22d.  Dr.  T.  B.  Carnett.  Dr.  George 
Fetterolf.  Dr.  Brooke  M.  Anspach.  Dr.  D.  J.  McCarthy, 
Dr.  Charles  A.  Fife,  and  Dr.  J.  Packard  Laird,  of  Philadel- 
phia, conducted  clinics  at  the  Altoona  Hospital  during  the 
meeting. 

Dr.  Bainbridge  to  Lecture  on  Cancer.-;-Announcement 
is  made  by  the  governors  of  the  Xew  York  Skin  and  Can- 
cer Hospital  that  the  fifth  annual  lecture  on  malignant  dis- 
ease will  be  delivered  by  Dr.  William  Seaman  Bainbridge 
in  the  out  patient  hall  of  the  hospital  on  Wednesday  after- 
noon. May  I2th.  at  4:15  o'clock.  The  lecture  will  be  free 
to  the  medical  profession. 

Opposition  to  the  Establishment  of  a  Tuberculosis 
Hospital  on  Staten  Island. — At  a  meeting  of  the  Xew 
York  Board  of  Alderman,  on  April  27th.  the  Staten  Island 
member;  of  the  board  protested  against  the  appropriation 
of  $1,350,000  corporate  stock  for  the  Sea  View  Hospital 
for  Consumptives  at  Richmond,  and  e.xpressed  their  disap- 
proval of  the  plan  of  establishing  such  a  hospital  on  Staten 
Island. 

New  Chelsea  Hospital  Opened. — The  new  hospital  on 
Powderliorn  Hill.  Chelsea.  Ma-;-.,  has  been  completed  and 
is  now  occupied  b\-  155  patients,  who  were  transferred  to 
the  new  building  last  week.  There  was  no  formal  opening. 
The  new  hospital  has  accommodations  for  175  patients 
It  was  built  at  a  cost  of  $200,000  and  is  strictly  fireproof 
A  tuberculosis  ward,  with  accommodations  for  18  patient?, 
will  be  established  in  the  near  future. 

Generous  Gift  to  the  University  and  Bellevue  Medical 
College. — Mr.  Andrew  Carnegie  has  donated  $75,000  to 
this  college,  in  commemoration  of  twenty-five  years"  suc- 
cessful work  in  bacteriology-  and  pathology  done  by  the  Car- 
negie Medical  Laboratory.  The  money  will  be  applied  to  the 
•extension  of  the  present  laboratory  building  by  an  addition 
to  it.  whicii  will  face  on  First  Avenue,  the  present  building 
frontnig  on  East  Twenty-sixth  Street.  The  first  floor  of 
the  new  building  will  form  an  addition  to  the  public  clinic, 
which  has  been  so  crowded  this  year  that  patients  have 
been  compelled  to  sit  on  the  stairs  outside,  awaiting  their 
turn  to  be  admitted. 


Contagious  Diseases  in  Chicago. — During  the  week 
ending  April  17,  1909,  there  were  839  cases  of  contagious 
diseases  reported  to  the  Department  of  Health,  as  follo\ys : 
Diphtheria,  107;  scarlet  fever,  132;  measles,  268;  whooping 
cough,  25;  tuberculosis,  102;  pneumonia,  69;  typhoid  fever. 
27;  ciiickenpox,  46;  mumps,  53;  cerebrospinal  fever,  i; 
puerperal  fever,  i ;  erysipelas,  8. 

The  New  Dean  of  Howard  University. — Dr.  Edward 
A.  Ballock  has  been  appointed  dean  of  Howard  University, 
Washington,  D.  C,  to  succeed  Dr.  Robert  Reyburn,  lately 
deceased.  Dr.  Ballock  has  held  the  chair  of  surgery  in  the 
University  for  over  twenty  years,  and  the  honor  was  con- 
ferred upon  him  by  a  unanimous  vote  of  the  medical  fac- 
ulty-. Dr.  D.  F.  Lamb  was  at  the  same  time  elected  vice- 
dean. 

The  Summer  Care  of  Babies. — The  next  meeting  of 
the  Conference  on  the  Care  of  Babies  will  be  held  in  Room 
40,  Department  of  Health  Building,  Fifty-fifth  Street  and 
Sixth  Avenue,  Xew  York,  on  Monday,  May  3d,  at  4  p.  m. 
This  conference  represents  more  than  fifty  public  and  pri- 
vate agencies  for  the  instruction  of  mothers  and  the  care 
of  sick  babies.  Dr.  Walter  Bensel,  of  the  Health  Depart- 
ment, is  chairman  of  the  executive  committee. 

Officers  of  Florida  State  Medical  Association. — The 
following  officers  were  elected  at  the  annual  meeting  of  the 
association  held  recently  in  Pensacola :  Dr.  H.  E.  Palmer, 
of  Tallahassee,  president;  Dr.  C.  P.  Rogers,  of  Jacksonville, 
first  vice-president ;  Dr.  U.  S.  Bird,  of  Tampa,  second  vice- 
president,  and  Dr.  H.  L.  Simpson,  of  Pensacola,  third  vice- 
president ;  Dr.  J.  D.  Fernandez,  of  Jacksonville,  reelected 
secretary-;  Dr.  Charles  E.  Terry,  of  Jacksonville,  reelected 
librarian. 

A  Pavilion  for  Contagious  Diseases  at  the  Buffalo 
General  Hospital. — Contracts  have  been  let  for  the  erec- 
tion of  a  pavilion  at  the  Buffalo  General  Hospital  to  be  used 
for  cases  of  contagious  diseases  which  develop  in  the  hos- 
pital, cases  from  the  outside  not  being  received  indiscrim- 
inatel}-.  The  cost  of  the  new  pavilion  will  be  borne  by 
private  subscription  of  the  trustees  and  their  friends.  Work 
will  be  begun  immediately  and  it  is  expected  that  the  new 
building  will  he  ready  for  occupancy  in  about  si.x  months. 

The  Clinical  Society  of  the  New  York  Throat,  Nose, 
and  Lung  Hospital  will  meet  on  Wednesday  evening. 
May  5th,  at  the  hospital.  229  East  Fifty-seventh  Street. 
Xew  York.  The  programme  will  include  the  demonstra- 
tion of  a  new  pharyngoscope  by  Dr.  Harold  M.  Hays,  and 
a  paper  by  Dr.  E.  M.  Scripture  entitled  The  Treatment  oi 
Stuttering  and  Lisping  by  the  General  Practitioner.  The 
officers  of  this  society  are:  Dr.  S.  Goldstein,  president; 
Dr.  C.  J.  Imperatori.  vice-president :  Dr.  P.  B.  Hough,  sec- 
retary: and  Dr.  J.  A.  Gonzales,  treasurer. 

A  "Symposium"  on  Cancer. — The  programme  pre 
sented  at  the  April  28th  meeting  of  the  Central  Branch  of 
the  Philadelphia  County  Medical  Society  consisted  of  a 
■'symposium"  on  Cancer.  Papers  were  read  as  follows : 
Cancer  Mortalities,  bj-  Dr.  John  A.  !McGlinn;  Some  Condi- 
tions in  the  Growth  of  Tumors,  by  Dr.  Leo  Loeb;  Cancer 
of  the  L'terus,  by  Dr.  Thomas  S.  Cullen,  of  Baltimore ; 
Rontgen  Diagnosis  of  Gastric  Carcinoma,  by  Dr.  George 
E.  Pfahler.  The  discussion  was  opened  by  Dr.  James  M. 
Anders,  Dr.  John  G.  Clark,  and  Dr.  H.  S.  Wieder. 

The  Canadian  Association  for  the  Prevention  of 
Tuberculosis  will  hold  its  ninth  annual  meeting  in  Ham- 
ilton, Ont..  on  May  19th  and  20th,  under  the  patronage  of 
His  Excellency  the  Governor  General.  The  local  arrange- 
ments are  in  the  hands  of  a  committee  appointed  by  the 
Hamilton  Health  Association,  who  have  prepared  an  inter- 
esting programme  and  have  made  arrangements  for  the 
entertainment  of  the  visiting  members  and  their  friends. 
Among  the  speakers  will  be  Dr.  J.  George  Adami.  of  Mon- 
treal, and  Dr.  William  C.  White,  of  Pittsburgh,  Pa 

Endowment  Fund  of  the  Mary  Gates  Hospital. — It 
was  announced  recently  that  Mr.  John  W.  Gates  had  made 
arrangemeirts  for  the  erection  and  equipment  of  a  hospital 
at  Port  Arthur,  Texas,  as  a  memorial  to  his  mother,  who 
died  at  that  place  a  short  time  ago.  In  endowing  this  hos- 
pital Mr.  Gates  has  adopted  a  novel  method.  He  will  start 
the  fund  with  $500,000,  and  will  add  to  it  each  year  2  per 
cent.  Qf  his  net  profits  from  oil,  which,  it  is  said,  will 
amount  to  from  $2,500  to  $5,000.  Plans  for  the  hospital 
have  been  accepted,  and  the  work  of  construction  will  he 
l)egun  in  a  few  weeks. 


914 


NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


The  Health  of  Pittsburgh.— During  the  week  ending 
April  17,  1909.  the  following  cases  of  transmissible  diseases 
w  ere  reported  to  the  Bureau  of  Health :  Chickenpox,  9 
cases,  0  deaths ;  typhoid  fever,  20  cases,  2  deaths ;  scarlet 
fever,  10  cases,  4  deaths ;  diphtheria,  9  cases,  i  death ; 
measles,  24  cases,  i  death ;  whooping  cough,  ,36  cases,  2 
deaths;  pulmonary  tuberculosis  47  cases,  17  deaths.  The 
total  deaths  for  the  week  numbered  i6g,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death  rate 
of  15.55      1  thousand  population. 

The  Traveling  Tuberculosis  Exhibition  of  the  Com- 
mittee on  the  Prevention  of  Tuberculosis  of  the  New  York 
Charity  Organization  Society  w'as  opened  on  April  26th.  in 
the  new-  office  building  at  Fourteenth  Street  and  Fifth 
Avenue.  This  exhibit  is  a  part  of  the  international  tuber- 
culosis exhibition  shown  recently  in  the  American  Museum 
of  Natural  History,  New  York,  and  later  in  Philadelphia. 
The  exhibition  is  open  daily  from  9  a.  m.  to  7  p.  m.,  and 
some  one  is  on  hand  at  all  times  to  answer  questions  and 
demonstrate  the  various  features  of  the  exhibit. 

Surgeon  Wanted  at  Bellevue  Hospital. — Announce- 
ment is  made  l)y  the  board  of  trustees  of  Bellevue  and  Al- 
lied Hospitals  tl'.at  an  attending  surgeon  is  wanted  in  the 
Fourth  Division  of  Bellevue  Hospital.  Applications  should 
be  sent  at  once  to  Dr.  Cyrus  J.  Strong,  secretary  of  tlie 
medical  board,  60  West  Seventy-fifth  Street,  New  York. 
It  is  also  annoimced  in  this  connection  that  a  rule  has  beep 
adopted  by  the  trustees  of  the  hospital  in  accordance  with 
which  hereafter  no  one  occupying  the  position  of  attending 
physician  or  surgeon  in  the  Fourth  Division  shall  be  at  lib- 
erty to  affiliate  himself  with  any  of  the  three  colleges  (Co- 
lumbia, Cornell,  New  York  University)  now  having  teach- 
ing connections  at  Bellevue  Hospital. 

Connecticut  Hospital  Allowances. — .\  bill  was  re- 
cently passed  in  Connecticut  carrying  hospital  appropria- 
tions as  follows:  Bridgeport  Hospital,  $15,000;  Danbury 
Hospital,  $10,000;  Day-Kimball  Hospital,  $6,000;  Gener  al 
Hospital  Society  of  Connecticut,  $20,000;  Grace  Hospital 
Society,  $10,000;  Hartford  Hospital,  $20,000;  Litchfield 
County  Hospital,  $6,0G0;  Meriden  Hospital,  $6,000;  Alid- 
dlesex  Hospital.  $6,000;  New  Britain  General  Hospital 
$10,000;  St.  Vincent's  Hospital,  of  Briageport,  $15,000; 
Stamford  Hospital,  $10,000;  Norwalk  Hospital,  $10,000; 
St.  Francis's  Hospital,  $20;000;  St.  Joseph's  Hospital,  of 
Willimantic.  $5,000. 

Infectious  Diseases  in  New  York: 

/IV  (/;v  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folloiving  statement  of  nexv 
eases  and  deaths  reported  for  the  fn'o  zi'eeks  ending  April 
24,  igog: 

.  .\pril  1 7  ,  .\pril  24  , 

Cases.     Deaths.     Cases.  Deaths. 

Tuberculosis  pulmonalis    601  201  578  211 

Diphtheria    316  41  319  44 

Measles   1,224  45       1.274  47 

Scarlet   fever    379  J3         297  17 

Smallpox   

Varicella    147  •  ■  '9' 

Typhoid  fever    17  3  26  4 

Whooping  cough   63  8  84  4 

Cerebrospinal  meningitis    11  10  8  3 

Total   2,758         331       2,777  330 

The  Fund  for  Dr.  Carroll's  Widow. — At  a  stated  meet- 
ing of  the  Mcflical  Society  of  the  County  of  New  York, 
held  at  the  New  York  Academy  of  Medicine  last  Monday 
evening.  Captain  Joseph  Siler.  of  the  Medical  Corps,  U.  S. 
Army,  on  the  invitation  of  President  Houghton,  stated  cer- 
tain facts  concerning  the  fund  which  is  being  raised  by 
subscription  among  medical  men  to  pay  off  the  mortgage 
on  the  home  left  by  Dr.  James  Carroll,  who  died  from  the 
effects  of  yellow  fever  brought  on  by  experimental  inocu- 
lation in  Cuba.  Mrs.  Carroll,  who  was  left  with  seven 
children,  has  been  granted  a  pension  of  $125  a  month  by 
congress,  but  this  income  is  not  sufficient  to  enable  her  to 
pay  instalments  on  a  mortgage  of  $7,000  on  the  home 
bought  by  Dr.  Carroll  shortly  before  his  death.  The  offi- 
cers of  the  Medical  Corps  have  undertaken  to  raise  this 
sum  by  subscription,  and  so  far  over  $3,000  has  been  sub- 
scribed. Dr.  Siler  said  that  small  individual  subscriptions 
would  be  welcome,  as  it  was  the  desire  of  the  corps  to 
make  the  subscription  as  widespread  as  possible,  but  to 
confine  it  to  the  medical  profession.  The  censors  of  the 
society  were  instructed  by  vote  to  make  a  suitable  dona- 
tion to  the  fund,  the  amount  being  left  to  their  discretion. 


A  Public  Health  Conference  in  Chicago. — .\  confer- 
ence for  the  purpose  of  discussing  matters  relating  to  pub- 
lic health  was  held  at  the  University  of  Illinois  on  April 
23d,  under  the  auspices  of  the  president  of  the  University 
of  Illinois,  Dr.  Edmund  J.  James,  and  the  president  of  the 
Illinois  State  Board  of  Health.  Dr.  George  W.  \Vebster. 
Professor  William  T.  Sedgwick,  of  the  Massachusetts  In- 
stitute of  Technology,  was  present  and  took  part  in  the 
discussion.  During  the  week  Professor  Sedgwick  deliv- 
ered six  lectures  on  science  in  the  service  of  public  health. 
Scientific   Society   Meetings   in   Philadelphia   for  the 

Week  Ending  May  8,  1909: 
MoxD.w,  May  jd. — Philadelphia  Academy  of  Surgery;  Bio- 
logical and  ^Microscopical  Section,  Academy  of  Nat- 
ural-Sciences ;  West  Philadelphia  Medical  Association; 
Northwestern  Medical  Society. 
Tuesday,  May  4th. — Academy  of  Natural  Sciences ;  Phila- 
delphia Medical  E.xaminers'  Association ;  Wills  Hos- 
pital Ophthalmic  Society. 
Wednesd.w,  May  jth. — College  of  Physicians. 
Thursday,  May   6th. — Obstetrical   Society;  Germantown 
Branch,  Philadelphia  County  Medical  Society;  Section 
Meeting,  Franklin  Institute ;  Delaware  Valley  Ornith- 
ologists' Club. 

Friday,  May  ytli. — American  Philosophical  Society;  Ken- 
sington Branch,  Philadelphia  County  Medical  Society. 

The  American  Proctological  Society  will  hold  its 
eleventh  annual  meeting  in  Atlantic  City,  N.  J.,  on  June  7th 
and  8th.  The  headquarters  and  place  of  meeting  will  be 
Haddon  Hall,  and  the  medical  profession  is  invited  to  at- 
tend the  sessions.  The  programme  includes  twenty-si.x  papers 
on  subjects  relating  to  proctology  by  w'ell  known  specialists 
in  that  branch  of  medicine,  and  the  meeting  promises  to  be 
both  interesting  and  instructive.  Further  information  re- 
garding the  meeting  may  be  obtained  from  the  secretary  of 
the  society.  Dr.  Lewis  H.  Adier,  Jr.,  1610  Arch  Street. 
Philadelphia.  Dr.  George  B.  Evans,  of  Dayton,  Ohio,  is 
president.  Dr.  John  L.  Jelks,  of  ]\Iemphis,  Tenn.,  is  vice- 
president,  and  the  executive  council  consists  of  the  follow- 
ing members :  Dr.  .\.  Bennett  Cook,  of  Nashville.  Tenn., 
chairman ;  Dr.  George  B.  Evans,  of  Dayton,  Ohio ;  Dr. 
Samuel  T.  Earle,  of  Baltimore;  and  Dr.  Lewi<  H.  .Vdler, 
Jr.,  of  Philadelphia. 

Gifts  and  Bequests  to  Charity. — The  Episcopal  Hos- 
pital of  Philadelphia  has  received  a  gift  of  $25,000  from  a 
person  whose  name  is  withheld  from  publication  by  request. 

A  check  for  $20,000  has  been  received  from  the  Count 
and  Countess  Szechenyi  to  be  added  to  the  building  fund' 
of  the  Hungarian  Home  in  New  York  City. 

By  the  will  of  Charles  E.  Ellis,  the  millionaire  traction 
magnate,  who  died  in  Philadelphia  on  April  6th,  the  Pres- 
byterian Flospital.  of  Philadelphia,  will  receive  $10,000  to 
endow  a  private  room ;  the  Sanatorium  for  Children  at  Red 
Bank  will  receive  $500  yearly;  and  about  $3,000,000  will  be 
devoted  to  the  endowment  of  the  Charles  E.  Ellis  College 
for  the  Education  of  Fatherless  Girls. 

Mrs.  H.  E.  Frederick,  of  Montpelier,  Ohio,  ha^  donated 
a  site  for  the  new  hospital  which  is  being  planned  by  the 
^Montpelier  Hospital  .\ssociation.  It  is  hoped  that  suffi- 
cient funds  will  be  collected  to  enable  them  to  begin  work 
on  the  building  this  fall. 

The  Mortality  of  Chicago  for  the  week  ending  April 
17,  1909,  was  higher  than  it  has  been  for  more  than  a  year. 
The  total  number  of  deaths  reported  was  735.  which  was- 
68  more  than  for  the  preceding  week  and  108  in  excess  of 
the  number  reported  for  the  corresponding  period  in  1908. 
The  increase  in  the  total  mortality  was  wholly  among 
adults,  the  number  of  deaths  of  persons  under  tw-enty 
years  of  age  being  in  fact  fifteen  less  than  in  the  corre- 
sponding period  a  year  ago.  Of  the  principal  causes  of 
death,  pneumonia  heads  the  list,  there  being  154  deaths 
from  this  disease.  Tuberculosis  was  second  in  order  of 
highest  mortality  with  83  deaths,  69  of  which  were  due  to 
the  pulmonary  form.  The  munber  of  deaths  from  chronic 
diseases  was  also  unusually  high,  there  having  been  81 
deaths  from  heart  diseases,  52  from  Bright's  disease,  and 
36  from  cancer.  Other  important  causes  of  death  were : 
Diphtheria,  11  deaths;  scarlet  fever,  6  deaths;  measles,  5 
deaths ;  whooping  cough,  2  deaths ;  influenza,  4  deaths ; 
typhoid  fever.  6  deaths ;  diarrhceal  diseases,  50  deaths,  of 
which  48  were  under  two  years  of  age;  nervous  diseases, 
19  deaths ;  apoplexy,  13  deaths ;  bronchitis,  2  deaths ;  vio- 
lence, 61  deaths,  of  which  14  were  suicides. 


-May  I,  1 909. J 


NEWS  ITEMS. 


Officers  of  the  American  Society  of  Tropical  Medi- 
cine.— At  the  annual  meeting  of  the  societi-,  held  in 
Washington  on  April  loth,  the  following  officers  were  elect- 
ed for  1909-1910:  President,  Dr.  William  C.  Gorgas,  of 
Ancon,  Canal  Zone;  vice-presidents,  Dr.  William  S.  Thayer, 
of  Baltimore,  and  Dr.  Rudolph  Matas,  of  New  Orleans ; 
treasurer,  Dr.  Charles  Lincoln  Fnrbush,  of  Philadelphia ; 
secretary,  Dr.  John  M.  Swan,  of  Philadelphia ;  assistant 
secretary,  Dr.  Edward  R.  Stitt,  of  Washington;  councillors, 
to  serve  for  two  years,  Dr.  Ramon  Guiteras  and  Dr.  James 
Ewing.  of  New  York.  Dr.  William  S.  Thayer,  of  Balti 
more,  and  Dr.  James  M.  Anders,  of  Philadelphia,  wers 
elected  managers  of  the  International  Society  of  Tropical 
Medicine. 

Insanity  Increasing  in  New  York  State. — According 
to  the  Sixteenth  Annua!  Report  of  the  State  Charities  Aid 
Association  to  the  State  Commission  in  Lunacy,  which  has 
just  been  issued,  the  total  number  of  insane  persons  in  the 
State  hospitals  and  licensed  private  asylums  in  New  York 
State  on  October  i,  1908.  was  30,507,  an  increase  of  1,414 
over  the  previous  jear.  These  figures  represent  the  largest 
annual  increase  in  the  number  of  insane  persons  in  the  his- 
tory of  the  State,  the  average  annual  increase  during  the 
past  ten  years  being  741.  Of  the  total  number  of  in- 
sane persons,  28,399  were  in  the  thirteen  State  institutions. 
1,073  iri  the  hospitals  for  ihe  criminally  insane  at  Matteawan 
and  Dannemora,  and  1,035  in  licensed  private  asylums.  The 
capacity  of  the  State  hospitals  is  considered  to  be  27,346. 
making  a  total  excess  of  census  over  capacity  of  1,052.  It 
is  feared  that  this  overcrowding  will  be  likely  to  be  in- 
creased rather  than  be  diminished,  as  the  total  number  of 
beds  W'hich  will  be  available  with  the  completion  of  the 
buildings  now  under  construction  is  less  than  500,  and  it  is 
hoped  that  the  legislature  of  1909  will  see  fit  to  make  ad- 
ditional provision  for  the  insane  of  New  York. 

Vital  Statistics  of  New  York. — The  total  number  of 
deaths  reported  to  the  Department  of  Health  of  the  City 
of  New  York  during  the  week  ending  April  17,  1909,  was 
1,705,  as  against  1,544  for  the  corresponding  period  in  1908. 
The  annual  death  rate  in  a  thousand  population  was  19.48 
for  the  whole  city,  and  for  each  of  the  five  boroughs  it  was 
as  follows:  Manhattan,  20.41:  the  Bronx,  19.49;  Brooklyn, 
18.20;  Queens, "16.19;  Richmond,  27.43.  The  death  rate  for 
the  corresponding  week  in  1908  was  18.21.  The  high  death 
rate  which  has  prevailed  for  the  past  few  weeks  has  been 
largely  due  to  the  prevalence  of  diseases  of  the  respiratory 
system.  During  the  week  ending  April  17th  there  were  201 
deaths  from  pulmonarj'  tuberculosis.  27  from  bronchitis,  191 
from  pneumonia,  168  from  bronchopneutnonia,  41  from 
diphtheria  and  croup,  and  19  from  influenza.  Other  im- 
portant causes  of  death  were:  Contagious  diseases,  113 
deaths ;  diarrhoeal  diseases,  92  deaths,  of  which  43  were  un- 
der five  years  of  age;  Bright's  disease,  128  deaths;  organic 
heart  diseases,  151  deaths,  and  cancer,  ,65  deaths.  There 
were  81  violent  deaths,  of  which  17  were  suicides,  7  homi- 
cides, and  57  due  to  accidents.  There  were  116  still  birthb. 
Five  hundred  and  ninety-two  marriages  and  2,250  births 
were  reported  during  the  week. 

Meetings  of  State  Medical  Societies  to  be  Held  in  May: 

Arizona  Medical  Association — Prescott,  May  19th  to  20th. 
Arkansas  Medical  Society — Pine  Bluff,  May  i8th  to  21st. 
Connecticut  Medical  Societj- — Hartford,   Alav  26th  and 
27th. 

Illinois  State  Medical  Society — Quincy,  May  i8th  to  20th. 
Iowa  State  IMedical  Society — Dubuque,  'May  19th  to  21st. 
Kansas  Medical  Society — Emporia,  May  5th,  6th,  and  7th. 
Louisiana  State  Medical  Societv — New  (Orleans,  Mav  4th, 
5th,  and  6th. 

Missouri  State  Medical  Association — Jefferson  City,  ^lay 
i8th  to  20th. 

Montana  State  ^ledical  Association — Missoula,  May   . 

New  Hampshire  Medical  Societj- — Concord,  May  13th 
and  14th. 

Nebraska  State  Medical  Association — Omaha,  Mav  4th, 
5th,  and  6th. 

North  Dakota  ^Medical  Association — Fargo,  Mav  13th 
and  14th. 

Ohio  Stale  Medical  Association — Cincinnati,  May  5th, 
6th.  and  7th. 

Oklahoma  State  Medical  Association — Oklahoma  City, 
May  nth.  12th,  and  13th. 

State  Medical  .Association  of  Texas — Galveston,  May 
I  ith.  I2th.  and  13th. 


The  Official  Call  for  the  Pharmacopoeial  Convention 

has  been  issued  by  Dr.  Horatio  C.  Wood,  as  president.  The 
convention  will  meet  in  Washington,  D.  C.,  on  May  10, 
1910.   It  will  be  composed  of  delegates  from  the  bodies  rep- 
resented at  the  previous  convention,  and  from  all  medical 
and  pharmaceutical  colleges,  whether  incorporated  or  affil- 
iated with  universities,  all  State  medical  and  pharmaceuti- 
cal associations,  the  American  Medical  Association,  the 
American     Pharmaceutical     Association,    the  American 
Chemical  Society,  the  Army,  the  Navy,  and  the  Marine 
Hospital  Service  of  the  United  States.    Each  body  entitled 
to  representation  must  submit  in  advance  of  the  date  of 
meeting  a  proper  evidence  of  their  eligibility  and  of  the 
proper  authorization  of  their  delegates.  Correspondence 
should  be  addressed  to  Dr.  Murray  Gait  Motter,  secretary 
of  the  Board  of  Trustees  of  the  U.  S.  Pharm.acopoeial  Con- 
vention, 1841  Summit  Place,  Washington,  D.  C. 
Society  Meetings  for  the  Coming  Week: 
MoxD.w,  May  3d.— The  German  Medical  Society  of  the 
City  of  New  York;  Utica,  N.  Y.,  Medical  Library  As- 
sociation ;  Niagara  Falls,  N.  Y.,  Academy  of  Medicine 
(annual)  ;  Practitioners'  Club,  Newark,  N.  J.  (annual;  , 
Hartford,  Conn.,  IMedical  Society. 
TvzsB.w,  May  4?/?.— New  York  Academy  of  Medicine  (Sec- 
tion in  Dermatology)  ;  New  York  Neurological  Society ; 
Bulfalo  Academy  of  Medicine  (Section  in  Surgery')  ; 
Ogdensburgh,  N.  Y.,  Medical  Association ;  Syracuse, 
N.  Y.,  Academy  of  Medicine ;  Hudson  County,  N.  J., 
Medical  Association  (Jersey  City)  ;  Medical  Associa- 
tion of  Troy  and  Vicinity;  Hornellsville,  N.  Y.,  Medi- 
cal and  Surgical  Association  (annual)  ;  Long  Island, 
N.  Y.,  Medical  Society;   Bridgeport,  Conn.,  Medical 
Association. 

Wednesday,  May  fith. — Psychiatrical  Society  of  New  York ; 
Society  of  Alumni  of  Bellevue  Hospital,  New  York ; 
Harlem  Medical  Association,  New  York;  Elmira,  N. 
Y.,  Academj'  of  Medicine. 

Thursd.w,  May  6th. — New  York  Academy  of  Medicine, 
Dansville,  N.  Y.,  Medical  Association. 

Frid.\y,  May  7th — New  York  Academy  of  Medicine  (Sec- 
tion in  Surgery)  ;  New  York  Microscopical  Society : 
Gynaecological  Society,  Brooklyn,  N.  Y. ;  Manhattan 
Clinical  Society,  New  York ;  Practitioners'  Society  of 
New  York. 

S.\TURD.\v,  May  <S/,'!.— Therapeutic  Club,  New  York. 

Army  Medical  Corps  Examinations. — The  surgeon 
general  of  the  army  announces  that  preliminary  examina- 
tions for  the  appointment  of  first  lieutenants  in  the  Medical 
Corps  of  the  array  will  be  held  on  July  12,  1909,  at  points 
to  be  hereafter  designated.  Full  information  concerning 
the  examination  can  be  procured  upon  application  to  the 
Surgeon  General,  U.  S.  Army.  Washington.  D.  C.  The 
applicants  must  be  citizens  of  the  United  States,  must  be 
between  twenty-two  and  thirty  years  of  age,  graduates  of 
reputable  medical  schools,  of  good  moral  character  and  hab- 
its, and  have  had  at  least  one  year's  hospital  training  or 
its  equivalent  in  practice.  The  examinations  will  be  held 
concurrently  throughout  the  country  at  points  where  boards 
can  be  convened.  The  recent  act  of  Congress  giving  an 
increase  in  the  Medical  Corps,  together  with  a  larger  regu- 
lar army,  will  permit  of  a  great  variety  of  medical  and 
surgical  work,  besides  affording  ooportunities  for  those 
specially  qualified  to  engage  in  special  work,  such  as  sur- 
gery, sanitation,  chemistry,  pathology,  microscopy,  and  bac- 
teriology. All  appointments  are  made  with  the  rank  of 
first  lieutenant  ($2,000  per  annum).  At  the  end  of  three 
years  the  officer  is  promoted  to  captain  at  $2,400.  which,  at 
the  end  of  five  years'  service,  is  increased  to  $2,640,  etc.  In 
addition  to  this,  officers  are  furnished  with  quart  ?r'^.  med- 
ical attendance  and  medicines  for  themselves  and  their 
families,  the  privileges  of  the  commissary,  mileage  at  the 
rate  of  seven  cents  a  mile  when  traveling  under  orders, 
and  allowed  one  month's  leave  each  year  with  full  pay, 
which  may  be  allowed  to  accumulate  to  a  maximum  of 
four  months ;  also  the  privilege  of  retirement.  These  allow- 
ances are  estimated  to  add  from  $1,200  to  $1,600  to  the 
\esr!v  co"''ir)ei"^ation  in  the  srades  of  first  lieutenant  and 
captain.  Applications  must  be  complete  and  in  possession 
of  the  Adjutant  General  of  the  Army  on  or  before  June  10, 
1909.  Early  attention  is  therefore  enjoined  upon  all  in- 
tending applicants,  and  free  correspondence  with  the  Sur- 
geon General's  Office  is  invited  on  any  subject  connected 
with  the  examination.  There  are  at  present  one  hundred 
and  three  vacancies  in  the  Medical  Corps  of  the  Army. 


gi6 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

At^ril  22,  igog. 

1.  A   Case  of   Infrapubic  Cystotomy.     Three  Cases  of 

Bladder  Tumors,  By  Benjamin  Tenney. 

2.  Intracranial  Haemorrhage  in  the  Newborn, 

By  James  R.  Torbert. 

3.  The  Luys  Urine  Separator.    Second  Report  of  Forty- 

one  Cases,  By  Benjamin  S.  Barringer. 

4.  A  Peculiar  Form  of  Family  Nervous  Disease  Resem- 

bling Multiple  Sclerosis  Occurring  in  Children, 

By   ISADOR  H.  COKIAT. 

5.  Vaccines  in  Typhoid, 

By  W.  H.  Walters  and  C.  A.  Eaton. 

3.  The  Luys  Urine  Separator. — Liarringer  says 
that  there  is  a  class  of  cases  in  which  knowledge 
of  the  condition  of  the  kidneys  is  necessary  and  in 
which  the  ureters  cannot  he  catheterized.  These 
cases  are  those  in  which  (o)  one  or  both  ureteral 
openings  are  obscured  by  cystitis  or  {h)  in  which 
the  rapid  excretion  of  pus  or  blood  into  the  bladder 
clouds  the  bladder  fluid.  These  are  cases  in  which 
the  separator  is  invaluable.  In  children,  the  child's 
model  of  the  separator,  17  F.,  may  be  used  when 
ureteral  catheterisiu  is  impossible  because  of  the 
large  size  of  the  catheterizing  instrument.  Cystitis 
forms  no  barrier  to  the  use  of  the  separator  and  to 
obtaining  an  exact  knowledge  of  the  kidney  condi- 
tions in  such  cases.  The  exception  to  this  is  when 
a  bacteriological  examination  is  necessary,  when 
catheterization  of  the  ureters  is  more  accurate. 
Separation  is  much  simpler  than  ureteral  catheter- 
ization. The  sterilization  of  the  instrument  is  abso- 
lute, as  the  separator  can  be  boiled.  Infection  of 
the  ureters  from  the  bladder  is  excluded.  In 
women  the  pain  or  discomfort  caused  by  the  sepa- 
rator is  about  the  same  as  that  caused  by  the  use  of 
a  simple  examining  cystoscope.  In  men  the  pain  of 
separation  is  slightly  more  marked.  There  are  cer- 
tain classes  of  cases  in  which  the  separator  cannot 
be  used.  They  are  the  following:  i.  Those  in  which 
the  bladder  capacity  is  less  than  20  c.c. ;  2,  those  in 
which  the  urethra  is  not  penetrable  to  the  instru- 
ment ;  and  3,  those  in  which  the  base  or  neck  of  the 
bladder  is  distorted  by  (a)  marked  prostatic  hyper- 
trophy, (h)  extreme  anteversion  or  anteflexion  of 
the  uterus,  (c)  certain  uterine  tumors,  and  (c?) 
marked  cystocele.  Slight  haemorrhage  occurs  in 
some  cases  resulting  from  the  bladder  muscle 
grasping  the  instrument  too  vigorously  and  causing 
trauma  of  the  vesical  mucous  membrane.  This  is 
shown  by  •  I ,  small  blood  clots  along  the  membrane 
when  the  separator  is  withdrawn  :  and  2,  slight  and 
equal  increase  in  the  fresh  red  blood  cells  of  both 
sides.  Any  inaccuracy  of  results  obtained  by  the 
use  of  the  separator  is  to  be  attributed  to  its  em- 
jjloyment  in  unsuitable  cases  or  to  a  failure  to 
recognize  traumatic  haemorrhage  when  it  occurs, 
and  does  not  arise  from  leakage  of  the  urine  from 
one  side  to  the  other. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

1.  Critical  Periods  in  the  Life  of  a  Physician. 

'  Rv  W.  T.  Porter. 

2.  Hysterical  Riindnc^s.  By  The  )I)ore  Dii.i.er. 
.V  The  Blindness  of  Hysteria.  By  H.  Gradi.e. 
4.    Thymol  as  a  Source  of  Error  in  TTcller's  Test  for 

l^rinary  Protein,  By  Wii.i.iam  Weiniierger. 


5-    Experiences  with  the  Oatmeal  Diet  in  Treatment  of 
Diabetes  Mellitus,  By  .Alfred  C.  Croftan. 

6.  Indurative    Headache    ( Schwielenkopfschmerz ) ,  with 

Report  of  '1  hree  Cases,  By  N.  S.  Vawger. 

7.  ihe  Veins  in  Throniboangitis  Obliterans  with  Particu- 

lar Reference  to  Arteriovenous  Anastomosib  as  a 
Cure  for  the  Condition,  By  Leo  Bleugek. 

S.    The  Appropriate  Insignia  for  the  American  Medical 
Association,  By  Samuel  P.  Gerhard. 

2,  3.  Hysterical  Blindness. — Diller  says  that 
hysterical  blindness  may  be  of  sudden  or  gradual 
onset  and  affect  one  or  both  eyes.  It  may  last  from 
a  few  hours  to  several  years,  and  may  be  intermit- 
tent in  character.  In  all  recorded  cases  vision  was 
sooner  or  later  restored,  so  the  prognosis  is  good. 
Blindness,  in  the  absence  of  inflammatory  changes, 
and  with  normal  fundi  and  pupillary  reaction,  is 
strongly  suggestive  of  hysteria.  Sudden  onset  and 
sudden  termination  also  argue  for  this  diagnosis 
and  indeed  hardly  admit  of  any  other.  Among  the 
other  symptoms  accompanying  hysterical  blindness 
have  been  ptosis,  nystagmus,  strabismus,  ard  conju- 
gate deviation.  Commonly,  in  the  recorded  cases, 
there  have  been  other  manifestations  of  hysteria, 
but  amaurosis  may  be  the  sole  expression  of  it. 
Unilateral  hysterical  amaurosis  occurs  rather  more 
rarely  than  the  bilateral  form,  according  to  Kron, 
and  offers  distinctive  different  diagnostic  problems. 
But  bilateral  hysterical  amaurosis  is  almost  as  rare 
an  aff"ection.  Diller  describes  such  a  case  which 
presents  several  interesting  features ;  The  sudden 
blindness,  and  later  sudden  monoplegia  with  loss  of 
pain  sense,  the  loss  of  stereognosis  sense  in  the 
aff'ected  member  due  apparently  to  loss  of  muscular 
and  articular  sensation,  and  contracted  visual  fields 
of  the  tubular  variety.     The  author  reports  two 

other   cases.  Cradle   reports   cases   of  double 

sided,  complete  blindness ;  one  sided,  hysterical 
blindness;  partial  impairment  of  sight  in  otherwise 
npnhysterical  subjects  ;  and  hysterical  exaggeration 
of  congenital  amblyopia. 

5.  Oatmeal  in  Diabetes  Mellitus. — Croftan  re- 
marks that  the  most  brilliant  results  are  obtained 
in  children,  particularly  if  the  oatmeal  cure  is  ad- 
ministered as  soon  as  possible  after  the  diabetes  is 
discovered.  He  has  seen  in  the  last  five  years  three 
cases  of  diabetes  in  children  within  two  or  three 
weeks  after  the  first  symptoms  were  discovered. 
And  these  three  children,  after  a  lapse  of  from 
three  months  to  three  and  one  half  years,  are  alto- 
gether well,  one  on  a  general  diet,  one  on  a  partially 
restricted  diet,  one  (the  most  recent  one)  on  a  diet 
still  incorporating  no  other  carbohydrate  than  oat- 
meal. In  cases  of  diabetes  of  longer  duration  chil- 
dren below  fifteen  years,  in  his  experience,  do  not 
fare  so  well.  Of  eleven  children,  with  a  diabetes 
of  longer  standing,  varying  in  age  from  seven  to 
fourteen  years  (whom  he  either  treated  himself  or 
in  whom  he  advised  the  oatmeal  treatment)  who 
were  fed  on  the  oatmeal  diet  as  a  last  resort  and 
who  had  been  fed  for  periods  of  several  months 
before  with  a  strict  diet,  not  one  is  even  sympto- 
matically  well  to-day.  .Seven  of  them  have  suc- 
cumbed to  coma,  one  to  intercurrent  tuberculosis, 
three  arc  still  alive,  but  none  of  them  sugar  free. 
In  adolescents  and  adnlts  the  results  have,  on  the 
whole,  been  favorable  rather  than  otherwise.  Tn  so 
far  as  the  mild  cases  and  certain  other  cases  are  ex- 


I\Iay  I,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


eluded  a>  altogether  unsuitable  from  this  summary, 
there  remain  only  a  limited  number  of  severe,  usu- 
ally quite  old,  cases  of  diabetes  to  be  considered. 
In  no  adolescent  patient  has  he  seen  permanent 
cessation  of  the  glycosuria  in  the  sense,  namely, 
that  a  general  diet  could  safely  be  resumed.  In  a 
considerable  number  of  the  cases  the  oatmeal  diet, 
however,  produced  a  decidedly  favorable  effect,  and 
when  persisted  in  led  to  a  complete  disappearance 
of  the  sugar,  without  much  acetonuria,  a  result  that 
had  been  impossible  to  obtain  by  any  other  method 
of  feeding ;  associated  with  these  changes  was  often 
a  marked  gain  in  weight  and  strength  and  a  dis- 
appearance of  the  most  distressing  general  symp- 
toms of  severe  diabetes  and  of  certain  of  the  com- 
])lications  (neuralgias,  furunculosis,  constipation, 
itching).  None  of  these  patients  maintained  their 
improvement  when  abundant  proteid  feeding  was 
resumed.  In  so  far  as  continuous  feeding  with  the 
oatmeal  diet  is  impossible,  and  in  so  far  as  in  sev- 
eral of  the  patients  the  oatmeal  ceased  to  be  so 
well  tolerated  after  several  weeks  as  at  first,  this 
improvement  is  only  relative ;  nevertheless,  it  is  an 
improvement,  a  much  to  be  desired  one,  and  one, 
in  liis  judgment,  not  obtainable  by  any  other  means. 
Even  when  the  oatmeal  diet  was  administered  with- 
in two  or  three  weeks  after  the  discovery  of  the 
diabetes  in  adults  or  adolescents  suffering  from 
types  suitable  for  this  treatment,  no  such  good 
results  as  those  occasionally  obtained  in  children 
under  similar  conditions  have  ever,  in  his  experi- 
ence, been  observed. 

6.  Indurative  Headache. — Yawger  states  that 
indurative  headache  is  of  organic  origin,  chronic  and 
usually  paroxysmal,  occurring  in  various  parts  of 
the  head,  and  due  to  infiltrations  or  thickenings  at 
various  points,  chiefly  in  the  muscles  of  the  head 
and  neck.  The  symptoms  are  of  two  groups — those 
of  the  chronic  condition  and  those  of  the  paroxysm. 
In  the  development  of  these  pains,  they  are  at  first 
slight  and  infrequent :  gradually  they  occur  more 
often,  are  of  greater  severity,  and  of  longer  dura- 
tion. Sometimes  they  are  of  the  nature  of  a  dull 
ache  and  almost  constant :  again  thev  may  be  sharp 
in  character.  Local  pressure  often  af¥ords  relief,  but 
if  an  actual  neuritis  is  present  the  suffering  will  be 
intensified  by  pressure.  These  patients  are  very  sus- 
ceptible to  colds,  subject  to  depression  of  spirits  and 
mental  torpor,  and  frequently  there  are  associated 
symptoms  in  other  parts  of  the  body,  some  of  which 
are  gastrointestinal  disturbance,  toxjemic  in  charac- 
ter, painful  spasms  of  the  calf  muscles,  an  occa- 
sional attack  of  nephritic  colic,  myalgia  in  many  dif- 
ferent parts  of  the  body,  and  the  oral  cavity  mav 
give  manifestations  in  the  form  of  oversensitive- 
ness  of  the  teeth  and  pyorrhoea  alveolaris.  It  is 
probable  that  all  these  local  conditions  are  but  dif- 
ferent manifestations  of  the  same  general  disturb- 
ance of  nutrition.  Many  of  these  patients  are  neuras- 
thenic and  it  seems  likely  that  an  excess  of  uric  acid 
or  an  allied  substance  is  concerned  in  the  production 
of  this  condition.  Before  an  attack  of  headache  the 
enlargements  become  swollen  and  sensitive  :  the  pain 
which  develops  a  little  later  may  be  mild  or  agoniz- 
ing. It  occurs  in  various  parts  of  the  head,  de- 
pending on  the  location  of  the  enlargements  :  it  is 
usually  over  the  site  of  these  areas,  but  there  mav  be 


radiation  of  the  pain.    Fever  and  redness  are  absent. 
All  cases  of  headache  should  be  examined  by  forci- 
ble flexions  and  twistings  of  the  neck,  which  may 
bring  out  intense  pain  at  the  insertions  or  along  the 
bodies  of  the  neck  muscles.    The  exploration  may 
be  made  advantageously  during  a  paroxysm,  for  at 
such  a  time  the  swellings  are  more  apparent  and 
their  sensitiveness   greater,  so   that   points  which 
might  otherwise  be  overlooked  are  then  easily  de- 
tected.   The  head  and  neck  should  be  thoroughly 
palpated  in  the  following  manner :    INIoderatelv  firm 
pressure  should  be  employed  over  the  entire  scalp, 
where  thickenings,  irregularities,  indurations,  and 
nodules  may  be  found.    These  parts  may  be  only 
slightly  sensitive  or  they  may  be  exceedingly  so. 
The  same  condition  is  then  sought  at  the  insertions 
of  the  trapezius,  scaleni,  splenii,  and  sternomastoid 
muscle.     Oversensitive    points    are    often  found 
around  the  base  of  the  skull  from  one  mastoid  pro- 
cess to  the  other,  on  the  spinous  processes  of  the 
cervical  vertebras,  and  particularly  on  the  transverse 
processes  of  the  upper  cervical  vertebras.    The  sup- 
raorbital region  is  often  involved,  and  the  temporal 
muscle  may  be  the  seat  of  marked  thickening.  Any 
portion  of  the  scalp  may  be  thickened  or  nodular. 
Chronic  glandular  enlargement  due  to  irritation  pro- 
duced by  proximity  to  these  accumulations  is  some- 
times present,  and  congestive  headache  may  be  pro- 
duced by  the  circulation  being  retarded  through 
pressure  from  these  swellings  on  the  veins.  This 
ceases  after  the  dispersement  of  the  enlargements. 
Internal  medication  does  but  little  good  unless  a 
reconstructive  tonic  is  indicated  by  general  debilitv. 
Potassium  iodide  may  give  some  relief  in  advanced 
cases.    For  a  severe  acute  attack  a  brisk  purgative 
should  be  given,  a  warm  bath,  hot  dry  applications 
to  the  affected  part,  and  repeated  large  doses  of 
'sodium  salicylate,  aspirin,  or  salophen.     The  re- 
moval of  the  thickenings  will  require  from  one  to 
three  months,  and  the  measures  given,  in  the  order 
of  their  efficiency,  are  massage,  vibration,  and  gal- 
vanism.   The  galvanic  current  may  possibly  be  made 
useful,  the  anode  being  placed  over  the  affected  area 
and  the  cathode  at  an  mdifferent  point.  Vibration 
by  means  of  the  electric  vibrator  helps  to  remove 
the  thickenings  and  is  conducive  to  more  rapid  ab- 
sorption, but  should  not  be  used  about  the  head  in 
cases  of  arteriosclerosis.    The  most  effectual  means 
of  removing  these  enlargements  is  without  doubt 
massage.    This  is  at  first  painful,  but  after  a  few 
treatments  the  oversensitiveness  disappears.  Dur- 
mg  these  treatments  a  local  application  of  an  oint- 
ment containmg  methyl  salicylate  and  capsicum  is 
of  some  benefit,  the  former  drug  acting  bv  absorp- 
tion and  the  latter  doing  good  as  a  counterirritant. 
Alas.sage  sometimes  causes  enlargement  and  tender- 
ness of  the  lymph  glands  which  receive  lymph  from 
the  site  of  the  swellings,  but  this  soon  subsides.  In 
all  these  cases  the  bowels  should  be  kept  active  and 
it  is  not  enough  that  they  be  opened  dailv ;  they  must 
be  emptied;  this  may  be  accomplished 'by  the  gen- 
erous use  of  the  laxative  mineral  waters.   The  treat- 
ment is  complete  when  the  swellings  have  disap- 
peared and  tenderness  no  longer  exists. 

7.  Thromboangitis  Obliterans. — Buerger  re- 
marks that  anteriovenous  anastomosis  between  fe- 
moral artery  and  vein  should  be  suggested  in  throm- 


9i8  PITH  OF  CURRENT  LITERATURE. 


boangitis  obliterans  under  the  following  considera- 
tion: I.  The  feasibility  of  performing  a  perfectly 
functionating  anastomosis ;  this  necessitates  a  fairly 
healthy  condition  of  the  femoral  artery  and  vein. 

2.  The  presence  of  proper  conditions  for  the  pro- 
duction of  a  better  vascular  system.  This  includes 
patency  of  the  deep  veins,  patency  of  the  super- 
ficial veins,  at  least  of  the  internal  saphenous  and  its 
tributaries  (the  external  saphenous  not  being  theo- 
retically necessary),  a  good  pulsating  femoral  ar- 
tery, and  a  good  general  condition  of  the  patient. 

3.  The  absence  of  extensive  local  infection  with 
ascending  chronic  interstitial  inflammatory  process. 

4.  The  suffering  of  the  patient.  5.  The  uselessness 
of  the  limb.  6.  The  history  of  the  loss  of  the  other 
limb.  7.  The  absence  of  attacks  of  migrating  phle- 
bitis. 8.  Evidence  of  arterial  occlusion,  such  as  ab- 
sent pulsation  of  anterior  tibial,  posterior  tibial,  and 
popliteal  arteries.  9.  The  presence  of  signs  indi- 
cating that  the  limb  can  not  be  saved  by  other 
means. 

MEDICAL  RECORD 

At>rU  24,  igog. 

1.  Some  Remarks  on  the  Practice  of  Medicine  as  a  Ca- 

reer, By  A.  Jacobi. 

2.  The  Army  Aledical  Service,       By  Edward  L.  Munson. 

3.  The  Public  Health  and  Alarinc  Hospital  Service, 

By  M.  J.  RosENAU. 

4.  The  Insurance  Examiner,       By  Henry  H.  Schroeder. 

5.  The  Railway  Surgical  Service, 

By  Clinton  B.  Herrick. 

6.  Medical  Service  in  the  Merchant  Marine, 

By  James  Francis  Donnelly. 

7.  Institutional  Work  for  Young  Physicians, 

By  William  P.  Spratling. 
iS.    Salaried  Positions  Open  to  Medical  Men  in  the  Larger 
Cities,  •  By  Wilson  G.  Wood. 

9.    Legal  Rights  and  Obligations  of  the  Medical  Practi- 
tioner, By  Arthur  N.  Taylok. 
TO.  Postgraduate  Study  in  Europe, 

By  George  Mannheimer. 
Ti.  State  Medical  Practice  Laws,  By  R.  J.  E.  Scott. 

I  to  9.  Practice  of  Medicine  as  a  Career. — This 
"postgraduate  number"  is  introduced  by  a  general 
article  from  Dr.  Abraham  Jacobi,  and  contains 
articles  on  the  Army  Medical  Service,  the  Public 
Health  and  Marine  Hospital  Service,  the  Insurance 
Examiner,  the  Railway  Surgical  Service,  the  Med- 
ical Service  in  tlie  Merchant  Marine,  Institutional 
Work  for  Young  Physicians,  Salaried  Positions 
Open  to  Medical  Men  in  Larger  Cities;  in  conclu- 
sion is  given  an  article  by  Arthur  N.  Taylor  on 
Legal  Rights  and  Obligations  of  the  Medical  Prac- 
titioner. 

10.  Postgraduate  Study  in  Europe. — Mann- 
heimer says  that  a  knowledge  of  Ercnch  in  France 
and  German  in  Germany  and  Austria  is  indis- 
pensable. Courses  are  given  in  English  in  P)erlin 
and  Vienna,  but  arc  insufficient.  In  Berlin  and 
\'ienna  the  student  selects  his  teacher,  pays  him 
and  their  relations  are  personal.  In  'London,  the 
student  pays  the  school  and  there  are  no  personal 
relations  between  student  ?.nd  instructor.  In  Paris 
the  pliysician  is  cither  the  guest  of  the  professor 
or  an  f)rdinarv  visitor.  In  P)erlin  and  \^icnna,  do- 
cents  cfive  roirular  courses  on  one  subject  gonei'allv 
lasting  one  month.  The  instruction  is  individual 
or  to  a  small  group.  In  London,  the  courses  are 
given  to  classes,  a  general  ticket  being  good  for 


[New  York 
Medical  Journ.\l. 

three  months  or  more,  and  covering  all  subjects 
taught  in  a  number  of  hospitals  and  schools.  Amer- 
icans have  exceptional  opportunities  to  obtain  in- 
terneships  in  German  and  Austrian  clinics.  Paris 
is  best  for  dermatology,  genitourinary  work,  and 
bacteriology.  Berlin  is  best  for  original  research, 
pathology,  diseases  of  the  stomach,  and  metabolism. 
Most  American  physicians  who  go  abroad  for  post- 
graduate instruction  go  to  Vienna  and  Berlin,  con- 
cludes our  author.  Both  cities  have  medical  soci- 
eties composed  of  Americans  who  hold  w'eekly 
scientific  meetings  and  maintain  headquarters  where 
newcomers  can  obtain  information  on  all  subjects 
connected  with  their  stay  and  studies.  Such  infor- 
mation can  be  obtained  by  correspondence.  The 
American  Medical  Association  of  Vienna  is  so  well 
organized  that  it  almost  monopolizes  the  best 
courses,  and  no  time  is  lost  in  traveling  about,  as 
almost  every  scientific  demand  can  be  met  within 
the  confines  of  the  general  hospital.  These  two 
points  and  the  attractiveness  of  life  in  Menna  make 
is  still  the  most  popular  medical  centre  of  Europe 
for  the  American.  This  does  not  imply  that  one 
can  learn  more  in  A'ienna  than  in  Berlin ;  in  fact, 
some  subjects  are  better  represented  in  the  latter 
city.  If  a  man  has  a  good  introduction  to  a  pro- 
fessor in  one  of  the  smaller  university  towns,  and 
intends  to  take  up  the  professor's  specialty,  he 
should  by  all  means  go  to  him,  because  he  is  in 
close  touch  with  the  head,  unhampered  by  scores 
of  visitors.  It  is  a  mistake  to  suppose  that  the  small 
universities  have  a  small  supply  of  material.  They 
all  draw  from  a  large  outlying  district.  A  special 
advantage  of  these  small  towns  is  the  low  cost  of 
living. 

BRITISH   MEDICAL  JOURNAL^ 
April  10.  igog. 

1.  Remarks  on  Paralysis  of  the  Movements  of  the  Trunk 
in  Hemiplegia,  and  the  ]Muscles  Which  Are  .Effected. 

By  Charles  E.  Beevor. 

2.  A  Clinical  Lecture  on  Traumatic  Heart  Disease  and 

Compensation  for  .\ccidents, 

By  Lauristox  E.  Shaw. 

3.  A  Clinical  Lecture  on  the  Treatment  of  a  Case  of  Ex- 

tensive Infantile  Paralysis  by  Operation  and  Appa- 
ratus, By  R.  P.  Rowlands. 

4.  The  Nerve  Sheath  in  the  Causation  and  Treatment  of 

Neuralgia.  By  Robert  M.  Simon. 

5.  Aural  Vertigo,  By  W.  S.  Syme. 

6.  On  Lead  Poisoning  in  Childhood, 

By  A.  Jefferis  Turner. 

7.  A  Case  of  Crossed  Paralx  sis.        By  Gordon  Lambert. 

4.  The  Nerve  Sheath  in  the  Causation  and 
Treatment  of  Neuralgia. — Simon  remarks  that 
morphologically  there  is  no  such  thing  as  a  nerve 
sheath — that  is,  no  separate  structure  which  can  be 
clearly  defined  and  exhibited  ;  but.  while  this  is  no 
doubt  true,  and  nerve  elements  cannot  be  found  ly- 
ing loose  in  a  nerve  sheath  as  a  nut  in  its  shell,  it  is 
true  enough  for  all  practical  purposes  that  there  is 
a  distinct  nerve  sheath.  The  connective  tissue  which 
forms  a  nerve  sheath  is  continuous  externally  with 
the  connective  tissue  outside  it.  and  from  its  inner 
surface  fine  trabecuLx  of  connective  tissue  extend 
to  form  a  protective  covering  between  and  around 
the  myelin  and  axis  cylinders  of  the  nerve  elements. 
Bloodvessels  are  carried  in  all  these  connective  tis- 
sue structures,  and  it  is  upon  the  cons:estion  of  these 
vessels  that  the  occurrence  of  pain  depends.  There 


May  I,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


919 


is  no  lym])h  space  between  the  sheath  and  the  nerve 
elements  proper,  and  for  this  reason  any  material 
overfullness  of  the  vessels  of  the  sheath,  or  a  ver}' 
slight  oedema  around  them,  or  exudation  into  the 
lymph  spaces  in  the  interstices  of  the  sheath  will,  of 
necessity,  cause  an  amount  of  pain  altogether  out 
of  proportion  to  the  pain  which  would  be  caused  b)' 
an  equal  or  vastly  greater  efifusion  outside  and 
around  the  nerve  sheath  itself.  If  this  theory  of  the 
cause  of  pain  is  correct,  remarks  the  author,  the  fail- 
ure of  many  methods  of  treatment  in  some  cases  of 
sciatica  and  brachial  neuralgia  will  be  explained  and 
the  reason  for  the  success  of  other  methods  ren- 
dered probable.  Simon  has  observed  two  patients 
in  whom  the  nerve  sheath  was  opened,  adhesions  be- 
tween the  sheath  and  nerve  broken  down,  and  the 
nerve  stretched  inside  the  sheath.  The  patients 
gained  their  former  health,  as  the  pain  of  the  nerve 
entirely  disappeared.  In  one  case  the  seat  of  pain 
was  the  left  buttock  and  leg,  in  the  other  in  the  arm. 

5.  Aural  Vertigo.  —  Syme  states  that  if  the 
destruction  of  the  vestibular  apparatus  is  at  once 
complete  the  first  attack  of  vertigo  will  be  the  last. 
In  cases  in  which  the  effect  on  the  labyrinth  is  tem- 
porary the  vertigo  passes  ofi,  and  the  ear  may  re- 
turn completely  to  normal.  In  many  cases,  however, 
a  constant  dizziness  remains,  with  recurring  attacks 
of  severe  vertigo,  or  indeed  there  may  be  constant 
vertigo  of  such  severity  that  the  patient  is  quite  in- 
capacitated from  work.  There  may  be  accompany- 
ing tinnitus  and  nausea,  or  these  may  usher  in  an 
attack.  In  most  cases  the  auditory  part  of  the  in- 
ternal ear  is  also  the  seat  of  pathological  changes 
showing  themselves  by  increasing  deafness.  The 
only  termination  that  one  can  hope  for  in  many  cases 
of  severe  vertigo  is  complete  disorganization  of  the 
internal  ear  when  this  distressing  phenomenon  dis- 
appears, but  complete  deafness  results.  In  the  re- 
currences of  vertigo  it  is  not  always  possible  to  de- 
cide on  the  exciting  cause.  Certain  it  is  that  any- 
thing which  leads  to  cerebral  congestion  may  bring 
on  an  attack.  In  cases  in  which  unabsorbed  blood 
pigments  or  the  results  of  exudation  remain  in  the 
labyrinth  the  attack  may  be  referred  to  a  summa- 
tion of  stimuli.  As  regards  treatment,  this  naturally 
has  reference  especially  to  the  underlying  aural  af- 
fection, and  in  giving  a  prognosis  one  has  to  take 
into  consideration  the  possibility  of  the  amelioration 
of  this  condition,  and  also  the  period  of  association 
of  the  deafness  and  vertigo.  In  nonsuppurative  af- 
fections of  the  middle  ear  in  which  the  vertigo  has 
shown  itself  much  later  than  the  deafness  or  tin- 
nitus, it  has  seemed  to  the  author  that  the  treatment 
of  the  aural  condition  was  more  likely  to  lead  to  its 
improvement  or  disappearance.  In  treating  the 
symptom  itself  the  drug  of  most  efficacy  is  quinine. 
Given  a  grain  at  a  time,  it  seems  to  reduce  the  ir- 
ritation of  the  vestibular  nerve,  probably  by  over- 
coming congestive  changes.  On  the  ground  that 
vertigo  is  due  to  anaemia  of  the  labyrinth,  which, 
however,  is  probably  not  as  a  rule  well  founded, 
Lermoyez  suggested  the  use  of  amyl  nitrite.  We 
are  all  aware,  of  course,  that  in  conditions  of  severe 
anaemia  vertigo  is  common,  but  whether  this  is  an 
aural  phenomenon  or  not,  even  when  associated,  as 
it  often  is,  with  tinnitus,  is  a  doubtful  point.  At  the 
same  time  it  is  quite  possible  that  the  actual  cause 


of  vertigo  is  not  so  much  either  congestion  or  anae- 
mia as  the  alterations  in  the  pressure  of  the  en- 
dolymph  which  may  be  brought  about  by  either  of 
these  states.  The  bromides  and  iodides  are  some- 
times useful,  and  pilocarpine,  especially  in  patients 
in  whom  the  aural  condition  is  dependent  on  con- 
genital or  tertiary  acquired  syphilis,  has  sometimes 
seemed  of  value.  Repeated  lumbar  puncture  has 
been  used  with  some,  though  probably  only  with 
temporary  benefit.  Patients  should  be  advised  to 
eschew  alcohol,  tea,  coffee,  and  tobacco,  to  avoid 
as  far  as  possible  mental  excitement  and  loud  noises, 
and  to  keep  the  bowels  acting  well.  During  a  severe 
attack  the  recumbent  posture  should  be  enjoined, 
with  ice  to  the  side  of  the  head.  When  all  other 
measures  fail,  and  when  life  is  made  practically  in- 
tolerable, the  advisability  of  destroying  the  labyrinth 
— at  any  rate  the  static  portion  of  it — should  be 
entertained. 

LANCET 

April  10,  1909. 

1.  Some  Disorders  of  the  Cerebral  Circulation  and  Their 

Clinical  Manifestations  (Goulstonian  Lectures), 

By  Alfred  E.  Russell. 

2.  The  Etiology  of  Acne  Vulgaris  and  Its  Treatment  by 

Vaccines,  By  Alexander  Fleming. 

3.  The  Physiological  and  Therapeutical  Properties  of  the 

Serum  of  Milk  (Lactoserum).     By  Raoul  Blondel. 

4.  The  Treatment  of  Graves's  Disease  with  the  ^lilk  of 

Thyreoidless  Goats.  By  W.\lter  Edmunds. 

5.  Radiography  as  an  Aid  to  the  Diagnosis  of  Diseases 

and  Injuries  of  the  Skull  and  Brain, 

By  Robert  Knox. 

6.  Some  Remarks  on  Tuberculin  Therapy, 

By  A.  J.  Landm.\x. 

7.  The  Cerebrospinal  Fluid  in  General  Paralysis  and  the 

Xervous  Lues.  By  G.  S.  Williamson. 

2.  Acne  Vulgaris  and  Its  Treatment  by  Vac- 
cines.— Fleming  describes  the  acne  bacillus,  as 
seen  in  smears  of  comedones  and  pustules,  as  a  small 
Gram  staining  bacillus  varying  in  length  from  under 
to  3,"  or  4/'  and  about  y?:'-  wide.  The  younger 
forms  stain  evenly  and  darkly,  but  commonl}-  the 
older  forms  show  one  or  more  deeply  stained  dots 
in  their  interior.  These  dots  may  be  situated  at  the 
poles  or  they  may  be  present  along  the  whole  length, 
resenibling  a  chain  of  small  cocci.  The  tenacity 
with  which  these  bacilli  retain  Gram's  stain  is  not 
nearly  so  marked  as  in  the  case  of  the  staphylococ- 
cus, and  it  is  quite  easy  to  so  stain  a  film  that  the 
bacilli  are  decolorized,  while  the  cocci  are  deeply 
stained.  The  arrangement  of  the  bacilli  in  pus  is 
very  irregular,  single  bacilli  are  present,  pairs  are 
common,  especially  arranged  as  a  V,  and  large  ir- 
regular groups  are  almost  invariably  to  be  seen :  the 
microscopical  characters -of  the  bacillus  in  pus  films 
and  also  in  smears  from  cultures  are  very  similar  to 
some  of  the  diphtheroid  bacilli  one  meets  with  in 
superficial  ulcers  and  elsewhere,  and  it  is  very  prob- 
able that  it  is  to  this  group  that  the  bacillus  belongs. 
The  bacilli  are  often  found  inside  the  pus  cells,  and 
the  same  film  may  show  phagocytosis  of  both  bacilli 
and  cocci,  one  may  see  both  taken  up  by  the  same 
cell.  In  the  comedo  the  bacilli  are  in  general  shorter 
and  stouter,  and  stain  evenly,  while  in  the  pustule 
longer  forms  are  seen  with  very  irregular  staining. 
The  author  thinks  that  it  is  definitely  proved  now 
that  in  localized  infection,  when  one  inoculates  the 
patient  with  appropriate  doses  of  a  carefully  prepared 


920 


PITH  UI-  CURRENT  UlERATURli. 


[New  Vork 
Medical  Journal. 


vaccine  derived  froiii  tiie'  infecting  organism,  one 
obtains  a  definite  beneficial  effect.  Very  frequently 
in  treating  a  case  of  acne  with  staphylococcus  vac- 
cine it  is  found  that  there  is  a  definite  improvement 
for  a  time,  then  the  condition  remains  stationary  in 
spite  of  any  modification  in  the  dose  or  character  of 
the  staphylococcic  vaccine.  This  is  exactly  what 
would  be  expected  fpom  a  consideration  of  the  \rdc- 
teriology.  as  it  is  only  in  a  certain  number  of  cases 
that  the  staphylococcus  is  pi-esent,  and  even  when 
present  it  is  not  responsible  for  the  whole  condition. 
W'e  can.  therefore,  divide  cases  of  acne  vulgaris  for 
therapeutical  purposes  into  three  classes.  The  first 
will  consist  of  those  cases  in  which  the  comedo  is 
the  dominant  feature,  with,  also,  some  of  those 
which  have  progressed  further  to  the  indurated  and 
pcjstular  stages.  In  this  class  of  case  the  acne  bacil- 
lus is  the  offending  agent  and  the  staphylococcus  if 
present  at  all  is  playing  a  subordinate  role.  This 
class,  therefore,  may  be  treated  with  a  vaccine  of 
acne  bacillus  alone.  The  second  class  consists  of  a 
large  number  of  the  indurated  and  pustular  varieties 
where  both  staphylococcus  and  the  acne  bacillus  ap- 
pear to  be  playing  an  active  part  in  the  causation  of 
the  iTitlammatory  process.  The  therapeutic  require- 
ments of  this  class  are  best  met  with  a  mixed  vac- 
cine of  staphylococcus  and  acne  bacillus.  The  third 
class  consists  of  those  less  common  cases  where 
there  is  a  more  acute  inflammation,  tending  almost 
toward  a  furuncular  form.  Here  microscopical  ex- 
amination will  show  that  the  staphylococcus  is  the 
chief  offender  and  treatment  should  be  directed  at 
first  against  this  factor,  not  forgetting,  however, 
that  at  the  basis  of  the  condition  there  is  an  acne 
bacillus  infection. 

6.  Tuberculin  Therapy. — Landman  gives  a 
review  of  the  history  of  Koch's  tuberculin.  He  then 
remarks  that  during  the  last  few  vears  there  has 
been  a  considerable  revival  of  interest  in  the  tul^er- 
culin  treatment.  This  has  been  due  in  England 
chiefly  to  the  researches  of  Wright  on  opsonins  and 
the  application  of  his  opsonic  index  determinations 
to  the  treatment  placing  it  in  a  line  with  the  treat- 
ment by  other  vaccines.  Ikit  it  must  not  be  forgot- 
ten tliat  manv  physicians  have  continued  to  use  tu- 
berculin ever  since  its  introduction  quite  independ- 
ently of  Wright's  work  on  the  subject.  The  de- 
tailed method  associated  with  Wright's  name  for 
the  determination  of  the  opsonic  index  is  not  an  es- 
sential part  of  the  therapeutic  a])plication  of  tu- 
berculin. Previously  the  tuberculin  treatment  has 
been  regulated  by  other  clinical  signs,  including 
pulse,  temperature,  patient's  aspect,  local  symptoms 
and  signs,  and  prolonged  experience  justifies  the 
statement  that  these  clinical  signs  will  suffice,  apart 
from  opsonic  index  determinations.  The  complex- 
ity of  the  technique  of  Wright's  method  is  also  an 
insurmountable  difficulty  in  many  cases,  and  detracts 
greatly  from  its  general  utility.  The  margin  of 
error  in  such  a  complicated  process  must  neces- 
sarily be  considerable,  and  this  fact  must  also  be 
taken  into  consideration  in  estinriting  the  practical 
value  of  opsonic  index  determinations.  The  question 
of  the  utility  of  the  method  in  practice  must  there- 
fore still  remain  an  open  one.  Wright's  work,  how- 
ever, has  given  a  fresh  start  to  the  active  immuni- 


zation method  of  the  treatment  of  tuberculosis,  and 
what  we  particularly  owe  to  Wright  is  the  demon- 
stration that  small  closes  of  tuberculin  are  effectual 
and  that  large  ones  are  unnecessary.  The  peculiar 
action  of  the  tubercle  bacillus,  as  shown  by  the 
slowness  and  chronicity  of  the  ksions  which  it  pro- 
duces, the  tendency  to  sjiontaneous  healing  of  tu- 
berculous foci  by  casea'ticn  and  encapsulation,  place 
this  organism  on  a  somewhat  different  footing  from 
the  other  organisms  as  regards  the  process  of  im- 
munization, and  the  dosage  of  tuberculin  may  dif- 
fer from  that  of  the  other  vaccines.  There  is  little 
doubt,  however,  that  in  certain  cases  of  localized  tu- 
berculosis, such  as  lupus,  tuberculous  joints,  glands, 
and  genitourinary  tuberculosis,  improvement  has 
followed  the  use  of  tuberculin  according  to  Wright's 
method.  Dr.  Landman  has  observed  twelve  patients 
and  concludes  that  the  results  cannot  be  said  to 
show  anything  conclusive.  Several  patients  seemed 
to  derive  benefit  from  the  tuberculin  inoculations. 
The  injections  raised  the  opsonic  index  in  several 
cases,  but  the  negative  phase  was  not  at  all  constant. 
It  is  difficult  to  say  whether  the  favorable  results 
observed  might  not  have  been  clue  to  the  open  air 
treatment  alone.  No  harmful  results  were  noticed 
after  the  inoculations  in  one  patient. 

BERLINER  KLINISCHE  WOCH LNSCH Rl FT. 

March  22,  igog. 

1.  Tumor  of  the   Spinal   Cord   Presenting  the  Clinical 

Picture  of  Myelitis, 

By  C.  A.  EwALD  and  R.  Wincklek. 

2.  Bronze  Diabetes  and  Pigment  CirrlTOsis. 

By  M.  SiMMONDS. 

3.  Where  is  the  Portio  Pylorica  ? 

By  J.  W.  Th.  Lichtenbelt. 

4.  The  .Signific.-J.nce  of  the  Form  of  the  Two  Anaesthetic 

Zone.-.,  By  Giuseppe  Calligakis. 

5.  Habitual  Constipation  as  the  Cause  of  Death  in  In- 

fancy, By  Glaserfeld. 

6.  Wassermann's  Reaction  in  Congenital  Syphilis, 

By  Thomsen  and  Boas. 

7.  Thyresol,  a  New  Interna!  Remedy  for  Gonorrhoea. 

By  A.  HiRSCHBERG. 

8.  Ear  I'orceps  and  Little  Rolls  of  Cotton  for  Purulent 

Ears,  By  Sprexger. 

9.  The    -Applicability   of    Bock's    Distinguishing  Stetho- 

scope, By  H.  Bock. 

2.  Bronze  Diabetes  and  Pigment  Cirrhosis. — 

Simmonds  comes  to  the  conclusion  that  the  triad  of 
symptoms  in  bronze  diabetes  is  to  be  ascribed  to  a 
common  cause,  as  a  rule  to  misuse  of  alcohol.  This 
same  poison  causes  the  hiemochromatosis,  the  cir- 
rhosis of  the  liver,  the  changes  in  the  pancreas,  and 
the  diabetes. 

3.  Where  is  the  Portio  Pylorica? — Lichten- 
belt gives  as  his  conclusion  from  the  examination  of 
])atients  iti  a  standing  jxisition  that  the  portio  pylor- 
ica lies  to  the  right  of  the  median  line,  the  pylorus 
under  the  left  portion  of  the  liver. 

5.  Habitual  Constipation  as  the  Cause  of 
Death  in  Infancy. — (llaserfeld  reports  the  case  of 
a  child  that  came  under  ob^^ervation  at  four  months 
of  age  and  died  two  and  a  half  months  later  from 
liabitual  constipation,  or  obstipation,  which  induced 
a  perforating  ulcer  in  the  s]:)lenic  flexure  of  the  de- 
-scending  colon  followed  l\v  dift'use  peritonitis.  The 
coecum,  a.scending  and  transverse  colon  were  di- 
lated. This  case  shows  that  habitual  constipation  in 
infancy  may  result  fatally  and  that  constipation  dur- 


-May  I,  .909.]  FlIH  01-  CUKREXT  LITERATURE. 


ing  the  first  year  of  life  should  be  met  by  energetic 
therapeutic  measures,  the  result  of  which,  and  the 
prognosis,  must  remain  doubtful  as  we  have  no 
means  to  act  directly  upon  the  muscle  of  the  large 
intestine. 

6.  Wassermann's  Reaction  in  Congenital  Syph- 
ilis.— Thomsen  and  Boas  present  the  following 
conclusions  from  their  investigations.  The  examin- 
ation of  the  blood  of  the  infant  for  Wassermann's 
reaction  together  with  the  anatomical  examination 
of  the  umbilical  cord  and  the  placenta  render  pos- 
sible the  distinction  whether  the  child  is  syphilitic  or 
not.  A  positive  Wassermann's  reaction  on  the  part 
of  the  mother  lessens  the  chances  that  the  child  is 
born  health}-.  In  the  organism  of  the  latently  syph- 
ilitic child  there  is  an  increase  during  the  first  month 
cf  the  material  necessary  to  a  positive  \A'assermann's 
reaction  and  the  reaction  may  be  absent  at  birth. 
In  little  children  with  clinical  symptoms  of  congeni- 
tal syphilis  a  positive  Wassermann's  reaction  seems 
to  be  constajitly  present :  this  is  in  contrast  with 
older  people  with  late  hereditary  syphilis.  Possibly 
in  individual  cases  material  which  causes  the  positive 
Wassermann's  reaction  in  the  child  may  pass  the 
l)lacenta  of  the  syphilitic  mother  without  infection 
of  the  child.  Mothers  who  have  borne  syphilitic 
children  are  themselves  to  be  considered  syphilitic 
when  their  blood  gives  a  positive  Wassermann's  re- 
action. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 
March  i>j,  7909. 

1.  Treatment  of  Fractures,  Bj-  Lexer. 

2.  Why  does  Beliring's  Antidiptheritic  Serum  Fail  in  Cer- 

tain Cases?  By  Uffe.xheimer. 

3.  Sterile,  Serous  Pleuritic  Effusion  with  Empyema  of 

the  Pleura  and  Abscess  of  the  Lung, 

By  K6 NIGER. 

4.  A  Simple  Method  of  Estimation  of  the  Diastolic  Blood 

Pressure,  By  Ehret. 

5.  X  Ray  Treatment  of  Malignant  Neoplasms  of  the  Up- 

per Air  Passages,  By  M.\der. 

6.  The  Technique  and  Indications  for  Washing  out  of  the 

Stomach.  By  .Agerox. 

7.  The  Influence  of  the  Ma.x  Spring  at  Diirkheim  upon 

the  Development  of  Rabbits.  By  B.vche.m. 

8.  A  New  Dressing  of  Wire  and  Plaster  of  Paris. 

By  LUXCKEN'BEI.V. 

9.  A  ^lovable  .Apparatus  for  IHumination,  By  L.\xgem.\k. 

10.  A  Simple  Scale  for  Weighing  Qiildren, 

By  HoLZ.\PFEL. 

11.  The  Clinical  Demonstration  of  Blood  in  the  Faeces, 

By  ScHU.M.M. 

12.  The  Clinical  -Demonstration  of  Blood  in  the  F.-eces. 

By  Gehrm-XXX. 

13.  Bradycardia  and  the   Stokes-Adams   Symptom  Com- 

plex (Concluded).  By  Huism.xxs. 

14.  Dr.  Carl  Driver,  By  Wolff. 

15.  Serious  and  Hilarious  Remarks  Concerning  the  Felkc 

Lawsuit.  By  Schmitz.  . 

2.  "Why  does  Behring's  Antidiphtheritic  Serum 
Fail  in  Certain  Cases? — L'ftenheinier  points  out 
that  a  certain  number  of  cases  of  diphtheria  fail  to 
react  to  the  injection  of  the  antidiphtheritic  serum 
and  by  experiment  has  determined  that  the  amount 
of  complement  in  the  organism  has  absolutely  no  re- 
lation to  the  curative  action  of  the  antitoxic  serum 
introduced  to  combat  the  diphtheria  poison.  Diph- 
theria bacilli  from  patients  who  fail  to  respond  to 
the  antitoxine  should  be  cultivated  and  compared  in 
all  ways  with  the  Park-\\'illiams  bacillus. 

3.  Sterile,  Serous  Effusions  with  Empyema  of 
the  Pleura. — Koniger  says  that  with  early  encap- 


sulation of  acute  empyema  of  the  pleura  extensive 
serous  exudates  frequently  appear  in  the  neighbor- 
ing portions  of  the  pleura  which  do  not  communicate 
with  the  focus  of  infection,  are  free  from  bacteria, 
and  contain  many  cells,  particularly  polynucleated 
neutrophile  leticoc}tes  together  with  Ivmphocytes 
and  endothelia,  only  a  small  ntmiber  of  which  show 
similar  degenerative  changes  to  those  of  the  pus 
cells.  These  serous  exudations  are  to  be  looked  upon 
as  the  results  of  reactive  processes  probably  pro- 
duced by  the  toxic  influence  of  acute  purulent  in- 
flammations in  their  neighborhood.  Similar  serous 
exudations  are  to  be  met  with  in  connection  with 
abscesses  and  gangrene  of  the  lung  as  well  as  other 
severe  purulent  processes  in  the  neighborhood  of 
the  pleura.  They  are  of  clinical  importance  because 
they  render  difficult  the  detection  of  the  collection 
of  pus.  but  on  the  other  hand  they  may  serve  as  a 
valuable  diagnostic  aid  through  their  cytological  ex- 
amination, which  may  give  the  indication  of  a  focus 
of  infection  near  by. 

5.  X  Ray  Treatment  of  Malignant  Neoplasms 
of  the  Upper  Air  Passages. — Mader  asserts  that 
X  ray  treatment  is  indicated  in  all  of  those  cases  in 
which  operative  intervention  is  rejected,  or  is  ex- 
cluded as  hopeless,  and  also  in  recurrences  after  op- 
eration. 

13.  Bradycardia  and  the  Stokes- Adams  Com- 
plex.— Huismans  concludes  that  the  brain  cortex 
plays  at  any  rate  an  important  part  in  the  Stokes- 
Adams  complex.  Most  probably  in  the  Stokes- 
Adams  attack  the  vagus  nucleus  is  put  in  an  idio- 
pathic state  of  excitement  and  thereby  the  heart  and 
respiration,  and  at  the  same  time  the  muscles  of  the 
body. 

THE  MILITARY  SURGEON. 
April,  igoQ. 

1.  The  Sanitary  Organization  of  the  Isthmian  Canal  as  it 

bears  upon  Antimalarial  Work, 

By  \\'iLLi.A.M  Cr.wvford  Gorg.a.s. 

2.  Hygiene  of  Torpedo  Boat  Destroyers  in  the  Philip- 

pines, By  Fr.\xcis  Mertox  Muxsox. 

3.  Care  of  the  Chelsea  Refugees,    By  P.\trick  F.  Bltler. 

4.  Iron  Aristol  for  Chronic  Skin  Ulcers, 

By  ]\[.\RK  J.  White. 
5-    Blastomycosis  of  the  Skin  in  the  Philippines. 

By  J.\MES  M.  Ph.\lex  and  Hexrv  J.  Xichols. 

6.  The  Medical  Log  of  the  U.  S.  S.  rirgiiiia  on  the  Cruise 

to  the  Pacific.  By  C.  H.  T.  Lowxdes. 

7.  Mosquito  Bars.  By  George  F.  C.\mpbell. 

8.  Cocaine:  Its  Relation  to  the  ^lilitary  Surgeon, 

By  William  Dc.xlop  Owexs. 

9.  A  Plea  for  Specialism,  By  Edw.^rd  B.  \^edder. 

10.  Sanitary  Service  in  the  Swiss  Army, 

By  Louis  C.  Duxc.^x. 

11.  Note  on  Color  Blindness.        By  Walter  Scott  Hoex. 

12.  The  Origin  and  Beginnings  of  The  Military  Surgeon, 

with  some  Notes  on  the  Life  and  Character  of  its 
First  Editor,  with  Portrait,     By  William  H.  Ames. 

2.    Hygiene  of  Torpedo  Boat  Destroyers. — 

Munson  remarks  that  naval  service  in  the  tropics 
is  not  an  easy  one  under  the  most  favorable  con- 
ditions, and  aboard  destroyers  it  is  one  of  the  hard- 
est experienced  by  the  naval  personnel.  The  heat, 
cramped  quarters,  and  hard  work  wear  out  all  but 
the  strongest  men.  If  it  were  not  for  the  open 
air  life  many  men  would  succumb  in  a  few  months. 
Appreciating  these  conditions,  every  efifort  is  made 
to  preserve  the  health  and  add  to  the  contentment 
of  the  crews.    The  author  gives  a  vivid  description 


(>22 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Jouenal. 


of  the  life  on  these  boats -and  the  precautions  taken 
to  make  the  men  as  healthy  as  possible.  He  con- 
cludes that  it  is  a  far  healthier  life  for  the  men 
to  live  aboard  ship  than  to  be  quartered  ashore  in 
barracks,  as  are  the  crews  of  the  French  destroy- 
ers at  Saigon,  French  Indo-China,  and  has  been 
suggested  for  our  service.  The  increased  exposure 
to  mosquitoes,  hence  greater  opportunity  for  in- 
fection with  malaria  and  dengue,  would  more  than 
counteract  the  greater  comfort  afforded  by  more 
spacious  quarters. 

5.  Blastomycosis  of  the  Skin. — Nichols  ob- 
serves that  in  the  Philippines  a  blastomycotic  infec- 
tion of  the  skin  is  one  of  the  common  skin  diseases. 
It  exists  in  at  least  three  forms,  two  of  which  are 
milder  than  those  seen  in  the  United  States.  It 
is  usually  unrecognized,  in  milder  forms  passing 
as  ringworm  or  some  form  of  dhobie  itch ;  in  se- 
verer forms  as  tuberculosis  or  syphilis.  The  milder 
forms  yield  to  local  antiseptics,  the  more  chronic 
and  severe  only  to  potassium  iodide  internally.  The 
author  concludes  that  further  development  of  the 
subject  will  be  necessary  before  these  forms,  as  well 
as  those  found  in  horses,  in  ulcers,  in  sprue,  and  hill 
diarrhoea,  can  be  definitely  classified. 

6.  The  Medical  Log  of  the  U.  S.  S.  Virginia 
on  the  Cruise  to  the  Pacific. — Lowndes  gives  the 
contents  of  the  medical  log  of  the  Virginia.  We  see 
that  during  the  long  cruise  there  were  treated  in 
the  hospital  four  cases  of  pneumonia ;  one  of  dipth- 
theria ;  six  of  measles ;  two  of  insanity ;  two  of  pul- 
monary tuberculosis ;  three  of  long  drawn  out 
chronic  rheumatic  troubles ;  three  cases  of  hernia, 
needing  operation ;  two  of  syphilis,  in  the  most 
acute  stage  and  highly  contagious ;  making  a  total 
of  twenty-two  cases  that  urgently  needed  hospital 
treatment.  At  no  time  was  the  sea  so  rough  that 
these  patients  could  not  have  been  transported,  and, 
had  the  surgeon  general's  desire  that  a  hospital  ship 
make  the  cruise  with  the  fleet  been  realized,  much 
sufifering  would  have  been  prevented  and  great  ben- 
efit resulted. 

THE  PRACTITIONER. 

April,  igoQ. 

1.  A  Note  on  Local  An;esthesia  in  Regard  to  the  Causa- 

tion of  "Idiopathic"  Paralysis  and  Dilatation  of  the 
Urinary  Bladder.  By  F.  Parkes  Webek. 

2.  The  Treatment  of  Extroversion  of  the  Bladder  by  Im- 

plantation of  the  Ureters  into  the  Rectum, 

By  C.  Arthur  Ball. 

3.  The  Increased  Death  Rate  from  Diabetes,  and  the  Pos- 

sibility of  Preventing  the  Disease,  or  of  Postponing 
its  Onset,  By  R.  T.  Williamson. 

4.  Cancer  of  Tongue,   '  By  Alexander  Don. 

5.  Some  Points  in  the  Treatment  of  Ischiorectal  Abscess 

and  Fistula,  By  P.  Lockhart  Mummery. 

f).    On  Some  Considerations  involved  in  the  Treatment  of 
Mental  Disease,  By  C.  H.  Fennell. 

7.    Acute  Infective  Osteitis,  By  H.  W.  Kaye. 

S.    Rhinological  Treatment  of  Consumptives, 

By  W.  C.  Rivers. 
Q.    Diagnosis  and  Treatment  of  Gonorrhoea, 

By  J.  E.  R.  McDonaugh. 
10.  Chronic  Infantile  Paralysis  Diagnosticated  as  Morbus 
Coxse,  By  Francis  Hernaman-Johnson. 

IT.  The  Operative  Technique  of  a  General  Practitioner, 

By  A.  J.  Fairlie  Clarke. 

3.  Increased  Death  Rate  from  Diabetes. — \\"\\- 
liamson  remarks  that  statistics  show  that  the  death 
rate  from  dial)etcs  niellitus  in  iMigland  and  \\  ales  is 


steadily  increasing.  From  the  annual  reports  of  the 
registrar  general  we  see  that  the  death  rate  from 
diabetes  mellitus  in  England  and  Wales,  in  1866,  was 
thirty-two  per  million  living ;  in  1886,  fifty-nine ;  in 
1906,  it  was  ninety-seven.  Taking  the  records  for 
the  last  twenty  years,  we  find  that,  in  1887, 
there  were  registered  1,750  deaths  from  diabetes 
mellitus;  in  1906,  3,342.  The  death  rate  from  the 
disease  per  million  living  increased  from  sixty-three, 
in  1887,  to  ninety-seven,  in  1906.  The  increase 
was  seen  in  both  males  and  females.  In  1887,  the 
death  rate  from  the  disease  in  males  was  seventy- 
five  per  million  Kving;  in  1906,  it  was  104  per  mil- 
lion. In  females,  the  death  rate  from  the  disease 
per  million  living  was  fifty-one  in  1887,  ninety  in 
1906.  The  risk  of  the  disease  is  greater  after 
thirty  years  of  age.  In  250  private  patients  Wil- 
liamson found  forty-five  under  30  years ;  from  30  to 
40,  thirty ;  40  to  50,  sixty ;  50  to  60,  seventy-two ; 
60  to  70,  thirty-eight ;  70  to  80,  five.  Among  the  Jews 
diabetes  is  much  more  frequently  met  with  than 
among  Christians.  The  highest  death  rate  is  among 
publicans.  Among  jurists  it  is  "three  times  the 
average,  and  higher  than  in  any  other  occupation 
in  the  list,  except  innkeepers."  Among  medical 
men  the  mortality  is  also  high.  The  mortality 
among  chemists  and  druggists  is  high,  but  is  less 
than  among  medical  men.  In  occupations  in  which 
there  is  great  mental  worry,  mental  strain,  or  ex- 
citement, there  appears  to  be  an  increased  risk  of 
diabetes  developing.  The  possibility  of  diabetes 
developing  is  worthy  of  a  thought  in  the  case  of 
men  who  are  working  at  high  pressure,  and  have 
little  time  for  exercise  or  holidays,  and  also  in  the 
case  of  publicans,  who  are  taking  alcoholic 
beverages  in  liberal  quantities.  The  physical  and 
mental  overstrain,  connected  with  the  nursing  of  a 
sick  relative  or  friend  through  a  long  illness,  should 
be  avoided  by  those  who  are  thought  to  have  any 
predisposition  to  diabetes.  In  the  case  of  married 
couples,  if  one  should  sttfifer  from  diabetes,  it  is 
probable  that  the  liability  to  diabetes  in  the  other  is 
very  slightly  increased,  whatever  may  be  the  ex- 
planation. 

4.  Cancer  of  the  Tongue. — Don  states  that 
beyond  the  fact  that  continued  irritation  of  the 
mticous  membrane  and  consequent  ulceration  may 
predispose  to  cancer  in  the  tongue,  there  are  prob- 
ably no  recognizable  precancerotis  stages.  It  is 
either  cancer  or  not  cancer,  but  even  with  the  aid 
of  the  microscope  its  true  nature  may  not  be  evi- 
dent. Predisposing  conditions,  also  irritative,  are 
described  as  leucoplakia,  ichthyosis,  chronic  super- 
ficial glossitis,  etc.  All  warty  growths  and  thick- 
enings of  the  surface,  or  ulcerations,  arc  distinctly 
suspicious,  and  while  they  may  be  syphilitic  and  dis- 
appear with  proper  treatment,  excision  of  a  small 
part  for  diagnosis  is  advisable,  and  shottld  be  in- 
sisted on  in  every  case.  The  author  describes  the 
methods  of  operation,  and  says  that  prognosis  de- 
pends very  much  on  the  condition  of  the  patient, 
and  the  spread  of  the  disease  at  the  time  of  the 
operation.  The  operative  death  rate  in  extensive 
operations  has,  hitherto,  been  excessive,  as  many 
of  the  patients  have  succumbed  to  such  preventable 
causes  as  septic  pneumonia,  local  sepsis,  shock,  and 


May  I,  1 909. J 


PITH  OF  CURREXJ  LITERATURE. 


hiemorrhage.  The  deaths  due  to  those  is  almost 
eighty-five  per  cent.,  while  septic  infection  causes 
more  than  fifty  per  cent,  of  the  immediate  fatalities. 
If  one  considers  that  much  more  extensive  opera- 
tions for  removal  of  tuberculous  glands  can  be 
done  with  an  almost  negligible  mortality,  and  that 
septic  pneumonia  is  rare  after  nose  and  throat 
operations  and  dental  extractions  under  complete 
anaesthesia,  one  is  forced  to  admit  that  a  consider- 
able factor  must  be  the  weakened  condition  and  age 
of  most  of  the  patients  that  submit  themselves  to 
the  surgeon,  and  for  this  the  family  physician  is 
much  to  blame.  With  proper  preparation  of  the 
mouth,  and  good  technique  during  the  operation, 
the  death  rate  should  be  reduced  to  below  twenty 
per  cent,  for  all  operations  offering  a  fair  chance 
of  complete  eradication  of  the  disease,  and  a  much 
smaller  percentage  for  picked  cases. 

7.  Acute  Infective  Osteitis. — Kaye  concludes 
in  his  thesis  for  the  degree  of  D.  M.  that  acute  in- 
fective osteitis  is  an  acute  infection  of  the  nature 
of  a  pyaemia,  which  attacks  the  bones  during  the 
period  of  their  active  growth,  and  especially  the 
diaphysial  side  of  epiphysial  cartilages — partly  be- 
cause of  the  weakness  of  this  juxtaepiphysial  re- 
gion in  virtue  of  its  actual  growth  and  vascularity, 
but  to  a  greater  extent,  because  of  its  special  lia- 
bility to  injury  owing  to  its  peculiar  mechanical 
structure  during  this  period.  The  resulting  disease 
is  seldom  a  pure  periostitis,  osteitis,  or  osteomye- 
litis. In  almost  every  case  the  primary  suppurative 
lesion  is  on  the  diaphysial  side  of  the  epiphysial 
cartilage,  and,  by  its  spread,  gives  rise  to  prepon- 
derating signs  and  symptoms  of  one  or  other  of 
these  conditions.  The  direction  of  spread  depends 
primarily  upon  the  exact  location  of  the  initial  ab- 
scess on  the  diaphysial  side  of  the  epiphysial  carti- 
lage. 

THE  GLASGOW  MEDICAL  JOURNAL 
April,  igog. 

1.  A  Consideration  of  Some   of   the  More  Recent  Re- 

searches on  Immunitj-,  Especially  in  Relation  to  Di- 
agnosis and  Treatment,  By  Robert  Muir. 

2.  Cerebral  Physiology  and  the  Education  of  Abnormal 

Children,  By  James  Kerr  Love. 

2.  Cerebral  Physiology  and  the  Education 
of  Abnormal  Children. — Love's  idea  in  this  paper 
is  that,  having  due  regard  to  the  physiological  in- 
dications present,  the  teacher  should  be  left  as  free 
as  possible  in  selecting  the  method  and  in  ordering 
the  education  of  the  abnormal  child.  The  author 
brings  forward  some  other  physiological  indications 
with  regard  to  the  education  of  the  orally  taught 
deaf :  As  signs  are  used  very  extensively  in  the  early 
teaching  of  the  hearing  child — dtiring  his  first  and 
second  years  of  life — there  is  no  physiological  rea- 
son for  suppressing  them  at  the  beginning  of  the 
school  education  of  the  deaf  child.  They  should  be 
used  just  as  they  are  with  hearing  children,  and 
excluded,  as  in  the  case  of  the  latter,  as  soon  as  the 
more  accurate  equivalent  has  been  learned.  Dur- 
ing the  early  years  of  school  life  the  acquisition  of 
articulate  speech  should  be  the  chief  business  of  the 
deaf  child.  As  soon  as  may  be,  a  vocabulary  of 
common  words  should  be  so  thoroughly  learned  that 
its  use  in  speech  becomes  automatic.  In  the  educa- 
tion of  the  deaf,  drawing  should  follow  speech  and 


precede  writing.  Until  speech  has  become  automatic 
no  finger  spelling  should  be  known  to  a  deaf  child. 
A  combined  method,  where  the  combination  is  that 
of  finger  spelling  and  speech  is,  from  the  physio- 
logical standpoint,  to  be  condemned.  This  means 
the  banishment  of  the  manual  alphabet  from  the 
schoolroom  of  the  orally  taught  for  the  first  years 
of  school  life.  In  the  later  years  of  school  life, 
physiology  would  not  condemn  the  practice  of  the 
manual  alphabet  by  the  child  whose  speech  had  al- 
ready become  automatic,  but  in  practice,  and  for 
reasons  quite  apart  from  physiology,  it  is  undesir- 
able to  introduce  manual  spelling  into  the  oral 
schoolroom  at  all. 

THE  DUBLIN  JOURNAL  OF  MEDICAL  SCIENCE. 
April,  1909. 

1.  Unusual  Case  of  Lupus  Mutilans, 

By  W.A.LTER  G.  Smith. 

2.  Prognosis  in  Valvular  Disease  of  the  Heart, 

By  Sir  John  F.  H.  Broadbext. 

3.  Report  on  an  Outbreak  of  T\-phoid  Fever  Caused  by 

Infected  Milk,  By  Sir  Charles  A.  Camerox. 

2.    Prognosis  in  Valvular  Disease  of  the  Heart. 

— Broadbent  remarks  that  aortic  incompetence  due 
to  degenerative  change  in  later  life,  is  usually  the 
result  of  chronic  degenerative  change,  affecting  not 
only  the  valves  but  the  aorta.  The  degree  of  in- 
competence is  seldom  very  great,  but  is  liable  to  be 
progressive  from  the  nature  of  the  changes  in  the 
aorta  which  have  given  rise  to  it.  If  at  all  severe, 
the  left  ventricle  is,  as  a  rule,  unable  to  respond  to 
the  extra  strain,  and  soon  breaks  down  with  result- 
ing secondary  mitral  incompetence.  The  effect  of 
aortic  stenosis  is  to  diminish  the  size  of  the  blood 
stream  flowing  from  the  heart  into  the  aorta,  and 
to  throw  extra  work  on  the  left  ventricle,  which  has 
to  use  greater  force  to  overcome  the  obstruction. 
Pure  aortic  stenosis  is  not  very  common,  but  is 
more  frequently  met  with  in  combination  with 
aortic  regurgitation,  when  the  modification  in  the 
character  of  the  pulse  which  it  entails  is  of  great 
diagnostic  value.  It  is  one  of  the  least  serious  of 
the  valvular  lesions  unless  associated  with  degen- 
erative changes  in  the  aorta  in  later  life.  It  is  not 
progressive  in  the  same  degree  as  mitral  stenosis. 
The  prognosis  in  mitral  stenosis  is  always  serious 
as  regards  duration  of  life,  though  the  patient  may 
survive  a  considerable  number  of  years,  as  the  tend- 
ency is  for  the  constriction  of  the  mitral  orifice  to 
be  progressive.  The  symptoms  are  some  of  the 
most  important  factors  in  prognosis.  Cyanosis  and 
dyspncea  on  slight  exertion  are  especially  liable  to 
be  present,  and  the  degree  of  ease  with  which  they 
are  induced  affords  useful  evidence  as  to  the  bane- 
ful eft'ect  the  high  pressure  in  the  pulmonary  circu- 
lation is  having  on  the  lungs.  The  range  of  possi- 
bilities as  regards  prognosis  is  greater  in  mitral  in- 
competence than  in  any  other  valvular  affection.  It 
may  be  due  to  a  variety  of  causes,  such  as  dilation 
of  the  left  ventricle  without  any  lesion  of  the  valves, 
as  may  occur  after  various  acute  febrile  infections, 
more  especially  when  the  patient  returns  to  work 
too  soon  after  illness.  There  can  be  no  question 
here  that  the  fatal  issue  is  the  result  not  of  the 
valvular  lesion,  but  of  the  damage  to  the  myocar- 
dium inflicted  by  the  toxine  of  the  rheumatic  micro- 
organisms and  consequent  loss  of  tone  of  the 
muscle,  which  gives  rise  to  extreme  dilation  of  the 
ventricle. 


rROCEEUlXGS  Of  SOCItTIES. 


[Xew  Vork 
Medical  Journal. 


AMERICAN  SOCIKTV  OF  TROPICAL  MEDICINE. 

Sixlli  Annual  Meeting,  Held  in  ll'asliinglon,  D.  C,  Satur- 
day, April  10.  1909. 

The  President.  Dr.  James       Anders  of  Phila 
dclpliia.  in  tlie  Chair. 

A  Review  of  the  Year's  Progress  in  Tropical 
Medicine. — The  President  said  that  the  Ameri- 
can Society  of  Tropica!  Medicine  had,  by  its  work 
and  discussions,  created  a  Hvely  interest  in  this  spe- 
cial branch  of  medicine,  and  had  served  to  stimulate 
investigations  tliat  would  resuh  in  actual  scienHfic 
achievement.  The  urgency  of  the  matter  of  acq\'ir- 
ing  sufficient  knowledge  to  support  the  United 
States  government  with  more  well  authenticated 
facts  and  authoritative  advice  bearing  upon  the  sub- 
ject was  not  sufficiently  appreciated.  Obviously, 
workers  would  multiply  and  knowledge  increase  as 
the  result  of  the  establishment  of  schools  of  tropical 
medicine.  A  similar  effect  would  be  produced  by 
the  founding  of  a  successful  journal  of  tropical 
medicine.  It  was  worthy  of  records  that  quite  re- 
cently there  had  been  founded  the  Socictc  dc  patho- 
logic cxotiquc  in  Paris,  with  Dr.  Laveran  as  presi- 
dent. The  first  bulletin,  containing  the  proceeding? 
of  the  meeting  held  on  January  22d.  was  issued  in 
■March.  1908. 

Tni]iicc.l  medicine  in  America,  which  owed  its 
interesting  development  to  the  closer  relations  of  the 
United  States  with  the  people  of  Cuba,  P\ierto  Rico, 
the  Philippines,  and  Panama,  had  continued  to  at- 
tract increasing  attention  on  the  part  of  scientific 
investigators.  The  progress  had  been  influenced 
mostly  by  the  brilliant  researches  of  men  connected 
with  the  various  tropical  administrations,  many  of 
whom  were  either  active  or  honorary  members  of 
this  society.  In  an  address  before  the  British  Medi- 
cal Association,  Sir  Patrick  Manson  had  stated  that 
the  United  States — the  youngest  of  the  colonizing 
l)0\vers — had  been  the  first  to  grapple  with  the 
ankylostoma  problem  and,  by  her  efforts  in  Cuba, 
I'uerto  Rico,  Havana,  and  Panama,  had  set  others 
an  example  and  shown  what  could  be  done  by  in- 
telligent and  energetic  tropical  sanitation.  In  this 
connection,  reference  might  be  appropriately  made 
to  a  recent  article  on  the  subject  of  Sanitation  of 
the  Tropics,  with  Special  Reference  to  Malaria  and 
^'ellow  Fever,  by  Dr.  William  C.  Gorgas.  in  which 
he  described  a  model  organization  and  further  stated 
tliat,  while  yellow  fever  had  been  successfully 
stamped  out  of  Panama  and  Cuba,  it  could  have 
been  done  more  expeditiously  with  a  better  organi- 
zation. Gorgas  also  maintained  that  in  municipal- 
ities the  same  measures  that  were  directed  against 
yellow  fever  would  avail  against  malaria. 

Dr.  Anders  then  gave  a  brief  resume  of  the  defi- 
nite and  noteworthy  advances  in  tropical  medicine 
during  the  year  just  ended. 

A  Biographical  Sketch  of  Azel  Ames,  M.  D. — 
Dr.  JiiiiN  M.  "^ww.  of  Piiiladelphia,  included  a 
biograiihical  sketch  of  Dr.  Azel  Ames,  a  member  of 
the  society  who  had  died  during  the  past  year,  in 
the  secretary's  report.    Dr.  Azel  .\nies  was  born  in 


Chelsea,  Mass..  August  10.  1845.  He  enlisted  in 
the  United  States  Army  in  1862,  but  was  compelled 
to  resign  the  ne.xt  year,  on  account  of  an  attack  of 
malaria  contracted  while  on  duty  in  the  swamps  of 
Louisiana.  He  entered  the  Harvard  Medical  School, 
from  which  he  was  graduated  in  1871.  He  then 
began  to  practise  medicine  in  Wakefield,  Mass.,  but 
he  at  once  became  more  interested  in  sanitary  sci- 
ence and  engineering  than  in  the  work  of  a  general 
family  practitioner.  In  1872  he  framed  a  code  of 
health  regulations  for  Wakefield.  He  held  several 
public  positions  of  honor  in  that  town  during  the 
next  few  years,  and  in  1878  was  elected  a  repre- 
sentative in  the  State  legislature  of  Massachusetts. 
During  the  Spanish-American  War  he  was  a  con- 
tract surgeon  in  the  United  States  Army,  and  in 
1898  was  ordered  to  Puerto  Rico  as  sanitary  inspec- 
tor. An  epidemic  of  smallpox  was  in  progress  in 
that  island,  and  he  instituted  a  farm  for  the  manu- 
facture of  vaccine  and  a  system  of  compulsory  vac- 
cination, which  was  conducted  from  February  until 
July,  1898,  860,000  vaccinations  being  performed 
during  this  time  in  a  population  of  960,000.  In 
1898  Dr.  Amos  was  commissioned  major  and  brig- 
ade surgeon  of  volunteers,  and  he  was  mustered  out 
at  the  end  of  June  of  the  same  year. 

In  1903  he  published  a  paper  entitled  The  Vacina- 
tion  of  Puerto  Rico :  a  Lesson  to  the  World,  which 
he  had  read  before  the  Association  of  Military  Sur- 
geons. At  the  time  of  the  publication  of  this  paper 
the  death  rate  from  smallpox  in  Puerto  Rico  had 
fallen  from  621  to  2  per  annum,  as  the  result  of  the 
work  accomplished  there  through  his  efforts. 

In  1907  Dr.  Ames  began  to  fail  markedly  in  pliysi- 
cal  and  mental  health.  He  was  soon  discovered  to 
be  suffering  with  chronic  nephritis,  which  endcl  fa- 
tally on  November  12,  1908. 

Dr.  Ames  was  a  member  of  the  number  of  medi- 
cal societies,  in  addition  to  the  American  Society 
of  Tropical  Medicine,  as  well  as  of  several  organi- 
zations open  to  those  who  had  taken  part  in  the  civil 
war.  Genealogy  and  colonial  history  were  his  hob- 
bies ;  and  he  was  the  author  of  The  Mayfiozvcr  and 
her  Log  and  The  History  of  the  Ames  Family  in 
America. 

Malaria,  with  Special  Reference  to  what  is  not 
Malarial  Fever. — John  Peliiam  IS.vtes,  of  Xash- 
ville,  said  in  this  paper  that  malaria  was  an  extreme- 
ly simple  disease,  and  had  positively  no  exceptions 
in  its  course,  unless  complications  were  present.  In 
true  malaria,  quinine  given  when  the  patient  wa  -  at 
])erfect  rest  would  control  all  sym])toms  within  five 
days,  if  the  attack  was  at  all  amenable  to  treatment. 
If  not,  death  wotdd  be  so  prompt  that  there  would 
be  no  time  to  hesitate  over  the  diagnosis.  The  most 
important  point  to  remember  in  the  study  of  malaria 
w^as  the  large  number  of  infections  that  might  be 
present  along  with  an  acute  malarial  infection.  .\ 
lack  of  the  knowledge  of  this  fact  no  doubt  account- 
ed for  the  confusion  in  our  ideas  with  regard  to  the 
course  of  malaria  and  its  nonamenability.  in  excep- 
tional instances,  to  treatment. 

i'inding  malarial  parasites  in  the  blood  was  not 
the  end  of  the  diagnosis,  but  just  the  beginning. 
When  quinine  was  properly  given  and  failed  to  liave 
a  marked  effect  upon  the  fever  within  forty-eight  to 


May  I,  1909.1 


PROCEEDINGS  OF  SOCIETIES. 


925 


sixty-hours,  although  parasites  might  he  present  in 
the  blood,  there  was  some  complication  ;  and  when, 
in  an  acute  malarial  infection,  the  fever  was  once 
reduced  by  quinine  and  tiiere  was  again  a  rise  of 
fever,  all  treatment  remaining  the  same,  the  second 
rise  was  not  due  to  malarial  infection,  but  to  sonv^ 
underlying  condition  aroused  to  activity,  or  to  an 
intercurrent  infection  manifesting  itself  late  in  the 
attack. 

Diagnosticating  a  fever  that  persisted  over  five 
days,  in  spite  of  quinine,  as  "clinical  malaria"  v.-as 
not  justifiable.  Leucocytosis  from  inflammatory 
diseases  was  inimical  to  the  development  of  the  ma- 
larial parasites.  In  the  presence  of  a  marked  leuco- 
cytosis the  idea  of  malarial  infection  should  be  aban- 
doned, and  search  should  be  made  for  the  real 
cause. 

In  a  malarial  climate,  if  we  would  but  bear  these 
few  facts  constantly  in  mind  and  govern  ourselves 
accordingly,  we  should  be  the  means  of  great  com- 
fort to  our  patients — the  means  of  preventing  un- 
necessary loss  of  life  by  too  long  a  neglect  of  tuber- 
culosis, deep  seated  suppuration,  and  sepsis ;  and, 
finally,  be  the  means  of  preventing  the  spread  of 
useless  and  unnecessary  epidemics. 

Dr.  WiLLi.Ajr  .S.  Thayer,  of  FJaltimore,  said  that 
he  was  astonished  that  I\Ir.  Bates  should  make  the 
statement  that  the  malarial  parasites  were  not 
found  in  any  greater  number  in  the  internal  organs 
than  in  the  peripheral  blood.  He  considered  this  a 
strange  statement  from  one  who  had  had  such  op- 
portunities for  observation  as  Dr.  Bates.  Dr.  Thayer 
said  that  one  not  infrequently  found  a  moderate 
number  of  parasites  in  the  peripheral  circulation  and 
an  enormous  -number  in  the  internal  organs — the 
brain,  the  spleen,  or  the  bone  marrow.  A  red  cor- 
puscle containing  a  parasite  of  any  size  was  often 
more  in  the  nature  of  a  foreign  body  than  of  a  red 
corpuscle,  as  could  be  easily  seen  in  fresh  blood : 
and  one  would  expect  that  corpuscles  so  changed 
and  shrunken  as.  those  in  the  jestivoautumnal  ma- 
laria or  as  the  swollen  cells  in  tertian  malaria  would 
be  retained,  in  great  part,  in  the  bone  marrow  and 
other  internal  organs.  There  were  occasionallv 
cases  of  severe  infections  with  malarial  fever  in 
which  there  were  no  parasites  found  in  the  periph- 
eral circulation,  even  with  the  most  careful  staining. 
He  referred  to  such  a  case  that  he  had  seen  recent- 
ly. The  spleen  was  enlarged  and  paroxysms  oc- 
curred. The  spleen  was  no  aspirated  ;  but  no  para- 
sites of  any  kind  were  found  in  the  peripheral  cir- 
culation, though  stained  specimens  were  made. 
Upon  the  administration  of  quinine,  the  fever  imme- 
diately disappeared,  and  the  evidence  was  very 
strong  that  this  was  a  case  of  malaria  in  whicli 
parasites  were  absent  from  the  peripheral  circula- 
tion. Dr.  Thayer  said  that  it  was  impossible  for 
him  to  believe  that,  unless  parasites  had  been  pres- 
ent in  great  numbers,  they  could  have  produced 
such  severe  symptoms. 

He  had  seen  several  cases  in  which  tuberculosis 
exactly  simulated  malaria,  but  in  which  the  blood 
showed  no  parasites,  the  existence  of  tuberculosis 
having  been  demonstrated  by  an  examination  of  the 
sputum.  He  had  also  encountered  cases  of  trichini- 
asis  resembling  malaria  most  markedly.    The  par- 


oxysms were  like  those  of  .-estivoautumnal  infection. 
Embryos  were  discovered  in  the  muscles  of  the  leg. 
There  was  a  history  of  oedema  of  the  eyelids  at  the 
outset  of  the  attack,  and  there  was  no  reason  to  be- 
lieve that  malaria  existed. 

Dr.  George  Dock,  of  Xew  Orleans,  said  that  ih.e 
circulation  did  not  go  on  in  a  series  of  tubes  with- 
out an  outlet ;  it  was  like  the  circulation  in  a  citv 
water  supply.  When  the  faucets  were  opened,  th'i 
current  changed  ;  and  when  there  were  outlets  into 
the  spleen  and  other  organs,  there  were  niodifica- 
tions  in  the  peripheral  blood  stream.  He  had  him- 
self reported  a  case  in  which  he  was  unable  to  find 
parasites  in  the  circulating  blood,  yet  found  enor- 
mous numbers  of  them  on  puncturing  the  spleeii ; 
and  he  thought  that  the  fact  that  this  frequently 
occiu'red  must  be  accepted. 

In  regard  to  Dr.  Bates's  remark  about  intoxica- 
tion, Dr.  Dock  said  that  he  did  not  believe  it  to  be 
necessary  to  have  a  large  amount  of  toxic  substance 
present  in  order  to  produce  symptoms  of  intoxica- 
tion. In  suppurative  middle  ear  disease  or  appendi- 
citis, in  which  bacteria  grew  imder  special  condi- 
tions, they  produced  toxines  of  great  potency ;  and 
in  malarial  fever  there  were  other  factors  at  work, 
such,  for  instance,  as  susceptibility.  He  did  not 
think  that  the  idea  of  a  toxic  origin  could  be  given 
up  on  the  grounds  advanced  by  Dr.  Bates. 

In  regard  to  treatment.  Dr.  Dock  was  glad  that 
Dr.  Bates  considered  that  the  majority  of  cases  of 
malaria  could  be  checked  in  forty-eight  hours,  as  he 
himself  had  held  that  Dr.  Osier's  limit  of  five  days 
was  too  long.  He  thought  it  would  be  well  to  ask 
those  that  believed  in  the  "therapeutic  test"  to  con- 
fine themselves  to  forty-eight  hours,  as  cases  existed 
in  which  paroxysms  continued  for  several  days  after 
the  patients  were  filled  with  quinine.  Dr.  Dock  be- 
lieved the  "therapeutic  test"  to  be  a  poor  guide.  He 
thought  that  one  should  use  the  microscope  and,  if 
necessary,  puncture  the  spleen,  although  care  should 
be  taken  in  the  latter  manijmlation. 

A  Case  of  Quartan  Malaria,  and  a  Case  of 
.ffistivoautumnal  Malaria  by  Dr.  Joiix  M.  Sw.\x. 
(  To  be  published.) 

Dr.  C.  C.  Bass,  of  New  Orleans,  said  that  he  liad 
had  a  case  of  quartan  malaria  similar  to  the  one  re- 
ported by  Dr.  Swan.  There  w'ere  few  or  no  symp- 
toms. The  patient  had  been  infected  five  months 
previously,  and  had  had  chills  and  fever,  which  re- 
sponded occasionally  to  quinine  and  then  recurrecj. 
UHien  the  patient  came  into  the  hospital  he  had  a 
temperature  of  101.5°  or  101°  F..  but  most  of  the 
time  the  temperature  was  normal  or  subnormal.  After 
he  had  been  in  the  ward  three  or  four  days,  twen- 
ty grains  of  quinine  were  given  him  through  mis- 
take. He  had  previously  shown  three  crops  of  para- 
sites and  had  had  irregular  j^eriods  of  chills  and 
fever.  The  administration  of  quinine  was  stopped 
as  soon  as  the  error  was  discovered.  The  Plas- 
modia were  absent  the  next  day.  and  from  that  time 
on,  until  a  month  and  a  half  later,  he  had  no  more 
parasites.  He  was  then  discharged,  though  not  per- 
fectly well,  no  satisfactory  explanation  for  his  con- 
dition being  apparent.  He  returned  to  the  hospital 
about  a  month  later,  two  months  and  a  half  from  the 
time  that  he  had  had  parasites  in  his  blood.  Quinine 


926 


PROCEEDINGS  OF  SOCIETIES. 


[New 
Medical 


York 
Journal. 


was  given  him,  but  no  plasmodia  could  be  found. 
He  died  about  a  month  afterward,  never  having 
had  fever  or  shown  parasites,  and  the  autopsy  dis- 
closed tuberculous  peritonitis.  The  spleen  failed  to 
reveal  parasites  on  post  mortem  examination.  The 
case  was  not  an  old  infection  in  which  the  patient 
had  got  so  accustomed  to  the  malarial  condition  that 
he  had  stopped  having  fever,  for  he  had  not  been 
infected  more  than  five  months,  the  history  being 
very  definite  on  that  point.  Dr.  Bass  laid  stress  upon 
the  fact  that  the  patient  had  had  three  crops  of 
parasites,  and  that  he  had  received  but  one  dose  of 
quinine  and  some  calomel,  nothing  else  having  been 
given ;  yet  that  he  had  got  rid  of  his  parasites  and 
had  shown  none  afterward. 

Dr.  Thayer  referred  to  a  case  of  quartan  malaria 
that  he  had  seen  at  Johns  Hopkins  Hospital  a  num- 
ber of  years  ago.  The  patient  died  within  a  short 
time  after  treatment,  and  showed  remarkably  few 
evidences  of  malaria  at  the  autopsy.  He  also  re- 
ferred to  a  case  of  the  obstinate  type  of  quartan  m.a- 
laria  in  a  man  who  had  consulted  Dr.  Osier  on  ac- 
count of  recurrent  chills  from  which  he  had  been 
suttering  for  two  years.  Dr.  Osier  did  not  think  the 
case  was  one  of  malaria,  but  Dr.  Thayer  foimd  quar- 
tan parasites.  After  treatment  with  quinine  for 
a  week  or  ten  days  the  patient  was  well  enough  to 
return  to  business. 

Dr.  Bass  related  two  other  cases  of  quartan  ma- 
laria that  had  occurred  at  the  Charity  Hospital  in 
Xew  Orleans.  One  was  in  a  patient  who  had  lived 
in  Honduras  for  two  years,  and  had  had  chills  and 
fever.  He  paid  no  attention  to  it.  On  admission, 
he  showed  an  enlarged  spleen  and  an  infection,  with 
three  crops  of  quartan  parasites.  .  As  soon  as  quinme 
was  given  him  the  parasites  immediately  disappear- 
ed from  his  blood.  Quinine  was  discontinued  at  the 
end  of  three  days,  but  although  he  was  kept  in  the 
ward  ten  days  longer  and  the  spleen  remained  en- 
larged, no  more  parasites  could  be  discovered. 

Dr.  Basb  said  that  quartan  malaria  was  very  rar*^ 
in  his  section  of  the  country.  The  pathologist  at  the 
Charity  Hospital,  however,  thought  that  he  oould 
recognize  a  different  type  of  plasmodium  in  the  pa- 
tients coming  from  Honduras,  and  had  named  it  the 
Honduran  malarial  parasite.  The  case  related  by 
Dr.  Bass  was  one  of  these  cases,  and  the  patholo- 
gist had  made  the  diagnosis  in  this  instance  with- 
out knowing  where  the  patient  had  come  from.  Al- 
though Dr.  Dock  and  other  had  studied  slides  from 
tliese  cases  and  from  others  that  had  not  come  from. 
Honduras,  they  were  of  the  opinion  that  no  such 
distinction  could  be  made.  The  rosette  of  the  Hon- 
duran type  of  quartan  showed  from  eight  to  nine 
spores,  and  the  reduction  in  the  size  of  the  red  cor- 
jiuscle  as  the  organism  developed  was  perfectly 
typical.  Although  a  good  deal  of  fine  and  pretty 
active  pigment  was  found,  it  was,  as  general  rule, 
tlie  coarse  pigment  of  the  quartan  type. 

In  another  case  which  occurred  in  the  same  hos- 
pital the  diagnosis  was  made  from  the  history,  with 
out  microscopical  confirmation.  This  patient  came 
from  Alexandria,  La.  He  gave  a  clear  historv  of 
quartan  malaria,  but  had  no  paroxysms  while  in  the 
hospital. 

Dr.  Dock  said  that  the  cases  of  Honduran  fever 


in  the  Charity  Hospital  had  not  been  allowed  to  go 
untreated,  and,  therefore,  that  the  type  of  fever  was 
not  determined.  He  confirmed  what  Dr.  Bass  had 
said  about  the  diagnosis  of  the  organism  from  that 
locality,  it  having  been  made  without  the  type  of  the 
fever  being  known.  He  thought  that  one  explana- 
tion why  the  diagnosis  of  quartan  malaria  was  not 
made  was  that  a  number  of  the  patients  had  not  been 
allowed  to  furnish  proper  temperature  charts,  and 
said  that  the  old  English  idea  of  the  greater  severity 
and  obstinacy  of  quartan  malaria  did  not  always 
hold  good.  In  a  case  of  quartan  malaria  reported 
by  him  some  years  ago,  the  patient  was  easily  cured 
b}-  a  single  dose  of  quinine. 

Dr.  Dock  then  referred  to  the  enormous  number 
of  parasites  that  had  been  found  in  Dr.  Bass's  sec- 
ond case,  several  segmenting  bodies  having  often 
been  found  in  every  field ;  yet  the  patient  had  d'ed 
without  showing  marked  symptoms.  There  was  also 
a  very  decided  sestivoautumnal  infection,  a  crescent 
having  been  found  later  on. 

Dr.  O.  T.  Logan,  of  Changteh,  China,  said  that 
the  recovery  of  the  patient  mentioned  by  Dr.  Bass 
was  easily  explained,  that  being  the  way  in  which 
our  forefathers  got  well  before  the  discovery  of 
quinine,  ^^^^ile  in  China,  Dr.  Logan  had  observed 
cases  of  malaria  in  persons  who  refused  to  take 
medicine.  By  going  to  bed  they  would  get  rid  of 
their  fever  and  eventually  recovered ;  but  as  soon  as 
they  got  up  the  symptoms  would  recur.  Eventually, 
however,  they  would  get  rid  of  the  disease  entirely. 
This  same  fact,  he  thought,  accounted  for  the  im- 
munity from  malaria  enjoyed  by  the  natives  of 
Africa. 

Dr.  Henry  Skinner  said  that  a  distinct  species 
or  a  geographical  race  of  malarial  parasites  might 
be  expected  from  analogy  of  other  forms  of  life. 
Whenever  there  was  a  wide  geographical  range  of 
distribution,  changes  in  morphology  existed,  so  that 
it  was  often  possible  for  a  naturalist  to  say  whence 
an  individual  came.  Even  though  certain  individ- 
uals were  considered  to  belong  to  the  same  species, 
it  was  possible  to  distinguish  a  European  from  an 
American  specimen.  Dr.  Skinner  believed  that  the 
Honduran  parasite  might  be  either  another  species 
or  a  distinct  geographical  race. 

Dr.  W.  P.  Chamberlain,  of  Jackson  Barracks, 
La.,  said  that  in  an  investigation  made  by  him  four 
years  ago  the  anopheles  had  been  found  to  constitute 
seven  per  cent,  of  all  mosquitoes  in  that  locality.  In 
studying  malaria  he  had  found  that  four  patients 
resisted  the  administration  of  quinine  by  the  moutli 
for  four  days,  but  that  all  others  promptly  yielded 
to  this  treatment.  Among  the  latter  were  four  cases 
of  quartan  malaria,  which  yielded  as  quickly  as  the 
others.  None  of  the  quartan  cases  relapsed,  whereas 
many  of  the  others  did  or  the  patients  became  re- 
infected a  few  months  after  the  original  attack. 

A  Study  of  the  Leucocytes  in  Tropical  Malarial 
Infection.— Dr.  Paul  T.  Talbot,  of  Xew  Or- 
leans, referred  to  a  group  of  twenty-four  malarial 
cases  that,  on  account  of  their  peculiar  history  and 
their  marked  an?emia.  suggested  to  him  the  neces- 
sity for  careful  study.  All  these  patients  had  seen 
recent  service  in  and  around  Central  .\mcrica,  the 


Jlay  I,  locg.] 


PROCEEDINGS  OF  SOCIETIES. 


927 


majority-  having  come  from  Spanisla  Honduras. 
Their  condition  had  been  termed  by  the  physicians 
^nd  laity  of  their  locality  "tropical  anaemia." 

The  patients  all  gave  a  history  of  ague,  and  on 
studying  their  blood,  he  was  impressed  with  the  rela- 
tive white  count,  which  showed  a  constant  increase 
of  the  small  lymphocytes,  coupled  with  a  very  er- 
ratic form  of  Plasmodium.  Only  one  of  the  patients 
had  had  any  previous  malarial  infection.  A  great 
amount  of  physical  depression  existed,  and  the  re- 
turn of  the  chills  was  not  so  periodic  as  in  the  or- 
dinary forms  of  malarial  infection.  Chills  were  often 
entirely  absent,  being  supplanted  by  severe  head- 
ache and  other  symptoms  of  toxaemia;  All  the  con- 
comitant diseases  that  might  be  thought  to  have  any 
influence  on  the  lymphocytes  were  shown  to  be  ab- 
sent in  these  cases,  yet  there  was  a  relative  and  con- 
stant increase  in  small  lymphocytes — contrary  to  the 
previous  teachings  on  malaria.  Every  blood  dis- 
ease had  its  own  picture,  within  certain  bounds  :  and, 
though  the  relative  leucocyte  count  had  not  been 
studied  in  every  disease,  it  was  probable  that  there 
was  some  change  in  the  leucocytes,  not  yet  deter- 
mined, that  represented  a  certain  organism  or  toxine. 
The  leucocytes  responded  in  a  peculiar  relation,  dif- 
ferently for  different  toxines,  but  constantly  for 
each  particular  toxine.  In  the  ordinary  forms  of 
malaria  the  leucocyte  count  was  a  valuable  aid  in 
the  diagnosis ;  there  was  a  relative  increase  in  the 
lymphocA'tes,  but  this  was  most  evident  in  the  large 
lymphocytes.  The  cases  studied  by  Dr.  Talbot, 
however,  showed  this  relative  increase  in  the  lym- 
phocytes in  the  small  rather  than  in  the  large  va- 
rieties. In  addition  to  this,  the  parasites  found  some- 
times presented  the  outlines  of  a  tertian  and  some- 
times those  of  an  asstivoautumnal  form.  The  author 
concluded,  therefore,  that  he  was  dealing  with  a 
different  toxine,  produced  by  a  different  parasite. 
While  he  had  not,  as  yet,  found  any  definite  and 
constant  cause  for  the  condition,  he  considered  the 
results  obtained  so  far  from  study  very  encourag- 
ing. 

Schistosomiasis  (Japonica),  with  Special  Ref- 
erence to  Observations  in  Hunan  Province,  China. 

— Dr.  O.  T.  LoG.\N,  of  Changteh,  China,  described 
schistosomiasis  as  a  peculiar  disease,  characterized 
by  enlarged  spleen  and  liver,  dysentery,  etc.,  prev- 
alent in  certain  parts  of  Japan  and  sometimes  en- 
countered in  other  portions  of  the  Orient,  due  to  a 
trematode.  The  fact  that  over  a  dozen  cases  had 
recently  been  seen  in  different  parts  of  Hunan 
Province,  China,  and  that  some  of  the  patients  had 
reported  their  neighbors  to  have  been  suffering  with 
a  disc^ise  similar  to  their  own,  made  it  probable  that 
the  disease  was  not  uncommon  in  that  part  of  China 
at  least.  Its  existence  seemed  to  be  connected  with 
wet  farming,  particularly  when  dependent  upon 
ponds  and  reservoirs  for  the  water  supply.  The 
diagnosis  was  usually  easy,  particularly  if  the  micro- 
scope was  used,  though  it  might  be  necessarv  to 
make  examinations  on  successive  days  before  the 
charactic  ova  were  found  in  the  tools.  The  mode 
of  infection  was  not  known,  though  it  was  believed 
to  take  place  through  the  skin  in  persons  who  waded 
in  stagnant  water.  The  prognosis  was  bad  in  heavy 
infections,  and  even  light  infections  lowered  the  vital 


resistance  and  rendered  the  patient  more  liable  to 
complicating  infections. 

Three  cases  were  treated  by  the  author,  one  be- 
ing fatal.  The  second  patient  stayed  in  the  hos- 
pital only  a  few  days,  and  the  third  remained  about 
two  months.  He  was  treated  with  laxatives  and 
iron  tonics,  and  improved  greatly  though  ova  were 
still  present  in  the  faeces  when  he  left  the  hospital. 
He,  however,  died  home  a  few  months  afterwards, 
presumably  of  the  same  disease.  When  ascites  was 
present,  tapping  the  abdomen  was  recommended  in 
addition  to  the  other  treatment. 

The  Prevalence  and  Importance  of  Uncinaria- 
sis among  Apparently  Healthy  Southern  Bred 
White  Men  in  the  United  States  Army. — -Dr. 
Weston  P.  Chamberlain,  of  Jackson  Barracks, 
La.,  said  that  uncinariasis  was  found  to  be  very  com- 
mon among  southern  bred  soldiers  of  less  than  three 
years'  service.  Of  a  hundred  soldiers  serving  in 
their  first  enlistment,  sixty  were  infected.  Among 
new  southern  bred  recruits,  the  percentage  of  in- 
fections had  been  found  by  some  to  be  as  high  as 
eighty-five  per  cent.  Apparently  the  worms  died 
out  mostly  during  the  soldier's  first  three  years  in 
the  army,  for  in  men  in  their  second  and  subse- 
quent enlistments,  only  four  in  thirty-three  cases 
showed  ova  in  the  stools.  Among  sixty-four  cases 
of  uncinariasis  among  southern  bred  soldiers,  the 
parasite  was  in  all  cases  Necator  amcricamis.  The 
number  of  worms  found  after  one  treatment  ranged 
from  one  to  ninety-nine,  the  average  being  sixteen. 
In  some  cases  it  was  necessary  to  examine  six  or 
eight  cover  glass  preparations  before  an  egg  was 
found. 

The  symptoms  from  these  light  infections  were 
practically  nil,  though  most  of  the  men,  after  treat- 
ment, reported  feeling  more  vigor  than  before. 
The  haemoglobin  was  little  reduced,  the  lowest  being- 
eighty  per  cent.,  and  the  average  gi.5  per  cent.  The 
eosinophile  count  was  8.5  per  cent.  About  one-fifth 
of  the  cases  showed  less  than  five  per  cent  oi.  eosin- 
ophiles,  so  that  absence  of  eosinophilia  was  small 
evidence,  against  the  existence  of  this  intestinal 
parasite.  Among  eighty-three  negative  cases,  the 
percentage  of  eosinophiles  was  2.2. 

It  was  believed  that  uncinariasis  in  childhood  was 
the  cause  of  the  poor  development  so  common 
among  southern  recruits,  which  led  to  the  rejec- 
tion of  a  great  many  applicants  for  the  Army.  Fann 
life  was  an  important  predisposing  cause  of  lui- 
cinariasis.  Of  seventy-four  men  who  had  farmed 
at  some  time  in  their  lives,  eighty-one  per  cent,  were 
infected  with  hook  worms,  the  majority  of  patients 
reported  having  gone  barefooted  in  childhood ;  and 
a  little  over  half  having  at  some  time  suffered  from 
ground  itch,  but  usually  not  since  childhood. 

Treatment  of  these  very  light  infections,  while 
not  of  great  important  in  the  interest  of  the  pa- 
tient, was  urgently  demanded  if  the  disease  was  to 
be  stamped  out  and  severe  cases  prevented. 

Mild  Uncinaria  Infections. —  Dr.  Charles  C. 
Bass,  of  New  Orleans,  said  in  this  paper  that  for 
every  well  marked  case  of  uncinariasis  in  the  south- 
ern States,  there  were  several  cases  that  had  from 
one  parasite  to  a  sufficient  number  to  cause  the  ordi- 
narily recognized  symptoms.    He  called  attention  to 


928 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


the  fact  that  negroes  presented  few  symptoms,  even 
\Vhen  laboring  among  parasites.  Mild  cases  were  a 
source  of  infection,  and  therefore  demanded  treat- 
ment. He  compared  these  cases  to  bacillus  carriers 
and  to  cases  of  chronic  malaria.  The  symptoms  of 
these  mild  cases  were  generally  few  and  vague ; 
right  sided  abdominal  pain  and  tenderness  were  the 
most  constant. 

He  described  in  detail  the  technique  by  which  the 
diagnosis  might  be  more  certainly  made  than  by  the 
ordinary  examinaton  of  the  ffeces.  The  stool  must 
be  fresh,  and  one  should  be  chosen  following  a  dose 
of  Epsom  salts.  The  stool  was  then  well  diluted 
with  water  and  strained  through  gauze,  to  get  rid 
of  the  coarser  particles.  It  was  then  centrifuged 
just  long  enough  to  throw  the  eggs  to  the  bottom. 
This  must  be  determined  with  each  centrifuge  ;  but 
with  one  running  3,500  revolutions  a  minute,  ten 
seconds  at  the  first  washing  and  four  or  five  seconds 
afterward  was  about  correct.  The  separated  fluid 
was  poured  off,  and  more  diluted  faeces  carried 
through  the  same  process,  until  all  was  in  the  cen- 
trifuge tube.  This  was  washed  several  times  with 
water,  then  several  times  with  a  solution  of  calcium 
cloride  of  a  specific  gravity  of  1.050.  In  this  man- 
ner most  of  the  freces  were  got  rid  of.  The  eggs 
remained,  if  any  were  present,  and  a  few  crystals, 
grit,  etc.  This  might  be  explained  at  once ;  or,  pre- 
ferably, after  centrifuging  again  with  a  solution  of 
calcium  cloride  of  a  specific  gravity  of  1.250.  The 
eggs  then  rose  to  the  top,  and  nearly  all  of  the  other 
stuff  settled  to  the  bottom.  A  few  drops  taken  from 
the  surface  of  the  fluid  was  poured  off,  and  exam- 
ined ;  or,  still  better,  the  top  of  the  fluid  was  poured 
off  and  diluted  with  sufficient  water  to  bring  the 
specificic  gravity  again  below  1.050.  Centrifuga- 
tion  of  this  produced  a  sediment  which  contained 
nearly  all  the  eggs  in  the  original  quantity  of  faeces. 
One  slide  prepared  in  this  way  might  contain  all  the 
eggs  that  could  be  found  in  several  hundred  ordi- 
nary slide  preparations  of  faeces.  The  author  was 
able  to  recover  ninety-six  per  cent,  of  one  hundred 
eggs  placed  in  one  once  of  faeces. 

IDr.  W.  .S.  Th.wer,  of  Baltimore,  said  that  it 
would  be  of  great  interest  to  try  to  study  the  stools 
for  the  ova  of  Strongylns  stercoralis  by  the  method 
described  by  Dr.  Bass,  in  order  to  determine  the 
relative  measurements  of  these'  eggs  and  those  of 
uncinaria.  The  eggs  of  the  former  were  very  rare- 
ly found  in  the  stools,  and  when  they  were  found 
they  were  so  like  uncinaria  eggs  that  there  was 
sometimes  a  question  as  to  their  identity.  Dr. 
Thayer  doubted  whether  the  eggs  found  in  Dr. 
Bass's  first  case  were  those  of  strongylus.  The  eggs 
obtained  were  those  hatched  outside  of  the  body, 
which  were  not  the  same  as  those  hatched  in  the 
intestine. 

Dr.  (iEORGE  Dock,  of  New  Orleans,  said  that  he 
thought  that  a  great  deal  more  work  should  be  done 
in  detecting  mild  cases  of  uncinariasis  with  atypical 
symptoms,  many  of  which  could  undoubtedly  be 
remedied  by  treatment.  He  also  thought  that  it 
would  be  interesting  to  find  out  how  much  of  the 
al)errant  psychic  condition  in  certain  sections  of 
the  country  might  be  due  to  such  infections. 

Dr.  JuiiN-  M.  Sw\N',  of  Philadelijhia,  said  that  he 
!iad  had  an  opp(jrtunity  to  stn;l\  a  ])atienl  who  was 


a  native  of  Alabama  who  had  had  several  epileptoid 
convulsions.  The  patient  was  twenty-five  years  old 
and  a  traveling  salesman.  He  had  had  epileptoid 
attacks  of  considerable  severity  at  intervals  of  about 
a  month.  Examination  of  the  blood  showed  an 
eosinophilia  of  13.4  per  cent.  On  examining  the 
stools,  a  fairly  large  flagellate  infection  was  seen. 
The  patient  was  put.  on  appropriate  treatment,  and 
withm  a  short  time  the  flagellates  had  disappeared, 
and  the  eosinophile  count  fell  to  3.4  per  cent,  in  a 
total  leucocyte  count  of  18.000.  The  patient  then 
improved  very  much  in  health.  He  had  one  other 
convulsive  attack,  which  was  of  a  true  epileptoid 
character.  After  two  months  there  was  no  recur- 
rence of  the  convulsions,  and  just  before  the  patient 
was  to  return  to  his  home  another  blood  study 
showed  2.2  per  cent,  of  eosinophiles.  In  spite  of  re-, 
peated  examinations  of  the  faeces.  Dr.  Swan  failed 
to  discover  luicinaria  eggs ;  yet  he  felt  reasonably 
sure  that  a  proper  technique  might  have  discovered 
these  eggs  in  the  stools.  He  thought  that  the  meth- 
od suggested  by  Dr.  Bass  would  have  cleared  up 
this  point.  In  the  only  other  case  of  uncinariasis 
that  Dr.  Swan  had  seen  during  the  last  three  years 
the  diagnosis  was  indicated  by  an  eosinophilia  of  8.4 
per  cent.,  and  uncinaria  ova  were  found  in  the  stools 
in  fairly  large  numbers  by  means  of  the  ordinary 
technique. 

Dr.  Joseph  F.  Siler,  of  Fort  Jay,  N.  Y..  said  that 
the  question  of  prophylaxis  of  uncinariasis  ought  to 
be  more  thoroughly  studied.  He  thought  that  the 
South  would  never  be  rid  of  the  hook  worm  unless 
the  question  was  taken  up  by  the  governinent.  He 
believed  that  the  society  should  try  to  have  this  work 
undertaken  by  the  Federal  authorities.  The  fact 
that  practically  all  the  children  of  the  South  were 
infected  made  him  conclude  that  if  that  section  could 
be  rid  of  the  hook  worm,  a  great  deal  would  be  done 
for  humanity.  The  cases  were  very  widely  scat- 
tered, and  the  disease  practically  riddled  the  whole 
of  the  southern  country. 

Dr.  Ch.vmberlain  said  that  his  cases  were  wide- 
ly distributed.  They  came  from  every  State  in  the 
South,  as  far  north  as  Maryland.  Consequently  it 
appeared  that  the  disease  was  universal  throughout 
the  southern  States. 

Dr.  Bass  said  that  the  question  of  ridding  the 
South  of  uncinaria  infection  was  of  very  great  eco- 
nomic importance.  He  thought,  however,  that  the 
])roblem  was  one  of  education  rather  than  of  legisla- 
tion, as  it  would  be  impossible  to  force  the  layman 
by  law  to  observe  such  sanitary  measures  as  would 
be  necessary  to  prevent  the  disease.  He  must  be 
educated  to  the  necessity  of  avoiding  such  infec- 
tion and  in  his  relation  to  infection  of  others. 

Dr.  liass  said  that  he  had  not  been  able  to  apply 
the  method  to  a  large  number  of  the  parasitic  eggs. 
He  had  used  it  for  Trichoccphahts  triclntiris  and  the 
ordinary  a.scaris,  though  it  did  not  apply  well  to 
ascaris  eggs,  because  their  coating  was  rough  and 
they  did  not  go  down  any  faster  than  the  other 
coarse  material  of  the  faeces.  The  albumin  coat- 
ing of  the  a.scaris  eggs  also  rapidly  ab.sorbed  the  salt 
solution,  and  they  soon  came  to  be  of  the  same  speci- 
fic gravity  as  the  salt  solution. 

(  To  be  coiitinui'd. ) 


Slay  1.  1909.] 


BOOK  NOTICES. 


[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.} 


Rudinicnis  of  Latin.  With  Special  Reference  to  the 
Nomenclature  of  the  U.  S.  Pharmacopceia,  the  National 
Fornnilary,  and  the  Textbooks  in  Materia  IMedica  and 
Botany.  Including  also  Prescription  Writing  and  Notes 
on  the  Nomenclature  of  the  German  Pharmacopoeia.  By 
Julius  William  Sturmer,  Ph.  G.,  Professor  of  Phar- 
macy, Purdue  University,  Lafayette,  Ind.  Published  by 
the  Author.    Pp.  92.    (Price.  $1.) 

In  a  fmall  volume  the  autlior  has  succeeded  in 
covering  with  an  vuuisual  degree  of  fuhiess  the  La- 
tinity  uf  nomenclature  as  applied  to  the  drugs  and 
medicines  in  common  use.  While  evidently  intended 
more  especially  for  pharmaceutical  students,  the 
book  is  likelv  to  be  well  appreciated  by  medical  stu- 
dents and  practising  physicians.  The  rules  for  the 
pronunciation  of  Latin  titles  are  interestingly  pre- 
sented. (.)f  special  pharmaceutical  interest  are  the 
chapters  on  nomenclature,  the  rules  laid  down  in  the 
United  States  Pharmacopceia  being  clearly  explain- 
ed. In  a  separate  part  the  Latin  nomenclature  of 
the  German  Pharmacopoeia  is  contrasted  with  that 
of  the  L'nited  States  Pharmacopoeia,  and  this  forms 
a  useful  and  well  presented  chapter.  Without  any 
sacrifice  of  essentials  the  general  rules  for  the  form- 
ation of  botanical  names  are  given  in  four  pages, 
together  with  explanatory  paragraphs.  Of  the  va- 
rious small  works  relating  to  the  Latin  of  prescrip- 
tion writing  which  have  made  their  appearance  in 
this  coui^try  and  Great  Britain  during  the  past  few 
years,  we  are  -inclined  to  regard  this  as  one  of  the 
most  practical  and  useful. 

Dcr  Hirnabszcss.  Von  Professor  Dr.  H.  Oppexheim  und 
Privatdozent  Dr.  R.  Cassirer  in  Berlin.  Zweite,  um- 
gearbeitete  Auflage.  Mit  3  Tafeln  in  Farbendruck  und 
6  Abbildungen  im  Texte.  ^Vien  und  Leipzig:  Alfred 
Holder,  1909.    Pp.  304. 

This  is  a  very  thorough  work  on  brain  abscess — 
the  bibliography  runs  through  thirty-eight  royal  oc- 
tavo pages,  printed  in  nonpareil  type — v.'hich  well 
represents  our  present  knowledge  and  theories  of 
this  interesting  chapter  of  medicine,  wdiich  includes 
surgery,  medicine,  neurology,  rhinology,  and  otiat- 
rics.  both  authors  being  neurologists. 

The  causes  of  brain  abscesses  are  of  course  pus 
generating  microorganisms,  which  mostly  immigrate 
into  the  brain  from  a  situation  near  the  brain ;  thus 
they  are  oftenest  of  traumatic  or  otitic  origin.  We 
mostly  find  Streptococcus  pyogenes  and  StapJiylo- 
coccns  pyogenes  aureus,  not  so  often  Staph\lococ- 
cus  pyogenes  albus  and  cifrcus.  also  Bacillus  pyo- 
cyaneits.  Pyogenes  fa^tidns,  and  Micrococcus  pyo- 
genes tenuis,  also  the  pneumonia,  tubercle,  and  ty- 
phus bacillus,  even  Bacterium  coli  and  Proteus  -z  ul- 
garis.  etc.    The  aetiology  is  therefore  manifold. 

The  authors  have  divided  their  book  into  seven 
chapters:  Introduction  (pp.  i  and  2);  aetiology 
(pp.  3  to  ig)  ;  pathogenesis  (pp.  20  to  28)  ;. patho- 
logical anatomy  (pp.  29  to  54)  ;  symptomatology 
(pp.  57  to  147)  ;  diagnosis  (pp.  148  to  231)  :  prog- 
nosis and  therapy  (pp.  232  to  265)  ;  and  literature. 

The  authors  say  that  brain  abscess  will  always 
terminate  fatally  if  left  to  itself,  although  such  an 
abscess  may  exist  for  a  long  time  without  showing 


any  symptoms.  This  sad  prognosis  has  lately  been 
bettered  through  our  progress  in  surgery  and  pro- 
phylaxis ;  the  main  point  is  to  destroy  the  original 
forms  of  pus.  Trepining  should  be  undertaken  only 
when  the  diagnosis  is  positive. 

Atlas  und  Grundriss  dcr  topographischen  und  angezvandten 
.-inatoinic.  Von  Dr.  med.  Oskar  Schultze.  Professor 
der  Anatomie  in  Wiirzburg.  Zweite  vermehrte  Auflage. 
'Mit  22  vielfarbigen  lithographischen  Tafeln  und  205  meist 
farbigen,  zum  grossen  Teil  auf  Tafeln  gedruckten  Ab- 
bildungen nach  Originalen  von  Maler  A.  Schmitsox  und 
Maler  K.  H.\jek.  Miinchen :  J.  F.  Lehmann,  igog.  Pp. 
224.    (Price,  :6  Mk.) 

In  October.  1902,  appeared  the  first  edition  of 
this  valuable  atlas,  of  which  an  English  translation 
by  Professor  G.  Stewart  was  published  in  1905. 
The  text  of  the  second  German  edition  has  been 
greatly  changed  and  enlarged,  while  the  remarks  on 
applied  anatomy,  which  in  the  first  edition  were  in- 
terwoven with  the  topographical  anatomy,  have  been 
separated  and  are  now  to  be  found  under  addenda 
following  each  chapter.  The  illustrations  have  been 
augmented  by  not  fewer  than  115  new  illustrations. 

The  atlas  is  a  very  valuable  book ;  the  illustra- 
tions are  well  executed,  many  of  them  multicolored : 
the  text  is  well  written  ;  and  the  paper  as  well  as 
the  printing  is  worthy  of  the  publishing  house  of 
Lehmann. 

• 

Anatomic  und  Mechaniswus  dcr  Skoliosc.  Von  weil.  Dr. 
C.\RL  NrcoLADoNi,  a.  o.  Professor  der  Chirurgie  an  der 
Universitat  Graz.  k.  k.  Hofrat.  Mit  54  Figuren  auf  37 
Tafeln  und  dem  Portrat  des  \'erfassers.  Berlin  und 
Wien  :  Urban  &  Schw  arzenberg,  1909.    Pp.  58. 

This  handsome  volume,  an  evidence  of  the  scien- 
tific zeal  of  the  author,  attests  also  the  love  and  ad- 
miration of  his  surviving  sister  Henriette.  He  evi- 
dently possessed  an  intimate  practical  knowledge  of 
his  theme.  The  salient  feature  of  this  affection  is 
here  variously  presented  as  torsion  and  rotation. 
Discussion  of  its  cause  gives  way  in  these  pages  to 
minutely  described  and  exquisitely  illustrated  details 
of  the  morbid  anatomy.  Not  only  the  vertebrae,  the 
discs,  and  the  ribs,  but  also  the  longitudinal  and  radi- 
ating ligaments,  the  diaphragmatic  crura  and  medi- 
astinal contents,  and  the  relation  of  these  parts  to 
each  other,  become  subject  to  the  microscopic  nicetv 
of  the  writer's  remarkable  descriptive  ability.  Every 
item  is  marshalled  with  such  a  refinement  of  pre- 
cision that  in  following  his  footsteps  one  is  so  enam- 
ored of  the  skilful  array  of  minute  and  multiform 
details  that  it  is  difficult  to  rise  to  the  distant  level  at 
which  alone  it  is  possible  to  see  that  rotation  is  due 
to  the  reaction  of  the  wall  of  the  cavity  on  a  limited 
portion  of  its  contents  rather  than  to  anatomical  ele- 
ments and  their  relation  to  each  other. 

I'oriesungcn  iiber  Tubcrkulosc.  Herausgegeben  von  Dr. 
Georg  Liebe,  Leiter  und  Inhaber  der  Heilanstalt  Waldhof- 
Elgershausen.  L  Die  mechanische  und  psychische  Be- 
handlung  der  Tuberkulosen  besonders  in  Heilstiitten. 
\"on  Dr.  Georg  Liebe.  Miinchen ;  J.  F.  Lehmann,  1909. 
Pp.  viii-267.    (Price.  5  Mk.) 

This  is  a  classical  work  on  tuberculosis,  contain- 
ing as  part  one  the  mechanical  and  psychic  treat- 
ment of  the  tuberculous,  especially  in  sanatoria.  The 
author,  physician  in  chief  of  a  sanatorium,  has  had 
a  very  wide  experience  and  is  fully  entitled  to  speak 
of  tuberculous  disease  and  its  treatment.  The  text- 
books on  this  disease  published  in  Germany  are 
more  or  less  from  university  professors  who  in  their 


930 


M  ISC  ELLA  N  Y—OFFICIA  L  .V£  JVS. 


[New  York 
Medical  Journal. 


clinics  do  not  have  the  latge  experience  that  a  sana- 
torium alone  will  furnish. 

Although  the  book  appears  in  the  form  of  lectures, 
these  addresses  have  not  been  delivered,  but  it  would 
be  a  great  step  forward  if  such  men  as  Liebe  were 
added  to  the  list  of  public  speakers  who  are  to  in- 
struct the  laity  on  the  questions  of  tuberculous  dis- 
ease. 

The  book  is  not  a  theoretical  or  empirical  dis- 
course, is  not  based  on  laboratory  and  microscopical 
findings  only,  but  well  represents  the  clinical  aspect. 
It  undoubtedly  will  be  added  to  the  list  of  good 
American  books,  and  an  English  translation  should 
soon  appear. 

Physiotherapie.  Kincsithcrapic.  Massage — mobilisation- — 
g)'mnastique.  Par  les  docteurs  P.  C\rnot,  Dagron, 
DucROQUET,  Nageotte  Wilbouchewitch.  C.\utru,  Bour- 
CART.  Avec  356  figures  dans  le  texte.  Paris :  J.  B.  Bail- 
liere  et  fils,  1909.    Pp.  xii-559. 

Kinesitherapie  is  the  therapeutics  of  motion,  the 
aim  of  which  is  to  produce  by  mechanical  actions, 
active  or  passive,  the  proper  functional  activity  of 
the  different  parts  of  the  body,  thus  so  to  influence 
an  organ  that  its  development  and  repair  may  be 
produced  by  its  own  functions.  This  is  the  defini- 
tion the  authors  give  of  kinesitherapeutics.  The 
study  of  the  physical  agents  has  received  consider- 
able attrition  during  the  past  decade,  and  massage, 
gymnastics,  hydrotherapeutics,  electricity,  and  radio- 
therapeutics  have  been  adopted  by  many  practition- 
ers. 

Our  authors  speak  in  the  present  volume  of  the 
Bibliotheque  de  thcrapeutiquc,  which  is  edited  by 
Professor  Gilbert  and  Professor  Carnot  and  will 
contain  twenty-six  volumes,  on  massage,  mobiliza- 
tion, and  gymnastics'.  The  book  contains  seven 
chapters.  The  three  on  kinesitherapeutics  and  its 
laws,  massage  and  mobilization,  and  Swedish  gym- 
nastics may  be  taken  as  an  introduction,  that  is,  as 
presenting  the  theoretical  side  of  the  subject ;  while 
the  four  following  chapters  are  of  practical  impor- 
tance :  Kinesitherapeutics  in  the  treatment  of  the 
spinal  column,  of  the  respiratory  organs,  of  the  ab- 
domen, and  of  the  female  organs.  The  book  is  well 
illustrated  and  should  find  a  large  circle  of  readers. 
Perhaps  we  may  expect  an  English  translation. 

 <^  

Pistdliing. 


A  New  Heat  Stroke  Theory. — Under  the  sub- 
ject of  Military  Medicine  {Deutsche  Militararztliche 
Zeitschrift)  Dr.  Hiller  discusses  Dr.  Senftleben's 
recent  theory  of  heat  stroke,  which  may  be  briefly 
stated  as  follows :  In  consequence  of  the  continual 
perspiration  of  the  soldiers  on  the  march,  the  red 
blood  corpuscles  undergo  dissolution.  The  haemo- 
globin of  the  red  blood  cells,  dissolved  in  the  blood 
plasma,  destroys  the  white  blood  corpuscles,  and  liber- 
ates, from  the  protoplasm  of  the  white  cell's,  the  fibrin 
ferment,  which  calls  forth  an  active  rise  in  tempera- 
ture and  coagulation  of  the  blood,  especially  in  the 
venous  .system,  and  by  obstructing  the  pulmonary 
artery  and  its  branches  leads  to  death  with  lightning 
rapidity.  The  severity  of  the  attacks  of  heat  stroke 
depends  upon  the  amount  of  fibrin  ferment  pro- 
duced and  the  varied  intensity  of  coagulation.  The 
experimental  support  of  Senftleben's  theory  are  the 


experiments  of  Alaas ;  'Tnfluence  of  the  rapid  with- 
drawal of  water  from  the  organism,"  and  three  dis- 
sertations of  Koehler,  Sachsendahl,  and  Mais- 
surianz ;  "Fibrin  ferment  and  haemoglobin  intoxica- 
tion," from  Schmidt's  laboratory  in  Dorpat.  Hiller 
made  a  thorough  study  of  the  investigations  of 
Maas  and  the  dissertations  from  Schmidt's  labora- 
tory and  comes  to  a:  widely  different  conclusion. 
He  cannot  see  how  the  perspiring  of  soldiers  on  the 
march  can  be  compared  to  the  withdrawal  of  water 
caused  b}'  exposing  in  a  room  of  warm,  dry  air  the 
contents  of  the  abdominal  cavity  of  a  narcotized 
rabbit,  nor  do  the  injections  of  a  concentrated  sugar 
solution  into  the  peritoneal  cavity  of  a  rabbit  or  dog 
confirm  Senftleben's  theory  to  him.  The  experi- 
ments of  Koehler,  Sachsendahl.  and  Maissurianz 
were  made  to  explain  blood  transfusion.  They 
found  that  dissolved  haemoglobin,  prepared  from 
the  blood  of  an  animal,  when  injected  in  the  jugular 
vein  of  the  same  or  any  other  animal,  led  to  a 
rapid  disintegration  of  the  colorless  blood  cells  and 
a  sudden  accumulation  of  a  large  amount  of  fibrin 
ferment,  which  caused  coagulation  of  the  venous 
blood  in  the  lesser  circulation  and  produced  sudden 
death  by  asphyxiation.  Since  Senftleben's  theory 
requires  coagulation  of  the  venous  blood  in  the 
lesser  circulation,  then  one  should  find  clots  in  the 
pulmonary  artery  and  its  branches  in  a  patient  dead 
from  heat  stroke.  No  such  findings  have  as  yet  been 
reported.  Senftleben's  explanation  that  the  fibrin 
ferment  has  been  used  up  does  not  explain  the 
absence  of  a  coagulation. — The  Military  Suri^coii. 

The  Quantity  and  Quality  of  Breast  Milk 
during  the  First  Two  Weeks  of  the  Puerperium. 

—Davis  observes  that  the  system  of  estimating  the 
quantity  of  breast  milk  by  weight  is  a  decided  aid 
in  determining  a  feeding  schedule  for  the  new1x)rn. 
Both  mother  and  child  must  be  considered  before  a 
thoroughly  useful  law  can  be  established.  The  early 
secretion  from  the  mother's  breasts  is  useful  in  sus- 
taining the  child,  and  babies  should  be  encouraged 
to  nurse  from  the  first  day  of  life  in  every  case  pos- 
sible. When  the  milk  is  abundant,  a  three  hour  in- 
terval soon  becomes  the  shortest  interval  during  the 
day  for  breast  feeding,  but  a  longer  interval  at 
night  can  be  sustained  by  the  child  with  benefit. 
Both  the  digestive  capacity  of  the  child  and  the 
quality  of  the  breast  milk  may  enter  into  the  results 
in  a  given  case  exclusive  of  quantity  and  the  time 
interval. — Journal  of  flic  American  Medical  .-Isso- 
tiation. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports: 

The  folloxiniig  cases  of  siiiallf>o.v,  yellow  fei'er.  cholera 
ami  plague  hai'c  been  reported  to  the  surgeon  general. 
United  .S'lates  Public  Health  and  Marine  Hospital  Serricc, 
duriug  the  7\.rck  ending  April  23.  igog: 

Places.  Date.  Ca~es.  Deaths. 

Smallpo.v — United  States. 

.M.ibama — Biniiingliain  Mar.  1-31   10 

California — Los  .\ngeles  Mar,  27-.\pril  3.....  i 

Ceorgia — Macon  .'\nril    4-11   .6 

Illinois — .Mton  ^iar.  1-31   1 

Illinois — (lalesburg  .\pril    3-10   j 

ln<liana — Indianapolis  .\pril    4-1 1   1 

Indiana — La  Kavettc  .\pril    5-12   i 

Tow.i — Council  liluffs  .\pril    5-12   i 

low.i — New  Hampton..  l"eb.  26-.'\pril  15   8 

Kansas — Kansas  Cit.v  \pril   3-10   j 


^lay  1.  ioog.] 


OFflCIAL  XEirS. 


7 
13 


14 


Places.  Uati.  Cases.  I)iatli> 

Kansas — Topeka  Mar.  6-April  3   12 

Kcntutky — Covington  \])ril  3-10  

Kentucky — Lexington  April    3-10   i 

Kentucky — Paducah  Mar.  26-April  3   i 

Michigan — Saginaw  Mar.  26-April  3   2 

Minnesota — Duluth  \pril    i-8   6 

^Montana — Butte  Mar.  30-.\pri!  6   2 

Nebraska — South  Omaha  \pril    3-10   2 

New  Jersey — Camden  .\pril    3-10   i 

New  jersey- — Lodi  Mar.    12   i 

North  Dakota — Sherwood  and  vi- 
cinity Jan.    i2-.April    5   73 

Ohio — Cincinnati....  \pril    1-7   7 

Te.xas — San  Antonio  .\- ril    3-10   i 

\'irginia — Richmond  \- ril    3-10   i 

West  Virginia — St.  Albans Feb.    i6-.\pril    12....  19 

Wisconsin — La  Crosse  \pril    3-10   2 

Wisconsin — ;Milwaukee  Mar.    13-April  3   23 

Wisconsin — Racine  \pril    3-10   i 

Smallpox — Foreign. 

Algeria — Bona  Jan.    1-31   16 

Feb.    1-28   2S 

Brazil — Para  Mar.    20-27   i 

Brazil — Pernambuco  Feb.  15-28  

Brazil — Rio  de  Janeiro  Feb.   27-Mar.    7   25 

Canada — Haiifa.x  Mar.    7- April   3   2 

Ceylon — Colombo  Jan.  23-Feb.   13   31 

CI<ina — Tientsin  Feb.   20-27   ' 

France — Paris  Mar.  20-27   3 

Great  Britain — Bristol  Mar.  20-27  

India — Bombay  Mar.  9-16  

India — Calcutta  Feb.    27-Mar.  6  

India — Madras  ilar.  6-13   i 

India — Rangoon  Feb.   27-Mar.   6   8 

Italv — General  Mar.  21-28   2 

Italv — Catania  ilar.  20-27   2 

Italy — Naples  Mar.  21-28   16 

Indo-China — Saigon  Feb.   20-27   7  5 

Java — Batavia  Feb.  20-Mar.  6   9  t 

Mexico — Guiidalajara  Mar.  25-April   i   2 

Mexico — Monterey  Mar.  29- April  4   3 

Newfoundland — St.  John's  Mar.  22-April  3   2 

Peru — Lima  Mar.   25   i 

In  Lazaretto 

Portugal — Lisbon  Mar.  20-.\pril  3   11 

Russia — Moscow  Mar.  13-20   19  11 

Russia — Odessa  Mar.    2   i 

Russia — Riga  Mar.  29-April  5   i 

Russia — Warsaw  Jan.    16-30   6 

South  Africa — Cape  Town  Mar.  6-13   i 

Spain — Barcelona  Mar.  22-29   2 

Spain — \'alencia  Mar.  19-26   5  3 

Soain — \igo  .Mar.  20-27   1 

Straits  Settlements — I'mang  Feb.  27-Mar.  6   i  Imported 

Tripoli — Trinoli  Mar.  20-27   2 

Turkey — Constantinople  Mar.  20-28   r 

Turkey — Smyrna  Feb.  26-Mar.  4   2 

•    Mar.  T8-25   3 

Yellow  Fever — Foreign. 

Barbados  Mar.  27-.\priI  3   3  2 

Fcuador — (iuay.Kiuil  Mar.   13-20   26  10 


3'  = 


Cholera — Foreign. 

Tndia — Bombay  M-ir.  9-16  

India — Calcutta  Feb.  27-Mar.  6  

India — Rangoon  Feb.  27-Mar.  6  

Russia — St.  Petersburg  Mar.  27-31   13 


Plague — Foreign. 


Brazil- 
Chile- 
Chilc- 

Ecuad 
India- 
India- 
India- 
India- 
Peru- 
Peru— 


—Rio  de  Janeiro  Feb.  28-Mar 

-Antofagasta  Mar. 

-Iqv.ique  Mar 


ir — Guayaquil  Mar. 

-General  Mar. 

-Bombay  Mar. 

-Calcutta  Feb. 

-Rangoon  Feb. 

-General  Mar. 

-Callao  Mar. 


1-20   24 

21   26 

In  Lazaretto 


13-  20  

30-.\pril  6. 

9-16  

29-Mar.  6.  . 
29-Mar.  6.  . 
1327  

14-  27  


■  ■  ■  5 
■5.033 


3 

4.109 
286 
71 
9 


54 
4 


Public  Health  and  Marine  Hospital  Service: 

Official  list  of  cJiaiiges  of  stations  and  duties  of  commis- 
sioned and  other  otRcers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
April  21,  igog: 

Rlanchard,  J.  F.,  .Acting  Assistant  Surgeon.  Granted  one 
day's  extension  of  leave  of  absence,  April  16,  1909. 

CoFER.  L.  E.,  Passed  Assistant  Surgeon.  Detailed  to  repre- 
sent the  Service  at  the  annual  meeting  of  the  South 
Carolina  State  Medical  Association  at  Summerville,  S. 
C,  April  20,  1909. 

Delg.\do.  J.  M..  Acting  Assistant  Surgeon.  Granted  two 
days'  extension  of  annual  leave  from  April  6,  1909,  oh 
account  of  sickness. 

Eldredge,  M.  B..  Pharmacist.  Granted  three  days'  leave  of 
absence  from  April  19.  1909,  under  paragraph  210, 
Service  Regulations. 


CIahx,  Hexkv.  Pharmacist.  Granted  one  day  s  leave  of 
alj.sence  in  April,  1909.  under  paragraph  210,  Service 
Regulations. 

Geudings,  H.  D..  Assistant  Surgeon  General.  Relieved 
from  duty  in  Bureau  as  Assistant  Surgeon  General,  to 
take  effect  April  20,  1909. 

GeddingSj  H.  D..  Assistant  Surgeon  General.  Directed  io 
proceed  to  certain  points  in  Europe  upon  special  tem- 
porary duty  as  inspector  of  vaccine  and  antitoxin  es- 
tablishments. 

Hurley,  J.  R.,  Assistant  Surgeon.  Relieved  from  tem- 
porary duty  at  San  Francisco  Quarantine  and  directed 
to  proceed  to  Manila,  P.  I.,  and  report  to  the  Chief 
Quarantine  Officer  for  duty. 

Long.  J.  D.,  Passed  Assistant  Surgeon.  Granted  one 
month's  leave  of  absence  from  Max-  i.  1909. 

jMcIxtosh,  W.  p.,  Surgeon.  Granted  seven  days'  leave 
of  absence  from  April  24,  1909. 

McLartv,  A.  A.,  Acting  Assistant  Surgeon.  Granted  three 
days'  leave  of  absence  from  April  6,  1909,  under  para- 
graph 210,  Service  Regulations. 

RoBixsox.  D.  E.,  Passed  Assistant  Surgeon.  Granted  five 
days'  leave  of  absence  from  March  28,  1909,  on  account 
of  sickness. 

Rogers.  Edward.  Pharmacist.  Granted  three  days'  leave  of 
absence  from  April  6,  1909,  under  paragraph  210,  Ser- 
vice Regulations. 
Stimsox.  a.  M..  Passed  Assistant  Surgeon.  Relieved  from 
special  temporary  duty  at  Los  Angeles.  Cal.,  and  di- 
rected to  rejoin  station.  Washington,  D.  C. 
Wertexi! \ker,  C.  p..  Surgeon.  Directed  to  report  at  Bu- 
reau upon  special  temporary  duty. 

Board  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital.  San  Francisco,  Cal.,  May  3,  1909,  for  the  exam- 
ination of  candidates  for  admission  to  the  Service  as  As- 
sistant Surgeon.  Detail  for  the  board :  Surgeon  H.  W. 
Austin,  chairman;  Passed  Assistant  Surgeon  Rupert  Blue; 
Passed  Assistant  Surgeon  F.  E.  Trotter,  recorder. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi' 

ccrs  serving  in  the  Medical  Corps  of  the  United  States 

Army  for  the  zi-eek  ending  April  24,  igog: 

Bow>rAX.  M.  H.,  First  Lieutenant,  ^ledical  Reserve  Corps. 
Ordered  from  Depot  of  Recruits  and  Casuals,  Angel 
Island,  Cal.,  for  temporary  duty. 

Browx.  p.  D.,  First  Lieutenant,  iledical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Saint  Philip.  La.,  and  or- 
dered to  Fort  Sam  Houston,  Tex.,  for  duty  . 

Bcrket.  J.  A.,  First  Lieutenant,  ^ledical  Reserve  Corps. 
Ordered  to  active  duty,  and  assigned  to  Fort  Snelling, 
Minn.,  for  duty. 

Chase.  A.  M.,  First  Lieutenant,  Medical  Reserve  Corpb. 
Relieved  from  duty  at  Fort  .Sam  Houston,  Tex.,  and 
ordered  to  Fort  Saint  Philip,  La.,  for  duty. 

CoFFix,  J.  ]\L,  Captain,  ^ledical  Corps.  Relieved  from 
duty  at  the  Army  and  Navy  General  Hospital,  Hot 
Springs,  Ark. ;  will  sail  July  5,  1909,  for  service  in  the 
Philippines. 

Co.K,  W.,  Captain,  Medical  Corps.  Honorably  discharged 
from  the  service  of  the  United  States,  with  one  year's 
pay. 

D^:^f^tER,  C.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  active  duty,  and  assigned  to  duty  at  Fort 
Ontario.  X.  Y. 

Edger.  B.  J.,  Jr..  Major.  Medical  Corps.  Relieved  from  duty 
in  the  Philippines  Division  in  time  to  sail  July  15th  for 
San  Francisco,  Cal. 

Fjsk.  O.  C.  First  Lientenant,  ^ledical  Reserve  Corps.  Or- 
dered to  active  dut.\',  and  assigned  to  duty  at  Fort 
Le.ivenworfh.  Kans. 

Foster.  G.  B..  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  active  dutv.  and  assigned  to  Fort  Totten, 
X.  Y. 

Fox,  J.  S..  First  Lieutenaiit.  ^ledical  Reserve  Corps.  Or- 
dered to  active  duty,  and  assigned  to  duty  at  Fort  Sam 
Houston,  Tex. 

Filler.  L.  A..  Major,  Medical  Corps.  Relieved  from  duty 
in  the  Philippines  Division  in  time  to  sail  July  15th 
for  San  Francisco,  Cal. 


BIRTHS.  MARRIAGES.  AXD  DEATHS. 


[New  ^'oRK 
Medical  Julrxal. 


(iK.WES,  L.  K.,  I'lrst  Lieutenant.  .\Jcclical  Reserve  Corps. 
Honorably  discharged  from  the  service  of  the  United 
States  Maj-  8,  1909,  his  services  being  no  longer  re- 
quired ;  granted  leave  of  absence  to  include  i\Iay  8th. 

1I.\LEY,  J.  C,  First  Lieutenant,  .Medical  Reserve  Corps. 
Ordered  to  active  duty,  and  assigned  to  duty  at  Fort 
Porter,  N.  Y. 

Haktxett,  F.  H.,  Major,  Medical  Corps.  Ordered  to  duty 
at  Fort  Du  Pont,  Del.,  upon  the  expiration  of  his  pres- 
ent leave  of  absence. 

Hess.  L.  T.,  Major,  Medical  Corps.  Granted  an  extension 
of  one  month  to  his  leave  of  absence. 

Johnson,  T.  H.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to'active  duty,  and  assigned  to  duty  at  Fort 
Du  Pont,  Del. 

Ke.vn,  J.  R.,  Lieutenant  Colonel,  Medical  Corps.  Ordered 
to  New  York  City  to  represent  the  Medical  Department 
of  the  Arm_v  at  the  meeting  of  the  Medical  Society  of 
the  County  of  New  York,  April  26,  igog. 

KiERULFF,  H.  N.,  First  Lieutenant.  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  twenty-three  days. 

King,  C.  T.,  I-'irst  Lieutenant,  Medical  Reserve  Corps.  Or- 
dered to  active  duty,  and  assigned  to  duty  at  the  Pre- 
sidio of  Alonterey,  Cal. 

KiKKP.VTKKK.  T.  J.,  Major,  Medical  Corps.  Relieved  from 
duty  at  Fort  Moultrie,  S.  C,  in  time  to  proceed  to  San 
Francisco,  Cal..  and  sail  July  5,  1909,  for  service  in  the 
Philippines. 

L.\  G.VRDE.  L.  A..  Lieutenant  Colonel,  Aledical  Corps.  When 
relieved  from  duty  at  Denver,  Colo.,  ordered  to  Sail 
Francisco,  Cal,  for  duty  as  Chief  Surgeon,  Department 
of  California. 

MuKK.w,  A..  Captain,  ^Medical  Corps.  Ordered  to  Fort  Du 
Pont,  Del.,  instead  of  to  the  Philippines  Division. 

X.vpiEk,  Fmv.  L.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  active  duty,  and  assigned  to  duty  at  Fort 
McPherson,  Ga. 

Perley,  H.  O.,  Colonel,  Medical  Corps.  Ordered  at  the 
expiration  of  his  present  leave  of  absence  to  Denver, 
Colo.,  for  duty  as  Chief  Surgeon,  Department  of  the 
Colorado,-  and  Attending  Surgeon  in  Denver. 

Reynolds,  C.  R.,  Captain.  Medical  Corps.  Relieved  from 
duty  with  Conipanj'  C,  Flospital  Corps,  and  ordered  to 
duty  at  the  Walter  Reed  Army  General  Hospital,  Wash- 
ington. D.  C. 

RiCH.\Rns,  R.  L..  Captain,  Medical  Corps.  Relieved  from 
duty  at  Fort  Wayne,  Mich.,  and  ordered  to  Washing- 
ton, D.  C,  for  a  special  course  of  instruction  at  the 
Army  Medical  School. 

RoBBixs,  C.  P.,  Major,  Medical  Corps.  Relieved  from 
duty  in  the  Philippines  Division  in  time  to  sail  July 
15th  for  San  Francisco,  Cal. 

Skinner.  G.  A.,  ALijor,  Medical  Corps.  Relieved  from 
duty  in  the  Philippines  Division  in  time  to  sail  July 
15th  for  San  Francisco.  Cal. 

Smith,  A.  M..  Major,  Medical  Corps.  Relieved  frojn  duty 
in  tlic  Philippines  Division  in  time  to  sail  July  15th  for 
San  Francisco,  Cal. 

Snyder,  H.  D..  Major.  Relieved  from  duty  in  the  Philip- 
pines Division  in  time  to  sail  July  T5th  for  San  Fran- 
cisco, Cal. 

Tei-tt,  W.  H.,  Captain,  Medical  Corps.  Fort  Baker.  Cal. 
Ordered  to  dut\-  with  troops  at  .Secpioia  NatiiMial  Park. 
Cfl. 

Trotter-Tyler,  G..  First  Lieutenant.  Medical  Reserve 
Corps.  Ordered  to  Washington  Barracks.  D.  C.  for 
temporary  duty,  and  then  to  return  to  Fort  .'\dams.  R.  T. 

Wilson.  J.  S..  Major.  Medical  Corps.  Relieved  from  duty 
in  the  Philippines  Division  in  time  to  sail  July  15th 
for  San  I'Vancisco,  Cal. 

WoiDKfKK.  C.  F...  Major,  Medical  Corps.  Relieved  from 
duty  at  Fort  Wadsworth.  N.  Y..  in  time  to  proceed  to 
San  Francisco,  Cal.,  and  sail  July  5,  1909,  for  service 
in  the  Pliilippines. 

Yost.  J.  D.,  Captain,  Medical  Corps.  Granted  leave  of  ab- 
sence fov  (iiu-  month. 

Navy  Intelligence: 

Official  hit  of  chaiifics  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  ivcek  ending  April  .24.  igog: 
Bcjcert,  E.  S.,  Jr.,  Surgeon.    Detached  from  the  Marine 

Rccrniting  Station,  New  York,  N.  Y.,  and  ordered  to 

llic  Na\;il  .Academy. 


De  Fi(;.\niere  P.  A..  Acting  Assistant  Surgeon.  Detached 
from  duty  at  the  Xaval  :\Iedical  School.  Washington. 
D.  C,  and  resignation  accepted,  to  take  effect  April  21. 
1909. 

DeValin,  C.  M.,  Surgeon.  Orders  of  Alarcli  22d  modified. 
Detached  from  the  Washington  and  ordered  to  the 
Navy  Yard,  Washington,  D.  C. 

Dt  NN,  H.  A.,  Passed  Assistant  Surgeon.  Detached  from 
the  Colorado  and  ordered  to  the  Independence. 

Imske.  C.  N.,  Passed  Assistant  Surgeon.  Detached  from 
the  Bureau  of  Aledicine  and  Surgery,  Navy  Depart- 
ment, and  ordered  to  temporary  duty  at  the  Navy 
^'ard,  \\'ashington,  D.  C. 

Kennedy.  J.  T..  Surgeon.  Detached  from  the  Independ- 
ence and  ordered  to  the  Colorado. 

Leach.  P.,  Surgeon.  Detached  from  the  Hancock  and  or- 
dered to  the  Marine  Recruiting  Station.  New  York. 
N.  ^  . 

MiMtKiio.  H.  B.,  Acting  .Assistant  Surgeon.  Detached 
fr;)m  dnt\-  at  the  Naval  Medical  School,  Washington, 
1).  C,  and  resignation  accepted,  to  take  effect  .April 
21.  iQog. 

TrKXEu.   H.   W.   B..  Assistant  Surgeon.    Ordered  to  the 

HullCrch. 


Iirt^s,  Carriages,  anU  ftat^s. 


Married. 

.\i'i>EL — M.\c  Kay. — In  Chicago,  on  Thursday,  April  15th, 
Colonel  Daniel  AL  .Appel.  Medical  Corps,  United  States 
-Army,  to  ]\Iiss  Fmma  Scribner  Mac  Kay. 

Craic — Havemeyer. — In  Yonkcrs.  New  York,  on  Tues- 
day, April  20th,  Dr.  Robert  Henry  Craig,  of  Montreal, 
Canada,  and  Aiiss  Harriette  Frances  Havemeyer. 

Cussler — Cati.in. — In  Washington.  D.  C.  on  Thursday, 
.April  22nd.  Dr.  Edward  Cussler  and  Miss  Mary  Lansing 
Catlin. 

Henry — Giuson. — In  Philadelphia,  on  Wednesday,  April 
14th.  Dr.  J.  Norman  Henry  and  Miss  Mary  K.  Gibson. 

Rockwell  —  Burnham. — In  Detroit,  Alichigan.  on 
\\'ednesday.  April  21st,  Dr.  James  W.  Rockwell  and  Mrs. 
Emma  L,  Buniham. 

S.M'SSER — AIooRE. — III  Philadelphia,  on  Wednesday.  April 
I4tli.  Dr.  Emerson  Randolph  Sausser  and  Miss  Eleanor 
Moore. 

WiNS.MORE — Rec;\r. — In  Philadelphia,  on  Monday,  .April 
T2th.  Dr.  Edward  Clift  Winsmore  and  Miss  .Alice  Regar. 


Died. 

Chittenden. — In  Binghamton,  New  York,  on  Wednes- 
day, .April  i_|tb.  Dr.  J   11.  Chittenden,  aged  seventy  years. 

Davis. — In  New  Carlisle.  Indiana,  on  Sunday,  April  i8th, 
Dr.  Josephus  Davis,  aged  seventy-four  years. 

Draper. — In  Brookline.  Massachusetts,  on  Tuesday, 
.April  20th.  Dr.  Frank  Winthrop  Draper,  aged  sixt\--six 
years. 

Griffith. — In  Rome,  New  York,  on  Tuesday,  April  20th, 
Dr.  W.  H.  Griffith,  aged  fifty-four  years. 

H.M.L. — In  Oyster  Bay,  New  York,  on  Friday.  .April  gth. 
Dr.  James  W.  Hall,  aged  sixty-six  years. 

HiFF.— In  Gobleville,  Alichigan.  on  Wednesday.  .Aiirii 
21st,  Dr.  Charles  Wright  Huff",  aged  iifty-nine  years'. 

Jordan. ^In  Philadelphia,  on  Sunday,  .April  i8tli.  Dr. 
Robert  J.  Jordan,  aged  se\enty-nine  years. 

Marshall. — In  Fruitvale,  California,  on  Saturday,  .April 
loth.  Dr.  Norali  Sprague  Marshall,  aged  forty  years. 

Mitchell. — In  Lancaster,  New  Hampshire,  on  Tuesday, 
.April  20th.  Dr.  Ezra  Alitcliell. 

Mitchell. — In  Cumberland.  Marvlaiid,  on  Wednesdav. 
.April  7th.  Dr.  H.  F.  Mitchell. 

PA^■NE. — In  Meridian.  Mississippi,  on  l-'riday.  .April  i6th. 
Dr.  W.  W.  Pa\ne,  aged  tifty-nine  years. 

Rennolds. —  In  Color.ido  Springs,  Colo.,  on  SatuVday. 
.April  17th,  Dr.  Michael  P.  Reynolds,  aged  forty-two  years. 

S.\NDERSoN. — In  New  York,  on  Monday,  .April  igtli.  Dr. 
John  E.  W.  Sanderson. 

Ward. — In  Washington,  D.  C,  on  Monday,  .April  lotli. 
Dr.  William  L.  Ward,  aged  sixty-nine  years. 

Yoi  Nc. — In  Washington.  D.  C,  on  Friday.  .April  oth.  Dr. 
Edward  Young,  aged  ninety-four  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  rlt  Medical  News 

A   Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  19. 


NEW  YORK,  MAY  8,  1909. 


Whole  No.  1588. 


EPHRAiM  McDowell.* 

By  Lewis  S.  McMurtry,  A.  M.,  M.  D., 
Louisville,  Ky. 

We  are  living  in  an  age  of  marvelous  scientific 
achievement.  In  the  medical  sciences  the  advance 
of  knowledge  has  been  so  essential  and  far  reaching 
as  to  constitute  a  veritable  revolution.  Within  the 
period  of  professional  activity  of  those  present  the 
science  of  medicine  has  been  recast,  medical  practice 
altered  beyond  recognition,  medical  literature  made 
anew,  and  medical  education  set  to  new  systems  and 
enlarged  scope.  The  very  foundation  of  the  temple 
of  medicine  seems  to  have  been  replaced  to  sustain 
a  superstructure  more  magnificent  than  the  early 
builders  could  have  pictured  in  glowing  fancy.  Em- 
piricism, theory,  and  hypothesis  are  replaced  with 
experimental  research,  demonstration,  and  applied 
science,  so  that  modern  medicine  as  a  science  com- 
mands the  admiration  of  the  civilized  world. 

To  the  superficial  observer  it  would  appear  that 
our  predecessors  from  the  age  of  Hippocrates  down 
to  the  latter  quarter  of  the  nineteenth  century  had 
almost  lived  in  vain,  and  that  medicine  as  a  science 
emanated  from  very  recent  times.  But  one  has  stud- 
ied history  to  little  purpose  if  he  has  failed  to  learn 
that  all  knowledge  is  correlated,  that  a  single  ob- 
servation of  Nature's  work  may  lead  to  important 
scientific  discoveries,  and  that  the  perfection  of 
achievement  is  based  upon  the  accumulated  knowl- 
edge of  successive  generations.  Vesalius,  Pare, 
Harvey,  Malpighi,  and  John  Hunter  prepared  the 
way  for  Cooper,  Brodie,  Dupmtren,  Velpeau,  Simp- 
son, von  Graefe,  von  Langenbeck,  Gross,  Paget, 
Billroth,  Sims,  and  Lister.  Sir  Humphrey  Davy 
was  needed  for  the  development  of  Morton,  the  dis- 
coverer of  anaesthesia,  as  was  Virchow  for  the  bril- 
liant work  of  Koch ;  and  likewise  Sydenham,  Louis, 
and  Trousseau  provided  for  the  coming  of  their  suc- 
cessors in  the  field  of  internal  medicine.  Messieurs 
Bernutz  and  Goupil  cleared  the  ground  and  pre- 
pared the  soil  which  Mr.  Lawson  Tait's  genius  so 
abundantly  cultivated.  The  chief  and  abiding 
achievement  in  medicine  and  surgery  of  the  latter 
half  of  the  nineteenth  century  is  the  establishment 
of  scientific  methods  of  study,  from  the  pursuit  of 
which  methods  have  come  the  marvelous  results  of 
our  own  times.    We  are  impressed  most  profound- 

"An  address  delivered  at  the  Centennial  Celebration  of  the 
1-oundation  of  Abdominal  Surgery,  by  the  American  Gynaecological 
Society,  held  in  Xew  York,  April  22,  1909. 


ly  with  the  culmination,  and  are  prone  to  overlook 
the  early  steps  in  the  progress  of  knowledge. 

It  is  both  becoming  and  illuminating  to  revert  t» 
the  pathfinders,  and  while  doing  homage  to  their 
discoveries,  consider  also  their  influence  upon  the 
teachings  of  the  present  time.  It  is  most  appropriate 
that  in  this  one  hundredth  year  since  McDowell's 
epoch  making  work,  this  society,  founded  by  his 
followers  in  America,  should  celebrate  his  achieve- 
ment and  thereby  keep  afresh  in  the  professional 
mind  the  source  and  origin  of  a  great  department  of 
surgery. 

No  conception  of  Ephraim  McDowell's  character 
and  personality  could  be  more  remote  from  the 
truth  than  that  he  was  a  rude,  but  courageous,  back- 
woodsman, who  by  accident  or  mishap  undertook  an 
untried  feat  in  surgery  and  succeeded  in  spite  of  a 
disregard  of  all  surgical  rules  and  established  prin- 
ciples.  Let  us  for  a  moment  consider  his  origin  and 
preparation.    He  was  born  in  Rockbridge  County, 
Virginia,  on  the  eleventh  day  of  March,  ijyi,  when 
the  American  colonies  were  in  the  agitation  pre- 
ceding the  revolution.    His  father,  Samuel  Mc- 
Dowell, was  a  prominent  man  in  Virginia  and  a 
member  of  the  Assembly  of  that  State.    In  1782  he 
was  sent  by  the  legislature  as  a  land  commissioner 
to  Kentuck}%  which  was  then  a  county  or  appanage 
of  Virginia.    A  year  later  he  was  appointed  judge 
of  the  district  court  of  Kentucky  and  removed  his 
family  to  the  town  of  Danville,  where  the  sittings  of 
the  court  were  held  and  where  he  resided  perma- 
nently thereafter.   Ephraim  McDowell's  mother  was 
Sarah  McClung.  a  member  of  a  distinguished  Vir- 
ginia family.   McDowell  was  a  product  of  that  civil- 
ization which  was  planted  on  the  Virginia  coast,  and 
from  which  came  Washington,  Jefferson,  Richard 
Henry  Lee,  Patrick  Henry,  Benjamin  Harrison,  Ed- 
mund Pendleton,  George  Mason,  and  other  soldiers, 
statesmen,  and  patriots. who  founded  the  great  re- 
public.   His  early  education  was  attained  at  the 
classical  seminary  at  Georgetown,  Kentucky,  the 
best  school  accessible  at  that  time.    After  complet- 
ing his  studies  at  the  seminary,  he  went  to  Staun- 
ton, Virginia,  and  following  the  custom  of  that  per- 
iod entered  upon  the  study  of  medicine  in  the  office 
of  Dr.  Humphreys,  a  graduate  of  the  University  of 
Edinburgh  and  a  practitioner  of  high  reputation. 
In  1793-4  he  attended  the  University  of  Edinburgh, 
then  universally  regarded  the  most  famous  centre 
of  medical  education  in  the  world.    As  fellow  stu- 
dents McDowell  was  associated  there  with  Dr.  Sam- 
uel Brown,  afterward  one  of  the  founders  and  teach- 
ers of  Transylvania  L'niversity  at  Lexington,  Ky., 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Comi  any. 


934 


McMURTRY:  EPHRAIM  McDOlVELL. 


[New  York 
Medical  Joubnal. 


and  Dr.  Hosack  and  Dr.  Davidge,  of  New  York,  all 
of  whom  subsequently  attained  eminence  in  the  pro- 
fession. As  far  as  we  know,  the  degree  of  M.  D. 
was  not  conferred  upon  him  until  1823,  when  en- 
tirely unsolicited  on  his  part  the  University  of  Mary- 
land conferred  upon  him  the  honorary  degree  of 
M.  D.  The  Medical  Society  of  Philadelphia,  at  the 
time  the  most  distinguished  of  its  kind  in  this  coun- 
try, sent  him  its  diploma  in  1807,  two  years  before 
he  performed  his  first  ovariotomy.  Thus  it  will  be 
seen  that  McDowell  had  attained  national  distinc- 
tion as  a  surgeon  before  he  undertook  the  work 
which  has  made  him  famous. 

While  at  the  University  of  Edinburgh,  McDowell 
attended  the  private  instructions  of  John  Bell,  the 
most  able  and  eloquent  of  the  Scottish  surgeons  of 
his  day.  That  portion  of  Mr.  Bell's  course  in  which 
he  lectured  upon  the  diseases  of  the  ovaries  and 
depicted  the  hopeless  fate  to  which  their  victims 
were  condemned,  made  a  powerful  impression  upon 
his  auditor.  Indeed  McDowell  afterward  stated  that 
the  principles  and  suggestions  at  this  time  enun- 
ciated by  his  master  impelled  him  sixteen  years  af- 
terward to  attempt  what  was  considered  an  impos- 
sibility. In  1795  McDowell  returned  to  his  home  at 
Danville,  and  entered  upon  the  practice  of  his  pro- 
fession. Being  a  man  of  classical  education,  coming 
from  the  most  famous  medical  school  of  the  world, 
he  soon  easily  assumed  the  first  professional  posi- 
tion in  his  locality,  and  within  a  few  years  was 
known  throughout  the  Western  and  Southern  States 
as  the  first  surgeon  of  his  entire  section  of  country. 
Indeed  until  Dr.  Benjamin  W.  Dudley,  of  Lexing- 
ton, Ky..  came  upon  the  field,  McDowell  was  un- 
disputediy  the  most  eminent  surgeon  west  of  the 
Alleghenies.  During  this  time  his  practice  extended 
in  every  direction,  persons  coming  to  him  from  all 
the  neighboring  States,  and  he  frequently  making- 
long  journeys  on  horseback  to  operate  upon  persons 
whose  condition  would  not  permit  them  to  visit  him 
at  his  home.  As  far  as  is  known  he  was  in  the 
habit  of  performing  every  surgical  operation  then 
practised.  In  lithotomy  he  was  especially  success- 
ful, and  was  known  to  have  operated,  up  to  1828, 
twenty-two  times  without  a  death.  He  operated 
many  times  for  strangulated  hernia,  and  did  success- 
fully various  amputations  and  other  operations,  in- 
cluding tracheotomy.  We  must  remember  that 
anaesthesia  was  unknown  in  his  day. 

In  1809,  fourteen  years  after  he  began  the  prac- 
tice of  his  profession,  McDowell's  opportunity  was 
presented.  He  was  called  to  see  a  Mrs.  Crawford, 
living  sixty  miles  distant  from  Danville,  who  was 
supposed  bv,  herself  and  her  physicians  to  be  preg- 
nant and  beyond  her  term,  with  most  serious  com- 
plications. After  careful  examination  he  pronounced 
the  case  to  be  one  of  ovarian  tumor ;  explained  the 
hopeless  character  of  the  disease ;  expressed  his  con- 
victic'U  that  it  was  feasible  to  undertake  its  removal ; 
frankly  announced  that  it  would  be  in  the  nature  of 
an  exj)erimcnt  but  an  exjieriment  that  was  promis- 
ing. In  a  word,  he  had  faith  in  himself  and  his 
resources,  which  inspired  confidence  and  hone  in  the 
patient.  Mrs.  Crawford  accepted  the  proffered  aid 
at  once,  and  in  a  few  days  went  to  Danville,  sixty 
miles  distant,  on  horseback,  where  the  operation 


was  successfully  performed  and  followed  by  prompt 
and  perfect  recovery. 

It  is  known  that  McDowell  had  an  excellent  medi- 
cal library  for  that  time,  and  that  he  devoted  much 
of  his  leisure  time  to  his  books,  but  he  possessed 
an  aversion  to  writing.  Like  many  able  men  in  our 
profession  of  the  present  day,  he  was  absorbed  in 
practice,  and  literary  work  of  every  kind  was  bur- 
densome to  him.  Moreover,  we  must  remember  that 
he  did  not  have  the  stimulus  of  the  daily  mail  and 
numerous  medical  journals ;  also  that  no  medical 
society  was  in  existence  in  his  section  of  the  coun- 
try. Seven  years  elapsed  after  the  operation  before 
he  made  a  report  for  publication,  during  which  time 
he  had  operated  in  two  additional  cases,  both  fol- 
lowed by  recovery.  The  title  of  his  paper  is  Three 
Cases  of  Extirpation  of  Diseased  Ovaries,  and  his 
description  of  the  symptoms  and  operation  is  con- 
cise and  clear,  describing  most  essential  points  but 
without  any  minute  account  of  the  pathology  and 
daily  progress  after  operation.  That  he  was  in- 
spired by  the  teachings  of  Mr.  John  Bell,  of  Edin- 
burgh, to  undertake  the  operation  is  apparent  from 
the  fact  that  his  report  of  his  cases  was  forwarded 
to  his  revered  master.  The  report  failed  to  reach 
Mr.  Bell,  who  was  absent  on  account  of  ill  health, 
and  McDowell  prepared  another  copy  and  forward- 
ed it  to  the  Eclectic  Repertory  and  Analytical  Re- 
niezv,  published  in  Philadelphia,  where  it  appeared 
in  the  issue  of  October,  18 16.  The  brevity  and  dis- 
regard of  many  essential  details,  which  character- 
ized the  report,  exposed  McDowell  to  criticism,  and 
articles  sarcastic  and  incredulous  appeared  in  the 
Repertory,  while  Dr.  James  Johnson,  the  learned 
editor  of  the  London  Medico-Chirurgical  Review, 
expressed  outright  his  disbelief  of  McDowell's  state- 
ments. A  few  years  afterward,  when  the  accuracy 
of  the  reports  had  been  verified  and  confirmed  by 
the  report  of  additional  cases,  Dr.  Johnson  editor- 
ially acknowledged  his  error,  saying  "there  were 
circumstances  in  the  narrative  of  the  first  three  cases 
that  raised  misgivings  in  our  mind,  for  which  un- 
charitableness  we  ask  pardon  of  God  and  Dr.  Mc- 
Dowell, of  Danville." 

In  October.  1819,  three  years  subsequent  to  his 
first  publication,  he  published  in  the  same  journal 
two  additional  cases.  In  this  report  he  alludes  to 
the  several  criticisms  which  had  appeared  regarding 
his  first  paper  in  these  words:  "I  thought  my  state- 
ment sufficiently  explicit  to  warrant  any  surgeon's 
performing  the  operation  when  necessary  without 
hazarding  the  odium  of  making  an  experiment,  and 
I  think  my  description  of  the  mode  of  operating,  and 
of  the  anatomy  of  the  parts  concerned,  clear  enough 
to  enable  any  good  anatomist,  possessing  the  judg- 
ment requisite  for  a  surgeon,  to  operate  with  safety. 
I  hope  no  operator  of  any  other  description  may  ever 
attempt  it.  It  is  my  most  ardent  wish  that  this  oper- 
ation may  remain  tc  tlie  mechanical  surgeon  forever 
incomprehensible."  If  we  had  no  other  knowledge 
of  McDowell's  mental  cast  and  surgical  ideals,  these 
words  would  stamp  him  as  a  surgeon  of  broad  and 
elevated  view,  with  lofty  conception  of  the  science 
and  art  of  surgery,  and  keen  appreciation  of  the  ad- 
vanced ground  on  which  he  trod.  The  total  number 
of   ovariotomies   he   performed    is   not  certainly 


May  8,  1909.] 


McMURTRY:  EPHRAIM  McDOlVELL. 


935 


known.  Dr.  William  A.  McDowell,  his  nephew  and 
pupil,  afterward  his  partner,  stated  that  the  total 
number  of  ovariotomies  done  by  Ephraim  McDowell 
was  thirteen,  with  eight  recoveries  and  five  deaths. 

The  essential  points  of  ^McDowell's  operative 
technique  are :  ( i )  The  parietal  incision  was  made 
external  to  the  border  of  the  rectus  muscle;  (2)  the 
pedicle  was  ligatured  before  opening  and  evacuating 
the  cyst ;  ( 3 )  care  was  observed  to  cleanse  the  peri- 
tonaeum of  fluids;  (4)  drainage  was  provided  by 
bringing  the  ligature  out  through  the  lower  angle 
of  the  incision  and  the  ligature  eliminated  in  that 
way  •  ( 5  j  the  operation  occupied  only  twenty-five 
minutes,  expedition  resulting  more  from  the  absence 
of  an  anaesthetic,  doubtless,  than  otherwise.  In  the 
report  of  the  second  case,  he  says :  'T  laid  her  side 
open."  In  the  third  case  he  adopted  the  median  in- 
cision, which  he  indicates  thus :  "I  changed  my  place 
of  opening  to  the  linea  alba."  In  all  his  cases  he 
ligatured  the  pedicle  before  separating  adhesions  or 
tapping  the  tumor.  In  the  third  case  he  mentions 
that  the  ligatures  were  not  released  for  five  weeks, 
at  the  end  of  which  time  the  cord  was  taken  away. 

In  the  brief  report  of  his  first  case.  Dr.  McDowell 
failed  to  record  such  details  of  environment,  prep- 
aration, and  after  treatment  as  so  important  an  oper- 
ation should  have  received.  He  even  failed  to  re- 
cord the  room  or  house  in  which  the  operation  was 
performed.  Either  tradition  or  imagination  has  de- 
picted the  operator  fearlessly  doing  his  work  while 
a  mob  gathered  about  his  house  threatening  his  life 
on  account  of  the  fancied  reckless  hazard  of  life  in 
attempting  an  untried  experiment.  Having  been 
born  and  reared  near  Danville,  and  educated  there, 
and  having  know-n  some  of  McDowell's  contempor- 
aries, I  am  sure  this  story  is  pure  fiction,  without 
any  semblance  of  facts  for  its  basis.  McDowell  was 
perhaps  the  most  prominent  and  popular  citizen  of 
the  community,  commanding  the  respect  and  confi-  • 
dence  of  all  classes,  and  known  far  and  near  as  a 
great  surgeon.  The  house  in  which  Mrs.  Crawford 
underwent  operation  and  remained  while  under 
treatment  is  not  known.  It  is  not  probable  that  such 
an  operation  was  done  in  the  doctor's  office ;  but 
more  probably  m  some  bedroom  prepared  for  her 
care  and  nursing  after  operation. 

In  a  most  accurate  and  painstaking  sketch  of  Mc- 
Dowell by  the  late  Dr.  John  D.  Jackson,  of  Danville, 
he  states  that  in  1822  McDowell  made  a  journey  of 
several  hundred  miles  on  horseback  to  the  Hermit- 
age, the  residence  of  President  Andrew  Jackson, 
near  Nashville.  Tenn.,  to  do  an  ovariotomy  in  the 
case  of  a  Mrs.  Overton.  He  was  assisted  in  the 
operation  by  General  Jackson  and  a  Mrs.  Priestly. 
Mrs.  Overton  recovered.  ^McDowell  was  the  guest 
of  General  Jackson  during  his  stay  in  the  neigh- 
borhood. Another  one  of  his  patients  in  Tennessee 
was  James  K.  Polk,  afterward  president  of  the 
United  States,  upon  whom  he  did  lithotomy  when 
the  patient  was  fourteen  years  of  age. 

In  1802  Dr.  McDowell  married  Sarah,  a  daughter 
of  Isaac  Shelby,  Kentucky's  first  and  greatest  gov- 
ernor, a  soldier  and  statesman,  with  whom  he  lived 
most  happily  and  raised,  a  family  of  two  sons  and 
four  daughters,  only  three  of  whom  survived  him. 
Airs.  McDowell  survived  her  husband  by  ten  years. 
Dr.  McDowell  was  nearly  six  feet  in  height,  with 


dark  hair  and  eyes  and  possessed  of  exceptional 
strength  and  endurance.  He  was  dignified  in  bear- 
ing and  possessed  a  commanding  presence,  but  quite 
free  from  austerity.  He  is  described  as  an  amiable 
and  approachable  man.  with  abundant  cheerfulness 
and  good  humor.  As  a  citizen  he  took  an  active 
part  in  all  movements  for  the  welfare  of  the  com- 
munity. He  was  especially  interested  in  education 
and  contributed  liberally  of  his  time  and  means  to 
provide  educational  facilities  so  much  needed  at  that 
time.  He  was  a  member  of  the  first  Board  of  Trus- 
tees of  Center  College  of  Kentucky,  now  Central 
University  of  Kentucky.  He  contributed  personally 
the  lot  upon  which  Trinity  Episcopal  Church  in 
Danville  now  stands.  In  his  fifty-ninth  year,  while 
in  the  full  vigor  of  life,  he  was  seized  with  an  acute 
fever  and  died  on  the  twentieth  day  of  June,  1830, 
after  a  brief  illness. 

In  1852,  twenty-two  years  after  the  death  of 
Ephraim  McDowell,  Professor  Samuel  D.  Gross, 
then  a  resident  of  Louisville,  presented  to  the  Ken- 
tucky State  Medical  Society  a  sketch  of  the  life  and 
original  surgical  work  of  the  first  ovariotomist.  Pro- 
fessor Gross  brought  to  his  task  his  characteristic 
accuracy  and  thoroughness  of  investigation.  He  en- 
gaged in  a  laborious  correspondence  with  the  family, 
lelatives,  and  contemporaries  of  McDowell,  and  col- 
lected all  available  knowledge  bearing  upon  his  life 
and  character.  This  sketch  was  subsequently  in- 
corporated in  Gross's  American  Medical  Biography, 
published  by  Lmdsay  &  Blakiston.  of  Philadelphia, 
in  1861.  The  critical  investigations  by  Professor 
Gross  of  the  original  reports  of  various  operators, 
together  with  the  incontrovertible  testimony  pre- 
sented as  to  McDowell's  priority,  placed  McDowell's 
claims  beyond  all  dispute  and  established  firmly  his 
position  as  the  originator,  by  successful  accomplish- 
ment, of  the  radical  cure  of  ovarian  tumors  by  ab- 
dominal section. 

In  1879  the  Kentucky  State  Medical  Society 
erected  over  the  grave  of  McDowell,  at  Danville,  a 
monument  to  perpetuate  his  name  and  fame.  The 
dedication  of  this  monument  on  the  fourteenth  day 
of  May,  1879,  was  the  most  imposing  event  in  the 
annals  of  the  medical  profession  of  Kentucky.  The 
address  of  the  occasion  was  delivered  by  Professor 
Gross  before  a  large  audience  composed  of  members 
of  the  State  r^Iedical  Society,  officials  of  the  State, 
and  a  large  concourse  of  prominent  citizens.  Upon 
the  speaker's  stand  were  seated  the  governor  of  the 
Commonwealth,  the  secretary  of  State,  and  other 
officials ;  the  president  of  the  American  Medical  As- 
sociation (Dr.  Lewis  A.  Sayre)  ;  the  venerable  Dr. 
Gilman  Kimball,  of  Lowell,  Mass.  (who  had  per- 
formed ovariotomy  nearly  three  hundred  times)  ; 
and  numerous  other  eminent  American  surgeons. 
Among  the  tributes  to  McDowell  presented  on  this 
occasion  were  letters  from  Sir  Spencer  Wells,  Oliver 
^^'endell  Holmes,  T.  Gaillard  Thomas,  Edmund 
Randolph  Peaslee,  Theophilus  Parvin,  and  others. 
The  oration  of  Professor  Gross  is  a  masterpiece  of 
biographical  literature,  quite  worthy  of  the  occa- 
sion and  its  distinguished  author.  The  occasion  is 
memorable  for  the  achievement  it  celebrated,  and 
memorable  for  the  poet  who  put  it  in  verse.  Achilles 
can  never  be  forgotten  because  Homer  fixed  his 
fame. 


936 


WATSON:  PELLAGRA. 


[New  York 
Medical  Jourkal. 


Other  and  more  eloquent  speakers  will  tell  you 
of  the  struggles  of  McDowell's  followers  in  Amer- 
ica, in  Great  Britain,  in  France,  and  in  Germany. 
The  work  was  in  the  hands  of  a  few  courageous 
spirits,  who  fought  on  in  the  face  of  opposition  and 
even  persecution  until  the  dawn  of  the  Listerian  era 
lighted  the  way  to  the  present  proud  position  of  ab- 
dominal surgery.  Pelvic  and  abdominal  surgery 
began  with  ovariotomy ;  ovariotomy  began  with 
McDowell. 

The  Atherton. 

 ^  

(Original  tomwnicalions. 


PELLAGRA. 
By  J.  J.  Watson,  M.  D., 
Columbia,  S.  C. 
Observations  on  the  Disease,  as  a  Result  of  Study  of  One 
Hundred  Cases  in  South  Carolina  and  Italy* 

After  the  learned  and  interesting  dissertation  on 
pellagra,  presented  at  our  last  meeting  by  my  friend 
Dr.  J.  W.  Babcock,  I  direct  your  attention  to  this 
subject  with  great  trepidation,  and  console  myself 
by  hoping  that  interest  will  be  kindled  by  these  ef- 
forts toward  the  fact  that  pellagra  does  exist  in 
South  Carolina.  Believing  as  I  do  that  this  patho- 
logical and  clinical  entity  does  exist  and  is  not  rare 
in  our  State  (contrary  to  the  teaching  of  all  medi- 
cal authorities)  I  do  not  think  that  our  attention 
can  be  too  vigorously  drawn  to  it,  so  that  we  may 
place  ourselves  in  a  position  to  recognize  it  in  its 
incipiency,  thereby  r-endering  that  aid  to  those  who 
seek  us,  that  they  so  urgently  need  and  for  which 
we  are  consulted.  After  we  have  become  ac- 
quainted with  the  manifestations  of  this  disease  we 
will  be  able  to  add  one  more  to  our  list  of  correctly 
classified  disorders,  and  our  cases  of  so  called  ec- 
zema, with  digestive  disorders,  and  neurasthenic, 
hysterical,  melancholic,  or  hypochondriacal  symp- 
toms will  appreciably  diminish.  It  has  been  impos- 
sible for  Dr.  Babcock  to  give  any  accurate  history 
of  the  cases  reported  by  him  on  account  of  the  fact 
-that  the  patients  themselves  were  not  in  a  mental 
condition  to  give  intelligent  answers  to  questions, 
and  relatives  could  not  be  interviewed. 

The  case  reported  here  has  been  under  my  obser- 
vation for  three  years,  and  my  own  knowledge  of 
the  symptoms  and  facts  obtained  from  her  mother 
and  husband  are  detailed  below. 

Case  L — Mrs.  N.  E.  O.,  white,  multipara,  aged  thirty-six, 
native  of  Newberry  County,  had  resided  in  Columbia  for 
past  seven  years,  two  years  prior  to  moving  to  this  city 
lived  at  Ninety-Six,  six  years  before  that  resided  in  Green- 
wood. 

Family  history  was  negative.  She  had  been  in  good 
health  until  sixteen  years  ago,  at  which  time  she  com- 
menced to  suffer  with  diarrhoea  at  longer  or  shorter  inter- 
vals, and  also  other  digestive  disorders,  nausea,  vomiting, 
and  capricious  appetite,  etc.  The  diarroea  increased  in 
severity  until  three  years  ago,  she  was  then  treated  in  a 
hospital  for  two  months  with  marked  improvement  of  the 
diarrhoea]  condition,  and  also  in  her  general  condition ; 
since  then  she  had  had  occasional  attacks  of  diarrhoea.  Her 
previous  habit  was  that  of  constipation ;  the  diarrhoea  would 
alternate  with  constipation,  but  the  diarrhceal  periods  pre- 

•Read  by  invitation  before  the  Chester  County,  S.  C,  Medical 
Society  on  September  7,  1908. 


dominated.  Soon  after  the  commencement  of  the  diarrhcea 
there  was  noticed  a  marked  lack  of  energj',  sleeplessness, 
and  headache.  Ten  years  ago  (while  living  in  Greenwood) 
an  eruption  appeared  on  the  back  of  her  hands,  which  re- 
curred every  year  since  then  in  the  spring  and  seemed  to  be 
connected  with  the  digestive  disturbances,  that  is,  the  acme 
of  these  disorders  being  synchronous  with  the  acme  of  the 
eruption.  The  eruption,  always  made  its  appearance  in  the 
early  spring,  gradually  disappearing  until  fall,  leaving  the 
skin  pigmented,  thick,  and  rough.  Two  years  after  onset  of 
this  diarrhcea  it  was  noticed  that  she  was  not  as  jocose  as 
formerly,  and  did  not  manifest  interest  in  persons  or  sur- 
roundings, as  was  her  custom,  apparently  mentally  de- 
pressed. This  condition  gradually  increased  until  she 
reached  her  present  mental  condition.  Four  years  ago  her 
ovaries  were  removed  for  this  nervous  condition,  but  with- 
out benefit.  She  had  been  in  a  state  of  valetudina- 
riailism  for  the  past  twelve  years,  complaining  constantly, 
besides  the  digestive  disorders  of  pain  the  whole  length  of 
spine,  but  more  especially  between  the  shoulder  blades,  and 
also  across  the  buttocks,  and  constant  headache.  Occasion- 
ally there  has  been  typical  hysterical  seizures  for  the  past 
seven  years. 

Status  present:  February  3,  1908.  Patient  fairly  well 
nourished,  slightly  anaemic,  abdomen  tympanitic,  bowels 
constipated,  temperature  99°  P.,  pulse  96,  respiration  24; 
mental  attitude  dull,  very  nauseated  and  vomited  frequently, 
excessive  salivation,  and  buccal  mucosa  bright  red.  She 
complained  of  haemorrhoids  protruding  and  painful,  exam- 
ination disclosed  the  fact  that  she  had  neither  external  nor 
internal  haemorrhoids,  but  mucosa  of  rectum  was  a  z'ery 
bright  red.  Erythema  on  back  of  hands  extending  from 
three  inches  above  wrist  joint  to  within  one-eighth  inch  of 
nails  on  fingers  giving  the  finger  tips  a  peculiarly  white  and 
glistening  appearance.  The  skin  was  slightly  swollen,  re- 
minding one  of  a  severe  sunburn.  It  was  also  thick,  pig- 
mented parchmentlike,  and  fissured.  Right  pupil  was  di- 
lated, contracted  to  both  light  and  accommodation,  patella 
reflexes  were  exagg'erated,  marked  tenderness  over  spine  in 
middorsal  region. 

February  4,  1908.  Patient  was  apparently  in  a  state  of  acute 
delirium,  oblivious  to  her  surroundings;  she  was  removed 
to  the  Columbia  Hospital  at  10:30  a.  m.  On  admission  her 
pulse  was  found  to  be  96  and  intermittent ;  temperature 
98.5°  F.,  respiration  72.  11  :oo  a.  m.  patient  was  very  noisy, 
received  one  fourth  morphine  hypodermically.  12  m. 
respiration  64,  other  conditions  the  same.  4  p.  m.  pulse 
92,  temperature  97°  F.,  respiration  62.  8  p.  m.  pulse  120, 
temperature  98°  F.,  respiration  62.  8  p.  m.  pulse  120,  tem- 
perature 98°F.,  respiration  60;  spoke  a  few  "clear  minded 
words." 

February  5,  1908.  4:30  a.  m.  pulse  90,  temperature 
98.6''F.,  respiration  40.  Involuntary  evacuation  of  bladder; 
8:30  a.  m.  pulse  84,  temperature  99 '^^F.,  respiration  29.  Since 
then  pulse  ranged  from  104  to  70,  respirations  24.  Mental 
attitude  the  same,  would  not  talk,  groaned  incessantly. 

February  9th.  Mental  condition  not  altered;  digestive 
disturbances,  nausea,  vomiting,  etc.,  had  disappeared ;  with 
difficulty  she  was  induced  to  take  nourishment.  Hands 
were  not  so  red  or  swollen  at  site  of  eruption,  the  skin  had 
a  swarthy,  slightly  purplish,  parchmentlike  appearance,  fis- 
sured, and  squamous. 

Was  the  hurried  respiration  on  admission  hysterical? 
Why  such  marked  periodicity  in  the  appearance  of  the 
eruption?   If  this  was  not  pellagra  what  was  it? 

Blood  showed  evidences  of  mild  secondary  anaemia. 
Twelve  slides  were  examined  for  hook  worm,  but  none 
found. 

Patient  died  on  February  12,  1908.  Temperature  for 
twenty-four  hours  prior  to  death  varied  from  101°  F.  to 
103°  F.    Arms  were  fixed  on  chest  and  rigid. 

Case  II. — Seen  August  5,  1908.  with  Dr.  Black.  Mrs.  B.. 
white,  occupation  cotton  mill  operative,  aged  twenty-four 
years ;  two  children,  youngest  three  years  old.  Native  of 
Aiken  County,  South  Carolina ;  had  resided  in  this  county 
eight  years. 

Persistent  diarrhcea  was  noticed  ten  years  ago.  recurring 
each  spring ;  eruption  on  hands  and  arms  was  first  noticed 
about  three  years  ago.  occurring  also  in  spring  with  diar- 
rhoea. Patient  was  nervous  and  depressed  at  each  exacer- 
bation of  eruption,  not  before  eruption  appeared.  Two 
years  ago  after  the  death  of  her  infant  she  was  very  de- 
pressed and  never  regained  her  former  mental  attitude. 


May  8,  1909.] 


WATSON:  PELLAGRA. 


937 


First  symptom  of  insanity  appeared  July  25,  1908,  consist- 
ing in  delusions  ot  hearing,  hallucinations ;  especially  im- 
pressed that  she  saw  and  talked  to  her  father,  who  had  been 
dead  for  years. 

August  5th.  At  intervals  of  a  few  hours  she  clutched 
her  throat  with  both  hands  and  tried  to  pull  "something  oui 
that  is  burning  so."  These  efforts  became  so  frantic  that 
it  was  necessary  to  restrain  her  to  prevent  asphyxiation. 
She  talked  constantly,  and  was  in  a  state  of  acute  delirium. 
Pupils  were  widely  dilated,  tongue  very  red,  profuse  saliva- 
tion. There  was  marked  tenderness  in  middorsal  region. 
Reflexes  were  exaggerated. 

August  6th.    Acute  mania. 

August  7th.  Patient  died.  This  woman  has  always  eaten 
bought  meal  (Western  meal). 

Deiinition. — Pellagra  is  a  chronic,  endemic  dis- 
ease, caused  by  eating  Indian  corn  infected  with 
specific  microorganisms.  It  is  characterized  by  di- 
gestive disorders,  dermatitis  on  the  parts  of  the 
body  exposed  to  the  sun,  and  various  mental  phe- 
nomena, principally  depression,  and  in  some  cases 
by  symptoms  referable  to  spinal  degeneration.  The 
history  of  pellagra  cannot  be  traced  further  back 
than  1735,  although  in  1600  Baruino  described  a 
condition  that  was  evidently  pellagra  in  the  Ameri- 
can Indians,  and  he  attributed  it  to  the  eating  of 
diseased  Indian  corn.  In  1735  Casal  first  described 
the  disease  in  Spain,  it  having  followed  almost  im- 
mediately the  cultivation  of  Indian  corn  in  that 
country.  It  soon  after  appeared  in  Italy,  and  since 
then  has  been  recognized  in  every  maize  producing 
country. 

In  December,  1907,  Dr.  J.  W.  Babcock,  superin- 
tendent of  the  Hospital  for  the  Insane,  Columbia, 
S.  C,  submitted  to  the  South  Carolina  State  Board 
of  Health  a  paper  entitled  What  are  Pellagra  and 
Pellagrous  Insanities.  Does  such  a  Disease  exist 
in  South  Carolina?  This  paper  was  published  with 
the  annual  report  of  the  South  Carolina  Board  of 
Health,  1907.  It  was  reprinted  in  the  Journal  of 
the  South  Carolina  Medical  Association  in  Feb- 
ruary, 1908,  and  in  the  American  Journal  of  In- 
sanity, April,  1908. 

To  the  wide  circulation  of  this  article  published 
in  this  way  is  due  the  general  interest  which  is  now 
being  manifested  in  this  disease. 

Jt'.tiology.  The  Italian  Maize  Theory.  This  the- 
ory is  based  upon  the  following  facts,  viz.:  i.  That 
maize  is  the  staple  cereal  consumed  by  the  inhab- 
itants in  pellagrous  countries;  2,  that  pellagra  is  now 
recognized  as  a  disease  in  every  maize  producing 
country ;  3,  that  extracts  made  from  damaged  maize 
will  produce  in  men  and  animals  symptoms  similar 
to  pellagra ;  and  4,  that  symptoms  similar  to  pel- 
lagra have  been  produced  in  animals  by  feeding 
them  on  damaged  maize. 

Tl^  North  American  continent  is  the  natural 
habitat  of  Zea  niais,  therefore,  I  believe  the  original 
home  of  pellagra.  In  1600  Baruino  described  a  con- 
dition that  was  evidently  pellagra  in  the  American 
Indians,  and  he  attributed  it  to  the  eating  of  Indian 
corn.  MafFei  in  the  same  year  noticed  that  Indians 
eating  damaged  corn  had  a  peculiar  weakness.  This 
was  evidently  pellagra.  (Lombroso.)  Authors  after 
Baruino  and  Maffei  do  not  speak  of  the  malady  in 
men,  but  references  are  found  to  a  condition  exist- 
ing among  horses  in  Mexico,  which  was  character- 
ized by  the  animal  becoming  paretic,  tabetic,  with 
loss  of  hair.  This  was  attributed  by  the  writers  to 
the  animal  having  eaten  damaged  corn.  The  dis- 
ease followed  quickly  the  introduction  of  corn  in 


Spain  and  also  in  Italy.  Frappoli,  physician  for  the 
hospital  of  Milan,  observed  the  disease  there,  and 
gave  it  its  present  name  (Pellis,  the  skin,  and  'V,'"^! 
a  seizure).  At  this  time  the  disease  was  believed 
to  be  in  some  way  associated  with  the  eating  of 
damaged  corn,  for  in  1776,  an  act  was  passed  by  the 
request  of  the  Sanitary  Committee  of  Venice  that 
no  one  in  the  public  markets  of  Venice  could  of- 
fer for  sale  or  exchange  corn  that  had  a  bad  odor 
or  taste. 

In  1844  Balladini  stated  and  demonstrated  that 
pellagra  was  caused  by  eating  damaged  maize.  At 
that  time  he  had  not  become  acquainted  with  the 
conditions  that  rendered  corn  dangerous  as  an  ali- 
ment, but  later  propounded  the  theory  that  damp- 
ness caused  a  fungus  to  develop  on  the  corn  and  that 
the  fungus  caused  the  disease.  He  also  recommend- 
ed that  those  suffering  with  pellagra  should  not  eat 
maize,  and  was  gratified  to  observe  cases  of  recent 
origin  recover  on  a  maize  free  diet.  This  circum- 
stance confirmed  him  in  his  theory  as  to  causation. 
He  was  vigorously  opposed  in  his  opinion  by  a  great 
many  physicians  and  he  as  vigorously  maintained 
his  position.  The  acrimonious  discussion  that  arose 
as  the  result  of  doctors  disagreeing,  and  the  fact 
that  the  disease  had  increased  in  Lombardy  from 
fourteen  a  thousand  in  1839  to  twenty-eight  a  thou- 
sand in  1856,  naturally  directed  the  attention  of  the 
public  to  the  disease,  and  we  find  that  a  commission 
was  appointed  by  the  Lombardian  government  to 
look  into  and  report  on  the  causation  of  the  malady. 
This  commission,  after  the  usual  vacillations  that 
are  inseparable  from  ignorance,  reported  that  Bal- 
ladini's  maize  theory  in  their  opinion  was  correct, 
but  that  they  could  not  concur  in  his  opinion  that 
a  maize  free  diet  had  any  effect  on  the  disease. 
They  inclined  to  the  belief  that  the  improvement  that 
followed  Balladini's  efforts  was  due  to  better  con- 
ditions of  alimentation.  Subsequently  Balladini  dis- 
covered in  the  copper  green  mould  that  is  on  the 
bad  maize  a  microorganism,  Sporiosorinm  niaidis. 
He  cultivated  this  fungus  artificially  and  with  it 
was  able  to  produce  in  men  a  burning  sensation  in 
the  mouth,  pharynx,  oesophagus,  gastritis,  and  diar- 
rhoea. Chickens  fed  on  this  infected  corn  lost  their 
feathers  and  showed  other  symptoms  of  pellagra.  It 
has  been  shown  and  admitted  by  Balladini  that  this 
is  a  very  rare  fungus  on  corn  and  is  not  the  cause 
of  pellagra.  Yet  the  finding  of  this  fungus  was  of 
great  moment,  for  it  was  the  cause  of  further  re- 
searches, and  these  studies  have  been  of  great  prac- 
tical value  in  preventing  pellagra  in  Italy. 

The  present  practically  universally  accepted  the- 
ory of  the  causation  of  pellagra  is  the  theory  of  Pro- 
fessor Lombroso,  of  Turin.  Evidently  stimulated 
by  Balladini's  work,  he,  in  1864,  commenced  ex- 
periments with  bad  maize,  and  eventually  arrived  at 
conclusions  that  after  having  been  vigorously  op- 
posed, have  been  accepted  by  nearly  every  one  who 
has  given  any  time  and  study  to  the  disease.  The 
Italian  physicians  are  fully  satisfied  that  if  damaged 
maize  could  be  excluded  from  Italy,  there  would  be 
no  pellagra  there.  This  is  practically  the  universal 
opinion  of  men  who  have  lived  with  the  disease  and 
have  studied  it  for  generations,  and  cannot  be  light- 
ly passed  over.  The  prevention  and  treatment  of 
pellagra  in  every  country  to-day  is  a  result  of  Lom- 
broso's  labors.     His  theory  is  that  certain  fungi, 


938 


IVATSON:  PELLAGRA. 


[New  York 
Medical  Journal. 


penicilli,  and  aspergilli  form  on  maize  if  it  is  ex- 
posed to  moisture.  That  these  fungi  produce  in  the 
corn  a  toxine,  and  this  toxine  when  taken  into  the 
system  produces  pellagra.  These  organisms  when 
injected  in  persons  or  animals,  or  when  grown  on 
any  other  culture  medium  than  maize  are  nontoxic. 
If  grown  on  a  culture  media  of  corn  meal  gruel,  it 
appears  in  three  portions;  the  upper  portion,  fungus, 
nontoxic ;  middle  portion,  liquid,  toxic ;  and  lower 
portion  or  precipitate,  toxic.  He  has  made  a  33.33 
per  cent,  alcoholic  extract  from  damaged  maize  that 
the  calls  pcllagrozina,  and  with  this  extract  he  has 
produced  in  both  men  and  animals  symptoms  sim- 
ilar to  pellagra.  He  conjectures  that  two  toxines 
are  found  in  unsound  maize ;  one  resembling  strych- 
nine and  the  other  resembling  hemlock. 

Professor  Ceni  has  demonstrated  that  the  penicilli 
and  aspergilli  develop  on  maize  two  toxines,  one  ex- 
citant producing  convulsions,  and  the  other  de- 
pressant or  paralyzing.  His  experiments  have 
shown  him  that  these  fungi,  under  certain  condi- 
tions, can  at  one  time  produce  the  excitant  toxine 
and  at  another  time  produce  the  depressant  toxine ; 
the  cause  of  these  opposite  actions  not  now  being 
well  understood.  He,  however,  has  shown  that  the 
toxine  produced  in  spring,  summer,  and  autumn  is 
very  much  more  potent  than  the  toxine  produced  in 
winter,  and  it  may  be  due  to  this  fact  that  we  have 
in  winter  the  remission  that  characterizes  this  dis- 
ease. 

Experiment  on  Tzcclve  Healthy  Men.  Twelve  healthy 
men  were  given  tincture  of  bad  maize  by  mouth  for  many 
days,  and  all  symptoms  were  carefully  noted.  There  were 
forty-three  symptoms  noted  in  ten  patients,  while  two  were 
not  affected.  The  symptoms  diarrhoea,  increased  appetite, 
soft  faeces,  revulsion  to  food,  weakness,  lassitude,  erythema, 
desquamation,  and  skin'  lesions  were  the  most  important. 
There  was  also  a  pronounced  effect  on  the  heart  and  kid- 
neys. There  was  diminution  in  weight  from  four  to  twenty 
pounds.  Two  patients  increased  in  weight  six  and  eight 
pounds.  Many  of  these  symptoms  lasted  two  and  one  half 
months,  and  in  one  patient  for  nine  months  after  the  ex- 
periment was  discontinued.  Six  of  the  men  were  accus- 
tomed to  alcohol.  Two  of  these  had  no  symptoms  and 
two  resisted  more  than  the  others.  One  of  the  subjects  was 
a  victim  of  psoriasis  and  the  skin  disease  was  cured  by  the 
experiment.  Since  then  the  tincture  of  bad  maize  has  been 
used  by  Lombroso  as  a  treatment  of  psoriasis  with  success. 

Experiment  on  a  Dog.  Weight,  fifteen  pounds.  The  dog 
was  given  15  c.c.  of  pellagrozina  hypodermically.  No  symp- 
toms for  forty-five  minutes.  After  one  hour  he  walked 
with  his  legs  far  apart  and  hind  legs  rigid.  Photophobia. 
In  one  hour  and  six  minutes  slight  tetanic  contractions. 
Reflexes  exaggerated,  very  rigid,  convulsions  if  the  least 
irritant  was  applied ;  drank  a  great  deal  of  water  but  could 
eat ;  after  two  and  one  quarter  hours  had  general  convul- 
sions ;  could  not  stand  water ;  after  three  hours  had  a  real 
tetanic  convulsion;  after  four  hours  was  better,  could  be 
touched  but  could  not  stand  noise.  Faeces  very  soft  and  bad 
odor.  After  nineteen  hours  could  not  walk;  paresis  of  hind 
legs,  had  convulsions,  salivation ;  died  in  twenty-four  hours. 

Experiment  on  a  Dog.  The  dog  was  given  one  half 
pound  of  bad  meal  each  day  from  Feljruary  4th  to  May  4th. 
The  dog  gradually  lost  weight  and  strength.  The  last  two 
days  of  his  life  he  lost  four  and  a  half  pounds.  May  4th 
his  gait  was  not  natural,  rigid  in  hind  legs;  reflexes  exag- 
gerated; appetite  good,  but  could  not  swallow  food;  thirsty, 
tremor,  slow  respiration ;  diarrhoea.  From  May  4th  was  fed 
on  good  bread  and  milk.  May  5th  and  6th  he  had  very 
rough  hair;  convulsions  when  he  tried  to  walk;  thirsty; 
not  as  intelligent.  May  7th,  dilated  pupils,  not  active  to 
light.  Tetanic  spasm  on  least  irritation.  Respiration  in- 
creased. While  healthy  dog  makes  twelve  respirations,  this 
affected  dog  made  one  hundred  and  twelve,  whining  with 
each  respiration.  May  8th,  completely  rigid.  Kvery  three 
seconds  had  tetanic  convulsions,  general  tremor,  could  not 


stand  on  his  feet,  temperature  104°  F.  May  9th,  could  not 
stand  or  drink,  rigid.    May  nth,  died. 

Chickens  when  fed  with  infected  corn  lose  feath- 
ers, become  very  poor,  have  erythema,  with  thick- 
ened and  wrinkled  skin  ;  the  feet  and  legs  assume 
a  rough  and  scaly  condition ;  the  feet  and  legs  of  a 
chicken  three  months  old  resemble  the  legs  of  a  very 
old  chicken.  They  •  eventually  become  paretic, 
ataxic,  and  die.  Young  chickens  when  infected  do 
not  develop,  do  not  feather,  have  erythema,  becoine 


Fig.  I. — All  three  of  these  chickens  are  of  the  same  age  and  breed. 
Pellagra  developed  iu  the  two  small  ones  from  eating  infected 
corn. 

paretic  and  ataxic,  and  die.  The  photographs  illus- 
trate plainly  this  effect,  as  all  three  chickens  are  the 
same  age  and  bred  and  hatched  at  the  same  time. 

Lombroso's  experiments  have  been  confinned  by 
a  great  many  experimentors  in  various  pellagra 
countries. 

From  my  own  observation  and  studies.  I  am  fully 
convinced  that  damaged  maize  is  the  cause  of  the 


KiG.  2. — Chickens  with  pellagra  lose  their  feathers  and  horny  scales 
and  excresences  develop.  Their  feet  and  legs  resemble  those 
of  old  chickens. 

disease  here.  Our  season  and  climate  both  are  con- 
ducive to  the  thorough  maturing,  curing,  and  pre- 
serving of  Indian  corn  and,  therefore,  in  exceptional 
cases  only  Indian  corn  will  cause  the  disease.  I  am 
of  the  opinion  that  corn  properly  gathered  and 
housed  in  the  southern  States  will  not  cause  pel- 
lagra. All  of  the  cases  that  I  have  seen  in  this 
.State  give  a  history  of  having  used,  bought,  or 
rather  shipped  meal  at  some  tiirie  during  the  year, 
and  a  great  many  of  tliem  used  it  continuously.  I, 


!May  8,  1909.] 


WATSON:  PELLAGRA. 


939 


therefore,  believe  that  Western  corn  goes  through  a 
heat  before  it  readies  its  destination,  and  it  is  dur- 
ing this  heating  process  that  the  fungi  develop  and 
when  sold  the  corn  is  infected  with  the  fungi,  as  the 
samples  I  have  secured -from  the  markets  here  plain- 
ly show.  By  inspection,  you  will  see  that  the  sam- 
ples of  corn  from  Turin  and  Venice  are  not  so  much 
affected  as  samples  one  and  two.  The  Turin  and 
\'enice  corn  would  not  be  allowed  to  be  sold  in 
their  respective  markets. 

Horses  also  suffer  from  the  disease,  which  is 
manifested  in  several  ways.  If  large  quantities  of 
the  diseased  corn  has  been  fed  them,  they  die  sud- 
denly with  what  is  ordinarily  termed  "blind  stag- 
gers/' Symptoms  that  are  produced  by  corn  not 
so  much  infected  or  fed  in  small  quantities  are 
paresis  or  rigidity  ;  the  horses  manifest  symptoms  of 
tetanus  except  there  are  no  clonic  convulsions ;  they 
lose  their  hair  and  become  very  thin.  When  proper 
food  is  supplied  the  animals,  recovery  commences, 
but  convalescence  is  very  protracted. 

The  disease  is  more  prevalent  between  the  ages 


Fig.  3. — Normal  chicken;  same  brood  as  shown  in  Fig.  2. 


of  twenty  and  forty,  but  it  may  occur,  and  I  have 
seen  cases  in  children  six,  seven,  and  nine  years  old, 
who  had  had  the  disease  for  three  years  in  succes- 
sion. Poverty  is  ascribed  as  one  of  the  prime  aetio- 
logical  factors.  In  Italy  only  the  poorest  peasants 
have  the  disease,  for  the  reason  that  they  sell  the 
better  part  of  their  crop  and  keep  the  "nubbins"  or 
immature  corn  for  their  own  use,  and  their  diet  con- 
sists almost  entirely  of  pollenta  (corn  meal  mush), 
and  they  seldom  eat  meat  or  any  other  cereal.  Con- 
ditions in  America  are  quite  different,  for  the  poor- 
est of  our  population  live  more  sumptuously  than 
even  the  well  fed  peasant  in  Italy ;  that  is,  they  have 
a  more  varied  diet,  meat,  vegetables,  etc.  While 
the  disease  is  more  prevalent  among  the  poorer 
classes  here,  it  is  not  entirely  confined  to  them,  for 
I  have  seen  cases  in  men  and  women  who  were  well 
to  do.  Also,  it  occurs  in  the  towns  and  cities,  while 
in  Italy  it  is  almost  entirely  confined  to  the  rural 
districts.  T.he  reason  for  this  is  that  the  country 
people  here  usually  use  home  ground  meal,  and 
those  residing  in  the  cities  are  forced  from  neces- 
sity to  buy  shipped  meal.  Women  are  more  often 
affected  than  men.  Seventy-five  per  cent,  of  the  pa- 
tients here  are  women.  In  Italy  both  sexes  are 
about  equally  affected. 

There  has  been  some  doubt  expressed  as  to 


whether  the  disease  we  have  here  is  pellagra  or  not, 
but  having  seen  numbers  of  cases  in  Italy  at  the 
Pellagrosario,  at  Inziago,  and  several  cases  with 
Professor  Lonibroso  in  his  clinic  at  Turin,  I  most 
emphatically  state  that  the  disease  as  it  exists  in 
South  Carolina  is  identical  with  a  disease  in  Italy 
which  is  called  pellagra. 

Pathology. — Unfortunately,  I  am  unable  to  give 
a  pathological  report  from  a  case  occurring  in  this 
country.  I  have  been  unable  tp  get  a  competent 
pathologist  to  examine  the  brain  and  cord.  There- 
fore, I  cite  a  case  reported  by  Professor  Lombroso : 

Case, — A  man,  twenty-eight  years  old,  eating  only  pol- 
lenta, was  received  in  the  hospital  in  1882.  He  had  had  for  five 
years  erythema  and  desquamation  on  hands,  and  diarrhoea. 
In  1887  symptoms  of  insanity  developed.  Insonmia,  de- 
pression of  spirits,  suicidal  tendencies;  difficult  gait  on  ac- 
count of  paresis  of  lower  limbs ;  was  therefore  unable  to 
stand.  Tremors  around  the  mouth ;  coma  vigil,  ansesthetic 
on  the  backs  of  hands  and  arms;  hypersesthetic  on  the  face; 
pupils  dilated ;  choreic  movements ;  strong  contractures 
like  epilepsy  in  arms;  temperature  105°  F..  Dyspnoea; 
death. 

Autopsy:  CEdema  of  malleoli  and  decubitus.  Cerebral 
convolutions  slightly  atrophic;  floor  of  fourth  ventricle 
ansemic ;  heart  and  aorta  slightly  dilated.;  aortic  segment 
thick;  lungs  oedematous ;  spleen  and  liver  congested, both  had 
spots  of  fatty  degeneration.  Kidneys  soft ;  cortical  sub- 
stance very  thin.  Bowels  atrophic;  muscular  coat,  and  in- 
testinal mucosa  very  anaemic ;  hypertrophy  of  the  salivary 
gland  ;  mesentery  glands  reddened. 

Spinal  cord :  The  inside  dura  appeared  to  be  polished , 
the  pia  was  thick  and  opaque,  especially  on  the  dorsal  sur- 
face; on  the  arachnoid  were  many  hard,  small  placques 
that  resembled  bone.  Meninges  were  hyperasmic.  The  con- 
sistency of  the  cord  was  decreased  in  the  cervical  region, 
the  gray  matter  resembled,  one  section,  commencing  de- 
composition. Microscopical  examination  of  cord  showed 
degeneration  of  the  pyramidal  tract.  This  lesion  was  sym- 
metrical from  the  site  of  the  fifth  pair  of  cervical  nerves 
and  increased  as  it  descended  the  cord  with  maximum  at 
the  lumbar  vertebrse.  On  this  pair  very  few  nerve  fibres 
w  ere  preserved,  the  nerve  fibres  being  replaced  by  sclerosed 
nerve  tissue.  The  posterior  columns  are  very  slightly  af- 
fected and  limited  to  the  column  of  Goll  and  a  few  fibres 
of  the  column  of  Burdach.  This  degeneration  stopped  at 
the  first  cervical  nerves  where  the  sclerosed  nerve  tissue 
could  not  be  seen.  The  ganglian  cells  of  the  gray  matter, 
especially  on  the  anterior  cornu  of  the  dorsal  region  were 
atropic,  very  pigmented.  The  principal  pathological  lesion 
was  in  the  spinal  cord,  and  the  pyramidal  tract  had  suf- 
fered most ;  next  the  ganglia  as  well  as  of  the  anterior 
cornu. 

It  is  typical  of  the  disease  that  the  different  por- 
tions of  the  cord  are  not  affected  alike.  Sometimes 
you  will  find  the  disease  in  the  cervical  or  dorsal  or 
lumbar  region,  in  one  or  in  all  parts,  and  that  ac- 
counts for  the  variety,  or  rather  seemingly  contra- 
dictory symptoms  seen  in  different  cases.  The 
lesions  found  in  other  portions  of  the  body  do  not 
differ  from  those  found  in  any  chronic  exhausting 
disease. 

Symptoms.  The  malady  is  so  insidious  in  the  be- 
ginning that  it  is  difficult  to  state  what  the  premoni- 
tory symptoms  are,  except  that  in  all  cases  the  his- 
tory of  gastrointestinal  disarrangement  for  a  longer 
or  shorter  period  before  the  characteristic  eruption 
appears,  can  always  be  obtained.  There  is  usually 
more  or  less  depression,  coincident  with  digestive 
disorders,  and  it  increases  as  the  disease  progresses. 
The  gastrointestinal  symptoms  consist  of  a  burning 
sensation  in  the  oesophagus  or  stomach,  with  chang- 
ing in  the  color  of  the  buccal  mucosa.  This  mem- 
brane assumes  a  red,  denuded  appearance,  which 
in  some  cases  is  accompanied  by  salivation  and  gin- 
givitis.   The  appetite  is  never  normal ;  either  in- 


940 


WATSON:  PELLAGRA. 


[New  York 
Medical  Journal. 


creased  or  diminished,  the  patients  drinking  large 
amounts  of  water  when  the  burning  sensation  in  the 
stomach  appears.  Loss  of  weight  occurs  in  eighty- 
four  per  cent,  of  all  cases,  being  more  pronounced 
in  cases  with  diarrhoea.  Diarrhoea  is  a  most  con- 
stant feature  of  the  disease,  but  constipation  is  some- 
times met  in  the  earlier  months  and  in  those  mildly 
infected.  After  these  disorders  have  lasted  for 
months,  the  characteristic  symptom  of  the  disease 
appears,  namely,  erythema  on  the  hands  and  arms 
not  covered  by  the  clothing. 

The  Skin  Eruption.  This  appears  first  in  the 
early  spring  months,  and  while  it  is  one  of  the  most 
characteristic  features  of  the  disease,  it  is,  per  se. 
one  of  the  most  insignificant.  It  is  usually  an  index 
to  the  severity  of  the  infection.  The  eruption  com- 
mences as  a  severe  sunburn  on  the  back  of  the 
hands  and  the  extensor  surface  of  the  arms  to  the 
height  that  the  sleeves  reach,  usually  extending 
around  to  the  flexor  surface  just  above  the  wrist, 
assuming  a  somewhat  triangular  shape,  the  base  be- 
ing on  the  radial  side  of  the  arm  and  not  more  than 
two  inches  wide  in  this  locality.  It  does  not  usual- 
ly exhibit  a  tendency  to  extend  to  the  flexor  sur- 
face. After  a  time  the  skin  desquamates  in  fine 
scales  if  the  inflammation  has  been  mild ;  if  severe, 
large  flakes  will  be  exfoliated,  leaving  denuded 
areas.  As  the  redness  fades,  the  skin  assumes  a 
characteristic  light  liver  or  chocolate  color,  which 
if  once  seen  cannot  be  mistaken  or  confounded  with 
any  other  skin  disease.  In  some  severe  cases,  the 
palmar  .surface  of  the  hand  is  also  affected,  and  I 
have  seen  the  skin  desquamate  in  large  flakes,  leav- 
ing the  inside  of  the  hand  soft  and  velvety.  This 
eruption  commences  in  February  or  March  and  con- 
tinues until  June,  when  it  gradually  fades,  disap- 
pearing in  July  or  August.  In  some  localities  there 
is  a  slight  recrudescence  in  October,  but  usually  the 
skin  remains  healthy  until  the  following  spring, 
when  the  eruption  reappears  and  follows  the  same 
course  as  it  did  the  previous  year,  except  that  it  is 
more  apt  to  be  more  severe.  As  a  result  of  the  re- 
peated inflammatory  attacks,  the  skin  becomes  pig- 
mented and  rough ;  the  hands  of  a  person,  twenty- 
five  years  of  age,  resembling  those  of  a  person 
seventy-five  years  old.  Portions  of  the  body  pro- 
tected by  clothing  are  not  subject  to  this  erythema 
except  the  skin  over  the  olecranon,  which  becomes 
very  rough  and  pigmented,  which  Dr.  Babcock  at- 
tributes to  pressure.  The  hands,  arms,  feet,  and 
legs  (of  those  who  go  bare  footed),  forehead,  neck, 
and  chest  are  the  sites  aflfected  in  the  order  named. 

Digestive  Disorders.  Diarrhoea  is  a  feature  of 
the  disease  at  some  time  in  its  course.  It  usually 
precedes  the  eruption  by  weeks  or  months.  The 
stools  vary  in  number  from  three,  to  thirty  in  twenty- 
four  hours,  as  many  at  night  as  in  the  day.  It  is 
in  no  way  affected  by  ordinary  treatment  or  diet. 
I  have  seen  it  persist  in  spite  of  the  most  careful 
feeding  and  large  doses  of  opium  and  bismuth,  and 
improve  when  no  treatment  was  given  and  diet  not 
restricted.  It  is,  therefore,  not  dependent  upon 
errors  in  diet  for  its  presence,  but  is  a  neurotrophic 
manifestation  dependent  upon  disease  of  the  spinal 
cord  that  affects  the  sympathetic  system.  The  diar- 
rhoea is  at  its  maximum  of  intensity  when  the  skin 
eruption  is  at  its  maximum,  and  gradually  improves 
after  June  or  July  coincident  with  the  improvement 


of  the  eruption.  With  this  diarrhoea  there  is  meteor- 
ism.  This  condition  persists  sometimes  after  the 
diarrhoea  has  disappeared. 

Tongue.  During  the  eruption,  the  tongue  as- 
sumes a  characteristic  condition.  It  becomes  bright 
red,  first  on  the  tip  and  edges,  and  gradually  the 
whole  surface  is  almost  or  quite  a  cardinal  red.  It 
being  a  cardinal  symptom  of  the  disease,  I  have  de- 
nominated it  the  cardinal  tongue.  In  addition  to 
the  color,  it  has  other  striking  peculiarities.  The 
epitheHum  seems  to  have  been  exfoliated,  and  the 
surface  has  a  smooth,  glistening  appearance.  The 
tongue  is  sometimes  flabby,  large,  and  marked  by 
the  teeth.  In  other  cases  it  is  rigid  and  pointed, 
and  seems  smaller  than  normal.  In  cases  of  mod- 
erate severity,  the  whole  buccal  mucosa  is  also  very 
red,  and  there  is  considerable  increase  in  the  salivary 
flow.  In  severe  cases  this  salivation  is  extreme,  the 
saliva  constantly  pouring  out  of  the  corners  of  the 
patient's  mouth.  This  and  the  swollen  condition  of 
the  gums  and  enlargement  of  the  salivary  glands 
are  very  apt  to  be  mistaken  for  mercurial  salivation, 
but  just  remember  that  in  mercurial  salivation  there 
is  always  quite  a  disagreeable  odor  to  the  breath, 
and  while  there  is  an  odor  to  the  salivation  in  pel- 
lagra, it  is  not  the  same  disgusting,  foetid  odor  that 
is  characteristic  of  mercurial  salivation. 

The  Stomach.  The  burning  sensation  has  already 
been  mentioned.  This  continues,  and  in  some  cases 
pyrosis  is  a  prominent  feature,  with  or  without 
belching.  Vomiting  occasionally  occurs,  but  is  not 
a  constant  feature  in  the  early  picture  of  the  dis- 
ease. These  patients  often  have  hallucinations  re- 
ferable to  their  stomach.  One  insane  patient  com- 
plained of  worms  in  her  stomach,  and  she  said  she 
could  feel  them  moving  and  eating  the  walls  of  it. 

The  Pupils.  In  eighty  per  cent,  of  the  patients 
you  will  find  some  abnormality  of  the  pupils.  The 
usual  condition  is  dilation ;  the  mydriasis  resembling 
that  produced  by  atropine.  It  may  be  bilateral  or 
unilateral.  In  the  latter  the  right  pupil  is  more  apt 
to  be  the  one  affected.  Pupillary  contraction  is 
rather  rare.  Diplopia  is  not  unusual,  also  photo- 
phobia. Lambroso  observes  that  the  left  lachrymal 
papilla  is  sometimes  white  and  the  right  pink.  How 
can  this  pupillary  manifestation  be  explained  ?  Is  it 
through  the  cervicle  sympathetic  trunk  or  through 
the  cilio  spinal  centre  ?  This  centre  is  located  in  the 
cord  between  the  first  cervicle  and  the  two  dorsal 
nerves,  the  part  of  the  cord  that  is  nearly  always  af- 
fected. We  know  that  in  apical  pneumonia,  it  is 
not  at  all  unusual  to  find  mydriasis  bilateral  or  uni- 
lateral. When  unilateral,  on  the  side  correspond- 
ing to  the  consolidation.  This  is  accounted  for  by 
the  stimulation  of  the  cervicle  sympathetic,  for  in 
this  disease  there  is  no  spinal  lesion. 

Pain  in  the  Back.  This  is  a  striking  feature  of 
the  disease  in  the  Italian  patients  whom  I  saw. 
.Some  of  the  patients  walking  stooped  over.  But  I 
have  not  observed  it  in  patients  I  have  seen  here. 
Pains  in  various  portions  of  the  body,  however,  are 
often  complained  of.  Tenderness  at  some  point 
along  the  spinal  column  is  almost  constant.  It  is 
usual  in  the  middorsal  region  and  is  easily  located. 
It  may  be  more  acute  on  one  side  than  on  the  other. 
In  the  patients  I  have  examined,  the  right  side  was 
the  tenderest.  The  reflexes  are  exaggerated,  the 
patella  reflexes  especially  being  more  lively.  One 


May  S,  1909.] 


BOGGS:  ROENTGEN  RAYS  IN  THORACIC  I.ES/OXS. 


may  be  more  exagg-erated  than  the  other,  and  when 
this  is  the  case,  the  most  exaggerated  corresponds  to 
the  side  that  has  the  most  acute  spinal  tenderness. 
In  very  severe  cases,  rather  those  in  which  there  are 
tetanic  contractions,  ankle  clonus  may  be  found. 
There  is  usually  analgesia  or  anaesthesia  on  the  backs 
of  the  hands  and  arms,  corresponding  to  the  site  of 
the  eruption.  Later  in  the  disease,  when  paresis 
sets  in,  the  reflexes  are  abolished.  The  pulse  is  ac- 
celerated, the  usual  rate  being  ninety  to  one  hun- 
dred. The  usual  temperature  is  97°  to  i03°  F. 
The  urine  is  pale,  and  the  patient  complains  of  a 
burning  sensation  during  micturition,  and  a  sensa- 
tion of  weight  on  the  bladder.  The  quantity  is  de- 
creased ;  two  pints  is  the  average ;  specific  gravity, 
1.005  to  1.025,  a  low  specific  gravity  being  the  rule. 
Reaction  was  in  seventy-six  per  cent,  slightly  acid  ; 
fourteen  per  cent,  neutral,  and  ten  per  cent,  alka- 
line. The  cases  with  alkaline  urine  are  very  severe. 
\"ertigo  is  complained  of  by  nearly  every  patient  and 
forms  a  very  common  feature  of  the  disease. 

Gait.  The  gait  is  either  simple  paralytic  or  par- 
alytic spastic.  The  patients  walk  with  their  legs  far 
apart,  and  as  paresis  sets  in  the  stride  is  very  much 
decreased,  and  the  patients  assume  a  peculiar  shuf- 
fling gait. 

Psychic  Phenomena.  Mental  depression  is  as 
constant  as  the  erythema  and  diarrha:a.  and  varies 
from  a  mild  case  of  the  blues  to  severe  melancholia. 
The  patients  seem  to  have  "forgotten  how  to 
laugh."  The  poor  sufferers  imagine  they  have  not 
a  friend  on  earth ;  that  even  their  own  children  or 
parents  dislike  them  and  have  some  unreconcilable 
grievance  against  them.  They  are  easily  provoked 
to  anger,  and  in  many  ways  indicate  lack  of  mental 
force.  Hallucinations  and  delusions  are  sure  to 
occur  at  some  time  in  the  disease,  and  no  two  pa- 
tients will  have  the  same  delusions.  In  Italy  ten 
per  cent,  of  the  patients  become  insane.  As  yet  we 
cannot  form  any  opinion  as  to  what  portion  of  our 
patients  will  become  insane,  but  if  records  of  cases 
are  kept  it  will  be  a  very  easy  matter  to  ascertain 
what  proportion  is  demented. 

I  have  endeavored  to  give  a  description  of  pel- 
lagra as  it  is  ordinarily  seen,  dealing  only  with  the 
symptoms  that  are  most  apt  to  be  present  and  the 
ones  that  should  be  carefully  looked  for  and  in- 
quired into.  The  disease  is  very  protean  in  its  man- 
ifestations. In  one  case  you  will  find  rigidity  with 
contractures,  in  another  case  you  will  find  paresis. 
The  symptoms  that  are  frequent  in  one  locality  are 
not  observed  in  another.  The  disease  has  so  many 
various  manifestations  that  it  would  be  too  tedious 
to  go  into  a  description  of  the  prominent  features 
of  each  case.  The  Italians  have  recognized  seven 
dif¥erent  kinds  of  pellagra,  viz. :  Pellagra  with  ery- 
thema ;  pellagra  with  insanity ;  pellagra  with  desire 
for  suicide  by  water ;  pellagra  with  desire  to  get 
away  from  water ;  pellagra  with  tendency  to  walk 
stooped  ;  pellagra  with  vertigo  ;  pellagra  with  desire  to 
eat  a  great  deal.  Lombroso  designates  the  following 
varieties :  Cerebral,  spinal,  ganglia,  atrophic,  gastric, 
cutaneous,  aphrodisiac,  and  tetanic.  Symptoms  that 
are  common  in  one  locality  are  not  known  in  an- 
other. For  example,  in  Pavia,  contractures  and 
mutism ;  in  Verona,  dilation  of  the  pupils  and.  sel- 
dom insanity.  In  the  Austrian  provinces,  patients 
complain  of  a  sensation  of  salt  in  their  mouths  and 


severe  pain  in  their  backs.  In  some  countries  it  is 
common  to  find  suicides,  in  others  infrequent.  Os- 
cillation of  the  head  is  also  frequent  in  some  locali- 
ties and  not  so  in  others. 

Complications.  In  Italy  one  of  the  most  frequent 
is  alcoholism.  This  is  not  so  in  the  Southern  states, 
for  the  few  men  whom  I  have  .seen  were  not  alco- 
holic, and  the  women  here  do  not  drink.  Ace- 
tonsemia  is  a  frequent  complication  here  and  the 
same  condition  obtains  in  Egypt  fSandwith),  and 
as  one  would  expect,  the  patients  are  often  victims 
of  phthisis,  as  the  diarrhoea  incident  to  the  disease 
is  conducive  to  debility  and  lowered  resistance. 

There  is  a  condition  described  by  Lombroso  that 
I  have  never  seen,  yet  I  have  no  doubt  that  the  con- 
dition exists  in  this  State.  He  calls  it  typhus  pel- 
lagra. The  symptoms  are  those  of  ordinary  pel- 
lagra for  several  years,  and  in  addition  the  patients 
have  tetanic  convulsions,  dysphasia,  vomiting,  pro- 
fuse diarrhoea  with  ammoniacal  odor,  also  the  same 
odor  of  the  perspiration  and  urine ;  temperature 
104°  F.  or  over.  This  commences  with  the  convul- 
sions, and  the  patients  become  unconscious  and  have 
acute  delirium.  The  face  is  rigid  and  contracted, 
and  sometimes  tremor  is  noticed  around  the  n.ou'h. 
Opisthotonus  occurs,  reflexes  are  exaggerated,  and 
there  is  ankle  clonus.  The  least  irritation  causes 
convulsions.  There  is  a  great  increase  of  urea  in  the 
blood;  and  the  case  always  terminates  in  death. 

Treatment.  The  direct  treatment  of  the  malady 
has  not  been  very  satisfactory.  Lombroso  recom 
mends  Fowler's  solution  of  arsenic  in  ascending 
doses.  Babes  is  an  advocate  of  and  uses  atoxyl  (a 
form  of  arsenic)  hypodermically  and  reports  very 
assuring  results  from  its  use.  These  results  have 
not  been  confirmed,  and  possibly  the  improvement 
following  the  use  of  the  drug  may  be  mistaken  for 
the  natural  remissions  that  occur  in  the  disease.  The 
drug  is  given  in  doses  from  one  to  three  grains  in- 
jected deep  into  the  gluteal  muscles  every  three  01^ 
four  days.  It  is  stated  by  Dr.  Babcock  that  the, 
diarrhoea  and  rash  is  controlled  better  by  atoxyl  in 
the  first  stage  than  by  any  other  procedure.  Good 
hygienic  surroundings,  good  food,  especially  meat? 
and  avoidance  of  all  articles  containing  Indian  corn, 
and  hydrotheraphy  are  all  conducive  to  improve- 
ment. 

1312  Blandixg  Street. 


THE    VALUE    OF    THE    ROENTGEN    RAYS  IN 
THORACIC  LESIONS.* 

By  Russell  H.  Boggs,  M.  D:, 
Pittsburgh,  Pa. 

Time  and  experience  have  shown  the  value  of 
the  rays,  not  only  in  mediastinal  growths  and  aneu- 
rysms, but  also  in  tuberculosis.  I  here  show  a  few 
plates  of  large  thoracic  tumors,  some  of  which  have 
been  overlooked  by  clinicians  of  the  first  rank. 
Since  tuberculosis  has  become  so  common  a  disease, 
it  has  received  the  most  attention.  It  has  been 
demonstrated  by  many  observers  that,  when  physical 
signs  were  present,  infiltration  is  well  marked,  and 
in  many  cases  the  opposite  lung  is  found  to  be  in- 
volved without  giving. any  ph}  sical  signs^  . 

*Read  before  the  Kalamazoo  Academy  of  Medicine,  Deceraht. 
10,  1908. 


<)42 


BOGGS:  ROENTGEN  RAYS  IN  THORACIC  LESIONS. 


[New,  York 
Medical  Journal. 


A  radiogram  is 
but  a  record  of  tis- 
s  u  e  densities  as 
shown  in  shadows. 
This  is  absolutely 
exact,  and  these 
variations  in  densi- 
ties, in  most  in- 
stances, give  a  clin- 
ical picture  which 
alone  is  sufficient  to 
make  a  diagnosis. 
However,  in  many 
instances,  we  can- 
not tell  whether  the 
densities  are  due  to 
active  or  inactive 
tuberculosis,  and  in 
many  cases  we  can- 
not even  tell  wheth- 
er the  densities  have 
been  caused  by  a 
tuberculous  process, 
any  more  than  we 
could  make  a  diag- 
nosis of  cancer 
€very  time  abnor- 
mal epithelial  cells 
are  found  by  the 
microscope. 

Professor  Albers 


Fig.  1. — Cavity  and  infiltration  of  both  lungs. 


Schonberg,  of  Hamburg,  states :  "The  Ront-  marize  by  saying  that  we  can  never  recognize  ca- 
genological  diagnosis  is  on  a  par  with  percus-  tarrhal  conditions,  but  can  always  detect  foci  of  in- 
sion,  but  inferior  to  auscultation  in  the  early  filtration,  before  they  can  be  found  by  percussion, 
stages,  that  is,  in  catarrh  of  the  apices.  The  present  and  in  some  cases  before  they  can  be  perceived  by 
position  of  Rontgenological  knowledge  I  can  sum-     auscultation.    The  Rontgenological  examination  in 

doubtful  cases  fre- 
quently yields  the 
deciding  factor." 

Before  studying 
thoracic  lesions  it  is 
important  to  be 
familiar  with  the 
shadows  cast  by  the 
normal.  This  re- 
quires a  careful 
study  of  a  large 
number  of  cases. 
When  studying  a 
radiogram  one  will 
observe  three  verti- 
cal zones,  a  light  in 
the  centre  and  a 
dark  on  each  side. 
The  light  zone  in 
the  centre  is  caused 
l)y  the  shadows  of 
the  dorsal  vertebra, 
.sternum,  heart,  and 
large  vessels.  To 
the  left  of  the  upper 
part  is  a  bulge 
caused  by  the  shad- 
ow of  the  dcscend- 
ine  aorta ;  below 
is  the  curved  edge 

Fig.  2. — Incipient  tuberculosis.  '^^     ^'^^      '^^^  VCU- 


May  8,  igog. ] 


BOGGS:  ROENTGEN  RAYS  IN  THORACIC  LESIONS. 


943 


Fig.  3. — Pleurisy  with  effusion. 

tricle.  Between  the  two  is  a  more  indistinct  shadow, 
caused  by  the  left  auricle  and  pulmonary  artery. 
The  right  edge  shows  the  superior  vena  cava  above 
and  the  right"  auricle  below.    The  two  dark  zones, 
one  on  each  side  of  the  light,  are  caused  by  lung 
tissue    being  less 
dense.  These  extend 
from   the  neck  to 
the  curved  zones  of 
the  diaphragm,  the 
right,  as  a  rule,  be- 
ing slightly  higher 
than  the  left.  The 
pulmonary  zones 
are  crossed  by  the 
ribs,    which  curve 
and  form  a  lattice 
work  arrangement, 
more    apparent  in 
anterior   than  pos- 
terior  positions  on 
the  plate. 

Other  normal 
shadows  are  those 
of  the  scapula,  pec- 
toral muscles,  and 
in  women  the  mam- 
mary glands.  The 
lung  structure  pro- 
duces a  veiled  ap- 
pearance, and  on 
each  side  of  the 
central  shadow  are 
ill  defined  shadows, 
more  marked  i  n 
some    people  than 


in  others,  and  also 
more  prominent  on 
the  right  side. 
These  are  caused  by 
the  bronchial  ves- 
sels and  tubes. 

Enlarged  glands 
in  the  lung  are  diag- 
nosticated by  char- 
acteristic dense, 
white  spots  on  the 
plate.  When  en- 
larged glands  in  the 
chest  are  observed 
on  the  radiogram,  it 
must  not  be  stated 
that  the  patient  has 
or  has  had  a  tuber- 
culous lesion,  be- 
cause  e  n  1  arged 
glands  in  the  chest 
are  frequently  caus- 
ed by  other  diseases 
than  tuberculosis. 
The  following  are 
some  of  these  dis- 
eases: I,  Tubercu- 
losis ;  2,  syphilis ;  3, 
lymphosarcoma ;  4, 
carcinoma;  5, 
leuchaemia  or  Hodg- 
skin's  disease ;  and  6,  inflammatory  processes.  If  the 
glands  cast  a  very  dense  shadow,  almost  dense  as  that 
cast  by  the  bony  structure,  they  have  undergone  a 
calcareous  degeneration,  while  glands  which  are  in 
the  acute  or  subacute  inflammatorv  state  cause  less 


Fig.  4. — Infiltration,  of  right  zpex. 


944 


HOGGS:  ROENTGEN  RAYS  IN  THORACIC  LESIONS. 


[New  York 
jSIedical  Journal. 


distinct  shadows. 
Defore  the  time  of 
r  a  p  i  d  exposures 
such  glands  could 
not  he  shown  by  the 
radio  g"  r  a  m.  T  h  e 
glands  back  of  tlic 
heart  shadow  and 
the  larger  vessels 
are  not  shown  on 
the  plate  except  in 
advanced  cases, 
w  h  e  n  they  cause 
widening  of  the 
mediastinum.  It  has 
been  stated  that, 
when  the  glands  are 
enlarged  to  such  an 
extent  that  they  cause 
widening  of  the 
mediastinum,  it  is 
easy  to  diagnosti- 
cate a  tumor  with- 
o  u  t  the  Rontgen 
ra\-s.  Since  a  num- 
ber of  these  cases 
have  been  studied 
by  c  o  m  p  a  r  a  tive 
methods  it  has  been 
demonstrated   t  h  at 

such  is  not  the  case.  s  -Con 

In  fact,  a  mediastinal  tumor  of  large  size  may  give 
only  vague  symptoms  and  no  physical  signs. 

I  have  radiograms  of  a  number  of  patients  I 
was  treating  for  tuberculous  adenitis,  and  in  almost 
every  instance  where  the  patient  had  a  large  amount 
of  glandular  involvement  in  the  neck,  the  picture 


solidation  of  lower  lobe  of  left  lung. 

showed  enlargement  of  the  glands  in  the  lung  on 
the  affected  side.  Sputum  from  these  patients  was 
examined,  and  in  more  than  one  half  of  the  cases 
tubercle  bacilli  were  found. 

Carcinoma  of  the  bronchial  glands  shows  quite 
distinctly  on  the  x  ray  plates,  but  usually  not  as 

plainly  as  tubercu- 
lous glands.  Three 
years  ago  I  radio- 
graphed a  series  of 
cases  following  op- 
eration for  cancer 
of  the  breast,  as 
well  as  a  series  of 
cases  where  recur- 
rence had  taken 
place,  and  I  found 
that  wherever  the 
glands  were  much 
enlarged  they 
s  h  o  \\  e  d  on  the 
plate. 

Thickened  pleura, 
old  scars,  and  fi- 
broustissue  will  cast 
a  shadow,  but  not  as 
distinct  as  that  of 
calcareous  glands. 
Consolidations  o  f 
any  size  and  shape 
can  be  shown  dis- 
tinctly by  a  radio- 
gram. 

A  thicken  e  d 
jilcura  produces  a 
shadow  of  very 
slight  density,  wliicii 


May  8,  loog.] 


BOGGS:  ROENTGEN  RAYS  IN  THORACIC  LESIONS. 


945 


Fig.   y. — Infiltration  of  both  lungs,  more  in  left. 


might  be  compared  to  a  deeper  » 
veiling-  of  the  affected  side.  The 
shadow  of 'a  thickened  pleura  is 
usually  irregular  in  outline  and 
very  vmequal  in  density.  The  ribs 
are  closer  together  on  the  affect- 
ed side.  The  pleural  cavity  is  de- 
creased in  size,  and  curvature  of 
the  spine  is  usually  present.  Ab- 
normal collections  of  air  or  fluid  in 
the  chest  cavity  cast  shadows  which 
are  usually  recognized  by  both  the 
radiogram  and  the  fluoroscope. 

The  shadow  of  a  large  effusion 
is  denser,  more  even,  and  more 
diffuse  than  that  cast  by  any  other 
thoracic  lesion.  The  hydrostatic 
property  of  the  fluid  seeking  its 
own  level  shows  the  necessity  of 
making  two  radiograms,  one  with 
the  patient  lying  down  and  the 
other  in  the  upright  position.  Of 
course,  if  the  fluid  fills  the  entire 
cavity  or  is  encapsulated,  radio- 
grams taken  in  different  positions 
would  not  be  necessary.  Effusion 
(on  account  of  casting  a  more 
dense  shadow  than  an  v.  other  tho- 
racic lesion)  renders  the  ribs  on 
the  affected  side  much  less  distinct. 
When  the  effusion  is  at  the  base 
of  the  lung  it  usually  obliterates 
the  shadow  of  the  diaphragm  and 
fuses  with  its  adjacent  organs. 
Compressed  lung  above  the  effu- 
sion is  denser  than  that  corre- 
sponding to  the  normal  lung  on  the 


opposite  side.  Large 
effusions  usually 
show  a  displacement 
of  the  heart  and 
mediastinal  con- 
tents. Empyema 
casts  a  similar  shad- 
ow to  that  of  pleur- 
isy with  eft'usion, 
but  there  is  usually 
more  marked  dis- 
placement of  the 
heart  and  mediastin- 
al contents.  A 
p  n  e  u  m  o  t  h  o  rax 
shows  the  ribs  much 
plainer  than  normal 
lung,  this  being  due 
to  more  air  in  the 
pleural  cavity,  mak- 
ing it  less  dense  to 
the  rays.  The  dia- 
phragm is  lower 
than  the  normal,  and 
its  movement  either 
greatly  restricted  or 
absent,  and  the 
heart  and  mediastin- 
al contents  are 
usually  displaced  to- 


946 


HOGGS:  ROEXTGEX  RAYS  IN  THORACIC  LESIONS. 


[New 
Medical 


VoHK 
Journal. 


ward  the  nonaffect- 
ed  side.  The  shad- 
ow cast  by  the  edge 
of  the  heart  and  the 
al¥ected  side  is  more 
clear  cut,  on  account 
of  the  contrast  of 
the  air  in  the  pleural 
cavity.  Hydropneu- 
niothorax  and  pyo- 
pneumothorax give 
interesting  pictures, 
on  account  of  the 
three  distinctive 
shadows  on  the  af- 
fected side.  The 
collapsed  lung 
shows  a  dark,  hazy 
structure,  sometimes 
dotted  with  small 
tuberculous  areas. 
Beneath  this  is  a 
dark  space  caused 
by  the  free  air  in  the 
pleural  cavity,  and 
btlow  there  is  a 
light,  uniform  shad- 
ow having  hydro- 
static properties. 
The  diaphragm  is 
usually  fused  to- 
gether with  the  abdominal  organs,  and  there  is 
a  displacement  of  the  heart  and  mediastinal  con- 
tents, similar  to  that  observed  in  pneumothorax.  In 
emphysema  the  pulmonary  area  is  increased  as  well 
as  being  less  dense  to  the  rays.    The  pulmonary  area 


Fig.  9. — Cavity  in  right  apex. 

usually  reaches  higher  above  the  clavicles  and  fur- 
ther downward,  depressing  the  diaphragm.  It  has 
been  stated  that  in  emphysema  the  diaphragm  pre- 
sents two  or  more  less  distinct  curves  instead  of  a 
large  curve  on  each  side  as  is  seen  normally.  In 

pneumonia  there  is 
usually  compensa- 
tory emphysema  of 
the  other  lung.  It 
has  been  stated  that 
the  heart  occupies  a 
lower  position  in  the 
chest  and  is  in  a 
more  vertical  posi- 
tion than  normal. 

The  shadow  pro- 
duced by  consolida- 
tion of  pneiunonia  is 
more  uniform  and 
homogeneous  than 
that  produced  by 
consolidation  of  the 
lung,  caused  by  tu- 
berculous process. 
T  h  e  tuberculous 
lung  presents  a 
more  unequal  and 
spotted  appearance 
with  clear  shadows. 

Cavities,  one  half 
inch  in  diameter,  are 
easily  recognized  on 
the  plate.  An  empty 
cavity  produces  a 
dark  area  surround- 


FiG.   10. — Ncol  lastic  pericardium  (tuberculous  or  carcinomatous). 


cd  by  a  lighter  mar- 


^lay  8.  1909.] 


BOGGS:  ROENTGEN  RAYS   IN  THORACIC  LESIONS. 


947 


Fig.  ti. — Aneurysm  of  the  aorta 

gin,  while  rtiled  cavities  cast  shadows  about  as 
dense  as  consoHdated  areas.  The  density  of  a  filled 
cavity  becomes  less  after  the  patient  has  been  induc- 
ed to  cough,  thus  partially  emptying  the  cavity. 
Cavities  are  usually  surrounded  by  a  fibrous  ring.  It 
has  been  stated  that 
this  is  caused  by  the 
attempt  to  wall  off 
the  process.  Kassa- 
bian  states,  "a  di- 
lated bronchus  with 
exudative  material 
and  consolidated 
structures  surround- 
ing it  cannot  be  dis- 
tinguished from  a 
small  cavity  by 
means  of  the  x  ray." 

In  order  to  com- 
pare the  fluoroscope 
and  radiograph  with 
clinical  methods, 
forty  patients  as 
they  presented  them- 
selves to  the  service 
of  Dr.  I.  H.  Alex- 
ander, of  the  Pitts- 
burgh Branch  of  the 
State  Tuberculous 
Dispensary,  were 
carefully  examined, 
and  the  lesions 
marked  out  on  a 
chart.  Dr.  Boyce 
described  the  results 
of  the  findings  in  a 


paper  read  before 
the  Allegheny  Val- 
ley Medical  Society 
as  follows:  "The  pa- 
tients were  then  sent 
to  the  West  Penn 
Hospital.  There  I 
examined  them  with 
the  fluoroscope  and 
made  similar  draw- 
ings of  the  extent  of 
the  lesions.  The  pa- 
tients were  then  sent 
to  Dr.  Russell  H. 
Boggs,  who  made 
chest  plates,  and 
from  them  drew  a 
third  diagram. 
Each  of  us  were 
thus  committed  to  a 
definite  diagnosis,  in 
entire  ignorance  of 
the  other's  work. 
Comparisons  of  the 
findings  showed  ex- 
act agreement  in 
most,  substantial  in 
nearly  all.  Patients 
in  which  there 
seemed  discrepan- 
cies were  examined 
by  the  three  of  us  jointly,  after  joint  study 
of  the  plates.  The  first  important  point  that  devel- 
oped itself  was  that  the  novice  (in  the  case,  myself) 
^vould  make  as  many  errors  in  recognizing  and  in- 
terpreting shadows  as  would  the  novice  in  ausculta- 


FlG.  12. — Mediastinal  tumor. 


048 


BUGGS:   ROEXIGLiX  RAYS    /.V   THORACIC  LESWXS. 


[New  York 
Medical  Journal 


tion  and  percussion.  Often,  I  would  detect  shadows 
that  the  chance  bystander  overlooked.  In  several 
instances,  I  overlooked  infiltrated  spots  on  first  view 
that  were  readily  seen  when  the  lesion  had  been 
otherwise  located.  Yet  on  the  whole,  the  screen 
view  gave  a  more  definite  and  satisfactory  notion  of 
ihe  physical  conditions  within  the  chest  than  did 
the  ordinary  examination.  The  plate  regularly  gave 
more  detail  than  any  other  method.  Cavities  only 
suspected  by  Dr.  Alexander  and  myself  were  posi- 
tively diagnosticated  and  more  exactly  located  by 
Dr.  Boggs.  The  extent  of  glandular  involvement 
was  regularly  shown  better  on  the  plate.  In  one 
most  interesting  case,  physical  signs  showed  exten- 
sive consolidation,  and  the  history  indicated  a  hid- 
den cavity.  Finding  a  light  spot  in  the  midst  of  the 
shadow,  I  assumed  that  this  meant  a  spot  of  destruc- 
tion of  tissue.  Dr.  Boggs  disputed  this  because  of 
the  absence  of  a  distinct  fibrous  wall  that  regularly 
surrounds  such  an  area.  The  patient  returned,  and, 
using  a  small  diaphragm,  a  careful  picture  of  this 
particular  area  was  made.  The  exact  outline  of  the 
light  spot  was  shown,  and  this  made  it  clear  that  it 
was  produced  by  an  extreme  tubular  dilatation  of  a 
bronchus." 

On  one  other  point  it  is  necessary  to  speak  with 
some  hesitation  since  none  of  our  cases  have  as  yet 
qualified  for  an  autopsy.  My  impression  is,  how- 
ever, that  by  careful  watching  the  changes  of  den- 
sity during  respiratory  motion  we  get  a  more  just 
idea  of  the  extent  of  fibrosis.  What  we  know  as 
Williams's  sign,  a  one  sided  limitation  motion  of 
diaphragm,  is  important  in  many  cases  of  early 
tuberculosis.  To  elicit  this  sign  we  are  absolutely 
dependent  on  the  screen. 

Out  of  a  series  of  more  than  eighty  patients  whom 
I  have  examined  for  pulmonary  tuberculosis,  where 
the  disease  has  been  either  before  or  later  confirmed 
by  other  methods.  I  am  justified  in  summarizing  the 
following : 

( 1 )  That  the  extent  of  the  disease  is  more  ac- 
curatelv  determined  by  the  x  ray  than  the  physical 
findings  alone. 

(2)  That  in  doubtful  cases  the  rays  often  af¥ord 
sufficient  information  to  make  an  accurate  diagnosis. 

(3)  That  the  rays  are  a  useful  method  of  record- 
ing the  lesions  and  to  determine  the  progress  made 
by  treatment. 

(4)  That  the  radiogram  records  nothing  but  var- 
iations in  density  and  leaves  the  .-etiological  factors 
to  be  determined  by  other  clinical  methods. 

(5)  That  frequently,  when  physical  signs  were 
present  in  one  side,  the  radiogram  would  show  in- 
filtration in  both  lungs. 

As  before  stated  the  Rontgen  rays  give  a  valuable 
method  of  diagnosticating  mediastinal  tumors.  Any 
shadow  cast  cither  to  the  right  or  left  of  that  caused 
by  the  normal  mediastinal  contents,  can  be  accurate- 
ly determined,  .\bnormal  widening  of  the  medias- 
tinal shadow  may  be  due  to  a  variety  of  conditions, 
such  as :  I,  Anetirvsm  ;  2,  tuberculosis  ;  3,  carcinoma  ; 
4,  sarcoma ;  5,  Hodgskin's  disease ;  6,  fibroma  ;  7, 
dermoid  cyst:  8.  dydatid  cyst;  9,  lipoma;  and  10, 
enlarged  thvmus. 

Before  examining  for  mediastinal  widening  it  is 
important  to  observe  whether  there  are  any  abnor- 


malities as  to  the  formation  of  the  chest  and  spine. 
A  diseased  vertebra  with  displacement  may  push  the 
aorta  aside  and  simulate  aneurysm  of  mediastinal 
tumor. 

The  shadow  of  the  normal  aorta,  when  examined 
radiographically  either  anteriorly  or  posteriorly  is 
almost  totall}-  obscured  by  the  superimposed  shad- 
ows of  the  sternum  atid  the  vertebral  column,  with 
the  exception  of  a  small  shadow  in  the  left  caused  by 
the  lateral  aortic  bulge.  It  can  readily  be  seen  that 
a  very  small  aneurysm  may  be  overlooked,  if  only 
anterior  and  posterior  radiograms  are  made.  In  or- 
der to  detect  a  small  aneurysm  it  is  usually  neces- 
sary to  make  an  oblique  examination.  The  diagnosis 
of  a  small  aneurysm  of  this  kind  can  possibly  be 
made  out  by  the  fluoroscope  when  it  cannot  be 
made  out  by  the  radiogram.  This  I  have  never  been 
able  to  prove.  If  the  aorta  is  pushed  by  a  growth 
laterally,  this  would  give  a  shadow  both  on  the  plate 
and  the  fluoroscope,  similar  to  that  produced  by  an 
aneurysm. 

From  a  clinical  standpoint,  in  many  cases,  it  is 
difficult  to  distinguish  an  aneurysm  from  a  medias- 
tinal growth,  as  few  rules  can  be  laid  down.  Osier 
states,  '  scarcely  a  sign  is  found  in  aneurysm  which 
may  not  be  duplicated  in  mediastinal  tumor.  This 
is  not  strange  since  the  symptoms  of  both  are  largely 
due  to  pressure." 

The  age  for  aneurysm  is  much  the  same  as  that 
for  mediastinal  disease.  Pulsation  of  a  mass  always 
points  to  aneurysm,  but  it  is  not  to  be  relied  upon, 
as  a  growth  situated  over  the  large  vessels  often 
pulsates,  and  especially  a  sarcomatous  tumor. 

Post  mortem  examinations  of  mediastinal  tumors 
have  proved  this  to  be  a  fact.  In  the  cases  which  I 
have  studied,  pulsation  is  usually  less  when  the  mass 
is  tuberculous  than  when  it  is  sarcoma  or  carcinoma ; 
probably  this  is  due  to  the  fact  that  a  tuberculous 
tumor  usually  grows  slower  and  produces  more  in- 
filtration and  adhesions  than  in  malignant  growths. 
A  tumor  if  pulsating  has  not  the  forcible,  heaving 
impulse  of  aneurysm.  Another  point  in  distinguish- 
ing malignant  and  tuberculous  growths,  is  that  there 
are  usually  more  calcified  glands  in  tuberculosis. 
Possibly,  syphiloma  may  produce  a  similar  density  in 
the  bronchial  glands. 

Tuberculin  should  always  be  used  in  distinguish- 
ing mediastinal  growths.  Occasionally  the  diagno- 
sis may  be  confined  by  the  removal  and  examination 
of  a  supraclavicular  gland. 

It  is  generally  supposed  that  sarcoma  of  the  medi- 
astinum is  denser  than  carcinoma,  and  also  that  the 
glandular  involvement,  which  takes  place,  produces 
denser  shadows.  Sarcoma  grows  more  rapidly  than 
carcinoma,  and  the  mass  is  greater.  This  can  be 
demonstrated  by  a  series  of  radiograms  taken  a  few 
weeks  apart.  Exceptions  to  this  rule  are  rare.  By 
percussion,  mediastinal  growths,  as  a  rule,  cannot  be 
made  out  imtil  the  tumor  is  of  considerable  size. 

The  oesophageal  pressure  produces  dysphagia.  Tra- 
cheal involvement  may  produce  a  lateral  or  vertical 
displacement  or  fixation  of  the  larnyx.  which  may  be 
drawn  to  a  notably  low  position.  Difficult  breathing, 
either  in.spiratory  or  expiratory,  of  the  noisv  tvpe 
may  result  from  a  partial  stenosis.  Pressure  on  one 
of  the  large  lironchi  may  produce  a  diminution  of 


May  8,  1909.] 


PRINCE:   FRONTAL  SINUS  OBLITERATION. 


lesonance  and  breath  sounds  and  fremitus  over  the 
corresponding  lung.  When  the  pulmonary  veins  are 
pressed  upon,  a  systolic  murmur  may  be  audible  in 
the  left  back  and  congestion  of  the  lungs  may  ensue. 
Pressure  on  the  innominate  and  subclavian  veins  pro- 
duces cyanosis  or  oedema  of  the  head,  neck,  shoul- 
ders, and  arms,  while  the  superficial  veins  of  the 
chest  may  enlarge  and  become  prominent  owing  to 
an  attempt  of  collateral  circulation,  especially  if  the 
vena  cava  superior  is  pressed  upon.  Fluid  may  ac- 
cumulate in  one  or  both  pleural  cavities  if  the  vena 
azygos  or  thoracic  duct  is  involved.  Aphonia  or 
hoarseness  points  to  pressure  on  the  recurrent  laryn- 
geal nerve.  Laryngoscopic  or  bronchoscopic  exam- 
ination may  show  paralysis  of  one  of  the  vocal  cords. 
Several  cases  of  mediastinal  involvement  were  re- 
ferred to  Dr.  Chevalier  Jackson,  who  stated  that 
while  the  patients  did  not  have  any  characteristic 
symptoms  there  was  a  paralysis  of  one  of  the  vocal 
cords  and  the  possibility  of  a  mediastinal  growth 
must  be  considered.  Also,  in  several  cases  he  dis- 
covered, by  the  use  of  the  bronchoscope,  that  there 
was  pressure  on  one  bronchus,  and  in  several  in- 
stances on  the  oesophagus.  Inequality  of  the  pupils 
due  to  pressure  on  the  sympathetic  nerve  is  not  un- 
common, and  severe  pain  along  the  distribution  of 
the  intercostals  or  running  down  the  arm  indicates 
that  the  spinal  ganglia  or  brachial  plexus  are  pressed 
upon.  !Much  rarer  are  symptoms  of  pressure  on  the 
vagus  with  bradycardia  or  tachycardia.  When  the 
phrenic  nerve  is  involved  hiccough,  unilateral  spasm, 
or  paralysis  of  the  diaphragm  occurs.  Pressure  upon 
the  subclavian  artery  changes  the  manometer  read- 
ing for  the  two -sides. 

It  has  been  frequently  stated  that  another  impor- 
tant sign  of  aneurysm,  first  pointed  out  by  Walsham, 
is  the  change  in  position  of  the  heart  which  makes  it 
lie  more  transversely,  the  right  side  being  pushed 
down  and  the  aneurysm  tilting  up  the  apex. 

In  order  to  illustrate  the  difificulty  in  diagnosti- 
cating mediastinal  growths,  I  will  report  several 
cases  briefly. 

Case  I. — The  following  case  I  reported  shortly  after  the 
time  of  the  first  examination  in  the  transactions  of  the 
Rontgen  Ray  Society  for  1904.  The  patient  had  been  seen 
by  physicians  of  considerable  ability  and  prominence,  both 
in  this  country  and  abroad,  and  his  case  was  diagnosticated 
as  aneurysm.  After  making  a  series  of  radiograms  a  diag- 
nosis of  a  mediastinal  growth  was  made.  The  distinctive 
diagnosis  between  aneurysm  and  mediastinal  growth  was 
made  on  account  of  the  following  reasons:  (i)  That  the 
picture  showing  the  growth  was  slightly  irregular,  while,  ii 
it  was  aneurysm,  the  circumference  wouM  be  more  regular, 
like  the  outer  border  of  the  heart,  as  seen  on  a  radiograin. 
(2)  That  the  entire  mass  was  not  of  the  same  density.  (3) 
That  there  was  a  certain  amount  of  fibrous  deposit  in  the 
lung.  f4)  That  under  a  fluoroscopic  examination  tlie 
growth  did  not  pulsate. 

The  patient  was  kept  under  observation  until  his  death, 
a  year  later,  when  a  post  mortem  examination  proved  a 
tumor  to  be  tuberculous  and  no  aneurysm  existed. 

Case  II.— Mrs.  J.  had  been  seen  by  a  number  of  physi- 
cians, among  whom  was  a  neurologist,  who  made  a  diag- 
nosis of  a  typical  case  of  hysteria.  On  account  of  pain  in 
the  spnie  she  was  referred  for  an  x  ray  examination.  The 
plates  revealed  a  large  tumor  which  was  either  a  medias- 
tmal  growth  or  an  aneurysm. 

Empire  Birir.DiNG. 


AN  OPERATION  FOR  FRONTAL  SINUS  OBLIT- 
ERATION AVOIDING  SUPRAORBITAL 
DEFORMITY  AND  NASAL  SCAR.* 

By  A.  E.  Prince,  M.  D., 
Springfield,  111. 

While  it  is  probable  that  the"  climax  in  the  devel- 
opment of  the  operation  for  frontal  sinus  oblitera- 
tion has  been  reached  in  so  far  as  pertains  to  thor- 
oughness in  curettement,  drainage,  and  the  probabil- 
ity of  efifecting  a  cure,  it  would  seem  that  there  is 
still  an  opportunity  to  improve  the  cosmetic  result. 

Hoping  that  my  contribution  mav  be  regarded  as 


Fig.   I. — Showing  deformity   from  operation. 


a  step  in  this  direction,  I  am  presenting  two  oper- 
ated cases,  a  specimen,  and  an  instrument  for  your 
criticism,  together  with  a  technique  by  following 
which  a  cosmetic  result  has  been  uniform. 

The  specimen  is  of  an  original  operation  by  Pro- 
fessor Killian,  performed  upon  a  cadaver.  Those 
who  care  to  do  so  may  have  the  opportunity  to  ex- 
amine the  specimen.  It  is  typical  of  his  classic  pro- 
cedure. The  subject  had  a  very  small  frontal  sinus, 
hence  the  amount  of  front  wall  removed  is  very 
small.  It  is  instructive  to  any  one  who  has  not  seen 
him  operate,  as  it  illustrates  his  radical  method  of 

*A  specimen  and  two  patients  presented  before  the  Illinois  State 
Medical  Society  in  Peoria.  III.,  and  the  Section  in  Laryngology 
of  the  American  Medical  Association  in  Chicago,  1908. 


950 


PRINCE:  FRONTAL  SINUS  OBLITERATION. 


[Xew  York 
Medical  Journax- 


drainage.  It  exhibits  the  usual  incision  extending 
along  the  side  of  the  nose.  The  front  wall,  above 
the  supraorbital  ridge,  and  the  entire  floor  of  the 
sinus  have  been  removed.  The  cells  of  the  ethmoid 
have  been  obliterated.   The  sphenoid  has  been  curet- 


FlG.  2. — Showing  entire  absence  of  deformity. 

ted.  The  anterior  portion  of  the  os  planum,  and  a 
portion  of  the  nasal  process  of  the  superior  maxilla 
have  been  removed. 

The  entire  frontal  cavity  is  opened  directly  into 
the  nose  through  a  wide  space  which  renders  im- 
probable any  future  stricture  between  the  sinus  and 
the  nose.     The  efficiency  of  the  curettement  needs  i 
no  comment. 

The  second  exhibit  is  a  case,  Mrs.  McL.,  exhibited  ' 
in  person,  and  by  photograph,  (Fig.  i).  She  was 
operated  upon  by  the  Killian  method,  in  which  the 
result  is  exactly  what  may  be  expected  under  simi- 
lar circumstances.  This  patient  is  exhibited  to  im- 
press the  fact  that  the  depression  is  proportionate  to 
the  size  of  the  sinus.  Such  a  deformity  may  be  toler- 
ated in  Germany,  but  would  be  resented  by  the 
American  public. 

It  is  fair  to  state  that  the  sinus  was  unusuallv 
large,  and  the  amount  of  depression  is  in  excess  of 
that  usually  obtained  by  the  Killian  method.  In  the 
majority  of  cases,  the  deformity  may  be  corrected 
by  a  paraffin  injection,  but  in  this  c|ise  it  will  re- 
quire introduction  of  some  form  of  plate.  I  propose 
to  introduce  a  silver  filigree. 


The  third  presentation  is  that  of  Miss  W.  (Fig. 
2).  She  is  exhibited  in  person  as  an  example  of  the 
entire  absence  of  deformity  following  the  operation 
to  be  hereafter  described. 

The  slight  linear  scar,  covered  by  the  eyebrow,  is 
all  that  is  left  to  suggest  an  operation  having  been 
performed.  A  lateral  radiograph  exhibited  a  rather 
high  and  moderately  deep  sinus,  which  would  have 
inevitably  resulted  in  considerable  depression.  I  re- 
solved not  to  make  a  supraorbital  incision,  except  as 
a  last  resort,  and  the  result  of  this  and  subsequent 
cases  has  convinced  me  that  the  supraorbital  depres- 
sion and  the  nasal  scar  may  be  avoided. 

The  patient  was  first  subjected  to  Ingals's  intra- 
nasal drainage  operation.  There  was  no  difficulty  in 
passing  a  burr  into  the  sinus,  after  removing  the 
anterior  portion  of  the  middle  turbinal.  Pain,  which 
at  first  was  relieved,  later  returned  in  its  former 
severity,  notwithstanding  daily  irrigation.  Con- 
vinced that  chronic  inflammation  of  the  sinus  was 
present,  and  that  curettement  was  indicated,  I  pro- 
ceeded to  remove  the  floor  of  the  sinus,  through  a 
minimum  skin  incision,  and  drain  after  the  Killian 
method.  She  made  an  uneventful  recovery ;  was 
ambulatory  in  a  few  days,  and  has  never  suffered 
pain  since  the  operation,  and  is  an  example,  as  you 
see,  of  an  absolute  cosmetic  result. 

^To  facilitate  the  removal  of  the  floor  of  the  sinus 
I  had  made  a  sinus  rongeur,  illustrated  by  Fig.  6. 
It  is  the  reversal  of  a  Kerason,  cutting  toward  the 
handle. 

The  technique  employed  in  this  and  subsequent 
cases  is  as  follows : 

I.  Intranasal  preparation.  Introduce  a  postnasal 
plug.  Correct  any  considerable  deflection  of  the 
sasptum,  as  a  preliminary  step.  Remove  the  ante- 
rior end  of  the  middle  turbinal,  preferably  by  means 
of  a  forceps. 

I  have  discarded  the  snare  in  favor  of  the  middle 
turbinal  forceps  (Fig.  3).  This  same  instrument 
may  be  used  to  remove  the  posterior  ethmoidal 
cells,  and  expose  the  sphenoid  sinus. 


Fig.  3. — Middle  turbinal  forceps 


If  polypi  are  present,  the  inferior  turbinal  forceps 
(Fig.  4),  on  account  of  its  length  and  curve,  mav 
serve  better. 

2.  Clip  and  sterilize  the  eyebrow.  Make  a  skin 
incision  extending  along  the  middle  of  the  eyebrow 
from  a  point  opposite  the  junction  of  the  frontal, 
nasal,  and  maxillary  bones.  Omit  the  usual  nasal 
extension  of  the  incision  which  is  made  for  the  pur- 
pose of  reaching  the  ethmoid  cells,  through  an  open- 


May  8,  iQog.] 


PRIME:   FRONTAL  SIXUS  GBLITERATJOX. 


ing  made  by  resecting  a  portion  of  the  nasal  pro- 
cess of  the  superior  maxilla.  This  is  not  required. 
It  is  particularly  undesirable  to  extend  the  incision 
along  the  side  of  the  nose  on  account  of  the  possi- 
bility of  producing  an  objectionable  scar.    This  is 


Fig  4. — Inferior  turbinal  forceps. 


especially  true  when  the  underlying  bony  support 
has  been  removed.  Many  of  these  scars  which  I 
have  seen,  resemble  a  welt,  and  some  take  on  the 
appearance  of  a  chelyoid. 

3.  Periosteal  Incision.  The  periosteal  incision  is 
made  parallel  to  the  skin  incision.  It  extends  some- 
what under  the  skin  at  the  nasal  angle.  Then  it  is 
separated  from  the  roof  and  inner  wall  of  the  orbit. 
The  trochlea  remains  attached  to  the  periosteum. 

I  1 


Fig.  3. 

and  is  brought  back  into  position  with  the  closure  of 
the  incision,  thus  preventing  diplopia  or  cyclophoria, 
which  might  result  from  its  injury  or  dislocation 
from  its  attachment  to  the  periosteum. 

4.  Removal  of  the  Sinus  Floor.  The  orbital  con- 
tents are  separated  from  the  inner  wall  by  means  of 
a  retractor,  and  the  nasofrontal  angle  of  the  orbit  is 
exposed.    The  bone  is  thinnest  at  this  point,  which 


is  the  usual  location  of  spontaneous  perforation,  and 
is  the  point  of  election  for  entering  the  sinus. 

An  opening  is  made  with  a  rounded  chisel.  The 
sinus  rongeur  (Fig.  6)  is  made  to  enter  through  this 
opening,  and  the  anterior  portion  of  the  floor  of  the 
frontal  sinus  is  removed. 

x\ny  portion  of  the  posterior  margin  of  the  nasal 
process  of  the  superior  maxilla,  which  may  conceal 
ethmoid  cells,  may  be  removed.  The  os  planum  is 
removed  back  to  the  anterior  ethmoid  foramen.  The 
opening  thus  formed  gives  access  to  the  posterior 
ethmoid  foramen,  which  gives  access  to  the  poste- 
rior ethmoid  cells  and  the  sphenoid  sinus.  The  re- 
mainder of  the  floor  of  the  sinus  is  removed  by 
means  of  forward  or  lateral  biting  forceps.  The 
operator's  finger  is  passed  into  the  nose  through  the 
wound,  and  made  to  serve  as  a  guide  to  the  middle 


turbinal  forceps,  which  is  introduced  through  the 
nose,  and  made  to  clear  a  free  opening  from  below 
into  the  sinus.  The  sinus  rongeur  or  appropriate 
curette,  is  introduced  upward  through  the  nose,  and 
made  to  remove  the  internal  nasofrontal  spine. 

5.  Curettem^t.  The  septa  are  removed  and  all 
the  mucous  membrane  of  the  frontal  sinus  is  scru- 
pulously curetted.  A  special  burr  (Fig.  7)  has  been 
devised  for  facilitating  the  curettement.  All  doubt- 
ful points  of  the  surface  are  cauterized  with  pure 
phenol  or  trichloracetic  acid.  Most  cases  require  no 
ocular  inspection,  the  sense  of  touch  being  sufficient. 
It  is  gratifying,  however,  and  at  times  important,  to 
see  the  remote  angles  of  the  sinus.  This  is  accom- 
plished by  means  of  a  sinuscope  which  is  on  the  or- 
der of  a  myringoscope,  excepting  that  the  lamp  is 
placed  on  the  side  of  the  instrument,  which  permits 
the  instrument  to  be  inserted  into  a  shallow  cavity. 
This  may  be  done  through  a  beveled  window  in 
case  the  sinus  is  extensive  and  shallow.  The  sinus- 
cope  was  made  at  my  suggestion. 

The  opening  found  below  the  frontal  sinus  and 
the  nasal  cavity  is  sufiicient  to  permit  of  the  curette- 
ment of  the  ethmoidal  cells,  and  the  removal  of  the 
anterior  wall  of  the  sphenoid.  In  practice,  the  writer 
has  found  this  best  accomplished  through  the  nose. 

Fig.  8  exhibits  a  modification  of  a  dental  instru- 
ment which  enables  the  operator  to  manipulate  gold 
in  the  distal  side  of  a  tooth.  It  is  found  quite  effi- 
cient in  chiseling  out  the  anterior  wall  of  the  sphe- 
noid sinus.  It  is  also  applicable  to  the  posterior  eth- 
moid cells.    This  instrument  was  made  at  mv  sug- 


952 


PRINCE:  FRONTAL  SINUS  OBLITERATION. 


[New  York 
Medical  Journal. 


gestion.  It  has  been  on  trial  for  a  year,  and  is  not  through  the  wound,  carrying  infection  from  the 
found  wanting.   Besides  the  removal  of  the  floor  of    nose.    The  wound  is  sealed  with  a  strip  of  gauze 


Fig.  7. — Special  burr. 


the  sinus,  it  has  a  variety  of  applications  as  illus-  soaked  in  collodion,  which  effectively  closes  and 

trated  by  Fig.  9.  strengthens  the  line  of  union. 

6.  Closing  of  the  Wound.    The  cut  edges  of  the       The  after  treatment  is  not  essential,  excepting 

periosteum  are  united  with  pyoktannin  catgut  su-  that  the  patient  must  not  blow  the  nose.    The  cavitv 


BV.MUELLERiai.CO.i 


Fig.  8.— Chisel. 


tures,  care  being  exercised  to  insure  correct  replace-  is  wiped  out  with  cotton,  saturated  with  a  twenty- 
ment  of  the  trochlea.  Horse  hair  sutures  are  used  to    live  per  cent,  solution  of  alcohol.    Healing  usuallv 


i 
1 
I 


Fir,.  9.  —  IlUi>itrnting  use  of  chisel. 

insure  more  perfect  coaptation  of  the  edges  of  the  takes  nlace  by  first  intention,  and  granulations  rap- 
skin  ;  perfect  closure  prevents  air  being  forced    idly  fill  the  cavity. 


May  8,  1909.] 


WAXDLESS:  AMAUROTIC  FAMILY  IDIOCY. 


953 


AMAUROTIC   FAMILY  IDIOCY.* 
A  Preliminary  Report  of  Three  Cases. 
Bv  H.  W.  Wandless,  M.  D., 
New  York, 

Lecturer   in   Ophthalmology   and   Chief   of   Clinic,    University  ami 
Bellevuc  Hospital  Medical  College. 

Amaurotic  family  idiocy  is  as  yet  a  rare  disease, 
but  rarer  still  is  it  found  in  other  than  the  Jewish 
people,  according  to  Sachs  and  others.  Not  orily 
are  my  patients  not  Hebrews,  but  they  are  in  a 
family  known  to  be  five  sixths  Irish.  This  is  a  de- 
parture ;  to  say  the  least,  it  is  unique. 

Both  father  and  mother  are  well  and  hearty.  The  father 
has  had  no  serious  illness  except  a  pain  in  the  hegd  which 
lasted  some  three  weeks  and  prevented  him  from  working, 
and  one  attack  of  rheumatism.  The  mother  has  been  well 
generally,  and  has  given  birth  to  seven  children.  The  old- 
est child  is  twenty-two  years  of  age  and  presents  no  history 
of  serious  illness.  The  second  child  was  a  seven  months 
baby  and  died  at  the  age  of  thirteen  months  of  convulsions, 
said  to  be  due  to  teethmg.  The  next  oldest  living  child  is 
eighteen  j'ears  old  and  is  well  and  strong.  The  youngest 
child  is  five  years  of  age  and  seems  in  perfect  condition. 

There  appears  to  be  nothing  in  the  familj'  to  indicate  any 
family  heredity.  No  blood  relationship  between  the  pa- 
rents has  been  established,  though  a  kinship  between  the 
father's  mother  and  the  mother's  father  may  e.xist. 

I  am  not  aware  that  any  case  has  been  reported  where 
the  disease  occurred  in  other  than  the  Hebrew  race,  or  that 
this  malady  developed  after  the  third  year  of  life,  except  one 
mentioned  by  Sachs.  If  this  is  true  my  own  cases  stand 
alone  in  these  important  features.  I  do  not  intend  to  go 
into  much  detail  of  them,  as  I  shall  exhaust  the  subject 
very  thoroughly  in  my  final  report. 

John,  the  first  to  sicken  with  the  awful  malady,  died 
January  17,  1908,  at  the  age  of  fourteen  years.  In  his  early 
life  he  appeared  normal  in  every  respect.  At  the  age  of 
seven,  after  having  gone  to  school  for  a  year,  he  was  taken 
out  on  account  of  his  failing  vision,  it  being  noticed  that  he 
saw  with  difficultyr  Up  to  this  time  he  had  progressed  well. 
He  was  then  put  into  a  blind  school,  where  he  remained 
a  year,  it  being  then  necessary  to  remove  him  on  account  of 
his  failing  mentality.  From  this  time  on  he  failed  both 
mentally  and  visually.  It  was  noticed  that  his  mind  began 
to  give  way  in  his  tenth  year. 

About  eight  months  before  death  he  became  bedridden 
and  absolutely  void  of  human  intelligence.  I  saw  him  for 
the  first  time  three  weeks  before  his  death,  the  most  ema- 
ciated and  the  most  pitiable  human  being  I  have  ever  seen 
alive.  During  all  this  fatal  illness  Dr.  W.  H.  Zabriskie, 
to  whom  I  am  indebted  for  valuable  information,  had  the 
case  in  charge  until  death  relieved  him. 

I  had  asked  for  a  post  mortem  examination,  which  was 
granted.  Dr.  Harlow  Brooks  performed  the  autopsy  at  my 
request,  with  my  assistance.  We  are  indebted  to  Dr.  Brooks 
for  a  most  thorough  examination  of  the  body.  His  gross 
report,  which  is  attached  herewith  and  is  a  part  of  this  re- 
port, will  be  found  most  interesting.  The  full  microscopical 
findings  will  be  reported  in  my  final  paper. 

Frank,  the  lifih  child  and  the  second  to  be  attacked  wii:h 
tine  disease,  is  now  twelve  years  of  age.  He  was  apparently 
well  until  his  eighth  year,  attending  school  until  that  time 
when  his  eyes  began  to  fail,  and  about  fifteen  months  later 
his  mind  also  showed  deterioration,  his  development  of 
symptoms  being  the  same  in  every  detail  as  his  brother's. 
This  boy  now  presents  a  well  developed  frame  of  ovei- 
grown  size,  is  fairly  strong,  and  is  always  on  the  move. 

I  might  add  that  both  afflicted  boys  began  to  show  signs 
of  puberty  at  eleven  years  of  age,  the  genitals  of  each  being 
unusually  well  developed,  with  changing  voices  as  is  usual 
in  the  pubescent  state.  A  peculiarity  common  to  botli  boys 
was  their  habit  of  running  in  a  circle,  and  always  to  the 
right,  until  tired  out.  when  they  would  sometimes  fall,  per- 
fectly exhausted.  Both  boys  Tia-v  e  a  history  of  a  fall  with 
injury  to  the  head. 

Marguerite,  the  third  patient,  is  now  eight  years  of  age 
and  is  the  sixth  child  of  the  family.  She  is  yet  only  in  the 
very  incipiency  of  the  di=case,  the  onlv  evidence  which  she 
presents  being  a  slight  hyperremia  of  the  chorioids  and  the 

*Read  before  the  Xew  York  .\cadeiny  of  Medicine,  Section  in 
Ophthalmology,  -\pril   19,  1909. 


retinse,  and  a  somewhat  increased  irritability  of  tempera- 
ment. 

Frank  presents  the  following  interesting  eye  conditions: 
Palpebral  fissures,  cornes,  size  of  the  globes,  and  general 
appearance  of  the  lids — all  normal.  The  eyes  keep  up  a  con- 
stant irregular  movement.  The  pupils  are  dilated,  contract- 
ing very  well  to  strong  daylight,  but  poorly  to  artificial  light. 
The  lenses  and  vitrea  are  normal.  Vision  is  very  poor, 
amounting  only  to  seeing  objects  imperfectly.  No  accurate 
knowledge  of  the  fields  could  be  ascertained,  on  account  of 
lack  of  mtelligence,  but  I  am  satisfied  that  they  are  enor- 
mously contracted. 

The  retinte  on  my  first  examination  were  oedematous,  tnt 
chorioids  being  congested  and  the  optic  nerves  atrophied. 
Since  then  the  cedema  of  the  retinse  has  practically  disap- 
peared, while  the  chorioid  has  passed  into  a  deep  congestion, 
which  now  is  giving  place  to  a  general  atrophy.  The  retiuce 
are  likewise  in  a  state  of  general  atrophy  and  show  small 
pigmentations,  few  in  number,  over  their  surfaces.  The 
veins  are  prominent  and  well  filled ;  arteries  are  small,  noi 
well  filled,  and  show  no  hardening.  There  is  no  evidence 
of  any  previous  papillitis.  The  usual  systematic  changes  in 
the  macular  region  are  not  present,  and  there  is  nothing  to 
indicate  that  they  ever  existed. 

Frank  gets  around  alone  and  recognizes  me.  He  is  in- 
clined to  acquaint  me  with  the  happenings  of  the  chickens, 
horses,  dogs,  etc.  He  is  particularly  fond  of  the  chickens 
and  will  spend  most  of  his  time  with  them  teasing  the 
mothers  of  broods  with  evident  satisfaction.  He  shows 
great  tenderness  in  handling  the  very  young  chickens.  His 
voice  is  pitc'ned  low  and  he  seems  to  use  more  air  than  is 
necessary  in  talking,  and  spends  considerable  time  outdoors. 
Generally  he  is  in  a  pleasant  frame  of  mind,  but  at  times 
is  sullen  and  morose.  His  ef¥orts  to  relate  things  con- 
sist of  exclamations  of  not  more  than  two  or  three  words, 
often  repeated  several  times,  accompanied  by  considerable 
show  of  animation.  His  articulation  is  thick,  and  he  mum- 
bles his  words.  He  often  speaks  of  his  dead  brother  John, 
but  with  no  feeling  whatever. 

An  odd  feature  of  this  case  is  the  boy's  love  and  appre- 
ciation of  music.  He  often  suggests  certain  pieces  to  be 
played  on  the  gramophone  and  becomes  much  elated  with 
the  joy  and  pleasure  thus  given  him,  ragtime  pleasing  him 
the  most,  while  a  religious  melody  seemingly  throws  hint 
into  a  "brown  study." 

Post  Mortem  Examination :  The  body  was  that  of  a  boy 
fifteen  years  of  age.  About  five  feet  in  height.  The  entire 
body  showed  extreme  emaciation  and  the  posterior  bony 
prominences  were  marked  in  many  instances  by  large  but 
well  cared  for  bed  sores.  The  skin  showed  almost  complete 
absence  of  panniculus  and  was  of  a  dirty  white  color  ex- 
cept where  congested,  and  in  several  areas  small  hsemor- 
rhagic  extravasations  of  a  purpuric  character  were  evident. 
Tlie  em.aciation  of  the  face  was  tremendous  and  the  eyeballs 
had  sunk  0.5  cm.  back  of  the  orbital  arch.  The  size  of 
the  head  was  normal,  as  was  also  the  size  of  the  feet  and 
hands.  The  thorax  was  poorly  developed  both  in  depth  and 
in  breadth ;  otherwise  the  body,  that  is,  the  skeleton,  was 
well  formed.  The  head  was  surmounted  by  a  profuse 
growth  of  thick,  fine,  black  hair.  The  face  had  an  idiotic 
expression,  quite  distinct  from  the  extreme  emaciation. 

Rigor  mortis  was  general  but  not  pronounced,  apparently 
due  to  the  very  small  bulk  of  the  muscular  tissue. 

The  scalp  was  thin,  and  though  the  skull  was  well  formed 
the  bone  averaged  one  centimetre  in  thickness  and  in  places 
was  entirely  composed  of  compact  bone.  The  dura  mater 
was  normal  except  that  it  was  abnormally  intimately  ad- 
herent to  the  pia  along  the  median  fissure.  The  brain  cov- 
ered by  the  pia  was  loose  in  the  skull  base,  from  one  to 
three  and  five  tenths  centimetres  space  existing  between  it 
and  the  skull — this  was  most  notable  in  the  frontal  region, 
but  was  everywhere  apparent.  The  pia  was  hyperjemic  and 
apparently  thickened.  Between  it  and  the  cerebral  tissue 
was  a  considerable  amount  of  clear  and  in  places  gelatinous 
fluid. 

The  brain  was  very  small ;  this  atrophy  had  reduced  the 
organ  to  about  the  size  of  that  normal  to  a  twelve  month 
infant,  and  it  weighed  in  its  entirety,  including  cerebellum 
and  medulla,  twenty  ounces.  The  cortex  was  of  a  peculiar 
vellowish  or  safYron  color.  The  convolutions  were  como'°v 
but  very  small,  more  like  wrinkles  over  the  surface  of  the 
brain,  which  had  the  aooearance  of  being  flabby,  but  "'as 
really  abnormally  firm  in  consistence.  The  atrophy  of  the 
convolutions  was  most  extreme  in  the  frontal  lobes,  but  ex- 


954 


McMURTRY:   SERUM   DIAGNOSIS  CHART. 


[Ne.v  York 
Medical  Journal. 


tended  to  all  portions  of  the  cerebrum,  though  the  cerebel- 
lum showed  less  definite  alterations  except  for  an  atrophy, 
which  was,  however,  disproportionate  to  that  of  the  cere- 
brum. The  optic  and  other  cranial  nerves  were  very  firm, 
but  did  not  present  the  usual  emaciated  conditions  of 
ordinary  degeneration.  They  were  quite  firm  on  palpation. 
The  frontal  lobes  were  so  markedly  atrophied  tliat  they 
had  taken  on  a  lanceolate  form,  and  the  frontal  lobes  as  a 
whole  presented  the  "cloven  hoof"  type.  The  medulla  and 
the  cervical  segments  of  the  spinal  cord  presented  no  gross 
alteration  except  for  increased  consistence  and  yellowish 
coloration.  The  differentiation  of  white  and  gray  matter 
was  definite.  In  the  cerebrum  the  cortical  layer  of  gray 
matter  was  very  thin  and  irregular,  but  the  chief  decrease 
in  size  appeared  to  have  resulted  from  the  shrinking  of  the 
white  matter,  which  retracted  from  the  cut  surface.  The 
encephalon  was  not  sectioned,  but  was  placed  in  a  solution 
of  formalin  for  fixation. 

Trunk:  The  abdominal  and  thoracic  musculature  was 
very  scant,  stringy,  and  pallid.  The  amount  of  panniculus 
was  very  minute,  but  highly  colored  with  lipochromes. 

The  trachea  showed  an  anaemic  mucosa  throughout,  but 
in  the  larynx  a  few  old  adhesions  were  found  about 
the  posterior  attachment  of  the  left  vocal  cord.  The 
bronchi  contained  a  moderate  amount  of  mucus.  The  pul- 
monary tissue  was  normal  except  that  in  the  posterior  por- 
tion of  the  left  lower  lobe  were  found  a  few  recent  small 
haemorrhagic  infarctions.  There  was  perhaps  a  slight  de- 
gree of  emphysema. 

The  peribronchial  and  peritracheal  lymph  nodes  showed 
slight  anthracosis,  but  they  were  small  and  not  tuberculous. 

The  thyreoid  gland  was  small,  its  tissue  compact  and  ap- 
parently rich  in  colloid.  The  thymus  was  represented  by  a 
mass  of  fiabby,  fibrous  tissue. 

The  heart  was  small  and  its  chambers  were  firmly  con- 
tracted. It  had  a  peculiar  brownish  purple  color,  was  ob- 
viously atrophied,  and  its  muscle  tissue  was  increased  in 
consistence,  apparently  brown  atrophy  with  hyaline  degen- 
eration. Weight  of  heart,  about  3.5  ounces.  The  valves 
were  entirely  normal,  except  that  the  aortic  segments  were 
somewhat  thickened  and  the  sinuses  were  here  deeply 
cupped.  The  arch  of  the  aorta  was  thickened,  and  the  in- 
tima  was  marked  by  many  striae  of  fatty  deposit — still  the 
elasticity  of  the  vessel  appeared  to  be  fair. 

The  liver  was  small,  weight  about  two  pounds.  It  was 
deep  purple  in  color,  firm  in  consistence,  and  showed  no 
fibrous  increase.  The  gallbladder  was  distended  witli  about 
30  c.c.  of  gelatinous  deep  green  bile ;  the  duct  was  pervious. 

The  spleen  was  very  small,  deep  purple  in  color,  and  in- 
creased in  consistence.  It  showed  apparently  a  moderate 
amyloid  degeneration  of  the  diffuse  type. 

The  adrenal  bodies  were  atrophic,  especially  in  the  medul- 
lary portions;  they  were  deeply  pigmented. 

The  mesenteric  and  abdominal  lymph  nodes  were  small 
and  showed  no  apparent  changes. 

The  kidneys  were  normal  in  size  for  a  boy  of  this  age. 
The  capsules  were  diffusely  adherent  and  the  consistent 
increased.  The  cortex  was  thick,  but  swollen  and  turbid 
in  appearance,  apparently  an  acute  parenchymatous  plus  a 
fatty  degeneration. 

The  gastrointestinal  tract  contained  but  a  very  small 
amount  of  faecal  material.  It  showed  a  considerable  degree 
of  post  mortem  decomposition,  but  otherwise  presented 
nothing  of  note. 

The  pancreas  was  small,  verv  firm,  yet  not  fibroid,  and 
was  of  a  bright  yellow  color,  probably  from  lipochromes. 

The  retroperitoneal  fat  was  very  scant  and  highly  colored. 

The  body  as  a  whole  contained  but  a  very  small  amount 
of  blood,  which  was  mostly  fluid  and  very  pale.  The  clot 
found  was  pinkish  and  of  the  "currant  jelly"  type. 

The  bones  were  firm,  presented  no  evidences  of  rarifica- 
tion,  but  rather  appeared  to  be  more  than  usually  calcified. 
The  medulla  was,  however,  very  light  in  color. 

Causa  Mortis :  Asthenia  and  aniemia  terminating  cerebral 
atrophy. 

Since  writing;-  the  above  I  have  received  from  Dr. 
Harlnw  P.rooks  a  preliminary  microscopical  report 
as  follows : 

Micro'^copical  examination  showed  a  very  marked  degen- 
eration nf  the  ganglion  cells  throughout  the  entire  cerebro- 
spinal axi'i.  The  most  marked  degenerations  were  seen  in 
the  ennpiion  cells  of  the  cortex  of  the  cerebrum.  T'"- 
medulla  and  the  gray  matter  of  the  spinal  cord  showed  the 
■^ame  chanjjcs  thoiigii  in  a  less  degree. 


Degeneration  in  the  structure  of  the  pituitary  body,  in 
the  adrenal  glands,  and  in  the  thymus  were  found.  These 
we  shall  report  in  detail  after  our  study  of  these  very  sug- 
gestive alterations  have  been  completed. 

Optic  nerve :  Grossly  the  optic  nerve  showed  little  change 
except  in  shrinkage  in  size.  Microscopically  no  nerve  fibres 
could  be  seen  and  sections  prepared  by  Marchi's  method 
showed  occasional  droplets  of  fatlike  staining  fluid  scat- 
tered as  a  detritus  through  the  scant  stroma  remaining  as 
representative  of  the  structure  of  the  optic  nerve. 

Retina :  The  layers  of  the  retina  were  hopelessly  degen- 
erated, so  much  so  that  the  normal  strata  could  not  be 
identified  and  the  ganglion  cells  could  not  be  found.  The 
degeneration  was  practically  complete. 

Chorioid :  No  change  in  the  chorioid  or  in  the  sclera 
was  evident. 

The  iris,  lens,  and  cornea  could  not  be  secured  for  exam- 
ination. 

9  E.\ST  TiTlRTV-XIXTH  StREET. 


THE  USE  OF  A  PRINTED  CHART  IN  THE  SERUM 
DIAGNOSIS  OF  SYPHILIS. 
By  Charles  Wood  McMurtry,  M.  D., 
New  York, 

Clinical   Assistant,    Skin    and   Cancer   Hospital;    Clinical  .Assistant, 
Dermatological  Department  of  Vanderbilt  Clinic.  Ehenialiger 
unbesoldeter  Assistent   der  kgl.   dermatologischen  Uni- 
versitats-Klinik   zu   Breslau  (Geheimratli 
Professor  Dr.  .-V.  Neisser). 

After  considerable  practical  laboratory  experience 
with  the  complement  fixation  test  of  Wassermann- 
Neisser-Bruck,  it  appeared  to  the  writer  that  for 
noting  down  the  many  details  of  this  test  a  printed 
chart  could  advantageously  be  substituted  for  the 
usual  laboratory  notebook.  The  chart  illustrated  is 
the  outcome  of  the  writer's  study  of  this  little,  prac- 
tical question.  While  this  chart  is  certainly  not  per- 
fect and  will  inevitably  be  superseded  by  something 
better,  yet  it  has  been  found  in  actual  laboratory 
work  to  possess  certain  features  of  undoubted  value 
which  merit  enumeration. 

The  chart  may  be  used  for : 

1.  Testing  one  or  more  specimens  of  seruin,  to- 
gether with  the  usual  control  tubes,  from  the  same 
patient. 

2.  Testing  a  group  of  sera,  as  for  instance  these 
of  a  man.  his  wife,  and  their  children. 

3.  Testing  either  antigen  or  amboceptor  for  titre 
or  for  activity. 

4.  Testing  the  serum  of  one  patient  with  scaled 
doses  of  antigen  and  of  amboceptor  or  with  diflfer- 
ent  antigens  and  amboceptors. 

5.  The  chart  may  be  used  to  note  the  results  of 
several  tests  made  at  different  periods  of  the  serum 
of  one  patient — as,  for  instance,  when  it  is  desirable 
to  ascertain  the  influence  of  different  forms  of  mer- 
curial treatment,  .diet,  and  general  hygienic  meas- 
ures, or  a  change  of  climate. 

The  advantages  claimed  for  this  chart  are  as  fol- 
lows : 

I.  Being  printed  and  ready  for  instant  use  it 
saves  time  by  eliminating  the  necessity  of  drawing 
with  pen  or  pencil  a  chart  for  each  group  of  tests  in 
a  blank  laboratory  notebook. 

II.  By  reason  of  the  absolute  uniformity  and 
greater  clearness  of  the  heading  of  each  colunin  and 
questions  of  the  blank  space  absolute  accuracy  in 
technique  as  well  as  thoroughness  in  noting  all  nec- 
essary details  of  scientific  or  clinical  importance  are 
made  easier  and  the  chances  of  error  or  incomplete- 
ness correspondingly  diminished. 

III.  Clearness  of  text  and  ease  of  reference  are 
secured  by  the  use  of  the  chart  in  each  case.  The 


May  8,  1909.] 


McMURTRY:    SERUM    DfAGNOSIS  CHART. 


955 


chart  is  printed  so  that  it  is  suitable  for  use  in  a 
filing  box  or  cabinet  with  all  the  advantages  of  this 
system. 

IV^.  Better  utilization  of  clinical  material  and 
work  done,  owing  to  the  clearness  and  completeness 


of  records,  the  ease  with  which  each  may  be  found 
and  referred  to,  if  properly  filed,  and  the  details  of 
the  cases  tested  used  statistically,  deductively  or 
otherwise  as  material  for  literary  work. 
812  Fifth  Avenue. 


SERUM 


DIAGNOSIS 


CHART 


For  the 

Wassermann-Neisser-Bruck  Complement  Fixation  Test 


By 

Charles  Wood  McMurtry,  M.D. 
New  York 


No. 


Name  Date. 


JS 


Remarks: 

Extract: 

Sera: 


No. 
of  Tube 

Extract 
Kind    No.  Dose 

Inactivatea 
Human 
Serum 

Name  Dose 

Comple- 
ment 

i-nysi- 
ological 

NaCr 
Solution 

I 

1 

1 

1 

1 

1  1 
2          1  1 

1 

1 

1 

3  1 

1  1 

i  i 

,      i  1 

!  ! 

5 

i        1  ! 
1        1  1 

6          1                   II  1 

1 

i 

s  1 

1  1 
1  1 

Haemolytic 
Ambocepter 


5% 
Sheep' 
Blood 


.  190 . 


Result. 


Results: 

30      1  I 
Minutes  |  Hour 

2      1  3 
Hours  1  Hours 

1      .  .      1  Intensity  of 
Hours  1  the  Reactior 

I  1 

1 

1  1 

1  1 

1 
1 

CLINICAL  DATA. 


Age?   Profession?. 


Married?. 


Parents  2? 


Patient? 


Z   History  (I,  II,  III,  Hr.  Malign.) 


Date  of  last 
Treatment  ? 


Date  of  last 
S  Symptoms? 


Abortions? 
Children  ? 


Nervous  System? 


 Results  of  earlier  Serum  Tests 

2    Treatment  (Sort?    When?)  ' 


TAICHELL:   SL  RGICAL   TREATMENT  OF  TU BERCULOCS  DISEASE.  [New  York 

Medical  Journ 


SURGICAL  TREATMENT  OF  TUBERCULOUS  DIS- 
EASE. 

Bv  W.  Arthur  Tatchell,  M.  R.  C.  S.  (Eng.),  L.  R.  C.  P. 
(Lond.). 
Hankow,  Central  China. 

One  of  the  most  common  diseases  here  in  China, 
(as  probabl}'  also  in  other  countries)  with  which 
we  are  confronted,  is  tuberculous  disease  of  the 
joints,  bones,  glands,  and  skin.  Phthisis  belongs  to 
the  province  of  the  physician.  The  treatment  of 
such  disease  is  generally  most  disappointing.  Ulcers 
and  sinuses  appear  to  resist  our  most  careful  and 
radical  methods  of  treatment.  Are  we  not  all  too 
familiar  with  our  old  enemy  "the  tuberculous  sinus"? 
It  seems  to  defy  our  every  effort  and  persists  like  a 
monstriim  nulla  virtute  redemptum  a  vitiis. 

In  conversation  upon  this  very  subject  with  a  very 
able  surgeon,  he  informed  me,  with  a  certain  degree 
of  reluctance,  that  he  had  finally  decided  to  severely 
leave  alone  most,  if  not  all,  cases  of  tuberculous  dis- 
ease of  joints.  Such  a  decision  could  but  claim 
our  sympathy,  if  not  assent.  Although  some  of  us 
in  China  have  frequently  felt  almost  compelled  to 
arrive  at  the  same  conclusion,  yet,  in  spite  of  our 
hopelessness  and  helplessness,  have  we  continued  to 
excise,  erase,  scrape,  use  poor  carbolic  acid,  iodo- 
form, etc. 

Last  summer,  we  seemed  to  be  afflicted  with  a 
special  consignment  of  tuberculous  joint  cases,  which 
either  occupied  our  beds,  or  daily  attended  the  out 
patient  department  for  change  of  dressing.  One 
day — or  rather  night — in  our  despair,  it  occurred 
to  us,  to  try  a  form  of  treatment  which  was  new  to 
us.  Of  course,  we  had  heard  of  and  for  a  long  time 
had  used  iodide  in  the.  form  of  the  tincture,  or  iodo- 
form, but  had  never  heard  of,  or  used  the  iodide 
liniment  (liquor  iodi  fortis).  This  we  decided  to 
try.  The  result  was  so  surprising  and  satisfactory, 
tliat  we  continued  the  treatment  more  vigorously, 
with  increasing  success  and  satisfaction  to  both  pa- 
tients and  ourselves. 

C.\SE. — The  first  case  which  we  seriously  undertook  to 
treat  by  this  method,  was  that  of  a  lad  with  tuberculous 
disease  of  his  right  elbow.  As  usual,  a  native  doctor  had 
acupunctured  the  swollen  member  and  like  the  unclean 
spirit  of  old,  who  decided  to  enter  its  human  dwelling  ac- 
companied with  "seven  other  spirits  more  wicked  than 
itself,"  the  "last  slate  of  that  man  (lad)  was  worse  than 
the  first."  Having  a  poisoned  hand  myself,  I  asked  my 
colleague  to  operate.  He  excised  the  joint  and  removed 
every  vestige  of  disease.  Every  possible  care  and  precau- 
tion was  exercised  to  secure  a  good  result.  After  a  few 
weeks,  with. the  usual  treatment  of  iodoform  dressings  the 
condition  of  the  elbow  was,  as  the  experience  of  similar 
cases  had  proved  us  to  expect  it  would  be,  i.  e. — healed  to 
a  certain  degree  but  with  several  sinuses  persisting.  We 
again  put  the  lad  under  ciiloroform  and  thoroughly 
-craped  the  sinuses  from  which  pus  was  freely  discharging. 
Then  we  thorouglily  swabbed  the  sinuses  witli  iodide  lini- 
ment; we  did  not  put  in  any  drainage,  but  dressed  with 
gauze  and  wool,  replacing  fhe  arm  upon  an  angular  splint. 
Two  days  afterwards  we  removed  the  dressings  and  to  our 
surprise,  there  was  not  a  particle  of  discharge.  Every  day 
after,  we  swabbed  the  sinuses  with  the  iodine  liniment, 
and  the)-  healed  as  thouirli  they  had  been  touclieil  with  a 
n.agic  wand.  Before  the  lad  left  the  hospital,  he  liad  se- 
cured splendid  movement.  He  could  write  with  a  Chinese 
pr-n  and  manipulate  his  chopsticks  with  celerity. 

It  is  quite  unnecessary  to  record  similar  cases,  or 
describe  the  many  cases  of  tubcrculotis  abscesses, 
ulcerated  glands,  skin  ulcers,  etc..  which  have  all  cn- 
tirolv  liOTled  tmder  this  treatment. 

Our  experience,  after  over  six  months'  IriTl.  is 


that  although  iodine  liniment  acts  well  upon  ulcers 
and  sinuses  of  a  mixed  infection,  the  results  are  not 
quite  so  rapid,  or  satisfactory,  as  is  its  action  vtpon 
tuberculous  disease. 

Our  modus  operandi  is  as  follows :  We  operate 
or  scrape  (which  is  not  exactly  surgery)  as  usual. 
Then  we  thoroughly  swab  the  cavity  with  iodine 
liniment,  liquor  iodi  fortis  (B.  P.,  1898).  A  piece 
of  cotton  wool  twisted  around  the  end  of  a  probe 
forms  a  good  swab  and  can  be  graduated  according 
to  the  size  of  the  sinus.  The  liniment  is  applied 
every  day.  The  application  does  not  caitse  pain, 
except  a  momentary  sensation  when  applied  to  some 
surfaces,  neither  does  it  destroy  tissues,  as  does  pure 
carbolic  acid.  Granulations  do  not  become  excess- 
ive. At  the  first  application  we  insert  a  thin  piece 
of  gauze  or  pack  lightly,  but  never  at  subsequent 
dressings.  (Gauze  plugs  and  strips  for  drainage 
have  undotibtedly  been  responsible  for  many  "chronic 
sinuses").  From  the  first,  we  give  a  mixture  inter- 
nally containing  syrupus  ferri  iodi,  drachm  one ;  and 
potassium  iodidi,  grains  five ;  t,  d,  s. 

In  the  case  of  large  phagedenic  ulcers,  which  form 
so  large  a  part  of  our  clinics  in  China,  we  first  of  all 
either,  scrape,  or  foment,  so  as  to  get  access  to  the 
base  of  the  ulcer.  Then  the  iodine  liniment  is  ap- 
plied daily.  One  of  the  worst  cases  of  this  charac- 
ter that  we  have  been,  called  tipon  recently  to  treat, 
included  the  entire  dorsum  of  the  man's  foot  and 
toes,  exposing  the  tendons  and  bones.  It  was  scraped 
and  iodine  liniment  used  from  the  first.  To-day  it 
has  almost  completely  healed  and  without  any  signs 
of  the  usual  extensive  granulations. 

One  is, — or  ought  to  be, — very  reticent  to  rush 
into  print  with  "things  medical  or  surgical,"  espe- 
cially touching  the  all  absorbing  subject  of  tubercu- 
losis. We  happened  to  mention  this  method  of 
treatment  at  a  medical  meeting,  since  when,  I  have 
received  several  letters  from  those  who  have  tried  it. 
They  all  report  satisfactory  results,  so  I  make  no 
apology  for  publishing  it. 

So  far,  we  have  failed  to  discover  any  reference  to 
this  special  form  of  treatment  in  any  available  med- 
ical literature.  Perhaps  it  has  been  and  is  still  be- 
ing used  by  our  more  enlightened  colleagues.  To 
sttch,  this  article  will  read  very  much  like  the  par- 
tnriunt  montes-  nascetur  ridiciilus  iiiiis,  but  to  those 
who  are  prepared  to  persevere  with  this  particular 
form  of  treatment,  we  can  wish  them  no  higher  joy 
or  greater  satisfaction,  than,  up  to  the  present,  has 
been  our  reward. 

Wesleyan  Mission  Hospit.-\l. 


THE  VERMIFORM  APPENDIX  A  RUDIMENTARY 
ORGAN  IN  THE  CARNIVORA. 

Bv  Je.n'nie  G.  Drennan,  M.  D.,  C.  M., 
Kingston,  Ont.,  Canada. 
Environment  determines  function  and  function 
determines  structure.  .Animals  ascended  from  a 
certain  common  type  may.  on  account  of  dift'erent 
environments,  develop  diftcrent  functions  and  con- 
sequently different  structures.  A  reptile  may  gfive 
rise  to  three  distinct  ty])es,  viz..  the  fish,  the  bird, 
and  the  mammal,  each  being  evolved  by  slow  de- 
grees. The  structiu-es  of  these  being  respectively 
those  best  adapted  for  the  functions  they  are  called 


Jlay  8,  1909.] 


DRENNAX 


VERMIFORM  APPENDIX. 


957 


upon  to  perform  in  order  to  dwell  under  certain 
conditions.  The  digestive  organs  of  the  carnivora 
must  essentially  differ  from  those  of  the  granivora 
for  in  each  type  there  is  a  dift'erent  function  to  per- 
form. The  one  digests  vegetable,  the  other  animal 
food,  each  demanding  a  dift'erent  process.  As  the 
granivora  is  the  more  likely  to  have  preceded  the 
carnivora,  consequently  in  the  latter  will  be  found 
organs  rudimentary  of  the  former ;  for  Nature  does 
not  by  one  stroke  alter  the  structures  of  her  ani- 
mals ;  but  by  slow,  slow  degrees ;  for  environment 
cannot  be  and  is  not  instantly  changed.  If  it  was 
annihilation  of  the  animal  would  result ;  but  Nature 
works  by  slow  degrees  only  and  changes  are  not 
wrought  by  her  quickly.  It  is  by  evolution ;  not  by 
revolution,  that  she  achieves  her  ends.  The  car- 
nivora retain  a  vermiform  appendix  to  which  no 
function  can  correctly  be  attributed,  and  which 
structure  has  led  to  much  controversy  pro  and  con- 
tra its  function  in  the  human  economy.  There  is 
every  reason  to  believe  that  the  granivora  preceded 
the  carnivora ;  the  vegetable  kingdom  preceded  the 
animal,  this  is  the  outgrowth  of  that;  therefore  the 
animal  that  fed  on  vegetable  aliment  preceded 
the  one  that  fed  on  a  flesh  diet. 

On  examining  such  an  animal — granivorous — as 
the  duck,  one  obsen-es  that  there  are  two  appen- 
dices situated  at  the  point  which  in  the  carnivora 
corresponds  to  the  junction  of  the  ileum  and  of  the 
colon ;  and  that  there  is  no  dilatation  of  the  main 
portion  of  the  intestine  at  this  point,  corresponding 
to  the  caecum  in  the  carnivora ;  but  that  the  intes- 
tine maintains  its  length  in  a  tube  of  if  anything  a 
lessened  calibre.  These  two  appendices  are  long 
and  of  a  size  corresponding  to  the  main  portion  of 
the  intestine  at  this  point.  They  are  filled,  if  the 
duck  has  been  fed  recently,  with  a  dark,  greenish, 
semisolid  matter,  the  apparent  function  of  these 
appendices  being  that  of  reservoirs  for  food,  which 
has  already  been  partially  digested ;  but  which  from 
the  habit  of  the  animal  of  feeding  almost  continu- 
ously during  its  waking  hours,  has  not  been  fully 
digested,  there  being  in  the  digestive  tract  too  much 
aliment  to  allow  of  perfect  digestion  at  this  time. 
When  the  animal  rests,  then  these  reservoirs  empty 
themselves  by  peristaltic  action  into  the  small  intes- 
tine, and  any  partially  digested  food  may  be  further 
digested  and  absorption  of  its  absorbable  contents 
may  take  place,  after  which  the  nonabsorbable  por- 
tion may  be  passed  along  through  the  large  intes- 
tine and  discharged  from  the  body  per  anum.  In 
the  carnivora  the  greater  part  of  the  function  of 
digestion  occurs  in  the  stomach,  and  when  the  con- 
tents of  this  organ  are  emptied  into  the  small  intes- 
tine, the  absorbable  portion  is  at  once  absorbed  and 
the  nonabsorbable  is  conveyed  on  into  the  colon  and 
expelled,  there  being  no  need  of  a  reservoir  to  con- 
tain any  partially  digested  food.  The  habits  of  the 
carnivora  in  partaking  of  food  at  longer  intervals 
and  not  almost  continuously  during  the  waking 
hours  will  render  a  reservoir  still  more  unnecessary. 

Man  partakes  of  the  nature  of  both  granivora 
and  carnivora :  especially  is  this  true  of  civilized 
man ;  and  it  is  his  vermiform  appendix  which 
causes  so  much  controversy.  Having  organs  well 
suited  for  both  varieties  of  digestion  he  is  not  in 
need  of  a   reservoir  for  his  vegetable  diet  and 


moreover  his  habit  of  partaking  of  food  at  regular 
intervals  renders  such  still  less  necessary,  hence  the 
vermiform  appendix  which  he  has  is  simply  a  rudi- 
mentary organ  of  a  state  out  of  which  he  has  slow- 
ly evolved.  He  has,  however,  made  somewhat  of 
an  attempt  at  supplying  himself  with  a  reservoir  in 
the  event  of  his  intestinal  contents  being  of  too 
liquid  a  nature.  A  condition  which  arises  from 
man's — civilized  man's — abnormal  habit  of  taking 
too  much  liquid  nutriment  at  meal  time  is,  that 
this,  on  being  intimately  mixed  with  his  solid  food 
escapes  proper  absorption  and  is  carried  through 
the  small  intestine  to  its  lower  end.  This  liquid 
condition  of  the  contents  of  the  small  intestine  may 
also  arise  from  faulty  absorptive  powers  of  the  in- 
testinal tract.  This  attempt  at  the  formation  of  a 
reservoir  consists  in  the  development  of  the  caecum, 
a  blind  pouch  formed  at  the  upper  end  of  the  colon 
at  its  junction  with  the  ileum.  From  this  pouch  the 
contents  may  be  regurgitated  into  the  small  intes- 
tine; but  this  is  an  abnormal  act,  for  between  the 
ileum  and  colon  there  is  a  valve,  which  denotes  that 
Nature  intended  the  contents  to  pass  in  one  direc- 
tion alone,  and  that  from  the  ileum  to  the  colon  and 
not  vice  versa. 

395  Brock  Street. 


A  SERIES  OF  PRIZE  ESSAYS. 

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1909-) 

LXXXVI. — How  do  you  make  an  early  diagnosis  of  pul- 
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May  /J,  7909.) 

LXXXV 1 1 . — Hozv  do  you  treat  supraorbital  neuralgia? 
{Anszvers  due  not  later  than  June  13,  iQog.) 

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PRIZE  QUESTION  LXXXIV. 
THE   THERAPEUTIC   USE   OF  .\LCOHOL. 
(Concluded  from  page  go8.) 
Dr.  D.  E.  Warren,  of  Pa.<;saic.  N.  /.,  zirifes: 

During  recent  vears  there  has  been  much  contro- 
versy about  the  physiological  action  of  alcohol,  and 
now  the  generally  accepted  theory  is  that  it  is  a 
depressant  rather  than  a  stimulant  to  all  of  the  func- 
tions of  the  body  upon  which  it  exerts  any  influence. 


958 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


Hence  the  growing  tendency  has  been  to  use  it  less 
and  less  as  a  therapeutic  agent. 

Alcohol  is  used  internally,  externally,  and  hypo- 
dermically,  and  is  administered  in  the  form  of  whis- 
key, brandy,  wine,  beer,  porter,  and  pure  alcohol  in 
solutions  of  various  strengths. 

There  seems  to  be  no  question  that,  when  given 
in  medicinal  doses,  it  decreases  tissue  change  by  re- 
tarding the  giving  off  of  nitrogen  compounds  and 
thus  increases  the  vital  power.  It  is  in  this  way  that 
it  is  valuable  in  adynamic  fevers  and  wasting  dis- 
eases, as  it  acts  as  a  supportive.  Given  in  milk  it 
aids  in  the  absorption  of  the  food,  as  owing  to  its 
irritation  of  the  mucous  membrane  of  the  stomach 
there  is  an  increased  secretion  of  gastric  juice. 

It  is  not  used  as  frequently  as  formerly  as  a  car- 
diac stimulant,  as  we  have  other  drugs  which  are 
more  efficient,  without  the  untoward  depressing  ef- 
fects. There  is  a  question  as  to  its  value  in  shock, 
it  being  stated  by  many  observers  that  the  shock  is 
more  profound  and  death  is  more  liable  to  ensue 
when  it  is  used. 

It  is  used  in  the  form  of  whiskey  or  brandy  as  a 
supportive  measure  in  the  latter  part  of  the  second 
week  during  the  third  week  and  convalescence  of 
typhoid  fever,  especially  when  there  is  extreme  pros- 
tration, in  typhus  fever,  typhoid  states  of  erysipelas, 
erysipelas  of  the  newly  born,  exhaustion  of  acute 
rheumatism,  collapse  of  scarlet  fever,  smallpox,  if 
heart  action  is  weak,  puerperal  and  ulcerative  endo- 
carditis, acute  sepsis,  second  stage  of  acute  meningi- 
tis when  there  is  much  exhaustion,  and  in  pericardi- 
tis, when  the  heart  action  fails.  In  the  stage  of  con- 
solidation in  pneumonia,  especially  in  children,  one 
quarter  to  one  half  ounce  of  whiskey  or  brandy  every 
three  or  four  hours  is  of  value  if  the  patient  is  weak. 
If  the  patient  has  been  addicted  to  the  use  of  alcohol, 
whiskey  or  brandy  must  be  given  freely  during  the 
entire  course  of  the  disease.  Whiskey  or  brandy  in 
milk  is  useful  as  a  supportive  in  cold  abscesses  and 
other  prolonged  suppurative  conditions. 

In  angina  pectoris  when  there  is  a  relaxed  condi- 
tion of  the  vessels  it  may  be  given  in  full  doses. 
W'hiskev  often  allays  the  vomiting  in  collapse  of 
puerperal  eclampsia,  and  iced  champagne  or  brandy 
is  of  service  in  incessant  vomiting  and  seasickness. 
Wine,  particularly  port  and  the  other  red  wines,  is 
useful  as  a  tonic  in  convalescence. 

Beer  and  porter  are  used  by  nursing  women  to 
increase  the  flow  of  milk. 

Alcohol, .  preferably  in  the  form  of  whiskey  or 
brandy,  to  counteract  the  constitutional  effects,  is 
indicated  in  poisoning  from  the  following  drugs : 
.■\conite,  veratrum,  viride,  antipyrine,  acetanilide,  an- 
timony, chloral,  cocaine,  eucaine,  iodine,  iodoform, 
and  opium.  It  should  be  used  hypodermically  in 
iodine  and  iodoform  poisoning,  as  it  acts  as  a  sol- 
vent for  those  drugs  when  given  by  stomach  and 
would  increase  their  absorption.  In  carbolic  acid 
poisoning  it  acts  as  a  diluent  as  well  and  should  be 
given  in  large  quantities  by  mouth.  Alcohol  in  a 
ninety-live  per  cent,  solution  should  be  used  freely 
as  a  lotion  in  burning  with  carbolic  acid. 

Pure  alcohol  in  fifty. per  cent,  solution  is  useful  as 
an  intrauterine  douche  in  puerperal  sepsis.  Gauze 
saturated  with  twenty-five  per  cent,  to  fifty  per  cent, 
solution  may  be  used  as  a  packing  in  the  same  con- 
dition. 


Absolute  alcohol  has  been  recommended  as  an  in- 
jection into  cancerous  tissue  in  inoperable  cases,  to 
reduce  the  amount  of  discharge,  and  bleeding.  It 
also  reduces  the  odor  and  alleviates  the  pain.  Dilute 
alcohol  is  used  locally  to  stimulate  weak  granula- 
tions in  healing  wounds. 

Recently  alcohol  in  eighty  per  cent,  solution  has 
been  used  successfully  in  tic  douloureux,  sciatica, 
and  other  neuralgias ;  also  in  blepharospasm.  It  is 
injected  into  the  sheath  of  the  nerve  and  causes  an- 
aesthesia in  sensory  nerves  and  paralysis  in  motor 
nerves,  together  with  more  or  less  degeneration  of 
the  nerve  fibres. 

Alcohol  in  solution  twenty-five  per  cent,  to  ninety- 
five  per  cent,  is  used  externally  as  a  cooling  and 
soothing  lotion  in  contusions  and  inflamed  joints. 
It  is  also  used  upon  the  skin  of  chronic  invalids  to 
harden  it  and  prevent  the  formation  of  pressure 
sores,  especially  over  the  sacrum  and  trochanters. 

Dr.  G.  A.  Graham,  of  Kansas  City,  Mo.,  says: 

Externally  alcohol  acts:  i.  By  coagulating  the 
albuminous  elements  of  the  skin,  thus  hardening  and 
shrinking  it.  So  I  use  it,  rubbed  on  the  back  and 
hips,  twice  daily,  as  a  preventative  of  bed  sores ; 
applied  as  a  wash  for  some  time  before  expected 
confinement,  to  harden  the  nipples,  and  prevent  their 
cracking  and  excoriation  after  delivery ;  also  as  a 
wash  in  relaxed  conditions  of  the  skin,  excessive 
sweating,  and  tender  feet.  2.  As  an  antiseptic  and 
germicide.  It  is  useful  in  sterilizing  the  hands,  the 
site  of  operation,  or  instruments  which  can  not  be 
boiled.  3.  By  rapid  evaporation,  it  cools  the  skin, 
and  reduces  the  body  temperature.  Diluted-  with 
two  parts  of  water,  and  applied  to  the  surface  of 
the  body  with  a  large,  soft  sponge,  it  is  cooling  and 
grateful  in  typhoid  and  other  fevers,  and  will  con- 
trol the  fever,  when  the  full  bath  either  can  not  be 
given,  or  is  not  required.  I  use  alcohol  as  a  lini- 
ment in  sprains,  bruise?,  and  to  abort  threatened 
abscesses.  The  benefit  derived  from  the  use  of  the 
tincture  of  arnica  in  sprains,  and  spirit  of  camphor 
in  mastitis,  seems  to  depend  entirely  on  the  cooling 
produced  by  the  rapid  evaporation  of  the  alcohol 
contained  in  these  preparations.  The  benefit  de- 
rived from  the  popular  "alcohol  rub"  is  entirely  a 
matter  of  suggestion,  and  its  supposed  strengthen- 
ing properties  are  mythical.  Alcohol  is  not  absorbed 
when  rubbed  on  the  skin.  When  used  in  this  way 
in  depressed  conditions,  it  is  liable  to  do  harm,  by 
reducing  the  body  temperature  when  it  should  be 
sustained.  Olive  oil,  or  cacao  butter  should  be  used 
instead  of  alcohol  in  massage. 

Hypodermically,  I  use  alcohol,  preferably  in  the 
form  of  brandy,  when  its  rapid  action  is  required, 
and  we  can  not  wait  for  its  absorption  from  the 
digestive  tract,  as  in  cases  of  syncope,  poisoning  by 
prussic  acid,  chloroform,  aconite,  and  other  heart 
depressants ;  when  the  patient  is  unconscious  and 
unable  to  swallow  as  in  asphyxia ;  also  alone  or  com- 
bined with  cocaine  and  morphine,  by  direct  injec- 
tion into  the  nerve,  or  as  near  the  nerve  as  possible, 
in  obstinate  cases  of  sciatica,  neuritis  following  in- 
fluenza, and  in  inctractable  neuralgias. 

Internally.  Alcohol  is  a  rapid  and  reliable  heart 
stimulant.  In  small  quantities  taken  after  eating,  it 
promotes  digestion ;  in  larger  quantities  it  inhibits 
digestion,  until  the  alcohol  has  been  absorbed  fronv 


May  8,  1909.] 


OUR  READERS'  DISCUSSIONS. 


959 


the  stomach.  As  a  heart  stimulant,  it  should  be 
used  judiciously.  Do  not  apply  the  whip  at  the  be- 
ginning of  the  race.  Hold  the  alcohol  in  reserve 
until  its  use  is  clearly  indicated.  In  pneumonia  and 
typhoid  fever  I  seldom  use  alcohol  until  late  in  the 
course  of  the  disease  and  not  then  unless  the  condi- 
tion of  the  heart  demands  it.  In  pneumonia  of  the 
apex,  which  generally  occurs  in  alcoholics,  or  old 
and  debilitated  persons,  the  free  use  of  alcohol  is 
imperative.  It  is  best  given  in  the  form  of  brandy. 
In  pneumonia  of  children,  complicating  or  follow- 
ing acute  exanthematous  diseases,  alcohol  should  be 
used ;  but  in  uncomplicated  cases  in  otherwise 
healthy  children,  it  is  seldom  needed.  In  the  third 
week  of  tvphoid  fever,  when  the  characteristically 
slow  pulse  of  that  disease  grows  rapid,  short,  and 
feeble,  and  septic  secondary  fever  sets  in,  I  use 
brandy  in  doses  varying  with  the  severity  of  the 
case,  in  desperate  cases  using  one  ounce  of  brandy 
every  hour.  It  is  well  borne.  In  shock,  faintness, 
chill  from  exposure  to  cold  or  wet,  and  in  nervous 
rigor  sometimes  following  delivery,  a  single  dose 
of  good  whiskey  or  brandy  will  relieve. 

In  seasickness  and  vomiting  of  pregnancy  a  glass 
of  champagne,  or  of  selected  beer,  will  often  give 
relief,  after  other  means  have  failed. 

As  a  stomachic  and  digestive,  I  rarely  prescribe 
alcoholic  drinks  or  wines,  on  account  of  the  danger 
of  creating  a  habit,  though  they  are  of  undoubted 
value  in  chronic  suppurative  cases,  anaemia  from 
hemorrhages,  incipient  phthisis,  and  convalescence 
generally."  The  large  amount  of  alcohol  in  patent 
medicines  accounts  for  both  their  popularity  with 
the  laity,  and  their  apparent  benefit  in  some  cases. 

The  free  use  of  alcohol,  in  the  form  of  beer,  to 
promote  the  flow  of  milk  in  nursing  women,  is  a 
pernicious  practice,  and  diminishes  the  quantity  and 
deteriorates  the  quality  of  the  milk,  witness  the  qual- 
ity of  the  milk  in  distillery  fed  cows. 

In  poisoning  by  carbolic  acid,  alcohol  is  a  use- 
ful antidote,  checking  the  caustic  action,  and  also 
of  use  in  surgery  for  the  same  purpose.  If  I  had 
a  case  of  snake  poisoning  to  treat,  in  addition  to 
other  measures,  I  should  give  alcohol  freely. 

Alcohol  should  be  used  as  a  solvent  for  aspirin, 
acetanilide,  phenacetin,  etc.,  when  it  is  advisable  to 
administer  such  drugs  in  mixtures,  and  because  the 
amount  of  alcohol  required  to  efifect  their  perfect 
solution,  is  sufficient  to  counteract  any  depressing 
effect  they  may  have  on  the  heart. 

Per  rectum.  In  rectal  feeding,  whenever  alcohol 
is  indicated,  brandy  should  be  added  to  the  nutrient 
enemata.  Diluted  brandy  per  rectum  is  a  useful 
substitute  for  the  hypodermic  use  of  it,  and  the  in- 
dications for  its  use  are  the  same. 

Dr.  John  L.  Bonner,  of  Buffalo,  N.  Y..  remarks: 

"Take  a  little  wine  for  your  stomach's  sake  and 
for  your  often  infirmities"  is  scriptural  authority 
for  its  value  as  a  therapeutic  agent.  Everything  in 
nature  has  its  uses  and  abuses,  but,  to  make  the  latter 
a  reason  for  neglect  of  the  former,  would  reduce  to 
nothingness  the  whole  economy  of  Nature  and  its 
fruitful  supply  of  all  necessaries  for  mankind  and 
the  lower  animal,  each  the  accessory  of  the  other. 
Therefore  it  becomes  obvious  that  alcohol  in  its 
various  forms,  fitted  for  the  palate,  or  otherwise 


adapted  to  therapeutic  purposes,  fills  its  own  niche. 
I  eliminate  from  discussion  abuses  of  this  agent  and 
confine  my  remarks  to  its  uses. 

Classified  as  a  stimulant,  antifermentative  agent, 
we  have  at  once  a  latitude  of  service  for  this  agent, 
which  places  it  upon  vantage  ground  not  readily 
assailable  by  the  most  zealous  advocates  of  total  ab- 
stinence. I  waive  no  rights  in  that  reform,  where 
beverage  is  advocated,  but  decline  to  confound  ther- 
apy with  "wine  bibbing."  Hence,  as  a  healing  agent 
only,  I  now  present  its  cause. 

In  all  cases  of  depression  of  vital  energy  its  quick 
stimulus  is  ever  an  agency  in  therapy,  its  exclusion 
from  his  armamentarium  would  relegate  to  censure 
any  one,  who,  for  prudish  reasons,  declines  to  use  it. 
That  its  value  is  definite  and  specific  need  only  to  be 
mentioned,  yet  to  specify  may  impress  such  more 
fully.  When  sudden  fear  prostrates  the  energy, 
every  man  seeks  his  flask  of  brandy.  Morally  speak- 
ing such  may  appear  objectionable,  scientifically, 
however,  its  efficacy  is  paramount  in  its  uses  for 
therapy ;  hence,  whatever  agency  meets  the  emerg- 
ency, must,  in  such  emergency,  be  acceptable.  Its 
comparative  safety  in  laymen's  hands  is  not  the  least 
of  its  merits. 

Asthenic  conditions  in  all  diseases  present  its  most 
frequent  field  of  service.  It  is  also  a  most  potential 
agency  for  relief  of  gastric  distress,  whether  neural- 
gic or  lithiac.  Syncope  aflfords  occasion  for  its  use, 
when  taken  before  loss  of  consciousness  or  by  enema 
or  inunction.  Any  sudden  heart  weakness  demand- 
ing quick  reaction,  would  call  for  its  use. 

When  taken  as  a  regular  medicament  it  is  better 
to  administer  upon  an  empty  stomach.  Dilute  the 
brandy  or  whiskey  in  hot  water  and  give  twenty 
minutes  or  more  before  eating,  thus  permitting  its 
absorption  before  food  and  gastric  juice  is  in  the 
stomach,  thus  avoiding  one  of  the  objections — pre- 
cipitation of  pepsin  or  other  albuminous  substances, 
thrown  down  by  alcohol,  while  securing  its  pure 
stimulation  and  resultant  tone  to  the  nerves  and 
organs  of  digestion  and  assimilation,  partially  ham- 
pered if  given  when  active  digestion  was  present. 

Its  uses  as  an  extractive  agent  for  gums  and  al- 
kaloidal  substances  and  preservative  vehicle  for  such 
need  only  to  be  mentioned  to  be  admitted  as  indis- 
pensable. 

I  cannot  speak  too  highly  of  the  great  therapeutic 
value  of  diluted  alcohol  or  brandy  or  whiskey,  as  a 
topical  dressing  of  wounds,  fresh  or  chronic,  where 
its  antiseptic  or  germicidal  value  is  demonstrated 
by  its  uniform  healing  powers  in  such  tissue  injury. 

As  a  therapeutic  agency  in  contrast  with  such 
drugs  as  strychnine,  morphine,  nitroglycerin,  and 
strophanthus,  while  admitting  their  great  and  al- 
most indispensable  value  for  hypodermic  therapy  in 
emergencies,  we  must  keep  in  plain  sight  the  greater 
danger,  both  in  the  hands  of  the  physician  and  es- 
pecially in  the  hands  of  laymen. 

Therapy  in  its  broadest  uses  being  adapted  to 
healing  by  the  populace,  as  well  as  the  physician, 
therefore  an  agent  of  such  marked  and  indubitable 
value  in  emergency  becomes  relatively  much  higher 
in  the  scale  of  therapy  when  known  to  be  safe  in 
the  hands  of  those  not  able  to  administer  the  more 
poisonous  remedies  I  have  mentioned. 


960 


CORRESPONDENCE. 


[New  York 
Medical  Journal. 


Dr.  JoscpJi  Di  Rocco,  of  New  York,  states: 

There  is  no  doubt  that  alcohol  per  se  is  injurious 
and  detrimental  and  acts  as  a  poison  to  the  healthy 
body  and  mind.  But,  at  the  same  time,  this  drug, 
when  judiciously  given  and  administered,  is  very 
useful  in  pathological  conditions.  There  must  be 
positive  indications  which  call  for  its  administration. 

Alcohol  is  the  most  abused  drug,  and  given  when 
not  required  is  useless  and  harmful ;  and  no  one 
should  be  prejudiced  against  its  use  when  judicious- 
ly given.  Thus  alcohol  may  be  useful  in  two  gen- 
eral conditions,  namely,  acute  diseases,  useful  here 
for  its  stimulating  power  and  effect,  and  in  chronic 
diseases,  for  its  power  to  sustain  and  to  check  ex- 
haustion and  tissue  waste. 

In  regard  to  the  chronic  diseases,  of  which  the 
most  prominent  is  tuberculosis  of  the  lungs,  alcohol 
stands  as  the  most  abused  of  all  drugs  used.  Al- 
cohol should  never  be  given  in  a  routine  way,  but 
when  given  it  is  best  administered  in  the  form  of  ale 
or  porter  and  it  should  always  be  given  with  the 
food.  And  positive  indications  must  be  met  which 
show  that  the  alcohol  is  doing  good ;  such  indica- 
tions are :  if  it  increases  the  desire  for  food  and  the 
digestion ;  and  the  strength  and  the  desire  for  exer- 
cise. Alcohol  always  does  good  with  cases  of  high 
fever  and  in  the  late  stages  of  the  disease.  Of 
course,  whiskey  or  brandy  (half  ounce  in  a  glass  of 
water)  can  be  given  instead  of  ale  and  porter. 

Now,  it  is  in  the  acute  conditions  such  as  lobar 
pneumonia  and  typhoid  fever  that  alcohol,  given  in 
the  form  of  whiskey  or  brandy,  does  the  most  good 
when  judiciously  administered.  In  these  conditions 
we  have  as  our  guide  the  pulse  and  the  heart.  Then 
in  acute  conditions  where  there  is  a  bad  assimila- 
tion of  milk,  shown  as  more  or  less  nausea,  often 
vomiting,  and  at  times  more  or  less  hiccough,  al- 
cohol, either  given  as  stated  or  very  often  in  the 
form  of  the  various  alcoholic  foods,  such  as  egg 
nog,  milk  punch,  and  wine  whey,  will  relieve  the 
condition  and  anxiety  of  the  patient.  Perhaps  this 
is  best  noted  in  typhoid  fever  after  a  prolonged  milk 
diet.  With  low  nutrition  and  high  fever,  the  heart 
weakens  and  alcohol  in  some  form  is  called  for  to 
improve  the  condition. 

Alcohol  is  doing  good  when  those  symptoms  for 
which  the  drug  was  given  disappear ;  then  the  pulse 
becomes  slower,  the  tongue  less  dry,  sleep  is  pro- 
duced, and  delirium  is  quieted.  In  the  principal 
New  York  hospitals  alcohol,  practically  in  the  form 
of  whiskey  (half  ounce  every  four  hours  or  oftener) 
is  the  only  stimulant  used,  when  any  stimulant  is 
caMed  for  in  typhoid  fever. 

During  the  convalescence  alcohol  is  given  for  its 
sustaining  qualities.  In  pneumonia,  after  the  crisis, 
you  increase  yom^  alcohol  to  one  ounce  given  at  the 
same  interval  as  stated. 

The  abuse  of  alcohol  is  shown  by  the  cases  seen 
in  the  alcoholic  wards,  such  as  acute  alcoholism 
(delirium  tremens ,  "wet"  brain)  and  the  effects  pro- 
duced by  the  alcoholic  habit. 

Resume:  Alcohol,  when  given  at  the  proper  time 
and  when  positive  indications  call  for  its  adminis- 
tration, does  its  work  just  as  strychinne  and  digitalis 
flo  theirs  when  given  at  the.  right  time.  But  alcohol 
should  not  be  abused  and  one  must  bear  in  mind 
that  every  patient  does  not  need  alcohol.  Alcohol  in 
actite  diseases  furnishes  stimulation  and  in  chronic 


diseases,  used  chiefly  to  check  exhaustion  and  tissue 
waste,  is  practically  a  food. 

Dr.  M.  B.  Kirkpatriek,  of  Trenton,  N.  J.,  observes: 

Alcohol  may  be  used  therapeutically  both  as  an 
internal  remedy  and  as  an  external  application. 

Taken  in  large  quantities  alcohol  is  of  great  value 
in  the  treatment  of  snake  bites  and  carbolic  acid  poi- 
soning. In  the  latter  case  besides  being  a  convenient 
and  stimulating  remedy  it  has  the  added  virtue  of 
being  an  antidote. 

A  single  large  dose  of  alcoholic  liquor  is  one  of 
the  best  therapeutic  measures  in  cases  of  fainting  or 
collapse  especially  when  due  to  prolonged  exposure 
to  cold. 

In  small  doses,  well  diluted,  alcohol  is  indicated 
in  the  treatment  of  febrile  cases  where  there  is  a 
rapid,  soft,  weak,  compressible  pulse ;  great  weak- 
ness ;  or  perhaps  the  typhoid  state  recognized  by  the 
presence  of  hebetude,  indifference,  muscular  twitch- 
ings.  or  low,  muttering  delirium,  as,  for  example, 
in  the  late  stages  of  septichsemia  or  typhoid  fever. 

Again  small  doses  of  alcohol  are  of  especial  value 
after  a  crisis  as  in  pneumonia. 

Still  another  indication  for  alcohol  is  in  the  toxic 
diseases,  such  as  diphtheria,  where  it  should  be  em- 
ploved  as  soon  as  the  depressing  symptoms  appear. 

As  a  tonic  it  is  of  value  in  combination  with  the 
bitters,  nux  vomica,  quinine,  etc.,  and  as  the  bitter 
wine  of  iron. 

In  chronic  wasting  diseases  such  as  tuberculosis 
alcohol  lessens  tissue  waste,  favors  the  deposition  of 
fat,  and  tends  to  check  the  progress  of  the  disease. 

As  an  injection  in  neuritis  although  useful  in  some 
cases,  its  value  is  limited. 

P'inally  its  use  in  checking  the  pain  of  dysmenor- 
rhoea  at  the  beginning  of  the  menstrual  period  de- 
serves mention. 

Externally  in  combination  with  alum,  alcohol  is 
invaluable  in  the  prevention  of  bed  sores,  cracked 
nipples,  and  sore,  tender  feet. 

In  combination  with  the  fluid  extract  of  ham-- 
amelis  it  forms  a  very  satisfactory  solution  in  cases 
requiring  massage  such  as  myalgia  and  chronic 
rheumatism. 

Lastly  the  old  remedy,  dilute  alcohol,  used  as  a 
gargle  ofttimes  gives  good  results  in  case?  of 
pharyngitis  and  amygdalitis. 

'  <^  

Comsponicnre. 


LETTER  FROM  LONDON. 

'I'Jie  Anccsthesia  Bill. — The  Nc.vt  Meeting  of  the  British 
Medical  Association. — Tlic  Pathological  Buildings  of 
St.  Bartholoniczv's  Hospital. — The  Royal  College  of 
Surgeons. 

London,  April  20.  igog. 
A  bill  has  recently  been  introduced  into  Parlia- 
ment with  the  object  of  amending  the  existing  hws 
regulating  the  administration  of  anaesthetics.  The 
provisions  of  the  bill  require  a  medical  practitioner 
applying  for  registration  on  or  after  January  i. 
191 1,  to  submit  evidence  of  having  received  prac- 
tical instruction  in  the  administration  of  ana;s- 
ihetics.  forbid  any  person  not  a  registered  medical 
practitioner  to  administer  an  an;esthetic  except  un- 
der certain  conditions,  safeguard  the  rights  of  all 
])ersons  registered  as  dentists  before  the  act  goes 


May  8,  igoo.) 


THERAPEUTICAL  NOTES. 


961 


into  efifect,  and  prohibit  any  certificate  of  death  be- 
ing given  in  the  case  of  any  person  dying  under  an 
anaesthetic.  The  penaky  for  a  nonregistered  medi- 
cal practitioner  who  shall  administer  any  anaes- 
thetic shall  be,  on  first  conviction,  a  fine  not  exceed- 
ing iio,  and  on  any  subsequent  conviction,  a  fine 
not  exceeding  £20.  A  clause  is  also  inserted  to 
protect  medical  students  giving  anaesthetics  under 
the  direction  and  supervision  of  a  registered  medi- 
cal practitioner,  or  if  the  circumstances  attending 
the  administration  are  such  that  the  person  giving 
the  anaesthetic  had  reasonable  grounds  for  believ- 
ing that  the  delay  which  would  have  arisen  in  ob- 
taining the  services  of  a  registered  medical  prac- 
titioner would  have  endangered  life.  The  penalty 
for  giving  a  death  certificate  in  the  case  of  any 
person  dying  while  under  the  influence  of  an  an- 
aesthetic shall  be  a  sum  not  exceeding  £5.  Any 
person  registered  under  the  Dentists'  Act  of  1878 
before  this  act  goes  into  effect,  shall  be  allowed  to 
give  an  anaesthetic  for  any  dental  operation  or 
procedure.  The  only  objection  likely  to  be  taken 
to  this  bill  is  by  the  dentists.  The  bill  forbids  any 
dentist  registered  after  its  passage  to  give  an  an- 
aesthetic. It  is  probable,  however,  that  this  clause 
will  be  altered  before  the  bill  becomes  law. 

The  arrangements  for  the  next  annual  meeting  of 
the  British  Medical  Association  are  now  complete. 
The  meeting  will  be  in  Belfast,  Ireland,  from 
July  23d  to  July  31st.  The.  president  elect  is  Sir 
William  Whitla,  ^I.D.,  LL.D.,  professor  of  ma- 
teria medica  and  therapeutics  in  Queen's  College, 
Belfast.  The  address  in  surgery  will  be  delivered 
by  Professor  A.  E.  Barker,  F.R.C.S.,  surgeon  at 
the  University  College  Hospital.  The  address  in 
obstetrics  will  be  delivered  by  Sir  John  W.  Byers. 
jM.D.,  professor  of  midwifery  and  diseases  of 
women  in  Queen's  College,  Belfast,  and  the  popu- 
lar lecture  will  be  delivered  by  Dr.  J.  A.  iNIacDonald. 
;  hvsician  to  the  Taunton  and  Somerset  Hospital 
and  chairman  of  the  Representative  meetings.  It 
is  proposed  to  gather  together  at  this  meeting  a 
series  of  exhibits  relating  to  (o)  tuberculosis,  {h) 
diseases  of  warm  climates,  (c)  cancer  of  the  uterus 
and  {d)  x  rays  and  photography.  The  honorary 
secretaries  are  Thomas  Houston,  M.D.,  and  W.  J. 
Wilson,  M.D.  Arrangements  have  also  been  made 
for  recreation  and  social  entertainments. 

The  splendid  new  buildings  at  St.  Bartholomew's 
Hospital  which  in  future  will  contain  the  patholog- 
ical department  are  to  be  opened  by  the  Lord  Mayo- 
next  month.  May  7th  is  the  day  fixed  for  the  cere- 
mony, which  will  take  place  in  the  great  hall  of 
the  hospital.  These  new  pathological  buildings  are 
being  equipped  in  the  most  up  to  date  manner  and 
will  contain  all  the  best  modern  apparatus  and  ap- 
pliances for  carrying  out  post  mortem  examina- 
tions, making  bacteriological  investigations,  and 
generally  studying  the  processes  of  disease. 

The  Council  of  the  Royal  College  of  Surgeons 
have  a  custom,  instituted  comparatively  recently, 
by  which  they  from  time  to  time  elect  to  the  fel- 
lowship of  the  college  distinguished  members  of 
more  than  twenty  years'  standing,  the  F.R.C.S. 
(our  highest  surgical  distinction)  under  ordinary 
circumstances  being  obtained  only  after  passing 
two  very  difficult  examinations.  At  the  last  meet- 
ing of  the  Council  two  very  distinguished  members 


were  thus  honored,  namely,  Sir  Shirley  ^lurphy 
and  Mr.  George  Dancer  Thane.  Sir  Shirley  ^lur- 
phy  is  the  medical  officer  of  health  to  the  County  of 
London  and  is  well  known  for  his  work  on  hy- 
giene and  sanitation.  Mr.  Thane  is  one  of  our 
most  celebrated  anatomists  and  holds  the  appoint- 
ment of  professor  of  anatomy  at  University  Col- 
lege, London.  The  Jacksonian  prize  was  awarded 
to  Mr.  J.  P.  Lockhart  flummery,  F.R.C.S.,  for  his 
essa}'  on  The  Pathology  and  Treatment  of  those 
Conditions  which  are  Relievable  by  Operative 
Measures.  The  John  Tomes  prize  was  awarded  to 
Mr.  Arthur  Swayne  Underwood  for  original  work 
in  dental  anatomy,  pathology,  and  surgery. 




The  Therapeutic  Action  of  Rattlesnake  Venom. 

— Dr.  Thomas  J.  Mays  published  a  preliminary 
paper  on  the  therapeutic  action  of  rattlesnake  venom 
in  the  Boston  Medical  and  Surgical  Journal  of 
April  15,  1909.  The  venom  used  is  the  salivary 
secretion  of  Crotaltts  horridus,  which  he  has  termed 
crotalin.  Crotalin  is  the  dried,  yellow,  scaly,  gran- 
ular residue  of  evaporated  rattlesnake  venom,  and 
is  soluble  in  water  and  glycerine.  Experience  has 
shown  that  the  most  practical  hypodermic  dose 
ranges  from  gr.  1/200  to  i/ioo  once  or  twice  a 
week,  and  that  it  is  preferable  to  begin  with  the 
smaller  dose  in  every  case,  unless  a  decided  impres- 
sion is  desired  to  be  made  at  the  beginning  of  treat- 
ment. 

The  following  formula  has  been  employed  in  mak- 
ing a  proper  solution  for  hypodermic  use : 

R    Crotalin  gr.  i ; 

Glycerin,   TTL  C ; 

Water,  HI  CCCC. 

Two  and  a  half  minims  equal  gr.  1/200.  and  5  minims 
equal  gr.  i/ioo. 

The  back  of  the  forearm  is  the  point  which  has 
been  chosen  as  the  site  of  injection,  although  no 
reason  exists  so  far  as  the  writer  knows  why  the 
upper  arm  should  not  be  used.  The  swelling  be- 
comes pronounced  when  the  larger  dose  is  given, 
but  in  no  instance  has  this  been  excessive  or  detri- 
mental in  the  two  hundred  and  more  injections  that 
have  been  given  thus  far.  There  is,  however,  a 
great  difference  in  the  local  reaction  among  the 
phthisical.  Far  advanced  patients  having  a  lowered 
vitality  are  less  susceptible  to  it  and  tolerate  larger 
doses  than  patients  of  acute  cases.  The  hypodermic 
administration  of  the  drug  may  be  reinforced  by 
giving  it  by  the  mouth  at  the  same  time,  according 
to  the  following  formula : 

R    Crotalin,   Sr.  ^  ; 

Glycerin,  fl.  5ii ; 

Peppermint  water,   fl.  5xxx. 

Sig. :  Dose  from  one  to  two  teaspoonfuls  four  times  a 
day.    One  teaspoonful  represents  gr.  1/128  of  crotalin. 

Dr.  Mays  concludes  from  his  experiments  and 
investigations  that  the  improvement  of  his  patie.its — 
he  gives  the  history  of  twenty-one  cases — was  main- 
ly due  to  the  action  of  crotalin.  Whether  these  re- 
sults are  ephemeral  or  whether  they  are  positive 
proof  that  diseases  of  the  chest  may  be  permanently 
improved  in  nearly  every  stage  of  their  existence, 
must,  of  course,  be  relegated  to  future  experience. 


962 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


NEW  YORK  MEDICAL  JOURNAL 

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NEW  YORK,  SATURDAY,  MAY  8,  1909. 


THE   PHYSICIAN   IN  PHARMACOPCEIAL 
REVISION. 

The  Ninth  Decennial  Convention  for  the  Revi- 
sion of  the  Pharmacopoeia  of  the  United  States  of 
America  will  begin  in  Washington  on  Tuesday, 
May  10,  191  o.  All  medical  and  pharmaceutical 
schools,  whether  incorporated  independently  or 
associated  with  universities,  all  medical  and  pharma- 
ceutical State  associations,  the  American  Medical 
Association,  the  American  Pharmaceutical  Associa- 
tion, the  American  Chemical  Society,  the  army,  the 
navy,  and  the  ^Marine  Hospital  Service,  are  each 
entitled  to  send  to  the  convention  three  delegates. 

The  United  States  Pharmacopoeia  is,  we  think, 
the  only  national  standard  for  drugs,  save  the  Mex- 
ican Pharmacopoeia,  the  revision  and  publication  of 
which  are  not  controlled  either  directly  or  indirectly 
by  the  government.  In  Great  Britain  the  revision 
of  the  pharmacopoeia  is  carried  on  under  the  direc- 
tion of  the  General  Medical  Council,  a  body  com- 
prising thirty  members  chosen  by  the  Royal  Col- 
leges of  Physicians  and  Surgeons  of  London,  of 
Edinburgh,  and  of  Ireland,  the  Apothecaries'  Soci- 
ety of  London,  the  Faculty  of  Physicians  and  Sur- 
geons of  Glasgow,  the  Apothecaries'  Hall  of  Ire- 
land, eleven  different  universities,  the  British  Med- 
ical Association,  and  the  government.  The  general 
supervision  of  the  preparation  of  the  work  is  in  the 
hands  of  a  committee  of  eight  physicians,  the  actual 
editing,  however,  being  done  by  Professor  Attfield. 
the  pharmaceutical  chemist,  while  the  assistance  of 


a  committee  of  the  Pharmaceutical  Society  of  Great 
Britain  is  mentioned  in  the  preface.  The  Mexican 
Pharmacopoeia,  on  the  other  hand,  is  the  product 
and  property  of  the  Pharmaceutical  Society  of 
Mexico,  and  was  revised  by  a  committee  of  that 
society  without  the  official  aid  of  any  organized 
body  of  physicians  and  was  made  official  by  govern- 
mental edict  based  on  a  national  law.  The  revision 
of  the  other  pharmacopoeias  of  the  world  is  strictly 
a  government  function,  carried  out  by  commissions 
appointed  and  remunerated  by  the  government,  the 
commissions  comprising  both  medical  and  pharma- 
ceutical representatives. 

The  actual  revision  of  the  United  States  Pharma- 
copoeia is  done  by  a  committee,  and  the  last  com- 
mittee numbered  twenty-six  members,  selected  for 
that  purpose  by  a  vote  of  the  Pharmacopoeial  Con- 
vention. The  number  of  medical  delegates  author- 
ized is  greater  than  that  of  the  pharmaceutical  dele- 
gates;  consequently,  if  all  the  medical  organizations 
entitled  to  representation  send  to  the  convention 
their  full  quota  of  delegates,  the  physicians  will 
outnumber  the  pharmacists  and  may  therefore  con- 
trol the  general  course  of  the  convention.  As  a 
matter  of  fact,  physicians  have  heretofore  failed  to 
take  sufficient  interest  in  pharmacopoeial  revision  to 
avail  themselves  of  their  privileges  and  power  in 
connection  with  the  work,  the  control  of  which  has 
thus  largely  fallen  into  the  hands  of  pharmacists. 
Fortunately  they  have  been  wise,  skilful,  and  un- 
selfish in  their  labors,  producing  a  volume  which  in 
its  main  features  compare  favorably  when  issued 
with  any  in  force  elsewhere.  But  whether  or 
not  the  results  of  entrusting  the  work  to  pharma- 
cists have  been  satisfactory,  it  seems  plainly  the 
duty  of  the  physician  to  participate  in  this  labor 
and  to  share  in  the  responsibility. 

A  cry  has  been  raised  by  a  physician  of  Phila- 
delphia that  the  pharmacopoeia  has  been  "captured" 
by  pharmacists  and  should  now  be  recaptured  by 
physicians.  As  a  matter  of  fact,  pharmacists  have 
only  accepted  the  responsibilities  that  were  thrust 
upon  them  by  the  negligence  of  the  medical  pro- 
fession, and  we  deem  it  most  unfortunate  that  any 
suggestion  likely  to  lead  to  antagonism  between  the 
two  professions  in  relation  to  this  national  standard 
should  be  offered.  It  is  for  the  physician  to  give 
information  as  to  what  drugs  should  be  incorpo- 
rated in  the  pharmacopoeia.  He  knows  what  medica- 
ments are,  or  should  be.  ordered.  It  is  the  province 
of  the  pharmacist  to  establish  standards  of  identity, 
strength,  and  purity  and  to  devise  proper  methods 
of  procedure  for  the  manufacture  of  galenical 
preparations.  There  is  no  question  whatever  of  a 
capture  or  of  a  recapture  of  the  pharmacopoeia, 
'i'liere  is  a  legitimate  field  of  labor  in  the  revision 


May  8,  1909.] 


EDITORIAL  ARTICLES. 


03 


of  the  pharmacopoeia  for  both  physicians  and  phar- 
macists, and  just  in  so  far  as  either  medicine  or 
pharmacy  is  excluded  from  this  work  will  it  fall 
short  of  being  truly  representative  and  attaining  to 
its  greatest  possible  value  and  usefulness. 


LUMBAR   PUNCTURE   FOR  NOCTURNAL 
INCONTINENCE  OF  URINE. 

It  seems  to  have  been  Babinski  who  first  had  the 
idea  of  resorting  to  lumbar  puncture  in  the  treat- 
ment of  nocturnal  incontinence  of  urine.  Accord- 
ing to  Dr.  C.  Billaud  {Gazette  medicale  de  Nantes, 
April  loth),  Babinski's  undertaking  was  successful 
in  a  number  of  instances,  and  generally  only  one 
puncture  was  required.  M.  Billaud,  who  presents 
us  with  an  interesting  resume  of  our  knowledge  and 
speculation  concerning  enuresis  nocturna,  reports  a 
successful  case  of  his  own. 

The  patient  was  a  rather  ill  developed  girl,  four- 
teen years  old,  somewhat  defective  in  intelligence 
and  affected  with  hysterical  manifestations.  She 
was  found  to  be  living  under  very  insanitary  condi- 
tions, but  these  were  eliminated  by  conveying  her 
to  a  department  hospital,  where,  however,  she  did 
not  improve.  She  was  then  transferred  to  the  ho- 
pital  du  Lude.  As  she  was  still  a  little  pale  and 
thin,  it  was  thought  that  malnutrition  might  be  at 
the  bottom  of  her  incontinence,  and  a  generous  diet 
was  ordered.  In  addition,  she  was  directed  to  sleep 
with  her  head  low  and  her  buttocks  decidedly  ele- 
vated. Moreover,  she  was  awakened  several  times 
every  night.  Cold  douches  also  were  employed,  and 
atropine  was  prescribed.  These  measures  were  with- 
out effect. 

Some  severity  was  now  resorted  to,  the  patient 
bcin.'.i  promised  that  it  would  be  relaxed  as  soon 
as  she  stopped  wetting  the  bed.  This,  too,  was  of 
no  use.  Sodium  bicarbonate  was  given,  though 
there  was  no  undue  acidity  of  the  urine.  As  the 
child  had  never  menstruated,  ovarian  extract  was 
employed  for  a  time,  and  during  the  time  of  its 
administration  there  was  a  slight  amelioration. 
Methylene  blue  was  prescribed,  but  the  girl  was 
not  disquieted  by  passing  blue  urine.  Evidently  her 
incontinence  was  not  amenable  to  measures  affect- 
ing her  equanimity. 

After  having  had  the  girl  under  treatment  for 
more  than  two  months,  M.  Billaud  performed  lum- 
bar puncture.  By  jerking  her  body  the  patient 
caused  the  needle  to  enter  to  an  unwonted  distance, 
so  that  it  doubtless  pierced  the  spinal  cord  through 
and  through.  It  was  feared  that  further  movements 
on  her  part  would  break  the  needle,  and  it  was  with- 
drawn.  The  puncture  was  a  "dry"  one,  and  it  was 


followed  by  unpleasant  and  somewhat  disquieting 
nervous  symptoms  which  lasted  for  several  days. 
These  untoward  effects  subsided,  however,  and 
there  was  no  further  incontinence  of  urine.  How, 
asks  M.  Billaud,  did  this  "dry"  jpuncture  act?  He 
intimates  that  it  was  not  psychically,  for  the  girl 
began  again  with  some  of  her  pretended  symptoms. 


"FULGURATION"  IN  THE  TREATMENT 
OF  CANCER. 

In  a  recent  discussion  before  the  German  Surgical 
Society  (Semaine  medicale,  April  21st)  Dr.  Czerny, 
of  Heidelberg,  expressed  the  opinion  that  the  results 
of  the  treatment  of  cancer  by  "fulguration"  were 
very  variable.  He  had  subjected  163  patients  to  it, 
and  some  of  them  seemed  to  have  been  cured.  He 
thought  that  after  an  operation  it  was  certainly  use- 
ful in  assuring  a  good  result.  It  was  but  rarelv 
that  he  had  observed  propagation  of  the  tumor  in 
consequence  of  a  sitting.  Caustics  might  sometimes 
give  the  same  results,  but  with  less  certainty  and 
with  more  pain.  The  rapidity  of  cicatrization  was 
very  striking;  enormous  wounds  closed  very 
quickly.  Healing  of  the  wound  did  not  prevent  a 
relapse,  but  it  relieved  the  patient  of  a  source  of 
terrible  pain. 

Dr.  Abel,  of  Berlin,  did  not  take  such  a  favorable 
view  as  Czerny's,  though  he  had  sometimes  observ- 
ed a  salutary  action  directly  attributable  to  the 
sparks.  In  three  cases  he  had  known  the  procedure 
to  render  a  cancer  of  the  uterus  susceptible  of  op- 
eration, its  mobility  ensuing  upon  a  few  sittings. 
However,  he  thought  that  relapses  occurred  with 
increased  rapidity  after  "fulguration."  Cancroids 
might  be  definitively  cured,  but  cancers  properly  so 
called  were  not  favorably  influenced.  Dr.  Cohn,  of 
Berlin,  had  tried  the  application  in  a  hundred  cases, 
but  the  results  had  not  been  very  encouraging.  It 
had  no  effect  at  all  upon  cancer  en  cuirasse.  Dr. 
Hofmeister  had  seen  transitory  improvement  in  in- 
operable cases,  but  in  not  one  of  fifty-six  cases  had 
a  cure  been  effected. 


THE  DANGERS  OF  WIRELESS 
TELEGRAPHY. 
A  French  naval  surgeon,  Dr.  P.  Bellile  {Archives 
de  medecine  navale,  March ;  Tribune  medicale, 
March  20th),  has  observed  facts  which  he  thinks 
warrant  him  in  attributing  certain  morbid  conditions 
to  overexposure  to  the  electrical  waves  employed  in 
wireless  telegraphy.  For  the  most  part  they  have 
affected  the  eye,  generally  in  the  form  of  conjunc- 
tivitis, though  in  one  instance  there  was  keratitis. 


964 


EDITORIAL  ARTICLES. 


[New  York 
Mf.dical  Journal. 


Eczema,  too,  has  been  observed,  and  the  author 
ihuiks  that  many  cases  of  neurasthenia  are  attribut- 
able to  the  current.  He  remarks  that  induced  cur- 
rents are  a  common  product  of  the  action  of  the  ap- 
paratus, and  intimates  that  these  may  cause  trouble 
among  other  persons  than  those  immediately  con- 
cerned in  the  telegraphic  operations.  He  recom- 
mends that  operators  be  provided  with  blue  or  yel- 
low spectacles.  It  seems  to  be  the  general  rule,  he 
says,  that  each  step  in  scientific  progress  shall  be 
marked  in  the  annals  of  pathology  and  require  a 
new  chapter  of  hygiene  and  prophylaxis. 


GROCCO'S  SIGN  IN  INFANTILE  PLEURISY. 

The  diagnosis  of  serofibrinous  pleurisy  is  rather 
difficult  to  make  in  children,  and  consequently  every 
new  diagnostic  sign  that  is  offered  to  detect  it 
should  be  carefully  examined.  Rauchfuss  and  Groc- 
co  pointed  out  some  time  ago  the  presence  of  an  area 
of  relative  dulness  on  percussion  over  the  back,  near 
the  vertebral  column,  on  the  normal  side.  Rauch- 
fuss described  the  triangular  form  presented  by  this 
dulness.  The  apex  of  the  triangle,  he  says,  reaches 
the  upper  limit  of  the  pleural  exudate,  and  its  ex- 
ternal angle  corresponds  to  the  outer  limit  of  the 
absolute  dulness  on  the  diseased  side.  In  order  to 
map  out  this  triangle,  very  light  percussion  is  ad- 
vised. Hamburger  has  confirmed  the  existence  of 
this  symptom,  although  he  has  not  always  found 
that  the  area  took  on  a  triangular  shape ;  he  noticed 
that  the  pleural  cavity  containing  the  collection  pre- 
sented an  area  very  near  the  spine  which  gave  a 
slightly  dull  note,  that  is  to  say,  a  slightly  higher 
tone  than  that  obtained  in  the  area  of  absolute  dul- 
ness, but  relatively  more  distinct  than  the  sound  ob- 
tained in  the  triangle  on  the  healthy  side.  In  this 
way,  by  percussing  the  posterior  aspect  of  the 
thorax,  four  areas  may  be  made  out,  extending  from 
the  healthy  side  to  the  diseased  side,  viz.,  the  area 
of  normal  resonance,  that  of  relative  dulness,  that  of 
relative  resonance,  and  that  of  absolute  dulness.  It 
is  by  hard  or  medium  percussion  that  these  areas 
may  be  detected. 

The  Grocco-Rauchfuss  sign  was  afterward  rec- 
ognized by  a  number  of  observers,  particularly  by 
liaduel,  Siciliano,  Pollak,  Thayer,  and  Fabyan.  Pol- 
!ak  confirmed  the  presence  of  relative  dulness  and 
resonance  near  the  spine  and  sternum  in  pleurisy,  and 
lie  points  out  that  the  same  sign  may  make  its  ap- 
])earance  in  pneumonia ;  he  reports  six  cases  of 
pneumonia  in  the  lower  lobe  and  one  in  the  upper 
left  lobe  where  this  sign  was  discovered  near  the 
sternum.  Thayer  and  Fabyan  looked  for  Grocco's 
sign  in  thirty-two  cases  of  pleurisy,  and,  fuit  of 


these,  it  was  found  wanting  in  two ;  one  of  these 
was  a  case  of  very  large  pleural  collection,  while  the 
second  was  an  instance  of  interlobar  exudate.  In 
the  area  of  the  dull  triangle  the  respiration  may  be 
either  weakened  or  bronchial  in  nature ;  sometimes 
aegophony  may  be  present.  The  dulness  disap- 
pears when  the  patient  is  placed  on  the  diseased 
side  and  reappears  when  he  sits  up  or  lies  on  the 
liealthy  side.  Thayer  and  Fabyan  have  also  found 
this  sign  present  in  pneumonia,  and  they  are  of  the 
opinion  that,  in  this  case,  dulness  is  less  complete 
and,  what  is  particularly  characteristic,  that  it  does 
not  change  its  position  with  the  position  of  the 
patient. 

Quite  recently  (Archives  de  medccine  des  enfants, 
March)  Brudzinski  has  published  the  results  of  his 
researches  into  these  symptoms  in  eighteen  cases  of 
infantile  pleurisy.  He  concludes  that  the  absolute 
diagnostic  value  of  Grocco's  sign  is  doubtful.  Its 
value  is  in  reality  diminished  by  the  fact  that  it  is 
also  found  in  pneumonia.  However,  in  the  latter 
affection  the  dulness  is  not  quite  so  absolute,  and, 
what  is  still  more  important,  the  vertebral  dulness 
does  not  change  with  the  position  of  the  patient, 
while  in  pleurisy  the  dulness  disappears  when  the 
patient  lies  on  the  diseased  side  and  reappears  when 
he  sits  up  or  lies  on  the  healthy  side.  This  fact 
would  seem  to  confirm  the  supposition  that  the  sign 
owes  its  presence  to  the  pushing  of  the  mediastinum 
toward  the  healthy  side. 


MEDICAL  SCHOOLS  IN  CHINA. 

It  is  stated  that  the  China  Emergency  Appeal 
Committee,  of  which  Sir  Robert  Hart  is  chairman, 
is  about  to  make  an  appeal  on  medical  training  and 
other  educational  work  in  China.  The  sum  re- 
quired is  not  less  than  $500,000  for  the  development 
of  medical  and  other  educational  enterprises  and 
for  the  translation  of  the  best  Western  literature 
into  Chinese.  In  China  at  the  present  time  trained 
medical  men  are  provided  for  the  army  and  the 
navy  only.  Consequently  the  most  urgejit  need  of 
the  empire  is  for  medical  schools  where  thorough 
scientific  training-  may  be  given  to  Chinese  students. 
The  medical  missionaries  in  the  field  are  frequently 
forced,  through  lack  of  funds  and  scarcity  of  assist- 
ants, to  neglect  the  purely  scientific  side  of  their 
profession  and  to  devote  too  much  time  to  the  emo- 
tional and  sentimental  aspect  of  the  physician's 
duties.  The  China  Medical  Missionary  Society, 
however,  is  working  to  put  an  end  to  the  parsi- 
monious policy  of  the  home  boards,  and  we  may 
see  the  medical  schools  already  established  in  China 
rise  to  tlie  opjiortunity  here  offered. 


May  8,  1909. J  XISll'S    HEMS.  9^,5 


^tm  luuii. 


An  Anonymous  Gift  to  the  College  of  Physicians  and 
Surgeons. — The  department  of  pathologj'  of  the  College 
of  Physicians  and  Surgeons,  New  York,  has  received  $5,000 
from  an  anonymous  source,  for  equipment. 

Doctors'  Mistakes  was  the  title  of  a  paper  read  at  the 
May  4th  meeting  of  the  Section  in  Surgery  of  the  Buffalo 
Academy  of  Medicine  by  Dr.  George  W.  Gay,  of  Boston, 
lecturer  in  surgery  at  the  Harvard  Medical  School. 

Public  Health  Problems  of  the  Municipality  will  be 
discussed  by  Dr.  Walter  Bensel,  Sanitary  Superintendent, 
New  York  Health  Department,  at  a  meeting  of  the  Section 
in  Public  Health  of  the  New  York  Academy  of  Medicine 
to  be  hela  on  May  nth. 

Presentation  to  Dr.  Sheffield. — The  medical  staff  of  the 
Yorkville  Dispensary  and  Hospital,  246  East  Eighty-second 
Street,  New  York,  recently  presented  to  Dr.  H.  B.  Shef- 
field a  beautiful  electrolier  and  stand,  in  recognition  of  his 
valuable  services  to  the  hospital. 

The  Medical  Society  of  the  District  of  Columbia  held 
its  annual  meeting  in  Washington  recently  and  elected  the 
following  officers  for  the  ensuing  year :  President,  Dr. 
Thomas  N.  McLaughlin ;  vice  president.  Dr.  James  A.  Wat- 
son ;  treasurer.  Dr.  Frank  Leech ;  and  secretary,  Dr.  L.  H. 
Reichelderfer. 

The  Fourth  Latin-American  Medical  Congress  will 
be  held  in  Rio  de  Janeiro  from  August  ist  to  8th,  and  in 
connection  with  the  congress  an  International  Exposition 
of  Hygiene  will  be  held  from  September  ist  to  30th.  An 
official  invitation  has  been  sent  to  the  United  States  to  be 
represented  at  both  the  congress  and  the  exhibition. 

Contagious  Diseases  in  Chicago. — There  were  896  cases 
of  contagious  diseases  reported  to  the  Department  of 
Health  during  the  week  ending  April  24th,  as  follows ; 
Diphtheria,  91 ;  scarlet  fever,  145 ;  measles,  347 ;  chicken- 
pox,  40;  pneumonia,  44;  typhoid  fever,  25;  whooping  cough, 
16;  tuberculosis,  118;  mumps,  61;  erysipelas,  8,  and  cerebro- 
spinal fever,  i. 

A  Night  Clinic  for  Women  in  Brookl}m. — A  night 
dispensary  and  clinic  was  opened  at  the  Brooklyn  Hospital, 
De  Kalb  Avenue  and  Raymond  Streets,  Brooklyn,  on 
April  29th.  The  clinic,  which  is  for  women  exclusively, 
will  be  open  on  Thursday  evenings  from  7  to  9  o'clock. 
Although  there  are  night  clinics  in  some  of  the  hospitals 
in  Manhattan,  this  is  the  first  to  be  established  in  Brooklyn. 

Separate  Schools  for  Tuberculous  Children  may  be 
established  in  Philadelpliia  in  the  near  future.  The  new 
school  code  specifically  states  that  children  suffering  from 
tuberculosis  cannot  be  admitted  into  the  public  schools, 
and  at  the  same  time  provides  for  the  compulsory  attend- 
ance of  all  children  between  the  ages  of  six  and  sixteen 
years.  It  is  the  opinion  of  the  educational  officials  that  the 
only  solution  of  the  problem  is  to  set  aside  special  schools 
for  the  use  of  the  tuberculous  pupils. 

Ambulance  Board  Bill  Passes  the  Senate. — The  Hoey 
bill,  providing  for  the  establishment  in  New  York  of  a 
Board  of  Ambulance  Control,  has  passed  the  Senate,  and 
will  go  to  Governor  Hughes  for  signature.  The  board  is 
to  consist  of  the  Commissioner  of  Police,  the  Commissioner 
of  Charities,  the  president  of  the  board  of  trustees  of 
Bellevue  and  Allied  Hospitals,  and  of  two  citizens  repre- 
senting private  hospitals,  who  will  be  appointed  by  the 
Mayor.  The  board  will  have  complete  control  of  the  am- 
bulance service  of  the  city. 

The  Dr.  Bull  Memorial  to  be  a  Research  Fund. — The 
members  of  the  committee  appointed  about  six  weeks  ago 
to  decide  upon  a  fitting  memorial  to  the  late  Dr.  William 
T.  Bull,  are  unanimously  in  favor  of  the  establishment  of 
a  research  foundation  at  the  College  of  Physicians  and 
Surgeons.  The  committee  hopes  that  the  fund  will  reach 
$500,000  at  least,  and  five  thousand  appeals  for  contributions 
have  been  issued  by  Dr.  John  B.  Walker,  secretary  of  the 
committee.  The  money  will  not  be  used  for  the  "erection 
of  buildings  or  the  equipment  of  laboratories,  but  for  the 
maintenance  of  a  department  in  connection  with  the  College 
of  Physicians  and  Surgeons  where  a  systematic  study  can 
be  carried  on  of  problems  in  practical  surgery  from  the 
standpoints  of  pathology,  bacteriology,  and  anatomy.  In 
possessing  access  to  the  well  equipped  laboratories  of 
Columbia  and  the  clinical  facilities  afforded  by  the  hospi- 
tals, this  foundation  will  have  unsurpassed  advantages. 


Appointments  on  House  Staff  of  Beth  Israel  Hospital 

luivc  been  made  as  follows:  Internes — Dr.  Samuel  Altman, 
surgical,  July  ist;  Dr.  Meyer  Solomon,  medical,  January 
1st;  Dr.  Jacob  Poleveski,  surgical,  January  ist;  Dr.  Mau- 
rice L.  Wieselthier,  medical,  July  ist.  Externes — Dr.  Max- 
well J.  Siegelstein,  medical,  July  ist,  and  surgical,  Janu 
ary  ist;  Dr.  Adolph  Tacobowitz,  surgical,  July  ist,  and  med- 
ical, January  ist;  Dr.  Asher  Bernstein,  surgical,  July  1st, 
and  medical,  January  1st;  Dr.  Benjamin  Rosenthal,  labora- 
tory, July  1st,  and  surgical,  January  1st. 

Physicians  Wanted  at  Fordham  Hospital. — The  fol- 
lowing vacancies  exist  on  the  staff  of  Fordham  Hospital, 
in  the  out  patient  department :  Neurologist,  attending  phy- 
sician to  the  paediatric  department,  assistant  surgeon,  two 
assistant  physicians,  assistant  in  the  nose  and  throat  de- 
partment, assistant  in  the  eye  and  ear  department,  assistant 
in  the  orthopjedic  department,  and  assistant  in  the  gyna;- 
cological  department.  For  application  blanks  and  fur- 
ther information  regarding  these  positions  apply  to  the 
secretary.  Dr.  Alexander  Nicoll,  123  West  Seventy-fourth 
Street,  New  York. 

Changes  of  Address. — Dr.  Maxwell  Branner,  to  1804 
Lexington  Avenue,  New  York. 

Dr.  Irving  Townsend,  to  55  East  Fifty-fifth  Street.  New 
York. 

Dr.  Henry  Graham  Mac  Adam,  to  542  West  One  Hun- 
dred and  Twenty-fourth  Street,  New  York. 

Dr.  M.  K.  Elmer,  to  3906  Chestnut  Street,  Philadelphia. 

Dr.  Albert  Ehrenfried,  to  1112  Boylston.  Street,  Boston. 

Dr.  William  E.  Rink,  to  799  Ocean  Avenue,  near  Avenue 
C,  Flatbush,  Bro9klyn,  N.  Y. 

Dr.  Albert  Robin,  to  18,  rue  Beaujon  (avenue  de  Fried- 
land),  Paris. 

The  New  Bellevue  Training  School  for  Women 
Nurses  was  dedicated  by  Mayor  McClellan  on  the  even- 
ing of  April  28th,  the  ceremony  following  the  graduation 
exercises  of  the  training  schools  connected  with  Bellevue 
and  Allied  Hospitals,  held  in  Cornell  Medical  College, 
twenty-seven  women  and  nineteen  men  receiving  diplomas. 
The  new  school,  which  is  a  six  story  brick  building,  taking 
up  the  lower  end  of  the  block  between  East  Twenty-fifth 
and  Twenty-sixth  Streets,  has  accommodations  for  three 
hundred  women  nurses.  It  cost  nearly  $1,000,000,  including 
the  land. 

A  Testimonial  Dinner  to  Mr.  Henry  Phipps,  founder 
of  the  Henry  Phipps  Institute,  Philadelphia,  will  be  given 
in  the  Bellevue-Stratford  Hotel  on  the  evening  of  Wednes- 
day, j\Iay  I2th,  on  the  occasion  of  the  presentation  to  Mr. 
Phipps  of  the  gold  medal  awarded  to  him  by  the  Interna- 
tional Antituberculosis  Association  in  recognition  of  his 
work  in  the  crusade  against  tuberculosis.  This  medal  is  con- 
ferred once  in  every  three  years  on  the  two  men  who,  dur- 
ing the  interim,  have  distinguished  themselves  most  in  the 
worldwide  tuberculosis  war.  This  is  the  first  time  the 
medal  has  been  awarded  to  an  American. 

Tours  for  Delegates  to  the  International  Medical 
Congress. — .The  preliminarj-  programme  of  special  tours 
arranged  for  the  American  delegates  attending  the  Sixteenth 
International  A'ledical  Congress,  to  be  held  in  Budapest, 
Hungary,  August  29th  to  September  4th,  has  just  been  is- 
sued, and  full  details  of  the  routes  will  be  published  short- 
ly. The  business  arrangements  are  in  the  hands  of  Messrs. 
Thomas  Cook  &  Son,  the  well  known  tourist  agents. 
Transportation  arrangements  and  hotel  reservations  are  m 
the  hands  of  Dr.  Charles  Wood  Bassett,  of  St.  Joseph,  Mo., 
who  will  be  glad  to  furnish  full  information  upon  the  sub- 
ject. 

American  Delegates  to  the  International  Congress  of 
Applied  Chemistry. — Among  the  delegates  from  the 
United  States  to  the  Seventh  International  Congress  of 
.A.opIipd  Chemistry,  which  will  be  held  in  London  from 
^lay  27th  to  June  2d,  are  the  following:  Dr.  Harvey  W. 
Wiley.  Chief  of  the  Bureau  of  Chemistry  of  the  Depart- 
ment of  Agriculture ;  Dr.  Allerton  S.  Cushman,  of  the  De- 
partment of  Agriculture ;  Dr.  Frank  Wigglesworth  Clarke, 
of  the  U.  S.  Geological  Survey ;  Dr.  Charles  Baskerville, 
professor  of  chemistry  in  the  College  of  the  City  of  New 
York;  Dr.  William  H.  Nichols,  Dr.  Maximilian  Toch,  Dr. 
Herbert  Plant,  and  Dr.  Morris  Loeb,  of  New  York ;  Dr. 
William  L.  Dudley,  of  Vanderbilt  University;  and  Dr.  L. 
H.  Baekeland.  of  Yonkers,  N.  Y. 


966 


NEM^S  ITEMS. 


[New  York 
Medical  Journal. 


The  Mortality  of  New  Orleans. — During  the  month  of 
Marc!i,  1909,  there  were  reported  to  the  Department  of 
Heakh  of  New  Orleans  563  deaths  from  all  causes,  342 
white  and  221  colored,  in  an  estimated  population  of  265,- 
000  white  and  97,000  colored.  The  annual  death  rate  in  a 
thousand  population  was  15.49  for  the  white  population, 
27.34  for  the  colored,  and  18.66  for  the  total  white  and 
colored  population.  There  were  35  still  births,  19  white 
and  16  colored. 

The  Mortality  of  Minneapolis. — According  to  the  offi- 
cial report  of  the  Department  of  Health  of  the  City  of  Mii>- 
ncapolis  during  the  month  of  March,  1909,  there  were  re- 
ported a  total  of  319  deaths  from  all  causes,  in  an  estimated 
population  of  310,000,  corresponding  to  an  annual  death 
rate  of  9.83  in  a  thousand  population.  The  average  mortality 
rale  for  the  year  1908  was  8.92.  Of  the  principal  causes  of 
death,  pneumonia  iieaded  the  list  with  54  deaths,  while 
tuberculosis  came  second  with  38  deaths.  There  were  17 
deaths  from  Bright's  disease,  30  from  nervous  diseases,  10 
from  typhoid  fever,  19  from  organic  heart  disease,  and  16 
from  cancer.  There  were  28  still  births,  20  males  and  8 
females. 

Scientific   Society   Meetings   in   Philadelphia   for  the 
Week  Ending  May  15,  1909: 

TuEsn.w.  Miiy  7/.— Philadelphia  Paediatric  Society. 
Wednesd.w.  May  1.2th. — Philadelphia  County  Medical  So- 
ciety. 

Thursd.w.  May  13th. — Pathological  Society;  Section  meet- 
ing, Franklin  Institute;  Lebanon  Hospital  Medical 
Society. 

FiuD.w,  May  14th. — Northern  Medical  Association;  West 
Branch,  Philadelphia  County  Medical  Society;  Phila- 
delphia Psychiatric  Society. 
Harvard  Graduates  to  Establish  a  Medical  College  in 
China. — Ten  graduates  of  the  Harvard  Medical  School 
are  planning  to  establish  in  China  a  thoroughly  equipped 
school  for  the  purpose  of  teaching  scientific  medicine,  and 
the  plan  is  endorsed  by  President  Eliot  and  the  medical 
faculty.  The  Chinese  are  in  favor  of  the  movement,  and 
several  hospitals  have  already  been  placed  at  the  disposal 
of  the  school  for  clinical  instruction.  It  is  proposed  to 
raise  an  endowment  fund  which  will  be  held  in  this  country 
by  a  board  of  trustees  who  will  direct  the  financial  affairs 
of  the  institution.  Dr.  Eliot  has  consented  to  serve  as 
chairman  of  the  board,  and  his  associates  will  be  Dr.  H.  P. 
Wolcott.  Dr.  A.  T.  Cabot,  Dr.  W.  T.  Councilman,  Dr.  W. 
B.  Cannon,  Dr.  H.  A.  Christian,  and  Professor  E.  C. 
Moore. 

Vital  Statistics  of  New  York. — During  the  week  end- 
ing April  24th,  1909.  the  total  number  of  deaths  reported 
to  the  Department  of  Health  was  1,594,  in  an  estimated 
population  of  4,564,792,  corresponding  to  an  annual  death 
rate  of  18.22  in  a  thousand  population.  The  death  rate  for 
each  of  the  five  boroughs  for  the  week  was  as  follows : 
Manhattan,  19.39;  Bfronx,  19.64;  Brooklyn,  16.16;  Queens, 
16.83;  Richmond.  21.41.  The  mortality  from  pulmonary 
tuberculosis  was  high,  the  deaths  from  that  disease  num- 
bering 211,  while  the  deaths  from  pneumonia  numbered  300, 
59  less  than  for  the  preceding  week.  The  mortality  from 
diarrhcc:;!  diseases  was  higher  than  it  had  been  for  many 
weeks,  the  deaths  numbering  152,  of  which  64  were  of 
children  under  five  years  of  age.  The  total  infant  mortal- 
ity was  529.  315  under  one  year  of  age  and  214  between 
one  and  five  years  of  age.  There  were  138  still  births. 
Eight  hundred  and  ninety  three  marriages  and  2,228  births 
were  reported  during  the  week. 

The  National  Confederation  of  State  Medical  Exam- 
ining and  Licensing  Boards  will  hold  its  nineteenth 
annual  meeting  at  Atlantic  City,  N,  J,,  on  Monday,  June 
7,  rgog,  in  the  Park  Avenue  hall  of  the  Hotel  Marlborough. 
The  subjects  to  be  taken  up  at  this  meeting  relate  to  the 
standing  of  medical  colleges,  and  practical,  oral  and  divided 
examinations  before  State  medical  examining  boards. 
These  topics,  at  this  time,  are  urgent,  practical,  and  vital 
to  the  maintenance  and  development  of  the  influence  and 
efficiency  demanded  of  State  boards  both  by  the  profession 
and  by  the  State.  Among  the  contributors  of  papers  are 
men  of  the  highest  standing  in  the  medical  profession,  and 
their  productions  will  undoubtedly  be  cf  great  value.  An 
earnest  and  cordial  invitation  is  extended  to  all  members 
of  State  medical  examining  boards,  and  all  others  who  are 
interested  in  this  work.  The  officers  of  the  confederation 
arc :  Dr.  A.  Ravogli,  acting  president,  5  Garfield  Place, 
Cincinnati.  Ohio;  Dr.  Murray  Gait  Motter,  secretary,  1841 
Summit  Place,  Washington,  D.  C. 


The  Health  of  Pittsburgh.— During  the  week  ending 
April  24,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health :  Chickenpox, 
6  cases,  o  deaths;  typhoid  fever,  12  cases,  o  deaths;  scarlet 
fever,  16  cases,  o  deaths;  diphtheria,  12  cases,  i  death; 
measles,  19  cases,  i  death;  whooping  cough,  39  cases,  4 
deaths ;  pulmonary  tuberculosis,  70  cases,  7  deaths.  The 
total  deaths  for  the  week  numbered  141,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  12.97  in  a  thousand  population. 

"Symposium"  on  Intralaryngeal  Carcinoma. — A  meet- 
ing of  the  New  York  Academy  of  Medicine  will  be  held 
on  Thursday  evening.  May  20th.  under  the  auspices  of  the 
Section  in  Laryngology.  The  programme  will  consist  of 
a  "symposium"  on  intralaryngeal  carcinoma,  and  papers  on 
tlie  subject  will  be  read  as  follows :  Clinical  Diagnosis  and 
Operative  Procedures  from  the  Standpoint  of  the  Laryn- 
gologist,  by  Dr.  Chevalier  Jackson,  of  Pittsburgh;  Histo- 
logical Diagnosis  and  Pathology,  by  Dr.  Jonathan  Wright; 
Operative  Procedures  from  the  Standpoint  of  the  General 
Surgeon,  by  Dr.  George  E.  Brewer.  Among  those  who 
will  take  part  in  the  discussion  are  Dr.  Clarence  C.  Rice, 
Dr.  Walter  F.  Chappell,  and  Dr.  John  A.  Bodine. 
Infectious  Diseases  in  New  York: 

We  arc  indebted  to  the  Bureau  of  Rec07-ds  of  the  De- 
partment of  Health  for  the  following  statement  of  new 
cases  and  deaths  reported  for  the  two  weeks  ending  May 
I,  1909: 

I  April  24  V     ,  May  i  v 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    578         211         590  181 

Diphtheria    319  44         337  56 

Measles   1,274  47       1.389  37 

Scarlet  fever    297  17         326  11 

Smallpox   

Varicella    191  . .  191 

Typhoid  fever   26  4  19  11 

Whooping  cough    84  4  62  13 

Cerebrospinal  meningitis    8  3  3  6 

Total   2,777         330      2,917  315 

The  Mortality  of  Chicago. — There  was  a  decided  im- 
provement in  health  conditions  in  Chicago  during  the  week 
ending  April  24th,  the  death  rate  for  the  week  being  14.77, 
as  against  17.23  for  the  preceding  week.  The  total  number 
of  deaths  from  all  causes  reported  during  the  week  was 
630,  as  compared  with  735  for  the  week  previous,  and  623 
for  the  corresponding  period  in  1908.  The  reduction  in  the 
death  rate  was  largely  due  to  a  lower  mortality  from 
chronic  diseases,  such  as  Bright's  disease,  heart  diseases, 
and  cancer,  and  from  pneumonia,  diarrhoeal  diseases  and 
typhoid  fever.  The  principal  causes  of  death  were :  Diph- 
theria, II;  scarlet  fever,  8;  measles,  6;  whooping  cough,  3; 
influenza,  8;  diarriiceal  diseases,  41,  of  which  33  were  under 
two  years  of  age;  pneumonia,  142;  tuberculosis,  83,  of 
which  72  were  pulmonary;  cancer,  24;  nervous  diseases,  22; 
heart  diseases,  62;  apoplexy,  11;  chronic  bronchitis,  i; 
Bright's  disease,  48;  violence,  41,  of  which  7  were  suicides; 
all  other  causes,  119. 

Society  Meetings  for  the  Coming  Week: 

MoND.\Y,  May  loth. — Society  of  Medical  Jurisprudence, 
New  York;  New  York  Ophthalmological  Society; 
Corning,  N.  Y.,  Medical  Association;  Waterbury, 
Conn.,  Medical  Association :  New  York  Academy  of 
Medicine  (Section  in  Neurology  and  Psychiatry). 

TuEsn.w,  May  nth. — New  York  .Academy  of  Medicine 
(Section  in  Public  Health)  ;  New  York  Obstetrical 
Society;  Newburgh  Bay  Medical  Society;  Buffalo 
-Academy  of  Medicine  (Section  in  Medicine)  ;  Medical 
Society  of  the  County  of  Rensselaer,  N,  Y,  (annual)  ; 
Practitioners'  Club  of  Jersey  City,  N,  J, ;  Medical  So- 
ciety of  the  County  of  Schenectady,  N.  Y, 

Wednesday,  May  I3th. — New  York  Pathological  Society; 
New  York  Surgical  Society ;  Medical  Society  of  the 
Borough  of  the  Bronx,  New  York;  Alumni  Associa- 
tion of  the  City  Hospital,  New  York;  Brooklyn  Med- 
ical and  Pharmaceutical  Association ;  Medical  Society 
of  the  County  of  Richmond,  N.  Y. 

Thursday,  May  13th. — New  York  Academy  of  Medicine 
(Section  in  Pediatrics)  ;  Brooklyn  Pathological  So- 
ciety; Blackwell  Medical  Society  of  Rochester,  N.  Y. ; 
Jenkins  Medical  Association,  Yonkers,  N.  Y. 

Friday,  May  14th. — New  York  .A.cademy  of  Medicine  (Set- 
lion  in  Otology)  ;  New  York  Society  of  Dermatology 
and  Genitourinary  Surgery ;  Eastern  Medical  Society 
of  the  City  of  New  York ;  Saratoga  Springs,  N.  Y., 
Medical  Society  (annual). 


May  8,  1909.] 


NEWS  ITEMS. 


967 


The  Establishment  of  County  Tuberculosis  Hospitals 
in  New  York  State. — The  New  York  State  Senate  has 
passed  the  Hamilton-Whitney  bill  amending  the  county  law 
in  relation  to  the  establishment  of  county  hospitals  for 
tuberculosis.  This  bill  enables  county  boards  of  super- 
visors to  care  for  tuberculosis  patients  in  a  hospital  main- 
tained for  that  purpose  by  the  county,  but  not  in  connec- 
tion with  the  almshouses.  The  plans  for  such  hospitals  are 
subject  to  the  approval  of  the  State  Commissioner  of 
Health  and  the  hospital  is  to  be  administered  by  an  expert 
superintendent  responsible  to  a  board  of  managers  appomted 
by  the  supervi.^ors.  The  unique  feature  of  this  liill  is  its 
provision  for  admission  without  delay  of  any  person  found 
to  be  suffering  from  tuberculosis,  irrespective  of  his  ability 
to  pay  for  his  care  and  treatment.  If  it  is  later  found  that 
a  patient  is  able  to  pay,  in  whole  or  in  part,  he  is  required 
to  do  so,  except  that  he  is  not  permitted  to  pay  more  than 
the  regular  per  capita  cost  of  maintenance,  and  employees 
of  the  hospital  are  forbidden  to  accept  any  fee  or  gratuity. 
The  new  law  also  permits  hospitals  now  existing  in  con- 
nection with  almshouses  to  be  governed  under  its  provis- 
ions, and  requires  that  any  hospitals  hereafter  established 
by  the  board  of  supervisors  shall  be  subject  to  the  pro 
visions  of  this  new  act. 

University  News. — Dr.  W.  F.  Dearborn,  assistant 
professor  of  psychology  in  the  University  of  Wisconsin, 
has  resigned  to  take  a  similar  position  in  the  University 
of  Chicago. 

Professor  W.  H.  Haake  has  resigned  as  professor  or 
materia  medica  in  Western  Reserve  University,  Cleveland, 
Ohio,  and  will  be  succeeded  by  Dr.  T.  Sollmann. 

Dr.  Max  Woif  has  been  appointed  director  of  the  Uni- 
versity of  Heidelberg,  to  take  the  place  of  Dr.  Wilhelm 
Valentiner,  who  recently  retired  on  account  of  ill  health. 

Dr.  William  W.  Cadbury  has  resigned  as  pathologist  to 
the  Henry  Phipps  Institute,  Philadelphia,  and  has  sailed 
for  China,  where  he  will  aid  in  establishing  a  medical 
school  in  Canton. 

St.  Andrews  University  has  conferred  the  degree  of 
LL.  D.,  on  Mr.  James  Wallace,  F.  R.  S.,  professor  of  chem- 
istry in  the  University  of  Edinburgh. 

Dr.  W.  E.  McVey  v;as  recently  elected  dean  of  the  Kan- 
sas Medical  College  (Medical  Department  of  Washburn 
University),  to  succeed  Dr.  W.  S.  Lindsay,  who  has  been 
dean  of  the  college  for  the  past  three  years.  Dr.  McVey 
has  been  a  member  of  the  faculty  ever  since  the  school  was 
organized  in  1890,  and  now  occupies  the  chair  of  rhinology, 
laryngology,  and  diseases  of  the  chest.  Dr.  J.  B.  Tower 
was  elected  secretary  to  succeed  Dr.  McVey. 

The  Hospital  Saturday  and  Sunday  Association  ot 
New  York  collected  $85,752.55,  for  the  fiscal  year  just 
ended,  this  being  about  $2,000  more  than  for  the  preceding 
year.  The  distributing  committee  of  the  association  has 
authorized  the  distribution  of  $72,000  among  the  forty- 
three  hospitals  in  Manhattan  and  the  Bronx  which  belong 
to  the  association,  on  the  basis  of  the  amount  of  free  work 
done  by  each  hospital.  The  apportionment  was  as  follows  .- 
Montefiore  Home,  $7,200;  Mount  Sinai  Hospital,  $7,200; 
St.  Luke's  Hospital,  $4,411.37;  German  Hospital,  $3,439.20; 
New  York  Infant  Asylum,  $3,043.24;  Lying-in  Hospital. 
$2,923.89;  Hospital  for  the  Relief  of  the  Ruptured  and 
Crippled,  $2,920.99;  Post-Graduate  Hospital,  $2,814.11; 
Orthopaedic  Hospital,  $2,708.10;  Lebanon  Hospital,  $2,680; 
Misericordia,  $2,623.18;  St.  Mary's,  $2,412.54.  Roosevelt 
Hospital,  $2,288.66;  Lincoln  Hospital,  $2,143.88;  Qiild's 
Hospital,  $2,095.12;  Home  for  Incurables,  $1,946.70;  Beth 
Israel  Hospital,  $1,764.09;  Manhattan  Eye,  Ear,  and 
Throat  Hospital,  $1,677.47;  House  of  the  Holy  Comforter, 
$1,512.38;  Isabelle  Heimath,  $1,742.23;  Babies'  Hospital, 
$1,149.03;  House  of  Rest  for  Consumptives,  $1,068.25; 
Sloane  Maternity  Hospital,  $971.55;  St.  Mark's  Hospital, 
$898.16;  French  Hospital,  $886.50;  New  York  Skin  and 
Cancer  Hospital,  $794.38;  New  York  Polyclinic  Hospital, 
$731.27;  Flower  Hospital,  $688.75;  Woman's  Hospital, 
$641.76;  J.  Hood  Wright  Memorial  Hospital,  $603.01;  Gen- 
eral Memorial  Hospital,  $491 ;  New  York  Infirmary  for 
Women  and  Children,  $471.60;  Sydenham  Hospital,  $445.29; 
New  York  Ophthalmic  Hospital,  $434.02;  Volunteer  (St. 
Gregory's)  Hospital,  $312.10;  St.  Andrew's  Convalescent 
Hospital,  $311.62;  Hahnemann  Hospital,  $284.99;  New  York 
Eye  and  Ear  Infirmary,  $274.80;  Hospital  for  Deformities 
and  Joint  Diseases,  $264.73 ;  New  York  Medical  College 
and  Hospital  for  Women,  $250;  New  York  Convalescent 
Home,  $250;  New  York  Ophthalmic  and  Aural  Institute, 
$250;  New  York  Red  Cross  Hospital,  $250.    Total,  $72,000. 


American  Pharmaceutical  Association. — The  last  gen- 
era! meeting  of  the  season  of  the  Philadelphia  Branch  of 
tiie  association  was  held  on  the  evening  of  Tuesday,  May 
4th.  The  topic  presented  for  consideration  was  Some  Ad- 
ditions and  Corrections  in  the  Coming  Edition  of  the  Na- 
tional Formulary.  Papers  were  read  as  follows :  The 
Compound  Powder  of  Pepsin  and  the  Compound  Elixir  of 
Pepsin  of  the  National  Formulary,  by  Mr.  George  M.  Ber- 
inger;  The  Syrups  of  the  National  Formulary,  by  Profes- 
sor E.  Fullerton  Cook ;  Foreign  Formularies  compared 
with  our  National  Formulary,  by  Mr.  Otto  Raubenheimer, 
of  Brooklyn,  who  also  exhibited  several  foreign  formu- 
laries. The  general  discussion  was  participated  in  by 
prominent  m.embers  of  the  medical  profession.  At  a  meet- 
ing of  the  Scientific  Section  of  the  Philadelphia  Branch  of 
the  association,  to  be  held  on  May  13th,  the  evening  will 
be  devoted  to  a  consideration  of  ergot,  and  the  programme 
will  include  the  following  papers :  The  Chemical  Assay  of 
Ergot,  by  Dr.  H.  C.  Wood,  Jr.;  The  Physiological  Assay 
of  Ergot,  by  Dr.  Clarence  A.  Hofer ;  Some  Notes  on  Er- 
got Testing,  by  Dr.  Charles  E.  Vanderklud.  A  discussion 
will  follow. 

The  Prevalence  of  Animal  Tuberculosis  in  the.  United 
States. — The  reports  of  the  Bureau  of  .\nimal  Industry 
of  the  United  States  Department  of  Agriculture  indicate 
that  tuberculosis  among  live  stock  is  steadily  increasing,  as 
shown  by  the  number  of  animals  found  affected  at  the  vari- 
ous slaughtering  centres.  The  increase  in  tiie  number  of 
cases  found  is  due  in  part,  but  only  in  part,  to  the  increased 
efficiency  of  the  methods  of  inspection.  The  meat  inspec- 
tion figures  show  that  nearly  one  per  cent,  of  the  cattle  and 
over  two  per  cent,  of  the  hogs  slaughtered  are  tuberculous. 
Figures  for  the  last  year  secured  from  abattoirs  where 
Federal  inspection  is  maintained  show  that  over  ten  billion 
pounds  of  meat  was  inspected,  forty-six  million  pounds  of 
which  was  condemned,  nearly  three  fourths  being  for  tuber- 
culosis. Considerable  testing  of  cattle  lias  been  done  in 
Washington,  D.  C.,  and  vicinity,  for  the  purpose  of  assist- 
ing the  District  authorities  in  obtaining  a  pure  milk  supply, 
and  securing  for  the  bureau  further  information  regarding 
the  extent  of  tuberculosis  in  the  locality.  Reactions  took 
place  in  about  seventeen  per  cent,  of  the  cattle  tested.  The 
percentage  of  tuberculosis  in  various  States,  shown  by 
tests  conducted  by  the  officials  in  those  States  with  bureau 
tuberculin,  indicates  that  from  2.79  to  19.69  per  cent,  of  the 
cows  react,  and  it  is  estimated  that  in  the  country  at  large 
at  least  ten  per  cent,  of  the  cows  in  dairy  herds  are  tuber- 
culous. The  recent  agitation  against  the  milk  of  tubercu- 
lous cows  as  human  food  has  had  the  effect  of  causing 
many  herds  to  be  examined,  with  astonishing  results  not 
only  to  the  owners  but  to  the  officials  themselves. 

Charitable  Gifts  and  Bequests. — Mr.  William  New- 
comer, of  Hagerstown,  Md.,  made  a  gift  of  $15,000  to  the 
Washington  Coimty  Hospital,  in  celebration  of  the  fiftieth 
anniversary  of  his  marriage.  The  money  is  to  be  added  to 
the  building  fund  of  ihe  hospital. 

By  the  will  of  Mr.  Peter  F.  Collier,  who  died  in  New 
York  recentlj-,  St.  Joseph's  Roman  Catholic  Hospital,  Syra- 
cuse, and  the  Hospital  for  Incurable  Consumptives,  the 
Bronx,  New  York,  will  each  receive  $2,000  a  year  for  ten 
years. 

A  benefit  matinee,  arranged  by  Miss  Blanche  Bates,  was 
given  recently  at  the  Lyric  Theatre,  Philadelphia,  for  St. 
Luke's  Hospital.    About  $2,500  was  realized. 

The  House  of  Mercy  Hospital,  Pittsfield,  Mass.,  has  re- 
ceived the  sum  of  $6,000  to  endow  two  memorial  rooms  in 
the  hospital.  Mrs.  Morris  K.  Jesup,  of  New  York,  and  the 
family  of  the  late  Edward  D.  Jones,  of  Pittsfield,  each  gave 
$3,000. 

By  the  will  of  the  Rev.  Dr.  Amos  B.  Kendig,  who  died  in 
Brookline,  Mass.,  some  time  ago,  the  Deaconesses'  Hospital 
at  Brookline  receives  $1,500,  of  which  $500  is  to  be  used  in 
equipping  a  room  to  be  known  as  the  Mary  Bancroft  Kel- 
logg room,  and  the  income  from  the  remaining  $1,000  is  to 
be  used  in  maintaining  the  room. 

By  the  will  of  Miss  Elizabeth  Brigham,  of  Boston,  the 
Robert  E.  Brigham  Hospital  for  Incurables  receives  $1,- 
500,000. 

By  the  will  of  Colonel  Edwin  N.  Benson,  who  died  m 
Philadelphia,  on  April  i8th,  the  Pennsylvania  Hospital  will 
receive  $50,000,  and  the  Bethesda  Children's  Christian 
Home  and  the  Chestnut  Hill  Hospital  will  each  receive 
$ic,ooo. 


968 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
McDicAL  Journal. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

April  2<),  igiog. 

I.    Intermittent  Hydronephrosis.    With  a  Report  of  Four 
Cases,  By  Daniel  Fiske  Jones. 

2.  Treponemata    (Spirochjetse)    in    Syphilitic  Aortitis. 

Five  Cases,  One  with  Aneurysm, 
By  James  Homer  Wright  and  Oscar  Richardson. 

3.  Treatment  of  Obstruction  of  the  Lachrymal  Duct, 

By  John  C.  Berry. 

I.    Intermittent  Hydronephrosis. — Jones  enu- 
merates some  of  the  conditions  wliicli  are  men- 
tioned by  different  authors  as  causes  of  intermittent 
hydronephrosis.   A  few  of  them  are  primary  causes, 
but  most  of  them  are  secondary  to  some  primary 
cause  usually  not  mentioned:    i.  A'alve  formation 
at  the  opening  of  the  pelvis  into  the  ureter.    2.  Ob- 
lique insertion  of  the  ureter  into  the  pelvis.   3.  High 
insertion  of  the  ureter  into  the  pelvis.   4.  Stricture 
of  the  ureter.    5.  Twists  of  the  ureter.    6.  Kinks 
or  angulations  of  the  ureter.    7.  Flexure  over  ab- 
normal vessels  or  pressure  upon  the  ureter  by  ab- 
normal vessels.   8. '  Pressure  by  the  normal  vessels 
oi  the  kidney.    9.  Tumor  of  the  bladder.    10.  Tu- 
mor of  the  pelvis  of  the  kidney.    11.  Stone  in  the 
pelvis  of  the  kidney.    12.  Pressure  by  new  growths 
or  inflammatory  masses  anywhere  along  the  course 
of  the  ureter.    13.  Adhesions  along  the  course  of 
the  ureter.    14.  Prolapse  of  the  uterus.    15.  In- 
juries to  the  kidney.     16.  Scoliosis.      While  the 
aetiology  of  intermittent  hydronephrosis  is  of  great 
interest,  the  importance  of  the  subject  lies  in  early 
diagnosis  and  treatment.    That  diagnosis  is  difficult 
would  seem  to  be  indicated  by  the  frequency  with 
which  a  wrong  diagnosis  is  made.   In  former  times 
probably  the  most  frequent  error  was  in  confound- 
ing a  large  hydronephrosis  with  an  ovarian  cyst. 
Among  the  collected  cases,  appendicular  inflamma- 
tion, gallstones,  stone  in  the  kidney,  and  lumbar 
hernia  are  some  of  the  conditions  for  which  it  was 
mistaken.    Another  indication  of  the  difficulty  of 
diagnosticating  is  shown  by  the  fact  that  in  one  hun- 
dred cases  in  which  the  duration  of  the  disease  was 
given,  it  averaged  eight  and  two  tenths  years.  Pain 
is  the  most  constant  symptom,  although  this  need 
not  necessarily  be  present ;  as,  for  example,  those 
cases  of  hydronephrosis  in  which  a  tumor  of  enor- 
mous size  suddenly  appears  without  any  previous 
history  of  pain.    The  pain  may  be  severe  in  char- 
acter and  can  be  compared  to  a  gallstone  or  renal 
colic,  or  it  may  be  a  feeling  of  great  pressure  and 
distress  in  the  flank.   It  does  not  often  radiate  down 
the  course  of  the  ureter  or  into  the  testicle,  as  in 
renal  colic,  but  it  is  more  frequently  a  fixed  pain 
in  the  side  and  back.    There  is  with  the  pain,  at 
times,  a  desire  to  urinate  almost  constantly.  Nausea 
and  vomiting  are  the  symptoms  next  in  frequency. 
They  are  present  in  nearly  every  case  in  which  the 
symptoms  are  at  all  severe.    Tumor,  an  important 
diagnostic  aid  when  present,  is  a  late  symptom, 
and  the  diagnosis  should  be  made  in  the  great  ma- 
jority of  cases  before  the  pelvis  of  the  kidney  be- 
comes dilated  to  such  an  extent  that  it  can  be  felt. 
A  tumor  in  either  flank,  which  appears  with  attacks 
of  jnin  and  disappears  with  the  pain,  is  almost 


pathognomonic.  The  tumor,  which  is  at  times  felt 
in  early  cases,  may  be  simply  an  enlarged  kidney, 
owing  to  the  congestion  caused  by  the  shutting  off 
of  the  ureter.  Increase  in  the  amount  of  ttrine 
voided  after  a:i  attack  of  pain  is  a  symptom  of  im- 
portance, but  it  depends  so  much  upon  the  intelli- 
gence and  powers  of  .observation  of  the  patient  that 
it  is  often  unnoticed.  There  is  an  increased  flow 
in  all  cases  after  a  shutting  oft'  of  the  ureter,  but  it 
is  often  not  observed.  The  increased  quantity  of 
urine  passed  after  an  attack  is  not  owing  to  the 
quantity  of  urine  stored  up  in  the  pelvis  of  the  kid- 
ney, as  is  often  stated,  but  is  owing  to  an  increased 
secretion  brought  about  by  the  hyperaemia  of  the  kid- 
ney. The  course  of  the  disease  is  in  nearly  every 
case  progressive,  that  is,  the  attacks  may  at  first 
come  at  infrequent  intervals,  varying  from  a  few 
months  to  one  or  more  years.  The  frequency  in- 
creases steadily  until  the  attacks  recur  every 
week  or  two,  or  until  the  hydronephrosis  becomes 
permanent.  The  author  describes  the  operations, 
among  which  the  method  introduced  by  Trendelen- 
burg in  1886  is  one  of  the  best. 

3.  Treatment  of  Obstruction  of  the  Lach- 
rymal Duct. — Berry  observes  that  ordinary  cases 
of  dacryocystitis  in  infants  require  no  treatment 
other  than  nasal  cleanliness, boracic  acid  collyria,and 
slight  pressure  over  the  sac.  More  persistent  cases 
may  require  nasal  aspiration  or  possibly  the  passage 
of  the  lachrymal  probe.  The  obstruction  is  some- 
times due  to  membranous  clostire  of  the  nasal  end 
of  the  canal,  and  intranasal  inspection  is  always 
prudent  and  at  times  necessary  when  probing  the 
duct.  The  seton  is  a  remedial  measure  of  great 
promise  in  certain  rebellious  cases.  In  adults,  the 
ideal  treatment  is  by  gradual  dilation  avoiding  vio- 
lence to  the  membrane  of  the  canal.  If  this  proves 
unsuccessful,  then  division  of  the  stricture  with 
rapid  and  full  dilation  is  necessary.  Dilation  be- 
yond 2  mm.  is  seldom  necessary.  Forced  dilation 
to  4  mm.  exposes  the  eye  to  nasal  contamination 
and  lessens  the  propulsive  power  of  the  sac.  The 
leaden  style  can  be  employed  to  advantage  between 
treatments,  reducing  the  frequency  of  probing  and 
favoring  absorption  of  hypertrophied  isstie  by  con- 
tinuous pressure.  Acute  cases  of  inflammation  of 
the  sac  can  be  aborted  if  seen  early,  the  treatment 
being  to  wash  out  the  sac,  inject  argyrol,  and  follow 
v/ith  hot  stupes  of  lead  and  laudanum,  general  anti- 
phlogistic treatment  being  observed.  Following 
phlegmon,  the  passage  of  the  probe  should  be  de- 
layed until  swelling  and  induration  subside. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 
May  I,  igog. 

T.    Remarks  on  Tic  and  Chorea,      By  Hugh  T.  P.\trick. 

2.  The  Anamnesis  of  Surgical  Cases.    Its  Peculiar  Im- 

portance to  the  House  Pupils  of  Hospitals  as  a 
Means  of  Stimulating  Interest  in  History  Taking, 

By  John  T.  Bottomley. 

3.  Operative  Treatment  of  Tuberculous  Joints, 

By  H.  J.  Whitacre. 

4.  Phosphorus  as  Brain  Food,  By  W.  Koch. 

5.  Relation  of  Anomalous  Renal  Bloodvessels  to  Hydro- 

nephrosis,     By  Wii.i.iam  J.  Mayo,  W.  F.  Braasch. 
and  W.  C.  MacCarty. 

6.  .Ankylostomiasis  in  Mexico  and  Its  Diagnosis, 

By  W.  C.  Alvarez. 


May  8,  1909.] 


PITH  Of  CURRENT  LITERATURE. 


7.  The  Scope  of  a  ^Maternity  Hospital  and  of  Obstetrics 

as  a  Surgical  Specialty,       By  Barton  Cooke  Hirst. 

8.  National  Formulary  Nomenclature,     By  L.  F.  Kebler. 

9.  Tlie  Philosophical  Anatomy  of  the  Tongue, 

By  Edmond  Souchon. 

10.  Some  of  the  Possibilities  and  Limitations  of  the  X  Rays 

as  a  Therapeutic  Agent,  By  A.  L.  Gray. 

3.  Operative  Treatment  of  Tuberculous  Joints. 

— Whitacre  reports  twenty-five  such  cases.  There 
were  twelve  female  patients  and  thirteen  males.  All 
except  one  were  of  the  working  class  and  were  de- 
pendent on  their  own  or  their  parents'  daily  labor  for 
support.  There  was  no  family  history  of  tubercu- 
losis in  nineteen  cases.  There  had  been  a  definite 
injury  to  the  joint  in  but  seven  cases.  The  dura- 
tion of  the  joint  trouble  ranged  from  five  weeks 
to  twenty-one  years.  In  fifteen  cases  it  had  been 
more  than  one  year.  The  general  health  was  bad 
in  ten,  fairly  good  in  six,  good  in  nine.  There  were 
tubercitlous  lesions  elsewhere  in  five  cases,  one  in 
lung,  one  in  opposite  knee,  one  in  opposite  ankle, 
one  in  Falloppian  tube,  one  in  spine  and  lung. 
There  were  three  children  whose  ages  were  six, 
seven,  and  fifteen.  The  ages  of  the  remaining  pa- 
tients varied  from  eighteen  to  forty  years.  Three  were 
under  twenty.  Thirteen  were  between  twenty  and 
thirty  :  six  were  over  thirty.  There  were  no  sinuses 
present  in  nineteen  cases.  Twelve  are  completely 
cured  and  are  using  the  extremity  without  support 
in  their  ordinary  duties.  Two  have  a  single  per- 
sistent sinus  of  minor  importance  but  have  good 
function.  In  one  the  result  is  not  known,  but  the 
progress  was  favorable  up  to  the  time  of  the  pa- 
tient's disappearance,  one  year  after  operation.  In 
three  the  extremity  was  amputated  subsequently.  In 
the  remaining"  seven  recent  cases  the  wotmds  have 
healed  satisfactorily,  the  primary  result  is  good,  and 
a  cure  is  confidently  expected  in  all,  but  a  sufficient 
length  of  time  has  not  elapsed  since  operation  to 
justify  a  report  of  final  results.  In  the  three  cases 
in  which  amputation  was  done  two  showed  extensive 
and  extreme  destruction  of  the  joint  at  the  time 
of  the  excision,  and  the  general  condition  of  the 
patient  was  bad.  Excision  became  in  these  cases 
a  trial  measure  of  conservatism.  There  were  other 
cases  in  this  list,  however,  in  which  that  joint  seem- 
ed to  be  as  extensively  involved,  cases  in  which  am- 
putation had  been  advised,  yet  excision  and  erasion 
accomplished  a  cure.  Seven  erasions  have  been  done 
in  the  knee,  seven  in  the  ankle,  three  in  the  elbow, 
and  one  in  the  wrist.  Xo  flexures  have  developed, 
and  useful  motion  has  been  developed  in  three  knees 
and  two  elbows.  The  motion  is  perfect  in  one  elbow. 
The  motion  in  other  cases  is  slight,  varying  from 
10  to  25  degrees,  but  is  much  prized  by  these  pa- 
tients. The  endurance  in  the  recovered  cases  seems 
good.  In  one  case  a  secondary  operation  was  neces- 
sary, and  in  two  a  persistent  sinus  was  cured  by 
local  applications  and  without  the  use  of  a  general 
anjesthetic.  There  were  no  deaths  from  operation. 
Tuberculosis  did  not  develop  elsewhere  in  any  of 
the  patients. 

4.  Phosphorus  Compounds  as  Brain  Foods. — ■ 

Koch  concludes  from  his  observations  that  there 
is  no  evidence  of  any  need  to  supply  phosphorus  to 
the  brain  in  conditions  of  exhaustion,  as  a  lack  of 
that  element  has  not  yet  been  demonstrated.  The 
actual  amount  lost  in  the  exhaustion  of  general  par- 


alysis can  not,  of  course,  be  replaced  on  account  of 
the  inability  of  the  central  nervous  system  to  re- 
generate. The  phosphorus  required  for  the 
growth  of  the  brain  is  amply  supplied  by  the  phos- 
phorus of  our  dail}'  diet.  If  desired,  the  addition 
of  phosphorus  rich  foods,  such  as  eggs,  sweetbreads 
(pancreas),  liver,  and  some  meats,  can  be  made  to 
meet  further  requirements,  and  will  far  exceed  in 
amount  the  phosphorus  obtained  in  less  natural  form 
from  the  prescribed  doses  of  any  of  the  various 
drugs  in  commercial  use.  The  use  of  such  foods 
is,  however,  limited  by  their  richness  and  their  ten- 
dency, on  account  of  their  rich  fat  content,  to  inter- 
fere with  gastric  digestion.  As  far  as  the  nervous 
system  is  concerned,  the  addition  to  the  diet  of  com- 
mercial phosphorus  compounds,  such  as  hypophos- 
phites,  glycerophosphate,  phytin,  lecithin,  etc.,  is  to 
be  discouraged  because,  in  the  first  place,  there  is 
no  conclusive  evidence  that  they  have  any  effect 
on  the  growth  of  the  brain,  and,  second,  the  ainount 
usually  recommended  means  only  a  very  insignificant 
addition  to  the  amount  of  phosphorus  (even  in  its 
special  forms  such  as  lecithin)  taken  with  the  daily 
food. 

5.  Relation  of  Anomalous  Renal  Bloodvessels 
to  Hydronephrosis. — Mayo,  Braasch,  and  Mac- 
Carty  remark  that  the  frequency  with  which  a  t)pe 
of  renopelvic  distention  is  observed,  caused  by 
anomalous  bloodvessels  constricting  the  upper  ureter 
and  characterized  by  intermittent  attacks  of  abdom- 
inal pain,  is  so  marked  that  the  condition  deserves 
to  be  considered  as  clinically  distinct  at  least,  if  not 
anatomically  so.  The  diagnostic  data  are :  Ap- 
pearance of  symptoms  in  the  young  adult ;  intermit- 
tent attacks  of  abdominal  pain  referred  to  the  kid- 
ney zone  and  occurring  with  more  or  less  regular- 
ity during  a  number  of  years ;  cystic  tumor  palpable 
in  about  a  third  of  the  cases ;  presence  of  small 
amounts  of  pus  in  urine :  usual  absence  of  haemor- 
rhagic  urine,  rise  of  temperature  and  bladder  ir- 
ritability ;  cystoscopic  findings. 

8.  National  Formulary  Nomenclature. — Kebler 
points  out  stich  defects  and  shortcomings  as  have 
come  to  his  attention.  He  speaks  of  the  question 
of  the  proper  correspondence  of  the  name  of  the 
preparation  to  its  constituents,  and  he  cites  several 
instances  of  misleading  names,  such  as  a  proposed 
preparation,  called  mandragovin,  or  elixir  of  cin- 
chona, emulsion  of  petrolatum,  etc.  It  has  long  been 
the  practice  to  name  medicinal  preparations  after  a 
valuable  constituent,  even  though  such  constituent  is 
only  one  of  a  number,  and  is  frequently  present  in 
small  quantities  and  in  some  cases  not  at  all.  In 
view  of  recent  legislation,  it  soon  began  to  be  real- 
ized that  such  names  were  improper  and  informa- 
tion was  sought  relative  to  the  proper  use  of  the 
word  '"compound"  in  connection  with  certain  mix- 
tures. It  is  clearly  evident  that  the  naming  of  a 
preparation  after  a  constituent  which  is  either  not 
present,  or  is  virtually  inactive  or  is  present  in  such 
a  small  quantity  as  to  impart  little  if  any  activity 
to  the  product,  a  practice  formerly  not  uncommon, 
with  or  without  the  use  of  the  word  "compound," 
is  improper  and  misleading.  Another  question  is 
that  of  priority  of  name  and  the  use  of  geographic 
names  stich  as  German  diphtheria  remedy,  Swedish 
asthma  cure,  Japanese  oil.  etc.    The  use  of  such 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


names  is  misleading.  Suggestive  therapeutic  names 
and  habit  forming  drugs  are  also  mentioned.  A  num- 
ber of  preparations  are  named  either  after  some 
anatomical  portion  of  the  body  or  suggest  some  dis- 
eased condition :  for  example,  pectoral  tincture, 
mistura  pectoralis,  antineuralgic  pill,  catarrh  pow- 
der, etc.  Are  these  suggestive  names  intended  for 
the  benefit  of  the  physician  or  the  druggist?  In 
either  case  they  are  uncalled  for,  particularly  in 
view  of  the  fact  that  most  of  the  preparations  con- 
tain habit  forming  agents.  The  practice  of  conceal- 
ing the  presence  of  these  insidious  drugs  by  various 
innocent  names  should  be  looked  on  with  disfavor. 
There  is  a  host  of  commodities  on  the  market  which 
owe  their  virtue  chiefly  to  the  alcohol  contained 
therein.  They  are  usually  sold  under  generic  names, 
such  as  medicinal  wines,  bitters,  tonics,  vermouths, 
etc.,  many  of  which  contain  only  traces  of  certain 
medicinal  agents,  such  as  extract  of  cinchona,  gen- 
tian, beef,  calumba,  various  combinations  of  iron, 
etc.,  or  very  small  amounts  of  one  or  more  of  the 
cinchona  alkaloids. 

MEDICAL  RECORD. 

May  I,  1909. 

1.  A  Catalytic  Theory  of  Infection  and  Immunity, 

By  J.  W.  McLaughlin. 

2.  Cerebral  Lobules.    Anatomy  of  the  Holmes  Nautilus, 

By  Wallace  Wood. 

3.  Personal  Observations  upon  Ureteral  Calculi, 

By  Alexis  V.  Moschcowitz. 

4.  Mastoiditis  Followed  by  Infected  Sinus  Thrombosis 

in  a  Young  Pregnant  Patient ;  Operation ;  Abortion ; 
Pulmonary  Abscess ;  Cerebral  Hernia ;  Other  Com- 
plications ;  Recovery,  By  M.  D.  Lederman. 

5.  The  Conservative  Treatment  of  Some  Traumatic  In- 

juries of  the  Extremities, 

By  Walter  T.  Dannreuther. 

6.  Further  Research  Regarding  the  Phosphatic  Index  or 

the  Pulse  of  the  Nervous  System, 

By  Henry  Dowo. 

7.  Hints  on  Fluoroscopy  and  Radiography, 

By  ASPINWALL  JUDD. 

I.    Catalytic  Theory  of  Infection  and  Immun- 

nity. — -McLaughlin  observes  that  pathogenesis  is 
a  catalytic  reaction  in  which  a  pathogen  or  toxine 
is  the  catalyst,  a  group  of  albumin  molecules  is  the 
substrate,  and  a  specific  antibody  is  the  endproduct. 
In  this  process  the  albumin  molecules  of  the  sub- 
.=trate  are  dissociated  and  transformed  into  a  tox- 
albumin,  and  this  is  the  essential  cause  of  the  disease 
produced,  the  type  of  which  is  determined  by  the 
character  of  the  toxalbumin,  and  the  character  of 
the  toxalbumin  is  determined  by  the  species  of 
pathogen,  and  the  vulnerable  substrate  engaged  in 
the  reaction.  When  it  is  concluded  that  pathogene- 
sis depends  on  the  coaction  of  two  factors — the 
pathogenic  agent  and  its  substrate,  the  absence  of 
either  of  these  will  result  in  immunity.  When,  for 
example,  there  is  a  natural  absence  of  the  albumin 
molecules  which  comprise  a  substrate,  the  organism 
will  be  naturally  immune  to  the  pathogenic  agent  of 
this  substrate.  And  when  a  substrate  has  been  de- 
stroyed by  the  pathogenic  agent,  either  in  a  prior 
attack  of  the  disease  or  by  inoculations  of  this  agent, 
the  organism  will  be  made  artificially  immune 
against  further  infection  by  the  pathogenic  agent. 
This  agent  is  then  nonpathogenic  to  the  organism, 
which  may  remain  harmlessly  in  the  tissues  of  the 
immune  body.  The  role  which  the  specific  anti- 
bodies play  in  this  scheme  of  immunity  can  be  seen 


from  the  following :  It  has  been  explained  why 
an  antibody  is  an  endproduct  of  a  catalytic  reac- 
tion, especially  when  the  reacting  bodies  are  colloids 
and  the  state  of  the  endproduct  is  molecular,  and 
why  the  specific  relation  of  antibody  and  catalyst 
is  a  relation  of  wave  energy  of  opposite  sign,  in 
which  the  waves  of  the  antibody  neutralize  the 
waves  of  the  catalyst^  It  may  be  seen,  therefore, 
that  an  antibody- — say  an  antigen  to  a  pathogen,  or 
an  antitoxine  to  a  toxine,  combines  with,  neutralizes, 
and  thus  makes  harmless,  the  pathogenic  agent. 
But  since  such  combinations  are  bodies  which  are 
foreign  to  the  organism  they  are  soon  disposed  of, 
and  the  immunity  produced  by  them  is  transient  n 
character.  On  the  other  hand,  immunity  produced 
by  destruction  of  the  substrate  is  lasting,  and  will 
remain  until  the  substrate  is  restored. 

5.  Conservative  Treatment  of  Some  Traumatic 
Injuries  of  the  Extremities. — Dannreuther  states 
that  the  essential  prerequisites  for  a  conservative 
method  of  treatment  are,  a  good  constitution,  age 
under  sixty,  the  integrity  of  at  least  a  third  of  the 
circumference  of  the  limb  preserved,  adequate 
blood  supply  to  the  site  of  injury  and  the  part  be- 
yond, and  a  good  nurse.  Contributing  factors  are, 
perfect  asepsis  and  antisepsis  to  the  greatest  attain- 
able degree,  .immediate  restoration  of  the  injured 
structures  to  their  normal  relations  as  far  as  possi- 
ble, free  drainage,  and  constant  wet  dressings.  In 
the  two  latter  lie  our  only  hopes  that  the  patient 
will  not  die  of  septichaemia.  The  author  advocates 
the  use  of  glycerin  in  conjunction  with  wet  dress- 
ings. It  will  be  found  a  very  valuable  aid  in  keep- 
ing the  gauze  moist,  and  its  powerful  hydroscopic 
properties  promote  drainage  and  hasten  sloughing. 

6.  Further  Research  Regarding  the  Phosphatic 
Index  or  the  Pulse  of  the  Nervous  System. — 
Dowd  says  that  the  phosphatic  index,  together  with 
the  size,  shape,  and  appearance  of  the  crystals,  is 
analogous  to  a  blood  count  with  a  haemoglobin  esti- 
mation as  made  with  the  blood  scale  and  the  appear- 
ance of  the  corpuscles  on  the  microscopical  field. 
A  comparison  may  be  made  as  follows :  The  index, 
the  amount  in  20  c.  c.  of  urine  from  a  twenty-four 
hour  sample  (or  the  urine  passed  between  7  and  11 
o'clock  in  the  morning)  will  answer  to  the  number 
of  blood  cells  per  cubic  millimetre.  The  size,  shape, 
and  appearance  of  the  crystals  indicate  the  amount 
of  nuclein  and  lecithin  which  they  contain,  the  same 
as  the  blood  scale  shows  the  amount  of  haemoglobin 
present.  Such  being  the  fact,  it  at  once  must  be 
clear  that  to  take  the  phosphatic  index  and  study 
the  crystals  carefully  is  as  important  as  a  blood 
count.  In  fact,  in  the  writer's  opinion  it  is  more 
so,  for  the  reason  that  disease  is  prolonged  and 
recovery  postponed  more  often  on  account  of  neu- 
rotic conditions  than  of  blood  changes.  Blood  ex- 
aminations necessitate  an  expensive  apparatus  and 
most  careful  technique,  whereas  the  reverse  is  true 
of  the  phosphatic  index.  Upon  the  addition  of  the 
alkaline  solution  (8  c.  c.  to  20  c.  c.  of  urine),  the 
mixture,  if  normal,  should  change  to  a  milky  char- 
acter at  once ;  the  precipitate  rapidly  sinking,  in  ten 
minutes,  the  time  allowed  for  an  estimation,  should 
appear  in  a  semisolid  mass  in  the  bottom  of  the 
tube,  displacing  3  c.c.  of  the  fluid.  This  phenom- 
enon is  liable  to  great  variations,  depending  upon 


ilay  S,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


the  size,  weight,  and  number  of  crystals  present. 
To  be  of  aid  in  the  diagnosis,  prognosis,  and  treat- 
ment of  disease,  one  must  know  why  these  crystals 
are  small,  light,  and  diminished  or  increased  in 
number.  The  phosphates  found  in  the  urine  are 
derived  from  the  food,  and  their  presence  in  the 
urine  is  influenced  greatly  by  certain  foods  and 
drugs.  Thus,  there  is  a  marked  increase  on  an  ani- 
mal diet,  and  drugs  like  phosphorus,  strychnine,  and 
lecithin  (which  should  be  considered  a  food)  in- 
crease them  greatly,  providing  assimilation  is  nor- 
mal. The  urinary  phosphates  depend  upon  the  de- 
composition of  nuclein  and  lecithin,  a  class  of 
bodies  derived  from  the  brain,  nerves,  amniotic 
fluid,  yolk  of  eggs,  spermatozoa,  and  certain  vege- 
table substances.  In  other  words,  nuclein  and  leci- 
thin are  the  food,  the  life  of  every  nervovital  cell, 
and  the  phosphatic  crystals  will  show  the  amount 
present.  That  lecithin  and  nuclein  exist  in  the 
nerve  cell  in  reserve  is  shown  when  a  person  in  a 
pronounced  state  of  nerve  excitement,  lasting  days 
or  weeks,  does  not  take  food  to  speak  of,  yet  the 
phosphates  in  the  lU'ine  are  greatly  increased.  Let 
the  condition  continue  for  some  time,  and  it  will  be 
found  that  the  crystals  decrease  in  size,  become 
light  in  weight,  and  may  even  go  so  far  as  to  be 
practically  amorphous. 

BRITISH  MEDICAL  JOURNAL. 
April  17,  igog. 

1.  Address  on  Dysmenorrhoea,  By  Ernest  Herman. 

2.  On  the  Importance  of  Pain  and  Hemorrhage  as  Symp- 

toms of  Extrauterine  Gestation. 

By  Th  iMAs  Watts  Eden. 

3.  Three  Recent 'Cases  of  Tubal  Pregnancy, 

By  C.   E.  PURSLOW. 

4.  The  Surgical  Treatment  of  the  I'mbilical  Cord, 

By  J.  W.  Ballantyne. 

5.  A  Case  of  Chronic  Inversion  of  the  Uterus,  with  Re- 

marks on  the  Mechanism  of  Reinversion, 

By  R.  J.  Johnstone. 

6.  Inguinal  Hernia  of  Uterus :  Herniotomy  with  Radical 

Cure  ;  Unusual  Complications  ;  Recovery, 

By  Rushton  Parker. 

7.  Cesarean  Section  with  Unusual  Indications, 

By  R.  C.  Buist. 

8.  Tetanus  Occurring  after  Surgical  Operations.    Is  the 

Infection  Introduced  by  Catgut  Ligatures? 

By  W.  G.  Richardson. 

9.  Fracture  of  the  Thigh  in  the  Newborn, 

By  J.  L.  T.  Isbister. 

I.  Dysmenorrhoea. — Herman  says  that  dys- 
menorrhcpa  has  no  tendency  to  spontaneous  cure. 
The  only  cure  other  than  by  medical  treatment  is 
childbearing.  Although  the  coordination  of  the 
menstrual  and  sexual  function  are  both  imperfect, 
and  consequently  the  meeting  in  utero  of  the  germ 
cell  and  the  sperm  cell  is  not  helped  as  it  should 
be;  yet,  nevertheless,  the  germ  cell  and  the  sperm 
cell  may  meet,  and  pregnancy  occur;  and  then,  in 
most  such  cases,  dysmenorrhoea  is  cured.  The  au- 
thor does  not  speak  of  palliative  treatment,  that  is 
the  relief  of  pain  when  it  has  arrived.  The  cure 
is  to  prevent  the  arrival  of  pain.  Every  case  of  dys- 
menorrhoea can  be  cured;  the  unfailing  cure  is  to 
stop  menstruation.  There  is  one  dr^g  that  some- 
times will  cure  it,  that  is  guaiacum.  If  drug  treat- 
ment fails  the  next  thing  to  do  is  to  dilate  the  cervix. 
This  is  best  done  with  a  metal  bougie,  and  when  the 
patient  is  young  and  unmarried,  under  anaesthesia. 


But  if  dilation  does  not  help  and  menstruation  can 
not  be  stopped,  then  the  ovaries  may  be  removed. 

2.  Pain  and  Haemorrhage  as  Symptoms  of ' 
Extrauterine  Gestation. — Eden  observes  that  few 
of  the  conditions  which  come  under  the  notice  of 
the  gynjecological  surgeon  are  of  greater  interest 
in  diagnosis  than  extrauterine  gestation.  Occasion- 
ally cases  occur  which  present  features  so  striking 
and  so  characteristic  that  their  nature  is  readily 
recognized.  But  this  is  not  always  the  case,  for 
the  clinical  features  may  be  so  complex  as  to  puzzle 
the  most  experienced  observers.  And  not  only  are 
the  clinical  features  complex,  they  are  also  subject 
to  extraordinary  variation  in  character  and  severity, 
so  that  it  may  be  difficult  to  believe  that  the  same 
pathological  condition  has  given  rise  to  them  all. 
The  explanation  of  these  difficulties  lies  in  the  fact 
that  the  symptoms  associated  with  extrauterine  ges- 
tation arise,  not  directly  from  the  presence  of  the 
growing  ovum  in  the  Falloppian  tube,  but  from  cer- 
tain secondary  lesions,  either  traumatic  or  inflam- 
matory, which  supervene.  These  secondary  lesions 
he  gives  as  follows:  i.  Intraperitoneal  flooding  from 
tubal  abortion  or  rupture.  2.  Intratubal  bleeding, 
leading  to  acute  distension  of  the  tube,  the  abdomin- 
al ostium  being  sealed.  3.  Slowly  progressive  or  re- 
current haemorrhage,  leading  to  the  formation  of 
encysted  collections  of  blood— for  example,  pelvic 
haematoma,  in  the  broad  ligament ;  pelvic  haemato- 
cele,  in  the  pouch  of  Douglas ;  peritubal  haematocele, 
around  the  abdominal  end  of  the  tube.  4.  Infection 
of  the  gravid  tube,  or  of  an  encysted  collection  of 
blood,  leading  to  suppuration.  Until  one  or  other  of 
these  secondary  lesions  is  produced,  extrauterine 
gestation  gives  rise  to  no  more  local  or  general  dis- 
turbance than  does  an  early  pregnancy  in  the  uterus. 
An  important  symptom  associated  with  this  phase 
— namely,  a  brief  period  of  amenorrhoea — is  a  most 
useful  aid  in  diagnosis,  but  it  is  by  no  means  always 
present.  As  it  is  quite  unusual  for  an  extrauterine 
gestation  to  continue  undisturbed  beyond  the  end 
of  the  second  month,  there  is  consequently  no  time 
for  the  appearance  of  other  general  symptoms  of 
pregnancy.  But  occasionally  morning  sickness  and 
early  breast  changes  may  be  met  with. 

5.  Chronic  Inversion  of  the  Uterus. — John- 
stone remarks  that  there  is  no  need  to  use  an  intrau- 
terine instrument  in  reducing  inversions  by  means 
of  repositors.  When  the  fundus  has  been  reduced 
within  the  external  os  the  use  of  repositors  may  be 
discontinued,  and  the  uterus  will  reinvert  itself. 

LANCET. 

April  17,  iQog. 

!.    Some  Disorders  of  the  Cerebral  Circulation  and  Their 
Clinical  Manifestations  (Goulstonian  Lectures), 

By  Alfred  E.  Russell. 

2.  The  Role  of  the  Saliva  in  the  Transmission  of  Tu  • 

bercle,        Ey  Newman  Neild  and  E.  V.  Dunkley. 

3.  Two  Unusual  Conditions  of  the  Gallbladder, 

By  Hugh  Lett. 

\.    A  Case  of  Vascular  Degeneration:  A  Study  in  Cardiat- 
Arrhythmia,  By  A.  M.  Gossage. 

5.  Some  Applications  of  the  Precipitin  Reaction  in  the 

Diagnosis  of  Hydatid  Disease,       By  D.  A.  Welsh. 

6.  Recurrent  Haematoporphyrinuria  with  Toxic  Symptoms 

not  due  to  Sulphonal, 

By  W.  Langdon  Brown  and  H.  O.  Williams. 

7.  Note  on  a  Case  of  Intussusception  of  the  Sigmoid  Flex- 

ure of  the  Colon,  By  Alexander  Don. 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Jourxai.. 


8.  A  Case  of  Disease  of  the'Hipjoint  due  lo  Streptococcal 

Invasion,  with  Secondary  Manifestations  in  Other 
Parts,  By  W.  Oliver  Beddard. 

9.  An  Interesting  Case  of  Appendicitis ;  Perforation ;  Op- 

eration ;  Recovery,  By  T.  Wilson  Parry. 

1.  Some  Disorders  of  the  Cerebral  Circula- 
tion and  Their  Clinical  Manifestations. — Russell, 
in  his  third  Goulstonian  Lecture  reviews  the  symp- 
toms as  follows :  The  cases  come  under  very  differ- 
ent categories :  First,  sudden  cardiac  inhibition  dur- 
ing puncture  of  the  chest  or  lavage  of  the  pleura; 
secondly,  cardiac  inhibition  in  patients  already  un- 
conscious from  the  influence  of  chloroform;  and 
thirdly,  experiments  on  animals  in  which  no  cardiac 
inhibition  occurs,  the  supply  of  blood  to  the  brain 
alone  being  abolished.  In  the  first  group  the  inhibi- 
tion may  be  of  varying  degrees  of  intensity  and 
duration,  (a)  Sudden  severe  fatal  syncope ;  num- 
erous cases  as  noted  are  on  record,  (b)  Sudden 
syncope  followed  by  complete  recovery  after  the 
most  alarming  symptoms,  (c)  Sudden  syncope; 
partial  recovery,  followed  by  death  after  varying 
periods  of  time ;  this  class  may  be  compared  with 
the  cases  occurring  under  chloroform  anaesthesia  in 
which  the  onset  of  symptoms  is  denoted  by  arrest 
of  pulse  and  respiration,  but  with  the  resuscitation 
of  the  heart  and  with  the  disappearance  of  the  ef- 
fects of  the  anjesthelic  these  cases  are  identical  save 
for  the  extra  shock  attending  the  surgical  operation. 
It  is  also  comparable  to  a  considerable  extent  with 
the  third  group — the  animals  whose  cerebral  vessels 
were  ligatured  for  varying  times,  save  that  in  these 
the  circulation  through  the  rest  of  the  body  was 
maintained.  The  onset.— The  suddenness  of  onset 
is  highly  characteristic  and  may  be  compared  with 
the  equally  sudden  onset  of  unconsciousness  in  the 
fit  of  idiopathic  epilepsy.  The  pulse. — This  in  some 
cases  cannot  be  felt  at  the  wrist,  in  others  it  has 
been  noted  as  feeble  or  slow  or  intermittent. 
Spasms. —  (a)  Initial  tonic  spasm.  In  the  case  of 
sudden  death  tonic  extensor  spasm  of  arms  was 
noted,  with  a  convergent  squint.  In  other  cases 
sudden  tonic  spasm  has  been  noted.  This  initial 
spasm  is  to  be  distinguished  from  the  later  convul- 
sive movements  and  would  appear  to  be  the  direct 
result  of  the  sudden  cessation  of  the  cerebral  cir- 
culation. Subsequent  course  of  these  cases. — In  ad- 
dition to  the  symptoms  already  mentioned  the  pupils 
dilate  and  become  insensitive  to  light.  Involuntary 
micturition  and  defaecation  occur.  Severe  perspira- 
ations  are  common.  Consciousness  does  not  return, 
convulsions'  may  recur  from  time  to  time,  the  deep 
reflexes  may  be  exaggerated,  irregular  movements 
or  rigidity  of  one  limb  or  of  both  limbs  of  one  side 
may  occur,  hemianaesthesia  may  be  detectable,  and 
finally  death  occurs. 

2.  The  Role  of  the  Saliva  in  the  Transmis- 
sion of  Tuberculosis. — Neild  and  Dunkley  ob- 
serve that  to  prevent  the  transmission  of  the  tubercle 
bacillus  from  the  tuberculous  to  the  nontuberculous 
and  to  maintain  the  general  health  of  the  nontubercu- 
lous are  the  main  principles  in  the  prophylaxis  of  tu- 
berlosis.  The  danger  of  sputum  as  a  carrier  of  tubercle 
bacilli  is  fully  recognized  and  every  patient  under 
proper  treatment  is  educated  in  the  care  of  the 
sputum.  But  the  tuberculous  use  their  saliva  for 
purposes  in  no  way  connected  with  the  digestion, 
and  also  by  the  fact  that  few,  if  any,  tuberculous 


patients  are  warned  against  such  uses.  The  uses 
to  which  saliva  is  put  are  numerous :  The  closing  of 
envelopes  and  sticking  of  stamps;  the  "rubbing  out" 
on  a  slate ;  as  a  styptic  in  bleeding ;  the  applying  of 
saliva  to  the  nipples  by  nursing  women  to  encour- 
age the  infant  to  take  the  breast,  etc.  He  suggests 
that  all  patients  with  pulmonary  tuberculosis  should 
be  forbidden  to  close  envelopes  and  stick  stamps 
with  their  saliva  and  forbidden  to  moisten  their 
fingers  with  saliva  for  any  purpose  whatsoever. 
There  is  little  to  be  said  in  favor  of  such  uses,  and 
when  we  have  admitted  that  they  are  convenient  and 
very  common,  they  remain  disagreeable  and  danger- 
ous. But  since  the  nontuberculous  who  moistens 
his  fingers  with  saliva  to  turn  the  leaves  of  the  of- 
fice ledger  or  grip  the  handle  of  a  spade  immeas- 
urably increases  the  risk  to  himself  of  the  same  habit 
in  the  tuberculous,  and  since  the  tuberculous  patient 
has  usually  been  included  among  the  nontubercu- 
lous for  some  months  at  any  rate  before  his  disease 
is  discovered,  some  attempt  should  be  made  to  re- 
duce the  frequency  of  this  habit  even  if  it  is  thought 
to  be  impossible  to  put  an  end  to  it.  Surely  it  is 
not  too  much  to  ask  that  wherever  there  is  an  inkpot 
there  should  be  a  gum  or  finger  damper,  and  that 
it  should  be  taught  in  all  schools  that  moistening  the 
fingers  with  saliva  is  a  dirty  habit  and  a  habit  that 
is  fraught  with  danger  both  to  the  possessor  and 
to  others. 

5.  Precipitin  Reaction  in  the  Diagnosis  of 
Hydatid  Disease. — Welsch  and  Chapman  base 
their  paper  on  fifty  precipitin  reactions  tested  in 
regard  to  thirty-six  patients  known  or  suspected 
to  harbor  hydatid  cysts.  Of  these  patients  twenty 
were  definitely  proved  to  be  infested  by  hydatids 
and  thirty  precipitin  tests  were  carried  out  in  re- 
gard to  them  in  addition  to  the  usual  controls.  The 
analysis  of  these  thirty  reactions,  the  nature  of  the 
hydatid  fluids  employed,  and  the  results  obtained 
constitute  the  substance  of  this  paper.  They  note 
that  of  the  other  precipitin  tests  eleven  were  con- 
ducted with  the  serum  of  ten  patients  from  which 
hydatids  were  in  all  probability  absent,  since  an  op- 
eration, or  the  subsequent  history,  revealed  the  pres- 
ence of  some  other  condition  (new  growth,  sup- 
puration, calculus,  etc.)  sufificient  to  account  for  the 
symptoms.  In  all  of  these  cases  the  precipitin  re- 
actions were  negative.  The  remaining  nine  precipi- 
tin tests  Avere  made  with  the  serum  of  six  patients 
in  whom  an  operation,  or  the  progress  of  the  case, 
was  inconclusive  as  regards  the  presence  or  absence 
of  hydatid  invasion.  Of  these  doubtful  cases  two  gave 
a  slight  positive  reaction  and  four  a  negative  reaction. 
As  to  their  results  the  authors  state  that  while  they 
have  obtained  further  evidence  of  recognizable  and 
specific  interactions  between  fluids  from  hydatid  cysts 
and  sera  from  hydatid  patients,  they  have  not  been 
able  to  find  a  method  of  applying  this  reaction  so 
that  it  will  hold  good  in  all  cases  in  conditions  of 
diagnosis.  This  failure  appears  to  be  due  to  diffi- 
culties relating  to  the  serum  of  hydatid  patients  and 
to  difficulties  relating  to  the  hydatid  fluids. 

6.  Haematoporphyrinuria. — 15  row  n  and  Wil- 
liams obscrvetl  such  a  case  in  a  woman  twenty-two 
years  of  age.  They  remark  that  ha"matt)porphyrin 
is  present  in  normal  urine,  though  in  such  small 
quantities  that  it  does  not  alter  the  color  or  ex- 


May  8,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


973 


hibit  its  typical  bands  on  spectroscopical  examina- 
tion. The  term  hsematoporphyrinuria  is  reserved  for 
those  cases  in  which  enough  of  this  pigment  ap- 
pears to  render  the  urine  either  of  a  port  wine  color 
or  of  a  dark  brown  hue,  when  the  spectroscope  will 
at  once  reveal  the  cause  of  the  alteration.  Such 
haematoporphyrinuria  occurs  under  two  sets  of  con- 
ditions: (i)  After  sulphonal,  trional,  or  tetronal 
have  been  administered,  when  it  forms  one  of  a 
group  of  toxic  symptoms  of  grave  import ;  and 
(2)  a  disturbance  of  pigment  metabolism,  continu- 
ous over  long  periods,  or  recurrent  and  paroxys- 
mal, for  which  in  some  cases  diffused  morbid  condi- 
tions of  the  liver  appear  to  be  mainly  responsible. 
In  the  majority  of  these  instances  it  does  not  seem 
to  have  had  any  evil  significance.  Occasionally, 
however,  cases  of  haematoporphyrinuria  occur, 
which,  though  not  due  to  any  administered  drug, 
present  definite  toxic  symptoms  resembling  the  sul- 
phonal cases  in  important  particulars. 

LA  PRESSE  MEDICALE. 

March  24,  i<)og. 

1.  Meningeal  Reactions  in  the  Erythemata  of  Children, 

By  Professor  Hutinel. 

2.  The  Mechanisms  of  Albuminuria  and  Orthostatic  Oli- 

guria, By  G.  H.  Lemoine  and  G.  Linossier. 

3.  The  Tuberculous   Patient  and   Farrier's  Recalcifying 

Method,  By  Maurice  Letulle. 

2.  The  Mechanism  of  Albuminuria  and  Or- 
thostatic Oliguria. — Lemoine  and  Linossier  ob- 
serve that  there  are  two  factors  which  combine  to 
form  the  syndrome  of  orthostatic  albuminuria.  The 
one  is  the  retardation  of  the  circulation  of  the  kid- 
ney ;  the  other  is  a  change  in  the  kidney  itself. 
These  two  factors  will  produce  many  different 
forms,  and  thus  "form  distinctive  clinical  types.  We 
have  no  clinical  proof  that  it  is  impossible  for  the 
first  factor  to  cause  orthostatic  albuminuria,  but 
physiological  experiments  have  proved  that  by  an 
incomplete  ligature  of  the  renal  pedicle  albuminuria 
can  be  produced ;  but  in  the  practice  it  is  difficult  to 
admit  that  such  a  condition  can  be  produced  patho- 
logically ;  we  furthermore  cannot  imagine  that  such 
albuminuria  can  exist  in  otherwise  normal  kidneys. 

3.  Recalcifying  Method  in  Tuberculous  Pa- 
tients.— Letulle.  describes  the  treatment  as  pro- 
posed by  Ferrier :  All  alcoholic  drinks  are  forbid- 
den ;  butter,  fat,  and  gravies  should  not  be  used,  and 
only  cream  is  allowed :  the  amount  of  bread  given 
should  not  be  more  than  300  grammes  a  day ;  food 
should  be  taken  at  long  intervals ;  acid  fruits  and 
old  cheese  are  also  forbidden ;  but  allowed  are  pota- 
toes, carrots,  split  peas,  pastry,  eggs,  lean  meat 
(300  to  400  grammes  a  day),  fish,  cooked  fruits; 
calcium  bicarbonate  mineral  water  should  be  taken 
in  the  morning ;  and  during  the  day  the  patient 
should  take  three  pills,  each  containing  calcium 
carbonate,  0.5  gramme ;  calcium  phosphate,  0.2 
gramme ;  magnesium  oxide,  0.05  gramme.  The 
patient  should  also  sleep  as  much  as  possible  and 
exercise  his  strength. 

March  37,  igog. 

1.  Immediate  and  Ultimate  Results  of  Arteriovenous  Su- 

tures, By  Albert  Frouin. 

2.  The  Fracture   of  Boxers.     Fracture  of  the  Inferior 

Extremity  of  the  First  Metacarpal  Bone, 

By  Oliver  Lenoir. 

3.  An  Antipneumococcic  Serum.  By  L.  Bertrand. 


2.  Fracture  of  Boxers. — Lenoir  has  observed 
a  condition  of  the  hand  in  prize  fighters  to  which 
he  thinks  very  httle  attention  has  been  paid  so  far. 
He  gives  five  radiographs  of  the  hands  of  well 
known  American  boxers  and  shows  on  these  radio- 
graphs that  in  the  hands  of  these  men  is  usually  to 
be  found  a  fracture  of  the  inferior  extremity  of  the 
first  metacarpal  bone.  He  explains  this  fact  thus : 
While  in  the  punch  with  the  closed  fist  the  heads 
of  the  four  last  metacarpal  bones  are  projecting, 
strong,  and  in  one  line,  the  knuckles  will  not  be 
used  in  the  same  way  in  swings,  hooks,  or  crosses, 
and  the  force  will  be  very  often  placed  on  the  first 
metacarpal  bone  alone,  which  then  will  give  way. 

March  31,  1909. 

1.  Infections  and  Suppurations  of  the  Pancreas, 

By  J.  L.  Faure. 

2.  Noguchi's   Simple   Method  for   Serum  Diagnosis  of 

Syphilis,  By  Professor  A.  Calmette. 

2.  Noguchi's  Simple  Method  for  Serum  Diag- 
nosis of  Syphilis. — Calmette  gives  a  review  of 
the  report  which  appeared  in  the  Journal  of  Experi- 
mental Medicine  of  March,  1909. 

LA  SEMAINE  MEDICALE. 
March  31,  1909. 

1.  The  Work  of  the  Imperial  Cancer  Research  Fund, 

By  Professor  R.  de  Bovis. 

2.  The  Two  Types  of  Incontinence  of  the  Urine  and  Their 

Treatment, 

1.  The  Work  of  the  Imperial  Cancer  Research 
Fund. —  De  Bovis  gives  a  very  good  and  condensed 
review  of  the  British  Cancer  Research  Fund.  He 
says  that  although  the  sum  total  of  these  experi- 
ments may  seem  to  be  very  small,  it  still  shows  a 
great  progress.  Our  former  doctrines  on  contagion 
of  cancer  and  its  parasitic  origin  have  been  de- 
stroyed, and  it  has  been  proved  that  we  have  to 
search  for  the  real  cause  of  this  disease  in  the  in- 
terior of  the  cancer  cell  itself  and  in  its  biology. 

BERLINER  KLINISCHE  WOCHENSCHRIFT 
March  29,  1909. 

1.  A  Small  Contribution  to  the  Statistics  of  Cancer, 

By  Johannes  Ortii. 

2.  Artificial  Respiration  in  Apparent  Death  from  Drown- 

ing, By  SCHAFER. 

3.  Treatment  of  Nervous  Bronchial  Asthma, 

By  N.  VON  Jagic. 

4.  Some  Cases  of  Typhus,  By  H.  Rosii*. 

5.  Etiology  and  Treatment  of  Coxa  Vara  Adolescentium, 

By  Drehmann. 

6.  The  Importance  of  Wassermann's  Reaction  in  the  Treat- 

ment of  Syphilis,  By  Harald  Boas. 

7.  Serum  Stu'lies  in  Lepra, 

By  Carl  Bruck  and  E.  Gessner. 

8.  The  Origin  of  the  Central  Epithelial  Tumors  of  the 

Lower  Jaw,  By  L.  von  Bakay. 

9.  A  Milk  Whey  Obtained  by  Colloidal  Separation, 

By  Paul  Grosser. 

10.  A  Contribution  to  the  Subject  of  Foreign  Bodies  in  the 

Frontal  Sinus,  By  Felix  Kramer. 

2.  Artificial  Respiration.  —  Schafer  gives  the 
following  directions.  The  movements  of  artificial 
respiration  should  be  begun  at  once,  as  soon  as  the 
patient  has  been  removed  from  the  water,  and  no 
time  should  be  lost  in  removing  or  loosening  the 
clothing.  As  soon  as  taken  from  the  water  lay  the 
patient  on  his  stomach  with  outstretched  arms,  the 
face  turned  to  one  side,  the  operator  kneeling  astride 
or  to  one  side  of  the  patient.    Place  the  hands  on  the 


974 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journai.. 


small  of  the  back  of  the  patient,  one  on  each  side,  with 
the  thumbs  parallel.  Bend  forward  with  outstretched 
arms  so  that  the  weight  of  the  operator  will  rest  on 
his  wrist  joints  and  so  make  even,  strong  downward 
pressure  upon  the  lower  ribs  and  loins  of  the  patient, 
and  remain  so  while  counting  slowly  i — 2 — 3.  The 
operator  then  swings  back,  taking  away  the  pres- 
sure on  his  hands,  which  are  kept  in  the  same  posi- 
tion and  remains  so  while  counting  slowly  i — 2 — 3. 
This  forward  and  backward  movement,  producing 
and  relieving  the  pressure  on  the  loins,  is  to  be  main- 
tained without  noticeable  intermission  at  the  rate  of 
about  twelve  times  a  minute.  The  pressure  drives 
the  air  from  the  lungs,  the  removal  of  the  pressure 
draws  the  air  in  again.  The  movements  are  to  be 
continued  until  natural  respiration  begins. 

3.  Nervous  Bronchial  Asthma. — Von  Jagic  re- 
ports five  cases  of  bronchial  asthma  in  which  he  ob- 
tained excellent  results  with  no  bad  after  effects 
from  the  subcutaneous  injection  of  adrenalin. 

6.  Wassermann's  Reaction  in  the  Treatment 
of  Syphilis. — Boas  says  that  a  positive  Wasser- 
mann's reaction  after  a  well  carried  out  treatment  of 
a  case  of  syphilis  promises  a  quick  recurrence,  and 
that  by  a  monthly  serum  test,  and  treatment  instituted 
immediately  after  the  occurrence  of  a  positive  re- 
action, recurrence  may  be  prevented  in  many  cases. 

9.  A  Milk  Whey  Obtained  by  Colloidal  Siepa- 
ration. — Grosser  separates  the  whey  from  the 
milk  in  a  way  analogous  to  that  used  by  Rona  and 
Michaelis  for  the  separation  of  the  albumin  from 
the  blood  serum  by  the  addition  of  a  colloid  which 
will  separate  the  colloids  present  from  the  milk. 

10.  Foreign  Bodies  in  the  Frontal  Sinus. — 
— Kramer  reports  a  case  in  which  he  removed  a 
piece  of  charcoal  from  the  frontal  sinus  of  a  man 
who  had  been  injured  twenty  years  before. 

 ®  


WESTERN    SURGICAL    AND  GYNAECOLOGICAL 

ASSOCL\TION. 
Eighteenth  Annual  Meeting,  Held  in  Minneapolis,  Decem- 
ber 29  and  30.  1908. 
The  President,  Dr.  W.  W.  Grant,  of  Denver,  in  the  Chair. 

The  Value  of  Enterostomy  in  Intestinal  Ob- 
struction.— Dr.  John  P.  Lord,  of  Omaha,  said 
that  the  general  mortality  after  operations  for  in- 
testinal obstruction  was  probably  from  fifty  to 
eighty  per  cent.  According  to  Elsberg,  in  only 
about  ten  to  fifteen  per  cent,  of  cases  in  Mount  Sinai 
Hospital,  New  York,  was  the  condition  still  to  be 
considered  a  good  one ;  and  fifty-four  died  out  of 
a  hundred  patients  in  three  of  the  large  hospitals 
in  New  York  during  igo6. 

The  extreme  conditions  commonly  met  with  re- 
quired too  much  anesthetic,  too  much  surgery,  and 
too  much  time  for  relief  by  the  radical  interven- 
tion too  commonly  resorted  to.  Until  earlier  diag- 
noses were  made  and  more  prompt  surgical  inter- 
vention resorted  to,  enterostomy  by  the  Senn  or 
Kader  principles  should  be  done  to  drain  the  toxic 
contents  of  the  intestinal  tube  and  to  stop  the  ab- 
sorption of  the  ptomaine  poisons,  although  an  effort 


should  be  made  to  relieve  the  efifects  of  distention 
of  the  intestines  and  its  hindrance  to  respiration. 
All  this  was  but  common  sense.  It  relieved  condi- 
tions which,  if  allowed  to  continue,  rapidly  became 
fatal.  It  met  the  indications  without  necessarily 
killing  those  who  were  extremely  ill.  It  was  not  to 
be  withheld  from  those  who  were  in  good  or  fair 
condition.  Done  in  the  modern  way,  it  was  not 
formidable,  or  very  objectionable,  in  the  face  of 
so  serious  an  affiiction.  Inanition,  formerly  feared, 
skin  excoriation,  and  the  necessity  for  a  secondary 
operation,  were  all  eliminated  by  the  present  meth- 
ods. Liquid  nourishment,  stimulants,  and  cathar- 
tics might  be  administered  with  most  valuable  re- 
sults. Irrigation  and  drainage  and  the  use  of  the 
Moynihan  tube,  now  considered  so  valuable,  might 
also  be  accomplished  before  the  wound  was  closed, 
and  might  be  used  to  a  limited  extent  afterward. 
The  necessity  for  a  radical  secondary  operation  was 
sometimes  obviated  by  this  "tide  over"  procedure, 
because  of  the  subsidence  of  peritonitis,  the  conse- 
quent infiltration,  the  paralysis,  and  even  the  angu- 
lation which  was  due  to  overdistention.  The  im- 
proved results  from  this  "tide  over"  procedure  jus- 
tified its  more  extensive  use.  It  was  not  so  for- 
midable as  to  preclude  its  use  among  general  prac- 
titioners who  had  had  hospital  training  and  posses- 
sed surgical  instincts.  The  coming  generation  of 
physicians  could  be  more  depended  on  to  make  ear- 
lier diagnoses  and  to  possess  the  skill  to  relieve 
most  surgical  emergencies.  The  mortality  from  in- 
testinal obstruction  would  be  lowered  in  the  near 
future.  The  author  reported  four  successful  cases 
to  illustrate  the  results  of  enterostomy  in  acute  post- 
operative obstruction. 

Dr.  William  D.  Haggard,  of  Nashville,  thought 
that  if  we  heeded  the  lesson  of  this  paper,  we 
should  be  able  to  transfer  some  of  the  desperate 
cases  from  the  dead  class  to  the  living.  There  was 
not  a  surgeon  who  had  not  had  the  mortif}  ing  ex- 
perience of  a  tremendously  high  mortality  attending 
the  hopelessly  delayed  cases  of  intestinal  obstruc- 
tion. If  we  could  operate  in  these  cases  quickly, 
under  local  anaesthesia,  by  enterostomy,  he  had  no 
doubt  we  should  be  able  to  save  a  much  larger 
proportion  of  the  patients  primarily. 

Dr.  J.  F.  Percy,  of  Galesburg,  111.,  said  that  in 
1902  he  opened  the  abdomen  of  a  doctor's  son  for 
delayed  appendicitis.  He  did  it  at  the  request  of 
the  young  man,  and  found  therein  a  condition  that 
was  embraced  in  the  title  of  Dr.  Lord's  paper,  where 
everything  was  black,  and  he  recognized  that  there 
was  something  besides  opening  the  abdomen  for^ 
drainage  to  be  done  in  the  care  and  cure  of  these 
patients.  His  next  patient,  about  a  year  afterward, 
was  brought  into  the  hospital  in  a  moribund  condi- 
tion. He  was  cyanotic.  He  directed  the  anaesthe- 
tist to  put  cold  water  on  the  mask,  because  the 
man  was  nearly  dead,  and  he  wanted  one  or  two 
members  of  the  family  in  the  room,  so  that  if  the 
patient  died  on  the  table  there  would  not  be  any 
question  as  to  responsibility  on  the  part  of  the  op- 
erator. He  made  a  quick  opening  in  the  right  iliac 
region  fjnd  grasped  the  first  piece  of  intestine  that 
presented,  fastened  it.  and  opened  it.  The  patient 
remained  in  a  semiconscious  condition  tor  three 
weeks,  but  made  an  operative  recovery.    Some  two 


May  8,  igog.] 


PROCEEDINGS  OF  SOCIETIES. 


or  three  months  afterward,  when  he  got  tired  of 
the  fistula  he  had,  Dr.  Percy  opened  the  abdomen 
and  resected  about  sixteen  or  eighteen  inches  of  the 
gut,  after  which  the  patient  made  a  perfect  recov- 
ery. He  had  had  three  similar  cases,  this  one  mak- 
ing four  in  all,  since  1903,  and  all  the  patients  had 
recovered  by  that  treatment. 

Dr.  R.  C.  Coffey^  of  Portland,  Oregon,  said  that 
the  mortality  from  intestinal  obstruction  was  doubt- 
less fifty  per  cent.  less  than  it  was  two  years  ago. 
This  lowered  mortality  rate  was  due  to  two  or  three 
things.  First,  the  family  physician  now  recognized 
that  acute  distention  of  the  abdomen  which  could 
not  be  accounted  for  in  any  other  way  was  to  be 
looked  upon  with  grave  suspicion.  Second,  we  had 
learned  that  a  paralyzed  bowel,  distended,  with 
ecchymotic  spots  developed  on  the  intestine  above, 
was  dangerous,  and  it  would  not  empty  itself,  even 
though  the  constriction  was  relieved.  One  of  the 
most  important  things  in  dealing  with  these  cases 
of  intestinal  obstruction  was,  as  in  the  Ochsner 
treatment  for  appendicitis,  to  keep  out  everything 
from  the  stomach  that  was  possible,  in  order  to 
prevent  the  formation  of  gas ;  second,  the  injection 
of  fluids  from  below  by  Murphy's  proctoclysis. 

Dr.  F.  Gregory  Connell,  of  Oshkosh,  Wis., 
said  that  there  could  be  no  question  as  to  the  advisa- 
bility of  performing  enterostomy  in  severe  cases  of 
intestinal  obstruction,  and  he  did  not  think  any  one 
would  doubt  the  inadvisability  of  doing  this  opera- 
tion in  the  early  or  mild  case.  In  a  case  of  obstruc- 
tion of  the  bowel,  if  we  did  a  laparotomy  and  re- 
lieved obstruction,  when  should  we  do  enterostomy, 
and  when  should  we  close  the  abdomen  and  allow 
the  patient  to- get  well?  If  we  did  enterostomies 
unnecessarily,  the  mortality  rate  would  be  higher 
than  was  necessary.  This  point  should  be  empha- 
sized, and  he  brought  it  up  for  the  purpose  of  re- 
ceiving enlightenment.  In  cases  of  acute  intestinal 
obstruction  we  should  emphasize  the  necessity  of 
infiltration  anaesthesia  because  of  the  danger  of  the 
patient  drowning  in  the  vomited  matter  on  the  table 
in  case  a  general  anaesthetic  was  used. 

Dr.  James  E.  Moore,  of  Minneapolis,  asked  when 
should  we  do  enterostomy  and  when  a  radical  op- 
eration in  these  cases  of  acute  intestinal  obstruction. 
We  had  to  depend  upon  the  judgment  and  experi- 
ence of  the  operator  who  had  the  case  in  charge. 
He  thought  it  would  be  equally  objectionable  to 
undertake  to  do  radical  operations  in  all  these  cases 
as  to  do  enterostomy  in  all  cases,  because  a  faecal 
fistula  was  a  very  uncomfortable  thing  for  the  pa- 
tient, and  it  did  not  enhance  the  reputation  of  the 
surgeon.  It  would  necessitate  an  operation  later, 
which  was  not  free  from  danger.  At  the  begin- 
ning of  surgery  for  this  condition,  the  mortality 
rate  from  intestinal  obstruction  was  stated  by 
Treves  to  be  ninety-five  per  cent.,  and  yet  there 
were  men  in  every  community  who  would  treat 
these  cases  to-day  just  as  they  were  treated  in  the 
days  before  Treves  was  born ;  they  would  wait, 
wait,  and  wait,  and  their  mortality  rate  was  ninety- 
five  per  cent.,  just  as  it  was  many,  many  years  ago. 
We  should  reduce  the  mortality  of  intestinal  ob- 
struction very  considerably  bv,  first,  operating  in 
these  cases  early  and,  second,  by  using  advanced 
methods  of  technique 


Dr.  Frederick  A.  Dunsmoor,  of  Alinneapolis, 
reported  briefly  a  case  that  was  peculiar.  The  pa- 
tient was  a  girl  who  had  been  operated  upon  three 
times  for  obstruction  of  the  bowels.  He  operated 
on  her  a  year  ago  for  an  acute  appendicitis,  from 
which  she  made  a  good  recovery.  Six  months  later 
she  was  operated  on  again  by  a  colleague  in  his 
absence  for  acute  intestinal  obstruction,  which  was 
relieved.  Later,  while  skating,  she  was  seized  with 
pain,  and  was  operated  on,  the  operation  disclosing 
obstruction  at  the  upper  part  of  the  ileum,  and  by 
liberating  bands  and  separating  adhesions  he  was 
enabled  to  establish  perfect  patency  of  the  intestinal 
tract.  Two  weeks  later  he  was  called  to  see  the 
girl  again  for  obstruction  of  the  bowels,  with  enor- 
mous dilatation  of  the  entire  small  intestine.  The 
intestine  was  filled  with  the  same  kind  of  fluid  that 
had  been  described  in  cases  of  acute  dilatation  of 
the  stomach.  There  were  three  quarts  of  this  black 
fluid,  which  was  largely  made  up  of  bloody  sub- 
stance. He  succeeded  in  establishing  normal  paten- 
cy of  the  bowel,  and  while  the  patient  was  not  in 
the  very  best  of  condition  at  the  present  time,  she 
was  still  alive.    She  had  a  fistula. 

Dr.  A.  L.  Wright,  of  Carroll,  Iowa,  spoke  from 
the  standpoint  of  a  patient.  In  March  he  had  his 
first  attack  of  appendicitis.  Within  eight  hours 
from  the  onset  the  appendix  had  ruptured,  and  it 
was  removed  within  fifteen  hours  from  the  onset 
of  the  first  symptoms  of  any  trouble  in  his  right 
flank.  Following  the  operation  he  had  septic  ileus, 
and  for  four  or  five  days  suffered  intensely.  The 
abdomen  had  been  packed  open,  but  not  until  a  liga- 
ture was  placed  about  the  appendix  for  closure  did 
he  get  relief,  which  was  prompt.  He  wished,  there- 
fore, as  a  recent  sufferer,  to  urge  opening  the  bowel, 
if  the  patient  was  in  such  a  condition  that  further 
operative  interference  was  unwarranted,  by  using 
a  sharp  pointed  scissors  and  giving  vent  to  the  con- 
tents, as  he  thought  that  by  so  doing  we  should  save 
a  much  larger  percentage  of  these  patients. 

Dr.  Clifford  U.  Collins,  of  Peoria,  111.,  said' 
the  remarks  of  Dr.  Connell  raised  the  question  in 
his  mind  with  regard  to  the  drowning  of  these  pa- 
tients in  the  faecal  vomit.  A  few  years  ago,  when 
Dr.  E.  Wyllys  Andrews  published  his  paper,  he  saw 
a  case  in  which  the  material  which  came  from  the 
mouth  of  the  patient  was  greatly  in  excess  of  any 
quantity  that  could  be  contained  in  the  stomach. 
Probably  under  the  influence  of  the  anaesthetic  the 
pylorus  became  relaxed  and  a  vast  quantity  of  ma- 
terial was  forced  into  the  stomach  by  the  combined 
pressure  below.  If  that  was  the  case,  it  occurred 
to  him  that  washing  out  of  the  stomach  as  a  pre- 
liminary to  anaesthesia  would  prevent  that  trouble. 
Since  then  he  had  operated  upon  patients  in  the  re- 
verse Trendelenburg  position,  allowing  gravity  to 
keep  the  intestinal  contents  from  escaping,  and  so 
far  that  trouble  had  been  obviated. 

Dr.  Van  Buren  Knott,  of  Sioux  City,  Iowa, 
said  that  enterostomy  had  lowered  the  mortality 
from  intestinal  obstruction,  but  it  had  by  no  means 
eHminated  it.  From  the  general  trend  of  the  dis- 
cussion it  would  seem  that  enterostomy  in  these 
cases,  no  matter  how  late  it  was  done,  in  the  hands 
of  a  good  surgeon,  was  a  life  saving  procedure. 
This  was  by  no  means  his  experience.   He  had  had 


976 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


many  cases  in  which  enterostomy  had  been  done, 
yet  the  patients  had  gone  on  and  died  just  the  same. 
Multiple  enterostomy  with  draniage  had  proved 
valuable  in  his  hands. 

Abscess  of  the  Brain. — Dr.  W.  H.  Magie,  of 
Duluth.  Minn.,  reported  two  cases  of  brain  abscess 
in  detail  and  made  a  plea  for  a  more  thorough  and 
systematic  exploration  of  the  brain  in  suspected 
cases.  From  the  study  of  these  cases  he  was  satis- 
fied that,  as  a  rule,  the  surgeon  of  ordinary  experi- 
ence was  too  timid  in  his  exploration  of  the  brain 
in  suspected  abscess.  These  cases  were  absolutely 
hopeless  unless  the  abscess  was  located  and  drained. 
Knowing  this  to  be  the  fact,  we  were  justified  in 
undertaking  almost  any  operative  procedure  in  our 
efforts  to  locate  and  drain  such  abscesses.  He  re- 
membered the  late  Dr.  Fenger  demonstrating  what 
he  (Fenger)  termed  his  systematic  exploration  of 
the  brain  for  suspected  abscess  before  the  Surgical 
Section  of  the  American  Medical  Association  at 
its  meeting  in  St.  Paul,  in  1901.  He  was  astonished 
at  the  time  at  what  seemed  to  him  Dr.  Fenger's 
reckless  disregard  for  the  brain.  He  used  a  skull 
to  demonstrate  his  method  with  numerous  trephine 
openings  through  which  he  introduced  a  trocar  or 
aspiration  needle,  passing  it  first  in  one  direction, 
then  another,  if  pus  was  not  found,  until  the  entire 
hemisphere  had  been  explored.  The  essayist  was 
now  of  the  opinion  that  Fenger's  method  was  the 
proper  one,  and  that  we  were  more  apt  to  err  on 
the  side  of  caution  than  otherwise.  In  his  future 
cases  he  was  determined  that  his  exploration  should 
be  so  exhaustive  that  abscesses  like  the  last  two 
would  not  be  overlooked,  believing  that  exploration 
of  the  most  searching  character  was  not  only  justi- 
fiable, but  demanded,  .in  order  that  the  lives  of,  at 
least,  some  of  these  unfortunates  might  be  saved. 

Indications  for  Obliterative  in  Contradistinc- 
tion to  Reconstructive  Endaneurysmorrhaphy. — 
Dr.  W.  J.  Frick,  of  Kansas  City,  Mo.,  believed  that 
in  the  vast  majority  of  cases  the  radical  obliterative 
endaneurysmorrhaphy  was  the  operation  to  be  pre- 
ferred, for  the  following  reasons:  i.  The  proced- 
ure was  definite,  thorough,  and  radical.  2.  No 
plastic  work  in  diseased  tissue  was  required,  such 
work  being  notoriously  uncertain.  3.  In  a  majority 
of  cases  the  sac  configuration  and  intrasaccular 
conditions  would  preclude  plastic  work.  4.  In  re- 
ported cases,  where  apparently  either  method  might 
have  been  employed  equally  well,  the  obliterative 
method  had  been  more  satisfactory  and  had  shown 
greater  freedom  from  untoward  sequelae,  such  as 
recurrence,  haemorrhage,  thrombosis,  gangrene,  etc. 
5.  A  pathological  aneurysm  was  a  malignant  degen- 
eration in  a  vital  structure.  The  diseased  vessel 
could  no  longer  be  depended  on  and  deserved  ob- 
literation. The  author  reported  two  cases  in  which 
he  had  operated,  with  recovery,  in  both  instances. 

The  technique  of  intraaneurysmal  surgery  re- 
solved itself  into  several  distinct  essential  steps:  i. 
Preliminary  haemostasis.  To  accomplish  this  was 
more  or  less  difficult,  according  to  the  situation  of 
the  aneurysm.  Esmarch  compression  of  the  main 
artery  above  and  temporary,  direct  compression 
above  and  below  were  variously  used.  A  bloodless 
field  was  almost  a  sine  qua  non.  2.  Free  opening 
of  the  aneurysmal  cavity  to  permit  of  a  careful  sur- 


vey of  the  interior  of  the  sac  before  deciding  on 
the  plan  of  procedure.  3.  Intrasaccular  suture  of 
orifices.  4.  Obhteration  of  the  cavity  by  sutures. 
5.  Closure  and  drainage. 

The  after  treatment  of  these  cases  was  usually 
simple,  only  one  or  two  points  being  worthy  of  com- 
ment. The  part  operated  on  was  best  immobilized 
by  some  suitable  fixed  dressing  in  a  position  of  re- 
laxation. This  prevented  tension  on  the  vessel  wall 
longitudinally,  and  also  allowed  free  play  for  the  es- 
tablishment of  a  collateral  circulation.  Drainage 
should  be  discontinued  early,  as  soon  as  its  purpose 
was  served. 

Dr.  John  P.  Lord,  of  Omaha,  had  been  greatly 
interested  in  the  work  of  Matas  from  the  first,  as 
well  as  in  that  done  by  others,  and  had  been  looking 
for  cases  that  were  suitable  for  the  Matas  proced- 
ure. He  had  had  two  cases  of  popliteal  aneurysm, 
but  when  he  came  to  consider  the  feasibility  of 
treatment  by  this  method,  and  began  to  look  up  the 
subject,  he  found  that  both  were  poor  subjects  for 
surgical  exploitation.  The  arteries  were  generally 
sclerosed ;  their  arterial  tension  was  high,  while  the 
kidneys  were  not  in  a  good  condition.  One  of  his 
patients  was  a  man,  sixty  years  of  age.  When  one 
looked  over  the  literature  he  became  impressed  with 
the  wisdom  of  John  Hunter  and  the  value  of  his 
procedure  of  ligation  of  the  femoral  artery.  He 
was  likewise  impressed  with  its  simplicity  and  with 
how  easily  the  operation  was  borne  by  the  patient. 
Dr.  Lord  resorted  to  ligation  in  both  his  cases ;  the 
patients  did  well  and  were  still  alive.  He  was  not 
fully  convinced  of  the  advantage  of  doing  aneurys- 
morrhaphy  in  all  cases  of  popliteal  aneurysm.  It 
did  not  appeal  to  him.  He  had  still  to  be  con- 
vinced of  its  desirability,  as  it  was  known  there 
had  been  failures  and  very  anxious  periods  in  the 
treatment  after  such  an  operation. 

Subserous  Appendectomy. — Dr.  E.  M.  Sala, 
of  Rock  Island,  111.,  reported  four  cases  in  which  he 
had  resorted  to  the  removal  of  the  appendix,  except 
its  serous  coat,  thus  avoiding  disturbing  adhesions 
of  the  appendix  to  other  viscera.  He  believed  the 
method  had  a  permanent  place  in  surgery  and  was 
the  operation  of  choice  in  certain  forms  of  adherent 
appendix.  Conclusions:  i.  The  vermiform  appendix 
might  be  shelled  out  of  its  peritoneal  covering  (^r 
serous  coat.  2.  The  remaining  serous  coat  could 
not  cause  a  recurrence.  3.  This  method  of  dealing 
with  an  appendix  which  was  glued  to  other  impor- 
tant structures  avoided  the  disagreeable  sequences 
of  loosening  up  strong  adhesions,  and  in  many  cases 
might  preclude  the  need  of  subsequent  operations, 
which  were  always  embarrassing  to  the  operator  and 
a  misfortune  to  patients. 

Dr.  Lord  had  availed  himself  of  this  procedure 
in  suitable  cases,  and  was  reminded  of  one  paticMit 
upon  whom  he  operated  eight  years  ago,  following 
a  technique  similar  to  the  one  that  had  been  de- 
scribed by  the  essayist.  In  this  case  a  young  sur- 
geon had  worked  for  an  hour  and  a  half  in  trying 
to  draw  out  the  appendix,  and  by  this  means  the 
speaker  was  enabled  to  extract  it  from  the  bottom  of 
the  pelvis.  This  procedure  was  valuable  in  that  it 
saved  lots  of  trouble  and  lessened  danger. 

{To  be  continued.) 


May  8,  1909.] 


BOOK  NOTICES. 


977 


[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


Transactions  of  the  American  Gyncccological  Society.  Vol- 
ume xxxiii,  for  the  Year  1908.  Philadelphia :  W.  J. 
Dornan,  1908.    Pp.  lvi-5S5. 

The  volumes  of  Transactions  of  this  society  may 
well  be  called  classical,  for.  the  organization  is 
among  the  oldest  of  the  national  special  societies. 
The  present  volume  opens  with  the  president's  an- 
nual address,  by  Dr.  J.  Montgomery  Baldy,  of 
Philadelphia,  entitled  The  General  Administration 
of  Anaesthetics.  It  is  an  appreciative  review  of  a 
most  important  subject,  one  that  engaged  special 
attention  at  the  following  meeting,  as  will  have 
been  gathered  from  our  pages.  It  is  to  be  regretted 
that  in  the  last  sentence  there  appears  the  misprint 
of  "Emmett"  for  Emmet. 

The  papers  which  follow  have  already  been  ab- 
stracted in  our  columns,  except  those  presented  as 
candidates'  theses.  These  are  entitled  Transplanta- 
tion of  Ovaries,  by  Dr.  Franklin  H.  Martin,  of 
Chicago ;  The  Intraabdominal  Route  for  the  Re- 
moval of  Calculi  from  the  Pelvic  Portion  of  the 
Female  Ureter,  by  Dr.  Dougal  Bissell,  of  New 
York;  and  A  Report  of  Fifty-two  Pregnancies  and 
Labors  Following  Ventrosuspension  of  the  Uterus 
for  Retrodisplacements,  by  Dr.  John  Osborn  Polak, 
of  Brooklyn.  The  papers  presented  by  the  mem- 
bers and  the  theses  presented  by  the  candidates  are 
all  of  solid  value,  and  the  volume  cannot  fail  to 
maintain  the  society's  reputation  for  bringing  out 
substantial  additions  to  the  literature  of  gynaecol- 
ogy- 

Quain's  Elements  of  Anatomy.  Editors:  Edward  Albert 
ScHAFER,  LL.  D.,  Sc.  D.,  F.  R.  S.,  Professor  of  Physiol- 
ogy and  Histolog>-  in  the  University  of  Edinburgh; 
Johnson  Symington,  M.  D.,  F.  R.  S.,  Professor  of 
Anatomy  in  Queen's  College,  Belfast ;  Thomas  Hastie 
Bryce,  M.  a.,  M.  D.,  Lecturer  in  Anatomy,  University 
of  Glasgow.  In  Four  Volumes.  Vol.  Ill,  Neurology, 
By  E.  A.  ScHAFER  and  J.  Symington.  Part  I,  Contain- 
ing the  General  Structure  of  the  Nervous  System  and 
the  Structure  of  the  Brain  and  Spinal  Cord.  With  Nu- 
merous Illustrations,  Many  of  which  are  Colored.  Elev- 
enth Edition.  London,  New  York,  Bombay,  and  Cal- 
cutta: Longmans,  Green,  &  Co.,  1908.    Pp.  ix-421. 

This  edition  of  Quain's  Elements  of  Anatomy  is 
a  remarkable  amplification  of  the  original  work. 
Necessarily  it  is  the  production  of  others  than 
Quain,  who  died  many  years  ago,  and  it  may  almost 
be  called  a  tribute  to  his  memory.  It  would  be  well, 
we  think,  if  other  meritorious  works  were  perpet- 
uated in  like  manner.  As  things  are  now,  a  medical 
book  generally  dies  when  its  author  dies,  and  that, 
too,  in  spite  of  its  presenting  features  of  originality 
which  should  meet  with  continued  recognition  as 
the  author's  own,  rather  than  become  public  proper- 
ty. The  distinguished  men  who  are  contributing  to 
the  gracious  task  of  insuring  an  exceptional  sur- 
vival of  Quain's  reputation  as  an  anatomist  are 
therefore  deserving  of  rare  credit. 

This  edition  is  no  students'  textbook ;  it  is  a  book 


of  reference,  however,  which  no  scholarly  practi- 
tioner of  medicine  can  afford  not  to  possess.  The 
particular  part  now  under  notice  is  a  cornprehen- 
sive  and  well  digested  conspectus  of  all  that  con- 
cerns the  anatomy,  gross  and  minute,  human  and 
comparative,  of  the  central  nervous  system,  includ- 
ing histology  and  a  great  deal  of  physiology,  to- 
gether with  so  much  of  embryology  as  is  necessary 
to  a  clear  understanding  of  the  subject.  It  is  pro- 
fusely and  admirably  illustrated  and  the  printing  is 
such  as  could  hardly  be  excelled.  The  completed 
work  will  undoubtedly  be  looked  upon  as  one  of 
the  most  important  additions  to  medical  literature 
made  in  our  generation. 

There  are  some  defects  of  a  minor  nature.  For 
example,  it  is  to  be  regretted,  we  think,  that  the 
nomenclature  of  the  German  Anatomical  Society 
has  not  been  strictly  adhered  to.  Particularly  to  be 
wondered  at  is  the  clinging  to  "raphe"  for  rhaphe 
and  "hilus"  for  hilum.  "Trigonum  subpinealis"  (on 
page  204  and  again  in  the  index)  is  of  course  an  out 
and  out  slip. 

Parsimony  in  Nutrition.  By  Sir  James  Crichton-Brovvne, 
M.  D.,  LL.  D.,  F.  R.  S.,  Lord  Chancellor's  Visitor  in 
Lunacy,  London.  London  and  New  York:  Funk  &  Wag- 
nalls  Company,  igog.    Pp.  vi-iii.    (Price,  75  cents.) 

Sir  James  Crichton-Browne  reviews  critically  the 
theories  of  Horace  Fletcher  and  Professor  Chitten- 
den, whose  ideas  of  economic  nutrition  made  such 
a  furore  about  two  years  ago.  The  conclusions 
which  the  eminent  English  physician  reaches  are 
diametrically  opposite  to  the  ideas  of  Fletcher,  Chit- 
tenden, and  their  followers.  And  Sir  James  does 
not  stand  alone.  Horace  Fletcher's  statement  that 
''Professor  Chittenden's  results  have  been  accepted 
in  scientific  circles  the  world  over  as  authoritatively 
conclusive,"  is  at  least  misleading,  and  the  number 
of  their  followers  is  certainly  not  increasing,  but 
decreasing.  While  Fletcherism  may  do  good  in 
some  cases,  it  is  wrong  to  apply  it  generally.  Sir 
James  concludes  that  "the  poor  have  much  to  learn 
in  the  way  of  economy  in  food,  but  it  is  ect)nomy 
in  the  selection  and  preparation  of  food,  and  not  in 
the  lopping  of¥  of  proteid.  The  urgent  question  for 
us  to-day  is  not  how  we  may  teach  them  to  thrive 
on  an  attenuated  fare,  but  'whence  shall  we  buy 
bread  that  these  may  eat?'  We  should  aim  not  at 
parsimony  in  nutrition,  but  try  to  'scatter  plenty 
o'er  a  smiling  land.'  "  The  book  can  well  be  recom- 
mended to  the  profession. 

Rotunda  Practical  Midwifery.  By  E.  Hastings  Tweedy, 
M.  D.,  F.  R.  C.  P.  I.,  Master  of  the  Rotunda  Hospital, 
and  G.  T.  Wrench,  M.  D.,  Late  Assistant  Master.  Lon- 
don :  Henry  Frowde  and  Hodder  &  Stoughton,  1908. 
Pp.  xix-464. 

The  practice  of  the  Dublin  Rotunda  Hospital  has 
long  been  held  in  high  esteem,  and  that  old  institu- 
tion has  been  renowned  in  obstetrics.  "The  require- 
ments of  practical  midwifery,"  says  Dr.  Tweedy  in 
the  preface,  "are  so  inadequately  provided  for  in  the 
ctirriculum  of  our  universities  and  licensing  corpor- 
ations that  it  is  not  an  exaggeration  to  say  that 
many  recently  qualified  practitioners  are  a  danger 
rather  than  a  help  to  their  lying-in  patient.  For 
this  lamentable  result  the  different  examining  bodies 
must  be  held  solely  accountable,  for  it  is  unreason- 


■978 


MEDICOLITERARY  NOTES.— MISCELLANY. 


[New  York 
MtDicAL  Journal. 


able  to  expect  a  student  to  pursue  knowledge  to  a 
greater  degree  than  that  which  is  found  necessary 
for  qualification  purposes" — a  proposition  which 
may  well  be  applied  in  other  branches  of  practice 
than  obstetrics.  Overpreparation  for  examinations 
is  the  fault  of  the  day  in  medical  education. 

It  is  to  meet  this  need  that  the  authors  have  pre- 
pared this  book,  and  remarkably  well  have  they  suc- 
ceeded in  the  undertaking.  In  homely  language 
they  give  directions  which  we  have  never  seen  sur- 
passed in  value.  There  ought  to  be  a  great  demand 
for  the  book. 

Medicolitcrary  Notes. 

In  the  May  American,  Mr.  James  Oppenheim  of- 
fers a  story,  The  Seventh  Night,  which  gives  a 
somewhat  hysterical  account  of  the  crisis  of  pneu- 
monia in  a  young  woman  of  the  lower  East  Side. 
Dr.  Rast  takes  the  stage  in  most  melodramatic  fash- 
ion, pushing  about  the  patient's  relatives,  shouting 
and  praying,  falling  on  the  bed  with  convulsive  sobs, 
and  finally  stumbling  out  of  the  door  "in  a  trance." 
To  the  nonmedical  reader,  we  can  well  imagine, 
the  story  will  prove  realistic  and  exciting. 


shirtsleeves  a  hypodermic  injection  at  the  hands  of 
two  "new  laid"  doctors.  The  superintendent,  Dr. 
Witherspoon,  is  a  quack  of  quacks,  a  caricature  of  a 
decent  physician.  Craighead,  an  irresponsible,  witty, 
and  slangy  drunkard,  is  a  lifelike  and  amusing  char- 
acter. He  is  of  the  type  that  seems  to  have  a  chem- 
ical affinity  for  alcohol,  so  that  the  two  fly  together 
when  placed  in  propinquity. 

 <^  


French  Medical  Science  during  the  Middle 
Ages. — Alfred  Rambaud  in  his  Histoire  de  la  ciz'il- 
isation  francaise,  while  speaking  of  French  medical 
science  during  the  middle  ages,  says: 

Heaven  was  peopled  with  healing  saints.  If  one  had  a  sore 
throat  he  addressed  himself  to  Saint  Christopher ;  if  dropsy, 
to  Saint  Eutropius ;  if  fever,  to  Saint  Pernella ;  if  insanity, 
to  Saint  Mathurin ;  if  the  plague,  to  Saint  Roque ;  if  hy- 
drophobia, to  Saint  Hubert,  the  patron  of  the  chase  and  of 
the  dogs.  At  the  monastery  of  Saint  Hubert,  near  Liege, 
a  monk  touched  the  patient  with  the  saint's  stole,  and  cau- 
terized him  with  "the  key  of  Saint  Hubert." 

Often  the  choice  of  the  saint  was  determined  by  a  kind  of 
pun.     For  scurf   (teigne^   they  addressed  Saint  Aignan 


In  the  June  Cosmopolitan  alcohol  furnishes  the 
motif  of  a  short  story,  Eliza  Calvert  Hall's  The  Re- 
formation of  Sam  Amos,  the  hero  of  which  is  an  oc- 
casional drunkard  of  excellent  temperate  heredity. 
He  is  powerfully  moved  by  a  sudden  demonstration 
of  his  wife's  great  love  for  him  and  "swears  ofif" 
publicly  in  a  sensational  manner. 

In  tlie  same  magazine  the  third  and  fourth  chap- 
ters of  X'irginia  of  the  Air  Lanes,  by  Herbert 
Quick,  narrate  the  hero's  unpremeditated  descent  by 
parachute  into  the  gardens  of  a  private  drink  cure 
sanatorium.  He  is  mistaken  for  a  patient,  and  is 
forced  into  the  line  of  subjects  awaiting  with  slit 


(.  .  .)  ;  for  trouble  with  the  eyes.  Saint  Claire:  for  gout, 
Saint  Genou  (genou.  knee)  :  for  cramps.  Saint  Crampan. 

Certain  maladies  were  even  designated  only  by  the  name 
of  the  saint  who  cured  them  :  thus  Saint  Vitus's  dance,  a 
nervous  disease  which  we  now  call  chorea;  Saint  John's  ill, 
which  was  epilepsy;  Saint  .Anthony's  evil,  which  was  can- 
cer ;  Saint  Eloy's  evil,  which  was  scurvy ;  Saint  Firmin's 
evil,  which  was  erysipelas ;  Saint  Lazarus's  evil,  which  was 
leprosy ;  Saint  Quentin's  e\  il,  which  was  dropsy ;  Saint  Syl- 
van's  evil,  which  seems  to  have  been  a  kind  of  eruptive 
fever.  (Extract  from  the  Library  of  the  World's  Best  Lit- 
erature, by  Charles  Dudley  Warner.) 

The  accompanving  illustration  is  a  reproduction 
from  a  cut  which  has  been  made  the  subject  of  an 
article  on  Heilige  Krankenheiler  by  Dr.  Sf.  Hofler, 


May  8.  1909.] 


OFFICIAL  NEWS. 


979 


of  Bad  Tolz,  Germany,  in  Janus,  March,  1909.  The 
saints  described  here  are,  from  left  to  right,  St.- 
Lubin,  the  saint  of  blindness  and  dropsy :  St.- 
Mamert,  the  saint  of  abdominal  disease;  St.-Meen, 
the  saint  of  skin  diseases ;  St.-Hubert,  the  saint  of 
rabies  ;  St.-Livertin,  the  saint  of  headaches  ;  and  St.- 
Houarniaule,  the  saint  of  night  terrors. 

In  conclusion  we  give  the  prescription  for  the  true 
Saint-Ange  powder  according  to  Dr.  SchefHer  in  the 
Journal  de  medecine  de  Paris  of  March  20,  1909: 

B    Wild  ginger,   500  parts; 

Wood  betony,    12  parts; 

Verbena,    4  parts. 

Powder  and  mix  well  and  add  4  parts  of  dried  toad. 
This  was  a  specific  sternutatory  powder,  which  is 
still  preserved  in  the  French  Pharmacopoeia  in  the 
following  formula : 

Wild  ginger,    ^ 

Wood  betony,   (  j 

Origanum   j      ^  ^ 

Convallaria   ) 

M. 

 ^  

Official  Metos. 


4 
13 


Public   Health   and   Marine   Hospital  Service 
Health  Reports: 

The  follozving  cases  of  smallpox,  yellow  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  iveek  ending  April  30,  1909: 

Places.  Date.  Cases.  Deaths. 

Smallpo.r — United  States. 

Alabama — Dallas  County  Feb.   20- April    12....  12 

Alabama — Selma  Feb.  28-April  12....  26 

California — San  Ffancisco  April 

District  of  Columbia — Washington.  April 

Georgia — Macon  April 

Illinois — Danville  April 

Illinois — Galesburg  April 

Illinois — Springfield  .\pril 

Indiana — Fort  Wayne  April 

Indiana — Indianapolis  April 

Indiana — Lafayette  April 

Iowa — Davenport  April 

Kansas — Kansas  City  April 

Kansas — Wichita  April 

Kentucky — Newport  Mar. 

Louisiana — New  Orleans  April 

4  Imported 

Massachusetts — Taunton — One   case   erroneously    reported   by  local 
health  officer,  January  9. 

Michigan — Saginaw  April 

Minnesota — Duluth  April 

Minnesota — Minneapolis  Mar. 

Missouri — St.  Louis  April 

Montana — Butte  Mar. 

April 

New  Jersey — Camden  .\pril 


3-  10  

10-  17 .  • 

11-  18.  . 

4-  18  

10-  17.  •  ■ 

2-  16  

6-17 ... . 

11-  i8... 

12-  19. . . 
11-18.  . . 
10-17... 

3-  10  

30- April 

3-17  


3-10  

8-15.... 

27-April 
3-17  

23-30  


New  Jersey — Plainfield  April  3-10  

Ohio — Ashtabula  April  10-17  

Ohio — Cincinnati  April  9-16  

Ohio — Cleveland  April  g-i6  

Tennessee — Knoxville  April  10-17  

Tennessee — Nashville  April  10-17  

Texas — Galveston  April  2-16  

Texas — ^San  Antonio  April  10-17  

Washington — Spokane  Mar.  27-ApriI  10. 

Wisconsin — Appleton  April  12-19  

Wisconsin — La  Crosse  .\pril  10-17  

Wisconsin — Milwaukee  .\pril  3-17  

Smallpox — Insular. 
Philippine  Islands — Manilla  Feb.    21-Mar.  6.. 

Smallpo.r — Foreign. 

Algeria — Bona  ilar  1-31  

Brazil— Bahia  Feb.  27-Mar. 

Brazil — Rio  de  Janeiro  Mar.  7-14... 

Canada — Halifax  .\pril  3-10.. 

China — Amoy  Mar.  6-13.., 

China — Hongkong  Feb.  27-Mar. 

Egypt — Cairo  Feb.  25-Mar. 

Egypt — Suez  Feb.  4-25... 

France — Nantes  Mar.  14-21.. 

France — Paris  Mar.  27-ADri 

India — Bombay  Mar. 

India — Calcutta  Mar. 

India — Madras  Mar. 


13- 


16-23. 
6-13.. 
13-19. 


6 

3 

6 

3 

I 
I 

Imported 

4 

2 

2 

3 

7 

I 

2 

2 

6 

5 

6 

I 
3 

25 

6 

I 

18 

12 

2& 

c 

21 

9 

I 

Present 

3 

I 

77 

28 

27 

2 

I 

5 

I 

Present 


98 
I 
6 
4 


Present 
Epidemic 
Present 


15 
264 


Places.  Date.  Cases.  Deaths. 

India — Rangoon  Mar.  6-13   n 

Indo-China — Saigon  Feb.  27-Mar.  13   15  6 

Italy — General  Mar.  27-April  4   56 

Italy — Naples  Mar.  27-Ai  ril  4   15  ^ 

Java — Batavia  Mar.  6-13   3 

Manchuria — Dalny  Mar.  6-13   i 

Mexico — Acapuico  Feb.   7-14   3 

Mexico— Monterey  April  4-11   7 

Portugal — Lisbon  April  3-10   2 

Russia — Moscow  Mar.  20-27   35  'i 

Russia — Odessa  Mar.  20-27   4  i 

Russia — St.  Petersburg  Mar.  13-20.   17  2 

Spain — Barcelona  Mar.  28-April  5   4 

Spain — Madrid  Mar.  1-31...   28 

Spain — Valencia   Mar.  26- April  3   7 

Straits  Settlements — Singapore ...  Feb.  27-Mar.  6  

Turkey — Bassorah  Mar.  20-27  

Yellow  Fever — Foreign. 

Barbados  April   3-10   3 

Ecuador — Guayaquil  Alar.  13-27  

Cholera — Foreign . 

India — Bombay  Mar.  16-23  

India — Calcutta  Mar.  6-13  

India — Madras  Mar.  13-19  

India — Rangoon  Mar.  6-13  

Russia — St.  Petersburg  .April    1-6   11 

Plague — Foreign. 

Azores — Fayal  April  i   i 

Brazil — Bahia  Feb.  27-Mar.  6   2 

Brazil — Rio  de  Janeiro  Mar.  7-14   4 

China^ — -Amoy  Mar.  6-13  

China — Chang  Poo  Mar.  13  

China — Chin  Chew  Mar.  13  

China — Hongkong  F"eb.  27-Mar.  6   3  2 

Ecuador — Guayaquil  Mar.  13-27   15 

Great  Britain — Elstrec  Feb.    1-4   i  i 

Plague  laboratory. 

India — Bombay  Mar.  16-23   436 

India — Calcutta  Mar.  6-13   85 

India — Rangoon  Mar.  6-13  

Indoo-China — Saigon  Feb.  27-Mar.  13....,  3 

Russia — Libau  Mar.  29-April  5   i 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
April  28,  1909: 

Bailey,  C.  A.,  Acting  Assistant  Surgeon.  Directed  to  pro- 
ceed from  St.  John,  N.  B.,  to  Quebec,  Can.,  for  duty. 

BULL.A.RI),  J,  T.,  Acting  Assistant  Surgeon.  Granted  nine 
days'  leave  of  absence  from  ilarch  31,  1909,  without 
pay. 

Caktek,  p.  L,  Acting  Assistant  Surgeon.  Granted  twenty 
days'  leave  of  absence  from  April  29,  1909. 

Duffy,  Francis,  Acting  Assistant  Surgeon.  Granted  three 
days'  leave  of  absence  from  April  28,  1909. 

G.^HN,  Henry,  Pharmacist.  Granted  three  days'  leave  of 
absence  from  April  21,  1909,  under  paragraph  210,  Ser- 
vice Regulations. 

Gale,  R.  G.,  Acting  Assistant  Surgeon.  Granted  thirty 
days'  extension  of  annual  leave  on  account  of  sickness 
from  January  16,  1909. 

Gale,  R.  G.,  Acting  Assistant  Surgeon.  Granted  thirty 
days'  leave  of  absence,  from  February  16,  1909.  and 
nine  days'  leave  of  absence,  without  pay,  from  March 
24,  1909. 

Gustetter,  a.  L.,  Acting  Assistant  Surgeon.  Granted  one 
day's  leave  of  absence,  April  3,  1909. 

Herty,  F.  J.,  Pharmacist.  Granted  three  aays'  leave  of 
absence  from  April  18,  1909,  under  paragraph  210,  Ser- 
vice Regulations. 

HoTCHKiss.  Samuel  C.,  Assistant  Surgeon.  Directed  to 
proceed  to  San  Francisco,  Gal.,  and  report  to  the  Med- 
ical Officer  in  Command  of  the  Marine  Hospital  for 
duty  and  assignment  to  quarters. 

Ott,  C.  R.,  Pharmacist.  Leave  of  absence  granted  March 
29,  1909,  for  thirty  days  from  March  23,  1909,  amended 
to  read  eighteen  days  from  March  23,  1909.  • 

Terry,  M.  C,  Acting  Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence  from  April  11,  1909,  under  para- 
graph 210,  Service  Regulations. 

Trask,  J.  W.,  Passed  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  April  26,  1909. 

Van  Ness,  George  I.,  Jr..  Pharmacist.  Granted  thirty 
days'  leave  of  absence  from  May  7,  1909. 

Wasdin,  Eugene,  Surgeon.  Granted  one  month's  leave  of 
absence  from  April  22.  iQog,  on  account  of  sickness. 


98o 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journau 


Wertenb^vker,  C.  p.,  Surgeon.    Detailed  to  represent  the 

Service  at  the  annual  meeting  of  the  Virginia  State 

Conference  of  Charities  and  Corrections  to  be  held  in 

Lynchburg,  Va. 
Wetmore,  W.   O.,  Acting  Assistant   Surgeon.  Granted 

two  days'  extension  of  annual  leave  on  account  of 

sickness  from  April  17,  1909. 
Wetmore,  W.   O.,  Acting  Assistant   Surgeon.  Granted 

twelve  days'  leave  of  absence  from  April  23,  1909. 
Wherry,  William  B.,  Acting  Assistant  Surgeon.  Granted 

three  days'  leave  of  absence  from  April  21,  1909,  under 

paragraph  210,  Service  Regulations. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  iveek  ending  May  i,  igog: 
Bowman,  M.  D.,  First  Lieutenant,  Medical  Reserve  Corps 
Ordered  from  Fort  Baker,  Cal.,  to  the  Depot  of  Re- 
cruits and  Casuals,  Angel  Island,  Cal.,  for  duty. 
Brooks,  W.  H.,  Captain,  Medical  Corps.    Granted  an  ex- 
tension of  four  months  to  sick  leave  of  absence. 
Brownlee,  C.  Y.,  Captain,  Medical  Corps.    Ordered  to  re- 
port at  Manila,  P.  1.,  for  examination  for  promotion. 
Carter,  W.  F.,  Major,  Medical  Corps.    Ordered  to  report 
on  May  20th  at  Washmgton,  D.  C,  for  examination 
for  promotion. 

Chamberlain,  W.  P.,  Major,  Medical  Corps.  Relieved 
from  duty  at  present  stations  in  time  to  sail  August 
5th,  from  San  Francisco,  Cal.,  for  service  in  the  Phil- 
ippines. 

Dale,  F.  A.,  Captain,  Medical  Corps.    Ordered  to  report 

at  Washington,  D.  C,  for  examination  for  promotion. 
Enders,  W.  J.,  First  Lieutenant,  Medical  Reserve  Corps. 

Granted  sick  leave  of  absence  for  twenty-six  days. 
Farr,  C.  W.,  Captain,  Medical  Corps.    Ordered  to  report 

at  Washington,  D.  C,  for  examination  for  promotion. 
GiBSOx,  R.  J.,  Major,  Medical  Corps.    Ordered  to  report 

on  May  20th  at  Washington,  D.  C,  for  examination 

for  promotion. 

Haley,  J.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Porter,  N.  Y.,  and  ordered 
to  Fort  Jay,  N.  Y.,  for  duty. 

Johnson,  R.  W.,  Major,  Medical  Corps.  Ordered  to  re- 
port on  May  20th  at  Washington,  D.  C,  for  examina- 
tion for  promotion. 

Krebs,  L.  L.,  Captain,  Medical  Corps.  Relieved  from  duty 
on  the  transport  Thomas  and  from  treatment  at  San 
Francisco,  Cal.,  and  ordered  to  Fort  Bayard,  N.  M.,  for 
duty  at  the  Army  General  Hospital. 

Kress,  C.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  an  extension  of  leave  of  absence  to  June  ist. 

Lambie,  J.  S.,  Jr.,  First  Lieutenant,  Medical  Corps.  Re- 
lieved from  duty  at  Fort  Monroe,  Va.,  in  time  to 
proceed  to  San  Francisco,  Cal.,  and  sail  July  5th  for 
service  m  the  Philippines. 

McCornack,  C.  C,  First  Lieutenant,  Medical  Reserve 
Corps.  Ordered  to  active  duty  and  assigned  to  Van- 
vouver  Barracks,  Wash.,  for  duty. 

Page,  Henry,  Major,  Medical  Corps.  Relieved  from  duty 
at  present  stations  in  time  to  sail  August  5th  from 
San  Francisco,  Cal.,  for  serv'ice  in  the  Philippines. 

Palmer,  F.  W.,  Captain,  Medical  Corps.  Granted  leave  of 
absence- for  two  months. 

PiNKSTON,  O.  W.,  First  Lieutenant,  Medical  Corps.  Grant- 
ed leave  of  absence  for  ten  days. 

Rafferty,  Ogden,  Major,  Medical  Corps.  Granted  sick 
leave  of  absence  for  two  months. 

Richard,  Charles,  Lieutenant  Colonel,  Medical  Corps. 
Relieved  from  duty  at  Fort  Jay,  N.  Y.,  in  time  to  pro- 
ceed to  San  Francisco,  Cal.,  and  sail  August  5th,  for 
service  in  the  Philippines. 

Roberts,  W.  M.,  Captain,  Medical  Corps.  Ordered  to  re- 
port gt  Washington,  D.  C,  for  examination  for  pro- 
motion. 

RuFFNER,  E.  L.,  Captain,  Medical  Corps.  Ordered  to  re- 
port Pt  Manila,  P.  I.,  for  examination  for  promotion. 

Rutherford,  H.  H.,  Captain,  Medical  Corps.  Ordered  to 
report  at  Manila,  P.  L,  for  examination  for  promo- 
tion. 

Shockley,  M.  a.  W.,  Major,  Medical  Corps.  Relieved 
from  duty  at  present  station  in  time  to  sail  August 
5tb  from  .San  Francisco,  Cal.,  for  service  in  the  Philip- 
pines. 


Shook,  J.  R.,  Captain,  Medical  Corps.  Ordered  to  report 
at  VVashington,  D.  C,  for  examination  for  promotion. 

VosE,  W.  E.,  Captain,  Medical  Corps.  Ordered  to  report 
at  Washington,  D.  C,  for  examination  for  promotion. 

Wheate,  J.  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  temporary  duty  at  Fort  Snelling,  Minn., 
and  ordered  to  return  to  his  proper  station.  Fort  Lin- 
coln, N.  D. 

Whitmore,  R  R.,  Capuin,  Medical  Corps.  Ordered  to  re- 
port at  Manila,  P.  L,  for  examination  for  promotion. 

Woodbury,  F.  T.,  Captain,  Medical  Corps.    Ordered  to  re- 
port at' San  Francisco,  Cal.,  for  examination  for  pro 
motion. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  week  ending  May  i,  igog: 
Bass,  J.  A.,  Acting  Assistant  Surgeon.    Appointed  an  act- 
ing assistant  surgeon  from  April  19,  1909. 
Blackwell,  E.  M.,  Surgeon.    Detached  from  the  Naval 

Academy  and  ordered  to  the  Chicago. 
Breck,  F.  W,  Pharmacist.    Ordered  to  the  Navy  Yard, 
Norfolk,  Va. 

BucHER,  W.  H.,  Surgeon.    Ordered  to  treatment  at  the 

Naval  Hospital,  Las  Animas,  Col. 
Clifton,  C.  L.,  Assistant  Surgeon.    Detached  from  duty  at 

the  Naval  Hospital,  Philadelphia,  Pa.,  and  ordered  to 

the  Naval  Recruiting  Station,  Cincinnati,  O. 
McDoNELL,  W.  N.,  Passed  Assistant  Surgeon.  Detached 

from  the  Naval  Academy  and  ordered  to  the  Hartford. 
Ohnesorg,  K.,  Surgeon.    Ordered  to  the  Louisiana. 
Smith,  W.  B.,  Passed  Assistant  Surgeon.    Detached  from 

the  Helena  and  ordered  to  the  Denver. 
Sutton,  D.  G.,  Assistant  Surgeon.    Detached  from  the 

Naval  Academy  and  ordered  to  the  Tonopah. 
Trotter,  C.  E.,  Acting  Assistant  Surgeon.    Appointed  an 

acting  assistant  surgeon  from  April  19,  1909. 

 ^  

lirt^s,  llarriagts,  anb  ieatfes. 


Married. 

Crowell — HoRTON. — In  New  York,  on  Saturday,  April 
24th,  Dr.  Bowman  Corning  Crowell  and  Miss  Frances 
Everett  Horton. 

Died. 

Berkaw. — In  Annandale,  New  Jersey,  on  Thursday, 
April  29th,  Dr.  W.  E.  Berkaw,  aged  fifty-two  years. 

Bryan. — In  Detroit,  Michigan,  on  Monday,  April  12th, 
Dr.  Alonzo  Bryan,  aged  sixty--four  years. 

Bryant. — In  Crewe,  Virginia,  on  Mondaj-,  April  12th, 
Dr.  J.  W.  Bryant. 

Campbell. — In  Tiffin,  Ohio,  on  Thursday,  April  22nd, 
Dr.  Alexander  Miller  Campbell,  aged  sixty-two  years. 

Caughlin. — In  Bay  City,  Michigan,  on  Tuesday,  April 
30th,  Dr.  John  W.  Caughlin. 

Cross. — In  Cobleskill.  New  York,  on  Monday,  April  26th, 
Dr.  Lemuel  Cross,  aged  seventy-five  years. 

Donovan. — In  Elizabeth,  New  Jersey,  on  Monday,  April 
26th,  Dr.  Alfred  Quinn  Donovan,  aged  fifty-five  years. 

Garvin. — In  Horse  Cave,  Kentucky,  on  Tuesday,  April 
20th,  Dr.  Thomas  H.  Garvin,  aged  sixty-seven  years. 

Hill. — In  Bethlehem,  Pennsylvania,  on  Friday,  April 
23d,  Dr.  Harry  A.  Hill,  aged  thirty  years. 

Laing. — In  Dallas,  Pennsylvania,  on  Saturday,  April  24th, 
Dr.  James  Gardner  Laing,  aged  seventy-eight  years. 

Mandeville.— In  Newark,  New  Jersey,  on  Monday,  April 
26th,  Dr.  Frederic  B.  Mandeville,  aged  sixty-nine  years. 

Metcalfe. — In  Thurso,  Quebec,  Canada,  on  Thursday, 
April  15th,  Dr.  Henry  James  Metcalfe,  aged  fifty-eight 
years. 

Pinkard. — In  Washington,  D.  C,  on  Wednesday,  April 
28th,  Dr.  Henry  Marshall  Pinkard,  aged  seventy-two  years. 

Powers. — In  Philadelphia,  on  Monday,  April  26th,  Dr. 
Michael  R.  Powers,  aged  thirty-three  years. 

Pressiv. — In  Due  West,  South  Carolina,  on  Fridav, 
April  23d,  Dr.  H.  R  Pressly. 

Taubf.l. — In  Philadelphia,  on  Monday,  April  26th,  Dr. 
Louis  Edward  Taubcl. 

Williams. — In  S.iginaw,  Michigan,  on  Thursday,  .April 
22nd,  Dr.  Harvey  Williams,  aged  sixty-three  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  ilt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


\"or..  LXXXIX.  Xo.  20.  XE\\'  YORK,  MAY  15,  1909.  Whole  Xo.  1589. 


(•Original  (tommunintions. 


THE   CLEFTS   OF   THE   AXIS    CYLINDER,  THE 
CABLE  OF  THE  NERVOUS  SYSTEM. 

By  Sir  J.\mes  Grant,  K  C.  M.  G.,  F.  R.  C.  P.,  London, 

Ottawa,  Canada, 

Consulting  Physician,   General  Hospital  and   St.    Luke's  Hospital, 
Ottawa. 

At  present  I  desire  to  place  on  record  a  few  facts, 
as  to  the  nervous  system,  which  have  been  under 
observation  for  some  years,  and  which  I  have  de- 
layed publishing  until  there  was  sufficient  time  for 
careful  investigation.  In  October,  1898,  I  first  ven- 
tured to  direct  attention  to  this  subject,  by  a  paper 
in  the  Montreal  Medical  Journal,  on  The  Alimen- 
tary Canal  and  Human  Decay,  in  Relation  to  the 
X'eurones,  and  followed  by  notes  on  Electrolysis  and 
the  Xervous  System,  in  the  Xezv  York  Medical 
Journal  of  September  14,  1907,  now  publishing 
some  data  on  the  clefts  of  the  axis  cylinder,  the 
cable  of  the  nervous  system,  in  hopes  that  connect- 
ing links,  in  the  complex  histogenetic  process,  may 
/    find  complete  solution  in  abler  hands. 

Sir  Michael  Foster  says  in  his  PJtysiology,  p. 
122 :  "So  long  as  the  nerve  is  in  a  fresh  living,  per- 
fectly normal  condition  the  medulla  appears  smooth 
and  continuous,  showing  no  marks  beyond  the 
double  contour,  but  in  nerves  removed  from  the 
body  for  examination,  and  according  to  some  ob- 
servers at  times  in  nerves  still  within  the  body, 
clefts  make  their  appearance  in  the  medulla,  run- 
ning obliquely  inward,  from  the  neurilemma  to  the 
axis  cylinder.  The  clefts  are  spoken  of  as  indenta- 
tions. ^^"e  may  conclude  that  the  changes,  making 
up  what  we  have  called  a  nervous  impulse  takes 
place  primarily,  and  chiefly  at  all  events  in  this  es- 
sential part  of  the  nerve  fibre,  the  axis  cylinder. 
Possibly  it  may  also  play  a  part,  as  an  insulator  in 
the  electric  phenomena.  It  is  along  the  axis  cylinder 
that  the  nervous  impulses  sweep." 

From  these  carefully  defined  statements,  it  is 
quite  evident,  the  author  detected  the  result  most 
likely  to  follow  clefts,  in  so  exceedingly  important  a 
structure,  as  the  axis  cylinder  the  most  essential  part 
of  nerve  fibre,  in  fact  the  very  cable  of  the  nervous 
system.  Clefts  such  as  defined,  are  the  factors,  in 
the  production  of  an  imperfect  nervous  impulse, 
amply  demonstrated  by  defective  transmission,  of 
the  electric  current,  and  such  current  reestablished 
brings  to  light  the  idea,  that  the  internal  solution 
of  conductivity,  the  highest  order,  in  the  transmis- 
sion of  nerv'e  power,  in  the  axis  cylinder,  depends 


as  to  electrical  phenomena,  on  the  organic  salts, 
which  it  contains,  and  the  change  propagated  by 
electricity,  is  the  result  of  a  dislocation  of  preexist- 
ing discrete  particles,  thus  restoring  the  continuity, 
and  conductivity,  of  the  medulla  of  the  axis  cylinder. 
Xerve  action  to  be  of  service  must  be  normal  in  its 
distribution,  so  clefts  in  the  axis  cylinder,  are  pro- 
ductive of  constitutional  troubles,  occupying  a  wide 
range  in  the  general  system.  The  marked  change 
for  the  better,  in  the  following  cases,  in  digestive 
power,  points  to  some  latent  irregularit}-,  such  as 
defined,  far  reaching  in  its  influence,  and  corrected 
by  a  clearing  up  process  of  electrolysis,  in  the  ner- 
vous system,  concerned  in  the  elaboration  of  chyme, 
from  food  products,  and  subsequent  formation  of 
blood.  The  histogenetic  action  of  the  abdominal 
gangleonic  nerve  centres  is  a  complex  problem,  and 
so  the  part  nerve  tissue  plays,  in  the  most  remark- 
able transformation,  from  food  to  blood,  the  very 
pabulum  of  life. 

A  broken  electric  wire  will  not  transmit  an  elec- 
tric message,  nor  will  a  cleft  axis  cylinder  convey  a 
normal  nervous  impulse.  The  remarkable  results  of 
the  direct  electric  current  in  the  improvement  of 
gastric  and  intestinal  digestion,  as  well  as  increased 
general  vitality  and  rapid  reduction  of  colon  disten- 
tion, give  to  this  subject  a  degree  of  attractiveness 
unsurpasse.d  in  the  whole  domain  of  physiological 
enquiry.  In  carrying  out  treatment,  great  benefit 
is  derived  in  each  case  by  vigorous  massage,  over 
the  abdomen,  with  liquid  antiseptic  soap,  prior  to 
the  application  of  an  induction  apparatus  actuated 
by  a  dry  cell.  This  form  of  massage  arouses  latent 
energy  in  the  abdominal  tissues  concerned  in  the 
digestive  process  and  blood  elaboration,  and  fol- 
lowed up  by  electricity,  the  results  are  of  the  most 
telling  and  satisfactory  character,  pointing  toward 
a  restoration  of  continuity  in  the  medulla  of  the 
axis  cylinder,  without  which,  the  well  defined  prac- 
tical results,  could  not  have  been  achieved. 

Case  I. — Lady  Superior  of  a  Convent  in  Ottawa,  aged 
seventy-nine  years,  of  thin  and  spare  conformation  of  body, 
Habby  miiscular  conditions,  no  indication  of  rheumatisni. 
and  usually  discharged  the  onerous  duties  of  her  position 
with  ease  and  comfort.  In  January,  1908.  she  had  an  at- 
tack of  bronchitis,  of  fully  six  weeks"  duration.  Owing  to 
well  defined  defective  action  in  the  gastrointestinal  mucous 
membrane,  the  result  of  imperfect  function  in  the  intestinal 
gangleonic  nervous  system,  she  was  placed  under  electrical 
treatment  January  15,  1908,  for  two  weeks,  once  daily, 
which  consisted  of  using  an  induction  apparatus  actuated 
by  a  dry  cell,  chiefly  over  the  abdominal  walls  and  extremi- 
ties, at  the  expiration  of  which  time  there  was  a  marked 
improvement  in  every  particular.  The  digestive  power  in- 
creased gradually,  there  was  rest  during  night  time,  sleep 
more  composed  and  reg^ular,  entire  absence  of  her  usual 
headache,  pulse  regular,  uniform,  and  increased  in  volume, 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


982 


B'CLL:  OPHTHALMIA  NEONATORUM. 


[New  York 
Medical  Journal. 


respiration  normal,  and  a  general  well  defined  increase  in 
the  activity  of  the  muscular  system,  tongue  clean,  and  food 
relished.  At  the  end  of  t.he  second  week,  the  face  and 
hands  showed  quite  a  change  from  their  former  exsanguine 
color,  indicating  vessels  well  filled  with  blood,  and  increased 
coloration  of  these  parts.  At  the  end  of  the  fourth  w;eek. 
she  enjoyed  a  walk  in  the  open  air,  and  about  the  sixth 
week  entered  quietly  into  her  usual  scholastic  duties,  with 
e\ery  evidence  of  increased  activitj',  feeling  like  her  usual 
self.  Marked  reduction  in  distended  colon,  so  evident  dur- 
ing my  first  visit.    Reflexes  normal. 

Case  II. — R.  F.,  farmer,  aged  fifty-four,  tall,  well  formed,  and 
usually  of  robust  habit  of  body.  For  fully  five  years  he  had 
experienced  difficult  digestion,  accompanied  by  excessive 
flatus  in  stomach  and  bowels ;  no  pain,  but  a  sense  of 
smothering  and  faintness  at  times.  Bowels  were  distended, 
usually  sluggish,  but  responded  to  salines.  For  fully  a  year 
he  had  suffered  from  marked  falling  off,  in  strength,  with 
lessened  activity  of  muscular  system,  associated  with  dizzi- 
ness, and  occasional  palpitation,  not  the  outcome  of  or- 
ganic disease,  but  rather  the  result  of  a  want  of  plasticity 
in  the  normal  power  of  the  blood.  Urine  was  voided  in 
normal  quantity,  but  sleep  was  restless  and  defective.  There 
was  no  evidence  whatever  of  organic  disease,  the  disturb- 
ance of  the  digestive  functions  resulting  from  inactivity  in 
the  ganglionic  nerve  centres  supplying  those  parts ;  reflexes 
were  generally  normal. 

On  May  10,  1908,  he  was  placed  under  the  electrical  treat- 
ment daily  until  June  12,  1908.  The  acuteness  of  nervous 
sensation  over  the  entire  body  was  quite  restored,  together 
with  a  most  marked  activity  in  digestive  power ;  he  rested 
well  at  night ;  had  no  pain  or  uneasiness  in  abdomen,  bow- 
els became  regular  and  were  much  reduced  as  to  distention ; 
action  of  skin  more  normal ;  in  fact  he  felt  as  well  as  dur- 
ing any  period  of  his  life,  and  quite  equal  to  his  usual 
lumber  duties. 

Case  III. — D.  S.,  farmer,  aged  seventy-eight  years,  usual- 
ly enjoyed  good  health,  and  no  indication  of  organic  dis- 
ease. Two  years  ago  he  experienced  difficulty  in  digesting 
food;  no  vomiting,  but  frequent  attacks  of  flatulence,  and 
sense  of  uneasiness  in  the  bowels,  attended  by  diarrhoea. 
The  general  strength  of  his  system  failed  rapidly,  declining 
in  weight  from  190  pounds  to  150  pounds  in  a  few  months. 
Sleep  was  restless,  and  frequent  attacks  of  dizziness,  and 
marked  lassitude. 

On  May  21,  1908,  he  was  placed  under  electric  treatment. 
Percussion  over  the  abdomen  gave  undoubted  evidence  of 
greatly  distended  colon,  the  outcome  of  gases,  from  the  im- 
perfect assimilation  of  food  products.  The  acuteness  of 
cutaneous  nervous  sensibility,  in  legs  and  abdomen  at  first 
defective,  was  gradually  restored. 

June  i6th :  Digestive  power  normal,  rested  well  at  night, 
diarrhoea  entirely  absent,  walked  vigorously,  and  in  every 
particular  felt  like  himself  of  forty  years  ago. 

Case  IV. — Reverend  T.  C.  B.,  aged  thirty-five  years,  usu- 
ally of  vi.gorous  habit  of  body,  and  generally  enjoying  ex- 
cellent health,  until  February,  1905.  when  loss  of  appetite, 
with  a  sense  of  lassitude  and  insomnia  gradually  supervened, 
marked  by  incapacity  for  ministerial  duties.  About  March, 
1908,  he  experienced  difiiculty  in  digesting  food,  associated 
with  a  feeling  of  mieasmess  in  the  stomach.  No  nausea  or 
vomiting,  but  inability  to  sleep,  for  more  than  an  hour  or 
so  at  a  time.  Xo  pain  in  stomach,  but  a  sense  of  pressure, 
from  accumulation  of  gas.  Bowels  confined,  but  responded 
to  salines.  Falling  off  in  weight  20  pounds  in  three  months. 
Feeling  of  depression  and  languor.  Tongue  coated  and 
frequent  eructation  of  gas.  Little  desire  for  food,  and 
only  for  liquid  material,  drinking  largely  of  water.  Urine 
normal,  also  the  reflexes,  with  marked  distension  of  colon. 

On  July  20,  1908,  he  was  placed  under  daily  electrical 
treatment  over  the  abdominal  region,  particularly  the  blood 
making  gangleonic  centre.  At  first  the  superficial  cutaneous 
abdominal  nerves  responded  indifferently  to  the  electric  cur- 
rent, b'.it  after  ti  e  fourth  application  the  sensation  became 
quite  acute,  and  continued  so,  until  the  twelfth  application, 
at  which  the  entire  nervous  power  and  tone  were  quite  re- 
stored. Gradually  the  digestion  became  active  and  vigorous, 
and.  as  usual,  attended  by  a  return  of  normal  mental  equi- 
librium, marked  also  by  regular  and  uninterrupted  sleep. 
Tongue  quite  clean,  pulse  and  temperature  normal,  also  en- 
tire reflexes. 

.August  1.3th  :  At  present  he  feels  quite  restored  in  health, 
and  in  every  way  equal  to  his  usual  duties. 


Directions  for  the  Electrical  Treatment.. 

1st.  Moisten  the  skin  of  the  abdomen  with  warm 
water,  and  a  sponge,  before  applying"  the  electrical 
current,  to  the  space,  midway  between  the  hip  crest 
and  the  last  rib,  about  three  inches  to  the  right  of 
the  navel ;  this  application  to  continue  about  ten 
minutes.  Afterward  pass  the  current  mildly  over 
the  entire  abdomen,  for  five  minutes  and  dry  the 
surface  carefully,  after  each  application. 

2nd.  Moisten  each  leg,  from  the  knee  to  the 
ankle,  and  apply  the  current  freely,  for  five  minutes 
to  each  leg  and  dry  carefully.  The  object  in  A'iew, 
in  the  application  of  the  current  to  the  extremities, 
is  to  arouse  increased  nervous  activity  in  the  termin- 
als of  the  sciatic  and  saphenous  nerves,  and  their 
varied  communications,  in  the  pelvic  and  abdominal 
regions,  accessories,  to  the  remarkable  histogenetic 
spaces,  where  is  produced  the  very  pabttlum  of  life. 

These  applications  will  be  repeated  each  day,  at 
bed  time,  for  two  weeks,  and  repeated  once  or  twice 
afterwards,  each  week,  for  three  or  four  weeks, 
should  any  evidence  of  the  weakness  continue.  No 
application  of  the  treatment  should  be  made  less  than 
two  hours  after  a  meal.  Before  the  application  of 
the  electrical  current  drop  fifteen  or  twenty  drops  of 
liqttid  atitiseptic  soap  over  the  navel,  and  use  vig- 
orous massage  for  ten  minutes,  over  the  entire  ab- 
domen, with  open  hand,  placed  in  warm  water,  and 
then  dry  carefully.  This  massage  to  take  place  be- 
fore each  application  to  the  abdomen  of  the  current. 
In  no  case  where  any  form  of  paralysis  is  in  evi- 
dence, should  electricity  be  used  as  such  is  contrain- 
dicated.  Close  attention  to  diet  and  freedom  from 
alcohol  are  important  factors  in  the  prolongation  of 
life. 

150  Elcix  Street. 


OPHTHALMIA  NEONATORUM  AND  ITS  PROPHY- 
LAXIS. FROM  THE  STANDPOINT  OF  THE 
OPHTHALMOLOGIST.* 

Bv  Charles  Stedman  Bull,  A.  M.,  M.  D., 
New  York. 

Ophthalmia  neonatorum,  or  conjunctivitis  of  the 
newly  born  infants,  is  an  inflammation  of  the  con- 
junctiva, characterized  by  great  swelling-  and  discol- 
oration of  the  eyelids,  serous  infiltration  or  oedema 
of  the  ocular  conjunctiva,  ulceration  and  abscess  of 
the  cornea,  and  the  free  discharge  of  contagious  pus. 
It  is  a  fonn  of  purulent  conjunctivitis,  distinctive 
in  its  origin,  disastrous  in  its  results  if  left  to  it- 
self, and  particularly  important  as  to  its  specific 
prophylaxis  and  treatment. 

jEtiology.  It  is  caused  by  the  introduction  into 
the  infant's  eyes  of  the  infecting  material  from  some 
portion  of  the  genitourinary  tract  of  the  mother  dur- 
ing the  act  of  parturition  or  shortly  after.  The  ma- 
jority of  all  the  cases,  and  all  the  severe  cases,  are 
caused  by  a  special  microorganism,  the  gonococcus. 
in  some  cases  associated  with  the  streptococcus  and 
other  organisms.  There  are  two  forms  of  ophthal- 
mia neonatorum  to  be  recognized.  First,  the  severe 
type,  always  caused  by  the  gonococcus  and  forming 

•Read  before  the  American  Society  of  Sanitary  and  Moral 
Prophylaxis,  April  8,  1909. 


May  IS,  1909.] 


BULL:  OPHTHALMIA  NEONATORUM. 


983 


the  great  majority  of  the  cases,  developing  with 
great  rapidity  and  severity,  and  tending  to  in- 
volve the  cornea;  and  second,  a  milder  type,  non- 
specific as  to  the  gonococcus,  which  may  be  caused 
by  various  other  microorganisms ;  and  this  milder 
type  has  a  tendency  to  recover  without  destroying 
the  sight. 

The  exact  time  of  inoculation  cannot  be  accur- 
ately determined,  but  it  may  occur  at  any  moment 
after  the  rupture  of  the  intrauterine  enveloping 
membranes.  The  symptoms  usually  begin  within 
the  first  forty-eight  hours  after  birth,  but  the  disease 
may  set  in  as  earh-  as  twelve  or  twenty-four  hours 
after  birth,  and  in  cases  of  delayed  labor,  has  been 
known  to  be  well  advanced  before  the  actual  birth 
of  the  child.  In  not  a  few  cases,  children  have 
been  born  with  the  cornea  of  both  eyes  already  far 
advanced  in  destruction. 

In  the  true  gonococcic  cases  the  symptoms  de- 
velop with  great  rapidity.  There  is  a  distinct  rise 
of  temperature,  enormous  swelling  of  the  lids,  great 
chemosis  and  congestion  of  the  conjunctiva,  and  the 
constant  discharge  of  pus.  As  the  chemosis  of  the 
ocular  conjunctiva  increases,  the  bloodvessels  and 
lymphatics  become  strangulated,  the  nutrition  of  the 
cornea  is  impaired,  the  protecting  epithelium  is  cast 
ofl^,  an  abscess  forms  in  the  cornea,  the  whole  cornea 
becomes  infiltrated,  ruptures,  and  may  be  cast  oft 
as  a  slough ;  the  contents  of  the  eyeball  are  evacu- 
ated, and  the  eye  is  destroyed.  This  entire  chain  of 
symptoms  I  have  seen  occur  within  twenty-four 
hours.  Then  the  disease  begins  to  subside,  the 
swelling  of  the  lids  diminishes  so  that  they  can  be 
everted,  the  discharge  becomes  less  purulent  and 
more  a  mixture  of  blood  and  serum,  and  gradually 
in  from  six  to"  eight  weeks  the  discharge  ceases. 
The  conjunctiva,  however,  remains  thickened  and 
granular  for  several  weeks  and  usually  ends  in  real 
cicatricial  tissue.  If  the  cornea  perforates  but  does 
not  slough,  a  scar  forms,  composed  of  the  tissues  of 
the  cornea,  iris,  and  lens,  which  gradually  yields  to 
the  continuous  pressure  of  the  intra-ocular  tension, 
and  the  scar  tissue  bulges  forwards  and  forms  an 
anterior  staphyloma,  and  in  some  instances  becomes 
so  prominent  as  to  protude  between  the  closed  lids. 
In  these  severe  cases,  restlessness,  fever,  and  other 
constitutional  symptoms  are  present,  and  I  have 
known  synovitis  of  the  knees,  wrists,  and  ankles  to 
occur  in  the  course  of  the  disease,  or  after  it  has 
subsided,  just  as  it  does  in  the  gonorrhoea!  conjunc- 
tivitis of  adults,  proving  the  systemic  as  well  as  local 
nature  of  the  disease.  Usually  both  eyes  are  in- 
volved, but  not  always  to  the  same  extent. 

In  the  milder  form  of  the  disease,  the  specific 
gonococcus  being  absent,  the  symptoms  are  much 
less  severe,  the  cornea  is  rarely  involved,  the  dura- 
tion of  the  disease  is  much  shorter,  and  the  vision 
is  rarely  permanently  damaged  and  never  destroyed. 
The  severe  type  of  the  disease  is  so  typical  in  its 
symptoms  and  course,  that  it  is  not  possible  to  make 
a  mistake  in  diagnosis.  In  any  inflammation  of  the 
eyes  of  infants,  no  matter  how  trivial,  bacteriologi- 
cal examination  of  the  secretion  should  at  once  be 
made,  and  the  findings  will  indicate  its  true  nature. 

Prognosis.  In  all  the  cases  of  the  severe  type, 
the  prognosis  is  always  grave,  even  when  the  case 
is  properly  treated.    Unfortunately  in  too  many  of 


the  cases  among  the  poor,  no  medical  advice  is 
sought  until  it  is  too  late,  and  attempts  at  prophy- 
laxis are  rarely  if  ever  made.  The  attendants  of 
newborn  children  should  be  compelled  by  law  to  seek 
medical  advice  as  soon  as  any  eye  symptoms  appear. 

In  the  mild  type  of  the  disease,  if  properly  cared 
for,  the  prognosis  as  to  vision  is  favorable.  It  is 
not  claimed  that  every  case  of  ophthalmia  neona- 
torum is  gonorrhoeal  in  nature,  for  the  gonococcus 
is  not  always  found.  All  the  pathological  discharges 
from  the  vagina  of  the  mother  are  likely  to  cause 
a  purulent  inflammation  of  the  conjunctiva  in  in- 
fants, and  while  a  severe  inflammation  occasionally 
arises  from  other  causes  than  the  gonococcus,  the 
presence  of  the  latter  should  always  be  suspected. 

That  the  infection  comes  from  the  vagina  of  the 
mother  almost  without  exception,  is  proved  by  the 
results  of  the  measures,  which  have  been  instituted 
for  its  prevention  and  cure ;  the  success  of  which  is 
one  of  the  greatest  triumphs  of  modern  scientific 
medicine. 

We  can  state  that  almost  absolute  prevention  of 
this  disease  is  possible,  if  the  directions  are  proper- 
ly carried  out.  Think  what  this  would  mean.  We 
know  from  carefully  computed  statistics  by  respon- 
sible men  in  the  various  civilized  countries  of  the 
world,  that  more  than  one  quarter  of  the  cases  of 
blindness  in  the  world  at  the  present  time  is  caused 
by  ophthalmia  neonatorum.  Aside  from  the  purely 
humanitarian  standpoint,  this  has  a  distinct  eco- 
nomic bearing,  for  the  blind  person  is  so  handi- 
capped for  life,  that  instead  of  becoming  a  producer, 
he  becomes  with  rare  exceptions  a  charge  upon  the 
community.  The  loss  to  the  commonwealth  from 
this  cause  alone  is  enormous,  for  at  the  last  census, 
there  were  about  sixty  thousand  blind  in  the  United 
States,  and  of  these  blind  persons,  the  percentage  of 
blindness  due  to  ophthalmia  neonatorum  varied 
from  fifteen  to  fifty  per  cent.  Comparing  the  aver- 
age cost  of  maintenance  per  year  of  a  single  indi- 
vidual in  one  of  our  asylums  with  the  average  net 
earnings  of  an  able  bodied  individual  for  the  same 
period,  it  has  been  estimated  that  the  total  loss  to 
the  United  States  from  the  ravages  of  this  disease 
reaches  the  sum  of  $7,000,000  annually. 

So  much  for  the  economic  side  of  the  question. 
For  the  humanitarian  side  much  more  can  be  said, 
and  the  first  question  that  naturally  arises  is,  ^^'hat 
can  we  do  to  prevent  it?  Here  scientific  medicine 
comes  to  our  aid,  and  let  it  be  remembered  that 
modern  scientific  medicine  is  essentially  prcientiz-e 
medicine. 

This  disease  is  one  of  infection,  and  we  know  ab- 
solutely its  cause  and  its  source.  The  infection 
comes  from  the  vagina  of  the  mother,  and  its  cause 
is  the  gonococcus.  As  before  mentioned,  it  is  not 
to  be  asserted  that  everv  case  of  ophthalmia  neona- 
torum is  of  gonorrhoeal  origin,  but  all  discharges 
from  the  vaginal  passages  of  the  mother  which  are 
pathological,  may  cause  a  purulent  inflammation  in 
the  conjunctiva  of  infants  of  a  destructive  type. 
The  gonococcus  does  not  seem  to  be  essential  for 
virulence  and  destructiveness,  but  its  presence 
should  always  be  suspected  and  dilisrently  searched 
for.  It  has  been  alleged  that  absolute  prevention 
of  this  disease  is  possible  in  every  case,  and  that 
with  proper  precaution,  there  need  never  be  another 


BL'l.L:   OPHTHALMIA  NEONATORUM. 


LNew  York 
Medical  Journal. 


case  of  destructive  ophthalmia  neonatorum.  This 
is  going  too  far,  for  even  with  the  most  rigid  pre- 
cautions in  the  hands  of  skilled  observers,  some 
cases  may  stil)  deveop ;  but  the  severity  of  the  symp- 
toms can  be  modified,  the  duration  cut  short,  and 
the  destruction  of  the  eyes  positively  prevented. 

The  prophylactic  or  preventive  treatment  of  oph- 
thalmia neonatorum  was  first  suggested  and  carried 
out  by  Professor  Crede,  of  Leipzig,  in  1882,  and  all 
honor  should  be  accorded  him  for  the  persistence 
with  which  he  has  urged  the  method  on  the  medical 
profession  and  on  the  laity.  The  tremendous  im- 
portance of  this  subject  may  be  appreciated  when  it 
is  remembered  that  a  large  proportion  of  all  causes 
of  blindness  operate  only  in  adult  life  or  in  old  age, 
while  this  disease  entails  blindness  from  birth. 

Previous  to  the  introduction  of  Crede's  method  of 
prophylaxis,  the  number  of  cases  of  ophthalmia 
neonatorum  occurring  in  cases  ,of  confinement  in 
lying  in  hospitals  and  asylums  varied  from  four  to 
nineteen  per  cent.  Since  that  time,  in  those  institu- 
tions in  which  the  method  of  Crede  has  been 
promptly  begun  and  thoroughly  carried  out,  the  per- 
centage has  been  reduced  to  0.2  per  cent.,  and  even 
this  small  percentage  may  possibly  be  due  to  neglect 
or  carelessness  on  the  part  of  the  attendant. 

In  W'idmark's  statistics  in  Stockholm,  while  the 
percentage  of  cases  after  the  introduction  of  the 
Crede  method  only  fell  from  1.2  to  0.2  per  cent., 
the  number  of  cases  of  corneal  complication  fell 
from  thirty  to  six  per  cent. 

In  Kosling's  statistics  of  17,000  cases  of  births 
in  which  no  preventive  measures  were  used,  there 
occurred  9.2  per  cent,  of  cases  of  ophthalmia  neo- 
natorum. In  a  second  series  of  24,000  births  in 
which  the  Crede  method  was  employed,  the  number 
of  cases  of  ophthalmia  was  only  0.65  per  cent. 

The  various  steps  in  the  preventive  treatment  in- 
troduced by  Professor  Crede  are  as  follows :  For 
several  days  before  the  expected  confinement,  the 
vaginal  passages  of  the  woman  are  carefully  irri- 
gated by  some  antiseptic  solution  preferably  mer- 
curic bichloride,  in  order  to  remove  as  far  as  possi- 
ble all  infectious  secretions.  It  is  not  possible  to 
render  these  passages  thoroughly  aseptic,  but  they 
can  be  made  relatively  so.  As  soon  as  the  child  has 
been  born,  the  face  and  scalp  should  be  cleansed 
with  sterilized  water,  especially  about  the  eyelids. 
The  eyelids  should  then  be  opened  and  one  drop  of 
a  two  per  cent,  solution  of  silver  nitrate  should  be 
dropped  into  each  eye  from  an  aseptic  dropper  or 
a  glass  rod.  But  little  reaction  usually  follows,  but 
should  it  occur,  it  can  be  readily  controlled  by  cold 
compresses  soaked  in  a  two  per  cent,  solution  of 
boric  acid  or  salicylic  acid.  If  these  precautions  arc 
adopted,  the  disease  will  generally  be  prevented. 

So  grave  a  calamity  is  blindness  from  purulent 
conjunctivitis,  that  the  use  of  this  precautionary 
method  has  been  urged  at  the  birth  of  every  child. 
P.ut  we  should  go  slow  in  absolutely  recommending 
the  universal  application  of  this  method,  for  in  the 
hands  of  ignorant,  dirty,  and  careless  midwives,  it 
might  do  harm  in  unsuitable  cases.  It  should,  how- 
ever, be  borne  in  mind  and  resorted  to  wlienever 
there  is  a  probability  that  the  mother  is  infected 
with  gonorrhoea.  This  can  readily  ix-  settled  in  every 
case  by  making  a  bacteriological  test  of  the  vaginal 
secretions  before  the  birth. 


It  is  a  most  significant  fact  that  since  a  full 
knowledge  of  this  method  has  been  disseminated 
among  the  members  of  the  medical  profession, 
wherever  statistics  have  been  kept,  there  has  been 
a  most  marked  diminution  in  the  number  of  cases 
of  the  disease. 

It  is,  therefore,  the  manifest  duty  not  only  of 
ophthalmic  surgeons  and  obstetricians,  but  of  every 
member  of  the  medical  profession,  to  use  every 
means  in  their  power  to  extend  among  the  laity  of 
all  classes,  and  especially  among  the  poor,  in  whose 
families  the  disease  is  met  with  most  frequently,  a 
knowledge  of  the  danger  to  the  eyes  of  newborn  in- 
fants from  this  disease,  and  to  rid  them  of  the  idea 
that  it  is  merely  a  simple  "cold  in  the  eyes,"  and 
prevent  their  resorting  to  manifold  household  reme- 
dies, such  as  a  little  breastmilk,  or  a  tealeaf  poultice, 
or  worst  of  all,  washing  out  the  eyes  of  the  infant 
with  urine  from  the  infected  mother. 

This  is  a  matter  which  concerns  the  state  in  an 
important  degree,  and  is  very  properly  a  subject  for 
legislation.  Most  of  the  European  governments  re- 
quire by  law  the  reporting  of  all  cases  of  ophthal- 
mia neonatorum  to  the  constituted  authorities. 
Many  of  our  own  States  have  passed  laws  making 
the  report  of  cases  of  this  disease  compulsory.  But 
it  is  not  enough  to  pass  such  laws ;  we  must  see  that 
the  laws  are  enforced  with  stringency,  and  the  pen- 
alty for  failure  to  comply  with  the  requirements  of 
the  statute  should  be  a  heavy  fine,  and  in  case  of 
a  second  violation  of  the  law  by  midwives,  their 
license  should  be  revoked.  Such  laws,  when  enacted, 
should  bring  all  cases  of  ophthalmia  neonatorum,  as 
soon  as  they  occur,  imder  the  care  of  some  person 
competent  to  treat  them.  Moreover,  in  addition  to 
general  legislation,  it  is  necessary  that  the  laity  be 
thoroughly  informed  of  the  dangers  of  a  disease 
which  too  many  of  them  have  been  accustomed  to 
regard  as  simple  and  harmless.  All  charitable  insti- 
tutions and  organizations  which  have  to  deal  with 
women  about  to  become  mothers,  or  with  those  hav- 
ing the  care  of  infants,  should  keep  the  women  in- 
formed of  the  necessity  of  carefully  watching  the 
eyes  of  newly  born  infants,  and  of  the  need  not  only 
of  calling  in  a  physician  as  soon  as  any  symptoms 
appear,  but  also  of  the  wisdom  of  taking  precaution- 
ary measures  such  as  those  of  the  Crede  method. 
This  plan  of  prophylaxis  is  at  once  simple,  safe,  and 
inexpensive,  and  if  universally  employed,  would 
have  saved  the  eyes  of  many  thousand  children,  who 
because  of  this  neglect  have  passed  their  lives  in 
darkness.  There  is  no  doubt  that  through  the  un- 
ceasing efforts  made  by  physicians  during  the  past 
few  years,  the  number  of  cases  of  infection  due  to 
this  cause,  and  the  amount  of  blindness  resulting 
from  this  infection,  has  been  greatly  diminished. 
But  very  many  cases  occur  with  the  most  diastrous 
results,  which  are  never  seen  by  physicians,  but  are 
cared  for  by  midwives.  and  we  only  become  aware 
of  their  existence  when  statistics  are  sought  as  to 
the  cause  of  blindness.  Moreover,  there  seems  to 
have  been  no  concerted  eflfort  in  the  past  on  the  part 
of  the  health  authorities  to  determine  just  how  fre- 
quently the  infection  occurs,  under  what  conditions 
it  may  be  looked  for,  or  how  the  eyes  of  the  new- 
born infant  may  be  adequately  protected. 

We  have  entered  upon  a  campaign  of  education 
which  must  be  loyally  carried  out.    The  first  essen- 


.\i:iy   15.  1909.] 


BULL:   OPHTHALMIA  NEONATORUM. 


tial  in  any  movement  of  this  kind  is  to  bring  about 
a  public  understanding  of  the  conditions,  and  secure 
the  sympathy  and  assistance  of  the  people  in  our 
endeavors  to  carry  it  out.  One  powerful  means  of 
developing  watchfulness  and  care  is  the  publication 
in  health  bulletins  of  the  dangers  of  infantile  oph- 
thalmia, and  the  possibility  of  its  prevention.  Then 
it  is  all  important  to  fix  on  an  effective  and  satis- 
factory antiseptic,  which  can  be  used  even  by  un- 
skilled hands  without  causing  damage.  My  own 
experience  has  taught  me,  that  except  where  the 
disease  already  exists,  a  two  per  cent,  solution  of 
silver  nitrate  is  too  irritating  and  is  likely  to  cause 
what  is  known  as  "silver  catarrh."  After  a  very 
large  experience,  I  now  recommend  a  one  per  cent. 
solution,  as  nonirritating  and  at  the  same  time  an 
effective  bactericide.  This  solution  can  be  employed 
by  inexperienced  physicians  and  ignorant  midwives 
with  perfect  safety. 

Another  step  in  the  campaign  of  education  is  to 
inform  prospective  mothers  and  others  of  the  dan- 
ger which  threatens  the  eyes  of  the  newborn  child, 
from  which  they  can  be  protected  by  the  use  of  the 
prophylactic,  and  thus  induce  them  to  seek  and  de- 
mand its  use. 

Still  another  step  in  this  campaign  is  to  teach  not 
only  the  laitv  but  the  medical  profession  that  the 
prophylaxis  of  the  disease  rests  with  the  obstetrician 
or  midwife.  The  case  is  brought  to  the  notice  of 
the  ophthalmologist  only  after  irreparable  damage 
has  been  done.  The  physician  attending  at  the  birth 
needs  explicit  advice  as  to  the  proper  employment 
of  the  prophylactic,  and  this  advice  is  still  more 
necessary  in  the  case  of  midwives,  who  from  igno- 
rance or  carelessness  are  often  afraid  to  apply  any- 
thing to  the  baby's  eyes  without  exact  information 
as  to  its  necessity,  and  explicit  directions  as  to  the 
method  of  use.  These  midwives  should  all  be  in- 
structed by  printed  leaflets  for  each  in  her  own  lan- 
guage, telling  how  to  manage  the  child's  head  to 
keep  infection  out  of  the  eyes.  They  should  be  sup- 
plied with  the  prophylactic,  with  directions  as  to  its 
use.  They  should  be  compelled  by  law  to  report  the 
condition  of  the  eyes,  when  they  report  the  birth. 
This  should  also  be  done  by  all  practising  physi- 
cians, at  the  same  time  stating  what  prophylactic 
was  used. 

The  birth  certificates  should  also  serve  to  advise 
all  whose  duty  it  is  to  record  births,  of  the  possible 
danger  to  the  eyes  of  the  infant,  and  the  means  of 
protecting  them. 

In  1906  the  American  Medical  Association  took 
up  the  subject,  and  a  committee  was  appointed  for 
the  purpose  of  determining  and  putting  in  practice 
such  methods  as  would  put  a  stop  to  the  pestilence, 
and  this  committee  is  still  working  to  secure  in 
every  State  the  combined  efiforts  of  the  medical  pro- 
fession and  the  public  health  authorities.  The 
recommendations  of  the  Committee  on  Ophthalmia 
Neonatorum  of  the  American  Medical  Association 
are  as  follows : 

1st.  The  enactment  of  laws  in  each  State  or  Territory 
requiring  the  registry  of  births,  and  placing  the  supervisory 
control  and  licensing  of  midwives  in  the  hands  of  the 
hoards  of  health,  requiring  that  all  midwives  be  examined 
and  registered  in  each  county,  and  that  they  be  required  to 
report  immediately  each  case  of  ophthalmia  occurring 
under   their   ministrations,   under   penalty   of  neglect,  if 


found  guilty,  of  a  fine,  and  for  a  subsequent  ofifense,  for- 
feiture of  license. 

2d.  The  distribution  by  health  boards  through  bulletins 
and  otherwise,  of  circulars  of  advice  to  midwives  and 
mothers,  giving  instruction  as  to  the  dangers,  methods  of 
infection,  and  the  prophylaxis  of  ophthalmia  neonatorum. 

3d.  The  preparation  and  distribution  by  the  health  boards 
of  ampoules  or  other  receptacles  containing  the  prophy- 
lactic, with  specific  directions  for  its  use. 

4th.  The  maintenance  of  proper  records  in  all  maternity 
institutions  and  other  hospitals  in  which  children  are  bom, 
of  the  number  of  cases  of  ophthalmia  neonatorum,  with 
the  methods  of  treatment  and  results.  These  reports  should 
be  filed  at  regular  intervals  with  the  Department  of  Public 
Health,  and  the  records  published. 

5th.  Periodic  reports  to  boards  of  health  by  all  physi- 
cians engaged  in  obstetrics  of  the  number  of  cases  of 
ophthalmia  neonatorum  which  have  occurred  in  their  prac- 
tice within  a  specified  time ;  whether  or  not  a  prophylactic 
was  used ;  if  so,  what  remedy,  together  with  the  result. 

Through  the  efiforts  of  Dr.  F.  Park  Lewis,  chair- 
man of  the  committee  of  the  American  Medical  As- 
sociation, assisted  by  Dr.  Herman  J.  Boldt  and  Dr. 
Charles  Stedman  Bull,  members  of  this  cominittee 
for  the  State  of  New  York,  the  subject  has  been 
brought  before  each  District  Branch  of  the  New 
York  State  Medical  Society,  and  the  recommenda- 
tions of  the  Committee  of  the  American  Medical  As- 
sociation have  been  endorsed,  'and  referred  to  each 
county  society  in  the  State  for  its  action.  It  has 
been  urged  on  the  county  societies  that  the  organ- 
ized work  in  controlling  these  conditions  be  taken 
up,  and  that  all  sanitary  ineasures  suggested  be 
considered  and  carried  out.  Further  that  it  be 
shown  that  the  use  of  the  prophylactic  is  a  protection 
to  the  physician,  as  the  failure  to  employ  it  lays  hiin 
open  to  censure.  It  is  also  urged  that  each  county 
society  endeavor  to  secure  the  written  assurance  on 
the  part  of  each  member  that  he  will  use  some 
prophylactic  in  all  cases  under  his  charge,  unless 
there  should  be  some  special  reason  for  not  doing 
so,  and  that  these  appear  recorded  on  the  birth  cer- 
tificate. 

In  this  State  we  need  a  more  stringent,  enforce- 
ment of  the  laws  regulating  the  practice  of  midwif- 
ery, and  especially  the  reporting  of  cases  of  oph- 
thahrJa  neonatorum.  In  this  city,  the  Board  of 
Health  requires  all  physicians  to  report  all  cases  of 
ophthalmia,  and  prophylactics  are  provided  by  the 
Health  Department  for  gratuitous  distribution.  But 
there  is  no  law  providing  for  the  early  registration 
of  birth  certificates,  and  no  inquiry  is  made  on  the 
birth  certificates  whether  a  prophylactic  has  been 
employed,  or  when  omitted,  the  reasons  for  its  omis- 
sion. 

One  of  the  encouraging  signs  that  this  campaign 
for  education  has  already  produced  some  efifect  is 
the  awakening  of  the  public  to  the  importance  of 
public  health  work,  as  evidenced  by  the  willingness 
on  the  part  of  certain  philanthropic  associations  to 
cooperate  with  the  Department  of  Health  in  its  cam- 
paign for  the  prevention  of  blindness  in  infants.  The 
New  York  Association  for  the  Blind  has  appointed 
a  special  committee,  the  object  of  which  is  to  ascer- 
tain the  direct  causes  of  preventable  blindness,  and 
to  take  such  measures  in  cooperation  with  the  medi- 
cal profession  and  the  health  authorities,  as  may 
lead  to  the  elimination  of  such  causes.  The  chair- 
man of  this  cominittee,  Mr.  P.  Tecumseh  Sherman, 
has  drawn  a  bill,  entitled  "An  act  to  amend  the 


986 


EDGAR:  PREVENTABLE  BLINDNESS. 


[New  York 
Medical  Journal. 


public  health  laws,  relating  to  vital  statistics,"  which 
has  been  introduced  in  the  Assembly,  and  referred 
to  the  Committee  on  Public  Health.  Every  mem- 
ber of  the  Senate  and  Assembly  has  been  written 
to,  and  many  of  them  personally  interviewed  on  the 
subject.  This  part  of  the  campaign  must  be  dili- 
gently kept  up  until  the  bill  has  passed  both  houses 
of^the  Legislature,  and  has  come  before  the  gov- 
ernor for  his  approval. 
47  West  Thirty-sixth  Street. 


PREVENTABLE  BLINDNESS  FROM  THE  STAND- 
POINT OF  THE  OBSTETRICIAN.* 

By  J.  Clifton  Edgar,  M.  D., 
New  York. 

No  doubt  some  medical  and  lay  members  of  this 
society  upon  receiving  the  programme  for  this  even- 
ing remarked  '"What!  Preventable  blindness  again, 
surely  the  last  word  has  been  said  upon  the  subject 
of  ophthalmia  neonatorum." 

To  the  medical  man  unfamiliar  with  the  present 
status  of  the  subject  the  questions  naturally  suggest 
themselves :  "Why  all  this  agitation  about  ophthal- 
mia neonatorum  ?  Why  national,  State,  county,  and 
local  committees  in  the  past  three  years  to  recon- 
sider this  subject?  Why  should  it  occupy  so  much 
time  of  medical  congresses  and  societies?  Why  of 
so  much  importance  that  at  the  present  moment  a 
movement  is  on  foot  to  call  a  special  International 
Congress  on  Preventable  Blindness  in  Washington 
in  1910?  Why  are  the  medical  journals  teeming 
with  articles  and  discussions  upon  this  subject? 
Why  are  individuals  devoting  years  of  their  life  to 
propaganda  for  the  prevention  of  this  unnecessan' 
waste  of  human  eyes?" 

Did  not  the  Leipsic  obstetrician,  Carl  S.  F.  Crede, 
twenty-nine  years  ago  give  to  the  world  practically 
a  sure  prophylactic  against  blindness  having  its 
origin  at  birth — at  once  safe,  simple,  and  inex- 
pensive?  Yes,  he  did. 

Did  not  the  employment  of  the  two  per  cent, 
solution  of  silver  nitrate,  as  recommended  by  Crede, 
in  the  year  1880,  reduce  the  percentage  of  birth  eye 
inflammation  from  percentages  ranging  between  7.6 
and  13.6  to*  0.5?   Yes,  all  true. 

Is  it  not  true  to-day  that  when  some  solution  of 
silver,  whether  the  nitrate,  argyrol,  or  protargol,  is 
properly  used  in  maternity  hospitals,  the  proportion 
of  cases  of  infant  eye  inflammation  approaches  the 
vanishing  point?   Yes,  this  is  also  true. 

But  it  is  further  true  that  of  the  new  pupils  ad- 
mitted into  ten  of  the  principal  schools  for  the  blind 
of  this  country  during  the  year  1907,  the  percent- 
ages of  those  who  had  lost  their  sight  from  opthal- 
mia  of  the  newly  born  ranged  from  9.83  to  42.80 
or  an  average  for  the  ten  schools  of  25.21,  as  vic- 
tims of  ophthalmia  of  the  newly  born.  One  quarter 
of  the  new  pupils  admitted  during  1907  were  there- 
fore needlessly  blind. 

These  figures  were  obtained  for  the  report  of  the 
Committee  on  Ophthalmia  Neonatorum  of  the  Amer- 
ican Medical  Association  of  June.  igo8. 

The  report  of  the  Pennsylvania  School  for  the 

•Rrad  before  tlic  .^merican  Society  of  Sanitary  and  Moral  Prophy- 
laxis, .\pril  8,  1909. 


Blind  for  the  eight  years  from  1900  to  1907,  shows 
that  the  percentage  of  pupils  admitted  each  year, 
who  had  lost  their  sight  from  ophthalmia  of  the 
newly  born,  ranged  from  twenty-three  to  fifty,  or 
an  average  percentage  of  these  eight  years  of  33.36 
of  the  whole  number  admitted. 

Just  how  frequent  this  dread  ophthalmia  of  the 
newly  born  is  outside  of  maternity  hospitals  in  this 
country  is  not  known  and  is  exceedingly  difficult  to 
determine ;  but  it  is  known  to  cause  a  large  amount 
of  infantile  blindness  as  the  figures  just  quoted 
show. 

In  the  preparation  of  this  paper  I  have  had  ac- 
cess to  the  mass  of  data  accumulated  in  the  past 
three  years,  by  that  untiring  worker  in  the  cause  of 
the  prevention  of  this  form  of  blindness,  namely 
Dr.  F.  Park  Lewis,  of  Buffalo,  chairman  of  the 
Committee  on  Ophthalmia  Neonatorum  of  the 
American  ^vledical  Association,  and  in  addition  I 
have  in  the  past  month  sent  between  thirty  and 
forty  letters  of  inquiry  upon  the  subject  to  as  many 
ophthalmologists. 

It  has  been  customary  in  the  past  to  place  the 
blame  for  from  one  quarter  to  one  third  of  the 
world's  blindness  upon  the  midwife,  but  the  opinion 
is  gradually  gaining  ground  among  us  that  the  dis- 
ease is  as  often  the  fault  of  the  physician  as  the  mid- 
wife, and  when  the  former  is  asked  why  he  did  not 
use  silver  in  a  given  instance  of  infection,  he  usu- 
ally answers  "that  he  did  not  think  it  a  suspicious 
case." 

jMiss  Annette  P.  Rogers,  chairman  of  the  Social 
Service  Work,  at  the  Massachusetts  Charitable  Eve 
and  Ear  Infirmary  of  Boston,  writes  me  on  the  sub- 
ject and  sends  their  last  report  for  the  year  ending 
October,  1908.  This  report  contains  an  investiga- 
tion by  the  social  worker,  which  covers  the  history 
of  forty-six  cases  of  infant  ophthalmia.  These 
cases  \vere  taken  at  random  from  the  records  of 
the  number  treated  at  the  infirmary  within  a  period 
of  about  twelve  months,  1907  to  1908.  Of  these 
forty-six  cases,  the  births  of  thirty-one  children  had 
been  attended  by  a  private  physician,  and  five  by 
a  dispensary  physician.  Six  births  took  place  in 
hospitals,  three  only  were  attended  by  midwives,  and 
the  remaining  one  was  unattended  by  either  phy- 
sician or  professional  midwife.  Of  the  thirty-one 
children  whose  birth  had  been  attended  by  a  private 
physician,  twenty  were  referred  to  the  infirmary  by 
the  attending  physician,  eleven  by  other  advice.  Of 
the  five  attended  by  the  dispensary  physician,  all 
were  referred  to  the  infirmary  by  him.  Of  the  three 
attended  by  midwives.  none  was  referred  to  the 
infirmary  by  them.  The  six  whose  births  took  place 
in  the  hospitals  were  all  directly  referred  to  the  in- 
firmary. The  one  unattended  by  either  physician  or 
midwife  was  later  sent  to  the  infirmary  by  a  dis- 
pensary physician. 

A  short  history  of  twelve  of  these  cases  is  given 
in  the  report.  Of  these  twelve,  two  infants,  cases 
one  and  twelve,  became  totally  blind.  In  three  other 
cases,  however,  one,  three  and  five,  it  is  doubtful 
if  the  children  can  be  educated  as  seeing  children, 
being  "border  line"  cases  of  those  who  are  neither 
blind  nor  seeing. 

Several  physicians  connected  witli  eye  dispens- 
aries sent  me  series  of  instances  of  infant  ophthal- 


May  15,  1909.] 


EDGAR:   PREl' EST  ABLE  BLL\'DXES:>. 


987 


mia  in  children  delivered  by  physicians  in  which 
no  drops  were  used  in  the  eyes  at  birth. 

A  physician  connected  with  the  New  York  Eye 
and  Ear  Infirmary  gives  me  the  history  of  ten  re- 
cent cases  of  infant  ophthalmia.  Nine  of  the  cases 
were  delivered  by  physicians  and  one  by  a  midwife. 
In  none  of  the  nine  cases  could  a  history  be  ob- 
tained of  "drops"  being  used  in  the  babies"  eyes 
at  birth.  In  the  one  case  delivered  by  the  midwife, 
"drops"  which  had  been  obtained  from  the  Board 
of  Health  were  used. 

Several  ophthalmologists  of  wide  dispensary  and 
hospital  experience  wrote  me  that  they  have  been 
impressed  with  the  number  of  cases  of  the  disease- 
that  developed  in  spite  of  the  fact  that  silver  nitrate 
solution  was  used  at  birth,  and  some  of  these  cases 
were  born  in  maternity  hospitals. 

In  the  study  of  the  prevention  of  blindness  due 
to  infant  ophthalmia  two  facts  stand  out  more 
boldly  than  any  others,  namely: 

1.  The  frequency  with  which  these  cases  occur 
in  the  practice  of  physicians  themselves,  although 
the  profession  is  ever  ready  to  place  the  burden  of 
the  blame  upon  the  ignorant  and  careless  midwife. 

2.  The  number  of  cases  of  the  disease  that  are 
attacked  in  spite  of  the  fact  that  silver  nitrate  was 
used  at  the  time  of  birth. 

Granted  that  about  one  third  of  all  the  totally 
blind  in  this  country  have  lost  their  sight  as  the  re- 
sult of  infant  ophthalmia,  and  this  does  not  include 
the  partially  blind  and  the  "border  line"  cases  from 
the  same  cause;  granted  that  regular  physicians  as 
well  as  midwives  are  about  equally  responsible  for 
this  fact  because  they  either  do  not  use  preventive 
measures  at  aH,  or  use  them  in  a  perfunctory  man- 
ner;  and  further  granted  that  a  practically  certain, 
a  safe  and  simple  preventive  measure  exists  in  the 
use  of  some  silver  solution  at  birth,  the  problem 
naturally  presents  itself  how  shall  the  rank  and  file 
of  the  physician  and  midwife  be  reached,  so  that 
they  may  be  brought  face  to  face  with  these  facts, 
and  they  may  be  induced,  if  not  compelled,  to  use 
some  preventive  measure  against  the  disease,  if  for 
no  better  reason  than  their  own  protection  against 
censure. 

Dr.  F.  Park  Lewis  started  the  machinery  in  mo- 
tion, that  will  eventually  undoubtedly  solve  this 
problem,  when  he  introduced  in  1906  before  the 
American  Medical  Association,  the  following  reso- 
lutions, which  were  unanimously  adopted : 

Whereas,  Notwithstanding  the  long  continued  efforts  of 
the  medical  profession  to  make  generally  known  the  infec- 
tious character  of  ophthalmia  neonatorum  and  its  dangers 
to  sight,  the  ranks  of  the  blind  are  still  largely  increased 
annually  by  those  who  have  unnecessarily  lost  their  vision 
as  a  result  of  this  disease ;  and 

Whereas,  We  possess  in  the  silver  salts  an  almost  abso- 
lute specific  for  its  prevention  and  treatment,  therefore 
be  it 

Resolved.  That  this  section  recommends  that  a  commit- 
tee consisting  of  at  least  one  ophthalmologist,  one  obstet- 
rician, and  one  sanitarian,  with  invited  cooperation  of  a 
subcommittee,  consisting  of  the  president  and  secretary  of 
each  State  society,  be  appointed  by  the  president  of  the 
association  to  formulate  and  make  eflfective  the  details  of 
a  plan  that  may  give  uniform  legislation  and  definite  in- 
struction to  the  profession  and  laity  concerning  the  pre- 
vention and  treatment  of  this  disease : 

Resolved,  That  this  section  recommend  an  ophthalmolo- 
gist for  such  committee  to  be  appointed  by  the  incoming 
chairman  and  executive  committee. 


The  preair.ble  to  this  resolution  is  but  the  ex- 
pression of  the  opinion  of  other  large  bodies  of 
medical  men,  concerning  the  infectious  character, 
the  prevalence,  and  the  specific  for  the  prevention 
of  the  disease.  In  fact,  it  can  safely  be  stated  that 
the  foregoing  is  the  consensus  of  medical  opinion 
the  world  over. 

Why  then  ophthalmia  neonatorum  ?  Simply  be- 
cause the  recognized  preventive  measure  is  either 
not  used,  or  is  applied  in  such  a  careless  and  per- 
functory manner  as  to  be  inefficient. 

The  fact  still  stands  out  boldly  before  us  that  we, 
members  of  the  medical  profession,  are  largely  re- 
sponsible for  the  present  status  of  the  subject. 

The  problem  then  before  us  is  to  reach  the  phy- 
sicians and  enlist  their  support  and  interest,  and 
incidentally  through  the  physicians,  the  midwives. 

This  is  what  is  being  done  under  the  strenuous 
leadership  of  Dr.  Lewis,  and  a  campaign  has  been 
inaugurated  which  is  enlisting  the  support  of  the 
medical  profession  throughout  this  country  and  that 
of  other  countries  as  well. 

Dr.  Lewis  has  in  the  last  three  years  caused  cir- 
cular letters  to  be  sent  out  to  the  ophthalmologists, 
obstetricians,  and  sanitarians  of  this  country,  Eng- 
land, France.  Germany,  and  Italy,  relative  to  the 
use  of  silver  solutions,  its  free  distribution,  mention 
of  its  use  on  the  birth  certificate,  the  classing  of 
ophthalmia  neonatorum  as  a  communicable  disease, 
and  the  penalty  for  failure  to  report  cases.  Nine 
tenths  of  the  replies  were  in  favor  of  all  the  ques- 
tions. Other  circular  letters  have  been  sent  out 
to  the  various  States  relative  to  existing  and  pend- 
ing laws  governing  the  practice  of  midwifery  or 
the  reporting  of  cases  of  ophthalmia  neonatorum ; 
the  gratuitous  distribution  of  prophylactics  by  the 
health  departments ;  the  early  registration  of  birth 
certificates ;  the  mention  of  the  preventive  measures 
used  on  the  birth  certificate ;  special  resolutions 
proposed  by  the  inedical  societies  for  the  control  of 
the  disease ;  measures  to  determine  how  large  a 
number  of  newly  born  children  have  been  infected, 
or  who  is  responsible  for  these  infections ;  lay  move- 
ments for  the  control  of  ophthalmia  neonatorum ; 
and  suggestions  to  the  committee  that  may  be  help- 
ful in  securing  control  of  the  disease. 

Subcom.mittees  upon  the  subject  have  been 
formed  in  many  States ;  State  Medical  Society  com- 
mittees are  now  at  work,  notably  in  California,  Col- 
orado, Kentucky,  ^Maine,  ^Missouri,  Xew  York,  first 
and  eighth  districts ;  other  States  are  expressing 
their  intention  of  appointing  committees. 

Special  medical  societies  have  also  appointed 
committees  for  the  work ;  and  two  lay  organizations 
are  in  the  field,  namely,  the  American  Association 
Workers  for  the  Blind,  and  the  Special  Committee 
for  the  Prevention  of  Blindness  of  Xew  York  Citv. 
The  last,  with  ]\Iiss  Louisa  Lee  Schuyler,  vice- 
president  of  the  State  Charities  Aid  Association,  as 
its  leader.  Resolutions  and  recommendations  have 
been  adopted  by  many  national  bodies,  notablv : 
American  Association  of  Obstetricians  and  Gyne- 
cologists ;  American  Academy  of  Ophthalmologists 
and  Otolaryngologists :  American  Public  Health 
Association ;  and  American  Ophthalmological  As- 
sociation. 

Bills  b.ave  been  passed  in  several  and  are  pending 


988 


MORROU 


BLIXDNESS  OP  THE  XEIVBORX. 


[New  York 
Medical  Journal. 


in  other  legislatures,  relative  to  the  control  of  this 
form  of  blindness,  and  the  regulation  of  the  mid- 
wives.  It  must  not  be  understood  that  health  of- 
ficers have  in  the  past  remained  inactive  in  this  mat- 
ter. In  iyo2  the  health  officer  of  this  city  declared 
ophthalmia  neonatorum  to  be  a  contagious  disease, 
and  as  such,  required  it  to  be  reported  promptly  by 
physicians  to  the  Health  Department.  Our  pres- 
ent health  officer.  Dr.  Darlington,  in  1908,  caused  to 
be  published  Rules  and  Regulations  Governing  the 
Practice  of  Midzvifery  in  the  City  of  Nezu  York. 

A  rule  requires  that  the  midwife  carry  with  her. 
as  part  of  her  equipment,  a  one  per  cent,  solution 
of  silver  nitrate,  and  another  rule  demands  that  a 
physician  must  be  summoned  should  "swelling  and 
redness  of  the  eyelids  with  a  discharge  of  matter 
from  the  eyes"  develop  in  an  infant. 

The  New  York  State  Commissioner  of  Health, 
Dr.  Porter,  was  one  of  the  first  to  lend  his  support 
to  the  cause  of  prevention  and  has  been  active  in 
many  directions  looking  to  the  control  of  the  dis- 
ease, and  the  free  distribution  of  a  suitable  prophy- 
lactic, as  is  shown  in  the  Tzventy-ninth  Annual 
Report  of  the  State  Department  of  Health,  under 
date  of  February  15,  1909. 

Two  important  measures  looking  to  the  early 
control  of  ophthalmia  neonatorum  have  recently 
been  proposed  in  New  York  State : 

The  first  is  the  early  notification  of  births  to  the 
health  officer,  and  the  second  such  change  in  the 
form  of  the  certificate  of  birth  as  will  draw  the  at- 
tention of  the  physician  and  midwife  to  the  preven- 
tion of  infant  ophthalmia. 

The  importance  of  the  early  notification  of  births 
to  health  officers  has  attracted  the  attention  of 
other  countries  than  our  own.  By  a  recent  Act  of 
Parliament  in  England,  entitled:  ''An  Act  to  Pro- 
vide for  the  Early  Notification  of  Births"  (Chnpter 
40,  August  28,  1907)  the  attendant  upon  the  mother 
is  required  to  notify  the  health  officer,  by  pasting  a 
letter  or  post  card,  a  form  of  notice  being  provided 
for  the  purpose,  within  thirty-six  hours  after  the 
child's  birth. 

At  the  present  writing  an  amendment  to  our  ten 
day  limit  in  New  York  State  has  been  introduced 
into  the  Legislature  at  Albany,  whereby  certificates 
of  birth  shall  be  sent  to  the  health  officer  within 
thirty-six  hours. 

The  State  commissioner  of  health  proposes  short- 
ly to  so  change  the  form  of  the  certificates  of  birth 
issued  hereafter  by  the  New  York  State  Board  of 
Health,  as  to  require  a  statement  whether  any 
prophylactic  against  ophthalmia  of  the  newly  born 
has  been  used,  and  if  not  any,  the  reason  for  omit- 
ting its  use. 

The  thirty-six  hour  limit  for  the  recording  of 
births  and  the  changes  in  the  birth  certificate  calling 
the  attention  of  physician  and  midwife  to  the  pre- 
vention of  ophthalmia,  can  hardly  work  otherwise 
than  to  eliminate  to  a  large  extent  the  results  of 
thoughtlessness,  carelessness,  and  negligence. 

The  value  of  the  thirty-six  hour  time  limit  for 
birth  notification  is  certain  to  work  in  the  interest  of 
the  baby. 

If  by  reason  of  forgctfulness  no  prophylactic  has 
been  used  in  a  given  instance,  within  a  day  and  a 
half  the  forgetful  jilivsician  or  the  negligent  mid- 


wife is  brought  face  to  face  with  the  questions  on 
the  birth  certificate  calling  attention  to  the  matter. 
It  is  not  too  late  for  preventive  measures,  and  few, 
if  any,  will  neglect  their  use — the  physician,  for 
fear  of  possible  censure,  and  the  midwife,  because 
if  she  uses  no  preventive  measure,  and  gives  no 
adequate  reason  for  its  omission,  and  ophthalmia  neo- 
natonmi  develops  in  the  child,  she  is  liable  to  fine 
or  imprisonment  or  both.  (Chapter  325 — Laws  of 
f892.) 

As  long  as  men  cohabit  with  their  seminal  ducts 
swarming  with  millions  of  gonococci.  so  long  will 
the  child,  during  its  struggle  through  the  birth 
canal,  have  its  eyes  saturated  with  gonorrhoeal  pus, 
and  it  becomes  the  duty  of  the  obstetrician  to  stand 
ready  with  a  chemical  antidote,  that  the  child  may 
not  emerge  into  a  world  of  darkness  to  endure  a 
living  death. 

As  long  as  the  public  remains  uneducated  to  the 
dangers  of  gonorrhceal  infection  and  to  the  fact  that 
man  to-day  is,  unconsciously  let  us  hope,  infecting 
something  like  four  fifths  of  womankind,  so  long 
will  it  be  necessary  for  the  obstetrician  to  instill  into 
the  eyes  of  the  infant  immediately  upon  its  birth 
some  drug  that  will  counteract  this  almost  universal 
poison  in  order  to  keep  the  proportion  of  those  who 
lose  their  sight  from  infant  ophthalmia  within  at 
least  reasonable  bounds. 

28  West  Fifty-sixth  Street. 


BLINDNESS  OF  THE  NEWBORN.* 
Prophylaxis  through  Education  of  the  Public. 

Bv  Prince  A.  Morrow,  A.  ]M.,  M.  D., 
New  York. 

The  object  of  this  society  is  the  study  and  pre- 
vention of  a  class  of  diseases  which,  through  their 
introduction  into  the  family,  are  most  injurious  to 
the  highest  interests  of  human  society.  The  chief, 
impelling  motive  to  this  movement  was  the  existence 
of  abuses  against  the  innocent  and  helpless  mem- 
bers of  society,  of  which  the  blinding  of  babies  at 
birth  is  an  example.  While  the  terrible  affliction  of 
bhndnefs  is  a  comparatively  infrequent  risk,  and 
is  vastly  overshadowed  in  significance  and  danger 
by  other  infective  risks  to  the  wife  and  offspring, 
it  furnishes  an  object  lesson  to  illustrate  the  con- 
sequence? of  infection  introduced  into  the  family 
and  may  serve  as  a  basis  for  the  study  of  the  most 
efficient  ijicans  of  prevention. 

It  was  recognized  bv  those  who  inaugurated  this 
movement  that  the  measures  most  available  and 
practical,  and  which  promised  to  be  most  effective 
in  this  prophylactic  work  were  education  and 
treatment.  The  brilliant  results  of  the  pi^eventive 
and  curative  treatment  of  the  infection  which  causes 
blindness  in  the  newborn  have  been  most  ably  pre- 
sented m  the  patters  to  which  you  have  just  listened. 

Thf  distinctive  feature  of  the  educative  work  pro- 
po.sed  by  this  society  is  to  get  at  the  root  of  things ; 
to  stu  h'  and  search  out  underlying  causes ;  to  in- 
terpret their  relation  and  significance,  and  to  set 
forth  their  consequences  for  the  education  of  pub- 
lic opinion. 

*Rcai|  brfoif  tlif  mcctiiiR  of  the  .\mcrican  Society  of  Sanitary 
an<l  Mural  Propliylaxis,  April  8,  1909. 


May  15,  1909.] 


MOKROIV:   BLINDNESS  OP   THE  N  El  I' BORN. 


989 


The  specific  cause  of  the  infection  which  blots 
out  the  eyes  of  babies  is  definitely  known.  Practically 
all  the  ophthalmia  of  the  new  born,  of  a  virulent 
type,  is  caused  by  a  specific  germ — the  gonococcus. 
There  are  other  organisms  which  may  cause  inflam- 
mation of  the  eyes ;  but  this  is  usually  of  a  mild, 
catarrhal  type,  and  rarely  affects  the  integrity  of 
the  vision.  Stephenson,  the  recognized  highest 
authority  on  this  subject,  says,  "The  serious  cases 
of  ophthalmia,  that  is  such  as  are  likely  to  imperil 
sight,  are  almost  invariably  due  to  the  specific  mi- 
crobe of  gonorrhoea." 

The  causal  relation  of  this  germ  to  the  infection 
being  established,  it  is  evident  that  the  elimination 
of  the  gonoccocus  from  the  process  of  childbirth 
would  mean,  practically,  the  eradication  of  blind- 
ness of  the  newborn ;  obviot;sly  the  most  radically 
efifective  measure  would  be  to  prevent  its  introduc- 
tion. 

The  question  arises  whether  the  same  radical  re- 
sult can  be  accomplished  by  concentrating  our  ef- 
forts upon  preventive  or  sterilizing  treatment  after 
the  eyes  of  the  child  have  been  exposed  to  this  in- 
fection. While  conceding  the  value  of  the  Crede 
method,  when  promptly  and  skillfully  employed,  I 
do  not  believe  that  it  can  ever  accomplish  the  wished 
for  extermination  of  blindness  of  the  newborn  un- 
less conjoined  with  education  of  the  public  as  to 
the  nature,  source,  and  communicative  mode  of  the 
infection  which  causes  blindness.  We  must,  in 
recognizing  the  undoubted  value  of  this  method, 
also  recognize  its  limitations.  It  is  not  an  infallible 
method ;  even  in  the  most  skillful  hands  it  sometimes 
fails.  It  is  inapplicable  in  cases  of  primitive  and 
ante  partum  infection  which  Stephenson  declares 
are  much  mo-re  numerous  than  is  commonly  sup- 
posed. It  is  ineffective  against  late  secondary  in- 
fections— comprising  a  proportion  of  from  ten  to 
thirty-two  per  cent,  of  all  cases — by  some  author- 
ities rated  much  higher.  Finally,  when  it  is  re- 
flected that  one  half  of  the  births  of  this  country 
are  attended  by  midwives,  many  of  them  ignorant 
and  totally  incompetent  to  apply  this  powerful  rem- 
edy, which  in  unskillful  hands  may  do  much  harm, 
it  is  evident  that  its  universal  application  is  imprac- 
ticable. The  midwife  is  a  condition,  not  a  theory, 
and  she  must  be  reckoned  with  as  an  essential  fac- 
tor in  carrying  out  this  treatment.  For  these,  and 
other  reasons  that  might  be  adduced,  it  seems  hardlv 
probable  that  prophylaxis  by  treatment  alone  will 
ever  accomplish  the  extinction  of  this  preventable 
affliction. 

In  the  praiseworthy  crusade  against  preventable 
blindness  undertaken  by  the  New  York  Association 
for  the  Blind,  the  committee  of  the  American  Med- 
ical Association,  and  other  organizations,  efforts  are 
chiefly  directed  to  the  recommendation  of  the  em- 
ployment of  the  Crede  method  in  all  cases  of  child- 
birth, while  the  responsibility  for  blindness  is 
squarely  placed  upon  the  shoulders  of  physicians 
and  midwives  for  neglect  in  employing  this  method. 
I  would  not  criticize  the  motives  of  the  public  spir- 
ited men  and  women  engaged  in  this  noble  work ; 
•but  I  would  honestly  question  the  wisdom  of  a  pol- 
icy which  deems  it  inexpedient  to  enlighten  the  pub- 
lic to  a  knowledge  of  the  nature  of  the  infection 
which  causes  blindness,  and  the  conditions  under 


which  it  occurs,  and  thus  place  the  responsibility 
where  it  fairly  belongs.  Farther  than  this,  I  would 
protest  against  the  injustice  involved  in  the  charge 
"that  they,  and  they  alone  (referring  to  the  attend- 
ants), are  directly  responsible  for  the  blindness  of 
the  many  little  children,  the  many  men  and  women 
who,  for  all  their  lives  must  grope  their  way  through 
a  world  of  darkness."'  Now,  what  are  the  facts? 
The  cause,  communicative  mode,  and  consequences 
of  this  infection  may  be  traced  step  by  step.  In 
the  vast  majority  of  cases  it  has  been  contracted  by 
the  father  of  the  child  in  licentious  relations  either 
before  or  after  marriage,  and  communicated  to 
the  mother,  who  is  made  the  passive  and  uncon- 
scious medium  of  instilling  the  virulent  poison  into 
the  eyes  of  her  own  child. 

Now  it  is  utterly,  unthinkable  that  a  man  would 
knowingly  communicate  an  infection  to  his  wife 
which  puts  out  the  eyes  of  his  own  child,  and  yet 
statistics  show  that  the  eyes  of  no  fewer  than  seven 
thousand  persons  in  this  country  have  been  put  out 
by  purulent  ophthalmia,  not  to  speak  of  the  many 
thousands  more  who  have  run  the  gauntlet  of  this 
infection  and  have  escaped  with  more  or  less  dam- 
aged vision.  What  is  the  explanation  of  this  strange 
and  most  unnatural  crime  against  one's  own  flesh 
and  blood?  The  only  possible  explanation  is  ignor- 
ance— ignorance  in  most  cases  on  the  part  of  the 
man  that  he  is  the  bearer  of  contagion,  and,  especi- 
ally, ignorance  of  its  terrible  consequences  to  his 
wife  and  children.  The  most  rational  prophylactic 
measure  would  be  to  correct  this  ignorance. 

Admitting  that  there  are  some  conscienceless  men 
who,  enlightened  as  to  the  possible  and  even  cer- 
tain danger  of  marrying  with  an  uncured  venereal 
disease,  nevertheless,  for  selfish  or  sordid  reasons, 
take  the  risk,  or  rather  subject  their  family  to  the 
risk  of  infection,  would  not  such  a  man  more  likely 
take  this  risk  if  assured  that  medical  science  had 
discovered  a  simple,  safe  and  efficacious  remedy  for 
its  prevention,  and  that  in  case  of  its  failure,  the 
entire  responsibility  would  be  placed  upon  the  physi- 
cian, while  his  own  agency  would  be  covered  up 
and  concealed. 

How  can  this  ignorance  be  corrected?  Since 
comparatively  few  men  consult  physicians  as  to  their 
fitness  for  marriage  and  parentage,  it  is  evident 
that  if  this  education  is  to  have  its  full  force  and 
efficacy  as  a  prophylactic  measure,  it  must  extend 
to  the  collectivity,  it  can  only  come  through  edu- 
cation of  the  public. 

What  would  be  the  preventive  value  of  the  pul)- 
licity  of  these  facts?  In  the  first  place  it  would 
awaken  the  perceptions  of  the  public  to  an  appre- 
ciation of  the  right  horrible  dangers  which  come 
from  the  introduction  of  this  infection  into  the  fam- 
ily, of  the  inhumanity  involved  in  these  crimes 
against  helpless  women  and  children.  In  the  con- 
ception of  the  laity  blindness  at  birth  is  generally  re- 
garded as  an  unavoidable  misfortune,  a  visitation  of 
Providence.  The  public  should  know  that  it  is  the 
fateful  expression  of  ignorance  and  criminal  care- 
lessness, the  working  of  that  relentless  law  of  Na- 
ture which  visits  the  sins  of  the  fathers  upon  the 
children.  Nature  would  seem  to  resent  with  es- 
pecially severe  penalties  violation  of  the  law  of  sex. 
particularly  when  it  concerns  the  integrity  of  that  • 


990 


MORROW:  BLINDNESS  OF  THE  NEWBORN. 


[New  York 
Medical  Journal. 


function  to  which  the  Hfe  of  the  human  race  is 
entrusted.  It  is  a  sad  commentary  upon  humanity 
that  man  is  the  only  animal  who  soils  his  system 
of  generation  with  infections  that  maim  or  destroy 
his  offspring ;  none  of  the  brute  creation  brings 
forth  its  young  exposed  to  such  dangers.  The  chil- 
dren of  men  are  the  only  beings  whose  eyes  may 
be  subjected  to  a  veritable  baptism  of  virulence  the 
moment  they  open  to  the  light  of  the  world. 

These  are  ugly  facts  which  should  be  fairly 
faced ;  however  unpleasant,  they  are  needful  for  the 
public  to  know  if  we  would  wipe  out  this  foul  blot 
upon  our  social  civilization.  Publicity  of  these  facts 
would  arouse  the  conscience  of  the  public,  and  cre- 
ate a  public  sentiment  which  would  no  longer  tol- 
erate these  social  crimes.  Conscienceless  men  fear 
public  opinion  more  than  the  penitentiary. 

One  word  in  regard  to  the  attitude  of  the  san- 
itary officials  in  relation  to  the  prevention  of 
ophthalmia  neonatorum :  Some  years  ago  the  health 
board  of  this  city  passed  an  ordinance  requiring  the 
prompt  report  of  every  case  of  ophthalmia  occurring 
in  the  newborn.  So  far  as  I  can  learn  this  provision 
is  not  enforced — it  is  practically  a  dead  letter.  The 
only  explanation  I  have  heard  of  its  nonenforcement 
is  that  it  would  cast  a  slur  upon  the  morality  of 
the  parent.  Is  there  not  some  inconsistency  in  this 
attitude?  Is  not  the  advocacy  of  the  use  of  silver 
nitrate  in  all  cases  of  child  birth  based  upon  the  as- 
sumption that  every  woman  who  bears  a  child  is 
the  possible  bearer  of  gonococcus  infection?  Ob- 
viously this  is  so,  since  silver  nitrate  is  specific  only 
against  the  gonoccocus;  it  would  not  be  recom- 
mended as  a  bactericide  against  the  pneumococcus, 
the  streptococcus  or  other  organisms  which  might 
be  present.  Now,  statistics  would  seem  to  show  that 
gonorrhoeal  ophthalmia  occurs  in  one  out  of  every 
200  cases  of  childbirth ;  but  for  fear  of  casting  a 
slur  upon  the  morality  of  one  individual  who  wQuld 
have  no  cause  to  complain,  we  cast  a  perhaps  un- 
deserved slur  upon  the  morality  of  the  199  in  whom 
the  infection  may  not  be  present. 

It  is  possible  that  the  rigid  enforcement  of  this 
ordinance  would  encounter  hostility  on  the  part  of 
social  sentiment  which  has  always  proved  to  be  the 
most  powerful  obstacle  to  any  real  hygienic  progress 
in  dealing  with  this  entire  class  of  infections.  This 
same  social  sentiment  is  the  real  obstacle  to  the  gen- 
eral dissemination  of  knowledge  regarding  the 
social  dangers  of  these  infections.  Social  tradition 
holds  that  it  is  a  greater  violation  of  conventional 
pro])riety  publicly  to  mention  this  infection,  than 
privately  to-  contract  it  and  carry  the  poison  home 
to  the  family.  The  tyranny  of  this  tradition  is 
shown  in  the  attitude  of  the  public  press,  which  de- 
mands as  the  price  of  its  support  of  the  work  for 
the  prevention  of  blindness,  suppression  of  the  truth  ; 
it  is  manifest  in  the  attitude  of  contributors  to  this 
work,  whose  financial  support  is  conditioned  upon 
silence  as  to  the  cause,  and  concealment  of  the  real 
culi)rit. 

The  medical  profession  has  always  stood  as  a 
buffer  between  "the  pleasant  vices  of  men"  and  the 
exjKjsure  of  their  social  dangers.  Most  of  these 
dangers  are  hidden,  and  by  their  very  nature  con- 
cealed from  observation — their  existence  unsuspect- 
ed even ;  but  blindness  does  not  lend  itself  to  con- 


cealment— it  may  be  seen  and  perceived  of  all  men. 
It  must  be  explained.  In  explaining  blindness  must 
we  subserviently  bow  to  social  sentiment,  which  de- 
mands that  we  conceal  the  cause  and  assume  the 
entire  blame  by  declaring  that  "to  the  criminal  care- 
lessness or  ignorance  of  those  who  preside  at  the 
birth  of  the  child  is  due  the  loss  of  sight  of  almost 
every  child  whose  eyes  have  been  destroyed  by 
infant  ophthalmia?"  Shall  the  medical  profession 
submissively  serve  as  a  scapegoat  for  the  sins  of  the 
men  who  have  ignorantly  or  carelessly  passed  over 
to  their  wives  an  infection  received  from  a  prosti- 
tute? 

Let  the  public  be  enlightened  as  to  the  true  facts 
so  that  the  educational  value  of  the  truth  may  have 
its  full  force  and  effect.  In  sacrificing  truth  to  ex- 
pediency do  we  not  sacrifice  too  much,  not  only  the 
health  and  lives  of  women  and  children,  but  the 
principlesof  humanityand justice,  which  are  outrag- 
ed by  those  who  carry  infection  into  the  family? 

It  is  to  be  observed  that  this  prophylactic  education 
has  a  broader  and  higher  value  than  would  at  first 
appear.  The  saving  knowledge  which  would  preserve 
the  eyes  of  babies  from  infection  would  also  pro- 
tect them  from  other  serious  risks  introduced  by 
gonococcus  infection  into  the  family,  the  vulvo- 
vaginitis, the  arthritis,  the  septic  and  other  systemic 
complications  which  not  only  endanger  health  but 
destroy  life ;  but  its  protective  value  in  shielding  the 
offspring  is  entirely  overshadowed  by  its  value  in 
safeguarding  the  mothers  from  that  vast  cortege 
of  infective  risks  which  make  up  the  martyrdom 
of  so  many  women  in  marriage.  Infection  of  the 
eyes  at  birth  may  mean  the  loss  of  vision,  the  in- 
fection of  the  mother  may  mean  lifelong  invalidism 
or  death.  These  serious  infections  in  women  can- 
not be  cured  by  instillation  of  a  simple  solution  of 
silver  nitrate ;  they  can  be  cured  only  by  the  sur- 
geon's knife,  by  the  unsexing  of  the  woman,  and 
mutilation  of  her  body. 

The  knowledge  we  seek  to  convey  would  also 
protect  against  the  vastly  more  serious  and  destruc- 
tive effects  upon  the  offspring  which  comes  from 
the  introduction  of  syphilis  into  the  family. 

Finally,  this  problem  of  prevention  should  not  be 
considered  simply  as  a  question  of  the  invasion  of 
microbes  affecting  a  single  organ  of  the  bod\- — of 
when,  and  how,  we  can  most  effectively  intervene 
in  sterilizing  the  infectious  elements.  Associated 
with  this  danger  to  the  eyes  of  children  there  are 
other  and  far  more  serious  dangers,  all  united  by  a 
common  causality  of  origin.  In  the  presence  of  an 
outbreak  of  typhoid  it  would  be  the  height  of  san- 
itary unwisdom  to  rely  upon  treatment  alone  while 
neglecting  the  polluted  water  supply.  It  is  neither 
good  science  nor  good  prophylaxis  to  ignore  the 
stream  of  infection  continually  polluting  the  chan- 
nels of  maternity,  and  make  no  effort  to  prevent  its 
introduction.  The  best  prophylaxis  is  to  prevent  ef- 
fects by  correcting  the  cause. 

In  setting  forth,  what  I  conceive  to  be,  the  su- 
perior value  of  education  of  the  public  in  the  pro- 
phylaxis, not  only  of  blindness  of  the  newborn,  but 
of  the  entire  class  of  infections  of  which  it  is  typi- 
cal, I  would  distinctly  disclaim  any  intention  to  dis- 
parage the  value  of  the  Crede  method,  or  to  dis- 
credit its  employment  in  every  case  of  childbirth 


May  15,  1909.] 


KRALSS:   OPHTHALMIA  XEONATORUM. 


991 


where  there  is  reason  to  beheve  that  the  mother  has 
been  contaminated.  In  the  existing  conditions  of 
popular  ignorance  it  is  perhaps  the  best  means  that 
can  be  employed  to  avert  blindness  in  this  class  of 
cases,  but  the  correction  of  this  ignorance  through 
a  general  diffusion  of  a  knowledge  of  the  facts  es- 
sential for  the  public  to  know,  would  render  its  em- 
ployment entirely  unnecessary.  The  withholding  of 
this  knowledge  is  simply  perpetuating  the  ignor- 
ance which  is  the  basic  cause  of  the  evil  we  wish 
to  prevent. 

This  society  has  instituted  a  new  departure  in 
dealing  with  this  class  of  infections,  which  is  a  re- 
versal of  the  policy  of  silence,  concealment,  and  sup- 
pression of  facts  that  has  always  prevailed,  and  is 
also  in  direct  contravention  of  the  traditional  social 
sentiment  which  refuses  to  recognize  the  existence 
of  these  infections  and  tabooes  all  knowledge  con- 
cerning them.  We  believe,  however,  that  the  health 
and  lives  of  helpless  women  and  children  are  of 
more  value  than  mere  sentiment.  The  law  of  in- 
fctious  disease  knows  no  sentiment,  it  should  find 
no  place  in  the  counsels  of  preventive  medicine. 

66  West  Fortieth  Street. 


OPHTHALMIA  NEONATORUM.* 

By  Frederick  Krauss,  M.  D., 
Philadelphia. 

Ophthalmia  neonatorum  has  been  discussed  so 
frequently  that  there  remains  little  that  is  new. 
Nevertheless  the  importance  of  the  subject,  especial- 
ly its  prevention,  renders  its  consideration  of  con- 
stant interest.  It  is  my  intention  to  present  this 
subject  in  stich  a  manner  that  the  general  practi- 
tioner will  have  a  review  of  the  practical  side  of  this 
disease. 

Before  the  adoption  of  his  method,  Crede  had  an 
average  of  10.8  per  cent,  of  ophthalmia  neonatorum 
develop  in  all  his  cases  at  the  Leipzig  Lying  in  Hos- 
pital notwithstanding  efforts  at  cleanliness.  After 
the  adoption  of  the  silver  nitrate  treatment  the  pro- 
portion fell  to  from  o.i  to  0.2  per  cent.  A  similar 
success  attended  its  use  in  other  institutions.  In 
private  practise,  at  least  in  the  United  States,  oph- 
thalmia neonatorum  develops  in  a  much  smaller 
proportion  of  cases  as  a  rule,  but  in  every  case  in 
which  there  is  a  vaginal  discharge,  benign  or  gonor- 
rhoeal,  the  safest  thing  to  do  is  to  use  the  Crede 
method. 

When  we  consider  that  in  spite  of  the  knowledge 
of  the  efficacy  of  the  Crede  method,  that  from  ten 
to  fifty  per  cent,  of  all  cases  of  blindness  in  institu- 
tions of  this  country  and  Europe  are  due  to  ophthal- 
mia neonatorum,  criminal  neglect  is  glaringly  evi- 
dent. 

Ophthalmia  neonatorum  inay  develop  and  even 
destroy  the  eye  previous  to  birth.  After  birth,  it 
assumes  two  types,  the  mild  one,  due  to  various 
pathogenic  organisms  of  the  genital  tract,  and  the 
second  or  severe  type  due  to  the  Neisser  gonococcus. 
It  is  an  easy  matter  to  stain  a  drop  of  pus  from  the 
conjunctival  cul-de-sac,  with  methylene  blue  and  ex- 
amine under  the  microscope  with  an  oil  immersion 
lens,  and  thus  discover  the  microorganisms  at  fault. 

*Read  before  the  Northern  Medical  Association,  April  9,  1909. 


In  the  milder  type  of  inflammation  about  four  days 
to  two  weeks  after  birth  the  eyes  become  red  and 
swollen  and  secrete  a  }'ellowish  mucopurulent  mat- 
ter. The  lids  adhere  after  sleep.  The  tarsal  con- 
junctiva is  red  and  velvety,  while  the  chemosis  is 
quite  moderate  in  amount.  The  secretion  is  not  ex- 
cessive. The  cornea  is  clear.  Under  mild  cleans- 
ing solutions  the  eyes  become  quiet  and  the  dis- 
charge ceases  in  a  few  days.  In  the  severe  type 
due  to  the  gonococcus,  the  aft'ection  begins  soon 
after  birth,  usually  before  the  fifth  day  and  quickly 
becomes  very  acute.  The  lids  become  chemosed 
with  great  rapidity  and  bulge  out  with  secretion 
retained  because  of  the  adherence  of  the  lid  edges, 
caused  by  the  drying  of  the  secretion  on  contact 
with  the  air.  When  the  lids  are  separated  a  watery 
and  a  few  hours  later  a  purulent  discharge  rolls 
out  in  quantity.  Careless  separation  can  cause  a 
projection  of  this  discharge  into  the  eyes  of  the 
surgeon  or  bystander  with  serious  results.  In  a  few 
days  the  conjunctiva  becomes  succulent,  especially 
in  the  fornix,  which  separates  into  numerous  hori- 
zontal folds.  At  the  bottom  of  these  folds,  lateral 
and  intercommunicating  fissures  with  a  greyish  in- 
filtrated base  are  apt  to  develop  forming  a  lodging 
place  for  pus,  and  by  pressure  on  the  cornea  often 
produce  a  cloudiness  or  ulceration.  The  bulbar  con- 
junctiva is  aft'ected  in  a  much  less  degree.  When 
the  disease  is  fully  developed,  the  lids  are  reddened 
and  bulged  out.  Their  edges  are  adherent  in  places, 
between  which  the  pus  gradually  oozes  out.  The 
discharge  is  very  free,  purulent,  and  greenish  yel- 
low as  in  urethral  gonorrhoea. 

Under  treatment,  the  swelling  of  the  lids  grad- 
ually decreases,  the  discharge  becomes  less  free  and 
more  mucoid  in  character,  and  finally  ceases,  after 
which  the  lids  no  longer  adhere  after  sleep.  ~Siore 
or  less  thickening  of  the  conjunctiva  with  some 
chronic  discharge  may  presist  for  a  long  time  in 
spite  of  treatment. 

If  the  patient  has  been  carefully  handled,  in  the 
great  majority  of  cases  the  cornea  will  remain  clear. 
In  other  cases,  the  cornea  becomes  cloudy,  infil- 
trated, or  ulcerated,  and  finally  in  healing,  there  re- 
mains a  deep  opacity  in  the  cornea,  or  the  disease 
may  extend  transforming  the  cornea  into  a  slough- 
ing mass  which  exfoliates  with  loss  of  the  eye. 

The  prognosis  of  ophthalmia  neonatorum,  when 
properly  treated  in  its  early  stages  is  very  good.  In 
later  stages  and  especiallv  if  the  cornea  is  affected, 
it  is  more  serious.  Deep  involvement  of  the  cornea 
always  means  great  loss  of  sight.  Treatment  is  of 
great  avail  and  lack  of  treatment  fatal.  The  physi- 
cian who  has  a  case  of  ophthalmia  neonatorum  due 
to  the  gonococcus  and  treats  it  lightly  should  be 
held  criminally  liable.  T  say  this  because  I  have,  on 
a  number  of  occasions,  seen  cases  of  great  severity 
in  which  the  physician  had  prescribed  a  simple  boric 
acid  wash  to  be  used  three  times  daily,  never  apply- 
ing any  treatment  himself  or  seeing  that  others  do 
it  properly,  feeling  that  his  whole  duty  was  per- 
formed in  the  writing  of  the  prescription.  In  other 
cases  physicians  had  directed  "mother's  milk"  to 
be  used  in  the  eye  at  intervals.  In  such  instances, 
this  sort  of  treatment  had  been  continued  for  weeks 
with  blindness  resulting. 


CRfSI'JX:  IXDIVIDUAL  AS  A  SURGICAL  FACTOR. 


lXew  Voek 
Medical  Journal. 


i'he  treatment  of  ophthalmia  neonatorum  is  sim- 
ple and  can  be  performed  by  any  physician. 

Treatment  may  be  divided  into  prophylactic  and 
curative.  Prophylaxis  is  of  the  utmost  importance. 
It  should  consist  of  the  thorough  cleansing  of  the 
parturient  tract  in  a  suspected  case  with  a  solution 
of  potassium  permanganate  or  other  antiseptic  wash, 
always  remembering  that  strong  solutions  may  in- 
jure the  eye  of  the  newborn  baby.  In  every  con- 
finement case,  the  following  treatment  of  the  baby's 
eyes  is  simple,  and  efficacious :  Immediately  after 
birth,  before  the  cord  is  tied,  the  closed  evelids 
should  be  gently  cleansed  with  a  piece  of  dry  gauze 
followed  immediately  by  cleansing' of  the  eyelids  and 
adjacent  parts  with  a  piece  of  gauze  wet  with  a 
l)oric  acid  solution.  After  the  tying  of  the  cord,  the 
nurse  should  again  carefully  cleanse  the  region 
about  the  eye,  being  careful  not  to  rub  anything  into 
the  conjunctival  sac.  Then  the  latter  should  be 
thoroughly  flushed  with  a  boric  acid  solution  (gr. 
X  to  51)  and  in  suspected  cases  one  drop  of  a  two 
per  cent,  solution  of  silver  nitrate  should  be  instilled 
into  the  lower  conjunctival  sac.  If  too  much  silver 
is  dropped  into  the  eye  it  should  be  immediatelv 
neutralized  with  a  normal  salt  solution  or  in  its  ab- 
sence, with  the  boric  acid  solution.  Otherwise  a 
traumatic  conjunctivitis  may  ensue.  Protargol, 
argyrol,  and  other  substitutes  for  silver  nitrate  are 
not  as  efficacious  and  should  not  take  its  place.  It 
is  necessary  to  warn  the  attendants  and  especially 
the  mother,  of  the  contagiousness  of  the  disease,  and 
the  necessity  of  destruction  of  the  gauze  used  in 
cleansing  of  the  eye  should  be  dwelt  upon.  It  must 
not  be  forgotten  that  in  spite  of  care  at  the  birtli 
and  the  use  of  the  Crede  method,  infection  may  take 
place  later  from  the  mirse  or  mother's  fingers,  or 
even  soiled  clothes. 

Curative  treatment  consists  of:  i,  Thorough 
cleansing ;  2,  silver  nitrate ;  3.  compresses,  cold  and 
hot;  4,  solution  of  organic  silver;  5,  atropine  if  the 
cornea  is  affected. 

1.  Thorough  cleansing  is  best  obtained  by  the 
use  of  a  proper  soft  rubber  syringe  and  the  free  use 
of  a  boric  acid  or  weak  potassium  permanganate 
solution.  This  solution  should  be  used  not  less  than 
every  hour,  day  and  night.  Constant  attendance  is 
a  necessity.  The  nurse  should  be  instructed  about 
careful  separation  of  the  lids,  and  the  necessity  of 
the  tlushing  of  the  conjunctival  sac. 

2.  Silver  nitrate  should  be  applied  i)y  the  physi- 
cian himself  once  or  twice  daily,  according  to  the 
amount  of  the  discharge.  As  the  discharge  lessens, 
it  can  be  done  every  .second  day,  but  early  cessation 
of  the  silver  solution  will  bring  a  recrudescence  in 
many  cases.  To  apply  the  silver  solution  properly, 
the  lids  are  everted,  which  is  easily  accomplished 
by  traction  along  the  lid  margins  with  the  finger 
til)s.  A  ten  grain  to  the  ounce  solution  of  silver 
nitrate  is  applied  to  the  everted  lids  by  means  of  a 
cotton  swab,  being  careful  to  apply  the  same  thor- 
oughly in  the  conjunctival  fornix.  Have  a  second 
swab  wet  with  normal  salt  solution  conveniently 
ready  and  apply  the  same  at  once  to  the  everted  lids. 

3.  The  question  of  hot  or  cold  compresses  is 
rather  confusing.  Formerly  ice  compresses  were 
used  freely  with  the  result  that  if  applied  too  zeal- 
ously the  cornea  would  be  deprived  of  its  vitality 


and  develop  opacity.  Intermittent  ice  compresses 
are  of  great  service  in  the  early  stages,  but  judg- 
ment should  be  used  by  the  physician.  Hot  com- 
presses in  the  later  stages  applied  for  a  short  time 
daily,  seem  to  assist  in  clearing  corneal  opacities. 
The  applications  of  compresses  are  of  value  also 
because  they  keep  the  lids  from  adhering  to  some 
extent  by  their  moisture  thus  allowing  of  the  exit 
of  the  pus. 

4.  Constant  bathing  of  the  eyes  with  a  twent}-  to 
twenty-five  per  cent,  solution  of  organic  silver  solu- 
tions seems  to  be  of  some  value  and  should  be  used 
in  every  case.  One  drop  instilled  after  every  cleans- 
ing of  the  eye  is  most  satisfactory.  In  this  way,  the 
eye  is  constantly  bathed  in  a  solution  that  is  mildly 
antiseptic,  and  has  sufficient  color  to  allow  us  to 
watch  its  diffusion. 

5.  Should  the  cornea  become  hazy,  atropine 
(gr.  ii  to  31 )  should  be  dropped  into  the  affected 
eye  two  to  three  times  daily  and  every  bright  light 
excluded  from  the  room. 

This  in  brief  is  the  method  which  has  proved  to 
be  of  great  value  to  me  in  the  treatment  of  ophthal- 
mia neonatorum. 

Other  antiseptics  and  other  minor  variations  are 
possible,  but  I  have  purposely  kept  the  treatment  as 
simple  as  possible  to  avoid  confusion.  If  I  have 
been  too  elementary  in  my  descriptions  I  beg  vour 
pardon. 

1701  CifESTXUT  Street. 


THE  INDIVIDUAL  AS  A  SURGICAL  FACTOR. 

Bv  Antoxio  M.  Crispin,  M.  D., 
New  York. 

The  following  remarks  have  been  prompted  by 
the  recent  discussion  on  the  preparatory  treatment 
of  patients.  The  diversity  of  opinion  among  the 
honored  chiefs  in  surgery  is  such  that  a  review  of 
the  facts  seems  to  be  worthy  of  our  attention.  They 
are  divided  into  two  camps,  those  who  advise  a 
thorough  and  extended  course  of  preparatory  treat- 
ment and  those  who  condemn  everything  in  the  na- 
ture of  delay,  and  who  rush  patients  into  the  oper- 
ating room,  probably  after  a  mere  cursorv* examina- 
tion of  the  urine. 

During  many  years  I  collected  notes  on  the  re- 
ciprocal influence  of  diseases  and  traumatism,  either 
produced  accidentally  or  intentionally,  not  with  the 
intention  of  publishing  them  but  for  my  own  guid- 
ane.  Finding  now  such  disparity  of  opinion  it  is 
manifest  that  it  may  interest  others. 

It  is  a  dangerous  error  to  undervalue  the  consti- 
tutional disturbances  which  underlie  many  surgical 
diseases,  and  it  is  a  useless  nicety  to  establish  a  dis- 
tinction between  a  diathesis  and  the  lesion  which 
they  produce ;  it  is  a  well  known  fact  that  wounds 
are  very  dangerous  in  persons  who  are  suffering 
certain  general  diseases,  such  as  diabetes,  malaria, 
syphilis,  general  intoxications,  either  from  internal 
or  external  sources,  as  those  from  the  intestines,  al- 
coholism, saturnism,  etc.,  conditions  all,  which  may 
eventually  cause  alterations  of  the  liver,  heart,  or 
kidneys.  Alcoholism  has  only  to  be  mentioned  to 
evoke  that  dreaded  postoperative  sequel,  delirium 
tremens,  and  the  general  alterations  of  the  organ- 


May  15,  1909.1 


CRIi,I'IX:  IXDll  'IUUAL  AS  A  SURGICAL  I' ACTOR. 


993 


ism,  for  it  is  a  truism  that  chronic  alcoholism  pro- 
foundly modifies  the  recuperative  process.  These 
morbid  conditions  have  a  decided  influence  on  all 
surgical  operations,  even  before  the  lesions  which 
they  produce  become  appreciable. 

To  trust  blindly  in  our  perfect  asepsis  and  in  our 
excellent  technique,  overlooking  other  factors  which 
are  of  no  less  importance  and  influential  in  the  final 
outcome,  does  not  seem  to  comply  with  that  exacti- 
tude which  modern  surgery  demands.  -\ny  treat- 
ment, to  be  perfect,  and  we  are  all  striving  to  at- 
tain perfection,  must  take  in  consideration  the  indi- 
vidual's physical  and  psychic  peculiarities ;  his  tem- 
perament, his  sex,  his  age,  his  ideas,  and  habits ;  in 
one  word  his  personality.  Remembering  that  a  pa- 
tient is  not  merely  a  subject  of  interest  as  the  vic- 
tim of  some  morbid  process,  offering  opportunity 
for  the  display  of  surgical  audacity,  but  an  organism 
possessing  the  attributes  of  humanitv.  that  a  patient 
is  a  man  for  a'  that,  and  as  such  he  should  be  treated 
and  studied  in  his  manifold  variations  and  individ- 
ual traits. 

The  great  progress  of  modern  operative  surgery 
has  been  accomplished  by  close  attention  to  minute 
details,  and  a  more  extended  recognition  of  the  laws 
of  causation  is  essential  to  its  further  advancement. 
The  modern  surgeon  has  to  be  a  "superman,"  he 
must  know  all,  seek  all,  control  all  that  relates  to 
his  patient.  Nothing  left  to  chance.  Surgery  must 
take  cognizance  of  all  details,  however  trivial  they 
may  appear,  before,  during,  and  after  operations. 
There  are  several  motives  for  this  undue  haste,  the 
first  is  the  pruritus  operandi  so  prevalent  nowadays, 
and  secondly  that  "interesting  and  ever  present 
question."  as  Dr.  H.  C.  Coe  would  say ;  for  if  it  be 
a  payingi  patitnt,  the  sooner  he  is  out  of  the  hos- 
pital, the  quicker  will  he  show  his  gratitude  to  the 
surgeon,  and  if  a  charity  one,  the  earlier  he  be  dis- 
charged the  better  for  the  institution. 

This  preoperative  preparation  of  the  patient  has 
reference  to  those  cases  which  are  to  undergo  a 
major  operation  and  in  which  time  is  at  our  dis- 
posal. Of  course  it  does  not  include  the  emergency 
operations,  the  so  called  imperative  operations, 
where  the  nature  of  the  cases  is  such  that  we  have 
to  interfere  immediately  to  save  life.  The  constitu- 
tional states  which  have  to  be  corrected  or  elimi- 
nated if  possible  before  attempting  any  surgical  pro- 
cedure, are  here  given  in  the  order  in  which  it  ap- 
pears their  gravity  demand. 

Renal  InsuMcieiicy. 

Probably  no  other  function  is  of  so  much  impor- 
tance to  the  surgeon,  if  we  except  the  heart,  than 
the  renal  elimination,  and  surely  nothing  has  been 
more  radical,  nay,  almost  revolutionary,  than  the 
advances  recently  made  in  the  conception  of  its 
pathology. 

It  has  been  demonstrated  that  the  excretion  by 
the  kidneys  offers  an  invaluable  guide  to  the  con- 
dition of  the  system  in  general,  and  that  the  esti- 
mation of  the  functional  capacity  of  this  great  en- 
munctory  is  of  vast  importance  in  determining  the 
conduct  of  the  surgeon.  Not  only  in  diseases  clas- 
sified as  nephritic  but  in  every  other  disease,  even 
without  any  demonstrable  lesion  of  the  kidney,  is 
the  estimation  of  this  function  of  value.    The  urine 


may  be  absolutely  negative  as  to  albumin  or  cast, 
but  suppression  of  urine  may  supervene  after  oper- 
ations, especially  in  persons  who  have  a  weak  or 
fatty  heart,  or  in  whom  the  system  is  below  par  as 
the  result  of  any  chronic  disease  or  inflammatory 
condition  of  the  liver. 

It  has  been  conclusively  shown  within  the  last 
few  years,  that  our  knowledge  of  the  functional  in- 
sufficiency of  the  kidneys,  as  disclosed  by  the  total 
output  of  urine  in  the  twenty-four  hours,  is  by  far 
more  important  in  estimating  their  true  condition 
than  the  presence  or  absence  of  albumin  or  cast.  The 
great  merit  of  having  first  directed  the  attention  of 
the  profession  to  this  important  question  is  due  to 
the  late  Dr.  James  E.  Etheridge,  of  Chicago,  who 
some  years  ago  noted  "the  close  relation,  even  that 
of  cause  and  effect,  existing  between  renal  insuffi- 
ciency and  pelvic  disorders."  He  also  had  compiled 
excellent  working  tables,  for  clinically  estimating 
the  functional  efficiency  of  the  kidneys,  which  I  re- 
produced in  an  article  on  Renal  Insufficiency  pub- 
lished in  the  New  York  Medical  Journal  of  August 
20,  1904.  Since  then  this  fact  has  received  addi- 
tional corroboration  from  the  observations  of  Dr.  R. 
C.  Cabot,'  of  Boston,  who  sa}  s :  "What  I  wish  to 
especially  emphasize  is  that  the  evidence  of  irrita- 
tion albumin  and  cast,  is  not  evidence  of  nephritis 
which  may  or  may  not  be  present.  Hence  the  folly 
of  sending  a  urine  to  a  laboratory  or  to  an  urologist 
for  diagnosis,  or  for  anything  more  than  a  descrip- 
tion of  what  he  finds."  And  in  the  notable  contri- 
bution of  Dr.  Charles  P.  Emerson  of  Johns  Hop- 
kins, who  presented  them  to  The  American  Medical 
Association,  at  the  meeting  in  Portland,  Ore.,  in 
July,  1905,  and  published  in  the  Journal  of  the 
American  Medical  Association  of  January  6,  1906, 
Dr.  Emerson,  who  has  especially  attended  to  this 
subject,  bases  his  conclusion  on  1,000  cases  with  500 
autopsies  of  supposed  diseases  of  the  kidney,  has 
demonstrated  the  great  difficulty  in  diagnosticating 
a  nephritis  from  the  characteristics  of  the  urine 
alone.  Of  diseases  grouped  under  the  term  nephri- 
tis. Dr.  Emerson  found  that  out  of  eleven  cases  of 
extreme  chronic,  passive  congestion  without  any 
microscopic  evidence  of  nephritis  postmortem,  eight 
were  clinically  diagnosticated  as  nephritis.  Thirteen 
out  of  109  cases  of  acute  nephritis  were  recognized 
first  at  autopsy.  One  in  every  four  was  wrongly 
diagnosticated.  In  forty-six  of  104  cases  of  chronic 
incurable  nephritis  (or  forty-three  per  cent.),  the 
diagnosis  was  not  made  in  life.  The  presence  of 
cast  and  of  albumin  in  the  chronic  interstitial  nephri- 
tis has  been  much  overrated.  Dr.  Emerson  con- 
tinues :  "The  cast  may  be  a  good  index  of  the  pres- 
ent state  of  the  cell  ....  but  gives  abso- 
lutely no  clue  to  the  process  behind  that  condition 
of  the  cell.  In  fact,  it  seems  as  if  the  cell  of  a  nor- 
mal kidney  could  give  a  more  brilliant  demonstration 
of  their  disturbed  condition  by  a  more  brilliant  out- 
put of  cast  than  could  those  of  a  diseased  kidney : 
Diseased  kidneys  'seem  to  become  accustomed  to 
their  condition." 

These  facts  show  decisively  that  the  methods  gen- 
erally employed  merely  give  the  roughest  sort  of 
information,  and  how  difficult  it  is  to  predicate  the 

^Cabot,  New  York  Medical  Journal,  May  12.  1906. 


1 


994 


CRISPIN:  INDIVIDUAL  AS  A  SURGICAL  FACTOR. 


[New  York 
Medical  Journal, 


actual  condition  of  the  kidneys  by  the  customary  ex- 
amination now  in  vogue. 

The  question  which  the  surgeon  has  to  answer  is 
How  are  the  kidneys  functionating?  Is  there  renal 
inadequacy?  The  cumulative  evidence  since  that 
question  was  propounded  is  of  such  a  nature  as  to 
serve  rendering  the  facts  more  clear.  The  surest 
way  to  know  whether  the  kidneys  are  working  prop- 
erly, and  that  there  is  any  toxic  retention  with  its 
consequence,  is  by  the  quantitative  valuation  of  the 
solids  voided  in  the  twenty-four  hours.  In  the  ir- 
ritation of  the  kidneys,  as  Dr.  Cabot  calls  it,  in  in- 
flammations, be  it  acute  or  chronic,  or  in  insuffi- 
ciency from  whatever  cause,  there  is  retention  of 
the  excrementitious  products,  and  the  solid  materials 
of  the  urine  are  represented  by  lower  figures ;  ac- 
cording to  this  falling  it  indicates  the  power  or 
elimination  of  the  kidneys  and  shows  when  oliguria 
or  anuria  are  imminent.  It  is  a  well  known  physio- 
logical fact,  that  the  amount  of  water  in  the  urine 
voided  is  subject  to  great  variations,  depending  on 
the  quantity  of  water  ingested,  but  the  amount  of 
solids  in  the  urine  has  a  certain  fixidity  in  health, 
and  that  any  increase  or  diminution  of  which  indi- 
cates some  abnormality  and  is  pathological.  The 
proportion  of  solids  in  normal  urine  bears  also  a 
certain  ratio  to  the  normal  body  weight,  below  which 
it  can  not  fall  without  indicating  embarrassment  of 
the  renal  function.  Taking  this  as  a  basis.  Dr. 
Etheridge  had  a  physiologist  to  construct  two  tables 
of  the  relation  of  the  body  weight  of  healthy  human 
beings  to  the  total  excretion  of  urinary  solids.  One 
of  the  tables  was  for  women  who  naturally  exercise 
less,  and  the  limit  was  fixed  at  500  grains  for  a  wo- 
man weighing  90  pounds  and  1,100  grains  for  one 
weighing  180  pounds,  or  at  the  rate  of  35  grains  for 
each  additional  five  pounds  or  seven  grains  to  the 
pound.  Collecting  and  measuring  the  urine  of  the 
twenty-four  hours,  the  total  amount  of  solids  can  be 
easily  reckoned  by  Haine's  modification  of  Haeser's 
method,  which  consist  in  multiplying  the  last  two 
figures  of  the  specific  gravity  of  the  urine  by  the 
number  of  ounces  voided  in  the  twenty-four  hours, 
and  adding  ten  per  cent,  to  the  product.  Thus,  if 
the  amount  passed  in  the  twenty-four  hours  was  36 
ounces,  and  the  specific  gravity  i. 021  it  would  be  36X 
21  =  756  -H  10  per  cent.  =  831,  the  amount  of  grains 
of  solids  in  the  whole  quantity.  By  referring  to  the 
tables  it  can  readily  be  seen  whether  this  is  above 
or  below  the  normal  amount.  This  is  an  easy  and 
accurate  clinical  procedure  which  can  be  convenient- 
ly employed  by  all,  superior  to  the  cumbersome 
methods  of  the  laboratory.  It  is  superior  to  the  von 
Norden's  method,  of  large  injections  of  water,  al- 
though it  can  be  used  in  conjunction  with  it,  and 
also  more  certain  than  the  employment  of  drugs, 
such  as  methylene  blue  or  iodine,  given  with  the 
purpose  of  testing  the  eliminative  power  of  the  kid- 
neys. None  of  these  means  will  answer  as  well  and 
as  faithfully  as  the  one  herein  advocated.  It  is  clear 
that  if  a  patient  is  eliminating,  let  us  say  150  grains 
of  solids  in  the  twenty-four  hours,  when  he  ought 
to  pass  1,100  grains,  there  is  a  very  serious  condi- 
tion present,  and  to  subject  such  a  patient  to  an 
operation  under  the  circumstances  is  fraught  with 
grave  danger. 

There  are  certain  symptoms    occurring  during 


pregnancy,  of  a  menacing  nature  to  the  life  of  the 
mother,  in  which  the  question  of  the  induction  of 
premature  labor  may  have  to  be  considered.  Symp- 
toms which  the  chemical  and  microscopic  uranalysi? 
fail  to  announce,  but  in  which  the  total  valuation  of 
the  solids,  together  with  other  symptoms  which  de- 
note an  impending  eclampsia,  may  throw  a  flood  of 
light  as  to  the  indication  of  inducing  labor. 

Renal  insufficiency  is  one  of  the  predisposing 
causes  of  shock,  and  close  attention,  before  opera- 
tion, to  the  eliminating  power  of  the  kidney,  will 
do  much  toward  guarding  against  this  calamity. 

Asthenia. 

The  apparently  inexorable  character  of  economic 
laws,  which  condemns  thousands  of  laborers  to  a 
cramped  and  miserable  existence,  and  thousands 
more  to  semi-starvation,  is  responsible  for  many  of 
the  failures  encountered  by  the  surgeon  in  his  work. 
For  in  the  nature  of  things,  most  of  our  patients  are 
recruited  from  the  ranks  of  the  tired  and  underfed. 

The  evil  effect  of  overwork  and  poor  feeding,  al- 
though known,  has  not  received  the  attention  it  de- 
serves, specially  in  the  way  of  the  previous  prepara- 
tory treatment  of  the  patient  who  is  to  be  put  to  the 
crucial  test,  undergoing  a  severe  strain  on  his  al- 
ready exhausted  reserve  forces. 

The  question  of  the  nitrogenous  equilibrium  is 
of  great  importance,  especially  among  the  poorer 
classes  of  the  community  in  whom  the  output  of 
nitrogenous  matter  from  the  system  far  exceeds 
that  taken  in  by  way  of  food.  This  nitrogenous 
waste  is  so  great  that  it  lowers  the  individual  to  a 
physiological  misery,  in  which  he  is  hardly  able  to 
withstand  any  additional  strain  upon  his  powers.  In 
the  well  fed,  healthy  person,  the  store  of  glycogen 
within  the  organism  is  kept  at  a  level  amply  suffi- 
cient to  meet  the  requirements  of  the  system,  and 
even  if  on  any  occasion  the  daily  supply  falls  short, 
there  is  the  fat  stored  within  the  body,  which  can  be 
easily  drawn  upon  as  occasion  requires.  The  experi- 
mental researches  of  Schulz  have  shown  that  the 
amount  of  fat  in  the  body  is  no  measure  of  the  re- 
sistance of  the  organism  when  the  food  is  insuffi- 
cient. In  every  case  it  is  the  lack  of  proteids  that 
causes  death  of  starving  individuals.  In  the  poorly 
fed  organism,  when  the  other  two  sources  of  supply 
are  exhausted,  the  daily  expenditure  is  met  by  draw- 
ing from  the  nitrogenous  tissue  of  the  body  with 
great  diminution  of  energy  and  strength.  The  nor- 
mal output  is  from  fifteen  to  twenty  grammes  daily 
(Grainger  Stewart),  and  in  this  case  it  rises  to 
thirty  or  forty  grammes. 

Overwork  by  lowering  the  resistance  of  the  tissue 
favors  microbic  infection,  and  is  thereby  a  surgical 
factor  of  no  mean  importance. 

It  was  demonstrated  long  ago,  by  Charrin  and 
Roger,  that  fatigue  diminishes  the  resistance  to  mi- 
crobic diseases,  and  this  they  proved  by  the  simple 
experiment  of  subjecting  several  guinea  pigs  and 
rats  to  excessive  work.  They  constructed  a  drum 
or  cylinder,  similar  to  those  attached  to  the  cages 
of  squirrels,  forty  centimetres  in  height  by  one 
metre  in  diameter,  carefully  protecting  its  interior 
so  that  the  animals  could  not  injure  themselves.  It 
was  arranged  so  that  the  animal  had  to  walk  in  the 
opposite  direction  to  the  movement  CDmnumicated  to 


May  15,  1909.] 


CRISPIN:  INDIVIDUAL  AS  A  SURGICAL  FACTOR. 


995 


the  cylinder,  which  moved  at  the  rate  of  2,260 
metres  per  hour.  In  this  way  they  were  made  to 
undergo  fatigue.  Different  species  behaved  differ- 
ently, and  showed  an  unequal  resistance  to  the  ex- 
ercise. 

Thirty-six  rats  were  used  in  this  experiment,  six- 
teen of  which  served  as  controls ;  the  other  twenty- 
one  were  subjected  to  excessive  labor.  Two  micro- 
organisms were  employed  to  inoculate,  the  bacterium 
of  carbuncle  and  the  bacterium  of  symptomatic  car- 
buncle. After  the  lapse  of  twenty-four  hours,  those 
which  had  been  overworked  died,  while  the  controls 
lived  to  the  fifth  day,  and  to  kill  them,  they  had  to 
be  injected  repeatedly  and  very  large  doses  used. 
The  dead  animals  presented  the  following  lesions : 
The  intestines  were  congested  and  full  of  diarrhoeal 
liquid;  the  urine  contained  albumin,  and  in  some 
cases  the  parenchyma  of  the  liver  hardly  contained 
any  glycogen.  These  animals  are  normally  refrac- 
tory to  this  bacteria,  nevertheless  they  were  found 
even  in  their  tissues. 

Fatigue  has  a  very  marked  influence  on  the  struc- 
ture of  the  nerve  cells,  which  was  investigated  by 
Guido  Guerini,  Lancet,  October  21,  1899.  His  ex- 
perimental study  in  dogs  showed  extensive  altera- 
tion in  the  nerve  cells,  with  increase  of  the  peri- 
cellular lymphatic  spaces  and  decomposition  of  the 
pigment  mass. 

These  are  weighty  physiological  reasons  which 
emphasize  the  great  importance  of  the  proper  prepa- 
ration of  the  patient  in  the  way  of  rest  and  food. 
It  is  of  moment  to-day,  when  the  "gospel  of  stren- 
uousness"  has  been  preached  on  all  sides. 

There  are  those  who  advocate  immediate  opera- 
tions, ambulatory  treatment  of  fractures,  and  quasi 
ambulatory  treatment  of  laparotomy  cases,  which 
they  state  ought  to  be  out  of  bed  on  the  second  or 
third  day,  forgetting  the  danger  of  hernia,  phlebi- 
tis, and  thrombosis.  Rest  is  as  essential  before  as 
after  operation,  for  at  both  times  it  is  highly  con- 
ducive to  the  repair  of  wounds.  In  this  connection 
we  can  well  recall  the  advice  of  Dr.  H.  Gushing, 
that  patients  of  advanced  years  be  kept  in  bed  a  few 
davs  before  operation,  to  test  their  ability  to  endure 
recumbency  and  to  train  them  to  void  urine  in  this 
position.  This  practice  ought  to  be  followed  with 
every  patient,  be  they  young  or  old.  With  the  fee- 
ble it  is  imperative  as  with  all,  for  if  nothing  else,  it 
will  increase  their  postoperative  comfort.  There  is 
no  better  cardiac  tonic  than  rest,  it  is  a  balm  to  the 
overwrought  nervous  system,  the  best  regulator  of 
the  circulation  and  thereby  increasing  the  function 
of  the  kidneys.  It  husbands  the  forces  of  the  or- 
ganism, and  is  an  invaluable  aid  to  aseptic  surgery. 
Autointoxication. 

Science  is  so  correlated  that  progress  in  one 
branch  is  certain  to  influence  the  others.  Surgery 
has  profited  by  the  stimulus  given  it  by  physiolog- 
ical advances,  and  we  can  truly  say  that  it  is  now 
entering  a  new  era.  The  tendency  is  in  the  direc- 
tion of  a  better  appreciation  of  physiological  facts, 
and  their  application  to  the  surgical  art.  Nowhere 
else  is  this  so  marked  than  in  abdominal  work.  Here 
the  due  appreciation  of  the  doctrine  of  phagocy- 
tosis and  opsonic  reactions  is  swaying  the  'conduct 
of  surgeons,  and  the  time  is  not  far  distant  when 
patients  will  be  prepared  for  operation  by  routine 


immunization  with  vaccines  which  control  the 
causes  of  infection,  or  prevent  their  development. 
This  is  now  done  in  those  communities  where  teta- 
nus is  endemic. 

With  a  better  understanding  of  the  ductless 
glands,  due  to  the  great  work  of  Dr.  Sajous,  of 
Philadelphia,  a  new  horizon  is  visible ;  and  when 
we  learn  to  control  the  function  of  these  glands,  a 
decided  advance  wall  be  accomplished.  The  role 
played  by  microorganisms  which  normally  inhabit 
the  alimentary  canal  is  becoming  more  appreciated. 
The  two  principal  microbes  with  which  we  have  to 
contend  in  the  digestive  tract  are  the  Bacillus  coli 
and  the  Staphyloccociis  aureus.  How  to  control 
their  number  and  virulence  is  a  problem  of  the 
greatest  importance,  specially  in  operations  of  the 
stomach  and  intestines. 

Intestinal  putrefaction  is  one  of  the  most  prolific 
causes  of  autointoxication  and  is  one  of  the  notable 
advances  in  pathology  due  to  the  admirable  re- 
searches of  Bouchard.  This  intestinal  autointoxi- 
cation is  due  to  the  action  of  bacteria  both  upon  the 
proteids  and  the  carbohydrates  which  induce  putre- 
faction which  may  be  either  proteolytic  or  sacchar- 
olytic.  In  the  proteolytic  digestion  certain  ferments 
are  obtained  as  byproducts  forming  indol,  skatol, 
etc. ;  and  in  the  saccharolytic  fermentation  no  indol 
is  produced  but  ethereal  sulphates.  Putrefactive  or- 
ganic matter  produces  at  times  certain  alkaloids 
which  are  the  most  deadly  known  poisons,  causing 
death  even  in  infinitesimal  quantities.  Even  in  its 
milder  forms,  intestinal  toxaemia  predisposes  to  sa- 
praemia,  septichsemia,  and  even  pyaemia,  and  in  many 
instances  the  bloodpoisoning  manifested  by  surgical 
patients  is  not  due  to  the  surgical  wound,  or  to  the 
neglect  of  asepsis,  but  rather  to  the  failure  of  having 
previously  corrected  this  condition.  We  have  to 
consider  the  enterogenic  toxines  as  setiological  fac- 
tors, but  also  the  possibility  of  their  being  the  causes 
of  a  continuance  of  the  symptoms  after  the  more 
generally  recognized  and  accepted  causes  have  been 
overcome.  It  is  true  that  intestinal  intoxication  may 
sometimes  be  interpreted  as  an  effort  of  elimination 
by  the  development  of  a  skin  disease,  and  also  on 
another  occasion  as  a  choroiditis  or  uveitis. 

The  symptoms  of  intestinal  autointoxication  not 
unfrequently  closely  simulate  other  diseases,  such 
as  septicaemia  and  typhoid.  In  intestinal  putrefac- 
tion these  products  of  a  toxic  nature  possessing  a 
haemolytic  action  prevent  or  retard  the  healing  of 
wounds,  and  on  other  occasions  exert  their  influ- 
ences on  the  nervous  system,  according  to  the  locus 
minoris  resistentia. 

The  urine  shouldalways  be  tested  for  indican,and 
when  it  is  present  it  should  receive  serious  attention, 
although  indicanuria  may  exist  for  years  and  be 
compatible  with  a  perfect  state  of  health,  especially 
when  the  tissues  are  unimpaired  and  able  to  cope 
with  them,  the  system  eliminating  rapidly  all  this 
toxic  matter.  The  individual  may  establish  a  toler- 
ance to  these  bodies,  which  may  be  interrupted  or 
suspended  when  he  suffers  any  severe  traumatism. 

Until  now  our  resource  for  the  control  of  these 
bacteria  and  toxines  has  been  limited  to  the  action 
of  cathartics,  regulation  of  diet,  buccal  asepsis,  and 
intestinal  antiseptics.  Valuable  means  no  doubt, 
but  not  wholly  efficient. 


996 


CRISPIN:  INDIVIDUAL  AS  A  SURGICAL  FACTOR. 


[New  York 
Medical  Jourval. 


The  ingenuity  of  surgeons  and  specially  of  the 
American  surgeon,  who  is  to-day  foremost  in  ab- 
dominal work,  has  been  in  the  direction  of  prevent- 
ing infection,  by  cleverly  contrived  devices  to  shut 
off  the  intestines  between  the  parts  which  are  to 
be  resected  by  means  of  forceps,  ligature,  etc.  A 
good  deal  is  accomplished  in  this  way,  but  an  asep- 
tic operative  field  is  not  oljtained.  The  method  pro- 
posed by  Metchnikoff  of  substituting  the  noxious 
microbe  with  an  inoffensive  lactacid  one,  adminis- 
tered in  the  form  of  a  scientifically  soured  milk  to 
control  and  arrest  intestinal  putrefaction,  deserves 
a  more  extended  trial  than  what  has  been  given  it. 
It  IS  easy  of  employment  and  it  serves  as  a  food 
and  as  a  corrective  to  the  intestinal  flora. 

In  operations  of  the  large  bowels,  an  extended 
preparation  of  the  patient  is  becoming  more  gener- 
alized, and  in  a  recent  number  of  the  A^ew  York 
Medical  Journal,  September  5,  igo8.  Dr.  J.  P.  Tut- 
tle  asserts  that  the  lower  mortality  in  his  recent 
series  of  cases  is  more  largely  due  to  this  than  to 
improved  skill  in  operating.  He  now  prepares  his 
patients  a  full  week  or  more  instead  of  three  or  four 
days,  as  previously. 

In  addition  to  the  regulation  of  the  diet,  and  of 
all  the  other  means  necessary  to  eliminate  as  many 
as  possible  of  the  colon  bacillus,  the  recommenda- 
tion of  Dr.  P.  E.  Truesdale,  of  Fall  River,  Mass., 
is  full  of  promise.  Dr.  Truesdale  advises  an  im- 
munizing dose  of  stock  vaccine  to  be  given,  basing 
his  suggestion  on  the  opsonic  theory  on  which  the 
vaccine  therapy  has  been  laid  down  by  Wright  and 
others.  He  advises  that  immunizing  doses  of  from 
0.5  CO.  to  0.25  c.c,  of  the  vaccine  be  administered 
before  operation  in  cases  of  acute  infection  of  the 
bile  duct,  pancreas,  and  of  the  large  intestines ;  for 
it  is  found  that  the  'colon  bacillus  is  the  common 
cause  of  the  infection.  We  may  thus,  possibly,  con- 
trol the  acute  infection  and  operate  during  the  in- 
terval. 

Tlie  tlusliing  of  the  system  with  water,  days  l)e- 
fore  the  operation,  is  another  effective  means  of  di- 
minishing the  number  of  these  organism.  Water 
dilutes  and  aids  in  the  elimination  of  the  injurious 
ferments  produced  by  these  bacteria,  which  act 
chemically  on  the  tissues.  It  has,  besides,  the  prop- 
erty of  preventing  the  tormenting  thirst  .so  often 
complained  of  by  patients  after  operations.  The  suf- 
fering caused  by  depriving  patients  of  water,  after  a 
laparotomy  or  herniotomy,  is  a  thing  that  can  not 
be  recalled  but  with  regret.  From  the  early  days 
of  modern  abdominal  surgery,  the  established  prin- 
ciple has  been  to  deprive  the  patients  of  water,  and 
until  recently  their  burning  thirst,  their  dry  and 
parched  tongues,  and  their  ineffectual  cry  for  "just 
a  little  water"  was  met  with  the  mockery  of  a  piece 
of  cotton  moistened  with  water.  It  still  lingers  in 
my  mind,  the  plaintive  pleading  of  a  man,  eighty 
years  old,  upon  whom  I  had  to  operate  for  a  stran- 
gulated hernia.  His  tormenting  thirst  could  not  be 
t|uenched  l)y  the  few  drops  of  water  given  him.  He 
watched  for  the  opportunity  to  get  out  of  bed,  and 
spying  a  bottle  of  wliiskey  at  the  other  end  of  the 
warcl,  drank  its  contents,  which  was  more  than  half 
a  bottle.  There  was  a  recurrence  of  the  hernia, 
stitches  torn,  and  death  from  colIap.sc.  Fortunately 
to-day  the  canon  of  "water  externally,  internally, 


and  eternally"  has  a  recognized  position,  and  the 
administration  of  saline  solution,  by  intravenous, 
intraperitoneal  cellular,  and  rectal  methods,  are  ex- 
tensively used  to  combat  shock  and  haemorrhage. 
The  first  one  to  use  large  injection  of  saline  salution 
intravenously  was  Latta,  of  Leith,  who  in  1830 
conceived  this  bold  idea. 

These  procedures  are  to-day  securely  fixed  in  the 
routine  of  every  surgeon  as  a  postoperative  pro- 
cedure. But  why  not  use  it  before  operations,  so 
as  to  anticipate  those  terrible  twins  shock  and 
haemorrhage  ?" 

The  filling  up  of  the  lymphatics,  to  the  physio- 
logical limit,  by  the  administration  of  large  injec- 
tions of  water  by  way  of  the  rectum,  before  opera- 
tions, has  a  salutary  effect  on  the  final  result.  This 
water  will  be  absorbed  and  will  help  keep  the  vascu- 
lar tension  within  the  norm,  it  will  replace  the  lost 
blood,  and  help  to  eliminate  toxic  substances,  stim- 
ulating every  function  of  the  body,  for  without  water 
they  can  not  be  performed.  It  may  be  feared  that 
this  increase  in  the  liquids  of  the  body  will  favor 
haemorrhage,  but  experience  has  proved  the  con- 
trary. The  facility  of  its  employment  is  another 
important  point.  Following  the  customary  cathar- 
sis, and  the  regulation  of  the  diet  the  patient  should 
be  instructed  to  drink  water  freely,  and  large  high 
rectal  injections  be  used  several  days  before  operat- 
ing. After  the  operation,  the  method  of  Dr.  ]\Iur- 
phy,  of  Chicago,  of  continuous  rectal  irrigation  may 
be  continued. 

Hepatic  IiisiitHciency. 
More  than  a  quarter  of  a  century  ago,  \"erneuil 
wrote :  "We  shall  understand  what  weight  hepatism 
possesses  in  the  question  of  surgical  indication,  and 
we  shall  wonder  that  a  fact  of  such  gravity  should 
have  for  so  long  a  time  remained  unrecognized." 
And  to-day  we  are  still  wondering  that  no  great 
progress  has  been  accomplished  in  this  direction. 
The  influence  which  hepatic  disease  may  have  on 
the  termination  of  surgical  diseases  is  a  subject 
hardly  mentioned  by  the  authors,  and  the  importance 
of  hepatic  insufficiency  is  nowhere  treated  in  ex- 
tenso. 

There  is  no  doubt  that  this  unique  gland,  which 
has  no  analogue  in  the  system,  must  have  an 
important  influence  in  the  final  recuperative  process, 
and  when  we  consider  its  varied  functions,  uroge- 
nous,  chromatogenous,  glycogenic,  and  the  deten- 
tion and  destruction  of  toxic  intestinal  substances, 
there  is  no  good  reason  to  suppose  that  it  has  not 
a  prominent  influence  on  surgical  operations.  Not 
only  of  those  diseases  of  the  liver  or  gallbladder  it- 
self, but  of  every  other  part  of  the  organism.  .Ml 
chronic  and  progressive  lesions  of  the  liver,  from 
whatever  origin,  converge  sooner  or  later  to  the 
.same  end,  the  degeneration  of  the  hepatic  cells  with 
the  abolition  of  its  multiple  functions  or  hepatic  in- 
sufficiency. The  urogcnic  function  of  the  liver  is 
probably  the  most  important.  Hepatic  urine  is  gen- 
erally scanty,  hardly  reaching  one  quart  in  the  twen- 
ty-four hours,  dark  in  color  with  a  reddish  uratic 
deposit.  There  exist  with  this  oliguria  a  more  se- 
rious phenomenon,  the  diminution  of  the  quantity 
of  solids,  and  this  progressive  diminution  is  of  the 
most  grave  prognostic  value.  I  have  said  elsewhere 
that  the  kidnevs  are  in  afl'ections  of  tlie  liver,  like  a 


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997 


barometer,  by  means  of  which  we  can  prognosticate 
the  outcome. 

This  need  not  apply  solely  to  those  extreme  cases 
to  which  Dr.  C.  H.  Cumston  refers  in  a  very  inter- 
esting article.  The  Frontiers  of  Death  in  Surgery  in 
the  Xezv  York  Medical  Journal,  July  28,  19C6,  in 
which  he  says:  "Generally  speaking  oliguria  and 
anuria  indicate  that  a  patient  is  a  noli  mc  tangcrc 
and  consequently  should  not  be. interfered  with  sur- 
gically." These  patients  are  in  extremis  and  ever  No- 
thing will  bo  useless.  But  in  other  conditions  in 
which  there  does  not  exist  such  absolute  anuria,  in 
which  the  liver  seems  to  have  lost  its  oxidizing  pow- 
ers momentarily,  with  subsequent  retention  of  the 
excremcntitious  products,  as  expressed  by  lower  fig- 
ures in  the  total  amount  of  urinary  solids,  every  ef- 
fort should  be  made  to  correct  this  before  interfe;- 
ing  surgically. 

As  the  liver  partakes  of  or  reflects  the  general  con- 
dition of  the  system,  the  estimation  of  its  functiofal 
capacity  is  of  importance  even  independently  of  the 
lesion  of  the  organ  itself.  It  has  been  said  that  tho 
toxiemia  depends  on  an  acid  intoxication,  and  re- 
tention of  the  cholesterine,  the  bile  being  generally 
alkaline,  but  Bernard  found  it  to  be  sometimes  acid 
in  dogs  and  rabbits  on  whom  he  operated,  this  was 
probably  due  to  the  severe  operation  which  these 
animals  underwent.  It  has  also  been  noted  (Flint) 
that  anjesthetics  and  irritating  vapors  produce  alter- 
ation in  the  glycogenic  function  of  the  liver,  pro 
ducing  a  diabetes  which  has  been  attributed  to  the 
i'  i  itation  conveyed  to  the  nerve  centres  by  the  pneu- 
mogastric  which  is  then  reflected  in  the  form  of  a 
stimulus  to  the.  liver.  This  shows  that  the  f\jnctions 
nf  the  liver  can  be  influenced  through  the  nervous 
system,  which  may  stimulate  or  depress  it.  Much 
confusion  exists  on  the  subject  of  jaundice.  There 
is  a  clinical  tradition  that  certain  morbid  conditions 
are  accompanied  by  a  predominant  symptom — jaun- 
dice— which  generally  terminates  in  a  complete  cure, 
while  another  ends  generally  in  death.  This  was 
the  ancient  division  into  simple  and  grave  jaundice. 
Osier  divided  those  cases  into  a  hepatogenous  and 
hemotogenous  jaundice,  according  to  the  supposed 
location  of  the  trouble.  The  great  difficulty  is  in 
the  dividing  line  between  the  two  forms,  clinically 
we  know  that  behind  the  jaundice,  be  it  simple 
(benign)  or  grave,  there  is  a  condition  which  is  es- 
sentially toxic  and  that  its  gravity  depends  on  two 
factors,  the  degree  of  alteration  of  the  hepatic  cells, 
and  the  degree  of  renal  permeability. 

The  best  defence  of  the  organism  against  this 
autoinfection  is  the  kidneys,  and  we  know  that  if 
a  patient  continues  to  urinate,  the  urinary  and  toxic 
crisis  will  terminate  favorably.  Simple  jaundice  is 
the  one  in  which  the  renal  function  is  sufficient,  and 
is  produced  by  many  causes',  especially  the  propaga- 
tion by  continuity  of  a  gastroduodenal  catarrh  as 
was  first  described  by  Virchow.  Grave  jaundice  is 
that  in  which  the  integrity  of  the  hepatic  cells  is  al- 
tered anatomically  and  functionally,  with  insufficient 
renal  excretion.  Of  this  grave  jaundice  there  are 
two  types,  the  primitive,  which  is  a  rare  disease,  due 
to  some  unknown  pathogenic  agent,  which  attacks 
individuals  in  perfect  health ;  and  the  secondary 
grave  jaimdice.  which  is  the  most   common  and 


which  may  supervene  on  a  preexisting  jaundice  :  it 
is  observed  in  hypertrophic  cirrhosis  and  often  fol- 
lows a  lithiasis,  a  colangeitis  or  any  retention  of 
bile.  This  very  old  nomenclature  of  simple  and 
grave  jaundice  has  the  advantage  of  being  uncom- 
plicated with  any  theory,  although  by  no  means  ex- 
act, in  the  present  state  of  our  knowledge,  it  is  as 
good  as  any  and  better  than  many.  It  is  weak  in 
as  much  as  it  does  not  include  those  cases  which  lie 
between  the  two  groups  and  for  which  it  was  pro- 
posed the  name  of  semigrave.  But,  provisionally, 
this  division  is  the  best,  meeting  the  surgical  re- 
quirement. 

It  is  difficult  to  generalize  on  a  subject  compact 
of  individual  cases,  specially  with  insufficient  data, 
but  the  capital  question  is.  what  is  the  condition  of 
the  hepatic  cells?  How  are  they  functionating?  Is 
there  insufficiency?  For  after  all,  it  all  hinges  on 
the  number  of  hepatic  cells  which  remain  unim- 
paired, and  on  the  efficiency  of  the  renal  function. 

The  presence  of  grave  jaundice  is  generally  a  con- 
traindication to  operation,  for  besides  the  changes 
in  the  blood,  the  kidneys  become  affected,  the  blood 
appears  to  have  lost  its  power  of  coagidation  or  this 
power  is  markedly  delayed.  The  anuria  may  not 
supervene  immediately,  but  a  few  davs  after  opera- 
tion and  jeopardize  the  life  of  the  patient.  An  icteric 
person  takes  the  anaesthetic  badly;  the  respiration 
is  often  interrupted  during  operation,  with  great 
danger  to  sudden  death.  ]\Inay  remedies  have  been 
proposed  to  increase  the  coagulability  of  the  blood, 
such  as  large  doses  of  calcium  chloride,  gelatine, 
and  adrenalin,  and  notwithstanding  the  distin- 
guished authorities  who  recommend  them,  it  has 
proved  futile  in  my  hands. 

There  are  two  things  which  can  not  be  sufficiently 
emphasized,  the  precious  information  which  is  to  be 
gained  by  the  valuation  of  the  total  amount  of  uri- 
nary solids,  both  for  diagnostic  and  prognostic  pur- 
poses, and  the  great  danger  attending  operations 
when  grave  jaundice  is  present. 

Glycosuria. 

The  presence  of  sugar  in  the  urine  is  of  consider- 
able importance  to  the  surgeon.  A  patient  may  not 
have  an  established  diabetes,  but  the  existence  of 
sugar  in  his  urine  is  of  grave  omen.  It  is  well 
known  since  the  time  of  \'erneuil,  that  certain  gan- 
grene, ulcer,  and  furuncular  eruptions  are  intimate- 
ly connected  with  diabetes  and  that  they  can  not  be 
cured  until  all  the  sugar  has  disappeared  from  the 
urine.  At  present  the  aetiology  of  glycosuria  is  still 
unsettled.  Diabetes  may  be  considered  a  cryptogenic 
disease,  possibly  having  multifarious  causes,  often 
traced  to  some  abnormalit}-  of  metabolism.  When 
permanent  it  is  a  cellular  disease,  having  some  simi- 
larity with  gout.  Diabetes  frequently  follows  trau- 
matism, especially  those  of  the  head,  also  tumors  of 
the  cerebellum.  It  is  not  necessary  for  the  tumor  or 
the  traumatism  to  involve  exactly  the  floor  of  the 
fourth  ventricle  and  thus  realize  the  experiment  of 
Claude  Bernard.  It  has  also  been  observed  in  other 
injuries  besides  those  of  the  head,  as  in  fracture  of 
the  long  bones.  This  glycosuria  is  generally  of  a 
transitory  nature,  lasting  but  a  few  days.  In  the 
traumatic  variety  the  glycosuria  has  shock  for  its 
principal  setiological  factor,  especially  concussion  of 


998 


CRISPIN:  INDIVIDUAL  AS  A  SURGICAL  FACTOR. 


[Ne'V  lORK 

Medical  Journal. 


the  cerebrospinal  axis.  It  has  been  said  by  Kausch, 
that  in  addition  to  the  mechanical  concussion  of  the 
body,  the  psychic  effect  of  trauma,  causing  mental 
shock,  is  capable  of  determining  a  glycosuria. 

Diabetic  patients  constitute  a  dangerous  class,  and 
surgical  interference  must  be  limited  to  emergency 
cases  where  the  exigency  of  the  condition  is  such 
that  operation  canot  be  withheld,  as  in  intestinal  ob- 
struction, strangulated  hernia,  or  gangrene.  The 
percentage  of  sugar  needs  not  be  large  to  cause 
death,  and  I  have  seen  a  fatal  termination  by  coma 
following  a  rapidly  formed  herniotomy,  and  where 
a  very  small  amount  of  sugar  was  obtained.  The 
slightest  contusion  or  abrasion,  even  the  most  insig- 
nificant wounds  and  punctures,  are  liable  to  produce 
in  diabetics,  extensive  sloughing  and  gangrene.  The 
moderate  pressure  of  the  shoe  I  have  known  to  pro- 
duce gangrene  of  the  toe.  Prophylaxis  is  therefore 
imperative  in  diabetics,  who  should  be  warned  as  to 
the  danger  of  small  wounds.  The  absence  of  sugar 
in  a  diabetic  is  no  security  against  postoperative 
coma,  and  a  case  is  cited  where  coma  supervened 
after  operation  in  a  patient  whose  urine  had  been 
free  from  sugar  for  two  years  (Halstead). 

It  is  said  by  some  that  the  presence  of  acetone  and 
oxybutyric  acid,  and  especially  the  ammonia,  is  of 
greater  significance  than  the  amount  of  sugar. 

Besides  the  danger  of  the  traumatism,  the  anaes- 
thesia itself  is  a  source  of  grave  peril  to  diabetics. 
Beesly  has  called  attention  to  an  acute  anaesthetic 
acetonuria,  occurring  even  in  nondiabetics,  which 
causes  symptoms  after  operation,  sometimes  fol- 
lowed by  death,  which  are  either  unaccounted  for  or 
are  attributed  to  wrong  causes,  and  which  are  due 
to  an  acid  intoxication  of  sudden  occurrence  and  of 
variable  intensity  originated  by  the  anaesthetic  and 
indicated  by  the  degree  of  acetone  in  the  urine. 
Diabetics  are  especially  prone  to  this  acetonuria,  and 
therefore,  when  possible,  local  anaesthesia  should  be 
given  the  preference. 

Be  this  as  it  may,  one  thing  is  certain  beyond  per- 
adventure,  that  all  surgical  intervention  on  persons 
having  glycosuria  should  be  treated  with  the  great- 
est circumspection ;  for  not  only  is  there  danger  to 
fatal  coma,  but  the  existence  of  sugar  in  the  blood 
results  in  arterial  sclerosis  and  trophic  nerve  degen- 
eration, which  causes  a  lower  power  of  resistance  of 
the  tissue,  favoring  infection  and  preventing  the 
healing  of  operation  wounds.  The  administration 
of  alkalies  has  been  recommended  to  neutralize  the 
acidity,  and  the  sodium  bicarbonate  has  been  ex- 
tolled, but  nothing  diminishes  the  sugar  so  rapidly 
in  diabetics  as  the  use  of  the  sodium  salicylate,  which 
unfortunately  is  not  permanent.  Very  large  doses 
are  well  tolerated  and  it  may  be  used  with  advantage 
at  critical  times  to  stop  the  waste.  The  question 
arises,  what  is  the  best  course  to  pursue  when  gan- 
grene has  set  in?  What  shall  we  do?  This  ques- 
tion has  not  been  satisfactorily  settled,  but  the  con- 
sensus of  opinion  is  to  operate  under  local  anaesthe- 
sia, avoiding  general  narcosis  if  possible  and  to  am- 
putate when  the  line  of  demarcation  is  well  marked, 
and  to  cut  far  away  from  the  gangrene,  and  to  do  it 
as  rapidly  as  possible.  It  is  necessary  to  go  beyond 
the  obliterating  endarteritis  and  phlebitis  which  has 
produced  the  gangrene,  not  forgetting  to  employ  a 
vigorous  medical  and  antidiabetic  regime. 


Cardiac  Insufficiency. 
Advanced  heart  disease  is  a  contraindication  to 
surgical  operations,  especially  when  compensation 
is  broken  and  there  exists  dilatation  or  fatty  degen- 
eration. 

The  condition  of  the  myocardium  is  of  greater 
importance  than  the  valvular  lesion,  and  it  is  gen- 
erally agreed  that  the  valvular  lesion  per  se,  when 
well  compensated,  needs  not  be  deterrent  to  surgical 
intervention. 

The  influence  which  certain  diseases  have  on  the 
heart  is  well  demonstrated  in  uterine  fibroids. 
These  neoplasm  have  a  peculiar  selective  action  on 
the  heart,  weakening  it  to  a  marked  extent,  espe- 
cially when  of  large  size,  often  leading  to  venous 
thrombosis,  pulmonary  embolism,  or  shock.  It  is 
here  where  a  carefully  preparator}'  treatment  mani- 
fests its  undisputed  utility.  The  desire  to  keep 
within  the  limits  of  this  generalization  prevents  me 
from  referring  to  cases  where  these  precautions  were 
advised  but  not  followed  and  the  omission  was  paid 
with  life.  But  I  can  not  refrain  from  citing  a  case 
lately  sent  me  by  Dr.  Guillermo  Cook,  of  Maracaibo, 
Venezuela,  in  which  I  successfully  removed  a  fibroid 
weighing  eleven  pounds.  The  condition  of  this  pa- 
tient's heart  was  very  serious,  as  the  result  of  myo- 
carditis which  was  aggravated  by  the  fatigue  result- 
ing from  her  long  voyage ;  in  her  case  a  prolonged 
preparatory  treatment  markedly  contributed  to  the 
success.  The  preparation  consists  in  an  extended 
and  absolute  rest  in  bed,  with  the  internal  adminis- 
tration of  ergot.  The  beneficial  effect  of  this  treat- 
ment is  soon  manifested  by  better  heart's  action, 
diminution  of  metrorrhagia,  and  a  more  buoyant 
state  of  the  patient's  mind. 

Anmnia. 

The  undervaluation  of  the  state  of  the  blood,  and 
overvaluation  of  the  lesion  producing  it,  has  so  in- 
fluenced surgeons  that  they  are  liable  to  overlook 
the  irreparable  condition  of  the  blood  before  under- 
taking operation. 

Valuable  information  is  obtained,  no  doubt,  by  the 
previous  examination  of  the  blood,  enabling  the 
clinician  to  estimate  the  resisting  power  of  the  pa- 
tient, and  also  to  appreciate  the  degree  and  type  of 
anaemia  which  the  patient  might  be  suffering.  The 
type  of  anaemia  which  a  patient  may  have  will  influ- 
ence very  materially  the  final  result,  therefore  the 
importance  of  knowing  if  it  is  a  mild  anaemia  result- 
ing from  the  surgical  lesion  or  merely  associated 
with  it,  or  if  he  has  pernicious  anaemia  or  a  grave 
secondary  anaenjia.  Pernicious  anaemia  may  be  as- 
sociated with  anv  surgical  lesion  and  the  patient  is 
foredoomed,  therefore  the  great  importance  of  the 
distinctive  diagnosis,  for  pernicious  anaemia  is  ab- 
solutely incurable.  There  may  be  lulls  and  tem- 
porary pauses  in  his  condition,  but  the  patient  never 
recovers.  In  grave  secondary  anjemias  the  prog- 
nosis is  brighter,  and  the  patient  may  recover,  par- 
tially at  least  from  his  anaemia. 

When  the  blood  making  organs  have  lost  their 
power  of  forming  red  blood  corpuscles,  and  exam- 
ination shows  no  nucleated  or  polychromatophilic  red 
corpuscle,  and  their  number  arc  less  than  2.000,000 
to  the  cubic  millimetre,  the  condition  is  extremely 
grave  and  to  operate  in  such  cases  is  useless.  The 


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CRISPIN:  INDIVIDUAL  AS  A  SURGICAL  FACTOR. 


999 


presence  of  the  nucleated  red  corpuscles  should  not 
deceive  us  into  predicting  a  favorable  termination, 
since  they  indicate  that  the  haematopoietic  organs 
are  being  forced  beyond  their  capacity  of  reproduc- 
in,g  the  normal  red  corpuscles.  They  appear  after 
a  haemorrhage  in  small  amounts.  Both  in  pernicious 
and  grave  secondary  anaemias  a  pokilocytosis  or 
irregular  character  of  the  red  blood  cells  occurs. 
In  anaemias  resulting  from  haemorrhage  the  num- 
ber of  red  blood  corpuscles  is  not  greatly  reduced 
nor  do  they  attain  the  giant  sizes,  megalocytes,  as 
occurs  in  the  pernicious  and  grave  anaemias.  The 
haemoglobin  is  not  diminished  in  the  same  propor- 
tion, notwithstanding  the  great  diminution  of  red 
corpuscles  in  pernicious  anaemia,  in  fact  it  is  rela- 
tively increased. 

The  percentage  of  haemoglobin  is  very  important, 
and  when  it  falls  below  thirty  any  surgical  operation 
undertaken  under  this  condition  is  very  serious,  and 
if  it  falls  to  twenty  death  can  confidently  be  expect- 
ed. The  increase  of  the  white  cells  is  also  a  matter 
of  importance  in  establishing  the  distinctive  diagno- 
sis between  pernicious  anaemia  and  secondary  grave 
anaemia  which  does  not  happen  in  the  pernicious 
type. 

A  leucocytosis  may  supervene  to  any  traumatism 
or  shock  due  to  haemorrhage,  and  may  be  present  in 
suppurations  and  also  in  certain  nervous  conditions, 
and  is  found  after  convulsions  and  in  certain  forms 
of  insanity.  There  is,  besides,  a  leucocytosis  of  preg- 
nancy with  maximum  intensity  at  time  of  labor. 

The  value  of  leucocytosis  in  inflammatory  or  sup- 
purative lesion  is  still  in  doubt.  Many  observers  at- 
tach a  high  value  to  it,  while  others  seem  to  think 
that  its  importance  has  been  much  overrated.  Those 
who  advocate  it  trust  more  to  a  leucocytosis  with 
high  polynuclearlymphocytes  than  to  the  total  count. 

Dr.  John  Douglas,  who  has  treated  this  subject 
very  thoroughly  in  a  recent  article  in  the  Nezu 
York  Medical  Journal,  September  28,  1908,  Leu- 
cocytosis Count  in  Abdominal  Surgery,  says  very 
justly,  ''so  should  one  consider  both  the  total  and 
differential  count  as  part  of  the  symptom  complex 
■or  clinical  picture  of  the  case  to  be  considered." 

Considered  alone  a  leucocytosis  is  no  criterion  of 
suppuration. 

Malaria. 

In  our  northern  latitude  malaria  has  not  the  in- 
fluence on  the  termination  of  surgical  operations,  as 
it  has  below  the  INIason  and  Dixon  line,  for  here  we 
do  not  observe  its  baneful  effects  as  often  as  they 
•do  in  the  south  and  in  tropical  countries. 

The  opinion  of  surgeons  practising  in  malarious 
climates  is  unanimous  as  to  this  influence,  and  they 
recognize  that  malaria  reacts  most  upon  traumatism, 
and  that  wounds  excite  or  renew  attacks  of  intermit- 
tent fever.  jMalaria  is  often  latent  in  the  system, 
without  arousing  any  suspicion  of  its  presence,  and 
it  may  be  confounded  with  other  conditions,  espe- 
cially when  the  attack  of  malaria  occurred  several 
years  previous.  This  has  been  well  exemplified  in 
my  practice  by  patients  coming  from  those  regions 
to  be  operated  upon  here,  and  in  whom  the  most 
painstaking  search  failed  to  reveal  any  malarial  in- 
fection, but  in  whom  postoperative  complications  of 
a  disturbing  nature  ensued.  The  first  case  to  di- 
rect my  attention  to  this  danger  occurred  in  an  in- 


terval appendectomy  performed  on  an  otherwise 
healthy  man,  who  on  the  third  day  was  seized  with 
a  continuous  fever  which  made  my  associates  and 
myself  believe  was  of  septic  nature ;  I  decided  to 
reopen  the  wound,  and  to  my  amazement  found  it 
perfectly  healthy.  Quinine  checked  all  the  symp- 
toms immediately.  Having  learned  the  lesson,  I  in- 
variably precede  all  operations  on  individuals  com- 
ing from  those  countries  by  a  course  of  antima- 
larial treatment,  thereby  anticipating  this  eventual- 
ity and  securing  my  peace  of  mind. 

Syphilis. 

The  relation  which  in  many  instances  syphilis 
bears  to  surgical  operations  is  of  importance  on  ac- 
count of  the  widespread  influence  which  the  disease 
has  on  the  entire  organism,  and  although  often  with- 
out any  serious  consequence  to  the  immediate  repair 
of  wounds,  at  times  it  interferes  seriously  with  this 
process — preventing  the  union  of  fractures  and 
causing  suppuration  and  troublesome  ulceration  of 
operation  wounds.  There  is  occasionally  almost  in- 
surmountable difficulties  in  diagnosticating  it,  due 
in  part  to  its  chronicity,  and  the  periods  of  quies- 
cence for  which  it  is  noted,  often  remaining  latent  in 
the  system  until  awakened  to  renewed  activity  by  an 
injury  or  other  cause. 

Syphilis  may  coexist  and  be  associated  with  all 
other  acute  and  chronic  diseases,  thereby  giving  rise 
to  the  most  complicated  conditions.  Little  reliance 
can  be  attached  to  the  history  given  by  the  patient; 
it  has  been  said  that  all  syphilitics  are  liars  and  that 
their  statement  cannot  be  trusted.  This  is  true  of 
many  who  by  false  representations  try  to  conceal  its 
presence,  because  of  the  bad  repute  in  which  syphilis 
is  held  by  the  laity,  and  the  stigma  with  which  it  is 
associated ;  while  others  deny  it,  thinking  that  there 
cannot  be  any  possible  connection  between  their 
present  troubles  and  a  chancre,  say,  fifteen  years 
ago.  Aside  from  these  instances  and  of  the  heredi- 
tary cases,  there  are  many  persons  who  are  syphi- 
litic without  ever  having  suspected  it ;  and  their  de- 
nial of  all  knowledge  of  a  primary  and  even  of  sec- 
ondary symptoms  is  undoubtedly  sincere  and  honest. 
The  cases  of  syphilis  insontium  are  very  numerous, 
a  circumstance  which  reduces  the  value  of  the  his- 
tory, on  which  we  rely  to  a  certain  extent.  The 
most  virtuous  woman  may  be  the  innocent  victim 
of  it,  having  unknowingly  acquired  it  from  her  hus- 
band. The  social  condition  of  the  patient  should 
have  no  weight  in  our  diagnosis,  for  syphilis  is  no 
respecter  of  rank  or  station,  and  it  may  be  equally 
possessed  by  the  most  exalted  personage  as  well  as 
by  the  humblest  individual.  We  have  therefore  to 
trust  more  to  our  own  investigation  than  to  the  in- 
formation furnished  by  the  patient,  remembering 
that  syphilis  may  affect  every  tissue  of  the  body,  ex- 
tending its  influence  over  the  entire  organism,  and 
that  it  has  a  peculiar  way  of  imitating  other  dis- 
eases. 

It  is  not  necessary  to  share  the  extreme  opinion  of 
Ricord,  who  would  have  given  mercury  to  the  Venus 
of  ]\Iilo,  it  is  prudent,  nevertheless,  to  be  always  on 
the  alert,  and  to  employ  the  Latin  method  of  juris- 
prudence, considering  the  patient  ^ilty  until  proved 
otherwise,  and  to  sin  more  by  excessive  carefulness 
than  to  allow  it  to  escape  our  observation. 

How  often  are  we  not  chagrined  to  find  that  our 


lOOO 


DITMAN  AND  WELKER:   DEFICIENT    OXIDATION  AND  NEPHRITIS.       [New  York 

Medical  Journal. 


carefully  repaired  perinaeum,  on  which  all  care  was 
bestowed,  both  as  to  the  proper  coaptation  of  the 
turn  muscles  and  mucus  membrane  has  come  to 
naught,  with  stitches  torn,  wound  suppurating?  We 
hastily  blame  some  defect  in  our  asepsis,  when  in 
truth  the  cause  is  somewhere  else.  This  is  no  ex- 
aggeration ;  every  operator  can  recall  similar  expe- 
rience. This  probably  would  have  been  prevented 
by  proper  treatment. 

Many  suppurating  joints  in  children  which  pass 
for  tuberculous  are  in  reality  syphilitic.  This  was 
forcibly  impressed  on  the  writer  years  ago,  by  a  lit- 
tle patient,  two  and  a  half  years  old,  who  came  very 
near  having  her  leg  amputated  in  one  of  our  hos- 
pitals, and  what  saved  her  leg  was  the  unwillingness 
of  her  mother  to  have  it  severed.  Under  specific 
treatment,  a  rapid  cure  was  effected. 

It  is  unnecessary  to  enumerate  all  the  multitud- 
inous forms  which  this  protean  disease  may  assume, 
for  volumes  could  be  written. 

The  Mind. 

Never  has  my  pen  been  more  timid  than  now, 
when  treating  this  arduous  question  of. the  mind. 
The  difficulty  is  enhanced  by  the  scarcity  of  avail- 
able data,  for  very  little  has  been  said  on  this  sub- 
ject, and  the  chapter  on  surgical  psychology  re- 
mains to  be  written.  What  an  interesting  and  ab- 
sorbing chapter  will  it  not  make! 

The  reciprocal  influence  between  mind  and  body 
is  well  exemplified  at  surgical  operations.  The  hope- 
ful and  courageous  patient  is  more  likely  to^  live  than 
the  crestfallen  and  cowardly.  Amongst  the  very 
few  modern  authors  who  have  treated  this  matter. 
Fowler  is  one  who  said :  "That  the  mental  condition 
bears  some  relation  to  the  occurrence  of  shock  there 
can  be  no  doubt,  since  it  has  been  shown  that  the 
stoically  inclined  individual  and  those  hopefully  in- 
clined, as  well  as  children  and  the  insane,  other 
things  being  equal,  suffer  comparatively  little 
shock." 

There  can  be  no  doubt  of  the  influence  of  the 
mind  in  causing  the  physical  symptoms  of  shock, 
and  the  depressing  effect  of  fear  is  even  experienced 
by  the  bravest.  True  courage,  as  Van  Buren  con- 
tended, consists  in  fact  "in  persistently  facing  danger 
after  fully  recognizing  its  extent."  All  men  are 
born  cowards,  but  familiarity  with  danger  will  con- 
quer this  mental  weakness.  Fear  has  an  aetiological 
value,  which  is  not  generally  recognized,  and  no 
matter  how  the  patient  fears  before  operation,  we 
are  wont  to  feel  secure  in  the  thought  that  when 
he  has  "gone  under  the  anaesthetic"  we  have  con- 
quered his  fright,  when  in  fact  we  have  only  mas- 
tered his  resistance.  To  some  the  idea  of  the  knife 
is  sufficient  to  cause  an  agonizing  terror,  capable  of 
terminating  in  mortal  shock.  Dr.  R.  H.  M.  Daw- 
barn,  of  New  York,  relates  a  case  where  the  patient 
died  through  sheer  cowardice,  before  anything  had 
been  done  to  him. 

Aside  from  these  extreme  cases,  the  effect  of  fear 
and  anxiety  is  well  known  to  alter  the  heart's  action, 
the  respiration,  and  of  having  a  relaxing  influence 
on  the  bowels,  the  skin,  and  micturition.  The  lulin- 
burgh  surgeon  who  confessed  that  he  always  had  a 
diarrhoea  before  any  serious  operation  is  an  exam- 
ple of  this  relaxation. 

The  attitude  of  the  surgeon,  his  belief  in  the  final 


success  of  the  operation,  seems  to  filter  through  the 
patient,  for  in  that  supreme  moment,  the  patient's 
mind  has  many  eyes  and  perceives  by  a  sort  of  in- 
tuition or  mental  transmission  of  thought,  what 
transpires  in  the  mind  of  those  surrounding  him. 
Patients  are  very  susceptible  to  suggestion,  especial- 
ly those  who  possess  a  pusilanimous  mind ;  and  who 
knows  how  much  harm  can  be  done  by  an  impru- 
dent and  loquacious  nurse? 

.So,  too,  during  anaesthesia,  in  which  the  waked 
consciousness  is  subdued,  as  psychologists  tell  us, 
but  the  second  self,  the  great  subconscious  self,  is 
never  asleep.  The  possibility  of  this  is  of  high  im- 
portance at  time  of  operations,  where  incautious  re- 
marks may  be  passed  between  those  present,  and 
which  may  have  an  injurious  effect  on  the  patient's 
mind.  That  this  is  no  idle  speculation — that  the 
mind  is  never  asleep  in  its  totality — is  sustained  by 
no  less  an  authority  than  Sir  William  Hamilton,  and 
recent  experience  with  hypnotism  seems  to  confirm 
this  view.  It  is  therefore  convenient  to  bear  this 
in  mind,  that  although  the  conscious  ego  may  not 
be  cognizant  of  what  transpires  during  narcosis,  the 
subconscious  self  may  do  so. 

CONCLUSIONS. 

The  main  conclusion  arrived  at  in  this  paper  is  an 
earnest  plea  for  a  more  extended  recognition  of  the 
heterogeneity  of  the  individual  and  a  fuller  appreci- 
ation of  the  constitutional  conditions  underlying  or 
associated  with  surgical  diseases,  which  emphasizes 
the  advisability  of  an  extended  preparatory  treat- 
ment before  undertaking  surgical  operations. 

854  Lexington  Avenue. 


DEFICIENT  OXIDATION  IN  ITS  RELATION  TO 
THE  .^ITIOLOGY,  PATHOLOGY,  AND 
TREATMENT  OF  NEPHRITIS. 

By  Norm.\n  E.  Ditman,  Ph.  D.,  M.  D.. 
New  York, 

Assistant  Attending  Physician,   St.   Luke's   Hospital;  Instructor  in 
Pathology,    College    of    Physicians    and    Surgeons,  Columbia 
University;  Clinical  Pathologist,  Tlie  Roosevelt  Hospital, 

In  collaboration  with  William  H.  Welker,  A.  C,  Ph.  D., 
New  York, 

Assistant  in  Biological  Chemistry,  College  of  Physician?  and 
Surgeons,  Columbia  University. 

I.  The  Toxicity  oi-  Products  of  Incomplete 
Oxidation. 

In  proportion  to  the  extent  of  its  occurrence  in 
the  field  of  biology  and  to  its  great  fundamental  im- 
portance in  all  life  processes,  there  are  few  subjects 
of  greater  interest  to  medical  men,  and  yet  which 
have  received  less  attention  from  them,  than  that  of 
the  process  of  oxidation. 

In  a  complicated  structure  like  the  human  body, 
processes  of  oxidation  and  reduction  occur  simul- 
taneously and  maintain,  in  health,  an  equilibrium. 
The  disturbance  of  such  an  equilibrium  might  well 
be  supposed  to  give  rise  to  conditions  not  only  ab- 
normal, but  harmful  in  their  effects. 

The  fact  that  oxidation  and  reduction  processes 
in  the  organism  tend  toward  the  production  and 
maintenance  of  chemical  equilibrium  was  shown  bv 
Kastle  and  Elvove  (i).  who  demonstrated  that  the 
higher  animal  can  oxidize  a  nitrite  and  also  reduce 


May  15.  1909.)       DITMAN  AND  WELKER:  DEFICIENT   OXIDATION  AND  NEPHRITIS. 


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a  nitrate.  These  influences  are  seen  not  only  in  the 
conduct  of  nitrites  and  nitrates  in  the  organism,  but 
also  in  the  behavior  of  such  compounds  as  alde- 
hydes. We  know  now  from  the  researches  of 
Schmiedeberg  (2),  Pohl  (3),  Medwedew  (4), 
and  Jacoby  (5),  that  aldehydes,  such  as  salicylic, 
benzoic,  and  formic  aldehydes,  are  oxidized 
in  the  animal  organism  to  the  corresponding 
acids,  and  also  by  the  extracts  of  several  or- 
gans, notably  the  liver  and  kidney.  On  the 
other  hand,  that  these  substances  are  sometimes  re- 
duced in  the  organism  is  rendered  evident  by  the 
fact  that  urochloralic  acid,  a  conjugation  product  of 
trichlorethyl  alcohol  and  glycuronic  acid,  appears 
in  the  urine  after  the  administration  of  chloral. 
Mechanism  of  Body  Oxidation. 

In  view  of  this  action  on  the  part  of  the  body,  the 
method  by  which  oxidation  is  accomplished  by  the 
tissues  is  one  of  considerable  interest."  Though  sev- 
eral theories  of  oxidation  have  been  advanced,  none 
seems  so  satisfactory  as  that  of  Hoppe-Seyler  (6), 
which  is  the  one  most  generally  accepted. 

According  to  this  theory,  processes  of  fermenta- 
tion take  place  in  the  protoplasm  which  result  in  the 
formation  of  nascent  hydrogen.  This  combines  with 
oxygen,  if  it  is  present,  forming  water  and  setting 
free  molecules  of  oxygen  (H2  +  O2  =  H=0  +  O) . 
The  nascent  oxygen  thus  formed  attacks  the  proto- 
plasm, producing  the  oxidations  characteristic  of 
living  matter  at  comparatively  low  temperatures.  If 
oxygen  is  not  present  in  sufficient  amount  to  satisfy 
the  nascent  hydrogen,  this  hydrogen  reduces  sub- 
stances in  the  cell  and  forms  entirely  different  prod- 
ucts, which  are  more  or  less  poisonous. 

Since  Pasteur's  work  on  the  influence  of  oxygen 
on  the  growth  of  bacteria  and  their  products,  the 
relation  of  oxidation  to  toxicity  has  been  one  of  in- 
creasing interest,  and  through  modern  researches 
this  relationship  has  been  demonstrated  in  zymotic, 
bacterial,  and  purely  chemical  processes. 

Enzymes.  Zymase  (of  Buchner)  is  ordinarily 
not  poisonous  in  its  influences  :  but  if  it  exists  under 
conditions  of  insufficient  oxidation  it  gives  rise  to 
poisonous  products  (7).  Silber  (8)  demonstrated 
the  detoxicating  effect  of  animal  and  vegetable  oxi- 
dases on  the  toxines  of  diphtheria  and  tetanus,  and 
proved  that  this  detoxicatnig  action  occurs  not  only 
in  vitro,  but  also  in  the  animal  organism  after  in- 
jection of  the  toxine  and  the  oxidase  in  difi:erent 
parts  of  the  body. 

Bacteria.  A  great  many  pathogenic  organisms 
are  either  anaerobic,  or  facultatively  anserobic,  and 
it  is  a  very  interesting  fact  in  this  connection,  that 
the  anzerobic  bacilli  of  tetanus,  symptomstic  an- 
thrax, malignant  oedema,  and  the  Bacillus  cadaveris 
are  among  the  most  pathogenic  organisms  known. 
The  gradual  loss  of  pathogenic  power  which  Pas- 
teur has  shown  occurs  in  cultures  of  the  anthrax' 
bacillus  and  the  micrococcus  of  fowl  cholera,  is 
ascribed  by  him  to  exposure  to  oxygen,  and,  as  proof 
of  this,  he  states  that  cultures  kept  in  hermetically 
sealed  tubes  do  not  lose  their  virulence  to  the  same 
degree.  Other  experimenters  have  found  that,  in 
the  absence  of  air,  the  diminution  in  the  toxic  activ- 
ity of  diphtheria  toxin  brought  about  bv  sunlight  is 
comparatively  slight.  The  fact  has  long  been  known 
by  clinicians  that  when  in  chronic  appendicitis  oc- 
clusions occur,  thereby  cutting  of¥  the  supply  of 


oxygen  to  the  imprisoned  organisms,  the  virulence 
of  the  colon  bacillus  is  distinctly  augmented.  We 
have  found  that  the  Bacillus  protcus,  which  is  usu- 
ally not  pathogenic  when  grown  under  ordinary  con- 
ditions, is  uniformly  pathogenic  for  rabbits  when 
grown  under  conditions  of  poor  oxygen  supply,  due 
to  the  development  of  such  toxic  products  as  aethyl- 
endiamine,  gadinine,  and  trimethylamine.  In  a  sim- 
ilar way  neurine,  which  is  very  toxic,  may  be  formed 
by  the  decomposition  of  lecithin  in  the  intestinal  canal 
when  access  of  oxygen  is  prevented,  as  in  condi- 
tions of  obstruction,  largely,  according  to  Foa  and 
Benone,  as  a  result  of  the  activity  of  the  Bacillus 
proteus  under  such  circumstances.  EUinger  (9),  on 
decomposing  ornithine,  derived  from  arginine,  by  the 
aid  of  bacteria,  especially  in  the  absence  of  oxygen, 
obtained  the  ptomaine  putrescine  :  NH2.  CHs.  CH2. 
CH--.  CH  (XHO.  COOH  =  XH2.  CH^.  CH.. 
CH..  NH2  +  CO2. 

Ornithine.  Putrescine. 

Chemicals.  The  action  of  chemicals  in  processes 
of  reduction  in  the  animal  organism  is  becoming 
daily  better  understood.  The  number  of  reducing 
substances  which  possess  toxic  properties  is  indeed 
remarkable.  The  following  are  examples :  Nitrites  : 
hydrogen  sulphide  ;  arsenites  ;  aniline  ;  phosphorus  ;; 
hydroxylamine  ;  phenylhydrazine  ;  benzene,  toluene, 
turpentine,  and  other  hydrocarbons ;  formic,  acetic, 
and  other  aldehydes;  methyl,  ethyl,  amyl,  and  other 
alcohols;  pyrocatechol,  resorcinol,  hydroquinol, 
pyrogallol. 

The  effect  on  their  toxicity  of  reduction  of  simple 
chemical  compounds  in  the  body  is  clearly  shown  by 
Cushny  (10)  in  the  case  of  iodates,  bromates,  and 
chlorates.  According  to  this  authority,  while  the 
iodates,  which  are  the  most  poisonous  of  these,  are 
completely  reduced  in  the  body,  the  bromates  are 
less  poisonous  and  are  slightly  reduced,  the  chlorates 
which  are  the  least  poisonous,  are  not  reduced  in 
the  body. 

Likewise  Kastle  and  Elvove  ( i )  have  concluded 
that  among  a  series  of  analogous  compounds,  the 
toxicity  and  power  to  efifect  oxidation  stand  in  the 
same  order.  Of  two  reducing  agents,  that  one  is  the 
more  toxic  which  possesses  the  greater  capacity  for 
oxygen.  In  this  connection  it  is  interesting  to  note 
that  in  order  to  pass  to  nitrate,  hydroxylamine  re- 
quires three  times  as  much  oxygen  as  is  required  bv 
sodium  nitrite,  the  former  being  three  times  as  toxic 
as  the  latter. 

A  similar  observation,  and  one  of  more  interest 
for  us  on  account  of  its  application  to  body  pro- 
cesses, was  made  by  \"aughan  and  Novy  (11),  to 
the  effect  that  while  a  certain  quantity  of  oxygen  is 
necessary  for  the  formation  of  poisonous  bases,  a 
free  supply  of  oxygen,  on  the  other  hand,  invariably 
yields  nontoxic  ptomaines. 

Mandel's  (12)  observation  that,  in  aseptic  fevers 
following  surgical  leucocytosis,  the  temperature  is. 
always  elevated  in  proportion  to  the  increase  of  al- 
loxuric  bases  excreted,  is  similarly  interesting  for 
us  when  we  recall  that  the  alloxuric  bases  are  in- 
complete products  of  cell  oxidation.  This  observa- 
tion is  reinforced  by  Burian  and  Schur  (13),  who^ 
found,  in  their  work  on  the  relationship  of  purin 
bases  to  human  metabolism,  that,  whenever  these 
bases  were  introduced  into  the  human  body.,  certain 
toxic  symptoms  invariablv  followed. 


DITMAN  AND  WEIKER:   DEFICIENT    OXIDATION  AND  NEPHRITIS.  t^'"^^^' 

Medical  Journ 


With  reference  to  urea,  one  of  the  most  common 
of  the  products  of  human  metabolism,  its  ordinary 
lack  of  toxic  action  is  vastly  changed  if  its  atom  of 
oxygen  is  removed  and  replaced  by  certain  others. 

Urea  0  =  C.C^^^%  by  the  loss  of  oxygen  and  the 
replacement  of  this  atom  by  NH,  becomes  guanidine 
a  substance  slightly  toxic;  and  by  the 
replacement  of  the  oxygen  atom  by  sulphur  it  be- 
comes sulphourea  SO'^?^!^',  a  substance  which  has 
\i\  rl- 

been  found  in  normal  urine  and  which  is  also  slight- 
ly toxic.  By  the  substitution  of  a  methyl  radical 
for  one  of  the  H's  of  guanidine,  the  highly  poison- 

ous  methyl  guanidine  is  obtained,  HNC^  ^^^  and 

by  the  introduction  of  the  allyl  radical  into  sulpho- 
urea, the  highly  toxic  allvl-sulphourea  is  obtained, 

^^\XH  (CH..  CH.CHO. 

When  it  is  recalled  that  the  two  latter  substances, 
if  injected  into  animals,  produce  respectively  dysp- 
noea, coma,  and  convulsions ;  and  oedema  of  the 
lungs  and  hydrothorax  (14) — cardinal  symptoms  of 
uraemia — it  becomes  apparent  that  the  study  of  the 
insufficiently  oxidized  products  of  protein  decompo- 
sition assumes  a  growing  importance  in  the  study 
of  nephritis. 

In  view  of  what  has  already  been  said  in  regard 
to  the  toxicity  of  reducing  agents,  it  is  significant 
that  creatinine,  which  exists  normally  in  the  body, 
acts  as  a  reducing  agent,  capable  of  reducing  mer- 
curic oxide  to  metallic  mercury,  and  in  this  process, 
in  addition  to  oxalic  acid,  there  is  formed  the  toxic 
substance,  methylguanidine,  already  alluded  to. 

II.  Evidences  of  Incomplete  or  Poor  Oxida- 
tion IN  Nephritis. 

The  problem  of  obtaining  a  true  insight  into  the 
processes  of  oxidation  in  the  human  body  is  one 
beset  with  profound  difficulty. 

Not  only  is  it  difficult  to  ascertain  the  action  of 
any  one  organ  is  this  connection,  but  even  the  de- 
termination of  the  sum  of  all  bodily  metabolic  oxi- 
dative activity,  as  exhibited  by  products  demon- 
strable in  the  urine,  is  difficult  to  make  and  to  inter- 
pret aright,  on  account  of  the  great  complexity  of 
the  process.  There  are  some  end  products,  how- 
ever, which,  by  variations  of  their  form  and  quan- 
tities, point  with  some  definiteness  toward  certain 
more  or  less  specific  reactions,  and  some  chemical 
"indicators"  are  undoubtedly  of  assistance  in  de- 
noting the  general  trend  of  the  oxidative  process. 

Of  the  chemical  "indicators,"  one  which  has  long 
been  in  use  as  a  probable  means  of  testing  the  func- 
tional efficiency  of  the  kidney  is  methylene  blue. 
Due,  possibly,  to  the  fact  that  the  methylene  blue 
molecule  is  large,  this  substance  is  not  readily  elim- 
inated by  the  normal  kidney,  and  often  still  less  so 
by  this  organ  in  the  diseased  state. 

Acting  upon  this  principle,  Landau  (15),  using  a 
constant  amount  of  methylene  blue, — o.i  gramme  by 
mouth  or  0.05  grannnc  hypodermically — demonstrat- 
ed in  many  diseased  conditions  of  the  kidneys,  the 
phenomena  of:  I,  Extension  of  the  excretion  period 
with  delayed  bcgimiing;  2,  shortening  of  the  excre- 
tion period  witli  early  or  normal  beginning;  3,  short- 


ening of  the  excretion  period  with  delayed  begin- 
ning; and  inclined  to  the  view  that  the  first  type  is 
more  or  less  characteristic  of  the  chronic  atrophic 
type  of  nephritis.  He  concluded,  however,  that  the 
functional  efficiency  of  the  kidneys  could  not  be  ab- 
solutely and  invariably  determined  by  this  method, 
although  a  more  or  less  definite  departure  from  the 
normal  was  found  in  the  cases  of  atrophic  nephritis. 
Methylene  Blue  in^  Oxidation  and  Reduction. 

More  recently,  by  virtue  of  its  behavior  in  the 
presence  of  oxidizing  and  reducing  agents,  methy- 
lene blue  has  been  found  to  be  an  excellent  agent  for 
the  study  of  the  oxidation  and  reduction  processes 
of  the  animal  organism. 

Its  behavior  in  the  body  and  its  elimination  there- 
from have  been  the  subjects  of  many  investigations, 
the  more  important  of  which  have  been  carried  out 
by  Ehrlich  (16),  Dreser  (17),  IMiiller  (18).  Eisner 
(19),  Herter  (20),  and  others. 

Underbill  and  Closson  (21),  in  1905,  called  atten- 
tion to  the  fact  that  when  methylene  blue  is  intro- 
duced into  the  normal  body,  whether  intravenously, 
intra-peritoneally,  or  by  way  of  the  mouth,  it  appears 
in  the  urine  as  methylene  blue,  methylene  azure — an 
oxidation  product  of  methylene  blue — as  well  as  re- 
duction compounds  in  the  form  of  colorless  leuco- 
bases.  These  products  suggested  that  the  processes 
involved  were  essentially  those  of  oxidation  and  re- 
duction, which  may  possibly  occur  simultaneously 
in  the  same  tissue  or  tissues.  Underbill  and  Closson 
also  observed  a  point  of  interest  from  the  thera- 
peutic aspect — viz.,  that  the  transformation  of 
methylene  blue  into  its  oxidation  product,  methylene 
azure,  is  facilitated  or  inaugurated  by  the  presence 
in  the  tissues  of  traces  of  alkaline  salts.  Small  doses 
of  methylene  blue  failed  to  appear  in  the  urine  as 
such. 

In  view  of  the  fact  that  reduction  processes  re- 
duce the  colored  methylene  blue  to  the  colorless 
leucobase,  and  that  if  the  reduction  processes  were 
greater  than  normal,  a  greater  amount  of  methylene 
blue  might  be  reduced  to  its  colorless  form,  an  at- 
tempt was  made  by  one  of  us  to  see  whether  more 
methylene  blue  could  not  be  thus  reduced  in  nephri- 
tis than  under  normal  conditions — thus  indicating  a 
greater  bodily  reducing  activity.  This  was  done  by 
gradually  increasing  the  dose  of  methylene  blue, 
which  was  administered  by  the  method  employed  by 
Herter  (22),  until  it  was  eliminated  in  the  urine  in 
its  own  form.  This  quantity  was  then  regarded  as  a 
rough  indication  of  the  amount  of  reduction  occur- 
ring in  the  body,  to  which  any  substance  circu- 
lating for  the  same  length  of  time  in  the  blood 
stream  would  be  exposed.  This  point  is  empha- 
sized, for  while  the  delayed  elimination  in  nephritis 
would  in  this  disease  expose  this  substance  to  a  more 
prolonged  and  therefore  greater  reducing  action 
than  normal,  the  reducing  effect  to  which  the  methy- 
lene blue  is  exposed  is  no  more  than  that  to  which 
any  substance  is  exposed,  which  remains  in  the 
blood  of  cases  of  nephritis  for  a  similar  length  of 
time. 

In  the  series  of  cases  here  cited  (Table  I),  the 
amount  of  methylene  blue  recorded  represents  the 
minimal  quantity  that  brought  about  a  perceptible 
excretion  of  unchanged  methylene  blue  in  the  urine. 

The   methylene   blue    (Merck's   purified),  was 


May  15,  1909.]      DITMAN  AND  WELKER:  DEFICIENT   OXIDATION  AND  NEPHRITIS. 


1003 


given  hypodermically  in  1.5  per  cent,  solution  in 
normal  salt  solution. 

Because  of  difficulty  in  following  up  cases  7,  8,  9, 
and  10,  to  the  conclusion  of  the  experiments,  it  was 
impossible  to  tell  how  much  more  than  40  mg.  of 
methylene  blue  could  have  been  injected  before  some 
of  this  substance  would  have  appeared  unchanged  in 
the  urine.  The  fact  is  evident  from  observation  of 
Table  I,  that  while,  in  the  normal  cases,  after  injec- 
tion of  as  small  an  amount  of  methylene  blue  as 
3.9  mg.  (average)  some  appeared  unchanged  in  the 
urine,  in  the  tested  cases  of  chronic  nephritis,  on  the 
other  hand,  at  least  as  much  as  40  mg.  could  be  in- 
jected without  resulting  in  the  excretion  of  methy- 
lene blue  in  the  urine  in  any  other  form  than  the  re- 
duced leucobase. 

TABLE  I— METHYLENE  BLUE  EXCRETION  IN  THE  URINE. 


Methylene 

blue. 

Methylene 

Leuco- 

amount  in 

blue  in 

methylene 

Diagnosis. 

No. 

milligrammes 

urine. 

bases. 

I 

4 

-\-2  hours 

2 

0.66 

4-2  hours 

3 

5 

-j--  hours 

4 

6 

-f3  hours 

Occasional  albuminuria 

5 

8 

-1- 

Chronic  nephritis  .... 

6 

12 

+  7  hours 

Chronic  nephritis  .... 

7 

40 

-f- 

Chronic  nephritis  .... 

8 

40 

Chronic  nephritis  .... 

9 

40 

-f- 

Chronic  nephritis  .... 

10 

40 

As  a  means  of  determining  the  gross  extent  of 
bodily  reduction  this  method  is  undoubtedly  crude, 
and  it  is  to  be  regretted  that  the  number  of  cases 
upon  which  this  method  could  be  tried  was  not 
greater,  as  some  irregularities  would  undoubtedly 
have  developed ;  but  even  in  its  present  form  it  can 
not  but  be  highly  suggestive  of  the  surmise  that  the 
extent  of  the  reducing  action  to  which  any  sub- 
stance in  the  circulation  is  exposed,  is  greater  in 
nephritis  than  under  normal  conditions. 

Reference  has  already  been  made  to  the  possi- 
bility of  determining  the  degree  of  oxidative  pro- 
cesses in  the  body  by  the  appearance  and  relative 
amount  of  the  end  products  of  oxidation  in  the 
urine. 

Urinary  Evidences  of  Oxidation. 
For  the  condition  under  discussion  (nephritis), 
the  determination  of  the  products  of  decomposition 
of  the  purin  and  allied  groups  would  seem  to  con- 
tribute most  satisfactorily  to  the  solution  of  the 
question  of  the  relative  degree  of  oxidation.  Be- 
fore entering  further  upon  this  subject,  however, 
it  might  not  be  amiss  to  review  in  a  very  brief 
manner  some  of  the  data  of  physiological  chemistry 
which  bear  most  directly  upon  the  subject  involved. 

Among  the  purin  bases  which  have  been  found 
in  the  normal  urine,  the  following  have  been  deter- 
mined in  the  designated  amounts  : 
In  10,000  litres  of  urine : 

Xanthine   10  grammes; 

Heteroxanthine   22  grammes; 

Paraxanthine   15  grammes; 

Hypoxanthine    8  grammes; 

1- — methyl  xanthine   31  grammes; 

Epiguanine    3  grainmes ; 

Adenine    3  grammes. 

A  great  deal  of  obscurity  still  attaches  to  the 
mode  of  formation  of  some  of  these  derivatives ; 
but  an  immense  stride  was  accomplished  by  Jones 
and  Partridge  (23),  who,  after  the  publication  of 
Kutscher's  experiments  on  pancreatic  autolysis,  iso- 
lated an  enzyme  froin  the  pancreas,  and  from  the 


suprarenals  and  thymus,  which  is  capable  of  trans- 
forming guanine  into  xanthine.  They  also  isolated 
an  enzyme,  adenase,  existing  in  the  thymus,  supra- 
renals and  pancreas,  which  is  capable  of  transform- 
ing adenine,  into  hypoxanthine.  An  enzyme,  oxy- 
dase, was  found  to  oxidize  hypoxanthine  to  xan- 
thine. 

It  has  been  shown  by  Kossel  and  his  pupils  that 
guanine  and  adenine  in  the  body  are  undoubtedly 
derived  from  nuclein.  Guanine  has  been  met  with 
normally  in  a  large  number  of  tissues — the  liver, 
pancreas,  lungs  and  thymus,  and,  under  pathological 
conditions,  in  the  joints  of  swine,  constituting  a  dis- 
ease known  as  guanine  gout.  Oxidation  here  has 
ostensibly  not  pursued  its  usual  course  to  its  ulti- 
mate products — which  is  also  the  case  in  some  of 
the  lower  animals  where  guanine  is  one  of  the  pro- 
ducts of  excretion. 

The  spleen,  lungs,  liver,  intestine,  muscle,  and  kid- 
ney are  all  capable  of  converting  these  and  other 
purin  bases  into  uric  acid.  The  stages  in  this  pro- 
cess for  adenine  and  guanine  are  indicated  below : 

Adenine. 

N  =  C— NH. 


HC 

il 


■NH 
CH 


Guanine 

HN  — CO 

I  I 

XH.  — C     C— XH 

!|     I  CH 

II  I  II 
N  — C— X 


X  —  C  —  X 

By  action  of 

adenase 

HX  — CO 

NH 


HC 


/ 

/ 


By  action  of 
guanase 


\ 


I     II  CH 
11     II  II 
N  — C— X 

'  Hypo.xanthine 
Bv  action  of  oxydase 


HN- 
I 

OC 


/ 

CO 


XH 


CH  Xanthine 


HN-C— X 


HX  — 

CO 

1 

1  XH 

1 

1/1 

OC 

c  1 

1 

II  CO 

HX  — 

C  1 

XH 

Uric  acid 


"An  abundant  supply  of  oxygen  is  essential  in 
every  case  for  the  change  to  uric  acid,"  (24).  From 
this  series  of  oxidation  products  it  is  evident  that, 
when  the  oxidation  of  the  antecedent  substances  is- 
greatest,  the  amount  of  uric  acid  will  be  at  its  max- 
imum ;  while  any  interference  with  the  oxidation  of 
this  group  would  result  in  the  relative  increase  of 
these  antecedents  and  a  relative  diminution  of  the 
end  product,  uric  acid.  This  fact  has  been  m.ade 
use  of  by  us  as  a  means  of  detennining  one  phase  of 
the  extent  of  the  bodily  oxidation  process.  The  sub- 
stances quantitatively  compared  were  the  purin 
bodies  and  uric  acid. 


I004 


DITMAK  AXD  WELKER:   DEFICIENT    OXIDATION  AND  NEPHRITIS         t><'^"-  ^ork 

Mkdical  Jolrnal. 


Purin  Base — Uric  Acid  Ratio. 
In  this  connection  it  niuSt  be  borne  in  mind  that 
Salkowski  found  that  the  ratio  of  purin  base  nitro- 
gen to  uric  acid  nitrogen,  which  was  not  so  constant 
in  disease,  was  perfectly  constant  in  heaUh — i  :  13. 
Umber  determined  this  ratio  at  i  :  14,  Weintrand  at 
I  :  6,  and  Camerer  (25)  at  i  :  9.  By  the  method 
cited  later  (Hall)  the  ratio  in  a  normal  case  was  de- 
termined as  I  :  5.8,  and  in  a  case  of  pleurisy  with 
efifusion  as  i  :  6. 

Table  II. 

Ratio  of  purin 
base  nitrogen 
to  uric  acid 
nitrogen. 

Acute  nephritis    1:2.60       Milk  diet 

Chronic  diffuse  nephritis   1:0.77 

Chronic  diffuse  nephritis   1:0.59 

Chronic  diffuse  nephritis   1:0.51 

Chronic  diffuse  nephritis  .•  i  :o.38  " 

Acute  nephritis    i  :o.36  " 

Chronic  diffuse  nephritis   1  :o.35  " 

Post  partum  eclampsia   i  :o.26  " 

Chronic  diffuse  nephritis   1:0.20  " 

Pernicious  anaemia    1:0.20  " 

Nephritis  and  threatened  eclampsia...  1:0.17  " 

Chronic  diffuse  nephritis   1:0.15  " 

Chronic  diffuse  nephritis   1:0.09  " 

Chronic  parenchimatous  nephritis....  1:0.02  • 
Case  of  uraemia  (Table  III),  average,  i  :o.32  " 

Toxaemia  of  pregnancy   1:0.24  " 

Toxaemia  of  pregnancy  and  eclampsia.  1:0. 90  " 
Normal  pregnant  woman  at  term....  1:6.24  " 
Normal  pregnant  woman  at  term....  1:2.63  " 

Toxaemia  of  pregnancy   1:0.76  " 

Toxaemia  of  pregnancy   i  :o.66  " 

Albuminuria    i  :o.44  " 

Eclampsia    i  :o.8o  '" 

Eclampsia  and  toxaemia  of  pregnancy.  1:0.24  " 

The  following  results  (Tables  III.  and  IV.)  were 
•  obtained  with  patients  on  purin  free  diets  in  a  series 
vof  cases  of  diseases  of  the  kidney. 

TABLE  HI— URIX.VRV  MTROCEX. 
_  (Expressed  in  grammes.') 


1.  Chronic  diffuse  nephritis    6.40    5.50    0.660    0.000    0.016  0.060 

2.  Chronic  diffuse  nephritis    1.95    0.107    0.006  .... 

3.  Chronic  diffuse  nephritis    6.48    ....     0.070    0.280    0.056  0.425 

4.  Chronic  diffuse  nephritis    4.95    4.20    0.160    0.210    0.046  0.105 

5.  Chronic  diffuse  nephritis    3.55    2.82    0.029    0.170    0.115  0.300 

6.  Chronic  diffuse  nephritis    3.13    2.60    0.126    0.146    0.009  0.103 

7.  Chronic  parenchymatous 

nephritis    9.45    7.65    0.900    0.380    0.045  0.249 

8.  Acute  nephritis    9.77    7.70    0.380    0.500    0.130  0.477 

9.  Pernicious  anaemia   9.93    9.01      ....    0.320    0.015  o.o8q 

10.  Pleurisy,  with   effusion.  11.89  10.09    0.714    0.460    0.144  0.168 

11.  Acute    nephritis   7.47    6.65    0.035    0.130    0.123  0.388 

12.  Nephritis  and  threatened 

eclampsia    9.50    6.86    1.270    0.160    0.067  0.448 

13.  Chronic  diffuse  nephritis    5.70    0.213    0.030  0.17; 

14.  Normal   man..-   16.50  14.30    0.490    0.680    0.210  o.24fi 

15.  Chronic  diffuse  nephritis    0.059  0.175 

16.  Chronic  diffuse  nephritis    0.035  0.126 

17.  Post  partum  eclampsia   0.042  0.204 

TABLE  IV— CASE  OF  UR.EM.\— CHRONIC  DIFFUSE 
NEPHRITIS. 

-■775  grammes  of  creatinine  were  administered  at  the  end  of  the 
fifteenth  day. 

Day.  13.  14.  15.  16.  17. 

Total  nitrijiien    4-7470      4.3370      6.5570      4.8680  4.35/0 

Ammonia  nitrogen    ....  0.8537      0.2740      0.4774      0.9378  0.8107 

Urea  nitrogen    3-57i8      3.2805      5-3137      2.5819  2.7754 

Uric   acid  nitro-4[en   0.0367      0.0204      0.0760      0.0671  0.0520 

Purin  bodies  minus 

Uric  acid  nitrogen   0.1862      0.2088      0.1953      0.1356  0.1068 

Crf atinine  nilrog;n  ....  0.2050  0.2250  0.2380  0.9470  0.2540 
Balance  (Undetermined 

nitrogen)    ?  0.3283      0.2566      0.1786  0.3581 

Indican    -|--f-  0000 

Diet    Mixed     Purin       Purin      Purin  Purin 

free         free         free  free 

Ratio     of     purin  base 
nitrogen   to   uric  acid 

nitrogen    1:0. iq      1:0.07       1:0.39      1:0.49  1:0.48 


In  these  particular  experiments,  and  in  the  re- 
maining portion  of  the  work  herein  described,  the 
following  quantitative  analytic  methods  were  em- 
ployed: Kjeldahl's  for  total  nitrogen,  Folin's'  for 
ammonia,  urea,  uric  acid,  and  creatinine;  the  .\rn- 
stein-Salkowski'  process  for  purin  bases,  and 
Loewi's'  or  Poduschka's'  for  allantoine.  Purin 
bases  were  also  sometimes  determined  (Table  11. 
first  17  cases)  by  means  of  Hall's  purinometer'. 

These  observations  agree  with  those  of  Kolish. 
who  found  that  in  nephritis  the  ratio  between  the 
uric  acid  and  alloxuric  bases  is  so  displaced  tliat  the 
first  is  excreted  in  very  small  amounts,  while  the  al- 
loxuric bases  are  increased  at  the  expense  of  the 
uric  acid.  The  uric  acid  is  absolutely  and  relatively 
diminished — being  in  some  cases  infinite?iii:al  in 
amount. 

In  perfect  accord  with  this  is  the  statement  of 
Martin,  that  the  relation  of  alloxuric  bases  to  uric 
acid  in  nephritis  is  "brought  nearei^,"  esj)ecially  in 
atrophic  kidneys,  where  along  with  smaller  excretion 
of  uric  acid  there  occurs  the  greatest  excretion  r  f 
the  alloxuric  bases. 

In  comparison  with  our  own  series  of  cases,  a 
series  published  by  Zuelzer  (27)  shows  a  slightly 
higher  uric  acid  ratio,  although  the  series  as 
a  whole  averages  slightlv  below  the  normal.  His 
results  were  the  following:  (Table  V). 

Table 

Ratio  of 
purin  base 
nitrogen  tu 
uric  acid 
nitrogen. 

Chronic  parenchymatous  nephritis   1:7 

Acute  haem.  nephritis   1:2 

Acute  hsem.  nephritis   1:4 

Postdiphtheritic  nephritis    1:3 

Postscarlatinal  nephritis    1:3 

Postscarlatinal  nephritis    1:2 

Postscarlatinal  nephritis    1 :8 

Postdiphtheritic  nephritis    1:3 

Toxic  nephritis    1:4 

Chronic  parenchymatous  nephritis   1:6 

Chronic  interstitial  nephritis   1:5 

Chronic  interstitial  nephritis   1:4 

Table  YI. 

Ratio  of 
purin  base 

Purin  nitrogen  to 

nitrogen  Uric  acid  uric  acid 
(Total).         nitrogen.  nitrogen. 

.■Vcute  nephritis    0.145  0.130  1.86 

.\cute  nephritis    0.129  0.106  1.46 

Parenchymatous  nephritis  ..  0.179  0.145  i-42 

Chronic  diffuse  nephritis....  0.109  0.094  1-62 

Chronic  diffuse  nephritis....  0.203  0.172  r.55 

Chronic  diffuse  nephritis....  0.184  0.151  1.45 

Chronic  diffuse  nephritis....  0.182  0.105  1.13 
.\cute  yellow  atrophy  of  the 

liver      1.03 

From  a  perusal  of  the  preceding  series  of  observa- 
tions the  probability  is  indicated  that  in  nephritis, 
especially  of  the  chronic  atrophic  type,  oxidation  of 
the  purin  group  to  uric  acid  does  not  proceed  to  the 
normal  extent.  These  observations  therefore  tend  to 
confirm  the  results  already  obtained  by  us  in  our 
use  of  methylene  blue,  and  indicate  diminished  oxi- 

'Folin.    American  Journal  of  Physiology,  1905,  xiii,  p.  45. 

-Hammarstcn.  Textbook  of  Physiological  Chemistry.  Translation 
by  Mandel,  1908,  p.  581. 

'T^ev/'t.  Archir  fiir  e.vperimeittelle  Pathologic  iiiirf  Pharmacologic, 
xliv,  p.  20,  1900. 

'Poduschka.    Ibid.,  p.  65. 

"Hall.     Wiener  klinische  Wochenschrift ,  xvi.  p.  411,  1903. 


May  IS.  1909I     DITMAN  AND  WELKER:  DEFICIENT    OXIDATION  AND  NEPHRITIS. 


1005 


dation  in  nephritis.  The  fact  that  this  allo\ui"ic  base- 
uric  acid  ratio  may  be  altered — with  a  relative  in- 
crease of  the  former — as  a  result  of  diminished  oxi- 
dation in  the  body,  is  capable  of  proof,  which  ma\- 
be  afforded  in  the  following  way : 

Experimental  Alteration  of  Purin  Base — Uric  Acid 
Ratio. 

It  is  possible,  through  chemical  agents  introduced 
into  the  body,  to  interfere  with  and  diminish  the  pro- 
cess of  oxidation.  When  this  subject  firs*  came  to 
the  notice  of  one  of  the  writers  in  1902,  among  all 
such  agencies  none  seemed  better  fitted  for  experi- 
mental purposes  than  the  cyanide  radical. 

Schonbein  proved  that  through  the  formation  of  a 
stable  combination  of  haemoglobin,  with  the  cyanide 
radical,  after  the  administration  of  prussic  acid  or 
potassium  cyanide,  the  red  blood  corpuscles  lost  their 
power  of  conveying  oxygen  to  all  parts  of  the  sys- 
tem and  the  phenomena  of  asphyxia  were  produced 
(28).  Geppert  (29)  has  proved  that  this  is  really 
the  case  by  showing,  in  a  series  of  researches,  that, 
under  the  action  of  hydric  cyanide,  less  oxygen  is 
taken  up,  and  less  carbon  dioxide  formed  than  nor- 
mal. The  deficiency  of  CO2  is  in  part  due  to  the 
fact  that  substances  like  lactic  acid,  products  of  in- 
complete combustion,  are  formed  instead  of  CO-.  At 
the  same  time  the  protoplasm  of  the  tissues  is  para- 


lyzed and  unable  to  lake  up  the  loosely  bound  oxy- 
gen presented. 

This  is  the  principle  upon  which  Richards  and 
Rowland  (68)  recently  acted  in  using  potassium 
cyanide  as  a  reducing  agent  in  showing  the  toxicity 
of  the  indol  group  when  introduced  into  the  body 
under  conditions  of  impaired  oxidation. 

By  the  use  of  this  substance  (potassium  cyanide), 
the  oxidation  processes  of  dogs,  on  a  constant  diet, 
were  interfered  w'ith  and  an  attempt  was  made  to 
learn  whether  the  altered  ratios  already  seen  in  ne- 
phritis could  not  be  produced.  Three  groups  of  dogs 
were  used,  two  dogs  in  each  group.  Dogs  I  and  II 
were  placed  on  a  diet  containing  a  moderate  amount 
of  meat,  dogs  III  and  I\^  on  a  diet  containing  a 
small  amount  of  meat,  and  dogs  \"  and  VI  on  a  diet 
containing  a  large  amount  of  meat.  The  diets  were 
otherwise  similar.  After  a  preliminary  fore  jieriod 
during  which  no  cyanide  was  administered,  the  dogs 
were  injected  with  cyanide  hypodermatically  in  doses 
and  at  intervals  indicated  in  the  tables.  .\s  a  rule 
this  treatment  was  followed  by  an  after  period  dur- 
ing" which  no  cyanide  was  given.  The  urines  from 
these  dogs  were  carefully  collected  and  analyzed. 

The  analytic  results  are  given  in  full  in  the  fol- 
lowing tables:   VII,  VIII,  IX,  X.  XI.  XIT. 

The  results  for  the  ratio  of  purin  base  nitri  gen  to 
uric  acid  nitrogen  were  as  follows  (Table  XIII)  : 


TABLE  \         FIRST  DOG.    SUMMARY  OF  ANALYTIC  TOTALS. 
Urinary  Nitrogen. 


Xo. 
I. 

II. 
III. 
IV. 

V. 

I. 
II. 
III. 

IV. 

V. 


I. 
11. 
III. 

IV. 


No. 
I. 
II. 
III. 


I. 
II. 
III. 


I. 
II. 
III. 


No. 
I. 
II. 
III. 


I. 
II. 
III. 


I. 
II. 
III. 


Period.  Total 

condition.  grammes. 

Normal    29.4046 

Dosage    35.8040 

Dosage    13.2566 

Dosage    25.3814 

Recovery    31.7290 

Normal    3.2672 

Dosage    2.9833 

Dosage    3-3141 

Dosage    3.1727 

Recovery    3.1729 


Allantoinc. 
grammes. 
0.3636 
o . 4294 
o . 2072 
0.2616 
0.30.?  4 


Normal  .  . 
Dosage  . . 
Dosage  . , 
Dosage  . 
Recovery 


Per  cent. 


TABLE  VIII 


Period.  Total 

condition.  grammes. 

Normal    48.1456 

Dosage    43-6395 

Recovery    27-9053 

Normal    4.6509 

Dosage    5-4549 

Recovery    5-3495 


1 .24 
1 . 20 
1.56 
1 .03 
0.96 


I .0943 
0.7130 
0.5049 


Per  cent. 
0.03 
0.15 
0.06 


Normal  . 
Dosage  . 
Recovery 


Per  cent. 


TABLE  IX 


Period.  Total 

condition.  grammes. 

Normal    13-7550 

Dosage    20.8930 

Recovery    18.5440 

Normal    2.2925 

Dosage    2.6116 

Recovery    2.3180 


Urea, 
grammes 
25.3128 
30.9750 
1 1 . 1690 
21 .4379 

26. 442 T 

Daily  Averages. 
2.8125  0.0404 
2.5813  0.0358 
2.7922  0.0518 
2.6797  0.0327 
2.6443  0.0305 
Relation  to  the  Total  Nitrogen 
Per  cent.        Per  cent.         Per  cent. 
86.10 
86.52 
84.30 
84-45 
83-30 

— SECO.N'D  nOG.    SUMMARY  OF 
Urinary  Nitrogen. 

Urea.  Allantoinc 
grammes.  grammes. 
38.9304 
37.8996 
24.6448 

Daily  Averages. 
4.3256  0.1216 
4-7374  0.0891 
4.1075  0.0841 
Relation  to  the  Tot.\l  Nitrogen 
Per  cent.         Per  cent.         Per  cent. 
3.41  80.90  2.27 

3.09  86.86  1.63 

3-05  88.35  1-81 

—THIRD  DOG.    SUMMARY  OF  ANALYTIC  TOTALS 
Urinary  Nitrogen. 


.\mmonia, 
grammes. 
1 .0326 
1-3504 
0.4192 
0.8215 
1 .0879 


0.1147 
0.1125 
o. 1048 
0. 1027 
o. 1088 


3-51 

3-77 
3.16 
3-24 
3-43 


-Kminonia, 
grammes. 
1-6435 
1-3504 
0.8521 


o . 1420 
0.1688 
0. 1826 


Uric  acid, 
grammes. 
0.0462 
o . 0470 
o . o 1 66 
0.0358 
0.0590 


0 . 005 1 
0.0039 
o . 0042 
0.0045 
o . 0050 

Per  cent, 
o.  16 
0.13 
0.13 
o.  14 
o.  19 


Purin  bases, 
gran-mes. 
0,0092 
0.0430 
0.0076 

0.1451 


0.0010 
0 .0044 
0.0019 


0.45 

.ANALYTIC  TOTALS. 


Uric  acid, 
grammes. 
0.0426 
0.0342 
0 . 0245 

0.0047 
0.0043 
o . 004  I 

Per  cent. 
0.00 
0.08 
0.09 


Purin  bases, 
grammes. 
0.0258 
o . 0696 
o .  0 1 6 1 


0.0028 
0.0087 
o . 0027 


Per  cent. 
0.05 
o.  16 
0.06 


Normal  . 
Dosage  . 

Recovery 


Per  cent. 


Ammonia, 

Urea, 

Allantoinc, 

Uric  acid, 

grammes. 

grammes. 

grammes. 

grammes. 

0.6825 

1 1  .S405 

0.21 19 

0.0279 

2.2241 

16.5367 

0.0962 

0.0467 

0.9647 

15-6654 

0 . 2709 

0 . 0461 

Daily  Averages. 

0.1138 

I -9734 

0-0353 

0.0046 

0.2780 

2.0671 

0.0120 

0.0058 

0. 1206 

1.9582 

0.0339 

0 . 0057 

Relation  to  the 

Total  Nitrogen. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

4.96 

86.10 

I -54 

0.21 

10.64 

79-30 

0.46 

0.22 

84.50 

1 . 46 

0.25 

Purin  bases, 
grammes. 


Per  cent. 


Undeter- 

Creatinine, 

mined. 

grammes. 

grammes. 

0.6315 

2.0087 

0-7332 

2 . 2 160 

0.2442 

1.1928 

0-4275 

2.3971 

0-5835 

3-1054 

0.0702 

0.2232 

0.0611 

0. 1847 

0.0607 

0.2982 

O.0S34 

0.2996 

0.0584 

0.3105 

Per  cent. 

Per  cent. 

2-15 

6.83 

2.0"; 

6.20 

1 .84 

8.99 

1.68 

9.46 

1 .84 

9-79 

Undeter- 

Creatinmc, 

mined, 

grammes. 

grammes. 

0.8482 

5.5608 

0.7900 

2.7S27 

0. 5600 

I .30^9 

0.0942 

0.6179 

0.0988 

0.3478 

0.0933 

0.2171 

Per  cent. 

Per  cent. 

1 . 76 

11-55 

1.81 

6.37 

2.01 

4.67 

Undeter- 

Creatinine, 

mined, 

grammes. 

grammes. 

0.3662 

0.6260 

0.3225 

1.6368 

0.4287 

I. 1682 

0.0610 

0.1043 

0.0403 

0. 2046 

0.0536 

0. 1460 

Per  cent. 

Per  cent. 

2.66 

4-55 

I -54 

7-85 

2-31 

6.30 

"The  dififerences  between  the  results  of  the  determinaUons  of  the  alloxuric  nitrogen  and  the  uric  acid  were  so  .slight  as  to  warr.mt 
the  conclusion  that  the  uric  acid  nitrogen  was  the  only  purin  nitrogen  eliminated  in  quantities  sufficiently  large  for  consideration. 


ioo6 


DITMAN  AND  WELKER:  DEFICIENT   OXIDATION  AND  NEPHRITIS. 


[New  York 
Medical  Journal. 


TABLE  X.— FOURTH  DOG.    SUMMARY  OF  ANALYTIC  TOTALS. 
Urinary  Nitrogen. 


Period,  Total 

No.    condition.  grammes. 

L    Normal    14-6555 

II.    Dosage    16.1440 

III.    Recovery    18.41 13 

I.    Normal    2. 93 11 

II.    Dosage    2.6907 

III.    Recovery    2.6302 

Per  cent. 

I.  Normal   

II.  Dosage   

III.  Recovery   

TABLE  XL- 


Period,  Total 

No.  condition.  grammes. 

VI.  Normal    49.9520 

V'll.  Dosage    66.8012 

IX.  Recovery    60.6486 

X.  Dosage    47.5932 

XI.  Recovery    53-5932 

VI.  Normal    9.9904 

VII.  Dosage    9-543° 

IX.  Recovery    10.1081 

X.  Dosage    9.5186 

XI.  Recovery    10.7186 

Per  cent. 

VI.  Normal   

VII.  Dosage   

IX.  Recovery   

X.  Dosage   

XI.  Recovery   

TABLE  XII.- 


Period.  Total 

No.    condition.  grammes. 

I.    Normal    52.0633 

II.    Dosage   ....    62.0987 

III.    Recovery    73.8900 

I.    Normal    10.4126 

II.    Dosage    10.3496 

III.    Recovery    10.5557 

Per  cent. 

I.  Normal   

II.  Dosage   

III.  Recovery   


Ammonia, 
grammes. 
0.7624 
0.8143 
0.9860 


o. 1525 
o. 1357 
o. 1409 


Urea, 
grammes 

12-7303 
13.0203 
15-5368 


Allantoine, 
grammes. 
0.2934 
0.3541 
0.5753 


Daily  Averages. 
2.5461  0.0587 


2. 1700 
2.2195 


0.0590 
0.0822 


Uric  acid, 
grammes, 
o  .0294 
0.0317 
0.0323 


0.0059 
0.0053 
0.0046 


Relation  to  the  Total  Nitrogen. 


Per  cent. 
5.20 
5.06 
5-36 


Per  cent. 
86.90 
80.60 
84.40 


Per  cent. 


3.12 


Per  cent. 


0.20 
o.iS 


Purin  bases, 
grammes. 
0.0194 
0 . 0209 
0.0503 


0.0039 
0.0035 
o . 0072 


Per  cent. 


0.13 
0.13 
0.27 


-FIFTH  DOG.    SUMMARY  OF  ANALYTIC  TOTALS. 
Urinary  Nitrogen. 


Ammonia, 
grammes. 
I . 7669 
3-7047 
2.1259 
1-7958 
2.0168 


0.3534 
0.5294 
0.3543 
0.3592 
0.4034 


Urea, 
grammes 
45-3227 
59-5497 
54.8448 
44.4831 
48.9210 


Allantoine, 
grammes. 

0.3312 
0.2028 
0.4291 
0. 5206 
0.3120 


Daily  Averages. 
9.0645  0.0662 
8.5071  0.0290 
9.1408  0.0715 
8.8966  0.1041 
9. 784  J  0.0624 


Uric  acid, 
grammes. 
0.0364 
0.0482 
0.0456 
0.0430 
0.0369 


0.0073 
0 . 0069 
0.0076 
0 . 0086 
0.0074 


Relation  to  the  Total  Nitrogen. 


Per  cent. 

3-54 
5-55 
3-5' 
3-77 
3-76 


Per  cent. 

90.73 
89. 14 
90 .40 
93-50 
91.25 


Per  cent. 
0.66 
0.30 
0.71 
1 . 09 
0.58 


Per  cent. 
0.07 
0.07 
0.07 
0.09 
0.07 


Purin  bases, 
grammes. 
0.0469 
0.0383 
0.0417 
0.03S9 
0.0656 


0.0094 
0.0055 
0.0069 
0.0078 
0.0131 


Per  cent. 
0.09 
0.06 
0.07 
0.08 
0.12 


-SIXTH  DOG.    SUMMARY  OF  ANALYTIC  TOTALS. 
Urinary  Nitrogen. 


Ammonia, 
grammes. 
I .4845 

1-  9332 

2-  3317 


0.2969 
0.3222 
0.3331 


Urea, 
grammes. 
46.8047 
57-8937 
66.6083 


Allantoine, 
grammes. 
0.7120 
0.7574 
1 .0550 


Daily  Averages. 
9.3609  0.1424 
9.6489  0.1262 
9-5155  0.1507 


Uric  acid, 
grammes. 
0.0340 
0 . 0706 
0. 1690 


.0068 
.0117 
.0241 


Relation  to  the  Total  Nitrogen. 
Per  cent.         Per  cent.         Per  cent.        Per  cent. 
2.85  89.89  1.37  0.07 

3.11  93.20  1.22  O.II 

3.16  90.10  1.43  0.23 


Purin  bases, 
gram.mes. 


0. 1772 
o.  1963 


0.0296 
0.0295 
0.0280 


Per  cent. 
0.28 
0.29 

0.27 


Creatinine, 
grammes. 

0.3033 
o . 3802 
0.6284 


0.0607 
0.0634 
0.0898 


Per  cent. 
2 . 07 
2.36 
3-42 


Creatinine, 
grammes, 
o . 6j  30 
0.7415 
0.744s 
0.5812 
0.6074 


0 . 1226 
0. 1059 
0. 1 24 1 
0 . 1 162 
o.  1215 


Per  cent. 
1 .23 
1 . 1 1 
1-23 
1 .22 
1 . 14 


Creatinine, 
grammes, 
o .  8672 
0.9486 
0.8774 


0.1734 
o. 1581 
o. 1253 


Per  cent. 
1.67 
1-53 
1 . 19 


Undeter- 
mined, 
grammes. 

0.5173 
1 . 5225 
0.6022 


o. 1035 
0.2538 
0.0860 


Per  cent. 

3-53 
9.42 
3-27 


Undeter- 
mined, 

grammes. 
1.8349 
2.5159 
2.4171 
0. 1306 
1-6335 


0.3670 
0.3594 
0 . 4028 
o . 0261 
0.3267 


Per  cent. 

3-67 
3-77 
3-98 
0.27 
3-05 


Undeter- 
mined, 
grammes. 
2.0128 
0.3180 
2.6523 


0.4026 
0.0503 
0.3789 

Per  cent. 

3-8- 
0.51 
3-56 


Table  XIII. 

Medium  protein  plane  (see  Tables  VII  and  VIII.) 

Ratio  of 
purin  base 
nitrogen  to 
uric  acid 
nitrogen. 


Dog  I :  . 

No  cyanide  (Period  I)   1:5.10 

Cyanide  (Period  II)   1:0.89 

Dog  II : 

No  cyanide  (Period  I)   1:1.60 

Cyanide  (Period  II)   1:0.49 

No  cyanide  (Period  III)   1:1.50 

Low  protein  plane  (see  Tables  IX  and  X.) 

Dog  IV : 

No  cyanide  (Period  I)   1:1.5 

Cyanide  (Period  II)   1:1.5 

No  cyanide  (Period  III)   1:0.6 


High  protein  plane  (see  Tables  XI  and  XII.) 


Dog  V : 

No  cyanide  (PeriodVI)   1:0.77 

Cyanide  (Period  VII)   1:1.20 

No  cyanide  (Period  IX)   1:1.10 

Dog  VI : 

No  cyanide  (Period  I)   1:0.23 

Cyanide  (Period  II)   1:0.39 

No  cyanide  (Period  III)   1:0.87 


From  this  it  is  seen  that  while  the  changes  in  the 
dogs  on  low  and  high  protein  planes  are  indefinite, 
in  the  case  of  the  dogs  on  medium  planes  of  pro- 
tein nutrition  (I  and  II)  the  results  are  striking. 
The  reduction  of  the  oxidation  processes  in  these 
dogs  by  KCN  administration  appeared  to  increase 
relatively  the  unoxidized  products  of  the  purin 
group  in  the  urine.  That  this  relative  increa^^e  of 
unoxidized  purin  bodies  in  the  urine  of  nephritis, 
under  certain  dietary  conditions,  may  be  due  to  an 
interference  with  normal  bodily  oxidizing  functions, 
is  indicated  by  these  results. 

{To  he  continued.) 


^lay  13,  1909.] 


PRATT:  DEAFNESS  AFTER  FEBRILE  DISEASE. 


DEAFNESS  FOLLOWING  FEBRILE  DISEASES, 
AND  ITS  PREVENTION.* 

By  J.  A.  Pratt,  M.  D., 
Aurora,  111. 

When  we  see  the  number  of  acute  suppurative 
otitis  media  cases  that  follow  the  febrile  diseases, 
some  starting  under  the  most  favorable  conditions, 
and  again  when  we  would  expect  it  to  be  present 
by  the  virulence  of  the  attack  it  does  not  appear,  it 
certainly  brings  to  our  minds  that  there  are  some 
condition  or  conditions  present  which  favor  the  ap- 
pearance of  this  sequela  that  is  so  dangerous  to  the 
hearing,  and  life  of  the  patient. 

Under  the  heading  of  .Etiology  of  Acute  Suppu- 
rative Otitis  Media  given  by  Dr.  Ballenger  in  his 
admirable  book  on  Diseases  of  the  Nose,  Throat, 
and  Ear,  besides  the  febrile  diseases  he  speaks  of 
cold,  exposure,  chronic  rhinitis,  chronic  and  acute 
epipharyngitis,  adenoids,  enlarged  tonsils,  syphilis, 
tuberculosis,  snuffing  cold  fluids,  and  the  nasal 
douche,  the  list  being  certainly  thorough.  How  often 
do  we  find  in  the  most  severe  colds,  even  when 
we  have  a  previous  chronic  rhinitis,  or  chronic 
or  acute  epipharyngitis,  that  there  is  no  ear  compli- 
cation or  only  a  slight  stuflfy  feeling  which  passes 
away  in  a  few  hours.  Let  the  patient  who  has  ade- 
noids and  enlarged  or  inflamed  tonsils  contract  a 
cold  and  in  nearly  every  case  there  will  be  ear  com- 
plications which  generally  end  in  acute  suppuration 
in  a  few  hours. 

That  deafness  and  its  sequelae  following  febrile 
diseases  is  caused  in  the  majority  of  cases  by  the 
toxines  of  these  diseases  has  been  the  accepted  the- 
ory for  many  years.  Jarechy  finds  that  there  are 
three  elements  in  the  aetiology^  of  ear  diseases  re- 
sulting from  febrile  diseases:  i,  Toxines;  2,  exten- 
sion oJf  infection  from  the  throat;  3,  general  weak- 
ness. I  cannot  conceive  how  the  toxines  have  an\- 
particular  eftect  except  as  they  cause  a  transitory 
neuritis,  and  lowering  of  vitality.  The  germ  infec- 
tion undoubtedly  extends  from  the  nose  and  throat. 
^Vhen  the  doctor  still  further  sa3's  that  "the  neces- 
sity of  removing  hypertrophied  tonsils,  adenoid 
vegetations,  and  nasal  obstructions  in  all  our  little 
patients  so  that  when  subjected  to  the  strain  of 
scarlet  fever  they  may  avoid  the  principal  method 
of  ear  infection,"  he  is  very  near  the  truth;  but  in 
this  he  refers  to  his  second  element,  the  extension 
of  the  infection  from  the  nose  or  throat. 

While  the  infection  may  extend  from  the  nose 
and  throat,  in  the  majority  of  cases  I  believe  the 
germs  are  already  deposited  in  the  middle  ear 
awaiting  the  favorable  moment.  Dr.  Barnhill  in 
bis  exhaustive  work  on  Modern  Otology  states  as 
follows  :  "The  dangers  to  which  the  child  with  ade- 
noids is  submitted  are  very  greatly  increased  dur- 
ing an  attack  of  scarlet  fever,  measles,  or  diph- 
theria. Any  one  of  these  diseases  which  might 
otherwise  be  quite  mild  and  harmless  to  the  ear  in 
the  case  of  a  child  with  a  normal  throat,  may  run 
a  violent  course,  and  cause  serious  and  extensive 
destruction  of  the  tissues  of  the  ear  in  the  child 
whose  upper  respiratory  tract  is  blocked  with  these 
growths.  Undoubtedly  diphtheria  frequently  be- 
gins in  the  diseased  nasopharynx  several  hours  be- 

*Read  before  the  International  iledical  Association  of  Mexico, 
which  met  at  Tampico,  Mexico.  January  20,  21,  and  22,  1909. 


fore  it  makes  its  appearance  in  the  fauces,  where  it 
is  most  commonly  first  detected.  The  author  has 
had  an  opportunity  to  examine  several  cases  of  this 
disease,  in  which  there  was  present  a  well  formed 
diphtheritic  membrane  covering  the  adenoid  tissue 
in  the  vault  of  the  pharynx  at  a  time  when  abso- 
lutely no  evidence  of  the  disease  existed  in  any  part 
of  the  oropharynx.  The  large  extent  of  surface 
provided  by  the  exterior  of  a  well  formed  adenoid, 
together  with  that  of  all  the  numerous  and  deep 
fissures  between  its  various  lobes,  furnishes  an  ex- 
tensive field  for  the  deposit  of  such  a  membrane, 
as  well  as  for  the  absorption  of  the  pathogenic 
products  of  the  disease  which  are  produced  in  the 
crypts  and  upon  the  glands. 

During  the  angina  which  accompanies  scarlatina, 
measles,  and  amygdelitis  the  Streptococcus  pyo- 
genes is  very  frequently  and  perhaps  always  pres- 
ent. The  well  known  fact  that  the  occurrence  of 
one  of  these  diseases  is  a  menace  to  the  integrity 
of  the  hearing  apparatus  is  explained  on  the  fol- 
lowing grounds  :  (a)  During  the  inflammatory  state 
of  the  tonsils  and  nasopharyngeal  adenoids  which 
accompanies  the  height  of  the  particular  disease, 
there  is  a  rapid  increase  of  the  normal  number  of 
streptococci,  pneumococci,  or  other  pathogenic  bac- 
teria which  inhabit  these  structures.  (b)  The 
mechanical  stimulus  produced  by  the  presence  of 
the  pharyngeal  growth,  together  with  the  inflam- 
matory action  taking  place  within  these  glandular 
structures,  induces  the  secretion  of  a  large  amount 
of  ropy  mucous  in  the  nasopharynx,  of  which  the 
patient  rids  himself  by  blowing  the  nose  and  hawk- 
ing, (c)  The  mucous  lining  of  the  Eustachian  tube, 
together  with  that  of  the  tympanic  cavity,  is  more 
or  less  congested  and  swollen  in  common  with  that 
of  the  entire  upper  air  tract,  and  is  therefore  in  a 
state  receptive  of  inflammatory  action  as  soon  as 
the  necessary  bacteria  are  added,  (d)  Owing  to 
the  blocking  of  the  nose  and  nasopharynx  by  the 
inflamed  adenoids  and  tonsils,  blowing  the  nose  for 
the  purpose  of  dislodging  the  infected,  ropy  mucous 
becomes  difficult,  and  the  powerful  efforts  of  the 
patient  to  clear  the  upper  air  tract  often  drives  the 
Ijacteria  laden  mucous  through  the  Eustachian  tube 
into  the  middle  ear,  where  violent  infection  at  once 
ensues,  and  suppuration  and  tissue  destruction  are 
the  inevitable  results.  It  must  be  admitted  that 
bacteria  may  find  their  way  into  the  middle  ear  by 
means  other  than  that  provided  by  the  patient  when 
blowing  the  nose,  since  the  inflammation  accom- 
panying these  diseases  in  children  too  young  to 
perform  this  act  must  be  otherwise  explained.  In 
infancy  and  early  childhood  the  Eustachian  tube  is 
shorter  and  wider  in  proportion  than  in  adults,  and 
the  bacteria,  no  doubt,  find  their  way  through  such 
a  channel  much  more  readily  than  would  be  possible 
in  the  long  narrow  tube  of  the  grown  individual." 

Blake  and  Reik,  in  Surgical  Pathology  and 
Treatment  of  Diseases  of  the  Ear,  state:  "But  the 
vast  majority  of  simple  exudative  middle  ear  dis- 
orders are  of  secondary  rather  than  of  primary 
occurrence,  and  have  their  origin  on  similar  afTec- 
tions  of  the  nasal  or  nasopharyngeal  mucous  mem- 
branes. The  transmission  of  the  disease  from  one 
point  to  another  may  be  accomplished  by  its  spread 
through  directly  contiguous  tissue,  or  some  of  the 
irritating  secretion  may  be  conveyed   from  the 


looS 


FKATT:   DEAFNESS  AFTER  FEBRILE  DISEASE. 


[New  York 
Medical  Jourxajl. 


pharynx  to  the  tympanic  cavity  by  forcible  inliation 
through  the  tympanopharyngeal  tube.  Still  another 
explanation,  applicable  to  a  large  proportion  of 
cases,  IS  the  continuous  irritation  of  the  tubal  and 
tympanic  mucous  membranes,  the  obstruction  to 
proper  ventilation  of  the  drum  cavity,  and  the  inter- 
ference with  the  blood  supply  of  these  parts,  wliich 
usually  accompany  adenoid  growths  in  the  pharyn- 
geal vault,  hypertrophied  turbinates,  and  enlarged 
or  congested  tonsils.  '  Ostmann,  in  the  Al iincliciicr 
inedizinische  VVochenschrift,  April  ii,  1905,  en- 
dorses this  statement  when  he  says:  "In  reference 
to  infective  diseases  the  ear  is  especially  endan- 
gered in  children  who  have  previously  been  affected 
with  chronic  inllammation  of  thf  nose  and  naso- 
pharynx." 

We  see  that  Jarechy's  three  elements  practically 
cover  the  up  to  date  setiology  of  the  cause  of  ear 
diseases  resulting  from  febrile  diseases.  While  it 
is  considered  that  the  adenoids  and  tonsils  have  a 
great  deal  to  do  with  ear  diseases  I  do  not  think 
they  are  given  the  prominence  they  should  have, 
and  that  the  way  they  are  detrimental  is  far  from 
being  properly  explained,  and  certainly  not  to  my 
satisfaction,  so  I  wish  to  submit  the  following  for 
thought  and  consideration. 

The  middle  ear  is  an  ideal  cavity  for  trouble 
making ;  being  a  chamber  entirely  enclosed  except 
by  the  opening  of  the  Eustachian  tube,  which  opens 
into  it  from  a  germ  infected  nasopharynx,  and  is 
repeatedly  filled  with  the  air  taken  from  a  germ 
laden  atmosphere.  It  is  really  a  wonder  that  we 
have  as  little  ear  trouble  as  we  do.  In  the  different 
sinuses  of  the  nose  where  the  air  is  not  forcibly 
changed  as  in  the  ear,  as  soon  as  we  have  a  mechan- 
ical obstruction  of  their  ostium,  inllammation  soon 
starts  and  suppuration  follows,  if  the  opening  re- 
mains closed.  Which  fact  certainly  demonstrates 
that  there  are  continually  present  in  these  sinuses 
germs  which  as  soon  as  ventilation  and  drainage 
are  interfered  with  start  to  make  trouble.  By  this 
I  do  not  mean  that  this  is  the  only  way  by  which 
germs  can  enter  the  sinuses.  If  this  is  true  how 
much  more  frequently  would  we  have  trouble  if 
these  cavities  were  forcibly  ventilated,  thus  bring- 
ing more  germs  to  their  mucous  membranes,  and 
have  growths  present  near  their  openings  which 
would  give  quicker  and  more  lasting  obstructions. 

While  the  authorities  do  not  agree  that  germs  are 
present  in  the  normal  middle  ear,  the  chances  are 
very  favorable  from  a  common  sense  point  of  view, 
that  the  air  which  ventilates  the  middle  car  must 
leave  some  germs  deposited  on  its  mucous  mem- 
brane, and  if  the  tube  is  patulous  these  would 
l)e  augmented  by  the  forcing  of  secretion  from  the 
nasopharynx  in  the  early  stages  of  inflammation. 

In  patients  who  have  adenoids  and  enlarged  ton- 
sils, on  account  of  the  chronic  inflammation  ])resent, 
the  blood  vessels  in  the  surrounding  tissues  are 
chronically  dilated,  and  respond  quickly  to  the 
'•lightest  inflammation.  The  Eustachian  tube  sur- 
rounded as  it  is  by  the  veins  and  arteries  supplying 
the  middle  ear  and  its  own  mucous  lining,  and  be- 
ing unable  to  dilate  in  its  bony  portion  is  occluded 
either  by  the  mechanical  dilation  of  the  vessels  in  its 
bony  portion,  or  closed  by  the  pressure  of  the  swol- 
len tonsils,  adenoids,  and  vessels,  in  its  soft  portion. 
When  the  tube  is  closed  we  soon  have  the  air  con- 


tained m  the  middle  ear  absorbed  and  the  vessels 
in  its  mucous  lining  dilate,  and  serum  transudes  to 
tr}-  and  hll  the  vacuum.  It  is  then  we  have  our  ideal 
condition  for  germ  culture.  A  serum  culture  me- 
dium, and  a  warm,  moist,  closed  chamber,  and  we 
soon  have  germs  enough  present  to  begin  destruc- 
tive work,  if  the  tube  is  not  opened. 

The  germs  most  frequently  present  in  suppu- 
rative otitis  media  are  the  Diplococcus  pncniiionics. 
Streptococcus  pyogenes,  Staphylococcus  albus, 
citreus,  and  aureus,  and  as  they  are  facultative 
anaerobes  the  conditions  are  particularly  -uitable  to 
their  quick  development. 

If  the  predominant  germ  is  particularly  virulent, 
and  of  destructive  nature,  and  there  should  happen 
to  be  a  weak  spot  around  the  round  or  oval  win- 
dows, or  at  the  capsule  of  the  labyrinth,  where  it 
forms  part  of  the  middle  ear  wall,  the  germs 
would  force  their  way  into  the  internal  ear  before 
the  pressure  would  be  great  enough  to  rupture  the 
membrana  tympani,  thus  causing  our  early,  stidden 
internal  ear  deafness  that  has  been  attributed  to  tox- 
ines.  Later  entrance  into  the  internal  ear  might  be 
gained  through  the  horizontal,  semicircular  canal 
by  way  of  the  mastoid,  and  yet  the  mastoiditis  will 
disappear  without  operation.  This  might  account 
for  later  internal  ear  complications. 

Thus  we  find  that  patients  who  have  enlarged 
adenoids  and  tonsils  are  more  prone  to  ear  troubles 
simply  from  the  mechanical  obstruction  to  the  Eus- 
tachian tube,  and  if  this  condition  is  not  present 
the  ears  will  not  be  afifected  often  in  the  most  se- 
vere nasal  congestions,  and  yet  is  so  frequent  even 
in  mild  congestions  in  those  patients  so  affected. 
As  children  are  more  subject  to  adenoid  and  tonsil 
enlargement,  so  it  is  here  we  have  the  grave  ear 
diseases  that  are  destructive  to  hearing.  In  febrile 
diseases  with  the  intense  mucous  membrane,  and 
lymphatic  inflammation,  the  patients  who  have 
these  hypertrophies  are  practically  always  affected 
with  ear  complications.  While  it  is  true  that  we 
can  have  middle  ear  inflammation  and  suppuration 
withovit  enlarged  adenoids  or  tonsils  I  do  not  be- 
lieve the  converse  to  be  true. 

In  order  to  arrive  at  some  statistics  I  sent  out  a 
number  of  letters  to  some  of  the  leading  ear  and 
throat  men  throughout  the  world.  The  two  ques- 
tions asked  were : 

r.  W'hat  percentage  of  your  incurable  deaf  cases, 
or  intractable  suppurating  ear  cases,  have  been 
caused  by  the  febrile  diseases  ? 

2.  What  percentage  of  the  patients  had  adenoids, 
or  their  facial  development  showed  that  they  were 
previously  afilicted  with  adenoids? 

Dr.  Alexander,  of  Vienna,  who  for  many  years 
was  Politzcr's  first  assistant,  and  with  whom  I  had 
the  pleasure  of  studying,  states  that  thirty-five  per 
cent,  of  his  patients  are  referred  to  febrile  diseases, 
and  that  sixty  per  cent,  of  these  have  had  adenoids. 

Dr.  Herbert  Tilley,  of  London,  states  that  the 
larger  majority  of  patients  come  from  the  febrile 
diseases,  and  that  the  larger  percentages  of  these 
have  adenoids. 

Dr.  M.  D.  Lederman,  of  New  York,  gives  sev- 
enty-five per  cent,  to  each  of  the  questions. 

Dr.  Frank  .\llf)ort.  of  Chicago,  in  a  personal  in- 
terview !,^ave  scvcntv-five  per  cent,  to  each  of  the 
nuestions. 


May  J  5.  1909.1 


1  H  ERAPE  U  TIC  A  L  XOJ  ES. 


1 000 


Dr.  Edwin  Pynchon,  of  Chicago,  states  that  near- 
ly every  case  can  be  traced  to  both. 

Dr.  F.  B.  Eaton,  of  Portland,  Oregon,  gives  ten 
per  cent,  and  ninety  per  cent. 

Dr.  Barnhill  reports  a  very  large  percentage  in 
both  cases. 

Dr.  Francis  R.  Packard,  of  Philadelphia,  gives 
the  vast  majority  to  both  questions. 

And  Dr.  H.  P.  Mosher  of  Boston  gives  twenty 
per  cent,  to  the  first  question,  and  seventy-five  per 
cent,  to  the  second. 

While  this  does  not  give  us  anything  absolutely 
definite  it  certainly  agreed  with  my  own  observa- 
tions, and  I  am  quite  postive  in  my  own  mind  that 
at  least  twenty  per  cent,  of  our  incurable  deaf  cases, 
that  date  from  childhood,  can  be  traced  to  the  fe- 
brile diseases,  and  that  practically  all  of  these  are 
due  to  enlarged  tonsils  and  adenoids. 

Dr.  H.  F.  True,  medical  examiner  of  Los  .Aji- 
geles  city  schools,  states  that  thirty  per  cent,  of  the 
school  children  are  defective  in  hearing,  and  of 
5,321  children  examined  thirty-one  per  cent,  had 
adenoids  and  twenty-five  per  cent,  enlarged  tonsils. 
In  my  visual  examination  of  the  lower  grades  in 
Aurora,  III,  about  twenty-five  per  cent,  show  ade- 
noids, and  under  a  thorough  examination  I  think 
the  percentage  would  run  as  high  or  higher  than 
the  thirty-one  per  cent,  of  Dr.  True.  At  a  low  esti- 
mate I  think  we  can  safely  say  that  twenty-five  per 
cent,  of  children  have  adenoids,  and  practically 
every  one  of  these  will  have  defective  hearing,  or 
total  deafness  when  they  mature. 

Dr.  A.  B.  Duel  found  in  the  study  of  6,000  cases 
of  infectious  fevers,  at  Willard  Parker  Hospital, 
treated  under  the  most  favorable  conditions,  that 
acute,  purulent  otitis  media  developed  in  twenty 
per  cent,  of  the  cases  of  scarlet  fever;  ten  p;r  cent, 
of  the  diphtheria  cases ;  and  five  per  cent,  of  the 
cases  of  measles ;  in  diphtheria  and  measles  in  the 
acute  stage,  and  in  scarlet  fever  during  the  second 
or  third  week  when  the  throat  congestion  is  greater 
after  exposure. 

This  would  give  us  nearly  a  thirty  per  cent,  com- 
plication which  will  support  the  figures  of  Dr.  True 
of  thirty-one  per  cent,  of  the  children  examined 
having  adenoids.  Yet  all  this  suffering  and  incon- 
venience, to  say  nothing  of  the  inability  to  learn, 
can  be  avoided  by  proper  means,  and  still  these 
means  are  being  neglected  every  day,  and  either 
through  ignorance  or  carelessness  the  family  physi- 
cian allows  the  children  to  "outgrow"  the  condition. 

The  time  is  not  far  distant  when  the  State  will 
take  this  matter  into  its  own  hands  and  do  in  the 
name  of  charity  and  authority,  what  the  parents 
and  physicians  should  do  for  love  and  duty.  As  to 
the  remedy  it  is  hardly  necessary  to  say  that  (.very 
physician,  who  has  given  the  subject  the  least 
thought,  or  study,  agrees  that  the  diseased  lym- 
phatic tissue  should  be  removed  as  early  and  as 
thoroughly  as  possible. 

It  is  well  to  recall  the  admonition  of  Sir  William 
Dalby :  "If  one  thing  more  than  another  stands 
out  in  relation  to  what  is  written,  said,  and  done  in 
connection  with  this  matter,  it  is  the  necessitv  of 
tol  erance  for  other  methods-  while  advocating;'  our 
own,  and  for  the  following  reason,  that  it  is  char- 
acteristic of  the  complaint  that  if  the  growths  are 
removed  in  any  way.  so  long  as  they  are  completely 


removed,  the  patients  receive  the  benefit."  W'e 
must  continually  bring  to  the  minds  of  the  general 
practitioners  and  the  public  the  irreparable  damage 
that  is  done  to  future  generations  by  allowing  these 
conditions  to  go  unrelieved.  It  is  not  what  shall 
we  do  for  our  deaf  cases,  but  how  to  prevent  this 
most  serious  pathological  ear  sequela. 

Summary. 
In  conclusion  I  wish  to  say  that : 

1.  The  majority  of  ear  diseases  are  caused  by 
adenoids  and  enlarged  tonsils. 

2.  These  conditions  are  in  the  greater  propor- 
tion caused  by  mechanical  obstructions  of  the  Eu- 
stachian tube. 

3.  The  germs  found  in  the  secretions  are  pres- 
ent in  the  normal  middle  ear  as  they  are  in  the 
nasopharynx  and  sinuses. 

4.  While  varying  in  different  parts  of  the  coun- 
try, from  twenty-five  per  cent,  to  thirty  per  cent, 
of  the  children  have  adenoids  or  enlarged  tonsils. 

5.  All  hypertrophied  lymphatic  tissues  of  the 
nasopharynx  should  be  early  and  completely  re- 
moved so  that  mechanical  obstruction  of  the  Eu- 
stachian tube  will  not  occur  during  congestion  of 
the  nasopharynx  thus  interfering  w^ith  the  drain- 
age and  ventilation  of  the  middle  ear. 

 ^  


The  Treatment  of  Pellagra.— Babes,  V'asilu,  and 
Gheorghas  give  the  following  treatment :  An  hypo- 
dermic injection  of  0.5  gramme  atoxyl  is  adminis- 
tered, internally  the  patients  are  given  one  to  five 
milligrammes  of  arsenic  trioxide,  and  receive  an  in- 
unction of  a  salve  containing  five  grammes  arsenic 
trioxide  in  the  proportion  of  i  to  50.  In  mild  cases 
only  one  combined  treatment  is  given,  in  other  case< 
the  treatment  is  repeated  on  the  succeeding  dav, 
while  in  severe  cases  the  two  days'  treatment  is  re- 
peated after  an  interval  of  a^  week.  (Berliner 
Klinische  Wochenschrift,  February  8,  1909.) 

Otitis  Media. —  In  the  Jouniai  of  the  American 
Medieal  Association  we  find  the  following  prescrip- 
tions for  otitis  media :  If  no  fluid  is  present  in  the 
tympanic  cavity,  but  the  drum  shows  congestion  and 
there  is  pain,  the  following  ear  drops  may  be  used : 

Boric  acid  gr.  xv  ; 

Glycerin,    • 

Water,   '.  .V.V.V.'.V.V.aci 'Sii'. 

M.  et  Sig. :  Use  warm,  and  pour  half  a  teaspoonful  into 
the  ear  once  in  three  or  four  hours. 

This  fluid  should  be  held  in  the  ear  a  minute  or 
two  and  then  allowed  to  run  out.  The  outer  part  of 
the  canal  is  then  gently  dried  with  absorbent  cotton 
and  a  plug  of  cotton  left  in  the  orifice. 

Or: 

I*    Boric  acid,  gr.  xv  ; 

Tincture  of  opium  3iss  .' 

Glycerin   3jjj " 

Water  '..'.'.".'.'.'.'.'.'.■.ad  Si'. 

M  et  Sig. :  Use  warm,  and  place  a  few  drops  in  the  ear 
every  hour,  if  needed,  and  then  plug  with  cotton. 
Or: 

R    Adrenalin  chloride,  gr.  ss  : 

Glycerin,   3v  • 

Water  ^jj" 

M-  et  Sig.:  Use  warm,  and  pour  half  a  teaspoonful  into 
the  ear  every  three  hours. 


1010 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


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NEW  YORK,  SATURDAY,  MAY  15,  1909. 


SANITARY  HOMES  FOR  TUBERCULOUS 
FAMILIES. 

Ground  has  been  broken  for  the  construction  of 
the  group  of  sanitary  tenements  to  be  erected  by 
Mrs.  William  K.  Vanderbilt,  Sr.,  in  East  Seventy- 
seventh  and  Seventy-eighth  streets.  The  execution 
of  this  design,  providing  as  it  practically  does  for 
sanatorium  conditions  to  be  enjoyed  as  long  as  need 
be  by  consumptives  and  their  families,  will  doubt- 
less mark  a  new  and  hopeful  era  in  the  home  treat- 
ment of  tuberculous  disease.  The  demonstration  in 
recent  years  that  climate  is  not  so  very  important  a 
factor  in  successful  treatment  as  had  been  thought, 
the  excellent  results  obtained  in  sanatoria  in  all  sec- 
tions of  the  country,  and  the  recognition  of  the  fact 
that  the  sanatorium  is  always  a  costly  and  often  an 
impracticable  means  of  obtaining  temporarily  fresh 
air,  light,  and  decent  living  conditions  for  the  tu- 
berculous poor  are  considerations  which  have  led 
up  to  the  evolution  of  the  sanatorium  tenement. 
The  advantages,  aside  from  economy,  are  the  avoid- 
ance of  interruption  of  domestic  life  and  the  disper~ 
^ion  of  young  children ;  the  fact  that  the  patient  is 
not  returned  after  a  brief  period  of  hygienic  living 
to  the  slum  conditions  which  generated  his  disease, 
but  is  given  a  chance  to  get  well  in  the  favorable 
environment  in  which  he  may  continue  to  live ;  and, 
most  important  of  all,  the  protection  of  a  healthful 
home  for  others  in  the  patient's  family  who  in  the 
usual  tenement  surroundings  are  extremely  likely  to 
furnish  additional  victims  to  the  disease.  The  clinic 
physician  and  visiting  nurse  arc  well  aware  of  the 


appalling  frequency  with  which  other  unsuspected 
cases,  especially  in  children,  are  found  in  the  fami- 
lies of  tuberculous  patients  applying  for  treatment  in 
our  city  dispensaries. 

With  rare  discernment  and  a  sense  of  practical 
philanthropy  akin  to  the  intuition  of  genius,  Mrb. 
Vanderbilt  has  attacked  the  problem  in  the  squalid 
homes  which  are  the  hotbeds  of  consumption  and 
other  infectious  diseases.  Her  first  great  contribu- 
tion to  the  warfare  against  tuberculous  disease  was 
her  effective  organization  and  continued  support  of 
the  visiting,  nursing,  and  social  service  department 
(the  first  of  its  kind  in  New  York)  of  the  Presby- 
terian Hospital.  The  sanitary  tenements  now  being 
built  after  the  designs  of  Dr.  Henry  L.  Shively,  in 
collaboration  with  the  architect,  will  possess  every 
hygienic  and  architectural  device  to  make  them  po- 
tent instruments  in  the  control  and  suppression  of 
tuberculous  disease.  Apart  from  this,  the  primary 
great  object  of  their  construction,  there  will,  it  is 
evident,  incidentally  accrue  many  other  advantages, 
for  the  clean,  hygienic  living  necessary  in  the  treat- 
ment is  also  favorable  to  good  morals,  health,  tem- 
perance, good  citizenship,  and  all  the  social  virtues 
which  make  for  the  higher  development  of  the  indi- 
vidual in  every  way. 


ARTERIOSCLEROSIS. 

The  annual  conversational  meeting  of  the  Patho- 
logical Society  of  Philadelphia  has  for  many  years 
been  an  event  of  considerable  importance.  The 
address  of  the  occasion  has  always  been  delivered 
by  a  pathologist  of  national  and  occasionally  of 
international  reputation.  The  review  of  the  arterio- 
sclerotic process  presented  by  Professor  J.  George 
Adami,  of  Montreal,  on  the  evening  of  April  22d, 
was  well  up  to  the  high  standard  of  excellence  thus 
set. 

The  subject  of  arteriosclerosis  is  of  great  im- 
portance. Dr.  Adami 's  remarks  were  based  upon 
the  work  that  has  been  done  in  the  laboratories  of 
McGill  University,  of  Montreal.  The  leading  in- 
vestigator of  the  subject.  Dr.  Oscar  Klotz,  whose 
contributions  we  have  noted  from  time  to  time,  has 
done  much  to  elucidate  some  of  the  problems  raised 
by  an  endeavor  to  coordinate  the  various  fully  de- 
veloped conditions  met  with  on  the  autopsy  table. 
The  speaker  referred  frequently  to  the  experi- 
mental work  of  Dr.  Klotz  in  the  course  of  his 
remarks. 

Dr.  Adami  is  of  the  opinion  that  the  two 
types  of  arteriosclerosis,  the  arterial  thinning  of 
Moenckeberg  and  the  intimal  thickening  of  the 
ordinary  senile  type,  are  diverse  manifestations  of 
a  common  process.  In  both  of  them  the  essential 
lesion  is  considered  to  be  a  weakening  of  the 


May  15,  1909.] 


EDITORIAL  ARTICLES. 


lOI  I 


media.  In  the  one,  however,  the  vessel  wall  gives 
way  from  increased  pressure ;  in  the  other  there  is 
a  compensatory  thickening  of  the  intima  by  the 
deposition  of  fibrous  tissue.  The  compensatory 
thickening  of  the  intima  is  seen  in  its  highest  de- 
velopment in  young  subjects,  in  whom  the  regen- 
erative powers  are  generally  more  exuberant. 


THE  NOMENCLATURE  AND  CLASSIFICA- 
TION OF  DISEASES. 

It  is  doubtless  in  great  measure  to  the  fact  that 
the  International  Classification  of  Causes  of  Death 
is  soon  to  be  revised  that  is  to  be  attributed  the  un- 
wonted interest  in  these  subjects  which  has  of  late 
been  manifested  in  the  United  States.  The  confer- 
ence of  revision  would  in  the  ordinary  course  of 
events  not  be  convened  until  some  time  in  the  year 
191  o.  At  the  request  of  our  government,  however, 
in  order  that  the  revision  may  be  available  for  the 
census  statistics  of  1910,  the  government  of  France 
has  most  courteously  consented  that  it  shall  be  held 
this  year.     It  will  assemble  in  Paris  in  July. 

Nearly  two  years  ago  the  American  Medical  As- 
sociation took  measures  to  aid  in  the  revision,  and 
like  action  had  been  previously  taken  by  the  Ameri- 
can Public  Health  Association.  The  committees  ap- 
pointed by  these  bodies  have  worked  together,  with 
the  cooperation  also  of  various  other  national  medi- 
cal societies  and  of  the  government  medical  services, 
to  formulate  certain  recommendations  to  be  submit- 
ted for  consideration  by  the  Paris  conference.  It  is 
to  be  presumed  that  other  countries  have  taken  sim- 
ilar action.  The  outcome  is  likely  to  be  a  decided 
improvement  upon  the  present  classification,  excel- 
lent as  it  is. 

As  was  to  have  been  expected,  general  interest  in 
the  subject  of  nomenclature  has  kept  pace  with  that 
displayed  regarding  classification.  The  Medical 
Corps  of  the  Navy  has  recently  adopted  a  revised 
and  most  scholarly  form  for  its  Statistical  Reports, 
and  the  Bellevue  Hospital  Nomenclature — a  most 
useful  form — has  lately  undergone  careful  revision. 
In  this  issue,  in  our  department  of  Special  Articles, 
we  give  the  first  part  of  the  revised  version,  and  we 
shall  complete  the  publication  in  subsequent  issues. 
The  State  societies  might  contribute  materially  to 
the  general  revision,  and  a  beginning  of  such  work 
on  their  part  seems  to  have  been  made  at  the  recent 
annual  meeting  of  the  IMedical  Association  of  the 
State  of  Alabama,  at  which  the  Council  on  Nosology 
passed  the  following  resolutions  : 

Resolved,  that  the  Medical  Association  of  the  State  of 
Alabama  endorse  the  International  Classification  of  Causes 
of  Death,  subject  to  its  revision  at  Paris  in  1909,  and  that 
the  Council  of  the  Medical  Association  of  the  State  of 
Alabama  be  instructed  to  cooperate  with  the  committee  of 
the  American  Medical  Association  and  with  the  Bureau  of 


the  Census  in  the  preparation  of  a  nomenclature  of  diseases 
for  general  adoption  in  this  country. 

Resolved,  that  it  is  imperatively  necessary  that  the  United 
States  be  represented  in  the  second  revision  of  the  Inter- 
national Qassification  of  Causes  of  Death  at  Paris  in  1909, 
and  that  the  Alabama  delegation  in  Congress  be  notified 
by  telegram  to  this  effect. 

So  far  as  we  know,  the  Medical  Association  of  the 
State  of  Alabama  is  the  only  State  society  that  main- 
tains a  standing  committee  on  nomenclature  and 
classification.  The  Alabama  committee  is  styled  the 
Council  on  Nosology.  Its  members  at  the  time  of 
the  recent  meeting  in  Birmingham  were  as  follows : 
Dr.  D.  L.  Wilkinson,  of  jMontevallo  (chairman)  ; 
Dr.  R.  ]\I.  Cunningham,  of  Ensley ;  Dr.  Julian  F. 
Peavey,  of  Atmore ;  Dr.  W.  G.  Somerville,  of  Tus- 
caloosa ;  and  Dr.  M.  P.  Gaines,  of  Mobile.  It  seems 
to  us  that  all  the  State  societies  might  do  well  to 
establish  similar  bodies. 


"BERTILLONAGE." 
A  good  description  of  M.  Alphonse  Bertillon's 
system  of  identifying  human  beings,  by  the  late 
Dr.  Persifor  Frazer,  is  begun  in  the  Journal  of  the 
Franklin  Institute  for  April,  and  is  to  be  continued. 
It  is  in  the  form  of  a  lecture  which  was  delivered 
in  the  Popular  Science  series  at  the  Franklin  Insti- 
tute, in  Philadelphia,  on  February  15th.  Dr.  Frazer. 
who  was  an  expert  anthropologist,  but  was  perhaps 
better  known  on  account  of  his  study  of  hand- 
writing, died  of  cardiac  disease  on  April  7th. 


PRIMARY  SARCOMA  OF  THE  STOMACH. 

Among  the  neoplasms  arising  in  the  stomach, 
sarcoma  is  undoubtedly  one  of  the  most  infrequent, 
but  it  cannot  be  considered  as  very  rare,  because 
Burgaud  (These  de  Paris,  1908)  has  collected  a  suf- 
ficient number  of  instances  to  enable  him  to  describe 
the  general  clinical  characters  of  the  affection.  A 
classification  of  primary  sarcoma  of  the  stomach  is 
essential,  and  this  classification  is  justified  as  much 
by  macroscopical  and  microscopical  appearances  as 
by  the  prognosis  and  clinical  manifestations.  There- 
fore Burgaud  has  distinguished  between  gastric  and 
exogastric  sarcoma. 

Gastric  sarcoma  is  met  with  as  either  a  circum- 
scribed or  diffuse  nodular  infiltration,  or  it  may  pro- 
ject into  the  stomach  cavity  in  the  form  of  a  vege- 
tation. Exogastric  sarcoma  gives  rise  to  a  tumor 
which  usually  occupies  the  lower  portions  of  the 
stomach,  developing  outside  of  the  organ,  and  it 
may  attain  very  large  dimensions.  It  not  infre- 
quently extends  very  low  into  the  abdomen  and  may 
be  attached  to  the  stomach  only  by  a  rather  narrow 
pedicle.  Both  these  forms  are  different  histological- 
ly.   The  gastric  type  is  a  round  cell  sarcoma,  while 


IOI2 


EDITORIAL  ARTICLES. 


[New  York 
Mepical  Journal. 


Ulc  cxogastric  type  is  often  a  fusiform  cell  sarcoma. 
As  to  the  clinical  evolution,  it  ma\-  be  said  that  it 
differs  essentially  according  to  the  type  of  growth. 
In  the  gastric  type  the  symptoms  are  those  of  an 
epithelioma  of  the  stomach,  and  therefore  gastric 
symptoms  are  usual.  The  evolution  is  so  like  that 
of  cancer  that  the  diagnosis  is  practically  impos- 
sible. On  the  other  hand,  exogastric  cancer  is  made 
evident  bv  symptoms  of  an  abdominal  tumor  hav- 
ing an  obscure  origin.  The  growth  is  movable  and 
dips  down  into  the  abdominal  cavity  when  artificial 
flistention  of  the  stomach  is  resorted  to. 

The  prognosis  of  the  gastric  type  of  sarcoma  is 
the  same  as  that  of  epithelioma,  with  the  exception 
that  vi.sceral  and  glandular  metastases  are  less  com- 
mon, also  extensive  adhesions,  and  consequently  the 
growth  remains  operable  for  a  longer  time.  The 
diagnosis  is  usually  impossible,  but  it  has  been  made 
in  some  cases  from  the  fact  that  sarcoma  cells  have 
been  found  in  the  gastric  contents.  In  other  cases 
it  may  be  suspected  if  the  patient  is  still  young. 
Burgaud  believes  that  an  exploratory  incision  should 
always  be  undertaken,  and  that  the  operation,  if 
possible,  should  be  the  complete  resection  of  the 
neoplasm.  In  cases  of  large  growths  which  are 
pedunculated  this  end  may  easily  be  attained,  cither 
with  or  without  a  limited  resection  of  the  gastric 
wall.  In  more  complicated  cases  gastrectomy  or 
gastroenterostomy  should  be  done. 


THE  OPERATIVE  TREATMENT  OF 
HEMORRHOIDS. 
Dr.  T.  Chittenden  Hill,  surgeon  to  the  Rectal 
Department  of  the  Boston  Dispensary,  gives  in  the 
Boston  Medical  and  Surgical  Journal  for  April  8th 
a  very  practical  appreciation  of  the  three  established 
operations  for  hasmorrhoids — excision  of  the  pile 
bearing  area  (Whitehead's  operation),  ligation,  and 
the  employment  of  the  clamp  and  cautery.  In  pa- 
tients under  fortv  years  of  age.  lie  says,  in  agree- 
ment with  Goodsall.  of  London,  neither  ligation  nor 
the  clamp  and  cautery  operation  holds  out  an  ab- 
solute guarantee  against  the  recurrence  of  hsemor- 
rhoidal  trouble,  for  below  that  age  not  all  the  piles 
may  yet  have  developed.  Whitehead's  operation 
does  give  .such  a  guarantee,  but  in  most  cases  it  is 
needlessly  severe  and.  unless  primary  union  of  the 
cutaneous  and  mucous  edges  is  secured,  and  ulcera- 
tion results,  troublesome  cversion  of  the  mucous 
membrane  is  apt  to  follow.  .Any  one  of  the  three 
operations,  properly  performed,  ought  to  confer  rea- 
sonable freedom  from  relapse.  Ligation  appears  to 
be  the  author's  favorite  operation,  and  he  remarks 
that  it  ought  not  to  be  followed  by  anything  worse 
than  a  little  soreness  lasting  for  a  few  days.  Local 
anesthesia  suffices  for  its  painless  perfdruiance. 


THE  BULL  ^lEMORIAL. 
The  movement  for  perpetuating  the  memory  of 
the  late  Dr.  William  Tillinghast  Bull's  services  to 
medicine  and  to  humanity  looks  to  the  creation  of  a 
substantial  fund  for  conducting  original  research  un- 
der the  direction  of  the  surgical  department  of  the 
School  of  Medicine  of  Columbia  University,  in 
which  for  many  years  Dr.  Bull  was  a  teacher  of  sur- 
gery. The  research  work  is  to  be  carried  on  from 
the  various  standpoints  of  pathology,  bacteriology, 
chemistry,  physiology^  and  anatomy  in  the  labora- 
tories of  the  College  of  Physicians  and  Surgeons 
and  in  such  of  the  hospitals  of  New  York  as  afford 
facilities  for  its  proper  prosecution.  The  scheme 
does  not  call  for  the  expenditure  of  much  money  for 
new  buildings,  but  most  of  the  income  of  the  fund 
will  be  devoted  to  remunerating  the  actual  investi- 
gators and  to  the  publication  of  their  accounts  of 
their  work.  It  seems  to  us  that  no  more  admirable 
memorial  could  be  devised. 


NEPHRITIS  AND  CUTANEOUS  IRRI- 
TATION. 

Though  they  are  rare,  there  are  cases  of  severe 
renal  disturbance  that  seem  to  be  connected  with 
cutaneous  irritation,  especially  with  impetigo.  Dr. 
L.  Duvernay  (Lyon  medical,  April  25th)  records 
three  cases  of  his  own  occurring  in  children,  and 
says  that  there  are  thirty  others  registered  in 
French  literature.  In  his  cases  dyspnoea  was  a 
prominent  symptom.  One  of  them  proved  fatal.  It 
seems  quite  likely  that  the  impetigo  is  not  in  itself 
the  etiological  element,  but  that  the  impetiginous 
lesions,  the  vesicles  being  torn  open  by  scratching, 
serve  as  avenues  of  access  for  microorganisms  that 
really  give  rise  to  the  kidney  trouble. 


THE  MORTALITY  STATISTICS  OF  1907. 

The  mortality  statistics  of  the  United  States  have 
lately  been  issued  by  the  Bureau  of  the  Census  in 
the  form  of  a  quarto  volume  of  over  five  hundred 
pages.  The  report  has  been  prepared  under  the  di- 
rection of  Dr.  Cressy  L.  Wilbur,  the  chief  statisti- 
cian for  vital  statistics,  and  it  well  exemplifies  Dr. 
Wilbur's  painstaking  methods.  It  covers  the  entire 
registration  area,  including  48.8  per  cent,  of  the 
population  of  the  United  States  proper,  a  percentage 
which  has  gradually  increased  from  seventeen  in  the 
census  year  1879- '80.  In  the  year  1908  two  States. 
Wisconsin  and  Washington,  were  added  to  the  area, 
but  in  1907  there  was  no  addition.  The  statistics 
arc  arranged  in  a  great  variety  of  forms,  and  the 
tables  cannot  fail  to  prove  extremely  useful. 


May  15.  1 909. 1 


NEll'  S  ITEMS. 


1013 


Changes  of  Address. — Dr.  J.  W  heeler  Smith,  to  685 
St.  Marks  Avenue,  Brooklyn,  X.  Y. 

"Tag  Day"  in  Paterson,  N.  J.,  for  the  benefit  of  St. 
Joseph's  Hospital,  yielded  over  $10,000.  The  enterprise  was 
so  successful  that  "tag-  day"  will  hereafter  be  an  annual 
event  in  Paterson. 

A  New  Hospital  in  Austin,  111.,  to  cost  $100,000,  is 
being  planned  by  the  Protestant  churches  of  the  locality. 
Immediate  steps  will  be  taken  to  raise  the  necessary  funds, 
and  as  soon  as  $50,000  has  been  subscribed  the  work  on  the 
building  will  be  begun. 

Violations  of  Registration  Laws. — The  Bureau  of 
Health  of  the  City  of  Philadelphia,  on  Thursday,  April 
29th,  issued  warrants  for  the  arrest  of  fifteen  physicians 
and  midwives  charged  with  failure  to  register  births  in  the 
office  of  the  Registrar  of  Vital  Statistics. 

The  Army  General  Hospital  was  installed  in  its  new 
quarters  in  Takoma  on  May  2d.  The  old  building  which  is 
new  the  post  hospital  of  Washington  Barracks,  will  soon 
be  torn  down.  The  new  building  is  said  to  be  one  of  the 
handsomest  Army  general  hospitals  in  the  country. 

Change  in  Date  of  Meeting  of  the  New  Jersey  State 
Society. — The  annual  meeting  of  the  Medical  Society' 
of  New  Jersey  will  be  held  at  Cape  May  on  Wednesday, 
Thursday,  and  Friday,  June  23d.  24th,  and  25th,  instead  of 
on  the  dates  mentioned  in  the  original  announcement. 

The  Gloucester  County,  N.  J.,  Medical  Society  will 
meet  in  Woodbury,  N.  J.,  on  Thursday  afternoon.  May 
20th,  at  I  -.30  o'clock.  Dr.  Alfred  Gordon,  of  Philadelphia, 
will  deliver  a  clinical  lecture,  and  Dr.  Edwards  will  read 
a  paper  on  Rabies.  A  full  attendance  of  members  is  de- 
sired. 

The  American  Therapeutic  Society  elected  the  follow- 
ing officers  at  its  annual  meeting,  held  in  New  Haven, 
Conn.,  last  week  :  President,  Dr.  James  C.  Wilson,  of  Phil- 
adelphia; secretary.  Dr.  Noble  P.  Barnes,  of  Washington; 
treasurer.  Dr.  A.  Ernest  Gallant,  of  New  York.  The  next 
meeting  of  the  society  will  be  held  in  Washington,  D.  C, 
in  May,  1910. 

"The  Benefit  for  the  New  York  Association  of  the 
Blind,  given  at  the  Hippodrome  on  Tuesday  evening, 
IMay  loth,  was  very  successful.  The  gross  receipts  for  the 
matinee  and  evening  were  about  $10,000,  the  profits  of 
which  will  be  applied  on  the  $100,000  endowment  fund 
needed  by  the  association.  Of  this  sum  $85,000  has  al- 
ready been  collected. 

A  New  Dispensary  for  Lebanon  Hospital. — A  number 
of  prominent  women  in  New  York  are  making  plans  to  ob- 
tain funds  for  the  erection  of  a  modern  dispensary  for 
Lebanon  Hospital,  as  the  facilities  and  accommodations  of 
the  present  building  are  wholly  inadequate  to  meet  the  de- 
mands made  upon  it.  Last  year  over  5,000  persons  received 
free  treatment  at  this  dispensary. 

Contagious  Diseases  in  Chicago. — During  the  wecK 
ending  May  i,  1909,  the  following  cases  of  contagious  dis 
eases  were  reported  to  ihe  Department  of  Health:  Diph- 
tneria,  89;  scarlet  fever,  112;  measles,  346;  whooping  cough, 
30;  tuberculosis,  90;  pneumonia,  87;  typhoid  fever,  26: 
chickenpox,  17;  mumps,  18;  cerebrospinal  fever,  i;  puer 
peral  fever,  2;  erysipelas,  9;  total,  827. 

The  New  Addition  to  the  Phipps  Dispensary  for  Con- 
sumptives, .Tt  the  Johns  Hopkins  Hospital,  Baltimore, 
was  opened  on  May  3d.  The  building  was  erected  with 
funds  given  to  the  dispensary  by  ^Ir.  Henry  Phipps.  There 
are  no  beds  in  the  dispensary,  and  the  physicians  in  charge 
cooperate  with  the  tuberculosis  sanatoria  throughout  the 
State.    Dr.  Louis  Hamman  is  in  charge. 

Preparing  for  the  Atlantic  City  Meeting  of  the  Amer- 
ican Medical  Association.— A  special  effort  has  been 
made  by  the  local  entertainment  committee  to  make  the 
June  meeting  of  the  American  Medical  Association  par- 
ticularly enjoyable.  While  a  complete  programme  of  the 
entertainments  provided  for  the  visiting  members  and  their 
friends  has  not  been  made  public,  it  is  announced  that  the 
opening  reception  to  the  ladies  will  be  held  in  the  parlors 
of  the  Hotel  Chalfonte  on  Tuesday  afternoon,  June  8th, 
between  4  and  5:30  o'clock.  This  hotel,  which  is  head- 
quarters for  the  Section  in  Surgery  and  .\natoray,  is  mak- 
ing special  preparations  to  provide  accommodations  for  be- 
tween three  and  four  hundred  of  the  physicians  who  will 
visit  Atlantic  City  during  the  second  week  in  June. 


Flower  Hospital  to  be  Enlarged. — Plans  have  been 
filed  for  the  enlargement  of  this  hospital  by  the  addition 
of  the  five  story  tenement  house  at  427  East  Sixty-third 
Street,  which  will  be  made  over  into  an  annex,  to  be  con- 
nected with  the  dispensary  of  the  institution.  The  annex 
will  contain  a  clinic  and  diet  kitchen,  in  addition  to  rooms 
for  the  college  professors  and  the  hospital  physician. 

Vacancies  at  Beth  Israel  Hospital. — Two  physicians 
are  wanted  at  Beth  Israel  Hospital,  Jefferson  and  Cherry- 
Streets,  New  York,  one  to  act  as  chief  of  the  neurological 
department  of  the  dispensary,  and  the  other  a.-s  assistant 
in  the  dermatological  department  of  the  dispensary.  Ap- 
plications should  be  sent  at  once  to  Dr.  Wolff  Freudenthal, 
1003  Madison  Avenue,  chairman  of  the  dispensary  commit- 
tee of  the  hospital. 

Officers  of  the  Alabama  State  Medical  Association. — 
At  the  recent  annual  meeting  of  this  association  officers  for 
the  ensuing  year  were  elected  as  follows :  President,  Dr. 
W.  W.  Wilkinson,  of  Montgomery ;  senior  vice-president, 
Dr.  Robert  J.  Redden,  of  Sulligent ;  junior  vice-president. 
Dr.  R.  L.  Sutton,  of  Orv-ille ;  secretary.  Dr.  J.  Norman 
Baker,  of  Montgomery,  reelected ;  treasurer.  Dr.  Henry 
Gaither  Perry,  of  Greensboro,  reelected. 

Prize  for  Essay  on  Lister. — Announcement  is  made 
by  the  medical  faculty  of  Johns  Hopkins  University  that 
Dr.  A.  E.  Malloch,  of  Hamilton,  Ontario,  Canada,  has  pre- 
sented to  the  Aledical  Department  of  the  university  the  sum 
of  $150,  which  is  to  be  given  as  a  prize  to  the  undergradu- 
ate student  who  submits  the  best  essay  on  Lister  and  His 
Work.  All  essays  subm.itted  in  competition  for  the  prize 
must  be  in  the  hands  of  the  advisory  board  on  or  before 
February  r.  1910.  Tlie  right  is  reserved  by  the  board  to 
withhold  the  award  in  case  no  essay  is  received  that  seems 
to  be  sufficiently  meritorious. 

Alumni  Day  at  the  Harvard  Medical  School  will  be 
celebrated  on  May  20th.  The  usual  lectures  and  recitations 
will  be  carried  on  at  the  school  during  the  day.  and  there 
will  be  clinics  and  demonstrations  at  the  various  hospitals. 
In  the  evening  the  triennial  dinner  of  the  Harvard  Medical 
School  Alumni  Association  will  be  held  at  the  Hotel  Som- 
erset. Dr.  Alfred  Worcester,  president  of  the  association, 
will  act  as  toastmaster,  and  among  the  speakers  will  be 
President  Eliot,  President-elect  Lowell,  Dr.  William  Osier. 
Major  \\'ood.  of  the  United  States  .\rmy.  Lieutenant 
Governor  Frothingham,  and  Mayor  Hibbard. 

The  Medical  Association  of  the  Greater  City  of  New 
York. — The  last  regular  meeting  of  this  association  be- 
fore the  summer  vacation  will  be  held  in  Du  Bois  Hall. 
New  York  Academy  of  Medicine,  on  Monday  evening,  Mr.;. 
17th,  at  8  o'clock.  Dr.  Woods  Hutchinson  will  read  .1 
paper  entitled  Asthma  and  Its  Allies,  which  will  be  di-- 
cussed  by  Dr.  William  H.  Thomson.  Dr.  L.  F.  Bishop,  Di. 
James  J.  W'alsh,  and  Dr.  Harlow  Brooks.  Compensatory 
Albuminuria  is  the  title  of  a  paper  to  be  read  by  Dr.  Hein- 
rich  Stern.  A  general  discussion  will  follow.  A  special 
meeting  of  the  association  will  be  held  in  the  Borough  of 
Richmond  on  ^^'edne^day  evening.  June  2d. 
Scientific    Society   Meetings   in    Philadelphia    for  the 

Week  Ending  May  22,  1909: 
.Mfi.vi'Av.  May  lyth. — Medical  Society  of  the  Woman's  Hos- 
pital. 

Tle.^d.w.  May  i8th. — Dermatological  Society;  Academy  of 
Natural  Sciences ;  North  Branch,  Philadelphia  County 
Medical  Societv". 
Wedxesd.w.  .1/(7_v  igih. — Section  in  Otology  and  Laryngol- 

og>-.  College  of  Physicians :  Franklin  Institute, 
i  HfR.SD.w,  .l/(iy  20lh. — Section  Meeting,  Franklin  Institute: 
Southwark  Medical  Society:  Northeast  Branch,  Phila- 
delphia   County    Medical    Society:    Delaware  Vallej^ 
Ornithologists  Club. 
Fi(iDAV..l/(;y  2ist. — ^American  Philosophical  Society. 

Charitable  Bequests. — By  the  will  of  Fannie  B.  Shoe 
maker  the  Episcopal  Hospital,  of  Philadelphia,  the  Phila- 
delphia Home  for  Incurables,  the  Home  for  Consumptives 
of  the  Protestant  Episcopal  City  Missions,  and  the  Shelter- 
ing Arms,  participate  in  the  distribution  of  the  residual 
estate. 

By  the  will  of  George  C.  Thomas,  the  Episcopal  Hos- 
pital, of  Philadelphia,  receives  $10,000. 

By  the  will  of  Mrs.  James  H.  Brown  the  Maiden.  Mas^.. 
Hospital  will  receive  $^.ooo  to  endow  a  free  bed,  to  be 
known  as  the  Abbie  L.  Brown  bed. 

Bv  the  will  of  Ida  M.  Claggett.  the  Miami  Valley  Hos- 
pital, Davton.  Ohio,  and  the  Widows'  Home  each  receive 
$500. 


IOT4 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


The  Health  of  Pittsburgh.— During  the  week  ending 
May  I,  1909,  the  following  cases  of  transmissible  diseases 
were  reported  to  the  Bureau  of  Health :  Chickenpox,  10 
cases,  o  deaths ;  typhoid  fever,  8  cases,  2  deaths ;  scarlet 
fever,  5  cases,  o  deaths;  diphtheria,  17  cases,  i  death; 
measles,  16  cases,  2  deaths ;  whooping  cough,  36  cases,  2 
deaths ;  pulmonary  tuberculosis,  59  cases,  12  deaths.  The 
total  deaths  for  the  week  numbered  154  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  14.17  in  a  thousand  population. 

The  East  Side  Physicians'  Association  of  New  York 
will  hold  its  regular  monthly  meeting  on  Thursday  even- 
ing. May  27th,  at  Scheffel  Hall,  194  Third  Avenue.  In  ad- 
dition to  the  exhibition  of  patients  and  the  reports  of  in- 
teresting cases,  the  programme  will  include  two  papers,  as 
follows :  The  Treatment  of  Croupous  Pneumonia,  by  Dr. 
A.  Seibert ;  Malposition  not  the  Cause  but  a  Symptom  of 
Dystocia,  by  Dr.  C.  A.  von  Ramdohr.  Among  those  who 
will  take  part  in  the  discussion  are  Dr.  Augustus  Wads- 
worth,  Dr.  Jewett,  Dr.  H.  J.  Boldt,  Dr.  J.  O.  Polak,  Dr.  F. 
A.  Dorman,  and  Dr.  A.  Brothers.  A  collation  will  be 
served  at  the  close  of  the  meeting,  to  which  members  and 
guests  are  invited. 

Mr.  Heinsheimer's  Bequest  to  Hebrew  Charities. — An 
effort  IS  being  made  to  carry  out  the  wishes  of  Mr.  Louis 
A,  Heinsheimer,  who  recently  bequeathed  $1,000,000  to  six 
Hebrew  institutions  in  New  York  on  condition  that  an 
agency  should  make  the  collections  and  distribute  the  funds 
among  them.  Three  of  the  institutions  have  refused  to 
subscribe  to  these  conditions,  and  as  a  result  the  bequest 
may  revert  to  Mr.  Heinsheimer's  brother,  who  is  named  in 
the  will  as  a  residuary  legatee,  unless  the  beneficiaries  come 
to  some  agreement.  Mr.  Heinsheimer  has  authorized  the 
executors  of  the  will  to  pay  over  the  $1,000,000  if  some  plan 
can  be  agreed  to  by  five  out  of  the  six  institutions  named  in 
the  will.  A  committee  has  been  appointed  to  make  a  care- 
ful study  of  the  whole  situation,  and  it  is  expected  that 
some  arrangement  will  be  made  by  which  it  will  be  possi- 
ble to  accept  the  large  bequest. 

The  Mortality  of  Chicago. — During  the  week  ending 
May  I,  1909,  there  were  reported  to  the  Department  of 
Health  596  deaths  from  all  causes,  34  less  than  for  the 
preceding  week,  and  60  more  than  for  the  corresponding 
period  in  1908.  The  annijal  death  rate  in  a  thousand  pop- 
ulation was  13.97,  as  against  a  death  rate  of  14.77  for  the 
preceding  week.  The  total  infant  mortality  was  171 ;  106 
were  under  one  year  of  age,  and  65  between  one  and  five 
years  of  age.  The  principal  causes  of  death  were :  Diph- 
theria. 21  deaths;  scarlet  fever,  6  deaths;  measles,  9  deaths: 
whooping  cough,  4  deaths ;  influenza,  5  deaths ;  typhoid 
fever,  2  deaths ;  diarrhoeal  diseases,  28  deaths,  of  which  25 
were  under  two  years  of  age ;  pneumonia,  135  deaths ; 
tuberculosis,  67  deaths,  of  which  52  were  pulmonary ;  can- 
cer, 22  deaths ;  nervous  diseases.  26  deaths ;  heart  diseases, 
57  deaths ;  apoplexy,  12  deaths ;  Bright's  disease,  44  deaths ; 
violence,  34  deaths,  of  which  9  were  suicides ;  all  other 
causes,  124  deaths. 

Personal.— Dr.  W.  B.  Trimble,  of  New  York,  has  been 
promoted  from  an  instructor  to  a  lecturer  on  diseases  of 
the  skin  at  the  University  and  Bellevue  Hospital  Medical 
College. 

Dr.  Hugh  Angus  Stewart,  of  Baltimore,  has  been  ap- 
pointed an  adjunct  professor  of  pathology  at  the  College  of 
Physicians  and  Surgeons  (Columbia  University),  New 
York. 

Dr.  J.  Kent  Worthington,  for  many  years  a  member  of 
the  staff  of  Roosevelt  Hospital,  has  resigned,  and  his  resig- 
nation has  been  accepted  by  the  board  of  trustees  of  the 
hospital. 

Dr.  Robert  F.  Williams,  of  Richmond,  Va.,  has  resigned 
as  superintendent  of  the  State  Sanatorium  for  Tuberculosis, 
and  his  resignation  has  been  accepted. 

Dr.  Edward  R.  Walters  has  been  appointed  director  of 
the  Department  of  Health  and  Public  Charities,  Pittsburgh, 
Pa. 

Dr.  J.  Frank  Daniel,  of  Baltimore,  who  is  now  working 
in  the  laboratories  of  the  Pasteur  Institute,  Lille,  France, 
has  been  appointed  instructor  in  zoology  at  the  University 
of  Michigan. 

Dr.  Reuel  Stewart,  of  Philadelphia,  celebrated  his  eigh- 
tieth birthday  on  May  7th.  An  informal  reception  was 
given  in  his  honor  by  a  number  of  his  confreres. 


Prizes  for  Essays  on  Tuberculosis. — -The  Societe  In- 
ternationale du  la  tuberkulose  will  hold  a  concours  in  May, 
loog,  under  the  presidency  of  Professor  Lancreaux,  and 
will  distribute  prizes  for  the  best  essays  concerning  tuber- 
culosis as  follows:  i.  A  prize  of  300  francs.  2.  A  prize  of 
100  francs.  3.  Two  prizes  of  50  francs  each.  4.  Two  gold 
medals  with  diplomas  of  honor.  5.  Three  silver  medals 
with  diplomas  of  honor.  Those  who  desire  to  participate  in 
the  competition  should  send  their  essays,  in  sealed  en- 
velopes, to  Dr.  Georges  Petit,  secretary  general  of  the  so- 
ciety, 51  rue  de  Rocher,  Paris,  before  January,  i,  1910. 

The  Far  Eastern  Association  of  Tropical  Medicine.— 
The  first  biennal  meeting  of  this  association  will  open  in 
Manila  on  Sunday  afternoon,  March  6,  1910,  and  close  with 
a  business  session  at  Baguio,  Benguet,  the  summer  capital 
of  the  Philippines,  on  Monday,  March  14th,  the  sessions  ex- 
tending over  the  intervening  nine  days.  According  to  the 
preliminary  programme,  which  has  just  been  issued,  the  ses- 
sions on  tuberculosis,  climate,  hygiene,  and  sanitation  will 
be  held  at  Baguio,  and  the  sessions  on  protozoology,  helmin- 
thology,  cholera,  plague,  leprosy,  surgery  and  obstetrics,  dis- 
eases of  children,  tropical  fevers,  dysenteries,  and  beriberi 
will  be  held  in  Manila.  A  good  programme  of  entertain- 
ments is  also  being  prepared  by  the  local  committee.  For 
further  information  regarding  the  meeting  write  to  Dr.  E. 
R.  Whitmore  secretary-treasurer  of  the  Philippine  Branch 
of  the  Far  Eastern  Association  of  Tropical  Medicine,  Ma- 
nila, P.  I. 

The  Association  of  American  Teachers  of  Diseases  of 
Children  will  meet  in  annual  session  in  Atlantic  City, 
N.  J.,  on  June  7,  1909,  under  the  presidency  of  Dr.  Charles 
Douglas,  professor  of  diseases  of  children  in  the  Detroit 
College  of  Medicine.  The  preliminary  programme,  which 
has  just  been  issued,  gives  promise  of  an  interesting  meet- 
ing. Among  those  who  will  present  papers  are  Mr.  X-  Ross 
Robertson,  of  Toronto,  Canada;  Dr.  Le  Grand  Ken,  of 
Brooklyn ;  Dr.  Charles  Wright,  of  Minneapolis ;  Dr.  Ed- 
ward J.  Wyncoop,  of  Syracuse ;  Dr.  E.  W.  Mitchell,  of 
Cincinnati ;  Dr.  E.  H.  Bartley,  of  Brooklyn,  and  Dr.  H. 
Brooker  Mills,  of  Philadelphia.  A  "symposium"  on  How 
Should  the  Subject  of  Infant  Feeding  be  Taught,  is  in- 
cluded in  the  programme,  and  eight  papers  on  the  subject 
have  been  promised,  among  the  authors  being  Dr.  John 
Zahorsky,  of  St.  Louis ;  Dr.  Isaac  Abt,  of  Chicago ;  Dr.  J. 
Finley  Bell,  of  Englewood,  N.  J.,  and  Dr.  J.  Warren  Van 
Derslice,  of  Chicago. 

Alumni  Day  at  the  Jefferson  Medical  College  Com- 
mencement.— Plans  have  been  completed  for  the  enter- 
tainment of  the  alumni  of  Jefferson  Medical  College  at 
the  next  commencement,  and  reunions  of  several  classes 
will  be  held  on  June  7th,  which  has  been  set  aside  as 
Alumni  Day.  At  3:30  p.  m..  Professor  W.  W.  Keen  will 
hold  a  public  clinic  in  the  Jefferson  Hospital  amphitheatre. 
At  7  p.  m.  the  regular  annual  meeting  of  the  association 
will  be  held  at  the  Bellevue-Stratford  for  the  election  of 
officers  and  the  transaction  of  business,  followed  by  the 
annual  banquet,  the  subscription  to  which  is  $5.00.  All 
who  wish  to  attend  the  banquet  should  send  their  subscrip- 
tions at  once  to  Dr.  A.  Heineberg,  1327  Pine  Street,  Phila- 
delphia. A  large  attendance  is  anticipated,  as  the  meeting 
of  the  American  Medical  Association  begins  the  following 
(lay  at  Atlantic  City,  and  an  excellent  opportunity  is  af- 
forded the  visiting  alumni  to  inspect  the  new  hospital,  as 
well  as  to  renew  old  acquaintances. 

Vital  Statistics  of  New  York. — During  the  week  end- 
ing May  I,  1909.  there  were  reported  to  the  Department  of 
Health  1,521  deaths  from  all  causes,  in  an  estimated  popu- 
lation of  4,564,792,  corresponding  to  an  annual  death  rate 
of  17.38  in  a  thousand  population.  The  death  rate  in  each 
of  the  five  boroughs  was  as  follov>'s  :  Manhattan,  18.55  '■  f'lc 
Bronx,  24.74;  Brooklyn,  14.95;  Queens,  11. 71:  and  Rich- 
mond, 15.39.  The  mortality  for  the  week  was  lower  than 
it  has  been  since  the  second  week  in  March,  largely  due  to 
the  decrease  in  the  number  of  deaths  from  pulmonary 
tuberculosis  and  pneumonia.  The  total  number  of  deaths 
from  pulmonary  tuberculosis  for  the  week  was  181.  as 
against  211  for  the  preceding  week,  while  the  number  of 
deaths  from  pneumonia  was  reduced  from  300  to  264.  The 
total  infant  mortality  was  487.  290  under  one  year  of  age, 
and  197  between  one  and  five  years  of  age.  There  were 
122  still  births.  Seven  hundred  and  forty-seven  marriages 
and  2,156  births  were  reported  during  the  week. 


May  15,  1909.] 


XEIVS  ITEMS. 


IOI5 


The  Health  of  the  Canal  Zone. — During  the  month  ot 
Februarj-,  1909,  the  followmg  deaths  from  transmissible 
diseases  were  recorded  in  the  Canal  Zone :  Typhoid  fever. 

2  deaths  :  malarial  fever,  16  deaths  ;  sestivoautuinnal  malaria, 
6  deaths ;  malarial  cachexia,  i  death ;  haemoglobinuric  fever, 

3  deaths  ;  influenza,  i  death :  dysentery,  5  deaths ;  amcebic 
dysentery,  3  deaths ;  beriberi,  2  deaths ;  purulent  infection 
and  septichasmia,  4  deaths ;  tuberculosis  of  the  lungs,  22 
deaths ;  general  tuberculosis,  3  deaths ;  gonorrhoea,  i  death ; 
cancer,  2  deaths ;  tetanus,  i  death ;  bronchopneumonia,  8 
deaths ;  pneumonia,  15  deaths ;  diarrhoea  and  enteritis,  un- 
der two  years  of  age,  15  deaths;  and  uncinariasis,  i  death. 
The  total  deaths  for  the  month  numbered  197  in  a  popula- 
tion of  127,174.  corresponding  to  an  annual  death  rate  of 
18.59  in  a  thousand  population.  The  total  morbidity  rate 
among  the  employees  of  the  Canal  Commission  was  69  in 
a  thousand. 

Infectious  Diseases  in  New  York: 

ll'e  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  follozeing  statement  of  ue-iu 
cases  and  deaths  reported  for  the  tuo  zceeks  ending  May 
8,  igog  : 

,  May  I  V      ,  May  8  , 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    590         181         559  183 

Diphtheria    337  56         339  35 

Measles   1,389  37       I.-97  3^ 

Scarlet  fever    326  11  371  29 

Smallpox   

Varicella    191  ..  188 

Typhoid  fever    :9  11  58  4 

Whooping  cough    62  13  86  5 

Cerebrospinal  menirgitis    3  6  7  6 

Total   2,917         315       2,905  298 

The  Health  of  Philadelphia. — During  the  week  end- 
ing April  24,  1909,  the  following  cases  of  transmissible 
diseases  were  reported  to  the  Bureau  of  Health  of  Phila- 
delphia :  Malarial  fever,  i  case,  o  deaths ;  typhoid  fever,  22 
cases,  9  deaths ;  typhus  fever,  2  cases,  o  deaths ;  scarlet 
fever,  82  cases,  3  deaths ;  chickenpox,  52  cases,  o  deaths ; 
diphtheria,  85  cases,  18  deaths;  measles,  213  cases,  11 
deaths :  whooping  cough,  26  cases,  o  deaths ;  tuberculosis 
of  the  lungs,  104  cases,  63  deaths;  pneumonia,  49  cases,  65 
deaths;  erysipelas,  11  cases,  3  deaths;  tetanus,  I  case,  i 
death ;  mumps,  39  cases,  o  deaths.  The  following  deaths 
were  reported  from  other  transmissible  diseases:  Tubei- 
culosis,  other  than  tuberculosis  of  the  lungs,  7  deaths ; 
diarrhoea  and  enteritis,  under  two  years  of  age,  9  deaths ; 
puerperal  fever,  3  deaths.  The  total  deaths  numbered  524 
in  an  estimated  population  of  1,565.569,  corresponding  to  an 
annual  death  rate  of  17.40  in  a  thousand  population.  The 
total  infant  mortality  was  85;  63  under  one  year  of  age, 
22  between  one  and  two  years  of  age.  There  were  39  still 
births ;  26  male;  and  13  females.  The  total  precipitation 
was  1.54  inches. 

The  Laennec  Society  Prize  for  Essay  on  Tubercu- 
losis.— A  prize  of  $100  is  oitered  bj-  the  Laennec  Society 
for  the  Study  of  Tuberculosis  of  the  Johns  Hopkins  Hos- 
pital, Baltimore,  for  the  best  paper  on  any  subject  relating 
to  tuberculosis  presented  by  a  member  of  the  Johns  Hop- 
kins University  faculty;  a  member  of  the  hospital  or  dis- 
pensary staff:  an}'  student  of  the  university;  or  any  inde- 
pendent investigator  working  in  any  clinic  of  the  hospital, 
or  in  any  laboratory  connected  with  the  hospital  or  univer- 
sity'. The  conditions  of  the  prize  are  as  follows :  i.  All 
papers  must  be  presented  to  Dr.  W.  H.  Welch,  chairman 
of  the  Award  Committee,  on  or  before  March  i,  1910.  2. 
All  papers  must  be  typewritten  and  signed  by  some  ficti- 
titiou.^  name,  and  must  bear  no  mark  to  reveal  the  identity 
of  the  author.  The  paper  should  be  accompanied  by  a 
sealed  envelope  bearing  on  the  cover  the  fictitious  name, 
and  within  the  true  name  and  address  of  the  author.  3. 
Original  work  will  be  the  basis  of  award,  and  careful  clin- 
ical observation  will  receive  as  much  consideration  as  la- 
boratory experiments.  ^lere  compilations  from  the  literature 
will  receive  no  recognition.  4.  The  paper  receiving  the 
prize  will  be  read  by  the  author  at  the  meeting  of  the 
Laennec  Society  in  April,  1910,  and  be  published  in  the 
Bulletin  of  the  Johns  Hopkins  Hospital.  5.  The  unsuccess- 
ful papers  will  be  returned  to  their  authors  without  delay, 
so  that  they  may  make  other  disposition  of  them.  6.  The 
Committee  of  Award  may  withhold  the  prize  if  in  their 
judgment  none  of  the  papers  are  worthy  of  it.  The  mem- 
bers of  the  Award  Committee  are :  Dr.  William  H.  Welch, 
Dr.  William  S.  Thayer,  and  Dr.  J.  M.  T.  Finney. 


A  Special  Train  to  Atlantic  City  from  the  Missouri 
Valley  and  the  Southwest. — A  special  train  will  leave 
St.  Louis,  Mo.,  on  Saturday,  June  5th,  at  noon,  via  the 
Big  Four  and  C.  &  O.  Railways,  stopping  at  Hot  Springs, 
Va.,  for  Sunday.  It  will  run  through  to  Atlantic  City 
without  change,  arriving  at  8  o'clock  on  Monday  morning, 
in  ample  time  for  the  meeting  of  the  House  of  Delegates 
and  several  of  the  auxiliary  meetings.  Stopovers  will  be 
allowed  at  Philadelphia,  ^^'ashington,  Baltimore,  and  other 
points,  and  tickets  are  good  for  thirty  days  from  date  of 
sale.  The  fare  for  the  round  trip  is  $29.70  from  St.  Louis, 
and  the  rates  will  be  low  from  other  points.  State,  county 
and  district  societies  are  cordially  invited  to  join  this  party, 
and  enjoy  the  privileges  incidental  to  traveling  by  special 
train  and  in  congenial  company.  The  Grand  Atlantic  Hotel 
will  be  headquarters  for  the  party,  ample  reservation  of 
rooms  having  been  made.  This  hotel  is  on  Virginia  Ave- 
nue, only  a  few  steps  from  the  Steel  Pier,  where  the  Sec- 
tions in  ^ledicine.  Surgery,  Anatomy,  and  Gynaecology  will 
hold  their  sessions.  For  reservations  and  full  information, 
address  the  Secretary,  Dr.  Charles  Wood  Fassett,  St.  Jo- 
seph, Mo. 

The  Ohio  State  Medical  Society  held  its  sixty-fourth 
annual  meeting  in  Cincinnati,  on  ^May  5th  and  6th,  under 
the  presidency  of  Dr.  D.  R.  Silver,  of  Sidney.  A  splendid 
programme  of  papers  was  presented  by  leaders  in  the  med- 
ical profession  in  the  State  and  the  following  well  known 
men  from  elsewhere :  Dr.  Curran  Pope,  of  Louisville.  Ky. ; 
Dr.  Bertram  Shippey,  of  Chicago ;  Dr.  H.  S.  Plummer,  of 
Rochester,  Minn. ;  Dr.  Bransford  Lewis,  of  St.  Louis ;  Dr. 
W.  L.  Moss,  of  Johns  Hopkins  University,  Baltimore ;  Dr. 
Frank  Allport,  of  Chicago;  Dr.  Joseph  C.  Beck,  of  Chi- 
cago ;  and  Dr.  Samuel  G.  Gant,  of  New  York.  A  special 
feature  of  the  meeting  was  the  nnlk  exhibit  of  the  Cincin- 
nati Academy  of  Medicine.  The  social  features  consisted 
of  a  smoker  in  the  rooms  of  the  Business  Men's  Club  and 
a  banquet  at  the  Hotel  Sinton,  at  which  Dr.  Dan  Milliken, 
of  Hamilton,  acted  as  toastmaster.  Officers  for  the  en- 
suing year  were  elected  as  follows :  President,  Dr.  W.  H. 
Snyder,  of  Toledo ;  vice-presidents.  Dr.  H.  R.  Geyer,  of 
Zanesville ;  Dr.  A.  D.  Rudy,  of  Lima ;  Dr.  O.  M.  Wiseman, 
of  Zanesville,  and  Dr.  C.  A..  Hough,  of  Lebanon ;  secretary. 
Dr.  H.  J.  H.  Upham,  of  Columbus,  reelected;  treasurer.  Dr. 
James  A.  Duncan,  of  Toledo,  reelected.  Toledo  was  se- 
lected as  the  next  place  of  meeting. 
Society  Meetings  for  the  Coming  Week: 
MoxD.XY,  May  17th. — New  York  Academy  of  Medicine 
(Section  in  Ophthalmology)  ;  Medical  Association  of 
the  Greater  City  of  New  York;  Hartford,  Conn.,  Med- 
ical Society. 

TuESD.w,  May  i8th. — New  York  Academy  of  Medicine 
(Section  in  Medicine)  ;  Buffalo  Academy  of  Medicine 
(Section  in  Pathology)  ;  Tri-Professional  Medical  So- 
ciety of  New  York ;  Medical  Society  of  the  County  of 
Kings.  N.  Y. ;  Binghamton,  N.  Y.,  Academy  of  Medi- 
cine; Clinical  Society  of  Elizabeth,  N.  J.,  General  Hos- 
pital ;  Syracuse,  N.  Y.,  Academy  of  Medicine ;  Ogdens- 
burgh,  N.  Y.,  ^ledical  Association ;  ]\Iedical  Society  of 
the  County  of  Westchester,  N.  Y. 

Wednesday,  May  igth. — New  York  Academy  of  Medicine ; 
(Section  in  Genitourinary  Diseases);  New  York  So- 
ciety of  Dermatology  and  Genitourinao'  Surgery ; 
Woman's  Medical  Association  of  New  York  City  (New 
York  Academy  of  Medicine)  ;  Medicolegal  Society, 
New  York;  New  Jersey  Academy;  of  IMedicine  (Jersey 
City)  ;  Buffalo  Medical  Club  (annual)  ;  New  Haven, 
Conn.,  Medical  Association ;  New  York  Society  of  In- 
ternal Medicine ;  Northwestern  Medical  and  Surgical 
Society  of  New  York. 

Thursday,  May  20th.- — New  York  Academy  of  Medicine; 
German  Medical  Society,  Brooklyn;  Newark,  N.  J., 
Medical  and  Surgical  Society. 

Friday,  May  21st. — New  York  Academy  of  Medicine  (Sec- 
tion in  Orthopcedic  Surgery)  ;  Clinical  Society  of  the 
New  York  Postgraduate  ^ledical  School  and  Hospital; 
East  Side  Physicians'  Association  of  the  City  of  New 
York;  New  York  Microscopical  Society;  Brooklyn 
Medical  Society'. 

Saturday,  May  22d. — West  End  Medical  Society ;  New 
York  Medical  and  Surgical  Society:  Harvard  Medical 
Society,  New  York;  Lenox  Medical  and  Surgical  So- 
ciety, New  York. 


ioi6 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  XOMENCLATURE. 


.    [New  York 
Medical  Journal. 


THE   BELLEVUE    HOSPITAL    NOMENCLATURE  OF  DISEASES  AND 

CONDITIONS.* 

First  Edition,  1903. 
First  Revision,  1909. 

COMJ'ILED  BY  THE  COMMITTEE  ON   CLINICAL  RECORDS,  COMPOSED  OF  ROBERT  J.  CARLISLE,  WarREN  CoLEMAN, 

Thomas  A.  Smith,  and  Edmund  L.  Dow.' 


The  incentive  for  publishing  the  revised  Bellevuc 
Xoinoiclatnre  in  a  prominent  medical  journal  is  the 
following  excerpt  from  the  Mortality  Statistics. 
1907.  recently  issued  b'y  the  Census  Bureau, 
Washington.'  "For  the  immediate  present  and  until 
a  standard  nomenclature  shall  have  been  prepared 
for  the  United  States  and  brought  into  general  use, 
it  would  be  of  great  service  if  every  progressive 
physician  would  familiarize  himself  with  some  ac- 
ceptable nomenclature  of  diseases,  either  the  Bel- 
levtic  Nomenclature  or,  as  perhaps  more  generally 
accessible',  the  Nomenclature  of  the  Royal  College  of 
Physicians  of  London  and  employ  only  the  definite 
terms  contained  therein  in  making  out  certificates  of 
cause  of  death." 

THE  BELLEVUE  HUSriTAL  NOMENCLATURE. 

The  words  and  phrases  in  bold  face  type,  e.  g., 
anaemia,  simple,  are  the  exact  terms  in  which  the 
diagnosis  must  be  stated  upon  the  bedside  card  both 
as  to  the  principal  disease  and  the  complications.  No 
other  words  may  be  used  on  the  bedside  card  for 
this  purpose. 

The  words  in  italics  are  for  purposes  of  classifi- 
cation only;  e.  g.,  tumor  of  liver  is  not  to  be  used  as 
a  diagnosis,  but  for  the  word  tumor  the  variety  of 
tumor  must  be  substituted,  as  carcinoma  of  liver, 
angioma  of  liver,  etc. 

The  words  in  roman  type  are  suggestions  to  ph}  - 
sicians  using  the  nomenclature  in  diagnosis  and  in- 
structions to  record  clerks  for  filing  the  histories. 

DISEASES  AND  CONDITIONS. 
ABNORMITIES  AND  MALFORMATIONS, 
CONGENITAL. 

Tu  include  congenital  absence  of,  and  accessory,  organs. 
Branchial  Cyst. 
Cervical  Rib. 

Congenital  Amputation  of.    State  part  ;iflfected. 
Congenital  Fistula  of.    State  site. 
Congenital  Fracture  of.    State  bone  afYccted. 
Congenital  Malformation  of  Abdominal  Wall.    Not  to 

include  Hernise. 
Congenital  Malformation  of  Arm. 

Congenital  Malformation  of  Forearm. 

Congenital  Malformation  of  Hand. 
Congenital  Malformation  of  Circulatory  Syslnii. 
Congenital  Malformation  of  Diaphragm. 
Congenital  Malformation  of  Digestive  System. 
Congenital  Malformation  of  Ductless  Glands  and  Sfylccii. 
Congenital  Malformation  of  Ear.    Not  to  include  ex- 
ternal ear 

Congenital  Malformation  of  Eye.    Not  to  include  eye- 
lid. 

"Copyright  by  the  Board  of  Trustees  of  Bellevue  and  Allied  Hos- 
pitals, 1904. 

'The  Committcp  on  Oinical  Records  desires  to  make  grateful 
acknowledgment  for  valuable  suggestions  and  for  assistance  in  the 
work  of  compilation  and  revision  to  Dr.  Sam  Alexander,  Dr.  W.  C. 
Lusk,  Dr.  Minas  S.  (Jregory,  and  Dr.  W.  E.  .Studdiford. 

JThe  quotation  is  made  with  the  consent  of  Dr.  Crcssy  L.  Wilbur, 
chief  statistician.  Census  Bureau,  Washington. 

•All  the  hospitals  in  Brooklyn  and  many  others  throughout  the 
**r,iiiitr\   :lT'    n«-ini^  thf  Prltr:ur  \' "t):  rtir  Int  >irr 


Congenital  Malformation  of  Face.  File  here  alphabet- 
icaliy  congenital  malformations  of  eyelid,  exter- 
nal car,  lip,  nose,  palate  and  uvula. 

Congenital  Malformation  of  Cheek. 

Congenital  Malformation  of  Lower  Jaw. 
Congenital  Malformation  of  Joint.    State  joint  affected. 

Congenital  Dislocation  of. 
Congenital  Malformation  of  Leg. 

Congenital  Malformation  of  Foot. 
Congenital  Malformation  of  Lymphatic  System. 
Congenital  Malformation  of  Muscular  System. 
Congenital  Malformation  of  Nervous  System. 

Congenital  Malformation  of  Skull. 

Congenital  Malformation  of  Spinal  Column. 
Congenital  Malformation  of  Pelvic  Girdle. 
Congenital  Malformation  of  Reproductive  Organs. 
Congenital  Malformation  of  Respiratory  System. 
Congenital  Malformation  of  Shoulder  Girdle. 
Congenital  Malformation  of  Skin. 

Congenital  Malformation  of  Hair. 

Congenital  Malformation  of  Nails. 
Congenital  Malformation  of  Thorax. 
Congenital  Malformation  of  Urinary  Organs. 
Hermaphroditism. 
Monster. 

Transposition  of.    State  viscus  or  viscera  tran.sposed. 

THE  BLOOD. 
Anaemia,  Pernicious. 
Anaemia,  Simple. 

Anasmia,  Splenic.    To  include  Banti's  disease,  primary 

splenomegaly,  splenic  pseudoleuchsemia. 
Chlorosis. 
Haemophilia. 
Leuchaemia. 

Polycythaemia,  Chronic. 
Pseudoleuchaemia,  Infantile. 

Purpura.  Do  not  use  as  a  primary  diagnosis  when 
cause  can  be  determined. 

BONES  AND  CARTILAGES. 

State  bone  or  cartilage. 
Abscess  of.    When  tuberculous,  diagnosticate  as  Abscess 

of,  Tuberculous.    Use  only  as  a  secondary  diagnosis 

under  Tuberculosis  of  Bone. 
Atrophy  of. 

Calcification  of  (cartilage).  State  site.  Do  not  use  as 
a  primary  diagnosis  when  cause  can  be  deter  - 
mined.    File  when  possible  under  organ  affected. 

Chondritis  of. 

Perichondritis  of.  State  site.  Do  not  use  as  a  pri- 
mary diagnosis  when  cause  can  be  determined. 
File  when  possible  under  organ  afTected. 

Chondrodystrophia  Foetalis. 

Congenital  Malformation  of  Bone.  Diagnosticate  ac- 
cording to  the  list  of  Congenital  Malformations. 

Curvature  of  Spine.    File  under  Joints. 

Exostosis.  Diagnosticate  as  Osteoma  of.  File  under 
Tumors. 

Fragilitas  Ossium. 

Genu  Recurvatum.    File  under  Joints. 
Genu  Valgum.    I'ile  under  Joints. 
Genu  Varum.    File  under  Joints. 
Hypertrophy  of. 
Leontiasis  Ossea. 
Loss  of  Substance  of. 
Necrosis  of. 
Caries  of. 

Ossification  of  (cartilage).  State  site.  Do  not  u.se  as  a 
|irimarj'  diagnosis  when  cause  can  be  determined. 
I'ilc  when  possil>lc  under  organ  affected. 


ilay  15,  I909-]  CARLISLE  ET  AL.:  BELLEl'UE 


Osteitis  Deformans. 
Osteogenesis  Imperfecta. 
Osteomalacia. 
Osteomyelitis  of,  Acute. 

Epiphysitis  of,  Acute. 
Osteomyelitis  of,  Chronic. 

Epiphysitis  of.  Chronic. 
Parasite  of.    State  variety.     File  under  Parasitic  Dis- 
eases. 
Periostitis  of,  Acute. 
Periostitis  of.  Chronic. 

Rickets.  File  under  Miscellaneous  Diseases  and  Con- 
ditions. 

Syphilis  of.    File  under  Syphilis. 

Tuberculosis  of.    File  under  Tuberculosis. 

Tumor  of.    State  variety.    File  under  Tumors. 

Union  of,  Faulty.    To  include   delayed   union,  faulty 

union,  non-union,  vicious   union  and  exuberant 

callus. 

BURS.ffi. 

State  bursa. 
Bursitis,  Acute.    To  include  absces--. 
Bursitis,  Chronic. 

Hallux  Valgus  (Bunion).    File  under  Joints. 
Syphilis  of.    File  under  Syphilis. 
Tuberculosis  of.    File  under  Tuberculosis. 
Tniiior  of.    State  variety.    File  under  Tumors. 

THE  CIRCULATORY  SYSTEM. 
State  artery  or  vein. 
ARTERIES  AND  VEINS:' 
Aneurysm  of. 
Aneurysm  of.  Cirsoid. 
Aneurysm  of.  Varicose. 
Aneurysmal  Varix  of. 
Aortitis. 

Arterial  Sclerosis,  General. 
Claudication,  Intermittent. 

Vascular  Crisis  of.  Use  only  as  secondary  diagnosis 
ti  Arterial  Sclerosis,  General. 

Congenital  Malformation  of.  File  under  Congenital 
Alalformations  of  Circulatory  System. 

Embolism  of.  File,  when  possible,  under  organ  af- 
fected. 

Phlebitis  of. 

Thrombosis  of.  File,  when  possible,  under  organ  af- 
fected. 

Varix  of.  State  site.  File  hremorrhoids.  varicocele, 
varix  of  bladder,  broad  ligament,  oesophagus,  and 
vulva  under  organ  affected. 

HEART: 

Congenital  Malformation  of  Heart.    File  under  Con- 
genital Malformations  of  Circulatory  System. 
ENDOCARDIUM  AND  VALVES: 
Endocarditis,  Acute. 

Endocarditis,  Chronic.    These  term-  nui-t  not  be  used 

for  Valvular  Disease,  Chronic  Cardiac. 
Valvular  Disease,  Chronic  Cardiac. 
:^IYOCARDIUM: 
Aneurysm  of  Heart. 
Atrophy  of  Heart. 
Dilatation,  Acute  Cardiac. 
Dilatation,  Chronic  Cardiac. 
Embolism  of  Coronary  Artery. 
Fatty  Heart. 
Heart  Block. 

Hypertrophy  of  Heart.    Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 
Myocarditis,  Acute. 
Myocarditis,  Chronic. 

Parasite  of  Heart.    State  variety.    File  under  Parasitic 

Diseases. 
Rupture  of  Heart. 

Syphilis  of  Heart.    File  under  Syphilis. 
Tuberculosis  of  Heart.    File  under  Tuberculosis. 
Tumor  of  Heart.    State  variety.    File  under  Tumors. 
NEUROSES: 
Angina  Pectoris. 

Bradycardia.  Do  not  use  as  a  primary  diagnosis  when 
cause  can  be  determined. 

Palpitation,  Cardiac.  Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 


HOSPLTAL  NOMENCLATURE.  1017 

Tachycardia.  Do  not  use  as  a  primary  diagnosis  when 
cause  can  be  determined. 

PERICARDIUM: 

Parasite  of  Pericardium.     State  variety.     File  under 

Parasitic  Diseases. 
Pericarditis. 

Adherent  Pericardium. 

Mediastinopericarditis. 
Pneumopericardium. 
Pyopneumopericardium. 

Syphilis  of  Pericardium.    File  under  Syphilis. 
Tuberculosis  of  Pericardium.    File  under  Tuberculosis. 
Tumor  of  Pericardium.    State  variety.    File  under  Tu- 
mors. 

THE  DIGESTIVE  SYSTEM. 

APPENDIX  AND  INTESTINE. 
APPENDIX: 
Appendicitis,  Acute. 
Appendicitis,  Chronic. 

Congenital  Malformation  of  Appendix.  File  under  Con- 
genital IMalforniation  of  Digestive  System. 

Foreign  Body  in  Appendix.  Not  to  include  concre- 
tions. 

Parasite  of  Appendix.    State  variety.    File  under  Para- 
sitic Diseases. 
Tuberculosis  of  Appendix.    File  under  Tuberculosis. 
7'!n;n';-  of  Appendix.    State  variety.    File  under  Tumors. 

INTESTINE: 

Autointoxication. 
Colitis,  Acute. 

Colitis,  Chronic.  To  include  catarrhal,  membranous, 
mucous  and  ulcerative  colitis.  File  Dysentery 
(Bacillary)  under  Infective  Diseases,  and  Amoebic 
Dysentery  under  Parasitic  Disease. 

Congenital  Malformation  of  Intestine.  File  under  Con- 
genital Malformations  of  Digestive  System. 

Constipation. 

Diverticulum  of  Intestine,  Acquired. 

Diverticulitis. 
Duodenitis. 

Embolism  of  Mesenteric  Artery. 

Enteritis,  Acute.    To  include  catarrhal,  phlegmonous, 

and  ulcerati\o  enteritis. 
Enteritis,  Chronic. 
Enterocolitis. 
Enterolith. 

Faecal  Fistula.    To  include  artificial  anus. 
Fermentation,  Intestinal. 
Foreign  Body  in  Intestine. 
Gastroenteritis. 

Haemorrhage,  Intestinal.    Do  not  use  as  a  primarj'  di- 
agnosis when  cause  can  be  determined. 
Impacted  Faeces. 

Neurosis,  Intestinal.    To  include  enteralgia,  enteropare- 

sis,  enterospasm  and  nervous  diarrhoea. 
Obstruction,  Acute  Intestinal. 

Obstruction,  Chronic  Intestinal.  To  include  intussus- 
ception and  volvulus. 

Parasite  in  Intestine.     State  Parasite  and   File  under 
Parasitic  Diseases. 
Amcebic  Dysentery.    File  under  Parasitic  Diseases. 

Parasite  in  Intestinal  Wall.  State  parasite.  File  under 
Parasitic  Diseases. 

Splanchnoptosis. 

Sprue  (Psilosis). 

Stricture  of  Intestine. 

Syphilis  of  Intestine.    File  under  Syphilis. 
Thrombosis  of  Mesenteric  Artery. 
Thrombosis  of  Mesenteric  Vein. 

Tuberculosis  of  Intestine.    File  under  Tuberculosis. 
Tumor  of  Intestine.    State  variety.    File  under  Tumors. 
Ulcer  of  Duodenum. 

Ulcer  of  Duodenum,  Perforating. 
Ulcer  of  Intestine. 

Ulcer  of  Intestine,  Perforating. 

LIVER,  GALLBLADDER,  AND  GALLDUCTS. 

LIVER: 

Abscess  of  Liver. 

Amoebic  Abscess  of  Liver.  File  under  Parasitic  Dis- 
eases. 


lOU 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  XOM EXC LATU RE. 


[New  Vork 
Medical  Tournal. 


Amyloid  Liver.    Diagnosticate  as  Amyloid  Disease. 

File  under  Miscellaneous  Diseases  and  Condi- 
tions. 

Atrophy  of  Liver,  Acute  Yellow. 
Cirrhosis  of  Liver,  Atrophic. 
Cirrhosis  of  Liver,  Hypertrophic. 

Congenital  Malformation  of  Liver.    File  under  Con- 
genital Alalforniations  of  Digestive  System. 
Deformity  of  Liver,  Acquired. 
Displacement  of  Liver. 
Fatty  Liver. 

Functional  Derangement  of  Liver  (Biliousness). 
Obstruction  of  Portal  Vein.    Do  not  use  as  a  primary 

diagnosis  when  cause  can  be  determined. 
Parasite  of  Liver.    State  variety.    File  under  Parasitic 

Diseases.    Not  to  include  Amoeba  Coli. 
Perihepatitis. 
Pylephlebitis. 

Syphilis  of  Liver.    File  under  Syphilis. 
Thrombosis  of  Portal  Vein. 

Tuberculosis  of  Liver.    File  under  Tuberculosis. 

Tumor  of  Liver.    State  variety.    File  under  Tumors. 

GALLBLADDER  AND  GALLDUCTS: 

Adhesions  about  Gallbladder. 

Cholangitis,  Catarrhal. 

Cholangitis,  Suppurative. 

Cholecystitis,  Catarrhal. 

Cholecystitis,  Suppurative. 

Cholelithiasis. 

Congenital  Malformation  of  Gallbladder.  File  under 
Congenital  Malformations  of  the  Digestive  Sys- 
tem. 

Congenital  Malformation  of  the  Gallducts.  File  un- 
der Congenital  ^klalformatioiis  of  the  Digestive 
System. 

Fistula,  Biliary. 

Icterus  Neonatorum.    File  under  Newborn  Child. 
Parasite  of  Gallbladder.  State  variety.  File  under  Para- 
sitic Diseases. 

Parasite  of  Gallducts.  State  variety.    File  under  Para- 
sitic Diseases 
Stenosis  of  Gallducts. 

Tumor  of  Gallbladder.  State  varietj-.  File  under  Tu- 
mors. 

Tumor  of  Gallducts.  State  variety.  File  under  Tumors. 
MOUTH,  PHARYNX,  SALIVARY  GLANDS,  ETC. 

LIPS: 

Congenital  Malformation  of  Lip.    File  under  Congenital 

Malformations  of  Face. 
Herpes  Labialis. 

Syphilis  of  Lip.    File  under  Syphilis. 

Tuberculosis  of  Lip.    File  under  Tuberculosis. 

Tumor  of  Lip.    State  variety.    File  under  Tumors. 

MOUTH: 

Angina  Ludovici. 

Stomatitis.    To  include  Thrush. 

Stomatitis,   Gangrenous.     To   include   Cancrum  Oris 

(Noma.) 

Syphilis  of  Mouth.    File  under  Syphilis. 
Tuberculosis  of  Mouth.    File  under  Tuberculosis. 
Tumor  of  Mouth.    State  variety.    File  under  Tumors. 
Ulcer  of  Mouth.    Do  not  use  as  a  primary  diagnosis 

wheii  cause  can  be  determined. 
Vincent's  Angina. 
Xerostomia. 

PALATE  AND  UVULA: 

Congenital  Malformation  of  Palate.  File  under  Con- 
genital Malformations  of  Face. 

Congenital  Malformation  of  Uvula.  File  under  Con- 
genital Malformations  of  Face. 

Elongation  of  Uvula. 

Syphilis  of  Palate.    File  under  Syphilis. 

Syphilis  of  Uvula.    File  under  Syphilis. 

Tuberculosis  of  Palate.    File  under  Tuberculosis. 

Tuberculosis  of  Uvula.    File  under  Tuberculosis. 

Tumor  of  Palate.    State  variety.    File  under  Tumors. 

Tumor  of  Uvula.    State  variety.    File  under  Tumors. 

PHARYNX. 

Abscess  of  Pharynx. 

Congenital  Malformation  of  Pharynx.  File  under  Con- 
genita! .Malfr)rniations  of  Digestive  System. 


Foreign  Body  in  Pharynx. 
Mycosis  of  Pharynx. 
Neurosis  of  Pharynx. 
Pharyngitis,  Acute. 
Pharyngitis,  Chronic. 
Stricture  of  Pharynx. 

Syphilis  of  Pharynx.    File  under  Syphilis. 
Tuberculosis  of  Pharynx.    File  under  Tuberculosis. 
Tumor  of  Pharynx.    State  variety.    File  under  Tumors. 

SALIVARY  GLANDS  AND  DUCTS.    State  gland  or 

duct  involved. 
Abscess  of. 
Concretion  of. 

Congenital  Malformation  of.     File  under  Congenital 

Malformation  of  Digestive  System. 
Fistula  of. 

Gaseous  Tumor  of  Parotid. 

Inflammation  of.  File  Mumps  under  Infective  Diseases. 
Tumor  of.    To  include  ranula.     State  variety  and  file 
under  Tumors. 

TEETH,  GUMS,  AND  ALVEOLI: 
Abscess,  Alveolar. 
Caries  of  Tooth. 
Gingivitis. 

Pyorrhoea  Alveolaris. 

Tumor  of  Gum.    State  variety.    File  under  Tumors. 

TONGUE: 

Abscess  of  Tongue. 

Atrophy  of  Tongue.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Congenital  Malformation  of  Tongue.    File  under  Con 

genital  Malformations  of  Digestive  System. 
Foreign  Body  in  Tongue.    File  under  Injuries. 
Glossitis,  Acute. 
Glossitis,  Chronic. 
Hypertrophy  of  Lingual  Tonsil. 

Parasite  of  Tongue.    State  variety.    File  under  Parasitic 

Diseases. 

Syphilis  of  Tongue.    File  under  Syphilis. 

Tuberculosis  of  Tongue.    File  under  Tuberculosis. 

1  umor  of  Tongue.    State  variety.    File  under  Tumors. 

TONSILS: 

Abscess,  Tonsillar. 

Amygdalitis,  Acute  Follicular. 

Amygdalitis,  Chronic. 

Amygdalolith. 

Hypertrophy  of  Tonsil. 

Mycosis  of  Tonsil. 

Syphilis  of  Tonsil.    File  under  Syphilis. 
Tuberculosis  of  Tonsil.    File  under  Tuberculosis. 
Tumor  of  Tonsil.    State  variety.    File  under  Tumors. 

MESENTERY,  OMENTUM,  AND  PERITON.EUM- 

MESENTERY: 

Chyle  Cyst  of  Mesentery. 

Embolism  of  Mesenteric  Artery.     1  p--,  , 
Thrombosis  of  Mesenteric  Artery.  I  ^  """^^ 
Thrombosis  of  Mesenteric  Vein.     )  intestine. 
Tumor  of  Mesentery.    State  variety.     File  under  Tu- 
mors. 
OMENTUM: 
Abscess  of  Omentum. 

Parasite  of  Omentum.  State  variety.    File  under  Para- 
sitic Diseases. 
Torsion  of  Omentum. 

Tuberculosis  of  Omentum.    File  under  Tuberculosis. 
Tumor  of  Omentum.  State  varictj'.    File  under  Tumors. 

PERITONAEUM: 
Adhesions  of  Peritonaeum. 

Chylous  Ascites,  Non-filarial.  Do  not  use  as  a  primary 
diagnosis  w  hen  cause  can  be  determined. 

Parasite  of  Peritonaeum.  State  variety.  File  under  Par- 
asitic Diseases. 

Peritonitis,  Acute  General.  /  ?°  ^  primary 

Peritonitis!  Acute  Local.     \  ^'agnosis  when  cause  can 


Abscess,  Pelvic. 

Abscess,  Subphrenic. 
Peritonitis,  Chronic. 
Syphilis  of  Peritonaeum. 


determined. 


File  under  Syphilis. 


May  15,  1909.] 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  NOMENCLATURE. 


IOI9 


Tuberculosis  of  Peritonaeum.    File  under  Tuberculosis. 
Tumor  of  Peritonaeum.    State  variety.    File  under  Tu- 
mors. 
(ESOPHAGUS: 

Congenital  Malformation  of  (Esophagus.    File  under 

Congenital  Malformations  of  Digestive  System. 
Dilatation  of  CEsophagus. 
Diverticulum  of  CEsophagus. 
Foreign  Body  in  CEsophagus. 
CEsophagitis. 

Rupture  of  CEsophagus,  Spontaneous. 
Spasm  of  CEsophagus. 
Stricture  of  CEsophagus. 

Syphilis  of  CEsophagus.    File  under  Syphilis. 
Tuberculosis  of  CEsophagus.    File  under  Tuberculosis. 
Tumor  of  CEsophagus.    State  variety.    File  under  Tu- 
mors. 

Varix  of  CEsophagus. 
PANCREAS: 
Atrophy  of  Pancreas. 
Calculus  of  Pancreas. 

Congenital  Malformation  of  Pancreas.    File  under  Con- 
genital Malformations  of  Digestive  System. 
Obstruction  of  Pancreatic  Duct. 
Pancreatitis,  Acute.  • 
Pancreatitis,  Chronic. 

Parasite  of  Pancreas.    State  variety.    File  under  Para- 
sitic Diseases. 
Syphilis  of  Pancreas.    File  under  Syphilis. 
Tuberculosis  of  Pancreas.    File  under  Tuberculosis. 
Tumor  of  Pancreas.    State  variety.    File  under  Tumors. 

RECTUM  AND  ANUS: 
Abscess  about  Rectum. 

Congenital  Malformation  of  Anus.  File  under  Congen- 
ita! Malformations  of  Digestive  System. 

Congenital  Malformation  of  Rectum.  File  under  Con- 
genital Malformations  of  Digestive  System. 

Fissure  of  Anus. 

Fistula  in  Ano. 

Fistula  of  Rectum.  Not  to  include  Rectovaginal  Fis- 
tulae. 

Foreign  Body  in  Rectum. 

Haemorrhage  frorn  Rectum.    Do  not  use  as  a  primary 

diagnosis  when  cause  can  be  determined. 
Haemorrhoids. 

Parasite  of  Rectum.  State  variety.  File  under  Para- 
sitic Diseases. 

Proctalgia.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Proctitis.    When  due  to  gonococcus,  diagnosticate  as 

Gonococcus,  Infection  of.    File  under  Infective 

Diseases. 
Prolapse  of  Rectum. 

Pruritus  Ani.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Spasm  of  Rectum.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Stricture  of  Rectum. 
Syphilis  of  Anus.    File  under  Syphilis. 
Syphilis  of  Rectum.    File  under  Syphilis. 
Tuberculosis  of  Anus.    File  under  Tuberculosis. 
Tuberculosis  of  Rectum.    File  under  Tuberculosis. 
Tumor  of  Anus.    State  variety.    File  under  Tumors. 
Tumor  of  Rectum.    State  variety.    File  under  Tumors. 
Ulcer  of  Rectum.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
STOMACH: 

Achylia  Gastrica.  ♦ 
Adhesions  of  Stomach. 

Atony  of  Stomach.  Do  not  use  as  a  primary  diagnosis 
when  cause  can  be  determined. 

Atrophy  of  Stomach.  Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 

Cardiospasm. 

Congenital  Malformation  of  Stomach.    File  under  Con- 
genital Malformations  of  Digestive  System. 
Cribbing  (Pneumophagia). 
Deformity  of  Stomach. 
Dilatation  of  Stomach,  Acute. 

Dilatation  of  Stomach,  Chronic.  Do  not  use  as  a  pri- 

marv  diagnosis  when  cause  can  be  determined. 
Fermentation,  Gastric. 


Foreign  Body  in  Stomach. 

Gastritis,  Acute  Catarrhal.  Do  not  use  as  a  primary 
diagnosis  when  cause  can  be  determined.  When 
due  to  a  poison  always  use  as  a  secondary  diag- 
nosis. 

Gastritis,  Acute  Phlegmonous. 
Gastritis,  Chronic  Catarrhal. 
Gastroduodenitis. 

Gastroenteritis.    File  under  Diseases  of  the  Intestine. 
Gastroptosis. 

Hasmatemesis.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Hyperchlorhydria. 
Hyperchylia  Gastrica. 
Hypochlorhydria. 

Nervous  Dyspepsia.  Do  not  use  as  a  primary  diagnosis 
when  cause  can  be  determined. 

Parasite  of  Stomach.  State  variety.  File  under  Para- 
sitic Diseases. 

Perversion  of  Appetite. 

Pyloric  Incontinence. 

Pylorospasm. 

Regurgitation  from  Stomach. 

Rumination. 

Stenosis  of  Stomach. 

Syphilis  of  Stomach.    File  under  Syphilis. 
Tuberculosis  of  Stomach.    File  under  Tuberculosis. 
Tumor  of  Stomach.    State  variety.    File  under  Tumors. 
Ulcer  of  Stomach. 

Ulcer  of  Stomach,  Perforating. 

THE  DUCTLESS  GLANDS  AND  SPLEEN. 

CAROTID  GLAND: 

Tumor  of  Carotid  Gland.  State  variety.  File  under 
Tumors. 

PARATHYREOID  GLAND: 

Tumor  of  Parathyreoid  Gland.  State  variety.  File  un- 
der Tumors. 

PITUITARY  BODY: 
Acromegaly. 

Tumor  of  Pituitary  Body.  State  variety.  File  under 
Tumors. 

SPLEEN: 
Abscess  of  Spleen. 

Amyloid  Spleen.  Diagnosticate  as  Amyloid  Disease. 
File  under  Miscellaneous  Diseases  and  Condi- 
tions. 

Anaemia,  Splenic.    File  under  Diseases  of  The  Blood. 

Congenital  Malformation  of  Spleen.  File  under  Con- 
genital Malformations  of  Ductless  Glands  and 
Spleen. 

Infarct  of  Spleen. 

Parasite  of  Spleen.    State  variety.    File  under  Parasitic 

Diseases. 
Perisplenitis. 

Rupture  of  Spleen,  Spontaneous. 

Splenitis,  Acute. 

Splenitis,  Chronic  Interstitial. 

Splenoptosis. 

Syphilis  of  Spleen.    File  under  Syphilis. 
Tuberculosis  of  Spleen.    File  under  Tuberculosis. 
Tumor  of  Spleen.    State  variety.    File  under  Tumors. 
SUPRARENAL  GLAND: 
Addison's  Disease. 

Congenital  Malformation  of  Suprarenal  Gland.  File  un- 
der Congenital  Malformations  of  Ductless  Glands 
and  Spleen. 

Haemorrhage  into  Suprarenal  Gland. 

Syphilis  of  Suprarenal  Gland.    File  under  Syphilis. 

Tuberculosis  of  Suprarenal  Gland.  File  under  Tuber- 
culosis. 

Tumor  of  Suprarenal  Gland.    State  variety.    File  under 

Tumors. 
THYMUS  GLAND: 

Persistent  Thymus  Gland.  Not  to  include  Status 
Lymphaticus. 

Syphilis  of  Thymus  Gland.    File  under  Syphilis. 

Tuberculosis  of  Thymus  Gland.  File  under  Tubercu- 
losis. 

Tumor  of  Thymus  Gland.  State  variety.  File  under 
Tumors. 


I020 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


THYREOID  GLAND: 

Congenital  Malformation  of  Thyreoid  Gland.  File  un- 
der Congenital  Malformations  of  Ductless  Glands 
and  Spleen. 

Cretinism. 

Exophthalmic  Goitre. 

Goitre. 

Myxcedema. 

I'arasitc  of  Thyreoid  Gland.    State  variety.    File  inider 

Parasitic  Diseases. 
Syphilis  of  Thyreoid  Gland.    File  under  Syphilis. 
Thyreoiditis,  Acute. 
Thyreoiditis,  Chronic. 

Tuberculosis  of  Thyreoid  Gland.  File  nnder  Tubercu- 
losis. 

I'limor  of  Thyreoid  Gland.  State  variety.  File  under 
Tumors. 

THE  EAR. 

Ankylosis  of  Ossicles. 
Cerumen,  Accumulation  of. 

Congenital  Malformation  of  Ear  (Middle  and  Internal). 

I'"i!e  under  Congenital  Malformations. 
Congenital  Malformation  of  External  Ear.    File  under 

Congenital  Malformations  of  Face. 
Deaf  Mutism.    File  under  ^liscellaneous  Di&eases. 
Deformity  of  External  Ear,  Acquired. 
Eustachian  Salpingitis,  Acute. 
Eustachian  Salpingitis,  Chronic. 
Foreign  Body  in  Auditory  Canal. 
Haematoma  of  External  Ear,  Nontraumatic. 
Haemorrhage  into  Labyrinth. 
Mastoiditis,  Acute. 
Mastoiditis,  Chronic. 

Fistula,  Mastoid. 
Meniere's  Disease.    File  under  Diseases  of  the  Xervous 

System. 
Mycosis  of  External  Ear. 
Myringitis,  Acute. 

Myringitis,  Chronic.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Necrosis  of  Ossicles. 

Caries  of  Ossicles. 
Otitis  Externa. 
Otitis  Interna,  Acute. 
Otitis  Interna,  Chronic. 
Otitis,  Media,  Acute. 
Otitis  Media,  Chronic. 
Ossification  of  Auricle. 

Parasite  of.    State  variety  and  site.    File  under  Parasitic 

Diseases. 
Perichondritis  of  Auricle. 

Syphilis  of.    State  location.    File  under  Syphilis. 
Tuberculosis  of.    State  location.    File  under  Tubercu- 
losis. 

Tumor  of.    State  variety  and  site.    File  under  Tumors. 
( To  be  continued.) 
 ^>  

Jitfe  «f  Cttrrtnt  f  iterstot. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

May  6,  1901^. 

1.  The  Results  of  Operation  for  Cancer  of  the  Tongue 

Mouth,  and  Jaw  at  the  Massachusetts  General  Hos- 
pital, 1890  tc  1904.  By  Robert  B.  Greenough, 
Cii.\NNi.\G  C.  SiMMO.xs  and  Robert  M.  Green. 

2.  Random  Medical  Notes, 

By  George  Cheever  Sh.\ttuck. 
X    Intermittent  Hydronephrosis.    With  a  Report  of  Four 
Cases,  By  Daxiei,  I'"iske  Jones. 

4.    A  Report  on  the  Circulation  of  the  Lobar  (ianglia, 

By  J.  D.  .\yer  and  H.  F.  Aitken. 
I.  Results  of  Operations  for  Cancer  of  the 
Tongue,  Mouth,  and  Jaw  at  the  Massachusetts 
General  Hospital,  1890  to  1904. — Greenough,  Sim- 
mons, and  Green  give  the  results  from  opera- 
tioiLs  for  cancer  of  the  tongue,  mouth,  and  jaw,  as 
found  at  the  records  of  the  Massachusetts  General 
Hospital  in  the  years  1890  to  1904.  There  were  172 


patients,  112  were  operated  upon,  50  were  judged 
inoperable,  and  10  refused  operation.  Of  the  112 
operations  of  all  varieties,  20  resulted  in  death  witli- 
in  sixty  days  (  17.8  per  cent.).  Of  cancer  of  the 
tongue  and  floor  of  mouth,  there  were  98  cases,  of 
which  62  patients  were  operated  upon  and  36  were 
inoperable  or  refused  operation.  Of  the  62  cases 
operated  in,  in  58  (93.5  per  cent.)  the  end  result  is 
known.  Sixty-two  cases  of  operation  gave  an  op- 
erative mortality  of  8,  or  12.9  per  cent.  Of  the  58 
cases  in  which  the  end  result  is  known,  10  patients 
were  free  from  recurrence  three  years  or  more  after 
operation  (17.2  per  cent.).  Of  the  forty  cases  in 
which  recurrence  did  take  place  after  operation,  in 
38  patients  death  occurred  before  the  lapse  of  three 
years  after  operation.  Operations  for  cancer  of  the 
tongue  involving  section  or  resection  of  the  jaw 
caused  a  much  higher  operative  mortality  and  no 
greater  percentage  of  cures  than  the  intrabuccal  op- 
erations. Of  cancer  of  the  lower  jaw,  there  were  40 
cases;  28  operable,  12  inoperable.  The  operative 
mortality  of  28  cases  was  10,  or  35.5  per  cent.  In 
26  cases  of  operation  the  end  result  is  known,  and  5 
patients  (19.2  per  cent.)  were  free  from  recurrence 
three  3-ears  or  more  after  operation.  There  were  14 
cases  of  cancer  of  the  upper  jaw.  Ten  were  oper- 
ated in  and  4  were  not.  The  end  result  is  known  in 
9  of  the  10  operated  cases,  and  in  each  of  these  9 
cases  death  occurred  within  three  years,  although 
there  were  no  deaths  as  an  immediate  result  of  op- 
eration. Cancer  of  the  tonsil,  soft  palate,  or  fauces 
occurred  in  1 1  cases,  8  of  which  were  inoperable 
and  4  were  submitted  to  operation.  One  patient  was 
alive  and  well  seven  years  after  operation  (25  per 
cent.).  There  was  no  operative  mortality.  Cancer 
of  the  cheek  occurred  in  9  cases,  i  of  w^hich  was  in- 
operable. Of  the  8  patients  operated  upon,  2  died  of 
operation  (25  per  cent.)  and  none  were  cured. 

3.  Intermittent  Hydronephrosis.  —  Jones  re- 
ports four  such  cases,  and  remarks  that  open  and  in- 
termittent hydronephrosis  occurs  much  more  fre- 
([uently  than  the  small  number  of  reported  cases 
would  indicate.  By  far  the  larger  number  of  cases 
are  owing  to  congenital  conditions,  but  movable  kid- 
ney may  be  a  cause,  though  much  less  frequently 
than  is  generally  stated.  Movable  kidneys  in  which 
Dietl's  crises  have  occurred,  or  which  have  caused 
symptoms  suggesting  intermittent  hydronephrosis, 
should  not  be  fixed  without  first  examining  the  up- 
per portion  of  the  ureter  and  its  insertion  into  the 
pelvis.  Conditions  usually  given  as  the  primary 
causes  of  open  hydronephrosis,  such  as  valve  forma- 
tion, high  or  oblique  insertion,  and  insertion  at  an 
acute  angle,  are  always  secondary  to  a  dilatation  of 
the  pelvis.  Mxtrapelvic  operations  are  to  be  preferred 
to  transpelvic.  Trendelenburg's  operation, — pyelo- 
ureterostomy. — although  not  applicable  to  all  cases, 
is  easy  of  execution,  and  the  results  are  equal  to.  if 
not  better  than,  the  results  in  other  operations.  Pre- 
liminary nephrotomy  should  be  carried  out  in  all  in- 
fected cases.  A  catheter  left  in  the  ureter  after  ;» 
plastic  operation  is  unnecessary  and  even  harmful. 
Fixation  of  the  kidney  is  unnecessary  in  infected 
cases.  Pyelotomy  is  a  useful  and  less  harmful  pro- 
cedure than  nephrotomy  in  mildly  infected  cases,  and 
should  be  preferred,  except  in  cases  in  which  a  pre- 
liminary ne|)hrotomy  has  already  been  done.  E.\- 
ploration  of  the  ureter  from  the  pelvis  to  the  bhukUr 


May  15,   T 909.1 


PITH  OF  CURRENT  LITERATURE. 


102  I 


is  always  essential.  Earlier  diagnosis  and  operation 
should  be  made.  Operation  should  be  advised  early, 
even  though  the  attacks  of  pain  are  at  infrequent  in- 
tervals, for  destruction  of  the  kidney  may  be  going 
on  without  symptoms. 

4.  A  Report  on  the  Circulation  of  Lobar  Gan- 
glia.— Ager  and  Aitken  give  a  beautifully  illus- 
trated report  on  the  circulation  of  the  lobar  ganglia. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

May  8,  igog. 

1.  The  Insane  Diathesis,  ^   By  Sanger  Brown. 

2.  Carcinoma  of  the  Bowel  and  of  the  Appendix  in  the 

Young,  By  J.  Shelton  Horsley. 

3.  Erosive  and  Gangrenous  Balanitis,  the  Fourth  Venereal 

Disease,   By  B.  C.  Corbus  and  Frederick  G.  Harris. 

4.  Cervical  Dilatation,  By  Curran  Pope. 

5.  Penmanship  Stuttering,  By  E.  W.  Scripture. 

6.  The  County  Society,  By  L.  Rock  Sleystek. 

7.  A  Disorder  Due  to  Exposure  to  Intense  Heat, 

By  William  H.  Cameron. 

8.  A  Case  of  Poisoning  from  the  Bite  of  a  Rattlesnake, 

By  Ch.\rles  S.  White. 

2.  Carcinoma  of  the  Bowel  and  of  the  Appen- 
dix in  the  Young. — Horsley  concludes  from  a 
case  which  he  reports  that  cancer  of  the  bowel  may 
originate  in  the  young;  we  should,  therefore,  not 
exclude  carcinoma  because  of  the  youth  of  the  pa- 
tient. As  regards  prognosis,  he  remarks  that 
when  cancer  in  the  young  is  not  due  to  a  lack  of 
general  resistance  in  an  important  organ  or  to  a 
peculiar  virulence  of  the  disease,  but  merely  to  the 
lowered  resistance  of  a  vestigial  organ,  as  the  ap- 
pendix, the  chances  of  permanent  cure  after  exci- 
sion are  excellent. 

3.  Erosive  and  Gangrenous  Balanitis. — Corbus 
and  Harris  observe  that  there  is  a  characteristic 
clinical  picture  or  form  of  erosive  gangrenous 
balanitis,  which  under  favorable  conditions  may 
cause  deep  and  widespread  gangrene,  and  which  is 
of  stifficient  importance  as  to  be  called  a  fourth 
venereal  disease.  In  the  erosive  and  gangrenous 
types  there  is  regularly  found  a  microorganism 
(vibrio),  which  should  be  considered  the  cause  of 
the  disease.  In  addition  to  this  organism  there  is 
constantly  present  a  Gram  negative  spirochaeta. 
On  account  of  the  rapid  development  of  phimosis 
with  a  tendency  to  produce  gangrene,  it  is  impera- 
tive that  a  diagnosis  should  be  made  at  once. 
Whether  these  organisms  are  identical  with  those 
found  in  similar  processes  in  the  mouth  and  pha- 
rynx is  still  a  question.  This  disease  is  not  so  un- 
common as  one  might  suspect ;  it  is  very  common 
and  is  usually  mistaken  for  chancroidal  infection. 
The  period  of  incubation  may  be  the  same  in  the 
two  conditions ;  but  with  the  characteristic,  thin, 
yellowish  white,  ofifensive  discharge,  in  which  one 
finds  a  vibrioform  organism  and  a  spirochaeta.  the 
diagnosis  should  not  be  difficult.  The  ulcers  of  the 
two  forms  of  infection  may  simulate  each  other 
very  closely.  In  this  form  of  balanitis  when  the 
infection  is  at  all  severe  there  is  marked  phimosis 
and  considerably  more  inflammatory  reaction.  The 
enlarged  inguinal  glands  are  painless,  while  with  3 
very  insignificant  chancroidal  sore  a  suppurating 
bubo  is  often  present.  On  account  of  the  indolent 
adenopathy  that  accompanies  balanitis  erosiva.  it 
must  be  di'^tinguished  from  syphilis.    In  syphilis 


the  period  of  incubation  is  longer,  although  the  two 
infections  may  occur  simultaneously.  When  such  a 
condition  exists  we  may  be  compelled  to  defer  our 
diagnosis  of  syphilis  until  the  period  of  incubation 
for  syphilis  has  elapsed ;  or  in  case  of  a  mixed  lesion 
the  Spirochccta  pallida  may  be  easily  demonstrated  by 
the  dark  ground  illuminator  and  is  so  characteristic 
as  to  be  easily  distinguished  from  the  spirochaeta 
of  balanitis.  Herpes  preputialis  always  occurs  as 
grotips  of  small  insignificant  vesicles  in  which  local 
reaction  is  mild  or  entirely  absent.  This  condition 
simulates  somewhat  the  mild  form  of  balanitis 
erosiva,  but  in  herpes  one  fails  to  find  the  organ- 
isms characteristic  of  balanitis.  As  a  prophylactic 
measure  the  practice  of  circumcision  should  be  en- 
couraged ;  it  is  absolutely  impossible  for  balanitis 
to  exist  in  an  individtial  who  has  been  circumcised. 
In  many  cases  in  which  the  condition  is  mild  and 
the  foreskin  can  easily  be  retracted  all  that  is 
necessary  is  a  thorough  cleansing,  but  in  the  mild 
ulcerative  forms  in  which  there  is  the  slightest  evi- 
dence of  phimosis  a  dorsal  incision  should  be  per- 
formed. As  the  organism  of  balanitis  is  anaerobic, 
this  incision  serves  a  twofold  purpose,  that  is,  of 
admitting  air  and  exposing  the  diseased  parts  for 
treatment.  The  authors  say  that  they  were  in  the 
habit  of  burning  all  these  slotighing  ulcers  in  this 
disease,  but  such  treatment  subjects  the  patient  to 
needless  punishment.  As  the  organisms  of  the  dis- 
ease are  anaerobic,  and  as  hydrogen  peroxide  liber- 
ates oxygen  when  in  contact  with  organic  matter, 
it  acts  as  a  specific  for  this  form  of  infection.  They 
have  used  the  ordinary  two  per  cent,  solution,  but 
in  severe  cases  of  gangrenous  balanitis,  twenty-five 
per  cent,  was  painted  on  the  parts. 

4.  Cervical  Dilatation. — Pope  uses  galvanic 
and  faradic  currents  in  dilating  the  cervical  canal  of 
the  uterus,  employing  the  negative  pole  in  the  gal- 
vanic current  only.  When  the  galvanic  current  is 
turned  on  slowly  and  the  "flow"  between  the  poles 
is  established  a  profound  hyperaemia  at  the  negative 
pole  resttlts,  with  increased  fluidity  and  a  local  ac- 
cumulation and  excess  of  the  electropositively 
charged  ions  of  hydrogen,  sodium,  potassium,  am- 
monium, and  calcium  with  a  resultant  formation  of 
the  alkaline  caustics,  the  hydrates  of  hydrogen,  so- 
dium, etc.  At  the  same  time  the  current  exer'^ises 
an  electro,  antiseptic,  anaesthetic  action  peculiar  to 
both  poles.  The  tissues  are  flooded  with  blood,  ren- 
dered more  fluid  and  rapidly  softened  by  the  dif- 
fusive absorption  or  accumulation  of  the  alkaline 
caustics,  this  rendering  them  less  resistant  and  much 
more  easily  dilatable.  At  th:-  same  time,  those  nu- 
tritional effects  the  result  of  the  current  per  sc,  and 
its  accompanying  hyperasmia  becomes  manifest.  Or  a 
high  tension  faradic  current,  from  a  secondary  coil 
of  exceedingly  fine  wire,  of  great  length  is  used.  A 
coil  of  this  character  is  distinctly  sedative,  pain  re- 
lieving, and  an  obtunder  of  sensibilitv.  A  faradic 
outfit  to  possess  these  qualities  must  at  least  have  a 
coil  of  No.  36  wire  (or  smaller)  of  many  turns;  the 
ribbon  vibrator  mtist  "sing"  smoothly,  evenly,  and 
with  the  least  possible  variation  and  he  activated  by 
at  least  four  cells  or  from  the  "main"  current.  After 
describing  his  method  of  application,  the  author  savs 
that  to  overcome  obstructions  or  stenosis  in  the  canal 
.associated  with  flexions  and  displacements,  whether 


I022 


PITH  Of  CURRENT  LITERATURE. 


[New 
Medical 


York 
Journal. 


the  stenosis  is  primary  and  accompanied  by  the  so 
called  pin  hole,  os,  or  cicatricial  following  operation, 
pressure,  sloughs,  labor,  the  applications  of  acids, 
caustics  of  ulcerative  changes,  this  method  will  be 
found  to  answer  the  purpose,  by  securing  free  drain- 
age through  the  cervical  canal  for  the  retained  ute- 
rine secretions  or  menstrual  blood.  It  will  be  found 
of  use  in  dysmenorrhcea  due  to  oophoritis,  salpingi- 
tis (without  suppuration),  and  in  those  cases  in 
which  the  organs  seem  normal  but  great  pain  is 
present  in  the  menstrual  periods,  as  well  as  in  those 
cases  in  which  the  pain  begins  before  the  flow  for  a 
few  hours  and  is  sharp  and  intense  in  character. 
Patients  with  metritis,  cervicitis,  and  endometritis, 
in  whom  we  have  to  deal  with  hypertrophied  and 
swollen  mucosa,  in  whom  the  uterus  is  flabby  and  its 
walls  atonic,  or  in  which  hard  and  hyperplastic,  and 
in  whom  the  obstruction  has  dammed  up  the  secre- 
tions, are  particularly  benefited.  In  the  imperfectly 
developed  or  infantile  uterus  it  is  an  ideal  method 
for  opening  the  canal  preparatory  to  intrauterine 
applications  of  coarse  wire  faradic  electricity  for 
muscular  development,  as  well  as  in  those  cases  of 
sterility  in  which  a  mechanical  hindrance  or  a  thick- 
ened mucosa  prevents  conception.  It  is  valuable  in 
uterine  haemorrhage  as  a  preliminary  to  obtaining 
scrapings  or  for  preparing  the  canal  and  uterine 
body  for  heavy  currents  of  positive  galvanization.  In 
inflammations  resulting  from  gonorrhoeal  infection 
it  not  only  secures  free  drainage  but  tends  to  wash 
out  in  the  hypersecretion  that  follows  its  application, 
the  specific  germ. 

8.  Rattlesnake  Poisoning.  —  White  remarks 
that  if  the  therapeutic  measures  which  we  possess 
could  be  applied  promptly  in  each  case  of  poisoning 
by  the  bite  of  a  venomous  snake,  the  mortality  would 
be  much  lower  than  at  present,  from  twenty-five  to 
forty  per  cent.  The  venoms  are  partially  neutral- 
ized  by  ammonia  and  by  potassium  permanganate, 
but  the  best  chemical  antidote  is  two  per  cent,  solu- 
tion of  the  hypochlorite  of  lime,  which  will  immedi- 
ately and  surely  destroy  the  venom  by  contact. 
When  possible  to  apply  the  ligature  proximal  to  tht 
wound,  we  have  a  means  which  controls  the  intakt 
of  venom,  but  endangers  the  viability  of  the  member 
so  constricted. 

MEDICAL  RECORD 
May  8,  1909. 

r.    The  Point  of  View  in  Medicine, 

By  Beverley  Robinson. 

2.  The  Reeducational  Trealnient  of  Locomotor  Ataxia, 

By  J.  Ralph  Jacobv. 

3.  A  Plea  for  the  Establishment  of  Hospitals  for  the  Ra- 

tional Treatment  of  Inebriates, 

By  Charles  A.  Rosen wasseu. 

4.  Examination  of  the  Lungs  by  Rontgen  Rays, 

By  Henry  Hulst. 

5.  The   Relation  between  Aneurysm  of  the  Aorta  and 

Tabes  Dorsalis  :  with  the  Report  of  a  Case, 

By  Paul  H.  Bikle. 

6.  r-xzema,  By  Samuel  Stern. 

7.  Two  Cases  of  Cancer  Treated  with  Trypsin.  Supple- 

mentary Report,  By  F.  B.  Goi,ley. 

8.  Wholesale  Baby  Washer,  By  W.  P.  Northrui'. 

4.  Examination  of  the  Lungs  by  Rontgen 
Rays.— Tlulst  states  that  al)out  a  year  ago  lie  first 
noticed  in  an  uncommonly  good  lung  picture  a  spot 
wliicli  he  could  not  interpret  and  which  he  was 
astonislicfl  to  find  afterward  more  or  less  clearly 


defined  in  every  normal  lung  negative.  It  appears 
as  a  relatively  dark  area,  about  the  size  of  a  dollar, 
not  far  from  the  right  hilum,  and  corresponds  to 
the  space  between  the  eparterial  bronchus  and  ves- 
sels to  the  upper  and  the  hyparterial  structures  to 
the  middle  lobe  of  the  right  lung.  It  has  not  been 
possible  to  locate  it  b)-  percussion.  An  interesting 
problem  remains  for  pathology  to  solve.  Rontgen- 
ologists have  learned  long  ago  to  look  to  the  hilum 
instead  of  the  region  supplied  by  the  posterior 
branch  of  the  eparterial  bronchus  for  the  earliest 
evidence  of  tuberculous  invasion.  Nes^atives  re- 
vealmg  apical  involvement,  show  hilum  alteration 
as  well.  On  the  other  hand,  when  the  lungs  them- 
selves appear  normal,  enlarged,  and  even  calcified 
glands  are  often  seen  about  the  hilum.  The  shad- 
ows due  to  the  vessels  and  bronchi  crossing  each 
other,  often  quite  marked  in  mitral  insufficiency, 
should  cause  no  confusion.  Dissections  have 
proved  tlie  well  defined  dense  spots  so  frequently 
seen  in  so  called  normal  lung  pictures  to  be  calci- 
fied glands.  These  are  records  of  past  conflicts 
and  partial  or  complete  victories  over  disease,  and 
are  so  common  that  it  is  difficult  to  find  adults 
without  them.  Thus  "normal"  applied  to  the  lungs 
as  well  as  to  the  position  of  the  stomach  seems  to 
be  the  exception.  The  diagnostician  who  neglects 
the  Rontgen  rays  in  his  examinations  of  the  lungs 
has  no  conception  of  the  rich  field  he  is  neglecting. 
But  a  rapid  change  in  this  respect  is  working  its 
way.  Last  April  an  entire  Congress  was  devoted 
to  this  single  subject  in  Berlin.  Professor  Wenke- 
bach,  of  the  University  of  Groningen,  Holland, 
reported  that  he  made  stereoscopic  pictures  of  every 
chest  examined,  and  his  students  were  trained  to 
consider  no  examination  of  the  lungs  complete  with- 
out this. 

5.  The  Relation  between  Aneurysm  of  the 
Aorta  and  Tabes  Dorsalis. — ^Bikle  says  that  there 
can  be  no  doubt  that  syphilis  is  one  of  the  most 
frequent  causes  of  aneurysms  of  the  aorta,  but 
wide  differences  exist  in  the  opinions  of  writers 
concerning  the  degree  of  the  frequency  of  its  rela- 
tion to  this  form  of  vascular  disease.  The  ex- 
tremes are  represented  on  the  one  hand,  by  Isl. 
Schmidt,  who  finds  syphilis  present  in  twenty-nine 
per  cent,  of  cases,  and  on  the  other,  by  Drummond, 
who  believes  that  lues  is  responsible  for  aortic 
aneurysms  in  every  instance.  Debove  also  shares 
the  latter  view,  while  Gerhardt,  more  conserva- 
tively, regards  fifty-three  per  cent,  as  nearer  the 
truth.  Julius  Citron,  in  a  recent  consideration  of 
the  relationship  of  syphilis  to  aortic  insufficiency, 
calls  attention  incidentally  to  the  frequency  of  lues 
as  a  cause  of  arteriosclerosis.  Syphilis  is  likewise, 
without  question,  the  chief  jetiological  factor  of 
almost  all  the  cases  of  tabes.  Fournicr.  in  1875, 
first  called  attention  to  the  parasypliilitic  nature  of 
the  disease.  He  reported  87  to  93  per  cent,  of 
cases  as  due  to  syphilitic  infection,  while  Dejerine 
found  02  to  94  per  cent.,  and  Cliurch.  out  of  a 
scries  of  one  hundred  cases,  found  onlv  two  which 
failed  to  disclose  a  history  of  svphilis.  W.  Erl> 
thinks  it  probable,  tliough  not  absolutely  proved, 
that  all  cases  of  locomotor  ataxia  are  due  to  syphi- 
lis. In  the  instances  where  tabes  and  abdominal 
aneurysm  are  found  associnted,  it  nntural  to 
question   whether  the  pains  tint  are  experienced 


May  15,  I909-1 


PITH  OF  CURRENT  LITERATURE. 


1023 


may  not  be  partially  due  to  the  pressure  of  the 
aneurysm  on  certain  nerves.  Such  a  dilation  of 
the  aorta,  if  of  sufficient  size,  may  cause  pains 
which  are  lancinating  in  character  and  very  similar 
to  those  of  tabes,  particularly  if  such  dilation  is 
located  low  enough  to  press  upon  the  lumbar 
nerves.  When  high  in  the  abdomen,  it  impinges 
upon  the  solar  plexus  and  splanchnic  nerves,  caus- 
ing a  more  fixed  and  constant  pain  in  the  back. 
Thus,  in  a  given  case,  where  tabes  is  known  to  be 
present,  it  is  obvious  that  this  symptom  of  an  aortic 
aneurysm  in  the  abdomen  may  readily  be  attributed 
to  the  tabetic  condition.  When  we  remember,  then, 
concludes  the  author,  that  syphilis  is  an  important 
cause  of  both  aortic  aneurysm  and  tabes  dorsaHs. 
and  when  it  is  observed  that  they  frequently  occur 
together,  the  question  suggested  by  Lesser  not  in- 
aptly arises  whether  there  may  be  in  tabes  dorsalis 
an  setiological  factor  in  the  production  of  aneu- 
n,^sms  of  the  aorta.  The  author  is  inclined  to  be- 
lieve that  this  association,  \vhich,  as  has  been 
shown,  not  infrequently  exists,  is  merely  accidental, 
and  that  each,  in  such  cases,  is  a  parasyphihtic  con- 
dition independent  of  the  other. 

7.  Two  Cases  of  Cancer  Treated  with  Trypsin. 
— Golley  reports  two  such  cases,  and  concludes  that 
trypsin  exerts  some  influence  upon  the  metabolism  ot 
the  general  system,  and  indirectly  upon  the  growth. 
It  is  a  self  evident  truth,  he  remarks,  that  if  the  or- 
ganism could  be  maintained  indefinitely  at  a  suffi- 
ciently high  standard,  it  would  not  only  not  be  sub- 
ject to  the  onslaughts  of  disease,  but  would  live  on 
for  all  time.  It  is  upon  this  element,  to, a  very  mod- 
erate degree  in  his  opinion,  that  depends  whatever 
influence  the  trypsin  treatment  has  over  cancerous 
growths.  Somehow  it  influences  the  metabolic  pro- 
cesses particularly  and  estabHshes  a  resistance  to  the 
cell  activity  of  malignancy. 

BRITISH  MEDICAL  JOURNAL. 
April  24,  1909. 

1.  General  Principles  in  the  Treatment  of  Diseases  of  the 

Heart,  By  Sir  James  Barr. 

2.  A  Case  of  Heart  Block,  with  Fibrous  Degeneration  and 

Partial  Obliteration  of  the  Bundle  of  His, 

By  B\T{OM  Br.\m\vell. 

3.  Xote  on  the  Pulsus  Bigeminus,         By  E.  K  Laslett. 

4.  The  Ineffectiveness  of  Calcium  Salts  and  of  Citric  Acid 

a?  Used  to  Modify  the  Coagulation  Time  of  the 
Blood  for  Therapeutic  Purposes.  With  a  Description 
of  a  Modification  of  McGowan's  Method  of  Estimat- 
ing the  Coagulation  Time  of  the  Blood, 

By  T.  Addis. 

5.  A  Cast  of  Typhoid  Complicated  with_  Staphylococcal 

Septichsemia.      By  X.  E.  Roberts  and  E.  E.  Glyxx. 

6.  How  Much  Fluid  Does  the  Body  Require? 

By  Alexaxder  Haig. 

7.  The  Occurrence  of  Tubercle  Bacilli  in  the  Blood  in 

Tuberculosis.  By  Charles  E.  P.  Forsyth. 

8.  Chronic  Nephritis  Terminating  with  Haemorrhage  from 

the  Bowel  and  Perforation  of  the  Bowel. 

By  Leoxard  G.  J.  Mackev. 

9.  Rontgen  Cinematography  and  its  Importance  in  Medi- 

_  cine.  By  Fraxz  M.  Groedel. 

10.  Notes  on  a  Case  of  Tetanic  Spasm  with  Reference  to 

the  Distinctive  Diagnosis  between  Tetanus  and 
Strj-chnine  Poisoning,     By  W.  Sixclair  Ste\-exsox. 

11.  Preliminary  Note  on  the  Histo!og>'  of  Eg>-ptian  Mum- 

mies, By  ^IARC  Armaxd  Rl'ffer. 

I.  The  Treatment  of  Diseases  of  the  Heart. — 
Barr  says  that  in  heart  diseases  drtigs  should  only 
be  used  when  necessary  and  always  under  strict 
medical  supervision.    Unfortunately  for  the  public 


the  people  have  taken  to  drugging  themselves  with 
all  manner  of  noxious  tablets,  and  an  enormous 
amount  of  mischief  is  caused  by  the  indiscriminate 
use  of  cardiac  tonics.  The  continued  high  arterial 
tension  which  is  thus  long  maintained  often  works 
irreparable  mischief  in  the  aorta.  It  is  better  for  a 
jaded  horse  to  lighten  his  load  than  apply  the  whip, 
so  remedies  which  lessen  the  work  of  the  heart  are 
often  more  eflfective  than  cardiac  tonics.  When 
the  balance  between  the  two  sides  of  the  heart  is 
effectively  maintained,  drugs  are,  as  a  rule,  unneces- 
sar\%  except  to  regulate  the  blood  pressure,  and. 
when  this  is  high,  decalcifying  agents  and  moder- 
ate cathartics  answer  best.  \\'hen  there  is  cardiac 
failure,  tonics  such  as  digitalis,  squills,  strophan- 
thus,  caffeine,  strychnine,  and  the  lime  salts  must 
be  used,  but  as  soon  as  compensation  is  restored  their 
use  should  be  discontinued.  If  there  is  any  ten- 
dency to  thrombosis  or  embolism,  decalcifying 
agents,  such  as  phosphoric  and  citric  acids  and 
their  soluble  salts,  should  be  employed.  In  cases 
of  cardiac  thrombosis  and  pulmonic  embolism 
w'here  the  symptoms  are  ver\-  urgent  strong  am- 
monia should  be  freely  used ;  a  mixture  of  five 
minims  each  of  ammonia  and  spirit  of  chlor- 
oform in  a  wineglassful  of  barley  water  ever}-  hour 
or  half  hour  is  an  effective  remedy.  In  mitral  sten- 
osis there  appears  not  infrequently  a  free  haemopty- 
sis, which  in  this  case  is  the  best  form  of  blood  let- 
ting, and  should  not  be  too  quickly  checked.  In  all 
spasmodic  affections,  such  as  angina  pectoris,  the 
best  remedies  are  nitroglycerin,  morphine,  atropine, 
amyl  nitrate,  ethyl  iodide,  and  other  preparations 
of  iodine.  When  the  blood  pressure  is  very  high, 
there  are  a  whole  host  of  remedies  at  our  com- 
mand in  addition  to  those  mentioned  for  the  treat- 
ment of  spasmodic  or  painful  affections,  but  we 
may  specially  specify  decalcifying  agents,  the  ben- 
zcates,  the  hippurates,  iodine,  and  thyreoid. 

6.  The  Fluid  Required  by  the  Body. — Haig 
says  that  if  a  m.an  living  an,  ordinary  sedentary  life, 
not  entailing  visible  perspiration,  takes  from  fifty  to 
sixty  ounces  of  fluid  a  day,  then  a  weight  of  150 
pounds  apparently  requires  about  fifty  ounces  of 
fluid,  this  amount  being  passed  each  day  through 
the  kidney  s.  The  question  is,  by  how  much  mav 
this  quantity  be  reduced  before  physiological  dif- 
ficulties are  encountered?  As  these  quantities  of 
fluid  are  more  a  habit  than  a  necessity,  most  people 
can  accustom  themselves  to  do  with  less  than  fifty 
ounces  a  day.  and  thirty  ounces  should  not  be  in- 
jurious. The  gain  to  a  diseased  or  dilated  heart 
is  obvious ;  the  total  fluids  in  the  body  are  grad- 
ually reduced  by  several  pints,  and  weight  falls  a 
corresponding  number  of  pounds?  What  harm 
may  be  done  by  diminishing  fluids?  Uric  acid 
gravel,  or  the  presence  of  large  quantities  of 
urate  in  the  ears,  joints,  and  fibrous  tissues,  for- 
bid liminution  of  fluid  over  a  long  period,  for  the 
excretion  of  stich  urate  gravel  is  almost  certain  to 
give  trouble  in  the  tubules  and  pelvis  of  the  kid- 
neys if  sufficient  fluid  is  not  taken.  Yet  when  a 
patient  is  obviously  dying  of  heart  failtire  on  the 
one  hand,  or  cerebral  oedema  on  the  other,  we  must 
immediately  cut  down  fluids  and  consider  the  ex- 
cess of  urates  afterwards.  There  might  be  increased 
tendency  to  thrombosis,  but.  as  the  ultimate  effect  is 


I024 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


a  general  improvement  of  the  circulation,  this  does 
not  seem  important,  especially  if  a  purin  free  diet 
is  adopted.  Constipation  is  another  possible  trou- 
ble, and  sufferers  on  an  ordinary  diet  will  not  be 
better  on  diminished  fluids.  But  what  is  the  incon- 
venience of  a  little  constipation  if  weighed  in  the 
balance  against  heart  disease,  or  uraemia,  or  cerebral 
(jedema?  The  use  of  common  laxatives  will  coun- 
teract it  while  matters  are  critical,  and  later  there 
will  not  be  much  trouble  from  constipation  if  fruit 
is  used  daily.  In  serious  conditions  the  author 
takes  thirst  as  a  guide,  and  thinks  that  most  pa- 
tients can  reduce  their  fluids  to  thirty  ounces  a 
day, i-nd, with  the  help  of  fiuit,  to  twenty-five  ounces, 
twenty  ounces,  or  less,  at  least  for  a  time.  If  salts, 
salines,  and  diuretics  are  given  more  fluid  will  be 
called  for,  and  then  we  have  to  decide  whether 
most  good  is  done  by  withholding  drugs  and  water, 
or  by  giving  both.  As  a  rule,  he  is  in  favor  of  the 
former  course,  though  drugs  can  be  used  at  first, 
as  it  takes  several  days  to  reduce  the  fluids  of  the 
body.  He  orders  that  thirty  ounces  be  aimed  at,  but 
that  fruit  or  extra  water  shall  be  given  whenever 
thirst  imperatively  demands  it. 

LANCET. 

April  34,  1909. 

1.  Movable  Kidney,    with   Details  of  an  Operation  for 

Fixing  the  Kidney,       By  Sir  W.  Watson  Cheyne. 

2.  Rheumatic  Fever  and  Valvular  Disease, 

By  Norman  Moore. 

3.  The  Blood  in  Rickets,  By  Leonard  Findlay. 

4.  Two  Cases  of  Metrorrhagia  at  an  Advanced  Age  not 

due  to  Malignant  Disease, 

By  Arthur  H.  N.  Lewers. 

5.  An  Enormous  Faecal  Tumor  in  a  Girl  with  Congenital 

Abnormalities  of  her  Pelvic  Viscera,  By  H.  B. 

Butler,  Arthur  F.  Hertz,  and  W.  Arbuthnot 
Lane. 

6.  Delayed  Delivery  in  a  Case  of  Central  Placenta  Praevia, 

with  Remarks  on  the  Treatment  of  the  Latter, 

By  N.  L  Spriggs. 

7.  On  the  Termination  of  the  Thoracic  Duct, 

By  F.  G.  Parsons  and  Percy  W.  Sargent. 

8.  Epsem  Salts  as  a  Poison.    With  a  Record  of  a  Case 

of  Unusual  Symptoms  Due  to  this  Drug, 

By  Charles  Eraser. 

9.  A  Case  of  Anomalous  GEdema  with  Bright's  Disease, 

By  R.  W.  S.  Walker. 

2.  Rheumatic  Fevers. — Norman  Moore,  in  his 
Lumleian  lecture,  observes  that  the  grounds  for  the 
diagnosis  of  rheumatic  fever  are  :  i.  Evidence  of  the 
results  of  endocarditis ;  2,  a  multiple  transient  arth- 
ritis; and  3,  a  temperature  chart  showing  an  initial 
rise  followed  after  a  fall  by  occasional  rises  with 
intervals  of  normal  temperature  and  with  evidence 
of  the  existence  of  some  disease  for  a  considerable 
period,  seldom  less  than  three  weeks.  The  diag- 
nosis ought  not  to  be  made  till  these  three  factors 
are  ascertained.  If  endocarditis  is  clearly  present 
without  arthritis  ulcerative  endocarditis,  and  not 
rheumatic  fever  is  likely  to  be  the  true  diagnosis. 
The  same  is  true  if  there  is  a  temperature  chart 
of  high  f)scillations  with  uncertain  evidence  of  en- 
docarditis Init  signs  of  disturbed  heart  and  no  ar- 
thritis. If  there  are  no  signs  of  endocarditis  and  a 
nniltipic  arthritis  at  present,  then  a  gonococcal  in- 
fection and  not  rheumatic  fever  is  the  probable  di- 
agnosis. The  same  is  true  if,  though  there  are  signs 
of  endocarditis  and  of  multiple  arthritis,  any  of 
the  afFcrtcd  joints  come  to  show  signs  of  permanent 


damage.  It  should  be  added  that  a  culture  mav  be 
the  only  way  of  ascertaining  whether  the  gono'coc- 
cus  or  some  septic  organism  is  the  origin  of  the 
condition  which  after  some  resemblance  in  symp- 
toms to  rheumatic  fever  leaves  the  patient  with  a 
stiff  joint.  The  administration  of  sodium  salicylate 
so  commonly  relieves  the  pains  in  the  joints  as  well 
as  reduces  the  temperature  in  rheumatic  fever  that 
whenever  it  is  found  in  any  case  that  sodium  sal- 
icylate has  no  effect,  even  in  a  large  dose,  the 
suspicion  will  arise  that  ulcerative  endocarditis, 
a  gonococcal  infection,  or  some  other  condi- 
tion and  not  true  rheumatic  fever  is  present. 
The  disease  belongs  to  the  first  half  of  life, 
though,  like  measles,  mumps,  and  some  other  mor- 
bid conditions  of  childhood  and  youth,  it  may  ap- 
pear for  the  first  time  in  the  second  half  of  life, 
but  here  again  the  difficulty  of  certainty  as  to  a  pa- 
tient's true  history  often  raises  doubt  as  to  whether 
his  earlier  life  has  been  free  from  any  attack.  Be- 
fore the  diagnosis  is  made  great  care  should  be 
taken  to  ascertain  that  no  septic  source,  such  as  a 
uterine  one  in  women,  exists,  or  has  recentlv  ex- 
isted, in  the  patient.  The  duration  of  rheumatic 
fever  is  indefinite.  The  exact  day  of  its  commence- 
ment can  rarely  be  fixed.  In  many  cases  the  state 
of  the  heart  proves  that  the  disease  has  been  in 
progress  for  some  time  before  the  patient  is  aware 
that  he  has  a  definite  illness.  The  date  of  its  ab- 
solute termination  is  always  obscure.  The  difficulty 
of  determining  it  is  increased  by  the  knowledge 
that  endocarditis  may  continue  to  affect  the  heart 
— in  other  words,  that  the  organism  which  produces 
it  may  continue  to  live  within  the  heart,  capable 
of  fresh  development,  long  after  the  temperature 
has  become  normal.  What  is  commonly  called  an 
attack  of  rheumatic  fever  probably  continues  not 
less  than  three  weeks  after  a  normal  temperature  is 
reached. 

3.  The  Blood  in  Rickets. — Findlay  remarks 
that  in  active  and  uncomplicated  rickets  anaemia  is 
not  the  rule  but  is  to  be  regarded  as  exceptional 
and,  when  it  occurs,  due  to  adventitious  causes.  On 
the  contrary,  in  rachitic  children,  the  amount  of 
haemoglobin  and  the  number  of  red  cells  in  the 
series  examined  are  notably  in  excess  of  the  nor- 
mal average.  The  red  blood  corpuscles,  as  a  rule, 
vary  more  in  size  than  in  normal  individuals  of 
similar  ages,  but  otherwise  there  is  no  abnormality. 
Nucleated  red  cells,  polychromatophilia,  and  myelo- 
cytes are  of  the  rarest  occurrence.  In  rickety  sub- 
jects there  is  little  characteristic  change  as  far  as 
the  leucocytes  are  concerned.  They  may  be  nor- 
mal, slightly  increased,  or  even  diminished  in  num- 
ber. The  mononuclears  more  frequently  than  the 
jralymorphics  show  an  absolute  increase  in  number. 

7.  Termination  of  the  Thoracic  Duct. — Par- 
sons and  Sargent  have  made  some  interesting  ana- 
tomical observations  on  the  thoracic  duct.  They 
proved  in  forty  observations  that  the  thoracic  duct 
was  divided  in  the  root  of  the  neck  in  eighteen  out 
of  forty  cases  (nearly  fifty  per  cent.).  In  nine 
of  these  it  joined  again,  in  seven  it  opened  by  two 
orifices,  ancl  in  two  by  four  orifices.  In  thirty-five 
cases  (87.5  per  cent.)  the  duct  opened  wholly  or 
])artly  into  the  lower  centimetre  of  the  internal  jug- 
ular vein.    It  usually  opened  into  a  pouch  and  th^ 


May  IS,  1909.] 


PROCEEDINGS  OF  SOCIETIES. 


1025 


opening  of  this  acted  as  a  valve,  though  a  definite 
morphological  valve  was  only  occasionally  seen.  The 
duct  passed  sometimes  in  front,  sometimes  behind, 
and  sometimes  on  both  sides  of  the  vertebral  vein. 
The  internal  jugular  valve  was  a  very  constant  bi- 
cuspid structure  rarely  absent,  but  occasionally  tri- 
cuspid or  unicuspid.  Comparing  their  results  with 
those  of  Verneuil  and  Wendel,  they  found  that  their 
proportion  of  nuiltiple  ducts  was  much  greater  than 
that  of  Verneuil,  theirs  being  eighteen  out  of  fortv 
and  his  being  only  six  out  of  twenty-four  ;  whilst  their 
figures  agreed  closely  with  those  of  Wendel,  eight 
multiple  out  of  seventeen,  who  also  used  injected 
ducts  for  his  dissections.  They  conclude  that,  as 
there  appear  to  be  multiple  ducts  in  "nearly  half  of 
all  cases,  some  at  least  of  the  reported  cases  of 
injury  must  have  involved  damage  to  a  division 
and  not  to  the  whole  duct,  the  ligature  of  which 
would  cause  no  serious  hindrance  to  the  chylous 
flow  into  the  veins.  In  the  few  cases  which  have 
recovered  spontaneously  after  chylorrhcea  of  many 
days,  or  even  weeks,  it  is  probable  that  a  second 
channel  already  existed,  either  of  the  common  kind 
or  of  some  rarer  sort,  such  as  a  large  communica- 
tion with  an  azygos  or  some  other  vein. 

 €^  ■ 

JrocfjJiings  of  ^ociciifs. 


WESTERN    SURGICAL    AND  GYNECOLOGICAL 

ASSOCIATION. 
Eighteenth  Annual  Meeting,  Held  in  Minneapolis,  Decem- 
ber 29  and  30,  1908. 
The  President,  Dr.  W.  W.  Grant,  of  Denver,  in  the  Chair. 

{Continued  from  page  976.) 

Chronic  Dilatation  and  Prolapse  of  the  Stom- 
ach.— Dr.  Arthur  E.  Ben'jamix,  of  ]\Iinneapolis. 
said  that  dilatation  of  the  stomach  was  now  engag- 
ing the  attention  of  the  medical  and  surgical  world. 
The  association  and  relative  importance  of  stomach 
prolapse  was  also  being  recognized.  Recent  inves- 
tigations had  demonstrated  that  reported  deaths  due 
to  heart  failure,  gastralgia,  acute  indigestion,  etc., 
might  have  been  in  some  instances  due  to  acute  di- 
latation of  the  stomach.  The  various  terms  applied 
to  acute  dilatation  of  the  stomach,  such  as  gastro- 
mesenteric  ileus,  postoperative  gastric  paralysis, 
etc.,  indicated  that  the  patholog}-,  aetiology,  and 
modus  operandi  of  this  form  of  dilatation  were  not 
universally  or  thoroughly  understood.  From  per- 
sonal observations  the  writer  had  come  to  the  con- 
clusion that  there  were  preexisting  conditions  to  be 
reckoned  with  in  tracing  out  the  true  causes  of  this 
disease.  Important  among  these  conditions  were 
chronic  dilatation  and  prolapse  of  the  stomach. 
Jtidging  from  their  writings,  Kussmaul,  Albrecht, 
and  others  were  of  this  opinion.  The  necessity  of 
determining  the  existence  of  a  chronic  prolapse  or 
dilatation,  or  both,  in  a  patient  to  be  operated  upon 
should  be  apparent.  Where  both  existed,  as  was 
frequently  the  case,  it  was  often  impossible  to  say 
which  was  primary  and  which  was  secondary. 

The  symptoms  in  chronic  dilatation  and  prolapse 
of  the  stomach  were  so  variable  that  thev  were  of- 


ten diagnosticated  as  neurasthenia,  hysteria,  reflex 
neuroses,  nervous  dyspepsia,  indigestion,  hyper- 
chlorhydria,  etc.  A  dilatation  due  to  frequent  over- 
loading of  the  stomach  with  bulky  foods  might  be 
followed  by  a  prolapse  and  kinking  of  the  pylorus. 
In  consequence  the  gastrohepatic  ligament  was  of- 
ten stretched  and  greater  prolapse  and  dilatation 
resulted.  A  crisis  followed,  when  the  obstruction 
became  acute,  due  to  a  kink  at  the  pylorus  or  ob- 
struction at  another  point  along  the  duodenum.  The 
symptoms  were  severe  and  might  last  several  hours. 
Strictures  from  healed  ulcers,  bands  61  adhesions 
from  gallstone  disease  and  local  peritonitis  were  oc- 
casional causes  of  chronic  obstruction  and  dilata- 
tion. 

When  motor  insufiiciency  resulted  and  stagna- 
tion of  food  occurred,  the  stomach  mucous  m.em- 
brane  and  wall  became  diseased,  making  it  more 
possible  for  ulcers  or  cancerous  growths  to  super- 
vene. Simple  cases  of  gastroptosis  or  stomach  di- 
latation were  often  relieved  by  attention  to  diet, 
general  physical  and  abdominal  muscle  exercise,  hy- 
giene, and  mechanical  support.  Gastric  disturbance 
with  dilatation  might  be  dependent  upon  trouble 
farther  along  the  intestinal  canal,  such  as  disease 
of  the  appendix  or  kinks  of  or  adhesions  around 
the  colon.  A  careful  search  should  be  made  at  the 
time  of  operation  and  all  these  conditions  corrected, 
if  possible. 

The  removal  of  the  primary  cause  of  adhes'o'is 
about  the  pylorus  often  resulted  in  a  cure.  A  short 
loop  gastroenterostomy  might  be  necessary  to  brin^ 
relief,  if  there  was  cicatricial  contraction  at  the  py- 
lorus. In  case  of  a  kink  from  prolapse  and  motor 
insufiiciency  from  dilatation,  a  shortening  of  the 
gastrohepatic  ligament  and  possibly  a  plication  op- 
eration for  dilatation  would,  at  least  temporarily, 
restore  the  organ  to  its  proper  functional  power  and 
result  in  permanent  relief,  if  proper  subsequent 
medical,  mechanical,  dietetic,  and  hygienic  treat- 
ment was  followed. 

Conclusions :  1.  Chronic  dilatation  and  prolapse 
of  the  stomach  were  often  interdependent  and  asso- 
ciated. 2.  As  possible  antecedents  of  an  acute  di- 
latation they  must  be  recognized.  3.  As  factors  in 
the  causation  of  ulcers  or  cancer  they  should  be  con- 
sidered. 4.  The  causes  for  dilatation  and  prolapse 
might  be  similar,  and  primarily  were  often  due  to 
indiscretion  in  diet,  followed  by  weakened  gastric 
support,  motor  insufiiciency,  or  partial  obstruction. 
5.  The  exact  nature  and  variety  of  the  ptosis  or  the 
dilatation  should  be  determined,  if  possible,  by  the 
x  ray  and  other  means.  6.  Symptoms  actually  due 
to  chronic  dilatation  or  prolapse  were  frequently 
thought  to  proceed  from  hysteria,  neurasthenia,  or 
nervous  dyspepsia.  7.  Acute  upper  abdominal  pain 
or  attacks  of  vomiting  were  often  misinterpreted ; 
they  were  frequently  due  to  acute  pyloric  or  duo- 
denal obstruction  and  gastric  distention.  8.  Hyper- 
chlorhydria,  postoperative  vomiting,  and  vomiting 
of  pregnancy  might  be  dependent  upon  the  presence 
of  chronic  dilatation  or  prolapse  of  the  stomach.  9. 
The  treatment  should  depend  on  the  conditions 
found.  10.  Simple  cases  were  often  amenable  to 
medical  and  mechanical  means,  such  as  diet,  exer- 
cise, mechanicaJ  support,  hygiene,  etc.    11.  Certain 


I026 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


patients  should  be  operated  upon,  especially  those 
with  actual  pyloric  or  duodenal  obstruction  or  with 
dilatation  of  the  sagging  type,  and  in  other  aggra- 
vated cases  not  relieved  by  medical  means.  12. 
Some  cases  were  dependent  on  an  associated  splan- 
chnoptosis and  relaxed  abdominal  walls.  These 
should  be  properly  treated  to  bring  about  the  re- 
lief dependent  on  such  a  general  prolapse.  13.  In 
the  sagging  type  the  Beyea  operation,  \yhether  alone 
or  supplemented  by  the  Coffey  operation,  if  there 
was  an  associated  sagging  of  the  transverse  colon, 
should  be  done.  14.  Chronic  dilatation  of  the  stom- 
ach not  dependent  on  obstruction  and  when  not 
otherwise  relieved  was  greatly  benefited  and  often 
cured  by  the  Bircher  operation  of  plication.  15.  In 
chronic  dilatation,  dependent  on  a  benign  pyloric 
obstruction,  a  short  loop  gastroenterostomy  should 
be  performed.  16.  Obstruction  or  dilatation  de- 
pendent on  malignant  growths  might  call  for  py- 
lorectomy.  17.  In  operating  a  careful  search  should 
be  made  for  any  other  points  of  chronic  bowel  ob- 
struction, as  from  disease  of  the  gallbladder,  ap- 
pendix, or  a  kinking  colon,  etc.  These  conditions 
might  add  to  digestive  disturbances  and  should  be 
corrected  at  the  same  time.  18.  All  patients  oper- 
ated upon  should  be  followed  for  some  time  and 
the  subsequent  treatment  carefully  managed. 

The  Surgical  Importance  of  the  Intestinal 
Gases.  —  Dr.  B.  B.  Davis,  of  Omaha,  said  the 
points  that  practical  surgeons  needed  especially  to 
have  in  mind  were,  i  to  have  as  little  fermentable 
substance  as  possible  in  the  intestines  before  opera- 
tion. 2.  To  do  as  little  as  possible  during  the  opera- 
tion which  would  interfere  with  the  normal  circula- 
tion in  the  intestinal  wall.  This  could  probably  best 
be  prevented  by  a  minimum  amount  of  handling  and 
resulting  trauma.  3,  To  leave  the  intestines  in  the 
l)est  condition  for  active  peristalsis.  Long  exposure 
and  much  cooling  were  inimical  to  active  peristalsis. 

Postoperative  Acute  Dilatation  of  the  Stomach. 

Dr.  D.  S.  Fairchild,  of  Des  Moines,  Iowa,  read 
a  paper  on  this  subject. 

Dr.  R.  C.  Coffey,  of  Portland,  Oregon,  said 
there  were  able  men  who  considered  prolapse  of  the 
stomach  a  nonsurgical  condition,  while  there  were 
others  whc  believed  that  it  was  a  surgical  condition 
under  practically  all  circumstances.  From  the  ex- 
perience he  had  had  in  this  work  he  should  say 
there  was  a  happy  medium  in  this  just  as  there  was 
a  few  years  ago  in  gastric  surgery  of  other  kinds. 
One  could  not  go  to  any  important  clinic  in  the 
country  to-day  and  see  gastroenterostomy  per- 
formed for  gastric  ulcer  without  the  ulcer  being 
easily  demonstrated  and  the  scar  being  shown.  It 
could  be  demonstrated,  not  only  to  the  surgeon  him- 
self, but  to  those  who  were  looking  on.  Not  more 
than  twenty-five  per  cent,  of  the  cases  of  i>rolapse 
of  the  stomach,  as  seen  by  the  internist,  had  any 
surgical  features.  Probably  not  more  than  one  m 
five  had  any  surgical  features,  but  the  fact  re- 
mained that  a  certain  number  of  them  did  have 
surgical  features  and  the  results  of  surgical  treai- 
ment  were  i)ractically  as  good  as  in  gastric  ulcer. 
In  a  series  of  cases  of  last  year's  surgical  work, 
of  twenty-nine  stomach  operations,  fourteen  were 
for  cancer,  ten  for  obstruction  by  gastric  ulcer,  and 
four  for  prolapse  of  the  stomach. 

(To  be  continued.) 


VWe  publish  full  lists  of  books  received,  but  we  acknozvl- 
edge  no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  arc  likely  to  be  interested.^ 

Principles  and  Practice  of  Physical  Diagnosis.  By  John  C. 
Da  Costa,  Jr.,  M.  D.,  Associate  in  Clinical  Medicine, 
Jefterson  Medical  College,  etc.  With  Two  Hundred  and 
Twelve  Original  Illustrations.  Philadelphia  and  London : 
W.  B.  Saunders  Company,  1908.    Pp.  548.   (Price,  $3.50.) 

"With  all  our  varied  instruments  of  precision, 
useful  as  they  are,  nothing  can  replace  the  watchful 
eye,  the  alert  ear,  the  tactful  finger,  and  the  logical 
mind  which  correlates  the  facts  obtained  through 
all  these  avenues  of  information  and  so  reaches  an 
exact  diagnosis."  This  apt  quotation  from  the  writ- 
ings of  the  well  known  Philadelphia  surgeon,  W.  W. 
Keen,  opposite  the  title  page,  may  be  taken  as  the 
keynote  of  Dr.  Da  Costa's  carefully  prepared  vol- 
ume on  physical  diagnosis.  The  physician  or  stu- 
dent who  follows  the  practical  methods  of  the 
author  cannot  fail  to  be  a  better  observer  and  bene- 
fit from  the  training  in  inductive  methods  he 
teaches.  To  be  especially  commended  is  the  care 
with  which  the  minor  changes  of  diagnostic  signifi- 
cance are  studied,  such  as  the  lesser  stigmata  of 
tuberculosis,  alterations  of  the  facial  expression  in 
different  diseases,  myxoedema,  tinea  versicolor,  and 
pigmentation  of  the  skin. 

All  the  ordinary  textbook  facts  are  dealt  with  in 
an  adequate  manner,  showing  a  wide  familiarity 
with  recent  medical  Hterature,  and  the  writer's 
style  is  pleasing  and  lucid.  The  work  is  thoroughly 
up  to  date,  such  subjects  as  sphygmomanometry, 
the  tuberculin  reactions,  cytodiagnosis,  and  radiog- 
raphy as  applied  to  the  chest  being  fully  described. 
The  writer  has  a  fondness  for  attaching  proper 
names  to  anatomical  landmarks  and  symptoms, 
thereby  crediting  and  commemorating  the  names  of 
original  observers,  but  increasing  the  difficulties  of 
the  student.  Thus  no  fewer  than  twenty-nine  signs 
are  described :  Auenbrugger's,  Boccelli's,  Biermer's. 
Broadbent's,  Bryson's,  Drummond's,  '  Duroziez's, 
Erni's,  Ewart's,  Friedreich's,  Gerhardt's,  Glasgow's, 
Grocco's,  Jiirgensen's,  Kussmaul's,  Litten's.  Lo- 
renz's,  Musset's,  Naunyn's,  Oliver's,  Rotch's,  Roth- 
schild's, Sander's,  Sansom's,  Skoda's,  Stiller's. 
Traube's,  Williams's,  and  Wintrich's.  We  wonder 
how  many  good  diagnosticians  would  recognize 
them  all  under  these  names. 

Practical  Dietetics,  with  Reference  to  Diet  in  Disease.  By 
Ai.iDA  Frances  Pattee,  Graduate,  Department  of  House- 
hold Arts,  State  Normal  School,  Framingham,  Mass.,  etc. 
Fifth  Edition.  Mount  Vernon,  N.  Y. :  A.  F.  Pattee. 
Pp.  xvi-312. 

The  popularity  of  Miss  Pattee 's  book  is  not  to  be 
questioned,  and  it  is  owing  to  its  many  points  of 
excellence.  It  is  essentially  a  book  on  cookery,  and 
as  such  we  are  not  aware  that  it  has  a  superior  in 
the  field  of  cooking  for  the  sick.  We  are  informed 
in  the  preface  that  the  text  of  this  edition  is  pre- 
cisely the  same  as  that  of  the  fourth,  ''which,"  says 
the  author,  "is  sufficiently  up  to  date."  .A.nd.  yet, 
there  are  some  things  in  it  that  we  think  might 
with  advantage  have  been  changed  or  omitted,  (^n 
page  40  there  is  a  receipt  entitled  "Fgg  and  Wine 
(Milk  Punch)."  We  have  heard  of  "milk  punch 
with  the  milk  extracted."  but  into  this  formula  milk 
docs  not  seem  to  enter  at  any  stage.    The  descrip- 


May  15,  1909.] 


OFFICIAL  NEWS. 


1027 


tion  of  sweetbreads  given  on  page  117  is  grotesque- 
ly incorrect.    ''Sweetbreads,"  says  the  author,  "are 


the  thymus  eland  of  the  calf. 


The  gland 


consists  of  two  parts  connected  by  a  tubing;  the 
long,  slender  portion  called  the  'neck'  sweetbread, 
and  the  round,  thick  part  known  as  the  'heart' 
sweetbread.  These  are  sometimes  sold  separately, 
but  should  be  together.  Of  the  two,  the  heart 
sweetbread  is  the  more  desirable."  Fancy  the  thy- 
mus and  the  pancreas  "connected  by  a  tubing!" 

It  is  in  somewhat  of  an  imaginative  vein,  it  seems 
to  us,  that  Miss  Pattee  writes  of  gelatin  as  follows 
(page  177)  :  "It  is  valuable  in  cases  of  fever,  as 
the  fever  feeds  on  the  gelatin,  saving  much  tissue 
waste.  And  also  for  the  convalescent  where  the 
portion  of  the  system  in  which  the  gelatin  is  needed 
has  been  wasted."  These  passages  show,  we  think, 
that  it  would  have  been  better  for  Miss  Pattee 
to  stick  to  cookery  and  avoid  the  snags  of  high 
dietetics  and  of  bovine  anatomy. 


Affinal  Jftos. 


17-  24   ! 

18-  25   S 

18-25   12 

18-25   I 

17-24   3 

17-24   I 

17-24   I 

17-24   I 

17-  24   I 

18-  24   5 


27 


Public   Health   and   Marine   Hospital  Service 
Health  Reports: 

The  following  cases  of  smallpox,  ycllozv  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  -iceek  ending  May  7,  igog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

California — Oakland  April    12-19   2 

California — Sacramento  April 

Georgia — Macon  April 

Illinois — Danville  April 

Indiana — South  Bend  April 

Kansas — Kansas   City  April 

Kansas — Wichita  .-\pril 

Kentucky — Covington  April 

Kentucky — Lexington  Ai'ril 

Kentucky — Newport  April 

Louisiana — New  Orleans  .April 

Maryland — House    of  Correction, 

Bridewell   Marcli  iS-.'Vpril  24. 

Michigan — Grand   Rapids  .April  18-24  

Michigan — Saginaw  April  18-24  

Minnesota — Duluth  .-Vpril  15-22  

Minnesota — Minneapolis  .\pril  10-24  

.Minnesota — St.   Paul   Feb.   i-March  31.. 

Missouri — Kirksville  Jan.    i-.\pril    17   i 

Missouri — .St  Louis  April    17-24....'   i 

Montana — Butte  April    13-20   2 

Nebraska — Polk  March  20-April  26...  14 

New  Jersey — Camden  April    17-24   3 

New  York — Little  Falls  .April    10-24   2 

North  Carolina — 19  Counties  Feb.    1-28   20 

Ohio — Cincinnati  .April    16-24   10 

Ohio — Columbus  .April    17-24   2 

Ohio — Conneaui  •  March  and  .April....  2 

South    Carolina — Yorkville  and 

vicinity  April  26   8 

Tennessee — Nashville  .April  26   1 

Texas — San  Antonio  April    17-24   i 

Utah — Salt  Lake  City  March  1-31  

\'irginia — Botetourt  County  April  28  

Virginia — Portsmouth  Vi.ril'  20-27.  •  .  • 

Washington — Spokane  .April    10-17.  .  .  • 

Washington — Tacoma  March  7-.April  4 

Wisconsin — La  Crosse  -Aiiril  17-24.... 

Wisconsin — Milwaukee.  .  \pril    17-J4.  .  .  . 

Smallt>ox — Insular. 

Philippine  Islands — Manila  March  6-13.  .  .  . 

Smallpox — Foreign. 

Algeria — .Algiers   March  1-31.... 

Austria — Trieste  Marcli   20-27 .  •  • 

Brazil — Rio  de  Janeiro  Marcli  14-2.S... 

Brazil — Sao  Paulo  March  1-14.... 

Canada — Halifax  April 

China — .Amoy  April 

China — Hongkong  March 

Egypt — Cairo  March 

Great  Britain — Bristol  March 

Great  Britain — Cardiff  March 

India — Bombay  Marcli 

India — Calcutta  .March 

India — Rangoon  Alarch 

Mexico — Guadalajara  Vpril 


5 
68 


62 
1 00 


10-17.  .. . 
I  ,i-JO .  .  .  . 

6-20.  .  .  . 

18-25.  .  . 
27-April 

3-10.  .  .  . 

23-30.  .  . 

1 3-20  .  .  . 

13-20.  .  . 


42 


16 


17 

16 


Present 
4 


Places.  Date.  Cases.  Deaths. 

Mexico — Monterey  April    11-18   7 

Mexico— Veracruz  April    11-18   1 

Russia — Odessa  March  27-April  3....  6 

Russia — St.  Petersburg  March   20-27   11  6 

Russia — Warsaw  Jan.   30-Feb.   6   2 

Spain — Barcelona  March    5-12   3 

Spain — Huelva  March    1-31   2 

Spain — -Valencia  .April    2-9   5 

Turkey — Constantinoiile  March  28-.April  11...  i 

Yellow  Fever — Foreign. 

Barbados  April    10-17   i  i 

Brazil — Manaos  March  13-April  3....  5 

Brazil — Para  .April    3-10   3  3 

Mexico — Merida  Feb.  27-March  6....  1 

Mexico — Ticul  April    1-24   2  i 

Cholera — Insular. 
Philippine  Islands — Provinces  March   6-13.  .  .  . 

Cholera — Foreign. 

India — Bombay  March  23-30... 

India — Calcutta  March  13-20... 

India — Rangoon  March    13-20.  .  . 

Russia — General  March  6-20.... 

Plague — Foreign. 

Brazil — Rio  de  Janeiro  Match  14-28... 

Chile — Antofagasta  April  3  

Chile — Iquique  April  3  

China — Canton  March  6-20  

China — Hongkong  March  16-20... 

India — Bombay  March  23-30  

India — Calcutta  March  13-20  

India — Madras  March  20-26... 

India — Rangoon  March  13-20  

Tapan — Formosa  March  27  

Japan — Kobe  March  20-27... 

Peru — General  March  27-April 

Peru — Callao  March  29-.April 


.262 


76 


17 
35 


76 
5 


•  13 


lOI 

3 


30 
6 

450 
77 


16 

Present 


31 
30? 
9 


Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and -Marine  Hospital  Service  for  the  seven  days  ending 
May  5,  1909: 

Amesse,  J.  W.,  Passed  Assistant  Surgeon.  Directed  to 
proceed  to  Caibarien,  Cuba,  upon  special  temporary 
duty. 

EowERS,  Paul  E.,  Acting  Assistant  Surgeon.    Granted  one 

day's  leave  of  absence  in  April,  1909,  under  paragraph 

210,  Service  Regulations. 
Delc.ado,  J.  M.,  Acting  Assistant  Surgeon.    Granted  nine 

days'  extension  of  annual  leave  from  April  15,  1909, 

on  account  of  sickness. 
Fox,  Carroll,  Passed  .Assistant  Surgeon.  Relieved  from 

duty  at  San  Francisco,  Cal.,  and  directed  to  report  to 

the  commanding  officer  of  the  Revenue  Cutter  Bear. 
Gahn,  Henry,  Pharmacist.    Granted  one  day's  leave  of 

absence.  April  26,  1909,  under  paragraph  210  Service 

Regulations. 

Gregory,  George  A.,  Acting  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  May  4,  1909. 

Irwin,  Fairfax,  Surgeon.  Relieved  from  duty  on  the 
Revenue  Cutter  Rush  and  directed  to  report  to  the 
commandnig  officer  of  the  Revenue  Cutter  Thetis. 

Kerr,  J.  W.,  Assistant  Surgeon  General.  Directed  to  pro- 
ceed to  Cincinnati,  O.,  upon  special  temporary  duty. 

Lavinder,  C.  H.,  Passed  Assistant  Surgeon.  Directed  to 
proceed  to  Columbia,  S.  C,  and  vicinity,  upon  special 
temporary  duty. 

Lanza,  A.  J.,  Assistant  Surgeon.  Relieved  from  duty  on 
the  Revenue  Cutter  McCulloch  and  directed  to  report 
to  the  commanding  officer  of  the  Revenue  Cutter  Rush. 

Moore,  Dunlop,  Passed  .Assistant  Surgeon.  Granted  one 
month's  leave  of  absence  from  May  3,  1909,  on  account 
of  sickness,  and  three  months'  leave  of  absence  from 
June  3,  1909,  with  permission  to  go  beyond  the  sea. 

MacCaffry  W.  B.,  Acting  Assistant  Surgeon.  Granted 
two  days'  leave  of  absence  in  April,  1909,  under  para- 
graph 210  Service  Regulations. 

R.AMUS,  Carl,  Passed  Assistant  Surgeon.  Granted  one 
day's  leave  of  absence,  April  29,  1909,  on  account  of 
sickness. 

Rea,  Robert  H.,  Acting  Assistant  Surgeon.  Granted  one 
day's  leave  of  absence,  April  26,  1909;  granted  three 
days'  leave  of  absence  from  May  6,  1909. 

Rush,  John  O.,  Acting  Assistant  Surgeon.  Granted  three 
days'  leave  of  absence  from  April  20,  1909,  under  para- 
graph 210  Service  Regulations. 

Simpson,  F.,  Assistant  Surgeon.  Relieved  from  duty  at 
Fort  Stanton,  N.  M..  and  directed  to  report  to  the 
commanding  officer  of  the  Revenue  Cutter  Perry. 


I028 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal. 


Stimson,  a.  M.,  Passed  Assistant  Surgeon.  Granted  two 
days'  leave  of  absence,  jVIay  i  and  3,  1909. 

Stimpson,  W.  G.,  Surgeon.  Granted  five  days'  leave  of 
absence  from  May  3,  1909. 

Stimpson,  W.  G.,  Surgeon.  Relieved  from  duty  at  Port 
Townsend,  Wash.,  and  directed  to  report  to  the  com- 
manding oi?icer  of  the  Revenue  Cutter  Manning. 

Wakefield,  H.  C.,  Acting  Assistant  Surgeon.  Granted 
four  days'  leave  of  absence  from  April  28,  1909,  under 
paragraph  210  Service  Regulations. 

Boards  Convened. 
■  Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital,  Baltimore,  Md.,  May  i,  1909,  for  the  purpose  of 
conducting  a  physical  examination  of  eight  cadets  of  the 
U.  S.  Revenue  Cutter  Service  for  commissions  as  third 
lieutenants.  Detail  for  the  board:  Surgeon  W.  P.  Mc- 
intosh, chairman;  Passed  Assistant  Surgeon  M.  K.  Gwyn, 
recorder. 

Board  of  medical  officers  convened  to  me.et  at  the  Maine 
General  Hospital,  Portland,  Me.,  ]\Iay  3,  1909,  for  the  pur- 
pose of  conducting  a  physical  examination  of  a  captain  of 
engineers  of  the  U.  S.  Revenue  Cutter  Service.  Detail 
for  the  board :  Surgeon  P.  C.  Kalloch,  Chairman  ;  Acting 
Assistant  Surgeon  A.  F.  Stuart,  recorder. 

Board  of  medical  officers  convened  to  meet  at  the 
Bureau,  Washington,  D.  C,  May  4,  1909,  for  the  purpose 
of  conducting  a  physical  reexamination  of  an  applicant  for 
the  position  of  cadet  in  the  Revenue  Cutter  Service.  Detail 
for  the  board :  Assistant  Surgeon  General  W.  J.  Pettus, 
chairman ;  Passed  Assistant  Surgeon  J.  W.  Trask,  recorder. 

Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital  office,  Philadelphia,  Pa.,  May  4,  1909,  for  the 
purpose  of  conducting  a  physical  reexamination  of  an  ap- 
plicant for  the  position  of  cadet  in  the  Revenue  Cutter 
Service.  Detail  for  the  board :  Surgeon  J.  M.  Gassaway, 
chairman ;  Acting  Assistant  Surgeon  H.  Horning,  recorder. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  week  ending  May  8,  190^: 
Appel,  D.  M.,  Colonel,  Medical  Corps.    Granted  an  exten- 
sion of  one  month  to  leave  of  absence. 
BisPHAM,  W.  N.,  Major,  Medical  Corps.    Promoted  to  the 
rank  of  major  in  the  Medical  Corps,  from  January  i, 
1909. 

BouRKE,  James,  Captain,  Medical  Corps.  Granted  leave 
of  absence  for  three  months,  nineteen  days. 

Bowman,  M.  H.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  duty  with  troops  on  the  transport  Sheri- 
dan to  Manila,  P.  I.,  and  return  to  San  Francisco,  Cal. 

Brown,  I.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  in  the  Philippines  Division  in  time 
to  sail  from  Manila  for  San  Francisco,  September  15, 
1909. 

Farr,  Charles  W.,  Captain,  Medical  Corps.  Granted  an 
extension  of  two  months  to  his  sick  leave  of  absence. 

Grupbs,  R.  B.,  Captain,  Medical  Corps.  Left  Fort  Mc- 
intosh, Tex.,  on  leave  of  absence  for  ten  days. 

Humphreys,  H.  G.,  Captain,  Medical  Corps.  'Relieved 
from  duty  at  Fort  Terry,  N.  Y.,  and  ordered  to  Fort 
Wadsworth,  N.  Y.,  for  duty. 

KiRKPATRicK,  T.  J.,  Major,  Medical  Corps.  Granted  leave 
of  absence  for  twenty-one  days,  about  June  7th. 

Loving,  R.'C,  Captain,  Medical  Corps.  Left  West  Point, 
N.  Y.,  on  leave  of  absence  for  two  days. 

Marrow,  C.  E.,  Major,  Medical  Corps.  Granted  an  exten- 
sion of  one  month  to  his  leave  of  absence. 

Pace.  Henry,  Major,  Medical  Corps.  Granted  leave  of 
absence  from  June  loth  to  about  July  31st. 

Persons,  E.  E.,  Major,  Medical  Corps.  Promoted  to  the 
rank  of  major  in  the  Medical  Corps,  from  January  i, 
1909. 

QuiNTON,  W.  W.,  Captain,  Medical  Corps.  ILaving  been 
found  physically  disqualified  for  the  duties  of  a  major 
in  the  Medical  Corps,  placed  on  the  retired  list  as 
major,  to  date  from  February  26th. 

RocKun.r.,  E.  P.,  Captain,  Medical  Corps.  Having  l)een 
found  physically  disqualilied  for  the  duties  of  a  major, 
placed  on  the  retired  list  as  major,  to  date  from  Feb- 
ruary 26th. 

Stephenson,  William,  Lieutenant  Colonel,  Medical  Corps. 
Granted  leave  of  absence  for  four  months. 


Wertenfjaker.  C.  I..  First  Lieutenant,  Medical  Reserve 
Corps.  Ordered  from  Fort  Wadsworth,  N.  Y.,  to  Fort 
Terr}-,  N.  Y..  for  temporary  duty. 

Navy  Intelligence : 

Official  list  of  chawj^cs  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  zuech  ending  May  S,  /pop.- 
HAR'r,  S.  D.,  Acting  Assistant  Surgeon.     Appointed  an 

acting  assistant  surgeon  from  April  27th. 
AIuRPHY',  J.  A.,  Surgeon.    Detached  from  the  Naval  Medi- 
cal School  Hospital.  Washington,  D.  C,  and  ordered 
to  the  Olympia. 

 ^  


Born. 

Porter. — In  Brookline,  Massachusetts,  on  Monday,  April 
26th,  to  Passed  Assistant  Surgeon  Frederick  E.  Porter, 
U.  S.  N.,  and  Mrs.  Porter,  a  daughter. 

Married. 

Dana — Quinn. — In  Brighton,  Massachusetts,  on  Wed- 
nesday, May  5th,  Dr.  Harold  Ward  Dana  and  Miss  Ger- 
trude Veronica  Quinn. 

Green — Seeley. — In  Lake  Waccabuc,  New  York,  on 
Wednesday,  May  5th,  Dr.  Arthur  Randolph  Green  and 
Miss  Florence  Elizabeth  Seeley. 

Me.rriman — Betts. — In  Norwalk.  Connecticut,  on  Mon- 
day, May  3d,  Dr.  ]\I.  Fleminway  Merriman  and  Miss  Sallv 
Mallory  Betts. 

Died. 

Auler. — In  Elgin,  Texas,  on  Tuesday.  April  20th,  Dr. 
Hugo  A.  Auler,  of  St.  Louis,  Missouri,  aged  forty-two 
years. 

B.\TES. — In  Broad  Ripple,  Indiana,  on  ^londay.  May  3d, 
Dr.  J.  W.  Bates,  aged  fifty-two  years. 

BixBY. — In  Poultnev,  Vermont,  on  Mondav,  May  3d, 
Dr.  A.  B.  Bixby. 

Boyd. — In  Philadelphia,  on  Monday,  April  19th,  Dr. 
George  M.  Koyd,  aged  thirty-one  years. 

Burroughs. — In  Houston,  Texas,  on  ^Monday,  May  3d. 
Dr.  J.  J.  Burroughs,  aged  seventy-nine  years. 

CoKER. — In  Chicago,  on  Saturday,  May  ist.  Dr.  William 
Wilson  Coker,  aged  sixty-nine  years. 

De  Bruler. — In  San  Juan,  Puerto  Rico,  on  Friday,  Ma}- 
7th,  Passed  Assistant  Surgeon  James  P.  De  Bruler,  aged 
thirty-two  years. 

DoRNSiFE. — In  Tunkhannock,  Pennsylvania,  on  Sunday, 
April  25th,  Dr.  Daniel  Dornsife,  aged  seventy-six  years. 

DowLiNG. — In  Leslie,  Michigan,  on  Tuesday,  April  27th, 
Dr.  Martin  S.  Dowling,  aged  seventy-one  years. 

Finn. — In  Philadelphia,  on  Wednesday,  May  5th,  Dr. 
William  Henrj'  Finn,  aged  seventy-four  years. 

Foster. — In  Milwaukee,  Wisconsin,  on  Friday,  April 
30th,  Dr.  James  J.  Foster,  aged  forty  years. 

Freeman. — In  Saginaw,  Alichigan,  on  Monday,  May  3d, 
Dr.  James  Warren  Freeman,  aged  eighty-one  years. 

Houghton.— In  Brooklyn,  on  Saturday,  May  ist.  Dr. 
Burr  L.  Houghton,  aged  fifty-five  years. 

MiDDLEDiTCH. — In  Pasadena,  California,  on  Monday, 
April  26th,  Dr.  Alvarado  Middleditch,  aged  eighty  years. 

North. — In  Jackson,  Michigan,  on  Fridav,  April  30th. 
Dr.  John  D.  North. 

Opie. — In  New  York,  on  Sunday,  May  2nd,  Mrs.  Ger- 
trude Simpson  Opie,  wife  of  Dr.  Eugene  L.  Opie. 

P.\UL. — In  Des  Aloines.  Iowa,  on  Saturdav,  May  8th, 
Dr.  C.  B.  Paul. 

PLUNKErr. — In  McComb  Citv,  Mississippi,  on  .Thursdav, 
April  29th,  Dr.  J.  H.  Plunkett.' 

Ross. — In  Seattle,.  Washington,  on  Friday,  May  7th,  Dr. 
Hugh  Ross,  aged  sixty-four  years. 

Scott. — In  Little  Rock,  Arkansas,  on  Friday,  April  30th, 
Dr.  Andrew  Homer  Scott,  aged  sixty-nine  years. 

Smith. — In  Marion,  Kansas,  on  Sundav,  Mav  2nd,  Dr. 
N.  M.  Smith. 

Valadier. — In  Paris,  France,  on  Saturday,  April  25th, 
Dr.  C.  A.  Valadier. 

Watson. — In  Richmond,  Virginia,  on  Fridaj-.  .\pril  30th, 
Dr.  James  Clark  Watson,  aged  seventy-eight  years. 

Wesley. — In  Salt  Lake  City,  Utah,  on  Sunday,  .-\pril 
25th,  Dr.  John  E.  Wesley,  aged  eighty-two  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal      Medical  News 


A  Weekly  Review  of  Medicine,  Established  184J. 


You  LXXXIX.  Xc.  21.  NEW  YORK,  MAY  22,  1909.  Whole  No.  1590. 


(Original  Comimmiriitious. 

THE  MEDICAL  IMPORTANCE  OF  THE  STUDY  OF 
ANTHROPOLOGY. 
By  Major  Chakles  E.  Woodruff, 
Fort  Wadsworth,  N.  Y. 
Surgeon.  United  States  Army  Medi?al  Corfs. 

Our  expansion  to  tropical  climates  has  taken  sol- 
diers into  new  environments  which  have  created  an 
entirely  new  subject  for  sanitary  investigation — the 
relation  of  races  and  climates.  Heretofore  no  one 
has  given  the  subject  a  thought,  indeed  it  is  quite 
likely  that  the  vast  majority  of  physicians  believe 
that  the  preservation  of  the  health  of  white  men  in 
the  tropics  is  exclusively  a  matter  of  avoidins:  the 
infections.  To  be  sure,  almost  every  case  of  sick- 
ness is  an  infection,  and  since  we  have  discovered 
how  to  avoid  the  causes,  we  have  enormously  re- 
duced the  morbidity  and  mortality  rates.  First 
smallpox  was  avoided,  then  yellow  fever,  then 
cholera  and  the  other  intestinal  infections,  and  now 
malaria  is  gradually  being  reduced  as  we  increase 
the  efficiency  of  the  mosquito  warfare. 

There  is  another  field  which  has  scarcely  been  cul- 
tivated, that  curious  reduction  of  resistance  vrhich 
makes  all  infections  far  worse  than  in  the  normal 
environment.  We  have  found  that  some  patients 
will  not  get  well  at  all,  and  that,  as  a  rule,  recovery 
in  all  cases  is  vastly  hastened  by  sending  the  patient 
home.  Then  there  is  the  class  of  cases  with  chronic 
conditions  such  as  vascular,  nervous,  and  card'ac 
diseases,  and  we  find  that  these  patients  begin  to 
break  down  far  sooner  than  they  would  if  they 
stayed  at  home.  Finally  there  is  a  large  class  of 
cases  of  a  general  failure  of  the  powers  of  life,  in 
which  we  can  find  no  definite  disease,  and  these  mav 
be  so  severe  as  to  be  fatal,  unless  the  patient  is  sent 
home.  So  there  has  grown  up  the  custom  of  send- 
ing cases  north  as  soon  as  it  is  discovered  that  re- 
covery in  the  tropics  will  be  slow  or  difficult.  Thus 
it  happens  that  such  patients  die  at  home,  few  in  the 
tropics,  and  the  death  rate  is  often  lower  than  in  the 
home  cities.  This  phenomenon  has  been  accepted 
as  evidence  that  the  tropics  are  now  as  healthv  fo- 
northern  types  as  the  temperate  zone.  As  a  matter 
of  fact  there  is  a  constant  stream  of  invalids  sent 
home  from  all  tropical  climates  and  omitting  a  few 
dissenters,  there  is  a  generally  accepted  opinion  that 
two  years  is  the  longest  period  it  is  safe  to  remain 
in  hot  places' without  a  more  or  less  prolonged  vaca- 
tion in  a  cold  country.  That  is,  we  have  only 
learned  to  dodge  some  of  the  dangers  and  run  away 


from  the  others,  but  the  conquest  of  the  tropics  is 
as  far  off  as  ever.  Colonization  by  northern  types 
who  w-ill  never  need  a  trip  north  for  recuperation, 
or  who  can  raise  their  children  in  the  tropics  and 
thus  propagate  their  kind,  is  still  an  impossibility. 
If  our  troops  are  to  be  kept  healthy  we  must  dis- 
cover the  reason  for  this  loss  of  resistance  and 
vigor,  and  the  new  investigations  in  this  line  are 
also  of  vital  importance  to  Americans,  for  in  every 
part  of  the  land  there  are  migrant  types,  some  of 
whom  may  be  injured  by  climatic  factors. 

Explanation  of  this  failure  to  retain  vigor  when 
out  of  our  usual  environments  is  quite  easy  on  gen- 
tral  laws  but  most  difficult  when  we  get  down  to 
particulars.  While  biologists  for  a  half  century 
have  been  talking  about  adaptation  to  environments, 
the  medical  profession  has  completely  ignored  it,  and 
the  opinion  is  widespread  that  the  diflferences  be- 
tween types  of  men  are  of  no  significance  whatever. 
Consequently  no  investigations  have  been  made. 
The  opinion  is  the  more  remarkable  because  there 
does  not  seem  to  be  any  dissent  from  the  theory  that 
in  lower  animals  specific  characters  have  a  survival 
value,  that  is  the  origin  of  species  is  merely  the  sur- 
vival of  the  individuals  which  have  so  varied  as  to 
be  the  best  adjusted  to  the  environment.  There  are 
differences  of  opinion  as  to  the  survival  value  of 
characters  which  distinguish  varieties  of  a  species, 
because  to  a  certain  extent  varieties  are  future  spe- 
cies under  trial,  struggling  for  existence,  and  some 
of  them  must  perish  through  unfitness.  Occasion- 
ally we  hear  vehement  assertions  that  every  specific 
character  exists  because  beneficial,  and  that,  instead 
of  denying  the  fact,  it  is  our  duty  to  discover  the 
unknown  uses. 

Unfortunately  all  races  of  men  have  generally 
been  considered  to  constitute  one  species,  but  there 
is  a  vigorous  reaction  apparent,  for  every  now  and 
then  we  see  articles  in  which  it  is  stated  by  eminent 
botanists  and  zoologists,  that  if  any  groups  of  living 
things  show  differences  of  the  degree  found  between 
men,  those  groups  are  invariably  considered  to  be 
species.  If  this  opinion  prevails  we  must  consider 
all  racial  characteristics  as  so  beneficial  in  some  way 
that  they  have  led  to  survival  in  the  appropriate  en- 
vironment. There  was  once  a  prevalent  notion  that 
man  was  superior  to  the  universal  natural  laws  gov- 
erning all  other  animals,  and  the  anthropologists  of 
a  half  centurv  ago  were  strenuous  in  their  opposi- 
tion to  the  flood  of  new  ideas  created  by  Darwin's 
work.  There  is  still  a  great  deal  of  that  opposition, 
and  very  able  men  assert  that  physique  is  of  little 
survival  value,  for  man  by  his  intelligence  escapes 


Copyright,   1909,  by  A.  R.   Elliott  Publishing  Company. 


1030 


U  OODlWFf:  STUDY  OF  ANTHKOI'OI.OGY. 


(.\e«'  Vork 
-Mfdical  Journal. 


adversities  which  lower  animals  must  fight.  They 
point  to  the  loss  of  the  body  hair  as  an  illustration, 
yet  that  loss  is  of  tremendous  advantage  in  standing 
changes  of  temperature,  and  was  undoubtedly  of  se- 
lective value  in  the  evolution  of  the  race  in  the  great 
temperature  changes  of  glacial  times  when  summers 
wtre  so  short  and  hot.  The  more  intelligent  c^uld 
guard  themselves  in  winter,  but  could  not  survive 
the  summer  if  heavily  Inirdened  with  hair.  Pro- 
fessor William  Ridgeway,  of  Cambridge,  has  recent- 
ly protested  against  the  old  idea  of  man's  isolation 
from  the  rest  of  creation,  and  has  pleaded  for  the 
view  that  we  are  governed  by  all  the  natural  laws 
which  modify  other  animals. 

( )ne  of  the  greatest  obstacles  to  the  determina- 
tion of  characters  due  to  the  selection  of  variations 
is  the  fact  that  a  modification  may  appear  genera- 
tion after  generation  as  long  as  the  cause  acts, 
though  such  acquirements  are  never  hereditary. 
For  instance,  a  race  is  forced  into  an  inhospitable 
place  where  sufficient  food  is  not  available,  and  at 
once  they  show  reduction  of  stature,  which  mav  last 
for  centuries  as  though  it  were  an  hereditary  useful 
variation.  Let  them  come  to  America  where  the 
children  can  be  well  fed,  and  the  latter  at  once  grow 
to  a  much  higher  stature  than  their  parents,  thus 
proving  that  the  knv  stature  was  not  a  specific  char- 
acter like  that  of  tropical  natives,  but  a  mere  ac- 
quirement sure  to  disa])pear  with  its  causes.  ■Man, 
like  bacteria,  is  intensely  sensitive  to  change  of  this 
sort,  but  reverts  to  the  normal  promptly  upon  resto- 
ration of  the  normal  environment. 

Another  disturbing  factor  is  the  effect  of  use  or 
disuse.  I  well  remember  a  fencing  instructor  whose 
left  arm,  always  held  in  the  air,  had  become  small 
and  short,  but  whose  right  arm  was  longer  and  its 
bones  and  muscles  much  larger.  Xow  if  all  men  on 
earth  followed  similar  employments  we  would  all 
be  one  sided  as  though  it  were  a  racial  character. 
Certain  aquatic  or  canoe  races  are  noted  fo"  the 
slenderness  of  their  legs  and  their  powerful  arms 
and  shoulders,  and  thi>  was  once  believed  to  be  a 
matter  of  selection,  but  it  proved  to  be  mereh'  the 
result  of  use  and  disuse  in  each  generation.  I  have 
lived  among  such  a  people  and  know  that  their  chil- 
dren grow  up  like  other  Indians  if  given  normal  ex- 
excises  for  their  legs.  It  is  a  nonhereditary  modifi- 
cation, disappearing  ])n)mptl\  with  its  causes.  On 
the  other  hand  pi'.imentation  is  a  result  of  survivd 
of  favorable  variations  caused  we  do  not  know  how. 
for  sunburn  is  never  transmitted. 

It  beh(;oves  us  then  to  take  up  each  character  and 
determine  why  it  exists.  If  it  is  shown  to  be  of  sur- 
vival value  it  will  be  easy  to  determine  whether  that 
character  is  a  disadvantage  if  the  man  migrates  to  a 
markedly  (lift"erent  environment,  or  whether  it  is 
merely  neutral.  Take  stature  and  bulk  for  instance, 
why  is  it  that  there  is  such  a  general  tendency  to 
shortness  of  stature  in  the  tro])ics  and  great  tallness 
toward  the  colder  ])laces.  There  arc  .some  remark- 
able exceptions  to  this  generalization,  even  in  hot 
countries,  but  it  h.ilds  so  often  that  it  has  been  tl  e 
subject  of  comment  for  hundreds  of  years- -pcr- 
hai)s  thousan<ls.  for  tin-  Romans  knew  it.  Excep- 
tions by  the  way  are  often  due  to  migration,  and 
even  if  the  character  is  a  disadvantage  it  ma\'  take 
many  generations  to  kill  off  the  unfit.  Kvoluti'm  is 
a  slow  im|)erce|)tible  jjrocess  like  the  movement  of 


glaciers,  which  have  only  recently  been  found  to  be 
real  rivers,  though  people  have  lived  near  them  for 
100,000  years. 

As  before  mentioned,  it  has  been  found  that  lack 
of  proper  nourishment  is  the  cause  of  low  stature 
here  and  there,  but  that  does  not  explain  the  differ- 
ences in  the  well  nourished.  A  hunting  life  some- 
times causes  survival  of  the  tall  but  just  as  often  the 
reverse.  Indeed,  there  is  no  explanation  of  tallness 
as  an  advantage  in  survival.  The  only  thing  we  are 
certain  about  is  the  reverse  proposition  as  to  weight, 
for  heavy  northern  men  do  not  stand  the  tropics  as 
well  as  the  little  ones.  This  has  been  known  by 
British  East  India  surgeons  for  a  long  time,  and  it 
has  excited  no  end  of  amazement  to  see  the  big  men 
break  down  so  often  and  the  undersized  stand  the 
strains  for  many  years.  Some  noted  soldiers  in 
India  were  even  below  par  physically  and  so  were 
many  famous  tropical  explorers  like  Livingston.  I 
have  been  struck  by  the  fact  that  men  of  short 
stature — particularly  if  brunette — often  enjoyed  the 
Philippine  climate,  and  that  the  big  men  with  some 
exceptions  labored  under  it.  To  be  sure,  tall  Euro- 
peans are  mostly  blond  and  that  mav  be  a  factor, 
as  we  will  see  later,  but  I  have  also  noticed  the  suf- 
ferings of  the  heavy  brunettes.  So  there  is  sc/me- 
thing  about  tallness  and  bulk  which  makes  it  an  ad- 
vantage in  cold  places  and  a  decided  disadvantage 
in  the  hot  ones.  Consequently  we  find  in  America 
that  the  tall  men  so  common  in  the  north  have  e'ther 
b^cn  killed  off  in  the  south  or  else  something  has 
prevented  the  children  of  the  south  from  reaching 
the  stature  of  their  ancestors.  In  examining  \olun- 
teers  in  New  Orleans  in  i8f)8  I  was  painfully  im- 
pressed by  the  ]joor  physit|ues,  so  different  from  the 
men  of  the  Montana  and  Colorado  regiments.  What 
diseases  in  the  southern  lowlands  then  are  more 
prevalent  in  the  tall  than  in  those  of  short  stature? 

The  disadvantage  of  overweight  in  America  h^s 
been  clearly  shown  by  Dr.  Ilrandreth  Symonds 
(Medical  Record,  Se])tember  5,  i()o8)  from  a  study 
of  life  insurance  statistics.  It  must  be  rememSered 
that  the  Cnited  States  is  nuich  nearer  the  trop'cs 
than  we  generally  realize.  Our  northern  parallel 
passes  through  the  vicinity  of  Paris  and  Viemn, 
while  Texas  extentls  as  far  south  as  the  Sahara 
Desert.  Europeans  in  the  L'nited  States,  therefore, 
are  far  out  of  their  normal  environment  and  should 
show  the  same  ]:)henomena  as  in  India  only  in  minor 
degree,  and  this  is  a  fact.  Symonds  shows  that 
overweights  suffer  an  undue  mortality  from  diseases 
of  the  nervous,  circulatory,  urinary,  and  digestive 
systems,  and  though  they  have  an  immense  advan- 
tage in  respiratory  diseases  their  average  length  of 
life  is  decidedly  less  than  the  underweights,  .\llow- 
ancc  must  be  made  for  the  fact  that  underweight  is 
a  great  cause  for  rejection  by  insurance  comi)anies, 
and  those  accepted  must  have  been  exeept'on;i!ly 
perfect  in  other  ways.  In  addition,  good  nutrition 
frequently  blinds  us  to  other  faults  and  leads  to  the 
acceptance  of  poorer  material.  Yet  even  with  all 
allovyances  made  it  is  evident  that  bulky  men  here 
sufi'er  from  the  identical  conditions  so  marked 
among  them  in  the  tro])ics. 

W'e  are  still  no  nearer  the  cause  of  this  than  we 
were  before,  because  we  have  no  comparative  data 
from  i)laces  in  the  northwest  corner  of  Eurojje. 
where  the  average  height  is  decidedly  greater  than 


May  22,  i  909. 1 


WOODKUFf :  STl'DV  OF  ANTFIROPOLOCV. 


here,  and  wlicrc  these  overweights  would  be  luarei 
the  normal.  So  we  can  only  form  a  preliminary 
hypothesis,  until  the  medical  profession  collects  suf- 
ficient data  to  form  a  scientific  theory.  Tint  h\- 
pothesis  has  long  ago  been  mentioned  ;  surface  va- 
ries as  the  square  and  weight  as  the  cube  of  length, 
so  that  heavy  men  have  less  radiating  surface  than 
thin  men  of  equal  height.  Eulkiness  or  stockincss 
then  is  a  decided  advantage  in  retaining  body  heat 
in  cold  climates,  but  it  prevents  sufificient  radiatioii 
in  the  tropics,  so  that  the  disturbances  of  bodv  tem- 
perature break  down  the  nervous  system  in  the 
course  of  some  years. 

Now.  this  is  a  serious  practical  matter.  Among 
some  thousands  of  cases  investigated  in  the  United 
.States  not  one  overweight  attained  the  age  of  eightv. 
\vhile  fort\'-four  underweights  passed  it.  We  must 
find  out  why,  heavy  men  are  killed  prematurely  in 
America,  if  they  are  long  lived  elsewhere.  A  dis- 
covery of  the  cause  and  avoidance  of  it  will  prolong 
their  lives.  Does  it  mean  that  until  we  do  find  the 
cause  we  must  advise  these  cases  to  migrate  north 
every  spring — run  away  from  an  unknown  dane'er 
as  we  do  in  the  tropics,  or  will  it  be  possible  to  fin  1 
a  cause  which  can  be  avoided?  It  is  a  typical  in- 
stance where  preventive  medicine  is  waiting  for  an 
acceptable  theory  from  anthropology  and  anthr.)pol- 
ogy  is  waiting  for  pathological  facts  upon  which  to 
form  a  judgment.  A  similar  phenomenon  i.s  the 
shortness  of  stature  of  a  city  population  as  com- 
pared with  the  surrounding  rural  ones,  and  the  re- 
cently discovered  fact  that  the  big  blond  type  can- 
not survive  city  life  many  generations. 

A  short  while  ago  there  was  considerable  medical 
comment  upon  the  fact  that  in  .\orfolk.  England, 
in  nearly  every  small  village  there  were  some  people 
over  eighty  years  old  and  not  infrequently  one  or 
two  over  ninety,  while  seventy  was  not  considered 
too  old  for  severe  farm  labor — and  this  in  spite  of 
the  fact  that  rheumatism  there  is  very  rife,  often 
crippling  the  aged,  and  that  there  is  a  woful  lack  of 
proper  housing  and  sanitary  appliances.  What  a 
flood  of  light  we  would  have  on  the  causes  of  this 
longevity,  if  the  physicians  would  only  report  the 
types  which  survive.  On  the  other  hand,  we  are 
frequently  bombarded  with  statistics  showing  the 
increase  of  arteriosclerosis  in  America  and  the  al- 
leged lessened  length  of  life  as  compared  with  the 
same  types  in  their  native  lands — Germans  for  in- 
stance— but  no  one  has  ever  stated  what  types  of 
Germans  are  thus  afflicted.  As  a  general  rule  it  is 
probably  safe  to  say  that  in  this  country  the  abilit}- 
to  perform  hard  labor  disappears  five  to  ten  years 
before  it  does  in  Europe. 

Another  character  which  has  been  long  noted  as 
varying  with  the  climate  is  the  nasal  index,  or  width 
of  nose  divided  by  the  length.  The  index  is  the 
smallest  in  cold  countries  and  largest  in  the  tropics, 
where  the  width  may  even  exceed  the  length.  This 
has  no  fixed  relation  to  the  size  of  the  nose,  but 
there  has  long  been  an  hypothesis  that  it  is  related 
to  the  size  of  the  nasal  cavities,  which  are  supposed 
to  be  larger  in  the  tropics  to  admit  more  air,  which 
expands  over  one  third  of  its  volume  when  heated 
from  a  temperature  of  — 40°  to  +  110°  F.,  and  there- 
fore the  tropical  native  needs  considerable  more  cubic 
inches  at  each  respiration  than  men  in  cold  climates. 


It  seems  also  that  in  the  tropical  skulls  the  turbin- 
ated bones  leave  larger  air  spaces  between  them,  but 
I  have  not  been  able  to  verifv  this  by  a  sufficient 
number  of  skulls.  The  only  bony  variation  discov- 
erable in  the  skulls  1  have  examined  through  the 
courtesy  of  Dr.  Clark  Wissler  of  the  American 
Museum  of  Natural  History  is  the  narrowness  of 
the  anterior  nasal  a]:)erture  in  arctic  skulls,  as  though 


]'ic;.    1. — Tlie   narrow  nasal  aperture  of  tlie  arctic  skull  and  wide 
aperture  of  tlu-  tropical  skull. 

it  were  of  selective  value,  survival  falling  to  those 
who  breath ;d  their  air  in  thin  ribbons  more  easily 
warmed.  In  the  tropics  selection  acts  the  other  way. 
Whatever  the  cause  we  do  know  it  must  be  a  vital 
matter  to  have  made  such  a  great  change  as  we  see 
in  the  two  classes  of  skulls.  Now  the  point  to  de- 
termine is  wdiether  the  open  nostril  has  anvthing  to 
do  with  the  susceptibility  of  negroes  to  pulmonary 
diseases  in  the  north  and  whether  a  northern  tvpe 
is  really  inconvenienced  in  any  way  by  his  narrow 
nares  if  he  migrates  to  the  tropics.  Is  this  interfer- 
ence with  respiration  one  of  the  factors  which  make 
tuberculosis  in  white  men  so  incurable  in  the  tropics? 
And  will  it  help  us  to  explain  whv  we  often  see 
such  amazing  benefit  in  vtrv  cold  phces.  and  in  the 
winter?  It  would  be  ridiculous  with  our  present 
knowledge,  in  selecting  a  climate  for  patients,  to  pay 
the  slightest  attention  to  the  shape  and  size  of  the 
nose  and  nasal  aperture,  but  we  must  wake  up  to 
the  fact  that  Nature  is  not  ridiculous  in  making  the 
great  dift'erences  we  find.  She  has  been  at  work 
killing  off  the  unfit,  but  in  what  diseases  is  this  un- 
fitness shown  ?  Is  atrophic  rhinitis  an  unmixed  in- 
jury in  hot  places  or  a  desperate  attempt  of  Nature 
to  enlarge  the  air  s])aces?  Is  the  alleged  erectile 
tissue  in  the  turbinated  bones  of  some  use  in  con- 
stricting the  air  space?  And  is  the  tumefaction  of 
acute  coryza  a  benefit  also?  Here  again  the  special- 
ists may  furnish  valuable  data  by  recording  the 
conditions  and  what  nationalities  and  types  are  suf- 
fering mostlv  from  each  disease  of  the  respirator) 
tract  in  America,  and  whether  popular  operations 
invariably  have  happy  results  in  all  types. 

My  own  investigations  have  been  exclusivelv  as  • 
to  the  use  of  the  pigments  of  the  skin,  hair,  and 
eyes.  As  far  as  we  can  now  d.etermine  with  the 
data  recorded,  it  seems  that  for  the  greatest  ef- 
ficiencv  we  are  dependent  upcn  the  stimulation  of 
a  small  amount  of  light,  and  though  mere  health  is 
possible  with  very  little,  as  in  the  case  of  subway 
employees,  miners,  and  night  workers,  vet  total  de- 
privation seems  decidedly  depressing.  But  light  in 
large  amounts  is  invariably  lethal,  and  even  ,  in 
smaller  doses  it  may  be  unduly  stimulating,  so  that 
the  limit  of  safety  is  far  below  the  point  generally 


1032 


JFQODRUFF:  STUDY  OF  ANTHROPOLOGY. 


[New  York 
Medical  Journal. 


accepted  by  the  medical  profession.  Consequently 
Nature  is  always  at  work  removing  the  specimens 
insufficiently  protected,  so  that  in  course  of  time  the 
people  at  any  place  become  pigmented  in  proportion 


Fig.  2. — Bartlioloniew's  map  of  mean  annual  cloudiness. 

to  the  maximum  intensity  of  the  light — irrespective 
of  the  temperature.  The  negro's  skin  does  not  keep 
out  all  the  light  of  the  tropical  sun,  but  as  far  as  we 
know  it  transmits  about  as  much  as  goes  through  the 
skin  of  a  blond  in  the  feeble  light  of  cloudy  places  in 


Fig.   3. — RipUy's  map  of  complexions,   showing  tliat  ligiiu-ntaiion 
increases  with  sunshine. 

.  Europe.  Each  ty])e  e.xcludcs  practically  all  the  ul- 
traviolet rays  and  is  sufficiently  ])rotcctcd  from 
harm,  but  receives  the  stimulus  it  needs  from  the 
longer  frequencies  which  penetrate  in  amounts  pro- 


portionate to  the  wave  length.  That  is,,  red  pene- 
trates most  and  violet  least.  Innumerable  experi- 
ments of  this  sort  have  been  made  and  all  tend  to 
this  generalization.  Curiously  enough  it  is  found 
that  the  light  in  the  Finsen  method  does  not  pene- 
trate in  sufficient  amounts  to  kill  the  bacilli  or  even 
injure  them,  and  the  cures  must  be  explained  in 
other  ways.  I  do  not  remember  any  explanation 
which  is  not  open  to  objection.  Finsen,  by  the  wav, 
always  seemed  to  believe  that  the  light  was  really 
germicidal — a  matter  disproved  at  his  institute  after 
his  death. 

It  takes  time  to  eliminate  animals  which  have  mi- 
grated out  of  the  environment  to-  which  ,they  are 
adjusted,  and  for  this  reason  we  often  find  blonds 
and  brunets  living  side  by  side  as  in  Switzerland, 
and  these  migrants  are  the  great  stumbling  blocks 
to  those  who  do  not  like  to  accept  a  generalization 
unless  all  the  facts  are  covered  without  further  ex- 
planation. Nevertheless  the  evidence  is  fairly  con- 
clusive that  blond  races  do  disappear  when  they 
migrate  to  lands  of  excessive  sunshine,  but  that  thev 
survive  longer  if  the  light  is  less  intense,  even  to  the 
extent  of  1,500  years  as  in  the  cloudiness  of  the 
Alps  and  northern  mountains  of  Spain.  These  phe- 
nomena are  occurring  in  America,  but  have  only 
been  noted  in  a  general  way  by  anthropologists, 
who  have  repeatedly  called  attention  to  the  increas- 
ing brunetness  of  our  population,  even  before  the 
present  flood  of  brunet  immigration. 

There  are  of  course  more  blonds  in  the  United 
States  than  ever  before,  but  that  is  due  to  new  arri- 
vals. The  original  migration  which  settled  New 
England  was  not  more  than  20,000  souls,  and  the 
total  prior  to  the  revolution  not  much  more  than 
80,000.  We  receive  that  many  in  less  than  a  month 
nowadays.  The  point  is,  that  the  blonds  do  not 
maintain  their  proportion  because  of  a  higher  death 
rate,  or  lower  birth  rate,  or  both. 

Now,  what  diseases  are  carrying  them  off  in  the 
rest  of  the  country?  Here  is  where  the  medical 
profession  can  be  of  immense  value  to  anthropology 
by  simply  recording  the  complexion  of  patients  of 
each  group  of  diseases.  By  a  study  of  cases  which 
have  been  under  identical  influences  we  can  quick- 
ly determine  what  diseases  afflict  brunets  mo.st  an:l 
whicli  the  blonds.  Then  we  can  evolve  therapeu- 
tics and  preventative  means.  At  present  we  have 
only  the  general  law  to  guide  us,^ — men  who  mi- 
grate to  a  climate  where  the  native  is  heavil\-  pig- 
mented are  in  some  way  damaged  by  the  light.  Ex- 
periments and  observation  in  India  during  the  last 
three  or  four  years  have  established  that  generaliza- 
tion on  a  firm  basis.  The  medical  director  of  the 
ilritish  army  informed  me  some  months  ago  that  it 
was  then  proposed  to  take  up  the  matter  of  protect- 
ing the  soldiers.  In  other  words,  pigmentation  is 
of  survival  value  and  men  the  world  over  instinc- 
tively hide  from  the  light  or  protect  themselves. 
Sambon,  of  the  London  School  of  Tropical  Medi- 
cine, has  devised  a  cloth  with  the  outer  surface  liglit 
to  reflect  the  rays  as  much  as  possible  and  an  inner 
opaque  surface  to  stop  the  rays  which  arc  not  re- 
flected. It  is  cool  and  comfortable.  In  the  I'hilip- 
pines  there  is  a  growing  tendency  to  wear  black  un- 
derclothing, and  if  one  must  go  abroad  in  the  day- 
time, the  outer  garments  are  of  light  color.  Pro- 


May  22,  1909.] 


WOODRUFF:  STUDY  OF  ANTHROPOLOGY. 


1033 


fessor  William  Ridgeway  has  discovered  the  iden- 
tical protection  of  the  tropical  horse.  The  Arabian 
thoroughbred,  even  if  it  has  white  hair,  has  a  black 
skin — is  really  a  negro  as  he  so  aptly  says.  Some 
northern  white  haired  horses  also  have  a  black  skin, 
but  generally  it  is  white,  and  Ridgeway  says  that  is 
the  reason  they  do  not  survive  a  tropical  climate.  Nor 
can  the  white  pigs  of  northern  Europe  become  accli- 
mated to  our  southern  States,  where  the  black  pig 
thrives.  The  hair  of  the  normal  Arab  horse  is  gen- 
erally of  the  color  which  reflects  light  and  heat, — 
the  color  we  attempt  to  approximate  in  our  khaki 
cloth — the  color  of  lions,  coyotes,  and  other  animals 
exposed  to  intense  light  and  heat,  though  the  origi- 
nal purpose  of  selecting  this  color  for  clothing  is  the 
same  as  in  the  case  of  these  animals — concealment. 
It  must  be  remembered  that  though  black  absorbs 
heat  it  aids  radiation  when  the  surroundings  are 
cooler  than  the  body,  so  that  black  tropical  animals 
tend  to  hide  in  the  daytime  to  avoid  absorption,  and 
are  cooler  for  their  black  skin.  In  like  manner,  it 
is  found  that  in  evening  and  indoors  in  the  day- 
time, dark  outer  clothing  is  more  comfortable  than 
white  of  equal  thickness  and  porosity.  The  blackest 
negroes  do  not  live  in  the  hottest  parts  of  the  world, 
and  contrary  to  popular  opinion  they  cannot  stand 
a  high  degree  of  heat  as  well  as  white  men,  and 
sulfer  more  from  thermic  fever  in  such  conditions. 

So  much  for  generalities ;  the  trouble  is  with  the 
particulars.  What  diseaes  are  more  common  in  one 
type  than  in  the  opposite?  There  is  little  on  record 
because  few  observations  have  been  made,  for  no 
one  has  ever  thought  of  recording  complexions  for 
comparisons-^but  what  little  is  available  leads  to 
conclusions  the  opposite  of  what  we  formerly  had. 
Symonds's  statistics  as  to  bulk  show  that  what  we 
once  considered  the  best  are  really  the  worst  for  this 
climate,  and  the  same  is  found  as  to  complexions. 
These  old,  false,  baseless  opinions  persist  with  won- 
derful tenacity,  like  the  opinion  that  venesection  was 
good  for  everything  and  that  indoor  life  was  essen- 
tial for  consumptives — the  latter  opinion  held  on  for 
forty  years  after  it  was  known  to  be  false. 

A  careful  investigation  of  several  regiments  in  the 
Philippines  some  years  ago  showed  that  even  in  the 
short  time  of  two  years  the  blonds  did  have  a  high- 
er morbidity  and  much  higher  mortality  rate  than 
the  brunets.  I  have  often  been  struck  by  the  fact 
that  even  in  one  family  the  blond  women  would 
fade  while  the  brunet  flourished,  and  in  the  case  of 
many  dark  brunets  the  health  was  even  better  than 
at  home.  There  are  exceptions — many  of  them  in- 
deed— but  this  is  the  general  trend,  and  there  has 
not  been  sufficient  time  to  tell  what  the  final  result 
will  be  in  those  who  remain  there  a  long  time.  So 
far  we  know  that  if  a  man  can  hide  from  the  sun 
and  escape  the  infections,  his  health  may  not  break 
for  many  years. 

If  a  type  is  injured  in  any  way,  it  ought  to  show 
less  resistance  to  about  every  infection  than  the  un- 
injured, but  it  is  necessary  to  eliminate  all  other  fac- 
tors except  the  one  under  investigation.  For  in- 
stance, Europeans  in  the  tropics  have  lower  inci- 
dence and  mortality  rates  from  cholera,  plague,  and 
beriberi  than  the  natives,  and  the  figures  alone 
would  indicate  that  white  men  are  the  better  fitted 
for  such  a  life.     More  intelligence  in  escaping  in- 


fection and  better  feeding  explain  the  facts.  That 
is,  we  must  compare  types  under  similar  conditions. 
It  would  not  do  to  compare  the  consumptive  rates  of 
overcrowded,  underfed  brunets  in  the  slums,  with 
well  fed  blonds  in  the  suburbs.  Making  such  al- 
lowances, the  statistics  already  available  {New  York 
Medical  Journal,  September  12,  1908)  show  that 
blonds  do  furnish  more  cases  of  tuberculosis  than 
the  brunets  in  America  and  have  a  quicker  mortal- 
ity of  the  infected.  The  rapidity  and  malignance 
of  the  disease  among  blond  immigrants  is  now  a 
matter  of  record,  and  is  the  same  phenomenon  as  the 
awful  rapidity  of  the  disease  among  white  people  in 
the  tropics.  A  similar  phenomenon  has  also  been  ob- 
served in  central  Europe,  but  as  far  as  known  there 
is  little  or  no  dif¥erence  between  the  two  types  in 
such  cloudy  places  as  Scotland.  Moreover,  the  dif- 
ferences are  more  marked  in  our  south  than  in  our 
north. 

These  facts  open  up  an  entirely  new  field  for 
study.  It  is  well  known,  for  instance,  that  some  pa- 
tients do  not  improve  in  our  northern  mountains. 
What  types  are  they?  Why  are  we  not  informed 
so  that  we  will  no  longer  send  them  north?  Are  the 
unimproved  patients  types  who  come  from  the  Med- 
iterranean basin  and  are  unadjusted  to  cold,  patients 
who  are  known  to  do  better  in  Southern  California 
or  lower  Egypt  than  men  of  the  Baltic  race? 

It  is  also  known  that  there  is  a  deplorable  mortal- 
ity among  patients  sent  to  the  southwest.  We  have 
been  informed  that  one  town  in  Arizona  spends 
$25,000  a  year  burying  pauper  consumptives 
dumped  on  them  by  the  north  and  the  county  in 
which  the  town  is  situated  spends  $65,000  similarly. 
What  a  blot  on  our  reputation !  Why  are  we  not 
informed  what  types  are  so  promptly  destroyed? 
There  is  a  little  evidence  that  the  blonds  are  the 
worse  sufiferers,  and  it  is  sufficient  to  justify  us  in 
advising  bright  blonds  not  to  go  to  such  a  climate, 
or  at  least  if  they  do  go,  to  avoid  the  sun.  But  be- 
fore we  can  convince  every  one  it  is  absolutely  nec- 
essary to  collect  much  more  data.  The  blonds  who 
survive  in  spite  of  the  sun,  make  us  forget  those 
who  perished.  Moreover,  prolongation  of  life  is  far 
dififerent  from  cure,  and  we  must  be  informed  what 
types  cannot  be  cured  in  each  environment. 

In  explaining  the  excessive  mortality  of  over- 
weights in  America,  let  us  remember  that  stature, 
weight,  and  blondness  all  three  increase  from  the 
?\Iediterranean  to  Norway.  A  group  of  ten  thou- 
sand very  blond  immigrants  then  would  be  decided- 
ly above  the  weight  average  for  all  immigrants,  and 
ten  thousand  very  brunet  ones  would  be  decidedly 
below  the  average,  and  all  the  combined  over- 
weights of  all  classes  would  necessarily  be  blonder 
than  the  underweights.  If  none  of  these  over- 
weights reach  eighty  years  of  age,  who  is  bold 
enough  to  assert  that  it  is  overweight  itself,  or  some 
other  factor  in  addition,  tallness  or  blondness?  As 
a  matter  of  fact  those  who  have  resisted  tropical  cli- 
mates in  vigor  for  thirty  or  forty  years  are,  as  a 
rule,  not  only  short  but  brunet  also,  though,  of 
course,  there  are  many  exceptions. 

These  few  illustrations  show  that  the  different 
characters  of  the  races  may  be  of  survival  value  and 
probably  injurious  in  an  environment  which  has  se- 
lected the  opposite  characters.     We  might  go  on 


I034 


I  k/MMlM:  JXi'XCTION  'J  UBERCUIJ X  Kli.iCTION. 


[New  York 

MkUICAL  jdUKXAL. 


with  sucli  questions  as  the  reasons  for  the  hair  over 
the  cerebral  area,  and  why  it  is  so  kinky  in  the 
tropics,  and  so  straight  in  Asia,  but  enough  has  been 
given  t(j  justify  the  assertion  that  every  chmate  is 
approximately  perfect  for  the  type  it  has  selected, 
and  more  or  less  injurious  to  all  others  and  that  ac- 
climatization is  a  myth.  There  is  no  perfect  climate 
for  any  disease,  except  the  one  by  which  the  pa- 
tient's physique  is  evolved.  In  sending  invalids 
away  in  search  of  health,  we  must  consider  each  in- 
dividual far  more  than  we  have  heretofore,  or  we 
may  be  sending  them  to  their  death. 

In  regard  to  the  effects  of  climate  on  unadjusted 
t_\pes  we  have  the  grandest  field  in  the  world,  for 
we  have  all  kinds  of  climates,  and  in  each  there  are 
specimens  from  every  region  of  the  globe.  We  need 
first  of  all  an  anthropological  survey,  something  like 
that  made  by  \'irchow  for  Prussia,  and  it  is  to  be 
hoped  that  the  census  bureau  or  ethnological  bureau 
can  undertake  it.  Xext  we  must  know  what  dis- 
eases are  more  frequent  in  each  characteristic,  and 
here  we  must  be.  prepared  for  many  surprises. 
Symond's  proof  of  the  mortality  of  the  overweights 
was  like  a  bolt  of  lightning  from  a  clear  sky,  though 
it  was  really  predicted  in  a  way  by  tropical  experts. 
(J])hthalmoiogists  and  dermatologists  are  particularly 
fortunate  in  the  material  at  their  hands,  and  they 
are  sure  to  find  that  many  diseases  fasten  on  one 
type  more  than  another.  Hyde,  of  Chicago,  for  in- 
stance has  found  that  pigmentation  is  a  decided  pre- 
ventative of  skin  cancers  and  other  pathological  con- 
ditions. It  has  long  been  known  that  blonds  suf¥er 
unduly  from  the  ill  effects  of  x  rays,  but  nr)ihing 
has  been  published  as  to  the  complexions  of  those 
who  have  died  of  cancers  thus  produced.  One  pa- 
tient known  to  the  writer  was  decidedly  dark,  but 
she  was  most  careless. 

Physicians  mu.st  record  the  physique  of  all  cases 
to  let  statesmen  know  what  types  are  surviving  in 
America.  And  just  here  let  me  say  a  word  about 
the  prevalent  delusion  that  we  are  producing  a  new 
type  by  mixture.  It  was  once  said  that  the  old  as- 
similated the  new,  but  it  is  just  as  reasonable  to  as- 
sume that  the  hordes  now  coming  from  southern 
Europe  will  assimilate  the  old  stock  from  the  north 
of  Europe.  .As  a  matter  of  fact.  Nature  has  been 
mixing  Euroj^eans  for  some  hundreds  of  thousands 
of  years  and  has  been  unable  to  produce  a  type  fit 
to  live  everywhere  from  Scotland  to  Sicil\.  and  she 
will  be  equally  unsuccessful  here.  So  far  sh.e  has 
been  solely  occupied  in  killing  off  some  and  select- 
ing others  for  survival  and  will  work  on  the  same 
lines  here.  Hybrids  are  es])ecially  vulnerable  and 
have  no  climate  on  earth  to  which  they  are  adjusted 
— they  are  injured  wherever  they  go — men  without 
a  country.  Amalgamation  is  a  biological  absurdity. 
No  .American  type  has  yet  been  produced,  and  ,'is  a 
matter  of  fact  1  find  by  a  daily  experience  of  twenty  - 
two  years  with  .soldiers,  all  of  whom  are  dressed 
alike,  that  until  questioned  it  is  impossible  to  distin- 
guish recently  arrived  foreigners  from  the  natives 
of  twelve  generations'  residence.  The  same  typ:s 
are  found  in  each  class. 

The  military  importance  of  this  matter  is  self  evi- 
dent. It  is  (juite  likely  that  we  will  always  hive 
garri.sons  in  the  tropics,  and  we  are  slowly  gathering 
facts  showing  what  types  must  be  selected  fnr  this 


duty,  so  as  to  entail  the  least  loss  in  health  and  life. 
We  cannot  be  sure  of  our  ground  until  the  '.iiedical 
profession  makes  the  investigations  outlined.  Noth- 
ing will  be  done  until  we  fully  realize  that  Nature  is 
not  a  fool  to  go  to  all  the  trouble  of  selecting  so 
many  types  of  men  in  the  world.  We  must  wake 
up  to  the  fact  that  the  reasons  for  her  selections 
must  be  found,  and  that  the  study  of  anthropology 
is  of  vast  practical  therapeutic  importance.  If  we 
will  only  realize  the  importance  of  Darwin's  law  of 
adaptation,  the  science  of  climatology  will  be  reor- 
ganized, and  our  whole  idea  in  therapy  v.'ill  be  to 
select  that  climate  which  is  fitted  to  the  individual 
or  has  factors  in  exaggerated  degree  if  we  need 
such  for  temporary  use.  Take  the  one  question  of 
neurasthenia  which  is  so  bad  in  the  tropics  as  to 
leave  no  doubt  that  it  is  partly  due  to  excessive  stim- 
ulation of  light.  It  has  been  found  that  ])atients 
promptly  recover  as  a  rule  if  sent  to  a  darker  cli- 
mate, and  the  sanitoria  on  our  northwest  coast  have 
great  success  with  those  sent  down  from  the  intense 
sunshine  of  the  interior  plateau.  Similar  facts  have 
been  observed  as  to  those  sent  to  these  regions  from 
the  south.  Yet  we  occasionallv  hear  of  remarkable 
benefit  from  a  short  stay  in  sunny  places,  but  never 
a  word  as  to  what  manntr  of  people  they  v,'ere,  and 
whether  they  were  not  sluggish  autotoxic  cases 
needing  stimulation  anrl  not  exhausted  ones  needing 
the  reverse. 

Life  insurance  companies,  who  have  been  so  hard 
on  tropical  residents,  might  profitably  increase  their 
business  by  accepting  proper  types  whicli  can  also 
guard  themselves  from  known  dangers. 


THE  DIAGNOSTIC  VALUE  OF  THE  INUNCTION 
TUBERCULIN  REACTION  IN  CUTANEOUS 
TUBERCULOSIS.* 

Bv  William  B.  Trimble,  M.  D.. 
New  York, 

Lecturer  on  Diseases  of  the  Skin,  New  York  University  (Univer- 
sity and  Bellevue):  Chief  of  the  University  Clinic;  Assistant 
at  the-  New  York  Skin  and  Cancer  Hospital. 

"What  is  the  motive,"  is  an  expression  common 
among  counsellors  and  lawyers,  especially  during 
trials.  The  sum  total  of  these  investigations  may 
be  considered  in  the  light  of  a  trial,  although  of  a 
dififerent  kind  :  still  the  expression  seems  a])propri- 
ate  in  this  connection,  and  the  motive  of  this  com- 
munication will  be  disclosed  in  the  first  j^aragraph. 
It  is  nothing  more  than  an  endeavor  to  set  forth 
the  results  of  some  work  done  with  the  inunction 
tuberculin  test  along  derniatological  lines,  and  to 
draw  a  few  conclusions  therefrom. 

It  is  not  intended  to  decry  or  endorse  the  meth- 
od, but  merely  to  relate  the  observations,  and  let 
those  interested  judge  for  them.selves  as  to  its  value. 
In  reviewing  this  subject,  it  may  be  well  to  enumer- 
ate the  various  methods  by  which  tuberculin  is  used 
for  diagnostic  purposes.  They  can  be  divided  into 
svstemic  and  local. 

The  svstemic  reaction  is  produced  by  the  well 
known  method  of  subcutaneous  injection.  The  local 
reactions  are  the  ophthalmic  of  Calmette  and  W'olf- 

*Read  before   a   stated  meeting  of  the   New   York  \i.i.l>ii:> 
Medicine,  .\pril  i.  lOiiQ. 


May  22,  1909.]  TRIMBLE:  INUNCTIOX  TUBERCULIN  REACTION. 


1035 


Eisner,  and  the  integumentary  of  von  Pirquet,  Lig- 
nieres,  and  Moro. 

The  Calmette  consists  in  the  instillation  of  one 
drop  of  a  one  or  one  half  per  cent,  tuberculin  solu- 
tion, in  the  eye.  The  von  Pirquet,  which  is  quite 
similar  to  vaccination,  is  done  by  placing  one  drop 
of  tuberculin  solution  on  the  arm,  and  scarifying 
through  it.  The  Lignieres  is  performed  by  shav- 
ing the  part  closely,  and  rubbing  in  the  tuberculin 
solution.  The  method  of  Moro  is  the  subject  of 
this  paper. 

A  test,  which  is  harmless,  easy  of  application,  and 
can  be  relied  on  to  determine,  whether  a  patient  is 
suffering  from  tuberculosis  or  not,  would  be  ideal, 
but  up  to  the  present  time  no  such  ideal  has  been 
realized,  although  some  of  the  local  reactions  are 
not  devoid  of  value. 

The  inunction  test  was  devised  by  Professor  Er- 
nest Moro,  of  Munich,  and  consists  in  rubbing  into 
the  unbroken  skin  a  tuberculin  ointment.  This  oint- 
ment is  made  up  of  equal  parts  of  Koch's 
old  tuberculin  and  anhydrous  lanolin. 
Three  degrees  of  reaction  are  describerl — 
mild,  medium,  and  strong. 

Mild. — After  twenty-four  to  forty-eight 
hours,  there  appears  at  the  point  of  appli- 
cation a  ninnber,  sometimes  ten  or  twelve, 
dusky  red  papules  varying  in  size  from  a 
pin  to  that  of  a  small  match,  the  more 
diminutive  predominating. 

Medium. — This  reaction  is  practically 
the  same  as  the  first  with  the  exception, 
that  about  twice  the  number  of  papules 
are  observed,^  and  they  are  probably  some- 
what larger  than  in  the  mild  reaction. 
The  area  of  erythema  is  also  more  dis- 
tinct. 

Strong. — This  is  an  exaggeration  of  the 
second,  with  a  stronger  erythema,  a  great- 
er number  of  papules  of  a  larger  variety, 
and  the  symptom  of  itching  is  rather  an- 
noying. 

In  all  three  degrees  the  papules  persist 
from  three  or  four  days  to  a  week,  leav- 
ing a  slight  pigmentation,  which  gradually 
fades. 

The  technique  is  simple,  and  consists  in  select- 
ing a  place  on  the  side  of  the  chest,  about  the  mid- 
axillary  line,  or  the  side  of  the  abdomen,  if  desired, 
which  is  free  from  eruption  or  irritation  of  any 
kind.  Then  with  soap  and  water  gently  cleanse  an 
area  about  two  inches  square.  Alcohol  is  then  used 
to  remove  the  soap  and  any  little  grease  that  might 
remain,  and  lastly,  clear  water  to  remove  the  al- 
cohol. 

The  index  finger  of  the  patient  is  cleansed  in  the 
same  manner.  About  one  grain  of  the  ointment 
is  now  placed  on  the  finger,  and  this  is  gently  mas- 
saged into  the  skin  over  an  area  as  large  as  a  half 
dollar  for  a  minute  or  more.  A  pledget  of  cotton 
is  then  placed  over  the  anointed  surface,  and  held 
in  position  bv  a  strip  of  adhesive  plaster.  This 
technique  differs  in  a  few  minor  particulars  from 
that  originally  described  by  Moro.  He  uses  about 
one  and  a  half  grains  of  the  ointment,  and  advises 
"energetic"  rubbing.   The  slight  modification  of  the 


plan,  using  only  one  grain  and  "gentle"  rubbing  for 
the  same  length  of  time,  was  made  in  an  effort  to 
avoid  the  strong  degree  of  reaction,  which  is  con- 
sidered imnecessary. 

Personal  observations  were  made  on  fifty-four 
patients  with  dermatological  complaints.  A  tabu- 
lated list  follows : 

Number  of 

Disease:  Patients:  Positive:  Negative; 

Tuberculosis  of  skin   22  -|-    22  —  o 

Tuberculides   2  2  o 

Lupus  erythematosus,    9  2  7 

Psoriasis,    10  3  7 

Syphilis,    10  o  10 

Acne   I  I  o 

The  average  time  for  the  reaction  to  appear  was 
thirty-six  hours  ;  it  was  perceptible  in  twenty-four 
hours  on  one  individual,  and  in  one  or  two  others 
it  did  not  begin  under  forty-eight  hours. 

The  cases  of  cutaneous  tuberculosis  comprised 
several  different  clinical  varieties.    Lupus  vulgaris. 


Fig.   I. — Moro  tuberculin  reaction,  lirst  degree. 

14;  ages  ranging  from  eight  to  seventy  years. 
•Scrofuloderma,  3  ;  ages,  eight,  nine.  ten.  Tubercu- 
losis orificialis,  2 ;  ages  twenty-three,  twenty-eight. 
Tuberculosis  cutis  verrucosa,  3 ;  ages,  twelve, 
eighteen,  twenty-one. 

The  two  tuberculides  were,  one  man  with  lupus 
pernio,  and  one  girl  with  erythema  induratum, 
or  Bazin's  disease.  It  will  be  noticed,  that  all  the 
cases  of  cutaneous  tuberculosis  gave  a  positive  re- 
action. In  two  of  these  there  were  other  evidences 
of  tuberculosis  in  the  body,  both  patients  suffer- 
ing from  phthisis,  which  was  demonstrated  clini- 
cally, and  the  bacilli  were  found  in  the  sputum.  One 
other  gave  a  clear  tuberculous  history  among  his 
antecedents,  but  personally  he  was  in  good  health. 

In  this  group  of  twenty-two  cases,  the  reaction 
was  mild  in  one,  moderate  or  medium  in  eighteen, 
and  strong  or  intense  in  three  cases.  Curiously 
enough  the  sole  case,  reacting^  only  in  an  extremely 
mild  manner,  was  one  of  those  who  had  pulmonary 


1036 


TRIMBLE:  INUNCTION  TUBERCULIN  REACTION. 


[New  York 
Medical  Journal. 


tuberculosis  in  addition  to  the  skin  lesion.  This 
patient  was  in  an  advanced  stage  of  the  disease, 
and  it  is  a  known  fact,  that  advanced  cases  some- 
times fail  to  react  at  all.  This  patient  was  sub- 
jected to  a  second  inunction,  as  the  reaction  was 
extremely  doubtful  after  the  first ;  and  it  was  only 
after  the  second  application,  that  the  mild  reaction 


1  IG.  2. — Moro  tuberculin  reaction,  second  degree. 

took  place ;  this  might  be  explained  by  the  state 
of  anaphylaxis  or  vocal  supersusceptibility  having 
been  produced,  though  the  second  inunction  was 
made  a  little  to  one  side  of  the  first. 

The  two  tuberculides  require  no  explanation,  ex- 
cept to  say  that  erythema  induratum  is  classed  as 
a  true  tuberculosis  of  the  skin  by  some  writers,  who 


profess  to  have  demonstrated  the  bacilli  in  the 
lesions. 

The  test  was  tried  on  the  nine  cases  of  lupus 
erythematosus,  merely  because  they  happened  along, 
while  the  investigations  were  proceeding,  not  with 
any  intention  of  attempting  to  establish  a  relation 
betv.'fcn  that  disease  and  tuberculosis.  That  ques- 
tion is  outside  the  scope  of  this 
article.  The  reaction  was  posi- 
tive in  two,  and  negative  in 
seven  cases ;  in  those  giving  a 
positive  reaction,  no  evidence  of 
tuberculosis  could  be  found  af- 
Jer  careful  clinical  examination. 
One  of  these  latter  patients  ha: 
the  disseminated  variety  o  f 
erythematous  lupus,  and  is  at 
present  having  night  sweats  fre- 
quently ;  however,  the  family  his- 
tory is  good,  and  the  patient  has 
no  physical  signs. 

The  other  case  is  on  the  bor- 
der line,  and  although  the  diag- 
nosis of  erythematous  lupus  has 
been  confirmed  by  consultation, 
it  is  quite  possible,  after  repeat- 
ed examinations,  to  class  it  in 
the  type  vulgaris. 

Psoriasis  was  selected  as  a 
control,  as  patients  afifected  with 
this  disease  are  usually  healthy 
otherwise ;  there  is  also  a  preva- 
lent opinion  that  psoriasis  pa- 
tients enjoy  some  degree  of  im- 
munity from  the  tubercle  bacil- 
lus ;  attention  has  been  directed 
to  this  point  by  Kingsbury  in  an 
article  on  the  Calmette  reaction. 
As  stated  in  the  table,  seven  of 
the  cases  were  negative,  and 
three  positive ;  of  the  latter,  one 
reacted  in  the  mild  degree,  the 
remaining  two  in  the  medium. 
All  three  patients  were  subjected 
to  a  thorough  physical  examina- 
tion. One  was  found  to  be  suf- 
fering from  incipient  phthisis  at 
both  apices  of  the  lungs,  and 
there  was  a  general  infiltration 
over  the  entire  left  lung.  The 
patient's  family  history  was  also 
very  bad,  both  parents  having 
died  of  consumption.  No  evi- 
dences of  disease  were  discov- 
ered in  the  other  two  positive 
cases,  and  no  explanation  can  be 
offered. 

The  syphilitic  cases  were  sub- 
jected to  the  test,  to  ascertain,  if  any  other  of 
the  group  of  infectious  granulomata  would  re- 
act; it  was  applied  in  the  primary,  secondary, 
and  tertiary  stages,  and  as  can  be  noted,  all 
gave  negative  results.  The  single  case  of  acne 
was  also  chosen  as  a  control,  for  the  reason 
that  she  appeared  perfectly  healthy  ;  the  reaction  was 


May  22,  1909.] 


TRIMBLE:  IXUXCTIOX  TUBERCULIN  REACTION. 


1037 


positive,  but  nothing  could  be  found  on  careful 
chest  examination.  A  very  little  dullness  and  a 
slight  increase  of  breath  sounds  could  be  detected 
over  the  right  ap§x,  but  these  are  generally  consid- 
ered normal  on  the  right  side.  Her  family  history 
was  tuberculous. 

The  idea  occurred,  that  probably  the  tuberculin 
ointment  itself  might  cause,  from  a  mechanical 
standpoint,  an  irritation  of  the  skin ;  so  it  was  de- 
cided to  investigate  the  test  in  a  different  mode : 
this  was  to  try  to  reproduce  the  positive  reaction 
with  some  kind  of  irritant.  In  pursuing  this  course, 
it  was  only  fair  to  use  the  irritant  in  ointment  form, 
and  also  to  have  it  of  the  same  strength  as  the  tu- 
bercuhn  salve.  Sulphur,  mercury,  and  chrysarobin 
were  selected :  Unguentum  sulphuris,  fifty  per 
cent.,  applied  to  three  patients ;  unguentum  hy- 
drargirum,  fifty  per  cent.,  applied  to  four  patients ; 
and  unguentum  chrysarobini,  fifty  per  cent.,  applied 
to  five  patients. 

Xo  effect  whatever  was  observed  after  gentl\- 
massaging  either  of  them  for  one 
minute  (the  same  time  required  for 
the  tuberculin  ointment)  ;  but  upon 
brisk  rubbing  for  at  least  five  min- 
utes a  dermatitis  was  produced.  The 
irritation  from  the  chrysarobin  was 
only  a  diffuse,  brilliant  redness,  the 
characteristic  chrysarobin  dermatitis ; 
the  reaction  from  the  sulphur  was 
also  diffuse,  but  much  milder.  The 
mercur^^  after  energetic  rubbing, 
brought  out  a  few  papules  in  one 
case,  but  the  -eruption  bore  no  resem- 
blance to  that  produced  by  the  tuber- 
culin salve.  In  a  number  of  the  cases, 
the  opposite  side  of  the  same  patient 
was  used  for  the  irritant  for  the  sake 
of  comparison,  and  in  a  few  inde- 
pendent cases  the  irritant  ointment 
alone  was  applied. 

Moro  has  observed,  in  a  few  in- 
stances, what  he  terms  a  "nervous  re- 
flex reaction,"  that  is,  occurring  at  a 
distant   point,    from   that  ori'^inally 
treated  with  the  ointment.  Alderson 
has  also  cited  one  case  in  which  a 
general   eruption    followed   an   intense   reaction ; 
this  patient  had  been  tested  with  the  von  Pirquet 
method  just  two  weeks  previously,  and  in  all  proba- 
bility sensitization  had  occurred. 

Xo  general  eruption  or  nervous  reflex  reaction 
has  ensued  in  any  of  the  cases  herein  reported,  and 
it  might  also  be  added,  that  no  systemic  reaction,  has 
been  noticed. 

The  reaction  is  supposed  to  be  due  to  the  defen- 
sive forces  of  the  body  exerting  their  activity  :  a 
brisk  reaction  indicating  that  the  patient  is  success- 
fully dealing  with  the  malady ;  a  very  mild,  or  no 
reaction,  representing  the  two  extremes ;  either  the 
patient  is  in  an  advanced  stage,  or  the  lesion  has 
healed  and  is  inactive ;  this,  according  to  the  opinion 
of  the  writer,  bears  some  weight  on  the  prognosis, 
although  other  observers,  working  with  the  ocular 
test,  hold  contrary  views,  stating  that  the  degree  of 
reaction  has  no  clinical  value. 

It  is  an  established  fact  that  tuberculosis  is  found 


in  the  autopsy  room  on  numerous  occasions,  where 
it  was  impossible  to  demonstrate  it  during  life ;  this 
might  explain  why  the  reaction  sometimes  occurs  in 
patients  who  are  apparently  healthy. 

The  negative  and  positive  phase  of  the  opsonic 
index  might  also  be  concerned  in  the  reaction ;  this 
explanation  might  suffice  for  those  advanced  cases 
that  fail  to  react ;  the  index  being  much  below  nor- 
mal, or  the  negative  phase  existing. 

COXCLUSIOXS. 

1.  The  test  is  not  absolutely  confirmatory,  but  is 
probably  just  as  much  so  as  the  Calmette. 

2.  According  to  the  literature,  the  inunction  test 
is  even  more  conclusive  than  the  von  Pirquet,  since 
it  gives  a  less  number  of  positive  reactions  in  ap- 
parently healthy  people. 

3.  A  positive  reaction  is  fairly  convincing  that  tu- 
berculosis exists  in  some  form ;  and  if  other  foci  can 
be  eliminated  by  clinical  examination,  the  skin  le- 
sion is  probably  responsible. 

4.  A  negative  reaction  does  not  preclude  tubercu- 


FlG.  3. — Moro  tuberculin  reaction,  third  degree. 

losis,  as  some  advanced  cases  and  also  a  few  with 
healed  lesions  fail  to  react ;  it  is,  however,  of  value 
in  cases  of  doubtful  diagnosis,  where  other  evi- 
dences of  tuberculosis  can  be  excluded ;  in  such  a 
contingency  it  would  be  fairly  reliable  evidence,  that 
the  skin  lesion  was  not  of  a  tuberculous  nature. 

5.  It  is  perfectly  harmless,  which  cannot  be  as- 
serted of  the  Calmette  test. 

6.  In  using  the  method  it  is  not  necessary  to 
break  the  skin,  thereby  opening  a  port  of  entrv  to 
possible  secondary  infection. 

7.  It  will  not  be  commonly  employed,  since  it  is 
fairly  easy,  as  a  rule,  to  make  the  diagnosis  of  cuta- 
neous tuberculosis  from  the  clinical  examination 
alone. 

8.  Although  this  test  is  not  absolutely  reliable,  it 
is  an  addition  to  our  diagnostic  armamentarium 
from  the  position  that  every  little  helps. 

The  greater  part  of  this  work  was  done  in  the 
Ford}  ce  Clinic  at  the  Xew  York  University,  but 


TOL'SEY:   ELECTRICITY   L\  GENITOURINARY  DISEASES. 


[New 
Medical 


VoRK 
JOVKNAL. 


some  valuable  cases  were"  recruited  from  the  Fox 
service  in  the  New  York  Skin  and  Cancer  Hospital. 
Thanks  are  due  to  Dr.  Broeman,  house  physician  of 
the  hospital,  for  assisting  me  in  keeping  accurate 
histories ;  and  also  to  Dr.  Aitken  and  Dr.  Mackee 
for  use  of  some  clinical  material. 
56  E.AST  Twenty-fifth  Street. 


ELECTRICITY   IN  GENITOURINARY  DISEASES* 

Bv  Sinclair  Tousey,  M.  D., 
New  York. 

Dr.  Rermingham  is  to  be  congratulated  upon  hav- 
ing covered  the  ground  of  electricity  in  genitouri- 
nary diseases  so  well,  and  it  is  a  pleasure  to  be  able 
to  corroborate  his  facts  and  conclusions.  Especially 
valuable  are  the  clear  distinction  drawn  between  the 
effects  of  the  positive  and  the  negative  poles  and  the 
technique  of  the  electrolytic  treatment  of  stricture 
and  gonorrhoea. 

Some  of  the  thoughts  called  up  by  the  doctor's 
paper  and  concerning  which  a  few  words  of  amplifi- 
cation may  not  be  amiss,  relate  to  the  use  of  the  x 
ray.  A  most  important  matter  is  its  use  with  safetv 
to  the  operator  and  the  patient.  The  danger  to  the 
operator  lies  in  the  fact  that  mild  exposures  repeated 
many  times  have  an  accumulative  efifect,  the  tragic 
seriousness  of  which  is  well  known  to  readers  of  the 


I'lr,.   I. — a  and  h.  Vesical  calculi  <if  tlic  consistence  of  inilly. 


(I'lily  p  ipers  as  well  as  of  the  ])r()fessi<)nal  journals. 
Anv  one  of  the  series  of  exposures  to  which  these 

*P,tVt  of  llie  discussion  of  a  paper  by  Dr.  Francis  Henry  Hcnning- 
Iiain.  Klcctricity  in  (lenitourinary  Diseases,  Brooklyn  Section  of  tlio 
■Medical  .Association  of  (Ireatcr  City  of  New  Voik,  Fchriiary  1,  igoq. 


scientists  have  succumbed  would  have  been  entirely 
devoid  of  perceptible  efifect  either  immediate  or  re- 
mote ;  and  even  the  efifect  of  the  entire  series  may 
be  insidious  in  its  onset.     Everv  one  has  looked  at 


I'lG.  2. —  Prostatic  calculus. 


the  bones  of  his  own  hand  as  a  matter  of  curiosity, 
and  knows  that  no  sensation  or  after  efifect  occurs 
from  such  an  exposure.  When,  however,  the  hand 
is  used  a  great  many  times  as  a  test  object  in  regu- 
lating the  intensity  and  quality  of  the  x  ray  the  oper- 
ator runs  the  greatest  risk  of  chronic  dermatitis  and 
cancer.  The  manufacturers  of  x  ray  apparatus  have 
encountered  this  danger  in  demonstrating  their  out- 
fits and  have  been  among  the  greatest  sufiferers  An- 
other insidious  efifect  upon  the  operator  is  that  of 
sterility,  and  this  may  occur  without  any  other  symp- 
tom. The  spermatozoa  are  reduced  in  number  or 
are  killed. 

Many  excellent  x  ray  operators  are  daily  exposing 
themselves  to  the  most  serious  consecjuences  by 
standing  near  the  naked  x  ray  tube  while  in  opera- 
tion. All  danger  may  be  avoided  only  by  the  oper- 
ator never  exposing  himself  to  the  direct  rays  and 
very  seldom  to  the  transmitted  rays.  An  excellent 
plan  is  to  have  the  different  switches  by  which  the 
current  is  controlled  in  a  separate  room,  so  that  the 
operator  is  protected  by  a  brick  wall  or  a  lead  lined 
partition.  If  the  operator  must  be  in  the  same  room 
the  x  rav  tube  should  be  completely  enclosed  in  a 
case  lined  with  le-id  oxide,  opaque  to  the  x  ray,  and 
provided  with  lead  glass  windows  through  which  the 
condition  of  the  tube  may  be  noted.  .A.  diaphragm 
of  adjustable  size  regulates  the  size  of  the  opening 
through  which  the  rays  may  be  directed  toward  the 
l)atient.  .\dditional  protection  always  employed  by 
the  author  is  aflforded  by  leadglass  spectacles,  lead 
lined  cap,  leaded  gloves  and  apron. 

Safety  to  the  i)atient  is  usually  easily  .secured. 
The  principal  elements  are  the  employment  of  ap- 
l)aratus  and  technique  which  will  give  a  good  picture 
with  an  amount  of  exposure  which  is  absolutely 
safe.  I  do  not  think  it  makes  nuich  difference  in 
the  matter  of  safety  whether  the  exposure  is  for  sev- 
eral minutes  with  a  moderate  current  or  for  a  few 


ilay  2..,        1  TOt  'SJ:)':   lilJiC'l' RIC IT Y   JX  GEXnOCRfX.lR)'  I>IS/-.ISI-:S.  IO39 


seconds  with  an  intensely  powerful  current.  Hut 
the  quality  of  the  ray  makes  all  the  difference  in  the 
world.  Some  years  ago  I  knew  of  a  case  in  w  hich  a 
certain  type  of  apparatus  and  strength  of  current 
that  I  knew  would  produce  a  good  kidney  picture  in 
three  and  a  half  minutes  was  apj)lied  for  six  minutes 
without  producing  a  picture.  Shortly  afterward  the 
operator  gave  another  exposure  of  sixteen  minutes. 
Again  there  was  no  image  on  the  plate,  but  there 
was  a  burn  with  extensive  sloughing  of  the  abdom- 
inal wall.  A  man  must  therefore  become  an  expert 
radiogra])her  in  order  to  make  these  difficult  exami- 
nations safely  and  well.  Only  the  portion  of  the  pa- 
tient under  examination  should  be  exposed  to  the  x 
rav,  and  nephritis  and  leuchaemia  sometimes  make 
even  this  limited  exposure  dangerous. 

A  case  which  may  be  of  interest  was  that  .of  Capt. 
\\'.,  aged  sixty-seven,  who  had  suffered  for  a  num- 
ber of  vears  apparently  from  prostatic  enlargement. 
He  was  confined  to  bed  a  large  part  of  the  time,  get- 
ting only  slight  relief  from  frequent  bladder  irriga- 
tions. Two  vears  before  I  saw  him  he  had  a  Bottini 
operation  during  which  the  prostate  was  slit  open  by 
a  galvanocautery  and  the  bladder  explored.  This  had 
not  produced  any  improvement.  The  radiogra]j]i 
(Fig.  i)  showed  two  large  calculi  in  the  bladder, and 
on  operation  these  proved  not  only  to  lie  covered  b\ 
folds  of  mucous  membrane  but  to  be  of  the  consist- 
ence of  jiutty.  The  x  ray  aiTorded  the  onl\-  practi- 
cable wav  of  discovering  them.  A  few  da\s  later 
the  captain  was  running  up  and  down  stairs,  and  a 
vear  later  he  rode  a  hundred  miles  on  horseback  in 
a  single  day. 

The  X  ray  has  a  curative  effect  in  pruritus  ani  and 
has  given  me_  wonderfully  successful  results  both  in 


I'iG.  3. — I'liiSLTtic  calculus  and  ri;lc  graduated  in  inches. 

cases  with  extensive  moist  eczema  and  in  the  dry 
noninflammatory  type. 

.\nother  interesting  case  was  that  of  a  patient  re- 
ferred bv  Dr.  J.  P.  ]\IcGowan,  with  a  history  of  dif- 
ficulty in  urinating  for  the  last  eight  years.  The  ra- 
diograph ("Fig.  j"!  showed  an  enormous  calculus  in 


the  prostrate,  and  this  had  l)een  successfully  re- 
moved (Fig.  3). 

Another  case  presents  an  interesting  question  in 
medical  ethics.  The  patient  had  suffered  from  typ- 
ical renal  calculus  symptoms,  but  thirteen  previous 
radiographs  made  in  this  coimtry  and  iMigland  had 
not  revealed  the  stone.    The  last  previous  radiog- 


l"ic.  4. — Renal  calculus  which  had  not  been  detected  in  thirteen 
previous  radiographs.  The  bottom  edge  of  calculus  is  just  two 
inches  above  crest  of  ilium. 


rapher  had  refused  to  allow  the  surgeon  to  see  the 
plate,  saying  that  he,  the  radiographer,  was  an  ex- 
pert in  the  interpretation  of  such  plates  and  that  the 
plate  showed  that  no  calculus  was  present.  A  sin- 
gle picture  (Fig.  4)  by  the  author  showed  a  large 
renal  calculus  with  h(5rnlike  projections.  The  pre- 
vious radiographer's  diagnosis  was  therefore  in- 
correct. 

The  consensus  of  opinion  among  radiographers  is 
that  they  are  employed  to  make  a  diagnosis,  not 
merely  a  jjicture.  Still  it  is  the  surgeon  upon  whom 
rests  the  responsibility  of  accepting  this  diagnosis 
and  either  performing  a  serious  operation  or  refus- 
ing to  give  the  patient  the  benefit  of  an  operation 
according  as  the  x  rav  findings  are  positive  or  nega- 
tive. It  seems  to  the  author,  therefore,  that  the  sur- 
geon has  a  right  to  see  the  picture  and  to  know  that 
it  is  a  good  one,  and  to  have  the  diagnostic  ])oints 
explained  to  him  before  he  stakes  his  patient's  life 
and  health  upon  it. 

I  am  not  the  only  one  to  report  successful  results 
ill  cases  of  prostatic  hypertrophy.  Xly  own  cases 
have  been  those  with  considerable  residual  urine  and 
frequent  and  difficult  micturition.  These  patients 
have  done  so  well  that  I  am  led  to  give  full  credence 
to  the  reports  of  other  operators  in  patients  who 
have  entered  upon  catheter  life  and  am  using  such 
treatment  in  a  case  recently  referred  to  me. 

In  a  case  of  tuberculosis  of  the  prostate  treated  in 
the  same  way,  the  x  ray  applications  proved  resolv- 
ent, causing  a  mass  of  exudate  to  break  down  into 


1040 


F AUGHT:  BLOOD  PRESSURE  AND  LIFE  INSURANCE. 


[New  York 
Medical  Journal. 


pus ;  while  high  frequency  currents  applied  from  an 
ultraviolet  ray  vacuum  electrode  in  the  rectum  were 
eliminant.  The  latter  action  caused  the  abscess  cav- 
ity to  contract  and  expel  its  contents  to  be  voided  in 
the  urine. 

Cases  of  cancer  of  the  prostate  treated  by  the  au- 
thor have  not  been  cured,  but  the  pain  and  tenesmus 
have  been  greatly  relieved,  the  urine  has  cleared  up 
to  some  extent,  and  life  has  been  prolonged. 

The  technique  employed  differs  according  to  cir- 
cumstances. In  case  of  cancer  and  hypertrophy  of 
the  prostate  the  x  ray  has  been  applied  from  an  ordi- 
nary X  ray  tube  in  a  localizing  shield  which  allows 
the  rays  to  shine  only  upon  the  perinaeum,  while  in 
tuberculous  cases  a  special  tube  has  been  introduced 
into  the  rectum  and  the  x  ray  has  been  generated 
almost  in  contact  with  the  diseased  tissues. 

59  West  Fortx-sixth  Street. 


BLOOD   PRESSURE   OBSERVATIONS   AND  LIFE 
INSURANCE.* 

By  Francis  Ashley  Faught,  M.  D., 
Philadelphia, 

Assistant  to  the  Professor  of  Clinical  Medicine,  and  Director  of  the 
•Laboratory  of  the  Department  of  Clinical  Medicine,  Medico- 
Chirurgical  College  and  Hospital. 

During  the  past  few  years  greatly  increased  in- 
terest has  been  taken  in  the  important  subject  of 
blood  pressure  and  the  methods  for  clinically  meas- 
uring it.  It  is  therefore  timely  to  consider  exactly 
what  is  implied  in  the  word  "blood  pressure"  as  at 
present  employed  by  physicians,  and  to  determine 
its  relation  to  physiological  and  pathological  teach- 
ing, and  finally  to  fix  if  possible  the  clinical  status 
of  the  observation. 

The  difficulty  which  presents  itself  when  diseases 
of  the  arterial  wall  are  considered  is  largely  due  to 
the  names  which  have  been  used  to  designate  the' 
conditions  met.  Thus  we  find  the  that  term  blood  pres- 
sure as  now  used  is  hopelessly  confounded  with  the 
terms  tone  and  tension,  despite  the  obvious  fact  that 
these  several  conditions  are  easily  separated  when 
the  true  sense  of  the  terms  are  understood.  Great 
confusion  arises  also  when  we  attempt  to  correlate 
clinical  observation  with  pathological  teaching  and 
the  terms  used.  In  illustration  of  this  it  is  only 
necessary  to  mention  the  fact  that  in  pathology  the 
term  atheroma  refers  to  a  distinct  and  well  recog- 
nized change  in  the  walls  of  vessels,  while  clinically 
it  is  commonly  applied  to  all  thickenings  of  arter- 
ies irrespective  of  the  origin,  location,  or  e.xtent. 
Thus  in  the  present  accepted  clinical  sense  the  terms 
arteriosclerosis  and  atheroma  are  identical  and  syn- 
onymous. In  Dr.  William  Osier's  Modern  Medicine 
we  find  the  following  definition  of  arteriosclerosis. 
(Osier's  Modern  Medicine,  Vol.  IV,  1908,  page 
429.)  "A  general  disease  of  the  arteries,  charac- 
terized in  the  small  vessels  by  thickening  of  all 
the  coats,  and  in  the  larger  by  gelatinous  swelling, 
necrosis,  fatty  degeneration,  and  calcification,  the 
process  to  which  the  name  atheroma  has  been 
given." 

It  is  further  generally  held  that  atheroma  neces- 

*Read  before  the  Philadelphia  Medical  Examiners'  Association. 
March  2,  1909. 


sarily  implies  rigid  arteries  with  loss  of  elasticity. 
Thus  thickened  arteries  are  spoken  of  as  atherom- 
atous arteries,  and  as  atheromatous  arteries  are  rigid 
then  all  thickened  arteries  must  be  rigid.  This  in 
the  light  of  pathological  evidence  is  very  far  from 
the  fact. 

With  the  exception  of  the  writings  of  a  few  recent 
investigators,  we  find  very  little  reference  to  that 
condition  of  the  arterial  system  which  is  the  result 
of  over  action  of  the  muscular  coats  of  the  vessels, 
to  which  the  name  hypertonus  or  hypertonic  con- 
traction has  been  given.  Before  considering  these 
several  conditions  and  the  relation  which  they  bear 
to  the  clinical  readings  of  blood  pressure  it  will  be 
necessary  to  fix  clearly  m  mind  the  correct  interpre- 
tation of  these  terms. 

According  to  Russell  (William  Russell,  Arterial 
Hypertonus,  Sclerosis  and  Blood  Pressure,  1908) 
atheroma  may  be  defined  as  a  focal  or  pathy  affec- 
tion of  arteries,  characterized  by  local  thickenings 
and  degeneration  in  the  intima.  A  condition  which 
does  not  involve  the  vessel  as  a  whole,  which  is  un- 
common in  the  smaller  and  superficial  arteries,  be- 
ing confined  usually  to  the  larger  vessels  and  the 
vessels  at  the  base  of  the  brain.  These  patches  of 
softening  may  later  undergo  calcareous  infiltration 
and  present  the  characteristic  bonelike  atheromatous 
plates. 

In  arteriosclerosis,  on  the  other  hand,  the  changes 
are  not  usually  confined  to  limited  areas  in  the  ves- 
sel walls,  as  in  atheroma,  but  involve  quite  uni- 
formly the  length  of  the  vessel.  The  alterations  are 
generally  distributed  throughout  the  body,  in  the 
coronary,  and  renal  arteries  for  example.  In  this 
condition  we  find  great  thickening  in  the  vessel  wall 
with  loss  of  elasticity,  the  wall  appearing  thicker 
and  the  lumen  of  the  vessel  reduced.  These  al- 
terations are  due  to  structural  changes  and  are 
therefore  permanent. 

A  hypertonic  vessel  is  one  whose  muscular  coat 
is  unduly  contracted.  As  the  direct  result  of  this 
contraction  the  vessels  appears  smaller,  its  wall  is 
thickened,  and  the  lumen  of  the  tube  reduced.  This 
change  is  due  to  excessive  contraction  of  the  cir- 
cular fibres  of  the  media  and  not  to  any  structural 
change  or  permanent  alteration  in  the  tissues  form- 
ing the  arterial  walls. 

To  the  palpating  finger  such  a  vessel  will  feel 
thicker  than  the  normal  artery.  The  degree  of  hard- 
ness varies  of  course  with  the  amount  of  muscular 
contraction.  This  condition  unless  understood  will 
frequently  be  mistaken  for  arteriosclerosis,  because 
the  change  is  uniform  in  the  vessel  as  far  as  it  can 
be  followed,  but  such  a  vessel  does  not  present  the 
tortuosity  of  the  vessel  of  astcriosclerosis. 

It  seems  evident  then  that  the  term  arteriosclerosis 
as  commonly  employed  among  clinicians  includes 
three  distinct  conditions:  i,  atheroma;  2,  arterio- 
sclerosis; and  3,  hypertonus  or  arterial  hyperten- 
sion. 

Unless  careful  examination  of  the  superficial  ves- 
sels is  made  in  an  effort  to  distinguish  hypertonus 
from  the  true  structural  change,  many  vessels  pre- 
senting typical  hypertonus  will  be  mistaken  for  ar- 
teriosclerosis and  so  reported.  In  this  connection 
it  must  not  be  forgotten  that  a  normal  degree  of 


May  22,  .909.J  I'.iL'GHJ :  BLOOD  PRESSURE  AND  LIFE  INSURANCE. 


tonicity  exists  which  may  vary  in  degree  within  nor- 
mal hmits.  What  is  important  and  practical  to 
know  is  that  such  normal  tonicity  does  exist  and 
that  is  may  vary,  and  to  be  able  to  determine  when 
this  tonicity  exceeds  normal  and  becomes  hyper- 
tonic contraction. 

Hypertonus  would  appear  to  be  very  important 


I'lG.    I. — Showing  instrument  packed   for  transportation,   lid  partly 
closed. 

from  a  clinical  standpoint,  for  the  modern  life  of 
the  average  successful  business  man  is  very  con- 
ducive to  the  occurrence  of  this  condition,  through 
constant  high  nervous  tension,  alteration  in  the  con- 
dition and  composition  of  the  blood  through  defec- 
tive hygiene,  coupled  frequently  with  excessive  use 
of  tobacco. 

In  close  relation  to  the  condition  of  hypertonic 
contraction,  is  that  bone  of  contention  praesclerosis. 
The  term  praesclerosis  was  introduced  by  Huchard 
to  indicate  a  condition  of  the  blood  vessels  supposed 
to  precede  arteriosclerosis.  By  this  he  meant  a  pe- 
riod during  which  there  was  continuously  maintain- 
ed an  elevation  in  blood  pressure.  While  authorities 
are  divided  as  to  the  possibility  of  such  a  condition, 
it  seems  to  me  reasonable  to  conclude  that  the  pres- 
ence of  toxic  substances  in  the  blood  (whether  of 
syphilitic  origin  or  not)  may  directly  cause  contrac- 
tion of  the  muscular  coat  of  the  vessels,  a  condition  of 
more  or  less  permanent  arterial  spasm  results,  caus- 
ing a  moderate  rise  in  blood  pressure  perhaps  as  high 
as  150  or  160  mm.  Hg.  The  long  continued  action 
of  this  pressure  gradually  induces  structural  change 
in  the  vessel  walls  as  the  direct  effort  of  nature  to 
cope  with  the  increased  pressure.  The  rapidity  of 
progress  and  degree  of  this  change  depending  on 
the  degree  of  pressure  and  the  length  of  time  during 
which  it  acts,  possibly  also  upon  the  nature  of  the 
excitant ;  for  it  is  well  known  that  a  mere  rise  in 
blood  pressure  even  if  continued  does  not  necessarily 
cause  structural  change  in  the  vessel  walls.  It  is 
evident  then,  that  although  hypertonus  may  be  a 
precursor  of  arteriosclerosis,  and  should  therefore 
be  given  careful  consideration  at  the  hands  of  the 
examiner,  arteriosclerosis  need  not  necessarily  fol- 
low hypertonus. 

The  actual  blood  pressure  at  any  given  time  is 
determined  by  several  factors,  chief  among  which 
are:  The  driving  power  of  the  heart,  particularly 
the  left  ventricle;  the  condition  (the  lumen)  of  the 
channels  through  which  the  bloods  flows ;  and  the 
condition  of  the  flowing  blood. 


1041 

The  factor  of  the  condition  of  the  vessel  wall  is 
determined  partly  by  the  state  of  muscular  contrac- 
tion of  the  muscular  coat,  and  partly  by  the  pres- 
ence or  absence  of  structural  changes  in  the  arterial 
wall.  Omitting  the  possible  factor  of  the  amount 
and  condition  of  the  tissues  between  the  vessel  and 
the  instrument  or  fingers  of  the  observer  (experi- 
ment has  shown  this  factor  to  be  negligible),  we 
have  remaining  two  distinct  factors  which  go  to 
make  up  what  is  commonly  considered  as  blood 
pressure.  The  actual  pressure  of  the  blood  within 
the  vessel,  as  would  be  shown  by  a  cannula  and 
manometer,  and  the  resistance  offered  by  the  vessel 
wall.  Our  ability  as  clinicians  in  the  study  of  the 
pulse  will  depend  on  our  ability  to  separate  these 
two  factors  and  appreciate  the  individual  bearing 
of  each  upon  the  condition  of  the  subject  under  ob- 
servation. In  the  clinical  examination  of  blood  pres- 
sure we  must  then  constantly  bear  in  mind,  besides 
the  sensation  caused  by  the  actual  pressure  of  the 
blood,  the  tactile  sensation  conveyed  by  the  normal 
vessel  wall.  We  will  then  be  able  to  appreciate  the 
sensation  caused  by  excessive  muscular  contraction 
or  hypertonus.  We  also  must  be  able  to  appreciate 
the  tactile  sensation  conveyed  by  actual  anatomical 
change;  these  may  include  atheroma  (rarely),  cal- 
carious  infiltration,  and  arteriosclerosis. 

A  knowledge  of  and  careful  study  of  these  con- 
ditions will  undoubtedly  develop  a  tactile  sense 
which  can  distinguish  between  these  changes  in  the 
vessel  walls,  although  the  possibility  of  accurate 
and  unfailing  estimation  of  actual  blood  pressure 
with  the  finger  is  extremely  doubtful. 

Owing  to  the  difficulties  and  uncertainty  exist- 
ing in  the  tactile  study  of  tension,  etc.,  the  sphyg- 
momanometer has  recently  come  to  the  front  as  a 
means  of  actually  measuring  and  clinically  record- 
ing blood  pressure.  That  any  such  instrument  does 
actually  measure  the  pressure  within  the  vessel  in 
all  cases,  and  that  the  enormous  readings  obtained 


Fig.  2. — A,  Mercury  guard  cocks;  B,  release  valve;  C,  nipple  and 
cock  for  bellows;  D,  nipple  for  tube  from  armband. 

in  certain  disease,  notably  nephritis,  represents  ac- 
tual blood  pressure,  I  do  not  believe.  For  it  is  in- 
conceivable that  any  heart,  especially  one  the  seat 
of  muscular  degeneration,  could  exert  the  enormous 
force  required  to  elevate  blood  pressure  to  two  or 
three  times  that  sustained  by  the  normal  heart. 
Even  were  such  a  thing  possible,  where  is  the  ar- 


I042 


r AUGHT:  BLOOD  PRESSURE  AND  LIhk  INSURANCE. 


[New  YriKK 
Mkihcal  Jol;knai.. 


terv.  the  subject  of  rtbrcul  degeneration,  that  could 
for  a  moment  withstand  the  enormous  increase  in 
pressure  ? 

The  sphygmomanometer  rea(Hno-  probably  indi- 
cates actual  blood  pressure  only  in  normal  soft  and 
perfectly  elastic  vessels  ;  under  these  conditions  the 
readings  will  vary  between  from  no  and  130  mm. 
Hg.  This  reading  will  be  influenced  slightly  by 
age,  exercise,  digestion,  and  time  of  day.  Palpa- 
tion of  such  a  vessel  will  be  almost  impossible  when 
the  blood  stream  is  stojiped  above  the  paliMtating 
hand. 

In  the  presence  of  hypertonic  contraction  the 
vessel  wall  becomes  a  factor  and  the  reading  is 
then  made  up  of  a  composite  factor  representing 
partly  blood  pressure  and  partly  resistance  of  th.^ 
vessel  wall.  The  sphygmomanometer  reading  will 
now  range  between  from  130  and  150  mm.  Hg.  or 
even  higher.  Constriction  above  the  pal];ating 
hand  will  not  cause  the  artery  to  become  lost. 
Such  a  vessel  will  f.el  snial'er  and  thicker  than 


Fk;.    j, — I ii*truinciit    "set    up"    and    ix-ady    for   blood    iircssuve  observation. 


iKjrmal  but  will  not  present  nodtdes  or  tortuosity 
along  the  length  of  the  vessel. 

In  true  atheroma  (not  difi'tise  arteriosclerosis) 
the  sphygmomanometer  reading  will  rarely  be  ef- 
fected unless  there  be  coincident  hypertomts  and 
arteriosclerosis  Palpation  of  such  a  vessel  will  not, 
as  a  rule,  furnish  additional  evidence,  since  this 
condition  rarely  appears  in  the  superficial  vessels, 
except  possibly  in  the  aged. 

In  arteriosclerosis,  owing  to  the  general  involve- 
ment of  the  arterial  tree,  the  vessel  wall  factor  is 
especially  prominent.  Palpation  will  reve-il  hard 
and  fibrous  vessels,  which  owing  to  their  elonga- 
tion incident  to  loss  of  elasticity,  will  be  found  to 
be  tortuous.  The  narrowing  in  tlie  lumen  of  the 
vessel  and  the  thickening  and  hardening  of  the  ves- 
sel wall  will  offer  great  resistance  to  the  constrict- 
ing band  of  the  sphygmomanometer,  ami  the  read- 
ings will  therefore  i)e  high.  The  readings  begin- 
ing  at  about  160  mm.  I  Ig..  will  run  up  to  300  and 
above.  Here  with  a  reading  of  300  or  mcire  it 
may  be  had  in  spite  of  marked  evidence  of  dilata- 
tion and  muscular  degeneration  of  the  heart. 

To  me  this  has  a  most  important  bearing  upon 


the  examination  of  a  life  insurance  risk,  and  makes 
the  usual  run  of  questions  upon  the  examination 
form  wholly  inadequate.  The  answers  that  are  al- 
most uniformly  asked  cannot  convey  to  the  medical 
director  the  information  that  he  should  have.  Many 
questions  are  altogether  too  vague,  and  offer  but 
uncertain  guides  to  the  examining  physician,  often 
admitting  of  ambiguous  if  not  actually  incorrect  in- 
formation 

For  examjjle,  the  Prudential  asks:  Is  there  anv 
abnormality  of  the  heart  or  blood  vessels?  Is  the 
pulse  irregular  or  intermittant? 

The  Economic  asks :  Are  the  heart  sounds  nor- 
mal ?  Is  there  any  evidence  of  disease  of  the  heart 
or  blood  vessels?  Is  the  pulse  regular  or  irregular 
and  normal  in  qtiality  and  tension  ? 

The  Union  Central  asks :    Is  there  any  evidence 
of  disease  of  the  heart  or  blood  vessels?    Is  there 
any  evidence  of  arteriosclerosis,  if  so  to  what  ex- 
tent ?    Is  there  evidence  of  high  arterial  tension  ? 
The  .American  Central  asks:    Is  the   pulse  of 
high,    meditmi.    or    low  tension.'' 
\\  hat  evidence  of  atheroma  or  aneu- 
rysm ? 

The  Penn  Mutual  asks :  Is  there 
any  atheroma  of  the  radial  arteries? 
What  is  the  character  of  the  pu'ses 
as  to  fulness,  compressibility,  and 
strength  ? 

I  take  these  to  be  fair  examples 
of  the  general  character  of  the  qties- 
tions  tisually  asked.  These,  as  they 
stand,  overlook  almost  completely 
the  finer  and  important  details  which 
our  present  knowledge  of  diseases 
of  the  cardiovascular  system  permit 
us  to  determine,  and  which  should 
l)lay  an  important  part  in  the  selec- 
tion of  risks. 

To  be  sure  gross  lesions  of  the 
heart  and  blood  vessels  are  discov- 
erable with  comparative  ease  and 
will  hardly  be  overlooked  even  dur- 
ing the  most  superficial  examina- 
tion. .\  gross  valvular  defect,  or  high  grade  arterio- 
sclerosis, could  hardly  pass  unnoticed :  on  the  other 
hand.  I  feel  certain  that  many  applicants,  who  arc 
rcall}'  good  risks,  are  rejected  because  of  an  inade- 
quate ajjpreciation  of  the  dift'erence  between  vessel 
contraction  and  vessel  disease,  wdiich  necessarily  re- 
stdts  in  a  too  frequent  diagnosis  of  arteriosclerosis. 

Finally,  it  is  of  utmost  importance  to  remember 
that  feeling  the  radial  pulse  is  not  always  a  reliable 
guide  as  to  what  the  instrumental  reading  will  be. 
Cases  have  come  under  observation  in  which  the 
reading  of  the  sphygmomanometer  was  above  200 
mm.  Ilg..  while  the  vessel  felt  neither  hard  nor  in- 
compressible. On  the  other  hand,  the  reading  of 
the  pressure  may  be  lower  than  |)aIi)ation  of  the  ves- 
sel would  suggest. 

Siiimuary. 

1.  Recent  increase  in  clinical  data,  which  is  the 
result  of  finer  methods  of  observation,  demand 
greater  recognition  bv  the  practising  physician  and 
the  medical  examiner. 

2.  To  facilitate  a  better  understanding  of  the 
conditions  met,  more  care  should  be  exercised  in 
the  employment  of  clinical  terms. 


May         1909. J 


BARTHOLOIV :  ALLYL  COMPOUNDS. 


1043 


3.  More  careful  study  should  be  made  of  the 
vessels  in  an  effort  to  distinguish  atheroma,  hyper- 
tension, •  and  arteriosclerosis. 

4.  The  sphygmomanometer  is  a  valuable  aid  in 
determining  arterial  tension,  and  in  differentiating 
diseases  of  the  cardiovascular  system. 

5.  Our  present  knowledge  of  the  subject  of  dis- 
eases of  the  circulatory  apparatus  demands  a  crit- 
ical revision  of  the  present  exmination  questions 
to  be  answered  bv  the  life  insurance  examiner. 

Description  of  the  Faii-^hf  S pliygmoDtaiiometer. 
This  instrument  is  a  modification  of  the  Janeway 
apparatus  and  is  at  once  accurate,  durable,  compact, 
and  portable. 

The  mahogany  case  which  encloses  the  complete 
apparatus  measures  16x4x4^/2  inches  and  weighs 
3  pounds,  9  ounces.  The  lid  is  hinged  at  one  end 
and  when  raised  supports  all  the  working  parts  of 
the  instrument  (see  Fig.  i).  A  spring  check  allows 
the  lid  to  be  raised  only  into  the  vertical  position 
where  it  is  automatically  locked  during  the  observa- 
tion. 

All  parts  of  the  instrument  are  of  nickelled  brass 
with  the  exception  of  the  glass  manometer  tube. 
Between  the  arms  of  the  U  tube  is  the  scale  which 
is  arranged  to  give  the  readings  directly  in  milli- 
metres of  mercury.  For  convenience  the  average 
normal  systolic  reading  of  120  mm.  Hg.  is  stamp- 
ed in  red. 

A  special  and  distinctive  feature  of  this  appara- 
tus is  the  means  of  guarding  and  preventing  the 
loss  of  the  mercury  in  the  manometer  tube.  This 
is  accomplished  by  two  small  cocks  (see  Fig.  2,a) 
placed  one  upon  each  arm  of  the  manometer  tube. 
These  are  kept  closed  except  during  the  operation 
of  the  instrument.  The  possibility  of  closing  the 
case  while  these  cocks  are  open  is  guarded  against 
by  making  it  impossible  to  close  the  lid  while  they 
are  in  the  open  position. 

Figure  3  gives  a  general  idea  of  the  instrument 
as  it  should  be  adjusted  to  the  arm  of  the  patient 
during  the  observation. 

In  figure  2,b,  is  an  escape  valve  to  gradually  re- 
lease the  pressure  while  determining  the  diastolic 
reading.  The  nipple  at  c  is  supplied  with  a  stop 
cock,  and  serves  for  attachment  of  the  tube  from 
the  hand  bellows.  This,  as  soon  as  a  pressure  has 
been  reached  that  obliterates  the  artery,  is  closed 
to  eliminate  all  elasticity  from  the  pneumatic  sys- 
tem which  is  so  essential  to  a  diastolic  reading. 

The  second  nipple  at  d  is  for  the  tube  emerging 
from  the  cuff  and  serves  to  connect  it  to  the  man- 
ometer. 

By  the  elimination  of  all  detachable  parts  the 
time  required  to  make  the  observation  is  reduced 
to  a  minimum.  The  only  preliminary  step  to  t^re 
test  being  the  raising  of  the  lid  of  the  case,  open- 
ing the  three  cocks,  and  attaching  the  tube  from 
the  cuff  to  its  respective  nipple. 

The  small  bore  of  the  U  tube  eliminates  a  large 
mass  of  mercury  thereby  reducing  its  inertia  and 
thus  facilitating  the  diastolic  reading. 

This  instrument  has  given  great  satisfaction  to 
a  number  of  observers  during  the  past  few  months 
and  has  proved  a  great  time  saver  as  compared  with 
other  forms  of  sphygmomanometer. 

5231  B.VLTiMORE  Avenue. 


THE  ALLYL  COMPOUNDS.  OR  THE  ETHEREAL 
OIL  OF  GARLIC: 

Being  an  I ntroduction  to  u  Furtlicr  Rcf>ort  on  the  I'sc  of 
Allyl  Sulphide  in  Tubereulosis. 

By  Paul  Bautholow,  M.  D., 
New  York, 

Assistant  Physician,  Mount  Sinai  Hospital,  Tulitrculosis  Clinic. 

Garlic  may  be  treated  deductively,  that  is,  in  rela- 
tion to  science  (in  which  case  it  is  of  great  and  even 
unguessed  importance)  ;  or  critically,  by  a  mode  of 
oblique  research  into  a  miscellaneous  literature. 
"Miscellaneous"  is  perhaps  too  soft  a  word.  "Mud- 
dled" is  better  suited  to  describe  so  wretched  a  dis- 
play. This  literature  I  shall  abridge  as  much  as 
possible,  but  an  exact  account  of  it  is  necessary  to 
my  purpose. 

Hippocrates,  as  may  well  be  imagined,  fathomed 
the  virtues  of  allium,  which  he  honors  with  a  mem- 
orial in  at  least  three  different  parts  of  his  Medi- 
cine;  and  in  a  fourth,  ascribed  to  him  by  an  un- 
known author.  "Garlic  is  reputed  an  antidote  to 
poison  and  a  sympathetic  preservative  against  dis- 
ease {allium  ad  aiuulcta  et  reincdia  alexipharmaca) . 
Again,  in  his  genuine  writings,  we  find  that  "the 
bulbs  of  garlic,  of  the  garden  kind,  when  boiled  and 
roasted,  are  diuretics  and   purgatives" — kay/vM,>-^  iVz 

T'l  rT/.<ipii<^(j.   y.ai   Ltftla    xai    o~ra   xai    (hnu/irjZixu  /.a)   \it.i  - 

yi»f,riTi/.d  {Opera  omnia,  ed.  Kiihn,  II,  422) — as  to 
which  he  makes  this  commentary  that  "they  should 
not  be  given  to  the  weak"  roiiri,'   aiT(is-A<"jr7'.  jiii 

-fHiatfifisv,.,  since,  "they  cause  fever  and  diarrhoea 
through  the  effect  of  their  acrid  juice"  •(■'>!' 

dfniv'm,za    ti\><i.    -Hjiiyti^   ojfrrs    otayut/jisi'^,    though  the 

"leek  is  less  heating,"  -paaw  Oepiiahsi  fihj  r)<TtT(iv. 
Others,  besides  Hippocrates,  have  taken  an  interest 
in  garlic.  The  opinions  of  antiquity  were  collected 
by  Wedelius  {i),  Emhardus  (2),  and  Haller  (3). 
who  in  two  places  speaks  of  its  value  in  pulmomry 
diseases  {ad  inorbos  pectoris  laiidat,  D.  Bowles)  — 
to  which  he  might  have  added  \'an  Helmont — and 
in  struma  (p.  26).  In  more  recent  times,  garlic  has 
been  treated  with  misplaced  levity  by  Saint-Olive, 
who  retouches  the  subject  with  an  apparent  anxiety 
for  its  humorous  effect  (4).  He  cites  the  remarkable 
passage  from  Pliny  (Hisforia  naturalis.  XX,  23 — 
"extenuat  phfliisin  i)i  fabcc  sorbitioiie" — it  lessens 
phthisis  in  a  bouillon  of  beans — an  idea  that  may 
perhaps  have  started  the  uisus  of  Cuguillere's 
serum. 

In  the  literature  of  modern  science,  a  circumstan- 
tial account  of  garlic  is  given  by  Casella,  with  a  par- 
ticular description  of  the  work  of  Italian  laborato- 
ries (6).  In  his  experiments,  he  used  two  forms  of 
garlic  juice — sncco  di  aglio  a  and  siicco  di  aglio  b~ 
making  the  almost  universal  blunder  of  supposing 
the  oil  of  the  bulbs  to  be  the  same  as  allyl  sulphide. 
As  to  its  synthesis,  he  says:  "In  1856,  the  sulphide 
of  allyl  was  artificially  obtained  by  Cahours  and 
Hoffmann.  Allyl  iodide  is  added  drop  by  drop  to  a 
concentrated  solution  in  alcohol  of  potassium  sul- 
phide. The  reaction,  which  takes  place  violently 
(mnlta  encrs^ica),  follows:  2  CsHsI  +  K-.S  =  KI + 
(CHOP'S." 

Great  misconceptions  have  always  prevailed  about 
allyl  sulphide,  and  here  is  one.     For,  Wertheim  in 


I044 


BARTHOLOW:  ALLYL  COMPOUNDS. 


[New 
Medical 


York 
Journal. 


1844,  discovered  not  only  allyl  sulphide  but  the  tri- 
hydric  alcohol  radical  allyl,  and  gave  it  its  name 
(7).  He  drew  a  distinction,  which  few  have  since 
preserved,  between  the  oil  of  garlic  quantum  the 
juice,  and  the  purified,  or  rectified  oil,  in  which  he 
really  did  find  the  compound  of  allyl  and  sulphur 
known  as  allyl  sulphide.  In  1892,  Semmler  tried  to 
amend  this  analysis  of  Wertheim's,  asserting  that 
the  raw  oil  of  garlic  (Rohdl)  which  he  derived  from 
the  best  material  at  hand  (welches  mir  vorlag)  con- 
tained not  "a  trace  of  allyl  sulphide"  (8).  These 
are  seemingly  opposite  views.  But  the  correction 
that  Semmler  makes  will  be  found  superfluous  when 
a  close  comparison  of  the  original  papers  is  made. 
For,  as  he  says  himself,  he  found  it  impossible  to  ob- 
tain the  oil  that  ^^'ertheim  used, — an  oil,  colorless 
and  lighter  than  water,  and  produced  by  distilling 
the  raw  substance  over  a  bath  of  sodium  chloride, 
"without  causing  the  liquid  to  boil"  (ohne  dass  die 
Fliissigkeit  sum  Siedcn  koiuint").  The  distinction 
between  the  purified  oil  thus  obtained  and  the  raw 
oil  is  (in  Wertheim's  own  terms)  that  the  pure  oil  is 
not  "decomposed  by  boiling"  {das  so  gereinigte 
Oel  ist  zum  Unterschiede  von  dem  rohen  Icichter  als 
Wasscr  und  wird  heim  Sieden  nicht  cerstort). 
Semmler,  on  the  other  hand,  obtained  by  fractional 
distillation,  several  oils,  of  dififerent  boiling  points. 
In  the  first  fraction,  he  found  allyl  propyl  disulphide 
or  GHi^S. ;  in  the  second  and  third  fractions,  h'gh- 
er  .sulphides,  CiHi"S=,  and  GHioS^,  and  so  on,  but 
the  ratio  of  carbon  and  hydrogen  in  the  radical  be- 
ing always  3  :5. 

By  the  mere  light  of  reason,  it  seems  difficult  to 
prove  anything  from  Semmler's  studies ;  his  argu- 
ments are  apparently  meant  to  refute  some  fancied 
contention  of  Wertheim's  rather  than  to  reconcile 
two  separable  methods.  The  question  respecting  the 
existence  of  allyl  sulphide  in  the  "rectified"  oil  of 
Wertheim  is  not  settled  by  Semmler's  saying  that 
he  was  unable  to  find  it  in  the  raw  oil.  It  appears  to 
me  that  the  two  writers  are  in  substantial  harmony, 
the  purified  oil  of  Wertheim  being  identical  with  the 
true  allyl  sulphide,  which  Semmler  found,  not  in  his 
raw  oil,  but  in  the  synthesis  of  C  :  H  =  3  :  5  +  S,. 
The  real  allyl  sulphide,  concerning  which  so  many 
erroneous  assertions  have  been  made,  he  thus  de- 
scribes:  "Chemically  pure  allyl  sulphide  is  a  color- 
less oil,  whose  specific  gravity  at  16°  C.  is  0,8991, 
and  whose  boiling  point  at  15  millimetres  is  from 
36-38°  C."  (9),  (^10). 

In  its  activities,  both  physiological  and  upon  bac- 
teria, allyl  sulphide  is  a  powerful  substance.  As  re- 
gards its  attributes,  a.  strange  mistake  is  made  by  a 
writer  in  the  Medical  Record  (11),  who  pronounce^ 
it  "inert."  Such  an  error  ought  to  be  impossible 
since  the  publication  of  the  excellent  studies  of  Car- 
lier  and  Evans,  which  leave  no  doubt  as  to  its 
strength  (12).  Their  paper,  though  confined  to  an 
exposition  of  the  physiological  effects  of  the  syn- 
thetic oil,  seems  to  me,  after  exhaustive  reading, 
the  best ;  both  as  regards  its  primary  purjiosc  as  a 
statement  of  facts,  and  for  its  method,  which  is 
brief,  perspicuous,  unelaborate.  .\  few  words  (  nly 
are  needed  to  interpret  their  results.  Allyl  sulphide 
then  is  not  the  neutral  substance  that  may  be  sup- 
posed.    It  is  far  different ;  being  expansive  in  its 


energy  and  definite  in  its  action ;  a  few  minims  apply 
a  stimulus  to  the  vasomotor  centre,  cause  a  fall  of 
blood  pressure,  and  lessen  the  amplitude  of  the 
breathing  arc.  Two  other  effects  of  great  impor- 
tance remain,  it  is  excreted  by  the  lungs, — and  it 
has  the  power  of  producing  immunity  to  itself. 
"After  the  effects  of  a  nonlethal  dose  have  passed 
ofif,  the  animal  is  iqimunized  for  a  time  against  a 
similar  and  larger  dose." 

Studies,  asserted  to  be  tests  of  the  power  of  allyl 
sulphide  over  the  fission  fungi,  but  in  reality  nothing 
more  than  hasty  glimpses  of  the  effects  of  some 
emulsion,  solution,  or  "essence"  (Saft,  siicco,  Es- 
senc),  have  been  published  by  Casella,  Ingianni,  Ca- 
vazzani,  and  Kathe  (13).  All  four  fall  into  th.e 
error,  which  Gildemeister  and  Hoffmann  rightly  say 
has  passed  into  all  the  textbooks  (in  allc  Lehr- 
bilchcr  iibcrgegangen)  of  thinking  that  the  juice  of 
garlic  stands  in  some  fixed  relation  to  allyl  sulphide 

(14)  .  But  even  the  reports  of  these  authors,  upon 
even  their  mixed  substance,  with  its  incongruent  in- 
ternal economy,  lead  to  the  conclusion  that  in  the 
ethereal  oil  of  garlic  there  exists  an  agent  that 
strongly  inhibits  bacteria.  So  much  may  even  be  as- 
sumed of  any  ethereal  oil,  a  fact  clearly  determined 
by  many,  and  among  others,  by  Koch  (15). 

His  authority  has  been  cited  by  Poore  {Nervous 
Affections  of  the  Hand  and  Other  Studies,  1897,  p. 
275)  and  Minshin  {The  Lancet,  1904,  I,  p.  482). 
With  regard  to  two  different  but  cognate  substances 
allyl  alcohol  and  mustard  oil,  Poore  writes :  "The 
allyl  compounds,  such  as  allylic  alcohol  and  oil  of 
mustard,  were  shown  by  Koch  to  be  strongly  anti- 
septic and  to  have  a  remarkable  power  of  inhibiting 
the  growth  of  bacillus  anthracis."  This  is  ascrib- 
ing to  Koch  more  than  he  probably  intended.  The 
effects  of  allyl  alcohol  and  oil  of  mustard  on  anthrax 
spores,  he  tested  by  the  silk  thread  method.  The 
threads  were  dipped  in  six  tubes  containing  respec- 
tively, I,  2,  3,  4,  5,  6,  drops  of  pure  allyl  alcohol 
A  seventh  tube  was  prepared  to  check  the  results 
which,  he  tells  us  himself,  v^'ere  not  unequivocal. 
Hence,  his  language  may  appear  ambiguous:  "In 
none  of  the  tubes  did  there  occur  even  a  trace  that 
could  show  the  development  of  anthrax  spores"  (/;/ 
keineni  der  Gefdsse  zeigte  sich  audi  nur  erne  Spin 
von  Entivickehing  der  Mihbrandsporen) .  As  to 
allyl  sulphide,  he  mentions  it  but  once,  and  then  more 
or  less  picturesquely  in  a  letter  from  South  Africa. 
{Deutsche    medicinische    Wochenschrift,  1897), 

(15)  -. 

It  is  chiefly  in  these  links  of  connection,  such  as, 
for  instance,  exist  between  allyl  alcohol  and  oil 
of  mustard,  that  the  allyl  scries  become  interesting, 
that  is,  in  their  manifold  relations  and  the  mode  of 
their  evolution  from  each  other,  and  in  the  different 
agencies  that  thus  arise ;  and.  viewed  in  this  man- 
ner, the  evidence  is  constant  that  allyl  sulphide 
stands  almost  midway  between  two  groups,  both  of 
which  are  powerfully  antagonistic  to  the  vegetable 
cell — the  group  of  alcohols  represented  by  the  rad- 
ical allyl,  and  the  grou])  of  mineral  acids  represent- 
ed by  sulphuric  acid,  which,  as  von  Bunge  writes  in 
his  discussion  of  this  obscure  subject,  "destroy  all 
forms  of  life."  The  radical  allyl  is,  in  fact,  the  key 
to  many  derivatives  of  exquisitely  complex  structure 


May  22,  1909.] 


BARTHOLOW :  ALLYL  COMPOUNDS. 


1045 


— to  allyl  sulphide  for  instance,  though  it  is  an  open 
question  whether  this  exists  preformed  in  the  oil 
of  garlic  bulbs,  or  whether  it  is  not,  after  all,  a  pro- 
duct of  the  action  of  two  organic  substances  that  do 
exist  there,  of  myronic  acid  in  the  form  of  potassium 
myronate  and  the  ferment — my  rosin. 

And  what  are  the  other  affinities  of  this  casual 
nexus  between  two  such  opposite  agencies  as  a  free 
mineral  acid  (H^SO*).  and  a  ferment,  myrosin? 
"("asual"  because  not  impressed  with  certainty  and 
fixed  science  (cf.  v.  Bunge,  Lclirbuch  dcr  Physiol- 
ogic, II,  p.  202).  If  we  seek  these  from  the  formal 
teachers  of  chemistry,  our  perplexity  is  not  much 
relieved.  All,  or  nearly  all,  agree  that  the  oils  of 
garlic  and  of  mustard,  as  well  as  of  asafcetida,  con- 
tain homologous  allyl  radicals.  But  when  we  at- 
tempt to  trace  the  intercalations  of  this  series,  we 
find  our  authors  vague  and  indefinite,  if  not  contra- 
dictory. Waiving  many  others,  I  shall  cite  Wurtz, 
according  to  whom  the  radical  allyl  (which  does  not 
exist  in  the  free  state)  was  obtained  in  1856  by 
pjerthelot  and  S.  da  Luca  (Coiiiptcs  rcndiis,  1864, 
serie  I,  58,  p.  460).  His  words  are:  "One  knows 
that  in  1856  MM.  Berthelot  and  S.  da  Luca  obtained 
by  treating  allyl  iodide  with  sodium  a  hydrocarbon 
which  they  designated  by  the  name  of  allyl."  Con- 
trast this  with  what  the  real  discoverer,  Wertheim 
says,  and  we  shall  see  what  the  statement  is  worth : 
"To  the  group,  CHs  belong  all  the  signs  of  an  or- 
ganic radical ;  I  propose  for  this  radical  the  name 
Allyl  =  All  vor."  If  now,  we  consult  the  original 
paper  of  Berthelot  we  find  that  "glycerin  treated 
with  the  iodide  of  phosphorus  gives  rise  to  propy- 
lene iodide,  CHsI.  Accordingly,  the  formula  of 
the  essense  of-  garlic  GHsS  differs  from  that  of 
propylene  iodide  in  that  it  contains  sulphur  in  place 
of  iodine.  It  suffices,  therefore,  according  to  these 
reactions,  simply  to  effect  this  substitution,  and  then 
by  combining  the  product  with  isosulphocyanic  acid 
to  obtain  the  essence  of  mustard."  According  to 
Semmler,  the  terms  of  this  reaction  may  be  trans- 
posed as  in  an  equation,  mustard  oil  being  converted 
into  oil  of  garlic ;  oil  of  garlic  in  turn  being  con- 
verted into  oil  of  mustard.  We  may  here  conclude 
from  analogy  that  the  allyl  compounds  in  oil  of 
garlic  and  oil  of  mustard  form  compounds  with  the 
sulphides  of  asafcetida  and  with  the  acetylene  series, 
or  tetravalent  alcohols.  Such  is  the  opinion  of 
Semmler,  while  De  Fleury  is  equally  satisfied  that 
G:H2i,  the  eleventh  term  of  the  acetylene  series,  is 
the  carbohydride  of  asafcetida.  Here  are  two  views, 
to  which  we  may  add  a  third,  that  of  Rohmann, 
who,  after  showing  that  in  AUiaria  officinalis,  oil  of 
garlic  and  oil  of  mustard  exist  together,  traces  their 
addition :  "The  alcohol  group  of  mustard  oil  may 
arise  from  sulphides,  since  it  is  possible  easily  to 
obtain  mustard  oil  from  sulphides  by  the  action  of 
potassium  thiocyanate"  {Die  in  den  Senfolen  en- 
thaltene  Alcoholgriippe  kann  aus  Sulfiden  stammen, 
da  man  Senfole  aus  den  Sulfiden  durch  Einzvirkung 
von  Rhodatikalinm  Icicht  erhdlt).  Sulphides,  illus- 
trative of  these,  exist  in  the  higher  boiling  fractions 
of  asafcetida  oil,  e.  g.,  GHi4S=,  and  CnH-S^ 
From  these  views  we  descend  to  the  level  of  mere 
copying  or  to  arts  like  those  of  alchemy,  when  we 
read  (Allen,  Commercial  Organic  Analysis,  II,  part 


3,  p.  386),  that  "it  is  doubtful  whether  allyl  sulphide 
exists  in  nature."  The  argument  to  disprove  the 
existence  of  allyl  sulphide  would  apply  with  ex- 
actly the  same  force  to  disprove  the  existence  not 
only  of  the  disulphide,  but  also  of  vinyl  sulphide, 
concerning  which,  however,  we  hear  no  doubts. 
The  matter  is  one  that  I  should  not  mention  if  my 
purpose  were  not  chiefly  that  of  criticism.  For 
certainly,  no  materials  ever  needed  more  to  be  cast 
into  the  furnace  and  remelted  than  these. 

In  my  own  view,  I  may  be  permitted  to  say, 
I  coincide  with  that  of  Liebcrmann,  who  carefully 
establishes  the  true  relation  between  the  tetravalent 
alcohols,  represented  by  Ci;H=2 ;  and  GHs,  the  rad- 
ical of  the  allyl  compounds.  His  explanation  in- 
volves a  very  essential  peculiarity  of  one  of  the  allyl 
series,  allyl  iodide.  "For  though  the  carbon  atom 
may,  in  our  calculations,  be  able  to  take  up  four 
hydrogen  atoms,  as  appears  from  the  compounds 
of  the  ethylene  series,  there  are  for  instance,  two 
open  chains  (bince  apertcc  affinitates)  in  ethylene, 
propylene,  butylene,  and  certain  other  members  of 
this  group  that  combine  with  bromine  and  chlorine ; 
and,  similarly  in  the  allyl  series,  allyl  iodide  mani- 
fests a  violent  ?ffinity  for  bromine,  giving  rise  to 
the  saturated  compound  GHnBra"  quodsi  satu- 
randi  capacitatcm  unius  carbonii  atomi  (C)  capaci- 
tati  quafuor  hydrogenii  atouiorum  aequalcni  esse 
aestimainns.  ut  patct  ex  connubiis  seriei  acthxli  .  .  . 
sunt  igitur  exempli  gratia  acthyleno,  propyleno, 
butyleno,  et  cateris  singulis  hujiis  ordinis  bincc  aper- 
tce  afdnitates,  quas,  simulatque  cum  chloro  hrornove 
conveniunt,  his  recipicndis  summo  ardore  explere 
student.  Similiter  in  allyli  serie  allylum  jodatum  ve- 
hementissimam.  prae  se  fert  rcactioneni  in  bronium 
quocumquc  satiiratum  coimubinm  C-^HsBr-.  init"). 

This  is  that  "key"  of  which  we  spoke,  and  which, 
by  its  turning  is  able  to  reveal  so  many  combina- 
tions. Allyl  iodide,  in  its  chains  of  connection,  is  a 
deeply  interesting  substance.  "Allyl  iodide,"  writes 
Rohmann,  "possesses  for  chemists  a  signification 
similar  to  that  of  the  iodides  of  the  saturated  carbon 
compounds.  Just  as  with  the  one,  the  alcohol  radi- 
cal, so  with  the  other,  the  allyl  radical,  can  be  made 
to  enter  into  combination  with  other  substances. 
In  the  first  case,  the  iodine  atom  is  as  mobile  as  in 
the  second, — even  more  mobile."  {Das  Allyl jodid 
hat  fiir  den  Cheniikcr,  cine  dhnlichc  Bedeiitung  wie 
die  Iodide  dcr  gesiittigfen  Kohlenzvassertoffe. 
Ebenso  wie  man  mit  jcnen  die  Alkoliolradikale, 
kann  man  mit  diesem  das  Allyl radikal  in  andcre  Ver- 
bindungen  einfiigen.  Das  Jod  ist  in  ihm  ebenso 
leicht,  ja  sogar  leichter  als  in  jenen. 

We  are  now  arrived  at  a  point  from  which  we 
may  overlook  the  whole  of  this  literature.  What 
place  is  to  be  assigned  to  allyl  sulphide,  and  for 
what  is  it  most  remarkable  ?  The  two  questions 
really  resolve  themselves  into  one.  Allyl  sulphide 
has  all  the  potentialities  of  a  powerful  bacterial  poi- 
son, since  its  energies  are  confined,  like  those  of  an 
explosive  in  a  cartridge.  It  is  not  enough  that  a 
substance,  which  poisons  bacteria,  should  be  such 
in  a  test  tube  only.  The  main  condition  lies  in  the 
key  to  its  evolution  in  the  economy,  to  the  lazv  of 
its  action  in  the  blood,  or  wherever  a  mycobacter- 
ium,  like  that  of  tuberculosis,  attacks  the  red  cells. 


DITMAX  AXD  ll'ELKER:  DEFICIENT  OXIDATION  AXD  NEPHRITIS. 


[New  York 
Medical  Journal. 


Upon  this  subject,  however,  I  shall  not  dwell  here. 
It  is  one  that  has  been  treated  physiologically  by 
Creighton — and  philosophically.  In  contrast  to  oth- 
ers, he  writes  clearly,  taking  a  comprehensive  ac- 
count of  the  great  works  of  Borrel,  Koch,  and 
Metchnikotif,  and  never  losing  himself  in  the  laby- 
rinth of  terminology  nor  in  the  bore  of  that  blunder- 
buss crammed  with  the  stuffings  of  Greek  hybrids 
in  "-in."  The  histogenesis  of  the  young  tubercle 
is  the  question  which  is  entitled  to  our  deepest  at- 
tention, if  we  would  avoid  the  error  of  misrelated 
treatment. 

The  problem  again  concerning  tuberculin  is  not 
connected  with  our  purpose.  It  is  a  question  that 
many  have  doubtless  answered  to  their  satisfaction ; 
yet  it  is  one  that  a  prudent  man  may  well  be  at  a 
loss  to  understand,  until  it  is  clearly  determined 
what  tuberculin  ( 19)  is.  On  the  other  hand,  we  are 
satisfied  that  ally!  sulphide  is  oxidized  into  sulphuric 
acid,  and  that  the  simple  condition  of  this  reaction 
is  the  presence  of  a  ferment.  From  this  projection 
of  its  action,  depend  many  things  of  remarkable  na- 
ture. "These  noteworthy  facts,"  writes  Professor 
von  Bunge,  "that  from  the  mere  action  of  a  fer- 
ment, the  most  powerful  mineral  acid  may  be  freed 
from  an  entirely  neutral  compound,  such  as  potas- 
sium mvronate,  seem  to  me  matters  of  curious  ob- 
servation in  respect  of  many  questions  in  animal 
physiology.''  {Lehrhuch  dcr  Chcmic.  p.  223  and 
Lehrbiich  dcr  Pliy.uologic.  second  edition,  1905,  II, 
Vortrag  12). 

References. 

1.  Wedelius.  De  bttlbo  zcterum.  Propciiifticon  inaugu- 
rate, Jenae. 

2.  Emhardus.    Dissertatio  iiiauguralis  de  allio. 

3.  Haller.  Propemticon  inauguraJe  genus  alliorum, 
Jenae  et  Gottingae. 

4.  Saine-Olive.    Gazette  medicale  de  Lyon.  1868,  p.  75. 

5.  Cuguillere.  Congres  international  de  la  tuberculose, 
Paris.  1905.  ii.  p.  11.  Progres  veterinaire,  Premier  semes- 
tre,  1906,  p.  298. 

6.  Casella.  Sull"  azione  battericida  del  succo  d'aglio. 
Giornale  dclla  reale  Societa  cd  Aeadeniia  vcterinaria  ital- 
iana,  1898.  xlvii,  p.  876. 

7.  Wertheim.    Liebig's  Annalen,  li,  p.  297,  1844. 

8.  9,  10.  Semmler.  Archiv  der  Pharmacie.  1892.  p.  438 ; 
and  Die  Aetherischen  Oele,  1906,  i.  p.  843. 

11.  Medical  Record,  Ixxiv,  p.  520,  1908. 

12.  Ally]  Sulphide:  Some  Aspects  of  its  Physiological 
Action.    The  Biochemical  Journal.  1907.  p.  326. 

13.  Ingianni.  Sull'  azione  di  aglio,  etc.  Bollctino  della 
reale  Acadcntia  mcdica  di  Genozv.  ix.  p.  329,  1894.  Cavaz- 
zan:.  rallium  sativum  nella  cura  della  tuberculosi  pul- 
monare.  Supplement.  Policlinico.  April.  1900,  Gazzctta 
medica  Lonibarda,  xii.  1902.  Congresso  medico  interna- 
zionale,  Roma,  1902.  The  Lancet,  1904.  i.  pp.  482  et  passim. 
Kathe.  Das  actherischc  Del  im  Knoblauch.  Inaugural 
Dissertation.  1908. 

14.  Gildemeister  and  Hoffmann.  Die  Aetherischen  Oele, 
1809. 

15.  Koch.  Mitteilungcn  aus  dim  kaiscrlichen  Gcswid- 
heitsamt.  18S1,  p.  264. 

16.  De  Fleury.  Le  Tribromurc  d'allylr;  medicament 
nouveau.  1886. 

17.  Rohmann.   Biochemie,  1908.  p.  377. 

18.  Liebermann.  De  allyleno  atquc  nonnullis.  quae  ittde 
proficiscuntur,  connubiis,  1865.  p.  9. 

IQ.  Kant.    Kritik  der  reincn  Vernunft. 

23  W'l^sT  Thirty-sixth  Street. 


DEFICIEXT  OXIDATION  IN  ITS  RELATION  TO 
THE  --ETIOLOGY.  PATHOLOGY.  AND 
TREATMENT  OF  NEPHRITIS. 
By  Norman-  E.  Ditmax.  Ph.  D..  M.  D.. 
New  York, 

Assistant   Attending   Physician.   St.   Luke's  Hospital;    Instructor  in 
Pathology.    College    of    Physicians    and    Surgeons.  Columbia 
University;  Clinical  Pathologist,  The  Roosevelt  Hospital. 

In  collaboration  with  William  H.  Welker.  A.  C.,  Ph.  D., 
New  York, 

Assistant  in/  Biological   Chemistry,    College   of   Physicians  and 
Surgeons.  Columbia  Universky. 

(Continued  from  page  1006.) 
Urinary  Ez'idcnces  of  Altered  Oxidation  in 
Eclani  psia. 

There  is  another  disease  condition — eclampsia — 
the  study  of  w-hich  may  also  throw  some  light  upon 
this  problem  of  diminished  oxidation  in  nephritis. 
For,  while  a  large  part  of  the  pathological  concept 
of  eclampsia  is  concerned  with  the  profound  changes 
in  the  liver,  which  in  recent  years  have  been  ob- 
served with  great  uniformity,  still  the  kidney  lesion 
is  so  grave  that  it  must  still  constitute  an  important 
part  of  the  picture. 

A  means  of  esimating  the  degree  of  oxidation 
by  analysis  of  the  end  products  of  metabolism  in 
the  urine,  in  a  manner  similar  to  that  just  described, 
is  afforded  in  eclampsia  by  the  relation  of  the  ex- 
cretion of  the  substances  uric  acid  and  allantoin. 

AUantoine  is  excreted  to  some  amount  in  normal 
pregnant  women,  and  occurs  as  a  direct  oxidation 
product  of  uric  acid — ^as  first  demonstrated  by  Lie- 
big  and  \\'ohler'"'  bv  means  of  the  oxidizing  agent 
Pb  O^-. 


Uric  acid 
HN  — CO 


AUantoine 


OC 


HN 


NH 

I 

CO 

I 

NH 


HN  — 

CO 

1 

OC 

1 

i 

HN  — 

1 

CH 

\ 

NH 

\ 

CO 

/ 

NH= 

The  transformation  of  allantoine  from  uric  acid  in 
the  body  by  processes  of  oxidation  has  more  re- 
cently been  shown  by  Swain'',  ^lendel  and  White'', 
and  Sundwick"^. 

\\'e  appetid  the  results  of  some  of  our  analyses 
in  this  connection : 

Table  XI\'. 


Eclampsia 
Eclampsia 
Eclampsia 


Toxa?mia  of  pregnancy  with  severe 
nephritis   

In  these  cases  the  ratio  is  not  uniform,  but  it  is  suf- 
ficientlv  suggestive  to  indicate  that  in  all  probability 


Ratio  of 

uric  acid 

nitrogen  to 

allantoine 

nitvogen. 

Diet. 

I  :i.77 

Milk 

1:1.38 

Milk 

1:1.5 

Milk 

I  :i.5 

Milk 

i:3-5 

Milk 

1:2.4 

Milk 

i;i.4 

Milk 

I  :o.9 

Milk 

I  :o.6 

Milk 

I  :o.2 

Milk 

I  :o.4 

Milk 

I  :o.2 

Milk 

May  22,  ,909.]         DITMAN  AND  WELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS. 


1047 


the  oxidation  of  uric  acid  to  allantoine  is  not  so 
great  in  eclampsia  as  in  the  normal  pregnant 
Avoman. 

That  this  altered  ratio  may  be  due  to  processes 
of  insufficient  oxidation  can  be  shown  here,  as  in 
the  case  of  purin  bases,  by  experimental  methods, 
with  KCX  as  the  agent  to  reduce  bodily  oxidation. 
Dogs  were  used,  as  before,  on  a  constant  diet,  that 
of  I  and  II  containing  a  moderate  amount  of  nitro- 
gen, that  of  III  and  IV  containing  a  relatively  small 
amount  of  nitrogen  and  that  of  \'  and  VI  contain- 
ing a  relatively  large  amount  of  nitrogen.  During 
the  middle  period  each  received  cyanide  in  the  des- 
ignated doses  daily  and  during  a  fore  and  after  pe- 
riod no  cyanide  was  given.  The  urine  was  collected 
as  before.  Each  result  represents  the  daily  aver- 
age of  each  period — the  periods  being  one  week  to 
ten  davs  duration  as  a  rule.  (Tables  ATI.  \TI1, 
IX,  X,' XI.  XII).    The  results  follow: 

Table  X\'. 

Medium  protein  plane  (see  Tables  \l\  and  VIII). 


Ratio  of  uric 
acid  nitrogen 

_       -  to  allantoine 

Dog  1  :  nitrogen. 

No  cyanide  (Period  I)  ;  i  :7-9 

Cyanide  (Period  II)   1:9.2 

Dog  II : 

No  cyanide  (Period  I)   1:25. 

Cyanide  (Period  II)   1:20. 

No  cyanide  (Period  III)   1:20. 

Low  protein  plane  (see  Tables  IX  and  X.) 
Dog  III: 

No  cyanide  -(Period  I)   1:7.6 

Cyanide  (Period  II)   1:2.0 

No  cyanide  (Period  III)   1:5 -9 

Dog  IV : 

No  cyanide  (Period  I)....   i:  9.9 

Cyanide  (Period  II)   i  :ii.O 

No  cyanide  (Period  III)   1:18.0 

High  protein  plane  (see  Tables  XI  and  XII.) 
Dog  V: 

No  cyanide  (Period  VI)   1:9.0 

Cyanide  (Period  VII)   1:4.2 

No  cyanide  (Period  IX)   1:9.4 

Dog  VI : 

No  cyanide  (Period  I)..".   1:20.9 

Cyanide  (Period  II)   1:10.8 

No  cyanide  (Period  III)   i:  6.2 


While  the  results  in  this  table  are  not  uniform,  with 
the  exception  of  those  for  the  dogs  on  the  medium 
protein  planes,  there  is  a  decided  tendency  toward 
a  relative  increase  of  the  incompletely  oxidized  al- 
lantoine precursor,  uric  acid,  due  to  the  interference 
of  bodily  oxidizing  functions  by  the  action  of  the 
cyanide. 

That  the  altered  relation  of  these  two  substances 
occurring  in  eclampsia,  similar  to  that  produced  ex- 
perimentally by  the  means  here  shown,  mav  be  due 
to  a  diminution  of  oxidative  activity,  is  therefore 
apparent. 

Hydrazine  and  Diminished  Allantoine  Excretion. 
An  interesting  and  suggestive  fact  in  this  con- 
nection, which  may  have  a  special  bearing  upon  the 
extreme  liver  lesions  in  eclampsia,  is  one  connected 
with  allantoine  metabolism  discovered  by  Pohl,  and 


of  special  interest  where  the  excretion  of  allantoine 
is  diminished. 

It  is  a  simple  chemical  process  to  transform 
guanidine  nitrate — which  substance  has  been  found 
in  pancreatic  metabolism  —  into  nitroguanidine. 
which,  upon  reduction,  becomes  aminoguanidine. 
Pohl's'*  experiment  consisted  in  proving  that  amino- 
guanidine gives  rise  in  vivo  to  allantoine  and  inav 
very  well  be  an  allantoine  precursor  in  pregnan.cy 
under  certain  conditions  of  reduction  in  the  body. 

The  fact  of  special  interest  above  referred  to  re- 
sults from  the  relationship  of  these  products  to  hy- 
drazine. E.  Fischer  has  given  the  name  of  hy- 
drazines to  a  series  of  peculiar  bases,  tnostly  liquid 
and  closely  resembling  the  amines,  but  containing 
two  atoms  of  nitrogen  in  the  molecule  and  differ- 
ing from  the  amines  especially  by  their  capability 
of  reducing  Fehling's  solution — for  the  most  part 
even  in  the  cold. 

This  product,  hydrazine,  is  of  great  interest  here, 
as  it  is  easily  formed  from  aminoguanidine,  already 
referred  to,  and  is  capable  of  producing  severe  liver 
necrosis  when  introduced  into  the  animal  circula- 
tion— thus  simulating  the  well  known  hepatic 
lesions  of  eclampsia.  The  diminuation  of  urinary 
allantoine  in  eclampsia,  and  the  increase  of  the 
amino  group,  would  appear  to  add  special  interest 
to  this  phenomenon.  The  addition  of  as  strong  a 
reducing  agent  as  hydrazine  to  the  reduction  pro- 
cesses already  existing  would  aid  in  aggravating 
a  condition  which,  as  may  be  proved  later,  is  already 
a  potent  factor  in  the  causative  complex  of 
eclampsia. 

Other  Evidences  of  Diminished  Oxidation. 
The  observation  has  often  been  made  that 
acetonuria  may  occur  in  pregnant  women,  and  is 
frequently  augmented  in  the  cases  presenting  signs 
of  toxjemia — often  accompanied  by  evidences  of 
nephritis. 

The  occurrence  of  insufficient  oxidation  as  a  fac- 
tor is  here  assumed  by  von  Xoorden'".  who  states 
that  in  certain  toxic  conditions  disturbances  of  oxi- 
dation occur,  and  the  excretion  of  acetone  mav  be 
due  to  defficient  catabolism  of  certain  bodies  which 
would  ordinarily  be  oxidized  further  than  the  ace- 
tone stage. 

A  phenomenon  familiar  to  the  practitioner  of 
medicine  in  most  remote  periods,  and  indicative  of 
diminished  oxidation  in  uraemia,  is  seen  when  blood 
is  removed  by  venesection  during  ursemic  coma. 
The  extremely  dark  appearance  of  the  blood,  due 
to  an  excess  of  reduced  hemoglobin  and  a  diminu- 
tion of  oxyhaemoglobin  is  familiar  to  all,  and  is  a 
simple,  yet  convincing,  demonstration  of  the  in- 
creased reduction  processes  existing  in  that  condi- 
tion. 

There  would  seem,  then,  to  exist  in  some  forms 
of  kidney  disease,  a  demonstrable  diminution  of  the 
oxidizing  powers,  or  an  increase  in  the  reducing 
powers  of  the  body.  That  some  forms  of  protein 
substances,  when  insufficiently  oxidized,  are  toxic, 
has  already  been  shown.  It  is  of  great  interest, 
then,  to  discover  whether,  during  the  course  of  the 
body  metabolism,  there  may  not  be  some  definite 
decomposition  products  in  renal  afYections,  which., 
when  insufficiently  oxidized,  are  capable  of  produc- 
ing toxic  effects. 


,1048 


DITMAN  AND  WELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS. 


[New  York 
Medical  Journal. 


The  nature  of  such  possible  substances  in  uraemia 
and  eclampsia  is  of  special  interest,  and  the  great 
similarity  in  the  clinical  picture  of  these  two  condi- 
tions would  give  zest  to  the  effort  to  find  out 
whether  it  might  not  be  possible  for  the  same  sub- 
stance or  group  of  substances  to  be  active  in  both. 

Metabolism  of  Guanine  Group. 
Inasmuch  as  the  presence  of  allantoine  in  large 

Guanine 


HN  — 

CO 

1 

-C 

1 

c  — 

NH 

II 

Ij 

1 

il 

ll 

lH 

11 

N  — 

c— 

II 

N 

H vpoxanthine 
H.\  — CO 

i  I 
HC     C  — NH 

I 

CH 

II 

N  — C  — N 

Xanthine 

HN  — CO 

I  I 
OC     C  — NH 

I      I!  CH 
I      II  II 
HN— C— N 


Good  oxidation 


Metliyl  hypoxanthine 
CH3N— CO 

I  I 
HC     C  —  NH 

\ 

CH 

,  II 
N  — C  — N 

Methyl  xanthine 

CH3N  —  CO 

I  I 
HC     C  — NH 

II  II  I 
II     ))  CH 
II      ll  II 

NH  — C  — N 


Uric  acid 

HN  — CO 

I  I  NH 
I  I/I 

OC     c  I 
I      ll  CO 

HN  — C  I 
\ 

NH 


Allantoine 

HX  — CO 


OC 

I 
I 

HN 


H 


-C 


NH 

\ 
CO 

/ 

NH. 

quantities  is  almost  a  specific  condition  in  preg- 
nancy, the  metabolism  of  this  group  might  with 
profit  be  inquired  into  under  conditions  of  sufficient 
and  insufficient  oxidation.  This  search  would  re- 
<;ult  as  follows :  Guanine  and  methyl  guanine  exist 
normally  in  the  i)lood. 

Their  nxiflation  products  are  indicated  above. 


Metabolism  of  Creatinine  Group. 

In  the  case  of  nephritis  and  uraemia,  the  group 
of  urinary  constituents  which  attracts  special  inter- 
est for  reasons  which  will  subsequently  develop,  is 
the  group  of  nitrogenous  "extractives" — among 
which  creatinine  is  found.  The  decomposition  pro- 
ducts of  the  basic  substance  of  this  group,  creatine, 
which  exists  normally  in  the  blood,  under  conditions 

Methyl  guanine 

CH3N  —  CO 

I  I 

NH  =  C     C  — NH 

III 
CH 

I      I  II 
N  =  C  — N 


NH  CH, 


NH.. 


NH  =  C 


/ 


XH. 
Gnanidme 


/ 

XH  =  C 

NH. 

Methyl 

GUANIDINE 


of  greater  and  lesser  degrees  of  oxidation- 
follows  (37)  : 

Creatine 
N(CH3)  CH..COOH 

/ 


-are  as 


NH  =  C 


\ 

NH2 


Poor  oxidation 

Creatinine 

N(CH3)  CH. 

/  I 

NH  =  C  I 


Good  oxidation 

Methvl  hydantoine 
"  N(CH3)  CH= 
/  I 
0  =  C  I 


XH 


CO 


Methyl  guanidine 
NH.CH3 

/ 

NH  =  C 

\ 

NH. 
Guanidine 

NH, 

/ 

NH  =  C 

\ 

XH> 


NH 

Methyl  urea 
NH.CH, 

/ 

0  =  C 

\ 

NH. 

Urea 

NH. 


CO 


0  =  C 


/ 


NH. 


By  comparison  of  these  two  lists  it  is  at  once 
apparent  that  there  does  exist  a  substance  occurring 
in  common  in  the  form  of  methyl  guanidine  as  well 
as  guanidine. 

Wlien  it  is  realized  that  methyl  guanidine  is  one 
of  the  most  poisonous  substances  resulting  from 
protein  decomposition  and  is  capable  of  killing  ani- 
mals in  small  doses  with  symptoms,  many  of  which 
resemble  those  of  uraemic  and  eclamptic  seizures, 
the  metabolism  of  this  common  group  of  luider- 


May  22,  1909.]        DITMAN  AXD  U'ELKER:  DEFICIEXl    OXIDATION  AND  NEPHRITIS. 


oxidized  substances  is  seen  to  be  of  the  greatest 
importance. 

III.    Significance  of   Diminished  Creatixin 
Excretion  in  Nephritis. 

The  possibihty  of  the  presence  of  these  poisonous 
derivatives  of  creatinine  (methyl  guanidine  and 
guanidine)  having  been  estabhshed,  it  becomes 
of  immense  importance  to  find  evidence,  chnical 
and  chemical,  of  unoxidized  creatine  products  in 
the  blood,  if  such  exist. 

Owing  to  the  difficulty  of  the  process,  the  amount 
of  time-  and  expense  involved  in  such  a  search,  we 
have  not  yet  attempted  by  chemical  analysis  to 
establish  the  presence  of  these  products  in  the  blood 
of  nephritis.  It  is  necessary  then  to  accumulate 
evidence  in  other  ways,  relying  upon  clinical  and 
experimental  data  for  our  conclusions. 

The  attempt  was  first  made  to  ascertain  definitely 
whether  the  excretion  of  creatinine  more  or  less 
regxilarly  diminished  in  certain  forms  of  nephritis. 

Creatinine  Excretion  in  Disease  Processes. 

The  table  appended  (Table  X\'I)  for  the  various 
forms  of  nephritis  and  other  diseases  gives  the 
amount  of  creatinine  in  twenty-four  hour  urines  in 
these  diseases.  Many  of  these  figures  represent  an 
average  of  determinations  on  from  two  to  fifty  suc- 
cessive days. 

The  normal  average  of  creatinine  excreted  in  the 
urine  for  healthy  people  living  under  conditions 
such  as  those  here  considered,  may  be  said  to  lie 
between  1.5  and  2.  grammes  in  twenty-four  hours, 
and  is  surprisingly  constant  for  any  one  person. 

From  these  observations  it  is  seen  that  the  crea- 
tinin  excretion  is  uniformly  low  in  chronic  diffuse 
nephritis,  especially  of  the  atrophic  type :  often  low 
in  chronic  parenchymatous  nephritis,  as  well  as  in 
eclampsia  and  the  toxaemia  of  pregnancy.  If  this 
diminution  represents  a  storing  up  in  the  blood  of 
one  of  the  toxic  products  of  creatinin  metabolism, 
the  amount  stored  up  and  the  toxic  power  of  this 
material  in  extreme  cases  are  of  interest  and  may 
very  well  be  computed  as  follows,  and  are  then 
shown  to  be  striking. 

Toxic  Possibilities  Resulting  from  "Retention." 

The  normal  excretion  of  creatinine  may  be  two 
to  three  grammes  maximum.  The  excretion  of  crea- 
tinine in  nephritis  is  sometimes  as  low  as  o.i  gramme 
m  twenty-four  hours.  Now  0.2  gramme  of  methyl 
guadinine  is  able  to  kill  one  guinea  pig,  and  since 
some  products,  as  shown  by  the  facts  of  methylene 
blue  excretion,  are  retained  in  the  body  for  three 
days,  enough  methyl  guanidine  might  collect  under 
the  extreme  conditions  mentioned  durine  this  time, 
to  produce  a  toxic  effect  capable  of  killing  thirty 
guinea  pigs. 

TABLE  XVT.— CREATININE  l\  CLINICAL  CASES. 
Chronic  Diffvse  Nephritis. 
T'iet.  Low.  Medium.  High. 

Milk  diet   0.6 

Milk  diet   0.8 

Meat   free   ,.3   (mild  case) 

Ch'.cken    0.8 

Milk  diet   0.7 

^li'k  diet   1.3   (mild  case) 

Milk  diet   0.4 

Milk  diet   0.7 

Milk  diet   0.6 


Milk  diet   0.4    (glomerular  type.  postdiphtlieritiL j 

Meat   free   0.5    (secondary  to  heart  lesions) 

.Meat    tree   0.4 

Meat    tree   o..; 

Meat  diet   1.2  pernicious  anaemia 

Meat   free   0.6 

Milk  diet   o.j 

Milk  diet   0.1 

Meat   free   0.3 

Milk  diet   0.6 

Jleat    free   0.4 

Milk    0.4    Threatened  eclampsia. 

Meat   free   0.0 

Milk    0.2    Chronic  gout  and  interstitial  nephritis. 

Meat    free   0.7 

Meat    free   0.5 

Meat    free   0.4 

Meat    free   0.3 

^leat    free   0.2 

Chronic  Congestion  of  Kidney. 

Diet.                          Low.  Medium.  High. 

Milk  diet   0.8 

Chronic  P.\rexchy>i.\tous  Nephritis. 

Diet.                          Low.  Medium.  High. 

Milk  diet                           —  —  2.3 

Milk  diet                           —  1.4* 

Milk  diet                           —  i.i* 

Milk  diet   0.8 

Milk  diet   0.3      (decapsulated  kidney)  postoperative. 

Meat   free   0.9 

Milk  diet   0.9 

Meat    free   0.25 

Chicken    o.io 

*Same  case. 

Acute  Nephritis. 

Diet.                          Low.  Medium.  High. 

Milk  diet                           —  —  2.3 

Milk  diet                         0.8  1.7 

Milk   diet                             —  ,1.7 

Meat  diet                           —  1.5 

Milk  diet                           —  1.4 

Meat    free                         —  1.1 

Milk  diet   0.3 

Meat    free                         —  1.3 

Milk  diet                           —  I. 

Miscell.\neous  Dise-^ses. 

Diet.  Low.       Medium.  Hig'i. 

Typhoid                                 Milk  —  —  2.2 

1 'ry  pleurisy                            Milk  —  —  2,9 

-Alcoholic  gastritis   —  1.6 

Typhoid                                   Milk  —  1.6 

Typhoid                                 Milk  —  1.5 

Iliac  thrombosis                      ililk  —  1.4 

(normal   kidney)                 Meat  —  1.7 

Endocarditis                             Light  —  2.2 

Diabetes                                   Regular  —  1.2 

Diabetes                                   Mi.xed  —  1.5 

Purpura  haemorrhagica.  .  .  .    Meat  free         —  i.j 

Eclampsia                                 Milk  o.o 

Eclampsia                               Milk  —  1.3 

Carcinoma  of  liver   —  1.2 

Normal                                    Mi.xed  —  1.8 

Eclampsia                                 Milk  —  1.2 

Eclampsia                                 Milk  —  i. 

Threatened  eclampsia 

(nephritis)                            Milk  0.4 

Eclampsia                                 Milk  0.6 

Eclampsia                                 Milk  0.6 

Pleurisy  with  effusion....  —  1.2 

Pernicious    anaemia   0.8 

Pernicious    anemia   —  1. 

Eclampsia                                Milk  —  1.2 

Eclampsia                                ililk  0.7 

Eclampsia                                Milk  0.6 

Eclampsia                                Milk  0.5 

Normal  pregnant  woman..     Mixed  —  1.3 

Eclampsia                                Milk  0.4 

Normal  pregnant  woman.,     ililk  0.8 

Eclampsia                                Milk  — 

Normal  pregnant  woman..     Milk  0  - 

Eclampsia                                Milk  o  9 

Eclampsia                                Milk  —  i 

Eclampsia                                Milk  o.s 

-Normal   man   _  g 

Toxsmia  of  pregnancy.]!    Milk  o  162 

ioximia  of  nregnancy.  . .     Milk  o  8^ 

Eclampsia  and  toxaemia. . .     Milk  o  yi 

Toxaemia  of  pregnancy...     Milk  o  18 

toxaemia  of  pregnancy...     Milk  0.7, 

toxaemia  of  pregnancy...    Milk  _            r  c, 
-Albuminuria     and  preg- 

nancy    Milk   

To.xsmia  of  pregnancy! Milk  o.,,  '"^^ 
toxaemia  of  pre^ancv  and 

severe  nephritis                 Milk  0.0 

The  observation  that  the  excretion  of  creatinine, 
in  some  forms  of  nephritis,  is  diminished,  is  not  a 
new  one.  but  has  been  frequentlv  made  since  the 
observation  by  K.  B.  Hoffmann  in  1869  (38). 


1050 


DITMAN  AND  WELKER:  DEFICIENT   OXIDATION  AND  NEPHRITIS.         [Ne"-  Vork 

Medical  Journal. 


Tlie  significance  of  this  diminution  is  a  problem 
fery  difficult  of  solution  and  one  which  it  is  the  de- 
sire of  the  authors  to  still  further  pursue  in  the 
future.  For  an  intelligent  understanding  of  the 
data  at  hand,  a  short  review  of  the  metabolism  of 
creatine  and  creatinine,  as  at  present  known,  is  ap- 
pended ; 

Metabolism  of  Creatinine. 

Creatinine  has  two  chief  sources  in  the  body ; 
that  ingested  as  such,  or  ingested  creatine ;  and  the 
muscle  creatine,  formed  from  albuminous  materials. 

That  the  urine  creatinine — apart  from  that  re- 
ceived in  the  nourishment — originates  really  from 
muscle,  formed  there  from  other  substances,  is 
proved  by  the'  facts  in  progressive  muscular  atro- 
phy. In  severe  cases  the  amount  of  urinary  crea- 
tinine is  often  only  one  decigramme  (Langer,  Jaku- 
bowitsch,  Weiss).  The  antecedent  of  creatinine  in 
the  muscles  is  undoubtedly  creatine,  and  as  the  con- 
version of  creatine  into  creatinine  is  one  which  is 
brought  about  with  great  difficulty  by  purely  chem- 
ical processes,  the  presence  of  an  enzyme  effecting 
this  transformation  is  here  undoubtedly  indicated. 

Folin  believes  that  creatin  is  a  food,  derived  from 
protein — according  to  Van  Hoogenhuyze  and  Ver- 
ploegh  (39)  the  amount  being  independent  of  the 
kind  of  protein — and  is  absorbed  from  the  blood  by 
the  tissues,  v/hose  capacity  is  great,  until  they  are 
saturated.  It  is  not  until  this  point  is  reached  that 
ingested  creatine  occurring  in  excess,  or  its  pro- 
ducts, appears  in  the  urine. 

Conversely,  during  the  process  of  catabolism,  the 
creatine  of  the  tissues  is  given  up  reluctantly,  and 
after  other  supplies  of  energy  have  been  utilized. 
This  fact  is  illustrated  by  Van  Hoogenhuyze  and 
Verploegh,  who  showed  that,  as  a  result  of  muscu- 
lar work,  an  increase  in  creatine  excretion  in  the 
urine  occurs  only  if  the  body  is  compelled  to  live 
entirely  at  the  cost  of  its  own  tissues — as  during 
--tarvation. 

The  observation,  made  by  Folin  (40),  that  crea- 
tinine, other  than  that  ingested,  is  a  product  of 
strictly  endogenous  metabolism,  is  an  interesting 
one,  and  may  result  in  our  obtaining  a  clearer  in- 
sight into  certain  obscure  phases  of  nitrogenous 
metabolism. 

In  view  of  Folin's  observation,  one  is  prepared 
for  the  fact  that,  in  health,  creatinine  elimination  is, 
in  general,  dependent  on  body  weight  (41),  (42), 
and  acfe  (^39),  (41),  but.  with  meat  free  diet,  inde- 
pendent of  diet  (40)  and  total  nitrogen  elimination. 

The  effect  of  endogenous  inactivity  is  probably 
well  shown  by  the  creatinine  figure  in  a  table  by 
\'an  Hoogenhuyze  and  Verploegh,  pertaining  to  a 
child  suffering  merely  from  malnutrition  (No.  3), 
who  excreted  a  very  small  amount  of  creatinine. 

1.  Eight   clays  old....  i.ii  milligrammes  creatinine  (per  kilogramme) 

2.  Thirty-two  days  old  0.91  milligrammes  creatinine  (per  kilogramme) 

3.  Two  months  old...  0.41  milligrammes  creatinine  (per  kilogramme) 

4.  Two  months  old...   i  .70  milligrammes  creatinine  (per  kilogramme) 

It  may  reasonably  be  assumed  from  this  and  the 
muscle  atrophy  observation,  that,  if  the  nutrition 
and  condition  of  the  muscles  are  normal,  the 
amount  of  creatine  capable  of  disintegration  into 
creatinine  shoujd  be  not  far  from  the  normal. 


Creatinine  Metabolism  in  Nephritis. 

In  nephritis  the  amount  of  creatine  ingested  may 
be  normal,  the  bulk  of  muscle  and  tissue  substance 
normal,  but  still  the  creatinine  in  the  urine  is  di- 
minished in  amount.  The  loss  probably  comes  then 
at  some  point  during  the  catabolism  of  creatine. 

At  this  point  it  becomes  a  matter  of  the  utmost 
interest  to  knozv  whether  this  diminished  excretion 
of  creatinine  implies  a  diminished  formation  of 
creatinine,  or  whether  it  results  from  the  disappear- 
ance of  creatinine  through  increased  decomposition 
before  excretion.  The  last  point  is  apparently  capa- 
ble of  proof  one  way  or  the  other,  and  an  attempt 
to  ascertain  the  facts  has  resulted  in  a  striking  out- 
come. 

Before  considering  the  results  of  our  experiment 
in  this  connection,  it  should  first  be  borne  in  mind 
that,  under  normal  conditions,  in  the  human  body, 
practically  the  entire  amount  of  ingested  creatinine 
may  be  recovered  in  the  urine  as  creatinine  and 
within  twenty-four  hours  after  its  intake.  \'on 
Noorden  states  that  it  is  possible  thus  to  recover  as. 
much  as  ninety-five  to  one  hundred  per  cent.  Mal- 
lett  (43)  found  that  from  1.7  to  3.8  per  cent,  was 
retained,  and  \>rploegh,  after  ingesting  0.5 
gramme  of  creatinine,  was  able  to  recover  all  but 
three  per  cent. 

If,  then,  a  definite  amount  of  creatinine  is  fed 
to  a  nephritic,  and  it  is  impossible  completely  to  re- 
cover it  from  the  urine,  the  urirecovered  balance 
evidently  undergoes  decomposition  in  the  body  ;  and 
it  would  be  inferred  that  such  a  decomposition  is 
directly  responsible  in  nephritis  for  the  failure  of  a 
certain  percentage  of  the  creatinine  to  appear  in  the 
urine. 

An  experimental  test  of  this  deduction  was  posi- 
tive, as  shown  hy  the  following  example : 

A  case  of  advanced  chronic  diffuse  nephritis,  exhibiting 
symptoms  of  uraemia,  having  a  low  creatinine  excretion, 
abundant  evidence  of  intestinal  putrefaction,  and  high 
pulse  tension,  was  given  2.775  grammes  of  creatinine  by 
mouth  and  careful  analytical  control  of  diet,  vomitus,  stools, 
and  urine  was  maintained.  The  entire  amount  of  crea- 
tinine was  quickly  absorbed  (as  determined  by  analysis  of 
vomitus  and  stools  obtained  shortly  after).  Analysis  of 
the  entire  amount  of  urine  collected  during  the  twenty-four 
hours  succeeding  the  administration  of  the  creatinine,  the 
twenty-four  hours  succeeding  this,  as  well  as  the  three 
days  preceding,  is  shown  in  tables  IV  and  XVII. 

The  conclusion  arrived  at  is  definite  and  positive.  Of 
the  2.775  grammes  ingested,  but  1.96  grammes  were  recov- 
ered, i,  e..  29  per  cent,  disappeared. 

On  theoretical  grounds,  assuming  the  breaking  up  of  this, 
substance  in  a  medium  of  poor  oxidation,  toxic  substances 
should  result  which,  in  a  case  so  nearly  ura?niic  and  so 
laden  down  with  products  of  poor  metabolism,  should 
cause  clinical  symptoms  of  to.xamia.  The  striking  fact  is 
that  this  was  indeed  the  onteome. 

Vomitinfr  occurred  repeatedly  and  was  severe.  In  four 
hours  after  the  administration  of  the  dose,  convulsions 
Ijcgan,  followed  by  coma  of  six  hours'  duration,  accom- 
panied by  a  noticeable  increase  of  pulse  tension. 

While  this  is  the  recital  of  a  single  case  and  the 
onset  of  these  symptoms  may  have  been  but  a  co- 
incidence, the  relation  of  dosage  to  effect  was  ap- 
parently so  direct  that  it  apjiears  to  have  been  a 
causative  one. 

The  difficulty  of  its  execution  and  the  re.grettable 
features  of  adding  to  the  discomfort  of  one  alreadv 
a  iSTQi\\.  sufferer,  make  this  experiment  one  that  is 


,May  22,  igoy.l 


UiTMAN  AND   IVELKER:  DElUClENl    UXWAIluN  AND  XEl'HKlilS. 


not  likely  often  to  be  repeated.  The  corroboration 
of  such  an  experiment,  by  repetition,  will  be  less 
urgently  demanded,  therefore,  than  in  the  case  of 
an  experiment  easier  to  perform. 

The  fact  that  Mallett,  during  his  experiments  on 
healthy  human  beings,  showed  that  fifteen  grammes 
of  creatinine  could  be  ingested  with  impunity,  not 
only  seemed  to  justify  the  use  of  2.775  grammes  in 
this  case,  but  goes  to  prove  how  relatively  great  the 
formation  of  toxic  decomposition  products  in  this 
case  must  have  been. 

Whether  the  creatinine  which  failed  to  appear  in 
the  case  of  uraemia  was  retained  as  such,  or  as  a 
decomposition  product,  or  excreted  in  some  un- 
known form,  is  difficult  to  say  from  the  results  in 
the  analytical  table  referred  to  in  this  case  (Table 
IV),  for  the  amount  of  ingested  nitrogen  could  not 
be  kept  absolutely  constant. 

The  increase  of  ammonia  in  the  urine  on  the  day 
of  the  creatinine  administration  was  marked  and  the 
reduction  of  lu'ca  upon  that  day  was  enormous ;  but 
an  interpretation  of  these  changes  with  reference  to 
the  lost  creatinine  would  be  difficult. 

T.ABLE    XVII.— CREATININE    ADMINISTERED    IN  NEPH- 
RITIS. 

Amount  of  creatinine  administered,  2.775  grammes. 
Date.  Creatinine  e.xcieted  (grammes). 

.1    0.621  f      (fore  period). 

16,  12-3  p.  m   0.303 

3-4:45    0.477 

4:45-8:30    0.700 

8:30-3:20  a.  m   0.502 

3-  ^0-7    0.252 

7-12  noon    0.230 

2.464 

■7.  12-3:45   p.   m._  ■. .  .  0.127 

.■?:45-6:4S    n.ioo 

6:45-9:50    0.103 

9:50-4  a.   m   0.156 

4-  12  noon    0.175 

0 . 661 

Creatinine  administered  wliicli  failed  to  be  excreted,  0.81  gramme 
— 29  per  cent. 

The  fact  that  similar  results  were  obtained  in  ex- 
periments on  dogs  after  diminished  cellular  oxida- 
tion, lends  weight  to  the  belief  that  the  result  in  the 
case  just  described  was  due  to  the  reducing'  effect 
of  the  introduced  creati  nine  on  the  liver — the  liver 
being  the  organ  which,  normally,  converts  ammonia 
into  urea  by  "synthetic  oxidation." 
Creatinine  Excretion  Diniinishcd  by  Experimental 
Means. 

That  diminished  excretion  of  creatinine  may  re- 
sult from  impairment  of  the  oxidation  processes  of 
the  body,  is  capable  of  proof  in  the  same  way  that 
the  diminished  transformation  of  the  purin  bases  to 
their  more  highly  oxidized  products  has  already 
been  shown  to  be  due  to  this  impairment. 

This  may  be  accomplished  by  the  use  of  potas- 
sium cyanide.  To  three  groups  of  two  dogs  each, 
which  for  some  days  had  been  on  a  constant  diet — 
in  one  case  low.  in  one  medium,  and  in  one  high  in 
nitrogen  (see  Tables  VIII.  IX.  X,  XI.  and 

XII),  potassium  cyanide  was  administered  daily 
during  a  period  of  several  days.  During  fore  and 
after  periods,  in  these  same  dogs,  no  cyanide  was 
given.  The  efifect  of  cvanide  on  the  excretion  of 
creatinine  during  this  middle  period  in  each  experi- 
ment is  shown  in  Table  XVIII. 

There  is  moderate  uniformity  in  the  results  of 
-this  table — suggesting  the  fact  that  the  administra- 


tion of  the  reducing  substance,  cyanide,  tends  to 
cause  a  diminution  in  the  amount  of  urinary  crea- 
tinine. 

That  the  diminished  excretion  of  creatinine  in 
nephritis  may  be  due  to  such  a  process  of  impaired 
oxidation,  is  obviously  possible. 

As  was  seen  from  our  references  to  the  case  of 
ura?mia,  a  certain  amount  of  creatinine  apparently 
underwent  decomposition  before  excretion,  as  indi- 
cated by  the  recovery  of  less  creatinine  in  the  urine 
than  had  been  administered.  That  such  an  occur- 
rence may  result  from  impairment  of  o.xidation  pro- 
cesses is  a  matter  which  also  seems  capable  of 
proof. 

A  dog  was  put  on  constant  diet  consisting  of 
cracker  meal,  lard,  bone  ash,  and  water,  and  the 
daily  excretion  of  creatinine  determined.  He  was 
then  given  daily  doses  of  2.936  grammes  of  crea- 
tinine and  all  but  eighteen  per  cent,  was  recovered 
in  the  urine.  During  a  subsequent  period  of  five 
days  this  dog  was  given  daily  2.015  grammes  of 
creatinine  with  repeated  doses  of  KCN,  as  shown 
in  the  following  table  (XIX).  Twenty-nine  per 
cent,  failed  to  appear  in  the  urine  under  these  con- 
ditions. 

Another  dog,  which  fasted  during  a  fore  period 
in  which  nothing  was  administered,  was  given  daily 
1.27  grammes  of  creatinine  with  small  doses  of 
KCN  as  shown  in  the  following  table  (Table  XX). 
During  the  dosage  period,  the  amount  of  creatinine 
that  failed  to  appear  in  the  urine  amounted  to  61.3 
per  cent,  of  the  amount  administered.  The  part 
played  by  the  agent  that  interfered  with  oxidation, 
(KCN),  is  here  clearly  apparent,  and  the  result 
simulates  closely  the  result  obtained  after  the  ad- 
ministration of  creatinine  in  the  case  of  urjemia. 

TABLE  XVIII.— EFFECT  OF  POT.\SSIUM  CVANIDE  ON 
CREATININE  EXCRETION. 

Alcdiiim  protein  plane  table. 

Creatinine  nitro- 
gen, daily  average 
Dog  I  :  in  grammes. 

No  cyanide  (Period  I)   0.0702 

Cyanide  (Period  II)   0.0611 

Dog  II : 

No  cyanide  (Period  I)   0.0942 

Cyanide  (Period  II)   0.0988 

No  cyanide  (Period  III)   0.0933 

Low  protein  plane  table. 

Dog  III: 

No  cyanide  (Period  I)   0.0610 

Cyanide  (Period  II)   0.0403 

No  cyanide  (Period  III)   0.0536 

Dog  IV : 

No  cyanide  (Period  I)   0.0607 

Cyanide  (Period  II)   0.0634 

No  cyanide  (Period  III)   0.0898 

Higli  protein  plane  table. 

Dog  V : 

No  cyanide  (Period  VI)   0.1226 

Cyanide  (Period  VII)  ■..  D.1059 

No  cyanide  (Period  IX)   0.1241 

Dog  VI : 

No  cyanide  (Period  I)   0.1734 

Cyanide  (Period  II)   0.1581 

No  cyanide  (Period  III)   0.1253 

In  nephritis  of  the  types  manifesting  the  reac- 
tions in  question,  either  the  enzyme  that  converts 
creatine,  into  its  end  products  is  at  fault,  probably 
through  impairment  or  absence,  or  body  reduction 
processes  are  in  excess  of  the  normal,  or  both  con- 
ditions may  be  present  simultaneously. 


I052 


rrriTCHELL:  THERAI'EUTIC  USE  OF  ALCOHOL. 


[NevV  York 
Medical  Journal. 


Variations  in  Metabolism  Dependent  Upon  Diet. 

Although  a  matter  very  difficult  of  interpretation, 
great  interest  attaches  to  the  different  behavior 
manifested  by  animals  under  different  conditions  of 
diet  toward  reducing  agencies,  with  reference  espe- 
cially to  the  different  nitrogen  constituents  of  the 
urine.    (See  Tables  VII.  VIII.  IX.  X.  XI,  XII.) 

TABLE  XIX.— RETENTION  OF  CREATININE  WHEN  ADMIN- 
ISTERED WITH  POTASSIUM  CYANIDE  IN  A  DOG. 
Constant  diet  of  cracker  meal,  lard,  bone  ash,  and  water. 


Date. 


Creatinine 
injected, 
grammes. 


11   0.0 

12   2.936 

13   2.936 

14   2.936 


IS- 


18. 


;.0I5 
J.0I5 


2.015 


KCN  (milli- 
grammes per 
kilogramme  of 
weight). 


1.8,  1 .8.  1 .2.  I . 
1.8.  1.8.  1 .8.  I . 


19   2.015 


.4.  2.4,  2.4 
.4,  2.4.  2.4, 
.4,  2.4,  2.4 


Average, 
0.24 

.\verage, 
2 .627 


Average, 
1 .667 


1.644 


Creatinine  lost  after  administration  of  creatinine 
alone,  eighteen  per  cent. 

Creatinine  lost  after  administration  of  creatinine 
and  KCN.  twenty-nine  per  cent. 

Further  investigation  will  be  required  to  solve 
these  puzzles  of  metabolism.  The  fact  that  most 
of  the  changes  are  probably  due  to  disturbances  of 
oxidation,  with  variations  in  their  effects,  may  ulti- 
mately help  to  throw  light  on  some  of  the  obscure 
oxidative  processes  of  metabolism. 

The  data  now  at  hand  from  microscopical  exam- 
ination of  the  organs  of  these  dogs  gives  a  sugges- 
tion of  what  visceral  activities  may  be  involved,  for 
it  was  found  that  while  the  liver  was  most,  and  the 
kidney  least  affected  in  the  "loiv  nitrogen  dogs" 
(marked  parenchymatous  degeneration  of  the  liver 
cells  and  nearly  normal  kidneys),  the  liver  was  least 
and  the  kidney  most  affected  in  the  "high  nitrogen 
dogs."  In  these  dogs  there  was  mild  parenchyma- 
tous degeneration  of  the  liver  cells,  mild  parenchy- 
matous degeneration  of  the  cells  of  the  convoluted 
tubules  of  the  kidneys,  and  a  slight  increase  of  the 
connective  tissue,  especially  about  the  bloodvessels 
in  the  neighborhood  of  the  glomeruli.  This  lesion 
is  the  sanie  as  that  found  in  the  creatine  adminis- 
tration experiments  referred  to  in  the  next  chapter, 
and  has  a  suggestive  similarity  to  the  kidney  lesions 
seen  in  the  early  stages  of  chronic  diffuse  nephritis. 

TABLE  XX.— RETENTION  01-"  CREATININE  WHEN  ADMIN- 
ISTERED WITH  POTASSIUM  CYANIDE  IN  A  FASTING 
DOG. 

KC'.V             Creatinine  Creatinine 

administered,    administered,  excreted. 

Day.              c.c.             grammes.  grammes. 

19                   0.0                  0.0  0.2358 


23- 
24- 

»5- 

S6. 

a?. 

28. 
29. 
30. 


0.0 

0.0 
0.0 

1.8 
1.8 
1.8 

1.8 

1.8 


0.0 
0.0 
0.0 

1.27 
1.27 
1 .27 

0.0 

0.0 

1 .27 
1 . 27 
1.27 


0.0970      I     Daily  average, 
0.0972      I  0.1417 
0.1371 


0.5026 
0.9945 
0.8175 

0.1688 
0.0798 


(.  Daily  average, 
i  0.771S 

(     Daily  average, 
0.1243 


0.8640     ^  ., 

0.0476  p>a'iy 

0.57.2  j 


average, 
4942 


Average  creatinine  excretion  after  administration 
of  creatinine  and  KCN.  0.6328  gramme. 

Percentage  of  creatinine  not  excreted  as  such. 
61.3  per  cent. 

{To  be  continued.) 


THE  THERAPEUTIC  USE  OF  ALCOHOL  IN 
INTERNAL  MEDICINE. 

By  George  B.  Twitchell,  M.  D.. 
Cincinnati,  Ohio. 

The  present  crusade  against  the  use  of  alcohol  as 
a  beverage  has  had  quite  an  effect  on  its  use  as 
a  medicine.  More  and  more  physicians  are  dis- 
continuing its  use  until  now  it  seems  threatened 
with  the  fate  that  befell  calomel  some  fifty  years 
ago.  Calomel  regained  its  place  in  therapeutics,  and 
no  doubt  alcohol  will.  I)ut  let  us  hope  without  a 
long  continued  period  of  nonuse. 

An  interesting  point  of  similarity  between  the  old 
history  of  calomel  and  the  present  history  of  alco- 
hol is  the  variance  of  opinion  among  observers  as 
to  its  physiological  action.  The  present  question  as 
to  whether  alcohol  is  a  food  or  not,  whether  it  is  a 
true  stimulant  or  not,  sounds  not  unlike  the  old  dis- 
cussion of  the  action  of  calomel  on  the  liver. 

Our  knowledge  of  drugs  and  their  uses  is  after 
all  empirical.  And  while  our  laboratories  have 
taught  us  much  it  must  be  remembered  that  opium 
relieved  pain  and  that  digitalis  stimulated  the  heart 
long  before  man  dreamed  of  laboratory  experi- 
ments. 

I  believe  that  even  to-da\"  we  must,  while  we 
avail  ourselves  of  all  scientific  researches,  consider 
that  our  use  of  alcohol  is  laro-ely  empirical,  and  so 
in  this  discussion  the  questions  of  physiological 
action  will  be  avoided. 

It  is  a  matter  of  clinical  observation  that  a  man 
in  bed  with  a  high  fever  can  take  much  larger  doses 
of  alcohol,  without  producing  signs  of  intoxication, 
than  can  a  man  in  ordinary  health.  This  does  not 
mean  that  therefore  alcohol  must  be  good  for  him. 
but  it  does  mean  that  if  it  is  indicated  at  all  the 
dosage  must  be  accordingly  large.  No  one  would 
try  to  relieve  a  severe  renal  colic  with  the  same  dose 
of  morphine  he  might  use  in  allaying  an  irritating 
cough. 

In  few  of  the  acute  febrile  conditions  do  we  find 
so  great  a  tolerance  for  alcohol  -as  in  lobar  pneu- 
monia, and  I  believe  that  in  this  disease  the  use  of 
alcohol  and  sometimes  the  extremely  free  use  of 
alcohol  (a  quart  of  whiskey  in  twenty-four  hours) 
has  positively  saved  many  lives.  In  alcoholic  pneu- 
monias its  use  is  very  important  to  prevent  the  ner- 
vous disturbance  its  discontinuance  would  arouse, 
but  in  the  nonalcoholic  its  value  appears  as  a  thera- 
peutic agent  pure  and  simple.  Of  course  it  should  not 
be  used  in  every  case.  In  children  it  is  rarely  needed. 
Many  cases  in  adult  life  do  well  without  alcohol. 
In  the  severer  forms  of  the  disease,  however,  its 
value  is  very  great.  The  pulse  and  the  first  heart 
sound  are  the  best  indications  of  its  need.  This 
means  of  course  that  definite  rules  for  its  use  can- 
not be  given.  While  this  is  true  of  every  active 
drug  it  is  esnecially  true  of  alcohol. 

The  experienced  clinician  must  determine  the 
dosage.  W'hrn  alcohol  is  properly  used,  we  often 
find  decided  improvement  in  wliat  before  had 
seemed  a  lost  case.  The  temperature  comes  down 
a  little,  the  pulse  is  quieted  and  strengthened,  and 
a  flush  comes  over  a  formerly  livid  face.  Keep  the 
alcohol  up  and.  this  condition  will  often  persist  to 
the  crisis. 

T!ie  discontinuance  of  the  remedv  can  often  be 


"May  22,  1909.] 


CORRESPOSDEXCE. 


1053 


abrupt  without  bad  effects.  Sometimes  it  should 
be  gradually  discontinued.  Here  again  it  is  often 
the  art  rather  than  the  science  that  proves  to  be 
«he  guide. 

Oi  course  alcohol  is  a  narcotic  poison,  and  it 
would  be  as  objectionable  in  pneumonia  as  in  health 
were  it  not  for  the  more  than  compensating  good 
it  accomplishes.  But  what  drug  of  any  value  do  we 
use  that  is  not  a  poison  ? 

The  great  trouble  in  the  use  of  alcohol  in  this 
disease  and  \\hat  has  often  led  to  unsatisfactory  re- 
sults is  its  use  in  too  small  doses.  This  is  especially 
true  now  when  we  hear  so  much  of  its  poisonous 
qualities  and  our  "native  hue  of  resolution"  is  too 
apt  to  be  "sicklied  over  by  the  pale  cast  of  thought 
and  lose  the  name  of  action." 

The  dosage  must  be  free  ;  it  is  better  to  rely  on 
other  drugs  than  to  give  small  doses  of  alcohol  in 
a  perfunctory  way.  Whiskey  is  usually  the  most 
reliable  form  to  be  had.  At  times  a  quart  in  twen- 
ty-four hours  has  proved  to  be  not  too  much.  This 
of  course  is  not  routine  treatment.  Some  patients 
do  not  tolerate  alcohol  at  all.  Even  where  large 
doses  of  alcohol  have  been  used  in  pneumonia  there 
is  no  more  danger  of  the  patient  acquiring  the  al- 
cohol habit  than  there  is  of  his  acquiring  the  am- 
monium carbonate  habit. 

I  have  described  rather  briefly  the  use  of  our 
drug  in  pneumonia  as  a  type  of  its  use.  In  septic 
conditions  generally  it  is  very  valuable.  In  pyaemia,  in 
septichaemia.  and  in  the  suppurating  stage  of  small- 
pox it  is  a  great  help  to  the  physician.  In  typhoid 
fever  especially  toward  the  end  when  we  have  to 
deal  wnth  a  septic  fever  which  in  a  worn  out  patient 
may  be  dangerous  its  use  is  very  valuable,  nor  may 
we' dread  any  untoward  effect  it  may  have  on  the 
ulcerated  Peyer's  glands  if  indeed  it  ever  reaches 
them. 

And  now  as  to  "a  little  wine  for  the  stomach's 
sake."  Can  alcohol  help  digestion?  Probably  not. 
However  a  drink  of  wine  or  whiskey  will  often 
allay  an  uncomfortable  feeling  in  the  stomach. 

In  cases  of  ptomaine  poisoning  a  good  dose  of 
alcohol  in  some  form  will  relieve  symptoms. — 
sometimes  even  alarming  ones. — that  are  left  after 
a  thorough  cleansing  of  the  alimentary  tract.  Prob- 
ably when  wines  are  useful  in  dyspepsia  we  are 
dealing  with  mild  forms  of  ptomaine  poisoning. 

A  drink  of  whiskey  will  often  increase  an  appe- 
tite, but  whether  that  does  much  good  or  not  is  an- 
other question.  Beer.  ale.  and  wine  have  been  used 
with  apparently  good  results  in  convalescence  and 
in  wasting  diseases. 

In  cases  including  dyspepsia  in  which  the  drug 
is  continued  some  time  and  the  patient  is  not  very 
sick  the  possibility  of  forming  an  alcohol  habit  must 
be  considered.  Fortunately  in  such  cases  alcohol  is 
not  needed,  indeed  we  can  usually  do  much  better 
without  it. 

Envoy. 

Through  all  the  antialcohol  talk  of  the  present 
day  I  can  still  hear  the  words  of  my  brave,  old 
teacher — the  greatest  surgeon  of  his  day — who. 
when  leaving  a  case  of  pneumonia  or  apparently- 
hopeless  sepsis,  would  add  as  a  final  admonition 
"and  the  whiskey  is  not  to  be  measured." 

1616  Freem.^n  Avenue. 


Coms^onljencf. 


LETTER  FROM  LONDON. 

Cervical  Ribs. — Nurses'  Qualifications. — Alleged  Frauds  in 
Life  Insurance. 

LoxDox,  May  4.  igog. 
At  the  meeting  of  the  Medical  Society  of  London 
on  April  26th  several  ver\"  interesting  cases  were 
exhibited.  Dr.  F.  Parkes  ^^  eber  showed  a  case  of 
symmetrical  atrophy  of  the  hand  muscles  occurring 
in  a  girl,  aged  thirteen.  There  was  marked  wasting 
of  the  thenar,  the  hypothenar.  and  the  intermeta- 
carpal regions  in  the  right  hand,  and  to  a  less  ex- 
tent in  the  left  hand.  Reaction  to  faradism  was 
much  reduced  or  altogether  absent  in  the  muscles 
of  the  right  hand.  The  right  hand  was  weaker  and 
usually  felt  colder  than  the  left.  The  dynamome- 
ter grasp  in  the  right  hand  was  5  and  in  the  left 
hand  15.  There  was  no  absolute  anaesthesia,  but 
there  was  decided  diminution  of  sensibility,  especial- 
ly to  temperature,  on  the  ulnar  side  of  the  right  up- 
per extremity.  The  patient  complained  of  pain  in 
the  front  of  the  right  arm  and  forearm  and  some- 
times in  the  hand.  A  skiagram  showed  a  small 
cervical  rib  (or  enlarged  transverse  process)  on 
each  side,  but  the  one  on  the  right  side  was  the 
bigger  of  the  two.  and  its  extremity  appeared  almcst 
to  touch  the  first  dorsal  rib.  They  could  not  be 
felt  on  palpation.  The  interesting  fact  was  that  a 
brother  and  sister  of  the  patient  both  showed  cer- 
vical ribs  on  skiagraphic  examination.  The  father, 
however,  was  found  free  from  this  abnormity,  and 
it  was  impossible  to  make  an  examination  in  the 
case  of  the  mother.  The  family  history  confirmed 
the  observations  of  Theodore  Thompson  and  others 
that  the  presence  of  a  cervical  rib  was  a  family  pe- 
culiarity. The  connection  between  symmetrical 
atrophy  of  the  intrinsic  muscles  of  the  hand  and 
the  presence  of  seventh  cervical  ribs  had  been  ex- 
plained by  the  writings  of  Thorburn,  Lewis  Jones, 
and  others.  It  appeared  that  the  pressure  of  the 
supernumerary  rib  on  the  first  dorsal  nerve  root  was 
the  cause  of  the  wasting  of  the  intrinsic  muscles  of 
the  hand.  Dr.  Guthrie  pointed  out  that  the  ulnar 
side  of  the  left  hand  of  the  patient  showed  a  differ- 
ent temperature  from  that  on  the  radial  side,  and 
said  that  the  condition  might  be  produced  by  in- 
volvement of  the  first  dorsal  and  last  cerA'ical  nerves. 

A  nursing  and  midwifery  conference  was  held  in 
London  during  last  week  at  the  Grafton  Galleries. 
Bond  Street.  It  continued  for  four  days  under  the 
chairmanship  of  Mrs.  Stephen  Glanville.  Many 
questions  important  to  nurses  and  midwives  were 
dealt  with  in  a  series  of  debates.  Dr.  T.  O.  Wood, 
in  reviewing  the  present  position  in  the  nursing 
world,  said  that  the  chief  want  felt  was  a  uniform 
system  of  training,  examination,  and  certification, 
that  a  definite  standard  of  proficiency  might  be 
reached  which  would  entitle  successful  candidates 
to  a  qualification,  not  of  this  or  that  hospital,  which 
might  be  a  variable  quantity,  but  of  one  great  quali- 
fying body.  Nurses  might  broadly  be  divided  into 
the  following  classes;  i.  Those  trained  at  general 
hospitals  in  both  medical  and  surgical  nursing.  2. 
General  hospital  nurses  who  had  in  addition  special 


1054 


THERAPEUTICAL  NOTES. 


[New  York 
MzoicAL  Journal. 


hospital  training,  as  in  fever,  at  children's  hospitals. 
3.  Obstetric  nurses  or  midwives.  4.  Male  and  fe- 
male nurses  trained  in  asylums  to  attend  upon  the 
insane.  He  referred  to  the  several  organizations 
that  existed  to  register  these  classes,  namely,  the 
Royal  British  Xurses'  Association,  which  was  form- 
ulating regulations  for  the  state  registration  of 
nurses,  and  the  Medicopsychological  Association  of 
Great  Britain  and  Ireland,  which  had  already  one 
uniform  standard  of  training,  examination,  and  cer- 
tification throughout  the  Kingdom  and  the  colonies. 
Other  speakers  also  favored  the  principle  of  state 
registration.  On  the  last  day  Dr.  David  Walsh 
dealt  very  interestingly  with  the  question  of  hospi- 
tal accommodation  for  the  middle  classes. 

An  interesting  legal  action  was  tried  recently.  At 
the  Glamorgan  Assizes,  held  on  April  5th,  two  med- 
ical men  appeared  to  answer  to  indictments  pre- 
ferred .by  the  Colonial  Mutual  Life  Assurance  So- 
ciety, Limited,  charging  them  with  obtaining  from 
the  societv  by  false  pretenses  certain  sums  of  money 
and  with  conspiring  to  obtain  various  policies  of  as- 
surance. The  money  referred  to  consisted  of  los. 
6d.  for  examining  and  reporting  on  persons  to  be 
insured,  and  the  other  charge  implied  that  the  de- 
fendants had  combined  with  an  agent  of  the  society 
to  defraud  the  society  by  helping  to  bring  about  the 
issue  of  policies  which  would  have  been  refused  if 
the  society  had  had  full  information  with  regard  to 
them.  When,  however,  the  case  was  called,  coun- 
sel for  the  prosecution  asked  permission  to  with- 
draw the  prosecution,  and  this  was  accorded,  the 
judge  intimating  that  from  a  perusal  of  the  deposi- 
tions he  was  satisfied  that  there  had  been  no  crim- 
inal intent  on  the  part  of  the  defendants,  although 
there  had  been  very  great  negligence.  The  evidence 
given  before  the  magistrate  showed  that  both  de- 
fendants, when  asked  to  do  so  by  the  local  agent 
of  the  insurance  company,  had  signed  reports  relat- 
ing to  the  physical  fitness  for  insurance  of  certain 
proposed  lives  without  making  any  physical  exam- 
ination of  the  persons  named  in  their  reports.  In 
the  cases  which  formed  the  subject  of  the  inquiry 
the  persons  to  be  insured  were  not  aware  that  poli- 
cies on  their  lives  were  being  taken  out,  and  one 
of  them  had  died  before  the  case  came  before  the 
magistrate.  The  medical  men  had  not  intended  to 
defraud.  They  were  acquainted  with  the  persons 
as  to  whose  bodily  health  they  deposed,  and  one 
of  them,  when  he  was  before  the  magistrate,  point- 
ed out  that  if  a  woman  as  to  whom  he  had  signed 
a  report,  and  who  had  been  his  patient  on  past  oc- 
casions, had  been  asked  to  allow  an  examination 
and  had  refused,  he  could  have  marked  the  papers 
"refused,"  and  would  then  have  been  entitled  to  his 
fee  of  los.  6d.  just  the  same.  This  case  showed  that 
some  companies  still  pay  only  los.  6d.  for  a  medical 
examination,  although  it  has  been  decided  by  various 
medical  associations  that  the  fee  is  insufficient. 

 e  


Therapeutics  of  Hedge  Mustard  and  Leeks. — 

In  an  article  contributed  to  the  Bulletin  <^ciie)'al  de 
thcrapeutique  (cited  by  The  Pharmaceutical  Journal 
awl  Pharmacist  for  March  27,  1909)  Saintignon 


comments  on  the  therapeutic  value  of  leek  mucilage 
and  of  an  infusion  or  a  syrup  of  the  common  hedge 
mustard,  Sisymbrium  oificinale.  The  latter  was  offi- 
cial in  the  Codex,  1884.  but  has  been  discarded.  It 
is  stated  that  the  plant  is  of  real  value  for  the  treat- 
ment of  inflammatory  affections  of  the  pharyngeal 
or  laryngeal  mucous  membrane,  such  as  laryngitis 
and  catarrh,  either  acute  or  chronic.  An  infusion  of 
the  leaves,  taken  as  such,  or  as  syrup,  will  rapidly 
cure  an  acute  attack,  often  in  twenty-four  hours,  and 
in  chronic  cases  in  a  few  days.  It  is  specially  valu- 
able in  simple  laryngitis.  It  has,  besides,  distinct 
expectorant  and  diuretic  properties. 

Although  the  emollient  and  expectorant  properties 
of  mucilage  of  leeks  was  known  and  recorded  by 
Aristotle,  the  real  medicinal  value  of  the  prepara- 
tion has  been  forgotten.  It  is  prepared  by  boiling 
leeks  until  the  acrid  volatile  oil  has  been  dissipated, 
and  evaporating  the  expressed  decoction  to  the  con- 
sistence of  a  mucilage.  This  has  an  elective  emolli- 
ent action  on  the  pharyngeal  mucous  membrane, 
which  renders  it  a  remedy  of  great  value  in  catarrhal 
attacks,  both  acute  and  chronic.  It  rapidlv  allays 
congestion,  and  is  expectorant  and  detersive.  It  also 
exerts  a  diuretic  action.  Leek  mucilage  appears  to 
be  a  remedy  of  real  value  for  these  cases. 

The  Therapeutics  of  Calcium  Salts  and  of  Cit- 
rates.— In  Part  II  of  a  Clinical  Causerie  pub- 
lished in  Folia  Therapcntica  for  April,  1909,  the  au- 
thor speaks  of  the  present  popularity  of  calcium  lac- 
tate and  sodium  citrate  with  special  reference  to  the 
physiological  role  they  play.  In  doses  of  thirty 
grains  every  other  day  calcium  lactate  has  been 
found  very  beneficial  in  amenorrhoea  following  acute 
or  debilitating  diseases.  It  is  assumed  here  that  an 
insufficiency  of  calcium  prevents  menstruation. 
When  undigested  curds  appear  in  the  motions  of  in- 
fants artificially  fed  sodium  citrate  is  indicated. 
Cows'  milk  is  very  rich  in  calcium,  and  the  casein 
formed  from  it  is  quite  tough.  Sodium  citrate  be- 
ing capable  of  forming  a  double  salt  with  calcium, 
the  addition  of  it  to  cows'  milk  tends  to  produce  a 
digestible  casein.  Two  grains  of  the  salt  m  an  ounce 
of  milk  is  sufficient  to  yield  a  very  fine  and  soft 
casein.  For  this  purpose  it  is  convenient  to  order 
the  following  prescription,  with  the  directions  that 
one  teaspoonful  be  added  to  each  ounce  of  milk: 

R     Sodium  citrate  gr.  Ixiv; 

Oil  of  peppermint  gtt.  ii;. 

Distilled  water,   5v. 

.Some  authorities  hold  that  the  thrombosis  which 
so  often  follows  typhoid  fever  is  due  to  the  exclusive 
milk  diet  usually  prescribed  in  this  disease.  The 
moral  is  to  add  sodium  citrate  to  the  milk  when  this 
is  to  form  the  staple  diet  over  a  prolonged  period. 

For  patients  whose  blood  coagulability  is  low  Dr. 
Luff  prescribes  calcium  lactate  as  being  more  pleas- 
ant and  soluble  than  the  chloride.  The  vehicle  he 
suggests  is  one  half  minim  of  tincture  of  capsicum 
and  one  ounce  of  chloroform  water  for  fifteen  grains 
of  the  lactate.  In  giving  this  it  is  necessary  to  see 
that  the  stomach  is  empty  at  the  time  of  taking, 
otherwise  the  phosphates  of  the  food  may  precipitate 
it.  For  a  stmilar  reason  saline  aperients  must  be 
interdicted,  and  other  laxatives  used  to  counteract 
the  constipation  usually  set  up  by  calcium  salts. 


May  22,  1909.] 

NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

Philadelphia  Medical  Journal 
and  The  Medical  News. 

A  Weekly  Review  of  Medicine. 

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FRANK  P.  FOSTER,  M.  D. 

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John  M.  Swan,  M.  D., 
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NEW  YORK,  S.\TURU.AY,  M.AY  22,  1909. 


A  STEP  TOW  ARD  UNITY. 

We  learn  that  the  Board  of  Regents  of  the  L'ni- 
versity  of  Minnesota  lately  took  action  which,  it 
is  thought,  practically  eliminates  all  questions  of 
"school""  in  the  medical  profession  of  the  State.  ( )n 
May  6th  they  passed  a  s.ries  of  resolutions  setting 
forth  that,  after  mature  consideration,  they  found 
no  differences  of  teaching  in  the  nonsectarian  and 
the  homoeopathic  departments  of  the  medical  school 
such  as  wouM  justify  the  maintenance  of  a  sep- 
arate homoeopathic  college.  In  view  of  this  fact, 
they  woitld  discontinue  the  homoeopathic  college, 
allowing  two  professorships  to  stand — that  of  ho- 
moeopathic materia  medica  and  that  of  homoeopathic 
therapeutics — the  teaching  in  each  of  them  to  be 
didactic  purely.  .Any  student  might  choose  between 
the  regular  materia  medica  and  therapeutics  and 
the  homoeopathic ;  if  he  elected  the  latter,  he  would 
thereby  become  a  homoeopath  and  his  diploma 
should  so  read. 

It  seems  that  the  legislature  had  appropriated 
$50,000  for  the  erection  of  a  new^  building  on  the 
university  grounds  for  the  use  of  the  homoeopathic 
medical  school,  and  this,  too,  in  face  of  the  fact 
that  the  homoeopathic  faculty,  made  up  of  twent\- 
six  men,  was  teaching  only  three  students — one 
senior  and  two  juniors,  no  sophomores  and  no 
freshmen  having  been  registered  for  the  course.  It 
was  felt  that  under  the  circumstances  the  continued 
maintenance  of  an  entire  homoeopathic  faculty,  to 


105.5; 

say  nothing  of  a  new  separate  building,  would  be 
an  unjustifiable  use  of  the  public  funds.  It  is  dif- 
ficult to  see  on  what  grounds  the  soundness  of  this 
feeling  can  be  questioned.  So  far  as  we  are  aware, 
nobody  pretends  that  a  homoeopathic  student  re- 
quires teaching  dift'erent  from  that  of  other  med- 
ical students,  save  in  materia  medica  and  thera- 
peutics, and  it  follows  that  duplicated  chairs  and 
laboratories  pertaining  to  the  other  branches  of  the 
curriculum  are  unwarranted. 

We  understand  that  this  is  the  first  instance  in 
which  the  authorities  of  a  State  school  have  taken- 
action  to  do  away  with  needless  distinctions  between 
the  requirements  of  homoeopathic  students  and  those 
of  other  students  of  medicine,  and  it  is  our  opinion 
that  the  University  of  Minnesota  is  deserving  of 
great  credit  for  thus  taking  the  initiative.  It  is  to 
be  hoped  that  other  State  universities  will  follow- 
the  example.  The  present  feeling  in  the  medical 
profession,  unless  we  grossly  misinterpret  it.  is  t") 
the  effect  that  any  physician  has  a  right  to  practise 
in  accordance  with  his  convictions,  but  that  he  must 
have  a  regular  medical  education,  and  that  to  af- 
ford the  means  of  such  education  expensive  plants 
must  be  provided  and  kept  up — so  expensive  that 
their  duplication  to  suit  theoretical  ideas  is  an  in- 
tolerable weakening  of  the  total  of  appliances  re- 
quired. 

Furthermore,  in  its  corporate  capacity  the  pro- 
fession must  make  as  close  an  approach  a?  possible 
to  unanimity.  It  is  most  regrettable  that  in  the 
past  certain  diff'erences  of  opinion  have  served  to 
keep  alive  an  attitude  of  antagonism.  Of  late  years, 
whenever  this  state  of  things  has  been  thrust  into 
the  background,  as  has  happened  on  several  oc- 
casions, the  profession  as  a  whole  has  profited  by 
the  fact.  It  is  to  be  expected,  we  think,  that  the 
action  of  the  University  of  Minnesota  will  be  favor- 
able to  unanimitv  in  everything  but  admissible  dif- 
ferences of  opinion. 


THE  NECROTIC  AXGIXA  OF  SCARLET 
FEVER. 

Necrotic  angina  is  not  an  infrequent  complication  ■ 
of  scarlet  fever,  and  Girou  {Archives  de  incdecinc 
des  enfants,  November,  1908)  has  observed  twelve - 
cases  in  a  few  months  and  has  pointed  out  the  im- 
portant characters.    This  angina  may  appear  at  any 
time  during  the  disease.     In  certain  cases  it  is  pre- 
ceded by  a  nongangrenous  primary  angina,  and  it  is  . 
only  after  si.x  or  eight  days  that  it  takes  on  the  ne- 
crotic aspect.    If  the  angina  is  necrotic  from  the 
start,  the  slough  appears  within  forty-eight  hours. 

At  the  most  characteristic  period  of  the  affection  ■ 
the  tonsils,  the  posterior  pillars,  and  occasionally  the  • 


EDITORIAL  ARTICLES. 


1056 


EDITORIAL  ARTICLES. 


[NevV  Vurk 
JIedical  Jolrxal. 


uvula  and  posterior  portion  of  the  velum  are  in- 
volved, but  the  anterior  pillars  are  always  free.  The 
mucosa  throughout  this  entire  extent  becomes  gray- 
ish, while  in  certain  spots  yellow  or  blackish  points 
appear.  The  parts  bleed  easily  and  the  slightest 
contact  produces  small  haemorrhages,  but  the  essen- 
tial character  is  that  the  layer  of  slough  cannot  be 
detached  from  the  underlying  surface  ;  it  adheres  in- 
timately and  portions  of  it  can  be  removed  only  at 
certain  points  where  the  gangrene  is  the  most  ad- 
vanced. Consequently  this  angina  can  be  distin- 
guished from  others  having  false  membranes  by  the 
dif¥erence  in  the  consistence,  adhesion,  and  color  ol 
the  latter. 

Necrotic  angina  gives  rise  to  a  decided  nasal  dis- 
charge, the  breath  is  foetid,  and  the  process  may  ex- 
tend to  the  conjunctiva,  middle  ear,  or  mastoid.  The 
temperature  remains  high,  the  general  condition  is 
bad,  and  the  pulse  is  small.  Albuminuria  is  usually 
absent.  When  these  patients  do  not  die  from  gen- 
eral infection,  the  improvement  is  often  very  rapid, 
and  at  the  end  of  several  days  only  a  few  large  and 
deep  ulcerations  on  the  tonsils  remain.  -  The  prog- 
nosis is  governed  by  the  general  condition  of  the 
patient.  Girou  found  the  streptococcus  and  occa- 
sionally the  staphylococcus.  As  to  treatment,  large 
irrigations  of  a  solution  of  hydrogen  peroxide  should 
be  used  and  local  applications  of  a  two  per  cent,  so- 
lution of  zinc  chloride  or  iodine  and  glycerin  should 
be  resorted  to.  The  general  treatment  should  be 
carefully  followed  out,  the  usual  tonics  being  em- 
ployed. 

STREPTOTRICHIASIS. 

There  is  a  group  of  infections,  more  or  less 
widespread  geographically,  the  causes  of  which  are 
a.  group  of  organisms,  of  somewhat  uncertain  sys- 
tematic position,  that  offer  a  fertile  field  for  in- 
vestigation. Two  of  the  best  known  examples  of 
this  group  are  actinomycosis  and  Madura  foot. 
From  both  thesa  diseases  organisms  have  been 
isolated  which  bear  certain  resemblances  to  each 
■other,  but  have  distinguishing  features.  From 
the  lesions  of  a  disease  occurring  in  the  Philip- 
pine Islands,  which  is  similar  in  its  course  and 
symptomatology  to  Madura  foot,  Musgrave  and 
Clegg  isolated  in  1907  an  organism  which  they 
named  Streptothrix  Freeri.  Recently  {Philippine 
Journal  of  Science,  Section  B.  December,  1908) 
they  have  published  an  exhaustive  study  of  the 
subject  of  infection  with  organisms  of  this  class. 

The  original  work  consisted  of  a  study  of  the 
biological  characteristics  of  twelve  cultures  of 
streptothrix  obtained  from  various  sources,  with 
animal  inoculations  for  the  purpose  of  elucidating 


their  pathogenesis.  One  result  of  this  study  was 
to  show  that  Streptothrix  Freeri,  which  had  been 
ihought  to  be  a  distinct  species,  was  identical  with 
Streptothrix  Eppingeri,  isolated  by  Eppinger  in 
1890.  The  authors  have  adopted  the  name  Strep- 
tothrix Cohn,  1875,  for  the  genus  in  spite  of  the 
fact  that  nocardia  has  priority.  The  principal 
characters  of  the  organisms  are  their  branching, 
filamentous  morphology,  the  fact  that  they  develop 
into  colonies  made  up  of  the  organisms  and  trans- 
formation products,  their  positive  reaction  with  the 
Gram  stain,  and  the  tendency  of  the  terminal 
hyphae  to  develop  "clubs." 

By  the  term  "streptothricosis"  (to  which  wc 
prefer  streptotrichiasis)  the  authors  mean  an  in- 
fectious disease  of  man  and  animals  caused  by  one 
or  more  species  of  streptothrix,  characterized  ana- 
tomically by  a  peculiar  low  grade  inflammation. 
This  process  is  accompanied  by  suppuration,  and 
the  pus  contains  granules  made  up  principally  of 
colonies  of  the  organism.  The  infection  probably 
takes  place  by  the  respiratory  and  gastrointestinal 
tracts  as  well  as  by  direct  wound  infection. 

The  following  clinical  varieties  of  the  infection 
are  recognized  :  Generalized,  abdominal,  thoracic, 
cerebral,  and  external.  Of  all  these  forms,  strepto- 
trichiasis pedis,  Madura  foot,  or  mycetoma,  is  the 
most  common.  The  lesions  resemble  those  pro- 
duced by  Bacillus  tuberculosis  very  closely.  The 
infection  requires  surgical  means  for  its  relief,  and 
often  amputation  of  the  affected  part  is  necessary. 
Large  doses  of  potassium  or  sodium  iodide  have 
given  good  results  when  administered  for  long 
periods  of  time,  particularly  when  the  infection  in- 
volves parts  of  the  body  not  readily  accessible  for 
surgical  intervention. 


SIMPLE  ACUTE  THYREOIDITIS. 

A  writer  in  the  Scmaiiic  medicalc  for  May  5th 
remarks  that,  while  we  have  knowledge  of  the  acute 
inflammations  of  the  thyreoid  gland  which  occur  in 
the  course  of  such  febrile  infective  diseases  as  ty- 
phoid fever,  cholera,  diphtheria,  measles,  and  acute 
articular  rheumatism,  primary  simple  thyreoiditis 
seems  to  be  a  disease  of  exceptional  rarity.  He 
therefore  thinks  that  a  case  recently  reported  by  Dr. 
E.  Weber  (Revue  inedicale  de  la  Suisse  roniaiide, 
March)  is  deserving  of  attention. 

The  patient  was  a  woman,  sixty-seven  years  old. 
who  had  been  .gouty  for  a  great  many  years.  Tiie 
disease  attacked  her  suddenly  after  a  fit  of  indiges- 
tion. The  right  lobe  of  the  thyreoid  gland  was  aug- 
mented in  volume  and  of  a  hard  consistence.  At 
the  same  time  serious  general  symptoms  made  their 


May  22,  igog.] 


EDITORIAL  ARTICLES. 


1057 


appearance.  Sleeplessness  and  loss  of  appetite 
were  very  pronounced,  the  patient  complained  of 
pains  in  all  her  limbs,  and  already  it  was  noticed 
that  she  had  decidedly  lost  flesh.  A  month  later  the 
right  lobe  was  found  to  have  become  reduced  in 
size,  while  the  left  lobe  in  turn  showed  enlargement 
and  the  patient  had  lost  more  than  eleven  pounds 
in  weight.  At  the  end  of  a  few  weeks  more  it  was 
observed  that  the  median  lobe  was  participating  in 
the  inflammation.  Then  there  followed  a  rather 
rapid  and  progressive  improvement  which  ended  in 
recovery,  though  the  two  lateral  lobes  still  remained 
voluminous. 

It  was  found  impossible  to  settle  upon  the  point 
of  entrance  of  the  infecting  agent  which  had  given 
rise  to  this  thyreoiditis,  but  the  suggestion  is  made 
that  perhaps  the  attack  was  the  result  of  an  unrec- 
ognized inflammatory  affection  of  the  throat.  From 
the  therapeutic  point  of  view,  the  writer  thinks  it 
important  to  avoid  the  employment  of  preparations 
of  iodine,  for,  he  says,  they  only  aggravate  the 
symptoms.  It  is  better,  he  remarks,  to  confine  our- 
selves to  disinfection  of  the  digestive  passages  and 
to  the  application  of  revulsives  to  the  thvreoid  re- 
gion. 


FOOT  AND  MOUTH  DISEASE  AND 
CONTAMINATED  VACCINE. 

An  interesting  investigation  of  the  source  and 
avenues  of  conveyance  of  the  latest  outbreak  of 
foot  and  mouth  disease  in  the  United  States  has 
recently  been  carried  on  jointly  by  the  Bureau  of 
Animal  Industry  and  the  Public  Health  and  ^Marine 
Hospital  Service,  and  the  conclusions  reached  have 
now  been  published.  It  appears  from  the  report 
that  the  epizootic  was  introduced  by  contaminated 
vaccine  imported  from  a  foreign  country.  Such  a 
breadth  of  metonymy  has  of  late  years  been  ac- 
corded to  the  word  vaccine — rather  unwarrantably, 
we  think — that  it  may  be  noted  in  passing  that  the 
authors  of  the  report  find  it  necessary  to  specify 
that  they  mean  "smallpox  vaccine." 

The  country  from  which  the  foreign  vaccine  was 
obtained  is  not  mentioned.  It  was  imported  by  the 
H.  K.  ]\Iulford  Company,  of  Glen  Olden.  Pa.,  and 
some  vaccine  of  the  same  strain  seems  to  have  been 
procured  from  that  company  by  Parke,  Davis,  & 
Co..  of  Detroit.  It  appears  that  the  calves  used  as 
vaccinifers  by  the  ]\Iu!ford  company  are  killed 
soon  after  the  virus  is  taken  from  them,  so  that 
they  did  not  spread  the  foot  and  mouth  disease.  On 
the  other  hand,  the  calves  employed  by  the  Detroit 
firm  are  put  upon  the  market  after  having  served 
as  vaccinifers.  In  this  way  they  conveyed  the  in- 
fection through  the  stock  yards  of  Detroit  and  Buf- 


falo to  certain  farms  in  Michigan,  New  York,  and 
Pennsylvania,  and  to  one  locality  in  Maryland. 

The  resulting  epizootic  was  not  extensive,  but  it 
involved  great  financial  loss,  no  less  than  $300,000 
having  been  expended  by  the  Federal  government 
alone  in  its  eradication.  It  is  now  completely  exter- 
minated, and  quarantine  on  the  last  of  the  infected 
territory  was  raised  on  April  24th.  No  blame  is 
attached  to  either  the  Alulford  company  or  Parke. 
Davis,  &  Co.,  though  under  the  law  it  was  necessary 
to  suspend  their  vaccine  licenses  for  a  time.  In- 
deed, both  firms  are  credited  with  intelligent  and 
prompt  cooperation  in  the  destruction  of  all  sus- 
pected vaccine  on  hand.  It  is  believed  that  there  is 
not  now  on  the  market  any  vaccine  contamiiiated 
with  the  virus  of  foot  and  mouth  disease,  and  regu- 
lations have  been  formulated  with  a  view  to  pre- 
venting hereafter  the  propagation  of  contaminated 
vaccine. 

In  this  outbreak  there  appears  to  hav^  been  no 
instance  of  the  communication  of  foot  and  mouth 
disease  to  the  human  subject,  and  the  investigators 
doubt  its  communicability  in  cutaneous  vaccination 
as  ordinarily  performed.  Moreover,  as  they  prop- 
erly remark,  the  disease  in  human  beings  is  rarely 
fatal,  but  generally  so  trivial  as  not  to  be  brought 
to  the  attention  of  the  family  physician.  Still, 
every  possible  source  of  infection  should  be  stamped 
out  at  once,  and  the  country  has  reason  to  con- 
gratulate itself  on  the  efficient  measures  taken  in 
this  instance,  not  the  first  one,  apparently,  of  infec- 
tion caused  by  imported  vaccine,  for  "the  investi- 
gation also  indicates  that  the  outbreaks  of  foot  and 
mouth  disease  in  New  England  in  i902-'3  were 
probably  due  to  contaminated  vaccine  of  Japanese 
origin." 


THE  DECREASE  OF  TUBERCULOUS 
DISEASE  IN  NEW  YORK. 

The  statement  recently  made  that  tuberculous 
disease  was  greatlv  on  the  increase  in  New  York  nO' 
doubt  astonished  those  who  have  followed  the  ex- 
cellent work  which  has  been  carried  on  for  the  past 
fifteen  years.  The  author  of  the  statement  called 
attention  to  the  enormous  increase  in  the  number  of 
new  cases  reported  in  1908.  and  concluded  that  the 
present  measures  had  proved  entirely  inadequate  to 
meet  the  situation.  A  careful  analysis  of  the  data 
given  out  by  the  Health  Department  places  the  en- 
tire matter  in*a  different  light  and  once  more  shows 
how^  dangerous  it  is  to  draw  conclusions  from  iso- 
lated facts.  It  is  true  that  there  was  a  large  in- 
crease in  the  nurnber  of  new  cases  of  tuberculous 
disease  reported,  but  further  examination  shows 
that  this  increase,  instead  of  being  paralleled  by  an 
increased  death  rate  from  the  disease,  was  actuallv 


NEM^S  ITEMS. 


[N'e.v  York 
Mkdical  Journal. 


accompanied  by  a  considerable  decrease  in  the 
mortality  from  this  cause.  Moreover,  it  is  found 
•that  the  increase  in  the  reported  cases  occurred  al- 
most entirely  in  the  last  two  quarters  of  the  year, 
i.  e.,  in  a  period  in  which  there  has  always  been  a 
smaller  proportion  of  cases.  It  is  difficult  to  escape 
the  conclusion  that  the  increase  in  the  reported  cases 
was  due  to  the  publicity  attending  the  International 
Congress  on  Tuberculosis  in  Washington  and  the 
Tuberculosis  Exhibition  connected  with  it,  a  large 
number  of  tuberculous  individuals  being  thereby  led 
to  seek  medical  advice.  It  is  gratifying  to  note 
that  there  has  been  a  steady  decrease  in  the  deaths 
from  tuberculous  disease  in  New  York,,  and  that  the 
rate  for  1908,  namely  2.29  to  a  1,000  population,  is 
only  about  forty  per  cent,  of  what  it  was  twenty-five 
years  ago. 

 ^  

(©bituarri. 


GERHARDUS  HILLES  WYNKOOP,  M.  D., 
of  New  York. 

Dr.  W'ynkoop  died  at  his  home,  in  Madison  Ave- 
nue, on  Sunday,  May  l6th.  He  had  been  in  poor 
health  for  a  great  part  of  the  winter,  but  appar- 
ently had  recovered  when  he  was  seized  with  dis- 
ease of  the  vermiform  appendix,  which  proved  fatal 
in  spite  of  a  prompt  operation.  He  was  born  in 
Wilmington,  Delaware,  in  1843.  After  an  academic 
course  in  Yale  he  took  the  medical  course  in  the 
College  of  Physicians  and  Surgeons,  New  York, 
and  received  his  medical  degree  in  1866.  He  was 
for  several  years  one  of  the  surgeons  of  St.  Luke's 
Hospital,  but  his  life  work  was  that  of  a  family 
physician.  His  sagacity,  tact,  and  kindliness  brought 
him  a  large  practice  and  the  affectionate  regard  of 
his  professional  brethren.  Dr.  Wynkoop  was  a  dis- 
criminating lover  of  paintings  and  a  well  known 
-collector  of  works  of  art. 

 <^  

llttos  Items. 

Changes  of  Address.— Dr.  M.  I.  Blank,  to  1845  Seventh 
A\cnue.  New  "\'ork. 

New  Buildings  for  the  University  of  Minnesota. — The 

recv.--.it  ;ii;))r(  ipriation  of  $2,150,000  to  the  State  imiver.sity 
by  the  legislature  included  $.200,000  for  a  general  medical 
building,  and  the  same  sum  for  an  anatomical  building. 

Detroit  College  of  Medicine  Commencement. — Invita- 
tions lia\ e  Keen  issued  by  the  trustees  and  faculty  of  the 
Detroit  Ct'llege  of  Medicine  to  the  forty-first  annual  com- 
mencement exercises,  to  he  held  on  'lliursday  evening.  May 
27tli,  at  7  ■p.o  o'clock. 

The  New  Home  for  Women  Nurses,  on  Blackwell's 
Island,  New  York,  was  formally  opened  on  May  17th, 
the  Hon.  Joseph  H.  Cboate  delivering  the  principal  address. 
The  building  is  four  stories  in  height,  with  a  frontage  of 
two  hundred  feet,  and  cost  $315,000. 

St.  John's  Guild  opened  its  Seaside  Hospit;d  at  New 
Dorp,  Staten  Island,  on  Monday.  May  17th,  two  weeks 
earlier  than  usual.  Tickets  have  been  issued  to  the  De- 
partment of  Health,  hospit.'ds.  dispensaries,  day  nurseries, 
and  similar  institutions  coming  into  contact  with  the  sick 
poor  of  the  city,  where  they  can  be  easily  obtained. 


The  Board  of  Quarantine  Commissioners  Abolished. 

— Governor  Hughes  has  signed  the  bill  transferring  to  Dr. 
Doty,  health  officer  of  the  port  of  New  York,  the  duties  of 
the  Quarantine  Commission  at  that  port,  and  abolishing  the 
Quarantine  Commission.  Provision  is  made  for  an  ade- 
quate corps  of  employees  to  aid  Dr.  Doty  in  carrying  on  the 
work. 

Contagious  Diseases  in  Chicago. — Nine  hundred  new- 
cases  of  contagious  diseases  were  reported  to  the  Depart- 
ment of  Health  of  the  City  of  Chicago  for  the  week  ending 
May  8,  1909,  as  follows:  Diphtheria,  89;  scarlet  fever,  loi ; 
measles,  406;  whooping  cough,  31;  tuberculosis,  64;  pneu- 
monia, 49;  tvphoid  fever,  15:  chickenpox,  58;  mumps,  74; 
smallpo.x,  i;  puerperal  fever,  i;  erysipelas,  11. 

The  Association  of  Ex-Resident  Physicians  of  the 
German  Hospital  of  Philadelphia  elected  the  following 
officers  at  the  annual  meeting  of  the  association  held  at  the 
University  Club  on  the  evening  of  May  7th :  Dr.  Henry  F. 
Page,  president ;  Dr.  John  C.  Gittings.  secretary,  and  Dr. 
A.  P.  Miller,  historian.  The  annual  banquet,  which  was 
held  at  the  close  of  the  business  meeting,  was  a  great  suc- 
cess. 

American  Paediatric  Society. — The  twenty-first  annual 
meeting  of  this  society  will  be  held  in  Lenox,  Mass.,  on 
May  27th  and  28th.  According  to  the  preliminary  pro- 
gramme, which  has  just  been  received,  well  known  special- 
ists in  diseases  of  children  will  contribute  papers,  and  the 
meeting  gives  promise  of  being  specially  interesting.  Dr. 
Samuel  S.  Adams,  i  Dupont  Circle,  Washington,  D.  C,  is 
the  secretary  of  the  societ}-. 

Vermont's  Tuberculosis  Exhibition. — The  traveling 
tuberculosis  exhibition  of  the  Vermont  State  Board  of 
Health  was  opened  in  Bellows  Falls  on  May  6th.  Dr. 
Henry  Holton  had  the  matter  in  charge,  and  a  large  corps 
of  assistants  were  enga.ged  to  aid  him  in  demonstrating  the 
various  features  of  the  exhibit  and  in  answering  the  ques- 
tions of  the  visitors.  The  usual  course  ot  lectures  was 
given  in  connection  with  the  exhibit. 

Officers  of  the  Association  of  American  Physicians. 
— At  the  twenty-fourth  annual  meeting  of  the  association, 
held  in  Washington,  D.  C,  May  nth  and  12th,  the  follow- 
ing officers  were  elected  for  the  ensuing  year :  President. 
Dr.  Henry  Hun,  of  Albany :  vice  president,  Dr.  V.  P. 
Forchheimer,  of  Cincinnati ;  secretary.  Dr.  George  M. 
Kober,  of  Washington :  recording  secretary.  Dr.  Solomon 
Solis  Cohen,  of  Philadelphia ;  treasurer.  Dr.  J.  P.  Crozer 
Griffith,  of  Philadelphia;  councilor.  Dr.  Henry  Sewall.  of 
Denver. 

Ambulance  Bill  Signed. — Governor  Hughes  has  signed 
the  Hoey  bill,  which  provides  for  the  establishment  in  New 
York  City  of  a  Board  of  Ambulance  Service,  to  be  com- 
posed of  the  Commissioner  of  Police,  the  Commissioner  of 
Public  Charities,  the  President  of  the  Board  of  Trustees  of 
Bellevue  and  Allied  Hospitals,  and  two  private  citizens  who 
will  be  named  by  the  Mayor.  The  board  will  have  com- 
plete control  over  the  ambulance  service  of  the  city,  ex- 
cept that  maintained  by  the  Department  of  Elealth.  with 
power  to  establish  rules  and  regulations. 

The  New  Library  Building  of  the  Medical  and  Chi- 
rurgical  Faculty  of  Maryland,  Baltimore,  was  formally 
dedicated  on  May  I3tli.  Dr.  William  Osier,  regius  pro- 
fessor of  medicine  at  O.xford,  was  present  and  received  an 
ovation.  The  auditorium  of  the  new  building  has  been 
named  Osier  f-tall  in  his  honor.  Dr.  S.  Weir  Mitchell,  of 
Philadelphia,  delivered  the  dedicatory  address,  and  among 
those  who  responded  were  Dr.  Abraham  Jacobi.  of  New 
York ;  Dr.  James  Tyson,  of  Pliiladelphia ;  Dr.  John  W. 
Farlow,  of  Bostcgi ;  Dr.  John  S.  Billings,  of  the  New  York 
Public  Library;  and  Dr.  Robert  Fletcher,  of  the  Army 
Medical  Museum,  Washington. 

The  Medical  Society  of  the  County  of  New  York  will 
hold  a  stated  meeting  in  Hosack  Hall,  New  York  .Academy 
of  Medicine,  on  Monday  evening.  May  24th,  at  8:15  o'clock. 
The  programme  for  the  evening  includes  the  following  pa 
pers :  Further  Studies  on  the  presence  of  Tubercle  Bacilli 
in  the  Circulating  Blood,  by  Dr.  Randic  C.  Rosenberger. 
of  Philadelphia;  Problems  connected  with  Tuberculosis,  by 
Dr.  Henry  G.  Piffard  ;  The  Clinical  Diagnosis  of  Tubercu- 
losis of  the  Tonsils,  by  Dr.  Lee  Maidment  Hurd,  with  re 
marks  on  the  Microscopic  Diagnosis  by  Dr.  Jonathan 
Wright :  The  .-Etiology  and  Treatment  of  Diarrha;a.  by  Dr. 
Joseph  F.  Winters. 


May  22,  1909.] 


NEWS  ITEMS. 


American  Neurological  Association. — The  thirty-fifth 
annual  meeting  of  this  association  will  be  held  at  the  New 
^'ork  AcadePiV  of  Medicine  on  May  27th.  28th,  and  29th. 
In  addition  to  an  excellent  programme  of  scientific  com- 
nuinicaticns,  ample  arrangements  have  been  made  by  the 
local  committee  for  the  entertainment  of  the  visiting  mem- 
bers and  their  friends.  The  present  officers  of  the  society 
are:  President,  Dr.  S.  Weir  ilitchell,  of  Philadelphia  ;  vice- 
presidents.  Dr.  Pearce  Bailey,  of  New  York,  and  Dr.  F. 
W.  Langdon.  of  Cincinnati ;  secretary  and  treasurer,  Dr. 
Graeme  M.  Hammond,  of  New  York;  councillors,  Dr.  11. 
M.  Thomas,  of  Baltimore,  and  Dr.  C.  W.  Burr,  of  Phila- 
delphia. 

Resolutions  on  the  Death  of  Dr.  Robert  A.  Murray 

were  adopted  at  a  recent  meeting  of  the  New  York  Ob- 
stetrical Society  as  follows : 

Whereas,  By  the  death  of  Dr.  Robert  A.  Murray  this 
society  has  lost  one  of  its  oldest  and  most  esteemed  mem- 
.bers.  a  fine  type  of  the  old  fashioned,  upright  practitioner. 

Resolved,  That  we  feel  keenly  the  absence  of  a  loyal, 
big  hearted  fi-iend.  as  well  as  of  one  who  possessed  to  an 
unusual  degree  skill  and  sound  judgment  as  an  obstetrician. 
A  man  of  sterling  integrity,  he  was  the  friend  and  coun- 
sellor of  a  large  circle  for  nearly  thirty-five  years.  He 
■was  a  familiar  figure  in  this  community  and  a  constant 
attendant  at  our  meetings,  giving  us  the  fruits  of  his  ex- 
perience. We  sorrow  over  the  fact  that  his  kindly  face  and 
genial  presence  will  never  again  be  with  us. 

Resolved.  That  these  resolutions  be  inserted  in  our  min- 
utes and  that  copies  be  sent  to  the  family  of  the  deceased 
fellow  and  to  the  leading  medical  journals. 

(Signed)  Egbert  H.  Grandin, 

George  W.  Jarman, 
Henrv  C.  Coe, 

Conmiittee. 

The  American  Otological  Society  will  hold  its  forty- 
second  annual  meeting  in  Boston,  on  June  ist  and  2d.  con- 
currently with  the  American  Laryngological  As'^ocintion. 
The  headquarters  of  the  society  will  be  at  the  Hotel  Som- 
•erset,  and  the  sessions  will  be  held  in  the  Harvard  Medical 
School.  On  Wednesday  morning  a  joint  meeting  of  the 
American  Laryngological  Society-  and  the  .American  Oti- 
logical  Society  will  be  held,  and  the  topic  selected  for  dis- 
-cussion  at  this  meeting  is  Nasal  and  Pharyngeal  Conditions 
as  Factors  in  the  Causation  of  Aural  Disease.  Dr.  Cor- 
nelius G.  Coakley,  of  New  York,  and  Dr.  D.  Braden  Kyle, 
of  Philadelpiiia,  will  represent  the  Laryngological  Associa- 
tion, and  Dr.  George  A.  Leland,  of  Boston,  and  Dr.  Norval 
H.  Pierce,  of  Chicago,  will  represent  the  Otological  So- 
ciety. In  addition  to  this  "symposium"'  the  programme  in- 
cludes twenty-one  papers  b\-  leading  specialists  in  otology, 
and  n  is  expected  that  the  meeting  will  be  one  of  the  most 
interesting  in  the  history  of  the  organization.  Dr.  F'reder- 
ick  L.  Jack,  oi  Boston,  is  president  of  the  society;  Dr.  R. 
-A..  Reeve,  of  Toronto,  Canada,  is  vice-president,  and  Dr. 
James  F.  McKernon,  62  West  Fifty-second  Street,  New 
York,  is  secretary  and  treasurer. 

The  American  Gastroenterological  Association  will 
hold  its  twelfth  annual  meeting  in  Atlantic  City,  N.  J.,  on 
Monday  and  Tuesday,  June  7th  and  8th.  All  the  sessions 
will  be  held  in  the  Hotel  Windsor,  and  a  cordial  invitation 
is  extended  to  the  medical  profession.  The  programme  for 
the  Monday  morning  session  consists  of  the  address  of  the 
president,  Dr.  Julius  Friedenwald,  of  Baltimore,  on  the 
Development  of  Gastroenterology ;  and  the  following 
papers:  Duodenal  Ulcers,  by  Dr.  Max  Einhorn,  of  New 
York:  Disturbances  of  the  Chemical  Coordinations  of  the 
■Organism,  by  Dr.  John  C.  Hemmeter,  of  Baltimore ;  and 
the  Pathogenesis  of  Gastric  Tetany,  by  Dr.  W.  G.  Mac- 
'Callum.  of  Baltimore.  The  programme  for  the  afternoon 
session  includes  a  "symposium"  on  Gastroenterostomy,  and 
papers  on  the  subiect  will  be  presented  bv  Dr.  W.  B.  Can- 
non, of  Boston  :  Dr.  F.  T.  Murphy,  of  Boston  :  Dr.  H.  W. 
Bettmann.  of  Cincinnati :  Dr.  F.  W.  White,  of  Boston,  and 
Dr.  J.  M.  T.  Finney,  of  Baltimore.  On  Tuesday  morning 
Dr.  .A.  L.  Benedict,  of  BuiTalo,  will  read  a  paper  entitled 
Alcohol  Not  Necessarily  a  Cause  of  Hepatic  Sclerosis : 
Dr.  Morris  ]\Ianges,  of  New  York,  will  report  a  case  of 
Carcinoma  of  the  CEsophagus :  Dr.  Harry  Adler,  of  Balti- 
more, will  read  a  paper  on  the  Relation  between  Gastric 
Symptoms  and  Gallstone  Disease ;  and  Dr.  Charles  D. 
Aaron,  of  Detroit,  will  give  a  demonstration  of  a  corset 
for  viscerooto'is.  The  annus!  dinner  of  the  association 
will  take  place  ^t  the  Hotel  Windsor  on  Monday  evening 
at  seven  o'clock. 


Alumni  Dinner  of  the  Long  Island  College  Hospital. 

— The  class  of  1899  of  the  Long  Island  College  Hospital 
held  its  tenth  anniversary  dinner  on  the  evening  of  Salur- 
da)-.  May  15th.  In  the  absence  of  Dr.  G.  H.  Cruikshaak. 
the  president  of  the  class,  the  position  of  toastmaster  wa^ 
filled  by  Dr.  A.  Slee.  Among  those  present  were  :  Dr.  H. 
VV.  Casey,  Dr.  George  Simrell.  Dr.  H.  B.  Snell,  Dr.  W.  D. 
Price,  Dr.  R.  E.  Soule,  Dr.  J.  H.  Ohiy.  Dr.  A.  C.  Doupl.i^s, 
Dr.  J.  .A.  McCreedy,  Dr.  G.  J.  Tieck,  Dr.  E.  F.  Luhrsen. 
Dr.  F.  J.  Keller,  Dr.  J  .J.  Dooling.  Dr.  J.  A.  Nile,  Dr.  Alex- 
ander Giiligan,  Dr.  F.  .A.  Kins;,  Dr.  F.  P.  Hatfield,  Dr.  W.  E. 
.Aldridge,  Dr.  G.  L.  Stivers,  Dr.  C.  Chase.  Dr.  R.  E.  King- 
man. Dr.  F.  C.  Eastman,  Dr.  J.  H.  Staub.  and  Dr.  A.  W'. 
S'ee. 

Contributions  to  the  Carroll  Fund  by  the  Medical 
Society  of  the  County  of  New  York. —  In  compliance 
with  a  resolution  passed  at  a  meeting  of  the  society,  held 
on  .April  26th,  the  Comitia  Minora  have  voted  $150  from 
the  general  funds  of  the  society  to  be  applied  to  the  fund 
which  is  being  collected  for  the  purchase  of  a  house  for  the 
widow  of  Dr.  Carroll.  The  amount  needed  is  $7,800,  of 
which  the  .Army  and  Navy  have  subscribed  $3,000.  The 
president  of  the  society,  Dr.  H.  Seymour  Houghton,  an- 
nounces that  he  will  receive  contributions  from  individual 
members,  and  expresses  the  hope  that  the  subscription  will 
be  large  enough  to  adequately  represent  the  interest  taken 
in  the  welfare  of  those  who  were  dependent  upon  the  ef- 
forts of  one  who  sacrificed  his  life  for  the  benefit  of  hu- 
manity. 

Summer  Camps  of  Instruction  for  Militia  Medical 
Officers. — The  Surgeon  General  of  the  Army  is  plan- 
ning to  establish  three  camps  of  instruction  for  the  beneli: 
of  the  medical  officers  of  the  National  Guard  during  the 
coming  svmmer,  one  at  Antietam,  Md.,  one  at  Sparta,  Wis., 
and  one  near  San  Francisco.  Each  camp  will  be  provided 
with  a  field  hospital  with  an  ambulance  company  section 
complete,  the  hospital  and  company  to  be  supplied  with  a 
full  war  complement  of  officers  and  men.  In  addition  to 
this,  three  specially  selected  medical  officers  will  be  assigned 
to  each  camp  as  instructors,  one  as  instructor  in  hygiene, 
one  as  instrv.ctor  in  field  work,  and  the  other  as  instructor 
in  regulation  papers,  etc.  According  to  present  plans  each 
camp  will  be  maintained  for  a  period  of  four  weeks,  and 
the  course  of  instruction  will  be  divided  into  two  periods  of 
two  weeks  each. 

Personal. — Dr.  John  J.  Gilbride,  of  Philadelphia,  read 
a  paper  on  Starch  Dyspepsia  before  the  Delaware  County. 
Pa.,  Medical  Society,  at  a  meeting  held  in  Chester,  on  May 
13,  1909. 

A  dinner  was  given  on  April  r7th  at  the  Hotel  Somerset, 
Boston,  ii:  honor  of  the  seventieth  birthday  of  Professor 
F.  W.  Putnam,  for  twenty-five  years  permanent  secretary 
and  later  president  of  the  American  .Association  for  the 
.Advancement  of  Science.  Dr.  Putnam  has  been  professor 
of  American  archaeology  and  anthropology  at  Harvard 
University  since  1866.  A  large  volume  of  essays  on  an- 
thropology contributed  by  various  friends  and  associates 
was  presented  to  Dr.  Putnam. 

Professor  Wallace  C.  Sabine,  dean  of  the  Graduate 
Sciiool  of  .Applied  Science  of  Harvard  University,  sailed 
for  Naples  'on  .April  29th.  He  will  visit  the  technical 
schools  of  the  principal  cities  of  Europe  in  the  interests  of 
the  university. 

Sir  Ja'iie<  Grant,  of  Ottawa.  Canada,  delivered  an  ad- 
dress r"'"ently  on  The  Life  of  Our  Young  Nations,  in  To- 
ronto University.  This  address  is  to  be  published  and  cir- 
culated throughout  the  Dominion  of  Canada.  Sir  James 
at  the  same  time  was  elected  president  of  the  International 
'Congress  of  Hygiene,  for  Canada,  of  which  Earl  Gray  is 
patron  and  the  Right  Honorable  Sir  Wilfred  Laurier  \Tce- 
patron. 

It  is  reported  that  Dr.  .A.  C.  Abbott,  who  has  been  the 
president  of  the  Board  of  Health  of  Philadelphia  and  Di- 
rector of  its  Bacteriological  Laboratory  for  the  past  six 
years,  will  resign  in  the  near  future,  and  resume  the  duties 
oi  his  position  as  professor  of  bacteriology  in  the  Univer- 
sity of  Pennsylvania. 

Dr.  William  S.  Washburn,  for  seven  years  director  of  the 
Civil  Service  in  the  Philippines,  has  been  appointed  Civil 
Service  Commissioner,  to  succeed  Mr.  James  T.  Williams. 
Dr.  Washburn  graduated  from  the  medical  department  of 
George  Washington  University,  and  was  an  instructor  in 
that  college  for  a  time. 


io6o 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  May  29,  1909: 

IMoNDAV,  jlay  J4th. — Mineralogical  and  Geological  Section, 
Academy  of  Natural  Sciences. 

Wednesday,  May  26th. —  Philadelphia  County  Medical  So- 
ciety. 

Thursday  ,  May  j/tli. — Pathological  Society  :  American 
Entomological  Society  and  the  Entomological  Section, 
Academy  of  Natural  Sciences :  Section  Meeting,  Frank- 
lin Institute ;  Philadelphia  Botanical  Club ;  Lebanon 
Hospital  Medical  Society. 

Friday,  May  28th. — Philadelphia  Neurological  Society ; 
Northern  Medical  Association ;  South  Branch,  Phila- 
delphia County  Medical  Society. 

S.\TURDAY,  May  2gtlt. — Samaritan  Hospital  Medical  Soci- 
ety. 

Infectious  Diseases  in  New  York: 

We  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partiiient  of  Health  for  the  follozving  statement  of  new 
cases  and  deaths  reported  for  the  two  zveeks  ending  May 
75,  7909.- 

,  May  8  ,     ,  May  15  , 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  luihiionalis    559  183  550  176 

Diphtheria   339  35         318  32 

Measles    I.-297  36       ',5/8  32 

Scarlet   fever    371  29         338  33 

Smallpox   

X'aricella    188  .  .  167 

Typhoid  fever    58  4  56  4 

Whooping  cough    86  5  11 1  14 

Cerebrospinal  meningitis    7  6  Ji  S 

Total   2,905         298       3.1^9  299 

The  Health  of  the  Canal  Zone. — During  March,  1909, 
the  following  deaths  from  transmissible  diseases  were  re- 
ported to  the  health  authorities  of  the  Isthmian  Canal 
Commission :  Typhoid  fever,  4  deaths ;  malarial  fever,  25 
deaths ;  aestivoautumnal  fever,  5  deaths ;  haeinoglobinuric 
fever,  2  deaths ;  dysentery,  5  deaths ;  beriberi,  2  deaths ; 
purulent  infection  and  septichfemia,  2  deaths ;  pulmon- 
ary tuberculosis,  21  deaths ;  other  forms  of  tuberculosis, 
3  deaths ;  cancer,  3  deaths ;  tetanus,  2  deaths :  broncho- 
pneumonia, 7  deaths;  pneumonia.  17  deaths;  diarrhcea  and 
enteritis,  under  two  years  ©f  age,  13  deaths ;  uncinariasis,  3 
deaths ;  puerperal  septich?emia,  i  death  ;  gangrene,  i  death. 
The  total  deaths  from  all  causes  for  the  month  numbered 
184,  in  a  population  of  129,323,  corresponding  to  an  annual 
death  rate  of  17.07  in  a  thousand  population.  The  morbid- 
ity rate  for  all  the  'employees  of  the  Comtnission  was  20.60 
in  a  thousand;  of  the  white  employees,  38.97  in  a  thousand; 
of  the  blacks.  13.44  in  ^  thousand. 

Louisiana  State  Medical  Society. — The  thirtieth  an- 
nual meeting  of  this  society,  which  was  held  in  New  Orleans 
on  May  4th,  5th,  and  6th,  was  one  of  the  most  successful 
in  the  history  of  the  organization.  Many  papers  on  sub- 
jects ol  interest  to  the  inedical  profession  were  read  and 
discussed,  and  considerable  important  business  was  trans- 
acted. The  closing  business  session  \\'as  one  of  the  most 
important  of  the  meeting,  r.s  it  was  devoted  to  a  discussion 
of  the  question  of  compulsory  vaccination  as  a  means  of 
stamping  out  smallpox,  and  it  was  unanimously  agreed  by 
those  present  that  everything  possible  would  be  done  to 
bring  about  the  enactment  of  a  law  to  this  effect.  The  fol- 
lowing officers  were  elected  to  serve  for  the  ensuing  year : 
Dr.  Charles  McVea,  of  Baton  Rouge,  president ;  Dr.  John 
J.  -Archinard,  of  New  Orleans,  first  vice-president;  Dr.  R. 
.\I.  Mittell,  of  Opelousas,  second  vice-president;  Dr.  V. 
P.  S.  Smith,  of  New  Orleans,  third  vice-president;  Dr. 
C.  M.  Willis,  of  Shreveport,  councillor  from  the  Fourth 
Congressional  District ;  Dr.  Thomas  Ragan,  of  Ruston, 
councillor  from  the  Fifth  Congressional  District;  Dr.  Sims, 
of  Donaldsoi-.ville,  from  the  Sixth  Congressional  District; 
Dr.  R.  O.  Simmons,  of  Alexandria,  reelected  as  councillor 
from  the  Seventh  Congressional  District.  The  other  offi- 
cers who  will  be  continued  another  year  arc  as  follows: 
Dr.  E.  M.  Hummel,  of  New  Orleans,  secretary;  Dr.  C.  C. 
Bass,  of  New  Orleans,  treasurer;  Dr.  P.  E.  Archinard, 
coimcillor  from  the  First  Congressional  District ;  Dr.  E. 
J.  Graner,  councillor  from  the  Second  Congressional  Dis- 
trict, and  Dr.  A.  C.  luistis,  of  Abbeville,  from  the  Third 
Congressional  District.  Dr.  T.  R.  Tolson,  of  Lafayette, 
and  Dr.  E.  Dcnegre  Martin,  of  New  Orleans,  were  elected 
delegates  to  the  American  Medical  .Association,  and  Dr.  J. 
W.  Sanders  and  Dr  Sterling  Gates  were  selected  to  fill 
the  vacanciis  on  the  State  I'oard  of  Examiners. 


The  Health  of  Pittsburgh. — During  the  week  ending. 
May  8,  1909.  the  following  cases  of  transmissible  diseases- 
were  reported  to  the  Bureau  of  Health:  Chickenpox,  9 
cases,  I  death;  typhoid  fever,  21  cases.  2  deaths;  scarlet 
fever,  13  cases,  I  death ;  diphtheria,  13  cases.  1  death ; 
measles,  19  cases,  o  deaths  ;  whooping  cough,  39  cases,  4 
deaths ;  pulmonary  tuberculosis,  79  cases,  id  deaths.  The 
total  deaths  for  the  week  numbered  134,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death, 
rate  of  12.33  in  a  thousand  of  population. 

Vital  Statistics  of  New  York. — The  total  number  of 
deaths  from  all  causes  reported  to  the  Department  of 
Health  of  the  City  of  New  York  during  the  week  ending. 
May  8,  1909,  was  1.560,  as  compared  with  1,483  for  the 
corresponding  week  of  1908.  The  death  rate  for  the  week 
was  17.83  for  the  whole  city,  and  for  each  of  the  boroughs 
it  was  as  follows:  Manhattan,  18.86;  the  Bronx,  19.19; 
Brooklyn,  16.37;  Queens.  16.61;  Richmond,  13.38.  The  total 
infant  mortality  was  485;  298  under  one  year  of  age,  and 
187  between  one  and  five  years  of  age.  There  were  130- 
still  births.  There  were  260  deaths  from  pneumonia,  183 
from  pulmonary  tuberculosis,  104  from  contagious  diseases,. 
93  from  diarrhoeal  diseases,  of  which  45  were  under  five 
years  of  age,  142  from  organic  heart  disease.  70  from  can- 
cer, and  112  from  Bright's  disease.  There  were  106  vio- 
lent deaths;  19  from  suicide,  10  from  homicide,  and  77 
from  accidents. 

The  Mortality  of  Chicago,  for  the  week  ending  May 
8.  1909,  was  slightly  higher  than  for  the  preceding  week. 
The  tot:->l  number  of  oeaths  from  all  causes  reported  to  the 
Department  of  Health  was  675,  as  compared  with  596  for 
the  week  before  and  531  for  the  corresponding  period  in 
1908.  The  annual  death  rate  was  15.82  in  a  thousand  popu- 
lation. The  comparatively  high  death  rate  was  largely  due 
to  an  increased  number  of  deaths  from  pulmonary  tubercu- 
losis, diarrhceal  diseases,  heart  diseases,  cancer,  and  acci- 
dents. The  total  infant  mortality  was  177;  123  under  one 
year  of  age.  and  54  between  one  and  five  years  of  age. 
The  principal  causes  of  death  were:  Diphtheria.  13  deaths; 
scarlet  fever,  7  deaths  ;  measles,  5  deaths ;  w  hooping  cough, 
3  deaths;  influenza.  3  deaths;  typhoid  fever.  2  deaths:  diar- 
rhoeal diseases,  43  deaths,  of  which  40  were  under  two 
years  of  age ;  pneumonia,  130  deaths ;  pulmonary  tubercu- 
losis, 79  deaths ;  other  forms  of  tuberculosis,  9  deaths ;  can- 
cer, 33  deaths;  nervous  diseases,  15  deaths;  heart  diseases, 
71  deaths;  apoplexy,  14  de.^.ths;  Bright's  disease,  39  deaths; 
violence,  46  deaths — 9  from  suicides,  5  from  manslaughter, 
and  32  from  accidents. 

Society  Meetings  for  the  Coming  Week: 

MoND.w,  May  24th. — Medical   Society  of  the  County  of 
New  York. 

TtJESDAY,  May  2^th. — New  York  Otological  Society ;  New 
York  Medical  Union;  New  York  Dermatological  So- 
ciety (annual)  ;  Metropolitan  Medical  Society  of  New 
York;  Buffalo  Academy  of  Medicine  (Section  in  Ob- 
stetrics and  Gynaecology ). 
Wednesday,  May  26th. — New  York  Academy  of  Medicine 
(Section  in  Laryngology  and  Rhinology)  ;  New  York 
Surgical  Society. 
Thursday,  May  2yth. — New  York  Academy  of  Medicine 
(Section   in   Obstetrics   and    Gynsecology)  ;  Hospital 
Graduates'  Club.  New  York  (anniversary);  New  York 
Celtic  .Society ;  Brooklyn  Society  for  Neurology. 
Friday,  May  28th. — .Academy  of  Pathological  Science.  New 
York ;  New  York  Society  of  German  Physicians ;  New 
York  Clinical  Societ} . 
The  Health  of  Philadelphia. — During  the  week  end- 
ing May  8,  1909,  the  following  cases  of  transimssible  dis- 
eases were  reported  to  the  Bureau  of  Health  of  Philadel- 
phia :  Typhoid  fever.  25  cases.  5  deaths ;  scarlet  fever,  77 
cases,  3  deaths  ;  chickenpox,  34  cases,  o  deaths  ;  diphtheria. 
80  cases,  9  deaths ;  cerebrospinal  meningitis,  2  cases,  i 
death ;  measles,  306  cases,  7  deaths ;  whooping  cough,  16 
cases.   1   death ;  tuberculosis  of  the  lungs,  92  cases,  67 
deaths;   pnemnonia,  37  cases,  61   deaths;   erysipelas,  il 
cases,  I  death ;  trachoma,  3  cases,  o  deaths ;  mumps,  31 
cases,  o  deaths.  The  following  deaths  were  reported  from 
other  transmissible  diseases:  Tuberculosis,  other  than  tuber- 
culosis of  the  lungs.  8  deaths;  diarrhoea  and  enteritis,  under 
two  years  of  age,  6  deaths;  pucr])eral  fever.  3  deaths.  The 
total  deaths  numbered  510  in  an  estimated  population  of 
I..S65,569,  corresponding  to  an  annual  death  rate  of  16.93 
a  thousand  population.     The  total  infant  mortality  was 
102:  70  under  one  year  of  age.  32  between  one  and  two 
years  of  age.    There  were  33  still  births;  18  males  and  15 
females.    The  total  precipitation  was  0.66  inch. 


May  22,  1909.]  CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  XOMEXCLATURE.  1061 

THE   BELLEVUE    HOSPITAL    NOMENCLATURE  OF  DISEASES  AND 

CONDITIONS* 

'First  Edition,  1903. 
First  Revision,  1909. 

Compiled  by  the  Commute  ox  Clinical  Records,  Comi'osei)  of  Robert  J.  Carlisle,  Warrex  Coleman, 

Thomas  A.  Smith  and  Edmuxd  L.  Dow. 

{Continued  from  page  1020.) 


THE  EYE  AND  ANNEXA. 

Abscess  of.    State  site. 

Absence  of  Lens.  Not  to  include  Congenital  Malforma- 
tions. 

ACCOMMODATION    AND    RKFRACTIOX,  ER- 
RORS OF: 
Astigmatism. 

Hypermetropia. 

Myopia. 

Presbyopia. 

Amaurosis.   (  Do  not  use  as  a  primary  diagnosis  when 

Amblyopia.  )  cause  can  be  determined. 

Ankyloblepharon. 

Blepharitis. 

Cataract. 

Chalazion. 

Chorioiditis. 

Congenital  Malformation  of  Eye.  File  under  Congen- 
ital Malformations. 

Congenital  Malformation  of  Eyelid.  File  under  Con- 
genital Malformations  of  Face. 

Conjunctivitis,  Acute.  When  due  to  gonococcus  diag- 
nosticate as  Gonococcus  Infection  of  Eye;  file 
under  Infective  Diseases.  When  due  to  diph- 
theria bacillus  diagnosticate  as  Diphtheria;  file 
under  Infective  Diseases. 

Conjunctivitis,  Chronic. 

Conjunctivitis,  Phlyctenular. 

Conjunctivitis.  Trnchomatous.  Diagnosticate  as  Tracho- 
ma. 

Cramp  of  Ciliary  Muscle. 

Cyclitis. 

Dacryoadenitis. 

Dacryocystitis. 

Detachment  of  Chorioid. 

Detachment  of  Retina. 

Ectropion. 

Embolism  of  Retinal  Artery. 

Entropion. 

Epiphora. 

Fistula  of  Lachrymal  Sac. 
Fistula  of  Nasal  Duct. 
Glaucoma,  Acute. 
Glaucoma.  Chronic. 

Haemorrhage  into  Retina.  Do  not  use  as  n  primary 
diaenosis  ^vhen  cause  can  be  determined. 

Haemorrhage  under  Conjunctiva.  Do  not  use  as  a  pri- 
mary diagnosis  when  cause  can  be  determined. 

Hemianopsia.  Do  not  use  as  a  primary  diagnosis  when 
cause  can  be  determined. 

Hordeolum. 

Hyperaemia  of  Conjunctiva. 
Hypersesthesia  of  Retina. 

Insufficiency  of  ocuior  lunsclc.    State  muscle  involved. 
Iritis. 

Iridochorioiditis. 

Iridocyclitis. 

Synechia. 
Keratitis. 

Keratitis.  Phlyctenular.  , 

Ke'-.-toiritis. 

Leucoma. 

Muscas  Volitantes.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Neuritis,  Optic. 

Atrophy  of  Optic  Nerve.    Do  not  use  as  a  primary 
diagnosis  when  cause  can  be  determined. 
Neuroretinitis. 


^Copyright  by  the  Board  of  Trustees  of  Bellevue  and  Allied  Hos- 
pitals, 1904. 


Nystagmus.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Opacity  of  Vitreous  Humor. 
Ophthalmoplegia. 
Panophthalmitis. 

Paralysis  of  ocular  muscle.    State  muscle  involved. 
Parasite  of.   State  variety  and  site.    File  under  Parasitic 

Diseases. 

Perverted  Visual  Sensation.    To  include  Color  Blind-  ' 

ness,  Erj-thronsia,  etc. 
Pterygium. 
Retinitis. 

Scleritis.    To  include  Episcleritis. 
Staphyloma  of  Cornea. 
Stenosis  of  Punctum  Lacrimale. 
Stenosis  of  Nasal  Duct. 
Symblepharon. 

Syphilis  of.    State  site.    File  under  Syphilis. 

Throm.bosis  of.    State  vessel. 

Trachoma. 

Trichiasis. 

Tuberculosis  of.    State  site.    File  under  Tuberculosis. 
Tumor  of.    State  site  and  varietj-.    File  under  Tumors. 
Ulcer  of.    State  site. 

Hypopyon. 
Xerosis. 

HERNIA. 

Epigastric  Hernia. 

Epigastric  Hernia,  Strangulated. 
Femoral  Hernia. 

Femoral  Hernia,  Strangulated. 
Inguinal  Hernia. 

Inguinal  Hernia,  Strangulated. 
Internal   Hernia.    To   include   Diaphragmatic  Hernia, 
Retroperitoneal  Hernia  and  Hernia  into  the  lesser 
peritoneal  sac. 

Internal  Hernia,  Strangulated. 
Ischiadic  Hernia. 

Ischiadic  H  emia,  Strangulated. 
Ischiorectal  Hernia. 

Ischiorectal  Hernia,  Strangulated. 
Lum.bar  Hernia. 
T,umbar  Hernia,  Strangulated. 
Obturator  Hernia. 

Obturator  Hernia,  Strangulated. 
Umbilical  Hernia. 

Umbilical  Kemia,  Strangulated, 
Ventral  Hernia. 

Ventral  Hernia,  Strangulated. 

INFECTIVE  AND  VEGETABLE  PARASITIC 
DISEASES. 

Abscess  of.  State  site.  Xot  to  include  Abscess  of. 
Tuberculous.  File  when  possible  under  organ 
affected. 

Actinomycosis  of. 

Aerogenes  Capsulatus  Infection. 

Anthrax. 

Blastomycosis. 

Bubonic  Plague. 

Carbuncle  of.    State  site. 

CeIIuli«^'s  of.  State  site.  Xot  to  include  Pelvic  Cellu- 
litis. 

Cerebrospinal  Fever. 
Chancroid  of.    State  site. 
Cholera,  Asiatic. 
Dengue. 
Diphtheria. 

Diphtheria  Bacillus  Carrier. 
Dysentery  CBacillary'). 

Amoebic  Dysentery.    File  under  Parasitic  Diseases. 


io62 


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[New  Yokk 
Medical  Journal. 


Erysipelas. 

Fever  of  Unknown  Cause.    Do  not  use  this  diagnosis 

when  it  can  be  avoided. 
Foot  and  Mouth  Disease. 
Furunculosis. 
Gangosa. 

Gangrene  of,  Infective.    State  site. 

German  Measles. 

Glanders.    To  inchule  Farcy. 

Gonococcus  Infection  of.    State  site. 

Influenza. 

Jaundice,  Acute  Infective. 
Leprosy. 

Malaria,    i-ile  under  Parasitic  Diseases. 

Malta  Fever. 

Measles. 

Mumps. 

Oriental  Sore  (.Meppo  Boil,  Delhi  Boil,  Biskra  Button). 
Pneumonia,  Lobar.     File  under  Diseases  of  the  Lung. 
Pyasmia. 
Rabies. 

•  Rheumatic  Fever,  Acute. 
Rheumatic  Fever,  Subacute. 
Scarlet  Fever. 
Septichaemia. 

Syphilis,    l-ile  under  Parasitic  Diseases. 

Syphilis  of.    File  under  Parasitic  Diseases. 
Tetanus. 

Tuberculosis,  Acute  General. 

Tuberculosis  of.    State  site.    File  alphabetically  accord- 
ing to  site. 
Abscess  of,  Tuberculous. 
Typhaceae  Infection.    Not  to  include  infections  of  a  ty- 
phoid type. 

Typhoid  Fever.    To  include  all  forms  of  infection  of  a 

typhoid  type,  caused  by  the  Typhace;e. 
Typhoid  Bacillus  Carrier. 
Typhus  Fever. 
Vaccinia. 
Varicella. 
Variola. 
Veldt  Sore. 
Verruga  Peruviana. 
Whooping  Cough. 
Yellow  Fever. 

JOINTS. 

State  joint. 

Ankylosis  of.    Do  not  diagnosticate  cicatricial  cfuitrac- 

tion  afYecting  joint  as  ankylosis. 
Arthritis  of.  Acute. 

Arthritis  of,  Chronic.  To  include  acute  and  chronic 
Synovitis.  When  due  to  gonococcus  diagnosticate 
as  Gonococcus  Infection  of.  File  under  Infective 
Diseases. 

Arthritis  Deformans. 

Arthropathy  of  Syringomyelia.  Do  not  use  as  a  pri- 
mary diagnosis. 

Arthropathy  of  Tabes  Dorsalis.  Do  not  use  as  a  pri- 
mary diagnosis. 

Congenital  Malformation  of.  File  inider  Congenital 
Malformations  of  Joint. 

Congenital  Dislocation  of.  l-'ile  under  Congenital  Mal- 
formations of  Joint. 

Contracture  of. 

Coxa  Valga  )   Do  not  use  as  a  primary  diagnosis  when 

Coxa  Vara.  )  cause  can  be  determinecl. 

Curvature  of  Spine. 

Derangement  of.  Internal. 

Genu  Recurvatum. 

Genu  Valgum. 

Genu  Varum. 

Haemorrhage  into.  Nontraumatic.    Do  not  use  as  a  pri- 
mary diagnosis  when  cause  can  be  determined. 
Hallux  Valgus  (Bunion). 
Hallux  Varus. 
Pes  Cavus. 
Pes  Planus. 
Pes  Valgus. 
Spondylitis  Deformans. 
Syphilis  of.    l-'ilc  under  Syi)liilis. 
Talipes. 


Trigger  Finger. 

Tuberculosis  of.    File  under  Tuberculosis. 
Tumor  of.    State  varietj'.    File  under  Tumors. 

LYMPHATIC  SYSTEM. 

Abscess  of.  State  nodes.  Not  to  include  tuberculous 
abscess. 

Chyle  Cyst  of  Mesentery.  File  under  Diseases  of  the 
Mesenterj'. 

Chylocele,  Nonfilarial.  File  under  diseases  of  Tunica 
Vaginalis.  W  hen  due  to  Filaria  diagnosticate  as 
Filariasis.    File  under  Parasitic  Diseases. 

Chylothorax.  Do  not  use  as  a  primarj'  diagnosis  when 
cause  can  be  determined.  File  under  Diseases  of 
Pleura. 

Chylous  Ascites,  Nonfilarial.  Do  not  use  as  a  primary 
diagnosis  when  cause  can  be  determined.  File 
under  Diseases  of  Periton;eum.  When  due  to 
filaria  diagnosticate  as  Filariasis.  File  under 
Parasitic  Diseases. 

Chyluria,  Nonfilarial.  Do  not  u?e  as  a  primary  diag- 
nosis when  cause  can  be  determined.  File  under 
Diseases  of  Kidney.  When  due  to  filiaria  diag- 
nosticate as  Filariasis.  File  under  Parasitic  Dis- 
eases. 

Congenital  Malformation  of.  File  under  Congenital 
Malformations  of  Lymphatic  System. 

Elephantiasis  of,  Nonfilarial.  State  part  affected.  When 
due  to  filaria  diagnosticate  as  Filariasis.  Pile  un- 
der Parasitic  Diseases. 

Fistula  of  Thoracic  Duct. 

Hodgkin's  Disease. 

Lymphadenitis  of,  Acute.  State  nodes.  When  due  to 
gonococcus  diagnosticate  as  Gonococcus  Infec- 
tion of.    File  under  Infective  Diseases. 

Lymphadenitis  of.  Chronic.  State  nodes.  Not  to  in- 
clude Tuberculosis  of  Lyinpli  Xoda. 

Lymphangiectasis  of.    State  site. 

Lymphangitis  of. 

Status  Lymphaticus. 

Syphilis  of.    State  nodes.  File  under  Syphilis. 
Tuberculosis  of.    State  nodes,    l  ile  under  Tuberculosis. 
Tumor  of.    State  variety  and  site.    File  under  Tumors. 

DISEASES  OF  THE  MIND. 

Constitutional  Inferiority. 

Constitutional  Psychopathic  State.  To  include  Per- 
verted Sexual  Instincts  and  Imperative  Ideas  and 
Acts. 

Dementia  (Cause  unknown). 

Dementia  Paralytica. 

Dementia  Praecox. 

Idiocy. 

Imbecility. 

Melancholia,  Involutional. 

Paranoia. 

Paranoid  State. 

Psychosis,  Exhaustive,  Infective,  and  Toxic.  (Caused  by 
infective,  exhausting  and  toxic  diseases,  such  as 
puerperal  infections,  rheumatism,  influenza,  pneu- 
monia, typhoid,  malignant  tumors,  ur?emia,  etc.). 

Psychosis,  Intoxication  (Caused  by  .\lcohol.  Cocaine- 
Morphine,  and  other  Intoxicants.) 

Psychosis  Due  to  Coarse  Brain  Lesion. 

Psychosis,  Epileptic. 

Psychosis,  Hysterical. 

Psychosis,  Manic  Depressive.    To  include  Depressed, 

Maniacal,  and  Mi.xed  Phases. 
Psychosis,  Senile. 
Psychosis,  Thyreoigenous. 
Psychosis,  Traumatic. 

MISCELLANEOUS  DISEASES  AND  CONDI- 
TIONS. 
Ainhum.  « 
Amputation  Stump. 
Amyloid  Disease. 
Beriberi. 

Cicatricial  Contraction  of.    .State  part  affected. 

Deaf  mutism. 

Dentition. 

Deprivation  of  Water. 
Diabetes  Insipidus. 


May  22.  1909.] 


CARLISLE  ET  AL. 


BELLLfUL  HOSPITAL  XUMEXCLATURL. 


1063 


Diabetes  Mellitus. 
Diet  Regulation. 
Dwarfism. 
Erythromelalgia. 

Gangrene  of.  Not  to  include  Infective  Gangrene.  (See 
Infective  Diseases.)  State  site.  Uo  not  use  as  a 
primarj'  diagnosis  when  cause  can  be  determined. 
I-'ile  alphabetically  according  to  i)art  affected. 

Gigantism. 

Gout,  Acute. 

Gout,  Chronic. 

Hasmochromatosis. 

Infancy.    (See  Newborn  Child). 

Infantilism. 

Lipaemia. 

Malnutrition. 

Malingering. 

Marasmus. 

Migraine. 

Milk  Sickness  (Trembles). 

Nostalgia. 

Obesity. 

Adiposis  Dolorosa. 
Osteoarthropathy,  Hypertrophic. 
Phantom  Tumor. 
Precocity. 
Raynaud's  Disease. 
Rheumatism,  Chronic  Articular. 
Rheumatism,  Muscular. 
Rickets. 
Scurvy. 
Sea  Sickness. 

Senility.    Diagnosticate  as  Arterial  Sclerosis,  General. 

File  under  Diseases  of  Circulatory  Sjstem. 
Serum  Inoculation  for.    File  under  appropriate  disease. 
Shock.    ])o  not  use  as  a  primary  diagno-is. 
Sinus  of.    State  location. 
Starvation. 

Syncope.    Diagnosticate  as  Anaemia  of  Brain.    File  un- 
der Diseases  of  Nervous  System. 
Tetany. 

Unknown.    To  include  cases  refusing  examination,  or 
niii  presenting  any  definite  disease  nr  condition 
Vagrancy. 

MUSCLES,  FASCIA,  TENDONS.  AND  TENDON 
SHEATHS. 

State  Muscle  or  Tendon. 
MUSCiJ-:S  AND  FASCI/E: 
Abscess  of. 
Atrophy  of. 

Congenital  Malformation  of.     {•"ilc   under  Congenital 

.Malformation  of  Muscular  System. 
Contracture  of. 
Cramp  of. 
Degeneration  of. 
Dupuytren's  Contraction. 
Hernia  of. 
Myositis,  Acute. 
Myositis,  Chronic. 
Myositis,  Progressive  Ossifying. 
Myositis,  Traumatic  Ossifying. 
Myotonia  Congenita. 
Paralysis  of,  Ischaemic. 

Pdiasitr  of.  State  variety.  File  under  Parasitic  Dis- 
eases. 

Syphilis  of.    File  under  Syphilis 

Turticollis.  Diagnosticate  as  Contracture  of  or  Cramp  of . 

Tuberculosis  of.    File  under  Tuberculosis 

Tumor  of.    State  variety.    File  under  Tumors. 

TFNDONS  AND  SHEATHS: 

Abscess  of. 

Ganglion. 

Hammer  Toe. 

Mallet  Finger. 

Syphilis  of.    File  under  Syphilis. 

Tenontosynovitis.  When  due  to  gonococcus  diagnosti- 
cate as  Gonococcus  Infection  of.  File  under  In- 
fective Diseases. 

Tuberculosis  of.    File  under  Tuberculosis. 

Tiiii'or  of.    State  variety.    File  under  TuniDrs. 


THE  NERVOUS  SYSTEM. 

BRAIN,  SPINAL  CORD,  AND  MENINGES: 

Abscess  of  Brain. 

Anaemia  of  Brain  (Syncope). 

Apoplexy.     J)()  not  use  as  a  primary  diagnosis  when 

cau^e  can  be  determined. 
Arterial  Sclerosis,  Cerebral. 
Ataxia,  Hereditary. 
Bulbar  Paralysis. 
Caisson  Disease. 

Congenital  Malformation  of  Brain,  l-ile  under  Congen- 
ital .Malformation  of  .Ncrxou^  Sy>tem. 

Congenital  Malformation  of  Spinal  Cord.  I'ile  under 
Congenital  .Malformation  ot  Ners'ous  System. 

Cyst  of  Brain.    Nut  to  include  Cystic  Tumor. 

Dystrophy,  Progressive  Muscular. 

Embolism  of.    State  artery. 

Encephalitis,  Acute. 

Haematomyelia. 

Hasmatorrhachis. 

Haemorrhage,  Epidural. 

Haemorrhage,  Subdural. 

Haemorrhage  into  Cerebellum. 

Haemorrhage  into  Cerebrum. 

Haemorrhage  into  Medulla. 

Haemorrhage  into  Pons. 

Hemiplegia,  Old. 

Hernia  of  Brain. 

Hydrocephalus,  Acquired. 

Meningitis,  Cerebral. 

Meningitis,  Spinal. 

Morvan's  Disease. 

Myelitis,  Disseminated. 

Myelitis,  Transverse. 

Pachymeningitis,  Cerebral. 

Pachymeningitis,  Spinal. 

Paralysis,  Acute  Ascending. 

Paralysis,  Brown-Sequard's. 

Paralysis,  Infantile  Spastic. 

Paraplegia,  Ataxic. 

Paraplegia,  Hereditary  Spastic. 

I\triisi!i   of  Brain.    .State  \'ariet\-.     File  under  Parasitic 

Diseases. 

Parasite  of  Spinal  Cord.    State  variety.    File  under  Par 

asitic  Diseases. 
Poliomyelitis,  Acute  Anterior. 
Poliomyelitis,  Chronic  Anterior. 
Sclerosis,  Amyotrophic  Lateral. 
Sclerosis,  Disseminated. 
Sclerosis,  Lateral. 

Syphilis  of  Brain.    ImIc  under  Syphilis. 

Syphilis  of  Cerebral  Meninges.    File  under  Syphilis. 

Syphilis  of  Spinal  Cord.    I'ile  under  Syphilis. 

Syphilis  of  Spinal  Meninges.    I'ile  under  Syphilis. 

Syringomyelia. 

Tabes  Dorsalis. 

Thrombosis  of.    State  sinus  or  vessel. 
Tuberculosis  of  Brain.    File  under  Tuberculosis. 
Tuberculosis  of  Cerebral  Meninges. 

Tuberculosis  of  Spinal  Meninges.  P'ile  under  Tubercu- 
losis. 

T iiiiior  of  Brain.    State  \ariety.    File  under  Tumors. 
Tumor  of  Spinal  Cord.    State  \ariety.    File  under  Tu- 
mors. 

CRANI.\L  .\vi)  SPINAI  NERVES: 

Meniere's  Disease. 
Neuralgia  of.    State  nerve. 
Neuritis  of.    State  nerve. 
Neuritis,  Multiple. 

Paralysis  of.  State  nerve.  Do  not  use  as  a  primary 
diagnosis  when  cause  can  be  determined. 

Tumor  of.    State  variety  of  tumor  and  nerve  affected. 
File  under  Tumors. 

Zoster. 

FUNCTIONS  I.  Nl'.RVOUS  DISORDERS: 

Angeiospastic  CEdema. 

Athetosis. 

Catalepsy. 

Chorea. 

Chorea,  Chronic  Progressive. 


1064 


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[New  York 
Medical  Journal. 


Convulsions,  Infantile.    Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined.  , 
Epilepsy. 

Epilepsy,  Jacksonian. 

Hiccough.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Hypochondriasis. 
Hysteria. 
Neurasthenia. 
Neurosis,  Occupational. 

Neurosis,  Traumatic.    To  include  railway  spine. 

Night  Terrors. 

Paralysis  Agitans. 

Paramyoclonus  Multiplex. 

Somnambulism. 

Spasm,  Habit. 

Spasm,  Nodding 

Spasm,  Saltatory. 

Stammering. 

Stuttering. 

Tic,  Simple.    Diagnosticate  as  Spasm,  Habit. 
Tic,  Convulsive. 
Tic,  Coordinated. 

Tic,  Painful  of.    Diagnosticate  as  Neuralgia  of.  File 

under  Neuralgia. 
Tic,  Psychical. 

PARASITIC   DISEASES   AND   ANIMAL  PARA- 
SITES.' 

BLOOD: 
Filariasis. 

Frambcesia  (Yaws). 
Haemoglobinuric  Fever. 
Kala  Azar. 
Malaria. 

Relapsing  Fever. 
Ssrahilis. 

Syphilis  of. 
Trypanosomiasis. 

INTESTINAL: 

Amoeba  Coli. 

Amoebic  Abscess  of  Liver. 

Amoebic  Dysentery. 
Ascaris  Lumbricoides. 
Oxyuris  Vermicularis. 

Taenia  Dibothriocephalus  Latus,  Saginata,  Solium,  etc. 
Tricocephalus  Dispar. 
Uncinariasis, 
etc. 

MISCELLANEOUS: 
Bilharziasis. 

Cysticercus  of.    State  site. 
Distoma  Hepaticum. 
Echinococcus  of.    State  site. 
Trichiniasis. 

Skin  Parasites.    File  under  Diseases  of  the  Skin. 
Etc. 

POISONINGS  AND  INTOXICATIONS. 

Absinthe  Poisoning. 
Acetanilide  Poisoning. 
Acetic  Acid  Poisoning. 
Acetylene  Poisoning. 
Aconite  Poisoning. 

Aconitine  Poisoning. 
Adrenalin  Poisoning. 
Alcohol  Poisoning. 
Alcohol  Poisoning,  Methyl. 
Alum  Poisoning. 

Ammonium  Carbonate  Poisoning. 
Ammonium  Hydroxide  Poisoning. 
Amylene  Hydrate  Poisoning. 
Amyl  Nitrite  Poisoning. 
Aniline  Poisoning. 
Antimony  Poisoning. 
Antipyrine  Poisoning. 
Arsenic  Poisoning,  Acute. 
Arsenic  Poisoning,  Chronic. 
Arsenureted  Hydrogen  Poisoning. 

'File  alphabetically  any  parasites  not  mentioned  in  this  abridged 
nomenclature. 


Aspidium  Poisoning. 
Belladonna  Poisonmg. 

Atropine  Poisoning. 
Benzine  Poisoning  (Benzol). 
Boric  Acid  Poisoning. 

Borax  Poisoning. 
Botulism. 

Bromine  Poisoning. 
Bromoform  Poisoning. 
Carmibis  Indica  Poisoning  (Hashish). 
Cantharides  Poisoning. 
Carbon  Bisulphide  Poisoning. 
Carbon  Dioxide  Poisoning. 
Carbon  Monoxide  Poisoning. 
Castor  Oil  Seed  Poisoning. 
Chloral  Hydrate  Poisoning. 
Chloralamide  Poisoning. 
Chlorethyl  Poisoning. 
Chlorine  Poisoning. 
Chlorinated  Lime  Poisoning. 
Chlorinated  Soda  Poisoning. 
Chloroform  Poisoning. 
Chloroform  Poisoning,  Delayed. 
Choke  Damp  Poisoning. 
Chromic  Acid  Poisoning. 

Chromate  Poisoning. 
Chrysarobin  Poisoning. 
Cinchona  Poisoning. 

Quinine  Poisoning. 
Coca  Poisoning,  Acute. 

Cocaine  Poisoning,  Acute. 
Coca  Poisoning,  Chronic. 

Cocaine  Poisoning,  Chronic. 
Cocculus  Indicus  Poisoning. 

Picrotoxine  Poisoning. 
Coffee  Poisoning. 

Caffeine  Poisoning. 
Colchicum  Poisoning. 

Colchicine  Poisoning. 
Conium  Poisoning. 
Copaiba  Poisoning. 
Copper  Poisoning. 
Cordite  Poisoning. 
Creoline  Poisoning. 
Creosote  Poisoning. 

Guaiacol  Poisoning. 
Croton  Oil  Poisoning. 
Curare  Poisoning. 
Delphinium  Poisoning. 
Digitalis  Poisoning. 
Duboisia  Poisoning. 
Egg  Albumen  Poisoning. 
Elaterium  Poisoning. 

Elaterin  Poisoning. 
Ergot  Poisoning,  Acute. 
Ergot  Poisoning,  Chronic. 
Ether  Poisoning. 
Fish  Poisoning. 

Shell  Fish  Poisoning. 
Fish  Venom  Poisoning. 
Fluorine  Poisoning. 
Formaldehyde  Poisoning. 
Fusel  Oil  Poisoning. 
Gasoline  Poisoning. 
Gelsemium  Poisoning. 
Hydrochloric  Acid  Poisoning. 
Hydrocyanic  Acid  Poisoning. 

Cyanide  Poisoning. 

Cyanogen  Poisoning. 
Hydrofluoric  Acid  Poisoning. 
Hyoscyamus  Poisoning. 

Hyoscyamine  Poisoning. 

Hyoscine  Poisoning  1  Scopolamine), 
Illuminating  Gas  Poisoning. 
Insect  Sting. 
Iodine  Poisoning. 
Iodoform  Poisoning. 
Iron  Poisoning. 
Kerosene  Poisoning. 
Lathyrism. 

Lead  Poisoning,  Acute. 
Lead  Poisoning,  Chronic. 
Lobelia  Poisoning. 
Lysol  Poisoning. 


May  22,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


Marsh  Gas  Poisoning. 
Mercury  Poisoning,  Acute. 
Mercury  Poisoning,  Chronic, 
Milk  Poisoning. 

Cheese  Poisoning. 
Mushroom  Poisoning. 

Muscarine  Poisoning. 
Naphthalene  Poisoning. 
Naphthol  Poisoning. 
Nitric  Acid  Poisoning. 
Nitrobenzol  Poisoning. 

Nitrobenzin  Poisoning. 
Nitroglycerin  Poisoning. 
Nitrous  Oxide  Poisoning. 
Nux  Vomica  Poisoning. 

Strychnine  Poisoning. 
Opium  Poisoning,  Acute. 

Codeine  Poisoning,  Acute. 

Dionine  Poisoning,  Acute. 

Heroin  Poisoning,  Acute. 

Morphine  Poisoning,  Acute. 

Peronine  Poisoning,  Acute. 
Opium  Poisoning,  Chronic. 

Codeine  Poisoning,  Chronic. 

Dionine  Poisoning,  Chronic. 

Heroine  Poisoning,  Chronic. 

Morphine  Poisoning,  Chronic. 
Oxalic  Acid  Poisoning. 

Acid  Potassium  Oxalate  Poisoning. 
Paraldehyde  Poisoning. 
Parathyreoid  Extract  Poisoning. 
Pellagra. 

Pennyroyal  Poisoning. 
Petroleum  Poisoning. 
Phenacetin  Poisoning. 
Phenol  Poisoning. 
Phosphoric  Acid  Poisoning. 
Phosphorous  Acid  Poisoning. 
Phosphorus  Poisoning,  Acute. 
Phosphorus  Poisoning,  Chronic. 
Physostigma  Poisoning. 
Picric  Acid  Poisoning. 
Pilocarpus  Poisoning. 

Pilocarpine  Poisoning. 
Potassium  Carbonate  Poisoning. 
Potassium  Hydroxide  Poisoning. 
Potassium  Nitrate  Poisoning. 
Quicklime  Poisoning. 
Resorcin  Poisoning. 

Rhus  Toxicondendron  Poisoning.  Diagnosticate  as 
Dermatitis  Venenata.  File  under  Diseases  of  the 
Skin. 

Salicylic  Acid  Poisoning. 

Santonin  Poisoning. 

Sapraemia. 

Serum  Intoxication. 

Sewer  Gas  Poisoning. 

Silver  Poisoning. 

Snake  Venom  Poisoning. 

Sodium  Carbonate  Poisoning. 

Sodium  Chlorate  Poisoning. 

Sodium  Hydroxide  Poisoning. 

Stramonium  Poisoning. 

Strophanthus  Poisoning. 

Strophanthin  Poisoning. 
Sulphonal  Poisoning. 
Sulphureted  Hydrogen  Poisoning. 
Sulphuric  Acid  Poisoning. 
Tansy  Poisoning. 
Tartaric  Acid  Poisoning. 
Tea  Poisoning. 
Thymus  Extract  Poisoning. 
Thyreoid  Extract  Poisoning. 
Tin  Poisoning. 
Tobacco  Poisoning. 

Nicotine  Poisoning. 
Trional  Poisoning. 
Turpentine  Poisoning. 
Veratrum  Poisoning. 
Veronal  Poisoning. 
Zinc  Poisoning. 

(To  be  continued.) 


Ipitj^  at  €mm  $ntxmit. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL 

May  IS,  1909. 

1.  Breast  Abscesses.    A  Report  of  Seven  Cases  Treated 

by  Bier's  Suction  Method, 

By  Robert  L.  de  Nor.mandie. 

2.  On  the  Effects  of  Coffee  and  Their  Remedj', 

By  Walter  Wesselhoefft. 

3.  Coffee  as  a  Beverage ;  Its  Use  and  Abuse, 

By  Robert  Amory. 

4.  Case  of  Imperforate  Anus,  By  L.  C.  Kingman. 

5.  Intermittent  Hydronephrosis.    With  a  Report  of  Four 

Cases,  By  D.\niel  Fiske  Jones. 

1.  Breast  Abscesses. — De  Xormandie  reports 
seven  cases  of  breast  abscess  treated  by  Bier's 
suction  method,  six  successfully,  one  a  failure.  He 
remarks  that  his  cases  have  taken  a  longer  time 
than  that  in  which  Bier  says  he  can  cure  cases.  The 
reason  probably  is  that  in  all  of  these  cases  the 
abscess  was  well  developed  and  a  large  amoimt  of 
inflammatory  tissue  was  about  it.  In  other  words, 
the  incision  was  not  made  early  enough.  Bier  favors 
early  incisions,  and  our  author  is  confident  that  if 
he  could  have  made  a  much  earlier  stab  incision 
in  these  cases  the  time  for  healing  would  have  been 
much  lessened.  The  immediate  lessening  of  pain 
following  the  treatment  and  the  painlessness  of  this 
treatment  are  among  the  strongest  points  for  its 
use.  The  temperature  and  pulse  gradually  drop, 
and  by  the  third  or  fourth  day  reach  normal.  The 
mass  gradually  and  steadily  becomes  smaller.  The 
pus  changes  in  character  from  the  thick,  creamy 
discharge  to  thin  yellowish  serum,  which  coagu- 
lates quickly  and  very  firmly.  Because  of  this  quick 
coagulation  in  some  of  the  cases  he  used  a  sodium 
citrate  dressing.  The  scars  left  are  minute ;  the 
ugly  disfiguring  scars  of  the  open  surgical  method 
are  not  seen.  The  destruction  of  tissue  is  reduced 
to  the  minimum  and  thereby  the  function  of  the 
breast  is  preserved.  Etherization  is  not  necessary 
except  possibly  in  the  highly  neurotic  woman. 
Ethyl  chloride  anaesthesia  is  sufficient  for  the  in- 
cision, which  is  but  a  stab  one.  The  only  real  dis- 
advantage of  this  method  is  the  expense  entailed 
in  providing  the  apparatus,  for  it  is  obviously  out 
of  the  question  for  each  physician  who  may  have 
a  breast  abscess  in  his  practice  to  provide  himself 
with  one  or  more  bells  and  an  exhaust  pump  for  a 
condition  which  he  may  not  meet  again  for  some 
time,  even  years. 

2,  3.  Coffee. — ^^'esselhoef^t  speaks  of  the  bad 
eflfect  of  coffee  upon  the  system.  The  coflfee  habit 
is  charged  with  the  production  of  arteriosclerosis, 
spinal  degeneration,  proliferation  of  connective  tis- 
sue in  the  kidneys  and  other  organs,  heart  neuroses, 
etc.  He  states  that  caffeine  is  the  materia  peccans. 
It  is  possible  to  extract  this  alkaloid,  and  thus  pro- 
duce a  caffeine  free  coffee,  without  depriving  the 
infusion  of  its  savor  and  aroma. — Amory  is  in  favor 
of  cold  water  infusion  of  coffee,  as  advocated  by 
Younghusband.  In  order  to  make  an  agreeable  cup 
of  coffee  the  following  directions  should  be  care- 
fully observed :  Grind  the  coffee  bean  rapidly  to 
a  fine  powder,  as  the  heat  from  rapid  friction  will 


1  o()6 


I'lTH  or  Ci'RREXT  LITERATURE. 


[New  York 
Mkiiical  Journal. 


excite  the  evolution  of  the  volatile  oils.  It  i.-^  im- 
portant that  the  grinding  should  be  done  immediate- 
ly before  preparing  the  extract.  If  the  ground  cof- 
fee stands  in  the  air  the  volatile  oils  will  evaporate. 
The  cofifee  should  be  ground  to  an  inii:)alpable  pow- 
der. Place  the  ground  j^owder  in  the  upi^er  part 
of  an  Austrian  china  "biggin"  (percolator),  leaving 
of¥  the  cover  and  the  small  saucer :  put  in  a  lump 
of  ice  and  pour  on  cold  water  from  a  water  tap 
(not  well  or  spring  water),  and  let  the  ice  cold 
water  drip  through  the  ground  coffee,  stirring  the 
mixture  carefully  and  thoroughly  into  a  paste  like 
mass.  To  facilitate  the  percolation  of  the  infused 
watery  extract  it  is  advisable  to  place  a  small  piece 
of  wood  between  the  lower  edge  of  the  receiver 
which  contams  the  coffee  grounds  and  the  upper 
])ortion  of  the  vessel  which  receives  the  infusion, 
as  this  leaves  a  little  air  space  between  these  parts. 
When  the  liquid  coffee  infusion  has  all  dripped 
through  the  percolator,  pour  back  through  the  wet 
grounds  all  the  liquid  from  the  bottom  receiver  and 
allow  the  percolation  to  go  through  the  same  pro- 
cess as  before,  replenishing  the  ice  if  necessary. 
Now  place  the  lower  ])ortion  of  the  "biggin"  in  a 
cool  place  and  put  on  the  cover.  It  should  be 
noticed  that  the  result  of  this,  unltss  too  much 
water  is  used  in  the  percolation,  will  produce  a  very 
strong  extract.  This  is  desirable,  because  in  pre- 
paring it  for  the  cup  it  is-  advisable  to  add  sufficient 
boiling  water  to  reduce  it  to  the  required  strength, 
and  the  boiling  water  will  set  free  the  aromatic  vola- 
tile oils  which  give  the  agreeable  flavor. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

May  J 3.  1909. 

r.  Cancer  of  tiie  Breast.  By  Maurice  H.  Rkharhson. 
>.    Pliarmacological  Fetishisms.     By  Wilfred  M.  Barton. 

3.  Tuberculosis  of  the  Kidney.  By  M.  L.  }Iakkis. 

4.  'I'lic  Inoculation  Accident  in  Manila  in  1906. 

By  W.  M.  Haffkine. 

5.  Subnnicous  Perineorrhaphy,     By  W.  Wayne  Babcock. 

6.  The   Treatment  of  S'-oliosis,        By  .Arthur  Steindler. 

1.  Cancer  of  the  Breast. — See  Journal.  Apn\  3. 

I  w.  p.  717- 

2.  Pharmacological  Fetishisms. — Barton  takes 
up  twelve  remedies  to  which  in  certain  diseases  a 
specific  therapeutic  action  has  been  credited  and 
which,  upon  experimentation,  have  proved  valueless 
in  these  conditions.  He  mentions  olive  oil  as  a  chola- 
logue,  valerian  in  hysterics,  tannic  acid  in  internal 
h.'emorrhage,  alcohol  and  ether  hypodermically  in  ject- 
ed in  shock  and  collapse,  the  anilin  dyes  as  tissue  an- 
tiseptics.epinephrin  hyjxxlermically as  a  heart  stimu- 
lant, potassium  iodide  in  sclerosis,  jwtassium  chlor- 
ate in  stomatitis,  the  hy]X)])hosphites  in  neurasthenia, 
lithium  salts  and  the  uric  acid  diathesis,  and  calcium 
salts  in  internal  h.emorrhage. 

3.  Tuberculosis  of  the  Kidney. — I  larris  urges 
a  more  thorough  and  systematic  investigation  of  all 
patients  presenting  urinary  .symptoms  in  order  to 
recognize  tuberculosis  of  the  kidney  in  its  early 
stages.  He  believes  that  bilateral  involvement  is  not 
in  itself  a  contraindication  to  operation  but  that  in 
suitably  selected  ca.scs,  in  which  one  organ  is  only 
slighth   inv'lved.  the  removal  of  the  more  exten- 


sively diseased  kidne\-  may  be  an  aid  to  the  recov- 
ery of  the  other.  When  a  diagnosis  has  been  made 
early,  and  the  lesion  is  presumably  slight,  hygienic, 
general,  and  specific  treatment  should  be  given  a 
fair  trial  before  a  resort  is  had  to  nephrectomy,  and, 
when  an  operation  is  undertaken  it  should  be  a 
complete  ne])hrectomy,  if  possible,  as  incomplete  oj)- 
erations,  such  as  nephrotomy,  partial  resection,  etc., 
have  not  been  followed  by  good  results. 

4.  The  Inoculation  Accident  in  Manila  in  1906. 
— Haffkine  reviews  the  history  of  the  accident  which 
occurred  in  JNIanila  in  1906,  when  Haffkine  anticho- 
lera  vaccine  was  contaminated  with  virus  of  plague. 
It  will  be  remembered  that  a  number  of  natives 
were  inocidated  with  plague,  and  several  died.  It 
is  supposed  that  some  one  placed  a  forty-eight  hour 
virulent  plague  culture,  insufficiently  labeled,  among 
the  cholera  cultures,  and  that  the  whole  was  mixed 
and  inoculations  immediately  made.  Haffkine  re- 
marks that  the  details  of  the  Manila  accident  re- 
ported b}-  Dr.  Freer  tend  to  show  that  its  occur- 
rence did  not  stand  in  connection  with  the  degree 
of  perfection  or  deficiency  which  belong  to  cholera 
vaccination  or  to  any  bacteriological  method  as  such. 
In  all  pharmacies  and  shops  where  collections  of 
drugs  are  kept,  simple  regulations  are  adopted,  on 
the  responsibility  of  those  in  charge,  for  making- 
it  impossible  for  dangerous  materials  to  get  mixed 
with  harmless  ones.  Obviously  these  measures  had. 
at  the  time  of  the  accident,  not  been  in  force  at 
Manila ;  and  it  must  be  presumed  that  some  par- 
ticular circumstances  which  existed  at  the  time,  did 
not  allow  them  to  be  put  in  force. 

5.  Submucous  Perineorrhaphy.  —  ISabcock  re- 
marks that  the  operation  which  he  describes  is  bas^d 
on  the  following  urinciples  :  First.no  tissue  is  removed 
or  extensive  denudation  made.  Second,  buried,  ah- 
sorbable.  layer  sutures  are  used  exclusively,  none 
of  which  penetrates  the  skin  or  mucous  meiubrane. 
Third,  the  operation  is  done  from  the  outside  of  the 
vagina,  rendering  the  introduction  of  sutures  easier 
and  the  exi)osure  of  tissues  better  than  with  those 
operations  done  from  within  the  vagina.  I'ourth. 
each  structure  is  sutured  with  precision  under  the 
guidance  of  the  eye  :  there  is  no  blind  groping  with 
the  needle  for  tissues  not  seen  and  perhaps  not  felt. 
I'^ifth.  each  of  the  layers  of  the  perineal  floor — 
vaginal  wall,  submucosa.  muscular  supports,  fascial 
])lanes.  and  skin — are  united  seriatim  in  layers  after 
the  plan  of  the  better  types  of  herniotomy.  Sixth, 
the  vagina  is  not  separated  from  the  rectum  and 
therefore  there  is  no  danger  of  wounding  the  bowel. 
The  operation  has  the  following  advantages :  It 
restores  and  increases  the  length  of  the  vagina  in- 
stead of  shortening  the  posterior  wall  of  the  vagina 
as  occurs  with  many  of  the  older  operations.  .\1- 
though  no  tissue  is  removed  it  is  questionable  if  any 
other  type  of  perineorrhaphy  is  capable  of  ])roduc- 
ing  greater  narrowing  of  the  external  portion  of  the 
vagina  or  of  affording  greater  support  to  the  ante- 
rior vaginal  wall.  .\s  it  greatly  supports  the  ante- 
rior vaginal  wall,  slight  or  moderate  degrees  of 
cystocele  may  not  recjuire  additional  operation.  The 
o])eration  restores  the  normal  H  shaped  section  to 
the  vagina  instead  of  destroying  or  obliterating  the 
lower  lateral  sulci.     There  is  the  added  advantage 


May  22,  :909.]  FiTH  OF  CURRliXT  IJTEKATURE.  loUj 


that  no  sutures  require  removal ;  that  no  foreign 
bodies  in  the  shape  of  shot,  suture  ends,  or  the  like 
are  left  in  the  vagina  to  promote  and  to  hold  secre- 
tion and  that  the  seton  action  of  through  and 
through  sutures  is  avoided.  }tloreover.  the  prone- 
ness  of  knots  in  catgut  to  untie  when  exposed  on  a 
mucous  membrane  is  obviated  by  the  burial  of  all 
knots  in  the  tissue.  Comparing  Babcock's  experi- 
ence with  the  Emmet  operation  with  his  own  under 
equal  aseptic  precautions,  the  liability  to  suppura- 
tion seems  less,  the  required  period  of  disability 
shorter,  and  the  inconvenience  of  suture  removal, 
and  the  danger  of  nonabsorbable  sutures  obviated 
in  the  present  operation.  Comparing  the  end  re- 
sults of  the  two  methods  a  more  perfect  perinasiun 
with  a  better  muscular  support  and  a  closer  ap- 
proximation to  a  normal  restoration  is  secured  by 
the  method  of  submucous  perineorrhaphy.  In  do- 
ing the  operation,  one  should  realize  that  the  vagina 
runs  nearly  parallel  with  the  skin  perinseum,  and 
that  the  finger  introduced  to  the  cervix  may  be  but 
half  an  inch  distant  from  the  finger  of  the  external 
hand  placed  on  the  skin  adjacent  to  the  coccyx. 
Lateral  to  the  vagina  one  may  nearly  always  distin- 
guish the  thick  broad  bands  of  the  levator  ani 
muscle.  In  the  nulliparous  woman  the  muscle  is 
close  to  the  introitus,  in  the  multiparous  it  is  more 
deeply  situated.  By  placing  a  finger  against  the 
anterior  edge  of  this  muscle  on  either  side  and  com- 
paring the  relative  depths  of  the  muscle  from  the 
surface,  one  may  acquire  an  idea  as  to  the  relative 
injury  to  the  two  muscles.  Rarely  ever  will  one 
find  the  muscle  completely  divided  lateral  to  the 
vagina ;  but  on  the  side  of  greater  laceration  the 
edge  of  the  nurscle  will  usually  be  found  to  be  from 
one  to  several  centimetres  deeper  than  that  of  the 
opposite  side. 

MEDICAL  RECORD. 

1.  Newer  Conceptions  of  Cardiac  Arrliytlmiias  and  Their 

Treatment.  By  Thomas  E.  S.\tte."<th\v.\ite. 

2.  The  Cause  of  Trembles  and  Milk  Sickness, 

By  E.  L.  MosELEv. 
X  Ray  Diagnosis,  By  Homer  E.  Smith. 

4.  Cerebral  H?emorrhagc  Follow  ing  Arteriosclerotic  Gran- 

ular Nephritis  Mistaken  for  Cerebral  Embolism. 

By  BoxD  Stow. 

5.  A  Note  on  the  Benedict  Method  of  Quantitative  Elsti- 

mations  of  Sugar  in  the  Urine,  By  I.  R.  Pels. 

I.  Newer  Conceptions  of  Cardiac  Arrhythmias 
and  Their  Treatment.  —  Satterthwaite  remarks 
that  until  quite  recently  physicians  have  relied  main- 
ly on  the  radial  pulse,  as  felt  by  the  finger,  to  con- 
tradistinguish the  various  forms  of  arrhythmias. 
But  the  newer  instruments  of  precision  have  been 
enlarging  our  field  of  vision,  the  sphygmograph.  the 
polygraph,  and  to  some  extent  the  x  ray.  enab'ing 
us  not  only  to  locate  with  a  gradually  increasing  de- 
gree of  certainty  the  sources  of  these  irregulari- 
ties, but  also  to  classify  them  on  a  more  scientific 
basis.  The  first  important  move  was  made  bv  Gas- 
kell.  who  in  1882  demonstrated  that  the  heart  mus- 
cle has  five  separate  physiological  activities  or  func- 
tions. His  propositions  have  now  been  accepted  bv 
physiologists  generally.  These  functions  are  as 
follows:  I.  Rhythmicity,  i.  e.,  the  facultv  of 
rhythmically   initiating  a   stimulus.    2.  Irritabilit\- 


or  excitability,  the  faculty  of  receiving  a  stimulus. 
3.  Contractility,  or  the  power  of  responding  to  a 
stimulus.  4.  Conductivity,  or  the  power  of  convey- 
ing a  stimulus.  5.  Tonicity,  or  the  power  of  main- 
taining the  tone  of  the  heart.  It  is  on  these  post- 
ulates that  the  present  classification  of  cardiac  ar- 
rhythmias is  based.  Clinically  speaking,  however, 
the  physiological  or  pathological  disturbances  of 
these  functions  are  not  always  clearly  distinguish- 
able, for  one  reason,  because  they  may  occur  to- 
gether and  then  are  not  always  or  easily  separable. 
In  the  matter  of  excitability  and  tonicity,  too.  we 
have  as  yet  no  criteria  for  determining  abnormali- 
ties of  function.  And  yet  very  often  there  can  be 
seen  a  predominating  disturbance  of  function  suf- 
ficient to  distinguish  each  form  clinically  from  its 
fellows ;  while  there  is  reason  to  believe  from  the 
progress  that  has  recently  been  made,  that  far 
greater  accuracy  is  going  to  be  attained,  and  be- 
fore very  long.  Already  we  have  learned  enough 
from  sphygmographic  and  pol\graphic  tracings, 
studied  in  conjunction  with  other  objective  and 
some  stibjective  signs,  to  enable  tis  to  classify  clin- 
ically at  least  five  difterent  forms  of  arrhythmias, 
which  the  author  describes  on  the  hand  of  poly- 
graphs. He  concludes  that  while  the  polygraph  has 
enabled  tis  to  make  more  exact  diagnoses,  we 
shotild  not  altogether  pin  our  faith  on  polygrams, 
without  careful  study,  remembering  always  that  to 
be  truthful  representations  of  actual  conditions,  they 
must  be  taken  by  an  experienced  hand.  But  poly- 
grams are  so  necessary  in  the  diagnosis  of  arrhyth- 
mias, that  no  well  equipped  hospital  shotild  be  with- 
otit  a  good  polvgraphic  instrument.  Polyg.'ams 
should  be  taken  of  every  arrhythmic  case,  as  far 
as  practicable,  certainly  whenever  there  is  a  venous 
pulse.  Up  to  the  present  time  we  are  lacking  in 
a  good  portable  instrument.  It  is  to  be  hoped  that 
one  will  soon  be  devised. 

2.  The  Cause  of  Trembles  and  Milk  Sickness. 
— Aloseley  has  made  some  experiments  on  rabbits, 
which  prove  the  theory  that  trembles  and  milk  sick- 
ness are  due  to  aluminum  phosphate.  In  Ohio  and 
Illinois  animals  get  this  substance  by  eating  white 
snakeroot.  in  New  Mexico  by  eating  the  rayless 
goldenrod.  In  the  northern  States,  wherever  trem- 
bles prevails,  the  white  snakeroot  grows  abundantly. 
He  knows  of  a  number  of  cases  of  trembles  follow- 
ing the  eating  of  this  weed  by  animals  in  the  woods, 
and  he  believes  that  in  every  case  of  trembles  in- 
vestigation careftilly  made  would  show  that  they 
had  eaten  it.  On  the  other  hand,  they  may  eat 
small  amotints  withotit  serious  effects.  The  weed 
grows  in  many  places  where  trembles  is  tinknown, 
but  in  these  places  better  tasting  plants  are  so  much 
more  abundant  that  white  snakeroot  forms  btit  an 
insignificant  part  of  their  food.  Commonly  in  these 
places  the  white  snakeroot  shows  no  sign  of  brow^s- 
ing.  Millions  of  animals  in  the  northern  States  are 
pastured  Avhere  white  snakeroot  does  not  grow.  He 
does  not  know  of  a  single  case  of  trembles  ever  oc- 
curring among  them.  The  Bureau  of  Plant  In- 
dtistry  of  the  U.  S.  Department  of  Agrictilture 
failed  to  obtain  such  results  in  their  experiments 
with  white  snakeroot  becatise  they  used  aqtieotts 
extracts,  and  aluminum  phosphate  is  not  soluble  in 


io68  ^'''^'^  OF  CURRENT  LITERATURE. 


water,  though  readily  soluble  ni  dilute  acid,  like 
that  of  the  stomach.  The  only  experiment  in  which 
they  actually  fed  the  weed  is  described  in  two  lines, 
in  their  bulletin  of  sixteen  pages,  "The  Supposed 
Relationship  of  White  Snakeroot  to  INIilk  Sickness 
or  Trembles,"  as  follows :  "A  lamb  weighing  about 
25  kilos,  when  fed  58  grammes  of  the  fresh  plant, 
showed  merely  some  diarrhoeal  symptoms."  This 
quantity  would  probably  not  kill  a  full  grown  rab- 
bit, although  a  much  smaller  weight  of  dry  leaves 
will  do  so. 

BRITISH   MEDICAL  JOURNAL. 
May  I,  igog. 

1.  An  Addre.-^s  on  the  Duty  of  the  Medical  Profession  in 
the  Prevention  of  -National  Deterioration, 

By  William  Coaxes. 

2.  A  Lecture  on  Fistula  between  the  Stomach  and  Bile 

Passages.  With  Remarks  on  other  Internal  Biliary 
Fistuke,  By  A.  W.  Mayo  Robson. 

3.  An  Unusual  Case  of  Appendix  Abscess  due  to  the 

Pneumococcus  and  Bacillus  Coli  Communis.  Treat- 
ment by  Double  Vaccine  :  Recovery.  With  Opsonic 
Estimations  and  Vaccine  Treatment, 

By  Edward  Harrison  and  Edward  Turton. 

4.  The  Indications  for  Nephropexy, 

By  William  Billington. 

5.  Ipoma  in  the  Site  of  a  Femoral  Hernia, 

By  C.  J.  Patten. 

6.  Bilateral  Nephrolithotomy,  in  which  the  Kidney  was 

Kept  Outside  the  Wound  for  Seven  Days  before  Re- 
turning it  to  the  Loin.  By  John  Clay. 

7.  Removal  of  a  Large  Varix  of  the  Orbit, 

By  Sir  William  J.  Collins. 

8.  The  Application  of  Continuous  Suction  in  Surgery, 

By  H.  T.  Herring. 

9.  A  Fatal  Case  of  Lead  Poisoning  due  to  Diachylon, 

By  F.  Strong  Heaney. 

2.  Fistula  between  Stomach  and  Bile  Pas- 
sages.— Robson  reports  nine  interesting  cases 
with  operation,  and  calls  attention  to  the  serious 
responsibility  of  allowing  gallstone  disease  to  pass 
on  until  complications  such  as  those  he  mentions 
have  supervened,  since  operation  for  cholelithiasis 
at  a  time  before  the  gallbladder  and  bileducts  have 
become  seriously  damaged,  and  the  neighboring  or- 
gans have  participated  in  the  trouble,  is  almost  de- 
void of  danger  if  the  operation  is  performed  by  an 
experienced  and  careful  surgeon ;  whereas,  if  opera- 
tion is  only  done  after  the  parts  have  become  matted 
together,  after  fastul?e  have  formed  and  the  patient 
is  run  down  by  fever  and  other  septic  complica- 
tions, the  mortality  will  be  greatly  increased. 

4.  Indications  for  Nephropexy. — Billington 
sums  up  liis  conclusion  from  his  experience  of  150 
cases  in  wliich  he  has  operated  for  movable  kidney 
(luring  the  past  three  years :  Nephropexy  is  a  safe 
and  satisfactory  surgical  procedure.  Renal  mobil- 
ity alone  is  not  an  indication  for  operation.  Local 
pain  of  sufficient  severity  to  diminish  working  ef- 
ficiency is  an  indication  for  operation.  Chronic 
functional  disturbance  of  the  digestive  system  may 
be  caused  by  movable  kidney.  Such  patients  often 
resist  all  kinds  of  general  and  medicinal  treatment, 
and  are  greatly  benefited  by  nephropexy.  Nephro- 
pexy is  indicated  in  progressive  spinal  and  cerebral 
neurasthenia  occurring  in  association  with  movable 
kidney,  when  other  measures  have  failed  to  cure, 
or    improvement    is    followed    by    rapid  relapse. 


[New  York 
Medical  Journal. 

Nephropexy  is  indicated  when  movable  kidney  is  as- 
sociated with  insanity. 

8.  Continuous  Suction  in  Surgery. — Herring 
describes  a  suction  pump  which  he  has  found  very 
useful  as  a  means  of  removing  blood  during  opera- 
tion, and  of  subsequently  draining  wounds  and 
withdrawing  secretions.  It  consists  of  a  rotary 
pump,  which  will  mechanically  extract  air,  and  a 
small  electric  motor  to  drive  it,  both  being  enclosed 
in  a  portable  box.  This  apparatus  is  exceedingly 
efficient,  extracting  ten  to  twelve  cubic  feet  of  air 
an  hour,  and  will  produce  a  high  negative  pressure 
(over  29.5  in.  of  mercury). 

LANCET. 

May  I,  igog. 

1.  Rheumatic  Fever  and  Valvular  Disease, 

By  Norman  Moore. 

2.  The  Removal  of  Tumors  of  the  Large  Intestine, 

By  Arthur  E.  J.  Barker. 

3.  When  to  Operate  for  Enlarged  Prostate :  With  a  Re- 

view of  600  Cases  of  Total  Enucleation  of  that  Or- 
gan, By  P.  J.  Freyer. 

4.  On  the  Discrimination  of  Unrecognized  Diseases  and 

on  a  Disease  of  Overcrowding  in  Ships,  especially 
at  Malta,  By  W.  E.  Home. 

5.  Notes  on  a  Fatal  Case  of  Splenomegalic  Polycythaemia 

(Erythraemia),  By  W.  F.  Umney. 

6.  Adenoids,  Nocturnal  Incontinence,  and  the  Thyreoid 

Gland,  By  Leonard  Williams. 

7.  Streptococcal  Pericarditis  and  Colitis  following  Ton- 

silitis.  By  J.  Sidney  Pearson. 

8.  A  Simple  Method  for  the  Sterile  Collection  of  Blood, 

By  Hugh  W.  Bayly. 

9.  The  Charitable  Dispensaries  in  the  Punjab, 

By  D.  F.  Keegan. 

I.    Rheumatic  Fever  and  Valvular  Disease. — 

!Moore,  in  his  second  Lumleian  lecture,  states  that  the 
first  attempt  in  England  to  explain  the  pathology 
of  rheumatism  was  that  of  Dr.  Clopton  Havers,  of 
St.  Catharine's  College,  Cambridge,  in  his  Osteologia 
Nova,  published  in  1691.  Few  have  read  the  book, 
yet  its  account  of  the  structure  of  bone  has  se- 
cured for  its  author  the  mention  of  his  name  with 
the  Haversian  canals  by  every  student  of  medicine, 
since  his  time.  He  advanced  the  view  that  rheuma- 
tism was  due  to  a  sort  of  jelly  "concreted  upon  the 
superficies  of  the  muscles."  He  mentioned  in  sup- 
port of  this  hypothesis  that  rheumatism  was  due 
to  this  mucilage  or  jelly  a  case  of  a  curious  tumor 
of  the  leg,  perhaps  a  hydatid,  since  it  contained 
"many  smaller  pieces  of  white  curd  mixed  with  a 
serum,"  which  he  thought  showed  that  mucilaginous 
glands  existed  in  the  muscles  and  became  diseased, 
and  that  they  were  the  source  of  the  outpouring 
which  constituted  rheumatism.  Since  the  time  of 
Havers  many  pathological  hypotheses  have  arisen 
on  the  causation  of  rheumatism.  None  of  those  re- 
lating to  rheumatic  fever  need  be  recapitulated.  Its 
resemblance  to  diseases  produced  by  definite  organ- 
isms is  too  close  for  any  other  hypothesis  of  origin 
to  be  at  present  probabble.  It  might  obviously  l)e 
included  among  what  Sydenham  would  have  called 
the  epidemic  diseases  of  the  year.  The  pain  which 
it  produces  we  know  how  to  relieve,  but  when  it 
is  considered  that  it  is  the  origin  of  most  of  the 
valvular  disease  of  the  first  half  of  life  and  of  some 


May  22,  ,909.]  PITH  OF  CURRENT  LITERATURE.  io6g 


proportion  of  the  valvular  disease  of  the  second  half 
of  life,  and  through  them  of  all  the  distresses  of 
slow  death  by  dropsy  and  instant  death  by  affec- 
tion of  the  muscular  tissue  of  the  heart,  as  well  as 
of  all  the  diminution  of  working  power  which  is 
a  necessary  result  of  valvular  disease  long  before 
it  has  begun  to  threaten  life,  we  anxiously  look  to 
the  bacteriologists  for  a  conclusive  demonstration  of 
the  nature  of  the  organism  which  produces  it  and 
of  its  natural  history  as  an  important  aid  to  the 
prevention  of  rheumatic  fever  and  the  diminution  of 
its  incidence  on  the  population  and  of  its  long  train 
of  disastrous  consequences. 

3.  When  to  Operate  for  Enlarged  Prostate. — • 
Freyer  gives  a  review  of  six  hundred  cases  in  which 
he  performed  total  enucleation  of  the  prostate  for 
enlargement  of  that  organ,  the  patients  varying  in 
age  from  forty-eight  to  eighty-nine  years,  with  an 
average  of  sixty-eight  and  one  half  years.  There 
were  forty-seven  octogenarians  between  the  ages  of 
eighty  and  eighty-nine,  and  seven  patients  aged 
seventy-nine  years.  The  prostates  ranged  from 
54  to  16%  ounces,  with  an  average  weight  of  about 
25^  ounces.  The  great  majority  of  the  patients  had 
been  entirely  dependent  on  the  catheter  for  periods 
varying  up  to  twenty-four  years.  Nearly  all  were 
in  broken  health  and  many  apparently  dying  before 
operation.  Existence  was  simply  intolerable  to  most 
of  them.  Few  were  free  from  one  or  more  grave 
complications,  such  as  cystitis,  stone  in  the  bladder, 
pyelitis,  kidney  disease,  diabetes,  heart  disease, 
chronic  bronchitis,  paralysis,  hernia,  and  in  a  few 
instances  there  was  malignant  diseases  of  some  other 
organ  than  the  prostate.  Such  were  the  unfavorable 
circumstances  under  which  the  operation  was  un- 
dertaken. In  connection  with  these  600  operations 
there  were  thirty-seven  deaths,  in  periods  ranging 
from  six  hours  to  thirty-seven  days  after  the  opera- 
tion, or  a  mortality  of  6.15  per  cent.  The  mortality 
has  been  steadily  decreasing  from  ten  per  cent,  in 
the  first  100  cases  to  four  per  cent,  in  the  last.  The 
causes  of  death  were :  Ursemic  symptoms  due  to 
chronic  kidney  disease,  16;  heart  failure.  6;  septi- 
chasmia,  2;  shock,  3;  exhaustion  (kidneys  much  dis- 
eased), i;  mania  (hereditary  in  i),  2;  malignant 
disease  of  liver,  2 ;  heat  stroke,  i ;  pneumonia,  i  ; 
acute  bronchitis,  i  ;  pulmonary  embolism,  i  ;  and 
cerebral  haemorrhage  with  paralysis,  i.  Though  all 
these  deaths  are  accepted  in  connection  with  the  op- 
eration, in  not  more  than  half  the  number  can  the 
fatal  result  be  attributed  thereto,  the  remaining 
deaths  being  due  to  disease  incident  to  old  age  and 
unconnected  with  the  operation.  In  108  cases  ves- 
ical calculi  were  removed  at  the  same  time ;  but  all 
the  deaths  in  these  patients  are  accepted  in  connec- 
tion with  the  prostatectomy,  none  being  put  down 
to  the  suprapubic  lithotomy  involved. 

6.  Adenoids,  Nocturnal  Incontinence,  and  the 
Thyreoid  Gland. — Williams  reports  fifteen  cases 
of  nocturnal  enuresis.  He  remarks  that  adenoid 
vegetations  can  no  longer  be  regarded  as  a  cause 
of  nocturnal  enuresis,  the  adenoids  affording  some 
measure  of  protection  from  nocturnal  accidents  of 
this  nature.  He  thinks  that  when  the  two  conditions 
are  associated,  which  they  often  are,  they  are  both 
due  to  a  common  cause — namely,  insufficiency  of 


the  internal  secretion  of  the  thyreoid  gland.  This 
insufficiency  accounts  for  the  vast  majority  of  cases 
of  nocturnal  enuresis  in  children,  as  shown  by  the 
fact  that  the  exhibition  of  thyreoid  extract  will  in 
a  comparatively  short  space  of  time  effect  not  only 
a  cure  of  the  enuresis  but  a  great  amelioration  of 
many  •  coexisting  evidences  of  ill  health.  In  his 
cases  belladonna  and  hyoscyamus,  which  constitute 
the  sheet  anchors  of  the  textbooks,  have  not  played 
any  part  in  the  treatment.  Where  it  was  thought 
desirable  to  employ  anything  in  addition  to  the  thy- 
reoid extract,  these  additions  have  consisted  of  tonics, 
such  as  iron,  arsenic,  and  iodine.  The  very  remark- 
able improvement  in  the  general  health  of  his  pa- 
tients under  treatment  for  enuresis  by  thyreoid  ex- 
tract induced  him  to  try  the  eft'ect  of  the  drug  on 
two  or  three  children  who  suffered  from  debility 
due  to  other  causes.  He  found  that  his  patients 
who  had  not  suft'ered  from  nocturnal  enuresis,  un- 
der the  new  treatment  with  thyreoid  extract, 
now  had  nocturnal  enuresis.  He  comes  to  the  con- 
clusion, that  the  thyreoid  secretion  is  a  regulator  of 
the  mechanism  by  which  urinary  incontinence  is 
controlled,  an  excess  of  the  secretion  being  almost, 
if  not  quite,  as  deleterious  as  an  insufficiency.  In 
the  treatment  of  enuresis  by  thyreoid  extract  the 
question  of  dosage  is  therefore  not  only  of  para- 
mount importance  but  also  of  the  utmost  delicacy. 
It  is  essential  to  success  that  the  initial  dose  should 
be  very  small ;  that  this  dose  should  be  increased 
very  cautiously,  if  at  all ;  and  that  the  minimum  dose 
which  experience  proves  to  be  productive  of  good 
results  should  be  steadily  persevered  with,  rein- 
forced, if  necessary,  by  such  tonics  as  have  already 
been  mentioned. 

LA  PRESSE  MEDICALE. 

April  s,  1909- 

1.  Mechanism  of  Death  in  Intestinal  Occlusion, 

By  GuiBE. 

2.  Retrocaecal  Appendix  and  Cholecystic  Syndrome, 

By  E.  Meriel. 

3.  Clinical  Examination  of  the  [Musculature  of  the  Lower 

Extremity  in  Infantile  Paralysis,    By  C.  Ducroquet. 

4.  The  Triangle  of  Grocco,         By  Jacyxtho  de  Barros. 

5.  On   the   Technique   of   Direct   Endoscopy :  Tracheal 

Bronchoscopy,  CEsophagoscopy,  Gastroscopy, 

By  Francis  Munch. 

2.  Retrocaecal  Appendix  and  Cholecystic  Syn- 
drome.— ]\Ieriel  concludes  from  his  observations 
that  retrocecal  appendicitis  may  be  confounded 
with  hepatic  colitis  or  cholecystitis  on  account  of 
the  higher  position  of  the  appendix  ;  this  kind  of  ap- 
pendicitis and  cholecystitis  may  exist  together  and 
may  thits  make  a  correct  diagnosis  difficult. 

4.  The  Triangle  of  Grocco. — Barros  refers  to 
the  publication  of  Grocco,  who  in  1902  demon- 
strated in  exsudative  pleurisy  the  presence  of  a  rela- 
tive dulness  in  a  triangular  area  situated  over  the 
back,  near  the  vertebra  on  the  normal  side.  Conto 
demonstrated  later  that  this  dulness  was  not  only 
to  be  found  in  fluid  effusions  of  the  pleura  but  also 
in  fibrinous  pneumonia  and  even  in  tumors  of  the 
spleen.  Barros  reports  one  case  of  exsudative 
pleurisy  in  which  he  could  demonstrate  Grocco's 
sign. 


lO/O 


PROCEEDINGS  OF  SOCIETIES. 


[Nkw  York 
Medical  Journal. 


Afril  7,  igog. 

1.  The  Nervous  System  and  the  Phenomena  of  Acute 

Anaphylaxy,  By  Professor  Charles  Richet. 

2.  The  Treatment  of  Epidemic  Cerebral  Spinalmeningitis, 

By  Chambelland. 

^■    Treatment  of  Puhnonary  Tuberculosis  by  Inhalation  of 
Verdigris  Dust.  By  G.  Billard. 

3.  Treatment  of  Pulmonary  Tuberculosis  by 
Inhalation  of  Verdigris  Dust. — Billard  gives  the 
following  treatment :  One  kilogramme  of  chemically 
pure  powdered  verdigris  is  allowed  to  slowly  fall 
from  some  height,  the  patient  inhaling  the  di:st. 
This  is  to  be  done  mornings  and  evenings  for  half 
an  hour.  Billard  found  in  his  patients  who  under- 
took this  treatment  a  diminution  or  even  a  disap- 
pearance of  the  cough ;  an  increase  of  the  bodily 
weight  of  the  patient  and  of  his  strength ;  a  dim- 
inution or  even  a  disappearance  of  the  expectora- 
tions ;  and  as  a  objective  sign  he  could  demonstrate 
upon  auscultation  a  decrease  of  the  af¥ected  area. 
He"  has  thus  successfully  treated  three  patients.  He 
explains  the  action  of  verdigris  in  the  following 
manner :  It  will  be  found  that  a  watery  solution 
of  verdigris  will  deposit  on  its  surface  acetic  acid 
which  again  will  form  with  verdigris  copper  oxide. 
Our  author  is  of  the  opinion  that  the  verv  fine  crys- 
tals of  verdigris  when  inhaled  reach  the  area  of  affec- 
tion in  the  lungs  where  they  then  will  deposit  acetic 
acid  and  form  copper  oxide.  He  attributes  a  cura- 
tive principle  to  the  action  of  acetic  acid,  but  he 
says  it  is  also  possible  that  the  copper  oxide  plays 
a  role. 

April  10.  iQOi). 

T.    ""Lcishmanioses,"  By  A.  Laveran. 

2.    Drainage  of  the  Popliteal  Space  in  Ostomyelitis  of  the 
Inferior  Extremity  of  the  Femur,    By  P.  Hardouin. 

I.  _  "Leishmanioses." — Laveran  speaks  of  kala 
azar  and  of  the  Aleppo  boil. 

LA  SEMAINE  MEDICALE. 

,  April  7,  igw). 

1.  Crises  of  Intestinal  Pain  in  Tabes, 

By  Maurice  Loeper, 

2.  A  New  Method  for  Reconstruction  of  the  Anal  Sphinc- 

ter, By  J.  Schoemaker. 

1.  Crises  of  Intestinal  Pain  in  Tabes. — Loeper 
remarks  that  the  intestines  can  also  be  the  seat  of 
extreme  functional  trouble  in  tabetics.  He  divides 
intestinal  pains  into  three  classes :  The  simple  crisis, 
the  choleroid  crisis,  and  the  enteritic  crisis.  In  the 
first,  the  simple  crisis,  the  pains  are  very  similar  to 
the  pains  of  lead  colic ;  the  abdominal  pains  become 
intolerable,  the  belly  is  much  enlarged,  and  the  con- 
sti])ation  is  obstinate  ;  the  retention  of  urine  is  habit- 
ual, but  there  is  no  fever.  The  crisis  may  last  for 
twelve  days.  2.  The  choleroid  crisis  shows  itself 
by  violent  abdominal  cramps  and  persistent  diar- 
rhoea. 3.  In  the  enteritic  crisis  the  patient  shows 
an  oversensitiveness  of  the  entire  abdominal  wall. 
The  author  explains  the  intestinal  pains  as  a  crisis  in 
the  j)Osterior  roots  of  the  sym])athetic  system  inntrv- 
ating  the  intestines.  Of  drugs  only  morphine,  bella- 
donna, and  atropine  will  come  into  consideration  on 
account  of  their  action  upon  the  intestines ;  surgical 
interference  should  be  excluded  :  and  proper  pro- 
phylaxis with  a  carefully  selected  diet  sliould  take 
the  first  pl'ice  in  treatment. 


IrocMMngs  of  Societies. 


WESTERN    SURGICAL    AND  GYNtECOLOGICAL 

ASSOCIATION. 
Eighteenth  Annual  Meeting,  Held  in  Minneapolis,  Decem- 
ber 29  and  30,  igo8. 
The  President,  Dr.  W.  W.  Grant,  of  Denver,  in  the  Chair. 

{Coiitiinicd  from  page  1026.) 

Dr.  Daniel  X.  Eisendrath,  of  Chicago,  said 
that  during  the  past  few  years  at  the  Michael  Reese 
Hospital,  Chicago,  they  had  paid  special  attention 
to  acute  cases  of  dilatation  of  the  stomach  in  order 
to  determine  the  cause  of  some  of  them.  They  had 
fottnd  in  cjuite  a  large  proportion  of  cases  that  the 
direct  cause  of  the  acute  dilatation  of  the  stomacii 
was  repeated  capillary  haemorrhages,  and  had  sub- 
stantiated this  by  examinations  of  the  washed  con- 
tents of  the  organ  and  by  other  tests,  showing  that 
the  hyperacid  contents  were  bloody.  There  was  no 
hjematemesis  in  the  sense  that  we  observed  it  from 
a  gastric  tilcer  or  from  gallstone  complications. 
During  the  month  of  August  he  operated  upon  a 
man  v.ho  had,  in  addition  to  appendicitis,  an  acute 
gangrenous  cholecystitis  complicating  gallstones. 
Everything  went  smoothly  for  thirty-six  hours. 
The  patient  was  very  happy,  sat  tip  in  bed,  and 
passed  some  flatus,  so  that  it  was  felt  there  was  no 
indication  of  peritonitis.  Stiddenly  he  began  to 
vomit  a  typical  cof¥ee  grotind  material  in  pint 
quantities  at  a  time.  He  had  a  rapid  pulse,  with 
extreme  prostration.  Washing  out  his  stomach, 
they  fotmd  this  typical  cofifee  ground  vomit,  which 
on  analysis  was  blood.  From  the  physical  examina- 
tion of  the  abdomen  a  diagnosis  was  made. 

Dr.  Charles  H.  Mayo,  of  Rochester,  Minn., 
said  that  if  the  internist  picked  out  one  patient  in 
twenty-five  and  sent  him  to  the  sttrgeon,  he  would 
probably  operate  upon  one  in  five,  which  wotild  be  one 
in  a  hundred  and  twenty-five  that  presented  symp- 
toms. If  the  stomach  got  larger  and  was  able  to  do 
its  work  and  to  empty  itself,  it  was  probably  not  a 
surgical  condition.  If  one  could  find  the  pylorus 
open,  and  there  was  no  kinking  of  it,  an  operation 
might  not  be  called  for.  They  (the  Mayos)  had 
done  gastroenterostomies  in  cases  in  which  there 
was  kinking  of  the  pylorus.  In  cases  of  large  stom- 
ach they  had  been  asked  whether  or  not  they 
drained.  They  had  never  drained  one  of  these 
stomachs  unless  there  was  really  obstruction  or 
signs  of  obstruction  by  the  retention  of  food.  If 
the  stomach  was  dilated,  and  yet  still  able  to  do  its 
work,  look  for  the  condition  which  might  be  behind 
it.  This'  might  be  a  chronic  congestion  of  some  of 
the  vessels. 

Dr.  Jauez  i\.  Jackson,  of  Kansas  City.  Mo., 
said  that  some  years  ago  he  had  two  ini fortunate 
experiences.  In  each  instance  the  ])atient  belonged 
to  that  class  of  ])eopIc  in  whom  there  was  a  marked 
disturbance  of  metabolism  ])revious  to  operation,  as 
evidenced  by  a  change  in  the  color  of  the  skin, 
fiabbiness  of  the  complexion,  and  general  laxity  of 
the  tissues.  These  patients  consumed  an  unusual 
amount  of  the  an;esthetic.    He  had  therefore  come 


-Ma)'  J-'.  1909. J 


PROCEEDINGS  OF  SOCIETIES. 


to  believe  that  ])robably  the  primary  cause  in  most 
cases  was  a  disturbance  of  tlie  metaboHsm,  which 
was  increased  as  the  result  of  the  toxic  influence 
of  the  excess  of  amesthetic,  and  in  recent  years, 
since  the  open  method  of  administering  ether  had 
been  adopted  and  the  giving  of  it  in  small  quan- 
tities, this  trouble  had  disappeared ;  and,  while  he 
had  occasionally  seen  the  early  signs  and  symptoms 
of  beginning  acute  intestinal  obstruction,  yet  they 
had  not  been  attended  with  the  fatal  results  which 
had  previously  occurred. 

Dr.  J.  W.  Andrews,  of  Alankato,  ]\Iinn.,  was  re- 
minded of  the  case  of  a  woman,  past  middle  age. 
with  malignant  kidney  of  sufificient  size  to  bulge 
forward  to  a  considerable  extent,  which  he  removed 
through  the  peritoneal  cavity.  The  patient  did  well 
for  about  ten  days,  then  acute  dilatation  of  the 
stomach  occurred,  beginning  with  vomiting  of 
coffee  ground  material.  She  died,  and  at  the  post 
mortem  examination  he  found  the  largest  dilated 
stomach  he  had  ever  seen.  It  was  so  enormously 
dilated  that  it  reached  down  to  the  brim  of  the 
pelvis. 

During  the  past  year  a  severe  epidemic  of  ty- 
phoid occurred  in  his  region,  and  there  were  several 
cases  of  acute  dilatation  of  the  stomach  accompany- 
ing the  typhoid.  In  these  typhoid  patients  the 
stomach  was  greatly  dilated,  but  the  intestines  were 
no  more  distended  than  was  usually  the  case  in  ty- 
phoid fever ;  yet  every  one  of  those  patients  died 
from  acute  dilatation  of  the  stomach.  Whether  the 
cause  was  the  capillary  hfemorrhages  spoken  of  or 
not  he  did  not  know.  At  any  rate,  it  was  an  ex- 
tremely fatal  condition. 

The  -President  asked  if  the  stomach  was  washed 
out. 

Dr.  Andrews  replied  that  they  did  not  wash  out 
the  stomach  in  the  typhoid  cases. 

Dr.  M.  L.  H.arris,  of  Chicago,  said  that  in 
chronic  dilatation  of  the  stomach  he  had  come  to 
classify  the  cases  under  two  heads — those  in  which 
there  was  mechanical  obstruction  and  where  surgical 
interference  was  the  proper  treatment,  and  those 
in  which  there  was  no  mechanical  obstruction.  It 
was  doubtful  in  his  mind  whether  in  the  latter  class 
the  patients  w.ere  benefited  by  operative  measures. 
He  had  never  seen  any  good  reason  for  the  plica- 
tion of  a  dilated  stomach.  If  a  stomach  was  dilated 
as  the  result  of  mechanical  obstruction,  plication 
was  useless.  If  it  was  not  dilated  from  mechanical 
obstruction,  but  from  atony  or  any  other  condition, 
the  plication  would  interfere  with  vermicular  action. 
He  had  never  seen  the  rationale  of  plication  of  the 
stomach. 

Dr.  Henry  T.  Byford,  of  Chicago  said  that  a 
dilated  stomach  was  different  from  a  normal  stom- 
ach. If  one  plicated  the  normal  intestine,  for  in- 
stance, it  would  interfere  with  its  function,  and  if 
the  stomach  was  plicated  it  would  interfere  with  its 
contraction.  There  was  a  pouch,  it  hung  down,  and 
would  not  relieve  itself,  and  we  could  not  very  well, 
if  it  was  a  surgical  case,  diminish  the  contractile 
power  of  the  stomach.  In  such  a  case,  if  we  could 
bunch  it  up,  relieve  the  pouch,  help  drainage 
through  the  duodenum,  and  help  the  physical  condi- 
tion, we  were  establishing  temporarily  postural 
treatment,  thus  giving  the  stomach  a  chance  to 


empty  itself,  and.  as  probably  the  adhesions  would 
stretch  after  a  while,  we  had  not  injured  the  stom- 
ach :  we  had  not  injured  motility  which  did  not  exist. 

Diagnosis  in  its  Relation  to  the  Laboratory 
and  the  Bedside. — Dr.  W.  W.  Gr.\nt,  of  Denver, 
selected  this  title  for  his  presidential  address,  and, 
among  other  things,  said  that  a  detailed  critical 
study  of  the  history  of  cases  and  the  meaning  of 
clinical  signs,  subjective  and  objective,  was.  he 
feared,  not  the  common  practice,  even  of  surgeons. 
There  was  too  much  reliance,  even  when  not  neces- 
sarily exclusive,  placed  upon  instruments  of  scien- 
tific precision  and  upon  laboratory  diagnoses,  and 
too  little  upon  the  training  and  discipline  of  one's 
own  faculties  in  his  accustomed  work.  The  result 
was  a  few  expert  diagnosticians  in  certain  depart- 
ments and  a  general  decadence  in  diagnostic  skill 
and  acumen.  It  seemed  strange  that  competent  men 
should  commit  errors  in  diagnosis  that  could  often 
be  avoided  if  well  known  resources  were  employed 
in  the  solution  of  ]^roblems  common  to  experience. 
Sound  judgment  in  the  many  phases  of  otir  work 
was  the  growth  of  natural  fitness,  education,  close 
observation,  and  the  knowledge  of  laws  and  facts 
governing  specific  and  general  diseases.  A  great 
surgeon  was  not  a  mere  mechanic  ;  he  was  as  well 
a  good  phvsician  and  a  trained  clinician. 

Science  was  not  the  exclusive  property  of  the 
expert  or  the  necessary  product  of  the  laboratory. 
The  aim  should  be,  not  to  produce  fewer  experts  in 
research  work,  but  more  scientific  clinical  experts 
and  diagnosticians.  This  was  necessary  to  the 
broader  ctilture  and  usefulness  of  the  profession,  as 
well  as  to  the  best  welfare  of  the  sick.  Surgery  as 
a  study  was  not  exclusive,  although  its  practice 
might  be.  A  narrower  view  of  the  subject  was  not 
conducive  to  the  best  edtication  or  to  the  most  thor- 
ough equipment.  The  personal  equation  was  of 
the  greatest  moment ;  but  great  surgeons  were  not 
made  by  imitation,  and  skill  in  diagnosis  was  a  pro- 
tean product  that  could  never  be  measured  by  the 
rod  and  the  plumb. 

Sarcoma  of  the  Fibula. — Dr.  J.  Clark  Stew- 
.\RT,  of  Minneapolis,  read  a  paper  on  this  subject 
which  was  based  upon  two  cases  observed  within  a 
month.  The  tumor  was  quite  rare,  though  prob- 
ably not  so  rare  as  the  study  of  the  literature  would 
show,  as  many  cases  were  not  reported. 

The  first  case  was  that  of  a  child,  eight  years  of 
age,  periosteal  fibrosarcoma  of  the  upper  end  of  the 
fibula  of  six  months'  duration.  Excision  of  one 
third  of  the  fibula  was  performed,  removing  the 
whole  tumor  down  to  healthy  fibula. 

The  second  was  in  a  girl,  aged  thirteen ;  sarcoma 
of  the  lower  end  of  the  fibula  of  about  a  year's 
duration,  destroying  the  lower  third  of  the  bone. 
Amputation  of  the  leg  was  performed,  with  excision 
of  the  whole  fibula.  The  tumor  was  an  alveolar 
central  sarcoma  and  had  perforated  the  bone  at  one 
point.  In  preparing  the  leg  for  amputation,  an  Es- 
march  bandage  was  used  above  the  knee  to  prevent 
the  danger  of  dissemination  by  the  necessary  mani- 
pulation. 

In  each  of  these  cases  treatment  was  modified 
to  meet  the  individual  conditions.  In  the  first  case 
it  was  deemed  that  very  much  would  be  gained  by 
the  excision,  followed  bv  the  Colev  treatment.  In 


10/2 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


the  second  the  amputation  secured  the  removal  of 
the  whole  fibula,  with  a  much  better  stump  than 
would  have  been  obtained  by  higher  amputation. 

The  trend  of  the  best  modern  practice  seemed  to 
lean  toward  the  less  severe  operation,  followed  by 
the  Coley  treatment,  rather  than  the  classical  high 
amputation  or  disarticulation.  The  histological  type 
of  sarcoma  seen  before  dissemination  determined 
the  result.  The  softer  periosteal  sarcomata,  as  well 
as  their  prototypes  in  the  central  groups,  after  they 
had  penetrated  the  bone  and  invaded  the  soft  parts, 
were  probably  never  cured  by  operation,  and  only 
rarely  by  the  Coley  treatment,  while  giant  and  large 
spindle  cell  tumors  were  of  slow  growth  and  slow  to 
form  metastases,  and  thus  made  possible  better  re- 
sults and  permitted  of  conservative  operations. 

With  out  present  knowledge,  he  thought  that 
ever}'  case  of  inoperable  sarcoma  and  every  case  of 
sarcoma  after  operation  should  be  given  the  Coley 
injection  treatment,  as  the  successes  of  this  method 
had  been  too  numerous  and  striking  to  justify  any 
one  in  not  giving  his  patient  what  was  certainly  a 
fighting  chance  for  his  life.  His  personal  experi- 
ence with  this  treatment  had  not  been  large,  but  had 
convinced  him  of  its  positive  value.  Using  it,  as 
he  had,  only  as  a  last  resort  in  inoperable  cases,  he 
had  never  failed  to  produce  marked  improvement, 
as  shown  by  shrinkage  of  the  tumor  and  retardation 
of  its  growth,  and  in  one  case  of  sarcoma  of  the 
lower  jaw  he  was  able  to  obtain  a  complete  disap- 
pearance of  the  tumor  without  recurrence  during 
the  two  years  the  patient  survived. 

Dr.  James  E.  Moore,  of  Minneapolis,  thought 
that  conservative  operations  were  the  proper  ones. 
Patients  w^ho  were  to  be  saved  by  operation  could 
be  saved  by  a  conservative  operation,  and  those  with 
the  most  malignant  type  were  not  saved  by  an  ex- 
treme operation ;  so  that  it  was  proper  and  right  to 
remove  the  bone  involved  or  part  of  it  at  times  and 
take  the  chances,  because  the  chances  were  no  bet- 
ter with  that  operation  than  with  high  amputation 
or  disarticulation.  Surgeons  should  observe  the 
pathological  law  that  recurrence  of'  malignant 
growth  of  any  type  in  the  long  bones  was  more  like- 
ly to  occur  in  the  proximal  end  of  the  bone.  Many 
of  these  patients  would  permit  of  a  considerable 
operation  when  the  chances  for  the  preservation  of 
life  were  best,  whereas  they  hesitated  before  sub- 
mitting to  amputation  until  such  time  as  hope  of 
saving  life  by  an  extreme  operation  had  been  de- 
ferred too  long. 

Dr.  J.  W.  Andrews,  of  Mankato,  Minn.,  said  that 
a  few  years  ago  he  had  a  case  similar  to  the  one  re- 
ported. In  this  case  the  sarcoma  occurred  at  the 
distal  end  of  the  fibula  and  involved  one  third  or 
possibly  one  half  of  the  bone.  He  recommended  the 
removal  of  the  fibula ;  but  the  patient  went  to 
Rochester,  where  amputation  above  the  knee  was 
recommended.  She  was  not  willing  to  submit  to 
that  operation,  returned,  and  concluded  to  take  the 
speaker's  advice  of  excision  of  the  entire  fibula. 
This  operation  was  performed  by  him,  and  she  made 
a  good  recovery. 

Dr.  B.  B.  Davis,  of  Omaha,  said  that,  of  the 
number  of  cases  of  sarcoma  he  had  seen,  he  had  ob- 
served a  number  of  them  which  involved  the  tibia, 
but  only  one  of  the  fibula. 


Dr.  Jabez  N.  Jackson,  of  Kansas  City,  Mo.,  re- 
ported a  case  of  sarcoma  of  the  upper  end  of  the 
fibula  which  was  treated  by  operation,  but  recur- 
rence took  place  in  less  than  a  year  after  the  opera- 
tion, at  the  site  of  the  original  tumor. 

{To  be  continued.) 




VWe  publish  full  lists  of  books  received,  but  we  acknoivl- 
edge  no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  ive  think 
our  readers  arc  likely  to  be  interested.] 


The  Body  at  Work.  A  Treatise  on  the  Principles  of 
Physiology.  By  Alex  Hill,  M.  A.,  M.  D.,  F.  R.  C.  S., 
sometime  Master  of  Downing  College,  Cambridge.  With 
46  Illustrations.  London :  Edward  Arnold,  1908.  Pp. 
xi-448. 

This  is  an  excellent  popular  treatise,  "such  sec- 
tions of  the  subject  as  are  generally  considered  un- 
suitable for  ordinary  discussion"  being  omitted,  so 
that  it  may  be  read  in  the  family  without  offense  to 
any  sensible  person's  feelings  of  propriety.  It  is 
wonderfully  interesting,  thanks  to  the  author's  tell- 
ing use  of  metaphorical  language  and  to  his  excep- 
tional power  of  narrating  incidents  illustrative  of 
his  meaning.  We  know  of  no  other  recent  author 
who  presents  science  in  so  alluring  a  garb,  except 
Professor  Robert  Kennedy  Duncan,  of  the  Univer- 
sity of  Kansas,  whose  work  entitled  The  Chemistry 
of.  Commerce  we  noticed  in  our  issue  for  October 
19,  1907.  We  regret  that  we  cannot  say  as  much 
in  commendation  of  his  granimar.  The  fads  of 
present  day  schoolmasters,  subversive  of  idiomatic 
English,  are  rampant  in  the  book,  especially  that  of 
tampering  with  the  good  old  practice  of  making  de- 
pendent verbs  correspond  in  tense  with  the  tense 
of  the  declaratory  verb.  And  our  author  occasion- 
ally employs  the  shocking  locution  "different  to." 

We  have  said  that  the  book  was  a  popular  treat- 
ise, but  it  is  not  for  the  masses ;  with  all  Dr.  Hill's 
power  of  making  abstruse  things  plain,  his  bnok  can- 
not be  read  undcrstandingly  by  persons  who  have 
not  had  a  good  general  education.  But  there  are 
multitudes  of  educated  men  and  women  who  ought 
to  read  it,  and  we  cannot  doubt  that  it  will  have  a 
large  sale  and  come  to  many  further  editions.  There 
are  numbers  of  us  in  the  medical  profession,  indeed, 
who  might  derive  more  information  from  it  than 
from  most  treatises  on  physiology.  \\^e  hope  that 
in  future  editions  the  index  will  be  amplified. 

NEW  PUBLICATtONS. 
Chemistry. 

Oppeithciiuer,  Carl,  uiid  aiulcrc. — Handbuch  der  Biochemie 
des  Menschen  und  der  Ticre.  Erstcr  Band.  Die  cliem- 
ischcn  Baustoft'e  der  tierischen  Siihstanz.  Mit  43  Abbil- 
dungen.   Jena :  Gustav  Fischer,  1909. 

Anatomy,  Histology,  and  Microscopy. 

Korschclt,  E.,  und  Heidcr.  K. — Lehrbuch  der  vergleich- 
cnden  Entwickhingsgeschichtc  der  wirbcllosen  Ticre.  .Aill- 
gemeiner  Teil.  Dritte  Licfcrung,  Mit  104  Abbildnngen  im 
Text.    Jena:  Gustav  Fischer,  1909. 

Hertzi/ig,  Oskar. — Der  Kanipf  inn  Kernfragen  der  Ent- 
wicklungs-  und  Vcrerbuugslchrc.  Jena :  Gustav  Fischer, 
1909.    Pp.  122. 


May  22,  1909. j 


BOOK  NOTICES. 


Schultzc,  O^s^ar.— Atlas  und  Grundriss  der  topograph- 
ischen  und  angewandten  Anatomic.  Zweite  vermehrte 
Auflage.  Mit  22  vielfarbigen  lithographischen  Talefn  und 
205  meist  farbigen,  zum  grossen  Teil  auf  Tafeln  gedruckten 
Abbildungen  nach  Originalen  von  Maler  A.  Schmitson  und 
Maler  K.  Hajek.  Muncben :  J.  F.  Lehmann,  1909.  Pp.  224. 
Physiology. 

Spiess,  C. — Recherches  sur  revolution  de  la  fonction  di- 
gestive.   Paris :  Vigot  freres. 

Bechtcreiv,  IV. — Encyclopedic  scientifique.  Bibliotheque 
de  physiologic.  Les  fonctions  nervcuscs.  Les  fonctions 
bulbo-medullaires.  i  vol.  in  18  jesus,  cartonne  toile,  de  400 
pages,  avcc  figures  dans  le  texte.  Paris :  O.  Doin  et  fils, 
1909.    (Price,  5f.) 

Pathology. 

Studies  from  the  Department  of  Pathology  of  the  Col- 
lege of  Physicians  and  Surgeons,  Columbia  University,  New 
York.  Volume  XI.  For  the  Collegiate  Years  1906-1908. 
Reprints.    Pp.  469. 

Internal  Medicine. 

Pel,  P.  K. — Die  Krankheitcn  der  Leber,  der  Gallenwcge 
lind  der  Pfortader  auf  Grund  cigener  Beobachtungen.  Ein 
Buch  fiir  praktischc  Aerzte.    Jena :  Gustav  Fischer,  1909. 

Ribot,  Alexandre. — Recherches  experimentales  sur  le  foie 
renal.    Avec  5  figures.    Paris :  G.  Steinheil,  1909.    Pp.  100. 

Moncorge. — L'Asthme,  etiologie,  pathogenic,  traitement. 
Paris:  Vigot  freres,  1909. 

Lorand,  A. — Die  rationelle  Behandlung  der  Zuckerkrank- 
heit.  Zweite  veranderlich  Auflage.  Berlin :  A.  Hirschwala, 
1909.    Pp.  59. 

Glacsel,  Paul  Frederic. — Contribution  a  I'etude  de  la  bil- 
harziose.  Paris :  G.  Steinheil,  1909.  Pp.  viii-192.  (Price,  5f.) 

Landousy,  L. — Cent  ans  de  phthisiologie.  Paris :  Masson 
et  cie,  1909.    Pp.  64.    (Price,  2f.) 

Liebe,  Georg. — Vorlesungen  iibcr  Tuberkulosc.  Die  me- 
chanische  und  psychische  Behandlung  der  Tuberkulosen 
besonders  in  Heilstiittcn.  Miinchen  :  J.  F.  Lehmann,  1909. 
PP;  267. 

Schicalbe,  I. — Lchrbuch  der  Grciscnkrankhciten.  Stutt- 
gart :  Ferdinand  Enke,  1909.    Pp.  914. 

Hausviann,  Theodor. — Ueber  das  Tasten  normaler  Ma- 
gentcile.  Nebst  Bemerkungen  zur  Hohenbestimmung  der 
Bauchorgane.    Berlin  :  S.  Karger,  1909.    Pp.  38. 

Guiteras,  G.  M. — The  Prophylaxis  of  Yellow  Fever.  Yel- 
low Fever  Institute  Bulletin  No.'  17.  February,  1909. 
Treasury  Department,  U.  S.  Public  Health  and  Marine 
Hospital  Service.  Washington  :  Government  Printing  Of- 
fice, 1909.    Pp.  14. 

•  Cohiilieim,  Paul. — Die  Krankheiten  des  Verdauungskanal 
(CEsophagus,  Magen,  Darm).  Ein  Leitfaden  fiir  praktische 
Aerzte.  Mit  17  Abbildungen  im  Text.  Zweite,  vermehrte 
und  neubearbeitete  Auflage.  BerHn :  S.  Karger,  1908.  Pp. 
viii-252. 

Surgery. 

Aichel,  Otto. — Fine  neue  Hypothese  fiber  Ursachen  und 
Wescn  Ixisartiger  Geschwulste.  Munchen  :  J.  F.  Lehmann, 
190S.    Pp.  36. 

Bardcnhcuer,  B.,  und  Graessiicr.  R. — Die  Technik  der 
F.xtensionsx  erbande  bei  der  Behandlung  von  Frakturen  und 
Luxationen  der  Extremitaten.  Vierte,  umgearbeite  Auflage. 
Mit  68  Abbildungen  und  i  Tafel.  Stuttgart:  F.  Enke, 
1909.    Pp.  120. 

IViillstein  und  JVilins. — Lehrbuch  der  Chirurgie.  Zweiter 
Rand.  Erste  Lieferung.  Mit  127  zum  Teil  mehrfarbigen 
Abbildungen.    Jena :  Gustav  Fischer,  1909.    Pp.  320. 

Steinniann,  Frits. — Die  Schusswirkung  des  schweizer- 
ischen  Ordonnanzrevolvers  Modell  1882  und  der  schweizer- 
ischen  Ordonnanzpistole  Modell  1900.  Mit  21  Tafeln  und 
fiber  200  Abbildungen  im  Text.  Bern  :  Hallers'sche  Buch- 
druckerei.    Pp.  167. 

Tripier. — Etudes  anatomo-cliniques  (cneur,  vaisseaux, 
pnumons).  Avec  32  figures.  Paris:  G.  Steinheil,  1909. 
Pp.  604. 

Mnrct.  Paul  Louis. — L'Epanchement  de  sang  dans  les 
fractures  de  la  base  du  crane.  Avec  graph.  Paris :  G. 
Steinheil,  1909.    Pp,  92. 

Lucas-Championniere,  lust. —  Pratique  de  la  chirurgie  an- 
tiseptique  (legons  professees  a  I'Hotel  Dieu).  Avec  4  fig- 
ures et  I  portrait  de  Lord  Lister.  Paris:  G.  Steinheil,  1909. 
Pp.  464- 

Reubsaet.  A. — Essai  sur  les  vraies  et  fausses  exostoses 
-osteogeniques  multiples.    Paris :  G.  Steinheil,  1909.  Pp.  148. 


Obstetrics  and  Gyncecology. 

Machenhauer. — Ueber  Retroflexio  uteri.  Leipzig:  B. 
Konegen,  1909. 

Kiistner,  Otto. — Kaiserschnitt,  Ruckblicke  und  Ausblicke. 
Stuttgart:  Ferdinand  Enke,  1909.    Pp.  77. 

Bouquet,  Paul. — Grosscsse,  accouchements,  direction  du 
travail.    Avec  68  figures.    Paris  :  G.  Steinheil,  1909.    Pp.  80. 

Rousseaux,  Charles. — Du  traitement  de  certains  prolapsus 
uterins  par  Tobliteration  du  cul-de-sac  Douglas.  Avec  3 
figures.    Paris :  G.  Steinheil,  1909.    Pp.  72. 

Hennig,  A. — Der  Heilwert  des  Ostseebades  Cranz  bei 
Frauenkrankheiten.    Leipzig:  B.  Konegen,  1909. 

Veil,  I. — Handbuch  der  Gynakologie.  Zweite  vollig  um- 
gearbeitete  Auflage.  Mit  zahlreichen  Abbildungen  im  Text. 
Dritter  Band.  Zweite  Halfte.  Wiesbaden :  J.  F.  Bergmann. 
1908.    Pp.  404. 

Veil,  J. — Handbuch  der  Gynakologie.  Zweite,  vollig  um- 
gearbeitete  Auflage.  Mit  185  Abbildungen  im  Text  und  auf 
10  Tafeln.  Vierter  Band.  Erste  Halfte.  Wiesbaden:  j. 
F.  Bergmann,  1908.    Pp.  549. 

Mallet. — De  la  conduite  a  suivre  dans  les  cas  de  physo 
metric.    Paris :  G.  Steinheil,  1909.    Pp.  96. 

Le  Cointe,  Fernand.- — Contribution  a  I'etudc  de  la  dys- 
tocie  par  brides  et  cloisonnements  vaginaux  d'origine  con 
genitale.    Paris :  G.  Steinheil,  1909.    Pp.  92. 

Bouquet,  Paul. — Action  de  la  contraction  uterine  sur 
TtEuf  humain.  Phenomenes  passifs  dc  la  grosscsse  et  du 
travail.  LJn  tableau  synoptique  et  45:  planches  hors  texte. 
Paris :  G.  Steinheil  1909.    Pp.  180. 

Jacobee,  Pierre. — Des  fibromes  scssilcs  et  pedicules  du 
vagin.    Paris :  G.  Steinheil,  1909.    Pp.  88. 

Neurology  and  Psychiatry. 

Cotard,  Lucien. — Contribution  a  I'etude  senieiologique  du 
psittacisme  et  dc  ses  divers  aspects  en  cliniquc  psychiatrique. 
Paris :  G.  Steinheil,  1909.  Pp.  124. 

Briigelmann,  IV. — Die  Migraine  (Hemicrania) ,  ihre  Ent- 
stehung,  ihre  Wescn  und  ihre  Behandlung  respective 
Heilung.    Wiesbaden  J.  F.  Bergmann,  1909.    Pp.  51. 

Loezvenfeld,  L. — Grenzfragen  des  Ncrven-  und  Seclen- 
lebens.   Wiesbaden :  J.  F.  Bergmann. 

Wichmann,  Ralf. — Lebensregcln  fur  Neurastheniker.  6. 
Auflage.    Berlin :  O.  Salle,  1909.    Pp.  72. 

Bon  jour,  I. — La  Suggestion  hypnotique  et  la  psychothe- 
rapie  actuelle.  Critique  de  la  psychotherapie  rationelle  de 
MM.  les  Drs.  Dubois  (Berne),  Dejerinc,  Blindel  (Paris), 
Bourget  (Lausanne),  etc.  Lausanne  et  Paris:  Theodor 
Sack-Rcymond,  1909.    Pp.  ill. 

Serieux,  P.,  et  Capgras,  I. — Les  Folies  raisonnantcs.  Le 
delire  d'intcrpretation.    Paris :  Felix  Alcan,  1909.    Pp.  392. 

Nissl,  Franz,  und  Alzheimer.  Alois. — Arbeiten,  histolo- 
gische  und  histopathologische,  fiber  die  Grosshirnrinde  mit 
besonderer  Berucksichtigung  der  pathologischen  Anatomic 
der  Geisteskrankheiten.  Dritter  Band.  Erstes  Heft.  Mit 
15  Tafeln  und  6  Abbildungen  im  Text.  Jena:  Gustav 
Fischer,  1909. 

Reichardt,  Martin. — Arbeiten  aus  der  psychiatrischen 
Klinik  zu  Wurzburg.  Viertes  Heft.  Mit  6  Abbildungen  im 
Text.    Jena :  Gustav  Fischer,  1909. 

Myers,  Charles  S. — A  Textbook  of  Experimental  Psych- 
ology. With  66  Figures  and  Diagrams.  New  York :  Long- 
mans, Green,  &  Co.,  1909.    Pp.  xvi-432. 

Bancroft,  Margaret,  and  Farriugtov,  E.  A. — Manual  of 
the  Course  of  Study,  Bancroft  Training  School  for  Men- 
tally Subnormal  Children,  Haddonficld,  N.  J.  Philadelphia: 
Ware  Brothers  Company,  1909.    Pp.  120. 

Jung,  C.  G. — The  Psychology  of  Dementia  Prsecox.  Au- 
thorized Translation,  ^\ith  an  Introduction  by  Frederick 
Peterson,  M.  D.,  Professor  of  Psychiatrj',  Columbia  Uni- 
versity, and  A.  A.  Brill,  Ph.  B.,  M.  D.,  Assistant  in  Psychia- 
try, Columbia  University.  New  York :  The  Journal  of 
Nervous  and  Mental  Disease  Publishing  Company,  1909. 
Pp.  XX-153. 

Ophthalmology. 

de  Riddcr,  Paul. — La  Ponction  lombaire  dans  les  aflfec- 
tions  ocnlaires.    Paris  :  G.  Steinheil,  1909.    Pp.  120. 

Mailer,  Andres. — Die  Augendiagnose  in  ihren  gesicherten 
Ergebnisscn.  Mit  einer  orientierenden  farbigen  Tafel. 
Oranienburg :  Orania-Verlag,  1909.    Pp.  28. 

Rucker. — Contribution  a  I'etude  des  angiofibronies  de 
I'orbite.    Avec  3  figures.    Paris :  G.  Steinheil,  1909.    Pp.  76. 

Onfray,  Rene. — Manuel  pratique  du  strabisme.  Avec  73 
figures.    Paris :  G.  Steinheil,  1909.    Pp.  viii-296. 


1074 


BOOK  NOTICES. 


[New  York 
Medical  Joi'rnau 


Jiivuje,  Tatsiiji. — Die  Sehstoriingen  l)ei  Schussverletzun- 
gcn  der  kortikalen  Sehsphare.  Nacli  Beobachtungen  an 
Verwiindeten  der  letzten  japanischen  Kriege.  Mit  39  Fig- 
nron  im  Texi.  nnd  zwei  Tafeln.  Leipzig:  Wilhelm  Engel- 
maiin.  1909.    Pp.  114. 

Haab.  O. — Atlas  and  Epitome  of  Ophthalmoscopy  and 
C3l)hthalmoscopic  Diagnosis.  Second  American  Edition, 
from  the  Fifth  Revised  and  Enlarged  German  Edition. 
Edited  by  G.  E.  de  Schweinitz,  A.  M.,  M.  D.,  Professor  of 
Ophthalmology  in  the  University  of  Pennsylvania  and  Oph- 
thalmic Surgeon  to  the  University  Hospital,  etc.  With  152 
Colored  Lithographic  Illustrations.  Philadelphia  and  Lon- 
don: W.  B.  Saunders  Company,  1909.    Pp.  94. 

flaab,  O. — Atlas  of  the  External  Diseases  of  the  Eye. 
Including  a  Brief  Treatise  on  the  Pathology  and  Treat 
mcnt.  Authorized  Translation  from  the  German.  Third 
Edition,  Revised.  Edited  by  G.  E.  de  Schweinitz,  A.  M., 
M.  D.,  Professor  of  Ophthalmology  in  the  University  of 
Pennsylvania,  etc.  With  loi  Colored  Lithographic  Illustra- 
tions on  46  Plates.  Philadelphia  and  London :  W.  B. 
Saunders  Company,  1909.    Pp.  224.    (Price,  $3.) 

I.ary)igology  and  Rhinology. 

Guisca,  J. — La  Pratique  oto-rhino-laryngologique.  Avec 
/I  figures.    Paris:  J.  B.  Balliere  et  tils,  1909.    Pp.  207. 

Hajck,  M. — Pathologic  und  Therapie  der  entziindlichen 
F.rkr.inkungen  der  Nebenhiilen  der  Nase.  jVIit  150  Abbil- 
(lungen,  grosstenteils  nach  eigenen  Originalen,  und  2  Tafeln 
in  Lichtdruck.  Dritte  verniehrte  .Autlage.  Leipzig  und 
W'ien :  Franz  Deuticke,  1909.    Pp.  443. 

Moure,  E.  J. — Elementary  Practical  Treatise  on  Diseases 
of  the  Pharynx  and  Larynx.  Translated  and  adapted  by 
J.  Malcolm  Farquharson,  M.  B.,  F.  R.  C.  P.,  Edin..  Lec- 
turer on  Diseases  of  the  Nose,  Ear,  and  Throat  in  the  School 
of  Medicine  of  the  Royal  Colleges,  Edinburgh,  etc.  With 
210  Illustrations.  New  York:  Rebman  Co.,  1909.  Pp. 
ix-403. 

I  >cr}iiiilol(>gy. 

Aiidry.  C.,  Nicholas,  J.,  ct  Duraiid.  .1/. — Traitement  des 
maladies  cutanees  et  veneriennes.  Bibliotheque  de  thera- 
IK'utique  Gilbert-Carnot.  Avec  143  figures,  cartonne.  Paris  : 
J.  P>.  Bailliere  et  fils,  1909.    (Price,  I2f. ) 

Venereal  and  Genitourinary  Diseases. 

Klinuisac-a-ski,  JV. — Dauerndc  Heilung  der  Syphilis 
mittels  uiigiftiger  Kriiuterpraparate.  Berlin :  H.  Ber- 
imihlcr.  1909.    Pp.  120. 

f'laut,  F. — Die  wassermannsche  Serodiagnostik  der  Syph- 
ilis in  ihrer  Anwendnng  auf  die  Psychiatric.  Jena:  G. 
Fischer,  1909.    Pp.  188. 

Finger.  E. — La  Sj'philis  ct  les  maladies  veneriennes. 
Troisiemc  edition  franqaise  par  P.  Spillmann,  M.  Doyen  et 
L.  Spillmann.  Avec  8  planches  hors  texte  en  couleurs. 
Paris:  F"elix  Alcan.    Pp.  439.    (Price  I2f.) 

Luys,  Georges. — Exploration  de  Tappareil  urinairc,  ou- 
\rage  couronne  par  rAcademie  de  medecinc  (prix  Laborie, 
T907).  Deuxieme  edition  eiitiercment  refondue.  .Avec  226 
lit;ures  dans  ic  texte  et  6  planches  en  couleurs.  Relie  toile 
aiiglaisc.     Paris:  j\Iasson  et  cie,  1909.     Pp.  610.  (Price. 

20f.) 

Catlielin,  F. — .'\tlas  d'aiiatomie  pathologiquc  chirurgicale 
nrinaire.  Avec  50  planches.    Paris :  H.  Paulin  et  cie. 

Hanekcn.  Wilhelm. — Beilrag  zur  Serodiagnostik  der 
Syphilis.    Berlin  :  R.  Trenkel,  1909.    Pp.  48. 

Deguy. — Therapeutique  venerienne.  Avec  24  figures. 
Paris :  G.  Steinheil.  1909.    Pp.  280. 

S[>iUmann,  Louis. — Syphilis  osseuse  (syphilis  acquiset. 
.•\vec  12  planches  contenant  21  figures.  Paris:  G.  Steinheil. 
1909.    Pp.  viii-136.    (Price,  3f.) 

Pccdialrics. 

Cserny,  A.,  und  Keller.  A. — Des  Kindcs  Erniihrung,  Er- 
nahrungsstorungen  imd  Ernahrungstherapie.  Ein  Hand- 
buch  fiir  .-Xerzte.  Siebente  .Abteiluiig.  (  Bogen  9-16  des 
zweiten  Baiidcs.)     Wien  :  Franz  Deuticke,  1909. 

Ginrstous.  E. — Hygiene  oculaire  de  la  premiere  enfance. 
Paris:  Vigot  freres.    (Price,  2f. ) 

Hagenbuch-fiurekhardt.  E. — Ueber  oflfentliche  I-'iirsorgc 
fiir  kranke  Kinder.  Akademischer  Vortrag.  Basel :  Helb- 
ing  &  Licbtenhabn,  1909.    Pp.  39. 

Salge.-li. — Thcrapcutisches  Tashenbiich  fiir  die  Kinder- 
praxis.  Viertc,  vcrbesserte  Auflage.  Berlin  :  Mscher,  1909. 
Pp. 

Moll-U  eiss.  Augusta. — 1.  .Alimentation  de  1  enfant  de  2 
a  5  ans  dans  l;i  faniillc  et  a  I'ecole  maternelle.    Preface  dn 
Dr.  Eugene  Terrien.    .Xvec  nonibreuses  recettes  alimen 
taircs.    Paris:  G.  Steinlicil.  if/x).    Pp.  128.    (Price,  2f.) 


Girard.  L. — La  Tuberkulose  du  poignet  chez  I'enfant. 
Avec  16  figures.  Paris:  G.  Steinheil,  1909.  Pp.  100. 
(Price.  3f.) 

FoiAcr,  J.  S. — Infant  Feeding.  .\  Practical  Guide  to  the 
.«\rtificial  Feeding  of  Infants.  London  :  Henry  Frowde  and 
Hodder  &  Stoughton,  1909.    Pp.  x-230. 

Hygiene  and  Public  Health. 

Dif^pe.  H. — Die  wichtigsten  Gesundheitsregeln  fur  das 
tagliche  Leben.  Zweite  Auflage.  Leipzig:  S.  Hirzel,  1909. 
Pp.  108. 

Klciuschrod .  Franj. — Die  Erhaltung  der  Lebenskraft. 
Eine  neue  Lehre  voni  gesunden  und  kranken  Leben.  zu- 
g'eich  ein  Losungsversuch  des  Problems  vom  Leben.  Ber- 
lin :  O.  Salle.  1909.    Pp.  306. 

Hohel.  Marie. — Die  Mutter.  Ein  Geleitbuch  fiir  die  junge 
Frau.  Neue  bearbeitete  von  Therese  Danner.  Mit  Vor- 
wort  von  Geheimrat  Dr.  von  Kerschensteiner.  Sechste,  vcr- 
besserte .\uflage.  Miinchen :  Ernst  Reinhardt.  1909.  Pp. 
122. 

IVard.  Archibald  Robinson. — Pure  Milk  and  Public 
Health.  A  Manual  of  Milk  and  Dairy  Inspection.  With 
two  Chapters  by  Myer  Edward  Jaffa,  M.  S.,  Professor  of 
Nutrition  and  Director  of  the  State  Food  and  Drug  La- 
boratory, L'niversity  of  California.  With  Seventeen  Illus- 
trations. Ithaca :  Tavlor  &  Carpenter,  1909.  Pp.  xiii-218. 
(  Price.  $2. ) 

i\ober.  George  ^L — Industrial  and  Personal  Hygiene.  A 
Report  of  the  Committee  on  Social  Betterment  of  the  Pres- 
ident's Homes  Commission.  Washington:  The  President"? 
Homes  Commission.  1908.    Pp.  iv-i7S. 

Dieudonne.  A. — Bacterial  Food  Poisoning.  A  Concise 
E.xposition  of  the  .ttiology.  Bacteriology,  Patholog;. . 
Symptomatology.  Prophylaxis,  and  Treatment  of  so  called 
Ptomaine  Poisoning.  1  ranslated  and  Edited,  with  Addi- 
tions, by  Charles  Frederick  Bolduan,  Bacteriologist  to  the 
Research  Lai)oratory,  Department  of  Health  of  the  City  ot 
New  York.  Authorized  Translation.  New  York :  E.  B. 
Treat  &  Co.,  1909.    Pp.  128. 

Sternberg,  George  M. — Report  of  Committee  on  the 
Building  of  Model  Houses  of  the  President's  Homes  Com- 
mission, 1908.  Washington :  President's  Homes  Commis- 
sion, 1908.    Pp.  III. 

Baldz\.'in,  ll'illiani  H. — Report  of  the  Committee  on  the 
Improvement  of  Existing  Houses  and  the  Elimination  of 
Unsanitary  and  Alley  Houses  of  the  President's  Homes 
Commission.  Washington  :  President's  Homes  Commission. 

1908.  Pp.  23. 

Gerhard.  W'illuun  Paul. — Sanitation  and  Sanitary  En- 
gineering. Second  Revised  and  Enlarged  Edition  of  Sani- 
tary Engineering.    New  York:  Published  by  the  Author, 

1909.  Pp.  vi-174. 

Bactenology. 

Sittler.  Paul. — Die  wichtigsten  Bakterientypen  der  Darm- 
rtora  beim  Saugling.  ihre  gegenseitige  Beziehuiigen  und 
iiire  Abhiingigkeit  von  iiusseren  Einfliissen.  Wiirzburg : 
C.  Kabitzsch.  1909.    Pp.  70. 

Jensen.  Orla. — Die  Hauptlinien  des  natiirlichen  Bakterien- 
systems  nebst  einer  Uebersicht  der  Giirungsphanomene. 
Mit  ein  Figur.    Jena  :  G.  Fischer,  1909.    Pp.  42. 

Thera/'cuties. 

Leinoine.  G. — Therapeutique  medicale  et  medicine  jour- 
naliere.  Cinf|uieme  edition  refondue.  Paris:  \'igot  fixTes. 
Pp.  1 128. 

Crinon.  C. — Revue  des  medicaments  nouveaux  et  de 
quelques  medications  nouvelles.  Seizieme  edition.  Car- 
tonne.    Paris :  Vigot  freres. 

.'ichurig.  F. — Operationslose  Krebsbehandlung  mittels  Ar- 
sen.    Mit  3  farbigen  Tafeln.    Dresden:  R.  Heinze,  1909. 

.]Ioneany.  C. — Les  Nouveaux  einplois  therapeutiques  dn 
chlorure  de  calcium  Paris.  G.  Steinheil,  1909.  Pp.  192. 
(Price.  4f.) 

Lehianshi. — L'.Art  pratique  de  formuler  a  I'usage  des 
etudi;mts  et  des  jeunes  practiciens.  Troisiemc  edition  com- 
pletemenl  refondue  et  mise  d'accord  avec  le  nouvean 
codex.  Cartonne.  Paris:  G.  Steinheil.  1909.  Pp-  ,^02. 
(Price,  4f.) 

Penaoldt.  Fn///::.— Lehrbuch  der  klinisclien  .Arzneibeband- 
luiig  fiir  Studiereiule  und  .\erzle.  Mit  einem  .Anbang : 
Chirurgische  Technik  dor  .\rzneianwendung  von  Professor 
Dr.  M.  von  Kryger  in  Erlangeii.  Siebente.  veriuulcrte  und 
verniehrte  .-\nflage.    Jena  :  (Tiustav  Fischer,  tqoS.    Pp.  42(1. 

liircher-Benner,  M. — (Jrundziige  der  Ernahrungs-Tlier- 
apie  auf  Grund  der  l-'nergetik.  Dritte,  verniehrte  Aiillage. 
Rerliii:  O.  Salle.  I'W     Pp  2<)0. 


^lav  22,  1909.]  OFFICIAL  NEWS.  1075 


Guillon,  A. — Manuel  dc-  therapeutique  clinique  des  mala- 
dies tropicales.  Avec  13  figures.  Cartonne.  Paris :  O. 
Doin  et  fils,  1909.    Pp.  387.    (Price,  7f.) 

Huchard  ct  Fiessingcr. — Clinique  therapeutique  du  prac- 
ticien,  tome  II.    Paris:  Maloine.    (Price,  8f.) 

Rouchardt.  A.  and  G. — Nouveau  formulaire  magistral. 
Precede  de  generalites  sur  I'art  de  fornuiler.  de  notions 
sur  I'emploi  des  contrepoisons,  sur  les  secours  a  donner 
au.K  empoisonnes  et  aux  asphyxies,  suivi  d'un  precis  sur 
les  caux  minerales  naturelles  et  artificielles.  de  notes  sur 
i'opotherapie.  la  serotlierapie.  la  vaccination,  I'hygiene 
therapeutique,  le  regime  dechlorure,  da  la  liste  des  mets 
permis  aux  glycosurique>  et  d'un  memorial  therapeutique. 
Trente-quatrieme  edition.  Collationee  avec  le  nouveau 
codex  de  1908,  revue  et  augmentee  de  forniules  nouvelles. 
Paris :  Felix  Alcan.  1909.    Pp.  672. 

Pensoldt,  F..  und  Stint  zing.  R. — Handbuch  der  gesamten 
Therapie  in  sieben  Banden.  Vierte  Auflage  des  Handbuch 
der  Therapie  innerer  Krankheiten.  Zweite  Lieferung.  Mit 
5  Abbildungen  und  i  Kurve.  im  Text.  Jena  :  Gustav  Fis- 
cher, 1909. 


Public    Health    and    Marine    Hospital  Service 
Health  Reports : 

The  folloiciiig  cases  of  sniall/'o.v.  yclloii.-  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  z^'cek  ending  May  14.  iqoq: 

Places.  Date.  Cases.  Deaths. 

Sinalll^ox — United  States. 

California — Berkeley  April    17-24   i 

California — Oakland  Xljril  iq-26  

California — Sacramento  March    i-.5i   2 

Georgia — Macon  \|  ril  .'5-Mav   2   7 

Illinois — Danville  \\n'\\   j  5-Mav   2   S 

Illinois — Gaksburg  April   24-May    1   1 

Illinois — Springfield  Kl-ril'  23-.)o   ? 

Indiana — Fort  Wayne  April    17-2.^   i 

Indiana — Indiana  olis  April  25-May  _>   1 

Indiana — La   Fayette  April   26-May  ,;   3 

Indiana — South  Bend  \pril  25-May    j   j, 

Iowa — Cedar    Rapids  \pril    1-30..   '.: 

Iowa — Council    Bluffs  April  25-May  3   1 

Iowa — Sioux  City                            Ajjril    1-30.....   i 

Kansas — Kansas  City  April  25-May    1   i 

Kansas — Wichita  Xpril  25-May    1   4 

Kentucky — Lexington  .April   _>5-^Iay   i   2 

Louisiana — New  Orleans  April  25-May   i   5 

Minnesota — Duluth  April    22-29   2 

Missouri — St.   Louis  April   25-May    i   i 

Montana — State  of  March    1-31   55 

Nebraska — South  Omaha  April    3-10   i 

New  Jersey — Trenton  \pril  25-May   i   2 

New  York — Niagara  Falls  April  25-May   1   i 

Ohio — .\shtabula  April  25-May   i   6 

Ohio — Cincinnati  April    23-30   18 

Ohio — Cleveland  April    23-30   i 

Tennessee — Knoxville  \pril  25-5lay    1   13 

Texas — Hidalgo  County  Jan.    15-April    i   16 

T'-xas — San   Antonio  April  25-May   i   4 

L'tah — State  of  March    1-31   136 

Washington — Spokane  \pril    17-24   6 

Wi-iconsin — La  Crosse  \pril  25-May   i   i 

Wisconsin — Superior  April   25-May   i   3 

.Siiiiilll^o.r — Insular. 

I'liilipi  ine  Islands — ilanila  March    13-20   4  2 

Smttllpo.v — Foreign. 

Brazil — Bahia                                   March    13-27   8  2 

lirazil — Pernambuco  March    1-15   5 

Canada — Halifax  April    17-24   i 

Canada — Toronto  Feb.   28-April    17....  14 

Ccylor — Colombo  Dec.    12-Jan.    16   64  12 

China — Amoy  March  20-27   Present 

China — Hongkong  March   20-Apnl   3...  2 

l'"rance — Paris  April    10-17   1 

India — Bombay  March   3o-A]n-il   6...  17 

India — Calcutta  March    20-27   44fi 

India — Madras  March   27-.\pril   2...  3 

India — Rangoon  March    20-27   3 

Indo-China — Saigon  March    14-21   2  1 

Italy — General  April    10-18   61 

Italy — Catania  April    10-17   i 

Italy — Naples  April    11-18   11 

Java — Batavia  March    13-20   3 

Mexico — Guadalajara  April    15-22   i 

^fexico — Mexico  City  Feb.  27-March   27...  qi 

Ale.xico — Monterey  April    18-25   8 

Mexico — \'eracruz  April    18-25   2  2 

Persia — Karmanshah  Feb.    17-March    17...  22 


Places.  Date.  Cases.  Deaths. 

Portugal — Lisbon  \pril    10-17   6 

Russia — Batoom  Feb.    1-28   i 

Russia — Moscow  March  27-April    10..  52  2.- 

Russia— Riga  April    10-17   - 

Russia — Warsaw  Feb.   6-13   ^ 

South  Africa— Durban  March   20-27   1  Imported 

Spain — Almeira  March    1-31   ' 

Spain — Barcelona  -Xpril    12-19   ' 

Straits  Settlements— Penang  March   20-27   1  Imported 

Switzerland — Canton  Zug  -Vpril    11-17   ' 

Tripoli — Tripoli  .March   27-April    10..  90  'o 

Uruguay — Montevideo  Feb.    1-28   11 

Yellow  Feicr — Foreign. 

Brazil— Bahia  Morch    13-27   21  12 

Brazil — Pernambuco  March    1-15   1 

Ecuador — Guayaquil     March  27-Apnl  3   18 

Mexico — San  Bernardo,  vicinity  of 

Ma.-ccanu  April   24-May   i   i 

Mexico — Ticul  -Vpnl    10-17   2 

Cholera — Insular. 

Philippine  Islands — Provinces  March    13-20  118  72 

Cholera — Fo  reign. 

Cevlon — Colombo  Dec.   12-Jan.   2   4  3 

India— I'.omhav  March  27-.\pril  6   14 

India— Calcutta  March    20-27   143 

India— Madras  March  27-April  2   3 

India— Rangoon  March    20-27   4 

Russia — St.  Petersburg  \pril    16-21   22  2 

Plague — Foreign. 

Brazil — I'.ahia                                   March    13-27   5  i 

China— Hongkong  March  20-April   3...  n 

Kgvpt — (leneral  \  ril    2-8   2  i 

India — General                                 March    20-27  6.059  5.035 

India— lioinbav  M^rch    30- April   6...  407 

India — Calcutta  March   20-27   6 

India — Rangoon  March    20-27   16 

Japan — Formosa.    Island  March    13-27   99  ''S 

laran— Kobe,  vicinity  Match  27-April  3....  i 

Japan — Port  Louis  Jan.    1-31   12  12 

Straits  Settlements — Singa.  ore  .... -March    13-20   ' 

Turkey — Jiddah  \pril    19-21   i  - 

Public  Health  and  Marine  Hospital  Service: 

OfHcial  list  of  changes  of  stations  and  duties  of  commis- 
sioned end  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
May  12.  /yoy.- 

A.MES.  R.  P.,  .Acting  .\ssistant  Surgeon.  Directed  to  pro- 
ceed to  Gualan.  Guatemala,  and  other  places  on  line  of 
Guatemala  Railway  to  observe  sanitary  conditions. 

C-VRMicHAEL,  D.  A.,  Surgcon.  Granted  fourteen  days"  leave 
of  absence  from  May  26,  1909. 

Collins,  G.  L..  Passed  Assistant  Surgeon.  Granted  three 
days'  leave  of  absence  from  April  30,  1909,  under  para- 
graph 189  Service  Regulations. 

Foster,  J.  P.  C,  Acting  Assistant  Surgeon.  Granted  four 
days'  leave  of  absence  from  May  13.  1909- 

GoLDSBORorcH.  B.  W..  Acting  Assistant  Surgeon.  Granted 
five  days'  leave  of  absence  from  May  12.  1909,  without 
pay. 

Hume.  Le.\.  Acting  Assistant  Surgeon.  Directed  to  pro- 
ceed to  Del  Rio,  Texas  and  vicinity. 

L.^viNDER.  C.  H.,  Passed  Assistant  Surgeon.  Granted  four 
days"  leave  of  absence  en  route  to  Columbia,  S.  C. 

Lu.MSDEN,  L.  L.,  Passed  Assistant  Surgeon.  Granted  seven 
days"  leave  of  absence  from  May  19,  1909.  under  para- 
graph 191  Service  Regulations. 

M-\RSH.^LL.  E.  R..  Assistant  Surgeon.  Granted  two  days" 
leave  of  absence  from  May  13.  1909. 

Pettyjohn,  Joseph,  Passed  Assistant  Surgeon.  Upon  ar- 
rival of  Assistant  Surgeon  J.  R.  Hurley,  directed  to 
proceed  to  San  Francisco,  Cal. 

RoD.\[.\N,  John  C,  Acting  Assistant  Surgeon.  Granted 
fourteen  days'  extension  of  leave  from  April  13,  1909, 
on  account  of  sickness. 

Ryder,  L.  W.,  Pharmacist.  Granted  one  day"s  leave  of  ab- 
sence. May  7,  1909,  under  paragraph  210,  Service  Reg- 
ulations. 

Ste.xrns,  H.  H.,  Acting  Assistant  Surgeon.    Granted  two 

days"  leave  of  absence,  April  12  and  14,  1909,  under 

paragraph  210,  Service  Regulations. 
Terry,  M.   C.  Acting  Assistant  Surgeon.    Granted  two 

days"  leave  of  absence  from  April  18,  1909. 
Warren,  B.  S.,  Passed  Assistant  Surgeon.    Detailed  to 

represent  the  Service  at  the  meeting  of  the  Arkansas 

State  Medical  Sodety  to  be  held  at  Pine  Bluff,  Ark.. 

May  19  to  21,  1909. 
W.\tters.  M.  H..  Pharmacist.    Granted  ten  days"  leave  of 

absence  from  May  2.  T909. 


10/6 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal 


Wertenbaker,  C.  p.,  Surgeon.  Detailed  to  represent  the 
Service  at  the  annual  meeting  of  the  National  Associa- 
tion for  the  Study  and  Prevention  of  Tuberculosis  to 
be  held  in  Washington,  D.  C,  May  13  to  15,  1909- 

Boards  Convened. 

Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital,  St.  Louis,  Mo.,  May  12,  1909,  for  the  purpose  of 
making  a  physical  reexamination  of  an  applicant  for  the 
position  of  cadet  in  the  Revenue  Cutter  Service.  Detail  for 
the  board:  Passed  Assistant  Surgeon  B.  S.  Warren,  chair- 
man :  Acting-  Assistant  Surgeon  H.  C.  Wakeheld,  recorder. 

Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital  office,  Galveston,  Texas,  May  12,  1909,  for  the 
purpose  of  making  a  physical  examination  of  an  applicant 
for  the  position  of  cadet  in  the  Revenue  Cutter  Service. 
Detail  for  the  board:  Passed  Assistant  Surgeon  G.  M. 
Corput,  chairman ;  Acting  Assistant  Surgeon  William  H. 
Gammon,  recorder. 

Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital,  Baltimore,  Md.,  as  soon  as  practicable,  for  the 
purpose  of  making  a  physical  examination  of  a  lirst  lieu- 
tenant, United  States  Revenue  Cutter  Service.  Detail  for 
the  board :  Surgeon  W.  P.  Mcintosh,  chairman ;  Passed  As- 
sistant Surgeon  M.  K.  Gwyn,  recorder. 

Boards  of  medical  officers  convened  to  meet  on  May  15. 
1909,  for  the  purpose  of  making  physical  examinations  of 
officers  of  the  Revenue  Cutter  Service  for  promotion,  as 
follow  s : 

Portland,  Me.  Surgeon  P.  C.  Kalloch,  chairman ;  Acting 
Assistant  Surgeon  A.  F.  Stuart,  recorder. 

Boston,  Mass.  Surgeon  L.  L.  Williams,  chairman; 
Passed  Assistant  Surgeon  T.  W.  Salmon,  recorder. 

New  York.  Passed  Assistant  Surgeon  C.  W.  Vogel, 
chairman ;  Assistant  Surgeon  F.  A.  Ashford,  recorder. 

Baltimore,  Md.  Surgeon  W.  P.  Mcintosh,  chairman; 
Passed  Assistant  Surgeon  M.  K.  Gwyn,  recorder. 

Norfolk,  Va.  Passed  Assistant  Surgeon  G.  L.  Collins, 
chairman ;  Acting  Assistant  Surgeon  R.  W.  Browne,  re- 
corder. 

Galveston,  Tex.  Passed  Assistant  Surgeon  G.  M.  Cor- 
put, chairman;  Acting  Assistant  Surgeon  W.  H.  Gammon, 
recorder. 

Board  of  commissioned-  medical  officers  will  be  convened 
to  meet  at  the  Bureau,  Monday,  June  14,  1909,  for  the  ex- 
amination of  applicants  for  the  position  of  Assistant  Sur- 
geon in  the  Public  Health  and  Marine  Hospital  Service. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Army  for  the  week  ending  May  15,  igop: 

Ch.\mberlain,  W.  p.,  Major,  Medical  Corps.  Granted 

leave  of  absence  for  ten  days. 
Crosby,  E.  D.,  Lieutenant  Colonel,  Medical  Corps.  Detailed 

to  represent  the  Medical  Department  of  the  Army  at 

the  meeting  of  the  .American  Medical  Association  at 

Atlantic  City,  N.  J.,  June  8th  to  nth. 
Field,  Peter  C,  Captain,  Medical  Corps.    Ordered  to  duty 

at  a  military  tournament  at  Toledo,  Ohio,  June  26, 

1909. 

Hanson,  L.  H.,  First  Lieutenant,  Medical  Corps.  Granted 
leave  of  ,absence  for  fourteen  days. 

Ireland,  M.  W.,  Major,  Medical  Corps.  Detailed  to  repre- 
sent the  Medical  Department  of  the  Army  at  the  meet- 
ing of  the  American  Medical  Association  at  Atlantic 
City,  N.  J.,  June  8th  to  nth. 

Kean,  J.  R.,  Lieutenant  Colonel,  Medical  Corps.  Detailed 
to  represent  the  Medical  Department  of  the  Army  at 
the  meeting  of  the  .American  Medical  Association  at 
Atlantic  City,  N.  J.,  June  8th  to  nth. 

Love,  Albert  G.,  First  Lieutenant,  Medical  Corps.  Granted 
leave  of  absence  for  fourteen  days. 

Russell.  F.  F.,  Major.  Medical  Corps.  Ordered  to  Phila- 
delphia. Pa.,  and  New  York  City,  on  business  of  the 
Mcdir;il  Department,  and  then  to  return  to  Washing- 
ton ;  detailed  to  represent  the  Medical  Department  of 
the  Army  at  the  meeting  of  the  .American  Medical  As- 
sociation at  Atlantic  City,  N.  J.,  June  8th  to  nth. 

SciiMiTTER,  I'>.Ri)iNANn.  First  Lieutenant,  Medical  Corps. 
Granted  leave  of  absence  for  (en  days. 

Thomason.  H.  D.,  Captain,  Medical  Corps.  Relieved  from 
duty  at  Fort  Douglas.  Utah,  and  ordered  to  Fort  Mis- 
soiiia,  Mont.,  for  duty. 


Whitmore,  E.  R.,  Captain,  Medical  Corps.  Detail  with 
Bureau  of  Science,  Department  of  the  Interior,  Philip- 
pine Islands,  extended  one  year. 

Woodson,  R.  S.,  Major,  Medical  Corps.  Granted  leave  of 
absence  for  four  months. 

Navy  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
A^avy  for  the  week  ending  May  15,  igog: 
Byrnes,  J.  C,  Medical  Inspector.    Detached  from  the  West 
Virginia  and  ordered  to  the  Tennessee  as  fleet  sur- 
geon of  the  Pacific  Fleet. 
Fauntleroy,  a.  M.,  Passed  Assistant  Surgeon.  Detached 
from  Marine  Recruiting  Office,  Fliiladelphia,  Pa.,  and 
ordered  to  the  Hartford. 
Gardner,  J.  E.,  Medical  Inspector.    Ordered  to  additional 

duty  at  the  Naval  Recruiting  Station,  Boston,  Mass. 
MiNTER,  J.  M.,  Assistant  Surgeon.    Detached  from  the  Na- 
val Recruiting  Station,  Cincinnati,  Ohio,  and  ordered 
to  the  Naval  Medical  School  Hospital,  Washington, 
D.  C,  for  treatment. 
Nash,  F.  S.,  Surgeon.    Ordered  to  additional  duty  at  the 

Marine  Recruiting  Station,  Philadelphia,  Pa. 
Porter,  F.  E.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Recruiting  Station,  Boston,  Mass.,  and  or- 
dered to  the  Naval  Station,  San  Juan,  P.  R.,  sailing 
from  New  York,  N.  Y.,  May  22nd. 
Turner,  H.  W.  B.,  Assistant  Surgeon.  Detached  from  the 
Hancock  and  ordered  to  the  Paducah.  sailing  from 
New  York,  N.  Y.,  May  21st. 

 «>  

iirt^s,  llarriagts,  anb  italics. 


Married. 

Bray — Belair. — In  Philadelphia,  on  Wednesday,  .^prii 
2ist,  Dr.  Walter  D.  Bray,  of  Hartford,  Connecticut,  and 
Miss  Florence  Rae  Belair. 

Janvier — Marshall. — In  Lansdowne,  Pennsylvania,  on 
Tuesday,  April  27th,  Dr.  George  Victor  Janvier  and  Miss 
Margaret  Levis  Marshall. 

Mackenny — Carmany. — In  Philadelphia,  on  Wednesday, 
April  14th,  Dr.  William  H.  Mackenny  and  Miss  Lillie  Car 
many. 

Snyder — Dunlap. — In  Trenton,  New  Jersey,  on  Satur- 
day, May  1st,  Mr.  Clarence  Snyder,  and  Dr.  Mary  Dunlap, 
of  Vineland,  New  Jersey. 

Died. 

Brewer. — In  New  Orleans,  on  Wednesday,  ]\Iay  5th,  Dr. 
William  Peale  Brewer,  aged  sixty-seven  years. 

Brooke. — In  Sandy  Spring,  Maryland,  on  Sunday,  May 
9th,  Dr.  Roger  Brooke,  aged  sixty-two  years. 

Crandall. — In  Burlington,  Vermont,  on  Thursday,  May 
6th,  Dr.  H.  A.  Crandall,  aged  seventy-eighth  years. 

Garten. — In  Lincoln,  Nebraska,  on  Thursday,  May  6th, 
Dr.  Melchert  H.  Garten,  aged  sixty-three  years. 

Lane. — In  East  Pittsburgh,  Pennsylvania,  on  Friday, 
May  7th,  Dr.  H.  C.  Lane,  aged  thirty-two  years. 

Meyer. — In  Sabetha,  Kansas,  on  Saturday,  May  8th,  Dr. 
I.  L.  Meyer,  of  Hiawatha,  aged  fifty-one  years. 

MosLANDER.— In  Camdeii.  New  Jersey,  on  Wednesday, 
May  I2th,  Dr.  William  S.  Moslander,  aged  forty  years. 

Murray. — In  Seville,  Ohio,  on  Thursday,  April  29th,  Dr. 
L.  S.  Murray,  of  Medina,  aged  sixty-nine  years. 

Payne. — In  Boston,  on  Friday,  May  14th,  Dr.  James 
Henry  Payne,  aged  eighty-si.x  jears. 

Plotner. — In  Turtle  Creek,  Pennsylvania,  on  Saturday, 
May  8th,  Dr.  William  S.  Plotner,  aged  forty-seven  years. 

Plush. — In  Areola,  Pennsylvania,  on  Tuesday,  May  4th. 
Dr.  Samuel  M.  Plush,  aged  sixty-eight  years. 

Reager. — In  Littleton,  West  Virginia,  on  Monday,  May 
toth,  Dr.  J.  F.  Reager. 

RiGCS. — In  Rochester,  Minnesota,  on  Friday,  May  7tli. 
Dr.  David  W.  Riggs,  of  Pittsburgh,  Pennsylvania,  aged 
seventy-five  years. 

SriiULTZ. — In  Lebanon,  Indiana,  on  Friday,  May  7th,  Dr. 
William  H.  Schultz,  aged  sixty-nine  years. 

Thrash. ^ — In  Candler,  North  Carolina,  on  Monday,  May 
3d,  Dr.  George  Thrash. 

Wynkoop. — In  New  York,  on  Sunday,  May  istli.  Dr. 
Gerardus  Hilles  Wynkoop,  aged  sixty-four  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  tH  Medical  News 

A   Weekly  Review  of  Medicine,  Established  184J. 


\'oL.  LXXXIX.  Xo.  22. 


XEW  YORK,  MAY  29,  1909. 


Whole  Xo.  1591. 


(Origiuiil  eommuiiitations. 

REPORT  OF  A  CASE  OF  IDIOPATHIC  DILATA- 
TION OF  THE  CESOPHAGUS. 
With  Cure  and  Description  of  a  Ncu'  Cardiodilafor. 
By  Max  Einhorn,  M.  D., 
New  York, 

Professor  of  Medicine  at  the  Postgraduate  Jledical  School. 

Idiopathic  dilatation  of  the  oesophagus  (chronic 
spindle  shaped  dilatation  of  the  oesophagus)  was 
considered  by  most  clinicians  until  recently  an  in- 
curable af¥ection.  Alikulicz'  was  the  fir.st  to  use 
forced  dilatation  of  the  cardia  for  the  removal  of 
that  affection.  In  igoo  this  surgeon  first  performed 
a  gastrostomy  in  a  girl,  in  order  to  accomplish  per- 
manent dilatation  of  the  cardia  according  to  von 
Hacker's  method.  This  was  successful  in  a  slight 
degree.  In  1903  Mikulicz'  chose  a  different  opera- 
tive procedure.  After  laparotomy  and  transverse 
incision  of  the  stomach,  he  introduced  two  fingers 
into  the  cardia,  stretched  it,  and  then  under  con- 
trol of  his  fingers  inserted  a  dilator,  the  branches  of 
which  were  covered  with  rubber  and  opened  to  a 
circumference  of  13  cm.  Of  six  patients  operated 
upon  five  were  permanently  cured. 

In  New  York  Erdman^  treated  two  cases  of 
dilatation  of  the  oesophagus  according  to  INIikulicz's 
method  and  also  obtained  cures. 

It  was  perfectlv  natural   that   clinicians  should 


mer's  report  is  particularly  of  great  import.  He 
has  treated  forty  cases  of  cardiospasm  by  forcible 
dilatation  of  the  cardia,  and  says:  "The  immerliate 
results  are  most  striking.  The  patients  are  almost 
invariably  able  to  take  any  kind  of  food  at  the  fol- 
lowing meal.  There  is  often  a  complaint  of  soreness 
for  the  first  twenty-four  hours.  The  gain  in  weight 
and  strength  is  rapid.  In  twenty-nine  cases  there 
was  no  recurrence."  All  the  clinicians  used  a  di- 
lator consisting  of  a  rubber  tube  with  an  inflatable 
air  balloon  at  its  end  which  resembled  Schreiber's 
instrument.  W  ith  these  dilators  various  cures  have 
been  observed.  Gottstein  covered  the  rubber  bal- 
loon with  silk,  and  published  only  lately  six  cases 
of  cardiospasm  with  good  results. 

About  six  years  ago  I  constructed  a  dilator  for 
the  cardia,  in  which  through  a  screw  mechanism 
the  lower  end  is  considerably  spread  apart.  I  tried 
the  instrument  at  that  time  on  a  patient,  without 
much  success  however,  and  did  not  make  further 
use  of  the  instrument.  In  some  cases  of  dilatation 
of  the  oesophagus  I  was  able  to  pass  sounds  of  from 
48  to  54  F.  through  the  cardia,  although  meeting 
with  some  resistance,  and  it  did  not  seem  probable 
that  the  dilatation  of  the  cardia  could  be  of  an} 
practical  benefit.  For  this  reason  I  had  discontinued 
the  use  of  this  method  of  treatment.  When,  how- 
ever, the  favorable  reports  on  forced  dilatation  of 
the  cardia  became  more  numerous,  I  concluded  to 
try  this  therapeutic  method  in  my  next  cases. 

In  the  case  of  dilatation  of  the  oesophagus  de- 


/2  SIZE 


The  cardiodilator.     a,  Expanding  end;  b,  flexible  shaft;  c,  pilot  wh 
shaft  enclosing  transmission  wire;  /,  hard  rubber  ring;  aa. 


eel;  <f,  handle  and  casing  for  actuating  mechanism;  e,  flexible  spiral 
expanding  end  when  giving  maximum  dilatation. 


make  a  trial  to  dilate  the  cardia  without  previous 
operation  (gastrotomy).  Among  these  are  Rosen- 
heim,* Sippey,''  Plummer,"  and  Gottstein.'  Plum- 

'Mikulicz.  Quoted  after  Gottstein,  Archiv  fiir  klinischc  Cli'- 
riirgic,  Ixxxvii,  3,  p.  497. 

^Mikulicz.  Zur  Pathologic  und  Therapio  dcs  Cardiospasmus, 
Deutsche  mcdicinische  IVoclicnschrift,  1904.  Nos.   i  and  2. 

^Enhnayi.     Cardiospasmus.  Annals  of  Surgery,  February,  1906. 

^Theodore  Rosenheim.  Beitrage  zur  Erkenntnis  der  Divertike 
und  Ektasieen  der  Speiserohre,  Zeitschrift  fiir  klinische  Medisin, 
xli.  TQ02. 

■■'Sippey.     Quoted  by  Plummer. 

•^Plummer.  Cardiospasm,  with  a  Report  of  Forty  Cases,  Journal 
of  the  American  Medical  Association,  August  15,  1908,  p.  549. 

'George  Gottstein.  Weitere  Fortschritte  in  der  Therapie  des 
chronischen  Cardiospasmus,  Archiv  fiir  klinische  Chirurgie,  Ix.xxvii, 
3.  P-  497- 


scribed  in  the  following  I  tried  to  dilate  the  cardia 
with  the  dilator  constructed  by  me  some  years  a.%o. 
On  account  of  the  length  (17  cm.)  of  the  stiff  part 
the  instrument  could  not  be  introduced  into  this  pa- 
tient. I  therefore  changed  the  instrument  some- 
what, so  that  the  stiff  part  was  shortened  (10  cm.), 
It  is  now  easy  to  introduce  the  instrument  and  a 
successful  treatment  can  thus  be  carried  out.  I 
would  first  like  to  give  a  more  accurate  description 
of  the  instrument  as  well  as  of  its  mode  of  use.  I 
also  desire  to  mention  that  Gottstein  constructed  a 
dilator  on  the  principle  of  the  Otis'  urethral  dilator. 


Copyright.  1009,  by  .\.  R.  Elliott  Publishing  Company. 


WRIGHT:  HEREDITY. 


[Xew  Vork 
ilEDicAL  Journal. 


It  did  not,  however,  prove  practical,  and  Gottstein 
says:  "In  using  the  instrument  it  was  found  that  the 
thin  yielding  metal  branches  could  not  withstand  the 
enormous  pressure  that  had  to  be  exerted,  but  bent." 

A  metal  dilator  would  certainly  be  preferable  to 
the  inflatable  dilators,  since  it  would  be  easier  to 
handle  and  would  work  quicker.  Therefore  I  un- 
dertook to  construct  such  an  instrument.  The  in- 
strument consists  mainly  of  a  metal  spiral  covered 
with  a  rubber  tube  and  is  divided  into  the  following 
parts  (see  fig.):  a.  An  expanding  end;  b.  flexible 
shaft ;  c.  pilot  wheel ;  d.  handle  and  casing  for  actu- 
ating mechanism ;  e.  flexible  spiral  shaft  enclosing 
transmission  wire ;  /.  hard  rubber  ring ;  aa.  expand- 
ing end  when  giving  maximum  dilatation. 

Before  using,  the  dilator  is  covered  with  a  rub- 
ber bag  which  is  fastened  with  a  hard  rubber  ring ; 
the  instrument  after  immersion  in  warm  water  is 
introduced  into  the  patient  in  the  sitting  position, 
pushed  through  the  cardia  so  that  only  one  centimetre 
projects  beyond  it.  The  distance  of  the  cardia  from 
the  lips  is  determined  by  a  larger  bougie  ( abovit 
from  40  to  50  mm.),  by  determining  the  point  at 
which  resistance  at  the  cardia  can  be  found.  The 
distance  of  this  point  from  the  lips,  which  can  easily 
be  measured  on  the  whalebone  bougie  shows  the  lo- 
cation of  the  cardia. — Now  the  pilot  wheel,  c.  is 
turned  to  the  right,  until  the  patient  complains  of 
pain  ;  when  this  point  has  been  reached  we  must 
stop  the  dilatation.  The  instrument  is  left  from  one 
to  two  minutes,  then  the  wheel  is  turned  back  en- 
tirely to  the  left,  and  the  instrument  is  withdrawn. 

In  a  few  days  the  dilator  can  be  opened  to  the 
maximum  width  without  causing  the  patient  pain. 
The  patient  feels  only  a  sensation  of  distention  in 
the  cardia.  It  is  well  to  do  this  once  weekly  for 
several  months.  The  dilator  which  has  just  been 
described,  and  whose  maximum  circumference  is  8 
cm.,  was  successfully  used  in  a  patient  whose  history 
is  here  given : 

December  15,  1908,  Miss  Kate  G.,  forty-three  years  old, 
hoiiseworker,  has  always  been  well  until  five  years  ago 
when  her  food  started  to  regurgitate.  Patient  vomited 
almost  after  each  meal.  At  times  even  a  drink  of  water 
would  stop  at  the  throat  and  gag  her  until  she  would  have 
to  vomit  that  drink  of  water.  She  also  used  to  spit  up  a 
great  quantity  of  phlegm.  Last  winter  she  became  hoarse 
and  a  cough  developed,  which  stayed  with  her  ever  since. 
This  cough  especially  troubled  her  at  night  and  persisted 
until  she  vomited,  when  her  cough  would  disappear.  Bow- 
els were  normal,  no  headaches,  and  patient  slept  well. 

She  consulted  a  number  of  physicians  but  without  any 
benefit.  Some  ascribed  her  condition  to  a  severe  gastric 
catarrh  due  to  the  abuse  of  alcohol.  Patient,  however, 
was  always  a  total  abstainer  from  alcohol. 

Present  condition  :  Bougie  No.  54  passed  through.  After 
fourteen  inches  of  the  tube  had  been  introduced,  a  fluid 
mixed  with  food  was  obtained,  about  120  c.c.  slightly  acid 
reaction,  cnngo  paper  negative.  The  tube  was  then  pushed 
on  to  about  twenty  inches  and  now  a  turbid  fluid  was  re- 
moved, containing  mucus  and  only  traces  of  food,  but  of 
strongly  acid  reaction,  congo  paper  and  (ninzburg's  test 
positive.  Microscopically  we  found  in  the  oesophageal  con- 
tents numerous  oesophageal  epithelia.  in  the  second  (stom- 
ach) portion,  however,  no  such  elements  were  found. 
Swallowing  soimd  was  absent ;  bougie  No.  54  encountered 
resistance  at  16V2  inches  and  after  overcoming  it,  passed 
into  the  stomach.  Similar  results  were  obtained  on  De- 
cember T8tli  and  22A. 

During  January  and  February  patient  was  treated  twice 
wecklv  with  the  cardiodilator.  On  February  23.  uxx).  she 
swallowed  the  sound  after  nine  seconds.  Patient  drank 
ICQ  c.c.  of  water.    After  fi\  e  niinute.s  10  c.c.  of  fluid  without 


food  were  recovered  from  the  oesophagus  by  means  of  the 
tube. 

March  i6th  the  patient  had  gained  eighteen  pounds  since 
the  beginning  of  the  treatment. 

Course  of  the  Disease. — Whereas  at  first  the  patient  was 
able  to  press  through  the  cardia  even  liquid  food  only  with 
great  exertion  and  then  only  incompletely — for  there  were 
always  found  from  120  to  150  c.c.  of  contents  in  the 
oesophagus — soon  after  the  institution  of  forced  dilatation 
she  began  to  eat  better,  i.  e.,  she  was  able  to  eat  even  semi- 
fluid food.  Some  time  thereafter  patient  was  able  to  take 
solid  food  without  any  difficulty.  She  did  not  now  need 
to  practice  thoracic  gymnastics  after  meals.  The  oesophagus 
was  empty  after  meals,  and  the  swallowing  sound  was 
present  after  about  nine  seconds. 

We  have  therefore  to  deal  here  with  a  case  of  di- 
latation of  the  oesophagus  with  a  real  cure. 
20  E.\ST  Sixty-third  Street. 


THE  THEORIES  AND  PROBLEMS  OF  HEREDITY. 
Bv  JoN.\TH.\N  Wright,  M.  D., 
New  York. 

V.  Cancer  as  a  Problem  of  Heredity  'Ji  its  Bearing 
on  the  Problems  of  Histology. 
In  the  analysis  of  cell  division  attempted  in  the 
previous  articles'  an  attempt  was  made  to  show  that 
the  term  "extrinsic  origin  of  cancer"  may  signifv 
very  little.  Heat,  moisture,  and  food  may  pull  the 
trigger  for  bacterial  fission,  and  if  the  protoplasm  of 
the  patient's  cell  is  in  a  certain  condition  of  molecu- 
lar arrangement  influences  as  common  as  these  may 
suffice  as  the  extrinsic  agents  of  cancer.  The  ob- 
servations of  Boveri  on  dispermia,  those  of  Klebs. 
Hansemann,  and  Galeotti  on  the  irregular  and  un- 
equal distribution  of  the  chromosomes  in  the  divi- 
sion of  cancer  cells  show  that  the  irregularity  mav 
be  due  to  a  variety  of  causes,  such  as  the  action  of 
certain  acids  and  alkaloids  upon  the  dividing  cells 
of  the  lower  organisms'.  The  first  observer  has 
shown  that  the  disturbances  produced  by  dispermia 
may  be  inherited,  but  soon  bring  about  the  death  of 
the  descendent  cells.  Not  so  in  cancer.  The  mi- 
totic figures  are  not  arranged  with  any  reg- 
ularity, yet  the  cells  divide  and  survive.  Ths 
experiments  of  Galeotti,  as  Wilson  remarks,  sug- 
gest that  the  pathological  mitoses  may  be  due  to 
some  toxine.  We  have  seen  some  reason  to  believe 
that  the  normal  mitotic  figure  itself  is  due  to  some 
molecular  arrangement  behind  it.  All  the  work  on 
immunity  has  only  taught  us  we  must  assume  the 
same  thing  for  the  production  of  the  toxine  or  the 
enzyme.  Manifestly  then,  if  such  a  thing  e.xists  as 
an  agent  in  cancer  production,  it  must  depend  upon 
the  molecular  arrangement  within  or  without  the 
cell.  It  would  seem  then  that  the  invention  of  a 
self  perpetuating  enzyme  does  not  simplify  matters 
any.  It  is  on  a  par  with  the  formative  stimuli  of 
\'irchow,  as  Hansemann'  very  clearly  points  out.  It 
is  of  the  same  kind  of  logomachv  as  Weismann's 
determinants.  I  fanseniann  insists  from  the  evi- 
dence furnished  by  his  experiments  on  hibernating 
animals  that  physiological  activities,  the  brisk  in- 
terchange of  metabolic  proflucts,  are  necessary  for 
the  normal  stimulation  of  that  power  of  formative 
regeneration  exhibited  within   cells  without  which 

'See  A'ew  York  Medical  Jo'imul. 

■Kef.:  Wilson.    The  Cell.  3d  Ed.,  1904,  p.  98. 

'"Zcit^chrtft  fiir  hrcbsforschung.  vii.  No.   1,  1908. 


May  29,  1 909.  J 


IV RIGHT:  HEREDITY. 


1079 


external  injury  would  be  irreparable.  The  slowing 
down  of  metabolism  by  the  advance  of  age.  the 
weakness  in  the  equilibrium  of  slow  molecular 
movement,  are  considerations  to  be  correlated  with 
this  in  the  conception  of  the  cancer  cell  as  a  muta- 
tion, and  in  the  conception  of  heredity  as  due  to  the 
inertia  of  molecular  forces.  It  is  becoming  the  cus- 
tom now  to  look  upon  this  formative  power  both  of 
regeneration  and  generation  within  cells  as  one  of 
"tissue  tension,"  for  the  efficient  discharge  of  which 
the  impingement  of  some  physiological  dynamic 
stimulus  is  necessary.  In  the  senescence  of  cells 
(not  necessarily  though  frequently  coincident  with 
the  senescence  of  individuals)  as  in  the  hibernating 
cell,  we  might  have  an  abnormal  discharge  of  en- 
ergy from  the  usual  stimulus.  It  results  from  this 
conception  that  the  endogenic  origin  of  cancer  is  not 
incompatible,  indeed  entirely  reconcilable  with  ex- 
ogenic factors  of  inflammation  and  irritation.  It 
must  be  born  in  mind  that  ascribing  the  change  of 
cell  form  to  a  mutation  in  the  heredity  of  the  so- 
matic cell  in  no  way  explains  the  causal  factor  in  the 
process.  What  it  does  do,  however,  is  to  correlate 
a  pathological  phenomenon  from  the  domain  of 
medicine  with  a  phenomenon  in  the  wider  field  of 
biology  in  such  a  way  that  a  certain  amount  of  light 
is  thrown  on  the  mystery  of  each.  I  fancy  this  is 
the  way  our  knowledge  of  cosmic  law  has  always 
advanced. 

I  need  not  discuss  the  enzyme  theory  of  cancer 
further  than  I  have  done.  If  an  enzyme  is  regularly 
present,  like  the  "organelle"  idea  I  have  ref  rred  to 
and  the  entelechy  of  Driesch  and  the  determinants 
of  Weismann,  I  cannot  see  it  in  any  way  goes  to  the 
bottom  of  the  matter.  Some  of  the  literature  may 
be  found  in  an  article  by  Hemmeter'  and  it  is  dis- 
cussed more  recently  by  Riilf".  W'e  may  more 
profitably,  at  least  more  in  accord  with  the  object 
of  this  dissertation,  turn  to  other  aspects  of  the 
question. 

Riilf  has  drawn  the  analogy  between  a  biological 
phenomenon  and  a  sociological  one  so  common  with 
many  writers  that  I  should  be  inclined  to  omit  it 
here  were  it  not  done  in  such  a  way  as  to  bring  out 
points  of  more  importance  from  the  purely  biologi- 
cal point  of  view.  "The  decline  of  altruism  is  a 
phenomenon  of  every  organized  community  as  it 
passes  from  youth  to  old  age."  This  may  be  so  or 
not  in  sociology,  but  as  tissues  arise  in  the  scale  of 
evolution  and  become  more  complex,  as  the  cell 
from  its  original  epithelial  form  in  the  blastom  be- 
comes more  differentiated,  it  loses  its  power  of  re- 
generation, at  least  in  man.  They  lose  in  primordial 
vigor  what  they  gain  in  delicacy  of  adjustment.  The 
muscle  cell  and  the  nerve  cell  have  a  complexity  of 
function,  or  are  at  least  so  distantly  evolved  from 
the  blastom  that  they  form  a  contrast  to  the  epithe- 
lial covering  of  the  body  within  and  without.  Ma- 
lign transformations  of  these  cells  are  curiosities  in 
pathology. but  the  epithelioma  is  by  far  the  common- 
est of  all  malignant  tumors.  ?iIetamarphosis  of  the 
epithelium,  the  so  called  metaplasia,  the  change  of 
function  it  is  capable  of  undergoing,  the  prospective 
fate  of  its  cells,  seen  to  be  largely  the  function  of 

^Hemmeter.  The  American  Journal  of  the  Medical  Sciences. 
July,  1903. 

'Riilf.    Zcitschrift  fi'ir  Krebsiorschung,  vii.  No.  i,  igo&. 


their  location  in  the  words  of  Driesch.  are  famil-ar 
phenomena.    In  this  it  but  betrays  its  mutability. 

Now  we  are  ready  to  discuss  what  is  declared  to 
be  a  startling  thing  as  revealed  to  many  investi- 
gators, though  not  one  entirely  foreign  to  the  ex- 
perience of  many  histologists.  I  refer  to  the  un- 
doubted proof  that  epithelial  tumors  change  their 
type  occasionally  in  the  experimentation  which 
passes  them  from  mouse  to  mouse.  They  even  be- 
come sarcomatous.  In  other  w^ords  they  have  not 
escaped  from  their  state  of  mutability  by  the  strike- 
back  in  atavism  to  the  germ  cell". 

I  presume  most  of  us  twenty-five  years  ago  were 
indoctrinated  with  the  Cohnheim  view  of  the  blas- 
togenetic  origin  of  all  malignant  tumors.  The  spe- 
cificity of  the  primordial  embryonic  layers  was  a 
natural  outcome  of  the  growth  the  new  tscience  of 
embryology  had  attained  when  \^irchow  wrote  his 
Cellular  Pathology  and  still  more  his  Krankhafte 
GcscJnvi'tlste.  It  is  an  evidence  also  of  the  resist- 
ance offered  by  that  master  mind  to  the  rising  tide 
of  evolutionary  doctrine,  which  was  to  teach  us  the 
mutability  of  form  and  species.  It  has  pervaded 
pathology  ever  since. 

Let  us  be  careful  not  to  obscure  a  possible  point 
of  difference.  The  transition  of  form  in  certain 
histological  characters  as  the  result  of  inflammation, 
is  to  a  certain  extent  recognized  by  all.  There  is 
no  dispute  about  the  meta])lasia  of  the  epithelium 
from  one  form  of  it  into  another.  It  is  singular  that 
we  have  borrowed  from  the  biology  of  tumors  in 
animals  a  light  with  which  to  illuminate  the  further 
transformation  of  structure,  which  goes  so  far  as 
to  transgress  the  line  drawn  between  the  embryonic 
layers  by  the  early  histologists.  Nevertheless  there 
have  been  large  numbers  of  men  working  with  the 
microscope  since  the  early  days  of  X'irchow  and 
Cohnheim,  and  some  of  them  have  been  compelled 
to  believe  that  under  certain  conditions  there  is  a 
genetic  connection  between  the  surface  epithelium 
and  its  underlying  stroma.  I  have  been  chiefly  in- 
fluenced in  that  belief  myself  through  study  of  bits 
of  inflamed  tissue  removed  from  mucous  surfaces 
and  submitted  to  me  for  diagnosis,  a  practice  con- 
tinued over  many  years'  experience  in  special  hos- 
pitals. I  need  not  go  over  the  accumulated  testi- 
mony of  many  competent  observers,  but  I  may  con- 
tent myself  here  with  quotations  from  the  most  re- 
cent w'ork  of  an  histologist  of  note',  "In  the  eyes  of 
the  classical  writers  the  fixity  of  the  blastodermic 
folds  is  a  dogma."  Orth  has  been  influenced  by  this 
when  he  has  of  late  repeatedly  declared  that  to  ac- 
cept the  transmutation  of  a  malignant  epithelial 
tumor  into  a  malignant  connective  tissue  tumor  as 
a  fact  we  must  abandon  all  we  have  learned  by 
twenty  years  and  more  of  tissue  study.  To  resume 
the  quotation  from  Retterer :  "In  my  opinion  on  the 
contrary,  the  derma  comes  from  the  epiderm,  but 
there  are  those  who  also  believe  that  connective  tis- 
sue cells  can  return  to  the  condition  of  epithelial 

°I  perhaps  should  explicitly  allude  to  the  fact  that  the  view  whicli 
I  have  urged  is  one  which  of  late  has  been  repeatedly  advanced  by 
others.  See,  for  instance,  Westenhoeffer.  Berliner  ktmischc  IVochen- 
schrift,  No.  19,  May  13,  1907;  Welsh,  The  Lancet.  June  8,  igiiv, 
clxxii,  articles  published  before  the  exhibition  of  much  of  the  evi- 
dence now  at  hand. 

•l)e  la  Structure  de  la  cellule  epidermique  et  des  facteurs  qui 
la  modifient,  par  E.  Retterer,  Journal  dc  i  anatoinie  ct  tic  la 
physiologic,  xliv,  No.  6,  November- December,  1908. 


io8o 


WRIGHT:  HEREDITY. 


[New- 
Medical 


York 
Journal. 


ells."  Under  certain  conditions  and  from  certain 
observations  "one  arrives  at  the  firm  conviction  that 
in  the  adult,  as  during  the  embryonal  period,  the 
epithelial  cells  are  transformed  into  connective  tis- 
su.'."  I  cannot  here  go  into  the  exceedingly  inter- 
esting demonstration  by  which  he  objectively  shows 
the  'process  of  the  transformation  of  an  epithelial 
cell  into  connective  tissue.  I  have  simply  to  remark- 
that  I  have  not  been  able  to  discredit  the  continual 
testimony  of  mv  eyes  which  have  for  many  years 
furnished  me  indications  that  in  certain  changes 
dependent  on  chronic  inflammation  or  irritation 
the  basal  cells  of  the  epithelium  in  the  mucosa 
arise,  at  least  partly,  from  the  connective  tissue,  al- 
though possibly  the  reverse  may  be  the  case.  I  am 
constrained  also  to  believe  that  epithelium,  in  the 
tonsil  for  instance,  when  crypts  are  being  obliter- 
ated, suffers  not  altogether  absorption  by  the  large 
lymphocytes  but  also  a  certain  amount  of  trans- 
formation into  connective  tissue. 

Let  us  not  confound  the  point  as  to.  cancer  as  a 
mutation.  The  concept  it  furnishes  to  histology 
that  an  epithelial  cell  may  change  to  a  fibroblast  is 
of  course  not  conclusive  in  itself,  for,  even  if  this 
is  admitted,  it  may  not  be  analogous  to  a  mutation 
at  all.  It  may  very  well  be  that  under  a  change  of 
environment  the  flat  epithelial  cell  adapts  itself  not 
only  to  the  function  of  a  columnar  cell  or  of  a  gland 
cell  but  even  to  the  form  and  function  of  a  connec- 
tive tissue  cell.  We  may  accept  this  as  an  adapta- 
tion and  it  may  not  even  be  fatal  to  the  Cohnheim 
theory  of  the  origin  of  cancer  in  a  misplaced  em- 
bryonic cell.  It  is  important  to  remember  that  there 
is  not  in  this  vicarious  function  that  radical  change 
in  the  acquisition  of  energy  and  in  the  loss  of  syn- 
thetic control  which  di-stinguishes  the  transition  of 
flat  celled  epithelium  into  a  squamous  celled  car- 
cinoma. That,  too,  is  what  the  Cohnheim  theory  does 
not  explain.  That  is  the  apparent  jump  of  charac- 
ter. Viewed  thus  the  distinction  seems  obvious 
enough,  but  just  as  we  are  able  to  trace  through  in- 
flammatory changes  a  certain  transition  in  the  dc- 
i^^rcc  of  transition  between  epithelial  cell  and  the 
fibrils  of  connective  tissue,  so  we  will  be  able  to  find 
approximating  instances  between  the  neoplasms  of 
inflammation,  the  so  called  true  benign  tumors  and 
malignant  growths.  Yet  in  realitv  the  existence  of 
these  transitions  of  form  and  energy  again  allies  the 
phenomena  to  the  transition  forms  between  species, 
which  makes  it  so  difficult  to  decide  what  are  to  be 
called  species  and  what  are  to  be  thought  of  as  va- 
rieties in  bif)logy.  So  this  docs  not  invalidate  the 
propriety  of  regarding  many  of  the  sharp  transi- 
tions between  a  flat  epithelial  cell  and  a  virulent 
e])ithelioma  as  essentiallv  mutations,  a  sudden  ac- 
quisition of  something  or  a  sudden  loss  of  some- 
thing, rather  probably  a  sudden  rearrangement  of 
something  which  before  it  did  not  possess,  l^ut  the 
cancer  (juestion  (juitc  aside,  as  to  the  loss  in  the 
identity  of  the  embryonic  layers,  I  am  not  among 
those  who  would  join  Orth  in  the  feeling  of  a  loss 
of  landmark  in  histology.  I  can  only  look  upon  it 
as  one  of  the  evidences,  constantly  coming  under 
notice  in  biology,  of  the  transmutation,  adaptability 
if  you  will,  of  living  matter.  I  do  not  believe  we 
shall  have  to  learn  histologv  all  over  again,  thouTfh 
I  do  believe  we  will  have  to  stud}'  it  in  otiu  r  I'glils 


than  that  furnished  by  the  pristine  form  of  Weis- 
mannism.  This  seems  to  be  the  tendency  of  the 
discussion  at  the  recent  meeting  of  the  German 
Pathological  Society. 

Lewin,  while  agreeing  with  Lubarsch  in  the  be- 
lief that  carcinoma  was  transformed  into  sarcoma, 
as  was  indicated  at  the  85th  generation  of  Jens- 
sen's  tumor  in  the  results  of  Ehrlich  and  Apolant 
(also  supported  by  the  results  of  Bashford  and  his 
associates  in  England),  does  not  ascribe  the  change 
in  type  to  a  metaplasia  of  an  epithelial  cell  into  a 
connective  tissue  type  in  the  tumor,  but  to  a  change 
in  the  unknown  agent  of  malignant  tumor  forma- 
tion. This  is  postulating  a  mutation  in  an  un- 
known, an  unproved  and  a  discredited  extrinsic  bio- 
logical factor,  which  he  is  not  willing  to  allow  for 
the  cell  itself.  Several  years  ago  we  had  a  prelim- 
inary but  no  less  marked  and  significant  indication 
of  this  mutability  in  the  observation  that  Jenssen's 
mice,  inoculated  originally  with  an  adenocarcinoma 
in  the  lung,  came  after  a  few  generations  to  exhibit, 
on  the  testimony  of  Hansemann,  an  endothelioma- 
tous  tumor.  Indeed  the  very  strife  as  to  the  nature 
of  endothelium,  which  has  appeared  from  time  to 
time  in  the  past,  whether  it  is  an  epithelial  or  a  con- 
nective tissue  cell,  is  an  indication  pointing  in  the 
same  direction.  In  a  recent  communication*  Krom- 
pecher  resumes  his  contention  that  the  so  called 
basal  celled  epitheliomata,  a  classification  I  have 
found  very  useful,  form  the  connecting  link  between 
the  epithelial  and  the  connective  tissue  tumors. 
There  is  no  doubt  that  malignant  tumors  tend 
strongly  to  keep  the  same  type  as  the  epithelium 
from  which  they  sprang  when  they  run  their  life 
history  in  one  individual,  and  this  is  nowhere  more 
clearly  seen  than  in  the  epitheliomata  springing 
from  the  basal  layer  of  the  mucosas  in  the  nose  and 
throat.  This  is  the  line  of  supposed  genetic 
connection  between  epithelium  and  stroma.  I 
think  every  one  would  be  disposed  to  admit 
that  this  is  less  true  of  distant  metastases,  as 
in  the  glands,  but  also  it  is  the  rule  there,  to  which 
marked  exceptions  are  few.  But  a  tumor  spring- 
ing originally  spontaneously  from  the  tissues  of  one 
mouse,  transferred  to  those  of  another,  enters  upon 
those  conditions  of  mutability  to  be  observed  in  the 
transplantation  of  the  primrose  from  one  continent 
to  another,  or  in  the  escape  of  it  from  the  garden 
to  the  woods.  As  between  individual  mice,  the  soil 
varies  as  it  does  between  that  of  the  garden  and  the 
woods.  Thus  in  inoculating  one  cancer  stem  in 
different  mice  we  make  an  analysis  impossible  in 
man,  and  naturally  the  results  vary  from  those 
of  observation  in  man.  In  man  we  observe 
the  behavior  of  one  cancer  stem  in  one  man 
and  we  observe  the  behavior  of  diflferent  cancer 
stems  in  different  men.  In  mice  it  has  even  been 
possible  1:0  observe  that  the  same  individual  reacts 
dift'erently  to  dift'erent  kinds  and  to  diflferent  stems 
of  the  same  kind  of  cancer.  Still  more,  variability 
has  been  noted  as  to  cancer  growth  in  dift'erent 
breeds  of  mice  and  of  mice  at  different  ages.  It  has 
even  been  declared  that  the  same  mice  ])resent  a 
different  reaction  in  London  and  England.  Finally, 
mice  will  not  grow  a  human  cancer.    In  short,  as 

'"^L'il'-rge    :ttr    fathologi.tchfii    .-Inaiowic    (Zicglcr),  No.  i, 

I  ^o8.    See  also  xlii. 


May  ^9,  1909.] 


WRIGHT:  HEREDITY. 


1081 


Sticker"  observes,  many  observations  by  various  ex- 
perimental investigators  go  to  show  that  "the  va- 
riety of  animal  in  which  the  tumor  has  had  its 
origin  furnishes  a  more  favorable  soil  for  continued 
transplantation  than  a  foreign  one,"  which  is  quite 
in  accord  with  what  we  know  of  adaptations  of  suc- 
cessful mutations  in  general.  If  cancer  research 
in  animals  has  thrown  an  expected  light  upon  can- 
cer in  man,  it  has  thrown  considerable  light,  it 
seems  to  me,  on  the  problems  of  heredity,  and  cer- 
tainly an  unexpected  light  upon  histology  and  upon 
embryology,  that  recapitulation  of  heredity.  If  the 
study  of  cancer  in  mice  has  helped  us  in  histology 
it  has  only  supplemented  the  results  (long  discred- 
ited) attained  in  the  study  of  cancer  in  man.  Many 
observers,  Krompecher  among  them  in  his  study  of 
basal  celled  epithelioma,  the  repeated  observations 
of  sarcoma  and  carcinoma  observed  occurring  to- 
gether in  man  and  even  in  animals'"  have  long  ago 
indicated  like  conclusions.  Krompecher 's  remark 
is  not  an  exaggeration,  when  he  says :  "After  all 
is  said,  the  products  of  the  different  embryonic 
layers  cannot  be  sharply  distinguished.  Rather  it 
is  apparent  the  dififerent  embryonic  layers,  through 
independent  development  and  the  subsequent  unit- 
ing of  the  fibrous  and  cellular  elements  enter  into  a 
highly  complex  relationship."  I  have  referred  to 
the  observations  of  Retterer  upon  cells  of  the  epi- 
dermis under  conditions  of  irritation, — I  may  refer 
to  an  earlier  observation  on  tumors  by  Zipkin."  He 
shows  the  genesis  of  what  appears  fibrous  stroma 
from  the  basal  portions  of  the  epithelial  cells  of 
malignant  growths,  through  the  medium  of  the 
hyaline  exudate  from  them.  He  draws  a  parallel 
with  Stohr's  discovery  of  the  genesis  of  an  inner 
glasslike  capsule  of  the  hair  follicules  from  the 
epithelial  cells.  Hitherto  the  view  has  prevailed 
that  the  stroma  of  an  epithelial  cancer  is  derived 
from  the  connective  tissue  surrounding  it.  I  think 
that  in  the  future  this  can  hardly  be  maintained  in 
its  entirety,  in  view  of  the  rising  flood  of  testimony 
to  some  of  which  I  have  referred.  Notwithstanding 
all  this,  and  notwithstanding  the  fact  that  Lubarsch 
strongly  upholds  the  credibility  of  the  reports  of  va- 
rious observers  that  a  metaplasia  of  one  form  of 
epithelial  growth  (adenocarcinoma)  may  take  place 
in  the  one  human  host,  I  cannot  but  feel  that  this 
is  liable  to  be  a  kind  of  testimony  which  may  re- 
ceive undue  exaggeration.  All  my  experience  goes 
to  support  the  view  that  the  type  of  tumor  in  the 
human  individual  remains  practicalh'  the  same  so 
far  as  structure  is  concerned  throughout  the  life 
of  the  host,  and  while  I  cannot  but  believe  that 
epithelial  cells  may  furnish  stroma  and  connective 
tissue  cells,  a  benign  tumor  does  not  change  to  a 
malignant  one,  nor  does  the  latter  change  its  type 
except  very  rarely.  That  it  does  so  occasionally  in 
the  one  human  host  perhaps  cannot  be  denied ;  that 
is,  a  few  of  the  apparent  instances  of  a  benign 
tumor  becoming  malignant  are  perhaps  real  ones  in 
the  sense  that  the  intra  and  extracellular  structure 
from  a  form  of  simple  hyperplasia  changed  so  that 
it  showed  the  atypical  structure  of  cancer,  but  I 
have  never  seen  any  proof  of  it  in  practice,  nor  have 

"Zeitsclirift  fiir  Krebsforschimg,  vii,  No.  i. 

'"See,  for  instance,  most  recently,  Schone:  Sarkom  und  Karzinom 
in  einer  Schilddriise  beim  Hunde,   Virchoiv's  Arcliiv,  cxcv.  No.  i. 
^'Virclww's  Arcliiv.  cl.xxxii,  No.  3. 


I  ever  seen  any  adduced  in  literature  satisfactorily 
establishing  the  fact.  There  are,  however,  indubita- 
ble instances,  not  of  the  change  of  a  malignant 
tumor  formation  into  a  simple  hyperplasia,  but  of 
the  exhaustion  of  that  so  called  immortality  of  ma- 
lignant tumor  growth  to  be  observed  in  the  death 
and  absorption  of  the  exhausted  cells  and  the  recov- 
ery of  the  host  from  its  ravages,  as  instanced  by 
many  observers.  The  case  referred  to  by  Dr.  Har- 
mon Smith  in  1908'"  which  had  been  previously  re- 
ported by  Dr.  Gleitsmann"  in  1896  was  an  instance 
not  of  change  in  type  of  structure  or  potentiality, 
but  it  was  of  a  feeble  potentiality  in  the  first  place. 
If  I  may  be  allowed  to  put  my  own  interpretation 
on  it,  the  liberation  of  atomic  energy  from  first  to 
last  was  small,  but  it  gained  somewhat  perhaps  with 
advancing  years.  An  epithelioma  of  the  larynx,  as 
this  was,  existing  for  more  than  twelve  years  with- 
out causing  the  patient's  death,  is  of  course  excep- 
tional in  these  days  of  thryotomy  and  laryngectomy, 
but  I  know  of  more  than  one  case  whose  history 
exceeded  the  term  limit  usually  set  for  the  course 
of  cancer  of  the  larynx.  This  is  said  not  as  a  dis- 
couragement to  operation,  in  which  I  am  a  believer, 
but  in  order  to  present  as  fairly  as  possible  the  evi- 
dence for  the  difference  in  cancer  potentiality  in 
man.  Observations  in  animals  have  repeatedly 
shown  that  cancer  may  heal  spontaneously.  There 
is  a  certain  tissue  form  of  sarcoma  in  man,  not  to 
confine  the  illustration  to  the  adenomata,  aiigeiosar- 
coiiia,  said  by  Hansemann  to  be  indistinguishable 
from  a  benign  granuloma,  at  least  in  the  early 
stages, — yet  one  thing  is  clinically  very  malignant 
and  the  other  quite  the  opposite".  In  the  dog  the 
same  kind  of  structure  is  seen  very  frequently  in  a 
tumor  whose  process  is  usually  so  slow  that  it  rarely 
curtails  the  dog's  existence,  sometimes  disappear- 
ing spontaneously. 

At  the  close  of  the  preceding  article''"  I  broached 
the  opinion  that  tissue  structure  is  frequently  not  a 
guide  either  for  diagnosis  or  prognosis  in  man.  In 
its  further  development  here  I  may  continue  the 
subject  by  referring  to  the  sententious  expression 
of  Lubarsch  in  concluding  the  discussion  before  the 
German  Pathological  Society  in  April  1908:  ''Ein 
specifisiches  histologisches  Aussehen  des  Carcinom's 
giebt  es  nicht."  The  declaration  is  no  less  true  of 
epithelioma  than  of  sarcoma.  Malignancy  is  not  an 
expression  which  belongs  to  objective  diagnosis.  It 
is  a  term  of  clinical  prognosis.  It  refers  to  the  host 
not  to  the  cancer  guest.  Final  as  the  testimony  of 
the  microscope  is  so  frequently  thought  to  be,  it  is 
by  no  means  a  court  of  last  resort.  It  can  never  be 
sufficiently  urged  that  the  biological  activities  evi- 
denced in  the  clinical  history  and  the  biological  con- 
dition noted  in  the  structure  must  be  correlated  in 
forming  an  opinion  as  to  the  fate  of  the  patient. 
While  the  structure  is  usually  an  indication  of  the 
hidden  potentialities,  which  we  have  called  im- 
mortal and  which  I  have  hinted  may  have  their 
origin  in  atomic  disintegration,  all  things  are  rela- 
tive.   A  skin  cancer  may  linger  for  many  years  /';/ 

'-T/;e  Laryngoscope.  January,  1909. 

"Transactions  or  the  American  Laryngological  Association,  1896. 
may  refer  briefly  to  my  own  report  of  a  case  of  this  kind 
constantly  recurring  on  the  nasal  septum  of  a  woman  at  the  same 
term  of  each  succeeding  pregnancy.  American  Journal  of  the  Medi- 
cal Sciences,  June,  1903. 

'■^New  York  Medical  Journal. 


io82 


WRIGHT:  HEREDITY. 


[New  York 
Medical  Journal. 


statu  quo.  Its  extirpation  having  as  a  result  a  per- 
manent cure  reflects  credit  upon  the  operator  per- 
haps, but  it  is  often  only  an  indication  of  a  feeble- 
ness of  potentiality  which  its  structure  does  not  be- 
tray. A  sarcoma  of  the  tonsil  having  at  the  start 
of  the  growth  of  the  organ  a  structure  in  no  way 
distinguishable  from  the  usual  hypertrophy,  may 
rapidly  exhibit  a  potentiality  of  growth,  a  malig- 
nancy, present  from  the  first  but  not  exhibited  in 
the  first  hypertrophy,'"  which  rapidly  leads  to  the 
death  of  the  patient,  small  round  cell  sarcoma  struc- 
ture being  of  course  recognizable  in  the  later  stages. 
It  is  with  a  feeling  of  gratification  and  even  of  re- 
lief that  I  find  support  for  a  conclusion  so  at  vari- 
ance with  that  of  many  of  my  confreres  for  whose 
acumen  in  histological  diagnosis  I  have  a  great  re- 
spect. Orth  in  an  article  on  the  nomenclature  of 
cancer  says'' :  "As  to  the  reversion  of  a  cancerous 
growth  to  a  noncancerous  one,  an  adenoma  simplex, 
there  can  be  as  little  ground  for  argument,  in  my 
opinion,  as  in  the  majority  of  cases  to  the  trans- 
formation of  a  benign  adenomatous  tumor  into  a 
cancerous  one.  The  original  adenoma, — in  the 
latter  case, — was  already  a  carcinoma,  and  it  is  not 
a  case  of  an  adenoma  become  cancerous,  but  of  a 
malignant  adenoma :  an  adenocarcinoma  has  taken 
on  itself  the  general  form  of  a  carcinoma,  the  form 
has  changed,  not  the  reality  of  malignancy."  This 
change  of  form  in  malignant  growths  in  man  is  not 
one  with  which  I  am  familiar,  at  least  in  a  marked 
degree,  but  I  think  there  can  be  no  doubt  that  Orth 
also  looks  upon  the  character  of  malignancy  as 
something  aside  from  the  character  of  form. 

As  has  been  pointed  out,  the  epithelial  cell  is  that 
form  of  cell,  normally,  which  retains  not  only  much 
of  the  ability  of  vicarious  function  of  the  original 
blastomere  from  which  it  sprang,  but  much  of  its 
actual  form.  Not  highly  organized  and  differen- 
tiated, not  incapable  of  change  as  is  the  nerve  cell 
and  the  muscle  cell,  in  the  greater  frequency  of 
epithelioma  and  adenocarcinoma  we  may  find  an 
expression  of  a  greater  tendency  of  the  epithelial 
cell  to  variation  and  mutation.  In  its  new  form  of 
cancer  it  exhibits  its  mutability  of  form  and  func- 
tion according  to  its  environment,  i.  e..  its  host,  but 
in  mv  belief  it  is  more  or  less  constant  in  the  same 
environment.  There  is  one  observation  which  I 
have  frequently  made  which  may  be  noted  here  as 
having  some  bearing  upon  what  I  have  quoted  from 
Orth.  It  has  not  infrequently  happened  in  exam- 
ining adenomatous  growths  of  the  mucous  mem- 
brane of  the  nose  in  their  initial  stages  that  I  have 
been  able  to  see  that  the  abnormal  cell  formation, 
whether  malignant  or  not,  was  springing  away  from 
the  surface  epithelium  in  the  form  of  acini  and  yet 
was  entirely  unconnected  with  neighboring  glands. 
In  view  of  the  fact  that  racemose  glands  are  gen- 
etically but  inversions  of  the  surface  epithelium  on 
mucous  surfaces,  we  note  here  that  in  the  patho- 
logical proliferation  there  is  a  betrayal  of  an  hered- 
ity toward  physiological  proliferation. 

In  the  expression  of  opinion  by  histologists  which 
I  have  cited  in  the  words  of  Orth  and  Lubarsch  there 

"Wright.  Recurring  Nasal  Papillomata,  The  Laryngoscope,  Feb- 
ruary, 1908. 

"Ceiilralblatt  fiir  ollgcmcine  Pathologic,  etc.,  June  15,  1908. 


is  a  sharp  contradiction  of  the  opinions  drawn  from 
the  experiments  on  animals.  Therefore  while  Apo- 
lant  and  Ehrlich  from  their  experimental  work  have 
been  influenced  to  declare  that  "the  virulence  of  a 
tumor  is  the  measure  of  its  histological  structure"' 
that  does  not  seem  in  man  to  be  true, — at  least  clin- 
ical experience  combined  with  histological  observ^a- 
tion  has  not  demonstrated  the  fact  with  sufficient 
accuracy  to  make  the  opinion  of  the  hislologist  as 
to  the  degree  of  malignancy  in  any  given  specimen 
of  any  great  value.  The  citations  I  have  made  are 
fair  indications  I  think  of  the  experience  of  prac- 
tical pathologists.  Apolant  and  Ehrlich,  however, 
seem  to  have  derived  their  experience  largely  from 
the  transmission  of  cancer  in  mice  from  one  indi- 
vidual to  another.  It  is  a  question  how  far  their 
conclusions  in  other  respects  may  be  applied  to  man 
where  one  cancer  stem  is  followed  only  through  one 
host. 

The  results  attained  in  the  immunization  of  mice, 
i.  e.,  about  fifty  per  cent,  of  the  mice  treated  with 
attenuated  carcinoma  showing  a  more  or  less  com- 
plete immunity  to  virulent  inoculations,  might  be 
urged  against  the  conception  of  the  growth  which  I 
have  here  discussed,  but  this  would  be  entirely 
erroneous.  Considering  it  a  mutation  in  cell  hered- 
ity places  it  in  fact  in  the  same  category  as  any 
other  foreign  protoplasm  to  whose  successful  strug- 
gle for  existence  in  the  organism  the  resisting 
powers  are  developed  in  the  same  way  as  to  bac- 
terial infection.  These  phenomena  of  the  reaction 
of  protoplasm  to  protoplasm  are  always  interesting, 
but  considering  their  profusion  and  the  small  num- 
ber which  have  thus  far  been  made  useful  in  human 
therapy,  the  results  thus  far  attained,  or  at  least 
published,  in  regard  to  cancer  immunity  are  not  very 
encouraging.  While  optimism  is  a  valuable  adjunct 
to  other  influences  in  the  raising  of  enthusiasm  in 
the  workers  as  in  the  raising  of  funds  for  cancer 
research  from  the  rich,  it  can  hardly  be  considered 
an  attribute  of  value  in  forming  a  scientific  opinion 
from  facts.  There  are  some  facts  elicited  which 
may  be  of  significance.  The  immunity  attained 
from  the  use  of  an  attenuated  cancer  of  the 
stomach  has  not  been  limited  to  an  im- 
munity against  stomach  cancer,  nor  to  that  against 
anv  specific  form  of  cancer,  but  it  is  an  immunity, 
such  as  it  is,  against  malignant  growths  in  general. 
In  other  words,  neither  the  growth  nor  the  local- 
ity in  the  host  seems  to  show  any  evidence  of 
specificity  in  regard  to  immunity.  Attenuated 
carcinoma  immunized  against  sarcoma  and  vice 
versa,  according  to  the  testimony  of  Ehrlich  and 
Apolant  and  other  workers.  They  found  marked 
evidence  of  a  great  difference  in  the  natural  and 
the  acquired  immunity  of  the  individual  mice,  as  al- 
ready noted.  The  influence  of  geographical  local- 
ity and  climate  was  affirmed  and  denied.  The  af- 
firmation of  it  is  supported,  as  is  well  known,  by  the 
statistics  of  the  geographical  incidence  of  cancer  in 
the  human  race.  .\s  may  be  gathered  from  what 
I  have  said,  it  is  too  early  to  attempt  to  reconcile 
all  the  various  facts  elicited  from  the  study  of  can- 
cer immunity  with  one  another  or  with  other  biolog- 
ical observations. 


May  29,  1909.] 


G I  LB  RIDE:  OPERATION  ON  STOMACH. 


In  bringin,^;  to  a  close  this  consideration  of  can- 
cer in  its  relationship  to  the  problems  of  heredity,  it 
may  be  urged  that  it  is  a  small  result  attained  at 
the  expense  of  so  many  words  to  have  placed  one 
mastery  alongside  of  another.  The  further  sug- 
gestion that  atomic  disintegration  may  play  an  im- 
portant part,  besides  its  vagueness  and  lack  of  con- 
vincing objective  support,  is  the  introduction  of  an- 
other mystery  half  revealed.  But  the  fact  that  in 
reality  all  these  things  are  more  or  less  shrouded 
in  the  mist  of  uncertainty  is  all  the  more  reason  for 
trying  to  trace  out,  by  means  of  a  few  dim  land- 
marks, where  the  one  ma  stery  merges  into  the 
others. 

44  \\'est  Forty-ninth  Street. 


INDICATIONS  FOR  OPERATIONS  ON  THE  STOM- 
ACH* 

By  John  J.  Gilbride.  A.  B.,  M.  D., 
Pliiladelphia, 

Instructor  in  Diseases  of  the  Stomach  and  Ir.testines,  Philadelpl'ii 
Polyclinic;  .Assistant  Demonsti ator  of  .\natomy  at  the 
Medico  Chirurgical  College. 

There  is  probably  no  field  in  major  surgery  in 
which  the  result  is  more  gratifying  than  in  opera- 
tions on  the  stomach  in  suitable  cases.  Taking  the 
number  of  patients  who  present  themselves  at  the 
stomach  clinic  of  a  hospital,  it  is  probable  that  not 
more  than  five  per  cent,  are  subjected  to  an  opera- 
tion. In  private  practice  in  which  most  of  the  pa- 
tients have  been  referred  the  percentage  of  operative 
cases  is  considerably  higher  because  nearly  all  of 
the  cases  have, resisted  the  treatment  ordinarilv  em- 
ployed for  dyspepsia. 

The  most  common  conditions  of  the  stomach  for 
Avhich  an  operation  is  performed  is  stenosis  of  the 
pylorus.  Benign  obstruction  at  the  pylorus  may 
be  divided  into  three  grades, — mild,  moderate,  and 
severe.  In  stenosis  of  a  mild  degree  there  is  found 
a  small  amount  of  gastric  contents  still  present  in 
the  stomach  seven  hours  after  a  full  meal.  Those 
patients  are  usually  amenable  to  medical  treatment 
and  they  get  along  fairly  well  so  long  as  they  adhere 
to  a  rigid  dietetic  regime.  In  patients  who  have 
a  moderate  grade  of  pyloric  stenosis  the  gastric  re- 
tention is  greater  than  in  those  of  the  first  class, 
but  when  the  stomach  is  washed  out  in  the  evening 
and  a  full  meal  eaten  the  stomach  will  be  found 
empty  the  following  morning.  A  few  of  these  pa- 
tients get  along  under  continuous  medical  treat- 
ment but  the  majority  of  them  sooner  or  later  need 
an  operation. 

In  stenosis  of  a  severe  form,  after  lavage  in  the 
evening  preceding  a  full  meal,  food  in  various 
amounts  will  still  be  found  in  the  stomach  the  next 
morning.  In  all  of  those  patients  an  operation  is 
demanded.  I  have  seen  a  few  patients  with  a  severe 
stenosis  of  the  pylorus  and  a  greatly  dilated  stom- 
ach, the  greater  curvature  of  which  extended  two 
or  three  inches  below  the  umbilicus,  and  the  gastric 
retention  amounted  up  to  three  or  four  quarts  which 
was  vomited  every  three  or  four  days,  go  along 
in    a    state    of    invalidism    losing    but    little  in 

*Read  before  the  Philadelphia  County  Medical  Society  on  Feb- 
ruary 24,  1909. 


weight  and  strength,  continuing  light  work  and  re- 
fusing operative  treatment.  These  instances  are, 
of  course,  the  exception,  and  all  of  these  patients 
should  be  operated  upon. 

Of  course,  the  primary  condition  such  as  gall- 
stone disease,  etc.,  which  may  be  the  cause  of  the 
obstruction  may  demand  an  operation  irrespective 
of  the  degree  of  stenosis.  Then,  again,  pain,  vomit- 
ing, loss  of  weight,  or  some  other  symptom,  may 
call  for  operative  interference.  The  retention  of 
gastric  atony  or  continuous  secretion  of  gastric 
juice  are  not  apt  to  be  confounded  with  the  reten- 
tion due  to  stenosis  of  the  pylorus. 

The  onset  of  symptoms  of  pyloric  stenosis,  with 
or  without  previous  stomach  disturbance,  in  persons 
over  thirty-five  years  of  age  should  receive  prompt 
surgical  attention.  I  have  seen  several  such  cases 
recently  in  which  there  were  no  symptoms  except 
the  age  of  the  patient  and  sudden  onset  of  symp- 
toms suggestive  of  the  presence  of  malignancy. 
The  symptoms  and  signs  in  those  cases  were  these 
of  benign  stenosis,  and  yet  the  patients  had  cancer 
of  the  pylorus. 

Cancer  of  the  stomach  is  strictlv  a  surgical  dis- 
ease when  it  is  recognized  sufficiently  early  to  per- 
mit of  an  operation.  A  relatively  early  diagnosis 
is  unfortunately  all  that  can  be  made  with  the  pres- 
ent methods  of  diagnosis.  The  best  that  can  be 
done  is  a  recognition  of  the  disease  at  a  time  when 
a  radical  operation  can  still  be  performed.  It  re- 
mains to  be  seen  whether  any  of  the  blood  serum 
tests  are  of  value  in  diagnosticating  this  disease. 

As  the  disease  occurs  most  frequently  at  the  py- 
lorus, the  first  symptoms  may  be  those  of  pyloric 
stenosis  occurring  in  a  person  thirty-five  years  of 
age  or  older.  Cancer  of  the  curvatures  or  of  the 
body  of  the  stomach  may  be  advanced  before  symp- 
toms appear.  The  growth  should  be  removed  when 
that  is  possible.  If  the  growth  cannot  be  extirpated 
and  stenosis  is  present  then  gastroenterostomy  is  in- 
dicated, for  this  latter  operation  does  prolong  life 
a  few  months  and  makes  existence  more  tolerable. 

In  certain  cases  of  extensive  cancerous  involve- 
ment of  the  stomach  a  jejunostomy  may  be  advis- 
able to  prevent  death  from  starvation.  A  gas- 
trostomy is  likewise  indicated  in  some  cases  of  can- 
cer of  the  cardia.  One  should  not  wait  to  estab- 
lish a  definite  diagnosis  of  cancer  before  recom- 
mending an  operation,  as  an  exploratory  operation 
is  demanded  if  one  has  a  definite  suspicion  of  the 
presence  of  malignant  disease  of  the  stomach.  Any 
operation  on  the  stomach  is  contraindicated  when 
metastasis  to  distant  parts  has  occured.  or  when  ad- 
vanced cachexia,  ascites,  etc.,  are  present. 

The  frequency  of  the  occurrence  of  cancer  on 
the  basis  of  gastric  ulcer  calls  for  more  aggressive 
treatment  of  chronic  ulcer  of  the  stomach.  The 
treatment  of  acute  gastric  ulcer  is  medical  unless 
some  accident  such  as  perforation  should  occur  or 
some  other  complication  should  develop.  Contin- 
ued bleeding  in  ulcer,  even  if  of  small  amount,  and 
repeated  hsemorrhages  demand  surgical  treatment, 
A  single  large  haemorrhage  is  best  treated  medically. 

In  chronic  ulcer  when  the  patient  fails  to  get  well 
after  a  reasonable  time  under  skillful  medical  treat- 
ment, or  when  there  are  relapses  of  symptoms  the 


1084 


HERZIG:  DACRYOCYSTITIS. 


[New  York 
Medical  Journal. 


patient  should  be  operated  upon.  Medical  treat- 
ment in  chronic  ulcer  of  the  stomach  frequently  ame- 
liorates the  symptoms  only  and  does  not  cure  the 
ulcer.  \Mien  an  operation  is  performed  for  chronic 
ulcer  I  believe  the  removal  of  the  ulcer  when  prac- 
ticable is  the  better  procedure.  This,  of  course,  will 
depend  upon  the  condition  of  the  patient  and  the 
skill  of  the  operator  as  well  as  the  conditions  which 
may  be  met  with  when  the  abdomen  is  opened. 

Duodenal  ulcer  which  occurs  most  commonly  in 
the  first  few  inches  of  the  duodenum  is  frequently 
difficult  and  sometimes  impossible  to  distinguish 
clinically  from  gastric  ulcer.  Its  recognition  is 
very  important  as  it  is  believed  to  be  a  more  serious 
disease  than  gastric  ulcer.  Moynihan  says  that  duo- 
denal ulcer  should  always  be  treated  by  operation. 

The  great  majority  of  cases  of  gastroptosis  can 
by  treated  by  mechanical,  dietetic,  and  medicinal 
measures.  An  operation  is  necessary  in  those  cases 
only  in  which  there  is  an  obstruction  due  to  a  kink 
or  other  cause.  Under  these  conditions  it  will  be 
necessary  to  elevate  the  stomach  and  remove  the 
kink,  perform  a  gastroenterostomy,  or  do  both 
operations.  In  some  cases  even  though  there  be 
no  obstruction  the  patients  do  not  improve  on  med- 
ical and  mechanical  treatment  and  those  patients 
too,  if  suitable  otherwise  should  be  operated  upon. 
Little  or  nothing  will  be  accomplished  by  operation 
if  the  abdominal  wall  is  such  as  to  give  no  support 
or  if  there  is  a  marked  splanchnoptosis. 

Gastroenterostomy  has  been  performed  in  some 
cases  of  refractive  hyperchlorhydria.  However, 
there  are  few  cases  of  uncomplicated  hyperchlor- 
hydria that  one  will  subject  to  operation.  These  pa- 
tients should  be  put  on  an  itlcer  cure. 

Some  cases  of  atonic  dilatation  of  the  stomach 
in  which  gastroplication  was  performed  with  ben- 
eficial results  have  been  reported.  However,  gas- 
tric atony,  hyperchlorhydria,  and  other  neuroses 
are,  as  a  rule,  not  suitable  cases  for  operation. 
Hourglass  contraction  of  the  stomach  unless  it  is 
due  to  advanced  cancer,  calls  for  a  gastrogas- 
trostomy,  gastroenterostomy  with  the  several 
pouches,  or  a  resection.  Hourglass  stomach  is  diag- 
nosticated bv  the  irregular  outline  of  the  stomach, 
by  the  presence  of  food  in  the  stomach  when  the 
stomach  is  thought  to  be  empty  after  the  use  of  the 
stomach  tube,  and  by  the  Rontgen  ray,  etc. 

Adhesions  which  cripple  the  functions  of  the 
stomach  or  when  they  produce  other  severe  symp- 
toms, such  as  pain,  dragging  sensations,  etc.,  should 
be  subjected  to  operation.  Benign  tumors  of  the 
stomach,  although  they  are  not  common,  should  be 
resected,  (iastrntomv  is  occasionally  necesary  for 
the  removal  of  foreign  bodies  such  as  large  masses 
of  hair,  etc.,  from  the  stomach. 

-Acute  dilatation  of  the  stomach  is  a  very  severe 
disease  and  if  not  relieved  by  lavage,  etc.,  an  opera- 
tion may  be  urgently  demanded.  Those  patients  with 
congenital  stenosis  of  the  pylorus  that  get  better 
under  medical  treatment  have  stenosis  of  a  mild 
grade.  If  the  stenosis  is  at  all  marked  an  opera- 
tion .should  be  performed  without  delay. 

Hernia  of  the  linea  alba  is  occasionally  met  with, 
and  if  it  interferes  with  the  motility  of  the  stomach 
it  may  be  necessary  to  operate  for  its  relief  if  a 


suitable  belt  does  not  give  the  desired  benefit.  These 
hernijE  occur  in  the  median  line  and  may  be  single 
or  multiple.  They  vary  in  size  from  being  so  small 
as  to  be  only  seen  or  felt,  up  to  the  size  of  the  end  of 
one's  thumb  or  even  larger.  They  are  brought  out 
more  distinctly  by  having  the  patient  raise  his  or 
her  head  while  lying  down  and  are  due  to  a  defect 
in  the  muscular  aponeurosis.  Other  conditions  such 
as  subphrenic  abscess,  etc.,  that  may  be  caused  by 
stomach  disease  may  call  for  operative  intervention. 
Exploratory  laparotomy  has  its  indications  in  ob- 
scure stomach  symptoms  which  fail  to  respond  to 
skilled  treatment,  but  as  a  short  cut  to  diagnosis 
it  should  not  be  employed. 
1934  Chestnut  Street. 


DACRYOCYSTITIS. 
By  .\.  J.  Herzig,  M.  D., 
New  York, 

Adjunct  Rhinologist  and  Otologist,  Sydenham  Hospital;  Surgeon  in 
Chief,  Eye  Department,  Beth  Israel  Hospital. 

Dacryocystitis  is  divided  into  two  forms,  catarrhal 
and  purulent.  The  latter  being  subdivided  into 
acute  .and  chronic. 

Before  describing  the  course  and  treatment  of 
dacryocystitis,  the  author  will  devote  a  few  lines  to 
the  anatomy  and  physiology  of  the  lacrymal  organs, 
which  consist  of  the  lacrymal  gland  and  lacrymal 
passages.  The  lacrymal  gland  is  an  acinous  gland 
and  consists  of  two  portions ;  a  larger  or  superior 
gland  and  a  smaller  or  inferior,  or  as  it  is  sometimes 
called,  the  accessory  gland.  The  excretory  ducts  of 
the  first  or  larger  gland  pass  downward  to  empty 
into  the  superior  fornix  conjunctivae.  The  second 
division  of  the  gland,  namely,  the  accessory  portion, 
as  it  is  most  commonly  called,  is  much  smaller  an  1 
consists  of  two  lobules,  its  lobules  lying  along  the 
excretory  ducts  of  the  superior  gland.  The  lac- 
rymal passages  consist  of  the  lacrymal  duct  and 
two  canaliculi.  The  duct  consists  of  a  body  which 
ends  in  the  nose  under  the  middle  half  of  the  infe- 
rior turbinal  body,  and  the  upper  end  terminates  in 
a  neck,  which  later  dilates  in  its  upper  portion  and 
forms  the  sac.  The  two  canaliculi  run  respectively 
from  the  upper  and  lower  puncta^  and  empty  into  the 
sac.  The  lacrymal  sac  lies  in  the  cleft  which  the 
lacrymal  bone  forms  for  its  reception.  The  sac  is 
bounded  on  the  inside  by  the  lacrymal  bone,  on  the 
outer  side  it  is  enclosed  by  the  ligamentum  palpeb'-a? 
mediale.  The  lacrymal  crest  is  above  and  to  the 
Jnner  side  of  the  sac,  and  is  the  most  important  laml- 
mark  in  all  operations  on  the  sac  and  duct.  In  its 
downward  course  the  lacrymal  duct  passes  from  its 
vertical  position  backward  and  downward  in  its  pas- 
sage to  the  nose.  That  portion  of  the  .<;ac  which  lies 
upon  the  lacrymal  bone  is  alone  distended  in  in- 
flammations and  accunnilated  secretions.  This  is 
impossible  in  the  duct  which  is  deeply  incised  in  p 
bonv  wall.  The  canaliculi,  sac.  and  duct  are  lined 
with  a  mucous  membrane  and  supplied  by  a  plexus 
of  veins  from  the  nose,  namely,  those  of  the  inferior 
turbinal  body.  The  neck  of  the  organ,  the  duct,  and 
the  two  canaliculi,  especially  near  the  puncti,  nre 


May  29.  1909.] 


HERZIG:  DACRYOCYSTITIS. 


most  often  subject  to  stricture  formation.  The  sac 
proper  is  hardlv  ever  strictured,  except  at  its  orifice 
and  exit,  though  it  is  frequently  attacked  in  kipus, 
etc.  The  lacrymal  passages  are  always  filled  with 
a  small  quantity  of  mucuslike  secretion.  The  lac- 
rymal secretion  contains  a  few  salty  constituents, 
e.  g..  sodium  chloride,  hence  we  have  salty  tears. 
The  secretion  of  the  lacrymal  glands  is  absorbed 
by  the  duct  normally,  and  should  not  cause  an  over- 
flow cf  tears.  The  glands  of  the  conjunctiv.-e  keep 
the  eveball  moist,  as  is  shown  in  the  pathological 
condition,  where  the  lacrymal  sac.  ducts,  and  glands 
have  been  resected.  The  cessation  of  tears  usually 
takes  place  several  weeks  after  the  removal  of  the 
duct  and  sac ;  this  occurring  reflexly.  This  latter 
condition  will  be  described  later  on.  The  method  of 
the  conveyance  of  tears  is  our  next  considera- 
tion. This  is  performed  by  the  act  of  wanking,  and 
the  conveyance  through  the  duct  is  by  gravitation, 
and  also  by  the  fresh  charge  of  tears  constantly  go- 
ing on  from  time  to  time.  The  distention  of  the  sac 
by  means  of  its  elasticity  also  helps  the  discharge 
of  tears  through  the  nose.  Hence  in  diseased  con- 
ditions of  the  sac,  this  elasticity  is  lost  and  the  sac 
does  not  discharge  its  contents  and  remains  full, 
thus  causing  an  overflow  of  tears.  The  mucous 
membrane  of  the  canaliculi  is  lined  with  laminated 
epithelium,  while  that  of  the  duct  and  sac  are  lined 
with  a  single  laver  of  cylindrical  epithelium.  The 
mucous  membrane  lining  the  sac  and  duct  sometimes 
contains  acinous  glands.  The  mucous  membrane  of 
the  duct  and  sac  contains  folds,  the  largest  of  which 
is  situated  at  the  lower  end  of  the  nasal  end  of  the 
duct  and  is  callecF  Hasmer's  valve. 

C.\TARRHAL  DACRYOCYSTITIS,  OR,  AS  IT  IS  MORE  COM- 
MONLY  CALLED,   liLENNORRHCEA  OF  THE 
LACRYMAL  SAC. 

/Etiology. — The  immediate  cause  of  catarrhal  in- 
flammation of  the  lacrymal  sac  is  due  to  a  stricture 
or  closure  at  the  nasal  end  of  the  duct.  This  may  be 
caused,  firstly,  my  acute  inflammations  of  the  tur- 
binal  body,  or  congestion  :  secondly,  by  specific  or 
other  ulcers ;  and  thirdly,  by  a  tumor  blocking  up 
the  nasal  end  of  the  duct.  The  contents  of  the  sac 
are  not  permitted  to  escape  and  hence  readily  de- 
compose. The  contents  of  the  sac  are  now  mixed 
with  pus  cocci  and  irritate  the  lining  of  the  sac,  so 
that  exfoliation  of  the  mucous  membrane  takes  place, 
causing  the  otherwise  normal  mucous  secretion  to 
become  flaky  and  even  purulent.  The  secretion  leav- 
ing the  canaliculi  as  its  exit,  the  nasal  end  of  the 
duct  being  closed,  iritates  the  cornea  and  may  cause 
ulcus  serpens,  which  is  due  to  the  fact  that  the  secre- 
tion contains  pus  cocci. 

Sxuiptoiiis. — The  patient  usuall\-  complains  of  an 
overflow  of  tears  (epiphora).  Later  on,  of  a  bulg- 
ing in  the  region  of  the  sac,  which  annoys  the  pa- 
tient considerablv.  and  when  comoressed,  gives  of¥ 
a  glairy  mucous  fluid,  which  is  sticky  and  mixed  w'ith 
flakes  of  debris.  Oftentimes  a  mucopurulent  secre- 
tion is  present.  When  exerting  pressure  upon  the 
mass,  the  fluid  is  usually  passed  from  the  canaliculi, 
but  som.etimes  makes  its  exit  into  the  nose.  The 
best  way  to  compress  the  bulging  sac  is  from  below 
upward,  thus  practically  closing  off  the  nasal  exit. 


.Associated  with  this  condition  we  often  find  stric- 
tures in  the  lacrymal  passages,  which  are  usually 
demonstrated  by  the  passing  of  prooes. 

Co i//'j-e.— Spontaneous  cures  are  rare.  If  the  in- 
flammation of  the  mucous  membrane  in  the  nose 
abates,  so  that  the  closure  of  the  nasal  end  of  the 
duct  is  relieved,  the  sac  will  empty  itself  and  a  cure 
result.  The  rule  is,  that  tmless  artificial  means  are 
taken  to  cure  the  disease,  it  usually  becomes  chronic, 
and  is  very  difficult  to  cure.  In  its  chronic  form  the 
secretion  usually  becomes  purulent  in  the  later 
stages,  so  that  the  treatment  and  symptoms  of 
chronic  dacryocystitis  will  be  taken  up  in  the  head- 
ing of  chronic  purulent  dacryocystitis. 

Blennorrhoea  of  the  sac  may  also  take  the  follow- 
ing course,  namely,  the  duct  may  disttnd,  until  it  is 
the  size  of  a  small  walnut.  This  enlargement  may 
take  place  anteriorly,  or  the  sac  may  distend  in  the 
direction  of  the  orbit,  thus  causing  exophthalmus. 
In  extreme  distention,  atrophy  of  the  mucous  mem- 
brane takes  place  (atonia  sacci  lacrimalis)  and  the 
secretion  is  not  mucous  any  more,  because  the  glands 
have  been  destroyed  by  pressure.  The  secretion 
consists  of  a  salty  fluid,  namelv  tears.  These,  on 
account  of  the  loss  of  propulsion  of  the  atrophied 
sac,  remain,  and  increase  the  size  of  the  tumor.  This 
condition  is  known  as  hydrops  sacci  lacrimalis.  The 
main  annoying  feature  in  catarrhal  dacryocystitis  is 
the  epiphora,  which  causes  the  patient  to  be  con- 
stantly dr}ing  his  eyes.  In  the  later  stages,  when 
the  disease  becomes  chronic,  the  mucopurulent  se- 
cretion may  cause  an  ulcer  of  the  cornea,  irritation 
of  the  skin,  and  finally  ectropion.  It  is  unwise  to 
perform  any  operation  upon  the  eyeball  or  even  an- 
ne.xa  while  this  process  is  going  on,  for  fear  of  in- 
fection. It  is  well,  before  doing  a  cataract  extrac- 
tion or  any  operation  upon  the  eyeball,  to  cure  the 
dacryocystitis  first,  or  if  this  is  not  possible,  to  enu- 
cleate the  sac  or  duct. 

Treatment. — First.  Treat  any  coexisting  nasal 
condition,  in  view  of  relieving  the  nasal  obstruction 
to  the  duct. 

Secondly.  Have  the  patient  express  the  secretion 
several  times  daily.  Astringents,  e.  g.,  zinc,  etc., 
should  be  used  at  home. 

Thirdly.  The  office  treatment  consists  in  express- 
ing all  secretions  from  the  duct,  and  then  with  a 
small  lacrymal  syringe,  cleanse  the  sac  out  first 
with  some  cleansing  solution,  such  as  sterile  w-ater, 
or  a  very  much  diluted  Thiersch's  solution  ;  follow- 
ing this  by  an  injection  of  a  one  per  cent,  silver  ni- 
trate solution.  The  author  makes  it  a  rule  to  first 
inject  a  two  percent,  solution  of  cocaine  into  the  duct 
before  syringing  it  with  silver.  In  addition  to  this 
treatment,  the  lower  canaliculus  is  probed  at  first 
daily,  and  later  at  less  frequent  intervals.  If  the 
author  can  introduce  a  number  four  catheter  with- 
out difficulty  in  subsequent  trials,  he  feels  that  the 
canalicula  are  normal  in  patency.  Under  no  condi- 
tion does  the  author  slit  the  canaliculus,  as  in  his 
experience  it  is  worse  than  useless,  as  strictures 
form  and  one  has  to  keep  catheterizing  the  duct  for 
life.  If  anything  radical  has  to  be  done  he  prefers 
complete  enucleation  of  the  sac.  This  will  be  de- 
scribed later,  in  the  treatment  of  chronic  dacrvo:vs- 
titis. 


Io86  ■  HERZIG:  DACRYOCYSTITIS. 


ACUTE  DACRYOCYSTITIS. 

The  aetiology  is  the  same  as  for  catarrhal  dacryo- 
cystitis, except  that  the  inflammation  is  a  phlegmon 
and  involves  the  tissues  surrounding  the  lachrymal 
sac,  beside  the  walls  of  the  sac  itself.  The  symp- 
toms are  exagerated  and  take  the  form  one  sees  in 
any  acute  inflammation.  An  abscess  forms  around 
the  lacrymal  sac,  causing  the  characteristic  picture 
of  swellmg,  redness,  pain.  heat,  and  tenderness.  Be- 
sides this,  we  have  extreme  lacrymation  and  oede- 
ma of  the  eyelids.  This  phlegmon  may  remain  dis- 
tended and  increase  in  size  and  finally  cause  a  gen- 
eral toxaemia,  unless  surgical  intervention  takes 
place ;  or  it  may  open  spontaneously  through  the 
skin,  in  the  latter  instance  leaving  a  fistula.  In  the 
purulent  form,  we  also  have  the  catarrhal  foma 
present.  As  long  as  the  fistula  remains  open,  there 
is  no  danger  from  recurrence  of  the  phlegmon  ;  but 
if  the  fistula  closes  up  it  is  apt  to  recur. 

Treatment. — ^Treatment  is  as  follows.  In  case 
one  is  unable  to  prevent  the  formation  of  the  ab- 
scess, it  is  the  physician's  duty  to  bring  the  abscess 
to  a  speedy  termination  by  making  an  artificial 
opening.  The  author  makes  a  large  incision, 
curettes  the  abscess  cavity,  and  then  drains  it  with 
sterile  iodoform  gauze.  The  author  makes  it  a  rule 
to  touch  the  inside  of  the  sac  with  a  ten  per  cent, 
.solution  of  silver  nitrate^  this  being  done  daily  at 
first,  later  at  less  frequent  intervals.  Otherwise, 
the  abscess  is  treated  the  same  as  any  other  phleg- 
mon. It  is  bad  to  incise  the  abscess  before  fluctua- 
tion has  taken  place.  Later  on,  the  duct  should  be 
catheterized  to  relieve  any  stricture  that  may  be 
present.  If  the  acute  condition  recurs  or  a  fistula 
remains,  the  condition  gradually  passes  into  the 
chronic  stage,  which  I  shall  now  describe. 

CHRONIC  DACRYOCYSTITIS. 

This  may  be  the  result  of  a  chronic  catarrhal  in- 
flammation or  of  a  fistula  or  of  repeated  attacks  of 
the  acute  form.  The  symptoms  are  those  of 
lacrymation  with  all  the  symptoms  of  the  acute 
form,  but  less  severe  in  character.  The  secretion 
which  can  be  expressed  is  generally  mucopurulent. 

Treatment.— The  treatment  of  this  condition  is 
medical  and  surgical.  The  medical  treatment  con- 
sists of  gradually  dilating  any  strictures  that  may 
be  present  and  syringing  the  sac  first ;  with  a  cleans- 
ing solution,  and  then  with  a  one  per  cent,  solution 
of  silver  nitrate  daily,  and  later  on  at  less  frequent 
intervals.'  The  home  treatment  for  these  cases  con- 
sists in  giving  the  patient  an  astringent  eyewash 
and  having  the  patient  express  the  secretion  from 
the  duct  as  fast  as  it  accumulates.  If  this  does  not 
result  in  an  improvement  within  a  reasonable  time, 
that  is  to  say  twenty  treatments,  which  extend  over 
a  period  of  two  to  three  months,  the  author  advises 
complete  enucleation  of  the  sac.  It  is  wrong  to 
advise  enucleation  at  first,  as  there  are  a  great  many 
of  these  chronic  cases  that  can  be  cured  by  this 
treatment. 

I'efore  going  into  the  surgical  treatment  of  this 
condition  and  that  of  the  lacrymal  gland,  the  au- 
thor wishes  to  tabulate  a  few  records  from  one  hun- 
dred cases  of  his  experience.  In  one  hundred  cases 
collected,  thirty-six  were  acute  and  sixty-four 
chronic.    Seventy-two  were  in  females  and  twenty- 


[New  York 
Medical  Journal. 


eight  in  males.    The  oldest  patient  was  eighty-two 


years  of  age,  and  the  youngest,  two  years  and  four 
months. 

Years  of  age :  Number  of  cases: 

I  to  TO   I 

TO  to  20   5 

20  to  30   10 

30  to  40  ■   20 

40  to  50   28 

50  to  60   18 

60  to  70   13 

70  to  80   4 

80  to  90   I 

By  this  table  the  disease  is  shown  to  be  most 

prevalent  from  the  ages  of  twenty  to  sixty.  The 

preponderance  of  females,  seventy-two  cases  to 
males  twenty-eight  cases. 

Microorganisms.  Cases. 

Staphylococcus,    32 

Streptococcus,    18 

Gonococcus,    14 

Pneumococcijs,    8 

Gonococcus  and  pneumococcus,   i 

Pneuniococcus  and  staphylococcus,   9 

Pneumococcus  and  streptococcus,   i 

Gonococcus  and  staphylococcus   8 

Gonococcus  and  streptococcus,   3 

Staphylococcus  and  streptococcus,   6 

The    most  common  organism    found   was  the- 


staphylococcus,  next  was  the  streptococcus,  and 
thirdly  the  gonococcus. 

Note:  The  duration  of  the  acitte  cases,  of  which 
there  were  thirty-six,  was  as  follows: 

24  cases,   4  to  8  days. 

8  cases   8  to  12  days. 

4  cases  12  to  20  days. 

Of  the  chronic  cases: 

52  cases  lasted  i  to  12  years. 
6  cases  lasted  2  to  10  years. 
6  cases  lasted  10  to  20  years. 

Fistulas  were  found  in  nine  cases,  strictures  in 
all  cases. 

The  indirect  and  direct  causes  of  dacryocystitis  in 


these  hundred  cases  were  as  follows : 

Chronic  hypertrophic  rhinitis  in   36  cases. 

Tumors  (sarcoma  of  the  antrum  of  Highmore) 

in    I  case 

Gonorrhoeal  ophthalmia  in    4  cases. 

Traumatism  m    4  cases. 

Other  causes  not  known  in   55  cases. 


It  may  be  interesting  to  note  that  complicating 
these  hundred  cases : 

Catarrhal  conjunctivitis  was  present  in  16  cases. 
Granular  conjunctivitis  (large  lymphoid)  in 
forty-eight  cases.  Trachoma,  of  which  there  were 
thirty-six  cases,  and  of  these  four  were  in  the  in- 
cipient stage,  twenty  in  the  hypertrophic  stage,  and 
twelve  in  the  tertiary  stage  (or  stage  of  scar  forma- 


tion). 

Hordeolum  was  present  in    3  cases. 

Mcil)omian  cyst  was  present  in   i  case. 

Cataract  was  present,  in  one  eye  in   12  cases. 

Cataract  was  present  in  both  eyes  in   3  cases. 

Iritis  (gonorrhoeal)  was  present  in   3  cases. 

Iridocxclitis  was  present  in   i  case. 

Entropion  was  present  in   14  cases. 

Ectropion  was  present  in   4  cases. 

Episcleritis  was  present  in   i  case. 

Optic  nerve  atrophy  was  present  in   2  cases. 

Old  chorioiditis  was  present  in   8  cases. 


These  secretions  were  neutral  in  si.xty-eight 
cases,  alkaline  in  thirty-one  cases,  and  acid  in  one 
case  (the  old  man,  eighty-two  years  old). 


May  29,  1909.] 


MACWHINNIE:  DIGITAL  ENUCLEATION  OF  TONSILS. 


Only  eight  urines  were  examined  of  the  chronic 
■cases,  only  one  patient  having  a  slight  trace  of  albu- 
min. Of  the  sixty-four  chronic  cases,  forty-eight 
patients  had  their  canaliculi  slit  by  other  oculists 
and  in  sixteen  not.  Of  the  forty-eight  cases  before 
mentioned,  I  had  to  remove  the  sac  in  twelve  cases. 

Surgical  treatment  in  acute  cases  consists  of  in- 
cision and  drainage.  This  was  done  in  all  except 
nine  patients,  who  had  responded  to  other  meas- 
ures. ,  Of  the  forty-eight  patients  operated  upon 
previously  by  other  physicians  (by  slitting  the  up- 
per canaliculus),  nine  had  fistulae.  These  nine  pa- 
tients were  among  the  twelve  cases  in  which  the 
author  enucleated  the  sac.  Fifty-two  patients  of 
the  chronic  cases  were  cured  by  treatment  alone, 
the  treatment  varying  from  four  months  to  two 
years.  In  none  of  these  cases  was  it  found  neces- 
sary to  slit  the  canaliculi,  as  the  latter  were  fully 
dilated  by  careful  and  regular  catheterizing.  The 
accessory  lacrymal  gland  was  removed  in  two 
cases  for  excessive  lacrymal  secretion,  after  a 
thorough  removal  of  the  sac  and  duct.  Here  the 
author  wishes  to  describe  the  operation  which  he 
pursues  in  the  removal  of  the  lacrymal  sac  and 
duct. 

Enucleation  of  the  sac  and  duct. — Before  oper- 
ating it  is  necessary  to  understand  the  landmarks 
of  the  sac  and  duct.  By  placing  the  finger  against 
the  outer  canthus  and  stretching  the  lids  outward, 
the  internal  palpebral  ligament  is  seen  as  a  promi- 
nent cord  underneath  the  skin.  The  lachrymal  sac 
lies  directly  behind  this  ligament  (tendo  oculi)  and 
the  top  of  the  sac  corresponds  with  the  edge  of  the 
ligament  or  sometimes  extends  above  it,  that  is, 
underneath  the  ligament.  The  next  step  for  us  to 
consider  is  the  anterior  lacrymal  crest,  which  is 
usually  found  at  the  inner  and  lower  angle  of  the 
eye.  The  preparation  of  the  duct  and  sac  before  the 
operating  is  the  same  as  for  any  surgical  procedure. 
The  duct  is  thoroughly  squeezed  out,  so  that  no 
more  secretion  can  be  expressed,  then  a  four  per 
cent,  solution  of  cocaine  is  dropped  into  the  eye 
and  ten  minims  of  a  two  per  cent,  solution  of  co- 
caine is  injected  into  the  sac.  A  one  half  per  cent, 
solution  of  cocaine,  with  ten  drops  of  a  i  in  2,000 
solution  of  adrenalin  chloride  is  injected  around 
the  operative  area.  Anaesthesia  takes  place  almost 
immediately,  although  it  is  wise  to  wait  five  minutes 
before  proceeding  with  the  operation.  A  number 
2  lacrymal  catheter  is  then  passed  into  the  sac  and 
left  there.  The  incision  starts  one  quarter  inch 
above  the  internal  palpebral  ligament  and  one 
quarter  inch  to  the  inner  side  of  the  inner  canthus, 
and  should  run  downward,  and  is  curved  outward. 
The  length  of  the  incision  varies  with  dififerent  op- 
erators. The  incision  should  only  go  through  the 
skin.  After  the  latter  has  been  dissected  free  and 
lield  by  two  sharp  pointed  retractors,  the  underlying 
fascia  is  divided.  2  The  orbicularis  muscle  and  the 
deep  fascia  is  then  divided  until  the  sac  is  seen.  It 
is  often  impossible  to  dissect  these  structures  sepa- 
rately and  they  may  be  laid  open  with  one  single 
sweep  of  the  knife.  All  haemorrhages  must  be 
stopped  by  ligation  or  pressure  before  the  operation 
can  proceed,  the  most  annoying  instance  being  the 
cutting  of  the  internal  angular  vein  with  the  pri- 
mary incision.     The  duct  with  the  probe  in  it,  is 


then  caught  up  with  an  iris  hook,  slightly  with- 
drawn, and  the  nasal  attachment  is  severed  first, 
then  the  duct  is  separated  from  its  underlying  at- 
tachments, the  probe  being  gradually  withdrawn  as 
the  dissection  takes  place  until  the  sac  is  reached ; 
when  the  cut  end  of  the  duct  is  grasped  with  a 
small  artery  clamp  and  the  sac  and  the  canalicular 
attachments  dissected  out  and  separated.  The 
wound  is  then  closed  with  three  or  four  black  silk 
sutures,  after  thoroujjhly  curetting  the  operative 
cavity.    A  wet  dressing  is  then  applied. 

The  latter  part  of  the  operation,  that  of  passing 
the  probe  in  the  duct  before  operation  and  also  dis- 
secting the  lower  part  of  the  sac  first,  the  author 
believes  is  original  with  him  and  would  be  greatly 
indebted  to  any  physician  giving  him  further  in- 
formation as  to  its  origin,  whether  or  not,  it  is 
original  with  the  author. 

Note :  Ordinarily  the  secretion  of  tears  will  stop 
reflexly,  within  six  to  eight  weeks.  Should  the  se- 
cretion continue  over  three  months,  the  author  ad- 
vises the  removal  of  the  accessory  lacrymal  gland : 
the  removal  of  which  stops  an)-  further  lacryma- 
tion.  The  sutures  can  be  removed  on  the  fifth  day, 
providing  there  is  no  infection,  in  which  case  they 
should  be  removed  before  and  the  wound  properly 
cared  for. 

Co.NCLUSIO.\. 

In  conclusion  the  author  wishes  to  emphasize. 

Firstly,  the  importance  of  treating  all  cases  of 
chronic  dacryocystitis  thoroughlv,  before  resorting 
to  surgical  procedure. 

Secondly,  should  this  treatment  fail  within  a  rea- 
sonable time^  then  a  thorough  enucleation  of  the 
sac  should  be  done. 

Thirdly,  the  advantage  of  removing  the  lower  end 
of  the  duct  first,  and  the  introduction  of  a  probe  to 
guide  the  operator. 

Fourthly,  condemning  the  useless  procedure  of 
slitting  the  canaliculus. 

2040  Seventh  Avenue. 


DIGITAL  ENUCLEATION  OF  THE  FAUCIAL 
TONSILS.* 

By  a.  Morgan  MacWhi.vnie,  M.  D., 
Seattle,  Washington. 

Radical  methods  of  treating  diseased  faucial  ton- 
sils are  numerous.  Every  few  months  some  new 
procedure  is  brought  forth  which  is  evidence  that 
the  methods  already  described  are  not  acceptable  in 
other  hands  than  those  of  the  originator.  The  ma- 
jority of  specialists  believe  in  total  extirpation  and 
whenever  they  can  the  capsule  is  included.  The 
large  amount  of  bleeding  obscures  the  field  and 
the  danger  of  tracheal  insufflation  adds  to  the  fear 
of  alarming  hiemorrhage.  A  timid  operator  or  one 
who  is  not  ready  for  any  emergency  should  never 
do  a  radical  procedure  on  the  tonsil.  Thorough, 
knowledge  of  the  anatomy  of  the  tonsil  and  its 
surrounding  relations  will  result  in  overcoming  of 
this  timidity,  which  is  the  cause  of  so  many  ampu- 
tations and  simple  punching  of  tonsil  tissue.  One 
operator  has  remarked  that  he  "removes  all  the  dis- 

*.\bridged  from  a  paper  read  before  the  King  County  Jledical 
Society,  September  21,  1908. 


io88 


MACWHINNIE:  DIGITAL  ENUCLEATION  OF  TONSILS. 


[New 
Medical 


York 
Journal. 


eased  tonsil  that  is  necessary"  but  he  fails  to  state 
where  this  dividing  line  takes  place. 

In  common  with  some  of  the  other  operators,  my 
method  is  one  of  total  extirpation  in  the  capsule 
which  prevents  ninety  per  cent,  of  peritonsillar  ab- 
scess and  ei^ht  per  cent,  of  tonsillar  tuberculosis, 
as  well  as  recurrent  hypertrophy,  submerged 
stumps,  and  the  attendant  evils  thereof.  To  me,  the 
four  cardinal  points  of  any  operative  procedure  are : 
I,  simplicity;  2,  rapidity;  3,  safety;  and  4,  thor- 
oughness. The  method  that  has  served  me  well  in 
extirpating  the  tonsil  in  its  capsule  consists  in  the 
use  of  my  index  finger  and  nail — a  separation  pro- 
cess. I  administer  ether  for  two  reasons:  i,  per- 
fect control  is  obtained  over  the  patient ;  2,  the 
consensus  of  opinion  is  against  the  use  of  chloro- 
form in  the  lymphatic  diathesis.  As  we  are  deal- 
ing strictly  with  lymphatics  in  both  adenoid  and 
tonsil  operations,  under  no  consideration  should  we 
give  chloroform.  The  use  of  a  local  anjesthetic  does 
not  seem  justifiable  from  the  fact  that  there  is  more 
or  less  fear  connected  with  any  operation.  It  is  not 
possible  to  stop  all  the  pain.  The  retching  and 
gagging  that  take  place  prevent  accurate  work 
around  the  capsule,  and  the  possible  injury  to  the 
surrounding  structures  is  greatly  increased  by  the 
movements  of  the  patient. 

In  the  pursuance  of  any  radical  measure  general 
anaesthesia  is  essential,  tranquillity  of  the  patient  be- 
ing one  of  the  requisites.  In  a  large  percentage  of 
cases  there  is  adenoid  tissue  to  be  removed  which 
may  be  accomplished  at  the  same  time,  rather  than 
to  use  a  dry  scrape,  which  is,  to  me,  always  doubt- 
ful as  to  its  being  thorough.  In  using  the  finger 
the  danger  of  wounding  the  pillars  and  the  superior 
constrictor  is  reduced  to  a  minimum  as  no  sharp 
instruments  are  used.  The  finger  serves  for  a  guide 
as  no  other  instrument  can  possibly  do.  All  forms 
and  kinds  of  tonsils,  regardless  of  size,  may  be  re- 
moved with  very  little  loss  of  blood  in  their  cap- 
sules, providing  there  are  no  adhesions,  in  a  frac- 
tion of  the  time  that  is  ordinarily  taken  by  the  use 
of  instruments.  Since  using  this  method  I  -have  not 
had  occasion  to  m.ake  use  of  a  hjemostat  to  tie, 
or  to  pack  the  pillars. 

A  separation  process  must  of  necessity  cause  less 
loss  of  blood  than  a  cutting  of  the  same  tissue, 
the  finger  giving  immediate  warning  of  anomalous 
vessels.  Anatomists  tell  us  that  the  tonsillar  artery 
sometimes  fails  to  divide  until  after  it  passes 
through  the  superior  constrictor  muscle,  dividing  as 
it  reaches  the  capsule  of  the  tonsil.  In  such  cases 
one  should  avoid  injury  to  this  muscle,  for  the 
haemorrhage  that  might  ensue  would  be  considerable. 

In  the  fibrous  as  well  as  the  soft  and  the  sub- 
merged forms,  this  method  has  been  applied  with 
success.  The  point  of  importance  that  should  be 
remembered  is  to  begin  the  procedure  outside  of 
the  capsule,  in  the  posterior  inferior  portion  of  the 
sinus,  working  up  to  the  supratonsillar  fossa.  The 
finger  is  then  brought  to  the  posterior  inferior  por- 
tion of  the  sinus,  working  up  to  the  supratonsillar 
fossa.  The  finger  is  then  brought  to  the  original 
starting  point  and  the  same  procedure  is  carried 
out,  posterior  to  the  anterior  pillar,  into  the  supra- 
tonsillar fossa  to  meet  the  first  dissection  ;  the  finger 
is  then  carried  to  the  original  starting  point,  and 
bv  working  forward,  the  thumb  being  on  the  an- 


terior surface  of  the  tonsil  the  enucleation  is  com- 
pleted, the  gland  coming  away  in  its  capsule.  At 
this  point  do  not  try  to  pull  the  tonsil,  for  if  you 
do  some  of  the  superior  constrictor  may  come  as 
well  and  hjemorrhage  result.  When  starting  the 
procedure,  be  sure  that  you  start  on  the  outside  of 
the  capsule ;  there  is  almost  no  danger  that  you  will 
get  inside  of  it,  for  if  you  do,  it  is  manifest  that 
the  work  would  be  incomplete. 

The  capsule  being  of  a  fibrous  nature,  it  is  al- 
most impossible  to  rupture  it  except  by  unneces- 
sary and  imdue  force.  The  amount  of  blood  lost 
is  small  compared  with  some  of  the  cutting  meth- 
ods. As  a  rule,  if  the  procedure  has  been  thorough, 
the  bleeding  stops  almost  instantaneously  on  re- 
moval of  the  gland ;  examination  of  the  removed 
gland  will  establish  this  fact.  The  loss  of  blood  is 
a  factor  in  any  case,  for  severe  anaemia  occasionally 
occurs  from  cutting  operations,  following  the  loss  of 
blood.  Naturally  you  will  ask  what  amoimt  of  re- 
action follows.  It  is  so  small  that  it  requires  no 
consideration,  and  I  have  yet  to  see  the  case  in 
which  the  temperature  exceeded  99.5°  F. 

During  the  preparation  of  this  paper  I  removed 
a  submerged  stump,  the  tonsil  having  been  ampu- 
tated three  times  previously,  and  in  twenty-four 
hours  the  patient  was  eating  hard  food.  I  certainly 
do  not  advise  this  to  my  patients,  but  it  occurs  every 
now  and  then  and  is  a  criterion  of  the  amount  of 
traumatism  that  takes  place.  In  this  case  there  was  a 
state  of  subacute  inflammation,  which,  according  to 
the  books,  would  be  a  contraindication  for  its  remov- 
al. I  have  removed  acutely  and  subacutely  inflamed 
tonsils  by  this  method  with  equally  good  results  and 
with  as  little  reaction.  The  use  of  the  tenaculum, 
especially  in  the  submerged  type,  to  draw  the  tonsil 
well  out,  will  aid,  decreasing  any  danger  of  injur- 
ing the  muscles.  At  the  present  time  I  do  not  use 
it  except  in  marked  degrees  of  submersion  where 
one  would  be  in  danger  of  the  tonsil  slipping  from 
the  fingers  and  the  patient  swallowing  it.  This  has 
occurred  a  number  of  times. 

In  regard  to  adhesions,  I  can  do  no  better  than 
to  quote  Ballenger,  who  says  that  in  his  experience 
they  are  a  myth,  but  would  add  that  they  are  of- 
ten present  when  a  previous  amputation  has  taken 
place  with  injury  to  the  pillars. 

As  before  stated,  ether  carried  to  the  third  stage, 
is  used,  the  patient  being  in  the  recumbent  position 
and  on  the  right  side.  The  body  is  placed  at  an 
angle  of  twentv  degrees,  which  allows  of  working 
without  interruption.  The  blood  is  thereby  kept 
from  being  drawn  into  the  trachea,  and  no  time  is 
lost  in  clearing  the  field  of  operation. 

Conclusions,  i.  Rapidity  of  the  operation.  2. 
Absolute  nonrecurrence  if  removed  in  its  capsule. 
3.  Minimum  amount  of  haemorrhage  and  subse- 
quent anaemia.  4.  The  importance  to  start  on  the 
outside  of  the  capsule.  5.  Ease  of  performance,  so 
amputation  should  never  be  thought  of,  even  as  a 
palliative  measure. 

BlIiLIOGRAl'HY    OF  ORIGINAL  PapER. 

Ballenger.  Textbook.  Ear,  Nose,  and  Throat:  Annals  of 
Otolo^iv.  Rliiiiologv.  and  Laryngology,  March,  1906. 

Pvnchon.  Annals  of  Otology,  Rhinology.  and  Laryngo- 
logy. INIarch  1907;  Journal  of  the  American  Medical  Associ- 
ation. June.  igo8. 

Wilson.  Journal  of  the  American  Medical  Association. 
May  26,  1906. 


May  29,  1909. J 


BLACKIVELL:  DIGITAL  ENUCLEATION  Of  TONSILS. 


Robertson.    Ibidem,  Nov.  24,  1906. 

Lennox  Browne.  Textbook,  Nose  and  Throat,  Wyati 
Wingrave,  pp.  37  to  39. 

Dclavan.    Medical  Reference  Handbook,  p.  812-813. 
Oiiain's  Anatomy. 

Rogers.    Medical  Record.  November  28,  1903. 

Goodale.  Quoted  by  Ballanger,  in  Annals  of  Otology, 
Rhinology,  and  Laryngology,  December,  igo8. 

Zr.ckerkandl.    Klinisclies  lahrbitch,  p.  155,  1Q05. 

Sprague.  Annals  of  Otology.  Rhinology,  and  Laryngol- 
ogy, March,  1907. 

Treves.    Surgical  Anatomy,  p,  117,  1881. 

Smith.  Manhattan  Eye  and  Ear  Reports,  March.  1905, 
pp.  79  to  81. 

Nos.  411-114,  THE  White  Building. 


THE    OTITIC    SIGNIFICANCE    OF  TONSILLEC 
TOiMY  WITH  REFERENCE  TO  DIGITAL 
ENUCLEATION. 

By  H.  B.  Bl.ackwell,  M.  D., 
New  York. 

My  reasons  for  writing-  on  this  subject  are  first, to 
indicate  its  important  otitic  significance  both  as  a 
curative  and  prophylactic  measure  in  the  acute  and 
chronic  suppurative  and  nonsuppurative  inriamina.orv 
conditions  of  the  middle  ear,  and,  second,  to  describe 
an  operative  technique,  that  I  have  used  continually 
for  the  past  year,  chiefly  in  children,  and  have  found 
to  be  both  simple  and  very  efficient. 

History.  The  simple  finger  enucleation  of  t";  e 
faucial  tonsils  is  perhaps  the  oldest  form  of  tonsil- 
lectomy of  which  we  have  any  authentic  record. 
Celsus,  who  lived  in  the  tenth  century  A.  D.,  in  his 
De  Mediciiia,  Sec.  XII,  Chap.  11,  speaks  of  it  as 
follows:  "Ilut  it  behooves  us  to  scrape  around  wi;h 
the  finger  and  to  pull  out  tonsils,  which  have  become 
hardened  with  inflammation."  Borelli  revived  the 
operation  in  the  Gaaactta  medica  italiana,  December 
30,  1 86 1.  The  two  comparatively  recent  articles  on 
the  subject  by  Hayes-Groves  may  be  found  in  the 
1905  edition  of  the  Bristol  M cdico-CJiintrgical 
Journal,  XIII,  p.  32  and  in  the  British  Medical 
Journal,  December  29,  1906.  (Also  compare  the 
article  of  Matthews  in  the  Annals  of  Surgery,  De- 
cember, 1908.)  I  have  also  been  informed  that  the 
.N'orth  Atnerican  Indians  practised  the  procedure 
although  I  am  unable  to  secure  any  authentic  in- 
formation on  this  point. 

Anatomical  Considerations.  The  portion  of  ths 
tonsil  with  which  the  otologist  is  inost  con- 
cerned is  that  part  known  as  the  velar  or 
superior  lobe,  and  its  associated  supratonsillar 
fossa.  These  two  structures  constitute  the  great- 
est source  of  otitic  menace  in  the  region  of  the  up- 
per passages.  The  velar  lobe  is  as  its  name  implies 
that  upper  portion  of  the  gland  which  lies  embedded 
in  the  tissues  of  the  soft  palate  and  adjacent 
pharyngeal  wall.  The  degree  cHt  its  development 
and  the  depth  of  its  location  varies  greatly  in  dif- 
ferent individuals.  The  supratonsillar  fossa  is  the 
name  applied  to  the  recess  which  lies  between  the 
superior  surface  of  the  velar  lobe  of  the  tonsil,  and 
the  V  shaped  angle  above  it  formed  by  the  junction 
of  the  anterior  and  posterior  faucial  pillars.  It  also 
varies  in  size  but  is  more  constantly  present,  and  in 
some  cases  it  has  been  demonstrated  as  extending 
almost  half  wav  down  on  the  outer  surface  of  the 
tonsil  between  it  and  the  pharyngeal  wall.    An  im- 


])ortant  point  to  be  remembered  in  connection  with 
this  fact  is  that  the  crypts  and  follicles  of  the  tonsil 
not  only  open  on  the  surface  of  its  superficial  por- 
tion, but  into  the  supratonsillar  fossa  as  well.  These 
ivvo  structures,  the  velar  lobe  and  its  associated  su- 
pratonsillar fossa,  are  separated  from  the  pharyngeal 
orifice  of  the  Eustachian  tube,  by  the  distance  of 
only  one  half  to  three  quarters  of  an  inch,  and  lie 
directly  beneath  it  in  the  same  vertical  axis.  It  :s 
evident,  therefore,  that  any  enlargement  of  the  lobe 
or  distension  of  the  fossa,  would  inevitably  bring 
more  or  less  pressure  to  bear  directly  beneath  the 
orifice  of  the  tube,  and  it  is  equally  obvious  that  this 
pressure,  however  small,  would  influence  in  some 
degree  the  luinen  of  both  the  afferent  and  efferent 
vessels  running  longitudinally  in  the  walls  of  the 
pharynx  and  supplying  the  region  of  the  tube,  there- 
by inducing  structural  changes  not  only  in  the  mu- 
cous membrane  of  its  orifice,  but  in  the  Eustachian 
tube  itself.  The  pressure  of  inspissated  secretion  in 
the  supratonsillar  fossa  may,  owing  to  a  stenosis  of 
its  orifice,  be  retained,  in  which  event  it  would  either 
undergo  calcareous  degeneration  and  form  a  tonsil- 
lith,  or  what  is  more  frequently  the  case  act  as  an 
excellent  nidus,  for  the  development  and  cultivation 
of  various  bacteria  which  under  favorable  circum- 
stances may  invade  the  Eustachian  tube  and  middle 
ear  by  either  direct  continuity  or  indirectly  by  means 
of  the  bloodvessels  and  lymphatics,  and  excite  an 
acute  inflammatory  condition  of  the  tube,  middle  ear, 
and  the  mastoid  cells.  The  indication  is  clear,  there- 
fore, in  any  and  all  cases  of  otitic  disturbance  which 
can  be  attributed  to  the  presence  of  either  one  or 
both  of  the  above  described  structures  to  completely 
remove  the  velar  lobe  of  the  tonsil,  and  thereby 
at  the  same  time  obliterate  that  danger  pocket , 
the  supratonsillar  fossa.  Any  operative  technique 
calling  for  the  thorough  removal  of  these  structures 
and  coinbining  the  general  surgical  requirements  of 
operative  celerity,  with  the  conservation  of  the  best 
possible  postoperative  interests  of  the  patient,  should 
recommend  itself  to  consideration  of  not  only  otol- 
ogists, but  to  the  general  profession  as  well. 

In  modern  times  finger  enucleation  of  the  tonsil 
as  a  formal  means  of  tonsillectomy  has  never  be^n 
a  popular  operation  either  in  this  or  any  other  coun- 
try for  the  following  reasons:  i,  The  intense  local 
traumatic  reaction  in  the  surrounding  tissues  which 
has  always  taken  place  when  the  procedure  has  been 
perfonned  by  an  unskilled  operator,  or  by  one  who 
has  not  yet  acquired  an  educated  sense  of  touch  in 
his  index  finger.  2,  Occasional  permanent  voice 
changes  and  difficulty  in  deglutition  due  to  lacera- 
tion of  one  or  both  of  the  faucial  pillars  or  soft 
palate,  occuring  in  those  cases  in  which  the  operator 
has  neglected  to  free  the  tonsil  froin  the  faucial 
pillars  prior  to  the  process  of  enucleation.  I  believe 
that  these  vmfortunate  results  are  due  to  faulty 
technique,  and  can  be  entirely  eliminated  provided 
the  operator  is  able  to  acquire  the  necessary  tactile 
sense  in  his  index  finger,  so  essential  to  the  proper 
performance  of  the  operation.  In  none  of  my  cases 
have  I  observed  any  permanent  postoperative  dys- 
phagia or  dysphonia,  and  I  also  do  not  believe  that 
the  after  soreness  in  the  throat  is  any  greater  or 
more  prolonged  than  that  subsequent  to  otlier  op- 
erations for  tonsillectomy. 

Operation.    The  patient  is  etherized  and  placed 


1090 


BLACKWELL:  DIGITAL  ENUCLEATION  OF  TONSILS. 


[New  York 
Medical  Journal. 


upon  the  table,  and  throug-hout  the  operation  al- 
lowed to  remain  in  the  horizontal  position.  The 
operator  who  has  taken  his  position  at  the  patient's 
right,  inserts  the  gag  in  the  left  side  of  the  pa- 
tient's mouth  where  it  is  also  allowed  to  remain. 
With  the  tongue  depressor,  the  operator  now  makes 
firm  pressure  downward  upon  the  base  of  the 
tongue,  thereby  placing  both  anterior  faucial  pillars 
upon  the  stretch.  The  blunt  end  of  a  Leland  knife 
is  next  introduced  just  behind  one  of  the  anterior 
faucial  pillars  between  it  and  the  tonsil  at  its  in- 
ferior pole,  and  is  brought  out  at  the  junction  of 
the  anterior  with  the  posterior  pillar  above  the  ton- 
sil, thus  entirely  liberating  the  tonsil  from  the  an- 
terior pillar  with  one  sweep  of  the  knife,  cutting 
from  below  upward.  The  opposite  tonsil  is  next 
freed  from  the  anterior  pillar  in  a  similar  fashion. 
The  blunt  tip  of  the  second  Leland  knife  is  now 
hooked  into  the  upper  extremity  of  the  first  in- 
cision and  the  posterior  pillar  freed  in  much  the 
same  manner  as  the  anterior  with  the  exception 
that  the  direction  of  the  incision  is  from  above 
downward. 

Both  the  tonsils  having  been  freed  from  their 
pillars  the  operation  is  now  concluded  entirely  by 
sense  of  touch.  The  tip  of  the  left  index  finger  is 
introduced  into  the  supratonsillar  fossa  and  each 
tonsil  in  turn  gently  shelled  out  of  its  bed,  the  same 
finger  of  the  same  hand  being  used  on  each  tonsil. 
The  dorsal  surface  of  the  finger  being  always  direct- 
ed upward  and  outward  and  the  palmar  surface 
downward  and  inward.  The  direction  of  applied 
force  is  first  from  above  downward  and  then  from 
side  to  side.  The  shelling  process  is  exactly  anala- 
gous  to  the  peeling  of  a  .prostate  or  the  blunt  dissec- 
tion of  a  hernial  sack.  I  do  not  attempt  to  shell  out 
more  than  the  upper  three  quarters  of  the  tonsil  for 
the  reason  that  the  capsule  of  its  inferior  pole  is 
extremely  thin,  the  lymphoid  tissue  of  this  portion 
of  the  gland  being  more  or  less  continuous  with  that 
of  the  base  of  the  tongue  and  along  the  floor  of  the 
mouth,  and  any  attempt  made  to  completely  enu- 
cleate and  remove  the  gland  in  this  way  would,  to 
a  more  or  less  extent,  strip  the  mucous  membrane 
along  the  floor  of  the  mouth  or  tear  into  the  tissues 
at  the  base  of  the  tongue,  resulting  in  marked  post- 
operative dysphagia  or  dysphonia.  Both  tonsils  now- 
having  been  shelled  out  of  their  beds,  they  may  be 
felt  in  the  throat  as  loose  foreign  bodies  attached 
only  by  a  pedicle  at  their  inferior  poles  to  the  lateral 
wails  of  the  pharynx. 

With  the  left  index  finger  in  the  throat  each  ton- 
sil is  now  in  turn  forced  against  the  side  of  the 
pharynx  to  which  it  is  attached  and  seized  with  an 
ordinary  curved  artery  clamp,  the  finger  grips  of 
which  have  been  fenestrated  to  allow  the  easy  pas- 
.sage  of  a  wire  loop  over  the  handles.  This  step  hav- 
ing been  accomplished,  the  anesthetist  now  grasps 
the  handles  of  the  clamp  and  draws  the  tonsil  to  the 
opjKjsite  side,  thereby  placing  its  inferior  attachment 
on  the  stretch,  and  with  the  aid  of  the  same  finger 
still  in  the  pharynx  acting  as  a  guard  the  wire  loop 
of  the  snare  is  now  guided  over  the  tonsil  and  ac- 
curately adjusted  on  that  i)')rtion  of  the  stretched 
inferior  jjedicle  that  the  oj^erator  desires  to  snare 
through.  During  this  step  of  the  operation  with  one 
finger  in  the  pharynx  acting  :is  a  guard  between  the 
uvula  and  soft  palate  on  the  one  hand  and  the  wire 


loop  of  the  snare  on  the  other,  it  becomes  a  physi- 
cal impossibility  to  include  any  of  the  tissues  of  the 
former  in  the  grasp  of  the  latter  when  the  operator 
tightens  the  wire  loop  of  his  snare. 

Both  tonsils  now  having  been  snared  out  in  this 
fash  ion,  the  removal  of  the  adenoids,  if  anv,  is  per- 
formed in  the  usual  manner,  and  the  operation 
completed. 

Special  points  to  be  observed  in  this  operative 
technique  are :  In  separating  the  tonsil  from  the 
faucial  pillars  great  care  should  be  taken  not  to  in- 
cise its  capsule  for  in  that  event  during  the  enuclea- 
tion process  the  operator's  finger  may  enter  the  sub- 
stance of  the  gland  instead  of  the  proper  cleavage 
plane,  and  so  disorganize  its  structure  as  to  render 
its  subsequent  peeling  out  impossible. 

The  operator  should  be  able  to  see  the  blunt  tip 
of  his  knife  through  the  stretched  tissues  of  the 
anterior  faucial  pillar  as  he  separates  that  structure 
from  the  surface  of  the  tonsil.  The  sense  of  touch 
in  his  index  finger  cannot  be  too  highly  educated, 
for  upon  this  together  with  the  proper  separation  of 
the  tonsil  from  the  faucial  pillars  as  a  preliminary 
step  in  the  operation  depends  the  success  of  the  pro- 
cedure. This  touch  dependence  not  onlv  greatly 
shortens  the  actual  time  of  the  operation,  by  doing 
away  with  the  necessity  for  frequent  sponging  and 
inspection  of  the  pharynx  rendering  it  perfectlv  p;  s- 
sible  to  go  through  the  entire  technique  including 
the  time  required  for  adenectomyin  somethingunder 
two  minutes,  but  also  enables  the  educated  finger  tip 
to  gently  shell  the  gland  out  of  its  bed,  instead  of 
tearing  it  out  and  lacerating  the  surrounding  soft 
parts  with  resulting-  marked  postoperative  soreness. 
Only  the  index  finger  should  be  used  in  the  peel- 
ing process.  The  use  of  two  or  more  fingers  as  ad- 
vised by  some  operators  I  consider  dangerous  as 
their  accumulatecl  pressure  behind  a  tonsil  may  re- 
sult in  laceration  of  one  or  both  of  the  faucial  pil- 
lars. The  enucleation  is  performed  entirely  with  the 
end  of  the  finger,  and  not  with  the  nail  as  is  com- 
monly supposed.  The  direction  of  force  should  be 
from  above  downward  for  the  reason  that  in  work- 
ing in  the  opposite  direction  there  is  great  danger 
of  tearing  the  velum.  By  using  one  hand  entirely 
for  all  of  the  throat  manipulation,  the  other  is  re- 
tained in  a  dry  condition,  greatly  facilitating  the 
handling  of  the  snare  and  clamp,  which  would  other- 
wise be  slipperv  with  blood  and  mucous. 

During  and  immediately  after  the  operation  the 
primary  hsemmorrhage  is  about  as  brisk  as  when 
the  tonsillotome  is  u.sed.  I  think,  however,  that 
the  danger  of  secondary  haemorrhage  has  been 
greatly  diminished.  The  internal  carotid  artery  is 
of  course  separated  from  the  tonsil  by  the  inferior 
pharvngeal  constrictor  muscle  and  a  plane  of  fascia. 

During  the  past  year  at  the  New  York  Eye  and 
Ear  Infirmary  over  five  hundred  cases  have  been 
operated  in  according  to  this  technique.  In  only 
two  instances  was  there  any  secondary  haemorrhage, 
which  on  both  occasions  was  found  to  be  very 
slight  and  easily  controlled  by  simple  measures. 

I  consider  the  use  of  the  snare  a  most  im]iortant 
feature  of  the  operation,  and  used  in  the  manner 
as  described  completes  the  process  of  enucleation 
in  a  most  exact  manner  without  any  undue  lacera- 
tion of  the  surrounding  parts. 

I  believe  that  its  use  in  dividing  the  pedicle  is  in 


May  2g.  1909.]  DiTMAS  ASD  II  hl-KER:  Dl-.l' IC I  LSI  UXIDATJOX'  A.\D  .\  Li' 1 1 KJ  1  J  ^. 


a  measure  responsible  for  the  lessening  of  the  oc- 
curance  of  secondary  hjemorrhage  which  has  in  a 
certain  percentage  of  the  cases  invariably  followed 
the  use  of  a  guillotine  or  scissors  for  that  purpose. 

Of  late  I  have  used  the  snare  recently  devised  by 
Eves.  It  is  the  simplest  and  least  complicated  in- 
strument that  I  have  seen  on  the  market.  The  Le- 
land  knives  as  originally  devised  possess  too  long 
a  curve  to  be  used  in  a  child's  pharynx.  By  simply 
filing  ofif  their  ends,  however,  they  may  be  reduced 
to  a  satisfactory  length. 

In  my  opinion  the  operation  as  described  may  be 
sucessfully  performed  in  any  and  all  varieties  of 
buried  tonsils,  having  not  as  yet  had  a  case  in  which 
they  could  not  be  easily  removed  in  this  manner. 

148  West  Fifty-eighth  Street. 


DEFICIENT  OXIDATION  AND  ITS  RELATION  TO 
THE  .T;TI0L0GY,  PATHOLOGY.  AND 
TREATMENT  OF  NEPHRITIS. 

Bv  NoRM.AN  E.  DiTM.xN,  Ph.  D.,  M.  D., 
New  York, 

Assistant   .Atending   Physician,    St.    Luke's   Hospital;    Instiuctov  in 
Patholog)',  College  of  Physicians  and  Surgeons,  Columbia 
University;  Clinical  Pathologist,  The  Roosevelt  Hospital, 

In  collaboration  with  William  H.  Welker,  A.  C,  Ph.  D., 
New  York, 

Assistant   in   Biological   Chemistry,   College   of   Physicians  and 
Surgeons,  Columbia  University. 

{Continued  from  page  10^2.) 

IV.    Experimental  Evidence  that  the  Mem- 
bers OF  THE  Partially  Oxidized  Group  of 
Cre.\tine  Metabolism  Products  are 
Capable  of  Producing  Patholog- 
ical Lesions  in  the  Kidney. 

That  the  pathological  lesions  of  nephritis  may 
occur,  largely  or  in  part,  as  the  result  of  toxic 
agencies  other  than  those  already  considered  here, 
is  not  only  possible,  but.  in  view  of  clinical  experi- 
ence, probable.  This  fact  does  not  detract,  how- 
ever, from  the  importance  of  the  effect  of  these 
substances,  occurring  either  at  the  beginning  of  a 
nephritic  process  or  developing  in  its  cotirse,  after 
this  process  has  been  initiated  by  some  other 
agency. 

The  mere  fact  that  such  substances,  capable  of 
formation  in  the  body,  may  produce  pathological 
effects  is  one  of  no  small  interest.  If.  in  addition, 
these  substances  produce  effects  closely  resembling 
the  effects  of  the  pathological  processes  in  nephritis, 
the  fact  would  be  not  only  one  of  first  importance, 
btit  would  lend  a  certain  amount  of  weight  to  the 
view  that  these  substances  really  are  formed  in  the 
body  and  may  occupy  an  important  place  in  the 
production  of  the  disease  processes  under  consid- 
eration. 

Toxic  Ori<^iii  of  Xcf^hritic  Ancrinia. 

To  those  who  come  intimately,  and  for  long 
periods,  into  contact  with  patients  sufTering  from 
nephritis,  one  of  the  most  impressive  and  discour- 
aging symptoms  thrust  repeatedly  upon  their  atten- 


tion is  the  terrible  destruction  of  the  blood  elements, 
occuring  out  of  all  proportion  to  the  intensity  o£ 
apparent  causative  factors  and  resulting  in  severe 
an?emia. 

Our  knowledge,  acquired  since  Hunter's  time,  of 
the  production  of  severe  anaemias  as  the  result  of 
toxic  agencies,  has  stimulated  our  efforts  to  account 
in  some  such  way  for  the  severe  anaemia  of  nephri- 
tis. A  knowledge  of  the  direct  effect  of  the  sub- 
stances under  consideration  upon  the  blood  might 
be  of  some  assistance  in  the  orientation  of  this 
point,  and.  with  this  in  view,  the  following  experi- 
ments were  conducted  to  determine  their  hjemolytic 
powers. 

A  five  per  cent,  solution  of  dog's  blood  in  normal 
salt  .solution  was  used,  to  which  was  added,  in  each 
case,  an  equal  amount  of  a  solution  in  normal  salt 
of  the  substance  to  be  tested. 

table  XXL— H.liMOLYTIC  .VCTIOX  OF  UREA,  CRE.\TL\}-:. 

cre,\tinine,  and  guanidixe  carbox.vte. 

Strength  of  solu- 


Substance.  tion,  per  cent.  H.-emolysis. 

Urea    5  0 

Creatine    i  o 

Creatinine    3  o 

Guanidine  carbonate    0.015  -f- (20  minutes) 


Except  in  the  case  of  guanidine  carbonate,  no  ac- 
tive haemolytic  action  was  observed.  (The  guani- 
dine carbonate  used  was  made  by  Kahlbaum  and 
was  the  nearest  preparation  to  simple  guanidine 
which  it  was  possible,  during  the  cotirse  of  these 
experiments,  to  secure.  Methyl  guanidine  could  not 
be  obtained.) 

It  would  seem,  however,  that  a  certain  degree 
of  haemolysis  may  develop  as  the  end  of  the  process 
of  oxidation  of  the  creatine  group  is  approached. 

A  determination  of  the  possible  haemolytic  action 
of  members  of  the  purin  and  other  groups  is  a  mat- 
ter of  great  interest  and  importance  which  the  au- 
thors hope  stilJ  further  to  pursue. 

Toxic  Aciioii  of  Fiiriii  and  Creatine  Groups. 

That  some  of  the  unoxidized  members  of  the 
purin  and  creatine  groups  have  direct  toxic  action 
on  the  body,  is  a  matter  which  has  alread\-  been  the 
subject  of  direct  observation.  Landois,  Bouchard, 
and  Feltz  and  Ritter  showed  the  cramp  and  coma 
producing  effect  of  creatinine  when  applied  directly 
to  the  cerebral  cortex.  Frankel's  experiments  have 
shown  the  depressing  effect  of  xanthine  on  the 
spinal  centres,  which,  he  says,  may  also  be  accom- 
panied by  the  production  of  small  areas  of  muscle 
necrosis.  The  same  author  has  observed  the  pro- 
duction of  sluggishness  and  diminished  reflexes  by 
paraxanthine  and  heteroxanthine. 

(^f  special  interest  to  us  at  the  present  time  is 
the  production  of  pathological  lesions  by  substances 
belonging  to  these  groups. 

Ebstein  and  Bendix  (44)  injected  guanine  into 
the  circulation  of  a  dog.  and  three  quarters  of  an 
hour  later,  when  the  dog  was  killed,  found  small  in- 
clusion spheroidal  masses  in  the  renal  epithelium,, 
free  in  the  tissue  and  within  the  cell  nuclei  of  the 
kidneys. 

After  its  injection  into  animals,  adenine,  a  com- 
pound whose  violent  toxicity  is  due  to  the  presence 


DITMAN  AND  WELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS.  [New  York 

Medical  Journal. 


of  the  amino  group,  repeatedly  caused  the  produc- 
tion of  albuminuria  as  was  repeatedly  observed  by 
IMinkowski  (45).  This,  as  a  rule,  was  slight  and 
transient.  Yet  renal  epithelium,  leucocytes,  hyaline, 
granular,  and  epithelial  casts,  were  found  in  cases 
where  the  albuminuria  was  hardly  discernible.  The 
anatomical  changes  in  the  kidney  were  noteworthy 
and  constant,  though  varying  in  intensity.  Crystal- 
like masses  were  found  in  the  lumina  of  the  kidney 
tubules  and  within  the  tubular  epitheliimi ;  and  in 
many  places  between  the  renal  epithelium,  in  the 
neighborhood  of  the  deposits,  masses  of  round  cells 
occurred.  At  times  the  interstitial  tissue  ap]ieared 
uniformly  rich  in  round  cells. 

While  this  group  of  substances  is  of  intense  in- 
terest with  reference  to  the  pathological  effects  they 
may  be  capable  of  producing  in  the  course  of  their 
metabolism,  it  is  the  creatine  group  which  has  espe- 
cially engaged  our  attention  during  the  course  of 
this  investigation. 

Creatine  Group  and  Impaired  Oxidation.  E.vpcri- 
iiiental  Lesions. 

As  has  been  shown,  the  products  resulting  from 
the  decomposition  of  creatine  under  less  favorable 
conditions  of  oxidation  are  creatinine,  methyl  guan- 
idine,  and  guanidine,  and  it  is  the  effect  of  these 
substances  when  introduced  into  the  body  under 
conditions  of  poor  oxidation  which  has  proved,  un-' 
der  experimental  conditions,  a  matter  of  striking 
and  probably  of  practical  interest. 

It  is  to  be  regretted  that  it  has  not  been  possible 
to  obtain,  up  to  the  present  time,  a  sufficient  amount 
of  methyl  guanidine  to  carry  out  the  desired  series 
of  experiments  with  this  substance.  It  is  hoped  that 
in  the  near  future,  however,  such  a  series  may  be 
accomplished. 

The  agent  employed,  here,  as  before,  to  produce 
a  condition  of  poor  oxidation,  was  potassium  cyan- 
ide in  sublethal  doses. 

That  as  marked  an  efl'ect  as  possible  might  be 
produced  with  this  substance,  without  killing  the 
dogs  used  for  experimental  purposes,  the  smallest 
fatal  dose  was  first  determined.  This  was  found  to 
be  one  centigramme  of  KCN  (ten  per  cent,  solu- 
tion) to  one  kilosramme  of  weight,  which  dose,  ad- 
ministered hypodermically,  killed  in  about  an  hour. 
Five  milligrammes  to  each  kilogramme  failed  to  kill, 
but  produced  marked  cyanide  effects  (dyspnoea, 
nausea,  vomiting,  and  diarrh'xa).  This  dose,  when 
repeated  in  an  hour  causes  convulsions,  in  addition 
to  the  other  syuiptoms  already  mentioned,  but  death 
does  not,  as  a  rule,  result. 

In  order  to  determine  the  effect  of  KCN  alone, 
this  was  administered  to  a  dog  at  the  same  intervals 
and  with  the  same  dosage  as  in  the  case  of  the  com- 
bined treatment  described  subsequently.  The  result 
of  the  microsco])ical  examination  of  the  sectioned 
and  stained  jwst  mortem  specimens  was  as  follows : 
Kidney,  practically  normal ;  heart  muscle,  normal ; 
spleen,  normal ;  ])ancreas,  normal :  liver,  a  very 
slight  degree  of  parenchymatous  degeneration. 

Guanidine .  The  effect  of  guanidine  (in  the  form 
of  the  carbonate)  was  then  tried,  and  it  was  found 
that  this  substance  could  be  injected  into  dogs  at 
least  u])  to  the  amount  of  66  mgs.  to  each  kilo- 


gramme without  producing  any  other  effect  than 
restlessness. 

When  a  dog.  which  for  a  week  has  received  daily 
hypodermic  doses  of  50  mg.  per  kilogramme  of  this 
substance  alone,  is  autopsied  and  the  viscera  sec- 
tioned, stained  and  examined,  no  other  kidney  le- 
sion than  slight  congestion  is  found,  though  the 
liver  shows  small  areas  oi  a  mild  degenerative  pro- 
cess about  the  central  veins.  When  these  two  sub- 
stances (potassium  cyanide  and  guanidine)  are  in- 
jected sinniltaneously,  the  most  startling  result  fol- 
lows. 

A  dog,  which  showed  no  unusual  effects  during 
preliminary  KCN  treatment  (administered  as 
shown  in  the  accompanying  table,  XXII),  and 
no  unusual  eft'ects  when  guanidine  was  administered 
alone,  showed  entirely  different  effects  as  a  result 
of  treatment  with  the  combination. 

When  fifty  milligrammes  of  guanidine  per  kilo- 
gramme were  given  shortly  after  dosage  with  KCN 
(two  milligrammes  per  kilo)  great  prostration  re- 
sulted and,  when  this  dose  of  guanidine  was  repeat- 
ed two  days  later,  after  an  energetic  cyanide  treat- 
ment, convulsions  occurred  ending  in  coma,  which 
continued  uninterruptedly  for  six  days  and  termin- 
ated in  death. 

A  second  dog  was  treated  with  these  two  sub- 
stances in  the  manner  shown  in  table  XXIII.  At 
first  there  was  partial  recovery  from  the  effect  of 
the  combined  dosage,  but  marked  symptoms  of 
stupor  shortly  developed  in  the  animal,  terminating 
in  coma.  After  two  weeks  the  dog  was  killed,  the 
viscera  hardened,  sectioned,  stained,  and  examined. 
The  condition  resembled  that  present  in  the  viscera 
of  the  other  dog  which  had  received  potassium  cyan- 
ide and  guanidine,  but  the  lesions  were  more 
marked.  There  were  no  evidences  of  cerebral 
haemorrhage  in  either  animal. 

The  renal  cortex  was  the  seat  of  an  active  acute 
albuminous  degeneration,  most  marked  in  the  cells 
of  the  convoluted  tubules.  (See  Fig.  i.)  The  liver 
cells  were  the  seat  of  a  inild  acute  parenchymatous 
degeneration  accompanied  by  congestion.  The 
heart  muscle  was  normal.  In  the  pancreas  there 
were  areas  of  glandular  acini  presenting  more  of  an 
appearance  of  functional  inactivity  than  of  any  dis- 
tinct morphological  pathological  lesion. 

Creatinine.  Into  another  dog  we  injected  repeat- 
ed doses  of  creatinine  in  amounts  of  1.24  grammes 
at  a  time,  at  the  intervals  shown  in  the  accompany- 
ing table  (XXI\').  During  the  same  period  (nine 
days),  the  animal  was  daily  given  3  mg.  of  KCN 
]3er  kilogramme  of  body  weight.  C^n  the  sixth  day 
prostration  was  extreme  and  continuous,  and  the 
dog's  condition  became  so  grave  that  it  was  neces- 
sar\-  to  kill  it  on  the  tenth  day. 

At  autopsy  the  kidney  showed,  on  microscopical 
examination,  extreme  acute  albiuuinous  degenera- 
tion of  the  cells  of  the  convoluted  tubules  with  more 
moderate  changes  in  tlie  other  ejMthelial  elements 
of  the  renal  cortex  ( l"ig.  2).  The  liver,  spleen,  and 
pancreas  were  normal. 

To  another  dog.  under  similar  conditions,  the 
same  amounts  of  the  same  preparation  of  creatinine 
were  administered  without  ]K)tassium  cyanide.  This 
dog,  upon  sul)se(juent  microscopical  examination  of 


May  zg,  .909.]  DITMAN  AND  IVELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS. 


1093 


the  viscera,  showed  no  pathological  changes  in  any 
organ. 

Creatine.  As  creatin  exists  normally  in  consid- 
erable amounts  in  the  blood  of  healthy  animals  as 


Fig.   I. — Giianidine  and  potassium  cyanide.     Albuminous  degenera- 
tion, convoluted  tubule,  renal  cortex. 

well  as  man,  it  was  not  considered  necessary  to  con- 
trol the  following  experiment  with  a  dog  by  inject- 
ing creatine  alone. 

A  dog  was  injected  with  creatine  at  the  intervals 


Fig.  2. — Creatinine  and  potassium  cyanide.     -Mbuminous  degenera- 
tion, convoluted  tubule,  renal  cortex. 

and  in  the  doses  shown  in  the  accompanying  table 
(  XXV).  Meanwhile,  the  dog  was  kept  more  or  less 
continuously  under  the  influence  of  KCN,  as  shown 


TAHLE  xxn. 

COMBINED    ADMINISTRATION    OF    GUANIDINE  AND 
POTASSIUM  CYANIDE. 


Date. 
Aug. 


KCN  (per 
kilogramme). 
2  milligrammes 
2  milligrammes 

2  milligrammes 

3  milligrammes 

2  milligrammes, 

3  milligrammes 
3  milligrammes 


Guanidine 
carbonate  (per 
kilogramme). 


50  milligrammes 
50  milligrammes 


50  milligrammes 


Remarks. 

Mild  cyanide  effect 
Mild  cyanide  effect 
No  effect 
Great  prostration 


Convulsions  and  coma 

Coma 

Coma 

Coma 

Coma 

Coma 

Death 


TABLE  XXIII. 


COMBINED 


ADMINISTRATION    OF    GUANIDINE  AND 
POT.XSSIUM  CYANIDE. 


Date. 
Aug.    I . 


13- 
14. 


KCN  (per 
kilogramme). 
3  milligrammes 
I  milligramme 
I  milligramme 
I  milligramme 
I  milligramme 

1  milligramme 
3  milligrammes 
3  milligrammes 
3  milligrammes 
3  milligrammes 

2  milligrammes 
2  miilligrammes 
2  milligrammes 
2  milligrammes 
2  milligrammes 
2  rr.illigrammes 

2  milligrammes 

3  milligrammes 
3  milligrammes 
3  milligrammes 
3  milligrammes 
3  milligrammes 
3  milligrammes 


Guanidine 
carbonate  (per 
kilogramme). 


Remarks. 


50  m.illigramraes    Prostration,  coma 

Very  weak  in  hind  legs 

40  milligrammes  Marked  prostration 
40  milligrammes  Marked  prostration 
50  milligrammes 


Unable  to  Stand 

50  milligrammes  Coma 
50  milligrammes 

45  milligrammes  Convulsions  and  coma 
50  milligrammes 


50  milligrammes 


Killed 


TABLE  XXIV. 

COMBINED   ADMINISTR.\TION   OF   CREATININE  AND 
POTASSIUM  CYANIDE. 


KCN  (per 

Date.  kilogramme).  Creatinine. 

Aug.  22   3  milligrammes  i  gramme 

23   3  milligrammes 

3  milligrammes  i  gramme 

24   3  milligrammes 

3  milligrammes  i  gramme 

26   3  milligrammes 

27   3  milligrammes 

3  milligrammes  i  gramme 

28   3  milligrammes 

3  milligrammes  i  gramme 

29   3  milligrammes 

3  milligrammes  i  gramme 

30  


Remarks. 


Great  prostration 

continuous 

continuous 

continuous 

continuous 
Killed 


in  the  table,  to  produce  a  condition  of  diminished 
oxidation.  This  treatment  was  continued  over  a 
period  of  eighteen  days,  during  the  latter  part  of 
which,  weakness  and  prostration  were  very  extreme. 
It  became  necessary,  at  this  point,  to  kill  the  dog. 
After  hardening  of  the  viscera,  sectioning,  and 
staining,  their  microscopic  appearance  was  as  fol- 
lows : 

The  degenerative  changes,  confined  to  the  con- 
voluted tubules,  were  very  slight.  About  these 
tubules,  however,  and  in  the  region  of  the  small 
bloodvessels  there  were  visible  in  small  numbers, 
areas  of  small  round  cell  infiltration  (Fig.  3),  pre- 
senting the  appearance  seen  in  the  early  stage  of  a 
chronic  inflammation.  This  was  accompanied  by 
moderate  congestion.  While  the  liver  cells  showed 
evidence  of  a  mild  albuminous  degenerative  process, 
the  spleen,  pancreas,  and  heart  muscle  were  normal. 

While  the  changes  described  in  this  experiment 
were  very  slight,  it  is  believed  that  by  a  longer  con- 


1094 


DITMAN  AND  IVELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS.       „  [New  York 

Medical  Journal. 


tinuation  of  the  process  under  suitable  conditions,  a 
still  more  marked  lesion  might  be  obtained.  We  in- 
tend to  further  investigate  this  point. 

It  will  be  desirable  in  the  future,  to  extend  the 
results  here  recorded  with  attempts  to  duplicate  the 
lesions  of  nephritis  b}^  experimental  conditions  more 
closely  resembling  those  existing  in  the  body.  While 
such  confirmation  will  prove  valuable,  the  experi- 

TABLE  XXV.— COMBINED  ADMINISTU.\TION  OF  CREATINF 


Creatine 
(per  kilogramme). 
1 50  milligrammes 


ICQ  milligrammes 


1 00  milligrammes 

50  milligrammes 

100  milligrammes 

100  milligrammes 
ICQ  milligramme.T 
100  milligrammes 
100  milligrammes 
100  milligrammes 
1 00  milligramm'rs 


AND  POTASSIUM  CV.\NIDE. 
KCN 

Date.  (per  kilogramme). 

Aug.    2   2  milligrammes 

2  milligrammes 
2  milligrammts 
3   2  milligrammes 

2  milligrammes 
5.                               2.5  milligrammes 

3  milligrammes 
6                                3  milligrammes 

2  milligrammes 

3  milligrammes 
3  milligrammes 

7   3  milligrammes 

2  milligrammes 

2  milligrammes 
2.5  milligrammes 
1.75  milligrammes 

8   3  milligrammes 

2.5  milligrammes 
2.5  milligrammes 

9   3  milligrammes 

2.5  milligrammes 

3  milligrammes 
3  milligrammes 

10   3  milligrammes 

12   3  milligrammes 

13   3  milligrammes 

2.8  milligrammes 

14   3  milligrammes 

3  milligrammes 

15   3  milligrammes 

3  milligrammes 

16   3  milligrammes 

3  milligrammes 

17   3  milligrammes 

.     3  milligrammes 

18   3  milligrammes 

4  milligrammes 

19   3  milligrammes 

3  milligrammes 

ments  already  conducted  and  cited  above  sup]:)ort 
the  conclusion  that  the  above  named  members  of  the 
creatine  group  are  capable  of  causing,  under  condi- 
tions of  impaired  oxidation,  pathological  lesions 
seen  in  nephritis.  Our  results  also  indicate  that  the 
products  of  the  group  representing  the  earlv  stages 
of  decomposition,  under  conditions  of  deficient  oxi- 
dation, are  less  toxic  and  more  prone  to  cause 
chronic  inflammatory  processes,  afifecting  the  inter- 
stitial tissue.  The  compounds  of  the  group  repre- 
senting the  later  stages  of  decomposition,  on  the 
other  hand,  are  highly  toxic  and  more  prone  to 
cause  acute  degenerative  lesions  affecting  the  renal 
parenchyma. 

V.    F.\croRs  Augmenting  the  Reduction  Pro- 
cesses OF  THE  Body  and  Their  Signific.vnce 

IN  THE  TrE.\TMENT  OF  XeI'IIRITIS. 

'i'he  clinical  picture  in  chronic  nephritis  is  prob- 
ably a  mixed  ('iie  produced  by  the  concurrent  action 
of  several  or  many  toxines. 

Insufficient  oxidation  is  probably  an  important 
factor  in  'he  manufacture  of  some  of  these  toxines. 
This  may  result  from  incompetence  of  some  organ 
allied  in  function  to  the  kidney,  as  intestine,  liver, 
skin,  or  lung;  from  inefficient  action  of  oxidizing 
enzymes,  as  those  of  the  kidney,  liver,  suprarenal, 
pancreas ;  or  from  increase  of  reducing  factors 
through  bacterial  or  chemical  agencies  in  the  intes- 
tinal canal. 

Bacterial  and  clirniicdl  ai^eitcics.   Of  these  causa- 


tive agencies  the  bacterial  and  chemical  are  the  ones 
best  known,  most  easily  investigated  and  most  im- 
portant, if  we  include  the  action  of  ingested  chem- 
ical substances,  such  as  alcohol. 

A  factor  in  the  field  of  intestinal  bacterial  pro- 
cesses which,  though  constantly  present,  is  subject 
to  great  variation  in  degree,  is  the  number  and  ac- 
tivity of  those  bacterial  forms  having  reducing  abil- 
ities, familiar  examples  of  which  are  members  of 
the  colon  group  and,  especially,  those  anerobic 
forms  more  recently  illuminated  for  our  considera- 
tion by  Herter  (46). 

A  simple  but  effective  demonstration  of  the  re- 
ducing action  of  the  colon  bacillus  on  an  important 
biological  agent  was  made  by  C'harlton  (47),  who 
showed  that  when  a  culture  of  this  organism  is 
added  to  blood  and  incubated,  not  only  do  the  red 
blood  corpuscles  become  deprived  of  their  haemo- 
globin, but  reduced  haemoglobin  is  also  formed. 

The  well  known  reduction  of  nitrate  to  nitrite  in 


Fic.   3. — Creatinine  and  potassium  cyanide.     Small  rtiUnil  cell  infil- 
tration of  stroma  of   renal  cortex. 


culture  media  by  this  organism  is  but  another  single 
example  of  a  general  chemical  capability  on  its  part. 

Another  specific  exam])le  of  this  reducing  junver 
of  bacteria  in  the  ga.strointestinal  tract  is  exhil)ited 
in  the  formation  of  reducing  gases,  among  wliich 
are  sulphur  dioxide,  methane  and  hydrogen.  This 
hydrogen,  as  an  example,  unites  very  readily  with 
oxygen  to  form  water.  It  thus  exerts  a  reducing 
action  on  compounds  or  solutions  containing  o.xy- 
gen,  and  this  reducing  power  of  the  bacteria  is,  ac- 
cording lo  llerter  (48),  one  of  the  most  character- 
i.stic  i)roc(sses  pertaining  to  the  intestinal  flora.  This 
is  especially  the  case  with  the  initrefactive  bacteria. 
who.se  activities  are  especially  capable  of  being  stud- 
ied througli  the  quantitative  determination  of  in- 
dican  formed  from  indol  and  the  ethereal  and  co  -^- 
bined  s'llnhates  in  the  urine. 

While  't  has  long  Iieen  known  that  evidence  of 
indol  production  was  present  in  some  cases  of  neph- 


May  29.  1909.]  LHTMAN  AND  ll'ELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS. 


ritis,  it  has  been  a  matter  of  comparatively  recent 
recognition  that  sucli  an  occurrence  is  a  very  fre- 
quent one.  In  the  writer's  experience  it  is  the  ex- 
ception not  to  obtain  strong  reactions  for  indican  in 
all  severe  cases  of  chronic  nephritis  which  have  not 
undergone  treatment  directed  toward  the  removal  of 
the  indican  reaction.  This  process  of  intestinal  pu- 
trefaction is  likewise  indicated,  as  is  known,  by  a 
relative  increase  of  ethereal  sulphates  in  the  urine. 

Biernacki  (^9)  has  estimated  the  ethereal  sul- 
phate of  the  urine  in  six  cases  of  acute  nephritis. 
Such  sulphates'  were  noticeably  increased  in  com- 
parison with  their  excretion  from  healthy  persons 
on  a  similar  diet.  The  frequent  increase  of  ethereal 
sulphates  in  the  urine  of  nephritis  has  been  con- 
firmed by  C.  Herter  (50)  who  observed  it  in  six 
out  of  eight  cases.  Von  Noorden  (36)  frequently 
finds  that  where  youthful  people  suffer  from  atro- 
phic kidneys,  very  strong  indican  reactions  and  a 
relatively  great  amount  of  ethereal  sulphates  o:cur 
in  the  urine.  Dapper,  von  Noorden's  assistant, 
found  the  value  for  ethereal  sulphates  in  the  urine 
normal  in  six  cases  of  acute  nephritis  and  unusual- 
ly high  in  five  cases  of  atrophic  kidneys. 

That  there  is  probably  a  distinct  connection,  not 
only  between  processes  of  intestinal  putrefaction  and 
ursemic  symptoms,  but  also  between  the  latter  and 
reduced  oxidizing  action  by  the  body  is  clearly 
shown  in  the  table  illustrating  the  metabolism  of  the 
anemic  case  previously  cited  (Table  IV).  The  ap- 
pearance of  a  strong  indican  reaction  on  the  13th 
was  not  only  an  indication  of  increased  urasmic 
symptoms,  but  was  followed  by  a  reduction  of  the 
purin  base  ratio  from  i  :  0.19  to  i  :  0.09,  a  return  to 
I  :  0.39  with  improvement  of  symptoms  following 
the  removal  of  the  indican  reaction  by  appropriate 
diet  and  treatment. 

Apart  from  the  disturbing  effect  which  the  reduc- 
tion compounds  of  bacterial  activity  have  on  the 
oxidation  processes  of  the  body  metatolism,  the  pro- 
ducts of  putrefaction  themselves  undoubtedly  have 
a  direct  injurious  eft'ect  upon  the  kidneys. 

Kidney  Lesions  FoUozcing  Intestinal  Absorption. 

A.  Jacobi  believes  that  the  quantity  of  absorbed 
toxines  determines  the  greater  or  smaller  injuries 
suffered  by  the  formerly  healthy  kidneys  during  the 
varied  putrid  and  infectious  processes  of  diseases. 
"Indeed,  the  number  of  renal  affections,  from  a 
slight  and  temporary  irritation  (with  renal  epith- 
elium and  hyaline  casts  and  a  few  blood  cells)  to  a 
serious  and  incurable  disease  brought  on  by  the  ab- 
sorption and  forced  elimination  of  toxines  are  very 
numerous."  (31.) 

We  are  strongly  impressed  by  the  harmful  effects 
of  the  reducing  action  of  intestinal  bacteria,  when 
we  realize  that  these  effects  are  not  only  direct  ones, 
exerted  by  the  bacterial  compounds  that  may  be  ab- 
sorbed from  the  intestine  in  unoxidized  conditions 
with  markedly  toxic  influences,  but  also  are  indirect 
ones,  exercised  by  many  of  these  products  which 
possess  reducin?  powers,  and,  as  do  creatinine  and 
hydrazine,  exhibit  independent  reducing  eft'ects  dur- 
ing their  sojourn  in  the  circulatory  system.  This 
intestinal  condition  is  of  extreme  importance  in 
eclampsia  anci  is  one  of  several  which  are  capable  of 
an.gn^mtin^-  the  reduction  processes  in  this  disease. 


Excessive  intestinal  putrefaction,  as  indicated  by 
marked  indican  reactions  in  the  urine,  is  so  uniform 
in  its  occurrence,  that  some  writers- doubt  the  oc- 
currence of  eclampsia  without  it.  The  author's  ex- 
perience has  been  that,  while  marked  intestinal  pu- 
trefaction does  not  exist  in  every  case,  its  presence 
may  be  detected,  usuall\-  in  marked  degree,  in  a 
great  majority  of  the  cases. 

Metabolism  in  Eclampsia. 

The  observation  of  Williams  (52),  that  the  prog- 
nosis in  eclampsia  is  favored  by  the  death  of  the 
foetus  is  of  immense  importance  in  throwing  light 
on  the  influence  of  foetal  metabolism  on  this  condi- 
tion. Embryonic  tissues,  rich  in  the  nuclear  ele- 
inents,  require  a  great  deal  of  oxygen,  which  they 
remove  from  the  available  maternal  supply,  causing 
thereby  a  danger  of  toxine  formation  in  other  parts 
of  the  maternal  body  from  diminished  oxygen  sup- 
ply. Should  this  supply  be  ever  so  slightly  inade- 
quate, underoxidized  purin  derivatives  of  the  nu- 
clein  group  would  be  formed,  which  have  already 
been  shown  to  be"  toxic.  This  increased  demand  for 
ox\-gen  has  been  carefully  measured  by  Magnus- 
Levy  (53),  who  finds  an  increased  utilization  of 
oxygen  on  the  part  of  the  mother  as  pregnancy  pro- 
gresses, as  follows:  (Table  XX VD. 

TABLE  XX\"I.— OXYGEN  UTILIZ.\TION  DURING  PREG- 
N.\NCY. 

Oxygen  in  c.c. 
|)er  minute. 


Nonpregnant    302 

Third  month  of  pregnane)-   320 

Fourth  month  of  pregnancy   325 

Fifth  month  of  pregnancy   340 

Sixth  month  of  pregnancy  -   349 

Seventh  month  of  pregnancy   378 

Eighth  month  of  pregnancy   363 

Ninth  month  of  pregnancy   383 


The  influence  of  the  metabolism  of  the  living 
foetus  in  eclampsia  is  shown  by  the  almost  imme- 
diate improvement  of  clinical  signs  and  renal  symp- 
toms following  the  emptying  of  the  uterus,  and  by 
the  greater  frequency  of  the  occurrence  of  eclampsia 
during  tv^an  'pregnancies.  That  the  unfavorable 
metabolism  of  the  foetus  alone  is  rarely  sufficient  to 
cause  eclampsia  is  evident  from  the  small  number 
of  eclampsias  occurring  without  some  such  marked 
catise  for  insufficient  oxidation  as  intestinal  putre- 
faction with  indicanuria.  That  stich  combinations 
are  necessary,  with  no  uniform  degree  of  their  in- 
tensities, implies  a  specific  oxidizing  capacity  foi 
each  case  concerned.  If  this  capacity  is  exceeded, 
eclampsia  supervenes. 

An  observation  bearing  on  the  influence  of  oxida- 
tion in  the  catisation  of  eclampsia  is  the  long  estab- 
lished clinical  fact  that  the  partially  oxygen  ex- 
hausted air  of  a  crowded  room — such  as  a  theatre — 
is  one  of  the  active  agents  in  inducing  an  eclamptic 
seizure  in  pregnant  women. 

Jnflnence  of  Cold  on  Oxidation. 

That  the  great  majority  of  cases  of  ursemia  and 
eclampsia  occur  in  winter  would  also  tend  to  con- 
firm the  view  that  oxidation,  which  is  influenced  by 
cold,  is  an  important  agent  in  the  production  of  this 
condition.  That  cooled  tissue  has  a  less  active  oxi- 
dizing capacity  than  warmed  tissue  has  long  been 
known. 


1096 


DITMAN  AND  WELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS. 


[New  York 
Medical  Journal. 


In  the  presence  of  suitable  heat  regulation,  when 
the  temperature  of  the  tissues  does  not  change,  La- 
voisier and  Rubner  have  found  that  in  order  to 
maintain  a  constant  normal  temperature  in  warm 
blooded  animals  in  the  presence  of  cold,  increased 
oxidative  activity  is  necessary. 

Thus,  Lavoisier  (1790)  found  that  while  the 
quantity  of  oxygen  absorbed  by  a  resting  man  at 
a  temperature  of  26°  C.  is  1,200  pouccs  de  France 
(l  cubic  pouce  =  o.oic)'^  litre)  hourly,  the  quantity 
required  at  a  temperature  of  12°  C.  rises  to  1,400 
polices. 

Rubner  {Entrgiegesctzc,  1902)  has  found  that,  in 
an  experimental  guinea  pig,  the  metabolism  at  0°  C. 
is  two  and  one  half  times  that  at  30°  C.  Rubner 
(54)  has  shown  the  influence  of  cold  on  increased 
metabolism  in  man,  by  a  bath  at  16°  C.  the  oxygen 
absorption  was  increased  46.8  per  cent.,  and  by  a 
douche  at  16°  C,  the  oxygen  absorption  was  in- 
creased 1 10. 1  per  cent. 

From  this  it  is  evident  that  in  health,  when  the 
available  oxygen  supply  is  large,  there  may  be  no 
difficulty  in  maintaining  this  increased  metaboHsm, 
with  none  but  physiological  effects.  When  the  avail- 
able oxygen  supply  is  diminished  or  oxygen  ex- 
change interfered  with,  however,  (the  demand  for 
the  maintenance  of  a  constant  temperature  continu- 
ing), the  body  cells  under  low  environmental  tem- 
perature require  an  increased  amount  of  oxygen  and 
become  reducing  agents  with  a  capacity  for  toxic 
action  proportional  to  their  increased  demand  for 
oxygen. 

That  deficient  oxidation  of  protein  derivatives  is 
an  active  factor  in  the  causation  of  toxaemias  of 
pregnancy  with  their  accompanying  renal  condi- 
tions, is  believed  by  Ewing  (55),  who  considers  that 
the  seriousness  of  any  case  may  be  established  by 
the  determination  of  incompletely  oxidized  protein 
derivatives  in  the  urine. 

Nephritis  a  Symptom,  not  a  Cause,  of  Eclampsia. 

The  view  that  eclampsia  is  independent  of  neph- 
ritis as  a  cause  but  may  be  due  to  interference  with 
oxidation,  is  illuminated  by  an  interesting  fact  com- 
municated to  us  privately  by  Dr.  Spitzley,  of  De- 
troit, who  observed  a  case  of  eclampsia  in  which  no 
kidney  lesions  were  apparent.  The  specially  inter- 
esting fact  about  this  case  was,  that,  as  a  result  of 
intrapelvic  pressure,  the  venous  system  of  the  pelvis 
and  lower  extremities  was  engorged  with  dark  ven- 
ous blood,  the  oxidizing  capacity  of  which  must 
have  become  seriously  impaired.  The  predominance 
of  reducing  over  oxidizing  factors  here  resulted  in 
the  production  of  an  eclamptic  seizure,  which  ceased 
upon  the  removal  of  the  foetus  and  relief  of  the  en- 
gorged condition.  Tlie  venous  engorgement  and  the 
onset  of  eclamptic  symptoms  had  been  sudden,  and 
sufficient  time  had  not  elapsed  to  produce  a  path- 
ological condition  in  the  kidney.  Such  a  case  em- 
phasizes the  importance  of  obeying  the  dictum  of 
the  physician  of  the  old  school,  against  tight  con- 
stricting articles  of  clothing,  which  might  produce 
venous  engorgement,  during  pregnancy. 

Chemicals.  Of  the  ingested  chemical  substances 
used  as  foods  or  drugs  the  one  of  greatest  import- 
ance for  our  consideration  in  nephritis,  is  alcohol. 
Rcebe  (56)  has  shown  that  alcohol,  even  when  in- 


gested in  moderate  amount,  causes  an  increase  in 
the  excretion  of  uric  acid.  The  eft'ect,  he  proves,  is 
due  to  a  toxic  effect  on  the  liver,  thereby  interfering 
with  the  oxidation  of  the  uric  acid  derived  from  its 
precursors  in  the  food. 

If  we  consider  the  origin  of  the  increased  quan- 
tity of  uric  acid  to  be  in  the  impaired  oxidative 
powers  of  the  liver,  the  results  of  these  experiments 
will  have  greater  significance  than  can  be  attributed 
to  uric  acid  alone ;  for  the  impaired  function  would 
affect  other  processes  which  are  normally  accom- 
plished by  that  organ,  and  the  possibilities  for  en- 
trance into  the  general  circulation  of  toxic  sub- 
stances, arising  from  intestinal  putrefaction,  for  in- 
stance, would  be  increased.  The  liver  performs  a 
large  number  of  oxidations  and  syntheses  designed 
to  keep  toxic  substances  from  reaching  the  body 
tissues,  and  if  alcohol,  in  the  moderate  quantity 
which  caused  the  increase  in  uric  acid  excretion, 
impairs  its  powers  in  this  respect,  the  prevalent  ideas 
regarding  the  harmlessness  of  moderate  drinking 
need  revision. 

Alcohol  is  a  food  in  the  sense  that  when  used  in 
small  quantities  the  energy  from  its  oxidation  may 
be  used  for  some  of  the  body  needs.  It  not  only 
undergoes  oxidation,  but  is  easily  oxidized  and  thus, 
as  can  readily  be  understood,  when  introduced  into 
the  body  in  large  amounts,  it  probably  appropriates 
a  large  percentage  of  the  accessible  oxygen  sup- 
ply, leaving  a  diminished  available  amount  for  those 
fluids  and  tissues  less  readily  oxidized.  In  this  way 
abundant  opportunity  is  given  for  the  formation  in 
the  body  of  products  of  insufficient  oxidation,  many 
of  which  are  toxic  and  capable  of  producing  patho- 
logical effects. 

The  effect  of  alcohol  on  the  liver,  in  its  relation 
to  processes  concerned  in  nephritis,  has  been  al- 
luded to.  That  such  interference  with  oxidation, 
probably  due  to  some  extent  to  interference  with 
enzyme  action,  may  also  exist  in  the  pancreas,  might 
be  inferred  on  pathological  grounds  from  Opie's  (57) 
observations.  By  him  alcoholic  excess  is  regarded 
as  a  frequent  cause  of  chronic  interstitial  pancre- 
atitis, this  condition  occurring  as  an  accompaniment 
of  cirrhosis  of  the  liver  and  granular  nephritis  in 
a  case  observed  by  Friedreich,  and  of  cirrhosis  of  th? 
liver  in  cases  observed  by  Choostels  and  Dieckhoff. 
all  in  alcoholic  subjects. 

lufluciice  of  Ijitestiiial  Lesions. 

That  pathological  conditions  of  the  intestinal  wall 
are  of  importance  in  the  occurrence  of  nephritis  has 
long  been  inferred  from  the  fact  of  their  frequent 
simultaneous  occurrence.  That  the  intestinal  mucosa 
is  an  organ  having  an  important  action  in  detox- 
icating  poisonous  protein  materials  during  absorp- 
tion, may  be  inferred  from  its  structure.  The  nucleus 
of  an  organ  is  the  chief  agency  in  the  intracellular 
activation  of  oxygen  and  the  oxidative  activities  of 
organs  are  largely  a  function  of  their  extent  of 
nuclear  surface.  The  nuclei  of  the  intestinal 
epithelial  cells  are  almost  in  contact  with  each  other. 
.\s  all  substances  which  are  absorbed  by  the  normal 
intestine  must  of  necessity  traverse  a  surface  in 
which  they  are  exposed  to  the  oxidative  action  of 
a  layer  of  closely  packed  nuclei,  it  may  be  s.en,  as 
is  affirmed,  by  Little  (58),  that  the  oxidative  activity 


May  29,  1909. J 


BERNSTEIN  AND  PRIED:  TUBERCLE  BACILLI  IN  THE  BLOOD. 


locjj 


of  the  intestinal  mucosa  is  intense.  It  may  also  be 
understood  from  this  fact,  how  any  disturbance  of  the 
activity  of  these  cells,  from  a  catarrhal  process  to 
necrosis,  would  tend  to  break  down  a  barrier  most 
important  in  protecting  the  body,  and  ultimately  the 
kidney,  from  unoxidized  toxins  produced  in  the  in- 
testinal canal. 

Experimental  Nephritis  in  Man  by  Reducing 
Agents. 

That  the  reducing  factors  here  recounted  are  of 
importance  in  reference  to  the  production  of  some 
of  the  symptoms  of  kidney  disease,  received  a  cer- 
tain amount  of  experimental  corroboration  from  the 
observations  of  Koritschoner  (  59).  He  reports  cases 
who  were  made  to  breathe  prussic  acid  vapor,  a 
strong  reducing  agent,  at  intervals,  during  many 
weeks,  with  the  idea  that  such  a  treatment  would 
destroy  the  tubercle  bacilli  in  the  pulmonary  areas 
affected.  Twenty-five  per  cent,  of  those  treated  in 
this  way  suffered  from  headache,  nausea,  vomiting, 
slow  pulse  and  even  albuminuria. 

In  this  connection  it  is  of  interest  to  note  that,  in 
the  case  of  the  lozu  and  medium  nitrogen  dogs  which 
received  cyanide  in  small  doses,  there  was  no  vomit- 
ing except  once  or  twice  immediately  after  the  cya- 
nide injection.  On  the  other  hand,  in  the  case  of  the 
high  nitrogen  dog,  which  also  received  cyanide  in 
small  doses,  vomiting  sometimes  occurred  as  late  as 
twenty-four  or  thirty-six  hours  after  the  injection 
of  cyanide. 

Underoxidized  nitrogenous  compounds  are  there- 
fore, probably  instrumental  in  producing  some  at- 
tacks of  toxic  vomiting.  The  same  may  be  said  of 
the,  partially  oxidized  members  of  the  acetone  group, 
whose  role  in  the  vomiting  of  pregnancy  and  child- 
hood is  already  a  matter  of  record. 

(To  be  concluded.) 


TEN  CASES  OF  TUBERCULOSIS  WITHOUT  TU- 
BERCLE BACILLI  IN  THE  BLOOD. 

Bv  E.  P.  Berxstein  M.  D.,  and  G.  A.  Fried,  M.  D., 
New  York. 

{From  the  Pathological  Laboratory  of  the  Mount  Sinai 
Hospital.) 

After  a  personal  interview  with  Dr.  Rosenberger, 
of  Philadelphia,  in  reference  to  his  article  in  the 
February  number  of  The  American  Journal  of 
Medical  Sciences,  for  1909,  we  examined  the  blood 
in  ten  cases  of  tuberculosis,  using  his  technique 
throughout. 

Two  smears  were  made  from  each  specimen  of 
blood,  and  at  least  half  an  hour  was  spent  over  each 
slide  in  the  search  for  tubercle  bacilli.  None  were 
found.  Two  cubic  centimetres  of  blood  from  each 
case  were  inoculated  intraperitoneally  into  guinea 
pigs.  Unfortunately  two  of  these  guinea  pigs  died 
from  accidental  causes  two  and  three  days  respect- 
ively, after  inoculation.  The  remaining  eight  were 
killed  after  seven  weeks  and  showed  absolutely  no 
evidence  of  tuberculosis. 

The  ten  patients  were  all  clinically  affected  with 
tuberculosis.  Two  cases  were  incipient ;  the  others 
were  in  the  third  stage  of  the  disease.  All  had  tu- 
bercle bacilli  in  their  sputum.    Between  5  c.c.  and 


10  c.c.  of  blood  was  taken  intra  vitam  in  all  but  two 
cases ;  in  these  the  heart  blood  was  withdrawn  im- 
mediately after  death. 

In  view  of  the  fact  that  none  of  the  guinea  pigs 
showed  any  signs  of  tuberculosis,  we  have  come  to 
the  conclusion  that,  although  demonstrable  tubercle 
bacilli  may  occasionally  be  found  in  the  blood  in 
some  cases  of  tuberculosis,  especially  in  those  of 
the  general  miliary  type,  they  are  not  found  so  fre- 
quently as  Rosenberger's  results  (125  times  in- 125 
cases)  would  indicate. 

 ^  

(But  ^tihtxi'  §mmiBn, 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXVl. — Hocv  do  you  make  an  early  diagnosis  of  pul- 
monary tuberculous  disease f   (Closed  May  ij,  iQOg.) 

LXXXVII. — How  do  you  treat  supraorbital  neuralgia? 
(Answers  due  not  later  than  June  15,  1909.) 

LXXXVIII. — Hoii)  do  you  treat  epistaxis?  (Answers 
due  not  later  than  July  15,  1909.) 

Whoever  ansxvers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prise  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  required)  that  the  answers  be  short;  if  prac- 
ticable no  one  answer  to  contain  more  than  si.v  hundred 
zvords. 

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whether  subscribers  or  not.  This  prize  will  not  be  awarded 
to  any  one  person  more  than  once  within  one  year.  Every 
answer  must  be  accompanied  by  the  writer's  full  name  and 
address,  both  of  which  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  JouR- 
N.aiL.  Our  readers  .\re  .'\sked  to  suggest  topics  for  dis- 
cussion. 

The  prize  of  $2^,  for  the  best  essay  submitted  in  answer 
to  question  LXXXV  has  been  awarded  to  Dr.  George  A. 
Graliam,  of  Kansas  City,  Mo.,  whose  article  appears  belozc. 

PRIZE  QUESTION  LXXXV. 
THE  NONOPERATIVE  TREATMENT  OF  DISEASE 
OF  THE  VERMIFORM  APPENDIX. 

By  George  A.  Graham,  M.  D., 
Kansas  City,  Mo. 

Of  late  prominent  surgeons  have  repeatedly  ac- 
knowledged that  many  normal  appendices  are  re- 
moved in  operations  for  the  relief  of  cases,  in  which 
positive  diagnoses  of  appendicitis  have  been  made. 

The  reason  for  this  is  that  many  cases  of  in- 
volvement of  the  vermiform  appendix  are  secondary 
to  inflammation  of  the  caecum,  caused  by  the  lodge- 
ment, in  the  csecal  cul-de-sac,  of  particles  of  undi- 
gested food,  seeds,  and  skins  of  fruit,  and  various 
foreign  bodies.  When  a  person  is  seized  with  sud- 
den pain  in  the  appendix  region,  or  pain  over  the 
abdomen,  becoming  localized  in  the  right  iliac  fossa, 
with  fever  and  local  tenderness,  often  with  distinct 
physical  signs  of  a  tumor  in  that  region,  in  the  ma- 
jority of  cases  the  exciting  cause  is  the  presence  of 
a  foreign  body  in  the  caecum,  below  the  ileocaecal 
valve,  which  causes  inflammation  of  the  caecum, 
with  all  the  cardinal  symptoms  of  appendicitis,  with- 
out as  yet,  any  involvement  of  the  vermiform  ap- 
pendix ;  and  in  many  cases  the  appendix  does  not 


1098 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal,, 


become  involved  to  any  appreciable  extent,  beyond 
a  slight  congestion,  which  passes  away  when  the 
condition  is  relieved. 

Why  then  do  these  patients  recover  after  the  re- 
moval of  the  appendix,  if  that  structure  is  not  in- 
volved ?  Simply  because  the  ofifending  material  in 
the  caecum  is  mechanically  dislodged  during  the 
manipulations  necessary  to  the  operation,  so  that  it 
comes  once  more  into  the  frecal  stream,  is  passed 
on,  and  ceases  to  be  a  source  of  irritation  and  con- 
sequent pain  ;  because,  the  appendix  having  be^n  re- 
moved, appendicitis  cannot  take  place  by  extension 
of  the  inflammatory  process  from  the  caecum  ;  and 
because  the  patient,  after  operation,  is  placed  under 
conditions  of  rest  and  diet  which  are  favorable  to 
recovery. 

A  faecal  impaction  is  not  found  on  operating,  be- 
cause in  most  cases,  the  foreign  material  is  of  such 
nature,  and  so  small  in  quantity,  as  to  be  not  notice- 
able frrm  without  the' bowel 

But,  if  the  ofifending  material  is  not  removed  then 
the  continued  irritation,  aided  by  the  many  germs 
ever  present  in  the  caecum,  will  cause  an  acute  in- 
flammation, which  soon  will  involve  the  appendix, 
and  we  have  a  true  appendicitis,  ending  according 
to  conditions,  either  in  death,  or  in  apparent:  recov- 
ery with  a  chronic  catarrhal  state  of  the  appendix, 
causing  so  called  physiological  involution  (atrophy 
or  obliterative  appendicitis)  or  causing  attacks  of 
appendicitis,  recurring  on  the  slightest  provocation, 
any  one  of  which  attacks  may  result  in  abscess 
formation,  gangrene,  or  perforation,  mostly  ending 
fatally  unless  the  appendix  is  removed  by  opera- 
tion. 

That  form  of  infection  of  the  appendix  which  oc- 
curs in  subjects  with  impaired  digestion,  sluggish 
liver,  obstinate  constipation,  and  autotoxsemia,  is  of 
gradual  onset,  the  first  symptom  being  occas'onal 
transitory  needlelike  pains  in  the  appendix  region, 
which  gradually  become  more  frequent  and  intense, 
until,  after  a  time,  well  marked  symptoms  of  appen- 
dicitis are  present.  This  is'the  form  to  which  neu- 
rasthenics are  specially  prone,  partly  due  to  the  ir- 
regularity and  unsuitability  of  their  diet,  and  partly 
to  their  obstinate  constipation. 

So  that,  in  the  prophylaxis  of  appendicitis  it  is 
necessary  to  regulate  the  diet  and  avoid  indigestible 
food,  and  food  which  may  contain  such  foreign 
bodies  as  seeds  and  shells  of  fruit  or  syrain.  Oat- 
meal is  safe,  but  the  chafiflike  shells  of  rolled  cats 
may  cau'se  trouble.  Aside  from  enteroliths,  foreien 
bodies  are  rarely  found  in  the  vermiform  appendix 
— Dslcr  found  them  only  twice  in  the  ten  years 
during  which  he  was  pathologist  to  the  Montreal 
General  Hospital — but,  as  already  stated,  they  are 
prone  to  accumulate  in  the  blind  end  of  the  caecum 
and  to  cause  inflammation  of  the  caecum,  and  by 
extension  to  involve  the  mouth  of  the  appendix,  oc- 
cluding or  narrowing  it,  and  infecting  the  contents 
of  that  organ.  This  accounts  for  the  number  of 
club  or  sausage  shaped  appendices  found  in  opera- 
tions for  chronic  appendicitis. 

When  digestion  is  imperfect,  appropriate  treat- 
ment should  be  given  to  remedy  that  condition, 
which  with  constipation  and  autointoxication  is  de- 
pendent on  improper  functionating  of  the  liver. 
Small  doses  of  true  salicylic  acid  or  .sodium  salicy- 


late with  phenolphthalein,  and  salts  of  the  bile  acids, 
will  act  as  a  cholagogue,  purgative  and  digestive, 
and  aid  this  condition.  Exercise  and  a  life  of  reg- 
ular habits  under  hygienic  conditions  are  important. 

Treatment.  Since  early  in  the  course  of  the  dis- 
ease it  is  impossible  to  distinguish  between  cases  of 
lodgment  of  foreign  bodies  in  the  caecum  which 
are  very  common,  and  cases  of  true  primary  ap- 
pendicitis which  are  rare,  in  all  cases  with  acute 
pain  in  the  region  of  the  appendix,  the  first  indica- 
tion is  to  remove  any  ofifending  material  by  flush- 
ing the  colon,  clear  down  to  the  caecum  with  as  large 
an  amount  of  fluid  as  the  patient  can  bear,  which 
should  in  adults  be  at  least  two  quarts.  It  may  he 
either  warm  water  or  a  mild  soapsuds  with  castor  oi'. 
or  glycerin.  The  patient  should  lie  on  his  right 
side  with  the  hips  slightly  elevated,  and  a  rectal 
tube  should  be  used,  inserted  as  high  up  as  possible. 
The  full  amount  of  fluid  having  been  used,  it  should 
be  retained  as  long  as  possible,  which  will  not  be 
long,  since  the  pain  is  markedly  increased.  Then  a 
clean  vessel  should  be  used,  and  the  resulting  pas- 
sage should  be  strained  through  gauze,  and  a  search 
made  for  foreign  bodies.  A  list  of  those  things 
which  I  have  found  in  various  cases  includes  grape 
and  apple  skins  and  seeds,  fig  seeds,  masses  of  rasp- 
berry seeds,  large  fish  bones,  date,  cherry  and  other 
fruit  stones,  orange  seeds  and  pulp,  the  shells  from 
rolled  oats  and  popcorn,  whole  pepper  corns,  cara- 
way seeds,  raisin  seeds  and  stems,  cucumber  se;ds, 
pickles,  peanuts,  chewing  gum,  and  in  one  cas2  a 
faecal  mass,  studded  with  watermelon  seeds  which 
had  been  swallowed  by  a  saloon  keeper  whilj  he 
was  intoxicated,  and  in  whose  case  appendicitis  had 
been  diagnosticated,  and  an  operation  advised  by 
a  consulting  surgeon.  The  operation  was  refused 
by  the  patient,  and  after  repeated  enemata,  the 
mass  was  passed  on  the  third  day  of  the  illness.  In 
most  cases  the  high  large  enema  gives  quick  relief. 
Usually  some  soreness  is  left,  and  some  tender- 
ness on  pressure,  for  a  day  or  two. 

It  is  advisable  to  repeat  the  enema  every  four 
hours  as  long  as  any  foreign  material  is  returned, 
with  the  fluid,  from  the  bowel.  The  enema  should 
be  used  in  spite  of  the  fact  that  the  patient's  bowels 
may  have  been  moved  freely  by  purgatives.  In  one 
case  of  a  boy,  aged  seventeen  years,  who  had  all 
the  symptoms  of  appendicitis  with  a  well  marked 
tumor  at  McBurney's  point,  the  bowels  had  moved 
a  dozen  times  on  the  day  on  which  I  first  saw  him, 
yet  straining  the  returned  fluid  of  the  enemata 
yielded  a  teacupful  of  grape  skins  and  seeds.  It 
is  difficult  to  pass  a  pin  along  the  interior  of  an 
empty  section  of  bowel,  but  fill  the  gut  with  water 
and  the  pin  will  drop  through  of  its  own  weight. 
Also  the  fluid  of  the  enema  mechanically  disturbs 
and  dislodges  the  foreign  matter  from  the  caiCiun 
and  throws  it  above  the  ileocaecal  valve,  and  into 
the  faecal  stream,  whence  it  is  carried  on  and  ex- 
])elled,  with  the  fluid,  from  the  bowel. 

Purgatives  should  never  be  given  in  either  true 
or  simulated  appendicitis. 

If  no  relief  is  t)i)taincd  from  the  use  of  several 
enemata  either  of  two  procedures  should  be  fo'. 
lowed — operation  or  the  starvation  treatment  as  laid 
down  by  Ochsner.  varied  in  this  much,  viz.,  the  ad- 
ministration, by  the  mouth,  of  intestinal  antiseptics, 


May  29,  1909. J 


CORRESPONDENCE. 


as  salol,  guiacol,  or  the  iodine  and  carbolic  acid  mix- 
ture— one  minim  of  carbolic  acid  and  two  m.nims 
of  tincture  of  iodine,  well  diluted  and  given  every 
three  hours. 

Counter  irritants  as  mustard  or  turpentine  and  a 
light  hot  water  bag  should  be  applied  over  the  ap- 
pendix region.  Do  not  use  ice,  and  under  no  cir- 
cumstances should  opiates  be  given.  Phenacetin 
and  aspirin  in  small  doses  every  four  or  five  hours 
will  control  the  fever,  allay  the  pain,  and  lessen  the 
inflammation.  The  intestinal  antiseptics  should  be 
continued  in  the  interval  between  the  attacks  of 
recurrent  appendicitis,  as  well  as  during  the  attacks, 
l^ut  these  patients  ,with  chronic  recurrent  appendi- 
citis can  no  more  recover  without  operation  than 
a  carious  tooth  can  cease  to  decay  v^dthout  a  dental 
operation.  These  patients  carry  about  an  appendix 
which  is  as  dangerous  as  a  stick  of  dynamite.  Either 
one  will  "get  them"  if  they  carry  it  long  enough. 

Yet  most  cases  of  chronic  appendicitis,  which 
were  originally  of  acute  and  sudden  onset,  could 
have  been  prevented  from  becoming  chronic  by  the 
free  use  of  colonic  or  rather  csecal  flushings  used 
early  in  the  acute  stage. 

During  many  years  of  general  practice  I  have 
used  this  method!^  with  recovery  in  every  case,  no 
acute  case  going  on  to  operation,  and  starvation 
treatment  has  only  been  precautionary  and  lim'ted. 

( To  be  continued.) 


LETTER  FROM  NEW  HAVEN. 

{From  a  Special  Correspondent.) 

Recent  Discussions  on  Psychotherapy.— The  Neiv  Haven 
Discussion. 

New  Haven,  Conn.,  May  18,  igog. 

The  recent  attempt  of  Emmanuel  Church,  of 
Boston,  to  enlist  the  cooperation  of  medical  men  in 
the  spiritual  healing  practised  by  its  pastors  has 
stimulated  medical  interest  in  the  attempts  of  Janet, 
Dubois,  and  Dejerine  in  Europe  and  of  Morton 
Prince,  Sidis,  Taylor,  and  others  in  this  country  to 
utilize  rationally  the  influence  of  the  mind  in  the  al- 
leviation of  disease.  In  order  to  reach  a  common  basis, 
the  physiology  and  pathology  of  psychic  reactions 
are  being  seriously  studied  by  many  American  neur- 
ologists. The  first  of  a  series  of  recent  discussions 
was  organized  by  the  Washington  Therapeutic  So- 
ciety, and  took  place  on  April  14th ;  the  second,  by 
the  national  body,  took  place  at  Yale  University, 
New  Haven,  on  May  7th.  At  the  latter  th.-  subject 
was  introduced  by  Dr.  Morton  Prince,  of  Boston, 
who  began  by  justifying  the  need  for  the  discus- 
sion with  the  remark  that  so  many  errors  and  mis- 
statements had  been  made,  both  lay  and  medical, 
that  skepticism  had  not  listened  to  really  serious 
workers.  The  practical  facts  accumulated  by  these 
must,  however,  tell,  if  they  were  examined  fairly. 

To  comprehend  the  subject  "the  complex"  must  be 
studied.  In  this  the  process  was  the  same  whether 
pathological  or  not,  dysergetic  in  place  of  synerge- 
tic  or  adaptive.  Pawlow's  experiments  were  already 
classic.     The   bladder   contracted   when  running 


water  was  heard.  The  complex  in  these  instances 
had  physical  elements  and  the  comprehensibility  of 
these  helped  us  to  understand  psychical  results, 
such  as  dizziness  and  confusion ;  indeed,  educat.on 
merely  consisted  of  the  formation  of  artificial  com- 
plexes. If  these  were  not  adaptive,  we  produced  a 
so  called  functional  neurosis,  which  in  turn  could 
be  removed  by  reeducation.  The  principle  depend- 
ed on  conservation  in  the  physical  memory  of  ex- 
periences once  associated.  Whether  formed  in  daily 
life,  dream,  or  hypnosis,  impressions  became  part 
of  us,  and  remained  organized  into  complexes, 
which  might  be  dissociated  cn  masse  from  the  com- 
plexes habitually  employed,  and  hence  appear  to  be 
forgotten ;  a  functional  amnesia,  only  reciuiring  the 
appropriate  psychological  stimulus  to  become  real- 
ized. The  emotional  factor  was  most  influential  in 
biting  impressions  into  memory,  and  perhaps  hyp- 
nosis was  effectual  on  this  account.  Psychotherapy 
thus  created  nothing  new  ;  it  acted  physiologically 
by  using  the  normal  mechanisms  of  the  body  to 
undo  perversions.  It  was  merely  the  changing  of 
the  patient's  point  of  view  by  a  larger  experience 
and  knowledge  and  its  fixing  into  the  personality. 
From  a  chaos  of  idea  and  emotion  the  physician 
weaved  a  pattern  comprehensible  to  the  patient.  "I 
am  myself  again";  "the  scales  have  fallen  from  my 
eyes,"  etc. 

Dr.  Ernest  Jones,  of  Toronto,  speaking  of  psycho- 
analysis, emphasized  the  precision  both  in  methods 
and  applications  which  was  demanded  in  modern 
psychotherapy,  which  might  be  compared  to  tre- 
phining and  laparotomy  in  that  it  both  laid  bare  and 
remedied  in  the  same  operation,  and  that  it  was 
applied  to  known  conditions  and  added  precision 
in  new  ones,  better  diagnosis  thus  resulting  from 
treatment.  Clear  conceptions  would  prevent  the  ab- 
surdity of  trying  to  remove  toxines  or  sclerosis  by 
mental  means,  as  former  empiricists  had  tried  to  do. 

The  symptoms  of  psychoneuroses  had  been  shown 
by  Freud  to  be  due  to  the  mental  conflict  of  com- 
plexes, which  acted  as  irritants  when  repressed.  This 
conflict  often  operated  unconsciously,  as,  for  in- 
stance, by  an  exaggerated  solicitude  for  the  person 
one  suspected  unjustly  or  by  a  painful  emotion 
when  certain  people  were  spoken  of.  The  physician's 
task  was  to  find  the  genesis  of  the  final  symptom, 
the  patient's  complaint,  often  merely  the  symbolic 
expression  of  a  submerged  wish,  the  emotional  tone 
of  which  had  been  transferred  by  association  to 
some  indifferent  complex,  such  as  a  bodily  process. 
The  patient  did  not  understand  this  until  the  doc- 
tor found  it  out  and  explained.  To  do  this,  hyp- 
nosis was  rarely  required,  having  been  superseded 
by  the  "free  association  method"  of  concentrating 
on  a  given  idea  and  spontaneously  repeating  the 
thoughts  which  came,  entirely  suspending  direction 
and  criticism  of  these.  At  first  it  was  hard  for  the 
patient  not  to  omit  irrelevant  and  painful  thoughts, 
but  a  few  sittings  remedied  this.  Other  means  of 
gaining  information  were  verbal  slips,  tricks  of 
manner,  the  association  test  words  of  Jung,  and  the 
analysis  of  dreams,  which  was  the  most  fruitful  of 
all  methods  of  retracing  the  genesis  of  a  psychosis. 
The  doctor,  in  understanding  the  veiled  language 
of  liis  subject,  learned  to  control  him.  It  was  not 
a  suggestion,  for  nothing  was  added ;  it  was  a  train- 


IIOO 


CORRESPONDENCE. 


[New  York 
Mebical  Journal. 


ing  in  ability  to  know  and  do,  and  the  results  were 
permanent  and  prophylactic,  whereas  suggestion 
was  neither,  merely  blocking  manifestations,  com- 
parably to  the  stopping  of  a  sinus.  The  time  re- 
quired was  no  greater  than  in  physical  orthopaedics, 
and  more  benefit  was  derived.  Every  physician 
would  not  employ  psychoanalysis  of  this  kind  any 
more  than  he  would  venture  to  extirpate  the  Gas- 
serian  ganglion,  but  a  knowledge  of  its  principles 
would  save  from  the  charlatan  and  their  own  future 
injury  a  considerable  number  of  neurotic  individu- 
als whose  fashion  it  was,  and  not  without  justifica- 
tion, to  scofif  at  the  measures  which  the  medical  pro- 
fession had  hitherto  employed  for  their  relief. 

Dr.  E.  W.  Taylor,  of  Boston,  expounded  the 
method  he  preferred,  that  of  simple  explanation  and 
education.  The  two  great  difficulties  in  rational- 
izing the  treatment  of  the  psychoneuroses  were  that 
it  was  believed  by  some  to  be  too  complex  for  prac- 
tical use,  and  by  others  to  be  merely  common  sense, 
and  too  simple  to  be  worth  considering.  Both  these 
opinions  were  wrong,  for  the  method  was  neither 
indefinite  nor  unattainable  by  the  majority.  Though 
the  means  were  always  there,  the  applications  were 
new,  and  the  practitioner  required  a  method  for 
searching  the  mind  just  as  much  as  for  the  heart 
and  lungs.  His  own  method  was  to  let  the  patient 
tell  his  story  with  the  minimum  of  interruption, 
then  for  himself  to  explain  his  difficulties  and  their 
origin,  and  lastly  to  show  him  where  lay  his  fault, 
the  correct  way  out,  and  how  to  find  it,  thus  edu- 
cating him  to  a  readjustment  of  his  life.  An  un- 
methodical appeal  could  not  do  what  this  method 
performed.  If  the  symptoms  were  too  deep  seated, 
however,  a  more  delicate  method  must  be  used.  In 
most  cases,  however,  this  simple  method  was  ade- 
quate, for  there  was  no  real  defect  of  nervous  or- 
ganization, but  merely  an  erroneousness  of  outlook 
to  which  the  patient  acted  normally.  The  patient 
only  needed  to  understand  in  order  to  readjust  him- 
self. He  was  a  child,  so  to  speak.  For  instance, 
because  a  man  could  not  recollect  what  he  read,  he 
concluded  that  his  memory  had  gone,  and  inferred 
that  he  was  losing  his  mind.  The  emotional  dread 
of  this  brought  him  to  the  doctor,  who  explained 
and  proved  that  the  amnesia  was  from  lack  of  con- 
centration, and  that  there  was  no  danger.  Again, 
the  popular  belief  that  the  regular  amount  of  sleep 
was  needed  to  maintain  mental  health  was  respon- 
sible for  much  anxiety  among  subjects  who  were 
wakeful  for  some  reason.  The  fear  of  not  sleeping 
thus  arising  caused  a  vicious  circle,  which  was  eas- 
ily broken  by  examination  and  the  removal  of  the 
false  premise  that  so  much  sleep  was  necessary. 
Any  physician  could  command  this  method.  Person- 
ality had  nothing  to  do  with  it ;  it  was  not  a  sug- 
gestion, but  an  appeal  to  reason,  and  was  not  con- 
fined to  nervous  cases  alone. 

Dr.  Tom  A.  Williams,  of  Washington,  dis;ussed 
psychoprophylaxis  in  childhood,  in  the  sense  of  pre- 
vention by  psychic  means,  not  necessarily  of  psychic 
disorders.  As  such,  it  played  a  large  part  in  public 
measures  of  sanitation.  Only  laymen,  and  especially 
ecclesiastics,  would  exaggerate  its  uses.  The  monis- 
tic physician  would  not  forget  the  physical  basis  of 
healthy  mentality,  and  would  take  care  that  his  ex- 
hortations were  not  obstructed  by  neuronic  intoxica- 


tions and  exhaustion.  A  psychological  training 
would  prevent  hypothetical  physiological  explana- 
tions not  yet  warranted  by  fact,  but  his  diagnosis 
was  none  the  less  exact  so  far  as  it  went.  The  es- 
sence of  psychoprophylaxis,  as  of  psychotherapy 
and  education,  was  to  associate  useful  activities  with 
agreeable  feeling  tones,  and  to  disassociate  from 
useless  or  injurious  acts  the  agreeable  feeling  tones 
they  might  have  acquired.  The  method  was  essen- 
tially a  "conditioning"  of  the  reflexes,  as  had  been 
done  by  Pawlaw  in  dogs.  The  emotional  element 
of  a  conditioned  reflex  tended  to  fade  as  a  rule, 
though  sometimes  an  effect  might  persist  alone. 

The  interest  sentiment  was  a  necessity,  and  was 
the  secret  of  the  method  of  substitution.  Sometimes 
much  repetition  was  needed  to  bring  an  idea  home, 
but  persuasion  was  often  the  most  powerful  weapon, 
as  shown  by  Judge  Lindsey's  management  of  incor- 
rigible boys.  The  increased  impressibility  of  hyp- 
nosis could  not  do  more  and  had  serious  drawbacks, 
in  that  the  patient  in  that  state  was  not  aware  why 
he  accepted  ideas,  his  judgment  was  stunted,  and 
his  hysterizability  increased.  A  dreamy  acceptance 
was  not  our  goal,  but  an  active  awareness ;  not  con- 
trol, but  training  was  our  aim.  We  must  learn  to 
obviate  and  outgrow  the  prepossessions  and  inertia 
which  interfered  with  judgment.  Overanxiousness, 
the  product  of  excessive  interference,  was  a  form 
of  mental  prepossession.  The  other  extreme  must 
be  avoided,  however,  and  a  sense  of  fitness  should  be 
encouraged. 

Bad  psychic  habits  might  quickly  form  during 
physical  depression ;  functional  perturbations  tended 
to  continue  when  once  begun.  The  increased  sug- 
gestibility in  these  states  must  be  allowed  for.  The 
states  of  well  being  and  buoyancy  should  be  used  to 
cultivate  difficult  acts  and  inhibitions,  remembering 
that  ample  outlet  must  be  afiforded  mental  energ\ . 
Suggestion  must  not  be  overworked ;  authoritative 
affirmation  was  often  preferable ;  for  the  child 
then  knew  he  was  acting  another's  will,  and 
was  not  cajoled  into  a  false  belief  that  he 
himself  was  the  determinant  of  his  action.  When 
duties  were  real  acts,  and  not  mere  prohibitions, 
they  were  not  apt  to  obsess,  even  though  they 
became  morally  imperative  and  deep  rooted.  Incul- 
cation was  useless  in  the  prevention  of  "fear 
thought"  ;  action  was  necessary. 

The  affections  must  not  be  suppressed,  but  the 
craving  for  sympathy  was  easy  to  prevent  by  arous- 
ing active  interest  in  impersonal  matters,  such  as 
the  cultivation  of  order,  which  was  the  precursor 
of  accuracy  in  word.  In  this  way  mythomanic  ten- 
dencies might  be  overcome.  To  secure  the  kinetism 
needed  for  an  efficient  morality,  boys  must  be 
trained  by  men,  who  could  participate  in  their  ac- 
tive games,  which  were  the  finest  of  all  means  of 
training  self  control,  and  preventing  despondency, 
suspiciousness,  and  such  antisocial  feelings.  Con- 
stant reference  to  others  bred  self  respect,  which  in 
turn  restricted  suggestibility.  With  such  condition- 
.  ing  of  the  reflexes,  no  man  would  weep  all  nisiht 
for  his  mother  after  two  months  of  married  life. 

Much  suffering  was  caused  by  the  failure  to  ra- 
tionalize the  management  of  the  sexual  instinct ;  the 
common  attitude  of  reserve  was  very  injurious  in 
that  respect.    The  mediaevalism  which  permitted  the 


May  29,  1909.] 


THERAPEUTICAL  NOTES. 


I  lOT 


imprisonment  of  a  writer  on  sexual  hygiene  could 
be  eradicated  to-morrow  if  the  medical  profession 
spoke  frankly. 

The  horrors  of  religious  forebodings  and  fears 
would  be  less  numerous,  too,  were  we  to  speak  more 
plainly  of  their  perniciousness  to  the  growing 
psyche,  and  were  we  to  substitute  for  it  the  fulfilled 
desires  of  productive  activity,  which  discouraged 
both  self  distrust  and  its  daughter,  pride,  which  so 
often  ended  in  ideas  of  reference  and  paranoia.  An- 
other indictment  against  medical  men  was  afforded 
by  the  so  called  gastric  neurosis,  which  was  gen- 
erally the  product  of  a  doctor's  imprudent  sugges- 
tion. 

The  neurotic  states  should  be  detected  at  their 
incipiency  by  neurological  inspection  of  school  chil- 
dren in  cooperation  with  the  teachers,  for  whom  a 
scientific  attitude  was  more  attainable  than  for  the 
priest.  Thev  were  seeking  our  assistance,  and  the 
duty  lay  at  our  hand.  It  was  by  us,  too.  that  mothers 
must  be  taught  how  to  give  their  children  healthy 
emotional  habits.  It  was  here  that  the  neurologist 
joined  his  brethren,  the  bacteriologist  and  sanitarian, 
in  sociological  functions  by  distinguishing  fboth  in 
the  individual  and  in  the  mass)  from  the  aberrations 
of  conduct  due  to  changes  of  the  secretions  of  the 
nervous  system  those  due  to  aberrant  notions,  and 
by  supplementing  by  his  broader  conceptions  those 
of  the  pedagogue  and  priest.  His  function  was  to 
mend  maladjustments  to  environment,  arrest  mor- 
bid trains  of  thought,  and  set  minds  at  rest.  His 
accurate  training  was  a  much  better  preparation  for 
this  duty  than  that  of  the  priest,  however  elaborate, 
for  he  would  not  be  turned  from  a  study  of  the 
truth  by  prepossessions,  however  sacred.  But  to 
affect  a  knowledge  he  did  not  possess  placed  him 
in  the  place  of  the  Christian  Scientist,  whose  rre- 
tensions  we  all  condemned.  To  meet  the  public's 
demand  for  psychic  treatment,  the  profession  re- 
quired psychopathological  wards  and  cut  patient 
clinics  under  competent  teachers :  and  their  want 
was  an  urgent  need  which  it  was  to  be  trusted  th-'s 
discussion  would  help  to  fill. 

Dr.  James  J.  Putnam,  of  Boston,  speaking  of 
character  formation,  believed  the  natural  uncon- 
scious self  to  constitute  the  character  as  against  the 
conventionalized  self.  In  training  it.  we  must  elim- 
inate occultism  and  militarism.  Even  invalidism 
might  develop  force.  Evil  tendencies,  even  when 
dependent  upon  bodily  mechanism  and  deep  rooted 
ideas,  might  be  eradicated,  as  examples  had  shown, 
by  side  tracking  or  substitution,  or  by  converting 
a  fault  into  a  virtue,  as  did  Bunyan  and  Paul.  In 
the  procedure,  prudence  should  sometimes  give  way 
to  passion,  science  might  be  too  cold  and  formal, 
and  physicians  were  often  too  hostile  to  sentiment 
and  spirituality,  which  had  held  up  many.  Prin- 
ciples were  better  than  rules ;  though  new  methods 
were  welcomed  and  skilful  treatment  was  required 
to  regulate  imperious  instincts. 

The  discussion  was  concluded  by  Donley,  of 
Providence,  in  an  illuminating  presentation  of  the 
treatment  of  obsessions  and  associated  states  in 
psychasthenia.  Every  one  of  these  had  its  historj,', 
each  arising  at  some  time  and  place,  being  continu- 
ous in  automatic  existence  and  often  intrusive.  Its 
nucleus  might  be  in  either  idea,  feeling,  or  emotion, 


which  had  not  been  assimilated  and  formed  a  separate 
complex,  which  might  be  partly  unconscious,  show- 
ing itself  only  in  physiological  states.  The  complex 
might  be  excited  by  the  accidental  stimulus  of  a 
word,  such,  for  instance,  as  the  mention  of  nursing 
a  child  recalling  a  fear  of  cancer  in  the  listener's 
mind. 

It  was  unfortunate  that  time  did  not  permit  of 
such  discussion  of  the  papers  that  the  views  of  the 
general  practitioner  could  be  declared.  As  it  was, 
much  informal  discussion  occurred  after  the  meet- 
ing and  very  varj'ing  opinions  were  expressed,  some 
declaring  that  they  believed  the  measures  discussed 
were  excellent  and  should  be  more  generally 
adopted,  and  others  expressing  profound  skeptic'sm. 

 «)  


Calcium  Lactate  in  the  Treatment  of  Epilepsy. 

— Littlejohn  {The  Lancet.  May  15,  1909)  reports 
successful  results  in  the  treatment  of  epilepsy  by  the 
use  of  calcium  lactate,  adrrynistered  in  doses  of  fif- 
teen grains  three  times  a  day. 

The  Treatment  of  Chronic  Constipation. — La 

Rcforma  Medica  for  January  11,  1909,  is  credited 
by  the  Revue  de  therapcutique  with  the  following 
prescription  for  overcoming  chronic  constipation : 
Sublimed  sulphur, 

Pulverized  senna  leaves,  washed  with  alco- 
hol,  aa  5iiss ; 

Pulverized  fennel. 

Pulverized  star  anise  seed  aa  ji ; 

Potassium  bitartrate,   .-.Sv; 

Pulverized  licorice,   Jii ; 

Ammoniated  glycyrrhizin,   .3i; 

Pulverized  sugar,   'viii ; 

M.  et  Sig. :  One  or  two  teaspoonfuls  to  be  mixed  with  a 
glassful  of  water  and  taken  at  night. 

Anaphrodisiacs  in  Gonorrhoea. — Against  erec- 
tions the  two  following  prescriptions  are  recom- 
mended by  a  contributor  to  The  Practitioner  for 
April,  1909: 

(1)  B    Monobromated  camphor  3i; 

Pulv.  et  divid.  in  dos.  x.  Dispense  in  catchets  or  wafers. 
Sig. :  One  three  or  four  times  daily. 

(2)  B    Potassium  bromide  3iiss-3iv; 

Lupulin. 

Camphor  aa  gr.  viii-gr.xxiv. 

M.  ft.  Pulv.  div.  in  dos.  x.    Dispense  in  waxed  paper. 
Sig. :  One  powder  two  to  four  times  daily. 

Sodium  Silicate  in  the  Treatment  of  Arterio- 
sclerosis.— ^Scheft'er  ( Archives  de  medicine.  No.  6. 
1908;  and  La  Clinique.  March  19.  1909)  nroposes 
the  treatment  of  arteriosclerosis  with  sodium  sili- 
cate. In  practise  it  is  noticed  that  arterial  pressure 
is  reduced  after  five  days  of  treatment,  and  the  cere- 
bral symptoms  are  also  lessened.  When  there  is 
albumin  it  is  raoidlv  diminished.  The  svruov  liquid 
of  commerce  [water  glass]  is  used  in  divided  doses 
of  from  twenty  to  forty-five  grains  dailv.  as  in  the 
following  prescription  : 

B     Sodium  silicate,   3'; 

Distilled  water  5xvi. 

M.  et  Sig.:  One  tablespoonful  in  a  little  water  two  or 
three  times  daily  with  meals. 

The  treatment  is  continued  for  one  or  two  month.« 
according  to  the  results  obtained. 


1 102 


EDITORIAL  ARTICLES. 


[New  York 
Medical  JouRN\t. 


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NEW  YORK,  S.\TURDAY,  MAY  29,  1909. 


THE  PAXXREAS  IN  DIABETES  MELLITUS. 

Since  the  publication  of  the  experimental  work 
of  von  Mering  and  Minkowski,  in  1889,  and  that  of 
Opie,  in  1900,  the  chief  interest  in  the  pathological 
anatomy  of  diabetes  mellitus  has  centred  in  the 
lesions  of  the  pancreas,  which,  as  is  well  known, 
consist  of  changes  in  the  bodies  of  Langerhans.  A 
recent  contribution  to  the  literature  of  this  subject 
is  an  excellent  paper  in  the  Journal  of  Experimental 
Medicine  for  March,  by  Dr.  Russell  L.  Cecil.  The 
author  describes  the  changes  in  the  pancreas  in 
ninety  cases  of  diabetes  which  came  to  autopsy. 
Seventy-one  per  cent,  showed  a  definite  chronic 
interacinar  pancreatitis.  The  distribution  of  the  new 
connective  tissue  was  found  to  be  irregular  in  the 
majority  of  the  cases.  In  four  cases  of  diabetes  oc- 
curring in  patients  under  twenty  years  of  age  this 
interacinar  pancreatitis  was  absent.  In  the  glands 
removed  from  patients  between  the  ages  of  twenty 
and  thirty  years  the  lesion  was  met  with  in  only 
about  twenty-five  per  cent.,  but  after  the  age  of 
thirty  it  was  the  rule.  Eighty  per  cent,  of  the  cases 
showed  decided  sclerosis  of  the  arteries  of  the  pan- 
creas and  many  of  them  showed  h valine  degenera- 
tion in  addition. 

The  author  points  out  that,  both  clinically  and  ex- 
'leriinentally,  cases  are  constantly  encountered 
which  give  no  evidence  of  a  disturbance  of  the  car- 
bohydrate metabolism,  although  histologically  the 
pancreas  .shows  extensive  destruction  of  the  gland- 


ular acini.  Compression  and  atrophy  were  the  most 
common  changes  in  the  glandular  tissue,  according 
to  the  results  of  the  author's  study,  in  association 
with  chronic  interacinar  pancreatitis.  Fibrosis  was 
the  most  common  change  shown  i-i  the  islands  of 
Langerhans  in  eighty  per  cent,  of  the  cases.  The 
fibrosis  was  moderate  in  forty  cases  and  advanced 
in  thirty-six.  Hyaline  degeneration  was  seen  in 
twenty-seven,  well  marked  leucocvtic  infiltration  in 
nine,  and  hypertrophy  of  the  bodies  of  Langerhans 
in  seven,  in  two  of  which  there  was  also  adenoma 
of  the  thyreoid  body,  and  in  another  adenoma 
of  the  pituitary  body.  In  twenty  cases  the  nu-iiber 
of  the  bodies  of  Langerhans  was  diminished ;  five 
times  in  glands  that  appeared  normal,  and  fifteen 
times  in  cases  of  chronic  interacinar  pancreatitis.  In 
eleven  cases  the  pancreas  appeared  normal.  Cir- 
rhosis of  the  liver  was  present  in  seven  cases ;  in 
one  case  there  was  exophthalmic  goitre ;  in  two 
cases  of  cirrhosis  of  the  liver  there  was  haemo- 
chromatosis ;  acromegaly  was  present  in  one  case. 

An  interesting  portion  of  the  study  is  that  which 
shows  the  duration  of  the  disease  when  the  various 
lesions  already  described  were  present.  Cecil  found 
that  when  there  was  hyaline  degeneration  of  the 
islands  of  Langerhans  the  average  duration  of  the 
disease  was  three  years  and  a  half  (  sixteen  cases)  ; 
when  the  bodies  were  sclerotic  the  average  was 
three  years  and  eleven  months  (forty-six  cases); 
when  the  bodies  were  infiltrated  with  leucocytes  the 
average  was  eleven  months  (six  cases).  The  con- 
tribvition  is  particularly  valuable  from  the  fact  that 
such  a  large  number  of  cases  has  been  studied  by 
a  single  observer,  thus  doing  away  with  the  "per- 
sonal equation"  in  the  interpretaticn  of  results  found 
when  a  large  number  of  cases  is  described  by 
numerous  authors,  each  contributing  a  few  exam- 
ples. 


THE  NEW  FRENCH  CODEX. 

The  fact  that  the  call  for  the  ninth  decennial 
convention  for  the  revision  of  the  L'nited  States 
Pharmacopoeia,  which  is  to  meet  at  Washington 
next  May,  has  recently  been  issued  lends  special 
interest  to  the  subject  of  pharmacopoeia  revision  in 
general.  The  newest  of  the  national  pharma- 
copoeias, the  Codex  Medicaincntaritis  Gallicus.  as 
the  French  Pharmacopoeia  is  officially  known,  was 
issued  in  September  of  last  year,  and  became  official 
on  May  15th  of  this  year. 

.V  comparison  of  the  volume  with  the  official 
standard  for  medicaments  in  the  I'nited  States 
shows  a  wide  divergence  between  the  two,  lx)th  in 
methods  and  in  results.  The  French  work  was  re- 
vised by  a  commission  appointed  by  the  govern- 
ment and  ]niblished  under  government  sanction  by 


May  29,  1909.] 


ILDITORIAL  ARTICLES. 


1103 


the  medical  publishers,  Masson  et  Cie,  of  Paris, 
•(.kir  own  pharmacopoeia  was  revised  by  a  committee 
which  served  without  compensation,  the  members  of 
which  were  elected  by  a  vote  of  individuals  attend- 
ing the  pharmacopoeial  convention,  which  is  mad  ■ 
up  of  delegates  from  various  medical  and  pharm  - 
ceutical  organizations.  The  French  commissic:; 
comprised  four  professors  in  the  Faculty  of  Medi- 
cine, five  professors  in  the  Paris  Superior  School 
of  Pharmacy,  two  members  of  the  Paris  Pharma 
ceutical  Association,  one  military  pharmacist,  on 
member  of  the  Pasteur  Institute,  and  one  professo; 
of  veterinarv  medicine.  The  American  Committee 
of  Revision  numbered  twenty-five  members,  ci 
whom  all  were  pharmacists  or  connected  with 
pharmacy  or  chemistry,  save  six  who  were  physi 
cians. 

The  most  striking  difference  between  tlie  French 
standard  and  our  own  is  the  abundance  and  com- 
plexity of  the  formula  used  by  the  French  as  com- 
pared with  the  more  simple  and  less  numerous 
formulae  for  compound  preparations  given  in  the 
United  States  book  of  standards.  There  are,  for 
instance,  in  the  French  Codex,  several  preparations 
containing  fifteen  to  nineteen  different  ingredients. 
Xo  such  examples  of  polypharmacy  are  to  be  found 
in  the  United  States  Pharmacopoeia.  The  tendency 
toward  the  exclusion  of  compound  preparations  in 
pharmacopoeia  making,  which  finds  its  highest  de- 
velopment in  the  German  Arziicihiich ,  has  been  fol- 
lowed to  a  certain  extent  in  this  country.  This  ten- 
dency has  found  exaggerated  expression  in  a  reso- 
lution adopted  recently  by  a  branch  of  the  American 
Pharmaceutical  Association,  which  requests  the  re- 
visers of  the  Pharmacopoeia  to  omit  from  future  re- 
visions all  formulae  for  compound  preparations.  The 
French  have,  it  is  true,  omitted  about  200  galeni- 
cals formerly  official,  but  they  still  have  retained 
a  number  of  compound  preparations  which  are  not 
official  in  our  own  book.  Among  the  classes  of 
preparations  which  are  recognized  by  the  French 
and  not  by  iis  are  alcoolatures,  or  fresh  drug  tinc- 
tures, apozemes  (either  decoctions  or  infusions), 
medicated  baths,  collutories  (semiliquid  prepara- 
tions for  application  to  the  gums),  eye  washes,  elec- 
tuaries, species,  soft  extracts,  granules,  medicated 
oils  (made  by  maceration  of  the  medicament  in  a 
fixed  oil),  a  foot  bath,  juleps,  or  potions,  granules, 
juices,  tablets,  and  tisanes,  or  extemporaneous  in- 
fusions. 

The  introduction  of  a  chapter  on  physiological 
preparations  in  the  French  work  is  a  step  in  ad- 
vance which  will  undoubtedly  be  followed  in  the 
revision  of  our  own  pharmacopoeia.  The  increas- 
ingly important  part  which  serum  treatment  has 
come  to  play  in  medicine  calls  for  the  official  recog- 


nition cf  this  class  of  medicam.ms  in  all  pharma- 
copoeias. The  French  work,  besides  giving  general 
monographs  on  organotherapy  and  therapeutic 
serums,  makes  special  reference  to  antidiphtheritic, 
antistreptococcic,  antitetanic,  antivenomous.  and 
antipest  serimis.  The  work  also  recognizes  tuber- 
culin and  pest  "vaccine."  A  feature  of  the  French 
Codex  which  will  probably  not  commend  itself  to 
the  American  physician  is  the  chapter  devoted  to 
veterinary  medicine,  which  occupies  nearly  loO- 
pages.  The  French  Codex  follows  the  form  of 
Latin  nomenclature  common  in  the  European  phar- 
macopoeias, the  Latin  title  being  given,  for  instance, 
as  natriiun  phosphoricum,  instead  of  sodii  phosphas, 
as  in  our  own  pharmacopoeia. 

The  inclusion  of  a  list  of  maximum  doses  in  th,- 
French  work  will  perhaps  not  meet  with  the  ap- 
proval of  the  medical  profession  in  America.  Under 
t!:e  French  law  any  physician  ordering  a  dose  in 
I  xcess  of  that  given  in  the  list  of  maximum  doses 
is  required  to  write  "Je  dis  telle  dose."  Unless  such 
a  notation  is  made,  the  pharmacists  must  decline  to 
fill  the  order.  '  This,  as  will  be  seen,  imposes  on- 
the  physician  the  task  of  remembering  exactly  the 
point  at  which  the  pharmacopoeial  authority  draws- 
the  line  in  doses.  We  are  confident  that  the  medical 
profession  in  America  would  not  welcome  the  im- 
position of  such  a  limitation  on  their  right  to  specif  s- 
doses. 

On  the  whole,  the  new  French  Codex  is  a 
marked  improvement  over  the  edition  published  in 
1884  and  the  supplement  published  in  1895,  but  we 
do  not  think  that  it  compares  favorably  with  the 
United  States  Pharmacopoeia  except  in  the  inclusion 
of  serums,  and  this  in  no  wise  reflects  on  the  re- 
visers of  the  American  standard  at  the  time  when 
the  eighth  revision  of  the  United  States  Pharma- 
copoeia was  made,  for  the  status  of  serum  therapv 
did  not  then  justify  the  inclusion  of  this  class  of 
preparation. 


BOAS'S  TREAT.MEXT  OF  ILEAIORRHOIDS. 

It  is  certain  that  piles  are  often  cured  spontane- 
ously, and  that  fact  lends  plausibility  to  a  method' 
of  treatment  recently  advocated  by  Professor  I. 
Boas,  of  Berlin,  an  interesting  exposition  of  which 
is  given  in  the  Seiiiainc  medicale  for  May  12th. 
Boas  contends  that  internal  haemorrhoids  should  not 
be  reduced  when  they  become  prolapsed ;  further, 
that  they  should  be  made  to  protrude  and  then  left 
outside  the  anus.  It  is  generally  easy,  as  Boas  re- 
marks, for  the  patient  to  extrude  his  piles,  but  his 
efTorts  may  in  case  of  need  be  facilitated  by  the 
previous  injection  of  glycerin  or  a  solution  of 
sodium  chloride  into  the  rectum,  or  Bier's  suction 
apparatus  may  be  employed.    We  may  add  that  in 


1 104 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


the  case  of  women,  as  was  long  ago  pointed  out  by 
Dr.  Horatio  R.  Storer,  backward  and  downward 
pressure  with  a  finger  in  the  vagina  will  generally 
cause  the  piles  to  protrude.  Once  protruded,  they 
must  not  be  allowed  to  return  within  the  rectum. 

The  rationale  is  that  of  the  ligature.  At  first  the 
piles  become  considerably  swollen  and  gorged  with 
blood  owing  to  the  constriction  exerted  by  the 
sphincter.  At  the  same  time  the  anal  region  is 
found  to  be  cedematous,  and  the  oedema  plays  an 
important  part  in  the  process  of  cure,  fixing  the 
tumors  in  their  new  situation  and  gradually  cutting 
them  off  from  the  circulation.  The  oedema  goes  on 
increasing  for  the  first  three  or  four  days,  and  the 
cedematous  ring  becomes  sensitive  to  pressure ;  then 
these  phenomena  subside,  and  it  is  observed  that  the 
haemorrhoids,  which  v/ere  at  first  very  tense  and  en- 
gorged, gradually  become  gray  and  contract,  some- 
times showing  little  ulcerations  on  the  surface.  At 
the  end  of  a  week  the  tumors  are  reduced  to  half 
their  original  size  and  the  smallest  ones  have  en- 
tirely disappeared.  In  a  week  or  two  more  there  is 
nothing  left  but  nodules  hardly  as  large  as  a  lentil 
and  slightly  ulcerated.  These  become  paler  and 
paler  and  finally  disappear  altogether. 

The  discomfort  of  this  treatment  is  said  to  be 
easily  borne.  For  two  or  three  days  the  patients 
complain  of  a  sense  of  weight  or  of  shooting  pains, 
but  the  pain  is  rarely  so  severe  as  to  call  for  the  use 
of  anodynes,  such  as  suppositories  of  morphine  or 
codeine  with  belladonna.  Nevertheless,  it  is  well 
to  prescribe  rest  in  bed  or  on  a  lounge  for  those  few 
days.  On  the  other  hand,  there  is  no  occasion  to 
modify  the  diet.  When  the  oedema  has  disappeared; 
a  few  warm  sitz  baths  are  useful.  If  there  is  pro- 
nounced ulceration  of  the  haemorrhoids,  they  may 
be  lightly  cauterized  with  the  stick  of  nitrate  of 
silver,  or  antiseptic  powders,  like  calomel,  bismuth, 
etc.,  may  be  applied.  Boas  has  employed  this  treat- 
ment in  only  eight  cases.  Though  it  was  satisfac- 
tory in  all  of  them,  he  admits  that  the  number  is  so 
small  that  further  trials  are  needed  to  enable  us  to 
estimate  its  value.  These  ought  to  be  made  readily, 
for  the  procedure  is  simplicity  itself. 


ANOTHER  MEDICAL  HERO. 
Another  name  was  added  to  the  roll  of  honor  of 
the  United  States  Public  Health  and  Marine  Hos- 
pital Service  and  to  the  long  list  of  medical  men 
who  have  laid  down  their  lives  for  their  fellow 
men  when  Passed  Assistant  Surgeon  William  M. 
Wightman  died  of  yellow  fever  at  his  post  of  duty, 
in  Guayaquil.  Ecuador,  recently.  This  brave  and 
efficient  young  officer  gave  his  life  for  his  country 
as  truly  as  if  he  had  fallen  in  the  smoke  and  tur- 
moil of  a  firing  line.  He  went  to  that  infected  port, 
mindful  of  the  danger  awaiting  him,  to  keep  infec- 


tion from  his  native  shores.  He  died  in  the  per- 
formance of  a  duty  which  demanded  high  scientific 
ability  as  well  as  that  quiet  and  cheerful  courage 
which  makes  men  undisturbed  by  personal  danger 
rather  than  heedless  of  it.  Dr.  Wightman's  life  and 
his  death  were  worthy  of  ,  the  finest  traditions  of  his 
profession.  To  the  members  of  his  own  corps,  his 
name,  like  those  of  Groenvelt,  Branham,  McAdam, 
and  many  others  who  died  of  yellow  fever  in  the 
Hne  of  duty,  will  long  prove  an  inspiration  in  the 
warfare  against  infectious  disease  for  which  they 
are  enlisted. 


A   METALLIC   SUBSTITUTE   FOR  THE 
ESMARCH  BAND. 

A  real  improvement  on  the  Esmarch  rubber  band 
for  the  prevention  of  haemorrhage  in  the  course  of 
operations  on  the  limbs  seems  to  have  been  made  by 
Professor  A.  Monprofit  {Archives  proiinciales  de 
chirurgie,  April).  The  author  recognizes  the  great 
service  which  Esmarch's  rubber  tube  has  rendered, 
but  points  out  that  the  difficulty  of  sterilizing  it  and 
the  tendency  of  the  material  to  deteriorate  are  dis- 
advantages which  it  is  a  great  object  to  do  away 
with.  Soft  rubber,  he  reminds  us,  is  readily  altered 
by  heat,  and  he  might  have  mentioned  other  de- 
structive agencies,  for  we  all  know  that  the  "life" 
of  articles  made  of  that  material  is  uncertain  and 
comparatively  short  at  best.  It  has  happened  to 
him  to  see  the  band  break  at  the  moment  of  its 
application,  and  he  remarks  that  in  hot  countries 
this  annoying  accident  is  frequent. 

M.  Monprofit  calls  his  device  the  haemostatic 
spring  {ressort  hemostatiquc).  It  consists  of  a 
strong  spiral  spring  of  suitable  length  and  flexi- 
bility. To  one  end  of  the  spiral  there  is  attached  a 
handle  in  the  shape  of  a  cross  bar  for  facilitating 
the  forcible  stretching  of  the  spring,  and  at  the 
other  end  there  is  a  simple  device  for  locking  the 
band  at  any  degree  of  tension  desired.  We  may 
have  our  doubts  about  the  ease  of  keeping  this  ap- 
pliance sterile  and  absolutely  clean,  and  the  author 
himself  advises  the  interposition  of  a  sterilized 
compress  between  it  and  the  skin,  though,  appar- 
ently, to  guard  against  injury  of  the  integument. 
As  to  its  durability  in  comparison  with  that  of  a 
piece  of  soft  rubber  tubing,  however,  there  can  be 
no  question. 

Unfortunately,  says  M.  Monprofit,  we  still  oc- 
casionally have  to  perform  a  major  amputation  in 
civil  practice,  though  the  need  of  a  good  haemostatic 
band  is  not  often  pressing.  In  case  of  war,  how- 
ever, such  a  device,  substantial,  practicable,  and  easy 
of  application,  may  save  many  a  life  on  the  field 
of  battle.  With  the  aid  of  his  haemostatic  spring 
the  author  has  done  two  amputations  of  the  th'gh. 


May  29,  1909  ] 


NEIVS  ITEMS. 


1105 


and  in  each  case  he  found  haemorrhage  thoroughly 
and  easily  prevented.  He  thinks  that  the  appliance 
should  be  made  in  two  sizes — the  larger  for  the 
thigh  and  the  smaller  for  the  leg  and  arm  of  adults 
and  for  general  use  with  children. 

When,  as  often  happens  in  case  of  battle,  there 
are  numbers  of  wounded  men  who  cannot  be  defi- 
nitively attended  to  at  once,  but  are  losing  blood  to 
a  dangerous  amount,  a  ready  and  trustworthy  means 
of  controlling  the  flow  becomes  imperative.  The 
field  tournequet,  which  stops  the  current  in  the  main 
artery  of  a  limb  while  not  interfering  with  the  re- 
turn circulation,  is  under  such  circumstances  to  be 
preferred  to  any  appliance  which  makes  pressure 
upon  the  whole  circumference  of  the  limb,  provided 
oni  can  make  sure  that  the  pad  does  not  slip  out 
of  place ;  but,  if  the  wounded  man  cannot  be 
watched  continuously,  it  is  probably  better  to  em- 
ploy the  Esmarch  band  or  this  substitute  devised  by 
M.  Monprofit. 

 ®  

Letchworth  Village. — Senator  Allds's  bill  giving  the 
name  of  Letchworth  Village  to  the  Eastern  New  York 
State  Custodial  Asylum  has  been  signed  by  Governor 
H  ughes. 

New  Nurses'  Home  on  Randall's  Island. — Plans  have 
been  filed  for  a  home  to  be  built  by  the  city  for  the  nurses 
of  Randall's  Island  Children's  Hospital.  It  is  to  be  a  four 
story  structure,  with  a  frontage  of  175  feet  and  a  depth  of 
56  feet,  and  will  cost  $200,000. 

The  Philadelphia  Club  for  Graduate  Nurses  opened  its 
new  club  house,  at  922  Spruce  Street,  on  May  26th.  There 
was  no  formal  opening,  a  reception  being  held  from  4  to 
10  p.  m.,  which  was  largely  attended  by  physicians  and 
nurses  of  Philadelphia  and  their  friends. 

A  National  Tuberculosis  Sanatorium  at  Asheville.— A 
bill  has  been  introduced  into  congress  by  Mr.  John  G. 
Grant,  representative  from  the  Tenth  North  Carolina  Dis- 
trict, providing  for  the  establishment  of  a  national  sana- 
torium for  the  treatment  of  tuberculosis  in  the  vicinity  of 
Asheville,  N.  C. 

Hospital  Benefits. — About  $8,000  was  collected  for  the 
Homoeopathic  Hospital  of  Albany,  N.  Y.,  on  "tag  day"  held 
recently  in  that  city. 

At  a  benefit  performance  given  a  short  time  ago  at  the 
Belasco  Theatre,  Washington,  D.  C,  for  the  Episcopal 
Eye,  Ear,  and  Throat  Hospital,  more  than  $900  was  raised. 

Improvements  at  the  Loomis  Laboratory. — Plans 
have  been  filed  for  remodeling  the  first,  third  and  fifth 
floors  of  the  Loomis  Laboratory  of  Cornell  University  Med- 
ical College.  As  made  over  these  floors  will  contain  pro- 
fessors' ofl^ces,  new  rooms  for  inoculation  operations,  spe- 
cial laboratory  work,  physiological  research,  and  photomi- 
crography. 

Annual  Commencement  of  the  College  of  Physicians 
and  Surgeons  of  San  Francisco. — The  thirteenth  annual 
commencement  exercises  of  the  college  were  held  on 
Wednesday  evening.  May  19th.  The  degree  of  Doctor  of 
Medicine  was  conferred  upon  eleven  graduates,  the  degree 
of  Doctor  of  Dental  Surgery  upon  six  graduates,  and  the 
Degree  of  Pharmaceutical  Chemist  upon  ten  graduates. 

The  New  Hospital  for  Contagious  Diseases,  Philadel- 
phia.— The  Mayor  of  Philadelpliia  and  the  Director  of 
the  Department  of  Public  Health  and  Charities  have  issued 
invitations  to  a  reception  luncheon  and  inspection  of  the 
new  Hospital  for  Contagious  Diseases,  Second  and  Luzerne 
Streets,  Philadelphia,  on  Tuesday  afternoon,  June  ist,  at 
2  o'clock.  Conveyances  will  meet  cars  at  Second  Street 
and  Erie  Avenue,  between  i  and  5  o'clock,  to  convey  guests 
to  and  from  the  buildings. 


New  Buildings  for  the  Baltimore  City  Hospital. — 

Plans  and  specifications  have  been  filed  for  additions  to  the 
City  Hospital,  Baltimore,  which  will  cost  about  $300,000. 
Ihe  plans  provide  for  the  erection  of  two  large  fireproof 
buildings,  to  be  constructed  of  steel,  concrete  and  brick. 

Directorship  of  the  Pathological  Institute,  Ward's 
Island. — The  New  York  State  Civil  Service  Commission 
announces  that  an  examination  will  be  held  on  June  19th, 
from  which  to  make  certification  to  fill  the  position  of 
director  of  the  Pathological  Institute,  State  Commission  in 
Lrnacy,  Ward's  Island.    The  salary  is  $6,500  a  year. 

A  Laboratory  for  Inoculation  Experimentation  at  the 
College  of  Physicians  and  Surgeons. — Plans  have  been 
hied  for  a  laboratory  and  animal  room  to  be  built  on  the 
roof  of  the  College  of  Physicians  and  Surgeons,  New  York, 
for  purposes  of  inoculation  experimentation.  The  con- 
struction will  be  a  steel  frame,  filled  in  with  cement  plaster, 
and  will  cost  $10,000. 

The  New  York  Dermatological  Society. — At  the  an- 
nual meeting,  held  on  Tuesday  evening.  May  25th,  officers 
for  the  ensuing  year  were  elected  as  follows :  President,  Dr. 
Samuel  Sherwell;  secretary  and  treasurer.  Dr.  William  B. 
Trimble ;  executive  committee,  Dr.  H.  H.  Whitehouse,  Dr. 
A.  R.  Robinson,  and  Dr.  G.  H.  Fox  (with  the  president 
and  secretary  c.v  officio).  Dr.  Howard  Fox  was  elected  a 
member  of  the  society. 

Alumni  Dinner  of  Harvard  Medical  School. — The 
triennial  banquet  of  the  Alumni  Association  of  Harvard 
Medical  School  was  held  at  the  Hotel  Somerset,  Boston, 
on  the  evening  of  May  20th.  Dn  Alfred  Worcester,  presi- 
dent of  the  society,  presided,  and  among  the  speakers  were 
Ex-President  Eliot,  President  Lowell,  Dr.  William  Osier, 
General  Wood,  Dr.  Henry  Christian,  dean  of  the  medical 
faculty.  Lieutenant  Governor  Frotliingham,  and  Dr.  Philip 
.A.  Rrown.  of  the  Unix-ersity  of  California. 

The  Centenary  of  the  Birth  of  Oliver  Wendell  Holmes 
v,"!l  ho  celebrated  by  the  Samaritan  Hospital  Medical  So- 
ciety, Philadelphia,  at  the  last  meeting  of  the  society  for 
the  senson,  to  be  held  on  Saturday  evening.  May  29th.  Dr. 
W.  Wayne  Babcock  will  deliver  an  address  on  Oliver 
Wendell  Holmes,  the  Physician  and  Teacher  of  Medicine, 
which  \\  ill  be  preceded  by  readings  from  the  poetical  works 
of  iJr.  Holmes  by  Mrs.  John  R.  Winehart.  President  Rus- 
sell H.  Conwell,  of  Temple  University,  will  also  be  present 
to  pay  a  tribute  to  the  memory  of  his  oldtime  friend. 

A  Special  Meeting  of  the  Medical  Association  of  the 
Greater  City  of  New  York  will  be  held  in  the  Staten 
Island  Club,  St.  George,  on  Wednesday,  June  2d,  at  8:30 
p.  m.  The  programme  which  has  been  arranged  for  this 
meeting  includes  the  following  papers  :  Tuberculosis  of  the 
Knee  Joint,  by  Dr.  Irxing  D.  Steinhardt,  to  be  discussed 
by  Dr.  James  Porter  Fiske  and  Dr.  Charles  H.  Jaeger; 
Congenital  Syphilis,  bv'  Dr.  Le  Grand  Kerr:  and  The  Con- 
tagion Theory  of  Tuberculosis,  by  Dr.  Blake  White.  A 
cordial  invitation  is  extended  to  all  to  attend  the  meeting. 

The  American  Society  for  the  Study  of  Alcohol  and 
Other  Narcotics  will  hold  its  thirty-ninth  annual  meet- 
ing in  the  parlors  of  Young's  Hotel,  Atlantic  City,  N.  J.,  on 
June  7th,  8th,  and  9th.  One  session  only  will  be  held  each 
day,  from  9  to  11  a.  m.  At  i  p.  m.  on  Wednesday,  June 
9th,  a  temperance  lunch  will  be  served  at  the  hotel.  .Ad- 
dresses will  be  delivered  by  eminent  physicians,  and  a  cor- 
dial invitation  is  extended  to  all  who  are  interested  in  the 
scientific  study  of  the  alcohol  problem.  For  programmes 
and  further  particulars  regarding  the  meeting  address  Dr. 
T.  D.  Crothers,  Hartford,  Conn.,  corresponding  secretary 
and  treasurer  of  the  society. 

Personal. — Dr.  E.  Southard  has  been  appointed  pa- 
thologist to  the  Massachusetts  Board  of  Insanity,  which  is 
a  new  position  in  that  State.  Dr.  Southard  will  be  required 
to  visit  the  dififerent  institutions  from  time  to  time  as  the 
representative  of  the  board. 

Dr.  Alax  Meyer,  professor  of  experimental  psychology  in 
the  University  of  Missouri,  expects  to  sail  for  Europe 
abotit  the  first  of  June.    He  intends  to  spend  a  vear  abroad. 

It  is  renorted  that  Dr.  James  Tyson  will  retire  as  presi- 
dent of  the  College  of  Physicians  of  Philadelphia  with  the 
completion  of  his  present  term.  In  all  probability  he  will 
be  succeeded  by  Dr.  G.  E.  de  Schweinitz,  the  vice  president. 

Professor  Irving-  Hardesty,  professor  of  anatomy  at  the 
University  of  California,  has  accepted  the  chair  of  anatomy 
in  Tulane  University,  New  Orleans. 

Dr.  E.  O.  Smith,  secretary  of  the  Cincinnati  Academy  of 
Medicine,  ha<  beei  elected  secretary  of  the  new  faculty  of 
the  merged  Ohio-Miami  Medical  College. 


iio6 


NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


Contagious  Diseases  in  Chicago. — During  the  week 
tmciing  Aiay  15.  igoy,  there  were  reported  to  the  Depart- 
ment of  Health  966  cases  of  contagious  diseases,  as  fol- 
lows: Diphtheria,  90;  scarlet  fever,  121:  measles.  462; 
tuberculosis,  72;  pneumonia,  34;  typhoid  fever,  18;  chicken- 
pox,  47:  mumps,  64;  cerebrospinal  fever,  3;  erysipelas,  15. 

The  Kansas  Medical  Society  held  its  forty-third  an- 
imal meeting  in  Emporia,  recently,  and  elected  the  follow- 
ing officers  to  serve  for  the  ensuing  year :  President,  Dr.  O. 
J.  Furst,  of  Peabody ;  vice-presidents.  Dr.  T.  F.  Foncannon, 
of  Emporia.  Dr.  Walthall,  of  Parsons,  and  Dr.  J.  P.  Raster, 
of  Topeka ;  secretary.  Dr.  C.  S.  Huffman,  of  Columbus, 
and  treasurer.  Dr.  L.  H.  Munn.  of  Topeka. 

The  American  Laryngological  Association  will  hold 
its  thirtj-first  annual  congress  in  Boston  on- May  31st,  June 
1st  and  2d.  The  sessions  will  be  held  in  the  Harvard  Med- 
ical School.  The  programme  gives  promise  of  a  specially 
interesting  meeting,  and  a  good  attendance  is  expected. 
Dr.  A.  Coolidge,  Jr.,  613  Beacon  Street,  Boston,  is  president 
■of  the  association,  and  Dr.  James  E.  Newcomb,  118  West 
Sixty-nintl'i  Street,  New  York,  is  secretary  and  treasurer. 

The  Connecticut  River  Valley  Medical  Association 
held  it^  annual  lueeting  in  Bellows  Falls,  Vt.,  on  ^lay  6th. 
There  was  a  large  attendance,  and  the  papers  presented 
were  of  unusual  interest  and  value.  Officers  for  the  en- 
suing year  were  elected  as  follows :  President,  Dr.  J.  D. 
Proctor,  of  Keene,  N.  H. ;  vice-president.  Dr.  A.  J.  Miller, 
of  Brattkboro,  Vt. ;  secretary.  Dr.  J.  S.  Hill,  of  Bellows 
Falls,  Vt. ;  and  treasurer,  Dr  Edward  R.  Campbell,  of 
Bellows  Falls.  Vt. 

The  Southwestern  Kentucky  Medical  Association 
held  its  annual  meeting  in  Paducah  on  May  12th  and  elected 
the  following  officers :  President,  Dr.  W.  L.  Mosby,  of 
Bardwell ;  first  vice-president.  Dr.  J.  S.  Davis,  of  Lovelace- 
ville ;  second  vice-president.  Dr.  W.  W.  Richmond,  of 
Clinton ;  secretary.  Dr.  C.  E.  Purcell,  of  Paducah  :  treasurer. 
Dr.  C.  H.  Brothers,  of  Paducah ;  historian,  Dr.  R.  T. 
Hockcr.  of  Arlington.  The  semi-annual  meeting  of  the 
society  will  he  held  in  Benton  in  October. 
Scientific   Society   Meetings   in   Philadelphia  for  the 

Week  Ending  June  5,  1909: 
TfESD.w,  June  Jst. — Academy  of  Natural  Sciences. 
Wedxesd.w.  June  3d. — College  of  Physicians. 
Tiii:ksu.\v,   .htiic  Obstetrical    Society:  Germantown 

Branch,  Philadelphia  Coifnty  Medical  Society:  South- 
wark  Medical  Society:  Section  Meeting,  Franklin  In- 
stitute. 

Fkid.w,  June  4th. — Kensington  Branch,  Philadelphia  County 
Medical  Society. 

The  Traveling  Tuberculosis  Exhibit  of  the  New  York 
State  Department  of  Hc;ilth  is  now  at  Kingston,'  N.  Y.,  and 
ill  connection  with  it  a  special  meeting  of  the  Medical  So 
ciety  of  the  County  of  Ulster  was  held  on  Friday  evening, 
AF'.y  2tst.  '{"he  evening  w^s  devoted  to  a  consideration  of 
the  question  of  tuberculosis.  Dr.  A.  H.  Garvin,  superin- 
tendent of  the  State  Hospital  for  Incipient  Pulmonary- 
Tuberculosis,  Raybrook,  read  a  paper  entitled  The  Diag- 
nosis of  Incipient  Pulmonary  Tuberculosis,  and  Dr.  Arthur 
F.  Holding,  of  .-\lbany,  N.  Y.,  read  a  paper  on  the  Cse  of 
the  X  Ra>-  in  the  Diagnosis  of  Tuberculosis. 

Charitable  Bequests.— By  the  will  of  Mrs.  Anson  G. 
Phelps,  Jr.,  whn  died  recently  in  Tarrytown,  N.  Y..  the 
Tarrytown  Hospital  receives  $5,000:  the  Presbyterian  Hos- 
pital, New  York.,  receives  $10,000;  and  the  Lincoln  Hos- 
pital and  Home.  New  York,  receives  $5,000. 

By  the  will  of  Mrs.  A.  E.  Brown,  who  died  recently  in 
East  Kingston.  Mass.,  the  Hou.se  for  the  Aged  in  Lawrence 
gets  $5,000,  and  the  Lawrence  General  Hospital  becomes  a 
residuary  legatee. 

By  tiie  will  of  Sarah  M.  Larnard.  the  Roxbury,  Mass., 
Home  for  .-\ged  Women  receixcs  $2,000  and  the  New  Eng- 
land Bapti-^t  Hospital,  Roxbury,  receives  $1,000.  • 

By  the  will  of  Charlotte  M.  Ely,  the  Hartford  Hospital 
receives  $6,000  to  cstai)lish  a  free  bed  in  memorv  of  the 
testator's  father,  William  Ely. 

Bv  the  will  of  Jacob  I^ncnthal,  who  died  in  Albany, 
N.  Y.,  on  May  6th,  the  following  bequests  were  made  to 
Albany  institutions:  Guardian  Society,  $5,000:  Home  for 
Aged  Men,  $5,000:  the  Hebrew  lU-nevoleut  Societv,  $10,- 
000:  the  Jewish  Home  Society,  $,.ooo:  the  .Albany  Hos- 
nital,  $5,000:  and  the  Albany  Hospital  for  Incurables, 
$5,000. 


The  Health  of  Pittsburgh. — During  the  week  ending 
May  15,  1909,  the  following  cases  of  transmissible  diseases 
were  reported  to  the  Bureau  of  Health:  Chickenpox,  2 
cases,  o  deaths ;  typhoid  fever,  14  cases,  i  death ;  scarlet 
fever,  12  cases,  o  deaths ;  diphtheria.  3  cases,  2  deaths ; 
measles,  16  cases,  o  deaths  ;  whooping  cough,  46  cases,  4 
deaths ;  pulmonary  tuberculosis,  69  cases,  12  deaths.  The 
total  deaths  for  the  week  numbered  173,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  15.92  in  a  thousand  population. 

The  Mortality  of  Minneapolis. — During  the  month  of 
.\pril,  1909.  there  were  reported  to  the  Department  of 
Health  of  the  City  of  ^Minneapolis  284  deaths  from  all 
causes,  in  an  estimated  population  of  310,000,  corresponding 
to  an  annual  death  rate  of  9.17.  The  annual  death  rate  for 
the  year  1908  in  a  thousand  population  was  8.92.  The  total 
infant  mortality  was  46;  34  under  one  year  of  age  and  12 
between  one  and  five  years.  Of  the  total  number  of  deaths 
35  were  from  pneumonia,  30  from  pulmonary  tuberculosis, 
17  from  Bright's  disease,  22  from  cancer,  26  from  organic 
heart  disease,  6  from  diarrhoeal  diseases,  5  from  suicide, 
and  12  due  to  accidents. 

The  Milk  Supply  of  Philadelphia  was  the  topic  chosen 
for  discussion  at  the  May  26th  meeting  of  the  Centra: 
Branch  of  the  Philadelphia  County  Medical  Society.  The 
programme  included  four  papers  on  the  subject,  as  fol- 
lows :  The  Proper  Method  of  Producing  Milk,  by  Leonard 
Pearson,  B.  S.,  V.  M.  D. ;  the  Proper  Method  of  Handling 
Milk,  bv  Mr.  George  Abbott ;  The  Risks  and  Safeguards 
of  Pubi"ic  Milk  Supplies,  by  Dr.  A.  C.  Abbott;  The  Milk 
Question  from  the  Podiatrist's  Point  of  View,  by  Dr. 
James  H.  McKee.  An  interesting  discussion  followed  the 
reading  of  the  papers,  among  those  taking  part  being  Dr. 
Seneca  Egbert,  Dr.  Charles  M.  Seltzer,  and  Mr.  Charles 
n.  La  Wall. 

Infectious  Diseases  in  New  York: 

]Vc  arc  indebted  to  the  Bureau  of  Records  of  the  Dc- 
f^artinent  of  Health  for  the  following  statement  of  nezc 
cases  and  deaths  ref>orted  for  the  two  weeks  ending  May 
22,  iQog: 

Cases.     Deaths.    Cas'-s.  1)"?'')=. 

Tuberculosis    pulmonalis   550  176         678  155 

Diphtheria    318  32  351 

Measles    '.578  32       1.365  i 

Scarlet   fever    338  33         335  19 

.Smallpox   

\'aricella    167  ..  22") 

Typhoid  fever    56  4  48  7 

Whooping  cough    iii  14  105 

Cerebrospinal  meningitis    11  8  12  8 

Total   .3.129         299       3. '-'4  -'".I 

The  Alumnae  Association  of  the  New  York  Medical 
College  and  Hospital  for  Women  will  hold  its  annual 
meeting  at  the  Hotel  Manhattan,  New  York,  on  Tuesday 
afternoon,  June  ist,  at  2  o'clock.    There  is  to  be  a  special 
gathering  of  the  classes  of  1869,  1879,  18S9,  and  1899  to 
meet  the  new  inembers  of  1909.    The  alumnre  dinner  will 
be  held  as  usual  on  the  evening  of  June  1st  at  the  hotel, 
and  accommodations  at  class  tables  will  be  provided  on  re- 
ovest  made  to  the  chairman  of  the  dinner  committee,  Dr 
Gertrude  Van  de  Mark.  69  West  Ninetv-third  Street.  New 
York,  who  will  provide  extra  tickets.    The  commencement 
exercises  of  the  college  for  the  class  of  1009  will  be  held 
at  the  Waldorf-Astoria  on  the  evening  of  May  31st,  and  the 
trustees  and  faculty  of  the  college  extend  a  cordial  invita- 
tion to  the  medical  profession. 
Society  Meetings  for  the  Coming  Week: 
TrESi)A>-.  /)(;;(•  isl. — New  York  .Academy  of  Medicine  (Sec- 
tion in  Dermatology)  ;   New  York  Neurological  So- 
ciety: Buffalo  -Academy  of  Medicine  (Section  in  Sur- 
gery);   Ogdensburgh,    N.    Y..    Medical  .Association: 
Syracuse,  N.  Y.,  .Academv  of  Medicine:  Hudson  Coun- 
ty, N.  J.,  Medical  Association  (  Tersev  City);  Horuells- 
ville,  N.  Y.,  Medical  and  Surgical  .Association;  Bridge- 
port, Conn.,  Mcdicnl  .-i  ssociptio'v 
\\M-:i)NE,sn..\Y,  June  2d. — Society  of  .Alumni  of  Bellevue  Hos- 
uital.  New  York-  Harlem  Medical  .Associpt'on.  New 
^'ork  (annual)  :  Elmira,  N.  Y.,  .Academy  of  Medicine. 
THri<si).\v,  Ju"e       — Ne-v  York  .Acadetuy  of  Medicine. 

Dnnsville,  N.  Y..  Med'cal  .Association. 
l-'Kun^v,  June  4th. — New  York  .Ac^de"n-  of  Medicine  (Sec 
tion  in  Surgery');  New  Yo-^k  Mic-oscooical  Society; 
Ci-iinecological   Societv.   Brooklyn.   N.   Y. ;  Manhattan 
Clinical  Societv.  New  York. 


May  29,  igog.] 


NEPVS  ITEMS. 


The  Health  of  Philadelphia.— During  the  week  ending 
May  15,  1909,  the  following  cases  of  transmissible  diseases 
M  ere  reported  to  the  Bureau  of  Health  of  Philadelphia : 
Typhoid  fever,  79  cases,  9  deaths ;  scarlet  fever,  67  cases, 
4  deaths;  chickenpox,  57  cases,  o  deaths;  diphtheria,  86 
cases,  II  deaths;  measles,  335  cases,  10  deatlis ;  whooping 
cough,  19  cases,  3  deaths;  tuberculosis  of  the  lungs,  93 
cases,  58  deaths ;  pneumonia,  39  cases,  24  deaths ;  erysipelas, 
14  cases,  5  deaths ;  puerperal  fever,  i  case,  o  deaths ; 
mumps,  40  cases,  o  deaths ;  trachoma,  9  cases,  o  deaths. 
The  following  deaths  were  reported  from  other  transmissible 
diseases:  Tuberculosis,  other  than  tuberculosis  of  the  lungs, 
2  deaths;  diarrhoea  and  enteritis,  under  two  years  of  age, 
14  deaths.  The  total  deaths  numbered  445  in  an  estimated 
population  of  1,565,569,  corresponding  to  an  annual  death 
rate  of  14.78  in  a  thousand  population.  The  total  infant 
mortality  was  93;  72  under  one  year  of  age,  21  between  one 
and  two" years  of  age.  There  were  40  still  births;  19  males 
and  21  females.    The  total  precipitation  was  0.06  inch. 

The  Mortality  of  Chicago. — During  the  week  ending 
May  15,  1909,  there  were  569  deaths  from  all  causes,  106 
less  than  for  the  previous  week  and  66  less  than  for  the 
corresponding  period  in  1908.  The  annual  death  rate  in  a 
thousand  population  was  13.35,  as  compared  with  a  death 
rate  of  15.82  for  the  preceding  week.  There  were  fewer 
deaths  from  practically  all  the  important  diseases,  as  com 
pared  with  the  preceding  week,  with  the  exception  of 
measles,  which  was  epidemic  in  certain  localities.  The 
typhoid  fever  situation  was  particularly  satisfactory,  the 
death  rate  from  that  disease  for  the  past  month  being  the 
lowest  in  the  city's  history.  The  total  infant  mortality  was 
153;  104  under  one  year  of  age,  and  49  between  one  and 
five  years  of  age.  The  principal  causes  of  death  were : 
Diphtheria,  8  deaths;  scarlet  fever,  4  deaths;  measles,  6 
deaths ;  whooping  cough,  4  deaths :  influenza,  4  deaths ; 
typhoid  fever,  3  deaths ;  diarrhoeal  diseases,  38  deaths,  of 
which  26  were  under  two  years  of  age;  pneumonia,  114 
deaths;  pulmonary  tuberculosis,  73  deatlis:  other  forms  of 
tuberculosis,  7  deaths  ;  cancer,  29  deaths  ;  nervous  diseases, 
9  deaths;  heart  diseases,  60  deaths;  apoplexy,  13  deaths: 
bronchitis,  I  death ;  Bright's  disease,  33  deaths ;  \-iolence, 
51  deaths,  of  which  it  were  from  suicide,  33  from  acci- 
dents, and  7  from  manslaughter. 

Meetings  of  National  Medical  Associations  to  be  Held 
in  June: 

American  Medical  Association,  at  Atlantic  City,  June  8th 
to  nth.    Dr.  George  H.  Simmons,  of  Chicago,  secretary. 

American  Academy  of  Medicine,  at  Atlantic  City,  June 
5th  and  7th.  Dr.  Charles  Mclntire,  of  Easton,  Pa.,  secre- 
tary. 

American  Dermatological  Association,  at  Philadclohia, 
June  3cl,  4th,  and  Sth..  Dr.  Grover  W.  Wende,  of  71  Dela- 
ware Avenue,  Buffalo,  N.  Y.,  secretary. 

American  Laryngological  Association,  at  Boston,  on  May 
31st.  June  1st  and  2d.  Dr.  J.  E.  Newcomb,  of  118  West 
Sixty-ninth  Street,  New  York,  secretary. 

American  Orthopsedic  Association,  at  Hartford,  Conn., 
on  June  14th  and  15th.  Dr.  Robert  B.  Osgood,  of  372 
Marlboro  Street,  Boston,  Mass.,  secretary. 

American  Medicopsychological  Association,  at  Atlantic 
Citv,  on  June  ist,  2d,  and  3d.  Dr.  Charles  W.  Pilgrim,  of 
Poughkeepsie,  N.  Y.,  secretary, 

American  Climatological  Association,  at  Fortress  Mon- 
roe, Va.,  on  June  4th  and  5th.  Dr.  Guy  Hinsdale,  of  Hot 
Springs,  Va.,  secretary. 

American  Surgical  Association,  at  Philadelphia,  on  June 
3d,  4th,  and  5th.  Dr.  Robert  G.  Le  Conte,  of  Philadelphia, 
secretary. 

American  Medical  Editors'  Association,  at  Atlantic  City, 
on  June  5th  and  7th.  Dr.  Joseph  MacDonald,  Jr.,  of  92 
Willirm  Street,  New  York,  secretary. 

American  Proctological  Society,  at  Atlantic  City,  on  June 
7th  and  8th.  Dr.  Lewis  H.  Adler,  Jr.,  of  1610  Arch  Street, 
Philadelphia,  secretary. 

American  Gastroenterological  .■Association,  at  Atlantic 
City,  on  June  7th  and  8th.  Dr.  Charles  D.  Aaron,  of  32 
Adams  Avenue,  West,  Detroit,  Mich.,  secretary. 

American  Urological  Association,  at  .Atbntic  City,  on 
June  1st.  Dr.  Hugh  Cabot,  of  87  Marlboro  'Street,  Boston, 
secretary. 


Advanced  Course  in  Medical  Zoology. — The  London 
School  of  Tropical  Medicine  (University  of  London)  is 
planning  to  hold  advanced  classes  in  general  medical  zool- 
ogy, protozoology,  arthropodology  and  helminthology,  for 
medical  men  and  veterinary  surgeons.  The  classes  will 
commence  on  or  about  January  15th,  May  ist,  and  October 
I  St  in  each  year.  Students  who  have  attended  the  ordinary 
course  are  eligible,  also  those  w^ho  are  able  to  present  satis- 
factory evidence  that  they  possess  sufficient  rudimentary 
knowledge  to  benefit  by  the  advanced  course.  The  object 
of  these  advanced  courses  is  to  provide  a  sufficient  ground- 
work of  practical  training  to  enable  those  going  to  the 
tropics  to  pursue  further  investigation  unassisted.  Students 
who  have  attended  these  courses  are  eligible  for  the 
Cragg's  Prize  and  for  the  appointments  as  Cragg's  Investi- 
gators. For  further  particulars  apply  to  Dr.  G.  W.  Daniels, 
director  of  the  school,  Connaught  Road,  Albert  Dock,  E., 
l.,ondon. 

Vital  Statistics  of  New  York. — The  total  number  of 
deaths  reported  to  the  Department  of  Health  of  the  City 
of  New  York  during  the  week  ending  May  15,  1909,  was 
1,484,  corresponding  to  an  annual  death  rate  in  a  thousand 
population  of  16.96.  The  death  rate  for  each  of  the  five 
boroughs  was  as  follows :  Manhattan,  17.77 ;  the  Bronx, 
17.39;  Brooklyn,  16.23;  Queens,  12.35;  Richmond,  19.40. 
The  principal  causes  of  death  were :  Contagious  diseases, 
99  deaths;  whooping  cough,  14  deaths;  pulmonary  tubercu- 
losis, 176  deaths;  cerebrospinal  meningitis,  8  deaths;  bron- 
chitis, 23  deaths;  diarrhoeal  diseases,  106  deaths,  of  ^\hich 
49  were  under  five  years  of  age;  pneumonia,  no  deaths; 
bronchopneumonia,  118  deaths;  heart  diseases,  117  de-iths ; 
cancer,  57  deaths;  Bright's  disease,  125  deaths;  accidents, 
60  deaths;  suicides,  17  deaths;  homicides,  i  death.  The 
total  infant  mortality  was  495 ;  284  under  one  year  of  age, 
and  211  between  one  and  five  years  of  age.  There  were  135 
still  births.  Seven  hundred  and  seventy-six  marriages  and 
2,ig8  births  were  reported  during  the  week. 

Examination  for  Assistant  Surgeons  in  the  Public 
Health  and  Marine  Hospital  Service. — A  board  of  com- 
missioned medical  officers  will  be  convened  to  meet  at  the 
Bureau  of  Public  Health  and  Marine  Hospital  Service, 
Washington,  D.  C,  on  Monday,  June  14,  1909,  at  10  o'clock 
a.  m.,  for  the  purpose  of  examining  candidates  for  admis- 
sion to  the  grade  of  assistant  surgeon  in  the  Public  Health 
and  Marine  Hospital  Service.  Candidates  must  be  between 
twenty-two  and  thirty  years  of  age,  graduates  of  a  reputa- 
ble medical  college,  and  must  furnish  testimonials  from  re- 
sponsible persons  as  to  their  professional  and  moral  char- 
acter. In  addition  to  the  physical  examination,  candidates 
are  required  to  certify  that  they  believe  themselves  free 
from  any  ailment  which  would  disqualify  them  for  service 
in  any  climate.  The  examinations  are  chiefly  in  writing, 
and  begin  with  a  short  autobiography  of  the  candidate, 
the  remainder  consisting  chiefly  of  examination  in  the 
various  branches  of  medicine,  surgery,  and  hygiene. 
The  clinical  examination  is  conducted  at  a  hospital,  and, 
when  practicable,  candidates  are  required  to  perform 
surgical  operations  on  a  cadaver.  Successful  candidates 
will  be  numbered  according  to  their  attainments  on 
examination,  and  will  be  commissioned  in  the  same  or- 
der as  vacancies  occur.  Upon  appointment  the  young  offi- 
cers are,  as  a  rule,  first  assigned  to  duty  at  one  of  the 
large  hospitals,  as  at  Boston,  New  York,  New  Orle^.ns,  Chi- 
cago, or  San  Francisco.  After  four  years'  service,  assistant 
surgeons  are  entitled  to  examination  for  promotion  to  the 
grade  of  passed  assistant  surgeon.  Promotion  to  the  grade 
of  surgeon  is  made  according  to  seniority  and  after  due 
examination  as  vacancies  occur  in  that  grade.  Assistant 
surgeons  receive  $1,600,  passed  assistant  surgeons,  $2,000, 
and  surgeons  $2,500  a  year.  Officers  are  entitled  to  fur- 
nished quarters  for  themselves  and  their  families,  or,  at 
stations  where  quarters  cannot  be  provided,  they  receive 
commutation  at  the  rate  of  thirty,  forty,  and  fifty  dollars 
a  month,  according  to  grade.  .'Ml  grades  above  that  of 
assistant  surgeon  receive  loi^evity  pay,  ten  per  cent,  in 
addition  to  the  regular  salary  for  every  five  years'  service 
up  to  forty  oer  cent,  after  t^venty  years'  service.  The  tenure 
of  office  is  permanent.  Officers  traveling  under  orders  are 
allowed  actual  expenses.  For  further  information,  or  for 
invitation  to  anpear  before  the  board  of  examiners,  address 
the  Surgeon  General,  Public  Health  and  Marine  Hospital 
Service,  Washington,  D.  C. 


iio8 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  XOMENCLATURE. 


[New  York 
Medicai,  Journal. 


THE  BELLEVUE    HOSPITAL    NOMENCLATURE  OF   DISEASES  AND 

CONDITIONS.* 

First  Edition,  1903. 
First  Revision,  1909. 


Compiled  by  the  Committee 


ON  Clinical  Records,  Composed  of  Robert  J.  Carlisle,  Warren  Coleman, 
Thomas  A.  Smith  and  Edmund  L.  Dow. 


(Continued  from  page  to6^.) 


REPRODUCTIVE  ORGANS. 

FCNCTIONAL  DISTURBANCES  INVOLVING 
MALE  AND  FEMALE  SEXUAL  ORGANS. 

Do  not  use  as  a  primary  diagnosis  when  cause 

can  be  determined. 
Amenorrhcea. 
Dysmenorrhoea. 
Dyspareunia. 
Impotence. 
Masturbation. 
Menorrhagia. 
Menopause. 

-Menstruation,  Precocious.  Diagnosticate  as  Precocity. 
File  under  Miscellaneous  Diseases  and  Condi- 
tions. 

Metrorrhagia. 

Pruritus  Vulvae. 

Spermatorrhoea. 

Sterility. 

Vaginismus. 

M.\MMARY  GLAND. 

Abscess  of  Mammary  Gland. 

Abscess  Submammary. 
Agalactia. 

Atrophy  of  Mammary  Gland. 

Congenital  Malformation  of  Mammary  Gland.  File  un- 
der Congenital  Alalforniation  of  Reproductive 
(Irgans. 

Fissure  of  Nipple. 

Fistula  of  Mammary  Gland. 

Galactocele. 

Galactorrhoea. 

Hypertrophy  of  Mammary  Gland. 

Mamilitis. 

Mastitis,  Acute. 

Mastitis,  Chronic. 

Milk  Retention. 

Neurosis  of  Mammary  Gland.  Do  not  use  as  a  primary 
diagnosis  when  cause  can  be  determined. 

Parasite  of  Mammary  Gland.  State  varietj'.  File  under 
Parasitic  Diseases. 

Syphilis  of  Mammary  Gland.    File  under  Syphilis. 

Tuberculosis  of  Mammary  Gland.  F'ile  under  Tuber- 
culosis. 

Tu  iiior  of  Mammary  Gland.  State  variety.  File  under 
Tumors. 

A.    FEMALE  REPRODUCTIVE  ORGANS.— LIGA- 
MENTS, OVARIES,  AND  TUBES. 
Abscess  of  Ovary. 

Abscess,  Pelvic.  Do  not  use  as  a  primary  diagnosis 
when  cause  can  be  determined.  When  due  to 
gonococcus,  diagnosticate  as  Gonococcus  Infec- 
tion of.  File  under  Infective  Diseases.  .'Ml  other 
cases  file  under  Diseases  of  the  Peritonaeum. 

Atrophy  of  Ovary. 

Cellulitis,  Pelvic.  When  dnc  to  gonococcus,  diagnosti- 
cate as  Gonococcus  Infection  of.  File  under  In- 
fective Diseases. 

Congenital  Malformation  of.  State  part  affected.  File 
under  Congenital  Malformations  of  Reproductive 
Organs. 

Displacement  of  Falloppian  Tube. 
Displacement  of  Ovary. 
Gestation,  Extrauterine. 

Haematocele,  Pelvic.  Do  not  use  as  a  primary  diagnosis 
when  cause  can  be  determined. 


Hsematoma  of  Ovary.  ' 
H  aematosalpinx. 

Hydrocele  of  Round  Ligament. 

Oophoritis,  Acute.  When  due  to  gonoccocus,  diagnosti- 
cate as  Gonococcus  Infection  of.  File  under  In- 
fective Diseases. 

Oophoritis,  Chronic. 
Scle'rosis  of  Ovary. 

Parasite  of  Ovary.  State  variety.  File  under  Parasitic 
Diseases. 

Peritonitis,  Acute  Local.  Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined.  When  due 
to  gonococcus,  diagnosticate  as  Gonococcus  In- 
fection of.  File  under  Infective  Diseases.  AU 
other  cases  file  under  Diseases  of  the  Peritonaeum. 

Salpingitis,  Acute.  When  due  to  gonococcus,  diag- 
nosticate as  Gonococcus  Infection  of.  File  under 
Infective  Diseases. 

Salpingitis,  Chronic.  To  include  Hydrosalpinx.  When 
due  to  gonococcus,  diagnosticate  as  Gonococcus 
Infection  of.    File  under  Infective  Diseases. 

Syphilis  of.    State  part  affected.    File  under  Syphilis. 

Tuberculosis  of.  State  part  affected.  File  under  Tu- 
berculosis. 

Tumor  of.  State  site  and  variety.  File  under  Tumors. 
Varix  of  Broad  Ligament. 

UTERUS: 

Atrophy  of  Uterus.  To  include  Hyperinvolution  of 
Uterus. 

Atresia  of  Uterus,  Acquired. 

Congenital  Malformation  of  Uterus.  File  under  Con- 
genital Malformations  of  Reproductive  Organs. 

Displacement  of  Uterus. 
Prolapse  of  Uterus. 

Endometritis,  Acute.  When  due  to  gonococcus,  diag- 
nosticate as  Gonococcus  Infection  of.  File  under 
Infective  Diseases. 

Endometritis,  Chronic.    When  due  to  gonococcus,  diag- 
nosticate as  Gonococcus  Infection  of.   File  under 
Infective  Diseases. 
Endocervicitis,  Chronic. 

Fistula  of  Uterus. 

Hypertrophy  of  Cervix  Uteri. 

Laceration  of  Cervix  Uteri,  Old. 

Metritis,  Acute. 

Metritis,  Chronic. 

Stricture  of  Uterine  Canal. 

Subinvolution  of  Uterus. 

Syphilis  of  Uterus.    File  under  Syphilis. 

Tuberculosis  of  Uterus.    File  under  Tuberculosis. 

Tumor  of  Uterus.    State  variety.    File  under  Tumors. 

VAGINA: 

Abscess  of  Vagina. 

Atresia  of  Vagina,  Acquired. 

Congenital  Malformation  of  Vagina.    File  under  Con- 
genital Malformations  of  Reproductive  System. 
Cyst  of  Vagina.    File  under  Retention  Cysts  under  Tu- 
mors. 
Fistula  of  Vagina. 

Fistula,  Rectovaginal. 

Fistula,  Ureterovaginal. 

Fistula.  Urethrovaginal. 

Fistula,  Vesicovaginal. 
Laceration  of  Pelvic  Floor,  Old. 

Prolapse  of  Anterior  Vaginal  Wall,  .\lways  use  as  a 
secondary  dia.s^nosis  either  of  Laceration  or  Re- 
laxation of  T'ch  ic  Floor. 


May  29.  1 909. J 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  NOMENCLATUKE. 


1 105 


Prolapse  of  Posterior  Vaginal  Wall.  Always  use  as  a 
sfcoiuiary  diaynosi^  either  of  Laceration  or  Re- 
laxation 01  Pelvic  l'"loor. 

Relaxation  of  Pelvic  Floor. 

Syphilis  of  Vagina.    File  under  Syphilis. 

Tuberculosis  of  Vagina.    File  under  Tuberculosis. 

Tiiiiinr  of  Vagina.    State  variety.    File  under  Tumors. 

Vaginismus.    File  under  Functional  Disorders. 

Vaginitis,  Acute. 

Vaginitis,  Chronic.  When  due  to  gonococcus  diagnos- 
ticate as  Gonococcus  Infection  of.  File  under 
Infective  .Diseases. 

VULVA: 

Abscess  of  Bartholin's  Gland.  When  due  to  gonococcus, 
diagnosticate  as  Gonococcus  Infection  of.  File 
under  Infective  Diseases. 

Abscess  of  Vulva. 

Adhesions  of  Clitoris. 

Atrophy  of  Vulva. 

Chancroid  of  Vulva.    File  under  Infective  Diseases. 

Congenital  Malformation  of  Vulva.  File  under  Con- 
genital Malformations  of  Reproductive  Organs. 

Cyst  of  Bartholin's  Gland.  F^ile  under  Retention  Cysts 
under  Tumors. 

Elephantiasis  of  Vulva,  Nonfilarial.    File  under  Dis 
eases  of  Lymphatic  System.    When  due  to  filaria 
diagnosticate  as  Filariasis.    File  under  Parasitic 
Diseases. 

Haematoma  of  Vulva,  Nontraumatic.    Do  not  use  as  a 

primary  diagnosis  when  cause  can  be  determined. 
Hydrocele  of  Vulva. 

Hypertrophy  of  Vulva.    State  part  affected.. 

Hypertrophy  of  Clitoris. 
Kraurosis  Vulvae. 

Pruritus  Vulvae.  Do  not  use  as  a  primary  diagnosis 
when  cause  can  be  determined.  File  under  Func- 
tional Disorders. 

Syphilis  of  Vulva.    File  under  Syphilis. 

Tuberculosis  of  Vulva.    File  under  Tuberculosis. 

Tuviior  of  Vulva.    State  variety.    File  under  Tumors. 

Varix  of  Vulva. 

Vulvitis,  Acute. 

Vulvitis,  Chronic.  ,^\Mlen  due  to  gonococcus  diagnosti- 
cate as  Gonococcus  Infection  of.  File  under  In- 
fective Diseases. 

R.    MALE  REPRODUCTIVE  ORGANS. 
COWPER'S  GLANDS: 

Abscess  of  Cowper's  Gland.  V.'hen  due  to  gonococcus 
diagnosticate  as  Gonococcus  Infection  of.  F^ile 
under  Infecti\e  Diseases. 

Tuberculosis  of  Cowper's  Gland.  File  under  Tubercu- 
losis. 

Tumor  of  Cowper's  Gland.    State  variety.    File  under 

Tumors. 
PENIS: 
Balanoposthitis. 

Chancroid  of  Penis.    File  under  Infective  Diseases. 
Congenital  Malformation  of  Penis.     File  under  Con- 
genital >.Ialforniations  of  Reproductive  System. 
Deformity  of  Penis,  Acquired. 
Paraphimosis. 
Redundant  Prepuce. 

Adhesions,  Preputial. 

Concretions,  Preputial. 

Phimosis. 
Sclerosis  of  Corpus  Cavernosum. 
Syphilis  of  Penis.    File  under  Syphilis. 
Tuberculosis  of  Penis.    File  under  Tuberculosis. 
TiDiior  of  Penis.    State  variety.    File  under  Tumors. 
PROSTATE  GLAND: 

Abscess  of  Prostate.  \\'hcn  due  to  gonococcus  diag- 
nosticate as  Gonococcus  Infection  of.  File  un- 
der Infective  Diseases. 

Atrophy  of  Prostate.  Do  not  use  as  a"  primary  diag- 
nosis when  cause  can  be  determined. 

Calculus  in  Prostate. 

Congenital  Malformation  of  Prostate.    File  under  Con- 
genital .M;>lfornuitioiis  of  Reproductive  System. 
Enlargement  of  Prostate.    Not  to  include  tumor. 
Prostatitis,  Acute. 


Prostatitis,  Chronic.  When  due  to  gonococcus  diag- 
nosticate as  Gonococcus  Infection  of.  File  under 
Infective  Diseases. 

Syphilis  of  Prostate.    F'ile  under  Sj^philis. 

Tuberculosis  of  Prostate.    F"ile  under  Tuberculosis. 

Tumor  of  Prostate.    State  variety.    File  under  Tumors. 

SCROTUM: 
Abscess  of  Scrotum. 

Congenital  Malformation  of  Scrotum.  F'ile  under  Con- 
genital Malformations  of  Reproductive  System. 

Elephantiasis  of  Scrotum,  Nonfilarial.  F"ile  under  Dis- 
eases of  the  Lymphatic  System.  When  due  to 
tilaria  diagnosticate  as  Filariasis.  File  under 
Parasitic  Diseases. 

Gangrene  of  Scrotum,  Infective.  File  under  Infective 
Diseases. 

Redundant  Scrotum.    Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 
Syphilis  of  Scrotum.    File  under  Syphilis. 
Tuberculosis  of  Scrotum.    File  under  Tuberculosis. 
Tumor  of  Scrotum.    State  variety.    File  under  Tumors. 

SEMINAL  VESICLES: 

Abscess  of  Seminal  Vesicles.  W'hen  due  to  gonococcus 
diagnosticate  as  Gonococcus  Infection  of.  File 
under  Infective  Diseases. 

Concretion  in  Seminal  Vesicles.  Do  not  use  as  a  pri- 
mary diagnosis  when  cause  can  be  determined. 

Congenital  Malformation  of  Seminal  Vesicles.  File  un- 
der Congenital  Malformations  of  Reproductive 
System. 

Gonecystitis,  Acute. 

Gonecystitis,  Chronic.  When  due  to  gonococcus  diag- 
nosticate as  Gonococcus  Infection  of.  File  under 
Infective  Diseases. 

Tuberculosis  of  Seminal  Vesicles.  File  under  Tuber- 
culosis. 

Tumor  of  Seminal  Vesicles.  State  variety.  File  under 
Tumors. 

SPER:MATIC  CORD: 
Haematocele  of  Spermatic  Cord. 

Haematoma  of  Spermatic  Cord.    File  under  Injuries  of 

Spermatic  Cord. 
Hydrocele  of  Spermatic  Cord. 

Inflammation  of  Spermatic  Cord.  Do  not  use  as  a  pri- 
mary diagnosis  when  cause  can  be  determined. 
When  due  to  gonococcus  diagnosticate  as  Gono- 
coccus Infection  of.  File  under  Infective  Dis- 
eases. 

Syphilis  of  Spermatic  Cord.    File  under  Syphilis. 
Torsion  of  Spermatic  Cord,  Nontraumatic. 
Tuberculosis  of  Spermatic  Cord.    F'ile  under  Tubercu- 
losis. 

Tumor  of  Spermatic  Cord.    State  variety,    File  under 

Tumors. 
Varicocele. 

TESTICLE  AND  EPIDIDY]\ITS : 

Abscess  of  Epididymis.  When  due  to  gonococcus  diag- 
nosticate as  Gonococcus  Infection  of.  File  under 
Infective  Diseases. 

Abscess  of  Testicle. 

Atrophy  of  Testicle.  Do  not  use  as  a  primary  diagno- 
sis wh6n  cause  can  be  determined. 

Congenital  Malformation  of  Testicle.  File  under  Con- 
genital Malformations  of  Reproductive  System. 

Epididymitis,  Acute. 

Epididymitis,  Chronic.  \\'hen  due  to  gonococcus  diag- 
nosticate as  Gonococcus  Infection  of.  File  under 
Infective  Diseases. 

Gangrene  of  Testicle.    Do  not  use  as  a  primary  diag 
nosis  when  cause  can  be  determined.    File  under 
Miscellaneous  Diseases. 

Orchitis,  Acute.  Do  not  use  as  a  primary  diagnosis 
when  cause  can  be  determined.  When  a  compli- 
cation of  Mumps,  diagnosticate  as  Mumps.  File 
under  Infective  Diseases. 

Orchitis,  Chronic. 

Syphilis  of  Epididymis.    File  under  Syphilis. 
Syphilis  of  Testicle.    File  under  Syphlis, 
Tuberculosis  of  Epididymis.    File  under  Tuberculosis. 
Tuberculosis  of  Testicle.    File  under  Tuberculosis. 


mo 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  XOMEXCLATURE. 


[New  York 
Medical  Journai_ 


Tumor  of  Epididymis.  State  variety.  File  under  Tu- 
mors. 

Tumor  of  Testicle.    State  variety.    File  under  Tumors. 
TUNICA  VAGINALIS: 
Chylocele,  Nonfilarial. 

Haematocele  of  Tunica  Vaginalis.    File  under  Injuries 

of  Tunica  \'aginalis. 
Hydrocele  of  Tunica  Vaginalis. 
Spermatocele. 

RESPIRATORY  SYSTEM. 
BRO.XXHI  AND  TRACHEA; 
Asthma. 
Bronchiectasis. 
Bronchitis,  Acute. 
Bronchitis,  Chronic. 
Bronchitis,  Fibrinous. 

Congenital  Malformation  of  Bronchus.  File  under  Con- 
genital Malformation  of  Respiratory  System. 
Congenital  Malformation  of  Trachea.    File  under  Con- 
genital .Malformation  of  Respiratory  System. 
Fistula  of  Trachea. 
Foreign  Body  in  Bronchus. 
Foreign  Body  in  Trachea. 

Parasite  in  Wall  of  Bronchus.  State  variety.  File  un- 
der Parasitic  Diseases. 

Parasite  in  Wall  of  Trachea.  State  variety.  File  under 
Parasitic  Diseases. 

Stenosis  of  Bronchus. 

Stenosis  of  Trachea. 

Syphilis  of  Bronchus.    File  under  Syphilis. 
Syphilis  of  Trachea.    File  under  Syphilis. 
Tracheitis. 
Tracheocele. 

Tuberculosis  of  Bronchus.    File  under  Tuberculosis. 
Tuberculosis  of  Trachea.    File  under  Tuberculosis. 
Tumor  of  Bronchus.    State  variety.    File  under  Tumors. 
Tumor  of  Trachea.    State  variety.    File  under  Tumors. 
Ulcer  of  Bronchus.    Do  not  use  as  a  primary  diagnosis 

wlic-n  cause  can  be  determined. 
Ulcer  of  Trachea.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
LARYNX  AND  EPIGLOTTIS: 
Abscess  of  Larynx. 
Adhesion  of  Epiglottis'. 
Ankylosis  of  Arytenoid  Cartilages. 

Congenital  Malformation  of  Epiglottis.  File  under 
Crmgenital  Maliormation  of  Respiratory  System. 

Congenital  Malformation  of  Larynx.  File  under  Con- 
genital Malformation  of  Respiratory  System. 

Fistula  of  Larynx. 

Foreign  Body  in  Larynx. 

Laryngitis,  Acute. 

Laryngitis,  Chronic. 

Neurosis  of  Larynx.  To  include  Laryngeal  Epilepsy. 
Laryngismus    Stridulus,    Spasmodic  Laryngeal 

Cough. 

CEdema  Glottidis.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Parasite  of  Larynx.    State  variety.     File  under  Para 

sitic  Diseases. 
Perichondritis  of  Larynx. 

Stenosis  of  Larynx.  To  include  retained  intubation 
tube. 

Syphilis  of  Larynx.    File  under  Syphilis. 
Tuberculosis  of  Larynx.    File  under  Tubercnlosis. 
Tuiimr  of  Larynx.    State  variety.    File  under  Tumors. 
Ulcer  of  Epiglottis. 

LUNG: 

Abscess  of  Lung. 
Atelectasis. 

Congenital  Malformation  of  Lung.    File  under  Con- 
genital Mr'.lfnrmations  of  Respiratory  System. 
Congestion  of  Lung.  Acute. 
Embolism  of  Pulmonary  Artery. 
Emphysema,  Congenital. 
Emphysema,  Pulmonary  Interlobular. 
Emphysema,  Senile. 
Gangrene  of  Lung. 

Haemoptysis.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Hernia  of  Lung. 
Infarct  of  Lung. 


CEdema  of  Lung.    Do  not  use  as  a  primary  diagnosis- 

when  cause  can  be  determined. 
Parasite  of  Lung.    State  variety.    File  under  Parasitic 

Diseases. 
Pneumonia,  Broncho-. 
Pneumonia,  Interstitial. 
Pneumonia,  Lobar. 
Pneumonoconiosis. 

Syphilis  of  Lung.    File  under  Syphilis. 
Thrombosis  of.    State  artery  or  vein. 
Tuberculosis,   Acute   Bronchopneumonic.     File  under 
Tuberculosis. 

Tuberculosis,  Acute  Pneumonic.  File  imder  Tubercu- 
losis. 

Tuberculosis,  Acute   Bronchopneumonic.     File  under 

Tuberculosis. 

Tuberculosis,  Chronic  Pulmonary.  File  under  Tuber- 
culosis. 

Tumor  of  Lung.    State  \ariety.    File  under  Tumors. 
NOSE,    NASAL    PASSAGES    AND  ACCESSORY 
SINUSES. 

NOSE  AND  NASAL  PASSAGES: 
Abscess  of  Nasal  Septum. 
Adenoids. 

Anosmia.  Do  not  use  as  a  primary  diagnosis  when 
cause  can  be  determined. 

Congenital  Malformation  of  Nose.  File  under  Con- 
genital Malformations  of  Face. 

Deformity  of  Nose,  Acquired. 

Deviation  of  Nasal  Septum. 

Epistaxis.    Do  not  use  as  a  primarj-  diagnosis  when 

cause  can  be  determined. 
Foreign  Body  in  Nasal  Passage. 
Hay  Fever. 

Ozaena.    Do  not  use  as  a  primary  diagnosis  when  cause 

can  be  determined. 
Parasite  of  Nasal  Passage.    State  variety.    File  under 

Parasitic  Diseases. 
Perforation  of  Nasal  Septum. 
Pneumatocele  Capitis. 
Rhinitis,  Acute. 
Rhinitis,  Atrophic. 
Rhinitis.  Hypertrophic. 
RhinoHth. 

Spur  on  Nasal  Septum. 

Syphilis  of  Nasal  Passage.    File  under  Syphilis.- 
Tuberculosis  of  Nasal  Passage.    File  under  Tubercu- 

losis- 

Tumor  of  Nasal  Passage.    State  variety.     File  under 

Tumors. 

Tumor  of  Nose.    State  varietj-.    File  under  Tumors. 

Ulcer  of  Nasal  Passage. 

ACCESSORY  SINUSES: 

Ethmoid  Sinus,  Empyema  of. 

Ethmoidal  Sinusitis. 

Foreign  Body  in  Frontal  Sinus. 

Foreign  Body  in  Maxillary  Sinus. 

Frontal  Sinus,  Empyema  of. 

Frontal  Sinusitis. 

Maxillary  Sinus.  Empyema  of. 

Maxillary  Sinusitis. 

Parasite  of  Frontal  Sinus.      State  variety.    File  under 

Parasitic  Diseases. 
Parasite  of  Maxillary  Sinus.    State  variety.    File  under 

P;ira-itic  Di-^ea-es. 
Sphenoidal  Sinusitis. 

Tumor  of  Ethmoid  Sinus.    State  variety.    File  under 

Tumors. 

Tumor  of  Frontal  Sinus.  State  variety.  File  under  Tu- 
mors. 

Tumor  of  Maxillary  Sinus.  State  variety.  File  under 
Tumors. 

Tumor  of  Sphenoid  Sinus.     State  variety.     File  under 

Tumors. 
PLEUR.X: 

Chylothorax.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Hasmothorax.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Parasite  of  Pleura.    State  variety.    File  under  Parasitic 

Diseases. 
Pleurisy,  Acute  Fibrinous. 


May  29.  1909.] 


CARLISLE  ET  AL.:  BELLEl'UE  HOSPITAL  XOMEXCLATURE. 


nil 


Pleurisy,  Chronic  Fibrinous. 

Pleuritis  Adhesions. 
Pleurisy,  Serofibrinous. 
Pleurisy,  Suppurative. 

Pneumothorax.    Do  not  use  as  a  primary  diagnosis 

wiien  cause  can  be  determined. 
Pyoneumothorax. 
Thoracointestinal  Fistula. 

Tuberculosis  of  Pleura,    i-'ile  under  Tuberculosis. 
Tumor  of  Pleura.    State  variety.    File  under  Tumors. 

SKIN,  HAIR,  AND  NAILS. 

SKIX  AND  H.\IR: 
Acne. 

Acne  Rosacea. 
Alopecia  Areata. 
Alopecia  Prasmatura. 
Angiokeratoma. 
Argyria. 
Callositas. 

Cicatrix  of.  State  site.  Do  not  use  tor  Cicatricial  Con- 
traction of.  See  Miscellaneous  Diseases  and  con- 
ditions. 

Clavus. 

Comedo. 

Congenital  Malformation  of  Skin.  File  under  Congen- 
ital Malformations.  ^ 

Congenital  Malformation  of  Hair,  l-ile  under  Con- 
genital Malformations  of  Skin. 

Congenital  Malformation  of  Nails.  File  under  Congen- 
ital M;i!lormations  of  Skin. 

Dermatitis  Gangraenosa. 

Dermatitis  Herpetiformis. 

Dermatitis  Medicamentosa. 

Dermatitis  Traumatica. 

Dermatitis  Venenata. 

Ecthyma. 

Eczema. 

Erythema  Multiforme. 
Erythema  Nodosum. 
Erythema  Simplex. 
Herpes.    State  site. 
Ichthyosis. 
Impetigo  Contagiosa. 
Impetigo  Herpetiformis. 
Impetigo  Simplex. 
Intertrigo. 

Keloid.     State  site.    Diagnosticate  as  Fibroma.  File 

tinder  Tumors. 
Keratosis. 
I.eucodermia. 
Lichen  Planus. 
Lichen  Ruber. 
Lupus  Erythematosus. 
Miliaria. 
Milium. 

Molluscum  Contagiosum. 
Mycosis  Fungoides. 

Naevus.    File  with  Angioma  under  Tumors. 

P.\R.\SITES: 
Chromophytosis. 
Dracontiasis. 
Erythrasma. 
Favus. 
Mycetoma. 

Phtheiriasis  (Pediculosis"). 
Scabies. 
Sycosis. 
Trichophytosis. 
Pemphigus. 

Pemphigus  Neonatorum. 
Pinta. 

Pityriasis  Rubra. 
Pityriasis  Simplex. 
Prurigo. 
Pruritus. 
Psoriasis. 

Purpura.    File  under  Diseases  of  the  Blood. 

Scleroderma. 

Seborrhcea. 

Syphilis  of  Skin.    File  under  Syphilic. 
Tuberculosis  of  Skin.    File  und.er  Tuberculosis. 


Tumor  of  Skin.    State  variety.    File  under  Tumors. 

Ulcer  of.  State  site. 

Urticaria,  Acute. 

Urticaria,  Chronic. 

Verruca. 

XAILS: 

Ingrowing  Nail. 
Onychauxis. 

Onychia.  , 

Onychogryphosis. 

Onychoma. 

Paronychia. 

TUMORS. 
State  Location. 

HEXIGX: 

Adenoma. 

Angioma. 

Chondroma. 

Cystoma. 

Fibroma.    To  include  epulis,  keloid,  mole. 

Glioma. 

Lipoma. 

Lymphangioma. 

Lymphoma. 

Myoma. 

Myxoma. 

Neuroma.     To    include    multiple   neuroflbromata  and 

plexiform  neuroma. 
Odontoma. 
Onchyom.a. 

Osteoma.    To  niclude  exostosis. 

Papilloma.    To  include  condyloma  nonspecific,  not  to 

include  urethral  caruncle. 
Retention  Cyst.    To  include  ranula  and  sebaceous  cyst. 
Teratoma.    To  include  dermoid  cyst. 
MALIGXAXT: 
Carcinoma. 
Endothelioma. 
Epithelioma. 

Chorioepithelioma.    To  include  hydatidiform  mole  and 

deciduonia  malignum. 
Sarcoma.    To  include  chloroma. 

MIXED  TUMORS: 

URINARY  ORGANS. 

BLADDER: 

Abscess  of  Bladder  Wall.  • 
Atony  of  Bladder.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Bacteriuria. 
Calculus  in  Bladder. 

Congenital  Malformation  of  Bladder.    File  under  Con- 
genital Malformations  of  Urinary  System. 

Cystitis,  Acute.  Xot  to  be  used  as  a  primary  diagnosis 
when  cause  can  be  determined.  \\'hen  due  tc 
gonococcus.  diagnosticate  as  Gonococcus  Infec 
tion  of.    File  under  Infective  Diseases. 

Cystitis,  Chronic. 

Deformity  of  Bladder,  Acquired. 

Fistula  of  Bladder.    File  \'esicovaginal  Fistula  under 

Diseases  of  the  \'agiua. 
Foreign  Body  in  Bladder. 

Incontinence  of  Urine.    Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 

Neurosis  of  Bladder.    Do  not  use  as  a  primary  diag- 
n'~'sis  when  cause  can  be  determined. 
Enuresis,  Functional. 

Parasite  of  Bladder.    State  variety.    File  under  .Parasitic 
Diseases. 

Retention  of  Urine.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Syphilis  of  Bladder.    File  under  Syphilis. 
Tuberculosis  of  Bladder.    File  under  Tuberculosis. 
Tumor  of  Bladder.    State  varietv.    File  under  Tumors. 
Ulcer  of  Bladder. 
Varix  of  Bladder. 
KTDXEY: 
Abscess  of  Kidney. 
Abscess,  Perinephritic. 

Albuminuria.    Xot  to  be  used  as  a  primarj-  diagnosis 
w  hen  cause  can  be  determined. 


III2 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Jourmal. 


Amyloid  Kidney.     Diagndsticate  as  Amyloid  Disease. 

File  under  ]\Iiscellaneous  Diseases  and  Condi- 
tions. 

Chyluria,  Nonfilarial.  Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined.  When  due 
to  lilaria  diagnosticate  as  Filariasis.  File  under 
Parasitic  Diseases. 

Colic,  Renal.    Diagnosticate  as  Ureteral  Colic. 

Congenital  Malformation  of  Kidney.  I'ile  under  Con- 
genital ^Malformations  of  Urinary  System. 

Congestion  of  Kidney.  Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 

Cyst  of  Kidney. 

Fistula  of  Kidney.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Haematuria,  Renal.    Do  not  use  as  a  primarj-  diagnosis 

when  cause  can  be  determined. 
Hasmoglobinuria.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Hydronephrosis.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Infarct  of  Kidney. 

Nepriralgia.    Do  not  use  as  a  primary  diagnosis  when 

cause  can  be  determined. 
Nephritis,  Acute. 
Nephritis,  Chronic  Interstitial. 
Nephritis,  Chronic  Parenchymatous. 
Nephritis,  Disseminated  Suppurative. 
Nephrolithiasis. 
Nephroptosis. 

Panisilc  of  Kidney.  State  variety.  File  under  Parasitic 
Diseases. 

Pyelitis.  When  due  to  gonococcus,  diagnosticate  as 
Gonococcus  Infection  of.  File  under  Infective 
Diseases. 

Pyelonephritis. 

Pyonephrosis. 

Syphilis  of  Kidney.    I-'ile  under  Sj'philis. 

Tuberculosis  of  Kidney.    File  under  Tuberculosis. 

Tittnor  of  Kidney.    State  variety.    F"ile  under  Tumors. 

Uraemia,  Acute.  Use  as  a  secondary  diagnosis  only  un- 
der appropriate  form  of  Nephritis. 

Uraemia,  Chronic.  Use  as  a  secondary  diagnosis  only 
under  appropriate  form  of  Nephritis. 

URETER: 

Calculus  in  Ureter,  Impacted. 

Congenital  Malformation  of  Ureter.    File  under  Con- 
genital Malformations  of  Urinary  Organs. 
Fistula  of  Ureter. 
Stricture  of  Ureter. 

Tuberculosis  of  Ureter.    File  under  Tuberculosis. 
Ureteral  Colic.     Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Ureteritis.    When  due  to  gonococcus,  diagnosticate  as 

Gonococcus  Infection  of.     File  under  Infective 

Diseases. 

URETHRA: 

Abscess  about  Urethra. 

Abscess  in  Male  Perinaeum. 
Calculus  in  Urethra,  Impacted. 
Caruncle  of  Urethra.    File  under  Tumors. 
Congenital  Malformation  of  Urethra.    File  under  Con- 
genital Malfi irmations  of  Urinary  Organs. 
Deformity  of  Urethra,  Acquired. 

Extravasation  of  Urine.    Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 
Fistula  of  Urethra.     File  urethrovaginal  fistula  under 

■    Di'-eases  of  Vagina. 
Foreign  Body  in  Urethra. 
Prolapse  of  Urethra. 
Stricture  of  Urethra. 

Syphilis  of  Urethra.    I'ile  under  Syphilis. 
Tuberculosis  of  Urethra.    File  under  Tuberculosis. 
Tuiiiiiy  of  Urethra.    Slate  variety,  I'ile  under  Tumors. 
Urethral  Fever,  Traumatic.    ImIc  under  Injuries  to  the 

Urethra. 
Urethritis,  Acute. 

Urethritis,  Chronic.  W  hen  due  to  gonococcus.  diag- 
nosticate as  Gonococcus  Infection  of.  File  under 
Infective  Disease-. 

( To  he  concluded. ) 


|itt  fff  Cttmnt  f  ittrstot. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL 

May  20.  igog. 

1.  A  Functional  Relation  of  the  Tonsil  to  the  Teeth. 

By  George  FI.  Wright. 

2.  A  Short  Description' of  Wertheim's  Radical  Abdominal 

Operation  for  Cancer  of  the  Cervix  of  the  Uterus, 
with  a  Report  of  Eight  Cases, 

By  Henry  T.  Hutchins. 
^.    The  Value  of  Ethyl  Chloride  as  a  General  .\n<'esthetic, 

By  .Albert  H.  ^Iiller. 

1.  A  Functional  Relation  of  the  Tonsil  to  the 
Teeth. — Wright  observes  that  when  a  tonsil  is 
normal,  infection  from  the  external  surface  is  rare. 
Secondary  infection  through  the  lymph  channels  is 
the  usual  source.  There  are  four  periods  of  molar 
eruptions,  with  some  variations  in  time  when  the 
tonsils  may  enlarge  without  infection  or  inflamma- 
tion, at  two  years,  six  years,  twelve  years,  and  seven- 
teen years.  Tonsils,  thottgh  slightly  enlarged  when 
not  infected,  return  to  normal  with  complete  erup- 
tion of  the  teeth.  Diseased  teeth  are  prolific  source 
of  enlargement  of  the  glands  through  proximity  of 
membranes,  either  directly,  by  infection,  or  by  tox- 
ines.  In  the  treatment  of  the  tonsil  by  the  speciaUst 
should  be  included  as  a  routine  the  observation  as 
to  carious  teeth  and  a  recognition  of  these  four  peri- 
ods of  eruption  coincident  with  slight  enlargement. 
In  the  discussion  that  followed  C.  F.  Cobb  says  that 
removal  of  tonsils,  which  obstruct  breathing  or 
swallowing,  or  where  disease  is  present,  is  justifiable 
and  wise,  but  radical  extirpation  should  only  be  done 
where  disease  of  the  tonsils,  chronic  amygdalitis,  or 
peritonsilar  abscess  make  it  necessary,  which  rule  is 
especially  true  in  early  youth. 

2.  Wertheim's  Radical  Abdominal  Operation 
for  Cancer  of  the  Cervix  of  the  Uterus. — Hutch- 
ins describes  Wertheim's  method,  the  success  of 
which  operation  depends  on  the  following  points : 
Thorough  disinfection  of  the  cervix  preceding  oper- 
ation. Perfect  exposure  of  the  pelvis.  Rapid,  care- 
ful, and  bloodless  dissection,  which  is  only  possible 
for  one  having  a  minute  knowledge  of  the  anatomv 
of  the  pelvic  structures.  It  is  readily  seen  that  this 
operation  should  not  be  attempted  by  any  btit  a  sur- 
geon experienced  in  pelvic  work  and  with  proper  in- 
struments and  assistants.  During  the  year  1907 
Hutchins  examined  sixteen  cases  of  carcinoma  of 
the  cervix  and  found  eight  operable,  tints  agreeing 
with  Wertheim's  statistics.  The  inoperable  cases 
were  curetted  only.  A  year  and  three  months  have 
elapsed  since  the  last  of  his  series  of  eight  cases,  the 
time  limit  which  is  usually  allowed  a  patient  with 
carcinoma  of  the  cervix  without  operation  to  live, 
and  he  gives  a  short  preliminary  report  of  the  eight 
women  operated  upon.  There  is  one  death  in  the 
series  of  cases.  In  this  patient  there  was  a  wide  ex- 
tension of  the  growth,  and  the  lower  end  of  the  left 
ureter  and  a  third  of  the  bladder  were  resected,  and 
the  patient  died  in  twenty-five  days  after  operation, 
of  infection.  Primary  mortality  in  first  eight  pa- 
tients was  12.5  per  cent.  The  ages  ranged  from 
thirty  to  fifty-six  years. 

3.  Ethyl  Chloride  as  a  General  Anaesthetic. — 
Miller  rcni'irks  that  nitrous  oxide  has  a  small  mar- 
gin of  s'ifttN.  but  the  danger  signs  are  so  marked 


May  29,  1 909. J 


PITH  OF  CURRENT  LITERATURE. 


III3 


that  nitrous  oxide  anaesthesia  is  the  safest  known. 
Ether  has  a  fairly  large  margin  of  safety  and  quite 
well  marked  danger  signs,  so  it  is  quite  a  safe  antes- 
thetic.  Chloroform  has  but  a  small  margin  of  safety 
and  the  danger  signs  are  readily  overlooked.  It  is 
always  a  dangerous  anaesthetic,  but  especially  so  in 
inexperienced  hands.  Ethyl  chloride  has  a  large 
margin  of  safety,  but  the  danger  signs  are  not 
marked.  While  it  is  very  safe  when  administered  by 
an  expert,  it  may  be  very  dangerous  in  unskilled 
hands.  With  an  expert  administrator,  it  should 
safer  than  ether,  but  less  safe  than  nitrous  oxide. 
With  an  unskilled  or  careless  administrator,  it  is 
probably  more  dangerous  than  ether,  but  not  as  dan- 
gerous as  chloroform. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

May  2.2.  igog. 

1.  An  Unusual  Outbreak  of  Typhoid  Fever, 

By  M.'^zYCK  P.  Ravenel  and  K.  W.  Smith. 

2.  The  Combined  Course  for  the  Degrees  of  A.  B.  or 

B.  S.,  and  M.  D.,  By  John  Milton  Dodson. 

3.  Surgical  Pathology:    Its  Scope  and  Teaching, 

By  Henry  S.  Wieder. 

4.  Cancer  of  the  Breast,  By  F.  S.  Dennis. 

5.  Cancer  of  the  Breast,  By  William  L.  Rodman. 

6.  C;ecostomy  and  Continuous  Coloclysis  in  General  and 

Other  Peritonitis,  By  Charles  A.  L.  Reeu. 

7.  The  Relation  of  Foreign  Bodies  in  the  Gallbladder  to 

Gallstone  Disease,        By  Joseph  Rilus  Eastman. 

8.  Removal  of  an  Embolus  from  the  Common  Iliac  Ar- 

tery with  Reestablishment  of  Circulation  in  the 
Femoral,  By  John  B.  Murphv. 

5.  Cancer  of  the  Breast. — See  Journal,  April  3, 
p.  716. 

6.  Caecostomy  and  Continuous  Coloclysis  in 
General  Peritonitis  and  Other  Conditions. — Reed 
recognizing  that  general  peritonitis  is  always  the  re- 
sult of  infection,  he  places  his  patient  in  the  Tren- 
delenburg position  and  operates  in  the  usual  way  to 
find,  and  if  possible  to  remove,  the  source  of  infec- 
tion. Whatever  may  be  the  details  of  that  operation 
he  brings  up  the  caecum  and  fixes  it  in  an  incision 
made  directly  over  its  situs,  opens  the  loop  thus 
anchored,  and  in  the  opening  inserts  a  soft  rubber 
catheter,  which  he  attaches  by  a  suture  to  the  ab- 
dominal wall.  He  then  places  a  selfretaining,  efflu- 
ent tube  into  the  rectum,  through  which  tube  he  sub- 
jects the  colon  to  such  treatment  as  the  conditions 
may  require.  In  general  peritonitis,  when  the  pa- 
tients are  in-  extremis,  he  begins  continuous  irriga- 
tion of  the  colon  with  normal  salt  solution  at  110°  F. 
About  three  quarts  of  solution  are  retained  before  the 
effluent  current  is  established  through  the  rectal  tube. 
By  this  internal  application  of  heat  in  direct  contact 
with  the  solar  plexus  and  by  the  incidental  absorp- 
tion of  water  from  the  colon,  a  reaction  is  generallv 
secured  with  a  promptness  that  seems  phenomenal. 
As  soon  as  this  is  secured,  the  free  flow  from  the 
irrigator  is  abandoned  and  the  drop  by  drop  clysis 
is  substituted  and  continued  for  the  next  twentv- 
four  hours  or  longer.  If  the  stomach  is  rebellious, 
the  caecal  tube  is  utilized  for  feeding  the  patient. 
This  line  of  treatment  is  eligible  not  only  in  general 
peritonitis,  but  in  several  other  conditions.  It  can 
be  readily  adopted  as  an  elective  measure,  in  acute 
gastric  ulcer  in  which  no  operation  has  been  done, 
but  in  which  it  is  necessary  to  keep  the  stomach  at 
rest  for  a  considerable  time.  It  is  a  capital  expedi- 
ent for  feeding  purposes  following  gastroenterosto 


my  and  in  cases  of  malignant  disease  of  the  stomach 
or  of  the  upper  segment  of  the  intestinal  tract,  in 
which  operation  is  not  practicable.  He  urges  that 
caecostomy  rather  than  appendicostomy  should  al- 
ways be  adopted  as  the  operation  of  choice.  As 
compared  with  the  presenting  part  of  the  cascum,  the 
caecoappendiceal  juncture  is  an  inch  or  more  further 
away  from  the  abdominal  wall.  The  mesocaecum  is 
ordinarily  so  short  and  is  always  so  inelastic  that  the 
appendix  can  not  be  drawn  and  held  forward  with- 
out a  degree  of  tension  that  is  fatal  in  its  integrity. 
The  distensive  pressure  of  any  tube  inserted  and  re- 
tained in  the  narrow  lumen  of  the  appendix  is  an- 
other influence  that  causes  it  always  to  perish  during 
the  first  few  days  after  the  operation.  Thus  an  ap- 
pendicostomy always,  sooner  or  later,  resolves  itself 
into  a  caecostomy.  It  is  better,  however,  to  do  a 
caecostomy  as  an  elective  operation. 

8.  Removal  of  an  Embolus  from  the  Common 
Iliac  Artery,  with  Reestablishment  of  Circulation 
in  the  Femoral. — Murphy  reports  such  a  case,  and 
remarks  that  in  cases  of  aseptic  embolism  immedi- 
ate removal  by  division  of  the  artery  at  the  line  of 
the  embolism  or  below  it  should  be  resorted  to. 
These  emboli  produce  mere  mechanical  obstruction, 
and  the  circulation  is  at  once  reestablished  bv  their 
removal.  The  symptoms  which  indicate  the  occlu- 
sion of  a  large  artery  are  pain,  ischaemia  of  the  limb, 
cooling  of  the  surface,  and  absence  of  pulsation  in 
the  arterial  trunk.  The  number  of  hour§  that  may 
elapse  before  a  tissue  becomes  incapable  of  restora- 
tion has  not  been  definitely  determined,  but  from  the 
length  of  time  a  constrictor  may  be  kept  on  a  limb 
for  the  suppression  of  haemorrhage  and  the  vitality 
of  the  limb  restored,  we  know  that  many  hours  of 
complete  suppression  of  the  circulation  is  not  in- 
compatible with  restoration  of  the  life  of  the  tissues. 
In  the  removal  of  septic  infarcts  there  is  little  to  be 
gained  in  a  practical  way,  as  they  are  usually  multi- 
ple. With  the  infarcts  resulting  from  acute  or 
chronic  vegetations  on  the  cardiac  vah'es,  good  re- 
sults should  be  obtained.  Even  cerebral  ischjemia 
should  be  amenable  to  this  treatment,  when  due  to 
an  embolus  arrested  in  the  common  or  internal  caro- 
tid by  opening  the  common  carotid  and  aspirating 
through  a  catheter ;  or  a  stibclavian  clot  by  incision 
of  the  axillary  artery.  He  believes  that  aspiration 
through  a  catheter  is  a  good  means  of  removing  the 
plug.  If  the  catheter  is  divided  on  the  slant  with  its 
end  open  it  can  be  readily  introduced  into  the  artery  ; 
unless  the  embolus  is  extremely  hard  it  can  with 
stiction  be  drawn  into  or  fragmented  by  the  catheter 
and  thus  the  artery  freed.  Incision  into  the  arterv 
at  the  seat  of  arrest  of  the  embolus,  if  it  has  been 
there  for  any  length  of  time,  is  not  an  advisable  pro- 
cedure :  the  artery  had  better  be  divided  above  or  be- 
low (preferably  the  letter)  the  ooint  of  impaction  of 
the  embolus;  A  gradual  occlusion  of  the  circulatio  i 
does  not  produce  gangrene  in  the  extremity.  The 
curved  needle  of  the  conjunctival  type,  which  has  its 
cutting  edge  easily  rubbed  of¥  on  a  whetstone,  is  ;i 
good  type  of  needle  for  deep  work.  After  the  re- 
moval of  the  Crile  clamp  or  the  digital  compression 
there  is  often  considerable  oozing  through  the  stitch 
holes.  A  gauze  compression  for  thirty  or  forty  sec- 
onds will  completely  stop  all  this  bleeding.  Silk 
should  be  used  and  not  animal  suture,  as  a  clot  rap- 
idly forms  around  the  silk,  plugging  the  stitch  hole. 


1114 


PITH  or  CURRENT  LITERATURE. 


[Xew  York 
Medical  Journal. 


MEDICAL  RECORD 

May  22.  looc). 

1.  The  Neurogenic  and  Myogenic  Theories  and  the  Mod- 

ern Classification  and  Interpretation  of  Cardiac  Ar- 
rhythmias, 'By  S.  J.  Meltzer. 

2.  Infant  MortaHty.     Comparison  of  the  Past  and  Pres- 

ent, By  William  Leland  Stowell. 

3.  Instantaneous  Radiography   in    Less  Than  One  Hun- 

dredth Second:   A  New  Method  of  Radiography, 

By  Friedrich  Dessauer. 

4.  Economy  in  Major  Anaesthesia:  More  Particularly  as 

to  Ethyl  Oiloride,  By  R.  H,  M.  Dawbarn. 

5.  Smoked  Tories — A  Menace  to  Health, 

By  Percy  R.  Wood. 

1.  Neurogenic  and  Myogenic  Theories. — Melt- 
zer remarks  that  the  neurogenic  is  the  older  of  the 
two  theories.  Netirogenic  means  the  supposition  that 
the  heart  beats  are  originated  in  some  part  of  the 
nervous  system.  The  heart  is  a  muscle  and  its  func- 
tion is  simply  that  of  contraction.  For  centuries  it 
was  assumed  that  the  rh\  thmic  contractions  of  the 
heart  were  carried  on  by  impulses  sent  to  that  mus- 
cle from  some  part  of  the  central  nervous  system  in 
the  same  manner  as  the  skeletal  muscles  are  prompt- 
ed to  their  sporadic  contraction  by  impulses  received 
through  the  motor  nerves  from  the  brain.  This  as- 
sumption was  easily  disproved  by  Haller,  the  cele- 
brated physiologist  of  the  eighteenth  century,  by  the 
following  experiment :  The  heart  continues  to  beat 
for  some  time  after  its  complete  removal  from  the 
animal  body  :  the  cause  of  the  rhythmic  beats  must 
therefore  be  located  in  the  heart  itself.  However, 
the  investigations  of  the  nineteenth  century  gradu- 
ally brought  to  light  new  facts  wiiich  permitted  the 
resuscitation  of  the  neurogenic  theory  to  new  life  in 
a  new  form.  It  was  shown  that  the  heart  possesses 
nerve  ganglia  of  its  own.  Volkmann,  in  1844,  for- 
mulated the  theory  that  the  nerve  cells  of  the  heart 
are  generating  automatically  the  impulses  which 
cause  the  rhythmical  contractions  of  the  heart,  the 
heart  ganglia  being  in  a  certain  way  comparable  to 
the  nerve  cells  of  the  respiratory  centre  which  causes 
the  rhythmical  contraction  of  the  respiratory  mus- 
cles. The  new  neurogenic  theory  agreed  with  the 
old  theory  that  the  heart  beats  originate  in  the  brain, 
with  the  diflference  that  it  assumed  that  the  heart 
carries  its  brain  in  its  own  tissue.  The  neurogenic 
theory  dominated  the  teachings  of  physiology  for 
many  decades.  FUit  this  has  been  changed  now.  The 
conception  of  the  myogenic  theory  is  that  the  auto- 
matic generation  of  impulses  as  well  as  their  con- 
duction are  carried  on  by  muscle  fibres.  The  fol- 
lowing various  properties  are  distinguished :  The 
rhythmicity,  that  is,  the  capability  of  the  heart  to 
generate  automatically  rhythmic  impulses.  The  con- 
(luctivity.  i.  e..  the  ability  to  conduct  a  given  im- 
l)ulse  from  one  place  in  the  heart  to  another.  Ex- 
cital)ilitv  or  irritahilit}',  i.  e.,  the  ability  to  receive  or 
respond  to  an  adequate  stimulus ;  it  is  this  property 
which  determines  the  threshold  of  a  stimulus,  so  that 
a  heart  which  possesses  more  of  that  property,  or  in 
other  words,  is  more  irritable,  is  more  ready  to  re- 
spond to  weaker  stimuli.  The  contractility,  i.  e.,  the 
ability  to  react  to  more  favorable  conditions  with 
stronger  contractions.  The  tonicity,  that  is,  the  de- 
gree of  contraction  which  the  heart  possesses  during 
the  diastole. 

2.  Infant  Mortality. — Sto.vell  says  that  some 
causes  of  infant  mortality  are  nonmaturity  of  the 


ovum ;  illegitimacy ;  heredity  of  diseases  such 
as  tuberculosis,  syphilis,  alcohol ;  race  condi- 
tions ;  epidemic  and  contagious  diseases ;  san- 
itary conditions ;  social  conditions,  etc.  He  gives 
fifteen  very  interesting  tables  in  which  he  ex- 
plains the  causes  for  infant  mortality.  In  con- 
clusion he  remarks,  that  Graham  says  that 
fifty  per  cent,  of  the  infant  deaths  are  preventable. 
If  this  is  true,  the  physicians  of  the  United  States 
should  be  indicted  for  homicide  in  50,000  instances 
a  }ear.  It  is  not  enough  to  complacently  watch  the 
death  rate  go  down  in  some  instances  ;  it  is  our  prov- 
ince to  make  it  go  down  bv  our  skill  in  treatment,  or 
better  b\-  prophylaxis,  and  not  take  praise  where  the 
credit  belongs  to  the  mildness  of  season  or  the  ab- 
sence of  epidemic.  We  need  to  study  physiology- 
more  closely,  especially  the  action  of  the  heart  and 
lungs,  and  the  in}-steries  of  metabolism.  Improved 
sanitation  will,  naturally,  include  inspection  of  the 
tenement,  with  a  study  of  the  methods  of  keeping 
food,  especially  milk.  Hygiene  of  a  general  sort 
taught  in  the  schools  makes  an  impression  on  the 
children  which  they  will  not  forget  when  they  are 
adults.  It  is  hardly  necessary  to  assert  again  that 
babies  shotild  be  nursed  by  their  mothers,  and  if  not 
should  be  given  milk  prescribed  in  proportions  or 
formulas  on  prescription  by  physicians  and  not  ac- 
cording to  chance  rules  of  the  laity. 

BRITISH  MEDICAL  JOURNAL. 

May  8,  igog. 

1.  A  Lecture  on  Myopathy  and  Syringomyelia, 

By  Sir  W.  R.  Gowers. 

2.  Remark's  on  Antispasmodics  and  the  Cure  of  Spasms, 

By  Eustace  Smith. 

3.  A  Clinical  Lecture  on  Amaurotic  Family  Idiocy, 

By  F.  J.  PovNTON. 

4.  An  Epidemic  of  Tinea  Cruris,        By  J.  Oderv  Symes. 

5.  A   Case   of   Landry's    (.\cute   Ascending)  Paralysis; 

Recovery,  By  C.  H.  Cattle. 

6.  On  the  Use  of  Certain  New  Chemical  Tests  in  the 

Diagnosis  of  General  Paralysis  and  Tabes, 

By  George  W.  Ross  and  Ernest  Jones. 

7.  Treatment  of  Facial  Paralysis  due  to  Mastoid  Disease 

or  to  the  Mastoid  Operation, 

By  Frederick  Sydenham. 

8.  Epidermolysis  Bullosa.    Three  Cases;  with  History  of 

the  Disease  in  Four  Generations  in  the  Same  Fam- 
ily, By  Leonard  B.  Cane. 

9.  Spirochseta  Pallida :  Methods  of  Examination  and  De- 

tection, Especially  by  Means  of  the  Dark  Ground 
Illuinination,  By  Alfred  C.  Coles. 

I.  Myopathy  and  Syringomyelia.  — ■  Gowers 
states  that  these  two  maladies  ought  not  to  be  con- 
founded, although  they  are  both  diseases  of  devel- 
opment. The  one  is  defective  structural  formation 
in  the  spinal  cord,  whereby  cavities  are  left  in  the 
process  of  its  development  or  portions  of  embryonic 
neuroglial  tissue  fail  to  achieve  their  change  into 
nerve  elements,  but  remain  as  tracts  of  low  con- 
sistence, which  break  down  into  cavities.  These 
enlarge  by  distention  and  thus  cause  symptoms,  or 
the  residual  tissue  may  increase  by  a  slow  process 
of  growth.  Myopathy,  or  muscular  dystrophy,  is 
a  defect  of  muscular  growth,  not  dependent  on  the 
nervous  system,  but  inherent  in  the  muscles,  by 
which  the  fibres  fail,  sometimes  early  in  life,  some- 
times later.  The  interstitial  tissue  grasps  the  nu- 
tritional influence  and  increases,  but  not  enough  to 
compensate  for  the  defect  in  the  fibres,  unless  fat 
forms  among  them,  when  the  bulk  of  the  feeble 


May  29,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


muscles  may  be  much  increased.  This  is  the  case 
in  the  early  variety,  the  pseudohypertrophic  form, 
which  is  known  best;  in  this  the  muscles  vary  in 
size,  the  calves  being  usually  largest,  the  extensors 
of  the  knees  often  increase  in  size  in  the  lower  part, 
the  infraspinati  are  large,  the  lower  parts  of  the 
pectoralis  and  the  latissimus  dorsi  are  small,  and 
often  they  seem  almost  absent.  The  face  is  free. 
This  form  affects  chiefly  males,  females  seldom : 
sometimes  all  the  males  of  a  family  suffer,  and  all 
the  females  escape,  but  transmit  the  disease  to  their 
sons.  The  malady  increases  in  degree  and  extent 
as  its  subjects  grow  up;  it  impairs  the  power  of 
breathing  until  some  pulmonary  disease  develops  ; 
or  it  may  be  some  slight  catarrh,  which  would  be  a 
trifle  to  a  normal  individual,  that  ends  the  feeble 
life  soon  after  adult  age  has  been  attained.  But 
there  are  others  forms  of  myopathy  which  do  not 
present  the  increased  size  of  muscles.  On  the  con- 
trary, all  or  most  lessen  in  size,  though  often  not 
to  the  same  degree  as  in  spinal  atrophy.  A  more 
abundant  growth  of  the  interstitial  tissue  takes 
place,  but  it  does  not  become  the  seat  of  fat  forma- 
tion, partly,  perhaps,  because  the  change  usually 
takes  place  after  the  period  of  growth  is  over.  The 
author  reports  two  cases  in  which  he  demonstrates 
the  distinctive  points  of  myopathy  and  syringo- 
myelia. 

3.  Amaurotic  Family  Idiocy.  —  Poynton  re- 
ports four  such  cases.  He  remarks  that  the  pathol- 
ogy of  this  disease  is  obscure,  and  it  is  only  in  com- 
paratively few  cases  that  a  complete  investigation 
has  been  made.  Microscopical  changes  were  dem- 
onstrated by  Sachs,  and  Dr.  Risien  Russell  with 
IMr.  Kingdoli  gave  a  full  account  of  the  changes 
they  had  observed  in  one  case,  and  that  account 
holds  good  at  the  present  date,  though  it  can  be 
supplemented  by  additional  observations  which  re- 
sult from  the  use  of  other  methods  than  staining 
with  the  aniline  dyes.  The  great  fact  to  grasp  in 
the  pathological  anatomy  is  the  remarkable  general 
and  extreme  disease  of  the  nerve  cells.  It  would 
appear  to  be  a  primary  cell  disease,  and  the  changes 
in  the  fibres  are  apparently  secondary.  We  may 
even  go  a  step  further  and  say  that  this  disease 
is  primarily  a  disease  of  the  interfibrillar  proto- 
plasms of  the  cells,  the  changes  in  the  neurofibrils 
being  secondary.  The  cell  destruction  may  be  most 
extensive.  It  is  also  important  to  recognize  that 
the  disease  of  the  nerve  cells  is  not  a  result  of  in- 
flammation, for  there  are  no  vascular  signs  of  either 
acute  or  chronic  inflammation.  The  changes  in  the 
nerve  cells  are :  Swelling  of  the  cell  bodv  with  fre- 
quently gross  alteration  in  shape ;  disappearance  of 
Xissl  bodies,  excentric  position  of  nuclei,  vacuoliza- 
tion of  the  protoplasm.  The  inevitable  progress  of 
the  disease  does  not  suggest  an  arrest  of  develop- 
ment but  some  active  process.  A  bacteriological 
cause  is  improbable,  for  there  are  no  positive  facts 
in  its  favor.  It  does  not  appear  from  the  microscop- 
ical evidence  to  be  a  pure  atrophy. 

9.  Spirochasta  Pallida. — Coles  describes  the 
method  of  taking  the  material  for  examination,  the 
most  approved  method  of  staining,  and  the  method 
of  examining  the  living  organism  by  means  of  the 
dark  ground  illumination.  He  states  that  the  eas- 
iest, quickest,  and  by  far  the  most  certain  method 


of  detecting  the  S pirochccta  pallida  is  by  the  exam- 
ination of  cover  glass  preparations  made  from  the 
serum,  by  means  of  dark  ground  illumination.  The 
most  important  part  of  the  whole  procedure  is  the 
correct  taking  of  the  material,  whether  for  fresh 
or  dry  film  preparations.  It  is  not  essential  to  ex- 
amine fresh  films  (which  have  been  rung  round 
wnth  petrolatum)  at  once,  as  the  organism  mav  be 
recognized  some  days  later.  The  serum  of  irrita- 
tion may  be  conveniently  taken  in  capillary  tubes 
or  blood  capsules,  provided  the  ends  are  sealed, 
and  cover  glass  preparations  made  from  it  may 
be  examined  at  leisure.  Whilst  the  finding  of  the 
S pirochccta  pallida  indicates,  as  far  as  our  knowledge 
goes  at  present,  syphilis,  a  negative  examination  is 
of  little  value,  at  most  it  only  justifies  a  suspicion 
that  the  disease  is  not  present.  The  Spirochccta 
pallida  in  stained  preparations  somewiiat  fades 
sooner  or  later.  This  fading  of  aniline  stained  pre- 
parations, blood,  or  other  films,  when  mounted  in 
Canada  balsam  is  a  source  of  great  disappointment. 
He  has  tried  Grubler's  neutral  balsam,  but  with 
only  moderate  success. 

THE  LANCET. 

May  8,  igog. 

1.  Rheumatic  Fever  and  Valvular  Disease. 

By  XoRMAX  Moore. 

2.  Gallstones.  By  Herbert  F.  Waterhouse. 
,v    Urachal  Cyst  Simulating  Appendicular  Abscess ;  Ar- 

rcsced  Development  of  Genital  Tract :  with  Notes 
on  Recently  Reported  Cases  of  Urachal  Cysts, 

By  Albax  H.  G.  Doran. 

4.  The  Alcohol  Injection  Treatment  for  Neuralgia  and 

Spasm.  By  Wilfred  Harris. 

5.  A  Simple  Operation  for  the  Complete  Remo\al  of  Ton- 

sils, w  ith  Notes  on  900  Cases,  By  George  E.  W.wgh. 

6.  A  Rare  Cardiac  Condition :  Mitral  Stenosis  with  Ball 

Thrombus  in  Left  Auricle, 

.  By  Alexander  Mills  Kennedy. 

7.  Two  Remarkable  Cases  of  Sudden  Death  from  Unsus- 

pected Cardiac  Lesion,  By  Hlgh  Galt. 

8.  Bilharzia  Hxinatobia  and  Circumcision, 

By  James  F.  Allen. 

9.  Rupture  of  the  Pregnant  LTerus  from  Contrecoup  in  a 

Woman  not  in  Labor ;  Operation  :  Recovery, 

By  John  Phillips. 

10  Motoring  Notes,  By  C.  T.  W.  Hirsch. 

I.    Rheum.atic  Fever  and  Valvular  Disease. — 

Moore,  in  his  third  Lumleian  lecture,  gives  a  splen- 
did review  of  the  treatment  of  rheumatic  fever  since 
Sydenham's  time :  The  treatment  of  rheumatic 
fever  proposed  by  Sydenham  was  based  on  the 
theory  that  it  was  an  inflammation  supported  by  the 
observation  that  the  blood  drawn  from  the  rheu- 
matic patient  presented  the  same  appearances  as 
that  drawn  from  one  with  pleurisy,  a  condition  then 
universally  described  under  the  pathological  head- 
ing inflammation.  His  first  proceeding  was  to  order 
ten  ounces  of  blood  to  be  taken  from  the  arm  on 
the  side  affected.  The  next  day  the  bleeding  was 
repeated  :  after  one  or  two  days  there  was  a  third 
bleeding,  and  after  three  or  four  days  more  a  fourth 
bleeding,  which  was  generally  the  last.  A  cooling 
julep,  which  was  little  more  than  a  draught  of 
sweetened  water,  was  to  be  taken  at  the  patient's 
pleasure.  The  painful  joints  were  to  be  relieved  by 
a  poultice  of  white  bread  tinctured  with  saffron  or 
by  the  repeated  application  of  a  cabbage  leaf.  The 
diet  w^as  one  of  barle\-  and  oatmeal  broth,  all  meat 
or  meat  broths  being  absolutely   forbidden.  The 


1 1 16 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


patient  was  allowed  to  drink'  small  beer,  everybody's 
daily  drink  at  that  time,  or  ptisans  of  barley, 
liquorice,  or  sorrel  boiled  in  water.  He  was  to  keep 
some  hours  every  dav  out  of  bed.  ( )n  the  alternate 
days  to  the  bleedings  enemata  of  milk  with  sugar 
were  given  and  for  eight  days  after  the  last  bleed- 
ing. After  that  a  purge  was  to  be  taken  in  the 
morning  and  the  same  evening  a  large  dose  of  dia- 
codium  in  cowslip  water.  Then  the  patient  was  al- 
lowed gradually  to  return  to  his  wonted  way  of  liv- 
ing with  one  caution — that  he  should  drink  no  wine 
and  no  spirits  and  should  avoid  salted  and  spiced 
meats  and  anything  difficult  of  digestion  for  a  long 
time.  Dr.  Peter  Mere  Latham,  who  wrote  in  1845  and 
whose  knowledge  of  the  practice  of  his  day  went 
back  to  a  few  years  before  the  battle  of  Waterloo, 
had  seen  rheumatic  fever  treated  by  bleeding,  by 
opium  ( 2  to  5  grains  very  twenty-four  hours),  by 
calomel,  by  colchicum,  and  by  drastic  purgatives. 
When  he  was  a  student  at  St.  Bartholomew's  Hos- 
pital from  about  1810  to  1814  the  treatment  of 
rheumatic  fever  usual  there  was  to  give  a  dose  of 
liquor  ammonias  acetatis  three  times  a  day  and  an 
opiate  at  night — a  humane  method  perhaps  trace- 
able to  the  practice  of  the  enlightened  David  Pit- 
cairn.  He  himself  thought  bleeding  expedient  in 
many  cases.  His  view  about  it  in  the  reign  of 
Queen  Mctoria  was  much  the  same  as  that  of  Sy- 
denham in  Charles  H.'s.  He  had  used  opium  with 
success,  though  as.  unlike  Sir  WiUiam  Gull,  he  had 
never  thought  it  right  to  leave  patients  quite  un- 
treated, he  had.  he  admits,  no  sufficient  standard  of 
comparison  to  tell  him  whether  he  had  done  more 
than  relieve  pain.  On  the  whole,  he  thought  that 
the  best  plan  of  treatment  was  that  by  large  (10  to 
20  grains)  and  repeated  doses  of  calomel  followed 
hy  i)urgatives.  Our  author  was  a  clinical  clerk  at  St 
Bartholomew's  Hospital  about  a  quarter  of  a  c  ntury 
after  the  end  of  Dr.  Peter  INIere  Latham's  active 
life  in  his  profession.  His  method  was  entirely  ob- 
solete and  the  general  method  of  treatment  of  rheu- 
matic fever  was  by  alkaline  salts.  This  method  and 
several  others  have  since  become  obsolete,  and  foi 
the  present,  so  far  as  the  pharmacopoeia  is  con- 
cerned, it  seems  clear  that  the  salicylates  are  much 
more  efficient  than  any  remedy  of  past  times.  The}- 
lead  to  a  rapid  cessation  of  the  pain  and  swelling 
of  the'  joints,  and  when  continuously  administered 
in  the  close  proper  to  each  patient  over  several  weeks 
they  seem,  so  far  as  the  temperature  chart  and  the 
absence  of  further  symptoms  enable  one  to  judge, 
to  prevent  the  further  development  of  the  organ- 
ism in  the  endocardium  or  to  destroy  it  altogether. 
The  difficulties  of  administration  which  occur  in 
particular  individuals  can  generally  be  overcome  by 
a  little  ingenuity  in  prescribing.  .A  more  rapid  ex- 
termination of  the  organism  is  desirable,  and  for 
this  we  have  yet  to  seek  a  drug.  For  the  present 
that  which  we  have  does  a  good  deal  for  the  re- 
lief of  the  patient's  pains  while  it  is  not  inoperative 
in  the  i)n)cess  of  terminating  his  maladv. 

2.  Gallstones.--\\'alerliouse  observes  that  as 
.sr)on  as  the  medical  attendant  makes  up  his  mind 
that  operative  treatment  is  indicated  the  less  the 
delay  the  better  for  the  patient.  The  operative  treat- 
ment of  gallstones  in  the  early  stages  of  the  disease 
is  one  of  the  safe.st  and  most  beneficent  of  all  surgi- 


cal procedures.  An  early  cholecystotomy  is  far 
less  dangerous  to  the  patient  than  the  passage  of  a 
single  stone  per  vias  natiiralcs.  There  is  no  opera- 
tion more  easy  or  more  entirely  satisfactory  than  an 
early  cholecystomy,  and  there  are  few  more  diffi- 
cult than  choledochotomy  or  extraction  of  a  stone 
from  the  common  bile  duct  in  a  long  standing  case. 
In  the  latter,  even  if  the  stone  is  removed,  the 
dangers  are  by  no  means  overcome,  as  infection  of 
the  biliary  passages  may  persist  or  adhesions  mav 
cause  trouble  in  adjacent  organs,  especially  the 
stomach.  Waterhouse's  advice  is,  therefore,  that 
as  soon  as  we  have,  with  some  assurance,  diagnosti- 
cated the  presence  of  biliary  calculi,  and  especially 
if  we  can  satisfy  ourselves  that  they  have  produced 
definite  symptoms  and  are  threatening  to  give  rise 
to  some  complication,  the  earlier  they  are  extracte  1 
from  the  gallbladder  the  better  for  our  patient's 
safety  and  for  our  peace  of  mind. 

5.  Kemovai  oi  tiie  lonsils. — Waugh  reports 
nine  hundred  cases  of  complete  removal  of  the  ton- 
sils. The  instruments  required  are  two  Hartmann's 
ring  conchotomes  (Hett's  modification  has  added 
a  useful  serration  to  the  margin  of  the  lower 
ring),  one  pair  of  curved  scissors,  and  a  finelv 
toothed  dissecting  forceps.  The  patient  must  be 
prepared  by  a  preliminary  visit  to  the  dentist,  so 
that  no  operation  in  the  oral  cavity  is  performed 
until  all  carious  teeth  have  been  stopped  or  removed. 
The  patient  is  placed  in  a  recumbent  position  with 
a  sandbag  beneath  the  shoulders,  with  the  head  fall- 
ing slightly  backward,  so  that  the  nasopharynx 
slopes  backward  and  downward,  thus  enabling  the 
small  quantity  of  blood  which  is  shed  to  trickle 
toward  the  nostrils  rather  than  toward  the  larynx, 
whilst  the  slope  is  not  so  great  as  to  cause  engorge- 
ment of  the  pharyngeal  venous  plexus.  A  loop  of 
silk  is  passed  through  the  tip  of  the  tongue  for  the 
purpose  of  retraction,  and  a  gag  is  inserted  between 
the  last  molar  teeth.  The  tonsil  is  then  seized 
in  the  ring  forceps  and  gently  drawn  toward 
the  middle  line,  so  that  the  imbedded  part  of 
the  gland  bulges  beneath  its  normal  covering  of 
the  anterior  pillar  of  the  fauces.  Immeriately  ex- 
ternal to  the  internal  margin  of  the  anterior  pillar, 
just  where  it  blends  with  the  surface  of  the  tonsil, 
an  incision  is  made  with  the  finelv  toothed  forceps, 
parallel  to  and  extending  for  the  whole  length  of 
the  free  margin  of  the  anterior  pillar.  This  incision 
reveals  the  capsule  of  the  tonsil  which  now  appears 
as  a  glistening  smooth  bluish  white  surface.  The 
ease  and  success  of  the  operation  depend  upon  this 
incision  displaying  the  capsule  of  the  tonsil  and  not 
entering  its  substance.  This  mistake  is  easily  made 
by  keeping  too  near  to  the  free  surface  of  the  ton- 
sil, and  it  is  the  common  cause  of  difficulty  and 
failure  for  beginners.  The  ring  forceps  is  then  re- 
adjusted so  as  to  get  a  firm  hold  upon  the  tonsil 
and  the  anterior  pillar  is  drawn  outward  by  means 
of  the  fine  toothed  forceps.  The  tonsil  is  then  prac- 
tically dislocated  from  its  bed,  and  the  sei)aration 
of  the  rest  of  the  layer  of  fine  cellular  tissue,  in- 
tervening betwcm  the  capsule  of  the  tonsil  and  the 
muscular  wall  of  the  pharynx,  is  easily  effected 
either  by  the  finely  toothed  forceps  or  by  a  closed  jiair 
of  curved  blunt  ended  scissors  which  fit  in  behind 
the  whole  of  the  tonsil  and  push  the  pharyngeal  wall 


May  29,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


II17 


away  from  it.  Since  the  tonsillar  vessels  are  thereby 
torn  across  and  are  able  to  retract  within  the  mus- 
cular wall  of  the  pharynx,  there  is  practically  no 
bleeding — in  fact,  the  absence  of  bleeding  forms  a 
striking  contrast  to  the  sharp  hsemorrhage  which  en- 
svies  after  the  tonsil  has  been  cut  across  by  a  guillo- 
tine. The  time  occupied  in  the  complete  removal 
of  both  tonsils  and  adenoids  is,  on  an  average,  three 
minutes.  A  brief,  deep  anaesthesia  with  chloroform 
is  necessary,  and  the  coughing  reflex  should  be  abol- 
ished. For  the  after  treatment  a  simple  mouth  w^ash 
is  provided  and  a  mixture  containing  sodium  salicy- 
late and  potassium  chlorate,  administered  every  few 
hours.  The  patients  are  kept  in  bed  for  about  forty- 
eight  hours  and  are  allowed  solid  food  when  they 
feel  inclined  for  it.  With  children  this  is  frequently 
on  the  day  after  the  operation. 

BERLINER  KLINISCHE  WOCHENSCHRIFT. 

April  3,  1909. 

1.  Suture  of  the  Lungs  in  Gunshot  Injuries, 

By  M.  BORCHARDT. 

2.  The  Usefulneis  of  Antiformin  in  the  Demonstration 

of  Tubercle  Bacilli,  By  Os\v.\ld  Seemann. 

3.  Chemistry  and  Microscopy  of  Fatty  Degeneration  of 

the  Kidney.  By  Erich  Kuznitzky. 

4.  Relations  between  Hypophysis  and  Ovaries, 

By  Leopold  Thumin. 

5.  Technique  and  Indications  for  Operations  for  Retro- 

flexion, with  Special  Reference  to  the  Vaginal  Fixa- 
tion of  the  Uterus.  By  Julius  Sonnenfeld. 

6.  Streptococci  in  Diseases  of  Children  and  the  Serum 

Treatment  of  these  AtTections,       By  Julius  Ritter. 

7.  Pyelocystitis  of  Children,  By  F.  Goppert. 

8.  The  Permanent  Hyperaemia  of  an  Extremity  due  to 

Occlusion  of  its  Principal  Vein, 

By  Heinrich  Bloch. 

9.  Galvanocaustic  Applications  in  the  Urethra. 

By  Hans  Goldschmidt. 

10.  A  Handy  Apparatus  for  Irradiation  with  Light  and 

Warmth,  By  Buttersack. 

11.  The  Biology  of  the  Suprarenal  System, 

By  Heinrich  Poll. 

1.  Suture  of  the  Lung  in  Gunshot  Injuries. — 

Borchardt  reports  two  cases  of  gunshot  injury  in 
which  he  opened  the  chest  and  sutured  the  lung. 
One  patient  recovered ;  the  other,  who  appeared 
moribund  before  the  operation,  died  six  hours  later. 
He  declares  that  the  operation  requires  no  special 
skill,  but  skill  is  needed  to  select  the  cases  in  which 
it  should  be  performed  in  order  that  unnecessary 
danger  may  be  avoided.  The  operation  should  be 
reserved  for  cases  in  which  there  is  a  primary  severe 
haemorrhage,  or  a  subacute  continual  bleeding  pro- 
ductive of  symptoms  of  internal  haemorrhage,  or 
lense  pneumothorax  and  extensive  emphysema  of 
the  cellular  tissue,  or  when  the  wound  is  infected  or 
gaping  widely. 

2.  Antiformin. — Seemann  confirms  the  obser- 
vation of  Uhlenhuth  that  a  mixture  of  Javelle  water 
and  liquor  sodse  known  as  antiformin  is  very  useful 
in  the  detection  of  tubercle  bacilli  in  material  of  the 
most  different  kinds. 

5.  Retroflexion. — Sonnenfeld  says  that  in  every 
case  of  retroflexion  the  question  arises  whether  the 
faulty  position  is  one  that  requires  treatment  at  all. 
If  it  requires  treatment  the  question  then  to  be  de- 
cided is  whether  pessaries  will  suffice,  whether  an 
operation  is  necessary,  or  whether  the  patient  would 
not  be  helped  much  more  by  a  rational  strengthen- 
ing of  the  entire  organism. 


6.  Streptococci  in  Diseases  of  Children  and 
the  Serum  Treatment  of  these  Affections. — Rit- 
ter reports  twenty-two  cases  of  erysipelas  in  chil- 
dren between  the  ages  of  nine  months  and  thirteen 
years  treated  with  serum  injections.  The  disease 
was  brought  to  a  standstill  in  from  fourteen  to  twen- 
ty hours,  the  fever  passed  off  in  from  one  to  three 
days  after  the  injection.  The  children  were  brought 
to  him  on  from  the  first  to  the  fourth  day  of  the  dis- 
ease according  to  the  statements  of  the  parents.  He 
then  reports  nineteen  cases  of  scarlet  fever  and  four- 
teen of  diphtheria  treated  in  the  same  way.  All  of 
these  cases  were  very  severe.  Of  the  nineteen  pa- 
tients with  scarlet  fever  ten  recovered  and  nine  died. 
Exactly  one  half  of  the  cases  of  diphtheria  recov- 
ered. 

7.  Pyelocystitis  in  Children. — Goppert  con- 
siders first  the  cases  met  with  in  children,  one  and 
one  half  years  old  and  under,  then  those  met  with  in 
children  over  that  age.  The  diagnosis  can  be  made 
as  soon  as  the  urine  is  examined.  The  prognosis 
he  considers  very  dependent  on  early  and  proper 
treatment.  He  finds  in  his  cases  a  mortality  of 
twenty  per  cent,  which  he  ascribes  to  the  treatment 
having  been  instituted  too  late,  or  discontinued  too 
soon.  Without  treatment  the  patients  of  all  of  the 
severer  cases  met  with  in  the  first  year  and  a  half 
of  life  die,  either  in  an  acute  attack  or  in  the  chronic 
stage.  Treatment  may  consist  of  washing  out  the 
pelvis  of  the  kidney,  or  of  weakening  the  energy  of 
the  bacteria  by  means  of  drugs.  The  washing  out 
is  accomplished  by  the  ingestion  of  large  quantities 
of  alkaline  water,  and  this  is  more  efficient  in  chil- 
dren than  in  adults.  In  acute  cases  salol  is  given 
in  appropriate  doses.  After  improvement  com- 
mences he  gives  urotropin,  particularly  if  the  con- 
dition threatens  to  become  chronic.  A  third  remedy 
that  he  mentions  is  hippol,  which  he  uses  when 
urotropin  is  not  borne  well. 

8.  Permanent  Hyperaemia  of  an  Extremity 
Due  to  Occlusion  of  Its  Principal  Vein. — Bloch 
reports  the  case  of  a  man,  twenty-three  years  of 
age,  who  recovered  from  an  attack  of  typhoid  fever 
with  a  swelling  of  the  right  leg  which  liad  persisted 
and  rendered  him  unfit  for  work. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT 

March  30.  1909. 

1.  Formation  of  Coxa  Vara  after  Reposition  of  Congeni- 

tal Dislocation  of  the  Hip,  By  Joachimsthal. 

2.  Bismuth  Poisonmg  and  a  Nontoxic  Substitute  for  X 

Ray  Absorption,  By  Lewin. 

3.  Knee  Pains  in  Diseases  of  the  Hip,       By  Heinecke. 

4.  Traumatism  of  the  Skull  and  Injury  of  the  Brain, 

By  Wevert. 

5.  Demonstration  of  Glycuronic  Acid  by  Tollens's  Reac- 

tion with  Naphthoresorcin  and  Hydrochloric  .A.cid, 

By  Tollens. 

6.  Chronic  Dilatation  of  the  Large  Intestine  in  Old  Age, 

By  Verse. 

7.  Ansesthetization  of  the  Tympanic  Membrane  and  of  the 

Tympanic  Cavity,  By  Tiefenthal. 

8.  A  New  Contrast  Stain  for  the  Detection  of  Intracel- 

lular Tubercle  Bacilli  in  the  Sputum,    By  Assmann. 

9.  The  Technique  of  the  Sunlight  Treatment  of  Laryngeal 

Tuberculosis,  By  Kraus. 

10.  The  Graphic  Representation  of  Pulmonary  Conditions, 

By  Pischinger. 


lll8  PITH  OF  CURRENT  LITERATURE. 


11.  A  Contribution  to  Onycliogryphosis  Symmetrica,  Con- 

genita, and  Hereditaria,  By  Kohler. 

12.  How  can  Digitalis  Leaves  with  Stable  Value  be  Intro- 

duced into  tlie  Dispensatory  ?  By  Focke. 

13.  An  Instrument  tor  tlie  Rapid  Application  of  Masses  of 

Ligatures,  By  Axh.xusen. 

14.  Tuberculosis  as  a  Children's  Disease,    By  Hamburger. 

15.  Recollections  of  Justus  von  Liebig,       By  von  Ranke. 

2.  Bismuth  Poisoning. — Lewin  gives  the  fol- 
lowing s\-mptoms  as  produced  by  bismuth :  Blackish 
discoloration  of  the  mucous  membranes  of  the  di- 
gestive tract,  inllammation  of  the  tissues  in  the 
mouth,  with  ^welling,  excoriation  or  croupous 
changes,  salivation  and  loosening  of  the  teeth,  nan- 
sea,  pains  along  the  oesophagus,  dysphagia,  vomit- 
ing, distention  of  the  abdomen,  diarrhoea,  diminution 
of  the  quantity  of  urine,  albuminuria,  cylindruria, 
desquamative  nephritis  atid  parenchymatous  degen- 
eration of  the  kidney,  disturbances  of  the  pulse,  sin- 
gultus, coldness  of  the  body,  dyspnoea,  cyanosis,  col- 
lapse, headache,  fever,  and  delirium.  The  substitute 
he  suggests  for  x  ray  absorption  is  magnetic  iron 
oxide. 

3.  Knee  Pains  in  Diseases  of  the  Hip  Joint. — 

Heinecke  reports  two  cases  in  which  the  patients 
suffered  a  contusion  of  the  knee  followed  by  effusion 
into  the  joint  and  great  disturbance  of  function. 
After  some  weeks  the  effusions  disappeared  and  the 
joints  retained  their  mobility  and  became  again  com- 
pletely normal.  Yet  severe  pain  persisted  in  the 
joint  in  both  cases  which  could  not  be  explained  by 
any  local  condition.  In  one  case  the  pain  appeared 
immediately  after  the  accident,  in  the  other  several 
months  afterward,  in  both  the  pain  increased  in  sev- 
erity. A  year  and  a  half  after  the  injury  in  one 
case,  three  years  after  in  the  other,  a  serious  disease 
of  the  hip  joint  was  found  on  the  same  side,  which 
had  doubtless  been  in  existence  for  several  months 
as  was  shown  by  the  great  disintegration  of  the 
joints,  and  this  was  held  to  explain  the  pains  in  the 
knee  joints.  An  exact  diagnosis  of  the  hip  disease 
was  not  made,  but  in  one  case  it  appeared  to  be 
arthritis  deformans,  in  the  other  tuberculosis.  A 
connection  between  the  accidents  and  the  hip  dis- 
eases seems  to  be  probable. 

4.  Traumatism  of  the  Skull  and  Injury  of  the 
Brain. — W'eytrt  asserts  that  while  a  vigorous 
brain  may  undergo  a  severe  traumatism  without  in- 
jury a  less  resistant  brain  may  easily  react  with 
serious  consequences  to  a  slight  traumatism. 

6.  Chronic  Dilatation  of  the  Large  Intestine. 
-  -Verse  reports  a  case  of  colossal  dilatation  of  the 
sigmoid  Hexure  and  a  slighter  one  of  the  splenic 
flexure  of  the  descending  colon  met  with  in  a  man, 
seventy-tvio  years  old. 

7.  Anaesthetization  of  the  Middle  Ear. — 'I  ic- 
fenthal  recommends  that  four  drops  of  a  twenty  per 
cent,  solution  of  cocaine  with  one  drop  of  adrenalin. 
I  in  1,000,  is  placed  in  contact  with  the  drum  mem- 
brane for  fifteen  minutes.  This  produces  a  slight 
reduction  of  sensibility,  insufficient  for  paracentesis. 
Then  with  a  small  syringe  having  a  thin,  angular 
needle,  he  injects  through  the  lower  part  of  the 
membrane  two  to  four  drops  of  a  five  or  ten  per 
cent  solution  of  cocaine  with  adrenalin.  After  a  few 
seconds  the  membrane  a])pears  whitish  gray  from 
the  an.xmia  of  the  tympanic  cavity,  the  anresthesia 
is  nearly  complete,  and  paracentesis  may  be  per- 
formed without  pain  or  luemorrhage. 


[New  York 
Medical  Jour.val. 

April  6,  1909. 

1.  Deep  Irradiation  with  the  X  Rays,  By  Dorn. 

2.  What  is  the  Effect  of  Specific  Treatment  upon  the 

Wassermann-A.  Neisser-Bruck's  Reaction, 

By  PURCKHAUER 

3.  The  Antitrysin  in  the  Mother's  Blood  Serum  during 

Pregnancy,  By  Gr.Kfenberg. 

4.  Auscultatory  Measurement  of  the  Blood  Pressure, 

By  ScHRUMPF  and  Zabel. 

5.  Diagnosis  and  Treatment  of  Pancreatitis, 

By  Drees  MANN. 

6.  The  Presence  and  Signification  of  Urobilin, 

By  HiLDEBRANDT. 

7.  How  a  Scientifically  Definable  Light  can  be  Obtained 

and  Used  for  Medical  Purposes,  By  Pick. 

8.  A  Simple  Procedure  in  the  Preparation  of  a  Tar  Bath, 

By  Tage. 

9.  Scarlet  P'cAer  and  Wassermann's  Reaction, 

By  HOLZMANN. 

ID.  Casuistic  Contribution  to  the  Postoperative  Pulmonary 
Complications,  By  von  Lichtenberg. 

11.  A  Case  of  Disease  of  the  Optic  Nerve  after  Injections 

of  Arsazetin,  By  ROte. 

12.  Concealed  Syphilitic  Places.  By  Vorxer. 

13.  Bezold's  Functional  Test  of  the  Ear  and  the  Investiga- 

tion of  Deaf  Mutes.  By  Rauch. 

14.  The  Influence  of  Castration  and  of  Hysterectomy  upon 

the  After  Condition  of  the  Women  Operated  upon, 

By  Fellner. 

15.  The  Medical  Service  in  the  French  Foreign  Legion, 

By  Granjux. 

2.  Effect  of  Specific  Treatment  on  Wasser- 
mann's Reaction. — Piirckhauer  finds  that  in  re- 
currences the  positive  serum  reaction  reappears  in 
most  cases  and  that  the  better  treated  latent  syphili- 
tics  are  the  more  frequently  is  the  reaction  nega- 
tive. Hence  he  advances  as  the  primary  principles 
of  the  treatment  of  syphilis  the  most  energetic  treat- 
ment possible  begun  as  quickly  as  possible  after  the 
establishment  of  the  diagnosis,  and  maintained  as 
energetically  as  possible  during  the  first  years  of  the 
disease  without  reference  to  whether  symptoms  do 
or  do  not  appear. 

4.  Auscultatory  Measurement  of  the  Blood 
Pressure. — Schrumpf  and  Zabel  compare  the  aus- 
cultatory method  of  determination  of  the  blood  pres- 
sure, suggested  in  1905  by  Korotkow,  with  the  os- 
cillatory method  of  von  Recklinghausen,  the  pal- 
patory method  of  .Strasburger,  and  the  graphic  of 
Janeway,  Masing,  and  Sahli.  He  finds  that  there 
are  sources  of  error  in  all  of  the  three  latter  methods 
which  can  be  avoided  in  the  auscultatory,  in  which 
the  tone  of  the  radial  artery  is  studied  by  auscul- 
tation about  the  junction  of  the  upper  and  middle 
thirds  of  the  forearm. 

5.  Pancreatitis. — Dreesmann  finds  acute  pan- 
creatitis fatal  in  ninety-three  per  cent,  of  cases  not 
operated  in,  and  therefore  urges  laparotomy  as  the 
proper  course  to  pursue  in  such  cases.  With  the 
operation  he  finds  the  mortality  to  be  fifty-five  per 
cent.  In  chronic  pancreatitis  he  likewise  advises 
operation. 

9.    Scarlet  Fever  and  Wassermann's  Reaction. 

— Holzmann  reports  a  case  of  .scarlet  fever  in  a  girl, 
sixteen  years  old,  in  which  Wassermann's  test  for 
syphilis  produced  a  positive  reaction.  I'our  weeks 
after  the  commencement  of  the  illness  the  test  be- 
came negative  tind  remained  so. 

II.  Disease  of  the  Optic  Nerve  after  Injec- 
tions of  Arsazetin. — Riite  reports  the  case  of  a 
man,  seventy-three  years  of  age,  who  was  given 
injections  of  arsazetin  to  treat  an  extensive  psor- 
iasis. .\trophy  of  the  optic  nerve  was  induced,  sim- 
ilar to  that  seen  in  cases  of  atoxyl  jmisoning. 


May  29,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


1 1 19 


AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 

May,  1909. 

1.  The  Diagnosis  of  Gastric  Ulcer  as  Tested  by  Opera- 

tion, By  J.  N.  Hall. 

2.  The  Diet  in  Typhoid  Fever,  By  S.  Strouse. 

3.  Typhoid  Bacilluria,  By  Karl  Connell. 

4.  The  Surgical  Treatment  of  Perforation  of  the  Intestines 

in  Typhoid  Fever,    By  Francis  Dexison  Patterson. 

5.  Spasm  of  the  Chest  Aliiscles,  particularly  the  Inter- 

costals,  as  a  Physical  Sign  of  Disease  of  the  Lungs, 

By  F.   M.  POTTENGER. 

6.  Gastric  Digestion  in  Infants,       By  T.  Wood  Clarke. 

7.  Syphilis  of  the  Stomach  and  Intestines, 

By  Alfred  D.  Kohn. 

8.  The  Liver  in  Tuberculosis, 

By  JosEPHUs  Tucker  Ullom. 

9.  Ascites  in  Cirrhosis  of  the  Liver  Cured  by  Repeated 

Tappings,  By  Henry  S.  Patterson. 

10.  Adiposis  Dolorosa.    A  Clinical  and  Pathological  Study, 

with  the  Report  of  Two  Cases  with  Necropsy, 

By  George  E.  Price. 

11.  The  Chemistry  of  the  Urine  in  Diabetes  Mellitus, 

By  Campbell  P.  Howard. 

12.  Intestinal  Obstruction ;  an  Outline  for  Treatment  Based 

upon  the  Cause  of  Death, 

By  J.  W.  Draper  IMaury. 

I.  Diagnosis  of  Gastric  Ulcer. — Hall  remarks 
that  ulcer  of  the  stomacb  is  much  more  frequent 
than  we  generally  believe ;  a  scar  may  be  frequent- 
ly found  blocking  the  pylorus  in  those  in  whom  no 
symptoms  have  pointed  toward  ulcer,  so  far  as  an 
intelligent  patient  can  inform  us ;  ulcer  is  probably 
present  in  the  majority  of  cases  of  persistent  sour 
stomach  ;  the  finding  of  tenderness  and  rigidity  over 
the  stomach  in  the  latter  class  of  cases  should  be 
regarded  as  practically  clinching  the  diagnosis,  ex- 
cept in  certain  neurotic  individuals  ;  a  markedly  di- 
lated stomacK  in  a  young  patient,  not  especially 
neurasthenic,  should  raise  a  presumption  of  pyloric 
ulcer  or  its  results,  if  there  have  been  any  symp- 
toms of  indigestion  in  the  past ;  no  neurasthenic 
should  be  treated  without  first  investigating  the 
size  and  digestive  power  of  his  stomach,  regardless 
of  the  presence  or  absence  of  a  history  of  ulcer ; 
patients  not  helped  promptly  by  medical  treatment 
should  be  studied  carefully  from  a  surgical  stand- 
point ;  the  bedside  examination  must  be  given  much 
greater  weight  in  the  diagnosis  than  the  report  from 
the  laboratory ;  and  the  diagnosis  of  ulcer  mav  be 
made  with  very  reasonable  certainty  if  a  careful 
investigation  is  carried  out. 

3.  Typhoid  Bacilluria. — Connell  says  that  ty- 
phoid bacilluria  is  a  great  menace  to  public  health. 
Of  all  excretions  containing  typhoid  bacilli,  the 
most  dangerous  is  the  urine  of  the  declining  and 
postfebrile  stage  of  typhoid  fever.  The  faeces  are 
a  greater  public  menace  during  the  active  stage  of 
the  illness,  but  taking  the  course  of  typhoid  fever 
as  a  whole,  the  urine  is  probably  the  great  spread- 
er of  this  disease.  However,  in  chronic  typhoid 
bacillus  carriers,  the  bile  more  frequently  than  the 
urine  is  the  medium  in  which  the  bacteria  have  per- 
petuated themselves.  As  a  routine  in  every  case  of 
typhoid  fever,  during  the  decline  and  convalescence, 
the  urine  in  the  bladder  should  be  rendered  inhibi- 
tory to  the  growth  of  typhoid  bacilli.  Bacilluria 
once  established  should  be  terminated  by  urinary 
antiseptics  or  by  irrigation  of  the  bladder.  Ob- 
stinate ulcerative  cystitis  should  be  treated  by  sur- 


gical drainage.  The  passed  urine  of  the  typhoid 
fever  patient  at  all  stages  of  the  illness  should  be 
disinfected  with  the  same  care  as  the  ixces. 

4.  Perforation  of  Intestines  in  Typhoid  Fever. 
— Patterson  observes  that  too  much  stress  cannot 
be  laid  upon  the  fact  that  an  early  diagnosis  and 
immediate  operation  is  all  important.  This  would 
seem  to  be  best  attained  by  a  close  cooperation  be- 
tween physicians  and  surgeons,  so  that  the  latter, 
when  the  complication  occurs,  may  not  be  at  the 
disadvantage  of  not  having  seen  the  patient  before. 
While  typhoid  fever  in  the  past  has  been  regarded 
as  a  disease  belonging  essentially  to  the  realm  of 
internal  medicine,  in  the  light  of  our  further  knowl- 
edge one  may  state  that  its  relation  to  surgery  is 
indeed  most  intimate.  Holscher  studied  the  results 
of  autopsies  upon  2,000  cases  of  typhoid  fever  and 
found  that  only  twenty-four  per  cent,  of  the  patients 
died  from  the  fever,  and  the  remaining  seventy-six 
per  cent,  died  as  the  result  of  the  various  sequels. 

6.  Gastric  Digestion  in  Infants. — Clarke  con- 
cludes from  his  investigations  that  many  and  con- 
tradictory results  have  been  obtained  ;  a  few  facts, 
however,  seem  to  be  pretty  definitely  proved.  In 
the  first  place,  it  may  be  said  that  all  the  factors 
present  in  the  adult  are  found  in  a  weaker  form 
in  the  young  infant.  In  the  newborn  child  on  breast 
milk  the  stomach  usually  empties  itself  in  from 
an  hour  to  an  hour  and  a  half ;  as  the  child  grows 
older  this  time  becomes  longer.  The  few  drops  of 
gastric  juice  found  in  the  empty  stomach  are  the 
remains  of  that  secreted  during  the  last  meal,  and 
are  not  due  to  a  secretion  into  the  empty  stom- 
ach. The  motility  is  more  rapid  in  breast  fed  chil- 
dren than  in  those  on  cows'  milk  or  artificial  foo  1, 
and  more  rapid  in  the  healthy  than  in  the  ill  child. 
The  acidity  immediately  after  a  meal  is  nil,  but 
steadily  increases  during  digestion,  and  is  less  in 
the  very  young  than  in  the  older.  On  a  barley 
water  diet  free  hydrochloric  acid  appears  in  the 
stomach  in  a  few  minutes,  but  on  a  milk  diet  it 
does  not  show  itself  for  an  hour  or  more,  due  to 
the  fact  that  the  casein  absorbs  it  or  combines  with 
it  in  some  way,  and  the  free  acid  does  not  appear 
until  the  casein  has  taken  up  all  required  for  its 
complete  digestion.  The  free  acid  appears  later  in 
disease  than  in  health,  due  to  the  increased  amount 
of  food  in  the  stomach  and  to  the  slower  secretion 
of  the  acid ;  in  cases  of  pylorospasm  the  acidity  is 
increased.  Opinions  dififer  as  to  the  occurrence  of 
lactic  and  volatile  fatty  acids,  but  these  probably  do 
not  occur  in  healthy  breast  fed  infants,  while  in 
those  ill  or  on  cows'  milk  they  are  fairly  common. 
Part  of  the  acidity  is  probably  due  to  a  fat  split- 
ting enzyme  in  the  infant's  stomach.'  Pepsin  is 
present  at  all  ages  and  in  all  kinds  of  health,  and 
acts  in  the  infant  stomach  though  to  a  less  degree 
than  in  the  adult.  The  peptic  digestion  goes  on  to 
the  stage  of  peptones,  but  not  beyond  that.  The 
fact  that  the  stomach  contents  will  no  digest  fibrin 
in  he  thermostat  is  due  to  the  fact  that  all  the  hy- 
drochloric acid  is  combined  with  the  casein,  and 
while  the  protein  with  which  it  is  combined  will  be 
acted  upon  by  the  pepsin,  a  foreign  protein  with- 
out the  addition  of  more  acid  will  resist  the  enzyme. 
Rennin  occurs  in  the  stomach  after  the  first  few 


1 120 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal. 


weeks  of  life ;  whether  during  the  first  week  is  a 
question. 

7.  Syphilis  of  the  Stomach  and  Intestines. — 

Kohn  states  that  the  diagnosis  of  stomach  syphilis 
can  be  considered  probable  if,  with  luetic  history 
and  specific  scars,  there  are  found  at  the  same  time 
gummatous  infiltrations.  The  haemorrhages  can  most 
easily  be  explained  by  concomitant  portal  obstruc- 
tion. Clinically,  the  fact  must  not  be  lost  sight  of 
that  in  luetic  subjects  who  have  been  overdosed  with 
iodides  and  mercury  there  are  often  profound  di- 
gestive disturbances,  and  that  these  disturbances 
must  in  no  wise  be  confounded  with  gastric  lues, 
for  in  gastric  syphilis  the  stomach  symptoms  im- 
prove under  specific  therapy,  whereas  the  first 
named  are  aggravated  by  mercury  and  potassium 
iodide.  The  conclusions  drawn  by  Reder  as  re- 
gards lues  of  the  small  intestine  are:  i.  Ulcers  are 
found  in  the  entire  small  gut,  especially  in  the  lower 
jejunum ;  2,  they  always  occur  in  groups,  and  the 
number  thereof  may  be  very  great ;  3,  they  are  al- 
ways annular,  and  the  floor  is  deep  and  smooth ;  4, 
they  always  produce  stenosis ;  5,  they  are  all  sim- 
ilar histologically ;  and  6,  the  lesion  begins  with  a 
new  celktlar  infiltration,  surrounding  the  vessels  es- 
pecially. 

8.  The  Liver  in  Tuberculosis. — Ullom  finds 
that  miliary  tubercles  are  found  in  the  great  ma- 
jority of  the  livers  of  the  cases  of  chronic  phthisis 
autopsied.  Solitary  tubercle  of  the  liver  is  a  very 
rare  manifestation.  The  infection  probably  is  haema- 
togenous,  the  bacilli  being  carried  to  the  liver  by 
the  portal  vein  and  the  hepatic  artery.  In  most 
cases  the  infection  arises  in  intestinal  ulcers.  Pas- 
sive congestion  of  the  liver  is  found  in  nearly  every 
case  of  pulmonary  tuberculosis,  while  amyloid  and 
fatty  change  are  found  in  a  relatively  small  number 
of  cases.  He  does  not  believe  that  a  fibrosis  or  cir- 
rhosis of  the  liver  due  to  the  tubercle  bacilli  does 
occur,  and  is  more  inclined  to  think  that  the  fib- 
roses found  are  due  to  other  a;tiological  factors. 


IprocetiJings  of  ^flftjtus. 


MEDICAL  JURISPRUDENCE  SOCIETY  OF  PHILA- 
DELPHIA. 
Meeting  of  April  jg,  igog. 
William  W.  Smithers,  Esq.,  in  the  Chair. 

Insanity  as  a  Defense. — In  a  paper  thus  enti- 
tled Georoe  a.  Drovin,  Esq.,  said  that  there  were 
several  reasons  why  the  plea  of  insanity  should  not 
be  permitted  to  save  a  murderer  from  his  fate.  In 
the  first  place,  the  example  afforded  by  this  maud- 
lin leniency  was  most  pernicious.  Of  the  convicted 
murderers,  few  came  to  their  deserved  end.  The 
person  who  was  -tempted  to  homicide  was  not  de- 
terred by  the  thought  that  his  life  must  atone  for 
the  life  he  was  about  to  take.  His  insanity  made 
him  all  the  more  reckless,  and  with  one  final  i).sycho- 
logical  impulse  the  pitiful  brute  became  a  mur- 
derer. Criminolf)gists  told  us  that  example  was  a 
factor,  and  legists  told  us  that  certainty  of  punish- 
ment was  a  deterrent.  If,  then,  capital  punishment 
was  a  valuable  and  eft'ectivc  part  of  our  penal  code, 
it  was  illogical  to  discriininate.    One  murderer  was 


as  deserving  of  death  as  another.  Had  not  public 
opinion  demanded  the  deaths  of  Probst,  Guiteau, 
Holmes,  and  Czolgosz.  the  defense  would  easily 
have  found  experts  to  declare  those  men  insane. 
What  would  have  been  the  effect  upon  other  de- 
fectives had  these  men  been  permitted  to  escape 
death  ?  For  the  sake  of  example,  therefore,  it  seemed 
that  the  defense  of  insanity  should  not  be  enter- 
tained. Let  it  be  clearly  understood,  however,  that 
we  did  not  here  advocate  the  slaughter  of  all  in- 
sane persons.  The  crime  was  the  punishable  of- 
fense, not  the  insanity.  In  the  second  place.  Why 
should  the  homicide  who  was  popularly  termed  in- 
sane be  saved?  Theoretically,  we  did  not  allow 
sentiment  to  intervene  in  the  criminal  code ;  logi- 
cally, therefore,  we  could  not  consider  it  in  this  con- 
nection. We  executed  an  ordinary  murderer  in 
order  to  prevent  him  from  repeating  his  crime,  but 
we  afifected  a  great  horror  at  the  thought  of  kill- 
ing the  insane  murderer,  and,  yet,  he  was  just  as 
likely  as  the  other  to  add  to  his  misdeed.  In  fact, 
instances  were  numerous  where  insane  criminals  in 
confinement  had  slain  their  jailers  and  their  fellow 
prisoners.  We  must  either  save  all  murderers  or 
execute  them  all.  The  practice  of  saving  the  insane 
murderer  from  the  executioner  was  illogical,  un- 
safe, unwise,  and  the  result  of  a  sentimentality  un- 
worthy of  a  people  who  desired  to  be  considered  the 
most  humane  among  the  nations  of  Christendom. 

Dr.  Henry  W.  Cattell  said  that  he  was  not  pre- 
pared to  go  as  far  as  the  reader  of  the  paper.  Two 
examples  which  had  come  under  his  observation 
were  of  interest  in  this  connection.  In  one  instance 
a  man  guilty  of  murder  was  pronounced  sane.  He  was 
taken  to  the  penitentiary  and  there  hanged  himself. 
A  post  mortem  examination  showed  gummata  in 
portions  of  the  brain,  which  led  to  the  belief  that 
the  man  had  not  been  accountable  for  his  actions. 
We  all  knew  how  possible  under  proper  treatment  it 
would  have  been  for  this  man  to  regain  his  normal 
self.  The  second  case  was  that  of  a  woman  who 
during  an  attack  of  puerperal  insanity  shut  herself 
and  her  two  children  in  the  bathroom  and  turned 
on  the  gas.  The  two  children  were  killed  and  the 
mother  was  saved.  The  woman  afterward  com- 
pletely recovered  from  her  attack  of  puerperal  in- 
sanity. We  might  do  awa}"  with  a  great  deal  of 
trouble  by  letting  the  person  be  committed  under 
the  death  sentence  without  attempting  to  show  at 
the  trial  that  he  was  insane,  and  then  afterward  let 
his  case  be  studied  by  experts  over  a  certain  lensjth 
of  time  to  show  that  he  was  or  was  not  insane. 

Mr.  CoGGiNS  could  not  go  as  far  as  the  reader  of 
the  paper  in  practically  cutting  out  the  defense  of 
insanity  altogether  and  saying  that  a  man  admitted- 
ly insane  when  he  committed  murder,  and  in  danger 
of  committing  another,  should  have  his  life  taken. 
This,  he  thought,  would  be  demoralizing  to  civili- 
zation. The  discussion  brought  up  the  question. 
What  should  be  the  true  basis  of  defense,  teclniical 
insanity  or  something  that  meant  simply  mo:-al  ir- 
responsibility? The  present  condition  was  not  a 
satisfactory  one,  and  there  ought  to  be  some  metlvKl 
which  would  reach  the  direct  ([uestion  of  mor  il  re- 
sponsibility. 

Dr.  Cii.VRi.KS  K.  IMii.r.s  said  ihat.  if  he  inider- 
stood.  the  reader  of  the  paper,  he  would  jiractically 


May  29.  1909.] 


PROCEEDIXGS  OF  SOCIETIES. 


1121 


sweep  away  the  defense  of  insanity,  and  he  oflfered 
us  nothing  in  place  of  it.  the  only  possible  defense 
in  the  large  number  of  cases  in  which  some  de- 
fense was  certainly  justifiable.  Certainly  he  dis- 
sented from  the  statements  and  the  recommendations 
of  'Sir.  Drovin's  paper.  That  we  should  have  some 
method  of  defense  in  which  the  question  of  moral 
responsibility  should  determine  the  issue,  as  main- 
tained by  Mr.  Coggins.  might  be  correct.  How- 
ever, in  order  to  determine  that  moral  responsibility 
we  must  have  methods,  and  from  the  very  nature 
of  things  these  methods  must  be  both  legal  and 
medical,  and  the  only  way  to  get  at  the  moral  re- 
sponsibility was  through  the  methods  already  in 
vogue.  It  was  inconceivable  to  his  mind  that  such 
a  person  as  in  the  case  cited  by  Dr.  Cattell  of  the 
woman  who  took  the  lives  of  her  children  should 
suffer  the  full  penalty  of  the  law.  In  arguments 
before  medicolegal  societies  we  were  always  trying 
to  improve  upon  current  methods  of  procedure.  In 
the  speaker's  earlier  years,  he  thought  he  had  had  a 
little  tendency  in  that  direction  himself,  but  he  had 
gradually  become  convinced  that  those  who  framed 
the  laws  had  known  better  than  he,  or  better  per- 
haps than  an}-  member  of  this  or  any  other  medico- 
legal association.  Undoubtedly  the  defense  of  in- 
sanity was  sometimes  resorted  to  when  it  should 
not  be.  but  in  a  far  larger  number  of  cases  it 
should  be  brought  forward,  and  should  be  allowed 
some  weight  when  not  pleaded  at  all. 

Dr.  William  D.  Robixsox  said  there  were  hun- 
dreds of  cases  of  persons  quite  as  dangerous  to  the 
community  as  those  with  smallpox  and  other  dis- 
eases which  were  reportable.  While  this  was  not 
entirely  pertinent  to  the  subject,  there  was  an  ele- 
ment of  responsibility  which  ought  to  be  placed 
where  it  belonged.  In  the  case  of  the  colored  fel- 
low in  the  penitentiary  who  cut  off  the  head  of  his 
cell  mate,  the  responsibility  lay  with  the  official  of 
the  institution.  It  was  inexcusable  to  fasten  him 
in  a  cell  with  another  man  at  night.  In  the  case 
cited  by  Dr.  Cattell.  that  of  the  man  whose  brain 
showed  gummata.  had  his  case  been  properly  diag- 
nosticated and  antisyphilitic  treatment  instituted, 
the  crime  would  not  have  been  done.  Should  the 
woman  with  puerperal  fever  who  destroyed  her 
child  be  hanged  because  the  doctor  and  nurse  had 
failed  to  do  their  duty.  Insanity  ought  to  be  a  very 
good  reason  for  not  destroying  life  If  such  per- 
sons were  dangerous  to  the  community,  there  was 
as  much  reason  for  caring  for  them  as  for  those 
with  contagious  diseases. 

Dr.  Horace  Phillips  did  not  agree  with  ]\[r. 
"Drovin  in  advocating  the  execution  of  men  who 
are  manifestly  insane  for  the  commission  of  homi- 
cide. They  often  suffered  from  a  curable  disease 
and  ought  to  be  protected.  He  thought  the  pro- 
longed observation  of  such  patients  before  trial  is 
an  excellent  idea. 

Dr.  Hkxrv  Leffmaxx  thought  there  were  two 
phases  of  this  question  which  were  constantly  con- 
founded in  the  minds  of  those  who  discussed  it — 
the  question  of  insanity  and  the  question  of  moral 
responsibility.  The  physician  made  a  diagnosis  of  in- 
sanity based  upon  certain  rules  known  to  the  profes- 
sion. When,  however,  he  entered  upon  the  question  of 
moral  responsibility,  he  was  going  beyond  his  prov- 


ince. The  only  way  to  determine  the  moral  respon- 
sibility was  by  the  majority  of  the  community  de- 
termining what  constituted  crime. 

Mr.  CoGGixs  asked  Dr.  Lef¥mann  what  he  would 
do  with  the  opinion  of  the  physicians  who  pro- 
nounced a  qian  insane  and  stopped  there. 

Dr.  Leffmaxx  said  the  question  was  to  be 
reached  by  the  law.  which  determined  the  degree  of 
responsibility  in  accordance  with  the  degree  of  in- 
sanity. He  would  have  the  physician  testify  only 
to  the  degree  of  insanity — for  example,  was  this 
true  paranoia  ?  And  then  let  the  law  place  the  moral 
responsibility.  It  was  a  matter  for  the  majority  to 
decide. 

Adolph  Eichholz,  Esq.,  thought  the  last  legis- 
lature had  taken  the  first  step  toward  the  intelli- 
gent handling  of  criminals  in  enacting  a  law  giving 
the  so  called  indeterminate  sentence  and  probation 
for  certain  criminals.  Public  opinion  was  taking 
the  stand  that  all  crime  was  an  abnormity  and  that 
abnormal  individuals  who  had  overstepped  the  stat- 
utes to  such  an  extent  that  the  law  must  deal  with 
them  should  be  treated  in  an  intelligent  manner. 
The  conflict  between  the  humanitarian  view  and 
the  abuse  of  the  defense  of  insanity  is  bound  to 
continue  until  we  treated  the  prevention  of  crime  in 
some  logical  and  intelligent  manner.  Our  present 
system  savored  of  revenge.  There  was  a  time  when 
the  horse  thief  was  hanged ;  yet  we  would  not 
think  of  hanging  him  to-day. 

Dr.  \\'iLFORD  W.  Hawke  thought  that  where  the 
crime  was  in  direct  relation  to  the  insanity  insanity 
is  a  most  justifiable  defense. 

Dr.  Alfred  Gordox  said  that,  if  a  man  was  so 
constituted  as  to  be  incapable  of  distinguishing  be- 
tween right  and  wrong  and  incapable  of  under- 
standing the  most  elementary  moral  principles,  we 
could  not  in  the  name  of  justice  hang  him.  We 
had  arrived  at  a  certain  standard  of  civilization  and 
considered  ourselves  in  duty  bound  not  only  to  pro- 
tect society,  but  to  take  care  of  individuals. 

Dr.  William  J.  Dugax  said  that  public  senti- 
ment should  not  be  allowed  to  count  for  the  con- 
viction of  a  man  who  had  been  proved  to  be  insane. 
He  did  not  believe  Guiteau  would  have  been  hanged 
had  it  not  been  for  the  public  clamor. 

WiLLi.vM  W.  Smithers.  Esq.,  was  against  the 
paper,  because  he  did  not  think  it  was  supported  by 
history,  or  by  the  scientific  school  of  criminology 
to-day. 

Mr.  Drovix  said  that  evidently  he  had  not  made 
himself  very  clear.  If  we  assumed  that  cap'tal 
punishment  was  necessary — and  he  had  based  his 
paper  upon  that  assumption,  because  it  was  the  law 
to-day, — he  could  not  see  how  we  could  logically  dis- 
criminate in  any  wav,  shape,  or  form.  He  had 
been  in  error  in  using  medical  terms  without  med- 
ical meanings.  He  feared  he  had  used  the  term  in- 
sanity a  little  too  generally.  Dr.  'SliWs  had  men- 
tioned cases  of  temporary  mania,  as  in  cases  of 
typhoid  fever.  The  speaker  would  look  upon  crimes 
committed  under  such  circumstances  as  purely  ac- 
cidental crimes,  which  were  really  not  crimes  at  all. 
But  the  man  who  was  really  insane  seemed  to  him 
to  be  the  dangerous  man  in  the  communitv.  Xow. 
if  the  remedy  for  murder  was  death — if  that  was 
the   solution  of  the  problem — then   logicall}-  we 


1122 


LETTERS  TO  THE  EDITOR.— BOOK  NOTICES. 


[New  York 
Medical  Journal. 


could  not  save  tlie  murderer  who  was  insane.  He 
did  not  grant  that  that  was  the  solution.  He  was 
not  satisfied  in  his  own  mind  that  possibly  there 
could  not  be  some  better  way  out  of  the  difificulty. 
By  a  system  of  probation,  of  suspended  sentence, 
we  might  more  effectually  deter  men  from  crime ; 
he  did  not  know.  He  did  not  know  that  any  of 
us  knew.    We  all  had  our  opinions. 



f  fttm  t0  Wit  (SMtor. 

NIGHT  CLINICS  IN  BROOKLYN. 

26  Schermerhorn  Street, 
Brooklyn,  .1/0^1  /j,  igog. 

To  flic  Editor: 

In  the  Journal  for  May  8th  the  statement  is  made 
that  a  night  clinic  for  women  has  been  opened  at 
the  Brooklyn  Hospital,  with  the  remark  that  "th-s 
is  the  first  to  be  established  in  Brooklyn."  By  way 
of  correction  let  me  say  that  several  years  ago  Dr. 
Mathewson,  Dr.  Newton,  and  the  undersigned,  while 
working  at  the  Brooklyn  Eye  and  Ear  Hospital, 
tried  the  experiment  of  a  night  clinic  for  eye  and 
ear  diseases.  It  was  kept  up  for  several  months, 
but  so  few  patients  came  that  it  was  finally  discon- 
tinued. As  there  was  no  lack  of  patients  at  our 
day  service,  the  small  night  attendance  was  a  sur- 
prise to  us.  J.  S.  Prout. 
 «>  

§0fllt  'gatittt. 


[We  publish  full  lists  of  books  received,  but  ive  acknowl- 
edge no  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  zve  think 
our  readers  are  likely  to  be  interested.] 

Marriage  and  Disease.  Being  an  Abridged  Edition  of 
Health  and  Disease  in  Relation  to  Marriage  and  the 
Married  State.  By  Professor  H.  Sen.-^tor  and  Dr.  S. 
Kaminer.  Translated  from  the  German  hy  J.  Dulberg, 
M.  D.,  Manchester,  Eng.  New  York :  Paul  B.  Hoeber, 
IQ09.    Pp.  ix-452.    (Price,  $2.50.) 

The  original  book  appeared  in  1905  and  was  re- 
viewed in  volvune  Ixxxii  of  our  Journal.  The  two 
large  volumes,  of  about  a  thousand  pages,  have  been 
condensed  into  one  volume  of  about  450  pages, 
which  contains  all  the  important  points.  The  re- 
writing and  condensing  have  been  well  done,  and 
the  book  has  thus  been  prepared  for  the  general  pub- 
lic, which  undoubtedly  will  receive  a  great  amount 
of  clean  and  wholesome  instruction. 

Diagnose  und  Therapic  dcr  Syphilide.  (Syphilis  der  Haut 
und  Schlcimhaut. )  I.  Teil :  Diagnose.  Von  Dr.  S. 
Jessner,  Konigsberg  i.  Pr.  Zweite  Auflage.  Wiirzburg : 
Curt  Kabilzscn,  igog.    Pp.  146.    (Price,  2.50  Mk.) 

It  is  only  natural  that  in  a  book  on  syphilides  the 
author  should  also  sjx-ak  of  the  primary  affection  of 
syphilis.  Dr.  Jessner  thus  treats  concisely  of  syphilis 
and  its  diagnosis,  and  then  proceeds  to  describe  the 
different  forms  of  svphilides ;  this  is  followed  by  the 
therapeutics  of  syphilides,  internal  and  local ;  while 
the  answer  to  the  question  whether  a  syphilitic 
."^hould  be  allowed  to  marry  is  added  as  a  conclusion. 

As  is  always  the  case  with  Dr.  Jessner's  books, 
they  are  not  only  theoretical,  but  also  very  practical, 
that  is,  they  contain  many  practical  forms  of  pre- 
scriptions. He  speaks  principally  of  mercury  and 
the  iodides,  and  mentions  also  hydrotherapeutics 
and  sulphur  baths.   Of  the  other  remedies,  especial- 


ly the  proprietaries,  he  says  that  only  radix  sar- 
saparillas  should  be  taken  into  consideration,  while 
our  experience  with  arsenous  acid  is  not  complete 
enough  to  unable  us  to  make  an  accurate  statement. 

Tuberculosis  of  the  Nose  and  Throat.  By  Lorenzo  B. 
LocKARD.  M.  D..  Laryngologist  to  the  Jewish  Consump- 
tives Relief  Society  Sanatorium ;  Fellow  of  the  American 
Academy  of  Ophthalmology  and  Otolaryngology,  etc.  With 
eighty-five  illustrations,  sixty-four  of  them  in  color.  St. 
Louis :  C.  V.  Mosby  Medical  Book  and  Publishing  Co.. 
igog. 

Lockard  presents  the  results  of  his  own  wide  ex- 
perience together  with  the  views  of  other  authorities 
on  a  subject  which  is  of  increasing  practical  import- 
ance. He  calls  attention  to  the  high  mortality  due 
to  the  common  neglect  of  laryngoscopic  examina- 
tions as  a  routine  measure  in  all  cases  of  pulmonary 
tuberculosis,  and  to  the  general  but  erroneous  belief 
that  the  throat  complications  are  almost  invariablv 
fatal  and  that  treatment  commonly  does  more  harm 
than  good.  The  main  object  of  the  book  is  to  place 
before  the  profession  the  modern  views  concerning 
the  early  recognition,  treatment,  and  progirosis  of 
the  disease.  Its  value  is  greatly  enhanced  by  a  large 
number  of  unusually  artistic  and  instructive  water 
color  drawings  of  the  local  conditions  in  various 
types  and  stages  of  tuberculous  disease  of  the 
larynx,  pharynx,  and  nose. 

Die  Parenchyiiiatdsr  H onthautcntzitnduug.  Von  Dr.  Kakl 
HooR,  o.  oe.  Professor  der  Augenheilkunde  a.  d.  konigl. 
Ung.  Universitat  in  Buda-Pest.  Halle:  Carl  Marhold, 
igog. 

This  little  monograph,  which  appears  as  one  of 
the  series  of  ophthahnological  essavs  edited  by  \'os- 
sius,  gives  a  summary  of  the  most  modern  views  as 
to  pathology,  diagnosis,  and  treatment  of  interstitial 
keratitis.  As  regards  the  clinical  picture  of  the  dis- 
ease, but  little  has  been  added  to  the  classical  de- 
scription of  Hutchinson,  while  recent  innovations  in 
the  views  as  to  aetiology  and  treatment  are  still  in 
the  theoretical  stage. 

NEW  PUBLICATtONS. 

Electricity,  Roiitgcn  Rays,  and  Emanations. 

Leven,  G.,  ct  Barret  G. — Radioscopie  gastrique  et  mala- 
dies de  I'estomac ;  clinique  et  therapeutique.  L'Adulte  tt 
le  nourisson.  Avec  35  figures.  Paris :  Doin  et  fils.   Pp.  200. 

Houdc,  Paul. —  Sur  le  traitement  de  la  leucemie  lymph- 
atique  par  le  radiotherapie.  Avec  8  figures.  Paris:  G. 
Steinheil,  igog.    Pp.  200.     (Price,  4.5of.) 

Veluet. — L'Aspect  radiograpliique  des  spinas-ventosas. 
.Avec  18  figures.    Paris:  G.  Steinheil,  igog.    Pp.  60.  (Price, 

2.50f.) 

Kellogg,  J.  H. — Light  Therapeutics.  A  Practical  Manual : 
Physics,  Physiological  Effects,  Technique.  Therapeutics, 
Clinical  .Applications.  With  75  Illustrations.  Battle  Creek, 
Mich. :  The  Modern  Medicine  Publishing  Company,  1909. 
Pp.  225.    (Price,  $2.) 

Rubarts,  //rftrr.— Practical  Radium.  The  Practical  Uses 
of  Radium  in  the  Treatment  of  Obstinate  forms  of  Dis- 
ease. Illustrated.  St.  Louis:  Published  by  the  .Author, 
1909.    Pp.  xviii — 139. 

Arthur,  Dai'id. — .\  Manual  of  Practical  X  Ray  Work. 
With  .About  120  Illustrations.  New  York:  Rebnian  Co., 
igog.    Pp.  xii — 244.    (Price,  $2.50.) 

.Miscellaneous. 

Midler,  Paul  T. — Technik  der  serodiagnostischen  Meth- 
odcn.    Zweite  .Auflage.    Jena :  Gustav  Fischer,  1909. 

Schwalbc.  Ernst. — Die  Morphologic  der  Missbildungen 
des  Menschen  und  der  Tiere.  Ein  Lehrbuch  fiir  Mor- 
phologen,  Physiologen.  praktische  .Aerzte  und  Studierende. 
III.  Teil.    Erste  Liefcrung.    Jena:  Gustav  Fischer,  1909. 

Schuster.  G. — Statistisclie  Studie  zur  Carcinomfrage. 
Bamberg:  Handels-Druckerci  und  Verlagsliandlung,  1909. 


May  29,  igcg.J 


OFFICIAL  NEWS. 


I123 


ScliTx-albc,  Ernst. — Vorlesungen  iiber  Geschichte  der 
]\Iedizin.  Zweite,  umgearbeitete  Auflage.  Mit  einem  kurzen 
Uebersichtstabelle  von  L.  Aschott.  Jena :  Gustav  Fischer, 
1909.    Pp.  213. 

Surbled.  G. — Die  Moral  in  ihren  Keziehungen  zur  Mede- 
zin  und  Hygiene.  Zweiter  Band ;  Das  geistig-sinnliche. 
Leben.    Hildesheim :  F.  Borgmeyer,  1909.    Pp.  205. 

Mallat.  A.,  ct  Coniilloii,  I. — Histoire  des  eaiix  mine- 
rales  de  Vichy.  Troisieme  fascicule ;  les  establissements 
thermaux  de  Vichy  depuis  le  seizieme  siecle  jusqu'a  nos 
jours.  Avec  18  planches  hors  texre.  Paris:  G.  Steinheil, 
1909.    Pp.  220. 

Sternberg.  Wilhelw. — Die  Kiiche  in  der  modernen  Heil- 
anstalt.  Stuttgart:  F.  Enke,  1909.    Pp.  92.  . 

Sehiiehing.  A. — Bad  Pyrmont.  Berlin:  A.  Hirschwald, 
1909.    Pp.  84. 

Cornet,  Paul. — Le  Regime  alimentaire  des  maladies. 
Paris:  G.  Steinheil,  1909.  Pp.  484.    (Price,  6f.) 

Tixicr.  Louis. — Les  ulceres  gastriques  experimentaux. 
Avec  u  figures.  Paris:  G.  Steinheil,  1909.  Pp.  64. 
(Price,  2f.) 

Eulenbcrg.  Albert. — Real-Enc\clopadie  der  gesamten 
Heilkunde.  Medicinisch-chirurgisches  Handworterbuch 
fiir  praktische  Aerzte.  Mit  zahlreichen  Abbildungen  und 
einer  Tafel.  Dritte,  umgearbeitete  und  vermehrte  Auflage. 
Band  xxxiii.  Berlin  und  Wien :  Urban  &  Schwarzenberg, 
1909.    Pp.  646. 

Fuchs.  Max. — Baden  beim  Wien  und  seine  Schwefel- 
quellen.  Dritte  umgearbeitete  Auflage.  Wien :  R.  Lech- 
ner"s  Sort.  1909.    Mit  Abbildungen.    Pp.  88. 

Kraus.  R..  und  Levaditi.  C. — Handbuch  der  Technik  und 
Methodik  der  Immunitatsforschung.  Antikorper.  Zweite 
Lieferung.  Mit  i  Tafel  und  75  teils  farbigen  Abbildungen. 
Jena :  Gustav  Fischer,  1909. 

I'on  Hansemann.  U. — Deszendenz  und  Pathologic.  \'er- 
gleichend  biologische  Studien  und  Gedanken.  Berlin : 
August  Hirschwald,  1909.    Pp.  x — 488. 

Gutzmann.  H. — Sprachstorungen  und  Sprachheilkunde. 
Beitrage  zur  Kenntnis  der  Physiologic,  Pathologic  und 
Therapie  der  Sprache.  Mit  15  Abbildungen  im  Te.xt  und 
cinem  Portrat.    Berlin  :  S.  Karger.  1908.    Pp.  189. 

Tibbies.  William. — The  Theory  of  Ions.  A  Consideration 
of  its  Place  in  Biology  and  Therapeutics.  New  York : 
Rebman  Co..  IQ09.    Pp.  ix — 131.    (Price.  $1.) 

Transactions  of  the  Medical  Association  of  the  State  of 
Alabama.  Meeting  of  1907,  held  in  Mobile,  April  i6th  to 
19th,  and  the  Meeting  of  1908,  held  in  Montgomery,  April 
2 1  St  to  24th. 

Rel>orts  of  the  Trustees  and  Superintendent  of  the  But- 
ler Hospital.  Presented  to  Corporation  at  its  Sixty-fifth 
Annual  Meeting,  January  27.  1909.  Providence,  R.  L  Provi- 
dence:  Snow  &  Farnham  Co.,  1909.    Pp.  51. 

Report  of  the  Committee  on  Social  Betterment.  Wash- 
ington: The  President's  Homes  Commission,  1908.  Pp.  281. 

Sixteenth  Annual  Report  of  the  State  Charities  Aid  As- 
sociation to  the  State  Commission  in  Lunacy.  November 
I,  1908.  No.  106.  New  York:  State  Charities  Aid  Asso- 
ciation, 1905.    Pp.  65. 


Official  geras. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports : 

The  folloiijing  cases  of  smallpox,  yellozv  fever,  cholera, 
and  plague  haze  been  reported  to  the  surgeon  general. 
United  States  Public  Health  and  Marine  Hospital  Sen-ice, 
during  the  neck  ending  May  21.  I'^ocj: 

Place?.  Date.  Cases.  Deaths. 

Smallpo.r — United  States. 

California — Sacramento  May    1-8   5 

Illinois — .Mton  .April    1-30   2 

IlUiiois — Danville  May  2-9   15 

Illinois — Chicago  May    1-8   i 

Illinois — Galesburg  May   i-S   i 

Illinois — Peoria  April    1-30   44 

Illinois — Springfield  April  3o-Maj'  7   3 

Indiana — Indianapolis  May  2-9   i 

Indiana — South   liend  May   1-8   i 

Iowa — Council    Bhins   May  3-10   i 

Kansas — Kansas  City  May    1-8   3 

Kansas — Wichita  May   1-8   2 

Kentucky — Le.Nington  May    1-8   i 

Kentucky — Newport  Maj-   1-8   2 

Michigan — Saginaw  May   1-8   7 


8 

Present 


281 
14 


Places.  Date.  Cases.  Deaths. 

Minnesota — Duluth  \pril  30-May  6   2 

Missouri — Kansas   City  April    17-May  8   10 

Missouri — St.  Joseph  March   27-April   3...  1 

Missouri — St.  Louis  May   1-8   i 

Montana — Butte  April  20-May  4   7 

Montana — Great  Falls  April  24-May   i   i 

New  Jersey — Camden  May   1-8   2 

New  Jersey — Trenton  May   1-8   i 

New  York — Little  Falls  April   24-May  8   2 

Ohio — Ashtabula  April   17-May  8   2 

Ohio — Cincinnati  April  30-May   6   9 

Ohio — Columbus  May  1-8  

Tennessee — Nashville  May  1-8  

\'irginia — Richmond  April  3o-May  i. 

Washington — Spokane  .April  30-M3y  i. 

Wisconsin — La  Crosse  .....May  1-8  

Smallpox — Insular. 
Philippine  Islands — Manila  March  27-April  3....  3 

Smallpox — Foreign. 

Canada — Halifax  April  24-May   i   i 

Canada — Yarmouth  May   1-8   i 

Ceylun — Colombo  Feb.  13-Mar.  27   37 

China — Amoy  March  27-April  3.... 

China — Canton  ilarch    20-27   20 

ligypt — Cairo  March   25-April   8...  28 

Gibraltar  March  26-May  2   i 

India — Bombay  April  6-13  

India — Calcutta.  March  26-.\pril  3 .  . . . 

India — Rangoon  March  26-April  3.... 

Italy — General  April    18-25   9 

Italy — Naples  April    18-25   13 

Java — Batavia  March  20-.April  3   7 

Manchuria — Dalny  .April  3-10   5 

Mexico — Chihuahua  -April    i8-May   2   4 

Monterey  April   25-May  2  

Portugal — Lisbon  April   i8-May  8  

Russia — Batoom  March    1-31   2 

Russia — Moscow  April  10-17   28 

Russia — Odessa  .April  3-17   23 

Russia — Riga  A|)ril  18-21   2 

Russia — St.   Petersburg  March  27-April  10...  46 

Russia — Warsau  Feb.  13-20  

Siam — Bangkok  Feb.    1-2S  m 

Spain — Barcelona  April  19-26  

Spain — \'alencia  April  17-24   10 

Straits  Settlements — Singapore ...  ilarch  20-27  

Yellow  Fever — Foreign. 

Barbados  .April  25-May   i   4 

Brazil — Para  -April    10-17   6 

Ecuador — Guayaquil  March  20- .April  3....  72 

Cholera — Insular. 
Philippine  Islands — Provinces.  ...  March  25-.April  3.  ...177 
Cholera —  Foreign. 

India — Bombay  .April  6-13  

India — Calcutta  March   26-.\pril  3... 

India — Rangoon  .March  26-.\pril  3... 

Russia — St.  Petersburg  April    22-28   12 

Plague — Foreign. 
.Arabia — Mascat  .April  14  

Australia — New  Castle  March  1-31  

-Australia — Sydney  March  6-12  

Chile — .\ntofagasta  April  7  

Chile — Iquique  \pril  8  

China — .\moy  March  27--April  3... 

China — Chang  Chew  March  27--April  3... 

Ecuador — Babohoyo  March  20-27  

Ecuador — Guayaquil  March  20--April  3... 

India — Bombay  -April  6-13  

India — Calcutta  -March  27-.April  3... 

India — Rangoon  March  27-.\pril  3... 

Japan — Kobe  .April  3-17  

Japan — Formosa  March  27-.April  10.. 

Peru — General  -April  10-17  


13 


6 
34 


97 
129 


Imported 
Imported 


Present 

Epidemic 

2 

34 

12 

370 

»4 

29 

2 

23 

99 

29 

19 

4 

3 

10 

4 

Peru — Lima  -April  10-17  

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Serz-ice,  for  the  seven  days  ending 
May  IQ,  1909: 

Hertv,  F.  J..  Pharmacist.  Relieved  from  duty  at  the  Hy- 
gienic Laboratory,  "and  directed  to  proceed  to  Mobile, 
Ala.,  and  report  to  the  medical  officer  in  command  for 
duty  and  assignment  to  quarters. 

M-AGUiRE,  E.  S.,  Pharmacist.  Relieved  from  duty  at  Mo- 
bile, -A.la.,  and  directed  to  proceed  to  Chicago.  111.,  and 
report  to  the  medical  officer  in  command  for  duty  and 
assignment  to  quarters. 

MiR.\XD.A,  R.\F.AEL  U.  L.,  -\cting  .A^ssistant  Surgeon.  Grant- 
ed one  month's  leave  of  absence  from  June  i,  1909,  and 
three  months'  leave  of  absence,  without  pay,  from  July 
I,  1909. 

Ramus,  C.vrl,  Passed  Assistant  Surgeon.  Granted  one 
day's  leave  of  absence.  May  11.  1909.  on  account  of 
sickness. 


1 124 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal. 


RosENAU,  Milton  J.,  Surgeon.  Granted  two  months'  leave 
of  absence  from  April  8,  1909,  on  account  of  sickness. 

Small,  Edward  M.,  Acting  Assistant  Surgeon.  Granted 
ten  days'  leave  of  absence  from  May  19,  1909. 

Spangler,  L.  C..  Pharmacist.  Relieved  from  duty  at  the 
Savannah  Qu.irantine  Station  and  temporary  duty  at 
the  South  Atlantic  Quarantine  Station,  and  directed- 10 
proceed  to  Washington,  D.  C,  and  report  to  the  di- 
rector of  the  Hygienic  Laboratory  for  duty. 

Stump,  F.  A.,  Pharmacist.  Granted  thirty  da\s'  lea\e  of 
absence  from  May  15,  1909. 

White,  J.  H.,  Surgeon.  Detailed  to  represent  the  Service 
at  the  annual  meeting  of  the  American  Medical  Asso- 
ciation to  be  held  in  Atlantic  City,  N.  J.,  June  8  to  11. 
1909. 

Prnmotwns. 

Passed  Assistant  Surgeon  Charles  H.  Gardner  commis- 
sioned a  surgeon,  to  rank  as  such  from  May  i,  1909. 

Passed  .Assistant  Surgeon  Rupert  Blue  commissioned  a 
surgeon,  to  rank  as  such  from  May  i,  1909. 

Passed  Assistant  Surgeon  James  H.  Oakley  commis- 
sioned a  surgeon,  to  rank  as  such  from  May  i,  1909. 

Passed  Assistant  Surgeon  Ezra  K.  Sprague  commissioned 
a  surgeon,  to  rank  as  such  from  May  i,  1909. 

Casualty.. 

Passed  Assistant  Surgeon  William  M.  Wightman  died 
from  yellow  fever  in  Guayaquil,  Ecuador,  May  16,  1909. 

Resignation. 

Pharmacist  ^I.  H.  Watters  resigned,  to  take  effect  May 
13,  1909. 

Boards  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital,  Boston,  Mass.,  May  14,  1909,  for  the  purpose  of 
making  a  physical  examination  of  an  applicant  for  appoint- 
ment as  cadet  in  the  Revenue  Cutter  Service.  Detail  for  the 
board :  Surgeon  L.  L.  Williams,  chairman ;  Passed  Assist- 
ant Surgeon  T.  W.  Salmon,  recorder. 

Army  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Army  {or  the  z^'eek  ending  May  2.2,  igog: 
Baker,  David,  Majoi;.  Medical  Corps.    Granted  leave  of 

absence  for  two  months. 
Hull,  A.  R.,  First  Lieutenant,  Medical  Reserve  Corps. 

Granted  leave  of  absence  to  May  31st. 
McLe')d,  H.  C,  First  Lieutenant,  Medical  Reserve  Corps. 

Relieved  from  duty  in  the  Philippines  Division ;  will 

proceed  on  first  available  transport  to  San  Francisco. 

Cal. 

Park,  Roswell,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  active  duty  May  26th  to  June  ist;  will  re- 
pair to  Washington  and  deliver  the  address  to  the 
graduating  class  of  the  Army  Medical  School,  May 
29  til. 

Reasoner,  M.  a..  First  Lieutenant.  Medical  Corps.  Grant- 
ed leave  of  .absence  for  twenty-four  days  ;  relieved  from 
duty  at  Fort  Caswell,  N.  C,  and  ordered  to  Vancouver 
Barracks,  Wash.,  for  duty. 

Stallman,  G.  p.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  from  San  Francisco,  Cal.,  to  Fort  Douglas, 
Utah,  for  duty. 

Stuckey,.  H.  W.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  in  the  Philippines  Division  and  or- 
dered to  sail  August  15th  from  Manila,  P.  L,  for  San 
Francisco,  Cal. 

Tritby.  a.  E.,  Major,  Medical  Corps.  Ordered  to  accom- 
pany Company  A,  Eng.,  to  Washington  Barracks,  D. 
C,  and  then  return  to  San  Francisco,  Cal. 

Winter,  Francis  A.,  Major,  Medical  Corps.  Granted 
leave  of  ab'^cnce  for  one  month,  about  July  1st. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  (Vtd  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  zveek  ending  May  23,  jgog: 
Bucher,  W.  H..  Surgeon.    Ordered  to  report  to  the  presi- 
dent of  the  Naval  Retiring  Board  at  the  Navy  Yard, 
Mare  Island.  Cal..  May  .31st,  for  examination"  by  the 
Board,  and  thence  to  treatment  at  the  Naval  Hospital, 
Marc  Island,  Cal.,  until  further  orders. 
CEriL,  A.  B.,   Acting  Assistant  Surgeon.     .Appointed  an 
acting  assistant  surgeon,  May  12,  igog. 


FiSKE.  C.  N.,  Passed  Assistant  Surgeon.  Detached  from 
the  Navy  Yard,  Washington,  D.  C,  and  ordered  to  the 
Bureau  of  Medicine  and  Surgery,  Navy  Department. 
Washington,  D.  C. 

Hart,  S.  D.,  Acting  Assistant  Surgeon.  Ordered  to  duty 
at  the  Naval  Hospital,  New  York,  N.  Y. 

Huntington,  E.  O.,  Surgeon.  Detached  from  the  Naval 
Station,  San  Juan,  P.  R.,  and  ordered  to  the  Naval 
Medical  School  Hospital,  Washington,  D.  C,  for  treat- 
ment. 

Le  ACH,  P.,  Medical  Inspector     Commissioned  a  medical 

inspector,  with  rank  of  commander,  from  April  i,  1909. 
P.\yne,  J.  H.,  Passed  Assistant  Surgeon.    Detached  from 

the  Salem  and  directed  to  await  orders. 
RvuEk,  C.  E.,  Passed  Assistant  Surgeon.    Detached  from 

the  Vermont  and  ordered  to  the  Massachusetts  nautical 

training  ship  Nezvport. 
Walton,  D.  C,  Acting  Assistant  Surgeon.    .Appointed  an 

acting  assistant  surgeon,  from  May  12,  1909. 
Zalesky,   W.   J.,    Passed   Assistant    Surgeon.  Detached 

from  the  Naval  Station,  New  Orleans,  La.,  and  ordered 

to  the  Salem. 

 <$:  

iirt^s,  parriages,  anii  f  eat^s. 


Married. 

Hand — Blattnek. — In  Cape  May.  New  Jersey,  on  Tues- 
day, May  nth,  Dr.  R.  A.  Hand,  of  Camden,  and  Miss  Eliz- 
abeth Hughes  Blattner. 

Died. 

Besnter. — In  Paris,  France,  on  Sunday,  May  i6tli.  Dr. 
Ernest  Besnier. 

Bird. — In  Chester,  Pennsylvania,  on  Thursday,  ]\Iay  13th. 
Dr.  William  Bird,  aged  fifty  years. 

Boyd. — In  Knoxville,  Tennessee,  on  Sunday,  ]\Iay  i6t'i. 
Dr.  John  M.  Boyd,  aged  seventy-five  years. 

Davls. — In  Agency,  Iowa,  on  Thursday.  May  13th,  Dr. 
I^Iorris  L.  Davis. 

Fisher. — In  Anacostia,  D.  C,  on  Monday,  ^lay  17th,  Dr. 
George  W.  Fisher,  aged  seventy  years. 

Galloupe. — In  Lynn,  Massachusetts,  on  Alonday,  May 
17th,  Dr.  Isaac  Francis  Galloupe.  aged  eighty-six  years. 

GiRARDiN. — In  Montreal,  Canada,  on  Sunday,  May  9th, 
Dr.  R.  A.  Girardin. 

Gomez. — In  Cuba,  on  Sunday,  May  i6th.  Dr.  Salvatore 
Gomez,  aged  forty-seven  years. 

Hall. — In  Chelmsford,  Massachusetts,  on  Friday.  May 
14th,  Dr.  Thomas  Hall,  of  Boston. 

Holland. — In  Beaumont,  Texas,  on  Monday.  May  loth. 
Dr.  J.  S.  Holland,  aged  seventy-three  years. 

Kinley. — In  Denver,  Colorado,  on  Thursday,  May  13th. 
Dr.  J.  B.  Kinley,  aged  fifty  years. 

Long. — In  Washington,  D.  C,  on  Friday,  May  14th.  Dr. 
William  Long,  aged  fifty  years. 

Ogden. — In   Fairmont.   West   Virginia,   on  Wednesday, 
May  I2th,  Dr.  W.  C.  Ogden.  of  Colorado  Springs,  Colo 
rado. 

Parker. — In  Atlanta,  Georgia,  on  Saturday.  Alay  15th. 
Dr.  C.  W.  Parker,  aged  eighty  years. 

Pavton. — In  Redlands,  California,  on  Tuesday,  May  iitli. 
Dr.  J.  E.  Payton.  aged  fiftv-five  years. 

Pinkard. — In  Washington.  D.  C.  on  Sunday.  May  gth. 
Dr.  H.  M.  Pinkard.  aged  seventy-two  years. 

Richards'^n. — In  Norristown,  Pensnylvania,  on  Saturday, 
May  isth.  Dr.  Margaret  Richardson,  aged  ninety-two  years. 

Sharretts. — In  Flushing,  New  York,  on  Friday.  May 
7th.  Dr.  C.  J.  Sharretts. 

Skidelskv. — In  Piniladelphia.  on  Thursday.  May  13th, 
Dr.  Rachel  S.  Skidelskv,  aged  fifty-three  years. 

Slonaker. — In  Pittsburgh,  Pennsylvania,  on  Friday.  May 
14th,  Dr.  .Alter  L.  Slonaker,  aged  forty-nine  vears. 

Stanger. — In  Trenton,  New  Jersey,  on  Friday,  May  21st. 
Dr.  Samuel  F.  .Stanger. 

Stati.er. — In  .Alum  Bank,  Pcnnsvhania.  011  Thursday, 
Mav  15th,  Dr.  S.  G.  Stattler,  aged  eighty  years. 

Tower. — In  Cambridge,  Massachusetts,  on  Friday.  May 
I4lh.  Y)T.  Charles  B.  Tower,  aged  sixty-six  years. 

Wightman. — In  Guayac|uil,  Ecuador,  on  Monday.  May 
17th.  Dr.  William  M.  Wiehtman.  of  the  United  States"  Publi"c 
Health  and  Marine  Hosnital  Scr\  irc.  aged  thirty-four  years. 

WiTitEc  K. — In  Cohoes.  New  York,  on  Thursday,  May 
13th,  Dr.  Charles  E.  Witbcck.  aged  sixty-five  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  rlt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


\"oL.  LXXIX.  Xo.  23. 


XE^^■  YORK,  JUNE  5,  1909. 


Whole  Xo.  1592. 


(0riiiiual  (Loiuinuuirations. 


OBSERVATIONS   OX    SOME   CUTANEOUS  CYST 
FORMATIONS  AND  AN  UNUSUAL  DISEASE 
OF  THE  HAIR  FOLLICLE.* 

By  A.  R.  RoBixsox,  M.  B.,  L.  R.  C.  P.  and  S.,  Edin., 
New  York, 

Professor  of  Dermatology,  New  York   Polyclinic;   Member  of  the 
New  York  Dermatological  Society  and  the  .\merican  Dermato- 
logical  Association;  Foreign  Corresponding  Member  of 
the  Societe  frangaise  de  dermatologie  et  de 
syphiligraphie,  etc. 

In  this  paper  I  shall  give  the  results  of  studies  of 
certain  pathological  conditions  of  the  skin  described 
by  writers  under  the  terms  follicular  cysts,  horn 
cysts,  sebaceous  cysts,  comedo,  and  milium,  and  con- 
cerning which  subjects  there  is  more  or  less  dif- 
ference of  opinion  among  writers,  especially  as  re- 
gards the  mode  of  origin,  the  anatomical  seat,  and 
the  structure  of  the  lesions.  I  am  satisfied  that 
the  views  expressed  in  the  majority  of  works  on 
dermatology  are  not  the  result  of  individual  studies 
on  the  subject,  but  an  acceptance  of  the  statements 
of  previous  authors ;  hence  in  this  paper  I  shall  limit 
my  references  of  the  opinions  of  ethers  to  that  of 
those  authors  who  have  in  special  articles  published 
the  results  of  their  personal  studies.  I  will  accom- 
pany the  paper  with  illustrations  of  microscopical 
sections  of  the  well  recognized  horn  and  sebaceous 
cyst  formations,  also  of  a  less  frequent  form  of  fol- 
licle cyst  or  comedo  condition,  an  example  of  which 
I  have  a  photograph  to  present  to  you ;  and  finally 
I  shall  describe  a  case  that  in  objective  characters 
resembled  considerably  the  comedo  or  milium  con- 
dition and  was  regarded  as  an  atypical  form  of  one 
or  other  of  these  formations  by  several  dermatolo- 
gists, ye.  appears  to  me  to  be  an  independent  con- 
dition, a  clinical  entity,  a  similar  example  of  which 
I  have  not  found  described  in  literature  on  cutane- 
ous diseases.  As  I  have  had  a  good  opportunity  for 
studying  this  peculiar  case  I  hope  the  subject  will 
be  interesting  to  you. 

My  views  as  regards  cysts  in  connection  with  the 
pilosebaceous  system  coincide  in  most  respects  with 
those  of  Unna,  Chiari,  Jarish,  and  Balzer  among 
others,  whilst  I  think  some  of  my  observations  are 
sufficiently  personal  in  view  to  be  entitled  to  publi- 
cation and  also  to  be  brought  before  this  association 
for  consideration  and  discussion. 

Cysts  of  the  pilosebaceous  system  can  hz  divided 

*Read  before  the  American  Dermatological  Association,  Anna ;;olis, 
September,  190S.  ^ 

Co]  yright.  1909.  hy  .\.  R. 


into  those  located  in  the  common  excretory  duct 
portion  and  those  located  in  the  deeper  parts  of  the 
structures,  although  those  which  can  be  regarded 
as  occupying  the  deep  part  of  the  follicle  may  have 
commenced  in  the  upper  two  thirds  or  above  the 
point  of  junction  of  the  special  excretory  duct  of 
the  sebaceous  gland  with  the  common  excretorv 
duct.  The  contents  may  consist  almost  exclusivel\-  of 
horn  cells,  or  a  more  or  less  equal  mixture  of  horn 
and  sebaceous  material,  or  principally  of  sebaceous 
matter,  and  the  division  into  horn,  mixed,  and 
sebaceous  cysts  is  a  convenient  although  not 
an  absolutely  correct  one ;  for,  although,  there  may 
be  a  pure  horn  cyst,  there  is  never  a  pure  sebaceous 
cyst.  The  division  into  five  kinds,  according  to  lo- 
cations, thus,- — I,  cyst  of  hair  follicle  excretory  part 
with  normal  hair  producing  part ;  2,  cyst  of  excre- 
tory duct  of  sebaceous  gland  with  intact  secretory 
part ;  3,  hair  follicle  cyst  with  normal  sebaceous 
gland ;  4,  sebaceous  gland  cyst  with  normal  hair 
formation  ;  5,  cyst  of  entire  follicle  after  destruc- 
tion of  secretory  cells. — is.  as  has  been  stated  bv 
Unna.  unnecessary,  and  I  would  add  incorrect,  as 
conditions  three  and  four  cannot  exist  separately ; 
that  is,  there  does  not  exist  a  pure  sebaceous  cyst 
with  a  normal  hair  condition,  nor  a  hair  follicle  cyst 
that  extends  to  the  follicle  base  with  a  normal  con- 
dition of  the  sebaceous  gland. 

According  to  my  observations  I  would  state 
further, — whenever  the  deep  parts  of  a  hair  follicle 
or  the  secretory  part  of  a  sebaceous  gland  are  the 
seat  of  a  cyst  formation,  this  condition  is  never 
primary,  but  always  the  sequence  of  a  process  that 
has  started  primarily  above  the  lower  third  of  the 
follicle  or  above  the  point  of  junction  of  the  ex- 
cretory duct  of  the  sebaceous  gland  with  the  com- 
m.on  follicle  duct,  and  that  a  cyst  that  may  be  called 
a  sebaceous  cyst  on  account  of  the  preponderance 
of  sebaceous  material  in  its  constitution  never  has 
its  origin  within  the  secretory  part  of  the  gland. 

As  has  been  pointed  out  by  others,  a  sebaceous 
cyst  cannot  exist  unless  the  secretory  part  of  the 
gland  is  more  or  less  intact,  and  I  am  satisfied  such 
cysts  never  arise  in  an  acinus,  but  are  always  the 
result  of  conditions  higher  up  in  the  gland  struc- 
tures. The  statement  that  milium  arises  from  reten- 
tion in  an  acinus,  whilst  in  acne  comedo  the  ob- 
struction is  in  the  general  excretory  duct,  is  not, 
in  my  opinion,  based  on  correct  microscopical  ob- 
servation, if  this  view  ever  was  based  on  the  study 
of  sections  of  such  cysts.  When  there  is  complete 
cystic  dilatation  of  the  follicle,  the  formation  of 
hair  and  sebum  ceases,  and  the  cyst  wall  is  lined 
with  ordinary  flattened  epithel'um. 

Elliott  Putlishirg  Company. 


1 126 


ROBJXSOS':  CUTANEOUS  CYST  FORMATIONS. 


[New  York 
Medical  Journal. 


Chiari  describes  cysts,  small  and  limited  to  the 
cutis,  consisting  at  first  of  sebum  and  later  contain- 
ing liorny  substance,  but  neither  Unna  nor  myself 
have  seen  such  cysts.  An  isolated  sebaceous  cyst  of 
the  special  excretory  duct  probably  does  not  exist, 
such  cysts  always  forming  primarily  in  the  common 
excretory  duct. 

If  a  horn  cyst  forms  in  the  upper  part  of  the 
common  excretory  duct,  a  sebum  cyst  does  not  form 
beneath,  but  owing  to  pressure,  if  the  cyst  contin- 
ues to  increase  in  size,  the  sebaceous  gland  may 
slowly  atrophy  and  the  secretory  epithelium  be  re- 
duced to  ordinary  epithelial  cells. 

In  a  mixed  cyst  the  sebaceous  glands  continue 
to  secrete,  and  even  when  the  cyst  has  attained  con- 
siderable size  and  encroached  upon  the  gland  proper, 
sebum  continues  to  be  secreted  until  the  cyst  oc- 
cupies the  entire  follicle. 

A  division  of  the  cysts  into  hair  cysts  and  sebace- 
ous cysts  cannot  be  made  absolutely,  as  the  hair 
follicles  and  sebaceous  gland  have  a  common  excre- 
tory orifice,  but  in  pure  horn  cysts  I  think  we  are 


6- 

 .  -  a 

r 

^  ,/ 

Fig.  I. — Early  stage  of  milium  formation  from  external  hair  follicle 
sheath.  From  a  case  in  which  the  lesions  were  numerous,  sit- 
uated upon  the  cheeks  and  were  of  recent  origin.  a,  early 
stage  in  cyst  formation;  h,  upper  part  of  hair  follicie;  c,  deeper 
part  of  hair  follicle;  d.  deep  part  of  hair  follicle.  The  out- 
growth of  epithelium  into  the  corium  in  tlie  formation  of  the 
milium  body  is  well  defined. 

justified  in  calling  them  hair  follicle  cysts  arising 
from  the  hair  follicle  neck  part  and  not  from  the 
sebaceous  gland  part  of  the  common  excretory  duct, 
that  is,  we  should  regard  the  common  excretory 
duct  as  essentially  a  part  of  the  hair  follicle,  more 
than  of  the  sebaceous  gland. 

It  appears  best  to  include  all  cysts  of  the  pilo- 
sebaceous  system  under  the  term  follicle  cysts,  and 
further  subdivide  into  horn  cysts  and  mixed  or 
sebum  cysts  according  to  the  comparative  composi- 
tion of  horn  cells  and  sebum  in  individual  cases. 

As  all  the  cyst  formations  appear  to  be  associated 
with  a  hyperkeratosis  follicularis,  a  pure  .sebum  cyst 
cannot  exist,  but  I  will  be  able  to  show  that  a  pure 
horn  cyst  may  exist  without  the  presence  of  sebum. 

A  horn  cyst  is  composed  of  horn  cells  arranged 
usually  more  or  less  in  a  concentric  manner  even 
when  in  immediate  connection  with  the  common 
excretory  duct  and  also  when  located  out.side  th  s 
structure,  and  especially  when  in  the  latter  situa- 


tion. In  shape  they  are  cylindrical  or  eggshaped 
when  in  a  follicle,  and  roundish  when  in  the  cutis. 
The  presence  of  a  dark  point  corresponding  to  a 
follicle  orifice  shows  the  seat  of  the  lesion  in  that 
instance,  but  horn  cysts  can  communicate  with  the 
common  excretory  duct  and  yet  the  follicle  orifice 
be  not  seen  with  the,  naked  eye,  not  from  oblitera- 
tion of  the  duct  but  from  the  lateral  location  of  the 
cyst  to  the  follicle  changing  the  normal  relations. 
The  absence  of  a  macroscopic  follicle  orifice,  in 
connection  with  a  small,  hard,  whitish,  pearllike 
body,  is  no  proof  that  the  condition  is  pure  milium 
as  separate  from  follicle  horn  cyst  or  from  the 
comedo  condition.  The  view  that  in  every  case  of 
horn  comedo  a  condition  of  hyperkeratosis  of  the 
general  cutaneous  surface  or  of  the  orifice  of  the 
excretory  duct  at  the  point  of  exit  is  not  always 
true,  but  is  probably  true  of  the  majority  of  cases, 
and  that  the  cyst  is  a  consequence  of  this  process 
extending  downward  to  the  middle  third  of  the  fol- 
licle and  the  source  of  the  excessive  amount  of 
horn  cells  the  condition  is  not  one  of  simple 
retention,  but  I  am  also  satisfied  that  the  hyperkera- 
tosis can  commence  within  the  follicle  neck,  as  is 
the  case  where  it  is  impossible  or  very  difficult  to 
detect  an  excretory  duct  opening  in  relation  with 
the  cyst,  or  where  the  duct  orifice  is  quite  narrow 
and  apparently  normal. 

A  pure  horn  cyst  can  exist  in  the  follicle  neck 
with  a  normal  condition  of  the  sebaceous  gland 
proper.  The  small,  miliumlike  bodies  observed,  al- 
though very  rarely  in  cases  of  chronic  lichen  planus, 
an  example  of  which  I  will  show  you,  is  an  example 
f  a  Dure  horn  cyst  in  the  upper  part  of  the  folli- 
cle, or  possibly  sweat  gland  orifice.  This  condition 
has  been  observed  in  other  diseases  in  which  there 
is  an  active  participation  of  the  corneous  layer,  as 
in  ichthyosis,  but  I  have  not  studied  these  cases. 
Horn  cysts  can  occur  as  small  microscopical  bodies 
in  the  follicle  or  as  black  points  at  the  orifice  or  as 
pearllike  bodies  shining  through  the  skin  ;  these  lat- 
ter are  usually  called  milium.  Whether  all  horn 
cysts  are  primarily  in  connection  with  the  follicle 
duct  or  W'hether  those  showing  no  duct  orifice  in 
the  skin  over  them  are  extrafollicular  primarily  or 
secondarily  has  been  studied  by  me  in  a  considerable 
muuber  of  lesions,  and  I  find  that  horn  cysts  may 
be  connected  with  a  follicle  and  yet  no  orifice  be 
detected  satisfactorily  by  macroscopical  examina- 
tion, that  is,  such  formations  can  appear  as  milium 
bodies  as  these  are  usually  defined.  In  this  case  the 
duct  orifice  is  not  dilated  and  lies  to  one  side  and 
partly  beneath  an  apparently  normal  epidermis. 

The  smallest  comedones  lie  in  the  follicle  neck, 
the  medium  sized  in  the  middle  part  of  the  duct, 
and  the  largest  occupy  the  greater  part,  if  not  all 
of  the  degenerated  follicle. 

The  drawings  from  the  sections  will  show  the  ir- 
regular arrangement  of  the  horn  cells  when  con- 
nected with  the  excretory  duct  as  compared  with 
the  concentric  or  onionlike  arrangement  present  in 
extrafollicular  cysts,  the  true  milium  cyst.  It  seems 
to  me  that  the  term  follicle  horn  cyst  can  be  ap- 
plied to  these  horn  cysts  or  collections  instead  of 
horn  comedo,  reserving  the  term  comedo  for  the 
mixed  cyst,  in  which  the  sebum  plays  such  an  im- 
])ortant  part  as  culture  medium  in  connection  with 


June  5,  1909.) 


ROBINSON:  CUTANEOUS  CYST  FORMATIONS. 


1 127 


acne  vulgaris.  I  think  clinical  observation  shows 
that  a  pure  horn  cyst  does  not  form  favorable 
ground  for  pus  organisms,  or  the  organisms,  what- 
ever they  be,  that  cause  acne  vulgaris. 


Many  horn  cysts  are  located  in  the  upper  part 
of  the  follicle  and  have  their  origin  in  a  hyper- 
keratosis of  the  inner  follicle  wall.  If  the  nnfif-e 
in  connection  with  them  cannot  be  recognized  by 


The  term  comedo  usually  signifies  the  presence  of    the  naked  eye,  the  lesions  are  usually  called  milium 


Fig.  2. — Section  of  a  lesion  from  same  patient. 
This  section  shows  a  large  cyst  (b)  lying  in 
the  corium,  lined  by  flattened  epithelial  cells 
and  apparently  without  a  connecting  excre- 
tory duct  connection.  At  the  lower  part  is 
a  portion  of  a  sebaceous  gland  acinus.  At 
a  an  apparently  isolated  cyst  independent  of 
a  glandular  structure  is  seen,  but  it  is  pos- 
sible a  serial  section  would  show  a  connec- 
tion witli  a  hair  follicle.  Later  this  con- 
nection ceases  and  the  cyst  appears  as  an 
isolated  horn  cyst,  a  milium  body.  The 
contents  of  cyst  b  have  fallen  out  of  the 
section. 


Fig.  3. — Section  of  lesion  from  same  pa- 
tient as  sections  in  Fig%  i  and  2,  show- 
ing a  cyst  apparently  independent  of 
any  glandular  structure.  The  origin, 
however,  has  been  from  a  hair  follicle. 
(7,  Empty  milium  like  cyst  with  epithelial 
walls.  At  b.  a  portion  of  a  sebaceous 
gland  is  observed  showing  relationship 
of  cyst  to  the  pilosebaceous  system. 


Fig.  4. — From  a  lesion  of  case  shown  in 
I-'ig.  21,  showing  a  Condition  similar  to 
that  in  ordinary  comedo.  I  would  di- 
rect attention  to  the  small  follicle  ori- 
fice and  absence  of  surface  hyperkera- 
tosis. The  cyst  is  a  mixed  cyst  con- 
sisting of  horn  cells  and  sebaceous  ma- 
terial; a.  cyst;  b,  comedo  plug  extend- 
ing beyond  the  general  surface. 


a  cyst  composed  of  horn  cells  and  sebum  in  varying 
proportions,  situated  in  the  common  excretory  duct, 
from  which, it  can  be  expressed  in  greater  part  in 
the  so  called  wormlike  form. 

A  follicle  horn  cyst  proper  arises  from  a  hyper- 
keratosis of  the  neck  and  the  contents  consist  of  an 
excess  of  normally  produced  horn  cells.  Many 


or  miliumlike  bodies.  I  think  this  hyperkeratosis, 
although  usually  associated  with  a  greater  or  less 
hyperkeratosis  of  the  general  surface,  may  b.;  con- 
fined to  the  follicle  and  exist  without  any  dilatation 
of  the  duct  orifice. 

The  structure  of  the  mixed  follicle  cyst,  the  or- 
dinary comedo  cyst,  needs  no  description  at  this 


Fig.  5. — Early  stage  of  mixed  cyst  formation. 
Origin  in  follicle  neck  without  surface  hyper- 
keratosis. In  the  cyst  were  some  broken 
hairs.    From  case  shown  in  Fig.  21. 


I'iG.  6. — .\lso  from  case  of  Fig.  21;  a,  empty 
cyst,  contents  have  fallen  out,  apparently  in- 
denendent  of  pilosebaceous  system.  Such  a 
lesion  corresponds  to  miliimi  as  generally 
diagnosticated  by  appearance,  location,  and 
absence  of  dilated  follicle  orifice  permitting 
of  expression  of  contents.  ,'\t  b  is  seen  an 
early  stage  in  the  formation  of  a  follicle 
cyst.  A  hair  is  still  present  and  the  lesio-i 
is  composed  of  horn  cells.  There  is  a  hy  er- 
keratosis  of  the  follicle,  but  not  of  the  gen- 
eral surface  corneous  layer. 


Fig.  7. — A  sebaceous  gland  showing 
an  e.xtension  of  the  follicle  cyst 
to  the  si^ecial  excretory  duct  of 
the  gland.  In  some  sections  this 
downward  formation  extended 
into  the  special  ducts:  a,  seba- 
ceous material,  sebaceous  r^lug, 
filling  a  distended  excretory  duct. 


writers  describe  milium  as  a  sebaceous  cyst  located 
in  an  acinus  of  the  sebaceous  gland.  If  the  term 
refers  to  horn  cysts  in  which  the  corneous  cells  are 
arranged  concentrically  or  otherwise  and  contain  no 
sebaceous  material  an  acinous  origin  is  excluded. 


time,  as  it  is  familiar  to  all  from  previous  writers 
or  personal  observation,  and  I  have  nothing  to  add 
to  our  existing  knowledge  of  the  subject. 

The  question  of  mode  of  origin  is  still  an  unde- 
cided one.   The  view  that  a  mixed  cyst  without  or- 


I  I2t 


■ROBIXSON:  CUTANEOUS  CYST  FORMATIONS. 


[New  York 
Medical  Journal. 


ganisms  should  be  separated  from  those  containin-^ 
tlie  so  called  acne  bacilli,  does  not  seem  to  me  to 
be  justifiable.  There  are  net  sufficient  grounds  in 
my  belief  for  the  view  that  these  bacilli  are  the 
cause  of  the  comedo  formation  and  the  hyperkerato 


cysts  on  account  of  the  small  orifice  sometimes  ob- 
served when  the  mixed  cyst  has  attained  some  size, 
in  fact,  on  account  of  the  difficulty  of  seeing  the 
follicle  orifice  in  many  mixed  cysts  it  cannot  be  di- 
agnosticated macroscopically  from  milium,  as  in 


Fig.  8. — From  same  case  as  Fig.  7;  j. 
c.njjty  cyst  occupying  greater  part  of 
pilosebaceous  system.  At  base  of  cyst  is 
.■ieen  at  6  a  sebaceous  gland  acinus  with 
normal  secreting  cells.  At  left  of  sec- 
tion a  hyperkeratosis  follicularis  is  pres- 
ent and  at  b  sebaceous  glands.  This 
lesion  at  a  resembled  a  milium  and  not 
a  comedo. 


Fig.  9. — From  same  case  as  Fig.  8,  shows 
a  miliumlike  horn  cyst  (a)  in  which 
broken  h^rs  were  present.  It  will  be 
observed  that  the  cyst  opened  on  the 
general  surface  at  b,  although  macro- 
scopically the  cpering  could  not  be  de- 
tected. The  hyperkeratosis  causing  the 
horn  follicle  cyst  evidently  had  its  origin 
in  the  funnel. 


F'iG.  10. — From  same  case  as  Fig.  9;  a, 
mixed  cyst  with  oj  ening  on  general  sur- 
face; b.  similar  cyst  lying  in  corium  and 
showing  no  follicle  orific  connection;  c, 
lower  part  of  hair  follicle  and  sebaceous 
gland. 


sis  of  the  follicle  neck.  As  every  mixed  follicle  cyst 
is  associated  with  .a  hyperkeratosis  and  contains,  as 
a  rule,  one  or  more  curled  up  lanugo  hairs,  which 
latter  may  form  irritation,  cause  the  hyperkeratosis 
and  narrowing  of  the  follicle  orifice,  or  the  hyper- 
keratosis is  the  primary  condition  and  the  retention 
of  hairs  secondary,  I  prefer  to  regard  the  retention 
of  the  sebum  as  a  consequence  of  the  other  con- 
ditions. I  do  not  think  a  pure  sebaceous  cyst  ever 
exists    primarily    from    whatever    cause,  either 


strophulus  albidus,  as  an  example.  I  know  no 
reason  why  the  curled  up,  retained  lanugo 
hairs  should  not  be  regarded  in  some  cases  as  the 
primary  condition,  with  or  without  changed  char- 
acter in  the  sebaceous  secretion,  or  the  hyperkera- 
tosis commence  deep  in  the  funnel  from  some  un- 
known cause,  perhaps  changed  sebaceous  material. 
As  the  mixed  cyst  increases  in  size  and  extends 
downward,  the  sebaceous  gland  may  be  gradually 
destroyed,  together  with  the  hair  follicle,  but  it  is 


l  iG.  II.— From  same  case  as  1-ig.  10;  represents  similar  conditions  as  in  Fig.  10;  a,  empty  cyst  on  free  surface;  b  empty  cyst  with, 
out  apparent  excretory  duct  opening;  c,  mixed  cyst  with  broken  hairs  (rf) ;  c,  hyperkeratosis  follicularis.  .Ml  these  sections  from 
case  shown  in  Fig.  21  show  hprn.  mixed 'or  sebaceous  cysts  in  connection  with  the  inner  part  of  the  i-itosebaceous  system  as  in 
ordinary  comedo  lesions;  that  is,  they  start  from  changes  occurring  in  the  common  excretory  duct  and  serial  sections  would  sho-v 
such  a  connection,  although  macroscopically,  as  in  this  patient,  some  of  the  lesions  resembled  objectively  ordinary  milium  lesions 
I  his  case  was  therefore  one  of  somewhat  atypical  comedo.     No  lesions  started  from  the  external  follicle  sheath  as"in  milium 


changed  nature  of  secretion,  the  presence  of  organ- 
isms, or  what  not. 

I  have  already  stated  that  a  sebaceous  cyst  never 
forms  primarily  in  an  acinus  or  any  part  of  the 
.secreting  portion,  but  always  in  an  excretory  duct, 
and  in  my  own  experience  always  in  some  part  of 
the  common  excretory  duct  and  not  in  a  special 
excretory  duct  of  the  gland. 

I  do  not  believe  that  a  follicle  orifice  hyperkera- 
tosis is  always  present  in  cases  of  mixed  follicle 


surprising  how  long  portions  of  the  gland  may 
continue  in  an  active  state.  As  soon  as  the  gland 
is  completely  occupied  by  the  cyst  formation,  sebum 
ceases  to  be  produced,  and  the  cyst  will  be  lined  with 
ordinary  flattened  epithelium,  the  original  special 
cells  losing  their  physiological  character.  The  base 
of  the  hair  follicle  also  is  gradually  changed,  and 
when,  .as  stated  by  Unna,  the  lowest  third  is  af- 
fected, hair  formation  is  interfered  with  or  ceases. 
The  contents  and  situations  of  cysts  depend  in  any 


June  5,  1 909.  J 


ROBIXSOX:  CUTAXEOUS  CYST  FORMATIONS. 


1 129 


individual  case  on  the  extent  of  the  cystic  process 
and  the  condition  of  the  secretory  parts  of  the  hair 
foHicle  and  sebaceous  gland. 

I  shall  now  describe  and  show  illustrations  of  sec- 
tions of  follicle  cysts  from  a  somewhat  unusual  case. 
(See  Fig.  21.) 

Case  I. — Patient,  woman,  fifty  years  of  age.  The  lesions, 
some  of  which  had  existed  for  more  than  one  year,  were 
confined  to  the  sides  of  the  nose  and  adjoining  part,  ex- 


FiG.  12. — Section  from  a  case  of  chronic  lichen  planus  of  seven 
j-tars  duration,  showing  the  unusual  condition  of  numerous 
pinhead  sized  pearllike  bodies.  They  have  been  regarded  a- 
arising  in  connection  with  follicles  and  that  is  probably  correct, 
aithough  I  never  found  a  hair  present  in  the  lesions  examined. 
They  are  certainly  not  from  the  sebaceous  gland  proper.  As 
a  general  surface  hyperkeratosis  is  always  present,  some  may 
arise  at  the  sweat  gland  orifice,  but  I  think  the  usual  seat  of 
origin  is  the  hair  follicle  neck,  or  possibly  from  the  general  sur- 
face as  occurs  to  an  extent  in  other  diseases  with  marked 
keratosis.  The  term  horn  cyst  correctly  designates  the  condi- 
tion, a.  Corneous  layer;  b,  granular  layer;  c,  rete;  d.  hair 
follicle  area;  c,  round  cell  infiltration;  f,  hair  follicle;  g. 
sebaceous  gland;  h,  corium. 

tending  to  near  the  inner  canthus.  They  numbered  prob- 
ably fifty  and  varied  in  size  from  pin  point  to  that  of  a  large 
pin  head.  The  smallest  lesions  were  very  closely  situated, 
not  elevated,  whitish  in  color,  and  according  to  naked  eye 
apoearances  there  was  usually  no  follicle  orifice  to  be  ob- 
served in  connection  with  them.  The  larger  lesions  were 
elevated,  showed  a  dilated  follicle  orifice  and  frequently  a 
black  spot  at  the  opening.  The  contents  could  be  expressed 
as  in  any  ordinary  mixed  follicle  cyst.  The  lesion  showed 
no  signs  of  an  inflammatory  process  at  any  stage  of  exist- 
ence, and  there  was  no  change  to  be  observed  in  the  circu- 
lation of  the  part.  The  sections  showed  horn  cysts  and  mixed 
cysts,  and  in  some  almost  complete  cystic  dilatation  of  the 
pilosebaceous  system  with  opening  on  the  free  surface.  The 
cysts  were  all  connected  with  the  excretory  duct,  although 

_   ^ 

A— ^ 


Fig.  13. — Section  from  chronic  lichen  planus  showing  the  "pearls" 
deeper  seated  and  apparently  independent  of  the  enidermis. 
They  are  evidently  of  deeper  origin.  They  are  probably  from 
old  atrophied  hair  follicles.  No  hairs  present,  a.  Corneous 
layer;  b,  granular  layer;  c,  rete;  d,  corium;  e,  horn  pearl;  /, 
round  cell  infiltration;  g,  excretory  sweat  duct. 

the  arrangement  of  the  horn  cells  was  somewhat  like  that 
in  milium,  and  a  follicle  orifice  connection  could  not  always 
be  observed  with  the  naked  eye.  One  section  showed  a 
horn  cyst  with  opening  sidewise  into  the  duct.  {Fig.  9). 
The  other  cysts  did  not  differ  from  the  ordinary  follicle 
cysts.  They  all  contained  hairs.  Microorganisms  were  not 
present  within  the  cyst. 


We  have  here  a  sebaceous  cyst  with  the  exact 
structure  of  the  so  called  acne  comedo,  in  which  or- 
ganisms were  not  present,  according  to  my  observa- 
tions, and  inflammation  did  not  occur, — tending  to 
show  that  organisms  probably  do  not  cause  comedo 
formation  in  any  case.  In  one  section  the  earliest 
stage  can  be  observed.  (Fig.  6.)  There  is  a  hair 
with  some  sebaceous  material  and  surrounded  by 
,horn  cells,  the  result  of  a  follicle  hyperkeratosis. 
The  follicle  is  not  dilated  abnormally  and  there  was 
no  hyperkeratosis  of  the  general  cutaneous  surface. 
My  individual  view  is  that  in  acne,  the  comedo 
formation  is  the  primary  condition  in  which  there 
are  predisposing  factors  as  changes  in  the  character 
of  the  sebaceous  secretion  secondary  to  altered  cir- 
culation in  the  part  or  from  other  causes,  impris- 
oned hairs,  etc.,  and  that  the  invasion  by  microbes, 
as  the  acne  bacillus,  is  secondary  to  the  comedo 
formation. 

Whether  all  milia  are  primarily  in  connection  with 


Fig.  14. — Early  stage  of  lesion  formation.  New  and  slightly  cede- 
matous  perifollicular  connective  tissue.  Hair  distorted  and 
bent.     From  case  shown  in  Fig.  22. 

the  pilosebaceous  system  or  whether  those  pearllike 
bodies,  showing  no  macroscopical  duct  orifice  in 
connection  with  the  lesions  are  extrafoUicular  dur- 
ing their  entire  existence  or  were  primarily  follicu- 
lar was  a  subject  of  study  and  'consideration.  I 
shall  be  able  to  show  that  the  absence  of  a  commu- 
nicating duct  orifice  over  the  lesion  does  not  ex- 
clude a  follicle  connection  as  the  orifice  may  be  on 
the  side  of  the  lesions  and  not  easily  recognized  as 
the  duct  belonging  to  the  milium  body. 

Many  writers,  including  some  of  the  most  recent, 
describe  milium  as  a  sebaceous  cyst  caused  by  re- 
tention of  sebaceous  material  in  the  duct  of  an 
acinus,  whilst  the  comedo  condition  arises  from  a 
retention  of  the  same  kind  of  material  in  the  com- 
mon excretory  duct,  the  diagnosis  between  the  two 
being  made  upon  the  macroscopical  presence  or  ab- 
sence of  an  excretory  duct  orifice  in  the  epidermis 
in  connection  with  the  cyst  formation.    My  own  ob- 


II30 


ROBINSON:  CUTANEOUS  CYST  FORMATIONS. 


[New  York 
Medical  Journal. 


servations  agree  with  those  writers  who  believe  that 
milium, — that  is,  the  pearly  white  subepidermal 
lesions  that  appear  devoid  of  connection  with  the 
follicles  on  account  of  the  macroscopical  absence  of 
a  duct  orifice  over  the  lesion  and  connecting  with 
it,  a  lesion  that  can  be  easily  removed  mechanically 


15. — Distorted  hair  witli  marked  cedema  of  connective  tissue 
and  prickle  cell  growth  into  the  corium.  a,  prickle  cell  out- 
growth into  corium;  b,  cedematous  connective  tissue  with  in- 
crease of  tissue;  c,  hair  follicle,  lower  part  of  neck.  From  case 
shown  in  Fig.  22. 

after  incision  of  the  overlying  tissue  and  when  ex- 
amined microscopically  is  shown  to  be  composed  of 
horn  cells  arranged  usually  concentrically,  onion- 
like— has  no  connection  with  the  secretory  portion 
of  the  sebaceous  gland,  that  is,  does  not  depend 
upon  retained  sebaceous  material  in  an  acnus. 

Whether  all  miliumlike  bodies  are  primarily  in 
connection  with  the  pilosebaceous  system  or  whether 
the  pearllike  bodies,  showing  no  macroscopical  duct 
openings  in  connection  with  the  lesions  are  extra- 
follicular  during  their  existence  or  only  become 
separated    from  the 

follicles  in  the  course  .  ''     .  ■ 

of   the    development  ,  -  ;. 

process  is  a  subject 
for  careful  study.  I 
shall  show  ■  that  a 
connection  may  exist 
with  the  pilosebaceous 
system,  and  general- 
ly does  exist  even 
when  the  lesions  ap- 
pear to  be  isolated 
and  independent  of 
gland  structure. 

Ehrmann.  Chiari. 
Unna,  Jarish,  Balzer, 
and  others  oppose 
the  view  of  connec- 
tion with  the  seba- 
ceous gland.  Jarish 
states  that  it  is  easy 
to  observe  the  con- 
nection with  the  hair 


follicle.  According  to  Unna  milium  is  caused  by  a 
hyperkeratosis  of  the  middle  portion  of  the  root 
sheath  of  a  short  lanugo  hair,  a  h3'perkeratosis  of 
the  epithelium  of  the  hair  follicle,  causing  an  out- 
ward expansion  of  the  follicle  sheath  at  one  point. 
Later,  this  outgrowth  extends  into  the  perifoUicu- 


Fig.  17. — Showing  new  growths  and  arrangement  of  the  tissues  to 
each  other,  a,  Hair  follicle  seat;  b,  sebaceous  gland  somewhat 
broken  down.    From  case  shown  in  Fig.  22. 

lar  tissue  and  becomes  finally  separated  from  the 
follicle. 

Whenever  sebaceous  material  is  present  it  is  not 
a  case  of  milium.    The  lesions  in  strophulus  al- 
bidus,  the  miliumlike  lesions,  forming  after  pemphi- 
gus, erysipelas,  along  the  edges  of  scars,  on  the 
male  genitals,  and  female  labii  are  pilosebaceous 
cysts  according  to  Ehrman,  JarisH  and  my  own  ob- 
servations.  The  horn  cysts  in  chronic  lichen  planus 
and  pityriasis  rubra  pilaris  are  follicle  cysts,  the  re- 
sult of  a  hyperkeratosis  foUicularis  and  are  not  ex- 
amples of  true  milium.  With  the  exception  of  lichen 
planus,  they  contain  usually  at  first  a  hair  and 
finally   consist  of  corneous  cells,   arranged  con- 
centrically.    The  hy- 
perkeratosis is  a  con- 
tinuation  of   a  sur- 
face hyperkeratosis 
into  the  follicle.  (See 
Figs.  12  and  13.) 
I  shall  not  discuss 
.4^--  "  the  embryonic  origin 

as  suggested  by  me 
many  years  ago  and 
supported  later  by 
Philippson  in  a  very 
able  paper,  as  such 
an  origin  is  not  capa- 
ble of  proof  by  mi- 
croscopic study,  but 
is  a  fair  inference  in 
cases  where  a  con- 
nection with  the  epi- 
dermis, hair  follicle, 
or  sebaceous  gland 
seems  excluded  and' 
doubtless  accounts 


.  16. — rt.  Part  of  hair  follicle;  b,  sebaceous  gland,  injured 
preparation.  Observe  arrangement  of  connective  tissue  to 
rete  tissue.    From  case  shown  in  Fig.  22. 


th-j 


June  5,  1909.] 


ROBINSON:  CUTANEOUS  CYST  FORMATIONS. 


for  those  lesions  where  the  onionlike  arrangement 
of  the  horn  cells  is  well  marked.  Some  milia  may 
have  an  origin  like  dermoid  cysts,  an  origin  Torok 
would  give  to  atheroma  also. 

Milium  is  usually  diagnosticated  from  the  loca«- 


FiG.  18. — A  well  develo]ied  lesion  as  shown  by  the  rete  invasion  and 
the  arrangement  of  the  connective  tissue,  a,  Hair  follicle  lower 
part  middle  third.    From  case  shown  in  Fig.  22. 

tion  in  the  skin,  the  color,  apparent  absence  of  a 
•dilated  excretory  duct  orifice  over  the  lesion,  inabil- 
ity to  expr£ss  the  contents  through  a  duct  orifice 
upon  the  skin,  and  ease  of  removal  as  a  pearllike 
firm  body  after  dividing  the  overlying  tissue,  and 
may  be  the  result  of  a  hyperkeratosis  follicularis 
with  horn  cyst  formation  in  the  follicle  neck  or 
from  hyperkeratosis  of  the  external  root  sheath  of 
the  hair  at  the  middle  third  of  the  follicle  or  from 
aberrant  embryonic  epithelium  from  hair  follicle  or 
epidermis.  I  have  observed  cases  of  numerous 
lesions  where  a  large  percentage  of  the  lesions 
showed  all  the  objective  characters  of  true  milium, 
whilst  the  remainder  showed  a  follicular  duct  orifice 
over  the  lesions  with  or  without  a  black  point,  all 
the  lesions  being  situated  superficially.  (See  Fig. 
21.) 

I  have  already  described  and  shown  drawings  of 
miliumlike  follicle  horn  cysts,  and  I  will  now  show 
drawings  of  cysts  arising  from  the  external  root 
sheath  of  the  hair.  We  all  know  how  difficult  it 
is  to  find  an  excretory  sweat  duct,  for  instance, 
in  connection  with  the  cyst  in  hidrocystoma,  unless 
serial  sections  are  made,  and  the  same  difficulty 
would  be  present  in  a  well  developed  milium  cyst 
if  it  is  connected  to  the  root  sheath  by  a  thin  band. 
The  difficulty  is  still  greater  in  showing  a  connec- 
tion, if  we  admit,  as  we  must,  that  the  cyst  in  its 
later  existence  is  quite  isolated  from  the  hair  fol- 
licle. Among  the  large  number  of  lesions  I  have 
studied  I  think,  however,  I  can  show  the  method 
of  formation  of  some  milium  lesions.  In  Figs,  i 
and  2  are  represented  two  sections  from  the  same 
lesion,  one  showing  the  growth  outward  of  the 
•epithelium  from  the  external  root  sheath  and  the 
commencement  in  the  cutis  of  a  milium  body.  The 


other  section  shows  an  apparently  isolated  milium  in 
an  early  stage  of  development.  I  have  a  third  sec- 
tion that  completes  the  picture.  For  further  de- 
scription I  refer  the  reader  to  the  illustrations  in 
Figs.  I  to  13  inclusive. 

Outgrowths  of  epithelium  from  the  hair  sheath 
occur  in  psoriasis,  pityriasis  rubra  pilaris,  prurigo 
of  Hebra,  and  other  affections  of  the  skin,  but  in 
these  cases  they  do  not  cause  nor  are  they  associated 
with  the  formation  of  miliumlike  lesions.  The  con- 
dition in  trichoepithelioma  will  be  referred  to  di- 
rectly. In  milium  as  usually  observed,  hair  follicle 
milium,  there  seems  to  be  an  aberrant  develoomental 
process  connected  with  the  external  root  sheath  of 
the  hair,  more  as  regards  location  than  process.  In 
benign  cystic  expithelioma  there  are  cyst  formations 
but  they  bear  no  resemblance  in  character  or  or- 
igin to  the  lesions  of  milium  and  do  not  require  dis- 
cussion at  this  time. 

A  short  resume  of  the  preceding  remarks  might 
be  given  as  follows :  Cysts  of  the  pilosebaceous 
system  should  be  classified  on  the  character  of  the 
contents  into  horn  cysts,  mixed  cysts,  and  sebaceous 
cysts.  A  pure  horn  cyst  may  exist  but  not  a  pure 
sebum  cyst.  A  sebum  cyst  never  arises  primarily 
in  the  secretory  part  of  the  sebaceous  gland  nor 
in  a  special  excretory  duct  of  this  structure  but  al- 
ways in  some  part  of  the  common  excretory  duct 
of  the  pilosebaceous  system.  A  pure  horn  cyst  may 
be  situated  in  the  follicle  opening  or  on  one  side  of 
the  excretory  duct  and  by  misplacing  the  orifice  make 
the  latter  invisible  or  apparently  not  connected  with 


Fig.  19. — Section  lower  middle  third  of  hair  follicle.  o.  Seat  of 
hair  cyst;  b,  prickle  cell  outgrowth;  c,  epithelial  wall  of  cyst. 
From  case  shown  in  Fig.  22. 

the  cyst.  A  horn  cyst  whether  it  appears  as  a  mil- 
iumlike body  or  not  arises  in  the  majority  of  cases 
from  the  external  root  sheath  of  the  hair.  It  may 
also  be  the  result  of  misplaced  embryonic  rudiments 
from  follicle  or  epidermis  when  the  cyst  is  sep- 
arated from  the  follicle  but  an  isolated  cyst,  a  mil- 


II32 


ROBLWSON:  CUTANEOUS  CYST  FORMATIONS. 


[New  York 
Medical  Journal. 


ium  body  may  arise  from  the  hair  sheath  and  later 
appear  microscopically  as  an  independent  formation. 

In  connection  with  this  subject  I  trust  a  report 
of  the  following  case  will  be  of  interest  as  to  the 
best  of  knowledge  it  represents  a  form  of  disease 
not  previously  described,  althou.o-h  in  some  respects 
both  clinically  and  microscopically  it  bears  consid- 


FiG.  20. — Similar  to  Fig.  19.  a,  Seat  of  hair  cyst:  b.  sebaceous 
gland;  c,  prickle  cell  outgrowth  from  external  root  sheath;  d, 
epithelial  wall  of  cyst;  /,  fan  shaped  arrangement  of  new  con- 
nective tissue.     From  case  shown  in  Fig.  22. 

erable  resemblance  to  cases  described  under  various 
names  as  epithelioma  adenoides  cysticum,  benign 
cystic  epithelioma,  trichoepithelioma,  etc. : 

Case  II  (Fig.  22). — Mrs.  O.,  Jewess,  aged  fifty  years,  mar- 
ried, dark  complexion,  well  nourished,  previous!}'  healthy. 
The  eruption  appeared  in  1899,  nine  years  ago,  first  on  the 
sides  of  the  neck  and  gradually  and  continuously  extended 
downward  on  the  front  and  back  of  the  thorax  until  it  cov- 
ered a  considerable  part  of  this  region.  In  1906,  the  last 
time  I  saw  the  patient  personally  the  eruption  had  extended 
along  the  arms,  the  lesions  being  especially  numerous  about 
the  elbows.  It  had  also  extended  upward  along  the  sides 
of  the  face.  A  glance  at  the  illustration  (Fig.  22)  will 
show  how  numerous  the  lesions  were,  as  they  were  quite 
evenly  distributed  over  the  areas  afifected.  As  a  rule  the 
lesions  were  not  specially  grouped,  although,  as  in  the  illus- 
tration, from  side  of  the  neck  there  was  a  tendency  to 
grouping.  The  individual  lesions  were  of  long  life  duration, 
if  not  coexistent  with  the  life  of  the  subject,  for  although 
a  few  seemed  to  disappear  after  a  time  the  vast  majority, 
according  to  my  own  observations  and  those  of  the  patient, 
remained  unchanged  after  obtaining  a  certain  size.  Itching 
was  a  very  prominent  feature  of  the  case,  causing  the  pa- 
tient great  discomfort  and  interfered  with  rest  and  sleep. 
The  constant  scratching  caused,  I  think,  the  dark  color  of 
the  skin  and  accounted  for  the  marked  increase  in  pigment 
in  the  rete  and  the  great  nuiuber  of  pigment  cells  observed 
in  the  corium  on  microscopical  examination. 

The  lesions  were  from  small  to  large  pinhead  in  size, 
very  few  were  larger  than  one  sixth  of  an  inch  in  diameter, 
whilst  the  majority  were  not  more  than  about  one  eighth 
of  an  inch.  They  resembled  in  size,  color  and  location  in 
the  skin  very  much  the  lesions  of  milium  and  were  con- 
sidered probably  a  somewhat  atypical  example  of  this  con- 
dition by  the  dermatologist  who  referred  the  case  to  me 
for  study.  The  majority  of  the  lesions  showed  a  follicle 
orifice  whilst  the  others  appeared  as  whitish,  pearlike 
lesions  situated  in  the  epidermis  exactly  as  in  milium.  A 
considerable  number  of  the  follicle  orifices  showed  a  black 
point,  as  seen  in  the  comedo  condition  and  horn  and  seba- 
ceous material  could  be  expressed  from  them.  There  was 
no  redness  or  any  signs  of  an  inflammatory  process  at  any 
time  observed  in  connection  with  the  lesions.  An  individ- 
ual lesion  was  more  or  less  elevated,  whitish  in  color  and 
firm  to  the  feel.  The  skin  from  long  continued  traumatism, 
scratching,  felt  firm  and  inelastic.  If  the  skin  was  incised 
over  a  lesion  and  an  attempt  made  to  remove  the  pearllike 
body  it  was  found  to  be  very  difficult  to  do  so  completely, 
di/Tcring  in  this  respect  greatly  from  the  conditions  in 
milium.  When  removed  in  this  manner  or  by  curetting  the 
lesions  did  not  reappear.    That  was  the  method  of  treat- 


ment before  the  case  came  under  my  observation  and  I 
could  easily  recognize  where  lesions  had  been  removed. 

The  case  was  exhibited  before  the  Manhattan  Dermato- 
logical  Society  and  tlie  New  York  Dermatological  Society, 
but  no  positive  diagnosis  was  made  by  the  members  pres- 
•ent.    The  case  was  shown  as  one  for  diagnosis. 

During  the  more  than  three  years  the  patient  was  under 
my  observation  I  removed  at  various  times  a  number  of 
lesions  of  various  size  and  microscopical  examination  of 
sections  showed  the  following  conditions : 

Microscopical  examination :  I  shall  refer  the  reader  to  the 
microscopical  drawings  and  the  accompanying  description 
for  a  fuller  understanding  of  the  condition,  giving  here  a 
more  general  description  of  the  pathological  process.  It 
will  be  observed  that  the  active  changes  took  place  in  the 
hair  follicle  and  perifollicular  tissue  and  not  in  the  seba- 
ceous or  sweat  glands,  and  that  the  primary  changes  started 
in  the  prickle  cell  sheath  of  the  follicle  and  surrounding 
connective  tissue.  Any  changes  in  the  sebaceous  glands 
were  secondary  and  of  a  degenerative  nature.  Tlie  cyst 
formation  occurred  only  in  the  hair  follicle  neck — the  com- 
mon excretory  duct  of  the  pilosebaceous  system.  The 
process  was  primarily  an  acanthoma  folliculare  with  pecu- 
liar changes  in  the  perifollicular  connective  tissue  associ- 
ated with  inore  or  less  cedema  and  connective  tissue  forma- 
tion within  a  limited  area.  Some  pathologists  who  examined 
sections  thought  at  first  view  that  the  process  appeared  to 
be  one  of  fibroma  formation  on  account  of  the  sharp  limita- 
tion, the  oedema,  the  increase  in  connective  tissue  and 
numerous  connective  tissue  corpuscles  without  any  signs 
of  an  inflammatory  process.  I  regarded  the  case  as  one  of 
acanthoma  and  fibroma  and  distinct  from  what  has  been 
described  as  trichoepithelioma  and  the  af¥ections  in  which 
trichoacanthosis  is  a  prominent  condition. 

General  description  of  sections :  Corneous  layer  normal 
no  hyperkeratosis  of  the  general  surface.  Granular  layer 
well  developed,  even  when  the  epidermis  was  very  thin  con- 
taining perhaps  not  more  than  two  or  three  layers  of  rete 
cells.  Rete  normal  as  regards  cell  characters,  except  that 
there  was  excessive  pigment,  especially  in  the  basal  layer 
of  cells.  In  the  corium  in  general,  some  places  showed 
slight  oedema,  with  much  increase  in  pigment  and  pigment 
cells,  mcrease  in  connective  tissue  corpuscles  and  increased 
density  of  the  tissue.    In  the  perifollicular  area  there  was 


Fig.   21. — Unusual  case  of  comedo  condition.     For  description  see 
text. 

either  limited  cedematous  condition  with  connective  tissue 
increase,  or,  as  was  a  most  marked  feature  in  all  sections, 
an  increase  in  the  connective  tissue  with  an  arrangement 
of  the  bundles  more  or  less  perpendicularly  to  the  out- 
growths of  epithelial  cells  where  the  latter  invaded  the 
corium,  either  as  single  columns  or  as  a  network  formed 
by  uniting  columns.  This  peculiar  arrangement  of  the 
bundles  can  be  seen  in  all  the  figures  accompanying  this 
paper  and  are  of  such  a  character  and  of  such  an  extent 
as  has  not  been  observed,  to  my  knowledge,  in  any  cuta- 
neous disease.  The  sharp  limitation  of  the  process,  the 
mild  cedema,  the  increase  in  connective  tissue  corpuscles 
and  fibrous  tissue  suggested  a  fibroma  condition  and  could 
be  regarded  as  such  if  those  were  the  only  changes  in  the 
part. 

There  was  a  follicle  hyperkeratosis  in  some  parts  of  the 
sections  independent  of  the  special  follicle  lesions.  A  hy- 
perkeratosis of  tiie  funnel  was  usually  pTv-sent.  and  in  some 


June  5,  1909.] 


L'EXGLE:  FLAGELLATIOX  OF  LEUCOCYTES. 


1 1 33 


instances  the  orifice  was  much  dilated  and  tilled  with  horn 
cells  or  with  mixed  material  as  in  the  comedo  plug.  This 
latter  form  of  plug  sometimes  extended  beyond  the  general 
surface  and  had  a  blackish  end  from  changed  corneous 
cells  as  in  ordinary  comedones.  Hairs  were  still  present 
in  some  of  the  cysts.  The  granular  layer  was  well  devel- 
oped deep  in  the  funnel.  A  hyperkeratosis  could  exist  in 
the  middle  third  of  the  follicle  without  involvement  of  the 
follicle  orifice. 

A  sebaceous  cyst  was  observed  in  some  cases  in  the 
lower  part  of  the  common  excretory  duct  and  might  extend 
to  the  special  excretory  sebaceous  duct. 

The  most  striking  features  of  the  sections  in  addition  to 
the  connective  tissue  changes  already  described  was  the 
acanthosis  condition  of  the  prickle  cell  follicle  sheath.  A 
study  of  the  sections  represented  in  the  figures  will  take 
the  place  of  an  extended  description. 

A  fairly  correct  idea  of  the  condition  usually  present  is 
to  imagine  the  palm  of  the  hand  as  representing  the  hair 
follicle  about  the  middle  third  and  the  fingers  as  represent- 
ing the  outgrowths  from  the  external  root  sheath.  These 
prolongations  of  epithelial  cells  always  represented  solid 
columns  of  varying  size,  frequently  uniting  to  form  a  mesh- 
like framework  with  the  peculiarly  arranged  connective 
tissue  in  the  spaces  separating  the  columns.  In  no  instance 
were  there  any  signs  of  a  lumen  in  these  columns  or  tend- 


I'lC.  22. — Case  of  trichofibroepithelioma,  or  trichofibroacanthoma. 
For  description  see  text. 


ency  to  formation  of  cysts.  I  think  the  manner  of  origin 
of  these  outgrowths,  their  extent,  the  preservation  of  the 
solid  column  condition  and  absence  of  all  cyst  formation 
outside  the  follicle  duct,  together  with  the  connective  tissue 
growth  in  the  periepithelial  area,  and  the  fanshaped  ar- 
rangement of  the  bundles  represent  a  picture  that  has  not 
been  observed  in  any  of  the  diseases  that  have  been  de- 
scribed as  associated  with  acanthosis,  as  trichoepithelioma, 
multiple  benign  cystic  epithelioma,  acanthoma  adenoides 
cysticum,  etc.  Were  it  not  for  the  changes  in  the  connec- 
tive tissue  the  case  could  be  regarded  as  one  of  tricho- 
epithelioma with  a  somewhat  unusual  clinical  character, 
but  with  these  changes  so  decided  and  peculiar  that  term 
is  not  applicable  unless  we  broaden  its  present  application. 
In  this  case  it  would  then  be  a  trichofibroepithelioma. 

The  formation  of  connective  tissue  in  connection 
with  maUgnant  epithelioma. — scirrhus  carcinoma 
for  instance — has  a  different  pathogenesis,  it  is  a 
secondary  condition  and  need  not  be  considered  in 
giving  the  disease  a  name,  but  in  our  case  the  con- 
nective tissue  formation  appears  to  be  an  essential 
part,  therefore  the  term  trichoepithelioma  is  not  a 
suitable  one.    In  invasions  of  connective  tissue  by 


epithelial  cells  as  ordinarily  observed,  the  invasion 
is  along  lines  of  least  resistance,  hence  in  carcinoma 
for  instance  the  epithelial  cells  lie  in  the  interfasicu- 
lar  spaces  and  the  long  axis  of  the  columns  of  cells 
correspond  with  the  long  axis  of  the  bundles,  while 
in  the  case  under  discussion  the  bundles  have  a  ten- 
dency to  a  fan  shaped  arrangement  at  the  end  of 
the  column  and  to  a  perpendicular  one  in  other 
parts.  For  further  description  see  drawings  of  sec- 
tions. The  sebaceous  glands  took  no  part  in  the 
active  process.  In  a  later  stage  degenerative  changes 
were  observed.  The  sweat  glands  were  unaffected. 
159  West  Forty-ninth  Street. 


THE  FLAGELLATION  OF  LELXOCYTES  IN  THE 
PRESENCE  OF  CHEMICAL  EXCITANTS  AND 
IN  OTHER  COXDITIONS. 
{Preliminary  Report). 

By  Edward  M.  L'Exgle,  M.  D., 
Philadelphia, 

Demonstrator  of   Pathology,    Medico-Chirurgical   College;  Assistant 
Pathologist,  Philadelphia  General  Hospital. 

Ross  and  Macalister'  have  recently  reported  the 
result  of  their  observation  of  blood  treated  with 
certain  chemical  substances,  describing  the  appear- 
ance of  flagella  on  certain  of  the  white  blood  cells. 
In  their  experiments,  the  blood  was  treated  with 
the  following  solution : 

a.  A  volume  of  Unna's  polychrome  methylene 
blue  diluted  with  an  equal  quantity  of  water. 

b.  A  neutral  solution  containing,  4.5  per  cent,  so- 
dium citrate;  1.5  per  cent,  sodium  chloride;  0.225 
per  cent,  atropine  sulphate. 

c.  A  five  per  cent,  solution  of  sodium  bicarbonate. 
Mix  I  c.c.  of  solution  a;  4  c.c.  of  solution  h;  0.2 

c.c.  of  solution  c.  A  portion  of  this  mixture  is  then 
added  to  an  equal  volume  of  freshly  drawn  human 
blood,  incubated  at  37°  C.  for  a  half  hour,  then 
spread  on  a  slide,  a  cover  glass  put  on.  and  the  slide 
examined  at  a  temperature  of  20°  C,  with  either 
1/6  or  1/12  oil  immersion  objective,  preferably  the 
latter.  The  polychrome  methylene  blue  is  used  for 
the  purpose  of  staining  the  granules  of  the  leuco- 
cytes, thus  making  easier  the  distinction  of  the  dif- 
ferent kinds  of  white  blood  corpuscles.  The  nucleus 
will  not  stain  as  long  as  the  cell  is  alive. 

I  have  repeated  the  experiments  of  Ross  and 
Macalister,  adhering  to  their  technique,  and-  can 
confirm  their  findings.  Certain  of  the  cells,  which 
on  account  of  their  size  and  general  appearance  are 
believed  to  be  small  mononuclears,  may  be  seen  to 
extrude  fine,  hairlike  projections  with  a  terminal 
granule.  These  at  first  are  quite  short,  but  gradu- 
ally grow  longer  and  are  apparently  in  quite  active 
motion.  The  length  finally  attained  may  exceed 
twice  the  diameter  of  the  cell  to  which  they  are 
attached.  There  may  be  one  or  several  of  the  pro- 
cesses on  a  cell.  Ross  and  Macalister  report  seeing 
as  many  as  twenty :  I  have  not  seen  more  than  two 
on  anv  one  cell.  This  phenomenon  may  not  be  seen 
in  every  blood  smear  examined,  but  one  or  two 

^Ross  and  Macalister.  British  Medical  Journal.  January  23.  igoq. 


1 134 


DITMAN  AXD  IVELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS.        [Nbw  York 

Medical  Journ'.l. 


or  sometimes  more  cells  can  usually  be  found  in 
which  this  process  may  be"  followed. 

The  flagella  are  very  easily  distinguished  from 
the  pseudopodia,  which  are  formed  on  the  amoeboid 
cells.  They  resemble,  in  a  general  way,  the  flagella 
seen  on  bacteria,  except  in  the  possession  of  a  ter- 
minal granule. 

After  a  varying  length  of  time,  the  flagella  sepa- 
rate from  the  cell  and  swim  away  as  independent 
bodies.  It  was  not  possible  in  any  of  my  cases  to 
follow  the  separated  flagellum  and  determine  its 
ultimate  fate.  Its  change  of  place  was  very  rapid 
and  the  gradual  drying  of  the  edge  of  the  smear 
caused  disconcerting  independent  movements  of  the 
blood. 

In  looking  over  some  stained  smears  from  a  case 
of  myelogenous  leuchaemia,  I  saw  two  or  three  cells 
which  showed  hairlike  projections,  similar  in  every 
way  to  those  seen  in  fresh  blood  chemically  treated, 
except  that  they  were  somewhat  longer  in  propor- 
tion to  the  cell  than  those  formerly  seen. 


Formation  of  flagella  t'roir.  a  myelocyte.     X  800. 


The  most  distinct  of  these  I  have  photographed. 
It  shows  a  long  process  extending  from  a  myelo- 
cyte. The  nucleus  of  the  cell  is  stained  lightly,  the 
dark  rim  partly  around  it  being  cytoplasm.  It  could 
be  noticed  that  the  i)rojection  took  the  same  stain  as 
the  cytoplasm.  At  the  point  where  the  flagella  come 
off,  there  is  a  slight  triangular  bulging  of  the  cyto- 
plasm. There  are  two  of  these  projections,  one  ex- 
tending in  a  straight  line,  but  showing  a  slight  wave 
at  one  point  and  with  a  very  distinct  terminal  gran- 
ule. The  other  is  bent  back  under  the  cell,  so  that 
only  the  proximal  end  can  be  seen. 

The  question  naturally  arises  as  to  the  interpreta- 
tion to  be  put  on  such  a  picture.  We  have  here 
blood  which  has  undergone  a  certain  amount  of 
manipulation,  which  might  and  probably  does  cause 
partial  destruction  of  some  of  the  cells,  with  the 
production  of  abnormal  appearances  in  outline  and 
staining,  some  of  which  can  undoubtedly  be  ex- 
plained as  artefacts.    The  striking  resemblance  of 


the  picture  shown  here,  however,  with  what  can  be 
observed  in  fresh  blood  leads  me  to  believe  that  we 
are  here  not  dealing  with  an  artefact,  but  with 
flagella  formation.  Its  occurrence  in  this  instance 
without  the  addition  to  the  blood  of  any  artificial 
excitant  raises  the  Question  as  to  whether  this  may 
not  be  a  function  of  certain  of  the  white  blood  cor- 
puscles in  normal  or  diseased  conditions.  Ross  and 
Macalister  suggest  that  it  may  be  of  some  impor- 
tance m  carcinoma,  as  they  have  stimulated  flagella 
formation  in  normal  blood  by  the  addition  of  sera 
from  cases  of  carcinoma. 

At  the  present  time,  any  theory  as  to  the  meaning 
of  this  phenomenon  must  be  advanced  with  great 
reserve,  but  in  view  of  our  ignorance  of  the  genesis 
of  the  blood  cells  in  general,  it  may  not  be  thought 
too  fanciful  to  suggest  that  it  may  be  concerned  in 
the  formation  and  multiplication  of  the  leucocytes. 

Merion  Station. 


DEFICIENT  OXIDATION  AND  ITS  REL.\TION  TO 
THE  .ETIOLOGY,  PATHOLOGY,  AND 
TREATMENT  OF  NEPHRITIS. 
By  Norman  E.  Ditman,  Ph.  D.,  M.  D., 
New  York, 

-Assistant  Attending  Physician,   St.   Luke's  Hospital;   Instructor  in 
Pathology,    College    of   Physicians   and   Surgeons,  Columbia 
University;   Clinical  Pathologist,   Roosevelt  Hospital, 

In  collaboration  with  William  H.  Welker,  A.  C.,  Ph.  D.. 
New  York, 

Assistant  in  Biological   Chemistry,  College  of   Physicians  and 
Surgeons,  Columbia  University. 

{Conchidcd  from  page  lOQ/.) 
\l.    The  Treatment   of  Nephritis  as  Influ- 
enced BY  Diminished  Oxidation  as  a  Cause. 

The  importance  of  the  problem  of  the  cure  of 
nephritis,  great  for  all  communities,  is  enormous 
for  us,  when  it  is  realized  that  not  only  is  the  present 
tribute  exacted  by  this  disease  in  the  city  of  New 
York  alone,  7,000  deaths  annually,  but  the  propor- 
tion of  sufferers  from  this  disease  has  doubled  dur- 
ing the  past  thirty  years. 

Its  solution,  therefore,  demands  the  greatest  eft'ort 
and  urgency  of  action  exceeding  that  in  other  dis- 
ease conditions  with  the  possible  exception  of  pneu- 
monia and  tuberculosis. 

Not  the  least  important  of  the  aspects  involved 
in  the  consideration  of  this  matter,  is  the  fact  that 
the  disease  is,  in  a  large  proportion  of  the  cases, 
preventable.  It  is  of  the  utmost  importance  then, 
that  this  aspect  should  be  emphasized  and  made  a 
matter  of  common  knowledge,  capable  of  utilization 
by  the  masses  long  before  the  first  premonitory 
signs  of  approaching  disease  present  themselves. 

The  importance  of  oxidation  as  a  factor  in  neph- 
ritis being  probably  largely  confined  to  the  chronic 
processes,  no  attempt  will  be  made  here  to  discuss 
the  prophylaxis  and  treatment  of  the  acute  forms. 
Moreover,  the  prevention  of  the  occurrence  of  the 
acute  forms  is  seen  to  be  far  more  difficult  to  ac- 
complish when  it  is  realized  that  a  large  part  of 
their  number  are  caused  by  the  poisons  of  specific 
fevers  and  toxic  chemical  agents,  and  sudden  ex- 
posure to  cold — agents  at  times  and  under  some 
circumstances  difficult  to  control. 


June  5,  1909.J         DITMAX  AXD  JI'ELKER:  DEFICIENT   OXIDATION  AND  NEPHRITIS. 


1 135 


Prophylaxis. 

As  a  preventive  measure  directed  against  the  oc- 
currence of  chronic  nephritis,  none  is  more  im- 
portant than  the  diminution  or  abolition  of  alcohol 
as  a  beverage. 

Alcohol.  The  efi'ect  of  its  interference  with  ox- 
idation has  been  shown.  Its  agency  in  the  produc- 
tion of  chronic  nephritis  has  long  been  recognized, 
and  the  prevalence  of  this  disease  in  the  greatest 
alcohol  consuming  countries  is  a  matter  directly 
traceable  to  this  habit. 

Cold.  Chronic  nephritis  is  most  prevalent  in  win- 
ter in  temperate  climates,  even  more  so  than  in  con- 
tinuous cold,  due,  undoubtedly,  to  sudden  change  to 
lower  temperatures.  For  while  continuous  cold  of 
northern  countries  gives  rise  to  permanent  condi- 
tions of  increased  tissue  activity  of  the  body — i.  e. 
more  active  oxidation  processes — the  sudden  chill- 
ing of  shorter  duration  of  temperate  climates  re- 
duces these  processes  in  a  body  less  capable  of  com- 
pensatory response  than  that  habitually  trained  to 
this  condition. 

For  the  well  tQ  do,  who  are  threatened  with  neph- 
ritis, this  cause  can  be  obviated  by  residence  in  a 
warm,  equable  climate.  For  those  less  fortunate 
who  must  continue  to  reside  in  the  temperate  zone, 
the  dangers  of  sudden  falls  of  temperature  and  the 
unfavorable  influence  of  cold  must  be  heeded. 

Exercise.  As  the  dweller  in  colder  climes  pro- 
tects himself  from  cold  by  an  increase  of  his  ox- 
idative activities  of  tissues  metabolism,  so  must  the 
dweller  in  temperate  regions  increase  his  by  exer- 
cise. 

A  woman  who  has  a  physiological  hypertrophy  of 
her  oxidizing- functions  need  have  so  much  the  less 
fear  from  the  reducing  processes  added  during 
pregnancy  and  the  consequent  dangers  of  eclampsia. 

Osier's  observation  that  the  chief  causes  of 
chronic  nephritis  in  this  country  are  worry,  hurried 
eating,  and  lack  of  exercise  may  in  this  sense  be 
misleading,  for  the  hurried  eating  is  usually  due 
to  the  first  cause,  and  it  is  the  excessive  time  de- 
voted to  its  cause,  business,  which  precludes  the 
possibility  of  exercise — the  important  factor-  in  the 
trio  of  causes. 

Pregnancy.  The  part  which  pregnancy  plays  in 
the  production  of  nephritis,  especially  of  the  eclamp- 
tic type,  has  been  dwelt  upon.  This  causative  re- 
lationship having  been  established  in  any  specific 
case,  the  prevention  of  its  recurrence  may  justify 
the  prevention  or  termination  of  future  pregnancies 
in  that  case. 

Fresh  Air  and  Sunlight.  The  benefits  of  fresh 
air  and  sunlight  in  their  eflfect  in  augmenting  oxi- 
dation are  well  known  and  are  of  immense  impor- 
tance in  nephritis,  especially  of  the  eclamptic  type 
for  reasons  already  given,  apart  from  their  stim- 
ulating effect  on  the  excretory  activity  of  the  skin. 
For  this  reason  the  use  of  the  sun-bath — a  thera- 
peutic measure  long  known,  but  little  used — should 
be  revived.  And  in  view  of  the  oxidizing  capacity 
of  the  skin  and  its  direct  dependence  upon  area  of 
surface  in  action,  the  amount  of  skin  surface  ex- 
posed to  sunlight  and  fresh  air  should  be  consid- 
erable, and  not  confined  to  the  few  square  inches 
of  the  face  and  hands. 


Food.  Chittenden  (60)  has  estimated  that  the 
average  human  being  consumes  about  three  times 
as  much  proteid  nourishment  as  he  requires.  The 
result  is  that  in  order  to  eliminate  this  excessive 
food  material  in  a  nontoxic  form  he  must  consume 
three  times  the  necessary  amount  of  oxygen, — 
which  oxygen  may  be  taken  from  the  supply  of  oxy- 
gen available  for  permanent  or  endogenous  body 
oxidation  processes. 

The  result  is  the  occurrence  of  unoxidized  pro- 
ducts in  those  with  the  smaller  oxidizing  capacities. 
The  connection  of  this  process  with  gout  has  al- 
ready been  established  to  the  satisfaction  of  many 
and  its  relation  to  nephritis  is  already  considered  a 
matter  of  moment. 

Meat.  Of  all  varieties  of  food,  that  most  capable 
of  being  transformed  into  toxic  products,  and  most 
active  in  its  reducing  power,  is  meat.  Cases  of 
excessive  intestinal  putrefaction  are  known,  depend- 
ent on  the  excessive  activity  of  anaerobic  bacteria  in 
the  intestinal  canal  in  which  the  conditions  of 
anasrobiasis  are  distinctly  favored  by  excessive  meat 
eating  (46). 

^^'hile  considerable  reducing  power  is  retained  by 
slightly  cooked  meat,  the  greatest  activity  in  this 
direction  is  exhibited  by  meat  in  the  raw  state. 

The  principle  of  reduction  shown  by  reducing 
methylene  blue  to  its  colorless  reduced  leucoform 
by  immersion  in  it  of  finely  divided  fresh  liver  from 
a  mammal,  has  been  utilized  by  Professor  Theobald 
Smith  in  producing  more  strictly  anaerobic  condi- 
ditions  than  are  otherwise  possible.  He  inserts  a 
small  piece  of  fresh  liver  in  the  closed  arm  of  a 
fermentation  tube  in  which  bacterial  cultures  are 
grown.  The  result  of  the  reducing  action  of  such 
agents  as  uncooked  meat  is  here  shown  to  be,  has 
already  been  alluded  to  and  its  importance  empha- 
sized. It  may  result  in  producing  a  complete 
anaerobic  condition  of  parts  of  the  intestinal  canal, 
resulting  in  a  significant  and  possibly  excessive  in- 
crease of  unoxidized  and  toxic  proteid  compounds. 

The  ban  which  such  a  dictum  would  put  on  the 
unwise  consumption  of  raw  oysters  and  German 
sausages,  would  have  the  added  virtue  of  decreas- 
ing the  possibility  of  infection  with  parasitic  pro- 
tozoa and  bacteria  of  the  typhoid  and  anaerobic 
putrefactive  type. 

Intestinal  putrefaction.  Of  all  conditions  con- 
cerned in  the  production  of  chronic  nephritis  and 
predisposing  to  the  possibility  of  an  eclamptic  at- 
tack in  pregnant  women  few  are  of  equal  impor- 
tance to  intestinal  putrefaction. 

The  prevention  of  many  cases  of  chronic  neph- 
ritis can  undoubtedly  be  accomplished  by  the  pre- 
vention of  this  condition.  Among  the  measures  ad- 
vised by  Herter  for  this  purpose  are  prohibition  of 
cheese  and  fruit  skins  containing  putrefactive 
bacteria :  frequent  cleansing  of  the  mouth ; 
prompt  digestion  and  normal  peristalsis  throughout 
the  gastrointestinal  tract  occasionally  requiring  the 
use  of  cathartics ;  and  kumyss,  matzoon,  and  bacil- 
lac  which  act  through  the  restraining  action  which 
the  lactic  acid  forming  bacteria  contained  therein 
have  on  the  bacteria  of  the  putrefactive  processes. 

O.vidation  index.  It  has  been  shown  that  cre- 
atinine elimination,  in  health,  is  an  index  of  en- 


DITMAN  AND  WELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS.        [New  York 

Medical  Journal. 


dogcnous  metabolism.  Creatinine  appears  in  normal 
quantities  in  the  urine  in  the  absence  of  decornpos- 
ing  factors,  when  the  oxidation  accompanying  en- 
dogenous "tissue  exchange"  is  normal. 

The  fact  that  the  quantitative  elimination  of  crea- 
tinine, though  exceedingly  constant  for  any  one 
person  on  a  meat-free  diet,  varies  directly  as  the 
endogenous  oxidation,  would  support  the  view  that 
the  elimination  of  creatinine  might  be  used  to  in- 
dicate the  activity  of  this  oxidation  and  thus  prove 
an  aid  in  avoiding  the  danger  of  developing  neph- 
ritis in  consequence  of  oxidative  deficiency. 

In  a  series  of  tests  made  by  Van  Hoogenhuyze 
and  \'erploegh  (39)  on  normal  people,  the  follow- 
ing excretion  of  creatinine  per  twenty-four  hours, 
as  dependent  on  body  weight  was  found : 


T.'\BLE  XXVII. 


Body 
weight. 


71 
80 

57 
79 
63 


-RELATION  OF  CREATININE  EXCRETION 

TO  BODY  WEIGHT. 

Creatinine  Creatinine 

in  grammes.  per  kilogramme. 

2.23  31.5  mg. 

2.16  27.  mg. 

1.69  29.  mg. 
2.21  28.  mg. 

1 .70  27.4  mg. 


Koch  found  the  excretion  to  range  from  twenty- 
six  to  thirty  millgrammes  per  kilogramme  of  body 
weight  (61). 

While  the  lowest  limit  of  creatinine  excretion 
which  must  be  maintained  to  insure  the  maintenance 
of  health  has  not  as  yet  been  determined,  future  re- 
search will  probably  find  here  a  signal  which  it  will 
be  dangerous  to  ignore  for  long  periods  without 
danger  of  encouraging  the  onset  of  a  chronic  neph- 
ritis ;  in  which  case  "the  creatinine  index"  will  be- 
come one  of  great  practical  value,  capable  of  sound- 
ing the  warning  note  for  the  necessity  of  increased 
activity  of  the  oxidation  processes. 

Treatment. 

Chronic  nephritis  being  in  the  course  of  develop- 
ment, its  only  cure  is  removal  of  its  cause — other 
treatment  being  effective  merely  in  the  amelioration 
of  its  symptoms.  To  this  extent,  treatment  would 
consist,  in  part,  in  the  application  of  those  methods 
already  suggested  under  the  head  of  prevention : 
— viz : — selection  of  suitable  climate  or  environ- 
mental temperature,  avoidance  of  alcohol,  use  of 
fresh  air  and  sunlight,  proper  exercise,  avoidance  of 
pregnancy,  prevention  of  intestinal  putrefaction,  and 
control  of  diet. 

It  has  been  stated  by  an  eminent  scientist  that 
if  any  new  doctrine  is  at  variance  with  most  pre- 
existing theories  on  that  subject,  the  doctrine  is 
in  all  probability  erroneous.  On  the  other  hand,  if 
any  new  doctrine  finds  corroboration  in  previously 
existing  principles,  this  fact  is  a  strong  endorsement 
of  its  probable  correctness.  It  is  probably  more  than 
a  coincidence,  then,  that  the  methods  most  in  use 
to  favor  body  oxidation  are  those  which  for  gen- 
erations have  been  the  sheet  anchors  in  the  treat- 
ment of  nephritis — not  only  warm  climates,  but  the 
use  of  hot  packs  in  ur?emic  attacks ;  the  avoidance 
of  atmospheres  overcharged  with  carbon  dioxide  in 
threatened  eclampsia — on  the  same  principle  that 
Schmidt  (62),  of  St.  Petersburg,  treated  eclampsia 
with  considerable  success  by  oxygen  inhalation.  The 
use  of  colon  irrigations,  removing  accumulated  mat- 


ter having  reducing  powers  from  the  large  intes- 
tine has  long  been  one  of  the  most  valuable  ad- 
juncts in  bad  urjemic  and  eclamptic  attacks. 

Alkalies.  Loeb  (63),  in  1898,  made  the  observa- 
tion that  while  the  addition  of  acids  to  sea-water 
delayed  the  development  of  the  larvae  of  sea  urchins, 
the  addition  of  alkalies  accelerated  the  rate  of  de- 
velopment and  growth.  Loeb  (64),  in  1904,  also 
reported  that  the  addition  of  alkalies  to  Van't  Hofif's 
artificial  sea  water  favored  the  regeneration  and 
growth  of  tubularians.  These  facts  may  be  inter- 
preted as  being  the  result  of  the  favorable  action 
of  alkalies  on  processes  of  oxidation  in  the  proto- 
plasm— an  action  already  referred  to  in  connection 
with  Underbill  and  Clossen's  work  on  methylene 
blue. 

That  alkalies  are  extensively  used  in  the  treat- 
ment of  nephritis,  largely  in  the  form  of  diuretic 
"remote  antacids"  is,  then,  another  endorsement  of 
theory  by  fact.  The  direct  indication  for  this  form 
of  treatment  would  seem  to  follow  from  the  fact 
that  the  alkalinity  of  the  blood  is  affirmed  by  Dick- 
onson  (65)  to  be  diminished  in  nephritis.  The 
maintenance  of  the  activity  of  the  functions  of  the 
organs  now  known  to  have  an  oxidizing  capacity 
has  long  been  considered  a  matter  of  importance 
and  for  this  reason  calomel  has  been  employed,  not 
only  as  a  cathartic,  but  as  a  hepatic  stimulant. 

Exercise.  C.  Edel  (66)  has  emphasized  the  ben- 
eficial influence  of  exercise,  especially  of  climbing 
mountains,  without  fatigue,  in  the  treatment  of 
chronic  nephritis — especially  of  the  interstitial  form. 
Judiciously  indulged  in,  to  gradually  increase  the 
powers  of  oxidation,  this  measure  has  much  to 
recommend  it,  but  must  always  be  discontinued 
short  of  fatigue,  or  the  powers  of  sufificient  oxida- 
tion may  be  noticeably  interfered  with. 

Causes  of  symptoms.  It  would  be  desirable  if 
each  symptom  of  nephritis  could  be  traced  to  a  defi- 
nite cause.  This  might  be  attempted  in  some  such 
way  as  the  following,  which  is  on  a  very  small  scale, 
attempting  to  record  the  variations  in  a  few- 
recordable  reactions.  In  this  case  an  attempt  was 
made  "to  trace  any  direct  connection  between  the 
symptoms  recorded  and  the  diminished  oxidizing  ac- 
tivity denoted  by  diminished  creatinine  excretion. 

TABLE  XXVIII. 
RELATION  OF  SYMPTOMS  TO  INDICAN  AND  CREATININE 
EXCRETION. 


No.    Diagnosis.  E 

1.  Clironic  diffuse  nephritis  13 

2.  Chronic  diffuse  nephritis  1.2 

3.  Chronic  diffuse  nephritis  15 

4.  Chronic  diffuse  nephritis  + 

5.  Chronic  diffuse  nephritis  20 

6.  Chronic  diffu.se  nephritis  3 

7.  Chronic  parenchymatous 

nephritis   Trace 

8.  Acute  nephritis   o 

9.  Chronic  diffuse  nephritis 


«i  1 

u  i-  O 


176 
210 
208 
170 


K 
-t- 
+ 
-I- 
+ 
-t- 
-1- 


si  I  I  «  -I 
i'l  1  HI 

-ll^  o  s  c3 


+         o  o 

-1-0     0  0 

-I-    +  +  o 

+  -I-  4-  -I- 

—  +  +  o 

+     00  + 


0.9  I4S  — 
1.3 1  174  o 
0.4    260  + 


+  —  +  +  

+  0-1-000 

+     -f-    0    0    -i-  -i- 


A  perusal  of  this  table  (XXVIII)  will  show  that 
there  mav  be  a  general  relationship,  which  is  not 
absolute,  however,  between  the  excretion  of  indican, 
the  increase  of  arterial  tension,  and  the  reduction 
of  creatinine.    The  relationship  between  headache 


June  5,  >909.J         DITMAN  AND  WELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS. 


1 


and  the  excretion  of  indican  and  diminished  cre- 
atinine also  seems  to  be  a  direct  one.  There  is  a 
frequent  relationship  between  diminished  creatinine 
excretion  and  lassitude,  a  general  one  between  dim- 
inished creatinine  excretion  and  nausea  and  vomit- 
ing, and  no  special  relationship  in  regard  to 
d}'spnoea  and  oedema. 

Indican  and  tension.  The  attempt  to  establish 
the  relationship  between  high  arterial  tension  and 
indican  producing  intestinal  putrefaction  as  a  causa- 
tive agent  has  been  made — recently  by  Houghton 
(67) — but  this  relation  has  never  been  fully  estab- 
lished, and  it  is  possible  that  not  only  is  tension 
probably  the  result  of  the  action  of  more  than  one 
agency,  but  that  the  action  of  indican  in  producing 
hypertension  is  far  from  a  constant  one.  It  is  cer- 
tainly eliminated  at  times  in  enormous  quantities  in 
some  cases  of  typhoid  fever,  for  example,  where 
hypertension  is  entirely  absent. 

Drugs.  Of  drugs  which  are  employed  in  neph- 
ritis, few  have  been  viewed  with  suspicion  except 
opium.  The  fear  expressed  by  the  older  physicians 
in  the  use  of  this  drug  in  uraemia,  founded  largely 
upon  their  ideas  of  its  uncertain  elimination,  is  jus- 
tified on  the  basis  of  the  text  of  this  thesis  by  the 
more  recent  observations  of  Cushny  (10)  and  White 
and  Wilcox  (69).  These  authors  state  that  opium, 
in  the  body,  independent  of  any  effect  on  the  stom- 
ach, lessens  hunger,  decreases  general  metabolism, 
and  diminishes  the  amount  of  uric  acid  and  carbon 
dioxide  excreted — due  to  diminished  oxidation  of 
the  tissues.  By  its  use,  therefore,  the  oxidizing 
functions  of  body  mttabolism  considered  desirable 
in  nephritis,  are  diminished. 

Of  drugs  considered  specific  for  the  condition  of 
nephritis,  its'elf,  and  capable  of  accomplishing  the 
cure  of  a  case  once  established,  there  are  none. 
Their  use  is  indicated  only  symptomatically  and 
brierty  as  follows :  For  the  bowels,  calomel  and 
saline  cathartics,  etc. ;  to  increase  alkalinity  of  blood 
and  urine  potassium  citrate,  tartrate,  etc. ;  for  sweat- 
ing pilocarpine  and  hot  baths ;  for  anaemia,  iron ; 
and  for  convulsions  of  uraemia,  chloral  and  chloro- 
form, but  no  opium.  For  the  last  two  symptoms 
colon  irrigation  is  recommended,  and  as  a  general 
dictum  throughout  the  course  of  the  disease,  oxy- 
gen administered  in  as  many  ways  as  possible. 

Anmnia.  It  must  alwaj's  be  borne  in  mind  that 
the  destruction  of  the  red  blood  corpuscles  is  one 
of  the  early,  characteristic  and  pronounced  symp- 
toms of  nephritis ;  therefore,  all  attempts  at  the  im- 
provement of  conditions  augmenting  oxidation  must 
accompany  or  follow  the  attempt  to  improve  the 
quality  of  the  blood  and  to  increase  the  number  of 
its  red  corpuscles.  For  this  purpose  the  use  of  the 
citrate  of  ammonium  and  iron,  ferric  perchloride, 
or  Blaud's  pill  is  recommended,  with  colon  irr'ga- 
tion.  Blood  pressure,  if  extreme,  may  be  reduced 
by  sweating,  and  the  arterial  dilators,  but  the  at- 
tempt should  never  be  made  in  advanced  conditions 
of  this  disease,  to  reduce  the  pulse  to  its  normal 
softness.  The  oedema  may  be  controlled  by  sweat- 
ing, cathartics,  and  the  use  of  salt  free  diets  as  sub- 
sequently described. 

(Edema.  Widal  and  Javal  (70)  called  attention 
to  the  inability  of  many  nephritics  to  eliminate 


sodium  chloride  in  a  normal  manner.  The  salt  re- 
tained in  the  tissues  requires  a  certain  amount  of 
water  to  maintain  it  in  the  proper  molecular  con- 
centration, thus  leading  to  oedema,  and  they  sug- 
gest this  as  the  probable  explanation  of  dropsy  in 
nephritis. 

As  a  rule  nephritic  patients  eliminate  half  of  the 
daily  quantity  of  sodium  chloride  normally  contained 
in  urine ;  an  approximation  to  the  normal  percent- 
age elimination  can  therefore  be  obtained  by  allow- 
ing the  patient  to  take  not  more  than  7.5  grammes 
of  salt  in  twenty-four  hours. 

In  order  to  reduce  albumin,  and  to  cause  the  dis- 
appearance of  oedema,  a  more  radical  course  is  neces- 
sary. This  consists  in  allowing  no  salt  for  season- 
ing purposes,  the  albumin  of  the  food  is  derived 
from  milk  and  vegetables,  and  a  free  use  of  fat  and 
carbohydrates  is  allowed.  ]\leats  are  especially  un- 
desirable here  on  account  of  the  great  salt  con- 
tent. The  undesirability  of  the  use  of  salt  in  ex- 
cess in  nephritis  is  also  emphasized  by  the  fact  that 
some  investigators  have  found  it  operative  in  bring- 
ing about  the  removal  of  too  much  alkali  from  the 
body,  thus  favoring  a  degree  of  acidosis.  The  in- 
fluence of  this  result  upon  the  oxidizing  functions 
cf-  the  body  may  be  seen  to  be  undesirable,  from 
what  has  already  been  said  in  regard  to  the  in- 
fluences of  alkalies  on  oxidation.  In  the  terminal 
stages  of  Bright's  disease  the  impermeability  of  the 
kidney  may  be  greater  to  salt  than  to  urea.  For 
this  reason  the  chloride  elimination  may  be  a  better 
index  of  the  functioning  power  of  the  ki'dney  than 
the  excretion  of  urea. 

Albuminuria.  -W  idal  and  Javal  (71)  showed  that 
in  a  case  of  small  contracted  kidney,  albuminur.'a 
could  be  increased  or  diminished  uniformly  bv  in- 
creasing or  diminishing  the  amount  of  sodium 
chloride  in  the  food.  They  concluded  that  the  al- 
bumin in  the  urine  was  entirely  uninfli;enced  by 
the  albumin  in  the  food,  as  has  long  been  believed. 

Elimination.  In  the  ordinary  form  of  chronic 
Bright's  disease  the  elimination  of  the  normal  pro- 
ducts of  metabolism  is  generally  good.  But  some  few 
substances  are  difficult  of  elimination,  a  fact  which 
shows  itself  first  in  a  certain  irregularity  of  excre- 
tion. 

Such  unfavorable  variations  take  place  with  re- 
gard to  the  following  substances:  i.  Urea,  as  soon 
as  the  food  produces  more  than  thirty  grammes ; 
smaller  quantities  of  urea  are  generally  eliminated 
easily,  and  in  constant  quantity.  2.  Inorganic  sul- 
phates. 3.  Uric  acid.  4.  Sometimes  water  (von 
Noorden). 

While  small  quantities  of  uric  acid  are  readily 
eliminated  in  the  urine,  large  quantities  are  elim- 
inated with  difficulty.  Hence  animal  tissues  rich 
in  nucleins  must  be  banished  from  the  table  of  neph- 
ritic patients.  Such  forbidden  dishes  are  sweat- 
bread,  liver,  kidneys,  and  all  other  glandular  or- 
gans. Tea  and  coffee  slipuld  be  taken  only  in  small 
amount.  For  while  the  diuretic  effect  of  caffeine, 
the  active  principle  of  coffee,  has  long  proved  use- 
ful as  a  diuretic,  it  introduces  an  element  which, 
in  a  compensated  case,  may  upset  the  nicelv  ad- 
justed balance  between  heart  action,  blood  pressure 
and  elimination.    Moreover,  as  it  is  a  .xanthine  and 


rxlTMAN  AND  ll'ELKER:  DEFICIENT  OXIDATION  AND  NEPHRITIS.        [New  Yokk 

Medical  Jour.n'\l. 


Fic.   40. — Absolute   milk  diLt   in  cats.     l.iver  after  six  weeks. 
Marked  fatty  infiltration  of  parenchyma  cells. 

closely  allied  to  the  purin  bases,  it  may  be  an  un- 
desirable article  of  diet  for  the  same  reason  that  the 
purin  bases  are  so  considered.  It  is  well  guarded, 
however,  by  the  stimulating  oxygen  and  methyl 
groups. 

Forms  of  albninin.  The  kidneys  make  no  distinc- 
tion between  the  various  different  forms  of  albumin. 
Von  Noorden,  Hoppe-Seyler,  and  W.  Hall  have 
shown  that  there  is  practically  no  diflference  in  the 
amount  of  "extractives"  obtained  in  red  and  white 
meat. 

Fluids.  Every  patient  with  advanced  nephritis 
has  also  heart  disease.  In  many  cases  the  cardiac 
trouble  is  more  dangerous  than  the  disease  of  the 
kidneys.  Von  Noorden  never  allows  his  patients  to 
drink  more  than  one  and  one-half  litres  of  water 
each  day,  on  account  of  the  strain  which  an  in- 
creased volume  of  blond  would  impose  upon  the 
heart. 

Milk  diet.  While  an  absolute  milk  diet  was,  in 
former  times,  considered  the  ideal  diet  for  all  forms 
of  nephritis,  it  is  now  considered,  for  all  chronic 
forms  of  nephritis  especially,  out  of  the  question. 
In  order  to  maintain  an  adult  in  a  condition  of 
normal  metabolism  on  this  diet  it  would  be  neces- 
.sary  to  consume  four  litres  of  milk — requiring  the 
consumption  of  far  too  large  an  amount  of  fluid 
for  the  best  effects  in  nephritis.  Moreover,  the  final 
decomposition  of  this  amount  of  albumin  represents 
an  amount  of  waste  product.s — over  forty  grammes 
of  urea — that  would  increase  the  demands  made 
\\\mr\  the  functional  activity  of  the  kidney,  and 
might  do  a  great  deal  of  harm. 

Smaller  amounts  must  therefore  be  used  and  the 
deficiency  in  caloric  units'  existing,  must  be  made 
up  by  the  use  of  fats  and  carbohydrates.  Other  un- 
desirable circumstances,  connected  with  milk  diet, 
are :  that  milk  is  highly  constipating ;  that  it  very 
readily  deranges  the  liver  and  causes  gouty  symp- 
toms in  some  subjects;  and  that  it  is  a  monotonous, 
imattractive  food  which  the  patient  presently  comes 


to  loathe  when  it  is  presented  to  him  at  regular 
short  intervals  for  weeks  on  end. 

The  derangement  of  the  liver  and  production  of 
gouty  symptoms  to  which  attention  has  been  c-^lled 
by  Bruce,  is  a  matter  of  living  interest  in  view  of 
a  simple  experiment  made  by  the  author  cn  the  in- 
fluence of  an  absolute  milk  diet. 

Pathology  of  milk  diet.  The  experiment,  prac- 
tised on  cats,  was  intended  for  a  control  on  some 
experiments  in  the  administration  of  nitrogenous  ex- 
tractives to  cats  on  a  milk  diet.  It  was  thought 
that  cats,  which  for  such  a  long  period  of  their 
infancy,  had  lived,  without  harm,  on  an  absolute 
milk  diet  could  continue  to  do  so  after  having 
reached  the  adult  period.  The  result,  however,  was 
rather  startling :  Two  cats  were  kept  on  this  diet 
for  six  and  nine  weeks  respectively.  Both  did  badly 
and  it  was  evident  from  their  appearance  that  such 
diet  continued  for  more  than  a  week  or  two,  was 
distinctly  unsuitable.  The  greatest  surprise  came, 
however,  from  an  e.xamination  of  the  viscera  after 
these  animals  had  been  killed. 

In  the  six  weeks'  cat  the  liver  cells  had  become 
almost  entirely  replaced  with  fat,  leaving  apparently 


l"iG.   46. — .\bsoIute   milk  diet  in  cats.     Kidney  after  nine  weeks. 
E.xtreme  fatty  infiltration  of  cells  of  renal  cortex. 

no  parenchyma  for  normal  functioning.  The  kid- 
ney also  showed  a  mild  degree  of  fatty  infiltration 
occ\irring  in  the  cells  of  the  convoluted  tubules. 
(See  illustration  a.  of  Fig.  4.) 

In  the  nine  weeks'  cat  a  certain  amount  of  varia- 
tion was  seen,  in  that  the  liver  was  almost  normal. 
The  kidneys,  however,  presented  an  appearance 
never  before  seen  by  the  author  in  his  exj^erience: 
viz. :  a  most  extreme  fatty  infiltration  of  all  the 
glandular  cells  of  the  renal  cortex.  (See  illustra- 
tions b  and  c.  Fig.  4.)  How  such  a  kidney  could 
functionate  it  is  difificult  to  conceive. 

The  lesson  is  striking:  for  the  diet  conditions  of 
the  cat  and  man,  while  slightly  different  in  adult 
life  are  similar  in  regard  to  their  absolute  milk 
diet  period  of  early  life,  and  their  toleration  for 


June  5,  >9oy.J         DITMAN  AND  IVELKER:  DEFICIENT   OXIDATION  AND  NEPHRITIS. 


1 


milk  during  the  later  life  periods  is  probably  some- 
what similar. 

There  is  a  strong  suspicion  then  that  a  long  con- 
tinued absolute  milk  diet  in  human  beings  may  have 
a  distinct  pathological  foundation  for  the  symptoms 
which  are  so  often  summed  up  by  the  clinician  under 
the  more  or  less  vague  expression  "poorly  borne." 

Diet.  In  bad  chronic  or  late  acute  cases,  the  diet 
must  be  so  arranged  that  it  has  sufficient  coloric 
value  to  keep  up  nutrition  and  at  the  same  time 
will  not  make  too  great  a  demand  upon  the  kidneys. 
This  diet  is  milk,  to  which  must  be  added  carbohy- 
drates or  fats. 

Forscheimer  (72)  uses  oatmeal  in  the  form  of 
oatmeal  jelly,  rice,  farina,  arrow  root,  or  wheat  flour, 
sugar,  crackers,  and  rusks.    As  an  example : 

Calories. 

Oatmeal  jelly  made  from  120  grammes  of  oatmeal...  32 

Milk  1,500  c.c   893 

Sugar    205 

1 130 

For  the  constant  treatment  of  patients  with 
chronic  nephritis  during  the  stage  of  compensation, 
the  following  rules  may  be  followed  in  diet : 

Albumin.  In  regard  to  albumin  the  quantity  al- 
lowed should  not  be  too  great.  The  exact  quan- 
tity can  only  be  worked  out  for  the  individual  case 
by  determination  of  nitrogen  retention  and  nitrogen 
elimination. 

The  amount  of  albuminoid  food  allowed  for  a  case 
of  chronic  nephritis  in  good  condition  of  seventy 
kilogrammes  weight,  von  Noorden  places  at  or  be- 
low ninety-two  to  one  hundred  and  twelve  grammes 
in  men,  and  eighty  to  one  hundred  grammes  in 
women.  This  corresponds  to  thirteen  to  sixteen, 
and  eleven  to'  fourteen  grammes  of  urinary  nitro- 
gen respectively. 

Optimum  Protcid  Intake. 
Chittenden  (74),  in  a  recent  investigation,  has 
found  that  a  normal  man  weighing  seventy  kilo- 


FiG.  4c. — Absolute  milk  ilui  m  cat^  .ifter  nine  weeks.    Extreme  fatty 
infiltration  of  cells  of  renal  cortex. 


grammes  can  live  in  perfect  health  and  nitrogenous 
equilibrium  when  excreting  only  8.4  grammes  of 
nitrogen  in  the  urine  daily,  provided  a  sufficient 
amount  of  fats  and  starches  are  ingested  to  bring 
the  daily  calorific  value  of  the  food  up  to  2,800 
calories.  This  being  the  case  it  would  appear  as 
though  there  was  no  necessity,  under  any  circum- 
stances, of  one  who  suffers  from  chronic  nephritis 
ingesting  more  than  sixty  grammes  of  proteid  food 
daily  and  there  is  every  reason  to  believe  that  the 
reduction  of  the  proteid  intake  to  this  figure  would 
greatly  relieve  the  kidneys  from  superfluous  work 
and  materially  diminish  the  chances  for  the  reten- 
tion of  toxic  nitrogenous  products. 

On  general  principles  the  food  is  to  be  of  such 
quantity  and  kind  that  the  nitrogenous  intake  shall 
not  strain  the  capacity  of  the  eliminating  organs,  par- 
ticularly the  kidneys,  whilst  supplying  the  metabo- 
lic demands  of  the  body  and  promoting  repair. 
Therefore  caution  is  given  in  the  use  of  meats  and 
meat  preparations,  and  of  alcohol ;  but  a  relative  ex- 
cess of  fats,  watery  solids,  farinaceous  materials, 
vegetables,  and  fruits  is  called  for. 

The  sufferer  from  chronic  nephritis  may  eat  po- 
tatoes with  the  Irishman,  oatmeal  with  the  Scot, 
rice  with  the  Hindu,  or  pulse  with  the  Prophet 
(73). 

In  any  case,  the  more  nearly  the  diet  approaches 
that  of  health  (without  inducing  disorder),  the  bet- 
ter ;  and  the  effects  of  different  foods  in  each  case 
and  in  the  different  phases  of  each  case  are  to  be 
intelligently  observed  and  employed  as  guides  to 
treatment. 

The  distinct  disadvantages  of  the  use  of  more 
nitrogen  food  than  is  barely  necessary  for  the  main- 
tenance of  nitrogenous  equilibrium  has  already 
been  mentioned  and  can  not  be  too  strongly  empha- 
sized. 

The  importance  of  attempts  to  prevent  intestinal 
putrefaction  have  already  been  considered. 

Intestinal  putrefaction.  The  disease  once  estab- 
lished and  such  putrefaction  continuing,  measures 
directed  toward  the  removal  of  this  process  become 
the  most  important  of  medical  agencies.  This  is 
attempted  by  continued  control  of  diet,  by  the  use 
of  intestinal  antiseptics,  by  the  use  of  intestinal  ox- 
idizing agencies,  and  by  the  mechanical  removal  of 
putrefactive  matter. 

Diet  has  already  been  considered. 

Of  intestinal  antiseptics,  Jacobi  has  found  the  ac- 
tion of  most  uncertain  in  their  effects.  While  he 
has  tried  iodine,  creosote,  carbolic  acid,  naphthol, 
iodoform,  and  charcoal,  as  well  as  many  others,  he 
has  usually  fallen  back  upon  creosote  and  charcoal, 
the  former  in  moderate,  the  latter  in  large  doses. 
Herter  has  found  that  salicylates,  aspirin,  and  salol 
exert  some  influence  in  controlling  the  amount  of 
intestinal  putrefaction. 

On  theoretical  grounds  oxidizing  agencies  should 
produce  a  desirable  effect,  especially  in  view  of  our 
knowledge  of  the  effect  of  such  substances  as  hy- 
drogen peroxide  and  potassium  permanganate  on 
bacterial  process  outside  the  body.  Attempts  to- 
produce  desirable  results  in  experiments  on  dogs  by 
Herter  and  Wakeman.  using  hydrogen  peroxide  and 
ferric  sulphate  were  not  entirely  satisfactory,  but  it 


1 140 


DITMAX  ASD  WELKER:   DEFICIENT   OXIDATION  AND  NEPHRITIS. 


[N£>v  York 
Medical  Journal. 


is  possible  that  some  suitable  agency  of  this  typ^ 
may  soon  be  found. 

Removal  of  the  putrefactive  material  by  mechan- 
ical means — involving  the  use  of  cathartics  and 
colon  irrigation — has  already  been  suggested  and 
operates  as  a  great  aid  to  the  other  measures  em- 
ployed. 

Specific  treatment.  The  use  of  oxidizing 
enzymes — within  the  intestinal  canal  to  influence  in- 
itial processes  of  toxine  formation  and  in  the  blood 
stream  to  act  on  remote  toxic  products — is  one  the- 
oretically desirable,  but  a  field  practically  unex- 
plored. Ihe  occasional  toxic  action  of  enzymes 
when  introduced  into  the  circulation  presents  a  dif- 
ficulty which  must  first  be  overcome.  It  is  along 
these  lines,  however,  that  some  of  the  most  bril- 
liant developments  in  the  therapy  of  these  condi- 
tions may  be  expected. 

VIT.  CONCLUSIONS. 

Many  chemical  substances  which,  by  complete 
oxidation,  are  converted  into  innocuous  products, 
may,  by  incomplete  oxidation,  be  decomposed  into 
products  of  great  toxicity. 

Among  the  most  toxic  substances  formed  in  the 
body  are  the  incompletely  oxidized  nitrogenous 
products  of  protein  decomposition. 

There  is  strong  evidence  that  the  oxidation 
processes  in  chronic  nephritis  are  deficient — espe- 
cially in  the  chronic  dififuse  type. 

Of  the  substances  capable  of  causing  toxic,  symp- 
tomatic, and  pathological  effects  in  nephritis,  the 
members  of  the  creatine  group  are  of  special  in- 
terest. 

There  are  many  factors  in  nephritis  capable  of 
diminishing  oxidation. 

Agents  which  increase  oxidation  have  long  been 
the  favorites  in  the  treatment  of  chronic  nephritis. 
Their  more  extended  use  should  not  only  be  advan- 
tageous in  the  treatment,  but  instrumental  in  pre- 
ventinsf  that  disease. 


The  authors  desire  to  express  their  greatest  ap- 
preciation of  the  generous  and  untiring  assistance 
and  encouragement  of  Professor  William  J.  Gics, 
of  the  College  of  Physicians  and  Surgeons,  in  the 
preparation  of  this  work. 

Grateful  acknowledgement  for  assistance  is  also 
made  to  Mr.  E.  P.  Valentine,  of  Richmond,  Va. ; 
Mr.  William  D.  Sloane,  of  New  York,  and  Profes- 
sor Walter  B.  James,  Professor  F.  C.  Wood,  Pro- 
fessor E.  B.  Cragin,  and.  Professor  John  S. 
Thacher,  of  the  College  of  Physicians  and  Sur- 
geons, as  well  as  to  the  stafifs  of  the  Roosevelt,  St. 
Luke's,  and  the  Sloane  iMaternity  Hospitals,  in  the 
laboratories  of  which  much  of  this  work  was  done, 
and  especially  to  the  officers  of  the  laboratories  of 
pathology  and  biological  chemistry  in  the  College 
of  Physicians  and  Surgeons,  where  the  greater  part 
of  the  chemical  and  i)athological  research  was  con- 
ducted. 

Xkw  '\'nRK.  Septenil)er  i.  KjO/. 

VIII.  Rii!i.i()f;R.\PHY. 

1.  Kasllc  and  Elvovc  :  Oxidation  and  Reduction  in  tlie 
Animal  Organism  and  t'le  Toxic  Action  of  Powerful  Oxi- 
dizing and  Reducing  Substances.  Am.  Clicm.  Jour,  xxxi. 
No.  3,  p.  ig.v 

2.  Sclimiedelierg :  Arch.  r.vf.  Patli.    xiv,  pp.  288  to  379. 


3.  Pohl :  Ibid,    xiv,  pp.  38  to  65. 

4.  Medwedew :  Pfliiger's  Archiv.    Ixv,  p.  249. 

5.  Jacoby :  i/trcnuws  Arcitiv.    clvii,  p.  235. 

0.  Hoppe-Seyler :  Zctscitrijt  filr  physiol.  Chem.  18//. 
i,  p.  126. 

7.  J.  Loeb :  ArtiAcial  Parthenogenesis  and  tlic  Problem 
of  Fertilization.    Columbia  Lecture,  igo2. 

8.  Silber :  Leber  die  Entgiftung  der  Toxine,  durch  die 
Superoxyde  sowie  thierische  and  pilanzliche  Oxydasen. 
Zeitschrift  fiir  physiol.  Chem.    xxxii,  p.  573. 

9.  Ellinger:  Bericiite:  xxxi,  3183  (1898).  Zeitschrift 
fiir  physiol.  Chem.    xxix,  p.  334. 

10.  Cushny :  pharmacology,    p.  513,  second  edition. 
.11.    Vaiighan  and  Novy :  Cellular  Toxines,  Chap.  xiv. 

12.  Mandel :  The  Alloxuric  Bases  in  Aseptic  Fevers. 
Am.  Jour,  of  Physiology,    x,  No.  vii,  p.  457. 

13.  Burian  and  Schur :  Archiv  fiir  die  gesammte  Physi- 
ologic.   Ixxxvii,  p.  239,  1901. 

14.  Frankel :  Arzneimittcl-Synthesc.  The  Significance 
of  the  Substitution  of  Uno.xidized  Sulphur. 

15.  Landau .  Untersuchungcn  iiber  die  Leistungsfahig- 
keit  der  iNieren  mit  Hilfe  des  Methylenblau.  Zcitschr.  fiir 
klin.  Med.    xlii,  p.  210. 

16.  Ehrlich  :  Centralblatt  fiir  die  medicinisclicn  IVissen- 
Kchaften.    xxiii,  p.  113,  1885. 

17.  Dreser :  Zcitschr.  f.  Biologic,  xxi,  p.  41,  1885.  Ibid. 
Kxii,  p.  56,  1886. 

18.  Muller:  Dcutsches  .4rchiv  fur  kliiiischc  Mediciii. 
Ixii,  p.  130,  1899. 

ig.    Eisner:  Il>:d.    Ixix,  p.  47,  1501. 

20.  Herter :  Zeitschrift  fiir  physiol.  Chem.  xlii,  p.  403, 
1904. 

21.  Underbill  and  Closson :  The  PhysioiOgical  Behavior 
of  Methylene  Blue  and  Methylene  Azure  :  A  Contribution 
to  the  Study  of  the  Oxidation  and  Reduction  Processes 
in  the  Animal  Organism.  Am.  Jour,  of  Physiology,  xii, 
No.  5. 

22.  Herter :  Ueber  die  Anwendung  reduzierbaren  Sau- 
ren  beim  Studium  der  Verteilung  von  Giften  und  ihrer 
Wirkimgen  auf  die  Zelltatigkeit.  Zeitschrift  fiir  physiol. 
Chem.    xlii,  p.  493. 

23.  Jones  and  Partridge :  Ueber  die  Guanase.  Zeit- 
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24.  Mendel:  Formation  of  Uric  Acid.  Journ.  Am.  Med. 
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GRUE.XING:  SIXUS  THROMBOSIS  AND  STREPTOCOCCHAiMIA.  1141 


June  3,  1909. 1 


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SINUS   THROMBOSIS   OF  OTITIC   ORIGIN  .\ND 
ITS  RELATION  TO  STREPTOCOCCH.EMIA.* 

By  Emil  Gruening,  M.  D., 
New  York. 

The  streptococcus  group  stands  out  preeminently 
among  the  various  microorganisms  causing  puru- 
lent inflammation  of  the  middle  ear.  Recent  studies 
on  the  bacteriology  of  acute  affections  of  the  middle 
ear  show  that  they  are  due  in  more  than  fifty  per 
cent,  of  the  cases  to  the  presence  of  Streptococcus 
pyogenes,  and  in  about  fifteen  per  cent  to  Strep- 
tococcus mucosus.  Leutert.  Suepfle,  and  E.  Lib- 
man,  of  the  pathological  laboratory  of  Mt.  Sinai 
Hospital,  report  identical  results.  It  seems  then 
that  the  pneumococcus  and  the  staphylococcus  do 
not  play  as  important  a  role  in  the  causation  of 
purulent  middle  ear  disease  as  has  formerly  been 
assigned  to  them.    Still,  these  organisms  are  fre- 

*Read  before  the  Academy  of  Medicine,  March  2,  igog. 


quently  demonstrable,  as  are  also  a  number  of  other 
bacteria  in  either  pure  or  mixed  cultures. 

One  of  the  most  dreaded  complications  arising  in 
the  course  of  purulent  middle  ear  disease,  throm- 
bosis of  the  lateral  sinus,  is  most  frequently  as- 
sociated with  a  general  systemic  infection.  Blcod 
cultures  taken  from  patients  thus  infected,  show 
that  the  cause  of  the  systemic  disorder  is  again 
the  streptococcus  w'hich  circulates  freely  in  the 
blood. 

In  the  last  ten  cases  of  thrombosis  of  the  lateral 
sinus  occurring  in  the  otological  service  of  Mt 
Sinai  Hospital,  the  blood  cultures  w^re  made  under 
the  supervision  of  Dr.  E.  Libman.  The  blood  used 
in  these  cultures  was  taken  from  the  median  vein 
before  and  after  ligation  of  the  internal  jugular 
vein.  The  blood  culture  reports  of  these  ten  cases, 
received  from  the  pathological  department,  are  pos- 
itive in  seven  cases,  negative  in  three.  The  micro- 
organisms causing  the  infection  w^ere,  in  five  cases 
the  Streptococcus  pyogenes,  in  one  case  Streptococ- 
cus mucosus,  in  another  the  Bacillus  protcus.  The 
same  organisms  had  previously  been  found  in  the 
purulent  discharge  of  the  ear.  As  stated  before, 
the  internal  jugular  vein  was  ligated  in  all  these' 
cases.  Of  the  ten  cases  here  grouped  together, 
eight  patients  recovered  and  two  died.  One  death 
occurred  from  meningitis  in  a  case  the  blood  of 
which  was  reported  negative,  and  the  second  death 
took  place  in  the  case  infected  by  the  Bacillus  pro- 
teus.  These  observations  go  to  prove  that  blood 
taken  from  the  veins  of  the  arm  will  demonstrate 
the  presence*  of  the  microorganisms  in  the  general 
circulation  more  convincingly  than  the  blood  taken  di- 
rectly from  the  sinus.  Leutert  has  advocated  the  latt.r 
method  to  indicate  the  presence  of  a  thrombus. 
Furthermore  do  the  clinical  data  prove  that  the 
presence  of  the  streptococcus  in  the  blood  does  not 
necessarily  lead  to  a  fatal  issue,  but  on  the  contrary, 
provided  the  internal  jugular  is  ligated.  permits  of 
a  favorable  prognosis. 

I  have  selected  of  this  group  of  ten  cases,  th.' 
last  two.  with  positive  blood  findings,  as  examples 
of  what  the  course  of  the  disease  may  be  under  dif- 
ferent conditions.  In  the  first  case  we  must  assume 
that  the  formation  of  new  foci  had  alread}'  begun 
before  ligation  of  the  jugular.  In  the  second,  the 
thrombosed  sinus  was  the  only  focus  and  this  was 
disposed  of  by  ligation  of  the  jugular  and  removal 
of  the  thrombus. 

C.^SE  I. — L.  H.,  a  schoolboy,  ten  and  a  half  years  old, 
was  admitted  to  the  ear  wards  of  ^h.  Sinai  Hospital  on 
March  31,  1908. 

Present  Illness :  Twelve  days  ago  he  began  to  complain 
of  severe  pain  in  the  left  ear,  with  headache,  fever,  and 
marked  prostration.  Severe  pain  in  the  left  ear  continued, 
together  with  high  fever.  For  the  past  four  days  he  had 
daily  shaking  chills  lasted  fifteen  minutes  and  fol- 
lowed by  marked  sweating.  He  also  vomited  repeatedly 
during  the  last  four  or  five  days,  and  the  contents  of  the 
stomach  were  ejected  with  considerable  force.  He  was 
very  drowsy  during  the  last  few  days,  and  two  days  ago 
seemed  delirious.  Bowels  moved  three  to  four  times  daily, 
loose  and  watery.  No  convulsions.  The  chief  complaints 
were :  Pain  in  ear,  headache,  high  fever  and  chills,  projec- 
tile vomiting,  diarrhoea,  marked  prostation,  lethargjv  and 
slight  cough. 

Physical  Examination :  The  child  remained  quiet  in  a 
lethargic  state,  but  answered  questions.  Lungs  were  clear 
except  for  an  occasional  sibilant  sound,  especially  in  the 


1 142 


GRUENING:  SINUS  THROMBOSIS  AND  STRLPTOCOCCHALMIA. 


[New  York 
Medical  journal. 


left  interscapular  region.  Slight  dullness  in  left  supraclav- 
icular fossa.  Pulse  was  equal,  regular,  small,  soft,  with 
fair  force.  Abdomen  was  slightly  distended,  no  rigidity,  no 
definite  point  of  tenderness.  There  was  no  Kernig  sign,  no 
Babinsky  reflex.  In  the  right  ear  the  drumhead  was  red 
and  bulging,  and  the  mastoid  process  was  very  tender.  In 
the  left  ear  the  drumhead  was  also  bulging;  there  was 
marked  tenderness  on  pressure  over  the  antrum,  the  tip, 
and  also  the  postmastoid  region.  In  the  neck  there  was  a 
decided  distension  of  the  left  superficial  veins ;  marked 
tenderness  along  the  course  of  the  internal  jugular  vein  on 
left  side. 

The  opthalmoscopic  examination  was  negative.  Temper- 
ature 105.4°  pulse  100,  respiration  28.  White  blood  cor- 
puscles count  was  11,200;  polymorphonuclear  count  86  per 
cent. 

Operation :  The  drumheads  were  incised  and  pus  was  ob- 
tained from  both  tympanic  cavities.  Pus  contained  Strep- 
tococcus pyogenes.  The  next  day,  April  ist,  the  operation 
on  the  left  mastoid  was  performed  in  the  usual  manner. 
The  antrum  and  mastoid  cells  were  full  of  pus,  the  sinui 
plate  was  softened,  and  therefore  removed.  It  was  found 
that  the  sinus  wall  had  sloughed,  and  pus  was  oozing  from 
the  interior  of  the  sinus.  No  flow  of  blood  from  sinus.  At 
this  juncture  it  was  deemed  necessary  to  expose  the  in- 
ternal jugular  vein.  It  was  found  diseased  in  its  whole 
course  from  the  jugular  foramen  to  the  clavicle,  and  was 
excised.  The  sinus  plate  was  then  cut  with  long  forceps 
until  the  jugular  foramen  was  nearly  reached.  There  was 
still  a  small  bridge  of  bone  covering  the  jugular  bulb.  This 
was  also  removed  with  the  forceps.  The  jugular  bulb  lay 
before  us  containing  a  disintegrated  clot.  The  anterior 
wall  of  the  sigmoid  and  lateral  sinus  to  a  distance  halfway 
between  the  upper  knee  and  the  torcular  were  then  removed 
until  free  haemorrhage  was  obtained  from  the  peripheral 
end  of  the  sinus.  And  now  the  sinus  and  the  bulb  had  been 
converted  into  a  groove  in  which  the  softened  grey  thrombi 
lay.  All  these  were  removed.  The  operation  on  the  bulb 
was  done  in  accordance  with  Grunert's  method.  There  was 
no  difficulty  in  the  removal  of  the  bridge,  and  the  trans- 
verse process  of  the  first  cervical  vertebra  was  not  in  the 
way. 

While  the  patient  was  on  the  table  the  pathologist  drew 
blood  from  the  median  vein  for  the  purposes  of  a  blood  cul- 
ture. The  report  we  obtained  from  the  pathologist  was 
that  the  blood  contained  the  Streptococcus  pyogenes.  The 
thrombi  of  the  sinus  and  the  jugular  and  the  pus  of  the 
mastoid  all  contained  the  streptococcus. 

April  2nd.  Postoperative  condition  was  rather  poor. 
Pulse  148,  respiration  38.  temperature  107.2°  F.  An  in- 
travenous infusion  was  made  as  the  temperature  dropped 
over  twelve  degrees  in  the  next  four  hours,  from  107.2°  to 
95°  F.  The  temperature  remained  at  95°  F.  several  hours, 
then  rose  to  96°  F.,  at  which  point  it  remained  stationary 
a  little  while,  and  then  rose  in  one  straight  line  with  a  chill 
to  106.4°  F-  The  blood  culture  made  at  this  stage  was 
negative,  showing  that  the  focus  had  been  thoroughly  dealt 
with. 

April  4th.  The  last  two  days  the  temperature  ranged 
between  99°  and  104°  F.  No  chills.  There  was  a  profuse 
discharge  from  the  right  ear  and  tenderness  over  the  right 
mastoid.  There  was  also  a  marked  oedema  over  the  whole 
scalp.  Patient  was  restless,  vomited  bilious  fluid,  com- 
plained of  pain  in  the  right  inguinal  region  and  right  knee. 
The  temperatiire  rose  again  to  106°  F.,  and  the  streptococ- 
cus reappeared  in  the  blood.  White  blood  corpuscles  count, 
20,000,  polymorphonuclear  count  eighty-nine  per  cent,, 
lymphocytes  ten  per  cent.,  eosinophiles  one  per  cent.  On 
the  same  day  an  operation  was  performed  on  the  right  mas- 
toid. The  antrum  and  the  mastoid  cells  contained  pus. 
The  sinus  plate  was  removed  and  one  inch  of  the  sinus  ex- 
posed.   It  was  soft,  blue,  and  appeared  normal. 

While  the  patient  was  on  th.e  table  and  under  the  influ- 
ence of  the  anaesthetic  the  wound  of  the  left  side  was 
dressed.  Tlie  wound  looked  clean.  No  purulent  discharge. 
It  was  found  that  a  disintegrated  clot  plugged  the  periph- 
eral end  of  the  lateral  sinus.  Tine  bone  over  the  latter  was 
removed  and  the  sinus  wall  incised.  The  plug  was  dis- 
lodged and  free  bleeding  followed. 

Aoril  Qth.  In  the  iiast  three  days  the  temperatures 
ranged  between  99°  and  103°  F.,  pulse  between  80  and  100. 
respiration  24.    An  abscess  appeared  on  the  outer  aspect  of 


the  middle  of  the  right  thigh.  It  contained  about  three 
ounces  of  yellowish,  frothy  pus.  Pathological  report  strep- 
tococcus. The  ma.^.toid  and  cervical  wounds  were  dressed 
and  looked  well. 

April  nth.  Temperature  ranged  between  99°  to  I02.S° 
F.  Over  the  occipital  region  an  area  about  the  size  of  a 
silver  dollar  was  infected  and  sloughing,  showing  bare  bone. 

April  13th.  There  Vv'as  a  swelling  of  the  right  knee  joint 
with  distinct  fluctuation  above  and  below  the  patella.  The 
right  knee  was  immobilized  with  a  starch  bandage. 

April  i6th.  In  the  inspection  of  the  wound  on  this  day 
it  was  noted  that  there  were  some  granulations  in-  the  sinus 
grooves.  Pus  in  both  antra.  The  wounds  were  washed 
with  hydrogen  peroxide  and  salt  solution,  and  sprayed  with 
a  three  per  cent,  carbolic  acid  solution.  Dry  dressing  ap- 
plied. The  riglit  knee  joint  was  distended  and  markedly 
tender.    Three  days  later,  on 

April  20th,  Dr.  Lilienthal,  one  of  the  surgeons  of  Mt. 
Sinai  Hospital,  aspirated  the  right  knee,  and  evacuated  a 
large  amount  of  thick  pus.  He  then  applied  a  compression 
bandage  and  immobilized  the  knee.  A  few  days  later  a 
large  s\\  elling  appeared  on  the  posterior  aspect  of  both 
arms.  They  were  large  intramuscular  abscesses  from  which 
about  six  ounces  of  pus  were  removed.  On 

May  1st  the  following  notes  were  made :  "There  is  a 
moderate  purulent  discharge  from  the  wounds  in  the  arms 
and  in  the  right  thigh.  Mastoid  wounds  and  wounds  in 
neck  are  clean  and  granulating.  Pressure  sore  on  scalp 
shows  granulations  completely  covering  bone.  Still  some 
fluid  in  knee  joint.  General  condition  fairly  good.  Lungs 
and  heart  negative.    Blood  culture  sterile."  On 

May  3rd  when  the  temperature  did  not  rise  above  100° 
F.  the  patient  began  to  complain  of  pain  in  the  perinxum. 
He  continued  to  complain  of  this  pain,  and  a  large,  hard 
nodular  mass  presented  itself  on  the  left  side  of  the  peri- 
naeum.  On 

May  9th  Dr.  Lilienthal  was  kind  enough  to  see  the  pa- 
tient for  me,  and  operated  upon  him  by  incising  and  drain- 
ing the  abscess  in  the  perinaeum,  and  also  incising  and 
draining  an  abscess  in  the  suprapubic  region.  On 

May  25th  the  boy  was  discharged  from  the  hospital  with 
all  his  wounds  closed,  with  good  hearing,  and  a  movable 
knee  joint. 

Case  II. — Mrs.  R.  R.,  thirty  years  of  age,  was  admitted 
to  Mt.  Sinai  Hospital  on  October  16,  1908. 

Present  History :  Four  weeks  ago  she  had  a  severe  cold 
in  the  head.  About  one  week  later  she  suffered  with  acute 
pain  in  the  right  ear,  headache,  and  fever.  This  lasted 
about  two  weeks  when  the  ear  began  to  discharge.  The 
discharge  was  slight  and  the  pain  in  the  ear  continued.  In 
the  past  three  or  four  days  the  discharge  ceased,  and  the 
patient  had  several  chills.  Pain  in  the  ear  became  very  in- 
tense, and  radiated  to  the  parietal  and  occipital  regions. 
The  throat  at  the  right  side  was  very  painful  inside  and 
out.  Temperature  on  admission  103.4°  respiration  30, 
pulse  120.  White  blood  corpuscles  count,  22,800;  polynu- 
clear,  ninety-four  per  cent. ;  lymphocytes,  si.x  per  cent.  Her 
chief  complaints  were :  Pain  in  right  ear  and  mastoid  re- 
gion, severe  headache,  fever  and  chills,  pain  in  upper  right 
neck,  deafness  of  right  ear,  and  drowsiness. 

Local  Physical  E.xamination  :  There  was  a  marked  ten- 
derness over  the  right  mastoid  from  the  antrum  to  the 
tip  and  over  the  postmastoid  region.  There  was  also  de- 
cided tenderness  over  the  upper  part  of  the  internal  jugu- 
lar vein.  There  was  no  redness  or  oedema  anywhere,  only 
pain  on  pressure.  The  right  auditory  canal  was  decidedly 
narrowed  by  swelling  of  its  walls  and  by  sagging  of  the 
postcrosuperior  wall.  The  drum  membrane  was  congested 
in  its  upper  part  and  bulged  outward.  In  its  lower  part 
there  was  a  small  opening  through  which  pus  exuded. 

General  Physical  Examination  :  Patient  looked  very  sick 
There  was  a  strong  tendency  toward  drowsiness,  patient 
closing  the  eyes  and  apparently  sleeping  as  soon  as  she  was 
left  undisturbed.  She  could  easily  be  aroused  and  kept 
awake,  but  when  left  alone  soon  returned  to  the  former 
state.  The  pupils  were  small  and  equal,  and  reacted  to 
light  and  with  normal  accommodation.  Examinations  of 
lungs  and  heart  were  negative.  Pulses  equal,  rapid,  of 
good  force  and  quality,  knee  jerks  active  and  equal,  no 
Kernig  sign,  clonus,  no  Babinski  reflexes. 

Operation  October  i6th :  Paracentesis  having  been  per- 
formed, the  usual  postauriciilar  curved  incision  with  pos- 


June  5,  1909. 1 


BRADDOCK:  TROPICAL  MALARIA. 


1 143 


terior  prolongation  was  made.  The  cortex  was  hard,  and 
after  its  removal  a  number  of  cells  were  exposed  filled  with 
recent  granulations.  The  antrum  contained  pus.  No  sinus 
plate  could  be  found.  The  anterior  wall  of  the  sigrnoid 
sinus  was  entirely  destroyed,  and  the  sinus  itself  filled^  with  a 
black  clot,  in  which  there  were  white  streaks.  After  all 
diseased  bone  had  been  removed  and  the  antrum  thoroughly 
curetted,  a  portion  of  the  lateral  sinus  was  exposed  and 
found  to  be  normal.  The  mastoid  wound  was  now  tem- 
porarily packed,  and  attention  directed  to  the  internal  jugu- 
lar vein.  This  was  identified  with  some  difficulty  as  the 
lower  two  thirds  were  grey  in  color  and  apparently  col- 
lapsed. The  silk  ligature  was  placed  about  the  vein  a  little 
above  its  juncture  with  the  subclavian.  In  dissecting  the 
internal  jugular  vein  from  the  adjacent  structures  a  chain 
of  enlarged  lymphatic  glands  was  found  along  the  posterior 
surface  forming  a  sort  of  bed  for  the  vein.  These  were 
removed.  The  highest  ligature  was  placed  about  the  vein 
just  above  the  point  of  entry  of  the  facial  branch,  which 
was  also  tied  of¥.  The  jugular  vein  was  then  resected. 
Tlie  wound  in  the  neck  was  then  packed  with  iodoform 
gauze. 

Returning  to  the  mastoid  wound  the  clots  referred  to  as 
occupying  the  opening  in  the  sinus  walls  W'ere  lifted  oflf. 
With  a  spoon  directed  toward  the  heart  a  portion  of  the 
clot  was  removed  from  below,  but  no  bleeding  ensued.  A 
second  time  the  spoon  was  introduced  downward,  and  al- 
most immediately  there  was  a  gush  of  blood  from  below 
with  dislodgmen't  of  a  very  long  clot.  It  measured  more 
than  an  inch,  was  black  in  color  and  had  white  streaks. 
The  wound  was  immediately  packed  with  iodoform  gauze. 
The  segment  of  a  vein  from  the  ligature  above  the  facial 
branch  was  apparently  not  thrombosed  but  contained  fluid 
blood.  Blood  culture  from  the  left  arm  taken  with  patient 
on  the  table. 

Postoperative  condition  was  good.  Pulse  128,  respiration 
32.   Report  of  blood  culture  showed  Streptococcus  mucosus. 

The  next  day  another  bloOd  culture  was  taken  which  was 
negative.  The  temperature  fell  to  99''  F.  arid  remained  so 
all  day.    Pulse  ranging  from  92  to  100,  respiration  24. 

October  20th.  Condition  of  the  patient  gradually  im- 
proved, and  on  October  22nd,  five  days  after  the  opera- 
tion fever  had  actually  disappeared.  Temperature  99°  F. 
The  wound  w'as  dressed  for  the  first  time.  The  mastoid 
wounds  showed  beginning  granulation  everywhere.  They 
were  fresh  and  healthy. 

The  patient  made  an  uneventful  recovery  and  was  dis- 
charged from  the  hospital  in  good  condition. 

In  the  two  cases  here  minutely  related,  and  in  the 
whole  .ijroup  of  the  ten  cases  mentioned,  the  diag- 
nosis of  sinus  thrombosis  was  made  from  the  clin- 
ical symptoms  alone.  The  blood  culture  was  not 
necessary  for  the  corroboration  of  the  diagnosis,  but 
it  was  important  to  become  acquainted  wath  the  re- 
lation which  sinus  thrombosis  bears  to  systemic  in- 
fection. This  relation  once  established  will  assist 
us  in  the  proper  appreciation  of  the  obscurer  cases 
in  which  the  clinical  data  are  insufficient  for  the 
recognition  of  thrombosis  of  the  sinus. 

That  a  positive  blood  culture  can  be  advantage- 
ously used  as  important  evidence  of  the  presence  of 
a  thrombus  has  been  repeatedly  demonstrated  at 
Mt.  Sinai  Hospital.  Patients  who.  after  a  thorough 
mastoid  operation,  did  not  do  well,  and  whose  tem- 
perature remained  high  though  the  accessible  part 
of  the  sinus  appeared  healthy,  improved  immedi- 
ately upon  ligation  of  the  jugular,  which  was 
thought  advisable  as  the  result  of  a  positive  blood 
culture. 

We  may  even  go  further.  In  two  cases  admit- 
ted to  the  medical  wards  with  high  fever,  systemi: 
infection,  and  no  previous  history  as  to  ear  trouble. 
Dr.  Libman  requested  me  to  examine  the  ears  and 
lay  bare  the  sinus  of  the  side  of  the  possibly  afTected 
ear.  He  arrived  at  the  diagnosis  of  sinus  throm- 
bosis by  the  exclusion  of  other  foci  in  the  presence 


of  a  positive  blood  culture.  In  both  these  cases 
the  lateral  sinus  was  found  thrombosed,  though  with 
the  exception  of  old  perforations  of  the  drum,  there 
were  no  external  evidences  of  ear  disease.  The 
two  patients  recovered  after  evacuation  of  thrombi 
from  the  lateral  sinus,  one  with  and  one  without 
ligation  of  the  jugular. 

36  East  Fiftv-sevexth  Street. 


MALARIAL  FEVER  AS  SEEN  AT  CLOSE  RANGE 
IN  THE  DEEP  JUNGLE  OF  THE  MALAY 
PENINSULA  AND  IN  THE  '  COUN- 
TRY OF  THE  GHOSTS." 
By  Charles  S.  Braddock,  Jr.,  Ph.  G.,  M.  D., 
Haddonfield,  N.  J., 

Former  Chief  Medical   Inspector    Royal   Siamese  Government. 

Bangtuphan  province  in  Siamese  Malaya  is  called 
by  the  common  people  the  "country  of  the  ghosts," 
because  the  death  rate  from  pernicious  malarial 
fever  has  been  so  large  in  centuries  past  that  the 
country  lias  been  absolutely  depopulated  and  the 
people  believe  in  spirits  that  are  wicked  and  cause 
all  human  suffering.  Hence  the  derivation  of  the 
name. 

Now  all  scientific  men  are  agreed  that  the  mos- 
quito carries  the  germ  of  malaria  and  transmits  it 
to  individuals,  and  as  time  goes  by  it  would  seem 
that  probably  all  mosquitoes  carry  it.  But  to  many 
men.  myself  among  the  number,  who  have  had  op- 
portunity to  study  malaria  in  the  most  malarial  parts 
of  the  world  it  seems  reasonable  to  believe  that  there 
are  other  means  and  ways  of  propagation  of  the 
disease,  and  that  the  mosquito  is  only  one  of  the 
carriers  and  not  the  only  one,  that  the  disease  orig- 
inates in  water  and  soil  and  is  carried  by  wind  and 
water  and  is  taken  into  the  system  by  drinking  un- 
boiled water. 

It  is  always  in  order  to  give  a  reason  for  the 
faith  that  is  in  us,  and  so  the  observations  made 
in  Cuba  during  the  Spanish  American  War,  when 
serving  as  a  lieutenant  in  the  United  States  navy, 
and  in  many  long  journeys  covering  thousands  of 
m'1'^s  through  the  "country  of  the  ghosts"  from 
Burma  to  Indo  China  and  f  roin  the  Federated  Malay 
States  to  the  Indo  Chinese  frontier  covering  the 
main  portions  of  Siam  and  the  Malay  peninsula,  are 
here  set  forth:  That  those  who  read  may  judge  for 
themselves. 

First:  On  a  jungle  trip  the  men  on  foot  are  first 
taken  ill  with  malarial  fever,  then  the  men  on  horse- 
back, and  last  of  all  and  very  seldom  the  men  who 
travel  on  elephants.  I  attribute  this  exemption  of 
the  men  traveling  on  elephantback  to  the  height  they- 
are  from  the  ground.  The  higher  you  keep  from  the 
groimd  whether  travelijig  or  sleeping  the  more  ex- 
empt you  are  from  fever.  I  am  leaving  out  in  my 
consideration  the  taking  of  prophylactic  doses  of 
quinine  and  am  only  considering  the  means  of  pre- 
vention not  medical. 

The  use  of  mosquito  curtains  is  absolutely  neces- 
sar}^  in  trophical  regions  for  comfort  so  they  are 
always  used  alike  by  rich  and  poor,  and  the  use  of 
theni  does  not  enter  into  discussion  here,  because 
they  are  always  used. 

As  you  travel  to  the  north  from  Bangkok  and 


II44 


BRADDOCK:   TROPICAL  MALARIA. 


[New  York 
Medical  Journal. 


leaving  civilization  behind  you  find  as  you  progress 
that  while  all  the  houses  are  built  above  the  ground 
they  are  built  higher  and  higher  in  direct  propor- 
tion as  perniciou?  malarial  fever  prevails  in  that  sec- 
tion of  the  country.  In  other  words,  the  natives 
have  found  by  long  experience  that  their  only  sal- 
vation in  certain  sections  of  the  country  is  to  live  and 
sleep  as  high  from  the  ground  as  possible,  and  it  is 
very  easy  to  judge  as  you  travel  through  the  jungle 
of  the  severity  of  the  disease  by  the  height  of  the 
houses  from  the  ground. 

The  same  varieties  of  mosquitoes  exists  in  the 
locality  where  the  ordinary  malarial  fever  prevails 
as  well  as  where  pernicious  malarial  fever  exists, 
and  as  you  travel  without  being  told  by  your  native 
guides  you  can  smell  the  miasma  as  it  arises  from 
the  ground,  and  if  prophylactic  doses  of  quinine  are 
not  given  at  once  to  everybody  whether  previously 
infected  with  malaria  or  not  all  hands  will  have 
fever. 

These  localities  are  well  known  to  the  natives  and 
dreaded  and  shunned  by  them  so  much  that  they 
avoid  traveling  through  them  if  possible.  In  cer- 
tain sections  of  Siam  business  and  trade  has  been 
absolutely  stopped  by  the  great  death  rate  suffered 
by  the  travelers.  The  only  case  of  blackwater  fever 
I  ever  saw  was  the  case  of  a  Jesuit  missionary  who 
crossed  one  of  these  mountain  chains  which  was 
notorious  for  its  unhealthfulness. 

In  the  north  this  is  true  in  sections  where  the 
thermometer  drops  to  34°  F.,  and  where  at  that  time 
of  the  year  there  are  no  mosquitoes,  and  yet  perni- 
cious malarial  fever  is  so  bad  that  the  Siamese 
troops  in  the  Laos  country  in  the  last  Shan  uprising 
died  by  hundreds  in  spite  of  the  best  European 
treatment.  The  bad  section  of  the  country  can  be 
mapped  out  and  is  known  to  the  natives  thoroughly 
who  shun  it  accordingly.  These  natives  know  by 
long  experience  that  if  they  drink  the  unboiled  water 
of  the  mountain  streams  they  will  have  fever,  so  that 
tea  is  almost  the  universal  beverage  of  the  common 
people  for  drinking  purposes  when  traveling,  and 
if  they  cannot  make  tea  they  will  dig  a  well  on  a 
sand  bar  and  patiently  wait  for  the  water  to  filter 
thrruHi  fo-  they  know  that  there  is  not  so  much 
danger  of  fever.  This  is  true  of  the  beautiful  moun- 
tain streams  in  the  foot  hills  of  the  Himalayas  as 
well  as  the  mountains  of  the  Malay  peninsula.  The 
mosquito  theory  by  itself  does  not  allow  for  this 
result. 

Now.  whenever  you  disturb  the  earth  in  the 
tropics  you  disturb  this  great  giant.  This  is  seen 
in  the  ruby  mines,  in  the  tin  mines,  and  in  the  dig- 
ging of  embankments  and  canals,  but  if  you  cut  off 
the  jungle  and  let  the  sun  in  you  can  do  more  good 
than  all  the  mos(|uito  curtains  in  the  world. 

This  was  shown  at  Port  Swettenham  in  the  Malay 
peninsula,  which  place  was  a  death  trap  in  spite  of 
mosquito  curtains,  but  when  the  jungle  was  cut  off 
and  the  sun  let  in  the  trouble  vanished,  and  to-day 
a  peaceful  village  exists  there,  where  before  was  a 
death  trap  to  stay  overnight,  although  at  present  as 
before  mosquitoes  are  a  very  pest,  and  every  one 
sleeps  under  a  mosquito  curtain.  But  mark  the  dif- 
ference, if  you  sleep  a  quarter  of  a  mile  away  in  the 
still  uncut  jungle  you  will  die,  mos(|uito  curtain  or 
no  mosquito  curtain. 


Now  these  are  the  things  to  do  to  keep  your  health 
in  the  jungle,  and  this  applies  to  all,  whether  to  the 
men  who  before  have  lived  in  a  malarious  country 
and  are  already  infected,  or  to  those  who  have  just 
arrived  in  the  country  and  have  never  been  in  any 
section  where  malaria  prevails.  I  have  seen  this  in 
men  fresh  from  the  United  States  and  Europe,  who 
never  have  lived  in  a  malarious  country  and  who 
never  had  a  sick  day  in  their  lives.  You  must  obey 
the  following:  Sleep  in  the  open  away  from  the 
deep  jungle.  Do  not  sleep  on  the  ground  or  near 
the  ground,  but  as  high  from  it  as  possible.  If  wet 
from  tropical  rain  or  fording  streams  change  cloth- 
ing as  soon  as  possible.  Always  drink  boiled  water. 
Use  a  mosquito  curtain.  Give  prophylactic  doses  of 
quinine  when  traveling  through  the  bad  districts. 
And  you  can  travel  through  the  "country  of  the 
ghosts"  v/ith  impunity.  I  have  seen  this  advice  dis- 
regarded many  times  by  sturdy  men  who  made  the 
boast  that  they  never  had  been  sick  in  their  lives, 
but  always  the  penalty  was  sure  to  come,  while  those 
who  regarded  the  advice  traveled  in  safety,  although 
both  always  used  mosquito  curtains. 

My  experience  in  Cuba,  during  the  war  with 
Spain,  was  the  same.  Dr.  Agramonte,  of  the  Cuban 
army,  had  told  me  that  there  were  certain  districts 
where  malarial  poison  was  so  intense  that  everyone 
passing  through  would  have  fever  unless  prophylac- 
tic doses  of  quinine  were  given.  This  I  verified  in 
many  thousands  of  miles  of  travel  in  Siam  and  the 
Malay  peninsula  in  charge  of  large  expeditions  of 
men. 

During  my  night  watches  as  lieutenant  and  senior 
watch  officer  of  the  United  States  Steamer  Resolute 
in  Guantanamo  harbor.  I  had  plenty  of  mosquito 
bites  as  we  lay  near  the  shore  and  the  Marine  Bat- 
talion of  600  men  at  Camp  McCalla  only  half  a  mile 
away  had  their  share  of  mosquito  bites  also,  but 
only  two  per  cent,  of  the  men  were  sick  from  all 
causes,  that  is  twelve  men  out  of  600  in  the  bat- 
talion. Now,  at  Santiago  and  Siboney  only  a  few 
miles  away  there  \yere  some  regiments  with  almost 
ICQ  per  cent,  sick  with  fever.  Why  this  dift'erence? 
Mosquitoes  of  the  same  varieties  in  both  places.  To 
my  mind  the  following  reasons  made  the  difference ; 
and  I  have  verified  it  on  the  other  side  of  the  world 
in  the  deep  jungle  of  the  Malay  peninsula  and  on 
the  Indo-Chinese  frontier  as  well  as  in  the  north 
of  Siam : 

The  men  of  the  jNIarine  Battalion  drank  only  dis- 
tilled water,  they  slept  on  board  floors  and  on  cots 
raised  from  the  groimd,  they  were  well  protected 
from  the  tropical  rains,  and  the  jungle  was  cleared 
away  for  hundreds  of  yards  in  all  directions  so  as 
to  afford  no  protection  to  the  enemy  and  to  give  free 
opportunity  for  rifle  fire.  The  men  at  Santiago  and 
.Siboney  slept  on  the  ground,  drank  unboiled  water 
from  trenches  and  ditches,  slept  directly  in  the 
jungle,  had  no  protection  from  the  tropical  rains, 
and  suft'ered  accordingly.  As  far  as  mosquitoes 
were  concerned  both  parties  of  men  were  on  a  par. 

If  you  clear  away  the  jungle  and  let  the  sun  in 
over  one  dry  season  you  can  dwell  with  impunity 
where  before  was  a  death  trap.  This  is  so  well 
known  to  those  who  have  lived  in  the  deep  jungle 
that  it  is  strange  so  little  stress  has  been  laid  upon 
it.    I  personally  knew  a  man  who  cleared  away  the 


June  5,  1909. J 


rOORHEES:  BROMOFORM  ERUPTION. 


jungle  and  obeyed  the  laws  I  have  stated,  and  lived 
for  nearly  a  year  in  perfect  health  on  the  very 
spot  where  two  hundred  Chinese  tin  miners  had 
died  in  a  short  time  of  pernicious  malarial  fever. 
I  have  seen  this  repeated  so  often  that  it  became  an 
old  story. 

When  a  member  of  the  royal  family  of  Siam  starts 
on  an  official  tour  through  the  jungle  for  an_\-  pur- 
pose men  are  sent  on  ahead  many  months  before  to 
clear  away  the  jungle  around  the  sleeping  bun- 
galows to  let  the  sun  in.  Whenever  a  new  town  is 
to  be  built  by  the  Siamese  government  for  any 
reason,  the  jungle  is  cleared  away  and  the  sun  is 
let  in  for  one  whole  dry  season  before  any  houses 
are  started.  I  asked  Phya  Outerakit,  governor  of 
Champawn  province,  who  was  educated  by  the 
Presbvterian  missionaries,  why  this  was  done  by 
him  when  the  site  of  the  town  of  Champawn  was 
changed  by  the  government.  I  asked  him  why  he 
did  not  go  ahead  and  build  the  houses  at  once.  He 
told  me  that  "long  experience  had  shown  that  if 
they  did  not  wait  over  one  dry  season  many  people 
would  die  of  fever."  This  man  eliminated  the  bound- 
arv  between  Siam  and  Burma  and  was  three  years 
in  doing  so,  starting  with  500  men,  officials  and 
coolies,  and  at  the  end  of  three  years  he  and  ten 
other  men  were  the  only  sitrvivors,  all  the  rest 
dying  of  malarial  fever. 

The  motto  is:  "Let  the  sun  in  and  the  fever  will 
go  out." 

This  is  also  shown  in  the  rice  fields.  The  men 
tilling  the  fields  will  have  fever,  but  it  will  be  of 
a  mild  type,  while  the  Chinese  tin  miners  only  a  few 
hundred  yards  away  in  the  uncleared  jungle  will 
have  pernicious  malarial  fever  and  die  by  hundreds, 
although  both  sleep  under  mosquito  curtains,  for 
it  is  absolutely  compulsory  for  all  to  do  so  in  that 
country,  especially  in  the  wet  season. 

While  the  mosquito  transmits  malarial  fever  I  be- 
lieve he  acquires  it  first  from  the  water  and  the  soil, 
no  other  explanation  can  be  given  in  those  acquir- 
ing' it  from  mosquitoes  who  have  landed  on  an 
utterly  uninhabited  coast  where  there  were  no 
human  beings  to  primarily  infect  the  mosquitoes 
there,  but  who  have  been  promptly  taken  down  with 
malarial  fever  when  they  have  disobeyed  the  laws 
of  the  jungle,  while  those  who  have  obeyed  these 
laws  have  escaped  entirely.  I  have  seen  this  in  my 
own  experience  time  and  again. 

In  the  island  of  Koh  Samui  in  the  gulf  of  Siam, 
which  is  ten  miles  long  and  three  miles  wide, 
runs  north  and  south,  during  the  northeast  mon- 
soon, fever  prevails  on  the  west  side  of  the  island. 
During  the  southeast  monsoon  fever  prevails  on  the 
east  side  of  the  island.  This  cannot  be  laid  to 
mosquitoes  being  blown  over,  for  there  are  just  as 
many  mosquitoes  on  one  side  as  the  other,  and  I 
have  stood  in  the  deep  jungle  almost  eaten  up  by 
them  on  the  windward  side  of  the  island,  the  jungle 
was  so  dense  that  not  a  breath  of  air  could  be  felt 
owing  to  the  density  of  vegetation  although  you 
could  hear  the  monsoon  roaring  through  the  tops 
of  the  trees,  so,  although  there  is  no  difference  in 
the  amount  of  mosquitoes  fever  prevails  in  the 
■direction  of  the  wind. 

Over  the  great  plain  of  Siam  comprising  the 


valley  of  the  Menam  there  are  two  different  seasons 
of  fever,  that  ebb  and  flow  as  regularly  as  do  the 
tides  of  the  sea :  First  at  the  commencement  of 
the  rains  when  the  rice  fields  are  being  planted  with 
rice,  everyone  has  fever  and  thousands  are  affected. 
Now,  as  time  goes  on  and  the  rice  is  planted  the 
fever  diminishes  but  there  is  no  diminution  of  the 
mosquito.  Again,  at  the  close  of  the  rainy  season- 
when  the  great  detritus  of  the  tropical  jungle  is 
deposited  on  the  plain  and  the  waters  subside  there 
is  another  great  wave  of  fever  that  sweeps  over 
the  land.  This  is  precisely  similar  to  what  occurred 
in  New  Jersey  in  1850,  when  cranberry  culture  was 
first  inaugurated.  The  head  waters  of  all  the  streams 
fiowing  into  the  Delaware  River  were  disturbed  by 
great  areas  of  land  being  drained  and  ditched  and 
the  mud  of  centuries  was  disturbed  and  distributed 
down  stream.  A  great  wave  of  malarial  fever  of 
great  virulence  spread  down  the  valleys  of  the  tribu- 
taries of  the  Delaware  river  and  was  confined  to 
the  streams  that  were  disturbed.  This  epidemic  of 
malarial  fever  has  never  been  repeated,  but  all 
malarial  outbreaks  have  been  lessened  year  by  year 
as  the  country  has  been  opened  up  and  cultivated. 
This  is  also  true  of  the  prairies  of  Illinois,  Iowa, 
and  Kansas,  although  there  has  never  been  any  dim- 
inution of  the  mosquito  in  those  States. 

In  the  great  dismal  swamp  of  Virginia  and  North 
Carolina  malarial  fever  is  very  bad.  and  those  who 
drank  the  surface  water  suffered  accordingly.  Deep 
wells  were  sunk  and  the  people  who  drank  the 
water  from  these  wells  suffered  far  less  from  mala- 
rial fever. 

Finally  I  believe  that  while  the  mosquito  carries 
malarial  fever  that  it  is  not  the  only  way  of  in- 
fection, and  that  if  you  disobey  the  laws  of  which 
I  have  spoken  you  will  suffer,  if  there  is  not  a 
mosquito  in  the  neighborhood.  I  am  upheld  in  mv 
contention  by  Dr.  Trumpp,  a  graduate  of  a  German 
university  and  chief  surgeon  of  the  royal  Siamese 
army,  also  by  Dr.  Kirkpatrick,  who  for  twenty 
years  was  a  medical  missionary  in  the  northern 
Shan  states  of  Burma,  and  who  has  traveled  many 
thousands  of  miles  through  the  jungle. 

A  CASE  OF  BROMOFORM  ERUPTION. 

Bv  Irving  Wilson  Voorhees.  M.  D.. 
New  York. 

Dr.  Frank  Crozer  Knowles's  well  considered  re- 
port  of  C^nusual  Cases  of  Bromide  Eruption  in 
Childhood  leads  me  to  give  the  facts  in  a  case  which 
has  just  passed  from  observation : 

Jennie  B.,  aged  seven  years,  was  seen  at  niy  office  March 
8,  190Q.  Her  mother  said  that  for  some  fifteen  days  the 
child  had  been  troubled  with  a  very  bad  cough  which  dis- 
turbed he.--  both  day  and  night.  Several  home  remedies 
and  proprietary  cough  cures  had  been  tried  but  were  of  no 
avail. 

Examination  :  Child  seemed  well  nourished  and  in  good 
general  condition,  but  exhibited  a  dry,  hacking  cough  with- 
out expectoration.  Auscultation  of  chest  showed  signs  of 
simple  bronchitis.  Heart  normal  in  all  respects.  Anterior 
rhinoscopy  revealed  a  normal  picture.  Posterior  rhinoscopy 
showed  a  slight  amount  of  adenoid  tissue,  but  not  enougii 
to  warrant  removal.  The  tonsils  were  operated  on  some 
two  years  ago  by  another  physician,  who  did  his  work 


GOEPP:   TYPHOID  FEVER  AND  UREMIA. 


[New  York 
Medical  jouRN.-iL. 


well,  as  no  fragments  remained  between  the  pillars  on  either 
side. 

Diagnosis  and  Treatment :  Inasmuch  as  a  playmate  was 
having  an  attack  of  whooping  cough  at  the  time  this  child 
was  seen  by  me,  a  tentative  diagnosis  of  that  disease  w^as 
made.  Compound  tincture  of  benzoin  was  given  as  an  in- 
halant, and  a  prescription  was  written  for  bromoform,  one 
drop  to  be  given  on  a  small  piece  of  saccharin  three  times 
a  day.  Four  days  later  I  was  called  to  see  the  child,  who 
was  said  to  be  very  ill.  1  found  her  with  a  temperature 
of  104°  F.  and  pulse  of  120.  Respirations  were  not  in- 
creased to  any  extent.  There  was  no  pain  anywhere  in  the 
body,  but  the  child  slept  much  of  the  time.  A  slight  rash 
was  appearing  on  the  cheeks  and  brow,  and  over  the  mas- 
toids. Upon  inquiry  I  found  that  the  mother  had  misread 
the  directions  and  was  giving  one  drop  of  bromoform  on 
saccharin  every  two  hours.  All  previous  medication  was 
stopped  at  once,  calomel  gr.  iss  was  given,  to  be  followed  by 
magnesium  citrate  next  morning.  Twenty-four  hours  later 
the  rash  had  spread  over  the  entire  body  and  consisted  of 
large  discrete  papules.  The  child  complained  of  some  itch- 
ing. At  this  visit  I  ordered  Fowler's  solution,  one  drop  to 
be  given  in  water  three  times  a  day.  Two  days  later  the 
paprles  had  become  confluent  in  many  places  and  the  rash 
was  beginning  to  fade  out.  The  temperature  became  nor- 
mal two  days  later,  and  the  child  made  an  uneventful 
recovery.  The  cough,  however,  persisted  and  a  whoop  had 
developed  when  the  child  was  last  heard  from. 

3544  Bro.adway.  , 


A  CASE  OF  TYPHOID  FEVER  USHERED  IN  BY 
AN  ATTACK  OF  UR.EMIA. 

By  R.  Max  Goepp,  M.  D., 
Philadelphia. 

Professor   of   Clinical   Medicine,   Philadelphia    Polyclinic;  Assistant 
Visiting  Physician,  Philadelphia  General  Hospital. 

It  is,  I  believe,  not  uncommon  for  uraemia  to  be 
mistaken  at  first  for  typhoid  fever,  and  in  the  ab- 
sence of  well  marked  -clinical  signs  and  a  positive 
reaction  in  the  blood  serum  the  diagnosis  may  re- 
main in  doubt  for  some  days.  In  the  present  in- 
stance the  diagnosis  of  uraemia  was  quite  clear  at 
the  first  visit  and  the  existence  of  typhoid  fever  was 
not  suspected  tintil  the  occttrrence  of  intestinal 
haemorrhages  for  which,  however,  there  was  a  p  ■  - 
sible  cause  and  the  appearance  of  rose  spots  and  a 
positive  Widal  reaction. 

The  history  of  the  case  is  as  follows  : 

Case. — A.  M.  W..  unmarried,  sixty-five  years  of  ag?. 
Family  History:  Father  died  of  heart  disease;  mother  of 
chronic  bronchitis:  no  history  of  tuberculosis. 

Previous  History:  Usual  diseases  of  childhood,  otherwise 
perfectly  well.  Menstruation  had  always  been  normal.  S'le 
had  used  coffee  moderately  and  tea  to  excess ;  no  alcohol. 
The  brother  stated  that  the  patient  had  had  several  attacl:s 
during  the  past  few  years  characterized  by  mental  con- 
fusion, constipation  of  the  bowels  followed  by  diarrha  a, 
and  almost  total  suppression  of  the  urine.  These  attacks 
lasted  from  a  few  days  to  two  weeks.  No  physician  was 
ever  called  in  attendance. 

Present  Trouble:  Chief  complaint  was  dryness  of  t'le 
mouth  and  throat,  general  malaise  and  thirst  for  the  prst 
four  or  five  days.  The  patient  was  very  much  confused, 
although  subsequent  observation  showed  that  she  was  child- 
ish and  silly  in  her  normal  condition.  There  had  been  no 
epista.xis.  the  bowels  had  been  constipated,  and  the  quantity 
of  urine  was  very  much  diminished.  The  skin  was  ex- 
cessively dry  and  scaly;  tongue  dry,  brown,  and  cracked; 
no  urinous  odor  detected  upon  tbe  breath.  A  specimen  of 
the  urine  obtained  at  this  time  was  found  to  contain  a  de- 
cided trace  of  albumin  and  large  numbers  of  granular  and 
hyaline  casts.    Temperature  100.4°  F- :  pulse  104. 

On  the  following  day,  December  11,  1907,  the  patient  was 
sent  to  the  hospital  with  a  diagnosis  of  nr,-emia. 

,As  soon  as  the  patient  was  admitted  she  was  placed  on 


absolute  milk  diet  and,  after  a  preliminary  course  of  calo- 
mel, treated  with  wet  packs  at  85°  F.  for  one  half  hour 
twice  a  day  and  a  refrigerant  diuretic.  Examination  of 
the  urine  at  this  time  showed  the  following ;  Total  quantity 
in  twenty-four  hours  sixteen  ounces  ;  amber,  acid,  specific 
gravity  1.014,  numerous  pale  and  dark  granular,  and  a  few 
epithelial  and  hyaline  casts ;  epithelial  cells,  leucocytes  an  i 
amorphous  urates ;  a  decided  trace  ol  albumin,  no  sugar. 

December  12th.  The  patient  was  in  a  mild  talkative  de- 
lirium ;  she  did  not  respond  to  we:  pack  yesterday.  The 
enema  was  returned  highly  colored  but  without  faecal  mat- 
ter. An  electric  light  bath  twice  a  day  was  substituted 
for  the  wet  pack  and  irrigation  of  the  bowels  with  normal 
salt  solution  ordered  once  a  day.  Two  small  brown  stools 
during  the  day.    Temperature  101.4°  F. 

December  13th.  Delirium  continued;  no  reaction  to  hot 
bath  yesterday.  The  treatment  was  repeated  but  was  not  fol- 
low'ed  by  sweating.  The  pulse  was  full  and  of  high  tension ; 
the  skin  very  dry  and  hot,  tongue  and  mouth  very  dry. 
Venesection  was  performed  on  the  right  arm  and  twenty- 
four  ounces  of  blood  removed.  This  was  immediately  fol- 
lowed by  an  intravenous  injection  of  650  c.c.  of  salt  solu- 
tion. The  fulness  and  tension  of  the  pulse  were  reduced  by 
the  venesection,  and  the  temperature,  which  was  103°  F.  in 
the  axilla  was  reduced  to  99.2°  F.  immediately  after  the 
venesection.  Enteroclysis  was  repeated,  and  magnesium 
sulphate  in  large  doses  (one  ounce,  four  times  a  day)  added 
to  the  treatment.  This  resulted  in  five  liquid  brown  stools 
during  the  day.  Total  quantity  of  urine  sixteen  ounces. 
Temperature  103°  F. 

December  15th.  Delirium  continued  and  there  was  some 
nausea.    The  patient  slept  better  last  night. 

December  i6th.  Hot  tub  bath  followed  by  hot  sweat, 
bath  and  i/io  grain  of  pilocarpin  hydrochlorate.  This  was 
followed  by  free  perspiration.  Diuretin  five  grains,  three 
times  a  day  added  to  the  treatment ;  seven  stools ;  total 
quantity  of  urine  sixteen  ounces.  The  diet  was  somewhat 
enlarged. 

December  17th.  The  patient  passed  two  stools  containing 
blood,  one  of  them  a  large  clot.  The  leucocyte  count  to- 
day was  7,800.    Tbe  Widal  reaction  was  returned  positive. 

December  i8th.  Urine  amber,  acid,  specific  gravity  1.020; 
small  amount  of  albumin ;  no  sugar ;  pale  and  dark  granu- 
lar casts ;  epithelial  cells  and  leucocytes. 

December  20th.  In  left  flank  there  were  six  pale  rose 
spots  which  disappeared  on  pressure.  The  spleen  was  not 
palpable.  The  pulse  was  of  moderately  good  tension.  The 
heart  sounds  were  of  good  force  and  slightly  irregular.  A 
loud  blowing  systolic  murmur  was  heard  in  the  mitral  area 
and  was  transmitted  to  the  axilla.  This  sound  was  also 
heard  at  the  pulmonary,  and  faintly  at  the  aortic  area.  The 
right  border  of  the  cardiac  dulness  was  found  one  and  a 
half  fingers'  breadths  to  the  right  of  the  right  sternal  bor- 
der; upper  border  at  the  third  rib;  the  ape.x  beat  was  in  the 
sixth  interspace  and  in  the  midclavicular  line.  The  abdo- 
men was  soft  and  somewhat  globular,  no  tenderness  or 
tympany.  Tlie  breath  sound's  posteriorly  were  feeble ;  no 
areas  of  dulness  were  found.  Second  Widal  test  reported 
positive.  There  were  no  more  bloody  stools.  Total  quan- 
tity of  urine  eight  ounces. 

December  22nd.  Temperature  remained  slightly  elevated. 
Mental  condition  somewhat  improved,  although  the  patient 
was  noisy  and  delirious  at  times.  The  bowels  moved  once 
or  twice  daily  and  there  were  occasional  involuntary  evacu- 
ations of  urine  and  fasces.  The  total  quantity  of  urine 
cannot  he  given  accurately. 

The  albuminuria  and  granular  casts  persisted  until  Janu- 
ary 14th,  thirty-seven  days  after  admission,  when  the  casts 
disappeared,  a  trace  of  albumin  persisting  almost  a  month 
longer,  when  convalescence  was  established.  On  the  same 
day  a  third  Widal  test  was  reported  indefinite.  Six  days 
later  the  fourth  Widal  test  was  reported  -positive.  The 
sy.stolic  murmur  had  disappeared.  Bacteriological  exam- 
ination of  the  urine  showed  the  presence  of  Staphylococcus 
aureus,  but  no  typhoid  bacilli. 

The  temperature  curve  was  quite  irregular,  the  highest 
was  103°  F.,  registered  on  the  fifth  day  of  the  disease.  On 
admission  and  the  next  day,  December  iith,  normal; 
December  12th.  101.4°  F. ;  December  13th,  103'  F. ;  Decem- 
ber 14th,  101.6°  F. ;  December  i8th,  normal:  during  the  fol- 
lowing week  it  did  not  rise  above  100.6°  F. ;  on  the  26th  it 
again  rose  to  toi.6°  F..  and  continued  to  rise  until  it 
reached  102.8°  F.  on  the  28th.  when  it  again  declined,  going 


June  5,  1909. J 


SOCLES:   CHIMAPHILA  IN  DIABETES. 


1147 


below  normal  on  the  30th,  31st,  and  January  ist.  There 
was  then  another  week  during  which  the  temperature  fluc- 
tuated between  98°  and  99°  F.  These  are  all  rectal  tem- 
peratures; on  January  gth  the  temperature  again  shot  up 
to  102.8"  F.  in  the  axilla,  dropping  to  99'  F.  on  the  same 
day  and  again  rising  to  almost  the  same  level.  This  up  and 
down  curve  continued  until  the  i8th  of  January.  From 
January  19th  on  until  her  discharge,  nearly  a  month  later, 
tlie  temperature  was  irregular,  fluctuating  between  100.4° 
and  97°  F. ;  the  last  week  being  subnormal  most  of  the 
time. 

The  patient  was  discharged  on  February  15th,  the  dura- 
tion of  her  illness  having  been  about  ten  and  a  half  weeks. 
During  the  next  two  weeks  convalescence  progressed  satis- 
factorily except  for  swelling  and  oedema  of  both  legs,  which 
subsided  on  the  administration  of  digitalis.  The  urine  was 
of  low  specific  gravity  and  contained  no  albumin  or  casts. 
The  heart  showed  nothing  abnormal.  When  last  seen  the 
patient  was  well  and  the  swelling  of  the  legs  had  almost 
disappeared.  The  urine  at  that  time  contained  no  albumin 
and  no  casts.    The  specific  gravity  was  1.012. 

Tlie  intestinal  haemorrhage  which  occtirred  on 
the  eleventh  or  twelfth  day  of  the  disease  followed 
a  period  of  acute  purgation  with  magnesium  sul- 
phate, and  the  increased  peristalsis  was  probably 
the  immediate  cause  of  the  bleeding.  An  exam- 
ination of  the  rectum  was  made  by  Dr.  Adler  but 
revealed  nothing  in  the  rectum  to  explain  the  haem- 
orrhage. The  blood  was  mixed  with  the  stools  ex- 
cept for  one  large  clot  and  was  therefore  derived 
from  the  small  intestine. 

A  point  of  interest  in  the  case  is  the  fact  that  no 
harmful  effects  appear  to  have  followed  the  vene- 
section and  vigorous  purgative  and  diaphoretic 
treatment  which  was  employed  during  the  first  week 
of  the  disease  and  which  would  not  have  been  re- 
sorted to  if  the  existence  of  typhoid  fever  had  been 
.suspected  at  that  time. 

332  South  Fifteenth  Street. 


CHIMAPHILA  IN  DIABETES. 

By  S.  G.  Soules,  M.  D.. 
Stanbridge  East,  P.  Q.,  Canada. 

On  the  T6th  of  November,  1907.  I  published'  some 
particulars  of  my  discovery  of  the  antidiabetic  qual- 
ities of  chimaphila.  I.  having  heard  very  favorably 
of  its  action  in  diabetes  since  that  time,  feel  justified 
in  giving  lo  the  medical  profession  some  facts  in 
relation  to  the  action  which  I  deem  worthy  of 
record. 

The  dose  which  I  recommended  in  the  paper  re- 
ferred to,  which  was  published  in  this  journal,  is  too 
small  to  produce  the  best  results.  Twice  as  much  is 
infinitely  more  satisfactory,  and  an  abstract,  made 
by  evaporating  the  fluid  extract  to  the  consistency 
of  thick  syrup,  is  the  best  form  in  which  to  give  it 
that  I  have  found  thus  far.  A  drachin  of  this  ab- 
stract represents  approximately  four  drachms  of  the 
fluid  extract.  Of  this  the  dose  for  an  adult  is  one 
or  two  teaspoonfuls  twice  or  three  times  daily,  ac- 
cording to  the  need  of  the  patient.  Of  this  large 
dose  no  one  need  be  afraid.  I  have  frequently  taken 
one  half  ounce  at  a  single  dose,  and  twice  one  ounce 
in  twelve  hours,  without  any  inconvenience  what- 
ever. 

The  disease  is  very  prone  to  relapse.  My  case 
relapsed  eleven  times,  but  the  sugar  disappeared  on 

'See  Nc7f  York  Medical  Journal  Ixxxvi,  p.  929. 


resuming  the  fall  treatment.  The  last  time  I  in- 
creased the  dose,  and  with  the  happiest  results, 
and  am  now  on  a  full  mixed  diet,  and  there  is  no 
sign  of  sugar  or  of  any  symptom  of  diabetes  what- 
ever. I  neglected  to  state  that  three  of  these  relapses 
occurred  after  1  wrote  the  article  to  which  I  have 
referred,  a  fact  which,  though  disappointing,  in  one 
sense,  was  pleasing  in  another  way,  as  it  gave  me 
an  opportunity  to  try  some  experiments  long  pon- 
dered over  and  the  scientific  aspect  of  the  case  was 
decidedly  paramount  at  that  time. 

I  have  taken  the  remedy  a  little  over  two  years 
altogether,  and  in  that  time  I  have  seen  little  diminu- 
tion in  its  good  effects.  Were  I  to  commence  the 
treatment  of  a  patient  to-day  I  should  not  look  for 
a  cure  in  less  -than  six  months  or  a  year,  and  per- 
haps longer.  1  want  to  impress  the  fact  upon  the 
minds  of  all  those  that  try  this  treatment  that  it 
seems  to  be  very  necessary  to  diet,  and  also  to  re- 
sume a  mixed  diet  gradually,  as  also  to  discontinue 
the  medicine  in  the  same  way. 

I  have  long  ago  discarded  arsenic  as  useless,  or 
nearly  so,  when  large  doses  of  chimaphila  are  taken. 

A  word  about  diet.  Above  all  do  not  give,  so 
called,  gluten  bread,  unless  you  know  exactly  how 
much  starch  it  contains.  1  have  known  "gluten" 
to  contain  seventy  per  cent,  of  starch.  Almond 
meal  is  reliable,  washed  or  not,  as  the  case  demands- 
Make  a  thick  batter  and  bake  in  a  gem  dish. 

I  want  to  say  that  I  do  not  expect  this,  or  any 
other,  treatment  to  cure  all  patients  with  diabetes. 
If  there  are  organic  chan2:es  that  are  in  themselves 
fatal,  chimaphila  will  do  little  good  certainly.  There 
may  be  a  difference  m  pathology  or  jetiology  which 
will  nullify  the  good  effects  of  the  treatment  which 
is  under  consideration.  The  virine  should  be  anal- 
ysed frequently,  not  only  for  the  presence  of  sugar, 
but  for  percentage  of  sugar,  that  the  progress  of 
the  case  may  be  fully  known  at  any  time.  If  Ein- 
horn's  saccharometer  is  used,  the  yeast  can  be  used 
for  months  without  renewal,  by  careftil  decanting. 
The  advantage  of  this  is  that  the  yeast  will  surely 
contain  no  sugar  after  the  first  analysis.  The  sac- 
charometer should  be  placed  in  a  moderately  cool 
room  between  examinations,  and  the  yeast  would 
better  be  moistened  with  distilled  water,  for  rea- 
sons that  are  obvious. 

Before  I  finish  my  paper  I  wish  to  say  a  few 
words  about  diabetic  cramps.  They  occur  usually 
in  the  calf  of  the  leg,  and  before  arising  from  bed 
in  the  early  hours  of  the  morning.  In  this  case  the 
plantar  surface  of  the  foot  of  the  affected  side 
should  be  placed  on  the  footboard  of  the  bed,  and 
the  patient  should  press  his  foot  hard  against  it, 
when  the  cramp  will  disappear  at  once.  \^''herever 
the  cranij;  is,  put  the  affected  muscle  in  action. 

I  would,  as  a  special  favor,  ask  all  physicians  that 
have  tried  chimaphila  and  succeeded,  if  onlv  par- 
tially, to  write  to  me  stating  whatever  facts  may  be 
of  interest  to  the  medical  profession,  that  I  may 
tabulate  them  for  publication.  Perhaps  I  may  be 
permitted  to  say  in  closing  that  if  my  long  labors 
shall  ameliorate,  in  any  degree,  the  condition  of 
mankind,  or  add  one  grain  to  the  power  of  the 
medical  profession  in  its  beautiful  and  fierce  strug- 
gle against  disease,  I  shall  feel  well  repairl  for  my 
feeble  efforts. 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Jookv.iL. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXVI. — How  do  you  make  an  early  diagnosis  of  pul- 
vionary  tuberculous  disease?   (Closed  May  15,  1909.) 

LXXXVII. — How  do  you  treat  supraorbital  neuralgia? 
(Answers  due  not  later  than  June  15,  1909.) 

LXXXVIH.—Hoiv  do  you  treat  epistaxis?  (Answers 
due  not  later  than  July  15,  1909.) 

Whoever  anszvers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $2$.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  required)  that  the  answers  be^  short;  if  prac- 
ticable no  one  answer  to  contain  more  than  six  hundred 
zvords. 

All  persons  will  be  entitled  to  compete  for  the  prize, 
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answer  must  be  accompanied  by  the  zvriter's  full  name  and 
address,  both  of  which  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Jour- 
nal. Our  readers  are  asked  to  suggest  topics  for  dis- 
cussion. 

The  prize  of  $2^  for  the  best  essay  submitted  in  answer 
to  question  LXXXV  has  been  awarded  to  Dr.  George  A. 
Graham,  of  Kansas  City.  Mo..  ziJwsc  article  appeared  on 
page  1097. 

PRIZE  QUESTION  LXXXV. 
THE  NONOPERATIVE  TREATMENT  OF  DISEASE 
OF  THE  VERMIFORM  APPENDIX. 

(Continued  from  page  ioqq.) 

Dr.  F.  H.  Smith,  of  Lewisburg,  IV.  Va.,  says: 

The  victim  of  an  acute  attack  of  appendicitis  is, 
admittedly,  on  precarious  ground.  His  illness  may 
be  trivial,  or  it  may  be  fraught  with  the  gravest 
consequences ;  and  so  insidious  is  the  attack  and 
its  progress  that  no  one  has  the  hardihood  to  fore- 
cast at  the  onset  which  of  these  two  extremes  will 
be  approached. 

No  doubt,  every  one  is  willing  to  admit,  that:  i. 
appendicitis  is  essentially  a  surgical  disease,  the 
only  question  being  when  to  operate  ;  2,  the  interim 
operation  has  a  mortality  practically  nil ;  3,  at  the 
very  onset  of  the  illness  operative  risks  are  nearly 
as  good ;  4,  the  operation  attended  with  any  great 
mortality  is  the  one  undertaken  during  the  height 
of  the  inflammation,  when  things  have  gone  wrong, 
complications  have  arisen,  extension  has  occurred, 
and  the  patient  lies  overwhelmed  with  his  disease. 

But,  in  default  of  an  infallible  prognostic  index 
as  to  whether  the  individual  patient  will  weather 
the  storm  successfully  and  finally  come  to  the  opera- 
tion with  every  rea.sonable  expectation  of  recov- 
ery ;  or  whether  he,  by  being  treated  conservatively, 
will  be  exposed  to  all  the  chances  of  a  fatal  illness 
and  after  all  be  brought  to  operation  with  his 
chances  at  the  worst — I  say,  so  long  as  we  lack  the 
ability  to  see  the  end  from  the  beginning,  there  will 
be  a  parting  of  the  ways  on  the  (piestion,  "When 
to  operate?" 

So,  granting  that  appendicitis  is  a  surgical  dis- 
ea.se,  there  are  but  few  practitioners,  medical  or 
surgical,  who  wf)uld  advise  immediate  operatitm  in 


every  case  diagnosticated  as  appendicular  inflam- 
mation, for  every  disease,  no  matter  how  essentially 
surgical,  will,  at  times,  challenge  medical  therapeu- 
tics to  do  its  best.  Thus,  nonoperative  methods  may 
be  demanded  in  the  treatment  of  appendicitis,  first, 
as  a  substitute  for  surgery,  when  operation  would 
be  desirable,  but  impossible ;  second,  as  a  deliberate 
preparation  for  operation ;  third,  as  an  adjunct  to 
surgery,  certain  nonoperative  measures  are  always 
demanded.  The  chief  of  these  factors,  intrinsic  and 
extrinsic,  may  be  outlined  as  follows : 

(a)  If  the  symptoms  are  mild  and  show  no  ten- 
dency to  progression,  especially  when  the  patient 
is  seen  after  twenty-four  hours,  this  feature  is  on 
the  side  of  expectant  treatment. 

(b)  If  there  is  evidence  of  active  suppuration, 
rupture,  gangrene,  or  peritonitis,  with  no  signs  yet 
of  localization,  the  general  experience  of  surgeons 
would  indicate  that  more  is  to  be  gained  by  waiting 
for  localization  than  by  immediate  operation,  for 
though  many  cases  will  be  lost,  admittedly,  on  either 
plan,  these  are  the  worst  operative  risks.  When 
these  accidents  have  arisen  some  hours  previously, 
perhaps  our  choice  of  treatment  might  just  as  well 
rest  upon  the  flipping  of  a  coin,  for,  while  some  few 
patients  recover  under  either  plan  of  treatment,  we 
know  not  whether  to  let  the  opprobrium  of  the  al- 
most certain  death  fall  upon  futile  surgery,  or  to 
stand  by  with  our  hands  tied,  and,  often,  watch  a 
life  pass  out.  Personally,  I  lean  toward  an  immedi- 
ate operation. 

(c)  The  general  condition  of  the  patient,  (as 
Bright's  disease  or  advanced  diabetes)  may  debar 
surgery. 

(d)  The  ability  to  command  reliable  nursing 
and  absolute  obedience  in  carrying  out  the  strict 
regime  of  the  nonoperative  treatment  are  pre- 
requisites to  the  adoption  of  such  methods  ;  for  with- 
out these  it  is  next  to  impossible  to  carry  out  the 
conservative  treatment,  and  almost  any  surgical 
risk  is  preferable  to  disobedience  of  the  rigid  regime 
of  nonoperative  treatment  as  it  is  at  present  under- 
stood. 

(e)  The  accessibility  of  a  competent  surgeon;  if 
it  is  necessary  to  transport  the  patient  to  a  hospital, 
the  facilities  for  conveyance ;  and  the  patient's  finan- 
cial ability  to  meet  the  expense  involved  in  the  lux- 
ury of  surgery,  must  be  considered. 

(f)  In  recurrent  attacks,  the  prognosis  is  beset 
with  much  the  same  difficulties  as  a  primary  attack, 
and  the  question  of  operating  during  the  attack  is 
to  be  decided  on  the  same  prinicples. 

fg)  If  the  patient  is  a  child.  I  always  feel  more 
dubious  in  starting  on  a  nonoperative  plan  of  treat- 
ment, because  children  are  much  more  difficult  to 
control,  and  because  it  has  alwavs  seemed  that, 
though  their  powers  of  recuperation  are  good,  they 
are  more  liable  to  rapid  and  virulent  attacks,  with  a 
greater  tendency  to  suppuration  and  perforation. 

(h)  The  wishes  of  the  patient  and  his  family 
must  be  considered,  as  not  infrequently  operation 
is  flatly  declined,  regardless  of  any  advice  of  the 
attendant. 

I'inally,  when  all  things  have  been  considered,  if 
I  am  in  doubt,  I  feel  that  I  am  giving  the  patient 
the  benefit  of  the  doubt,  when  I  decide  on  operation. 


J 11  lie  5,  igpy.J 


OUR  READERS'  DISCUSSIONS. 


1 149 


So  much  for  a  choice  of  cases.  Having  decided 
to  adopt  an  expectant  method,  what  is  the  treat- 
ment ? 

Nature's  great  antiphlogistic  is  rest.  One's  suc- 
cess over  another's  depends  largely  upon  the  one's 
infinite  capacity  for  taking  pains  in  prescribing  the 
minute  details  of  securing  rest,  in  persuading  the 
patient  and  his  attendants  of  the  reasonableness  of 
the  prescription,  and  his  eternal  vigilance  in  secur- 
ing the  enforcement  of  the  strict  regime  of 
quiescence. 

With  a  family  of  some  intelligence,  it  is  some- 
times well  to  take  them  into  your  confidence  a  little, 
to  tell  them  what  appendicitis  is,  what  are  the 
dangers,  what  is  the  treatment,  and  what  are  the 
objects  of  treatment.  Once  a  patient  can  be  made 
to  see  the  "why  and  wherefore,"  he  becomes  a  much 
more  willing  and  obedient  patient  than  when  blind- 
ly undergoing  an  irksome  and  painful  experience. 

Physiological  rest  in  a  case  of  appendicitis  is  to 
be  secured,  in  the  first  place,  by  putting  the  body 
at  rest.  I  always  order  the  patient  to  bed,  no  mat- 
ter how  trivial  the  attack  may  appear,  insist  upon 
the  use  of  the  bedpan  and  urinal,  and  advise  the 
patient  to  make  the  effort  to  curb  his  restlessness, 
making  as  few  unnecessary  movements  as  he  can. 

Next,  bv  emptying  the  stomach  and  bowels.  Usu- 
ally, the  stomach  has  been  thoroughly  emptied  by 
the  primary  emesis.  If,  however,  there  has  been 
no  vomiting,  and  there  is  reason  to  believe  that  there 
is  food  in  the  stomach,  or  if  the  nausea  and  retching 
continue  after  the  stomach  is  emptied,  then  it  is 
well  sometimes  to  use  the  stomach  tube  and  gentle 
irrigation,  unless  the  patient  resists,  gags,  and 
strains,  when  it  is  frequently  better  to  abandon  the 
attempt  lest  such  strains  endanger  the  damaged  ap- 
pendix. 

The  question  of  the  propriety  of  giving  an 
aperient  is  a  nice  one,  and  still  a  moot  point,  the 
dogmatic  stand  of  surgeons  '"to  the  contrary,  not- 
withstanding." It  must  depend,  for  the  most  part, 
on  the  circumstances  and  good  judgment  of  the 
physician  in  attendance.  A  safe  rule  to  follow  may 
be  summarized  as  follows:  (i)  If  the  patient  is 
seen  early,  and  indications  are  that  no  great  dam- 
age is  already  done,  and  constipation  has  been  ex- 
istent, so  that  the  bowel  is  loaded  with  fteces,  this 
should  be  removed.  Thus  a  diagnosis  may  often  be 
ef¥ectually  cleared  up,  and,  certainly,  rest  for  the 
appendix  and  bowel  can  be  much  more  safely  gained 
by  emptying  the  bowel  of  its  contents  quickly,  and 
finally,  the  nervous  system  and  other  vital  organs 
are  freed  fiom  a  large  handicaj:)  when  this  source 
of  poisoning  is  removed,  while  it  relieves  pressure, 
depletes  the  bloodvessels,  and  perhaps  diminishes  the 
dangers  of  peritonitis.  (2)  If,  however,  the  case 
is  so  far  advanced  or  severe — quick  pulse,  rigidity 
over  an  extensive  area,  and  tenderness — as  to  give 
one  reason  to  fear  that  suppuration  has  set  in,  then 
I  refuse  to  order  an  aperient,  or,  at  most,  a  small 
enema,  fearing  lest  Nature's  eflforts  to  wall  of¥  and 
confine  suppuration  may  be  defeated,  or  that  I  may 
add  the  additional  weight  of  the  straw  to  break 
the  camel's  back,  in  the  face  of  a  threatened,  or  ac- 
tual, perforation,  thus  forcing  faeces  out  through 
the  patulous  appendix.  (3)  Perhaps  a  safe  rule 
would  be.  "If  there  is  doubt,  do  not  purge." — (Ty- 
son.) 


The  aperient  selected  should  never  be  drastic : 
a  small  enema  is  the  safest  of  all ;  this  failing,  castor 
oil  is  perhaps  the  best,  or  the  solution  of  the  n.ag- 
nesium  citrate,  a  Seidlitz  powder,  or  Rochelle  salts. 
Once  having  emptied  the  bowels,  further  aperients 
should  be  tabooed  throughout  the  illness. 

Still  further  to  secure  rest,  interdict  anything  to 
be  given  by  mouth,  and  it  is  well  always  to  mention 
specificially  that  this  interdiction  applies  to  water 
in  any  quantity.  To  relieve  the  thirst,  which  is  al- 
ways most  painful  to  bear  during  the  first  day,  let 
the  patient  get  the  taste  of  water  by  rinsing  the 
mouth  out  frequently  with  cold  water,  and  get  the 
efifects  of  water  by  hypodermoclysis  or  enteroclysis, 
as  advised  below. 

Of  the  measures  for  the  relief  of  pain,  nothing 
so  far  used  can  compare  with  the  constant  local  use 
of  the  ice  bag.  The  relief  obtained  is  in  most  in- 
stances miraculous,  and  soon  the  sufiferer  demands 
that  it  be  kept  applied.  Should,  however,  the  ice 
bag  prove  objectionable  or  not  sufficient  to  relieve 
pain,  or  if  there  is  restlessness  or  sleeplessness,  the 
case  demands  the  use  of  some  opiate,  for  body  and 
mind  must  be  kept  at  rest.  The  opiate  serves  many 
good  purposes :  it  blunts  the  sensibility  to  hunger 
and  thirst,  in  small  doses  it  stimulates  the  heart  in- 
directly by  removing  the  inhibition  caused  by  pain, 
thus  steadying  its  action,  it  conserves  the  body 
forces,  and  puts  a  splint  on  peristalsis.  A  tablet  of 
codeine,  hersine,  or  morphine,  in  the  smallest  dosage 
to  take  '"the  edge  off  of  the  pain"  should  be  left 
with  the  nurse,  with  the  definite  instruction  to  use 
as  little  as  can  be,  and  it  is  remarkable  how  little 
really  is  necessary.  Remember  that  anything  that 
relieves  the  pain  "masks  symptoms,"  and  this  ap- 
plies to  the  ice  bag  fully  as  much  as  to  small  doses 
of  opiates. 

Should  the  question  of  nourishment  press  for  sol- 
ution before  food  can  safely  be  administered  by 
mouth,  we  must  have  recourse  to  rectal  feeding. 
The  most  convenient  form  consists  in  the  use  "of 
one  ounce  of  one  of  the  various  concentrated  liquid 
predigested  foods  dissolved  in  three  ounces  of  warm 
normal  salt  solution,  introduce  slowly  through  a  soft 
catheter  inserted  into  the  rectum  a  distance  of  two 
or  three  inches"  (Hare).  It  is  little  short  of  re- 
markable, though,  how  rarely  it  is  a  matter  of  real 
necessity  to  have  recourse  to  rectal  feeding.  The 
body  existing  at  this  low  ebb  of  activity  seems  to 
do  very  well  without  nourishment,  and  until  debil- 
ity is  manifest  it  seems  ju.st  as  well  to  omit  even 
the  rectal  feeding,  when  a  half  an  ounce  of  whiskey 
miffht  well  be  added  to  each  feeding. 

The  need  of  the  tissues  for  water  is  more  press- 
ing, and  this  may  be  supplied  also  bv  rectum.  Mur- 
phy's method  of  administering  normal  salt  solution 
by  a  tube  inserted  a  short  distance  into  the  rectum, 
and  the  solution  allowed  to  flow  in  under  low  pres- 
sure, drop  b}'"  drop,  allows  the  system  to  absorb 
large  quantities  of  fluid  ;  and  the  eood  effect  is  soon 
manifest  by  the  copious  action  of  the  kidneys,  and 
often,  in  a  decided  reduction  of  temperature. 

Such  treatment,  faithfully  and  patiently  persisted 
in,  should  soon  show  its  own  justification.  Within 
twentv-four  hours  improvement  should  begin,  and 
with  all  going  well  improvement  should  be  marked 
at  the  end  of  forty-eight  hours.  All  may  not  go 
so  well,  however,  or  the  case  mav  be  advanced  be- 


II50 


CORRESPONDENCE. 


fore  treatment  is  inaugurated.  In  such  a  case,  the 
temperature  continues  with  a  light  fall,  or  may  rise 
higher ;  or,  most  paradoxically,  there  may  be  no 
fever  at  all,  and  yet  suppuration  be  present.  A  sud- 
den fall  of  temperature  does  not  always  mean  that 
all  is  going  well,  for  not  rarely  it  means  instead 
that  perforation  has  occurred ;  and  it  is  also  im- 
portant to  bear  constantly  in  mind  that  the  tempera- 
ture may  be  normal  in  the  presence  of  a  gangrenous 
appendix.  (Tyson.)  The  pulse,  however,  whether 
there  is  fever  or  not,  rises  disproportionately  to  the 
temperature  whenever  things  are  going  wrong. 
There  is,  also,  an  extension  of  the  area  of  exquisite 
tenderness,  and  rigidity  becomes  even  more  board- 
like ;  vomiting  is  apt  to  reappear,  and  the  facies  as- 
sume that  anxious  expression  so  ominous  to  all  who 
have  seen  it ;  the  intellect  generally  remains  clear, 
and  "while  there  is  often  a  total  lack  of  realization 
of  the  inevitable  and  usually  dreaded  end,  it  is  as 
often  thoroughly  appreciated  by  the  patient  and 
viewed  with  a  calmness  which  increases  the  awe 
which  always  attaches  to  the  presence  of  the  shadow 
of  death"  (Tyson).  In  brief,  a  case  of  general  peri- 
tonitis. The  chances  are  slim  from  any  standpoint, 
and  there  is  but  one  course  to  pursue  ;  to  exert  every 
endeavor  to  cause  a  localization  of  the  pus  where 
it  will  do  the  least  harm,  to  limit  the  amount  formed, 
to  conserve  the  body  resistance,  and  to  prevent  as 
much  as  may  be  possible  the  absorption  of  the  pus, 
—provided  operation  is  still  refused  or  inapplicable. 

If  there  has  been  any  advance  made  in  the  treat- 
ment of  appendicitis  over  that  of  old  times,  it  is 
nowhere  more  marked  than  right  here  in  the  man- 
agement of  these  desperate  cases.  Everything  that 
has  been  suggested  before  for  limiting  the  move- 
ments of  the  body  and  .of  the  parts  involved  should 
be  continued  with  even  greater  reason  than  ever. 
To  these  suggestions  there  is  but  one  other  to  add : 
.\s  soon  as  there  is  any  suspicion  that  pus  is 
forming  or  that  perforation  or  gangrene  is  threat- 
ening, raise  the  head  of  the  bed  to  an  angle  of  forty- 
five  degrees  or  more,  with  support  under  the  but- 
tocks. This  posture,  called  Fowler's,  puts  the  pa- 
tient practically  in  a  sitting  position  in  bed  ;  it  re- 
lieves peritoneal  tension,  which  is  forcing  sepsis  into 
the  circulation,  and  drains  toxic  fluids  from  the  ab- 
sorptive surfaces  of  the  peritonaeum  of  the  upper 
abdomen  to  the  practically  unabsorptive  surface  of 
the  pelvis  (McGuire),  while  it  allows  freer  expan- 
sion of  the  chest  and  upper  abdomen,  hence  permits 
easier  breathing.  To  this  postural  treatment  should 
be  added  the  Murphy  treatment  of  introducing 
large  quantities  of  salt  solution  under  low  pressure 
into  the  bowel,  thus  overfilling  the  vessels  of  the 
jjeritonaeum  and  making  of  it  a  secreting  surface 
rather  than  an  absorptive  one.  Of  drug  treatment, 
morphine  for  its  staying  qualities,  digitalis  to  brace 
the  heart  against  its  burden  of  sepsis,  and  sparteine 
sulphate  in  half  grain  doses  whenever  the  kidneys 
.  begin  to  flag,  all  administered  hypodermically,  have 
their  places  well  defined. 

Under  such  a  i)lan  of  treatment,  the  acute  case 
of  appendicitis,  whether  it  has  had  a  smooth  course 
or  has  been  carried  through  only  with  the  greatest 
effort  and  has  still  as  a  trophy  of  the  conflict  an  ap- 
pendiceal abscess,  comes  to  the  point  where  it  is 


[New  York 
Medical  Journal. 

convalescent.  For  the  simple  case,  at  least  twenty- 
four  hours  should  elapse  after  the  cessation  of  all 
pain  and  tenderness  before  he  be  allowed  anything 
by  mouth,  when  small  sips  of  hot  water  frequently 
repeated,  and  still  later  small  sips  of  cold  water, 
may  be  allowed.  Feeding  must  be  resumed  in  the 
same  cautious  way,  feeling  one's  way,  as  it  were, 
and  carefully  watching  for  any  return  of  pain  or 
tenderness.  When  there  remains  an  abscess  or  an 
appendix  structurally  damaged  in  any  way,  I  be- 
lieve the  sooner  the  patient  is  operated  on  the  bet- 
ter. There  is  always  the  risk  that  dangerous  peris- 
talsis be  set  up  even  by  too  much  water  or  liquid 
food. 

Finally,  comes  the  time  when,  having  recovered 
from  the  illness,  with  strength  somewhat  regained, 
the  patient  can  be  turned  over  to  the  surgeon  for 
the  removal  of  the  offending  member — the  so  called 
"interim  operation,"  with  a  mortality  practically  nil. 
The  physician  has  not  done  his  full  duty  until  he 
has  advised  and  urged  his  patient  to  seek  a  surgebn 
just  so  soon  as  his  attack  is  well  over,  for  the 
longer  he  goes  without  operation  after  his  recovery, 
the  less  the  chances  that  he  will  ever  submit  him- 
self to  operation  until  another  attack  seizes  him. 

I  believe  nonoperative  treatment  of  chronic  dis- 
ease of  the  appendix  is  applicable  only  until  a  diag- 
nosis has  been  made  and  intelligent  ettort  is  under- 
taken to  correct  constipation,  relieve  intestinal  in- 
digestion, fermentation,  and  flatulence  :  when,  if  the 
symptoms  continue,  an  operation  becomes  practi- 
cally imperative  before  there  can  be  recovery  of 
health. 

{To  be  continued.) 
 <^  

Corrfsponbftta. 


LETTER  FROM  LONDON. 

.1  Discussion  on  Shock. — A  Carnival  in  Aid  of  King's  Col- 
lege Hospital. — Medical  Exhibits  before  the  Royal  So 
ciety. — Medical  Men  and  the  Budget. 

LoNnoN.  May  jS.  1909. 
At  a  meeting  of  the  Medical  Society  of  London 
on  May  loth,  Mr.  John  D.  Malcolm  read  a  paper 
on  the  Treatment  of  Shock.  He  disagreed  with 
Crile,  who  taught  that  in  shock  the  vasomotor  cen- 
tres were  paralyzed  and  the  vessels  relaxed.  He 
suggested  that  the  arteries  were  tensely  contracted. 
This  would  have  the  eflfect  of  making  the  tissues 
pale  and  the  veins  dilated.  He  quoted  W.  J.  Porter, 
of  the  Harvard  School,  and  M.  G.  Seelig  and  E. 
P.  Lyon,  of  St.  Louis,  AIo.,  who  had  shown  by  ex- 
perimental methods  that  the  vasomotor  centres  were 
not  paralyzed  or  inhibited  in  shock.  A  rise  in  the 
specific  gravity  of  the  blood  had  been  described  in 
shock,  indicating  a  contraction  of  the  vessels  and 
an  ex])ression  of  fluid  into  the  tissues.  Mummery 
and  S\mes  had  recently  stated  that  the  specific 
gravity  of  the  blood  was  lowered  in  shock,  but  they 
regarded  a  pithed  animal  as  being  in  a  state  of 
shock,  thus  assuming  a  sdlution  of  the  question 
of  issue  in  disregard  of  the  fact  that  Crile  described 
the  venous  pressure  as  raised  in  shock.  Roy  and 
Adami  had  shown   that   peripheral   irritation  not 


June  5,  1909.] 


CORRESPONDENCE. 


only  contracted  the  arteries,  but  also  increased  the 
force  of  the  ventricular  contractions,  and  Eugene 
Bois.  of  Grand  Rapids,  Mich.,  had  pointed  out  that 
as  shock  increased,  the  heart's  action  became  rnore 
limited  until  its  dilatations  were  so  small  that  it 
could  not  take  up  and  propel  sufficient  blood  into 
the  aorta ;  the  pressure  then  fell,  and  the  blood  ac- 
cumulated in  the  veins.  As  regarded  the  treatment, 
Crile  taught  that  the  vessels  dilated  as  shock  pro- 
gressed and  should  be  filled  with  fluid  and  contract- 
ed if  possible.  Mr.  Malcolm  held  that  the  vessels 
contracted  in  shock,  and  that  the  fluids  were 
squeezed  out  of  them  and  removed  from  the  body 
as  sweat.  Hence  vasodilators  and  sedatives  should 
be  given  as  shock  developed,  and  the  administra- 
tion of  fluids  was  necessary  in  the  stage  of  recov- 
ery. The  evidence  seemed  complete  that  in  shock 
fluids  were  removed  from  the  vessels  and  from  the 
body  and  had  to  be  replaced  before  recovery  was 
possible.  Hence  endeavors  to  force  blood  into  the 
veins  in  the  stage  of  developing  shock  were  con- 
sidered useless  and  dangerous.  When  the  vessels 
relaxed,  the  danger  of  collapse  was  great.  X'aso- 
dilators  were  then  necessary  and  increased  the 
danger  unless  fluid  was  also  supplied.  Hence  it  was 
desirable  to  introduce  fluid  in  anticipation  of  the 
necessity  for  it,  and  the  dangers  of  venous  injection 
could  be  avoided  by  introducing  the  fluid  into  the 
subcutaneous  tissues,  the  rectum,  or  the  peritoneal 
cavity.  The  employment  of  vas:c  nstrictors  when 
the  arteries  were  empty  was  irrational.  Alcohol 
was  useful  and  undoubtedly  improved  the  pulse  in 
that  stage.  The  use  of  strychnine  was  condemned 
by  Crile. 

In  the  discussion  which  followed  Mr.  Keetley 
said  that  shock  was  not  seen  now  as  often  as  it 
used  to  be.  because  of  the  care  taken  to  prevent 
hremorrhage  and  to  keep  the  patient  warm  and  be- 
cause of  the  substitution  of  ether  for  chloroform. 
He  deprecates  the  extent  to  which  strychnine  was 
used  in  the  operating  theatres.  Mr.  Pearce  Gould 
said  there  were  three  elements  of  primary  im- 
portance in  the  treatment  of  shock — external 
warmth,  rest,  and  a  small  dose  of  morphine.  He 
agreed  that  the  hypodermic  injection  of  strychnine 
was  useless.  Dr.  Alexander  Morison  pointed  out 
that  shock  passed  off  when  the  power  of  the  heart's 
action  returned.  The  application  of  warmth  or 
the  inh-'htion  of  amyl  nitrite  quickened  the  action 
of  the  heart.  ^ 

Arrangements  are  already  being  made  for  a  great 
carnival  and  fete  which  will  be  held  at  the  Crystal 
Palace  on  July  ist  in  aid  of  the  King's  College  Hos- 
pital Removal  Fund.  The  place  is  very  appropriate 
because  the  new  hospital  will  supply  the  needs  of 
that  district  in  the  southeast  of  London.  Central 
London  is  adequately  supplied  with  hospital  ac- 
commodation, but  the  South  side  is  not,  and  its 
poorer  inhabitants  have  increased  enormously  in  re- 
cent years.  As  far  back  as  1892  a  select  com- 
mittee of  the  House  of  Lords  strongly  urged  that 
at  the  first  opportunity  a  big  general  hospital  in  this 
district  should  be  provided.  The  sum  of  £300.000 
is  required  to  effect  the  transfer  and  erect  the  new 
buildings  for  the  hospital  and  school,  and  of  this 
up  to  the  present  time  £205.000  has  been  paid  or 
promised.    The  object  of  the  carnival  is  to  raise 


the  money  still  required  and  to  extend  the  sphere 
of  interest  in  the  undertaking.  It  is  hoped  that  the 
Prince  and  Princess  of  Wales  will  attend  to  open 
the  carnival,  and  there  are  a  large  number  of  other 
patrons. 

At  the  conversazione  of  the  Royal  Society  held 
at  Burlington  House  last  Wednesday  there  were 
several  very  interesting  medical  exhibits.  Dr.  A. 
D.  Waller  gave  a  demonstration  of  the  electrical 
variation  of  the  human  heart  and  of  the  dog's  heart 
on  Einthoven's  string  galvanometer.  The  subject 
was  Dr.  Waller's  own  bulldog,  which  did  not  show 
the  slightest  objection  to  the  proceeding.  He  was 
connected  with  the  galvanometer  with  his  near  fore 
and  off  hindfoot  in  two  pans  containing  salt  water 
and  the  electrodes.  The  apparatus  was  also  fitted 
with  vessels  into  which  visitors  could  dip  their 
hands  and  so  see  the  diphasic  variations  in  their 
own  heart  beats,  but,  probably  owing  to  the  fact 
that  the  electrical  resistance  of  the  skin  is  very  high 
unless  the  part  used  has  been  soaked  for  some 
length  of  time,  the  human  being  did  not  show  to 
such  advantage  as  the  dog.  Dr.  E.  F.  Bash  ford 
exhibited  a  fine  series  of  diagrams  illustrating  the 
recent  advances  in  our  knowledge  of  cancer. 
The  experimental  production  of  sarcoma  was 
illustrated  for  the  first  time  in  this  exhibit, 
sarcoma  being  developed  upon  an  antecedent  car- 
cinoma. Lieutenant  Colonel  Leishman,  R.A.M.C.,. 
presented  microscopic  specimens  illustrating  the 
transmission  of  tick  fever.  The  various  stages  of 
the  tick's  life  were  also  illustrated  by  living  exam- 
ples, and  the  microscopic  specimens  showed  the  al- 
terations which  the  spirochaetas  appear  to  undergo 
in  their  passage  from  one  generation  of  tick  to  an- 
other. Mr.  S.  G.  Shattcck  exhibited  a  microscopic 
section  of  the  aorta  of  King  Meriephtah  (tradition- 
ally regarded  as  the  Pharaoh  of  the  Exodus)  ob- 
tained from  a  mummy,  showing  senile  calcification. 

Apart  from  medical  exhibits,  one  of  the  most  re- 
markable things  shown  was  that  by  Professor 
Norman  Collie.  This  consisted  of  various  forms 
of  glass  tubes  containing  neon  and  mercury,  which^ 
when  shaken  together  even  at  ordinary  pressures 
were  seen  to  glow  with  a  peculiar  orange  red 
light.  The  explanation  of  this  phenomenon  was 
so  far  unknown.  Another  interesting  glow  effect 
shown  was  a  vaccum  tube  containing  a  strip  of 
palladium  foil  or  palladinized  platinum  foil.  On 
passing  the  current  through  the  foil  it  became  in- 
candescent, and  around  the  incandescence  appeared' 
a  beautiful  purple  blue  glow.  Sir  William  Ram- 
say's exhibit  of  liquid  radium  emanation  attracted 
considerable  interest.  It  can  be  reduced  to  a  solid,, 
which  when  cooled  further  phosphoresces  very 
strongly  and  more  intensely  than  the  gas.  Another 
very  interesting  exhibit  was  Mr.  J.  H.  Laby's  de- 
monstration of  Professor  E.  Rutherford's  method 
of  counting  the  alpha  particles  from  the  radium 
emanation,  a  marvel  of  ingenuity  and  accuracy.  By 
an  electrical  method  a  deflection  of  an  electrometer 
is  obtained  as  each  alpha  particle  passes  into  a 
tube.  Mr.  Francis  Fox  exhibited  samples  of  pitch- 
blende from  Trenwith  mi-Te.  Cornwall,  and  speci- 
mens of  uranium  bromide,  uranium  oxide,  and 
other  constituents. 

The  recent  budget  affects  the  medical  profession 


II52 


THERAPEUTICAL  NOTES. 


[New  York 
Medical  Joirwal. 


ill  the  British  Isles  in  many  ways.  First  of  all, 
medical  motorists  will  have  to  pay  a  tax  on  their 
motors  and  also  a  tax  on  "petrol."  The  tax  on 
motors  varies  with  the  horse  power  of  the  car  and 
ranges  between  2  and  40  guineas.  For  medical  men 
the  rate  is  a  half  of  that  for  other  people,  but  the 
tax  on  "petrol"  3d  a  gallon,  is  the  same  for  all. 
The  latter  will  be  especially  burdensome  to  coun- 
try practitioners  and  will  mean  an  increase  of  £5 
to  £15  a  year  in  the  cost  of  their  "petrol"  accord- 
ing to  their  mileage.  Many  medical  men  in  hilly 
districts  in  Wales  and  Yorkshire  drive  from  7,000 
to  10,000  miles  a  year  and  will  have  to  pay  over 
£20  in  tax  for  their  "petrol."  The  medical  men 
are  strongly  opposed  to  this  tax  on  "petrol."  and 
a  question  has  been  asked  in  Parliament  whether 
some  abatement  could  not  be  allowed  to  them.  Mr. 
Llovd  George,  the  Chancellor  of  the  Exchequer, 
could  not  see  his  way  to  do  it,  however,  and  so 
they  will  have  to  bear  this  added  burden.  Not  many 
medical  men  will  be  affected  by  the  rise  in  income 
tax,  which  is  J^d  on  incomes  over  £2,000.  On  in- 
comes lower  than  that  the  tax  remains  as  before, 
gd.  There  is  also  a  super  tax  of  6d  in  the  pound 
on  incomes  over  £5,000,  making  in  all  a  tax  of  is, 
8d,  but  the  number  of  medical  men  enjoying  such 
an  income  must  be  very  small.  There  is  also  an 
increase  of  3/9d  a  gallon  on  proof  spirit.'  This 
will  have  the  efifect  of  raising  the  price  of  medi- 
cines, especially  the  tinctures,  most  of  which  are 
alcoholic.  Medical  men  in  contract  practice,  who 
have  to  supply  their  own  medicines,  will  find  it  dif- 
ficult to  continue  to  do  so  at  the  old  rate  of  4s  a 
member  per  annum,  and  in  many  places  they  are  al- 
ready demanding  an  increase  over  this  rate. 


Modern  Methods  of  Treatment  of  Some  Com- 
mon Skin  Diseases. — J.  L.  Bunch,  in  his  lecture 
delivered  at  the  Medical  Graduates  College  and 
Polyclinic,  of  London,  remarks  according  to  1  he 
Lancet  of  April  3,  1909,  that  the  x  rays  have  ap- 
l^arently  a  selected  action  for  hair  papillae,  cancerous 
cells,  and  pathological  tissues  in  general.  Thus  a 
portion  of  .scalp  which  has  been  exposed  to  a  definite 
dose  of  X  rays  becomes  entirely  bald  at  the  end  of 
three  or  four  weeks,  and  then  new  hair  grows  again 
over  the  bald  area  after  another  period  of  twelve 
weeks.  In  the  case  of  ringworm  of  the  scalp,  the 
diseased  hairs  become  loose  and  fall  out,  and  are 
succeeded  by  a  fresh  crop  of  hair  entirely  free  from 
disease.  The  .patient  is  thus  entirely  cured  of  his 
ringworm  by  a  single  exposure  of  the  diseased 
patches  and  can  return  to  school  without  danger  of 
infecting  other  children.  The  only  essential  is  that 
the  amount  of  the  x  ray  dose  shall  be  accurately 
measured.  This  is  effectually  done  by  means  of 
greenish  pastilles  o.f  barium  platinocyanide  inter- 
posed between  the  tube  and  the  scalp  which  change 
to  a  browni.sh  tint  when  the  exact  dose  has  been 
given.  Children  are  not  frightened  by  this  method 
of  treatment,  and  for  children  over  four  years  of  age 
there  is  no  question  that  better  and  quicker  results 


are  obtained  in  this  way  tnan  in  any  other,  if  the 
scalp  has  not  been  previously  irritated  by  treatment. 
It  must,  however,  be  remembered  that  the  rays  do 
not  kill  the  fungus,  arid  the  diseased  hairs  may  as 
they  fall  out  infect  other  healthy  portions  of  the 
scalp.  Dr.  Bunch,  therefore,  always  applies  a  weak 
sulphur  and  carbonic  ointment  over  the  whole  scalp 
every  morning  in  order  to  avoid  any  such  possible 
infection.- 

Cases  which  have  already  been  irritated  by  treat- 
ment or  for  other  reasons  are  unsuitable  for  the  ap- 
plication of  X  rays,  are  best  treated  by  croton  oil 
ointment  applied  daily  with  frequent  bathing  with 
hot  water,  or  by  either  of  the  following: 

B    Chrysarobin,   gr.  xxv; 

Salicylic  acid,   gr.  x; 

Ichthyol,   gr.  xx  ; 

Benzoated  lard,   5i 

M.  ^ 

Or 

R     Oil  of  white  birch  ^i; 

Green  soap,   jiss; 

Spirit  of  lavender  5i. 

M. 
Or 

R     Naphthol,   gr.  ii- 

Precipitated  sulphur,   gr.  xlv; 

Balsam  Peru,   gr.  v; 

Lanolin,   51. 

M. 

A  method  which  is  said  to  cure  ringworm  in  from 
two  to  three  months  is  to  clear  the  patches  thor- 
oughly by  epilation  and  washing,  and  then  to  cleanse 
them  with  the  following  solution : 

B     Boric  acid,   gr.  v  ; 

Chloroform,   TTLxx, 

Alcohol,   5i. 

M. 

Then  rub  in  acetic  acid  in  crystals  gr.  iv ;  and  a 
solution  of  corrosive  mercury  chloride  i  in  1,000, 
,^i ;  finally  cover  it  with : 

B     Acetic  acid  gr.  iv; 

Mercurial  ointment  3'- 

When  as  the  result  of  treatment  there  remain  but 
a  few  scattered  stumps  or  black  dots.  Dr.  Bunch 
destroys  them  either  by  electrolysis  or  needling  with 
croton  oil  colored  with  methylene  blue.  The  dve 
enables  one  to  see  which  stumps  have  been  treated 
and  their  removal  two  days  afterwards  with  forceps 
is  an  easy  matter. 

Ringworm  of  the  nonhairy  skin  is  casv  to  cure. 
Our  author  us^  the  following: 

R    Ointment  of  ammoniated  mercury,  5ss ; 

Salicylic  acid,   gr.  x; 

Naphthol,   gr.  iii ; 

Petrolatum  ^i- 

M.  Sig. :  Rub  in  twice  a  day. 

Emulsion  of  Fat  for  Use  in  Diabetes. — .Accord- 
ing to  the  Joitnial  dc  mcdcciuc  dc  Paris  for  March 
20,  1909,  Rochaix  employs  the  following  fatty  emul- 
sion in  the  treatment  of  diabetes : 

B    Aledicinal  soap,  freshly  prepared  5ss: 

Cherrylaurcl  water  5v  ; 

Orange  Hower  water  3iiss  : 

Saccharin  gr.  iii; 

Olive  oil,  or  sesame  oil  q.s.  ad  3xvi. 

Flavor  with 

Oil  of  peppermint  gtt.  vi : 

Oil  of  lemon  gtt.  vi. 

M.  ct  ft.  emulsion,  sec.  art. 


June  5,  1909.1 


EDITORIAL  ARTICLES. 


I153 


NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

Philadelphia  Medical  Journal 
and  The  Medical  News. 

A  Weekly  Review  of  Medicine. 

Edited  by 
FRANK  P.  FOSTER,  M.  D. 

Associate  Editor, 
John  M.  Swan,  M.  D., 
Philadelphia. 


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Publishers, 

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NEW  YORK,  SATURDAY,  JUNE  5,  1909. 


ANTIVIVISECTION  AND  THE  BUTCHER'S 
ART. 

In  its  June  issue  the  Medical  Times  publishes  a 
strong  editorial  article  depicting  some  of  the  need- 
less sufferings  inflicted  upon  animals  in  the  process 
of  slaughter  and  contrasting  the  sum  of  such  suf- 
fering with  the  small  amount  endured  from  vivisec- 
tion by  the  extremely  few  animals  that  are  not  an- 
festhetized.  Our  contemporary  dwells  upon  the  un- 
warrantable transportation  of  cattle  for  long  dis- 
tances without  food  or  drink  and  upon  the  readily 
avoidable  prolongation  of  the  animals'  suffering  in 
the  actual  work  of  slaughter.  After  describing 
various  form  of  torture  the  Times  closes  its  article 
with  the  following  paragraph  : 

We  venture  to  suggest  to  humane  societies  that  the  ag- 
gregate amount  of  pain  involved  in  the  slaughtering  of 
animals  for  food  far  exceeds  that  due  to  vivisection.  All 
of  it.  e.xcept  the  single  and  practically  instantaneous  death 
dealing  stroke,  is  avoidable.  To  give  an  animal  time  to 
die  requires  merely  setting  back  the  whole  system  by  a  few 
minutes  for  a  whole  day,  not  a  similar  loss  of  time  for 
each  animal.  To  require  ordinary  humanity  in  transporting 
and  driving  animals  to  their  slaughter  is  not  a  matter 
which  requires  education  of  popular  sentiment.  One  in- 
spector at  a  salary  of  $75  a  month  could  supervise  as  many 
animals  in  a  week  as  are  sacrificed  in  all  the  laboratories 
of  the  country,  if  not  of  the  world,  in  a  year. 

There  are  cruelties  practised  in  the  butchering 
business  that  our  contemporary  does  not  mention. 
Some  of  them  are  resorted  to  for  the  purpose  of 


rendering  the  meat  pale,  paleness  being  demanded 
by  fastidious  purchasers,  doubtless  including  many 
antivivisectionists.  It  is  a  common  practice  to 
bleed  calves  a  day  or  two  before  they  are  to  be 
killed,  and  then  deny  them  all  food  up  to  the  time 
of  slaughter.  In  one  respect,  did  they  but  know 
it,  the  consumers  who  are  ultimately  responsible  for 
the  starvation  process  circumvent  themselves — by 
causing  deterioration  of  the  animal's  liver.  ''Not 
only,"  says  Dr.  Alex  Hill  (The  Body  at  Work, 
London,  1908),  "will  the  liver  of  a  sheep  killed 
during  active  digestion  be  found  to  be  heavier  than 
that  of  a  starved  sheep,  but  it  will  also  prove  more 
succulent,  for  it  is  loaded  with  sugar  (into  which 
glycogen  is  rapidly  converted  after  death)  as  well 
as  with  proteins  and  fats,  which  are  withdrawn 
from  it  when  the  animal  fasts."  "Butchers,"  says 
the  same  author,  "have  the  stupid  practice  of  starv- 
ing animals  before  they  kill  them."  It  is,  of  course, 
cruel  as  well  as  stupid. 

Another  horrible  piece  of  cruelty  is — at  least  it 
formerly  was — resorted  to  for  this  same  purpose 
of  blanching  the  animal's  flesh.  When  the  throat 
of  a  male  lamb  has  been  cut,  the  butcher  seizes  its 
testicles  and  squeezes  them  with  all  his  might.  The 
pain  thus  produced  causes  the  animal  to  kick  as 
forcibly  as  it  can,  and  the  muscular  action  is  sup- 
posed to  increase  the  amount  of  blood  lost  before 
death  ensues,  with  the  result  of  making  the  flesh 
pale.  Argument  is  thrown  away  on  fanatics,  but 
it  may  affect  some  of  the  reasonable  people  from 
whom  they  derive  their  support,  and  we  commend 
the  butcher's  exploits  to  their  attention. 


TRICHOCEPHALIASIS. 

It  is  the  prevailing  opinion  among  systeinatic 
writers  that  infection  with  the  whip  worm,  Tricho- 
ccphahis  trichinris,  is  productive  of  no  particular 
harm  to  the  host.  Other  intestinal  parasites  are 
also  looked  upon  at  present  as  productive  of  no 
great  amount  of  disturbance  to  the  physiology  of 
the  host.  It  is  likely,  however,  that,  in  some  cases 
at  least,  those  parasites  ordinarily  looked  upon  as 
nonpathogenic  may  produce  decided  and  possibly 
dangerous  disturbances.  Musgrave  and  Clegg 
{Philippine  Journal  of  Science,  December)  report  a 
case  of  trichocephalus  infection,  with  decided  pro- 
gressive anaemia,  which  resulted  fatally  ;  a  case  of  se- 
vere infection  with  diarrhoea,  muscular  cramps,  diz- 
ziness, oedema,  and  indigestion  ;  a  case  with  pronounc- 
ed secondary  anaetnia  ;  and  a  case  in  which  there  was 
plugging  of  one  of  the  coronary  arteries  with  an 
adult    Trichocephalus    trichinris,    which  resulted 


H54 


EDITORIAL  ARTICLES. 


[Ny.w  V'oBK 
Medical  JouHiNai  . 


fatally.  These  cases  are"  reported  in  detail,  and 
there  is  a  review  of  the  literature  of  the  subject. 
In  addition  to  the  discovery  of  these  worms  in  their 
usual  habitat,  the  caecum,  they  have  been  found  b\' 
various  authors  in  the  ileum,  the  vermiform  appen- 
dix, and  the  peritoneal  cavity.  The  infection  is 
characterized  by  symptoms  of  varying  kinds,  such 
as  fever,  meningeal  symptoms,  anaemia,  gastroin- 
testinal disturbances,  etc.  The  authors  suggest  the 
name  trichocephaliasis  for  the  infection,  and  they 
state  that  the  prevalence  of  whip  worm  infection  in 
a  locality  is,  to  a  certain  extent  at  least,  an  index  of 
the  intelligence  and  cleanliness  of  its  citizens.  The 
parasites  are  difficult  to  destroy,  on  account  of  the 
fact  that  they  thrust  their  attenuated  head  ends 
through  folds  of  the  mucosa,  and  so  have  a  very 
good  hold  on  the  bowel.  Enemata  of  solutions  of 
benzene  seem  to  have  been  most  successful  in  the 
hands  of  the  greatest  number  of  investigators.  In 
the  majority  of  cases,  when  it  has  been  possible  to 
destroy  the  worms,  complete  and  rapid  recovery  of 
the  symptoms  has  followed.  A  very  valuable  feat- 
ure of  the  paper  under  discussion  is  the  bibliography 
of  eighty-nine  titles  compiled  by  Miss  Mary  Polk, 
librarian  cf  the  Ihireau  of  Science,  ?^Ianila. 


ERYTHEMA  NODOSUM  AXD  TUBER- 
CULOUS. INFECTION. 

Several  of  our  French  colleagues  have  lately 
given  considerable  attention  to  the  relation  of  vari- 
ous skin  diseases  to  the  value  of  the  intradermic 
tuberculin  test,  and  in  particular  to  the  question  of 
tuberculous  infection  as  an  aetiological  element  in 
erythema  nodosum.  In  the  Bnllctius  ct  mcmoircs 
de  la  Socictc  medicale  des  hopitaux  de  Paris  for 
May  13th  Dr.  H.  Barbier  and  Dr.  C.  Lian,  of  the 
Herold  Hospital,  cite  Chaufifard  and  Troisier's  ex- 
perimental production  of  typical  lesions  of  erythema 
nodosum  by  injecting  minute  quantities  of  tuber- 
culin into  the  skin,  on  the  strength  of  which  those 
authors  have  argued  that  many  cases  of  erythema 
nodosum  are  due  to  tuberculous  infection.  On  the 
other  hand,  they  point  to  Thibierge  and  Gastinel's 
cautions  in  regard  to  drawing  conclusions  from  the 
intradermic  tuberculin  test  applied  to  persons  with 
various  skin  diseases.  At  the  society's  meeting  of 
May  7th  Barbier  and  Lian  showed  a  patient  and 
gave  the  history  of  the  case. 

A  girl,  fourteen  years  old,  entered  the  Herold 
Hospital  on  the  3(1  of  May  with  disappearing  lesions 
of  erythema  nodosum  on  both  legs,  which  had  made 
their  appearance  about  a  fortnight  before,  with  dif- 
fuse pains  in  the  legs  severe  enough  to  cause  her 


to  remain  in  bed  for  a  few  days.  She  did  not  cough, 
but  her  appetite  was  somewhat  impaired,  she  had 
lost  a  little  flesh,  and  she  had  moderate  fever  with- 
out night  sweats.  Though  there  had  been  nothing 
notably  pathological  in  her  previous  history,  it  was 
observed  that  her  hands  and  feet  were  violaceous, 
and  it  was  learned  that  this  condition  was  especial- 
ly pronounced  in  winter,  when  there  were  also 
cracks  in  the  skin,  through  one  of  which  there  had 
shortly  before  been  contracted  an  infection  that  had 
resulted  in  suppurating  adenitis  of  the  groin.  There 
was  an  ichthyotic  condition  of  the  skin  in  general. 
In  the  right  infraclavicular  region,  at  its  outer  por- 
tion, there  was  slight  dulness  on  percussion,  with 
exaggerated  vocal  fremitus,  rough  inspiration,  and 
a  blowing  sound  on  expiration.  The  child  was  rath- 
er pale,  but  on  the  whole  her  condition  was  good. 
The  temperature,  taken  in  the  rectum,  oscillated  be- 
tween 98.8°  and  99.5°  F. 

The  authors  thought  that  the  persistent  cyanosis 
of  the  extremities,  frequently  accompanied  by  fis- 
sures, as  well  as  the  erythema  nodosum  itself,  was  to 
be  attributed  to  tuberculous  infection.  To  test  theii 
opinion,  they  employed  tuberculin  intradermically, 
using  a  I  to  5,000  dilution,  one  drop  for  each  injec- 
tion. Simultaneously  they  injected  the  same  quan- 
tity of  antidiphtheritic  serum  and  antimeningococcic 
serum.  The  antimeningococcic  injections  were 
given  in  the  upper  third  of  each  arm,  the  right  hy- 
pochondrium,  and  the  upper  third  of  the  right  leg; 
the  antidiphtheritic  in  the  middle  third  of  the  right 
arm,  the  left  iliac  fossa,  and  the  lower  third  of  the 
right  leg;  and  the  tuberculin  in  the  middle  third  of 
the  left  arm,  the  right  iliac  fossa,  and  the  middle 
third  of  the  right  leg. 

On  the  following  day  there  was  found  no  reac- 
tion to  the  antidiphtheritic  and  antimeningococcic 
injectibns,  but  all  three  of  the  tuberculin  injections 
had  given  rise  to  positive  lesions.  The  reaction  was 
much  the  most  intense  on  the  right  leg,  where  there 
was  a  very  prominent  nodosity,  a  large  typical  lesion 
of  erythema  nodosum.  The  authors  argue  that  this 
was  not  due  to  ordinary  irritation,  for  none  but  the 
tuberculin  injections  had  had  an\-  effect.  But,  thoy 
remark,  it  may  be  asked  if  the  lesions  caused  by  the 
tuberculin  were  not  significant  of  a  cutaneous  reac- 
tive property  related  to  the  erythema  itself,  and  not 
of  a  susceptibility  peculiar  to  the  patient  affected 
with  it.  They  are  inclined  to  answer  in  the  nega- 
tive. It  was  not,  they  say.  in  the  immediate  or  close 
neighborhood  of  the  region  attacked  by  the  erythema 
nodosum  that  the  reaction  was  positive,  but  at  points 
far  distant  from  the  limited  area  occupied  by  the 
skin  disease.  Therefore  the  reaction  indicated  tu- 
berculous infection.    However,  it  is  to  be  empha- 


June  5,  1909.] 


EDITORIAL  ARTICLES. 


sized  that  the  tuberculin  gave  rise  to  a  lesion  typical 
of  erythema  ncdosum  only  in  the  region  attacked  by 
that  disease,  the  existence  of  which  tends  to  exag- 
gerate the  nodular  character  of  the  tuberculin  lesion 
observed  in  all  tuberculous  persons.  A  side  ques- 
tion of  some  interest  arises  from  the  fact  that  the 
reaction  on  the  abdomen  was  much  less  intense  than 
that  on  the  arm,  and  the  authors  ask  if  it  is  not  a 
fact  that  in  all  tuberculous  stibjects  it  is  more  pro- 
nounced on  the  limbs  than  on  the  belly. 

Continuing,  the  authors  say,  to  apply  their  case 
to  the  elucidation  of  the  setiological  relations  be- 
tween erythema  nodosum  and  tuberculous  disease, 
.an  extensive  series  of  clinical  facts  had  already  in- 
duced one  of  them  to  think  that  erythema  nodosum 
depended  on  tuberculous  infe|Ction  in  certain  cases ; 
nevertheless,  observation  of  a  positive  intradermic 
reaction  t'o  tuberculin  in  a  person  afifected  with  ery- 
thema nodosimi  does  not  justify  the  affirmation  that 
that  disease  of  the  skin  is  of  tuberculous  origin. 
As  is  usual  in  such  cases,  the  result  of  the  test 
shows  only  that  the  patient  has  tuberculous  lesions, 
without  presumption  as  to  their  situation.  Never- 
theless, the  identity  of  the  spontaneous  nodosities 
with  those  provoked  by  the  intraderniic  injection  of 
tuberculin  and  the  failure  of  injections  of  different 
sera  and  toxines  speak  eloquently  in  favor  of  the 
tuberculous  origin  of  certain  cases  of  erythema 
nodosum. 

Finally,  the  following  deductions  may  be  drawn 
from  all  recent  publications  concerning  the  applica- 
tion of  the  intradermic  tuberculin  test  in  cases  of 
skin  diseases.  In  the  polymorphous  erythemata  the 
intradermic  injection  of  a  drop  of  artificial  serum, 
of  an  antitoxic  serum,  or  of  tuberculin  is  capable  of 
giving  rise  to  cutaneous  lesions  identical  with  the 
spontaneous  lesions  of  diseases  occurring  casually. 
In  such  cases  the  diagnostic  value  of  the  intrader- 
mic tuberculin  reaction  is  manifestly  nil.  We  may 
assign  to  tuberculous  infection  a  place  in  the  setiol- 
ogv  of  erythema  nodosum,  a  place  the  importance 
of  which  will  be  ultimately  determined  by  compar- 
ing the  data  furnished  by  clinical  examinations  with 
those  obtained  by  laboratory  researches. 


THE  AN-^lMIA  of  uncinariasis. 
There  are  two  theories  to  account  for  the  anaemia 
which  is  such  a  prominent  feature  of  infection  with 
the  hookworm  {Ankylostomiun  duodenale  and 
Necator  anicricanus) .  One  is  that  the  multiple 
small  haemorrhages  produced  by  the  teeth  of  the 
parasite  as  they  puncture  the  mucosa  of  the  intes- 
tine are  the  aetiological  factor  of  the  anaemia  :  the 
other  is  that  the  parasite  secretes  a  haemolytic 
agent  which  is  the  cause  of  the  destruction  of  the 


blood  elements.  The  Permanent  Commission  for 
the  Suppression  of  Uncinariasis  in  Puerto  Rico  is 
of  the  opinion  that  haemolysis  is  at  the  bottom  of 
the  anaemia. 

The  principal  reasons  for  this  view  are  that  the 
lesion  produced  by  the  parasite  is  confined  to  the 
mucosa,  which  is  denuded  of  its  epithelium,  and 
that  the  intestinal  contents  of  the  worm  consist  of 
epithelial  cells  and  not  of  red. blood  corpuscles.  We 
would  point  out  in  this  connection  that  the  fact  that 
the  intestine  of  the  worm  contains  no  red  blood  cor- 
puscles is  no  indication  that  the  worm  does  not  live 
on  blood.  As  soon  as  blood  is  taken  into  the  intes- 
tine of  an  animal  the  acid  contents  of  tliat  tract  would 
naturally  destroy  all  of  the  histological  characteristics 
of  the  erythrocytes.  The  commission  decided  that 
the  testing  of  the  stools  of  their  patients  for  occult 
blood  was  unnecessary.  We  should  like  to  know 
the  results  of  such  a  series  of  examinations,  how- 
ever ;  because  we  have  been  of  the  opinion  that  the 
anaemia  of  uncinariasis  was  meth^morrhagic 
anaetnia.  Whipple  {Journal  of  Experimental  Med- 
icine, March),  as  the  result  of  a  series  of  experi- 
ments, has  shown  that,  although  there  is  a  weak 
haemolytic  agent  in  the  bodies  of  hookworms,  both 
of  the  Old  World  and  of  the  New  World  species, 
this  haemolysin  acts  very  slowly  and  only  in  rather 
concentrated  solutions.  Whipple  concludes  that  "it 
seems  very  unlikely  that  this  weak  haemolysin 
found  in  the  hookworm  can  have  any  relation  to 
the  anaemia  of  uncinariasis." 

We  would  call  attention  to  the  beautiful  photomi- 
crograph made  by  Dr.  Gray,  of  the  Army  Medical 
Museum,  in  the  last  report  of  the  Anaemia  Commis- 
sion. It  is  more  than  likely  that  the  capillary 
haemorrhage  from  the  intestine  caused  by  many 
hundreds  of  worms  attached  to-  the  intestinal 
mucosa  in  the  manner  shown  in  that  picture  will  be 
sufficient  to  cause  a  marked  anaemia.  The 
methaemorrhagic  hypothesis  would  explain  why  a 
person  with  a  few  parasites  would  show  less  im- 
poverishment of  the  blood  than  one  with  many  par- 
asites, and  why  an  infection  of  long  duration  would 
produce  more  marked  symptoms  than  an  infection 
of  short  duration. 


INVISIBLE  PATHOGENIC  ORGANISMS. 

At  a  recent  meeting  of  the  French  Academy  of 
Sciences  {Seniaine  nicdicale,  May  5th)  Dr.  A. 
Chauveau  presented  a  communication  which  he  sum- 
marized as  follows :  Inoculations  of  vaccine  lymph 
progressively  diluted  continue  to  demonstrate  the 
existence  in  this  liquid  of  solid  elements  which  play 
the  part  of  virulent  agents.  On  the  other  hand, 
diffusion  experiments  continually  exclude  from  all 


OBITUARY.— NEWS  ITEMS. 


[New  Y'ork 
Medical  Journal 


participation  in  this  role  the  colloids  which  vaccine 
lymph  contains  in  a  state  of  extremely  fine  emul- 
sion. It  follows  that  the  invisible  virulent  agents 
of  vaccine,  as  well  as  their  numerous  congeners, 
transmissible  indefinitely  in  living  subjects,  preserve 
every  title  to  be  considered  as  animated  parasitic 
beings. 

These  virulent  agents  hold  a  very  important  place 
in  the  domain  of  natural  history,  though  their  in- 
visibility precludes  the  study  of  their  morphology  by 
the  naturalist.  Such  study  therefore  is  out  of  the 
question  in  demonstrating  the  existence  of  these  ex- 
traordinary parasites ;  a  fortiori,  it  could  not  de- 
termine them  specifically.  To  lift  some  of  the  veils 
under  which  they  are  so  completely  concealed,  the 
investigator  must  be  governed  by  the  principles  and 
methods  of  molecular  physics  and  pathological  physi- 
ology. These  branches  of  science  are  as  far  re- 
moved from  each  other  as  they  are  from  natural 
history;  nevertheless,  the  invisible  virulent  organ- 
isms establish,  by  the  requirements  of  their  study, 
a  curious  solidarity  among  these  three  realms  of 
science. 


THE  AMERICAN  MEDICAL  ASSOCIATION. 

The  annual  meeting,  which  begins  on  Tuesday 
of  next  week  in  Atlantic  City,  will  doubtless  be 
largely  attended,  as  most  of  the  meetings  have  been 
for  several  years  past;  The  attractiveness  of  At- 
lantic City  and  its  peculiar  fitness  as  the  scene  of 
a  large  attendance  will  most  certainly  contribute 
powerfully  to  the  result  here  predicted,  but  the  af- 
fairs of  the  association  itself  and  those  of  other 
organizations  holding  their  meetings  at  about  the 
same  time  will  be  the  real  inducement  for  many 
members  of  the  profession  to  be  present.  Naturally 
there  will  be  a  very  widespread  desire  to  listen  to 
the  incoming  president.  Colonel  Gorgas^  who  of 
l&te  years  has  taken  a  prominent  part  in  sanitation 
of  a  character  that  has  met  with  interest  even 
among  the  laity. 


WILLIAM  HUGHES,  M.  D., 
Of  Lima,  Indiana. 

Dr.  Hughes  died  at  his  home  on  Thursday,  May 
13th,  aged  seventy  years.  He  was  a  graduate  of 
the  Medical  Department  of  the  University  of  the 
City  of  New  York.  After  taking  his  medical  de- 
gree he  served  for  a  year  on  the  house  stafif  of  the 
Nursery  and  Child's  Hos])itaI,  of  New  York.  He 
had  practised  medicine  in  Lima  for  nearly  forty 
years,  and  was  regarded  as  one  of  the  ablest,  kind- 
est, and  most  lovable  men  of  northeastern  Indiana. 


Personal.— Dr.  Charles  A.  Oliver,  of  Philadelphia,  has 
been  elected  a  corresponding  member  of  the  Socicdad  de 
Estiidios  Clinicos  dc  la  Habaiia,  of  Havana,  Cuba. 

An  Addition  to  Kings  County  Hospital,  Brooklyn. — 
Plans  have  been  filed  for  an  extension  to  the  westerly 
end  of  the  main  building-  of  the  hospital,  to  contain  wards 
and  administration  rooms.    The  estimated  cost  is  $150,000. 

The  Tuberculosis  Exhibit  in  Newark,  N.  J.,  continues 
to  draw  large  crowds  daily.  On  May  27th,  which  was 
called  "club  day,"  nearly  twenty-five  hundred  people  visit- 
ed the  exhibit  and  listened  to  a  number  of  interesting  ad- 
dresses on  various  phases  of  the  tuberculosis  problem. 

A  Floating  Hospital  for  Philadelphia  is  being  organ- 
ized by  Dr.  J.  Madison  Taylor.  It  is  planned  to  make 
use  of  a  barge  for  giving  the  patients  in  the  children's  de- 
partment of  the  Philadelphia  General  Hospital  the  benefit 
of  the  fresh  air  of  the  Delaware  River  during  the  summer. 

Dr.  Biggs  Honored. — The  degree  of  Doctor  of  Laws 
was  conferred  upon  Dr.  Hermann  M.  Biggs,  general  medi- 
cal officer  of  the  New  York  Department  of  Health,  by  the 
New  York  University,  on  the  occasion  of  the  seventy- 
seventh  annual  commencement  of  the  university,  held  on 
June  2d. 

The  New  German  Hospital  in  Cleveland,  Ohio,  was 

dedicated  with  suitable  ceremonies  on  Sunday.  May  30th. 
The  new  building,  which  was  erected  at  a  cost  of  $50,000, 
has  accommodations  for  fifty  patients,  and  it  will  be  en- 
larged in  the  near  future  by  the  erection  of  an  addition  in 
the  rear  of  the  present  building. 

Fordham  University  Commencement. — Invitations 
have  been  issued  by  the  president  of  Fordhain  University, 
New  York,  and  the  faculty  of  the  medical  school  for  tlie 
first  commencement  exercises  of  the  Fordham  LIniversity 
School  of  Medicine,  to  be  held  in  the  college  auditorium 
on  Wednesday.  June  gth,  at  8:15  p.  m. 

The  Fortieth  Anniversary  of  the  American  Medical 
Editors'  Association  will  be  celebrated  at  the  annual 
banquet  of  the  association,  which  will  be  held  at  the  Mnrl- 
borough-Blenheim  Hotel,  Atlantic  City.  N.  J.,  on  Monday 
evening,  June  Jth.  Special  preparations  have  been  made  to 
make  this  occasion  one  of  unusual  interest,  and  a  good 
time  is  expected. 

Roof  Gardens  on  Boston  Public  Schools. — At  a  joint 
meeting  of  the  trustees  of  the  Hospital  for  Consumptives 
and  the  members  of  the  school  board,  it  was  suggested  that 
roof  gardens  be  established  on  the  public  schools  of  Bos- 
ton for  the  use  of  tuberculous  pupils.  It  is  said  that  there 
are  about  15,000  tuberculous  children  in  Boston,  of  whom 
at  least  5,000  need  medical  care. 

A  Dinner  to  Dr,  Robert  Kunitzer. — The  medical  staff 
and  directors  of  the  Sydenham  Hospital,  in  East  One  Hun- 
dred and  Sixteenth  Street,  New  York,  gave  a  complimen- 
tary dinner  to  Dr.  Kunitzer,  in  recognition  of  his  untiring 
efforts  to  build  up  the  charitable  end  of  hospital  work  in 
New  York.  The  directors  of  the  hospital  presented  to  Dr. 
Kunitzer  a  pair  of  field  glasses,  and  the  medical  staff  gave 
him  a  loving  cup. 

Improvements  at  Mount  Sinai  Hospital. —  Plans  have 
been  filed  for  tlie  enlargement  of  the  dispensar\-  and  train- 
ing school  for  nurses  of  the  hospital.  Two  stories  will 
be  added  to  the  dispensary,  making  it  a  five  story  struc- 
ture, and  a  seventh  story  will  be  added  to  the  nurses' 
home.  The  ornamental  roof  house  of  the  medical  pavilion 
will  also  be  enlarged  considerably.  The  two  new  floors 
nf  the  dispensary  will  be  fitted  with  a  laboratory  and  a 
neurological  ward,  with  rooms  for  medical  treatment.  The 
proposed  improvements  will  cost  about  $126,000. 

Changes  of  Address.--Dr.  James  \V.  Markoe,  to  20 
West  Fiftieth  Street,  New  York. 

Dr.  Frederick  Peterson,  to  20  We.st  Fiftieth  Street,  New 
York. 

Dr.  Herman  L.  Reis,  to  the  Cadillac  Hotel,  Broadway 
and  Forty-third  Street.  New  York. 

Dr.  Timothy  D.  Sullivan,  to  44  West  Ninety-sixth  Street, 
New  York. 

Dr.  Harry  Bock,  to  59  East  Sixty-fifth  Street,  New 
York. 

Dr.  Henrv  B.  Orton,  to  i2!;o  Park  Boulevard,  Camden, 
N.  J. 


XEiyS  ITEMS. 


II57 


Scarlet  Fever  was  the  topic  discussed  at  the  June  2d 
meeting  of  the  Ehiiira,  N.  Y.,  Academy  of  Medicine.  Dr. 
K.  P.  is'usii  dealt  with  the  aetiology,  pathology,  symptoms, 
diagnosis,  and  prognosis  of  the  disease,  and  Dr.  Alexander 
Mark  discussed  its  treatment — hygienic,  dietetic,  and 
medicinal. 

Nebraska  State  Medical  Society. — The  following  offi- 
cers ^\ere  elected  at  the  annual  meeting  of  the  society 
held  recently  in  Omaha :  Dr.  P.  H.  Salter,  of  Norfolk, 
president ;  Dr.  W.  J.  Birkhofer,  of  Gothenberg,  and  Dr. 
W.  H.  Wilson,  of  Lincoln,  vice-presidents ;  Dr.  A.  D.  Wil- 
kinson, of  Lincoln,  secretary;  Dr.  A.  S.  Von  Mansfelde,  of 
Ashland,  treasurer. 

The  Health  of  Pittsburgh. — During  the  week  ending 
Alay  26,  1909,  the  following  cases  of  transmissible  diseases 
were  reported  to  the  Bureau  of  Health :  Smallpox,  i  case, 
o  deaths;  chickenpox.  2  cases,  0  deaths;  typhoid  fever,  15 
cases,  I  death;  scarlet  fever,  14  cases,  o  deaths;  diphtheria, 
4  cases,  o  deaths ;  measles,  21  cases,  i  death ;  whooping 
cough,  31  cases,  i  death ;  pulmonary  tuberculosis,  57  cases, 
14  deaths.  The  total  deaths  for  the  week  numbered  154,  in 
an  estimated  population  of  565,000,  corresponding  to  an  an- 
nual death  rate  of  14.17  in  a  thousand  of  population. 

The  Medical  Society  of  the  Borough  of  the  Bronx 
held  a  stated  meeting  on  Thursday  evening,  June  3d.  Dr. 
Joseph  Winters  read  a  paper  on  Diarrhoea  in  Infants,  and 
a  practical  method  of  reducing  the  mortality  from  this 
disease  among  infants  in  the  summer  was  the  subject  of  a 
paper  presented  by  Dr.  Charles  Hermann.  Dr.  Godfrey 
R.  Pisek  read  a  paper  on  the  feeding  of  difficult  cases 
during  the  summer.  An  interesting  discussion  followed  the 
reading  of  the  papers,  and  at  the  close  of  the  meeting  a 
collation  was  served. 

The  Contagious  Disease  Situation  in  Chicago  was  the 
most  unsatisfactory  feature  of  the  city's  health  during  the 
week  ending  May  22,  1909.  There  were  an  unusual  num- 
ber of  deaths  from  acute  contagious  diseases,  and  1,175 
new  cases  were  reported,  as  compared  with  966  for  the 
preceding  week.  The  new  cases  reported  were :  Diph- 
theria, 93 ;  scarlet  fever,  100 ;  measles,  629 ;  whooping 
cough,  43;  tuberculosis,  76;  pneumonia,  38;  t\phoid  fever, 
32;  chickenpox.  83;  muinps,  68;  cerebrospinal  fever,  2; 
puerperal  fever,  I  ;  erysipelas,  10. 

Charitable  Bequests. — By  the  will  of  .'\nna  M.  Mur- 
phy, the  Protectory  for  Boys  at  Flatlands,  St.  John's  Or- 
phan Asylum,  St.  Vincent's  Home,  and  the  Little  Sisters 
of  the  Poor,  of  Philadelphia,  receive  $2,000  each.  St. 
Joseph's  Home  and  the  House  of  the  Good  Shepherd  for 
Young  Girls  receive  $1,000  each. 

By  the  will  of  the  Rev.  Dr.  Samuel  E.  Appleton,  the 
Protestant  Episcopal  Hospital  of  Phdadelphia  receives 
$10,000. 

By  the  will  of  Mr.  William  B.  Rice,  of  Quincy,  Mass., 
the  Quincy  City  Hospital  receives  $20,000  ;  and  the  town  of 
Hudson  receives  $20,000,  to  be  used  to  establish  either  a 
manual  training  school,  a  hospital,  or  a  home  for  district 
nurses.  The  will  also  provides  for  a  bequest  of  $200,000 
for  the  establishment  of  a  charitable  institution  bearing 
his  name,  the  character  of  which  he  leaves  to  his  executors 
and  trustees. 

By    the    will    of    Sabina    Littenecker,    of  Ridgewood 

Heights.  St.  Catherine's  Hospital,-  Brooklyn,  receives  $500. 

Society  Meetings  for  the  Coming  Week: 

MoND.^v,  June  jth. — German  Medical  Society  of'  the  City 
of  New  York ;  Utica,  N.  Y..  Medical  Library  Associa- 
tion ;  Niagara  Falls,  N.  Y.,  Academv  of  'Medicine : 
Practitioners'  Club,  Newark,  N.  J. ;  Hartford,  Conn.. 
Medical  Society. 

Tuesday,  June  8th. — New  York  Academy  of  Medicine 
(Section  in  Public  Health)  ;  Medical  Society  of  the 
County  of  Schenectady,  N.  Y. ;  Practitioners'  Club  of 
Jersey  City,  N,  J. ;  Medical  Society  of  the  County  of 
Rensselaer,  N.  Y. ;  Buffalo  Academy  of  Medicine  (Sec- 
tion in  Medicine). 

Wednesday.  June  oth.—'Hew  York  Pathological  Society; 
Medical  Society  of  the  Borough  of  the  Bronx;  Brook- 
lyn Medical  and  Pharmaceutical  Association :  Medical 
Society  of  the  County  of  Richmond.  N.  Y. 

Thursd.\y,  June  loth. — New  York  Academy  of  Medicine 
(Section  in  Pjediatrics)  ;  Brooklvn  Pathologicil  So- 
ciety (annual)  :  Blackw^ell  Medical  Societv  of  Roches- 
ter, N.  Y. 

Frid.\y.  June  iitli. — Eastern  Medical  Society  of  the  City 
of  New  York:  New  York  Academy  of  Medicine  (Sec- 
tion in  Otologv). 


The  California  State  Medical  Society  held  its  annual 
meeting  in  San  Jose  on  April  21st,  and  elected  the  follow- 
ing officers  to  serve  for  the  ensuing  year :  President,  Dr. 
J.  H.  Parkinson,  of  Sacramento ;  first  vice-president.  Dr. 
vVilliam  Simpson,  of  San  Jose;  second  vice-president.  Dr. 
W.  B.  .Sawyer,  of  Riverside ;  secretary.  Dr.  Philip  M.  Jones, 
of  San  Francisco.  The  next  annual  meeting  of  the  society 
will  be  held  in  Sacramento. 

Scientific   Society   Meetings   in   Philadelphia  for  the 
Week  Ending  June  12,  1909: 

Monday,  June  7th. — Philadelphia  Academy  of  Surgery; 
Biological  and  Microscopical  Section,  Academy  of  Nat- 
ural  Sciences ;   West   Philadelphia   IMedical  Associa- 
tion ;  Northwestern  Medical  Society. 
Tuesday,  June  8th. — Philadelphia  Prediatric  Society. 
Thursday,  Jtme  loth. — Section  Meeting,  Franklin  Listi' 

tute ;  Lebanon  Hospital  Medical  Society. 
Friday,  June  nth. — Northern  Medical  Association;  West 
Branch,  Philadelphia  County  Medical  Society. 
Philadelphia  Training  School  Commencements. — The 
Training  School  for  Nurses  of  the  Philadelphia  General 
Hospital  held  its  commencement  exercises  at  the  hospital 
on  the  evening  of  Tuesday,  May  ilth.  Twenty-seven  young 
women  received  diplomas,  which  were  presented  by  Dr. 
Joseph  S.  Neff,  Director  of  the  Department  of  Public 
Health  and  Charities. 

The  Training  School  for  Nurses  of  the  Gentian  Hospital 
held  its  commencement  exercises  on  the  afternoon  of  Fri- 
day, May  14th.  Thirteen  young  women  received  the  diploma 
of  the  school.    Dr.  James  C.  Wilson  delivered  the  address. 

The  annual  commencement  exercises  of  the  Training 
School  for  Nurses  of  the  Presbyterian  Hospital  were  held 
on  the  evening  of  Thursday,  May  13th.  Dr.  Samuel  McC. 
Hamill  delivered  the  address.  The  class  was  composed  of 
sixteen  nurses. 

Infectious  Diseases  in  New  York: 

IVe  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  folloiving  statement  of  new 
cases  and  deaths  reported  for  the  tivo  iveeks  ending  May 
?g,  TC)og: 

■  May  22  ,    .  May  jq  

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis    678         195         510  152 

Diphtheria    355  20         313  45 

IMea.sIes    1.365  12       1,671  25 

Scarlet   fever    335  19         273  21 

.Smallpox   

Varicella    226  .  .  197 

Typhoid  fever    48  7  28  12 

Whooping  cough    105  12  66  8 

Cerebrospinal    meningitis    12  8  8  7 

Total   3.124         273       3,086  270 

The  Mortality  of  Chicago. — During  the  week  ending 
May  22,  1909.  there  were  reported  to  the  Department  of 
Health  563  deaths  from  all  causes,  in  an  estimated  popula- 
tion of  2,224,490,  corresponding  to  an  annual  death  rate 
of  13.19  in  a  thousand  population.  This  death  rate  is  al- 
most ten  per  cent.  lower  than  the  average  for  this  senson 
for  the  past  ten  years.  The  principal  causes  of  death  were : 
Diphtheria,  11  deaths;  scarlet  fever,  10  deaths;  measles, 
8  deaths;  wdtooping  cough,  4  deaths;  influenza,  I  death; 
tyohoid  fever,  2  deaths ;  diarrhoeal  diseases,  32  deaths,  of 
which  29  were  under  two  years  of  age ;  pneumonia,  94 
deaths ;  pulmonary  tuberctdosis,  70  deaths ;  other  forms 
of  tuberculosis,  13  deaths;  cancer.  20  deaths;  nervous  dis- 
ease, 20  deaths;  heart  diseases,  48  deaths;  apoplexy,  10 
deaths;  Bright's  disease.  47  deadis;  violence.  30  deaths — 
from  suicide,  4  from  manslaughter,  and  19  from  acci- 
dents. 

Vit^l  Statistics  of  New  York. — During  the  week  end 
ing  ^lay  22.  1909,  there  were  reported  to  the  Depirtment 
of  Health  of  the  City  of  New  York  1,466  deaths  from  all 
causes,  in  an  estimated  population  of  4,564,792,  correspond- 
ing to  an  annual  death  rate  of  16.76.  The  death  rate  in 
each  of  the  five  boroughs  was  as  follows:  Manhnttan. 
16.71  ;  the  Bronx,  18.89:  Brooklyn,  16.44;  Queens,  15.12; 
and  Richmond,  20.07.  There  were  189  deaths  from  pul- 
monary tuberculosis  during  the  week,  107  deaths  from 
pneumonia.  107  from  bronchopneumonia.  128  from  heart 
disease,  109  from  Bright's  disease.  115  from  diarrhceal  dis- 
eases, of  .which  54  were  under  five  years  of  age,  and  56 
froin  cancer.  There  were  20  deaths  from  suicide,  6  from 
homicide,  and  65  from  accidents.  The  total  infant  mortal- 
ity was  480;  270  under  one  year  of  age,  iii  between  one 
and  two  years  of  age,  and  99  between  two  and  five  years. 
There  were  no  still  births.  Seven  hundred  and  fifty-four 
marriages  and  1,934  births  were  reported  during  the  week. 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


The  Jefferson  Medical  College  Alumni  of  New  Eng- 
land held  their  fourth  annual  meeting  and  banquet  in 
Hartford,  Conn.,  recently.  Among  the  guests  were  two 
members  of  the  faculty  of  Jefferson  Medical  College,  name- 
ly, Dr.  H.  Augustus  Wilson,  professor  of  orthopaedic  sur- 
gery, and  Dr.  E.  E  Graham,  professor  of  diseases  of  chil- 
dren. Dr.  .'\.  S.  McKnight,  of  Fall  River,  Mass.,  presided, 
and  called  informally  upon  the  members  of  the  association 
for  remarks.  The  following  officers  were  elected :  Presi- 
dent, Dr.  A.  S.  McKnight,  of  Fall  River,  Mass. ;  vice- 
president,  Dr.  John  T.  Farrell,  of  Providence,  R.  I. ;  secre- 
tary. Dr.  A.  Alac  Odrum,  of  Cambridge,  Mass. ;  treasurer. 
Dr.  W.  N.  Thompson,  of  Hartford,  Conn. 

The  American  Hospital  Association  will  hold  its  elev- 
enth annual  conference  at  the  New  Willard  Hotel,  Wash- 
ington, D.  C,  on  September  21st,  22d,  23d,  and  24th.  Ac- 
cording to  the  preliminary  announcement,  which  has  just 
been  issued,  the  programme  will  include  the  president's 
address,  ten  papers  on  questions  relating  to  hospital  ad- 
ministration, the  reports  of  committees,  and  an  exhibition 
of  charts  and  printed  forms  used  in  hospitals  and  other 
institutions.  A  complete  programme  will  be  mailed  three 
or  four  weeks  prior  to  the  date  of  the  meeting  to  the 
members  of  the  association.  .\11  others  who  are  interested 
in  the  work  of  the  association  may  obtain  these  pro- 
grammes and  full  information  regarding  the  meeting  by 
i.pplving  to  the  secretary,  Dr.  W.  L.  Babcock,  of  Grace 
Hospital,  Detroit,  Mich.  Dr.  John  M.  Peters,  of  Provi- 
dence, R.  I.,  is  president  of  the  association. 

An  International  American  Congress  of  Medicine  and 
Hygiene  and  an  international  exposition  of  hygiene  will 
be  held  in  Buenos  Ayres,  Argentine  Republic,  in  May,  1910, 
under  the  patronage  of  His  Excellency  the  President,  Dr. 
Jose  Figueroa  Alcorta.  The  congress  commemorates  the 
centennial  of  the  revolution  of  1810,  which  gave  the  re- 
public its  independence.  Dr.  Eliseo  Canton,  dean  of  the 
medical  faculty,  is  president  of  the  executive  committee, 
and  the  general  secretaries  of  the  congress  are  Dr.  Luis 
-Agote  and  Dr.  Pedro  Lacavera.  The  congress  has  been 
divided  into  the  following  sections :  Biology,  medicine,  sur- 
gery, public  hygiene,  pharmacy  and  chemistry,  sanitation, 
veterinary  medicine,  and  dental  pathology.  The  official 
languages  are  English;  French,  Spanish,  and  Portuguese. 
Papers  for  the  congress,  or  titles  of  papers,  accompanied 
by  brief  extracts,  will  be  received  up  to  January  i,  1910. 
For  programmes  and  further  information  regarding  the 
congress  apply  to  the  general  secretaries. 

Commencements. — Fifty-five  graduates  of  the  College 
of  Physicians  and  Surgeons,  Baltimore,  were  presented 
with  diplomas  on  June  2d  by  Dr.  Charles  F.  Bevan,  dean 
of  the  faculty.  The  presentation  speeches  were  made  by 
Dr.  William  P.  Spratling,  professor  of  nervous  diseases, 
who  also  gave  the  four  gold  medals  to  the  four  men  who 
stood  highest  in  the  class.  The  first  prize  was  won  by  Dr. 
W.  Fawcett,  of  Alabama. 

The  fifty-seventh  annual  commencement  exercises  of  the 
Woman's  Medical  College  of  Pennsylvania  were  held  on 
Wednesday,  May  26th.  Twenty-four  women  received  the 
diploma  of  the  school.  The  address  was  delivered  by  Dr. 
Frederick  P.  Henry,  professor  of  the  theory  and  practice 
of  medicine.  Two  of  the  graduating  class  were  from  for- 
eign countries:  Miss  Marie  A.  Seixas,  of  Hayti ;  and  Miss 
Honoria  Acosta,  of  the  Philippine  Islands. 

The  graduation  exercises  of  the  Army  Medical  School, 
Washington,  D.  C,  were  held  on  May  29th.  Secretary  of 
War  Dickinson  presented  diplomas  to  the  twenty-nine 
graduates,  and  Dr.  Roswell  Park,  of  Buffalo,  delivered  the 
address  to  the  graduating  class.  The  Hoff  memorial  medal 
was  awarded  to  Henry  C.  Coburn,  of  the  District  of  Co- 
lumbia, who  had  attained  the  highest  average  for  the  year's 
work. 

Four  young  women  received  diplomas  at  the  commence- 
ment exercises  of  the  New  York  Medical  College  and  Hos- 
pital for  Women,  which  were  held  in  the  Waldorf-Astoria 
on  the  evening  of  May  31st.  The  Rev.  Charles  F.  Aked 
delivered  the  address. 

Columbia  University  celebrated  its  one  hundred  and  fifty- 
fifth  annual  commencement  on  June  2d.  Degrees  were 
conferred  upon  over  a  thousand  candidates,  of  whom  81 
were  from  the  College  of  Plivsicians  and  Surgeons.  The 
candidates  for  the  degree  of  Doctor  of  Medicine  were  pre- 
sented by  Dr.  Samuel  W  Lambert,  dean  of  the  medical 
faculty,  and  the  Hippocratic  oath  was  administered  by  Dr. 
John  S.  Curtis. 


The  National  Association  for  the  Study  and  Preven- 
tion of  Tuberculosis  held  its  fifth  annua!  meetnig  in 
Washington,  D.  C.  May  13th,  14th,  and  15th.  Owing  to 
the  illness  of  the  president,  Dr.  Vincent  Y.  Bowditch,  of 
Boston,  Mr.  Homer  Folks,  of  New  York,  vice-president  of 
the  association,  presided.  In  his  opening  address  Mr.  Folks 
emphasized  the  need  for  more  hospital  provision  for  ad- 
vanced cases  of  tuberculosis,  and  throughout  the  meeting 
particular  stress  was  laid  on  the  fact  that  the  best  way  to 
prevent  the  spread  of  tuberculosis  among  the  well  was  to 
segregate  the  sick.  The  report  of  the  executive  secretary, 
Dr.  Livingston  Farrand,  of  New  York,  showed  that  during 
the  year  ending  May  I,  1909.  there  were  established  86  new 
sanatoria  and  hospitals,  making  a  total  in  the  country  of 
298 ;  the  number  of  new  dispensaries  opened  was  85,  mak- 
mg  a  total  of  222;  and  the  number  of  associations  formed 
was  136,  making  a  total  of  290  at  the  present  time.  Thirty- 
four  out  of  forty  legislatures  in  session  during  the  year 
considered  bills  relating  to  tuberculosis,  and  in  many  cases 
passed  bills.  The  following  officers  were  elected  to  serve 
for  the  ensuing  year :  President,  Dr.  Edward  G.  Janeway, 
of  New  York ;  vice-presidents,  Mr.  Edward  T.  Devine,  of 
New  York,  and  Dr.  Henry  Sewall,  of  Denver ;  secretary, 
Dr.  Henry  Barton  Jacobs,  of  Baltimore ;  treasurer.  General' 
George  M.  Sternberg,  of  Washington.  The  members  of 
the  executive  committee  are :  Mr.  William  H.  Baldwin, 
of  Washington ;  Dr.  Hermann  M.  Biggs,  of  New  York ; 
Mr.  Edward  T.  Devine,  of  'New  York ;  Mr.  Homer  Folks, 
of  New  York;  Dr.  George  M.  Kober,  of  Washington:  Dr. 
John  H.  Lowman,  of  Cleveland ;  and  Dr.  Joseph  Walsh,  of 
Philadelphia.  The  directors  elected  for  terms  of  five  years 
are :  Dr.  Edward  G.  Janeway,  of  New  York ;  Dr.  Joseph 
Walsh,  of  Philadelphia:  Dr.  George  M.  Kober,  of  Wash- 
ington ;  Dr.  John  H.  Lowman,  of  Cleveland ;  Professor 
W.  T.  Sedgwick,  of  Boston ;  Dr.  E.  A.  Pierce,  of  Portland, 
Ore.:  Dr.  Joseph  Y.  Porter,  of  Key  West,  Fla. ;  Dr. 
Robert  H.  Babcock.  of  Chicago ;  Dr.  Walter  R.  Steiner, 
of  Hartford,  Conn. :  Mr.  R.  B.  Mellon,  of  Pittsburgh :  Mr. 
John  M.  Glenn,  of  New  York,  and  Dr.  W.  F.  Drewry,  of 
Petersburg,  Va. 

The  Atlantic  City  Meeting  of  the  American  Medical 
Association  will  open  with  the  meeting  of  the  House 
of  Delegates  on  Alonday,  June  7th,  at  10  a.  m.,  in  the 
solarunn  of  the  Traymore  Hotel.  The  first  general  ses- 
sion will  be  held  in  the  auditorium  on  Young's  new  pier 
at  10:30  Tuesday  morning,  June  8th.  The  section  meet- 
ings will  be  held  simultaneously  on  Tuesday  afternoon,  on- 
Wednesday,  Thursday,  and  Friday,  at  the  following  places : 
Practice  of  Medicine.  Alarin-e  Hall,  Steel  Pier;  Surgery 
and  Anatomy,  Ocean  Hall,  Steel  Pier;  Diseases  of  Children, 
First  Presbyterian  Church,  Pacific  and  Pennsylvania  Ave- 
nues ;  Obstetrics  and  Diseases  of  Women,  Casino  Hall, 
Steel  Pier ;  Nervous  and  ]\lental  Diseases,  Brighton  Cas- 
ino: Pharmacology  and  Therapeutics.  Jewish  Synagogue, 
Pacific  and  Pennsylvania  .Avenues;  Hygiene  and  Sanitary 
Science,  Baptist  Church,  Pacific  near  Pennsylvania  Ave- 
nue ;  Pathology  and  Physiologv-.  Central  Methodist  Church, 
1213  Pacific  Avenue ;  Ophthalmology,  Parochial  Hall  No. 
1,  Top  Floor,  Tennessee  and  Pacific  .Avenues:  Laryngology 
and  Otology,  Parochial  Hall  No.  2,  Second  Floor,  Ten- 
nessee and  Pacific  Avenues ;  Cutaneous  Medicine  and  Sur- 
gery, Olivet  Church.  Tennessee  and  Pacific  Avenues ; 
Stomatology,  Olivet  Church  Sunday  School  Room,  Ten- 
nessee and  Pacific  .Avenues 

On  arriving  in  Atlantic  City  members  should  promptly 
register  at  the  Office  of  Registration  and  Bureau  of  In- 
formation a:  the  shore  end  of  Young's  old  pier.  Both  the 
commercial  and  scientific  exhibits  will  be  held  on  this  pier. 
The  presidential  reception  will  be  held  on  the  steel  pier  6n 
Wednesday  evening  and  an  afternoon  tea  for  the  ladies 
will  be  given  at  the  Marlborough-Blenheim  Hotel.  A 
number  of  allied  organizations  will  hold  sessions  at  At- 
lantic City  during  the  week  and  tlie  medical  colleges  and 
hospitals  of  Philadelphia  will  hold  special  clinics  on  Alon- 
day,  June  7th,  and  on  Saturday,  June  12th,  to  which  all 
the  members  of  the  association  are  invited.  .Arrangements 
have  been  made  for  numerous  alumni  reunions  on  Tues- 
day evening.  June  8th.  In  some  cases  the  members  will 
dine  together  and  the  meetings  will  not  take  place  until 
after  the  dinner  hour.  The  reunion  of  the  Harvard 
.Alumni  will  take  place  at  the  Windsor  at  7 :30  p.  m. :  of 
the  Dartmouth  .Alumni  at  the  Chelsea,  at  0  n.  m  :  of  the 
Medicochirurgical  .Alumni,  at  the  Rudolf,  at  8:30  p.  m. ; 
of  the  Jefferson  at  the  Roval  Palace  at  9  p.  m. :  and  of  the 
Vanderbilt  Alumni  at  Young's  at  8  p.  m. 


June  5.  1909.] 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  NOMENCLATURE. 


II59 


THE  BELLEVUE    HOSPITAL    NOMENCLATURE  OF  DISEASES  AND 

CONDITIONS.* 

First  Edition,  1903. 
First  Revision,  1909. 

Cu.MPlLED  BY  THE  COMMITTEE    ON    CLINICAL    RECORDS,  CoMl'OSEU  OF  ROBERT  J.  CARLISLE,  WaRREN  CoLEMAN, 

Thomas  A.  Smith  and  Edmund  L.  Dow. 
(Continued  from  page  11 12.) 


OBSTETRICAL  CONDITIONS,  DISEASES,  AND 
INJURIES. 

Abortion,  Induced.    Up  to  fourth  month  of  pregnancy. 

Abortion,  Spontaneous. 

Abortion,  Threatened. 

Accidental  Haemorrhage,  Parturition. 

Accidental  Haemorrhage,  Pregnancy. 

Accidental  Haemorrhage,  Puerperium. 

Defonncd  Pelvis,  Parturition.    State  tjpe  of  pelvis. 

Deformed  Pehis,  Pregnancy.    State  type  of  pelvis. 

Displacement  of  Uterus,  Pregnancy. 

Displacement  of  Uterus,  Puerperium. 

Eclampsia,  Parturition. 

Eclampsia,  Pregnancy. 

Eclampsia,  Puerperium. 

Gestation,  Extrauterine.  File  under  Diseases  of  Re- 
productive Organs. 

Hydatidiforni  Mole.  Diagnosticate  a?  Chorioepitheli- 
oma.    File  under  Tumors. 

Hydramnios,  Pregnancy. 

Hydrorrhcea  Gravidarum. 

Laceration  of  Cervix  Uteri,  Recent.  Use  only  as  a  sec- 
ondary diagnosis  to  Puerperium. 

Laceration  of  Pelvic  Floor,  Recent.  Use  only  as  a  sec- 
ondary diagnosis  to  Puerperium. 

Mastitis,  Puerperium. 

Miscarriage,  Induced.    From  fourth  to  seventh  month 

of  pregnancy. 
Miscarriage,  Spontaneous. 
Miscarriage,  Threatened. 
PARTURITION,  ABNORMAL: 
Parturition,  M.  L.  A. 
Parturition,  M.  D.  A. 
Parturition,  M.  D.  P. 
■  Parturition,  M.  L.  P. 
Parturition,  Sc.  L.  A. 
Parturition,  Sc.  D.  A. 
Parturition,  Sc.  D.  P. 
Parturition,  Sc.  L.  P. 

PARTURITION,  NORMAL: 

Parturition,  O.  L.  A. 

Parturition,  O.  D.  A. 

Parturition,  O.  D.  P. 

Parturition,  O.  L.  P. 

Parturition,  S.  L.  A. 

Parturition,  S.  D.  A. 

Parturition,  S.  D.  P. 

Parturition,  S.  L.  P. 

Parturition,  Multiple.    State  positions. 

Placenta  Praevia,  Parturition. 

Placenta  Praevia,  Pregnancy. 

Pregnancy,  Normal.    State  month  in  all  cases. 

Pregnancy,  Vomiting  of. 

Premature  Birth,  Induced.     After  seventh   month  of 

pregnancy. 
Premature  Birth,  Spontaneous. 

Puerperium,  Normal.  State  number  of  days  post- 
partum. 

Retained  Secundines,  Parturition. 
Retained  Secundines,  Puerperium. 
Rupture  of  Uterus,  Parturition. 
Rupture  of  Uterus,  Puerperium. 

Septichaemia,  Puerperium.  File  under  Septichaemia.  In- 
fective Diseases. 

/Copyright  by  the  Board  of  Trustees  of  Bellevue  and  Allied  Hos- 
pitals, 1904. 


NEWBORN  CHILD. 

Haemorrhage  from  Umbilical  Cord. 
Icterus  Neonatorum. 

Newborn  Child.    Full  term  child  born  in  Bellevue  or 

an  Allied  Irlospital  or  Department  Ambulance. 
Prematurity. 
Stillborn  Child. 

INJURIES. 

I.    ORGANS  AND  SPECIAL  STRUCTURES. 

BONE:   State  Bone. 
Contusion  of. 

Epiphyseal  Separation  of.  Traumatic.    File  with  Frac- 
tures under  bone  affected. 
Foreign  Body  in. 

Fracture  of  or  about. 

Fracture  of  or  about.  Compound. 

about  Ankle  Joint.    To  include  Pott's  Fracture. 

Clavicle. 

Bones  of  Faee. 

Femur. 

Bones  of  Foot. 

Bones  of  Forearm. 

Bones  of  Hand. 

Humerus. 

Hyoid. 

Bones  of  Leg. 

Maxilla,  Inferior. 

Patella. 

Pelvis. 

Rib. 

Costal  Cartilage. 
Scapula. 
Skull. 
Sternum. 
.  Vertebra. 

about  Wrist  Joint.   To  include  Colles's  Fracture. 
Wound  of,  Gunshot. 
Wound  of.  Punctured. 
Wound  of,  Stab. 
BURSA:  State  Bursa. 
Wound  of — Bursa,  Incised. 
Wound  of — Bursa,  Lacerated. 
Wound  of — Bursa,  Punctured. 
Wound  of — Bursa,  Stab. 

CIRCULATORY  SYSTEM. 

ARTERIES  AND  VEINS: 
Contusion  of. 
Wound  of.  Gunshot. 
Wound  of.  Incised. 
Wound  of.  Laceration. 
Wound  of.  Punctured. 
Wound  of.  Stab. 

HEART  AND  PERICARDIUM:' 

Foreign  Body  in  Heart. 
Wound  of  Heart,  Gunshot. 
Wound  of  Heart,  Incised. 
Wound  of  Heart,  Lacerated. 
Wound  of  Heart,  Punctured. 
Wound  of  Heart,  Stab. 
Wound  of  Pericardium,  Incised. 
Wound  of  Pericardium,  Lacerated. 
Wound  of  Pericardium,  Punctured. 
Wound  of  Pericardium,  Stab. 


State  Artery  or  Vein. 


I  i6o 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  NOMENCLATURE. 


[New  York 
Medical  Journal. 


DIGESTIVE  SYSTEM. 

INTESTINE;  LIVER,  GALLBLADDER,  AND 
GALL  DUCTS;  MESENTERY,  OMENTUM, 
AND  PERITONEUM;  PANCREAS;  STOM- 
ACH.    State  organ. 

Contusion  of. 

Foreign  Body  in.     Not   to  include   Foreign   Body  in 

Stomach  and  Intestme. 
Foreign  Body  in  Abdominal  Cavity. 
Wound  of,  Gunshot. 
Wound  of.  Incised. 

Wound  of.  Lacerated.    To  include  rupture. 
Wound  of.  Punctured. 
Wound  of.  Stab. 

MOUTH;  GUMS,  TEETH,  AND  ALVEOLI;  LIPS; 
PALATE  AND  UVULA;  PHARYNX;  SALI- 
VARY GLANDS  AND  DUCTS;  TONGUE; 
TONSILS. 

State  part. 
Abrasion  of. 

Avulsion  of  Alveolar  Process. 

Avulsion  of  Tooth. 

Burn  of. 

Contusion  of. 

Foreign  Body  in. 

Fracture  of  Tooth. 

Wound  of,  Gunshot. 

Wound  of.  Incised. 

V\^ound  of.  Lacerated. 

Wound  of.  Punctured. 

Wound  of.  Stab. 

CESOPHAGUS: 

Abrasion  of  (Esophagus. 

Burn  of  CEsophagus. 

Wound  of  QSsophagus,  Gunshot. 

Wound  of  CEsophagus,  Incised. 

Wound  of  CEsophagus,  Lacerated.    To  include  rupture. 

Wound  of  CEsophagus,  Punctured. 

Wound  of  CEsophagus,  Stab. 

RECTUM  AND  ANUS: 

Abrasion  of  Anus. 

Abrasion  of  Rectum. 

Bum  of  Anus. 

Burn  of  Rectum. 

Contusion  of  Anus. 

Wound  of  Anus,  Gunshot. 

Wound  of  Rectum,  Gunshot. 

Wound  of  Anus,  Incised. 

Wound  of  Rectum,  Incised. 

Wound  of  Anus,  Lacerated.  Not  to  iiichide  obstetrical 
injury. 

Wound  of  Rectum,  Lacerated.    Not  to  include  obstet- 
rical injury. 
Wound   of  Anus,  Punctured. 
Wound  of  Rectum,  Punctured. 
Wound  of  Anus,  Stab. 
Wound  of  Rectum,  Stab. 
EAR: 

Abrasion  of  Auricle. 

Avulsion  of  Auricle  (partial  or  complete). 

Burn  of  Auricle. 

Contusion  of  Auricle. 

Frostbite  of  Auricle. 

Haematoma  of  Auricle,  Traumatic. 

Rupture  of  Tympanum,  Traumatic. 

Wound  of  Tympanum,  Punctured. 
Wound  of  Auricle,  Gunshot. 
Wound  of  Auricle,  Incised. 
Wound  of  Auricle,  Lacerated. 
Wound  of  Auricle,  Punctured. 
Wound  of  Auricle,  Stab. 
EYE  AND  EYELID: 
Abrasion  of.    State  site. 
Burn  of.    State  site. 
Contusion  of  Eyeball. 
Contusion  of  Eyelid. 
Dislocation  of  Eyeball. 
Dislocation  of  Lens. 
Foreign  Body  in  Eve. 
Haemorrhage  into  Eyeball. 


Haemorrhage  under  Conjunctiva,  Traumatic, 

Rupture  ot  Globe. 

Wound  of  Eye,  Gunshot. 

Wound  of.  Incised. 

Wound  of,  Lacerated. 

Wound  of.  Punctured. 

Wound  of,  Stab. 

JOINTS:  State  Joint. 

Contusion  of  Joint.    Use  as  a  diagnosis  only  when  the 

structures  of  the  joint  itself  are  involved. 
Dislocation  about  Ankle. 
Dislocation  of  Clavicle. 
Dislocation  of  Elbow. 
Dislocation  of  Upper  End  of  Fibula. 
Dislocation  of  Finger. 

Dislocation  of  Thumb. 
Dislocation  of  Hip. 
Dislocation  of  Hyoid  Bone. 
Dislocation  of  Knee. 

Dislocation  of  Semilunar  Cartilage. 
Dislocation  of  Maxilla,  Inferior. 
Dislocation  of  Metatarsus. 
Dislocation  of  Patella. 
Dislocation  of  Pelvis. 
Dislocation  of  Rib. 

Dislocation  of  Costal  Cartilage. 
Dislocation  of  Shoulder. 
Dislocation  of  Sternum. 
Dislocation  of  Tarsus. 
Dislocation  of  Toe. 

Dislocation  of  Vertebra.    State  vertebra. 

Dislocation  of  Coccyx. 

Dislocation  of  Occiput  from  Atlas. 
Dislocation  about  Wrist.    To  include  carpus. 
Foreign  Body  in. 

Haemorrhage  into,  Traumatic.    Do  not  use  as  a  pre- 
liminary diagnosis  when  cause  can  be  determined. 
Rupture  of.    State  ligament  involved. 
Sprain  of. 

Wound  of.  Gunshot. 

Wound  of.  Incised. 

Wound  of.  Lacerated. 

Wound  of.  Punctured. 

Wound  of.  Stab. 

LYMPHATIC  SYSTEM: 

Wound  of  Thoracic  Duct,  Gunshot. 

Wound  of  Thoracic  Duct,  Incised. 

Wound  of  Thoracic  Duct,  Lacerated.    To  include  Rup 
ture. 

Wound  of  Thoracic  Duct,  Stab. 
MUSCULAR  SYSTEM: 
MUSCLES.    State  muscle. 
Contusion  of. 
Dislocation  of. 
Foreign  Body  in. 
Rupture  of. 

Rupture  of  Sheath  of. 
Strain  of. 

Wound  of.  Gunshot. 
Wound  of.  Incised. 
Wound  of.  Lacerated. 
Wound  of.  Punctured. 
Wound  of.  Stab. 
TENDONS.    State  tendon. 
Dislocation  of. 
Rupture  of. 
Wound  of,  Incised. 
Wound  of.  Lacerated. 
Wound  of.  Punctured. 
Wound  of.  Stab. 

NERVOUS  SYSTEM: 

BRAIN: 

Foreign  Body  in  Brain. 

Intracranial  Injury.    To  include  concussion,  contusion, 

luTmorrhatjc  and  laceration. 
Wound  of  Brain,  Gunshot. 
Wound  of  Brain,  Incised. 
Wound  of  Brain,  Punctured. 
Wound  of  Brain,  Stab. 


June  5,  1909.] 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  XOMEXCLATURE. 


I161 


SPIXAL  CORD: 

Foreign  Body  m  Spinal  Cord. 

Intraspinal  Injury.    To  include  concussion,  contusion, 

hiemorrhage  and  laceration. 
Wound  of  Spinal  Cord,  Gunshot. 
Wound  of  Spinal  Cord,  Incised. 
Wound  of  Spinal  Cord,  Punctured. 
Wound  of  Spinal  Cord,  Stab. 

NERVES:  State  Nerve. 
Compression  of. 
Contusion  of. 
Displacement  of. 
Foreign  Body  in. 

Rupture   of.     To    include   injury  following  operative 

stretching. 
Wound  of,  Gunshot. 
Wound  of.  Incised. 
Wound  of.  Punctured. 
Wound  of,  Stab. 

REPRODUCTIVE  ORGANS: 

MAMMARY  GLAXD: 
Abrasion  of  Breast. 
Burn  of  Breast. 
Contusion  of  Breast. 
Foreign  Body  in  Breast. 
Hasmatoma  of  Breast. 
Wound  of  Breast,  Gunshot. 
Wound  of  Breast,  Incised. 
Wound  of  Breast,  Lacerated, 
Wound  of  Breast,  Punctured. 
Wound  of  Breast,  Stab. 

PFXIS: 

Abrasion  of  Penis. 

Amputation  of  Penis,  Traumatic.    To  include  avulsion. 

Burn  of  Penis. 

Contusion  of  Penis. 

Foreign  Body  in  Penis. 

Fracture  of  Penis. 

Frostbite  of  Penis. 

Haematoma  of  Penis.    Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 
Strangulation  of  Penis. 
Wound  of  Penis,  Gunshot. 
Wound  of  Penis,  Incised. 
Wound  of  Penis,  Lacerated. 
Wound  of  Penis,  Punctured. 
Wound  of  Penis,  Stab. 

SCROTUM: 
Abrasion  of  Scrotum. 
Burn  of  Scrotum. 
Contusion  of  Scrotum. . 
Foreign  Body  in  Scrotum. 
Frostbite  of  Scrotum. 

Haematoma  of  Scrotum.    Do  not  use  as  a  primarj-  diag- 
nosis when  cause  can  be  determined. 
Wound  of  Scrotum,  Gunshot. 
Wound  of  Scrotum,  Incised. 
Wound  of  Scrotum,  Lacerated. 
Wound  of  Scrotum,  Punctured. 
Wound  of  Scrotum,  Stab. 

SPERMATIC  CORD: 
Haematoma  of  Spermatic  Cord. 
Torsion  of  Spermatic  Cord,  Traumatic. 
Wound  of  Spermatic  Cord,  Incised. 
Wound  of  Spermatic  Cord,  Punctured. 
Wound  of  Spermatic  Cord,  Stab. 

TESTICLE: 
Castration,  Traumatic. 
Contusion  of  Testicle. 
Dislocation  of  Testicle. 
Wound  of  Testicle,  Gunshot. 
Wound  of  Testicle,  Incised. 
Wound  of  Testicle,  Punctured. 
Wound  of  Testicle,  Stab. 
TUNICA  VAGINALIS: 

Haematocele  of  Tunica  Vaginalis.    Do  not  use  as  a  pri- 
mary diagnosis  when  cause  can  be  determined. 


UTERUS: 
Bum  of  Uterus. 
Contusion  of  Uterus. 
Rupture  of  Uterus,  Traumatic. 
Wound  of  Uterus,  Gunshot. 
Wound  of  Uterus,  Incised. 
Wound  of  Uterus,  Lacerated. 
Wound  of  Uterus,  Punctured. 
Wound  of  Uterus,  Stab. 

VAGINA: 

Abrasion  of  Vagina. 

Burn  of  Vagina. 

Wound  of  Vagina,  Incised. 

Wound  of  Vagina,  Lacerated. 

Wound  of  Vagina,  Punctured. 

Wound  of  Vagina,  Stab. 

VULVA: 

Abrasion  of  Vulva. 
Burn  of  Vulva. 
Contusion  of  Vulva. 
Haematoma  of  Vulva,  Traumatic. 
Wound  of  Vulva,  Incised. 
Wound  of  Vulva,  Lacerated. 
Wound  of  Vulva,  Punctured. 
Wound  of  Vulva,  Stab. 
RESPIRATORY  SYSTEM: 
LARYNX: 
Abrasion  of  Larynx. 
Burn  of  Larynx.  ' 
Fracture  of  Larynx. 
Wound  of  Larynx,  Gunshot. 
Wound  of  Larynx,  Incised. 
Wound  of  Larynx,  Punctured. 
Wound  of  Larynx,  Stab. 
LUNG: 

Foreign  Body  in  Lung. 
Wound  of  Lung,  Gunshot. 
Wound  of  Lung,  Incised. 
Wound  of  Lung,  Punctured. 
Wound  of  Lung,  Stab. 
NOSE: 

Abrasion  of  Nose. 
Burn  of  Nose. 
Contusion  of  Nose. 
Dislocation  of  Nasal  Cartilage. 
Fracture  of  Nasal  Septum. 
Frostbite  of  Nose. 
Hasmatoma  of  Nasal  Septum. 
Wound  of  Nose,  Gunshot. 
Wound  of  Nose,  Incised. 
Wound  of  Nose,  Lacerated. 
Wound  of  Nose,  Punctured. 
Wound  of  Nose,  Stab. 
PLEURA: 

Foreign  Body  in  Pleural  Cavity. 
Wound  of  Pleura,  Gunshot. 
Wound  of  Pleura,  Incised. 
Wound  of  Pleura,  Punctured. 
Wound  of  Pleura,  Stab. 
TRACHEA: 
Abrasion  of  Trachea. 
Burn  of  Trachea. 
Fracture  of  Tracheal  Cartilage. 
Wound  of  Trachea,  Gunshot. 
Wound  of  Trachea,  Incised. 
Wound  of  Trachea,  Punctured. 
Wound  of  Trachea,  Stab. 
SPLEEN: 

Foreign  Body  in  Spleen. 
Wound  of  Spleen,  Gunshot. 
Wound  of  Spleen,  Incised. 

Wound  of  Spleen,  Lacerated.    To  include  rupture. 

Wound  of  Spleen,  Punctured. 

Wound  of  Spleen,  Stab. 

URINARY  SYSTEM: 

BLADDER: 

Abrasion  of  Bladder. 

Wound  of  Bladder,  Gunshot. 


I  1 62 


CARLISLE  ET  AL.:  BELLEVUE  HOSPITAL  NOMENCLATURE. 


[New  York 
Medical  Journal. 


Wound  of  Bladder,  Incised. 

Wound  of  Bladder,  Lacerated.    To  include  rupture. 
Wound  of  Bladder,  Punctured. 
Wound   of  Bladder,  Stab. 

KIDNEY: 

Contusion  of  Kidney. 
Foreign  Body  in  Kidney. 
Wound  of  Kidney,  Gunshot. 
Wound  of  Kidney,  Incised. 

Wound  of  Kidney,  Lacerated.    To  include  rupture. 
Wound  of  Kidney,  Pvnctured. 
Wound  of  Kidney,  Stab. 

URETER: 
Abrasion  of  Ureter. 
Wound  of  Ureter,  Gunshot. 
Wound  of  Ureter,  Incised. 

Wound  of  Ureter,  Lacerated.    To  include  rupture. 
Wound  of  Ureter,  Punctured. 
Wound  of  Ureter,  Stab. 

URETHRA: 
Abrasion  of  the  Urethra. 
Burn  of  the  Urethra. 
Urethral  Fever,  Traumatic. 
Wound  of  Urethra,  Incised. 

Wound"  of  Urethra,  Lacerated.    To  include  rupture. 
Wound  of  Urethra,  Punctured. 
Wound  of  Urethra,  Stab. 

II.  REGIONS. 

ABDOMINAL  WALL: 
Abrasion  of  Abdominal  Wall. 
Burn  pf  Abdominal  Wall. 
Contusion  of  Abdominal  Wall. 
Foreign  Body  in  Abdominal  Wall. 
Haematoma  of  Abdominal  Wall. 
Wound  of  Abdominal  Wall,  Gunshot. 
Wound  of  Abdominal  Wall,  Incised. 
Wound  of  Abdominal  Wall,  Lacerated. 
Wound  of  Abdominal  Wall,  Punctured. 
Wound  of  Abdominal  Wall,  Stab. 

BACK: 

Abrasion  of  Back. 
Burn  of  Back. 
Contusion  of  Back. 
Foreign  Body  in  Back. 
Hasmatoma  of  Back. 
Wound  of  Back,  Gunshot. 
Wound  of  Back,  Incised. 
Wound  of  Back,  Lacerated. 
Wound  of  Back,  Punctured. 
Wound  of  Back,  Stab. 

CHEST  WALL: 
Abrasion  of  Chest  Wall. 
Burn  of  Chest  Wall. 
Compression  of  Chest. 
Contusion  of  Chest  Wall. 
Foreign  Body  in  Chest  Wall. 
Haematoma  of  Chest  Wall. 
Wound  of  Chest  Wall,  Gunshot. 
Wound  of  Chest  Wall,  Incised. 
Wound  of  Chest  Wall,  Lacerated. 
Wound  of  Chest  Wall,  Punctured. 
Wound  of  Chest  Wall,  Stab. 

EXTREMITY.    LOWER:    Specify    Buttock,  Thigh, 

Leg,  Foot,  or  Toe. 
Abrasion  of. 

Amputation  of.  Traumatic.    To  include  complete  or 

partial  avulsion. 
Avulsion  of  Toenail. 
Burn  of. 
Contusion  of. 
Crush  of. 

Foreign  Body  in.    Not  to  include  foreign  body  in  spe- 
cial structures. 
Frostbite  of. 

Haematoma  of.     Do  not  use  as  a  primary  diagnosis 

uIk'u  can^c  can  be  determined. 
Wound  of.  Gunshot. 


Wound  of.  Incised. 
Wound  ot.  Lacerated. 
Wound  of,  Punctured. 
Wound  of,  Stab. 

EXTREMITY,  UPPER:  Specify  Shoulder,  Arm,  Fore- 
arm, Hand,  or  Finger. 
Abrasion  of. 

Amputation  of,  Traumatic.     To  include  complete  or 

partial  avulsion. 
Avulsion  of  Finger  Nail. 
Burn  of. 
Contusion  of. 
Crush  of. 

torcign  Body  in.    Not  to  include  foreign  body  in  spe- 
cial structures. 
Frostbite  of. 

Haematoma  of.     Do  not  use  as  a  primarj-  diagnosis 

when  cause  can  be  determined. 
Wound  of,  Gunshot. 
Wound  of.  Incised. 
Wound  of.  Lacerated. 
Wound  of.  Punctured. 
Wound  of.  Stab. 

FACE  AND  SCALP:  Specify  Face  or  Scalp. 
Abrasion  of. 

Avulsion  of  Scalp.    (Complete  or  partial.) 
Burn  of. 
Contusion  of. 
Epilation,  Traumatic. 
Foreign  Body  in. 

Frostbite  of  Face.    Not  to  include  ears  or  nose. 
Haematoma  of.    Do  not  use  as  a  primary  diagnosis 

when  cause  can  be  determined. 
Wound  of,  Gunshot. 
Wound  of.  Incised. 
Wound  of.  Lacerated. 
Wound  of.  Punctured. 
Wound  of.  Stab. 

NECK: 

Abrasion  of  Neck. 
Burn  of  Neck. 
Contusion  of  Neck. 
Foreign  Body  in  Neck. 

Haematoma  of  Neck.    Do  not  use  as  a  primary  diag- 
nosis when  cause  can  be  determined. 
Wound  of  Neck,  Gunshot. 
Wound  of  Neck,  Incised. 
Wound  of  Neck,  Lacerated. 
Wound  of  Neck,  Punctured. 
Wound  of  Neck,  Stab. 

MALE  PERIN.a:UM: 

Abrasion  of  Male  Perinaeum. 
Burn  of  Male  Perinaeum. 
Contusion  of  Male  Perinaeum. 
Foreign  Body  in  Male  Perinaeum. 
Haematoma  of  Male  Perinaeum. 
Wound  of  Male  Perinaeum,  Incised. 
Wound  of  Male  Perinaeum,  Lacerated. 
Wound  of  Male  Perinaeum,  Punctured. 
Wound  of  Male  Perinaeum,  Stab. 

III.    MISCELLANEOUS  INJURIES. 

Abrasions.  General. 
Air  Embolism. 
Burns,  General. 
Contusions,  General. 
Decapitation. 

Electric  Shock,  Injury  from. 

Lightning  Stroke. 
Emphysema,  Traumatic.    State  site. 
Exposure  to  Extreme  Cold. 
Multiple  Injuries,  Extreme. 
Powdered  Glass,  Injury  from  Swallowing. 
Smoke  Inhalation. 
Strangulation. 
Submersion. 

Suffocation.    To  include  overlying. 
Sunstroke. 

Heat  Exhaustion. 


June  5,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


%\\\  %i  Cvrrtnt  f  tttratsre. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

May  .27,  1909. 

1.  The  Early  Career  of  Sydenham,  with  Remarks  011  the 

Men  and  Medicine  of  His  Time, 

By  Charles  Greene  Cumston. 

2.  Cancer  of  the  Cervix  Complicating  Pregnancy, 

By  John  T.  Williams. 

3.  The  Oassification  of  the  Malarial  Plasmodia, 

By  Charles  F.  Craig. 

2.  Cancer  of  the  Cervix  Complicating  Preg- 
nancy.— Williams  remarks  that  cancer  of  the 
cervix  does  not  prevent  conception,  and  in  a  large 
percentage  of  cases  antedates  the  pregnancy.  As 
a  rule,  it  grows  with  great  rapidity  during  pregnan- 
cy and  the  puerperium.  While  the  prognosis  of 
cancer  of  the  cervix  is  more  grave  during  pregnan- 
cy, it  is  not  hopeless.  When  an  operable  cancer 
of  the  cervix  is  discovered  during  pregnancy,  no 
matter  at  what  period,  immediate  operation  is  indi- 
cated. Up  to  the  present  time  statistics  favor  the 
living  child  at  term,  conservative  Csesarean  section 
if  the  child  is  viable.  In  inoperable  cancer  with  a 
living  child  at  term,  conservative  Csesarean  section 
is  the  method  of  choice.  If  the  child  is  dead,  or 
premature,  a  subpubic  delivery  will  give  the  best 
result.  Williams  reports  seven  cases  and  gives 
statistics  referring  to  cancer  of  the  cervix ;  in 
100,481  cases  of  labor  there  were  found  fifty-seven 
complicated  with  cancer  of  the  cervix,  or  one  in 
every  1,762.  As  would  be  expected,  cancer  being 
most  frequent  between  the  ages  of  thirty-five  and 
fifty,  and  pregnancy  between  twenty  and  thirty- 
five,  the  complication  of  the  two  is  most  common 
on  the  borderline  between  these  periods,  and  we 
find  that  out  of  200  cases  in  which  the  age  was 
stated,  133,  or  66.66  per  cent,  were  between  thirty 
and  forty.  But  the  complication  may  be  met  with 
even  earlier.  25.5  per  cent,  occurring  at  or  before 
thirty,  and  seven  were  under  twenty-five. 

JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

May  ,29,  igog. 

1.  The  Resistance  of  the  Human  Body  to  Cancer, 

By  H.  Gideon  Wells. 

2.  Primary  Carcinoma  of  the  Liver.    With  Report  of  a 

Patient  Who  Remained  Well  over  Two  Years  after 
Operation,  By  Frank  C.  Yeomans. 

3.  Painless  and  Painful  Angina  Pectoris, 

By  William  Watt  Kerr. 

4.  A  New  Method  for  Transfusion  of  Blood.   An  Experi- 

mental Study, 

By  Robert  T.  Frank  and  George  Baehr. 

5.  The  Incunabula  in  the  Senn  Collection  at  the  John 

Crerar  Library,  By  Acksel  G.  S.  Josephson. 

6.  Streptococcic  Infections  of  the  Throat, 

By  Richmond  McKinney. 

7.  Advertising  by  Physicians,  By  Joseph  Grindon. 

I.  The  Resistance  of  the  Human  Body  to 
Cancer. — Wells  remarks  that  after  many  years 
of  careful  and  painstaking  work  by  the  surgeons, 
during  which  the  radical  operative  methods  have 
been  developed  to  a  high  degree  of  perfection,  we 
are  still  forced  to  admit  that  as  yet  the  results  of 
surgical  intervention  in  cancer  are  anything  but  sat- 
isfactory. The  most  skilful  operators  can  claim  at 
the  best  but  about  forty  per  cent,  of  recoveries  in 
cancer  of  the  female  breast,  while  in  cancer  of  the 
cervix  of  the  uterus  recovery  without  subsequent 


recurrence  is  an  exceptional  result  of  even  the  most 
radical  pelvic  operations.  Martin  gives  ten  to 
twenty  per  cent,  of  such  patients  free  from  recur- 
rence after  five  years.  Pylorectomy  has  but  occa- 
sional isolated  recoveries  to  its  credit,  and  even  in 
the  least  malignant  form,  carcinoma  of  the  skin  of 
the  face,  recurrence  follows  in  about  forty  per  cent., 
while  with  carcinoma  of  the  lip  success  is  even  less 
common,  and  Butlin  reports  a  three  years'  cure  in 
but  31.4  per  cent,  of  his  operations  for  cancer  of 
the  tongue.  Probably  we  have  nearly  reached  the 
extent  of  our  possible  progress  in  the  direction  of 
operative  skill,  at  least  so  far  as  extensiveness  of 
removal  of  tissue  is  concerned,  and  consequently 
the  surgeons  feel  that  the  only  possible  direction 
for  improvement  is  in  earl)'  diagnosis.  Admittedly 
there  is  room  for  great  improvement  in  this  respect,, 
and  with  the  rapid  bettering  of  the  conditions  of 
medical  education  it  is  to  be  hoped  that  soon  a 
larger  proportion  of  practising  physicians  will  be 
able  to  recognize  even  deeply  hidden  cancers  nr 
least  as  early  as  the  best  trained  men  now  can.  But 
while  earlier  diagnosis  and  operation  in  carcinoma 
will  undoubtedly  bring  up  the  percentage  of  com- 
plete cures,  yet  even  under  the  best  of  conditions 
the  mortality  will  still  be  high.  Of  interest  to  us 
in  our  search  for  natural  means  of  defence  are  in- 
stances in  which  malignant  tumors  show  healing 
changes  independent  of  merely  accidental  influ- 
ences. These  healing  changes  may  consist  of  i,. 
spontaneous  local  inhibition  of  temporary  retarda- 
tion of  growth ;  2,  retardation  of  recurrence  after 
removal ;  or  3,  retrogression  of  secondary  growths 
after  removal  of  the  primary  tumor ;  or  4,  disap- 
pearance of  portions  of  tumor  tissue  left  at  an  in- 
complete palliative  operation ;  or  even  5,  spon- 
taneous healing  of  primary  tumor  without  any 
operative  intervention  whatever.  But  total  healing; 
without  operative  interference  of  any  kind,  and' 
without  recurrence,  is  practically  unknown.  Be- 
sides natural,  congenital  immimity  it  has  been 
found  possible  to  obtain  a  varying  degree  of  ac- 
quired immunity,  both  active  and  passive,  in  ex- 
perimental animals.  This  fact  ofifers  us  Certainly- 
the  greatest  encouragement  in  our  search  for  means 
of  checking  malignant  growth.  Passive  immunity 
seems  as  yet  not  to  have  been  so  successfully  pro- 
duced as  active  immunity,  nevertheless  there  is  evi- 
dence that  the  blood  of  animals  spontaneously  re- 
covering from  tumors  may  sometimes  «ause  retro- 
gression and  even  healing  of  tumors  in  inoculated 
animals,  as  well  as  render  animals  more  or  less 
resistant  against  implantation  of  tumors.  Such  ob- 
servations accumulating  during  the  few  years  dur- 
ing which  systematic  investigations  of  tumor  trans-  ■ 
plantation  have  been  in  progress,  give  much  hope 
that  eventually  something  may  be  done  for  the 
cancer  patient  besides  radical  operation. 

2.  Primary  Carcinoma  of  the  Liver. — Yeo- 
mans reports  an  interesting  case  of  this  rare  affec- 
tion. He  gives  the  processes  which  were  at  work 
to  effect  the  result,  i.  Venous  obstruction  by  the 
growth  as  it  enlarged  resulted  in  congestion  and 
inflammation  at  its  peripher}'  and  degeneration  of 
the  major  part  of  the  tumor  into  a  soft  pultaceous 
mass.  2.  This  prevented  invasion  of  healthy  tis- 
sues by  the  carcinoma.    3.  Bodies  absorbed  from  : 


PITH  Of  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


tile  fluid  material  tended  to  immunize  the  system. 
4.  Infection,  already  presejit  or  accidental,  as  shown 
by  the  postoperative  temperature,  may  have  played 
an  important  role.  5.  The  incision  was  made  at 
the  opportune  moment;  i.  e.,  when  the  entire  tumor 
had  undergone  softening  and  was  ripe  to  be  cast 
off  as  soon  as  a  vent  was  provided. 

3.  Painless  and  Painful  Angina  Pectoris. — 
Kerr  observes  that  painless  angina  is  much  more 
common  than  one  would  suppose  it  to  be  from  the 
infrequencv  with  which  it  is  mentioned ;  but,  in  all 
probability,  the  disease  is  not  always  recognized, 
and  the  patient's  sufferings  are  attributed  to 
hysteria  or  some  reflex  disturbance.  When  the 
symptoms  are  accompanied  by  a  dilated  right  heart 
or  distinctly  atheromatous  changes  the  diagnosis  is 
easy,  but  when  physical  signs  are  absent  it  is  diffi- 
cult to  arrive  at  an  absolute  opinion.  If,  when  free 
from  the  paroxysms,  the  patient  continually  suf- 
fers from  a  feeling  of  weight  or  distress  over  the 
praecordia,  and  has  a  tendency  to  take  occasional 
deep  inspirations,  there  is  a  strong  probability  that 
the  right  ventricle  is  at¥ected ;  and  this  amounts 
to  certainty  if  the  symptoms  are  invariably  pro- 
duced or  aggravated  by  exertion.  This  form  of 
angina  is  entirely  different  from  the  painful  variety, 
and  in  many  instances  demands  a  diametrically  op- 
posite treatment.  The  cause  of  angina  pectoris  is 
still  a  matter  for  discussion,  but  in  all  probability 
it  is  due  to  some  local  obstruction  in  the  coronary 
circulation  which  may  be  organic,  spasmodic,  or  a 
combination  of  both.  The  fact  that  the  radial  pulse 
varies  in  dif¥erent  cases,  the  pressure  being  some- 
times high  and  at  other  times  low,  indicates  that 
the  attacks  can  not  invariably  be  attributed  to  in- 
creased resistance  in  the  peripheral  circulation.  It 
has  been  suggested  that  angina  pectoris  is  due  to 
strain  on  the  heart  by  obstruction  in  the  arterial 
system  and  that  while  in  certain  cases  the  vascular 
pressure  may  be  actually  low,  nevertheless  it  may 
he  too  high  for  the  capabilities  of  the  myocardium. 
The  treatment  of  those  two  forms  of  angina  will 
be  entirely  dififerent  during  the  seizures,  but  as  a 
rule  it  is  identical  between  the  paroxysms.  Since 
cardiac  asthma  is  due  to  failure  of  the  right  ven- 
tricle rapidly  acting  stimulants,  such  as  cafifeine. 
camphor,  or  strophanthus,  will  be  indicated 
for  the  relief  of  the  paroxysm  ;  while  angina  pec- 
toris, on  account  of  the  coronary  spasm,  will  call 
for  vasodilators  such  as  amyl  nitrite,  nitroglycerin, 
or  morphine.  It  not  infrequently  happens  that  the 
subject  nf  coronary  spasm  is  also  sufi^ering  from 
a  weak  heart'  and  under  such  circumstances  a  crm- 
bination  of  heart  stimulant  and  antispasmodic  is 
demanded.  Between  the  attacks  the  treatment  is 
that  which  has  been  recommended  in  cases  of 
chronic  myocarditis  and  arteriosclerosis.  The  reg- 
ulation of  diet,  in  regard  to  both  variety  and 
quantity,  so  that  the  circulation  never  will  be  over- 
loaded with  food  or  waste  material,  is  of  the  great- 
est importance.  Avoidance  of  mental  and  physical 
strain  and  the  regulation  of  exercise  in  accordance 
with  the  capabilities  of  each  individual  case  must 
be  carefidly  observed.  The  administration  of  pr- 
senic  and  the  prolonged  use  of  iodides  in  small 
doses  for  a  periotl  of  several  months  will  b  •  found 
in  many  instances  to  have  a  very  beneficial  effect  on 


both  the  cardiac  muscle  and  the  blood  vessels.  And 
last,  we  never  should  neglect  the  judicious  use  of 
remedies  which  will  aid  in  eliminating  by  their  nat- 
ural channels  all  toxic  substances  resulting  from 
physiological  activity  or  food  metabolism. 

4.  A  New  Method  for  the  Transfusion  of 
Blood. — Frank  and  Baehr  describe  their  method, 
which  they  have  used  so  far  on  animals  only.  The 
links  are  prepared  by  cuffing  dog's  carotids  at  both 
ends  over  Crile's  tubes,  stretching  them  on  a  wire 
frame  and  fixing  them  for  twenty-four  hours  in 
two  per  cent,  formalin.  The  formalin  is  removed 
by  two  changes  of  sterile  salt  solution  (thirty  to 
sixty  minutes  each),  and  the  links  permanently  pre- 
served in  sterile  paraffin  oil.  Of  twenty-six  trans- 
fusions performed  by  means  of  prepared  links,  but 
one  failed  (owing  to  kinking  of  the  vessel  during  its 
preservation).  The  method  of  preservation  kills 
bacteria,  including  spore  bearers.  The  technique 
corresponds  closely  to  that  used  in  intravenous 
saline  infusions.  As  far  as  can  be  predicted,  the 
use  of  the  prepared  links  affords  a  simpler  and 
easier  method  than  those  hitherto  described. 

MEDICAL  RECORD 

May  2g,  igog. 

1.  The  Etiology  of  Pain,  By  E.  G.  Janeway. 

2.  Hay  Fever  and  Other  Rhinological  Causes  of  Asthma, 

By  William  Wesley  Carter. 

3.  Report  of  a  Case  of  iMyelogenous  Leuchsemia, 

By  CoNDicT  W.  Cutler. 

4.  The  Future  of  the  Alcohol  Problem, 

By  T.  D.  Crothers. 
5-    The  Administration  of  Anaesthetics, 

By  H.  J.  Boldt. 

2.  iHay  Fever  and  Other  Rhinological  Causes 
of  Asthma. — Carter  says  that  hay  f'liver  is  an  af 
fection  having  no  pathology  of  its  own,  '  there- 
fore it  must  be  studied  and  discussed  en- 
tirely from  a  clinical  point  of  view.  Its  aetiol- 
ogy is  so  inseparably  linked  with  its  treatment 
that  a  consideration  of  this  is  necessary  to  make 
clear  the  application  of  the  various  measures  for 
its  relief.  It  is,  like  other  reflex  neuroses,  preemi- 
nently an  affection  of  civilized  man,  and  is  most 
common  in  our  large  cities  where  it  is  increasing 
pari  passu  with  the  increased  demands  for  nerve 
energy.  On  the  other  hand,  the  farmer  who  comes 
in  contact  with  more  pollen  than  any  one  else  is 
practically  never  affected.  In  this  case  the  im- 
munity may  have  been  acquired  by  constant  con- 
tact with  the  exciting  cause  of  the  disease,  but 
what  is  more  likely  it  comes  as  a  compensation 
for  his  simple  habits  of  life.  iHeredity  plays  a 
most  important  part,  and  the  disease  is  more  apt 
to  occur  for  the  first  time  between  the  ages  of  fif- 
teen and  forty-five  years.  True  hay  fever  and  hay 
asthma  are  reflex  neuroses  always  dependent  upon 
the  pollen  of  certain  grasses  and  plants  acting  as 
the  exciting  cause  upon  the  mucous  and  cutaneous 
end  organs  of  the  fifth  nerve,  chiefly  in  the  nose, 
throat,  conjunctiva,  and  on  the  face.  Pollen  is  a 
yellow  powder  thrown  off  from  grasses  and  plants 
only  during  the  flowering  season.  The  pollen 
grains  are  round  or  oval,  covered  with  spicules,  and 
vary  in  size  from  o.oi  to  0.001  of  an  inch  in  diam- 
eter. Each  grain  consists  of  an  envelope  enclosing 
a  granular  substance  which  constitutes  the  toxic 


June  s,  1909.1 


PITH  OF  CURRENT  LITERATURE. 


principle.  When  the  pollen  grain  comes  in  contact 
with  the  mucous  stirface  the  envelope  under  the  in- 
fluence of  the  natural  secretion  bursts,  the  toxic 
material  comes  in  contact  with  the  nerve  endings  in 
the  mucous  membrane,  and  in  the  susceptible  sub- 
ject immediately  exerts  its  characteristic  effect, 
that  of  a  vascular  dilator,  while  in  the  normal  in- 
dividual its  influence  is  merely  mechanical  like  that 
of  common  dust.  This  toxic  substance  is  very  pow- 
erful. Why,  in  the  hay  fever  subject,  the  vaso- 
motor centre  is  susceptible  to  the  toxic  effect  of 
pollen  acting  on  the  end  organs  of  the  trigeminus, 
whereas  it  is  inert  in  the  normal  individual,  is  a 
problem  still  open  for  solution.  It  ma\-  be  com- 
pared to  the  idiosyncrasy  which  some  people  ex- 
hibit for  certain  drugs,  as  iodine  and  quinine,  and 
the  violent  reflex  disturbances  which  some  individ- 
uals experience  after  eating  certain  articles  of 
food,  such  as  shellfish,  strawberries,  etc.  The  pri- 
mary cause  of  this  peculiar  susceptibility  in  the  hay 
fever  subject  may  depend  upon  a  faulty  metabolism 
in  the  tissues  causing  a  change  from  the  normal  in 
the  body  fluids,  the  latter  affecting  the  physiologi- 
cal condition  of  the  nerve  centres.  In  regard  to 
the  use  of  drugs,  with  a  view  to  curing  the  affec- 
tion, our  author's  experiences  have  been  most  un- 
satisfactory, and  he  is  inclined  to  think  that  those 
observers  who  have  reported  favorably  on  this  or 
that  drug  have  been  misled  by  the  normal  varia- 
tions in  the  severity  of  the  affection  due  to  the 
varying  amount  of  pollen  in  the  air,  which  in  turn 
is  dependent  upon  the  season,  atmospheric  condi- 
tions, etc.  Fie  has  used  quinine,  balladonna,  arse- 
nic, and  protiodide  of  mercury.  From  quinine  he 
obtained  no  good  results,  and  the  discomfort  was 
in  some  cases  increased.  Belladonna  and  Fowler's 
solution,  given  for  two  months  before  the  attack, 
were  not  followed  by  the  good  results  credited  to 
this  treatment  by  some  writers.  Protiodide  of  mer- 
cury administered  for  the  same  length  of  time  be- 
fore the  expected  attack  seemed  to  modify  it.  Local- 
ly adrenalin  gives  some  relief,  but  it  is  only  pallia- 
tive. All  excitement  and  worry  must  be  avoided, 
and  all  sources  of  irritation,  and  the  general  func- 
tions must  be  looked  after.  Meats  and  irritating 
foods  should  be  taken  sparingly.  '  Menthol  acts 
nearly  as  well  as  adrenalin.  Cauterization  of  the 
anterior  end  of  the  inferior  turbinate  is  of  value. 
He  believes  that  true  hay  fever  and  hav  asthma 
can  be  cured  only  by  correcting  the  basic  nutritive 
fault  that  is  responsible  for  the  susceptibility  to  the 
pollen  toxine,  and  this  can  be  accomplished  only 
by  a  complete  reform  in  the  personal  hygiene  of  the 
patient  before  the  aft"ection  has  reached  the  stage  of 
chronicity. 

3.  The   Future  of   the   Alcohol   Problem. — 

Crothers  states  that  it  is  evident  that  the  great  alco- 
holic problem,  urged  with  such  enthusiasm  by  lay- 
men and  philanthropists,  is  particularly  a  public 
health  and  hygienic  question,  and  one  in  which  phy- 
sicians should  be  the  leaders  and  teachers.  They 
must  tell  the  public  what  to  do  and  how  to  avoid 
the  causes  of  this  and  other  diseases.  These  are 
some  of  the  great  facts  rising  higher  and  higher  in 
the  confused  public  opinion  of  to-day  which  indi- 
cate clearly  the  new  dawn  and  the  new  solution 


along  scientific  lines  of  the  great  alcoholic  problem. 
The  legislatures  of  States  are  considering  prohibi- 
tion and  the  regulation  of  the  sale  of  alcohol.  Men 
and  women  are  working  to  save  the  drunkard.  Al- 
cohol is  now  known  to  be  a  depressant  and  narcotic, 
not  a  stimulant  and  tonic.  Many  diseases  are  trace- 
able to  it  as  their  cause.  Scientific  research  has 
pointed  out  beyond  question  that  alcohol  possesses 
tremendous  powers  for  heat  and  light  which  can 
be  made  force  producers  equal  to  electricity.  Every 
year  new  discoveries  show  that  alcohol  can  be  made 
from  a  great  variety  of  substances,  many  of  which 
are  now  regarded  as  waste  products,  and  these  can 
be  produced  very  cheaply.  As  a  fuel  it  is  far  su- 
perior to  coal,  wood,  and  oil,  and  in  the  manufac- 
ture of  electricity  it  is  cheaper  than  steam.  The 
recent  laws  denaturing  alcohol,  rendering  it  poison- 
ous as  a  beverage,  have  opened  up  a  new  realm  and 
new  uses  in  the  arts  and  in  other  directions.  As  a 
competitor  with  gas  and  electricity  it  has  already 
been  demonstrated  to  have  equal  and  greater  ca- 
pacity for  power  and  work.  The  great  liquor  in- 
terests with  their  millions  of  money  will  turn  to 
the  manufacture  of  this  product  with  greater  profit 
and  will  find  an  increasing  demand  for  it.  and  this 
is  a  positive  indication  of  its  future.  Alcohol  as  a 
fuel  will  take  the  place  of  coal ;  as  a  power  it  will 
supplant  gasoline,  and  the  great  alcoholic  problem 
will  merge  into  the  utilization  of  this  force  for  the 
benefit  of  mankind  and  the  world.  A  number  of 
different  manufactories  in  the  West  have  begun 
to  change  their  products  from  refined  liquors  to 
crude  alcohols  for  the  trade.  Thus  a  tremendous 
revolution  of  industrial  energies  has  already  begun 
and  promises  to  constitute  a  new  era  in  the  econo- 
mies of  the  race.  The  extinction  of  the  saloon  will 
follow  early,  the  change  in  the  breweries  and  distil- 
leries is  bound  to  come,  and  the  frantic  efforts  of 
the  trade  to  obstruct  progress  will  disappear.  Al- 
cohol, which  has  so  long  been  regarded  as  a  bever- 
age and  the  destructive  effects  of  which  are  now 
beginning  to  be  realized,  will  be  changed  to  a  great 
motor  power  to  propel  machinery,  heat  buildings, 
and  in  many  other  ways  contribute  to  the  advance- 
ment of  the  human  race.  With  the  extinction  of 
the  saloon  and  alcohol  as  a  beverage  man\-  of  the 
very  active  causes  of  criminality,  pauperism,  in- 
ebriety, and  insanity  will  disappear.  A  new  realm 
of  cause  and  effect  will  come  in  and  a  new  step  for- 
ward will  be  made  to  lengthen  life  and  avoid  its 
present  perils. 

BRITISH  MEDICAL  JOURNAL. 

May  15,  1909. 

1.  An  Address  on  Acute  Rheumatism,  Its  Allies  and  Its 

Counterfeits,  By  F.  de  Havilland  Hall. 

2.  An  Address  on  the  Diagnosis  and  Treatment  of  Mor- 

bid Conditions  of  the  Pleura,     By  T.  R.  Bradshaw. 

3.  A  Clinical  Lecture  on  a  Case  of  Bacillus  Pyocyaneus 

Pyaemia  Successfully  Treated  by  Vaccine, 

By  Ernest  W.  Hey  Groves. 

4.  A  Case  of  Tuberculous  Meningitis  without  Tubercules, 

By  F.  W.  HiGGS. 

5.  Observations  on  an  Outbreak  of  Meat  Poisoning  at 

Limerick,  By  E.  J.  McWeeney. 

I.  Acute  Rheumatism,  Its  Allies  and  Its  Coun- 
terfeits.— -Hall  says  that  the  whole  subject  of 
rheumatic  fever  has  been  much  clarified  since  its 


ii66 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


probable  microbic  origin  has  been  acknowl- 
edged, and  there  is  much  evidence  in  favor 
of  the  Diplococciis  rheumaticus  described  by  Payne 
and  Poynton  as  being  the  specific  organism.  Just 
as  the  discovery  of  the  tubercle  baciUus  cleared  up 
many  doubts  and  difficulties  which  formerly  existed 
in  tuberculous  cases,  so  the  recognition  of  the 
rheumatic  organism  will  enable  us  to  form  a  truer 
conception  of  its  nature,  and  we  shall  be  able  to 
exclude  many  conditions  which  were  in  the  past 
embraced  vmder  the  head  of  rheumatism,  but  which 
we  now  have  every  reason  to  believe  are  of  a  wide- 
ly different  pathology.  Time  was  when  the  joint 
lesions  of  acute  rheumatism  were  thought  to  be 
characteristic,  but  we  now  know  that  they  may  be 
simulated  by  pyasmic  conditions  and  by  gonorrhoeal 
rheumatism,  to  say  nothing  of  gouty  arthritis.  In 
children,  moreover,  the  disease  may  run  its  course 
with  hardly  any,  if  any,  joint  mischief,  the  heart 
bearing  almost  the  whole  brunt  of  the  disease.  We 
must,  therefore,  regard  rheumatic  fever  as  a  gen- 
eral disease  with  localization  in  the  heart  and  joints, 
and  not  a  local  disease  of  the  joints  with  sympto- 
matic fever.  Hall  then  speaks  of  its  allies, 
endocarditis  ;  pericorditis ;  pleurisy  ;  amygdalitis ; 
chorea ;  skin  affections,  as  erythema  multiforme, 
marginatum,  nodosum,  urticaria,  angioneurotic 
oedema,  destjuamation,  etc. ;  subcutaneous  nodules : 
etc.  He  also  speaks  of  the  distinctive  diagnosis,  and 
enumerates  here,  pyaemia,  influenza,  infective  en- 
docarditis, antitoxine  arthritis,  gonorrhoea,  and 
pneumococcic  arthritis. 

2.  Diagnosis  and  Treatment  of  Morbid  Con- 
dition of  the  Pleura. — Bradshaw  takes  up  the  indi- 
tions  for  paracentesis  -in  pleural  effusion  ;  when  the 
physical  signs  point  to  a  large  eff"usion,  or  when 
the  symptoms,  such  as  dyspnoea,  indicate  serious 
embarrassment  of  the  heart  or  lungs,  the  operation 
should  be  performed  without  delay.  But  the  per- 
sistency of  signs  of  a  small  effusion  is  no  less  an 
indication  for  paracentesis,  as  may  be  seen  from 
various  coniderations.  In  the  firt  place,  the  extent 
of  the  physicial  signs  is  not  always  proportionate 
to  the  size  of  the  effusion,  which  may  be  much 
greater  than  it  appears  to  be.  In  the  second  place, 
until  we  see  some  of  the  fluid,  we  can  never  be 
certain  as  to  its  nature,  whether  serous,  purulent, 
or  hydatid  ;  and  thirdly,  the  prolonged  presence  of 
a  small  collection  of  serous  effusion  in  the  pleura 
is  not  to  be  looked  on  with  indift'erence.  Apart 
from  the  iliechanical  compression  which  it  exerts 
on  the  lung  we  must  believe  that  a  tuberculous  ef- 
fusion having  a  lower  tuberculoopsonic  index  than 
the  other  fluids  of  the  body  favors  the  existence 
of  the  bacilli  in  the  parts  which  it  bathes,  and  so 
ought  to  be  got  rid  of  as  S])eedily  as  possible.  In 
speaking  of  empyema  he  remarks  that  there  are 
Tio  signs  or  symptoms  by  which  we  can  with  any 
api)roach  to  confidence  distinguish  it  from  serous 
effusion  until  some  of  the  fluid  has  been  removed 
for  inspection.  Hectic  fever  is  common  enough  in 
cases  of  serous  effusion,  as  might  be  expected  from 
the  frequent  coexistence  of  tubercle,  and  cases  of 
empyema  are  generally  attended  by  only  a  moder- 
ate rise  of  temperature,  rarely  above  102°  F.,  and 
^jencrally  less.  Xo  doubt  a  leucocytosis,  if  jjroved  by 


a  competent  observer  to  be  present,  will  be  a  point 
in  favor  of  suppuration,  but  it  is  seldom  of  practi- 
cal application  for  diagnosis  except  in  a  hospital. 
The  diagnosis  of  empyema  being  then  only  estab- 
lished on  finding  pus  flow  into  the  aspirator,  we 
have  to  consider  how  we  shall  deal  with  the  case, 
first  at  the  moment,  and  secondly  with  a  view  to 
permanent  recovery.  Many  of  these  patients  are 
suffering  from  urgent  distress  from  dyspnoea  and 
toxaemia,  and  are  in  need  of  immediate  relief,  and 
it  is  best  to  continue  the  extraction  and  remove  a 
considerable  quantity  of  pus,  perhaps  a  pint.  By 
this  means  the  urgent  symptoms  are  at  once  re- 
lieved for  a  time,  the  temperature  becomes  normal, 
and  the  patient  will  probably  have  a  good  night. 
We  thus  gain  time  to  make  our  arrangements  for 
performing  the  greater  operation  under  the  most 
favorable  conditions,  and  to  get  the  consent  of  the 
patient  or  his  friends. 

4.  A  Case  of  Tuberculous  Meningitis  without 
Tubercles. — ^Higgs  reports  such  a  case,  the  un- 
usual features  of  which  are:  i.  The  presence  of 
tuberculous  meningitis  with  much  fibrinopurulent 
exudate  at  the  base  of  the  brain  withous  any  miliary 
tubercle  formation ;  2,  the  absence  of  miliary  tuber- 
culosis of  the  lungs  and  other  organs ;  and  3,  the 
great  predominance  of  polymorphonuclear  leuco- 
cytes over  lymphocytes  in  the  cerebrospinal  fluid.  The 
child  only  lived  two  days  after  admission  to  the  hos- 
pital, but  a  diagnosis  of  tuberculous  meningitis  was 
made  from  the  history  and  physical  signs.  At  the  ne- 
cropsy, however,  doubt  was  thrown  on  this  diagnosis, 
•as,  although  there  was  an  actively  caseating  bronchial 
gland  to  serve  as  a  primary  focus,  there  was  no 
generalized  miliary  tuberculosis  and  no  tubercles  in 
the  meninges,  which,  moreover,  showed  much  thick 
fibrinopurulent  exudate,  mainly  posterior  basal  in 
distribution.  On  the  other  hand,  the  general  "sticki- 
ness" of  the  meninges  and  the  presence  of  some  ex- 
udate around  the  vessels  in  the  Sylvian  fissures  fa- 
vored the  diagnosis  of  tuberculous  meningitis.  The 
doubt  as  to  the  diagnosis  was  accentuated  by  the 
cytological  examination  of  the  cerebrospinal  fluid. 
With  regard  to  the  reason  why  tuberculous  granu- 
lations are  not  always  found  in  cases  of  generalized 
tuberculosis,  it  may  be  considered  that  while  gen- 
eral tuberculosis  infection  usually  takes  the  form  of 
a  pyaemia  it  may  occasionally  be  onh'  a  septichaemia. 
and  that  the  primary  tuberculous  focus  in  the  first 
case  discharges  into  the  circulation  clumps  of  ba- 
cilli with  tissue  debris,  and  that  these  clumps,  be- 
coming impacted  in  the  smallest  arterioles,  cause 
the  formation  of  miliary  tuberculous  granulations 
or  "tuberculous  pyaemic  abscesses"  around  the 
blocked  vessels,  but  that  in  the  second  case  sep- 
arate bacilli  only  are  discharged  into  the  circulation 
in  considerable  numbers,  and  that  these  isolated 
bacilli  do  not  get  lodged  in  the  small  vessels.  The 
difl'use  leucocytic  infiltration  of  the  cerebral  cortex 
and  the  cellulofibrinous  inflammation  of  the 
meninges  may  be  explained  as  being  the  result  of 
the  irritation  of  the  toxines.  and  of  the  bacilli, 
which  have  found  their  way. from  the  blood  vessels 
into  the  cortical  substance  and  into  the  cellular  tis- 
sues of  the  meninges,  these  parts  especially  easily 
reacting  to  the  tubercle  bacillus. 


June  5,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


THE  LANCET. 

May  15,  1909. 

1.  The  Spread  of  Tuberculosis — Heredity  or  Infection, 

Bj-  J.  G.  Emaxuel. 

2.  The  X  Ray  Treatment  of  Ringworm  of  the  Scalp,  with 

Special  Reference  to  the  Risks  of  Dermatitis  and  the 
Suggested  Injury  to  the  Brain, 

By  J.  M.  H.  :\Iacleod. 

3.  The  Histology  of  Rheumatic  Endocarditis, 

By  Carey  Coombs. 

4.  A  Simplified  Method  of  X  Ray  Application  for  the 

Cure  of  Ringworm  of  the  Scalp :  Kienbock  Method, 

By  H.  G.  Adam  SON. 

5.  A  Case  of  Lithokeh'phos,  By  J.  Basil  Hall. 

6.  Notes  on  a  Sporadic  Outbreak  of  Trichinosis  in  De- 

vonshire ;  with  Remarks, 

By  J.  Delpratt  Harris  and  R.  V.  Solly. 

7.  Calcium  Lactate  in  the  Treatment  of  Epilepsy, 

By  Arthur  R.  Littlejohn. 

8.  Two  Cases  of  Traumatic   Separation   of  the  Upper 

Mandible,  By  William  Bligh. 

9.  A  Case  of  Pulmonary  Tuberculosis  Terminating  with 

Acute  Streptococcal  ^Meningitis. 

By  Eric  H.  R.  Harries. 

10.  A   Case   of  Hepatoomental    Bands   Constricting  the 

Stomach,  By  George  A.  Hawkixs-Ambler. 

11.  A  Plea  for  the  L'se  of  Anlidiphtheritic  Serum  in  the 

Laryngitis  of  ^leasles.  By  A.  A.  Warden. 

2,  4.  X  Ray  Treatment  of  Ringworm  of  the 
Scalp. — ]\Iacleod  concludes  that  the  x  ray  treat- 
ment of  ringworm  by  the  single  dosage  method 
with  the  dosage  regulated  by  the  pastille  is  practi- 
cally safe  and  harmless.  It  is  a  method  of  treat- 
ment of  such  delicacy  that  even  in  the  hands  of  an 
experienced  operator  an  accident  such  as  an  over 
exposure  might  happen,  but  such  accidents  should 
be  of  such  extreme  rarity  as  not  to  discrerlit  a  mod 2 
of  treatment  possessing  such  obvious  advantages. 
Severe  dermatitis  followed  by  permanent  baldness 
is  the  result  of  an  over  exposure  or  is  due  to  some 
accident  such  as  the  exposing  of  an  area  the  re- 
sistance of  which  has  been  lowered  bv  the  previous 
application  of  strong  irritants  before  the  inflamma- 
tion has  entirely  subsided,  the  use  of  wrong  or  in- 
accurately standardized  pastilles,  or  from  overlap- 
ping. Permanent  baldness  or  delayed  hair  growth 
without  marked  dermatitis  is  the  result  of  over  ex- 
posure, but  it  might  in  rare  instances  be  due  to 
some  idiosyncrasy  on  the  part  of  the  patient  in  the 
same  way  as  the  occurrence  of  alopecia  areata  after 
ringworm.  Our  author  has  been  unable  to  obtain 
any  definite  evidence  of  injury  to  the  brain  by  this 
method  of  treatment  from  his  own  cases,  from  the 
literature  on  the  subject,  or  from  anyone  with  ex- 
perience of  this  treatment  whom  he  has  asked. — 
Adamson  remarks  that  depilation  by  means  of  the  x 
rays  is  now  fully  established  as  the  most  satisfac- 
tory method  of  treatment  for  ringworm  of  tlie 
scalp.  Briefly,  the  treatment  consists"  in  temporarilv 
depilating  the  affected  area  or  areas,  each  bv  a 
single  measured  dose  of  x  rays,  and  thus,  mechan- 
ically, and  without  actually  killing  the  fungus, 
eradicating  it  from  the  areas  exposed.  By  the  in- 
troduction of  the  pastille  of  Sabouraud  and  Xoire 
as  a  means  of  measurement  of  dosage,  in  trained 
hands,  the  dangers  of  the  treatment  have  disap- 
peared. One  disadvantage  it  still  has,  namely,  the 
length  of  time  occupied  by  the  actual  exposures  to 
the  rays,  and  any  means  of  shortening  this  period 
must  be  welcomed  by  all  who  have  many  such  cases 
to  treat,  more  especially  in  hospital  or  institution 


work.  In  a  large  majority  of  cases  it  is  found 
necessary  to  irradiate  the  whole  scalp.  By  Sabou- 
roud  and  Xoire's  well  known  method  with  circular 
localizers  from  ten  to  twelve  exposures  are  neces- 
sary in  order  to  x  ray  the  whole  scalp,  and  reck- 
oning onlv  fifteen  minutes  for  each  exposure  and 
a  certain  time  for  adjusting  the  localizers  for  each 
area,  the  time  occupied  in  x  raying  the  whole  scalp 
is  from  three  and  a  half  to  four  hours.  By  another 
method  that  of  dividing  the  scalp  into  rectangu- 
lar areas  and  irradiating  each  area,  surrounded  by 
a  lead  foil  shield,  in  succession,  the  time  may  be 
reduced  to  from  two  and  a  half  to  two  liours.  By 
the  author's  method  the  number  of  exposures  is 
reduced  to  five,  so  that  it  is  possible  to  irradiate 
the  whole  scalp  in  one  and  one  half  hours.  Its  es- 
sential features  are  that  no  cylindrical  nor  lead  foil 
localizers  are  used,  but  that  adjacent  x  ray  applica- 
tions are  made  in  such  a  manner  that  at  those  parts 
where  overlapping  does  occur  the  incidence  of  the 
rays  is  so  oblique  and  so  much  further  from  their 
source  that  no  excessive  dose  is  given.  It  is  im- 
portant to  make  the  irradiation  at  right  angles  to- 
the  direction  of  the  irradiation  of  adjacent  areas, 
and  to  aim  not  at  a  point  in  the  centre  of  the  ver- 
tex of  the  lower  occiput,  or  of  the  sides  of  the  scalp,, 
but  toward  the  outer  margin  of  these  areas,  so 
that  half  the  dose  goes  on  to  the  scalp  and  half  on 
to  the  shield  protecting  the  face  and  neck.  If  these 
precautions  are  taken  there  is  no  risk  of  overex- 
posure at  the  overlapping  margins  of  the  rayed 
areas.  In  practice  the  dosage  works  out  so  nicely 
that  every  part  receives  an  equal  amount  and  de- 
pilation is  total  and  complete,  without  anywhere 
a  sign  of  over  or  under  exposure.  In  theory,  ac- 
cording to  the  well  known  laws  that  the  quantity 
of  rays  received  at  any  point  exposed  varies  (  i) 
inversely  with  the  square  of  the  distance  from  the 
source ;  and  (2)  directly  Avith  the  size  of  the  angle 
of  incidence,  the  dose  received  by  any  part  of  the 
scalp  is  found  to  be  with  mathematical  accuracy, 
one  pastille  dose. 

7.  Calcium  Lactate  in  the  Treatment  of  Epi- 
lepsy.— Littlejohn  has  been  successful  with  cal- 
cium lactate  in  the  treatment  of  epilepsy.  All  his 
patients  have  improved,  some  more  so  than  others^ 
He  cites  two  cases.  The  usual  dose  was  fifteen 
grains  of  calcium  lactate,  three  times  a  day. 

II.  Antidiphtheritic  Serum  in  the  Laryngitis 
of  Measles. — Warden  says  that  laryngitis  is  a 
frequent  complication  of  measles,  occasionally 
membranous  in  character,  nondiphtheritic  mem- 
branes being  exceptional.  He  therefore  thinks  that 
in  all  cases  of  laryngitis  in  measles  antidiphtheritic 
serum  should  be  injected  as  soon  as  possible. 

LA  SEMAINE  MEDICALE. 

April  14,  igog.  ■ 
Globulin,  By  C.  Achard  and  M.  Ayxaud. 

Globulin. — Achard  and  Aynaud  reject  the  cur- 
rent idea  that  globulin  is  active  in  the  coagulation 
process  and  in  the  formation  of  red  blood  corpuscles,, 
and  say  that  the  bactericidal  property  attributed  to 
globulin  and  its  power  of  destroying  leucocytes  are 
only  hypothetical.  But  a  substance  such  as  globulin, 
found  in  all  animals  in  abundant  quantity  certainly 
plays  an  important  role ;  what  this  part  is  our  au- 


ii68 


PROCEEDINGS  OF  SOCIETIES. 


[New 
Medical 


York 
Journal. 


thors  are  not  able  to  state  according  to  our  present 
knowledge. 

April  .21,  i^og. 

1.  The  Twenty-sixth  German  Congress  of  Internal  Med- 

icine.   Mineral  Metabolism  in  Clinical  Pathology, 

By  M.  Magnus-Levy. 

2.  Dietetic  Treatment  of  Dechlorization  in  Bright's  Dis- 

ease ;  Distinction  between  Hypochlorhydric  and 
Nitrogenous  Condition  of  the  Blood, 

By  W.  F.  WiDAL. 

2.  Dechlorization  Treatment  in  Bright's  Dis- 
ease.— Widal  bases  his  treatment  upon  the  fact 
that  nephritic  dropsy  may  be  cured  by  restriction  of 
salt  in  the  diet.  He  uses  the  expression  chlontremie 
to  designate  the  condition  of  the  retention  of  a  chlo- 
ride in  the  organism,  hyperchlorhydric  condition  of 
the  blood,  but  this  does  not  mean  the  accumulation 
of  the  salt  in  the  blood  itself.  This  hyperchlorhydric 
condition  of  the  blood  from  intestinal  disease  can 
produce  troubles  in  the  lungs,  stomach,  intestines, 
nerve  centres,  and  kidneys.  A  patient  on  a  milk 
diet  receives  in  a  litre  of  milk  i.6  grammes  of 
salt,  the  actual  amount  of  salt  in  milk;  a  patient 
on  a  mixed  diet,  without  salt,  receives  about  1.5 
grammes  of  salt.  The  amount  of  salt  can  thus  be 
reduced  to  about  one  gramme  a  day.  It  is  possible 
for  patients  with  Bright's  disease  to  get  along  for 
months  with  only  2  grammes  of  salt. 

BERLINER  KLINISCHE  WOCHENSCHRIFT 
April  19,  igog. 

1.  Pathogenesis  and  Treatment  of  Anuria, 

By  Hermann  Kummell. 

2.  X  Ray  Examination  of  Surgical  Diseases  of  the  Stom- 

ach {Continued) ,   By  V.  Schmieden  and  F.  Hartel. 

3.  A  Case  of  Emphysema  of  the  Lung  Operated  in. 

By  GOTTSTEIN. 

5.    Sepsis  from  the  Friedlaender  Bacillus,       By  Wehrsig. 

5.  Cylindruria  in  Urine  not  Containing  Albumin  and  Its 

Relations  to  Chronic  Obstipation,     By  Wasserthal. 

6.  Acute  Infection  of  a  Congenital  Hydronephrosis, 

By  E.  Marcuse. 

7.  Electrocardiographic   Studies   of   the   Physiology  and 

Pathology  of  the  Heart  Beat,  By  Strubell. 

8.  A  New  Method  of  Recognition  and  of  Determination  of 

the  Position  of  Ulcers  in  the  Upper  Part  of  the 
Digestive  Tract,  By  Max  Einhorn. 

9.  Care  of  the  Teeth  and  Mouth,  By  Benninghoven. 

10.  A  Question  Concerning  External  Urethrotomy, 

By  C.  Posner. 

I.  Anuria. — Kiimmel  divides  anuria  into  two 
groups,  anuria  in  the  broader  sense,  false  anuria, 
or  anuria  from  occlusion  ;  and  anuria  in  a  narrow 
sense,  true  renal  anuria.  The  most  frequent  cause 
of  the  forrrier  is  the  presence  of  a  stone,  the  condi- 
tions of  which  are  considered  at  some  length,  but 
it  may  be  due  to  the  pressure  of  a  tumor,  or  any- 
thing else  which  may  occlude  the  ureter.  True 
anuria  is  of  renal  origin,  due  to  disease  of  the  kid- 
ney, general  diseases,  such  as  diphtheria  or  cholera, 
renal  troubles  during  pregnancy,  toxic  influences 
from  certain  antiseptic,  or  anaesthetic,  drugs,  de- 
struction of  the  kidney  tissue  by  tumors,  tubercu- 
losis, hydronephrosis  and  pyonephrosis,  or  to  re- 
flex causes,  such  as  phimosis.  Of  the  latter  he  dis- 
tinguishes two  groups,  the  purely  peripheral,  which 
is  very  rare,  and  the  more  frequent  and  important 
renal  form.  In  the  former  the  anuria  is  to  be  as- 
cribed to  a  spasm  of  the  vasomotor  vessels  of  the 
kidney  set  up  by  the  peripheral  irritation  of  a 
pliimosis.  in  the  latter  a  hitherto  normally  function- 


ating kidney  ceases  to  act  as  the  result  of  an  irri- 
tation set  up  by  the  other,  diseased,  kidney. 

2.  X  Ray  Examination  of  Surgical  Diseases  of 
the  Stomach. — Schmieden  and  Hartel  report  thir- 
teen cases  of  carcinoma  of  the  pyloric  portion  of 
the  stomach  illustrated  with  twenty-four  plates  re- 
producing the  X  ray  pictures  of  the  conditions  pres- 
ent in  each. 

4.  Sepsis  from  the  Friedlaender  Bacillus. — 

Wehrsig  gives  the  clinical  history  and  pathologi- 
cal conditions  found  on  autopsy  of  a  case  of  sepsis 
from  Friedlaender's  pneumobacillus  met  with  in  a 
woman,  fifty-eight  years  old.  The  anatomical  con- 
ditions found  were  general  anfeinia,  atrophy,  and 
fatty  degeneration  of  the  cardiac  muscle,  fibrinous 
pleuritis  over  the  left  lower  lobe  of  the  lungs,  dif- 
fuse pneumonic  infiltration  of  the  left  lower  lobe, 
lobular  foci  in  the  right  lower  lobe,  oedema  of  both 
lower  lobes,  pulpy  tumor  of  the  spleen,  metastatic 
abscesses  in  both  kidneys,  myoma  of  the  uterus,  and 
splenoid  medulla  in  the  humerus.  The  microscopi- 
cal examination  is  given  in  detail.  The  distinctive 
diagnosis  was  narrowed  down  to  the  coli  haemolyti- 
cus  and  the  pneumobacillus  of  Friedlaender,  and 
then  the  former  was  excluded  by  the  fact  that  the 
microorganism  did  not  coagulate  milk. 

5.  Cylindruria.  —  Wasserthal  shows  that  in 
chronic  obstipation  an  irritation  of  the  kidney  may 
take-  place  more  easily  than  under  normal  condi- 
tions, and  that  therefore  particulai;  attention  should 
be  paid  in  these  cases  to  the  microscopical  exam- 
ination of  the  urine. 

6.  Acute  Infection  of  a  Congenital  Hydro- 
nephrosis.— Marcuse  reports  the  case  of  a  man, 
twenty-four  years  old,  who  had  frequently  suffered, 
since  early  childhood,  from  a  feeling  of  pressure  in 
the  left  side  and  other  symptoms  of  a  hydronephro- 
sis. Three  weeks  before  coming  under  observation 
he  was  seized  with  severe  pains  in  the  left  lumbar 
region  associated  with  chills  and  fever.  The  tem- 
perature rose  to  39°  C.  His  condition  was  serious 
when  seen  and  he  was  at  once  operated  upon  with 
an  excellent  result.  A  hydronephrotic  sac  as  large 
as  an  apple  was  found  which  had  become  infected. 

 ®  

f  rwrcfiiittgs  of  .^ocictifs. 


WESTERN    SURGICAL    AND  GYN;EC0L0GICAL 
ASSOCIATION. 

Eighteenth  Annual  Meeting,  Held  in  Minneapolis,  Decem- 
ber 2g  and  30,  1908. 

The  President,  Dr.  W.  W.  Grant,  of  Denver,  in  the  Chair. 
(Continued  from  page  10^2.) 
The  Treatment  of  Tetanus.  —  Dr.  Willi.^m 
Hessert,  of  Chicago,  said  that  the  best  treatment  of 
tetanus  was  to  prevent  the  disease  by  prophylactic 
injections  of  antitetanic  serum.  The  indications  to 
be  met  in  cases  of  developed  tetanus  were:  i.  To 
remove  the  source  of  further  toxine  supply  by 
proper  local  wound  treatment.  2.  To  neutralize  the 
toxine  which  might  be  contained  in  the  tissue  juices 
!)y  massive  inje/rtions  of  antitoxine  subcutaneously. 
3,  To  employ  some  remedy  to  allay  the  reflex  ex- 
citability of  the  spinal  cord,  namely,  subarachnoid 


June  5,  1909.] 


FROCEEDINGS  OF  SOCIETIES. 


injections  of  magnesium  sulphate.  4,  To  nourish 
and  support  the  patient. 

Local  wound  treatment,  aside  from  general  well 
understood  measures,  such  as  drainag;e,  wide  inci- 
sions and  admission  of  air,  removal  of  fore'gn 
bodies,  etc..  should  include  the  use  of  balsam  of 
Peru,  which  had  been  shown  to  have  a  favorable 
influence  in  neutralizing  the  tetanic  process.  Hydro- 
gen peroxide  was  also  recommended.  In  the  gen- 
eral treatment  the  intraspinal  injections  were  better 
than  the  subcutaneous,  as  the  latter  were  accom- 
panied by  too  much  depression  of  the  higher  centres 
of  the  cerebrum  and  medulla.  The  same  introspinal 
dose  would  produce  in  some  individuals  a  more 
marked  eflfect  than  in  others.  Women  and  children 
were  more  susceptible  than  men,  and  required 
smaller  doses  in  proportion  to  their  weight.  As  to 
the  doses,  one  c.c.  of  a  sterile  twenty-five  per  cent, 
solution  of  magnesium  sulphate  was  injected  by 
lumbar  puncture  for  every  twenty  pounds  of  the 
weight  in  men.  For  women  and  children  the  pro- 
portion was  one  c.c.  of  the  solution  for  every  twenty 
to  thirty-five  poimds  of  weight.  The  initial  dose 
should  be  rather  smaller  than  the  average,  in  order 
to  ascertain  the  susceptibility  of  the  individual.  An 
overdose  would  paralyze  the  heart  or  respiratory 
centres  in  the  medulla.  To  avoid  this  effect  on  the 
medulla,  it  was  always  well  to  have  the  patient  in 
a  sitting  posture  after  the  injection. 

Fifteen  to  thirty  m.inutes  after  the  injection  the 
patient  began  to  experience  the  relaxing  effects.  The 
spasms  ceased  and  the  muscles  became  flaccid. 
Pains  were  relieved  and  opisthotonus  disappeared. 
The  boardlike  abdomen  and  spastic  chest  relaxed. 
Reflex  excitability  was  abolished.  Food  was  take.i 
and  sleep  was  possible  and  refreshing.  After 
twenty-four  to  thirty-six  hours  the  effect  of  the  in- 
jection W'Ore  oft'  and  the  spasms  reappeared.  Lum- 
bar injection  could  then  be  repeated,  and  there  was 
no  limit  as  to  the  number,  provided  the  dose  was 
proper  and  the  drug  was  well  borne.  Miller  had 
collected  eleven  cases  of  tetanus  treated  by  sub- 
arachnoid injections  of  magnesium  sulphate.  Add- 
ing the  author's  two  cases  made  thirteen  thus  far 
reported  as  treated  by  this  method.  In  these  th'r- 
teen  cases,  all  severe  and  acute,  six  patients  recov- 
ered. In  the  author's  cases,  one  died  and  one  re- 
covered. Some  of  the  deaths  recorded  were  un- 
doubtedly due  to  an  overdose  of  magnesium  sul- 
phate. 

Dr.  M.  L.  Harris,  of  Chicago,  thought  that  when 
tetanus  had  once  developed  antitoxine  was  practi- 
cally useless,  and  we  should  not  waste  time  simplv 
injecting  antitoxine.  hoping  for  good  results.  The 
best  way  to  treat  tetanus  was  to  prevent  it.  Coming 
to  the  cases  of  tetanus  already  developed,  our  hope 
must  be  centred  entirely  on  the  injection  of  some 
agent  which  would  control  the  spasms  of  the  patient 
long  enough  to  permit  the  system  to  break  up  the 
combination  of  the  toxines  in  the  body  and  elimi- 
nate them.  We  knew  of  no  wav  of  overcoming 
these  toxines  or  hastening  their  elimination.  If  we 
could  prevent  the  patient  from  dying  from  exhaus- 
tion incident  to  the  spasms  or  from  asphvxia  from 
the  spasms  of  the  chest  muscles  long  enough  to 
permit  the  system  to  break  up  this  co  ubination,  w? 
might  hope  for  recovery.    So  far,  the  best  treat- 


ment seemed  to  be  by  injections  of  sulphate  of 
magnesium.  He  had  used  them  in  three  cases ;  two 
of  the  patients  recovered  and  one  died. 

Dr.  Daniel  X.  Eisexdrath,  of  Chicago,  said  that 
every  punctured  or  blank  cartridge  wound  ought  to 
be  converted  into  an  open  wound,  and  the  only  way 
to  treat  these  cases,  no  matter  whether  the  wound 
or  w'ounds  w^ere  in  the  hand  or  foot,  was  to  anaes- 
thetize the  patient,  put  on  an  Esmarch  constrictor, 
and  open  up  the  wound  from  one  end  to  the  other, 
and  not  simply  be  content  w'ith  opening  up  the 
wound,  but  cut  away  all  necrotic  tissue,  taking  away 
the  pabulum  for  the  bacteria  to  develop  there. 

Dr.  F.  Gregory  Conxell,  of  Oshkosh,  reported 
two  cases  in  which  he  had  injected  magnesium  sul- 
phate into  the  spinal  canal,  but  both  patients  died. 

Dr.  Roger  B.  Brewster,  of  Kansas  City,  Mo., 
said  that  he  had  had  two  cases  under  observation  re- 
cently. One  was  in  a  boy  with  a  wound  of  the  hand. 
His  jaws  were  locked.  He  was  given  antitetanic 
serum,  the  wound  was  thoroughly  cared  for,  he  w^as 
put  on  potassium  bromide,  and  recovered.  The 
other  was  in  a  young  man,  twenty-one  years  of  age, 
with  a  wound  of  the  index  finger.  Dr.  Hertzler  am- 
putated the  finger,  gave  him  antitetanic  serum,  put 
him  on  twenty  grain  doses  of  potassium  bromide 
every  four  hours,  and  kept  him  under  that  for  about 
ten  days.  It  was  ten  days  before  the  trismus  was 
relieved.  His  spinal  and  neck  muscles  were  all  set, 
as  well  as  the  abdominal  muscles,  but  on  the  tenth 
day  he  was  relieved,  and  from  that  time  made  a 
good  recovery. 

Dr.  AIayo  asked  whether  these  were  acute  or 
chronic. 

Dr.  Brewster  replied  that  the  boy  had  a  punc- 
tured wound  from  a  nail.  The  accident  happened 
in  the  country.  He  came  to  the  hospital  on  the  third 
day  after  his  jaw'S  had  set,  and  it  was  the  tenth 
day  before  he  got  relief.  He  did  not  know  as  to  the 
time  in  the  other  case. 

Dr.  Mavo  said  that  the  incubation  period  was  the 
main  thing  in  considering  these  cases.  If  we  took 
the  cases  that  began  wdthin  seven  or  eight  days,  we 
lost  eighty  per  cent,  of  the  patients,  whereas  in  those, 
cases  that  did  not  begin  until  after  the  tenth  or 
twelfth  day,  we  would  save  eighty  per  cent. 

Dr.  W.  D.  Haixes,  of  Cincinnati,  said  that  pre- 
vention was  the  sine  qua  iioii  of  treatment,  and  sines 
they  had  introduced  an  ordinance  in  Cincinnati  do- 
ing away  with  the  toy  pistol  and  the  cannon  cracker, 
the}-  had  not  had  a  death  the  first  year,  and  since 
then  the  results  had  been  much  the  same. 

The  Technique  of  Cleft  Palate  and  Hare  Lip 
Operations. — Dr.  Joseph  Rilus  Eastman,  of  In- 
dianapolis, said  that  Lane,  who  declared  the  best 
time  for  cleft  palate  operations  to  be  the  day  after 
birth,  or  as  soon  thereafter  as  possible,  and  whose 
position  at  first  seemed  open  to  criticism,  had  many 
followers.  Man\-  operators  had  expressed  an  assured 
conviction  that  the  new  born  child  bore  surgery 
much  better  than  had  been  imagined.  In  ordinary 
cleft  palate  operations,  during  the  first  week,  the 
loss  of  blood  should  be  trivial,  but,  however  this 
rnight  be,  the  danger  from  loss  of  blood  was  not 
greater  than  at  a  later  period.  Experience  had  not 
suggested  the  slightest  foundation  for  the  statement 
that  young  infants  did  not  bear  the  loss  of  blood 


11  JO 


BOOK  NOTICES. 


[New  York 
Medical  Journal. 


well.  The  vital  resistance  of  guinea  pigs  and  rab- 
bits against  injury  and  haemorrhage  had  a  higher  in- 
dex upon  the  day  after  birth  than  upon  succeeding 
days.  Myers  had  called  attention  to  a  probable  re- 
lationship between  these  phenomena  and  the  cir- 
cumstance that  at  the  time  of  birth  the  sensory 
nerves  w^ere  in  an  imperfect  state  of  medullation 
and  were  therefore  not  good  conductors.  Another 
phenomenon  of  interest  in  this  connection,  referred 
to  by  Myers,  might  be  noted  by  removing  first  the 
heart  of  a  rabbit  twelve  hours  old,  and  then  that 
of  an  adult  rabbit.  The  heart  of  the  first  rabbit 
would  continue  to  beat  for  an  hour  and  a  half, 
whereas  that  of  the  second  would  cease  almost  im- 
mediately. 

In  denuding  the  margins  of  an  incomplete  palate 
cleft,  the  strip  of  mucous  membrane  should  be  re- 
moved, if  possible,  from  the  entire  edge  in  one  piece, 
in  order  that  the  denudation  might  be  complete  all 
around.  If  the  two  sides  of  the  cleft  were  denuded 
separately,  there  was  considerable  likelihood  that  a 
small  piece  of  mucosa  might  be  left  at  the  apex. 
In  the  presence  of  blood  and  mucus,  obscuring  the 
field  of  operation,  such  a  small  piece  of  mucosa  might 
be  unnoticed  and  allowed  to  remain,  interfering  with 
union  at  a  critical  spot.  Denudation  should  begin 
at  the  tip  of  the  uvular  half  upon  one  side  and  con- 
tinue all  around  the  edge  of  the  cleft,  finishing  at 
the  tip  of  the  opposite  half  of  the  uvula.  In  cutting 
off  the  strip  the  knife  should  be  so  held  that  more 
membrane  was  cut  from  the  nasal  than  from  the 
oral  side  of  the  palate.  This  facilitated  coaptation 
with  mattress  sutures. 

In  cases  of  a  narrow,  cleft  combined  with  a  high 
palatal  arch  it  was  often  not  difficult  to  coaptate  the 
edges  with  mattress  sutures  after  the  separation  of 
the  mucoperiosteum  from  the  hard  palate  with 
Brophy's  periosteotome  or  dentists'  scalers  curved 
at  right  angles  on  the  flat.  In  cases  of  high  palatal 
arch,  if  the  cleft  was  not  too  wide,  it  was  sometimes 
unnecessary  to  make  paralyzing  incisions  for  the 
relief  of  tension,  for  after  separation  the  two  flaps 
would  fall  together,  like  the  two  halves  of  a  canti- 
lever drawbridge,  and  might  be  sutured  without  ten- 
sion. The  soft  palate  must  be  quite  completely  sep- 
arated from  the  hard  palate  at  the  posterior  border 
of  the  latter,  as  emphasized  by  Barry. 

(To  be  continued.) 
■  «^  

[IVe  ('lihlish  full  lists  of  books  received,  but  zue  acknozvl- 
cdge  no  obligation  to  rcvieiv  them  all.  Nevertheless,  so 
far  as  space  permits,  zue  review  those  in  which  wc  think 
our  readers  are  likely  to  be  interested.] 

Constipation  and  Intestinal  Obstruction  (Obstipation).  By 
Samuel  Goodwin  Gant,  M.  D.,  LL.  D.,  Professor  of 
Diseases  of  the  Rectum  and  Anus  in  the  New  York  Post- 
graduate Medical  School  and  Hospital ;  Attending  Sur- 
geon for  Rectal  Diseases  at  the  New  York  Postgraduate 
and  St.  Mary's  Hospitals  and  the  German  Polyclinic  Dis- 
pensary. With  250  Original  Illustrations.  Philadelphia 
and  London :  W.  B.  Saunders  Company,  1909. 

The  author  has  succeeded  admirably  in  present- 
ing for  the  reader,  whether  specialist  or  general 
])ractitioner,  an  unusually  full  and  practical  exposi- 
tion of  the  entire  subject  of  constipation  and  dis- 
turbances of  function  of  the  lower  bowel.  Anatomy 
anfl  |)hysiology  are  sufficiently  considered,  and  the 


chapters  on  aetiology,  pathology,  symptomatology, 
diagnosis,  and  treatment  are  based  largely  upon  the 
writer's  own  ample  experience  and  his  teaching  of 
the  best  modern  methods,  to  the  advancement  of 
which  he  has  contributed  in  no  small  degree  him- 
self. There  is  shown  a  commendable  disposition  to 
prefer  dietetic  and  physical  methods,  such  as  mas- 
sage and  hydrotherapy,  in  treatment.  There  can 
be  no  question  that  the  general  run  of  practitioners 
are  too  much  inclined  to  resort  to  the  easy  expe- 
dient of  cathartics,  rather  than  take  the  time  and 
make  the  effort  necessary  to  instruct  their  patients 
in  diet,  exercise,  and  the  '  proper  hygiene  of  the 
bowels.  Among  the  newer  subjects  adequately 
treated  of  are  splanchnoptosis  and  angulations. 
Operations  for  the  graver  surgical  conditions  of 
which  constipation  is  a  symptom  are  described  in 
detail.  The  work  throughout  is  profusely  illus- 
trated and  is  clearly  written  in  a  good  literary 
style. 

Epoch  Making  Contributions  to  Medicine,  Surgery,  and 
the  Allied  Sciences;  Being  Reprints  of  those  Communi- 
cations which  First  Conveyed  Epoch  Making  Observa- 
tions to  the  Scientific  World,  together  with  Biographical 
Sketches  of  the  Observers.  Collected  by  C.  N.  B.  C.\mac, 
M.  D.  With  portraits.  Philadelphia  and  London :  W. 
B.  Saunders  Company.    (Price,  $4.) 

Dr.  Camac  has  made  the  medical  profession  his 
debtor  by  collecting  under  one  cover  reprints  of 
some  of  the  contributions  to  science  which  have 
turned  the  current  of  medical  thought.  In  the  in- 
troduction he  remarks:  "Upon  first  thought  one  is 
disposed  to  conclude  that  to-day  such  communica- 
tions would  be  obsolete  and  of  historic  value  only, 
but  on  reading  the  articles  the  fact  becomes  evi- 
dent that  the  work  and  observations  were  so  thor- 
oughly done  in  the  first  instance  that  the  teaching, 
practice,  and  terminology  of  to-dav  are  either  the 
same  as  when  first  communicated  or  based  directly 
on  these  foundations.  In  many  instances  subse- 
quent writers  have  merely  paraphrased  the  state- 
ments of  the  original  observers.  Indeed,  one  may 
go  further  and  say  that  some  of  the  errors  of  to- 
day are  the  result  of  disregarding  or  misquoting  the 
facts  clearly  set  forth  in  these  original  treatises." 

The  book  contains  the  more  notable  works  of  Lis- 
ter, Harvey.  Auenbrugger,  Laennec,  Jenner,  ]\Ior- 
ton,  and  Holmes,  accompanied  by  portraits  and 
biographical  sketches  of  unusual  interest.  A  val- 
uable feature  is  the  list  of  the  writings  of  each  of 
the  authors  considered.  The  book  is  attractively 
printed  and  bound. 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis.  By  Prof.  Dr.  O.  Haab.  of  Zurich. 
Edited  by  G.  E.  de  Schweinitz.  M.  D.,  Professor  of 
Ophthalmology  in  the  University  of  Pennsylvania  and 
Ophthalmic  Surgeon  to  the  University  Hospital,  etc.  Sec- 
ond American  Edition,  from  the  Fifth  Revised  and  En- 
larged German  Edition.  Philadelphia  and  London :  W. 
B.  Saunders  Company,  1909. 

The  practical  value  of  Haab's  ophthalmoscopic 
atlas  is  shown  by  the  appearance  of  a  fifth  edition. 
Its  low  price,  its  complete  and  authoritative  text, 
and  the  large  number  of  artistic  colored  plates,  in 
which  not  only  the  normal  variations  and  the  com- 
mon diseases  of  the  fundus  oculi,  but  rarer  pictures 
as  well  arc  included,  combine  to  give  the  reader  a 
knowledge  of  the  conditions  which  only  long  years 
of  clinical  work  could  supply. 


June  5,  1909.] 


MISCELLANY.— OFFICIAL  NEWS. 


MedicoUterary  Notes. 

One  of  the  Sun's  young  men,  in  the  issue  of  May 
loth,  in  describing  the  attractions  of  Coney  Island, 
speaks  of  the  legs  of  the  Philippine  princess,  Leg- 
may,  as  being  "uncovered  below  the  knee."  This 
is  familiar  newspaper  anatomy.  Is  it  only  members 
of  the  medical  profession  who  are  aware  that  that 
part  of  the  lower  extremity  extending  from  the 
knee  to  the  hip  is  the  thigh? 

A  certain  patent  medicine  advertisement  that  has 
adorned  the  daily  press  for  some  time  past  bears  as  a 
heading  in  large  display  type  the  words  "To  Them 
That  Hath  !"  This  sounds  at  first  like  the  English 
of  the  time  of  James  I,  but  examination  will  show 
that  it  is  merely  a  specimen  of  the  sloppy  grammar 
characteristic  of  much  of  the  business  English  of 
this  actual  twentieth  century. 

Some  of  our  popular  writers,  particularly  those 
of  the  daily  press,  have  so  frequently  annoyed  us 
by  descriptions  of  persons  falling  "prone  upon  their 
backs"  that  it  is  a  pleasure  to  note  in  the  Saturday 
Evening  Post  for  May  8th  that  the  artist  illustrating 
Will  Irwin's  The  McGregor  Rose  has  drawn  the 
heroine  really  prone  as  the  writer  describes  her. 
Her  face,  her  bosom,  and  the  entire  anterior  surface 
of  the  body  are  most  indubitably  in  immediate  jux- 
taposition with  the  floor.  \\'e  wish  to  say  to  the 
uninstructed  in  the  kindest  manner  in  the  world 
that  a  body  lying  on  its  back  is  "supine." 


Date. 


May  8-15   I 


Itiscdlang. 

A  Correction. — In  Dr.  Max  Einhorn's  article  en- 
titled Report  of  a  Case  of  Idiopathic  Dilatation  of 
the  CEsophagus,  published  in  our  issue  for  May 
29th,  an  error  occurred.  On  page  1078.  three  lines 
from  the  bottom  of  the  first  column,  the  sentence 
"On  February  23,  1909,  she  swallowed  the  sound 
after  nine  seconds"  should  read  as  follows :  "On 
February  23,  1909,  the  swallowing  sound  was  pres- 
ent after  nine  seconds." 


(Official  itujs. 


Public   Health   and   Marine    Hospital  Service 
Health  Reports : 

The  following  cases  of  smallpox,  yellozv  fever,  cholera, 
and  plague  hai'c  been  reported  to  the  surgeon  general, 
United  States  Public  Health  and  Marine  Hospital  Service, 
during  the  ivcek  ending  May  26,  igog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

Califori'ia — Lcs  .\ngeles  May    i-8   i 

Califorria — Sacramento  May  8-15   2 

California — .San  Fi.-incisco  May   1-8   i 

California — Stockton  -April    1-30   i 

Colorado  March    1-31   81 

Georgia — Macon  May  9-16   2 

Illinois — Danville  May  9-16   10 

Illinois — Galcsbiirg  May  8-15   i 

Illinois — Springfield  .■  May  7-14   i 

Indiana — Evansville  May   8-15   i 

Indiana — Kort  Wayne  May   1-8   2 

Indiana — South  Bend  May  8-15   i 

lowp. — Council  Piluffs  May  9-16   i 

Iowa — Davenport  May   2-9   2 

Kansas — .Atchison  Feb.   27-April   17....  5 

Kansas — Kansas  City   May  8-15   11  2 

In  Vicinity 

Kansas — Wichita   May  8-15   4 

Kentucky — Lexington  May  8-15   5 

Kentucky — Newport  May   8-15   i 

Kentucky — Paduc^h  May    1-15   12 

Louisiana — New  Orleans  May  815   6 


29. 


Places. 

Maine — \'an  Buren  

Minnesota — Duluth  May  6-13 

Nebraska — Lincoln  \pril    1-30.  .  . . 

New  Jersey — Perth  Amboy  March  4-.-\pril 

North  Carolina — Charlotte  May  7-14  

Ohio — Cincinnati  May  7-14  

Ohio — Massillon  May  9-16  

Ohio — Toledo   May  1-8  

Ohio — Warren  May  1-8  

Tennessee — Knoxville  May  8-15  

Texas — Fort  Wayne  .April  1-30.... 

Texas — San  .Antonio  May 

Texas — Waco  May 

Virginia — Portsmouth  May 

Washington — Seattle  .April  1-30  

West  V'irginia — Wheeling  May  8-15  

Wisconsin — Milwaukee  May  1-15  

Siiiallpo.r — Insular. 

Philippine   Islands — Manila  March   2o-.April  i 

Smallpo.r — Foreign. 

Algeria — Bona  April  1-30  

Argentina — Buenos  Aires  '"^eb.  1-28  

Brazil — Rahia  .March  27-.April  17 

Brazil — Sao  Paulo  March  15-21  

Canada — Halifax  '.May  1-8  

Canada — \'ancouver  .April  1-30  

Chile — Santiago  .April  27  

China — .\moy  .April  3-10  

Jigypt — -Alexandria  March  1-31  

France — Marseille  -April  1-30  

France — Paris  -April   i8-Ma5'  i.. 

India — Bombay  -April  13-20  

India — Calcutta  .April  3-10  

India — Madras  -March  7-16  

India — Rangoon  .April  3-10  

Indo-China — Saigon  March   27-April  3 

Italy — General  .April  25-May  2.. 

Italy — Genoa  April  1-30  


Cases.  Deaths. 


9 

24 
30 


15 


21   4  Imported 

11-18   4 

  4 


Java — Batavia  -April  3-10  

Mexico— Chihuahua  May  2-9  

Mexico — Guadalajara  -April  22-29  

Mexico — Monterey  May  2-9  

Mexico — Puebla  May  10  

Portugal — Lisbon  May  1-8  

Russia — -Moscow  .April  17-24  

Russia — Odessa  -April  17-24  

Russia — Riga  May  1-8  

Russia — Warsaw  Feb.   27-March  6... 

Siam — Bangkok  March  1-31  

Spain — Barcelona  April   27-May  3.... 

Spain — \'alencia  .April  24-May  i.... 

Straits  Settlements — Singapore. . .  .  May  27--April   3.  .  .  . 

Tripoli — Tripoli  April  10-24  

Turkey — Constantinople  April  18-25  

Turkey — Smyrna  April  8-15  

Yellow  Fever — Foreign. 

Brazil — Bahia  March  27  

Brazil — Para  .April    iS-May  i.... 

Ecuador — Guayaquil  .April  3-17  

Cliolera — Insular. 

Philippine  Islands — Provinces  March   2o-.April  11. 

Cholera — Foreign. 

India — Bombay  .April  13-20  

India — Calcutta  April  3-10  

India — Rangoon  April  3-10  

Russia — St.  Petersburg  .April  29-May  6.... 

Plague — Foreign. 

Chin; — .Amoy  .April  10  

Eci?;  dcT — (iuayaquil  -April  3-17  

India — (General  March  27--April  10.; 

India — Bombay  .April  13-20  

India — Calcutta  April  3-10  

India — Rangoon  April  2  

Indo-China — Saigon  March  27-April  3.. 

Japan — Kyoto  -April  17-24  


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2 

.  2 1 

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2 

■  3 

I 

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.  10 

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10 

•245 

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.    1 J 

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Present 

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,722 

4,684 

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2 

2 

Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  .'States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
May  26,  igog: 

Billings,  W.  C,  Passed  Assistant  Surgeon.  Relieved  from 
duty  at  the  Revenue  Cutter  School  of  Instruction  and 
directed  to  report  to  the  Commanding  Officer  of  the 
Practice  Cutter  Itasca. 

CoBE,  J.  O.,  Surgeon.  Granted  two  months'  leave  of  ab- 
sence from  June  15,  1909. 

Com  FORT,  N.  C,  Pharmacist.  Granted  six  months'  leave  of 
absence  after  July  i,  1909.    (Philippine  Service). 

CuRRiE,  Donald  H.,  Passed  Assistant  Surgeon.  Detailed 
as  Director  of  the  Leprosy  Investigation  Station  at 
Molokai,  T.  H..  to  take  effect  June  i,  1909,  vice  Acting 
Surgeon  Walter  R.  Brinckerhoff  resigned,  to  take  ef- 
fect May  31,  1909. 

Fox,  Carroll,  Passed  Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence  from  May  13,  1909. 


1 172 


BIRTHS/MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal. 


Gahn,  Henry,  Pharmacist.  'Granted  three  days'  leave  of 
absence,  May  18,  21,  and  22,  1909,  under  paragraph  210 
Service  Regulations. 

Gibson,  R.  H.,  Pharmacist.  Upon  arrival  of  Pharmacist 
Charles  Miller,  relieved  from  duty  at  New  Orleans, 
La.,  and  directed  to  proceed  to  the  South  Atlantic 
Quarantine  Station  and  report  to  the  Medical  Officer 
in  Command  for  duty  and  assignment  to  quarters. 

Hamilton,  H.  J.,  Acting  Assistant  Surgeon.  Granted  nine 
days'  leave  of  absence  from  May  8,  1909. 

Herring,  R.  A.,  Assistant  Surgeon.  Granted  one  month 
and  four  days'  leave  of  absence  from  June  5,  1909. 

Holt,  J.  M.,  Passed  Assistant  Surgeon.  Granted  one 
month's  leave  of  absence  from  July  5,  1909. 

Hunter,  Sam.  B.,  Acting  Assistant  Surgeon.  Granted  four 
days'  leave  of  absence  from  May  18,  1909. 

Keen,  Walter  H.,  Pharmacist.  Directed  to  report  to  Sur- 
geon Rupert  Blue  at  San  Francisco,  Cal.,  for  tem- 
porary duty. 

Kerr,  J.  W.,  Assistant  Surgeon  General.  Detailed  to  rep- 
resent the  Service  at  the  meetings  of  the  American  As- 
sociation of  Milk  Commissioners,  June  7,  1909,  and 
the  American  Medical  Association,  June  8  to  11,  1909. 
at  Atlantic  City,  N.  J. 

Miller_,  Charles,  Pharmacist.  Relieved  from  duty  at  San 
Francisco,  Cal.,  and  directed  to  proceed  to  New  Or- 
leans, La.,  and  report  to  the  Medical  Officer  in  Com- 
mand for  duty  and  assignment  to  quarters. 

Naulty,  Charles  W.,  Jr.,  Acting  Assistant  Surgeon. 
Granted  fourteen  days'  leave  of  absence  from  June  11, 
1909. 

Scott,  E.  B.,  Pharmacist.  Granted  nine  days"  leave  of  ab- 
sence from  May  26,  1909. 

Wasdin,  Eugene,  Surgeon.  Granted  one  month's  leave  of 
absence  from  May  22,  1909,  on  account  of  sickness. 

Appointment. 

Doctor  W.  H.  Kellogg  appointed  an  acting  assistant  sur- 
geon for  duty  in  the  office  of  the  U.  S.  Consul  at  La 
Guayra,  Venezuela. 

Rcinslatcinent. 

Walter  H.  Keen  reinstated  as  a  pharmacist  of  the  third 
class. 

Board  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  Bu- 
reau, May  18,  1909,  for  the  purpose  of  making  a  physical 
examination  of  an  officer  of  the  Revenue  Cutter  Service. 
Detail  for  the  board :  Assistant  Surgeon  General  W.  J. 
Pettus,  chairman ;  Passed  Assistant  Surgeon  J.  W.  Trask, 
recorder. 

Army  Intelligence : 

Oificial  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 

Army  for  the  zveck  ending  May  zg,  1900: 

Bailv,  PL  H.,  Captain,  Medical  Corps.  Ordered  to  accom- 
pany troops  from  Washington  Barracks,  D.  C,  to  San 
Francisco,  Cal.,  and  then  return  to  Fort  Myer,  Va. 

Gostin,  B.  S.,  First  Lieutenant,  Medical  Corps.  Granted 
leave  of  absence  for  three  months,  when  relieved  from 
duty  in  the  Philippines  Division. 

Hall.  J.  F.,  .Captain,  Medical  Corps.  Granted  leave  of 
absence  for  four  months,  about  October  15,  1909. 

Harris,  J.  R.,  Captain  Medical  Corps.  Relieved  from  duty 
at  Fort  Worden,  Wash,  and  ordered  to  Fort  George 
Wright,  Wash.,  for  duty. 

Ireland,  M.  W.,  Major.  Medical  Corps.  Ordered  to  pro- 
ceed to  New  York  City  and  return,  on  business  pertain- 
ing to  the  Medical  Supply  Department. 

Keeper.  F.  R.,  Major,  Medical  Corps.  Relieved  from  duty 
at  the  Presidio  of  Monterey,  Cal.,  and  ordered  to  Fort 
Wadsworth,  N.  Y.  for  duty. 

McCuLLOcH.  C.  C,  Jr..  Major,  Medical  Corps.  Granted 
leave  of  absence  for  four  months. 

Morse.  A.  W..  Major.  Medical  Corps.  Relieved  from  duty 
at  Fort  Leavenworth.  Kans.,  and  ordered  to  the  Pre- 
sidio of  Monterey.  Cal.,  for  duty. 

Shillock,  Paul,  Major.  Medical  Corps.  Ordered  to  Hot 
Springs,  Ark.,  for  treatment  at  the  Army  and  Navy 
General  Hospital. 

Sjhikklev,  M.  A.  W.,  Major.  Medical  Corns.  Granted 
leave  of  absence  for  one  month,  about  June  3d. 


Vose,  W.  E.,  Captain.  Medical  Corps.  Granted  leave  of 
absence  for  two  months,  about  August  20th. 

W.'iTERH'juse,  S.  M..  Major.  Medical  Corps.  Granted  leave 
of  absence  for  four  months,  when  relieved  from  duty 
in  the  Philippines  Division. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Navy  for  the  week  ending  May  .zg,  igog: 
Bogert,  E.  S.,  Jr.,  Surgeon.    Detached  from  the  Naval 
Academy  and  granted  leave  until  September  15th,  with 
permission  to  go  abroad. 
Butler,  C.  St.  J.,  Surgeon.    Commissioned  a  surgeon,  with 
rank  of  lieutenant  commander,  from  October  11,  1908. 
Cole,  H.  W.,  Jr.,  Passed  Assistant  Surgeon.  Commis- 
sioned a  passed  assistant  surgeon,  with  rank  of  lieuten- 
ant, from  October  5,  1908. 
FiSKE,  C.  N.,   Surgeon.     Commissioned  a  surgeon,  with 
rank  of  lieutenant  commander,  from  September  i,  1907. 
Gill,  J.  E.,  Passed  Assistant  Surgeon.    Detached  from  the 

Dubuque  and  ordered  home  to  wait  orders. 
Ledbetter,  R.  E.,  Surgeon.    Commissioned  a  surgeon,  with 
rank  of  lieutenant  commander,   from   September  19, 
1908. 

Rose,  M.  E.,  Assistant  Surgeon.    Ordered  to  the  Naval 

Hospital,  Norfolk,  Va. 
Smith,  C.  W.,   Assistant  Surgeon.     Detached  from  the 

Naval  Hospital,  Norfolk,   Va.,  and  ordered  to  tli.; 

Dubuque. 


iirt^s,  Itarriagts.  ani  ie-itbs. 


Married. 

Howard — Woodbury. — In  Washington,  D.  C,  on  Satur- 
dav,  May  29th,  Dr.  Tasker  Howard,  of  Brooklyn,  and  Miss 
iMary  Woodbury. 

J.\MES — McCulloch. — In  Ancon,  Canal  Zone,  Panama, 
on  Saturday,  May  ist,  Dr.  William  McCully  James  and 
Miss  Mary  Gurley  McCulloch. 

Died. 

Bass. — In  Campbellsville,  Kentucky,  on  Friday,  May 
2ist,  Dr.  Samuel  R.  Bass. 

Clarke. — In  Paris,  France,  on  \^'ednesday,  May  26th, 
Dr.  Alexander  S.  Clarke. 

Cook. — In  Sandusky,  Ohio,  on  Fridav,  Mav  14th,  Dr. 
Alta  F.  Cook. 

Corbett. — In  Sr.  Louisville,  Ohio,  on  Saturday,  May  8th, 
Dr.  R.  P.  Corbett,  aged  eighty-two  years. 

Co.x. — In  Albany,  New  York,  on  Friday,  May  21st,  Dr. 
George  A.  Co.x,  aged  sixty-three  years. 

GuNKEL. — In  Newport,  Kentucky,  on  Monday,  May  24th, 
Dr.  Henry  C.  Gunkel,  aged  eighty-four  years. 

Hall. — In  Burlington,  New  Jersey,  on  Saturday-,  May 
22nd,  Dr.  Walter  E.  Hall,  aged  fifty-one  years. 

Huber. — In  Lebanon,  Pennsylvania,  on  Tuesday,  May 
25th.  Dr.  William  S.  Huber,  aged  forty-three  years. 

Lansdale. — In  Damascus.  Maryland,  on  Friday,  May 
2ist.  Dr.  Benjamin  F.  Lansdale.  aged  sixty-four  years. 

McC'RMACK. — In  Boston,  on  Tuesday.  May  25th,  Dr. 
Alexander  L.  McCormack,  aged  fifty-three  years. 

Mills. — In  Reidsville,  North  Carolina,  on  Tuesday,  May 
i8th.  Dr.  J.  C.  Mills. 

Porter. — In  Boston,  on  Fridaj-,  May  21st.  Dr.  Charles  B. 
Porter,  aged  si.xty-nine  years. 

Smith. — In  Chelsea.  Vermont,  on  Monday,  May  17th, 
Dr.  A.  B.  Smith,  aged  fifty-eight  years. 

Smith. — In  Mount  Holly  Springs,  Pennsylvania,  on  Sat- 
urday, May  22nd.  Dr.  Jacob  H.  Smith,  aged  fifty-five  years. 

Stanton. — In  Willimaiitic.  Connecticut,  on  Thursday, 
May  27th,  Dr.  Thalcs  I.  Stanton,  aged  sixty  years. 

Stedman. — In  Brookline,  Massachusetts,  on  Monday, 
May  24th,  Dr.  Charles  Ellery  Stedman,  aged  seventy-eight 
years. 

Steele. — In  Helena,  Montana,  on  Sunday,  May  i6th.  Dr. 
William  L.  Steele,  aged  seventy-five  years. 

Wild. — In  Rochester,  New  York,  on  Monday,  May  24tli. 
Dr.  George  W.  Wild,  aged  fifty-four  years. 

Zech. — In  York  New  Salem.  Pennsylvania,  on  Saturday. 
May  22nd.  Dr.  Luther  E.  Zech.  aged  forty-scNcn  years. 


New  York  Medical  Journal 


INCORPORATING  THE 


Philadelphia  Medical  Journal  rlt  Medical  News 

A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXIX,  No.  24. 


NEW  YORK,  JUNE  12,  1909 


Whole  No.  1595 


^©riginal  Comnuinirations. 

DIET  AS  A  PROPHYLACTIC  AND  THERAPEUTIC* 

By  H.  W.  Wiley,  M.  D., 
Washington,  D.  C, 

Chief  Chtmisl,  Bureau  of  Chemistry,  Department  of  Agriculture. 

There  is  an  increasing  belief  in  the  medical  pro- 
fession, and  this  belief  is  founded  on  substantial  evi- 
dence, that  diet  is  an  important  factor  in  the  pro- 
duction and  cure  of  disease.  Both  the  words  "pro- 
duction" and  "cure"  are  used  here  in  their  ordinary- 
sense,  meaning  as  aids  to,  or  favorable  to,  and  not 
as  possessing  specific  properties  of  production  or 
efifacement.  By  reason  of  the  provisions  of  the 
Food  and  Drugs  Act  the  term  "cure"  is  now  some- 
what restricted  in  its  applications.  The  common 
practice  of  advertisers  of  patent  or  proprietary 
medicines  in  the  past  was  to  advertise  them  as  a 
"aire"  or  "stire  cure"  or  "infallible  cure"  for  vari- 
ous diseases,  and  also  to  place  similar  statements  on 
the  labels.  When  the  law  was  enacted  forbidding 
the  use  of  a  statement  which  was  false  or  mislead- 
ing in  any  particular,  and  especially  since  the  courts 
have  judged  that  the  word  "cure,"  in  the  strict  sense 
of  that  term,  may  not  be  applied  to  a  remedy  or 
medicine,  less  use  is  made  of  the  word.  For  this 
reason  I  have  used  the  term  in  the  restricted  sense 
of  establishing  favorable  conditions  whereby  the 
natural  removal  of  the  disease  might  take  place, 
rather  than  as  exerting  a  specific  influence  in  the 
removal  of  the  disease  and  the  restoration  of  the 
diseased  organ  to  a  state  of  health.  I  propose  to 
eliminate  from  the  present  discussion  the  well 
known  effects  of  adulterated  or  debased  foods  in 
the  promotion  of  disease,  and  shall  confine  myself 
in  the  main  to  the  influence  of  nutritious,  palatable, 
wholesome,  and  clean  foods,  both  as  a  preventive 
and  as  a  remedy. 

If  we  accept  the  modern  theory  of  specific  infec- 
tion in  the  aetiology  of  disease,  we  should  also  accept 
its  attendant  theories,  which  may  be  briefly  stated 
as  follows :  A  perfectly  healthy,  well  nourished  or- 
gan becomes  infected  with  any  disease  germ  with 
great  difficulty:  in  other  words  it  is  self  protective. 
T  shall  not  enter  here  into  any  details  concerning 
this  theory,  but  only  state  it  briefly.  Granting  this, 
therefore,  it  is  self  evident  that  the  food  or  diet 
must  play  a  most  important  part  in  the  prevention 
of  disease.  The  normal  condition  of  the  body,  or 
any  organ  of  the  body,  and  hence  its  maximum 

*Read.  by  invitation,  at  a  meeting  of  the  .American  Therapeutical 
Society,  Xevv  Haven,  Conn.,  May  6  to  8,  1909. 


power  to  protect  itself  against  infection,  is  directly 
dependent  upon  the  character  and  the  amount  of 
the  diet.  It  follows  then  as  a  necessary  conclusion 
that  the  debasement  of  the  diet,  the  addition  of  in- 
jurious substances  thereto,  or  the  abstraction  of 
valuable  ingredients  therefrom,  diminishes  the 
power  of  that  diet  to  maintain  the  body  in  a  state 
of  hygienic  equilibrium.  Hence,  the  normal  condi- 
tion follows  when  foods  are  furnished  of  a  proper 
c[uality,  assuming  as  a  basis  of  the  discussion  that 
such  foods  shall  not  be  so  manipulated  as  to  incor- 
porate with  them  an  ingredient  injurious  to  health; 
to  take  from  them  any  quantity  of  their  nourishing 
properties  which  would  unbalance  their  nutritive 
value ;  or  to  treat  them  in  any  manner  so  as  to  irrii- 
pair  their  power  to  sustain  life. 

The  second  condition  regarding  diet  as  a  prophy- 
lactic is  its  quantity.  It  will  be  easily  understood 
from  this  assumption  of  the  basis  of  discussion  that 
the  proper  quantity  of  food  to  maintain  the  equilib- 
rium is  a  condition  of  efficiency.  If  less  food. than 
is  necessary  is  ingested'the  body  must  lose  a  portiorL 
of  its  sustenance  and  a  part  of  its  ability  to  with^ 
stand  infection.  On  the  contrary,  if  a  larger  quan- 
tity of  food  is  ingested  than  is  necessary,  an  addi- 
tional burden  is  placed  upon  the  organs  of  digestion 
in  ridding  the  body  of  the  excess,  or  of  storing  the 
excess  of  nutriment  in  some  form,  usually  that  of 
fat,  in  the  tissues  of  the  body.  Either  conditior* 
must  be  regarded  as  unfavorable  to  complete  pro- 
phylaxis and  hence  either  a  deficiency  or  an  excess- 
of  food  would  to  that  extent  predispose  to  diseases 
of  the  kind  mentioned.  It  is  of  course  understood 
that  these  variations  within  ordinary  limits  are  not 
of  any  appreciable  effect.  If  on  one  day  a  person' 
should  eat  a  little  less  food  than  necessary  for 
normal  nutrition,  and  on  the  next  eat  a  little  more, 
varying  in  this  way  from  time  to  time,  no  appre- 
ciable effect  would  be  noticed.  On  the  other  hand, 
the  person  who  continuously  uses  less  food  than  is 
necessary,  or  one  who  continuously  uses  more  than- 
is  necessary,  must  to  that  extent  become  more  ob- 
noxious to  disease.  In  the  second  place,  assuming' 
that  the  total  quantity  of  the  food  remains  the  same, 
any  marked  and  continuous  change  in  the  relations 
of  its  natural  constituents  must  be  looked  upon  with 
suspicion. 

The  normal  food  of  man,  and  of  other  animals 
as  far  as  that  is  concerned,  may  be  divided  into  five 
great  classes,  namely,  protein,  fat.  suear  (starch, 
etc.),  minerals,  and  waste  or  indigestible  portions. 
Each  of  these  constituents  has  a  useful  function, 
and  the  sum  of  nutrition  is  the  normal  i^^Testion  of 


Copyright,  sgog,  by  .-X.  R.  Elliott  Publishing  Company. 


1174 


WILEY: 


DIET. 


[New  York 
MiDicAL  Journal. 


all  of  these  ingredients  ■  in  their  usual  proportions. 
Here  again  it  must  be  acknowledged  that  slight 
variations  in  distribution  of  ingredients  may  take 
place  without  any  notable  injury,  just  as  is  the  case 
with  the  variation  of  total  amount  of  nutrients. 
But  if  one  essential  ingredient  to  which  the  human 
body  is  accustomed,  and  on  which  it  has  been  de- 
veloped to  its  present  state  of  normal  equilibrium, 
should  be  persistently  removed  from  the  food,  in 
my  opinion  tiie  ultimate  power  of  resistance  to  dis- 
ease of  mankind  would  be  diminished.  It  is  well 
known,  for  instance,  that  a  diet  of  protein  alone 
will  speedily  lead  not  only  to  the  danger  of  infec- 
tion, but  also  to  positive  weakness  and  starvation. 
In  like  manner  a  diet  of  carbohydrates  alone  would 
result  in  the  same  condition,  and  this  is  true  of  a 
diet  of  fat,  or  a  diet  of  the  mineral  constituents,  or 
a  diet  of  the  waste  constituents.  I  take  it  as  a 
proposition  very  difficult  to  disprove,  and  sustained 
by  every  principle  of  analogy  and  reasoning,  that 
the  ordinary  normal  diet  of  man,  selected  by  the 
necessities  of  nutrition  and  by  taste,  is  considered 
all  in  all  the  best.  To  illustrate  more  particularly, 
I  heard  the  surgeon  general  of  the  Japanese  navy, 
in  a  lecture  in  Washington  about  two  years  ago, 
ascribe  the  disease  known  as  beriberi  to  a  carbo- 
hydrate diet.  Rice  being  one  of  the  principal  foods 
of  the  Japanese,  and  almost  the  only  food  of  the 
poor,  the  surgeon  general  ascribed  the  prevalence 
of  beriberi  among  the  Japanese,  especially  the  Jap- 
anese sailors,  solely  to  the  use  of  that  diet.  On  the 
other  hand  it  has  been  thought  that  scurvy  is  a  dis- 
ease due  largely  to  the  elimination  from  the  dietary 
of  the  vegetables  that  are  eaten  in  the  normal  con- 
dition of  nutrition.  These  two  illustrations,  which 
are  more  or  less  founded  upon  observation  and 
scientific  investigation,  I  think  may  be  accepted  as 
at  least  indicative  of  what  might  be  expected  should 
any  usual  elements  of  the  diet  be  either  increased 
or  decreased  proportionately  to  the  other  elements. 

Among  other  statements  which  have  been  made 
in  this  line  by  most  eminent  men,  and  those  whose 
scientific  learning  and  judgment  we  all  respect,  is 
the  one  that  the  normal  diet  of  man,  especially  in 
the  United  States,  contains  too  large  a  percentage  of 
protein.  Data  have  been  collected  in  an  experi- 
mental way  which  tend  to  show  that  a  diminution 
in  the  amount  of  protein  in  the  food  leads  to  very 
beneficial  results,  increasing  the  strength  and  endu- 
rance of  the  subjects  experimented  upon.  It  is  true 
that  this  conclusion  has  also  been  questioned  by 
high  scientific  authority,  and  so  we  may  regard  it  at 
the  present  time  as  neither  established  nor  disproved 
by  scientific  data.  Applying  the  principle  of  anal- 
ogy to  this  condition  of  affairs,  we  may  properly 
ask  if  a  diet  so  low  in, protein  should  be  continued 
for  a  long  period  of  time,  whether  some  notable  in- 
jury would  not  be  done  to  the  human  body  which 
would  render  it  more  obnoxious  to  disease.  In  fact, 
might  we  not  expect  an  approach  to  that  condition 
of  afifairs  already  alluded  to  in  the  case  of  the  beri- 
beri of-  the  Japanese  sailors?  Might  not  there  be 
other  effects  also  not  immediately  noticeable  which 
would  render  the  general  introduction  of  a  diet  into 
the  United  States  containing,  for  instance,  only  half 
as  much  pmtcin  as  thai  already  cnn^umed.  danger- 


ous to  the  general  health  of  the  community?  I  ask 
this  without  in  the  least  calling  into  question  the 
fact  that  the  actual  amount  of  protein  which  we 
consume  may  be  greater  than  is  desirable.  In  that 
case  we  would  expect  that  the  human  body  would 
b.e  subject  to  other  diseases,  especially  of  those 
organs  which  are  called  upon  particularly  to  ex- 
crete the  protein,  or  its  decomposition  products, 
from  the  body.  In  other  words  if,  for  the  sake  of 
illustration,  and  the  figures  are  somewhat  exag- 
gerated, we  should  assume  that  the  normal,  healthy 
man  of  the  United  States  at  the  present  day  con- 
sumes twenty  grammes  of  nitrogen  per  day  in  the 
form  of  protein  and  the  man  under  the  proposed 
regime  only  ten  grammes,  would  the  new  order  of 
afifairs  produce  a  race  of  men  less  subject  to  disease 
than  the  present  one  ?  We  might  all  admit  that  the 
reduction  of  the  quantity  of  nitrogen  from  twenty 
to  eighteen  grammes  might  be  desirable,  but  would 
not  be  inclined  to  go  to  the  extreme  of  supposing 
that  it  should  be  diminished  by  one  half  or  two 
thirds,  or  even  more. 

I  need  hardly  refer  here  to  another  question  in 
respect  of  wholesome  foods  in  their  relations  to 
health,  namely,  that  of  mastication.  I  believe  that 
all  admit  the  desirability  of  mastication,  both  as  a 
mechanical  necessity  preliminary  to  deglutition  and 
also  preliminary  to  the  proper  mechanical  state  for 
the  first  steps  of  hydrolysis  in  the  process  of  diges- 
tion. This  having  been  properly  accomplished,  the 
question  may  arise  whether  or  not  the  carrying  of 
mastication  to  excess  might  result,  first,  in  dimin- 
ishing the  actual  quantity  of  food  necessary,  and, 
second,  to  actually  interfering  with  the  proper  pro- 
cess of  digestion.  Since  the  beginning  of  the  human 
race,  and  before,  the  sense  of  hunger  has, been  the 
normal  gauge  of  the  quantity  of  food  ingested,  and 
I  think  it  must  be  admitted,  if  we  believe  in  the 
principles  of  evolution,  ,that  this  sense  of  hunger 
has  fixed  properly  the  quantity  of  food  necessary. 
We  need  not  discuss  those  abnormal  cases  where 
the  natural  sense  of  hunger  leads  to  overeating,  or 
where  its  absence  leads  to  undereating,  but  I  speak 
only  of  the  average  normal  condition.  I  believe  it 
may  be  accepted  that  excessive  mastication,  there- 
fore, would  tend  to  satisfy  the  sense  of  hunger  with 
a  less  quantity  of  food  than  is  needed  in  normal 
conditions.  Let  me  put  the  case  a  little  differently : 
Normal  man  must  masticate  his  food  in  a  mm^er 
whereby  it  can  be  easily  swallowed,  and  this  fits  it 
for  the  ordinary  process  of  digestion.  If  a  man 
should  excessively  chew  his  food  it  seems  to  me 
that  it  is  almost  certain  that  a  less  quantity  of  it 
would  satisfy  his  craving.  In  other  words,  a  man 
who  gives  his  whole  attention  to  mastication  must 
necessarily  in  a  short  time  lose  the  sense  of  hunger 
— in  a  much  shorter  time  in  so  far  as  the  quantity 
of  food  is  concerned,  than  he  would  otherwise. 
Hence,  while  it  is  perfectly  easy  of  demonstration 
that  a  somewhat  more  extensive  degree  of  com- 
minution of  the  food  may  be  desirable,  it  docs  not 
hnld  that  it  should  be  carried  to  extremes,  or  putting 
it  another  way,  speed  of  digestion  is  not  to  be  re- 
garded as  svnonymous  with  nutritive  digestion.  I 
think  it  may  be  easily  understood  that  just  the  con- 
trary would  be  the  case.    Suppose,  for  the  sake  of 


June  12,  J909.] 


WILEY:  DIET. 


H75 


argument,  that  mastication  could  be  continued  until 
the  food  was  reduced  to  its  molecular  condition. 
Such  food,  we  might  assume,  would  be  digested  al- 
most instantaneously,  but  if  the  absorbent  system 
remains  in  its  present  condition  it  would  be  quite 
impossible  for  that  food  to  enter  the  circulation  in 
an  instantaneous  manner.  Much  of  it  would  neces- 
sarily, in  the  natural  motion  of  the  intestinal  organs, 
soon  pass  beyond  the  region  of  absorption  and 
escape  entering  into  the  nutritive  processes  entirely. 
Thus  I  venture  to  ask  the  question  whether  it  may 
not  be  possible  that  excessive  mastication,  that  is, 
converting  the  meal  hour  into  a  mere  mechanical 
exercise,  may  not  in  the  end  threaten  the  human 
family  with  grave  dangers  of  insufficient  nutrition? 
I  ask  this  question  without  in  the  least  denying  the 
principle  that  mastication  is  a  desirable  and  neces- 
sary process. 

I  come  now  to  the  second  part  of  the  discussion, 
that  is,  a  condition  where  disease  has  already  be- 
come established.    What  now  is  the  function  of 
food  respecting  its  therapeutic  value?    Every  phy- 
sician recognizes  the  necessity  of  sustaining  to  the 
utmost  the  vegetative  functions  of  the  body  in  dis- 
ease.   Disease,  as  it  usually  is  found,  may  be  de- 
fined as  that  condition  of  metabolism  in  which 
calabolism  is  more  active  than  anabolism.    In  an- 
other sense  the  contrary  is  true  and  the  excessive 
production  of  tissue,  especially  of  adipose  tissue,  is 
in  some  r(?spects  just  as  much  a  disease  as  the  loss 
of  weight,  which  we  usually  associate  with  most  dis- 
eases.   In  my  opinion  the  disease  which  results  in 
hypertrophy  may.  as  a  rule,  be  entirely  controlled 
by  diminishing  the  amount  of  the  diet,  unless  it  has 
gone  so  far  'as  to  be  practically  irremediable.  The 
excess  of  activity  of  anabolism  is  associated  very 
frequently  with  advancing  years.   The  habit  of  eat- 
ing becomes  fixed  in  childhood, youth,  and  manhood, 
that  is  during  the  period  of  growth  and  maximum 
activity  of  life.    When  senectitude  approaches,  if 
the  habit  of  eating  remains  unchanged,  larger  quan- 
tities of  food  are  ingested  than  are  required  for  the 
new  conditions  tliat  attend  incipient  old  age.  There 
is  thus  an  accumulation  of  tissues  which  may  be- 
come of  a  character  conditioned  upon  an  actual  de- 
raneement  of  nutrition.    On  the  other  hand,  the 
condition  usually  found  in  disease  is  the  activity  of 
catabolism.    The  moment  the  temperature  of  the 
body  rises  above  the  normal,  catabolism  gains  the 
ascendancy.    This  is  based  upon  the  plain  laws  of 
thermodynamics.    The  waste  of  tissue  which  is  the 
attendant  of  disease  often  becomes  so  great  as  to 
threaten  and  even  actually  cause  the  death  of  the 
patient.    To  combat  this  condition  and  stimulate 
anabolism.  food  of  a  proper  kind  is  one  of  the  most 
valuable  of  the  armaments  of  the  phvsician.    But  in 
this  condition  we  have  an  entire  chanp-e  of  relations. 
The  natural  desire  for  food  usuallv  has  passed 
away.    The  -character  and  activitv  of  the  digestive 
ferments  are  changed.   There  is  often  actual  disease 
of  the  digestive  organs  themselves,  and  when  not 
actually  diseased  their  activity  is  so  impaired  by 
the  disease  of  other  organs  that  thev  cannot  be 
treated  as  in  the  case  of  health.    Hence  the  vse  o^ 
food  in  disease  is  regulated  by  enti"ely  diflfereiit 
conditions  from  the  use  of  it  in  health. 


1  may  say  that  the  introductioil  of  drugs  of  any 
<lescription  into  foods  which  are  intended  for  in- 
valids is  not  only  undesirable,  but  in  my  opinion, 
criminal.    Let  me  illustrate  this  by  a  simple  state- 
ment :  Among  all  the  foods  which  are  proposed  for 
conditions  of  disease,  there  is  none  which  is  so 
valued  as  milk.    The  value  of  sweet  milk  as  a  food, 
even  in  a  state  of  health,  depends  largely  upon  its 
purity  and  freshness,  and  in  a  state  of  disease  these 
two  qualities  are  absolutely  imperative.  The  healthy 
man  may  use  considerable  quantities  of  milk  that 
contains  millions  of  organisms  per  cubic  centimetre, 
or  milk  preserved  with  formaldehyde,  boric  acid, 
sodium  benzoate,  or  other  preservative,  and  receive 
no  apparent  injury;  but  the  case  is  entirely  different 
with  the  invalid.    The  ingestion  of  even  minu'e 
quantities  of  these  bodies,  or  of  old  milk  not  yet 
sour,  mav,  and  probably  does,  induce  positive  inju-y. 
Even  pasteurized  milk  may  be  undesirable,  espe- 
cially in  the  case  of  infants,  as  has  been  illustrated 
by  the  reports  of  many  physicians.    The  healthy 
adult,  in  my  opinion,  can  drink  pasteurized  milk 
with  impunity,  provided  the  milk  was  good  whei 
pasteurized  and  did  not  need  pasteurizing,  but  the 
same  good  milk,  pasteurized  and  used  in  a  state  of 
disease  might  be  open  to  serious  objections.  An- 
other illustration :  Physicians  often  prescribe  fresh 
fruit  juices  for  invalids  and  convalescents.  The 
fresh  juices  of  the  apple  and  of  the  grape  are  those 
usually  employed.    About  a  year  ago  Judge  Mor- 
row, of  the  Federal  Court  of  San  Francisco,  came 
to  my  ofifice  on  his  way  home  from  Germany.  While 
there  his  physician  had  advised  him  to  drink  fresh 
pasteurized  apple  juice,  and  he  had  done  so  with 
great  benefit.    He  came  to  see  me  to  ask  where  he 
could  get  fresh,  pasteurized,  unchemicalized  apple 
juice  in  this  country.    I  reluctantly  told  him  that  I 
did  not  know ;  that  my  experience  in  buying  fresh 
apple  juices  on  the  market  had  led  me  to  believe 
that  they  were  almost  universally  dosed  with  some 
antiseptic,  either  salicylic  acid,  sodium  benzoate.  or 
sulphurous  acid.    He  said  his  physician  had  told 
him  to  avoid  all  such  mixtures.   At  the  present  date, 
however,  I  can  say  that  matters  have  improved  very 
much.    Large  quantities  of  fresh  apple  juice  and 
fresh  grape  juices  are  now  placed  upon  the  markets 
without  the  addition  of  any  chemical  whatever,  and 
they  are  preserved  in  a  much  more  palatable  and 
much  more  salable  state  than  ever  before.    This  is 
illustrated  by  a  letter  I  have  recently  received  from 
a  manufacturer  of  fresh  grape  juice  at  Sandusky, 
Ohio,  which  is  as  follows : 

S.ANDUSKY,  Ohio,  March  ,?5.  iQog. 
We  wish  to  state  that  the  three  barrels  of  grape  juice 
which  you  and  our  Mr.  .A.ppel  had  sealed  last  October  kept 
in  first  class  condition,  as  did  also  our  entire  output,  and 
we  are  pleased  to  advise  you  that  with  the  exception  of  a 
small  stock  of  sulphur  grape  juice  still  on  hand,  which  we 
are  placing  in  a  limited  section  of  territory,  that  we  have 
withdrawn  the  sale  of  sulphur  juice  altogether  from  the 
market,  and  are  now  offering  nothing  but  the  absolutely 
pure  article. 

The  first  requisite  which  we  should  make  for 
foods  for  invalids  is  that  they  should  be  pure.  The 
next  most  important  thing  is  to  find  a  pure  food 
which  the  invalid  can  digest.  You  cannot  nourish 
an  invalid  7  f  ct  aniiis.    You  must  find  out  what  he 


11/6 


SHOEMAKER:  SODIUM,  LITHIUM,  ETC. 


[New  York 
Medical  Journal. 


can  eat  and  give  him  that,-  whatever  it  may  be,  and 
if  the  digestive  organs  themselves  are  diseased,  a 
greater  care  must  be  exercised.  \'ery  often  sick 
people  have  an  irreconcilable  antipathy  to  articles  of 
which  when  they  are  well  they  are  frequently  very 
fond,  and  this  idiosyncrasy  of  the  invalid  must  be 
respected  by  the  physician.  It  has  frequently  been 
observed  in  cases  of  low  nutrition  that  sour  milk, 
or  kumyss,  may  be  taken  with  relish  and  with  ben- 
efit when  other  forms  of  food  seem  to  be  rejected. 
I  am  not  a  protagonist  of  the  belief  of  Metchnikoft' 
that  sour  milk  is  the  elixir  of  life.  A  theory  of  this 
kind  would  have  to  be  demonstrated,  and  it  would 
take  a  hundred  years  to  demonstrate  it.  But  even 
from  theoretical  considerations  the  theory  does  not 
appeal  to  me,  and  I  am  not  going  to  discuss  it  here. 
In  my  limited  experience  at  the  bedside  of  the  sick, 
as  physician  or  friend,  I  have  seen  some  excellent 
results  from  the  use  of  kumyss.  In  my  opinion  the 
physicians  of  this  country  should  undertake  to  pro- 
mote the  manufacture  of  a  pure  kumyss,  and  I  do 
not  mean  by  that  that  it  shall  be  made  of  mare's 
milk  as  it  originally  was.  nor  do  I  use  the  word  in 
the  strict  sense  of  the  Food  and  Drugs  Act — I  mean 
good  milk  fermented  in  a  bottle,  or  in  other  words 
■'lacteal  champagne."  This  is  only  mentioned,  how- 
ever, as  one  of  the  things  that  might  be  more  prop- 
erly prescribed  in  conditions  where  inanition  is  often 
a  greater  danger  than  the  disease  itself,  and  here  I 
am  led,  in  the  kindest  of  spirits,  to  remark  that  the 
science  of  nutrition  is  unfortunately  not  very  exten- 
sively included  in  the  curricula  of  our  medical 
schools. 

I  must  also  be  allowed  to  say  that  the  most  pre- 
posterous dicta  that  I  have  ever  heard  concerning 
diet  have  come  not  from  teachers  of  dietetics  and 
cooking  but  from  physicians  themselves.  In  the 
progress  of  medical  education  the  near  future,  in 
my  opinion,  will  see  the  professorship  of  dietetics 
in  a  medical  school  advanced  to  the  same  rank  as 
that  of  medicine,  and  I  am  even  going  further  than 
this  and  say  that  the  practice  of  medicine  in  the 
future  will  be  largely  a  practice  of  dietetics. 

When  I  sat  down  to  write  this  article  I  had  ex- 
pected to  apply  the  principles  which  I  have  tried  to 
lay  down  to  some  particular  disease,  and  especially 
did  I  have  in  mind  tuberculosis,  but  I  have  used 
up  the  time  allotted  to  me,  and  I  have  not  even 
opened  one  of  the  ten  leading  authorities  on  diet- 
etics which  I  had  marked  and  placed  u])on  my  desk. 
I  shall  leave  this  for  another  time.  I  simply  want  to 
say  that  I  believe  it  is  now  acknowledged  by  physi- 
cians that  the  treatment  of  tuberculosis  is  largely 
conditioned  upon  the  diet.  Here  is  one  of  the  cases 
where  apparently 

'■\Vhile  the  Ranch  holds  out  to  burn 
The  lowest  lunger  may  return," 

I  have  the  greatest  faith  in  the  future  of  prophy- 
lactic medicine  and  perhaps  the  day  will  come  when 
the  physician  will  be  paid  in  proportion  to  the  eflFec- 
tiveness  of  prophylaxis.  While  it  is  true  that  diet 
is  only  one  of  the  factors  in  prophylaxis,  as  well  as 
in  therapeutics,  it  is,  in  my  opinion,  one  of  the  most 
potent  factors :  and  undoubtedly  a  symposium,  such 
as  that  of  to-day,  in  which  all  the  various  points  of 
view  relating  to  diet  are  oromincntly  Ijrought  out, 
cannot  fail  of  doing  effective  work  for  good. 


SODIUM,  LITHIUM,  CALCIUM,  AND  MAGNESIUM, 
AND  THEIR  ACTION  IN  THE  TREATMENT 
OF  DISEASE.* 

By  John  V.  Shoemaker,  M.  D.,  LL.  D., 
Philadelphia, 

Professor,  Materia  Medica  and  Therapeutics,  Clinical  Medicine  and 
Diseases  of  tlie  Skin  in  the  Medico-Chirurgical  College 
and  Hospital  of  Philadelphia. 

It  has  been  suggested  to  me  that  an  acceptable 
topic  for  our  consideration  this  evening  would  be 
the  therapeutic  applications  of  the  alkalies  and  al- 
kaline earths,  especially  sodium,  lithium,  calcium, 
and  magnesium.  As  potassium  is  usually  associated 
with  sodium  in  the  human  body,  both  in  the  solids 
and  the  fluids,  I  will  take  sodium  as  the  representa- 
tive of  the  alkali  metals.  Lithium  belongs  to  the 
same  group,  but  does  not  ordinarily  form  a  part  of 
the  body ;  it  has  special  therapeutic  properties,  how- 
ever, which  entitle  it  to  separate  consideration.  Cal- 
cium and  magnesium  are  also  metals  whose  oxides 
are  alkaline  ;  owing  to  their  insolubility  in  water  they 
are  generally  described  as  alkali  earths. 

The  elements  just  named  form  compounds  which 
normally  are  constituent  parts  or  proximate  prin- 
ciples of  the  human  body,  where  they  are  associated 
with  hydrogen,  oxygen,  carbon,  nitrogen,  phos- 
phorus, chlorine,  sulphur,  iron,  and  so  on,  each  of 
which  is  known  to  be  essential  to  life.  Physiologi- 
cal experiment  teaches  that  abstraction  of  any  one 
of  these  from  the  body  means  death  to  the  organ- 
ism. The  chemistry  of  protoplasm  has  been  declared 
to  be  the  cornerstone  of  biology,  and  I  hasten  to 
add  that  it  also  frequently  furnishes  the  clue  to 
therapeutics.  Not  only  is  the  presence  of  these 
substances  necessary  to  the  living  cell ;  but  they 
must  also  be  combined,  or  arranged,  in  a  particular 
or  normal  manner,  in  order  to  form  protoplasm,  and 
to  make  vital  phenomena  possible.  Anything,  there- 
fore, which  disturbs  this  arrangement,  as  has  been 
aptly  remarked  by  Professor  Lusk,  of  Yale  Uni- 
versity', will  tend  to  produce  sickness  or  death.  In 
order  to  approach  our  subject  from  the  proper 
standpoint,  I  will  briefly  review  some  of  the  funda- 
mental physiological  facts  relating  to  nutrition. 

Metabolism,  as  is  well  known,  is  a  comprehensive 
term  describing  certain  processes  occurring  in  the 
interior  of  the  cells  which  are  necessary  to  the 
growth  and  nutrition  of  the  body.  With  regard  to 
the  primarv  cause  of  metabolism  we  know  positively 
nothing  beyond  the  fact  that  it  is  a  vital  endowment 
of  protoplasm.  The  science  of  nutrition,  which 
was  first  laid  in  the  last  century  by  Liebig,  Berzelius, 
Schif¥,  and  others,  deals  principally  with  problems 
of  biological  chemistry.  Health  is  dependent  upon 
metabolism  by  living  cells,  which  are  constantly  be- 
ing destroyed  and  thrown  off  from  the  body,  and, 
therefore,  there  is  a  constant  demand  for  fresh  sup- 
plies of  the  material  of  which  they  are  constructed. 
Under  the  assimilative  and  procreative  power  of 
l)rotoplasm,  new  cells  are  formed,  and  are  endowen 
like  their  predecessors  with  inherent  power  of  burn- 
ing up  proteids.  starches  and  fats  in  order  to  gen- 
erate the  various  forms  of  energy  needed  to  carry 
on  the  life  of  the  organism.   

•Read  at  a  meeting  of  the  Mecklenburg,  Virginia,  County  Medi- 
cal Society,  ,  „,     .  ,  , 

'Graham  Lusk.  The  American  Textbook  of  Physiology,  I,  p.  499. 
igoo. 


June  12,  1909.] 


SHOEMAKER:  SODIUM,  LITHIUM,  ETC. 


If  a  young  puppy  be  incinerated  or  cremated  its 
ashes  will  be  found  to  correspond  exactly  with  the 
ashes  or  mineral  constituents  of  dog's  milk.  Na- 
ture, therefore,  supplies  to  the  young  animal  the 
necessary  proximate  principles  for  the  growth  of  its 
body.  If  this  is  true,  that  the  child  is  sup- 
plied in  infancy  with  a  perfect  food  to  sup- 
ply its  waste  and  to  favor  its  growth,  and 
its  correctness  will  not  be  questioned,  we  know  that, 
in  adult  life,  the  same  normal  relation  of  supply  and 
demand  does  not  exist,  and  the  food  that  is  taken 
each  day  is  only  approximately  adjusted  to  the  nu- 
tritional necessities  of  the  individual.  In  such  in- 
stances the  phenomena  of  disorder  and  disease  may 
be  manifested,  sooner  or  later,  and  it  becomes  the 
task  of  the  physician  to  recogruze  the  real  source  of 
the  difficulty  and  to  supply  the  deficiency  by  pre- 
scribing the  needed  elements.  In  numerous  cases, 
as  will  be  further  explained,  the  lacking  elements 
are  of  an  alkaline  character,  and  Nature,  in  her  al- 
kaline and  lithia  springs,  generously  supplies  the 
means  by  which  this  great  class  of  sufferers  may  be 
restored  to  health  and  usefulness. 

Alkalies  are  known  to  all  of  us  as  inorganic  sub- 
stances, usually  possessing  a  more  or  less  caustic, 
characteristic  taste ;  which  combine  with  acids  and 
neutralize  them ;  and  which  restore  the  blue  color 
of  litmus  after  it  has  been  made  red  by  an  acid. 
The  typical  alkalies  are  those  whose  carbonates  are 
soluble  in  water,  such  as  sodium,  potassium,  am- 
monium, and  lithium.  Magnesium  and  calcium  have 
insoluble  carbonates  and  are  properly  alkali 
earths,  but  in  medicine  they  are  also  included 
among  the  alkalies. 

This  group  of  agents  exists  as  proximate  princi- 
ples in  the  human  body  and  play  an  important  part 
in  both  physiology  and  therapeutics.  Briefly  re- 
viewing their  function  in  health,  we  find  that  in 
one  form  or  another  they  are  very  widelv  distrib- 
uted in  the  body.  They  are  necessary  to  preserve 
the  alkalinity  of  the  blood,  and  of  the  bile ;  they 
make  soluble  compounds  with  uric  acid,  and  by  their 
diuretic  action  they  carry  it  out  of  the  system.  They 
reduce  the  acidity  of  the  urine  and  relieve  irritabil- 
ity of  the  bladder.  They  increase  the  secretions  of 
the  intestinal  mucous  membrane  and  act  as  natural 
cathartics.  Some  of  their  compounds  are  antiseptic, 
notably  sodium  chloride.  This  agent  also  stimu- 
lates the  gastric  mucous  membrane,  excites  appe- 
tite and  thirst,  and  by  its  decomposition  supplies 
the  necessary  hydrochloric  acid  without  which  the 
pepsin  could  not  act  upon  albumin.  Human  milk 
contains  these  alkaline  salts,  with  an  excess  of  cal- 
cium which  exercises  such  an  important  office  in 
building  up  the  bony  skeleton  of  the  body  and  the 
teeth.    Magnesium  is  in  excess  in  the  muscles. 

What  are  some  of  the  clinical  indications  of  a 
deficiency  of  these  important  constituents  of  the 
human  organism?  In  infancy  marasmus  and  rickets 
may  arise  in  this  way.  A  deficiency  of  lime  is  shown 
in  the  imperfect  development  of  the  bony  system 
and  defective  teeth.  To  it  has  also  been  ascribed 
nervous  disorders,  and  especially  epilepsy  in  child- 
hood. Digestive  trouble,  owing  to  lack  of  secretion 
in  the  gastrointestinal  mucosa  and  defective  bile  pro- 
duction, is  very  common.  Gallstones  may  be  formed 


as  a  result  of  the  insufficient  alkalinity  of  the  bile, 
which  favors  bacterial  activity  and  also  the  deposit 
of  cholesterin  in  the  gallbladder.  Cholelithiasis,  in- 
deed, may  occur  at  all  ages  as  the  result  of  a  de- 
ficient supply  of  alkalies  to  the  system.  In  adults, 
indigestion,  both  gastric  and  intestinal,  is  a  very 
prominent  result  of  a  diminished  supply  of  alkalies, 
owing  to  deficient  secretion  of  digestive  juices  and  an 
increased  tendency  to  bacterial  growth,  and  forma- 
tion of  gas  in  the  intestines.  Indican  and  various 
toxines,  being  absorbed  by  the  blood,  affect  the 
nervous  system  and  produce  depression  of  spirits, 
headache,  and  various  pains,  which  are  sometimes 
called  rheumatic  and  sometimes  lithaeniic,  but 
which,  as  you  know,  are  really  due  to  absorption 
of  poisons  generated  in  the  digestive  tract.  A  severe 
form  of  chlorosis,  or  grave  anaemia,  may  be  pro- 
duced in  this  way.  Constipation  of  an  obstinate 
character  is  usually  present.  Various  chronic  skin 
eruptions  likewise  may  be  developed  as  a  result  of 
a  deficient  supply  of  these  alkaline  principles.  This 
is  fully  demonstrated  by  the  curative  effects  of  these 
alkaline  and  lithia  waters,  which  you  have  so  fre- 
quently witnessed  at  the  various  mineral  springs.  I 
am  satisfied  that  a  deficiency  of  these  elements  in 
the  blood  favors  the  occurrence  of  infection  by  patho- 
genic organisms ;  on  the  other  hand,  I  believe  that 
a  normal  supply,  especially  of  sodium  chloride, 
forms  a  good  protection  against  bacterial  invasion. 

I  think  it  will  be  found  that  the  presence  of  op- 
sonins in  the  blood  depends  normally  upon  a  proper 
supply  of  inorganic  substances  to  the  svstem,  and 
that  their  deficiency  favors  the  negative  condition 
of  this  important  protective  provision.  In  the  con- 
dition of  pregnancy,  when  the  inorganic  elements  of 
the  maternal  organism  are  largely  absorbed  by  the 
growing  foetus,  we  observe  that  the  saliva  loses  its 
alkaline  reaction,  and  becomes  acid  in  reaction.  The 
latter  condition  is  the  direct  result  of  the  invasion 
of  putrefactive  and  pathogenic  bacteria,  which  leads 
to  extensive  caries  of  the  teeth  unless  the  precaution 
is  taken  to  use  alkaline  mouthwashes  frequently,  and 
to  administer  alkalies  internally.  I  have  already, 
referred  to  the  necessity  of  maintaining  the  alkalin- 
ity of  the  blood,  and  will  merely  direct  your  atten- 
tion to  the  special  function  of  calcium  chloride  in 
maintaining  the  normal  coagulating  power  and  in 
preventing  haemorrhages. 

Having  outlined  the  importance  of  the  alkalies 
from  a  physiological  standpoint,  I  will  now  discuss 
some  of  their  more  important  therapeutic  applica- 
tions. 

Sodium. — Sodium  hydroxide  when  applied  in  a 
concentrated  form  is  a  powerful  escharotic.  It  is 
milder  in  its  action  than  caustic  potash,  and  is  used 
for  the  same  purposes ;  for  the  destruction  of 
malignant  pustule,  skin  cancer,  phagedenic  chancre, 
and  also  in  jauterizing  the  wounds  made  by  rabid 
animals,  and  other  poisoned  wounds.  A  mixture  of 
soda  and  lime  made  into  a  paste  with  alcohol  is 
known  as  London  paste  and  is  a  convenient  method 
of  using  this  caustic  agent.  Alkaline  solutions,  especi- 
ally of  sodium  bicarbonate,  are  useful  dressings  to 
burns  and  scalds,  and  also  to  inflammation  of  the 
skin  caused  by  sunburn,  or  following  exposure  to 
rhus  toxicodendron.  Weak  solutions  relieve  the  itch- 


1178  SHOEMAKER:  SODIUM.  LITHIUM,  ETC.  L'New  York 

'  Medical  Journal. 


ing-  of  acute  eczema  and  .intertrigo.  Inflamed  rheu- 
matic joints  may  be  relieved  by  being  enveloped  in 
a  compress  moistened  with  solution  of  sodium  bi- 
carbonate, or  salicylate.  Detergent  solutions  for  the 
nose,  mouth,  and  throat  are  made  with  sodium  bi- 
carbonate, sodium  borate,  and  sodium  chloride,  in 
strength  corresponding  with  the  specific  gravity  of 
the  blood  serum.  Sodium  bicarbonate  may  be  ap- 
plied in  powder  form  directly  to  inflamed  tonsils  to 
remove  the  exudation  in  follicular  amygdalitis. 

The  internal  uses  of  the  sodium  salts  are  very 
numerous  and  important.  Sodium  chloride  improves 
the  taste  of  food,  excites  the  salivary  secretion  and 
the  appetite.    It  acts  as  an  antiseptic  in  the  stom- 
ach, favors  the  formation  and  activity  of  pepsin, 
and  increases  the  secretion  of  hydrochloric  acid.  It 
is  partly  excreted  by  the  bronchial  tubes  and  the  up- 
per air  passages,  and  in  its  passage  from  the  body 
increases  the  secretions  of  the  pituitary  membrane. 
It  acts  also  as  a  diuretic,  and  assists  in  carrying  off 
the  urea  and  uric  acid.  A  small  quantity  of  sodium 
chloride  dissolved  in  a  tumblerful  of  water  or  cal- 
cium chloride  water  if  swallowed  early  in  the  morn- 
ing, on  rising,  or  about  an  hour  before  breakfast, 
will  act  as  a  laxative.    In  this  connection  I  may  re- 
mark that  this  also  is  the  best  time  to  take  the  nat- 
ural mineral  waters  if  it  is  desired  to  obtain  their 
direct  action  upon  the  stomach  and  liver.  Given 
just  before  a  meal,  as  you  are  aware,  the  alkalies 
stimulate  the  secretion  of  the  hydrochloric  acid,  and 
thus  increase  the  acidity  of  the  gastric  juice.  If 
the  stomach  is  too  acid,  then   sodium  bicarbonate 
will  correct  this  acidity  if  given  after  meals.  Mag- 
nesia may  be  substituted  if  a  laxative  effect  is  also 
desired.    On  the  contrary,  if  the  bowels  are  loose, 
chalk  mixture  can  be  given,  or  lime  water.    I  would 
recall  to  your  minds  the  valuable  service  rendered 
by  the  alkalies  when  the  bronchial  mucous  mem- 
brane is  congested,  swollen,  and  covered  with  thick 
tenacious  secretion.    The  alkaline  cough  mixture 
containing  sodium  citrate,  or  acetate,  combined  with 
ammonium  chloride,  or  acetate,  or  in  chronic  condi- 
tions the  sodium  iodide,  is  here  invaluable,  as  we  all 
know,  in  liquefying  the  secretion   and  facilitating 
expulsion.   The  mistake  is  frequently  made  by  thos? 
who  simply  prescribe  for  symptoms,  of  giving  mor- 
phine, heroine,  or  other  form  of  opiate  to  restraiii 
cough,  and  to  check  the  outflow  of  secretions  in  this 
class  of  cases.   If  the  cough  is  severe  or  paroxysmal, 
chloral  hydrate,  paraldehyde,  or  compound  spirit  of 
ether  would  give  relief ;  or  a  little  sodium  bromide 
at  night  would  afford  needed  rest,  without  the  bad 
effects  of  opium.    The  medicinal  treatment  of  the 
form  of  acute  rheumatism  which  is  accompanied  by 
sour  pers])iration  and  acid  urine  may  be  summed 
up  in  alkalies  and  salicin,  which  I  consider  the  best 
treatment.'' 

In  the  treatment  of  children's  diseases,  the  alka- 
lies are  largely  used.  Lime  water  reduces  irritabil- 
ity of  the  stomach  and  aids  in  developing  the  teeth. 
Sodium  citrate  added  to  cow's  milk,  prevents  the 
curdling  of  the  latter  in  the  child's  stomach,  and  fa- 
cilitates digestion.  In  the  acid  diarrhoea  of  children 
or  the  diarrhoea  of  relaxation  in  adults,  we  obtain 

=  Rhtiinialic  Fever,  by  Dr.  John  V.  Shoemaker,  New  York  Medi- 
cal Journal.    I"i  hruary  24,  1906. 


the  best  results  from  the  well  known  chalk  mixture. 
Sodium  chloride  is  a  valuable  constituent  of  chil- 
dren's food  as  it  favors  nutrition,  stimulates  the 
heart's  action,  and,  as  already  intimated,  protects, 
in  some  measure  at  least,  from  infection.  The  nor- 
mal salt  solution  may  be  thrown  into  the  bowel,  or 
under  the  skin,  in  many  conditions  in  which  it  is 
desired  to  strengthen  the  circulation  and  increase 
the  volume  of  blood,  and  produce  diuresis. 

Lithium.    On  account  of  the  faculty  which  the 
lithium  compounds  have  of  dissolving  readily  in 
water,  they  are  rapidly  carried  out  of  the  system, 
and  therefore  lithium  is  not  regarded  as  one  of  the 
constant  constituents  of  the  body.  When  introduced 
into  the  organism,  it  acts  like  the  other  alkalies,  ex- 
cept that  its  compound  with  uric  acid  is  much  more 
soluble  in  water  than  is  the  potassium,  or  the  sodium 
salt,  the  latter  being  in  fact  only  very  slightly  solu- 
ble.   Therefore  in  gouty  or  lithjemic  conditions  of 
the  body,  lithium  carbonate,  benzoate,  or  citrate,  is 
usually  administered  in  order  to  prevent  gouty  de- 
posits in  the  tissues  and  to  carry  away  those  which 
have  originally  been   deposited.    The  effervescent 
preparations  of  lithium  citrate   and  carbonate  are 
more  acceptable  to  the  palate  and  are  very  efficient 
in  their  alkaline  action.    Lithium  salicylate  is  use- 
ful in  both  gouty  and  rheumatic  conditions,  but  is 
considerably  more  expensive  than  sodium  salicylate. 
It  is  noteworthy  that  the  native  mineral  springs 
which  contain  lithia  are  precisely  those  which  enjoy 
the  greatest  amount  of  patronage,  universal  experi- 
ence having  shown  their  remarkable  value  in  remov- 
ing all  forms  of  lithsemic  disorder,  and  especially 
the  larval  forms  of  gout  and  rheumatism.  They 
have  also  been  shown  to  be  of  greatest  efiicacy  in 
the  treatment  of  diseases  of  the  kidneys,  and  in 
lithiasis,  whether  in  the  form  of  gravel  or  large 
concretions  in  the  kidney,  ureter,  or  bladder.  In 
various  eruptions  upon  the  skin,  such  as  psoriasis, 
eczema,  herpes,  erythema,  and  dermatitis,  the  lithia 
waters  are  used  with  great  success.    Where  there 
is  a  strong  gouty  heredity,  it  is  advisable  to  use 
antilithic  remedies  with  a  view  to  prevention  of  dis- 
eases of  this  character.   In  such  cases,  the  daily  use 
of  lithia  water  is  certainly  worthy  of  more  con- 
sideration than  has  yet  been  accorded  to  it.  By 
judicious  supervision  of  the  diet,  abstinence  from 
alcohol,  and  the  free  use  of  lithia  water,  I  have 
found  that  a  tendency  to  arteriosclerosis   may  be 
held  effectually  in  check,  and  premature  senility  be 
prevented.   The  use  of  alkalies  also  counteracts  the 
tendency  to  gastric  hyperacidity  in  these  cases  and 
prevents  those  severe  intestinal  disturbances,  which 
are  sometimes  so  acute  as  to  be  popularly  known  as 
attacks  of  "gout  in  the  stomach."    The  form  cf 
inflammation  of  the  kidney  which  results  in  cnn- 
traction,  the  so  called  "gouty  kidney."  is  probably 
caused  by  the  irritation  set  up  by  the  passage  of 
uric  acid,  or  its  deposit  in  the  tubules.   This  serious 
pathological  condition  can  be  ameliorated,  or  pre- 
vented, by  the  free  use  of  the  lithia  w.iter,  as  al- 
ready suggested.    The  patient  soon  becomes  accus- 
tomed to  the  slightly  sweet  alkaline  taste  of  the 
water,  and  will  drink  it  at  the  table,  or  elsewhere, 
in  preference  to  ordinary  drinking  water. 

Calcium.    The  physiological  value  of  calcium  is 


June  12.  1909.] 


SHOEMAKER:  SODIUM,  LITHIUM,  ETC. 


1 179 


very  great.    It  is  the  most  abundant  metallic  ele- 
ment in  the  body.    In  the  form  of  the  tertiary  phos- 
phate, it  predominates  in  the  composition  of  the 
bones,  and  outside  of  them  it  is  most  abundant  in 
tlie  blood  plasma.    In  loose  combinations  with  pro- 
teids.  calcium  is  found  in  all  the  cells  and  fluids  of 
the  body.    It  is  always  accompanied  by  magnesium. 
The  mineral  matter  of  bones  consisting  of  calcium 
phosphate  and  calcium  carbonate  is  essential  to  the 
growth  of  the  skeleton  and  the  repair  of  fractures : 
when  it  is  deficient  as  in  rachitis,  or  is  removed  by 
disease  as  in  osteomalacia,  the  bones  become  flexi- 
ble and  unable  to  maintain  the  weight  of  the  bodv. 
The  condition  of  rachitis  or  of  ununited  fracture, 
therefore,  is  rationally  treated  by  the  administration 
of  lime  salts.    Calcium  salts  exercise  an  important 
digestive  function.    For  example,  the  rennet  fer- 
ment of  the  pancreatic  juice  does  not  act  in  the 
absence  of  calcium  salts.    In  intestinal  indigestion, 
therefore,  especially  in  infants  or  patients  on  a  milk 
diet,  lime  water  or  a  calcium  chloride  water  will 
aid  in  the  digestion  of  the  milk.    The  coagulation 
of  the  blood  requires  the  presence  of  calcium  salts 
and  especially  the  chloride.    Therefore,  in  order  to 
increase  the  fibrinoplastic  quality  of  the  blood  we 
give  calcium  chloride.    This  has  been  vitihzed  by 
surgeons  when  called  upon  to  operate  in  cases  of 
haemophilia ;  the  preliminary  treatment  of  the  pa- 
tient by  this  salt  for  a  few  da}S  has  been  shown 
to  overcome  the  danger  of  haemorrhage.    The  pro- 
longed administration  of  small  doses  of  calcium,  as 
found  in  the  calcium  chloride  waters  in  cases  of  mal- 
nutrition, and  scrofula,  or  tuberculosis,  especially 
affecting  the-  skin  or  the  bones,  has  been  followed 
by  the  happiest  results,  as  you  have  repeatedly  wit- 
nessed.   Chronic  skin  disorders,  also  of  scrofulous 
nature,  are  amenable  to  this  form  of  treatment,  in 
many  cases.    The  condition  of  the  system  which 
predisposes  to  the  attacks  of  catarrhal  inflammation 
of  mucous  membranes,  as  well  as  the  actual  catar- 
rhal state,  which  so  frequently,   when  neglected, 
ends  in  tuberculosis,  can  be  overcome  by  a  com- 
bination of  the  calcium  chloride  waters  with  life  in 
the  open  air,  such  as  you  are  blessed  with  here  in 
this  beautiful  mountain  region,  far  removed  from 
the  dust  and  poisoned  atmosphere  of  cities,  which 
are  the  great  causes  of  catarrh.    Many  individuals, 
dwellers  in  cities,  have  impaired  health  from  a  sort 
of  chronic  infection'  with  various  forms  of  patho- 
genic bacteria,  such  as  tubercle  bacilli,  diphtheria 
bacilli,  the    streptococcus    of    scarlatina,  or  the 
staphylococcus  of  furunculosis.    The  infection  mav 
be  slight,  but  the  absorption  of  toxines  is  constant, 
producing  an?emia.  indigestion,  loss  of  energv,  and 
that  well  known  "tired  feeling."     I  mention  this 
condition  of  mild  septichaemia  merely  to  emphasize 
the  familiar  observation  that  removal  from  unhv- 
gienic  surroundings  to  a  bracing  atmosphere  of  a 
mountain  health  resort,  and  the  free  use  of  calcium 
chloride  water,  produces  in  a  short  time  a  marvel- 
ous change  in  the  condition  and  feelings  of  the  pa- 
tient.   ^^■e  know  that  there  is  an  intimate  relation 
between  calcium  salts  and  the  functional  activity  of 
protoplasm,  especially  as  it  exists  in  nerves  and 
muscles.    Calcium,  therefore,  should  have  a  larger 
place  in  our  therapeutics  than  we  have  hitherto  "ac- 
corded to  it. 


Mag}iesitiin.  Although  this  has  not  been  in- 
vestigated to  the  extent  that  calcium  has,  it  is  only 
second  to  it  in  importance.  It  is  found  constantly 
associated  with  calcium  in  the  bones,  the  blood,  and 
elsewhere  in  the  body,  and  in  the  muscles  it  pre- 
dominates over  calcium.  It  exists  principally  as 
phosphate.  Owing  to  the  greater  solubility  of  the 
magnesium  salts  over  the  calcium  compounds,  the 
former  appear  in  the  urine  in  greater  abundance. 
It  forms,  in  ammoniacal  urine,  the  well  known 
"ammonio-magnesium  phosphate"  which  occurs  as 
a  white  crystaline  deposit,  and  this  is  likely  to  forrn 
calculi  in  the  urinary  passages.  Exceptionally,  it 
may  form  a  concretion  in  the  intestine.  Mag- 
nesium salts  cannot  take  the  place  of  calcium 
in  the  formation  of  bone,  although  they  con- 
stantly accompany  the  latter  in  building  up  bone 
structure. 

The  therapeutic  applications  of  magnesium  are. 
in  the  first  place,  dependent  upon  its  power  to  neu- 
tralize acids.  Thus,  acid  dyspepsia  is  promptly  re- 
lieved by  the  administration  of  the  well  known  ox- 
ide, or  calcined  magnesia.  Sometimes  the  carbonate 
is  preferable  for  this  purpose.  This  also  makes  a 
useful  application  as  a  dusting  powder  in  various 
forms  of  irritation  of  the  skin.  The  hydrated  oxide 
or  so  called  milk  of  magnesia,  is  a  useful  antacid 
for  infants  with  acid  diarrhcea.  It  is  also  useful  as 
a  mouth  wash  for  pregnant  women,  and  as  an  anti- 
dote to  acid  poisoning,  except  oxalic  acid,  which  is 
better  treated  by  calcium  carbonate.  \\'hen  used 
internally,  magnesium,  like  calcium,  promotes  cell 
growth  and  favors  nutrition.  Owing  to  their  ac- 
tion in  the  intestinal  mucous  membrane,  magnesium 
salts  usually  have  a  laxative  effect.  This  is  best  il- 
lustrated bv  magnesium  sulphate,  which  is  the  prin- 
cipal ingredient  in  the  famous  Epsom  waters  of 
England,  and  hence  it  is  frequently  called  Epsom 
salt.  The  purgative  mineral  waters  Friedrichshall. 
Pullna,  Seidlitz.  and  Hunyadi  Janes,  owe  their 
cathartic  property  principallv  to  magnesium  sul- 
phate. It  has  been  shown  also  that  small  doses  of 
this  salt  produce  a  purgative  effect  when  adminis- 
tered hypodermicallv'.  I  wish  particularly  to  call 
to  your  mind  the  value  of  magnesium  sulphite,  when 
internally  administered,  in  infectious  dyspepsia,  and 
other  diseases  produced  by  pathogenic  bacteria.  It 
should  have  a  more  extended  trial  in  septic  condi- 
tions, such  as  phlebitis,  milk  fever,  and  some  cases 
of  acute  rheumatism.  In  conclusion.  I  may  briefly 
refer  to  the  recent  use  of  magnesium  sulphate  by 
spinal  injection  for  the  production  of  anaesthesia 
of  the  lower  portion  of  the  body,  thus  affording  to 
the  surgeon  an  opportunity  for  performing  sur- 
gical operations  upon  the  abdomen  and  lower 
limbs  without  the  resort  to  ether  or  chloroform 
anaesthesia. 

I  have  now  concluded  my  task  of  broadly  review- 
ing the  place  of  the  alkalies  and  alkali  earths  in 
the  treatment  of  disease.  I  have  shown  their  physi- 
ological importance  and  indicated  many  of  their 
therapeutic  applications.  I  will  not  trespass  upon 
your  forbearance  further ;  but  will  close  with  a  sin- 
gle observation  with  regard  to  the  combination  of 
these  remedial  agents  as  found  in  nature,  in  the 

Practical  Treatise  on  Materia  Medica  and  Therapeutics,  by 
John  V.  Shoemaker.  Philadelphia.  1906.  Sixth  Edition,  p.  612. 


ii8o 


WRIGHT:  MERCURY  IN  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


calcium  chloride  and  lithia  springs,  and  similar 
sources  in  this  country  and  Europe.  It  has  been 
recently  discovered  that  these  waters  as  they  issue 
from  the  earth  are  endowed  with  radioactivity, 
which  must  greatly  enhance  their  action  as  thera- 
peutic agents.  Artificial  waters  made  in  the  labora- 
tory have  no  such  remarkable  radioactivity  quality. 
I  leave  this  thought  with  you  for  further  consid- 
eration. The  whole  subject  of  radiotherapeutics  is 
still  in  its  undeveloped  stage ;  but  gives  great  prom- 
ise of  usefulness  in  the  treatment  of  disease. 

You  are  fortunate  in  being  residents  of  a  grand 
State  like  Virginia,  which  is  so  widely  celebrated 
for  its  mineral  springs.  There  is  hardly  any  other 
state  in  the  union  in  which  the  development  has 
been  so  great  as  in  this.  It  is  particularly  this  part 
of  the  country,  in  this  region  bordering  on  Tennes- 
see and  North  Carolina,  that  seems  especially  de- 
signed and  set  apart  as  a  grand  natural  sanatorium. 
In  fact,  this  garden  spot  has  been  already  utilized  for 
this  purpose  and  is  now  the  seat  of  numerous  health 
resorts,  where  the  advantages  of  altitude  and  an  in- 
vigorating climate  are  crowned  by  mineral  springs 
of  various  kinds  suited  to  heal  the  sick  and  suffering 
sons  of  men.  I  have  had  the  opportunity 
many  times  of  testing  the  efficacy  of 
these  springs,  containing  in  large  amounts 
the  mineral  materials  of  which  I  have 
spoken  to  you  in  this  paper.  In  rheu- 
matic and  gouty  subjects  I  have  ob- 
served a  most  decided  benefit  and  in 
many  cases  a  curative  action  in  both  the 
diseases  alluded  to  by  the  lithia  water 
taken  at  the  homes  of  the  patients.  I 
might  enumerate  to  you  many  diseases  of 
the  liver,  stomach,  and  bowels  that  have 
improved  and  in  some  cases  been  re- 
stored to  health  by  the  use  of  lithia  water. 
In  no  class  of  patients  have  the  calcium 
springs  been  of  so  much  service  in  my 
hands  as  in  some  of  the  chronic  forms  of 
gout,  and  in  many  diseases  of  the  skin  in 
which  the  surface  is  covered  with  a  large 
amount  of  deposit,  and  especially  in  those  hav- 
ing pustules,  boils,  and  carbuncles.  How  much 
more  efficacious  would  these  lithia  and  calcium 
waters  be  with  their  radioactivity  which  I  have 
called  your  attention  to  this  evening,  given  to 
patients  at  the  springs?  In  the  consideration 
of  the  prominent  constituents  of  these  waters 
which  I  have  had  the  honor  of  presenting  to 
you  this  evening,  I  hope  that  some  guiding 
principles  may  be  discerned  which  will  lead  to 
a  more  extended  application  of  these  marvelous 
gifts  of  Nature  in  the  treatment  of  the  class  of  dis- 
eases in  which  they  are  most  effective.  They  are 
often,  in  fact,  the  indispensable  means  for  the  re- 
storation of  many  poor  unfortunate  sufferers  to  a 
condition  of  health,  thus  enabling  them  once  more 
to  enjoy  the  delights  of  living.  The  miracle  is  no 
less  great  than  when  anciently  accomplished  by  the 
"royal  touch" ;  in  this  case,  however,  it  can  be  more 
accurately  ascribed  to  "One  touch  of  Nature,  which 
makes  all  the  world  kin." 

1805  Walnut  Street. 


THE  TREATMENT  OF  TUBERCULOSIS  BY  THE 
ADMINISTRATION  OF  MERCURY.* 

By  Barton  Lisle  Wright,  M.  D., 
Surgeon,  United  States  Navy. 
Las  Animas,  Col. 

In  the  issue  of  the  Netv  York  Medical  Journal  of 
August  29,  1908,  under  the  same  title,  I  reported 
the  cases  of  twelve  tuberculous  officers,  ten  of  whom 
were  receiving  injections  of  mercury,  and  two  who 
were  not  (Cases  I  and  III). 

I  desire  to  very  briefly  describe  the  present  con- 
dition of  these  patients,  reporting  the  cases  in  the 
same  order  in  which  they  appeared  in  the  Journal  of 
August  29,  1908,  and  inviting  special  attention  to 
Cases  VH  and  VIII,  the  first  of  which  had,  in  ad- 
dition to  the  pulmonary  lesions,  an  advanced  and 
extensive  infection  of  the  left  knee  joint  and  femur ; 
the  second,  in  addition  to  pulmonary  lesions,  had  a 
secondary  tuberculous  involvement  of  the  lower 
pharynx  and  larynx. 

Case  I,  carpenter,  U.  S.  N.,  admitted  May  4,  1907.  Re- 
ported in  former  paper  not  on  mercury,  as  holding  his  own. 


Fig.  I. — Case  VII. 

Was  discharged  from  the  hospital  at  his  own  request  Au- 
gust 25,  1908.  Since  November,  1908,  has  been  taking  mer- 
cury injections  irregularly  as  an  out  patient. 

Case  II,  warrant  machinist,  U.  S.  N.,  admitted  Novembef 
29,  1907.  Reported  in  former  paper  on  mercury  and  as 
improved.  Was  attacked  with  typhoid  fever  in  August. 
1908,  during  which  time  he  lost  twenty  pounds  in  weight, 
dropping  from  150  to  130  pounds.  Since  his  convalescence 
from  typhoid  he  has  not  done  particularly  well,  the  evening 
temperature  averagmg  from  99°  to  99.6°  F. ;  his  present 
weight  is  147H  pounds. 

Case  III,  gunner,  U.  S.  N.,  admitted  November  29.  1907. 
Reported  in  former  paper  not  on  mercury  and  having  failed. 
Typhoid  fever  developed  in  .A.ugust.  1908.  In  September, 
1908s  asked  to  be  given  mercury,  but  has  taken  treatment 
in  a  very  indifferent  manner  and  at  irregular  intervals.  Has 
failed. 

Case  IV,  midshipman,  U.  S.  N..  admitted  March  16,  1908. 
Reported  in  former  paper  on  mercury  and  as  improved. 
Discharged  from  this  hospital  as  cured,  and  returned  to 
duty  at  the  Naval  .'Academy,  February  23,  1909.  Weight, 
stripped.  170  pounds,  twenty  pounds  heavier  than  he  ever 
weighed  before. 

Case  V.  surgeon,  V.  S.  N.  admitted  .April  9,  1908.  Re- 
ported in  former  paper  as  on  mercury  and  as  having  slightly 
failed.  Discharged  from  treatment  as  markedly  improved. 
November  6.  1908,  since  which  time  he  has  been  on  sick 
leave.    He  is  still  improving. 


June  12,  1909.] 


WRIGHT:  MERCURY  IN  TUBERCULOSIS. 


I181 


Case  VI,  midshipman,  U.  S.  N.,  admitted  April  19,  1908. 
Reported  in  former  paper  on  mercury  and  as  improved. 
Discharged  from  treatment  as  cured  November  7,  1908. 
Weight  206  pounds ;  thirty-five  pounds  heavier  than  he  ever 
weighed  before.  He  has  since  passed  a  rigorous  physical 
examination  for  promotion,  and  is  now  at  sea. 

Case  VII,  midshipman,  U.  S.  N.,  admitted  May  2,  1908. 
This  patient  was  received  from  the  U.  S.  Naval  Hospital, 
Annapolis,  Md.,  with  the  diagnosis  of  tuberculosis  of  left 
knee  and  femur.  An  incision  on  the  inner  aspect  of  the 
ihigh  above  the  knee  joint  had  been  made,  an  opening 
about  two  inches  long  had  been  chiseled  in  the  femur,  open- 
ing up  the  medullary  canal,  which  had  been  curetted,  and 
the  wound  was  discharging  considerable  pus.  An  incision 
had  also  been  made  on  the  outer  aspect  of  the  knee  joint, 
which  had  been  opened  up  and  Curetted  and  healed.  Scrap- 
ings from  these  regions  confirmed  the  diagnosis. 

Phvsical  examination  at  this  hospital  revealed  a  consider- 
able area  of  involvement  of  both  lungs.  Sputum  examin- 
ation was  positive  for  tubercle  bacilli. 

Nationality:  Paternal  grandparents  Irish.  Maternal 
grandparents  Irish. 

Family  history:  Paternal  grandfather  dead,  age  and 
cause  unknown ;  paternal  grandmother  dead,  age  and  cause 
unknown.  Alaternal  grandfather  died  in  seventy-eighth 
year,  cause  unknown ;  maternal  grandmother  died  in  seven- 
tieth year,  cause  unknown.  Father  living  in  good  health, 
forty-fifth  year ;  mother  died  in  twenty-fifth  year,  from 
pneumonia.  Three  half  brothers  living  in  good  health. 
One  half  sister  living  in  good  health. 

Personal  history :  Born  June  17.  1886,  at  New  York, 
N.  Y. 

During  childhood  patient  had  measles,  mumps,  chicken- 
pox  and  scarlet  fever.  No  other  sickness  except  biliousness 
previous  to  his  appointment  to  the  Naval  Academy,  to 
which  he  was  admitted  June  28,  1904;  just  after  entering 
the  academy  he  was  on  sick  list  for  a  few  days  with  a 
sprained  ankle.  No  other  sickness  until  present  trouble 
evidenced  itself.  Present  trouble  commenced  December  4, 
1907 :  was  admitted  to  the  sick  list  as  with  rheumatism  of 
left  knee,  which  continued  to  grow  worse.  December  loth 
he  was  transferred  to  the  U.  S.  Naval  Hospital,  Annapolis, 
Md.  About  January  25.  1908,  his  case  was  diagnosticated 
as  tuberculosis  of  the  left  knee  joint  and  femur.  He  was 
operated  upon  February  22.  1908,  since  which  time  he  has 
been  slowly  improving.  Had  never  had  any  symptoms  of 
pulmonary  involvement.  Was  transferred  to  this  hospital 
by  medical  survey:  received  May  2.  1908. 

Habits :  Smokes  a  pipe  or  cigars  very  moderately,  drinks 
beer  moderately. 

Present  condition  :  Feels  well ;  appetite  good,  sleeps  well ; 
bowels  rather  constipated.  Does  not  cough  or  expectorate 
(?).  Height.  5  feet,  11  inches:  normal  weight  (stripped), 
160  pounds,  present  weight  (stripped).  115  pounds.  Tem- 
perature, from  99°  to  100°  F.  Respirations  14;  pulse  100, 
low  tension.  Chest  circumference  34^8  inches,  inflated  36^4 
inches,  deflated  31^  inches,  expansion  4-54  inches. 

Plate  I  shows  the  condition  of  the  lungs  at  this  time. 

Sputum  examination  :  Moderate  number  of  tubercle  ba- 
cilli. 

On  Alay  8th  injections  of  mercury  were  begun,  but  after 
the  ninth  injection  were  discontinued  at  the  patient's  re- 
quest, because  of  the  pain  produced  at  the  seat  of  injection, 
mercury  being  then  given  by  mouth.  The  sinus  was  dressed 
every  other  day  and  Bier's  hypercTmia  treatment  continued. 

On  July  3rd,  having  had  excellent  results  in  healing 
ischiorectal  fistula,  by  bismuth  paste  injections,  as  recom- 
mended by  Dr.  Beck,  this  was  injected  into  the  sinus,  and 
Bier's  hyperemia  treatment  discontinued.  On  August  loth 
mercury  was  discontinued  bv  mouth  and  administered  by 
injection.  About  this  time  the  right  first  metatarsophalan- 
geal articulation  became  swollen  and  tender. 

On  September  ist,  an  incision  was  made  over  this  region, 
and  a  small  quantity  of  pus  evacuated,  and  a  sinus  found 
leading  down  between  the  great  and  second  toe,  no  eroded 
bone  detected.  I  regret  that  bacteriological  examination 
of  this  pus  was  not  made,  but  it  would  seem  most  probable 
that  this  lesion  was  also  tuberculous. 

The  sinus  was  drained  for  a  few  days  and  promptly 
healed,  giving  no  further  trouble. 


About  the  middle  of  September  I  was  ordered  east  on 
duty  in  conection  with  the  International  Tuberculosis  Con- 
gress. At  this  time  the  bone  lesion  seemed  to  be  improv- 
ing, the  discharge  was  greatly  diminished,  thin  and  watery 
in  character,  and  the  temperature  was  normal.  Upon  my 
return  late  in  October  it  was  very  much  worse.  On  the  under 
surface  of  the  thigh  about  three  inches  above  the  joint,  two 
sinuses  about  an  inch  and  one  half  apart  had  opened,  one 
leading  downward  into  the  popliteal  space,  and  burrowing 
under  the  shaft  of  the  femur  communicated  with  the  orig- 
inal sinus  on  the  inner  side  of  the  thigh.  The  upper  sinus 
extended  upward  just  beneath  the  femur  for  about  nine 
inches,  from  these  a  large  amount  of  rather  foul  smelling 
pus  was  being  discharged. 

At  the  bottom  of  the  original  sinus  within  the  canal  a 
large  area  of  necrosed  bone  could  be  detected. 

On  November  ist  a  consultation  of  the  staff  was  called, 
two  of  whom  recommended  immediate  amputation  in  the 
upper  third,  and  two  a  more  conservative  operation ;  the 
latter  procedure  was  decided  upon. 

Upon  November  4th,  under  chloroform,  an  incision  was 
made  on  the  inner  aspect  of  the  part,  extending  from  below 


Fig.  2. — Showing  destruction  in  tlie  femur.    (See  Case  VII.) 


the  knee  joint  to  ten  inches  above  it.  the  joint  not  being 
opened,  the  entire  inner  bony  wall  of  the  femur  had  dis- 
appeared throughout  the  lower  half,  leaving  the  under  and 
outer  wall  very  much  necrosed  throughout  this  extent  of 
the  medullary  canal,  and  for  about  two  inches  above  where 
the  circumference  of  the  femur  was  intact.  The  destruc- 
tion of  bone  and  the  extent  of  the  involvement  of  the 
medullary  canal  is  fairly  well  shown  by  Fig.  2.  the  necrotic 
area  extending  up  to  the  dotted  line  "a."  This  entire  area 
was  thoroughly  curetted,  removing  much  debris,  and  four 
rather  large  pieces  of  dead  bone,  leaving  behind  a  mere 
shell  of  bone  on  the  under  and  outer  surface  of  the  femur, 
which  was  so  fragile  that  I  feared  I  might  produce  a  com- 
plete fracture  from  the  necessary  handling.  The  sinuses 
upon  the  under  surface  of  the  thigh  were  thoroughly  curet- 
ted, removing  a  comparatively  large  amount  of  unabsorbed 
bismuth  paste,  the  operative  field  was  thoroughly  irrigated 
with  I  in  5,000  hot  corrosive  mercuric  chloride  solution  and 
packed  with  corrosive  mercuric  chloride  (wet)  gauze. 

This  dressing  was  continued  every  other  day,  with  an 
occasional  injection  of  sterile  ten  per  cent,  iodoform  emul- 
sion, for  some  weeks,  and  then  every  fourth  day ;  bismuth 
paste  would  come  away  with  the  irrigating  fluid. 

About  the  first  of  February  the  upper  sinus  upon  the 
posterior  aspect  of  the  thigh  c'osed. 

About  March  ist  the  lower  sinus  closed,  and  at  the  same 
time  a  sinus  leading  into  the  knee  joint  opened  on  its  inner 
surface,  from  which  escaped  more  bismuth  paste.  Irriga- 
tion of  this  sinus  developed  the  fact  that  it  communicated, 
through  the  head  of  the  femur,  with  the  original  sinus, 
through  which  more  bismuth  paste  was  washed  for  about 
a  week,  when  the  sinus  into  the  joint  closed. 

A  rapid  improvement  in  the  original  sinus  took  place,  and 
on  April  6th  it  was  completely  healed.  A  small  amount  of 
motion  exists  in  the  joint,  and  I  hope  to  obtain  still  more. 

On  January  11.  1908.  physical  examination  of  the  lungs 
revealed  healed  lesions  of  these  organs  (See  Fig.  3). 

Tubercle  bacilli  have  not  been  prsent  in  sputum  for  six 
months,  nor  in  the  ffeces  for  four  months. 

Present  weight  (stripped)  131  pounds. 

Case  VIII,  chief  carpenter,  U.  S.  N..  admitted  May  8,  1908. 
Reported  in  former  paper  as  on  mercury,  improved.  Be- 
came an  out  patient  of  this  hospital  August  2;.  1908,  and 
was  discharged  as  markedly  improved  (infiltration  of 
pharynx  and  ulceration  of  glottis  cured)  on  November  27, 
1908. 

Sputum  negative  for  tubercle  bacilli  for  four  months. 
Weight,  150  pounds,  two  pounds  heavier  than  ever  before, 


1 182 


CROFTAN:    CALCIUM  EXCRETION  IN  TUBERCULOSIS. 


[New  York 
Medical  Journal, 


and  twelve  pounds  heavier  than  at  any  time  during  past  six 
years. 

Since  discharge  has  been  living  at  home  in  New  Hamp- 
shire, apparently  cured,  and  has  not  lost  a  pound  in  weight. 

C.\SE  IX.  A.  L.  P.,  civil  engineer,  U.  S.  N.,  admitted 
May  9,  1908.  Reported  in  previous  paper  as  on  mercury, 
improved. 

Discharged  to  duty,  cured,  March  5,  1909,  weight,  187 
pounds,  twentv-two  pounds  heavier  than  ever  before. 

Case  X.  mid.^'.lipman,  U.  S.  N.,  admitted  May  16,  1908. 
Reported  in  previous  paper  as  on  mercury,  improved.  Is 
now  markedly  improved,  weight,  143  pounds,  fourteen 
pounds  above  normal. 

Case  XI,  ensign,  U.  S.  N.,  admitted  May  20,  1908.  Re- 
ported in  previous  paper  as  on  mercury,  improved.  Dis- 
charged to  duty,  cured,  March  12,  1909 ;  weight,  140  pounds, 
five  pounds  heavier  than  ever  before.  Since  discharge  has 
passed  a  rigorous  physical  examination  for  promotion. 

Case  XII.  formerly  lieutenant,  U.  S.  N.,  admitted  June 
5,  1908.  Reported  in  former  paper  as  on  mercury,  mi- 
proved. 

Discharged  at  his  own  request  September  9,  1908,  im- 


l-ic.  3.- 


-Showin.s:  areas  of  fibrosis;  cured  tuberculosis   (Case  VII). 


proved.  Weight,  14.^^2  pounds,  eight  and  a  half  pounds 
above  normal. 

Since  his  discharge  has  been  working  at  his  desk  in 
Washington,  seven  lipurs  a  day.  Has  continued  the  injec- 
tions of  mercury,  and  is  still  improving. 

From  the  above  it  will  be  seen  that  of  the  two 
patients  not  on  mercury  in  the  previous  paper,  but 
who  have  taken  it  indififerently  and  irregularly  since 
then,  one  is  improving,  and  one  failing,  the  latter 
having  had  a  rather  severe  typhoid  in  August,  igo8. 

Of  the  ten  on  mercury  at  the  last  report,  six  have 
been  cured,  two  markedly  improved,  and  one  im- 
proved and  one  failed  (Case  II).  this  latter  case  hav- 
ing had  typhoid  in  August,  1908. 

U.  S.  N.\v.\L  Hosprr.\L. 


NOTES  ON  .'\N  INCREASED  URINARY  CALCIUM 
EXCRETION  IN  TUBERCULOSIS; 
Its  Pathological  Significance* 
By  Alfred  C.  Croftan,  M.  D., 
Chicago,  111. 

Scattered  through  the  literature  will  be  found  a 
nun.ber  of  isolated  statements  referring  to  an  in- 
creased excretion  of  calcium  (and  magnesium)  in 
the  urine  of  tuberculous  subjects.  The  first  of  these 
references  that  T  have  been  able  to  find  dates  back 
to  1877,  when  no  less  an  authority  than  Senator' 

'Read  before  the  Section  irt  Pathology 
International  Tuberculosis  Congress  at  Washington,  October 


'Centrnlhlall  (iir  innerc  Medicin,  1877. 


and  Bacteriology  of  tl:c 
1908. 


commits  himself  in  regard  to  this  matter  as  follows : 
"It  is  a  positive  fact  that  in  pulmonary  phthisis  an 
abnormal  quantity  of  calcium  is  excreted  in  the 
urine,  even  if  little  food  is  administered  and  if  the 
patients  suffer  from  diarrhcea."  The  last  important 
work  is  published  by  Ott,'  who  arrives  at  c[uite  con- 
clusive results  all  pointing  to  an  increased  excretion 
of  lime  salts  in  tuberculosis.  In  the  year  following 
I  presented  a  preliminary  report,^  also  referring  to 
the  calcium  excretion  in  tuberculosis,  before  the 
Pathological  Society,  of  Philadelphia,  the  main 
points  of  which  are  incorporated  in  this  article. 

Critiouk  of  Urinary  Calcium  Deter.minations. 

Determinations  of  the  urinary  calcium  excretion  in  order 
to  be  of  value  must  take  into  consideration  a  number  of 
factors.  In  the  first  nlace  it  is  necessary  to  distinguish 
between  what  may  be  called  the  exogenous  and  the  endo- 
genous urinary  calcium  excretion ;  the  former  comprises 
that  portion  of  the  calcium  introduced  with 
the  food  that  is  promptly  assimilated,  enters 
the  blood,  and  thence  passes  into  the  urine ; 
the  latter  the  calcium  that  is  liberated  from 
fixed  calcium  combinations  of  the  body  and, 
once  being  thrown  into  the  circulating  blood, 
is  at  once  excreted  in  the  urine. 

In  health  the  latter,  endogenous,  calcium 
excretion  is  essentially  a  constant  factor  and 
does  not  fluctuate  materially  from  day  to- 
day, varying,  however,  to  some  extent  in 
each  individual.  The  former,  exogenous, 
calcium  excretion  is  altogether  inconstant 
and  fluctuates  from  day  to  day,  inasmuch,  as 
it  is  dependent  exclusively  upon  the  amount 
of  calcium  ingested,  the  character  of  the 
calcium  compounds  present  in  the  food,  and 
the  assimilability  of  the  latter.  Moreover, 
only  a  small  proportion  of  the  calcium  ad- 
ministered by  mouth  appears  in  the  urine, 
the  bulk  being  excreted  in  the  faeces.  Fully 
ninety  to  ninety-five  per  cent,  of  calcium 
salts,  for  instance,  administered  by  mouth 
reappear  in  the  fseces.  the  greater  portion 
not  being  absorbed  at  all  (Voit,  Hoppe-Seyler)  and,  of  the 
small  proportion  absorbed,  a  large  percentage  being  carried 
back  to  the  bowel.  Fully  five  to  ten  per  cent,  of  the  in- 
gested calcium,  however,  always  appears  in  the  urine 
(  Saliorow,  Riesell,  Schetelig). 

In  studying  the  effect  of  any  abnormal  process  (infec- 
tion, intoxication,  metabolic  derangement)  upon  the  uri- 
nary calcium  excretion,  the  exogenous  calcium  excretion 
must  first  be  rendered  constant  hy  the  administration  of 
the  same,  weighed  and  measured,  quantities  of  food  of 
known  calcium  percentage  for  a  considerable  period  of 
time;  the  calcium  figures  obtained  even  in  this  way  must, 
however,  be  interpreted  with  much  conservatism,  because- 
the  individual  value  for  the  endogenous  excretion  is  not 
mathematically  determinable  in  advance.  Here  we  are 
forced  to  utilize  as  a  basis  for  comparison  the  average 
values  for  the  endogenous  calcium  excretion  as  determined 
in  a  number  of  normal  individuals. 

Such  preliminary  studies  involvin,g  an  immense  mass  of 
detail  (that  will  shortly  be  published  elsewhere,  as  these- 
data  do  not  properly  belong  within  the  narrow  frame  of 
this  article)  give  values  for  the  average  individual  endo- 
genous calcium  excretion  of  from  0.03  to  0.07  gramme  of 
calciinn  oxide  in  twenty-four  hours. 

Both  the  maintenance  of  the  exoeenous  calcium  excre- 
tion at  a  constant  level  and  the  preliminary  determination 
of  the  endogenous  calcium  excretion  are.  of  course,  carried' 
out  w'ith  nmch  greater  facility  in  animal  experiments  than 
in  human  studies.  The  greatest  care  must  naturally  be 
exercised  in  every  case  while  feeding  with  a  diet  of  known 
constant  calciutn  content  to  keen  the  subjects  in  a  condi- 
tion f)f  nutritive,  espcciallv  nitrogenous,  equilibrium,  as 
otherwise  disintegration  of  hodv  proteids,  abnormal  acidu- 
lation  of  the  blood  stream  (rhosnhates,  sulphates),  and' 
presumably  dissolution  of  fixed  calcium  combinations  are 

'Deutsrhcs  Archiz'  /lir,  kllnisclte  Mcdicin.  Ixx,  p.  582,  iQoi. 

'Croftan.  Prnce^'diiigs  of  the  Pathological  Society  of  Philadel- 

fhia.  March  7,  1902;  also  Journal  of  Tuberculosis,  v.  i,  January.. 
190.1. 


June  12,  1909. 1 


CROFT  AX:   CALCIUM  EXCRETION  IN    TCBERC  CLOSIS. 


brought  about  with  a  resulting  abnormal  endogenous  cal- 
cium niter  in  the  urine. 

The  Calcium  Excretion  is  Increased  in  Tuber- 
cuLizED  Dogs. 

The  first  experiments  in  animals  were  made  in 
dogs  tuberculized  by  a  pure  culture  of  the  eighth 
generation  of  a  tubercle  bacillus  derived  from  a 
mesenteric  gland  in  a  child,  injected  directly  into 
the  jugular"  vein.  The  urinary  calcium  analyses 
were  performed  according  to  the  following  method  : 

Take  sample  of  100  c.c.  of  urine ;  evaporate  to  dryness 
in  the  presence  of  2  c.c.  nitric  acid.  Add  water  and  nitric 
acid  and  evaporate  to  dryness  to  decompose  carbonaceous 
matter.  The  phosphoric  acid  in  the  sample  should  now  be 
in  the  orthoform.  Add  a  little  water  to  the  residue  in  the 
evaporating  dish,  filter,  ignite,  and  fuse  with  sodium  bicar- 
bonate. Add  the  mass  to  the  filtrate.  Precipitate  the  phos- 
phorus with  silver  carbonate,  filter.  Free  the  filtrate  from 
silver  with  hydrochloric  acid.  Have  the  solution  concen 
trated  and  add  50  c.c.  ammonium  oxalate  solution  to  pre- 
cipitate the  calcium.  Dilute  to  about  500  c.c.  bring  to  boil- 
ing, cool,  add  ammonia,  filter,  ignite,  and  weigh  the  calcium 
p.';  calcium  oxide. 

From  the  time  of  inoculation  to  the  death  of  the 
animal,  a  progressive  increase  of  the  calcium  excre- 
tion was  shown  from  traces  so  small  that  they  could 
not  be  quantitatively  determined  to  0.05  the  day  be- 
fore the  dog"s  death  from  general  miliary  tubercu- 
losis (autopsy  finding).  The  low  figure  on  the 
nineteenth  day  cannot  be  explained.  It  was  prob- 
ablv  due  to  a  technical  error.  (See  Table  I. 
Dog.  A.) 

The  following  table  shows  similar  results  ob- 
tained in  a  series  of  four  other  dogs,  all  corrobo- 
rating the  progressive  increase  of  the  urinary  cal- 
cium excretion  in  animals  kept  on  a  constant  diet 
and  artificiallv  tuberculized : 


TABLE  I. 


Dog.  A. 


-urinary  calcium  EXCRETIOX  IX  TUBERCU- 
LIZED DOGS. 


Dog.  B. 


Dog.  C. 


Dog.  D. 


w  5c          —  . 


Dog  E. 


1 

0 

.0 

I 

0 

.  0 

I 

Trace 

Trace 

1 

0  , 

.0 

g 

0. 

.0010 

10 

0, 

.0010 

6 

0 . 002 1 

14 

0.0034 

12 

0. 

.0034 

1 2 

0. 

.0078 

16 

0  , 

.0021 

21 

0.0063 

20 

0.0102 

19 

0, 

.01 13 

14 

0. 

.0107 

2  I 

0. 

.0093 

24 

o.oi 19 

29 

0.0148 

26 

0, 

.0190 

19 

0 . 

. 0042(?) 

28 

0 

.0142 

29 

31 

0.0147 

33 

0, 

.0248 

34 

0. 

.0203 

38 

0. 

•  0344 

34 

0 . 0294 

40 

0.0318 

40 

0. 

.0419 

3» 

0 

.0510 

4.^ 

0 

.0414 

35 

44 

0.0309 

43 

0. 

0429 

39 

44 

45 

44 

These  results  were  sufificiently  suggestive  to  war- 
rant the  analysis  of  a  number  of  human  tuberculous 
urines  for  calcium.  The  same  method  of  calcium 
determination  was  pursued ;  for  the  method,  while 
complicated,  precludes  error  and  gives  absolutely 
reliable  results. 

The  Calcium  Excretion  in  Tuherculous  Sur.- 
jects. 

A  summary  of  the  results  shows  that  in  cases  of 
advanced  pnthisis  with  destruction  of  lung  tissue 
the  urinary  excretion  of  calcium  is  markedly  in- 
creased, being  as  high  as  0.47  grammes  of  calciinn 
oxide  (the  normal  being  from  0.2  to  0.3  grammes 
of  calcium  oxide)  f>ro  die.  This  high  figure  re- 
mained constant.  In  other  cases  examined  since 
then,  in  which  it  was  possible  to  place  the  patients 
itpon  a  constant  diet,  the  calcium  fitrures  were  also 
higher  than  normal,  the  excretion  fluctuating  frrm 
•-O.37  to  0.41  gramme  in  twenty-four  hours. 


Relationship  Between  Calcium  and  the  Deu- 
teroalbumose  Accompanying  the  Tubercle 
Bacillus. 

Interest  in  the  increased  urinary  calcium  excre- 
tion in  tuberculosis  was  particularly  stimulated  by 
the  fact  that  I  had  found  in  previous  experimental 
work  that  a  cheinical  relationship  exists  between 
calcium  and  an  albumose  (deuteroalbumose)  that 
almost  constantly  accompanies  the  tubercle  bacillus. 
This  substance  has  been  found  in  the  bodies  of  the 
bacilli  themselves  and  in  culture  media  in  which 
tubercle  bacilli  had  grown  (Kiihne,  Hahn,  Koch, 
IMatthes).  Kuhne  showed  that  the  injection  of  this 
deuteroalbumose  manufactured  from  bacilli,  pro- 
duced a  typical  rise  of  temperature  in  tuberculized 
animals ;  ^Matthes  found  this  albumose  in  Koch's 
tuberculin  and  discovered  it  in  the  urine  after 
tuberculin  injections;  finally,  he  succeeded  in  pro- 
ducing a  "tuberculin  reaction"  with  deuteroalbu- 
mose manufactured  from  egg  albumen  without  the 
intervention  of  tubercle  bacilli.  Rouques  produced 
a  tuberculin  reaction  with  tuberculous  urine,  and 
von  Jaksch  found  deuteroalbumose  in  such  urine. 
Kossel  finally  found  it  in  tuberculous  sputum  and 
Alatthes  in  tuberculous  lymph  glands  and  in  case- 
ating  and  calcified  tuberculous  foci  in  the  lungs. 

]Moreover.  I  could  show  that  a  peculiar  selective 
affinity  exists  between  calcium  and  this  deuteroalbu- 
mose as  manifested  by  the  following  four  observa- 
tions : 

1.  In  attempting  to  manufacture  some  deuteroalbumose 
for  the  purpose  of  further  experimentation  with  this  inter- 
esting body  it  was  found  impossible  to  obtain  a  product 
that  was  altogether  free  from  calcium.  It  is  easy  to 
remove  the  other  inorganic  constituents  that  cling  to 
deuteroalbumose,  but  calcium  adheres  with  great  tenacity, 
so  that  it  cannot  be  rem.oved  by  mechanical  means  (dia- 
lysis, precipitation  with  alcohol,  etc.).  B3'  chemical  means 
only  (ammonium  oxalate)  can  the  calcium  be  removed 
and  a  calcium  free  albumose  be  obtained. 

2.  If  a  dilute  solution  of  a  calcium  salt  is  added  to  a 
solution  of  decalcified  deuteroalbumose,  a  definite  propor- 
tion of  the  calcium  will  be  bound  so  tightly  that  it  cannot 
again  be  removed  by  physical  means. 

3.  If  two  test  tubes  are  filled  with  equal  quantities  of 
milk  and  to  one  tube  is  added  ordinary  deuteroalbumose, 
to  the  other  the  decalcified  preparation,  and  rennet  is  added 
to  both,  the  curdling  of  the  milk  will  be  considerablj'  re- 
tarded in  the  latter  tube.  If  sufficient  decalcified  albumose 
is  added,  curdling  is  inhibited.  The  calcium  of  the  milk  is 
evidently  bound  so  tightly  to  the  albumose  that  paracasein 
calcium  (curdle)  cannot  he  formed. 

4.  If  blood  is  carefully  decalcified  hy  the  addition  of  a 
calculated  portion  of  oxalate,  and  if  equal  portions  of  this 
blood  are  distributed  in  a  number  of  tubes  and  varying 
quantities  of  decalcified  deuteroalbumose  added  to  each 
tube,  it  will  be  found  on  addition  of  a  definite  number  of 
drops  of  a  calcium  solution  to  these  mixtures  that  coagula- 
tion is  retarded  or  inhibited  in  proportion  to  the  quantity 
of  decalcified  deuteroalbumose  added  to  each  tube.  Deu- 
teroalbumose. therefore,  has  a  greater  affinity  for  calcium 
than  has  narathrombin :  consequently  the  formation  of 
a  calcium  parathrombin.  i.  e..  fibrin,  is  prevented. 

Interpretation  and  Clinical  Sign"ific.-\nce  of 
Increased  Calcil'm  Excretiox  from  the 
Deutero-klbumose. 

Having  established,  then,  two  apparently  discon- 
nected facts,  namely,  first,  that  the  urinary  calcium 
excretion  is  increased  in  tuberculosis,  second,  that 
calcium  has  a  selective  affinity  for  an  albuminous 
product  accompanyins'  the  tubercle  bacillus,  the 
natural  inquiry  suggested  itself  whether  or  not  the 


POLAR:  POSTOPERATIVE  GASTRIC  DILATATION. 


[New  York 
Medical  Journal. 


latter  observation  could  in  any  way  explain  the  in- 
crease in  the  urinary  calcium  excretion  and  whether 
any  clinical  significance  attached  to  these  findings. 
The  calcification  of  tuberculous  foci  seemed  to  point 
out  that  calcium  is  commonly  found  wherever  deu- 
teroalbumose  is  formed  by  the  action  of  the  tubercle 
bacillus. 

This  problem  was  approached  by  comparing  the 
effect  of  the  "decalcified"  and  of  the  calcium  sat- 
urated deuteroalbumose  upon  tuberculous  animals ; 
and  here  exceedingly  interesting  relations  were  dis- 
covered. 

For,  while  the  pure  deuteroalbumose  possessed 
very  marked  fever  producing  powers  when  injected 
into  tuberculous  animals,  this  power  was  to  a  great 
extent,  often  altogether,  lost  when  the  calcium  sat- 
urated product  was  injected  into  similar  animals. 
Through  the  courtesy  of  Dr.  Leonard  Pearson,  an 
opportunity  was  presented  to  inject  calcified  deutero- 
albumose into  a  herd  of  twenty  cattle  that  were 
known  to  be  tuberculous,  having  reacted  to  the  tu- 
berculin test  some  months  previously.  Deuteroal- 
bumose prepared  from  egg  albumen  according  to 
the  method  of  INIatthes  and  known  to  produce  pyrex- 
ia in  tuberculous  animals  was  dissolved  in  water 
and  saturated  with  calcium  by  the  addition  of  a  ten 
per  cent,  solution  of  calcium  chloride.  The  calci- 
fied albumose  was  precipitated  with  alcohol,  filtered 
off,  and  dried.  The  sediment  contained  4.89  per 
cent,  of  calcium.  Of  this  product  a  five  per  cent, 
watery  solution  V\'as  injected  into  the  herd  and  no 
temperature  reaction  was  obtained,  as  shown  by  the 
following  table : 


T.^BLE  II. 


Tempera- 
„•  .  tures  before 
P  injection. 


c 
ra 

0 

'  Date,  Feb- 
■    ruary  21st. 

u 
u 

ca 
c ' 

E 

0 

0  - 

COS 

- 

O  ■ 

0  i 

I 

I0I.2 

101.4 

4  C. 

2 

lOI 

100.6 

4  ' 

3 

IOI.3 

loi.S 

4 

4 

102.2 

102.4 

4  ' 

5 

6 

102.2 

101.6 

2  ' 

7 

I0I.6 

100.2 

8 

I  02.4 

101.2 

2 

9 

103.2 

102.6 

2 

10 

I0I.6 

101. 1 

4 

1 1 

100.8 

100.8 

4 

12 

103 

103 

4 

13 

101. 2 

100.6 

4 

>4 

lOI.I 

101.2 

5 

15 

16 

102.2 

102 

5 

17 

18 

700.8 

101.6 

6 

19 

102 

102.1 

8 

20 

lOI 

101.5 

10 

Temperatures  after  injection. 


Date,  Febuary  22d. 


Time  ( 
injecti 

Time, 
2  a.  m. 

Time, 
4  a.  m. 

Time, 
6  a.  m. 

Time, 
8  a.  m. 

Time, 
10  a.  n 

Time, 
12  ra. 

!  p.m. 

101.2 

101.6 

101.3 

102 

102.4 

102.4 

100.5 

100.6 

101.4 

101.8 

101.9 

101.9 

101 

101 

101.3 

101.4 

102.2 

102.6 

102 

102 

102.2 

102.1 

102.4 

102.4 

101.6 

101. 9 

101.8 

102.2 

102.6 

102.2 

101 

101.4 

101.4 

101.6 

101.4 

101 

101.6 

101.8 

101.6 

101.6 

102.6 

102.9 

102.4 

101.6 

102 

102 

102.4 

102.2 

101.4 

101.3 

101.4 

101.9 

102 

102.1 

101 

101 

101.9 

162.2 

102.6 

102.6 

101.3 

100.6 

101.6 

101 

101.4 

101.6 

101. 1 

101.2 

101.4 

102.2 

101.9 

101.8 

101.2 

101.1 

101.6 

102.4 

102.4 

102.4 

101.9 

101.4 

101.6 

102 

101.6 

103 

100.8 

101.5 

101.8 

1 02.2 

101.8 

102.2 

101.6 

100.9 

101.2 

101.6 

102.4 

102.2 

101.2 

101.6 

lOI 

101.6 

101.6 

lOI 

Similarly  negative  results  were  obtained  in  arti- 
ficially tuberculized  dogs  and  rabbits. 

Clinical  Suggestions. 

The  most  important  conclusions,  therefore,  that 
one  is  apparently  justified  in  formulating  from  these 
studies  is  that  the  addition  of  calcium  to  one  of  the 
main,  possibly  the  one,  pyretogenic  principle  manu- 
factured by  the  tubercle  bacillus  robs  it  of  its  fever 
producing  power.  One  is  impressed  by  the  idea  that 
this  is  a  disiufoxicntin^  process  and  occurs  in  the 
organism  whenever  albumose  is  generated  by  the 


tubercle  bacillus,  incidentally  leading  to  the  deposit 
of  abundant  calcium  salts  in  loco  and  an  excessive 
excretion  of  calcium  in  the  urine. 

Experiments  are  at  present  under  way  to  deter- 
mine experimentally  whether  or  not  the  exhibition 
of  calcium  salts  by  mouth  or  by  other  routes  can 
in  any  way  modify  the  temperature  movements  in 
tuberculized  animals.  '  Some  preliminary  results 
that  have  been  obtained  give  very  suggestive  fig- 
ures, but  I  consider  it  premature  to  make  any  an- 
nouncement on  this  subject. 

To  what  extent  an  increased  calcium  excretion 
may  be  utilized  in  the  early  diagnosis  of  tuberculo- 
sis remains  to  be  determined.  In  view  of  the  incon- 
stancy of  the  urinary  calcium  excretion  and  the 
many  factors  to  be  considered  when  interpreting 
this  excretion,  the  method  surely  will  never  be  of 
great  practical  value. 

Whether  the  calcium,  or  lime  salts,  can  be  used 
in  the  treatment  of  tuberculosis  particularly  with 
the  object  in  view  of  controlling  the  fever  move- 
ments remains  to  be  determined.* 

SUMMARY. 

1.  Evidence  old  and  new,  experimental  and  clin- 
ical of  an  increased  urinary  calcium  excretion  in 
tuberculosis. 

2.  Explanation  of  this  phenomenon  sought  for 
in  the  selective  affinity  recognized  to  exist  between 
calcium  and  an  albumose  (deuteroalbumose) 
known  to  be  universally  present  in  tuberculous  foci, 
culture  media,  in  the  bacillus  and  the  excreta  of 
tuberculous  subjects. 

3.  Evidence  to  show  that  this  albumose  produces 
fever  in  tuberculous  subjects  and  that  this  pyreto- 
genic power  is  lost  by  combination  with  calcium. 

100  Statf.  Street. 


ACUTE  GASTRIC  DILATATION  AS  A  POSTOPER- 
ATIVE COMPLICATION.* 

By  John  Osborn  Poi.ak,  M.  Sc.,  M.  D., 
Brooklyn,  N.  Y. 

Acute  gastric  dilatation  as  a  postoperative  com- 
plication, following  abdominal  section,  has  occurred 
with  sufficient  frequency  in  my  personal  work,  to 
justify  me  in  making  this  report,  and  thus  contrib- 
uting my  mite  to  the  literature  of  this  subject. 

In  more  than  a  thousand  sections  during  the  past 
five  years,  acute  gastric  dilatation  has  complicated 
the  postoperative  convalescence  of  eight  women,  or 
in  less  than  0.8  per  cent,  of  the  cases.  It  is  possible 
that  more  patients  have  sufifered  from  this  compli- 
cation, and  that  the  condition  has  gone  unrecog- 
nized, and  been  recorded  as  ileus,  or  intestinal 
paresis  ;  yet  the  clinical  picture,  with  its  symptom 
complex,  is  so  clear  to  me  at  this  writing,  that  I 
offer  these  records  as  the  sum  total  of  my  experi- 
ence. Two  patients  died  from  the  collapse  conse- 
quent upon  the  continuance  of  this  lesion,  one  five 

<Since  the  reading  of  this  report  a  very  suggestive  paper  on  the 
treatment  of  tuberculosis  by  the  inhalation  of  lime  dust  has  ap- 
peared from  the  pen  of  Dr.  S.  C.  Boston,  Tuberculosis  .Apparently 
Cured  by  the  Accidental  Inhalation  of  Lime  Dust,  American  Mi\1i- 
cine,  iii.  No.  lo,  p.  480,  October,  190S.  The  relative  immunity 
against  tuberculosis  recognized  to  exist  in  workers  with  lime  saUs 
(lime  stone  quarrymen,  etc.)  is  also  interesting  in  this  connection. 

*Rca{i  by  title  before  the  .American  Gynjccological  Society,  held  .it 
New  York.  April  22.  1909. 


June  12,  igcg.J 


POLAK:  POSTOFERATiyE  GASTRIC  DiLATAIIuS. 


days  after  an  appendectomy,  the  other  on  the  eighth 
day  followmg  a  salpingectomy  and  vaginal  drain- 
age, for  an  intercellular  abscess.  Both  had  been 
septic  for  several  weeks  prior  to  surgical  inter- 
vention. Each  had  extremely  low  haemoglobin  per- 
centages, and  red  cell  counts  at  the  time  of  opera- 
tion. This  was  particularly  marked  in  the  second 
patient,  whose  haemoglobin  was  only  thirty-six  per 
cent.,  and  red  cells  2,200,000.  All  evidence  of  acute 
sepsis  had  ceased,  as  was  shown  by  the  temperature, 
the  pulse,  and  differential  leucocyte  count,  before 
intervention  of  any  kind  was  resorted  to.  Both  pa- 
tients stood  their  operations  well. 

This  lowered  blood  resistance,  I  believe  to  be 
particularly  significant  in  the  aetiology,  as  we  have 
noticed  in  all  the  cases  of  this  series,  that  the  red 
cell  count  has  been  below  4,000,000,  while  the 
haemoglobin  percentages  ranged  from  thirty-six  to 
seventy.  All  occurred  in  women,  the  youngest 
being  twenty-four,  the  oldest  forty-eight.  Laf- 
fer,  in  his  statistical  analysis  of  217  cases,  found 
the  majority  occurring  between  th,e  ages  of  twenty 
and  forty.  This  is  probably  accounted  for  by  the 
fact  that  adolescence  and  sexual  maturity,  are  the 
periods  at  which  man  and  woman  are  more  subject 
to  acute  disease. 

Acute  gastric  dilatation,  was  noted  five  times  fol- 
lowing operations  for  septic  processes  within  the 
pelvis.  Once,  after  a  hysterectomy  for  malignant 
disease  of  the  uterus,  and  twice,  subsequent  to  an 
appendectomy.  All  of  the  patients  were  in  the  ele- 
vated head  and  trunk  posture  of  Fowler,  at  the  time 
when  the  dilatation  first  manifested  itself.  But  one 
patient  had  had  any  previous  history  of  gastric  trou- 
ble. She  had  suffered  from  more  or  less  gastric  dila- 
tation and  "nephroptosis  for  several  years  prior  to  the 
hysterectomy,  which  was  done  for  malignant  dis- 
ease. 

All  of  my  patients  were  operated  upon  under  a 
general  anaesthetic,  chloroform,  and  ether  oxygen 
being  the  agents  employed.  The  narcosis  was  pro- 
duced and  maintained  by  the  open  method  of  ad- 
ministration. The  time  consumed  by  the  anaesthesia 
and  operation  varied  from  thirty  minutes,  to  an 
hour  and  five  minutes.  One  half  ounce  of  chloro- 
form, and  five  and  one  half  ounces  of  ether,  was 
the  largest  quantity  consumed.  The  five  patients 
of  this  series,  who  were  operated  upon  for  septic 
processes  within  the  pelvis,  were  placed  in  the 
Fowler,  elevated  head  and  trunk,  posture,  imme- 
diately upon  their  return  to  bed.  There  can  be  no 
doubt,  that  this  position  favors  constriction  of  the 
lower  end  of  the  duodenum,  between  the  root  of 
the  mesentery,  which  crosses  in  front  of  it,  and  the 
vertebral  column,  because  of  the  traction  on  the 
mesenteric  root,  with  the  mesenteric  artery  which 
runs  in  it,  by  the  small  intestine  hanging  over  the 
brim  of  the  pelvis. 

Primary  dilatation  of  the  stomach  from  the  accu- 
mulation of  gas,  due  to  the  fermentation  and  the 
retention  of  the  ingested  food  and  drink,  together 
with  oversecretion  following  ether,  doubtless  in- 
cieases  the  liability  to  mesenteric  obstruction,  by 
crowding  the  intestines  into  the  pelvis,  or  by  pre- 
venting their  escape  from  the  pelvic  cavity,  which 
would  render  such  an  obstruction  when  once 
formed,  more  complete  and  permanent. 


Previous  gastroptosis  and  enteroptosis,  certainly 
predispose  in  producing  this  condition.  The  trans- 
verse colon  was  noted  well  below  the  umbilicus  in 
three  of  these  patients,  at  the  time  of  operation. 
Seven  were  multiparous  women  with  lax  abdominal 
walls,  and  some  degree  of  diastases  of  the  recti 
muscles.  Two  of  this  number  had  but  recently 
given  birth  to  children,  and  suffered  from  an  inter- 
current sepsis  during  their  puerperium,  which  had 
greatly  reduced,  not  only  their  general  tone,  but  the 
tonicity  of  the  abdominal  parietes,  as  well  as  that 
of  their  intraabdominal  contents. 

In  the  presence  of  such  conditions,  it  is  easy  to 
understand,  how  a  primary  dilatation  of  the  stom- 
ach, of  greater  or  less  degree,  may  occur,  and  may 
occur  and  become  serious  from  a  motor  insuffi- 
ciency, following  general  anaesthesia,  or  from  the 
too  early  ingestion  of  fluids  after  operation.  This 
gastric  content  is  further  augmented  by  the  usual 
oversecretion  which  follows  ether. 

The  truth  of  this  statement  had  a  clinical  demon- 
stration in  the  two  patients  just  referred  to.  These 
women  had  very  lax  and  pendulous  abdominal 
walls,  which  permitted  a  gastroptosis  and  enterop- 
tosis when  in  the  elevated  trunk  posture.  As  no 
vomiting  occurred  immediately  following  the  anaes- 
thesia, the  house  surgeon  allowed  water  to  be  given 
freely  by  the  mouth.  Epigastric  distension  was 
soon  noticed,  and  unsuccessful  attempts  to  relieve 
it  by  enemata  were  made,  and  as  no  vomiting  oc- 
curred, larger  quantities  of  water  were  allowed. 
Ihe  typical  regurgitant  vomiting  of  dilatation  did 
not  begin  until  thirty-six  hours  or  more  after  the 
operation,  it  then  continued  persistently,  until  the 
stomach  tube  was  passed,  and  the  stomach  emptied 
of  several  quarts  of  greenish  fluid. 

In  five  of  these  patients  the  vomiting  began 
toward  the  end  of  the  first  day,  and  was  persistent 
and  continuous,  coming  up  in  large  gulps,  without 
strain  or  effort ;  simply  a  regurgitation  of  mouth-  ' 
fuls  of  greenish  flocculent  material,  temporarily 
checked  by  lavage,  only  to  begin  again  as  the  stom- 
ach refilled  from  the  hypersecretion  of  mucus  and 
the  back  flow  of  bile,  because  of  the  duodena!  con- 
striction. 

One  patient  did  not  vomit  at  all  for  the  first  fifty 
hours  after  the  operation,  but  her  entire  abdomen 
became  enormously  distended,  the  epigastric  promi- 
nence was  most  noticeable,  no  flatus  was  passed  by 
mouth  or  rectum,  enemata  of  all  kinds  proved  in- 
efl^ectual.  The  distention  continued  to  increase,  the 
pulse  became  accelerated  and  weak,  until  the  stom- 
ach tube  was  passed,  and  seven  and  a  half  pints  of 
greenish,  yellow  fluid  syphoned  off.  The  stomach 
was  then  thoroughly  lavaged  with  normal  salt  solu- 
tion, which  resulted  in  the  free  exhibition  of  gas 
through  the  tube,  and  immediately  relieved  the  dis- 
tension. A  half  pint  of  normal  salt  solution  was 
left  in  the  stomach  before  withdrawing  the  tube, 
and  the  patient  was  placed  in  the  right  lateroprone 
posture,  with  her  hips  elevated,  to  favor  expulsion 
of  the  gastric  contents,  by  bringing  the  pylorus  into 
its  lowermost  position.  Nothing  was  allowed  by 
mouth,  and  her  secretions  were  maintained  by  a 
continuous  Murphy  irrigation.  The  lavage  was  re- 
peated in  eight  hours,  when  a  half  pint  of  bile 
tinged  fluid  was  withdrawn,  and  an  equivalent 


ii86 


KEOIVN:  QUININE  IN  PNEUMONIA 


LNew  York 
Medical  Journal. 


amount  of  normal  salt  solution  was  left  in  the  stom- 
ach. Enemata  of  soap  sudg  and  ox  gall  now  proved 
effectual,  and  the  distension  of  the  lower  abdomen 
rapidly  subsided. 

In  this  case,  I  believe,  the  dilatation  was  due  to 
an  anjesthetic  intoxication,  which  resulted  in  acute 
motor  insufficiency  of  the  stomach.  She  had  had  a 
prolonged  narcosis  (one  half  ounce  of  chloroform 
and  five  and  one  half  ounces  of  ether  being  used) 
and  an  operation  which  necessitated  extensive  intra- 
abdominal manipulation,  as  well  as  the  introduction 
of  numerous  gauze  rolls  to  wall  off  the  field  of  pro- 
cedure, all  of  which  tended  to  increase  her  shock, 
by  depression  of  the  great  abdominal  (solar) 
plexus.  The  mesenteric  occlusion  of  the  duodenum 
was  secondary,  as  was  shown  by  the  immediate  re- 
lief of  the  gastric  and  intestinal  paresis,  by  siphon- 
ing off  the  gastric  contents.  The  overfilling  of  the 
stomach  had  prevented  the  intestines,  which  were  in 
the  pelvis,  from  retlirning  to  the  abdominal  cavity, 
and  resuming  their  function. 

Dift'use  abdominal  .pain  and  unquenchable  thirst, 
were  constant  symptoms  in  all  of  these  patients. 
The  pain  was  diffuse  and  paroxysmal,  associated 
v.'ith  visible  peristalsis  over  the  distended  stomach. 
No  elevation  of  temperature  was  noted,  except  in 
one  of  the  fatal  cases  already  referred  to,  where  it 
rose  to  102.5,  twenty-four  hours  before  death.  This, 
however,  we  believe  to  have  been  due  to  an  asso- 
ciated pulmonary  complication.  The  pulse  gradu- 
ally rose  with  the  distention,  and  improved  when 
this  was  relieved  by  the  passage  of  the  stomach. 
The  respiration  also  bore  a  direct  relation  to  the 
degree  of  distention  present.  In  all  but  one  pa- 
tient, flatus  was  passed  by  rectum,  as  the  result  of 
enemata,  and  helped  to  exclude  the  presence  of  an 
intestinal  obstruction. 

Two  distinct  types  were  noted,  one  in  which  the 
gastric  dilatation  was  only  part  of  the  general  in- 
volvement of  the  intestinal  canal,  due  to  a  peri- 
tonitis. This  type  was  observed  but  once,  after  a 
double  salpingectomy  and  appendectomy,  where  the 
abdomen  was  closed  without  drainage.  In  the  sec- 
ond type,  the  dilatation  occurred  without  any  asso- 
ciated peritonitis,  due  to  some  degree  of  duodenal 
constriction,  which  acted  as  a  primary  cause,  or 
was  secondary  to  the  primary  dilatation  of  the 
stomach. 

The  remaining  seven  patients  are  included  in  this 
class.  Both  of  the  women  who  died  from  this  com- 
plication were  of  the  second  type.  Their  wounds 
were  reopened  and  enlarged  sufficiently  to  disclose 
an  enormously  distended  stomach,  which  filled  the 
entire  anterior  abdomen.  The  transverse  colon  and 
small  intestines  were  empty  to  within  a  few  inches 
of  the  stomach,  and  were  crowded  into  the  pelvis, 
and  could  not  be  released  until  the  stomach  con- 
tents were  withdrawn.  Constriction  of  the  duo- 
denum by  the  mesenteric  root  Avas  noted  in  each. 

The  diagnosis  of  postoperative  dilatation  is  not 
difficult,  if  one  is  but  on  his  guard  as  to  its  possible 
occurrence.  The  intense  thirst,  the  frequent  and 
persistent  vomiting,  appearing  one  or  two  days 
after  operation,  which  is  regurgitant  in  form,  com- 
ing up  in  mouth fuls,  without  effort,  of  large 
amount,  and  of  characteristic,  yellowish  or  green- 
ish, sour  smelling,  flocculent  material,  associated 
with  little  or  no  rise  in  temperature,  but  a  slight 


and  gradual  increase  in  the  frequency  of  the  pulse. 
The  marked  epigastric  distention,  without  tender- 
ness or  rigidity,  while  the  lower  part  of  the  abdo- 
men may  be  soft  and  flat,  and  the  absence  of  leuco- 
cytosis,  are  symptoms  which  strongly  suggest  the 
condition. 

The  vomiting  usually  does  not  begin  until  twenty- 
four  or  thirty-six  hours  after  the  operation,  but 
may  not  appear  until  much  later.  The  vomiting 
continues  until  the  stomach  tube  is  passed,  and  the 
gastric  contents  syphoned  off.  The  passage  of  the 
stomach  tube  makes  the  diagnosis  positive. 

The  treatment  in  all  of  these  patients  was  begun 
immediately  after  making  the  diagnosis,  and  con- 
sisted of  repeated  lavage  of  the  stomach  with  nor- 
mal salt  solution.  The  lavage  was  continued  until 
the  syphoned  fluid  was  free  from  bile  stain.  A 
pint  of  warm  saline  was  always  left  in  the  stomach 
before  withdrawal  of  the  tube,  and  the  patient 
turned  in  the  right  lateroprone  posture,  with  the 
hips  elevated.  The  foot  of  the  bed  was  also  ele- 
vated, and  eserine  saHcylate,  gr.  1/50,  with  strych- 
nine sulphate  gr.  1/50,  administered  hypodermic- 
ally.  This  procedure  was  repeated  in  eight  hours, 
nothing  being  given  by  mouth.  Nutrient  enemata 
of  sahne,  whiskey,  and  panopeptone  were  used 
every  four  hours,  and  the  lower  intestinal  tract  was 
emptied  from  time  to  time  by  soap  suds  enemata 
or  by  Kemp's  colonic  irrigation,  the  latter  proving 
most  successful. 

The  intense  thirst  was  relieved,  and  the  salivary 
secretion  stimulated  by  allowing  the  patient  to  use 
chewing  gum.  After  the  stomach  had  regained  its 
mobility,  as  shown  by  its  capacity  to  empty  itself, 
hard,  dry  toast  was  allowed.  The  ingestion  of  solid 
food  was  encouraged,  as  affording  greater  stimulus 
to  the  atonic  stomach. 

287  Clinton  Avenue. 


THE  TREATMENT  OF  PNEUMONIA.  WITH  SPE- 
CIAL REFERENCE  TO  THE  USE  OF  QUININE. 

By  J.  A.  Keown,  M.  D., 
Lynn,  Mass., 
Resident  Surgeon  at  the  Emergency  Hospital. 

I  have  noticed  that  in  the  severe  fatal  cases  of 
jineumonia,  there  is  extensive  and  increasing  con- 
solidation of  the  lung.  The  patient  seems  to  get 
sicker,  and  his  danger  exists  in  direct  ratio  to  the 
amount  of  consolidation.  Many  fatal  cases  are  un- 
doubtedly due  to  the  lack  of  lung  space  and  defi- 
cient oxidation  of  the  blood  and  the  absorption  of 
toxines  generated  in  the  consolidated  lung.  Is  it  pos- 
sible to  limit  this  consolidation,  and  if  so.  would  it 
l)e  for  the  best  interest  of  the  patient? 

It  seems,  as  a  result  of  seven  or  eight  years'  ex- 
j)erience,  with  special  treatment  in  pneumonia,  that 
liicse  two  questi  ins  may  be  answered  in  the  affirma- 
tive. 

The  pathology  of  pneumonia  shows  us  that  \\t 
first  have  congestion  with  transudation  of  red  and 
white  cells  from  the  blood  vessels  into  the  alveoli, 
together  with  serum.  At  first  the  red  cells  are  more 
alnmdant  but  later  the  white  cells  are  more  abun- 
dant, the  whole  mass  coagulating,  making  a  splen- 
(hd  media  imder  the  most  favorable  conditions  for 


June  12,  1909.] 


KEOWN:  QUININE  IN  PNEUMONIA. 


the  growth  of  the  particular  germ  or  germs  which 
l:;appens  to  cause  pnuemonia. 

If  this  consohdation  could  be  prevented  or  lim- 
ited, the  number  of  germs  would  be  lessened  and 
the  absorption  of  the  toxines  from  the  same,  the 
patient  would  have  greater  lung  space  for  oxida- 
tion, the  sputa  would  be  lessened ;  the  temperature 
would  be  lowered,  and  the  patient's  general  condi- 
tion much  improved. 

Fortunately  there  is  one  drug,  through  whose  ac- 
tion it  would  seem  this  object  may  be  accomplished, 
that  is,  qu.inine.  Physiology  shows  us  that  when 
the  mesentery  of  a  frog  is  exposed  under  the  micro- 
scope and  slightly  irritated,  there  is  a  transudation 
of  the  blood  cells  and  particularly  the  white  cells. 
If  quinine  is  hypodermically  administered  to  the 
frog,  or  if  quinine  solution  is  painted  on  the  mesen- 
tary,  this  transudation  of  the  cells  and  particularly 
the  w"hite  cells,  is  arrested  and  the  cells  already  in 
the  tissues  have  their  motions  arrested,  the  action  of 
quinine  in  this'  case  being  to  paralyze  the  movement 
of  the  white  cells. 

The  application  of  this  principle  to  the  treatment 
of  pneumonia  is  the  object  of  this  article  and  the 
report  of  the  following  cases : 

Case  I. — J.  P.,  man.  forty-hve  years  of  age :  ill  for 
twelve  hours  with  the  following  symptoms :  Cough,  rusty 
sputa,  pain  in  the  chest,  nausea,  respiration  36;  temperature 
104°  F. ;  pulse  130.  In  right  lung  behind,  subcrepitant 
rales  at  the  extreme  end  of  inspiration,  with  diminished 
breath  sounds  over  an  area  of  about  the  size  of  a  silver  dol- 
lar. This  patient  was  given  a  cough  medicine  composed 
of  ammonium  carbonate,  morphine  sulphate,  and  syrup  of 
wild  cherry.  He  was  also  given  15  grains  of  quinine  and 
10  grains  of  Dover's  powder. 

Next  day  the  temperature  was  normal;  pulse  90;  respira- 
tions 24;  no  bronchial  breathing  in  the  chest;  no  pains; 
rales  not  perceptible ;  feeling  much  better.  This  patient 
continued  to  improve  and  had  no  further  trouble  with  the 
lung. 

Case  II. — H.  'SI.,  man.  thirty-five  years  of  age;  ill  for 
one  week ;  left  of{  work  to-day  and  went  to  bed.  Pain  in 
neck,  shoulder,  and  chest.  At  11  a.  m.  had  chills  and 
sweating  with  severe  headache  and  pain  under  left  shoulder 
blade.  Temperature  103.5"  F. ;  pulse  120;  respirations  32. 
Subcrepita  rales  heard  under  the  left  shoulder  blade  be- 
hind. Patient  was  given  the  cough  medicine  which  was 
given  in  the  first  case  and  2  grains  of  quinine  every  three 
hours.  Next  day  better.  Some  pains  in  chest ;  no  fever. 
Very  little  cough.    No  signs  in  lung. 

Case  III. — A.  S.,  man,  forty-one  years  of  age;  not  feel- 
ing well  for  some  days;  quite  ill  during  the  last  twenty-four 
hours.  Complains  of  being  tired,  coughs,  had  a  chill  two 
days  ago.  Pain  in  left  side  behind  and  below  left  shoulder 
blade.  Pulse  120;  temperature  102°  F. ;  respirations  32. 
Bronchial  breathing  with  coarse  rales  in  left  back  below 
shoulder  blade  over  an  area  the  size  of  a  saucer.  Patient 
was  put  to  bed ;  was  given  cough  medicine,  and  4  grains 
of  quiriine.  three  times  a  day,  mustard  plaster  to  the  chest, 
morphine  1/8  of  a  grain  if  needed  for  severe  pain.  Patient 
was  given  1/30  grain  of  strychnine  every  six  hotfrs.  There 
was  a  mitral  systolic  murmur  at  the  apex  of  the  heart. 
Urine  contained  a  slight  trace  of  albumin.  Next  day  the 
patient  had  a  pulse  of  120.  He  is  feeling  somewhat  better. 
The  consolidation  in  the  lung  seemed  to  be  about  the  same. 
Pulse  was  strong.  Next  day  patient  had  a  temperature  of 
101.2°  F. ;  pulse  120.  The  consolidated  area  seemed  to  be 
slightly  larger.  On  inquiry  I  found  that  patient  had  not 
been  getting  the  full  dose  of  quinine,  receiving  only  one 
half  of  the  amount  ordered.  I  gave  him  6  grains  at  one 
dose,  and  then  increased  the  quinine  to  4  grains  every  six 
hours.  Next  day  patient  had  a  temperature  of  100.4°  F"- ; 
pulse  136:  respirations  38.  The  consolidation  seemed  to  be 
about  the  same  in  area.  Patient  presented  a  new-  area  of 
consohdation  in  right  front,  the  size  of  a  silver  half  dollar. 
Patient  looked  flushed  but  took  nourishment  quite  well. 
Cough  was  less  troublesome  and  raised  le>s  sputa. 


Next  day  the  consolidation  seemed  to  be  increasing. 
Temperature  101.6"  F. ;  pulse  132;  respiration  30.  The 
quinine  increased  to-day  to  6  grains  every  five  hours. 

Next  day  the  temp^^rature  was  100.5°  l'-  -  pi'lse  132  ;  con- 
dition of  the  patient  about  the  same.  Patient  was  given  a 
mixture  containing  tincture  digitaiis.  potassium  acetate, 
sodium  nitrite  for  kidneys  and  heart. 

Next  day  the  temperature  was  100.5°  F- !  pi'lse  132;  pa- 
tient about  the  same.  The  strychnine  increased  to  1/30 
of  a  grain  every  four  hours. 

Ne.xt  day  the  temperature  was  100.8°  F. ;  pulse  132;  con- 
solidation slightly  increasing.  The  quinine  increased  to  6 
gram  every  four  hours.  Patient  was  given  brandy  one  half 
tablespoonful  three  times  a  day. 

Next  day  the  pulse  was  120;  temperature  100.8°  F.  The 
air  seemed  to  be  entering  the  left  lung  in  site  of  the  first 
consolidation  a  lit'le  freer.  Patient  somewhat  delirious. 
The  face  much  flushed. 

Next  day  the  temperature  was  100.6°  F. ;  pulse  116. 
Respirations  .3c.  Patient  seemed  to  be  slightly  better.  No 
delirium.  Patient  steadily  improved,  and  four  days  later 
the  temperature  was  normal.  At  this  point  the  quinine 
was  reduced  to  4  grains  every  five  hours,  and  strychnine 
to  i,/30  gram  in  every  eight  hours.  The  brandy  was  re- 
duced one  half.  From  this  time  on  the  patient  continued 
to  improve,  and  four  days  later  the  pulse  had  reached  nor- 
mal, when  the  quinine  was  omitted  and  compound  syrup 
hypophosphites  with  tasteless  cod  liver  oil  given.  The  pa- 
tient continued  steadily  to  improve  and  has  remained  well 
up  to  date,  it  being  six  weeks  since  the  onset  of  his  disease. 

Case  IV. — ].  F.  B.,  a  man,  about  twenty-three  years  of 
age ;  ill  for  four  days  with  pain  in  the  back ;  weak ;  no  ap- 
petite ;  headache,  coughed  a  good  deal,  had  some  sputa ; 
pain  in  the  right  chest  and  shoulder  blade.  Pulse  108; 
temperature  101.5°  F- :  respirations  36.  Had  patch  of  bron- 
chial breathing  with  increased  transmission  of  voice  sounds 
under  right  scapula  behind  about  the  size  of  a  twenty-five 
cent  piece.  This  patient  was  given  the  usual  cough  medicine 
and  2  grains  of  quinine  every  four  hours.  Next  day.  tem- 
perature 100°  F. ;  pulse  110;  respirations  26.  signs  in  Jie 
chest  the  same  as  yesterday. 

Next  da\-  pulse  100 ;  temperature  100°  F. ;  respirations  26. 
Quinine  increased  to  4  grains  every,  four  hours. 

Ne.xt  day  temperature  normal;  pulse  100;  respirations 
20.  Signs  in  the  chest  the  same  as  before.  This  patient 
ran  along  for  four  or  five  days  substantially  in  the  same 
condition.  After  this  time  the  consolidation  in  the  lung 
slowly  grew  less  and  toward  the  end  of  the  week  had  dis- 
appeared. 

Case  \'. — V.  A.,  a  man,  forty-si.x  years  of  age :  had  a 
cold  for  twenty-four  hours;  pains  in  left  chest;  headache; 
sore  all  over  the  body:  pulse  108;  temperature  100.5°  F.; 
respirations  26.  This  patient  was  given  the  usual  cough 
medicine  with  powders  containing  phenacetin  and  Dover's 
powder. 

Ne.xt  day  temperature  103°  F. ;  pulse  120;  respirations 
36.  On  examination  patient  presented  patch  of  bronchial 
breathing  with  increased  transmission  of  voice  sounds  and 
coarse  rales,  the  patch  being  about  the  size  of  a  silver  dol- 
lar. Phenacetin  and  Dover's  powder  omitted;  cough  med- 
icine was  continued,  and  the  patient  received  4  grains  of 
quinine  three  times  a  day,  also  1/60  grain  of  strvchnine 
sulphate  ever>-  si.x  hours. 

Ne.xt  day  temperature  103°  F. ;  pulse  96;  respirations  36. 
Condition  of  lung  the  same.  Patient  continued  in  substan- 
tially the  same  condition  for  three  days  with  the  consolida- 
tion not  increasing.  The  quinine  was  then  increased  to  4 
grams  every  five  hours,  with  the  result  that  the  temperature 
next  day  fell  to  normal  with  the  pulse  remaining  at  about 
96;  respirations  28.  This  continued  for  five  or  six  days 
with  the  consolidation  slowly  resolving  and  the  pulse  and 
respirations  gradually  becoming  normal. 

Case  VI. — ^J.  K.,  a  man,  thirty-two  vears  of  age.  Com- 
plained for  the  past  few  days  of  pain  in  the  chest  and 
limbs ;  malaise ;  cough  with  pain  in  the  side ;  feverish  and 
chill.v.  Temperature  103°  F. ;  pulse  120;  respirations  30 
Subcrepitant  rales  at  the  end  of  inspiration  in  the  right 
chest  behind  over  an  area  the  size  of  a  50  cent  piece  No 
bronchial  breathing.  Patient  was  given  the  usual  cough 
medicine  and  4  grains  of  quinine  three  times  a  day,  also 
10  grains  of  Dover's  powder;  mustard;  to  the  chest  and 
an  extra  undershirt  put  on. 

Next  day  pulse  120;  temperature  103.5°  F. ;  respirations 
30.    I^elt  weaker.    Chest  now  showed  bronchial  breathing 


ii88 


KEOWN:  QUININE  IN  PNEUMONIA. 


[Kew  York 

MeMCAI.  JO'UR■^fAL. 


over  the  area  where  subcrepitant  rales  were  heard.  Quinine 
increased  to  4  grains  every  5  hours. 

Next  dav  temperature  101.3^  F. ;  pulse  84;  respirations 
26.  Condition  of  the  lung  about  the  same,  still  shovving 
bronchial  breathing  and  increased  transmission  of  voice 
sounds.  This  patient  slowly  continued  to  improve  with 
iallLng  pulse  and  temperature,  consolidation  lasting  about 
tweJve  days  and  then  disappearing. 

Case  VII.— R.  F.,  child,  two  years  of  age.  Measles  two 
months  ago  from  which  the  child  had  not  entirely  recov- 
ered. For  last  three  days  seemed  very  distressed  with  a 
pitiful  catch  in  the  respiration.  Child  was  weak  with  fre- 
>quent  and  distressing  cough.  Skin  hot  and  dry,  throat 
negative;  temperature  by  the  groin  104°  F. ;  pulse  140; 
jespirations  50.  The  patient  presented  a  small  patch  of 
consolidation  in  the  side  of  the  left  chest  anteriorly  below 
tthe  a.xilla  with  bronchial  breathing  and  increased  transmis- 
sion of  voice  sounds.  Patient  was  given  a  diluted  cough 
mixtiure  and  i  grain  of  quinine  with  4  minims  of  tincture 
of  nu.x  vomica  every  five  hours. 

Next  day  the  patient  seemed  somewhat  better ;  pulse  and 
•temperature  and  respirations  were  lower ;  condition  in  the 
chest  about  the  same.  Two  days  later  temperature  normal, 
respirations  32;  pulse  no;  chest  about  the  same.  Patient 
■continued  to  improve  slowly.  Pulse  and  respirations  came 
down  and  consolidation  had  entirely  disappeared  in  eight 
■tlays  from  the  beginning  of  the  treatment. 

Case  VIII. — B.  M.,  boy,  twelve  years  of  age;  ill  for  three 
■days  with  severe  cough  ;  some  pain  in  the  chest,  very  fever- 
ish with  considerable  dyspnoea.  Chest  was  full  of  sonorous 
and  moist  rales.  In  the  apex  of  the  lung  was  an  area  of 
consolidation.  Temperature  104°  F. ;  pulse  130 ;  respira- 
tions 32.  This  boy  was  given  the  usual  cough  mixture  but 
in  addition  some  potassium  iodide,  with  a  little  chloroform. 
He  was  also  given  2  grains  of  quinine  three  times  a  day. 
The  patient  continued  to  improve  daily,  and  six  days  after 
the  onset  of  the  disease  he  was  nearly  well,  temperature 
and  pulse  normal,  and  breathing  free  and  easy.  The  con- 
solidation took  some  days  more  to  clear  up. 

Case  IX. — G.  L.,  boy,  eight  months  old  ;  had  had  cough  for 
two  weeks,  slowly  getting  worse ;  much  worse  during  the 
last  twenty-four  hours.  Child  seemed  much  distressed  in 
breathing,  and  was  quite  flushed.  Pulse  120,  temperature 
103°  F.  in  the  axilla,  respirations  34.  Harsh  bronchial 
breathing  was  heard  in  the  right  apex  behind.  This  patient 
was  given  diluted  cough  mixture  and  quinine,  i  grain  every 
six  hours.  This  patient  continued  to  grow  better  each  day, 
temperature  and  pulse  falling  to  normal  in  three  or  four 
days,  and  the  harsh  breathing  disappearing  about  the  same 
time. 

Case  X. — G.  P.,  age  three  years.  The  child  had  had  a 
cold  for  three  days  with  cough  and  fever.  Appetite  poor. 
Pulse  144;  temperature  103°  F. ;  respirations  32.  Rough- 
ened breathing  heard  in  the  left  lung  behind  over  a  small 
area.  Some  rales  throughout  the  lung.  This  patient  was 
given  the  diluted  cough  mixture  and  quinine,  i  grain  every 
four  hours.  He  continued  to  improve  daily  and  in  six  days 
had  apparently  entirely  recovered. 

Case  XI.— L.  N.,  six  months  of  age.  This  patient  had 
been  sick  for  about  one  week  and  w  as  growing  worse ;  dur- 
ing the  last  twenty-four  hours  he  was  much  worse,  fever- 
ish with  severe  cough;  no  appetite:  pulse  very  rapid,  respi- 
rations 38,  temperature  102°  F.  Moist  rales  could  be  heard 
throughout  the  lungs,  with  harsh  breathing  in  right  apex 
behind.  This  patient  was  given  diluted  cough  mixture  and 
quinine,  I  graiii  every  five  hours.  He  continued  to  improve 
steadily  and  in  five  days  seemed  to  have  entirely  recov- 
ered. 

Case  XII. — H.  R.,  age  one  year.  The  child  had  been 
ill  for  some  days,  with  hoarseness  and  rapid  breathing; 
had  whooping  cough  when  seven  months  of  age. 
Skin  felt  warm ;  pulse  130.  temperature  103°  F. ;  had 
consolidation  of  top  of  the  left  lung.  He  was  given  quinine 
mixture  containing  i  grain  of  quinine,  every  five  hours  and 
also  dilutcfl  cough  mixture.  Next  day  temperature  became 
nearly  normal,  pulse  no;  child  felt  much  better  and  he 
continued  to  improve,  and  at  the  end  of  six  days  had  ap- 
parently c'-tircly  recovered. 

Case  XIII.— B.  C,  age  six  years;  ill  for  three  days  with 
cough,  sore  throat,  chills  and  fever;  pain  and  tenderness 
in  the  abdomen ;  headache,  no  appetite,  tongue  coated. 
Temperature  101.5"  F.,  pulse  120.  Examination  of  chest 
negative  except  for  a  few  moist  rales. 


Tonsils  contained  some  membrane  in  crypts;  throat  red- 
dened and  slightly  swollen.  Patient  was  given  quinine,  i 
grain  every  six  hours.  A  gargle  of  hydrogen  peroxide  and 
a  cough  mixture  containing  sodium  salicylate  was  given  to 
him.  Next  day  patient  was  no  better.  Condition  about  the 
same,  except  temperature  a  little  higher;  the  child  was  very 
warm  and  very  restless.  Next  day  pulse  120;  temperature 
104"  F. ;  clear  signs  of  consolidation  in  left  lung  behind. 
Treatment  continued  except  that  the  quinine  was  increased 
to  2  grains  every  five  hours.  Next  day  patient  felt  better. 
Pulse  108 ;  temperature  100°  F. ;  condition  about  the  same. 
Qiest  seemed  to  be  slightly  freer.  This  patient  continued 
to  improve  steadily,  and  at  the  end  of  five  days  had  entirely 
recovered. 

Case  XIV. — B.  F.,  seven  years  of  age.  A  few  days  ago 
this  patient  was  struck  on  the  head  by  a  baseball  and  also 
fell,  striking  his  left  chest.  He  now  complained  of  bad 
cold,  with  pain  in  chest.  Cough  was  severe  and  painful. 
Temperature  high,  pulse  130.  Chest  contained  moist  rales. 
He  had  been  in  bed  for  twenty-four  hours.  No  broken 
ribs  could  be  found;  head  presented  no  lesion.  Next  day 
patient  complained  of  considerable  headache,  pain  in  the 
cardiac  region ;  cough  .about  the  same  but  slightly  looser. 
Temperature  104°  F. ;  abdomen  quite  rigid,  pulse  144.  A 
small  pleuritic  rub  was  heard  in  the  left  chest  behind.  The 
examination  of  the  heart  was  negative.  Next  day  patient 
had  a  temperature  of  103°  F.,  pulse  132.  He  showed  clear, 
bronchial  breathing  throughout  the  middle  of  the  left  lung, 
front  and  back.  This  patient  was  put  on  diluted  cough 
mixture  and  quinine  4  grains  three  times  a  day.  Next  day 
pulse  was  118;  temperature  101°  F. ;  his  condition  was 
about  the  same.  The  treatment  was  continued  on  this  pa- 
tient and  the  symptoms  gradually  subsided,  temperature 
and  pulse  falling  to  normal,  and  the  consolidation  slowly 
clearing  so  that  at  the  end  of  six  days  patient  seemed  to  be 
quite  well. 

Case  XV. — A.  N.,  woman,  age  seventy,  married.  This 
patient  had  been  complaining  of  cough  the  last  few  days; 
she  felt  very  tired,  chilly,  and  had  some  fever.  Tempera- 
ture of  103°  F. ;  pulse  120;  respirations  30;  urine  contained 
a  trace  of  albumin.  She  had  a  systolic  murmur  at  the 
apex;  pulse  was  weak;  moist  rales  heard  throughout  the 
chest,  and  bronchial  breathings  heard  in  the  right  chest 
behind,  just  below  the  scapula  over  an  area  of  the  size  of  a 
silver  dollar.  Patient  was  given  4  grains  of  quinine  three 
times  a  day  with  the  usual  cough  mixture.  She  was  also 
given  a  mixture  of  infusion  of  digitalis  and  potassium 
acetate,  and  1/30  grain  of  strychnine  three  times  a  day. 
Next  day  patient  felt  somewhat  better.  Temperature  and 
pulse  were  lower.  This  patient  continued  to  improve  stead- 
ily up  to  the  fourth  or  fifth  day,  pulse  and  temperature 
slowly  reaching  normal  and  the  consolidation  standing 
practically  the  same.  Contrary  to  strict  orders,  this  pa- 
tient, feeling  so  much  better,  got  up  and  did  some  of  her 
housework,  even  venturing  out  into  the  back  yard  during 
the  cold  winter  weather.  I  was  called  two  days  later  and 
I  found  the  patient  somewhat  feverish ;  pulse  130,  tempera- 
ture 103°  F.,  respirations  28.  Owing  to  her  age  and  the 
condition  of  her  heart  and  kidneys  and  that  the  pneumonia 
seemed  to  have  relapsed,  I  was  a  little  afraid  to  continue 
the  quinine.  I  did  net  g:i\e  quinine  at  this  time  but  cough 
mixture,  strychnine,  digitalis,  and  potassium  acetate  with 
brandy.  This  patient  steadily  grew  worse  despite  of  this 
treatment.  The  pneumonic  consolidation  steadily  spread, 
the  dyspnoea  increased,  the  pulse  failed,  the  respiration 
grew  more  rapid,  and  the  patient  died. 

COMMENT  ON  CASES. 

In  Cases  I  and  II  are  presented  a  condition 
familiar  to  nearly  all  medical  men,  presenting  the 
preliminary  symptoms  of  pneumonia,  and  yet  under 
various  kinds  of  treatment,  to  suddenly  get  well, 
presenting  the  conditions  seen  in  various  diseases 
where  the  disease  seems  to  suddenly  abort.  In 
these  cases  I  cannot  assert  that  quinine  was  the 
cure,  but  certainly  the  patients  made  remarkable  re- 
coveries in  these  two  cases.  It  may  be  remarked 
that  all  these  patients  would  have  got  well  just  as 
readily  without  quinine  as  with.  That  may  be  so, 
but  at  all  events  the  consolidation  certainly  did  not 


June  12,  1909.] 


ERDMAXX:  URETERAL  CALCULI. 


increase  except  in  Case  III  where  only  one  half  of 
the  dose  of  quinine  was  given.  When  the  dose  was 
increased,  the  consolidation  seemed  to  stand  still 
or  at  least  did  not  increase  very  much  from  that 
time  on. 

'Sly  experience  with  quinine  leads  me  to  the  be- 
lief that  if  sufificient  quinine  is  given  the  consolida- 
tion can  either  be  prevented  from  coming  at  all  or 
arrested  where  you  commence  to  give  the  quinine  in 
sufificient  doses.  At  first  this  seemed  to  me  an  un- 
wise interference  with  the  natural  pathological  pro- 
cess of  the  disease,  but  continued  experience  with 
the  use  of  quinine  has  led  me  to  believe  that  this  can 
bring  only  good  results. 

In  addition  to  this  effect  of  the  drug,  quinine  in 
the  blood  is  considered  to  be  an  antiseptic.  It  is 
supposed  to  limit  metabolism  which  is  a  good  thing 
in  pneumonia  and  it  is  a  good  reducer  of  the  tem- 
perature. It  also  acts  as  a  tonic,  and  stomachic. 
Quinine  does  not  seem  to  shorten  the  course  of  a 
case  of  pneumonia  but  certainly  does  limit  the 
amount  of  consolidation,  and  converts  the  disease 
from  a  dangerovis  and  painful  one  into  one  of  mild 
severity  and  practically  no  danger.  Large  doses  of 
quinine  are  not  necessary,  but  sufificient  quinine 
should  be  given  to  control  the  process  of  consoli- 
dation, which  can  be  ascertained  by  careful  exam- 
ination of  the  chest  by  auscultation  and  percussion, 
and  it  is  also  indicated  by  the  temperature,  quinine 
reducing  the  temperature  acting  as  an  antipyritic. 
When  sufificient  quinine  has  been  given  the  tem- 
perature is  normal  or  nearly  so. 

Case  XIV  appears  to  be  an  exception,  but  in  this 
case  quinine  was  omitted  after  the  patient  had  had 
a  relapse  through  exposure. 

All  these  patients  were  put  to  bed  in  a  warm  room 
with  good  ventilation  ;  they  were  given  liquid  diet 
with  some  soft  solids  in  small  amounts  frequently 
repeated. 

I  have  been  exceedingly  interested  in  the  use  of 
quinine  in  pneumonia.  I  would  be  very  much 
obliged,  indeed,  if  some  of  my  medical  colleagues 
who  have  had  experience  with  this  drug  in  pneu- 
monia or  expect  to  have  experience  in  the  future 
would  write  me  the  results  of  their  experience. 


URETERAL  CALCULI: 

With  a  Consideration  of  the  Operative  Technique  below 
the  Pelvic  Brim.* 

By  Johx  F.  Erdmann,  M.  D., 
New  York, 

Professor  of  Surgery,  Postgraduate  Medical  School  and  Hospital. 

At  a  stated  meetinp-  of  the  Surgical  Society  of 
New  York,  held  April  12,  1905,  I  reported  two 
cases  of  removal  of  ureteral  calculi  by  the  com- 
bined transperitoneal  and  retroperitoneal  method 
from  that  portion  of  the  ureter  below  the  pelvic 
brim,  and  which  I  shall  throughout  this  paper  des- 
ignate as  the  pelvic  ureter.  At  that  time  I  reported 
one  case  by  this  method  as  being  operated  on  in 
March,  1905.    I  find  upon  searching  my  records 

*Rcad  before  the  Alumni  Association  of  Bellevue  Hospital,  at  a 
meeting  held  on  February  3,  1909,  and  before  the  Pittsburgh  Col- 
lege of  Physicians,  on  February  25,  1909. 


that  my  hrst  operation  was  done  on  November  26, 
1904,  and  is  the  second  case  reported  at  that  meet- 
ing. Since  that  time  I  have  removed  a  stone  by  this 
same  method  from  the  vesical  (mural)  portion  by 
incising  the  bladder  above  the  ureteral  entrance, 
and  then  cutting  down  upon  the  calculus  from  the 
mucous  surface  of  the  bladder.  The  ease  in  fiinding 
the  stone  and  controlling  it,  with  the  small  area  of 
transperitoneal  dissection,  and  the  subsequent  fa- 
cility of  delivering  the  stone,  led  me  to  adopt  this 
method.  I  have  reported  several  of  these  cases, 
and  briefly  touched  upon  the  technique  of  the  pro- 
cedure in  a  paper  read  before  the  Yonkers  Practi- 
tioners' Club,  December  8.  1907.  and  the  Physicians' 
Club  of  Xew  York.  January  29,  1908.  published  in 
the  Medical  Record,  Renal  and  Ureteral  Calculi 
Complicating"  or  Simulating  Appendicitis,  under 
date  of  ]\  larch  14.  1908.  i\Iore  recently.  February  5, 
1908,  Dr.  John  H.  Gibbon,  of  Philadelphia,  read  an 
exhaustive  paper  before  the  SuiTolk  District  Medi- 
cal Society,  etc.,  which  is  published  in  Surgery, 
Gyncccolo^iy.  and  Obstetrics,  vi.  1908.  pp.  482  et 
seq.,  in  which  he  states  on  page  400:  "At  the  time 
I  performed  my  first  operation,  which  was  on  Aug- 
'.ist  8.  1905.  I  did  not  know  of  any  operator  having 
previously  followed  this  plan,  t  have  since  dis- 
covered, however,  that  Erdmann  (Ref.  25  in  his 
article)  on  March  11,  1905,  accidentally  opened  the 
peritonf-eum  in  doing  an  extraperitoneal  iliac  opera- 
tion, and  then  intentionally  enlarged  the  opening, 
confirmed  the  diagnosis,  removed  the  appendix  and 
then  the  stone,  just  as  was  done  in  my  first  two 
cases."  As  stated  above,  through  the  date  not  hav- 
ing been  recorded  in  the  second  reported  case  of 
mine,  although  I  am  quoted  as  saying  "six  months 
before  this  meeting,"  April  12,  1905,  which  would 
have  made  the  first  operation  by  me  November  26, 
1904.  I  operated  upon  the  second  patient  shown, 
he  records  the  1905  case  as  my  first.  Nevertheless, 
no  claim  is  made  by  me  for  priority  in  this  method 
of  removing  calculi  from  the  pelvic  ureter. 

That  portion  of  the  ureter  extending  from  the 
kidney  to  the  pelvic  brim  will  receive  no  considera- 
tion in  this  paper,  as  the  methods  of  approach  are 
simple  and  well  considered  in  modern  textbooks. 

Although  it  is  authoritatively  stated  that  calculi 
are  very  apt  to  meet  with  obstruction  near  or  at 
the  brim,  the  major  portion  of  my  cases  have  been 
located  at  or  near  the  spine  of  the  ischium,  just 
outside  of  the  bladder,  or  in  the  mural  portion  of 
the  ureter  in  the  bladder.  Germane  to  this.  Gibbon, 
page  490,  in  the  article  quoted  before,  states  that 
"Recent  x  ray  reports,  however,  tend  rather  to 
show  that  the  portion  of  the  ureter  between  the 
pelvic  brim  and  the  vesical  portion,  measuring 
about  four  inches,  is  a  very  common  site  for  ure- 
teral calculi."  I  have  been  struck  with  the  dififi- 
culties  in  some  small  stones  passing,  and  again  with 
the  facility  with  which  large  ones  pass,  and  with 
the  fact  that  those  that  pass  are  decidedly  more 
spherical  in  shape,  while  those  that  obstruct,  or 
rather  do  not  pass,  are  oblong  and  usually  covered 
with  sharp  spicules. 

I  am  guided  in  suggesting  operative  procedures 
by  the  duration  of  the  pain  or  recurrence  of  at- 
tacks, the  size  of  the  stone  as  shown  by  the  x  ray, 
whether  it  appears  rough,  etc..  and  .by  evidences  of 


iigo 


ERDMANN:  URETERAL  CALCULI. 


INew  York 
Medical  Journal. 


obstruction,  infection,  etc.  That  an  impacted  stone 
does  not  necessarily  mean  obstruction  we  can  read- 
ily understand,  especially  with  the  rough  and  irreg- 
ularly formed  stones,  urine  being  able  to  escape  by 
the  gaps  formed  by  these  very  spicules  and  irreg- 
ularities, and  that  obstruction  is  not  of  necessity  due 


URETERS 

/  \ 


ABDOMINM 
INCISION 

\ 


LINE  OP 

C/ROSSl  SECTION 


\  f  / 

i'lc.   :. — Showing  line  of  incision,  peritoneum,  stone,  etc. 

to  a  large  stone  can  readily  be  seen  by  referring 
to  the  specimens  and  photographs.  No  obstruction 
was  present  with  any  of  the  large  stones,  but  M^as 
present  in  Cases  lY  and  Y.  In  both  of  these  a 
rupture  had  taken  place  in  the  ureter  above  the 
brim  of  the  pelvis,  the  stone  in  Case  IV  being 
in  the  pelvic  ureteral "  type,  and  the  other  in  the 
lumbar  ureteral  type.  The  latter  case  (V)  was  also 
accompanied  by  an  apparent  complete  anuria,  as  no 
urine  was  passed  or  draw-n  by  catheter  for  over 
three  days,  although  quite  a  marked  infiltration  had 
taken  place  in  the  left  loin,  etc. 

It  must  not  be  forgotten  that  an  obstruction  or  in- 
complete obstruction  is  followed  bv  changes  in  the 
kidney,  such  as  atrophy,  hydronephrosis,  or  pyone- 
phrosis, etc. 

Symptoms. — Careful  histories  of  our  cases  should 
give  us  evidences  relatively  important  in  the  order 
here  given,  pain  of  lumbar  and  abdominal  varieties, 
testicular,  vesicular,  and  penile ;  tenesmus  and  fre- 
quency of  desire  to  urinate.  These  being  present, 
a  careful  urinary  analysis,  the  x  ray,  and  occasional 
search  hy  the  cystoscope  and  ureteral  investigations 
are  in  order. 

Pain. — The  care  necessary  to  distinguish  ure- 
teral calculi  in  right  sided  cases  from  appendicitis, 
etc..  and  in  either  sided  cases  from  embolic  in- 
farcts, can  be  appreciated  by  the  numerous  cases 
cited  lately  of  both  of  these  conditions  being  mis- 
taken for  calculi,  (see  my  article  on  Renal  and 
Ureteral  Calculi  Complicating  or  Simulating  Ap- 
pendicitis, Medical  Record,  March  14.  1908.) 

Pain  in  the  back.  loin,  groin,  inner  surface  of  the 
thigh,  urethra,  testes,  and  penis  in  the  male,  and 
vulva  and  urethra  in  the  female,  with  occasional 
frequency  of  urination,  definitely  point  to  a  possible 
renal  calculus. 

Finally   for  the  exclusion  of  appendicitis,  or  for 


the  dual  diagnosis  of  appendicitis  and  stone,  the 
urine  and  its  channels  must  be  carefully  examined. 
The  microscopical  evidences  in  urine  analyses  that 
weigh  in  the  diagnosis  of  possible  stone  are  the 
presence  of  blood,  crystals  of  oxalates  and  urates 
in  excess,  and  epithelial  elements  from  the  hilum 
and  ureters. 

Blood  may  be  present  in  the  urine  in  cases  of 
appendicitis  due  either  to  a  toxaemic  nephritis 
(acute)  or  to  some  associated  condition,  such  as 
acute  nontoxic  and  chronic  nephritis  or  floating  kid- 
ney, embolic  infarcts,  etc.  Blood  without  other  renal 
elements,  and  in  the  absence  of  other  pathological 
lesions  of  the  bladder,  urethra,  etc.,  is  the  best  diag- 
nostic sign  of  stone  we  have,  barring  the  evi- 
dences of  a  definite  shadow  in  a  radiograph  or 
the  scratch  marks,  made  by  contact  wdth  the  stone, 
found  upon  a  waxed  ureteral  catheter  or  probe 
that  has  been  introduced  into  the  ureter. 

Blood  in  the  urine  obtained  by  catheterism  or 
after  ureteral  catheterism  should  be  given  the 
weight  of  evidence  of  trauma  rather  than  that  of 
calculus,  although  no  trauma  may  have  occurred  bv 
either  of  these  methods. 

X  Ray. — No  better  diagnostic  means  is  at  our 
disposal  than  the  use  of  the  x  ray,  as  in  practically 
all  cases  the  shadow  of  the  calculus  is  seen  if  the 
patient  has  been  submitted  to  an  expert  radi- 


/=>£/9/  TONAcUM 


-Sliowiiii;  HI 


i-Kr  and  extraiicritoiical  iiosition  of  lingers  in 
relation  to"  tUe  stone. 


ographer.  Failures  in  radiography  are  due  to  the 
subject  being  old  and  feeble  and  suffering  from 
calcareous  degeneration.  Failure  is  also  likely  in 
too  fat  subjects,  and  some  few  cases  of  uric  acid 
or  urate  stones,  although  according  to  Dr.  Cald- 
well these  latter  varieties,  i.  e.,  the  uric  acid  and 
urate  stones,  are  usually  depicted  on  the  plates  in 
the  lean  or  moderately  well  developed  patients.  In 


June  12,  1909.] 


ERDMAXK:  URETERAL  CALCULI. 


the  cases  where  the  symptoms  point  almost  defi- 
nitely to  the  presence  of  a  calculus,  and  no  shadow 
is  seen  upon  the  plate,  it  is  necessary  to  examine 
the  urinary  channels.  Cystoscopy  is  useful  in  ob- 
taining a  picture  of  the  ureteral  orifices,  and  the 
introduction  of  the  waxed  catheter  or  bougie  into 
the  ureters  to  obtam  contact  evidences  as  shown  by 
scratches  on  the  waxed  tips. 

Recently  I  had  an  x  ray  picture  taken  in  a  case 
presenting  some  of  the  clinical  earmarks  of  stone 
in  which  a  shadow  presented  resembling  a  stone, 
but  more  toward  the  iliac  spine  than  usual,  that 
proved  upon  operation  to  be  an  appendicular  con- 
cretion, and  upon  reviewing  Gibbon's  article,  I  find 
that  on  oage  495  he  mentions  a  case  of  his  own  and 
one  of  Brewer's  in  which  appendoliths  were  shad- 
owed upon  tlie  X  ray  plates. 

Shadov.-s  of  phleboiiths  as  a  source  of  error  must 


dent,  are  conclusive,  yet  this  proof  is  obtained  only 
bv  the  greatest  delicacy  in  construction,  as  a  very 
slight  roughness  to  the  outlet  of  the  cystoscope 
might  produce  the  very  signs  that  would  be  verj' 
disappointing  and  misleading. 

Operative  Consideration. — -The  operative  pro- 
cedures advocated  in  this  situation  consist  of  the 
transperitoneal,  retroperitoneal,  rectal,  vaginal, 
perineal,  and  suprapubic  for  those  stones  situated 
in  the  vesical  mural  portion  when  it  is  impossible 
to  extract  the  stone  by  properly  devised  cystoscopic 
and  urethral  instruments. 

The  transperitoneal  operation  has  been  super- 
seded, by  the  simplicity  and  the  removal  of  danger 
of  infection  of  the  peritoneal  cavity,  by  the  retro- 
peritoneal, or  this  latter  combined  with  the  trans- 
peritoneal and  retroperitoneal  method. 

The  rectal  and  perineal  operations  are  so  fraught 


"9 


0.. 


I 


r' 


€ 


/  o 


00 


i 
i 

1 


c.  /.  g. 

Fig.  3. — a.  First  operative  case  by  the  combined  method,  reported  as  second  case  in  Annals  of  Surgery,  xlii;  b,  second  operative  case 
by  the  combined  method,  reported  as  first  case  in  .4nnah  of  Surgery,  xlii;  c,  stone  from  mural  portion  of  bladder  by  combined 
method;  d,  e,  f,  g,  from  lumbar  ureter  and  hilum  of  kidney. 


also  be  taken  into  consideration,  but  the  shape,  size, 
and  position  are  usually  such  as  to  prevent  an  ex- 
pert radiographer  or  an  expert  reader  of  x  ray 
plates  from  falling  into  error. 

Toe  much  time  between  the  taking  of  an  x  ray 
plate  and  an  operation  cannot  be  allowed,  unless  by 
successive  plates  it  is  observed  that  no  progress 
has  been  made  in  the  advancement  of  the  stone. 
Once  the  plate  is  taken  and  the  operation  decided 
upon,  no  time  should  be  lost,  as  the  stone  may 
move  sufficiently  to  be  the  cause  of  great  difficulty 
in  finding  it,  particularly  if  a  retroperitoneal  opera- 
tion is  done,  whereas,  if  the  combined,  or  that  ad- 
vocated here,  is  done,  time  does  not  matter  so  much, 
as  the  palpating  fingers  can  readily  locate  the  stone. 

Cystoscopy. — In  stone  in  the  ureter  the  cysto- 
scope usually  shows  a  definite  and  diagnostic 
change  in  the  mouth  of  the  ureter  upon  the  affected 
side,  characterized  by  redness  and  eversion  or 
thickening.  Should  the  stone  be  in  the  ureteral 
orifice  it  may  be  seen  as  a  dark  object  in  or  pro- 
truding from  the  ureteral  opening,  ^^'hile  by  the 
aid  of  the  catheter  cystoscope  with  waxed  bougie  or 
catheter,  the  scratch  marks  of  the  stone,  when  evi- 


with  dangers  of  sepsis  and  ascending  ureteral  in- 
fections, added  to  the  operative  difficulty  in  the 
latter,  as  to  relegate  these  operations  also  to  the 
obsolete. 

The  vaginal,  in  certain  low  placed  and  vaginally 
palpable  calculi,  has  its  advantages  of  extreme  sim- 
plicity, but  its  disadvantages  of  likelihood  of  being 
followed  by  a  slow  healing  or  permanent  uretero- 
vaginal  fistula. 

The  suprapubic  route  for  stones  impacted  in  the 
mural  portion  is  both  rapid  and  safe :  but  if  when 
operating  by  the  combined  transperitoneal  and 
retroperitoneal  method  one  finds  the  stone  impacted 
in  the  bladder  wall,  and  the  cystoscope  and  its  aids 
are  not  successful  in  the  extraction,  then,  as  done 
once  very  successfully  by  me.  one  can  cut  the  blad- 
der wall  just  above  the  ureteral  entrance  in  the  re- 
troperitoneal dissection,  and  then  cut  through  the 
mucous  membrane  of  the  bladder  and  the  mural 
portion  of  the  ureter,  extract  the  stone,  and  sew  up 
the  bladder  injury,  draining  posteriorly  and  by  the 
urethra  with  a  permanent  catheter  for  a  few  davs, 
thus  obviating  the  making  of  two  distinct  wounds 
of  abdominal  entrv. 


1192 


ERDMAXN:  URETERAL  CALCULI. 


[New  York 
Medical  Journal. 


The  combined  transperitoneal  and  retroperitoneal 
operation:  This  operation  is  done  through  an  in- 
cision like  that  of  Kammerer  or  Deaver  for  ap- 
pendicitis, the  peritonaeum  being  incised  sufficiently 
to  admit  one  or  two  fingers  to  palpate  the  ureter. 
The  ureter  is  located,  and  then  rapidly  followed 
in  its  course  until  the  object  of  the  search  is  found. 
The  outer  flap  of  the  peritonaeum  is  then  rapidly 
dissected  away  from  its  contiguous  structures,  and 
in  a  ;ma!l  enough  well  to  expose  the  stone,  which  is 
held  or  raised  by  the  intraperitoneal  finger,  (see 
Figs.  I  and  2),  the  ureter  is  incised  longitudinally 
over  the  stone  just  long  enough  to  allow  of  the 
expulsion  of  the  calculus.  Ordinarily,  unless  one 
finds  a  very  large  calculus,  no  sutures  are  required 
in  the  closure  of  the  ureteral  incision.  A  wick  drain 
is  placed  down  to  the  ureteral  trauma,  the  peri- 
tonaeum closed,  and  a  final  closure  of  the  remainder 
of  the  abdominal  wound  to  the  emergence  of  the 
drain  is  made.  Several  patients  in  whom  this  no 
suture  of  the  ureter  method  has  been  followed  by 
me  had  practically  no  urine  leakage,  the  wound 
drain  being  removed  in  four  to  six  days. 

In  presenting  this  method  to  you  it  is  but  just 
that  the  objections  as  well  as  the  advantages  be 
considered.  Unnecessary  opening  of  the  peritoneal 
cavity  is  never  to  be  advocated  except  in  the  interest 
of  the  patient,  and  while  a  certain  element  of  danger 
attends  the  intraperitoneal  portion  of  this  pro- 
cedure, it  is  also  more  than  counterbalanced  by  the 
fact  that  we  knowingly  open  it,  and  therefore  take 
all  precautions  against  contamination,  whereas,  if  we 
accidentally  tear  through  the  peritoneal  cavity  while 
doing  a  retroperitoneal  operation,  such  care  is  not 
taken,  because  the  tear  may  be  in  such  a  position  as 
to  be  unobserv'cd,  etc. 

Should  the  urine  be  infected,  or  should  there  be 
an  obstructive  dilatation  above  the  calculus,  the  in- 
cision into  the  ureter  is  made  after  the  peritoneal 
opening  has  been  closed  and  properly  protected. 
The  slight  risk  run  in  exposing  the  peritoneal  cav- 
ity, I  believe,  is  more  than  overcome  by  the  cer- 
tainty of  locating  the  stone  rapidly,  the  nonnecessity 
of  making  a  large  and  tedious  retroperitoneal  dis- 
section, and  finally  the  control  of  the  calculus  site 
of  the  ureter  with  the  fingers,  obviating  the  use  of 
forceps,  which  will  tend  to  crush  or  injure  the  ureter 
to  such  an  extent  that  stricture  formation  is  more 
than  likely. 

The  following  are  the  reports  of  two  cases  pre- 
sented at  a  stated  meeting  of  the  Surgical  Society 
(Annals  of  Surgery,  xlii,  pp.  456  et  seq.)  : 

Case  I. — Dr.  Erdniann  presented  a  man,  twenty-nine  j  ears 
olfl,  who  first  came  under  his  observation  on  the  first  day  of 
March,  1905.  He  gave  a  history  of  having  had  a  pain  in  the 
right  side  for  three  or  four  years.  The  pain  was  pa- 
roxysmal in  character,  and  at  times  uncontrollable,  lih 
last  attack  had  occurred  about  five  weeks  before,  and  had 
necessitated  liis  going  to  bed  for  twenty-four  hours.  At  no 
time  had  he  been  bedridden  for  a  longer  period  than  this. 
Vomiting  sometimes  occurred  during  the  attacks,  and  he 
also  stated  that  they  had  been  accompanied  by  jaundice  "of 
the  face."  He  complained  of  pain  in  the  region  of  the  right 
kidney  and  extending  dmvn  toward  the  bladder,  .^t  the 
lime  of  voiding  urine  he  would  have  a  peculiar  pain  in  the 
bladder,  but  there  were  no  sym|)toms  pointing  to  the  genital 
organs.  He  was  constipated,  and  also  complained  of  pain 
in  ihe  region  of  the  appendix. 

F-xamination  of  the  abdomen  did  not  give  any  pronounced 
evidences  upon  palpation.  In  fact,  there  was  no  sensitive 
spot  on  pressure  anywhere  over  the  body.    A  tentative 


diagnosis  of  ureteral  stone  was  made.  The  patient  was  x 
rayed  by  Dr.  Caldwell,  and  the  plate  showed  a  large  shadow 
midway  between  the  spine  of  the  ischium  and  the  sacro- 
iliac synchondrosis,  in  the  region  of. the  right  ureter.  The 
shadow  was  seven  eighths  of  an  inch  long,  seven  sixteenthb 
of  gn  inch  wide  at  its  widest  point,  and  shaped  like  an 
olive  pit. 

Operation,  March  11,  1905.  An  incision  was  made  begin- 
ning at  the  inner  portion  of  the  right  rectus  muscle,  and 
extending  outward  with  a  very  slight  curve  to  and  above 
the  anterior  superior  spine  of  the  ilium.  The  peritonaeum 
was  accidentally  punctured,  and  feeling  that  no  harm  could 
be  done  by  making  a  transperitoneal  examination,  and  that 
thereby  the  operation  could  be  more  rapidly  terminated,  the 
opening  in  the  peritonaeum  was  enlarged.  Through  this 
opening  the  stone  was  readily  palpated.  Before  dissecting 
back  the  peritonaeum  for  a  retroperitoneal  operation,  the 
appendix,  which  was  found  to  be  adiierent  and  sclerosed, 
and  showed  evidence  of  earlier  disease,  was  removed.  The 
peritonaeum  was  then  dissected  up  and  the  ureter  exposed. 
By  keeping  two  fingers  within  the  peritoneal  cavity.  Dr. 
Erdmann  said  he  was  able  to  Uold  the  stone  in  such  a  posi- 
tion that  incision  of  the  ureter  retroperitoneally  was  readily 
accomplished.  The  stone  was  extruded  through  a  longi- 
tudhial  incision  which  was  closed  with  silk  sutures,  the 
peritoneal  wound  was  closed,  and  a  cigarette  drain  was 
placed  behind  the  peritonaeum  down  to  the  site  of  the  ure- 
teral wound.  The  abdominal  wound  was  closed,  with  the 
e-Kception  of  the  site  of  the  retroperitoneal  drain.  The  pa- 
tient made  a  perfect  recovery,  and  left  the  hospital  on  the 
fourteenth  day.  The  urine,  which  was  bloody  on  the  first 
and  second  days,  cleared  up  on  the  third.  The  patient  had 
not  complained  of  any  of  his  former  urinary  difficulty  since 
the  operation. 

Case  H. — Dr.  Erdmanfi  presented,  also,  a  man,  twenty-three 
years  old,  who  came  to  him  November  26, 1904,  and  who  stated 
that  six  months  ago  he  had  a  pain  in  his  abdomen  e.xtend- 
ing  well  into  the  back.  He  had  had  several  attacks  of  pain 
resembling  that  of  appendicitis,  necessitating  his  remaining 
in  bed  anywhere  from  one  to  four  da}''  at  a  time.  Three 
days  ago  he  had  an  attack  which  was  .sliered  in  by  vomit- 
ing and  pain  in  the  abdomen.  He  also  complained  of  pain 
in  the  right  side  of  his  back.  This  last  attack  kept  him  in 
bed  for  two  days.  He  had  suflfered  continuous  pain  from 
twelve  at  night  to  early  morning  of  the  following  day.  He 
also  had  attacks  of  pain  that  would  manifest  themselves  in 
the  glans  penis,  but  not  in  the  testes. 

Upon  examination,  the  abdomen  was  found  to  be  ex- 
tremely sensitive  in  the  high  at)pendical  region,  and  there 
was  also  pain  by  bimanual  examination  over  the  right 
kidney.  The  patient  was  x  rayed  twice,  four  plates  being 
taken.  In  one  of  these,  a  small  shadow  located  at  a  point 
opposite  the  ischial  spine  in  the  pelvis  was  taken  for  a 
stone  in  the  ureter,  but  the  physical  signs  and  the  urine 
analysis  tended  to  negative  that  diagnosis.  An  incision 
similar  to  that  employed  in  the  preceding  case  was  made. 
The  skin  was  retracted  in  the  course  of  the  rectus,  and 
the  anterior  layer  of  the  sheath  of  the  rectus  was  cut  in 
the  line  of  the  skin  incision,  so  that  a  separation  of  the 
muscle  fibres  of  the  abdominal  wall  could  be  produced. 
The  peritonaeum  and  deep  fascia  were  cut  in  the  axis  of 
the  rectus.  Exploration  revealed  a  hard  nodule,  like  a 
gland,  within  an  inch  of  the  bladder  wall.  The  appendix 
was  congested  and  bound  by  numerous  adhesions.  The 
pelvic  peritonaeum  was  loosened  from  the  deeoer  structures 
and  the  ureter  exposed.  It  was  then  seen  that  the  small, 
hard  body  was  a  calculus  of  the  ureter,  within  an  inch  of 
its  bladder  orifice.  The  ureter  was  incised  in  its  long  axis 
and  the  stone  extruded.  The  ureteral  opening  was  then 
closed  v/ith  silk,  the  periton.-eum  dropped  .back,  the  appen- 
dix removed,  and  the  peritoneal  w-ound  closed  after  the 
kidney  had  been  palpated,  with  negative  results.  A  drain 
was  then  put  down  to  the  incision  in  the  ureter,  and  the 
external  wound  completely  closed,  with  the  exception  of 
the  point  of  the  drain.  The  operation  occupied  about  forty 
minutes.  The  stone  was  seven  sixteenths  of  an  inch  long, 
five  sixteenths  of  an  inch  at  its  widest  point,  and  three 
sixteenths  of  an  inch  thick.  It  was  of  an  irregular  mul- 
berry shape. 

Case  III. — Retroperitoneal  cystotomy  and  ureterotomy; 
stone  forced  into  the  vesical  mural  portion  of  the  ureter : — 

G.  R.,  forty-tw-o  years  old,  was  sent  to  me  on  June  12, 
ro07,  by  Dr.  Kean,  of  Bridgeport.  Fourteen  years  before 
consulting  me  he  had  a  severe  pain  in  the  right  side,  ex- 


June  12,  1909.] 


TURCK:  HYSTEROSALPINGOSTOMY. 


tending  to  the  groin  and  right  testicle.  Three  years  ago 
he  had  another  attack,  very  similar.  At  this  time  blood 
was  discovered  in  the  urine  as  late  as  forty-eight  hours 
after  the  pain  had  ceased.  Some  "gravel"  had  also  been 
seen  in  the  urine.  At  this  time  he  says  he  had  stomach 
and  bowel  trouble,  consisting  of  nausea,  fullness,  etc.  Six 
weeks  ago  he  had  his  third  attack ;  no  bloody  urine,  no 
"gravel,"  and  had  been  bedridden  with  pain.  Pain  not  in- 
duced nor  accelerated  by  jolting  motion.  One  week  ago 
he  had  his  fourth  attack.  This  time  his  testicular  pain  was 
very  sharp.  The  urine  passed  two  and  a  half  hours  after 
the  pain  seemed  to  be  almost  pure  blood.  He  said  there 
was  great  pain  also  ar  this  time  in  the  left  side,  with  gen- 
eral abdominal  soreness  quite  well  marked.  The  following 
day  he  went  to  business,  and  returned  to  his  house  at 
6  p.  m.  The  urine  at  this  time  was  sandy,  contained  uric 
acid  and  some  hyaline  casts.  There  was  no  obstruction, 
and  no  calculus  expelled.  ^ 

Examination. — Painful  right  kidney,  and  appendical  re- 
gion very  sensitive.  Bladder  searching  was  negative  of  a 
calculus  or  growth  of  any  kind.  X  ray  plates  taken  by  Dr. 
Caldwell  showed  a  fair  sized  calculus  (see  No.  Ill,  Fig.  3), 
quite  rough,  and  just  below  the  spine  of  the  ischium.  A 
second  plate,  ten  or  twelve  days  later,  showed  the  stone  in 
practically  the  same  position. 

There  was  another  attack  before  he  submitted  to  opera- 
tion. This  was  done  July  15,  1907,  almost  five  weeks  after 
his  first  visit  to  me.  The  combined  operation  was  done, 
and  upon  exposing  the  peritoneal  cavity  the  appendix  was 
found  adherent,  with  other  evidences  of  previous  inflam- 
matory changes.  The  appendix  was  removed  and  the 
ureter  palpated.  The  stone  was  found  within  half  an  inch 
of  the  bladder,  and  was  forced  into  the  vesical  portion  of 
the  ureter.  Being  unable  to  force  it  into  the  bladder  I 
then  made  my  retroperitoneal  dissection,  being  surprised 
at  the  ease  with  which  the  peritonasum  was  dissected  from 
the  region  of  the  bladder.  The  bladder  wall  was  incised 
about  three  quarters  of  an  inch  above  the  ureteral  entrance, 
the  stone  being  readily  palpated  beneath  the  mucous  mem- 
brane of  the  bladder  through  this  incision.  This  area  of 
the  mucous  membrane  was  then  cut  down  upon  over  the 
stone,  and  the  stone  expelled.  As  there  was  no  necessity  for 
a  suture  in  this  incision,  the  posterior  cystotomy  was  closed 
with  two  rows  of  catgut,  a  cigarette  drain  placed  within  a 
short  distance  of  the  suture  area,  and  the  balance  of  the 
wound  closed.  After  closing  the  opening  in  the  peritoneal 
cavity  a  catheter  was  passed  and  tied  into  the  urethra  for 
four  days.  No  urine  leakage  took  place  from  the  posterior 
wound.  Voluntary  efforts  at  urination  were  made  in 
twenty-four  hours,  even  with  the  catheter  in  place.  Upon 
withdrawal  of  the  catheter  urination  was  under  control, 
but  I  deemed  it  advisable  to  catheterize  the  patient  for  five 
or  six  days,  so  as  to  obviate  extra  dangers  of  the  wound 
separating  or  tearing. 

There  was  an  absolute  repair,  with  a  discharge  of  the 
patient  within  three  week  and  a  half. 

Since  reading  this  paper,  I  have  removed  a 
large  stone  from  the  ureter  in  a  female  child,  seven 
years  old,  and  another  from  a  woman,  forty-three 
years  of  age. 

60  We.st  Fifty-.second  Street. 


HYSTEROSALPINGOSTOMY.* 

By  Raymond  Custer  Turck,  M.  D., 
Jacksonville,  Fla. 

In  reviewing  the  subject  of  conservative  surgery 
of  the  ovaries  and  Falloppian  tubes,  one  can  not  but 
be  struck  by  the  convincing  clarity  and  wisdom  of 
the  following  quotation  from  Hirst:  "It  is  often 
possible  to  leave  the  inner  third  of  one  or  both  tubes 
and  one  or  both  ovaries.  Even  if  only  the  inner 
third  of  one  tube  and  the  ovary  on  the  other  side 
remain,  the  woman  is  in  much  better  condition  than 
if  she  were  rendered  necessarily  sterile  by  double 
salpingooophorectomy.    She  is,  at  least,  sustained 

*Read  before  the  Florida  Medical  Association,  Pensacola,  April  8, 
1909. 


by  the  hope  of  maternity,  and  is  saved  from  the 
pitiable  melancholia  often  seen  in  the  woman  in- 
tensely desirous  of  offspring,  but  conscious  that  she 
is  doomed  to  a  childless  existence." 

That  many  thousands  of  ovaries,  tubes,  and  uteri 
have  been  sacrificed  and  that  thousands  of  young- 
women  have  been  needlessly  unsexed,  is,  in  the 
light  of  our  present  knowledge,  unquestioned.  Too 
much  praise  can  not  be  given  to  W.  M.  Polk, 
A.  Martin,  Howard  Kelly,  Hunter  Robb,  and  others 
for  their  invaluable  early  work  in  the  field  of  con- 
servatism, and  it  is  to  the  everlasting  credit  of  the 
profession  that  there  has  been  of  late  years  a  con- 
tinued and  generally  increasing  tendency  toward 
conservation  and  repair,  rather  than  to  a  continu- 
ance of  gynaecological  destructiveness. 

Enthusiasm  over  many  exceedingly  satisfactory 
end  results  of  conservative  gynaecological  surgery, 
has  perhaps  induced  operators  to  venture  too  far 
in  this  direction  in  many  instances.  Even  in  sub- 
acute gonorrhoea!  pyosalpinx  tubes  have  been 
opened,  irrigated,  drained,  and  left  in  situ,  good  re- 
sults being  given  in  a  fair  percentage  of  cases. 

In  acute  inflammations  of  the  uterus  and  annexa, 
the  writer  inclines  toward  the  view  that  conserv- 
atism should  be  along  the  line  of  local  treatment 
and  nonoperative  interference,  rather  than  in  any 
form  of  operative  technique.  Operation  in  the 
acute  stages  of  pelvic  infections  and  inflammations 
is  practically  always  contraindicated  because  of  the 
grave  danger  of  fatal  postoperative  peritonitis, 
either  from  dissemination  of  infective  material  dur- 
ing the  operation  or  from  postoperative  exacerba- 
tion of  an  existing  peritonitis. 

The  percentage  of  mortality  following  acute  stage 
operations  is  dangerously  high  (twenty  to  thirty), 
while  the  mortality  of  ablative  or  reparative 
operations  in  chronic  cases,  or  after  subsidence  of 
acute  inflammation  should  not  range  above  2.5.  The 
mortality  in  nonoperated  acute  pelvic  infections  is 
practically  negligible  when  compared  to  the  mortal- 
ity following  operation  in  acute  cases.  Acute  in- 
fections should,  therefore,  be  given  the  chance  of 
going  to  a  complete  resolution,  or  should  be  car- 
ried, if  possible,  to  the  mildly  subacute  or  chronic 
stage,  when  operative  relief  may  be  afiforded  with 
a  minimum  of  danger. 

Acute  cellular  pelvic  abscess  which  may  be 
drained  extraperitoneally  forms  the  exception  to  the 
mortality  percentages,  as  well  as  to  acute  cases  classi- 
fied as  unsuitable  for  operation. 

The  determination  at  operation  between  conserva- 
tive and  ablative  measures  in  chronic  pelvic  lesions 
is  dependent  upon  many  factors,  both  physical  and 
sentimental.  Nothing  more  than  general  principles 
can  be  laid  down,  and  in  perhaps  no  other  depart- 
ment of  surgery  is  a  definite  knowledge  of  clinical 
pathology  more  essential. 

The  disadvantages  of  conservative  pelvic  surgery 
may  be  summarized  as  i,  possible  recurrence  or 
exacerbation  of  the  original  trouble  ;  2,  possibility  of 
new  disease  of  remaining  structures;  and  3,  greater 
operative  ease  and  rapidity  of  total  ablation  as  com- 
pared with  reparative  measures.  The  statistics 
given  by  Hunter  Robb  alone,  in  his  report  of  419 
conservative  operations  in  which  but  from  two  to 
five  per  cent,  of  cases  required  secondary  operative 


1 194 


TURCK:  HYSTEROSALPINGOSTOMY. 


[New  Yosk 
Medical  Journal. 


relief,  are  conclusive  evidence  that  in  so  far  as  im- 
mediate results  are  concerned,  the  radical  has  no 
advantage  over  the  conservative  operation.  As  to 
the  end  results  there  can  be  no  comparison  when 
one  considers  the  melancholias,  the  psychic  disturb- 
ances, the  insanities,  and  the  purely  physical  dis- 
comforts so  often  following  total  double  ablation  of 
tubes  and  ovaries,  in  contrast  to  the  condition  of 
the  young  woman  who  has  even  a  portion  of  one 
functionating  ovary. 

That  the  probability  of  new  disease  of  structures 
remaining  in  the  patient  upon  whom  conservative 
work  has  been  done  is  greater  than  in  the  average 


stricture  of  the  proximal  end  of  the  Falloppian  tube 
has  not  received,  in  gynaecological  literature,  the  at- 
tention it  apparently  deserves.  It  is  true  that  this 
operation  is  comparatively  rarely  indicated ;  usu- 
ally some  form  of  salpingotomy  with  irrigation  and 
drainage,  salpingostomy,  salpingosalpingostomy,  or 
silpingostomatomy  fulfills  all  requirements  ;  yet  cases 
are  encountered  in  which  hysterosalpingostomy  may 
save  a  tube,  either  independently  or  in  conjunction 
with  work  upon  the  fimbriated  extremity. 

The  operation  of  hysterosalpingostomy  was  first 
performed  by  Dr.  Alexander  Hugh  Ferguson  in 
June,  1899,  ^^'^  reported  by  him  in  1903  (  The  Med- 


l-ir. 


nonoperated  female  has  not  been  demonstrated,  and 
even  if  so,  yet  would  not  counterbalance  the  mani- 
fold advantages  of  conservatism. 

The  deliberate  choice  of  a  simple  ablative  opera- 
tion, in  the  case  in  which  a  more  difficult  conserva- 
tion is  indicated,  may  arise  tlirough  ignorance,  or 
from  selfish  reasons,  but  is  incrmceivablc  in  the  con- 
scientious man  to  whom  the  future,  as  well  as  the 
immediate  well  being  of  the  patient,  is  the  first  con- 
sideration. 

Among  conservative  measures,  the  operation  of 
tubouterine  anastomosis  for  sclerosis,  chronic  in- 
flammatory hyperplasia,   or  other   obstruction  or 


/'(•(;/  fort}ii'^litl\\  July  25,  1903).  In  that  paper 
Ferguson  reported  six  cases;  pregnancy  following 
in  one  patient  upon  whom  right  tubo-oophorectomv 
and  left  hysterosalpingostomy  had  been  done.  This 
case  demonstrates  conclusively  that  the  operation 
provides  a  method  of  tubouterine  anastomosis,  in 
which  jiriniarv  and  terminal  tubal  patencv  is  possi- 
ble. 

The  operation  as  described  by  Ferguson  is  as 
follows : 

Determine  that  the  tube  is  ohstructcd  at  its  proximal  end 
by  inability  to  pass  a  probe,  or  force  air  through  it.  Then 
remove  the  obstntcted  portion,  inchiding  the  horn  of  the 


June  12,  1009.] 


TURCK:  HYSTEROSALPINGOSTOMY. 


"95 


uterus  down  to  the  uterine  mucous  membrane,  care  being 
taken  not  to  interfere  with  the  vessels  immediately  below 
the  Falloppian  tube.  Split  the  proximal  end  of  the  remain 
ing  portion  of  the  tube  about  half  an  inch.  Pass  a  mattress 
suture  through  the  uterine  wall  from  serosa  to  the  edge  of 
the  mucous  surface ;  continue  it  through  one  half  of  the 
split  proximal  end  of  the  tube  from  serosa  to  mucosa,  then 
back  from  mucous  surface  to  serous  surface  of  the  tube, 
and  finally  from  uterine  mucosa  to  the  outer  surface  of 
uterine  wall.  Deal  in  a  similar  manner  with  the  other  half 
of  the  split  end  from  the  opposite  surface  of  the  uterine 
wall. 

Traction  is  now  made  on  these  two  mattress  sutureSj  and 
the  Falloppian  tube  is  hereby  drawn  into  the  wound  in  the 
uterus,  its  mucous  membrane  becoming  continuous  with 
that  of  the  uterus,  and  its  serous  surface  coming  in  con- 
tact with  the  raw  uterine  tissue  on  both  sides.  The  sutures 
are  now  tied.  Pass  two  or  three  interrupted  sutures  above 
and  internal  to  the  tube  to  close  the  wound  in  the  uterus, 
care  being  taken  not  to  constrict  the  tube.  The  stitch  next 
the  tube  must  grasp  its  outer  coats,  so  as  to  more  firmly 


The  writer  has  modified  Ferguson's  technique  in 
a  few  unimportant  details,  as  may  be  observed  in 
Figures  i  and  2.  The  tube  is  rtot  split,  but  is  cut 
at  an  angle  from  above  downward  and  outward, 
somewhat  as  in  Van  Hook's  uteroureteral  anastomo- 
sis. But  one  mattress  suture  is  used.  This  suture 
is  threaded  upon  two  curved  needles,  both  of  which 
are  passed  from  the  mucosa  to  the  serosa  of  the 
tube,  thence  from  the  cut  edge  of  uterine  mucosa 
upward  through  the  uterine  wall.  Traction  upon 
this  suture  readily  brings  the  tube  into  its  new  posi- 
tion, with  the  cut  edges  of  tubal  and  uterine  mucosa 
m  approximation,  and  with  the  serotis  surface  of 
the  tube  in  contact  with  the  uterine  muscularis.  The 
tubal  serosa  should  first  be  gently  scarified  to  pro- 
mote rapid  union. 

The  writer  has  performed  the  operation  of  hys- 


secure  its  position.  All  sutures  are  made  with  chromicized 
catgut  No.  0. 

Ferguson  advocates  a  preliminary  curetting,  with 
application  of  pure  lysol  to  the  interior  of  th? 
uterus.  Contemporaneous  operations  on  the  cervix, 
vagina,  or  perinaeum  are  not  performed  until  the 
intraabdominal  work  is  completed. 

The  operation  of  hysterosalpingostomy  can  not 
be  done  satisfactorily  through  a  vaginal  incision  ; 
in  this  as  in  a  majority  of  conservative  tubal  opera- 
tions a  median  abdominal  or  Pfannenstiel  incision 
is  essential. 


Fig.  2. 

terosalpingostomy  eight  times.  Ovarian  resection 
was  found  to  be  necessary  in  all  cases,  while  six 
patients  required  contemporaneous  operations  on 
tubes,  cervix,  or  perinjeum. 

Two  of  these  eight  patients  have  become  preg- 
nant since  operation.  This  fortuitous  percentage  has 
no  value  as  a  criterion  of  pregnancy  expectation 
after  hysterosalpingostomy.  The  following  case, 
however,  proves  conclusively  the  success  of  the  pro- 
cedure, since  hysterosalpingostomy  was  done  on 
both  sides,  with  no  other  reparative  work,  except 
double  ovarian  resection  and  suspension : 


1 196 


MITCHELL:    OBSTRUCTIVE  PANCREATITIS. 


Case  I. — Miss  S.,  age  twenty-two,  operation  by  the  writer 
for  acute  exacerbation  of  a  chronic  appendicitis  in  Feb- 
ruary, 1903.  Incision  through  border  of  rectus.  Appendix 
removed  by  Murphy's  method.  Digital  examination, 
through  the  wound,  showed  no  apparent  pathology  in  gall- 
bladder, kidney,  or  pelvic  organs.  The  wound  was  closed 
without  drainage.  Patient  made  an  uneventful  recovery. 
Prior  to  this  operation  she  had  complained  of  no  pelvic 
trouble,  except  a  moderate  pain  during  the  first  day  of 
menstruation. 

In  June,  1903,  she  began  having  marked  dysmenorrhoea, 
which  gradually  increased  in  severity  until  in  September 
she  was  obliged  to  spend  nearly  a  week  in  bed  during  each 
menstrual  period.  Local  treatments,  douches,  baths,  mas- 
sage were  of  no  benefit.  Repeated  examinations  revealed 
no  apparent  pathology  in  the  pelvic  cavity,  uterus,  or  Fal- 
loppian  tubes,  except  that  both  ovaries  were  continuously 
tender,  with  but  little  enlargement.  A  moderate  ovarian 
prolapsus  was  determined  on  both  sides.  There  was  no 
vaginal  discharge  at  any  time.  The  patient  was  intensely 
nervous  and  occasionally  hysterical.  A  provisional  diag- 
nosis of  prolapsed  fibrocystic  ovaries  was  made.  Local  and 
medical  treatment  having  been  exhausted,  operation  was 
advised. 

Second  operation  December  5,  1903  (Fig.  i)  at  Chicago 
Hospital.  Dr.  A.  H.  Ferguson  fortunately  happening  in 
the  operating  room,  kindly  consented  to  go  into  the  opera- 
tion with  the  writer.  A  median  abdominal  incision  was 
made,  and  the  site  of  the  appendectomy  examined.  The 
cjecum  was  freely  movable ;  there  were  no  adhesions,  and 
neither  Dr.  Ferguson  nor  the  writer  could  positively  iden- 
tify the  former  location  of  the  appendix.  There  was  no 
remaining  hyperplasia  and  no  visible  scar.  There  were  no 
adhesions  in  the  pelvis.  Both  ovaries  were  markedly  cystic, 
though  but  little  enlarged.  Both  were  resected,  leaving  not 
more  than  one  quarter  normal  bulk.  The  fimbriae  of  the 
tubes  were  clear,  and  the  outer  portion  of  each  was  patent. 
The  left  tube  was  strictured  at  the  uterine  cornu,  while 
the  right  tube  was  somewhat  sclerosed  and  strictured  about 
three  quarters  of  an  inch  from  the  cornu.  There  was  no 
sign  of  tubal  infection. 

Hysterosalpingostomy  according  to  Ferguson's  original 
technique  was  done  on  one  side  by  Dr.  Ferguson  and  on 
the  other  side  by  the  writer.  The  resected  ovaries  were 
suspended  and  the  abdominal  wound  closed. 

The  wound  healed  kindly.  The  patient  complained  of 
pain  for  a  few  days.  She  left  the  hospital  in  excellent  con- 
dition, free  from  pain  at  end  of  second  week. 

January  3,  1904.  Menstruating,  intense  pain,  very  ner- 
vous; in  bed  four  days,  opiates  necessary. 

January  20,  1904.  Menstruating,  with  but  little  pain ; 
four  days'  flow,  not  profuse ;  one  day  in  bed. 

February,  20,  1904.    Menstruation  much  easier. 

March  18,  1904.    Menstruation  normal;  no  pain. 

July  22,  1904.  •In  excellent  condition;  no  pain  at  menstru- 
ation. Complained  of  aching  and  "bearing  down"  pains  if 
standing  or  walking  too  much ;  still  a  bit  nervous. 

November,  1904.    Apparently  well  in  every  respect. 

January,  1905,  wrote  "My  health  has  been  very  good. 
Every  day  I  seem  to  get  stronger  and  add  a  little  to  my 
weight.    My  operation  has  been  a  great  success,  etc.,  etc." 

November,  1905,  consulted  w  riter  regarding  marriage  and 
possible  effect  of  pregnancy.    Marriage  advised. 

March.  1906,  married. 

November.  1906.  became  pregnant. 

August,  1907,  delivered  of  perfectly  normal,  healthy  male 
child  without  difficulty. 

She  went  through  pregnancy  without  untoward  symp- 
toms, and  since  has  been  in  apparently  perfect  health. 

C.\SE  II. — Mrs.  J.,  .iged  thirty-two.  Operation  August 
26,  IQ04  (Fig.  2).  History  of  pelvic  trouble  resembling 
ch'"onic  pyosalpinx  for  several  years.  Had  probably  had  a 
gonerihceal  infection  in  early  married  life.  Physical  exam- 
ination revealed  a  completely  rctrodisplaced  and  adherent 
uterus,  with  much  tenderness  in  right  fossa. 

Operation:  .Abdominal  incision  through  border  of  right 
rectus.  The  utci  us  and  left  tuhe  were  bound  down  in  the 
cul-de-sac  bv  old  adhesions.  These  were  cleared  and  the 
uterus  suspended  by  the  round  ligaments  according  to  the 
tprhni<|ue  devised  by  Frank  .Andrews.  The  fimbriated  ex- 
tremities of  both  tubes  were  sealed,  while  the  right  tuljc 
presented  a  hypertrophic  sclerosed  mass  near  the  uterine 


[New  York 
Medical  Journal. 

cornu.  The  body  of  each  tube  being  in  fair  condition, 
salpingosiomatomy  was  done  on  both  tubes,  and  hystero- 
salpingostomy done  on  the  right  side  after  tubal  resection. 
Both  ovaries  being  cystic  they  were  resected  and  attached 
to  the  tube  ends. 

Patient  made  an  entirely  uneventful  recovery  and  left 
hospital  on  the  sixteenth  day  after  operation. 

Menstruation  following  operation  was  irregular,  but  not 
painful.  The  patient  became  pregnant  early  in  1907,  and 
was  delivered  at  term  of  a  healthy  male  child.  She  had, 
however,  at  intervals  during  her  pregnant  period  a  good 
deal  of  pain,  necessitating  anodynes.  Since  delivery  she  has 
been  in  good  health,  and  at  last  report  the  uterus  was  in 
correct  position. 

This  case  while  interesting  as  indicative  of  preg- 
nancy possibility  after  conservatism,  has  not  the 
value  of  the  first  case  reported  in  demonstrating  the 
occurrence  of  pregnancy  after  hysterosalpingostomy 
since  we  can  not  know  whether  the  fecundation  oc- 
curred through  the  right  or  the  left  tube. 

Conservative  gynjpcological  surgery  would  be 
practised  even  more  often,  did  operators  tnore  sys- 
tematically follow  their  cases  through  the  months 
and  years  succeeding  immediate  convalescence,  and 
compare  the  frequent  pitiable  end  restilts  of  radical- 
ism with  the  satisfaction  found  in  even  one  case  of 
restored  function. 

C0NS0LID.\TED  BuiLDING. 


PANCREATITIS,   CHRONIC  A.vD  ACUTE,  FROM 
OBSTRUCTION  OF  THE  DUCT  BY  A  CALCU- 
LUS AT  THE  AMPULLA  OF  VATER. 

By  O.  W.  H.  Mitchell,  M.  D., 
Columbia,  Mo. 

Case. — Patient's  history,  November  i6th.  The  patient 
was  fifty-two  years  old;  married:  American:  farmer.  His 
father  died  at  the  age  of  eighty-si.x,  from  old  age.  Mother 
died  at  the  age  of  forty-five  during  menopause.  Neither 
mother  nor  father  had  any  trouble  resembling  that  of  pa- 
tient. Patient  had  five  brothers,  four  of  whom  were  living. 
They  were  all  healthy  and  strong,  but  one.  who  had  been 
troubled  with  gallstones  at  times.  He  had  three  sisters,  all 
living,  well,  and  healthy.  Patient  had,  as  a  child,  measles, 
whooping  cough,  and  possibly  other  childhood  diseases. 
Said  he  thought  he  had  a  rupture,  but  was  not  certain,  but 
he  had  worn  a  truss.  Three  years  ago  this  fall,  he  had  an 
attack  of  what  the  physicians  called  "malarial  fever" ;  was 
troubled  at  times  by  a  belching  of  gas.  not  sour ;  had  chills 
every  other  day  for  a  week.  The  recvivery  from  this  at- 
tack was  uneventful.  He  had  since  been  troubled  by  belch- 
ing, especially  after  eating  heartily :  more  noticeable  in  the 
fall. 

Present  illness: — The  present  attack  began  in  .August; 
on  a  warm  day  the  patient  drank  three  glasses  of  ice  water 
and  innnediately  noticed  a  sharp  sticking  pain  felt  beneath 
the  point  of  the  sternum.  This  pain  lasted  from  5  p.  m.  to 
1 1  p.  m.  and  was  continuous.  Patient  applied  hot  cloths. 
This  attack  was  followed  by  pains  similar  in  type,  occur- 
ring every  day  and  averaging  about  two  a  day,  more  fre- 
quent in  the  morning.  These  attacks  lasted  about  a  week. 
He  had  a  good  appetite  during  the  week,  but  would  vomit 
everything  eaten.  A  physician  made  an  examination  and 
said  he  thought  the  patient  had  gallstones.  The  physician 
gave  morphine  and  some  kind  of  liver  medicine.  About 
two  weeks  after  this,  he  had  a  slight  attack  and  was  then 
free  from  attacks  until  November  2d,  when  he  had  one  on 
the  2d,  3d,  5th,  and  6th.  He  was  able  to  prevent  these  by 
not  eating  and  by  taking  morphine.  He  had  not  an  attack 
for  two  days. 

When  he  had  the  severe  pain  in  tlie  epigastrium,  it 
seemed  to  radiate  toward  the  right  shoulder  blade  and  the 
back.  Patient  said  he  noticed  a  jaundice  first  on  last  Mon- 
day.   Had  not  had  any  yellowness  of  vision.    He  had  vom- 


June  12,  1909.]  OGILVV:  so  CALLED  CHRONIC  RHEUMATISM.  1 197 


ited  very  little  during  last  attack ;  when  he  did,  the  vomi- 
tus  was  composed  of  what  he  had  eaten  and  was  never  yel- 
lowish or  greenish  in  color ;  but  in  the  first  attack  he  vom- 
ited bile,  but  in  no  large  quantity.  The  vomitus  was  more 
of  a  whitish,  slimy  character.  He  complained  of  a  dull, 
aching  pain  at  ^IcBurney's  point,  but  had  never  had  any 
acute  pain  in  this  region.  Patient  said  his  nose  bled  when 
he  vomited. 

'  Physical  examination: — Conjunctiva  and  skin  a  deep 
lemon  color.  Thorax  normal  on  inspection,  percussion,  and 
auscultation.  Heart  normal  in  size.  Sounds  clear;  pulse 
slow.  Abdomen  : — Liver,  upper  border  at  level  of  fifth  rib ; 
lower  border,  beginning  an  inch  internal  to  the  mammary 
line  at  the  lower  border  of  the  costal  cartilage  on  the  left 
side;  the  lower  border  extended  transversely  downward  and 
inward  just  below  the  umbilicus,  then  transversely  across 
the  abdomen  to  the  right  and  to  a  point  about  one  inch  be- 
low the  tenth  costal  cartilage  in  about  the  posterior  axillary 
line.    Examination  of  the  abdomen  otherwise  negative. 

Urine  examination  : — Dark  color  ;  specific  gravity,  1.020  to 
1.024;  sediment:  bile  present. 

Stomach  analysis  : — Test  breakfast  of  thirty-five  grammes 
of  wheat  bread,  400  c.c.  of  water ;  thirty-eight  c.c.  of  green- 
ish fluid  recovered.  2.7  c.c.  of  o.i  per  cent,  sodium  hydrox- 
ide: free  acid;  1.5  c.c.  of  o.i  per  cent,  sodium  hydroxide 
combined ;  4.2  c.c.  total  acids. 

The  patient  continued  to  have  these  atacks,  great  pain 
in  the  right  hypochondriac  region,  vomiting,  and  intermit- 
tent jaundice  with  increasing  weakness  and  gradual  loss  of 
flesh  until  the  middle  of  February,  when  he  showed  signb 
of  sepsis;  there  was  fever,  and  the  general  condition  be- 
came worse.    Death  resulted  in  a  few  days. 

At  the  necropsy,  performed  by  Dr.  W.  McN.  Miller,  the 
gross  findings  were  as  follows : — Liver  enlarged,  cloudy 
swelling.  Gallbladder  normal ;  contained  no  calculi.  The 
pancreas  enlarged ;  very  firm  and  presents  a  "cobble  stone" 
appearance.  \'ery  dense  upon  incision.  When  a  probe 
was  passed  through  the  pancreatic  and  common  bile  duct 
it  was  found  that  there  was  an  obstruction  at  the  lower, 
terminal  end  of  the  ducts  that  would  not  allow  the  probes 
to  enter  the  duodenum.  Upon  opening  the  duodenum,  the 
ampulla  of  Vater  was  found  to  contain  a  calculus  the  size 
of  the  tip  of  the  little  finger.  The  opening  of  the  duct  of 
Satorini  was  not  demonstrable.  Around  the  common  duct 
and  pancreatic  duct,  an  abscess  had  formed  and  there  was 
local  peritonitis.    Kidneys  enlarged ;  pale,  cloudy  swelling 

The  microscopical  findings  were  as  follows :  Pancreas, 
very  marked  increase  of  connective  tissue,  interlobular  and 
interacinar.  Many  lobules  were  entirely  replaced  by  con- 
nective tissue  and  many  of  the  remaining  showed  great  dis- 
tortion of  the  acini  from  the  presence  of  connective  tissue. 
Many  normal  islands  of  Langerhans  persisted  and  were 
disseminated  throughout  the  dense  connective  tissue  mass, 
which  contained  scattered  remnants  of  the  atrophic  lobules 
and  acini. 

Infiltrating  the  connective  tissue  stroma  and  collected 
into  isolated  areas,  especially  within  the  lobules,  were  to 
be  found  polymorphonuclear  leucocytes.  The  small  ab- 
scesses were  widely  distributed  and  were  very  numerous 
throughout  the  pancreas. 

The  Liver.  There  was  some  congestion.  The  cells  ap- 
peared very  granular,  especially  surrounding  the  bile  ducts, 
and  particularly  in  this  region  contained  bile  pigment. 
Some  of  the  bile  ducts  contained  polymorphonuclear  leuco- 
cytes and  these  also  were  to  be  found  between  the  liver 
cells  around  the  bile  ducts. 

Kidneys.  Moderate  parenchymatous  nephritis.  Slight  in- 
crease of  the  interstitial  tissue. 

Anatomical  Diagnosis.  Calculus  occluding  common  bile 
duct  and  pancreatic  duct.  Chronic  interstitial  and  acute 
suppurative  pancreatitis.  Localized  peritonitis  with  forma- 
tion of  abscess  around  common  bile  and  pancreatic  ducts. 
Cloudy  swelling  of  liver  and  kidneys. 

The  case  plainly  shows  itself  to  be  one  of  chronic 
interstitial  with  a  terminal  acute  suppurative  pan- 
creatitis resultmg  from  occlusion  of  its  duct  at  the 
ampulla  of  Vater  by  a  calculus.  The  symptoms  of 
the  patient  were  typical  for  gallstone  colic,  and  the 
gross  and  histological  findings  typical  for  chronic 
and  acute  pancreatitis. 

2TI  South  Ninth  Street. 


SYMPTOMS  AND  DIAGNOSIS  OF  SO  CALLED 
CHRONIC  RHEUMATISM.* 

By  Charles  Ogilvy,  M.  D., 
New  York, 

Adjunct   Professor   of   Orthopaedic   Surgery,    Postgraduate  School; 
Attending  Surgeon,  City  Children's  Hospitals  and  Schools;  etc. 

Chronic  rheumatism  opens  up  to  us  such  a  vast 
field  for  thought  that  it  is  difficult  in  the  short  time 
at  one"s  disposal  to  do  credit,  or  rather  would  I  say, 
discredit,  to  the  term.  So  many  are  the  affections 
to  which  this  diagnosis  is  given  and  so  often  are  we 
confronted  with  conditions  that  have  been  called 
chronic  rheumatism  by  the  attending  physician,  that 
it  seems  timely  to  appreciate  how  indefinite  is  the 
term  and  what  little  real  ineaning  it  conveys. 

The  subject  of  acute  articular  rheumatism  we  shall 
not  dwell  upon.  These  patients  have  a  sudden  rise  in 
temperature  accompanied  by  an  acceleration  of  the 
pulse.  There  is  general  debility,  loss  of  appetite, 
and'  scanty,  highly  acid  urine.  Different  joints,  in 
succession  affected,  become  hot,  swollen,  exceeding- 
ly painful,  and  tender ;  the  inflammatory  reaction  in- 
volves the  periarticular  structures.  In  children,  these 
articular  symptoms  are  less  severe  and  often  absent, 
though  the  accompanying  manifestations  of  endo- 
carditis, amygdalitis,  and  anaemia  enable  us  to  make 
a  confirmatory  diagnosis.  Seldom  if  ever  do  we  see 
acute  rheumatism  in  children  under  two  )'ears  of 
age.  At  this  age  the  diagnosis  of  a  painful  joint 
usually  rests  between  scurvy  and  acute  infectious 
arthritis. 

In  the  former  there  is  not  the  general  elevation  of 
temperature  or  the  same  degree  of  acute  local  s}  mp- 
toms  that  one  sees  in  the  latter.  Acute  articular 
rheumatistn  is  a  multiple  arthritis  ambulating  from 
one  joint  to  another,  and  runs  a  course  of  two  to 
three  weeks  and  does  not  pass  on  to  chronic  rheu- 
matism. 

infectious  arthritis. 

The  greater  number  of  cases  which  we  meet  with 
in  which  the  misleading  term  of  rheumatism  has 
been  applied  belong  to  that  class  of  joints  rightly 
designated  infectious  arthritis.  Joints  are  subject 
to  all  kinds  of  infection.  The  more  acute  the  infec- 
tion and  the  more  definite  the  history,  the  easier  is 
the  diagnosis.  Thus  an  acute  streptococcal  infec- 
tion, with  its  abrupt  onset,  and  rapid  course,  espe- 
cially when  we  are  able  to  trace  the  source  of  infec- 
tion, is  readily  diagnosticated,  which  diagnosis  can 
be  confirmed  by  an  examination  of  the  aspirated 
fluid.  An  acute  arthritis,  especially  of  the  shoul- 
der or  elbow  joint,  following  upon  a  pneumonia 
would  be  very  suggestive  of  a  pneumococcal  infec- 
tion, and  this  could  be  verified  by  finding  the  pneu- 
mococci  in  the  joint  fluid,  though  we  may  have  a 
pneumococcal  arthritis  in  which  we  are  unable  to 
find  pneumococci  in  the  effusion. 

AiTiong  the  joint  infections  which  are  less  acute 
than  the  two  just  mentioned  are  those  of  the  typhoid 
bacillus,  the  gonococcus,  the  staphylococcus,  the  in- 
fluenza bacillus,  and  the  dysenteric  bacillus.  These 
also  may  run  an  acute  course,  but  again  we  often 
see  during  some  stage  of  the  inflammation,  a  period 

*Read  before  the  Northwestern  Medical  and  Surgical  Society  of 
New  York,  February  17,  1909. 


OGILVY:  SO  CALLED  CHRONIC  RHEUMATISM. 


[New  York 
•Medical  .Tournai_ 


of  subacuteness,  during  which  time  the  diagnosis  of 
chronic  rheumatism  is  too  frequently  made. 

TYPHOID  INFECTION. 

The  joints  most  frequently  involved  by  the  typhoid 
bacillus  are  those  of  the  spine.  The  first  symptom 
of  a  typhoid  spine  is  pain.  This  may  not  be  very 
much  complained  of  for  weeks  or  even  months  after 
the  fever  has  subsided.  It  is  referred  to  the  back, 
and  frequently  there  is  a  localized  area  of  definite 
tenderness  to  one  or  the  other  side  of  the  spinous 
processes.  If  the  disease  is  unchecked,  there  is 
marked  rigidity  and  spasm  of  muscle.  The  pain  be- 
comes intense,  and  the  slightest  movement  is  fol- 
lowed by  great  suffering,  so  that  the  patient  lies 
upon  his  back  fearing  to  move  even  a  hand  or  a  foot. 
The  appearance  of  a  case  of  acute  typhoid  spine 
once  seen,  can  never  be  forgotten.  If  there  is  suffi- 
cient change  in  the  bone  structure,  a  small  kyphos 
appears.  There  is  usually  a  slight  temporary  scoli- 
osis. Before  reaching  this  acute  stage,  however, 
the  process  may  run  a  course  of  three  or  four 
months.  The  chart  of  such  a  patient  is  not  that  of 
an  acute  infection.  In  a  case  reported  by  the  writer 
last  year,'  both  pulse  and  temperature  remained 
practically  normal  throughout  the  course  of  the  dis- 
ease. 

GONORRHCEAL  ARTHRITIS. 

The  knee  joint  is  most  frequently  affected,  though 
any  joint  may  become  infected  and  several  may  be- 
come involved  in  rapid  succession.  The  onset  is 
sudden,  the  joint  becomes  hot,  swollen,  and  very 
painful.  The  slightest  motion  causes  marked  spasm 
of  muscle.  There  is  a  rising  temperature  and  gen- 
eral symptoms  of  infection.  The  disease  originally 
involves  the  synovia  and  periarticular  structures. 
We  see  all  degrees  from  the  mildest  to  the  most 
acute  type.  In  the  former,  the  exciting  cause  may 
be  simply  the  presence  of  the  toxines,  in  the  latter 
where  suppuration  and  destruction  of  tissue  results, 
the  gonococci  may  readily  be  found.  The  diagnosis 
is  most  frequently  overlooked  in  children,  as  we  are 
less  likely  to  suspect  this  infection  in  childhood.  The 
worst  case  of  gonorrhoeal  arthritis  which  the  writer 
has  seen  was  that  of  a  little  girl,  twelve  years  of 
age,  with  infection  of  the  right  knee.  Ofie  of  the 
great  barriers  to  a  correct  diagnosis  is  the  difficulty 
in  obtaining  the  history  of  the  infection,  or  of  even 
suspecting  any  such  infection  in  certain  cases.  Rare- 
ly does  one  receive  anything  but  a  negative  reply  to 
the  query  of  a  possible  infection.  The  joint  mav 
become  involved  long  after  (from  one  to  two  years) 
the  original  acute  infection  has  disappeared.  What 
we  fear  most  is  a  resulting  limit  of  motion  or  com- 
plete ankylosis.  This  may  be  fibrous  or  bony,  and 
is  sometimes  mistaken  in  this  stage  for  atrophic  or 
rheumatoid  arthritis.  Associated  with  this  joint  in- 
volvement we  frequently  meet  with  a  highly  neu- 
rotic condition,  especially  in  women. 

INFLUENZA  BACILLUS. 

Joint  involvements  after  an  attack  of  influenza  are 
not  at  all  common,  and  the  history  of  such  an  attack 
should  immediately  be  inquired  into  if  one  or  sev- 
eral joints  are  complained  of.    The  arthritis  is  often 

^Journal  of  the  American  Medical  Association,  August  i,  1908. 


subacute  without  any  acute  local  symptoms  and  the 
negative  findings  make  the  diagnosis  somewhat  dif- 
ficult and  obscure  without  the  history. 

The  X  rays  of  the  infectious  arthritides  show  a 
thickening  of  the  periarticular  structures  without 
any  involvement'  of  the  bones,  except  where  there 
has  been  destruction  and  disintegration  from  very 
acute  processes.  There  is  also  a  marked  leucocyto- 
sis  which  gradually  diminishes  as  the  acute  symp- 
toms subside. 

RHEUMATOID  ARTHRITIS  AND  ARTHRITIS  DEFORMANS. 

These  terms  have  been  used  to  designate  a  large 
class  of  obscure  cases  of  polyarthritis.  Especially 
are  these  cases  obscure  in  regard  to  their  aetiology. 
These  represent  two  distinct  types  of  disease,  the 
one  associated  with  atrophy  of  both  bone  and  soft 
structure,  rheumatoid  arthritis,  or  atrophic  arthritis, 
in  which  the  causative  factor  in  many  cases  seems 
to  be  due  to  some  infective  agent,  and  the  other  type 
associated  with  deformity  and  hypertrophy  of  bone 
with  exostoses,  viz.,  hypertrophic  arthritis  or  arthri- 
tis deformans. 

The  joints  become  enlarged,  swollen,  and  painful. 
There  is  an  excessive  effusion  into  the  joint,  motion 
is  somewhat  limited,  and  there  is  pain  on  joint  pres- 
sure, but  this  may  not  be  excessive,  and  a  patient 
with  knee  or  ankle  joint  involvement  may  be  able  to 
walk  some  distance,  without  th'  severe  pain  associ- 
ated with  the  acute  infections.  '  The  process  is  a 
much  slower  one,  extending  over  years  and  gradu- 
ally progressing,  and  involves  one  joint  after  the 
other,  most  frequentlv  attacking  shoulders,  knees, 
ankles,  and  elbows.  The  jaw,  too,  frequently  is  af- 
fected, and  when  this  is  the  case,  mastication  is  diffi- 
cult, and  the  facies  of  the  patient  is  expressionless. 
We  may  have  exacerbations  of  pain  from  time  to 
time  in  the  knee  joints.  There  is  no  leucocytosis  or 
gland  involvement.  The  affection  is  most  frequent- 
ly seen  in  adolescence,  but  it  must  not  be  forgotten 
that  children  are  also  subject  to  the  disease.  In  ref- 
erence to  this,  Whitman  says,  "that  although  it  is 
often  stated  that  arthritis  deformans  is  uncommon 
in  childhood,  it  is  certainly  not  particularly  so  in  or- 
thopaedic practice.  In  my  experience,  cases  of  this 
class  are  usually  of  the  atrophic  type  (rheumatoid 
arthritis),  yet  the  anatomical  descriptions  that  one 
finds  in  the  textbooks  are  usually  of  a  disease  ac- 
companied by  central  atrophy  of  the  cartilage,  thick- 
ening at  the  periphery,  distortion  of  the  joint's  sur- 
faces, and  the  like,  a  description  that  applies  to  the 
hypertrophic  form  (osteoarthritis)."^ 

HYPERTROPHIC  ARTHRITIS  OR  ARTHRITIS  DEFORMANS. 

This  is  exemplified  most  frequently  in  the  hip,  as 
the  morbus  coxas  senilis.  The  joint  very  gradually 
becomes  stiff  and  painful.  Little  is  at  first  com- 
plained of,  and  the  process  may  proceed  so  gradu- 
ally that  but  little  inconvenience  results  for  upward 
of  one  or  two  years.  Many  of  these  cases  give  a 
history  of  traumatism.  The  condition  may  remain 
as  a  monarticular  arthritis.  The  limb  can  be  moved 
slowly  in  all  directions,  but  with  a  constantly  resist- 
ing stiffness,  and  sometimes  a  distinct  grating  can 
be  felt.    This  rigidity  is  diagnostic,  and  is  very  dif- 

^Medicai  Record,  April  18,  1903. 


June  12.  1909.] 


OGILVY:  SO  CALLED  CHROXIC  RHEUMATISM. 


1199 


ferent  from  the  limit  of  motion  due  to  spasm  ot 
muscle  in  chronic  infection  such  as  tuberculous  dis- 
ease. Nathan  considers  that  the  changes  are  pri- 
marily due  to  a  faulty  bone  nutrition,  from  which 
follows  a  thickening  at  the  edges  of  the  cartilages,  a 
lipping  of  the  bone,  and  separation  and  absorption 
of  the  joint  cartilage.  The  joint  surfaces  soon  be- 
come inverted,  and  very  great  deformities  may  re- 
sult. Exosteal  growths  may  be  so  great  as  to  me- 
chanically obstruct  motion.  The  x  ray  lends  par- 
ticular aid  in  confirming  the  diagnosis  in  these  cases, 
showing  bony  hypertrophy,  and  the  distortions  in 
the  joint.  We  have  been  accustomed  to  associate 
this  condition  with  old  age,  but  it  occurs  also  in  mid- 
dle age,  as  seen  recently  in  the  case  of  a  male,  thirty- 
six  years  old.  Heberden's  nodes  typify  this  same 
condition  in  the  finger  joints. 

Arthritis  deformans  of  the  spine  or  spondylitis 
deformans  is  also  of  this  class.  A  number  of  the 
vertebrae  may  become  ankylosed  together.  The 
whole  spine  may  become  as  one  piece.  There  is 
marked  stiffness  of  the  entire  vertebral  column. 
There  is  pain  localized  at  the  seat  of  the  disease  and 
also  a  referred  pain  in  the  back,  arms,  or  legs,  due 
to  pressure  on  the  nerve  roots.  The  attitude  is 
striking,  and  the  patient  walks  with  short,  slow, 
characteristic  steps.  The  diagnosis  is  usually  not 
difficult  to  make. 

still's  disease. 

A  type  of  arthritis  in  childhood  belonging  neither 
to  the  atrophic  or  the  hypertrophic  class  just  de- 
.scribed.  is  that  of  Still's  disease,  which  simulates 
both  but  resembles  neither,  in  that  there  is  asso- 
ciated with  a  chronic  progressive,  subacute,  arthri- 
tis, of  childhood,  with  an  enlargement  of  the  joints, 
a  general  enlargement  of  the  lymphatic  glands  and 
spleen,  and  sometimes  of  the  liz'cr.  By  the  presence 
of  these  characteristic  symptoms,  the  disease, 
though  uncommon,  may  be  readily  recognized,  and 
it  stands  in  a  class  by  itself.  Of  the  cases  which 
Still  reported,  all  the  patients  died.  But  others  have 
since  reported  cases  in  which  the  patients  have  re- 
covered. 

villous  arthritis. 

Synovial  villi  occur  in  many  conditions,  especially 
where  a  chronic  irritation  is  present.  They  are 
common  in  tuberculous  joints,  and  are  also  seen  in 
syphilitic  and  gonorrhceal  joints.  They  occur  also 
in  the  atrophic  and  hypertrophic  type  of  arthritis 
above  described.  Any  irritative  cause  within  the 
joint  such  as  a  slipping  semilunar  cartilage  may  re- 
sult in  synovial  hypertrophy  and  villous  formation. 
The  condition,  however,  to  which  this  classification 
has  been  more  directly  applied  (Goldthwait')  is  ex- 
empHfied  by  the  dry,  creaking  knee  joint  so  fre- 
quently seen.  There  is  no  infection.  There  is  no 
disease.  The  condition  is  caused  by  faulty  posture, 
and  lack  of  tone  of  the  joint  membrane.  Flat  feet 
are  often  the  responsible  agent.  There  is  a  folding 
of  the  synovial  membrane,  a  passive  congestion,  and 
gradually  villi  develop.  These  may  be  few  or 
many.  Pain  is  a  ven,'-  variable  symptom.  A  catch- 
ing pain  may  result  from  the  pinching  of  a  fold  of 
the  synovial  membrane.  The  process  is  a  very  grad- 

^Bosfon  Medical  and  Surgical  Journal,  November  17,  1904. 


ual  one.  without  intense  pain  and  without  any  gen- 
eral s}  mptoms  coexisting.  The  condition  is  entirely 
a  local  one,  and  by  this,  and  the  absence  of  a  gen- 
eral inflammatory  reaction  with  the  presence  of 
the  before  mentioned  symptoms,  a  diagnosis  is  made 
clear. 

GOUT. 

Gout  is  easily  distinguished  from  any  of  the  de- 
scribed arthritides.  though  we  sometimes  see  other 
conditions  diagnosticated  as  gout.  The  deposit  of 
urates  in  the  joint  cartilage,  and  periarticular  struc- 
tures is  diagnostic.  The  joint  so  frequently  at- 
tacked, is  the  metacarpophalangeal  of  the  great  toe, 
and  therefore,  when  this  joint  is  inflamed,  and  there 
are  exacerbations  of  pain,  the  conclusive  diagnosis 
of  gout  is  frequently  made,  when  an  infective  arthri- 
tis is  present. 

Other  Affections. 

Chronic  rheumatism  we  also  frequently  see  repre- 
sented by  various  other  conditions,  more  often  per- 
haps by  flat  feet,  tuberculous  joints  inclusive  of 
Potts  disease,  scoliosis,  sacroiliac  strain,  syphilis, 
and  organic  nei-voiis  disease. 

Seventy-five  to  eighty  per  cent,  of  the  cases  of 
flat  or  better  weak  feet,  which  come  to  us,  have  been 
previously  diagnosticated  as  chronic  rheumatism. 
If  a  patient  complains  of  pain  in  the  feet  or  ankles 
only,  which  has  lasted  for  weeks  or  months,  without 
any  other  involvement,  the  likelihood  is,  that  the 
case  is  one  of  weak  feet.  An  examination  of  such  a 
patient  should  be  made  relative  to  eversion  of  the 
foot,  rather  than  the  deformity  of  a  flattened  arch. 
Pain  is  complained  of  for  a  considerable  time  before 
any  noticeable  deformity  of  the  arch  results.  The 
first  complained  of  is  an  indefinite  feeling  of  dis- 
comfort with  occasional  slight  pain  referred  to  the 
calf  of  the  leg.  These  symptoms  gradually  increase 
in  severity,  until  a  definite  and  somewhat  constant 
pain  and  tenderness  results.  The  pain  is  referred  to 
the  scaphocuneiform  articulation  and  to  the  outer 
side  of  the  foot,  immediately  below  the  external 
maleolus.  The  diagnosis  of  weak  feet  should  be 
made  before  any  flattening  has  taken  place. 

Tnbereiilous  joi)its  have  such  a  long,  insidious, 
early  course,  with  slight  limp  from  time  to  time,  and 
with  but  few  symptoms  of  any  active  process,  that 
the  opportunity  of  making  an  early  diagnosis  of 
chronic  rheumatism  is  ofYered  and  often  accepted. 
\\'hen  a  child  has  complained  of  pain  for  two  to 
three  months  or  longer,  in  any  one  joint  only,  sus- 
pect tuberculosis.  If  accompanied  by  an  associated 
limp,  atrophy  of  muscle  (which  atrophy  develops 
early  at  first  slight,  but  decided)  spasm  of  muscle, 
and  deformity  (which  deformity  is  usually  that  of 
flexion),  then-  the  case  is  almost  always  one  of 
tuberculosis.  We  also  have  the  difYerent  tuberculin 
tests  which  are  all  of  material  assistance,  but  which 
should  in  each  instance  be  taken  as  a  supplementary 
aid  to  the  clinical  conditions  which  are  present,  and 
upon  which  we.  to  a  greater  extent,  rely. 

A  careful  examination  should  reveal  the  diagnosis 
of  the  other  conditions  mentioned,  accompanied  as 
they  always  are  by  special  diagnostic  stigmata. 

125  West  Fifty-eighth  Street, 


I200 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


<$ux  fta&m'  iistttssions. 


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXVI. — Hon'  do  you  make  an  early  diagnosis  of  pul- 
monary tuberculous  disease?  (Closed  May  15,  1909.) 

LXXXVII. — How  do  you  treat  supraorbital  neuralgia? 
(A)iszcers  due  not  later  than  June  15,  1909.) 

LXXXyill.—Hozv  do  you  treat  epistaxis?  (Answers 
due  not  later  than  July  15,  1909.) 

Whoever  anszvers  one  of  th$se  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  award  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  required)  that  the  anszvers  be  short;  if  prac- 
ticable no  one  ansicer  to  contain  more  than  six  hundred 
words. 

All  persons  zvill  be  entitled  to  compete  for  the  prize, 
whether  subscribers  or  not.  This  prize  will  not  be  awarded 
to  any  one  person  more  than  once  zvithin  one  year.  Every 
anszver  must  be  accompanied  by  the  ztrriter's  full  name  and 
address,  both  of  which  zve  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Jour- 
nal. Our  readers  are  asked  to  suggest  topics  for  dis- 
cussion. 

The  prize  of  $2^  for  the  best  essay  submitted  in  answer 
to  question  LXXXV  has  been  awarded  to  Dr.  George  A. 
Graham,  of  Kansas  City,  Mo.,  whose  article  appeared  on 
page  1097. 

PRIZE  QUESTION  LXXXV. 
THE  XONOPER.\TIVE  TREATMENT  OF  DISEASE 
OF  THE  VERMIFORM  APPENDIX. 

(Contiinicd  from  page  11 50.) 

Dr.  Alan  Bellingham  Clcborne,  of  Savannah, 
Georgia,  remarks: 

In  the  treatment  of  appendicitis,  we  are  dealing 
with  a  process  of  disease  which  is  most  treacherous 
in  its  mode  of  onset,  and  most  deceiving  as  to  what 
changes  are  taking  place  after  once  beginning. 
Therefore  one  must  watch  a  case  of  appendicitis 
very  closely,  for  fear  this  little  member  down 
deep  in  its  hiding  place  does  not  fool  us  when  we 
least  e.xpect  it. 

Prophylaxis :  But  little  can  be  said  here,  for  other 
than  regulating  the  bowels,  refraining  from  over- 
eating, the  general  public  will  not  listen  to  your  in- 
structions any  longer  than  to  get  out  of  your  office. 

The  attack :  When  you  are  called  to  see  a  case  of 
appendicitis  you  are  confronted  with  the  fact,  that 
you  cannot  say  just  what  pathological  changes  have 
been  or  are  taking  place.  Therefore  the  cardinal 
points  to  be  considered  in  its  treatment  are  rest  of 
body  and  its  intestines.  Place  your  patient  in  bed  and 
keep  him  quiet,  thus  gaining  rest  of  body,  and  allow 
nothing  by  mouth  not  even  water  for  at  least  sev- 
enty-two hours,  and  you  gain  rest  of  the  intes- 
tines. .\s  Dr.  Ochsner  remarks,  "anything  passing 
into  the  stomach  immediately  starts  peristalsis  in  the 
intestines,  thereby  causing  a  condition  you  are  try- 
ing to  avoid."  Leave  the  bowels  alone  and  do  not 
purge  your  patient,  or  you  will  surely  intensify  the 
pathological  process,  if  the  intestines  are  made  to 
work  like  a  snake  about  an  inflamed  part.  Pain  and 
inllammalidn  are  the  next  to  be  considered,  and  by 
placing  an  ice  bag  over  the  abdomen  and  keeping 


it  there,  you  will  be  surprised  to  see  how  quickly 
the  pain  will  subside  and  the  inflammatory  process 
abate,  both  though  in  a  gradual  manner.  It  is  in- 
deed seldom  that  you  will  have  to  give  morphine 
if  the  ice  bag  has  been  applied  at  once.  An  ice  bag 
does  not  mask  the  symptoms  and  morphine  does. 
The  pulse  and  temperature  will  gradually  subside  as. 
the  inflammatory  process  abates,  therefore  rest  and 
the  ice  bag  will  control  temperature  and  pulse.  Feed- 
ing of  your  patient  if  such  is  needed,  though  it  sel- 
dom is,  should  be  done  per  rectum  and  kept  up  luitil 
all  symptoms  have  subsided.  I  have  left  my  ideas 
of  its  surgical  treatment  out  as  the  article  calls  for 
its  medical  treatment  only. 

Dr.  Austin  Hogan,  of  Johnstozvn,  N.  Y.,  observes: 

Disease  of  the  vermiform  appendix  may  be  di- 
vided clinically  into  acute,  chronic,  and  relapsing. 

The  acute  forms  w^ith  perforation  and  more  or 
less  peritonitis  may  be  treated  by  the  well  known 
Oshner  method ;  i.  e.,  rest,  starvation,  lavage,  elas- 
tic binder,  opium,  etc. 

The  acute  forms  without  perforation  are  best 
treated  in  the  following  manner:  i.  absolute  rest  in 
bed;  2,  starvation  for  twelve  to  thirty-six  hours; 
3,  castor  oil,  3i ;  4,  two  aloes  and  asafoetida  pills  to 
be  followed  by  one  pill  every  two  to  four  hours  till 
relief ;  5,  turpentine  stupes  to  the  abdomen  to  stim- 
ulate peristalsis.  I  can  not  praise  too  highly  this 
simple  and  effective  treatment  instituted  early  in 
acute  diseases  of  the  vermiform  appendix.  It  is 
directed  against  two  important  factors  in  the  pro- 
duction of  disease,  stasis  and  flatulence,  the  castor 
oil  by  its  purgative  action,  the  aloes  by  its  well 
known  action  on  the  musculature  of  the  large  intes- 
tine, and  the  asafoetida  by  its  action  in  intestinal 
indigestion  and  flatulence. 

Chronic  and  relapsing  forms  are  best  treated  after 
a  full  consideration  of  the  ^etiological  factors.  This 
comprises  a  searching  investigation  into  the  occu- 
pation, mode  of  life,  dietetic  errors,  digestive  func- 
tion, and  diseases  of  neighboring  structures  and 
pelvic  organs.  Occupations  causing  straining  and 
jolting  must  be  given  up.  Proper  mastication  and 
regularity  of  eating,  drinking,  and  exercise  must  be 
inisted  upon.  Such  articles  as  beans,  peanuts,  and 
overripe  corn  must  be  banished  from  the  diet ;  also 
excesses  in  eating  and  drinking  (especially  alcoholic 
beverages)  and  any  article  of  diet  which  through 
idiosyncrasy  produces  faulty  digestion  must  be  in- 
terdicted. Correction  of  constipation,  if  it  exists,  is 
a  prime  essential,  for  which  the  following  is  ef- 
ficient : 

R    Fluid  extract  of  cascara  sagrada  3iss; 

Tinct.  of  hyoscyamus  3v_; 

Fluid  extract  of  licorice,  q.s.  ad  Si"- 

M.  sig. :  Y2  teaspoonful  to  a  teaspoonful  two  or  three 
times  daily. 

This  will  be  found  almost  a  specific  for  dyspepsia 
associated  with  constipation. 

When  diarrhoea  or  recurrent  diorrhoeas  exist,  cas- 
tor oil,  one  half  to  one  teaspoonful  every  morning 
sup]>lementing  the  correction  of  dietetic  errors  will 
be  found  effective. 

Mental  rest  and  freedom  from  anxiety  during  di- 
gestion is  of  great  importance.    Where  there  is 


Jure  12,  1909.1 


OUR  READERS'  DISCUSSIONS. 


I20I 


marked  "nervous  dyspepsia"  the  following  is  most 


useful : 

R    Chloral,  3ii ; 

Potassium  bromide,   3iv; 

Morphite  sulphate,   gr.  i; 

Tincture  of  hyoscyamus. 

Compound  syrup  of  cardamom  aa  3' > 

Compound  syrup  of  sarsaparilla,   q.  s.  ad.  5iv. 


S.  Sig. :  y2  teaspoonful  to  a  teaspoonful  in  water  after 
meals. 

The  writer  has  never  found  it  necessary  to  resort 
to  the  artificial  perments  which  flood  the  market  to 
procure  relief  for  digestive  irregularities. 

Diseases  of  the  gallbladder  and  pelvic  organs 
should  receive  appropriate  treatment,  and  lastly, 
rheumatic  remedies  may  be  employed  in  patients 
with  rheumatic  tendency  or  dyscrasia. 

Dr.  George  0.  B.  DeBar,  of  Eugene,  Oregon, 
states: 

In  all  cases  of  acute  appendicitis — from  one  to  forty- 
eight  hours'  duration — in  which  the  patient  refuses 
to  submit  to  surgical  operation  for  relief,  or  in  which 
there  are  complications  of  chronic  affection,  such 
as  pernicious  an?emia,  diabetes  mellitus,  advanced 
neurasthenia,  parenchymatous  nephritis,  place  the 
patient  in  bed,  so  as  to  give  the  best  of  everything, 
rest.  Apply  over  the  appendix,  methyl  salicylate, 
and  the  suspended  ice  bag,  keeping  the  surround- 
ing parts,  and  body,  warm  with  proper  covering. 
Give  a  tablespoonful  of  saturated  solution  of  epsom 
salts,  and  repeat  this  dose  in  half  hours,  or  one  hour, 
until  there  is  a  passage  through  the  ileocaecal  valve, 
then  give  it  in  4rachm  doses,  every  two  to  six  hours, 
often  enough  to  cause  two  to  four  passages  through 
the  bowels,  in  every  twenty-four  hours.  Empty  the 
colon  completely  with  enemata  of  a  saturated  solu- 
tion of  epsom  salts  given  through  a  rectal  tube, 
twenty  or  more  inches  long,  and  open  in  the  distal 
end,  and  side  of  end.  Continue  giving  the  high 
enema  until  complete  bowel  movement  is  obtained. 
The  diet  must  be  water,  and  water  only,  for  the  first 
two  or  three  days,  then  give  buttermilk,  pasteurized 
milk,  barley  broth,  and  chicken  broth.  Keep  the 
patient  in  bed  until  completely  cured.  The  epsom 
salts  may  be  divided  with  Rochelle  salts,  equal  parts, 
and  given  by  the  mouth,  providing  the' epsom  salts 
is  not  tolerated  by  the  stomach. 

When  called  for  the  first- visit,  near  the  end  of 
the  second  day,  or  during  the  third  or  fourth  days, 
and  on  examination  you  find  the  patient  suffering 
from  severe  pain,  fever,  nausea,  and  constipation — 
with  or  without  tumor,  give  morphine  sulphate  witli 
atropine  sulphate  hypodermically  over  the  seat  of 
pain,  also  apply  methyl  salicylate,  and  over  that  a  hot 
poultice.  Emptv  the  colon  by  means  of  high  enemata 
of  saturated  solution  of  Epsom  salts  given  through 
the  rectal  tube,  and  when  it  is  empty,  carry  the  sat- 
urated solution  of  Epsom  salts  to  the  caput  coli,  and 
keep  it  there,  by  gentle  force,  until  the  pain,  the 
swelling,  the  inflammation  subsides,  and  the  tense- 
ness of  the  ileocjecal  valve  is  relieved  enough  to 
permit  a  partial,  and  later  complete  passage  through 
bowels,  and  finally  empty  the  small  intestines.  To 
relieve  the  stomach,  give  tincture  of  nux  vomica 
in  drop  doses  every  half,  or  every  hour,  also  tritur- 
ate of  mild  chloride  of  mercur\-,  i/io  gr. ;  sodium 
bicarbonate,  i  grain,  every  half,  or  every  hour  for 


half  day  or  longer  if  necessary.  The  morphine  re- 
lieves pain,  and  relaxes  the  tension  of  the  valve,  and 
gut.  The  Epsom  salts  may  be  injected  hypodermi- 
cally, directly  over  the  appendix.  It  relieves  pain, 
causes  inflammation  to  subside  when  not  too  far 
advanced,  and  produces  catharsis. 

Dr.  IV.  A.  Clary,  Jr.,  of  Memphis,  Tenn.,  writes: 

The  medical  treatment  for  appendicitis  is  applic- 
able only  in  those  patients  in  whom  it  is  inadvisable 
for  one  reason  or  another  to  follow  the  surgical 
treatment,  and  to  some  of  those  in  whom  surgical 
procedure  has  been  postponed  and  peritonitis  has 
developed. 

In  the  first  class  may  be  enumerated  a  large  num- 
ber of  cases  in  which  the  symptoms  are  mild.  These 
patients  are  put  to  bed  absolutely  at  rest,  no  food 
given  for  forty-eight  or  sixty  hours.  At  the  out- 
set give  a  tablespoon  full  of  castor  oil  and  repeat,  if 
it  is  vomited.  As  a  rule  saline  purgatives  do  more 
harm  than  good.  In  some  of  the  mild  cases,  how- 
ever, with  a  history  of  ingestion  of  indigestible  food 
and  constipation,  an  early  saline  purge  acts  hap- 
pily, but  a  prolonged  or  late  use  of  purgatives  is  a 
pernicious  practice.  Early  in  the  attack,  when  the 
pain  is  referred  to  the  umbilical  or  epigastric  re- 
gion, hot  fomentations  or  hot  water  bottles  are  most- 
soothing,  often  relieving  both,  the  pain  and  vomit- 
ing. When  the  pain  and  tenderness  have  b  e  me 
localized  in  the  iliac  region,  the  ice  bag  continu- 
ously applied  is  usually  most  satisfactory  in  reliev- 
ing the  pain. 

Xever  blister  the  skin  and  never  apply  leeches, 
for  thereby  you  render  the  field  unfavorable  for 
•  operation,  in  case  some  urgent  surgical  demand 
arises.  In  this  class  of  cases  never  use  an  opiate 
for  the  relief  of  pain,  for  you  obscure  the  symptom 
complex  and  lose  the  main  clue  to  the  case.  Mor- 
phine has  a  place  only  in  those  patients  in  whom 
there  is  some  constitutional  defect  contraindicating 
operation,  where  peritonitis  has  supervened  and  the 
palliative  treatment  determined  upon,  and  where  a 
diagnosis  of  appendicitis  has  been  positively  made 
there  being  some  delay  to  prepare  for  operation. 
The  rectum  and  colon  should  be  emptied  by  the  use 
of  enemata. 

Should  the  symptoms  gradually  abate  during  the 
first  forty-eight  hours  the  patient  can  be  placed  on 
egg  albumen  and  liquid  diet  for  two  or  three  days, 
then  light  diet  for  a  day  or  so.  gradually  returning 
to  regular  meals.  If  the  patient  suffers  greatly  with 
thirst,  high  nomial  saline  enemata  should  be  given. 
It  will  not  be  deemed  best  to  feed  by  the  mouth  at 
the  end  of  fifty  or  sixty  hours,  in  all  cases.  When 
the  need  for  food  exist,  give  nourishment  per  rec- 
tum, If  during  the  first  twenty-four  or  thirty-six 
hours  the  symptoms  have  increased  in  severitv,  pain, 
rigidity,  tenderness,  and  tympanites  more  marked 
with  slight  acceleration  of  the  pulse  rate  the  ca<;e 
is  no  longer  medical.  If  there  is  sudden  cessation 
of  pain,  no  opiate  having  been  given,  with  accelera- 
tion of  pulse  rate,  the  case  is  immediately  surgical ; 
for  gangrene  is  likely  to  have  occurred.  Finally 
those  patients  in  whom  the  early  surgical  period  has 
been  passed  and  peritonitis  has  supervened,  are  fre- 
quently best  treated  on  the  palliative  plan.  Here 
morphine  has  a  useful  application.    It  not  only  re- 


1202 


THERAPEUTICAL  NOTES. 


[New  York 
Medical  Journal. 


lieves  the  pain  but  limits  peristalsis  and  thus  favors 
localization  of  the  peritonitis  with  formation  of  ad- 
hesions, resulting  oftentimes  in  walling  of¥  abscess 
cavities.  In  those,  purgatives  of  every  type  are 
highly  contraindicated.  The  lower  bowel  must  be 
kept  flushed  out  with  warm  water  enemata.  Normal 
saline  enemata  given  every  six  hours  or  by  the  drop 
method.  All  food  is  given  by  the  rectum.  If  the 
stomach  is  irritable,  gastric  lavage  will  be  serviceable. 
Hofifmann's  anodyne  or  drop  doses  of  creosote  or 
phenol  may  be  of  assistance  in  the  alleviating 
nausea.  Absolute  rest,  use  of  the  bed  pan  and 
urinal,  local  application  of  ice  bags  should  be  main- 
tained. Patients  treated  medically  can  not  entirely 
be  dismissed  after  an  acute  attack.  They  should 
live  model  lives  as  to  diet  and  hygiene  and  never 
indulge  in  excesses  of  any  nature.  Special  attention 
should  be  given  to  regulation  of  the  bowels.  Laxa- 
tive food  or  laxative  medicines  are  a  necessity ;  so, 
also,  is  the  avoidance  of  purgatives. 

In  summing  up  the  medical  treatment  of  all  cases 
of  appendicitis  we  would  emphasize  the  absolute 
rest,  extreme  caution  in  the  employment  of  purga- 
tives and  morphine,  and  the  local  application  of  dry 
cold. 

{To  be  Concluded.) 


Treatment  of  Acute  Coryza. — Lemoine,  of  Lille, 
in  a  recent  article  {Journal  de  mcdccinc  et  dc  clii- 
nirgie  pratique;  through  The  Practitioner  for  l\Iay, 
1909)  gave  a  large  number  of  practical  suggestions. 

To  abort  a  cold,  a  pinch  of  one  of  the  following 
powders  should  be  taken  every  hour : 

R    Cocaine  hydrocliloride,   gr.  vijss; 

^Menthol  gr.  iv; 

Salol, 

Boric  acid  aa  jss. 

Misce.   Fiat  pulvis. 

•  Or, 

B    Salol,   Siiss; 

Salicylic  acid,  gr.  xxx; 

Tannic  acid,   gr.  xv; 

Boric  acid  5x. 

M. 

Saliil  c:innot  always  be  trusted  m^t  to  prove  some- 
what irritating  :  a  better  formula  is  : 

^*     Cocaine  hydrochloride,   gr.  1/4; 

Alum  gr.  xxx  ; 

Menthol.  '.  gr.  viiss  ; 

Pulverized  sugar, 

Boric  acid,   aa  5v. 

Insufflations  may  be  made  with  : 
Calomel. 

Morphine  hydrochloride,   aa  gr.  1/6; 

Bisnuith  suhnitrnte  5iiss. 

On  the  other  hand,  Weitlauer,  of  Innsbruck,  com- 
mends the  internal  use  of  .sodium  salicylate,  combined 
with  Dover's  powder,  which,  it  is  s'lid,  will  afford 
relief  one  hour  after  beginning  treatment. 

B     Sodium  salicylate  3j  ; 

Dover's  powder,   gr.  xlv ; 

Spirit  of  peppermint  TTtJ- 

Misce.  l-'iat  pulvis.  To  he  divided  into  20  portions,  one 
of  which  is  to  be  taken  in  a  little  water  every  three  or  four 
hours. 

.At  a  mf)re  advanced  stage,  when  the  nature  of 


the  secretion  has  changed,  inert  or  antiseptic  pow- 
ders should  be  prescribed. 
B     Cocaine  hydrochloride, 

Morphine  hydrochloride  aa  gr.  1/4; 

Tannic  acid,   3iiss  ; 

Bismuth  salicylate  5v; 

Boric  acid, 

Pulverized  talc  ■  aa  5vj. 

Misce.  Fiat  pulvis.  Sig. :  One  pinch  to  be  taken  every 
two  hours. 

Or, 

^    Cocaine  hydrochloride,   gr.  1/6 j ; 

Camphor  gr.  j ; 

Pulverized  sugar  3ij ; 

Morphine  hydrochloride,   gr.  j ; 

Pulverized  acacia,   3j ; 

Bismuth  subnitrate. 

Pulverized  mallow,   aa  5iss. 

For  the  application  of  antiseptics  to  the  nasal 
fossae,  Lemoine  prefers  to  make  use  of  ointments,  in 
which  dift'erent  substances  can  be  associated  in  order 
to  increase  the  antiseptic  effect. 
^     Cocaine  hydrochloride. 

Salol,  aa  gr.  1/3  ; 

Menthol  gr.  ss  ; 

Boric  acid,   3ss  ; 

Petrolatum,   ^j- 

Misce.  Fiat  unguentum.  Sig. :  A  piece,  the  size  of  a 
large  pea,  to  be  placed  in  each  nostril  three  or  four  times 
a  day. 

The  Treatment  of  Intestinal  Dyspepsia. — As 

laxatives  in  the  treatment  of  intestinal  dyspepsia,  a 
writer  in  the  Revue  de  therapeutique  for  March  15, 
1909,  quotes  Robin  as  recommending  the  following 
saline  purgative : 

B    Sodium  sulphate  3ii ; 

Magnesium  sulphate,   3i. 

M.  et  ft.  pulv.  No.  I. 

Sig. :  Dissolve  in  half  glassful  of  warm  water,  add  a 
quarter  of  a  glassful  of  seltzer  water,  and  take  on  rising 
in  the  morning. 

Another  rciore  drastic  purgative  recommended  by 
Robin  is  the  following: 
R    Aloes,  \ 

Jalap  resin,  I  aa  gr.  iss; 

Scammony  resm,  f 
Turpeth  root,  ) 

Extract  of  h^•oscvamus.  I  -- 

C  cyj"  1/7 

Extract  of  belladonna,  I 

Almond  soap,   q.s. 

M.  et  ft.  pil.  No.  20. 

Sig.    One  to  three  pills  to  be  taken  on  retiring. 

Laxatives  in  Hyperchlorhydria.  —  Linossier 
{Hygiene  des  dyspepfiques,  through.  The  Practi- 
tioner) advises  the  following  laxative  preparations 
as  more  especially  suited  to  cases  of  hyperchlor- 
hydria. If  this  condition  requires  correcting  to- 
wards the  end  of  digestion,  an  alkaline  powder  is 
then  given,  in  which  magnesia  is  the  chief  constitu- 
ent. Otherwise,  one  or  two  teaspoonfuls  of  the  fol- 
lowing are  given  after  the  evening  meal  in  half  a 
glassful  of  water : 
R  Magnesia, 
Rochelle  salt. 

Sugar  of  milk  aa  5ij ; 

Pulverized  licorice  5j ; 

M. 

Or,  on  waking  in  llie  morning,  a  teaspoonfnl  of: 

Sodium  sulphate. 
Sodium  phosphate. 

Roclielle  salt  p.e. 

M. 


June  12,  1909.] 


EDITORIAL  ARTICLES. 


1203 


NEW  YORK  MEDICAL  JOURNAL 

IN'CORPORATIXG  THE 

Philadelphia  Medical  Journal 
and  The  Medical  News. 

A  Weekly  Review  of  Medicine. 

Edited  by 
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Philadelphia. 

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NEW  YORK.  S.ATURDAY,  TUNE  12,  1909. 


SOME  PUBLIC  HEALTH  PROBLE^IS. 

There  was  a  time,  not  very  long  ago,  when  the 
functions  of  the  public  health  authorities  were  sup- 
posed to  be  irmited  to  the  control  of  malignant  epi- 
demic diseases  like  cholera  and  smallpox,  to  the  su- 
pervision of  scarlet  fever  and  diphtheria,  and  to  the 
disinfection  of  infected  dwellings.  In  contrast  with 
this  it  may  be  of  interest  to  glance  at  some  of  the 
problems  now  engaging  the  attention  of  health  offi- 
cials. Curiously,  one  of  the  most  difficult  problems 
is  also  one  of  the  oldest,  namely,  the  cause  and  the 
mode  of  spread  of  the  exanthemata.  It  is  true  that 
certain  cellular  structures  have  been  hailed  as  the 
aetiological  factor  in  variola,  and  that  similar  bodies 
have  been  looked  upon  by  some  as  the  cause  of  scar- 
let fever,  but  the  weight  of  evidence  appears  to  be 
against  this  interpretation  of  their  character.  The 
streptococcus  found  in  scarlet  fever  is  held  by  the 
best  authorities  to  be  merely  a  secondary  invader.  A 
great  deal  of  importance  has  heretofore  been  at- 
tached to  the  scaling  skin  as  the  carrier  of  the  in- 
fection of  scarlet  fever  and  measles,  but  there  is  con- 
siderable reason  to  doubt  that  this  plays  any  impor- 
tant role. 

The  recognition  of  the  causative  germ  in  an  in- 
fectious disease,  however,  is  by  no  means  all  that  is 
needed  to  combat  the  spread  of  that  disease.  An  in- 
structive example  of  this  is  presented  by  pneumonia. 
It  will  be  recalled  that  the  careful  investigations 
made  under  the  auspices  of  the  commission  appoint- 
ed bv  the  Xew  York  Board  of  Health  some  vears 


ago  showed  that  pneumococci  could  be  isolated  from 
the  throats  of  many  healthy  individuals,  and  that 
there  was  little  or  no  difference  between  such  or- 
ganisms and  those  isolated  from  pneumonic  lungs. 
HencCi  although  the  causative  germ  of  pneumonia  is 
known,  the  causes  of  the  disease,  i.  e.,  the  factors 
determining  infection,  are  still  entirely  unknown. 

Considerable  interest  has  recently  been  aroused  by 
the  so  called  "typhoid  bacilli  carriers."'  In  most  in- 
stances these  carriers  give  a  history  of  having  had 
typhoid  fever,  but  now  and  then  cases  are  encoun- 
tered in  which  no  previous  infection  can  be  discov- 
ered. Thus  far  no  general  method  has  been  discov- 
ered to  rid  these  carriers  of  typhoid  bacilli,  and  it 
is  obviously  impracticable  to  isolate  such  individuals. 
At  the  present  time,  therefore,  these  chronic  germ 
carriers  present  one  of  the  most  perplexing  prob- 
lems confronting  public  health  authorities.  Similar 
conditions  occur  in  diphtheria  and  in  other  infec- 
tious diseases,  though  probably  less  frequently. 

There  is  some  reason  to  believe  that  the  venereal 
diseases,  especially  syphilis,  are  becoming  more 
prevalent.  The  solution  of  the  problem  thus  pre- 
sented is  closely  bound  up  with  the  proper  control  of 
prostitution,  but  how  to  effect  this  control  is  itself  a 
problem  which  has  vexed  society  for  ages.  It  has 
been  realized  that  much  might  be  accomplished  by 
education,  and  in  many  schools,  especially  in  Ger- 
many, pupils  in  the  upper  grades  now  receive  care- 
ful instruction  in  sexual  hygiene. 

It  is  conceded  by  most  persons  who  have  studied 
the  question  that  cancer  is  becoming  more  preva- 
lent. This  is  most  disquieting,  especially  since  no 
agreement  has  been  reached  even  as  to  the  essential 
nature  of  cancer,  i.  e..  as  to  whether  it  is  of  extrin- 
sic or  of  intrinsic  origin.  It  is  true  that  Ehrlich  has 
succeeded  in  producing  a  certain  degree  of  im- 
munity in  mice,  but  this,  as  he  himself  points  out, 
does  not  necessarily  indicate  the  infectious,  i.  e., 
extrinsic,  nature  of  the  tumors. 

The  past  few  decades  have  also  witnessed  an  in- 
crease in  deaths  from  diseases  of  the  heart  and  kid- 
ney. The  relation  between  these  and  disease  of  the 
arteries  is  very  close,  so  that  it  is  proper  to  look  for 
a  common  jetiological  factor  for  all  these  conditions. 
It  is  true  that  the  use  of  alcohol  as  a  beverage  and 
also  the  indulgence  in  tobacco  have  been  charged 
with  bringing  on  much  of  this  disease,  but  the  evi- 
dence has  been  far  from  conclusive.  The  careful 
metabolism  investigations  now  being  made  in 
Bright's  disease  should  shed  some  light  on  this  im- 
portant group  of  diseases. 

The  enormous  mortality  among  infants  presents 
another  important  problem,  though  the  work  al- 
ready done  indicates  that  the  solution  lies  in  the 
maintenance  of  stations  where  mothers  mav  receive 


1  204 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal. 


proper  instruction  in  infant  feeding  and  where 
suitable  milk  may  be  supplied  when  needed.  In 
order  to  be  most  effective,  however,  this  work  should 
be  supplemented  by  having  trained  nurses  and 
physicians  visit  the  people  living  in  the  crowded 
tenement  districts,  giving  such  instruction  as  may 
be  needed.  Closely  connected  with  the  problem 
of  infant  mortality  is  that  concerning  the  milk 
supply  generally.  Through  the  system  of  permits 
introduced  by  the  board  of  health  it  is  pos- 
sible to  exercise  a  rigid  control  of  all  milk  offered 
for  sale  in  Xew  York.  At  the  present  time,  how- 
e\'er,  it  is  impossible  to  insist  on  standards  which 
will  always  insure  a  safe  milk  for  infant  feeding 
without  materially  raising  the  cost  of  milk  to  the 
consumer.   The  sooner  this  is  realized  the  better. 

A  great  deal  has  lately  been  written  about  the  role 
of  flies  in  the  spread  of  infectious  diseases.  It  is 
true,  of  course,  that  a  fly  may  infect  a  pitcher  of 
milk,  especially  with  intestinal  bacteria.  It  is  also 
true  that  the  curve  of  greatest  fly  prevalence  corre- 
sponds somewhat  to  that  of  deaths  from  diarrhoeal 
■diseases.  Much  more  careful  investigations,  how- 
ever, than  have  yet  been  reported  need  to  be  made 
to  establish  the  role  of  flies  in  the  transmission  of 
these  diseases. 

Despite  the  splendid  work  already  accomplished, 
much  remains  to  be  done  to  stamp  out  tuber- 
culous disease.  So  high  an  authority  as  Koch 
recently  prophesied  that  sooner  or  later  the  mere 
continuance  of  the  present  campaign  would  fail  to 
reduce  the  tuberculous  death  rate  further,  and  that 
only  by  the  application  of  new  knowledge  and  new 
methods  would  continued  improvement  be  possible. 
If  one  can  judge  from  the  interest  now  being  taken 
in  the  problem  all  over  the  country,  a  great  deal  of 
effective  work  can  still  be  done  along  the  old  lines 
for  many  years  to  come. 


THE  ATLANTIC  CITY  MEETING. 
The  annual  meeting  of  the  American  Medical  As- 
sociation, which  at  the  time  of  this  writing  is  draw- 
ing to  a  close,  was  one  of  normal  size  and  interest, 
by  no  means  so  large  as  either  the  Boston  or  the 
Chicago  meeting.  There  was  no  great  matter  to 
ruffle  the  House  of  Delegates,  and  everything  was 
harmonious.  The  formal  addresses  possessed  the 
usual  merits,  and  the  work  of  the  sections  was  sat- 
isfactorily interesting.  It  was  gratifying  to  note 
the  expansion  of  the  scientific  exhibits,  in  which  the 
indefatigable  Dr.  Wynn,  of  Indianapolis,  enjoyed 
the  cooperation  of  various  schools,  hospitals,  and 
sanitary  bodies ;  and,  in  particular,  it  was  pleasing 
to  observe  that  the  exhibits  bearing  upon  the  sub- 
ject of  tuberculous  disease  showed  a  wholesome  di- 


minution of  the  "scare"  element,  that  element  which 
may  so  easily  produce  in  the  public  mind  a  panicky 
dread  of  intercourse  with  tuberculous  individuals. 

The  charming  trivialities  of  the  Board  Walk  had 
to  contend  for  much  of  the  time  with  chilly  and 
rainy  weather,  the  general  effect  being  to  remind 
one  of  Dickens's  description  of  the  carnival  in  a 
small  Italian  town,  in  which  he  said  that  it  "con- 
sisted of  one  man  dressed  like  a  woman  and  one 
woman  dressed  like  a  man.  wading  through  the 
streets  and  looking  very  miserable."  Nevertheless, 
the  multitude  was  cheery,  the  dinners  and  other  fes- 
tivities lacked  nothing  of  their  expected  brilliancy, 
and  an  increased  number  of  college  alumni  associa- 
tions made  merry  and  cemented  anew  the  brother- 
hood of  their  members. 


THE  UNITED  STATES  PHARMACOPCEIA 
IN  SPANISH. 

At  the  second  International  Sanitary  Convention 
of  the  American  Republics,  held  in  Washington  in 
1905,  a  resolution  was  adopted  to  the  effect  that  a 
translation  of  the  United  States  Phannacopceia  into 
the  Spanish  language  would  prove  of  great  benefit 
to  the  medical  profession  and  the  pharmacists  in  each 
of  the  republics  represented.  It  is  in  consonance 
with  the  spirit  of  this  resolution  that  the  Board  of 
Trustees  have  undertaken  the  publication  of  that 
work  in  Spanish'.  In  view  of  the  fact  that  the  Food 
and  Drugs  Act  of  June  30,  igo6,  established  the 
Pharmacopoeia  as  a  legal  standard  in  all  the  posses- 
sions of  the  United  States,  it  became  our  duty  to  the 
Spanish  speaking  inhabitants  of  the  territory  com- 
prised within  Puerto  Rico  and  the  Philippine  Islands 
to  furnish  a  Spanish  edition  of  this  work  for  their 
guidance,  and  the  duty  has  been  well,  if  somewhat 
tardily,  performed. 

It  is  rather  unfortunate  that  the  publication  of  the 
Spanish  edition  has  been  so  long  delayed,  for  it 
seems  reasonable  to  suppose  that  its  publication  will 
be  a  considerable  factor  in  bringing  about  a  closer 
understanding  between  the  medical  profession  in  the 
United  States  and  that  of  the  Spanish  speaking 
countries.  The  importance  given  to  purely  commer- 
cial affairs  in  the  American  drug  stores  has,  wc  have 
no  doubt,  made  our  Spanish  South  American  neigh- 
bors underrate  the  scientific  attainments  of  Ameri- 
can pharmacists.  The  United  States  Pharmacopa:ia, 
which  may  in  its  details  be  taken  as  an  exponent  of 
the  scientific  status  of  American  pharmacy  at  the 

iFarmacopoea  de  los  Estados  Uiiidos  de  America,  Octava  Revision 
Decenal,  Autoiizada  por  la  Convcncion  de  la  Faimacopoea  de  los 
Estados  Unidos,  Rcunida  en  Washington  el  ano  1900  A.  D. 
Revisada  por  cl  Comite  el  Revision  y  publicada  per  la  Junta  Di- 
rectiva.  Official  desde  Septiembre  i  de  1905  ineluycnte  adiciont's 
y  corrcccioncs  hasta  i  de  Tunio  i907-  .Agentes,  .American  Dni.j;- 
gist  Publishing  Company,  fresidcnte  .\.  R.  Elliott.  Nucva  York, 
N.  v.,  pp.  v-lxxiii:  pp.  3-662. 


June  12,  1909.] 


EDITORIAL  ARTICLES. 


1205 


time  of  its  compilation,  some  six  or  eight  years  ago, 
will,  we  think,  give  to  the  Spanish  pharmacists  a 
much  more  favorable  idea  of  their  northern  con- 
freres. 

The  Spanish  speaking  physician  and  pharmacist, 
in  comparing  this  work  with  the  Spanish  Pharmaco- 
poeia and  the  French  Codex,  must  bear  in  mind  that, 
while  it  bears  the  date  of  1909,  it  represents,  save 
for  a  few  minor  corrections  made  in  1907,  the  thera- 
peutics and  pharmacy  of  1904  and  not  of  1909,  for 
it  was  in  1904  that  the  English  edition  of  the  phar- 
macopoeia went  to  press,  though  it  bears  the  date  of 
1905.  Such  omissions  as  that  of  the  curative  serums, 
for  instance,  which  appear  in  the  French  and  not  the 
American  work,  are  explicable  on  the  ground  that  in 
1900,  when  the  convention  was  held  which  author- 
ized the  eighth  decennial  revision,  the  subject  of  an- 
titoxines  was  comparatively  new  and  but  little  un- 
derstood. 

We  feel  sure  that,  on  the  whole,  the  Spanish  edi- 
tion of  this  work  will  make  a  favorable  impression, 
though  the  latinity  of  the  nomenclature  is  not  at  all 
in  accord  with  European  models,  and  is  perhaps  open 
to  adverse  criticism.  The  work  is  translated  in  its 
entirety,  the  only  additional  matter  inserted  being 
the  formal  authorization  of  its  publication  by  the 
Board  of  Trustees  and  a  brief  preface  by  the  trans- 
lator, Professor  Jose  Gtiillermo  Diaz,  of  the  Uni- 
versity of  H-avana,  who  was  assisted  by  Dr.  Placido 
Biosca.  The  Spanish  edition  follows  closely  the 
typography  of  its  English  prototype,  and  the  result 
is  a  clear,  legible,  and  well  made  volume  which  is 
bound  in  simple  green  cloth  in  a  fairly  satisfactory 
manner. 


SYSTEM  IN  NOMENCLATURE. 

However  desirable  it  may  be  to  have  a  nomencla- 
ture of  diseases  constructed  on  a  definite  and  uni- 
form system — for  example,  on  the  basis  of  aetiology 
— such  a  nomenclature  is  at  present  impossible  of 
attainment,  and  it  must  continue  to  be  unattainable 
until  our  knowledge  is  much  closer  to  perfection 
than  it  is  now.  But  a  diversified  system  does  not 
imply  lack  of  system,  and  we  shall  probably  always 
follow  the  plan  of  constructive  nomenclature  and 
classification  lists  on  variegated  patterns,  making 
aetiology  the  basis  in  one  place,  pathology  in  an- 
other, localization  in  a  third,  and  so  on.  This  is  one 
of  the  subjects  dealt  with  in  a  learned  address  re- 
cently delivered  before  the  Medical  Society  of  Lon- 
don by  Dr.  H.  D.  Rolleston,  senior  physician  to  St. 
George's  Hospital  (Lancet,  May  22d). 

Dr.  Rolleston  intimates  that  a  nomenclature  need 
not  be  consistent,  but  should  rather  be  convenient, 
inasmuch  as  it  should  serve  practical  purposes  and 


especially  facilitate  the  work  of  the  statistician.  One 
of  the  collateral  advantages  which  should  result 
from  an  official  nomenclature,  he  says,  is  "the  grad- 
ual extinction  of  the  numerous  synonyms  for  dis- 
eases which  often  serve  only  to  confuse."  "The  names 
of  diseases,"  he  continues,  have  been  arrived  at  in 
various  ways.  Some  refer  to  the  cause  of  the  dis- 
ease— for  example,  alcoholism ;  some  recall  the  mor- 
bid change  underlying  the  symptoms — e.  g.,  neuri- 
tis ;  others  mention  the  most  striking  symptoms — 
e.  g.,  paraplegia ;  or  the  disease  may  have  a  more  or 
less  arbitrary  name  which  does  not  attempt  to  de- 
scribe or  explain  its  nature." 

Though  a  name  may  be  of  such  trifling  signifi- 
cance that  it  is  "merely  a  label,"  it  is  apt,  when  of 
popular  origin,  as  is  the  case  with  mumps,  influenza, 
and  scarlatina,  to  be  "so  identified  with  our  concep- 
tion of  the  di  ease  that  any  change  is  undesirable." 
We  fully  agree  to  this,  and  we  agree  also  to  the  au- 
thor's defense  of  personal  names  under  certain  cir- 
cumstances, though  it  is  rather  trying,  as  he  points 
out,  to  struggle  with  "Addison's  disease  of  the  supra- 
renal capsules,  Addison's  cheloid  (morphoea,  or  cir- 
cumscribed sclerodermia),  and  Addison's  (perni- 
cious) anaemia ;  and,  on  the  surgical  side.  Pott's  dis- 
ease of  the  spine.  Pott's  fracture,  and  Pott's  pufify 
tumor  of  the  skull,  and  Paget's  disease  of  bone.  Pa- 
get's  disease  of  the  nipple,  and  the  almost  forgotten 
Paget's  'recurrent  fibroid'  (spindle  celled  sarcoma  of 
the  subcutaneous  tissues)." 

Examples  of  what  may  be  termed  aberrance  of 
the  eponymic  plan  of  naming  diseases  are  to  be 
found  in  the  assignment  to  a  disease  of  the  name  of 
a  person  who  was  the  subject  of  it,  as  in  "Thom- 
sen's  disease,"  and  in  the  compounding  of  names  of 
the  observer  and  the  patient,  as  in  "the  Flexner- 
Harris  strain  of  the  Bacillus  dysentericc,  which  de- 
pends on  its  isolation  by  Flexner  from  the  stools  of 
a  patient  named  Harris."  Eponymic  nomenclature 
doubtless  has  other  drawbacks  than  these  perplexi- 
ties and  absurdities,  but,  we  think,  it  still  has  a  legit- 
imate if  limited  place  in  any  onomatology  that  is  to 
prove  convenient.  It  is  evident  that  rigid  uniform- 
ity in  the  naming  of  diseases  is  impracticable. 

THE  NATURE  OF  DISEASE. 
Dr.  Hugo  Ribbert,  professor  of  pathology  in  the 
University  of  Bonn,  is  one  of  the  very  few  philoso- 
phical medical  writers  of  to-day,  of  whom  Germany 
had  formerly  quite  a  number.  He  has  written  a 
very  interesting  book  which  appeared  a  month  ago: 
Das  We  sen  der  Krankheit  (Bonn,  Friedrich 
Cohen,  1909),  in  which  he  lays  down  his  thera- 
peutical creed.  The  book  contains  a  few  recapitu- 
lations from  some  of  the  author's  former  writings. 


I206 


NEWS  ITEMS. 


[New  York 
Medical  Journal. 


but  it  gives  also  many  new  and  original  ideas.  We 
have  mentioned  in  these  pages  Dr.  Ribbert's  genesis 
of  carcinoma  (Nezv  York  Medical  Journal,  July  6, 
1907,  page  31)  and  his  theory  of  death  by  old  age 
{Xew  York  Medical  Journal,  September  26,  1908, 
page  608).  Both  these  theories  we  meet  again  in 
his  new  book.  There  are  many  pathologists  who 
will  not  follow  him  and  who  are  diametrically  op- 
posed to  his  ideas,  but  the  reading  of  his  book  is 
refreshing  and  stimulating. 

He  comes  to  the  conclusion  that  disease  is  the 
sequel  of  diminished  life  action,  resulting  from 
changes  in  the  construction  of  the  body ;  it  appears 
when  our  tissues  are  unable  to  adapt  themselves  to 
external  influences;  it  is  therefore  the  expression 
of  deficiency  in  adaptation.  The  obnoxious  influ- 
ences to  which  the  body  cannot  become  accustomed 
produce  disease  by  diminishing  the  function  of  one 
or  another  or  several  of  the  organs,  but  never  by 
directly  attacking  the  functions  of  the  cells  by  in- 
creasing their  activity.  Thus  increased  activity  in 
the  cells  is  not  a  symptom  of  disease,  but  is  a  sign 
of  changes  which  may  produce  disease,  or  this  in- 
creased activity  of  the  cells  may  result  in  improv- 
ing and  healing  processes,  such  as  regeneration, 
compensatory  hypertrophy,  inflammation,  etc.  The 
processes  which  produce  a  cure  are,  therefore,  the 
result  of  the  possibility  of  adaptation  to  a  change 
of  condition. 

 ^  

Changes  of  Address. — Dr.  Henry  I.  Fischer,  to  361 
West  Nineteenth  Street,  New  York. 

Dr.  Neil  Macpliatter,  to  249  Madison  Avenue,  New  York. 

The  Baltimore  College  of  Physicians  and  Surgeons 
held  its  annual  conmicncement  exercises  on  June  2d,  forty- 
six  new  physicians  receiving  diplomas. 

Bradford  Street  Hospital,  Brooklyn. — Plans  have  been 
filed  for  the  new  Bradford  Street  Hospital,  which  is  to  oc- 
cupy the  block  in  Dumont  Street  between  Bradford  Street 
and  Miller  Avenue.  The  building  will  be  of  light,  buff 
colored  brick,  and  will  cost  $250,000. 

Promotions  and  Appointments  at  the  Rockefeller  In- 
stitute for  Medical  Research  were  made  as  follows  at  a 
meeting  of  the  board  of  trustees  held  on  May  29th  :  Asso- 
ciate, Paul  A.  Lewis,  pathology ;  assistant,  F.  Peyton  Rous, 
pathology;  scholar,  Angelia  M.  Courtney,  chemistry. 

Improvements  at  Tufts  Medical  College. — Announce- 
ment was  made  by  the  trustees  of  the  college,  at  the  annual 
dinner  of  the  alumni  association,  that  the  sum  of  $100,000 
would  be  expended  in  enlarging  and  remodeling  the  medi- 
cal school.  Plans  are  being  made  and  the  work  will  be  car- 
ried on  as  rapidly  as  possible. 

Queens-Nassau  Medical  Society. — The  annual  meet- 
ing of  the  society  was  held  in  Brooklyn  on  June  4th.  The 
attendance  was  not  large.  Dr.  J.  P.  Wood,  of  Jamaica,  was 
elected  president ;  Dr.  A.  W.  Jaggar,  of  Flushing,  was  made 
vice-president,  and  Dr.  Jaines  S.  Cooley,  of  Glcncove.  was 
reelected  secretary  and  treasurer. 

Colonel  Gorgas  Honored. — At  the  eighty-fourth  an- 
nual commencement  of  Jefferson  Medical  College,  of  Phil- 
adelphia, the  honorary  degree  of  Doctor  of  Laws  was  con- 
ferred upon  Colonel  William  C.  Gorgas,  chief  sanitary  offi- 
cer of  the  Panama  Canal  Commission,  and  president  of  the 
American  Medical  Association. 


The  Harrington  Hospital  for  Children,  which  forms 
a  part  of  the  Buffalo  General  Hospital,  was  dedicated  with 
suitable  ceremonies  on  May  27th.  Mr.  Charles  W.  Pardee, 
president  of  the  Buffalo  General  Hospital,  presided  and  de- 
livered the  principal  address.  The  new  hospital  was  built 
as  a  meinorial  to  the  late  Dr.  Devillo  W.  Harrington, 
whose  generous  legacy  made  its  erection  possible. 

The  American  Medicopsychological  Society  met  in 

annual  session  at  the  Marlborough-Blenheim  Hotel,  At- 
lantic City,  N.  J.,  on  June  1st,  2d,  and  3d,  and  elected  the 
following  officers  for  the  ensuing  year :  Dr.  William  F. 
Drewry,  of  Petersburg,  Va.,  president ;  Dr.  Charles  W. 
Pilgrim,  of  Poughkeepsie,  vice-president;  Dr.  C.  G.  Wag- 
ner, of  Binghamton,  N.  Y..  secretary  and  treasurer. 

Officers  of  the  American  Gastroenterological  Associa- 
tion.—At  the  twelfth  annual  meeting  of  this  association, 
held  in  Atlantic  City,  June  7  and  8,  1909,  the  following 
officers  were  elected  for  the  ensuing  year:  President,  Dr. 
Julius  Friedenwald.  of  Baltimore;  first  vice-president,  Dr. 
W.  B.  Cannon,  of  Boston ;  second  vice-president,  Dr.  John 
A.  Lichty,  of  Pittsburgh ;  secretary  and  treasurer.  Dr. 
Charles  D.  Aaron,  of  Detroit. 

The  American  Paediatric  Society  elected  the  follow- 
ing officers  at  the  annual  meeting  of  the  society,  held  re- 
cently in  Lenox,  Mass. :  President,  Dr.  D.  L.  Edsall,  of 
Philadelphia ;  secretary.  Dr.  Samuel  S.  Adams,  of  Wash- 
ington ;  treasurer.  Dr.  Charles  H.  Dunn,  of  Boston ;  editor, 
Dr.  L.  E.  La  Fetra,  of  New  York.  The  next  meeting  of  the 
society  will  be  held  in  Washington,  D.  C,  in  1910. 

Officers  of  the  American  Dermatological  Association. 

— At  the  thirty-third  annual  meeting  of  this  association, 
held  in  the  Bellevue-Stratford  Hotel,  Philadelphia,  on  June 
3  to  5,  1909,  the  following  officers  were  elected  for  the  en- 
suing year:  President,  Dr.  William  Allen  Pusey,  of  Chi- 
cago; vice-president.  Dr.  Grover  William  Wende,  of  Buf- 
falo; secretary  and  treasurer,  Dr.  James  M.  Winfield,  of 
Brookl)'n.  The  next  meeting  of  the  association  will  be 
held  in  Washington,  D.  C. 

The  Medical  Club  of  Philadelphia  held  its  final  recep- 
tion for  the  season  at  the  Hotel  Bellevue-Stratford  on  Fri- 
day evening,  June  iith.  Dr. William  C.  Gorgas.  president 
of  the  American  Medical  Association  ;  the  president  elect 
of  the  American  Medical  Association ;  and  Dr.  George  W. 
Wagoner,  president  of  the  Medical  Society  of  the  State  of 
Pennsylvania,  were  the  guests  of  honor,  and  among  the 
guests  were  many  distinguished  members  of  the  profession, 
foreign  and  American,  wlio  were  in  attendance  at  the  At- 
lantic City  meeting. 

The  American  Academy  of  Medicine  held  its  thirty- 
fourth  annual  meeting  in  Atlantic  City  on  Saturday,  June 
5th,  and  Monday,  June  7th.  Officers  for  the  ensuing  year 
were  elected  as  follow-s :  President,  Dr.  James  H.  McBride, 
of  Pasadena,  Cal. ;  vice-presidents.  Dr.  Philip  Zenner,  of 
Cincinnati ;  Dr.  W.  Blair  Stewart,  of  Atlantic  City ;  Dr. 
Ruth  Webster  Lathrop,  of  Philadelphia;  and  Dr.  H.  W. 
Loeb,  of  St.  Louis ;  secretary  and  treasurer,  Dr.  Charles 
Maclrityre,  of  Easton,  Pa. ;  assistant  secretary,  Dr.  Alex- 
ander R.  Craig,  of  Philadelphia. 

The  Montana  State  Medical  Association  held  its 
thirty-first  annual  meeting  in  Missoula  on  May  13th  and 
14th.  Seventy-five  members  were  in  attendance,  and  a 
good  programme  was  presented.  Hunters  Hot  Springs  was 
chosen  as  next  year's  meeting  place,  and  the  following  offi- 
cers were  elected :  President.  Dr.  T.  D.  Tuttle,  of  Helena ; 
first  vice-president,  Dr.  J.  J.  Buckley,  of  Missoula :  second 
vice-president.  Dr.  F.  Cuttle,  of  Hunters  Hot  Springs; 
third  vice-president.  Dr.  F.  E.  Buchen.  of  Hamilton ;  sec- 
retarjs  Dr.  H.  C.  Kistler,  of  Butte;  treasurer.  Dr.  C.  T. 
Pigot,  of  Butte. 

A  Case  of  Suspected  Leprosy  at  the  Skin  and  Cancer 
Hospital,  New  York. — John  R.  Early,  who  has  been 
isolated  as  a  leper  by  the  Federal  authorities  in  Washing- 
ton for  the  past  nine  months,  is  to  be  brought  to  New 
York,  where  he  will  undergo  a  course  of  treatment  at  the 
Skin  and  Cancer  Hospital.  There  is  a  difference  of  opinion 
among  the  pathologists  who  have  examined  the  patient  as 
to  the  diagnosis  of  leprosy.  Tt  is  said  that  Dr.  L.  Bulkley 
Duncan,  in  whose  care  the  patient  will  be.  and  Dr.  William 
1 1.  Park,  pathologist  of  the  New  York  Department  of 
Health,  do  not  believe  that  Early  is  a  leper. 


June  12,  1909.] 


NEWS  ITEMS. 


1207 


Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  June  19,  1909: 

Tuesday,  June  15th. — Dermatological  Society;  Academy  of 
Natural  Sciences ;  North  Branch,  Philadelphia  County 
Medical  Society. 

Wednesday,  June  i6th. — Philadelphia  County  Medical  So- 
ciety (business  meeting  open  to  members  only)  ;  Frank- 
lin Institute. 

Thursday,  June  17th. — Section  meeting,  Franklin  Insti- 
tute ;  Southwark  Medical  Society ;  North  East  Branch, 
Philadelphia  County  Medical  Society. 
Clinics  at  the  Methodist  Episcopal  Hospital,  Phila- 
delphia, were  held  as  follows  for  the  benefit  of  visiting 
physicians:  On  Friday,  June  nth,  at  10  a.  m.,  Dr.  J.  Tor- 
rance Rugh — Excision  of  the  Knee ;  at  2  130  p.  m.,  Dr.  Wal- 
ter Roberts — Adenoids  and  Tonsils ;  at  3  p.  m.,  Dr.  Philip 
H.  Moore — Foreign  Bodies  in  the  Eye.  On  Saturday, 
June  I2th,  at  10  a.  m.,  Dr.  James  Hendrie  Lloyd — Lecture 
upon  nervous  diseases,  with  a  demonstration ;  at  10  a.  m., 
Dr.  Alfred  Hand— Ward  Walk;  Dr.  Harlan  Shoemaker- 
Surgical  Pathology  of  Uterine  Cancer;  at  i  p.  m.,  Dr.  Levi 
J.  Hammond — Operative  Surgery  of  Gallbladder,  Stomach, 
and  Intestines. 

The  Arizona  Association  for  the  Study  and  Preven- 
tion of  Tuberculosis  was  organized  recently  in  Pres- 
cott,  Ariz.,  with  the  following  officers  for  the  first  year : 
Dr.  John  W.  Foss,  of  Phcenix,  president ;  President  K.  C. 
Babcock,  of  Tucson  University,  first  vice-president;  Dr. 
John  E.  Bacon,  of  Tombstone,  second  vice-president;  Rev. 
J.  E.  Crutchfield,  of  Phoenix,  third  vice-president ;  Mr. 
Lloyd  Christy,  of  Phcenix,  treasurer,  and  Dr.  John  W.  Flinn, 
of  Prescott,  secretary.  The  consulting  medical  board  of 
the  association  consists  of  Dr.  O.  E.  Plath,  of  Phcenix; 
Dr.  H.  T.  Southworth,  of  Prescott;  Dr.  W.  V.  Whitmore, 
of  Tucson,  and  Dr.  W.  D.  Cutter,  of  Bisbee.  The  consti- 
tution and  by-laws  of  the  California  association  were 
adopted. 

Infectious  Diseases  in  New  York: 

We  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  followtng  statement  of  new 
cases  and  deaths  reported  for  the  two  weeks  ending  June 
5,  1909: 

,  May  29  V    ,  June  5  i 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis   pulmonalis    510  152         400  193 

Diphtheria    313  45         371  30 

Measles   1,671  25       1,458  30 

Scarlet  fever    .273  21  274  19 

Smallpox   

Varicella    197  ..  142 

Typhoid  fever    28  12  44  7 

Whooping  cough    66  8  66  10 

Cerebrospinal  meningitis    8  7  7  12 

Total   3,086         270      2,762  301 

Philadelphia  Medical  College  Commencements. — The 

Medicochirurgical  College  held  its  twenty-ninth  annual 
commencement  on  Saturday,  June  5th.  The  degree  of 
Doctor  of  Medicine  was  conferred  upon  fifty-six  graduates. 
The  doctorate  oration  was  delivered  by  the  Hon.  Chauncey 
M.  Depew. 

Eighteen  graduates  from  the  Medical  Department  of 
Temple  College  received  the  degree  of  M.  D.  at  the  annual 
commencement,  held  on  June  5th. 

The  Jefferson  Medical  College  held  its  eighty-fourth  an- 
nual commencement  on  June  7th,  one  hundred  and  thirty- 
nine  graduates  receiving  the  degree  of  Doctor  of  Medicine. 
Colonel  William  C.  Gorgas,  of  the  Isthmian  Canal  Com- 
mission, delivered  the  address  to  the  graduating  class. 

Vital  Statistics  of  New  York, — According  to  the 
weekly  report  of  the  Department  of  Health  of  the  City  of 
New  York,  during  the  week  ending  May  29,  1909.  there 
were  reported  1,333  deaths  from  all  causes,  as  compared 
with  1,335  for  the  corresponding  period  in  1908.  The  an- 
nual death  rate  in  a  thousand  population  was  15.23  for 
the  whole  city,  and  for  each  of  the  boroughs  as  follows : 
Manhattan,  15.95;  the  Bronx,  18.14;  Brooklyn,  13.96; 
Queens,  12.78;  Richmond,  13.38.  The  total  infant  mortal- 
ity was  410;  250  under  one  year  of  age,  84  between  one 
and  two  years  of  age,  and  76  between  two  and  five  years  of 
age.  There  were  147  still  births.  There  were  152  deaths 
from  pulmonary  tuberculosis,  120  from  organic  heart  dis- 
eases, 103  from  contagious  diseases,  loi  from  pneumonia, 
89  from  bronchopneumonia,  97  from  Bright's  disease,  120 
from  diarrhoea!  diseases,  of  which  55  were  under  five  years 
of  age,  and  6i  from  cancer.  There  were  68  violent  deaths 
— 10  from  suicide,  2  from  homicide,  and  56  from  accidents. 


A  Conference  of  Health  Boards. — The  twenty-fourth 
annual  Conference  of  State  and  Provincial  Boards  of 
Health  of  North  America  was  held  in  Washington,  D.  C, 
the  first  week  in  Jnue.  The  leprosy  problem  was  thorough- 
ly discussed,  and  a  resolution  presented  by  Dr.  William  C. 
Woodward,  health  officer  of  the  District  of  Columbia, 
recommending  the  establishment  of  a  national  hospital  for 
the  care  and  treatment  of  patients  suffering  from  leprosy, 
was  unanimously  adopted.  The  extension  of  federal  au- 
thority in  matters  relating  to  public  health  was  also  urged. 
All  the  officers  of  the  conference  were  reelected  with  the 
exception  of  the  president.  Dr.  C.  A.  Harper,  of  Wisconsin, 
who  is  to  be  succeeded  by  Dr.  Joseph  Y.  Porter,  of  Florida. 
Dr.  C.  A.  Hodgetts,  of  Montreal,  is  vice-president  of  the 
conference,  and  Dr.  H.  M.  Bracken,  of  Minneapolis,  is  sec- 
retary and  treasurer. 

The  Mortality  of  Chicago. — During  the  week  ending 
May  29,  1909,  there  were  reported  to  the  Department  of 
Health  of  the  City  of  Chicago  654  deaths  from  all  causes, 
as  compared  with  563  for  the  preceding  week  and  578  for 
the  corresponding  period  in  igo8.  The  annual  death  rate 
in  an  estimated  population  of  2,224,490,  was  15.33  'n  a  thou- 
sand population.  The  total  infant  mortality  was  190;  124 
under  one  year  of  age  and  66  between  one  and  five  years 
of  age.  The  principal  causes  of  death  were :  Diphtheria, 
10  deaths ;  scarlet  fever,  8  deaths ;  measles,  8  deaths ; 
whooping  cough,  8  deaths  ;  influenza,  i  death  ;  typhoid  fever, 
6  deaths ;  diarrhoeal  diseases.  42  deaths,  of  which  36  were 
under  two  years  of  age;  pneumonia,  108  deaths;  pulmonary 
tuberculosis,  85  deaths;  other  forms  of  tuberculosis,  17 
deaths ;  cancer,  27  deaths ;  nervous  diseases,  29  deaths ; 
heart  diseases,  62  deaths ;  apoplexy,  10  deaths ;  bronchitis, 
30  deaths ;  Bright's  disease,  46  deaths ;  violence,  52  deaths 
• — suicide,  12;  accidents,  36;  manslaughter,  4;  all  other 
causes,  135  deaths. 

The  Health  of  Philadelphia. — During  the  week  end- 
ing May  22,  1909,  the  following  cases  of  transmissible  dis- 
eases were  reported  to  the  Bureau  of  Health  of  Philadel- 
phia: Typhoid  fever,  89  cases,  11  deaths;  scarlet  fever,  58 
cases,  5  deaths;  smallpox,  i  case,  o  deaths;  chickenpox,  34 
cases,  o  deaths;  diphtheria,  82  cases,  12  deaths;  measles, 
239  cases,  7  deaths ;  whooping  cough,  35  cases,  2  deaths ; 
tuberculosis  of  the  lungs,  109  cases,  55  deaths ;  pneumonia, 
45  cases,  37  deaths ;  erysipelas,  i  case,  3  deaths ;  trachoma, 
I  case,  o  deaths ;  mumps,  28  cases,  o  deaths.  The  follow- 
ing deaths  were  reported  from  other  transmissible  dis- 
eases :  Tuberculosis,  other  than  tuberculosis  of  the  lungs, 
12  deaths;  diarrhoea  and  enteritis,  under  two  years  of  age, 
12  deaths ;  puerperal  fever,  i  death ;  tetanus,  i  death.  The 
total  deaths  numbered  448  in  an  estimated  population  of 
565, 569,  corresponding  to  an  annual  death  rate  of  14.88  in 
a  thousand  population.  The  total  infant  mortality  was 
100;  77  under  one  year  of  age,  23  between  one  and  two 
years  of  age.  There  were  18  still  births;  10  males  and  8 
females.    The  total  precipitation  was  1.37  inches. 

Society  Meetings  for  the  Coming  Week: 

Monday,  June  14th. — New  York  Academy  of  Medicine 
(Section  in  Neurology  and  Psychiatry)  ;  Society  of 
Medical  Jurisprudence,  New  York ;  Corning,  N.  Y., 
Medical  Association ;  Waterbury,  Conn.,  Medical  As- 
sociation. 

Tuesday,  June  15th. — New  York  Academy  of  Medicine 
(Section  in  Medicine)  ;  Buffalo  Academy  of  Medicine 
(Section  in  Pathology)  ;  Triprofessional  Medical  So- 
ciety of  New  York ;  Medical  Society  of  the  County  of 
Kings,  N.  Y. ;  Clinical  Society  of  the  Elizabeth,  N.  J.. 
General  Hospital ;  Syracuse,  N.  Y.,  Academy  of  Medi- 
cine; Ogdensburgh,  N.  Y.,  Medical  Association. 

Wednesday,  June  i6th. — New  York  Academy  of  Medicine 
(Section  in  Genitourinary  Diseases)  ;  Medicolegal  So- 
ciety, New  York ;  New  Jersey  Academy  of  Medicine 
(Jersey  City)  ;  Northwestern  Medical  and  Surgical 
Society  of  New  York ;  New  Haven,  Conn.,  Medical 
Association;  Buffalo  Medical  Club. 

Thursday,  June  ijth. — New  York  Academy  of  Medicine ; 
German  Medical  Society,  Brooklyn ;  Newark,  N.  J., 
Medical  and  Surgical  Society. 

Friday,  June  i8th. — New  York  Academy  of  Medicine  (Sec- 
tion in  Orthopaedic  Surgery)  ;  Clinical  Society  of  the 
New  York  Postgraduate  Medical  School  and  Hospital ; 
East  Side  Physicians'  Association  of  the  City  of  New 
York;  New  York  Microscopical  Society;  Brooklyn 
Medical  Society. 


I208 


NEWS  ITEMS. 


(New  York 
Medical  Journal. 


The  Annual  Dinner  of  the  Boston  University  Medical 
School  Alumni  was  held  on  the  evening  of  June  ist. 
About  one  hundred  alumni  were  present,  and  among 
the  speakers  were  President  Huntington,  of  the  uni- 
versity. Dr.  David  W.  Wells,  the  retiring  president  of 
the  medical  alumni,  Dr.  Elizabeth  B.  Cahill,  and  Dr.  Frank 
O.  Cass.  Announcement  was  made  that  the  fund  of  $3.6oo 
for  an  alumni  sholarship  had  been  completed.  Officers 
were  elected  as  follows :  President,  Dr.  W.  H.  Watters ; 
vice-presidents,  Dr.  Mary  A.  Leavitt  and  Dr.  Elizabeth  E. 
Shaw ;  secretary,  Dr.  Edward  S.  Calderwood ;  assistant  sec- 
retary. Dr.  Harry  J.  Lee,  of  Somerville ;  treasurer,  Dr.  H. 
A.  Boyd;  auditor,  Dr.  Clarence  Crane;  directors.  Dr.  E.  E. 
Allen,  Dr.  F.  L.  Emerson,  Dr.  Wesley  T.  Lee,  Dr.  J.  A. 
Rockwell,  and  Dr.  David  W.  Wells. 

Physicians  to  File  Death  Certificates. — An  amend- 
ment has  been  made  to  the  public  health  law  of  the  State 
of  New  York  which  provides  that  when  a  patient  dies  a 
certificate  of  the  death  and  the  probable  cause  must  be  de- 
livered to  the  local  registrar  by  the  physician  within  twen- 
ty-four hours.  This  amendment  transfers  the  responsibility 
from  the  undertaker  to  the  physician.  Under  the  new  law, 
in  case  an  inquest  is  required,  the  coroner  or  coroner's 
physician  must  fill  out  the  certificate,  and  if  no  inquest  is 
required  and  no  physician  has  been  in  attendance,  the  cer- 
tificate shall  be  filled  out  by  some  reputable  persons  known 
to  the  official  issuing  the  burial  permit,  and  the  person  thus 
acting  must  make  an  affidavit  to  the  facts  set  forth  in  the 
death  certificate.  The  old  law  required  an  undertaker  to 
file  the  physicians'  certificate  before  securing  a  buria^  per- 
mit. The  amendment  permits  the  State  Health  Depart- 
ment to  deal  directly  with  the  physician. 

The  Seventh  International  Congress  .of  Applied 
Chemistry  was  opened  in  London  on  May  27th,  the 
Prince  of  Wales,  representing  King  Edward,  welcoming 
the  polyglot  assembly  in  a  speech  in  which  he  expressed  his 
appreciation  of  the  important  part  chemistry  had  played  in 
almost  every  branch  of  modern  industry.  Sir  Henry  Ros- 
coe  then  welcomed  the  delegates  on  the  part  of  the  British 
chemists,  and  addresses  were  made  by  Dr.  H.  W.  Wiley 
and  Sir  William  Ramsay.  Over  three  thousand  members 
w^ere  in  attendance,  and  the  programme  included  papers  by 
men  of  international  reputation  in  the  chemical  world. 
The  work  of  the  congress  was  divided  into  eleven  sections. 
At  the  closing  session,  which  was  held  on  June  2d,  an  in- 
vitation was  tendered  by  Ambassador  Reid  to  hold  the  next 
congress  in  1912  in  Washington,  D.  C.  The  invitation  was 
accepted  by  acclamation.  Professor  E.  W.  Morley,  of 
West  Hartford,  Conn.,  was  unanimously  elected  honorary 
president  of  the  1912  congress,  and  Dr.  W.  H.  Nichols,  of 
New  York,  was  made  acting  president. 

Personal. — Dr.  Louis  L.  Seaman,  of  New  York,  who 
has  been  in  Africa  for  some  time  studying  the  sleeping 
sickness,  has  arrived  in  Paris  from  Mombassa.  While  in 
Africa  Dr.  Seaman  spent  some  time  with  the  Roosevelt 
party. 

Dr.  F.  M.  Pottenger,  of  Monrovia,  Cal.,  delivered  an  ad- 
dress on  Early  Diagnosis  of  Tuberculosis,  on  the  evening 
of  May  31st,  at  the  Cincinnati  Academy  of  Medicine. 

Dr.  Thomas  A.  Lee  has  been  appointed  resident  physi- 
cian of  the  Casualty  Hospital,  Washington  D.  C,  to  succeed 
Dr.  H.  Watson  Moffitt,  who  resigned  recently. 

Sir  Alexander  Simpson,  formerly  dean  of  the  medical 
faculty  of  the  University  of  Edinburgh,  delivered  an  ad- 
dress in  the  Fifth  Avenue  Presbyterian  Church,  New  York, 
on  Sunday  morning.  June  6th,  to  a  large  class  of  mission- 
aries who  are  about  to  start  for  the  Orient. 

Dr.  Sidney  Lange  has  been  appointed  head  of  the  Ront- 
gen  laboratory  of  the  Cincinnati  Hospital,  w  ith  the  rank  of 
staff  officer. 

Dr.  E.  A.  Meycrding  has  been  appointed  medical  inspec- 
tor of  the  public  schools  of  St.  Paul,  Minn. 

Dr.  J.  A.  Estopinal,  secretary  of  the  Louisiana  State 
Board  of  Health,  has  been  appointed  special  medical  in- 
spector of  the  island  of  Cuba,  with  headquarters  at  Havana. 
Dr.  Edward  S.  Kelly  has  been  appointed  secretary  of  the 
State  Board  to  succeed  him. 

Dr.  J.  W.  Kennedy,  of  Philadelphia,  was  severely  in- 
jured in  an  automobile  accident  in  Mount  Holly,  N.  j.,  on 
June  6th.  He  was  driving  with  Dr.  Roberts,  also  of  Phila- 
delphia, when  an  automol)ile  ran  into  the  carriage,  throw- 
nig  l>r.  Kennedy  out,  directly  in  the  path  of  the  motor  car. 
which  passed  over  his  body.  He  was  badly  bruised  and 
also  sustained  serious  internal  injuries. 


University  Notes. — Dr.  Samuel  Avery,  head  of  the 
department  of  chemistry  in  the  University  of  Nebraska,  has 
been  appointed  president  of  the  institution. 

Dr.  Ernest  Merritt,  professor  of  physics  in  Cornell  Uni- 
versity, has  been  appointed  dean  of  the  graduate  school. 

Dr.  Charles  T.  Burnett,  of  Bowdoin  College,  has  de- 
clined a  call  to  the  chair  of  psychology  in  Amherst  Col- 
lege. 

Dr.  J.  B.  Leathes,  of  London,  has  been  appointed  profes- 
sor of  chemical  pathology  in  the  medical  department  of 
the  University  of  Toronto. 

The  Campaign  against  Tuberculosis  in  Ireland. — The 

Countess  of  Aberdeen,  who  is  the  leader  of  the  antituber- 
culosis movement  in  Ireland,  arrived  in  New  York  on  June 
6th,  on  her  way  to  Montreal  to  attend  the  meeting  of  the 
International  Council  of  Women.  While  in  New  York  the 
countess  delivered  two  addresses,  one  in  Plymouth  Church, 
Brooklyn,  and  the  other  at  the  Catholic  Club,  Manhattan, 
in  both  of  which  she  made  a  direct  appeal  for  help  in  the 
crusade  against  tuberculosis  in  Ireland,  which  is  being 
carried  on  by  the  Women's  National  Health  Association. 
She  also  expressed  her  appreciation  of  the  help  and  sym- 
pathy she  had  received  from  America  in  the  work  which  is 
being  done  to  improve  health  conditions  in  Ireland. 

Gifts  and  Bequests  to  Charity. — The  $5,000  bequest  of 
John  G.  Brill  to  the  White  Haven  Sanatorium  for  Con- 
sumptives was  paid  to  the  institution  on  June  2d  by  repre- 
sentatives of  the  estate. 

By  the  will  of  John  A.  Reid,  who  died  in  Washington, 
D.  C,  recenti)',  the  following  institutions  becqrne  rever- 
sionary legatees :  The  National  Homoeopathic  Hospital, 
$5, 000;  The  Washington  Home  for  Incurables,  $1,000;  The 
Presbyterian  Home  for  Aged  People,  $1,000;  and  the 
Protestant  Episcopal  Eye,  Ear,  and  Throat  Hospital,  $500. 

By  the  will  of  Frank  J.  Walgering,  of  New  York,  the 
following  institutions  will  each  receive  $5,000:  Society  of 
St.  Vincent  de  Paul,  Little  Sisters  of  the  Poor,  Church  of 
the  Assumption,  St.  Francis's  Hospital,  St.  Francis's  Home, 
St.  Joseph's  Hospital  for  Consumptives,  St.  Catherine's 
Hospital,  of  Brooklyn ;  St.  Vincent's  Hospital,  Presbyterian 
Hospital,  German  Hospital  and  Dispensary,  Isabella  Home 
for  the  Aged,  Fritz  Reuter  Home  for  the  Aged,  Redemp- 
tionists'  College,  of  Esopus,  N.  Y. ;  Leo  House  for  German 
Emigrants,  St.  Gabriel's  Sanitarium  for  Convalescents  at 
Paul  Smith's,  in  the  Adirondacks,  and  St.  Joseph's  Orphan 
Asylum. 

The  will  of  Sebastian  D.  Lawrence  provides  $100,000  for 
the  erection  of  a  free  hospital  in  New  London,  Conn.,  and 
an  endowment  fund  of  $400,000  for  its  support.  His  resi- 
dence in  New  London  is  to  be  used  as  an  emergency  hos- 
pital, and  he  bequeaths  $50,000  to  the  city  for  the  erection 
of  a  new  almshouse. 

Thirteen  charitable  institutions  in  New  York  are  the 
beneficiaries  to  the  amount  of  $185,000  by  the  will  of  Mrs. 
Margaret  J.  P.  Graves,  who  died  on  May  30th.  The  be- 
quests are  as  follows :  Roman  Catholic  Orphan  Asylum, 
$25,000;  St.  Vincent's  Hospital,  $25,000;  Society  of  the 
New  York  Hospital,  $25,000 ;  Mount  Sinai  Hospital,  $10,- 
000;  Presbyterian  Hospital,  for  general  purposes,  $10,000; 
Presbyterian  Hospital,  to  be  expended  in  the  maintenance 
of  the  emergency  ward,  $10,000;  New  York  Mothers'  Home 
of  the  Sisters  Misericordi.'e,  $10,000;  New  York  Infirmary 
for  Women  and  Oiildren,  $10,000;  St.  Luke's  Hospital,  for 
society  work  under  the  direction  of  the  medical  board. 
$20,000;  St.  Luke's  Hospital,  for  the  care  and  treatment  of 
crippled  children,  $10,000;  Ursuline  Convent,  Bedford 
Park,  $10,000;  Hebrew  Benevolent  Orphan  Asylum,  $10,- 
000;  Society  for  the  Relief  of  the  Ruptured  and  Crippled. 
$10,000;  Hebrew  Technical  School,  $10,000. 

By  the  will  of  the  late  Dr.  F.  W.  Draper,  Harvard  Uni- 
versity will  receive  about  $100,000. 

Among  the  bequests  included  in  the  will  of  Mrs.  Samuel 
Mather,  who  died  a  short  time  ago  in  Cleveland,  Ohio, 
were  the  following :  $75,000  for  a  memorial  chapel  at  the 
Western  Reserve  University ;  $20,000  for  the  College  of 
Women  at  the  Western  Reserve  University ;  and  $25,000 
for  the  Lakeside  Hospital. 

The  Good  Samaritan  Hospital,  at  Lebanon,  Pa.,  raised 
no.irly  $2,000  by  a  "tag  day"  held  on  May  29th. 

The  Bronxviile  pageant,  held  in  Westchester  county  re- 
cently, netted  about  $3,000  for  the  new  Lawrence  Hospital 
in  Bronxviile. 

Over  $6,000  for  local  hospitals  was  collected  in  Troy, 
N.  Y.,  on  May  27th,  which  was  hospital  day  in  that  city. 


June  12,  I9Q9.]        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


1209 


The  American  Medical  Association, 

 Sixtieth  Annual  Meeting,  

Atlantic  City,  June  8,  9,  10,  and  11,  1909, 


tEte  iHcetmg  laebictoeb. 

Atlantic  City  is  an  ideal  place  for  the  meeting  of 
any  large  body  of  men.  Its  hotel  accommodations 
are  ample ;  its  climate  is,  as  a  rule,  delightful ;  and 
it  is  convenient  of  access.  The  American  Medical 
Association  is  apparently  partial  to  this  city  as  a 
place  of  meeting,  since  it  has  selected  it  for  four 
of  its  annual  meetings  within  the  past  ten  years. 
A  gentleman  wearing  the  badge  of  the  association 
was  met  on  the  boardwalk  on  Monday  afternoon 
and  was  heard  to  say  in  passing :  "Ain't  that  air  fine." 
The  member  was  slightly  ungrammatical,  as  a  mem- 
ber of  a  learned  profession  should  not  be ;  but  such 
sentiments  probably  account  for  the  frequency  with 
which  this  city  by  the  ocean  has  been  the  meeting 
place  of  the  American  Medical  Association. 

The  attendance,  as  was  to  be  expected,  was  not  so 
great  as  the  attendance  in.  Chicago  in  1908,  but  up 
to  Thursday  noon  3,213  members  had  been  enrolled 
at  the  registration  bureau  on  Young's  old  pier. 
The  opening  meeting  was  held  in  the  auditorium 
of  Young's  new  pier.  The  usual  programme  was 
followed.  The  introduction  and  installation  of  Dr. 
William  C.  Gorg.\s,  the  chief  sanitary  officer  of  the 
Isthmian  Canal  Commission,  and  a  member  of  the 
commission,  was  followed  by  enthusiastic  applause. 
Dr.  Gorgas's  address  was  entitled  The  Conquest  of 
the  Tropics  for  the  White  Race. 

Entertainments. — The  social  features  arranged 
for  the  meeting  by  the  local  committee  on  en- 
tertainment, of  which  Dr.  Emery  Marvel  was 
chairman,  included  the  usual  run  of  amusements 
for  which  Atlantic  City  is  famous  all  over  the 
United  States :  A  musicale  in  the  music  hall 
of  the  Steel  Pier  and  a  song  cycle  in  the  ball 
room  of  the  Steel  Pier;  a  vaudeville  and  smoker  in 
the  cafe  of  the  Islesworth  Hotel  and  in  the  New 
Berkeley  Cafe;  a  reception  at  the  Atlantic  City 
Country  Club ;  a  reception  at  the  Ventnor  Motor 
Boat  Club;  the  haul  of  the  fish  net  on  Young's  old 
pier ;  and  the  exhibition  of  life  saving  by  the  At- 
lantic City  Beach  Patrol.  Tuesday  evening  was 
given  over  to  college  reunions :  The  Medical  De- 
partment of  the  University  of  Pennsylvania ;  The 
Medical  Department  of  Harvard  University ;  The 
College  of  Physicians  and  Surgeons,  of  New  York ; 


The  Dartmouth  Medical  School ;  The  Jefiferson 
Medical  College,  of  Philadelphia ;  and  The  Medico- 
chirurgical  College,  of  Philadelphia ;  had  alumni 
smokers  which  were  well  attended.  On  Wednes- 
day evening  the  customary  president's  reception, 
which  was  followed  by  dancing,  was  given  in  the 
music  hall  of  the  Steel  Pier.  The  ladies  were 
given  an  informal  reception  at  the  Chalfonte  Hotel 
on  Tuesday  and  a  formal  reception  in  the  Plaza 
of  the  Marlborough-Blenheim  Hotel  on  Thursday. 

Guests. — The  foreign  delegates  included  Dr.  W. 
Arbuthnot  Lane,  of  London ;  Dr.  Max  Nonne,  of 
Hamburg ;  Dr.  George  Pernet,  of  London ;  Pro- 
fessor P.  L.  Friedrich,  of  Marburg,  who  delivered 
an  address  in  thoracic  surgery  in  the  section  in  sur- 
gery and  anatomy ;  and  Dr.  Juan  Guiteras,  of 
Havana. 

The  Scientific  Business. — The  scientific  work 
of  the  sections  of  the  meeting  was,  we  should 
say,  a  little  ahead  of  the  usual  standard.  It 
would,  of  course,  be  impossible  to  single  out  a 
few  papers  of  preeminent  merit  but  we  should  like 
to  call  attention  to, the  "symposium"  arranged  be- 
tween the  sections  in  pathology  and  physiology  and 
pharmacology  and  therapeutics,  on  the  present 
status  of  serum  and  vaccine  therapy,  with  special 
reference  to  the  products  of  the  American  market. 
In  this  "symposium"  papers  were  read  on  the  Fed- 
eral Control  of  Sera,  Vaccines,  etc.,  and  Vaccine 
Virus ;  on  Diphtheria  Antitoxine ;  on  Tetanus  Anti- 
toxine ;  on  the  General  Principles  of  Bacterial  Vac- 
cine Therapy ;  on  Streptococcus,  Staphylococcus, 
Pneumococcus,  Gonococcus,  and  Pyocyaneus  Vac- 
cines ;  on  Tuberculin  Diagnosis  and  Treatment ;  on 
the  Treatment  of  Inoperable  Sarcoma  by  Erysipelas 
andProdigiosus  Toxines ;  on  Antidysenteric  and  An- 
timeningococcic Serum  ;  and  on  Antivenins.  This 
"symposium"  forms  a  valuable  summary  of  the 
present  knowledge  upon  these  important  points. 
"Symposia"  are  of  great  value  in  correlating  the 
knowledge  of  active  subjects  in  science,  and,  we  are 
glad  to  note,  are  becoming  more  of  a  feature  of  med- 
ical programmes.  Other  "symposia"  were  arranged 
as  follows :  On  Physical  Therapeutics  in  the  section 
in  the  practise  of  medicine ;  on  the  Faucial  Tonsils 
and  on  the  Suppurative  Ear  Diseases  in  the  section 


ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION.         iNew  York 

Medical  Journal. 


I2I0 

in  laryngology  and  otology ;  on  the  Serum  Diagno- 
sis of  S>philis  and  its  Relation  to  Diseases  of  the 
Nervous  System,  in  the  section  in  nervous  and  men- 
tal diseases;  on  Syphilis,  in  the  section  in  cutaneous 
medicine  and  surgery ;  and  on  Dietetics  in  the  sec- 
tion in  pharmacology  and  therapeutics. 

The  Scientific  and  Commercial  Exhibits. — The 
scientific  exhibit  was  excellent ;  but  it  was  crowd- 
ed into  space  entirely  inadequate  to  accommo- 
date it.  We  should  like  to  see  more  space  given 
to  this  valuable  educational  feature  of  the  meeting. 
Among  the  most  interesting  exhibits  were  those 
of  the  New  York  Lying  in  Charity,  the  Jefferson 
Medical  College,  the  Philadelphia  Polyclinic,  and 
the  Gynaecean  Hospital  of  Philadelphia. 

^roccebinsfiJ  of  tlje  J^ousc  of  IBclesatcS. 

The  House  of  Delegates  was  called  to  order  on 
Monday  morning,  June  7th,  at  ten  o'clock.  In  the 
absence  of  the  president,  Dr.  Herbert  L.  Burrell, 
one  of  the  vice-presidents,  Dr.  T.  J.  Murray,  of 
Montana,  occupied  the  chair. 

The  secretary  of  the  association.  Dr.  George  H. 
Simmons,  read  the  president's  address.  This  ad- 
dress contained  the  following  recommendations : 

First,  that  the  president  of  the  association  and  the 
president-elect  should  meet  with  the  Board  of  Trus- 
tees. That  the  committees  should  always  be  an- 
swerable to  the  House  of  Delegates ;  but  under  the 
advice  of  the  Board  of  Trustees. 

Second,  that  the  defined  policies  of  all  committees 
and  sections  of  the  American  Medical  Association 
should,  before  being  issued  to  the  public,  be  ap- 
proved by  the  Board  of  Trustees. 

Third,  that  the  expenses  of  the  committees  should 
be  paid  by  the  association. 

Fourth,  that  the  Board  of  Trustees  be  requested 
to  report,  at  the  meeting  to  be  held  in  1910,  upon  the 
advisability  of  separating  the  offices  of  editor,  gen- 
eral manager,  and  secretary. 

These  recommendations  were  made  by  Doctor 
Burrell  in  his  capacity  as  an  individual  and  a  mem- 
ber of  the  association. 

The  report  was  referred  to  the  Reference  Com- 
mittee on  Reports  of  Officers. 

The  president  made  the  following  committee  ap- 
pointments : 

Judicial  Counsel. — Charles  E.  Cantrell,  of  Texas ; 
James  H.  Wilson,  of  Delaware ;  Harold  Gifford,  of 
Nebraska ;  C.  S.  Sheldon,  of  Wisconsin ;  and  H.  A. 
Christian,  of  Massachusetts.  Committee  on  Creden- 
tials.— H.  Bert  Ellis,  of  California ;  Edmund  W. 
Weis,  of  Illinois ;  Oscar  Dowling,  of  Louisiana ;  J. 
H.  J.  Upham,  of  Ohio;  and  D.  C.  Brown,  of  Con- 
necticut. Reference  Committee  on  Medical  Educa- 
tion.— George  Dock,  of  Louisiana;  Horace  D.  Ar- 
nold, of  Massachusetts ;  Albert  Vander  Veer,  of 
New  York ;  Victor  H.  Stickney,  of  North  Dakota ; 
and  William  W.  Richmond,  of  Kentucky.  Refer- 
ence Committee  on  Amendments  to  the  Constitution 
and  By-Laws. — H.  M.  Work,  of  Colorado;  George 
W.  Guthrie,  of  Pennsylvania ;  Floyd  M.  Crandall, 
of  New  York ;  Frank  Paschal,  of  Texas ;  and  J. 
Shelton  Horsley,  of  Virginia.  Reference  Committee 


on  Reports  of  Officers. — Alexander  R.  Craig,  of 
Pennsylvania  ;  Donald  Campbell,  of  Montana  ;  James 
W.  Pettit,  of  Illinois ;  D.  S.  Fairchild,  of  Iowa ;  and 
Charles  C.  Stevenson,  of  Arkansas.  Reference 
Committee  on  Sections  and  Section  Work. — ^J.  H. 
Carstens,  of  Michigan ;  S.  S.  Crockett,  of  Tennes- 
see ;  Luther  M.  Halsey,  of  New  Jersey ;  J.  H.  May, 
of  Kansas ;  and  T.  A.  MacDavitt,  of  Minnesota, 
Reference  Committee  on  Rules  and  Order  of  Busi- 
ness.— Arthur  L.  Wright,  of  Iowa  ;  B.  B.  Simms,  of 
Alabama ;  James  N.  Jenne,  of  Vermont ;  George 
Wythe  Cook,  of  the  District  of  Columbia ;  and  Hen- 
ry F.  Harris,  of  Georgia.  Reference  Committee  on 
Lci^islation  and  Political  Action. — Walter  B.  Dor- 
sett,  of  Missouri ;  George  Lane  Taneyhill,  of  Mary- 
land ;  Edward  Walker,  of  Indiana ;  J.  E.  Sawtelle, 
of  Kansas ;  and  J.  W.  Clemmer,  of  Ohio.  Reference 
Committee  on-  Hygiene  and  Public  Health. — Wil- 
liam N.  Wishard,  or  Indiana ;  Orlando  J.  Brown,  of 
Massachusetts ;  J.  B.  Bullitt,  of  Mississippi ;  J.  T. 
Bristow,  of  New  York ;  and  G.  B.  Young,  of  the 
United  States  Public  Health  and  Marine  Hospital 
Service.  Reference  Committee  on  Miscellaneous 
Business. — Thomas  A.  Woodruff,  of  Illinois ;  Ju- 
riah  Harris  Pierpont,  of  Florida  ;  Arthur  M.  Hume, 
of  Michigan  ;  Jefferson  D.  Griffith,  of  Missouri ;  and 
John  Champlin,  of  Rhode  Island. 

Report  of  the  General  Secretary. — Dr.  George 
H.  Simmons  submitted  the  report  of  the  general 
secretary  for  the  year  1908- 1909.  On  May  i,  1908, 
the  membership  of  the  American  Medical  Associa- 
tion was  31,343.  During  the  year  2,558  names  were 
dropped  from  the  list  and  5,150  names  were  added, 
so  that  the  membership  on  May  i,  1909,  was  33,935. 
He  gave  a  list  of  committees  that  had  been  appoint- 
ed during  the  time  between  the  last  annual  meeting 
and  the  present  meeting.  He  called  the  attention  of 
the  House  of  Delegates  to  the  necessity  of  appoint- 
ing a  Committee  on  Reapportionment,  which  should 
examine  the  membership  lists  of  the  constituent  as- 
sociations and  determine  therefrom  the  number  of 
delegates  to  the  American  Medical  Association,  to 
which  each  constituent  association  should  be  enti- 
tled for  the  ensuing  three  years.  He  called  atten- 
tion to  the  report  of  the  Committee  on  the  Regula- 
tion of  Membership,  and  asked  the  careful  consider- 
ation of  the  House  of  Delegates  for  this  report  on 
account  of  its  great  importance  to  the  future  growth 
and  development  of  the  association.  The  present 
session  brought  to  a  close  a  period  of  ten  years,  dur- 
ing which  Dr.  Simmons  had  served  the  association 
as  general  secretary  and  editor.  The  membership 
of  the  association  in  1899  was  7,997.  The  member- 
ship as  already  reported  for  the  year  1909  showed 
an  increase  of  424  per  cent.,  or  an  average  growth 
of  2,600  each  year.  The  greatest  increase  in  mem- 
bership had  come  from  Texas,  1,043  P^^  cent.,  the 
smallest  increase  from  Connecticut,  132  per  cent. 
In  1899  the  total  membership  of  the  medical  socie- 
ties of  the  United  States  was  approximately  3,400. 
At  the  present  time  the  societies  constituent  to  the 
American  Medical  Association  had  an  aggregate 
membership  of  67,362.  He  then  referred  to  the 
publications  owned  and  controlled  by  the  State  med- 
ical societies.  He  said  that  the  past  decade  had  in- 
creased the  effectiveness  in  county.  State,  and  na- 
tional societies ;  that  medical  education,  public  in- 


June  12.  1909.]        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


I2II 


struction,  the  regulation  of  pharmaceutical  and  drug 
products,  the  pubHcation  of  an  official  directory,  the 
compilation  of  uniform  State  laws,  while  not  com- 
pleted, had  been  begun  in  a  way  that  bid  fair  to  re- 
sult finally  in  the  definite  solution  of  the  problems. 

At  the  conclusion  of  the  reading  of  his  report. 
Dr.  Simmons  received  a  decided  ovation  from  the 
members  of  the  House  of  Delegates  present. 

The  Report  of  the  Board  of  Trustees.  —  Dr. 
\\'iLLiAM  H.  Welch,  of  Baltimore,  said  that  the 
manner  in  which  the  present  committees  of  the 
American  ]\Iedical  Association  acted  and  did  things 
was  in  marked  contrast  to  the  manner  in  which  they 
passed  resolutions  which  came  to  nothing  in  the 
years  gone  b\-.  He  thought  that  this  fact  was  one 
of  the  most  encouraging  features  of  the  present  or- 
ganization. In  order  to  encourage  and  facilitate 
the  work  of  these  committees  the  Board  of  Trustees 
had  appropriated  generous  funds  for  their  use, 
which  it  was  felt  had  been  eminently  justified.  He 
then  referred  to  the  large  amount  of  work  which 
had  been  done  gratuitously  by  men  of  the  highest 
scientific  attainments  imbued  with  a  purely  altruistic 
spirit,  under  the  supervision  of  the  Council  of 
Pharmacy  and  Chemistry.  The  council  was  con- 
stantly examining  a  large  number  of  preparations 
with  which  the  profession  was  being  exploited,  and 
weeding  out  the  frauds  and  fakes,  so  that  the  phy- 
sician to-day  need  not  be  deceived  by  false  repre- 
sentations into  using  or  administering  anything 
with  which  he  was  not  entirely  familiar.  Furtht-r- 
more,  the  council  was  constantly  calling  the  atten- 
tion of  reputable  manufacturers  to  defects  in  pro- 
ducts which  were  placed  on  the  market  with  en- 
tire honesty,  so  that  the  manufacturer  was  able  to 
modify  his  preparation  or  to  withdraw  it  from  sale, 
as  might  seem  best.  He  referred  to  the  great  amount 
of  work  which  was  constantly  being  done  in  the 
laboratory  of  the  association  under  the  supervision 
of  Professor  Puckner.  This  work  had  grown  to 
such  an  extent  that  the  trustees  had  recently  author- 
ized the  employment  of  another  chemist  to  help 
carry  it  on.  The  excellent  work  of  this  council  had 
received  general  recognition  both  at  home  and 
abroad. 

He  referred  to  the  excellent  work  done  by  Dr. 
IMcCormack  in  organization  and  education.  He  re- 
ferred to  the  work  of  revision  of  the  American 
Medical  Association  Directory,  w^hich  it  was  hoped 
would  go  to  press  in  the  near  future.  The  new  edition 
was  to  contain  additional  personal  information.  The 
Directory  was  designed,  not  primarily  as  a  commer- 
cial enterprise,  but  for  the  service  of  the  profes- 
sion and  the  public.  The  idea  was  to  supply  an  of- 
ficial register  of  the  medical  profession  which 
should  be  comparable  as  an  authority  to  the  Med- 
ical Register  of  Great  Britain.  He  said  that  the 
Journal  of  the  American  Medical  Association  had 
maintained  its  high  standard  of  excellence,  and  that 
it  now  ranked  with  the  greatest  medical  journals  of 
similar  scope  in  the  world.  The  Archives  of  In- 
ternal Medicine  had  succeeded  beyond  expectation  ; 
its  circulation  was  about  1,800;  and  it  was  self  sup- 
porting. In  spite  of  this  outlet  for  the  columns  of 
the  Journal  of  the  American  Medical  Association, 
the  latter  journal  was  still  forced  regretfully  to  re- 


turn manuscripts  to  their  authors  because  of  lack  of 
space. 

The  Board  of  Trustees  had  recently  authorized 
the  provisional  preparation  of  architect's  plans  and 
construction  bids  for  a  new  building  to  cost  ap- 
proximately ^200,000.  The  new  building  was  ur- 
gently needed  on  account  of  lack  of  space  in  every 
department.  He  hoped  that  the  House  of  Delegates 
would  approve  this  action  on  the  part  of  the  trus- 
tees, and  would  authorize  the  construction  of  the 
building. 

In  conclusion,  he  called  atention  to  the  remark- 
able growth  of  the  association  during  the  past  ten 
years,  and  after  enumerating  the  accomplishment 
of  the  various  committees  during  that  period,  said 
that  the  one  man  above  all  others  to  whom  they 
were  indebted  for  those  great  things  was  their  pres- 
ent editor  and  general  manager.  Dr.  George  H. 
Simmons. 

He  announced  the  death  of  Dr.  T.  J.  Heppel,  a 
member  of  the  Board  of  Trustees,  which  occurred 
on  May  24th. 

Appended  to  the  report  of  the  trustees,  was  the 
report  of  the  Subscription  Department,  showing  the 
weekly  issues  from  January  4,  1908,  to  December 
26,  1908,  which  gave  a  weekly  average  of  53.978 ; 
a  statement  of  the  number  of  copies  sent  to  mem- 
bers and  subscribers  by  States ;  a  statement  of  the 
increase  of  the  circulation  for  ten  years,  and  a  state- 
ment of  the  expenditures  for  the  manufacture  of  the 
publication.  In  addition,  the  report  of  the  treas- 
urer and  the  report  of  the  auditor  were  also  given, 
which  showed  the  finances  of  the  association  were 
in  a  satisfactory  condition. 

Report  of  the  Judicial  Council. — Dr.  C.  E.  C.an- 
TRELL,  of  Texas,  said  that  during  the  past  year  noth- 
ing of  importance  had  been  brought  before  the 
Judicial  Council. 

Report  of  the  Committee  on  Medical  Legisla- 
tion.— In  the  absence  of  Dr.  C.  A.  L.  Reed,  Dr. 
Ch.\rles  S.  Bacon,  of  Illinois,  read  the  report  of 
the  Committee  on  Legislation.  During  the  year  the 
committee  had  had  under  consideration  the  Navy 
^Medical  Reorganization  Bill ;  bills  relating  to  the 
Public  Health  and  Marine  Hospital  Service,  meas- 
ures relating  to  the  Federal  and  State  regulations  of 
the  public  health  :  relief  measures  for  the  surviving 
families  of  persons  who  have  died  in  the  medical 
service  of  the  countrv ;  the  unifomi  regulation  of 
the  practice  of  medicine  by  the  diflPerent  States;  uni- 
form regulation  of  vital  statistics  by  the  States ;  uni- 
form State  laws  on  foods  and  drugs ;  the  attitude 
of  the  last  administration  in  appointing  a  commis- 
sion for  the  purpose  of  reviewing  and  thus  overrid- 
ing certain  findings  of  the  governmental  agencies 
lawfully  established  for  the  interpretation  and  en- 
forcement of  the  National  Pure  Food  and  Drugs 
Act,  and  the  general  question  of  expert  medical  tes- 
timony. In  the  course  of  the  hearing  on  the  bill  to 
establish  a  National  Bureau  of  Public  Health,  it  be- 
came apparent  that  although  there  was  some  senti- 
ment in  congress  favorable  to  the  creation  of  a  De- 
partment of  Public  Health,  with  representation  in 
the  cabinet,  the  bill  as  introduced  into  congress  was 
looked  upon  as  obstructive  of  that  end ;  that  certain 
amendments  to  the  bill  had  been  so  framed  that  the 


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President  of  the  United  States  would  be  able  to 
change  at  his  discretion  the  organization  of  any  and 
all  of  the  departments  of  the  government ;  that  the 
members  of  congress  decidedly  objected  to  sur- 
rendering one  of  its  constitutional  prerogatives ; 
and  so  the  bill  did  not  come  up  for  passage. 

The  bill  to  reorganize  and  increase  the  efficiency 
of  the  Hospital  Corps  of  the  United  States  Navy 
and  regulate  its  pay,  carried  a  provision  for  the  cre- 
ation of  the  grade  of  chief  pharmacist.  The  bill 
authorizing  the  appointment  of  dental  surgeons  in 
the  navy  was  advocated  because  dental  surgeons 
were  needed  in  the  navy  quite  as  much  as  in  the 
army,  and  because  of  the  universally  recognized 
economic  importance  of  sound  teeth  in  military 
service.  The  bill  to  create  a  Medical  Reserve  Corps 
in  the  Navy  was  favored  because  such  a  corps  was 
urgently  required  to  place  the  Medical  Department 
on  a  sound  footing  in  respect  to  medical  assistance 
available  should  any  occasion  arise  for  emergency 
expansion.  If  this  corps  was  established,  the  Med- 
ical Department  of  the  Navy  w^ould  be  placed  in 
close  contact  with  the  members  of  the  medical  pro- 
fession and  would  be  in  a  position  to  call  them  into 
consultation  and  enjoy  the  advantage  of  their  ad- 
vice, should  the  occasion  require.  It  would  secure 
the  Medical  Department  adequate  and  efficient  as- 
sistance in  any  emergency.  It  would  make  the  med- 
ical service  in  the  navy  equally  attractive  with  that 
in  the  army. 

The  committee  advocated  the  bill  to  authorize  the 
equipment  of  two  ships  as  hospital  ships,  at  a  cost 
not  to  exceed  $3,000,000. 

The  report  referred  to  the  high  grade  of  sanitary 
efficiency  developed  in  the  canal  zone,  and  reported 
that  President  Taft  was.  giving  careful  attention  to 
the  future  sanitation  of  the  waters  connected  with 
the  canal.  A  detailed  description  was  given  of  work 
done  by  the  committee  in  the  various  States,  and 
referred  to  the  fact  that  Pennsylvania  was  left  by  the 
defeat  of  the  Herbst-Shreve  bill,  with  the  cumber- 
some and  ineffective  Medical  Practice  Act  of  previ- 
ous years. 

In  addition  to  cooperating  with  various  State 
committees,  and  assisting  in  the  legislative  campaign 
in  various  States,  the  committee  had  endeavored  to 
carry  on  constructive  work  in  the  direction  of  uni- 
form State  legislation.  The  most  difficult  and  in- 
tricate question  now  before  the  committee  was  that 
of  the  preparation  of  a  uniform  bill  for  the  regula- 
tion of  the  practice  of  medicine.  It  recommended 
the  call  of  a  general  conference  for  the  discussion  of 
the  essentials  of  a  uniform  act  for  adoption  by  the 
various  States. 

Report  of  the  Council  on  Medical  Legislation. 
—  Dr.  Arthur  I)i-:.\x  P.evan,  of  Illinois,  presented 
the  report  of  the  Council  on  Medical  Education.  The 
report  reviewed  the  work  of  the  council  for  the  past 
five  years.  At  the  fifth  conference  conducted  under 
the  auspices  of  the  committee,  in  Chicago,  April  5, 
1909,  one  hundred  prominent  educators,  represent- 
ing all  the  departments  and  specialties  in  medicine, 
recommended  a  4,100  hour  curriculum.  It  was  the 
unanimous  opinion  of  the  committee  that  a  hard  and 
fast  curriculum,  uniform  for  all  colleges,  was  not 
desirable,  and  not  for  the  best  interests  of  medical 


education,  therefore  it  was  distinctly  stated  the  cur- 
riculum recommended  was  to  be  regarded  as  sug- 
gestive and  educational  only.  A  recommendation 
was  also  adopted  that  in  addition  to  the  theoretical 
examination  conducted  by  State  Boards  of  Medical 
Examiners,  practical  examinations  should  also  be 
held. 

The  report  then  gave  a  summary  of  the  present 
status  of  preliminary  and  medical  education  in  the 
United  States.  During  the  past  year  five  im- 
portant mergers  of  medical  colleges  had  been  ac- 
complished, so  that  nine  medical  schools  had  been 
replaced  by  five  stronger  ones.  The  number  of 
medical  colleges  in  the  United  States  at  the  present 
time  was  148.  The  committee  believed  that  if  all 
of  the  medical  colleges  of  any  large  city,  such  as 
Chicago,  Philadelphia,  or  St.  Louis,  could  be  merged 
into  one  great  medical  school,  such  as  was  to  be 
found  in  Berlin,  Paris  or  Vienna,  it  would  be  of  the 
greatest  possible  advantage  to  medical  education  in 
this  country.  Other  details  of  medical  education 
were  referred  to  in  this  report. 

Many  changes  in  practice  acts  showed  that  the 
requirements  to  practise  medicine  in  the  various 
States  were  approaching  uniformity.  The  question 
of  reciprocity  was  discussed,  and  the  report  ended 
with  the  statement  that  the  legal  power  to  control 
and  elevate  the  standards  of  medical  education 
rested  entirely  and  alone  with  the  State  boards. 

Report  of  the  Board  of  Public  Instruction  on 
Medical  Subjects. — Dr.  John  G.  Clark,  of  Penn- 
sylvania, said  that  the  board  had  decided  to  limit 
its  work  to  the  publication  of  the  facts  about  a  few 
subjects  which  had  been  carefully  chosen,  principal- 
ly general  infectious  diseases.  The  policy  had  been 
adopted  of  having  the  literature  on  each  subject  re- 
vised by  an  expert  in  the  surgeon  general's  library, 
and  from  this  material  a  popular  article  was  con- 
structed by  a  writer  versed  in  medical  matters,  and 
adapted  by  a  special  literary  training  for  putting  it 
into  a  popular  and  attractive  form.  It  was  the  fixed 
policy  of  the  board  to  avoid  all  controversial  ques- 
tions and  all  therapeutic  questions. 

Report  of  the  Committee  on  Organization. — 
Dr.  J.  M.  McCoRMACK,  of  Kentucky,  said  th.at  dur- 
ing the  year  he  had  traveled  through  the  States  of 
South  Dakota,  Colorado,  Ohio,  Virginia,  Kansas, 
and  Missouri,  speaking  two  or  three  times  a  day. 
He  was  impressed  with  the  importance  of  educat- 
ing the  public,  which  he  deemed  to  be  on  a  par  with 
that  of  organizing  the  profession.  He  especially  ad- 
vocated the  good  results  to  be  obtained  by  speaking 
before  institutions  engaged  in  training  teachers,  edi- 
tors, and  clergymen,  in  order  that  a  generation  of 
moulders  of  public  opinion  might  be  raised  up, 
which  would  understand  the  aims  and  ideals  of  the 
medical  profession. 

Report  of  the  Director  of  Postgraduate  Study. 
— Dr.  John  H.  Bi.ackpurn,  of  Kentucky,  said  that 
the  munber  of  societies  that  had  taken  up  the  course 
of  postgraduate  study  during  the  past  year  was  200. 
About  eighty-five  per  cent,  of  the  societies  which 
followed  the  first  course  had  again  taken  up  the 
matter.  Many  societies  in  larger  towns  and  cities, 
even  in  some  of  the  medical  teaching  centres,  had 
been  using^the  outline  of  study  in  their  regular  work. 


June  12,  ,909.]        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


1213 


The  outline  for  the  third  year  was  now  in  prepara- 
tion and  would  soon  be  ready  for  the  printer,  so 
that  it  might  be  ready  for  distribution  by  the  first 
of  August. 

Report  of  the  Committee  on  Ophthalmia  Neo- 
natorum.— Dr.  F.  Park  Lewis,  of  Xew  York, 
made  a  summary  of  the  resolutions,  communica- 
tions, reports,  and  subcommittees  that  had  been 
formed  through  the  agency  of  the  Committee  on 
Ophthalmia  Neonatorum.  This  summary  showed 
that  the  whole  country  was  in  hearty  accord  with 
the  move.  There  was  a  committee  of  experienced 
physicians  in  every  State  ready  to  advise  with  the 
Department  of  Public  Health  as  to  methods.  The 
committee  had  no  desire  to  advocate  any  special 
form  of  prophylactic,  but  it  always  endeavored  to 
make  it  clear  that  the  treatment  of  a  birth  infecfion 
of  the  eyes  must  never  be  undertaken  by  a  midwife 
or  a  nurse.  In  order  to  achieve  success,  publicity 
and  the  placing  of  responsibility  were  necessary. 
It  was  recommended  that  the  committees  which  had 
assimied  the  responsibility  of  cooperating  with  the 
central  committee  should  actively  begin  an  organ- 
ized movement  for  the  control  of  ophthalmia  neona- 
torum in  their  several  States  or  territories.  At  the 
Eleventh  International  Ophthalmological  Congress 
resolutions  were  adopted  recognizing  the  im- 
portance of  ophthalmia  nepnatorum  as  a  cause  of 
blindness,  and  the  practicability  of  its  control  was 
admitted  by  the  appointment  of  a  committee  charged 
with  the  duty  of  its  consideration. 

Report  of  the  Committee  on  Scientific  Re- 
search.— Dr.  Alfred  S^  excel,  of  Philadelphia,  said 
that  the  Committee  on  Scientific  Research  had  paid 
grants  of  S200  each  during  the  past  year  to  Dr. 
Isabel  Herb,  of  Chicago,  for  a  contribution  entitled 
A  Study  of  the  /Etiology  of  Mumps ;  to  Dr.  H.  T. 
Ricketts,  of  Chicago,  for  a  study  entitled.  An  In- 
vestigation oit  the  Identity  of  the  Rocky  Mountain 
Fever  of  Idaho  with  that  Found  in  Montana ;  one 
to  Dr.  R.  jNI.  Pearce,  of  Xew  York,  for  papers  en- 
titled A  Study  of  the  Elimination  of  Inorganic  Salts 
in  a  Case  of  Chronic  Universal  CEdema  of  Un- 
known yEtiology  with  Apparent  Recovery,  and  A 
Comparative  Study  of  the  Physical  Changes  in  the 
Blood  in  Relation  to  Opsonic  and  Phagocytic  In- 
dices and  Cell  Content  under  Normal  Conditions ; 
and  one  to  Dr.  D.  J.  McCarthy  and  Dr.  ]M.  K.  'My- 
ers,  of  Philadelphia,  for  an  Experimental  Study  of 
Cerebral  Thrombosis.  For  the  year  1909  grants 
were  allowed  to  Dr.  Isabel  Herb,  of  Chicago,  S200  ; 
Dr.  Holmes  C.  Jackson,  of  Albany,  N.  Y.,  Sioo; 
Dr.  Gerald  B.  Webb,  of  Colorado  Springs,  Sioo; 
Dr.  H.  T.  Ricketts.  of  Chicago.  $200;  Dr.  R.  :\I. 
Pearce,  of  New  York,  $200;  Dr.  Carl  Voegtlin, 
of  Baltimore,  S200 :  Dr.  D.  T.  McCarthv  and  Dr. 
M.  K.  Myers,  S200;  and  Mr.  H.  T.  Glenn,  of 
Chicago,  S50.  A  recommendation  was  made,  that 
a  grant  made  to  Dr.  Carl  A'oegtlin,  of  Baltimore,  be 
paid,  although  through  a  misunderstanding  the  re- 
sult of  the  work  had  not  been  published  in  the 
Journal  of  the  American  Medical  Association.  It 
was  further  recommended  that  the.  appropriation 
to  the  committee  be  increased  to  Si, 000.00  per 
year. 

Report  of  the  Committee  on  the  Davis  Me- 
morial.— Dr.  Hexrv  O.  ^Iarcy.  of  Boston,  urged 


that  the  American  Medical  Association  make  an  ap- 
propriation to  the  fund  for  the  Memorial  to  Dr. 
Davis.  If  such  appropriation  was  made,  the  repre- 
sentatives of  the  difterent  States  had  promised  their 
active  and  hearty  cooperation. 

Report  of  the  Committee  on  Nomenclature  and 
Classification  of  Diseases. — Dr.  Frank  P.  Fos- 
ter, of  New  York,  reported  that  his  committee  had 
held  a  meeting  in  Philadelphia,  in  September,  1908, 
at  which  a  number  of  representatives  of  organiza- 
tions interested  in  the  matter  were  present.  The 
conference  adopted  a  number  of  amendments  to  the 
present  list  of  diseases  which  were  to  be  agreed  on 
by  the  Committee  of  the  American  Public  Health 
Association,  and  were  to  be  recommended  to  the 
Conference  on  the  Revision  of  the  International 
Classification  of  Causes  of  Death,  which  would  be 
taken  up  in  Paris  during  the  present  year.  The 
committee  and  the  representatives  of  the  interested 
organizations  had  been  invited  to  take  part  iii  the 
meeting  of  the  Committee  of  the  American  Public 
Health  Association  in  Washington,  in  October, 
1908. 

Keporf  of  the  Committee  on  the  Scientific  Ex- 
hibit.— Dr.  F.  B.  \\"vxx,  of  Indianapolis,  called 
attention  to  the  fact  that  the  first  scientific  exhibit 
was  held  at  the  Atlantic  City  meeting  ten  years  ago. 
The  exhibit  had  continuously  grown  in  importance 
and  extent ;  he  recommended  that  the  president  ap- 
point a  committee  of  three  who  should  be  known  as 
the  Committee  of  Awards  for  the  present  meeting. 
The  president  appointed  Dr.  Llewellys  F.  Barker, 
of  Baltimore,  Dr.  William  Mayo,  of  Rochester, 
Minn.,  and  Dr.  Henry  A.  Christian,  of  Boston,  upon 
this  committee. 

Report  of  the  Committee  on  Patents  and 
Trademarks. — Dr.  Charles  S.  B.\cox,  of  Illinois, 
said  that  the  resolution  introduced  at  the  1908  meet- 
ing authorizing  the  consideration  of  the  subject  of 
the  enactment  of  a  bill  for  the  purpose  of  securing 
a  modification  of  the  patent  and  trademark  laws,  so 
that  certain  abuses  might  be  corrected  had  been 
found  to  be  impracticable  at  the  present  time.  He 
advised  the  collection  of  judicial  opinions  upon  the 
subjects  concerned  in  the  resolution. 

Report  of  the  Committee  on  Uniform  Regula- 
tion of  Membership. — Dr.  Thomas  S.  INIcDavitt, 
of  Minnesota,  said  that  a  letter  had  been  sent  to  the 
secretary  of  each  State  association  asking  for  in- 
formation regarding  the  rules  concerning  the  regu- 
lation of  membership  in  each  association.  Reports 
had  been  received  from  the  secretary  of  each  State 
association  except  that  of  Georgia.  The  replies  to 
the  questions  contained  in  this  letter  were  tabulated. 
The  questions  were  "What  is  the  fiscal  year  of  your 
.State  Society?  Do  all  your  county  societies  have 
the  same  fiscal  year?  Do  your  by-laws  contain  any 
provisions  regarding  the  fiscal  year  of  your  county 
societies?  Do  you  think  the  fiscal  year  of  county 
and  State  societies  should  correspond?  What  do 
you  consider  the  best  arrangement  for  the  fiscal  vear 
so  far  as  the  county  societies  and  the  State  associa- 
tions are  concerned  ?  At  what  time  do  the  by-laws 
call  for  the  payment  of  county  society  dues  ?  When 
does  the  county  secretary  remit  to  the  State  secre- 
tary the  amount  of  the  State  per  capita  assessment? 
Does  the  secretary  of  each  county  society  remit  for 


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the  entire  society  or  for  each  individual  member  as 
he  pays  his  dues?  Do  you  as  the  secretary  of  the 
State  association  accept  pa3ments  of  the  per  capita 
assessment  from  individual  members  or  must  they 
come  through  the  county  society?  Do  you  enroll 
a  member  when  reported  by  the  county  secretary- 
regardless  of  whether  or  not  the  per  capita  assess- 
ment is  paid  for  him,  or  do  you  wait  until  the  in- 
dividual assessment  is  paid  before  enrolling  the 
member^  Are  delinquent  merfibers  suspended  for 
nonpayment  of  dues  and  if  so  how  far  in  arrears 
must  they  be  before  being  suspended?  Is  the  roll 
of  the  State  association  made  up  complete  each  year 
from  the  reports  of  the  county  secretaries :  or  is  a 
member  once  entered  carried  as  such  until  specifi- 
cally reported  as  died,  suspended,  resigned,  dropped, 
etc.  ?  Are  all  members  not  in  good  standing  re- 
garded as  suspended?  Are  members  notified  when 
dropped?"  .\  study  of  the  answers  to  these  questions 
showed  that  the  greatest  difficulties  in  the  way  of 
uniform  regulation  of  membership  were  lack  of  uni- 
formity regarding  fiscal  year  and  termination  of 
membership ;  lack  of  definite  specific  regulation  re- 
garding the  time  when  dues  must  be  paid  and  when 
members  were  suspended  for  nonpayment ;  and  lack 
of  a  sufficiently  comprehensive  system  adaptable  to 
conditions  in  different  parts  of  the  country  by  which 
.county  secretaries  could  report  changes  in  member- 
ship to  State  secretaries  easily  and  accurately,  thus 
keeping  the  .State  secretaries  informed  regarding 
the  status  of  membership  in  each  county.  The  com- 
mittee made  the  following  recommendations : 

( 1 )  That  all  State  associations  be  requested  to 
make  their  fiscal  year  conform  to  the  calendar  year 
and  to  request  their  com.ponent  county  societies  to 
adopt  the  same  rule. 

(2)  That  this  committee  be  continued,  that  it  be 
increased  by  the  addition  of  four  State  secretaries, 
and  that  it  be  instructed  to  draft  uniform  by-laws 
for  the  regulation  of  membership  for  State  and 
county  societies,  as  well  as  to  devise  a  system  of 
necessary  blanks,  forms,  etc.,  which  would  be  ap- 
plicable for  general  use  and  which  could  be  recom- 
mended to  the  House  of  Delegates  by  State  societies 
for  adoption. 

Report  of  the  Council  on  the  Defense  of  Med- 
ical Research. — Dr.  W.  B.  Cannon,  of  Boston, 
said  that  the  w^ork  of  the  council  during  the  past 
year  might  be  classified  under  three  headings : 
First,  investigating  the  conditions  of  animal  experi- 
mentation and  the  opposition  to  it ;  second,  taking 
precautions  against  abuse  of  animal  experimenta- 
tion and  against  misconceptions  of  the  conditions 
and  purposes  of  medical  rciearch ;  third,  diffusing 
information  regarding  laboratory  procedures,  and 
the  results  of  laboratory  study  of  disease.  A  cir- 
cular had  been  sent  out  to  1 1 1  of  the  most  prominent 
medical  schools  in  the  United  States,  and  reports 
had  been  received  from  eighty  of  them.  In  the  cir- 
cular questions  were  asked  as  to  the  approximate 
number  of  diff^erent  kinds  of  animals  used  per  year; 
the  method  of  securing  these  animals ;  the  number 
of  dogs  and  cats  killed  in  the  city  merely  to  get  rid 
of  the  excess;  the  care  of  animals  in  the  medical 
school,  including  the  ventilation,  warmth,  cleanli- 
ness, and  lighting  of  their  rooms ;  whether  opera- 


tions likely  to  involve  pain  were  always  performed 
with  anaesthetics ;  whether  students  were  permitted 
to  carry  on  independent  animal  experimentation  or 
were  cautioned  against  it ;  whether  experimental 
work  was  conducted  under  rules,  and  whether  any 
public  hostility  to  animal  experimentation  existed 
in  the  community.  In  order  to  understand  the  na- 
ture of  the  opposition  to  medical  research  the  coun- 
cil had  collected  antivivisection  literature  from  all 
the  societies  of  the  United  States,  and  had  sub- 
scribed to  antivivisection  journals.  It  had.  likewise, 
obtained  from  a  clipping  bureau  the  statements  for 
and  against  vivisection,  which  had  appeared  in 
newspapers  and  other  periodicals  throughout  the 
country.  An  analysis  of  this  literature  would  be 
presented  in  a  later  publication  of  the  council.  A 
ciucular  letter  had  been  sent  to  the  editors  of  medi- 
cal and  sciejitific  journals  urging  that-  terms  which 
might  p.ive  rise  to  misunderstanding  on  the  part  of 
the  public  be  eliminated  from  articles  published  in 
their  journals.  A  revised  set  of  rules  had  been  sent 
to  all  laboratories  in  which  animal  experimentation 
was  being  conducted,  with  a  request  that  they  be 
adopted.  They  advised  also  the  diffusion  of  infor- 
mation concerning  the  methods  of  animal  experi- 
mentation and  the  benefits  to  be  derived  from  it. 

The  meeting  of  the  House  of  Delegates  which 
was  held  on  Tuesday  afternoon,  June  8th,  was  pre- 
sided over  by  the  new  president  of  the  association. 
Dr.  William  C.  Gorgas.  The  greater  part  of  the 
session  was  taken  up  by  listening  to  the  reports  of 
the  various  reference  committees.  The  trustees  re- 
ported that  the  recommendations  made  in  the  report 
of  the  Committee  on  Scientific  Research  be  ap- 
proved and  its  work  commended.  The  Refen  nce 
Committee  on  Medical  Education  endor-' r;  the  re- 
port of  the  Committee  on  Medical  Educatioii  and 
recomiTjended  it  to  the  attention  of  the  meinbers  of 
the  association  and  the  faculties  of  the  -various  medi- 
cal schools  in  the  country.  The  Reference  Comniit- 
tce  on  the  Reports  of  Officers  recommended  that  the 
president  and  the  president-elect  be  invited  to  meet 
with  the  Board  of  Trustees.  That  all  committees 
be  required  to  act  with  the  advice  and  direction  of 
the  Board  of  Trustees.  That  no  action  be  taken  on 
the  recommendation  of  the  president  to  elect  sep- 
arate persons  to  the  office  of  secretary,  editor,  and 
general  manager.  They  recommended  that  the 
Board  of  Trustees  be  authorized  to  erect  the  new 
building  as  reconmiended  in  their  report.  Under 
the  head  of  new  business  several  resolutions  were 
introduced  which  were  referred  to  appropriate  com- 
mittees. The  most  important  of  these  were  a  reso- 
lution requesting  all  organizations  to  discontinue  the 
use  of  the  red  cross  or  Geneva  cross  except  the 
Medical  Department  of  the  United  States  .•\rmy,  the 
Medical  Department  of  the  United  States  Navy,  the 
United  States  Public  Health  and  Marine  Hospital 
Service,  and  the  National  Red  Cross  Society ;  a  res- 
olution recommending  the  establishment  of  a  section 
in  genitourinary  diseases;  and  a  resolution  approv- 
ing the  plan  of  the  George  Washington  Memorial 
Association  to  raise  funds  for  the  erection  of  a 
building  in  A\'ashington  which  should  be  suitable 
for  the  accommodation  of  national  and  international 
conventions. 


June  12,  1909.] 


ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


Miscellaneous  Business. — The  name  of  the  sec- 
tion in  -urgery  and  anatomy  was  changed  to  the 
section  in  surgery.  The  name  of  the  section  in 
cutaneous  medicine  and  surgery  was  changed  to  the 
section  in  dermatology.  A  section  in  urology  and 
venerea]  diseases  was  authorized  to  be  established 
provided  one  hundred  members  signified  their  in- 
tention of  joining  it. 

The  formation  of  an  anaesthesia  commission  was 
authorized  to  be  composed  of  one  member  from 
each  of  the  following  sections:  Surgery,  obstetrics, 
and  diseases  of  women,  practice  of  medicine,  oph- 
thalmology, and  pharmacology  and  therapeutics.  A 
recommendation  was  made  that  the  Board  of  Trus- 
tees furnish  funds  for  this  commission. 

Approval  was  given  to  the  bills  for  the  reorgani- 
zation of  the  Medical  Department  of  the  United 
States  Xavy;  for  the  estabUshment  of  a  reserve 
medical  corps  for  the  navy;  and  for  the  building  of 
two  hospital  ships. 

Approval  was  given  to  the  proposition  to  erect  a 
memorial  to  the  medical  officers  who  lost  their  lives 
in  the  civil  war. 

One  thousand  dollars  a  year  was  appropriated  to 
the  Committee  on  Scientific  Research. 

The  plan  of  the  George  Washington  [Memorial 
Association  was  approved. 

The  Committee  on  Nomenclature  and  Classifica- 
tion of  Diseases  was  continued  and  the  recom- 
mendatiiin  made  that  the  Board  of  Trustees  appro- 
priate the  funds  necessary  for  the  continuance  of 
the  work. 

Cpon  recommendation  of  the  Committee  of  Ap- 
portionment ihe  following  changes  were  made  in 
the  delegations  in  the  House  of  Delegates  for  1910: 
Increases — Illinois,  from  7  to  9 :  Kentucky,  from 
3  to  4 :  ]^Iissouri,  from  4  to  5 ;  Ohio,  from  6  to  7 ; 
Pennsylvania,  from  8  to  9 ;  Tennessee,  from  2  to  3 ; 
Washington,  from  i  to  2 ;  ^^'est  A'irginia,  from 
I  to  2 ;  decreases — Kansas,  from  3  to  2 ;  Michigan, 
from  4  to  3 ;  North  Carolina,  from  3  to  2.  All  the 
other  States  retained  their  former  representation. 
In  1910  the  House  of  Delegates  will  contain  149 
members. 

A  resolution  was  introduced  to  create  a  perma- 
nent council  on  Public  Health  and  Sanitary  Science 
which  should  consist  of  five  members. 

Election  of  Officers. — The  following  officers 
were  elected  for  the  coming  year :  President,  Dr. 
William  H.  Welch,  of  Maryland.  Mce-presidents, 
Dr.  Robert  Wilson,  Jr.,  of  South  Carolina :  Dr.  C. 
J.  Kipp,  of  New  Jersey;  Dr.  Alexander  Lambert,  of 
New  York  :  Dr.  Stanley  P.  Black,  of  California.  Gen- 
eral secretary.  Dr.  George  H.  Simmons,  of  Illinois. 
Treasurer,  Dr.  Frank  Billings,  of  Illinois.  Trustees 
to  serve  three  years,  Dr.  M.  L.  Harris,  of  Illinois  : 
Dr.  A.  C.  Dougherty,  of  Indiana  :  Dr.  W.  T.  Coun- 
cilman, of  Massachusetts.  Trustee  to  fill  the  unex- 
pired term  of  Dr.  T.  J.  Happell,  Dr.  Charles  E.  Cant- 
trelhof  Texas.  ?\lemberof  Committee  on  ^ledical 
Legislation,  Dr.  Charles  A.  L.  Reed,  of  Ohio.  Mem- 
ber rf  the  Council  on  Medical  Education,  Dr.  Arthur 
Dean  Bevan,  of  Illinois.  Two  members  of  the 
Board  of  Public  Instruction,  Dr.  C.  D.  Coleman,  of 
Georgia,  and  Dr.  James  Ewing,  of  New  York. 

The  next  meeting  will  be  held  in  St.  Louis. 


Jtlcctings;  of  Sections. 

SECTION  IX  PRACTICE  OF  MEDICINE. 

Medical  Supervision  of    Boarding  Schools. — 

The  first  meeting  of  the  Section  in  Practice  of 
Medicine  opened  with  a  short  paper  by  Dr.  N.  B. 
Potter,  of  New  York,  on  Medical  Supervision  of 
Boarding  Schools,  with  special  reference  to  the  sub- 
ject of  athletic  contests. 

Cardiac  and  Vascular  Complications  in  Pneu- 
monia, with  Special  Reference  to  Treatment. — 
The  second  number  on  the  programme  was  the 
paper  under  this  title  by  Dr.  Frederick  Forchhei- 
MER,  of  Cincinnati,  which  excited  much  interested 
discussion.  The  points  touched  upon  were :  The 
use  of  venesection  in  the  right  heart,  the  prominence 
of  the  vasomotor  phenomena  in  the  clinical  picture 
of  pneumonia,  and  the  fresh  air  treatment.  Bleed- 
ing was  a  time  honored  treatment  in  pneumonia, 
until  Skoda,  in  1847,  first  pointed  out  its  inutility 
and  occasional  danger,  and  inaugurated  the  symp- 
tomatic or  "nihilistic"  treatment.  Jiirgensen,  in  1874, 
recommended  plenty  of  fresh  air  for  pneumonia  pa- 
tients, and,  after  falling  into  disuse  for  some  years, 
this  method  had  recently  been  reinstated.  Dr. 
Forchheimer  emphasized  the  great  importance  from 
a  prognostic  as  well  as  Uierapeutic  viewpoint  of  the 
vasomotor  disturbances  which  form  such  a  promi- 
nent feature  in  the  clinical  picture.  The  vascmotor 
paralysis  was  attributed  to  the  action  of  the  toxic 
albuminoids  on  the  vasomotor  centre.  The  splanch- 
nic vessels  were  overfilled,  -aujemia  in  other  vital 
organs  resulted,  the  blood  pressure  fell,  the  heart 
was  no  longer  supplied  with  nutriment,  the  puLse 
became  rapid,  "the  heart  bled  itself  into  the  splanch- 
nic area.'  \'asomotor  and  other  vital  centres  ulti- 
mately became  asphyxiated  and  paralyzed.  Given  a 
normal  heart,  the  commonest  cause  of  pneumonia 
death  was  vasomotor  paralysis.  \\'ith  regard  to  the 
treatment  of  the  condition.  Forchheimer  failed  to 
confirm  the  good  results  claimed  bv  Frankel  with 
large,  very  large,  doses  of  digitalis.  His  mortalitv 
was  increased,  the  pulse  rate  was  not  lowered,  and 
the  bad  effects  of  digitalis  were  noted  without  tlie 
expected  benefits.  Strychnine  was  powerless  to  pre- 
vent the  vasomotor  syndrome.  As  soon  as  the  ear- 
liest vasomotor  symptoms  appeared  Forchheimer 
gave  a  large  dose  of  caffeine  and  saline  solution 
hypodermically  with  one  c.c.  of  adrenalin.  This 
was  repeated  as  often  as  necessary  to  maintain  a 
sufficient  blood  pressure,  which  was  the  object  to  be 
aimed  at  in  the  management  of  the  disease.  Ice- 
bags  were  to  be  applied  to  the  abdomen  to  bring- 
about  contraction  of  the  splanchnic  vessels  and  raise 
the  general  blood  pressure.  The  distinction  between 
vasomotor  palsy  and  dilatation  of  the  right  heart 
was  not  difficult.  F"or  the  latter  condition  venesection 
should  be  the  routine  measure.  Lack  of  time  for- 
bade more  than  a  mention  of  myocarditis,  endocar- 
ditis, and  pericarditis. 

Dr.  Rochester,  of  Buft'alo,  endorsed  the  use  of 
venesection  in  cases  of  failing  right  heart,  and  re- 
cited illustrative  cases.  The  procedure  had  fallen 
into  disrepute  undeservedly,  and  should  be  more 
generally  employed. 

Dr.  Billings,  of  Chicago,  deprecated  any  kind  of 
so  called  specific  drug  treatment  and  preferred  to 


12X6 


.hTLAXTIC  city  meeting  of  AMERICAN  MEDICAL  ASSOCIATION. 


[New  York 
Medical  Journal. 


depend  on  fresh  air  and  general  management  of  the 
case  until  definite  cardiovascular  symptoms  ren- 
dered intervention  imperative.  Digitalone  had  proved 
more  satisfactory  in  his  hands  than  digitalis  for  hy- 
podermic use.  If  great  promptness  was  essential  the 
intravenous  route  should  be  selected.  Caffeine, 
camphor,  and  musk  were  of  value  for  raising  a 
fallen  blood  pressure ;  strychnine  was  valueless  ex- 
cept as  a  general  tonic  to  the  nervous  system.  X'igi- 
lant  care  of  the  patient  without  specific  medication 
was  the  ideal  treatment.  Venesection  in  dilatation  of 
the  right  ventricle  should  be  done  freely ;  cold  ap- 
plication to  the  chest  and  bandaging  the  extremities 
were  of  some  value  sometimes.  Statistics  exhibited 
but  little  improvement  over  those  of  former  years, 
in  spite  of  more  rational  methods  of  treatment. 

Dr.  Hoover,  of  Cleveland,  remarked  that  reliance 
should  not  be  placed  on  blood  pressure  readings 
obtained  with  instruments  now  in  use.  The  mass 
movement  of  the  blood  was  the  crucial  question  and 
should  be  determined  not.  by  taking  the  blood  pres- 
sure but  by  determining  the  cardiac  dulness.  The 
diagnosis  between  vasomotor  palsy  and  failure  of 
the  right  heart  was  difficult,  but  of  practical  im- 
portance as  the  former  called  for  heart  tonics,  while 
venesection  was  indicated  for  relief  of  the  latter. 

Dr.  MussER,  of  Philadelphia,  said  that  cardiac 
failure  in  pneumonia  was  often  due  to  a  pericardial 
effusion  and  not  to  dilatation.  The  final  outcome  was 
influenced  by  early  treatment  of  the  heart  during 
the  first  period  of  the  disease.  Regulation  of  the 
food  was  an  important  factor  in  the  treatment,  as 
was  elimination  both  intestinal  and  renal.  Tympan- 
itis, one  of  the  most  dreaded  complications,  might 
be  due  to  an  accompanying  colitis.  Caffeine  should 
be  given  early  to  increase  urination  and  aid  in  pre- 
venting cardiac  failure.  Cocaine  might  also  be  used. 
The  physical  signs  in  the  heart  were  less  alarmino 
than  the  symptoms  of  vasomotor  paralysis  ;  patients 
with  mitral  insufficiency  got  along  pretty  well. 

Dr.  L.\MBERT,  of  Xew  York,  noted  an  improve- 
ment of  about  ten  per  cent,  in  cases  treated  with 
pressor  agents — digitalis,  caffeine,  and  camphor — as 
compared  with  another  group  treated  with  alcohol 
and  nitroglycerin. 

Dr.  FoRCHiiEiMER,  in  closing,  again  touched  upon 
the  diagnosis  of  failure  of  the  right  heart  and  vaso- 
motor palsy,, declaring  that  physical  examination  of 
the  heart  was  of  little  importance.  Digitalis  was 
not  indicated.  Camphor,  musk,  and  ether  were  use- 
ful only  in  myocardial  insufficiency.  In  reply  to 
Dr.  Hoover  he  pointed  out  that  the  blood  pressure 
as  a  matter  of  fact  was  low  after  two  days,  loo  or 
less,  and  the  sign  was  therefore  of  value. 

An  Experimental  Study  of  Gastric  Tetany  was 
the  title  of  a  paper  read  by  Dr.  VV.  G.  ^I.-\cC.\llum, 
of  Raltiniorc.  Gastric  tetany  was  usually  a  fatal  dis- 
ease. The  phenomena  of  the  disease  had  been  va- 
riously explained  as  due  to  desiccation  of  the  tissues 
CKussmaul).  reflex  nervous  disturbances,  and  auto- 
intoxication I)rought  about  by  absorption  of  poisons 
from  the  stomach,  .\nimal  experiments  appeared 
to  disprove  the  first  and  the  third  theories.  .\n  arti- 
ficial gastric  tetany  was  produced  by  complete  ob- 
struction of  the  pylorus,  converting  the  stomach  into 
a  sac  communicating  only  with  the  oesophagus.  The 
stomach  was  washed  out  daily,  and  the  animal  fed 


through  a  fistula.  The  quantity  of  gastric  juice  s-e- 
creted  varied  greatly  in  different  animals.  The  con- 
stant loss  of  hydrochloric  acid  caused  precipitation 
of  calcium  salts  and  withdrew  them  from  the  circu- 
lation. The  exhibition  of  salt  would  temporarily  ar- 
rest the  symptoms.  Calcium  salts  did  not  prove 
more  successful.  The  experiment  of  returning  the 
gastric  juice  to  the  intestine  was  also  made.  The 
results  were  as  yet  quite  inconclusive.  Some  ab- 
sorption of  ferments  might  possibly  take  place. 

Dr.  Jones,  of  Buft'alo,  and  Dr.  Potter,  of  New 
"^'ork,  both  reported  cases  which  ended  in  recovery 
In  Dr.  Jones's  case  there  was  intermittent  hyper- 
chlorhydria ;  in  Dr.  Potter's  case  calcium  salts  were 
given  but  appeared  to  have  no  eft'ect. 

Chronic  infectious  Endocarditis. — Dr.  Frank 
Billings,  of  Chicago,  read  this  paper.  The  pa- 
tients might  be  divided  into  two  classes,  those  in 
whom  the  disease  was  implanted  on  an  old  valvu- 
litis, and  a  small  proportion  who  showed  no  evi- 
dence of  a  previous  endocarditis.  This  series  em- 
braced fourteen  cases,  five  of  which  were  primary, 
two  were  doubtful,  and  seven  had  old  endocarditic 
lesions.  The  duration  varied  from  four  months  to 
eighteen  months.  Three  patients  had  been  regarded 
as  cases  of  tuberculosis.  Blood  cultures  revealed 
the  pneumococcus  in  eleven  and  streptococci  in  the 
remaining  three  patients.  The  pneumococcus  in 
these  cases  was  found  in  a  streptococcal  form  and 
continued  to  grow  as  a  streptococcus  in  subcultures, 
but  ultimately,  when  inoculated  on  suitable  media, 
returned  to  the  diplococcic  form.  When  injected 
into  animals  subcutaneously,  intraperitoneally,  or  in- 
travenoush',  an  endocarditis  or  a  pneumococchsemia 
was  produced ;  sometimes  by  continuing  the  passing 
through  subcultures,  pneumonia  was  produced  in 
the  test  animals.  The  source  of  infection  in  two 
cases  was  a  preceding  amygdalitis  ;  in  one  influenza  ; 
in  two,  alveolar  abscesses  containing  pneumococci 
with  other  microorganisms ;  in  the  remainder  the 
source  could  not  be  determined. 

Dr.  Stengel,  of  Philadelphia,  commented  on  the 
large  proportion  of  primary  cases  (five  out  of  four- 
teen) in  the  series.  The  diagnostic  problem  in  a 
case  of  fever  developing  in  the  course  of  an  endo- 
carditis was  a  difficult  one.  The  terms  "recurring" 
and  "efflorescing"  endocarditis  had  been  used. 
Other  possible  causes  of  such  fevers  were  long  con- 
tinued stasis,  cystitis,  pyelitis,  especially  in  the  aged. 
Severe  anaemia  of  a  chloranaemic  type  was  observed. 
Most  of  Stengel's  cases  were  found  to  be  due  to 
streptococcus,  in  one  case  an  anaerobic  bacillus  was 
isolated.  Many  of  these  cases  were  relatively 
benign ;  especially  when  the  disease  was  engrafted 
on  an  old  endocarditis.  The  symptoms  then  were 
mechanical  rather  than  toxic. 

Dr.  Anders,  of  Philadelphia,  believed  that  most 
cases  of  chronic  infectious  endocarditis  were  sec- 
ondary to  rheumatic  arthritis,  although  streptococci 
were  found  in  the  blood.  He  agreed  with  Dr.  Sten- 
gel that  secondary  cases  were  more  hopeful,  .\nti- 
streptococcic  serum  should  be  given  whenever  strep- 
tococci were  found  in  the  blood. 

Dr.  Billings,  in  closing,  said  in  answer  to  a  ques- 
tion by  Dr.  Stockton  that  no  treatment  whether 
with  drugs,  serum,  or  vaccine  was  of  avail.  The 
prognosis  was  absolutely  bad,  and  he  had  seen  only 


June  .2,  .909.J        ATLANTIC  CTTY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


1217 


one  recovery  in  which  the  disease  was  later  proved 
by  autopsy.  Vaccine  prepared  from  streptococci 
recovered  from  the  patient,  if  used  in  large  doses, 
did  harm,  and  in  small  doses  had  no  effect. 

Diverticulum  of  the  Pylorus. — Dr.  Allen  A. 
Jones,  of  Buffalo,  reported  such  a  case  resulting 
from  an  old  gastric  ulcer  which,  instead  of  con- 
stricting the  pylorus,  gave  rise  to  traction  and  pro- 
duced a  diverticulum  of  the  pylorus. 

Diet  in  Typhoid  Fever. — Dr.  Warren  Cole- 
man, of  New  York,  said  that  two  questions  should 
be  answered :  Should  the  patient  be  given  enough 
nourishment  for  his  energy  requirements?^  and 
What  is  enough  for  his  energy  requirements?  The 
history  of  the  treatment  of  typhoid  fever  was  brief- 
ly reviewed.  Underfeeding  was  the  direct  cause 
of  some  of  the  toxic  symptoms  of  the  disease.  Loss 
of  weight  was  attributed  partly  to  the  pyrexia  and 
partly  to  "toxic  destruction."  The  first  question  was. 
therefore,  answered  in  the  affirmative,  and  the 
amount  necessary  was  a  minimum  of  3,000  calories 
each  day,  or  forty  calories  per  kilogramme  of  body 
weight  each  day.  The  diet  selected  for  the  series 
of  forty-four  cases  which  formed  the  basis  of  the 
paper,  was  quarts  of  milk,  i  pint  of  cream,  3  to 
6  eggs,  i-l  pounds  of  milk  sugar,  toast,  and  butter. 
Some  practical  difficulty  was  found  in  getting  the 
patients  to  take  this  diet.  Of  the  series  one  patient, 
an  ambulance  case,  died  one  week  after  admission, 
apparently  of  acute  dilatation.  The  nitrogen  bal- 
ance was  practically  maintained  ;  one  patient  gained 
two  pounds  during  a  relapse  of  two  weeks. 

Dr.  EiNHORN,  of  New  York,  expatiated  on  the 
great  importance  of  giving  typhoid  patients  plenty 
of  water. 

Dr.  Clayton,  of  Washington,  spoke  warmly  in 
support  of  more  liberal  feeding. 

Dr.  Jacobi,  of  New  York,  congratulated  Dr. 
Coleman  on  his  good  results  with  such  a  diet  as  he 
had  employed,  but  criticized  the  proportion  of  fat, 
which,  he  thought,  was  too  high.  Fat  was  not  as 
good  a  tissue  saver  as  carbohydrates. 

Dr.  Anders.,  of  Philadelphia,  thought  the  milk 
sugar  a  very  digestible  carbohydrate,  largely  re- 
sponsible for  the  good  results  obtained,  and  warned 
against  too  much  proteid  food. 

SECTION  IN  OBSTETRICS  AND  DISEASES  OF 
WOMEN. 

Mental  Alienation  in  Women  and  Abdominal 
Pelvic  Disease. — Dr.  W.  P.  MantOiV,  of  Detroit, 
used  this  title  for  the  address  as  chairman  of  the 
section.  He  emphasized  the  importance  of  localiz- 
ing somatic  disease  as  a  factor  in  the  cause  of  in- 
sanity. The  reflex  element  was  too  much  ignored 
by  alienists,  it  being  only  recently  that  systematic 
examination  of  women  patients  in  asylums  had  been 
made  with  a  view  to  discovering  possible  gynaeco- 
logical lesions.  It  was  found  in  a  large  asylum  that 
eighty-one  per  cent,  of  the  female  patients  suffered 
from  some  form  of  pelvic  disease.  He  cited  the 
rates  of  postoperative  msanity  as  i  in  1000  of  pa- 
tients operated  upon,  and  insisted  that  women  were 
entitled  to  have  pelvic  lesion  cured  whether  they 
were  insane  or  not. 

The  Operation  of  Choice  for  Retrodisplace- 
ments  of  the  Uterus. — Dr.  A.  E.  Benjamin,  of 


Minneapolis,  read  this  paper.  He  said  that  retrodis- 
placement  predisposed  to  annexal  disease  and  was 
in  many  cases  synchronous  with  general  splanch- 
noptosis. The  retroversion  in  certain  cases  while 
not  causing  symptoms  per  sc  greatly  aggravated 
pain  due  to  salpingitis,  appendicitis,  or  any  form  of 
peritonitis.  Office  methods  of  replacement  were  us- 
ually inefficient.  The  operator  should  be  thoroughly 
familiar  with  all  varieties  of  operations,  as  no  one 
technique  would  apply  in  all  cases.  Ventrosuspen- 
sion  was  of  doubtful  value  inasmuch  as  it  forced  the 
uterus  into  an  unnatural  position  and  held  it  so  by 
an  luinatural  ligament.  The  Baldy  operation  was 
not  logical  by  reason  of  it  wasting  by  folding  the 
strongest  part  of  the  round  ligament  and  because  it 
formed  a  constricting  band  around  the  body  of  the 
uterus,  interfering  with  circulation.  The  other  op- 
erations devised  all  had  defects  of  more  or  less  im- 
portance. The  author  described  a  modification  of 
the  Gilliam  operation  in  which  after  a  median  inci- 
sion, the  skin  was  dissected  back  and  the  fascia 
penetrated  by  a  forceps,  the  round  ligament  grasped 
and  fastened  at  about  the  level  of  the  internal  in- 
guinal ring. 

Dr.  Barratt,  of  Chicago,  said  that  the  treatment 
of  retrodisplacement  was  largely  that  of  its  compli- 
cations. The  principles  which  must  be  possessed 
by  any  successful  operation  were:  Safety,  simplici- 
ty, it  must  allow  inspection  of  intraabdominal  condi- 
tions, must  deal  with  the  best  portion  of  the  round 
ligament,  and  must  use  the  ligaments  in  their  nor- 
mal relations,  not  using  them  as  suspensory  bands. 
He  favored  intramucal  trans]:)lantation  of  the  round 
ligaments,  first  shortening  them  intraperitoneally, 
then  h'-inging  them  out  through  the  inguinal  canal. 

Dr  Bovee,  of  Washington,  said  that  many  op- 
erations were  required  for  many  cases.  The  sub- 
ject was  at  best  a  vague  one  owing  to  the  lack  of 
definite  knowledge  concerning  the  normal  supports 
of  the  uterus.  In  many  instances,  simple  shortening 
of  the  round  ligaments  was  sufficient,  but  many  fac- 
tors interfered  such  as  long  uterovesical  ligaments 
and  long  uterosacrals. 

Dr.  BoLDT,  of  New  York,  defended  the  Alexan- 
der-Adams operations  when  done  for  uncomplicat- 
ed cases  only.  In  such  cases  the  operation  was  al- 
ways successful  in  relieving  symptoms.  When  an- 
nexal disease  was  present  an  intraperitoneal  opera- 
tion must  be  used,  but  the  choice  rested  with  the 
operator. 

Dr.  Hall,  of  Cincinnati,  believed  that  the  choice 
of  operations  should  be  varied.  He  did  not  be- 
lieve in  ventrosuspension  by  reason  of  the  great 
danger  of  subsequent  intestinal  obstruction  of  which 
many  cases  were  on  record. 

Dr.  Marcy,  of  Boston,  shortened  the  round  liga- 
ment in  the  inguinal  canal  and  at  the  same  time  re- 
paired any  defect  in  the  structures  about  the  canal. 

Dr.  Petersen,  of  Ann  Arbor,  usually  treated 
retrodisplacement  by  Edebohrs  modification  of  the 
Alexander  operation.  A  very  bad  experience  with 
ventrosuspension  with  two  subsequent  Csesarean 
sections,  led  him  to  entirely  abandon  this  operation 
in  pregnant  women. 

Dr.  Stone,  of  Washington,  thought  too  much 
stress  was  laid  on  modification  of  technique,  but 
not  enough  attention  was  paid  to  the  causes  respon- 


ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


sible  for  retroversion.  As  the  condition  usually  fol- 
lowed a  general  descent  of  the  viscera,  he  could  not 
understand  how  shortening  the  round  ligaments 
would  be  of  benefit.  He  thought  many  failures  due 
to  paralysis  of  the  nerve  supply  of  the  round  liga- 
ment by  trauma,  and  that  the  latter  as  a  result  were 
frequently  mere  atrophic  bands  of  connective  tis- 
sues with  no  muscle  discernible. 

Dr.  Fry.  of  Washington,  defended  ventrosuspen- 
sion,  though  fixation  occasionally  occurred  by  acci- 
dent. He  objected  to  the  Alexander  operation  by 
reason  of  difficulty  in  isolating  the  ligaments.  He 
thought  the  Eialdy-W'ebstcr  operation  the  best  yet 
described  as  it  so  completely  lifted  the  prolapsed 
ovary. 

Dr.  CoHE.x,  of  Bufifalo,  made  a  ])lea  for  better 
medical  preparation  of  the  patient  before  going  to 
operation.  He  would  have  the  operation  fit  the  pa- 
tient, not  the  patient  fit  the  operation. 

Dr.  Potter,  of  Rochester,  X.  Y.,  thought  retro- 
version was  more  difficult  to  cure  because  the  pa- 
tients were  not  seen  early  enough.  She  advocated 
an  early  examination  of  school  girls  as  a  routine, 
whether  anv  dvsmenorrhoea  was  present,  with  such 
treatment  as  might  be  indicated.  The  danger  of  a 
low  grade  infection  of  the  uterus  as  a  result  of  per- 
sistent retroversion  was  brought  out. 

Dr.  Shoemaker,  of  Philadelphia,  thought  too 
much  surgery  was  done  for  retroversion.  He  did 
not  think  the  condition  necessarily  implied  any  sort 
of  operation. 

Dr.  Bexj.\mix,  in  closing,  brought  out  the  great 
advantages  of  seeing  cases  early, before  visceroptoses 
had  occurred.  He  did  not  perform  ventrofixation 
by  reason  of  the  danger  resulting  from  the  false 
ligament.  He  again  described  his  operation  in  de- 
tail and  advocated  the  transverse  incision  in  selected 
cases. 

A  Study  of  the  Anatomy  and  Clinical  Impor- 
tance of  the  Sacroiliac  Joint. —  Dr.  Fkkdkkic  H. 
Albee,  of  Xew  York,  read  this  paper,  which  was 
based  upon  the  dissection  of  fiftv  sacroiliac  joints. 
A  great  variety  of  opinion  existed  among  anatomists 
as  to  the  movements  of  this  joint.  A  perfect  joint, 
with  synovial  membrane,  capsule,  and  ligaments 
was  found  in  all  the  author's  dissections.  There  was 
ver\-  slight  individual  viriatinn  in  the  joints  ex- 
amined. Relaxation  of  this  joint  was  a  common 
cause  of  constant,  dull  backache.  The  relaxation 
was  due  sometimes  to  trauma,  sometimes  to  pro- 
longed dorsal'  decubitus.  He  illustrated  cases  of  re- 
laxation, sprain,  and  true  dislocation  of  the  joint. 
Treatment  was  by  properly  applied  adhesive  band- 
age. 

Dr.  Frederick,  of  Buffalo,  said  the  paper  opened 
the  way  for  a  discussion  of  the  distinctive  diagnosis 
between  lesions  of  the  sacroiliac  joint  and  those 
within  the  pelvis.  He  cited  cases  and  thought  that 
owing  to  the  chronicity  of  the  condition  cure  was 
necessarily  slow. 

Dr.  Petersex,  of  .Ami  .\rbor,  thought  such  dis- 
tinctive diagnosis  very  difficult.  He  found  postop- 
erative backache  due  to  hardness  of  operating  table 
and  had  much  decreased  it  by  thoroughlv  j)adding 
the  table.  The  treatment  of  the  condition  was  more 
ooinplicatcd  than  merely  adjusting  a  bandage,  and 
he  advised  the  treatment  by  an  orthopaedist. 


Dr.  Barratt,  of  Chicago,  described  a  case  of 
true  inflammation  of  the  sacroiliac  joint. 

Dr.  SoLis-CoHEN,  of  Philadelphia,  thought  the  re- 
laxations caused  by  improper  posture,  with  tilting  of 
the  sacrum,  also  by  use  of  straight  front  corset 
causing  a  lordosis. 

Dr.  WiNDBRAKE,  of  'Scrauton.  Pa.,  thought  the 
injury  due  often  to  improper  application  of  high 
forcei)s.  He  thought  Caesarcan  section  much  sim- 
pler than  high  forceps  operation. 

The  Endometrium  and  Some  of  Its  Variations. 
— This  paper  was  presented  by  Dr.  William  S. 
Gardner  and  Dr.  Emil  Novak,  of  Baltimore.  The 
normal  endometrium  and  the  variations  in  its  glands 
and  in  the  stroma  at  different  periods  in  the  men- 
strual cycle  were  discussed,  as  w-ere  some  of  the 
conditions  found  in  the  endometrium  associated 
with  fibroids,  infection,  etc.  There  was  found  no 
true  difference  between  decidual  cells  and  those  of 
the  menstrual  period. 

Dr.  RIarcy,  Boston,  quoted  that  menstruation 
was  the  house  cleaning  for  the  little  tenant  that  may 
never  arrive.  He  thought  the  old  view  correct  that 
menstruation  was  a  necrotic  process  with  the  new 
production  of  endometrial  cells. 

Dr.  Clark,  of  Philadelphia,  thought  the  paper 
oft'ered  a  solution  to  the  question  of  the  nomencla- 
ture of  endometritis.  He  said  the  committee  ap- 
pointed by  this  section  some  time  ago  had  great  dif- 
ficulty in  arriving  at  conclusions.  He  advocated 
mentioning  the  time  of  the  menstrual  cycle  during 
which  endometrium  was  removed  to  the  pathologist 
in  order  to  facilitate  diagnosis. 

The  Pathology  of  Eclampsia  and  Toxaemia  of 
Pregnancy. — Dr.  J.  E.  \\'elcii,  of  New  York,  in 
reading  this  paper  discussed  eclampsia  and  tox- 
.'emia  of  pregnancy  from  a  pathological  standpoint 
with  refernce  to  fourteen  cases.  Post  mortem 
changes  were  usually  h?ep.iorrhage  or  central  ne- 
crosis of  liver  lobules,  sometimes  with  autolysis  and 
cerebral  hosmorrhage.  The  haemorrhage  was  caused 
by  a  solution  of  endothelial  cells  permitting  the  es- 
cape of  blood.  Blood  pressure  consistently  rose  in 
these  patients,  except  just  after  convulsion  when  it 
decreased.  The  blood  changes  were  discussed  at 
length.  The  hjemolytic  power  of  the  sera  of 
eclamptic  patients  was  doubtful.  The  headache  was 
due  to  disturbance  of  intracranial  tension.  The 
visual  changes  were  due  to  oedema  and  circulatory 
disturbance  at  the  base.  Nausea  and  vomiting  were 
due  to  irritation  of  the  vomiting  centres  and  to  re- 
flex causes.  The  jaundice  was  caused  by  cloudy 
swelling  of  the  liver  cells.  The  destruction  of  en- 
dothelial cells  was  possiblv  caused  by  an  enzyme 
which  was  developed. 

Study  of  Eclampsia  with  Results  in  Two  Hun- 
dred and  Fifty  Cases,  from  the  Wards  of  the 
Lying  in  Hospital  of  New  York  City. — This  pa- 
lmer was  read  by  Dr.  Ross  McPiierso.v,  of  New 
York,  who  said  that  climate  seemed  to  exercise 
some  effect  on  the  production  of  eclampsia.  Tt  was 
more  common  in  primipar.T  than  in  multiparre. 
Treatment  was  divided  into  prophvlactic  and  cura- 
tive. Curative  treatment  consisted  in  emptying  the 
uterus  as  quickly  as  possible  b\-  any  of  the  approved 
methods,  fhe  author  had  successfully  used  a  com- 
bination of  scopolamine  and  morphine  to  control 


June  12,  1909.]        ATLANTIC  CITY  MEETIXG  OF  AM 

convulsions.  Elimination  was  aided  by  hot  packs, 
bleeding,  rectal  injection  of  normal  salt  solutions. 
Immediate  examination  of  the  uterine  contents  was 
insisted  upon. 

A  Method  of  Complete  Nephroureterectomy  in 
Women. — Dr.  J.  Wesley  Bovee,  of  Washington, 
D.  C,  in  reading  this  paper,  described  a  method 
which  insured  rapidity  of  procedure,  caused  very 
slight  traumatism,  and  consisted  in  liberating  the 
tenninal  portion  of  the  ureter  from  the  bladder  and 
broad  ligament  through  a  vaginal  incision,  and  then 
completing  the  operation  from  above  by  a  trans- 
verse incision  in  the  abdominal  wall,  opposite  the 
kidney. 

Some  Factors  which  Contribute  to  Low  Mor- 
tality in  Abdominal  Section. — Dr.  F.  F.  Simpson, 
of  Pittsburgh,  read  this  paper.  He  said  that  such 
factors  were,  first:  Accurate  knowledge  of  the 
nature,  extent,  and  trend  of  the  disease.  Exact 
determination  of  the  reserve  strength  of  the  patient. 
Judicious  adaptation  of  time  of  operation  to  indi- 
vidual needs.  Competent  operative  and  postopera- 
tive coworkers.  Minimum  of  anaesthetic.  Speed 
with  precision. 

Remote  Results  of  Conservative  Surgery  of  the 
Ovaries. — Dr.  Jorix  O.  Polak,  of  Brooklyn,  pre- 
sented a  study  of  the  results  of  300  operations  for 
resection  of  one  or  both  ovaries,  and  included 
forty-one  secondary  operations  for  recurrent  dis- 
ease. He  studied  the  end  results,  and  concluded 
that  conservative  surgery  of  the  ovaries  was  a  valu- 
able procedure  but  had  very  distinct  limitations. 
He  quoted  Dudley's  statement  that  conservatism 
was  justifiable,- but  beheved  that  the  field  of  ovarian 
resection  was  a  somewhat  limited  one.  One  of  the 
reasons  for  failure  in  end  results  was  that  the  ovary 
was  not  elevated  in  the  pelvis  after  being  resected. 
This  should  always  be  done. 

The  Present  Status  of  Irrigation  and  Drainage 
in  Obstetric  and  Gynaecological  Operations. — 
Dr.  Horace  G.  Wetherh.l,  of  Denver,  read  this 
paper.  He  said  that  a  process  of  evolution  had  sim- 
plified the  approved  practice  of  to-day.  Irrigation 
was  valuable  for  washing  out  debris  from  the  ab- 
domen, but  should  not  be  practised  when  gentle 
sponging  would  suffice.  He  warned  against  the  use 
of  poisonous  and  irritating  solutions  within  the  ab- 
domen. Drainage  w^as  indicated  in  rupture,  a  leak- 
age of  a  hollow  viscus,  or  in  localized  pus  collec- 
tions. He  used  in  septic  cases  a  gauze  drain  down 
to  the  peritonaeum,  to  protect  the  incision  from  su- 
perficial infection  and  sloughing.  He  objected  to 
intrauterine  douches  after  normal  labor,  and  de- 
scribed a  rubber  irrigation  tube  which  was  to  be 
used  in  infected  cases,  and  the  uterus  frequently 
flushed  out  with  dilute  alcohol. 

Fibromyomata  of  the  Uterus. — Dr.  Ellice  Mc- 
Donald, of  New  York,  reported  700  cases  studied 
statistically  and  pathologically  as  to  their  relation  to 
cancer,  their  complications  and  degenerations.  The 
conclusion  was  drawn  that  in  view  of  these  changes, 
early  removal  of  the  tumors  Avas  indicated,  when 
they  were  of  sufficient  size  to  produce  symptoms. 
The  menopause  did  not  bring  cure  but  was  a  mere 
precursor  of  dangerous  complications.    He  thought 


IRICAN  MEDICAL  ASSOCIATIOX.  1219 

that  thorough  pathological  examinations  should  be 
made  of  all  fibroids  for  evidences  of  malignancy. 

Enucleation  of  Uterine  Myomata;  Why  and 
When  Performed. — This  paper  was  read  b\-  Dr. 
E.  E.  Montgomery,  of  Philadelphia,  who  said  that 
removal  of  myomata  b}'  enucleation  should  be  con- 
sidered :  I ,  When  they  were  few  in  number  and  the 
uterine  structure  was  but  little  involved.  2.  When 
the  growths  were  readily  accessible.  3.  When  the 
patient  was  under  forty  years  of  age.  4.  \\  hen 
tubes  and  ovaries  were  healthy.  Such  operation 
should  not  be  considered :  i ,  When  the  patient  was 
over  forty  years  of  age.  2,  When  the  uterus  was 
destroyed  by  presence  of  growths.  3,  When  the 
growths  were  so  distributed  that  the  circulation 
would  be  affected  by  the  necessary  sutures. 

Ovariotomy  and  Myomectomy  Early  in  Preg- 
nancy with  Full  Term  Delivery. — Dr.  H.  Grad, 
of  New  York,  reported  an  illustrative  case  and  con- 
cluded that  expectant  treatment  was  the  procedure 
of  choice,  unless  the  growths  interfered  with  de- 
livery or  caused  pressure  symptoms. 

Dr.  Kelly,  of  Baltimore,  said  that  the  treatment 
of  myoma  during  pregnancy  was  one  of  wide  dif- 
ferences. He  leaned  toward  a  policy  of  noninter- 
ference especially  when  the  tumors  were  in  the  up- 
per segment  of  the  uterus  and  were  not  causing 
symptoms. 

"  Dr.  Fry,  of  ^^'ashington,  said  the  danger  in  leav- 
ing fibroids  after  labor  was  that  suppuration  might 
ensue.    He  cited  two  cases  with  one  death. 

Dr.  Carstens,  of  Detroit,  said  that  as  the  mor- 
tality of  myomectomy  during  pregnancy  was  not 
appreciably  greater  than  when  pregnancy  did  not 
exist,  he  thought  such  patients  might  safely  be  oper- 
ated upon. 

Curettage    for    Uterine    Haemorrhage.  —  Dr. 

Howard  A.  Kelly,  of  Baltimore,  read  this  paper. 
He  observed  that  the  causes  of  uterine  haemorrhage 
might  be  due  to  changes  in  the  endometrium,  the 
myometrium,  the  uterine  vessels,  or  in  the  condi- 
tion of  the  blood.  Curettage  was  applicable  to  these 
cases  where  the  change  was  in  the  endometrium. 
Sometimes  curettage  had  to  be  repeated,  particu- 
larly before  the  menstrual  period.  He  reported  fa- 
vorable results  and  preferred  frequent  curettage  to 
hysterectomy. 

SECTION  IX  SURGERY  AND  ANATOMY. 

Localized      Subphrenic      Tuberculosis.  —  Dr. 

Charles  A.  Powers,  of  Denver,  who  read  this 
paper,  said  that  he  had  had  a  patient  with  tubercu- 
losis of  both  lungs.  Pain  was  also  marked  in  the 
region  of  the  gallbladder.  He  was  operated  upon 
and  no  involvement  of  the  gallbladder  was  found. 
Small  nodules  were  found  on  the  upper  surface  of 
the  liver,  and  a  large  caseous  mass  was  fotmd  be- 
tween the  liver  and  the  diaphragm.  This  mass  was 
found  on  examination  to  be  tuberculous. 

Another  case  was  one  that  gave  the  picture  of 
pneumothorax.  But  an  incision  along  the  costal 
arch  served  to  evacuate  gaseous  pus  and  opened  into 
a  large  cavity  reaching  as  far  as  the  third  rib.  The 
passage  of  infection  from  the  pleura  into  the  abdo- 
minal cavity  might  be  through  the  lymph  vessels, 
or  the  bacteria  might  penetrate  through  the  mem- 


I220  ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION.  JouTna... 


brancs  and  muscles  by  active  growth.  Research 
gave  no  cooperative  diagnosis. 

Treatment  of  Tuberculous  Pleuritis  and  Em- 
pyema.— This  paper  was  by  Dr.  Emil  G.  Beck,  of 
Chicago.  Close  relation  existed  between  tubercu- 
lous pleurisy  and  empyema.  Fully  seventy  per 
cent,  of  cases  of  serofibrinous  pleurisy  in  adults  were 
of  tuberculous  origin.  A  case  of  empyema  having 
a  daily  discharge  of  two  to  three  ounces  of  foetid, 
green  pus  came  to  his  notice.  The  drainage  tube 
was  removed  and  120  grammes  of  bismuth  petrola- 
tum paste  were  injected  into  the  cavity.  This  was 
repeated  for  a  few  days,  and  was  followed  by  re- 
covery of  the  patient.  He  reported  ten  cases  of  em- 
pyema and  three  cases  of  abscess  of  the  lung.  He 
also  reported  a  case  of  bismuth  intoxication  in  which 
720  grammes  of  bismuth  paste  had  been  injected 
and  allowed  to  remain  six  weeks.  The  symptoms 
were  slight  cyanosis,  blue  border  on  the  gums,  loss 
of  weight,  and  desquamative  nephritis.  At  once  500 
c.c.  of  warm  olive  oil  were  injected  and  formed  an 
emulsion  with  the  paste,  which  was  drawn  out  by 
suction.   The  symptoms  immediately  disappeared. 

He  said  it  was  not  necessary  to  drain  off  the  pus 
before  injecting  with  bismuth  paste. 

Bismuth  petrolatum  paste  was  composed  of  one 
part  bismuth  and  two  parts  petrolatum. 

Pneumectomy  with  the  Aid  of  Differential 
Pressure ;  an  Experimental  Study. — Dr.  Willy 
Meyer,  of  Xew  York,  said  that  he  had  been  doing 
research  W'Ork  in  the  Rockefeller  Institute  of  New 
York  along  the  line  of  differential  lung  pressure, 
both  negative  and  positive,  and  described  an  original 
and  safe  method  of  treating  the  stump  after  ampu- 
tation of  the  bronchus.at  the  base.  He  first  crushed 
the  cartilages  of  the  bronchus,  and  then  inverted  it, 
and  closed  the  top  by  a  number  of  sutures.  Silk 
was  used  throughout  the  operation.  He  reported 
eighty  per  cent,  of  recoveries. 

Intrathoracic  Physiological  and  Technical 
Studies. —  Dr.  tlEXRv  H.  J.\xjiWAY  and  Dr.  Xa- 
TiiAN  W.  Green,  of  New  York,  were  the  authors 
of  this  paper.  They  stated  that  they  had  limit- 
ed their  work  chiefly  to  intrathoracic  oesophageal 
operations  in  two  ways;  first,  by  circuiting  the  car- 
dia  by  the  establishment  of  an  anastomosis  between 
the  stomach  and  the  oesophagus  and  by  an  opera- 
tion for  the  resection  of  a  portion  of  both  the  stom- 
ach and  the  oesophagus.  They  had  two  methods  of 
artificial  respiration.  Inflation  by  an  intubation  tube 
and  by  a  positive  pressure  cabinet.  Intrathoracic 
surgery  depended  for  its  success  upon  speed,  abso- 
lute asepsis,  and  minimizing  the  trauma. 

Dr.  De  Forest  Willard,  of  Philadelphia,  said 
that  the  abdominal  organs  were  not  so  dangerous  to 
life  as  were  those  of  the  thoracic  cavity;  the  heart 
and  the  lungs  were  more  vital.  The  use  of  negative 
and  positive  pressure  cabinets  were  used  more  suc- 
cessfully than  in  the  past.  Pneumothorax  was  more 
likely  to  occur  in  healthy  than  in  diseased  lungs 
because  they  were  accustomed  to  an  abnormal  con- 
dition. He  advocated  the  treatment  of  tuberculous 
cavities  by  incision  and  drainage.  Tuberculous  cav- 
ities in  the  lung  were  not  always  single,  but  wore 
likely  to  be  scattered.  Extir])ation  or  pneumorec- 
toiny  was  feasible.    In  operations  upon  mediastinal 


tumors  a  transverse  incision  was  better  than  a  longi- 
tudinal one.  The  use  of  bismuth  petrolatum  paste 
in  cases  of  empyema  was  rational  and  good  treat- 
ment. 

Dr.  S.  J.  Meltzer^  of  New  York,  said  that  the 
statement  that  there  was  no  difference  between  ef- 
fect of  positive  and  negative  pressure  was  physiologi- 
cally incorrect.  The  heart  might  become  slow  on  ac- 
count of  the  carbon  dioxide,  and  sometimes  the  heart 
stopped,  due  to  pressure  on  the  medulla,  and  yet  an 
animal  might  not  be  in  danger.  He  also  said  that 
animals  did  not  require  any  respiratory  movement 
for  respiration.  Positive  and  negative  pressure  pre- 
vented the  lungs  from  collapsing.  By  putting  a  tube 
in  the  trachea  to  the  bifurcation  leaving  a  space  be- 
tween the  tube  and  the  trachea  an  animal  might 
live  for  many  hours.  The  lungs  were  in  a  state  of 
continuous  inspiration.  The  carbon  dioxide  escaped 
by  another  path.  There  were  no  respiratorv  move- 
ments. 

Dr.  Fell,  of  Chicago,  said  positive  respiration 
was  the  best,  giving  a  better  control  of  inspiration. 

Dr.  Robinson,  of  Boston,  said  that  he  had  oper- 
ated on  animals  both  by  negative  and  positive 
pressure,  and  that  he  had  operated  on  patients  by 
positive  pressure.  It  was  best  not  to  operate  in 
thoracic  cases  without  pressure.  Positive  pressure 
was  not  so  good  physiologically  as  negative  pres- 
sure. He  said  that  the  bismuth  paste  method  was 
used  in  cases  that  had  not  been  properly  operated 
in  by  surgeons  and  were  due  to  their  neglect. 

Dr.  Green,  of  New  York,  said  that  the  lung 
could  be  removed  with  certainty,  and  that  one 
could  open  the  chest,  and  explore  the  lung  by  direct 
inspection.  He  favored  giving  one  fiftieth  grain  of 
atropine  before  beginning  an  operation,  to  prevent 
shock.  Care  should  be  taken  not  to  over  expand' the 
chest,  as  it  might  cause  injury. 

Dr.  J.  B.  Murphy,  of  Chicago,  said  that  surgical 
conditions  of  the  thoracic  cavity  covered  an  ex- 
tended and  important  field,  and  could  be  divided 
into  two  heads ;  first,  the  management  of  empyema : 
second,  the  continued  course  in  the  management  of 
pleurisy.  If  the  empyema  did  not  communicate 
with  the  bronchus  what  would  one  do  to  render 
the  cavity  sterile,  and  cause  absorption  ?  First,  by 
simple  aspiration,  and  second  by  changing  the  wall 
of  the  abscess  by  injection  of  some  enzyme  into  the 
abscess,  such  as  trypsin  in  a  two  per  cent,  solution 
of  formalin  in  glycerin.  In  the  treatment  of  pleu- 
risy the  chest  wall  should  be  examined,  the  lung 
should  not  be  allowed  to  contract  during  the  process 
of  repair,  and  the  exudate  removed  by  absorption. 
The  fluid  should  be  rendered  sterile.  Circumscribed 
areas  should  be  drained  and  the  cavity  repaired  af- 
ter drainage.  No  cavity  should  be  opened  until  con- 
nection with  the  bronchus  had  occurred. 

Dr.  IlARTFOKn,  of  Youngstown,  Ohio,  exhibited  a 
child  wdio  had  been  operated  upon  by  Dr.  Beck  with 
bismuth  paste  after  two  surgical  operations  had 
failed  for  empyema:  the  patient  was  cured. 

Dr.  A.  H.  Ochsner,  of  Chicago,  advocated  the 
use  of  bismuth  paste  in  sinuses  and  abscesses,  and 
in  cases  of  empyema,  especially  in  cases  of  old 
sinuses  of  all  kinds.  The  bismuth  paste  could  be 
used  whether  the  abscess  opened  into  the  bronchus 


June  12.  ,909.]        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


122V 


or  not.  Should  there  be  any  indication  of  bismuth 
poisoning-  the  paste  should  be  removed  with  warm 
olive  oil. 

Electric  Sleep. — Dr.  Dldlev  Fait  and  Dr. 
Raymond  Russ,  of  San  Francisco,  were  ihe  authors 
of  this  paper.  They  said  that  an  analgesic  condition 
could  be  produced  by  the  means  of  the  electric  cur- 
rent. This  current  could  be  applied  to  the  head 
surface  without  trephining  the  skull.  The  respira- 
tory and  circulatory  system  remained  intact :  but  a 
condition  of  general  anaesthesia  existed.  Experi- 
ments on  the  rabbit,  showed  there  was  at  tirst  sur- 
prise, marked  excitability,  rigidity  of  the  neck,  no 
etfect  on  the  pupils.  The  rabbit  remained  senseless 
and  could  be  pinched  or  cut  without  feeling  it. 
There  was  a  slight  respiratory  disturbance  on  rais- 
ing the  potential.  One  case  proved  fatal.  The  skin 
surface  over  the  eye  of  a  dog  was  shaved,  and  the 
positive  electrode  was  applied ;  and  the  negative 
electrode  was  applied  over  wet  cotton  on  the  back 
of  the  neck.  This  caused  faecal  and  urinary  incon- 
tinence. The  current  was  pushed  until  the  eye  re- 
flexes disappeared.  Reducing  the  resisting  current 
diminished  the  danger.  Two  or  three  miliamperes 
were  used  without  danger.  The  current  was  made 
stronger  when  cutting  down  on  the  nerve  trunks. 
Five  and  one  half  miliamperes  could  be  used  in  man 
without  loss  of  reflexes.  The  more  rapid  the  revo- 
lution of  the  wheel  the  less  the  sensation  of  pain. 
For  resuscitation  the  same  current  could  be  used 
with  low  voltage  and  short  duration.  The  instru- 
ment used  was  shown  to  be  a  wheel  interruption 
controlled  by  a  rheostat.  Direct  lighting  current 
was  not  satisfa-ctory ;  as  was  the  indirect  lighting 
current.  The  galvanic  current  was  used.  Interrup- 
tion of  the  positive  rather  than  the  negative  pole 
was  shown  to  be  superior.  The  interruption  of  the 
current  was  even,  any  sudden  or  rapid  interruption 
would  likely  cause  death. 

The  Operative  Treatment  of  Fractures. — Dr. 
W.  Arbuthxot  Laxe,  of  London,  England,  read 
this  paper.  He  said  that  the  union  of  simple  frac- 
tures when  undergoing  repair  were  not  in  perfect 
apposition.  On  dissection  fracttires  had  shown  con- 
stant joint  changes  and  also  by  the  tise  of  the  x  ray. 
He  advocated  operation  on  all  simple  fractures 
from  infancy  to  old  age.  This  was  done  by  variotis 
methods  suitable  to  different  cases.  He  said  that 
the  methods  of  surgeons  were  prejudicial  to  suc- 
cess, because  of  the  un familiarity  of  the  use  of 
wire,  screws,  plates,  and  pegs.  By  exercising 
more  care  and  cleanliness  troubles  would  cease  to 
arise  and  that  a  surgeon  should  have  a  practical 
training  in  this  kind  of  work.  Care  should  be  taken 
when  the  incision  was  made  so  as  not  to  do  any 
damage  to  the  bloodvessels  or  nerves.  There  was 
very  little  danger  in  operating  on  the  lower  extremi- 
ty ;  but  there  was  in  the  upper  extremity.  An  incision 
was  made  over  the  seat  of  fracture,  folds  of  gauze 
v\  ere  laid  along  the  skin  incision,  and  held  by  fenes- 
trated forceps,  to  prevent  infection.  Haemorrhage 
was  controlled  by  haemostats,  the  fragments  were 
put  in  apposition  and  the  two  ends  of  the  bone  were 
fixed  bv  plate  or  wire.  No  amount  of  traction 
would  allow  of  setting  the  bone  ;  the  resistance  varv- 
ing  with  the  overlapping  of  the  fragments.  Care 


was  always  to  be  exercised  to  see  that  no  clots  or 
tissues  were  over  the  end  of  the  fragments.  He 
said  that  to  delay  m  operating  on  a  fracture,  ren- 
dered reducing  more  difficult,  and  that  in  epiphyseal 
fracture  there  was  little  danger  of  getting  out  of 
place  when  once  reduced.  In  fracture  of  femur  a 
plaie  and  screws  were  used  with  good  success. 
Shortening  was  minimized  by  extension  of  muscles, 
nerves  and  vessels,  as  there  was  no  limit  to  their 
stretching  capacity. 

Operative  Treatment  of  Fractures. — Dr.  WiL- 
'^lA^i  Darrach,  of  Xew  York,  in  reading  this  paper 
said  that  he  had  operated  in  several  cases  of  frac- 
ture by  the  open  method.  In  cases  of  fracture  of 
the  patella  he  said  that  he  favored  the  open  method. 
Out  of  3,500  fractures  he  had  used  the  open  method 
in  174  cases.  The  treatment  of  fractures  resolved 
into  the  use  of  simple  mechanical  means,  use  of 
chromisized  gut,  silver  wire,  plate,  and  screws. 

A  Plea  for  the  More  Careful  Diagnosis  of  Frac- 
tures and  Their  Treatment. — This  paper  Avas 
read  by  Dr.  E.  D.  Martix.  of  Xew  Orleans,  who 
said  that  to  obtain  better  results  mechanical  skill 
v.  as  required  and  that  such  cases  should  be  referred 
to  an  orthopaedic  mechanical  surgeon,  and  that  an 
X  ray  picture  should  be  taken  before  the  fracture 
was  set.  afterward,  and  in  about  2  weeks,  to  make 
sure  there  was  perfect  apposition.  He  advocated 
use  of  staples  made  of  piano  wire. 

Dr.  C.  L.  Sct'DDER.  of  Boston,  said  that  wire 
nails,  staples,  and  pegs  were  not  indicated.  He  al- 
ways tried  to  prevent  damage  to  the  soft  parts.  The 
results  by  the  use  of  apparatus  was  unsatisfactory. 
The  operative  treatment  for  fractures  was  vmwar- 
ranted  and  unsurgical.  He  said  that  he  believed 
in  immobilization,  care  of  the  joint,  masage,  and  the 
production  of  perfect  function.  Operations  did  not 
warrant  ideal  results. 

The  Oration  on  Surgery  was  read  b}'  Dr. 
Harviv  Cushixg,  of  Baltimore.  He  stated  that 
the  increase  and  decrease  of  secretion  of  the  thy- 
reoid and  perithyreoid  gland  had  made  myxoedema 
and  cretinism  a  curable  condition.  Progress  would 
have  been  slower  but  for  operation  on  the  cervical 
gland.  He  said  that  the  pituitary  body  was  a 
neural  projection  into  the  pouch,  and  that  the  epithe- 
lial portion  discharged  into  the  infundibuliform 
space.  The  pituitary  body  was  essential  to  life.  If 
the  posterior  gland  was  removed  there  would  be  no 
disturbance  of  equilibrium. 

The  Pseudoperitonaeum. — Dr.  A.  E.  Hertzler, 
of  Kansas  City,  in  reading  this  paper  said  that  it  was 
a  large  lymph  space,  compared  to  a  synovial  mem- 
brane. An  example  was  a  new  form  of  fibrous  tis- 
sue in  the  mesentery  and  peritoneal  adhesions. 

The  Early  Symptoms  of  Upper  Abdominal 
Disease,  by  Dr.  Johx  B.  Deaver.  of  Philadelphia. 
The  author  said  that  the  surgery  of  the  upper  ab- 
dominal organs  had  been  far  behind  that  of  the 
organs  contained  in  the  pelvis.  A  careful  diagnosis 
should  be  made :  gallstones  occurred  in  ninety  per 
cent,  of  the  cases,  and  a  history  of  constipation , 
flatulence,  pain  on  empty  stomach,  indican  in  urine 
was  demonstrated.  Carcinoma  of  stomach  could 
be  operated  on  with  success  if  diagnosticated  earh^ 
Pancreatitis. — This  paper  was  read  by  Dr.  A. 


1222 


ATLASTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION.     ^  [New  York 

Medical  Journal. 


J.  (JcHSXER,  of  Chicago,'  who  said  that  cases  of 
pancreatitis  were  not  examined  with  any  system  un- 
til five  years  ago.  Pancreatic  disease  cases  were 
a.ssociated  with  disease  of  the  gallbladder.  The 
Colon  bacillus  was  the  chief  cause  of  infection,  fol- 
lowed by  inflammatory  disease  of  the  gallbladder. 
Infection  through  the  infected  bile  occurred  into  the 
pancreatic  juice.  Exploratory  incision  was  permis- 
sible :  the  patient  should  be  dieted  and  observed ; 
it  was  difficult  to  make  a  distinctive  diagnosis.  The 
treatment  was  drainage  without  traumatism. 

Hypertrophic  Stenosis  of  the  Pylorus  of  In- 
fants, by  Dr.  St.\xlev  Stillmax,  of  San  Fran- 
cisco. He  said  that  pyloric  spasm  in  infants  might 
be  secondary  to  trouble  elsewhere,  or  might  be  con- 
genital. Cartilaginous  tumors  would  be  the  result 
of  congenital  condition  and  not  due  to  swallowing 
amniotic  fluid.  As  infants  could  stand  an  anaesthetic 
as  well  as  adults  an  exploratory  incision  should 
be  made.  He  reported  twenty  cases  of  perfor- 
ated gastric  and  duodenal  ulcers. 

SECTION  IN  HYGIENE  AND  SANITARY 
SCIENCE. 

The  Importance  of  Consolidation  of  All  the 
National  Health  Associations  into  the  Section 
on  Hygiene  and  Sanitary  Science  with  the  Pur- 
pose of  Making  it  What  it  Should  Be. — Dr.  J.  N. 

McCoRMACK,  of  Bowling  Green,  Ky.,  said  that  our 
energies  were  largelv  wasted  because  \\e  had  nol 
been  united.  This  might  be  done  as  an  Americar 
board  of  health — or  the  official  boards  might  be  thf 
governing  body.  We  should  grriup  our  bodies  anc 
so  interest  the  jniblic  who  were  anxious  for  infor- 
mation. We  should  uiiite  our  forces  and  send  out 
an  army  aiding  the  different  States  by  getting  the 
health  boards  out  of  politics,  and  giving  the  com- 
munity information.  The  time  had  come  to  get  to- 
gether not  b}'  a  group  of  meetings  here  and  there 
but  by  banding  our  forces.  Since  1880  we  had 
been  meeting  in  a  desultory  sort  of  fashion.  We 
should  have  a  national  health  department  at  Wash- 
ington. This  was  more  important  than  the  Supreme 
Court  of  the  United  States.  We  had  not  been  get- 
ting results,  and  the  lines  of  our  work  should  be 
changed  until  we  do. 

The  Relation  of  the  Medical  Profession  to  Pre- 
ventive Medicine. — Dr.  H.  M.  Bracken,  of  St. 
Paul,  said  that  medical  men  might  know  that  cer- 
tain diseases  were  transmissible — but  a  great  many 
of  them  did  not  know  how  to  prevent  these  trans- 
missible diseases.  In  preventive  medicine,  a  mere 
handful  of  men  got  together  and  discussed  topics 
that  were  familiar  to  every  one.  We  should  have 
a  strong  section  of  preventive  medicine  in  the 
American  Medical  Association.  It  should  be  simi- 
lar ti)  the  i)harmaco])(Eia  committee  and  should  be 
in  session  during  the  entire  year.  An  alliance  be- 
tween medical  men  and  sociologists  should  be  made. 
The  sociologist  was  in  danger  of  looking  tn  the 
demagogue  for  preventive  medicine.  More  was 
done  for  animals  than  for  the  human  race.  Our 
country  set  aside  money  to  sui)i)ress  foot  and  mouth 
disease  in  cattle — yet  nothing  was  done  financially 
to  stunp  out  contagious  diseases  in  the  human  race. 
Tuberculosis,  smallpox,  etc.,  were  surely  interstate 
proI)lcms.  Xot  a  dollar  of  national  money  was  s|)cnt 


to  protect  the  traveling  public  from  disease.  The 
nation  did  nothing  but  establish  quarantine.  Not 
one  cent  was  spent  to  stamp  out  yellow  fever. 

Dr.  George  M.  Sternberg,  of  Washington,  said 
that  he  hoped  the  ideas  of  the  men  in  consolidating 
would  be  carried  out.  We  must  consider  ourselves 
missionaries.  We  did  not  read  our  medical  papers 
for  our  own  good  alone  but  for  the  purpose  of  dis- 
seminating our  knowledge  to  the  public. 

Dr.  J.  Y.  Porter,  of  St.  Louis,  said  that  for  years 
in  Missouri  they  had  little  societies,  distributing 
books  and  lecturing  on  the  street  until  even  the  chil- 
dren knew  of  the  prevention  of  tuberculosis.  Such  an 
organization  must  be  started  in  the  work  of  educa- 
tion. It  was  absolutely  essential  to  educate  the  peo- 
ple first. 

Dr.  Henry  B.  Heminway,  of  Evanston,  111., 
said  that  in  medical  bodies  there  was  lack  of  ap- 
preciation of  sanitary  science.  In  medical  meetings 
the  man  who  spoke  on  preventive  medicine  was 
relegated  to  the  last  place  on  the  programme. 

Dr.  W.  A.  Evans,  of  Chicago,  said  that  there  was 
no  standardizing  of  training  in  sanitary  science  in 
this  country.  He  believed  the  subject  got  as  much  pop- 
ular support  as  it  deserved.  Most  of  our  health  officers 
had  been  misfits.  We  would  make  more  progress 
when  these  positions  came  into  abler  hands.  A  good 
idea  was  for  this  section  to  have  the  American  Med- 
ical Association  take  up  the  situation  officially.  The 
American  Public  Health  Association  had  several 
subsections.  Much  could  be  gained  if  the  different 
associations  were  amalgamated.  The  American 
Medical  Association  should  establish  a  council  on 
health,  which  should  do  research  work.  A  council 
constantly  in  session  would  be  a  gain  in  the  health 
question.  The  greatest  good  could  only  come  from 
conjoined  work.  The  American  Medical  Association 
should  be  asked  to  invite  other  organizations  to 
come  in  with  them  or  to  appoint  a  committee  to  look 
into  such  an  arrangement. 

Phthisiophobia. — Dr.  S.  Adolpiius  Knopf,  of 
New  York,  said  that  it  was  often  considered  that 
phthisiophobia  originated  in  the  minds  of  laymen. 
The  average  tuberculous  patient  according  to  Os- 
ier, Tyson,  and  others  was  of  a  high  mental  cali- 
bre. In  Oklahoma  the  State  Medical  Board  refused 
to  grant  licenses  to  tuberculous  physicians.  The  tu- 
berculous physician  was  not  a  menace  to  the  public 
and  he  had  shown  himself  to  be  the  ideal  one  for 
preventing  the  spread  and  curing  the  disease. 
Trudeau,  twenty-five  years  ago,  arrived  a  tubercu- 
lous victim  in  the  Adirondack  mountains  ;  he  was 
not  only  satisfied  to  cure  himself  but  cured  and  ben- 
efited hundreds  of  others ;  he  was  one  of  many. 
The  decision  of  the  Oklahoma  State  Board  could 
not  stand  the  test.  Many  useful  men  had  had  tu- 
terculosis  at  some  time  or  other.  Many  physicians 
who  now  had  tuberculosis  had  saved  many  afflicted 
l^aticnts.  To  exclude  these  men  who  had  never 
infected  any  one  was  a  most  inhuman  thing.  If  the 
medical  board  of  this  State  should  persist  in  its  in- 
human law,  we  should  offer  a  resolution  in  this  body 
showing  that  the  trained  physician  with  tuberculo- 
sis was  not  a  menace  but  had  done  good  and  that 
we  deeply  deplored  the  action  of  the  Oklahoma 
State  Board  and  we  trusted  that  they  would  with- 
draw their  most  cruel  and  inhuman  law  to  their 
fellow  practitioners. 


June  12,  1909.]        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


1223 


SECTION  IN  DISEASES  OF  CHILDREN. 
The  Field  for  Prophylaxis  among  Children  was 
the  title  of  the  chairman's  address.  Dr.  South- 
worth  said  that  the  general  or  family  practitioner 
owed  a  debt  to  the  development  of  specialization 
which  had  blazed  the  way  for  more  accurate  knowl- 
edge. Education,  better  wages,  and  better  food 
among  wage  earners  had  made  them  better  physic- 
ally and  morally.  Researches  indicated  that  reduc- 
tion of  infant  mortality  was  not  so  great  as  thought. 
Overcrowding  and  decrease  in  maternal  nursing  in 
large  part  accounted  for  postnatal  mortality.  [Mater- 
nal nursing  had  decreased  not  only  because  of  fail- 
ure on  part  of  mothers  to  do  their  duty  but  also  be- 
cause women  had  become  wage  earners.  ]\Iid- 
wives  had  considerable  influence  in  determining 
feeding  and  weaning  of  infants.  Forty-two  to  sixty 
per  cent,  of  births  in  large  cities  were  reported  by 
midwives,  ten  per  cent,  of  whom  were  unfit  for  their 
duties.  Breast  fed  children  were  more  fit  for  life's 
struggles.  ]\Iany  doing  only  fairly  well  passed  from 
medical  observation.  A  normal  gain  in  weight 
might  not  mean  that  normal  development  was  tak- 
ing place.  In  artificial  feeding  the  percentage 
method  ought  not  to  be  displaced.  Even  the  casein 
of  cow's  milk  could  not  take  the  place  of  human 
casein.  The  use  of  low  percentages  of  fat  had 
made  the  feeding  of  infants  better  understood.  But 
better  methods  were  to  be  obtained  by  combining 
new  principles  with  the  old  percentage  method.  Out- 
door dispensaries  were  creating  a  wider  knowledge 
among  the  poor  and  ignorant  and  leading  to  intel- 
ligent care  in  infant  feeding.  Supervision  of  in- 
fants, especially  from  the  seventh  to  the  twentieth 
month,  ought,  to  be  maintained.  The  measure  of 
growth  and  development  ought  to  be  both  gain  in 
weight  and  the  amount  of  physical  resistance. 

The  development  of  adenoids,  hypertrophied  ton- 
sils, and  allied  conditions  were  rarely  recognized 
and  cared  for  early  enough.  Ought  one  to  wait  for 
the  narrowed  chest,  chronic  bronchitis,  otitis  media, 
etc.,  before  correcting  the  causative  factors  ?  Den- 
tition in  prophylactic  measures  had  been  too  little 
considered.  Early  loss  of  temporary  teeth  led  to 
narrow  palatal  arch,  causing  imperfect  mastication, 
imperfections  of  speech,  and  diffidences  which  af- 
fected the  child  both  physically  and  socially. 

Laboratory  methods  had  added  materially  to  our 
knowledge  of  diagnosis  and  treatment,  but  the  ideal 
of  prevention  was  the  highest  attainment,  and  it 
was  in  prophylaxis  that  we  should  seek  our  final  ac- 
complishment. 

Transitory  Urinary  Findings,  Associated  with 
some  Diseases  of  Childhood.  —  This  paper  was 
read  by  Dr.  Walter  Lester  Carr,  who  said  that 
there  were  few  practitioners  who  did  not  neglect  to 
note  urinary  findings,  especially  after  acute  dis- 
eases. Routine  examinations  ought  always  to  be  made. 
After  such  conditions  as  amygdalitis,  otitis,  and  espe- 
cially gastroenteric  affections  the  specific  gravity  was 
low,  1.004  to  1.008,  the  urea  and  uric  acid  elimina- 
tion was  relatively  high.  Casts  were  not  infrequent, 
with  or  without  the  presence  of  albumin.  Frequent- 
ly the  kidney  lesions  were  transitory,  but  often 
enough  lasting  lesions  were  produced.  Koplik  and 
Moore  had  called  attention  to  urinary  findings  after 
influenza  and  gastroenteric  conditions.    Chapin  had 


found  albumin  in  twenty-five  per  cent,  of  gastroen- 
teric cases.  L  rinary  changes  were  more  frequent  in 
ileocolitis  than  in  autointoxication.  Jennings  had 
stated  that  toxic  products  of  erroneous  metabolism 
caused  irritation  of  renal  structure.  Pyelitis  from 
gastrointestinal  cases  was  often  seen  and  presence 
of  colon  bacillus  was  demonstrated  by  culture.  Neg- 
lect to  recognize  the  condition  might  lead  to  serious 
general  infection.  In  lithjemic  cases  an  interstitial 
nephritis  was  easily  overlooked.  The  presence  of 
indican,  skatoxyl,  etc.,  should  lead  to  careful  search 
for  casts  and  albumin ;  only  centrifugal  sediment 
should  determine  absence  or  presence  of  casts. 

Dr.  ]\IoRSE  said  that  he  had  recently  analyzed  the 
urines  from  700  infants.  Of  these  only  thirteen 
were  admitted  for  nephritic  lesions ;  300  were  gas- 
trointestinal cases,  ninety  per  cent,  of  which  showed 
kidney  lesions.  [Meningitis  associated  with  rtnal 
changes  stood  second.  His  findings  showed  that 
eczema  and  otitis  were  associated  with  kidney  le- 
sions less  often  than  stated  by  French  writers. 
From  his  studies  he  concluded  that  albumin  was  an 
index  of  toxicity.  The  presence  or  absence  of  al- 
l)umin  and  casts  had  no  direct  relation  to  vomiting 
and  coma.  The  few  autopsies  made  showed  that 
kidney  changes  rarely  went  beyond  hyperaemia. 

Dr.  Churchill  said  that  the  profession  was  not 
alive  to  renal  conditions  in  infants,  especially  to 
pyelitis.  He  believed  that  temperature  changes  in 
childhood  were  observed  in  pyelitis  second  only  to 
otitis  media.  Chemical  examination  of  urine  alone 
was  dangerous.  Sediment  ought  to  be  examined 
always.  Pyelitis  was  common  after  gastroenteric 
infections.  He  had  observed  that  constipation  was 
a  common  preceding  condition.  Personally  he  had 
found  that  pyelitis  was  common  in  streptococcic 
amygdalitis. 

Dr.  Carr  said  that  he  desired  to  emphasize  the 
necessity  of  making  routine  urine  examinations. 

Food  Intoxications  in  Childhood. — Dr.  John 
Ruhrah,  who  read  this  paper,  said  that  methods  of 
treatment  were  inexact.  The  causes  were  improper 
feeding,  in  a  large  number  overfeeding,  too  little 
exercise,  or  too  little  or  too  much  of  proteids,  fats, 
or  carbohydrates.  There  was  no  typical  symptom 
complex  for  each  form  of  food  poisoning.  Certain 
amount  of  experimenting  might  be  necessary.  But 
certain  recurring  symptoms  in  whatever  combina- 
tion were  suggestive.  The  physical  examination 
and  previous  history  were  important.  The  chief 
features  were  to  be  found  in  too  much  food,  that 
condition  called  biliousness,  with  headache,  nausea, 
and  vomiting,  coated  tongue,  malaise,  somewhat  en- 
larged and  tender  liver  with  constipation.  Too 
much  proteid  food  might  give  the  same  symptoms 
with  recurring  neuralgia  or  neuritis.  If  too  much 
fat  was  given  the  nutrition  would  be  made  worse, 
the  child  would  be  pale  and  delicate ;  foetid  breath, 
dark  circles  about  eyes,  fat  in  stools  would  be  noted. 
Carbohydrate  diet  was  the  most  common  cause  of 
disorders.  Many  children  had  deficient  power  to 
digest  carbohydrates  or  starches.  Asthma  in  addi- 
tion to  symptoms  noted  was  common. 

Recurrence  of  attacks  was  the  most  striking 
symptom  of  condition.  As  example  of  proteid  in- 
toxication he  reported  a  child,  two  and  one  half 
years  of  age,  which  had  periodical  attacks  of  fever, 


1224 


ATLAXTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION.      ,  [New  York 

Medical  Journal. 


with  seizures  almost  epileptic  in  type,  and  was  cured 
by  milk  diet  and  calomel.  A  case  of  fat  intoxica- 
tion was  shown  in  a  child  fed  on  cream,  cod  liver 
oil,  and  other  fats  which  had  typically  recurring 
seizures.  One  child  with  carbohydrate  intoxication 
and  another  with  asthma  had  had  cyclic  vomiting. 

Infantile  Eczema.  Some  Recent  Views  Con- 
cerning Its  Pathology  and  jS^tiology. — On  mo- 
tion the  paper  was  read  by  the  secretary.  Dr.  Abt 
being  absent.  The  paper  stated  that  infantile  eczema 
frequently  presented  great  difificulty  in  diagnosis 
and  treatment.  It  was  a  question  as  to  whether  or 
not  it  was  a  distinct  clinical  entity.  The  most  rational 
view  held  was  that  it  was  the  cutaneous  lesion  of  an 
internal  disorder.  Pure  eczema  depended  upon  an 
internal  disorder.  Infection  was  probably  only 
causal.  But  older  authors  differed.  Some  thought  it 
to  be  of  lithasmic  origin,  others  neuropathic,  others 
that  it  was  due  to  overfeeding,  underfeeding,  and 
to  other  factors.  There  were  two  types — idiopathic 
and  traumatic.  Czerny  advanced  the  idea  that  it  re- 
sulted from  inhibition  of  metabolism — a  suboxida- 
tion  of  nitrogenous  products.  Two  types  as  to  clinical 
evidence  were  moist  eczema,  most  common  on  the 
scalp  and  about  the  ears,  usually  called  milk  eczema. 
This  might  become  general  if  untreated.  Itching 
as  a  rule  was  absent.  It  was  found  in  infants  fed 
on  large  amounts  of  carbohydrate  food,  especially 
the  artificial  foods.  Secondly,  dry  eczema  found  in 
overfed  infants,  with  chronic  intestinal  disorders, 
who  were  delicate  and  thin.  The  lesions  were  dry  and 
scaly.  It  was  very  refractory,  and  Dr.  Abt  believed 
it  to  be  the  gouty  or  lithaemic  form.  Ray  observed 
that  albumin  was  common,  he  had  found  it  in  twelve 
out  of  twenty-one  cases,  although  all  twenty-one  in- 
fants had  intestinal  drsorders.  It  was  thought  by 
some  observers  that  the  status  lymphaticus  was  re- 
sponsible. Death  was  believed  to  result  from  cut- 
ting ofif  the  cutaneous  respiration,  to  infection,  or 
to  status  lymphaticus.  A  distinct  relationship  seemed 
to  exist  between  eczema  and  asthma. 

Treatment  should  be  both  local  and  constitutional, 
removal  of  crusts  with  petrolatum,  use  of  aluminum 
acetate,  and  later  zinc  paste ;  in  obstinate  cases  sul- 
phur, or  salicylic  acid,  zinc  oxide,  and  olive  oil  in 
convalescent  infants.  Tar  ointment  and  oil  of  cade 
was  occasionally  necessary.  In  the  dry  form -the 
use  of  simple  cerate,  dusted  with  talcum  or  rice 
powder,  was  of  great  help.  Internally,  Fowler's  so- 
lution, Carlsbad  water,  or  compound  infusion  of 
senna  should  be  given.  The  diet  should  be  regu- 
lated ;  this  was  very  important.  Dietetic  measures 
were  usually  sufficient  as  prophylaxis. 

I'^inkelstein  advanced  the  idea  that  eczema  de- 
pended upon  the  salts  found  in  cow's  milk,  but  ecze- 
ma was  found  in  both  breast  and  artificially  fed  in- 
fants. Mis  diet  consisted  in  precipitating  with  ren- 
nin  and  adding  water  and  cream.  Exclusion  of  egg 
albumin  and  meat  broths  was  important  in  some 
cases.    Thyreoid  extract  had  been  found  of  wq. 

Hair  Ball  or  Hair  Cast  of  the  Stomach  and  Its 
Occurrence  in  Children. —  Dr.  P.utti-.rwortii  said 
that  casts,  calculi,  etc.,  were  common  in  animals  but 
rare  in  humans.  Forty-three  cases  were  reported 
of  bczoar  in  human  beings.  Gastric  calculi  formed 
of  shellac,  others  of  vegetable  origin,  one  of  coconut 


fibre,  and  one  of  vegetable  debris  had  been  found. 
But  most  remarkable  were  hair  casts  or  hair  balls, 
thirty-nine  such  cases  were  reported,  the  youngest 
was  eight  and  the  oldest  forty-three  years  of  age. 

Of  his  own  case  he  mentioned  the  following  facts  : 
It  occurred  in  a  girl  of  eight  years,  whose  family 
history  was  negative  except  that  seven  brothers  and 
sisters  had  uncinariasis.  She  had  been  ill  since  her 
sixth  year,  was  pale  and  anaemic,  and  had  had 
ground  itch  every  summer  for  several  years.  She 
had  eaten  sand  and  dirt  for  several  months  prior 
to  her  death.  Her  mental  condition  was  excel- 
lent, yet  she  seemed  queer  in  some  ways.  She  was 
remarkably  placid  while  under  observation.  She 
had  a  rise  of  temperature  most  of  the  time. 
There  was  a  crescent  shaped  tumor  in  the  epigas- 
trium, the  liver  was  somewhat  enlarged,  the 
spleen  was  not  palpable.  Blood  examination  showed 
the  malaria  plasmodium.  The -stools  contained  mu- 
cus, ova,  and  developed  uncinarix.  Urine  examina- 
tion was  negative  except  for  some  pus  and  a  few 
hyaline  and  granular  casts.  Blood  examination 
showed  marked  ansmia,  but  only  one  per  cent,  eos- 
nophiles.  Operation  was  inadvisable.  There  was 
mucus  and  blood  in  the  stools.  At  times  it  was  ob- 
served that  she  twined  strands  of  hair  about  her 
finger,  but  she  was  never  observed  to  swallow  it. 
After  death,  numerous  bald  spots  were  found.  She 
was  acutely  ill  for  twenty-seven  days  when  death 
occurred.  At  autopsy  a  cast  was  found  to  occupy 
the  stomach  which  was  i6x8x5J/4  cm.  composed  of 
human  hair,  some  strands  being  27  cm.  in  length. 
Dr\-  it  weighed  three  and  three  quarter  ounces. 
Some  ulceration  of  gastric  mucosa  was  also  found. 

Eating  hair  occurred  usually  early  in  life,  begin- 
ning at  two  and  one  half  or  three  years.  Seventy- 
five  per  cent,  acquired  it  in  early  childhood.  It  was 
most  common  in  females,  which  was  probably  ac- 
counted for  by  the  fact  that  females  had  long  hair 
flying  about  the  face,  and  the  habit  followed  sugges- 
tion. Intestinal  parasites  were  a  causal  association. 
Alental  condition  did  not  seem  to  be  a  factor,  as 
the  demented  usually  eat  solid  things,  as  tacks,  glass, 
etc.  In  the  forty-three  cases  reported,  only  two 
were  demented,  only  one  hysterical.  Gastric  juice 
did  not  aft'ect  the  color  of  the  hair. 

The  diagnosis  might  be  mistaken  for  gastric  or 
duodenal  carcinoma,  faecal  impaction,  floating 
spleen,  or  omental  tumor. 

Dr.  RuHRAH  said  that  habit  of  eating  hair  was 
common. 

The  Treatment  with  Living  Lactic  Acid  Ba- 
cilli of  Summer  Diarrhoea,  due  to  Intestinal  Fer- 
mentation.— Dr.  Charles  Hl  nti:r  Dunx,  of  Bos- 
ton, read  this  paper.  He  said  that  modern  classifi- 
cation rejected  diarrhoea  as  the  name  for  a  distinct 
entity.  The  classification  from  the  view  point  of 
aetiology  would  be  nervous,  chemical,  bacterial  fer- 
mentation, and  bacterial  infection.  It  was  apparent 
that  the  last  view  might  bo  considered  as  one  causa- 
tive factor.  Personally  he  believed  that  distinction 
should  be  made  between  bacteria  which  were  of  par- 
asitic and  those  which  were  of  saprophytic  origin. 
The  antagonism  of  certain  groups  toward  other 
groups  as  shown  by  MetchnikofF  activated  study 
along  these  lines.  His  own  work  was  based  upon  that 


June  12,  1909. J        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


1225 


done  by  Tissier.  The  bacterial  examination  of  de- 
jecta showed  great  transformation  in  disease  as 
contrasted  with  normal  conditions.  He  took  the 
Bacillus  bitdus  as  a  type  in  the  normal  and  the 
Bacillus  peyfringcns  as  a  factor  in  fermentative 
diarrha'a.  A  predisposing  factor  was  the  chemical 
character  of  the  food,  ihe  indications  for  treat- 
ment were  to  get  rid  of  the  toxic  contents  of  the 
intestines  and  to  bring  about  reappearance  of  the 
normal  intestinal  flora.  The  lactic  acid  bacillus  was 
used  because  it  was  found  to  have  an  inhibitory 
action  upon  infecting  bacteria,  particularly  the  Ba- 
cillus perfringens.  Beenstalk  showed  that  it  also 
inhibited  the  Bacillus  petrificus.  Dunn  used  butter- 
milk not  because  of  its  chemical  constitution  but 
because  it  was  a  food  and  large  numbers  of  the 
lactic  acid  bacilli  could  be  given  in  that  manner. 
He  found  that  particular  stains  of  the  lactic  acid  or- 
ganism were  an  absolute  necessity  ;  one  which  he 
had  not  named  was  the  one  with  which  he  obtained 
the  most  specific  results.  He  also  began  work  with 
a  stain  which  he  received  from  Metchnikoff  in 
Bulgaria. 

Of  the  thirty-five  selected  cases  that  he  studied 
there  were  only  nine  patients  in  whom  there  was 
not  much  change ;  there  were  always  a  certain  nimi- 
ber  of  refractory  cases.  These  were  studied  and 
later  fourteen  so  called  resistant  cases,  with  favor- 
able reactions  in  the  majority.  His  reports  of  120 
cases  which  he  collected  showed  the  treatment  to 
have  been  successful  in  seventy-eight  cases,  par- 
tially successful  in  twelve ;  a  failure  in  thirty.  The 
latter  were  all  of  types  associated  w  ith  indigestion, 
and  after  this  had  been  alleviated  and  the  acute 
stage  was  p'ast  he  had  seventy-four  per  cent,  of 
recoveries  ;  twelve  per  cent,  partial  recoveries,  with 
fourteen  per  cent,  failure.  Fifty  per  cent,  of  the 
children  gained  weight  while  on  this  food  and  treat- 
ment alone.  In  all  instances  the  buttermilk  was 
pasteurized  before  inoculation.  His  studies  of  the 
administration  of  living  bacteria  in  bouillon  cultures 
produced  practically  the  same  results.  He  had 
found  that  lactone  and  other  tablets  prepared  com- 
mercially were  all  right  for  feeding  purposes  but 
would  not  combat  the  fermentative  diarrhoeas. 

Post  Hoc  Non  Ergo  Propter  Hoc.  Cases  in 
Children  Illustrating  Conditions  Mistakenly  At- 
tributed to  Injury. —  Dr.  J.  P.  Crozer  Griffith, 
of  Philadelphia,  read  this  paper.  He  had  frequently 
seen  cases  of  supposed  traumatism  which  were  defi- 
nite medical  conditions,  and  frequently  the  reverse. 
Among  those  he  cited  were  cranial  injuries  in  which 
there  was  a  coincident  development  of  cerebrospinal 
fever;  another  of  convulsion  in  which  trauma  was 
supposed  to  have  occurred  but  the  patient  recov- 
ered without  diagnosis.  He  had  repeatedly  seen 
cases  of  infantile  scurvy  diagnosticated  as  injuries. 

The  Treatment  of  Epidemic  Meningitis  with 
the  Flexner  Serum. —  Dr.  I-raxk  .Spooner 
Churchill,  of  Chicago,  who  read  this  paper,  said 
that  the  bacteriology  of  meningitis  could  be 
grouped  as  due  to  the  tubercule  bacillus,  and  not 
due  to  the  tubercle  bacillus.  Among  the  latter  the 
Diplococcus  intracellularis  was  the  most  important : 
the  Flexner  serum  was  useful  only  in  the  disease 
from  that  organism.  So  far  there  had  been  seventy- 
five  per  cent,  of  recoveries  with  its  use.  Those 
^  surviving   showed   little  if  any  serious  sequelae. 


Flexner's  figures  were  of  the  greatest  value.  The 
treatment  at  the  hospital  was  better  than  at  home, 
as  had  Ijeen  shown  by  the  highest  mortality  in  those 
treated  at  home.  In  the  twenty-five  per  cent,  of 
fatal  cases  there  had  been  an  abrupt  termination  by 
crisis.  In  all  cases  the  course  had  been  shortened ; 
the  symptoms  became  milder  or  disappeared ;  rigid- 
ity being  the  only  symptom  to  continue,  and  this 
not  causmg  apparent  discomfort.  A  suspected  case 
should  have  immediate  lumbar  puncture,  30  to  35 
c.c.  of  fiuid  should  be  withdrawn,  a  few  drops 
placed  on  slides  and  another  portion  on  culture 
media,  and  the  third  and  larger  quantity  in  a  sterile 
test  tube  for  centrifugation  and  study  of  the  sub- 
ject, li  turbid  fluid  was  obtained  40  to  45  c.c.  of  the 
Flexner  serum  should  be  injected  at  once.  The 
dosage  was  to  be  repeated  on  successive  days  three 
or  four  times,  each  time  withdrawing  30  to  35  c.c. 
of  spinal  fluid.  A  study  of  the  cell  content  showed  in 
the  beginnmg  that  ninety  to  niney-five  per  cent,  of 
the  white  blood  cells  were  polymorphonuclear  leuco- 
cytes, that  most  of  the  diplococci  were  extracellular. 
As  the  patient  improved  mononuclears  were  found 
to  increase  to  forty  or  forty-five  per  cent,  of  the 
total,  while  the  organisms  were  for  the  most  part 
intracellular. 

The  Treatment  of  Anaemia  in  Infancy  with 
Citrate  of  Iron  Subcutaneously. — Dr.  John  Lov- 
ETT  Morse,  of  Boston,  reviewed  the  reasons  for  the 
frequent  occurrence  of  anaemia  in  infancy.  He  said 
that  chlorosis  was  uncommon  but  a  chlorotic  type 
of  aneemia  occurred.  In  all  cases  iron  was  espe- 
cially indicated  because  of  the  low  haemoglobin.  He 
had  found  ihe  most  satisfactory  treatment  to  be  iron 
citrate  subcutaneously.  Fie  had  an  aqueous  solu- 
tion prepared,  sterilized,  and  put  in  perles.  The  in- 
jection caused  pain  for  a  few  minutes  or  possibly 
an  hour ;  but  it  was  not  marked  and  the  results  were 
more  than  justifiable. 

Sea  Water  Treatment  given  by  Subcutaneous 
Injections,  with  Results  Obtained  in  Children. — 
T.  Lf  Boutillier,  of  Philadelphia,  read  this  paper. 
He  said  that  the  preparation  was  important.  The 
water  should  be  obtained  far  out  at  sea  and  from 
a  great  depth  to  escape  the  surface  bacteria.  It  was 
then  diluted  to  a  condition  isotonic  with  the  blood 
using  eighty-three  parts  of  sea  water  and  a  hundred 
and  ninety  parts  of  spring  water.  The  preparation 
was  sterilized  and  injected  into  the  back  at  the 
angle  of  the  scapula  or  into  the  gluteal  region. 
Three  to  five  minutes  or  fifteen  to  twenty  minutes 
according  to  the  dose  should  be  taken  for  the  injec- 
tion. Absorption  occurred  from  three  to  four 
hours.  The  usual  dose  was  fifteen  to  thirty  c.c. 
three  times  a  week,  or  even  every  day  was  found 
to  be  of  value  in  inanition,  malnutrition,  marasmus, 
and  rachitis.  The  idea  was  essentially  that  it  was 
a  tonic  to  the  body  cells  and  acted  by  that  method. 

Middle  Milk  Mixtures. — This  paper  was  read 
by  Dr.  Alfred  S.  Hess,  of  New  York,  who  stated 
that  it  had  been  definitely  proved  by  experiment 
that  bacteria  rode  with  the  cream  in  bottled  milk 
where  they  were  found  in  the  largest  numbers  in  its 
uppermost  layer.  For  this  reason  he  thought  that 
the  upper  layers  should  be  discarded  in  preparing 
milk  for  infants.  His  bacteriological  investigations 
showed  that  it  was  possible  to  obtain,  by  manipulat- 
ing the  percentages  used,  a  proper  protein  percent- 


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ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION.       ,  t^'^^'  ^o^k 

^Iedical  Journal. 


age  and  also  of  fat  in  the  middle  layer,  and  he  had 
designated  such  mixtures  as  middle  milk  mixtures. 
For  the  past  year  he  had  been  using  this  modifica- 
tion with  great  succes  in  his  general  practice  among 
artificially  fed  infants. 

The  Relation  between  the  Science  and  Art  of 
Infant  Feeding. — Dr.  H.  D.  Chapin,  of  Xew 
York,  who  read  this  paper  observed  that  in  a  gen- 
eral way  all  food  was  acceptable  because  it  con- 
tained the  essentia]  elements  in  some  proportion.  All 
animal  life  had  something  in  common  in  its  appro- 
priation of  food  material,  and  of  the  foods  milk 
was  the  simplest  and  most  elemental.  The  nature 
of  the  digestive  tracts  should  be  studied  in  deter- 
mining what  was  acceptable  for  a  given  type  of 
animal  life.  He  quoted  the  biological  relationship 
between  the  herbivorous  and  carnivorous  types 
showmg  that  the  milk  coagulated  in  three  different 
ways.  In  the  stomachs  of  herbivorous  animals  it 
formed  a  solid  mass  paving  the  way  for  the  appro- 
priation of  hay,  etc.  These  were  the  animals  in 
which  the  digestion  was  essentially  gastric ;  in 
others  as  in  mares  and  asses  where  the  digestion  \yas 
principally  intestinal  the  milk  coagulum  was  gela- 
tinous. In  the  human  the  coagulum  was  flocculent 
in  type,  as  the  human  stomach  occupied  twenty  per 
cent,  of  the  digestive  processes.  For  these  reasons 
and  because  of  the  chemical  analysis  of  the  curds 
he  believed  that  not  in  the  study  of  the  food  alone 
but  in  the  broader  principle  of  the  application  of 
known  biological  laws  would  we  obtain  an  accurate 
idea  of  the  fundamentals  of  human  digestive  pro- 
cesses. ' 

Infant  Mortality.  The  Factors  Which  Com- 
pose It  and  How  These  May  Be  Influenced.^ — 
Dr.  L.  Emmet  Holt,  of  New  York,  observed  that 
his  paper  was  a  long  one  and  that  for  that  reason 
he  would  demonstrate  his  findings  with  charts  which 
he  had  prepared.  He  had  studied  the  statistics  of 
the  past  hundred  years  in  relation  to  infant  mortal- 
ity and  the  birthrate.  This  was  especially  made  in 
New  York.  In  the  first  half  of  that  century  there 
was  a  general  constant  rise  of  the  death  rate  with 
a  general  decline  in  the  last  half.  The  first  half  was 
extremely  irregular  due  to  violent  epidemics  of 
cholera,  smallpox,  diphtheria,  and  other  infectious 
processes.  These  increased  the  mortality  during 
that  period.  .  In  the  decline  in  the  last  fifty  years 
the  greatest  reduction  had  been  in  children  under 
five  years  of  age.  In  his  studies  of  children  under 
one  year  of  age  he  had  found  a  gradually  decreas- 
ing death  rate  as  contrasted  with  a  gradually  in- 
creasing birth  rate.  Especially  in  the  last  thirty 
years  there  had  been  a  marked  constant  reduction 
of  infant  mortality  seen  mostly  in  those  under  five 
years.  The  value  of  these  studies  was  to  be  found 
in  what  might  be  done  to  prevent  the  occurrence  of 
the  causes  of  death.  He  believed  that  we  had 
reached  the  highest  stage  in  our  study  of  feeding 
problems  and  thought  that  the  mortality  would  be 
reduced  only  by  the  study  of  other  conditions.  Thus 
from  the  first  to  the  fifth  year  the  highest  mortality 
was  to  be  found  in  the  winter  and  spring  months, 
and  from  gastrointestinal  diseases  it  was  found  in 
July  and  Augu.st.  In  Xew  York  city  there  had 
been  a  decrease  in  the  last  ten  years  of  the  deaths 
due  to  gastrointestinal  diseases  with  an  increase  of 
the  respiratory  diseases  ])rr)bal)ly  due  to  overcrowd- 


ing. The  largest  number  of  deaths  in  artificially 
fed  infants,  eighty-five  per  cent.,  occurred  in  such 
children.  He  believed  the  largest  factor  in  the 
cause  of  infant  mortality  was  ignorance,  and  only 
by  the  dissemination  of  a  wider  knowledge  would 
the  mortality  be  decreased. 

Heubner's  System  of  Infant  Feeding,  Based 
on  Calories  and  Low  Fat. — Dr.  E.  Lackner,  of 
Chicago,  said  that  Heubner  had  used  the  period  be- 
tween the  fourth  and  sixth  week  of  infant  feeding 
to  establish  a  normal  period.  He  otherwise  ■  re- 
viewed the  researches  of  Heubner  and  gave  in  detail 
the  caloric  method  of  infant  feeding. 

A  Convenient  Method  for  Determining  Caloric 
Value  of  Formulas  Based  on  Percentage  Feed- 
ing of  Infants. — Dr.  Henry  I.  Bowditch,  of  Bos- 
ton, who  read  this  paper,  said  that  there  were  two 
opposing  methods  or  ideas  as  to  the  feeding  of  in- 
fants, namely,  the  German  idea  of  caloric  feeding 
and  the  American  idea  of  percentage  feeding.  With 
the  hope  of  bringing  these  two  camps  into  a  closer 
relationshap  for  the  mutual  advantage  of  both, 
but  especially  of  the  third  part3\  namely  the  in- 
fant, he  had  devised  a  table  of  caloric  values 
which  may  be  used  in  infant  feeding,  by  means  of 
which  the  actual  caloric  value  of  any  combination 
made  by  the  percentage  system  could  be  readily  de- 
termined. He  submitted  copies  of  the  table  fo' 
a  closer  study. 

The  Transmission  of  Bovine  Tuberculosis  to 
Children. — Dr.  Hexry  L.  K.  Shaw,  of  Albany, 
said  that  it  was  universally  conceded  that  at  least 
two  types  of  a  tubercle  bacillus  exist,  namely  the  bo- 
vine and  the  human,  and  that  the  susceptibility  of 
human  beings  to  the  human  type  and  the  cow  to  the 
bovine  type  were  undisputed  facts.  He  stated  that 
the  literature  of  all  investigations  made  seemed  to 
support  the  decision  made  by  Coke,  though  no  case 
of  pulmonary  tuberculosis  due  to  the  bovine  type 
had  been  reported.  The  bovine  type  had  been 
found  in  tuberculous  lymphnodes  and  without  ques- 
tion was  distinguished  from  the  human  type.  He 
considered  this  of  great  importance  especially  in 
infancy  and  urged  that  a  determination  of  the  type 
of  bacilli  should  be  made  in  every  case  reported. 
This  problem  should  be  taken  up  by  special  labora- 
tories connected  with. recognized  medical  colleges. 

The  Antibodies  in  Tuberculosis;  Their  Rela- 
tion to  Tuberculin  Inoculation  and  Vaccination. 
— Dr.  William  J.  Butler,  of  Chicago,  described 
the  method  used  for  demonstrating  antituberculin 
in  the  blood  of  the  tuberculous  and  the  antigen?  that 
were  used.  He  gave  in  detail  the  influences  of  in- 
oculations on  the  blood  and  showed  the  relationship 
existing  between  that  and  tuberculin  vaccination. 

SECTION  IN  PHARM.-\COLOGY  AND  THERA- 
PEUTICS. 

Some  Problems  of  Pharmacopoeial  Revision. — 

Dr.  Ricri)  lluxT,  of  Washington,  as  chairman,  said 
that  the  Pharinacopa-ia  of  the  United  States  had 
grown  to  be  a  very  dift'erent  sort  of  book  from 
what  it  was  originally  intended  to  be.  and  that  it 
served  as  a  commercial  standard  and  as  a  textbook 
of  pharmacology.  But  that  it  had  failed  to  meet 
the  requirements  of  the  practising  physician  as  it 
should  have  done.  Of  the  factors  in  the  making 
of  the  book,  the  question  of  what  drugs  should  be 


June  12,  1909.]        ATLAXTIC  CITY  MEETIXG  OF  AMERICAN  MEDICAL  ASSOCIATIOX. 


1227 


included  and  what  drugs  should  be  excluded  ought 
to  be  in  the  hands  of  the  medical  profession.  This 
was  a  complicated  question,  but  there  was  a  large 
class  of  substances  such  as  solvents,  reagents,  etc., 
which  might  well  be  relegated  to  other  books,  leav- 
ing room  for  subjects  of  more  immediate  interest 
to  the  physician.  \\'hat  new  drugs  should  be  in- 
cluded, he  thought,  might  be  controlled  in  part, 
along  the  lines  laid  down  by  the  Council  on  Phar- 
macy, together  with  a  study  of  the  extent  to  which 
the  drugs  were  used,  such  as  was  being  carried  on 
by  the  American  Pharmaceutical  Association.  As 
to  nomenclature,  he  thought  that  there  was  a  re- 
grettable confusion  existing,  which  involved  phar- 
macopoeias of  all  nations,  each  having  its  own  name 
for  a  substance  and  scarcely  two  alike.  The  real 
science  of  medicine,  he  said,  was  international,  and 
it  was  to  be  hoped  that  steps  might  be  taken  toward 
international  uniformity  in  the  matter  of  nomen- 
clature. Finally,  Dr.  Hunt  thought  that  there  should 
be  a  permanently  organized  committee  on  the  phar- 
macopoeia with  permanent  headquarters. 

Address  of  the  Delegates  of  the  American 
Pharmaceutical  Association. — 'Sir.  George  M. 
Berrin'GEk.  of  Camden,  X.  J.,  conveyed  the  greet- 
ings of  the  Pharmaceutical  Association  to  the 
American  Medical  Association,  and  brought  a  mes- 
sage incorporating  three  suggestions :  First,  that 
the  spelling  and  nomenclature  of  the  Phannacopoeia 
of  the  United  States  and  the  Xatioual  Formulary  be 
consistently  adhered  to ;  second,  that  the  medical 
profession  extend  its  advice  and  cooperation  in  the 
revision  of  the  National  Formulary  which  was  being 
accomplished;  and  third,  that  the  respective  com- 
mittees of  the  two  associations,  which  were  work- 
ing along  the  same  lines,  should  cooperate,  so  that 
each  might  have  the  benefit  of  the  other's  experi- 
ence. 

The  Lowering  of  Blood  Pressure  by  Nitrites. 
— Dr.  George  B.  W  allace  and  Dr.  A.  S.  Rixger, 
of  Xew  York,  said  that  their  experiments  with  amyl 
nitrite,  nitroglycerin,  sodium  nitrite,  and  erjlhrol 
tetranitrite  showed  that  these  substances  all  caused 
a  uniform  percentage  fall  of  blood  pressure;  the 
higher  the  blood  pressure  the  greater  the  fall.  The 
effect  was,  within  certain  limits,  directly  propor- 
tionate to  the  size  of  the  dose.  While  the  effect  of 
amyl  nitrite  inhalations  was  almost  instantaneous, 
the  action  of  nitroglycerin  given  by  mouth  began  in 
about  two  minutes,  and,  therefore,  nothing  was 
gained  by  resorting  to  the  hypodermic  use  of  this 
drug.  Headache  following  the  administration  of 
the  nitrite  seldom  occurred  when  the  blood  pressure 
was  originally  high.  They  said  that  even  very  scle- 
rotic arteries  responded  readily  to  nitrites  and  that 
in  patients  with  arterial  hypertension  the  eff'ect 
lasted  much  longer  than  was  the  case  with  normal 
individuals.  Thus  the  duration  of  the  action  of 
erythrol  tetranitrite  in  their  series  with  hyperten- 
sion averaged  three  hours,  the  maximum  being 
reached  in  one  hour,  while  in  normal  individuals 
the  action  lasted  for  an  hour  only.  The  action  of 
sodium  nitrite  lasted  one  hour  in  the  normal  man 
and  two  in  men  with  high  blood  pressure.  Nitro- 
glycerin seemed  to  last  about  one  half  hour  in 
either  case.  They  said  that  they  had  found  the 
most  effective  method  of  exhibiting  these  drugs  to 


be  as  follows :  Amyl  nitrite  by  inhalation,  nitrogly- 
cerin in  the  official  one  per  cent,  solution,  sodium 
nitrite  in  freshly  made  solution  and  erythrol  in 
chocolate  tablets. 

Dr.  Reid  Huxt,  of  Washington,  asked  whether 
Dr.  Ringer  considered  that  erythrol  tetranitrite  had 
been  tried  thoroughly  enough  to  find  a  place  in  the 
pharmacopoeia,  and  Dr.  Ringer  responded  that  he 
thought  it  had. 

The  Therapeutic  Management  of  Arterioscle- 
rosis Based  on  the  Present  View  of  Its  Pathology. 
— Dr.  A.  G.  Browk,  Jr.,  of  Richmond,  Va.,  read 
this  paper.  He  said  that  the  treatment  of  arterio- 
sclerosis depended  somewhat  vipon  the  stage  in 
which  it  was  encountered.  He  described  a  'pre- 
sclerotic  stage  without  organic  change  but  charac- 
terized by  constant  or  intermittent  spasm  of  the  ves- 
sels. This  condition  he  attributed  to  a  circulating 
poison  acting  directly  on  the  vessel  walls,  and  said 
that  it  was  often  associated  with  symptoms  such  as 
intermittent  claudication,  vertigo,  headache,  etc. 
The  second  stage  was  that  of  established  sclerosis 
with  or  without  arterial  spasm,  and  cardiac  or  venal 
changes.  Later  the  stage  of  serious  visceral  lesions, 
cardiac  or  venal  breakdown,  appeared.  He  laid  much 
stress  on  the  recognition  of  the  presclerotic  stage 
and  the  institution  of  such  prophylactic  precautions 
as  might  be  hoped  would  prevent  the  development 
of  the  organic  changes.  This  involved  a  consider- 
ation of  the  eetiological  factors  which  he  thought 
should  be  carefully  studied  in  each  case.  Alcohol, 
tobacco,  tea,  and  coffee  should  be  forbidden  or  al- 
lowed in  moderation  only.  Any  other  source  of 
to.xasmia  should  be  sought  and  combated,  while 
elimination  should  be  encouraged.  He  thought  that 
there  was  great  need  for  education  of  the  public  in 
the  signs  of  early  cardiovascular  disease,  and  in  the 
evil  consequences  of  the  neglect  of  this  insidious 
condition.  For  the  more  developed  cases  he  sug- 
gested, beside  the  hygienic  measures  already  m.-n- 
tioned,  the  propriety  of  certain  physical  agents 
which  were  often  of  some  service,  particularly  mas- 
sage, baths,  and  the  high  frequency  current.  Of 
drugs,  he  recommended  the  iodides  most  highly  and 
urged  that  they  be  used  in  large  and  rapidly  in- 
creasing doses  instead  of  the  usual  small  long  con- 
tinued dose.  He  advised  that  they  be  guarded  with 
sodium  bicarbonate,  etc.  He  said  that  thyreoid  ex- 
tract or  iodothyrin  might  sometimes  be  used  for  its 
vasomotor  depressant  action,  and  that  the  nitrites 
were  valuable  for  the  same  reason.  Diuretics  and 
purgatives  might  be  called  for  symptomatically.  In 
the  later  stages  when  the  heart  gave  out  and  dropsy 
ensued  bed  rest  was  of  course  essential,  and  the  pa- 
tient must  be  treated  much  like  any  other  person 
with  an  incompetent  heart — i.  e..  with  digitalis  and 
the  like. 

Dr.  George  F.  Butler,  of  Chicago,  said  that,  ex- 
clusive of  syphilis,  m.ost  cases  of  arteriosclerosis 
were  due  to  toxaemia,  usually  of  intestinal  origin, 
nnd  usuallv  associated  witli  a  high  urinary  aciditv. 
He  stated  that  if  the  acidity  of  a  patient's  urine  ran 
persistently  above  forty  degrees  the  patient  was  in 
danger  of  arterial  degeneration.  He  thought  that 
this  urinary  acidity  corresponded  with  an  acidasmia 
and  that  this  fact  might  explain  the  beneficial  ef- 
fects of  the  alkalis.    The  iodides  h?  thought  stim- 


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ATLANTIC  CITY  MEETIXG  OF  AMERICAN  MEDIC. IL  ASSOCIATION.          t^'^w  York 

Medical  Journal. 


ulated  elimination  and  acted  -in  some  unknown  man- 
ner. 'The  use  of  the  nitrites  he  thought  was  not  de- 
void of  danger,  as  the  action  was  so  ephemeral  that 
repeated  doses  resulted  in  a  seesaw  ef¥ect  on  the 
blood  pressure.  He  emphasized  the  importance  of 
dietetic,  psychic,,  and  eliminative  treatment. 

Dr.  Upshur,  of  Richmond,  Va.,  said  that  arterio- 
sclerosis frequentl}'  depended  primarily  upon  dis- 
turbances of  nutrition,  which  in  turn  were  de- 
pendent upon  functional  nervous  disturbances 
through  which  the  gastrointestinal  tract  was  more 
or  less  incapacitated.  In  those  instances  where  the 
disease  was  due  to  indiscretions  in  diet,  etc.,  it  was 
almost  impossible  to  control  them,  as  instanced  by 
the  number  of  physicians  who  themselves  refused 
to  take  proper  precautions.  He  said  that  both  iodides 
and  alkalis  in  his  hands  had  done  more  harm  than 
good  in  this  condition.  \\'hen  a  stimulant  was  needed 
and  the  blood  pressure  already  high,  he  obtained 
good  results  with  spartine  sulphate. 

Dr.  A.  G.  Brown,  Jr.,  in  closing  said  that  he 
merely  wished  to  emphasize  the  importance  of  the 
early  recognition  and  serious  consideration  of  these 
cases. 

The  Determination  of  the  Quality  of  Ergot. 

Dr.  HoR.VTio  C.  Wood,  Jr.,  of  Philadelphia,  said 
that  for  years  the  cock's  comb  test  had  been  used 
as  a  test  for  the  efficacy  of  ergot,  but  that  the  de- 
termining factor  in  the  occurrance  of  the  gangrene 
was  entirely  unknown,  and  the  test  was,  therefore, 
of  little  use.  He  said  that  Dale's  test  for  the  activ- 
ity of  ernutin  of  the  ergot,  which  consisted  in  its 
power  to  reverse  the  action  of  adrenalin  when  it  was 
previously  administered,  was  of  more  value  but  was 
incomplete.  In  a  recent  series  of  experiments  on 
the  activity  of  different  specimens  of  the  fluid  ex- 
tract of  ergot.  Dr.  Edmunds  and  the  speaker  had 
devised  a  procedure  whereby  the  blood  pressure 
raising  power  of  the  drug  could  be  quite  accurately 
ascertained.  This  procedure  involved  testing  on 
dogs  and  as  such  tests  as  carried  out  by  commercial 
houses  were  frequently  very  inaccurate,  and  even  af- 
ter such  testing  the  drugs  often  reached  their  ulti- 
mate destination — the  patient — only  after  having 
stood  for  years,  it  seemed  to  him  that  this  test  must 
(.•rove  of  but  little  practical  use.  He  thought  that 
wherever  possible  (Irugs  should  be  assayed  by  the 
retail  dispenser  at  frequent  intervals  and  that  there- 
fore the  tests  should  be  of  a  chemical  nature  and  as 
simple  as  pos.sible.  He  had  discovered  in  the  percent- 
age of  benzole  soluble  substances  which  appeared  to 
be  a  reliable  index  to  the  activity  of  the  drug.  This 
had  been  checked  by  the  physiological  method  and 
the  results  had  been  remarkably  parallel  notwith- 
standing a  great  range  of  variability  in  the  drugs 
tested. 

Dr.  C.  S.  N.  Hallberg,  of  Chicago,  inquired 
whether  Dr.  Wood  were  sure  of  the  preparations 
with  which  he  experimented.  He  said  tiiat  it  h  id 
always  been  supposed  that  the  water  soluble  in- 
gredients in  ergot  were  those  which  gave  it  its 
physiological  activity.  As  to  the  deterioration  of 
ergot  on  standing,  he  believed  that  mainifacturers 
left  it  exposed  to  the  air  for  several  months  pur- 
posely. 

Dr.  Wood  ref)Iicd  that  the  preparations  used  in 


the  experiments  on  which  his  conclusions  were 
based  were  prepared  for  him  at  the  Philadelphia 
College  of  Pharmacy.  He  disagreed  with  Dr.  Hall- 
berg's  statement  as  to  the  activity  of  the  water  solu- 
ble ingredients  of  ergot,  and  explained  that  in  the 
manufacture  of  ergot  the  preparation  was  allowed 
to  stand  for  some  months  but  was  practically 
hermetically  sealed  by  the  fumes  of  alcohol  which 
displaced  the  air. 

Clinical  Results  with  Craetagus  Oxycanthus. 
—  Dr.  T.  F.  Reilly,  of  New  York,  remarked  that 
this  drug  was  originally  the  secret  of  a  South 
American  quack.  It  ultimately  became  known  to 
the  public,  and  had  been  used  by  eclectics  and  ho- 
moeopaths in  this  country  to  some  extent  as  a  heart 
tonic.  The  few  papers  which  had  been  published 
about  the  drug  were  so  extravagant  in  their  state- 
ments that  it  had  been  largely  neglected.  He  said 
that  it  consisted  in  the  berries  of  a  South  Amer- 
ican plant,  and  that  he  had  had  some  experience 
with  the  fluid  extract  and  the  tincture.  It  had  an 
agreeable  odor  and  taste,  and  did  not  cause  any  ir- 
ritation of  the  stomach.  The  chemistry  of  the  drug 
had  not  been  studied,  and  it  was  unknown  in  what 
the  active  principles  consisted.  He  said  that  it  was 
useful  as  a  cardiac  tonic  particularly  in  nervous 
heart  affections  and  cited  a  number  of  illustrative 
cases  in  which  it  had  proved  of  service.  On  the 
healthy  individual  it  had  no  apparent  effect.  In  or- 
ganic heart  trouble  it  was  rarely  of  any  service,  but 
might  be  tried  in  cases  in  which  digitalis  had  failed. 
He  said  it  was  best  given  in  combination  with  other 
cardiac  tonics. 

The  Use  of  Ferments  in  Medicine.  —  Dr. 
Charles  G.  Stockton,  of  Buft'alo,  read  this  paper. 
He  said  that  the  action  of  the  ferments  of  the  gastro- 
intestinal tract  was  one  of  hydrolysis  and  that  the 
series  of  chemical  and  ferment  reagents  was  so  ar- 
ranged that  at  each  step  the  action  of  the  preceding 
enzyme  was  stopped.  Thus  the  ptyalin  of  the  saliva 
ceased  to  act  on  the  starches  of  the  food  as  soon  as 
the  contents  of  the  stomach  became  acid  enough, 
and  so  on.  Most  of  the  ferments  which  were  ad- 
ministered by  mouth  as  medicine  were  rendered 
inert  by  the  hydrochloric  acid  of  the  gastric  juice. 
En  cases  of  lowered  acidity  or  anacidity  it  was  pos- 
sible, he  thought,  for  pancreatic  preparations  to 
have  some  action.  The  administration  of  pepsin 
and  hydrochloric  acid  in  proper  theoretical  propor- 
tions was  an  impossibility,  and  experiments  had 
shown  that  there  was  but  slight  proteolytic  diges- 
tion in  a  stomach  exhibiting  achvlia,  when  these 
-substances  were  given  in  the  usual  doses.  'It  was 
possible  that  the  good  effect  sometimes  seen  fol- 
lowing the  use  .of  preparations  of  pepsin  was  due 
to  some  quality  of  that  substance  having  no  connec- 
tion with  its  digestive  property.  He  had  never  been 
able  to  find  either  clinically  or  by  laboratory  studies 
any  evidences  of  improvement  in  intestinal  diges- 
tion after  the  administration  of  ferments.  He  said 
that  the  interrelation  of  the  digestive  juices  was  a 
very  complicated  matter  and  it  was  exceedingly  dif- 
ficult with  our  present  knowledge  to  figure  out  what 
or  how  an\ thing  could  be  accomplished  by  the  ad- 
ministration of  digestive  ferments. 

.\s  for  the  proprietary  preparations  of  ferments 


June  12,  .909.]        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


1229 


he  said  that  many  of  them  were  necessarily  self  de- 
structive if  they  were  put  up  as  stated,  and  that  as 
a  matter  of  fact  it  had  been  shown  experimentally 
that  many  of  them  were  absolutely  inert. 

Dr.  George  Dock,  of  New  Orleans,  said  that  he 
found  no  use  for  the  ferments  and  never  prescribed 
them. 

Dr.  C.  S.  N.  Hallberg,  of  Chicago,  quoted  sta- 
tistics showing  that  out  of  15,000  recent  unselected 
prescriptions,  754  called  for  one  of  the  two  prin- 
cipal preparations  of  pepsin.  This,  he  thought,  was 
evidence  that  the  profession  in  general  had  some 
faith  in  the  value  of  ferments. 

General  Principles  of  Dietetics,  with  Special 
Reference  to  the  Use  of  Proprietary  Foods. — Dr. 
David  L.  Edsall,  of  Philadelphia,  in  reading  this 
paper,  said  that  a  working  knowledge  of  dietetics 
was  not  an  easy  thing  to  acquire.  The  majority  of 
ph.ysicians,  he  thought,  depended  upon  empyricism 
in  feeding  with  the  exception  of  a  few  conditions  in 
which  there  were  pretty  definite  indications,  such  as 
diabetes.  Works  on  dietetics  were  not  of  as  much 
help  as  they  might  be,  and  the  help  which  the  stu- 
dent found  in  them  too  often  consisted  in  appropri- 
ate menus  for  various  conditions.  Many  physicians 
who  used  drugs  rationally  and  thoughtfully  were 
content  to  give  the  question  of  diet  but  very  super- 
ficial consideration.  The  appropriate  food  in  any 
given  case  should  be  selected  with  reference  to  the 
requirements  of  the  individual,  taking  into  consid- 
eration the  physical  qualities  of  the  food,  whether 
irritating  or  nonirritating,  the  chemical  qualities, 
fuel  value,  etc.  The  amount  of  food  eaten,  the 
speaker  thought,  was  not,  as  a  rule,  watched  as 
closely  as  it  should  be.  He  advised  that  patients  be 
instructed  to'  keep  a  written  record  of  everything 
eaten  for  a  period  of  days,  so  that  the  physician 
might  know  exactly  how  much  the  patient  was  get- 
ting. Undereating,  he  said,  was  far  more  common 
than  was  usually  supposed.  There  were  many  wo- 
men in  particular,  whose  ill  health  was  directly  de- 
pendent upon  their  habit  of  eating  little  or  no 
breakfasts.  The  efi^ect  of  any  given  diet  on  the 
general  nutrition  of  the  patient  should  be  watched 
with  as  much  care  as  the  effect  of  the  diet  on  the 
specific  condition  for  which  it  was  prescribed.  He 
had  seen  numerous  instances  in  which  the  patient 
had  been  much  run  down,  although  the  local  con- 
dition had  been  improved  by  strict  dieting,  and  in 
the  case  of  acute  infections  had  seen  several  in- 
stances terminating  fatally,  which  he  thought  were 
due  to  starvation.  A  knowledge  of  food  values 
was  as  important  as  of  the  dosage  of  drugs.  The 
word  "caloric"  had  a  formidable  sound  to  manv 
physicians,  but  the  subject  of  food  values  was  real- 
ly a  very  simple  one  and  a  very  important  one.  No 
restricted  diet  should  be  attempted  without  the 
knowledge  that  it  was  really  sufficient  to  support 
life.  This  was  of  great  importance  in  unusual  diets 
such  as  might  be  prescribed  in  diabetes  or  certain 
stages  of  Bright's  disease.  In  directing  a  patient's 
diet  it  was  not  sufficient  to  say  what  he  must  not 
eat,  but  one  should  always  tell  him  what  he  must 
eat. 

In  speaking  of  the  proprietary  foods  Dr.  Edsall 
said  that  their  existence  was  due  to  a  lack  of  knowl- 
edge on  the  part  of  physicians  concerning  the  mak- 


ing and  constitution  of  simple  home  foods.  Few 
physicians  had  any  idea  of  the  actual  constituents 
of  the  proprietary  foods  which  contained  very  little 
nutrition  and  usually  a  high  percentage  of  alcohol. 
He  knew  not  one  of  them  which  was  capable  of 
supporting  life  unaided.  They  cost  at  least  twenty 
times  as  much  as  ordinary  food,  and  they  were  quite 
unnecessary.  He  had  found  in  his  experience  that 
in  the  acute  diseases  for  which  these  were  usually 
recommended  he  could  almost  invariably  succeed 
better  with  milk  or  some  simple  modification  of 
milk.  It  was  well  known,  he  said,  that  so  called 
diabetic  breads  contained  almost  as  much  starch  as 
ordinary  bread.  The  beef  extracts  had  long  been 
known  to  contain  almost  no  nutriment  at  all,  some 
of  them  were  beef  extracts  or  beef  juice  only  by 
courtesy. 

Proprietary  and  Predigested  Foods  from  the 
Standpoint  of  the  Paediatrist,  read  by  Dr.  Johx 
HowLAND,  of  New  York.  He  said  that  there  were 
innumerable  kinds  of  infant  foods  which  simply  ex- 
isted because  the  doctors  knew  so  little  about  the 
principles  of  the  artificial  feeding  of  infants.  The 
percentage  method  of  modifying  milk  was  compli- 
cated and  difficult  to  use,  and  finally  the  difficulty 
of  getting  clean  milk  and  keeping  it  clean  made 
dry,  stable  preparations  of  value  in  some  instances. 
The  fact  that  these  foods  had  a  very  low  fat  con- 
tent was  one  reason  why  they  were  so  readily  pre- 
served, and  explained,  too,  why  infants  put  upon 
these  foods  immediately  after  a  mixture  too  high 
in  fat,  a  very  common  mistake,  thrived  upon  them, 
at  least  temporarily.  The  foods  contained  too  little 
fat  and  too  little  mineral  ash,  and  not  one  of  them 
could  support  life  without  the  addition  of  milk. 
Their  use  was  often  followed  by  rickets  or  scurvy. 
These  foods  were  very  variable,  changing  in  com- 
position not  infrequently.  He  believed  that  the 
skillful  use  of  ordinary  food  stuffs — milk,  sugar, 
white  of  egg,  etc.,  was  safer  and  more  satisfactory 
than  the  use  of  proprietary  foods.  ^Maltose  was 
sometimes  of  value,  and  as  pure  maltose  was  rather 
expensive  he  made  use  of  a  solution  of  maltose 
with  dextrin  which  occurred  as  a  by-product  in 
breweries  and  which  could  be  purchased  at  sixty 
cents  a  gallon.  He  said  the  predigested  medicinal 
foods  contained  ridiculously  little  nourishment  and 
a  large  percentage  of  alcohol.  The  use  of  ferments, 
such  as  pepsin,  he  thought  irrational,  as  the  normal 
ferments  of  the  digestive  tract  had  been  found  pres- 
ent in  their  usual  proportions  in  the  digestive  dis- 
turbances of  infancy. 

Dr.  Jacobi,  of  New  York,  said  that  he  had  been 
opposing  the  use  of  proprietary  infant  foods  for 
forty  years.  He  said  that  hydrochloric  acid  was 
often  indicated  even  when  the  gastric  acidity  wa.s 
high  as  the  acidity  might  be  due  to  organic  acids. 
He  recommended  the  following  formula  as  a  con- 
venient method  with  which  to  administer  hydro- 
chloric acid  to  infants :  One  part  of  dilute  hydro- 
chloric acid,  250  parts  of  water,  and  500  parts  of 
milk.  He  said  this  mixture,  gently  boiled,  might 
be  used  as  ordinary  milk,  with  cereals,  etc.  It  was 
not  curdled  and  was  very  digestible. 

Dr.  G.  C.  Smith,  of  iSoston,  said  that  the  ques- 
tion of  nutrition  in  the  first  ten  years  of  life  was 
very  important.    He  emphasized  the  importance  of 


1 230 


ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION.        ,  [i^'^w  York 

MEDICAL  Journal. 


a  recognition  of  food  values,  and  said  that  in  the 
case  of  chronic  illness,  he"  had  derived  more  benefit 
from  the  dietetic  control  than  from  the  vise  of 
drugs. 

Dr.  F.  E.  Stewart,  of  Philadelphia,  urged  more 
attention  to  dietetics  in  teaching — in  both  graduate 
and  undergraduate  schools. 

Dr.  C.  S.  i\.  Hallbekg,  of  Chicago,  said  that  the 
enzymes  were  of  use  m  predigesting  food,  particu- 
larly for  rectal  alimentation. 

Dr.  S.  SoLis-CoHEN,  of  Philadelphia,  protested 
against  the  absolute  rejection  of  all  predigested 
foods  and  ferments,  some  of  which  had  proved  of 
valuable  service.  As  an  example  he  mentioned  the 
use  of  pancreatized  milk  in  typhoid  fever,  which,  he 
said,  lessened  the  distention  and  tendency  to  hemor- 
rhage. 

Dr.  Edsall,  in  closing,  said  that  he  thought  cer- 
tain restricted  diets  recently  advocated,  particularly 
the  starvation  treatment  of  typhoid  fever,  were  very 
dangerous  and  that  all  patients  on  restricted  diet 
should  be  carefully  watched.  With  regard  to  rectal 
feeding  he  had  demonstrated  that  not  more  than 
one  fourth  to  one  sixth  of  the  nourishment  was  ab- 
sorbed and  that  it  was  obviously  impossible  to  sup- 
ply a  sufficient  amount  of  nourishment  in  this  man- 
ner for  any  very  long  period.  He  had  found  no 
advantage  in  predigesting  milk  in  a  large  series  of 
observations  on  ]jatients  sufi^ering  from  typhoid 
fever. 

The  Advantages  of  Adhering  to  the  Use  of 
Potassium  lodiae. — Dr.  George  Dock,  of  New 
Orleans,  who  read  this  paper,  said  that  potassium 
iodide  furnished  a  good  example  of  the  prevalent 
therapeutic  unrest.  Thousands  of  men  were  thor- 
oughly aware  of  its  value  and  constantly  used  it, 
and  yet  there  was  a  body  of  men  led  by  manufac- 
turers of  proprietary  remedies  who  were  always  de- 
crying it,  and  many  patients  were  warned  that  more 
than  fifteen  grains  was  a  dangerous  dose.  Dr. 
Dock  said  that  he  had  long  ago  adopted  the  method 
of  giving  it  in  saturated  aqueous  solution  with  milk 
as  a  vehicle,  and  that  in  this  manner  it  was  possible 
to  give  it  to  anybody  who  needed  it  in  the  required 
dose.  The  cutaneous  and  catarrhal  symptoms  of 
iodisin  were  usually  encountered  when  small  doses 
were  being  used  and  were  in  some  degree  due  to 
uncleanliness.  Other  features  of  so  called  "iodism" 
he  attributed  to  hyperthyreoidism.  particularly  when 
they  (;ccurred  in  goitre  cases.  Of  the  preparations 
of  iodine  he  had  found  ])otassium  iodide  the  most 
serviceable  .and  could  see  no  advantage  in  the  ex- 
pensive proprietary  compounds. 

The  Clinical  Use  of  Phenolphthalein.  —  Dr. 
John  J.  Gii, bride,  of  Philadelphia,  said  that  phe- 
nolphthalein was  a  yellowish  powder,  slightly  solu- 
ble in  water,  more  so  in  alkalis,  colorless  in  acid 
or  neutral  solution,  pink  in  alkali.  The  purgative 
action  of  the  drug  was  discovered  through  its  use 
as  a  preservative  of  wine.  He  mentioned  three 
possible  explanations  of  its  action  :  The  osmotic 
action  of  the  indiffusable  sodium  salt  presumably 
found  in  the  intestine,  the  .stimulation  of  peristalsis 
by  the  direct  action  on  the  unstriped  muscle  or  on 
the  i)lexus  of  .Auerbach.  The  speaker  .said  it 
had  no  apparent  action  on  the  kidneys  and  was  ex- 
creted in  the  urine  only  after  large  doses.    It  was 


recovered  largely  in  the  stools.  He  said  that  it  was 
a  harmless,  reliable  cathartic,  causing  little  or  no 
griping  and  with  no  tendency  to  later  constipation. 
The  dose  he  recommended  was  one  to  five  grains 
given  in  powder,  pill,  or  capsule,  though  he  stated 
that  patients  became  accustomed  to  it  and  ultimately 
required  larger  doses. 

Phenolphthalein  and  Its  Derivatives  as  Purga- 
tives.— Dr.  L.  T.  Rowntree,  of  Baltimore, 
sketched  a  history  of  the  search  for  a  subcutaneous 
purgative.  Various  inorganic  salts,  he  said,  had 
been  tried  and  found  wanting.  The  vegetable  prep- 
arations so  far  tried  had  proved  little  better.  Eser- 
ine  and  apocodeine  were  the  most  suitable  but  both 
of  these  were  very  uncertain.  The  speaker  had 
tried  phenolphthalein  and  a  number  of  its  deriva- 
tives in  this  manner,  and  of  these  the  most  satis- 
factory proved  to  be  the  phenoltetrachlorphtha- 
lein.  This,  he  said,  was  used  in  sterile  oil.  It  was 
absolutely  nonirritating  locally,  and  produced  a 
laxative  efi^ect  which  lasted  several  days  and  was 
the  only  effect  of  the  drug.  The  drug  was  found 
in  the  bile  of  dogs  in  forty-eight  hours  and  ap- 
peared in  the  faeces  for  five  days.  It  could  not  be 
found  in  the  urine.  The  speaker  said  that  after 
certain  experiments  on  dogs  the  drug  was  tried  in 
the  wards  of  a  hospital  and  in  a  dispensary.  Four 
hundred  milligrammes  of  the  drug  were  injected 
with  twenty  c.c.  of  oil  into  the"  buttock.  It  was 
found  to  act  after  about  twenty-four  hours,  the  ac- 
tion continuing  for  several  days,  and  one  dose  was 
found  sufficient  to  cure  a  certain  percentage  of 
cases  of  chronic  constipation.  The  ordinary  hy- 
gienic precautions  were  observed  in  these  cases  but 
they  had  been  tried  in  vain  previously  to  the  use 
of  the  drug. 

Dr.  H.  C.  Wood,  Jr.,  of  Philadelphia,  said  that 
phenolphthalein  was  quite  devoid  of  toxic  proper- 
ties. He  explained  its  action  through  a  direct  stim- 
ulation of  the  glands  of  the  intestine.  He  spoke  oi 
the  great  variabilty  in  the  potency  of  various  prep- 
arations of  the  drug. 

The  Analgesic  Effect  of  Local  Applications  of 
Solutions  of  Magnesium  Sulphate  and  of  Other 
Salts. — Dr.  Solomon  Soljs-Cohex,  of  Philadel- 
phia, read  this  paper.  He  said  that  he  had  noted  an 
unexpected  and  somewhat  inexplicable  effect  of  sat- 
urated solutions  of  magnesium  sulphate  in  relieving 
deep  seated  pain,  when  applied  to  the  surface  of 
the  body.  One  case  described  was  that  of  a  man 
suffering  intensely  from  an  aneurysm  of  the  tho- 
racic aorta.  Other  solutions  were  tried  without 
giving  the  same  relief.  The  magnesium  sulphate 
solution  itself  finally  failed  to  relieve  him.  Other 
instances  were  cited  where  this  solution  proved  a 
useful  anodyne.  He  was  able  to  demonstrate  no  lo- 
cal changes  in  sensibility,  and  said  that  he  could  not 
ab.solutely  rule  out  the  psychic  factor,  but  believed 
that  this  solution  might  be  of  service  under  certain 
conditions. 

Dr  Reid  Hunt  presented  for  Dr.  Melzer,  of 
Xew  York,  who  was  unable  to  be  present,  photo- 
graphs of  a  rabbit  both  of  whose  ears  had  been 
burned  and  one  dressed  with  saturated  solution  of 
magnesium  sulphate,  while  the  other  was  dressed 
with  some  other  solution  of  equal  density.  The  one 
dressed  with  magnesium  sulphate  was  in  very  nnich 


June  12,  1900.1        ATLANTIC  CITY  MEETIXG  Of  AMERICAN  MEDICAL  ASSOCIATION. 


better  condition.  This  furnished,  it  was  stated,  a 
very  comforting  and  efficient  dressing  for  burns  of 
the  first  and  second  degree. 

Dr.  Cohen  said  that  magnesium  sulphate  in  sat- 
urated solution  also  presented  a  very  agreeable 
dressing  for  mild  cases  of  erysipelas,  but  that  it 
should  not  be  trusted  in  severe  infections. 

SECTION  IN  PATHOLOGY  AND  PHYSIOCOGY. 

The  Haemolytic  Action  of  Crotalus  Venom  on 
Human  Erythrocytes. — JJr.  Joseph  McFarland 
and  Dr.  Paul  G.  \\'estox,  of  Pliiladelphia.  detailed 
studies  suggested  by  the  fact  that  but  little  mention 
had  been  made  by  previous  writers  of  the  effect  of 
rattlesnake  venom  on  human  corpuscles.  They 
found  that  the  venom  was  capable  of  haemolyzing 
the  red  cells  of  man  and  rabbits  in  the  presence  of 
serum  or  plasma.  Increase  in  the  amount  of  venom 
increased  the  haemolysis  up  to  a  certain  point  but 
then  ceased.  This  was  probably  due  to  an  excess 
of  amboceptors.  Heating  of  the  venom  diminished 
greatly  its  haemolyzing  powers.  Rabbits'  corpuscles 
w'ere  more  susceptible  than  those  of  human  beings 
and  also  showed  a  greater  difference  between  heat- 
ed and  unheated  serum.  As  to  the  leucoc>i;es,  the 
small  lymphocytes  and  eosinophiles  were  more  re- 
sistant to  the  cytolytic  action  than  were  the  poly- 
nuclears  and  large  lymphocytes,  the  polynuclears 
probably  being  the  most  susceptible. 

Dr.  D.  H.  Bergev,  of  Philadelphia,  asked  the 
explanation  of  the  loss  of  haemolytic  power  in  heat- 
ed venom,  especially  when  amboceptors  were  sup- 
posed to  be  somewhat  stable  substances. 

Dr.  McFarlaxd.  in  closing,  said  he  could  offer 
no  satisfactory  explanation  of  the  point  in  question. 
It  might  indicate  that  the  amboceptors  were  of  a 
class  different  from  the  ordinary  type,  but  he  did 
not  believe  it  was  the  case. 

The  Relation  of  Ether  to  Immunity. — Dr. 
EvARTS  A.  Graham,  of  Chicago,  reported  a  very 
instructive  study  made  in  the  effort  to  throw  light 
on  the  question  of  postoperative  infection.  He 
found  that  ether  had  no  eft'ect  upon  agglutinins  and 
bacteriolysins.  Upon  opsonins,  or  phagocytes, 
the  findings  were  entirely  different.  In  test  tubes, 
ether  diminished  phagocytosis  of  streptococci, 
staphylococci,  and  typhoid  bacilli  very  decidedly. 
The  effect  of  anjesthesia  on  eleven  patients,  nonin- 
fectious cases,  with  anaesthesia  not  lasting  over  an 
hour,  was  then  studied.  A  fall  in  the  opsonic  index 
was  noted,  this  beginning  one  and  one  half  hours 
after  the  beginning  of  anaesthesia  and  lasting  five 
or  six  days,  then  gradually  returning  to  normal.  In 
one  case  the  normal  was  not  reached  for  one  month. 
'Jsing  the  patient's  leucocytes  instead  of  normal 
mes,  the  result  was  in  general  the  same  but  the  re- 
duction w^as  greater.  The  effect  of  simple  anaes- 
thesia, without  operation,  was  then  studied  on  rab- 
bits, the  streptococcus  being  employed.  The  fall 
was  pronounced,  as  from  0.8  before  to  0.2  almost 
immediately  after  ether  was  begun :  this  lasted  for 
five  to  eight  days.  One  might  say  from  this  that 
ether  influenced  the  opsonins  but  this  conclusion 
was  considered  not  warrantable  because  the  ether 
in  the  serum  might  act  upon  the  normal  leucocytes 
employed.    Experiments  were  then  made  to  deter- 


mine if  the  serum  itself  was  affected.  These  indi- 
cated tnat  the  opsonins  were  attected.  Experiments 
were  then  made  to  see  if  ether  affected  tliC  leuco- 
cytes. 1  his  showed  that  the  amoeboid  action  was 
hindered,  tlius  rendering  it  probable  that  both  the 
leucocytes  and  serum  were  acted  upon  by  ether. 
The  possibility  that  this  action  was  due  to  the  fat 
solvent  powers  of  ether  then  was  raised,  and  the 
inference  made  that  lecithin  might  restore  the  pha- 
gocytic power  of  the  leucocytes.  It  was  found  that 
the  subcutaneous  injection  of  o.i  gramme  of  leci- 
thin in  a  rabbit,  aiier  the  lowering  ot  the  phago- 
cytic power  by  ether,  almost  immediately  raised 
that  power  to  a  point  approaching  the  normal.  The 
next  question  was  whether  any  fat  would  produce 
the  same  result,  and  rectal  injections  of  olive  oil 
were  given  immediately  after  anaesthesia.  The  in- 
dex within  four  hours  returned  to  normal.  The 
conclusions  in  part  were  that  agglutinins  and  bac- 
teriolysins were  unaffected  by  ether,  but  phagocy- 
tosis was  markedly  affected.  The  latter  was  due  to 
•action  upon  the  leucocytes,  and  probably  to  action 
upon  serum  as  well.  The  depressing  effect  of  ether 
lasted  about  five  days  and  was  lessened  by  the  in- 
jection of  olive  oil. 

Dr.  H.  Gideon  Wells,  of  Chicago,  said  the  pos- 
sible explanation  of  the  action  on  the  leucocytes 
was  that  the  surface  tension  was  changed  and  amoe- 
boid motion  hindered.  The  action  of  lipoids  was 
that  of  increasing  the  permeabihty  of  the  cell  mem- 
brane which  would  tend  to  counteract  the  effect  of 
the  ether.  Whatever  the  explanation  was.  the  study 
showed  why  postoperative  pneumonia,  which  pos- 
sibly had  a  greater  mortality  than  postoperative 
wotmd  infection,  and  wound  infection  itself,  were 
so  frequent  after  anaesthesia.  He  regarded  it  as 
strange  that  so  small  an  amount  of  lecithin  as  o.i 
grair.me  for  a  rabbit  should  act  so  decidedly  upon 
leucocytes. 

Dr.  Graham,  in  closing,  said  that  in  the  rabbit 
there  was  probably  not  more  than  0.12  gramme  of 
fat  normally,  hence  0.1  gramme  injected,  even  if 
not  all  in  the  circulation,  was  probably  able  to  ex- 
tract considerable  ether  as  it  was  brought  to  it. 

The  Histogenesis  of  the  Thymus  Cells,  and  the 
Normal  and  Pathological  Histology  of  the  Thy- 
mus.—  Dr.  Alwix  P appexhei.mer.  of  Xew 
York.  described  the  results  of  a  stud}-  of  eightv-five 
glands  from  people  of  various  ages  and  from  em- 
bryos of  dift'erent  periods.  He  gave  a  number  of 
reasons  why  the  thymus  could  not  be  regarded  as 
lymphoid  tissue.  He  was  able  to  find  in  one  case 
the  so-called  "myoid"  cells  which  nrevi-^uslv  had 
been  found  only  in  lower  animals.  The  studv  of  the 
thymus  from  cases  of  Basedow's  disease  and  a?ro- 
megaly  led  to  the  conclusion  that  the  change  in 
those  conditions  was  a  renewal  of  growth  rather 
than  a  persistence  of  thymic  staicture.  He  con- 
cluded that  the  thymus  was  an  epithelial  org^n 
made  up  of  two  kinds  of  cells.  The  reticular  epith- 
elium was  phagocytic  to  the  other.  They  gave 
rise  to  Hassall's  corpuscles  which  formed  during  the 
entire  evolution  of  the  gland  :  thymic  tissue  normal- 
ly persisted  throughout  life  and  possibly  function- 
ated. 

Cardiac  Thrombosis:  The  Clinical  and  Patho- 
logical  Findings   in   Four   Cases. — Dr.  Fraxk 


1232 


ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION.         [New  York 

JIedical  Journal. 


Smithies,  of  Ann  Arbor,  reported  three  cas.s,  in 
one  of  which  the  diagnosis  was  made  ante  mortem. 
The  cases  were  all  m  people  beyond  middle  life, 
suspected  of  syphilis,  and  all  had  cardiac  insuffi- 
ciency. All  showed  multiple  emboli  in  various  tis- 
sues. Dr.  Smithies  discussed  at  length  the  sympto- 
matology and  the  possibility  of  diagnosis.  Periph- 
eral vascular  changes  and  physical  examination  of 
the  heart  were  two  important  points. 

The  Relation  of  Venous  i-'ressure  to  the  Effi- 
ciency of  the  Heart. — Dr.  Yandell  Henderson, 
of  \ew  Haven,  said  such  determination,  if  a  satis- 
factory method  were  found,  would  prove  very  use- 
ful. Our  theoretical  knowledge  of  venous  pressure 
was  also  weak,  being  based  principally  on  observa- 
tions on  the  portal  vein  transferred  to  apply  to  the 
cava.  He  found  that  adrenalin  had  no  direct  efifect 
upon  venoiis  pressure.  Cutting  of  the  cord,  etc., 
had  no  effect,  hence  he  believed  it  was  not  under 
nervous  control.  His  experiments  upon  dogs  were 
made  to  determine  the  relation  of  venous  pressure 
to  its  function,  that  of  filling  the  heart.  The  re-' 
suits  indicated  that  no  to  120  beats  per  minute  rep- 
resented the  maximum  efficiency  of  the  heart,  and 
about  double  the  ordinary  amount  of  blood  was  its 
maximum  capacity.  The  venous  pressure  for  a  dog 
was  4  cm.  of  saline  solution,  but  a  pressure  of  one 
centimetre  in  the  jugular  would  keep  the  heart  as 
well  supplied  as  did  3  or  4  cm.  This  explained 
Porter's  findings  that  in  gradual  haemorrhage  there 
was  no  effect  upon  the  arterial  pressure  until  one 
third  of  the  fluid  was  lost.  So  long  as  there  was 
a  positive  venous  pressure  the  heart  was  at  its  max- 
imum efficiency. 

Dr.  A.  W.  Hewlett,  of  Ann  Arbor,  asked  what 
the  value  of  the  method  was  in  man,  as  the  inser- 
tion of  a  needle  into  a  vein  and  estimation  by  a  col- 
umn of  salt  solution  would  be  relatively  easy. 

Dr.  H.  C.  Wood,  Jr.,  of  .Philadelphia,  asked  Dr. 
Henderson  what  he  meant  by  the  term  direct  in 
connection  with  the  effect  of  adrenalin  upon  venous 
pressure. 

Dr.  Henderson,  in  closing,  said  the  method  de- 
scribed was  extremely  liable  to  error  in  clinical 
work  and  must  be  repeated  for  control.  As  to  the 
meaning  of  direct  effect  he  meant  that  when  arterial 
pressure  was  not  above  160  to  180  mm.  and  the  vagi 
were  cut,  adrenalin  produced  no  effect. 

The  Rate  of  Blood  Flow  in  the  Arm. — Dr.  A. 
W.  Hewlett  and  Dr.  J.  G.  van  Zwaluwenburg, 
of  Ann  Arbor,  studied  this  question  by  placing  the 
arm  in  a  plethysmograph  and  then  applied  above  it 
a  cuff,  tight  enough  to  obstruct  the  venous  exit  but 
not  interfering  with  the  arterial  inflow ;  the  result- 
ing swelling  of  the  arm  was  taken  as  representing 
the  flow  of  blood  into  the  arm.  They  found  that 
the  amount  entering  varied  in  normal  persons  be- 
tween 2  and  4  cc  per  100  grammes  of  arm  sub- 
stance. In  vasomotor  affections  there  was  much 
variation,  presumably  due  to  the  varying  condition 
of  the  vessels.  Exercise  increased  the  amount,  in 
one  person  eight  times.  Local  heat  caused  an  in- 
crease, but  not  so  much  as  was  expected.  Heating 
the  entire  body  very  greatly  increased  the  amount. 
Considerable  differences  were  found  in  different 
diseases;  anaemia  did  not  differ  from  the  normal, 


nephritis  showed  no  marked  change,  exophthalmic 
goitre  a  great  increase.  There  was  no  constant  re- 
lation between  the  pulse  and  the  other  findings.  The 
method  was  believed  to  be  an  approximate  means 
of  measuring  the  flow  of  blood  in  the  periphery; 
there  was  probably  twenty  per  cent,  error. 

The  Metabolic  Influences  of  Copious  Water 
Drinking  with  Meals. — Dr.  C.  C.  I'OWLEr  and 
Dr.  P.  h.  Hawk,  of  Urbana,  111.,  described  in  detail 
an  experiment  designed  to  throw  light  on  this  ques- 
tion. C)nly  one  man  was  studied  from  lack  of  help 
in  working  up  material.  During  a  preliminary 
period  of  six  days  he  was  given  a  fixed  diet,  then 
for  five  days  the  same  except  one  litre  of  water  was 
taken  durmg  each  meal,  tUe  food  being  carefully 
masticated  before  it  was  swallowed.  Fmally  for  a 
period  of  eight  days  the  original  diet  again.  They 
found  nothing  in  literature  to  support  the  general 
view  that  water  drinking  during  meals  was  inju- 
rious, and  the  experiment,  though  not  based  on 
enough  cases  to  be  conclusive,  was  opposed  to  such 
view.  On  the  contrary,  the  study  indicated  that  so 
large  an  amount  of  water  during  meals  was  a  desir- 
able feature  of  nutrition.  The  man  was  in  an  im- 
proved physical  condition  after  the  water  period 
and  weighed  two  pounds  more.  Fewer  bacteria 
were  excreted  in  the  fjeces  during  the  water  period 
and  also  during  the  third  period,  indicating  that 
digestion  was  improved.  There  was  a  decreased 
excretion  of  creatinin  and  the  coincident  appearance 
of  creatin  in  the  urine.  There  were  two  theories  re- 
garding the  increase  of  nitrogen  output  in  such 
cases,  one  the  flushing  out  of  waste  products  by  the 
water,  the  second  increased  proteid  metabolism.  The 
experiment  indicated  the  presence  of  the  latter  in 
this  case. 

Dr.  A.  MacFarland,  of  Albany,  said  that  from 
a  clinical  standpoint  it  was  not  right  to  say  that  in 
general  one  should  drink  a  litre  of  water  with  each 
meal.  It  would  not  do  in  persons  with  tendency  to 
dilatation  of  the  stomach.  It  was  questionable 
whether  mastication  would  be  carried  on  properly 
if  this  be  done.  Experiments  should  be  made  with 
water  drinking  between  meals. 

Dr.  S.  J.  Meltzer,  of  New  York,  asked  the  rea- 
son for  the  decrease  in  faecal  bacteria. 

Dr.  Hawk,  in  closing,  said  that  he  looked  upon 
the  metabolic  changes  as  due  to  stimulation  and 
hence  a  good  feature.  Increased  cell  activity  re- 
sulted in  increased  weight.  As  to  Dr.  McFarland's 
statements,  a  point  before  being  applied  to  clinical 
cases  must  be  oriented  by  finding  the  normal ;  this 
was  the  endeavor  in  the  experiment.  Even  if  food 
was  swallowed  more  hastily  it  must  be  remembered 
that  saliva  was  not  absolutely  necessary  for  diges- 
tion ;  it  had  even  been  shown  that  saliva  acted  bet- 
ter when  it  was  diluted  twenty  times.  As  to  dimi- 
nution of  bacteria,  they  had  not  the  material  in 
the  intestine  on  which  to  grow. 

Experimental  Analysis  of  the  Altered  Func- 
tion of  the  Kidney  in  Diabetes  Mellitus.  —  Dr. 
Harlan  Shoemaker,  of  Philadelphia,  detailed  the 
results  of  studying  two  cases  of  diabetes.  A.  E. 
Wright's  method  of  determining  the  function  of 
the  kidney  was  described,  and  the  results  in  the  two 
cases  given  in  the  units  of  that  method. 


June  12,  1909.]        ATLANTIC  CITY  MEETING  OF  AMERICAN  MEDICAL  ASSOCIATION. 


123s 


"SYilPOSIUM"  ON  THE  PRESENT  STATUS  OF  SERUM 
AND  VACCINE  THERAPY  WITH  SPECIAL  REF- 
ERENCE TO  THE  PRODUCTS  ON  THE 
AMERICAN  MARKET. 

Diphtheria  Antitoxine. — Dr.  H.  W.  Park,  of 
Xew  York,  said  the  globuHn  preparations  of  this 
antitoxine  were  rapidly  displacing  the  whole  serum. 
The  nonantitoxic  elements  were  diminished  by  the 
Gibson  method  twenty-two  per  cent.,  by  the  Banz- 
hof  method  forty  per  cent.  He  had  carefully 
watched  the  effect  upon  children  of  the  whole  se- 
runi;  of  the  Gibson,  and  of  the  Banzhof  prepara- 
tions. The  rashes  and  the  after  effects  were  un- 
doubtedly less  with  the  Gibson  article  than  with 
the  whole  serum,  and  with  the  Banzhof  somewhat 
less  than  with  the  Gibson.  The  French  and  the 
\'iennese  authors  said  that  antitoxic  sera  varied  in 
value,  and  even  that  sera  of  low  potency  were  of 
equal  value  with  the  same  amount  of  a  higher  po- 
tency. Consequently  Dr.  Park  started  investiga- 
tions to  determine  the  potency  and  value  of  the  dif- 
ferent types.  He  found  not  the  slightest  reason  to 
agree  with  the  F"rench  writers ;  all  the  tests  showed 
the  preparations  to  be  exactly  according  to  their 
unit  strength.  Both  the  protective  and  curative 
power  agreed  exactly  with  the  unit  strength.  With 
sera  obtained  from  the  Xew  York  laboratory  Roux 
has  not  yet  succeeded  m  obtaining  results  similar 
to  those  he  published  previously.  Dr.  Park  had  ex- 
amined samples  of  diphtheria  antitoxine  from  each 
of  the  manufacturers  and  with  the  exception  of  two 
minor  points  found  them  to  be  essentially  all  that 
was  said  for  them.  The  two  points  were:  i.  Some 
stated  that  the  greater  concentration  was  the  more 
valuable ;  and  2,  some  made  the  assertion  that  no 
harm  followed  the  use  of  their  serum.  The  latter 
was  of  course  a  false  statement  as  we  all  know 
urticaria  and  occasionally  more  serious  rashes  oc- 
curred. 

Tetanus  Antitoxine. — Dr.  John  F.  Axderso.v, 
of  Washington,  reported  on  tetanus  antitoxine.  He 
remarked  that  with  the  adoption  of  the  standard 
unit  by  the  United  States  Public  Health  and  ^Nla- 
rine  Hospital  Service,  the  physician  could  be  as- 
sured that  every  package  of  tetanus  antitoxine  now 
contained  the  number  of  units  claimed.  There  was 
yet  no  control  over  serum  for  veterinary  use ;  most 
of  it  contained  only  twenty-five  units  per  cubic  cen- 
timetre, very  much  less  than  that  for  human  use. 
The  Belgian  and  the  Brazilian  governments  would 
probably  adopt  our  standards.  Tetanus  antitoxine 
was  in  the  IBelgian,  French,  and  Swiss  pharma- 
copoeias, and  should  be  included  in  that  of  the 
United  States.  Its  value  as  a  prophylactic  alone 
entitled  it  to  that  recognition.  We  had  no  reliable 
data  as  to  the  prophylactic  or  curative  dose  needed, 
but  a  uniform  standard  having  been  established, 
these  data  should  be  gradually  accumulated.  A 
prophylactic  dose  of  1500  units  was  generally  rec- 
ommended, but  this  was  only  guesswork.  If  the 
wound  had  not  healed  by  the  end  of  three  weeks,  a 
second  prophylactic  dose  should  be  given. 

Dr.  W.  H.  HuTCHiNGS,  of  Detroit,  said  that  in- 
stead of  saying  so  many  cubic  centimetres  were  in- 
jected, as  was  the  usual  custom,  one  should  refer  to 
units.     The  prophylactic  use  of  the  serum  was  of 


great  value.  All  it  would  do  was  to  neutralize  the 
toxine  not  yet  combined  with  the  nerve  cells.  In 
experimental  work  he  had  given  a  sheep  4500  units 
intravenously,  after  symptoms  of  tetanus  appeared,, 
with  not  the  slightest  efifect. 

Dr.  E.  R.  Larned,  of  Detroit,  said  that  too  many 
practitioners  knew  nothing  about  the  necessity  for 
early  and  frequent  use  of  tetanus  antitoxines.  Fail- 
ure was  often  made  in  three  ways ;  the\'  waited  too 
long  before  beginning  injections,  they  gave  too 
small  an  amount,  and  they  gave  up  too  quickly.  He 
cited  a  case  which  was  given  up  as  hopeless,  but 
which  was  then  treated  for  thirty  days,  198,000 
units  of  antitoxine  being  given,  with  final  ctire.  It 
was  unjust  to  say  that  the  antitoxines  had  no  cura- 
tive value. 

Dr.  Anderson,  in  closing,  said  that  when  tetanus 
toxine  was  bound  by  the  nerve  cells  in  sufficient 
quantity,  antitoxine  was  of  no  avail,  but  ini 
any  case  should  be  used  to  combat  new  toxines 
where  formed.  As  stated  by  Dr.  Park,  antitoxine 
should  be  used  very  early  and  intravenously. 

General  Principles  of  Bacterial  Vaccine  Ther- 
apy.— Dr.  Mark  W.  "Richardson,  of  Boston, 
contributed  a  paper  (read  by  Dr.  ^Motter)  deahng 
Avith  general  points  as  an  introduction  to  the  discus- 
sion of  the  subject.  He  called  attention  to  the  fact 
that  vaccines  produced  an  active  immunity,  the  pa- 
tient producing  for  himself  the  antitoxines  to  com- 
bat the  toxines.  In  order  that  this  be  successful, 
the  individual  should  not  be  overwhelmed  with 
toxines  of  the  disease,  hence  overintoxication  should 
be  avoided.  A  vaccine  might  be  briefly  defined  as  a 
sterile  culture  of  the  organism  causing  the  disease 
for  which  it  was  to  be  used.  The  greater  efficiency 
of  living  organisms  in  general  should  be  borne  in 
mind,  and  efforts  taken  not  to  change  them  more 
than  necessary  during  sterilization.  Even  living 
bacilli  have  been  used  in  cases  of  tuberculosis.  As 
to  dosage  there  were  no  fixed  rules.  One  should 
begin  low  and  increase  gradually  to  avoid  idiosyn- 
crasy. As  to  the  opsonic  index  it  was  so  time  con- 
suming and  unreliable  that  it  was  not  to  be  advised, 
in  routine  practice  at  least.  In  the  case  of  typhoid 
fever,  vaccine  therapy  in  the  way  of  immunization 
had  given  good  results  in  England  and  these  re- 
ports had,  in  the  main,  been  confirmed  by  Germany. 
It  was  now  proposed  to  introduce  the  method  into 
the  United  States  army.  It  would  undoubtedly  not 
come  into  general  use  for  a  long  time,  but  its  em- 
ployment in  large  institutions  was  to  be  recom- 
mended. In  the  treatment  of  typhoid  fever,  Chante- 
messe,  of  Paris,  had  obtamcd  by  far  the  best  results, 
a  mortality  of  only  4.3  per  cent,  in  i.ooo  cases. 
There  appeared  to  be  a  bactericidal  element  in  the 
serum  he  employed.  Serum  studies  in  the  Massa- 
chusetts General  Hospital  gave  largely  negative  re- 
sults except  in  one  case.  Fewer  relapses,  however, 
occurred.  Recently  twenty-eight  cases  of  typhoid 
were  treated  by  vaccines,  twenty-five  being  primary 
cases,  three  relapses.  The  results  were  not  specially 
striking,  but  as  with  the  serum  there  were  fewer  re- 
lapses. With  the  Micrococcus  neofonnans  there 
was  but  little  basis  for  its  favorable  reputation.  In 
the  case  of  the  Bacillus  coli  communis  in  cystitis^, 
etc.,  amelioration  could  be  secured. 


PITH  or  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


^\\\  %i  (irrtnt  literature. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL 
June  3,  1909. 

1.  Extensive  Calcification  of  Pleuritic  Exudation  Causing 

Curvature  of  the  Spine,  By  Thomas  Dwight. 

2.  The  -Etiology  and  Diagnosis  of  Iritis, 

By  Peter  Hunter  Thompson. 
A  Case  of  Chronic  Glomerulonephritis,  in  which  Dou- 
ble Di  capsulation  was  Performed, 

By  Edcvr  Garce.au. 

4.  Placenta  Praevia.     An  Analysis  of  the  Cases  of  155 

Women  Delivered  at  the  Boston  Lying  in  Hospital 
during  the  Past  Thirty-five  Years, 
By  Xathaniel  R.  Mason  and  John  T.  Williams. 

5.  Oiiservations  upon  E.xercise  in   Pulmonary  Tubercu- 

losis, By  B.  SwAYNE  Putts. 

2.     The  .Etiology  and  Diagnosis  of  Iritis. — 

Thompson  states  that  the  distinctive  diagn-^sis  be- 
tween iritis  and  other  affections  of  the  eye  that  in 
anv  war  resemble  or  might  be  mistaken  for  it  is 
very  important,  since  the  treatment  appropriate  to 
one  may  be  of  no  avail  in  the  other,  and,  in  some 
cases,  glaucoma  in  particular,  great  damage  to  the 
eye  and  its  usefulness  for  vision  will  result  from 
using  the  wrong  treatment  "by  reason  of  a  mistaken 
diagnosis.  Acute  glaucoma,  acute  conjunctivitis  and 
keratitis  are  the  diseases  most  commonly  mistaken 
for  acute  iritis,  and  vice  versa.  Injection  is  red  in 
color  in  all  four  diseases,  but  in  conjunctivitis  it 
is  less  marked  near  the  cornea,  while  in  iritis  it  is 
more  notceable  surrounding  the  cornea,  forming  a 
bright  zone  of  ciHary  redness ;  in  keratitis  it  is  also 
most  conspicuous  near  the  cornea,  but  is  mor."  on 
the  rose  pink  .shade,  and  in  glaucoma  the  injection 
is  apt  to  be  a  dark  shade  of  red.  The  conjunctiva 
is  more  or  less  thickened  in  conjunctivitis,  it  can  be 
readily  thrown  into  fold's,  and  on  everting-  the  lid 
the  vessels  are  seen  to  be  partially  or  entirely  ob- 
scured bv  the  general  redness;  whereas  in  the  other 
affections,  as  a  rule,  these  conditions  are  not  partic- 
ularly noticeable.  Secretion  of  mucus  is  marked  in 
conjunctivitis,  appearing  as  flakes  which  mix  with 
the  tears  and  accumulates  on  the  cilia  and  margin 
of  the  lids,  often  causing  the  latter  to  stick  together 
after  closure  during  sleep ;  in  iritis  the  secretions 
consists  chiefly  of  tears;  in  keratitis  and  glaucoma 
there  is  no  hy])ersecretion  of  mucus,  but  there  is 
often  profuse  lachrymation,  especially  in  the  former. 
The  cornea  is  clear  in  uncomplicated  conjunctivi- 
tis :  in  iritis  it  is  usually  clear,  except  in  a  few 
varieties,  in  which  cases  the  opaque  spots  are  nearly 
always  on  the  posterior  surface  of  the  cornea  ;  in 
keratitis  there  is  more  or  less  cloudiness  or  opacity 
which  may  involve  its  superficial  layers  or  nearly 
all  of  its  substance,  obscuring  the  view  of  the  iris 
and  pupil ;  in  glaucoma  the  cornea  becomes  slightly 
liazy  gciurally.  and  as  the  disease  grows  more  severe 
it  ac(|uires  a  steamy  look  and  it  may  even  approach 
the  apearance  of  ground  glass.  Anae.sthesia  of  the 
cornea  is  more  or  less  pronounced  in  glaucoma, 
while  in  keratitis  it  may  be  hypersensitive,  exce])t 
the  neuropathic  type,  in  which  ansesthesia  is  a  char- 
acteristic feature,  but  in  iritis  and  conjunctivitis 
sensation  is  normal.  Iris  is  discolored,  thickened, 
puckered,  and  dull  looking  in  iritis,  but  in  the  other 
affections  it  is  normal  except  in  glauc<)ma,  when  it 
may  be  slightly  discolored.  Tiie  \m\n\  is  small,  slug- 


gish in  reaction  or  fixed,  and  irregular  in  shape  in 
iritis ;  in  glaucoma  it  is  dilated,  sluggish  and  may  be 
greenish  in  color ;  whereas  in  the  other  two  diseases 
it  is  not  affected.  Vision  is  slowly  impaired  in  iritis ; 
but  in  glaucoma  there  is  rapid  and  marked  loss  early 
in  the  attack ;  in  keratitis  it  is  more  or  less  blurred, 
depending  on  the  amount  of  haziness  or  opacity 
of  the  cornea;  in  conjunctivitis  it  is  very  slightly 
interfered  with  on  account  of  mucus  and  tears  flow- 
ing over  the  cornea.  Pain  is  severe  and  similar  in 
character  in  both  glaucoma  and  iritis,  but  in  the 
former  it  is  not  apt  to  be  worse  at  night ;  in  keratitis 
it  is  not  so  marked,  but  is  more  constant ;  in  con- 
junctivitis it  is  more  of  a  smarting  or  burning  sen- 
sation, as  if  there  were  sand  in  the  eye,  than  actual 
pain. 

4.  Placenta  Praevia. — Mason  and  Williams  re- 
view the  cases  of  155  women  delivered  at  the  Bos- 
ton Lying  in  .Hospital  during  the  past  thirty-five 
years.  They  remark  that  improvement  in  the  results 
of  the  treatment  of  placenta  praevia  is  to  be  ex- 
pected not  so  much  from  any  particular  method  of 
delivery  as  from  early  delivery.  The  advantages  of 
early  delivery  are  as  great  for  the  child  as  for  the 
mother.  Every  patient  should  be  instructed  and  en- 
abled to  notify  a  competent  obstetrician  at  once  of 
any  uterine  haemorrhage  during  pregnancy.  Anv 
haemorrhage  during  the  second  half  of  pregnancy 
demands  an  immediate  investigation  of  the  contents 
of  the  lower  uterine  segment.  A  routine  vaginal 
examination  should  be  made  on  every  patient  at 
the  end  of  the  seventh  month.  In  multiparae,  rapid 
dilatation,  followed  by  version  and  extraction,  of- 
fers a  safe  and  satisfactory  method  for  both  mother 
and  child.  In  primiparae,  at  the  beginning  of  haem- 
orrhage, while  still  in  good  condition,  Caesarean  sec- 
tion should  be  the  operation  of  choice. 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 
June  5,  fyoy. 

1.  Problems  and  Procedures  in  Cranial  Surgery, 

By  Charles  H.  Frazier. 

2.  The  Cincinnati  Milk  Show.  By  W.  A.  Evans. 
Acute  Pancreatis.              By  William  Fitch  Cheney. 

4.  Postoperative  Ileus,  By  William  H.  Wathen. 

5.  Gastric  Symptoms  Consequent  on  Arteriosclerosis, 

*  By  Henry  L.  Akin. 

6.  Cholelithiasis  and  Prancreatitis ;  Their  Early  Recogni- 

tion, By  Charles  N.  Smith. 

7.  Ankylostoma  Duodenale  (Uncinaria  Americana), 

By  J;)SEPH  Leidy,  Jr. 

I.  Cranial  Surgery. —  I'razier  reviews  some  re- 
cent developments  in  cranial  surgery.  He  speaks 
of  trigeminal  neuralgia,  cerebral  trauma,  operabil- 
ity  of  br-ain  tumors,  the  surgery  of  the  posterior 
fossa,  and  decompression.  He  cites  cases  to  illus- 
trate his  remarks.  As  to  tumors  he  says  that  the 
operable  tumor  must  be  accessible,  that  is,  either  on 
or  just  beneath  the  cortex  and  sufficiently  well  de- 
fined to  enable  one  to  determine  its  limitations.  The 
inoperable,  on  the  other  hand,  is  a  deep  seated  or  in- 
filtrating growth.  No  attempt  should  be  made  to 
remove  a  growth  of  an  excessively  vascular  in- 
filtrating type.  The  attending  haemorrhage  may 
prove  fatal,  and.  if  the  patient  survives  and  the 
growth  is  imperfectly  removed,  recurrence  will  be 
rapid  and  the  expectation  of  life  no  longer  than 
after  a  decompression,  if  as  long.  The  performance 
of  an  operation  for  the  exposure  of  lesions  in  the 


June  12,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


posterior  fossa  requires  as  mvich  experience  and 
practice  as  that  for  the  removal  of  the  Gasserian 
ganghon.  As  to  the  position  of  the  patient,  he  uses 
the  head  up  lateral  posture  as  the  most  desirable.  In 
this  position  venous  haemorrhage  is  minimized,  respi- 
ration is  not  interfered  with — a  very  important  con- 
sideration in  this  class  of  cases — by  slight  flexion  of 
the  head  the  field  of  operation  is  quite  accessible ; 
the  anaesthetic  can  be  administered  more  easily  than 
in  the  prone  posture  and  in  exploring  the  pontile 
space. 

3.  Acute  Pancreatitis. — Cheney  describes  sucli 
a  case,  and  remarks  that  from  all  the  reports  of 
published  cases,  as  well  as  from  his  own,  it  is  evi- 
dent that  the  onset  is  violent  and  sudden.  The  first 
symptom  is  usually  pain,  situated  in  the  epigas- 
trium, of  great  severity,  usually  paroxysmal  in  char- 
acter ;  vomiting  occurs  soon  after  pain  begins,  is 
persistent  and  severe,  and  frequently  the  vomitus 
is  bloody ;  collapse  quickly  follows,  with  rapid  and 
weak  pulse,  prostration,  and  possibly  death  within 
twenty-four  or  forty-eight  hours.  If  the  patient 
survives  the  shock  of  the  initial  symptoms,  hic- 
cough is  likely  to  become  a  persistent  feature ;  the 
bowels  are  obstinately  constipated,  and  the  symp- 
toms of  localized  peritonitis  in  the  upper  abdomen 
develop,  with  a  low  grade  of  fever  and  irregular 
chills,  in  addition  to  the  previous  vomiting,  hic- 
cough, and  prostration.  The  physical  signs  at  the 
outset  are  simply  those  of  intense  tenderness  in  the 
upper  abdomen,  with  marked  rigidity  of  the  abdom- 
inal wall ;  later  on  there  is  commonly  an  increased 
fulness  or  even  a  visible  and  palpable  swelling  ex- 
tending across  the  epigastrium  and  into  each  hypo- 
chondrium.  The  laboratory  evidence  is  not  diag- 
nostic nor  does  it  serve  to  distinguish  acute  pan- 
creatitis from  several  other  conditions  simulating  it. 
In  the  blood,  there  is  quickly  a  high  leucocyt?  count, 
with  an  increase  in  the  polymorphonuclears.  As 
regards  the  urine,  first,  it  does  not  show  sugar  ex- 
cept in  rare  instances,  because  the  pancreas  is  nOt 
uniformly  or  entirely  destroyed  ;  second,  the  absence 
of  indican  is  a  point  of  importance  in  distinctive  but 
not  in  direct  diagnosis ;  but  third,  Cammidge  asserts 
that  the  urine  gives  the  characteristic  pancreatic  re- 
action in  all  cases  of  acute  pancreatitis  in  wbi:h  h  ' 
has  examined  for  it — nine  in  all.  Other  o"~ servers 
however,  have  not  been  so  fortunate.  The  faeces  show 
an  excess  of  undigested  fat ;  but  the  constipation 
that  usually  accompanies  the  disease  rarely  permits 
of  the  use  of  this  method  of  diagnosis.  Taking  a  1 
these  facts  into  consideration  we  must  conclude  that 
there  is  no  absolutely  certain  way  to  recognize  acute 
pancreatitis  clinically.  It  may  be  objected  that  wher.- 
no  positive  diagnosis  can  be  made,  no  plan  of  treat- 
ment is  rationally  indicated.  But  that  is  not  alto- 
gether true.  The  symptoms  are  such  that  we  can 
promptly  arrive  at  a  conclusion,  limiting  the  diag- 
nosis to  one  of  a  very  few  conditions  arising  in  the 
upper  abdomen,  namely,  acute  pancreatitis  ;  perfora- 
tion of  a  gastric  or  duodenal  ulcer ;  perforation  of 
gallbladder ;  acute  intestinal  obstruction ;  or  em- 
bolism of  the  superior  mesenteric  artery.  As  a  mat- 
ter of  fact,  each  one  of  these  demands  surgical  in- 
terference if  life  is  to  be  saved,  and  the  indicat'on 
is  clear  for  laparotomy  just  as  soon  after  onset  as 
the  patient's  condition  will  permit  it.  Th's  is  the 
only  question  to  be  answered — whether  to  operate 


early  or  to  wait ;  whether  the  patient  will  be  harmed 
more  by  the  shock  of  the  operation  than  by  the  de- 
lay. There  is  no  medical  treatment  for  acute  pan- 
creatitis, except  for  the  early  symptoms,  such  as 
morphine  for  pain  and  stimulants  to  tide  ever  the 
crisis  of  imminent  collapse. 

5.  Gastric  Symptoms  in  Arteriosclerosis. — 
Akin  states  that  the  treatment  in  these  cases,  for  a 
time  at  least,  often  gives  quite  satisfactory  results. 
The  diet  should  be  restricted  to  plain,  nutritious,  and 
digestible  food,  the  evening  meal  very  strictly  lim- 
ited, so  as  to  leave  no  chance  for  gas  formation,  and 
careful  attention  paid  to  such  hygienic  aids  as  are 
suitable  to  the  case — bathing,  fresh  air,  suitable  ex- 
ercise, attention  to  the  bowels,  relief  from  work,  etc. 
The  results  obtained  from  the  use  of  drugs  in  these 
conditions  is,  as  a  rule,  very  satisfactory,  and  fore- 
most among  these  stand  the  vasodilators,  diuretin,  a 
saturated  solution  of  sodium  nitrite  and  nitroglyc- 
erin. Diuretin,  or  theobrominisodiosalicylate,  is  the 
most  effective  and  most  used,  being  employed  in 
doses  of  ten  to  fifteen  grains  three  times  a  day.  So 
prompt  and  satisfactory  is  its  action  in  cases  of  this 
kind  that  its  use  has  been  recommended  as  a  means 
of  diagnosis  in  doubtful  cases;  just  as  we  use  qui- 
nine in  suspected  malaria  and  mercury  in  syphilis. 
Its  effect  depends  on  its  powerful  action  in  overcom- 
ing the  vessel  spasm  and  dilating  the  arterioles  so 
that  they  allow  a  greater  flow  of  blood  to  the  scler- 
osed areas.  Of  diuretin  it  is  also  suggested  by  Buch 
that  it  may  neutralize  the  effect  of  some  toxic  agent 
which  tends  to  irritate  the  vasomotor  centres  and 
cause  contraction.  Whatever  the  exact  mode  of  ac- 
tion, its  effects  are  very  satisfactory,  and  its  use  may 
be  continued  for  one  or  two  weeks  or  even  longer 
without  harm.  Following  this  the  effect  may  be 
continued  by  the  use  of  tincture  of  strophanthus, 
five  to  eight  drops  three  times  a  day,  which  seems  to 
have  a  similar  action  to  the  diuretin,  so  much  so  that 
it  is  used  in  place  of  the  latter  in  some  cases  on 
which  expense  is  a  great  consideration.  As  in  all 
arteriosclerotic  conditions,  the  iodides  have  an  im- 
portant place.  Potassium  or  sodium  iodide  in  doses 
of  five  to  ten  grains  may  be  continued  over  a  long 
period,  but  it  is  asserted  that  the  good  they  accom- 
plish IS  not  due  so  much  to  their  so  called  alterative 
effects,  as  it  is  either  to  a  dilating  effect  on  the  ves- 
sels involved  or  to  a  lessening  of  the  blood  density. 

6.  Gallstones  and  Pancreatitis.  —  Smith  ob- 
serves that  the  early  symptoms  ascribed  to  gallstones 
are  but  the  symptoms  of  the  inflammation  which 
their  presence  has  provoked.  Gallstones  lying  in  the, 
gallbladder,  producing  or  aggravating  a  cholecysti- 
tis, are  attended  by  the  general  symptoms  of  the  lat- 
ter and  not  by  any  special  symptoms  attributable  to 
the  gallstones  themselves,  so  long  as  they  remain 
quietly  sequestered.  A  mild  degree  of  inflammation 
of  the  gallbladder,  however,  attended  by  a  varying 
amount  of  desquamation  of  epithelium,  the  "lithog- 
enous  catarrh"  of  Meckel,  is  a  necessary  aetiological 
condition  in  gallstone  disease.  Operation  based  on 
the  early  symptoms  under  consideration — the  symp- 
toms of  cholecystitis — may  disclose  a  cholecystitis, 
but  no  gallstones.  The  cholecystitis  so  found  may 
be  the  precursor  of  gallstone  formation,  or  the  re- 
sult thereof,  the  gallstones  at  one  time  present  in  the 
latter  instance  having  escaped  through  the  ducts  into 
the  intestines  and  thence  from  the  body.    The  one 


1236 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


great  stumbling  block  in  the  way  of  an  early  diag- 
nosis of  gallstone  disease. is  the  allurement  of  jaun- 
dice, which  seems  to  have  bewitched  the  judgment 
of  so  many  medical  men,  in  that  they  demand  its  evi- 
dence before  admitting  the  presence  of  gallstones. 
Jaundice,  however,  is  an  infrequent  and  inconstant 
event  in  gallstone  disease  and,  when  present  is  as  a 
terminal,  rather  than  as  an  inaugural  one.  Too  fre- 
quently, indeed,  does  jaundice  announce  the  ad- 
vanced stage  of  a  secondary  chronic  pancreatitis.  It 
is  high  time  that  the  medical  profession  should  break 
away  from  the  fetish  of  jaundice  ;  that  it  should  rec- 
ognize the  presence  of  gallstones  by  their  inaugural 
s\  mptoms :  that  it  should  appreciate  the  gravity  of 
gallstone  complications  and  sequels ;  and  that  it 
should  forestall  such  complications  and  sequels  by 
the  institution  of  operative  procedures  immediately 
following  the  establishment  of  a  diagnosis. 

MEDICAL  RECORD. 

June  5,  igog. 

1.  Alcohol   Injections   in   Neuralgia,   Especially   in  Tic 

Douloureux,  By  O.  Kiliani. 

2.  .Etiology  of  Arthritis  Deformans.    A  Preliminary  Re- 

port, By  Jacob  Heckmann. 

3.  A  Little  Abdominal  Surgery  by  the  Family  Physician; 

with  Report  of  My  First  Fifty  Cases  and  End  Re- 
sults, By  W.  H.  Dukemann. 

4.  A  Study  of  the  Urinary  Acidity  and  Its  Relations, 

By  Henry  R.  Harrower. 

5.  Adams-Stokes  Syndrome  (Heart  Block), 

By  A.  A.  Robinson. 
'6.    The  Present  Status  of  Prostatectomy, 

By  J.  Bentley  Squier. 

I.  Alcohol  Injection  in  Neuralgias. —  Kiliani 
makes  a  report  on  his  experience  with  alcchol  in- 
jection in  neuralgias.  Since  September,  1906,  he 
has  had  190  cases  with  five  failures,  the  other  185 
patients  were  all  entirely  free  of  pain  for  some 
time.  The  number  of  injections  necessary  to  pro- 
duce this  eft'ect  varied  according  to  the  number  of 
branches  atTected,  the  severity  of  the  case,  and  the 
anatomical  peculiarities  of  the  skull  in  question, 
from  two  to  ten  :  three  an  the  average.  The  amount 
of  eighty  per  cent,  alcohol  injected  is  from  i  c.c. 
to  4  c.c.  The  injection  is  done  without  narcosis. 
First,  because  hardly  any  of  the  patients  who  have 
gone  through  so  much,  object  to  the  pain  produced 
by  the  injections,  which,  apparently,  is  not  more 
severe  than  any  of  their  paroxysms.  Secondly,  the 
patients  ought  to  be  awake,  because  they  are  in  a 
position  to  describe,  during  the  injection,  the  course 
the  alcohol  seems  to  take.  They  at  once  feel  the 
nerve  branches  affected  by  the  injection.  The  re- 
sult, in  many  instances,  where  the  injection  has  been 
well  executed,  is  instantaneous  and  miraculous  for 
the  patients.  Pain  that  has  persisted  for  years  in 
its  most  violent  form,  leading  the  patients  to  the 
most  indiscriminate  use  of  morphine  or  to  repeated 
attempts  at  suicifle,  disappears  instantly  within  one 
minute.  ( )ther  cases,  again,  require  a  number  of 
injections,  and  the  improvement  is  more  slow,  con- 
suming about  two  weeks  of  time.  But  the  patients 
arc  not  permanently  cured.  There  seems  to  be  no 
permanent  cure  for  facial  neuralgia,  gasserectomy 
included.  .Xfter  peripheral  resection  the  pain  al- 
ways seems  to  recur.  Gasserectomy  is  pronounced 
the  only  absolute,  certain,  permanent  cure  by  its  in- 
ventors and  their  followers.  Kilian  has  treated  by 
injections  and  freed  from  pain  six  cases  of  intra- 


cranial operations,  with  complete  recurrence  of  pain, 
worse  than  before  the  operation.  Of  these  six  op- 
erations there  were  four  gasserectomies  performed 
by  our  best  surgeons  and  two  Abbe  operations,  per- 
formed by  himself.  Therefore,  it  seems  to  him 
there  is  no  permanent  cure  for  neuralgia.  Of  the 
190  cases  treated  by  him  by  injection,  42  per  cent, 
have  hand  no  recurrence  to  date.  If  we  take  only 
iirse  cases  into  consideration  where  at  least  eigh- 
teen months'  time  has  elapsed  since  the  time  of  the 
injection,  twenty-one  per  cent,  have  remained  free 
from  pain  for  that  length  of  time.  In  the  other 
cases,  the  time  when  the  recurrence  appeared,  var- 
ied from  three  months  to  two  years.  It  cannot  be 
denied  that  it  is  possible  that  some  of  those  pa- 
tients, treated  three  years  ago  and  free  from  pain 
since  then,  may  show  a  recurrence  at  some  future 
time.  But  one  or  two  further  injections  into  the 
branch  affected  will,  in  most  cases,  again  allay  the 
pain.  His  general  impression  is  that  the  recurrences 
become  rarer,  their  intensity  less,  and  he  expects 
that  a  number  of  those  patients  who  have  recur- 
rences at  all,  will  eventually  remain  free  altogether. 
On  the  other  hand,  it  is  his  belief  that,  in  a  very 
few  patients  the  recurrent  attacks  are  fully  as 
severe  and  less  prone  to  yield  to  treatment. 

4.  Urinary  Acidity. — Harrower  says  that  care- 
ful investigation  will  prove  that  the  majority  of 
chronic  diseases,  and  especially  those  diseases 
which  are  so  very  common,  such  as  tuberculosis, 
rheumatism,  neurasthenia,  etc.,  together  with  the 
hundred  and  one  other  conditions  associated  with 
autointoxication,  will  usually  show  a  decidedly  high 
degree  of  acidity,  and  also  a  marked  increase  in  the 
number  of  acid  units  eliminated  each  day.  When 
the  conditions  causing  this  are  modified  and  the  find- 
ings in  the  urine  changed,  the  chances  of  the  patient 
for  recovery  are  greatly  increased,  because  the  body 
and  its  cells  do  not  have  the  extra  work  of  getting 
rid  of  these  poisons,  and  hence  can  better  attend  to 
the  work  of  overcoming  the  ravages  of  the  tubercle 
bacillus  and  of  building  up  the  body  structure  in 
general.  The  index  of  urinary  acidity  undoubtedly 
varies  in  direct  ratio  with  the  metabolic  changes  go- 
ing on  in  the  body.  The  manufacture,  as  waste 
products,  in  the  body  cells  of  acid  substances— of 
which  sulphuric  acid  is  probably  the  most  important 
— must  have  a  decided  influence  upon  this  factor. 
In  addition  to  this,  certain  products  of  intestinal 
putrefaction  when  absorbed  into  the  blood  are  elim- 
inated in  the  urine  and  thus  serve  to  increase  its  de- 
gree of  acidity.  Several  factors  cause  the  normal 
urinary  acidity  to  vary  considerably,  such  as  an  ex- 
clusive meat  diet ;  excessive  muscular  exercise  ;  high- 
ly concentrated  urine,  due,  perhaps,  to  febrile  condi- 
tions, after  free  perspiration,  or  diminished  water 
drinking.  Then,  too,  the  internal  administration  of 
acids,  such  as  benzoic,  phosphoric,  or  boric  acid,  and 
the  presence  of  abnormal  fatty  acids  resulting  from 
pathological  conditions  also  play  their  part.  The  de- 
gree of  acidity  of  individual  voidings  of  urine  is 
quite  irregular,  and  in  order  that  the  physician  in  his 
diagnostic  work  may  gain  an  accurate  idea  of  the 
elimination  and  metabolism  of  his  patients,  it  is  dis- 
tinctly necessary  to  make  an  examination  of  a  part 
of  a  mixed  twenty-four  hour  specimen  of  urine.  The 
acidity  of  the  urine  varies  in  direct  proportion  with 
the  alkalinity  of  the  blood,  and  that  in  turn  depends 


June  12,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


1237 


upon  the  general  health  and  vital  powers  of  the 
body.  The  normal  blood  plasma  is  alkaline  in  reac- 
tion, due  to  the  fact  that  it  carries  in  solution  certain 
alkaline  salts,  especially  disodium  phosphate,  and  so- 
dium carbonate.  Upon  this  reaction  depends  to  a 
greater  or  less  extent,  the  ability  of  the  blood  to 
absorb  carbonic  acid  gas,  and  thus  to  carry  on  the 
good  work  of  elimination  by  means  of  the  lungs. 
When  the  normal  alkalinity  of  the  blood  is  dimin- 
ished and  there  is  an  excess  of  acid  substances  in 
the  blood,  an  acid  intoxication  results  which  is  called 
by  some  acidosis  and  by  others  acidsemia.  It  is  prob- 
able that  the  blood  never  becomes  acid,  as  in  such 
cases  death  would  undoubtedly  result,  since  the  ca- 
pacity of  the  blood  for  carrying  excrementitious  sub- 
stances from  the  cells  of  the  eliminative  organs 
would  be  absolutely  nil  and  thus  a  general  paralysis 
of  elimination  would  occur.  One  function  of  the 
kidneys  is  to  eliminate  from  the  blood  all  excess  of 
acid  substances,  and  they  are  so  constructed  that 
they  are  able,  not  to  filter,  but  to  secrete  from  an  al- 
kaline blood  plasma  an  acid  urine.  If  the  amount  of 
acid  substances  formed  in  the  body  metabolism  is 
excessive,  the  kidneys  frequently  can  no  longer  ac- 
complish the  work  required  of  them,  when  the  con- 
dition termed  acidaemia  results.  These  harmful  sub- 
stances are  carried  around  in  the  blood  stream,  neu- 
tralizing to  a  greater  extent  the  alkalies  of  the  blood 
and  thus  diminishing  its  power  to  carry  carbonic 
acid  gas,  hence  making  a  bad  condition  worse.  It 
must  be  evident,  therefore,  that  a  diminished  degree 
of  the  alkalinity  of  the  blood  plasma,  evidenced  by 
increased  urinary  acidity,  should  be  a  danger  signal 
of  extreme  value  to  the  practitioner. 

BRITISH  MEDICAL  JOURNAL. 

May  22,  1909. 

1.  A  Clinical  Lecture  on  the  Early  Diagnosis  of  Carcin- 

oma of  the  Prostate,        By  C.  Mansell  Moullin. 

2.  Diagnosis  and  Treatment  of  Some  Common  Inflamma- 

tory Affections  of  the  Eye,  from  the  Standpoint  of 
the  General  Practitioner,  By  E.  E.  Henderson. 
5.  Remark  on  Partial  Thyreoidectomy,  with  Special  Ref- 
erence to  Exophthalmic  Goitre,  and  Observations  on 
113  Operations  under  Local  Anjesthesia, 

By  T.  P.  DuNHiLL. 

4.  A  Contribution  to  the  Surgery  of  Lingual  Thyreoids, 

By  William  Stuart-Low. 

5.  Note  on  the  Removal  of  Portions  of  Doubtful  Tumors 

for  Diagnostic  Purposes,        By  Archibald  Leitch. 

6.  The  Incidence  of  ^Iorgan"s  Bacillus  No.  i  in  the  Nor- 

mal Fasces  of  Young  Children, 

By  J.  W.  H.  Eyre  and  E.  P.  Minett. 

7.  The  Employment  of  lodipin  in  Syphilis, 

By  Douglas  Freshwater. 

8.  Prostate  AVeighing  Seventeen  Ounces  Removed  by  the 

suprapubic  Route,  By  Andrew  Fullerton. 

I.  Cancer  of  the  Prostate. — Moullin  observes 
that  cancer  of  the  prostate  is  always  of  the  glandular 
type.  It  may  be  either  hard  or  soft.  The  former 
is  much  the  more  common.  The  growth  mav  or- 
iginate either  in  a  normal  gland  or  in  one  that 
has  already  been  the  seat  of  enlargement  for  years 
past.  In  either  case,  it  rapidly  infiltrates  the  tissue 
around,  flattening  the  outlying  parts  to  some  ex- 
tent against  the  inner  surface  of  the  capsule,  and 
only  penetrates  the  capsule  itself  at  a  comparatively 
late  period.  The  direction  of  the  growth  is  almost 
always  upward,  along  the  course  of  the  ejaculatory 
ducts — which  may  be  found  plugged  with  columns 
of  cancer  cells- — filling  up  the  intervesicular  space, 
and  spreading  from  there  along  the  lymphatics  into 


the  trigone  of  the  bladder.  From  thence  it  grows 
outward  toward  the  walls  of  the  pelvis  on  either 
side.  The  urethra  may  be  compressed  at  an  early 
date,  or  not,  according  to  the  position  and  direc- 
tion of  the  growth,  but  it  rarely  becomes  actually 
involved  until  late.  The  soft  variety  is  an  excep- 
tion, as  this  very  soon  spreads  into  the  neck  of  the 
bladder,  sprouting  out  as  a  fungating,  irore  or  less 
villous  mass.  The  internal  iliac  and  then  the  other 
pelvic  glands  are  the  first  to  become  infected.  As 
these  can  hardly  be  felt,  even  when  they  are  con- 
siderably enlarged,  and  not  at  all  when  the  infection 
is  only  recent,  it  is  very  difficult  to  ascertain  when 
this  takes  place.  In  many  instances  there  is  rea- 
son to  believe  that  it  is  not  till  very  late.  The  mi- 
croscopic appearances  in  cancer  of  the  prostate  may 
be  characteristic,  but  in  many  instances  they  are 
so  varied  and  so  complicated  by  those  due  to  pre- 
existing enlargement  and  chronic  inflammation  that 
a  very  exhaustive  examination  is  required  before  a 
definite  opinion  can  be  formed. 

2.  Chronic  Inflammatory  Diseases  of  the  Eye. 
— Henderson  speaks  of  conjunctivitis,  iritis,  includ- 
ing cyilitis,  and  acute  glaucoma.  There  are  three 
main  principles  underlying  the  treatment  of  all  vari- 
eties of  conjunctivitis :  First,  the  due  recognition 
of  the.  cantagious  nature  of  the  discharge.  This 
must  be  impressed  on  the  patient  and  his  friends 
or  attendants.  Nothing  that  has  been  contaminated 
by  the  discharge  must  be  allowed  to  be  used  by  any 
one  else.  Should  some  of  the  discharge  be  conveyed 
by  a  splash  or  in  some  other  way  to  the  eye  of  an 
attendant  or  surgeon,  it  must  be  immediately  re- 
moved by  free  irrigation  with  one  per  cent,  boric 
acid  lotion,  and  the  irrigation  should  be  followed 
by  the  instillation  of  a  few  drops  of  twenty  per 
cent,  protargol.  In  the  more  severe  purulent  cases 
the  patient  should  be  completely  isolated,  and  steps 
taken  to  protect  the  second  eye.  should  only  one  eve 
be  afifected  when  the  patient  comes  under  observa- 
tion. The  second  main  principle  is  to  provide  for 
the  due  removal  of  all  secretion,  and  to  prevent  the 
gumming  of  the  lids,  which  by  closing  the  palpebral 
fissure  converts  the  conjunctival  sac  into  a  closed 
cavity.  Thirdly,  we"  attempt  to  destroy  the  vitality 
of  the  microorganisms  that  are  producing  the  dis- 
ease by  the  application  of  certain  chemical  agents 
such  as  silver  nitrate,  boric  acid  as  solution  or  oint- 
ment, zinc  sulphate,  etc.  The  treatment  of  iritis 
must  be  local  and  general.  The  essential  of  the 
local  treatment  is  to  dilate  the  pupil  and  to  keep 
it  dilated.  For  this  purpose  atropine  ointment  is 
used,  I  per  cent.,  combined  with  0.5  per  cent,  co- 
caine, for  the  first  three  days.  The  cocaine  acts  as 
a  direct  stimulant  to  the  sympathetic  nervous  mech- 
anism of  the  pupillodilator  fibres,  and  so  increases 
the  efifect  of  the  atropine,  which  acts  chiefly  by  dim- 
inishing the  hypersemia  and  paralyzing  the  constric- 
tor pupillse.  The  use  of  cocaine  is  deleterious  to  the 
corneal  epithelium,  and  should  be  discontinued  as 
soon  as  the  maximum  dilatation  is  obtained.  The 
ointment  should  be  employed  every  four  hours  at 
first ;  later,  as  the  disease  yields  to  treatment,  atro- 
pine without  cocaine,  applied  two  or  three  times 
daily,  will  suffice  to  keep  the  pupil  dilated.  Hot 
fomentations  or  bathings,  or  dry  heat  supplied  from 
a  Japanese  muff  warmer,  diminish  the  pain  and  act 
beneficially.    In  all  severe  cases  a  couple  of  leeches 


I'lTH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


applied  to  the  temple  are  of  great  service.  If  high 
tension  persist,  paracentesis  should  be  done,  and, 
if  necessary,  repeated.  The  general  treatment  is  that 
of  the  condition  to  which  the  iritis  is  due.  All 
sources  of  sepsis,  and  more  especially  the  mouth, 
must  receive  energetic  treatment.  In  all  cases  of 
acute  primary  glaucoma,  iridectomy  should  be  per- 
formed as  soon  as  conveniently  possible. 

7.  lodipin  in  Syphilis. — Freshwater  enumer- 
ates the  advantages  and  disadvantages  of  iodipin. 
It  is  often  necessary  to  give  a  long  course  of  iodine 
to  patients  who  are  unwilling  to  take  iodide  either 
from  its  lowering  effects  or  that  they  are  the  sub- 
jects of  iodism.  All  the  iodipin  injected  is  used  up 
and  must  exert  its  specific  action ;  an  exact  dosage 
is  therefore  possible.  Injections  are  painless,  and 
there  is  no  fear  of  sepsis  if  proper  precautions  have 
been  taken.  Subcutaneously  it  does  not  produce 
iodism.  Patients  who  have  an  idiosyncrasy  to 
potassium  iodide  can  take  it  quite  well.  Patients  re- 
main much  longer  under  the  influence  of  iodine  than 
when  iodine  is  given  in  other  forms.  After  a  short 
course  of  injections  the  system  can  be  kept  for  a 
period  of  four  to  six  months  under  the  influence  of 
iodine.  The  body  is  under  a  slow,  continuous  reg- 
ular action  of  iodine,  which  is  of  prophylactic  value. 
In  nearly  all  cases,  after  a  prolonged  course  of 
potassium  iodide,  there  are  stomach  and  bowel 
troubles.  This  does  not  occur  with  iodipin.  It  has 
a  specific  action  in  tertiary  syphilis  and  arterial  de- 
generation. The  disadvantages  to  the  use  of  iodi- 
pin may  be  brieflv  summarized  as  follows :  In  cases 
of  syphilis,  when  a  rapid  therapeutic  effect  of  iodine 
is  required,  iodipin  is  of  little  use,  as  the.  absorp- 
tion of  iodipin  is  extremely  slow,  two  to  ten  days 
elapsing  before  the  iodirre  can  be  definitely  demon- 
strated in  the  urine,  so  that  in  cases  in  which  there 
is  a  threatened  perforation  of  the  palate,  cerebral 
gumma,  etc.,  potassium  iodide  should  be  given, 
lodipin  is  not  a  substitute  for  potassium  iodide 
when  active  lesions  are  in  progress.  A  further  dis- 
advantage is  that  only  a  small  amount  of  iodipin 
can  be  absorbed  per  diem,  about  one  third  what 
would  be  given  in  the  ordinary  way  by  the  mouth. 
This  can,  however,  be  turned  to  account  in  various 
ways.  For  example,  in  tertiary  syphilis,  after  potas- 
sium iodide  has  been  administered  somewhat  vigor- 
ously, a  course  of  iodipin  injections  may  be  given, 
and  the  ])atient  may  then  be  left  without  medicine 
for  some  months,  cluring  which  time  the  physician 
knows  that  iodine  is  daily  passing  through  his  tis- 
sues. 

THE  LANCET. 

May  22,  iQog. 

1.  'I'lic  Classification  and  Nomenclature  of  Diseases,  with 

Remarks  on  Diseases  due  to  Treatment. 

By  H.  D.  RoLLESTON. 

2.  The  Treatment  of  Chronic  Disease  of  the  Heart, 

Ky  F.  J.  Wethered. 

3.  Notes  on  the  Effect  of  Radium  in  Relation  to  Some 

Pathogenic  and  Nonpathogenic  Bacteria, 

15y  C.  v..  Ikkdei.i.  and  E.  P.  Mi  next. 

4.  The  Therapeutic  Effects  of  Radium  Emanations  in 

Some  Diseases  of  the  Skin, 

By  H.  Radci.iffe  Crocker. 

5.  The  Electrocardiograni  of  Man  and  of  the  Dog  as 

Shown  hv  Einthovcn's  String  Galvanometer, 

By  A.  D.  Waller. 

6.  The  Cause  of  Death  after  Operation  in  Acute  Appen- 

fhciti;,  By  Charles  Morton. 


7.  Prostatic   Calculi :    Three   Cases   Illustrating   a  New 

Method  for  their  Successful  Removal  by  the  Com- 
bined Suprapubic  and  Perineal  Routes, 

By  J.  Lynn  Thomas. 

8.  Case  of  Double  Pneumonia  after  Childbirth  ;  Pulmon- 

ary Infarcts;  Injections  of  Vaccine  of  Mixed  Pneu- 
mococci;  Recovery,  By  George  B.  Batten. 

9.  Disappearance  of  a  Tumor  (Sarcoma)  following  In- 

jections of  Coley's  Fluid, 

By  Wallace  C.  G.  Ashdowne. 

10.  A  Note  on  Normal  Menstruation  with  Absence  of  the 

Body  of  the  Uterus,  By  Alexander  Brown. 

2.  Treatment  of  Chronic  Diseases  of  the  Heart. 

— Wethered,  in  speaking  of  the  symptomatic  treat- 
ment, says  the  most  important  condition  probably 
is  insomnia.  Want  of  sleep  is  a  common  symptom 
in  heart  failure,  and  if  rest  is  procured  great  re- 
lief will  often  follow.  Simple  means,  such  as  change 
of  position,  bathing  the  face  with  warm  water,  a 
handkerchief  over  the  eyes,  or  a  little  warm  drink 
may  be  tried.  Frequently,  however,  a  hypnotic  will 
be  necessary.  After  trying  many,  he  has  found 
chloral  amide  dissolved  in  rectified  spirit  the  most 
favorable,  commencing  with  20  grains  and  push- 
ing it  up  to  70  grains  if  necessary.  Veronal  in  2 
to  7  grain  doses  may  also  be  tried,  but  must  be 
given  with  caution.  Sulphonal  or  trional  are  not 
so  good.  Paraldehyde  is  sometimes  useful.  In 
some  instances  opium  or  morphine  must  be  resorted 
to,  the  chief  contraindication  being  pulmonary  en- 
gorgement. Palpitation  may  be  caused  by  the  car- 
diac condition  or  by  digestive  disturbance.  Strych- 
nine, nux  vomica,  or  digitalis  may  be  necessary,  but 
in  many  cases  the  bromides  are  the  most  useful 
drugs.  If  indigestion  cannot  be  remedied  by  diet, 
relief  may  be  obtained  by  the  use  of  drugs  as  wn- 
ally  prescribed  in  dyspepsia.  If  there  is  undue 
fermentation  he  has  found  takadiastase  a  usef  il 
preparation.  BismAith  in  the  liquid  form,  given  with 
nux  vomica,  may  also  be  tried. 

3.  Radium  in  Relation  to  Bacteria.  —  Iredell 
and  Minett  have  made  experiments  to  determine  the 
direct  action  of  radium  on  various  cultures  and  or- 
ganisms as  regards  their  capacity  for  growth,  chem- 
ical properties,  staining  reactions,  and  also  motil- 
ity, after  being  exposed  for  varying  periods  of  time 
to  the  direct  action  of  radium  emanations.  The  first 
experiment  was  conducted  with  a  view  to  ascertain 
the  capacity  for  growth  of  organisms  after  exposure 
to  radium  rays,  and  also  to  observe  any  nossible 
effect  on  the  media  used.  Plates  of  nutrient  agar 
were  poured  and  dried  for  one  hour  in  the  incu- 
bator at  42°  C.  After  cooling,  a  loopful  of  a  twenty- 
four  hours'  broth  culture  of  Bacillus  pyocyaneus 
was  spread  evenly  over  the  surface  of  each  of  these 
plates.  The  radium  was  now  applied  directly  to 
the  surface  of  the  inoculated  media,  for  ten  min- 
utes, twenty  minutes,  and  si.xty  minutes  respective- 
ly. After  exposure  a  sterile  platinum  loop  was  rub- 
bed over  the  exposed  area  and  a  sloped  tube  of 
nutrient  agar  was  inoculated  with  the  loop.  Both 
the  tubes  and  plates  were  now  inoculated  with 
twenty-four  hours  at  37°  C.  and  examined  for 
growth,  the  exposed  and  unexposed  areas  on  the 
plates  being  carefully  compared  ;  three  cover  slides 
were  prepared  from  the  exjxjsed  and  unex])osL'd 
areas  on  the  plates,  also  from  the  tube  growth. 
These  were  each  stained  by  weak  carbolfuchsin, 
carbolmethylcne  blue,  and  by  Gram's  method.  Ai- 


June  12,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


1239 


ter  careful  comparison,  no  difiference  whatever 
conld  be  detected  in  the  capacity  of  the  orcranism 
to  take  the  various  stains  after  exposure,  its  ca- 
pacity for  growth  and  reproduction  was  unimpaired, 
as  also  was  the  amount  of  pyocyanin  diffused  into 
the  media.  Anthrax  culture.  Staphylococcus  aureus, 
Bacillus  siibtilis,  Bacillus  colis  communis,  etc.,  were 
treated  the  same  way  without  showing  any  changes. 
Other  experiments  were  made  with  the  Bacillus 
typhosus  as  to  the  influence  of  radium  rays  on  its 
motility  and  agglutinating  powers.  A  slight  increase 
of  motility  was  observed  after  fifteen  minutes  ex- 
posure, but  after  thirty  and  sixty  minutes'  exposure 
no  difference  whatever  could  be  detected. 

9.  Disappearance  of  a  Tumor  (Sarcoma?)  fol- 
lowing Injections  of  Coley's  Fluid. — Ashdowne 
reports  such  a  case  in  a  woman,  forty-five  years  of 
age.  She  had  a  fusiform  swelling  of  regular  out- 
line and  well  defined  limits  in  connection  with  the 
lower  part  of  the  right  humerus  with  no  suspicion 
of  fluctuation  or  egg  shell  crackling  about  it,  the 
skin  and  muscles  were  not  implicated,  but  the  su- 
perficial veins  were  a  little  prominent  and  there  was 
an  enlarged  gland  in  the  right  axilla.  The  arm  was 
wasted  and  the  muscles  were  weaker  than  those  of 
the  opposite  side ;  the  movements  of  the  elbow 
joint  were  unimpaired.  Pain  was  only  complained 
of  when  using  the  arm  or  on  applying  firm  pressure. 
No  other  bone  abnormality  could  be  made  out. 
There  was  no  history  of  injury  or  of  fracture,  and 
the  question  of  syphilis  was  carefully  gone  into,  but 
no  evidence  of  it  could  be  obtained.  Treatment  with 
Coley's  fluid  was  given.  He  began  with  half  minim 
doses  and  increased  them  by  quarter,  half,  and  ons 
minim  until  -  a  maximum  of  nine  minims  was 
reached;  the  first  injections  were  given  into  the  arm 
outside  the  limits  of  the  growth,  but  the  later  ones 
were  injected  into  it,  and  twenty-three  injections  in 
all  were  given.  They  were  followed  by  pain  and 
swelling  at  seat  of  injection,  with  general  malaise, 
headache,  nausea,  vomiting,  and'  pains  in  the  limbs 
and  joints  followed  by  the  appearance  of  subcu- 
taneous hjemorrhages  resembling  bruises,  but  with 
only  slight  rise  of  temperature  and  increase  of 
pulse  rate.  These  after  effects  were  very  unpleas- 
ant. The  swelling  disappeared  and  the  structure  and 
outline  of  the  bone  resumed  its  normal  appearance. 

LA  PRESSE  MEDICALE. 

April  14,  igog. 

1.  Traumatic   Nephritis  with  a  Unilateral   CEdema  and 

Secondary  Lesions  in  the  Other  Kidney, 

By  Klippel  and  E.  Chabrol. 

2.  The  Course  of  the  Deep  Wound  of  the  Abdomen,  Pro- 

duced in  War  by  Small  Calibre  Projectiles, 

By  J.  DocHE. 

3.  A  iSiew  Therapeutical  Method, 

Bv  Rene  de  Gaulejac. 

4.  Syphilitic  Infection  or  Mercurial  Intoxication? 

By  G.  Loygue. 

5.  On  the  Treatment  of  Cancer  by  Fulguration, 

By  J.  A.  Riviere. 

I.  Traumatic  Nephritis. — Klippel  and  Chabrol 
report  a  case  in  which  traumatic  nephritis  developed 
immediately  after  the  accident.  A  month  later  there 
appeared  oedema  of  the  left  arm,  which  spread  three 
days  later  to  the  breast  of  the  left  side,  the  injured 
side.  This  oedema  was  accompanied  with  severe 
pain  in  the  lumbar  region  and  albuminuria.  Finally 


nephritis  developed  also  in  the  previous  healthy  kid- 
ney, and  the  patient  died  about  eight*'weeks  after  the 
accident.  The  autopsy  proved  the  correctness  of 
the  diagnosis. 

April  ij,  igog. 

1.  Amyloid  Degeneration  of  the  Kidneys  from  the  Patho- 

genic and  Practical  Standpoint,       By  J.  Castaigne. 

2.  Semiological  Value  of  Apraxia,  • 

By  G.  Dromard  and  Miss  Pascal. 

I.     Amyloid  Degeneration  of  the  Kidneys. — - 

Castaigne  states  that  in  a  case  of  purulent  pleurisy 
complicated  with  intense  albuminin-ia,  the  organism 
tries  to  expel  or  destroy  a  foreign  albumin  intro- 
duced into  the  body  by  the  pus,  which  has  not  the 
same  composition  as  the  albumin  of  the  blood.  The 
elimination  of  this  foreign  albumin  in  purulent  pleu- 
risv  takes  place  through  the  kidneys  or  intestines, 
and  this  forced  elimination  will  finally  produce  par- 
ench}-matous  nephritis,  with  chronic  nephritis  as  se- 
quel, but  only  in  such  cases  in  which  the  pleura  re- 
tains its  absorbing  power ;  if  this  absorbing  power 
of  the  pleura  is  nil  the  circulation  is  protected 
against  an  attack  of  the  foreign  albumin.  But  as 
the  kidneys  retain  their  permeability,  which  is  some- 
times increased,  it  is  not  necessary  to  suppress  the 
nitrogen  in  the  food  ;  a  food  rich  in  albuminoids, 
even  in  the  form  of  meat,  should  be  given  to  com- 
pensate for  the  losses  of  the  organism  :  it  is  neces- 
sary to  avoid  only  sodium  chloride  and  albumins  dif- 
ficult of  digestion,  such  as  the  white  of  a  raw  egg. 
He  comes  to  the  conclusion  that  cases  in  which  the 
amyloid  degeneration  is  the  sequel  of  an  acute  con- 
dition, are  not  absolutely  fatal.  If  the  pleural  ab- 
sorption can  be  stopped  the  changes  in  the  kidneys 
can  be  cured,  as  it  is  only  an  acute  attack  without 
cachexia. 

April  31,  1909. 

1.  Orchiepididymitis  from  Staphylococcus  Infection. 

By  Professor  Quenu. 

2.  Diagnosis  of  Facial  Neuralgia,  By  J.  A.  Sicard. 
,3.    The  Immunizing  Bodies  of  Carl  Spengler, 

By  Andre  Bergeron. 

3.  Spengler's  Immunizing  Bodies. — Bergeron 
reviews  Spengler's  theory  of  antituberculous  bodies. 
Spengler's  theory  is  the  following :  A  tuberculous 
patient  has  always  been  attacked  by  the  two  types 
of  tubercle  bacilli,  the  human  as  well  as  the  bovine ; 
but  one  of  these  is  always  prevalent,  in  fact  they  pos- 
sess antagonistic  properties.  It  will,  therefore,  be- 
come only  necessary  to  stimulate  the  predominant 
type  through  tuberculin  or  vaccine.  Spengler  has 
found  a  product,  called  Immun  Kbrper,  which  is  a 
cellular  extract  from  the  blood  of  animals,  immun- 
ized against  both  types  of  tubercle  bacilli.  The  anti- 
bodies are  to  be  found  in  the  red  blood  corpuscles 
and  not  in  the  serum.  Spengler  and  others  report 
very  favorable  results  with  his  product,  while  Ber- 
geron's own  experience  has  not  been  large  enough, 
but  is  encouraging. 

MEDIZINISCHE  KLINIK. 

April  18,  iQog. 

1.  Muhiple  Acute  Periostitis,  By  R.  von  Jaksch. 

2.  Chronic  Intermittent  Albuminuria  as  a  Sequel  to  Infec- 

tious Diseases  of  the  Kidney, 

By  Hermann  Eichhorst. 

3.  Test  of  the  Function  of  the  Pancreas  by  Determination 

of  the  Trypsin  in  the  Faeces, 

By  Eduard  MiJLLER  and  Heinrich  Schlecht. 


1240 


NEIV  INVENTIONS. 


[New  York 
Medical  Journal. 


4.    Pulsus   Exspiratione  Intermittens.     Exspiratio  Aneu- 
rysmatis  Pulsatione  Sacc-ata,  B\-  N.  Ortner. 

3.    Organic  Demineralization  as  a  Characteristic  of  Soil 
Infected  with  or  Accessible  to  Tuberculosis, 

By  Albert  Robin. 

6.  The  Spontaneous  Separation  of  Nitrogen  and  Mineral 

Salts  in  the  Intestine  under  Normal  and  Pathological 
Conditions,  By  H.  Salomon  and  G.  Wallace. 

7.  Metabolism   of   Mineral    Substances   in   Early  Child- 

hood, By  L.  F.  Meyer. 

8.  Experiments  on  Frogs  with  Cardiac  Remedies. 

By  Hermann  Freund. 

g.    Theory  of  Evolution  in  Modern  Geology. 

By  F.  Frech. 

1.  Multiple,  Acute  Periostitis. — Von  Jaksch 
reports  in  cxtcnso  a  case  which  shows  there  exist 
acute  forms  of  this  af¥ection  which  may  recover  as 
well  as  chronic  forms  that  are  fatal.  It  is  very  prob- 
able that  the  clinical  picture  presented  has  hitherto 
always  been  confounded  with  that  of  acute  articular 
rheumatism,  which  it  greatly  resembles,  and  from 
which  it  is  to  be  distinguished  by  the  appearance  of 
eosinophilia,  myelocythasmia,  and  multiple  periosteal 
afifections. 

2.  Chronic  Intermittent  Albuminuria  as  a 
Sequel  to  Infectious  Diseases  of  the  Kidney. 

— Eichhorst  reports  the  case  of  a  young  man,  twen- 
ty-one years  of  age.  who  had  suffered  for  eight 
years  from  intermittent  albuminuria  that  appeared 
as  a  sequel  to  an  attack  of  nephritis  caused  by  scar- 
let fever. 

3.  Test  of  the  Function  of  the  Pancreas. — 

Rliiller  and  Schlecht  cleanse  the  lower  bowel,  give  a 
test  meal  and  half  an  hour  later  a  purge,  triturate 
the  resulting  stool  as  thin  as  possible,  alkalinize  with 
soda  and  dilute  with  certain  quantities  of  ten  per 
cent,  glycerin  water,  divide  a  serum  plate  into  eight 
sectors,  to  one  of  which  the  undiluted  stool  is  ap- 
plied, to  sectors  two  to  seven  various  dilutions  of 
the  stool,  to  the  eighth  sector  a  solution  of  trypsin 
for  a  control,  and  place  in  the  incubator  at  a  temper- 
ature of  from  50  to  60°  C.  for  twenty-four  hours. 
Positive  results  can  be  noted  at  the  end  of  half  an 
hour,  but  a  negative  result  is  certain  only  at  the  end 
of  twenty-four  hours. 

5.  Organic  Demineralization. — Robin  says  that 
his  studies  concerning  the  peculiar  conditions  of  tu- 
berculous soil  have  brought  two  characteristics  to 
the  front,  viz.,  the  acceleration  of  the  respiratory 
metabolism  and  the  organic  demineralisation.  Re- 
garding the  latter  he  presents  the  groundwork  of 
his  evidence,  replies  to  objections  that  have  been 
raised,  and  then  passes  to  the  compositioti  of  the 
blood,  the  excretion  of  lime  and  tuagnesia,  the  de- 
mineralization of  the  lungs  and  bones,  and  finallv 
considers  the  causes  and  pathogenic  importance  of 
the  demineralisation. 

7.  Metabolism  of  Mineral  Substances  in  Early 
Childhood. — Meyer  says  that  mineral  substances 
have  a  two  fold  duty  in  the  growing  organism,  first 
to  furnish  as  in  adults  the  necessary  means  for  the 
vital  processes,  second  to  form  the  necessary  mate- 
rial for  the  building  up  of  new  cell  territories.  The 
results  of  his  studies  he  sketches  under  three  heads: 
Salt  metabolism  and  the  process  of  nutrition  ;  rickets 
and  salt  metabolism  ;  and  tetany  and  salt  metabolism. 
Under  the  first  he  deals  with  the  general  need  of 


mineral  substances  in  nutrition,  in  the  second  he 
finds  rickets  due  to  three  possibilities ;  the  organism 
receives  too  little  lime  with  its  nourishment,  the  or- 
ganism receives  sufficient  lime  in  its  food,  but  a  suf- 
ficient quantity  is  not  absorbed,  or  too  much  is  ex- 
creted, and  while  sufficient  lime  is  present  the  bones 
are  not  able  to  take  it  up  because  of  disturbed  cell 
activity  and  lessened  power  of  absorption  of  lime  on 
the  part  of  the  bones.  Tetany,  he  thinks,  probably 
due  to  an  anomaly  of  the  salt  metabolism. 

 <$>  


Inljentroits. 

A  NEW  SOUND. 
By  Charles  Edward  Panoff,  M.  D., 
Brooklyn, 

Genitourinary  Surgeon.  Williamsburg  Hospital;   Instructor,  (ienito- 
urinary  and  Venereal  Diseases,  Brooklyn  Postgraduate  School. 

Part  of  the  proceedings  in  the  passage  of  sounds, 
is  to  irrigate  the  bladder  and  urethra  with  a  solu- 
tion of  silver  nitrate  in  varying  strengths  after  the 
withdrawal  of  the  sounds. 


V, 


Fig.  1. — Front  view  of  sound;  a,  handle  of  obturator;  b,  end  for 
tubing  to  be  attached;  c,  opening. 

I  have  found  a  great  many  cases  where  it  was 
impossible  to  fill  the  bladder  with  any  of  the  solu- 
tion on  account  of  a  spasmodic  condition  of  the  cut 
off  muscle,  and  in  every  instance  where  I  tried  to 
force  the  luuscle  the  result  has  been  bleeding  in 
varying  degree.  To  overcoiue  this  condition  I  have 
devised  a  tunneled  sound,  and  by  its  use  I  have 
overcome  these  disadvantages. 

The  sounds  as  shown  by  the  illustrations  Figures 

1  and  2  are  made  in  three  parts :  Part  i  consists 
of  the  sound  proper  from  ^  to  5  and  is  solid ;  part 

2  consists  of  the  sound  proper  froTri.5  to  C  and  is 
hollow,  and  has  the  opening  through  which  the  fluid 
enters  the  bladder ;  part  3  consists  of  the  obturator 
which  fits  over  the  opening  in  part  2. 


Fig. 


-Cross   section    of   sound    with    obturator   in  position; 
arrow  shows  opening. 


The  sounds  are  graded  and  passed  just  as  the 
ordinary  ones.  As  soon  as  the  .sound  is  in  position, 
(the  opening  of  the  sound  must  be  just  beyond  the 
neck  of  the  bladder  as  shown  in  Fig.  3)  the  obturator 
is  removed,  the  tubing  is  attached,  and  the  bladder 
filled,  the  amount  of  fluid  used  varying  with  the 
capacity  of  the  bladder.  .After  the  bladder  is  filled, 
the  tubing  is  removed,  the  obturator  is  replaced. 


June  12,  1909.] 


BOOK  NOTICES. 


1241 


and  the  sound  withdrawn.    Now,  the  patient  is  re- 
quested to  urinate,  and  the  operation  is  completed. 
The  irrigator  should  be  raised  about  a  foot  above 


Fig.  3. — Showing  so\md  in  position,  with  opening  of  sound  just 
beyond  the  neck  of  the  bladder;  a.  irrigator;  b.  tubing;  c, 
sound;  d,  prostate;  e,  rectum;  /,  opening;  g,  bladder. 

the  level  of  the  patient  so  that  too  great  an  amount 
of  pressure  should  not  be  used. 
1 73 1  St.  Mark's  Avenue. 

 <^  

[IV e  publish  full  lists  of  books  received,  but  ■^x.'e  acknowl- 
edge no  obligation  to  revieiv  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


A  Textbook  of  Materia  Medica,  Pharmacology,  and  Thera- 
peutics. By  George  F.  Butler,  A.  AI.,  Ph.  G..  M.  D., 
Professor  and  Head  of  the  Department  of  Therapeutics 
and  Professor  of  Preventive  and  Clinical  Medicine,  Qii- 
cago  College  of  Medicine  and  Surgery,  etc.  Sixth  Edi- 
tion, Thoroughly  Revised  and  Enlarged.  Philadelphia 
and  London  :  W.  B.  Saunders  Company,  1908.    Pp.  708. 

Butler's  Materia  Medica  appeared  for  the  first 
time  in  1896  and  was  reviewed  by  us  at  that  time 
(see  A'czv  York  Medical  Journal,  December  19, 
1896.  p.  821).  The  author  has  been  an  instructor 
in  therapeutics  and  clinical  medicine  for  over  twen- 
ty years  and  has  thus  acquired  a  great  experience, 
both  as  a  teacher  and  as  an  investigator.  He  is 
fully  acquainted  with  the  subject  and  the  points  of 
interest  to  students. 

Coinpared  with  the  first  edition,  the  book  has  been 
vastly  improved.  After  a  short  introduction,  in 
which  the  author  speaks  of  pharmacology  and  gen- 
eral therapeutics,  we  find  the  pharmaceutical  prepa- 
rations, which  are  classified  according  as  they  are 
solutions,  liquid  mixtures,  extractive  preparations, 
solid  mixtures,  preparations  for  external  use,  etc. 
The  author  then  treats  of  the  drugs  in  their  dis- 
tinctive actions,  as  on  the  nervous  system,  the  cir- 
culatory organs,  the  vasoconstrictors,  etc.    He  men- 


tions all  the  official  remedies  to  be  found  in  the 
eighth  edition  of  the  Phariiiacopa^ia  of  the  United 
States,  and  also  a  few  nonofficial  remedies  which 
have  been  accepted  as  of  sufficient  importance.  The 
chapter  on  opsonins  is  new.  The  work  concludes 
with  a  chapter  on  prescription  writing  and  an  index. 

Lehrbuch  dcr  Hebammenkunst.  Von  Dr.  Berxhard  Sig- 
MUXD  ScHULTZE,  wirkl.  geheimer  Rat,  ord.  Professor  der 
Geburtshilfe  zu  Jena.  Vierzehnte,  verbesserte  Auflage. 
Mit  103  Abbildungen.  Leipzig:  Wilhelm  Engelmann, 
1908.    Pp.  XXX-404.    (Price,  7  Mk.) 

Schultze's  book  on  the  science  of  midwifery  is 
well  known  in  Germany.  It  appeared  for  the  first 
time  nearly  fifty  years  ago — to  be  exact,  in  i860 — 
and  thus  well  represents  the  history  of  the  science 
of  midwifery  for  nearly  half  a  century.  It  contains 
over  a  hundred  illustrations,  and  is  divided  into 
seven  parts,  each  of  which  comprises  a  number  of 
chapters.  Part  one  treats  of  the  human  anatomy 
and  physiology,  especially  of  the  mother  and  infant ; 
in  parts  two,  three,  and  four  are  to  be  found  normal 
pregnancv,  birth,  and  the  after  treatment  of  mother 
and  infant ;  while  parts  five,  six,  and  seven  deal  with 
the  abnormal  conditions.  In  an  appendix  the  author 
speaks  of  the  duties  of  a  midwife,  the  German  laws 
pertaining  to  midwifery,  etc.  The  book  is  well  writ- 
ten, clear,  and  without  unnecessary  scientific  excur- 
sions, and  fulfills  the  expectations  gained  from  the 
title. 

The  Methods  and  Scope  of  Genetics.  An  Inaugural  Lec- 
ture Delivered  23  October,  1908.  By  W.  Bateson,  AL  A., 
F.  R.  S.,  Professor  of  Biology  in  the  University  of  Cam- 
bridge. Cambridge :  University  Press,  1909.  Pp.  i-49. 
(Price,  500.) 

The  author's  professorship,  he  says,  "though 
bearing  the  comprehensive  title  'of  biology,'  is 
founded  with  the  understanding  that  the  holder 
shall  apply  himself  to  a  particular  class  of  physio- 
logical problems  the  study  of  which  is  denoted  by 
the  term  genetics."  It  seems  to  us  that  the  uni- 
versitv  has  not  been  wise  to  accept  the  foundation 
of  so  broad  a  professorship  with  such  a  narrow  re- 
striction. What  is  here  dignified  with  the  name  of 
"genetics"  seems  to  be  not  much  more  exalted  than 
the  application  of  stock  breeder's  lore  (with  some 
expected  elaboration)  to  the  laws  of  heredity,  but 
a  few  interesting  facts  are  stated  in  the  lecture. 

Disease  of  the  Pharynx  and  Larynx.  By  Dr.  E.  J.  AIoure, 
Surgeon  in  Charge  of  the  Nose,  Ear,  and  Throat  Depart- 
ment of  the  Faculty  of  Medicine,  Bordeaux.  Translated 
and  Adapted  by  J.  ALvlcolm  Farquharsox.  M.  B..  F.  R. 
C.  P.,  Edin.,  Lecturer  on  Diseases  of  the  Xose,  Ear,  and 
Throat  in  the  School  of  Medicine  of  the  Royal  Colleges, 
Edinburgh,  etc.  With  210  illustrations.  New  York: 
Rebman  Companj-,  1909. 

As  an  elementary  practical  treatise.lNIoure's  work 
naturally  lays  most  stress  011  methods  of  clinical 
examination,  diagnosis,  and  treatment.  It  is  an  ex- 
cellent manual,  and  the  chapters  on  the  technique 
of  laryngoscopy  and  bronchoscopy  are  worthy  of 
special  mention  for  their  completeness  and  for  the 
unusually  instructive  way  in  which  the  subject  is 
presented  in  the  text  as  well  as  graphically  by  a 
large  number  of  excellent  illustrations.  The  rather 
complicated  conditions  in  vocal  cord  paralysis  are 
analyzed  so  clearly  and  so  well  elucidated  by  dia- 
grams that  they  cannot  fail  of  comprehension. 


1242  MEDJCOLITERARY  NOTES.— OFFICIAL  XEWS. 


MEDICOLITERARY  XOTES. 

Sufferers  from  Invidia  Medicorum,  if  indeed  any 
such  exist  in  this  irenic  century,  should  ponder  the 
words  of  Dean  Swift :  "Censure  is  the  tax  a  man 
pays  to  the  pubhc  for  being  eminent." 

Bacon,  in  his  A pothcgvis  pays  a  few  compliments 
to  the  medica*  profession ;  c.  g.,  there  was  a  painter 
who  became  a  physician,  whereupon  one  said  to 
him:  "You  have  done  well,  for  before  the  faults 
of  your  work  were  seen,  but  now  they  are  unseen." 

Luther  H.  Gulick's  Mind  and  Work  (Do.ible- 
day,  Page,  &  Co.)  is  a  collection  of  essays,  inter- 
esting alike  to  physician  and  layman,  in  which  is 
shown  forth  the  very  great  advantage  to  the  in.livid- 
ual  of  getting  hold  of  congenial  occupation.  The 
book  may  be  said  to  embody  what  has  come  to  be 
known  as  the  New  Thought,  shorn  of  its  mysticism 
and  other  quackish  attributes. 

The  Conservation  of  the  Defective  Child,  by 
Marion  Hamilton  Carter,  in  McClurc's  Magazine 
for  June  is  an  article  sure  to  interest  the  general 
practitioner.  It  shows  in  some  detail  how  children 
who  would  formerly  have  been  classed  indifferently 
as  "backward"  are  now  quickly  restored  to  a  normal 
level  by  such  simple  means  as  the  correction  of  er- 
rors of  refraction,  the  removal  of  adenoids,  etc. 

In  the  same  magazine  The  Animal  Mind  from 
the  Inside,  by  E.  T.  Brewster,  gives  considerable 
information  that  will  be  surprisingly  novel  to  many 
concerning  the  "mentality"  of  animals.  It  is  now 
concluded,  as  it  was  centuries  ago,  but  from  far 
different  premises,  that  animals  do  not  reason.  It 
is  surprising  to  learn,  too,  that  man  does  mucli  l^ss 
reasoning  than  he  fancies. 

Any  physician  with  half  an  hour  to  spare  might 
well  do  worse  than  pick  up  the  Red  Book  Magazine 
for  June  and  read  The  Awakening,  bv  Wood- 
ruff Xewell.  It  is  a  charming  psychological  stutly 
of  a  childless  and  consequently  unhappy  couple, 
brought  together  by  the  accidental  intrusion  into 
their  home  of  a  strange  baby.  Here  is  an  interest- 
ing therapeutic  hint  for  the  treatment  of  some  ex- 
tremely rare  but  important  cases  of  marital  in- 
felicity. 

The  Delineator  for  June  gives  its  readers  much 
good  advice  concerning  hygiene  and  care  of  the 
health.  The  physician  is  not  ignored,  as  is  often 
the  case  in  such  counsel,  and  his  aid  is  advised  in 
all  cases  of  doubt.  The  Child  Rescue  Campaign  is 
an  important  Charity  of  this  magazine.  The  object 
is  to  secure  good  homes  for  the  children  of  th?  asy- 
lums, and  the  enthusiasm  excited  among  childless 
couples  seems  'to  be  enormous.  It  seems  to  us 
that  a  childless  country  doctor  and  his  wife  would 
make  quite  ideal  guardians  for  one  of  these  little 
waifs.  Several  charming  pictures  of  candidates  for 
adoption  are  published  in  the  June  number.  Most 
of  them  are  Kinder  der  Liebe,  and  in  all  cases  full 
surrender  is  given. 

Collier's  Weekly  for  May  29th  contains  some  in- 
tere.sting  details  regarding  what  is  being  done  by 
the  manufacturers  of  Worcester,  Mass.,  for  the 
safeguarding  of  their  employees  against  tubercu- 


[New  York 
Medical  Journai.. 

lous  disease  and  their  treatment  free  of  cost  to 
them  if  attacked.  It  is  being  borne  in  upon  the 
business  world  that  it  is  worth  while  to  keep  work- 
men in  a  state  of  healthy  efficiency ;  so  economic 
considerations  are  solving  the  questions  of  tuber- 
culous infection  and  alcohol  that  have  so  long 
caused  anxiety  to  the  charitable  and  altruistic.  The 
same  journal  pays  high  tribute  to  a  certain  valua- 
able  type  of  physician  in  an  editorial  entitled  Ac- 
tion, the  apparent  sarcasm  of  the  article  being  for 
the  benefit  of  those  who  can  see  merit  in  work 
only  when  it  is  accompanied  by  trumpeting  noises. 

Bendy's  Sermon  appears  in  the  May  Strand  in 
facsimile  of  the  handwriting  of  the  author.  Sir 
Arthur  Conan  Doyle.  It  is  an  account  in  verse  of 
an  adventure  of  Bendigo,  once  a  famous  prize- 
fighter, "the  pride  of  Nottingham,"  who  subse- 
quently becomes  a  revivalist.  During  one  of  his 
sermons  he  is  interrupted  by  five  of  his  former 
ringmates  and  is  obliged  to  beg  a  few  moments  of 
the  Lord's  time  to  attend  to  this  personal  matter. 
He  descends  from  the  pulpit,  polishes  off  the  sacri- 
legious quintet  with  un  forgotten  art.  ranges  them 
in  a  row  in  the  front  pew,  and  returns  to  his  ex- 
hortations to  achieve  an  undistvu^bed  peroration. 
The  verse  is  easy  and  flowing,  but  will  not,  we 
think,  ever  help  our  distinguished  colleague  to  the 
laureateship. 


Public   Health   and    Marine    Hospital  Service 
Health  Reports : 

The  follo'icing  cases  of  suiallf>ox.  yclluzu  fever,  cliolcra. 
and  plague  have  been  reported  to  the  surgeon  general,  United 
Slates  Public  Health  and  Marine  Hospital  Service,  during 
the  ZL'eeli  ending  June  4,  loog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

Arizona — Winslow  .\pril  24-llay   i   i  I 

California — Los  Angeles  May   8-15   3 

California — San  Francisco  May  8-:5   i 

District  of  Columbia — Washington .  M ay   i5--'2   i 

Georgia — Atlanta  Jan.   I5-^[ay  21...'..  6-" 

Georgia — Macon  May   2-9   3 

Illinois — Danville  May    16-23   2 

Illinois — Springfield  May   14-21   i 

Kentucky — Covington  May   15-22   3 

Kentucky — Newport  May   15-22   i 

Massachusetts — Somerville  May   15-22   i 

Minnesota — Duluth  May   13-20   2 

Missouri — Kansas  City  May   15-22   2 

Montana — Rutte  May  6-20   11 

New  Jersey — New  Brunswick ....  May   1-22   5 

North  Carolina — State  of  .April    1-30  127 

Ohio — Columbus  May   15-22   i 

Ohio — Sandusky  May  8-15   i 

Pennsylvania — Philadelphia  May   14-21   i 

Pennsylvania— .Pittsburgh  May    15-22   i 

Utah — Stale  of  .\pril    1-30   37 

Virginia — Portsmouth  May   18-25   -  2 

Washington — Spokane  May    1-8   5 

Wisconsin — Milwaukee  May    15-22   2 

Smallpox — Insular. 

Philippine  Islands — Manila  \pril    10-17   9 

Smallpox — Foreign. 

.Africa — Kast  London  April    10-17   i  i 

.Algeria — Algeirs  .April    1-30   iS  Imported 

P.razil — Rio  de  Janeiro  March  29-.\pril  25...  44  26 

Urazil — .Sao  Paulo  April    5-1 1   i 

Canada — Halifax  May  8-15   2 

Canada — Toronto  April  24-May   15   5 

Canada — Yarmouth  May  22-29   2 

Ceylon — Colombo  March  27-April   17..  5  ^4 

China — .Amoy  .April  20   PresVnt 

Egypt — Cairo  .April    8-29   22  19 

India — Hombay  -April    20-27   -^o 

India — Calcutta  April    10-17   '71 


OFFICIAL  SEWS.  1243 


Tune  12.  1909.1 


Places.  Date.  Cases.  Deaths. 

India — Madras  April    17-23   ^ 

India — Rangoon  April    10-17   9 

Indo-China — Saigon  April   3-10   2  3 

Italy — Catania  Mev   1-8   i 

Italy — Naples  May  2-16   17  7 

Java — Batavia  .April    10-17   3 

Me.xico — Matamoras  May  8-15   i 

Me-vico — Monterey  May  9-16   10 

Mexico — Vera  Cruz  May  9-16   I 

Portugal — Lisbon  May  8-15   4 

Russia — Odessa  .\pril  24-May  i   i  i 

Russia — St.  Petersburg  .\pril    10-17   '3  5 

Russia — Warsaw  March  6-20   6 

Servia — Belgrade  May   1-8   10  2 

Spain — Barcelona  May  3-10   5 

Spain — Madrid  .\pril    1-30   30 

Spain — Vigo  May   1-8   i 

Yellow  Fever — Foreigr.. 

Barbados  May  8-15   i 

Brazil — Para  May   i-?   4  2 

Mexico — Merida  May  14   i  Imported 

Cholera — Insular. 

Philippine  Islands^ — Provinces  April    10-17  133  go 

ChoU'ra — Foreign. 

India — Bombay  .\pril    20-27   2^ 

India — Calcutta  .\;,ril    10-17  108 

India — Rangoon  .A' ril    10-17   5 

Russia — St.   Petersburg  May  7-14   15  7 

Plague — Foreign. 

Brazil — Rio  de  Janeiro  ilarch  27-.\pril  25..  3 

Chile — .Antotagasta  .\pril  17   9 

Chile — Iquique  _\pril   18   22 

Egypt — General  .\pril   16   29  ig 

German  East  .\mca — Muanza .... -April  14   60 

India — Genera!  -April  10-17  5-309  4»59+ 

India — Bombay  .April   20-27   508 

India — Calcutta  .April    10-17   90 

India — Rangoon  April    10-17   30 

Indo-China — Saigon  April   3-10   5  5 

Japan — Himeji  April  30   i  i 

Japan — Kobe  .April    17-24   2  ; 

Japan — Vokahama  -April  24-May  :   i 

Peru — Lima  -April   24-May    i   10  6 

Straits  Settlements — Singapore. .. -April    3-10   z 

Public  Health  and  Marine  Hospital  Service: 

Otncial  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  oificcrs  of  the  United  States  Public  Health 
and  Marine  Hospital  Sen-ice  for  the  seien  days  ending 
June  3.  igog:  • 

Ad-AMS.  F.  B.,  -\cting  .\ssistant  Surgeon.  Granted  twenty- 
one  days'  leave  of  absence  from  June  i.  1909. 

Bell.  J.  M..  Pharmacist.  Granted  thirty  days'  leave  of  ab- 
sence from  June  16.  1909. 

CoFER,  L.  E..  -Assistant  Surgeon  General.  Directed  to  pro- 
ceed to  Fortress  Monroe  and  Fisherman's  Island.  \"a.. 
upon  special  temporarj-  duty. 

GoLDBERGER.  JoSEPH.  Passed  -Assistant  Surgeon.  Directed 
to  proceed  to  Woods  Hole.  Mass.,  on  or  about  June  25. 
1909.  upon  special  temporarj'  dutj'. 

Grltsbs.  S.  B..  Passed  Assistant  Surgeon.  Directed  to  pro- 
ceed to  La  Guaira,  Venezuela,  upon  special  temporarj- 
duty. 

Hu-VT.  Reid,  Chief.  Division  of  Pharmacolog}-,  Hygienic 
Laborator>-.  Detailed  to  attend  the  annual  meeting  of 
the  -American  Medical  -Association  (Section  in  Phar- 
macology,- and  Therapeutics),  to  be  held  in  Atlantic 
Citj-,  X.  J..  June  8-1 1.  1909. 

M.\cCaffrv.  W.  B..  Acting  Assistant  Surgeon.  Granted 
four  days'  leave  of  absence  in  May.  1909.  imder  para- 
graph 210.  Service  Regulations. 

il.AGUiRE.  E.  S..  Pharmacist.  Upon  arrival  of  Pharmacist 
Frank  -A.  Southard,  directed  to  proceed  to  Cleveland. 
O..  and  report  to  the  medical  officer  in  command  for 
duty  and  assignment  to  quarters. 

Ryder.  L.  \V..  Pharmacist.  Granted  one  day's  leave  of  ab- 
sence. May  29.  1909,  under  paragraph  210.  Service  Reg- 
ulations. 

Southard.  Fr.xxk  -A..  Pharmacist.  Directed  to  proceed  to 
Chicago.  111.,  and  report  to  the  medical  officer  in  com- 
mand for  dut>-  and  assignm.ent  to  quarters. 

Stiles.  Ch.arles  W..  Chief.  Division  of  Zoolog>-.  Hygienic 
Laboratory.  Detailed  to  attend  the  fifty-sixth  annual 
meeting  of  the  Medical  Societ3-  of  North  Carolina  in 
-Asheville.  X.  C.  Jime  15,  1909. 

Stuart.  A.  F..  Acting  .Assistant  Surgeon.  Granted  thirty 
days"  leave  of  absence  from  June  30.  1909. 


TrO-KLEr,  R.  F.,  Pharmacist.    Granted  twelve  days'  leave  of 

absence  from  June  7.  1909. 
WiLSOx,  R.  L..  Passed  Assistant  Surgeon.    Granted  fifteen 

days'  leave  of  absence  from  June  2.  1909. 
Wright,  F.  T..  .Acting  Assistant  Surgeon.    Granted  thirty 

days'  leave  of  absence,  without  pay,  from  May  23,  1909. 
VouXG.  G.  B.,  Surgeon.    Detailed  to  represent  the  Service 

at  the  meeting  of  the  .American  Medical  Association  to 

be  held  in  .Atlantic  City,  X'.  J.,  June  7  to  11,  1909. 
Board  C omened. 
Board  of  medical  officers  convened  to  meet  at  the  Marine 
Hospital  office.  Seattle.  Wash..  May  29,  1909,  for  the  pur- 
pose of  examining  alien  Yutaka.  Detail  for  the  board : 
Passed  .Assistant  Surgeon  M.  W.  Glover,  chairman ;  Assist- 
ant Surgeon  C.  W.  Chapin.  recorder. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers sening  in  the  Medical  Corps  of  the  United  States 
.-Irmy  for  the  zveeli  ending  June  5.  igog: 
B.WLY,  R.  C.  First  Lieutenant,  ^ledical  Reserve  Corps. 
Ordered  to  Fort  D.  .A.  Russell.  Wyo..  for  duty  with 
Company  .A.  H.  C. 
Burket.  J.  W..  First  Lieutenant.  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Snelling,  Minn.,  and  or- 
dered to  Fort  Riley,  Kans.,  for  duty. 
Card.  D.  P.,  First  Lieutenant,  Medical  Reserve  Corps.  Or- 
dered to  San  Francisco,  Cal.,  for  dutv  with  Company 
B,  H.  C. 

Ch.ase.  C.  L..  First  Lieutenant,  Medical  Reserve  Corps. 
When  relieved  from  duty  at  Fort  Redman,  Mass.,  will 
proceed  to  Fort  Gibbon,  .Alaska,  for  dut}'. 

Coburx.  H.  C.  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  Fort  Slocum.  X.  Y.,  for  duty. 

CoFFi.v.  J.  M..  Captain.  Medical  Corps.  Granted  an  ex- 
tension of  eighteen  days  to  his  leave  of  absence. 

D-Wis.  .A.  D.,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  Fort  Law-ton.  Wash.,  for  duty. 

De.vr.  W.  R..  First  Lieutenant.  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  ten  days :  ordered  to  Fort 
Sheridan,  111.,  for  duty. 

De-Mmer.  C.  C,  First  Lieutenant.  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Ontario.  X'.  Y. :  will  pro- 
ceed to  Fort  Redman,  Mass.,  for  duty. 

Doerr.  C.  E..  First  Lieutenant.  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  ten  days :  ordered  to  Fort 
D.  A.  Russell,  Wyo.,  for  duty  with  Company  A,  H.  C. 

DuXB.\K.  L.  R.,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  Fort  Casey.  Wash.,  for  duty. 

FiSK.  O.  C.  First  Lieutenant.  Medical  Reserve  Corps.  Re- 
lieved from  duty  at  Fort  Leavenworth,  Kans.,  and  or- 
dered to  Fort  Terrv",  X'.  Y..  for  dutj-. 

Fox,  J.  S.,  First  Lieutenant.  Medical  Reserve  Corps.  Re- 
lieved from  dut>-  at  Fort  Sam  Houston.  Te.x..  and  or- 
dered to  Fort  ^^cKinley.  Me.,  for  duty. 

Froxk.  C.  E.,  First  Lieutenant.  ^ledical  Reserve  Corps. 
Ordered  to  Fort  Sam  Houston.  Tex.,  for  duty. 

G-XRCi.x.  L.  C.  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  Fort  McDowell.  Cal.  for  duty. 

George.  W.  R.  S..  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  proceed  home  from  his  present  station ; 
honorably  discharged  from  the  senice  of  the  L'nited 
States,  his  services  being  no  longer  required. 

GoLDTHWAiTE.  R.  H..  First  Lieutenant.  Medical  Reserve 
Corps.  Ordered  to  Fort  Xiagara.  X'.  Y..  for  duty  with 
Company,  C.  H.  C. 

Grissixger.  J.  W..  Captain.  Medical  Corps.  When  relieved 
from  duty  at  Fort  Egbert.  .Alaska,  will  proceed  to  Fort 
Gibbon.  .Alaska,  for  dut\-. 

H-\LL.  J.  F..  Captain.  Medical  Corps.  When  relieved  at 
Fort  Gibbon.  .Alaska,  will  proceed  to  Fort  Brady,  Mich., 
for  dutx-. 

H.ARMox,  D.  W.,  First  Lieutenant,  Medical  Reserve  Corps. 

Granted  leave  of  absence  for  twentj-  dajs :  will  proceed 

to  Fort  Davis,  .Alaska,  for  duty. 
He.ath.  G.  D.,  Jr..  First  Lieutenant.  Medical  Reserve  Corps. 

Ordered  to  San  Francisco.  Cal.,  for  duty  at  the  .Army 

General  Hospital. 
Hill.  Ebex  C.  First  Lieutenant,  Medical  Reserve  Corps. 

Ordered  to  Madison  Barracks.  X.  Y..  for  duty. 
HuTTOX.  P.  C,  Captain.  Medical  Corps.    When  relieved  at 

Fort  William  H.  Seward,  .Alaska,  will  proceed  to  Fort 

Snelling.  Minn.,  for  dutj-. 


1244 


BIRTHS,  MARRIAGES.  AXD  DEATHS. 


[New  York 
Medical  Journal. 


Kearnv,  R.  a.,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  proceed  home  from  his  present  station. 

Kennedy,  J.  S..  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  duty  at  Fort  Sam  Houston,  Tex.,  and 
ordered  to  Fort  Bliss,  Tex.,  for  duty. 

Kerr,  R.  W.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  San  Francisco,  Cal.,  for  duty  with  Com- 
pany, B,  H.  C. 

King.  C.  T.,  First  Lieutenant,  Medical  Reserve  Corps.  Re- 
lieved from  duty  at  the  Presidio  of  Monterey,  Cal., 
and  ordered  to  Fort  Williams,  Me.,  for  duty. 

Leary,  T.  J.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  Fort  D.  A.  Russell,  Wyo.,  for  duty  with 
Company  A,  H.  C. 

Lowe,  Thomas  S.,  First  Lieutenant,  Medical  Reserve  Corps. 
Relieved  from  further  duty  at  Fort  Walla  Walla, 
Wash.,  and  from  temporary  duty  at  Vancouver  Bar- 
racks, Wash. ;  will  proceed  to  Fort  Lawton,  Wash., 
and  report  for  duty  in  the  Army  Transport  Service. 

McCoRNACK,  C.  C,  First  Lieutenant,  Medical  Reserve 
Corps.  Relieved  from  duty  at  Vancouver  Barracks. 
Wash.,  and  ordered  to  Plattsburg  Barracks,  N.  Y.,  for 
duty. 

McDiARMiD,  N.  L.,  First  Lieutenant,  Medical  Reserve 
Corps.    Ordered  to  Fort  Sam  Houston,  Tex.,  for  duty. 

McLellan,  George  H.,  First  Lieutenant,  Medical  Reserve 
Corps.    Ordered  to  Fort  Crook,  Nebr.,  for  duty. 

Magee,  J.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  five  days ;  ordered  to  San 
Francisco,  Cal.,  for  duty  at  the  Army  General  Hospital. 

Miller,  E.  W.,  Captain,  Medical  Corps.  Granted  an  exten- 
sion of  one  month  to  his  leave  of  absence. 

Miner,  Donald,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  proceed  home  from  his  present  station. 

Mueller,  A.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  San  Francisco,  Cal.,  for  duty  at  the  Army 
General  Hospital. 

Murray.  A.,  Captain,  Medical  Corps.  Relieved  from  duty 
at  Fort  DuPont,  Del. ;  will  proceed  to  Fort  Egbert, 
Alaska,  for  duty. 

O'Day,  S.  F.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  proceed  home  from  his  present  station. 

Palmer,  F.  W.,  Captain.  Medical  Corps.  Relieved  from 
duty  at  Fort  Benjamin  Harrison.  Ind. ;  will  proceed  at 
the  expiration  of  his  present  leave  of  absence  to  Fort 
William  H.  Seward.  Alaska,  for  duty. 

Parce.  a.  D.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  Fort  Niagara,  N.  Y.,  for  duty  with  Com- 
pany C,  H.  C. 

Philips.  H.  F.,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  proceed  home  from  his  present  station. 

Porter.  E.  H.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  from  Fort  Worden,  Wash.,  to  Fort  Casey, 
Wash.,  for  temporary  duty. 

Shields.  W.  S..  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  from  San  Francisco,  Cal.,  for  duty  with  Com- 
pany B.  H.  C. 

Smith,  W.  H.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  Vancouver  Barracks.  Wash.,  for  duty. 

Snow.  C.  G.,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  Fort  Leavenworth,  Kans..  for  duty. 

Stayer,  M.  C,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  Fort  McDowell.  Cal.  for  duty. 

SwEAZEY,  V.  E..  Captain.  Medical  Corps.  When  relieved 
from  duty  at  Fort  St.  Michael.  Alaska,  will  proceed  to 
Plattsburg  Barracks.  N.  Y..  for  duty. 

Tenney,  E.  S.,  First  Lieutenant.  Medicnl  Reserve  Corps. 
Granted  leave  of  absence  for  one  month,  twenty  days, 
about  June  7th. 

TREt:nt)LTZ.  C.  A.,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  Fort  Baker,  Ca!.,  for  duty. 

Trotter-Tyler,  G.,  First  Lieutenant,  ]\Iedical  Reserve 
Corps.  Ordered  from  Fort  Adams.  R.  L,  to  Fort 
Strong,  Mass.,  for  temporary  duty:  relieved  from  duty 
at  Fort  Adams.  R.  L  ;  will  proceed  to  Vancouver  Bar- 
racks, Wash.,  for  duty. 

Trup-y,  W.  F..  Major,  Medical  Corps.  Granted  an  exten- 
sion of  fifteen  days  to  his  leave  of  absence. 

Tuttle,  a.  D.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  San  Francisco,  Cal.,  to  sail  July  5th  for 
service  in  the  Philippines. 

Waring.  J.  B.  H..  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  Fort  Lawton,  Wash.,  for  duty. 


Whaley,  a.  M.,  Captain,  Medical  Corps.  Relieved  from 
duty  at  Fort  Sam  Houston,  Tex.,  and  ordered  to  Fort 
St.  Michael,  Alaska,  for  duty. 

Wilson.  J.  A.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  Fort  Niagara,  N.  Y.,  for  duty  with  Com- 
pany C.  H.  C. 

Wright,  F.  S.,  First  Lieutenant,  Medical  Reserve  Corps. 
Ordered  to  New  York  City  on  business  of  the  Medical 
Department,  and  thence  to  the  Presidio  of  Monterey, 
Cal..  for  duty. 

Navy  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Naiy  for  the  week  ending  June  5,  igoQ: 
Angwin.  W.  a..  Passed  .A.ssistant  Surgeon.    Detached  from 

the  Philadelphia  and  ordered  to  the  Tennessee. 
BoGERT,  E.  S.,  Jr..  Surgeon.    Detached  from  the  Naval 

Academy  and  ordered  to  the  Navy  Yard,  New  York, 

N.  Y.,  for  temporary  duty. 
Clark,  G.  F.,  Assistant  Surgeon.    Commissioned  assistant 

surgeon,  with  rank  of  lieutenant  (junior  grade),  from 

April  14,  1909. 

Guest,  AL  S.,  Surgeon.  Detached  from  the  Tennessee  and 
ordered  to  the  Naval  Academy,  Annapolis,  Md. 

Harlan,  T.,  Assistant  Surgeon.  Commissioned  assistant 
surgeon,  with  rank  of  lieutenant  (junior  grade),  from 
April  14,  1909. 

Hart,  S.  D.,  Acting  Assistant  Surgeon.  Ordered  to  duty 
at  the  Naval  Hospital.  Navy  Yard.  New  York,  N.  Y. 

Hoen,  W.  S.,  Passed  Assistant  Surgeon.  Detached  from 
duty  at  the  Naval  Hospital,  Las  Animas,  Col.,  and  or- 
dered to  the  Philadelphia. 

Jenkins,  H.  E.,  Acting  Assistant  Surgeon.  Commissioned 
acting  assistant  surgeon,  with  rank  of  lieutenant  (junior 
grade),  from  May  26.  1909. 

Kerr,  W.  jVL,  Assistant  Surgeon.  Commissioned  assistant 
surgeon,  with  rank  of  lieutenant  (junior  grade),  from 
April  14,  1909. 

RiDDicK,  W.  J.,  Acting  Assistant  Surgeon.  Commissioned 

acting  assistant  surgeon,  with  rank  of  lieutenant  (junior 

grade),  from  May  26.  1909. 
RiKER,  G.  A.,  Assistant  Surgeon.    Commissioned  assistant 

surgeon,  with  rank  of  lieutenant  (junior  grade),  from 

April  14.  1909. 

ZiEGLER,  J.  G..  Assistant  Surgeon.  Commissioned  assistant 
surgeon,  with  rank  of  lieutenant  (junior  grade),  from 
April  14,  1909. 

 ^  


Died. 

BiNKLEY. — In  Chicago,  on  Thursday.  June  3d.  Dr.  John 
T.  Binkley.  aged  eighty-two  years. 

Cotton. — In  Zionsville.  Iowa,  on  Sunday,  May  30th,  Dr. 
H.  T.  Cotton,  aged  seventy-five  years. 

Fisher. — In  Altoona,  Pennsylvania,  on  Saturday,  May 
22nd.  Dr.  Albert  M.  Fisher,  aged  forty  years. 

Geisendorffer. — In  The  Dalles.  Oregon,  on  Wednesday, 
Alay  26th,  Dr.  John  A.  Geisendorffer,  aged  forty-three 
years. 

Keenan. — In  Brooklyn,  New  York,  on  Tuesday,  June 
1st.  Dr.  Henry  C.  Keenan,  aged  thirty-six  years. 

Nebeker. — In  Clinton.  Indiana,  on  Tuesday.  May  25th, 
Dr.  Henry  Nebeker,  aged  sixty-three  years. 

Reagan. — In  North  Tonawanda.  New  York,  on  Tuesday. 
June  1st,  Dr.  Cornelius  R.  Reagan,  aged  forty-six  years. 

Riggs. — In  Cambridge  Springs,  Pennsylvania,  on  Mon- 
day, May  31st,  Dr.  J.  W.  Riggs,  of  Pittsburgh,  Pennsylva- 
nia, aged  fifty-nine  years. 

RoBoss  ;n. — In  Flintstone,  Maryland,  on  Friday,  May 
28th,  Dr.  Thomas  Perry  Robosson.  aged  seventy-five  years. 

Thayek. — In  Elbon.  Pennsylvania,  on  Friday,  Mav  28th. 
Dr.  L.  J.  Thayer. 

Talfard. — In  Sylvania.  Ohio,  on  Friday,  May  28tli.  Dr. 
P.  B.  Talfard,  of  Pittsford.  Michigan,  aged  thirty-eight 
years. 

Welsh. — In  Eaton.  Ohio,  on  Saturday,  May  29th.  Dr. 
James  Barney  Welsh,  aged  eighty-eight  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  rlt  Medical  News 

A  Weekly  Review  of  Medicine  y  Established  184J. 


Vol.  LXXXIX,  No.  25.  NEW  YORK,  JUNE  19,  1909  Whole  Xo.  1594. 


(Briginal  Communications. 


SOME   PROBLEMS   CONNECTED  WITH  TUBER- 
CULOSIS* 

By  Hexry  G.  Piffard,  A.  M.,  M.  D.,  LL.D., 
New  York, 

Profess&r   Emeritus  of   Dermatology,   New   York   L'niversity;  Con- 
sulting Surgeon,  City  Hospital,  etc. 

The  unsolved  problems  relating  to  tuberculosis 
that  to-day  confront  us,  are,  it  seems  to  the  writer, 
worthy  of  the  most  thoughtful  consideration  of  the 
clinician  and  the  most  earnest  and  varied  endeavor 
of  the  laboratory  worker. 

For  more  than  forty  years  the  subject  has  inter- 
ested me  in  some  of  its  aspects,  and  especially  those 
of  its  superficial  manifestations  and  their  relations 
to  deeper  and  perhaps  diathetic  conditions. 

In  1864,  while  serving  on  the  house  staff  of  the 
old  Charity  (now  City)  Hospital.  I  became  acquaint- 
ed with  the  works  of  two  of  France's  then  most 
celebrated  dermatologists,  Bazin  and  Hardy.  They 
both  taught  substantially  the  same  doctrine,  name- 
ly, that  the  cutaneous  affection  commonly  known  as 
"lupus"  was  the  offspring  of  the  so  called  strumous, 
or  scrofulous,  diathesis,  which  at  that  time  was  re- 
garded as  the  parent  of  consumption  or,  as  we 
should  now  say,  pulmonary  tuberculosis. 

Twelve  years  of  observation  and  reflection  led 
the  writer  to  accept  the  French  rather  than  the  op- 
posing German  views  and  he  so  stated  in  his  early 
work  {Elementary  Treatise  on  Diseases  of  the 
Skin,  1876).  This  conception,  however,  was  not 
generally  accepted  by  his  American  colleagues. 

Further  observation  led  me  a  year  later  to  ex- 
press the  opinion  that  there  was  some  infective 
agent  at  the  bottom  of  the  trouble  and  I  did  so  in 
the  following  words :  "Another  peculiarity  is  its 
gradual  extension  and  involvement  of  new  regions 
by  an  apparently  infective  process,  similar  to,  but 
less  in  degree  than,  that  manifested  by  cancer." 
{Medical  Record,  July  21.  1877.) 

Two  weeks  later  an  article  from  the  pen  of  Mr. 
Jonathan  Hutchinson,  of  London,  appeared  in  the 
Medical  Tinics  and  Gazette,  August  4,  1877,  from 
which  I  quote  the  following:  "The  mode  in  which 
lupus  extends  itself,  and  more  especially  in  which 
multiple  patches  are  developed,  is  well  worthy  of 
investigation.  My  impression  is  that  the  processes 
are  by  cell  infection  and  ver\-  similar  to  what  we  ob- 
serve in  cancer." 

*Read  at  a  meeting  of  the  Medical  Society  of  the  County  ot 
New  York,  May  24,  1909. 


It  will  be  noted  that  the  dates  here  given  were 
four  years  prior  to  the  discovery  by  Koch  of  the 
actual  infecting  agent,  and  it  is  at  least  worthy  of 
note  that  the  same  fundamental  idea  should  have 
occurred  simultaneously  to  two  men  living  three- 
thousand  miles  apart.  It  was  but  a  few  years  later 
that  Koch  discovered  and  isolated  the  organism  that 
up  to  the  present  is  regarded  as  the  active  factor 
concerned  in  the  extension  of  the  disease,  namely, 
the  so  called  tubercle  bacillus,  and  to  distinguish  it 
from  allied  forms,  the  Koch  bacillus,  this  latter 
name  applying  only  to  the  human  species  or  type. 

Thus  one  mystery  has  been  cleared  up. 

Manv  others,  however,  await  an  equally  satisfac- 
tory solution,  to  wit :  What  is  the  tubercle  bacillus 
of  Koch?  What  are  its  allies  among  similar  or- 
ganisms met  with  in  other  mammalian  species  ? 
What  its  allies  in  the  avian  kingdom?  What  rela- 
tionship does  it  bear  to  similar  organisms  met  witlr 
in  the  reptilian  and  piscine  orders?  The  features 
common  to  the  organisms  met  with  in  these  wide- 
ly differing  orders  of  the  animal  kingdom  are  few 
but  positive.  As  usuallv  seen,  they  are  little  rods 
which  when  stained  with  fuchsin.  resist  the  decol- 
orizing action  of  acids  and  alcohol,  and  hence  are 
termed  "acid  fasts."  This  fact  alone  distinguishes 
them  from  the  great  majority  of  other  microorgan- 
isms met  with  in  the  animal  body,  but  not  from  all,, 
as  bacilli  possessing  similar  morphological  features 
are  constant  accompaniments  of  leprosy,  an  appar- 
ently widely  different  disease.  The  lepra  bacilli  are 
also  acid  fast.  The  smegma  bacilli  also  possess 
this  quality,  but  sometimes  to  a  minor  degree,  and 
I  prefer  then  to  speak  of  them  as  acid  semifasts. 
For  instance,  an  acid  alcohol  solution  that  fails  to 
remove  the  color  from  tubercle  and  lepra  bacilli 
may  remove  it  partially  or  wholly  from  the  smegma 
organism.  The  term  "acid  fast"  as  here  used  im- 
plies not  only  that  the  color  resists  the  acid,  but  also 
simultaneous  or  subsequent  application  of  alcohol.* 

While  many  bacilli  and  cocci  may  be  deeply 
stained  by  a  few  seconds'  exposure  to  an  appropri- 
ate dye,  the  tubercle  bacilli  require  either  prolonged 
contact  with  a  cold  solution  or  shorter  to  a  hot 
one. 

The  resistance  of  the  bacillus  to  the  reception  of 
the  dye  is  supposed  to  be  due  to  an  adipoceric  in- 
vestment or  capsule,  which  in  turn  protects  the 
stained  bacillus  from  the  acid  alcohol.  The  stain- 
ing peculiarities  here  described  are  those  common- 

'In  my  own  e.xperiniental  work  I  usually  employ  a  solution  con- 
sisting of  one  part  of  nitric  acid  and  nine  parts  of  ninety-five  per 
cent,  alcohol,  or  else  the  spiritus  etheris  nitrosi  as  recommended  by 
Baldwin. 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


1246 


PIFFARD:    PROBLEMS   OF  TUBERCULOSIS. 


[New  York 
Medical  JouRNAr.. 


ly  regarded  as  typical  an.d  the  ones  chiefly  rehed  on 
in  sputum  examinations.  The  bacilUis  itself  is  usu- 
ally described  as  a  little  rod,  straight  or  slightly 
curved,  of  uniform  contour  and  texture,  or  exhib- 
iting on  the  one  hand  small,  clear,  unstained  points, 
or  on  the  other  more  darkly  stained  granules.  No 
one  has  yet  satisfactorily  explained  either  the  light 
or  dark  particles.  By  some  the  light  ones  are  sup- 
posed to  be  spores,  but  this  view  is  not  generally  ac- 
cepted, and  does  not  appeal  to  me  as  a  probable  ex- 
planation. I  look  on  them  rather  as  degenerate  or 
degradation  forms  or  perhaps  a  stage  leading  mere- 
ly to  fragmentation  either  without  or  with  impair- 
ment or  loss  of  vitality.  The  darkly  stained  gran- 
ules, sometimes  called  "metachromatic,"  appear  to 
be  of  a  wholly  diflerent  nature  and  if  not  true 
six)res  are  thought  by  some  to  be  daiicr  forms,  that 
is,  bacillary  particles  that  possess  a  heightened 
power  of  resistance  to  adverse  conditions.  These 
are  mere  suppositions,  however,  and  constitute  an- 
other of  the  mysteries  connected  with  tuberculosis. 
The  life  histories  and  general  behavior  of  other 
bacilli  throw  but  little  light  on  the  biology  of  the 
tubercle  bacillus.  Of  the  better  known  forms  we 
have  these  that  form  distinct  and  undoubted  spores, 
whose  resistance  to  uncongenial  surroundings  is 
vastly  greater  than  the  resistance  of  the  parent  or- 
ganism, an  undoubted  provision  of  Nature  where- 
by the  species  is  preserved  from  destruction.  The 
common  Bacillus  subtilis  is  a  well  known  instance 
of  this.  On  the  other  hand,  where  simple  fission  is 
the  only  mode  of  increase,  surrounding  conditions 
must  be  favorable  or  the  species  becomes  extinct. 
This,  however,  presupposes  a  potential  immortal- 
ity. If  we  go  a  little  higher  in  Nature's  scale  we 
find  maintenance  of  species  provided  for  in  two  dis- 
tinct ways.  Indefinite  subdivision  in  the  manner 
observed  in  many  bacteria  does  not  occur.  In  some 
of  the  infusoria,  however,  increase  by  fission  may 
go  on  for  several  hundred  generations  but  not  for- 
ever. Evidences  of  senility  manifest  themselves 
and  would  lead  to  ultimate  death  were  it  not  for 
the  fact  that  two  individuals  of  the  late  generation 
fuse  together  forming  a  single  cell,  which  itself 
soon  divides  and  starts  a  new  cycle  of  existence. 
So  far  as  I  know  nothing  of  this  sort  has  been  ob- 
served among  bacteria.  Among  the  multicellular 
infusoria  and  the  lower  forms  of  aquatic  plants  Na- 
ture provides  a  means  whereby  the  species  though 
not  the  individuals  survive  the  rigors  of  winter. 
This  is  by  means  of  special  so  called  winter  eggs 
and  other  enduring  forms  which  survive  the  frosts 
that  destroy  the  parent  organism.  Nothing  exact- 
ly like  this  occurs  among  the  bacteria.  Some  kinds, 
indeed,  survive  through  the  medium  of  their  spores. 
In  the  majority,  however,  neither  spores  or  other 
daiicr  forms  have  been  observed.  How  then  do 
they  keep  up  their  continuous  life? 

Among  the  higher  plants  and  animals  we  know 
that  continuous  inbreeding  tends  inevitably  to  de- 
generation and  general  impairment  of  vigor.  Lab- 
oratory workers  have  found  this  true  of  certain  and 
especially  the  pathogenic  bacteria.  If  originally 
virulent  their  quality  becomes  impaired  or  lost  by 
continuous  inbreeding,  that  is,  repeated  cultivations 
on  artificial  nierlia.  On  the  other  hand  if  nonviru- 
lent,  they  may  be  made  virulent  by  repeated  trans- 


fers through  living  animals.  While  this  is  not  al- 
ways the  case  it  occurs  with  sufficient  frequency  to 
be  taken  into  account. 

The  characteristic  features  of  the  tubercle  bacillus 
as  met  with  clinically  are  the  plain  or  "beaded"' 
rodlets  with  acid  fastness,  features  commonly  relied 
on  in  the  diagnosis  of  pulmonary  and  other  lesions. 
When  found  in  the  excreta  they  are  supposed  to  in- 
dicate tuberculous  disease  of  the  corresponding  ex- 
cretory organs.  Under  these  circumstances  they 
exhibit  a  fairly  well  defined  type  usually  spoken  of 
as  the  typns  htimanns.  When  inoculated  into  lab- 
oratory animals  they  induce  local  or  generaUzed 
disease,  depending  on  the  method  employed.  Por- 
tions of  the  diseased  tissue  of  the  animal  may  be 
again  inoculated  into  other  animals  and  the  disease 
propagated  through  many  generations. 

In  purely  local  tuberculous  afifections  of  the 
glands,  for  instance,  the  cervical,  and  in  tuberculous 
abscesses  we  may  search  in  vain  for  acid  fast  rodlets 
and  yet  the  purulent  or  cheesy  matter  is  fully  as 
pathogenic  to  laboratory  animals  as  the  type  form. 
To  what,  then,  is  the  infective  quality  of  the  mate- 
rial due?  Manifestly  either  to  the  fluids  or  to  some 
other  morphological  element.  If  now  some  stain 
other  than  the  classic  Ziehl  is  employed.  Gram  for 
instance,  small  coccal  or  granular  bodies  become 
evident  and  it  is  probably  to  these  that  the  infection 
is  due.  Gram  positive  rodlets  may  also  be  found. 
The  tuberculous  organism  as  obtained  from  the  liv- 
ing human  bod}'  therefore  may  occur  as  acid  fast 
or  acid  nonfast  Gram  positive  rodlets  or  as  granu- 
lar forms  or  for  all  we  know  as  ultra  microscopic 
living  particles,  small  enough  to  pass  through  the 
filter  of  the  closest  texture  and  yet  possessing  all  the 
virulence  of  the  grosser  forms.  Why  the  tubercle 
bacillus  should  at  one  time  be  acid  fast  and  at  an- 
other nonfast  is  another  of  the  little  mysteries  con- 
nected with  the  organism.  Some  maintain  that  the 
lost  fastness  is  due  to  degeneration,  the  result  of  age 
and  other  causes,  while  others  hold  that  it  is  pe- 
culiarly a  feature  of  the  youthful  organism  ;  in  other 
words,  the  immediate  product  of  fission  has  not  ac- 
quired its  waxy  coating.  Personally,  I  believe  both 
explanations  are  correct,  so  far  at  least  as  my  own 
observations  are  concerned,  as  I  have  found  both 
conditions  in  sputum,  in  cultures,  and  in  bacilli  ob- 
tained from  the  circulating  blood  (Rosenberger's 
method),  as  I  have  seen  in  the  same  clump  deeply 
stained  fuchsin  rods,  and  others  which  have  ap- 
parently been  decolorized  and  then  taken  the  blue 
contrast  stain.  In  addition  there  were  others  light 
pink  in  color  which  for  convenience  I  designated 
as  acid  semifast,  as  if  the  alcohol  had  worked  a  par- 
tial decolorization. 

While  the  human  bacillus  is  of  the  first  interest, 
there  is  another  which  at  the  present  time  is  a  close 
second.  I  allude,  of  course,  to  the  bovine  organ- 
ism. While  closely  resembling  the  human  organism 
in  general  morphology  and  behavior  with  staining 
solutions,  there  are  some  points  of  difference,  first 
noted  by  Professor  Theobald  Smith.  P)riefly  de- 
scribed, the  rods  are  shorter,  thicker,  and  less 
curved  than  in  man,  and  they  differ  in  their  reactive 
influence  on  culture  media ;  and  these  dift"erences 
are  sufficiently  marked  to  warrant  the  designation 
of  bovine  type. 


June  19.  1909.) 


PIFFARD:    PROBLEMS   OF  TUBERCULOSIS. 


1247 


The  importance  of  bovine  tuberculosis  is  second 
only  to  that  of  the  human  affection.  In  the  first 
l^Iace,  the  possibility  of  its  setiological  relation  to  hu- 
man disease,  maintained  by  von  Behring  and  denied 
by  Koch,  is  at  present  sub  jtidicc.  Personally,  I 
believe  that  while  possible  it  is  very  infrequent,  as 
the  number  of  cases  in  which  human  tuberculosis 
could  with  any  probability  be  traced  to  bovine  in- 
fection is  extremely  limited.  On  the  other  hand, 
the  vast  number  of  consumers  of  milk  from  tuber- 
culous cows  in  whom  the  disease  does  not  develop 
w^ould  point  strongly  to  its  innocuousness.  There 
is  no  question,  however,  as  to  the  inroads  that  tu- 
berculosis is  making  in  our  dairy  herds  and  that  if 
unchecked  it  will  lead  to  great  financial  loss  to  the 
dairyman  and  to  personal  inconvenience  by  lessen- 
ing the  milk  supply.  It  is,  therefore,  an  economic 
question  to  which  our  legislators  and  administrative 
officials  should  give  their  most  earnest  attention. 

Swine  also  become  ready  victims  of  the  disease, 
while  sheep  and,  goats  suffer  to  a  much  less  de- 
gree. Wild  animals  in  a  state  of  nature  are  wholly 
or  comparatively  free  from  tuberculosis,  but  suf-, 
fer  greatly  from  it  in  confinement. 

Birds,  especially  those  under  domestication,  are 
liable  to  tuberculosis  and  in  not  a  few  instances 
flocks  of  poultry  have  been  found  in'  which  man\- 
if  not  all  the  individuals  were  affected. 

The  avian  bacilli,  referring  to  such  cultures  as  I 
have  examined,  differ  materially  from  the  human 
or  bovine  types,  the  individual  bacillary  elements  on 
some  media  being  longer  and  with  tapering  ends, 
on  other  media  they  exhibit  the  "beaded"  appear- 
ance in  the  most  striking  and  clean  cut  manner. 
If  cultivated  on  Dorset's  egg  medium  the  bacillary 
aspect  almost  wholly  disappears  to  be  replaced  by 
coccoid  forms.  Clubbed  and  spermatozooid  forms 
are  also  not  infrequently  found  in  the  older  cul- 
tures. The  acid  fastness,  as  in  the  other  types,  is 
not  uniform.  This  is  specially  noticeable,  if  after 
decolorizing,  the  slide  be  counterstained  with  me- 
thylene blue,  the  same  clump  of  bacilli  may  exhibit 
both  red  and  blue  rods  morphologically  identical. 
This  is  by  no  means  a  peculiarity  of  avian  tuber- 
culosis as*  I  have  seen  it  in  cultures  of  both  human 
and  bovine  origin  as  well  as  in  blood  smears  ob- 
tained from  the  living  subject.  Tuberculosis  is  not 
confined  to  warm  blooded  animals,  and  has  been 
met  with  in  reptiles  and  fishes.  INIoller,  some  years 
ago,  successfully  inoculated  the  "blind  worm" 
(Angnis  fragilis)  with  the  human  germ,  and  later 
Dubard  discovered  tuberculosis  in  carp  under  cir- 
cumstances that  left  no  doubt  as  to  its  human  or- 
igin. 

Leaving  the  animal  and  turning  to  the  vegetable 
kingdom  we  again  find  acid  fast  bacilloids ;  by  Mol- 
ler  iji  Timothy  grass  (Phlciiin  pratcnsc)  and  by 
Maher,  Moore,  and  others  in  a  variety  of  vegetable 
sources.  These  all  possess  the  characteristic  color 
reactions  of  the  animal  germs  and  most  of  them 
are  capable  of  producing  tuberculous  nodules,  or 
miliary  lesions  in  laboratory  animals.  As  a  rule 
their  virulence  is  less  than  that  of  the  germs  of  di- 
rect animal  origin,  but  may  be  more  so  than  ani- 
mal germs  that  have  been  cultivated  for  a  long  time 
saprophytically  on  laboratory  media.    In  these  acid 


fasts  there  is  no  more  precision  of  form  than  that 
met  with  in  those  of  nobler  origin.  There  are 
still  other  acid  fast  bacilloids  as  the  Bacillus  para- 
tuberculosis  of  Binot,  and  the  butter  bacilli  of  Korn 
and  of  Rabinowitsch.  In  fact  there  is  a  very  large 
series  of  organisms  which  possess  certain  striking 
features  in  common,  namely ;  variable  morphology 
under  cultivation,  varying  degrees  of  acid  fastness 
under  the  same  or  different  cultures,  varyingdegrees 
of  virulence,  and  all  or  nearly  all  of  them  capable 
of  inducing  the  formation  of  histological  tubercles 
in  experimental  animals.  One  of  the  most  im- 
portant peculiarities  of  this  wide  group  of  organ- 
isms is  the  fact  that  their  mode  of  life  can  be 
changed  at  will  from  parasitic  to  saprophytic  and 
back  again  to  parasitic.  It  is  true  that  in  some 
the  change  from  parasitic  to  saprophytic  life  is  at 
first  slow  and  tedious,  as  in  the  human  and  bovine 
bacilli,  and  on  the  other  hand  those  that  by  nature 
are  saprophytic,  often  fail  to  produce  in  the  living 
animal  tissues  the  prompt  and  serious  lesions  that 
may  follow  infection  by  the  parasitic  forms.  When 
we  consider  the  uncounted  billions  of  these  organ- 
isms constantly  around  us,  it  is  by  no  means  incon- 
ceivable that  some  of  them  may  find  lodgment  in  an 
animal  organism,  whose  natural  resistance  has  been 
greatly  impaired,  then  take  root  and  ultimately  be- 
come truly  parasitic  on  animal  tissues,  and  capable 
of  spreading  infection  to  other  individuals  of  the 
same  or  allied  species.  So  far  as  I  am  aware  noth- 
ing of  the  sort  has  been  actually  proved  to  occur, 
but  the  possibilities,  I  may  even  say  probabilities  of 
the  occurrence  should  not  be  lost  sight  of,  for  hav- 
ing once  been  accustomed  to  an  animal  host,  further 
infection  would  more  readily  occur. 

There  is  one  acid  fast  organism  that  in  some 
parts  of  the  world  is  more  dreaded  than  the  one 
with  which  we  are  more  familiarly  acquainted,  and 
one  that  in  all  parts  of  the  world  is  looked  on 
with  even  more  horror  than  the  germ  of  tubercu- 
losis. I  refer  to  the  so  called  bacillus  of  leprosy. 
Acid  fast  and  sometimes  even  more  so  than  the  tu- 
bercle bacillus'  difficult  of  direct  cultivation  on  lab- 
oratory media  even  more  so  than  the  other,  latent  in 
the  system  for  long  periods  of  time,  even  longer  per- 
haps than  the  tubercle  germ,  it  finally  makes  its 
presence  known  b\'  unmistakable  signs  and  is  vastly 
less  amenable  to  remedial  agencies.  Despite  these 
differences  there  are  many  points  of  similarity  be- 
tween the  clinical  behavior  of  the  two  diseases. 
Some  of  these  are  alluded  to  in  Hutchinson's  recent 
work  on  leprosy  where  the  parallelism  between  the 
two  is  dwelt  on  in  a  number  of  places.  Perhaps 
the  most  striking  and  possibly  essential  difference 
between  the  two  is  the  difficulty  experienced  in  the 
artificial  cultivation  of  the  lepra  bacillus,  and  the, 
thus  far,  unsuccessful  efforts  to  transfer  the  disease 
to  the  lower  animals.  Under  the  microscope  the 
respective  bacilli  are  practically  indistinguishable, 

;Like  that  of  tuberculosis  the  bacillus  of  leprosy  is  not  always 
acid  fast.  A  culture  (by  Czaplewski)  now  in  my  hands  is  not  acid 
fast  and  a  very  luxuriant  subculture  four  days  old  is  nonfast  but 
strongly  Gram  positive  with  very  rarely  a  Gram  negative  rod. 
This  variation  of  the  color  reaction  in  some  of  the  bacterial  species 
is  not  as  yet  thoroughly  understood  and  merits  further  careful 
study.  For  instance,  a  certain  bacillus  belonging  to  the  lactacid 
group  to  which  I  have  given  some  attention  is,  at  first,  almost 
wholly  Gram  positive;  after  that  Gram  negative  rods  gradually  in- 
crease supplanting  the  others,  until  at  the  end  of  three  months  the 
rods  are  almost  wholly  Gram  negative. 


1248 


PIFFARD:   PROBLEMS   OF  TUBERCULOSIS. 


[New  York 
Medical  Journal. 


except  that  in  sections  of  the  cutaneous  nodes  of 
tubercular  leprosy  the  bacilli  show  a  more  ex- 
uberant growth  than  is  usually  the  case  in  ordinary 
tuberculosis  of  the  skin  (lupus  znilgaris). 

Tuberculin  is  regarded  by  most  as  a  specific  in- 
dicator of  tuberculosis,  but  if  administered  in  the 
usual  way  by  injection  to  lepers  is  followed  by  the 
customary  reaction  thought  to  be  peculiar  to  or- 
dinary tuberculosis. 

One  question  that  presses  for  an  early  answer  is 
whether  these  little  red  fast  bodies  are  true  bacilli ; 
that  is  in  the  Strict  sense  in  which  the  term  is  used 
by  classic  writers.  In  other  words,  is  it  a  definite 
biological  entity,  complete  in  itself,  or  is  it  but  a 
phase  in  the  life  history  of  some  other  organism, 
probably  a  higher  type,  and  if  so,  is  it  a  degraded 
or  involution  form,  or  on  the  other  hand  does  it 
correspond  to  the  larval  stage  of  some  of  the  lower 
forms  of  animal  life?  This  much  we  know,  that  by 
artificial  cultivation  we  can  reduce  it  to  coccoid 
granules,  or  raise  it  to  branched  forms  and  thread- 
like filaments,  often  with  clubbed  ends,  and  sperma- 
tozoid  figures.  Some  systematic  writers  consider  it 
but  a  branch  of  the  actinomyces  family,  and  de- 
scribe all  the  varieties  of  tubercle  "bacilli"  under 
the  title  Mycobacterium  tuberculosis,  giving  Bacil- 
lus tuberculosis,  as  the  vulgar  or  common  name 
{Trievialname,  L.  and  N.)  ;  Metchnikofif  {Vir- 
choiv's  Archiv,  cxiii)  prefers  the  name  sclcrothrix. 

If  now  the  tubercle  bacilli  are  but  descendants, 
degenerate  perhaps  of  the  actinomyces,  how  is  it 
with  the  other  acid  fasts,  the  Timothy  bacillus,  the 
dung  bacillus,  the  butter  bacillus,  the  pseudotuber- 
culosis and  pseudoperlsucht  bacilli,  the  smegma 
bacilli,  etc?  Have  all  of  these  organisms  with  vary- 
ing degrees  of  acid  fs^stness  a  direct  common  an- 
cestor in  the  actinomyces  or  some  other  biological 
form  higher  than  themselves,  or  does  one  or  the 
other  of  them  occiipy  an  intermediate  position  as 
the  direct  ancestor  of  the  tubercle  germ? 

"These  questions  present  science  has  not  answered. 
It  is  still  a  mystery,  but  well  worthy  of  a  most 
determined  effort  at  solution. 

Practically  the  matter  amounts  to  this:  If  pul- 
monary and  the  other  clinical  forms  of  tubercu- 
losis are  in  all  cases  dependent  on  the  tubercle  bacil- 
lus as  we  now  know  it,  and  if  it  is  a  separate  and 
wholly  independent  organism,  then  every  ef¥ort 
should  be  made  looking  toward  its  destruction,  and 
the  most  strenuous  endeavors  should  be  made  to 
guard  the  human  and  I  may  say  the  bovine  body 
from  coming  in  contact  with  it. 

On  the  other  hand,  if  the  germ  is  originally  veg- 
eterian,  but  facultative  carnivorous,  then  the  task 
of  totally  destroying  it  is  almost  hopeless.  Certain- 
ly this  question  should  be  cleared  up  at  the  earliest 
I)ossible  moment.  Either  the  floral  acid  fasts, 
saprophytic  or  parasitic,  are  absolutely  innocuous 
and  incapable  of  becoming  faunal  parasites,  or  else 
the  reverse  is  the  case.  At  the  present  time  no  cer- 
tain answer  can  be  given.  So  far  as  I  am  aware 
there  is  no  positive  evidence  that  the  Bacillus  phlei, 
for  instance,  either  through  ingestion  or  inhalation 
of  the  dust  of  the  hay  mow  can  produce  tubercu- 
losis in  cattle,  but  the  possibilities  of  its  so  doing 
should  not  be  overlooked.  This  branch  of  the  in- 
quiry could  be  best  taken  up  at  some  of  the  veter- 


inary laboratories,  and  State  aid  should  be  freely 
given  to  the  undertaking.  If  the  findings  should  be 
positive,  that  is  if  some  of  the  acid  fasts  with  floral 
habitat  may  become  seriously  pathogenic  as  regards 
the  bovine  race  the  destruction  of  all  cattle  so  af- 
fected together  with  disinfection  of  their  sur- 
roundings will  prove  only  of  temporary  service. 

There  is  no  question  as  to  the  extensive  pre- 
valence of  tuberculosis  among  the  dairy  herds  in 
many  parts  of  both  Europe  and  America,  but  the 
causes  that  have  led  up  to  it  do  not  appear  to  have 
been  so  well  understood.  If  we  take  a  given  herd 
in  which  each  individual  is  equally  exposed  to  the 
dangers  of  infection  we  find  that  only  certain  ones 
of  them  succumb  while  the  others  escape.  To  what 
is  this  due?  Manifestly  to  the  fact  that  some  are 
capable  of  destroying  or  neutralizing  the  infecting 
agent  while  others  are  deficient  in  resisting  power. 

Every  creature  possesses  a  certain  degree  of  re- 
sistance to  infectious  disease,  and  it  is  the  loss  or 
impairment  of  this  natural  immunity  that  enables 
the  germ  to  overcome  and  destroy  its  host. 

The  causes  that  have  led  up  to  this  diminished 
resistance  in  our  dairy  herds  are  not  far  to  seek. 
Some  breeds  of  cattle  give  milk  that  is  richer  in 
butter  fat  than  others,  and  the  cupidity  of  man 
urges  him  to  adopt  every  means  known  to  him  to  still 
further  increase  the  fat  percentage.  This  he  seeks  to 
accomplish  by  inbreeding,  the  use  of  stimulating 
foods,  and  coddling  in  the  stable ;  and  impairment 
of  vigor  is  further  hastened  by  too  early  breeding. 
The  Jersey  heifer,  of  all  the  bovine  tribe,  is  cer- 
tainly the  most  attractive  to  the  eye  when  not  de- 
formed through  avarice.  As  fat  milk  brings  more 
money  than  lean  milk,  and  as  the  early  calf  brings 
a  quicker  return  to  the  breeder,  these  appear  to 
be  the  chief  desiderata  rather  than  health  and  vigor 
in  the  cow  itself.  To  me  it  has  always  been  a 
pathetic  sight  to  see  a  "high  bred"  Jersey  cow  with 
an  hypertrophied  udder  but  with  atrophied  lungs. 
The  vital  organs  in  the  thoracic  cavity  are  neglected 
while  those  at  the  pelvic  end  are  raised  to  the  seat 
of  honor.  The  dairyman  and  the  breeder  have  sown 
the  wind,  and  now  are  reaping  the  whirlwind.  The 
remedy  lies  in  their  hands.  Will  they,  use  it  in 
time  to  save  their  herds,  or  will  they  continue  the 
pernicious  practices  of  the  past,  tempted  by  the 
present  gain  without  thought  of  the  greater  loss  in 
the  future.  Space  will  not  permit  of  definite 
suggestions  as  to  the  proper  course  to  be  pursued ; 
but  certainly  a  reform  in  breeding  and  feeding  with 
abolition  of  close  walled  stables  will  tend  to  restore 
a  measure  of  "natural  immunity  and  possibly  ar- 
tificial immimization  may  do  the  rest. 

Turning  now  to  human  tuberculosis,  the  seticlog- 
ical  factors  certainly  present  problems  that  demand 
the  most  careful  examination.  Broadly  speaking, 
three  main  causes  have  been  prominently  advocated, 
and  are  considered  by  their  authors  to  be  the  fans 
et  origo  of  the  trouble.  Professor  E.  von  Behring 
has  definitely  settled  the  matter  in  his  own  mind 
and  distinctly  asserts  that  "the  milk  fed  to  infants 
is  the  chief  cause  of  consumption."  Fliigge,  on 
the  other  hand,  attributes  the  spread  of  tubercu- 
losis chiefly  to  "droplet"  infection.  Others  to  dust 
particles  in  the  air  carrying  the  virulent  germs.  I 
do  not  think  that  with  our  present  knowledge  we 


June  19,  1909.] 


PIFFARD:   PROBLEMS   OF  TUBERCULOSIS. 


1249 


are  justified  in  giving  preeminence  to  either  of  the 
foregoing,  or  for  that  matter  certain"  other  factors 
that  have  from  time  to  time  attracted  notice.  Each 
undoubtedly  has  a  greater  or  less  influence  in  the 
spread  of  the  infection,  and  with  so  many  separate 
causes  in  operation  it  would  certainly  be  remark- 
able if  any  of  us  failed,  temporarily  at  least,  to  play 
the  part  of  host  to  the  insidious  germ.  As  a  matter 
of  fact,  most  if  not  all  of  us  have  harbored  some 
of  these  pernicious  little  acid  fasts.  This  was  shown 
many  years  ago  at  the  autopsy  table  and  more  re- 
cently by  tuberculin  tests  of  apparently  healthy  sol- 
diers in  one  of  the  Austrian  regiments. 

Why  then  do  not  all  or  most  of  us  give  clinical 
evidence  of  the  infection?  Simply  because  nature 
curtails  the  activity  of  the  invaders.  In  the  first 
place  the  little  polynuclears  englobe  and  possibly  di- 
gest a  certain  number  of  them,  while  other  pro- 
tecting agencies,  through  chemical  means  perhaps, 
neutralize  the  virulence  or  impair  or  destroy  the 
reproductive  powers  of  the  organisms ;  and  in  ad- 
dition some  of  them  may  be  coralled  bodily  as  it 
were  and  placed  behind  the  bars  with  prison  walls 
around  them,  and  given  an  indeterminate  sentence. 
While  thus  imprisoned  some,  perhaps  all  of  them 
die  and  are  given  a  chalky  grave.  Thus  it  is  that 
with  most  of  us,  the  resistive  powers  of  the  body 
overcome  the  aggressive  force  of  the  parasites.  Cir- 
cumstances, however,  may  arise  while  the  impris- 
oned microbes  are  still  living  and  virulent,  that  per- 
mit them  to  escape  from  their  bonds,  and  bring 
about  a  clinical  picture  too  well  known  to  need  de- 
scription in  this  place. 

DIAGNOSIS. 

Many  years  ago,  when  the  writer  for  a  time  was 
a  clinical  assistant  of  the  late  Dr.  Austin  Flint,  the 
diagnosis  of  tuberculosis  depended  chiefly  on  the 
rational  symptoms  supplemented  by  the  then  newly 
acquired  art  of  auscultation  and  percussion.  Today 
we  have  a  number  of  additional  aids  each  possess- 
ing a  measure  of  usefulness,  and  all,  with  but  one 
exception,  entirely  free  from  danger  or  serious  ob- 
jection. 

Tuberculin.  When  this  agent  was  first  intro- 
duced as  a  therapeutic  resource,  the  writer  had  an 
abundant  opportunity  to  note  the  results  of  its  use, 
and  these  results  were  so  uniformly  unfortunate 
that  he  early  acquired  a  strong  prejudice  against  it, 
which  it  must  be  admitted  he  still  retains.  Others 
met  with  the  same  experience,  and  tuberculin  as  a 
therapeutic  agent  was  abandoned.  We  now  know 
that  it  was  the  large  dose  as  originally  recommend- 
ed that  caused  the  damage. 

To-day  the  former  therapeutic  dose  is  now  used 
for  diagnostic  purposes,  and  unquestionably  in  the 
majority  of  cases  correctly  indicates  the  presence 
or  absence  of  tuberculous  foci,  but  does  so,  I  be- 
lieve, at  some  risk  to  the  future  welfare  of  the  pa- 
tient, and  if  the  experiments  of  Courmont  and 
Chalier  are  reliable,  greatly  impairs  his  resistance 
to  infection.' 

^Discussing  a  case  of  bacillosis  in  a  foetus  the  authors  say:  "On 
sait  en  effet  que  dans  les  cultures  d'un  bacille  tuberculeux  I'un  de 
nous  a  decouvert  des  produits  solubles  favorisants."  (To  infection.; 
■"C'est  la,  en  faveur  de  I'heredo-predisposition  specifique,  im  argu- 
ment tres  important.  Expcrimentaleinent  on  pent,  en  faisant 
pcm'trer  ces  produits  solubles  dans  des  organismes  animau.r,  cobayes 
par  exemple,  rendre  ceux-ci  incomparablenient  plus  aptes  a  con- 
trader  la  tuberculose."  (Lyon  medical,  September  22,  1907). 
<ltalics  mine.) 


Among  the  more  recent  aids  to  diagnosis  the  ag- 
glutination test,  based. on  the  same  principles  as  the 
better  known  Widal,  appears  to  be  promising 
though  beyond  ordinary  application  except  with 
laboratory  aid.  Yamanouchi  has  brought  forward 
an  ingenious  test.  He  inoculates  a  rabbit  with  the 
serum  of  the  suspected  subject  and  after  a  suitable 
time  follows  this  with  an  injection  of  tuberculin. 
If  the  rabbit  reacts  he  considers  this  as  positive  evi- 
dence of  tuberculosis  in  the  patient. 

Finally  we^have  Rosenberger's  statement  that  in 
tuberculosis  the  bacilli  may  be  found  in  the  circulat- 
ing blood.  Experiments  thus  far  made  have  shown 
that  while  some  of  the  investigators  have  been  suc- 
cessful the  majority  have  not.  How  far  this  method 
can  be  made  practicable  in  the  hands  of  the  or- 
dinary microscopical  worker  remains  to  be  seen.' 
The  x  ray  has  also  proved  an  unquestionable  aid 
to  diagnosis. 

Iinniunity.  Natural  immunity  is  dependent  on 
hygiene,  understanding  the  term  in  its  broadest 
sense.  The  better  the  general  physical  condition  of  ' 
the  subject  the  less  cordial  will  be  the  reception  it 
offers  to  the  invaders.  A  person  in  perfect  health 
can  destroy  the  germs  unless  present  in  overwhelm- 
ing numbers.  Artificial  immunity  obtained  through 
the  aid  of  various  sera  has  received  but  a  very  lim- 
ited application,  so  far  as  human  beings  are  con- 
cerned. From  the  very  nature  of  the  case  crucial 
experiments  to  test  its  value  are  inadmissible. 

The  attempts  that  have  been  made  to  secure  an 
artificial  immunity  in  animals,  and  especially  in  cat- 
tle, appear  to  have  been  moderately  successful,  so 
far  at  least  as  being  effective  for  six  months  or  pos- 
sibly a  year.  It  is  certainly  a  promising  field  for 
investigation  by  the  argricultural  experiment  sta- 
tions and  veterinary  laboratories  throughout  the 
country. 

Treatment.  The  writer  has  a  vivid  recollection 
of  the  introduction  by  Koch  of  tuberculin  as  a  ther- 
apeutic agent  and  the  disastrous  results  that  fol- 
lowed its  use  at  that  time.  It  is  needless  to  say  that 
the  Koch  method  had  but  a  short  life  and  was  prac- 
tically abandoned  until  revived  on  the  one  hand 
by  Sir  A.  Wright  and  by  Trudeau  on  the  other. 
The  essential  difference  between  the  old  and  the 
new  method  lies  in  the  dose,  the  current  dose  being 
only  one  thousandth  of  that  recommended  at  first. 
Wright  relies  on  the  opsonic  index  as  to  the 
amount  and  frequency  of  administration,  while 
Trudeau  in  the  main  relies  on  the  thermometer,  cer- 
tainly a  simpler  and  more  practicable  procedure  in 
the  hands  of  the  majority  of  physicians. 

Mr.  Chisholm  Williams,  of  London,  has  had  re- 
markably favorable  results  with  high  frequency  cur- 

*Forsyth  writing  in  the  British  Medical  Journal  of  April  24, 
1909,  says  that  he  examined  the  blood  of  twelve  patients  by  a 
modification  of  Rosenberger's  method.  In  ten  of  these  there  were 
distinct  physical  signs,  and  vubercle  bacilli  in  the  sputum.  In  all 
of  these  ten  he  found  bacilli  in  the  blood.     He  says; 

"The  organisms  were  of  the  long  and  short  forms,  beaded  or  uni- 
formly stained,  and  were  acid  fast  rods  morphologically  indis- 
tinguishable from  the  tubercle  bacillus.  There  seems  little  possi- 
bility of  doubting  their  identity  with  it;  seen  in  the  sputum  they 
would  be  judged  absolutely  diagnostic. 

"In  each  case  they  were  few  in  numbers;  no  groups  were  seen; 
usually  the  bacillus  was  alone  in  the  field,  or  at  most  two  appeared 
together.  They  were  found  with  more  or  less  difficulty.  Often 
only  one  was  seen  after  long  and  laborious  search  over  a  whole 
slide,  and  in  a  few  cases  two  and  three  and  four  slides  had  to  be 
examined  before  success.  In  one  case  phagocytosis  was  noted,  and 
only  in  one  was  there  evidence  of  mixed  infection  in  the  blood. 
In  this  case  a  diplococcus  was  seen  in  fair  numbers,  and  it  is 
being  further  investigated." 


1 250 


ROSEN BERGER:  TUBERCLE  BACILLUS  IN  BLOOD. 


[Nea  York 
Medical  Journal. 


rents,"  and  Thielle,  of  Rouen,  has  made  a  most  ex- 
haustive study  of  the  method,  recording  his  ob- 
serv'ations  in  minute  detail,"  giving  the  respiratory 
exchanges  and  the  nitrogen  metaboHsm  as  well  as 
the  urinary  findings  in  each  case. 

The  year  just  past  has  brought  us  still  another 
method  at  the  hands  of  Dr.  Barton  L.  Wright,  sur- 
geon, United  States  Navy.  Mercury  is  here  the  ef- 
fective agent  and  the  results  recorded  by  this  author 
are  certainly  remarkable.  I  am  not  prepared  to  ac- 
cept his  theory  as  to  the  action  of  th^  drug',  as  I 
prefer  to  look  on  it  as  a  parasiticide  acting  through 
the  blood  directly  on  the  germs,  in  the  same  manner 
as  I  believe  it  acts  on  syphilis\  Whatever  specific 
method  of  treatment  is  adopted  the  fundamental  re- 
fjuirement  of  course  is  fresh  air  in  abundance,  and 
good  food,  but  not  too  much  of  it. 

Research.  One  of  the  most  important  objects  of 
laboratory  research  that  should  receive  early  atten- 
tion is  the  determination  of  the  relations  that  exist 
between  the  various  acid  fasts  and  acid  semifasts 
,  if  indeed  such  relations  do  exist.  Next  to  determine 
the  relative  pathogenicity  of  each,  and  whether  the 
same  is  increased  or  otherwise  by  passage  through 
animals ;  then  to  be  followed  by  efforts  to  determine 
positively  the  question  of  the  transformation  of 
species  or  types  into  each  other ;  and  finally  de- 
termine if  they  have  a  common  ancestor  that  can 
be  reached,  and  whose  activities  can  be  curtailed. 
Conclusions. 

If  researches  such  as  I  have  indicated  are  to  b  " 
successfully  carried  on,  two  things  are  essential. 
First,  better  optical  devices  than  most  existing  lab- 
oratories are  provided  with  ;  and  second,  men  wlio 
know  how  to  use  them  so  as  to  obtain  their  utm  st 
efficiency.  The  Abbe  condensers  in  common  use 
are  rated  as  having  a  tlumerical  aperture  of  either 
1.20  or  1.40  but  I  have  seldom  seen  them  used  in  a 
manner  that  made  these  apertures  available.  The 
apertures  they  actually  use  are  0.78  and  0.92  re- 
spectively, and  not  one  worker  in  ten  or  possibly 
in  twenty  knows  how  to  obtain  the  rated  aperture. 
The  Abbe  condenser  itself  is  but  a  cheap  makeshift 
and  should  be  replaced  by  an  achromatic.  These 
of  different  apertures  can  be  obtained  from  a  num- 
ber of  makers. 

The  common  laboratory  objective  used  in  bacteri- 
ological work  has  a  numerical  aperture  of  1.30  Years 
ago  the  London  firm  of  Powell  &  Lealand  (now  re- 
tired from  business)  made  oil  immersion  lenses  with 
an  aperture  of  1.50;  and  the  late  Herbert  R.  Spen- 
cer made  several  monobromide  of  naphthalin  im- 
mersion objectives  with  an  aperture  of  1.54.  Inas- 
much as  the  resolving  power  of  an  objective  varies 
directly  with  its  numerical  aperture  the  advantages 
of  these  high  apertures  is  self  evident.  Objectives 
of  high  aperture,  both  dry  and  immersion,  must  be 
adjustable.  Referring  to  such  objectives  the  author 
of  a  standard  work  on  bacteriology  writes:  "Thev 
are  successfully  used  only  in  the  hands  of  an  expert. 
One  of  them  out  of  adjustment  is  worse  than  an 
ordinary  objective."  Why,  then,  are  they  so  seldom 
seen  in  actual  use?    Either  the  laboratories  (some 

'•High  Frequency  Currents,   London,  1903. 

'TrailemenI  dc  la  tuherculose  f'ar  Ics  courents  dc  haute  frequence 
ct  dc  haute  tension.  Uom-n,  1905. 

'jVcti'   yV.rfr  Medical  Journal,   November  8,  1908. 
*New   York  Medical  Journal,  June  6,  1908. 


of  which  are  richly  endowed)  are  unwilling  to  pay 
the  price  of  the  best,  or  the  laboratory  workers  are 
not  sufficiently  expert  to  properly  utilize  them.  It 
certainly  seems  to  me  that  this  state  of  affairs 
should  be  corrected.  It  is  not  only  the  gun  but  the 
"man  behind  the  gun"  that  is  needed  if  we  are 
to  advance  much  beyond  our  present  knowledge 
of  the  morphology  and  natural  history  of  microor- 
ganisms. 

256  West  Fifty-seventh  Street. 


FURTHER  STUDIES  ON  THE  PRESENCE  OF  THE 
TUBERCLE  B.\CILLUS  IN  THE  CIRCU- 
LATING BLOOD.* 

By  R.\ndle  C.  Rosexberger,  M.  D., 
Philadelnhia, 

Assistant    Professor    of    Bacteriology,    Jefferson    Medical  College; 
Director  of  the  Clinical  Laboratory  of  the  Philadelphia  Hospital. 

(From  the  Laboratories  of  the  Jefferson  Medical  College  Hospital 
^         and  the  Clinical  Laboratory  of  the  Philadelphia  Hospital.) 

Following  the  preliminary  report  of  fifty  cases  of 
pulmonary  tuberculosis  in  which  the  tubercle  bacil- 
lus was  demonstrable  in  every  instance,  I  continued 
the  study  of  the  phenomenon  until  at  tfie  present 
time  the  number  of  cases  is  over  300.  That  tuber- 
cle bacilli  were  suspected  of  being  present  in  the 
circulating  blood  is  a  well  known  fact,  as  textbooks 
frequently  refer  to  the  infection  as  spreading  by 
means  of  the  blood  or  lymph  stream,  and  also  to 
the  presence  of  tubercle  bacilli  in  the  urine  in  all 
cases  of  acute  tuberculosis,  as  pointed  out  by  Four- 
nier  and  Beaume  {La  Mcdecine  moderne.  Decem- 
ber 4,  1902,  p.  397).  Anchi  and  Chambrelent 
(Archk'es  dc  iiicdcciiie  cxpcriincntalc  ct  d'auatoinie 
patliologiqnc,  1899,  ^i-  P-  521)  report  a  case  of  tu- 
berculosis in  a  foetus  delivered  between  the  sixth 
and  seventh  month,  the  mother  dying  three  days 
after  confinement  and  showing  tubercles  in  the 
lungs  and  all  the  abdominal  viscera.  Tubercles  were 
also  present  in  the  viscera  of  the  foetus  together  with 
"an  enormous  quantity  of  Koch's  bacilli."  Rabbits 
inoculated  with  fragments  of  the  liver  and  lung  of 
the  infant  exhibited  tuberculous  manifestations  two 
months  later.  Two  cubic  centimetres  of  blood  from 
the  umbilical  cord  were  injected  into  the  peritoneal 
cavity  of  another  rabbit,  which  died  in  a  year.  Tu- 
bercles were  demonstrated  in  the  peritonaeum,  me- 
senteric glands,  liver,  spleen,  and  lungs  with  bacilli 
in  all  the  lesions. 

Barbier  and  Pollener  (La  Tuherculose  infantile, 
August  15,  1900)  report  a  case  in  a  child  aged  three 
years  where  no  macroscopic  or  microscopic  lesions 
were  observed,  yet  portions  of  the  lung  inoculated 
into  guinea  pigs  produced  tuberculosis.  They  con- 
cluded that  the  results  obtained  could  only,  be  ac- 
counted for  upon  the  supposition  of  an  intense  tox- 
jemia.  possibly  a  bacill.'emia.  the  latter  being  unat- 
tended with  tiic  formation  of  tubercles  in  any  of  the 
tissues. 

The  studies  of  Liebcrmeister  (Ueber  Tnberkcl- 
bazillen  im  Blut  der  Phthisiker.  Internationales 
Ceiitralblatt  fiir  die  j^esainte  Tubcrculose  Fors- 
cluins^,  1909,  No.  4)  and  of  Hamberger  also  sug- 

•Kead  before  the  Medical  Society  of  the  County  of  New  York. 
May  24,  1909, 


June  19,  1909. J 


ROSENBER-GER:  TUBERCLE  BACILLUS  IN  BLOOD. 


gestcd  the  great  probability  of  the  presence  of  the 
tubercle  baciUus  in  the  circulating  blood. 

Jousset  {La  Scmaine  mcdicalc.  January  19,  1903) 
demonstrated  the  tubercle  bacillus  in  the  blood  at 
autopsy  in  a  case  of  acute  miliary  tuberculosis  and 
one  of  tuberculous  meningitis  by  his  method  of 
inoscopy. 

The  studies  of  Schmorl  and  Geipel  {Milnchencr 
mcdizinische  Wochenschrift,  ii,  No.  38)  upon  trans- 
mission of  tuberculosis  from  mother  to  child,  and 
especially  pointing  out  a  tuberculous  condition  of 
the  placenta,  also  show  that  the  bacillus  is  trans- 
mitted by  the  blood  to  the  foetus. 

Sitzenfrey  {Die  Lchrc  loti  dcr  koiigciiitalcn  Tn- 
hcrknlosc,  init  bcsondcrcr  Beriicksichtigitiig  dcr 
Placcntartubcrkulose,  Berlin,  S.  Karger,  1909) 
points  out  that  long  continued  engorgement  of  the 
venous  capillaries  may  lead  to  rupture  of  these  ves- 
sels into  the  maternal  intervillous  spaces ;  then  the 
possibility  arises  that  subsequent  lowering  of  the 
vascular  pressure  in  the  villous  tufts  may  permit 
the  entrance  of  maternal  blood  and  so  allow  the 
transference  from  the  maternal  to  the  foetal  vascular 
system  of  tubercle  bacilli  which  may  be  circulating 
in  the  former. 

In  the  present  study  I  included  (together  with 
pulmonary  types)  tuberculosis  of  other  structures, 
to  determine,  if  possible,  whether  the  bacillus  could 
be  demonstrated  in  the  blood. 

Glandular,  os.seous,  and  peritoneal  tuberculosis, 
together  with  three  tumors  of  the  nervous  system 
(cerebellar),  and  one  case  diagnosticated  as  trans- 
verse myelitis  came  under  observation.  In  the  case 
of  transverse  myelitis,  which  came  to  autopsy,  there 
was  a  broken  down,  thickened  condition  of  the 
membranes  of  the  cord  in  the  upper  dorsal  region, 
which  upon  histological  study  showed  typical  tuber- 
cles and  giant  cells.  Upon  removal  of  two  of  the 
tumors  above  referred  to,  a  histological  study 
showed  them  to  be  typically  tuberculous.  In  sev- 
eral cases  of  meningitis  tubercle  bacilli  were  dem- 
onstrated in  the  blood  ;  one  of  these  came  to  autop- 
sy, and  tuberculosis  developed  in  a  pig  inoculated 
with  the  cerebrospinal  fluid. 

In  a  case  where  a  tumor  was  present  just  above 
the  clavicle  the  diagnosis  rested  between  sarcoma 
and  tuberculosis  (though  there  was  no  history  of 
tuberculosis  in  the  family  or  patient),  the  bacillus 
was  present  in  the  blood,  and  when  the  tumor  was 
removed  it  proved  to  be  a  mass  of  tuberculous 
glands. 

In  Pott's  disease  of  the  spine  a  long  search  was 
necessarv  but  tubercle  bacilli  were  eventually  de- 
tected in  the  blood,  as  well  as  in  the  faeces  and 
urine.  Operation  in  two  cases  diagnosticated  as  tu- 
berculous peritonitis  showed  a  typical  picture  of  this 
disease,  and  in  both  the  test  had  been  positive. 

Genitourinary  cases  comprising  epididymitis,  cys- 
titis, and  orchitis  al.so  showed  tubercle  bacilli  in  the 
blood. 

Acute  pleurisy,  especially  pleurisy  with  eiTusion. 
was  diagnosticated  as  tuberculous  time  and  again 
by  resorting  to  an  examination  of  the  blood. 

In  a  number  of  insane  patients  comprising  de- 
mentia praecox,  paresis,  and  acute  mania,  where  a 
diagnosis  was  made  of  tuberculous  pneumonia  or 
incipient  tuberculosis,  the  test  was  positive. 


In  three  cases  where  the  tubercle  bacillus  was 
found  in  the  blood  of  a  tuberculous  mother  the  or- 
ganism was  demonstrated  in  the  blood  of  the  child. 
One  of  the  children  was  eight  months  old,  one  one 
month  old,  and  the  third  two  months.  As  no  autop- 
sy was  allowed  in  the  case  of  two  children,  the  blood 
was  obtained  directly  from  the  heart  by  puncture 
through  the  chest  wall,  while  in  the  two  months  old 
child  the  blood  was  obtained  from  a  vein  of  the  arm. 

Landouzy,  as  early  as  1883,  and  later  (1884.  1885, 
1886)  described  a  condition  which  he  termed  typho- 
bacillose,  characterized  exclusively  by  a  typhoid 
state,  with  continuous  fever  and  enlargement  of  the 
spleen  and  without  any  signs  of  visceral  localization. 
The  fever  exhibited  greater  oscillations,  and  the  ir- 
regularities were  greater ;  the  pulse  rate  was  more 
rapid  than  in  typhoid  fever;  no  pharyngeal,  bron- 
chial, or  intestinal  catarrh ;  no  rose  spots,  and  a 
striking  absence  of  localizing  symptoms  in  the  vis- 
cera. In  the  great  majority  of  the  cases,  after  three 
or  four  weeks  of  continuous  fever  accompanied  by 
more  or  less  marked  prostration,  convalescence  was 
established.  But  this  latter  state  was  imperfect.  In 
a  few  weeks  or  many  months  localizing  signs  of  tu- 
berculosis appeared,  either  suddenly  or  insidiously, 
usually  in  the  lungs  or  pleura,  and  in  the  case  of 
children  quite  frequentl\'  in  the  mesentery.  In  a 
number  of  cases  diagnosticated  as  typhoid  fever,  in 
which  no  positive  W'idal  reactions  were  obtained  (in 
some  cases  four  or  five  agglutination  tests  were 
made),  and  where  there  was  an  irregular  tempera- 
ture curve  following  convalescence  from  the  mal- 
ady, tubercle  bacilli  were  present  in  the  blood  and 
also  demonstrable  in  the  faeces. 

Fifty-seven  cases  diagnosticated  as  incipient  tu- 
berculosis and  nine  cases  of  acute  miliary  tubercu- 
losis were  proved  by  finding  tubercle  bacilli  in  the 
blood. 

The  technique  for  the  demonstration  of  the  bacil- 
lus in  the  blood  was  by  the  citrated  blood  method  ; 
sometimes  the  specimen  was  centrifugalized,  but 
usually  it  was  allowed  to  deposit  a  sediment  by 
standing  in  the  refrigerator  over  night.  After 
spreading  and  drying  upon  a  clean,  new  slide  it 
was  thoroughly  laked,  then  dried,  fixed,  and  stained 
by  ordinary  routine  technique  as  for  sputum. 

I  have  been  asked  how  long  I  leave  the  spread  of 
blood  in  distilled  water  to  lake.  If  the  preparation 
is  properly  dried  it  can  remain  an  hour  or  longer  in 
the  water,  and  the  longer  the  better.  Where  the 
spread  is  very  thin  the  laking  takes  place  quite  read- 
ily in  several  minutes,  but  longer  exposure  will  not 
harm  it  in  any  way. 

As  in  my  work  on  the  faeces,  I  used  Pappen- 
heim's  solution  as  a  decolorizer  and  counter  stain. 
I  advised  this  for  the  blood  work  also,  insisting  upon 
an  immersion  of  at  least  twenty  minutes  to  an  hour. 
As  this  called  forth  some  criticism  I  used  a  twenty- 
five  per  cent,  solution  of  sulphuric  acid  in  absolute 
alcohol ;  ten  per  cent,  nitric  acid  in  ninety-five  per 
cent,  alcohol ;  sweet  spirits  of  nitre  after  Pappen- 
heim"s  solution,  or  combined  with  malachite  green 
instead  of  Pappenheim's  solution,  and  I  also  used 
Gabbet's  solution.  In  some  of  my  preparations  I 
found  acid  fast  bacilli  after  two  hours  exposure  to 
twenty-five  per  cent,  sulphuric  acid  in  absolute  al- 
cohol.   Remembering  that  Pappenheim's  solution  is 


1252 


ROSENBERGER:  TUBERCLE  BACILLUS  /iV  BLOOD. 


[New  York 
Medical  Journal. 


an  alcoholic  solution  it  should  be  kept  in  a  jar  so 
that  evaporation  and  precipitation  of  the  stain  will 
not  take  place.  Rinsing  the  preparation  with  nine- 
ty-five per  cent,  alcohol  or  sweet  spirit  of  nitre 
makes  the  finished  slide  a  first  class  preparation. 

In  applying  carbol  fuchsin  to  the  preparation  I 
simply  allow  it  to  act  in  the  cold  for  ten  or  fifteen 
minutes  to  twenty-four  hours,  and  very  rarely,  if 
ever,  heat  it  except  when  in  haste.  In  these  investi- 
gations I  used  sodium  citrate  solutions  made  at  five 
dififerent  institutions.  Some  of  the  spreads  were 
made  in  one  laboratory  and  laked  and  stained  in 
another.  The  jars  containing  the  stains,  after  being 
washed,  were  replenished  twice  a  week  with  fresh 
•stain.  Ammonium  oxalate  (one  per  cent,  in  normal 
salt  solution)  was  also  used  for  treating  the  blood 
to  prevent  clotting.  The  solutions  of  sodium  citrate 
.and  ammonium  oxalate  were  sterilized  by  the  auto- 
clave or  steam  sterilizer  and,  before  using,  left  in 
the  incubator  for  several  days  at  body  temperature. 
Spreads  made  from  the  sediment,  which  occasional- 
ly took  place  in  the  citrate  solution  failed  to  show 
any  so  called  citrate  bacilli.  The  syringes  for  ob- 
taining the  blood  were  boiled  in  caustic  soda  for 
twenty  minutes,  then  boiled  in  water  or  sterilized  by 
•dry  heat  at  140^'  to  160°  C.  for  at  least  an  hour  and 
sometimes  for  two  hours.  The  pipettes  were  ster- 
ilized by  hot  air,  then  placed  in  nitric  acid,  or  were 
first  boiled  in  caustic  soda  and  sterilized  in  the  hot 
air  sterilizer  at  the  same  temperature  and  for  the 
same  length  of  time  as  the  syringes. 

As  to  the  morphology  of  the  organism ;  if  one 
should  take  a  young  or  old  culture  of  the  tubercle 
bacillus  upon  any  culture  medium,  and  stain  this  by 
ordinary  sputum  technique,  he  would  see  short 
(coccoid),  long,  thin,  thick,  solid  staining,  beaded, 
filam.entous,  clubbed,  arid  possibly  branching  forms 
of  the  organism.  Now.  which  of  these  is  the  typical 
form?  If  one  should  stain  a  specimen  of  sputum 
and  made  at  least  a  fifteen  or  twenty  minutes'  study 
of  the  preparation,  would  he  see  only  one  type  of 
the  bacillus?  He  would  observe  all  sizes  and  all 
degrees  of  intensity  of  staining. 

Another  point  about  the  culture  of  the  bacillus. 
All  of  the  elements  are  not  absolutely  acid  fast. 
When  stained  by  ordinary  technique,  as  for  sputum, 
and  using  any  of  the  decolorizing  solutions  which 
I  have  enumerated  elsewhere,  there  will  be  seen 
some  bacilli  that  are  absolutely  decolorized  and  tak- 
ing the  counter  stain.  Where  groups  of  organisms 
are  present  the  acid  fast  property  is  retained,  but 
where  the  spread  contains  isolated  bacilli  these  will 
be  seen  to  have  decolorized  completely,  or,  as  Dr. 
Pififard  suggests,  are  acid  semifast. 

In  the  preparations  of  the  blood  I  never  made  a 
diagnosis  of  a  tubercle  bacillus  unless  it  was  ab- 
solutely acid  fast.  The  organisms  were  of  the  mor- 
-phology  noted  in  cultures  or  sputum  but  none  of 
them  would  be  mistaken  by  a  bacteriologist  for 
granules  of  debris! 

In  some  preparations  the  organisms  were  very 
easily  detected,  requiring  only  a  very  short  time; 
but  on  the  other  hand  a  search  lasted  a  couple  of 
hours  a  day  for  two  days,  and  in  one  or  two  cases 
three  days,  before  bacilli  were  detected. 

As  a  rule,  two  spreads  were  made  from  each 
■.specimen,  and  on  several  occasions  a  second  and  in 


one  instance  a  third  lot  of  spreads  were  made.  If 
the  patient  came  to  autopsy  and  we  failed  to  find 
the  organisms  before  death,  additional  smears  were 
made  from  the  original  tube.  In  two  cases  a  month 
intervened  between  the  time  the  blood  was  obtained 
and  a  second  preparation  made,  and  the  bacilli  were 
plainly  demonstrable.  In  my  own  series  of  312  cases 
of  tuberculosis  an  acid  fast  bacillus  was  demonstra- 
ble in  every  case  which  was  indistinguishable  from 
the  tubercle  bacillus. 

No  attempt  to  grow  the  organism  from  the  blood 
has  as  yet  been  made. 

In  the  majority  of  the  frank,  tuberculous  cases 
the  diagnosis  was  always  corroborated  by  finding 
the  tubercle  bacillus  in  the  faeces,  sputum,  and  some- 
times in  the  urine.  In  one  case  we  found  the  organ- 
ism in  the  pleural  fluid,  urine,  sputum,  faeces,  and 
blood.  In  two  instances  the  bacillus  was  detected 
in  mother's  milk  simply  by  centrifugalization,  with- 
out the  addition  of  citrate  solution,  and  stained  in 
the  ordinary  way  (Dr.  Tint).  In  a  number  of 
cases  tuberculin  reactions  were  positive,  while  in  a 
few  no  reactions  to  this  product  took  place.  Two 
series  of  cases  may  be  cited  as  being  of  very  great 
interest : 

In  the  first  series,  eighty  cases  were  studied.  Mn 
which  the  tubercle  bacillus  was  found  in  the  blood. 
Forty-eight  specimens  of  faeces  were  obtained,  and 
forty-five  were  positive ;  fifty-six  specimens  of  spu- 
tum were  studied,  and  tubercle  bacilli  were  found 
in  thirty-three  and  none  at  all  in  twenty-three ;  of 
six  specimens  of  urine  studied,  tubercle  bacilli  were 
found  in  five ;  of  miscellaneous  materials  such  as 
pleural  fluid,  pus  from  joints  or  sinuses  or  from 
empyemata,  twenty-three  were  studied  wnth  posi- 
tive results  in  twenty-two  (Dr.  Keilty's  studies). 

In  a  second  series,  comprising  forty-two  cases  of 
tuberculosis,  the  bacillus  was  found  in  the  blood  in 
all,  and  of  nineteen  specimens  of  faeces  submitted 
for  examination  all  showed  tubercle  bacilli  (Dr. 
Knight's  studies). 

As  a  final  corroborative  test,  autopsies  Were  held 
in  thirty-two  cases  and  all  of  these  showed  some 
tuberculous  lesion  or  lesions. 

From  fifty  of  these  cases,  after  pouring  ofif  the 
citrate  solution  the  sediment  of  the  blood  (about 
2  to  3  c.c.)  was  inoculated  injto  the  peritoneal  cav- 
ity of  guinea  pigs.  One  of  the  animals  died  in  a 
month  with  miliary  tuberculosis  of  both  lungs. 
Three  other  pigs  died  in  two  months,  one  of  these 
presenting  miliary  tuberculosis  of  both  lungs  and 
spleen,  and  another  dying  of  a  frank  pneumonia 
developing  upon  a  tuberculous  condition  in  the  up- 
per lobe  of  the  right  lung.  Four  pigs  showed  a 
few  scattered  tubercles  in  the  lung  as  well  as  in  the 
liver.  The  remainder  of  the  animals  (30)  did  not 
present  any  gross  lesions,  but  the  blood  of  each  pig- 
contained  acid  fast  bacilli  resembling  those  found 
in  human  blood.  (A  study  of  the  blood  of  appar- 
ently normal  guinea  pigs  was  made  for  the  detection 
of  acid  fast  bacteria  but  none  were  demonstrable.) 
I  sacrificed  a  number  of  animals  at  the  end  of  two 
months  and  though  the  bronchial  glands  were  ap- 
parently enlarged  no  other  changes  were  noticed 
macroscopically.  I  have  decided  to  allow  the  re- 
mainder of  the  pigs  under  observation  to  live  on  for 
several  weeks  or  perhaps  months  to  determine  if 


June  19,  1909.] 


HUDSOX-MAKUEN:  REMOVAL  OF  FAUCIAL  TOXSIL. 


1253 


this  seemingly  avirulent  bacillus  will  eventually 
cause  the  development  of  tuberculosis.  The  fact 
that  the  bacillus  still  exists  in  the  blood  after  two 
months'  time  leads  me  to  suspect  that  it  will  persist 
for  an  indefinite  time,  and  for  this  reason  my  deci- 
sion to  allow  the  animals  to  live  longer  is  made. 
Portions  of  the  lung  and  spleen  were  taken  and  car- 
ried through  routinely  for  microscopic  study. 

Histological  examination  of  the  organs  of  the  ani- 
mals sacrificed  up  to  this  time  shows  the  lungs  to  be 
generally  the  seat  of  some  cellular  proliferation. 
This  proliferation  is  seen  mostly  around  the  smaller 
bloodvessels,  while  iipon  the  periphery  of  the  lung 
structure  are  accumulations  of  small,  round  cells 
which  strongly  suggest  the  beginning  formation  of 
tubercles.  The  spleens,  with  the  exception  of  those 
showing  gross  lesions,  do  not  reveal  any  change 
indicative  of  tuberculosis.  I  have  not  had  time  to 
study  all  of  the  organs  for  the  presence  of  tubercle 
bacilli,  but  in  each  one.  where  gross  lesions  are  pres- 
ent, the  organisms  are  very  plainly  observed. 

The  blood  was  studied  in  112  other  cases  in  which 
tuberculosis  was  not  diagnosticated  or  suspected, 
i.  e.,  typhoid  fever,  croupous  pneumonia,  erysipelas, 
uraemia,  apoplexy,  cardiac  disease,  strangulated 
hernia,  morphine  habitues,  alcoholics,  and  some  pre- 
senting symptoms  of  renal  disease.  In  only  six  were 
tubercle  bacilli  found  in  the  blood,  and  a  physical 
examination  and  study  of  the  fjeces  resulted  in  a 
diagnosis  of  tuberculosis  being  justified  and  was 
proved  in  several  cases  at  autopsy.  Of  the  nega- 
tive cases  seven  patients  came  to  autopsy,  and  not 
one  of  these  showed  the  most  minute  lesion  of  tu- 
berculosis in  any  part  or  organ  of  the  body. 

The  only,  reason  I  can  advance  for  the  almost 
general  condition  of  avirulence  of  the  organism 
found  in  the  blood  is  the  part  played  by  the  bac- 
teriolytic substances  in  the  blood.  The  continued 
circulation  of  the  organism,  in  the  blood  and  the  bac- 
teriolytic action  exerted  may  possibly  account  for 
the  irregular  morphology  of  the  organism. 

As  a  result  of  these  studies  I  am  more  than  ever 
convinced  that  tuberculosis  is  a  bacterisemia,  and 
that  the  tubercle  bacillus  can  be  demonstrated  in  the 
blood  in  every  case  where  there  is  an  active  tu- 
berculous process.  I  also  believe  that  the  bacillus 
is  present  in  the  blood  in  a  certain  percentage  of 
apparently  healthy  individuals  at  some  period  and 
perhaps  may  be  there  for  years  in  an  attenuated 
form,  and  when  the  general  resistance  is  lowered 
or  the  resistance  in  some  viscus  or  anatomical  struc- 
ture is  lessened  the  bacillus  becomes  pathogenic,  at 
once  lodges  at  this  point,  and  brings  about  the 
disease,  tuberculosis. 

If  the  bacillus  is  not  present  in  the  blood,  how 
can  instances  of  the  disease  be  explained  as  result- 
ing from  injuries  of  various  kinds,  or  even  after 
surgical  operations?  Surely  the  greatest  care  is  ex- 
ercised by  the  surgeon  as  regards  antisepsis  and  yet 
tuberculosis  is  said  to  follow  operations,  as  for  ap- 
pendicitis, where  absolute  cleanliness  is  exercised. 
I  also  believe  that  the  bacillus  is  transmitted  from 
mother  to  child  through  the  placenta,  as  the  exam- 
ination of  a  large  number  of  specimens  of  blood 
from  umbilical  cords  show  these  same  acid  fast  or- 
ganisms as  obtained  from  the  mother's  blood.  This 
phase  of  the  subject,  I  will  publish  in  a  later  paper. 


Finally,  I  wish  to  record  my  heartiest  thanks  to 
Dr,  Keilty,  Dr,  Tint,  and  Dr.  Knight,  resident  path- 
ologists of  the  Philadelphia  Hospital,  for  collecting 
specimens  and  making  preparations  for  this  study, 
and  to  the  resident  physicians  of  the  Jefferson  ^led- 
ical  College  Hospital  who  assisted  me  in  collecting 
blood  from  interesting  cases. 

2330  XoRTH  Thirteenth  Street. 


SOME  IXDICATIOXS  FOR  THE  REMOVAL  OF  THE 
FAUCIAL  TOXSIL  AXD  SUGGESTIOXS 
AS  TO  ITS  TECHXIQUE.* 

By  G.  Hudsox-M.akuex,  M.  D., 
Philadelphia, 

Professor  of  Defects  of  Speech  in  the  Polyclinic  Hospital  ar.d  College 
for  Graduates  in  Medicine;  Laryngologist  to  the  Roosevelt 
and  Frederick  Douglas  Memorial  Hospitals,  Phila- 
delphia, and  to  the  Chester  Hospital, 
Chester,  Pa. 

In  this  age  of  rapidly  advancing  major  surgery, 
it  may  be  well  for  us,  perhaps,  to  give  some  heed 
to  the  biblical  injunction  against  despising  "the  day 
of  little  things,"  and  therefore,  I  venture  to  direct 
your  attention  to  a  field  of  so  called  minor  surgery 
which  is  being  greatly  neglected.  Whether  or  not 
it  should  be  relegated  to  the  category  of  minor  sur- 
ger_\',  however,  I  shall  leave  you  to  judge  when  I 
have  finished. 

The  faucial  tonsil  is  that  portion  of  \\'aldeyer's 
ring  of  lymph  tissue  which  is  situated  within  the 
fauces,  in  contradistinction  to  the  pharyngeal 
tonsil  or  so  called  adenoid,  situated  in  the  vault  of 
the  pharynx,  and  the  lingual  tonsil  at  the  base  of  the 
tongue.  The  faucial  tonsil  rests  upon  the  fascia 
of  the  superior  constrictor  muscle,  and  in  its  normal 
condition  it  is  tucked  away  out  of  sight  between  the 
pillars  of  the  palate. 

This  tonsil  dififers  in  no  essential  respect  either 
histologically  or  functionally  from  the  lymph  tissue 
in  other  parts  of  the  body,  and  so  far  as  we  can  de- 
termine it  serves  no  useful  purpose.  In  other  words, 
its  function  in  man  has  not  been  demonstrated.  We 
only  know  that,  like  the  vermiform  appendix,  it  mav 
be  removed  in  its  entirety  without  producing  any 
appreciable  ill  efifects,  and  that  in  its  diseased  con- 
dition, like  the  appendix  again,  it  is  a  distinct  men- 
ace to  the  human  economy.  Speaking  of  the  appen- 
dix, I  am  of  the  opinion  that  the  tonsil  has  been  re- 
sponsible for  the  greater  number  of  deaths,  and  I 
am  not  sure  but  that  Gruber,  of  Jena,  who  has  given 
a  closer  study  to  this  subject  than  almost  any  one 
else,  may  have  been  right  when  he  advised  the  com- 
plete removal  of  all  tonsils,  without  waiting  for  the 
trouble  which  is  so  sure  to  come.  However,  no  one 
who  has  given  the  subject  any  attention  at  all  will 
doubt  the  advisability  of  removing  the  gland  when 
it  has  once  become  diseased, 

\\'hat  is  a  diseased  tonsil,  and  how  shall  we  dis- 
tinguish it  from  the  normal  one?  Generally  speak- 
ing it  may  be  stated  that  a  visible  tonsil,  or  one 
that  may  be  demonstrated  by  means  of  the  tongue 
depressor,  is  abnormal  and  pathological,  but  on  the 
other  hand,  a  tonsil  may  be  diseased  without  being 
large  and  without  encroaching  to  any  extent  upon 

*Read  before  the  Delaware  Coi;nty  Medical  Society  in  Chester, 
Pa.,  in  December,  1908. 


1254 


HUDSON-MAKUEN:  REMOVAL  OF  FAUCtAL  TONSIL. 


[New  York 
Medical  Journal. 


the  pharyngeal  space.  Indeed  the  more  diseased 
and  consequently  the  more  harmful  tonsil  is  the  one 
that  is  scarcely  visible  at  all ;  it  is  buried  deeply  be- 
tween the  pillars  of  the  palate,  it  has  little  or  no 
drainage  into  the  mouth,  its  secretions  are  retained 
and  absorbed,  and  it  becomes  a  veritable  hotbed  of 
infection,  a  kind  of  culture  tube  for  bacteria,  with 
splendidly  equipped  lymphatic  attachments  for  the 
distribution  and  dissemination  of  these  bacteria 
throughout  other  portions  of  the  body. 

The  following  are  some  of  the  systemic  diseases 
that  have  been  attributed  to  the  infection  from  this 
type  of  faucial  tonsils.  Measles,  scarlet  fever, 
whooping  cough,  diphtheria,  acute  articular  rheu- 
matism, endocarditis,  myocarditis,  pericarditis,  ade- 
nitis, arthritis,  osteomyelitis,  phlebitis,  neuritis,  iri- 
tis, nephritis,  appendicitis,  chorea,  pleurisy,  Hodg- 
kin's  disease,  and  tuberculosis.  This  is  a  long  list, 
and  some  of  them  remind  me  of  the  Englishman  and 
the  ox  tail  soup.  He  said,  "Isn't  that  going  rather 
far  back  for  soup  ?"  And  yet  every  one  of  these  sys- 
temic diseases  has  been  suggested  as  being  a  possi- 
ble result  of  tonsillar  infection.  We  have  all 
observed  the  relationship  between  rheumatism  and 
acute  amygdalitis ;  and  that  tuberculous  infection 
may  be  transmitted  directly  through  the  tonsil  and 
lymphatic  glands  of  the  neck  to  the  pleura  and 
apices  of  the  lungs  has  been  clearly  proved  by  ani- 
mal experimentation.  We  have  all  seen  tuberculous 
glands  of  the  neck  appear  and  reappear  in  spite  of 
repeated  operations,  until  the  focus  of  infection, 
viz.,  a  diseased  faucial  tonsil,  has  been  found  and 
removed,  and  I  have  no  hesitation  in  saying  that  if 
these  diseased  faucial  tonsils  were  found  (I  say 
found  because  as  a  rule  they  are  submerged  and 
must  be  looked  for)  and  removed  at  the  proper 
time,  tuberculous  and  otherwise  infected  glands  of 
the  neck  would  soon  be  in  great  measure  a  thing  of 
the  past,  and  many  cases  of  apical  and  other  re- 
gional tuberculosis  of  the  lungs  would  undoubtedly 
be  nipped  in  the  bud. 

As  to  the  exanthematous  diseases,  of  which  scar- 
let fever  may  be  taken  as  a  type,  we  all  know  how 
pronounced  and  distressing  oftentimes  are  the 
throat  symptoms.  Indeed  it  is  not  unusual  to  have 
the  attack  ushered  in  by  a  marked  amygdalitis,  and 
mav  we  not,  therefore,  with  good  reason  suspect  the 
tonsil  of  being  the  source  of  infection  in  such  dis- 
eases ? 

It  is  not,  however,  of  the  harmful  effects  of  dis- 
eased tonsils  upon  the  general  health  alone  that  I 
wish  to  speak,  but  also  of  their  effects  upon  the  or- 
gans of  special  sense  situated  in  their  immediate 
neighborhood.  We  hear  much  nowadays  about  the 
dire  consequences  of  the  neglected  pharyngeal  ton- 
sil, or  adenoid,  and  I  assure  you  that  I  see  in  my 
practice  every  day  good  reasons  for  continuing  this 
discussion  and  agitation,  but  I  am  nevertheless  of 
the  opinion  that  the  diseased  faucial  tonsil  is  the 
greater  enemy  of  mankind,  and  that  its  ill  effects  are 
not  only  ntore  far  reaching  but  also  more  noticeable 
and  pronounced  in  the  immediate  vicinity  of  the 
throat,  nose,  and  ear. 

Case  I. — By  the  way  of  illustration  I  may  cite  the  case 
of  a  little  girl  whom  I  saw  in  consultation  only  a  few  days 
ago.  She  was  nine  years  of  age,  of  average  size,  and 
fairly  well  developed.  She  was  anremic,  however,  and  of 
nervous  temperament.    The  first  thing  to  catch  the  eye 


was  a  chain  of  swollen  and  painful  glands  at  the  angle  of 
the  jaw.  There  was  a  history  of  recurrent  acute  amygdal- 
itis, and  she  was  only  just  recovering  from  her  last  attack. 
I  was  consulted  on  account  of  her  deafness,  which 
was  absolute  and  which  had  come  on  suddenly  during 
the  last  week  in  August.  The  child  had  a  sore  throat 
(amygdalitis),  but  she  was  convalescing,  and  she  went  to 
bed  one  night  hearing  perfectly  well  and  awakened  the  next 
morning  absolutely  deaf;  at  least  this  was  the  story  of 
her  parents  and  physician.  She  was  nervous  and  altogether 
intractable  at  first,  making  any  satisfactory  examination  of 
her  throat  and  ears  impossible,  and  inasmuch  as  sudden 
deafness  arising  from  tonsillar  disease  is  very  unusual,  I 
at  once  thought  of  hysterical  deafness  as  a  possible  diag- 
nosis, and  of  assumed  or  simulated  deafness.  While, 
therefore,  I  was  training  the  child  into  submission  to  the 
necessary  throat,  nose,  and  ear  examination,  I  referred  her 
to  Dr.  Charles  K.  Mills,  for  an  opinion  as  to  her  general 
nervous  condition,  but  he  was  unable  to  throw  any  light 
whatever  upon  the  actual  cause  of  her  deafness.  He 
thought,  however  (with  me),  that  tbe  theory  of  hysteria 
might  safely  be  excluded  and  also  that  of  simulation. 

All  this  time  I  was  succeeding  in  my  efforts  to  gain  the 
confidence  of  our  patient,  and  to  make  satisfactory  local 
examinations.  I  have  told  you  that  she  had  large  sub- 
maxillary and  cervical  glands  on  the  left  side,  and  I  now 
found  a  fairly  large  and  imbedded  faucial  tonsil  on  the 
same  side  and  a  similar  but  somewhat  smaller  one  on  the 
right.  The  pharynx  was  highly  congested,  especially  in  the 
region  of  the  anterior  faucial  pillars,  and  a  thick,  purulent 
substance  presented  at  the  orifices  of  the  tonsillar  crypts, 
especially  on  the  left  side.  There  was  also  a  slight  post- 
nasal catarrh  and  a  small  adenoid. 

Then  came  my  surprise  when  I  examined  the  cars.  In 
the  first  place,  I  discovered  slight  hearing  power  for  words 
spoken  very  loudly  in  close  approximation  to  the  right 
ear,  while  on  the  other  side  there  was  no  response,  even 
to  the  loudest  tones.  The  right  ear  drum  was  opaque  and 
considerably  retracted,  and  very  little  motion  could  be 
elicited  in  the  ossicular  chain.  Here,  I  thought,  is  the  ex- 
planation of  the  deafness,  but  why  its  sudden  onset  ?  I 
found  the  left  drum  even  more  opaque  and  retracted,  and 
in  addition  there  was  a  distinct  scar  in  the  lower  posterior 
quadrant,  showing  unmistakable  evidence  of  previous  ear 
disease.  When  I  described  my  findings  to  the  parents,  they 
recalled  an  attack  of  ear  ache  followed  by  a  slight  dis- 
charge, several  years  ago,  and  when  I  said  that  the  child 
had  been  growing  deaf  for  years  they  admitted  that  she 
had  complained  of  not  hearing  well  for  some  time,  but 
they  thought  nothing  of  it. 

Now  here  we  have  a  bright  little  girl  of  nine  years,  tiie 
only  child  of  an  intelligent,  well  to  do  family,  having 
gradually  grown  deaf  without  knowing  it,  and  as  a  result 
in  all  probability  of  neglected  faucial  tonsils.  The  hearing 
in  the  left  ear  had  doubtless  been  gone  for  many  months, 
while  that  in  the  right  was  only  slightly  impaired  until 
this  last  attack  of  amygdalitis,  accompanied  by  a  very  gen- 
eral systemic  infection,  cut  off  its  last  vestige  of  hearing 
and  rendered  her  absolutely  and,  as  I  fear,  irretrievably 
deaf.  If  this  child's  faucial  tonsils  had  been  removed  at  the 
proper  time,  her  hearing  in  all  probability  would  ha\-e  been 
saved. 

This  is  not  an  unusual  case.  It  is  peculiar  only  in  the 
apparently  sudden  onset  of  the  deafness.  When  I  re- 
moved the  child's  tonsils  I  found  on  the  left  side,  the  side 
of  the  most  profound  deafness  and  the  side  of  the  swollen 
cervical  glands,  nearly  a  drachm  of  foul  smelling  purulent 
detritus  filling  the  deep  pocketed  crypts. 

Case  il. — Another  case,  a  young  woman  with  good  health 
and  good  parentage,  was  obliged  to  give  up  her  position 
as  stenographer,  upon  which  she  was  dependent  for  a  live- 
lihood, on  account  of  increasing  hardness  of  hearing.  An 
examination  revealed  large,  adherent  and  submerged  fau- 
cial tonsils  with  a  remnant  of  an  adenoid,  between  which 
and  the  eustachian  orifices  numerous  strong  fibrous  bands 
had  formed.  The  ear  drums  were  markedly  retracted  and 
congested,  showing  a  considerable  inflannnation  in  both 
tympanic  cavities.  I  removed  this  young  woman's  tonsils 
and  adenoids  about  two  month?  ago.  and  she  has  resumed 
her  stenographic  work  with  fully  fifty  per  cent,  increased 
hearing  power. 

Case  III.— Still  anotlier  case  was  that  of  a  boy  fourteen 
years  of  age  in  whom  an  acute  otitis  media  developed,  which 


June  .9,  1909.]  HUDSON-MAKUEN:  REMOVAL  OF  FAUCIAj.  TONSIL.  1255 


went  on  to  suppuration.  He  was  operated  upon  two  or 
three  years  ago  for  "adenoids."  Upon  examination,  I 
found  the  ear  still  discharging  copiously,  the  vault  of  the 
pharynx  free  of  adenoid  tissue  but  full  of  tenacious  mu- 
cus, and  the  fauces  presenting  large  and  irnbedded  tonsils 
with  catarrhal  adhesions  and  crypts.  This  patient  wai 
again  put  under  general  ether  anesthesia  and  the  faucial 
tonsils  were  thoroughly  removed,  since  which  time  the  ear 
had  practically  ceased  discharging  and  he  has  gained  twelve 
pounds  in  weight  in  the  past  two  months. 

Many  cases  similar  to  the  aforementioned  might 
be  cited,  but  enough  has  been  said  to  show  the  re- 
lation of  the  fauces  both  to  the  general  health  and 
to  the  adjacent  structures,  and  from  what  has  been 
said  we  may  conclude  that  it  is  imperative  upon  us 
as  practitioners  of  medicine  to  examine  the  fauces 
as  a  routine  measure,  just  as-  we  examine  the 
tongue,  in  all  infectious  and  most  other  diseases  of 
the  general  system,  as  well  as  in  all  local  diseases  of 
the  head  and  neck,  and  whenever  we  find  evidences 
of  disease  in  the  tonsils  to  remove  them  in  their  en- 
tirety, after  the  acute  symptoms  have  subsided.  We 
may  conclude  also  that  so  called  amygdalitis  or  peri- 
tonsillitis or  quinsy,  both  painful  and  oftentimes 
dangerous  conditions  are  largely  preventable  by 
well  directed  surgical  interference.  I  may  go  fur- 
ther and  say  that  it  is  our  duty  to  examine  the 
fauces  and  nasopharynges  of  all  children  who  come 
under  our  jurisdiction,  in  order  that  we  may  antici- 
pate the  trouble  that  so  surely  comes. 

Among  the  local  symptoms  that  should  make  us 
suspicious  of  tonsillar  disease  are  recurrent  attacks 
of  pharyngitis  and  laryngitis  accompanied  by 
hoarseness  and  a  distressing,  hacking  cough. 

Operation. 

No  part  of  the  human  anatomy  is  so  frequently 
attacked  by  the  surgeon's  knife  as  the  faucial  ton- 
sil, and  I  think  I  may  add,  without  fear  of  contra- 
diction, that  no  operation  is  so  universally  bungled 
as  that  of  so  called  tonsillotomy. 

Practitioners  of  medicine,  however  young  or 
however  old  and  whatever  may  have  been  their 
training  or  lack  of  training,  have  seemed  to  think 
themselves  abtindantly  able  to  "clip  off"  a  tonsil, 
while  special  surgeons,  whose  operations  in  this  re- 
gion have  run  into  the  hundreds  and  even  thou- 
sands, have  only  recently  come  to  regard  the  pro- 
cedure in  the  nature  of  a  serious  operation,  requir- 
ing great  care  and  a  considerable  amount  of  dexter- 
ity and  skill,  and  not  wholly  without  danger  to  the 
life  of  the  patient. 

Moreover,  it  is  an  operation  that,  in  a  given  case, 
should  be  done  or  it  should  not  be  done,  and  if  it 
should  be  done,  it  is  not  as  Shakespeare  says, 
"well 

It  were  done  quickly," 
but  rather  that  it  were  done  deliberately  and  thor- 
oughly. 

The  diseased  tonsil  should  be  removed  in  foto 
with  its  capsule  intact.  The  modern  operation  is 
not  a  tonsillotomy  at  all,  but  a  tonsillectomy,  and  it 
(Tonsists  oftentimes  in  a  careftil  dissection  of  the 
gland  from  its  bed,  deep  down  between  the  pillars 
of  the  palate  upon  the  superior  constrictor  muscle. 

I  have  said  that  the  faucial  tonsils  are  the  seat  of 
ntnnerous  operations  and  I  shall  go  fttrther  and  say 
that  these  operations  should  be  far  more  numerous 
and  more  radical.    I  am  aware  that  there  are  those 


who  will  not  agree  with  me  in  this  position,  but  I 
think  I  am  peculiarly  qualified  to  speak  with  author- 
ity upon  the  subject,  because  of  my  unusual  oppor- 
tunities for  careful  studies  of  the  mouth  and  fauces 
both  before  and  after  operations  in  connection  with 
my  work  in  defects  of  speech.  Some  of  these  pa- 
tients, I  see  not  once  or  twice,  but  every  day  for 
months,  and  I  am  able  to  note  the  results,  as  well 
as  the  neglect,  of  operations.  And  following  up 
these  patients,  some  of  thein  for  many  years,  I  may 
say  that  I  have  never  yet  had  occasion  to  regret  the 
removal  of  a  tonsil  for  any  cause  whatsoever,  but  I 
have  had  many  occasions  to  regret  a  temporizing 
treatment  and  a  partial  removal  of  the  gland. 

I  have  not  always  taken  this  radical  view.  Fif- 
teen years  ago  I  wrote  a  paper  advocating  a  inodi- 
fied  surgical  treatment  of  diseased  tonsils,  and  I  de- 
vised some  instruments  for  the  special  procedure, 
but  I  have  now  abandoned  them  entirely  except  for 
adult  patients  in  whom  the  radical  operation  might 
appear  to  be  somewhat  hazardous  because  of  the 
danger  of  haemorrhage. 

It  is  interesting  to  follow  the  historical  develop- 
ment of  this  operation,  as  outlined  by  Dr.  John  N. 
Mackenzie  in  Diseases  of  the  Throat,  Nose,  and  Ear. 
We  find  that  early  in  the  Christian  era  a  thorough 
removal  of  the  tonsil  was  advocated  and  frequent- 
ly practised,  for  several  centuries,  after  which  there 
came  a  reaction  against  the  procedure  on  account 
of  the  difficulties  of  the  operation  and  the  reports 
of  death  from  haemorrhage. 

In  the  beginning  of  the  twelfth  century,  the  fear 
of  haemorrhage  became  universal,  and  the  operation 
was  practically  abandoned.  In  the  work  of  Pare, 
in  the  fifteentli  century,  we  read  of  the  nerformance 
of  preliminary  tracheotomies  in  cases  in  which  the 
removal  of  tonsils  seemed  imperative.  He  also 
speaks  of  ligation  of  the  glands,  but  advises  against 
their  removal  except  in  extreme  cases  of  enlarge- 
ment. 

This  feeling  continued  for  upward  of  two  hun- 
dred years  and  toward  the  close  of  the  seventeenth 
century,  Heister  said,  "The  operation  is  not  only  too 
severe  and  cruel,  but  also  too  difficult  in  its  per- 
formance to  come  into  the  practice  of  moderns  be- 
cause of  the  obscure  situation  of  the  tonsils."  This 
opinion  seems  to  have  been  well  founded  when  w-e 
consider  that  the  only  instruments  for  the  operation 
in  those  days  were  the  tenaculum  and  the  bistoury 
and  that  reflected  light  was  not  employed. 

It  was  well  along  in  the  eighteenth  century  that 
with  improved  instrumentation  and  technique,  the 
dread  of  haemorrhage  began  to  disappear.  Tonsil- 
lotomies now  came  into  vogue,  the  first  one  of 
which,  by  the  way,  is  said  to  have  been  devised  by 
Physick,  of  Philadelphia,  in  1827.  It  resembled 
somewhat  the  modern  Mackenzie  pattern,  which  is' 
now  often  used. 

Then  came  the  Fahnenstock  pattern,  with  the 
ring  knife  cutting  from  behind  forward,  and  now 
dozens  of  styles  are  on  the  market,  so  that  one's 
fancy  in  choice  may  be  fully  gratified.  As  for  mv- 
self,  I  rarely  use  the  tonsillotome,  because  I  think 
that  in  most  instances  the  operation  may  be  done 
better  and  more  safely  with  other  instruments. 

Operations  upon  the  tonsil  may  be  divided  into 
two  classes :  Those  which  should  be  done  under  gen- 


1256 


HUDSON-MAKUEN:  REMOVAL  OF  FAUCIAL  TONSIL. 


[New  York 
Medical  Journal 


eral  anaesthesia,  and  those  which  should  be  done  un- 
der local  anaesthesia.  In  the  first  or  general  anaes- 
thesia class,  I  put  all  children  under  ten  or  twelve 
3-ears  of  age,  all  or  nearly  all  of  any  age  when  ade- 
noids are  to  be  removed  at  the  same  time ;  and  in 
the  second  class,  or  local  anaesthesia  class,  I  put 
adults  and  older  children  having  no  adenoids  (a 
rare  condition)  and  whose  complete  cooperation  I 
can  secure. 

The  operation  is  altogether  too  delicate  to  per- 
form in  a  struggling  child,  although  with  our  mod- 
ern methods  of  local  aUcTsthesia,  it  may  be  made 
nearly  if  not  quite  painless  and,  I  may  add,  also 
bloodless,  although  secondary  or  reactionary  haem- 
orrhage is  more  liable  to  occur  after  the  use  of  adre- 
nalin. 

The  (.'peration,  upon  the  whole,  is  safer  under 
general  anaesthesia  because  with  it  there  is  rarely 
any  secondary  haemorrhage  and  all  primary  bleeding 
may  be  easily  controlled  either  by  pressure  or,  if 
necessary,  bv  ligation. 

Haen^.orrhage  in  this  operation  may  arise  from 
several  sources,  but  it  usually  comes  either  from  the 
tonsillar  or  ascending  pharyngeal  artery,  and  if  the 
anterior  pillar  is  wounded  it  may  come  from  the 
dorsal  artery  of  the  tongue. 

The  danger  of  injury  to  either  of  the  carotids  is 
exceedingly  remote  because  they  are  nearly  two  cm. 
from  the  tonsil  and  separated  from  it  by  the  superior 
constrictor  and  styloid  muscles,  and  a  mass  of  loose 
connective  tissue  and  semifluid  fat.  Occasionally 
however,  the  external  carotid  curves  in  toward  the 
danger  point,  but  this  is  extremely  rare.  It  should 
be  remembered  also  that  some  the  branch  arteries 
in  this  region  are  sometimes  large  and  bleed  freely 
when  injured.  Treves  in  his  surgical  anatomy  re- 
ports a  fatal  accident  from  a  perforation  of  the  as- 
cending pharyngeal  artery,  but  it  is  difficult  to  see 
how  such  an  accident  can  take  place  without  cutting 
through  the  superior  constrictor  muscle. 

As  I  have  said,  the  modern  operation  for  tonsil- 
lectomy, under  local  anaesthesia,  is  nearly  if  not 
quite  painless  and  bloodless.  It  is  much  to  be  pre- 
ferred when  the  cooperation  of  the  patient  can  be 
enlisted  and  when  there  is  at  least  a  moderate  de- 
gree of  toleration  to  manipulations  about  the  throat. 

Whenever  there  is  a  pharyngeal  tonsil  or  adenoid 
to  be  removed  also,  ether  is  to  be  preferred,  be- 
cause a  complete  local  anaesthetization  of  the  vault 
of  the  pharynx  is  difficult  if  not  impossible.  The 
preparation  for  faucial  tonsillectomy  under  locil 
anaesthesia  is  as  follows :  First  cleanse  the  parts  as 
thoroughly  as'  possible,  and  spray  the  fauces  with 
a  one  per  cent,  solution  of  cocaine  and  paint  lightly 
the  anterior  pillar  and  tonsil  with  a  twenty  per  cent, 
solution  of  same  drug.  Then  with  a  special  syringe 
inject,  through  the  anterior  pillar  if  necessary,  into 
the  j)tritonsillar  tissue,  a  half  drachm  of  a  sterile 
I  in  5000  adrenalin  solution  to  which  has  been  add- 
erl  0.5  per  cent,  of  cocaine.  This  should  be  done 
with  care,  making  sure  that  the  point  of  the 
syringe  is  in  the  tissue  and  not  in  one  of  the  crypts 
of  the  tonsil,  otherwise  the  solution  will  flow  out 
into  the  pharynx  and  thus  fail  in  part  to  accomplish 
its  mission. 

Five  minutes  after  the  injection  is  made  the  ton- 
sil is  ready  for  removal.    The  technique  of  the  op- 


eration is  exactly  the  same  as  that  under  general 
anaesthesia,  which  I  shall  presently  describe. 

Both  tonsils  may  be  removed  at  a  single  sitting, 
but  I  prefer  to  defer  the  second  one  until  another 
day.  The  only  trouble  about  this  operation  is  the 
danger  of  hiemorrhage  after  an  hour  or  two  during 
the  reaction  following  the  cocaine  adrenalin  injec- 
tion. This  may  usually  be  avoided,  however,  by 
keeping  the  patient  quiet  for  a  few  hours,  after 
which  he  may  go  about  his  business  as  usual. 

Coming  now  to  the  operation  under  general  anaes- 
thesia, my  own  preference,  and  that  of  the  ma- 
jority of  my  colleagues,  is  for  ether  anaesthesia, 
chloroform  being  regarded  as  somewhat  dangerous 
in  these  operations.  Tonsil  and  adenoid  patients 
may  be  safely  etherized,  although  they  are  generally 
rather  slow  in  going  under  the  anaesthetic.  More- 
over, the  anaesthesia  should  be  profound,  because 
the  faucial  reflexes  seem  to  be  the  last  to  succumb. 

Some  years  ago  men  advocated  the  removal  of 
tonsils  during  the  initial  stage  of  anaesthesia,  but  the 
practice  had  to  be  given  up,  because  it  did  not  give 
sufficient  time  and  because  it  proved  to  be  too  dan- 
gerous. When,  therefore,  anaesthesia  is  complete 
and  the  month  gag  is  in  place,  a  special  vaporizing 
device,  several  forms  of  which  are  on  the  market,  is 
desirable  for  continuing  the  ether  anaesthesia  during 
the  time  of  the  operation. 

Good  reflected  light  is  absolutely  essential  to  suc- 
cess in  this  operation,  and  one  that  may  be  attach- 
ed to  the  head  of  the  operator  is  to  be  preferred. 

In  many  instances  the  tonsil  must  be  dissected 
out  of  its  bed,  and  instruments  suitable  to  such 
dissection  should  be  at  hand.  It  is  only  the  excep- 
tional tonsil  that  can  be  removed  satisfactorily  with 
the  tonsillotome  or  snare.  The  latter  instrument 
has  no  advantages  over  the  tonsillotome  and  other 
cutting  devices,  and  it  has  the  great  disadvantage 
of  leaving  a  ragged  wound  which  is  more  painful 
and  slower  to  heal. 

The  forceps  devised  by  Dr.  George  Richards  is 
satisfactory,  and  his  method  of  using  over  it  a  ring 
tonsillotome  with  the  forks  removed,  has  been  ef- 
fective in  my  hands. 

Any  simple  rat  tooth  forceps  and  a  knife  with 
the  blade  slightly  curved  or  the  flat,  or  similarly 
curved  scissors,  may  often  be  used  to  advantage 
especially  when  the  operation  is  done  under  local 
anaesthesia. 

The  aim  in  all  cases,  of  course,  should  be  to  re- 
move the  diseased  gland  in  its  entirety,  and  differ- 
ent instruments  will  be  selected  and  required  by 
different  operations. 

Conclusions. 

The  normal  faucial  tonsil  is  small  and  scarcely 
demonstrable  without  the  aid  of  a  palate  retractor. 

The  function  of  the  faucial  tonsil  is  still  in 
doubt,  although  it  is  probably  to  guard  against 
bacterial  invasion  of  the  system. 

The  ])rotective  influence  of  the  fnuc'al  tonsil, 
however,  is  destroyed  as  soon  as  the  gland  becomes 
diseased. 

The  usual  symptoms  arising  from  the  diseased 
faucial  tonsils  are  sore  throat,  irritating  cough,  and 
foul  smelling  breath. 

The  diseased  faucial  tonsil  is  a  distinct  nicnac-\ 


June  19,  1909.] 


SWEENY:  HUMAN  AND  BOVINE  TUBERCLE  BACILLI. 


1257 


both  to  the  organs  of  special  sense  in  its  immedi- 
ate neighborhood,  and  to  the  general  health  of  the 
individual. 

The  large  faucial  tonsil  is  not  only  unhygienic, 
but  it  is  also  obstructive  to  respiration,  phonation, 
and  articulation. 

The  faucial  tonsil  may  be  very  large  or  very 
small,  and  its  size  is  no  criterion  as  to  the  extent 
of  its  disease. 

The  rather  common  belief  among  the  laity  that 
the  removal  of  the  faucial  tonsils  impairs  the  voice 
is  altogether  without  foundation,  except  in  those 
cases  in  which  injury  is  done  to  the  palate  or  other 
surrounding  structures. 

The  largest  faucial  tonsil  often  appears  small  be- 
cause it  is  held  within  the  grasp  of  the  faucial  pil- 
lars and  buried  in  the  tissues  of  the  neck. 

The  so  called  submerged  faucial  tonsils  are  es- 
pecially harmful  and  difficult  to  remove. 

The  chronically  diseased  faucial  tonsil  should  be 
removed  in  its  entirety,  because  remnants  do  not 
easily  drain  their  crypts  into  the  pharynx,  and  the 
secretions  are  more  readily  absorbed  into  the  sys- 
tem. 

The  base  of  a  submerged  tonsil  left  in  a  deep  ton- 
sillar fossa  afterwards  protrudes  itself  into  the 
fauces  and  leads  to  the  supposition  that  the  tonsil 
is  returning. 

The  tonsil  is  best  removed  under  local  anaesthesia 
when  the  complete  cooperation  of  the  patient  ma>- 
be  secured. 

General  anaesthesia  is  more  satisfactory  and  safer 
in  children,  and  should  always  be  used  when  an 
adenoid  is  also  to  be  removed. 

The  faucial- tonsils  should  be  removed  first,  care 
being  taken  that  all  haemorrhage  is  controlled,  be- 
fore going  from  one  tonsil  to  the  other. 

The  instruments  used  in  the  operation  vary  with 
each  individual  case,  and  celerity  in  the  perform- 
ance of  the  operation  should  be  sacrificed  to  thor- 
oughness. 

1627  Walxut  Street. 


HUMAN  AND  BOVINE  TUBERCLE  BACILLI. 

A  Study  of  Their  Relationship  and  Intertransmissibility, 
Zi'ilh  S'pecial  Reference  to  Infection  and  Immunity. 
Bv  GiLLiFORD  B.  Sweeny,  M.  D.. 
Pittsburgh,  Pa. 

Dr.  Koch's  contention,  at  the  International  Tu- 
berculosis Congress,  that  "it  is  impossible  to  settle 
or  add  anything  to  a  scientific  question  by  passing 
resolutions."  was  well  founded.  This  statement 
was  made  with  reference  to  the  intertransmissibil- 
ity of  tubercle  bacilli  of  the  human  and  bovine 
varieties. 

Reasoning  by  analogy,  it  is  easy  for  us  to  con- 
clude that  several  varieties  of  tubercle  bacilli  orig- 
inated from  one  single  source,  but  that  through 
adaptation  to  the  physical  organisms  of  their  sev- 
eral hosts  they  eventually  came  to  differ  in  form, 
method  of  growth,  and  virulence.  Thus,  we  recog- 
nize the  human,  the  bovine,  and  the  avian  types  of 
tubercle  bacilli. 

The  question  of  intertransmissibility  between  the 
human  and  bovine  species  depends,  of  course,  upon 


experimental  efforts  to  implant  the  bacilli  of  the 
human  variety  within  the  organism  of  the  bovine 
host,  and  also  the  availability  of  data  showing  that 
bovine  bacilli  are  actually  transmitted  to  the  human 
subject.  As  experimental  research  oft"ers  us  but 
little  assistance  in  this  latter  work,  we  are  com- 
pelled to  depend  largely  upon  clinical  observations 
in  the  case  of  children  who  have  been  reared  upon 
cows'  milk. 

It  has  been  proved  beyond  all  cavil  that  it  is 
possible  to  infect  cattle  by  feeding  them  with  foo:l 
impregnated  with  human  tubercle  bacilli.  An  objec- 
tion has  been  raised  regarding  the  value  of  such 
experiments,  it  being  stated  that  this  is  an  unnat- 
ural mode  of  infection.  It  would  be  valuable  data 
which  would  show  us  just  what  might  be  regarded 
as  natural  infection  in  any  subject,  whether  human 
or  otherwise,  whatever  the  nature  of  the  infecting 
agent.  That  it  is  at  all  possible  to  infect  the  bovine 
from  the  hutnan  being  seems  to  settle  the  ques- 
tion, without  critically  regarding  the  details  in- 
volved in  the  experiment. 

Koch  and  his  followers  looked  for  intestinal  tu- 
berculosis to  be  common  among  children  fed  upon 
cows'  milk,  and  failing  to  find  local  corroborative 
evidence  concluded  that  such  infection  seldom  took 
place.  Their  deductions  were  fallacious,  because  it 
is  possible  for  the  bacilli  to  penetrate  the  intestinal 
mucous  membrane  and  leave  no  trace  behind, 
just  as  we  find  them  enter  through  the  eye, 
genital  tract,  peritonaeum,  etc..  and,  migrating  to 
other  organs,  notably  the  lungs,  set  up  their  char- 
acteristic lesions.  When  we  add  to  this  fact  a  com- 
mon observation,  viz.,  the  deliberate  and  unob- 
trusive manner  in  which  tuberculosis  invades  the 
human  organism  and  may  remain  in  a  quiescent 
state  for  years  before  declaring  itself,  Koch's  de- 
duction is  robbed  of  all  material  support. 

Spengler's  study  of  the  characteristics  of  human 
and  bovine  tubercle  bacilli  throws  some  light  upon 
this  subject.  He  found  that  bovine  bacilli  grew 
best  on  culture  media  when  surrounded  by  but  lit- 
the  oxygen,  while  human  bacilli  grew  best  when 
surrounded  by  abundance  of  oxygen. 

The  favorite  location  and  nature  of  the  lesions 
of  tuberculosis  in  children  and  adults  vary  widely. 
In  the  former  we  find  the  glands,  meninges,  and 
joints  most  often  attacked.  In  adults  the  pulmon- 
ary tissue  is  the  most  vulnerable  point.  We  be- 
lieve that  Spengler's  deduction,  that  most  of  the  in- 
fections in  childhood  are  due  to  bovine,  while  those 
of  adult  life  are  due  to  human  bacilli,  will  be  more 
and  more  fully  confirmed  as  fuller  clinical  data  be- 
come available. 

Raw,  acting  independently  of  Spengler,  arrived  at 
virtually  the  same  conclusion,  as  to  the  clinical  dis- 
tribution of  cases,  which  he  attributes  to  human  and 
bovine  origin. 

The  German  Imperial  Health  Board  (Tuberku- 
lose  aus  dem  kaiserlichen  Gesundheitsamte ,  No. 
7,  1907)  offers  further  confirmation  of  Spengler's 
view  that  bovine  bacilli  grow  best  away  from  oxy- 
gen. Cattle  previously  immunized  against  bovine 
bacilli  by  inoculation  of  living  human  bacilli 
showed  great  resistance  to  infection  when  inocu- 
lated with  bovine  bacilli  later.  The  lungs  did  not 
show  foci  of  infection,  but  the  meninges,  eyes,  and 
genitourinary  tract  did. 


SWEENY:  HUMAN  AND  BOVINE  TUBERCLE  B'ACILU. 


[New  Yokk 
Medical  Journal. 


We  have  here  confirmation  of  the  view  that  or- 
gans remote  from  oxygen  ( eyes,  meninges,  and  gen- 
itourinary tract)  are  better  suited  to  infection  from 
bovine  bacilli,  and  that  even  when  immunization  has 
been  accomplished  in  the  animal  these  organs  are 
still  vulnerable  points  of  attack,  if  the  animal  is  at 
all  impressible  to  the  bovine  tubercle  bacilli. 

My  own  observations  while  at  Marburg  Uni- 
versity, in  the  service  of  Professor  von  Behring, 
convinced  me  that  the  immunity  conferred  upon  cat- 
tle through  the  use  of  a  sterile  emulsion  containing 
living  tubercle  bacilli  was  effective,  also  that  this 
immunization  was  accomplished  with  less  disturb- 
ance to  the  organism  of  the  bovine  subject  when 
human  bacilli  were  used  than  if  the  immunizing 
fluid  had  contained  bovine  bacilli.  This  opinion  has 
been  repeatedly  confirmed  by  subsequent  observers. 
Pottenger  oflfers  a  plausible  theory  to  account  for 
this  phenomenon.  It  is  to  the  effect  that  each  host, 
whether  human  or  bovine,  presents  physical  condi- 
tions favorable  to  the  propagation  of  tubercle  bacilli 
belonging  to  its  own  species  and  consequently  offers 
comparatively  little  resistance  to  infection.  On  the 
other  hand,  where  the  infecting  bacilli  have  been 
obtained  from  a  foreign  host,  while  primarily  de- 
rived from  one  parent  stem,  they  have  already 
changed  their  physical  characteristics  to  such  a  de- 
gree as  to  make  relatively  little  impression  upon  the 
new  subject,  other  perhaps  than  to  stimulate  phago- 
cytic activity. 

Clinical  data  are  certainly  not  at  variance  with 
this  theory.  In  my  monograph  published  in  1907 
{Animal  Therapy,  its  Relation  to  Immunity,  in  the 
Treatment  of  Tuberculosis) ,  I  gave  a  series  of  case 
reports  of  tuberculous  patients  treated  with  a  fluid 
derived  from  the  lymph  reservoirs  of  the  young 
bullock  which  had  been  previously  immunized  by 
the  method  suggested  by  von  Behring.  The  immu- 
nity thus  acquired  by  the  bovine  subject  was  accom- 
plished through  the  use  of  an  emulsion  containing 
living  tubercle  bacilli,  which  was  introduced  into 
the  general  circulation  through  the  jugular  vein. 

The  immunity  conferred  upon  the  human  subject 
through  the  hypodermic  administration  of  this  fluid, 
which  I  have  called  antituberculous  lymph,  has 
proved  to  be  effective  in  a  large  percentage  of  cases 
of  pulmonary  tuberculosis. 

In  my  article  published  in  the  Nczv  York  Med- 
ical Journal,  March  28,  1908,  entitled  The  Influence 
of  Animal  Therapy  upon  the  Opsonic  Index  in  Tu- 
berculosis, I  gave  a  detailed  report  of  five  cases 
which  had  been  selected  from  a  larger  list  of  fifty- 
two  patients  treated  with  antituberculous  lymph 
(AT.  L.) 

During  the  past  year  one  hundred  and  fifty  addi- 
tional cdses  successfully  treated  with  antituberculous 
lymph  by  myself  and  other  physicians  in  various 
parts  of  the  United  States  have  been  carefully 
studied. 

From  the  beginning  of  my  w'ork  in  immunizing 
cattle,  I  have  made  close  observations  upon  the  rela- 
tive merits  of  human  and  bovine  tubercle  bacilli  as 
immunizing  agents.  To  render  these  observations 
more  reliable,  I  have  during  the  past  five  years  kept 
the  immunized  cattle  in  two  distinct  herds ;  those 
immunized  through  the  use  of  bovine  tubercle  bacil- 
li being  cared  for  upon  a  farm  remote  from  the  cat- 
tle which  had  been  treated  with  human  tubercle 


bacilli.  The  lymph  derived  from  the  first  herd  was 
designated  AT.  L.  No.  i,  that  from  the  second  AT. 
L.  No.  2. 

That  there  was  a  marked  difference  between  the 
action  of  the  two  lymphs  when  administered  to  tu- 
berculous patients  was  at  once  apparent.  Even 
more ;  in  most  cases  where  AT.  L.  No.  i  improved 
the  patient's  condition,  a  change  to  AT.  L.  No.  2 
would  be  followed  by  untoward  symptoms.  In  ex- 
ceptional cases  a  change  from  one  lymph  to  the 
other,  at  definite  intervals,  would  be  followed  by 
improvement  for  a  time,  when  it  was  found  advan- 
tageous to  return  to  the  first. 

The  following  cases  will  illustrate  some  points  of 
special  interest  which  developed  during  treatment : 

Case  L— Male ;  aged,  thirty  years ;  occupation,  architect. 
Three  years  ago  this  man  had  several  haemorrhages  from 
kings,  after  having  complained  of  bodily  weakness  and 
loss  of  weight  for  about  six  months.  After  haemorrhages 
occurred  he  had  occasion  to  go  to  the  Northwest,  remain- 
ing in  the  State  of  Washington  for  about  a  year.  During 
that  time  a  severe  cough  developed,  accompanied  by  profuse 
expectoration.  Examination  by  a  physician  revealed  the 
presence  of  tubercle  bacilli.  At  the  same  time  marked 
hepatization  of  the  upper  lobe  of  the  right  lung  was  ob- 
served, together  with  rough  bronchial  breathing  over  both 
lungs.  A  recurring  diarrhoea  increased  the  patient's  dis- 
comfort and  emaciation.  Increased  temperature,  together 
with  profuse  night  sw-eats,  were  prominent  features  of  his 
case,  when  the  patient  returned  home  and  presented  him- 
self for  treatment. 

Regarding  this  as  a  case  of  infection  from  human  tuber- 
cle bacilli,  the  patient  was  placed  upon  daily  injections  of 
AT.  L.  No.  I,  administered  in  fifteen  minim  doses.  At  the 
end  of  thirty  days'  treatment,  the  temperature  was  almost 
constantly  normal,  every  third  or  fourth  day  a  rise  of  one 
fourth  to  three  fourths  of  a  degree  :  morning  temperature 
remaining  normal.  Night  sweats  ceased.  Cough  was  much 
decreased,  with  lessened  expectoration.  Hepatization  of 
right  lung  was  decidedly  improved.  The  diarrhoea,  together 
with  impairip.ent  or  lack  of  appetite,  etc.,  suggested  mixed 
or  bovine  infection,  and  it  was  decided  that  a  change  would 
be  made  to  AT.  L.  No.  2,  at  this  time.  Within  a  few  days 
there  was  an  aggravation  of  the  cough,  together  with  in- 
creased expectoration.  Higher  and  fluctuating  tempera- 
ture. No  material  change  took  place  in  the  digestive  or- 
gans, and  at  the  end  of  two  weeks'  treatment  it  was  decided 
to  return  to  AT.  L.  No.  r.  Almost  immediately  there  was 
an  amelioration  in  the  pulmonary  symptoms  and  a  return 
to  normal  temperature.  This  was  continued  for  six  weeks 
longer,  the  lymph  being  administered  in  twenty  minim  doses. 
Improvement  was  continuous,  the  digestive  symptoms 
gradually  abating  with  a  return  of  appetite,  and  gradual 
increase  of  weight. 

Here  is  a  case  where  we  undoubtedly  had  simple  infec- 
tion from  human  tubercle  bacilli.  When  treatment  w-as 
changed  from  AT.  L.  No.  i  to  AT.  L.  No.  2,  1  was  dis- 
posed to  think  that  we  had  a  case  of  mixed  infection.  The 
aggravation  of  pulmonary  symptoms  when  treatment  was 
changed  to  AT.  L.  No.  2  might  be  interpreted  as  indicating 
this,  but  the  lack  of  improvement  in  the  digestive  symptoms 
did  not  confirm  this  impression.  The  final  disappearance 
of  all  untoward  symptoms  and  return  to  perfect  health 
lead  me  to  believe  that  this  was  a  case  of  simple  infection 
from  human  tubercle  bacilli,  and  that  the  tardy  improve- 
ment in  the  digestive  organs  was  due  to  lowered  vitality. 

C.'^SE  II. — Female ;  aged  tw'enty-six  years :  married. 
Mother  of  three  children.  Enjoyed  good  health  until  two 
years  ago,  when  moderate  haemoptysis  caused  the  patient 
to  consult  her  physician.  She  likewise  complained  'of  sore- 
ness in  her  chest  and  pleuritic  pains.  Physical  examination 
revealed  extensive  tuberculous  involvement  of  left  lung,  as 
well  as  of  the  apex  of  right  lung.  Microscopical  investiga- 
tion w-as  corroborative. 

W^hilc  under  treatment  three  months  Inter,  a  swelling  in 
the  left  knee  joint  was  complained  of  which  increased  in 
severity,  until  I  saw  the  patient  one  year  and  a  half  ago. 
At  that  time  there  was  marked  emaciation,  cough,  and 
tubercle  laden  expectoration:  soreness  over  entire  chest 
and  severe  pleuritic  pains.  H?emoptysi«  continued  and  cav- 
ity formation  in  the  upper  lobe  of  the  left  King  seemed 


June  19,  1909.] 


SWEENY:  HUMAX  AXD  BOVINE   TUBERCLE  BACILLI. 


1259 


imminent.  The  tuberculous  knee  joint  was  greatly  swollen, 
hot,  and  painful. 

The  patient  was  then  placed  upon  twenty  minim  doses 
daily  of  AT.  L.  No.  i  which  was  continued  for  thirty  days. 
The  affected  limb  was  placed  in  a  fixation  apparatus,  and 
rest  enjoined.  During  the  first  month's  treatment  there 
was  marked  amelioration  of  the  pulmonary  symptoms.  The 
cough  and  expectoration  were  much  improved.  Area  of 
dullness  was  lessened  and  the  pleuritic  pains  disappeared. 
At  the  same  time  there  was  little  or  no  improvement  in  the 
knee  joint.  AT.  L.  No.  2  was  then  resorted  to.  twenty 
minim  doses,  when  within  a  few  days  there  was  marked 
aggravation  of  the  lung  symptoms.  The  patient  complained 
of  much  bodily  discomfort.  There  were  irregular  and 
spasmodic  fluctuations  in  the  temperature.  At  the  same 
time  the  improvement  in  the  knee  joint  was  the  most  strik- 
ing. Within  two  weeks  the  heat,  redness  and  swelling  had 
disappeared,  the  skin  hanging  in  folds  where  it  had  previ- 
ously been  distended  to  its  utmost  capacity.  The  dose  of 
AT.  L.  was  then  reduced  to  10  minims  daily,  and  continued 
for  a  period  of  two  weeks. 

At  the  end  of  that  time,  AT.  L.  No.  i  was  again  resorted 
to  for  a  third  month,  in  fifteen  minim  doses.  From  that 
time  forward  there  was  continuous  improvement  in  all  the 
tuberculous  symptoms,  and  no  further  change  was  made  in 
the  lymph.  The  patient  was  discharged  at  the  end  of  three 
months,  being  free  from  all  subjective  and  objective  symp- 
toms. 

Undoubtedly  this  was  a  case  of  mixed  infection, 
both  human  and  bovine  tubercle  bacilli  participating 
in  the  morbid  process. 

Case  III. — Patient,  a  little  girl ;  aged  eleven  years.  Sev- 
eral members  of  her  family  had  died  during  infancy  and 
childhood  of  "baby  consumption."  No  history  of  tuber- 
culosis in  previous  generation. 

Examination  revealed  enormous  enlargement  of  the 
cervical  and  axillary  glands,  the  mesenteric  glands  being 
also  moderately  swollen.  The  child  was  badly  nourished, 
listless,  and  remained  in  a  recumbent  position  most  of  her 
time.  There  was  slight  evening  rise  of  temperature,  vary- 
ing from  0.75  to  1.5  degrees.  The  faucial  tonsils  were 
normal ;  pulmonai:^-  symptoms  were  absent. 

Diagnosis :  Tuberculosis  of  the  lymphatics,  infection  be- 
ing due  to  bacilli  of  the  bovine  type.  The  patient  was 
placed  upon  ten  minim  daily  doses  of  AT.  L.  No.  2.  Dur- 
ing the  first  thirty  days  of  treatment  there  was  a  decided 
reduction  in  the  size  of  the  glands  in  the  cervical  and  axil- 
lary region.  Temperature  became  normal  and  remained 
so  after  the  twelfth  injection.  A  second  month's  treatment 
of  AT.  L.  No.  2  was  administered,  when  the  glandular  en- 
largement had  entirely  disappeared.  The  child  regained  her 
norm.al  vigor,  being  cheerful  and  disposed  to  resume  her 
normal  habits.  The  diagnosis  in  this  case  was  made  in 
such  confidence,  and  the  prompt  and  uninterrupted  im- 
provement was  so  fully  corroborative,  that  it  was  not 
deemed  necessary  to  make  use  of  AT.  L.  No.  1  in  order  to 
confirm  the  diagnosis. 

C.\SE  IV.— Patient ;  male,  aged  twelve  years.  Tubercu- 
losis developed  in  his  left  hip  joint  one  year  before  he  pre- 
sented himself  for  treatment.  At  that  time  he  was  in  bed, 
with  extension  apparatus  applied  to  the  affected  limb.  Deep 
and  extensive  suppurating  sinuses  had  burrowed  into  the 
gluteal  region.  Emaciation  was  extreme,  the  patient  being 
racked  with  pain,  especially  at  night.  There  was  slight 
dullness  over  the  posterior  aspect  of  both  lungs,  which  was 
regarded  as  probably  due  to  posture,  the  patient  being  com- 
pelled to  remain  continually  in  one  position.  From  the 
same  cause  extensive  bed  sores  had  developed. 

After  careful  examination  of  this  patient,  who  certainly 
presented  a  woebegone  spectacle,  the  conclusion  was 
reached  that  this  was  a  case  of  tuberculous  infection  of  the 
bovine  type,  and  the  patient  was  placed  upon  ten  minim 
daily  doses  of  AT.  L.  No.  2.  During  the  first  month's  treat- 
rnent  there  was  no  material  change  in  the  patient's  condi- 
tion. At  that  time  a  brisk  pneumonia  developed  in  the 
right  lung,  which  threatened  to  attack  the  left,  but  which 
fortunately  did  not  cross  over.  For  three  weeks  the  lymph 
was  di.'^continued,  chiefly  on  account  of  the  patient's  ex- 
treme discomfort.  As  the  pneumonia  gradually  cleared  up. 
the  cough  and  expectoration  abated  but  little,  and  a  tem- 
perature elevation  of  from  1.5  to  2.5  degrees  was  main- 
tained. 

Examination   of  the   sputum,  which   upon  preliminary 


investigation  was  negative,  now  showed  many  tubercle  ba- 
cilli present.  Recourse  was  now  had  to  AT.  L.  No.  i,  it 
being  believed  that  we  had  a  case  of  mixed  infection,  both 
human  and  bovine  bacilli  being  present.  A  month's  use  of 
AT.  L.  No.  I  was  followed  by  complete  clearing  of  the 
lungs  and  a  decided  lowering  of  the  temperature.  The 
condition  of  the  hip  involvement  was  still  serious,  but  little 
if  any  improvement  having  taken  place. 

The  use  of  AT.  L.  No.  2  was  now  resumed,  gradual  and 
continuous  improvement  being  apparent.  In  three  or  four 
months  the  patient  was  able  to  go  about  on  crutches.  Pain 
in  the  region  of  the  joint  had  abated,  and  the  sinuses  were 
much  less  extensive.  The  use  of  the  lymph  was  continued 
for  two  additional  months,  without  further  change  when 
the  patient  was  found  to  be  in  very  good  condition.  There 
was  but  trifling  shortening  in  the  leg  and  all  suppuration 
had  ceased. 

This  boy  was  treated  three  years  ago.  There  has  been 
no  recurrence  of  his  trouble,  and  at  the  present  time,  he  is 
apparently  in  perfect  health. 

Of  the  two  hundred  cases  studied  during  the 
past  year,  for  the  purpose  of  determining  the  specific 
character  of  the  bacilli  involved  in  the  tuberculous 
process,  whether  of  the  human  or  bovine  type,  manv 
other  cases  might  be  added  to  those  cited.  They 
would,  however,  only  strengthen  our  position,  by 
corroborating  the  observations  made  in  the  cases 
described  above. 

COXCLUSIOXS 

From  the  evidence  which  has  been  collected  upon 
the  subject,  I  believe  we  are  warranted  in  reaching 
the  following  conclusions : 

1,  That  human  and  bovine  tubercle  bacilli  are  dis- 
tinctly different  in  most  of  their  characteristics. 

2,  That  the  human  subject  may  become  the  host 
for  either  form  of  tuberculous  infection,  human  or 
bovine.  Likewise  that  the  bovine  may  be  inoculated 
in  the  same  way  and  under  like  conditions. 

3,  That  tuberculous  infection  of  the  respiratory 
tract  will  usually  be  found  to  be  due  to  bacilli  of 
the  human  type,  while  those  of  the  bones,  joints, 
and  lymphatics  are  likely  to  be  due  to  bacilli  of  the 
bovine  type. 

From  clinical  study  of  cases  treated  during  the 
past  five  years,  I  conclude  that  an  antitoxic  vaccine 
or  lyinph  may  be  derived  from  the  bovine  which  has 
been  previously  immunized  through  the  administra- 
tion of  attenuated  doses  of  tubercle  bacilli.  Also 
that  this  iminunity  may  be  accomplished  through  the 
use  of  either  human  or  bovine  tubercle  bacilli  in  the 
emulsion  which  is  used  for  immunizing  purposes. 

In  closing  I  wish  to  forestall  an  argument  which 
might  be  addressed  by  those  who  are  skeptical  upon 
the  subject  of  tuberculous  infection  through  milk, 
or  who  regard  this  source  of  contamination  as  an 
unimportant  factor  in  the  aetiology  of  tuberculosis. 
^^'e  must  admit  that  by  the  use  of  milk  which  con- 
tains a  few  bovine  bacilli  many  children  may  and 
probably  do  secure  a  degree  of  immunity  which  pro- 
tects them  against  infection  from  human  baciUi.  But 
let  us  look  further;  in  these  latter  days,  we  come 
gradually  to  return  to  a  position  upon  the  subject 
of  infection  which  was  almost  discredited  after  the 
first  discovery  of  the  specific  pathogenic  microbes, 
the  disposition  being  to  ascribe  everything  to  the 
microbic  factor — we  come  to  recognize  two  factors, 
the  resisting  powers  or  relative  susceptibility  of  the 
organism,  and  the  degree  of  virulence  possessed  by 
the  microorganism,  together  with  the  number  of  the 
same  gaining  entrance  to  the  body  by  a  particular 
route  and  at  a  particular  time. 


I260 


PORCHER:  RESECTION  OF  CARTILAGE  OF  NOSE. 


[New  York 
Medical  Journai„ 


If  it  were  practicable  to  immunize  children 
through  the  use  of  millc  containing  a  limited  num- 
ber of  tubercle  bacilli,  it  would  still  be  bad  practice 
to  permit  such  milk  to  be  used  by  children  without 
careful  consideration  of  their  physical  condition,  as 
well  as  the  degree  of  virulence  possessed  by  the 
bacilli  found  in  the  milk.  But  such  immunization 
by  a  scientific  method  has  not  been  accomplished  any 
more  than  that  which  von  Behring  hoped  for,  viz., 
immunization  through  the  use  of  milk  derived  from 
cattle  which  had  been  previously  immunized  to  tu- 
berculosis. 

Until  something  of  a  very  definite  nature  and 
founded  upon  a  scientific  basis  offers  a  more  satis- 
factory solution  to  the  milk  problem,  we  cannot  af- 
ford to  relax  our  efforts  to  safeguard  childhood's 
staple  article  of  food. 

230  South  Negley  Avenue. 


EXPEDITIOUS   METHOD   FOR  SUBMUCOUS 
RESECTION  OF  THE  TRIANGULAR  CARTI- 
LAGE OF  THE  NOSE. 
Jl-'ith  lUiistrative  Case* 

By  W.  Peyre  Porcher,  M.  D.," 
Charleston,  S.  C. 

In  no  other  field  of  surgery,  perhaps,  have  so 
manv  operations  been  devised  as  those  for  the  re- 
moval and  correction  of  displacements  of  the  nasal 
septum.  The  number  of  instruments  and  parapher- 
nalia have  also  been  proportionately  numerous. 
For  example,  between  twenty  and  thirty  instru- 
ments have  been  recommended  for  the  perform- 
ance of  one  of  these  operations.  To  prolong  gen- 
eral anjEsthesia  while'  operating  upon  the  nose  is 
manifestly  difficult  and  as  this  is  generally  neces- 
sary while  operating  on  children,  any  operation 
which  will  simplify  the  work,  do  away  with  un- 
necessary paraphernalia,  and  increase  the  rapidity 
with  which  the  results  can  be  obtained  should  be 
welcomed. 

Of  course  no  one  operation  will  be  equally  adapt- 
able to  all  cases,  but  I  will  report  the  following 
case  because  the  results  were  so  extremely  satis- 
factory and  the  operation  was  so  rapidly  and  easily 
performed. 

Case. — The  patient  was  a  physician  aged  fifty-nine,  whose 
hearing  had  gradually  become  worse  until  it  was  contact 
for  the  watch  in  the  left  ear  and  about  ten  inches  in  the 
right.  The  triangular  cartilage  was  found  to  be  dislocated 
on  the  right,  side,  causing  considerable  flattening  of  the 
end  of  the  nose,  and  almost  complete  occlusion  of  that 
nostril.  The  patency  of  the  tubes  on  both  sides  was  very 
poor.  In  consequence  of  his  deafness  liis  enunciation  had 
also  become  seriously  affected  so  that  he  could  neither 
speak  distinctly  nor  hear  when  spoken  to,  and  his  breathing 
while  asleep  was  very  stertorous. 

After  dissecting  up  the  mucous  membrane  over  the  dis- 
located portion  of  cartilage  I  determined  to  use  the  electric 
trephine  instead  of  the  knife  or  forceps  because  the  carti- 
lage proved  to  be  very  tough  and  situated  somewhat  fur- 
tlier  back  in  the  nose  than  usual.  With  a  rather  long  Cur- 
tis trephine  two  large  cones  of  cartilage  were  drilled  away, 
the  trephine  passing  through  the  mucous  membrane  in  the 
rear.  When  we  remember  how  rapidly  the  trephine  works 
we  can  appreciate  the  quickness,  simplicity,  and  case  with 
which  the  operation  was  performed.  Tlie  projecting  ends  of 
the  cartilage  having  been  removed  the  septum  resumed  its 

'Read  before  the  South  Carolina  Medical  Association,  April  22, 
1909. 


erect  position.  The  mucous  membrane  was  allowed  to  fall 
back  into  position,  and  a  compress  of  cotton  was  used  to 
hold  it  so  until  union  took  place,  which  was  by  first  inten- 
tion. 

A  most  excellent  feature  of  this  operation  is  that 
perforation  very  rarely  occurs.  Unless  thp  angle  of 
deflection  of  the  septum  is  extremely  acute,  it  is  al- 
most impossible  to  produce  a  perforation.  In  a 
straight  septum  the  trephine  would  have  to  be  held 
at  right  angles  to  the  partition  to  penetrate  through 
it,  and  therefore  this  accident  would  only  be  likely 
to  happen  in  proportion  to  the  acuteness  of  the 
angle,  or  the  amount  of  deflection  present.  In  the 
case  alluded  to  there  was  no  perforation  at  all,  al- 
though the  amount  of  dislocation  w^as  very  great. 
The  results  were  extremely  gratifying.  The  hear- 
ing promptly  came  up  to  ten  inches  in  his  left  ear 
and  two  and  one-half  feet  in  his  right.  The  im- 
provement in  his  enunciation  was  still  more  strik- 
ing. Not  only  could  he  speak  clearly  and  be  heard 
by  everyone  but  he  could  hear  plainly  when 
spoken  to. 

I  can  add  to  this  quite  a  number  of  cases  many 
of  which  I  have  called  attention  to  in  the  past  and 
which  have  had  what  may  be  termed  nose  deafness, 
as  marked  improvement  in  the  hearing  has  resulted 
from  the  restoration  of  the  normal  calibre  of  the 
nose  and  where  no  treatment  whatsoever  has  been 
made  to  the  ears,  but  the  case  I  have  mentioned  has 
been  the  most  striking  illustration  of  the  effect  of 
deafness  upon  the  enunciation,  and  the  immediate 
change  in  the  distinctness  of  speech  as  soon  as  the 
hearing  is  restored.  This  fact  was  so  noticeable  in  the 
case  just  cited  that  it  was  at  once  commented  upon 
by  his  friends.  One  of  these  stated  to  me  that  the 
improvement  was  so  noticeable  that  he  would  have 
known  of  the  operation  without  being  told.  This 
gentleman  had  been  to  another  specialist  who  had 
given  a  hopeless  prognosis,  and  at  first  it  appeared 
•  to  be  justifiable  because  of  the  length  of  time  which 
the  deafness  had  lasted,  although  it  had  become  re- 
cently more  decidedly  impaired.  He  had  no  defi- 
nite idea  of  how  long  the  dislocation  had  existed, 
but  supposed  that  it  occurred  during  childhood.  The 
theory  that  there  might  have  been  any  hysteria  or 
neurotic  tendency  about  the  case  was  entirely  un- 
tenable because  of  the  marked  stertorous  breathing 
while  asleep,  and  everything  pointed  to  marked 
nasal  obstruction. 

Like  so  marv  clinical  phenomena,  nasal  obstruc- 
tion is  attended  by  a  great  variety  of  symptoms 
dependant  upon  the  exact  location  and  character 
of  the  obstruction.  The  voice  can  generally  be  de- 
pended upon,  to  indicate  the  kind  and  location  of 
the  obstruction  as  it  varies  from  that  deadness  pro- 
duced by  hypertrophied  tonsils  to  that  resulting 
from  dislocation  of  the  triangular  cartilage. 

Recently  a  clergyman  applied  to  me  who  was 
much  given  to  open  air  preaching,  and  who  spoke 
as  if  he  had  a  chronic  cold  in  the  nose.  He  was 
found  to  have  marked  deflection  of  tho  seprum,  the 
correction  of  which  promptly  restored  his  normal 
tones.  A  repetition  of  these  cases  would  seem  to 
be  needless,  and  yet  when  those  patients  come  in  so 
often  in  which  the  condition  has  apparently  been 
unrecognized  one  feels  impelled  once  more  to  call 
attention  to  them. 

85  Broad  Street. 


June  19,  1909.] 


U'EIL:  IRRIGATION  IN  PUERPERAL  SEPSIS. 


IRRIGATION  TREATMENT  OF  PUERPERAL 
SEPSIS. 

Bv  Henry  Weil,  M.  D., 
New  York. 

The  phenomenon,  germ  invasion  of  the  uterine 
cavity  following  labor  or  abortion,  is  known  as 
puerperal  sepsis.  It  is  described  under  various 
headnigs,  such  as  sapraemia,  puerperal  endometri- 
tis, septichsmia,  bacterisemia,  pyjemia,  pelvic  perito- 
nitis, pelvic  cellulitis,  pelvic  abscess,  etc.  In  order 
to  appreciate  the  use  of  irrigation  as  practised 
under  this  treatment,  it  is  desirable  to  point  out 
the  fact  that  these  various  conditions  are  but  forms 
of  one  process,  (germ  invasion  of  the  uterus)  that 
they  are  in  no  sense  separate  phenomena  or  dis- 
eases, but  rather  different  stages  or  manifestations 
of  the  single  condition,  running  from  one  to  the 
other  and  often  associated.  Thus  infection  ordi- 
narily begins  in  some  retained  placental  tissue  or 
blood  clot,  unchecked  the  germs  soon  become  im- 
planted in  the  uterine  wall  and  vessels,  and  further 
progress  leads  to  the  periuterine  tissue,  with  in- 
flammatory reaction,  adhesions,  and  perhaps  ab- 
scess. Besides  germ  invasion,  the  disease  is  char- 
acterized by  another  element ;  toxine  absorption. 

Bacteria  in  the  absence  of  toxines  are  compara- 
tively inert  bodies,  and  the  leucocytes  seem  capable 
of  disposing  of  enormous  quantities  of  them  with 
impunity.  In  fact,  their  virulency  depends  upon 
this  poison,  thus  the  toxine  absorption  would  seem 
to  be  the  most  morbid  element  of  the  disease.  This 
poison  asserts  itself  in  two  ways:  i.  By  acting  upon 
the  nerve  and  circulatory  systems  in  general,  and  2. 
by  its  local  action  upon  leucocytes. 

For  the  absorption  of  this  poison  a  vascular  sur- 
face is  necessary,  and  the  more  highly  vascular  the 
more  rapid  absorption  takes  place.  Again  the  ex- 
tent of  this  vascular  surface  necessarily  influences 
absorption  (other  things  being  equal).  The  uterus 
in  puerperal  sepsis  possesses  these  two  attributes  to 
a  remarkable  degree.  The  body  contains  no  more 
vascular  a  tissue  than  the  placental  site  of  a  puer- 
peral uterus,  and  the  surface  exposed  to  the  infec- 
tion while  varying  considerably  may  be  roughly  es- 
timated as  from  100  to  200  square  inches  in  labor 
cases.  To  this  must  be  added  the  fact  that  the 
uterus  invariably  relaxes  when  infected,  thus  open- 
ing capillaries  and  lymphatics  which  otherwise 
might  be  closed. 

The  anatomical  peculiarities  of  the  part  are  such 
as  to  make  the  uterine  cavity  a  vast  breeding  pool 
where  germ  elaboration  may  go  on  unhindered, 
with  ideal  temperature,  and  a  perfect  culture  me- 
dium supplied  iDy  the  serum  exuded  from  the  uter- 
ine vessels.  So  that  here  we  have  unrestricted 
germ  growth  and  its  toxine  elaboration  in  a  cavity 
particularly  adapted  to  absorption.  This  pool  also 
supplies  the  deeper  germs  with  almost  unlimited 
reinforcements  to  replace  those  destroyed  by  the 
leucocytes,  for  it  is  improbable  that  the  germs  sit- 
uated in  the  deeper  tissues,  exposed  to  the  actions 
of  the  leucocytes  and  under  stress  of  combat  are 
capable  of  devoting  much  attention  to  reproduction. 
It  is  much  more  likely  that  this  important  function 
is  attended  to  by  the  germs  in  the  rear  and  less 
^exposed. 


The  irrigation  treatment  is  designed  to  dispose 
of  this  pool,  in  so  doing,  to  check  further  absorp- 
tion from  that  source,  and  to  deprive  the  process 
of  its  principal  source  of  germ  suppl}-.  It  is  a  sim- 
ple procedure,  not  intended  to  supplant  curettage 
or  other  recognized  treatments,  but  to  supplement 
them,  and  then  only  when  they  fail.  It  is  thus  re- 
served for  the  more  severe  infections  and  is  indi- 
cated when  we  have  arrived  at  the  end  of  our  re- 
sources and  are  forced  to  resort  to  silver  inunc- 
tions, high  enemata,  subcutaneous  injections,  etc. 

Under  these  circumstances,  it  is  not  necessary 
for  the  irrigations  to  check  all  absorption  to  make 
them  of  value.  If  the  treatment  ameliorates  the 
symptoms  to  any  perceptible  degree,  it  is  much  to 
be  desired,  and  if,  as  clinical  experience  seems  to 
indicate,  the  treatment  checks  further  absorption 
to  a  degree  sufficient  to  enable  the  patient  to  tide 
over  the  critical  period,  and  to  enable  the  leucocytes 
to  limit  further  germ  invasion,  it  is  then  of  inesti- 
mable value. 

As  its  name  implies,  the  treatment  is  merely 
intrauterine  irrigations  given  with  sufficient  fre- 
quency to  keep  the  uterine  cavity  empty  of  all 
lochia.  This  would  ordinarily  involve  considerable 
disturbance  and  pain  to  the  patient,  besides  neces- 
sitating the  almost  constant  presence  of  the  attend- 
ing physician.  To  avoid  this,  I  employ  a  technique 
by  which  the  irrigations  may  be  safely  entrusted  to 
any  intelligent  attendant,  they  are  painless,  and  do 
not  disturb  the  patient  any  more  than  is  necessary 
to  put  her  on  and  off  the  bed  pan.  This  I  do  in  the 
following  manner :  With  the  patient  in  the  dorsal 
position  on  a  bed  or  table.  I  insert  two  soft  rubl;er 
tubes  into  the  uterus,  one  well  up  to  the  fundus, 
the  other  beyond  the  internal  os.  The  tubes  are 
held  in  place  by  a  light  vaginal  pack.  Both  tubes 
project  a  few  inches  beyond  the  vulva.  To  irrigate, 
I  now  couple  a  fountain  syringe  to  the  longer  tube, 
the  other  tube  merely  providing  for  a  return  flow. 
In  this  manner  the  irrigations  are  readily  given  on  a 
bed  pan  or  Kelly  pad.  and  no  particular  skill  is 
required. 

This  treatment  involves  much  work  both  day  and 
night  and  is  not  adapted  to  the  milder  infections, 
being  essentially  an  heroic  procedure,  it  finds  its  use 
only  in  serious  cases.  Now,  no  physician  of  expe- 
rience looks  lightly  upon  puerperal  sepsis,  and 
especially  when  he  knows  the  disease  to  be  pro- 
gressing in  spite  of  curettage  or  manual  removal 
of  all  retained  tissues.  His  resources  being  limited, 
he  must  note  with  alarm  the  increasing  thready 
pulse  of  over  150  a  minute,  and  that  significant 
countenance  which  one  never  mistakes.  Surely 
under  these  circumstances,  heroic  treatment  is  jus- 
tified. 

Each  of  my  patients  presented  a  clinical  picture 
similar  to  the  one  described  and  in  each  case  fail- 
ure attended  curettage.  Leaving  out  the  irrigation 
treatment.  I  had  at  my  disposal  any  or  all  of  the 
following  recognized  treatments:  i.  medicatio  \ 
such  as  ergot,  alcohol  in  large  doses,  various  heart 
tonics,  nuclein.  and  colloidal  silver  salts,  such  as 
Crede's  ointment.  2.  Injections  of  salt  and  other 
solutions.  Salt  solution  injected  is  of  distinct  value 
in  surgical  shock  and  haemorrhage ;  it  is  much  used 
in  puerperal  disease,  and  is  supposed  to  act  by 


1262 


WEIL:  IRRIGATION  IN  PUERPERAL  SEPSIS. 


[New  York 
Medical  Journal. 


Stimulating  the  excretory  organs  and  thus  eUmin- 
ating  the  toxines.  Antiseptic  solutions  such  as 
iodine,  bichloride,  and  formalin  have  at  different 
times  been  injected  directly  into  the  circulation, 
and  it  is  only  recently  that  the  formalin  injections 
obtained  considerable  notoriety.  They  have,  how- 
ever, all  been  abandoned  as  useless  or  even  harm- 
ful. 3.  Serum.  This  is  most  promising  but  as  yet 
unsuccessful.  The  antistreptococcic  serum  of  Aiar- 
morek  has  been  given  extended  trial.  4.  Operative. 
This  includes  various  procedures,  such  as  hyster- 
ectomy, Pryor's  operation,  etc.  Hysterectomy  is 
done  with  the  view  to  disposing  of  the  entire  dis- 
eased organ ;  it  has  long  been  abandoned,  having  a 
higher  mortality  than  the  disease  itself.  Pryor's 
operation  consists  in  opening  the  cul-de-sac  through 
the  vaginal  fornix  and  surrounding  the  uterus  with 
gauze  impregnated  with  iodoform.  The  operation 
depends  for  its  virtue  upon  the  germicidal  prop- 
erties of  the  iodine.    It  is  not  generally  used. 

Of  these  different  treatments,  not  one  is  entitled 
to  much  confidence.  None  exert  any  but  very  re- 
mote benefits,  and  not  one  has  the  slightest  influ- 
ence on  either  the  germ  growth,  or  the  toxine  ab- 
sorption. It  will  not  serve  my  purpose  to  depre- 
ciate these  various  procedures,  each  has  been  tried 
and  all  found  wanting.  Some  are  used  for  the 
want  of  something  better  and  the  others  entirely 
abandoned. 

The  cases  reported  here  are  all  fairly  typical, 
possessing  no  very  imusual  features,  and  while 
each  was  a  severe  case,  they  are  in  no  sense  re- 
ported as  remarkable  cures.  We  have  no  reliable 
means  of  determining  in  advance  the  course  any 
case  is  likely  to  pursue,  for  occasionally,  apparently 
moribund  patients  recover,  and  the  mildest  sap- 
remic  case  may  end  in  virulent  septichjemia  and 
death.  I  have  used  the  treatment  in  eight  cases, 
manifestly  too  small  a  number  upon  which  to  base 
accurate  conclusions. 

.  C.-\SE  1.  has  already  been  published;  the  other  seven  are 
given  here. 

Case  II. — April,  1905.  Mrs.  S.,  primipara,  twenty-six 
years  of  age,  had  been  in  labor  about  twenty-four  hours 
and  was  much  exhausted ;  membranes  had  been  ruptured 
and  one  arrri'  presented.  Under  chloroform,  I  delivered 
child  by  internal  version.  Perinaeum  lacerated ;  placenta 
expelled  apparently  complete,  after  which  the  perin;Eum 
was  hastily  repaired.  The  surroundings  were  such  as  to 
make  asepsis  doubtful,  especially  since  the  patient's  condi- 
tion demanded  rapid  work.    She  promptly  became  septic. 

I  did  not  see  the  patient  ag;ain  until  four  days  later,  when 
I  found  a  well  advanced  puerperal  sepsis.  The  uterus  was 
relaxed  to  a  degree  sufficient  to  enable  me  to  insert  my  en- 
tire hand  and  part  of  my  forearm  and  resulted  in  detaching 
a  quantity  of  adherent  placental  tissue.  The  lochia  were 
purulent  and  cif  considerable  quantity.  After  assuring  my- 
self that  all  retained  tissue  had  been  removed,  I  irrigated 
and  packed  the  organ  with  iodoform'  gauze.  The  perineal 
sutures  were  infected  and  consequently  removed.  The  tear 
svvabb.cd  with  pure  carbolic  acid  and  a  light  tampon  in- 
serted. Temperature  103°  R,  pulse  136.  This  was  followed 
by  a  severe  chill,  with  a  temperature  running  to  104.6°  F., 
pulse  145. 

The  following  dav  the  temperature  was  103.6°  F..  pulse 
148,  appearance  characteristic  of  severe  sepsis,  mind  wan- 
dering at  times,  etc.  Uterus  was  curetted,  irrigated,  and 
packed;  it  measured  eleven  inches  internally  from  fundus 
to  external  os  and  was  so  much  relaxed  as  to-  make  curret- 
fage  rather  difficult  and  risky. 

On  the  next,  or  sixth  day,  the  patient  was  worse.  Tem- 
perature io.r2°  P.,  pulse  156;  patient  had  severe  chill  and 
was  almost  comatose.    She  was  carried  to  a  table,  the  gauze 


removed,  and  without  anaesthetic  the  tubes  inserted.  Con- 
tinuous irrigation  was  begun  at  once,  live  per  cent,  alcohol 
solution  being  used,  and  she  was  given  a  high  enema  of  salt 
solution.  Within  twenty-four  hours  improvement  was  evi- 
dent, the  mind  cleared  perceptibly  and  the  pulse  rate  im- 
proved.   Temptrature  103.6°  F.,  pulse  145. 

Eighth  day.  Temperature  102.4"  F.,  pulse  138.  respira- 
tion 24.    Irrigations  every  hour. 

Ninth  day  Temperature  101.3°  F.,  pulse  128,  respiration 
30.    Irrigations  every  two  hours. 

Tenth  day.  Temperature  103°  F.,  pulse  136,  respiration 
32.  Patient  complained  of  pain  in  rectum.  In  view  of  the 
rising  temperature,  she  was  again  placed  on  the  table  and 
the  tubes  removed.  The  discharge  was  still  abundant.  The 
uterus  measured  seven  and  one  half  inches,  was  fairly  firm, 
but  rigidly  adherent.  Rectal  examination  disclosed  a  mass 
of  induration  occupying  practically  the  entire  pelvis.  No 
fluctuations  could  be  elicited.  Fresh  tubes  were  inserted 
and  the  irrigations  continued  hourly. 

Eleventh  day.  Temperature  102.2°  F..  pulse  128,  respira- 
tion 36. 

Fifteenth  day.    Temperature  99°  F.,  pulse  94,  respiration 

Thirteenth  day.  Pelvis  drained  through  the  vaginal 
fornix,  liberating  considerable  pus.  Tubes  removed,  and 
uterus  packed  lightly.    Irrigations  discontinued. 

Fourteenth  day.  Temperature  99.2°  F.,  pulse  98,  respira- 
tion 20. 

Fifteenth  day.  Temperature  99°  F.,  pule  94,  respiration 
20.    Patient  passed  from  observation. 

Note. — During  the  autumn  of  1907,  I  examined  this  pa- 
tient.   The  uterus  was  freely  movable,  menstruation  normal. 

Case  III. — February.  1906.  Abortion  at  four  and  one 
half  months.  This  had  been  induced  by  a  "midwife,  who 
used  instruments."  The  f'Xtus  delivered  itself  on  the  fol- 
lowing day.  The  third  day  patient  had  a  severe  chill  and 
headache.  On  the  fourth  day,  had  another  chill  and  was 
"quite  feverish.'"  Dr.  Gladman  was  then  called.  Tempera- 
ture 103.4°  pulse  135.  Expression  good,  mind  clear. 
During  the  next  four  days,  the  patient  was  treated  with 
medication  and  vaginal  douches.  No  intrauterine  inter- 
ference. 

The  patient  did  not  do  well  and  I  was  called  on  the 
eighth  day.  I  found  the  expression  bad,  abdomen  dis- 
tended, uterus  fixed  and  relaxed,  and  discharge  copious. 
Temperature  104.2°  F.,  pulse  147,  respiration  30.  I  imme- 
diately curetted,  thoroughly  flushed  the  cavity,  and  packed 
it  lightly  with  iodoform  gauze. 

Ninth  day.  No  improvement.  Temperature  104°  F., 
pulse  156.  respiration  32.  Nausea  and  vomiting.  Patient 
drowsy  and  listless.  Gauze  removed,  tubes  inserted,  and 
irrigations  given  hourly. 

Tenth  day.  Temperature  104.2°  F..  pulse  152,  respira- 
tion 33.    Condition  about  the  same.    Irrigations  half  hourly. 

Eleventh  dav.  Temperature  103.6°  F..  pulse  146,  respir- 
ation 36.  Patient  had  a  severe  chill.  She  was  placed  on 
a  table  and  tubes  removed  and  fresh  ones  inserted.  Irri- 
gations continued 

Twelfth  day.  Temperature  103°  F.,  pulse  138.  respira- 
tion 34. 

Thirteenth  day.  Temperature  101.4°  F.,  pulse  120,  respir- 
ation 34.    Irrigations  every  two  hours. 

Fourteenth  day.  Temperature  101.2°  F.,  pulse  132.  res- 
piration 36. 

Fifteenth  day.  Temperature  101°  F..  pulse  132,  respira- 
tion 36.  Patient  was  anresthetized,  and  tubes  were  re- 
moved. The  uterus  measured  five  inches.  Packed  with 
iodoform  gauze,  cul-de  sac  opened,  considerable  adhesions, 
but  little  pus.  Uterus  separated  and  surrounded  with  iodo- 
form gauze.  I'terinc  pack  then  removed,  tubes  reinserted 
and  irrisfation  continued  every  three  hours. 

Sixteenth  da\-.  Temperature  994°  F.,  pulse  106,  respira- 
tion 32. 

Seventeenth  dav.  Temperature  99.2°  F..  pulse  90.  respira- 
tion 26. 

Eighteenth  day.  Temperature  99°  P.,  pulse  02,  respira- 
tion 22.  Tubes  removed.  Patient  here  passed  from  my 
hands 

Case  IV. — March,  1906.  This  case  was  one  of  miscar- 
riage of  later  months.  Patient  confessed  to  having  taken 
pills  during  early  pregnancy,  but  deniecl  all  further  efforts 
to  terminate  the  same.  She  was  a  healthv  young  woman, 
giving  no  history  of  svphilis  or  tuberculosis;  heart  and 
kidneys  were  sound,  etc.    Miscarriage  had  been  painful  and 


June  19,  1909.] 


IVEIL:  IRRIGATIOX  IN  PUERPERAL  SEPSIS. 


1263 


tedious,  with  considerable  haemorrhage  both  during  and 
particularly  after  deliver}-.  Afterbirth  expelled  naturally, 
i  his  occurred  under  the  care  of  a  midwife,  and  the  patient 
did  well  until  the  fifth  day,  when  she  had  a  slight  chill. 
During  the  next  four  days  the  chills  recurred  at  irregu- 
lar intervals.  She  vomited  occasionally,  and  the  tempera- 
ture and  pulse  rose  steadily.  During  this  period  and  while 
imder  the  midwife's  care,  she  was  treated  by  frequent  vag 
inal  douches  and  daily  intrauterine  (?)  douches.  The  latter 
were  given  in  bed  without  the  use  of  a  speculum ;  a  double 
current  metal  irrigator  being  passed  into  the  vagina  and 
then  to  the  uterine  cavity,  guided  by  the  finger.  Xo  curet- 
tage or  manual  e.vploration  was  attempted. 

I  was  called  on  the  tenth  day.  Temperature  102.4"  F.. 
pulse  144,  respiration  .30.  She  was  curetted  at  once,  re- 
moving a  small  plug  of  afterbirth  from  one  corner  of  the 
cavity  The  organ  was  irrigated  and  packed  with  iodoform 
gauze 

Eleventh  day.  Condition  about  the  same.  Gauze  re- 
moved and  cavit}'  irrigated.  Organ  measured  eight  inches. 
Cover  glass  smear  showed  streptococci. 

Twelfth  day.  Temperature  103.2°  F.,  pulse  148;  expres- 
sion bad.  Organ  measured  eight  and  one  half  inches. 
Again  irrigated  and  packed.  Patient  had  a  chill  toward 
evening. 

Thirteenth  day.    Temperature  104"  F.,  pulse  154,  mind 
wandering.    Tubes  inserted  and  irrigations  hourly. 
Fourteenth  day.    Xo  change. 

Fifteenth  day.    .About  the  same.    Irrigations  half  hourly. 

Sixteenth  day.  Temperature  103.2°  F.,  pulse  140.  Ap- 
pearance very  bad,  but  mind  clearer  and  eyes  brighter. 

Seventeenth  da}-.    X'o  further  change. 

Eighteenth  day.  Temperature  102.6°  F.,  pulse  128.  Mind 
now  clear.  Appearance  improved.  X'ourishment  now  re- 
tained. The  tubes  were  removed  and  fresh  ones  inserted. 
Uterus  well  involuted  but  adherent.  Rectal  examination 
failed  to  disclose  any  definite  fluctuation.  Irrigations  every 
two  hours. 

Nineteenth  day.   Temperature  102°  F.,  pulse  118. 

Twentieth  day.    Temperature  101.6°  F..  pulse  110. 

Twenty-first  day.    Temperature  101.2°  F..  pulse  104. 

Twenty-second  day.  Temperature  100.2°  F..  pulse  96. 
Irrigations  discontinued. 

Twenty-third  day.    Temperature  100.4°  F  -  pulse  96. 

Twenty-fifth  day.    Temperature  100°  F.,  pulse  86. 

Twenty-eighth  day.   Temperature  99  4°  F..  pulse  94. 

Case  V. — May,  1906.  This  was  a  typical  infection  fol- 
lowing labor  in  which  the  disease  first  showed  itself  on  the 
seventh  day,  and  which  was  curetted  two  days  later.  In 
spite  of  the  curettage,  the  patient  became  worse  and  six 
days  later,  (the  fifteenth  day)  I  was  requested  to  apply 
the  irrigation.  This  I  did  without  any  further  intrauterine 
■exploration,  being  assured  that  the  organ  had  been  carefully 
gone  over  and  all  placental  remains  removed.  The  cavity 
was  very  large,  the  organ  flabby,  and  the  lochia  while  not 
foul,  yet  of  characteristic  odor  containing  abundant  strep- 
tococci. The  patient's  appearance  v.as  unusually  bad,  al- 
most comatose.  No  distention.  Bowels  loose,  temperature 
moderate  (102.6°  F.).  pulse  rapid  (160)  and  of  poor  qual- 
ity, respiration  30.  Blood  count  showed  21.000  leucocytes, 
eighty-si.x  per  cent  polynuclear.  The  tubes  were  easily 
inserted  and  at  the  same  time  a  high  enema  given.  Irriga- 
tions were  ordered  continuously,  the  enema  of  one  pint 
normal  salt  solution  repeated  every  three  hours,  and  strych- 
nine. 1/60  grain,  given  every  six  hours.  Contrary  to  what 
was  expected,  the  patient  responded  promptly,  showing 
definite  improvement  eight  hours  later.  This  was  evi- 
denced in  a  lowered  pulse  (150). 

The  next  day  she  was  evidently  improved:  eyes  brighter 
^ind  mind  clearer.  Temperature  103.6°  F.,  pulse  150.  Ir- 
rigations continued,  hut  enemata  discontinued. 

Seventh  day.  Temperature  103.2°  F.,  pulse  145.  General 
condition  improved.    Irrigations  ordered  half  hourh". 

Eighteenth  day.    Temperature  103°  F.,  pulse  142. 

Nineteenth  day.    Temperature  103.2°  F.,  pulse  144. 

T\ventieth  day.  Tube?  removed  and  fresh  ones  inserted. 
Uterine  cavity  measured  eight  inches,  firmly  adherent.  Ir- 
rigations continued.  Temperature  103.2°  F.,  pulse  145.  Pa- 
tient's appearance  still  characteristically  septic,  pallor  pro- 
notmced.    Blood  count  21.000. 

Twenty-first  day.  Temperature  102.4°  pulse  138.  Gen- 
eral improvement:  taking  nourishment  resfularly. 

Twenty-second  day.    Temperature  102°  F.,  pulse  130. 


Twenty-third  day.  Temperature  104°  F.,  pulse  122.  Ir- 
rigations every  six  hours. 

Twenty-fourth  day.  Temperature  100.2°  F.,  pulse  94. 
Irrigations  discontinued.  Uterus  contracted  to  five  inches, 
but  firmly  fixed  by  adhesions.  Pelvis  occupied  by  large 
indurated  mass. 

Twenty-sixth  day.  Temperature  and  pulse  show  no 
change. 

Thirty-first  day.  Temperature  100.4°  F.,  pulse  100.  Pel- 
vic abscess  opened.  Considerable  foul  smelling  pus  dis- 
charged.   Cavity  packed  with  iodoform  gauze. 

Note. — August,  1906.  Uterus  slightly  adherent  in  retro- 
version, menstruation  normal,  but  scanty. 

November,  1906,  uterus  freely  movable. 

Case  VI. — This  case  was  one  of  incomplete  abortion  re- 
ferred to  me  for  curettage.  When  first  seen,  the  patient's 
temperature  and  pulse  were  normal.  She  was  flowing  pro- 
fusely with  pains  at  intervals.  The  cervix  was  soft  and 
easily  dilated,  and  the  operation  required  no  anjesthetic. 
It  was  comparatively  painless  except  at  one  period,  when 
she  complained  of  severe  pain  on  the  left  side,  and  follow- 
ing the  operation  lost  consciousness  and  became  cyanotic, 
necessitating  a  hypodermic  injection.  No  particular  atten- 
tion was  paid  to  this  at  the  time. 

The  following  day  she  complained  of  severe  pains  and 
constipation,  for  which  the  nurse  gave  an  active  cathartic. 
Temperature  102.4°  F.,  pulse  128. 

Third  day.  All  the  signs  cf  peritonitis  had  developed; 
distension,  muscular  rigidity,  and  pains  were  well  devel- 
oped, constipation  complete.  Temperature  103.2°  F.,  pulse 
128.  Had  chills  during  the  past  twenty-four  hours.  Believ- 
ing the  patient  to  be  septic,  I  again  curetted,  this  time  under 
anaesthetic ;  the  uterus  was  relaxed  and  flabby.  retro\-erted 
and  somewhat  adherent,  but  perfectly  sweet  and  clean,  and 
the  lochia  normal.  She  did  not  improve  from  the  second 
curettage. 

Fourth  day.  Temperature  104°  F..  pulse  132.  Distention, 
bowel  paralysis,  and  pain  increased,  to  which  was  added 
vomiting.  Her  appearance,  however,  was  rather  good. 
This  was  the  one  consoling  feature.  The  case  was  evi- 
dently one  of  sepsis  with  the  peritonitis  element  predomin- 
ating, and  while  I  could  hardly  attribute  the  condition  to 
uterine  infection,  yet  was  at  a  loss  to  account  for  the 
trouble  on  any  other  basis.  For  this  reason  I  began  irri- 
gations at  once.  Blood  count,  8,000  leucocytes.  Cover  glass 
specimen  of  lochia  proved  negative. 

Sixth  day.  Patient  was  unimproved.  Temperature  104° 
F.,  pulse  140.  Constipation,  pain,  distension,  and  rigidity 
still  present.  \^omiting  continued.  Her  facial  expression 
not  so  good. 

Seventh  day.  Tubes  were  displaced  and  had  to  be  rein- 
serted. The  uterus  relaxed  but  evidently  clean.  No  puru- 
lent discharge.  Entire  pelvic  contents  were  securely  matted 
together.  Temperature  103  2°  F.,  pulse  140.  Patient  list- 
less and  slept  continuousl}-. 

Eighth  day.  Under  anaesthetic  Douglas's  pouch  opened. 
Cutting  through  the  muco'^-s  membrane,  there  was  a  pro- 
fuse discharge  of  purulent  blood  stained  fluid,  and  on 
opening  the  peritonaeum  a  further  discharge  of  about  the 
same  amount.  The  abscess  cavity  was  well  drained  and 
lightly  packed,  and  the  irrigations  discontinued.  Her  tem- 
perature at  once  dropped  to  100°  F.,  and  pulse  to  110. 
the  pus  on  careful  examination  proved  sterile,  but  for  a 
few  scattered  gonococci. 

Note. — This  case  was  evidently  a  traumatic  rupture  of 
an  old  pus  accumulation,  yet  in  the  beginning  there  was 
room  for  some  doubt.  The  irrigations  were  given  not  be- 
cause I  suspected  uterine  absorption,  but  for  the  purpose 
of  eliminating  this  absorption  if  by  any  possible  chance 
it  were  the  cause  of  the  disturbance.  "The  fact  that  they 
had  no  influence  on  the  course  of  the  disease,  was  to  my 
mind,  of  diagnostic  significance. 

Case  VII.— September,  1907.  This  was  a  case  of  mis- 
carriage at  six  months  in  a  uterus  containing  a  large  sub- 
mucous fibroid  and  comolicated  by  retained  placenta.  At- 
ternpts  to  remove  the  placenta  resulted  in  breaking  it  up. 
Pain,  colick}-  and  intermittent,  was  present  from  the  begin- 
ning.   The  temperature  began  to  rise  on  the  fourth  day. 

Seventh  dav.  Patient  had  a  chill.  Temperature  104°  F., 
pulse  130.  Considerable  discharge.  Patient  treated  with 
ergot  and  quinine  in  large  doses  and  frequent  vaginal 
douches  of  bichloride  solution. 


II  EIL:  IRRIGATION  IN  PUERPERAL  SEPSIS. 


[New  Vork 
Medical  Journal. 


Eighth  day.  Had  another  chill.  Vomited.  Bowels  loose. 
Temperature  103.6°  F.,  pulse  130. 

Ninth  day.  Temperature  104.2°  F.,  pulse  142.  Patient 
looked  pinched  and  anxious.    Another  chill. 

Tenth  day.  I  was  called.  Examination  disclosed  a  uterus 
measuring  eight  inches,  relaxed,  but  movable.  Lacerated 
cervix,  discharge  foul ;  attempts  to  pass  sound  disclosed  a 
large  firm  mass  in  the  posterior  wall  projecting  into  the 
cavity  and  making  access  to  the  fundus  difficult.  The  pa- 
tient was  curetted  and  some  placenta  dislodged  from  be- 
hind-the  tumor  mass.  Believing  the  cavitv  clean,  it  was 
packed  with  iodoform  gauze  after  irrigation. 

Eleventh  day.  Patient  unchanged.  Gauze  removed.  Cav- 
ity irrigated  and  fresh  gauze  inserted.  The  gauze  removed, 
had  a  distinct  odor  in  spite  of  the  iodoform,  and  the  dis- 
charge on  cover  glass  e.xamination  showed  cocci  irregu- 
larly grouped  with  a  few  short  chains  (staphylococcus). 
Uterine  measurement  eight  inches.  Blood  count  16,000 
leucocytes. 

Twelfth  day.  Temperature  103.4°  pulse  158.  Patient 
had  two  chills  during  night,  vomited,  no  abdominal  dis- 
tension. Cachexia  marked.  Severe  headache.  The  gauze 
removed,  was  decidedly  foul.  Irrigation  treatment  being 
urgently  indicated  but  impossible  for  lack  of  attendants, 
the  patient  was  with  some  difficulty  removed  to  the  hospital 
and  irrigations  instituted  at  once.  The  tubes  were  not 
easily  inserted.    Irrigations  hourly. 

During  the  ne.xt  two  days,  she  about  held  her  own,  but 
at  least  the  pulse  showed  no  increase. 

Fifteenth  day.  Improvement  began  with  pulse  and  ap- 
pearance, but  with  little  temperature  change.  Temperature 
103.2°  F.,  pulse  142. 

Sixteenth  day.    Temperature  102.6°  F.,  pulse  136. 

Seventeenth  day.    Temperature  102.2°  F.,  pulse  130. 

Eighteenth  day.    Temperature  101.4°  F.,  pulse  no. 

Nineteenth  day.  Tubes  removed  and  fresh  ones  inserted. 
Organ  somewhat  contracted.  Irrigations  now  reduced  to 
every  two  hours.    Blood  count  21,000  leucocytes. 

Twentieth  day.    Temperature  100.4°  F.,  pulse  100. 

Twenty-second  day.    Temperattire  100.2°  F..  pulse  94. 

Twenty-fourth  day.  Temperature  100°  F..  pulse  86.  Ir- 
rigations three  tirr.es  a  day. 

Twenty-si.xth  day  Tubes  rem.oved,  uterus  measured  five 
inches.    Discharge  profuse  and  foul  smelling. 

Thirtieth  day.  Discharge  in  large  qtiantity,  temperature 
and  pulse  normal,  appearance  cachectic.  Blood  count  18,000 
white  cells. 

Thirty-sixth  day.  Uterus  adherent,  discharge  moderate. 
Temperature  and  pulse  normal.  Blood  count,  red  cells 
4,200.000,  leucocytes  18,000. 

C.\SE  VIII. — This  case  while  not  strictly  puerperal,  still 
belongs  to  that  class  of  cases.  The  patient  at  the  time, 
June,  1908,  had  a  child  about  eighteen  months  of  age.  She 
had  nursed  this  child  up  to  six  months  previously  and  only 
stopped  then,  because  as  she  thought,  she  had  become  preg- 
nant. All  the  symptoms  occurred  at  the  proper  time  and 
at  four  and  one  half  months  she  "felt  life."  The  abdo- 
men gradually  enlarged.  At  about  six  months,  she  began 
to  flow.  Being  really  anxious  to  bear  another  child,  she  im- 
mediately sent  for  her  physician,  who  put  her  to  bed  and 
prescribed.  The  flow  continued,  and  two  days  later  her 
physician  "used  instruments." 

A  few  (lavs  later  fever  developed  with  pain,  but  nothing 
else,  and  still  two  days  later,  her  physician  informed  her 
that  it  would  be  necessary  to  operate  to  remove  a  dead 
child.  A  consultation  was  held  and  this  verified  the  at- 
tendant's opinion.  The  patient  still  anxious  if  possible  to 
save  the  child,  still  refused  operation  and  requested  further 
consultation  :  but  even  this  did  not  satisfy  the  family.  Fin- 
ally a  fourth  consultation  was  held,  and  it  was  arranged  to 
operate  at  once,  .^ftcr  making  all  preparations  for  the 
operation,  the  familv  again  refused  cor.sent.  By  this  time, 
the  attending  physician  was  thoroughly  angry,  and  when  the 
familv  requested  a  consultation  with  me  he  refused.  He. 
however,  was  prevailed  upon  to  reconsider  the  matter  and 
agreed  to  meet  me.  which  he  did. 

Examination  disclosed  the  patient  with  the  abdomen  sym- 
metrically enlarged,  having  a  temperature  of  perhaps  102.4° 
F..  pulse  i.p,  abdomen  tender  and  tympanitic  over  the  en- 
tire surface  The  fundus  was  not  palpable.  She  was 
anxious  to  avoid  operation  if  possible,  declaring  that  she 
still  "felt  life." 

Vaginal  examination  disclosed  an  undilated  cervix  and 
bimanu.nlly  I  was  able  to  bring  the  fingers  of  both  hands 


together  immediately  over  the  pubic  bone.  The  uterus  was 
slightly  enlarged.  There  was  a  purulent  discharge  from 
the  cervix,  and  this  was  later  found  to  contain  streptococci. 
To  verify  the  diagnosis  the  patient  was  placed  in  a  dorsal 
position  on  a  table  under  anaesthetic  and  curetted.  In  all 
probability  the  flow  which  was  mistaken  for  miscarriage, 
was  merely  the  restored  menstruation  and  the  physician 
under  the  impression  that  miscarriage  was  inevitable,  re- 
sorted to  intrauterine  treatment.  This  resulted  in  infec- 
tion.   Diagnosis,  septic  endometritis. 

I  was  recalled  a  few  days  later,  and  found  the  patient 
in  severe  pain,  abdomen  distended  and  constipated  with 
rapid  thready  pulse,  septic  countenance,  etc.  The  uterus 
firmly  adherent,  cul-de-sac  bulging,  induration  extending 
throughout  the  entire  pelvis.  Temperature  103.2°  F.,  pulse 
154,  respiration  32.  She  was  immediately  removed  to  the 
hospital  and  under  anaesthetic  the  vaginal  vault  opened.  It 
was  necessary  to  dissect  through  a  considerable  mass  of 
plastic  adhesions  in  order  to  gain  entrance  to  the  peritoneal 
cavity.  No  pus  was  found,  but  the  broad  ligament  on  both 
sides  contained  a  large  mass,  attempts  to  puncture  which 
failed,  although  a  sharp  pointed  scissors  and  considerable 
force  were  used.  The  following  day  the  temperature  was 
103.6°  F„  pulse  over  160,  respiration  32.  In  view  of  the 
rapid  pulse,  I  inserted  a  small  double  current  catheter  into 
the  uterus  and  began  irrigations.  The  cervix  was  soft  and 
dilated  easily ;  the  uterus  was  small  but  relaxed  and  meas- 
ured about  three  inches.  Being  a  nonpuerperal  case,  I  did 
not  curette.  Distention  and  constipation  complicated  the 
case  considerably,  but  pain  was  not  marked.  She  took 
practically  no  nourishment  without  vomiting. 

The  next  day.  that  is  the  second  day  after  the  operation, 
the  temperature  was  104°  F.,  pulse  160,  respiration  30.  Ir- 
rigations were  given  hourly,  but  the  small  size  of  the  cath- 
eter made  them  almost  continuous.  Blood  count  14,000 
leucocytes.    Cover  glass  smear  showed  streptococci. 

Third  day.  Temperature  103.2°  F.,  pulse  154.  respiration 
30.    Irrigations  continued. 

Fourth  day.  Temperature  103.4°  F.,  pulse  160,  respiration 
28.  Irrigations  continued.  Nuclein  solution  given  hypo- 
dermically  twice  daily. 

Fifth  day.  Temperature  103°  F.,  pulse  152,  respiration 
28.  Anaesthetic  given  and  abscess  cavity  again  explored. 
About  two  ounces  of  pus  evacuated ;  opening  enlarged, 
and  cavity  well  packed.  Tube  reinserted  into  the  uterus. 
Nutrient  enema  ordered  twice  daily. 

Sixth  day.  Temperature  103°  F.,  pulse  148,  respiration 
26, 

Seventh  day.  Temperature  102.2°  F.,  pulse  138,  respira- 
tion 24. 

Eighth  day.  Temperature  102.4°  F,,  pulse  142.  respira- 
tion 22. 

Ninth  day     Temperature  102°  F.,  pulse  134. 

Tenth  day.  Temperature  102°  F.,  pulse  128.  Nuclein 
discontinued.  Cathartic  given  with  fair  results.  Blood 
count  20,000  leucocytes. 

Eleventh  day.  Temperature  101.4°  F„  pulse  116.  Food 
by  the  mouth  retained.  Nutrient  enema  discontinued. 
Bowel  moved  again. 

Twelfth  day.  Temperature  101°  F.,  pulse  104:  irrigations 
discontinued.  Vaginal  douches  substituted.  Blood  count 
26,000  white  cells. 

Thirteenth  day.    Temperature  100.4°  F..  pulse  92. 

Fourteenth  day.    Temperature  100°  F..  pulse  84. 

Fifteenth  day.    Temperature  99.6°  F.,  pulse  90. 

Patient  left  hospital  about  ten  days  later;  very  weak  and 
anaemic.    The  vaginal  discharge  had  ceased. 

About  a  month  later,  she  still  looked  bad.  but  was  re- 
gaining her  strength.  The  uterus  was  retroverted  and  ad- 
Iierent.  Four  months  later  I  again  examined  her.  B\-  this 
lime  she  was  looking  remarkably  well,  had  entirely  re- 
gained her  strength,  menstruated  regularly,  and  the  uterus 
was  now  freely  movable. 

Note. — This  case  is  given  because  it  illustrates  the  use 
of  irrigations  in  cases  of  a  somewhat  different  character. 
Usually  the  peritonitis  element  predominates  in  nonpuer- 
peral cases  because  thev  are  usually  gonorrhoeal.  In  this 
case,  however  the  infection  was  known  to  be  streptococcic. 
The  absence  of  pus  and  the  extremely  rapid  pulse  sug- 
gested absorption  of  a  particularly  virulent  poison.  The 
irrigations  were  cmploved  in  hope  of  limiting  this  absorp- 
tions. Curretage.  while  perhaps  indicated  early  in  these  cases, 
is  of  little  use  once  the  infection  is  firmly  established  and 
may  do  much  harm  :  i.  By  opening  up  thrombosed  vessels; 


June  19,  1909.] 


BERRY:  WEAKENED  FEET. 


1265 


2,  by  penetrating  Nature's  defenses  of  leucocytes;  3,  or 
even  perforating  a  necrotic  wall.  The  curette  finds  its  prin- 
cipal use  in  removing  retained  products  of  conception.  It 
cannot  dispose  of  the  germs.  On  the  other  hand,  irriga- 
tions are  to  say  the  least :  i,  Harmless :  2,  they  insure 
drainage ;  3,  they  exert  some  influence  on  absorption  ;  and 
4,  they  prevent  germs  from  breeding  within  the  cavity. 

The  error  of  diagnosis  in  this  case  merely  illustrates  the 
danger  of  taking  things  for  granted. 

The  frequency  of  irrigations  is  obviously  of  much 
importance,  and  it  is  better  to  err  on  the  side  of  too 
many.  It  is  needless  to  say  they  must  be  given  both 
day  and  night.  In  the  more  severe  cases,  I  suggest 
continuous  irrigation  from  the  start.  With  milder 
cases,  hourly  or  even  two  hourly  irrigations  should 
suffice.  When  no  improvement  is  evident,  the  irri- 
gations should  be  increased  if  necessary  to  the 
limit,  and  once  benefits  are  manifest  they  may  be 
cautiously  reduced.  In  short,  one  must  be  guided 
entirely  by  the  course  of  the  disease. 

The  solution  used  is  perhaps  of  little  consequence. 
Plain  salt  solution  is  as  good  as  any.  Still,  the 
antiseptics,  such  as  iodine,  alcohol,  formalin,  lysol, 
boric  acid,  etc.,  all  have  virtues  and  may  be  used 
with  good  efifect.  However,  care  must  be  taken  in 
the  use  of  antiseptics  that  the  solution  is  not  of 
toxic  strength.  Severe  poisoning  has  resulted  from 
irrigating  the  uterus  with  strong  antiseptics. 
Above  all,  the  solution,  whatever  it  be,  must  be 
sterile  and  the  whole  procedure  carried  out  with 
due  regard  for  asepsis.  I  use  one  half  gallon  of 
solution  at  each  irrigation,  at  body  temperature. 
Efforts  to  stimulate  the  septic  uterus  to  contraction 
bv  hot  solutions,  only  result  in  further  relaxation 
of  the  vessels. 

Of  the  eight  cases,  six  terminated  in  pelvic  ab- 
scess with  extensive  adhesions  necessitating  drain- 
age. Of  these  cases,  three  patients  that  I  was  able 
to  keep  under  observation,  made  perfect  symp- 
tomatic and  so  far  as  I  can  tell,  anatomical  recov- 
ery. In  each  case  menstruation  became  regular  and 
normal,  and  the  uterus  freely  movable,  and  one  pa- 
tient was  about  to  give  birth  to  a  child.  I  have  also 
records  of  several  nonpuerperal  {  ?)  cases  of  pelvic 
suppuration  (not  gonorrhoeal)  in  which  drainage 
was  instituted,  and  in  every  case  the  uterus  even- 
tually became  freely  movable  and  menstruation  per- 
fectly restored.  These  organized  exudates  are  at 
times  very  firm  and  dense  and  in  one  case  in  which 
I  operated  too  early,  the  inflammatory  mass  was  so 
tough  as  to  resist  sharp  instruments  and  consid- 
erable pressure.  Yet  this  mass  was  eventually  en- 
tirely absorbed  within  a  remarkably  short  period. 

The  view  once  held,  that  all  peritoneal  adhesions 
organized  and  became  permanent,  does  not  appear 
to  be  borne  out  by  facts.  It  seems  that  under  fa- 
vorable circumstances  Nature  absorbs  these  plastic 
adhesions  and  this  absorption  takes  place  upon  re- 
moval of  all  pus  or  other  foreign  material.  This, 
in  pelvic  suppuration,  depends  upon  careful  and 
thorough  drainage,  and  inversely,  it  would  appear 
that  thej3ersistence  of  adhesions  indicates  the  pres- 
ence of  pus.  This,  to  a  certain  extent,  I  believe 
true ;  like  local  leucocytosis,  peritoneal  exudation  is 
excited  by  the  proximity  of  germs,  or  other  irri- 
tants. The  object  of  both  is  to  limit  or  contend 
with  the  invaders.  The  irritant  once  disposed  of, 
the  leucocytes  disappear,  being  of  no  further  use. 
The  plastic  adhesions  occur  under  identical  condi- 


tions, with  similar  object  and  once  that  object  is  ac- 
complished, it  is  only  reasonable  to  assume  that 
Nature  would  remove  them,  and  the  fact  that  Na- 
ture has  not  done  so,  would  thus  indicate  that  the 
irritant  whatever  it  be,  is  still  present. 

I  look  favorably  upon  pelvic  abscess  as  a  term- 
ination of  severe  puerperal  disease,  for  I  consider 
it  Nature's  most  potent  means  of  disposing  of  the 
infection,  and  paradoxical  as  it  may  seem,  the  al- 
most constant  presence  of  pelvic  abscess  in  this  se- 
ries of  cases  is  irrigation  treatment's  best  argument ; 
for  severe  puerperal  sepsis  almost  invariably  ends 
thus,  unless  death  occurs  from  toxaemia  before  the 
abscess  has  had  time  to  develop,  and  the  fact  that 
in  a  series  of  severe  cases  death  from  toxaemia  did 
not  occur,  would  seem  to  indicate  the  ability  of 
irrigations  to  limit  absorption  to  a  degree  sufficient 
to  enable  Nature  to  strengthen  her  defenses  and  to 
completely  invest  the  invaders.  In  this  connection 
I  can  hardly  do  better  than  to  quote  that  eminent 
gynaecologist  Dr.  Howard  Kelly  (  Kelly  and  Noble, 
Gyncccology,  1908,  i,  p.  653),  "The  formation  of  the 
pelvic  abscess  .  .  .  constitutes  in  many  instances 
Nature's  best  ef¥orts  to  dispose  of  a  dangerous 
guest."  Again  (p.  654)  "Many  cases  are  recorded 
and  I  have  witnessed  some  within  my  own  experi- 
ence in  which  the  woman  so  treated  (vaginal  drain- 
age) has  not  only  recovered  her  health  but  has  gone 
through  a  normal  pregnancy  subsequent  to  the  op- 
eration." 

241  West  One  Hundred  and  First  Street. 


SOME  PRACTICAL  LESSONS  FROM  A  STUDY  OF 
TWO  HUNDRED  CASES  OF  WEAKENED  FEET. 

By  John  M.  Berry,  M.  D., 
Troy,  N.  Y. 

The  complaints  of  patients  suffering  from  a 
weakened  condition  of  the  feet  are  almost  as  va- 
ried in  character  as  the  indications  for  use  of  some 
extensively  advertised  patent  medicines,  and  they 
are  set  forth  by  the  patients  in  all  degrees  of  se- 
verity from  simply  an  unaccountable  tired  feeling 
with  nervous  irritability  to  total  inability  to  walk. 

When  the  attention  of  the  physician  is  called  di- 
rectly to  weakness  in  the  feet  by  the  complaint  of 
the  patient  there  is  small  excuse  for  his  making  a 
mistake  in  diagnosis,  but  oftentimes  the  only  C(^m- 
plaint  is  that  of  pain  in  the  back,  pain  in  the  limbs, 
pain  or  weakness  in  the  knees,  weak  ankles,  ina- 
bility to  skate,  or  difficulty  in  getting  a  comfortably 
fitting  shoe.  The  general  practitioner  or  surgeon 
should  bear  in  mind  these  various  complaints  and 
in  all  cases  of  pain  or  weakness  in  the  lower  ex- 
tremities make  an  intelligent  examination  of  the 
feet. 

Many  factors  enter  into  the  aetiology  of  weak- 
ened feet.  While  some  children  are  born  with  flat 
feet,  the  pes  valgus  form  of  club  foot,  undoubt- 
edly many  m.ore  are  born  with  simply  a  weakened 
condition  of  the  feet,  a  condition  which  manifests 
itself  only  in  later  life. 

A  frequent  cause  of  weak  feet  in  boys  is  found 
in  the  excessive  exercise  in  which  they  indulge, 
walking,  running,  and  jumping  oftentimes  with  the 
feet  covered  only  by  those  apologies  for  foot  wear 


1266 


BERRY:  WEAKENED  FEET. 


[New  York 
Medical  Journal. 


known  as  "sneaks."  ''Sneaks''  give  absolutely  no 
support  to  the  feet,  but  on  the  contrary  often  force 
the  front  part  of  the  foot  outward  into  an  abducted 
position  favoring  strain.  The  long,  low  type  of  arch 
is  found  to  be  especially  apt  to  give  trouble. 

Increase  in  weight  is  always  assigned  to  an  im- 
portant place  in  aetiology,  a  place  which  it  rightly 
deserves.  \'ery  frequently  the  physician  is  con- 
sulted b)^  an  individual  to  whom  nature  has  given 
a  foot  constructed  on  lines  v^^hich  adapt  it  to  carry 
120  pounds  at  the  most,  and  yet  later  in  the  life  of 
the  individual,  when  the  natural  energies  are  on  the 
wane,  that  same  foot  is  compelled  to  carry  from 
160  to  180  or  even  200  pounds.  It  is  small  wonder 
that  it  breaks  down.  It  is  impossible  to  get  ten 
horse  power  work  out  of  a  six  horse  power  engine 
for  any  great  length  of  time.  This  is  one  reason 
for  the  frequency  of  weakened  feet  among  house 
maids  and  cooks,  for  not  only  do  they  use  their  feet 
a  great  deal,  but  in  many  cases  as  they  have  grown 
older  they  have  gained  in  weight,  thus  putting  a 
constantly  increasing  load  on  the  feet. 

Increase  in  weight  is  especially  a  factor  in  indi- 
viduals who  have  to  go  up  and  down  stairs  fre- 
quently ;  oftentimes  in  these  cases  the  trouble  lirst 
shows  itself  in  pain  and  weakness  in  the  knees. 

The  causative  factor  in  the  production  of  weak- 
ened feet  which  stands  preeminently  at  the  head, 
however,  is  improper  shoes.  Many  articles  have 
been  written  in  recent  years  to  impress  this  fact 
upon  the  profession,  but  only  one  who  has  made  a 
study  of  the  subject  can  appreciate  how  little  out 
of  normal  in  shoes  is  necessary  to  cause  trouble. 
Sometimes  it  seems  difficult  to  tell  why  the  trouble 
comes  on.  Many  cases  seem  to  develop  rapidly 
without  any  apparent  cause.  Patients  frequently 
ask,  "Why  should  I  have  this  trouble?"  Nothing 
can  be  found  in  the  past  history  to  account  for  it, 
and  there  is  no  history  of  excessive  use  of  the  feet 
or  increase  in  weight.  Such  cases  must  be  due  to 
improper  shoes.  It  is  the  small  strain  often  re- 
peated which  at  last  breaks  down  the  arch. 

If  the  physician  would  note  how  lew  women, 
whether  they  are  complaining  of  their  feet  or  not, 
can  flex  the  foot  beyond  a  right  angle  he  would  get 
some  idea  of  how  markedly  shoes  affect  the  feet. 

Sometimes  patients  may  present  themselves  wear- 
ing seemingly  proper  shoes,  but  on  questioning  it 
will  be  found  that  the  harm  was  done  in  early  life. 
They  are  people  who  have  been  cursed  with  small 
feet  and  through  vanity  worn  as  small  a  shoe  as 
was  possible. 

I'hfc  cases  of  weakened  feet  so  often  observed 
following  a  severe  illness  are  rarely  due  to  the  ill- 
ness itself,  but  in  the  general  debilitated  condition 
a  hitherto  concealed  s])ccial  weakness  now  shows 
itself. 

Occasionally  trauma  plays  an  important  part 
either  in  starting  the  trouble  or  in  calling  attention 
to  a  v>'eakness  that  has  existed  for  some  time.  The 
usual  symptoms  of  weakened  feet,  pain  and  swell- 
ing resembling  rheumatism,  have  become  verv 
familiar  to  the  profession,  but  there  are  numerous 
symptoms  which  arc  commonly  overlooked  or  not 
reco<Tfni7.cd.  So  closely  do  the  symptoms  of  weak- 
ened feet  resemble  rheumatism  at  times  that  a  diag- 
nosis of  that  disease  is  made  and  the  patient  re- 
ceives rheumatic  treatment.     One  of  my  patients 


had  had  her  feet  in  plaster  casts  for  six  weeks  with 
a  diagnosis  of  rheumatism. 

Probably  the  most  common  point  of  tenderness 
in  weakened  feet  is  at  the  sides  of  the  heel,  more 
often  on  the  outer  side.  Sometimes  the  appearance 
of  the  foot  varies  greatly  at  diiterent  periods  of  the 
day.  In  the  morning  it  may  be  very  normal  look- 
ing and  in  the  evening  the  a.ch  show  distinct  weak- 
ening and  lowering.  On  the  other  hand  the  foot 
may  swell  during  the  night  and  in  the  morning 
the  arch  be  almost  obliterated  by  swelling. 

In  small  children  a  common  symptom  of  weak 
feet  is  "toeing  in."  As  has  been  pointed  out  in  ar- 
ticles on  the  mechanism  of  the  foot,  the  adducted 
position  is  the  strong  position,  and  this  "toeing  in" 
of  children  is  the  exaggerated  effect  of  Nature's 
effort  to  correct  the  trouble.  Sometimes  in  the  ef- 
fort to  relieve  the  weakened  foot  the  child  will  even 
walk  on  its  toes.  Sometimes  very  young  children 
with  weak  feet  will  not  attempt  to  walk  at  all.  In 
later  life  the  only  symptom  of  weak  feet  ma}^  be 
"weak  ankles"  shown  in  rolling  over  of  the  ankles 
and  inability  to  skate.  The  ankles  may  roll  over  on 
the  inside  or  on  the  outside.  When  they  roll  over 
on  the  inside  it  is  the  direct  result  of  the  weak  foot 
and  when  they  roll  over  on  the  outside  it  is  due  to 
Nature's  attempt  to  relieve  the  strain  by  adducting 
the  foot.  This  same  effort  of  Nature  can  be  seen 
in  adult  life.  One  of  my  patients  was  a  man  who 
noticed  that  his  shoes  "ran  over"  on  the  outer  side, 
so  in  order  to  stop  it  he  built  up  the  outer  side  of 
the  heel  and  sole  of  his  shoe.  This  stopped  the 
running  over  of  his  shoe,  but  in  a  short  time  he  be- 
gan to  have  pain  in  the  arches  of  his  feet.  Removal 
of  the  built  up  heel  and  sole  and  the  use  of  a  proper 
arch  support  quickly  cleared  up  the  trouble.  The 
man  was  running  his  shoes  over  on  the  outside  be- 
cause Nature  was  adducting  his  feet  to  relieve  the 
strain  on  the  arches. 

An  interesting  series  of  symptoms  is  frequently 
observed  in  women  with  weak  feet.  There  is  a  his- 
tory of  beginning  foot  trouble  with  pain  in  the  arch 
of  the  foot  or  occasionally  the  knee.  They  consult 
some  one,  usually  a  shoe  dealer,  in  regard  to  the 
trouble  and  he  advises  them  to  wear  higher  heels ; 
they  do  so,  and  at  once  the  trouble  seems  to  stop, 
but  in  reality  they  have  simply  shifted  the  strain  tc 
another  part  of  the  foot,  and  after  a  time  the 
trouble  comes  back  worse  than  before  and  they  can 
find  no  relief.  It  is  impossible  to  raise  the  heels 
any  higher  and  equally  impossible  to  go  back  to  the 
the  old  low  heel.  When  the  physician  tells  such  a 
patient  that  the  heels  of  her  shoes  are  too  high  she 
says.  "But  I  feel  better  when  I  put  them  on."  The 
physician  can  suggest  that  she  certainly  does  not 
feel  better  now  or  she  would  not  be  looking  for 
medical  advice. 

A  painful  and  enlarged  big  toe  joint  is  very  com- 
mon in  weakened  conditions  of  the  feet.  This  simply 
means  that  undue  weight  is  being  thrown  on  that 
ioint  and  is  usually  the  result  of  an  impropt-r  shoe 
abducting  the  front  part  of  the  foot  and  shifting 
the  line  of  body  weight  from  the  middle  of  the  foot 
where  it  belongs  over  to  the  inner  side,  .'\nother 
'■csiilt  of  this  shifting  of  the  body  weight  is  the 
formation  of  calluses  at  the  points  of  undue  pres- 
sure. Whenever  a  callus  forms  on  a  foot  it  means 
that  something  is  wrong.    The  reading  of  the  cal- 


June  19,  1909.]  BERRY :  IV I 

luses  on  a  man's  foot  would  really  be  a  scientific 
study  as  compared  with  reading  the  "bumps"  on  his 
head. 

Pains  in  the  legs,  numbness,  and  cramps  are  all 
at  times  symptoms  of  weak  feet.  Alany  painful 
feet  could  be  classified  as  strained  feet ;  all  they 
need  is  a  chance  to  rest  and  recover  their  strength. 

Occasionally  weakened  feet  are  associated  with 
chronic  knee  trouble.  The  patient  may  have  had 
some  injury  to  the  knee,  usually  a  strain,  and  in 
spite  of  all  local  treatment  the  knee  remains 
strained.  Sometimes  in  these  cases  an  examination 
of  the  foot  will  show  a  weakened  condition,  and  on 
relieving  this  by  a  brace  the  knee  trouble  will  cl  ar 
up.  The  explanation  is  that  in  order  to  relieve  the 
strain  on  a  weakened  foot  the  muscles  of  the  leg  are 
thrown  into  unusual  activity,  to  counteract  which  the 
thigh  muscles  are  used,  and  between  the  muscles  be- 
low and  above  the  strained  knee  has  no  chance  to 
recover.  In  weakened  feet  with  symptoms  refera- 
ble to  the  knee  it  is  sometimes  very  difficult  to  tell 
just  how  much  of  the  trouble  is  due  to  the  feet  and 
how  much  is  due  to  other  causes.  The  symptoms  of 
a  relaxed  knee  are  ver}-  similar  to  those  produced 
by  weakened  feet,  and  weak  feet  may  give  symp- 
toms in  the  knee  resembling  beginning  tuberculosis. 
One  of  the  patients  referred  to  me  had  a  persistent 
synovitis  of  one  knee  joint,  considerable  pain  in  the 
knee,  worse  at  night,  and  a  slight  elevation  of 
temperature.  .She  had  a  slight  tuberculous  lesion  in 
her  lungs,  and  had  been  taking  care  of  a  sister  with 
marked  pulmonary  tuberculosis.  There  was  a 
marked  relaxation  of  the  arch  of  the  foot  and  a  his- 
tory of  unusual  use  of  the  feet  especially  in  going  up 
and  down  stairs,  but  in  view  of  the  tuberculous  his- 
tory it  was  deemed  best  to.  put  the  knee  in  a  plaster 
cast.  The  cast  was  left  on  for  three  weeks  w'ith  no 
benefit.  It  was  then  removed  and  a  proper  arch 
support  applied,  and  the  knee  trouble  promptly 
cleared  up.  Subsequently  the  same  trouble  devel- 
oped in  the  other  knee  and  was  relieved  by  a  brace. 

There  are  numerous  conditions  in  the  foot  itself 
that  may  resemble  weakened  feet.  In  one  of  my  pa- 
tients a  fracture  of  a  tarsal  bone  had  occurred 
without  recognized  trauma  and  the  symptoms  were 
typical  of  a  broken  arch.  In  all  cases  where  the 
foot  is  badly  reddened  and  inflamed  the  x  ray  should 
be  used  before  making  a  diagnosis. 

One  of  the  most  difficult  conditions  to  diagnosti- 
cate from  weakened  feet  is  intermittent  claudica- 
tion. In  some  cases  of  this  disease  practically  all  the 
symptoms  are  referable  to  the  feet ;  in  fact,  the  dis- 
ease may  produce  a  weakened  condition  of  the  feet 
and  the  patient  suffers  from  both  conditions  at  the 
same  time. 

The  characteristic  symptom  that  distinguishes  in- 
termittent claudication  from  weakened  feet  is  that 
in  intermittent  claudication,  while  the  pain  and  dis- 
comfort in  the  feet  from  walking  may  become  al- 
most unbearable,  after  a  short  rest  the  trouble  clears 
up  and  the  patient  can  go  on  again.  A  diagnosis  of 
intermittent  claudication  is  of  special  value  as  re- 
gards prognosis.  Shoes  and  braces  and  otTier  appro- 
priate treatment  for  weakened  feet  will  aid  the  pa- 
tient in  so  far  as  the  weakened  condition  of  the  feet 
is  concerned,  but  will  not.  of  course,  cure  the  inter- 
mittent claudication. 

The  prognosis  in  most  cases  of  weakened  feet  is 


IKENED  FEET.  1267 

I 

very  good.  Those  patients  who  have  the  best  prog- 
nosis are  where  the  arch  has  actually  begun  to  give 
way.  Such  feet  are  very  painful,  and  the  patient 
can  scarcely  walk,  but  under  treatment  with  proper 
shoes,  braces,  massage,  and  gymnastics,  the  relief  is 
prompt  and  effective.  In  the  somewhat  worse  cases 
where  the  arches  have  actually  fallen  but  can  be 
forced  back,  the  prognosis  is  also  good,  and  even  in 
cases  of  seemingly  rigid  flat  foot  the  foot  will  loosen 
up  in  a  surprising  manner  and  give  a  fairly  good 
prognosis  as  regards  freedom  from  pain  and  discom- 
fort. The  chance  of  a  good  prognosis  is.  increased 
in  severe  cases  when  the  discomforts  of  braces  and 
shoes  are  not  greater  than  the  original  trouble,  and 
the  patient  gladly  follows  out  any  line  of  treatment 
that  relieves  him. 

The  cases  of¥ering  the  least  hopeful  prognosis  are 
those  associated  with  neurasthenia,  especially  in 
women.  The  patient  will  not  stand  the  d  scomfort 
of  treatment.  Another  type  of  case  in  which  the 
prognosis  is  not  good  is  one  in  which  the  foot  is 
pronated  and  very  painful.  The  whole  foDt  seems 
"flabby."  I  have  found  this  type  of  foot  especially 
in  Jewish  women,  and  it  seems  to  be  very  difficult  to 
cure  these  cases. 

Some  of  the  most  satisfactory  cases  to  treat  are 
those  of  pronated  feet  in  children.  The  outcome  is 
always  good  and  there  is  good  satisfaction  in  feeling 
that  a  case  of  weakened  feet  in  later  life  has  been 
averted.  Too  few  cases  of  this  sort  are  treated,  and 
it  is  due  to  the  fact  that  either  the  general  practi- 
tioner does  not  recognize  the  case  or  else  he  does 
not  realize  the  importance  of  having  it  attended  to. 

In  considering  the  treatment  of  weakened  feet  it 
must  be  recognized  that  not  every  patient  is  going 
to  be  cured,  but  enough  patients  respond  so  readily 
and  effectively  to  proper  treatment  that  the  value  of 
treatment  is  unquestioned. 

An  important  aid  to  treatment  of  weakened  feet 
is  to  get  the  patient  interested  in  what  is  being  done. 
Get  him  to  further  the  process  of  cure  by  home 
gymnastics,  massage,  etc.  The  home  treatment  of 
weak  feet  would  make  good  subject  matter  for  an 
article.  Another  important  element  in  the  treatment 
is  the  careful  supervision  of  the  patient.  The  treat- 
ment by  braces  is  sure  to  be  uncomfortable  and  if  a 
patient  is  given  braces  and  allowed  to  go.  the  prob- 
abilities are  that  he  will  try  to  wear  the  braces  for 
a  few  days  and  then  throw  them  away.  One  of  my 
patients  complained  that  she  could  not  possibly  wear 
her  braces,  and  on  investigation  I  found  that  she 
was  trying  to  wear  the  left  brace  on  the  right  foot, 
and  vice  versa 

The  patients  have  to  be  told  that  the  braces  are 
going  to  be  uncomfortable  at  first.  It  is  not  a  good 
plan  to  let  them  wear  the  braces  home  from  the 
office,  but  wait  and  put  them  on  at  home  in  the 
morning,  wear  them  as  long  as  possible,  then  re- 
move them,  and  when  the  feet  are  rested  put  the 
braces  back  again,  remembering  that  the  more  they 
wear  them  the  quicker  they  will  get  used  to  them. 
The  patient  should  report  every  few  days  for  mas- 
sage and  vibratory  treatment.  This  helps  a  great 
deal  in  overcoming  the  stififness  of  the  foot  and  in 
relieving  the  pain  and  discomfort  of  braces. 

The  price  of  treatment  is  an  objection  to  many 
patients.  Proper  braces  made  over  plaster  casts 
of  the  feet  require  time  to  make  and  are  expensive^ 


1268 


CORNWALL:  MALIGNANT  ENDOCARDITIS  WITHOUT  FEVER. 


[New  York 
Medical  Journal. 


but  the  patient  does  not  realize  this,  especially  when 
there  are  so  many  cheap  ready  made  braces  on  the 
market.  A  large  proportion  of  my  patients  come  to 
me  wearing  ready  made  supports. 

Patients  do  not  mind  paying  the  price  if  they 
know  they  are  going  to  be  relieved,  but  they  may 
have  tried  so  many  remedies  that  they  are  skeptical. 
If  treatment  is  carried  out  systematically  there  is  the 
added  cost  of  special  custom  made  shoes.  There 
are  ready  made  shoes  that  can  be  recommended  to 
some  people,  but  they  do  not  fit  all  feet. 

It  is  very  important  to  observe  children's  feet  and 
if  weakness  is  found  take  precautionary  measures. 
A  child  with  weakened  feet  can  consider  itself  very 
fortunate  if  its  trouble  is  recognized  at  an  early  date 
and  appropriate  treatment  instituted.  Children  do 
not  mind  the  discomfort  of  a  brace,  and  a  good  re- 
sult can  almost  certainly  be  guaranteed.  Occasion- 
ally massage  and  manipulation  will  cure  a  case  of 
weakened  feet  in  a  child. 

It  is  sad  that  more  of  these  simple  conditions  are 
not  recognized.  Too  often  the  cases  are  neglected 
and  allowed  to  develop  into  real  deformity  and  flat 
foot ;  the  best  treatment  is  correction  under  ether, 
if  possible,  and  prolonged  treatment  by  plaster  of 
Paris  casts  and  subsequent  braces  and  shoes,  mak- 
ing an  exceedingly  difficult  treatment  out  of  what 
would  have  originally  been  a  very  simple  matter. 

Likewise  in  older  individuals  weak  foot,  if  recog- 
nized earlv,  is  a  simple  matter  to  correct,  massage 
and  gymnastics  often  sufficing.  Qftentimes  with 
slight  weakness,  especially  in  women,  all  that  is 
needed  is  a  proper  shoe,  but  that  they  will  not  get. 
Such  patients  can  be  persuaded  to  get  a  proper  brace 
when  they  will  not  get  shoes. 

Many  times  the  practitioner  meets  with  "-omen 
who  have  great  trouble  'in  getting  shoes  fitted  and 
are  always  having  cold,  clammy,  painful  feet,  but 
when  the  trouble  is  explained  to  them  and  they  see 
what  the  remedy  means  (the  wearing  of  a  nonfash- 
ionable  shoe)  they  get  another  species  of  "cold  feet" 
and  decide  to  struggle  along  a  while  longer,  taking- 
it  out  on  their  nervous  system.  So  invariably  is  this 
the  case  that  the  following  might  be  put  down  as  a 
rule :  When  a  society  woman  tempts  you  to  order  a 
pair  of  proper  shoes  for  her,  consent  thou  not.  but  if 
you  do,  get  your  money  for  them  first. 

The  weight  of  a  brace  is  another  disadvantage  in 
treatment,  but  has  to  be  endured ;  a  broken  arch  is  a 
greater  disadvantage  and  must  be  overcome.  As 
an  inducement  to  the  patient  he  can  be  informe  1  that 
it  may  mA  be  necessary  to  wear  a  brace  very  long, 
especially  if  he  will  wear  proper  shoes. 

There  is  a  great  difference  in  the  sensitiveness  of 
feet.  It  seems  almost  impossible  for  some  people  to 
wear  a  brace.  I  remember  one  patient  who  stated 
that  she  fainted  away  whenever  she  tried  to  w  a--  a 
brace. 

The  special  forms  of  weakened  feet  afford  some 
interesting  practical  points  as  regards  treatment. 
Cases  of  rigid  flat  foot  are  extremely  difficult 
to  treat.  It  always  seems  a  great  ])ity  that  they 
shoi'ld  have  been  neglected  for  so  loir^-  that  they 
are  almost  impossible  to  cure.  Some  of  these  cases 
can  be  cured  only  by  operative  procedure,  but  in  the 
great  majority  of  cases  two  courses  of  action  are 
open  for  trial.  Either  with  or  without  an.'esthesia  the 
feet  can  be  put  up  in  jilastcr  of  Paris  casts  until  the 


deformity  is  reduced,  and  then  a  proper  brace  ap- 
plied, or  if  the  patient  feels  that  he  must  be  up  and 
around  and  does  not  mind  a  good  deal  of  discomfort, 
he  can  be  fitted  at  once  with  braces  which  exert  cor- 
rective force  on  the  foot,  and  then  as  the  foot  yields 
he  must  get  new  braces.  It  is  sometimes  remarkable 
how  a  rigid  foot  will  loosen  up  through  the  use  of  a 
brace. 

An  enlarged  and  painful  big  toe  joint  can  be 
treated  by  either  a  brace  or  a  proper  shoe,  but  a 
combination  is  the  best,  and  then  as  the  foot  recov- 
ers the  brace  can  be  given  up. 

Contracted  foot,  hammer  tee,  Morton's  toe,  all 
have  their  special  line  of  treatment.  In  some  cases 
the  ideal  treatment  is  operative,  but  oftentimes  the 
patient  will  not  consent  to  an  operation,  and  since 
the  underlying  cause  is  usually  weakened  feet,  very 
much  can  be  done  toward  relieving  the  patient  by 
fitting  him  out  with  proper  braces  and  shoes. 

The  weakened  feet  associated  with  rheumatism 
and  intermittent  claudication  can  be  much  benefited 
so  far  as  the  feet  themselves  are  concerned,  but  such 
treatment  has,  of  course,  no  effect  upon  the  rheuma- 
tism or  intermittent  claudication. 

Quite  frequently  it  will  be  found  that  a  patient 
with  weakened  feet  under  treatment  by  braces  and 
shoes  improves  rapidly  and  is  seemingly  well  for  a 
time,  then  without  warning  while  still  wearing  the 
braces  and  shoes  trouble  begins  again.  It  is  due  to 
the  fact  that  the  feet  have  changed  and  the  braces 
are  no  longer  a« perfect  fit.  The  remedy  is  to  supply 
a  new  brace  properly  fitted  to  the  changed  foot. 

The  Caldwell,  St.vte  and  Second  Streets. 


A  CASE  OF  MALIGNANT  ENDOCARDITIS  WITH- 
OUT FEVER* 

Bv  Ed\v.\rd  E.  Cornwall,  M.  D., 
Brooklyn,  N.  Y., 

.Attending  Physician  to  the  Williamsburg  and  Norwegian  Hospitals; 
Professor  of  Internal  Medicine  in  the  Brooklyn  Post- 
graduate Medical  School. 

The  occurrence  of  malignant  (septic,  ulcerative, 
infective)  endocarditis  without  fever  is  rare. 
Twenty-five  years  ago  Osier  in  his  Goulstonian  lec- 
tures on  malignant  endocarditis  said  :  "The  pyrexia 
is  constant  but  variable  in  type  and  intensity."  In 
a  recent  publication,  however,  he  says:  "an  afebrile 
form  has  been  described,  and  we  must  recognize 
that  a  chroni--  septichjemia  may  be  present  in  endo- 
carditis in  which  there  is  little  or  no  fever.  Ev.n 
the  severe  type  with  marked  toxaemia  may  be 
afebrile."  He  quotes  two  cases.  Souda  and  Bothe- 
zat  reported  an  afebrile  case  in  1893.  Jiirgen- 
sen  in  a  recent  work  says :  "There  are  cases  of  en- 
docarditis due  to  sepsis  which  arc  not  accompanied 
with  rises  of  temperature  at  any  time." 

The  case  of  malignant  endocarditis  reported  here 
was  under  observation  during  the  last  twenty  day.- 
of  its  course,  and  in  that  period  the  temperature 
(taken  by. the  mouth)  did  not  rise  above  98.2°  F. 
excei>t  on  one  occasion,  and  then  only  to  99°  F. 

The  clinical  history  of  the  case  is  as  follows: 

Qxsn. — A.  R.,  tliiity-tlirce  years  oki,  native  of  Sweclen, 
longshoreman,  had  always  been  noted  for  his  physical 
strength.    His  previous  history  was  without  significance  ex- 

•Read  before  the  Long  Island  Medical  Society,  April  6,  1909. 


June  19,  1909.] 


OUR  READERS'  DISCUSSIONS. 


■cept  as  it  mentioned  an  attack  of  amygdalitis  at  the  age  of 
twenty-five  and  an  attack  of  sickness  at  the  age  of  thirty 
attended  with  swelHng  of  the  feet  and  ankles  which  lasted 
four  months  and  then  disappeared  entirely. 

Present  illness  dated  back  about  three  months,  when  pa- 
tient was  awakened  from  sleep  by  a  sharp,  cramplike  pain 
in  the  epigastric  region.  Since  then  this  pain  had  never 
■  entirely  left  him,  though  at  times  it  was  scarcely  noticeable. 
It  was  worse  when  he  walked.  He  suffered  from  shortness 
of  breath  on  exertion.  His  appetite  was  good  and  his  bow- 
els regular.  He  was  admitted  to  the  Norwegian  Hospital 
•on  January  8,  1909. 

Physical  e.xamination  on  admission:  Patient  w-as  robust 
and  well  nourished,  somewhat  ansemic.  Face  slightly  cyan- 
osed.  Movable  masses,  of  the  size  of  peas,  were  felt  under  the 
skin  in  various  parts  of  the  body.  Lung  signs  were  normal. 
Area  of  cardiac  dulness  was  considerably  increased,  chiefly 
in  transverse  diameter.  Systolic  murmur  was  heard  at 
apex  which  was  transmitted  to  axilla  and  back.  Radial 
arteries  were  palpable.  Pulse  was  of  moderate  tension,  oc- 
casionally intermittent.  Area  of  liver  dulness  was  slightly 
increased.  Extremities  were  normal.  Temperature  98°  F., 
pulse  85,  respirations  22. 

January  9th.  A  troublesome  cough  developed  and  patient 
expectorated  mucus  tinged  with  blood.  He  complained  of 
pain  in  stomach.  Urine:  Specific  gravity,  1.019;  contained 
abundant  albumin  and  hyaline,  granular,  and  epithelial  casts. 
Temperature  remained  at  98'  F. ;  pulse  between  80  and  85; 
respirations  between  20  and  22. 

January  12th.  Patient  still  troubled  with  cough  and  ex 
pectoration  of  blood  tinged  mucus.  He  was  very  restless. 
Urine  as  before ;  quantity  in  last  twenty-four  hours,  thirty- 
five  ounces.  Since  last  noted,  temperature  between  97° 
and  98°  F. ;  pulse  between  90  and  100:  and  respirations  be- 
tween 25  and  30. 

January  i6th.  Cough  less  severe.  Patient  passed  forty- 
eight  ounces  of  urine  in  last  twenty-four  hours  similar  in 
■character  to  that  first  described.  Since  last  noted,  tempera- 
ture betw  een  96°  and  98°  F. ;  pulse  between  90  and  100;  and 
respirations  between  25  and  32. 

January  20th.  Patient  was  very  restless,  vomited  once  a 
little  brownish  fluid.  Systolic  murmur  could  not  be  heard, 
but  distinct  gallop  rhythm  was  present.  Area  of  cardiac 
dulness  was  increased.  Since  last  noted,  temperature  be- 
tween 97.5°  and  98.2°  F. ;  pulse  between  90  and  100;  and 
respirations  between  25  and  27. 

January  21st.  Patient  was  very  restless;  complained  of 
.pain  in  region  of  heart.  Gallop  rhythm  present.  Since  last 
noted,  temperature  between  97  7°  and  98.2°  F. ;  pulse  be- 
tween 95  and  100;  and  respirations  between  30  and  35. 

January  26th.  Patient  still  very  restless ;  had  vomited 
several  times  during  past  four  days.  Temperature  remained 
most  of  the  time  close  to  g8°  F.,  dropping  once  to  96° 
and  rising  once  to  99°.  Pulse  had  ranged  between  100 
and  120.  Respirations  most  of  the  time  had  been  about  30, 
rising  once  to  40.  Systolic  murmur  at  apex  again  heard. 
At  2  :30  p.  m.  patient  had  a  chill  lasting  five  minutes ;  face 
livid;  breathing  labored  and  rapid  (55),  pulse  about  100  and 
barely  perceptible.  Restlessness  was  intense.  Soon  after 
the  chill  his  lower  extremities  became  cyanotic  and  mottled. 
He  had  a  second  chill  about  10  p.  m.  which  was  followed 
by  signs  of  pulmonary  oedema.    Gallop  rhythm  again  noted. 

January  27th.  Patient  had  a  third  chill  at  6  a.  m,  which 
was  followed  by  cyanosis  and  mottling  and  also  anresthesia 
of  both  lower  e.xtremities.  Later  in  the  day  the  left  leg 
became  normal  in  appearance  and  sensation  returned  to  it. 
Patient  complained  of  pain  in  both  lower  limbs  and  of  great 
coldness  in  hight  hand  and  arm.  He  was  intensely  restless. 
'Urine  was  passed  involuntarily.  Pulse  at  wrist  was  almost 
imperceptible  and  uncountable  in  the  morning  but  slightly 
stronger  at  night;  temperature  98°  F. ;  respirations  between 
40  and  60. 

January  28th.  Pulse  barely  perceptible.  Heart  sounds 
very  faint.  Right  lower  extremity  mottled  and  anjesthetic. 
Right  hand  cold  and  clammy;  patient  said  he  could  not  gee 
it  warm.  Breathing  labored  and  rapid.  Temperature 
97^8°  F. 

January  29th.    Patient  died  at  i  a.  m. 

Autopsy  by  Dr.  Archibald  Murray :  Body  well  nourished ; 
rigor  mortis  well  marked ;  no  marks  of  violence.  Hypo 
static  congestion  of  right  leg  and  thigh.    About  eight  ounces 
of  straw  colored  fluid  in  nericardial  sac.    Heart  enormously 
hypertrophied  and  dilated,  particularly  left  ventricle.  What 


appears  to  be  an  ante  mortem  septic  thrombus  as  big  as  the 
end  of  the  little  finger  firmly  adherent  to  the  wall  of  the 
left  ventricle  near  the  apex.  Aortic  valve  normal.  Mitral 
valve  much  thickened  and  retracted.  Valves  of  right  heart 
normal.  Moderate  atheroma  about  coronary  openings. 
Both  lungs  free  in  pleural  cavities.  Left  pleural  cavity  con- 
tained eight  ounces  of  straw  colored  fluid.  Right  pleural 
cavity  contained  sixteen  ounces  of  same.  Both  lungs  con- 
gested and  oedematous.  Liver  about  one  third  larger  than 
normal  and  showed  passive  congestion  (nutmeg  liver). 
Spleen  moderately  enlarged  and  congested.  Both  kidneys 
about  normal  in  size;  capsules  adherent;  appendices  nor- 
mal ;  cortices  wider  and  paler  than  normal ;  they  showed  a 
few  white  infarcts,  probably  septic.  Pancreas  normal  ex- 
cept for  passive  congestion.  Gallbladder  normal.  Stomach 
congested.    Other  organs  apparently  normal. 

Microscopical  findings :  The  thrombus  from  the  left  ven- 
tricle consisted  of  a  mass  of  blood  cells,  fibrin,  polymor- 
phonuclear leucocytes,  and  micrococci  w'hich  apparently  be- 
longed to  some  variety  of  staphylococcus.  The  heart  mus- 
cle showed  chronic  interstitial  myocarditis.  The  liver 
showed  marked  passive  congestion  with  cloudy  swelling. 
The  kidneys  showed  very  marked  oedema,  passive  conges- 
tion, cloudy  swelling,  and  a  few  septic  infarcts. 

1239  Pacific  Street. 

 <$>  


A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  this  department  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
decided  upon,  the  further  questions  are  as  follows: 

LXXXVI. — How  do  you  make  an  early  diagnosis  of  pul- 
monary tuberculous  disease?   (Closed  May  15,  igog.) 

LXXXVII. — How  do  you  treat  supraorbital  neuralgia? 
(Answers  due  not  later  than  June  13,  iQog.) 

LXXXVIII. — How  do  you  treat  epistaxis?  (Answers 
due  not  later  than  July  15,  igog.) 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  advisers  will  re- 
ceive a  prize  of  $25.  No  importance  whatever  will  be  at- 
tached to  literary  style,  but  the  azvard  will  be  based  solely 
on  the  value  of  the  substance  of  the  answer.  It  is  requested 
(but  not  required)  that  the  answers  be  short;  if  prac- 
ticable no  one  ansiver  to  contain  more  than  six  hundred 
words. 

All  persons  will  be  entitled  to  compete  for  the  prize, 
ivhether  subscribers  or  not.  This  prize  will  not  be  awarded 
to  any  one  person  more  than  once  within  one  year.  Every 
ansiver  must  be  accompanied  by  the  writer's  full  name  and 
address,  both  of  which  zve  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Jour- 
nal. Our  readers  are  asked  to  suggest  topics  for  dis- 
cussion. 

The  prize  of  $23  for  the  best  essay  submitted  in  answer 
to  question  LXXXV  has  been  awarded  to  Dr.  George  A. 
Graham,  of  Kansas  City,  Mo.,  zvhose  article  appeared  on 
page  logj. 

PRIZE  QUESTION  LXXXV. 
THE  NONOPERATIVE  TREATMENT  OF  DISEASE 
OF  THE  VERMIFORM  APPENDIX. 

{Concluded  front  page  120?.) 

Dr.  Joseph  Di  Rocco.  of  A'ezv  York,  says: 
We  can  safely  and  practically  say  that  every  case 
of  appendicitis  can  wait  anywhere  from  thirty-six 
to  forty-eight  hours  before  the  knife  is  resorted  to. 
Medicinally  we  can  only  benefit  those  cases  of  a 
catarrhal  inflammatory  type.  As  the  catarrhal  in- 
flammation of  the  appendix  is  the  beginning  prac- 
tically and  clinically  of  all  the  appendicular  trotibles, 
the  treatment  in  this  stage  must  be  of  tise.  What 
shall  we  do  for  those  patients? 


12/0 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


Order  the  patient  to  bed,  so  that  there  will  be 
both  physical  and  mental,  rest.  The  doctor  is  gen- 
erally called  for  pain  on  the  right  side  of  the  ab- 
domen. An  ice  bag,  well  covered  with  a  towel  to 
protect  the  skin  generally  suffices.  But  if  this  does 
not  help,  resort  to  drugs,  and  codeine,  in  half  grain 
doses,  every  three  hours,  is  useful.  If  there  is  any 
objection  to  the  ice  bag,  a  hot  flaxseed  poultice  may 
be  applied  with  great  benefit. 

The  patients  are,  as  a  rule,  constipated.  Here 
calomel  in  small  and  repeated  doses  works  best; 
about  one  quarter  of  a  grain  every  half  hour  for 
eight  doses.  This,  at  the  same  time,  relieves  any 
tendency  that  there  may  be  of  nausea  or  vomiting. 
To  facilitate  the  action  of  the  calomel  half  an  ounce 
of  castor  oil  should  be  given  about  two  hours  after 
the  last  dose  of  calomel,  put  up  in  the  best  possible 
way  to  disguise  its  nauseous  taste.  If  in  about  four 
hours  there  is  no  movement  of  the  bowels,  give  a 
soapsud  enema,  using  a  rectal  tube  inserted  high 
up  in  the  bowel.  If  on  the  succeeding  days  the 
bowels  do  not  move  by  themselves,  resort  to  the  lat- 
ter procedure. 

In  regard  to  the  diet,  I  wish  to  say  that  while 
there  is  any  fever,  milk  exclusively  is  given ;  if  milk 
disagrees,  any  modification  of  it  may  be  used.  With 
no  fever,  the  diet  is  steadily  increased ;  to  consist  of 
soups,  broths,  farina  rice,  vegetables  and  meat  last. 

Should  tympanites  develop,  the  condition  is  best 
relieved  by  the  insertion  of  a  rectal  tube. 

Recurrent  appendicitis  (chronic)  can  be  dis- 
missed with  a  few  words.  If  the  patient  decHnes  an 
operation,  (the  time  of  which  will  eventually  come), 
he  must,  when  the  pain  comes,  "grin  and  bear  it."' 
The  other  alternative  he  has  is  the  regulation  of 
his  mode  of  life,  resort  to  the  simple  life — no  late 
dinners,  nor  dissipation  of  any  kind.  The  patient 
should  eat  moderately  and  avoid  all  coarse  foods ; 
in  fact  everything  that  is  liable  to  overload  the  in- 
testines with  accumulated  waste.  The  bowels  are 
to  be  kept  active ;  a  pill  of  this  mixture  will  answer 
the  purpose  very  well : 

■R    Aloin  gr.  1/4; 

Podophyllin   gr.  1/6; 

Ext.  of  belladonna,   gr.  1/8; 

Strychnine  sulphate,   ,  gr.  1/60. 

M.   Ft.  pil.    No.  I. 

Sig. :  One  three  times  a  day. 

I  do  not  think  that  the  mentioning  of  the  indica- 
tions for  operation  is  out  of  place.  They  are:  i. 
When  in  doubt;  2,  increasing  of  the  general  symp- 
toms, such  as  pulse,  pain,  and  tympanites ;  3,  when 
there  is  felt,  a  tumor,  unless  it  rapidly  disappears ; 
4,  increasing  rigidity  of  the  rectus  muscle;  and  5, 
recurrent  attacks  with  severe  pain. 

Dr.  Joscfa  Zavatt,  of  Philadelphia,  observes: 

Absolute  rest  in  bed.  A  purgative  is  indicated  in 
most  of  cases  in  which  the  disease  is  caused  by  gas- 
tric or  intestinal  disarrangements  as  fermentation, 
constipation,  fsecal  impaction,  etc.,  or  by  idiopathy. 
Salines  are  beneficial  as  they  produce  watery  move- 
ments without  increasing  peristalsis,  thus  removing 
anything  which  may  cause  local  irritation  and.  at 
the  same  time,  dej/leting  the  turgid  intestinal  and 
portal  circulation.  Of  course  purgatives  are  con- 
traindicated  when  the  disease  is  too  far  advanced 


or  secondary  to  some  other  disease,  such  as  typhoid 
fever,  etc.,  where  there  is  danger  of  perforation.  Af- 
ter the  bowels  have  been  moved,  an  ice  bag  should 
be  applied  to  the  abdomen  specially  if  there  is  fever ; 
it  relieves  pain  and  lowers  the  temperature.  If  the 
pain  is  not  relieved  by  local  applications,  small  doses 
of  opium  should  be  given ;  it  checks  peristalsis,  thus 
giving  rest  to  the  inflamed  part..  The  objection 
to  opium  is  that  it  may  obscure  clinical  symptoms 
which  should  be  observed ;  but  there  is  another  way 
of  keeping  track  of  the  progress  of  the  appendicular 
inflammation  without  depriving  the  patient  of  the 
comfort  while  relieving  his  pain.  I  speak  of  the 
examination  of  the  blood,  leucocytosis  in  direct 
proportion  to  the  stage  of  inflammation  is  the  rule 
in  appendicitis.  A  blood  count  higher  than  20,000 
leucocytes  after  forty-eight  hours  indicates  abscess 
formation  and  danger  of  peritonitis. 

After  the  bowels  have  been  evacuated  intestinal 
irrigation  with  warm  boiled  water,  with  little  pres- 
sure, should  be  given.  The  tube  is  to  be  inserted  high 
in  the  rectum,  the  irrigator  being  not  higher  than 
seventeen  to  eighteen  inches  over  the  bed.  The  diet 
should  be  liquid  until  all  abdominal  sensibility  to 
pressure  has  disappeared.  The  return  to  the  nor- 
mal diet  should  be  slow.  For  the  gastric  overacid- 
ity  which  usually  accompanies  appendicitis  alkalines 
should  be  used ;  sodium  bicarbonate,  magnesium  hy- 
drate, etc. 

Dr.  Kothe,  in  view  of  the  good  results  obtained 
in  the  treatment  of  diffused  peritonitis  by  continu- 
ous enemata  of  physiological  serum,  has  employed 
this  method  of  treatment  in  several  cases  of  peri- 
tonitis due  to  gangrenous  appendicitis  in  which  op- 
eration was  not  advisable  on  account  of  the  grave 
state  of  the  patients,  with  very  good  results.  Some 
glucose  or  soluble  albumin  has  been  added  to  the 
enema  to  aid  the  nourishment  of  the  patients.  Fif- 
teen to  twenty  quarts  of  liquid  should  be  injected 
in  twenty-four  hours. 

Dr.  C.  Herbert  Church,  Newark.  N.  J.,  remarks: 

^ledical  treatment  of  appendicitis  will  be  success- 
ful in  about  four  out  of  five  cases  if  properly  carried 
out  and  begun  early. 

At  the  same  time,  I  believe  that  every  paper  on 
appendicitis  should  contain  a  loud  note  of  warning: 
Do  not  neglect  surgery  if  the  patient  does  not  re- 
spond quickly.  By  this  I  mean,  in  the  ordinary  case, 
if  there  is  not  decided  improvement  in  twenty-four 
hours  operate  immediately. 

I  do  not  believe  in  ice  to  fight  hyperjemia,  but 
rather  in  Bier's  or  anyone  else's  method  of  inducing 
hyperemia.  Neither  do  I  believe  in  the  use  of  mor- 
phine, as  it  masks  the  symptoms  and  discourages 
drainage  into  and  cleansing  of  the  bowel,  while  I 
want  to  encourage  it. 

My  treatment  consists  in:  i.  A  thorough  cleans- 
ing of  the  bowels  with  castor  oil  or  salines  and  high 
enemata.  2,  Keeping  them  well  cleansed  by  means 
of  olive  oil  in  doses  of  to  4  oz.  given  three  to  six 
times  a  day ;  sufficient  to  cause  two  to  four  stools 
per  day.  I  try  to  get  the  oil  to  show  in  the  stools 
as  quickly  as  possible  and  then  keep  it  showing. 
Use  more  castor  oil  or  salines  if  necessary.  3,  Large, 
thick,  hot  poultices  such  as  the  cataplasma  kao- 
lini  renewed  every  twenty-four  hours  or  oftener. 


June  19,  1909.] 


CORRESPOXDEXCE. 


1271 


4,  If  possible  use  as  high  a  power  incandescent  elec- 
tric light  as  the  house  wiring  will  stand  for  ten  to 
twenty  minutes,  two  to  four  times  a  day,  on  the 
bared  skin  and  as  close  as  the  patient  can  stand  it, 
concentrated  by  a  good  reflector.  5,  A  strict  liquid 
diet  until  convalescence  is  practically  complete.  6, 
The  use  of  whatever  remedy  is  indicated  by  the  pa- 
tient's general  as  well  as  local  condition. 

One  of  the  most  important  remedies  to  my  mind 
is  one  which  we  very  seldom  use  and  which  is  bare- 
ly mentioned  in  our  textbooks,  and  that  is 
brvonia  alba.  It  seems  to  have  a  special  affinity 
for  serous  membranes,  whether  it  is  the  pleura, 
synovial  membranes,  or  peritonaeum.  Its  great  in- 
dication is  sharp  sticking  pains  worse  on  the  least 
motion  of  the  part.  The  dose  is  one  drop  or  less 
of  the  tincture,  ever\-  two  hours.  Another  rem- 
edy that  is  very  useful  in  about  the  same  doses  as 
bryonia  is  belladonna.  Many  other  remedies  might 
be  indicated  by  the  general  condition  of  the  patient. 

 'i>  


LETTER  FROM  LONDON. 

The  International  Congress  of  Applied  Chemistry. — The 
General  Medical  Council. — Tlie  Royal  Commission  on 
Vivisection. — A  Xezc  Hospital  for  the  Soiithzi-estern 
District  of  London. 

LoxDOX,  June  i.  I'^oq. 
The  Seventh  International  Congress  of  Applied 
Chemistr\^  held  its  inaugural  meeting  on  !May  27th. 
There  was  a  very  large  assembly  of  delegates  from 
all  parts  of  the  world,  and  the  programme  of  papers 
and  subjects  for  discussion  was  a  very  heavy  one. 
Among  the  sections  many  subjects  of  direct  inter- 
est to  medical  men  are  to  be  handled.  Standardiza- 
tion of  food  and  drugs  will  be  discussed  in  several 
of  the  sections.  The  legal  aspects  of  the  present 
Food  and  Drugs  Acts  will  be  discussed  by  the  Legal 
Section,  and  it  is  interesting  to  note  that  Dr.  Wiley 
has  been  sent  by  the  United  States  government  to 
take  a  share  in  the  proceedings  of  this  section.  The 
milk  question  will  be  dealt  with  thoroughly,  and  a 
large  number  of  papers  will  be  read  on  this  sub- 
ject. Natural  and  artificial  methods  for  the  purifi- 
cation of  water  are  to  be  discussed,  and  the  bad  ef- 
fects of  vitiated  air  will  be  considered.  At  yester- 
day's meeting  Professor  O.  H.  Witt,  president  of 
the  Congress  at  its  meeting  in  Berlin  some  years 
ago,  gave  an  address  on  Evolution  in  Applied 
Chemistry.  After  citing  many  examples  of  the 
principles  of  economy  which  universally  pervaded 
living  nature  he  asked  whether  these  principles  were 
not  the  very  essence  of  all  industrial  chemistry.  The 
history  of  applied  chemistry,  he  said,  was  teeming 
with  instances  in  which  survival  of  the  fittest  meant 
neither  more  nor  less  than  a  victory  of  economy. 
This  was  exemplified  in  the  question  of  fuel.  There 
was  a  time  when  smoke  was  considered  a  necessary 
evil,  but  after  a  time  it  began  to  be  looked  upon  as 
a  nuisance  and  war  was  declared  against  it.  But 
now  we  know  that  smoke  was  a  waste  and  that  .no- 
bodv  had  better  cause  to  wage  war  against  it  than 
he  who  produced  it.  A  smoking  chimney  not  only 
carried  visible  unburned  carbon  into  the  atmos- 
phere, but  in  nine  cases  out  of  ten  also  invisible 


carbonic  oxide  and  methane,  with  all  the  latent  ener- 
gies they  contained.  Smoking  chimneys  were  thieves. 
Regenerative  gas  heating  was  not  only  a  sure  pre- 
vention of  smoke,  but  also  the  most  powerful  means 
of  economizing  heat,  and  therefore  one  of  the  great- 
est acquisitions  of  modern  industry. 

A  new  method  of  sewage  disposal  was  described 
by  Dr.  J.  Grossmann,  of  ^lanchester.  It  was  com- 
puted that  400,000  tons  of  soap  were  used  every 
year  in  this  country,  practically  all  of  which  found 
its  way  into  the  sewage.  The  value  of  this  alone 
came  to  from  £8,000,000  to  £10,000,000,  and  it  was 
from  the  recovery  of  the  valuable  fatty  acids  con- 
tained in  the  soap  that  the  process  designed  by  Dr. 
Grossmann  derived  part  of  its  revenues,  the  other 
part  was  derived  from  the  residue,  which  was  of 
value  as  a  fertilizer.  In  Dr.  Grossmann's  process  the 
sewage  cake  was  dried  by  heat,  mixed  with  a  little 
acid,  and  passed  through  a  specially  designed  retort 
in  which  it  was  subjected  to  a  current  of  superheated 
steam.  The  latter  carried  with  it  the  fatty  acid, 
and  these  as  well  as  the  steam  were  condensed  in 
a  tower  into  which  water  was  injected.  The  con- 
densed fat  collected  on  the  surface  of  a  tank  and 
could  be  easily  and  cheaply  purified,  when  it  yielded 
a  grease  rich  in  stearic  acid  which  was  a  valuable 
article  of  commerce  and  used  in  large  quantities. 
Dr.  Grossmann  estimated  the  average  profit  for  a 
town  of  100,000  inhabitants  at  about  £2.500  per  an- 
num. A  large  experimental  installation  had  been 
intermittently  working  at  the  Oldham  Corporation 
Sewage  \\'orks  for  the  last  twelve  months  and  it 
was  now  being  extended  and  converted  for  continu- 
ous work,  when  the  plant  would  be  able  to  work  up 
about  1,000  tons  of  pressed  sludge  per  annum. 

The  eighty-ninth  session  of  the  General  Council 
of  Medical  Education  and  Registration  was  begun 
on  Tuesday  last,  under  the  presidency  of  Sir  Donald 
MacAlister.  In  his  opening  address  the  president 
stated  that  representations  had  been  made  to  the 
government  requesting  that  steps  be  taken  for  the 
appointment  of  a  Royal  Commission  to  inquire  into 
the  evil  effects  produced  by  the  unrestricted  prac- 
tice of  medicine  and  surgery  by  unqualified  persons. 
The  government  decided  to  make  preliminary  in- 
quiries on  the  subject  through  the  Local  Govern- 
ment Board.  A  circular  has  accordingly  been  issued 
to  medical  officers  of  health  asking  for  information 
concerning  the  extent  of  the  practice  complained  of 
and  its  effects  on  the  general  health  within  their 
several  districts.  When  the  replies  are  received  the 
Lord  President  will  be  in  a  position  to  determine 
what  further  steps  are  desirable  in  the  interests  of 
the  public. 

With  regard  to  anaesthetics,  the  Council  had 
recommended  that  all  licensing  bodies  should  re- 
quire candidates  to  produce  evidence  of  having  re- 
ceived practical  instruction  in  the  administration  of 
anaesthetics.  Nearly  all  the  licensing  bodies  have 
answered  that  this  requirement  is  already  or  will  in 
future  be  enforced. 

After  the  president's  address  Dr.  Langley  Browne 
moved  that  representations  be  made  to  the  Privy 
Council  that  it  was  expedient  to  confer  on  the  resfis- 
tered  practitioners  resident  in  England  and  Wales 
the  power  of  returning  an  additional  member  to  the 
General  Council.  He  pointed  out  that  the  number 
of  persons  resident  in  England  and  Wales  now  on 


1272 


THERAPEUTICAL  XOTES. 


[New  York 
Medical  Journai_ 


the  Medical  Register  was  25,168.  In  Scotland  there 
were  3,845  and  in  Ireland  2,656.  England  returned 
three  direct  representatives,  while  Scotland  and  Ire- 
land returned  one  each.  So  that  on  the  numbers 
alone,  in  his  opinion,  a  very  strong  case  was  made 
out  for  giving  the  general  practitioners  of  England 
and  Wales  an  additional  representative  on  the 
Council.  In  1887  the  Council  consisted  of  thirty 
members,  five  ot  whom  were  directly  nominated 
through  the  Privy  Council,  twenty  represented  dif- 
ferent universities  and  corporate  bodies,  and  five 
were  direct  representatives.  Since  that  time  four 
members  had  been  added  for  the  universities  or 
other  teaching  bodies,  but  there  had  been  no  addi- 
tional direct  representative.  He  proposed  that  the 
Council  should  recommend  the  Privy  Council  to  ap- 
point an  extra  direct  representative.  After  some 
discussion  the  motion  was  carried  by  a  small  major- 
ity. 

Another  matter  dealt  with  was  the  question  of 
voluntary  withdrawal  from  the  registers  and  the 
following  standing  order  was  adopted :  "Every  ap- 
plication by  a  registered  medical  practitioner  or 
dentist  for  the  removal  of  his  name  at  his  own 
request  from  the  Medical  or  Dentists'  Register  shall 
be  accompanied  by  a  statutory  declaration  to  be 
made  by  the  applicant,  that  he  is  not  aware  of  any 
proceedings  or  of  any  reason  for  the  institution  of 
any  proceedings  which  might  result  in  establishing 
cause  for  the  erasure  of  his  name  from  the  register, 
or  for  depriving  him  without  his  consent  of  any 
qualification  or  license  entitling  him  to  be  regis- 
tered." 

The  Royal  Commission  on  Vivisection  has  not  yet 
published  its  report,  though  it  is  a  considerable  time 
since  its  sittings  were  completed.  A  letter  signed 
by  the  Earl  of  Cromer,  the  president  of  the  Re- 
search Defense  Society,  has  been  sent  to  the  Secre- 
tary of  State  for  Home  Affairs  in  which  it  is  said : 
"The  Royal  Commission  on  Experiments  on  Ani- 
mals was  appointed  in  1906.  It  began  to  hear  evi- 
dence in  October  of  that  year,  and  during  1906  and 
1907  a  great  amount  of  evidence  was  given  by  many 
witnesses.  So  long  ago  as  December  18,  1907,  the 
commissioners  decided  that  they  did  not  wish  for 
further  evidence,  but  they  met  once  more,  on  March 
25,  1908,  to  hear  evidence  on  a  special  point.  Apart 
from  this  one  meeting  in  1908,  it  is  now  nearly  a 
year  and  a  half  since  the  commissioners  ceased  to 
hear  evidence,  but  they  have  not  yet  issued  their 
report."  In  a  subsequent  paragraph  the  letter  states 
that  "this  long  delay  is  contrary  to  the  public  inter- 
est and  is  likely  to  prejudice  the  public  mind."  The 
letter  is  also  signed  by  a  large  number  of  the  most 
prominent  members  of  the  Research  Defense  So- 
ciety. 

C)n  June  3d  an  important  meeting  of  the  Chelsea. 
Richmond,  and  Wandsworth  divisions  of  the  Brit- 
ish Medical  Association  will  be  held  to  consider  a 
scheme  for  the  establishment  of  a  new  hospital  in 
Putney,  in  the  southwest  district  of  London.  It  has 
already  l)ccn  agreed  that  the  hospital  shall  h;i,ve  no 
r)Ut  jjatient  department  and  that  its  active  staff  shall 
consist  of  the  general  practitioners  in  the  neighbor- 
hood. This  hospital,  when  completed,  together  with 
the  new  King's  College  Hospital,  will  sufficiently 
meet  the  hospital  needs  of  the  south  of  London. 


To  Control  the  Vomiting  of  Phthisical  Patients. 

— The  following  prescription  is  given  in  the  Journal 
de  mcdeciiie  de  t^aris: 

R     Hydrochloric  acid  Tn,xv  ; 

Extract  of  opium,'  gr.  3/4; 

Water  3iii ; 

M.  et  Sig. :  One  tablcspoonful  after  meals. 

The   Treatment   of    Arthritis   Deformans.  — 

Robin  employs  a  combination  of  sodium  arsenate 
and  potassium  iodide  and  keeps  up  the  treatment  for 
ten  days  at  least.    The  prescription  is  as  follows : 

R     Sodium  arsenate  gr.  3/4; 

Potassium  iodide.   gr.  Ixxv ; 

Distilled  water,  gx. 

M.  et  Sig. :  One  tablespoonful  twice  daily  before  break- 
fast and  dinner. 

Improved  Iodine  Ointment  for  the  Treatment 
of  Ringworm. — The  Eclectic  Medical  Gleaner  cred- 
its to  Thcrapcntic  Medicine  an  article  by  Dr.  George 
Thomas  Jackson  on  the  treatment  of  ringworm,  in 
which  he  commends  the  use  of  goose  grease  as  an 
excipient  for  iodine.  He  has  found  that  an  oint- 
ment composed  of  one  drachm  or  more  of  the  crys- 
tals of  iodine  added  to  one  ounce  of  goose  grease 
makes  a  most  effective  remedy  for  the  disease.  At 
the  Vanderbilt  Clinic,  Xew  York,  where  many  cases 
of  ringworm  are  treated,  this  preparation  has  been 
used  extensively  for  two  or  three  years,  almost  ex- 
clusively after  the  first  few  months,  when  it  was 
found  to  be  more  efficacious  than  other  remedies. 
It  is  to  be  applied  twice  a  day  until  it  produces  reac- 
tion, as  shown  by  a  little  swelling  of  the  patch.  Then 
once  a  day  will  be  sufficient.  In  two  or  three  weeks 
the  hair  falls  out  of  the  patch,  and  it  becomes  bald 
like  a  patch  of  alopecia  areata.  After  a  time  the  hair 
grows  again,  and  the  patch  is  well.  The  first  appli- 
cations are  apt  to  be  a  little  painful  for  a  few  mo- 
ments, but  after  that  even  little  children  do  not  com- 
plain of  pain.    Xo  epilation  is  necessary. 

The  Treatment  of  "Cold  in  the  Head."— C.  P. 

Grayson  in  The  Therapeutic  Gacette  for  May.  di- 
rects attention  to  the  faulty  method  of  treatment 
usually  employed  for  the  relief  of  acute  coryza, 
which  he  regards  as  the  results  of  a  triple  patho- 
genic alliance — a  chronic  rhinitis,  a  chronic  intes- 
tinal toxaemia,  and  an  exposure  to  an  accidental 
stress  of  some  kind,  not  necessarily  thermometric 
or  hygrometric.  A  cathartic  dose  of  one  of  the 
natural  saline  waters  should  form  the  first  step  in 
the  treatment.  .\  fast  of  twenty-four  hours'  dura- 
tion should  be  enjoined,  and  active  exercise  recom- 
mended for  fifteen  or  twenty  minutes  during  this 
])eriod.  He  does  not  favor  the  use  of  drugs,  though, 
if  they  must  be  given  only  the  simpler  ones  such  as 
will  harmonize  with  the  foregoing  therapeutic  plan 
should  be  employed — the  salicylates  or  their  syn- 
thetic substitutes,  the  saline  laxatives  on  rising  and 
retiring,  a  few  minims  of  aromatic  spirit  of  ammonia 
or  tincture  of  nux  vomica.  These  are  infinitely  to 
be  preferred,  the  author  says,  to  the  combinations  of 
opium,  belladonna,  aconite,  and  acetanilide  found  in 
most  of  the  "rhinitis"  and  "coryza"  tablets  manu- 
factured for  self  dosage. 


Tune  19,  19CO.] 


EDITORIAL  ARTICLES. 


NEW  YORK  MEDICAL  JOURNAJ> 

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and  The  Medical  News. 

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NEW  YORK,  SATURDAY,  JUNE  19,  1909. 


TUBERCULOUS  IXFECTIOX  FROM  AIEAT. 

An  exceedingly  valuable  paper  entitled  Meat  as  a 
Sotirce  of  Infection  in  Tuberculosis,  by  Mr.  Arthur 
R.  Litteljohn,  was  presented  before  the  National 
Tuberculosis  Congress  held  recently  in  London  and 
is  published  in  the  June  number  of  the  Practitioner. 
Mr.  Litteljohn  gives  it  as  the  prevailing  belief  that 
bovine  tuberculous  disease  is  transmissible  to  man 
by  way  of  the  digestive  canal,  though  with  difficu'tv 
except  in  the  case  of  children,  in  whom  it  is  probable 
that  the  infection  is  oftener  derived  from  milk  than 
from  meat.  What  is  generally  meant  by  "meat"'  i.- 
muscular  tissue,  and  the  author  attaches  grent  im- 
portance to  the  fact  that  the  muscles  of  tuberculous 
cattle  do  not  generally  contain  tubercle  bacilli, 
though  the  intermuscular  glands  may  be  tubercu- 
lous. 

But  various  parts  that  are  not  muscle  are  fre- 
quently eaten  by  human  beings,  and  such  portion-- 
of  a  carcass  arc  very  apt  to  be  tuberculous.  Xoi 
only  are  they  consumed  as  such,  but  the  butchers 
often  mince  them  and  smear  cuts  of  meat  with  them, 
with  the  result  of  contaminating  the  meit.  Besides 
using  such  dangerous  material  as  a  makeweight,  the 
butchers  sometimes  innocently  infect  good  meat  bv 
cutting  it  with  a  knife  that  has  previously  been  used 
on  tuberculous  meat.  Moreover,  an  improper  in- 
spection of  carcasses  mav  result  in  contaminating 
meat  that  was  innocuous  to  begin  with,  parts  obvi- 


ously or  apparently  tuberculous  being  cut  into,  anci 
then  the  muscular  tissue  examined  with  the  sairo 
knife. 

Small  as  is  the  danger  of  contracting  tuberculous 
disease  from  the  flesh  of  infected  cattle,  it  is  still  of 
importance  to  reduce  that  danger  to  the  minimum. 
Such  chemical  agents  as  would  be  tolerated  in  food 
have  no  great  effect  on  the  bacilli,  and  they  are  not 
subjected  to  the  action  of  the  gastric  juice  long 
enough  to  warrant  us  in  trusting  to  digestion  for 
their  destruction.  There  remains,  therefore,  onl> 
cooking  as  a  safeguard.  As  to  the  value  of  this, 
2\Ir.  Litteljohn  cites  Woodhead's  experiments. 
"Working  on  the  hypothesis  that  the  flesh  of  tuber- 
culous animals  was  rarely  if  ever  infective,  unless 
soiled  during  dressing  of  the  carcass,  he  (Wood- 
head)  artificially  infected  the  flesh  before  experi- 
menting. In  some  cases  he  injected  tuberculous 
material  into  the' interior  of  the  meat  substance,  and 
in  others  he  smeared  slices  of  meat  and  formed  them 
into  'rolls.'  The  latter  experiment  is  of  importance, 
as  it  is  the  custom  for  butchers  to  make  such  'rolls.' 
and  they  frequently  include  minced  lungs,  omentum, 
etc.,  structures  which  are  often  highly  virulent." 

Woodhead  subjected  his  samples  to  the-ordinarv 
processes  of  cooking,  noting  the  temperature  at 
various  depths  in  the  masses,  and  fed  animals  with 
the  central  portions  of  them.  He  concluded  that  a 
"joint"  weighing  six  pounds  or  more  never  reached 
a  higher  temperature  than  140°  F.  at  the  centre 
during  ordinary  cooking;  that  "rolls"  weighing 
more  than  three  or  four  pounds  were  not  rendered 
sterile  throughout,  and  therefore  cooking  could  not 
be  relied  upon  to  render  centrally  smeared  "rolls" 
innocuous  ;  that  ordinary  cooking  was  sufficient  to 
destroy  any  tuberculous  material  smeared  on  the 
outside  of  a  "joint"  or  "roll";  and  that  the  most 
trustworthy  method  of  cooking  was  by  boiling,  the 
next  by  baking  in  an  oven,  and  the  least  trust- 
worthy by  roasting  in  front  of  a  fire. 


THE  SALOMON  TEST  IX  CARCINOMA  OF 
THE  STOMACH. 

In  1903  Salomon  introduced  the  method  which 
bears  his  name  for  the  early  diagnosis  of  gastric 
carcinoma.  The  procedure  is  as  follows  :  Twenty- 
four  hours  before  the  test  is  to  be  made,  in  the 
morning,  the  patient  receives  a  meal  composed  of 
milk  and  gruel.  At  noon  on  the  same  day  he  re- 
ceives only  bouillon,  coffee,  or  tea.  Late  in  the  even- 
ing his  stomach  is  thoroughly  washed  out  with 
large  quantities  of  water  until  the  return  water  is 
perfectly  clear.  The  following  morning,  no  more 
food  having  been  taken,  the  stomach  is  washed 


1274 


EDITORIAL  ARTICLES. 


[New- 
Medical 


York 
Journal. 


twice  with  400  cubic  centimetres  of  normal  salt 
solution,  the  same  400  cubic  centimetres  being-  used 
for  both  washmgs.  This  water  is  then  examined 
for  its  total  amount  of  nitrogen  by  the  Kjeld-.hl 
method  and  for  its  albumin  by  the  Esbach  method. 
Salomon  found  that  cases  of  carcinoma  of  th; 
stomach  showed  between  ten  and  seventy  milli- 
grammes of  nitrogen  to  the  hundred  cubic  centi- 
n-:etres  and  from  0.00625  to  0.5  per  cent,  of  albu- 
min On  the  other  hand,  in  noncarcinomatous  cases 
there  was  no  detectable  amount  of  albumin  and  the 
r.itrogen  varied  from  nothing  to  sixteen  milli- 
graniiries  to  the  hundred  cubic  centimetres.  The 
method  has  been  repeated  by  numerous  investiga- 
tors, and  they  report  results  that  vary  in  some  de- 
tails   from  those  originally  reported  by  Salomon. 

The  most  serious  criticism  appears  to  be  that  the 
test  is  of  no  value  in  distinguishing  between  car- 
cinoma and  simple  ulcer  of  the  stomach.  Recently 
Goodman  {University  of  Pennsylvania  Medical 
Bulletin,  May)  has  reviewed  the  method  by  exam- 
ining fifty-six  patients  in  the  wards  of  the  Presby- 
terian Hospital  and  the  Hospital  of  the  University 
of  Pennsylvania,  nine  of  whom  were  normal  in- 
dividuals. He  finds  that  healthy  persons  and  those 
sufifering  from  other  diseases  than  carcinoma  of  the 
stomach  sometimes  show  more  than  twenty  milli- 
grammes of  nitrogen  to  the  hundred  cubic  centi- 
metres of  wash  water.  Some  cases  of  carcinoma  of 
the  stomach  fail  to  give  a  positive  reaction,  prob- 
ably on  account  of  absence  of  ulceration.  The 
method  is  not  conclusive  and  is  of  doubtful  assist- 
ance even  when  all  the  other  features  of  the  case 
are  considered. 

In  addition  to  determining  the  amount  of  nitro- 
gen and  the  percentage  of  albumin  in  the  wash 
water  in  these  cases,  Goodman  also^  ascertained  the 
amount  of  phosphatic  compounds  in  the  material 
removed  from  the  stomach.  He  found  that  in  car- 
cinoma the  phosphates  were  usually  above  ten  mil- 
ligrammes to  the  hundred  cubic  centimetres,  while 
in  noncarcinomatous  cases  the  phosphates  were  be- 
low that  amount  in  the  same  quantity  of  wash  water. 


THIOSIXAiMIXE  IX  TABES  DORSALIS. 

In  the  Scmainc  mcdicale  for  ]\Iay  26th  there  is  a 
summary  of  the  experience  of  Dr.  G.  J.  iNIuller,  of 
Berlin,  in  the  treatment  of  tabes  dorsalis  by  intra- 
muscular injections  of  thiosinamine.  The  solution 
employed  consisted  of  one  part  each  of  thiosinamine 
and  glycerin  and  two  parts  of  sodium  salicylate  in 
enough  distilled  water  to  make  ten  parts,  all  by 
weight.     About  fifteen  minims  were  injected  daily 


into  the  gluteal  muscles.  It  is  said  that  the  injec- 
tions produced  hardly  any  pain  and  did  not  cause 
either  abscesses  or  any  signs  of  poisoning. 

In  five  patients  out  of  eleven  the  treatment  was 
followed  by  the  complete  cessation  of  fulgarant 
pains,  and  in  the  six  others,  who  were  still  under 
treatment,  capability  of  sleeping  had  been  regained. 
In  one  case  the  gastric  crises,  which  had  been  pro- 
nounced, disappeared ;  in  another  the  vesical  and 
rectal  crises  were  overcome  ;  and  in  a  third  there  was 
amelioration  of  the  laryngeal  crises.  The  favorable 
influence  of  the  treatment  upon  the  behavior  of  the 
bladder  was  shown  rather  promptly ;  the  paradoxical 
ischuria  rapidly  disappeared  in  six  of  the  patients, 
and  in  all  of  them  urination  became  easier.  The 
general  condition  was  notably  ameliorated  in  all  the 
cases,  though  it  is  suggested  that  perhaps  this  re- 
sult was  due  simply  to  the  disappearance  of  the 
pains  and  the  restoration  of  sleep. 

The  thiosinamine  exerted  comparatively  little  ef- 
fect upon  the  ataxia  of  the  lower  limbs  and  none  at 
all  upon  the  other  objective  manifestations  charac- 
teristic of  the  disease.  The  mitigation  noted  above, 
says  the  Semaine,  is  all  the  more  significant  from 
the  fact  that  the  patients  were  living  under  disad- 
vantageous conditions,  so  that  no  adjuvant  treat- 
ment was  practicable.  The  efifects  cannot  be  attrib- 
uted to  the  sodium  salicylate,  for  the  doses  of  that 
drug  were  too  small  to  exert  such  an  energetic  ac- 
tion, and,  furtherrriore,  some  of  the  patients  had  al- 
ready been  treated  with  acetylsalicylic  acid  and  iodine 
preparations  without  the  least  result.  At  most,  too. 
the  effects  of  the  sodium  salicylate  had  been  inter- 
mittent, manifesting  themselves  immediately  after 
each  injection,  while  the  amelioration  recorded  was 
slow  and  progressive. 


THE  .^:TI0L0GY  of  TYPHOID  FEVER. 

Addressing  a  recent  meeting  of  the  French  So- 
ciety of  Military  Medicine  (Presse  mcdicale,  June 
2d),  M.  Granjux  maintained  that  typhoid  fever  was 
sometimes  autogenetic,  although  he  admitted  the 
conveyance  of  the  Bacillus  tyf'hosus  by  the  diges- 
tive and  by  the  respiratory  passages.  It  is  generally 
thought  that  infection  takes  place  solely,  or  with  an 
enormous  preponderance  in  frequency,  by  the  inges- 
tion of  the  germ  into  the  alimentary  canal.  Prac- 
tically it  is  to  contamination  of  food  and  drink  that 
we  attribute  all  instances  of  the  disease.  When 
Granjux  tells  us  that  emanations  and  dust  contain- 
ing the  microorganism  of  typhoid  fever  arc  taken 
in  with  the  breath,  we  cannot  say  that  he  is  mis- 
taken, but  we  may  suggest  that  such  material, 


I 


June  19,  1909.] 


EDITORIAL  ARTICLES. 


127s 


breathed  in  as  it  may  be  and  doubtless  is,  does  not 
produce  its  specific  pathogenic  effect  unless  it  is 
swallowed,  and  undoubtedly  we  swallow  much  of 
ihe  matter  that  we  take  in  through  our  noses. 

But  Granjux  believes  that  autogenesis  is  one  of 
the  commonest  causes  of  the  disease  in  military  life, 
the  saprophytes  of  the  intestine  being  transformed 
into  pathogenic  germs.  He  says  that,  whether  or 
not,  as  Spencer  believes,  the  BaciHiis  coli  communis 
is  transformed  into  the  bacillus  of  Eberth,  autogene- 
sis is  produced  chiefly  under  the  influence  of  three 
conditions,  heat,  overwork,  and  intestinal  sluggish- 
ness. It  is  easy  to  adduce,  as  the  speaker  did,  in- 
stances which  on  superficial  consideration  seem  to 
lend  some  support  even  to  so  fanciful  an  hypothesis 
as  that  of  the  autogenesis  of  typhoid  fever,  but  it  ap- 
pears to  us  that  they  lose  their  apparent  significance 
when  we  think  of  the  vast  number  of  data  that  have 
been  accumulated  in  support  of  the  general  view 
that  the  disease  is  almost  invariably  due  to  ingestion 
of  the  germ  by  the  mouth,  and  generally  by  drink- 
ing contaminated  water  or  milk  from  infected  re- 
ceptacles.  At  all  events,  the  results  of  guarding 
against  infection  by  the  mouth  are  so  satisfactory 
that  it  will  take  more  than  doubtful  plausibility  to 
shake  our  belief  in  the  ingestion  theory. 


GLANDULAR  FE\'ER. 

It  is  only  within  the  last  fifteen  years,  if  our 
memory  is  correct,  that  glandular  fever  has  been 
the  subject  of  discussion  in  this  country,  and  it  ha,s 
not  met  with  attention  elsewhere  for  a  much  longer 
period.  Presumably  there  are  but  few  observers 
who  would  now  admit  its  existence  as  an  essential 
fever,  but  the  name  has  met  with  acceptance  as  de- 
noting a  febrile  affection  characterized  by  mild 
lymphadenitis  occurring  as  a  coniplication  of  some 
recognized  infective  disease,  for  the  most  part 
probably,  as  maintained  by  Dr.  Maurice  Bureau 
{Gazette  medical c  dc  X antes,  May  ist),  influenza. 
Bureau  gives  an  excellent  resume  of  our  knowledge 
of  the  affection. 


A  XEW  TOURXAL  OF  PHAR^L\COLOGY. 

We  have  received  the  first  number  of  the  Journal 
of  Pharmacology  and  Exferimcntal  Therapeutics. 
dated  June.  1909.  It  is  edited  by  Professor  John  J. 
Abel,  of  the  Johns  Hopkins  University,  and  pub- 
lished in  Baltimore  by  the  Williams  &  Wilkins  Pub- 
lishing Company.  The  lists  of  associate  editors  and 
collaborators  are  imposing.    The  first  number  con- 


sists of  174  pages  of  reading  matter,  and  it  is  an- 
nounced that  each  volume,  made  up  of  six  bimonthly 
numbers,  will  contain  at  least  600  pages.  Pharma- 
cology is  now  deservedly  prominent  among  medical 
studies,  and  we  do  not  doubt  that  the  new  journal 
will  form  an  important  addition  to  our  periodical 
literature. 


BATHIXG  WITHOUT  WATER. 

The  conditions  and  conventions  of  our  civilization 
demand  frequent  bathing :  any  one  suspected  of 
avoiding  a  daily  bath  would  quickly  find  himself 
persona  non  grata  in  decent  society.  It  is  popularly 
supposed  that  this  frequent  bathing  is  essential  to 
health.  This  is  quite  untrue.  We  have  seen  fine 
and  vigorous  men  among  the  far  Eastern  habitants 
of  Canada  who  had  never  taken  a  full  bath  in  their 
lives,  and,  were  the  truth  known,  it  would  perhaps 
be  found  that  many  thousands  of  our  fellow  citizens 
know  nothing  of  the  alleged  benefits  of  the  tub 
while  maintaining  excellent  average  health. 

Such  people  do  not  present  the  fresh  and  pleas- 
ing appearance  of  the  frequent  bather,  however 
longlived  they  may  be.  Is  not,  however,  much  of 
the  benefit  attributed  to  the  water  in  reality  due  to 
the  complete  exposure  of  the  skin  to  the  air?  The 
respiratory  function  of  the  skin  is  of  high  impor- 
tance, and,  although  water  may  be  dispensed  with, 
closing  the  pores  to  air  would  result  in  speedy 
asphyxiation.  The  historic  instance  of  the  boy  who 
impersonated  John  the  Baptist  in  a  mediaeval  pro- 
cession and  whose  body  was  covered  with  gold  leaf, 
with  rapidly  fatal  results,  is  a  case  in  proof. 

The  ice  cold  bath  is  a  superstition ;  it  is  a  pastime 
for  the  abnormally  vigorous,  not  desirable  for  the 
average  civilized  man.  A  bath  not  too  cold  is  really 
an  agreeable  stimulant,  as  well  as  being  a  luxury 
foregone  by  those  accustomed  to  it  only  under  the 
direst  circumstances  and  with  the  greatest  sense  of 
annoyance.  The  feeling  of  well  being  after  a  bath 
can  hardly  be  obtained  in  any  other  way,  and  the 
rapid  multiplication  of  tubs  in  hotels  and  private 
residences,  soon  to  approach  one  to  the  individual, 
shows  how  they  are  appreciated. 

Unhappy  persons,  however,  whose  travels  in  the 
"provinces"  or  into  the  desert  may  temporarily  de- 
prive them  of  sufficient  water  for  bathing,  may  find 
a  substitute  that  will  at  least  afford  a  part  of  their 
accustomed  enjoyment.  The  body  may  be  ener- 
getically rubbed  with  a  brush  or  coarse  Turkish 
towel  and  afterward  exposed  to  the  air  for  fifteen 
minutes  or  so.  The  accustomed  feeling  of  vigor 
will  follow  and  the  process  will  be  found  by  the  un- 
initiated to  be  astonishingly  cleansing. 


1276 


NEWS  ITEMS. 


[New  Vork 
Medical  Journal. 


I'REPARING  FOR  THE  FOURTH. 

The  approach  of  the  Fourth  of  July  brings  to 
mind  the  dangers  incident  to  the  noisy  methods  of 
celebration  which,  in  some  unaccountable  manner, 
have  attached  themselves  to  this  particular  national 
holiday.  Notwithstanding  the  efforts  of  the  con- 
servative element  among  the  laity  and  of  sanitarians 
to  do  away  with  the  use  of  fireworks  in  celebrating 
the  Fourth,  the  indications  are  that  our  next  an- 
nual birthday  will  be  but  little  less  noisy  than  its 
predecessors.  The  New  York  State  Health  De- 
partment, in  the  June  Bulletin,  publishes  a  timely 
notice  regarding  the  danger  from  tetanus  incident 
to  the  discharge  of  firearms  and  the  ignition  of  fire- 
works in  connection  with  the  celebration.  The  de- 
partment advises  all  physicians  to  obtain  small  sup- 
plies of  tetanus  antitoxine,  which  will  be  furnished 
by  the  State  Hygienic  Laboratory  on  request,  with  a 
view  to  being  prepared  to  administer  immunizing 
doses  in  all  cases  of  wounds  from  either  firearms 
or  fireworks.  Any  wound  into  which  dirt  of  an\- 
kind  has  been  carried  may  become  the  seat  of 
tetanus  infection.  As  the  hands  of  children  are 
nearly  always  dirty,  the  probabilities  of  infection  in 
any  case  of  wounds  of  the  hands  of  children  are 
great.  It  is  well  in  such  cases  to  take  the  precau- 
tion of  administering  an  immunizing  dose  of  tetanus 
antitoxine.  Physicians  who  have  supplies  of  this 
antitoxine  issued  last  year  are  invited  to  return  it  to 
the  Hygienic  Laboratory  and  receive  fresh  antitox- 
ine in  exchange. 

 ®  

JpmS  ItEHlS. 


Changes  of  Address. — Dr.  Al.  D.  Keller,  to  65  East 
H4th  Street,  New  York,  N.  Y. 

The  Steele  Hospital,  Denver,  to  be  Enlarged.^Coii- 
tracts  have  been  approved  calling  for  the  expenditure  of 
$18,000  for  the  building  of  an  addition  to  the  Steele  Hos- 
pital in  Denver.  Colo. 

St.  Mary's  Maternity  Hospital  to  Become  a  General 
Hospital. — The  Sisters  of  Charity  who  conduct  St.  Mary's 
Maternity  Hospital,  in  Dean  Street,  Brooklyn,  have  re- 
quested permission  to  convert  this  into  a  general  hospital. 

Cholera  in-  St.  Petersburg. — It  is  reported  that  three 
new  clu)lcra  hospitals  have  been  opened  in  St.  Petersburg 
to  accommodate  the  increasing  number  of  patients.  In  the 
tlirce  da\  s  ending  June  I5t1i,  fnrt>--onc  new  cases  were  re- 
ported. 

The  National  Conference  of  Charities  and  Correction 

met  in  annual  session  in  Huffalo,  N.  Y.,  last  week.  A 
splendid  programme  had  been  arranged,  and  the  papers 
whicii  were  read  and  discussed  at  this  meeting  were  not 
onl\-  nitercstin<r,  but  of  practical  value.  An  elaborate  ex- 
hibit had  been  prepared,  one  section  of  which  being  devoted 
to  the  c'lnpest'ojT  of  population.  The  next  conference  will 
be  held  in  .St.  l.onis.  Mo. 

A  Hospital  for  Advanced  Tuberculosis  Patients  in 
Montreal. — The  committee  on  hygiene  of  the  Montreal 
City  Council  have  rcf|nestcd  the  committee  on  finance  t>^ 
a])j)rovc  a  grant  of  $150,000  for  the  establishment  of  a 
municipal  hospital  for  the  accommodation  of  palientr.  suf- 
fering with  tuberculosis  in  its  advanced  stages.  The  city 
has  now  paid  out  something  lik"  $150,000  a  year  for  the 
treatment  of  public  patients  in  private  hospitals. 


The  Society  of  Ex-Internes  of  the  Jewish  Hospital 
of  Brooklyn,  N.  Y.,  was  recently  reorganized,  and  the  fol- 
lowing officers  elected  for  the  ensuing  year:  President,  Dr. 
William  F.  Bozenhardt ;  vice-president,  Dr.  A.  G.  Horst- 
man ;  secretar_\-,  Dr.  J.  Ronsheim ;  treasurer,  Dr.  William 
Lintz. 

The  Cincinnati  Antituberculosis  League  has  made  sev- 
eral recommendations  to  the  Board  of  Public  Service  relat- 
ing to  the  care  of  tuberculosis  patients.  It  has  been  sug- 
gested that  open  shacks  be  constructed  to  take  the  place  of 
the  tents,  and  that  the  reception  hospital  for  smallpox  pa- 
tients be  con\-erted  into  a  tuberculosis  hospital. 

Bubonic  Plague  at  Caracas,  Venezuela. — It  is  reported 
that  an  epidemic  of  bubonic  plague  exists  in  Caracas,  Vene- 
zuela, and  that  the  physicians  of  the  Marine  Hospital  Ser- 
vice at  La  Guayra  have  gone  to  Caracas  to  confer  with  the 
authorities  as  to  the  best  means  of  stamping  out  the  plague. 
Up  to  June  loth  four  deaths  had  occurred  from  the  disease. 

Experimental  Inoculation  with  Antityphoid  Serum. — 
Nine  men  in  the  United  States  Army  were  inoculated  with 
the  new  antityphoid  serum  at  Fort  Omaha,  Neb.,  on  June 
15th.  If  the  experiment  proves  successful,  it  is  said  that 
the  entire  army  will  receive  similar  treatment.  The  opera- 
tions were  performed  by  Major  Harry  Gilchrist,  chief  sur- 
geon at  Fort  Omaha. 

Cornell  University  Medical  College  held  its  eleventh 
annual  commencement  on  June  9th.  The  degree  of  doc- 
tor of  medicine  was  conferred  upon  fifty-four  graduates, 
among  whom  were  two  women.  Professor  T.  F.  Crane, 
in  the  absence  of  President  Schurman,  conferred  the  de- 
grees and  also  delivered  the  address  to  the  graduating 
class. 

The  United  States  Hay  Fever  Association  will  hold  its 
thirty-sixth  annual  meeting  in  Bethlehem,  N.  H.,  on  Au 
gust  27th.  An  interesting  programme  has  been  prepared, 
and  a  good  time  is  expected.  The  association  has  177  mem- 
bers. Mr.  William  M,  Patterson,  45  Cedar  Street.  New- 
York,  is  secretary  of  the  association  and  will  furnish  all 
desired  information  relating  to  the  coming  meeting. 

A  Dinner  to  Dr.  Fowler. — A  number  of  the  profes- 
sional friends  of  Dr.  R.  S.  Fowler,  of  Brooklyn,  gave  a 
dinnei-  in  his  honor  at  the  Hotel  Astor  on  the  evening  of 
June  loth,  on  the  eve  of  his  departure  for  Europe.  Dr. 
Fowler  is  a  surgeon  in  the  German  and  Seney  hospitals, 
Brooklyn,  and  he  intends  spending  two  or  three  months 
in  Europe  studying  hospital  niethods  and  arrangements 

Hospital  Benefits. — The  proceeds  from  the  benefit  per- 
formance given  recently  at  the  Hartford,  Conn.,  Theatre, 
amounted  to  over  $1,600.  This  amount,  together  with  the 
cash  in  the  treasury,  making  nearly  $2,000,  will  be  used  as  a 
nucleus  for  the  establishment  of  a  free  maternity  bed  in  St. 
Francis's  Hospital. 

About  $5,000  was  collected  for  the  White  Plains  Hospital, 
on  "tag  day,"  held  there  on  June  12th. 

A  f'lir  was  held  at  Rockaway  Beach  during  the  past  week 
for  the  purpose  of  raising  funds  for  the  erection  of  a  hos- 
pital building  at  that  place 

Lectures  to  Mothers  on  the  Care  of  Babies. — The 
Philadelphia  Alliance  for  the  Care  of  Babies  has  arranged 
a  series  of  lectures  for  mothers  who  desire  to  learn  the 
best  methods  of  caring  for  the  babies  during  the  hot 
weather.  These  lectures  will  be  given  under  the  auspices 
of  the  Department  of  Health,  the  Board  of  Education,  the 
Congress  of  Mothers,  and  allied  associations.  They  will 
be  held  every  Wednesday  afternoon,  at  four  o'clock,  in  vari- 
ous public  schools  throughout  the  city.  More  than  one 
Inmdred  and  fifty  physicifins  have  volunteered  their  services 
as  lecturers,  and  the  subjects  for  the  talks  w-ill  be  selecte-:! 
by  the  Board  of  Health. 

To  Represent  America  Abroad. — Medical  Director  J. 
C.  Wise  and  Surgeon  Frank  L.  Pleadwell,  of  the  U.  S.  Navy, 
have  been  assigned  to  the  duty  of  representing  the  United 
States  at  five  scientific  congresses  this  summer  sailing  from 
New  York  frr  Europe  today.  Director  Wise  w  ill  attend  the 
International  Tubercular  Congress  on  July  8.  the  Interna- 
tional Scientific  Congress  on  Leprosy  at  Bergen  on  August 
16,  and  tlie  International  Medical  Congress  at  Budapest  on 
August  29.  Surgeon  Pleadwell  will  attend  the  Second  In- 
ternational Conference  for  the  Revision  of  Nomenclature 
of  Diseases  and  Causes  of  Death  at  Paris  on  July  i,  and 
the  Twelfth  International  Congress  on  Alcoholism,  at  Lon- 
don, on  July  iSth. 


June  19,  1909. J 


NEWS  ITEMS. 


1277 


The  New  York  Neurological  Institute,  a  hospital  for 
the  treatment  of  nervous  and  mental  diseases,  will  be 
opened  early  in  September  at  149  and  151  East  Sixty- 
seventh  Street.  The  medical  staff  has  not  yet  been  de- 
cided upon,  but  it  is  said  that  Dr.  Joseph  Collins,  Dr. 
Joseph  Fraenkel,  and  Dr.  Pearce  Bailey  will  be  at  the 
head.  A  sanatorium  is  to  be  conducted  in  connection  with 
the  hospital,  but  the  site  for  it  has  not  yet  been  decided 
upon.  The  aim  of  the  institute  is  not  only  the  treatment 
of  patients  suffering  from  nervous  and  mental  diseases, 
but  to  furnish  instruction  to  doctors  and  nurses  in  the 
principles  of  treatment  of  these  conditions. 

Giving  Away  Twenty-five  Thousand  Dollars  a  Day. — 
According  to  a  newspaper  writer,  Mrs.  Russell  Sage  has 
given  away  money  for  charity  at  the  rate  of  $25,000  a  day 
for  the  past  "three  years,  her  total  gifts  amounting  to  more 
than  $25,000,000  during  that  time.  Mrs.  Sage  has  made 
several  liberal  donations  to  medical  institutions,  among 
which  are  $200,000  to  the  Institute  of  Pathology  on  Black- 
well's  Island,  and  $1,000  to  the  Women's  Medical  Associ- 
ation of  New  York.  She  has  also  contributed  largely  to  the 
funds  for  carrying  on  the  campaign  against  tuberculosis. 
The  Sage  foundation,  established  by  Mrs.  Sage,  has  an  an- 
nual income  of  $450,000,  which  is  devoted  to  the  betterment 
of  social  conditions  in  the  United  States. 

A  Model  Milk  Company  Organized  in  New  York.- 
In  order  to  demonstrate  the  possibility  of  producing  milk 
under  conditions  satisfactory  from  a  sanitary  point  of  view, 
which  can  be  sold  at  a  moderate  price,  the  New  York 
Milk  Committee  has  organized  a  stock  company  at  a  cap- 
italization of  $25,000,  of  which  $5,000  has  already  been 
pledged.  It  is  planned  to  purchase  a  creamery,  and  work  in 
conjunction  with  the  farmers  in  the  immediate  vicinity  of 
the  creamery.  Among  the  subscribers  to  the  stock  are : 
Dr.  Samuel  W.  Lambert,  Dean  of  the  College  of  Physicians 
and  .Surgeons ;  Mr.  Charles  T.  Root,  Mr.  Mortimer  L. 
Schiff,  Mr.  Samuel  Sloane,  Jr.,  Mr.  V.  Everitt  Macy,  Mr. 
Stephen  C.  Williams,  and  the  Hon.  Seth  Low. 

The  International  Medical  Congress. — For  the  benefit 
of  those  who  are  planning  lo  attend  this  congress,  an- 
nouncement is  made  that  ample  arrangements  have  been 
made  for  hotel  accommodations  in  Budapest.  A  large 
number  of  rooms  were  engaged  a  year  or  more  ago  in  the 
Hotel  Hungaria  for  the  members  of  the  American  party. 
The  cost  of  the  entire  forty-one  days'  trip,  including  a 
week's  board  in  Budapest,  meals  en  route,  railroad  fare, 
etc.,  v/ill  be  $395.  The  American  party  will  sail  from 
New  York  on  August  12th.  Full  information  and  itin- 
erary may  be  obtained  by  addressing  Dr.  Charles  Wood 
Fassett,  St.  Joseph,  Mo.  Dr.  J.  H.  Musser,  of  Philadel- 
phia, is  chairman  of  the  American  Committee. 

Charitable  Bequests. — By  the  will  of  Edward  O.  Kind- 
berg,  the  Presbyterian  Hospital,  New  York,  becomes  a 
residuarjr  legatee,  to  the  amount  of  about  $50,000.  The 
entire  estate  goes  to  hospital,  with  the  exception  of  a  be- 
quest of  $100  to  the  brother  of  the  testator. 

By  the  will  of  Margaret  Kelly,  St.  Joseph's  Home  for 
Homeless  Boys,  of  Philadelphia,  receives  $1,000. 

By  the  will  of  George  W.  Fetter,  the  Medicochirur- 
gical  Hospital,  of  Philadelphia,  receives  $5,000  for  the  es- 
tablishment of  a  free  bed,  in  memory  of  Mary  A.  Fetter. 

By  the  will  of  Peter  Schemm,  the  German  Lutheran 
Orphanage,  of  Philadelphia,  receives  $2,500. 

By  the  will  of  Mrs.  Eva  Smith  Cochran,  who  died  last 
February,  the  Yonkers  Homoeopathic  Hospital  will  receive 
$20,000. 

The  Scientific  Exhibit  at  the  Atlantic  City  Meeting 
of  the  American  Medical  Association. — Diplomas  of 
honor  for  exhibits  of  superior  merit  were  awarded  to  the 
following :  American  Pharmaceutical  Association ;  Dr.  Emi] 
Beck,  of  Chicago  ;  Jefferson  Medical  College,  of  Philadelphia  ; 
Laboratory  of  St.  Mary's  Hospital,  Rochester,  Minn. ;  Phil- 
adelphia Rontgen  Ray  Society;  the  University  of  Mary- 
land; the  University  of  Pennsylvania;  the  Philadelphia 
Polyclinic;  the  Hartford,  Conn.,  Association  for  the  Pre 
vention  of  Tuberculosis  ;  the  Charity  Organization  Society  of 
the  City  of  New  York.  The  New  York  Lying-in  Hospital  re- 
ceived a  gold  medal  for  the  best  exhibit  of  research  work. 
The  gold  medal  for  the  best  tuberculosis  exhibit  according 
to  specifications  was  awarded  to  the  Indianapolis  Medical 
Society,  with  honorable  mention  of  the  excellent  exhibit  of 
the  New  York  State  Department  of  Health. 


Jefferson     Medical    College    Commencement. — The 

eighty-fourth  commencement  of  the  Jefferson  Medical  Col- 
lege, of  Philadelphia,  was  held  on  Monday,  June  7th.  The 
diploma  of  the  college  was  awarded  to  one  hundred  and 
thirty-nine  men.  Dr.  William  C.  Gorgas,  president  of 
the  American  Medical  Association,  delivered  the  address, 
and  received  the  honorary  degree  of  doctor  of  laws.  The- 
annual  dinner  of  the  Jefferson  College  Alumni  Associa- 
tion was  held  in  the  evening.  Dr.  Wiuiam  L.  Rodman, 
Dr.  A.  P.  Brubaker,  Dr.  Hobart  A.  Hare,  Dr.  Lawrence  F.. 
Flick,  and  Dr.  J.  A.  Stuckv  made  addresses.  The  di- 
rector of  the  Jefferson  Medical  College  Hospital,  Dr.  W'l- 
liam  M.  L.  Coplin,  was  presented  with  a  loving  cup. 

Pathologist  Wanted  at  Freedman's  Hospital. — The 
United  States  Civil  Service  Commission  announces  an  ex- 
amination on  July  14,  1909.  to  secure  eligibles  from  which 
to  make  certification  to  fill  a  vacancy  in  the  position  of 
pathologist  at  Freedman's  Hospital,  Washington,  D.  C.,. 
and  vacancies  requiring  similar  qualifications  as  they  may 
occur  in  that  hospital.  The  salary  is  $2,000  a  year.  Ap- 
plicants must  be  graduates  of  reputable  medical  colleges, 
and  have  had  at  least  one  year's  experience  in  a  patho- 
logical laboratory.  The  examination  is  open  to  men  only. 
The  age  limit  is  twenty  years  or  over  on  the  date  of  the 
examination.  Applicants  should  apply  at  once  to  the 
United  States  Civil  Service  Commission,  Washington,  D. 

C,  for  application  Form  1312. 

Personal. — Dr.  Charles  F.  Lafel,  house  surgeon  at  the 
Long  Island  College  Hospital,  has  been  appointed  in- 
structor in  anatomy  in  the  Long  Island  Medical  College. 

Dr.  Jacob  G.  Schurman,  president  of  Cornell  University, 
sailed  for  Europe  on  June  loth.  He  will  attend  the  five 
hundredth  anniversary  celebration  of  the  University  of 
Leipzig  and  the  three  hundredth  anniversary  celebration  of 
the  University  of  Geneva,  and  will  be  a  gues:  at  the  Dar- 
win celebration  at  Cambridge. 

Dr.  Charles  A.  Oliver,  of  Philadelphia,  has  resigned  as- 
professor  of  ophthalmology  in  the  Woman's  Medical  Col- 
lege of  Pennsylvania. 

Dr.  Freeman  A.  Tower,  for  five  years  assistant  patholo- 
gist at  the  Worcester,  Mass.,  Hospital  for  the  Insane,  has 
been  appointed  superintendent  of  the  Burbank  Hospital, 
Fitchburg.  Mass. 

Mr.  Frederic  S.  Mason,  the  pharmaceutical  chemist,  was 
one  of  the  honor  men  in  the  class  receiving  the  degree  of  M.. 

D.  at  the  twenty-ninth  annual  commencement  of  the  Med- 
icochirurgical  College  of  Philadelphia,  which  was  held  on 
Saturday,  June  5th.  Dr.  Mason  is  a  native  of  England. 
He, was  educated  in  Paris,  where  he  received  his  degree  of 
bachelor  of  science,  has  had  many  years'  experience  as  a 
pharmaceutical  chemist  in  both  public  and  private  labora- 
tories, and  has  done  considerable  original  research  work,, 
besides  being  a  prolific  writer  on  pharmaceutical  subjects. 

Foreign  Items  of  Interest. — The  Japanese  Red  Cross^ 
Hospital,  at  Tokyo,  opened  a  branch  hospital  in  Osaka  re- 
cently, which  will  have  accommodations  for  175  patients. 

The  Formosa  Government  General  ]\Iedical  School  cele- 
brated the  tenth  anniversary  of  its  establishment  re- 
cently. 

The  Emperor  of  Korea  has  been  vaccinated,  and  has  or- 
dered all  court  officials  to  follow  his  example. 

The  new  hospital  for  lepers,  which  is  being  built  in 
Tokyo,  Japan,  will  be  ready  to  receive  patients  about  the- 
end  of  the  year.  There  will  be  accommodations  for  about 
three  hundred  patients.  In  Osaka  and  Kumamoto  leprosy 
hospitals  are  under  construction,  each  to  have  accommo- 
dations for  three  hundred  patients,  and  in  Kagawa  Pre- 
fecture a  hospital  was  opened  recently  which  has  ample 
room  for  two  hundred  and  sixty  lepers. 

A  memorial  to  Dr.  Theodor  Schwann  was  unveiled  at 
Neuss,  Prussia,  on  June  6th.  Dr.  Schwann,  who  formu- 
lated the  cell  theory  of  living  matter,  yva.s  born  in  Neuss 
on  December  7.  1810.  and  died  in  Cologne  on  Januarv  14, 
1882. 

The  Socictc  des  hopitanx  policliniqnes  egyptiens  has 
opened  a  large  dispensary  in  Cairo,  Egypt.  The  protector  of 
the  society  is  the  khedive  himself,  while  his  uncle.  Prince 
Hussein,  is  the  president.  The  government  has  given  a 
house  and  funds  for  the  maintenance  of  the  institution  and 
for  adding  new  buildings,  when  necessary.  Tlie  present 
medical  staff  of  the  dispensary  includes  a  number  of  Euro- 
pean physicians,  but  in  future,  it  is  said,  that  the  entire  staff 
will  consist  of  Egyptians. 


12-8 


NEIVS  ITEMS. 


[New  York 
Medical  Journal. 


The  Nebraska  State  Medical  Association  held  its  an- 
nual meeting  in  Omaha  in  May,  and  elected  the  following 
officers:  President,  Dr.  P.  H.  Salter,  of  Norfolk;  first  vice- 
president,  Dr.  \V.  J.  Berkhofer,  of  Gothenburg;  second 
vice-president,  Dr.  S.  S.  Wilson,  of  Omaha ;  secretary,  Dr. 
A.  D.  Wilkinson,  of  Lincoln;  treasurer,  Dr.  A.  S.  von 
Mansfelde,  of  Ashland ;  corresponding  secretary,  Dr.  H. 
W.  Orr,  of  Lincoln. 

Mortality  Statistics  of  New  Orleans. — During  the 
month  of  April  the  total  number  of  deaths  reported  to  the 
Board  of  Health  of  the  City  of  New  Orleans  was  534 ; 
321  white  and  213  colored.  The  annual  death  rate  in  a 
thousand  population  for  the  month  was  14.53  for  the  white 
population:  26.35  for  the  colored;  and  17.68  for  the  total 
white  and  colored.  During  the  month  of  May  the  num- 
ber of  deaths  reported  was  609 ;  375  white  and  234  col- 
ored. The  annual  death  rate  in  a  thousand  population 
was  16.98  for  the  white,  28.84  for  the  colored,  and  20.18 
for  the  total  white  and  colored  population. 

The  Arkansas  Medical  Society. — At  the  annual  meet- 
ing of  the  societj',  held  recently  in  Pine  Bluff,  the  follow- 
ing officers  were  elected  for  the  ensuing  year :  President, 
Dr.  James  H.  Lenow,  of  Little  Rock ;  first  vice-president, 
Dr.  H.  D.  Wood,  of  Fayetteville ;  second  vice-president, 
Dr.  E.  L.  Watson,  of  Newport ;  third  vice-president.  Dr. 
F.  A.  Corn,  of  Lonoke ;  treasurer,  Dr.  J.  S.  Wood,  of  Hot 
Springs ;  secretary,  Dr.  Morgan  Smith,  of  Little  Rock. 
The  meeting  was  largely  attended,  and  was  in  every  way 
one  of  the  most  successful  in  the  history  of  the  organiza- 
tion. The  society  will  meet  at  Little  Rock  in  1910. 
Infectious  Diseases  in  New  York: 

IVe  are  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  follozving  statement  of  new 
cases  and  deaths  rcf^orted  for  the  tzvo  z^'eeks  ending  June 
12.  igog: 

,  June  5  ,    ,  June  12  v 

Cases.    Deatlis.    Cases.  Deaths 

Tuhirculosis   imlmonalis    400  193         527  180 

Diphtheria    371  30         270  32 

Measles   1,458  30       1,431  39 

Scarlet  fever    274  19         246  27 

Smallpo.x    .  .  2 

Varicella    142  .  .  197 

Typhoid  fever    44         "7  27  4 

Whooping  cough   .  ."   66  10  88  7 

Cerebrospinal  meningitis    7  12  12  2 

Total   2,7&2         301       2,800  291 

The  Health  of  Pittsburgh. — During  the  week  ending 
May  29,  1909,  the  following  cases  of  transmissible  diseases 
were  reported  to  the  Bin-eau  of  Health:  Chickenpox,  4 
cases,  o  deaths;  typhoid  fever,  12  cases.  6  deaths;  scarlet 
fever,  9  cases,  o  deaths ;  diphtheria,  4  cases,  i  death ; 
measles,  32  cases,  o  deaths ;  whooping  cough,  32  cases,  2 
deaths;  pulmonary  tuberculosis,  48  cases,  13  deaths.  The 
total  deaths  for  the  week  numbered  153,  in  an  estimated 
population  of  565,000,  corresponding  to  an  annual  death 
rate  of  14.0S  in  a  thousand  population. 

During  the  week  ending  June  5,  1909,  the  following  cases 
of  transmissible  diseases  were  reported :  Cliickenpox,  4 
cases,  o  deaths ;  typhoid  fever,  8  cases,  i  death ;  scarlet 
fever,  16  cases.  0  deaths :  diphtheria,  =:  cases,  2  deaths : 
measles,  13  cases,  i  death :  whooping  cough,  34  cases,  7 
deaths;  pulmonary  tuberculosis,  29  cases,  11  deaths.  The 
total  deaths  for  the  week  numbered  159,  corresponding  to 
an  annual  death  rate  of  14.44  i'l  i.ooo  of  popirlation. 

The  Medical  Society  of  New  Jersey  will  hold  its  one 
hundred  and  forty-third  annual  meeting  at  the  Hotel  Cape 
May,  Cape  Mav  City.  N.  J.,  on  June  23d,  24th,  and  25th. 
The  House  of  Delegates  will  meet  on  Wednesday  morning 
at  10.30  o'clock,  and  the  first  general  session  will  be  held 
in  the  afternoon  at  3.45  o'clock.  The  oration  in  medi- 
cine will  be  delivered  by  Dr.  Thomas  N.  Gray,  of  East 
Oransre.  X.  J. :  the  aimual  presidential  address  will  be 
delivered  bv  Dr.  David  St.  John,  of  Hackensack,  on  Some 
Recent  .'Xdvances  in  Medical  and  Surgical  Work,  and  the 
oration  in  surgery  will  be  delivered  by  Dr.  George  E. 
Brewer,  of  New  Vork.  The  annual  banquet  will  be  helil 
at  tlie  hotel  on  Thursday  evening,  at  7.30  o'clock.  The 
officers  of  the  society  are :  Dr.  David  St.  John,  president, 
of  Hackensack ;  Dr.  B.  .\.  Waddington,  first  vice-president, 
nf  S.Tlcm;  Dr.  Thomas  PI.  Mackenzie,  second  vice-presi- 
dent, nf  Trenton  ;  Dr.  Daniel  Strock,  third  vice-president, 
of  Camden :  Dr.  Harry  A.  Stout,  corresponding  secretary, 
of  Wcnonah ;  Dr.  William  J.  Chandler,  recording  secre- 
tary, (.f  South  Orange;  Dr.  .Archibald  Mercer,  treasurer, 
nf  Newark. 


Scientific  Society  Meetings  in  Philadelphia  for  the 
Week  Ending  June  26,  1909: 

Wednesday,  June  23d. — Philadelphia  County  Medical  So- 
ciety. 

Thursd.w,  June  24th. — Entomological  Section,  Academy  of 
Natural  Sciences;  Section  Meeting,  Franklin  Institute; 
Lebanon  Hospital,  Medical  Society. 

Frid.w,  June  25th. — Northern  Medical  Association ;  South 
Branch,  Philadelphia  County  Medical  Society. 

Society  Meetings  for  the  Comijig  Week: 

Moxday,  June  21st. — New  York  Academy  of  Medicine 
(Section  in  Ophthalmology)  ;  Medical  Association  of 
the  Greater  City  of  New  York;  Hartford,  Conn., 
Medical  Society. 

Tuesday,  June  .22d. — Buffalo  Academy  of  Medicine  (Sec- 
tion in  Obstetrics  and  Gynaecology). 

Wednesday,  June  23d. — New  York  Academy  of  Medicine 
(Section  in  Laryngology  and  Rhinology). 

Thursd.\y,  June  24th — New  York  Academy  of  Medicine 
(Section  in  Obstetrics  and  Gynaecology)  ;  New  York 
Celtic  Society ;  Brooklyn  Society  for  Neurology. 

Friday,  June,  25th. — Academy  of  Pathological  Science, 
New  York. 

Saturday,  June  26th. — Harvard  Medical  Societv,  New 
York. 

The  Health  of  Philadelphia. — During  the  week  ending 
June  5,  1909,  the  following  cases  of  transmissible  diseases 
were  reported  to  the  Bureau  of  Health  of  Philadelphia : 
Malarial  fever,  i  case,  0  deaths ;  typhoid  fever,  40  cases. 

7  deaths ;  scarlet  fever,  52  cases,  2  deaths ;  chickenpox,  33 
cases,  o  deaths ;  diphtheria,  68  cases,  10  deaths ;  measles, 
234  cases,  5  deaths :  wdiooping  cough,  37  cases,  3  deaths ; 
tuberculosis  of  the  lungs,  98  cases,  61  deaths ;  pneumonia, 
41  cases,  29  deaths ;  mumps,  22  cases,  o  deaths.  The  fol- 
lowing deaths  were  reported  from  other  transmissible  dis- 
eases :   Tuberculosis,  other  than  tuberculosis  of  the  lungs, 

8  deaths ;  diarrhoea  and  enteritis,  under  two  years  of  age, 
17  deaths ;  erysipelas,  3  deaths.  The  total  deaths  num- 
bered 437,  in  an  estimated  population  of  1,565,569,  corre- 
sponding to  an  annual  death  rate  of  14.51  in  a  thousand 
population.  The  total  infant  mortality  was  92;  78  under 
one  year  of  age,  14  between  one  and  tw-o  years  of  age. 
There  were  33  still  births ;  19  males  and  14  females.  The 
total  precipitation  was  0.21  inch. 

Vital  Statistics  of  New  York. — During  the  week  end- 
ing June  5,  1909,  there  were  reported  to  the  Department  of 
Health  of  the  City  of  New  York  1,405  deaths  from  all 
causes,  in  an  estimated  population  of  4,564.792,  correspond- 
ing to  an  annual  death  rate  of  16.06  in  a  thousand  popula- 
tion. The  death  rate  in  each  of  the  five  boroughs  was 
as  follows:  Manhattan,  15.69;  the  Bronx,  18.89;  Brooklyn, 
15.42;  Queens,  17.47;  Richmond,  22.75.  There  were  86 
deaths  from  contagious  diseases.  193  from  pulmonary  tu- 
berculosis, 109  from  diarrhoeal  diseases,  of  which  53  were 
of  children  under  five  years  of  age,  96  from  pneumonia, 
103  from  bronchopneumonia.  122  from  organic  heart  dis- 
eases, 74  from  cancer,  and  98  from  Bright's  disease.  There 
were  91  violent  deaths — 19  from  suicide,  3  from  homicide, 
and  69  from  accidents.  The  total  infant  mortality  was 
413 ;  246  under  one  year  of  age,  93  between  one  and  tw-o 
years  of  age,  and  74  between  two  and  five  years  of  age. 
There  were  128  still  births.  Seven  hundred  and  ninety- 
two  marriages  and  1.968  births  were  reported  during  the 
week. 

The  Mortality  of  Chicago. — The  total  number  of 
deaths  reported  to  the  Department  of  Health  for  the  w-eek 
ending  June  5,  1909,  was  573,  as  compared  with  654  for 
the  previous  week,  and  483  for  the  corresponding  period 
in  1908.  The  annual  death  rate,  in  an  estimated  popula- 
tion of  2,224,490.  was  13.43  i'l  «i  thousand  population,  as 
against  a  death  rate  of  11.63  for  the  corresponding  period 
last  year.  The  total  infant  mortality  for  the  week  was 
145;  100  under  one  year  of  age,  and  45  between  one  and 
fi\-e  >-ears  of  age.  The  principal  causes  of  death  were : 
Diphtheria,  7  deaths ;  scarlet  fever.  4  deaths ;  measles.  6 
deaths:  wTioopmg  cough,  3  deaths;  influenza,  2  deaths; 
typhoid  fever,  3  deaths:  diarrhrcal  diseases,  34  deaths,  of 
which  27  were  of  children  under  two  years  of  age;  pneu- 
monia, loi  deaths:  pulmonary  tuberculosis,  70  deaths; 
other  forms  of  tuberculosis.  17  deaths:  cancer,  33  deaths: 
nervous  diseases,  18  deaths:  heart  diseases,  6q  deaths: 
apoplexy.  12  deaths:  Bright's  disease,  42  deaths:  vio- 
lence, 44  deaths — suicides.  10.  accidents.  28,  and  man- 
slaughter. 6:  all  other  causes  of  death.  108  deaths. 


June  19,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


1279 


full  of  ^Lun•^ut  ^^itfuaUirf. 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

June  10,  igog. 

1.  A  Comparison  of  the  Guaiac  and  Benzidin  Tests  for 

Invisible  Haemorrhage  in  Diseases  of  the  Digestive 
Organs.  By  Fraxklix  \V.  White. 

2.  The  Relation  of  the  Spleen  to  Resistance  against  In- 

fection, By  J.  C.  Hubbard. 

3.  The  Medical  Inspection  of  Schools  in  Boston.  The 

Present  Limitations  and  Future  Possibilities, 

By  W.  P.  CouES. 

1.  Comparison  of  the  Guaiac  and  Benzidin 
Tests  for  Invisible  Haemorrhage  in  Disease  of 
the  Digestive  Organs. — \Miite  says  that  tests  for 
invisible  haemorrhage  in  diseases  of  the  digestive 
organs  are  very  valuable  and  will  be  much  used  in 
diagnosis  and  prognosis,  and  as  a  measure  of  the 
results  of  treatment.  It  is  important  to  recognize 
and  use  the  best  methods.  A  preliminary  step  is 
necessary  in  both  guaiac  and  benzidin  tests  to  ex- 
clude sources  of  error  from  food  ferments.  This  is 
more  important  for  gastric  contents  than  for  faeces. 
Acetic  acid  ether  extraction  is  best  in  the  guaiac  test, 
and  boiling  in  the  benzidin  test.  ]\Ietallic  salts,  po- 
tassium iodide,  and  charcoal  must  not  be  given  when 
the  stomach  contents  is  to  be  tested  by  the  benzidin 
method.  Before  using  these  tests,  meat  and  fish  and 
their  juices  must  be  excluded  from  the  diet  and  no 
haemoglobin  derivatives  used  as  a  drug  for  two  days 
for  the  guaiac  test,  and  for  three  or  four  days  for 
the  benzidin  test.  Gastric  contents  should  be  exam- 
ined when  available,  but  faeces  are  the  best  material 
for  examination,  as  they  alone  are  available  for  the 
repeated  examination  which  is  usually  necessary  for 
diagnosis,  arid  they  are  free  from  the  source  of  error 
introduced  by  the  use  of  the  stomach  tube.  The 
Weber  method  is  the  best  guaiac  test  for  routine  clin- 
ical work,  using  several  amounts  of  guaiac  as  rec- 
ommended by  Schroeder.  The  original  Adler  ben- 
zidin test  is  too  delicate  for  clinical  work.  This  ob- 
jection has  been  overcome  in  the  Schlesinger  ar  i 
Hoist's  modification  of  the  test,  which  is  about  five 
to  seven  times  as  delicate  for  blood  in  gastric  con- 
tents as  the  guaiac  test  and  only  about  twice  as  deli- 
cate for  blood  in  the  fjeces.  Schlesinger  and  Hoist's 
modification  is  the  best  benzidin  test  for  clinicil 
work.  It  has  all  the  clinical  value  of  the  guaiac 
test,  with  somewhat  greater  delicacy,  greater  clear- 
ness, and  much  simpler  technique,  and  as  carried 
out  acts  as  a  control  on  the  cleanliness  of  the  re- 
agents and  glassware.  Good  results  with  the  ben- 
zidin test  depend  on  careful  technique,  the  exclusion 
of  oxidizing  ferments  in  raw  food,  fresh  material 
for  examination,  clean  glassware,  and  the  quality, 
strength,  and  proportion  of  the  reagents  used.  A 
negative  benzidin  test  has  greater  value  than  a  neg- 
ative guaiac  test  in  ruling  out  haemorrhage,  and  if 
both  tests  are  used  as  a  control  much  time  will  be 
saved  by  using  the  benzidin  test  first,  which  takes 
only  two  minutes,  and  if  negative,  renders  any  fur- 
ther tests  for  blood  unnecessary.  It  is  wise  to  con- 
trol the  benzidin  test  with  the  guaiac  test  when  posi- 
tive results  are  found  until  the  technique  is  learned 
and  tested  individually. 

2.  The  Relation  of  the  Spleen  to  Resistance 
against  Infection. — Hubbard  reports  the  case  of 
a  patient  whose  spleen  had  been  removed  on  account 
of  splenic  anaemia.    A  month  later  an  acutely  in- 


flamed and  perforated  appendix  was  removed  under 
ether ;  the  patient  died  twenty-four  hours  after  oper- 
ation. The  anatomical  diagnosis  was  acute  peri- 
tonitis, generalized  ;  chronic  pleurisy  ;  bronchopneu- 
monia ;  absence  of  spleen ;  increased  connective  tis- 
sue and  fatty  infiltration  of  liver ;  persistence  of 
thymus ;  oedema  of  pia ;  congestion  of  superficial 
vessels.  The  author  experimented  on  animals,  and 
reports  that  two  splenectomized  pigs  died  of  general 
infection,  the  controls  surviving.  One  splenecto- 
mized pig  died  of  general  infection,  there  being  no 
control.  A  splenectomized  pig  died  of  local  infec- 
tion, not  at  the  point  of  inoculation,  some  time  after 
its  control  died  of  a  general  infection.  A  control 
died  of  a  general  infection,  while  the  splenectomized 
pig  lived  until  killed.  Both  the  splenectomized  pig 
and  the  control  lived  until  killed.  The  author  con- 
cludes that  from  a  perusal  of  these  few  experiments 
it  appears  that  there  is  no  marked  difference  in  the 
ability  of  splenectomized  and  normal  guinea  pigs  to 
withstand  infection  artificially  produced  by  the 
Staphylococcus  pyogenes  aureus.  Scattered  through 
literature  are  a  few  reports  of  experiments  under- 
taken to  determine  the  function  of  the  spleen  in  re- 
lation to  infection.  Xone  of  the  pieces  of  work  has 
been  sufficiently  extensive  to  settle  the  question.  By 
combining  them,  however,  a  fairly  good  estimate 
can  be  formed.  The  results  and  deductions  are  at 
great  variance,  and  it  can  be  said  that  no  work  has 
yet  shown  that  the  spleen  alone  plays  a  very  impor- 
tant role  in  fortifying  the  individual  against  infec- 
tion. While  it  may  be  one  of  several  organs  for  this 
purpose,  its  removal  causes  no  constant  change  in 
the  resistance.  It  is  probable  that  the  question  is 
far  from  being  simple  and  is.  without  doubt,  an  ex- 
ceedingly complicated  one.  The  author  has  observed 
a  man  from  whom  he  removed,  in  the  summer  of 
1905,  the  spleen  because  of  rupture.  His  occupation 
was  one  in  which  his  fingers  are  often  bruised  and 
cut.  He  reports  now  (three  and  three  quarter  years 
after  the  operation)  that  his  cuts  heal  as  readily  as 
before  and  that  he  is  no  more  susceptible  to  colds 
and  illnesses  than  formerly.  The  only  sickness  he 
has  had  since  the  operation  was  quinsv  sore  throat, 
for  which  an  incision  was  necessary.  Were  there  a 
decrease  in  susceptibility  as  a  result  of  splenectomy, 
it  certainly  would  have  been  noticeable  in  some  of 
the  many  human  cases  and  would  have  been  com- 
mented upon.  When  the  results  of  experimental 
work  correspond  with  the  findings  in  the  human 
case,  even  though  it  is  but  one,  there  can  be  little 
doubt  of  their  correctness.  It  seems  proper,  there- 
fore, to  conclude  that  the  removal  of  the  spleen  does 
not  alter  practically  the  individual's  susceptibility  to 
infection  and  that  its  functions  in  this  respect,  if 
they  do  actually  exist,  on  its  removal  are  readily 
taken  up  by  other  organs. 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 

Juuc  12,  igog. 

1.  Relation  of  the  Physician  in  Private  Practice  to  the 

Public  Health,  By  Walter  Wymax. 

2.  Chronic  Cholecystitis  as  Cause  of  Myocardial  Incom 

petence.    Report  of  Thirteen  Cases, 

By  Robert  H.  Babcock. 

3.  Management    of    Hemorrhage    from    the  Parturient 

Canal,  By  Johx  F.  Mor.\x. 

4.  Pain  and  Pott's  Disease,  with  Special  Reference  to 

Backache,  By  C.  C.  Wholey. 

5.  The  Clmical  Index  of  the  Thorax.  Associated  wifh  Pul- 

monary Tuberculosis,  By  W.alter  L.  Xiles. 


I28o 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


6.  Chloroform — the    Ideal    Hemostatic    in  Pulmonary 

Hemorrhage,  By  Joseph  B.  Fish. 

7.  Isohaemolysins  and  Isoagglutinins  of  Human  Sera,  with 

Special  Reference  to  Cancer, 

By  William  J.  Butler  and  W.  T.  Mefford. 

8.  Epilepsia    Partialis    Continua   Occurring    in  Cerebral 

Syphilis.    Report  of  a  Case  with  Operation, 

B'y  \ViLLi.\M  G.  Spiller  and  Edw.\rd  AI.^rtin. 
g.    Medical  Psychology,  By  Edmund  J.  A.  Rogers. 

2.  Chronic  Cholecystitis  as  a  Cause  of  Myo- 
cardial Incompetence. —  Babcock  reports  eleven 
cases  divided  into  four  groups,  from  which  he  tries 
to  explain  the  effect  of  gallbladder  disease  on  the 
heart  and  why  not  cardiac  symptoms  develop  in  all 
persons  with  chronic  cholecystitis.  He  says  that  a 
healthy  heart  muscle  niay  endure  such  a  disturbing 
influence  or  may  recover  quickly  from  its  derange- 
ment of  function.  A  myocardium  already  the  seat 
of  structural  disease,  on  the  contrary,  is  seriously 
af¥ected  by  conditions  of  strain  or  by  illness  which 
otherwise  would  prove  harmless.  Therefore,  since 
chronic  infection  of  the  gallbladder  manifests  itself 
■chiefly  in  persons  at  or  past  middle  age,  when  pre- 
sumably the  heart  muscle  is  no  longer  so  able  to 
resist  attacks,  there  are  furnished  the  conditions 
■capable  of  producing  the  symptom  complex  report- 
ed in  these  cases.  The  explanation  of  the  baneful 
effects  on  the  heart  of  some  cases  of  gallbladder 
disease  and  not  of  others  is  hypothetical,  and  ac- 
cordingly several  theories  may  be  advanced :  ( i ) 
The  circulation  in  the  blood  of  bacteria  or  their  tox- 
ines ;  (2)  the  depressing  influence  of  bile  constitu- 
ents on  the  myocardium;  (3)  disturbance  of  the 
splanchnic  circulation  and  secondarily  of  the  sys- 
temic circulation  and  heart;  (4)  a  reflex  inhibition 
through  irritation  of  the  vagus.  It  is  quite  possible 
that  a  different  explanation  is  applicable  to  different 
cases  and,  moreover,  that  there  must  be  a  predis- 
posing cause  residing  in  the  heart  muscle,  that  is, 
chronic  myocarditis,  in  consequence  of  which  the 
heart  is  unfavorably  affected  by  influences  which  a 
healthy  myocardium  would  be  able  to  resist. 

4.  Backache  in  Pott's  Disease. — Wholev  calls 
the  attention  to  backache  in  Pott's  disease.  He  be- 
heves  tliat  Pott's  disease  would  be  much  more  fre- 
•quently  and  earlier  diagnosticated  if  its  initial  man- 
ifestations, of  which  pain  in  the  form  of  backache 
is  often  conspicuous,  were  looked  for  and  recog- 
Tiized. 

5.  The  Phthisical  Chest. — Xiles  remarks  that 
the  typical  tuberculous  chest  is  more  nearly  round 
than  the  normal  chest.  The  increased  index  pre- 
cedes development  of  tubercle  infect-'on  in  the  lungs. 
It  is  due  to  an  arrest  of  development  at  or  about 
puberty  and  predisposes  to  pulmonarv  tuberculosis. 
Abnormally  high  indexed  chests  in  children  should 
"be  corrected  by  proper  exercises.  Until  very  re- 
cently almost  all  textbooks  on  medicine  and  physi- 
cal diagnosis  have  described  the  thorax  associated 
with  pulmonary  tuberculosis  as  flat,  and  even  now 
some  of  them  persist  in  this.  This  is  a  curious  sur- 
vival of  a  medical  fallacy  which  apparently  grew  up 
simply  because  in  the  past  no  one  had  measured  any 
considerable  number  of  such  chests.  Most  of  them 
tlo  appear  to  be  flat,  but  taking  measurements  on 
a  few  will  show  that  in  most  cases  the  flattening  is 
not  real  and  the  appearance  is  an  illusion.  This  is 
produced  by  the  shoulders  being  displaced  more 
forward  and  downward  tlian  normal,  which  m'lkes 
the  anterior  surface  of  the  chest  appear  to  I)o  dis- 


placed posteriorly — the  type  commonly  called 
"round  shouldered"  or  "hollow  chested."  There 
are  two  factors  which  tend  to  produce  the  displace- 
ment of  the  shoulders  in  this  manner:  (a)  a  more 
nearly  round  chest  than  the  normal,  and  (b)  relax- 
ation or  deficient  development  of  the  shoulder  gir- 
dle of  muscles. 

6.  Chloroform  in  Haemoptysis. — Fish  observes 
that  in  spite  of  the  great  advance  made  in  medi- 
cine during  the  last  half  century,  the  treatment  of 
pulmonary  haemorrhage  remains  practically  the 
same  as  at  the  time  of  Galen,  with  the  addition  only 
of  a  number  of  the  newer  drugs  which  do  not  seem 
to  materially  improve  the  solution  of  this  vexed 
question.  The  therapeutics  of  this  frequent  compli- 
cation in  pulmonary  tuberculosis  is  still  based  en- 
tirely on  clinical  experience,  which  in  the  main  is 
unsystematic  and  haphazard.  Morphine,  atropine, 
ergot,  hydrastis,  lead  acetate,  stypticin,  adrenalin, 
calcium  chloride,  gelatin,  nitrites,  magnesium  sul- 
phate, and  a  host  of  other  drugs  used  either  singlv, 
in  combination,  or  in  rotation,  are  doled  out  to  the 
patient  with  more  or  less  disappointment  until  Na- 
ture, in  spite  of  the  drugs  and  the  deranged  diges- 
tion resulting  from  their  employment,  comes  to  the 
sufferer's  rescue  and  by  her  vis  medicatrix  brings 
about  the  formation  of  a  blood  clot  at  the  bleeding 
point.  He  has  used  chloroform  in  the  treatment  of 
pulmonary  haemorrhage  and  reports  good  result  in 
nineteen  cases.  The  effect  of  chloroform  on  the 
circulation  is  chiefly  to  depress  the  vasomotor  sys- 
tem, causing  an  extraordinary  fall  of  blood  pres- 
sure. Complete  vascular  relaxation  ensues,  facil- 
itating' the  passage  of  the  blood  from  the  arteries 
into  the  capillary  network  and  veins.  The  patient 
is,  so  to  speak,  bled  into  his  own  vessels.  There  is 
also  some  cardiac  enfeeblement  and  dilatation, 
which  likewise  contributes  to  the  fall  of  blood  pres- 
sure. Chloroform  has  also  a  depressant  effect  on 
the  respiration,  because  of  the  lessened  supply  of 
blood  to  the  respiratory  centre.  As  chloroform  pro- 
duces coagulation  of  the  blood  vitro,  it  is  possible 
that  in  some  cases  its  action  in  the  body  is  aided 
by  direct  contact  of  the  vapor  with  the  bleeding 
point.  In  chloroform,  our  author  concludes,  we 
have  all  the  requirements  for  an  ideal  hremostatic. 
It  lessens  the  heart  action,  reduces  the  blood  pres- 
sure and  diminishes  the  respiratory  movement.  It 
acts  promptly  and  efiicientlv  and,  what  is  more,  it 
leaves  the  digestive  tract  intact.  Fish  describes  his 
method  as  follows :  The  patient  being  placed  in  a 
semirecumbent  position,  from  2  to  4  c.c.  of  chlor- 
oform are  dropped  on  the  usual  inhaler,  or  wad  of 
cotton,  and  held  near  the  nostrils  of  the  patient. 
The  haemorrhage  will  cease  within  five  or  ten  min- 
utes. During  the  following  twenty-four  or  forty- 
eight  hours  the  patient  will  bring  up  blood  clots. 
The  inhalation  of  fifteen  to  twenty  drops  every  hour 
is  continued  for  a  few  days.  Ammonium  chloride 
with  small  doses  of  codeine  is  given  internally  every 
four  hours.  The  ammonium  salts  favor  expulsion 
of  retained  secretions,  wlicrcby  we  hope  to  avoid 
an  aspiration  pneumonia -and  the  codeine  wilT  pre- 
vent excessive  coughing.  It  is  also  a  good  plan 
to  administer  a  teaspoonful  of  magnesium  sulphate, 
three  times  daily,  to  remove  excrementitious  matter 
which,  when  retained  in  the  blood,  will  stimulate 
the  vasomotor  centre  and  raise  the  blood  pressure. 


June  19,  1909.]  PITH  OF  CURRENT  LITERATURE.  1281 


MEDICAL  RECORD 

June  12,  /909. 

1.  The  Inadequacy  of  the  Sanatorium  Treatment  of  Tu- 

berculosis, By  Maurice  Fishberg. 

2.  The  Treatment  of   Syphilis  and   Parasyphilis  of  the 

Nervous  System,  By  D'Orsay  Hecht. 

3.  Concealed  Appendix,  By  Augustin  H.  Goelet. 

4.  Some  Coroner's  Cases,  By  Philip  F.  O'Hanlon. 

5.  Report  of  a  Case  of  Hydrophobia. 

By  John  F.  Anderson  and  Joseph  Goldberger. 

I.  The  Inadequacy  of  the  Sanatorium  Treat- 
ment of  Tuberculosis. — Fishberg  concUules  from 
the  literature  about  seventy  per  cent,  of  persons  com- 
ing to  autopsy  show  signs  of  tuberculosis,  fifty  per 
cent,  of  these  died  of  this  disease,  while  the  other 
half  died  from  other  causes,  and  a  large  percentage  of 
this  class  gives  ample  evidence  that  the  disease  has 
been  healed.  Against  these  statistics  it  has  rightly 
been  said  it  does  not  hold  good  for  humanity  at 
large.  These  figures  are  instructive  when  taken  in 
connection  with  the  sanatorium  population  of  some 
countries.  It  is  then  evident  that  b}"  far  more  con- 
sumptives are  cured  in  their  homes  than  in  sana- 
toria. Germany  is  the  home  of  the  sanatorium.  It 
is  there  that  the  institutions  for  the  cure  of  tubercu- 
losis have  been  developed  and  maintained  to  a  much 
larger  extent  than  in  any  other  country.  The  state, 
the  municipalities,  insurance  companies,  and  private 
enterprise  have  all  combined  to  establish  sanatoria 
for  the  treatment  of  the  disease.  The  latest  pub- 
Hshed  report  is  to  the  effect  that  in  the  spring,  igo8, 
there  were  99  sanatoria  for  adult  consumptives, 
comprising  6,500  beds  for  male  and  4,039  for  female 
patients.  In  addition  to  these  there  were  also  36 
private  sanatoria  with  2,175  beds.  The  total  was 
consequently  12,714  beds  for  the  treatment  of  adult 
consumptives.  Even  if  to  these  are  added  the  18  in- 
stitutions devoted  to  the  treatment  of  tuberculous 
children  which  contain  837  beds  :  and  also  the  73 
institutions  in  which  scrofulous  children  as  well  as 
children  predisposed  to  tuberculosis  are  cared  for 
and  which  have  available  6,843  beds  (among  the  lat- 
ter many  institutions  are  only  open  for  a  few  months 
during  the  summer)  we  have  only  20.394  beds  for 
the  treatment  of  tuberculosis  in  sanatoria.  In  the 
United  States  the  number  of  available  beds  in  sana- 
toria and  hospitals  for  consumptives  is  even  smaller 
in  proportion  to  the  population.  According  to  the 
last  report  of  the  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis  there  were  in 
August,  1908,  240  hospitals,  sanatoria,  and  day 
camps  in  the  United  States.  xAltogether  these  insti- 
tutions have  14,014  available  beds.  It  is  unfortunate 
that  we  do  not  know  the  exact  number  of  persons 
sick  with  tuberculosis.  In  some  countries  the  mor- 
tality rate  is  known  more  or  less  exactly.  In  Ger- 
many, where  the  registration  of  deaths  is  very  rigor- 
ously enforced,  it  is  known  that  around  120,000  per- 
sons die  annually  as  a  result  of  tuberculosis.  No- 
body knows  the  exact  number  of  deaths  in  the 
United  States.  The  registration  of  deaths,  as  well 
as  of  births,  marriages,  etc.,  is  in  many  States  not  at 
all  carried  out  in  a  manner  as  to  give  reliable  infor- 
mation on  the  subject ;  and  even  in  the  few  States 
and  cities  in  which  an  effort  in  this  direction  has 
been  made,  the  vital  statistics  leave  much  to  be  de- 


sired. But  assuming  that  there  occur  annually  20 
deaths  from  tuberculosis  per  10,000  population, 
which  is  rather  a  low  estimate,  it  appears  that  at 
least  175,000  persons  die  annually  in  the  United 
States  as  a  result  of  tuberculosis. 

2.  The  Treatment  of  Syphilis  and  Parasyphi- 
lis of  the  Nervous  System. — Hecht  observes  that: 

( 1 )  Syphilis  and  parasyphilis  of  the  nervous  system 
continue  to  stand  in  direct  and  indirect  causal  rela- 
tion to  primary  syphilis,  although  their  nassological 
position  is  very  likely  to  undergo  revision  of  the 
Schaudinn  discovery,  and  serodiagnostic  values  of  to- 
day stand  the  test  of  time  and  further  development ; 

(2)  the  therapeutic  position,  it  is  hoped,  will  also 
share  in  this  signal  advance,  but  in  the  expectant  in- 
terval it  is  well  to  insist  that  neither  a  routine  nor  a 
haphazard  administration  of  antispecifics  is  com- 
mendable; (3)  treatment  to  be  intelligent  must  meet 
the  requirements  of  each  case  with  due  regard  to  the 
many  collateral,  chiefly  supportive  measures;  (4) 
antispecifics,  .when  indicated  in  these  conditions, 
mean  mercury  and  iodides;  (5)  in  the  vast  majority 
of  the  cases  occurring  in  neurological  practice,  mer- 
cury by  inunction  is  the  method  of  choice ;  (6)  the 
Fraenkel  exercise  treatment  for  the  ataxia  of  tabess 
loses  none  of  its  efficiency  if  a  departure  is  taken 
from  the  original  complex  plan  to  a  simpler  one. 

BRITISH  MEDICAL  JOURNAL. 

May  2g,  igog. 

1.  Volvulus,  By  Henry  F.  Waterhouse. 

2.  The  Immediate  and  Ultimate  Results  of  the  Operation 

of  Gastroenterostomy  for  Gastric  and  Duodenal 
Ulcer,  By  Leonard  A.  Bidwell. 

3.  The  Treatment  of  Acute  Appendicitis, 

By  R.  Cozens  Bailev. 
5.    Resection  of  the  Ciecum  for  Cancer  of  the  Ileocaecal 
Valve,  By  Harristn  Cripps. 

5.  Perforated  Duodenal  Ulcer  Treated  by  Suture  and  Gas- 

troenterostomy, By  W.  Paynter  Noall. 

6.  Perforated  Gastric  and  Duodenal  Ulcers  Treated  Suc- 

cessfully without  Suture  of  the  Perforation, 

By  Edred  M.  Corner  and  Walter  Bristovv. 

7.  A  Case  of  Traumatic  Rupture  of  the  Sigmoid  Colon : 

Operation;  Recovery,  By  William  Sheen. 

8.  The  Treatment  of  Severe  Cases  of  Chronic  Colitis, 

By  P.  Lockhart  Mummery. 

9.  Enterospasm  :  Operation  ;  Death. 

By  Vaughan  Pendred. 
ID.  Fistulre  between  the  Stomach  and  Bile  Passages,  etc.. 

By  Alexander  Don. 
II   A  Fatal  Case  of  Acute  Volvulus  of  the  Ileum, 

By  S.  E.  Denyer. 

12.  Two  Cases  of  Appendicitis.  By  H.  Goodwyn. 

13.  .\  Case  of  Very  Large  Gallbladder  Successfully  Treat- 

ed by  Excision,  By  F.  W.  Collinson. 

14.  Secondary  Parotitis  due  to  Oral  Starvation  in  the  Med- 

ical Treatment  of  Gastric  Ulcer, 

By  H.  D.  RoLLESTON  and  M.  W.  B.  Oliver. 

15.  The  Prevention  of  Parotitis  during  Rectal  Feeding, 

By  W.  Soltau  Fenwick. 

I.  Volvulus.  —  Waterhouse  remarks  that  in 
volvulus  the  loop  of  bowel  twisted  upon  its  mesen- 
teric axis  provokes  vigorous  peristaltic  movements 
in  the  intestine  above  it.  The  first  indication  in 
treatment  is  to  calm  this  dangerous  peristalsis, 
which  tends  markedly  to  aggravate  the  existing  ob- 
struction and  strangulation.  No  food  must  be  given 
by  the  mouth,  but  water  is  permitted,  as  the  suf- 
fering of  the  patient  is  greatly  augmented  by  the 
intense  thirst  due  to  frequent  vomiting,  so  often  a 
prominent  symptom  in  intestinal  obstruction  of  all 


1282  PiTH  OF  CURRENT  LITERATURE. 


kinds.  Should  the  ejecta  consist  largely  of  bile  or 
the  contents  of  the  small  intestine  it  adds  greatly 
to  the  patient's  comfort  to  wash  out  the  somach 
either  by  the  stomach  tube  or  by  giving  water  free- 
ly by  the  mouth.  Many  authorities  advise  that  the 
exaggerated  movement  of  the  bowel  above  the  site 
of  obstruction  should  be  calmed  by  opium  admin- 
istered by  the  stomach  or  by  a  hypodermic  injec- 
tion of  morphine.  But  this,  otherwise  so  helpful 
drug,  should  never  be  used  here  as  it  is  in  such  cases 
treacherous  and  deceptive.  Waterhouse  is  a  pro- 
found believer  in  the  value  of  rectal  enemata,  as 
he  has  seen  many  cases  both  of  volvulus  and  intus- 
susception which  have  been  reduced  by  the  use  of 
repeated  rectal  enemata.  He  believes  that  cases  of 
volvulus  of  the  sigmoid  colon  which  can  be  reduced 
by  rectal  enemata  are  those  only  which  are  of  re- 
cent origin  (less  than  twelve  hours),  and  in  which 
the  angle  of  rotation  is  less  than  270  degrees.  In 
the  more  frequent,  in  which  the  upper  p?irt  of  the 
loop  travels  downward,  forward,  and  inward,  an- 
terior to  the  lower  part  of  the  loop,  it  is  clear  that 
distension  of  the  lower  segment  of  the  bowel  will 
have  a  tendency  to  undo  the  twist.  In  the  less  fre- 
quent variety,  in  which  the  upper  part  of  the  loop 
passes  downward,  backward,  and  outward,  posterior 
to  the  lower  end  of  the  loop,  distension  of  the  lower 
bowel  will  tend  rather  to  aggravate  the  twist.  The 
mortality  of  volvulus  is  appallingly  high,  it  is  un- 
doubtedly the  most  fatal  form  of  intestinal  obstruc- 
tion. The  two  conditions  that  make  for  success 
in  the  treatment  of  volvulus  are  immediate  diag- 
nosis on  the  part  of  the  practitioner  and  immediate 
reduction  of  the  volvulus  by  the  surgeon.  Should 
either  of  the  two  fail  in  his  part,  the  probable  result 
will  be  the  death  of  the  patient.  In  very  recent 
volvulus,  especially  of  the  omega  loop,  reduction 
may  be  accomplished  by  rectal  enemata  in  a  certain 
proportion  of  cases.  Should  they  fail,  and  this  will 
frequently  happen,  the  surgeon  must  in  every  in- 
stance open  the  abdomen.  The  incision  should  in 
every  case  be  made  in  the  linea  alba,  for  the  reasm 
that  by  a  median  incision  every  viscus  in  the  ab- 
domen may  be  examined. 

4.  Resection  of  Caecum. — Cripos  thinks  that  it 
is  a  mistake  to  remove  a  V  shaped  piece  of  mesen- 
tery as  generally  recommended.  It  is  important  that 
the  blood  supply  should  be  as  good  as  possible 
right  up  to  the  cut  edges  of  the  bowel.  The  entire 
blood  supply  comes  through  the  mesentery,  the  ves- 
sels anastomosing  very  freely  just  before  they  enter 
the  bowel.  No  portion  of  the  mesentery  can  be  re- 
moved, therefore,  without  including  some  of  the 
supply  vessels.  If  instead  of  removing  the  V  shaped 
piece  the  attachment  is  divided  close  up  to  and  par- 
allel with  the  bowel,  there  is  no  risk  of  cutting  ofif 
the  blood  supply  except  to  the  portion  actually  re- 
moved, and  even  this  is  utilized  through  the  anas- 
tomosing circulation  right  up  to  the  cut  edges.  In 
Sewing  the  bowel  together  about  one  fourth  of  its 
circumference  lies  between  the  two  layers  of  the 
mesentery.  It  is  this  portion  which  requires  the 
most  accurate  coaptation  to  get  good  union,  as  it  is 
not  peritoneal  surface  to  peritoneal  surface.  To  en- 
sure accuracy  this  part  of  the  circumference  should 
be  first  united,  the  needle  taking  a  good  grasp  of 


[New  York 
Medical  Journal. 

all  the  coats  except  the  mucous  membrane,  only  just 
the  edges  of  which  are  included.  The  sutures  (No. 
GO  silk)  are  tied  so  that  the  knot  lies  within  the 
bowel.  The  remaining  circumference  of  the  bowel 
is  united  by  Lembert's  sutures,  the  knots  of  which 
are,  of  course,  tied  on  the  outer  surface.  After  the 
two  rings  of  the  bowel  have  been  united,  a  few 
sutures  should  be  passed  so  as  to  bring  the  mesen- 
teric surfaces  together  and  make  them  continvious 
with  the  gut.  As  to  the  after  treatment,  it  is  well 
for  a  few  days  to  trust  to  rectal  feeding.  The  al- 
ternate sutures  in  the  abdominal  wound  can  be  re-  . 
moved  on  the  ninth  day,  the  remainder  three  or  four 
days  later. 

15.  Prevention  of  Parotitis  during  Rectal  Feed- 
ing.— Fenwick  has  observed  that  the  necessary 
prohibition  of  food  and  water  by  the  mouth  after 
severe  hasmatemesis  is  not  infrequently  followed  by 
inflammation  of  the  parotid  glands.  The  impossi- 
bility of  keeping  the  buccal  cavity  absolutely  clean 
in  this  case  permits  an  ascending  infection  of  Sten- 
son's  ducts  with  consequent  inflammation  of  the 
glandular  tissues.  He  found  that  an  india  rubber 
teat  about  2  in.  in  length  met  all  the  requirements 
of  the  case,  and  that  patients  were  quite  content  to 
suck  it  for  hours  at  a  time,  with  the  result  that 
the  mouth  remained  quite  clean  and  moist.  When  not 
in  use  the  teat  is  kept  in  a  weak  solution  of  Condy's 
fluid.  Since  this  simple  device  was  adopted  he  has 
treated  more  than  300  cases  of  hasmatemesis  by  rec- 
tal alimentation,  lasting  from  ten  days  to  seven 
weeks,  without  being  troubled  in  a  single  instance 
by  parotitis.  It  is  only  in  hospital  practice,  where 
the  mouth  is  very  foul  at  the  time  of  admission, 
that  the  gland  occasionally  becomes  inflamed  be- 
fore any  measures  can  be  taken  to  prevent  it. 

THE  LANCET 

May  2g,  igog. 

1.  The  After  Treatment  of  an  Uncomplicated  Case  of  E.x 

traction  of  Senile  Cataract,        By  Arnold  Lawson. 

2.  Prostatectomy,  By  James  H.  Nicoll. 

3.  On  Autoinoculation  and  Reinfection  of  Syphilis, 

By  J.  Hutchinson. 

4.  A  Simple  Method  of  Serum  Diagnosis  of  Syphilis, 

By  Alexander  Fleming. 

5.  The  Serodiagnosis  of  Syphilis,     By  James  McIntosh. 

6.  The  Biological  Syphilis  Reaction,  its  Significance  and 

Method  of  Application, 

By  Carl  H.  Browxixg  and  Ivv  McKenzie. 

7.  The  Serum  Diagnosis  of  Syphilis:  An  Analysis  of  200 

Consecutive  Sera  Examined  by  the  Wassermann 
Reaction,  in  which  a  Modified  Neisser's  Technique 
was  Used.  By  Hugh  Wansey  Bayly. 

8.  A  Note  on  Tracheotomy  Cases,  in  the  Course  of  which 

there  were  Long  Periods  of  Inability  to  Dispense 
with  the  Tube, 

By  Duncan  Forbes  and  Richard  M.  Courtauld. 

9.  Smallpo.x  as  it  Affects  London:  Retrospect  and  Fore- 

cast, By  A.  F.  Cameron. 

3.  Autoinoculation  and  Reinfection  of  Syphi- 
lis.— Hutchinson  says  it  is  often  stated  as  a  char- 
acter of  primary  syphilitic  sores  that  they  cannot  be 
inoculated  on  tlie  same  individual.  Although  clin- 
ical and  experimental  evidence  agrees  in  pointing  to 
a  rapid  spread  of  the  syphilitic  virus  throughout  the 
svstem  it  would,  indeed,  be  strange  were  it  true  that 
autoinoculation  is  impossible  after  the  sore  has  ex- 


June  19,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


128.^ 


isted  but  a  few  days.  It  is  a  fairly  frequent  occur- 
rence to  meet  with  two  indurated  chancres  situated 
on  parts  of  the  body  which  are  not  directly  continu- 
ous but  which  touch  each  other  from  time  to  time — 
for  example,  the  penis  and-  scrotum,  the  two  labia 
majora  and  minora  in  women,  the  upper  and  lower 
lip,  on  the  face,  etc.  These  are  in  all  probability 
examples  of  autoinoculation,  but  they  are  open  to 
the  explanation  of  simultaneous  infection  with  the 
spirochseta  in  two  places.  It  seems  to  have  been 
proved  that  primary  chancre  is  autoinoculable  onlv 
during  the  first  ten  days  of  its  existence,  and  mer- 
curialization  renders  autoinoculation  impossible.  He 
cites  Finger  and  Landsteiner,  who  say :  ''Reinocu- 
lation  is  successful  in  proportion  to  its  proximity,  in 
point  of  time,  to  the  primary  inoculation.  If  general 
infection  is  not  yet  complete  a  typical  chancre  can 
be  produced,  but  from  the  time  when  constitutional 
symptoms  appear  it  becomes  more  difficult  to  suc- 
ceed. During  the  secondary  period  the  result  has 
some  resemblance  to  a  secondary  papule."  Hutchin- 
son reports  seven  cases  of  reinfection  of  syphilis 
and  remarks :  Efficient  treatment  by  a  continuous 
course  of  mercury  for  one  or  two  years  is  the  surest 
way  of  rendering  a  patient  susceptible  to  second  in- 
fection. \Mth  this  proviso  he  may  contract  syphilis 
again  within  two  or  three  years  of  the  onset  of  the 
first  attac.  The  interval  between  the  two  attacks  of 
syphilis  may  be  so  short  a  time  as  eighteen  months, 
i.  e.,  the  patient  may  no  sooner  have  finished  his 
course  of  treatment  than  fresh  exposure  may  pro- 
duce a  complete  fresh  attack.  The  average  interval 
has  been  in  his  experience  six  years.  The  second 
attack  may  be  slighter  or  more  severe  than  the -first ; 
nothing  positive  can  be  laid  down  on  this  point.  If 
the  symptoms  on  the  first  occasion  have  readilv 
yielded  to  mercury  they  will  probably  do  so  in  the 
second.  There  is  no  reason  why  the  same  patient 
should  not  go  through  even  three  attacks  of  syphilis 
provided  the  first  two  have  been  well  treated. 

4,  5,  7.  Serum  Diagnosis  of  Syphilis. — Flem- 
ing describes  the  complement  fixation  test  for  syph- 
ilis, and  says  that  it  requires  only  a  very  small 
amount  of  the  patient's  blood,  such  as  may  be  drawn 
into  an  ordinary  blood  capsule  as  for  an  opsonic  in- 
dex or  a  Widai's  test,  and  thus  obviates  the  neces- 
sity of  drawing  off  blood  from  a  vein  with  a  syringe, 
while  at  the  same  time  making  it  easy  for  a  blood 
sample  to  be  sent  to  a  laboratory  for  the  test  to  be 
done.  It  does  away  with  the  use  of  an  animal  im- 
munized to  sheep's  corpuscles  as  in  Wassermann's 
test,  or  to  human  corpuscles  as  in  Xoguchi's  modifi- 
cation. This  process  of  immunizing  an  animal  is  a 
tedious  one  and  comes  under  the  heading  of  vivisec- 
tion. Thus  the  only  thing  one  requires  to  get  fre- 
quently is  the  sheep's  blood,  which  can  readily  be 
obtained  anvwhere  twice  a  week  or  oftener  from  a 
butcher.  Except  syphilis,  the  only  disease  in  which 
a  positive  result  is  at  all  constant  is  leprosy. — IVI'In- 
tosh  reports  145  observations,  and  concludes  that 
Wassermann's  reaction  possesses  a  sufficient  degree 
of  specificity  to  make  it  of  considerable  value  from  a 
diagnostic  and  therapeutic  point  of  view.  Appar- 
ently certain  extracts  of  congenital  syphilitic  livers 
give  the  most  consistent  results,  whereas  the  antigen 
cannot  be  kept  for  any  considerable  period  without 


losing  to  a  large  degree  its  specific  qualities.  The 
serum  may  be  kept  some  weeks  without  losing  any 
of  its  properties  if  it  is  kept  sterile.  A  marked 
positive  result  is  a  certain  sign  of  a  syphilitic  infec- 
tion, but  a  negative  result  does  not  always  mean 
that  no  infection  exists  or  has  existed.  At  present 
it  is  not  possible  to  give  a  definite  opinion  as  to  the 
influence  of  treatment  on  the  reaction,  or  as  to  what 
extent  the  reaction  can  be  used  to  indicate  whether 
sufficient  treatment  has  been  given  or  not,  as  the  re- 
sults obtained  seem  to  differ  in  almost  every  case. 
But  one  can  say,  as  a  rule,  that  the  more  complete 
the  treatment  has  been,  the  less  likely  is  one  to  find 
the  reaction  present  some  two  years  after  the  infec- 
tion. Energetic  treatment  should  be  commenced  at 
once  after  a  positive  reaction  has  been  obtained  in 
every  case,  without  waiting  for  the  development  of 
further  symptoms.  Bayly  describes  his  technique, 
which  is  a  modification  of  Neisser's  technique,  as 
follows :  A  rabbit's  heart  is  stripped  of  pericardium 
and  washed  free  from  blood  with  normal  salt  solu- 
tion. Two  grammes  of  heart  tissue  are  minced  and 
pounded  and  ground  into  a  cream,  and  made  up  tc 
20  c.c.  with  absolute  alcohol  and  well  shaken.  After 
twenty-four  hours  this  may  be  centrifuged  and  the 
clear  alcoholic  extract  removed.  Considerable  time 
is  saved  and  perhaps  greater  accuracy  obtained  if 
complement,  heart  extract,  and  normal  saline  are 
mixed  in  bulk  (instead  of  separately  in  each  test 
tube),  and  then  measured  into  the  test  tube  and  the 
serum  added.  By  this  method  there  are  only  two 
pipette  measurements  instead  of  four.  He  has  used 
three  controls,  one  normal  serum,  one  certainly  syph- 
ilitic serum,  and  one  without  any  serum.  He  has 
used  2.5  c.c.  normal  saline,  0.2  c.c.  heart  extract,  and 
0.1  c.c.  fresh  guinea  pig  serum  (complement),  and 
mixed  these  in  bulk  in  a  sterile  flask.  After  well 
shaking  he  places  2.5  c.c.  of  this  mixture  in  each  of 
twenty  small  test  tubes  and  adds  0.3  c.c.  of  either 
decomplementized  serum  to  be  tested,  or  control 
serum,  or  control  saline  without  serum  respectiveh'. 
The  tubes  are  then  placed  in  an  incubator  at  37°  C. 
for  a  half  hour.  A  dilution  in  normal  saline  of 
rabbit's  serum  that  has  been  rendered  hsemolytic  to 
sheep's  corpuscles  is  then  prepared  of  such  a  strength 
that  I  c.c.  of  this  dilution  when  added  to  i  c.c.  of  a 
7.5  per  cent,  suspension  of  sheep's  corpuscles  will 
just  produce  complete  haemolysis  when  incubated  for 
five  minutes  at  37°  C.  thus  using  velocity  of  reac- 
tion rather  than  the  end  point  as  his  guide.  For 
each  serum  to  be  tested  and  for  the  three  controls  i 
c.c.  of  a  7.5  per  cent,  suspension  of  sheep's  corpus- 
cles and  I  c.c.  of  the  diluted  decomplementized 
hsemolytic  serum  are  taken  and  mixed  together  in 
bulk  (=haemolytic  system).  There  is  plenty  of  time 
to  estimate  the  haemolytic  power  of  the  serum  and 
to  prepare  the  correct  dilution  and  mix  the  dilution 
of  serum  and  the  suspension  of  corpuscles  while  the 
tubes  of  heart  extract,  serum,  and  complement  are 
undergoing  their  one  and  a  half  hour's  incubation. 
After  this  complement  fixation  period  in  the  incu- 
bator the  tubes  are  removed  and  2  c.c.  of  the  hasmo- 
lytic  system  are  added  to  the  contents  of  each  tube, 
and  the  tubes  are  well  shaken  and  replaced  in  the 
incubator  for  two  hours,  when  they  are  removed 
and  placed  in  an  ice  chest  for  twelve  hours,  after 


1284 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


which  they  are  examined  for  the  reaction.  The 
amount  of  inhibition  of  haemolysis  will  be  found  to 
vary  and  any  definite  inhibition  of  haemolysis  he  has 
taken  as  a  positive  reaction,  while  only  those  tubes 
that  macroscopically  show  complete  haemolysis  have 
been  considered  to  give  the  negative  reaction. 

BERLINER  KLINISCHE  WOCHLNSCHRIFT. 
April  26,  igog. 

1.  Protection  of  Wounds  from  the  Germs  of  Infection  of 

the  Neighboring  Skin,  By  Fritz  Konig. 

2.  Pathogenesis  and  Treatment  of  Anuria  (Concluded), 

By  Hermann  Kummell. 

3.  X  Ray  Examination  of  Surgical  Diseases  of  the  Stom- 

ach (Concluded),   By  V.  Schmieden  and  F.  Hartel. 

4.  Two  Cases  of  Forster's  Operation  for  Spastic  Paralysis, 

By  Spiro  Livierato. 

5.  Biological  Studies  Concerning  Cancer  of  the  Stomach, 

By  Gottstein. 

6.  Treatment  of  Hjemorrhage  of  the  Stomach  with  Es- 

calin,  By  Hugo  Steinberg. 

7.  A  New  Contribution  to  the  Study  of  Situs  Viscerum 

Inversus  Partialis,  By  Curt  Schelenz. 

2.  Anuria. — Kiimmell  deals  in  this  portion  of 
his  paper  almost  exclusively  with  reflex  and  hyster- 
ical anuria.  Every  case  of  anuria  is  serious,  and  its 
prognosis  grows  worse  with  each  day  or  hour  of 
continuance.  The  treatment  must  be  energetic 
and  directed  toward  the  cause  in  each  particular 
case. 

3.  X  Ray  Examination  of  Surgical  Diseases  of 
the  Stomach. — Schmieden  and  Hartel  complete 
their  report  of  forty-nine  cases  illustrated  by  repro- 
ductions of  the  x  ray  pictures.  The  cases  reported 
in  this  paper  include  cancers  of  various  parts  of 
the  stomach,  benign  stenosis  of  the  pylorus,  ulcer 
of  the  stomach,  hourglass  contraction  of  the  stom- 
ach, with  and  without  cancer,  or  ulcers,  pseudohour- 
glass  contracture,  and  contractions  of  the  entire 
stomach.  The  illustrations  throughout  this  article 
are  worthy  of  close  study. 

6.  Escalin. — Steinberg  finds  escalin,  a  paste 
made  of  finely  pulverized  aluminum  and  glycerin, 
to  be  of  little  if  any  value  in  haemorrhages  from  the 
stomach. 

7.  Partial  Inversion  of  the  Viscera. — Schelenz 
reports  the  case  of  a  boy,  three  years  old,  in  whom 
the  heart  was  found  inverted,  that  is,  with  its  apex 
pointing  to  the  right,  with  its  vessels  transposed,  the 
liver  on  the  left  sioc,  while  the  spleen  and  stom- 
ach were  in  normal  positions.  Several  anomalies  of 
the  heart  and  of  the  veins  of  the  thorax  were  also 
present,  the  course  of  the  portal  vein  was  anoma- 
lous, the  small  intestine  was  wholly  on  the  left  side 
of  the  abdomen,  the  large  intestine  in  the  right.  The 
great  omentum  was  absent.  .  All  the  other  organs 
were  in  their  normal  positions. 

MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 
April  13,  1909. 

1.  The  Harmful  and  Beneficial  Effects  of  the  Fever  Tem- 

perature in  Infectious  Diseases,  By  Rolly. 

2.  The  Frequency  of  Meningitis  in  Pneumonia. 

By  Liebermeister. 

3.  Sipiion  Drainage  with  Aspiration  in  the  Treatment  of 

Tuberculous  lunpycma  of  the  Pleura,     By  Schmidt. 

4.  The  Treatment  of  Discharge  from  the  Female  Genitals, 

By  Nassauer. 

5.  Healing  of  Myositis  Ossificans  Traumatica  by  Fibro- 

lysin.  By  Aizner. 


6.  Iron  as  a  Substitute  for  Bismuth  for  X  Ray  Use, 

By  Tage.. 

7.  Ovarium  and  Osteomalacia,  By  Cramer. 

8.  Casuistics  of  Shot  Wounds  of  the  Heart,    By  Rimann. 

9.  Death  from  Late  Apoplexy  Recognized  as  the  Conse- 

quence of  an  Accident  for  which  Insurance  Indem- 
nity must  be  paid.  By  Franck.. 

10.  Combined  Arsenic  and  Tuberculin  Treatment, 

By  Friedmann. 

11.  A  New  Instrumentarium  for  Lumbar  Anaesthesia, 

By  Wittek. 

12.  Presence  and  Signification  of  Urobilin  (Concluded), 

By  Hildebrandt. 

1.  Harmful  and  Beneficial  Effects  of  Fever 
Temperature  in  Infectious  Diseases. — Roily  in 
his  experiments  with  animals  infected  with  pneu- 
mococci,  staphylococci,  colon  bacilli,  and  pyocya- 
neus  bacteria  found  that  an  increased  temperature 
exerted  a  favorable  influence  upon  the  course  of 
the  disease  and  increased  the  phagocytosis.  He  also 
found  that  the  vasomotor  weakness  was  caused  by 
the  infection  itself  and  not  by  the  rise  in  tempera- 
ture. Agglutinin  is  produced  more  rapidly  and  in 
greater  quantities  in  rabbits  when  the  animals  are 
kept  in  a  room  11°  to  13°  C.  hotter  than  another 
containing  the  control  animals,  and  the  production 
of  antitoxine  and  of  bacteriolysin  is  favored  by  the 
fever  temperature.  Finally  he  declared  that  taken 
all  in  all  the  increase  of  temperature,  if  within  mod- 
erate limits,  is  a  process  which  presents  tuore  ben- 
eficial than  harmful  effects.  We  recognize  in  the 
onset  of  the  rise  in  temperature  the  endeavor  on 
the  part  of  the  organism  to  throw  out  more  quickly 
and  efficiently  the  bacteria  that  have  entered,  or 
the  poisonous  material,  or'  to  neutralize  the  latter. 

2.  Meningitis  in  Pneumonia. — Liebermeister 
considers  meningitis  an  extremely  frequent  compli- 
cation of  pneumonia  as  well  as  of  all  other  acute 
infectious  diseases. 

4.  Treatment  of  "Discharge."  —  Nassauer 
points  out  that  the  most  various  and  unlike  causes 
can  produce  a  discharge  from  the  female  genitals. 
First  he  considers  the  constitutional  causes,  then 
the  local  pathological  causes,  of  which  he  enumer- 
ates a  very  great  number.  In  all  the  common  symp- 
tom is  the  discharge  from  which  the  patient  seeks 
relief,  and  Nassauer  goes  on  to  explain  how  he 
tries  to  meet  the  indications  and  give  relief. 

5.  Myositis  Ossificans. — Aizner  reports  a  case 
of  traumatic  myositis  ossificans  in  a  man,  twenty- 
three  years  of  age,  which  allowed  but  little  mo- 
tion of  the  knee  joint.  The  x  ray  picture  showed 
irregular,  fine  bone  formation  in  the  quadriceps 
muscle  not  connected  with  the  periosteum.  The  pa- 
tient was  put  to  bed,  allowed  slight  active  move- 
ments of  the  joint,  and  given  injections  of  fibroly- 
sin.  Thirty-four  injections  of  i  c.c.  each  were  made 
within  forty  days.  No  bad  effects  were  noted.  Im- 
provement was  quickly  noticeable.  Before  treat- 
ment the  knee  could  be  bent  only  to  an  angle  of  160 
degrees.  After  nine  injections  it  could  be  bent  to 
100  degrees,  after  twenty-four  to  65  degrees,  and 
at  the  end  of  the  treatment  the  knee  could  l)e  bent 
without  difficulty  to  50  degrees.  The  x  ray  pic- 
tures showed  that  the  retrogression  of  the  i)one 
formation  began  in  the  peripheral  parts  and  later 
involved   the   central.    Aizner  considers  that  this 


June  19,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


treatment  promises  well  in  the  commencing  and  still 
progressive  cases  of  this  nature. 

8.  Shot  Wounds  of  the  Heart. — Rimann  re- 
ports, two  successful  cases  of  surgical  intervention 
for  the  repair  of  shot  wounds  of  the  heart. 

12.  Urobilin. — Hildebrandt  has  made  an  ex- 
tensive study  of  urobilin  in  the  healthy  and  diseased 
organism,  with  special  reference  to  its  relations  to 
jaundice,  and  considers  that  with  a  healthy  liver 
urobilinuria  is  due  to  a  relative  insufficiency  on  the 
part  of  the  liver  to  reabsorb  the  urobilin.  He  thinks 
it  absolutely  certain  that  constipation  can  never  be 
the  cause,  even  to  a  slight  degree,  of  urobilinuria. 

April  .20,  iQog. 

1.  The  Influence  of  the  Streptococcus  Infection  upon  the 

Leucocytes  in  Monkeys,  with  Remarks  Concerning 
the  Method  of  Investigation, 

By  Zan'gexmeister  and  Cans. 

2.  The  Coagulation  Time  of  the  Blood,     By  Hartmaxx. 

3.  The  Results  of  Hot  Air  Treatment  in  Acute  Purulent 

Inflammations  of  the  Hand,  By  Iselix. 

4.  The  Appearance  of  Pains  with  Changes  of  the  Weather, 

By  Miller. 

5.  The  Radical  Operation  for  Chronic  Empyema  of  the 

Maxillary  Sinus,  By  Aexstoots. 

6.  Cortical  Motor  Aphasia  after  Pneumonia,        By  Port. 

7.  The  Suture  of  the  Principal  Vessels  after  Stab  Wounds 

of  the  E.xtremities,  By  Grassmaxx. 

8.  A  New  Successful  Transference  of  Variola  to  the  Calf, 

By  Meder. 

9.  The  Recently  Discovered  Oldest  Human  Skeleton, 

By  Reixhardt. 

10.  An  Aseptic  Caustic  Holder,  By  Arxold. 

3.  Hot  Air  Treatment  of  Acute  Purulent  In- 
flammations of  the  Hand. — Iselin  considers  the 
hot  air  treatment,  for  the  purpose  of  increasing  the 
hyperremia  of  tlie  inflamed  parts,  to  be  just  as  effect- 
ive in  the  control  of  acute  inflammations  as  Bier's 
method  of  producing  hyperaemia  b}'  stasis  and  much 
more  easily  applicable  in  general  practice. 

5.  Radical  Operation  for  Empyema  of  the  An- 
trum.— Aenstoots  describes  Dreesmann's  opera- 
tion in  which  the  facial  wall  of  the  sinus  is  removed 
throughout  the  most  of  its  extent.  He  states  that 
the  cosmetic  results  are  good. 

6.  Cortical  Motor  Aphasia  after  Pneumonia. — 
Port  describes  a  case  of  this  nature  that  he  met  with 
in  a  man,  twenty-one  years  of  age,  a  musician,  who 
denied  both  syphilis  and  hard  drinking. 

7.  Suture  of  Vessels  after  Stab  Wounds.— 
Grassmann  mentions  the  various  methods  that  have 
been  proposed  for  the  purpose  of  uniting  several 
vessels,  and  reports  four  cases  in  which  he  sutured 
the  common  femoral  vein,  the  subclavian  vein,  the 
femoral  artery,  and  a  circular  suture  of  the  common 
femoral  artery  with  suture  of  the  common  femoral 
vein.  The  fourth  patient  died  a  few  hours  after  the 
operation.  After  the  autopsy  the  soft  parts  about 
the  seat  of  injury  were  removed  from  the  right 
thigh  and  hardened  in  formalin.  Examination  five 
days  later  showed  that  there  had  been  no  secondary 
haemorrhage,  the  femoral  vein  was  not  narrowed, 
the  closely  placed  stitures  not  encroaching  on  its 
lumen.  The  lumen  of  the  artery  was  somewhat 
narrowed  by  the  sutures,  but  there  was  no  thrombo- 
sis. The  sutures  were  able  to  withstand  a  very  con- 
siderable tension.  At  the  place  of  suture  of  the 
peripheral  stump  of  the  vessel  a  lime  deposit  had 


been  displaced  and  projected  into  the  lumen,  through 
which  nevertheless  a  sound  could  be  passed.  A  fine 
network  of  fibrin  lay  upon  the  intimia  at  the  place  of 
suture. 

9.  Oldest  Human  Skeleton.  —  Reinhardt  de- 
scribes a  skeleton  recently  discovered  which  is  sup- 
posed to  be  that  of  a  prehistoric  man,  older  than  any 
other  now  known. 

April  .^7,  1909. 

1.  Indications  and  Technique  of  the  Classical  and  Extra- 

peritoneal Caesarian  Section  and  of  Hebosteotomy, 

By  JuxG. 

2.  Therapy  of  Retroflexio  Uteri  Gravidi  Fixata, 

By  Hexkel. 

3.  The  Normal  Point  of  Commencement  of  the  Activity 

of  the  Heart  and  Its  Change  under  Pathological 
Conditions,  By  Herixg. 

4.  Processes  of  Spontaneous  Healing  in  Tumors  of  the 

Brain,  By  Anton. 

5.  Syphilis  d'embl-ee  and  the  Syphilis  of  Physicians, 

By  Waelsch. 

6.  Flatfoot  and  Arthropathia  Psoriatica,  By  Stoffel. 

7.  A  New  Alternating  Current  Apparatus,         By  R.\ab. 

8.  A  New,  Washable,  Padded  Suspensory, 

By  SCHINDLER, 

9.  A  New,  Simple  Dressing  for  Luxatio  Clavicularis  Supra- 

acromialis,  By  Hartuxg. 

10.  The  Influence  of  the  Streptococcus  Infection  upon  the 

Leucocytes  in  Monkeys,  together  with  Remarks  Con- 
cerning the  Method  of  Investigation  {Concluded), 
By  Zangemeister  and  Gaxs. 

11.  Physicians  and  Schools,  By  Dornberger. 

3.  Normal  Point  of  Commencement  of  the 
Activity  of  the  Heart. — Hering  says  that  the  nor- 
mal place  of  commencement  of  the  activity  of  the 
heart  is  at  the  opening  of  the  superior  cava  in  the 
right  auricle,  in  the  anterior  section  of  the  sulcus 
terminalis  where  an  anatomically  characteristic 
trace  (node)  of  primitive  muscle  fibre  was  found 
by  Keith  and  Flack.  Auricular  starting  impulses 
also  arise  from  the  region  of  Tawara"s  node.  The 
pulsations  to  be  observed  in  this  region  follow  the 
ventricular  systole  after  an  interval  that  is  smaller 
than  when  the  pulsations  start  from  the  Keith-Rack 
node,  and  disturbances  of  the  ventricular  systole 
may  be  observed  when  the  pulsations  start  from  the 
region  of  Tawara's  node.  The  place  where  all 
starting  impulses,  which  are  not  from  the  Keith- 
Flack  node,  are  developed  extends  probably  from 
the  region  of  Tawara's  node  to  the  endings  of  the 
atrioventricular  bundle  in  the  ventricle.  These  ap- 
pear when  the  starting  impulses  in  the  Keith-Flack 
node  are  too  seldom,  are  discontinued,  or  are 
blocked,  or  when  in  consequence  of  some  special 
condition  they  are  formed  more  quickly,  hence  al- 
ways under  abnormal  conditions.  In  a  constantly 
irregular  pulse  the  originating  stimulus  comes  per- 
haps from  the  region  of  Tawara's  node.  The  atrio- 
ventricular activity  of  the  heart  to  be  observed  in 
paroxysmal  tachycardia  is  probably  caused  by  an 
overproduction  of  stimuli  in  the  atrioventricular 
region  of  the  transition  bundle.  The  ventricular 
originating  stimulus  arises  in  the  ventricular  section 
of  the  bundle  system. 

5.  Syphilis  of  Physicians. — Waelsch  calls  at- 
tention to  the  fact  that  physicians  are  exposed  in 
many  ways  to  the  infection  of  syphilis  and,  with  no 
desire  to  create  a  feeling  of  syphilophobia,  asserts 


1286 


PITH  Of  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


that  in  the  majority  of  cases  that  have  come  under 
his  notice  the  infection  could  have  been  avoided  by 
talxing  a  reasonable  amount  of  care.  Therefore  he 
urines  that  the  danger  should  always  be  borne  m 
mind  and  proper  precautions  taken  to  avoid  mfec- 
tion. 

10.  Influence  of  Streptococcus  Infection  upon 
Leucocytes. — Zangemeister  and  Cans  conducted 
their  experiments  on  monkeys  and  divided  the  cases 
into  three  groups:  i,  Those  that  recovered;  2,  those 
that  died  in  from  five  to  eleven  days ;  and,  3,  those 
that  died  within  twenty-four  hours.  They  find  that 
the  total  number  of  leucocytes  is  rapidly  increased 
in  slight  infections,  while  in  fatal  infections  it  be- 
gins to  sink  either  immediately  or  very  soon.  The 
neutrophiles  are  afifected  differently  as  they  are 
mononucleated  or  polynucleated ;  the  polynucleated 
are  much  less  afifected  by  the  course  of  the  infec- 
tion than  the  mononucleated,  which  increase  rapidly 
in  slight  infections  so  that  in  twenty-four  hours  the 
number  may  be  doubled,  increase  more  slowly  in 
the  moderately  severe  cases,  and  decrease  rapidly, 
sometimes  after  a  transient  increase,  in  the  worst 
infections.  Hence  we  have,  in  monkeys  at  least,  in 
the  curve  of  the  mononucleated  neutrophiles  during 
the  first  twenty-four  hours  a  means  by  which  to 
estimate  with  a  cetrain  degree  of  surety  the  result 
of  an  infection.  The  lymphocytes  fall  away  in  all 
cases,  the  nonfatal  as  well  as  the  most  severe,  but 
in  the  mild  cases  a  tendency  to  increase  appears  at 
the  end  of  a  few  hours,  in  the  moderately  severe 
ones  some  hours  later.  The  eosinophiles  furnish  no 
prognostic  standpoint,  they  are  usually  decreased 
more  and  more  quickly  in  severe  than  in  mild  cases, 
but  the  dififerences  are  not  characteristic. 

AMERICAN  JOURNAL  OF  OBSTETRICS. 

May.  igog. 

1.  Kphraim  McDowell,  the  Father  of  Ovariotomy, 

By  J.  R.  GoFFE. 

2.  A  Sequel  to  McDowell's  Triumph,  being  a  Brief  Sketch 

of  the  Rise  and  Progress  of  the  Samaritan  Free 
Hospital,  By  A.  H.  G.  Doran. 

3.  Ligation  or  Excision    of    Thrombosed  Veins  in  the 

Treatment  of  Puerperal  Pyaemia. 

By  J.  W.  WiLLi.\MS. 

4.  Exophthalmic  Goitre  and  Pregnancy,     By  H.  M.  Stowe. 

5.  The  Treatment  of  Inoperable  Cancer  of  the  Uterus, 

By  G.  Gellhorn. 

6.  Tuberculous  Peritonitis,  By  L.  Broun. 

7.  Diagnosis  of  Tuberculous  Peritonitis  in  Women, 

By  J.  N.  West. 

8.  Symphysiotomy.    Report  of  One  Case, 

By  D.  W.  PRENTissr 

9.  Meckel's  Diverticulum  and  other  Bands  as  Causes  of 

Ileus.    Report  of  Four  Cases,  By  G.  T.  Vaugh.«iN. 

10.  In  Memoriam,  G.  M.  Edebohls,  By  H.  J.  Boldt. 

11.  In  Memoriam,  R.  A.  Murray,  By  J.  A.  Booth. 

12.  Intestinal  Bacteria  of  Infants  and  the  Use  of  Lactic 

Acid  Bacteria,  By  H.  H.  Donnally. 

1.3.  Cerebral  Injuries  in  the  Newborn,  By  C.  S.  White. 
14.  Asthma  in  Children,  By  J.  D.  Thomas. 

3.  Ligation  or  Excision  of  Thrombosed  Veins 
in  the  Treatment  of  Puerperal  Pyaemia. — \\'il- 
liams  draws  the  following  conclusions:  i.  The 
average  mortality  of  |)ucr])cral  py;emia  being  66.66 
])cr  cent.,  anv  liopeful  operation  should  be  wel- 
comed. 2.  The  author's  paper  is  based  upon  the 
study  of  fifty-six  cases  in  which  jjclvic  veins  were 


excised  or  ligated.  The  mortality  was '  about  the 
same  as  by  the  expectant  method.  3.  Many  of  the  pa- 
tients were  not  susceptible  of  cure  and  the  technique 
was  often  faulty.  4.  If  thrombosis  is  limited  to  the 
spermatic  vein  the  mortality  of  early  operations 
should  not  exceed  ten  per  cent.  If  other  vessels  are 
involved  it  will  average  twenty-five  per  cen".  5.  Op- 
eration should  be  undertaken  as  soon  as  a  positive 
diagnosis  is  made,  a  wormlike  mass  being  palpable  at 
the  outer  portion  of  the  broad  ligament  in  patients 
who  have  had  chills  and  hectic  temperature.  6.  Ex- 
cision of  vessels  is  necessary  only  when  the  vessel 
appears  about  to  rupture  or  is  surrounded  by  peri- 
phlebitic  inflammation.  7.  The  transperitoneal  is 
preferable  to  the  extraperitoneal  route.  It  is  easier 
and  gives  a  more  extensive  view  of  the  vessels. 
8.  The  vaginal  route  is  applicable  only  to  cases  in 
which  the  thrombotic  process  is  limited  to  vessels 
of  the  broad  ligament.  The  author  thinks  that  ab- 
dominal section  should  be  preferred  whenever  an 
operation  is  decided  upon. 

4.  Exophthalmic  Goitre  and  Pregnancy. — 
Stowe  observes  that  Basedow's  disease  is  a  rare 
complication  of  pregnancy,  and  that  it  exerts  a  per- 
nicious influence  upon  that  condition.  Cases  which 
have  been  reported  show  important  kidney  symp- 
toms including  albuminuria,  glycosuria,  and  renal 
casts.  Vomiting  and  diarrhoea  are  also  of  common 
occurrence.  Skin  lesions  are  profuse  perspiration, 
erythema,  urticaria  oedema,  and  falling  of  the  hair. 
The  condition  of  the  heart  and  arteries  predispose 
to  spontaneous  abortion,  premature  separation  of 
the  placenta,  and  post  partum  hemorrhage.  The 
heart  may  be  dilated,  its  valves  insufficient,  its  mus- 
cle the  seat  of  fatty  degeneration.  A  pregnant  pa- 
tient with  goitre  may  grow  rapidly  worse  as  preg- 
nancy progresses,  and  die  in  the  early  months  under 
conditions  similar  to  those  with  the  pernicious  vom- 
iting-  of  pregnancy.  Or  the  bad  symptoms  may  be 
in  abeyance  during  pregnancy  and  recur  after  de- 
livery. Recurring  pregnancy  is  unfavorable  in 
those  who  have  goitre.  The  foetal  mortality  is  higher 
than  the  maternal.  If  the  bad  symptoms  are  not 
promptly  relievable  pregnancy  should  be  terminat- 
ed. The  thyreoid  gland  should  not  be  extirpated 
during  pregnancy. 

6.  Tuberculous  Peritonitis. — P>roun  thinks  that 
primary  tuberculosis  of  the  peritonreum  is  verv 
rare.  The  peritonaeum  is  usually  infected  by  bacilli 
which  pass  through  the  unbroken  intestinal  wall, 
deposits  being  formed  in  tlie  mesenteric  ghnds,  or 
from  a  focus  in  an  intestinal  ulcer,  or  through  the 
Falloppian  tubes.  The  onset  of  the  disease  is  in- 
sidious, and  diagnosis  is  very  difficult  before  ef- 
fusion has  occurred.  Hygienic  treatment,  as  in  all 
forms  of  tuberculosis,  is  of  primary  importance. 
The  most  important  medical  treatment  consists  in 
the  use  of  tuberculin.  The  best  time  for  operative 
treatment  is  after  the  effusion  has  become  chronic, 
that  is  after  the  subsidence  of  the  rapid  formation 
of  new  tubercles.  The  most  favorable  cases  are 
those  in  which  there  are  localized  collections  of 
serous  fluids,  without  adhesions.  Tiie  operation 
wound  should  be  closed  without  drainage,  other- 
wise a  tuberculous  sinus  may  result.  Patients  who 
have  been  o]K'rate(l  upon  should  be  kept  under  ob- 
servation from  three  to  five  vears. 


June  19,  1909. 1 


PROCEEDINGS  OF  SOCIETIES. 


Jrmbing  of  ^otutiw. 

WESTERN    SURGICAL    AND  GYNECOLOGICAL 

ASSOCIATION. 
Eighteenth  Annual  Meeting,  Held  in  Minneapolis,  Decem- 
ber     and  JO,  igoS. 

{Continued  from  page  ii/O.) 

The  simpler  the  technique,  the  better.  Even  manv 
of  the  special  instruments  might  be  dispensed  with. 
Small  French  needles  served  admirably,  and  there 
was  no  better  holder  than  a  good  Halsted  arterv 
clamp,  the  serration  upon  the  jaws  having  been  filed 
down  a  bit.  The  less  machinery  there  was  in  a 
child's  mouth  for  it  to  poke  at  with  the  tongue  tip, 
the  less  the  likelihood  of  failure.  Tying  as  large  a 
rope  of  gauze  as  could  be  passed  easily  through  the 
lateral  incisions  around  the  flaps,  tying  upon  the 
oral  side  and  tucking  the  ends  back  into  the  lateral 
incisions,  had  proved  in  a  few  cases  a  better  means 
of  splinting  the  flaps  and  preventing  tension. that  the 
use  of  tape.    It  did  not  cut  out  so  readily. 

In  operating  for  hare  lip  the  importance  of  re- 
lieving tension  by  separation  of  the  nose  from  its 
deep  connection  had  been  emphasized  by  Charles 
H.  Mayo.  Necessary,  however,  as  this  step  might 
be,  it  was  not  more  useful  in  practice  than  the  meas- 
ure of  passing  a  fine  chromic  catgut  suture  sub- 
cutaneously  through  the  base  of  the  septum  and  the 
base  of  the  ala  on  the  involved  side,  which  when 
tied  would  draw  and  hold  these  attachments  in  the 
proper  relationship  for  the  establishment  of  a  nor- 
mal narrow  nostril.  In  order  to  avoid  the  occur- 
rence of  a  notch  on  the  lip  after  the  wound  had 
shrunk,  the  following  practice  might  be  followed : 
After  freshening  was  done,  according  to  one  of  the 
well  known  methods  suitable  in  the  case,  and  after 
introducing  the  horsehair  sutures,  a  little  roll  of 
gauze  of  about  the  size  of  the  distal  phalanx  of 
one's  little  finger  was  fixed  with  its  long  axis  trans- 
versely to  the  plane  of  suture,  and  the  long  ends 
of  the  uppermost  and  lowest  horsehair  sutures  were 
tied  over  the  little  gauze  roll,  so  that  the  line  of 
suture  was  wrapped,  so  to  speak,  around  the  gauze 
for  about  two  thirds  of  its  circumference.  This 
simple  plan  would  effectively  prevent  notching  after 
healing  was  complete,  and,  moreover,  it  kept  the 
dressings  in  place  and  by  gently  stretching  the 
wound  margins  maintained  coaptation. 

The  Plastic  Surgery  of  the  Abdominal  Wall. — 
Dr.  Robert  C.  Coffey,  of  Portland.  (Oregon,  said 
that  abdominal  hernia  might  be  defined,  in  a  general 
way,  as  a  protrusion  of  the  abdominal  contents 
through  the  abdominal  wall  proper  or  beyond  the 
ordinary  plane  of  the  abdominal  wall ;  therefore 
there  was  either  an  absolute  hernia,  in  which  the 
contents  passed  through  an  actual  opening  in  the 
fascial  wall,  or  relative,  in  which  a  certain  portion 
of  the  abdominal  wall  or  fascia  was  weakened  to 
such  an  extent  as  to  allow  of  protrusion  of  the  con- 
tents of  the  abdomen  without  an  actual  opening  in 
the  fascial  wall.  Another  form  of  relative  hernia, 
which  occurred  almost  if  not  quite  as  often  as  dias- 
tasis of  the  recti,  was  manifested  by  an  increase  in 
distance  and  protrusion  between  the  umbilicus  and 


the  anterior  superior  spinous  process  of  the  ilium, 
due  to  transverse  stretching  of  the  fascia  of  the 
external  oblique.  This  condition  might  be  unilateral 
or  bilateral.  When  bilateral,  it  might  be  classed 
under  the  head  of  pendulous  belly,  dwelt  upon  by 
Webster  and  others,  but  was  anatomically  entirely 
different,  in  that  it  was  external  to  the  recti  muscles. 
This  condition  was  treated  as  follows :  Sjjlit  the 
fascia  of  the  external  oblique  parallel  to  the  fibres 
in  such  a  manner  as  to  converge  with  a  like  split  on 
the  opposite  side  at  a  point  just  above  the  svm- 
physis  pubis.  Separate  the  fascia  from  the  internal 
oblique.  Draw  one  layer  of  fascia  under  the  other 
with  quilt  sutures  of  linen,  taking  care  to  have  the 
loop  of  thread  include  the  fibres  of  fascia  in  a  trans- 
verse direction.  Suture  the  remaining  free  edge  of 
fascia  to  the  outer  surface  of  the  other  layer  with  a 
continuous  catgut  suture  to  further  improve  appo- 
sition at  the  free  edge.  Thus  the  distance  between 
the  umbilicus  and  anterior  superior  spinous  process 
was  diminished,  the  protrusion  was  reduced,  and 
the  fascial  wall  was  doubled.  The  result  was  an 
abdominal  supporter  made  of  the  patient's  own  tis- 
sues, which  might  therefore  be  termed  an  autoplas- 
tic bandage.  Two  cases  treated  by  this  method,  one 
unilateral  and  one  bilateral,  had  been  entirely  suc- 
cessful. The  one  was  performed  eighteen  months 
ago,  and  the  other  eight  months  ago. 

Extension  of  the  upper  portion  of  the  abdominal 
cavity  was  indicated  when  the  incision  for  surgery 
of  the  upper  abdominal  cavity  could  only  be  closed 
with  great  difificulty  and  much  tension.  As  an  aid 
in  the  cure  of  postoperative  herniae  of  the  upper 
abdomen,  notably  those  following  gallbladder  opera- 
tions on  fat  people,  and  in  cases  where  an  operation 
was  performed  for  chronic  prolapse  of  the  liver  and 
stomach,  either  producing  or  resulting  from  nar- 
rowing of  the  upper  segment,  it  was  of  value.  If 
the  peritoneal  cavity  was  already  opened  in  the  me- 
dian line,  the  operation  was  done  as  follows:  i. 
Close  the  peritonaeum,  if  possible.  2.  Slit  the  ante- 
rior sheaths  of  the  recti  an  inch  or  more  from  the 
median  incision  and  dissect  ofT  from  the  muscles 
toward  the  median  line.  3.  Bring  the  cut  edges  of 
the  fascial  flaps  together  and  suture  in  the  median 
line,  leaving  the  recti  muscles  bare.  If  the  operation 
was  done  to  relieve  tension  in  closing  a  wound  at 
or  near  the  outer  edge  of  the  rectus  muscle,  whether 
in  doing  a  primary  operation  or  in  curing  a  hernia,, 
the  median  incision  was  made  down  to  and  through 
the  fascia  to  the  peritoneal  fat,  taking  care  to  keep 
in  the  exact  median  line,  so  as  to  avoid  opening 
the  sheath  of  either  rectus  muscle  at  this  point.  The 
upper  abdomen  might  easily  be  expanded  two  or 
more  inches  by  this  method,  and,  so  far  as  his  ex- 
perience went  with  patients  and  in  animal  experi- 
ments, there  was  no  danger  of  subsequent  hernia  or 
of  adhesion  of  muscle  to  skin. 

Surgical  Types  of  Abdominal  Tuberculosis. — 
Dr.  WiLLiAJC  D.  Haggard,  of  Xashville,  said  that, 
after  the  lungs  and  bones,  the  intestines,  pelvic  or- 
gans, and  peritonaeum  were  the  strongholds  of  tu- 
berculosis. The  duodenum  and  oesophagus  seemed 
practically  immune,  owing  to  the  rapid  passage  of 
the  contents  of  these  tubes,  which  allowed  no  oppor- 
tunity for  microbial  fixation.    The  stomach  immun- 


1288 


LETTERS  TO  THE  EDITOR. 


[New  York 
Medical  Journal. 


ity  was  due  to  the  destructive  action  of  the  gastric 
juice  on  the  tubercle  bacilli.  There  were  nine  in- 
stances of  primary  gastric  tuberculosis  on  record, 
and  fifty-seven  cases  of  secondary  involvement  of 
the  stomach.  The  small  intestines  were  involved 
secondarily  usually,  but  the  disease  occurred  pri- 
marily oftener  than  was  formerly  believed.  About 
twenty-five  per  cent,  of  tuberculosis  was  said  to  gain 
entrance  into  the  system  through  the  intestinal  mu- 
cosa. It  was  a  disorder  of  child  life,  due  most 
probably  to  infected  cows'  milk.  It  attacked  lym- 
phoid tissue,  which  abounded  in  the  lower  ileum. 
Stagnation  invited  bacterial  entrance.  Intermittent 
pain  and  diarrhoea  were  the  chief  symptoms.  Stric- 
tures and  peritonitis  were  the  principal  sequelae. 
Nearly  half  of  the  cases  of  intestinal  stenosis  were 
caused  by  tuberculosis.  It  was  marked  by  chronic 
obstruction  and  the  "ladderlike"  appearance  of  the 
abdomen.  Resection  or  short  circuiting  was  indi- 
cated. Eighty-five  per  cent,  of  abdominal  tubercu- 
losis occurred  in  the  ileocaecal  region.  Swallowed 
bacilli  were  causative.  Chronic  obstruction  some- 
times resulted.  Clinical  examples,  with  operative 
records  of  the  author,  were  reported.  Hyperplastic 
tuberculosis  of  the  caecum,  with  perpendicular  indu- 
ration in  the  right  flank,  was  fatal  without  excision 
or  other  surgical  measures.  Illustrative  cases  were 
cited.  Mixed  infection  resulting  in  abscess  from 
ileocaecal  disease  was  also  illustrated  by  two  opera- 
tive cases,  with  recovery.  A  case  of  tuberculosis 
of  the  omentum,  which  was  adherent  in  a  hernial 
sac,  requiring  removal  of  almost  the  entire  omentum 
and  the  appendix,  was  narrated.  Tuberculosis  of 
the  appendix,  apart  from  the  caecum,  was  compara- 
tively rare. 

Chronic  peritonitis  with  ascites  was  usually  tu- 
berculous. Sixteen  per  cent,  of  tuberculosis  cases 
posted  had  peritonitis.  From  seven  to  seventeen 
per  cent,  of  all  Falloppian  tubes  removed  were  tu- 
berculous. Patients  failing  to  improve  under  treat- 
ment should  have  an  exploration.  Simple  laparo- 
tomy cured  only  those  cases  of  the  ascitic  variety  in 
which  the  tube  became  adherent  and  the  tuberculous 
process  was  thus  obliterated.  Recurrent  cases  re- 
quired the  removal  of  the  focus  of  disease  in  the 
tubes  for  permanent  cure.  The  ulcerative  and  fi- 
brous types  were  unsuited  to  operation.  The  sup- 
purative form  was  usually  fatal  in  spite  of  an  oper- 
ation. Aside  from  sacculated  peritonitis,  the  most 
constant  tumor  was  the  thickened,  sausage  shaped 
omentum,  lying  transversely  above  the  umbilicus. 
The  diagnostic  use  of  tuberculin  was  found  to  give 
positive  results  in  the  majority  of  cases.  Only  a 
third  of  the  medical  cures  were  permanent  (Rose). 
An  operation  gave  eighty-five  per  cent,  of  cures. 
.Advanced  visceral  tuberculosis  contraindicated  an 
operation.  An  abdominal  operation  should  include 
examination  of  the  caecal  region  and  the  pelvis,  with 
the  removal  of  all  foci  without  drainage.  The  oper- 
ative mortality  was  not  over  three  per  cent.  Post- 
operative tuberculous  wound  infection  had  been  ob- 
served by  the  author  in  three  cases.  The  import- 
ance of  fresh  air,  sunshine,  rest,  nourishment,  and 
the  tuberculin  bacillary  emulsion  was  urged. 

Repair  of  the  Internal  Ring  in  Oblique  In- 
guinal Hernia.— Dr.   l-".  GRiiC.uRV  Conxell,  of 


Oshkosh,  Wis.,  divided  the  methods  of  radical  cure 
of  oblique  inguinal  hernia  into  two  kinds:  i.  Those 
in  which  the  result  was  an  anatomical  reproduction 
of  the  normal  relations.  2.  Those  in  which  the  re- 
sulting relations  were  markedly  diflferent  from  the 
normal.  In  the  first  class  all  the  relations  were,  as  a 
rule,  reproduced  except  that  of  the  internal  ring  in 
the  transversalis  fascia,  which  was  usually  allowed 
to  remain  in  a  dilated  condition  or  was  sutured  from 
above  downward,  which  resulted  in  an  abnormal  de- 
scent of  the  ring,  with  consequently  a  shorter  and 
less  oblique  canal.  In  order  to  reproduce  the  nor- 
mal internal  ring,  the  transversalis  fascia  must  be 
sutured  from  the  lower  boundary  of  the  ring  up- 
ward to  the  cord,  in  this  way  elevating  and  dimin- 
ishing the  internal  ring,  with  consequently  a  longer 
and  more  oblique  canal.  The  various  steps  in  the 
anatomical  repair  of  oblique  inguinal  hernia  consist- 
ed of  ( I )  the  removal  of  the  sac,  with  redundant 
parietal  peritonaeum,  (2)  repair  of  the  internal  ring, 
(3)  protection  of  the  ring  by  suture  of  the  internal 
oblique  muscle  to  Poupart's  ligament,  (4)  reunion 
of  the  aponeurosis  of  the  external  oblique  muscle 
with  the  formation  of  a  proper  external  ring. 

Accidents  and  Complications  in  Operations  for 
Goitre. — Dr.  Charles  H.  Mavo,  of  Rochester, 
}ilinn.,  said  that,  out  of  the  few  deaths  from  opera- 
tions upon  goitre,  accidents  and  complications  were 
the  cause  in  a  large  percentage.  Haemorrhage, 
with  its  immediate  and  secondary  consequences, 
was  a  serious  accident,  \\  hen  secondary,  it  was 
usually  from  muscle  inclusion  in  ligating  the  in- 
ferior thyreoid  artery.  There  had  been  four  deaths 
in  575  operations  for  diffuse  or  encapsulated 
adenomata,  two  occurring  from  pneumonia.  Seven 
out  of  nineteen  deaths  in  410  cases  of  hyperthy- 
reoidism  occurred  in  the  first  forty-six  operations 
for  this  disease.  In  this  condition  the  complica- 
tions of  degenerative  conditions  led  to  hyperthy- 
reoidism  after  the  operation.  Preparation,  a  grad- 
uated operation,  and  better  technique  had  reduced 
this  mortality  to  four  or  five  per  cent.  Preserva- 
tion of  the  posterior  gland  capsule  tended  to  pre- 
serve the  recurrent  laryngeal  nerves,  also  the  para- 
thyreoid  bodies.  The  greatest  danger  of  parathy- 
reoid  injury  was  in  secondary  operations  for  goitre. 
Other  serious  conditions  requiring  an  operation 
which  occurred  with  marked  Graves's  disease  might 
call  for  preparation  or  a  graduated  operation  as  a 
])reliminary  procedure. 

{To  be  continued.) 
 ^  

fetters  to  the  m\^x. 


THE  UNAUTHORIZED  USE  OF  A  NAME. 

Phil.\delphi.\,  June  14.  1909. 

To  the  Editor: 

My  attention  has  been  called  to  the  fact  that  a 
concern  known  as  the  "A.  M.  C."  is  advertising  a 
number  of  preparations  said  to  possess  medicinal 
properties,  one  of  which  is  called  ''Expectorant 
(Hare)":  another  'Tonic  Comp.  (Hare"!."  I  am 
also  told  that  traveling  salesmen  employed  by  these 
parties  are  representing  that  I  am  responsilile  for 


June  ig,  1909.] 


BOOK  NOTICES. 


1289 


these  formulae  and  that  I  have  a  financial  interest  in 
them.  WiW  you  kindly  state  for  the  benefit  of  your 
readers  and  for  my  protection  that  such  a  use  of  my 
name  is  without  any  justification  whatever?  I  never 
heard  of  the  "A.  M.  C,"  whatever  that  may  mean, 
before  to-day,  nor  do  I  know  what  their  compounds 
contain.  It  is  hardly  necessary  for  me  to  add  that 
all  statements  made  by  any  one  to  the  efi^ect  that  I 
have  any  interest  in  any  pharmaceutical  or  chemical 
preparation  are  absolutelv  untrue. 

H.  A.  Hare. 

 ®  

[We  publish  full  lists  of  books  received,  but  we  acknowl- 
edge tto  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  rez-iew  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


Atlas  of  the  External  Diseases  of  the  Eye,  etc.,  by  Prof. 
Dr.  O.  Haae,  of  Zurich.  Third  Edition.  Revised.  Ed- 
ited by  G.  E.  DE  ScHWEixiTZ,  M.  D.,  Professor  of  Oph- 
thalmology in  the  University  of  Pennsylvania  and 
Ophthalmic  Surgeon  to  the  University  Hospital,  etc. 
Philadelphia  and  London :  W.  B.  Saunders  Companv, 
1909. 

The  last  issue  of  Haab's  instructive  manual  con- 
tains a  number  of  new  illustrations  of  external  dis- 
eases and  of  microscopic  specimens.  In  its  pres- 
ent shape  it  forms  an  exceedingly  valuable  volume 
with  a  most  complete  yet  succinct  introductory 
chapter  on  the  clinical  examination  of  the  eye  and 
explanatory  text  for  each  of  the  very  beautiful 
plates,  which  deals  not  only  with  diagnosis  but  in 
most  cases  with  treatment  as  well.  For  the  stu- 
dent as  well  as  the  practitioner  this  must  be  in- 
\"aluable  in  gaining  familiarity  with  the  appearance 
of  all  forms  of  external  ocular  disease. 

Traite  methodique  et  clinique  dcs  maladies  dc  I'appareil 
respiratoire.  Base  sur  les  doctrines  medicales  de  TEcole 
de  Montpellier.  Par  le  Docteur  Germ.mx  Rey,  Medecin 
dii  Preventorium  et  Dispensaire  Anti-Tuberculeux  an 
Bureau  de  Bienfaisance  de  Toulouse.  Montpellier :  Cou 
let  et  Fils.  1909.    Pp.  912. 

We  have  here  not  only  a  carefully  prepared  treat- 
ise on  respiratory  diseases,  but  an  ambitious  attempt 
on  the  part  of  the  author  to  expound  a  complete 
philosophy  of  medicine  based  upon  the  somewhat 
peculiar  tenets  of  the  Montpellier  school.  To  this 
reviewer  it  seems  that  Dr.  Rey  has  been  more  suc- 
cessful in  the  former  than  in  the  latter  object.  Many 
of  the  theoretical  doctrines  of  which  he  is  an  ardent 
disciple  will  appear  fantastic  to  the  American 
reader.  The  effort  to  reduce  the  practice  of  medi- 
cine to  an  arbitrary  system  and  the  dogmatic  form- 
ularies sanctioned  by  the  estimable  teachers  whom 
he  reveres  cannot  make  for  scientific  progress,  and 
is  really  a  reversion  to  the  modes  of  medical 
thought  current  in  the  Middle  Ages,  which  were 
founded  on  the  authority  of  Hippocrates  and  Galen. 
The  frequent  recurrence  of  such  vague  and  archaic 
expressions  as  "■fluxions,"  "phlogosis."  "vital 
force,"  and  "phleginasia"  is  almost  tmintelligible 
to  the  modern  reader.  Throughout  there  is  evinced 
a  familiarity  with  the  medical  classics  which  is  re- 
grettably rare  in  writers  of  to-day.  An  admirable 
feature,  a  trait  coinmon  to  much  of  the  best  French 
medical  literature,  is  the  excellence  and  fulness  of 


the  sections  dealing  with  the  psychology  of  disease 
and  the  details  of  dietetic  treatment.  The  chapters 
on  tuberculous  disease  are  very  good  as  relates  to 
diagnosis  and  symptomatology,  but  are  wanting  in 
breadth  of  view  where  pathology  and  treatment  are 
considered.  Thus,  no  mention  is  made  of  tuberculin 
in  any  form  as  a  diagnostic  agent,  and  its  thera- 
peutic use  is  incontinently  condemned.  The  admin- 
istration of  creosote  is  deemed  almost  a  crime,  and 
ipecac  is  extravagantly  praised.  The  Latin  races 
in  general  seem  to  have  an  exaggerated  fear  of 
couraiits  d'air,  and  our  author's  limited  and  rather 
reluctant  acceptance  of  the  fresh  air  treatment  is 
in  striking  contrast  to  his  abounding  faith  in 
ptisans,  hypodermic  medication,  and  mild  climates. 
There  are  also  chapters  on  bronchitis,  lobar  pneu- 
monia, bronchopneumonia,  bronchiectasis,  pulmon- 
ary gangrene,  syphilis  and  cancer  of  the  lungs, 
hydatid  cysts,  whooping  cough,  emphysema,  the  dif- 
ferent forms  of  pleurisy,  and  pneumothorax. 


Medicoliterary  Xotcs. 

Dr.  Harvey  \\".  Wiley  has  a  popular  exposition 
of  some  features  of  the  pure  food  law  in  the  June 
number  of  the  Xational  Slagaciiie. 

It  is  hard  to  say  whether  Charles  W.  ^Miller  is 
serious  or  joking  ponderously  in  the  same  maga- 
zine in  his  article  The  Doctors"  Trust.  Members  of 
our  profession  are  accused  of  rtishing  about  in 
four  cyhnder  automobiles,  charging  our  patients 
excessive  mileage  fees,  installing  costly  professional  . 
nursing  service,  prescribing  tablets  to  save  our- 
selves the  trouble  of  learning  to  write  a  prescrip- 
tion, unreasonably  charging  for  advice  by  telephone, 
and,  finally,  seriously  affecting  the  birth  rate  by  our 
excessive  fees  for  accouchcments.  We  are  much 
worse  than  Standard  Oil,  as  we  are  all  malefactors 
of  great  wealth,  whereas  the  great  trust  is  respon- 
sible only  for  one.  Notwithstanding  the  beautiful 
modern  roads,  we  make  the  same  mileage  charges 
as  we  did  in  1840!  The  picture  of  the  country 
practitioner  "reeling  mileage  fees  into  his  pocket" 
at  the  rate  of  a  inile  in  two  minutes  is  apparently  a 
familiar  one  to  Mr.  Miller,  however  lacking  in  veri- 
similitude it  may  appear  to  our  readers. 

In  his  farcical  story,  The  Rebellion  of  Lydia,  in 
the  July  Cosmopolitan,  Rowland  Thomas  brings 
four  doctors  simultaneously  upon  the  scene  to  treat 
a  choking  baby,  which  is  ultimately  saved  by  the 
ministrations  of  a  Chinese  cook.  This  is  very  irrev- 
erent. The  physician  is  too  massive  and  noble  a 
figure  to  be  grouped  and  bustled  about  as  a  chorus 
to  a  farce  comedy :  as  well  have  a  breakdown  by  the 
gods  of  high  Olympus. 

Farm  and  Home  (Phelps  Publishing  Co..  Spring- 
field. ]\Iass.)  should  be  an  interesting  and  valuable 
publication  to  the  coimtry  physician  who  has  one 
acre  or  fifty  acres.  We  wonder  if  the  distinguished 
floriculturist,  Eben  E.  Rexford,  who  gives  so  much 
useful  information  in  this  magazine  to  the  plant 
lover  either  with  only  one  flowerpot  or  rejoicing  in 
a  large  garden  is  the  author  of  that  song,  famous 
about  the  time  of  the  Hayes-Tilden  election.  Come 
Sit  by  My  Side,  Little  Darling. 


i2yo 


MI SCELLA N Y—OFFICIA L  NE IV S. 


[New  York 
Medical  Journal. 


llisteUanB. 


A  Correction. — Referring  to  our  report  of  the 
discussion  on  Dr.  Frank  Billings's  paper. on  Chronic 
Infectious  Endocarditis  (page  1216),  Dr.  J.  M.  An- 
ders, of  Philadelphia,  writes  to  us  as  follows:  "I 
am  reported  to  have  said  that  'most  cases  of  chronic 
infectious  endocarditis  were  secondary  to  rheumatic 
arthritis,"  etc.  I  intended  to  state  that  most  cases  of 
chronic  infectious  endocarditis  were  secondary  to 
rheumatic  endocarditis  (sclerotic),  or,  in  other 
words,  that  the  majority  of  instances  were  intercur- 
rent in  the  course  of  chronic  valvulitis,  particularly 
when  of  rheumatic  origin,  although  streptococci 
were  generally  found  in  the  blood." 

 <^  


Official  geliis. 


The  foIlo-:i.-iug  cases  of  siiiallpox.  cholera,  and  plague  have 
been  reported  to  the  surgeon  general.  United  States  Public 
Health  and  Marine  Hospital  Serz  ice  during  the  zveek  end- 
.ing  June  11.  igog: 

Places.                                          Date.                 Cases.  Deaths. 
Smallpox — United  States. 
Alabama — Birmingham  May   15-22   i 


15-  2^- 
22-29. 

16-  30. 


23-30   5 

21-28   I 

23-30   I 

■5-29   7 

1-31   3 

23-30   2 

15-29   7 

15-29   II 

15-29   3 

15-29   '4 

15-22   3 

1-24   2 

15-29   8 

  6 


California — San  Francisco  May 

District  of  Columbia — Washington.  May 

Georgia — Macon  May 

Illinois — Chicago  ^Iay 

Illinois — Iianville  May 

Illinois — Springfield  May 

Indiaia — Indianapolis  Maj- 

Indiana — South    Bend  May 

Iowa — Cedar  Rapids  .May 

Iowa — Davenport  May 

Kansas — Kansas    City  May 

Kansas — Wichita  May- 
Kentucky — Lexington  May 

Louisiana — New  Orleans.  .  .  ^  May 

Maine — \'aa  Buren  Slay 

Massachusetts—  Northfield  .\pril 

Michigai: — Grand   Rapids  May 

Michigan — Saginaw  May 

Minnesota — Duluth  May  20-27 

Missouri — Kansas   Citj'  May  22  29   2 

Missouri — Neosho  March   15   6 

Missouri — St.   Louis  May  22-27   i 

Montana — Butte  May  20-27   i 

Ohio — Ashtabula  May  22-29   ' 

Ohio — Cincinnati  May   14-27   11 

Ohio — Columbus  May  22-29   i 

Tennessee — Nashville  May  22-29   3 

Texas— rFort  Worth  Nlay  1-26. 

Texas — Galveston  May  21-28 

Texas — San  .Nntonio  May   8-29   13 

Utah — State  of  April    1-30   81 

Washington — Spokane  May  8-22   15 

West  Virginia — Wheeling  May  22-29   ■ 

Smallpox — Insular. 

Philippine  Islands — Manila  .\pril    17-24   13 

Smallpox — Foreign. 

Brazil — Fahia  .\pril    16-30   5 

Canada — Halifax  May  15-22   4 

China — .\moy  .'  .Vjiril  17-24  

China — Canton  March    27-.\pril    17..  20 

China — Tientsin  .\pril    17-May    i   8 

Egypt — Cairo  \pril  29-May  6   4 

Great  Britain — Bristol  May  8-15   2 

Great  Britain — Cardiff  \pril  24-May  1  

India — Bombay  .\pril   27-May  4  

India — Calcutta  .\pril  19-24 

India — Madras  .\pril 

India — Rangoon  .\pril 

Japan — Formosa  .\pril 

Java — Batavia  .\pril 

Mexico — Chihuahua  May 

Mexico — Mexico  City  March 

Mexico — Monterey  May  16- 


20 


24-30  

■7-24  

24-May    ■   ■ 

■7-24   4 

9-23   2 

'-.-\pril  17.. 
3  • 

Russia — Moscow  .April  24-May  8   46 

Russia— Odessa  May   1-8   i 

Russia — Riga  May  8-15   2 

Russia — St.    Petersburg  .Vpril 

Siam — Bangkoff  .\pril 

Spain — .Mmeira  .Arril 

Spain — Barcelona  May 

Spain — Valencia  May 

Uruguay — Montevideo  May 

Cholera — Insular. 
-Provinces  \;iril    17-24   17 


Present 


■3' 


1 7-24 . 

1-30  . . 

1-30.  . 
10-17.  • 
1-8.... 
I-3I-  ■• 


93 
3 
2) 


18 

9"? 


Present 
I 

Present 

Epidemic 
4.007 
43a 
■ ' " 
24 
■73 


Philippine  Islands- 


Places.  Date.  Cases.  Deaths. 

Cholera — Foreign. 

India — Bombay  .\pril   27-May  4  

India — Calcutta  .\pril  17-24  

Siam — Bangkok  .April    1-30   i 

Straits  Settlements — Singapore.  . . .  .April  8-24  

Plagu  e — Fo  re  ig  11 . 

-Azores — Fayal  March  1-31  

.Azores — Terceira  .April    1-30   2 

China — .Amoy  April  17-24  

China — Canton  :  .April    3-17   20 

China — Chang  Poo  .April  26  

India  .April    17-24  4.6S1 

India — Bonibay  .April  27-May  4  

India — Calcutta  .April  17-24  

India — Rangoon  .April  17-24  

Japan — I'ormosa  .April   lO-May   i  209 

Japan — Osaka  .April  25-May   i   i  i 

Japan — \  okah.^ma  May   15-18   8  2 

Persia — Bahrein  .May  12   3  2 

Sian. — Bangkok  .April    1-30   3  i 

Straits  Settlements — Singapore ...  .May   18-24   ■ 

Trinidad  May  27   i 

Vene;uiela — Caracas  May  20-June  3   6  3 

Public  Health  and  Marine  Hospital  Service: 

Ofhcial  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
June  9.  igog: 

Bailh.ache,  p.  H..  Surgeon.  Granted  seven  days'  leave  of 
absence  from  June  8.  1909.  under  paragraph  189,  Ser- 
vice Regulations. 

Bre.\dy,  J.  E.,  Acting  .Assistant  Surgeon.  Granted  three 
days'  leave  of  absence  from  June  17.  1909. 

Browne.  R.  W..  .Acting  .Assistant  Surgeon.  Granted  five 
days'  leave  of  absence  from  June  7,  1909,  under  para- 
graph 210,  Service  Regulations. 

Gibson.  R.  H..  Pharmacist.  Granted  eleven  days'  leave  of 
absence  from  June  8,  1909. 

Greg  )RV.  George  .A..  .Acting  .Assistant  Surgeon.  Leave 
granted  May  3.  1909,  for  seven  days  from  May  4.  1909. 
amended  to  read  five  days  from  May  4.  1909. 

Gwyn.  M.  K.,  Passed  .Assistant  Surgeon.  Granted  ten 
days"  leave  of  absence  from  June  11,  1909. 

Hughes,  Ch.\rles  \V.,  .Acting  .Assistant  Surgeon.  Granted 
rifteen  days'  leave  of  absence  from  June  5.  1909. 

Long.  J.  D..  Passed  .Assistant  Surgeon.  Granted  fourteen 
days'  leave  of  absence  from  June  i.  1909. 

Meg.wv.  H..  Pharmacist.  Granted  one  day's  leave  of  ab- 
sence, June  I.  1909.  under  paragraph  191,  Service  Reg- 
ulations. 

OxcF,  B.,  .Acting  .Assistant  Surgeon.  Granted  four  days' 
leave  of  absence  from  May  26,  1909,  under  paragraph 
210.  Service  Regulations. 

RoDM.sx,  J.  C.,  .Acting  .Assistant  Surgeon.  Granted  seven 
days'  leave  of  absence  from  June  S,  1909. 

ScHW  .vRTZ,  Louis.  .Acting  .Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  May  18.  1909,  under  para- 
graph 210,  Service  Regulations. 

ScoTT.  E  B..  Pharmacist.  Granted  six  days"  leave  of  ab- 
sence from  June  14.  1909. 

SiMONSON,  G.  T.,  -Acting  .Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  June  8.  1909. 

Spr.\tt.  R.  D.,  Passed  .Assistant  Surgeon.  Granted  twenty 
days'  leave  ot  absence  from  June  2.  1909. 

Sl.xmherg.  X.  L.  .A.  K..  .Acting  .Assistant  Surgeon.  Granted 
thirt\  days'  leave  of  absence  from  May  27.  1909. 

Stump.  F.  -A.,  Pharmacist.  Leave  granted  May  11,  1909, 
for  thirty  days  from  May  15,  1909,  amended  to  read 
thirty  davs  from  May  27.  1909. 

Thornto-V.  M.  J..  .Acting  .Assistant  Surgeon.  Granted  six 
days'  leave  of  absence  from  May  iS,  1909,  under  para- 
graph 210,  Service  Regulations. 

Tr.\sk.  J.  W.,  Passed  .Assistant  Surgeon.  Granted  two 
days'  leave  of  absence  from  June  8,  1909. 

Tro.xler.  R.  p..  Pharmacist.  Granted  one  day's  leave  of 
absence  in  May.  1909,  under  paragraph  210.  Service 
Regulations. 

W.^LKER.  T.  Dyson,  .Acting  -Assistant  Surgeon.  Granted 

fourteen  days"  leave  of  absence  from  June  2,  1909. 
"V.AN  Xess.  George  L.  Jr.,  Pliarmacist.  Granted  thirty  days* 
leave  of  absence  from  June  10.  1909,  without  pay. 
Board  Convened. 
Board  of  medical  officers  convened  to  meet  at  the  Bureau 
June  14,  1909,  for  the  examination  of  candidates  for  ad- 
mission to  the  Service.  Detail  for  the  board :  Surgeon  L.  L 
Williams,  chairman:  Passed  .Assistant  Surgeon  John  Mc- 
Mullen  :  Passed  .Assistant  Surgeon  .A.  M.  Stimson,  recorder. 


June  ig.  1909.] 


OFFICIAL  NEWS. 


I2gi 


Appointment. 

Dr.  Edward  G.  Whipple,  appointed  an  acting  assistant 
■surgeon  for  duty  at  Malone.  X.  V. 

Resignation. 

Pharmacist  R.  H.  Gibson  resigned,  to  take  effect  June  18. 

iQog. 

Army  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers seriing  in  the  Medical  Corps  of  the  United  States 
Army  for  the  iceek  ending  June  12,  igog: 
Baker.  Charles  L.,  First  Lieutenant,   Medical  Reserve 

Corps.    Relieved  from  duty  at  Fort  Huachuca.  Ariz. ; 

will  proceed  to  the  Presidio  of  San  Francisco,  Cal., 

for  duty. 

Baker,  Frank  C,  Major.  Medical  Corps.  Wlien  relieved 
from  duly  at  Fort  Oglethorpe.  Ga.,  will  proceed  to  Fort 
Moultrie.  S.  C,  for  duty. 

Bastion,  Joseph  E..  First  Lieutenant,  Medical  Reserve 
Corps.  Ordered  to  duty  with  troops  marching  from 
Fort  D.  A.  Russell,  Wyo..  to  Fort  Robinson,  Xeb. 

BiERBOWER,  Henry  C,  First  Lieutenant,  Medical  Reserve 
Corps.  Granted  leave  of  absence  for  tw  o  months,  w  hen 
relieved  from  duty  in  the  Philippines  Division. 

BisPHAM,  William  X..  Major.  Medical  Corps.  Ordered 
from  San  Francisco.  Cal.,  to  Fort  Leavenworth.  Kan., 
for  duty  at  the  U.  S.  Military  Prison. 

Blanchard,  Robert  M.,  Captain,  Medical  Corps.  Ordered 
to  dut}-  with  troops  from  Fort  Sheridan.  111.,  at  Toledo, 
O..  military  tournament.  July  5th  to  loth. 

Brown.  Polk  D..  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  Fort  Clark.  Tex.,  to  march  with  troops  to 
Fort  Sam  Houston.  Te.x. 

■Christie.  Arthur  C,  First  Lieutenant.  Medical  Corps. 
Granted  leave  of  absence  for  one  month,  upon  arrival 
in  the  United  States 

Conzelmanx,  Fred  J.,  First  Lieutenant,  Medical  Reserve 
Corps.  Relieved  from  duty  at  Fort  Williams.  Me. ;  will 
proceed  to  Fort  Casuell,  X.  C,  for  duty. 

D.wis,  Addison  D.,  First  Lieutenant,  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  eight  days. 

Dl'.vb.xr,  Lee  R.,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  ten  days. 

Foster,  George  B.,  Jr..  First  Lieutenant,  Medical  Reserve 
Corps.  Ordered  from  Fort  Totten.  X.  Y..  to  Fort 
Strong,  Mass.,  for  temporary  duty. 

Freeman.  Paul  L..  Captain.  Medical  Corps.  Ordered  from 
Fort  Riley,  Kan.,  to  Fort  Leavenworth.  Kan.,  for  tem- 
porary duty,  about  July  ist. 

Fronk.  Clarence  E..  First  Lieutenant.  Medical  Reserve 
Corps.    Granted  leave  01  absence  for  ten  days. 

•G.\rcia,  Leon  C.  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  fifteen  days. 

•Gilchrist,  Harry  L..  Major.  Medical  Corps.  Granted  leave 
of  absence  for  one  month,  about  June  20th. 

■Goldthw  aite.  Ralph  H.,  First  Lieutenant,  Medical  Reserve 
Corps.   Granted  leave  of  absence  for  ten  days. 

■Griswold,  W.  Church.  First  Lieutenant  Medical  Reserve 
Corps.  Relieved  from  duty  at  Fort  Du  Pont.  Del. ;  will 
proceed  to  Fort  Oglethorpe,  Ga..  for  duty. 

H.AjtTSOCK.  F"rlderick  M.,  Major.  Medical  Corps.  Relieved 
from  further  duty  at  Fort  Meade.  S.  Dak. :  will  pro- 
ceed at  the  expiration  of  his  present  leave  of  absence  to 
Fort  Wa>nie.  Mich.,  for  duty. 

Hasseltine,  Hermon  E..  First  Lieutenant.  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  fourteen  days. 

Hayne.  James  A.,  First  Lieutenant.  Medical  Reserve  Corps, 
Ordered  to  active  duty ;  will  proceed  to  Fort  Assini- 
boine.  Mont.,  for  duty. 

Heath.  George  D.,  Jr..  First  Lieutenant.  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  ten  days. 

Hill.  Eben  C,  First  Lieutenant.  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  six  days. 

Hoff.  John  Van  R..  Colonel.  Medical  Corps.  Grantei 
leave  of  absence  for  seven  days. 

Holmes.  Thomas  G.,  First  Lieutenant.  Medical  Reserve 
Corps.  Relieved  from  duty  in  the  Philippines  Divi- 
sion ;  will  proceed  to  San  Francisco,  Cal..  and  thence  to 
his  home.  Detroit.  Mich.,  for  orders.  • 

Howell,  Park,  Captain.  Medical  Corps.  Relieved  from 
duty  at  the  Army  General  Hospital.  Fort  Bavard,  Xew 
Mex.,  and  ordered  to  Fort  Huachuca,  Ariz.,  for  duty. 


Kearny,  Richard  A.,  First  Lieutenant,  Medical  Reserve 
Corps.  Honorably  discharged  from  the  service  of  the 
United  States,  his  services  being  no  longer  required. 

Kerr,  Rouert  W.,  First  Lieutenant,  Medical  Reserve  Corps. 
Granted  leave  of  absence  for  ten  days. 

L.\  Garde,  Louis  A.,  Lieutenant  Colonel,  Medical  Corps. 
When  relieved  at  Denver,  Colo.,  will  proceed  to  Wash- 
ington, D.  C,  for  temporarj-  duty  at  the  Army  Medical 
School. 

L.vMEiE,  John  S.,  Jr..  First  Lieutenant,  Medical  Corps. 
Granted  leave  of  absence  for  sixteen  days. 

Learv,  Thomas  J.,  First  Lieutenant.  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  ten  days. 

McDiAR.MiD.  XoRMAN  L..  First  Lieutenant,  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  ten  days. 

McPheeters,  Samuel  B..  First  Lieutenant,  Medical  Re- 
serve Corps.  Honorably  discharged  from  the  service  of 
the  United  States,  his  services  being  no  longer  required. 

Mount,  James  R.,  First  Lieutenant,  ^ledical  Reserve -Corps. 
Granted  an  extension  of  ten  days  to  his  leave  of  ab- 
sence. 

Mueller,  Armin,  First  Lieutenant.  Medical  Reserve  Corps. 

Granted  leave  of  absence  for  fourteen  days. 
Murr-\y.  Wilson.  First  Lieutenant,  Medical  Reserve  Corps. 

Ordered  from  Fort  William  Henry  Harrison,  Mont.,  to 

Fort  Yellowstone.  Wyo..  for  temporary  duty. 
Pipes.  Henry  F..  Captain.  Medical  Corps.    Granted  leave 

of  absence  for  one  month. 
Russell,  Frederick  F..  Major.  Medical  Corps.  Granted 

leave  of  absence  for  one  month,  fifteen  days. 
Shields,  William  S.,  First  Lieutenant,  Medical  Reserve 

Corps.    Granted  leave  of  absence  for  ten  days. 
Sl.\ter,   Ernest   F..   First   Lieutenant.    Medical  Reserve 

Corps.    Relieved  from  duty  at  Madison  Barracks,  X. 

Y. ;  will  proceed  to  Fort  Adams,  R.  I.,  for  duty. 
Smith,  William   H..  First  Lieutenant,  Medical  Resen-t 

Corps.    Granted  leave  of  absence  for  fourteen  days. 
Snow,   Corydon    G..    First   Lieutenant,   Medical  Reserve 

Corps.    Granted  leave  of  absence  for  five  days. 
St.xyer,  Morrison  C..  First  Lieutenant,  Medical  Reserve 

Corps.    Granted  leave  of  absence  for  ten  days. 
Suggs,  Fr-^nk.  First  Lieutenant,  Medical  Reserve  Corps. 

Ordered  from  Fort  Xiagara.  X.  Y.,  to  Fort  Strong, 

Mass..  for  temporary  duty. 
Waring.  John  B.  H..  First  Lieutenant,  Medical  Reserve 

Corps.    Granted  leave  of  absence  for  seven  days. 

Navy  Intelligence : 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serving  in  the  Medical  Corps  of  the  United  States 
Xavy  for  the  z^'eek  ending  June  12,  igog: 
Bass,  J.  A.,  Acting  Assistant  Surgeon.    Ordered  to  duty 
at  the  Xaval  Hospital.  X'aval  Heme,  Philadelphia,  Pa. 
Bell.  W.  H..  Surgeon.    Detached  from  the  Xaval  Medical 
School.  Washington,  D.  C.  and  ordered  to  the  Bureau 
of  Medicine  and  Surgery.  X"avv  Department,  Washing- 
ton. D.  C. 

Blackwood,  X'.  J..  Surgeon.  Detached  from  the  Xaval 
Medical  School.  Washington.  D.  C,  and  ordered  to  the 
Xavy  Yard.  Washington,  D.  C. 

Brooks,  F.  H.,  Assistant  Surgeon.  Detached  from  the 
Xaval  Medical  School.  Washington,  D.  C,  ordered  to 
examination  for  promotion,  and  then  to  await  orders. 

Brown.  E.  W..  Assistant  Surgeon.  Detached  from  the 
Xaval  Medical  School.  Washington,  D.  C.  and  ordered 
to  the  Vermont. 

Cecil,  A.  B.,  Acting  Assistant  Surgeon.  Ordered  to  duty 
at  the  Xaval  Hospital.  Xew  York,  X.  Y. 

CoHN.  L  F.,  Assistant  Surgeon.  Detached  from  the  Xaval 
Medical  School.  Washington.  D.  C.  ordered  to  examin- 
ation for  promotion,  and  then  to  await  orders. 

CuTHBERTSON,  R.,  Assistant  Surgeon.  Detached  from  dutj- 
at  the  Xaval  Hospital,  Mare  Island,  Cal.,  and  ordered 
to  the  West  Virginia. 

DeValin.  C.  M.,  Surgeon.  Detached  from  the  Navy  Yard, 
\\'ashington,  D.  C.  and  ordered  to  the  Marine  Recruit- 
ing Station,  Philadelphia,  Pa. 

EvTiNGE.  E.  O.  J..  Assistant  Surgeon.  Detached  from  the 
Xaval  Medical  School.  Washington,  D.  C,  ordered  to 
examination  for  promotion,  and  then  to  await  orders. 

FosTF.R.  T.  G..  Assistant  Surgeon.  Detached  from  Xaval 
Medical  School.  Washington.  D.  C.  and  ordered  to 
duty  at  the  Xaval  Prison.  Portsmouth,  X.  H. 


1292 


BIRTHS,  MARRIAGES,  AND  DEATHS. 


[New  York 
Medical  Journal 


Jenkins,  H.  E.,  Acting  Assistant  Surgeon.  Ordered  to 
duty  at  the  Naval  Hospital,  Norfolk,  Va. 

Kennedy,  R.  M.,  Surgeon.  Detached  from  'the  Naval  Med- 
ical School,  Washington,  D.  C.,  ordered  home,  and 
granted  leave  for  one  month. 

Ledbetter,  R.  E.,  Surgeon.  Detached  from  the  Naval  Med- 
ical School,  Washington,  D.  C,  and  ordered  to  the 
Naval  Academy,  Annapolis,  Md. 

MoRAN,  C.  L.,  Assistant  Surgeon.  Detached  from  the  Navy 
Yard,  Boston,  Mass.,  and  ordered  to  the  Georgia. 

Monger,  C.  B.,  Assistant  Surgeon.  Detached  from  the 
Naval  Medical  School,  Washington,  D.  C,  ordered  to 
examination  for  promotion,  and  '■.hen  to  await  orders. 

Murphy.  J.  F.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Medical  School,  Washington,  D.  C,  and  or- 
dered home  to  await  orders. 

Olson,  G.  M.,  Assistant  Surgeon.  Detached  from  the  Na- 
val Medical  School,  Washington,  D.  C,  ordered  to  ex- 
amination for  promotion,  and  then  to  await  orders. 

Orvis,  R.  T.,  Surgeon.  Detached  from  the  Naval  Medical 
School,  Washington,  D.  C,  and  ordered  to  duty  at  the 
Naval  Hospital,  Navy  Yard,  New  York,  N.  Y. 

Peck,  A.  E.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Medical  School,  Washington,  D.  C,  ordered 
to  examination  for  promotion,  and  then  to  await  or- 
ders. 

Raison,  T.  W.,  Assistant  Surgeon.  Detached  from  duty 
on  board  the  West  Virginia,  and  ordered  to  the  Naval 
Hospital,  Mare  Island,  Cal. 

Reed,  E.  U.,  Assistant  Surgeon.  Detached  from  the  Naval 
Medical  School,  Washington,  D.  C,  ordered  to  exam- 
ination for  promotion,  and  then  to  await  orders. 

Riddick,  W.  J.,  Acting  Assistant  Surgeon.  Ordered  to  the 
Navy  Yard,  Charleston,  S.  C. 

Robnett,  a.  H.,  Assistant  Surgeon.  Detached  from  the 
Naval  Medical  School,  Washington,  D.  C,  ordered  to 
examination  for  promotion,  and  then  to  await  orders. 

Rodman,  S.  S.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Medical  School,  Washington,  D.  C,  ordered 
to  examination  for  promotion,  ,and  then  to  'await 
orders. 

Smith,  C.  G.,  Passed  Assistant  Surgeon.  Detached  from 
the  Naval  Medical  School,  Washington,  D.  C.,  and  or- 
dered to  duty  at  the  Naval  Hospital,  Norfolk,  Va. ; 
orders  of  June  4th, .  to  duty  at  the  Naval  Hospital, 
Norfolk,  Va.,  revoked ;  detached  from  the  Naval  Medi- 
cal School,  Washington,  D.  C,  ordered  to  examina- 
tion for  promotion,  and  then  to  await  orders. 

Smith,  F.  W^,  Assistant  Surgeon.  Detached  from  the 
Wisconsin  and  resignation  accepted,  to  take  effect  June 
15,  1909. 

Strite,  C.  E.,  Assistant  Surgeon.  Detached  from  the  Na- 
val Medical  School,  Washington,  D.  C.,  and  ordered 
to  Naval  Recruiting  Station,  Baltimore,  Md. 

Traynor,  J.  P.,  Passed  Assistant  Surgeon.  Detached  from 
the  Georgia  and  ordered  to  the  Navy  Yard,  Boston, 
Mass. 

Trotter,  C.  E.,  Acting  Assistant  Surgeon.  Ordered  to  duty 
at  the  Naval  Hospital,  Portsmouth,  N.  H. 

WALTOiV,  D.  C,  Acting  Assistant  Surgeon.  Ordered  to 
duty  at  the  Naval  Hospital,  Norfolk,  Va. 

Wheeler,  L.  H.,  Passed  Assistant  Surgeon.  Detached 
from  the  Naval  Medical  School,  Washington,  D.  C., 
and  ordered  to  the  Hancock. 

Whit.more,  G.  B.,  Assistant  Surgeon.  Detached  from  the 
Naval  Recruiting  Station,  Baltimore,  Md.,  and  ordered 
to  the  Wisconsin. 

Woods,  E.  L.,  Assistant  Surgeon.  Detached  from  the  Na- 
val Medical  School,  Washington,  D.  C.,  ordered  to  ex- 
amination for  promotion,  and  then  to  await  orders. 

 <^  

Sirt^s,  Slarriagts,  snir  ^ti\\i. 


Born. 

Mi'NDORFF. — In  New  York,  on  Saturday,  June  12th,  to 
Dr.  George  T.  Mundorff  and  Mrs.  Mundorff,  a  son. 
Married. 

Bach  MANN — Bushong. — In  Philadelphia,  on  Friday. 
June  4th,  Dr.  George  Bachmann  and  Miss  Bertha  Bushong. 


Bosley — Danielson.— In  Seattle,  Washington,  on  Wed- 
nesday, May  26th,  Dr.  Captain  John  R.  Bosle\',  assistant 
surgeon  in  the  United  States  Army,  and  Miss  Gerda  Dan- 
ielson. 

Center — Pecinozsky. — In  Preston,  Iowa,  on  Tuesday, 
June  I  St,  Dr.  C.  D.  Center,  of  Quincy,  Illinois,  and  Miss 
Louisa  Pecinozsky. 

Eastmond — DoRLAND. — Ij)  Arlington,  New  Jersey,  on 
Wednesday,  June  i6th,.  Dr.  Charles  Eastmond,  of  Brook- 
lyn, and  Miss  Bonnie  Belle  Dorland. 

Harris — .'\ustin. — In  Philadelphia,  on  Wednesday, 
Jime  9th,  Dr.  Henry  F.  Harris,  of  Atlanta,  Georgia,  and 
Mrs.  Ada  E.  Austm. 

Howerton — Linton. — In  Langhorne,  Pennsylvania,  on 
Thursday,  June  3d,  Dr.  Thomas  Jefferson  Howerton,  and 
Miss  Margaret  Theresa  Linton. 

JoPSON — AIiCHENER. — In  Philadelphia,  on  Monday,  June 
7th,  Dr.  John  H.  Jopson  and  Aliss  Susanna  B.  Michener. 

McCoRMicK — King. — In  Philadelphia,  on  Tuesday,  June 
8th,  Dr.  John  A.  McCormick  and  Miss  Mary  Elizabeth 
King. 

Old — Smith. — In  Pittsburgh,  Pennsylvania,  on  Wednes- 
day, June  2nd,  Passed  Assistant  Surgeon  Edward  H.  H. 
Old,  United  States  Navy,  and  Miss  Anne  Eugenia  Smith. 

Seruglio — Whitelev. — In  Genoa,  Italy,  on  Wednesday, 
May  26th,  Dr.  Aldo  Seruglio  and  Miss  Pauline  Howard 
Whiteley. 

Steel — Spierlixg. — In  Philadelphia,  on  Thursday,  June 
3d,  Dr.  William  A.  Steel,  of  Tioga,  and  Miss  Frieda  Spier- 
ling. 

Strecker — Carroll. — In  Phila'delphia,  on  Tuesday,  June 
1st,  Dr.  Henry  Strecker  and  Miss  Nellie  Marie  Carroll. 

Trant— Martin. — In  Washington,  D.  C,  on  Wednes- 
day, June  2nd,  Dr.  James  G.  Trant,  of  Richmond,'  Vir- 
ginia, and  Miss  Nannie  L.  ]\Iartin. 

Webb — Hewes. — In  Philadelphia,  on  Friday,  June  4th, 
Dr.  Walter  Webb  and  Miss  Mary  F.  Hewes. 

White — Foltz. — In  Pasadena,  California,  on  Wednes- 
day, June  2nd,  Dr.  Laertes  T.  White,  of  Los  Angeles,  and 
Miss  Lulu  B.  Foltz. 

Died. 

Blakeslee. — In  Coatesville,  Pennsylvania,  on  Thursday, 
June  3d,  Dr.  William  R.  Blakeslee,  aged  eighty-six  years. 

De  Varona. — In  Forest  Hill,  New  York,  on  Saturday, 
May  29th,  Dr.  Joseph  L.  De  Varona,  of  Brooklyn,  aged 
twenty-seven  years. 

Gage. — In  Winthrop,  Massachusetts,  on  Monday,  May 
31st,  Dr.  Edward  F.  Gage,  aged  forty-six  years. 

Inglis. — In  Denver.  Colorado,  on  Saturday,  June  5th, 
Dr.  George  Inglis,  of  Claysville,  Pennsylvania,  aged  seven- 
ty-eight years. 

LuKEN. — In  Chicago,  on  Saturday,  June  5th,.  Dr.  L^artin 
H.  Luken,  aged  fifty-nine  years. 

MoNLEZUN. — In  New  Orleans,  Louisiana,  on  Friday, 
June  4th,  Dr.  John  Monlezun.  aged  thirty-six  years. 

Outhet. — In  San  Mateo,  California,  Dr.  John  C.  Outhet, 
aged  thirty-four  years. 

Pe.\rson. — In  Meridian,  Mississippi,  on  Monday,  May 
31st,  Dr.  W.  E.  Pearson,  of  Scooba.  aged  seventy-three 
years. 

Rl'ssell. — In  Ipswich,  Massachusetts,  on  Monday,  June 
7th,  Dr.  William  H.  Russell,  aged  forty-nine  years. 

Schayot. — In  New  Orleans.  Louisiana,  on  Saturday, 
I\Iay  29th,  Dr.  Vallery  O.  Schayot,  of  Pointe  a  la  Hache, 
aged  forty  years. 

Spiegelh ALTER. — III  St.  Louis,  Missouri,  on  Monday, 
June  "th.  Dr.  Joseph  Spiegelhalter,  aged  seventy-five  years. 

Trowbridge. — In  Watertown,  New  York,  on  Wednesday, 
June  9th,  Dr.  E.  W.  Trowbridge,  aged  sixty  years. 

Tuthill. — In  Poughkeepsie,  New  York,  on  Wednesday, 
June  gth.  Dr.  Robert  K.  Tuthill,  aged  seventy-four  years. 

Von  Boeckh. — In  Atlanta,  Georgia,  on  Wednesday, 
June  2nd,  Dr.  Ernest  von  Boeckh. 

Watts. — In  Sacramento.  California,  on  Tuesday,  June 
1st,  Dr.  Pliny  R.  Watts,  aged  forty-five  years. 

Weber. — In  Reading,  Pennsylvania,  on  Thursday,  June 
3d,  Dr.  Raymond"  K.  Weber,  aged  twenty-six  years. 

White. — In  Montpelier,  Indiana,  on  Wednesday,  June 
2nd,  Dr.  R,  B.  White,  aged  seventy-eight  years. 


New  York  Medical  Journal 

INCORPORATING  THE 

Philadelphia  Medical  Journal  The  Medical  News 


A  Weekly  Review  of  Medicine,  Established  184J. 


Vol.  LXXXIX,  No.  26.  NEW  YORK,  JUNE  26,  1909.  Whole  Xo.  1595. 


(Original  Communitaiions. 


THE  CLINICAL  HISTORY  OF  SOME  CASES  OF 
SO  CALLED  CARDIAC  EPILEPSY.* 

By  Rich.\kd  Cole  Newton,  M.  D., 
Alontciair,  N.  J. 

My  excuse  for  bringing  these  cases  into  notice 
is  that  they  are  not  without  some  inherent  interest, 
and  their  discussion  may  perhaps  throw  some  hght 
upon  an  obscure  subject. 

C.\SE  I. — F.  B.,  aged  forty-five,  single,  American,  clerk. 
Family  history  negative,  except  that  he  was  the  only  child 
of  a  family  of  nine  who  lived  to  reach  matr.iity.  He  had 
been  a  free  drinker  for  years.  At  about  thirty-eight  years 
of  age,  he  had  contracted  a  chancre,  followed  by  nonsup- 
purating  buboes,  a  large  cervical  abscess,  and  osteocopic 
pains.  There  was  no  history  of  any  cutaneous  lesions. 
When  I  first  saw  him.  he  was  afflicted  with  divergent 
squint  of  the  left  eye,  and  ptosis  of  that  eyelid. 

He  had  suffered  for  two  or  three  years  from  occasional 
attacks  of  angina  pectoris,  which  could  generally  be  traced 
to  the  excitement  accompanying  coitus,  or  some  meotal  or 
nervous'  disturbance.  He  had  a  loud  blowing  double  heart 
murmur  and  considerable  cardiac  hypertrophy.  He  was 
pale  and  somewhat  anaemic,  but  not  emaciated.  Shortly 
after  coming  under  observation,  I  saw  him  in  a  typical 
attack  of  angina  pectoris,  which  was  not  relieved  by  mor- 
phine hypodermically,  but  quickly  yielded  to  inhalations  of 
arnyl  nitrite. 

Five  months  afterwards,  the  patient  had  two  severe  epi- 
leptic convulsions  about  a  half  hour  apart.  After  the  first 
one,  the  heart  stopped  beating,  the  respirations  were  also 
suspended,  the  extremities  were  cold,  the  skin  was  covered 
with  a  clammy  perspiration,  and  to  all  appearance  the  man 
was  dead.  Inhalations  of  amyl  nitrite,  heat  to  the  extrem- 
ities, and  vigorous  rubbing  were  followed  after  a  time,  by 
gasping  and  shallow  respirations.  The  heart  beats  started 
with  a  jerk  and  then  became  regular.  Instead,  however,  of 
regaining  consciousness,  the  patient  passed  into  a  second, 
well  marked  epileptic  convulsion  (grand  mal),  with  the 
customary  tonic  and  clonic  spasms,  after  which,  he  slowly 
came  to  himself ;  still  it  was  a  considerable  time  before  he 
could  be  made  to  realize  where  he  was  and  recognize  those 
about  him. 

His  urine  was  alkaline  and  offensive,  and  boiling  and 
acidulation  showed  that  about  one  third  of  its  volume  was 
albumin.  The  microscope  showed  oxalates,  triple  phos- 
phates, amorphous  urates  with  a  few  granular  and  small 
hyaline  casts.  The  heart's  action  remained  weak  and  irreg- 
ular. The  diet  was  carefully  regulated,  bromide  and 
chloral,  alternating  with  Dover's  powders,  were  given  for 
the  extreme  nervousness  and  for  the  night  terrors,  which 
added  to  the  patient's  misery.  Several  mild  attacks  of 
angina  supervened,  but  were  easily  cut  short  by  inhalations 
of  amyl  nitrite.  Infusion  digitalis  was  also  given  up  to 
the  point  of  tQlerance  by  the  very  sensitive  stomach  and 
bowels.  Daily  inunctions  of  mercurial  ointment  were  ad- 
ministered and  potassium  iodide  was  exhibited  in  as  large 
doses  as  the  patient  could  bear.  Applications  of  galvanic 
electricity  were  tried,  but  affected  the  patient  very  unpleas- 
antly, and  were  discontinued.    After  the  third  seance,  the 

•Read  before  the  Section  in  Neurology  and  Psychiatry  of  the 
New  York  Academy  of  Medicine,  February  8.  loog. 


patient  ran  out  of  nis  private  room  on  the  second  floor  of 
the  hospital  downstairs  into  a  ward,  and  spent  the  night 
there.  On  waking  up  in  the  morning,  he  was  greatly 
astonished  at  his  changed  surroundings,  and  seized  his 
clothes  and  hastened  back  to  his  room  with  very  little 
ceremony. 

His  general  condition  had  improved  considerably  under 
treatment,  and  in  the  course  of  another  week,  he  was 
decidedly  better.  His  intellect  was  unclouded  now,  and 
the  doubts  and  suspicions  which  had  troubled  him  seemed 
to  have  passed  away.  His  principal  complaint  was  of 
neuralgic  pains  in  the  right  arm  and  leg.  The  muscles  of 
these  extremities  were  weaker,  and  their  surface  was  less 
sensitive  to  the  sesthesiometer  than  were  the  corresponding 
parts  of  the  left  limbs.  As  the  ptosis  and  squint  were  on 
the  left  side,  he  apparently  had  a  mild  case  of  alternate 
hemiplegia. 

About  six  weeks  after  the  two  epileptiform  seizures, 
already  spoken  of,  which  seem  to  have  been  the  only  grand 
mal  convulsions  the  man  ever  had,  he  had  a  distinct  mani- 
festation of  epilepsia  procursiva.  In  a  dazed  condition, 
muttering  incoherently,  he  walked  with  great  rapidity  out 
of  the  hospital  and  proceeded  two  or  three  hundred  yards 
before  he  came  to  himself  and  stopped.  He  was  aston- 
ished and  dazed,  but  suffered  himself  to  be  led  back  to  his 
room.  He  had  no  recollection  afterward  of  what  he  had 
done.  After  this  patient  had  learned  to  live  mostly  upon 
milk,  his  health  improved  so  much  that  he  was  able  to 
work  part  of  the  time,  and  to  oversee  the  work  of  others. 
He  was  still  subject  to  "queer  spells"  when  "he  did  not 
know  what  was  the  matter  with  him." 

In  about  fifteen  months  after  the  time  I  had  first  seen 
h\m.  he  died  suddenly.  The  autopsy  revealed  great  hyper- 
trophy and  some  dilation  of  the  heart,  which  weighed 
twenty-eight  ounces.  The  aortic  valves  were  incompetent 
and  were  thickened  and  altered  in  shape  by  an  extensive 
atheroma.  The  muscular  structure  of  the  heart  walls 
•■'^howed  light  colored  strije,  signifying  a  probable  former 
myocarditis."  There  were  calcareous  deposits  on  the 
walls  of  the  aorta,  which  was  dilated.  The  pleural  cavities 
showed  some  old  adhesions.  The  liver  was  enlarged  and 
congested  and  showed  signs  of  old  hepatitis." 

C.\SE  II.— M.  C. :  female :  aged  seventy-three.  Chronic 
nephritis.  Heart  dilated,  rather  weak  and  action,  at  times, 
quite  irregular.  A  mitral  regurgitant  murmur  was  gener- 
ally audible.  This  patient  had  "been  subject  to  "fainting 
spells"  all  her  life,  and  was  always  timid  at  night,  and 
somewhat  inclined  to  hysteria.  Any  suspicion  of  specific 
or  alcoholic  taint  was  quite  out  of  the  question  nor  did 
the  patient  ever  indulge  unduly  in  food,  tea.  or  coffee. 

About  two  years  before  her  death,  she  began  to  suffer 
from  nocturnal  nervous  seizures,  which  generallv  came  on 
between  3  and  4  a.  m..  while  she  was  sound  asleep.  The 
first  thing  noticeable  was  her  loud  stertorous  breathing, 
which  could  be  heard  in  the  next  room,  where  her  ci^ter 
slept.  When  the  latter,  who  had  been  awakened  by  these 
sounds,  had  reached  the  patient's  bedside,  she  would 
bo  round  lying  with  her  eves  open,  fixed  and  glassy,  froth- 
ing at  the  hps.  face  pallid,  hands  usuallv  clenched:  there 
was  more  or  less  clonic  snasm  chieflv  of  the  musc!e<:  of 
the  face  and  left  arm.  She  would  remain  unconscious  for 
about  two  hours  and  had  no  recollection  afterward  of 
what  had  tran.spired.  On  two  or  three  occasions,  the 
patient  was  sittme  when  the  seizures  occurred.  Twice  she 
was  using  the  commode,  as  her  neohritis  caused  her  to  get 

'You  may  recall  that  Gowers  5ays  that  two  observers,  Brera  and 
J^atham.  hold  that  angina  pectoris  may  be  simply  a  disorder  of  the 
liver  and  nothing  more. 


Copyright,  1909,  by  A.  R.  Elliott  Publishing  Company. 


1294 


NEWTON:   SO   CALLED  CARDIAC  EPILEPSY. 


[New  York 
Medical  Journal. 


Up  frequently  at  night  to  micturate.  She  fell  violently  to 
the  floor  biting  her  tongue  and  bruising  herself  severely. 
Once  she  was  sitting  in  a  chair  dressing  herself  and 
stooped  down  to  reacli  for  a  shoe  or  a  stocking  when  the 
fit  seized  her.  After  these  attacks  she  would  be  troubled 
by  cramps  and  ataxia,  and  some  clouding  of  the  intellect 
for  forty-eight  hours. 

There  were  eight  of  these  epileptic  seizures  in  all.  None 
of  them  occurred  during  the  last  year  of  her  life,  but  at- 
tacks of  syncope  were  frequent,  and  toward  the  last,  several 
attacks  of  pronounced  angina  pectoris  supervened. 

Dr.  Theodore  C.  Janeway  saw  the  patient  with  me  and 
found  that  the  blood  revealed  a  condition  of  pernicious 
anaemia.  The  angina,  fortunately,  was  readily  controlled 
by  morphine.  The  patient  died  in  a  state  of  semispasm. 
There  was  no  autopsy. 

Case  III. — Large  fleshy  woman;  married;  no  children; 
died  in  an  attack  of  angina  pectoris  at  sixty  years  of  age 
with  the  following  history.  This  was  only  the  third  attack 
she  had  suffered  and  was  very  severe.  It  lasted  probably 
about  two  hours  and  was  accompanied  by  a  profuse  perspi- 
ration, said  to  have  been  mixed  with  blood.  This  woman 
had  been  apparently  in  perfect  health  up  to  fifty-five  years 
of  age  when  she  had  suffered  an  apoplectic  stroke  fol- 
lowed by  hemiplegia ;  which  she  had  partially  recovered 
from.  Epileptiform  attacks  succeeded  the  apoplexy  in 
about  a  year.  There  was  no  second  stroke.  The  epileptic 
seizures  were  sometimes  only  short  lapses  of  consciousness, 
generally  coming  on  while  the  patient  was  seated  in  her 
chair.  She  was  not  known  to  have  fallen.  She  frothed  at 
the  mouth.  These  fits  became  more  frequent,  but  of 
milder  nature,  as  time  went  on.  The  memory  began  to 
fail,  and  at  last  was  nearly  gone.  The  lady  was  a  patient 
of  the  late  Dr.  Arthur  Ward,  of  Newark.  She  had  always 
been  and  continued  to  the  last  to  be  a  voracious  eater  of 
the  best  the  market  afforded. 

Case  IV.— I  was  called  suddenly  the  other  morning  to 
a  woman  aged  seventy-six,  who  had  awakened  her  friend 
in  an  adjoining  room  by  her  stertorous  breathing.  It  was  im- 
possible to  arouse  her  to  consciousness.  Her  face  was 
drawn  to  one  side.  Pulse  slow  and  full.  The  heart  was 
enlarged  and  somewhat  irregular  with  a  loud  blowing  sys- 
tolic murmur.  A  copious  involuntary  discharge  of  urine 
had  occurred.  In  about  two  hours  consciousness  was  com- 
pletely restored.  She  had  eaten  heartily  the  night  before, 
cucumbers  having  been  one  of  the  viands  in  which  she 
had  indulged.  She  had  only  had  one  similar  attack  in  her 
life  which  had  happened  some  months  before,  after  eating 
a  Welsh  rabbid,  and  had  closely  resembled  the  present 
seizure,  except  that  the  comatose  state  had  lasted  forty- 
eight  hours.  There  was  no  permanent  paralysis  after 
either  of  these  attacks.  The  patient  was  advised  to  give 
up  the  use  of  coffee,  of  which  she  was  excessively  fond, 
and  was  forbidden  to  eat  heartily  after  one  o'clock  p.  m. 

A  compliance  with  these  suggestions,  albeit  only  partial, 
seems  to  have  benefited  the  patient  who  has  had  no  similar 
troubles  since.' 

Case  V. — This  was  a  case  of  Stokes-Adams  syndrome 
under  the  care  of  Dr.  J.  Boyd  Risk,  of  Summit,  which  I 
saw  once.  At  the  beginning  of  the  last  illness  the  respira- 
tions were  at  times  more  rapid  than  the  pulse,  which  was 
usually  under  40  to  the  minute,  sinking  sometimes  to  22, 
for  several  days  it  averaged  about  34  beats  to  the  minute, 
while  the  respirations  were  quite  variable  in  rhvthm  and 
intensity,  rising  to  40  occasionally,  and  again  sinking  to  22. 
As  the  disease  progressed  the  respirations  became  more 
irregular,  often  ceasing  for  fifteen  seconds  or  more  in  a 
minute.  They  would  then  recommence  with  panting  or 
sighing,  gradually  lessening  in  force  and  in  rhythm  until 
they  again  ceased.  (Cheyne-Stokes  respiration).  There 
were  frequently  in  a  day  a  dozen  attacks  of  syncope  which 
came  on  apparently  without  warning,  were  characterized 
by  great  pallor  and  almost  complete  suspension  of  pulse 
and  respiration.  The  patient  would  fall  back,  if  sitting  up, 
and  would,  if  Iving-  in  bed,  sink  down  upon  his  pillow  in 
a  faint.    He  had  no  recollection  afterward  of  these  attacks. 

'Since  this  paper  was  written  this  patient  has  had  another  attack 
similar  to  the  one  described.  She  had  tonic,  followed  by  clonic 
spasms  and  accompanied  by  frothing  at  the  mouth.  She  did  not 
seem  to  have  bitten  her  tongue.  She  did  not  fall  as  she  was  sitting 
in  a  chair  when  the  attack  came  on.  She  was  unconscious  for  two 
or  three  hours.  She  had  eaten  heartily  of  salt  cod  fish  cakes  and  taken 
two  cups  of  cofTcc  at  breakfast  the  morning  before,  her  usual 
allowance  of  \h\^  beverage  being  only  one  cup  daily  at  breakfast, 
and  that  was  against  my  orders. 


He  twitched  and  trembled  a  great  deal,  and  his  mind 
wandered  markedly,  at  times.  He  had  hallucinations  and 
was  subject  to  fits  of  terror;  although  none  of  his  seizures 
seemed  to  be  distinctly  epileptoid  in  character,  nor  did  he 
suffer  from  typical  angina  pectoris.  His  most  troublesome 
symptom  was  dyspnoea  ("air  hunger"),  which  annoyed 
him  for  the  three  months  of  his  illness.  The  illness  began, 
however,  with  these  syncopal  attacks  which  persisted  until 
he  died. 

Although  the  radial  and  temporal  arteries  showed  much 
hardening  from  atheroma,  and  the  heart  beats  were  weak 
and  irregular,  no  cardiac  murmur  was  distinguishable 
when  I  saw  him  :  nor  did  Dr.  Risk  recollect  that  he  ever 
discovered  one.  The  weakness  of  the  cardiac  impulse  was 
such,  however,  as  to  leave  no  doubt  in  my  mind  of  degen- 
eration of  the  myocardium. 

Toward  the  last,  the  respiration  slowed  down  and  the 
pulse  rate  increased,  while  its  force  diminished.  There 
was  no  evidence  of  nephritis.  The  patient  died  after  a 
great  deal  of  suffering  three  months  subsequent  to  his  first 
attack  of  syncope.  There  was  no  post  mortem  examina- 
tion. 

I  have  selected  these  five  cases  (four  of  which 
I  saw  and  examined  carefully)  as  illustratin,g;  dif- 
ferent phases  of  what  have  been  called  cardiac  neu- 
roses, or  cardiac  epilepsy.  Both  terms  are  perhaps, 
unfortunate,  but  they  seem  to  be  the  best  now 
available,  and  refer  to  certain  definite,  albeit  often 
inexplicable  phenomena. 

In  Case  I,  we  find    distinct  spasms  of  angina 
pectoris  which  were  abundantly  explained  by  the 
autopsy  findings.    The  night  terrors  and  the  epi- 
leptic seizures  are  not  so  easy  to  explain.    As  there 
was  no  post  mortem  examination  of  the  brain,  the 
opportunity  was  lost  of  ascertaining  whether  there 
was  any  change  in  the  cerebral  structures  which 
might   account   for   these    seizures,    and  for  the 
slight  paralyses.     If  we  accept  Trousseau's  view 
that  angina  pectoris  may  be  a  form  of  epilepsy,  we 
may  say  that  the  different  nervous  seizures  in  this 
case  were  all  due  to  one  cause,  and  that  the  ather- 
oma and  myocarditis  were  sufficient  to  explain  all 
the  symptoms.    Professor  Gairdner  and  Professor 
Roberts  Bartholow  seemed  to  share  Trousseau's 
views  in  regard  to  the  setiological  identity  of  an- 
ginal and  epileptic  seizures.    Bartholow  says,  "it 
(angina)  is,  as  Trousseau  first  pointed  out,  some- 
times  a   masked    epilepsy,   and   angina  pectoris 
may  alternate    with    epileptic   attacks."     This  it 
certainly  seemed  to  do  in  the  case   under  dis- 
cussion.    In  Cases  II  and  III,  the  angina  suc- 
ceeded  the   epileptic   attacks,   and   there   can  be 
little  doubt  that  they  both  may  have  been  due 
to  the  same  cause.    In  Case  IV,  it  seems  quite 
likely   that   angina   may   supervene  later,   and  1 
shall  be  greatly  interested  in  watching  the  further 
progress  of  the  case.    Case  V,  perhaps,  we  ought 
not  to  call  epileptoid  at  all ;  yet,  Babcock  tells  us 
that  Tripier  held  that  Stokes-Adams  disease  was  a 
genuine  epilepsy,  "a  view  to  which  some  features 
of  the  attacks  in  certain  cases  appear  to  lend  sup- 
port."   Whereas  Barker  says,  that  Stokes-.Adams 
disease  is  regarded  by  some  as  angina  pectoris, 
without  the  angina,  while  it  is  believed  by  many 
to  be  due  to  disturbance  of  the  centres  in  the  me- 
dulla oblongata,  most  often  the  result  of  sclerosis 
of  the  cerebral   arteries.     In   this   view.  Satter- 
thwaite  appears  to  share,  as  he  says  that  "the 
Cheyne-Stokes  or  Adams-Stokes  signs  are  signifi- 
cant of  cerebral  implication,  and  though  thev  may 
disappear  in  rare  cases,  point  to  eventual  danger 


June  26,  1909.] 


FISCHER:   TOXJEMIC  MYOCARDITIS  I.\  CHII.DRHX. 


1^95 


from  cerebral  disease."  On  the  other  hand,  Eab- 
cock  points  out  that  "fatal  cases  of  this  disease 
have  been  observed  in  which  searching  post  mor- 
tem investigation  has  failed  to  reveal  any  lesion  capa- 
ble of  causing  the  symptoms,  and  indeed  any  recog- 
nizable changes  that  could  be  held  responsible  for 
the  death  of  the  patients.""  Still,  inasmuch  as  Stokes 
himself  and  the  early  writers  considered  the  at- 
tacks due  to  degeneration  of  the  heart  itself,  and 
this  is  probably  still  the  generally  accepted  view  of 
their  aetiology,  I  have  ventured  to  introduce  an  ex- 
ample of  the  disease  into  this  paper.  That  in  some 
cases  at  least,  the  syndrome  may  have  depended 
partly  upon  impaired  nr  enfeebled  cardiac  action, 
seems  evident  from  a  remark  of  Babcock's,  who 
says  that  one  of  Stokes's  men  "was  able  to  miti- 
gate or  arrest  an  impending  attack,  by  supporting 
himself  on  his  hands  and  knees  and  allowing  his 
head  to  hang  low,  the  position  favoring  improved 
cerebral  circulation.'"  Perhaps  we  should  say  that 
in  regard  to  none  of  the  conditions  and  symptoms 
mentioned,  is  it  proper  to  be  dogmatic.  A  long 
discussion  of  angina  pectoris,  or  cardiac  epilepsy, 
will  lead  us  too  far  afield,  and  will  probably  be 
anything  but  conclusive.  It  is  certain,  moreover, 
that  in  many  cases  it  is  impossible  to  state  positively 
whether  the  symptoms  are  due  to  a  "true"  or  a 
"false"  angina.  Huchard  believed  that  nicotine 
poisoning  is  capable  of  producing  a  fatal  form  of 
angina,  while,  as  stated  before.  Trousseau  and 
others  believe  that  angina  is  really  a  form  of 
epilepsy. 

Systemic  writers  are  prone  to  fall  into  self  con- 
tradiction and  "confusion  from  their  desire  to  label 
everything  exactly,  and  sometimes,  I  regret  to 
state,  from  their  evident  desire  to  make  the  phe- 
nomena fit  their  theories.  Babcock  says  that  car- 
diac epilepsy  is  a  term  which  has  been  employed 
to  designate  attacks  of  prsecardial  pain,  accom- 
panied by  loss  of  consciousness  and  succeeded  by 
twitchings  of  the  muscles  of  the  face,  which  is  pre- 
cisely what  may  occur  in  cases  of  Stokes-Adams 
syndrome,  which  some  of  the  best  authorities  assert 
is  not  due  to  cardiac,  but  to  cerebral  lesions. 

Only  one  of  the  cases  cited  was  remarkable  for 
its  persistent  slow  pulse.  Bradycardia,  again,  is  a 
symptom  which  leads  us  onto  disputed  ground. 
Balfour  says,  Xapoleon  was  an  epileptic  "like 
many,  if  not  most,  of  the  sufferers  from  brady- 
cardia" ;  and  then  points  out  that  Adams,  Richard 
Quain,  and  Stokes  (certainly  a  famous  trio)  en- 
deavored to  connect  sequentially,  a  slow  heart  with 
fatty  degeneration  of  the  myocardium.  "Indeed." 
he  continues,  "the  sole  survivor  of  these  three,  still 
quotes  slowness  of  the  pulse  as  a  symptom  of  this 
af¥ection.  acknowledging  at  the  same  time  that 
quickening  of  the  pulse  increasing  with  age,  may 
also  be  an  important  indication  of  the  same  path- 
ological condition."  I  will  not  load  down  this  paper 
with  further  quotations.  Certainly,  however,  we 
find  both  in  the  literature  and  in  medical  teaching, 
so  many  diverse  opinions  in  regard  to  the  signifi- 
cance of  the  symptoms,  that  we  are  considering  that 
any  one  may  well  hesitate  about  accepting  the  ex- 
planations offered  as  conclusive. 

It  was  only  to-day  that  I  was  consulted  by  a  man 
of  eiglitv-three.  who  has  always  enjoyed  remark- 


able health  and  vigor,  whose  pulse  is  38  per  min- 
ute and  irregular  in  rhythm.  He  says  that  his 
pulse  always  has  been  slow  and  he  has  never  had 
any  nervous  disease  of  any  sort.  He  acknowledges 
a  slight  attack  of  vertigo  a  year  or  two  ago.  With 
this  possible  exception,  there  is  nothing  in  his  his- 
tory to  indicate  that  his  bradycardia  has  ever  pro- 
duced any  symptoms  whatever. 

We  have  also  been  assured,  on  seemingly  excel- 
lent authority,  that  Xapoleon  Bonaparte  never  had 
true  epilepsy,  although  his  pulse  was  40  a  minute. 
Numbers  of  cases  of  slow  pulse  unaccompanied  by 
any  s\mptoms  have  been  reported  in  people  ap- 
parently in  excellent  health.  So  it  seems  that  an- 
other medical  superstition  is  likely  to  be  demolished, 
and  that  when  bradycardia  is  coincident  with 
epilepsy,  the  conjunction  may  be  purely  accidental. 
In  fact,  a  number  of  good  authorities,  probably  a 
majority  of  the  observers,  maintain  the  same  prop- 
osition with  regard  to  the  coincidence  of  cardiac 
disease  and  epilepsy.  Still.  I  beg  leave  to  differ 
with  them,  believing  that  such  cases  as  my  second 
make  it  extremely  probable,  if  not  certain,  that  the 
condition  of  the  heart  is  the  cause  of  the  epileptic 
attacks, 

42  Church  Street. 


TWO    UNUSUALLY    SEVERE    CASES    OF  MYO- 
CARDITIS IN  CHILDREN,  CAUSED  BY  PRO- 
FOUND TON.EMIA:  RECOVERY. 

By  Louis  Fischer,  M.  D., 
New  York, 

Attending   Physician    to   the   Children's   Wards   of   the  Sydenham 
Hospital,  and  to  the  Riverside  and  Willard  Parker  Hospitals,  etc. 

The  clinical  manifestations  of  myocarditis  in 
children  are  very  obscure.  Its  association  with  the 
acute  infectious  diseases  is  so  frequent  that  I  de- 
sire to  record  two  typical  cases.  The  first  case,  a 
child  six  years  old,  followed  an  unusually  severe 
form  of  scarlet  fever, 

C.\SE  I.— Frank  D.,  six  years  old.  was  admitted  to  the 
Sydenham  Hospital  January  22d,  with  diagnosis  of  congen- 
ital hernia.  He  was  operated  upon  (modified  Bassini)  on 
the  ninth  day  after  admission.  The  etitire  nine  days  pre- 
ceding operation  he  ran  a  normal  temperature.  Pulse 
ranged  between  80  and  94.  In  the  evening  of  the  day  of 
operation,  the  temperature  rose  to  103.2°  F.,  the  following 
day  to  104.8°  F.  The  pulse  on  the  same  day  ranged  be- 
tween 120  and  1.34.  The  characteristic  rash  was  fully  de- 
veloped all  over  the  body  within  twenty-four  hours  of  onset. 
The  child  complained  of  sore  throat,  and  an  examination 
revealed  a  congestion  of  tonsils,  fauces,  and  pharvTix. 
There  was  at  no  time  vomiting  or  convulsions.  The  tongue 
showed  the  characteristic  strawberry  type. 

The  temperature  ranged  between  103.6  and  102°  F.  for 
five  days,  then  went  down  by  lysis,  reaching  normal  on  the 
ninth  day  after  onset. 

During  the  entire  febrile  period,  four  blood  counts  re- 
vealed an  average  of  30.000  leucocytes :  polynuclear.  88 
per  cent. :  eosinophiles,  five  per  cent.,  and  lymphocj'tes, 
seven  per  cent.  Repeated  urinary  examinations  were  found 
to  be  negative  as  to  albumin  and  casts.  During  last  two 
daj's  of  febrile  period,  twenty-four  hour  specimens  showed 
only  250  c.c.  total  urine  voided.  The  rash  disappeared  on 
the  fifth  day. 

The  temperature  remained  normal  only  one  day.  On  the 
following  day.  February  9th.  the  child  had  a  distinct  chill, 
temperature  rose  to  103.2°  F.  There  were  four  distinct 
chills  on  successive  days,  the  temperature  ranging  between 
103°  and  104°  F.  after  every  chill.    There  was  a  corre- 


1296 


FISCHER:   TOXEMIC  MYOCARDITIS  IN  CHILDREN. 


[New  York 
Medical  Journal. 


sponding  increase  in  the  pulse  rate,  from  120  to  130.  Two 
blood  counts  after  two  of  these  chills  showed,  leucocytes, 
26,000 ;  polynuclear,  seventy-five  per  cent. :  lymphocytes, 
small,  fifteen  per  cent. ;  mononuclear,  eight  per  cent. ; 
eosinophiles,  two  per  cent.  Daily  urine  examinations  were 
negative,  but  there  was  a  diminution  in  twenty-four  hour 


On  February  27th.  the  heart  sounds  were  muffled,  pulse 
between  60  and  78.  The  systolic  murmur  at  apex  disap- 
peared. Reduplication  sounds  still  heard  over  pulmonic 
and  aortic  areas. 

On  March  3d,  at  4  a.  m.  the  child  had  a  convulsion, 
temperature  95°  F.,  pulse  60.    Apathy  marked.    Child  des- 


CHART  I. 


specimens,  ranging  between  200  and  400  c.c.  Desquamation 
was  first  noted  on  the  tenth  day  after  onset.  On  the  day  of 
the  last  chill,  February  12th,  counter  drainage  was  done  in 
scrotum.  There  was  about  one  half  ounce  pus  found.  The 
temperature  dropped  to  normal  and  for  the  next  ten  days 
ranged  between  98.6°  and  99.8°  F. ;  the  pulse  between  58 
and  70.  The  urine  was  negative,  the  throat  soreness  en- 
tirely gone,  and  desquamation  going  on  freely. 

On  February  21st,  ten  days  after  counter  drainage  of 
wound,  the  temperature  suddenly  rose  to  104.8°  F.  This 
was  preceded  by  a  distinct  chill.  The  pulse  was  126.  The 
wound  which  had  closed,  was  probed  open,  but  no  pus 
found.  The  child  complained  of  severe  pain  in  the  left 
knee.  The  scrotal  mass  was  very  hard,  red,  and  indurated. 
The  wound  was  allowed  to  close.  The  pain  in  the  knee 
lasted  two  days.  The  blood  count  after  this  last  chill 
showed  18.000  leucocytes ;  60  per  cent,  polynuclear.  The 
child's  face  became  puffed,  there  was  slight  oedema  of  both 
legs.  The  examination  of  urine  was  negative,  total  quantity 
in  twenty-four  hours.  250  c.c.  The  pulse  was  weak  and 
irregular.  Bradycardia  was  marked,  pulse  70  and  coming 
down  to  60,  50.  and  even  40  beats  per  minute. 

On  February  22nd  and  23rd  the  pulse  registered  40  and 
50  per  minute. 

On  February  25th  the  pulse  registered  20  per  minute  at 
4  a.  in.  The  heart  sounds  the  past  six  days  were  feeble, 
first  sound  approaching  the  second  sound  at  apex,  in  force 
and  duration.  There  was  a  reduplication  of  second  pul- 
monic. A  systolic  murmur  at  apex,  not  transmitted  could 
be  heard.  The  veins  all  over  the  body  were  very  much 
distended,  the  extremities  cold,  and  child's  expression  that 
of  marked  apathy.  lie  complained  of  frontal  headache,  and 
was  cyanotic.  The  lilood  count  at  this  time  showed  3,500,- 
000  red  blood  cells,  and  h.-emoglobin  seventy-five  per  cent. 

The  chief  points  of  interest  in  the  past  seven  days  (Feb- 
ruary 21st  to  27th)  were  the  bradycardia,  irregular  pulse, 
cyanosis  (one  night),  cold  extremities,  distended  veins 
over  abdomen  and  head,  and  character  of  heart  sounds  as 
previously  described.    The  child  was  quite  emaciated. 


quamating  freely.  Abdomen  distended.  Veins  prominent. 
General  condition  of  child  that  of  marked  weakness.  Urine 
negative.  Child  perspired  freely  during  past  eight  nights. 
The  total  twenty-four  hour  specimens  of  urine  gave  350 
and  450  c.c;  leucocytes,  16,000;  red  blood  corpuscles,  3,400,- 
000;  polj-nuclear,  fifty-si.x  per  cent. 

March  7th  to  i6th.  Temperature  past  nine  days  was 
subnormal.  The  child  felt  better  during  the  day.  sat  up  in 
bed,  apathy  was  gone.  The  pulse  was  more  regular,  the 
heart  sounds  more  audible.  Systolic  sounds  at  apex  were 
more  marked  than  the  second  sound  at  apex.  No  murmurs 
heard.  Double  second  sounds  over  base  still  heard.  Urine, 
total  in  twenty-four  hours  600  to  900  c.c.  Desquamation 
entirely  ceased  except  few  flakes  left  on  soles  of  feet. 

March  i6th  to  21st.  General  condition  markedly  im- 
proved. Heart  sounds  between  70  and  80.  good  action,  no 
murmurs.  Pulse  quite  regular.  Peripheral  circulation 
much  improved.  Child  was  cheerful :  had  good  appetite. 
Temperature  and  urine  were  normal.  Blood  count  showed, 
leucocytes,  12,000;  polynuclear,  fifty-eight  per  cent. 

Case  II. — The  second  case,  a  boy  nine  years  old.  was 
seen  as  a  sequelae  to  diphtheria  complicated  by  pneumonia. 
I  am  indebted  to  Dr.  H.  Enton  for  the  following  history 
of  the  case :  H.  P.  was  first  seen  in  the  office  on  September 
28,  1908.  Tonsils  bright  red  and  so  swollen  as  to  bring 
the  inner  surfaces  in  apposition.  The  pulse  was  100.  tem- 
perature not  taken.  Called  to  see  the  child  on  the  follow- 
ing day,  found  the  abdomen  swollen  and  somewhat  tense. 
Faint  suggestion  of  follicular  amygdalitis.  The  tongue  was 
heavily  coated  with  a  grayish  deposit.  There  was  consti- 
pation and  some  vomiting.  Anorexia,  headache,  and  pain 
in  the  right  liypochondrinm  were  complained  of.  Tiie  tem- 
perature ranged  from  101°  to  104°  F.  for  the  following  five 
days,  with  no  important  change  in  the  condition,  except 
that  the  bowels  moved  freely  on  September  27th,  as  the 
result  of  calomel  followed  by  a  saline.  On  September  28tli 
the  temperature  rose  above  105°  F.  when  Dr.  Fischer  was 
called  in  consultation. 

On  examination  of  this  patient.  I  found  marked  dullness 


June  26,  1909.] 


FJSCHER:  TOX.^MIC  MYOCARDITIS  IX  CHILDREN. 


1297 


on  percussion  over  the  apex  of.  the  right  lung,  bronchial 
breathing,  and  with  ,  the  respiration  of  54,  pulse  144,  and 
temperature  105'  F.,  the  diagnosis  of  lobar  pneumonia  was 
made.  The  following  day  the  symptoms  were  the  same. 
There  was  cough ;  very  active  delirium  also  was  present. 
'1  he  child  was  semicomatose  most  of  the  time.  The  ab- 
dominal distention  gradually  increased.  Dr.  Enton  decided 
to  call  a  surgeon,  believing  that  some  abdominal  complica- 
tion existed.  I  requested  Dr.  Willy  Meyer  to  see  this 
patient.  He  found  no  reason  for  surgical  interference,  and 
corroborated  my  diagnosis  of  lobar  pneumonia.  In  addi- 
tion to  the  pulmonary  and  abdominal  symptoms,  there  was 
marked  redness  of  the  fauces  and  small  patches  on  the 
tonsils.  A  culture  showed  Klebs-Loeffler  bacilli.  Thus  we 
were  dealing  with  diphtheria  complicated  by  pneumonia, 
and  this  abdominal  distention  was  due  to  paralysis.  The 
pyrexia  was  treated  with  packs.  Five  thousand  units  of 
antitoxine  were  injected,  and  repeated  the  following  day 
when  the  pseudomembranes  exfoliated.  There  was  pro- 
found toxaemia  due  to  the  severity  of  the  Klebs-Loeffier  in- 
fection, and  secondly  to  the  pneumococcasmia. 

The  kidneys  soon  showed  the  effect  of  the  toxaemia. 
Marked  evidences  of  albumin,  some  hyaline  and  granular 
casts,  and  a  few  blood  cells  showed  an  acute  renal  con- 
gestion induced  by  the  profound  toxaemia.  In  like  manner 
the  heart  sounds  were  muffled  and  indistinct,  and  brady- 
cardia was  present.  The  pulse  was  irregular,  at  times 
intermittent,  and  of  very  low  tension.  The  pulse  rate 
ranged  between  62  and  76,  for  two  weeks.  At  times  the 
diastole  was  very  faint.  The  extremities  were  cold,  and 
the  child  presented  a  sallow,  lifeless  appearance.  He  was 
listless  and  did  not  care  to  play.  Profuse  perspiration  was 
a  constant  symptom. 

Stimulation  consisted  of  hot  saline  colonic  flushings  at 
a  temperature  of  110°  to  115"  F.  Strychnine  was  given  in 
doses  of  1/100  grain  every  three  hours,  in  addition  to 
ammonium  carbonate  as  a  diffusible  stimulant.  My  greatest 
reliance  was  on  hot  soup,  hot  milk  with  coffee,  strained 
gruel,  malted  milk,  and  expressed  steak  juice,  to  stimulate 
nutrition. 

Camphor  has  served  me  when  an  impending  col- 
lapse was  noted.  In  like  manner  the  injection,  bv 
means  of  hypodermoclysis,  of  several  ounces  of 
warm  saline  sclution  is  frequently  lifesaving.  [NIus- 
tard  foot  bath  to  stimulate  the  circulation  and  2:en- 


grave.  In  the  first  case  reported  the  child  was  al- 
most constantly  under  the  superivision  of  Dr.  M. 
Goldman,  aided  by  a  competent  trained  nurse  at  the 
Sydenham  hospital.  In  like  manner  the  case  seen  in 
consultation  with  Dr.  Enton  owes  its  life  to  the 
careful  and  conscientious  supervision  both  dav  and 
night.  The  judicious  application  of  diffusible  stim- 
ulants is  life  saving.  Xot  the  least  of  these  is  nu- 
trition, such  as  egg  nog  with  or  without  whiskey  as 
required. 

Bodily  warmth  must  be  supplied  by  artificial 
means  such  as  hot  water  bags,  and  also  by  ineans 
of  massage.  The  stimulation  of  the  return  flow  of 
venous  blood  will  aid  in  maintaining  a  proper  cir- 
culation. Xo  better  remedy  can  be  found  than  care- 
ful and  gentle  manipulation  of  the  extremities  by 
means  of  massage. 

Therapeutic  Suggestions.  Whtn  we  consider  the 
effect  of  the  toxine  on  the  cardiac  muscles  and 
nerves,  and  its  tendency  to  produce  paralvsis,  then 
we  must  be  on  our  guard,  long  before  such  oc- 
currence, to  prevent  just  such  fatal  termination. 
One  of  the  greatest  mistakes  made  is  to  permit  a 
convalescent  child  out  of  bed  before  normal  con- 
ditions prevail,  hence  absolute  rest  in  bed.  and  the 
avoidance  of  excitement  by  vigorous  playing  must 
be  strictly  enforced.  There  is  no  specific  drug  that 
will  do  good  in  all  cases.  Diffusible  stimulants  such 
as  ammonium  carbonate,  ether  in  the  form  of  Hoff- 
mann's anodyne,  strychnine,  and  tincture  of  Ton- 
quin  musk  should  be  remembered.  Camphor  in  the 
form  of  spirit  of  camphor  or.  when  hypodermical- 
ly  used,  camphorated  oil,  will  do  good. 

The  effect  of  hot  saline  colonic  flushings  at  a 
temperature  of  no  less  than  115°  F.,  will  rouse  a 
poor  circulation.  So  also  will  the  subcutaneous  in- 
jection of  two  to  three  ounces  of  normal  saline  solu- 


CH.\RT  II. 


tie  faradization  of  the  vagus  and  pneumogastric 
several  times  a  day  has  seemed  to  benefit. 

Prognosis.  The  prognosis  in  cases  of  myocarditis 
following  the  acute  infectious  diseases  such  as 
diphtheria,  scarlet   fever,   and   typhoid   is  usuallv 


tion,  when  injected  into  the  loose  cellular  tissue  of 
the  abdomen,  prove  valuable.  When  the  above  men- 
tioned hypodermoclysis  is  .given,  we  add  to  the  vol- 
ume of  blood,  hence  such  injections  should  be 
made  no  hotter  than  100°  F.    Coilnterirritation  to 


1298 


COBB:  BALDNESS. 


[New  York 
Medical  Journal. 


arouse  a  poor  circulation  will  be  aided  by  the  use 
of  mustard  foot  baths.  A  tablespoonful  of  mus- 
tard is  placed  in  cheesecloth  and  added  to  a  basin  of 
warm  water,  temperature  100°  F.  Bathe  the  feet 
and  ankles  one  minute,  repeat  in  one  hour  if  no 
apparent  ef¥ect  is  noticed. 

Hot  food,  especially  cofifee  with  milk,  soup  or 
broth,  or  steak  juice  made  by  expressing  the  blcod 
from  slightly  broiled  steak,  with  a  meat  press.  The 
yolk  of  a  raw  egg  added  to  milk  or  coffee  or  soup 
is  one  of  the  best  means  of  aiding  the  circulation. 

The  outcome  of  a  case  of  myocarditis  depends  on 
persistence  in  the  nutrition  of  the  body,  aided  b\- 
carefully  selected  cardiac  and  vasomotor  stimu- 
lants. Fresh  air  and  sunshine  are  invaluable  as 
aids  in  the  proper  establishment  of  metabolism. 

162  West  Eighty-seventh  Street. 


BALDNESS.* 

Bv  J.  O.  Cobb.  M  D., 
Milwaukee. 

Surgeon,  United  States  Public  Healtli  and  Marine  Hospital  Service. 

The  loss  of  the  hair  by  old  men,  by  Nature's  pro- 
cess, has  always  been  considered  a  matter  of  course, 
and  brought  forth  nothing  but  expressions  of  re- 
spect, but  it  is  not  so  with  young  men,  for  the  mo- 
ment their  baldness  is  discovered  their  friends  begin 
to  slap  them  on  the  back,  and  nudge  and  wink  and 
point  the  accusing  finger  at  this  early  sign  of  their 
overtasted  forbidden  fruits.  A  young  man  thus  af- 
flicted springs  into  prominence  at  once  as  a  person 
who  is  more  or  less  of.  a  rake,  and  every  one  takes 
delight  in  poking  fun  at  him,  especially  so  if  he  is  a 
doctor.  And  though  the  baldheaded  man  may  try 
to  laugh  it  ofif,  and  pretend  that  he  does  not  mind  all 
the  "joshing"  he  gets,  nevertheless  he  very  soon  be- 
gins to  cast  about  for  counter  schemes  to  ofifset  this 
veiled  charge  against  his  "early  piety,"  and  he  soon 
discovers  that  profound  thinkers,  men  of  high  ideals 
and  great  mental  caliber,  such  as  judges,  lawyers, 
statesmen,  are  often  bald.  It  is  quite  natural  that 
this  comforting  bit  of  knowledge  should  lead  him 
into  the  conceit  that  his  own  baldness  is  an  especial 
mark  of  talent,  and  that  he  is  divinely  favored  along 
with  Socrates,  Caesar,  Napoleon,  and  other  noted 
individuals.  And  then  to  stif¥cn  up  the  spine  of  his 
self  esteem,  which  has  become  somewhat  wobbly  un- 
der these  continuous  insinuations,  one  need  not  be 
surprised  if  he  even  turns  to  church  history  to  bear 
him  out  that  St.  Paul,  and  many  of  the  Saints  were 
bald,  and  that  there  was  once  a  great  prophet,  and 
fairly  young  at  that,  who  sent  two  she  bears  to  tear 
the  forty  bad  little  children  for  calling  him  the 
naughty  name  of  baldhead.  But  though  he  may 
joke  about  his  condition,  and  quote  the  Bible,  and 
assert  that  baldness  is  a  mark  of  high  thinking,  and 
strong  mental  power,  nevertheless,  this  self  same 
baldheaded  man,  whether  doctor  or  layman,  will  run 
the  gamut  of  hair  restoratives,  fake  dandrufT  cures, 
and  mas.sagc  ajjpliances  in  the  vain  attempt  to  bring 
back  enough  hair  to  hide  his  disfigurement. 

Baldness  is  no  new  disease.  It  has  the  sanction 
of  medicine,  together  with  the  respectability  of  age, 
for  y^l.sculapius  and  Hippocrates,  the  grandsires  of 

•Read  before  the  Milwaukee  Medical  Society.  March  jj,  1909. 


medicine,  were  as  bald  as  Father  Time  himself.  It 
was  known  in  Bible  times,  as  well  as  among  the  an- 
cient Egyptians.  The  mummy  of  Pharaoh  Rameses 
II  shows  crown  and  frontal  baldness,  and  in  Papy- 
rus Ebers  (1500  B.  C.)  are  eleven  prescriptions  for 
this  trouble.  We  can  well  believe  the  statement  that 
even  in  those  days  toupets  and  wigs  were  worn  to 
conceal  the  loss  of  hair,  and  that  women  wore  rats 
and  switches,  justabout  like  what  they  wear  now.  The 
affliction  was  considered  a  sign  of  servitude,  or  im- 
morality, by  all  ancient  nations,  but  from  time  to 
time  there  were  reactions  against  this  unjust  atti- 
tude, and  artificial  baldness,  by  shaving  the  crown 
of  the  head,  became  the  fashionable  mark  of  rank,  or 
of  religion. 

Even  in  those  early  times  men  speculated  upon 
the  cause  of  the  difference  between  the  parasitic 
form  and  the  afl^ection  of  old  age.  Young  Egyptian 
and  Roman  soldiers  suffered  from  frontal  baldness, 
which  contemporaneous  writers  assert  was  caused 
by  wearing  the  metal  helmet.  The  disease  was  rare 
among  the  Jews,  excepting  the  class  who  wore 
heavy  headgear.  Among  semicivilized  peoples  it  ib 
nearly  unknown,  and  especially  is  this  true  of  the 
dark  races.  Old  Indians  and  old  negroes  seldom 
are  bald,  unless  they  have  adopted  the  white  man's 
stif¥  hat.  In  the  dirt  and  squalor  of  savage  life, 
where  one  would  naturally  expect  to  find  it,  the 
trouble  is  practically  unknown;  and  though  they 
Irive  all  kinds  of  diseases  of  the  scalp  baldness  is 
not  common,  even  among  the  aged.  Among  certair, 
European  rural  classes,  whose  headdress  is  distinct- 
ive, baldness  is  very  rare,  but  when  they  come  to 
America  and  begin  to  wear  stifif  hats,  the  usual  per- 
centage become  bald. 

While  this  affection  has  always  been  more  or  less 
common  among  men  of  certain  classes  or  castes,  it 
has  always  been  an  uncommon  occurrence  among 
women,  whether  rich  or  poor,  savage  or  civilized. 
And  what  was  true  then,  is  just  as  true  to-day,  for, 
though  a  woman's  hair  may  fall  and  thin  out  from 
worry,  lack  of  outdoor  exercise,  etc.,  she  seldom  be- 
comes bald  like  a  man,  even  in  old  age.  There  must 
be  some  prominent,  strongly  significant  reason  for 
this  peculiar  selective  action  of  baldness  for  men. 
It  is  certainly  not  the  excessive  brain  action  which 
causes  the  heat  of  their  noble  thoughts  to  rise  to  the 
dome  of  their  heads  and  singe  off  their  hair  as  these 
unfortunates  would  like  us  to  believe. 

It  is  hard  to  make  the  average  person  believe  that 
baldness  is  not  a  disease  caused  by  germs,  or  dan- 
druff, or  by  some  of  the  scarecrow  names  quacks  use 
in  their  advertisements.  That  it  is  a  condition 
brought  about  almost  solely  by  the  tight  hatband  and 
the  heavy  hat  few  will  believe.  It  is  granted,  for 
argument's  sake  onlv,  that  dandrufif  and  certain 
scalp  parasites  well  known  to  skin  specialists  may  be 
causative  factors  in  the  progressive  thinning  out  of 
the  hair,  but  they  become  harmful  only  after  the 
tight  hatband  has  caused  tropic  changes  in  the  nerves 
and  bloodvessels  which  supply  the  crown  of  the 
head.  After  the  fatty  cushion  at  the  top  of  the  head 
is  partly  destroyed,  the  scalp  becomes  bound,  and 
the  skin  thinned  out  and  shiny,  and  it  is  then  that  the 
hair  loses  its  vigor,  and  dandruff  and  hair  parasite.* 
may  attack  it — but  only  down  to  the  zone  of  the 
hatband.  Below  the  hatband  zone,  strangely  enough, 
the  hair  is  healthy,  and  persists  to  old  age,  and  it  is 


June  26.  1909.] 


COBB:  BALDNESS. 


1299 


but  reasonable  to  believe  that  if  the  falling  out  had 
been  due  to  germs,  or  parasites,  the  baldness  would 
have  been  general  over  the  entire  scalp,  even  down 
below  this  zone,  instead  of  selecting  the  frontal  por- 
tion, or  the  dome  of  the  head.  Then,  too,  if  the  de- 
formity is  caused  solely  by  hair  parasites,  why  is  it 
that  women  escape  baldness?  They  are  certainly 
not  immune  to  other  scalp  diseases,  and  if  baldness 
is  contagious  they  have  every  opportunity  to  catch 
the  disease,  if  it  is  catching. 

Heredity  is  given  as  the  predisposing  cause  of 
most  baldness,  and  it  is  true,  that  where  the  condi- 
tion is  found  in  a  young  man,  one  is  certain  to  find 
that  the  afifection  is  characteristic  of  the  male  rela- 
tives of  one  or  both  sides  of  his  house.  And  along 
with  his  own  susceptibility  to  baldness,  it  is  just  as 
likely  to  be  another  characteristic  of  this  man's  fam- 
ily that  its  women  will  have  fine  thick  heads  of  hair. 
That  is  a  frequent  coincidence,  not  easily  explainable 
from  the  standpoint  of  hereditary  family  traits,  for  it 
is  hard  to  believe  that  the  law  of  selection  has  been 
so  persistent  and  cruel  to  the  male  members  of  this 
family ;  nor  does  it  seem  reasonable  that  the  law  of 
heredit}-  had  been  so  lavish  to  the  women  as  to  give 
them  beautiful  heads  of  hair,  while  in  the  same  gen 
eration  it  had  abruptly  stepped  aside  to  lay  the 
blighting  hand  of  barrenness  upon  the  crowns  of 
their  brothers'  heads.  Indeed,  that  is  a  far  stretch 
of  the  imagination,  and  it  is  but  fair  to  insist  that 
the  only  law  that  has  applied  to  them,  is  the  one  of 
inheriting  the  thickness  of  the  scalp,  the  fineness  or 
coarseness  of  the  hair,  and  the  type  and  shape  of 
the  heads  of  their  parents.  Just  that  far  has  hered- 
ity played  a  part  and  no  farther. 

And  just  one  other  thought  here:  Whatever  fac 
tor  of  prominence  one  is  inclined  to  give  greatest 
weight  to  in  theorizing  upon  baldness,  that  factoi 
must  reasonably  apply  to  the  woman.  If  one  believes 
that  a  certain  thing,  heredity,  for  instance,  is  the 
cause  of  baldness  in  men,  then  it  is  only  fair  that  he 
apply  his  theory  intelligibly  in  explaining  why 
women  do  not  fall  within  this  law.  The  woman  has 
all  the  external  conditions  to  meet  that  the  man  has  ; 
she  is  subject  to  the  same  biological  laws  as  the 
man  :  she  inherits  the  type  of  head  and  quality  of 
hair  from  her  parents  just  like  her  brother ;  family 
traits  do  not  overlook  her  in  any  way ;  she  toils  in 
doors,  and  out  of  doors  by  the  man's  side ;  she  eats 
the  same  food ;  she  is  exposed  to  the  same  climatic 
and  racial  vicissitudes ;  and  surely,  among  all  races, 
the  woman  is  as  nervous  and  has  as  much  w  orry  as 
the  average  man. 

The  top  of  the  head  is  bountifully  supplied  with 
nerves  and  bloodvessels  which  run  from  the  neck  up 
the  sides  of  the  skull,  supplying  the  muscles,  fascia, 
and  hair  follicles  of  the  scalp  up  to  the  very  dome  of 
the  skull,  where  they  unite  in  a  beautiful  network. 
Over  this  portion  of  the  skull  Nature  has  placed,  be- 
sides the  muscles,  skin,  and  fascia,  a  thick  pad  of 
fatty  tissue,  in  which  are  imbedded  these  bloodves- 
sels and  ner\-es.  Dr.  George  Elliott,  of  Toronto,  sev- 
eral years  ago  (The  Anatomical  Factor  in  the  Pro- 
duction of  Baldness.  Journal  of  the  American  Med- 
ical Association,  March  29,  1902.).  called  attention 
to  the  great  anatomic  importance  of  this  cushion  of 
fat  in  preserving  the  hair  on  the  crown  of  the  head. 
It  protects  the  bloodvessels  and  nerves,  and  any- 
thing which  disturbs  the  nourishment  of  this  part  of 


the  scalp  will  cause  atrophy  and  thinning  of  the 
scalp,  with  consequent  degeneration  of  the  hair  fol- 
licles, which  will  invariably  be  followed  by  incura- 
ble baldness.  If  the  bloodvessels  and  nerves  are 
permanently  damaged,  and  this  fatty  pad  and  the 
scalp  have  thinned  out,  and  the  hair  bulbs  have  been 
destroyed  by  atrophy,  then  no  amount  of  massage, 
or  application  of  hair  restoratives  will  bring  back 
one  tiny,  scraggly  hair.  The  hair  is  gone,  never  to 
return.  But  if  the  hair  has  just  commenced  to  fall, 
it  may  be  stopped  bv  treatment,  and  by  changing  the 
habit  of  wearing  the  hat.  though  the  new  hair  will 
come  in  fine  and  delicate  just  like  a  baby's  hair. 
This  fine  hair  is  ver\-  hard  to  nurture,  and  is  nearly 
certain  to  fall  out  again  and  refuse  to  regrow,  be- 
cause, now  that  the  hair  is  so  much  thinner,  it  fails 
to  act  as  a  cushion,  and  so  the  original  cause  of  the 
loss,  viz.,  the  tight  hat.  becomes  more  ef¥ective  in 
damaging  the  blood  and  nerve  supply  to  the  top  of 
the  head.  The  condition  steals  upon  the  victim  so 
slowly  that  one  is  in  the  first  stage  of  baldness  be- 
fore he  knows  it.  The  natural  hair  falls  out  and  is 
replaced  by  a  less  vigorous  growth,  the  hair  coming 
back  thinner  and  thinner  each  time,  and  more  brit- 
tle, until  finally  for  lack  of  sustenance  it  gives  up 
the  ghost,  and  is  numbered  with  the  departed. 

Barbers  tell  one.  and  it  is  a  common  belief,  that 
when  the  hair  begins  to  fall  it  should  be  kept  cut 
short.  It  used  to  be  a  great  graft  among  the  barbers 
to  singe  the  ends  to  close  up  the  canal  of  the  hair,  so 
that  its  oily  substance  would  not  escape.  When  hair 
is  not  properly  nourished,  or  not  properly  cared  for. 
it  will  split  at  the  ends.  Cutting  out  these  hairs  will 
not  help  the  condition  at  all,  and  close  clipping  is 
the  most  harmful  thing  that  can  be  done  to  any  head 
of  hair.  Then,  of  all  times,  the  hair  should  be  worn 
long,  and  the  sufiferer  should  begin  vigorous  treat- 
ment by  means  of  brushing  and  massage,  and  if  pos- 
sible, an  out  of  door  life  to  improve  his  general 
health. 

Baldness  is  a  habit  disease.  The  majorit}-  of  men 
when  putting  on  their  hats  work  them  back  and 
forth  with  one  hand  to  make  them  fit  on  snugly. 
Often  one  sees  a  man  who  takes  two  hands  to  the 
hat,  and  pulls  hard  on  the  brim  to  force  it  well  down 
on  his  head.  It  is  not  hard  to  understand  that  the 
tight  fitting  hatband,  whether  of  a  stiff  hat,  or  of  a 
soft  hat  must  be  constricting  a  zone  around  the 
scalp  which  interferes  seriously  with  the  function 
of  the  nerves  and  bloodvessels  passing  under  this 
zone.  The  tighter  this  band,  the  more  certain  of 
ultimate  baldness,  but  even  with  tight  bands  and 
heavy  hats,  there  is  a  certain  percentage  who  escape 
altogether.  With  these  it  is  to  be  noticed  that  the 
shape  of  the  head,  and  the  mode  of  wearing  the 
hair,  has  much  to  do  in  preventing  the  trouble.  But 
if  a  man's  head  is  very  wide,  or  if  he  is  very  promi- 
nent fore  and  aft,  that  man  will  become  bald  in  time, 
because  such  a  person,  to  make  his  hat  fit  snugly,  in- 
variably pulls  it  down  tight.  The  man  with  low- 
brow, and  thick,  heavy-hair  rarely  is  bald.  If  one 
wears  the  hair  long  and  thick,  it  acts  as  a  cushion 
and  prevents,  in  a  large  measure,  the  constriction 
caused  by  the  hatband. 

The  stiff,  rigid  hats,  universally  worn  at  the  pres- 
ent day  are  causing  a  greater  percentage  of  bald- 
ness among  young  men  than  formerly  existed,  and 
of  these,  the  straw  hat  is  the  worst  offender,  because 


1300 


DANZIGER:  MASTOID  OPERATION. 


[New  York 
Medical  Journal. 


it  is  harder  to  keep  it  from  blowing  off,  and  there- 
fore the  wearer  is  certain  to  force  it  down  on  his 
head  just  that  much  tighter.  The  derby  hat,  and  the 
silk  hat,  are  great  hair  destroyers,  and  not  far  be- 
hind them  in  destructiveness  are  the  automobile 
caps,  which  are  being  pulled  down  on  the  head  very 
tightly.  It  is  noticeable,  too,  that  gentlemen  who 
ride  much  in  automobiles,  have  the  habit  of  pulling 
their  hats  tightly  down  on  their  heads.  Wearing  the 
hat  indoors,  like  offices  and  places  of  business,  is  be- 
coming a  general  habit  and  is  sure  to  increase  the 
number  of  baldheads. 

Every  possible  moment  that  the  head  can  be  re- 
lieved from  the  pressure  of  the  hat  should  be  taken 
advantage  of,  especially  when  playing  golf,  or  horse- 
back riding,  or  when  in  the  automobile.  A  great 
many  golfers  go  hatless,  with  the  idea  that  the 
hair  is  improved  by  ventilation  and  sunshine.  Un- 
doubtedly it  is  improved  in  this  manner,  but  the 
prime  secret  is  in  not  wearing  the  hat  at  all.  The 
ventilated  hat  will  not  prevent  baldness,  if  this  same 
hat  is  worn  tightly  fitted  down  on  the  head.  The 
greatest  care  should  be  exercised  in  selecting  the 
right  kind  of  hat,  if  such  a  thing  as  the  right  kind 
can  be  had,  which  is  doubtful.  All  stiff,  rigid  hats 
should  be  very  light,  and  one  should  select  a  size 
larger  than  the  head  measurement  calls  for,  and  this 
over-size  can  then  be  comfortably  corrected  by  in- 
serting a  few  felt  strips  underneath  the  hatband. 
This  gives  a  soft,  cushionlike  effect  to  the  hatband, 
makes  the  fit  just  as  comfortable,  and  in  a  great 
measure  prevents  the  constricting  zone  at  that  por- 
tion of  the  scalp. 

Ingenious  men  are  continually  contriving  new 
kinds  of  shoes,  new  suspenders,  and  hundreds  of 
different  kinds  of  braces,  but  so  far  no  one  has  taken 
up  the  idea  of  making  a  hat  which  will  hold  on  the 
head  and  not  blow  off,  and  at  the  same  time  not 
bind  the  head  all  around  like  a  constricting  band. 
Some  one  ought  to  invent  a  hat  which  will  prevent 
baldness,  though  the  idea  will  probably  not  become 
popular  because  there  is  more  money  in  hair  tonics; 
and  hair  restorers,  and  fake  electric  massage  appa- 
ratus, than  in  some  new  kind  of  a  hat  which  will 
prevent  the  disease.  Hundreds  of  remedies  are  on 
the  market  which  are  advertised  as  sure  hair  re- 
storatives, but  not  one  of  them  will  bring  back  one 
hair  once  the  hair  follicle  is  atrophied  and  function- 
less  ;  nor  will  any  of  these  remedies  prevent  the  fall- 
ing of  hair  unless  the  habits  of  the  sufferers  are 
changed.  At  best  these  remedies  are  merely  skin 
irritants,  which  promote  a  slightly  increased  flow  of 
blood  to  the  scalp.  Dandruff  cures  are  mostly  fakes, 
pure  and  simple.  The  only  good  in  the  world  ac- 
complished by  these  medicaments  is  the  scalp  mas- 
sage indulged  in  while  applying  them,  and  the  gen- 
eral practitioner  should  make  a  strong  fight  against 
their  use. 

The  time  to  cure  baldness  is  before  it  begins. 
Every  man  .should  devote  a  short  time  before  he  goes 
to  bed,  and  after  he  gets  up  in  the  morning,  to  scalp 
massage,  which  he  can  apply  himself.  During  the 
brisk  friction  he  should  gra.sp  his  hair  in  handfuls 
and  draw  the  scalp  back  and  forth  many  times,  to 
make  it  slide  over  the  .skull.  That  will  prevent  bind- 
ing and  thinning  of  the  scalp  and  preserve  the  cush- 
ion of  fat  on  the  top  of  the  head.  It  will  also  pull 
out  the  loose  hairs,  which  shed  naturally,  and  which 


are  quickly  replaced  by  a  more  vigorous  growth.  A 
woman  in  combing  her  hair  cannot  help  pulling  her 
scalp  back  and  forth,  and  this  very  necessity,  which 
she  cannot  prevent,  is  the  salvation  of  her  most  beau- 
tiful and  most  precious  adornment.  The  hair  should 
be  worn  as  thick  as  nature  will  allow  it,  and  long 
enough  for  the  cut  ends  to  extend  below  the  hatband 
zone.  Such  a  hair  cut,  or  trim,  is  far  more  becom- 
ing than  having  one's  hair  cropped  off  close  to  the 
scalp  like  a  prize  fighter.  Many  of  the  electric  and 
vacuum  massage  apparatus  are  good  enough  in  their 
way,  but  not  so  good  as  one's  own  hands  ;  though,  if 
one  can  afford  it,  additional  massage  given  by 
trained  hands,  or  by  a  good  machine,  is  a  luxury 
that  will  lessen  the  number  of  headaches  and  wrin- 
kles, and  pay  one  in  end  results,  that  is,  if  he  values 
his  personal  appearance,  and  certainly  the  baldhead- 
ed  man  is  not  handsome  at  his  best. 

But  all  these  personal  attentions  will  be  futile,  un- 
less one  uses  the  greatest  precaution  is  wearing  the 
hat.  Every  few  minutes,  when  outside,  the  hat 
should  be  lifted  from  the  head  and  gently  replaced. 
The  hat  has  a  tendency  to  settle  down  on  the  head 
very  snugly,  and  the  indentation  from  the  pressure 
of  the  hatband  is  quite  noticeable  on  the  forehead. 
Hats  like  the  stiff  straw,  which  are  easily  blown 
from  the  head,  should  never  be  worn  at  all,  for,  in 
spite  of  one's  self  such  a  hat  will  be  jammed  down 
on  the  head  actually  tight  enough  to  seriously  im- 
pede the  scalp  circulation.  Tie  a  string  around  your 
finger  ever  so  lightly,  and  watch  the  effect  on  the 
circulation  in  the  end  of  that  finger ;  in  like  manner 
demonstrate  in  your  own  case  the  surprising  amount 
of  pressure  exerted  on  your  scalp  by  the  careless 
manner  of  wearing  your  hat. 

So,  if  any  of  you  value  the  hair  on  the  crown  of 
your  head,  and  if  you  really  care  for  your  personal 
appearance,  then  the  wise  thing  to  do  is  to  begin 
scalp  massage  early,  and  have  the  right  kind  of  hats, 
and  wear  them  properly,  for  it  is  "as  plain  as  the 
plain  bald  pate  of  Father  Time  himself,  that  there's 
no  time  for  a  man  to  recover  his  hair  that  goes  bald 
by  nature." 

403  Iron  Block. 


INDICATIONS  FOR  OPERATION  IN  ACUTE 
MASTOIDITIS. 

By  Ernst  Danziger,  M.  D., 
New  York. 

In  formulating  the  indications  for  operation  in 
acute  mastoiditis,  it  is  my  object  to  discuss  briefly 
only  those  conditions  in  which  from  a  conservative 
point  of  view  operative  interference  is  absolutely 
necessary.  With  the  perfection  of  operative  tech- 
nique and  the  possibility  of  invading  new  territories, 
the  enthusiasm  of  the  surgeon  often  overshoots  its 
mark,  and  makes  him  attack  with  his  knife  patho- 
logical conditions  which  after  a  time  will  be  treated 
by  more  conservative  methods.  He  justifies  this 
procedure  with  a  comparative  impunity  with  which 
certain  operations  may  be  performed,  and  the  dan- 
ger to  which  the  patient  is  exposed  by  the  expectant 
treatment.  This  has  been  true  for  abdominal  sur- 
gery, where  the  removal  of  the  ovaries  has  been 
assigned  to  its  proper  place,  where  decapsulated 


June  26,  1909.] 


DANZIGER:  MASTOID  OPERATION. 


1301 


kidneys  remain  as  monuments  of  daring  surgery,  if 
of  nothing  more.  The  same  holds  good  for  aural 
surgery,  where  the  familiarity  with  the  operation 
for  acute  mastoiditis  has  bred  contempt  for  a  more 
conservative  tendency  of  treating  the  most  common 
complications  of  an  acute  purulent  otitis  media. 

I  know  that  I  am  treading  on  dangerous  ground, 
but  I  am  willing  to  shoulder  the  onus  of  being 
called  an  advocate  of  ill  advised  conservatism  and 
other  epithets  with  which  most  textbooks  at  the 
present  time  designate  the  man  who  believes  in 
drawing  closely  the  lines  for  surgical  interference. 

Before  entering  upon  a  discussion  of  the  indica- 
tions for  the  operation  for  acute  purulent  mastiodi- 
tis,  it  becomes  necessary  to  give  a  definition  of  what 
constitutes  that  condition.  To  do  so,  I  will  give  a 
short  schematic  review  of  the  anatomy  of  the  mas- 
toid process  of  the  temporal  bone.  The  middle  ear 
communicates  with  the  mastoid  antrum  through  the 
additus  ad  antrum;  the  antrum  again  communicates 
with  the  mastoid  cells.  The  three  structures,  tym- 
panum, antrum,  and  mastoid  cells,  are  lined  with 
a  continuous  mucoperiosteum,  which  nourishes  the 
underlying  bone.  In  infants,  the  tympanomastoidal 
fissure  is  often  not  closed,  allowing  the  escape  of 
discharge  from  the  middle  ear  directly  underneath 
the  periosteum  of  the  cortex.  After  the  fortieth 
year  of  life,  the  cortex  of  the  mastoid  becomes 
rather  thick  and  sclerotic.  During  inflammation  of 
the  middle  ear,  the  inflammatory  process  is  not  lim- 
ited only  to  the  middle  ear,  but  the  mucoperiosteum 
of  the  antrum  and  mastoid  cells  participate  to  a 
greater  or  less  degree.  When  the  mucous  mem- 
brane of  these  parts  becomes  cedematous,  the  com- 
munication between  the  mastoid  cells  will  be  inter- 
rupted, and  retention  of  secretion  takes  place  which 
may  be  either  serous  or  purulent,  according  to  the 
severity  of  the  infection  present.  If  the  secretion 
of  the  antrum  and  cells  is  purulent,  we  have  to  deal 
with  a  true  empyema  of  the  mastoid  process.  This 
condition  may  exist  for  a  short  time  without  any 
gross  pathological  changes  in  the  mucoperiosteum. 
After  the  mucous  membrane  has  been  exposed  for 
a  time  to  the  pressure  of  this  fluid,  it  will  begin  to 
ulcerate ;  granulations  begin  to  form,  and  the  un- 
derlying bone  will  suffer  by  reason  of  interference 
with  its  nutrition.  This  second  condition  is  a  real 
osteitis,  with  the  destruction  of  periosteum  and 
bone.  Thirdly,  we  may  have  to  deal  with  an  infec- 
tious thrombophlebitis  of  the  smaller  veins  of  the 
mastoid  process. 

Bearing  these  facts  in  mind,  let  us  now  consider 
the  clinical  symptoms — temperature,  pain,  local 
conditions,  and  bacterial  flora.  As  acute  middle  ear 
inflammations  are  almost  always  secondary  to  some 
infectious  process  of  the  nose  and  throat,  we  must 
expect  to  find  a  rise  of  temperature  typical  of  the 
primary  disease  present.  The  presence  of  the  acute 
purulent  otitis  will  cause  the  curve  to  climb  higher 
and  give  it  a  more  septic  aspect.  After  a  better 
drainage  has  been  established  by  paracentesis,  the 
curve  will  again  assume  the  typical  picture  of  the 
primary  disease.  But  sometimes,  in  spite  of  the 
paracentesis  the  temperature  will  remain  high  and 
more  or  less  septic,  and  then  the  question  arises — 
shall  we  operate  or  not?  As  stated  before,  there 
may  be  a  time  in  the  purulent  inflammation  of  the 


mastoid  cells  where  an  cedematous  condition  of  the 
mucoperiosteum  will  interrupt  the  communication 
between  the  cells,  and  cause  retention  and  resorp- 
tion. We  know  that  cedematous  conditions  of  the 
•mucous  membranes  of  the  pharynx  and  nose  will 
disappear  spontaneously  after  the  disease  has  run 
its  natural  course  as  an  acute  pharyngitis  and  ton- 
silitis.  The  same  infection  causes  the  acute  inflam- 
mation of  the  middle  ear  and  its  appendices,  and  if 
we  wait  for  the  spontaneous  decline  of  the  original 
disease  the  cedematous  condition  of  the  mucoperios- 
teum of  the  mastoid  cells  will  disappear  at  such 
time.  The  retention  will  be  relieved,  and  tempera- 
ture will  drop  to  the  normal.  Therefore  a  high  re- 
sorption temperature  alone,  without  distinct  chills, 
sweats,  or  hyperpyrexia  is  not  at  all  an  indication 
for  surgical  interference,  even  if  it  continues  for 
four  or  five  days  after  paracentesis.  If  we  have 
to  deal  with  a  case  where  the  temperature  has  a 
tendency  to  go  to  105°  F.  and  beyond,  with  chills 
and  sweats,  then  we  have  before  us  a  case  of 
thrombophlebitis  of  the  small  veins  of  the  mastoid 
process,  which  will  rapidly  cause  a  thrombosis  of 
the  lateral  sinus.  Such  cases  are  distinctly  surgical 
from  the  beginning. 

The  presence  or  absence  of  a  rise  of  temperature 
alone  does  not  give  an  absolute  indication  for  surgi- 
cal interference.  We  may  find  in  the  absence  of  a 
rise  of  temperature  a  rapidly  progressing  destruc- 
tion of  bone,  but  then  the  indications  will  be  given 
by  the  pain,  amount,  and  character  of  the  discharge, 
or  the  bacterial  finding.  In  the  so  called  genuine 
cases  of  otitis  media  purulenta,  cases  without  de- 
monstrable affections  of  the  nose  or  pharynx,  or 
other  constitutional  diseases,  we  may  expect  the 
temperature  to  drop  to  the  normal  after  free  drain- 
age has  been  established,  but  a  fluctuation  of  the 
curve  from  slightly  above  the  normal  to  about  101° 
F.  may  be  seen  for  a  few  days,  which  does  not  indi- 
cate serious  complications.  I  have  seen  repeated- 
ly in  infants  with  a  severe  pharyngitis  complicated 
by  an  acute  purulent  otitis  the  temperature  fluctuate 
between  100°  and  105°  F.  This  condition,  in  the 
absence  of  other  important  symptoms  on  the  part 
of  the  ear,  represents  a  sepsis  due  to  absorption 
through  the  lymphoid'  tissvie  of  the  nasopharynx, 
which  at  this  time  of  life  is  superabundantly  sup- 
plied with  it.  These  cases  sometimes  give  a  picture 
of  sinus  thrombosis,  and  when  in  doubt  a  differen- 
tial blood  count  may  assist  in  the  diagnosis. 

Every  acute  middle  ear  inflammation  is  accom- 
panied by  more  or  less  pain,  which  disappears  al- 
most entirely  when  the  drum  has  become  freely 
perforated  so  as  to  allow  proper  drainage.  In  the 
early  stages  of  every  acute  purulent  middle  ear  in- 
flammation you  can  elicit  more  or  less  pain  on  pres- 
sure over  the  mastoid  antrum  or  the  tip  of  the 
process — more  or  less  severe  according  to  the  pres- 
sure put  on  the  fluid  in  the  antrum  or  cells,  or  the 
degree  of  inflammation  of  the  mucoperiosteum.  This 
paint  may  persist  as  long  as  there  is  retention  of  se- 
cretion or  acute  inflammation  of  the  mucous  lining. 
Only  if  after  remission  of  the  primary  disease  the 
pain  becomes  more  severe  and  more  boring,  espe- 
cially at  night,  if  the  pain  is  present  even  without 
pressure,  then  we  have  to  suspect  that  the  muco- 
periosteum has  been  partially  destroyed,  that  the 


I302 


BRADLEY:  CONGENITAL  HEART  DISEASE. 


[New  York 
Medical  Journal. 


nutrition  of  the  bone  is  being  interfered  witli,  and 
that  necrosis  is  taking  place. 

In  tliis  connection,  the  amount  and  character  of 
the  discharge  are  also  of  importance.  If  the  amount 
of  pus  at  such  time,  instead  of  becoming  less,  in- 
creases in  quantity  and  drains  through  a  good  sized 
opening  in  the  drum,  if  it  becomes  more  yellowish, 
and  assumes  the  character  of  bone  pus,  we  may 
safely  assume  that  there  is  a  disease  of  the  bone 
proper,  which  indicates  surgical  interference. 

I  will  not  speak  of  oedema  over  the  mastoid  cor- 
tex, as  to  wait  for  such  a  progressed  condition 
would  not  be  the  correct  procedure  of  a  modern 
physician  caring  for  an  adult  patient.  There  may 
be  an  oedema  at  the  onset  of  the  disease  which  is 
due  to  the  hyperasmia  of  the  bone,  which  will  quick- 
ly disappear  with  proper  drainage  and  antiphlogistic 
measures. 

It  is  difYerent  in  very  young  children,  where  the 
mastoid  process  is  practically  a  solid  bine  with  one 
large  cell — namely,  the  antrum,  and  as  explained 
before  the  pus  may  travel  directly  underneath  the 
cortical  periosteum  without  destruction  of  bone. 
Sometimes  simple  drainage  through  the  drum  will 
relieve  this  condition.  An  important  indication  for 
operation  is  the  sinking  down  of  the  upper  posterior 
wall  of  the  external  meatus,  which  indicates  an 
oedema  due  to  an  osteitis  of  the  mastoid  process. 

Bacteriological  examination  of  the  pus,  while  not 
giving  a  direct  indication  will  put  us  on  our  guard, 
as  with  detection  of  the  pneumococcus  or  the  sta- 
phylococcus we  are  justified  in  taking  a  more  con- 
servative stand,  while  in  the  presence  of  the  strep- 
tococcus, especially  the  Streptococcus  mucosas  cap- 
sulatiis,  we  should  interfere  surgically  as  soon  as 
the  slightest  doubt  arises. 

The  condition  for  which  we  operate  is  either  a 
thrombophlebitis  of  the  mastoidal  veins,  or  an  oste- 
itis with  destruction  of  bone — not  the  presence  of 
purulent  secretion  of  the  antrum  and  cells. 

6  West  i26th  Street. 


REPORT  OF  A  CASE  OF  CONGENITAL  HEART 
DISEASE.* 

Bv  William  N.  Bradley,  M.  D., 
Philadelphia, 

Assistant  I'liysician  to  the  Out  Patient  Denartmcnt  of  the  Cliildier.'.. 
Hospital  of  Philadelphia. 

In  presenting  this  case  no  attempt  will  be  made 
to  touch  upon  the  difYerent  forms  of  congenital 
heart  disease,  but  will  be  confined  to  a  considera- 
tion of  such  data  as  relate  to  the  form  of  anomaly 
here  shown. 

Congenital  heart  disease  occurs  as  the  result  of 
two  main  causes:  i,  Arrest  of  development  of  the 
embryologic  structures,  and  2,  intrauterine  foetal 
disease  occurring  after  the  development  of  the  dif- 
ferent parts  has  been  completed,  lioth  of  these 
causes  may  be  operative  irj  the  same  case.  The  con- 
dition arising  from  either  cause  results  in  irregu- 
larities of  the  circulation,  thereby  producing  symp- 
toms which  call  attention  to  its  existence. 

It  is  believed  that,  in  cases  due  to  arrest  of  foetal 

•Read  before  the  Philadel|>hia  I'»(liatric  Society,  Pcceniber  8, 
1 908. 


development,  this  occurs  before  the  eighth  week  of 
intrauterine  life.  Heredity  as  a  cause  is  believed 
in  by  Strehler,  Orth,  Friedberg.  Dobney,  and 
others.  Rheumatism  and  infectious  diseases  in 
pregnant  women  as  causes,  is  doubted  by  most 
writers.  Syphilis  may  ,  exert  some  slight  influence. 
Blood  relationship  in  parents  and  traumatic  and 
psychic  influences  upon  the  pregnant  mother  are 
also  mentioned. 

Associated  with  cases  of  arrest  of  cardiac  devel- 
opment in  the  foetus,  are  many  cases  of  develop- 
mental arrest  in  other  parts  of  the  body.  Rokitan- 
sky  reported  twenty-four  cases  of  defects  of  the 
saeptum,  eight  of  which  showed  such  anomalies. 
Vierordt  collected  700  cases  with  eighty  associated 
.anomalies.  Osier  studied  412  cases,  in  fifty  of 
which  occurred  additional  anomalies,  among  those 
mentioned  being  anencephaly,  hydrocephaly,  spina 
bifida,  umbilical  hernia,  atresia  ani,  cleft  palate, 
hare  lip,  etc.  Acute  endocarditis  as  a  causative  fac- 
tor in  congenital  heart  disease  was  first  advanced 
by  Kreysig,  and  has  been  vigorously  supported  by 
Rokitansky,  H.  Meyer,  and  others. 

In  the  case  here  presented  the  foramen  ovale 
was  patulous  and  there  was  almost  complete  steno- 
sis of  tho  pulmonary  artery.  The  ductus  arteriosus 
was  patulous.  The  foramen  ovale  normally  closes 
soon  after  birth,  but  it  is  frequently  found  patulous 
in  adult  life.  We  may  find  a  widely  patent  fora- 
men ovale  existing  without  any  signs  or  symptoms, 
or  disturbing  the  comfort  of  the  individual  or 
shortening  life.  Pulmonary  stenosis  is  found  to  be 
the  most  frequent  of  all  congenital  heart  anomalies, 
and  is  therefore  of  much  clinical  importance.  Com- 
plete atresia  is  rare,  yet  it  is  of  importance  from  a 
standpoint  of  prognosis,  to  distinguish  between  a 
simple  stenosis  and  a  complete  atresia.  In  cases  of 
stenosis,  the  foramen  ovale  and  ductus  arteriosus 
ne^irly  always  persist.  In  stenosis  of  the  pulmonary 
artery,  some  cases  occur  in  which  the  valves  are 
thickened  or  shortened  forming  a  thick  diaphragm 
which  may  project  into  the  artery  funnel  shaped, 
sometimes  being  perforated  by  a  small  circular  open- 
ing of  varving  size.  The  pulmonary  artery  in  such 
cases  may  be  dilated  above,  the  conus  below  shar- 
ing in  the  general  hypertrophy  of  the  right  ven- 
tricle. The  interventricular  septum  is  nearly  always 
closed,  thus  giving  evidence  that  the  stenotic  condi- 
tion resulted  from  an  inflammatory  process  in  later 
foetal  life,  after  the  heart  had  been  entirely  formed. 

Hypertrophy  and  dilatation  of  both  the  right 
auricle  and  ventricle  are  usually  present  in  these 
cases.  In  cases  of  pulmonary  stenosis,  unaccom- 
panied by  any  patency  of  the  interventricular  srep- 
tum,  the  left  ventricle  is  greatly  hypertrophied  and 
dilated,  both  auricles  share  in  this,  and  the  right 
ventricle  undergoes  true  concentric  hypertrophy, 
sometimes  being  as  in  this  case  almost  obliterated. 
The  small  amount  of  blood  which  reaches  the  lungs, 
is  said  to  be  replaced  by  dilatation  of  the  bronchial 
arteries  vicariously,  sometimes  also  of  the  oesopha- 
geal veins.  Cyanosis  is  of  course  the  most  prom- 
inent feature  of  these  cases  and  varies  in  the  in- 
dividual case,  depending  upon  the  pathological  con- 
dition present. 

In  cases  similar  to  the  one  under  consideration, 
the  cyanosis  would  be  present  at  birth  and  remain 


June  2b.  1 909.  J 


SIXGER:  ACTOIX  TOXICATION  AXD  ACETOXL  RIA. 


more  or  less  constant  due  to  the  admixture  of  blood 
through  a  patulous  foramen  ovale,  while  the  in- 
creased pressure  due  to  the  stenosis  of  the  pulmon- 
ary artery,  renders  it  impossible  for  nature  to  aid 
in  the  closure  of  the  same.  Likewise  the  cyanosis 
may  vary  in  intensity,  being  influenced  by  disease 
of  the  respiratory  organs,  physical  exertion,  crying, 
etc.  The  degree  of  cyanosis  may  be  an  index  as 
to  the  probable  length  of  life  of  these  patients. 

Physical  signs.  Enlargement  of  the  right  side  of 
the  heart  gives  increased  dulness  to  the  right.  On 
auscultation,  murmurs  are  heard  which  vary  in 
quality  and  intensity.  As  a  rule  dyspnoea  occurs, 
increased  by  bodily  exertion.  Paroxysms  of  cry- 
ing or  coughing  induce  attacks  of  suffocation  in 
which  the  children  sometimes  lose  consciousness, 
become  deep  blue  with  accelerated  and  thready 
pulse,  and  death  appears  imminent.  Growth  and 
nutrition  are  usually  affected.  The  temperature  is 
subnormal. 

[Prognosis.  In  cases  of  severe  grades  of  pulmon- 
arv  stenosis  associated  with  patulous  foramen  ovale, 
the  prognosis  is  necessarily  grave,  the  children  liv- 
ing from  a  few  hours  to  at  most  several  months, 
dependent  upon  the  grade  of  stenoses  and  the  pres- 
ence of  other  associated  anomalous  conditions 
which  might  provide  for  a  fairly  good  circulation 
and  oxygenation  of  the  blood.  If  such  is  the  case 
the  life  of  the  individual  may  be  prolonged.  Any 
nutritional  or  infectious  disease  may  have  a  dele- 
terious effect. 

Treatment.  The  children  should  be  breast  fed  if 
possible.  Bodily  temperature  should  be  maintained, 
there  should  be  prevention  of  infectious  diseases 
and  diseases  of  the  respiratory  tract.  Small  doses 
of  bromides  should  be  used. 

Case. — P.  M. ;  male  ;  w  hite  ;  United  States  nativity  ;  born 
.\ugnst  18.  190S..  was  brought  to  the  out  patient  depart- 
ment of  the  Children's  Hospital  October  3,  1908,  with  the 
following  nistory :  Tenth  child,  born  at  full  time,  labor 
instrumental,  breast  fed.  Father  and  mother  well.  All 
other  children  livnig  and  well.  There  was  no  history  of 
occurrence  in  any  of  the  other  children. 

Examination :  The  child  was  cyanosed  over  the  entire 
body.  The  lips.  gums,  and  buccal  mucous  membranes  were 
deep  purple,  as  were  also  the  fingers  and  toes.  Other  parts 
of  the  body  were  less  deep  in  color.  On  crying  the  cyan- 
osis became  extreme.  The  ape.x  beat  was  in  the  fifth  inter- 
space in  the  nipple  line.  The  cardiac  dulness  extended 
from  the  second  rib  to  apex,  and  from  the  right  border  of 
the  sternum  to  the  left  nipple  line.  A  murmur  replaced 
the  normal  sounds  heard  at  the  apex ;  this  occupied  the 
systole,  there  being  no  second  sound,  but  the  murmurs  heard 
were  separated  by  a  short  diastole.  Tliis  murmur  grew  in 
intensity  upward  and  inward  from  the  apex  toward  the 
sternum,  and  at  a  point  opposite  the  nipple  near  the  left 
border  of  the  sternum  it  appeared  to  be  at  its  ma.ximum, 
and  there  was  heard  here  a  double  murmur,  the  first  of 
which  was  low,  harsh,  and  grating;  while  the  second  was 
apparently  of  the  same  character  but  lower  in  pitch  and 
shorter  in  duration.  These  sounds  were  heard  with  less 
distinctness  over  the  aortic  area,  and  almost  imperceptibly 
at  the  pulmonic,  yet  they  could  be  distinguished.  Xo  thrill 
could  be  anywhere  detected.  Subcrepitant  rales  were  heard 
at  the  bases  of  both  lungs. 

The  baby  was  given  small  doses  of  sodium  bromide. 

Five  days  later  there  developed  at  the  bases  of  both  lungs 
a  bronchopneumonia,  and  the  child  succumbed. 

A  post  mortem  examination  was  with  difficulty  obtained, 
and  the  removal  of  the  specimen  was  for  obvious  reasons 
hurried,  so  that  many  points  of  interest  could  not  be  de- 
termined. 

Post  mortem  examination  :  The  body  was  mottled  purple 
over  the  face  and  upper  extremities,  but  the  lower  limbs 
were  a  diffuse  dusky  red. 


On  opennig  the  chest  we  were  impressed  with  the  large 
size  of  the  heart,  extending  as  it  did  from  the  right  nipple 
line  to  the  left  nipple  line,  and  from  the  level  of  the  second 
rib  to  the  fifth  interspace.  The  pericardium  was  not  ad- 
herent, and  the  amount  of  pericardial  fluid  was  about  nor- 
mal or  slightly  greater.  The  heart  weighed  90  grammes. 
The  left  auricle  was  about  normal,  the  left  ventricle  small, 
the  wall  varied  from  ^  to  cm.  in  thickness.  The  right 
auricle  was  enormously  dilated,  and  could  hold  approxi- 
mately 20  cm.  of  fluid.  The  right  ventricular  cavity  was 
small,  the  tip  of  the  forefinger  just  filling  the  same."  The 
right  ventricle  was  more  globular  in  shape,  the  muscular 
wall  was  enormously  hypertrophied,  being  equal  in  thick- 
ness to  that  of  the  left  ventricle.  The  foramen  ovale  wao 
large  and  patulous,  although  the  valvular  flap  was  thick 
and  well  developed.  The  orifice  of  the  pulmonary  artery 
was  practically  occluded  .ind  would  admit  only  a  small  probe. 
The  pulmonary  valve  leaflets  still  probably  contained  some 
muscular  tissue.  The  pulmonary  artery  above  the  valves 
was  thickened  and  dilated.  The  aortic  valves  seemed  thick- 
ened, somewhat  roughened,  and  with  some  slight  stenosis. 
The  ductus  .^rteriosis  was  patulous. 

It  was  obvious  that  the  largest  stream  of  blood  leaving 
the  right  auricle,  did  so  through  the  foramen  ovale,  while 
a  small  part  was  forced  into  the  right  ventricle.  From  the 
right  ventricle  it  escaped  through  the  orifice  in  the  pul- 
monary valve,  but  as  a  very  small  stream  only  could  get 
through,  it  resulted  in  an  enormous  hypertrophv  of  the 
right  ventricle.  The  blood  which  did  manage  to'  get  into 
the  pulmonary  arterj-.  part  of  it  went  to  the  lungs,  though 
some  of  it  probably  mixed  w  ith  that  which  flowed  from  the 
aorta  through  the  ductus  arteriosus.  The  blood  from  the 
left  auricle  consisted  of  that  returned  by  the  pulmonarv 
veins  and  that  received  from  the  right  auricle  through  the 
foramen  ovale,  and  left  the  left  auricle  by  wav  of  the 
aorta.  It  was  possible  that  some  of  this  might  bv  the  force 
of  the  hearfs  systole  have  been  driven  backward  through 
the  ductus  arteriosus.  And  it  was  likewise  probable  that  this 
current  of  blood  might  have  caused  the  dilatation  of  the 
pulmonary  artery  noticed  in  the  specimen  above  the  valve. 
The  cause  of  the  cyanosis  was  therefore  readilv  under- 
stood and  that  the  condition  present  would  have  been  in- 
compatible with  long  duration  of  life. 

Referenxes. 

Osier.    Modem  Medicine,  iv,  1908. 

Pfaundler  and  Schlossman.  Diseases  of  Children,  1908. 
1532  South  Sixth  Street. 


A  CASE  OF  SEVERE  AUTOINTOXICATION  WITH 
ACETONURIA  AND  EXTREME  BRADYCARDIA.* 

By  D.wid  a.  Singer.  A.  B.,  M.  D.. 
New  York, 

Recently  House  Physician,  Beth  Israel  Hospital. 

The  following  case  presents  points  of  sufificient 
interest  to  warrant  its  report. 

S.  H.,  merchant,  aged  twenty-eight,  was  admitted  to  the 
Beth  Israel  Hospital,  to  the  service  of  Dr.  Charles  Good- 
rnan,  on  January  9.  1908.  with  the  following  history:  Mar- 
ried for  four  years,  wife  giving  birth  to  three  children. 
An  excessive  user  of  tobacco  lor  years,  smoking  as  many 
as  twenty-five  cigarettes  daily.    Moderate  alcohol  habit. 

Previous  History:  Had  phlebitis  of  right  external  saphe- 
nous vein  one  year  ago,  and  six  months  later  in  the  other 
leg.  Slightest  exertion  of  late  always  resulted  in  consid- 
erable dyspnoea.  No  history  of  rheumatism,  cardiac,  renal, 
or  pulmonary  diseases.  During  past  eight  weeks  had  been 
in  New  Orleans  on  business,  where  he  felt  perfectly  well 
until  his  return. 

His  present  illness  dated  back  three  days.  While  patient 
was  returning  from  the  south,  he  began  to  feel  uncom- 
fortable on  the  train,  with  slight  headache  and  an  indefinite 
feeling  of  discomfort  in  the  abdomen,  which  he  later  attrib- 
uted to  the  fact  that  he  had  been  constipated  for  three 
davs  and  was  unable  to  obtain  a  cathartic.  In  the  evening 
he  perspired  profusely  and  drank  a  good  deal  of  mineral 
water.    The  following  day  on  arriving  home  he  complained 

*Read  before  the  Eastern  Medical  Society  on  March  13.  1908 


1304 


SINGER: 


AUTOINTOXICATION  AND  ACETONURIA. 


[New  York 
Medical  Journal. 


of  a  sensation  of  tightness  across  the  chest  and  took 
cathartics  with  little  relief. 

On  day  of  admission  to  the  hospital,  on  his  way  to  busi- 
ness, he  experienced  considerable  dyspnoea  upon  climbing 
railroad  stairs  and  had  a  severe  headache.  In  the  after- 
noon of  the  same  day,  he  began  to  feel  extremely  weak, 


minute.  Synchronous  with  this,  the  radial  pulse  was  felt. 
The  pulse  gradually  improved,  and  the  patient  returned  to 
consciousness.  He  was  then  transferred  to  the  hospital 
where  upon  admission,  the  following  notes  were  made : 

Patient  fairly  well  nourished  and  developed ;  markedly 
prostrated  and  cyanotic ;  semistuporous ;  breathing  labored. 


'Autointoxication  with  acetonuria  and  extreme  bradycardia.' 
January  9,  1908,  to  February  2,  1908. 


headache  persisting.  Two  liours  later  he  was  obliged  to 
lie  down  and  felt  as  if  death  was  imminent. 

His  physician,  who  arrived  somewhat  later,  found  him 
seated  on  the  toilet,  pulseless  and  unconscious.  The  pa- 
tient was  immediately  placed  in  a  prone  position  and  given 
heroic  hypodermic  doses  of  strychnine  sulphate,  nitro- 
glycerin, whiskey,  and  adrenalin  chloride  as  well  as  oxygen 
inhalations.    For  fully  forty  minutes  there  was  an  apparent 


He  vomited  several  times  foul  undigested  food  and  mucus. 
This  was  followed  by  several  attacks  of  faintness  with 
temporary  loss  of  consciousness.  Pupils  equal,  contracted, 
and  reacted  to  light  and  accommodation;  no  rigidity  of 
neck;  tongue,  moist  and  heavily  coated.  Lungs,  dimin- 
ished respiratory  murmur  all  over.  Heart  presented  physi- 
cal signs  of  marked  dilation,  extending  from  the  right 
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\utointoxication 

with  ace 

to 

ni 

ri 

a 

and 

extreme 

bradycardia." 

January  9,  1908,  to  February  2,  1908. 


absence  of  pulse  and  heart  sounds.  Patient  appeared  very 
pallid,  lips  and  finger  nails  cyanotic.  Pupils  were  moder- 
ately dilated,  conjunctival  reflexes  diminished.  During 
this  time  an  occasional  very  shallow  respiratory  effort  was 
observed.  After  this,  the  heart's  action  became  audible 
with  the  stethoscope  and  was  counted  at  four  to  the 


line.  Apex  impulse  not  visible,  heard  best  in  fifth  left 
interspace.  Sounds,  weak  muffled,  distant,  irregular  and 
extremely  .slow.  First  sound  at  apex  indistinct.  Radial 
pulse  .synchronous  with  heart  action.  Pulse  very  irregular, 
.soft,  slow,  eight  to  minute,  vessel  walls  slightly  thickened. 
Blood  pressure,  as  recorded  by  the  Stanton  sphygmom- 


June  26,  1909.] 


SfXGER:  AUTOINTOXICATION  AND  ACETONURIA. 


1305 


anometer  was  60.  Abdomen  was  distended  and  tympanitic, 
with  slight  tenderness  in  epigastrium ;  liver  and  spleen 
negative.  Reflexes  present.  Blood  examination.  Red 
blood  cells  4,870,000 ;  white  blood  cells  22,000 ;  polynuclears 
seventy-seven  per  cent :  small  lymphocytes  twenty  per 
cent.;  large  lymphocytes  three  per  cent:  haemoglobin  ninety 


and  course,  viz. :  Face  and  neck  becoming  flushed,  eyes  roll- 
ing up  in  sockets,  pulse  becoming  imperceptible,  and  arms 
slightly  rigid.  Reflexes  or  excitabilitj-  of  muscles  were  not 
increased.  No  evidences  of  disturbance  of  respiration. 
Patient  was  free  from  convulsions  for  four  hours,  then  they 
began  anew  continuing  in  more  rapid  succession,  but  of 


S.  H. — ".\utointo.xication  with  acetonuria  and  extreme  bradycardia. 
January  9,  1908,  to  February  2,  1908. 


per  cent.  Urine  examination.  Specific  gravity,  1.020;  mod- 
erate cloud  of  albumin ;  trace  of  acetone  and  indican ;  few 
granular  and  large  number  of  hyaline  casts.  Many  white 
blood  cells.    Temperature  99.8°  F. 

The  following  day  January  loth,  patient  still  prostrated ; 
cyanosis  however  less  intense.  V'omited  profusely  during 
early  morning- hours,  vomitus  being  of  greenish  mucoid 
consistence  and  foul  odor.  Pulse  still  irregular  but  of 
better  quality;  its  rate  was  counted  at  56.  Heart  sounds 
more  regular  and  distinct.  Urine — He  voided  two  and 
one  half  ounces  during  first  twenty-four  hours.  Faint 
trace  of  albumin  ;  sugar,  negative  ;  trace  of  indican  ;  marked 
acetone  reaction ;  diacetic  acid,  negative.  Some  granular 
and  many  hyaline  casts.    Stools,  very  offensive. 

During  the  next  two  days,  his  condition  remained  about 
the  same,  patient  complaining  of  pain  in  right  hypochon- 
drium.  Tempeiature  was  remittent  and  ranged 
between  99.8°  and  101.8°  F.  Pulse  still  slow,  weak, 
and  irregular  between  46  and  68  to  minute  ;  very 
changeable  in  rate  and  rhythm.  Heart  borders 
normal.  Urine,  acetone  present  and  on  the  increase. 

On  the  13th  day  of  January,  the  fifth  day  of  his 
illness,  the  patient  had  twitchings  of  the  upper  ex- 
tremities. There  were  four  such  attacks  in  rapid 
succession,  occurring  in  a  period  of  fifteen  minutes. 
In  the  next  four  hours  convulsions  were  very  fre- 
■quent,  occurring  every  ten  or  fifteen  minutes,  each 
of  one  half  minute  duration.  The  upper  extremities 
during  these  attacks,  were  in  a  condition  of  clonic 
contraction.  At  the  onset  of  the  convulsive  seiz- 
ures, patient  would  become  cyanotic,  his  pulse  at 
first  becoming  very  irregular  and  intermittent,  then 
imperceptible.  One  of  these  attacks  was  precipitated 
by  placing  the  chest  piece  of  the  stethoscope  over  the 
prrecordium,  and  on  ausculating  the  following  was 
lieard  :  Sounds  became  very  rapid,  markedly  weak 
and  irregular,  then  no  heart  sounds  could  be  heard 
till  the  attack  was  over.  This  corresponded  to  what 
\\as  felt  in  the  radial  artery.  During  convulsions  the 
patient's  face  bad  a  pained  and  frightened  look,  and 
eyes  were  turned  upwards.  These  attacks  would 
end  with  a  sigh  and  a  relaxation  of  the  affected 
parts.  No  biting  of  the  tongue ;  no  frothing  at  the 
mouth ;  no  incontinence  of  urine  or  fasces.  Al- 
though the  patient  appeared  apparently  unconscious 
during  the  attacks  still  he  was  rble  to  recall  events 
occurring  in  those  periods.  Convulsions  showed  a 
tendency  to  decrease  in  severity  and  duration  as  the 
Tday  proceeded,  at  times  taking  the  following  form 


shorter  duration  for  two  and  one  half  hours,  and  then 
ceased.  His  temperature  reached  its  highest  point,  102.6"  F., 
on  that  day.  The  urine  showed  a  gradual  increase  in  the 
acetone  and  indican  reactions  although  the  quantity  had 
gradually  increased  to  from  fifty  to  sixty  ounces  in  twenty- 
four  hours.    No  albumin  or  casts. 

The  sixth  day  of  his  illness,  January  14th.  Convulsions 
abated,  leaving  patient  in  a  very  much  exhausted  condition. 
Pulse  still  shows  variations  amounting  to  20  to  30  beats 
per  minute,  rate  32  to  60  to  the  minute.  Heart  borders 
were  normal ;  sounds  still  slow,  weak  and  irregular.  Urine, 
acetone  still  increasing. 

The  eighth  day,  January  i6th.  The  pain  in  the  right 
hypochondrium  persisted  and  stools  became  clay  colored 
and  offensive. 

The  twenty-fifth  day.  February  2nd.    The  last  named 


H. — "Autointoxication  with  acetonuria  and  extreme  bradycardia.' 
January  9,  1908,  to  February  2.  1908. 


1306 


SI.XGEK:  AUrOIMOXICAlIUy    AXl)  ACETONURIA. 


[New  York 
Medical  Tournal. 


symptoms  gradually  disappeared  at  the  end  of  the  tenth 
day.  The  acetonuria  and  indicanuria  persisted  for  eight 
days  than  suddenly  disappeared. 

The  general  condition  of  the  patient  gradually  improved 
and  he  sat  up  in  bed  on  the  eighteenth  day  and  was  out 
of  bed  twenty  days  after  admission  to  the  hospital.  The 
lieart  action  showed  a  marked  increase  in  force,  with  de- 
cidedly less  irregularity  in  rate.  Heart  borders  normal. 
Blood  pressure  recorded  at  80.  Pulse  rate  between  60  to 
70;  full,  still  irregular  but  improved  in  quality,  with  less 
variations  in  rate  and  rhythm. 

Patient  discharged  cured. 


Su  -=0  5-^ 

°o  -<u— J3ajaj.i=t- 

—  £_  =0  .-^         _>,u-5=.0  5cj.o 

B'Z        >'~  --t'ii^";!," 
>c  ;:,=.xx-C'-;iro. 

On    admissi.ni   .j.v>,>y,u-o  yo  22,ouo  77  20  3 

Following  day   ....  ..  17,000  80  16  4 

Fourth  day   ....  ..  18,000  75  20  5  . 

Fifth  diy  j. 165, 000  80  19,000  76  22  2 

Xintli   day   4.275,000  80  13,00a  76  20  2 

Nineteenth  Jay   3,600,000  80  13,000  64  28  4 

Twenty-third,  day...  4,560,000  90  13,000  75  22  2 

Examination  of  Blood. 

On  admission  the  following  diagnoses  presented  them- 
selves: Ptomaine  poisoning;  embolism  of  coronary  artery; 
gumma  of  ventricular  wall  of  the  heart;  Stokes-Adams 
syndrome ;  and  nicotine  poisoning. 

Embolism  of  coronary  artery  was  considered  most  im- 
probable by  the  duration  of  the  case,  for  here  death  is 
invariably  instantaneous. 

Gumma  of  heart.  In  favor  of  this  might  be  adduced  his 
youth,  the  sudden  onset  with  dyspnoea,  cyanosis,  extremely 
slow  pulse,  and  dilated  heart.  But  it  was  ruled  out  as  it 
did  not  account  for  the  acetonuria,  ofTensive  stools,  _  and 
vomiting,  and  by  the  absence  of  a  history  of  syphilis  in 
patient  or  family. 

Stokes-Adams  syndrome,  which  may  be  classified  as  a 
group  of  symptoms  prominent  among  which  are  paroxys- 
mal bradycardia,  faintness,  and  syiicope  with  partial  or 
total  respiratory  failure  \vas  also  considered.  But  the 
youth  of  the  patient,  the  history,  the  absence  of  marked 
arteriosclerosis,  chronic  myocardial  and  endocardial  lesions 
which  are  the  usual  pathological  antecedents  in  this  condi- 
tion safely  excluded  the  disease  described  by  Stokes  and 
Adams.  Furthermore,  it  was  excluded  because  there  were 
no  signs  of  disassociation  between  the  auricular  and  ven- 
tricular portions  of  the  heart. 

It  was  evident  from  the  start  and  also  in  view  of  the 
subsequent  incidents  of  the  case,  that  we  had  to  deal  with 
a  profound  toxaemia.  The  highly  offensive  stools  and 
vomitus.  the  sudden  onset  of  the  disease  after  days  of 
constipation  and  the  condition  of  the  urine,  especially  the 
enormous  quantity  of  acetone  in  a  urine  without  sugar 
served  to  confirm  our  diagnosis  which  was  later  borne  out 
by  the  following  data : 
"  (a)  History  of  gastrointestinal  derangement  and  the 
presence  of  the  following  symptom  complex,  headache, 
di^^ziness.  and  finally  symptoms  of  collapse,  slow  weak 
pulse  and  cyanosis,  as  well  as  the  alidominal  symptotns 
such  as  vomiting,  diarrhoea,  foul  clay  colored  stools,  and 
in  addition  the  indicanuria,  are  sufficient  evidence  of  this 
intoxication. 

(b)  Furthermore  the  convulsions  and  attacks  of  slow 
pulse  already  mentioned  are  further  examples  of  toxic 
ab-orption  from  the  gastroenteric  tract,  the  onvulsion  = 
being  motor  cerebral  discharges,  the  attacks  of  slow  and 
imperceptible  heart  and  pulse  beats  having  as  their  cau-e 
the  effect  of  these  toxins  on  the  vagal  centres  in  the 
medulla. 

(c)  The  repeated  presence  and  increasing  amounts  of 
acetone  in  the  urine  above  the  normal  phvsiolocical  quan- 
tity viz.  one  to  three  centigrammes  during  a  day.  giving 
rise  to  the  condition  known  as  acetonuria. 

It  is  not  the  intention  of  the  writer  to  enter  into  p  dis- 
cussion of  the  acetone  group  or  their  antecedents.  Their 
nresence  in  the  urine,  however,  lias  long  been  known  to 
indicate  the  existence  of  grave  disturbances  of  metabolism 
This  doubtless  obtains  in  the  case  iu'^t  cited  and  becomes 
more  evident,  when  such  prime  xfiological  f.nctors  in  the 
nroduction  of  acetonuria  as  inanition  and  diabetes,  are 
lacking. 

The  symptoms  referable  to  the  liver  were  pi*obablv  due 
to  the  attempt  and  the  failure  on  the  part  of  this  organ  to 


exercise  its  detoxicating  ability,  the  toxic  products  of 
digestion  having  been  arrested  m  the  liver  which  soon 
proved  inadequate  to  discharge  this  function.  The  same 
toxic  products  gave  rise  to  the  urinary  picture  at  the  onset 
of  the  illness  viz.  the  large  amount  of  albumin,  hyaline, 
and  granular  casts,  with  the  diminution  m  urinary  excre- 
tion, by  their  irritating  actions  on  the  kidney  parenchyma, 
causing  a  toxic  nephritis  which  resolved  on  the  disappear- 
ance of  these  substances  from  the  body.  During  the  con- 
vulsions the  question  arose  as  to  whether  or  not  our  case 
was  one  of  uraemia.  But  the  fact  that  the  urine  had  been 
steadily  increasing  in  amount  and  was  free  from  albumin 
or  casts  excluded  it.  A  further  proof  that  these  attacks 
were  not  due  to  nephritis  or  to  primary  cardiac  disease 
but  were  cerebral  in  origin  and  precipitated  by  a  toxaemic 
acetonuria,  was  shown  by  their  cessation  and  the  increased 
strength  and  regularity  of  the  cardiac  contractions,  on  the 
disappearance  of  acetone  from  the  urine. 

The  fact  that  our  patient  was  addicted  to  the  nicotine 
habit  weakened'^liis  heart  muscle  by  interference  with  the 
vagal  ganglia,  thus  lessening  its  resistance  and  rendering 
it  more  liable  to  disturbance  in  its  rate  and  rhythm,  by 
stimuli  from  other  organs  of  the  body. 

The  leucocytosis  of  22,000  is  an  unusual  and  interesting 
feature  of  the  case.  It  is,  as  a  rule,  not  found  in  toxaemia, 
and  though  we  believe  it  was  probably  inflammatory  we 
are  not  prepared  to  explain  it. 

This  case  llien.  presents  the  following  points  of 
interest : — 

1.  Acetonuria. 

2.  Bradycardia.  We  have  here  one  of  the  most 
remarkable  cases  of  it  in  the  literature,  as  evidenced 
by  the  fact  that  the  pulse  registered  from  4  to  8 
to  the  minute  and  was  synchronous  with  the  heart 
beat.  This  shows  the  extreme  grade  of  the  intox- 
ication of  the  inhibitory  vital  centres  and  of  the 
myocardial  degeneration. 

3.  Leucocytosis  of  22,000. 

4.  Two  separate  and  distinct  toxa;mias  on  the 
one  hand,  a  clear  history  of  chronic  nicotine  poison- 
ing, and,  on  the  other,  superimposed,  an  acute  in- 
fection justified  by  the  history  and  symptoms  es- 
peciallv  the  acetonuria,  indicanuria,  an;em;a,  and 
convulsions. 

.\  word  as  to  the  therapy  pursued :  The  hypodermoclyses 
and  frequent  rectal  injections  of  saline  at  from  115°  to 
120°  F.  were  all  of  great  value  in  improving  the  pulse  and 
general  condition  as  well  as  serving  to  dilute  the  toxines 
that  were  being  manufactured  within  the  intestinal  canal 
and  to  diminish  the  absorption  of  the  products  of  putre- 
faction. A  similar  effect  in  our  efforts  to  cleanse  the  ali- 
mentary tract  was  produced  by  small  and  frequently  re- 
peated doses  .of  calomel  and  the  morning  doses  of  Carlsbad 
salts. 

At  the  onset  of  the  patient's  illness,  heroic  stimulation 
was  required  and  employed  hypodermically.  Strychnine 
sulphate,  caffeine  sodium  benzoate,  and  camphor  in  ether 
(ten  per  cent.)  and  in  olive  oil  (twenty  per  cent.)  being 
administered  in  sufficient  quantity  and  kept  up  in  gradually 
diminished  doses  till  the  end  of  the  eighth  day.  when  they 
were  discontinued.  During  the  convulsive  seizures  strych- 
nine sulphate  which  had  been  given  in  doses  of  gr.  1/30, 
four  times  daily,  was  omitted  at  once,  not  because  we 
feared  poisoning,  but  because  we  did  not  wish  to  increase 
the  reflex  excitability  of  the  motor  centres  of  the  1)rain. 
Dionin.  gr.  '4  relieved  his  restlessness  and  irritability,  giv- 
ing him  several  hours  of  sleep.  Morphine  sulphate  was 
ineffectual.  Hypodermoclyses  of  warm  saline  (200  c.c.) 
proved  valuable  at  this  period.  The  aromatic  spirit^  of 
ammonia  and  oxygen  inhalations  were  beneficial  in  faint- 
ing spells  and  during  frequent  attacks  of  weakness.  Strych- 
nine sulphate  gave  good  results  by  its  familiar  stimulation 
of  the  myocardium.  The  iron,  viz.  etheral  tincture  of 
ferric  chloride  was  given  for  the  anasmia  due  to  the  degen- 
eration of  the  red  blood  cells  always  incident  to  such 
toxaemias.  Finally,  the  rectal  injections  of  sodium  bicar- 
bonate (one  per  cent.')  while  slightly  irritating  served  to 
counteract  the  acid  intoxication  and  furnished  the  neces- 
sary alkali  so  usually  successful  in  these  cases. 

Diet;  Diet  for  the  fir<t  three  days  consisted  of  albumin 


lulle  26,   1909. J 


UOTER:  PHARMACOLOCY. 


1307 


water,  zoolak,  and  peptonized  milk.  For  the  next  four 
days  in  addition,  large  quantities  of  fat  in  the  form  of 
butter  and  cream,  sago  and  milk.  During  the  second  week, 
•^craped  beef  and  cooked  fruit  were  added  to  the  dietary. 
Regular  diet  at  the  beginning  of  third  week. 

The  patient  has  resumed  his  former  occupation  as  mer- 
chant and  feels  entirely  recovered. 

The  writer  desires  to  express  liis  thanks  to  Dr. 
Isaac  Adler.  consulting  physician,  and  to  Dr. 
Charles  Goodman,  associate  visiting  surgeon,  to  the 
Beth  Israel  Hospital,  for  their  kind  permission  to 
l)nblish  this  case  and  also  for  many  hints  and  sug- 
gestions in  preparing  same :  and  to  the  members  of 
tlie  medical  house  staff  for  their  cooperation  and 
assiduity  in  the  laboratory. 

17  West  Oxe  Hundred  axd  Fifteexth  Street. 

PHARMACOLOGY. 

A  Brief  Resume  of  the  General  Physiological  Effects  of 
Drugs. 

By  Clai«ence  A.  Hofer,  M.  D., 
Philadelphia, 

Assistant  Demonstrator  of  Pharmacology,  University  of  Pennsylvania. 

The  value  of  pharmacology  and  its  importance  to 
the  general  practitioner  is  not  fully  appreciated  hy 
many  physicians,  this  is  probably  due  to  their  not 
clearly  understanding  the  relation  that  this  branch 
of  medical  science  bears  to  the  treatment  of  diseases. 

Almost  all  of  our  exact  knowledge  of  the  action 
of  drugs  has  been,  thus,  obtained,  as  a  result  some 
of  the  older  drugs  have  found  a  more  important 
place  in  therapeutics  and  are  now  used  rationally 
instead  of  empirically,  as  an  illustration,  some  years 
ago  such  a  valuable  drug  as  digitalis  was  considered 
by  the  most  careful  clinical  observers  to  act  as  a 
cirdiac  depressant  and,  therefore,  recominended  to 
be  used  with  catition  when  the  heart  was  enfeebled  : 
until  Blake,  in  1839.  demonstrated  that  the  blood 
pressure  was  greatlv  raised  when  digitalis  was  i'l- 
jected  into  the  arterial  system,  later  Traube  in  1862 
experiinented  on  mammalian  circulation,  and  Fagg? 
and  Stevenson  on  the  frog's  heart. 

Some  drugs  long  in  use  have  been  replaced  by 
newer  and  superior  acting  drugs,  also,  the  true  valu? 
of  the  active  principles,  alkaloids,  glucosides,  etc., 
have  been,  thus,  demonstrated. 

Pharmacology  in  the  broad  sense  of  its  scope  is 
the  science  by  which  the  mode  of  action  of  drtigs 
has  been  determined,  by  observation  on  man  and 
experimental  research  on  the  lower  animals,  the 
basis  of  which  is  physiology,  pathology,  and  chem- 
istry. 

Drugs  alter  or  modify  functional  activity  of  liv- 
ing tissues  of  the  body,  we  must  first  decide  what 
special  tissue  is  to  b'e  stimulated  or  depressed,  and 
from  our  knowledge  of  the  pharmacological  action 
select  our  drugs  accordingly  ;  after  absorption  drug^ 
are  carried  to  all  tissues,  but  certain  ones  have  se- 
lective action  on  certain  tissues,  for  instance  atro- 
pine on  the  nerves,  depressing  or  paralyzing  the 
termination  of  certain  nerves,  especially  those  of  the 
secretory  glands,  plain  muscles,  and  the  heart ; 
curare  on  the  motor  nerve  endings,  overshadowing 
all  its  other  effects,  caffeine  on  all  muscle  fibre, 
striped,  plain,  and  cardiac. 

The  specific  action  of  a  drug  is  usually  due  to 
its  chemical  interaction  with  some  constituent  of 
the  living  cell ;  the  pharmacological  action  mav  be 


recognized  and  the  chtmical  constiaient  of  the  drug 
determined ;  when  the  composition  of  a  drug  is 
altered,  even  very  slightly,  the  physical  character  is 
also  changed  and  in  turn  influences  the  pharma- 
cological action,  the  altered  action  may  not  be  due 
to  the  formation  with  the  living  cell  a  different  type 
of  reaction,  but,  that  it  is  more  completely  absorbed 
or  more  perfectly  ionized  or  more  readily  penetrates 
the  cell,  etc. 

Some  drugs  may  be  taken  up  by  the  cells  and 
more  or  less  destroyed,  as  with  morphine,  which  is 
partiallv  destroyed  in  the  tissues,  if  the  animal  is 
tolerant  the  destruction  is  much  greater  than  nor- 
mal, while  other  drugs  form  such  a  loose  combina- 
tion, as  strychnine,  all  of  which  is  excreted.  Con- 
structive (anabolic)  and  retrograde  (catabolic) 
protoplasmic  changes  occur  in  definite  order;  it  has 
been  suggested  as  probable,  that  living  matter  pro- 
duces its  internal  changes  through  the  agencv  of 
ferments,  each  having  a  limited  degree  of  action, 
numerous  ferments  can  be  obtained  from  living 
structure,  thus,  about  twenty  have  been  extracted 
from  the  liver. 

Drugs  are  modified  in  their  action  by  the  relative 
amount  of  drug  and  tissue  acted  upon,  thus,  the 
relative  toxic  action  of  opium  in  children  may  be 
accounted  for  by  its  action  on  the  central  nervous 
systein.  which  is  one  of  the  last  tissues  to  reafh 
maturity. 

Inert  chemical  substances  which  are  absorbed  and 
excreted  without  forming  any  combinations  in  the 
body,  exert  a  greater  or  lesser  narcotic  action  ;  the 
most  powerful  narcotic  substances  are  those  which 
combine  a  very  slight  solubility  in  water,  with  a  very 
high  solubility  in  ether,  olive  oil  or  brain  lipoid, 
such  drugs  tend  to  accumulate  in  the  cerebral  cells, 
as  they  contain  a  much  larger  percentage  of  "lipoid 
matter,"'  and  are  more  sensitive  to  alterations  in 
their  compositions  than  other  cells. 

The  action  of  a  drug  should  be  considered  as  far 
as  possible,  first  outside  of  the  body,  its  effects  on 
protozoa,  bacteria,  or  ferment  action,  chemical  ac- 
tion on  proteids,  then  its  local  action  on  the  skiit 
and  mucous  membranes  of  the  mouth,  stomach,  and 
intestines,  the  direct  or  reflex  action  on  digestion, 
muscular  movements,  vascularity,  etc. 

The  effect  of  drugs  may  be  produced  in  one  of 
several  ways,  by  a  physical  action  on  the  alimentarv 
canal,  as  bismuth,  which  is  only  absorbed  in  minute 
amounts,  into  the  system  ;  osmosis  is  another  physi- 
cal means  by  which  drugs  may  act,  the  potassium, 
sodium,  lithium,  ammonium,  chlorine,  bromine,  anrl 
iodine  ions  are  rapidly  absorbed  into  the  tissues, 
while  magnesium  sulphate  ions  are  very  slow- 
ly absorbed,  when  a  salt,  the  result  of  the  union 
of  an  electropositive  and  an  electronegative  element, 
is  administered,  as  potassium  citrate  or  magnesium 
sulphate,  it  ionizes  when  dissolved  in  water  and  is 
broken  up  or  dissociated  into  its  electropositive  and 
its  electronegative  elements,  they  attract  fluids  and 
by  osmosis  become  isotonic  with  fluids  in  surround- 
ing tissues,  hence,  when  slowly  ionized,  an  increas  • 
in  fluids  in  the  intestines  occur,  and  by  the  increase 
in  bulk  peristalsis  is  increased. 

Manv  drugs  exert  their  effects  by  chemical  ac- 
tion, as  the  astringent  action  of  tannin  and  metallic 
salts  of  iron  combine  with  albumin  and  form  insolu- 
ble albuminates,  or  the  combining  of  an  acid  radicle 


FAULKNER:  HYDROCHLORIC  ACID  IN  STOMACH. 


[New  Vokk 
Medical  Journal. 


with  a  basic  radicle  and  form  a  salt,  as  calcium 
citrate ;  calcium  is  essential  to  certain  unorganized 
ferments  as  rennet  and  fibrin  ferment,  as  well  as 
living  protoplasm. 

The  time  of  administration  of  a  drug  should  al- 
ways be  considered,  as  the  rate  of  absorption  is  in- 
fluenced and  the  action  modified,  by  the  condition 
of  the  gastric  contents,  naturally  after  meals  ab- 
sorption is  much  slower  than  between  meals,  there- 
fore, when  the  indication  is  for  rapid  absorption  or 
local  action  on  the  stomach,  the  administration 
should  be  between  meals,  on  the  other  hand,  when 
it  is  desired  to  retard  or  prolong  the  action  or  pre- 
vent the  local  action,  as  with  irritants,  like  arsenic, 
or  when  the  drug  combines  with  albumin  like  tan- 
nin, they  should  be  administered  after  meals ;  hyp- 
notics should  be  administered  before  bedtime,  and 
purgatives  in  the  evening. 

Care  must  be  exercised  during  pregnancy  and  lac- 
tation, active  purges  by  reflex  stimulation  of  the 
uterus  may  cause  abortion ;  many  drugs  are  ex- 
creted in  the  mother's  milk,  and  great  care  should 
be  taken  lest  the  infant  be  poisoned. 

It  is  important  to  consider  the  absorption,  in 
what  form  the  drug  is  absorbed,  from  what  part  of 
the  alimentary  canal,  the  rapidity  of  absorption  and, 
also,  elimination,  from  what  organ  or  organs  does 
it  occur,  whether  from  bowels,  kidneys,  salivary 
glands,  and  also,  its  effect  in  modifying  or  altering 
the  secretions ;  some  drugs  are  changed  in  composi- 
tion, as  for  instance  tartrates  and  citrates  are  ex- 
creted as  carbonates  from  the  kidneys,  the  urine, 
therefore,  becomes  more  alkaline ;  to  know  about 
how  rapidly  a  drug  is  eliminated  is  most  essential, 
for  some  drugs  are  very  rapidly  eliminated  or  de- 
stroyed in  the  system,  as  the  nitrites,  while  some 
drugs  are  very  slowly  eliminated,  as  digitalis. 

Cumulative  effects  may  be  due  to  the  absorption 
being  more  rapid  than  elimination,  as  in  lead  poison- 
ing, or  when  the  preceding  dose  is  not  eliminated 
before  the  succeeding  dose  is  administered  and  ab- 
sorbed ;  or  by  inconstant  ab.sorption,  as  during  path- 
ological changes  (ascites)  may  temporarily  retard 
absorption  and  when  the  conditions  become  favor- 
able for  absorption  the  accumulated  doses  may  be 
absorbed  in  toxic  amounts ;  may,  also,  be  caused  by 
lowering  the  resisting  power  of  the  tissues,  or,  bv 
using  up  their  elements  that  are  required  to  unite 
or  neutralize  the  poison  ;  other  factors  whicli  tend 
toward  it  are  the  weight  and  the  age,  young  an'mils 
are  more  susceptible  to  drugs  than  older  ones. 

Tolerance  is  the  next  to  be  considered,  this  mav 
be  accomplished  by  drugs  being  eliminated  faster 
than  they  are  absorbed,  as  an  illustration,  curare  : 
or  it  may  be  due  to  a  greater  resisting  power  of  the 
organism,  habituation,  relative  immunity  in  animals. 

The  action  of  drugs  in  disease  is  capable  of 
producing  the  same  effects  as  on  healthy  animals, 
but  the  degree  may  be  efYected,  as  illustrations,  dig- 
italis slows  the  heart,  but,  when  rapid  as  in  valvu- 
lar defect,  the  relative  slowing  is  much  more 
marked;  pilocarpine  by  its  action  on  the  nerve  end- 
ings in  the  sweat  glands  causes  sweating,  if,  h  w- 
cver,  the  spinal  cord  is  crushed,  there  is  little  m  in- 
ifestation  l)clow  the  fracture,  thought  to  be  due  lo 
possible  overshadowed  inhibitory  imi)ul.ses. 

Physicians  have  another  very  important  and  seri- 
ous factor  to  take  into  c(in>;i(leratinn.  when  calculat- 


ing the  efifects  of  some  of  the  important  drugs,  that 
is  the  variableness  in  the  active  constituents  of  the 
drugs,  from  which  the  pharmaceutical  prepara- 
tions are  made,  unfortunately  excepting  those 
vegetable  drugs  for  which  a  fixed  standard  of 
strength,  based  upon  some  one  or  more  important 
active  constituents  have  been  fixed  by  the  United 
States  Phart)iacopa:ia,  as,  for  instance,  opium  as- 
sayed for  the  morphine ;  nux  vomica,  assayed  for 
the  strychnine  it  contains ;  cinchona,  assayed  for  the 
total  alkaloids  it  contains,  etc.  The  physician  cannot 
count  with  any  degree  of  certainty  on  the  physio- 
logical activity ;  such  very  important  drugs  as  ergot, 
digitalis,  and  Indian  cannabis  are  especially  liable  to 
wide  variance  in  activity,  and  from  our  present 
knowledge  of  chemistry  of  these  and  similar  drugs, 
it  would  appear  that  it  will  be  necessary  to  fix  a 
physiological  standard. 

It  is  every  physician's  duty  to  himself  and  his  pa- 
tients to  know,  as  far  as  possible,  the  action  of 
drugs  on  the  organism,  those  who  treat  cases  with 
routine  prescriptions,  without  due  consideration  for 
the  pharmacological  action,  certainly  are  not  ob- 
taining the  best  possible  results. 


NO  FREE  HYDROCHLORIC  ACID  IN  THE 
STOMACH. 
By  Richard  B.  Faulkner,  M.  D., 
Pittsburgh,  Pa. 

Free  hydrochloric  acid  is  not  a  normal  constituent 
of  the  human  gastric  juice.  Its  presence  in  the 
human  stomach  has  never  been  demonstrated. 
Color  tests  are  worthless.  Physiological  chemistry 
presents  no  problem  more  difficult  than  the  determi- 
nation of  free  hydrochloric  acid  in  the  gastric  juice. 
Medical  writers  have  invaded  this  field  in  chem- 
istry, and  with  opinion  and  assumption  have  at- 
teniDted  to  set  aside  some  of  the  best  established 
facts  in  chemistry.  Their  statements  are  vague, 
contradictory  and  confusing. 

As  an  example  of  the  medical  tangle,  please  note 
the  following  remarks  of  Professor  William  H. 
Howell,  of  the  Johns  Hopkins  University,  in  his 
t-KZ^Wtnt  .Textbook  of  Physiology,  second  edition, 
1908,  page  706:  "Satisfactory  complete  analyses  of 
the  human  juice  have  not  been  reported.  .  .  .  All 
recent  experiments  tend  to  prove  that  the  acidity  is 
due  to  HCl"  (page  707).  Scientific  data  are  not 
established  by  "experiments  that  tend  to  prove." 
This  is  meaningless  phraseology.  Professor  Howell 
states  farther  (page  707)  :  "The  gastric  juice  is 
the  only  secretion  of  the  body  that  contains  a  free 
rcid.  The  fact  that  this  acid  is  a  mineral  acid  and 
is  f)resent  in  considerable  strength  makes  the  cir- 
cumstance more  remarkable.  .  .  .  With  regard  to 
the  origin  of  the  acid  it  is  evident  it  is  formed  in  the 
secreting  cells,  since  none  exists  in  the  blood  or 
lymph.  It  seeins  also  perfectly  evident  that  the 
1  TCI  must  be  formed  from  the  chlorides  of  the 
blood.  The  chief  chloride  is  the  NaCl  and  by  some 
means  this  com])ound  is  broken  up ;  the  chlorine 
is  combined  with  hydrogen,  and  is  then  secreted 
upon  the  free  surface  of  the  stomach  as  HCl"  (page 
708). 

In  what  manner  tlie  stomach  renders  itself  im- 
mune to  corro'iion  when  "free  hydrochloric  acid  in 


June  26,  1909.] 


FAULKNER:  HYDROCHLORIC  ACID  IN  STOMACH. 


1309 


considerable  strength"  is  secreted  upon  its  surface 
Professor  Howell  fails  to  state.  It  would  also  be 
of  interest  for  the  professor  to  state  the  manner  in 
which  he  thinks  free  hydrogen  occurs  in  the  stom- 
ach? There  is  only  one  way  in  which  free  hydro- 
chloric acid  can  be  obtamed  from  a  chloride.  But 
there  are  no  means  by  which  hydrochloric  acid  can 
be  set  free  from  a  chloride  while  in  the  blood, 
stomach,  or  anywhere  in  the  human  body.  It  is 
absolutely  impossible.  Professor  Howell  seems  to 
have  faith  in  iiis  conjectures,  while  he  ofifers  no 
proof  of  the  alleged  "fact  that  the  acid  is  a  mineral 
acid" ;  no  proof  that  "it  is  evident  it  is  formed  in 
the  secreting  cells" ;  no  proof  that  "it  seems  also 
perfectly  evident  that  the  HCl  must  be  formed 
from  the  chlorides  of  the  blood" ;  no  proof  that  free 
hydrochloric  acid  "is  secreted  upon  the  free  sur- 
face of  the  stomach  as  HCl" ;  no  proof  that  free 
hydrogen  occurs  in  the  stomach.  Not  alone  no 
proof,  but  the  professor  has  stated  that  "satisfac- 
tory complete  analyses  of  the  human  juice  (gas- 
tric) have  not  been  reported."  Perhaps  he  means 
no  satisfactory  analysis  has  been  reported  of  the 
juice  before  it  has  escaped  from  the  secreting  cell<^  , 
before  it  has  been  secreted  upon  the  free  surface 
of  the  stomach? 

C.  A.  Ewald  {Diseases  of  the  Stoinacli,  second 
edition,  1901,  page  18)  states  that,  "Dr.  Boas  and 
myself  have  corroborated  the  results  of  Tieder- 
mann  and  Gmelin  and  others,  that  normally  there 
is  no  gastric  juice  in  the  stomach  when  fasting." 
And  on  page  19  he  states  :  "I  cannot  admit  that 
Schreiber's  experiments  are  convincing,  and  that 
the  glands  of  -the  stomach  unlike  all  other  secreting 
glands,  are  active  without  any  specific  stimulation." 
"Pawlow  has  shown  that  mechanical  stimulation 
of  the  gastric  mucous  membrane  has  no  effect  on 
the  secretion  of  the  tubules"  (Howell,  page  709). 
"The  secretion  of  hydrochloric  acid  occurs  at  the 
moment  when  the  glandular  cells  are  stimulated  to 
activity  by  the  ingestion  of  food"  (Ewald,  page 
25).  "All  authors  seem  to  agree  that  the  best  time 
to  examine  the  stomach  contents  for  practical  pur- 
poses is  at  the  height  of  digestion"  (Franz  Riegel, 
Diseases  of  the  Stomach,  1904,  page  76).  One 
hour  after  the  ingestion  of  Ewald's  test  breakfast 
is  the  time  selected  by  authorities.  "The  most  im- 
portant part  in  the  chemical  examination  of  the 
stomach  contents  is  the  determination  of  free  hy- 
drochloric acid"  (Riegel.  page  89).  "The  tests  for 
free  hydrochloric  acid  \vhich  are  of  chemical  value 
all  depend  upon  color  reactions"  (Professor  Her- 
mann Sahli,  Diaj^nostic  Methods.  1906,  page  372). 
"The  test  for  the  presence  of  free  hydrochloric 
acid  now  almost  universally  employed  is  one  in- 
troduced by  Giinzburg"  (Striimpell,  Textbook  of 
Medicine,  third  edition.  1901,  page  417).  "Giinz- 
^  burg's  test  is  the  most  reliable,  it  will  detect  the 
presence  of  hvdrochloric  acid  even  when  in  very 
great  dilution"  (Dr.  C.  Jacob,  Internal  Medicine 
and  Clinical  Diagnosis.  1898,  page  85).  "The  best 
and  simplest  test  is  that  of  Giinzberg"  (W. 
Osier,  Practice  of  Medicine,  1892,  page  345). 
"This  test  is  not  interfered  with  by  albuminates, 
acid  salts,  or  organic  acids"  (Pepper,  American 
Practice  of  Medicine.  1894,  v.  it.  page  735). 
"Giinzburg's  reagent,  it  is  true,  gives  more  uni- 
form results  than  Congo  paper,  as  the  former  re- 


acts only  to  free  hydrochloric  acid,  whereas  Congo 
paper  also  reacts  to  other  free  acids"  (Riegel,  page 
ybj.  "Gunzburg's  reaction,  however,  admits  of 
only  one  interpretation — the  presence  of  free  hy- 
drochloric acid.  It  not  only  admits  of  but  one 
meaning,  but  also  is  the  most  sensitive  of  all  the 
tests"  (Sahh,  page  373). _ 

A  distinct  conflict  of  opinion  exists  between 
chemists  on  the  one  side  and  medical  writers  on 
the  other.  The  chemists  maintain  that  free  hydro- 
chloric acid  is  never  found  in  nature,  except  as  an 
occasional  volcanic  product.  While  medical  writers 
assert  that  it  is  always  present  in  the  human  stom- 
ach. The  chemists  say  that  to  determine  its  pres- 
ence in  the  human  stomach  is  extremely  difficult,  if 
not  impossible,  and  if  possible  at  all,  it  can  be  ac- 
complished only  by  chemical  analysis  and  by  an 
expert  analyst. 

Hydrochloric  acid  is  a  transparent,  colorless 
liquid  ;  irrespirable,  suffocating  odor  ;  corrosive  ;  ex- 
posed to  the  air  it  emits  white  fumes ;  and  when  in 
contact,  blackens  organic  substances  like  sulphuric 
acid.  Dip  your  finger  into  hydrochloric  acid  and 
observe  the  effect.  After  that  imagine  the  effect  in 
the  stomach.  "Uncombined  hydrochloric  acid  is  not 
found  in  nature,  except  as  an  occasional  volcanic 
product"  (Brande  and  Taylor,  page  216).  "Hy- 
drochloric acid  occurs  in  the  uncombined  state 
among  the  gases  emitted  by  active  volcanoes" 
(National  Standard  Dispensatory  of  the  United 
States,  eighth  edition,  1905,  page  50). 

For  what  reason  should  hydrochloric  acid  be 
present  in  the  stomach?  It  is  not  necessary.  No 
mineral  acid  is  necessary  in  the  process  of  diges- 
tion. "HCl  has  no  particular  property  in  render- 
ing the  digestive  power  of  the  gastric  juice  more 
energetic"  (Pavy,  Food  and  Dietetics).  "In  labora- 
tory experimentation  other  acids  may  be  used  in 
place  of  hydrochloric  acid  in  producing  artificial 
digestion"  (Howell,  page  713). 

Ewald.  evidently  doubtful  of  the  value  of  the 
new  fangled  chemical  observations,  of  color  testing, 
remarks  :  "Unlike  many  other  investigators  in  this 
field,  I  have  maintained  that  we  ought  not  to  be 
too  one  sided  in  laying  undue  stress  upon  the  newly 
acquired  knowledge  of  the  chemical  processes  of 
gastric  digestion"  (Diseases  of  the  Stomach,  1901, 
page  i). 

A  color  test  is  not  a  chemical  analysis.  Sources 
of  error  are  infinite  in  color  testing.  Sahli,  the  as- 
tute diagnostician,  says:  "An  objection  to  two  of 
these  tests,  methylviolet  and  tropseolin,  is  that  free 
organic  (especially  lactic)  acid  will  produce  the 
same  color"  (page  373).  "Another  objection  to 
these  color  tests  cannot  be  disposed  of  so  easily. 
They  may  be  negative,  and  still  free  hydrochloric 
acid  be  present,  but  'masked'  by  other  substances. 
The  same  objection  applies  to  tropaeolin  and  to 
phloroglucin — vanillin  ;  in  fact,  to  all  the  tests  for 
free  hydrochloric  acid  which  are  known"  (Sahli, 
page  373). 

All  color  tests  are  unreliable.  That  of  Giinz- 
burg is  no  exception.  It  is  impossible  for  them  to 
determine  the  presence  of  hydrochloric  acid.  Giins- 
bnro^'s  test  is  not  a  test  for  free  hydrochloric  acid. 
It  will  show  the  presence  of  free  hydrochloric  acid 
where  none  existed  previous  to  its  application.  So- 
dium chloride  is  a  constituent  of  the  gastric  juice. 


1310 


I'AULKXER:  HYDROCHLORIC  ACID  IN  STOMACH. 


[New  York 
Medical  Journal. 


If  lactic  acid  is  present  in  the  stomach  contents, 
evaporation  of  a  drop  over  a  flame  will  concentrate 
the  acid,  which  will  then  attack  the  sodium  chloride 
and  form  free  hydrochloric  acid.  Other  concen- 
trated acids  will  do  the  same. 

Gi'tnzlnirg's  test  is  not  a  test  for  a  free  mineral 
acid.  The  identical  rose  red  tint  will  be  obtained 
when  no  free  mineral  acid  is  present.  Many  foods 
that  contain  no  acid,  mineral  or  other,  taken  into 
the  stomach  will  produce  precisely  the  same  rose- 
red  tint  of  the  supposed  test.  Again,  there  are 
acids  formed  in  the  body,  not  mineral  acids,  that 
will  produce  the  same  brilliant  rose  red  tint  of  the 
so  called  test.  For  example,  in  those  who  possess 
the  oxalic  diathesis,  oxalic  acid  is  formed  in  the 
living  body  by  oxidation. 

Oxalic  acid  decomposes  dry  sodium  chlorid 
when  heated,  with  evolution  of  hydrochloric  acid 
(Fownes,  Chemistry,  page  658;  Brande  and  Taylor, 
page  384).  Oxalic  acid  responds  perfectly  to  the 
Giinzberg  test  in  the  presence  of  sodium  chloride. 
Oxalic  acid  exists  in  many  of  our  food  plants,  as  a 
salt  of  potash,  and  is  widely  distributed  in  vegeta- 
tion. Potassium  binoxalate  is  found  m  common 
sorrel,  wood  sorrel,  and  in  garden  rhubarb  asso- 
ciated with  malic  acid  (Fownes,  page  659).  It  ex- 
ists in  great  abundance  in  tomatoes  and  in  many 
other  acid  fruits. 

Giinzburg's  test  is  utterly,  absolutely  tvorthless, 
as  proved  by  the  following  experimentation : 

Experiment  i.  With  a  minute  quantity  of  potas- 
sium binoxalate,  sodium  chloride,  and  lactic  acid, 
Giinzburg's  test  yields  on  evaporation  over  a  flame 
a  rosered  tint  identical  with  that  produced  in  the 
presence  of  free  hydrochloric  acid. 

Experiment  2.  With  a  minute  quantity  of  potas- 
sium binoxalate,  sodium  chloride,  and  tartaric  acid, 
the  same  brilliant  rose  red  tint  is  obtained  when 
evaporated  over  a  flame  in  the  presence  of  the 
Giinzburg  test  solution.  Baking  powders  contain 
tartaric  acid.  A  biscuit  or  a  roll  of  bread,  as  in  the 
Ewald's  test  breakfast  raised  with  baking  powder, 
contains  tartaric  acid.  And  wines  contain  tartaric 
acid. 

Experiment  3.  Potassium  binoxalate  and  sodium 
chloride,  dissolved  in  water,  and  Giinzburg's  test 
added,  yield  when  heated  over  a  flame  a  rosered 
tint  identical  with  that  produced  by  free  hydro- 
chloric acid. 

Experiment  4.  Tartaric  acid  and  sodium  chloride, 
dissolved  in  water,  and  Giinzburg's  test  added, 
yield  when  heated  over  a  flame  a  rosered  tint  iden- 
tical with  that  produced  by  free  hydrochloric  acid. 

The  presence  of  free  hydrochloric  acid  as  a  nor- 
mal constituent  of  the  gastric  secretion  has  never 
Ijeen  demonstrated.  There  is  no  way  to  prove  its 
presence  except  by  chemical  analysis.  Chemical 
analysis  is  always  difficult,  and  always  requires  an 
expert  analyst.  He  who  pursues  the  hues  of  a 
color  test  may  as  well  engage  in  rainbow  chasing, 
or  the  practice  of  Christian  Science.  The  onlv  way 
to  positively  pro7'e  the  presence  of  free  hydrochloric 
acid  is  to  separate  the  acid:  just  the  same  as  you 
would  be  required  to  separate  arsenic  from  the  con- 
tents of  the  stomach  in  a  supposed  case  of  poison- 
ing by  that  mineral. 

The  absence  of  free  hydrochloric  acid  as  a  nor- 
mal constituent  of  the  s:astric  secretion  has  been 


repeatedly  proved  by  the  most  competent  author- 
ities, including  such  original  investigators  as 
Claude  Bernard,  Robin,  Verdeil,  Professor  Rogers, 
of  the  University  of  Pennsylvania,  and  Dr.  George 
Hay.  Professor  John  C.  Dalton  taught  that  lactic 
acid  was  the  normal  acid  constituent  of  the  gastric 
secretion.  He  neither  taught  nor  acknowledged 
the  presence  of  free  hydrochloric  acid. 

Professor  Carl  Seller  records  a  series  of  highly 
interesting  experiments  in  the  Philadelphia  Medical 
Times,  February  6,  1875,  which  go  far  to  prove 
that  no  hydrochloric  acid  is  present  in  the  gastric 
secretions.  There  are  chlorides  in  the  stomach 
during  digestion;  but  no  free  hydrochloric  acid.  If 
the  contents  of  the  stomach  are  heated  over  a  flame, 
or  in  a  retort,  to  a  sufficiently  high  degree,  the  lactic 
acid  will  become  concentrated  and  will  then  set  free 
the  hydrochloric  acid.  Thus  free  hydrochloric  acid 
that  had  no  existence  in  the  stomach  will  appear 
in  the  retort. 

Howell  to  the  contrary  notwithstanding,  there 
are  cases  on  record  of  very  detailed,  complete  and 
entirely  satisfactory  chemical  analyses  of  the 
human  gastric  secretions.  There  is  one  case  on 
record  of  a  chemical  analysis  of  the  contents  of  the 
stomach  at  the  height  of  digestion  in  a  man  of 
giant  strength  and  stature,  possessing  the  power  of 
digestion  to  an  extraordinary  degree,  in  which  all 
circumstances  favoring  the  analysis  were  ideal.  It 
is  the  case  of  Heidenblut ;  analyzed  by  Professor 
Rogers,  the  very  able  chemist  of  the  University  of 
Pennsylvania,  with  Professor  R.  M.  Smith.  In  this 
case  no  hydrochloric  acid  was  present.  Another 
case  in  which  complete  and  satisfactory  chemical 
analyses  were  made,  in  which  the  surrounding  cir- 
cumstances were  good  though  not  so  perfect  as  in 
the  first,  was  that  of  Alexis  St.  Martin,  analyzed  by 
Beaumont.  The  analyses  in  this  case  showed  no 
hydrochloric  acid.  There  are  no  chemical  analyses 
on  record  in  which  free  hydrochloric  acid  was 
shown  to  be  present. 

The  most  remarkable  line  of  experimentation 
ever  conducted  upon  the  gastric  secretion  remains 
unnoticed  by  any  author,  compiler,  or  textbook, 
within  our  knowledge.  These  extraordinary,  ex- 
periments seem  to  have  been  forgotten.  These 
experiments,  unquestionabl}^  the  most  exhaustive, 
as  well  as  the  most  authoritative  upon  this  subject, 
were  conducted  under  circumstances  both  excep- 
tional and  fortuitous,  in  the  physiological  labora- 
tory of  the  University  of  Pennsylvania.  The  gas- 
tric contents  were  those  of  a  criminal  (Heiden- 
blut). He  was  of  strong  physique,  and  was  exe- 
cuted two  hours  after  partaking  of  a  hearty  break- 
fast. Immediately  after  the  execution,  his  stomach 
with  its  contents  were  removed  to  the  laboratory 
of  the  imiversity.  The  lining  of  the  stomach  was 
carefully  scraped,  and  this  with  the  contents  of  the 
stomach  were  macerated,  filtered,  and  distilled. 
This  case  is  reported  in  the  Philadelphia  Medical 
Times,  February  13.  1875.  .\nd,  to  quote  from  the 
article  in  the  Times,  "the  following  deductions  con- 
firm entirely  those  obtained  from  the  analysis  of 
the  gastric  juice  of  Alexis  St.  Martin : 

1.  The  gastric  juice  presents  an  acid  reaction  both  before 
and  after  filtration  and  distillation. 

2.  The  acidity  in  this  instance  was  not  due  to  the  pres- 
ence of  hydrochloric  acid. 

,"!.  Lactic  acid  did  exist. 


June  26,  1909.] 


OUR  READERS'  DISCUSSIONS. 


4.  Acid  phosphate  of  lime  showed  no  evidence  of  its 
presence. 

5.  Neutral  phosphate  of  lime  did  exist,  and  was  held  in 
solution  by  the  lactic  acid. 

I  would  take  this  opportunity  of  expressing  thanks  to 
^Ir.  George  Hay,  a  member  of  the  class,  and  a  gentleman 
of  great  experience  as  an  analytical  chemist,  under  whose 
careful  supervision  these  experiments  were  conducted. 

Hay  states  that  "free  HCl  is  never  present  in 
the  human  stomach,  unless  introduced  from  with- 
out;  that  it  would  seriously  damage  it  if  present; 
and  that  it  is  impossible  for  it  to  be  found  in  the 
stomach,  for  the  reason  that  its  liberation  from  a 
salt  of  any  kind  requires  the  presence  of  a  concen- 
trated acid,  and  any  concentrated  acid  in  the  stom- 
ach would  quickly  destroy  the  organ.  Concentrated 
acids  arc  not  secreted  by  the  stomach.  Free  min- 
eral acid  is  not  a  product  of  the  stomach  of  man  or 
animal.  Us  absence  is  not  a  sign  of  cancer."  The 
researches  of  Rogers,  Smith,  Hay,  Dalton,  Claude 
Bernard,  Robin,  and  Verdeil,  all  original  im'csttga- 
tors,  entirely  agree.  The  data  presented  by  them 
are  in  strict  accord  zvith  the  facts  and  principles  of 
analytical  ch emistry. 

306  Diamond  Bank  Buildixg. 




A  SERIES  OF  PRIZE  ESSAYS. 

Questions  for  discussion  in  tiiis  dcf>artnicnt  are  an- 
nounced at  frequent  intervals.  So  far  as  they  have  been 
.decided  upon,  the  further  questions  are  as  follows: 

LXXXVIl. — Hon'  do  you  treat  suf'raorbital  neuralgia? 
(Closed  June  13,  i()og.j 

LXXXVIII.—H'Jic  do  you  treat  epistaxisF  (Anszvers 
due  not  later  than  July  75,  1909.) 

LXXXIX. — Hotv  do  you  try  to  prevent  the  recurrence  of 
renal  colic?  (AnSiVers  due  not  later  than  August  16,  1909.J 

Whoever  answers  one  of  these  questions  in  the  manner 
most  satisfactory  to  the  editor  and  his  adiiscrs  will  re- 
ceive a  price  of  $^3.  Xo  importance  zcliatcver  will  be  at- 
tached to  literary  style,  but  the  azivrd  icill  be  based  solely 
on  the  value  of  the  substance  of  the  anszcer.  It  is  requested 
(but  not  REQUiKED)  that  the  anszvers  be  short;  if  prac- 
ticable no  one  anszcer  to  contain  more  than  six  hundred 
z^•ords. 

All  persons  zvill  be  entitled  to  compete  for  the  price, 
zdiether  subscribers  or  not.  This  prize  zvill  not  be  azvarded 
to  any  one  person  more  than  once  zvithin  one  year.  Every 
anszver  must  be  accompanied  by  the  zvriter's  full  name  and 
address,  both  of  zvhich  we  must  be  at  liberty  to  publish. 
All  papers  contributed  become  the  property  of  the  Jour- 
N.\L.  Our  re.aders  are  asked  to  suggest  topics  for  dis- 
cussion. 

The  price  of  $23  for  the  best  essay  submitted  in  anszver 
to  question  LXXXVI  has  been  azvarded  to  Dr.  Charles 
Xahum  Haskell,  of  Bridgeport,  Conn.,  whose  article  appears 
■belOiV. 

PRIZE  QUESTION  LXXXVI. 

THE    EARLY    DIAGNOSIS    OF  PULMONARY 
TUBERCULOUS  DISEASE. 
Bv  Charles  Nahum  Haskell.  M.  D., 
Bridgeport,  Conn. 
The  early  diagnosis  of  pulmonary  tuberculosis 
should  not  be  beyond  the  capacity  of  any  physician  ; 
furthermore,  the  serious  responsibility  of  its  earl\- 
discovery  rests  upon  the  shoulders  of  every  general 
practitioner.      It   is   estimated  that  the  patient's 
•chances  of  recovery  are  five  times  greater  if  the  dis- 
ease is  recognized  in  its  incipiency.  The  family  phA  - 
sician  is  usually  the  one  who  has  the  opportunity  itit 
■demonstrate  its  presence  or  absence,  and  this  oppor- 


tunity should  never  be  lost.  Without  the  most  care- 
ful and  thorough  routine  examination  of  all  patients 
coming  under  observation,  many  diseases  are  allowed 
to  advance  unnoticed,  and  pulmonary  tuberculosis 
stands  at  the  head  of  the  list. 

Too  little  importance  is  usually  attached  to  case 
history,  and  this  is  especially  true  of  the  disease  un- 
der consideration.  It  shotild  be  complete  in  every 
detail,  and  special  effort  should  be  made  to  establish 
an  exposure  to  infection.  The  question  should  be 
asked  whether  the  patient  has  come  in  intimate  con- 
tact with  a  consumptive  person  at  home,  in  social  in- 
tercourse, or  at  work.  The  date  of  infection  is  often 
quite  remote.  The  history  of  previous  disease  is 
often  helpful,  the  most  common  being  grippe,  pneu- 
monia, pleurisy,  and  fancied  attacks  of  malaria.  En- 
larged cervical  glands  and  perineal  abscess  or  fistula 
in  ano  are  suspicious  pretuberculous  if  not  tubercu- 
lous conditions. 

The  progress  of  tuberculosis  is  often  intermittent,  ' 
so  that  periods  of  good  health  are  often  deceptive. 
The  present  history  often  includes  one  or  several  of 
the  following  symptoms :  Cotigh,  malaise,  fickle  or 
diminished  appetite,  afternoon  rise  of  temperature 
(often  subnormal  in  the  morning) ,  digestive  disturb- 
ances, haemoptysis,  anaemia,  localized  anterior  chest 
pains,  interscapular  pain  or  pain  referred  to  one 
shoulder  blade,  headache,  nervousness,  vasomotor 
disturbances,  increased  rate  of  pulse  and  respira- 
tion. Any  combination  of  these  symptoms  should 
excite  suspicion  and  in  the  absence  of  definite  phys- 
ical signs  should  sttggest  repeated  examinations  un- 
der varying  conditions  and  at  frequent  intervals, 
especially  in  the  early  morning.  Attention  should 
be  called  to  the  temperature  excursion.  A  morning 
stibnormal  of  one  or  two  degrees  with  a  slight  after- 
noon rise  is  nearly  equivalent  to  a  morning  normal 
with  greater  elevation  later  in  the  day. 

Physical  examination  is  the  most  important  of  all 
methods  of  diagnosis.  Invariably  the  clothing  should 
be  entirely  removed  to  the  waist.  The  patient  should 
sit  on  a  stool  and  the  examiner  should  sit  at  the  side 
of  and  face  the  patient.  The  cooperation  of  an  in- 
telligent patient  in  eliciting  cough  and  breath  sounds 
is  helpful.  Inspection,  palpation,  and  percussion  are 
valuable  corroborative  methods  to  employ,  but  are 
not  nearly  so  valuable  as  auscultation.  On  inspec- 
tion, there  may  be  found  retraction  of  an  apex,  lag- 
ging of  the  affected  side,  best  determined  by  stand- 
ing behind  the  patient  and  looking  down  across  the 
anterior  aspect  of  the  chest ;  restricted  movement  at 
apex  or  base  (Litten's  sign).  Palpation  may  reveal 
some  degree  of  variation  of  vocal  fremitus  and  pul- 
monary resonance.  A  sense  of  resistance  on  percus- 
sion may  be  due  to  thickened  underlying  tisstie  or  to 
spasm  of  the  intercostal  muscles  (Pottenger's  sign), 
and  is  not  of  especial  value.  Some  importance  may 
be  attached  to  the  narrowing  of  the  normal  percus- 
sion resonance  above  the  clavicle  between  the  base  of 
the  neck  and  the  acrotnion.  Gentle  percussion  is 
preferable.  The  chest  cannot  be  successfully  aus- 
cultated without  the  use  of  a  stethoscope  or  a  pho- 
nendoscope  especially  adapted  to  the  various  irregu- 
larities of  its  contour.  Personally  I  prefer  the  ordi- 
nary bell  stethoscope,  as  it  seemingly  does  not  per- 
vert the  transmitted  sounds  as  does  the  phonendo- 
scope.  The  use  of  the  unaided  ear,  especially  with- 
out the  clothing  removed  from  the  chest,  is  to  be 


OUR  READERS'  DISCUSSIONS. 


[New  York 
Medical  Journal. 


condemned,  as  it  tends  toward  carelessness  and  in- 
accuracy. Every  portion  of  the  chest  should  be  care- 
fully examined,  and  certain  areas  should  receive  espe- 
cial attention  on  account  of  the  greater  frequenc}' 
of  their  involvement,  namely,  the  apices  above  the 
clavicles,  the  apices  posteriorly  in  the  supraspinous 
fossae  ;  the  region  just  below  the  clavicles  ;  the  space 
between  the  scapulae,  especially  that  which  corre- 
sponds to  the  apices  of  the  lower  lobes ;  the  lower 
angle  of  the  scapulae  when  the  arm  is  thrown  for- 
ward with  the  hand  on  the  opposite  shoulder  ;  the 
area  overlying  the  bronchial  glands  ;  the  axillae ;  at 
the  lingula  pulmonahs,  and  in  children  the  fifth  and 
sixth  interspaces  in  the  midclavicular  line.  The 
textbooks  say  that  the  left  apex  is  the  most  frequent- 
ly involved,  but  a  personal  experience  of  twenty 
years  gives  preference  to  the  right.  Respiration 
either  forced  or  natural,  augmented  by  a  short,  quick 
cough,  will  usually  reveal  any  abnormal  sounds.  The 
breath  sounds  ma}-  be  jerky  or  interrupted,  bron- 
chial, bronchovesicular,  prolonged,  and  high  pitched 
or  harsh.  The  cough  sounds  are  exaggerated  breath 
sounds  and  are  subject  to  the  same  variations.  The 
one  important  point  in  this  connection  is  that  cough- 
ing will  often  reveal  certain  rales  which  cannot  be 
detected  in  any  other  way.  The  voice  sounds  are 
changed  in  character  when  slight  consolidation  has 
taken  place  and  the  whispered  voice  is  appreciated 
more  accurately  than  the  spoken  voice. 

The  adventitious  sounds  or  rales  are  by  far  the 
most  important  consideration  in  the  detection  of 
early  pulmonary  tuberculosis.  These  are  semidry  or 
slightly  moist  and  sticky,  and  vary  from  a  finely 
crepitant  rale  to  a  sonorous  sound.  The  more  moist 
and  coarse  they  are  the"  farther  the  disease  has  pro- 
gressed, so  that  if  one  were  confined  strictly  to  early 
or  incipient  cases,  the  rales  must  needs  be  of  the 
finer  variety.  These  rales  are  sharply  localized  and 
usually  at  one  or  more  of  the  points  mentioned 
above. 

The  X  ray  has  become  a  most  valuable  aid  in  diag- 
nosis of  early  cases,  and  my  attention  has  been  called 
recently  to  a  case  in  which  a  skiagraph  revealed  a 
lesion  at  the  apex  when  no  physical  signs  were  de- 
monstrable. Negative  sputum  examination  is  not 
conclusive  while  a  positive  one  is.  Examination  of 
gastric  secretions,  exudates  of  pleural  and  spinal 
fluids,  faeces,  and  urine  are  not  practicable,  but  are 
possible  accessories  in  doubtful  cases.  Rosenberg- 
er's  blood  findings  have  not  been  confirmed.  Dis- 
tinctive blood  counts  show  an  increased  proportion 
of  lymphocytes,  and  this  is  true  of  serous  exudates, 
but  Arneth's  distinction  of  the  neutrophile  nuclei  is 
of  value  only  in  prognosis.  The  tuberculins  are  be- 
coming more  firmly  established  in  value  in  the  diag- 
nosis of  tuberculosis.  The  conjunctival  test  is  fall- 
ing into  disfavor  because  of  its  dangers.  The  Moro 
test  is  less  definite  than  the  von  Pirquet.  The  latter 
seems  the  most  useful  of  all  and  is  being  more  gen- 
erally used.  Sharp  reactions  mean  recent  infection, 
sluggish  or  delayed  reactions  mean  remote  infection, 
while  negative  results  are  most  valuable  in  exclud- 
ing the  disease  except  in  advanced  cases  with  poor 
resistance.  These  tests  should  form  only  a  link  in 
the  chain  of  evidence  which  should  confirm  the  diag- 
nosis. 

Influenza,  pneumonia,  chronic  bronchitis,  and  lung 


conditions  arising  from  mitral  disease  are  to  be  dis- 
tinguished most  frequently.  Influenza  is  commonly 
confounded  with  tuberculosis.  The  lesions  are  ex- 
tensive and  usually  in  the  lower  lobes,  influenza  ba- 
cilli are  present  in  the  sputum,  which  is  usually  abun- 
dant, and  there  is  a  disparity  between  the  extent  of 
the  lesion  and  the  constitutional  symptoms.  Pneu- 
monia furnishes  sputum  in  which  there  is  found  no 
tubercle  bacilli,  and  there  is  no  response  to  tubercu- 
lin tests.  Chronic  bronchitis  is  diiTused,  while  tuber- 
culosis is  localized.  Various  other  conditions  are 
easily  excluded. 

To  epitomize :  History  of  exposure  to  infection, 
constitutional  symptoms  of  toxaemia,  localized  ad- 
ventitious sounds,  tuberculin  reactions,  careful  and 
repeated  examinations  are  cardinal  points  to  be  re- 
membered. 

Dr.  M.  Braude,  of  Chicago,  zv rites: 

Xever  before  in  the  history  of  medicine,  has  a 
greater  interest  been  evinced  in  the  systematic  war- 
fare against  tuberculosis  in  general,  and  in  the  pul- 
monary form  in  particular,  than  in  the  past  few 
years.  It  is  now  a  national,  not  only  an  individual 
concern.  Statistics  need  not  be  invoked  to  prove 
the  social  and  economic  havoc  it  yearly  entails. 
Consequently,  its  early  recognition  should  be  the 
object  of  every  physician.  But  as  modern  society  is 
constituted,  it  is  notorious  how  really  few  are  in- 
cipient cases,  when  the  individual  presents  himself 
for  medical  consultation.  Hence  certain  require- 
ments, perhaps  a  trifle  sweeping  or  too  theoretical, 
necessarily  suggest  themselves,  which,  when  ful- 
filled, would  go  far  in  the  detection  of  early 
cases. 

1.  Systematic  medical  examination  of  school  chil- 
dren and  of  those  engaged  in  occupations,  necessi- 
tating their  confinement  indoors,  and  in  particular 
shops,  factories,  and  large  department  stores.  Such 
examinations  to  be  repeated  at  stated  intervals. 

2.  That  it  shall  be  useful  depends  upon  the  family 
physician,  he  should  be  on  the  alert  for  the  devel- 
opment of  early  phthisis,  especially  if  the  historv  is 
at  all  suggestive. 

3.  Minor  ailments  should  not  be  lightly  disposed 
of,  but  invariably  be  accompanied  by  a  physical  ex- 
amination of  the  entire  bodv. 

4.  Wherever  feasible — and  oftentimes  conditions 
make  it  imperative — the  individual  should  be  kept 
under  observation  preferably  in  a  hospital,  where 
all  methods  of  diagnostic  precision  can  be  employed, 
or  if  this  is  impossible,  confinement  in  bed  at  home, 
giving  the  physician  the  opportunity  to  use  the  or- 
dinary means  as  the  proper  taking  of  the  tempera- 
ture, daily  sputum  examination,  to  say  nothing  of 
the  physical  examination  of  the  chest. 

5.  Lastly,  we  m.ust  insist  on  the  value  derived  * 
from  a  proper  interpretation  of  the  sum  total  of  the 
results  of  even  the  ordinary  metlipds  at  one's  dis- 
posal, systematically  carried  out,  combined  with  a 
thorough  acquaintance  of  the  patient's  history,  ha- 
bits, and  occupation. 

Assuming  now,  that  the  physician  has  the  pa- 
tient entirely  under  his  control,  he  can  not  be  too 
searching  in  eliciting  a  history  not  only  personal, 
but  that  of  the  family,  habits,  and  occupation.  While 
it  is  generally  admitted  that  pulmonary  tubcrcu- 


June  26,  1909.] 


THERAPEUTICAL  XOTES. 


losis  may  aitect  individuals  apparently  in  the  best 
of  health,  it  is  just  as  true  that  where  the  soil  is 
prepared,  the  susceptibility  will  be  proportionately 
greater.  Inquiry  should  always  be  extended  to 
comprehend  not  only  the  lungs,  but  as  well  the 
h-mphatics,  bones,  joints,  and  serous  membranes. 
Personal  history  should  include  the  knowledge  of 
the  previous  existence  of  measles,  pertussis,  convul- 
sions, diarrhoea,  bone  and  joint  diseases.  Manner 
of  life  and  occupation  need  not  be  dwelt  upon  any 
more. 

To  the  medical  mind,  combined  with  a  sugges- 
tive history  and  occupation,  the  following  if  not 
entirely  unequivocal,  should  at  any  rate  be  highly 
presumptive  of  the  existence  of  early  phthisis:  De- 
cided indisposition,  even  lassitude,  but  especially  de- 
rangement of  appetite,  bringing  in  its  train  the  in- 
evitable consequences,  such  as  loss  of  weight, 
strength,  and  anaemia.  Undoubtedly  outweighing 
these  symptoms  is  the  complaint  of  a  feeling  of  heat 
every  afternoon  or  evening,  with  or  without  sweat- 
ing, but  accompanied  by  a  cough,  varving  in  its 
constancy  and  severity.  A\'ith  the  patient  in  a  hos- 
pital, certain  procedures  now  become  absolutelv 
necessary.  The.  temperature  should  be  recorded 
every  two  hours,  day  and  night,  along  with  the  pulse 
and  respiration,  all  of  which,  but  especially  the  first, 
will  be  found  increased,  even  at  the  earliest  stages 
of  pulmonary  tuberculization.  Daily  sputum  exam- 
ination for  the  presence  of  tubercle  bacilli  is  so  es- 
sential a  procedure,  that  imder  no  consideration 
should  it  ever  be  neglected,  for  how  often  are  the 
bacilli  found.,  when  all  other  data  are  negative ;  but 
to  be  of  any  value  diagnostically,  should  be  foimd 
in  every  sputum  examination. 

Nowadays  additional  evidence  is  furnished  by  the 
von  Pirquet  and  Moro  cutaneous  tests,  which 
though  not  strictly  necessary,  are  yet  corrobor- 
ative. A  very  essential  and  probably  insufficiently 
used  method  is  the  fluoroscopic  screen  and  x  ray 
photograph.  In  fact  one  of  the  earliest  uses  (1896) 
to  which  the  x  ray  was  put,  was  for  the  examina- 
tion of  incipient  phthisis.  Two  important  findings 
are  thus  secured,  one  being  a  limitation  of  the  ex- 
cursion of  the  diaphragm,  and  the  other  the  ap- 
pearance of  shadows,  where  early  tuberculization  is 
in  progress. 

The  physical  examination  of  the  chest  is  available 
everywhere  and  at  all  times.  All  clinicians  are  in 
perfect  agreement  that  careful  inspection  and  pal- 
pation will  often  give  the  first  clue  to  the  existence 
of  incipient  phthisis,  particularly  of  the  apices.  The 
expansion  is  limited.  Resonance  in  full  inspiration 
is  defective.  German  clinicians  have  lately  pointed 
out  that  if  percussion  of  the  apices  is  performed, 
by  beginning  high  up  on  the  neck  medially  and  pro- 
ceeding laterally,  and  if  the  percussion  strokes  are 
extended  downward  anteriorly  and  posteriorly, 
granting  that  apical  tuberculosis  exists,  the  form 
of  dulness  as  projected  on  the  surface  will  conform 
to  the  regions  commonly  covered  bv  suspenders, 
and  hence  they  designate  this  manner  of  percussion 
"suspender  percussion."  In  auscultation  the  breath- 
ing is  commonly  feeble,  for  no  air  is  admitted  into 
this  portion  of  the  lung,  the  breath  sounds  mav  be 
bronchovesicular  or  jerking,  and  there  may  be  heard 
sibilant  or  subcrepitant  rales. 


My  reason  for  entering  at  some  length  into  the 
matter  of  obtaining  a  connected  history  of  the  case 
as  a  whole  is  to  emphasize  a  great  principle,  name- 
ly, that  unless  the  proper  interpretation  is  given  to 
seemingly  unimportant  matters,  not  so  much  as  iso- 
lated facts,  but  as  to  its  bearing  to  one  another, 
many  early  cases  of  phthisis  will  be  overlooked.  My 
plea,  therefore,  is  for  a  sound  interpretation  of  the 
resultant  values  of  the  less  complicated,  and  hence 
more  readily  available  means  of  diagnostic  precision, 
added  to  a  clear  history. 

{To  he  coutintied.) 
 <$,  

f  Itraptutiral  gotfs. 


The  Oxytocic  Principle  of  Ergot.  —  According 
to  The  Prescribe/-  for  June.  1909,  the  principle  of 
ergot  having  a  specific  action  on  the  uterus  has  been 
isolated.  It  carries  the  rather  forbidding  name  of 
parahydroxyphenylethylamine,  and  the  substance  is 
said  to  be  identical  with  the  hormon  of  the  placenta 
recently  discovered  by  Taylor  and  Dixon,  and  shown 
by  them  to  have  an  action  identical  with  that  of  adre- 
nalin. It  is  suggested  that  a  certain  chemical  rela- 
tionship exists  between  some  drugs  and  the  hormons 
of  the  body,  and  that  in  administering  such  drugs 
we  are  after  all  only  supplying  the  body  with  what 
in  health  it  is  able  to  produce  for  itself. 

Local  Treatment  of  Neuralgia.  —  The  Practi- 
tioner for  June  contains  several  prescriptions  of  top- 
ical applications  for  the  relief  of  neuralgia,  attrib- 
uted to  Lemoine  (Nord  medical).  In  the  so  called 
rheimiatic  neuralgia  sodium  salicylate  is  given  in- 
ternally, while,  locally,  applications  are  made  of 
methyl  salicylate,  or  of  Bourget's  ointment,  having 


the  following  composition : 

R     Salicylic  acid  

Oil  of  turpentine,   

Wool  fat  p.  e. 

Mix  and  make  an  ointment. 

If  there  is  reason  to  suspect  the  gonococcal  nature 
of  the  affection,  this  liniment  should  be  used : 

R    Guaiacol,   ^ss; 

Methyl  salicylate  3iss  : 

Oil  of  hyoscyamus,   ^iii. 

Mix  and  make  a  liniment. 

Sig. :  Use  twice  daily. 

The  following  may  also  be  used : 

R    Guaiacol,   5ss  ; 

Tincture  of  belladonna  Siiss  ; 

Oil  of  hyoscvamus,   ^i. 

Or. 

Methyl  salicylate,   3iiss  ; 

Guaiacol.   3ss ; 

Liquid  petrolatum  5iss. 

M. 

For  internal  administration  acetphenetidin  is  par- 
ticularly useful : 

R    Antipyrine,   gr.  v; 

Acetphenetidin  •  gr.  iii ; 

Quinine  valerate  gr.  iiss  : 

Caffeine  citrate,   gr.  iss. 

Mix  and  make  one  cachet. 

Sig. :  One  or  two  to  be  taken  daily. 

Hurtz  combine?  acetanilide  with  valerian : 

R    Acetphenetidin,   gr.  iss; 

Acetanilide  gr.  iii ; 

Quinine  valerate  gr  iv. 

M. 


I3I4 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal 


NEW  YORK  MEDICAL  JOURNAL 

INCORPORATING  THE 

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and  The  Medical  News. 

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NEW  YORK,  S.A.TURD.\Y,  JUNE  26.  1909. 


EFFORTS    TO    POPULARIZE  THE 
.  PHARMACOPGEIA. 

We  have  heard  a  good  deal  of  late  to  the  efifect 
that  members  of  the  medical  profes.sion  ought  to 
make  more  use  of  the  pharmacopreia  than  they  do 
at  present,  and  certain  changes  in  the  book  have 
been  recommended  as  likely  to  render  it  more  pop- 
ular with  physicians.  Several  of  these  proposed 
changes  were  advocated  in  the  Section  in  Pharma- 
cology and  Therapeutics  of  the  American  Medical 
Association  at  the  recent  Atlantic  City  meeting,  the 
continued  report  of  whose  proceedings  will  be 
found  in  this  issue  of  the  Nczv  York  Medical 
Journal. 

We  do  not  know  precise!}-  what  physicians  are 
expected  to  gain  by  studying  the  present  pharma- 
copoeia beyond  fixing  in  memory  the  new  name  for 
catechu  and  learning  how  to  spell  hexamethylena- 
mine.  It  is  no  wonder,  therefore,  that  changes  are 
desired  by  those  who  are  convinced  of  the  need  of 
pharmacopoeial  study  by  medical  men.  Prominent 
among  the  proposed  alterations  is  that  of  including 
only  the  names  of  single  drugs  and  simple  prepara- 
tions in  the  pharmacopcfial  list,  those  of  mixtures 
being  relegated  to  the  National  Formulary,  a  book 
which  docs  not  ])uri)()rt  to  be  niuch  more  than  a 
codified  collection  of  fornuihe  tliat  are  somewhat 
extensively  cmjjloyed  in  medical  i)ractice. 

While  "shotgun  prescriptions"  are  iin(louI)te(lly 
In  be  deprecated  in  general,  we  have  never  been 


able  to  see  why  the  "mere  mixture,"  as  it  is  con- 
temptuously termed,  should  be  scouted  and  de- 
graded. The  compound  cathartic  pill  of  the  United 
States  Pharmacopoeia  is  of  such  recognized  excel- 
lence that  it  is  often  ordered  in  foreign  prescrip- 
tions, but  of  course  it  is  only  a  mixture,  and  so,  too, 
is  the  time  honored  Dover's  powder,  to  say  nothing 
of  Warburg's  tincture  and  chlorodyne,  both  of 
which  are  largely  prescribed,  though  their  intro- 
duction was  perhaps  not  carried  out  with  full  ethi- 
cal decorum.  It  is  with  the  composition  of  such 
preparations  that  the  practitioner  of  medicine  needs 
to  familiarize  himself  rather  than  with  the  chemical, 
physical,  and  botanical  attributes  of  simple  drugs, 
though  those  qualities,  it  is  true,  cannot  safely  be 
neglected.  We  cannot  see  that  the  omission  of  such 
compounds  from  the  pharmacopceia  is  likely  to 
make  that  book  more  attractive  to  physicians. 

As  a  matter  of  fact,  physicians  are  far  more  apt 
to  turn  to  a  dispensatory  than  to  either  the  pharma- 
copoeia or  a  formulary  to  refresh  their  memories 
concerning  the  remedial  and  poisonous  effects  of 
drugs  and  their  preparations.  The  dispensatories 
are  excellent  books.  They  give  practically  every- 
thing that  is  contained  in  the  pharmacopoeia,  most 
of  what  is  excellent  in  the  formulary,  and  much 
additional  information.  The  dispensatories,  to  be 
sure,  are  bulky  and  expensive,  but  those  drawbacks 
must  attach  to  the  pharmacopoeia  also  if  it  is  to  be 
made  a  book  that  medical  practitioners  will  often 
resort  to.  We  do  not  at  present  understand,  then, 
how  the  pharmacopoeia  is  to  be  made  attractive  to 
physicians. 


CRITICISMS   OF   THE    PHAR^I  ACOPCEIA. 

The  period  for  the  ninth  revision  of  the  Phanua- 
copoeia  of  the  United  States  is  fast  approaching. 
Those  who  use  the  pharmacopoeia  know  that  it  has 
its  faults.  In  order  that  its  faults  may  be  corrected, 
it  is  necessary  that  they  should  be  known.  To  that 
end.  criticism  of  a  proper  character  should  be  en- 
couraged. Stimulated  by  the  surgeon  general  of 
the  United  States  Public  Health  and  Marine  Hos- 
pital Service,  Mr.  Murray  Gait  Motter  and  Mr. 
Martin  I.  Wilbert  have  put  out  as  Bulletin  Xo.  4<) 
of  the  Hygienic  Laboratory  a  Digest  of  Comments 
on  the  Pharmacoporia  of  the  United  States  for  the 
Period  Ending  December  jr.  /po-s. 

This  digest  is  a  valuable  collection  of  criticisms 
of  the  various  features  of  the  pharmacopoeia  and  of 
the  various  articles  admitted  into  its  list  of  official 
remedies.  Wy  using  this  digest  as  a  ])oint  of  de- 
parture the  committee  of  revision  which  will  he  rp- 
l)ointed  in-  the  Pharmacopoeial  convention  in  i()io 
shoulil  find  some  of  its  labors  lightened.    W  e  h  pe 


June  :;6.  igog.l 


EDITORIAL  ARTICLES. 


13 1 5 


that  the  Hygienic  Laboraton-  will  continue  to  col- 
lect and  edit  this  material,  and  we  congratulate  Mr. 
Motter  and  Mr.  Wilbert  on  this,  their  tirst.  but  we 
hope  not  their  last,  digest. 


\' AUDE VILLE  "  H Y P X OT I S M . ■ ' 

There  has  recently  been  revived  in  the  vaudeville 
circuits  a  form  of  humbug  that,  so  far  as  intelligent 
centres  were  concerned,  we  thought  was  dead  and 
"buried  twenty  years  ago.  This  is  the  supposed  ef- 
fects of  hypnotism  exhibited  on  the  public  stage  on 
"subjects"  apparently  volunteering  for  experiment 
from  among  the  audience.  These  ""volunteeers'' 
undergo  a  series  of  theatrical  free  arm  passes,  as- 
sociated in  the  minds  of  the  vulgar  from  time  im- 
memorial with  the  hypnotic  sleep.  The  performer 
then  "suggests"'  to  these  persons  that  they  are  en- 
gaged in  a  baseball  game,  a  Marathon,  a  balloon  as- 
cension, a  high  jumping  contest,  or  the  like.  A 
:stick  is  given  one  and  he  is  told  he  cannot  drop  it 
until  permitted  by  the  performer ;  another  at  the 
word  of  command  is  inhibited  from  walking. 

The  most  striking  "test"  is  the  placing  of  an  evi- 
dently frail  young  man  or  boy  upon  two  chairs, 
some  distance  apart,  the  body  being  apparently  sup- 
ported only  by  the  heels  and  the  occiput.  The  per- 
former mounts  upon  the  boy's  abdomen  and  jumps 
up  and  down  thereon  a  few  times,  the  bod\'  yield- 
ing and  recovering  its  horizontal  position  when  the 
performer's  weight  is  removed.  These  "hypnotists'" 
occupy  the  same  relation  to  genuine  and  skillful 
sleight  of  hand  performers  as  advertising  quacks  do 
to  decent  physicians.  Their  exhibition  is  amusing 
and  the  acting  of  the  "subjects"  consummately  artis- 
tic. It  is.  however,  a  base  fraud  upon  the  audience, 
and  it  is  a  question  whether  such  an  exhibition 
should  not  be  prohibited  by  law.  The  public  in- 
duction of  hypnotism  upon  perfect  strangers  is  al- 
most an  impossibility,  and  such  complete  control  as 
is  apparently  manifested  is  a  farce. 

Professional  men  know  well,  although  apparently 
most  others  do  not,  that  hypnotism  is  strictly  a  sub- 
jective phenomenon,  and  that  the  "power"  claimed  by 
these  humbugs  is  quite  fictitious.  It  is  unwise  that 
weak  minds  should  be  allowed  to  think  that  such  a 
power  exists,  or  that  there  should  be  a  generaPbelief 
that  hypnotism  has  such  possibilities  as  are  seeming- 
ly shown.  The  effect  upon  possible  future  jurymen 
is  a  case  in  point  and  might  lead  to  a  grave  mis- 
carriage of  justice  in  a  capital  trial.  Children  of 
sensitive  nature  should  certainly  not  be  permitted 
to  witness  such  performances  :  in  them  a  foundation 
might  easily  be  laid  for  a  piteous  credulity  and  ab- 
ject superstition  in  the  future,  rendering  them  an 
easy  prey  to  spiritualists,  fortune   tellers,  astrolo- 


gists,  and  the  other  quacks  that  infest  our  cultured 
centres. 

The  crowd  that  pushes  its  way  on  the  stage  upon 
request  of  the  performer  is  made  up  of  some  gen- 
uine inquirers  and  a  half  dozen  or  more  of  carefully 
trained  confederates,  who  are  taken  from  town  to 
town  on  regular  salaries.  Some  of  the  "hypnotists" 
carry  over  a  dozen  people  on  their  travels.  The 
genuine  volunteers,  after  a  little  foolery,  are  ex- 
cused as  not  being  "good  subjects."  and  the  main 
farce  begins.  In  the  smaller  towns  the  advance  agent 
secures,  by  bribery  or  by  a  subtle  appeal  to  vanity 
and  the  desire  to  appear  in  public,  young  men  willing 
to  be  parties  to  deception  of  their  fellow  townsmen. 
Strange  as  it  may  seem,  many  are  found  anxious 
to  assist  in  the  fraud  without  pay.  This  betrays  a 
singular  attribute  of  human  nature,  which  is  ex- 
tensively used  by  "spiritualists"  visiting  a  town  for 
temporary  residence.  These  unworthy  citizens  re- 
ceive careful  instruction  and  join  the  regular  c'on- 
federates  at  the  proper  time. 

The  explanation  of  the  "stunts"  done  by  the  sub- 
jects is  obvious.  The  suspension  of  the  youth  be- 
tween two  chairs,  very  astonishing  to  the  uninif 
ated,  and  usually  exhibited  as  an  example  of  "cat:  - 
leptic  trance,"  is  effected  by  the  use  of  a  ste.l  h  r- 
ness,  carefully  adjusted  to  the  confederate's  b  :cl\- 
and  fastened  to  his  neck,  thighs,  and  legs ;  this  bears 
the  weight  of  the  performer's  body,  gives  to  his 
jumping,  and  recovers  owing  to  its  efficient  temper- 
ing. The  chief  faker  announces  not  uncommonly, 
with  the  assurance  of  his  class,  that  he  is  frequently 
called  upon  by  "eminent  physicians"  to  assist  in  sur- 
gical operations.  Dear  old  band  of  eminent  physi- 
cians !  Are  ye  not  the  same  who  from  time  to  time 
decide  to  "waive  all  hidebound  ethical  considera- 
tions" and  do  your  delayed  duty  to  the  dear  pub- 
lic by  signing  a  fulsome  testimonial  to  some  quack 
cureall  ? 


SANITATION   IN   THE  TROPICS. 

The  history  of  all  advances  in  civilization  points 
to  the  man,  or  the  group  of  men,  who  have  had  the 
courage  to  break  loose  from  routine  and  to  adopt 
new  methods  as  the  direct  cause  of  betterment.  The 
achievements  of  the  white  man  in  the  tropics  have 
been  repeatedly  recounted  in  these  columns,  but  we 
cannot  refrain  from  making  one  more  allusion  to 
the  results  of  American  energy  in  the  Philippine 
Islands. 

71ie  Annual  Report  of  the  Bureau  of  Health  for 
the  Philippine  Islands,  by  the  Director  of  Health, 
Dr.  Victor  G.  Heiser,  is  the  text  for  these  remarks. 
Dr.  Heiser  and  his  staff  have  had  the  courage  to 
break  away  from  the  routine  cleaning  up  of  back 


EDITORIAL  ARTICLES. 


[New  York 
Medical  Journal 


yards,  alleyways,  and  individual  premises,  and  to 
expend  their  energies  and  their  money  on  larger 
and  more  general  problems,  to  the  end  that,  a  sound 
foundation  being  laid,  the  superstructure  of  details 
may  naturally  follow.  Each  peso  that  has  become 
available  for  sanitation  and  public  health  work  has 
been  spent  in  vaccination,  in  combating  intestinal 
parasites,  in  boring  artesian  wells,  and  in  other  sim- 
ilar projects.  By  thus  attempting  to  eradicate  small- 
pox, to  lessen  the  depressing  influences  of  intestinal 
parasites,  and  to  provide  a  better  water  supply,  the 
resisting  power  of  the  community  has  been  raised 
and  both  morbidity  and  mortality  have  been  low- 
ered. 

This  policy  has  naturally  produced  caustic  criti- 
cism from  those  who  believe  that  the  end  and  aim 
of  the  sanitarian's  existence  should  be  the  sweeping 
of  sidewalks,  the  penning  up  of  pigs,  and  the  clean- 
ing of  back  yards.  It  may  be  readily  seen  that  in  a 
country  like  the  Philippine  Islands  the  former  poli- 
cies will  be  productive  of  more  good  than  the  latter. 
In  a  graphic  table  on  page  98  of  the  report  the 
death  rate  in  the  Swahig  Penal  Settlement  is  shown 
to  have  been  reduced  from  261  in  1,000  in  1905  to 
10.78'  in  1,000  in  six  months  of  1908,  by  the  sani- 
tary measures  introduced  by  the  Bureau  of  Health 
of  the  Philippine  Islands.  There  are  many  interest- 
ing details  in  the  report,  which  will  amply  repay  the 
perusal  of  one  interested  in  the  sanitation  of  a  trop- 
ical country  hitherto  allowed  to  pursue  its  unham- 
pered unsanitary  way. 


CONGENITAL  ABSENCE  OF  THE  RECTUM. 

It  seems  that  this  very  serious  defect  of  devel- 
opment is  "extremely  common"  in  China.  A  re- 
markable instance  of  recovery  after  an  operation 
performed  under  discouraging  circumstances  is  re- 
ported by  Dr.  W.  H.  Jefferys  in  the  May  number 
of  the  China  Medical  Journal,  published  by  the 
Medical  Missionary  Association  of  China.  The 
baby  was  twenty-four  days  old  when  it  was 
brought  for '  treatment.  Dr.  Jefiferys  took  great 
pains  to  satisfy  himself  as  to  its  age,  and  he  is  con- 
vinced that  it  was  of  the  age  stated. 

The  child  was  still  able  to  nurse,  though  its  ap- 
petite was  small.  It  had  not  vomited.  The  urine, 
which  was  passed  normally,  was  "dark  in  color  and 
heavy  looking,  as  if  the  kidneys  were  doing  extra 
work."  There  was  a  wrinkling  of  the  skin  at  the 
normal  situation  of  the  anus,  but  no  natural  per- 
foration. There  was,  however,  a  little  to  one  side, 
a  small  opening  through  which  a  probe  could  be 
passed,  but  it  turned  out  that  this  opening  had 
been  made  by  a  Chinese  doctor  in  an  attempt  to 
open  the  rectum.    He  had  cut  about  half  an  inch 


deep  and  then  "developed  rigor  pedes"  (  an  expres- 
sion that  leaves  something  to  be  desired  from  the 
point  of  view  of  Latinity,  but  one  that  will  readily 
be  understood  as  purporting  to  mean  "cold  feet"). 

Though  the  child  was  in  bad  condition,  being 
emaciated,  showing  exceeding  dryness  of  the  mouth,, 
having  shallow  respiration  and  an  anxious,  pained 
expression,  and  with  tenderness  of  the  abdomen,, 
it  was  felt  that  an  operation  must  be  performed,  and 
it  was  done  without  an  anaesthetic.  A  median  in- 
cision was  carried  to  the  depth  of  two  inches,  and) 
then  bogginess  of  the  tissues  was  encountered.  The 
wound  was  deepened  by  puncturing,  and  a  haemo- 
stat  inserted  into  the  puncture.  Upon  the  with- 
drawal of  that  instrument  faecal  matter  was  observed* 
to  flow  out,  and  with  the  aid  of  a  salt  douche  a 
large  amount  was  withdrawn.  The  baby  soon  be- 
gan to  recover  and  to  gain  in  weight,  but  natur- 
ally Dr.  Jefferys  looks  forward  to  the  necessity  of 
a  secondary  operation  to  secure  continued  patency 
of  the  opening,  and  he  candidly  says  that  "undoubt- 
edly the  bowel  should  have  been  drawn  down  and' 
stitched  into  the  anal  margin,  as  should  always  be 
done  except  in  the  case  of  simple  imperforate  anus."' 

The  case  reported  by  Dr.  Jefferys  is  certainly  re- 
markable from  more  than  one  point  of  view,  but 
chiefly,  as  he  points  out.  by  reason  of  the  length 
of  time  that  had  elapsed  before  the  child  was 
brought  to  him.  "Literature  on  the  subject,"  he 
says,  "does  not  cover  the  point,  since  babies  in  civ- 
ilized countries  would  never  be  left  so  long  as  a 
week,  under  any  circumstances,  without  some  op^ 
erative  attempt  being  made."  He  learns  from  Dr. 
Garner,  of  the  Margaret  Williamson  Hospital, 
Shanghai,  that  they  have  many  similar  cases  in  that 
institution,  and  that,  unless  the  patients  are  treated 
earlier,  they  usually  succumb  about  the  eighth  day. 


THE   INTERNATIONAL  CLASSIFICATION 
OF  CAUSES  OF  DEATH. 

The  International  Classification  of  Causes  of 
Death,  which  has  now  been  adopted  in  almost  alT 
civilized  countries,  is  essentiallv  a  French  produc- 
tion and  largely  the  work  of  M.  Bertillon.  Neces- 
sarily it  is  subject  to  periodical  revision — once  im 
ten  years  as  originally  intended.  The  next  revision' 
would  naturally  be  effected  in  the  year  1910.  For 
the  convenience  of  the  United  States,  however,  so- 
as  to  make  it  available  for  the  purposes  of  our  next 
census,  the  French  government  most  courteously 
changed  the  year  of  revision  to  1909  and  invited 
the  American  government  to  send  delegates  to  the 
conference  of  revision,  which  opens  in  Paris  on 
July  1st.    Up  to  the  time  of  this  writing,  so  far 


June  2b,  1909.] 


NEIVS  ITEMS. 


1317 


as  we  have  been  able  to  ascertain.  Congress  has 
failed  to  provide  for  a  delegation.  This  lack  of 
action  has  doubtless  been  owing  to  some  strange 
oversight,  for  surely  our  government  would  not 
show  intentional  discourtesy  to  that  of  France. 
Fortunately,  we  shall  not  be  altogether  unrepre- 
sented ;  the  Navy  Department  has  sent  Surgeon 
Pleadwell,  the  Bureau  of  the  Census  is  represented 
by  Dr.  Cressy  L.  Wilbur,  the  Pennsylvania  State 
Board  of  Health  has  deputed  Dr.  Wilmer  R.  Batt, 
and  the  Health  Department  of  the  City  of  New 
York  has  for  its  representative  Dr.  William  H. 
Guilfoy.  American  opinion  is  therefore  sure  to  be 
suitably  brought  out  in  the  Paris  conference. 
 ®  

Sites  |tms. 


The  Chicago  Eye,  Ear,  Nose,  and  Throat  College  has 

completed  its  new  annex  at  206  East  Washington  Street, 
which  doubles  the  capacity  of  the  institution.  A  house  phy- 
sicians is  appointed  twice  a  year,  June  and  December,  and 
the  term  of  service  is  one  year. 

The  Examinations  for  Appointment  to  the  Medical 
Corps,  to  be  held  on  July  12th  at  various  army  posts 
throughout  the  country,  have  attracted  an  unusually  large 
number  of  applicants,  considerably  more  than  two  hundred 
applications  having  already  been  filed. 

The  Cholera  Epidemic  in  St.  Petersburg,  according  to 
newspaper  despatches,  is  rapidly  assuming  the  proportions 
of  the  epidemic  in  1908.  On  June  19th  fifty-three  new  cases 
were  removed -to  the  hospitals,  making  a  total  of  176  cases. 
Eight  cholera  hospitals  are  now  open. 

A  Student  Regiment  at  Toronto  University. — Dr.  J. 
T.  Fotheringham,  colonel  of  the  Army  Medical  Corps  for 
Military  District  No.  2  of  the  Province  of  Ontario,  is  or- 
ganizing a  student  regiment  of  undergraduates  at  the  To- 
ronto University,  the  hospital  corps  of  which  will  be  made 
up  of  medical  students. 

Anaesthetist  Wanted  at  St.  John's  Hospital,  Brooklyn. 
— The  medical  board  of  the  hospital  announces  that  the 
position  of  visiting  ansethetist  to  the  hospital  is  vacant. 
Applications  should  be  sent  at  once  to  the  secretary  of  the 
board,  Dr.  Frank  Henry  Knight,  St.  John's  Hospital,  Al- 
bany and  Atlantic  Avenues,  Brooklyn,  N.  Y. 

The  Alumni  Society  of  the  New  York  Skin  and  Can- 
cer Hospital. — At  a  recent  meeting  of  the  society  the 
following  ofhcers  were  elected  for  the  ensuing  year : 
President,  Dr.  Jerome  Kingsbury ;  first  vice-president, 
Dr.  J.  T.  Gwathmey :  second  vice-president.  Dr.  O.  M.  Wil- 
son; treasurer,  Dr.  H.  A.  Pulsford;  secretary.  Dr.  Fred 
Wise. 

Actual  Command  for  Medical  Officers. — Officers  of 
the  Medical  Corps,  U.  S.  Army,  have  been  detailed  to  act 
as  commanding  officers  of  the  field  officers  in  the  three 
camps  for  the  instruction  of  medical  officers  of  the  militia. 
Major  Albert  Truby  will  command  at  the  camp  near  San 
Francisco,  Major  Powell  C.  Fauntleroy  at  Sparta,  Wis.,  and 
Major  Frederick  P.  Reynolds  at  Antietam. 

A  Floating  Hospital  in  Philadelphia. — Arrangements 
have  been  completed  for  the  establishment  in  Philadelphia 
of  a  floating  hospital  for  sick  babies,  which  was  proposed 
by  Dr.  J.  Madison  Taylor  some  weeks  ago.  A  barge  has 
been  secured  and  has  been  properly  fitted  up,  and  the  nec- 
essary funds  are  now  being  collected.  The  project  is 
similar  to  that  of  St.  John's  Guild,  in  New  York. 

The  University  of  Kansas.— At  a  recent  meeting  of  the 
board  of  trustees  of  the  medical  department  of  the  Uni- 
versity of  Kansas  the  following  officers  were  elected :  Presi- 
dent, Dr.  Jabez  Jackson ;  dean.  Dr.  J.  M.  Frankenberg ; 
secretary.  Dr.  George  W.  Davis  ;  treasurer.  Dr.  C.  A.  Ritter  ; 
curator.  Dr.  Walter  M.  Cross,  and  Dr.  S.  C.  James,  a  mem- 
ber of  tbe  executive  committee. 


To  Save  the  Lives  of  Babies. — The  New  York  De-  ^ 
partment  of  Health  has  announced  a  list  of  si.xty-eight 
public  and  private  mstitutions  which  are  cooperating  in  the 
work  of  caring  for  the  babies  during  the  hot  weather.  Last 
week  there  w  as  a  decrease  in  the  death  rate  of  children  un- 
der one  year  of  age.  and  those  engaged  in  the  work  believe 
that  still  better  results  will  be  shown  before  the  summer  is 
over. 

The  Medical  Examining  Board  of  the  State  of  Wash- 
ington, recently  appointed  under  the  new  medical  prac- 
tice act,  is  composed  of  five  regulars,  two  homoeopaths,  and 
two  osteopaths.  The  officers  of  the  newly  appointed  boarJ 
are  as  follows:  President,  Dr.  E.  P.  Witter,  of  Spokane ;^ 
vice-president.  Dr.  E.  J.  Taggart,  of  Bremerton :  secretary^ 
Dr.  J.  C.  McFadden.  of  Seattle,  and  treasurer,  Dr.  G.  K. 
Dow,  of  Chehalis. 

A  Tuberculosis  Sanatorium  in  the  Laurentian  Moun- 
tains.— It  is  reported  that  Mr.  D.  Lorne  McGibbon,  of 
Montreal,  has  given  $125,000  for  the  establishment  of  a 
sanatorium  for  tuberculous  patients  at  St.  Agathe  in  the 
Laurentian  Mountains.  It  is  said  that  Mr.  McGibbon  once 
suffered  from  tuberculosis,  but  was  cured  by  spending  much 
time  in  the  Adirondacks,  and  it  is  his  desire  to  aid  others 
who  are  victims  of  the  disease. 

Sir  James  Grant  on  Clefts  in  the  Axis  Cylinder. — Sir 
James  A.  Grant,  of  Ottawa,  Canada,  whose  article  on  this 
subject  appeared  in  our  issue  for  May  15,  1909,  explained 
and  demonstrated  his  views  at  the  recent  meeting  of  the 
.\mcrican  Society  for  the  Study  of  Alcohol  and  other  Nar- 
cotics. On  the  miOtion  of  Dr.  T.  A.  MacNicholl.  of  New 
York,  seconded  by  Dr.  T.  D.  Crothers,  of  Hartford,  the 
meeting  passed  a  vote  of  thanks  to  Sir  James  Grant. 

The  Medical  Society  of  the  Woman's  Hospital  of 
Philadelphia  held  a  regular  meeting  on  Monday,  June 
2ist.  The  programme  included  the  following  papers:  Car- 
cinoma of  the  .Vulva  treated  by  Cataphoresis,  by  Dr  Marie 
K.  Formad ;  Cases  of  Typhoid  Fever  from  the  Recent  Med- 
ical Service,  b\'  Dr.  Elizabeth  R.  Bundy ;  Unrecognized 
Fractures  in  Infancy,  by  Dr.  Matilda  Osborne;  The  Use  01 
Surgical  Wax  in  the  Treatment  of  Sinuses  and  Abscesses, 
by  Dr.  Kate  W.  Baldwin. 

Cancer  in  Russia. — Tiie  statement  was  made  at  the 
annual  meeting  of  the  Anticancer  Association,  which  was- 
held  in  St.  Petersburg  on  ^lay  i6th,  that  every  sixth  death 
in  St.  Petersburg  of  persons  over  fifty-four  years  of  age 
was  due  to  cancer.  A  cancer  laboratory  was  opened  in  St, 
Petersburg  some  time  ago.  and  a  special  committee  is  now 
taking  steps  to  collect  funds  for  the  founding  of  a  cancer 
hospital,  and  it  is  hoped,  that  it  will  be  possible  to  establish 
a  Pan-Russian  Cancer  Institute  later  on. 

Appointments  at  Cornell. — The  board  of  trustees  of 
Cornell  University  announce  the  following  appointments 
in  the  Medical  College :  Dr.  Frank  Sherman  Meara,  pro- 
fessor of  therapeutics  and  clinical  medicine;  Dr.  C.  N.  B, 
Camac,  professor  of  clinical  medicine :  Dr.  William  J. 
Elser,  professor  of  bacteriology ;  Dr.  John  A.  Hartwell,  pro- 
fessor of  clinical  surgery :  Dr.  William  B.  Coley,  professor 
of  clinical  siugery :  Dr.  S.  P.  Beebe.  assistant  professor  of 
experimental  therapeutics;  and  Dr.  John  R.  Murlin,  assist- 
ant professor  of  physiology. 

The  Massachusetts  Medical  Society  held  its  one  hun- 
dred and  twenty-eighth  annual  meeting  in  Boston  last  week. 
Its  veieran  secretary.  Dr.  Francis  W.  Goss,  who  has  served 
the  society  in  that  capacity  for  thirty-four  years,  declined 
to  be  a  candidate  for  another  term,  and  Dr.  Walter  L. 
Burrage,  of  Boston,  was  appointed  to  succeed  him.  Dr. 
Silas  D.  Presbrey,  of  Taunton,  was  reelected  president;  Dr. 
J.  C.  Pinkham,  of  Lynn,  was  elected  vice-president ;  Dr. 
Edward  M.  Buckingham,  of  Boston,  was  reelected  treas- 
urer ;  and  Dr.  Edwin  H.  Brigham,  of  Brookline,  was  re- 
elected librarian. 

The  Chicago  Medical  Society. — At  the  annual  meet- 
ing of  the  society,  held  on  June  15th,  Dr.  John  Albt'rt 
Robison  was  elected  president,  defeating  Dr.  Hugh  T.  Pat- 
rick by  twenty-two  votes.  It  was  one  of  the  most  hotly 
contested  elections  in  the  history  of  the  organization.  Dr. 
George  F.  Suker  was  elected  secretary.  The  five  councilors 
at  large  elected  are  Dr.  William  Senn.  Dr.  Edward  A. 
Fischkin,  Dr.  George  W.  Webster,  Dr.  Charles  C.  O'Byrne. 
and  Dr.  Merlin  Z.  .Albro.  The  alternate  councilors  elected 
are  Dr.  Willis  O.  Nace.  Dr.  James  P.  Houston,  Dr.  John 
Edwin  Rhodes,  and  Dr.  Bernard  Fanti:s. 


1318 


XEirS  ITEMS. 


-MiDICAL    .1  jLRNAL 

[New  York 


The  Blackwell  Medical  Society,  an  organization  of 
womt-n  physicians  in  Rochester,  X.  V..  held  its  annual  meet- 
ing and  picnic  on  June  17th.  The  members  of  the  society 
were  the  guests  of  Dr.  Anna  Lott.  of  Williamson,  and  a 
most  enjoyable  afternoon  and  evening  were  spent.  At  the 
business  meeting,  which  was  held  during  the  evening,  the 
following  officers  were  elected  to  serve  for  the  ensuing 
year :  President,  Dr.  M.  May  Allen ;  vice-president,  Dr. 
Kathleen  Buck;  secretary,  Dr.  i\Iay  Xickerson,  of  the  Roch- 
ester State  Hospital ;  treasurer,  Dr.  Ida  Porter.  The  coun- 
cilors are  the  officers  with  the  addition  of  Dr.  Evelyn  Bald- 
win and  Dr.  White-Thomas. 

Vital  Statistics  of  San  Francisco. — During  the  month 
of  April.  1909,  there  were  reported  to  the  Department  of 
Health  of  the  City  and  County  of  San  Francisco  513  deaths 
from  all  causes,  in  an  estimated  population  of  475,000,  cor 
responding  to  an  annual  death  rate  of  10.93  in  a  thousand 
population.  The  annual  birth  rate  for  the  week  was  12.84. 
There  were  34  still  births,  18  males  and  16  females.  Of 
the  total  deaths  67  were  from  tuberculosis.  43  from  pneu- 
monia, 72  from  organic  heart  diseases,  27  from  Bright's 
disease,  36  from  diseases  of  the  digestive  system,  8  from 
diphtheria,  10  from  influenza,  5  from  whooping  cough,  16 
from  diseases  of  early  infancy,  and  56  deaths  by  violence. 

Reunion  Dinner  of  Alumni  of  Michigan  College  of 
Medicine  and  Surgery. — A  large  majority  of  the  class  of 
'92  of  the  Michigan  College  of  iMedicine  and  Surgery,  De- 
troit, held  a  reunion  dinner  on  the  evening  of  June  15th. 
Dr.  M.  V.  Meddaugh  and  Dr.  E.  T.  Milligan  divided  the 
honors  and  duties  of  the  position  of  toastmaster,  and  among 
those  who  responded  to  toasts  were  :  Dr.  Dayton  Parker.  Dr. 
L.  E.  Maire,  Dr.  William  Cheney.  Dr.  William  Hamlen, 
Dr.  Kenneth  Gunsolus,  Dr.  Oscar  Armstrong,  Dr.  E.  B 
Smith.  Dr.  Samuel  Bell,  Dr.  C.  N.  Raymond,  Dr.  Charles 
A.  Blair,  Dr.  Frank  C.  Dunn,  Dr.  W.  G.  Young.  Dr.  Wash- 
ington Foster,  Dr.  John  F.  Bennett,  and  Dr.. J.  W.  Squires. 

The  American  Climatological  Society. — The  follow- 
ing officers  were  elected  at  the  annual  meeting  of  the  society, 
which  was  held  in  Fortress  Monroe.  \'a.,  on  June  4th  and 
5th  :  President,  Dr.  E.  L.  Baldwm,  of  Saranac  Lake,  N.  Y. ; 
first  vice-president.  Dr.  J.  M.  Anders,  of  Philadelphia ; 
second  vice-president.  Dr.  H.  "L.  Taylor,  of  St.  Paul,  Minn. ; 
secretary  and  treasurer.  Dr.  Guy  Hinsdale,  of  Hot  Springs, 
Va. ;  member  of  council.  Dr.  E.  C.  Quimby,  of  New  York ; 
delegate  to  International  Congress  of  Physicians  and  Sur- 
geons, Dr.  R.  G.  Curtin,  of  Atlantic  City :  alternate.  Dr. 
Tliomas  Darlington,  of  New  York.  The  next  meeting  of 
the  society  will  be  held  in  Washington,  D.  C,  in  1910. 

The  North  Carolina  Medical  Society  held  its  fifty- 
si.xth  annual  convention  in  Asheville  last  week,  and  elected 
the  following  officers  for  the  ensuing  year :  President,  Dr 
J.  A.  Burroughs,  of  Asheville:  first  vice-president.  Dr.  E. 
J.  Wood,  of  Wilmington  ;  second  vice-president.  Dr.  John 
Q.  Myers,  of  North  Wilkesboro ;  third  vice-president.  Dr. 
L.  D.  Wliarton,  of  Smithfield ;  secretary.  Dr.  D.  A.  Stanton, 
of  High  Point,  reelected ;  orator.  Dr.  Cyrus  Thompson,  of 
Jacksonville;  essayist.  Dr.  R.  V.  Brawley,  of  Salisbury; 
leader  of  debate.  Dr.  D.  A.  Garrison,  of  Gastonia ;  treasurer, 
Dr.  H.  D.  Walker,  of  Elizabeth  City;  delegate  to  the  Amer- 
ican Medical  Association,  Dr.  T.  E.  W.  Brown,  of  Ashe- 
ville: alternate.  Dr.  J.  B.  McGoughan,  of  Fayetteville.  Dr. 
George  G.  Thomas,  of  Wilmington,  was  chosen  as  chairman 
of  tile  committee  on  arrangements  for  the  meeting  next 
year,  which  will  be  held  in  Wrightsville. 

The  Health  of  Philadelphia.— During  the  week  ending 
June  12.  1909,  the  following  cases  of  transmissible  diseases 
were  reported  to  th.;  Bureau  of  Health  of  Philadelphia: 
Typhoid  fever,  15  cases,  6  deaths:  scarlet  fever.  48  cases,  1 
death  :  chickenpox.  .39  cases,  0  deaths :  diphtheria,  54  cases, 
6  dcatli*;;  measles,  202  cases,  4  deaths:  whooping  cough,  31 
cases.  4  deaths;  tuberculosis  of  the  lungs.  io§  cases.  54 
deaths:  pneumonia.  38  cases,  28  deaths:  erysipelas,  11  cases, 
o  deaths:  mumps,  21  cases,  o  deaths.  The  following  deaths 
were  reported  fron)  other  transmissilile  diseases :  Tubercu- 
losis, other  than  tnl)erculosis  of  tiie  lungs,  8  deaths;  puer- 
peral fever,  2  deaths;  diarrhnea  and  enteritis,  under  two 
years  nf  age,  7  deaths.  The  total  deaths  numbered  388.  in 
an  estimated  ponulation  of  1.565. jfiy.  corresponding  to  an 
ann-ial  death  rate  of  12.&S  in  a  thousand  population.  The 
total  infant  mortality  was  73;  58  under  one  year  of  age,  15 
between  one  and  two  years  of  age.  Tiiere  were  21  still 
births;  13  males  and  8  females.  Tiie  total  precipitation  was 
0.88  inch 


Infectious  Diseases  in  New  York: 

We  arc  indebted  to  the  Bureau  of  Records  of  the  De- 
partment of  Health  for  the  follozviiig  statement  of  new 
cases  and  deaths  reported  for  the  tzvo  zveeks  ending  June 
19,  i9og: 

,  June  \2  ,  ,  June  19  v 

Cases.    Deaths.    Cases.  Deaths. 

Tuberculosis  pulmonalis   527  180         394  145 

Diphtheria    270  32         397  38 

^leafles    1,431  39       1,331  25 

scarlet  fever    246  27         221  21 

Smallpox    2 

Varicella    197  .  .  1 52 

Typhoid  fever    27  4  24  7 

Whooping  cough    88  7  55  6 

Cerebrospinal    meningitis    12  2  3  ^ 

Total   2,800         291       2,57-  24- 

Mortahty  Statistics  of  Boston.— The  total  number  of 
deaths  reported  to  the  Board  of  Health  for  the  week  end- 
ing June  12,  1909.  was  ii-'5,  as  against  206  during  the  cor- 
responding w-eek  in  190S.  The  death  rate  for  the  week  was 
15.63.  The  number  of  cases  and  deaths  from  infectious 
diseases  reported  during  the  week  was  as  follow  s :  Diph- 
theria, 44  cases,  3  deaths ;  scarlatina,  37  cases,  2  deaths : 
t.vphoid  fever,  8  cases,  0  deaths;  measles,  69  cases,  o  deaths: 
tuberculosis.  57  cases.  11  deaths.  The  deaths  from  pneu- 
monia numbered  17,  from  whooping  cough,  i,  from  heart 
disease  23,  and  from  bronchitis  4.  There  were  19  deaths 
from  violent  causes.  The  number  of  children  who  died 
under  one  year  was  26;  the  number  between  one  and  five 
was  37.  The  number  of  persons  over  sixty  years  of  age 
who  died  was  53. 

Charitable  Bequests.— By  the  will  of  Michael  Heck- 
man,  the  Bethesda  Leper  Home,  of  Surinam.  South  Africa, 
receives  $150  upon  the  death  of  the  testator's  widow.  The 
German  Lutheran  Orphans"  Home  and  the  Samaritan 
Home,  of  Philadelphia,  receive  $100  each,  also  upon  tlie 
death  of  the  testator's  widow. 

By  the  will  of  Andrew  B.  Jones,  who  died  in  Albany. 
N.  Y.,  on  May  29th,  the  Albany  Hospital,  the  Albany  Or- 
phan Asylum,  and  the  Homoeopathic  Hospital  w  ill  each  re- 
ceive $500. 

Four  Hebrew  charitable  and  benevolent  institutions  re- 
ceive $25,000  under  the  will  of  Ernest  Ehrmann,  who  died 
in  New  York  on  June  3d.  The  Mount  Sinai  Hospital,  the 
Montefiore  Home  for  Chronic  Lnvalids,  and  the  Beth  Israel 
Hospital  each  receive  $5,000,  to  be  devoted  in  each  case  to 
the  founding  of  a  bed  in  perpetuity,  to  be  known  as  the 
Ernest  Erdmann  Bed.  To  the  Arthur  Erdmann  memorial 
fund  in  connection  with  the  United  Hebrew  Charities  the 
testator  leaves  $10,000. 

The  Mortality  of  Chicago. — During  the  week  ending 
June  12,  1909.  the  total  number  of  deaths  from  all  causes 
reported  to  the  Department  of  Health  was  544.  in  an  esti- 
mated population  of  2.224.4CK),  corresponding  to  an  annual 
death  rate  of  12.75  i'l  a  thousand  population.  The  death 
rate  for  the  corresponding  week  last  year  was  11.93.  The  total 
infant  mortality  was  152,  104  under  one  year  of  age.  and  48 
between  one  and  five  years  of  age.  The  principal  causes  of 
death  were:  Diphtheria,  15  deaths;  scarlet  fever.  7  deaths: 
measles.  11  deaths;  whooping  cough.  1  deaths:  influenza. 
2  deaths :  typhoid  fever,  3  deaths ;  diarrhoeal  diseases,  46 
deaths ;  pneumonia.  69  deaths ;  pulmonary  tuberculosis,  54 
deaths;  other  forms  of  tuberculosis,  16  deaths:  cancer,  27 
deaths :  nervous  diseases.  9  deaths :  heart  diseases,  44 
deaths:  apoplexy,  9  deaths;  Bright's  disease,  47  deaths: 
violence.  63  deaths,  t6  from  suicide,  9  from  manslaughter, 
and  37  from  accidents. 

Vital  Statistics  of  New  York. — During  the  week  end- 
ing June  12,  1909,  there  were  reported  to  the  Department  of 
Health  of  the  City  of  New  York  1.263  deatlis  from  all 
causes,  in  an  estimated  population  of  4,564.792.  correspond- 
ing to  an  annual  death  rate  of  14.43  a  thousand  popula- 
tion. The  death  rate  for  each  of  the  five  borougiis  was  as 
follows:  Manhattan,  14.T3:  the  Bronx.  18.14;  Brooklyn. 
13-96;  Queens.  16.19;  Richmond.  10.70.  The  death  rate  for 
the  corresponding  week  last  year  was  14.38.  The  total  in- 
fant mortality  was  418:  225  under  one  year  of  age.  103  be- 
tween one  and  two  years  of  age.  and  90  between  two  and 
five  years  of  age.  There  were  126  still  births.  There  were 
180  deaths  from  pulmonary  tuberculosis,  174  from  pneu- 
monia, 119  from  heart  diseases.  56  from  cancer.  94  from 
Bright's  disease,  and  92  from  diarrhovil  diseases,  of  which 
43  were  under  five  years  of  age.  There  were  67  violent 
deaths:  15  from  suicide,  2  from  homicide,  and  50  from 
accidents. 


June  ;6,  1909.] 


XEll-S  ITEMS. 


University    of    Pennsylvania    Commencement. — The 

one  hundred  and  fifty-third  commencement  exercises  of  the 
Uni\ersity  of  Pennsylvania  were  held  on  Wednesday,  June 
i6th.  The  dean  of  the  college  faculty.  Dr.  Josiah  H. 
Penniman,  delivered  the  oration.  One  hundred  and  ten 
men  received  the  degree  of  doctor  in  arte  iiicdica.  The 
alumni  medal,  offered  to  the  members  of  the  graduating  class 
who  attained  the  highest  general  a\  erage  in  examinations, 
and  the  Dr.  Spencer  Morris  prize,  which  consists  of  the 
interest  on  $io.coo.  offered  to  the  student  who  passed  the 
best  exammation  for  the  degree  of  doctor  of  medicine,  was 
awarded  to  Dr.  George  Howard  Hungerford.  The  Fred- 
erick A.  Packard  prize  of  $100.  off'ered  to  the  member  of 
the  graduating  class  who  proved  himself  most  proficient  in 
the  course  in  clinical  medicine,  was  awarded  to  Dr.  Tsing 
Meu  Li.  of  Shanghai,  China.  The  honorary  degree  of  doc- 
tor of  laws  was  conferred  upon  Dr.  Charles  Bingham  Pen- 
rose. 

Personal. — Dr.  L.  W.  Littig,  of  Iowa  City,  Iowa,  has 
returned  from  abroad,  fully  restored  to  health. 

Dr.  George  Dock,  of  New  Orleans,  sailed  for  Europe  a 
short  time  ago.  He  will  attend  the  International  Medical 
Congress  at  Budapest. 

Dr.  H.  E.  Jordan,  adjunct  professor  of  analonn-  at  the 
University  of  Virginia,  has  l.een  made  associate  professor 
of  that  braiifh  of  medicine. 

Dr.  Francis  Wilson,  of  Washington,  D.  C.  has  been  ap- 
pointed a  member  of  the  board  of  fire  and  police  surgeons, 
to  succeed  Dr.  Wall,  who  resigned  recently. 

Dr.  Adolph  Feldstein,  for  forty-four  years  a  visiting  phy- 
sician to  the  Philadelphia  Jewish  Hospital,  has  resigned, 
and  his  resignation  has  been  accepted  with  regret  by  the 
board  of  directors,  who  adopted  a  resolution  thanking  Dr. 
Feldstein  for  his  long  and  faithful  service. 

Dr.  Owen  Copp,  secretary  and  executive  officer  of  the 
Massachusetts  State  Board  of  Insanity,  has  been  appointed 
superintendent  of  the  Boston  State  Hospital,  formerly  the 
Boston  Insane  Hospital. 

Dr.  Ernest  Fox  Nichols  formerl.\-  head  of  the  physics 
department  at  Dartmouth  College,  has  been  elected  presi- 
dent of  the  institution,  to  succeed  Dr.  W.  J.  Tucker,  who 
resigned  recently  on  account  of  ill  health. 

Dr.  A.  W.  McAlester,  dean  of  the  medical  department  of 
the  University  of  Missouri,  has  resigned.  Dr.  McAlester 
was  appointed  dean  in  1873. 

Dr.  William  S.  Thayer  and  Dr.  Thoilias  F.  Cullen,  both 
of  Johns  Hopkins  Hospital,  Baltimore,  ha\e  gone  to  Eu- 
rope for  the  summer. 

Physicians  Wanted  in  the  Panama  Canal  Service. — 

The  United  States  Civil  Service  Commission  announces 
that  an  examination  will  be  held  on  July  21st  to  secure 
eligibles  from  which  to  make  certification  to  fill  vacancies 
as  they  may  occur  in  the  position  of  physician  in  the  Pan- 
ama Canal  Service.  The  salary  is  $150  a  month.  Appli- 
cants must  be  citizens  of  the  United  States,  graduates  of 
recognized  medical  schools,  and  have  had  at  least  one  year's 
experience  as  interne  in  a  general  hospital.  The  element 
of  experience  will  be  rated  upon  the  statements  made  in 
application  Form  1312,  and  special  credit  will  be  given  to 
physicians  who  show  that  they  have  been  for  more  than 
a  year  members  of  the  house  staff  of  large  metropolitan 
hospitals.  Men  only  will  be  admitted  to  this  examination. 
The  age  limit  is  twenty  to  forty-five  years  on  the  date  of 
the  examination.  Each  applicant  for  the  Isthmian  Canal 
Service  will  be  required  to  submit  to  the  examiner,  on  the 
day  he  is  examined,  a  photograph  of  himself,  taken  within 
three  years,  which  will  be  filed  with  his  examination  papers 
as  a  means  of  identification  in  case  he  receives  an  appoint- 
ment. The  county  officer's  certificate  in  the  application 
form  need  not  be  executed.  No  person  will  be  appointed 
for  service  on  the  Isthmus  who  is  not  physically  sound  and 
in  good  health.  Persons  appointed  to  positions  under  the 
Isthmian  Canal  Commission  will  be  expected  to  proceed 
promptly  to  the  Isthmus.  Persons  examined  for  positions 
under  that  Commission  will  not  be  eligible,  as  the  result 
of  such  examination,  to  positions  in  the  United  States  and 
Philippine  services.  Applicant*  should  at  once  apply  to  the 
United  States  Civil  Service  Commission,  Washington.  D. 
C,  for  application  Form  1312.  The  medical  certificate  in 
Form  1312  nuist  be  filled  in  by  a  reputable  practicing  phy- 
sician other  than  the  applicant.  No  application  will  be  ac- 
cepted unless  properly  executed  and  filed  with  the  Com- 
mission at  \\'ashington  prior  to  the  hour  of  closing  business 
or,  July  10,  1909. 


The  American  Surgical  Association  held  its  annual 
meeting  in  Philadelphia,  Pa.,  on  June  3d,  4th,  and  5th,  and 
elected  the  following  officers  for  the  ensuing  year:  Presi 
dent,  Dr.  Rudolph  Matas,  of  New  Orleans,  La. ;  vice-presi- 
dents, Dr.  J.  M.  T.  Finney,  of  Baltimore,  and  Dr.  Georgt- 
H.  Monks,  of  Boston;  secretary.  Dr.  Richard  G.  Le  Conte, 
of  Philadelphia,  reelected ;  recorder.  Dr.  Richard  H.  Harte, 
of  Philadelphia,  reelected  ;  treasurer.  Dr.  Charles  A.  Pow- 
ers, of  Denver,  reelected ;  member  of  the  council,  Dr.  C. 

B.  G.  De  Nancrede,  of  Ann  Arbor,  Mich.    Washington,  D. 

C,  was  chosen  as  the  place  of  the  next  meeting,  in  con- 
junction with  the  Congress  of  American  Physicians  and 
Surgeons. 

The  British  Medical  Association  will  hold  its  seventy- 
seventh  annual  meeting  in  Belfast  on  July  23d  to  31st.  The 
president,  Sir  William  Whitla,  M.  D.,  LL.  D.,  Professor 
of  metcria  medica  and  therapeutics  in  Queen's  College, 
Belfast,  will  deliver  the  annual  address  on  Tuesday,  July 
27th,  and  the  sections  will  meet  on  the  three  following 
days.  The  annual  representative  meeting  will  begin  011 
Fridav.  July  23d.  The  address  in  medicine  will  be  delivered 
by  R.'W.  Phihp,  M.  D.,  F.  R.  C.  P.  Edin.,  Physician,  Royal 
Infirmary,  and  Royal  Victoria  Hospital  for  Consumption, 
Edinburgh ;  the  address  in  surgery  will  be  delivered  b\ 
Arthur  Edward  James  Barker,  F.  R.  C.  S.,  Professor  oi 
the  Principles  and  Practice  of  Surgery,  University  College, 
London  ;  the  address  in  obstetrics  will  be  delivered  by  Sir 
John  W.  Byers,  M.  D.,  Professor  of  Midwifery  and  Dis- 
eases of  Women,  Queen's  College.  Belfast ;  and  the  Popu- 
lar Lecture  will  be  delivered  by  Dr.  J.  A.  Macdonald,  Phy- 
sician to  the  Taunton  and  Somerset  Hospital,  Chairman  of 
the  Representative  Meetings.  The  scientific  work  of  the 
meeting  will  be  conducted  in  fifteen  sections,  which  will 
meet  on  Wednesday,  July  28th,  Thursday,  July  jQth,  and 
Friday,  July  30th. 

The  National  Confederation  of  State  Medical  Exam- 
ining Boards  held  its  nineteenth  annual  convention  at 
Atlantic  City  on  June  7th.  The  sessions  were  presided 
over  I)y  the  vice-president,  Dr.  A.  Ravogli.  of  Ohio.  Reso- 
lutions of  regret  on  the  death  of  the  president.  Dr.  T.  J. 
Happel,  of  Tennessee,  which  occurred  during  the  year,  were 
adopted.  A  committee  of  five  was  appointed  to  investigate 
and  report  on  the  clinical  instruction  given  at  the  medical 
colleges.  Dr.  James  A.  Duncan,  of  Ohio,  presented  a  re- 
port on  the  standing  of  the  medical  colleges,  and  Dr.  J.  C. 
Guernsey,  of  Pennsylvania,  reported  for  the  Examination 
Committee.  A  resolution  was  also  adopted  recommending 
that  the  necessary  steps  be  taken  to  bring  about  in  every 
State  mixed,  oral,  written,  and  practical  examinations.  The 
secretary,  Dr.  Murray  Gait  Motter,  of  Washington,  pre- 
sented a  sunmiary  of  the  work  of  the  subcommittee  of  the 
Council  on  Medical  Education  of  the  ."-Vmerican  Medical 
Association  on  the  teaching  of  materia  medica  and  thera- 
peutics, recommending  the  adoption  of  resolutions  advising 
that  instruction  should  be  confined  to  the  more  important 
preparations  of  the  more  important  drugs.  The  following 
pppers  were  read :  The  Necessity  of  a  Practical  Test  for 
Candidates  in  the  State  Examinations,  by  Dr.  A.  Ravogli ; 
The  Need,  Methods,  and  Value  of  Medical  College  Inspec- 
Hon,  by  Dr.  N.  P.  Colwell ;  Practical  xrrsus  Theoretical 
Examination,  by  Dr.  W.  T.  Councilman  ;  The  Inadequacy  of 
'be  Written  Examination,  by  Dr.  Edwan  B.  Harvey:  What 
Branches  or  Portions  of  Branches  Should  Be  Included  in 
the  Written,  and  What  in  the  Oral  Examinations?  by  Dr. 
J.  C.  Guernsey :  Is  it  to  the  Best  Interests  of  Students  and 
Medical  Examining  Boards  to  Have  Divided  Examina- 
tions? by  Dr.  William  Warren  Potter;  The  Feasibility  of 
Practical  Examinations,  by  Dr.  Augustus  Korndoerfer : 
Flow  Can  Practical  Examinations  be  Graded  and  Recorded  ? 
by  Dr.  L.  F'.  Bennett.  The  following  officers  and  members 
of  the  Executive  Council  were  elected  for  the  ensuing  year : 
President,  Dr.  A.  Ravogli.  of  Ohio;  vice-president.  Dr. 
J.  C.  Guernse}',  of  Pennsylvania  ;  second  vice-president,  Dr. 
Charles  A.  Tuttle.  of  Connecticut ;  secretary-treasurer,  Dr. 
M.  G.  Motter,  of  Washington,  D.  C.  Executive  Council : 
Dr.  N.  R.  Coleman,  chairman.  Dr.  Edwin  B.  Harvey.  Dr 
James  A.  Duncan,  Dr.  Henry  Beates,  and  Dr.  D.  P.  Mad- 
dux. The  following  committees  were  appointed:  Commit- 
tee on  Clinical  Instruction  :  Dr.  Henry  Beates.  chairman  ;  Dr. 
Charles  A.  Tuttle.  Dr.  Fred  C.  Zapffe.  Dr.  M._  J.  Lewi,  and 
Dr.  L.  F.  Bennett.  Committee  to  compile  list  of  drugs : 
Dr.  M.  G.  Motter.  chairman.  Dr.  J.  C.  Guernsey,  and  Dr. 
George  MacDonald.  The  confederation  adjourned  to  meet 
on  the  day  preceding  the  annual  convention  of  the  Ameri- 
can iNIedical  Association  in  St.  Louis.  1910. 


I320 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journai. 


JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

June  i<),  igog. 

1.  The   Conquest  of  the   Tropics   for  the  White  Race. 

President's  Address  at  the  Sixtieth  Annual  Session 
of  the  American  Medical  Association,  at  Atlantic 
City,  June  9,  1909,  By  W.  C.  Gorgas. 

2.  Teaching  of  Dermatology — Dermatology  and  the  Phar- 

macopoeia. Chairman's  Address  before  the  Section 
on  Cutaneous  Medicine  and  Surgery,  June,  1909. 

By  William  Allen  Pusey. 

3.  Twelve  Years  of  Pulmonary  Tuberculosis  Treatment  in 

the  West,  By  E.  S.  Bullock  and  C.  T.  Sands. 

4.  Phagocytosis  in  Relation  to  Arneth's  Classification  of 

Neutrophiles,  By  J.  E.  Pottenger. 

5.  A  Study  of  Malnutrition  in  the  School  Child, 

By  E.  Mather  Sill. 

6.  Scissors  Magnet   Extraction  of  Iron  from  the  Eye- 

ball, By  Edward  Jackson. 

7.  The  Faucial  Tonsils  and  the  Teeth, 

By  G.  Hudson-Makuen. 

8.  Amoebic  Dysentery,  By  Granville  S.  Hanes. 

9.  The  Accommodation  and  Donders's  Curve  and  the  Need 

of  Revising  our  Ideas  Regarding  Them.  An  Ex- 
perimental Study,    .  By  Alexander  Duane. 

I.  The  Conquest  of  the  Tropics  for  the  White 
Race. — Gorgas  believes  that  the  debiHty  from 
which  the  white  man  lias  suffered  in  tlie  past  at  Pan- 
ama and  in  other  tropical  countries  is  due  to  malaria 
principally,  and  that  if  he  protects  himself  from  this 
infection  he  will  remain  as  vigorous  and  strong  as 
if  he  was  living  in  a  temperate  climate.  As  a 
reason  for  his  belief,  he  cites  the  health  conditions 
of  the  Americans  at  Panama.  There  are  about  8,000 
white  Americans  living  under  the  same  conditions 
that  exist  at  home  among  men  doing  the  same  char- 
acter of  work.  They  'are  exposed  to  the  weather 
fully  as  much  as  they  are  at  home,  a  large  propor- 
tion of  them  being  exposed  for  eight  hours  daily  to 
the  tropical  sun  and  rains.  Notwithstanding  this, 
figures  show  that  their  general  health  remains  fully 
as  good  as  it  was  in  the  United  States.  It  is  neither 
difficult  nor  expensive  for  the  white  man  going  to 
the  tropics  to  protect  himself  from  malaria.  It  is 
only  necessary  that  he  should  screen  his  house  well, 
drain  and  clear  off  the  brush  within  one  hundred 
yards  of  his  residence.  These  measures  are  much 
less  expensive  than  those  he  must  take  in  the  tem- 
perate zones  to  protect  himself  from  cold.  The 
advances  in  tropical  sanitation  in  the  last  fifteen 
years  have  shown  that  the  white  man  can  live  in 
the  tropics  and  enjoy  as  good  health  as  he  would 
have  if  living  in  the  temperate  zone-  This  has  been 
demonstrated  both  by  our  two  military  occupations 
of  Cuba  and  by  our  present  occupancy  of  Panama. 
The  returns  for  labor  are  many  fold  greater  in  the 
tropics  than  they  are  in  the  temperate  zone.  He 
thinks,  therefore,  that  during  the  next  few  centuries 
the  tendency  will  be  for  the  white  man  to  drift  to 
the  tropics,  and  he  predicts  that  after  the  lapse  of 
a  period,  let  us  say  to  that  which  now  separates  the 
year  1909  from  the  Norman  conquest  of  England, 
localities  in  the  tropics  will  be  the  centres  of  as 
powerful  and  as  cultured  a  white  civilization  as  any 
that  will  then  exist  in  temperate  zones. 

3.  Twelve  Years  of  Pulmonary  Tuberculosis 
Treatment  in  the  'West. —  lUiUock  and  Sands  state 
that  it  has  been  proved  that  coincident  with  im- 


provement in  tuberculosis  there  is  a  rise  of  blood 
pressure,  and  this  phenomenon  occurs,  of  course,  in 
any  altitude.  Dr.  Thayer,  of  Baltimore,  recorded 
the  blood  pressure  in  a  large  number  of  consump- 
tives and  found  it  to  average  100  mm.  Hg.,  show- 
ing conclusively  the  influence  of  tuberculosis  in  low- 
ering blood  pressure.  Granting  that  Dr.  Thayer's 
figures  are  correct,  it  becomes  clear  that  continued 
residence  in  a  great  altitude  tends  to  raise  the  blood 
pressure,  after  the  primary  fall  has  been  recovered 
from.  Among  350  of  the  author's  patients,  the 
average  blood  pressure  in  all  classes  was  130  mm. 
Hg.  Thus,  one  of  the  specific  reasons  was  demon- 
strated, why  great  altitudes  are  beneficial  in  tuber- 
culosis- Continued  residence  in  a  great  altitude 
causes  complicated  changes  in  the  blood  itself,  as 
well  also  as  an  increase  in  haemoglobin,  but  further 
studies  are  required  to  elucidate  them. 

6.  Scissors  Magnet  Extraction  of  Iron  from 
the  Eyeball. — Jackson  reports  two  cases  in  which 
the  iron  was  so  firmly  imbedded  in  the  eyeball  that 
it  was  impossible  to  extract  it  with  the  magnet 
alone.  He  says  that  it  has  been  found  by  many 
ophthalmologists  that  in  a  considerable  proportion 
of  cases  the  electromagnet,  whatever  its  form  and 
however  used,  fails  to  extract  pieces  of  iron  capa- 
ble of  magnetic  attraction,  because  they  are  too 
firmly  imbedded  in  recent  exudate  or  organized  tis- 
sue. Such  cases  are  sufficiently  numerous  to  make 
it  of  interest  and  importance  to  consider  a  method 
by  which  some  of  these  eyes  may  be  saved,  and  such 
a  method  we  have  in  the  use  of  scissors  held  in  con- 
tact with  the  magnet  while  used  to  set  free  the 
foreign  body.  The  scissors  he  used  were  curved  on 
the  flat  and  had  fine  but  slightly  blunted  points.  It 
is  important  that  the  contact  with  the  tip  of  the 
magnet  should  be  made  at  the  joint  of  the  scissors, 
where  the  attraction  of  the  magnet  for  the  scissors 
will  cause  little  or  no  interference  with  the  neces- 
sary movements  for  snipping.  The  scissors  should 
be  introduced  so  that  their  tips  are  a  very  little  short 
of  the  position  of  the  foreign  body ;  and  the  mag- 
net tip  should  be  brought  in  full  contact  with  them 
and  in  the  proper  position  before  the  current  is 
turned  on.  Then  the  magnetic  attraction  will  force 
the  intervening  tissue  between  the  tips  of  the  scis- 
sors and  hold  it  there.    The  snipping  first  causes 

opening  of  a  passage  to  the  foreign  body.  Later, 
as  the  foreign  body  tends  to  slip  on  the  blades 
of  the  scissors,  the  repeated  cuts  divide  bands  of 
tissue  that  tend  to  retain  it.  It  is  conceivable  that  a 
fragment  of  iron  or  steel  might  be  of  such  shape  as 
to  require  to  be  thus  freed  on  both  sides  before  it 
could  be  withdrawn ; 'but  generally  the  movements 
of  the  scissors'  tips  will  so  disturb  its  position  that 
reintroduction  in  a  somewhat  different  direction  will 
not  be  necessary. 

7.  The  Faucial  Tonsils  and  the  Teeth.— Hud- 
son-Makuen observes  that  the  faucial  tonsils  and 
the  teeth  are  in  close  approximation  and  they  are 
alike  subject  to  disease  or  degeneration.  Diseased 
tonsils  and  teeth  are  locally  and  systemically  unhy- 
gienic. Secretions  from  the  tonsils  may  infect  the 
teeth,  and  vice  versa,  the  tonsils  may  be  infected 
by  the  teeth.  Diseased  tonsils  and  teeth  cause  head- 
ache, earache,  and  facial  neuralgia,  and  they  become 


June  26,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


a  direct  source  of  infection  to  the  glands  of  the 
neck  and  through  the  efferent  lymphatics  to  the 
general  respiratory  and  circulatory  systems.  Hy- 
pertrophied  faucial  tonsils  often  become  so  large  as 
to  effect  the  hearing,  the  circulation  of  blood,  tlie 
nerve  supply  of  the  face  and  head,  and  the  normal 
development  of  the  alveolar  arches.  The  teech 
serve  important  purposes,  but  the  exact  function 
of  the  tonsil  has  not  yet  been  demonstrated.  The 
importance  of  preserving  the  teeth  is  fully  recog- 
nized, but  the  diseased  tonsil  is  not  worth  preserv- 
ing, because  it  has  lost  its  usefulness  and  become 
a  menace  to  the  human  economy.  The  only  rational 
remedy  for  diseased  faucial  tonsils  is  total  extirpa- 
tion. 

MEDICAL  RECORD 

June  ig,  1909. 

1.  The  Conquest  of  the  Tropics  for  the  White  Race, 

By  W.  C.  GORGAS. 

2.  Caisson  Disease,  By  AI.  Allen  Starr. 

3.  The  Value  of  Cystoscopy  in  Gynaecology, 

By  Arthur  Stein. 

4.  On  the  Amount  of  Pepsin  in  Various  Disorders  of  the 

Stomach, 

By  Max  Einhorn  and  George  L.  La  Porte. 

5.  Calculus  in  the  Lower  Segment  of  the  Ureter  in  the 

Female,  with  Special  Reference  to  the  Operative 
Method,  By  A.  E.  Isaacs. 

6.  The  ^Etiology  of  Carcinoma, 

By  Abdullah  K.  Sallom. 

2.  Caisson  Disease. — Starr  analyzes  310  cases 
of  caisson  disease  which  have  been  reported  in 
recent  years,  and  states  that  the  following  list  of 
symptoms  occur  in  the  order  of  frequency:  (i) 
Myalgia,  or  severe  pain  in  the  muscles,  and  espe- 
cially in  the  muscles  of  the  back,  but  also  in  the 
muscles  of  the  extremities,  seems  to  be  a  uniform 
accoinpaniment  of  the  disease.  It  is  the  symptom 
which  has  given  rise  to  the  common  term  used  by 
the  workmen  for  this  affection,  viz.,  "the  bends," 
the  patient  being  practically  doubled  up  with  pain 
and  tmable  to  move  the  muscles  or  to  straighten 
himself  out,  as  in  a  case  of  intense  lumbago.  (2) 
The  second  most  frequent  symptom  is  an  affection 
of  the  ears,  either  a  rupture  of  the  drum  or  such 
an  intense  congestion  of  the  inner  ear  as  to  produce 
symptoms  comparable  to  Meniere's  disease  ;  vertigo, 
vomiting,  intense  prostration,  tinnitus  aurium,  and 
deafness.  (3)  Pain  in  the  joints,  classed  together 
as  arthralgias.  It  seems  probable  that  in  these 
cases  there  has  been  a  sudden  eff'usion  of  fluid  into 
the  joints,  stretching  the  capsules  of  the  joints  with- 
out any  acute  inflammatory  condition,  and  in  proof 
of  this  the  frequency  of  swelling  without  heat  or 
redness  can  be  cited.  (4)  Acute  paraplegia.  (5) 
Monoplegia,  cerebral  in  type  rather  than  spinal, 
and  undoubtedly  due  to  localized  areas  of  softening, 
or  to  malnutrition  in  the  cortex  produced  by  bub- 
bles of  air  in  the  veins  of  the  brain.  Such  bubbles 
can  act  as  emboli,  and  hence,  if  in  the  cortex,  are 
more  liable  to  produce  monoplegia  than  hemiplegia. 
(6)  Symptoms  of  intense  vertigo  of  cerebral 
nature,  undoubtedly  due  to  emboli  in  the  cerebellum. 
These  resemble  in  many  respects  the  symptoms  of 
Meniere's  disease,  but  are  followed  by  paralvsis 
of  some  of  the  cranial  nerves,  indicating  that  the 
origin  of  the  symptoms  is  not  in  the  ear.  (7)  The 
seventh  most  frequent  set  of  symptoms  are 
classed  together  as  asphyxia,  the  patients  showing 


all  the  signs  of  faintness  with  irregular  heart  ac- 
tion, btit  these  are,  of  course,  temporary  in  their 
nature.  (8)  Aphasia  has  been  observed  in  a  number 
of  the  cases.  Recoveries  have  also  been  recorded 
in  many  of  the  cases  where  the  symptoms  were 
largely  cerebral.  Thus  in  cases  presenting  the 
phenomena  of  acute  transitory  mania,  in  other 
cases  presenting  symptoms  of  hemiplegia,  in  other 
cases  presenting  the  symptoins  of  various  types  of 
aphasia,  and  temporary  deafness  and  temporary 
blindness,  as  well  as  in  those  very  numerous  cases 
in  which  peripheral  disturbance  of  the  auditory 
nerve  has  been  produced  by  lesions  of  the  inner  or 
middle  ear,  recoveries  have  been  recorded.  It  is 
evident,  therefore,  that  in  the  cases  of  apoplexy  or 
of  paraplegia  occurring  in  connection  with  caisson 
disease,  the  prognosis  is  very  different  from  that  in 
cases  occurring  under  other  circumstances. 

4.  On  the  Amount  of  Pepsin  in  Various  Dis- 
orders of  the  Stomach. — Einhorn  and  La  Porte  ex- 
amined no  patients;  among  these  were  forty-eight 
cases  of  hyperchlorhydria,  four  of  subacidity, 
twenty-one  of  absence  of  free  hydrochloric  acid, 
and  thirty-seven  of  normal  acidity.  In  looking  over 
the  results  of  these  tables  it  is  found  that  there  is 
no  strict  relation  between  the  amount  of  pepsin  and 
the  acidity  in  the  group  of  hyperchlorhydria  and 
normal  acidity.  In  fifteen  cases  of  achylia  the  ricin 
deposit  was  cleared  up  entirely  only  once,  and  in 
five  cases  of  cancer  of  the  stomach  without  free 
hydrochloric  acid  it  also  occurred  only  once.  In 
one  case  of  achylia  the  amount  of  pepsin  was  fairly 
considerable,  as  the  precipitate  disappeared  in  seven 
minutes.  Among  the  cases  of  subacidity  were 
only  seven  that  showed  a  correspondingly  increased 
amount  of  pepsin;  in  all  other  cases  the'amount  of 
pepsin  did  not  exceed  the  normal  limits.  Pepsin 
and  rennet  usually  occur  together  ;  in  fact  the  physi- 
ologists are  not  yet  in  accord  whether  rennet  and 
pepsin  are  two  difi'erent  ferments  or  whether  the 
action  of  dissolving  albumin  and  coagulating  milk 
is  not  due  to  one  and  the  same  substance  (Pavloff 
and  his  school).  It  appeared  to  our  authors  of 
value  to  make  a  comparative  study  between  the 
amounts  of  pepsin  and  those  of  rennet  in  some  of 
the  cases.  When  pepsin  is  present  rennet  is  also 
present.  When  pepsin  is  absent  rennet  is  also  often 
absent. 

BRITISH   MEDICAL  JOURNAL, 
June  5,  igog. 

1.  Clinical  Lecture  on  the  Neurotic  Element  in  Disease, 

By  Guthrie  Rankin. 

2.  A  Lecture  on  the  Treatment  of  Eczematous  Patients. 
~,    ^r^.     .,  By  E.  Graham  Little. 

3-  Ine  Distribution  of  Longevity  in  England  and  Wales, 
„,  .  By  W.  Gordon. 

4-  Ihe  Diagnosis  and  Treatment  of  Severe  Anjemia, 

.  .  By  Charles  H.  Melland. 

5-  Pernicious  Anaemia  with  Pigmentation  of  the  Skin  and 

Buccal  Mucous  Membrane,  By  John  Aitken. 

6.  Two  Cases  of  Cardiac  Disease.     Bv  W.  Black  Jones. 

7.  Case  of  General  Paralysis  of  the  Insane,  with  Extraor- 

dinary Lymphocytosis  in  the  Cerebrospinal  Fluid, 
„     .       ,  By  William  Boyd. 

8.  .-^n.-esthetics  in  General  Practice. 

.  By  H.  Bellamy  Gardner. 

9.  Resection  of  the  Trachea  for  Cicatricial  Stenosis, 

By  G.  Grey  Turner. 

10.  I  reatment  of  Facial  Paralysis  due  to  Division  of  the 

Facial  Nerve  in  the  Mastoid  Operation, 

By  F.  Marsh. 


1322 


PITH  Of  CURREXT  UTERATU RE. 


[Xew  York 
Medical  Journal. 


4.  Severe  Anaemia. — Alellaiid  observes  that 
ever  since  Byrom  Bramvvell  first  demonstrated  its 
value  arsenic  has  been  our  sheet  anchor  in  perni- 
cious ansemia.  The  mode  of  giving  it  is  of  the 
greatest  importance.  It  is  quite  useless  to  give  two 
or  three  minims  of  liq.  arsenicalis  as  is  too  often 
done  in  a  perfunctory  fashion.  It  must  be  started 
at  four  or  five  minims  three  times  a  day  and  rapidly 
run  up  by  increments  of  one  minim  a  dose  every 
day  or  every  other  day  to  a  dose  of  twelve,  or,  if 
j)ossible,  fifteen  minims.  When  these  large  doses 
are  being  approached,  the  blood  should  be  again 
examined,  and,  if  improvement  is  commencing,  the 
(lose  should  be  dropped,  and  then  again  increased. 
The  reason  for  this  is  that  if  improvement  has 
started  there  is  less  need  to  push  the  drug  and 
greater  need  to  avoid  setting  up  toxic  symptoms, 
which  might  entail  its  being  wholly  stopped  for  a 
while,  with  consequent  liability  to  relapse.  If  the 
second  examination  of  the  blood  shows  no  com- 
mencing improvement,  the  arsenic  must  still  be 
])ushed,  and,  in  the  hope  of  its  eventually  proving 
fft'ective,  the  risk  of  poisonous  effects  must  be  taken. 
The  history  of  a  case  under  such  treatment  usually 
is  that  the  patient  improves  rapidly  after  he  has 
imce  started  to  ])ick  up,  gives  up  treatment,  and 
before  long  relapses,  and  the  successive  relapses 
which  may  occur  are  usually  each  more  severe  and 
more  difficult  to  cure  than  their  predecssors.  He 
feels  so  well  as  the  result  of  treatment  that  nothing- 
will  convince  him  that  he  is  not  permanently  cured, 
and  too  often  his  doctor  falls  into  the  same  belief 
and  sends  him  off  for  a  long  holiday,  with  most 
dire  consequences.  It  is  of  the  utmost  importance 
that  the  patient  should  keep  on  with  small  doses 
of  arsenic,  even  though  feeling  perfectly  well,  that 
he  should  never  go  longer  than  ten  days  or  a  fort- 
night without  being  seen  by  his  doctor,  and  that  if 
there  is  any  suspicion  of  a  commencing  relapse  a 
blood  examination  should  be  at  once  made,  for  the 
relapses,  if  detected  early,  may  respond  readily  to 
treatment,  but  if  overlooked  (and  their  onset  is 
nearly  always  most  insidious)  they  prove  more  stub- 
born than  the  previoixs  attack.  There  is  another 
line  of  treatment  which  may  be  combined  with  the 
arsenical,  based  on  Hunter's  theory  that  the  essen- 
tial cause  of  the  disease  is  a  chronic  orogastrointes- 
tinal  infection.  The  removal  of  carious  teeth,  the 
use  of  antiseptic  month  washes,  and  of  gastric  and 
intestinal  antiseptics  should  never  be  neglected. 
\'arious  internal  antiseptics  may  be  used.  He  has 
employed  salol,  beta  naphthol,  mercury  perchloride, 
and  petroleum  emulsion.  The  same  rule  applies  to 
these  as  to  arsenic — they  should  be  continued  in 
small  doses  during  the  well  periods  and  in  full 
doses  on  any  sus]:)icion  of  relapse.  The  author  then 
takes  up  treatment  with  red  bone  marrow.  Dr. 
Gullan  has  published  some  cases  in  which  its  use 
appears  to  have  been  effective.  He  suggests  that  in 
addition  to  the  vital  process  of  reproduction  of  red 
and  white  cells  which  goes  on  in  the  bone  marrow 
there  may  be  a  chemical  process — the  production  of 
an  internal  secretion.  He  supposed  that  w^hen  the 
red  bone  marrow  is  administered  this  internal  secre- 
tion mav  be  such  as  to  stimulate  the  vital  prodtic- 
tion  of  blood  corpuscles  in  the  patient's  bone  mar- 


row, and  also  that  it  may  act,  as  there  is  some  ex- 
perimental evidence  to  show  that  arsenic  does,  by 
increasing  the  resistance  of  the  red  corpuscles  to 
the  action  of  the  haemolytic  toxines  which  are  looked 
on  as  the  cause  of  the  disease.  The  author  believes 
that  combined  with  other  methods  the  red  bone  mar- 
row is  one  which  shoiild  not  be  neglected. 

8.  Anaesthetics  in  General  Practice. — Gardner 
gives  good  review  of  anaesthetics  in  general  prac- 
tice. He  remarks  that  the  most  sensitive  spot  on 
the  eye  is  the  centre  of  the  cornea  opposite  the  pu- 
pil. This  is  protected  from  injury  in  daily  life  by 
the  closure  of  the  upper  eyelid  on  contact  with  a 
foreign  body.  \\'hen  a  patient  is  unconscious  the 
muscular  reflexes  are  gradually  lost  in  a  definite 
order  as  narcosis  deepens,  but  the  sensitiveness  of 
the  centre  of  the  cornea  does  not  disappear  until 
last  of  all.  and  this  happens  before  the  respiratory 
and  cardiac  centres  are  themselves  invaded.  It  is 
impossible  under  any  known  conditions  for  the 
respiratory  centre  or  the  cardiac  centre  to  be  pois- 
oned by  chloroform  or  ether  while  the  upper  eye- 
lid still  closes  when  the  centre  of  the  cornea  i^ 
touched  by  the  finger.  This  sign,  therefore,  fur- 
nishes an  absolute  guide  to  safety,  in  that,  if  by 
careful,  f^-equent  testing  of  both  corne^e  a  condition 
of  weakly  active  reflex  closure  of  the  upper  eyelid 
is  alwa\-s  retains!,  anv  complications  which  occur 
cannot  be  due  to  central  poisoning  of  the  respira- 
torv  or  cardiac  nervous  mechanisms.  An  extra- 
ordinary fact  connected  with  this  simple  ]:)rocedure 
is  that  so  very  few  know  how  to  do  it.  The  ad- 
ministrator stands  behind  the  patient,  and  uses  only 
one  finger  with  which  to  raise  the  upper  eyelid  and 
touch  the  cornea.  That  is,  he  should  insert  the 
pulp  of  his  middle  finger  between  the  palpebral 
edges,  drawing  the  upper  eyelid  upward  and  at  the 
same  time  brushing  that  finger  pulp  lightly  against 
the  centre  of  the  cornea.  When  he  has  arrived  at 
the  upper  limit  of  the  pupil  he  should  let  go  alto- 
gethei'.  noting  both  by  the  senses  of  touch  and 
sight  the  degree  of  briskness  with  which  that  up- 
per eyelid  closes.  There  is  only  one  proviso  with 
regard  to  this  sign,  which  is  that  when  a  definite 
difference  exists  in  the  activity  of  the  two  upper 
eyelids,  we  mtist  be  guided  by  the  more  active. 
Working  on  this  principle,  on  account  of  the  fac" 
that  a  large  pupil  is  found  both  in  the  second  and 
fourth  stages  of  anjesthesia.  which  can  onlv  be  dis- 
tinguished by  reference  to  the  activity  of  the  corneal 
reflex,  pupillary  signs  may  be  neglected  altos^ether. 
.\  progressive  dose  of  chloroform  or  ether  having 
been  given  until  the  upper  eyelid  is  weakly  active 
in  response  to  corneal  contact,  this  condition  can 
be  exactlv  retained  throughout  by  stopjiing  the  an- 
aesthetic for  a  few  breaths  to  quicken  its  activity,  or 
giving  more  anaesthetic  to  weaken  it  as  required.  As 
to  the  air  ways,  the  author  says  that  it  is  nocessarv 
to  know  by  the  sound  of  the  breathing  when  they 
are  clear.  There  is,  of  course,  a  distinct  dift'erence 
between  the  sounds  of  inspiration  and  expiration: 
but  this  is  only  known  in.stinctively  after  careful 
practice.  The  rule  in  anresthesia  is  that  every  ex- 
piration must  be  either  heard  or  felt  by  the  admin- 
istrator in  order  to  make  sure  that  efficient  b'-eath- 
ing  is  going  on.    It  is  of  no  use  to  see  the  abdom- 


June  26,  1 909.  J 


Pll'H  OF  CURRENT  LITERATURE. 


1323 


inal  and  thoracic  movements,  for  they  may  procted 
for  a  considerable  time  after  obstruction  to  air  en- 
try has  taken  place.  The  successful  elimination  of 
the  numerous  possible  asphyxial  factors  as  they 
arise  depends  upon  their  immediate  detection,  causal 
distinction,  and  application  of  the  proper  remedial 
measure  without  hesitation.  So  subtle  in  their  ac- 
tion are  som.e  of  these  factors  that  th^  clinical  ef- 
fect first  noticed  is  often  only  a  secondary  syncopal 
result  upon  the  heart  and  circulation,  when  the  gen- 
eral condition  is  graver  than  it  ought  to  have  been 
allowed  to  become.  Duskiness  of  the  lips  and  ea-s 
is  a  sign  that  air  is  not  entering  the  lungs  in 
adequate  amount,  and  is  due  to  this  absence  of  air 
intake,  not  to  ether  or  chloroform  per  sc.  Here  we 
have  a  definite  physical  sign,  and  the  man  who 
guides  himself  by  the  sound  of  breathing,  putting  in 
a  small  mouth  prop,  raising  the  jaw  or  drawing  the 
tongue  forward  directly  the  sound  of  breathing 
through  clear  air  ways  is  replaced  by  that  of  parti- 
ally olistructed  respiration,  prevents  the  onset  of 
duskiness  and  its  consequent  additional  dangers. 

THE  LANCET. 

J  line  5,  iQog. 

1.  Hypernephroma,  By  Wilfred  Trotter. 

2.  The  Results  of  a  Year's  Use  of  Vaccines  in  General 

Medicine,         By  W.  Hale  White  and  J.  W.  Eyre. 

3.  Experimental  Evidence  of  ihe  Infective  Origin  of  Car- 

cinoma and  of  the  Transmissibility  of  the  Disease 
from  the  Human  Subject  to  the  Mouse, 

By  W.  Ford  Robertson. 

4.  A  Note  on  the  Recurrence  of  Vesical  Calculi  after  Re- 

moval in  a  Series  of  160  Operations. 

By  F.   A.  SoUTH.aiM. 

5.  Pustrle  Simulating  Anthrax  due  to  Organisms  of  the 

Proteus  Group,  By  Thomas  Orr. 

6.  Sudden  Failure  of  Respiration  Restored  by  .'\rtificial 

Means,  Occurring  during  the  course  of  an  Acute 
Pneumonia  Complicated  by  Coma  of  Uraemic  Origin, 

By  Robert  Knox. 

7.  A  Tropical  Form  of  Adenitis  Apparently  Due  to  an  as 

yet  Unrecognized  Organism.       Bv  R.  Leonard  Ley. 

8.  An  Investigation  of  the  Action  of  Digestive  Ferments 

and  Tissue  Extracts,  Hypodermically  Injected,  on 
Malignant  Tumors  in  Mice, 

By  J.  A.  Shaw-Mackenzie. 

9.  Motoring  Notes,  By  C.  T.  W.  Hirsch. 

I.  Hypernephroma. — Trotter  says  that  put- 
ting together  a  few  of  the  more  recent  series  of 
•  cases  of  kidney  tumor  we  find  that  out  of  196,  146 
were  hypernephromata — that  is,  almost  exactly  75 
per  cent.  The  remaining  25  per  cent,  are  made 
up  mostly  of  sarcomata,  to  a  much  less  extent  of 
squamous  epitheliomata  of  the  pelvis,  while  a  true 
carcinoma  of  the  kidney  apart  from  hypernephroma 
is  a  very  great  rarity  or  possibly  does  not  exist.  The 
kidney  tumors  of  children  are  practically  all  sar- 
comata :  there  is  but  one  case  on  record  of  a  true 
hypernephroma  in  an  infant,  and,  as  was  long  ago 
pointed  out  by  Kiister.  malignant  disease  of  the  kid- 
ney is  a  disease  of  earliest  childhood  and  middle 
age,  affecting  but  little  young  adults  and  the  aged. 
Hence,  we  may  lay  it  down  definitely  that  hyper- 
nephroma is  the  common  kidnev  tumor  of  adults  and 
conversely  that  any  given  kidnev  tumor  in  an  adult 
is  much  more  likely  to  be  one  of  this  type  than  any- 
thing else.  This  is  the  only  aetiological  fact  bear- 
ing on  the  disease  which  we  can  regard  as  abso- 
lutely definite.  There  is,  of  course,  the  ubiquitous 
history  of  injiiry,  but  the  conditions  here  make  it 


even  more  than  usually  liable  to  suspicion.  We 
know  that  the  tumor  may  be  present  for  a  very  long 
time  before  it  is  discovered,  so  that  injury  may 
come  to  have  its  apparent  importance  merely  by 
calling  attention  to  the  part ;  moreover,  it  is  very 
probable  that  it  may  induce  a  haemorrhage  from  a 
kidney  the  seat  of  a  tumor  when  it  would  not  do 
so  from  a  sound  one.  The  indications  for  treat- 
ment when  once  the  diagnosis  is  established  are  usu- 
ally quite  clear.  A  kidney  containing  a  hyper- 
nephroma must  be  removed.  However  tempting  it 
may  appear  to  do  a  local  resection  of  the  kidney 
when  the  tumor  is  small,  experience  teaches  that 
nothing  less  than  a  total  nephrectomy  is  justifiable. 
In  the  absence  of  secondary  growths  mere  size  of 
the  tumor  should  not  be  regarded  as  a  contraindica- 
tion unless  there  is  obvious  involvement  of  other 
abdominal  organs.  In  this  connection  it  is  interest- 
ing to  notice  that  although  tumors  of  the  colon  suit- 
ably placed  frequently  involve  the  kidney,  tumors 
of  the  kidney  rarely  involve  the  colon.  As  to  re- 
currence of  the  disease,  it  may  be  stated  fairly  defi- 
nitely that  in  favorable  cases  there  is  always  an 
excellent  probabilitv  of  very  prolonged  immunity — 
a  period  of  ten  years'  freedom  from  recurrence  is, 
for  example,  not  unknown,  but  it  is  probable  that 
unless  the  patients  can  be  operated  upon  a  good 
deal  earlier  than  happens  at  present  permanent 
cures  are  likely  to  be  rare. 

3.  Experimental  Evidence  of  the  Infective 
Origin  of  Carcinoma. — Robertson  believes  from 
his  experiments  that  the  pathogenic  agent  trans- 
ferred from  the  human  subject  sufifering  from  can- 
cer to  the  mouse  was  not  merely  a  chemical  sub- 
stance but  must  have  been  a  living  virus.  This  con- 
tention has,  however,  a  still  stronger  support.  It 
is  borne  out  by  abundant  evidence  of  a  direct  char- 
acter. From  one  of  the  mammary  tumors  occurring 
in  these  mice  he  has  made  several  cultures  upon 
nonnutrient  agargelatin.  These  cultures  have  been 
studied  in  section  by  means  of  the  ammoniosilver 
process  by  Dr.  M.  C.  W.  Young,  who  has  been 
able  to  demonstrate  in  them  certain  morphologically 
characteristic  forms  identical  with  those  already  ob- 
served by  the  author  in  malignant  tumors  from  the 
human  subject  and  more  recently  in  one  of  the  orig- 
inal Jensen  mouse  tumors.  Some  of  these  forms 
have  also  been  demonstrated  in  these  experimental 
tumors,  as  well  as  in  a  mammary  tumor  produced 
in  a  previously  healthy  mouse  by  inoculation  of  one 
of  these  growths.  His  more  recent  observations  lead 
him  to  conclude  that  a  group  of  protozoan  organ- 
isms, to  be  classed  among  the  mycetozoa  and  in- 
cluding very  numerous  pathogenic  species,  is  as- 
sociated with  tumor  growth,  just  as  very  numerous 
pathogenic  species  of  schizomycetes  are  associated 
with  inflammation.  He  thinks  that  the  main  phases 
in  a  complicated  life  cycle  have  now  been  demon- 
strated in  sections  of  tumors,  in  sections  of  agar 
cultures  from  tumors,  and  in  films  of  the  centrifuge 
deposit  from  fluid  from  cases  of  malignant  pleurisy 
secondary  to  carcinoma  of  the  breast.  The  phases 
recognized  include  forms  with  flagella,  sporoblasts 
and  their  residua,  nucleated  forms,  some  of  which 
have  been  observed  in  mitosis,  and  certain  other  re- 
markable bodies  of  characteristic  appearance  which 
almost  certainly  represent  gametes. 


1324 


PITH  OF  CURRENT  LITERATURE. 


[New  York 
Medical  Journal. 


BERLINER  KLINISCHE  WOCH ENSCH Rl FT, 
May  3,  1909. 

1.  Experimental  Cavernous  Pulmonary  Tuljerculosis, 

By  Paul  H.  Romer. 

2.  Plastic  and  Cosmetic  Operations, 

By  EuGEN  Hollander. 

3.  ,'Etiology  of  Yellow  Fever,    .        By  Harald  Seidelin 

4.  Lime  in  the  Pathology  of  Rhachitis,    By  J.  A.  Schabad. 

5.  Contributions  to  the  Pathology  of  the  Secretion  of  the 

Gastric  Mucus, 

6.  A  Contribution  to  the  Theory  and  Technique  of  Was- 

sermann's  Reaction  and  to  the  Measurement  of  the 
Value  of  the  Tested  Sera,  By  Meyer. 

7.  Orthopjedic  Apparatus   in   Contract    {Kraakenkassen  ■ 

Practice,  By  A.  Schanz. 

8.  Another  Contribution  to  My  New  Distinctive  Staining 

Alethod  of  Tubercle  Bacilli,     By  Demetrius  Gasis. 

9.  The  Use  of  Forest's  Needle  as  an  Aid  in  Cancer  Oper- 

ations, By  M.  CoHN. 

10.  A  New  Contribution  to  the  Study  of  Situs  Viscerum 

Inversus  Partialis  (Concluded) .  By  Curt  Schelenz. 

I.  Experimental  Cavernous  Pulmonary  Tu- 
berculosis.— Romer  states  that  he  finds  as  the 
result  of  his  experiments  that  the  artificial  produc- 
tion of  true  pulmonary  tuberculosis  may  be  pro- 
duced with  a  fair  degree  of  certainty  by  a  moder- 
ate new  infection  of  an  animal  suffering  from 
chronic  tuberculosis,  and  that  such  animals  exhibit 
then  an  increased  power  of  resistance  to  a  new  in- 
fection of  tuberculosis.  Hence  the  onset  of  cav- 
ernous tuberculosis  of  the  lungs  is,  absurd  as  it 
sounds,  to  a  certain  degree  a  phenomenon  of  im- 
munity. 

3.  Yellow  Fever. — Seidelin  describes  the  mi- 
croorganisms he  has  found  in  the  blood  of  a  num- 
ber of  patients  suffering  from  yellow  fever.  In 
the  majority  of  cases  the  parasites  had  similar 
forms,  they  were  mainly  intraglobular  ring  and 
amrjeboid  forms  of  varying  size.  There  were  also 
numerous  little  intraglobular  chromatin  granule^ 
which  showed  no  distinct  protoplasma  bodies,  the 
nature  of  which,  whether  little  parasites  or  the  pro- 
ducts of  degeneration,  is  not  determined.  In  only 
a  few  cases  no  parasites  were  found,  and  in  these 
the  blood  was  obtained  very  late.  In  only  two 
cases  were  repeated  examinations  of  the  blood  pos- 
sible, the  report  of  which  is  reserved  for  a  future 
paper.  The  different  forms  met  with  are  pictured 
and  described. 

4.  Rhachitis. — Schal)ad  discusses  in  this  paper 
rickets  due  to  lack  of  lime  ( Kalkhungcr) .  Und.r 
physiological  conditions  the  amount  of  lime  taken 
up  by  the  infant  may  be  insufficient,  both  when 
they  are  nursed  and,  more  often,  when  they  are  fed 
artificially,  and  a  reduction  of  the  amount  of  lime 
in  the  milk  below  the  physiological  minimum  is 
[)roductive  of  pathological  changes  in  the  bones  as 
has  been  shown  by  experiments  on  animals. 

5.  Secretion  of  the  Gastric  Mucus. — \'on 
Aldor  says  that  under  normal  conditions  there  is  no 
mucus  present  in  the  empty  stomach,  but  that  dur- 
ing the  period  of  digestion  it  appears  in  moderate 
quantity.  Clinical  experience  shows  that  the  ab- 
sence of  this  moderate  quantity  during  digestion  is 
of  pathological  importance.  The  secretion  of  mu- 
cus must  be  looked  upon  as  a  function  of  the  se- 
cretory apparatus  of  the  stomach  of  no  less  impor- 
tance than  the  secretion  of  the  gastric  juice,  and 
the  two  secretions  should  run  parallel  with  eacli 
other. 


MUNCHENER  MEDIZINISCHE  WOCHENSCHRIFT. 

May  4, 

1.  Bacterial  Antiferments  and  Bacteriolysis, 

By  Kantorowicz. 

2.  Contribution  to  the  Treatment  of  Pulmonary  Diseases 

with  Kuhn's  Suction  Mask,  By  Greef. 

3.  Contribution  to  the  Study  of  Digitalis  Treatment, 

By  MiJLLER. 

4.  Comparative  Studies  Concerning  the  Action  of  Carbo-  • 

hydrate  and  Albuminous  Food  in  Diabetes  Mellitus, 

By  GiGox. 

5.  Keeping  Meat  with  Ice  and  Meat  Poisoning, 

By  CONR.ADI. 

6.  Bacteriology  and  Specific  Treatment  of  Epidemic  Cere- 

brospinal Meningitis,  By  Mayer. 

7.  Qianges  in  the  Nervous  Elements  of  the  Spinal  Cord 

in  Epidemic  Cerebrospinal  Meningitis, 

By  Liebermeister  and  Lebsanft. 

8.  Adams-Stokes'    Symptom    Complex :    Gumma   of  the 

Auricular  Septum  of  the  Heart,       By  Handwerck. 

9.  A  Case  of  Pseudohermaphroditismus  Masculinus  Ex- 

ternus,  By  Heinzmann. 

10.  A  Skiascope,  By  Brand. 

11.  Bismuth  and  its  Substitutes  in  the  X  Raying  of  the 

Human  Gastrointestinal  Canal,  By  Kastle. 

12.  A  New  Contrast  Stain  for  the  Detection  of  Intracellu- 

lar Tubercle  Bacilli  in  the  Sputum,       By  Russow. 

13.  Technique  of  Laryngoscopy  with  Sunlight, 

By  Lissauer. 

14.  The  Indications  and  Technique  for  the  Classical  and 

Extraperitoneal  Cassarean  Section  and  for  Heboste- 
otomy  (Concluded) ,  By  Jung. 

I.    Bacterial  Antiferments  and  Bacteriolysis. 

— Kantorowicz  says  that  the  resistance  of  bacteria 
to  tryptic  ferments  does  not  depend  on  a  protec- 
tive capsule  or  vital  properties,  but  on  antiferments. 
The  resistance  of  the  Gram  negative  coli  vibrion 
group  disappears  after  heating  to  about  80°  C.  The 
resistance  of  the  Gram  positive  cocci  and  bacilli  is 
not  destroyed  by  heat.  A  ferment  is  present  in 
serum,  leucocytes,  and  leucocyte  extracts  which 
renders  bacteria  robbed  of  their  resistance  to  tryp- 
sin by  heat  incapable  of  being  stained.  Bacterial 
extracts  have  an  antifermentative  action  to  trypsin, 
and  also  prevent  the  destruction  of  the  staining  ca- 
pacity of  the  bacteria  in  serum.  Aggresin  contain? 
bacterial  antiferment.  Bacterial  antiferment  is  not 
identical  with  the  so  called  antitrypsin. 

3.  Digitalis  Treatment. — Alliller  presented  his 
first  paper  on  this  subject  several  months  ago,  and 
considers  in  this  article  the  action  of  digalen,  which 
may  be  given  not  onl\-  by  mouth,  but  also  by  sub- 
cutaneous and  intranuiscular  injections.  According 
to  his  observations  digaltii  does  not  prove  greatly 
superior  to  other  forms  of  digitalis,  though  it  per- 
mits of  a  greater  variation  in  the  treatment  of 
chronic  diseases  of  the  heart. 

5.  Ice  and  Meat  Poisoning. — Conradi  shows 
that  meat  kept  on  ice  may  become  infected  by  mi- 
cro(M\ganisms  in  the  ice. 

6.  Cerebrospinal  Meningitis. — Mayer  re])orts 
a  sporadic  case  of  acute  epidemic  cerebrospinal 
meningitis,  the  patient  recovering  after  lumbar 
puncture  and  injection  of  the  specific  serum.  It  is  of 
Ijacteriological  as  well  as  clinical  interest  because  of 
some  peculiarities  of  the  stock  of  meningococci  iso- 
lated from  the  cerebrospinal  fluid,  but  these  can 
best  be  studied  in  the  original. 

7.  Changes  in  the  Nervous  Elements  of  the 
Spinal  Cord  in  Epidemic  Cerebrospinal  Menin- 
gitis.— Liebermeister  and  Lebsanft  divide  the 
changes  met  with  in  the  nerve  elements  of  the  spinal 


June  26,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


1325 


cord  after  cerebrospinal  meningitis  into  four 
groups:  I,  The  frequently  described  discrete,  puru- 
lent, and  inflammatory  melted  down  areas  ;  2,  the  de- 
generations of  the  nerve  fibres  in  the  neighborhood 
of  the  purulent  exudates  that  appear  in  the  early 
stages  of  the  disease,  are  slight  at  first,  but  become 
more  marked  the  longer  the  disease  lasts,  marginal 
degenerations  with  destruction  of  the  medullary 
sheaths  of  the  white  substance,  destruction  of  the 
medullary  sheaths  of  the  nerve  roots ;  3,  the  degen- 
erative processes  in  the  ganglion  cells  of  the  gray 
substance,  which  appear  after  the  disease  has  lasted 
some  time  and  are  independent  of  the  neighboring 
purulent  foci ;  4,  the  secondary  degenerations  in  the 
posterior  cords  after  degeneration  of  the  posterior 
roots,  in  the  anterior  roots  within  the  spinal  cord 
after  destruction  of  the  ganglion  cells  of  the  ante- 
rior horns,  and  in  other  bundles  of  fibres  conse- 
quent on  the  discrete  inflammatory  softenings  and 
the  marginal  degenerations.  The  degenerations 
seen  on  section  of  the  spinal  cord  are  characteristic 
and  are  clearly  divisible  into  two  types:  i.  The 
slight,  early  changes  met  with  in  cases  in  which  the 
patient  died  in  the  first  acute  attack ;  2,  the  greater 
changes  combined  with  secondary  processes  found 
after  the  course  of  the  disease  has  been  protracted 
for  weeks.  The  great  difiference  between  the  slight 
early  changes  and  the  severer  combined  processes 
present  in  long  continued  cases  serves  to  explain 
many  differences  in  the  statements  of  earlier 
writers. 

8.  Gumma  of  the  Auricular  Septum. — Hand- 
werck  reports'a  case  of  gumma  of  the  auricular  sep- 
tum met  with  in  a  woman,  thirty-five  and  a  half 
years  old,  which  caused  symptoms  of  insufficiency 
of  the  aortic  valves  with  possibly  stenosis  of  the 
ostium  aort^,  bradycardia,  dysrhythmia  of  the  auri- 
cle and  ventricle,  and  epileptoid  attacks,  the  Adam- 
Stokes  symptom  complex. 

AMERICAN  JOURNAL  OF  SURGERY. 
May,  JQOQ. 

1.  The  Surgical  Importance  of  the  Visceral  Crises  in  the 

Erythema  Group  of  Skin  Diseases, 

By  Henry  Mann  Silver. 

2.  The  Use  of  Fluorescent  Salts   (Eosin,  Scarlet  Red, 

etc.)  in  the  Practice  of  Surgery, 

By  V.  Pleth  and  V.  W.  Pleth. 

3.  Operation  for  Ingrowing  Toenail, 

By  John  Edw.^rd  Jennings. 

4.  Scar  Tissue — Its  Prevention  and  Obliteration, 

By  Ch.arles  H.  Duncan. 

5.  An  Electricalh'  Lighted  Pharyngoscope.    A  New  Meth- 

od of  Examining  the  Nasopharynx, 

By  Harold  Hays. 

6.  Treatment  of  Habitual  Scoliosis  by  Passive  and  Active 

Correction,  By  Theodore  Toepel. 

7.  Ligation  of  fhe  Common  Iliac  Artery  under  Unfavor- 

able Conditions;  A  Case  Report. 

By  Emory  Lanphear. 

8.  Penetrating  Wound  of  the  Abdomen  without  Symp- 

toms ;  A  Case  Report,  By  Charles  H.  Jaeger. 

2.    The  Use  of  Fluorescent  Salts  in  Surgery. — 

Pleth  and  V.  W.  Pleth  have  experimented  with 
the  application  of  eosin  and  scarlet  red  in  various 
surgical  and  medical  afflictions.  It  has  been  shown 
that  certain  fluorescent  substances,  e.  g..  eosin  and 
magdala  red  are  inimical  to  the  growth  of  many 
fungi.  Many  bacilli  are  acted  upon  in  a  similar 
way  and  in  the  presence  of  sunlight.  During  the 
last  vear  thev  have  used  eosin  and  scarlet  red  in 


pus  infections  and  large  skin  defects,  both  on  man 
and  animals,  especially  rabbits  and  dogs.  Ulcera- 
tions were  artificially  produced,  and  the  infected 
area  was  treated  by  the  application  of  a  five  to  ten 
per  cent,  aqueous  solution  of  eosin.  The  animals 
treated  with  eosin  always  recovered  rapidly,  while 
some  of  the  control  animals  even  died  from  the 
infected  wounds;  the  eosin  animals  were  always 
kept  in  direct  sunlight,  while  those  who  were  kept 
in  dark  boxes  always  showed  delayed  healing.  They 
have  employed  the  eosin  solution  in  conditions  like 
stitch  abscesses ;  in  suppurating  incised  wounds ; 
after  operations  for  osteomyelitis;  in  infected  joints; 
in  several  cases  of  eczema ;  in  several  cases  of  gon- 
orrhasa,  injecting  the  eosin  into  the  urethra,  and 
keeping  the  solution  in  contact  with  the  mucosa 
for  at  least  half  an  hour.  In  several  cases  of 
actinomycosis  they  injected  a  five  per  cent,  solu- 
tion of  eosin  into  the  affected  parts,  at  the  same 
time  giving  copper  sulphate  internally  in  doses  of 

0.  008  gramme.  When  the  wound  was  clean  it 
was  finally  treated  with  scarlet  red  to  promote 
epithelial  growth.  They  have  also  seen  a  few  good 
results  following  the  use  of  eosin  in  tuberculous 
affections  of  the  skin  and  tendons.  In  the  treat- 
ment following  removal  of  the  turbinated  bones 
and  in  infections  of  the  nose  and  antrum  of  High- 
more,  there  was  astonishing  success.  In  cases  of 
endometritis,  the  endometrium  is  first  swabbed 
with  formalin  forty  per  cent.,  dried  thoroughly  and 
then  treated  with  a  10  per  cent,  solution  of  eosin. 
The  results  have  been  uniformly  good.  In  car- 
cinoma of  the  uterus,  mammae,  and  the  face  and 
neck,  they  have  employed  it  by  injecting  it  into  the 
substance  of  the  tumor  and  painting  the  surface 
of  the  growth.  In  uterine  cancer,  especially,  exten- 
sive separation  of  the  cancerous  masses  took  place  ; 
curetting  was  then  practised  with  application  of 
more  eosin  and  acetone  (to  remove  the  odor).  They 
also  employed  it  in  infected  inguinal  glands  by  mak- 
ing a  minimal  incision,  removing  the  infected  ma- 
terial and  painting  the  abscess  cavity  with  eosin, 
and  then  filling  it  with  gauze  moistened  with  eosin. 
The  cases  of  bubo  treated  in  this  manner  healed 
faster  than  those  treated  with  silver  nitrate. 

ANNALS  OF  SURGERY. 

Alay,  1909. 

1.  An  -Analytical  and  Statistical  Review  of  One  Thousand 

Cases  of  Head  Injury,  By  Charles  Phelps. 

2.  Osteosarcoma  of  the  Mandible,    By  Addinell  Hewson. 

3.  Congenital  Mesenteric  Cysts,        By  Harry  C.  Deaver. 

4.  On  "Essential  Hjematuria"  and  "Nephralgia," 

By  Arnold  Schwyzer. 

5.  Renal   Varix — Angiomatous    Disease   of   the  Papillae 

Renales,  By  Paul  Monroe  Pilcher. 

6.  Observations  on  Renal  and  Ureteral  Calculi, 

By  George  Woolsey. 

7.  Procidentia  Recti ;  Treatment  by  Excision, 

By  John  H.  Cunningham. 

8.  Intestinal  Anastomosis  by  Invagination, 

By  A.  Ernest  Maylard. 

9.  Excision  of  the  Shoulder  Joint :  A  Study  of  Nineteen 

Excisions  of  the  Shoulder  Joint, 

By  Charles  L.  Scudder  and  J.  D.  Barney. 

3.  Congenital  Mesenteric  Cysts. — Deaver  says 
that  mesenteric  are  not  commonly  mistaken  for 
ovarian  cysts.  In  avoiding  this  error,  it  is  helpful 
to  ascertain  if  the  tumor  has  grown  from  the  abdo- 
men toward  the  pelvis  or  znce  versa;  if  an  inferior 


1326 


F'lTH  or  CURRENT  UTERATURh. 


[New  York 
Medical  Journal. 


zone  of  resonance  can  be  obtained  by  the  Trendel- 
enburg position  :  and  if  both  ovaries  are  independent 
of  the  tumor.  Furthermore,  there  must  be  excluded 
h3'dronephrosis,  omental,  pancreatic,  and  renal  cysts, 
cysts  of  the  urachus,  and  lipoma  of  the  mesentery. 
It  is  probable  that,  as  in  the  past,  most  of  these  cysts 
will  be  diagnosticated  first  on  the  operating  table. 
Gas  cysts  of  the  intestine  might  at  first  sight  cause 
confusion  at  operation ;  but  these,  it  seems,  occur  in 
clusters  of  very  small  cysts,  which  explode  on  pres- 
sure. The  prognosis  of  mesenteric  c\  sts  conforms 
with  that  of  abdominal  lesions  of  similar  magnitude. 
Patients  with  uncomplicated  cases,  operated  upon 
with  good  judgment,  should  recover,  especially  since 
infection  is  not  concerned  in  the  setiology  of  such 
tumors.  In  adhesions  and  intestinal  obstruction, 
however,  lurk  dangers  commensurate  with  the  ex- 
tent of  the  one  and  the  duration  of  the  other.  As 
soon  as  discovered,  an  intramesenteric  cyst  should 
be  removed  even  in  the  absence  of  symptoms,  and 
this,  if  for  no  other  reason,  as  prophylactic  against 
intestinal  obstruction.  It  is  known  that  chyle  cysts 
frequently  cause  emaciation,  and  it  is  conceivable 
that  operative  delav  here  might  dangerously  impair 
the  operative  stamina  of  the  patient.  There  are 
four  ways  of  dealing  with  intramesenteric  cysts:  i, 
Bv  aspiration ;  2,  by  cystostomy  and  drainage,  with 
or  without  the  use  of  caustics ;  3,  by  enucleation ; 
4.  by  resection  of  the  involved  intestinal  segment. 
The  first  method  was  followed  by  recurrence  in 
over  fifty  per  cent,  of  cases,  and  is  now  obsolete. 
The  second  method  is  useful  in  the  presence  of 
numerous  adhesions,  to  dissever  wdiich  might  im- 
pair the  nutrition  of  the  intestinal  wall,  or  in  an 
emergency.  The  third  method  is  considered  by 
many  ideal,  and  is  ideal  when  practicable.  The 
fourth  method  Deaver  recommends  in  multiple, 
juxtaposed  cysts,  when  it  is  deemed  that  too  much 
surgical  interference,  as  from  dealing  with  the 
CNSts  one  bv  one.  carries  more  risk  than  simple  re- 
section. 

4.  "Essential  Hasmaturia"  and  "Nephralgia." 

— Schwyzer  says  that  if  treatment,  in  which  pro- 
longed rest,  diet,  calcium  salts,  and  perhaps  serum 
for  the  hjemophilia  cases  play  an  important  role,  is 
fruitless,  and  if  eventually  ureteral  catheterization, 
which  has  in  some  cases  a  curative  effect,  is  tried, 
the  operation  of  choice  is  the  nephrotomy,  though 
its  serious  effect  upon  a  rather  extensive  area  of 
kiflney  substance  must  be  kept  in  mind.  Longi- 
tudinal si>litting  of  the  kidney  gives  good  chance 
for  inspection  and  good  results.  Drainage  of  the 
kidney  itself  is  as  a  rule  not  needed  nor  advisable. 
Careful  complete  catgut  suture  of  the  kidney  in 
layers  (or  by  figure  "8"  sutures)  gives  very  good 
results.  Especial  attention  must  be  paid  to  the 
suture  of  the  innermost  layer.  The  patients  need 
usually  not  be  in  bed  any  longer  than  about  ten 
days,  and  the  operative  chances  are  quite  good. 

5.  Renal  Varix. — Pilcher  concludes  that  renal 
varix  is  a  distinct  pathological  entity  and  may  he 
described  as  an  angiomatous  disease  of  the  papillae 
rcnales,  whose  .Ttiology  and  pathology  resemble 
that  of  varicocele,  varicose  veins  of  the  leg,  vari- 
cosities at  the  cardiac  end  of  the  stomach,  haemor- 
rlK)idal  varices,  etc.  Many  of  the  so  called  cases 
of  essential  hfcmaturia  are  due  to  this  condition  oi 


the  kidney.  It  has  its  own  distinct  symptomatology ; 
but  it  may  be  impossible  to  distinguish  it,  before 
operation,  from  hjematuria  due  to  nephritis  and 
hasmaturia  due  to  renal  papilloma.  In  the  majoritv 
of  cases,  at  operation,  when  the  kidney  has  been 
bisected,  no  gross  pathological  lesions  will  be  noted, 
but  on  the  microscopical  examination  of  the  papillae 
renales  a  typical  angiomatous  disease  will  be  found. 
Renal  decapsulation  and  fixation  of  the  kidney  will 
cure  the  cases  of  unilateral  hasmaturia  due  to 
nephritis.  Nephrotomy  is  the  operation  of  chrice, 
because  it  allows  a  thorough  examination  of  the 
kidney,  and  also  for  the  reason  that  it  accomplishes 
exactly  what  the  operation  of  multiple  ligation  does 
in  the  treatment  of  varicosities  in  other  portions  of 
the  body,  in  that  it  cuts  six  of  the  main  connecting- 
venous  radicles  of  the  kidney  and  in  this  way  de- 
stroys the  varicosities.  Nephrectomy  is  indicated 
only  when  rapid  and  bloodless  operation  is  demand- 
ed, or  when  nephrotomy  fails  to  relieve  the  hsema- 
turia. 

ARCHIVES  OF  PEDIATRICS 

May,  igog. 

1.  Anterior  Poliomyelitis  (An  Epidemic), 

By  Henry  Koplik. 

2.  Early  Symptoms  of  Poliomyelitis,    By  L.  E.  L.\  Fetr.\. 

3.  Occurrence  of  Pepsin  in  the  Infant  Stomach, 

By  Walter  Reeve  R.\msev. 

4.  Sea  Water  Treatment  by  Subcutaneous  Injection, 

By  Theodore  Le  Boutillier. 

5.  Five  Cases  of  Epidemic  Infantile  Paralysis, 

By  A.  Hymanson. 

6.  Congenital  Heart  Disease,  By  Alfreb  Hand,  Jr. 

7.  Angioneurotic  CEdema,  By  S.  Seilikovitch. 

I,  2.  Anterior  Poliomyelitis. — Koplik  says  that 
as  to  the  causation  and  the  mode  by  which  the  in- 
fectious agent  enters  the  system,  he  has  two  theo- 
ries to  offer.  In  the  vast  majority  of  the  cases  he 
has  seen,  and  in  fully  sixty  per  cent,  of  those  seen 
by  Gibney  in  the  Ruptured  and  Crippled  Hospital, 
there  was  a  history  of  some  disturbance  of  the  in- 
testine. In  many  of  his  own  cases  there  was  a  dis- 
tinct history  of  diarrhoea,  in  others  constipation.  In 
another  set  of  cases,  especially  those  with  neuritis, 
he  found  that  there  had  been  a  distinct  attack  of 
amygdalitis,  and  in  several  of  these  cases  a  culture 
had  actually  been  taken  of  the  throat  and  nothing 
found  but  streptococcus  infection,  so  that  he  believes 
that  through  the  tonsils  and  through  the  gut  an  in- 
fectious agent  must  have  reached  the  general  nerv- 
ous system.  Our  nomenclature  of  this  disease  will 
certainly  have  to  be  revised.  We  can  scarcely  now 
speak  of  this  disease  as  poliornyelitis,  nor  can  we 
exclude  from  this  epidemic  the  cases  which  resem- 
bled very  closely  the  classical  cases  of  anterior 
poliomyelitis  and  the  classical  cases  of  acute  infec- 
tious neuritis.  In  other  words,  here  we  have  a 
new  infectious  agent  which  is  capable  of  causing 
])aralytic  disturbances,  even  death,  by  affecting  the 
gray  matter  not  only  of  the  cerebrum,  the  medulla, 
and  the  thorax,  but  also  the  white  matter  and  axis 
cylinder  of  the  nerve  trunks. — La  Fetra  remarks 
that  the  diagnosis  of  the  disease  in  the  beginning 
of  the  epidemic  may  be  very  difficult.  This  has 
been  noted  many  times,  confounding  it  with  acute 
meningitis,  as  well  as  with  multiple  neuritis,  being 
very  easy  when  the  irritative  .symptoms  are  pro- 
noimccd.   The  careful  studies  that  have  come  from 


June  26,  1909.] 


PITH  OF  CURRENT  LITERATURE. 


1327 


Norway  and  Sweden  in  the  last  few  years,  particu- 
larly those  of  Medin,  of  Harbitz  and  Scheele,  and 
recently  of  Wickman,  have  shed  new  light  upon 
this  disease  and  upon  other  nervous  disorders  close- 
ly related.  Medin  found,  alongside  typical  cases  of 
spinal  poliomyelitis,  cases  of  poliomyelitis  of  the 
bulb — pontine  encephalitis — and  also  cases  of  local 
cerebral  spastic  paralysis  due  to  encephalitis.  The 
epidemic  of  1905  showed  also  a  meningitic,  a  poly- 
neuritic, and  an  abortive  form  in  which  there  was 
no  paralysis.  Cases  of  progressive  paralysis — as- 
cending or  descending — were  also  seen.  On  ac- 
count of  the  existence  of  these  types  of  trouble  in 
the  same  epidemic,  and  on  account  of  their  all  hav- 
ing essentially  the  same  pathological  basis,  Wick- 
man has  proposed  to  group  them  all  under  tlie 
name  of  the  Heine-Medin  Disease.  This  disease 
he  would  classify  as  appearing  under  eight  dif¥er- 
ent  forms,  as  follows:  i,  Ordinary  spinal  paralysis, 
anterior  poliomyelitis ;  2,  progressive  paralysis,  usu- 
ally ascending,  less  often  descending,  Landry's 
paralysis;  3,  bulbar  paralysis,  polioencephalitis  of 
the  pons ;  4,  acute  encephalitis,  giving  spastic  mono- 
plegia or  hemiplegia;  5.  ataxic  form;  6,  polyneu- 
ritis, multiple  neuritic  type ;  7,  meningitic  form ; 
and  8,  abortive. 

3.  Occurrence  of  Pepsin  in  the  Infant  Stom- 
ach.— Ramsay  concludes  that,  1,  the  gastric  juice 
of  normal  breast  infants  contains  pepsin ;  2,  the 
stomachs  of  infants  suffering  from  acute  digestive 
disturbances  usually  contain  pepsin  ;  3,  the  stomachs 
of  infants  suffering  from  pylorospasm  contain  both 
pepsin  and  hydrochloric  acid  in  greater  quantity 
than  the  stomachs  of  normal  infants  of  the  same 
age ;  4,  the  stomachs  of  chronic  atrophic  infants 
frequently  contain  no  pepsin  :  5.  when  these  chronic 
atrophic  infants  begin  to  improve  in  health  and  to 
gain  in  weight,  the  stomachs  again  contain  pepsin  ; 
6.  the  gastric  juice  of  normal  infants  is  capable  of 
transforming  proteid  into  peptone,  and  that  it  is 
able  to  do  this  without  the  addition  of  any  other 
acid  than  that  found  normally  in  the  stomach ;  7, 
the  pepsin  in  the  gastric  juice  is  capable  of  active 
digestion  when  lactic  acid  and  no  hydrochloric  acid 
is  present ;  8,  both  hydrochloric  and  lactic  acid  mav 
be  present  in  the  gastric  juice  without  pepsin,  and 
pepsin  may  be  present  without  either  liydrochloric 
or  lactic  acid. 

THE  MILITARY  SURGEON 
May,  1909. 

1.  The  Modern  Organization  of  the  ]Medical  Department 

of  the  U.  S.  Army  in  the  Field  and  its  Application 
to  one  of  the  Battlefields  of  the  Civil  War, 

By  V.ALERY  Havard. 

2.  First  Aid  Corps,  P.  &  R.  C.  &  I.  Co.    .\  New  Model 

Mine  Ambulance,  By  G.  H.  Halberstadt. 

,"5.    Compulsory  Prophylaxis  against  Venereal  Disease, 

By  E.  M.  Brown. 

4.  Camp  Sanitation,  By  Thomas  J.  Kirkpatrick. 

5.  The  Treatment  of  Gunshot  Wounds  of  the  Abdomen 

.Advocated  by  French  Military  Surgeons. 

By  Charles  Norton  Barney. 

6.  .\  Litter  Carrier  for  Transporting  Two  Litters,  De- 

signed, Constructed,  and  Described 

By  AL  A.  Reason'er. 

3.  Compulsory  Prophylaxis  against  Venereal 
Disease. — Brown  quotes  from  the  report  of  the 
surgeon  general  of  the  navy  in  reference  to  gon- 
orrhoea, which  shows  a  decrease  of  this  disease  of 


twelve  per  cent,  in  1907  as  compared  with  1906. 
The  report  reads :  "This  gratifying  fact  may  be  ex- 
plained by :  The  better  and  more  enlightened  class 
of  men  now  being  enlisted  in  the  navy ;  the  more 
continual  occupation  of  the  men  with  absorbing  du- 
ties during  the  working  hours ;  the  increasing  in- 
dulgence in  athletics  and  other  healthful  e.xercises, 
which  inspire  an  ambition  for  physical  prowess  an(\ 
consequently  greater  care  in  avoiding  exposure  to 
disease  influences ;  the  improved  intellectual  oppor- 
tunities now  offered  for  the  employment  of  leisure 
hours ;  the  more  considerate  manner  in  which  lib- 
erty men  are  treated  and  provided  for  ;  the  policy  of 
assigning  ships  to  definite  home  ports  and  returning 
them  to  those  ports  more  frequently,  particularly 
those  ships  serving  in  tropical  waters,  where  there 
is  little  or  no  opportunity  for  profitable  or  decent 
recreation;  the  instruction  in  matters  of  personal 
hygiene  conducted  by  the  medical  officers ;  and  the 
various  systems  of  direct  prophylactic  treatment 
conducted  by  the  medical  officers  with  the  approval 
and  cooperation  of  commanding  and  executive  of- 
ficers." Dr.  Brown  describes  a  packet  which  he 
has  planned,  and  which  includes  the  following  ar- 
ticles :  ( I )  .\  small  glass  syringe  already  filled  with 
a  dilute  solution  of  protargol ;  (2)  a  small  wide 
necked  bottle  filled  with  additional  protargol ;  ( 3 ) 
a  box  containing  calomel  to  be  used  as  a  dusting 
powder;  (4)  a  box  containing  bichloride  tablets.  On 
the  lid  of  the  box  are  printed  the  instructions  for 
use.  At  first  glance  all  these  articles  would  seem 
to  make  too  bulky  a  packet,  but  a  syringe  can  be 
obtained  that,  after  .being  filled,  has  a  plunger  rod 
which  can  be  unscrewed,  thus  reducing  the  size  of 
the  box  to  the  length  of  the  syringe,  and  the  bottle 
and  bo.xes  can  be  made  to  conform  to  the  remaining 
space  so  that  when  perfected  the  packet  need  not 
be  any  larger  than  our  first  aid  packet,  if  as  large. 

THE  PRACTITIONER. 

May,  igog. 

1.  The  Use  and  Abuse  of  Proprietary  Foods  in  Infant 

Feeding,  By  Edmund  Cautley. 

2.  .-V  Contribution  to  the  Surgery  of  Inguinal  Hernia, 

By  Rutherford  Mokison. 

3.  Observations  on  the  Therapeutic  Value  of  Radium  and 

its  Application,  By  J.  M.  H.  Maci.eod. 

4.  On  the  Diagnosis  of  Transitory  Hemiplegia  in  Elderly 

Persons,  By  F.  H.  Edgewokth. 

5.  .^cute  Appendicitis,  By  A.  Ernest  Mavi.ard. 

6.  Variations  of  Arterial  Blood  Pressure  in  Cases  of  .^r- 

teriorsclerosis.  By  O.  K.  Williamson. 

7.  The  Rheumatic  Infection :  A  Clinical  Study, 

By  W.  H.  Maxwell  Telling. 

8.  Labyrinthine  Nystagmus  and  Labyrinthine  Disease, 

By  Dan  McKenzie. 

9.  The  Signs  and  Symptoms  of  Thoracic  Aneurysm, 

By  H.  Letheby  Tidy. 

10.  Practical  Points  in  the  Diet  of  the  Tuberculous  Patient, 

By  Sidney  H.  Hall. 

11.  Advances  in  Clinical  Pathology,   By  W.  D'Este  Emery. 

12.  The  Value  of  Mouth  Washes, 

By  Stanley  Parkes  Mummery. 

13.  Chloroform  An;eslhesia.         By  R.  Ernest  Humphry. 

I.     Use  and  Abuse  of  Proprietary  Foods. — • 

Cautley  remarks  that  proprietary  foods  are  not  real- 
ly necessary  in  ordinary  circumstances.  They  are, 
however,  often  of  very  great  value,  more  especially 
the  malted  foods,  provided  that  they  are  used  wi:;h 
discrimination  as  additions  to  the  diet,  and  not  as 
substitutes  for  cream  or  milk.    Anyone  acquainted 


1328 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Jourkal. 


with  their  composition,  can  clearly  use  them  scien- 
tifically and  advantageously,  whereas  ignorance  is 
likely  to  lead  to  errors  in  selection  and  in  quantity, 
and  to  fatal  dietetic  calamities.  Unfortunately,  the 
evil  results  of  erroneous  methods  of  feeding  are  not 
immediately  apparent,  perhaps  do  not  develop  for 
months,  and  they  are  constantly  ascribed  to  other 
causes.  The  author  concludes  that  the  greater  his 
experience  in  the  feeding  of  infants  is,  the  more 
rarely  does  he  find  it  necessary  to  have  recourse  to 
these  foods.  On  the  other  hand,  they  are  often 
necessary  and  most  beneficial. 

6.  Variations  of  Arterial  Blood  Pressure. — 
Williamson  concludes  from  his  observations  that  the 
main  difi^erence  between  the  arteriosclerotic  and  the 
nonarteriosclerotic  cases  would  seem  to  be  that  there 
is  produced  in  the  former,  owing  to  an  abnormal 
degree  of  arterial  constriction,  as  the  result  of  in- 
fluences, which  diminish  this  constriction  and  pro- 
duce vascular  relaxation,  a  more  marked  effect  than 
usual,  and,  in  consequence,  either  a  greater  fall  of 
pressure,  or  a  fall  of  pressure  when  in  the  nonar- 
teriosclerotic cases  there  would  be  a  rise.  This  dif- 
ference is  evidenced  more  especially  in  the  diurnal 
variations,  but  also  to  a  less  degree  as  the  result  of 
the  ingestion  of  food.  In  cases  of  arteriosclerosis, 
blood  pressure  readings,  taken  in  the  evening,  tend 
to  be  lower  than  the  morning  readings ;  in  other 
words,  the  normal  diurnal  variation  tends  to  be  re- 
versed. In  the  majority  of  both  the  arteriosclerotic 
and  nonarteriosclerotic  cases,  change  of  posture, 
from  recumbency  to  sitting,  causes  a  rise  of  arterial 
pressure  affecting  either  the  systolic  or  the  diastolic 
pressure,  or  both.  The  change  from  the  sitting  to 
the  standing  position,  on  the  other  hand,  corres- 
ponds in  a  majority  of  the  cases  of  arteriosclerosis 
to  a  fall  of  systolic  pressure  and  a  rise  of  diastolic 
pressure.  The  same  tendency  is  noticeable  in  the 
nonarteriosclerotic  cases.  In  the  cases  of  arterio- 
sclerosis, whether  associated  with  high  or  with  low 
blood  pressure,  the  physiological  alteration  in  arter- 
ial calibre,  as  the  result  of  change  of  posture  from 
recumbency  to  sitting,  is  in  the  majority  of  instances 
reversed.  The  same  tendency  showed  itself  in  the 
nonarteriosclerotic  cases.  The  variations  in  arterial 
calibre,  resulting  from  change  of  posture,  are,  in 
the  arteriosclerotic  cases,  on  the  average  approxi- 
mately normal  in  amount,  and  seem  to  be  about 
equal  to  those  in  the  nonarteriosclerotic  cases.  As 
the  result  of  ingestion  of  food,  a  fall  of  pressure  af- 
fecting either  the  systolic,  or  both  systolic  and  dias- 
tolic pressures,  seems  to  be  more  frequent  in  the 
cases  of  arteriosclerosis  than  in  the  nonarteriosclero- 
tic cases.  An  equally  common  result  in  the  arterio- 
sclerotic cases  is  an  inverse  variation  of  the  systolic 
and  diastolic  pressures  (the  one  increasing  while  the 
other  diminishes,  or  vice  versa).  This  seems  to  be 
likewise  a  common  phenomenon  in  the  nonarterio- 
sclerotic cases. 

7.  Rheumatic  Infection. — Telling  defines  true 
rheumatism,  i.  c.,  the  rheumatic  infection  thus :  Prac- 
tically everyone  to-day  regards  it  as  a  bacterial  dis- 
ease, and  therefore  it  can  include  all  and  only  those 
morbid  conditions,  which  arise  as  a  result  of  such 
bacterial  infection.  It  is  clear,  then,  that  it  is  to  the 
bacteriologists  we  must  look  in  the  final  event  to 
supply  us  with  the  exact  limitations  of  true  rheuma- 
tism as  a  clinical  entity.    Two  main  views  are  hold 


at  the  present  day,  one,  that  rheumatism  is  a  specific 
infectious  disease,  with,  of  course,  a  specific  micro- 
organism, the  other  denies  that  the  infection  is  due 
to  a  single  or  specific  organism.  On  this  latter  view, 
it  has  been  regarded  as  an  attenuated  pyaemia,  a 
pathology  which  has  now  but  few  supporters ;  and 
others  would  regard  the  soil  as  the  specific  element, 
whicli  means  that  a  variety  of  organisms  may,  in 
specially  predisposed  persons,  bring  about  the  dis- 
ease. The  view  that  it  is  a  specific  infection  is  that 
to  which  bacteriological  and  clinical  research  more 
and  more  converge.  At  present  there  are  many 
pathologists  who,  while  accepting  the  hypothesis  of 
specificity,  assert  that  the  microbe  has  so  far  eluded 
discovery,  but,  in  England,  at  least,  the  researches 
of  Triboulet,  Poynton  and  Paine,  Seattle,  and  others 
have  carried  conviction  to  the  minds  of  many  that 
the  Micrococcus  rhcumaticus,  which  they  describe, 
is  the  cause  of  rheumatism. 

•  ^  

f  rflacMngs  of  .Societies. 


THE  AMERICAN  MEDICAL  ASSOCIATION. 
Sixtieth  Annual  Meeting  Held  in  Atlantic  City,  June  8, 
g,  10,  and  11,  1909. 

SECTION  IN  PHARMACOLOGY  AND 
THERAPEUTICS. 
{Continued  from  page  1231.) 

Some  of  the  Preparations  of  the  United  States 
Pharmacopoeia  from  the  Practitioner's  Stand- 
point.— Dr.  H.  FussELL,  of  Philadelphia,  said 
that  most  physicians  made  little  use  of  the  pharma- 
copoeia and  the  National  Formulary.  This  was  due 
in  part  to  defective  education  and  in  part  to  the 
efiforts  of  the  detail  men  of  the  manufacturing 
houses,  who  constantly  reminded  the  physician  of 
unofficial  preparations.  He  said  that  the  prepara- 
tions contained  in  the  two  works  mentioned  were 
sufficient  to  meet  any  demand.  The  pharmacopoeia, 
he  thought,  was  the  proper  place  for  the  consid- 
eration of  single  drugs  only,  and  that  compounds 
and  mixtures  should  be  relegated  to  the  formulary. 
It  should  not  be  the  function  of  the  pharmacopoeia 
to  dictate  formulae.  Certain  of  them,  such  as  the 
compound  acetanilide  powder  and  the  elixir  of  iron, 
quinine,  and  strychnine,  he  thought  were  either  use- 
less or  harmful.  The  book  contained  the  names  of 
a  number  of  drugs  which  had  become  obsolete  and 
might  well  be  dropped.  He  thought  that  a  short 
description  of  the  therapeutic  action  of  each  drug 
would  render  the  book  more  valuable  to  the  practi- 
tioner. .\s  long  as  the  book  retained  its  present 
form  he  saw  little  hope  of  persuading  the  average 
physician  to  make  much  use  of  it.  The  long  chem- 
ical names  with  which  some  of  the  drugs  were  bur- 
dened might  well  be  replaced  by  simpler  names. 

Additions  to  and  Eliminations  from  the  United 
States  Pharmacopoeia  from  the  Viewpoint  of 
Statistics. —  Dr.  C  .S.  X.  Hallberg,  of  Chicago, 
said  that  the  statistical  work  that  he  was  doing  for 
the  American  Pharmaceutical  Association  had  not 
yet  been  completed,  and  he  was  able  to  report  on 
only  about  125,000  prescriptions  which  had  been 
collected  in  certain  sections  of  the  country,  but  that 
ultimately  it  was  hoped  that  a  million  might  be  col- 


June  26,  1909.] 


PROCEEDIXGS  OF  SOCIETIES. 


1329 


lected.  The  figures  collected  went  to  show  that  cer- 
tain drugs  that  were  absolutely  neglected  in  one 
part  of  the  country  were  used  in  other  parts,  and 
this  fact  would  make  the  elimination  of  drugs  from 
the  pharmacopoeia  a  matter  of  much  difficulty. 
There  was  noted  a  marked  increase  in  the  use  of 
caffeine,  codeine, and  the  newer  derivatives  of  opium, 
with  a  corresponding  decrease  in  the  use  of  opium 
and  morphine.  Xux  vomica  was  still  more  largely 
used  than  any  other  vegetable  preparation.  The 
use  of  aspirin  was  increasing  and  it  was  found  that 
this  drug  was  being  largely  bought  by  laymen  with- 
out prescriptions.  If  aspirin  was  known  by  its 
chemical  name  this  would  not  be  the  case. 

Do  We  Possess  in  the  Drugs  and  Preparations 
that  are  Recognized  by  the  United  States  Phar- 
macopoeia and  the  National  Formulary  a  Suffi- 
cient Armamentarium  for  the  Medicinal  Treat- 
ment of  Disease? — Dr.  M.  Claytox  Thrush,  of 
Philadelphia,  said  that  there  was  a  growing  recog- 
nition of  the  usefulness  of  these  works  and  an  in- 
creasing employment  of  them  which  promised  ul- 
timately to  drive  from  the  field  the  nostrums  and 
unethical  preparations.  The  Council  on  Pharmacy 
and  Chemistry  had  already  been  of  inestimable  serv- 
ice to  the  practitioner  in  guiding  him  as  to  the  new 
remedies,  and  it  was  to  be  hoped  that  the  Council 
might  act  in  an  advisory  capacity  to  the  convention 
for  the  revision  of  the  pharmacopoeia  in  its  choice 
of  .  new  remedies  to  be  admitted.  The  speaker 
thought  the  growing  cordiality  between  the  pharma- 
ceutical and  medical  professions  was  a  ver\-  desir- 
able state  of  affairs.  The  pharmacopoeia  had  been 
made  a  legal  standard  by  the  passage  of  the  Pure 
Food  and  Drugs  Act,  and  it  was  the  best  book  of 
its  kind  in  the  world.  He  thought  that  medical 
schools  ought  to  require  a  more  exact  knowledge 
of  the  pharmacopoeia  and  the  formulary,  for  they 
afforded  everything  in  the  way  of  drugs  that  a  phy- 
sician required.  The  proprietary  remedies  were 
only  mixtures  of  well  known  drugs  and  were  very 
expensive.  It  was  justifiable,  however,  to  desig- 
nate on  a  prescription  whose  preparation  of  any 
drug  was  wanted,  as  it  was  a  w-ell  known  fact  that 
the  products  of  different  manufacturers  varied  in 
potency  and  reliability. 

Professor  Joseph  P.  Reminx,tox,  of  Phila-lel- 
phia,  said  that  the  matter  of  long  names  was  of 
little  moment  and  physicians  invariably  abbreviated. 
To  the  suggestion  of  enlarging  the  scope  of  the  book 
by  the  addition  of  therapeutic  notes,  etc.,  he  ob- 
jected, on  the  grounds  that  a  pharmacopoeia  was 
an  official  standard  of  drugs  and  should  not  be  ex- 
pected to  express  opinions  as  to  their  uses. 

Dr.  H.  C.  Wood,  Jr..  of  Philadelphia,  said  that 
as  to  nomenclature,  the  chemical  names  of  drugs 
should  be  retained  in  order  that  the  prescriber  might 
have  a  definite  idea  of  the  nature  of  the  drug  that 
he  was  ordering  and  of  the  relationship  of  the  vari- 
ous drugs.  He  did  not  believe  that  it  was  proper 
to  designate  any  special  make  of  drug,  as  all 
pharmacists  should  be  required  to  dispense  drugs 
which  answered  pharmacopoeial  requirements.  The 
pharmacopoeia  did  not  recommend  the  use  of  any 
drug,  but  merely  fixed  a  standard  of  excellence,  and 
every  drug  which  was  prescribed  should  find  a  place 
in  the  pharmacopoeia  and  thus  a  standardization. 


Dr.  Hexry  Be.\te&,  of  Philadelphia,  said  that  the 
patent  and  copyright  laws  in  connection  with  drugs 
were  a  source  of  much  of  the  trouble,  and  he  hoped 
that  the  association  would  be  able  to  accomplish 
some  reform  in  that  direction. 

Mr.  ^l.  I.  Wilbert,  of  \\'ashington.  said  that 
the  habit  of  writing  for  drugs  of  certain  manufac- 
turers was  unwise  for  several  reasons.  In  the  first 
place,  it  was  never  certain  that  it  was  dispensed  as 
written  for,  and  the  drug  might  have  deteriorated 
since  the  receptacle  w^as  opened,  some  time  previ- 
ously. The  dispenser  was  responsible  for  the  qual- 
ity of  the  drug  in  any  case  as  soon  as  the  package 
had  been  opened.  ^lost  important,  he  thought, 
were  the  training  and  encouragement  of  the  retail 
pharmacist  to  maintain  a  pharmacopoeial  standard 
of  all  his  preparations,  and  this  the  medical  pro- 
fession should  constantly  insist  upon. 

Mr.  H.  P.  Hyxsox,  of  Baltimore,  said  that  it  was 
evident  that  "therapeutic  nihilism"  was  not  increas- 
ing. The  criterion,  for  the  admission  of  a  drug  to 
the  pharmacopoeia  should  be  whether  or  not  it  pos- 
sessed proved  pharmacodynamic  or  adjuvant  prop- 
erties. 

Dr.  C.  S.  X.  Hallberg  said  that,  as  to  the  long 
chemical  names  which  the  physicians  complained 
of,  they  were  no  more  difficult  than  many  of  the 
other  terms  used  in  medical  science  and  were  fully 
as  important. 

Dr.  Thrush  said  that  a  preliminary  course  in 
pharmacy,  before  the  study  of  medicine,  would  be 
of  great  advantage  and  would  obviate  many  of  the 
disadvantages  of  the  present  system. 

The  Nature  of  Preparations  Used  in  the  Treat- 
ment of  Drug  Addictions. — Dr.  L.  F.  Kebler. 
of  Washington,  said  that  examinations  by  the  De- 
partment of  Agriculture  during  the  past  few  years 
had  shown  that  preparations  used  for  the  treatment 
of  drug  addictions  usually  contained  large  quanti- 
ties of  the  drug  for  which  treatment  was  instituted. 
He  cited  examples  in  which  he  had  found  prepara- 
tions containing  as  much  as  thirty-two  grains  of 
morphine  to  the  fluid  ounce.  Sometimes  they  con- 
tained also  atrophine.  strychnine,  quinine,  or  other 
substances.  In  some  cases  there  was  a  gradual  re- 
duction in  successive  supplies  of  the  preparation,  but 
the  reduction  was  so  small  as  virtually  to  extend  the 
treatment  over  years.  In  other  cases  the  treatment 
was  with  packages  serially  numbered  from  one  to 
ten,  and  each  package  was  found  to  contain  the 
same  amount  of  the  habit  forming  drug.  The  books 
of  some  institutions  showed  that  the  treatment  was 
intended  to  be  continued  indefinitely.  These  prac- 
tices were  exceedingly  difficult  to  control,  but  the 
Post  Office  Department  had  been  of  the  greatest 
assistance,  and  it  was  hoped  that  it  would  be  suc- 
cessful in  eliminating  them  entirely. 

What  can  Physicians  Do  to  Improve  the  Phar- 
macopoeia?— Dr.  Hexry  Leffmaxx,  of  Philadel- 
phia, said  that  the  physicians  of  the  countr\"  should 
take  more  interest  in  the  construction  of  the  phar- 
macopoeia and  should  support  it  more  heartilv. 
They  had  been  negligent,  although  the  advances  of 
medicine  and  pharmacy  had  been  largely  along  such 
lines  as  required  the  aid  of  pharmacists.  The  pres- 
ent board  of  trustees  was  composed  almost  ex- 
clusively of  pharmacists.    Since  the  book  had  be- 


J  330 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal 


come  a  legalized  standard,  the  method  of  constitut- 
ing the  convention  should  be  more  businesslike  and 
the  representation  more  equitable.  He  suggested 
that  the  convention  be  called  by  the  Federal  gov- 
ernment, that  the  American  Medical  Association 
and  the  American  Pharmaceutical  Association  be 
equally  represented,  and  that  a  smaller  number  of 
delegates  be  sent  from  certain  government  depart- 
ments. The  pharmacopoeia  should  l)e  revised  every 
five  years. 

Professor  Remington  said  that  he  thought  the 
present  Pharmacopoeial  Convention  was  more  repre- 
sentative than  the  one  suggested  by  the  speaker. 
Suggestions  for  improvement  were  welcome  from 
any  source. 

Dr.  Beates  thought  that  any  such  revolutionary 
change  would  be  exceedingly  unwise. 

The  Nomenclature  of  the  United  States  Phar- 
macopoeia and  National  Formulary  Mixtures. — 

Dr.  L,  F.  Kebler,  of  Washington,  said  that  the 
names  of  compounds  should  always  indicate  the 
most  important  therapeutic  ingredient  which  they 
contained.  He  instanced  a  number  of  preparations 
which  were  very  dififerent  from  what  would  be  ex- 
pected from  the  name,  some  being  harmless  decep- 
tions, such  as  the  elixir  of  calisaya,  and  some  ccn- 
taining  dangerous  narcotics.  Were  such  com- 
pounds put  out  under  these  names  by  private  individ- 
uals they  would  be  immediately  suppressed  by  the 
government,  and  it  was  embarrassing  to  the  govern- 
ment in  pursuing  its  work  to  have  such  preparations 
within  the  covers  of  the  pharmacopoeia  or  the 
formulary. 

The  National  Formulary;  Its  Genesis,  Char- 
acter, and  Utility.— Mr.  H.  P.  Hvnson,  of  Balti- 
more, said  that  any  compound  prescription  was  the 
natural  child  of  insufficient  knowledge  respecting 
patholog}',  pharmacology,  and  therapeutics,  and 
must  continue  as  long  as  such  conditions  existed. 
Toward  the  end  of  the  last  centur\-  the  advent  of 
concentrated  medicines  and  the  advancement  in  the 
isolation  of  active  principles  resulted  in  the  exploi- 
tation of  iimumerable  proprietaries.  In  several  dif- 
ferent localities  the  physicians  and  pharmacists 
joined  in  establishing  local  formularies  for  their 
own  convenience.  Thereupon  the  American  Phar- 
maceutical Association  undertook  to  compile  and 
publish  a  national  formulary  including  only  formula? 
which  were  largely  prescribed  and  without  any  idea 
of  dictating  to  the  physicians.  The  idea  was  to 
furnish  a  standard  to  the  pharmacists  in  order  that 
they  might  prepare  these  compounds  in  bulk  and  at 
their  leisure  in  the  most  acceptable  manner.  The 
compilers  of  the  book  were  no  more  responsible  for 
the  thera]K'utic  worth  of  the  formula;  than  was  the 
man  behind  the  counter  for  the  prescriptions  which 
he  dispensed.  It  was  simply  a  compilatinn  of  com- 
monly used  i)rescriptions.  Since  the  recognit'on  of 
the  work  by  the  government  the  American  Pharma- 
ceutical Association  had  been  stimulated  to  revise 
it  and  hoped  to  make  the  next  edition  a.>  scientific 
and  accurate  as  possible.  The  criticism  and  coop- 
eration of  the  physicians  was  very  earnestly  desired 
in  the  preparation  of  the  next  edition. 

Dr.  .\i!R.\ii.\M  J.vcoHi,  of  Xew  York,  thought  that 
all  preparations  or  mixtures  in  the  pharmacopceia 
and  the  formulary  ought  Ui  be  therapeuticallv  as 


well  as  pharmacologically  commendable.  The  last 
edition  of  the  pharmacopceia  had  included  some  ex- 
ceedingly objectionable  preparations. 

Professor  Remington  said  that  the  physicians 
were  responsible  for  the  preparations  included  in 
the  pharmacopoeia.  The  formulary  contained  some 
narcotic  concealing  preparations  which  were  quite 
as  bad  as  the  nostrums  of  the  "soothing  syrup" 
type,  and  he  thought  they  ought  to  be  expunged. 

Dr.  Hallberg  said  that  he  thought  it  was  justifi- 
able and  necessary  to  provide  narcotic  containing 
preparations  which  could  be  prescribed  without  in- 
forming the  patient  of  the  character  of  the  drug 
which  he  was  taking.  The  formulary  did  not  copy 
successful  proprietaries,  as  had  been  charged.  Tlie 
proprietaries  were  copies  of  popular  formulae  sucii 
as  were  found  in  the  formulary. 

On  motion  of  Mr.  Hynson  the  section  voted  that 
the  chairman  be  directed  to  appoint  a  committer 
of  five  members  to  confer  with  the  committee  of 
the  American  Pharmaceutical  Association  on  the 
revision  of  the  National  Formulary. 

The  Report  of  the  Committee  on  the  United 
States  Pharmacopoeia  was  presented  by  its  chair- 
man. Dr.  Reid  Hunt,  of  Washington,  who  said  that 
a  circular  letter  had  been  sent  to  the  other  sections 
of  the  association  asking  for  suggestions.  He  cited 
the  action  of  the  Section  in  Ophthalmology  as  an 
encouraging  example  of  interest  and  activity.  This 
section  had  selected  from  the  list  of  new  prepara- 
tions approved  by  the  Council  on  Pharmacy  and 
Chemistry  fourteen  drugs  which  might  prove  of 
particular  interest  to  the  members  of  the  section, 
and  had  sent  the  list  to  every  member  with  a  re- 
quest for  an  opinion  on  the  advisability  of  admittinj;^ 
a  certain  proportion  of  them  to  the  pharmacopoeia. 
The  Section  in  Surgery  had  been  asked  to  submit  a 
report  on  anaesthetics,  but  this  section  had  decided 
that  the  question  of  chemical  and  therapeutic  speci- 
fications of  anaesthetic  agents  might  better  be  passed 
upon  by  the  Council.  The  committee  was  of  the 
opinion  that  the  aid  of  the  Council  on  Pharmacy 
and  Chemistry  would  be  very  desirable  in  the  re- 
vision of  the  pharmacopoeia.  They  also  recom- 
mended that  the  influence  of  the  section  be  directed 
toward  a  simpler  nomenclature  of  the  newer  drugs 
m  the  pharmocopoeia. 


WESTERN    SURGICAL    AND  GYNECOLOGICAL 

ASSOCIATION. 
Eighteenth  Annual  Meeting,  Held  in  Minneapolis,  Decem- 
ber ^g' and  jo,  1908. 

(Coiiliuncd  from  page  1288.) 

The  Diagnosis  and  Treatment  of  Renal  Calculi. 

—  r3r.  Damki,  X.  FisKxXDRATii.  of  Chicago,  dis- 
cussed the  influence  of  the  presence  of  renal  cal- 
culi upon  the  kidney  in  which  they  were  lodged, 
as  well  as  upon  the  opposite  one.  The  number  of 
cases  in  which  calculi  were  found  in  both  kidneys 
simultaneously  was  increasing.  The  chief  points 
in  the  diagnosis,  so  far  as  symptoms  were  con- 
cerned, were  haematuria,  pain,  and  the  passage  of 
calculi.  The  value  of  x  ray  diagnosis  and  the  most 
approved  methods  of  taking  skiagraphs  for  renal 
calculi  were  described  in  detail.    He  spoke  of  the 


June  26,  1 909. J 


I'ROCEEDIXGS  OF  SOCIETIES. 


133' 


value  of  a  thorough  knowledfje  of  the  functional 
capacity  of  each  kidney  before  operating,  and  al- 
luded to  the  influence  of  prognosis  in  aseptic  and 
infected  cases.  The  treatment  was  considered 
chiefly  from  a  surgical  standpoint.  The  operations 
of  choice  were  nephrotomy  and  pyelotomy.  Th,^ 
relative  merits  and  disadvantages  of  each  were 
pointed  out. 

The  Removal  of  the  Gallbladder. —  Dr.  Arciu- 
B.J^LD  AIacLaren  and  Dr.  H.  P.  Ritchie,  of  St. 
Paul,  in  a  joint  paper  on  this  subject,  said  that 
cholecystectomy  had  been  performed  twenty-one 
times  in  165  operations  upon  the  gallbladder,  liver, 
and  pancreas.  Pain  was  the  most  constant  symp- 
tom and  was  definitely  localized  in  the  gallbladder 
in  all  the  cases,  except  two,  in  which  the  symptoms 
were  ascribed  to  other  abdominal  conditions.  An 
inflammator}'  history  was  obtained  in  fourteen 
cases.  The  occurrence  might  have  been  remote, 
recent,  or  immediate.  A  tumor  was  found  in  seven 
cases.  The  ages  of  the  patients  ranged  from  twenty- 
five  to  seventy-four  years.  There  were  four  cases 
in  males  and  seventeen  in  females.  The  gallblad- 
der was  without  stones  in  four  cases.  Six  histories 
gave  evideiice  of  jaimdice,  in  three  of  which  there 
was  a  stone  in  the  common  duct,  and  in  the  re- 
maining three  a  stone  was  found  in  the  cystic  duct. 
Three  cases  showed  perforation  of  the  gallbladder. 
In  two  cases  the  gallbladder  was  removed  at  a 
second  operation.  The  cystic  duct  was  tied  nine 
times,  and  drained  with  a  tube  nine  tim^s.  Once 
the  forceps  was  left  in  situ.  The  reasons  for  re- 
moval of  the  gallbladder  were:  Contracted  anf' 
useless  gallbladders  in  ten  cases ;  dilated  and  hy- 
pertrophied  in  six  cases :  phlegmonous  and  gan- 
grenous in  one  case :  empyema  in  two  cases :  mu- 
cous fistula  in  two  cases.  Three  deaths  had  oc- 
curred— a  mortality  of  14.2  per  cent.  Unsuspected 
gallbladder  conditions  found  in  the  course  of  in- 
traabdominal examination  had  given  signs  which 
might  be  demonstrated  by  reviewing  the  histories 
with  patients  after  operations.  The  svmptoms  had 
been  neglected  by  the  patient  or  misinterpreted  by 
the  surgeon. 

The  gallbladder  had  been  removed  in  three  cases 
in  which  the  common  duct  was  invoh'ed.  It  would 
have  been  impossible  to  use  it  in  any  subsequent 
operation.  They  believed  in  leaving  the  gallbladder 
in  common  duct  cases  for  the  purpose  of  cholec\'S- 
tenterostomy  if  it  could  be  so  used  when  needed. 
Both  drainage  and  ligation  of  the  cystic  duct  were 
proper  procedures,  and  the  choice  between  them  de- 
pended upon  the  individual  case. 

The  greatest  interest  in  the  pathology  of  the  gall- 
bladder was  centred  in  the  gross  changes.  Each 
specimen  should  be  studied  for  malignanc>-.  but  the 
study  usually  ended  in  demonstrating"  difterent  de- 
grees of  changes  resulting  from  infection  or  circu- 
latory interference.  No  specimen  of  their  series 
had  been  removed  until  it  was  definitely  shown  that 
the  organ  was  irreparably  damaged.  It  was  diffi- 
cult to  lay  down  rules  for  the  removal  of  the  gall- 
bladder. The  fear  of  a  second  operation  had  been 
the  cause  of  the  excision  of  organs  which  might 
have  been  saved.  Nme  cases  were  reported  in 
which  contracted  and  cystic  gallbladder  empyema 


from  typhoid  fever  and  other  conditions  had  been 
left  and  the  patients  had  remained  well  for  varying 
periods  up  to  nine  years.  Many  times  after  drain- 
age bile  would  not  begin  to  flow  until  the  fourth 
or  even  the  seventh  day.  There  were  many  cases 
in  which  the  gallbladder  was  so  definitely  diseased 
that  there  would  be  no  question  as  to  the  necessity 
of  its  removal,  and  any  one,  ho  matter  how  lim'ted 
his  experience,  would  know  that  such  gallbladders 
ought  to  be  removed.  Those  in  which  it  was  dif- 
ficult to  decide  were  the  cystic  gallbladders,  where 
the  stone  had  been  impacted  a  short  time,  or  those 
which  presented  small  hasmorrhagic  .'-pots,  or 
moderate  sized  perforations.  And  they  believed 
with  Deaver  that  in  case  of  doubt  drainage  should 
be  used. 

Pancreatic  disease  occurred  frequently  in  gall- 
bladder diseases,  and  drainage  was  necessary  for 
its  cure.  This  fact  must  not  be  overlooked  when 
the  question  of  cholecystectomy  was  to  be  consid- 
ered. '  Cholecystectomy  was  influenced  by  the^  sur- 
geon's own  experience,  and  we  must  not  look  at 
the  records  of  others  and  tell  patients  that  the 
mortality  from  this  operation  had  been  reduced  to 
two  or  three  per  cent.,  forgetting  that  the  man 
whom  we  were  tmconsciously  quoting  had  only  at- 
tained his  three  or  four  per  cent,  by  a  greater  ex- 
perience than  our  own.  and  no  doubt  th'-ough  bit- 
ter trials  and  losses. 

A  Nevi^  Incision  to  Reach  the  Bile  Tracts. — Dr. 
Clifford  U.  Collins,  of  Peoria.  111.,  described  a 
new  incision  through  which  to  reach  the  bile  tracts. 
It  began  at  the  inner  edge  of  the  sheath.  The  rec- 
tus muscle  was  separated  from  its  sheath  and  re- 
tracted outward.  The  same  diagonal  incision  was 
then  made  through  the  posterior  wall  of  the  sheath 
and  peritonaeum.  A  short  transverse  incision  from 
the  upper  end  through  the  linea  alba  and  another 
from  the  lower  end  through  the  linea  semilunaris 
completed  it.  The  advantages  were:  i.  There  was 
not  a  continuous  opening  down  through  the 
layers  of  the  abdominal  wall.  The  openings  through 
the  aponeurotic  structures  w^ere  protected  by  the 
uninjured  muscle,  which  lay  between  them.  2,  The 
intercostal  nerves  were  not  injured  as  they  entered 
the  muscle  through  its  outer  border.  3,  It  made  a 
stronger  closure  where  drainage  was  required.  The 
tube  or  gauze  held  the  rectus  muscle  to  the  outer 
side.  When  it  was  removed,  the  muscle  slid  over 
to  its  former  bed  and  placed  a  barrier  of  uninjured 
muscle  across  the  drainage  tract.  4,  No  injury 
was  done  to  the  muscular  structure. 

He  also  presented  an  instrument  to  facilitate  the 
removal  of  stones  from  the  first  portion  of  the  com- 
mon duct.  It  consisted  of  a  forceps  with  an  in- 
complete ring  at  the  end  of  each  jaw%  covered  with 
rubber  tubing.  If  the  stone  was  found  in  the  first 
portion  of  the  common  duct,  or  could  he  ptished 
up  into  the  first  portion,  the  lower  jaw-  of  the  for- 
ceps was  passed  into  the  foramen  of  Winslow  be- 
low the  stone.  When  the  jaws  were  closed,  the 
incomplete  rings  would  surround  the  stone  and  it 
might  be  drawn  up  into  the  incision. 

Pericolitis. — Dr.  Jabez  N.  Jackson,  of  Kansas 
City,  Mo.,  said  that  the  term  pericolitis  had  gener- 
ally been  vaguely  used  to  denote  adhesions  about 


1332 


PROCEEDINGS  OF  SOCIETIES. 


[New  York 
Medical  Journal 


the  colon,  at  most  times  of  unknown  origin.  He 
believed  that  there  was  a  form  of  pericolitis  which 
had  a  distinct  pathological  identity,  and  was  char- 
acterized by  a  distinct  clinical  picture,  for  whicli 
an  operation  was  suggested,  thus  far  limited  to  five 
experiences  of  rather  recent  date,  which,  while  not 
conclusive,  had  been  sufficiently  satisfactory  to 
warrant  hope  in  its  future. 

This  pericolitis  was  characterized  by  the  forma- 
tion of  apparently  an  entirely  new  layer  of  distinct- 
ly vascularized  periton?eum  in  which  the  vessels 
were  parallel  and  appeared  to  begin  on  the  outer 
side  at  the  root  of  the  mesocolon,  whence  they  ad- 
vanced on  to  the  colon  and  then  generally  passed 
in  the  direction  parallel  to  the  long  axis  of  the  as- 
cending colon.  This  membrane  served  to  bind  the 
ascending  colon  close  to  the  posterior  abdominal 
wall,  and  the  longitudinal  strands  tended  to  produce 
a  shortening  and  often  a  marked  angulation  of  the 
colon.  Sometimes  this  membrane  passed  across  the 
ascending  colon  and  up  on  to  the  transverse  colon, 
which  was  then  drawn  downward  and  to  the  right 
until  the  transverse  colon  paralleled  the  ascending 
colon  and  distinct  angulation  was  produced  at  the 
hepatic  flexure  above  and  below  where  the  trans- 
verse colon  turned  back.  With  this  latter  condi- 
tion the  stomach  was  always  drawn  down  and  a 
mechanical  gastroptosis  was  produced.  The  gen- 
eral effect  of  this  membrane  was  a  mechanical  in- 
terference with  the  free  peristalsis  of  the  colon,  also 
the  stomach,  thus  producing  stagnation,  distention, 
pain,  flatulency,  and  a  train  of  nervous  symptoms 
distinctly  neurasthenic  in  character.  This  condition 
was  believed  to  be  of  very  frequent  occurrence,  and 
must  have  been  observed  by  all  surgeons  of  experi- 
ence, but  thus  far  had  not  been  adequately  described. 
He  had  found  that  this  membrane  could  be  dissected 
off  in  toto,  and  when  this  was  done  the  mobility  of 
the  colon  was  restored.  Five  cases  in  which  the 
diagnosis  had  been  definitely  made  before  opera- 
tion and  in  which  this  specific  procedure  had  been 
followed  out  were  reported,  with  results  that  were 
extremely  gratifying  thus  far.  The  author  had  in 
course  of  preparation  a  series  of  pathological  ex- 
hibits by  which  it  was  hoped  to  establish  the  identity 
of  the  condition. 

Gastric  and  Duodenal  Ulcer.  —  Dr.  W.  D. 
Haines,  of  Cincinnati,  presented  the  autopsy  find- 
ings in  a  large  series  of  examinations,  with  special 
reference  to  ulcer  cicatrices.  He  showed  that  from 
one  to  four  per  cent,  of  all  cases  recorded  in  Europe 
and  the  United  States  exhibited  ulcer  evidence  rang- 
ing from  active  ulcer  to  carcinoma.  After  a  short 
consideration  of  the  embryology  of  the  stomach  and 
duodenum,  he  took  up  the  lymph  anastomosis  and 
traced  it  from  the  stomach  until  the  flow  was  emp- 
tied into  the  general  circulation.  A  strong  plea  was 
made  for  the  removal  of  the  gland  bearing  tissue 
between  the  les.ser  curvature  of  the  stomach  and  the 
pancreaticosplenic  group  of  glands  in  operating  for 
cancer  of  the  pylorus.  A  concise  resume  of  the  di- 
agnostic features  of  gastric  and  duodenal  ulctr,  to- 
gether with  their  distinctive  diagnosis,  was  followed 
by  a  consideration  of  the  surgical  treatment  of 
chronic  nicer.  By  pushing  an  instrument  through 
the  crater  of  the  ulcer  producing  artificial  perfora- 


tion, ligating  the  surrounding  varicose  vessels,  and 
turning  in  the  margin  of  the  ulcer  by  two  layers  of 
serous  sutures,  local  rest  was  obtained  for  the  in- 
flamed, indurated  tissues,  and  a  gastrojejunostomy 
completed  the  technique.  It  was  shown  that  nearly 
all  gastric  cancers  had  their  origin  in  chronic  ulcer. 
The  author  recommended  excision  of  the  ulcer  bear- 
ing area,  after  Rodman,  when  practicable,  as  the 
best  method  of  dealing  with  chronic  ulcer. 

Mistakes  in  Diagnosis  in  the  Upper  Abdomen. 
■ — Dr.  James  E.  Moore,  of  Minneapolis,  made  no 
effort  to  elucidate  obscure  or  moot  points  in  diagno- 
sis, but  endeavored  to  point  out  some  common  er- 
rors that  could  and  should  be  avoided.  The  principal 
reason  for  mistakes  in  diagnosis  in  all  regions  of 
the  body  was  lack  of  careful  and  systematic  exami- 
nation, and  the  two  special  reasons  for  mistakes  in 
the  upper  abdomen  were  difficulty  in  palpation  and 
the  comparatively  recent  origin  of  upper  abdominal 
surgery.  He  cited  a  case  in  which  two  operations 
had  been  done,  one  for  appendicitis,  and  one  for 
gallstones,  in  which  the  whole  trouble  was  diie  to 
splanchnoptosis. 

He  pointed  out  the  dangers  of  a  false  history 
given  by  the  patient,  particularly  when  she  was  neu- 
rasthenic. Every  patient,  especially  every  female 
patient,  coming  for  examination  for  conditions  in 
the  upper  abdomen  accompanied  by  abdominal 
crises,  should  be  carefully  examined  with  a  view  to- 
establishing  the  presence  or  absence  of  splanchnop- 
tosis, because  of  the  danger  of  mistaking  crises  due 
to  the  ptosis  of  organs  for  gallstones  or  other  con- 
ditions. It  was  not  safe  to  conclude  in  the  pres- 
ence of  splanchnoptosis  that  the  patient  was  not  suf- 
fering from  other  pathological  conditions,  because 
they  were  oftentimes  combined.  The  evidences  of 
ptosis  of  the  various  organs  were  so  plain  that  they 
should  always  be  discovered  when  proper  examina- 
tion was  made.  The  liver  was  more  frequently  mis- 
placed and  misshapen  than  was  generally  under- 
stood, and  was  very  apt  to  give  rise  to  mistaken  di- 
agnoses. He  warned  the  profession  against  the  dan- 
ger of  overlooking  pathological  conditions  amenable 
to  surgical  treatment  in  neurasthenic  patients.  Pott's 
disease  in  its  early  stages,  when  located  in  the  mid- 
dle or  upper  dorsal  regions,  caused  pain  that  had 
frequently  been  the  cause  of  mistaken  diagnoses. 
This  mistake  could  usually  be  avoided  by  ascertain- 
ing the  presence  or  absence  of  rigidity  of  the  spine. 

Peritoneal  Adhesions. — Dr.  A.  W.  Abbott,  of 
Minneapolis,  said  the  cause  of  peritoneal  adhesions 
was  often  questionable.  Rough  handling,  hjemor- 
rhage,  and  traumatism  were  given  more  credit  than 
they  should  receive.  The  relation  between  adhesions- 
and  symptoms  was  very  contradictory.  Extensive 
adhesions  often  were  not  accompanied  by  symptoms, 
and,  vice  versa,  severe  symptoms  were  acconi])anied 
with  very  few  adhesions.  The  treatment  at  the 
present  time  was  inadequate.  The  author  offered 
suggestions  for  the  treatment  of  these  adhesions. 

The  Versatile  Omentum. — Dr.  Frederick  A. 
DuNSMOoR.  of  IMinneapolis,  referred  to  the  impor- 
tance of  the  functions  of  the  omentum  in  surgery. 
It  was  his  practice  to  use  the  omentum  as  a  patch 
for  an  intestine  wounded  or  denuded  of  peritonanmi. 
or  to  fill  in  ulcerations  which  were  not  roadilv  or 


June  26,  1909.] 


LETTERS  TO  THE  EDITOR.— BOOK  NOTICES. 


1333 


safely  closed.  When  large  purulent  cavities  were 
opened,  after  removing  the  pus  and  wiping  con- 
taminated parts  with  iodoform  gauze,  the  omentum 
was  in  all  cases,  where  possible,  made  to  adhere  to 
the  infected  part  instead  of  using  a  drainage  tube. 
The  author  reported  two  cases  illustrating  how  this 
most  important  organ  might  be  utilized.  His  con- 
clusions were:  i.  It  seemed  sensible  to  follow 
natural  and  physiological  efforts  in  attempts  at  cure. 
2.  The  functions  of  the  omentum  in  combating  in- 
fection and  draining  dangerous  elements  from  the 
peritoneal  cavity  were  well  established.  3.  We 
should  aim  to  secure  the  assistance  of  such  func- 
tions, and  at  the  same  time  use  ingenuity  to  prevent 
permanent  adhesions,  which  might  be  harmful.  4. 
We  should  deprecate  the  wasteful  amputation  of 
parts  of  the  omentum  appearing  redundant  or  occu- 
pying a  hernial  sac.  5.  Damaged,  overaft'ected.  or 
strangulated  portions  of  the  omentum  should  be  re- 
moved, in  order  that  greater  utility  might  be  possi- 
ble from  the  portion  remaining. 

Colles's  Fracture. — Dr.  J.  W.  Andrews,  of 
r^Iankato,  ]\Iinn.,  discussed  the  surgical  anatomy  and 
the  reasons  for  the  characteristic  deformity  in 
Colles's  fracture.  He  spoke  of  making  the  diagnosis 
by  inspection.  Crepitus  and  increased  mobility 
were  rarely  present.  An  anaesthetic  was  necessary 
for  complete  reduction,  if  not  for  accurate  diagno- 
sis. The  injuries  sustained  by  the  soft  tissues  were 
extensive  and  important.  In  this  form  of  fracture 
rapid  bony  union  was  the  invariable  rule.  The  pre- 
vention of  deformity  was  not  alwavs  possible. 

The  Cancer  Question,  with  Special  Reference 
to  the  Treatment  of  Cancer  of  the  Breast. — This 
paper,  by  Dr.  J.  E.  Su-mmers,  of  Omaha,  appeared 
in  the  Nez<.-  York  Medical  Journal  of  Februarv  27, 
1909. 

Officers  were  elected  as  follows :  President, 
Dr.  A.  L.  Wright,  of  Carroll,  Iowa,  vice-presidents, 
Dr.  J.  F.  Percy,  of  Galesburg,  111.,  and  Dr.  W.  B. 
Haines,  of  Cincinnati ;  secretary-treasurer,  Dr.  Ar- 
thur T.  Mann,  of  AlinneapoHs.  The  next  meeting 
will  be  held  in  Omaha  on  December  20  and  21, 
1909. 

 <S>  

f  ftttrs  to  the  ^bitor. 


THE  ANOPHELES  THE  SOLE  CARRIER  OF  MA- 
LARL\. 

Crescent  Citv,  Fla.,  June  8,  igog. 

To  the  Editor:  In  ycur  issue  of  June  5th,  Dr. 
Charles  S.  Braddock,  Jr.,  questions  the  fact  of  the 
anopheles  being  the  sole  carrier  of  malarial  infec- 
tion. While  it  is  possible  that  later  research  work 
may  prove  that  there  are  other  modes  of  infection, 
all  the  evidence  on  the  subject  to  date  tends  to 
prove  that  the  mosquito  is  the  sole  carrier. 

The  statement  that  "on  a  jungle  trip  the  men  on 
foot  are  first  taken  ill  with  malarial  fever,  then  the 
men  on  horseback,  and  last  of  all,  and  very  sel- 
dom, the  men  that  travel  on  elephants"  requires 
more  than  this  bare  statement  to  verify  the  theory 
that  malarial  fever  is  of  miasmatic  origin.  It  would 
be  interesting  to  know,  for  instance,  the  different 


classes  of  men  traveling  in  these  various  manners, 
so  that  an  idea  might  be  formed  of  their  respective 
natural  powers  of  resistance.  Again,  with  this 
knowledge,  an  idea  of  the  intelligence  of  these  in- 
dividuals would  have  weight.  On  the  theory  that 
the  anopheles  is  the  sole  malarial  carrier,  sleeping 
under  mosquito  bars  would  be  of  little  service  if 
the  individual  had  no  protection  from  mosquitoes 
during  the  evening  hours  previous  to  going  to  bed. 

Again,  the  fact  that  in  the  northern  part  of  Siam, 
''where  the  thermometer  drops  to  34°  F.,  and  where 
at  that  time  of  year  there  are  no  mosquitoes,  and 
yet  pernicious  malaria  is  so  bad,"  etc.,  is  of  little 
significance,  for  it  is  established  beyond  any  doubt 
that  the  organism  of  malaria  may  remain  inactive 
in  the  circulation  for  a  considerable  period  of  time. 

The  assertion  that  "whenever  you  disturb  the 
earth  in  the  tropics  you  disturb  this  great  giant" 
is  hardly  borne  out  in  the  Panama  Canal  Zone, 
where  recently  much  earth  has  been  disturbed,  and 
yet  the  magnificent  work  carried  on  under  the  di- 
rection of  Colonel  Gorgas,  this  work  being  solely 
toward  the  extermination  of  mosquitoes,  has  re- 
sulted in  the  cleaning  up  of  as  bad  a  malarial  zone 
as  ever  existed. 

It  mtist  be  borne  in  mind  that  in  no  diseases  are 
there  as  many  errors  of  diagnosis  as  in  malaria. 
The  writer  served  in  the  Spanish-American  war, 
where  thousands  of  cases  of  "malaria"  were  later 
proved  to  be  typhoid  fever.  This  was  not  the  fault 
of  the  army  surgeons,  however,  two  factors  enter- 
ing into  this  cause:  i.  Microscopes  were  inacces- 
sible. 2.  The  Army  Regulations  provided  that  all 
sick  be  held  in  the  regimental  hospitals  but  forty- 
eight  hours,  when  they  had  to  be  transferred  to  the 
division  hospitals.  A  positive  diagnosis  of  typhoid 
fever  can  seldom  be  made  in  this  time,  while  few 
cases  of  sestivoautumnal  malaria  can  ever  be  posi- 
tively diagnosticated  without  the  aid  of  a  micro- 
scope. 

"Let  the  sun  in  and  the  fever  will  go  out"  is  true, 
provided,  however,  that  the  sun  dries  up  the  breed- 
ing places  of  the  mosquitoes.  In  conclusion.  Dr. 
Braddock's  inquiry  as  to  the  marked  difference  of 
the  morbidity  among  the  land  forces  and  that  of 
the  naval  forces  before  Santiago,  during  the  Span- 
ish-American war,  is  answered  with  the  statement 
that  it  was  typhoid  fever  that  infected  our  land 
forces,  and  not  malaria. 

Grah.mi  E.  Hensox. 


[We  publish  full  lists  of  books  received,  but  we  acknowl' 
edge  HO  obligation  to  review  them  all.  Nevertheless,  so 
far  as  space  permits,  we  review  those  in  which  we  think 
our  readers  are  likely  to  be  interested.] 


Bacterial  Food  Poisoning.  A  Concise  Exposition  of  the 
/Etiology,  Bacteriology,  Pathologj',  Symptomatology, 
Prophylaxis,  and  Treatment  of  So  Called  Ptomaine  Poi- 
soning. By  Prof.  Dr.  A.  Dieudonne.  Munich.  Trans- 
lated and  Edited,  with  Additions,  by  Dr.  Charles  Fred- 
erick Baldwin',  Bacteriologist.  Research  Laboratory.  De- 
partment of  Health,  City  of  New  York.  Authorized 
Translation.    New  York :  E.  B.  Treat  &  Co.,  1909. 

Many  subjects  of  the  greatest  practical  interest 
for  which  one  would  look  in  vain  in  the  ordinary 


1334 


BOOK  NOTICES. 


[New  Vork 
Medical  Journal. 


textbooks  on  medicine  and  diet  are  comprehensively 
treated  in  this  small  volume.  Epidemics  and  iso- 
lated cases  of  poisoning  due  to  the  ingestion  of  dis- 
eased and  decayed  meat  and  fish,  oysters  and  mus- 
sels, ice  cream  and  puddings,  potatoes  and  canned 
goods  are  carefully  studied,  methods  of  clinical  and 
bacteriological  diagnosis  are  described,  and  the  ra- 
tional treatment  is  indicated.  The  most  frequent  in- 
fective agents  to  which  serious  or  fatal  symptoms 
may  be  ascribed  are  the  Bacillus  proteiis,  Bacillus 
cnteritidis,  Bacillus  botulismi,  and  the  paratyphoid 
bacillus.  It  is  probable  that  in  most  instances  the 
cases  of  illness  attributed  to  "ptomaine"  or  tyrotox- 
icon  poisoning  are  due  to  bacteria  of  some  kind 
or  their  toxines.  In  the  following  expression  of 
opinion  we  emphatically  concur :  "There  is  really 
no  reason,  aside  from  convenience,  why  canned  foods 
should  be  used  in  the  household.  It  seems  not  to  be 
appreciated  that  canned  goods  are  always  inferior  to 
fresh  vegetables,  fruits,  etc."  At  the  end  of  the  vol- 
ume is  an  excellent  bibliography  which  will  be  ap- 
preciated by  any  one  wishing  to  pursue  the  subject 
to  original  sources. 

A  System  of  Diet  and  Dietetics.  Edited  by  J.  A.  Suther- 
land, M.  D.,  F.  R.  C.  P.  London:  Henry  Frowde,  Ox- 
ford University  Press ;  Hodder  &  Stoughton,  1908.  Pp. 
893- 

This  handsome  volume  is  one  of  the  well  known 
Oxford  Medical  Publications  and  constitutes  a  really 
noteworthy  addition  to  the  series.  Nineteen  con- 
tributors, among  them  Sir  Lauder  Brunton,  Colcott 
Fox.  Arthur  P.  Luff,  and  other  eminent  British 
practitioners,  have  collaborated  in  the  production  of 
a  modern  work  on  food  and  diet  of  the  greatest 
practical  value.  The  volume  is  marked  throughout 
by  strong  common  sense,' at  once  avoiding  fads  and 
hobbies  and  yet  voicing  with  emphasis  and  authorit}- 
the  change  in  professional  opinion  based  upon  recent 
advances  in  the  study  of  metabolism  and  physiologi- 
cal chemistry,  which  has  taken  place  with  regard  to 
a  number  of  controversial  subjects.  Among  these 
the  alcohol  question  is  easily  first  in  interest,  and 
there  is  a  striking  unanimity  in  the  views  of  these 
representative  writers  that  alcohol,  in  either  health 
or  disease,  is  seldom  of  much  value  and  is  often  dan- 
gerous and  harmful.  The  results  of  Chittenden's 
interesting  experiments  with  a  low  protein  diet  are 
fully  discussed,  but  are  not  accepted  as  conclusive. 
There  is  a  disposition  to  favor  liberal  feeding  in 
typhoid  fever  in  the  absence  of  contraindications, 
such  as  haemorrhage,  delirium,  or  vomiting.  It  has 
been  sufficiently  demonstrated  that  no  method  of 
rectal  alimentation  can  be  depended  u])on  for  any 
great  length  of  time  to  maintain  a  proper  nutritive 
balance. 

Much  attention  is  given  to  diet  in  tuberculous  dis- 
ease, and  carefully  constructed  diets,  based  upon 
calorimetric  estimates,  are  given  in  great  detail  for 
the  consumptive  poor.  There  are  good  formulae  for 
invalid  foods,  and  there  is  a  critical  and  discriminat- 
ing chapter  on  the  value  of  the  different  proprietary 
preparations  most  used.  Tlie  difficult  subject  of  diet 
in  gout  is  ably  and  conservatively  treated.  It  would 
have  been  desirable  to  have  a  fuller  presentation  of 
diet  in  diabetes ;  but  nine  pages,  inadequate  in  detail, 
are  given  to  this  important  subject.    There  is  an  ex- 


cellent chapter  on  obesity  and  its  treatment.  Diet  in 
diseases  of  the  stomach  and  intestines,  of  the  kid- 
neys and  nervous  system,  and  of  the  skin  is  ably 
discussed  by  specialists  in  these  departments  of  medi- 
cine. Especially  good  are  the  chapters  on  the  feed- 
ing of  infants  and  children,  and  on  diet  in  hot  cli- 
mates and  for  tropical  diseases.  The  American 
reader  will  note  with  interest  the  frequent  references 
to  the  work  of  Atwater,  Chittenden,  Irving  Fisher, 
Herbert  2^Iaxon  King,  Holt,  Rotch,  Kinnicutt,  and 
others  in  this  country. 

Die  Krankheiten  des  J'erdauiingslianals  (Oesophagus. 
Magen.  Darm. ),  Ein  Leitfaden  fiir  praktische  Aerzte. 
Von  Dr.  P.\ul  Cohnhei:.i.  Spezielarzt  fiir  Magen-  iind 
Darmkrankheiten  in  Berlin.  Mit  17  .A.bbildungen.  Zweite, 
vermehrte  und  neubearbeitete  Auflage.  Berlin :  S. 
Karger,  1908. 

The  first  edition  of  this  practical  manual  on  dis- 
eases of  the  digestive  organs,  by  a  pupil  of  Boas's, 
has  already  been  favorably  noticed  in  this  journal.  In 
this  second,  enlarged,  and  revised  edition  the  same 
general  plan  has  been  followed,  the  newer  diagnostic 
and  therapeutic  procedures  have  not  been  neglected, 
but  special  emphasis  is  given  to  clinical  methods  and 
the  importance  of  diet.  It  is  to  be  noted  also  that 
all  recent  works  on  the  stomach  and  intestine  are 
devoting  an  increased  amount  of  space  to  the  exam- 
ination of  the  faeces,  based  upon  the  original  work  of 
Schmidt  and  Strassburger. 


M cdicolitcrary  Notes. 

A  name  new.  we  think,  to  readers  of  fiction  is 
that  of  Oliver  Cabot,  who  has  written  a  capital  story 
The  Mail  U'lthout  a  Shadozv  (New  York,  D.  -Ap- 
pleton  &  Co.  ).  It  concerns  a  man  suffering  from  lost 
identity,  who  is  finally  able  to  blend  his  two.  exis- 
tences through  the  care  of  a  delightful  French 
nerve  specialist.  Dr.  Charles  Marie  de  Villiers.  The 
story  is  verv  well  told,  and  the  reader  who  placidly 
foresees  the  denouement  is  treated  to  a  genuine 
surprise. 

All  forms  of  art  are  susceptible  of  analysis  into 
certain  fundamental  principles  which  may  be  ac- 
quired by  any  earnest  student,  although  striking  suc- 
cess will  come  only  to  those  who  have  the  divine 
spark.  A  book  like  Writing  the  Short  Story  (Hinds, 
Xoble,  &  Eldredge,  New  York),  by  J.  Berg  Escn- 
wein,  editor  of  Lippincott's,  is  valuable  not  only  to 
intending  authors,  but  also  to  critics  who  prefer  to 
analyze  their  likes  and  dislikes  and  are  not  content 
merely  to  state  that  a  given  story  is  plea.^ing  or  (iis- 
tasteful.  A  perusal  of  the  book  is  highly  recom- 
mended to  those  who  are  beginning  to  write  for  pub- 
lication. It  will  teach  them  quickly  certain  details 
necessary  to  success,  otherwise  to  be  acquired  by  re- 
peated painful  experience  with  editors.  These  per- 
sons are  incidentally  shown  to  be  unexpectedly  hu- 
man inside,  once  the  hard  outer  crust  is  penetrated. 
An  analysis  is  made  of  many  successful  stories  and 
.some  masterpieces,  hints  as  to  tidiness  of  copv  and 
other  important  little  matters  are  thrown  out,  and 
all  the  possible  forms  of  introduction,  denouement, 
development,  etc.,  are  discussed.  There  is  hardly  a 
writer  who  will  not  find  he  can  improve  Iiis  tech- 


June  2b,  1 909. J 


OFFICIAL  NEWS. 


1335 


nique  by  study  of  this  work.  One  valuable  piece  of 
advice  is  lacking,  vis.,  the  advantages  of  securing  a 
steady  salaried  job  in  a  rolling  mill  or  elsewhere 
and  writing  only  for  recreation.  Physicians  intend- 
ing to  spin  yarns  are  sure  to  profit  by  Mr.  Esen- 
wein's  instructions. 

In  The  Wretches  of  Povertyville  (Chicago,  Jos. 
J.  Lanzit)  Dr.  I.  L.  Nascher,  of  New  York,  has 
produced  a  sociological  study  of  the  degenerate  and 
criminal  population  of  the  Bowery  and  its  environs 
from  sketches  made  at  first  hand.  Details  of  the 
peculiar  life  led  by  the  abnormal  individual  are 
faithfully  given,  the  efforts  of  well  meaning  but 
mistaken  philanthropists  to  apply  their  a  priori 
methods  of  reform  are  scientifically  and  dispassion- 
ately criticised,  and  a  number  of  fake  helpers  are 
exposed  w'ho  batten  on  the  unthinking  charitable. 
Particularly  are  revival  methods  discredited.  In  his 
last  chapter  Dr.  Nascher  makes  a  serious  attempt 
to  solve  the  problem  along  scientific  lines,  thor- 
oughly recognizing  the  immense  difficulties  in  the 
way  of  normalizing  a  character  originally  cursed 
with  bad  heredity  and  steadily  debased  by  vicious 
surroundings.  The  book  will  not  please  a  large 
proportion  of  earnest,  religious,  impracticable  peo- 
ple, but  is  well  worthy  of  the  attention  of  scientific 
students  of  crime  and  moral  relaxation.  We  think 
the  illustrations  of  the  book  might  well  have  been 
spared.  Dr.  Nascher  announces  for  early  publica- 
tion The  Wretches  of  Upper  Tendoin. 

 ^>  


Official  Sftos. 


Public   Health   and    Marine   Hospital  Service 
Health  Reports : 

Tlic  follozuing  cases  of  smallpox,  yellozv  fever,  cholera, 
and  plague  have  been  reported  to  the  surgeon  general,  Pub- 
lic Health  and  Marine  Hospital  Service,  during  the  zveek 
ending  June  j8.  iQog: 

Places.  Date.  Cases.  Deaths. 

Smallpox — United  States. 

California — Sacramento  May  22-29  

Delaware — Millboro  May  6-June  to  

Florida — Pensacola  May  1-31  

Georgia — Macon  May  31-June  6  

Indiana — Fort  Wayne  May  28-June  5  

Indiana — South  Bend  May  28-.Tune  5  

Kansas — Kansas  City  May  28-June  5  

Kentucky — Lexington  May  29-June  5  

Kentucky — Newport  May  30-June  6  

Kentucky — Paducah  May  23-30  

Louisiana- — Hammond  May  15-Tune  5  

Michigan — Grand  Rapids  May  29-June  5  

Minnesota — Duluth  May  28-June  4  

Missouri — Kansas  City  May  28-June  4  

Montana — Butte  May  26-June  3  

New  Jersey — Hoboken  May  28-June  5  

Pennsylvania — Bullis  Mills  April  29-June  14.... 

Pennsylvania — Harmony  May  15-June  14  

Ohio — Cincinnati  May  27-June  4  

Ohio — Geneva  April  20-June  10.... 

Ohio — Plain  City  March  i-June  10....  74 

Texas — San  .-\ntonio  May  28-June  5  

Virginia — Richmond  May  28-June  5  

Washington — Tacoma  May  23-30  

Washington — Walla  Walla  May  28-June  5  

West  Virginia— Wheeling  May  28-June  5  

Wisconsin — La  Crosse  May  28-june  5  

W^isconsin — Marinette  May  22-29  

Wisconsin — Milwaukee  May  22-29  

Smallpox — Foreign. 

Canada — Halifax  May  24-31   2 

Canada — Winnipeg  May  22-29   2 

Ceylon — Colombo  April    17-24   3 

China — Canton  April   17-May   i   10 

France — Paris  Jan.    16-23   4  Received 

France— Paris  Feb.    20-27   3    out  of 

date 

France — Paris  May   8-22   4 

Germany — Hamburg  May   16-23   2 

Russian  emigrants 


Cases.  Deaths. 


'4 

t 

8 
4 
4 


I'laccs.  Date 

Great  Britain — Bristol  May   15-22   2 

India — Bombay  May  4-1 1  

India — Calcutta  April  24-May   i  100 

India — Madras  May  1-7  

India — Rangoon  April  24-May  i  

Indo-China — Saigon  April  lo-May  i   10 

Italy  May   16-23   10 

Italy — Turin  May   :4-2i   i 

Java— Batavia  .\pril  24-May  i   4 

Mexico — Guadalajara  May  20-27   3 

Mexico — Mexico  April  17-May  8   t6 

Mexico — Monterey  May   23-30   5 

Persia — Astrabad  April    13-24   Epidemic 

Portugal — Lisbon  May   15-29   12 

Russia — Moscow  May  8-15   29  6 

Russia — Riga  May   15-29   18 

Russia — St.  Petersburg  April  24-May  8   28  13 

Russia — Warsaw  March  20-April  3...  5 

Sen,'ia — Belgrade  May  8-15   4  4 

Spain — Barcelona  May  17-24   6 

Spain — Valencia  May  8-15   10  i 

Switzerland — Geneva  May   8-15   2 

Turkey — Constantinople  May  8-16   2 

Turkey — Smyrna  April  29-May  6   i 

Uruguay — Montevideo  March    1-31   8 

Yellow  Fever — Foreign. 

Barbados  May  15-29   3 

Brazil — Manaos  May  8-15   9  4 

Brazil — Para  May  8-22   10  lo 

Mexico — Merida  May  30-June  2   2 

Portugal — Lisbon  June  1-14   2 

In  quarantine  from  S.S.  Lang- 
franc  from  Para. 

Venezuela — Maiquetia  May  24   i  i 

Clwlera — Foreign. 

India — Bombay  May  4-1 1   10 

India — Calcutta  April  24-May   i  105 

India — Rangoon  April  24-May  i   7 

Russia — St.  Petersburg  May  20-27   4 

Plague — Foreign. 

Chile — Antofagasta  May 

Chile — Arica  May 

Chile — Iquique  May 

China — Amoy  May  5  

China — Am  Phau  April  24-May  i   5 

China — Canton  April  17-May  i   80 

India — Bombay  May  4-1 1  

India — Calcutta  .*\pril  24-May  i  

India — Rangoon  April  24-May  i  

Indo-China — Saigon  April   lo-May   i   9 

Peru  April  24-May  8   57 

Venezuela — Caracas  June   3-9   2 


13- 


Present 
14 

Present 
.3 
55 
313 
127 
18 
9 
32 


Public  Health  and  Marine  Hospital  Service: 

Official  list  of  changes  of  stations  and  duties  of  commis- 
sioned and  other  officers  of  the  United  States  Public  Health 
and  Marine  Hospital  Service  for  the  seven  days  ending 
June  16,  1909: 

Brooks,  S.  D.,  Surgeon.  Granted  one  month's  leave  of 
absence  from  July  i,  1909. 

C.^MPBKLL,  p.  M.,  Acting  Assistant  Surgeon.  Granted 
thirty  days'  leave  of  absence  from  June  10,  1909. 

Clark,  Tallaferro,'  Passed  Assistant  Surgeon.  Granted 
seven  days'  leave  of  absence  from  June  11,  1909,  under 
paragraph  191,  Service  Regulations. 

E.\GER,  J.  M.,  Assistant  Surgeon  General.  Relieved  from 
duty  at  the  bureau  in  charge  of  the  Division  of  Sanitary 
Reports  and  Statistics,  to  take  effect  June  23,  1909,  and 
directed  to  proceed  to  Portland,  Me.,  and  assume  com- 
mand of  the  Portland  Quarantine  Station. 

G.-VHN,  Henry,  Pharmacist.  Reassigned  to  duty  in  the  Pur- 
veying Depot,  to  date  from  May  27,  1909. 

Geddings,  H.  D.,  Surgeon.  Detailed  to  attend  the  meeting 
of  the  International  Commission  for  the  revision  of  the 
international  classification  of  diseases  and  causes  of 
death  to  be  held  in  Paris,  France,  July  1-3,  1909. 

GoLDBERGER,  JoSEPH,  Passed  Assistant  Surgeon.  Directed 
to  proceed  to  Philadelphia,  Pa.,  upon  special  temporary 
duty. 

Hunter,  S.  B.,  Acting  Assistant  Surgeon.  Leave  granted 
May  19,  1909,  for  four  days  from  May  18,  1909,  amend- 
ed to  read  fourteen  days  from  May  18,  1909. 

Kalloch,  p.  C,  Surgeon.  Upon  arrival  of  Surgeon  J.  M. 
Eager,  relieved  from  command  of  the  Portland,  Me., 
Quarantine  Station. 

Lawhorn.  C.  C,  Acting  Assistant  Surgeon.  Granted  fif- 
teen days'  leave  of  absence  from  June  it,  1909. 

Lox^'THiAN.  Elvin,  Acting  Assistant  Surgeon.  Granted 
three  days'  leave  of  absence  from  June  9,  1909,  under 
paragraph  210.  Service  Regulations. 

McIntosh,  W.  P.,  Surgeon.  Detailed  as  member  of  board 
of  medical  officers  convened  under  bureau  order  of 
June  5.  1909. 


BIRTHS.  M.-IRRIAGES.  AXD  DEATHS. 


[New  York 
Medical  Joukxa,.. 


McMuLLEN,  JoHX,  Passed  Assistant  Surgeon.    Relieved  as 

member  of  board  of  medical  officers  convened  under 

.bnreau  order  of  June  5.  1909. 
Miranda,  R.  U.  L.,  Acting  Assistant  Surgeon.  Leave 

granted  May  15,  1909,  tor  four  months  from  June  i, 

1909.  amended  to  read  four  months  from  June  8,  1909. 
MooRK,  Dl'xlop,  Passed  Assistant  Surgeon.    Leave  granted 

May   I,   1909.   for  three  months  from  June  3,  1909, 

amended  to  read  three  months  from  June  3,  1909,  on 

account  cf  sickness. 
Porter,  Joseph  Y.,  Jr.,  Acting  Assistant  Surgeon.  Granted 

thirty  days"  leave  of  absence  from  July  i,  1909. 
Rea,  Robert  H.,  Acting  Assistant  Surgeon.    Granted  two 

days'  leave  of  absence  from  June  16,  1909. 
RoDMAX.   JoHX    C..   Acting   Assistant   Surgeon.  Leave 

granted  June  3,  1909,  for  seven  days  from  June  8,  1909, 

revoked. 

RosEXAC.  yi.  J.,  Surgeon.    Granted  one  month's  leave  of 

absence  from  June  8,  1909,  on  account  of  sickness. 
Schwartz,   Louis,   Acting   Assistant    Surgeon.  Granted 

twenty-eight  days'  leave  of  absence  from  July  12,  1909. 
Stodd.\rd,  C.  S.,  Acting  Assistant  Surgeon.    Granted  thirty 

days'  leave  of  absence  from  June  15,  1909. 
Stoxer,  George  \V..  Surgeon.   Reassigned  to  duty  as  Chief 

^ledical  Officer  at  Ellis  Island,  X.  Y.,  to  date  from 

March  8.  1909. 

Tr.\sk,  J.  \\'.,  Passed  Assistant  Surgeon.  Detailed  as  As- 
sistant Surgeon  General  in  charge  of  the  Division  of 
Sanitary  Reports  and  Statistics,  to  take  effect  June  24. 
1909. 

\0UXG,  G.  B..  Surgeon.  Reassigned  to  duty  in  command 
of  the  Marine  Hospital  at  Chicago.  111.,  to  date  from 
March  24.  1909. 

Army  Intelligence: 

Official  list  of  changes  in  the  stations  and  duties  of  offi- 
cers serzing  in  the  Medical  Corj^s  of  the  United  States 
Army  for  the  xveek  ending  June  ig,  igog: 
Austin,  T.  C,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  active  duty;  will  proceed  to  Jackson  Bar- 
racks, La.,  for  duty. 
Banister,  W.  B.,  Major.  Medical  Corps.    Ordered  from 
San  Francisco,  Cal..  to  Fort  Snelling.  Minn.,  for  duty 
as  surgeon,  and  as  acting  chief  surgeon.  Department  of 
Dakota. 

BiSPHAM,  \V.  N..  Major,  Medical  Corps.  Granted  leave  of 
absence  for  fourteen  days. 

CoNZELMANX,  F.  J..  First  Lieutenant,  Medical  Reserve 
Corps.    Granted  leave  of  absence  for  ten  days. 

Fauntleroy,  p.  C.  Major.  Medical  Corps.  Ordered  to 
command  held  hospital  at  camp,  Sparta,  ^Vis. 

Johnson,  R.  \V.,  Major,  Medical  Corps.  Retired  from 
active  service  June  16,  1909. 

Jones,  H.  \V.,  First  Lieutenant.  Medical  Corps.    Ordered  , 
to  Washington.  D.  C,  for  tcm.porary  duty  at  the  Wal- 
ter Reed  Army  General  Hospital. 

McAndrew,  p.  H.,  Captain,  Medical  Corps.  Leave  ex- 
tended ten  days. 

McLellan,  G.  H.,  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  from  Fort  Crook.  Xeb.,  to  Fort  Omaha,  Xeb., 
for  temporary  duty. 

Miner,  Donald,  First  Lieutenant.  Medical  Reserve  Corps. 
Honorably  discharged  from  the  service  of  the  United 
States,  his  services  being  no  longer  required. 

PiLLSBURY.  H.  C.  First  Lieutenant,  Medical  Corps.  Granted 
leave  of  absence  for  two  months  when  relieved  from 
duty  in  the  Philippines  Division. 

Reynolds,  F.  P.,  Major,  Medical  Corps.  Relieved  from 
duty  at  Fort  Snelling,  Minn.;  will  proceed  to  Fort 
Monroe.  Va.,  for  duty ;  ordered  to  command  field  hos- 
pital at  camp,  .\ntietam,  Md. 

Snow,  C.  G..  First  Lieutenant.  Medical  Reserve  Corps. 
Ordered  to  dutv  with  troops  en  route  and  at  Sparta, 
Wis. 

Snyder.  C.  R..  Captain.  Medical  Corps.  Granted  leave  of 
absence  for  fifteen  days. 

Truby.  a.  E..  Major,  Medical  Corps.  Ordered  to  command 
field  hospital  at  camp  near  San  Francisco.  Cal. 

Van  Poole.  G.  X..  Captain.  Medical  Corps.  Relieved  from 
duty  at  Fort  Slocum.  N.  Y. ;  will  proceed  at  the  ex- 
piration of  his  present  leave  of  absence  to  Fort  Sheri- 
dan. 111.,  for  duty. 


Navy  Intelligence: 

Official  list  of  ciianges  in  the  stations  and  duties  of  offi- 
cers serz'ing  in  the  Medical  Corps  of  the  United  States 
Aazy  for  the  zveel:  ending  June  ig,  jgog: 
Hathaway,  G.  S.,  Passed  Assistant  Surgeon.    Ordered  to 

the  Xavy  Yard,  Mare  Island,  Cal. 
Irvixe,  W.  L.,  Acting  Assistant  Surgeon.  Commissioned 
acting  assistant  surgeon,  with  rank  of  lieutenant,  junior 
grade,  from  June  9,  1909. 
Minter,  J.  M.,  Assistant  Surgeon.    Discharged  from  treat- 
ment at  the  Xaval  Medical  School  Hospital,  Washing- 
ton, D.  C,  and  granted  sick  leave  for  one  month. 
Russell,  A.  C.  H.,  Medical  Inspector.    Transferred  to  the 

retired  list  from  June  30,  1909. 
Stitt.  E.  R.,  Surgeon.  Detached  from  the  Xaval  Medical 
School,  Washington.  D.  C.  and  ordered  to  command 
the  Xaval  Hospital,  Canacao,  P.  I. 
WiEBER.  F.  W.  F.,  Surgeon.  Detached  from  command  of 
the  Xaval  Hospital.  Canacao.  P.  I.,  and  ordered  home 
to  await  orders,  with  three  months"  delay  en  route. 

 ^  

iirtjjs,  Slarriagfs,  ani  ffatfes. 


Married. 

Bacon— Tagg.\rt. — In  Washington,  D.  C,  on  Wednes- 
day. June  i6th.  Dr.  Sankey  Bacon,  U.  S.  X.,  and  Miss 
Emily  Elizabeth  Taggart. 

Dill — Rice. — In  Greeley,  Colorado,  on  Thursdav,  June 
loth.  Dr.  Paul  Dill  and  Miss  Kathryn  Rice. 

Earnshaw — Tatnall. — In  Bryn  Maw  r,  Pennsylvania,  on 
Saturday.  June  12th.  Dr.  Henry  Gulp  Earnshaw"  and  Miss 
Rachel  Burroughs  Tatnall. 

Hastings — Morgan".—  In  Alton,  Illinois,  on  Tuesday, 
June  15th,  Dr.  James  B.  Hastings  and  ISIiss  Elizabeth  Xor- 
ris  Morgan. 

Hollingsworth — Robertson. — In  Spokane,  Washington, 
on  Thursday.  June  24th,  Dr.  Israel  Pemberton  Pleasants 
Hollingsworth,  of  Philadelphia,  and  Miss  Delphine  L. 
Robertson. 

;Mershon — Small. — In  Philadelphia,  on  Wednesday, 
April  28th.  Dr.  O.  F.  Mershon  and  Miss  Goldie  May 
Small. 

Reasoner — MiLNOR. — In  Litchfield,  Illinois,  on  Thursday, 
June  loth.  Lieutenant  Mathew  A.  Reasoner,  Medical  Corps, 
U.  S.  A.,  and  Miss  ^label  Sparks  Milnor. 

Weiss — Blau. — In  Xew  York,  on  Sunday,  June  20th,  Dr. 
Bernard  Weiss  and  Miss  Hermine  Blau. 

Died. 

Anderson. — In  Toronto.  Ontario.  Canada,  on  Tuesday, 
June  8th.  Dr.  J.  X.  Anderson,  aged  sixty-eight  years. 

Curtis. — In  Marietta.  Ohio,  on  Monday.  June  7th.  Dr. 
Harry  X.  Curtis,  aged  fifty-six  years. 

DisMUKES.- — In  Mayfield,  Kentucky,  on  Wednesday,  June 
i6th.  Dr.  John  L.  Dismukes.  Sr..  aged  seventy-nine  years. 

DuNX. — In  Dolgeville.  X'^ew  York,  on  Tuesdav,  June  8th, 
Dr.  E.  J.  Dunn. 

EvA.vs. — -In  Butte.  Montana,  on  Tuesday.  June  8th,  Dr. 
Richard  D.  Evans,  aged  fifty-three  years. 

Fergu-sox. — In  Boston,  on  Sunday,  June  13th,  Dr.  Hugh 
Ferguson,  aged  seventy-three  years. 

Guxther. — In  X'ew  York,  on  Saturday,  Jime  12th,  Dr. 
C.  E.  Gunther,  aged  forty-eight  years. 

Hughes. — In  MuFcogec,  Oklahoma,  on  Sunday.  June  6th, 
Dr.  Hugh  J.  Hughes. 

^Ieans. — In  Geneva.  X'ew  York,  on  Monday.  June  14th, 
Dr.  Georsje  Sherwood  Means,  aged  thirty-nine  years. 

I^IoFFETT. — In  West  Xew  York.  Xew  Jersey,  on  Saturday, 
June  I2th.  Dr.  Edmond  M.  Moffett.  aged  sixty-one  years. 

Paxton. — In  Lexington.  Virginia,  on  Saturday,  June  12th, 
Dr.  Horace  .\.  Paxton.  aged  sixty-six  years. 

Phillips. — In,  Fremont.  Ohio,  on  Saturday,  June  12th, 
Dr.  O.  E.  Phillips,  aged  seventy-three  years. 

SxYDER. — In  Sharpsburg,  Pennsylvania,  on  Wednesday, 
June  Qth,  Dr.  John  E.  Snyder. 

Steer. — In  St.  Louis.  Missouri,  on  Sunday,  June  20th.  Dr. 
Justin  Steer,  aged  sixty  years. 

Zufpppecht. — In  Dubuque.  Iowa,  on  Tuesday,  June  8th, 
Dr.  W.  G.  Zuepprecht,  aged  eighty-three  years. 


INDEX  TO  VOLUME  LXXXIX. 


PAOt. 

ABBOTT,  Alexander  C.  The  role  of  the 
Bureau  of  Health  in  public  vaccina- 
tion   97 

Abdomen,  behavior  of  lungs  and  heart  af- 
ter operations  on    766 

means  of  preventing  accident  of  leaving 

sponge   in    45 

penetrating    wounds    of  354,  521 

upper,   disease   of  1221 

incisions  for  operations  on   711 

mistakes  in  diagnosis  in  133^ 

Abdominal  aneurysm    405 

emergencies    295; 

myomectomy    352 

section,  factors  which  contribute  to  low 

mortality   12 19 

supporters  after   laparotomies   92 

tuberculosis,  acute  form  of   245 

surgical  types  of   1287 

Abnormities,  congenital    243 

Abortion  followed  by  infection  with  ba- 
cillus  aerogenes   capsul^tus   760 

vesicovaginal  fistula  following   157 

Abscess,    intrapelvic,    coeliotomy    and  col- 

potomy  in  treatment  of   44 

of   appendix,    treatment    of   133 

of    brain    976 

drainage  in    247 

of  Gartner's  canal   89 

of  spleen  after  epityphlitis   456 

otitic  brain    246 

subdiaphragmatic    90 

Abscesses,  fixation,  in  therapeutics   734 

new  methods  of  treatment  of   299 

of  breast   1065 

Academy  of  Medicine,  New  York,  synopsis 

of  two  years*  work  of   613 

Accidents,    first   aid   in   459 

Acetonuria  with  autointoxication  1303 

Achondroplasia,  clinical  picture  of   190 

Achromasia  in  leucocytes   351 

Achylia  gastrica  Z'crsus  insufficientia  pylori  502 
Acid,   free   hydrochloric,   in   gastric  juice, 

method  of  detecting   286 

in    stomach   1308 

lactic,  bacteria    710 

ferment  preparations    763 

therapy   307 

osmic,  in   trifacial  neuralgia   345 

thyminic,  in  treatment  of  gout   136 

Acidimeter    24 

Acidity  of  urine,  instrument  for  estima- 
tion of    24 

Acne,   hygiene   of    face    in   389 

vulgaris  and  its  treatment  by  vaccines.  .  919 

Acromegaly    453 

Adami,  J.  George.  Pathological  discovery 
and  its  bearing  upon  jireventive  medi- 
cine   c;68 

Addison's  disease    609 

Adenoids  and  nocturnal   incontinence.  ...  1069 
secretion  of  thyreoid  gland   in  relation 

to   1069 

sequelae   of    267 

Adenoma   of   cervix,    malignant   617 

Adenomyoma  of  uterus   349 

Adhesions,  peritoneal   1332 

Adulteration    of    food   613 

.Agglutination  of  paratyphus  bacilli  in  ty- 
phoid   352 

Air,  fresh,  in  treatment  of  disease   612 

hot,  in  treatment  of  purulent  inflamma- 
tions  1285 

open,  in  surgical  tuberculo.^is   50; 

passages,  upper,  methods  of  cocainizing  271 
x  ray  treatment  of  malignant  neo- 
plasms  of    921 

Albumin  in  urine,  quantitative  estimation 

of    y6i> 

Albuminuria,  alimentary    47.^ 

and  orthostatic  oliguria,  mechanism  of.  g-'i 
chronic  intermittent,  a  sequel  to  infec- 
tious diseases  of  kidney  1240 

Albumosuria,  clinical  significance  of   660 

Alcohol  and  other  medicines,  consumption 

of,  in  Massachusetts  General  Hospital  864 
in  internal  medicine,  therapeutic  use  of.  1052 
influence  of,  upon  the  hungry  organism.  85q 

injections  of  189,   249,  1236 

physiological   action  of,  and  therapeutic 

indications  for    473 

problem,   the  future  of  1 163 

therapeutic  use  of  854,  905,  957,  ios2 

Alcoholism    480 

immunity  of  Jewish   race  from   298 

treatment   of    769 

Allonhanic  acid    230 

Ally!  compounds,   or   the   ethereal    oil  of 

garlic   1043 

Allyn,  Herman  Ti.  The  diagnosis  of 
chronic  Bright's  disease  by  signs  other 
than  those  furnished  by  the  urine...  326 

.'\loin  or  guaiac  test  for  blood   451 

Almond  cakes  for  diabetics   286 


Page. 

Alopecia  of  dental  origin   558 

.\menorrhofa  mechanically  produced   870 

.\mes.  Dr.  .\zel,  a  biographical  sketch  of.  924 

.\mnesia  from  a  medical  standpoint   260 

".\mpoule"   or   "ampul"   773 

Aniyl  nitrite,  therapeutics  of   285 

Amyluria    379 

Anieinia  in  infancy,  subcutaneous  injections 

of  citrate  of  iron  in  treatment  of....  1225 

infantile   splenic    351 

of   uncinariasis   "SS 

severe,  diagnosis  and  treatment  of  1322 

surgical,   and   resuscitation  30,  817 

Anesthesia,  general,  ethyl  chloride  in....  500 

local,  in  general  surgery   459 

lumbar    816 

and    slumbering    I37 

spinal    459 

venous    868 

Anaesthetics  in  genera!  practice  1322 

local,  as  substitutes  for  cocaine   814 

.VuEesthetist,    the   professional   912 

.Vnaesthetization  of  eye  and  anne.xa   86 

of   middle   ear  1118 

.\naphr0di5iacs  in   gonorrhcea  iioi 

-\nastomosis,  arteriovenous,  as  a  cure  for 

thromboangitis  obliterans    917 

Anderson,   A.    M.     A   new   frontal  sinus 

punch    460 

Aneurysm,   abdominal    40; 

of  aorta  and  tabes  dorsalis,  relation  be- 
tween  1 022 

therapeutics  of    124 

of  hepatic   artery   713 

thoracic    424 

spontaneous   cure   of   868 

Angina,  diphtheritic,  treatment  of   701 

necrotic,  of  scarlet  fever  1055 

pectoris  and  overfeeding   573 

painless   and   painful  1164 

Anopheles  the  sole  carrier  of  malaria ....  1333 
Anthropology,   medical   importance   of  the 

study  of   1030 

Antibodies,  complement  binding,  in  tuber- 
culosis   41 

.Antiformin   in    demonstration   of  tubercle 

bacilli   1 117 

.Antigen   of   tuberculosis   402 

Antitoxine,     diphtheria,     and  tuberculous 

disease    251 

preparation  of   1233 

untoward  effects  of    240 

tetanus,   preparations  of  1-233 

Antivivisection  agitation  in  New  York....  756 

and  the  butcher's  art  "53 

movement,  a  counterblast  to   231 

.Antrum,  radical  operation  for  empyema  of.  128c 
Anuria,    pathogenesis    and    treatment  of, 

1 168,  1284 

-Aorta,  incompetency  of,  of  muscular  origin  242 

spontaneous  rupture  of   713 

Aphasia,  cortical  motor,  after  pneumonia.  .  1285 

Apoplexy,  cerebral,   hemiplegia   from   502 

-Appendectomy,    subserous    976 

Appendicitis,  aetiology   of   766 

chronic,  causing  chronic  diarrhcea   769 

complicating  pregnancy    890 

diagnosis  and  differential  diagnosis  of..  886 

diffuse  septic  peritonitis  caused  by   42 

intestinal  obstruction  following  operation 

for    560 

leucocytosis   in    296 

medical   treatment  of  493,  540 

necessity  for  second  operation  for   304 

nonoperative  treatment  of...  1097,  1148, 

1200,  1269 

retrocaecal,  and  the  cholecystic  syndrome.  io6q 

successful   medical   treatment   of   773 

treatment  of    885 

Appendicostomy  in  pernicious  anaemia.  .  .  .  303 

Appendix,  carcinoma  of  102  t 

cystic    dilatation    of   819 

preservation   of    248 

removal  of    660 

retrocaecal,  and  cholecy.stic  syndrome ...  1069 

treatment  of   abscess  of   133 

vermiform,  hernia  of   8ig 

a  rudimentary  organ  in  the  carnivora  936 

Argyrol   in   urethritis   610 

.Army  medical   service   17S 

officers'   endurance,   tests   of   23: 

.Arrhythmia,    cardiac    503 

Arsazetin,  injections  of,   followed  by  dis- 
ease of  01  tic  nerve   iii3 

.Arsenic  and  tuberculin,  intravenous  treat- 
ment with    402 

in  muscle  work  and  muscle  rest   299 

.Arteriosclerosis   656,  loio 

and  sexual  continence    298 

gastric   symptoms   in  1235 

gastrointestinal   disturbances  due  to....  657 

hydriatic    treatment   of   298 

nervous  disturbances  in   41 

of  uterus    43 


Pac-s. 

Arteriosclerosis,   pathogenesis  of    87 

sodium  silicate  in  treatment  of  iioi 

the  suprarenal  bodies  and  nephritis....  180 
therapeutic   management  of  1227 

Artery,   cerebral,    diseases   of   500 

hepatic,    aneurysm    of   713 

iliac,  removal   of  embolus  from  Iii3 

Arthritis  deformans    187 

treatment  of   1272 

Arthropathia  psoriatica    401 

Ashmead,   Albert   S.     Fish   contagion  in 

leprosy    409 

Asiphyl    177 

Asphyxia  neonatorum,   treatment  of... 26, 

70,  120,  174 

Association,  American  Hospital   254 

Assyrians,  medicine  among,  in  1300  B.  C.  403 

Asthma    187 

bronchial,    treatment    of   86 

causes  and  treatment  of   348 

nasal  disease    380 

nervous   bronchial    974 

rhinological  causes   of   1164 

treatment  of    73 

Atheroma,  decalcifying  regime  in   40 

experimental    and    spontaneous   352 

Athletics   and   mentality   703 

Atoxyl    456 

and  arsenic  in  treatment  of  pellagra...  610 
mercuric    iodide    for   hypodermic  injec- 
tions   389 

.Atropine    as  a   hemostatic   564 

Attix,  J.  C.    A  consideration  of  poisons.  .  904 

Auricle,  synergy  and  asynergy  of   714 

Autodigestion,  resistance  of  stomach  to...  297 
Autointoxication   with   acetonuria   and  ex- 
treme  bradycardia   1303 

Autoprotective   mechanism   of   the  human 

body   361,  431 

Autoserotherapy  in  serofibrinous  pleuritis.  456 
Axis  cylinder,  clefts  of   981 

DACILLI,    paratyphus,   agglutination  of, 

in   typhoid    352 

tubercle,  human  and  bovine,  intertrans- 

missibility  of    708 

in  New  York  City  milk   709 

Bacilluria,    typhoid   .1119 

Bacillus    aerogenes    capsulatus,  infection 

with,    following    abortion   760 

Bordet's,  of  whooping  cough   457 

colon,  a  cause  of  purpura  haemorrhagica  658 

of  epidemic   diarrhoea   399 

typhosus,    infection    by   762 

Backache  in   Pott's  disease  1280 

Bacteria  in  the  body,  persistence  of   39 

lactic  acid,  reports  of  cases  treated  with 

culture  of    710 

living,    immunization   with   806 

radium    in    relation    to  I2,j8 

Bacterial  antiferments  and  bacteriolysis. .  1324 
Bacteriolysis  and  bacterial  antiferments.  .  1324 

Balanitis,   erosive   and   gangrenous  1021 

Baldness   1298 

Bandage,    new   method   of  applying   194 

Baptist,  H.  L.  Treatment  of  acute  dys- 
entery   700 

Barclay,    W.    F.     Treatment    of  chronic 

eczema    336 

Bartholow,    Paul.     The    allyl  compounds, 

or  the  ethereal  oil   of  garlic  1043 

Basch,  Seymour.  Indications  for  the 
drinking  of  mineral  waters  in  gastro- 
intestinal   disorders    486 

Bassler,  .Anthony.     The  common  forms  of 

gastroenteritic   neuroses    384 

Bathing   without   water  127.15 

Baths  and  exercise  in  treatment  of  ab- 
normal tone  of  bloodvessels  and  heart  242 

hot  and  cold,  size  of  heart  in   506 

Bauer,  F.  M.    The  sting  of  bees  as  a  cure 

for  rheumatism    876 

Bauer's  modification  of  technique  of  Was- 

sermann   reaction    505 

Baum,    Joseph.      Treatment    of  asphyxia 

neonatorum    122 

Beardsley,    E.   J.    G.     The  genitourinary 

complications   of   typhoid   fever   372 

Beck,  Carl.  External  Rontgcn  treatment 
of     internal     structures  (eventration 

treatment)    621 

Beck,  Emil  G.  Toxic  effects  from  bis- 
muth   subnitrate    16 

Bee  stings,  a  cure  for  rheumatism   S76 

in  therapeutics    703 

Behring's   antidiphthcritic   serum   921 

Bellevue  Hospital  nomenclature  of  dis- 
eases and   conditions  1016,  1061, 

1 108,  1 1 59 

Benjamin,  A.  E.     Chronic  dilatation  and 

prolapse  of  stomach   745 

Benzoates  in  food  injurious  to  health....  83 
Beriberi,  aetiology  of   504 


1338  INDEX  TO  VOLUME  LXXXIX. 


Page. 

Bernstein,  E.  P.,  and  Fried,  G.  A. 
Tuberculosis    without    tubercle  bacilli 

in  the  blood  1097 

Berry,  John  M.  Practical  lessons  from  a 
study  of  two  hundred  cases  of  weak- 
ened  feet   1265 

Bile  duct,  common,  cysts  of   818 

in  urine,  test  for  286,  445 

passages  and  stomach,  fistula  between. .  1068 

surgery   of    70S 

tracts,  new  incision  to  reach  1331 

Bilharziosis.  skin  infection  theory  of   814 

15iorontgenogra|>hy    611 

Birth  mark,   so  called   334 

Bismuth  paste  in  suppuration  of  ear,  nose, 

and  throat    132 

poisoning   iiiS 

subnitrate,  toxic  effects  from   16 

Blackwell,  H.  B.  Otitic  significance  of 
tonsillectomy  with  reference  to  digital 

enucltrtion   T089 

Bladder   and   urethra,   common    errors  ir-. 

tieatment    895 

diseases  of  musculature  of   662 

exstrophy  of    61; 

implantation    of   carcinoma   of   C61 

injuries  to,  during  operation  for  hernia  91 

Blake,  James,  biographical  sketch  of   11  i 

Blastomycosis  of  s-kin   922 

Blindness,   hysterical      916 

of  newborn   982,   986,   988,  991 

Blood,  aloin  or  guaiac  test  for   .  451 

circulating,  tubercle  bacilli  in  1250 

crisis   455 

diseases    and    digestive    tract,  relations 

between    768 

examination  of,  in  surgical  diagnosis. .  299 
factors  influencing  clotting  time   of....  768 

flow  in  arm,   rate   of  1232 

in  faeces,  clinical  demonstration  of   714 

in   rickets   1024 

pressure  and  life  insurance  853,  1040 

arterial,   variations   of  1328 

auscultatory   measurement   of  1118 

in   diagnosis  of  preeclamptic  toxaemia  714 

lowering   of,    by   nitrites  1227 

measurements  of    66:; 

study   of,    after    splenectomy   865 

transfusion  of  242,  662,  767,  1164 

tubercle  bacilli  in   1097 

vessels,  anomalous  renal,  relation  to  hy- 
dronephrosis of    969 

baths  and  exercise  in  treatment  of  ab- 
normal  tone   of   242 

plastic    surgery    of   767 

Bloodletting,    decay   of  .•   7x5 

Boards,    State   licensing   76 

Boas's    treatment    of   haemorrhoids  1103 

Bodies,  foreign,  in  frontal  sinus   974 

immune,  treatment  with   559 

parathyreoid,   and    tetany   44b 

Body,  amount  of  fluid  required  by  1023 

human,  autoprotective  mechanism  of  361,  431 

weight  in  relation  to  tuberculosis   348 

Boggs,  Russell  H.    The  value  of  Rontgen 

rays  in  thoracic  lesions   941 

Boldt,  H.  J.  Some  drugs  that  may  be 
used  with  benefit  to  gynjecologica!  pa- 
tients   368 

Bonain's  local  anaesthetic   545 

Bone,  disease  of   87 

marrow,  lymph   follicles  in   766 

syphilitic    hyperplasia    of   300 

Bonnar.  John  D.     The  therapeutic  use  of 

alcohol    959 

BOOK  NOTICES: 

Abderhalden.  Emi!.    Lehrbuch  der  phys- 

iologischen  Chemie    617 

Textbook   of    Physiological    Chemistry  72) 

Abel,  R.,  und  -Ficker.  M.  Einfache 
Hiilfsmittel  zur  Ausfiihrung  bakterio- 
logischer   Untersuchungen    566 

Aichel,  Otto.  Einc  neue  Hypothesc 
iiber  Ursachen  und  Wesen  bosartiger 
Ge«chwiilste    619 

Bandclier  and  Roepke.  Lehrbuch  der 
spezifischen  Diagnostik  und  Therapie 
der  Tuberkulosc    619 

Eateson.  \V.  The  Methods  and  Scope 
of    Genetics   124T 

Bicganski.  W.     Medizinische  Logik....  667 

Bockenhcimer,  Ph.  Atlas  of  Clinical 
Surgery    410 

Brickner,  Walter  M.,  and  Moschcowitz, 
Eli.  Seven  Hundred  Surgical  Sug- 
gestions   618 

Brnadbent.  Sir  William.  Selections 
from  Writings,  Medical  and  Neuro- 
loK-cal    143 

Brubakcr,  Albert  P.  A  Textbook  of 
Human    Physiology    774 

Brunton.  Lauder.  Therapeutics  of  the 
Circulation    94 

Butler.  George  F.     The  Exploits  of  a 

Physician   Detective    411 

A  Trxtbook  of  Materia  Medica  and 
Therapeutics   1241 


Page. 

BOOK  NOTICES: 

Camac,  C.  N.  B.  Epoch  Making  Con- 
tributions to  Medicine,  Surgery,  and 
the  Allied   Sciences  1170 

Carnot,  P.,  etc.  Physiotherapie,  Kine- 
sitherapie    930 

Casper,  Leopold.  A  Textbook  on  Gen- 
itourinary  Diseases    774 

Clark,     L.    Pierce.      Neurological  and 

Mental   Diagnosis    358 

Coakley.  Cornelius  Godfrey.  A  Manual 
of  Diseases  of  Nose  and  Throat....  462 

Conheim,  Paul.  Die  Krankheiten,  des 
Verdauungskanals   1334 

Cramer,  Friedrich.  Chronischer  Magen- 
katarrh    47 

Crichton  Browne,  Sir  James.  Parsi- 
mony in  Nutrition   977 

Cutten,  George  Barton.  The  Psycho- 
logical Phenomena  of  Christianity....  823 

Da  Costa,  John  C,  Jr.  Principles  and 
Practice   of   Physical   Diagnosis  1026 

Dahlstroem,  Anna.  Anatomische  Veran- 
derungen  in  vier  wegen  Drucksteige- 
rung  enukleierten  Augen  mit  Netz- 
hauthamorrhagieen    462 

Dana,  Charles  L.  Textbook  of  Nervous 
Diseases  and  Psychiatry   47 

Davis,  Edward  P.  Obstetrical  and 
Gynecological  Nursing    142 

Dearborn,  George  V.  N.  A  Textbook 
of  Human  Physiology   6:7 

De  Lee,  Joseph  B.  Obstetrics  for 
Nurses    197 

Dickson,  W.  E.  Carnegie.  The  Bone 
Marrow    564 

Dieudonne,  A.  Bacterial  Food  Poison- 
ing 1333 

Douglas.  Richard.  Surgical  Diseases  of 
the  Abdomen    877 

Edmunds.  Arthur.  Glandular  Enlarge- 
ment and  Other  Diseases  of  the  Lym- 
I)hatic   System    357 

Ehrlich.  Paul.  Experimental  Researches 
on    Specific   Therapeutics   512 

Elliott,  J.  F.     Hints  to  Ships'  Surgeons  774 

Findlay,  Palmer.    Gonorrha;a  in  Women  774 

Fisher,  Theodore.  The  Heart  and  Sud- 
den Death   512 

Fordyce,  John  A.  Transactions  of 
Sixth    Dermatological    Congress   512 

Gant.  Samuel  Goodwin.  Constipation 
and  Intestinal  Obstruction  (Obstipa- 
tion)  1170 

Gaskell.  Walter  Holbrook.  The  Origin 
of   Vertebrates    565 

Gierlich,  Nikolaiis,  and  Friedmann,  M. 
Studies    in    Paranoia   824 

Gordon,  Alfred.  Diseases  of  the  Ner- 
vous   System   462 

Gottschalk.    Sigmund.     Gynakologie.  . .  .  877 

Groves.  Ernest  W.  Hey.  A  Synopsis 
of  Surgery    618 

Haab.  O.  Atlas  and  Emtome  of  Oph- 
thalmoscopy     and  Ophthalmoscopic 

Diagnosis   1170 

Atlas  of  External  Diseases  of  the  Eye  1289 

Hardesty.  Irving.  A  Laboratory  Guide 
for  Histology    142 

Harte.  Richard  H.  Transactions  of 
-American  Surgical  Association   5 '3 

Herbert,  H.     Cataract  Extraction   30s 

Herter,  C.  A.  On  Infantilism  from 
Chronic  Intestinal   Infection   721 

Hill,  Alex.     The  Body  at  Work  1072 

Hiss,    A.    Emil,    and    Ebert,    Albert  E. 
The  New  Standard  Formulary.  Vol- 
ume   I    824 

Holland,    James    W.      h    Textbook  of 
Medical    Chemistry    and   Toxicology..  824 
The  Urine  and  Clinical  Chemistry  of 
the   Gastric   Contents,   the  Common 
Poisons,   and  Milk   878 

Hoor,  Karl.  Die  Parenchymatose  Horn- 
hautentziindung   1122 

Janselme.  E.     Maladies  des  reins.   775 

Jessner,  .S.    Diagnose  und  Therapie  der 

Gonorrhea   beim   Manne  94 

Diagnose  und  Therapie  der  Syphilide.  1 122 
Diagnosis  und  Therapie  des  Rkzems.  .  878 

Jordan.  Edwin  O.  Textbook  of  General 
Bacteriology    409 

Kanasugi,  H.  E.  Beitrage  zur  topo- 
graphisch-chirurgischen  .Xnatomie  der 
Pars  mastoidea    94 

Ken.  William  Williams,  and  Da  Costa, 
lohn  Chalmers.     Surgery   I97 

Kerr.  Le  Grand.  The  Baby,  Its  Care, 
and   Development    4ti 

King,  Willis  P.     Stories  of  a  Country 

Doctor    '97 

Knortz.  Karl.     Der  menschliche  Korper 

in   Sage,   Brauch  und   Snrichwort .  .  .  .  877 
Kollmann,    Prof.    Dr..   und   Jacoby.  S. 
Tahresbcricht  iiber  die  I.eistungin  und 
Fortschrittc  auf  dcm  Gcbietc  der  Er- 
krankungen  des  Urogcnitalapparates.  .  198 


Pag^:. 

BOOK  NOTICES: 

Kopetzky,   Samuel  J.     The   Surgery  of 

the  Ear    143 

Latham,  Arthur.  A  Dictionary  of  Medi- 
cal  Treatment    721 

Lazarus-Barlow,  W.  S.    Archives  of  the 

Middlesex  Hospital.     Volume  xii....  411 
Le  Dentu  et  Delbert.    Nouveau  traite  de 

chirurgie    877 

Le  Mehaute,  G.  L'Eau  de  mer  en  in- 
jections hypertoniques  dans  le  traite- 

ment  des  maladies  chroniques   60S 

Liebe,  Georg.  Vorlesungen  iiber  Tuber- 
kulosc   9_>9 

Lockard,    Lorenzo    B.     Tuberculosis  of 

Nose   and  Throat  1122 

McGuire,  Stuart.  Lectures  on  Prin- 
ciples of  Surgery   46 

Mclsaac,  Isabel.  Hygiene  for  Nurses.  .  46 
Macllwaine,    Sydney.      The    Future  of 

Medicine    663 

Mallory,  Frank  Burr,  and  Wright, 
James  Homer.  Pathological  Tech- 
nique  357 

Maugerot,      Reine.  Cholecysto-pancre- 

atite,  essai  de  pathogenic   410 

Meierowsky,  E.  Ueber  den  Ursprung  des 
melanotischen  Pigments  der  Haut  und 

des  Auges    463. 

Merzbach,  Georg.    Die  krankhaften  Er- 

scheinungen   des   Geschlechtssinnes.  .  .  46 
Metchinkoff,  etc.     Bacteriotherapie,  Vac- 
cination,  Serotherapie    461 

Miller,  Charles  C.    The  Cure  of  Rupture 

by  Paraffin  Injections   358^ 

Minot,  Charles  S.    The  Problem  of  Age, 

Growth,   and   Death   35/ 

Moulton,  Charles  Wells.    The  Doctor  in 

Art    94 

Moure,  E.  J.    Disease  of  Pharynx  and 

Larynx   1241 

Neef,  Frederick  Emil.    Practical  Points 

in  Anaesthesia    463 

Nicoladoni,  Carl.     Anatomic  und  Mecli- 

anismus  der  Skoliose   929. 

Nuttal,  George  H.  F.     Ticks   721 

Onodi,  A.     Das  Gehirn  und  die  Nebcn- 

holen  der  Nase   yi-r 

Oppenheim,  H.,   and  Cassirer,  R.  Der 

Hirnabszess    929. 

Osier,     William.       Modern  Medicine. 

Volume  V   197 

Pattee,  Alida  Frances.  Practical  Di- 
etetics  1026 

Phillips,  R.  J.  Spectacles  and  Eye- 
glasses  252- 

Pick,    Alois.     Klinische    Semiotik   462 

Poisot,  Marcel.     Les  Erythemes  graves.  253. 
Preiswerk,  Gustav.    Lehrbuch  und  -Vtlas 
der  Zahnheilkunde  mit  Einschluss  der 

Mundkrankheiten    56<i 

Prince,  Morton.     The  Dissociation  of  a 

Personality   •  198- 

Puppe,    George.     Atlas   und  Grundriss 

der   gerichtlichen   Medizin   410 

Quain's  Elements  of  Anatomy   977 

Report  from  Pathological  Department, 
Central  Indiana  Hospital  for  the  In- 
sane   5'.T 

Rey,  Germain.  Traite  methodique  et 
clinique    des    maladies    de  I'appareil 

respiratoire   1289 

Ricketts.  Benjamin  Merrill.    Surgery  of 

the   Ureter    47 

Riecke,   Erhard.     Lehrbuch   der  Haut- 

und  Geschlechts-Krankheiten    720' 

Robinson.  Byron.  The^  Arteries  of  the 
Gastrointestinal  Tract,  with  Inoscula- 
tion Circle    667 

Ross,  Ronald.  Report  on  the  Preven- 
tion of  Malaria  in  Mauritius   303 

Sawyer,  James.     Points  of   Practice  in 

Maladies  of  the  Heart   305 

Scliamberg.    Frank.      Diseases    of  the 

Skin   and  the   Eruptive   Fevers   02 

Schnirer,     M.     T.      Taschenbuch  der 

Therapie    877 

Schultze.  Bernhard  Sigmund.  Lehrbuch 

der  Hebammenkunst   .1241 

Schultze,  Oskar.  Atlas  und  Grundriss 
der  topographischen  und  angewandten 

Anatomic    929 

Senator.  H.,  and  Kaminer,  S.  Marriage 

and  Disease   1122 

Shoemaker,  William  T.  Retinitis  Pig- 
mentosa   

Sluss,  Tohn  W.  Emergency  Surgery...  357 
Sommer.    H.    J.,    Jr.      Index    of  1,180 

Postmortems  of  the  Insane   4'' 

Stitt.  E.   R.     Practical  Bacteriology  878 

Sturmer,  Tulius  William.    Rudiments  of 

I^tin  ."  ; 

Sutherland.  T.   A.     A  System  of  Diet 

and  Dietetics   '334 

Taber.    Clarence   W.     Pocket  Encyclo- 

n.Tdic  Medical  Dictionary   S'2 

Tavlor.  Henry  Ling.  Orthopsdic  Sur- 
gery for  Practitioners   610 


INDEX  TO  VOLUME  LXXXIX. 


1339 


Page. 

eOOK  NOTICES: 

Todd,  James  Campbell.  A  Manual  of 
Clinical  Diagnosis    305 

Transactions  of  the  American  Gynasco- 
logical    Society    977 

Transactions  of  the  American  Surgical 
Association    513 

Transactions  of  the  Sixth  International 
Dermatological  Congress    512 

Transactions  of  the  Society  of  Tropical 
Medicine  and  Hygiene   252 

Transactions  of  the  Thirtieth  Annual 
Meeting  of  the  American  Laryngo- 
logical  Association    566 

Tweedy.  E.  Hastings.  Rotunda  Practi- 
cal Midwifery    977 

Vaudet,  Paul.  Technique  precis  de  ra- 
diotherapie  et  de  radioscopie   306 

Von  Baumgarten,  P.  Jahresbericht  iiber 
die  Fortschritte  in  der  Lehre  von  den 
pathogenen  Mikroorganismen    411 

Von  Leube,  Wilhelm.  Spezielle  Diag- 
nose der  inneren   Krankheiten   306 

\'on  Linne,  Carl.     Bref  och  Skrifvelser  667 

V'on  Schrotter,  Hermann.  Klinik  der 
Bronchoscopie    410 

Walker,  J.  \V.  Thomson.  Estimation  of 
the  Renal  Function  in  Urinary  Sur- 
gery   47 

Ward,  Robert  De  Courcy.  Climate 
Considered  Especially  in  Relation  to 
Man    143 

AVatson,  Francis  S.  Diseases  and  Sur- 
gery of  the  Genitourinary  System....  92 

Wells,  H.  G.     Tono-Bungay   807 

Westall.  Laura  M.  A  Common  Sense 
View  of  the  Mind  Cure   252 

Whipple.  George  C.     Typhoid  Fever...  252 

AVilliams.  Herbert  U.  A  Manual  of 
Bacteriology    618 

Woolsey,  George.  Applied  Surgical 
Anatomy    617 

Ziegler,   Ernst.     General  Pathology...,  461 

Bopp,  Walter  F.     Treatment  of  asphy.xia 

neonatorum    122 

Bordet's  bacillus  of  whooping  cough....  457 

Bottle   stoppers,   stuck,   how   to   remove.  .  95 

Bowel   and  appendix,  carcinoma  of  lo^i 

resection  of    304 

Bowels,  obstruction  of   353 

Braddock,  Charles  S.     Tropical  malaria ..  1 143 

Bradley,  William  N.  Congenital  heart  dis- 
ease  1302 

Congenital  hypertrophic  stenosis  of  py- 
lorus  .   33_- 

Brady,  William.  Therapeutic  use  of  al- 
cohol   8s  s 

Bradycardia  and  the  Stokes-Adams  com- 
plex   921 

in  autointoxication   1303 

Brain    abscess    976 

drainage  in   2.J7 

otitic    246 

acusticus  tumor  at  base  of   189 

fag,    formula   for   177 

injury   of   11 18 

lesions  complicating  otitis  media   792 

puncture  of    611 

Brandy,  introduction  of,  into  Greece,  by 

physicians    46 

Branth,  John  Herman.  Treatinent  of  neu- 
rasthenia by  static  electricity   114 

Braude,  M.    Early  diagnosis  of  pulmonary 

tuberculous  disease   1312 

Brav.  Aaron.  Discoloration  of  conjunc- 
tiva from  an  indelible  pencil   2\ 

Breast,    abscesses   of  1065 

borderline    tumors   of   81 S 

cancer  of   413,  716 

in  men    392 

tuberculosis   of    502 

Brickner,  Samuel  M.    Vesicovaginal  fistula 

following   abortion    157 

Bright's  disease,  decapsulation  of  kidneys 

for    18s 

dechlorization   treatment  in  n68 

Bromide  eruption  in  childhood   586 

Bromides,  injections  of,  for  puerperal  ec- 
lampsia   338 

Bromoform    eruption,    a   case    of  ii45 

Bronchitis  in  children,  treatment  of   753 

Bronchocesophagoscopy,       diagnosis  and 

treatment  by    29.^ 

Bronchopneumonia,     Heubner's  mustard 

treatment  of    389 

in  children,   treatment  of   753 

Brovalol    230 

Brown,  .Arthur  Erwin.     The  life  and  the 

work  of  Darwin   517 

Bryant.  Jose'^h  D.  Address  at  the  Tuber- 
culosis Exhibition   ■. . . .  257 

Bryant,  W.  Sohier.  Preventive  and  abor- 
tive treatment   of  mastoiditis   222 

Bull.  Charles  Stedman.  Onhthslmia  neo- 
natorum and  its  prophylaxis  from  the 
standpoint  of  the  ophthalmologist....  082 

Bursaf   cnbdeltoid.    inflammation   of   352 

Butler.  William  J.     The  serum  diagnosis 

of  syphilis  and  its  clinical  value....  207 


Page. 

/CACHEXIA  reaction  in  cancer  patients.  299 

^    Cactus  pavimeiitarius  caninus   289 

Ca:costoniy  and  coloclysis  in  general  peri- 
tonitis  I  "3 

Caecum,    resection   of   1282 

Csesarean   section   90,   686,  690 

elective   303,  656 

Porro    303 

Caisson   disease   1321 

Calcium  chloride  in  seasickness   299 

creosote  in  treatment  of  typhoid  fever.  .  64<J 

in    the   treatment   of   disease  1170 

lactate  in  treatment  of  epilepsj' . .  1 1  o  i ,  1167 

salts,    therapeutic   action   of  546,  1054 

use  of    398 

Calculus,  renal,  diagnosis  and  treatment  of  1330 

salivary    375 

ureteral    50S 

Calhoun,  F.  Phinizy.    Results  in  four  hun- 
dred operative  cases  of  mastoiditis.  .  314 
Calmette  ophthalmic  reaction  to  tuberculin 

in  the   diagnosis  of  tuberculosis   377 

Calomel  as  a  cathartic,  administration  of  229 
Cammidge  reaction  in  diseases  of  pancreas  812 

in    experimental   pancreatitis   822 

Camphosan   230 

Canal,  digestive,   ferments  of   85 

Gartner's,  abscess  of   89 

hepatic,    drainage    of   765 

Zone,   health   of,   during    1908   878 

Canals,  semicircular,  and  vestibule,  func- 
tions of  end  organs  in   761 

Cancer,  .etiology  of,  and  the  x  ray   710 

affiliation  of,  w-ith  fundamental  theories 

of    heredity    673 

cachexia    reaction    in   299 

caused  by  .x  rays   764 

cocaine  in    399 

fulguration   treatment   of   963 

historical  and  critical  studies  in   251 

hypochlorites   in    399 

injections  of  mercury,  arsenic,  and  iron 

in    treatment    of   425 

laryngotomy   and   laryngectomy   for....  293 

nature    and    treatment    of   659 

of  breast    716 

of  cer\i.x  complicating  pregnancy  1163 

of    cervi.x    uteri,    Wertheim's  operation 

for   1112 

of  parotid  gland   406 

of  tongue   247,  922 

of   uterus   500 

present  means  of  lessening  the  mortal- 
ity from    606 

Research  Fund,   Imperial,   work  of....  973 

resistance  of  human  body  to  ii6j 

serum    reaction    in   251 

specific  problems  of,  affiliation  of,  with 

specific  problems  of  heredity   S29 

treatment   of,   by   fulguration   765 

trypsin  treatment  of  1023 

Capsules,  suprarenal,  and  sexual  character- 
istics, correlation  between    456 

Carbonic  acid  snow,  therapeutic  use  of.  .  866 

Carcinoma  and  the  leucocytes   494 

and  nephroma,  simultaneous  occurrence 

of   154 

caused  by  the  x  ray   66 r 

gastric,   early   diagnosis  of   767 

implantation,    of   bladder   661 

infective   origin   of  1323 

nature  of    767 

of  body  of  uterus  in  virgins   713 

of  bowel   and   appendix  1021 

of  cervix,  vaginal  hysterectomy  for  405 

of  skin,  superficial   506 

of  stomach,  Salomon  test  in  ■2~3 

X  rays  in  diagnosis  of   606 

primary,    of   liver  11 63 

Cardiac   arrhythmia    505 

Cardiovascular    diseases    242 

Carlisle.  Robert  J. :  Coleman,  Warren : 
Smith.  Thomas  A.,  and  Dow,  Edmund 
L.  The  Bellevue  Hospital  nomencla- 
ture of  diseases  and  conditions 

1108,  1016,  1061,  1159 

Carotid  gland,  perithelioma  of   55; 

Carr,   W.   P.     The  surgical  treatment  of 

epilepsy    788 

Carrington,  P.  M.  Economic  housing  of 
consumptives,  with   especial  reference 

to  the  Southwest    727 

The    Marine    Hospital    Sanatorium  for 
Tuberculosis  at  Fort  Stanton,  N.  M.  417 
Carson.  Hampton  L.    The  legal  aspects  of 

vaccination    106 

Cartilage  of  nose,  submucous  resection  of.  1260 
Castelli.    E.     Technique    of  Wassermann 

reaction    777 

Castoreum  bromide    598 

Castration  and  hj'sterectomy,  influence  of  61 1 

Cataphoresis.    radium    506 

Cataract,  incipient,  spontaneous  absorption 

of    69 

technique  of  extraction  of   230 

Cathartic,  administration  of  calomel  as  a.  229 
Cavities,  oral  and  nasal,  in  relation  to  skin 

diseases    46.=) 

Cellasin    598 


Page. 

Cells,  clear  hepatic   456 

Censorship,  medical,  for  the  lay  press....  470 
Cerebral    circulation,     clinical  manifesta- 
tions  of   disorders   of   972 

disorders  of    867 

lesions   complicating   otitis   media   792 

Cerebrum,  surgery  of    185 

Cerolin    598 

Cervical   ribs   299 

triangles,  surgery   of   562 

Cervix,  malignant  adenoma  of   617 

repair   of   lacerations   of,    during  puer- 
peral convalescence    153 

uteri,  myoma  of    90 

Chalazion    85 

Chancre,  excision  of    579 

Chest,  the  typical  tuberculous  1280 

Childbirth,  retroversion  of  uterus  after.'.  616 
Children,    abnormal,    cerebral  physiology 

and  education  of    923 

care  of,  by  the  State  of  New  York..  282 

diseases  of   1223 

field  for  prophylaxis  among  1223 

physical  training  of    239 

streptococci  in  diseases  of  1117 

Chimaphila  in  diabetes   444,  1147 

Chloroform  in  haemoptysis  1280 

Chlorosis,    iron    in   177 

Choledochus    and    hepatic    ducts,  surgery 

of    548 

Cholelithiasis,  surgical  treatment  of   88 

Cholera,  Asiatic   12,  561 

bacteriologj-   of    561 

in  relation  to  commerce   561 

Chorea  of  Sydenham,  treatment  of   85 

Chromocystoscopy  in  functional  renal  di- 
agnosis   617 

Church,  C.  Herbert.  Nonoperative  treat- 
ment of  appendicitis  1270 

Circulation,  artificially  diminished,  narcosis 

caused  by    87 

cerebral,  clinical  manifestations  of  dis- 
orders of   J   972 

disorders  of    8()7 

of  lobar  ganglia   1021 

Circumcision   of   infants   352 

Citrates,    therapeutics    of  1054 

Clark.  Franklin  C.    Treatment  of  chronic 

eczema    284 

Clary,  W.  A.     Nonoperative  treatment  of 

appendicitis   1201 

Classification,   international,    of   causes  of 

death   1316 

Clay,  T.  A.  Treatment  of  asphyxia  neo- 
natorum   121 

Cleborne,  Alan  Bellingham.  Nonoperative 

treatment  of  appendicitis   1200 

Climates,  Alpine,  in  tuberculosis   348 

for   consumptives    542 

hot,   and  long  life   800 

Clinics,  night,  in  Brooklyn  1122 

Clothier,  Joseph  V.    Neuroretinitis  due  to 

typhoid  fever    748 

Cobb,  J.  C.     Baldness  1298 

Cocaine-adrenalin    solutions,  physiological 

action    of   271,  398,  814 

Codex,  the  new  French  iioz 

Coeliotomy  and  colpotomy  in  treatment  of 

intrapelvic   abscess    44 

Coflfee,  effects  of   1065 

Cold,  common    754 

aetiology  of    347 

Coleman,  Warren;  Carlisle,  Robert  J.; 
Smith.  Thomas  A.,  and  Dow,  Edmund 
L.  The  Bellevue  Hospital  nomencla- 
ture of  diseases  and  conditions 

1016,   1061,   1108,  1159 
Coley's  fluid,  injections  of,   in  treatment 

of  tumor   1239 

Colitis,  surgery  of   247 

ulcerative,  nature  and  treatment  of....  813 
Collargol.    action   of,    upon   opsonins  and 

leucocytes    661 

Colles's  fracture   1333 

Colon  bacillus  a  cause  of  purpura  haemor- 

rhagica    658 

sigmoid,    intestinal,    obstruction   due  to 

adhesions  of    560 

Colpotomy  and  coeliotomy  in  treatment  of 

intrapelvic  abscess    44 

Combustion,    spontaneous   782,  843 

Complement  binding  antibodies  in  tuber- 
culosis   41 

Concrenients,  formation  of   401 

Condurango   and   kawar   229 

Conjunctiva,  discoloration  of,  from  an  in- 
delible pencil    24 

Conjunctivoma,   the  pure   136 

Consciousness,  the  seat  of   819 

Constioation,   chronic,  treatment  of  not 

habitual,  a  cause  of  death  in  infancy.  . .  .  920 
Constitutional   conditions,    relation    of,  to 

local  lesions   .   612 

Consumptives,  classification  of   731 

climates  for    54a 

economic  housing  of.  with  especial  ref- 
erence to  the   Southwest   727 

Continence,  sexual,  and  arteriosclerosis..  298 
Contract  practice    407 


1340 


INDEX  TO  VOLUME  LXXXIX. 


Page. 

Contracture,   Dupuytren's,  of  fingers   457 

Contractures    ^43 

cicatricial   palatopharyngeal    243 

Cooke,  Charles  O.  Ajjpendicitis  complicat- 
ing pregnancy    Sgu 

Cord,  spinal,  syphilitic  disease  of   501 

Cornwall,  Edward  E.  Jlalignant  endocar- 
ditis without   fever  126S 

Correction    ii/i 

CORRESPONDENCE : 

Letter  from  London,  28,  123,  227,  337,  442, 
544,  646,  ys-.  **56.  960,   1053,   1150,  1271 

Letter    from    Montreal   175 

Letter    from    New    Haven  1099 

Letter  from  Toronto   go'S 

Letter   from    Winnipeg   647 

Coryza,  acute,  treatment  of  1202,  1272 

Cough  of  phthsis,  remedy  for  vomiting  of  641; 
Crstagus   oxycanthus,   clinical    results  ob- 
tained  by   122S 

Cramp,  writer's,  aetiology  and  treatment  of  505 

Cranium,   surgery  of  1234 

Creosote  treatment  of  pulmonary  tubercu- 
losis   177 

Cretinism,  a  curable  condition  1221 

Crispin,  Antonio  M.     The  individual  as  a 

surgical  factor   99-' 

Croftan,  Alfred  C.  Alimentary  albumi- 
nuria  •  •  ■  ■  :  •  474 

Increased  urinary  calcium   excretion  in 

tuberculosis  1182 

Crotalus  venom,   hemolytic  action   of,  on 

human  erythrocytes   1231 

Crothers,  Bronson,  and  Morse,  John 
Lovett.  The  urine  in  diseases  of  in- 
fancy   524 

Cumston,     Charles     Greene.  Benjamin 

PranUlin   from  the  medical  viewpoint  3 
Epiploitis  following  the  radical  cure  of 

inguinal   hernia    270 

Curds  in  infants'  stools,  composition  of..  131 

Curettage  for  uterine   hemorrhage  1219 

Curette,  use   and  abuse  of...   38 

Currents,  high  frequency,  in  tabes  dorsalis, 

233,  249 

in  treatment  of  enlarged  thyreoid.... 

in  treatment  of  glandular  tumors....  138 

Curvature  of  knee,  unusual  case  of   401 

Cyanide  fumes,  effect  of   54^ 

Cylindruria   1168 

Cyst,   dermoid,   of   kidney   302 

formations,   cutaneous   1125 

of  common   bile   duct  •  818 

Cystectomy   followed  by  haemorrhage   559 

Cysticercus,    treatment    of,    with  ethereal 

extract  of  filix  mas   249 

Cystitis   244 

Cystocele,  accidents  and  complications  of  390 
Cystoma,  ovarian,  complicating  pregnancy  90 
Cystoscope,  new,  for  eatheterizing  ureters  560 
Cysts,   congenital   mesenteric  1325 

D.ACRYOCYSTITIS  1084 
Daland,  Judson.    .Angina  pectoris  and 

overfeeding    57.t 

Dante  as  a  physician   755 

Danziger,  Ernst.  Indications  for  opera- 
tion  in   acute  mastoiditis  1300 

Darwin,  life  and  work  of   517 

Davison,   Robert   E.     Salivary  calculi....  375 

Dead,   disposal   of,   at   sea   601 

Deafness  following  febrile  diseases  and  its 

prevention   1007 

Death,   hereditary   sudden    136 

international  classification  of  causes  of..i3r6 

mechanically  caused  by  the  thymus   86 

Dcaver,  John  B.  Intracranial  causes  and 
optrative  treatment  of  trigeminal  neu- 
ralgia   623 

De  Bar,  Ceorge  O.  B.  Nonoperative  treat- 
ment of  api'endicitis   1201 

Decapsulation  of  kidneys  for  Bright's  dis- 
ease   185 

Deformities,'  multiple   congenital   87 

of  face,  nose,  and  jaw,  aetiology  of....  709 

Deformity,   Madelung's  wrist  joint   249 

Delirium  tremens,  drug  treatment  of.  .  .  .  865 
Delivery,  h.Tmorrhage  at  time  of,  a  factor 

in  prevention  of  full  secretion  of  milk  715 

Dementia  choreoasthcnica    87 

Dementia   pr.tcox    92 

Demireralization,    organic   1240 

Dental  and  systemic  disturbances,  relation- 
shin  between    65 

Diabetes,  bronze,  and  pigment  cirrhosis..  920 

chimaphila   in  treatment   of  444.  '>47 

diet   in    558 

dietetic    treatment    of    663 

emulsion  of  fat  for  use  in  ii^' 

increased  death  rate  from   922 

mellitus.  .iltered  function  of  kidney  in.  1232 

oatmeal   in    916 

pancreas   in   1102 

pathology  and  treatment  of   84 

with  rriedreich's  disease   190 


Pace. 

Diabetes    mellitus,    pancreatic    extract  in 

treatment    of    6oy 

treatment  of   

Diabetics,  almond  cakes  for   286 

glycosuria  of,   influence   of  temperature 

upon   '   400 

uranium  wine  for    649 

Diachylon  as  a  poison   3,. 

Diagnosis,    bacteriological    versus   clinical.  651 

errors  in,  in  diseases  of  children  1225 

in  relation  to  laboratory  and  bedside.  .  1071 
.Morris's  point  of  tenderness  as  an  aid 

in    81 

Rontgen  rays  in    241 

Diarrhoea,  chronic,  caused  by  chronic  ap- 
pendicitis   769 

epidemic,  bacillus  of   399 

summer,  treatment  of,  with  living  lactic 

acid  bacilli   1224 

Diet  as  a  prophylactic  and  therapeutic ...  1 1 73 

in  diabetes    558 

in  tuberculosis   397 

in  typhoid  fever   1217 

poor  in  salt    817 

Dietetics,  general   principles  of  1229 

Digestion,  disturbances  of,  and  psycho- 
neuroses    816 

gastric,    action   of   salt   in   45ti 

in   infants   1 1  ig 

physiology  and  pathology  of   190 

organs  of,  invisible  haemorrhage  in  dis- 
eases of   1279 

troubles  of,  in  rickets   85 

Digitalis  treatment   299,  1324 

Dilatation,  acute  po6tO|)erative,  of  stom- 
ach   801 

gastric  and  duodenal,  treated  by  gastro- 
jejunostomy   70 

as  a   [jostonerative  complication ......  1 1 84 

idiopathic,    of    oesophagus  1077 

of  stomach,  acute    137 

Dilator,   double  uterine   627 

Diphtheria  antitoxine,  preparations  of....  1233 

untoward  effects  of   240 

Behring's  serum  for    921 

epidemic    346 

heart  in    300 

ocular  complications  in    300 

renal   complications  in    300 

Diplosal    230 

Dipropaesin    177 

Di  Rocco,  Joseph.     The  therapeutic  use  of 

alcohol    960 

Nonoperative  treatment  of  appendicitis.  .  1269 

Disc,   choked    294 

operative  treatment  of   511 

Discharges,    treatment   of  1284 

Discoloration  of  conjunctiva  from  an  in- 
delible pencil    2\ 

Disease,  acute  infectious,  treatment  of....  818 

malignant,  x  rays  in   818 

preventable,  relation  of  municipality  to  452 
Diseases  and  conditions,  Bellevue  Hospital 

nomenclature   of...ioi6,   1061,   1108,  1159 
classification  of.  and  nomenclature,  126,  loii 

of  children,  serum  treatment  of  11 17 

transmissible    495 

Disinfectants,  standardizing    127 

Disinfection   712,  764 

and  measles    807 

Disturbances,  dental  and  systemic,  rela- 
tionship between    65 

Ditman,  Norman  E..  and  Welker,  William 
H.  Deficient  oxidation  in  its  relation 
to  aetiology,   pathology   and  treatment 

of  nephritis  1000,  1046,  1091,  1134 

Diverticulum  of  pylorus  1217 

Doctor  and  the  nurse   881 

Doctor's  income,  helps  and  hindrances  to  407 
Dow.    Edmund    L. ;    Carlisle.    Robert    J. ; 
Coleman,  Warren,  and  Smitli.  Thomas 
A.     The  Bellevue  Hospital  nomencla- 
ture  of   diseases  and  conditions 

1016,  1061,  1108,  1159 

Drainage   in   brain   abscess   247 

in   surgery   of   pelvic    organs   616 

Drennan.  Jennie  G.  The  vermiform  ap- 
pendix  a   rudimentary   organ   in  the 

carnivora    9s5 

Drug    addictions,    preparations    used  in 

treatment    of   1329 

Drugs,    administration    of,    by  inunction 

method    191 

and  prenarations  of  U.  S.  P.  and  N.  F. 
a  sufficient  armamentarium  for  medi- 

cinaj  treatment  of  disease  '320 

general  physiological  effects  of  '307 

science  of   action   of   456 

used  in  gynaicology    36S 

Drum.  J.   H.       Tuberculous  disease  and 

diphtheria  antitoxine    .  .  .•   251 

Duct,  thoracic,  termination  of  1024 

Ducts,  choledochus  and  hepatic,  surgery  of  54S 
Dufficld,   Warren   L.     .\  clinical  study  of 

hypernephroma  of  the  kidney   898 

Duodenum,  dilatation  of,  treated  by  gas- 
trojejunostomy   70 


Page. 

Duodenum,   ulcer  of    80 

Duijuytren's   contracture   of   fingers   457 

Duty,   professional,   and   professional  sec- 
recy   7lg 

Dysentery,  acute,  treatment  of... 643,  698,  750 

pAR,  bismuth  paste  in  suppuration  of.  .  132 
functions  of  end  organs  in  vestibule 

■and   semicircular  canals  of   761 

influence  of  eye  on   (i7i 

middle,   ana:sthetization   of  iii.S 

infections   of    241 

removal  of  wax  from   389. 

Earp,  Samuel  E.     Bedside  clinic  summary 
of  the  treatment  of  acute  rheumatism 
at  the  Indianapolis  City  Hospital....  898 
Ears  and  nose,  affections  of,  in  relation  to 

skin  diseases    465 

Echinococcus,  treatment  of,  with  ethereal 

extract  of  filix  mas   24) 

Eclampsia  and  placenta  praeviq,  treatment 

of    457 

and  toxaemia  of  pregnancy  138,  1218 

puerperal    jg 

injections   of  bromides   for   338 

placental    theory   of   18^ 

Eczema,  chronic,  treatment  of... 225,  283,  3,,4 
infantile,  pathology  and  aetiology  of....  122^ 

treatment    of    909 

Edgar,  J.  Clifton.     Preventable  blindness 
from  the  standpoint  of  the  obstetrician  986 

EDITORIALS: 

Ampoule,  use  of,  for  preservation  of  hy- 
podermic solutions    651 

Anaemia  of  uncinariasis  i'55. 

An.Tsthetist,    the    professional   912 

Antivivisection  agitation  in  New   York.. 750 

and  the  butcher's  art  ii53 

movement,   a   counterblast   to  23; 

Army   Medical    Service   178- 

officers'   endurance,   tests  of   231 

Artci  iosclerosis   loio 

Association,  American  Medical ....  1 1 56,  1204 

Athletics  and  mentality    703 

Bacteria,   living,   immunization  with....  806 

Bathing   without   water  1275. 

Bee  stings  in  therapeutics  703,  876 

Bertillonage   1011 

Blackwell,    Dr.    Elizabeth   447 

Boards,    State   licensing    7b 

Bull  memorial   ioi2- 

Bureau  of  Animal  Industry,  annual  re- 
port of   601 

Cancer,  fulguration  treatment  of   963 

of  the  breast  in  men   392 

Carcinoma  and  the  leucocytes   494 

of  stomach,  Salomon  test  in  1273 

Census  of   1910   652- 

Chemical  corielation  and  the  pathology 

of  the  kidney    39.) 

Choledochus  and  hepatic  ducts,  surgery 

of    548 

Classification,  international,  of  causes  of 

death   1316- 

Codex,  the  new  French  1102 

Cold,  the  ordinary    754 

Coroner,  the  office  of   33 

Cystocele,  accidents  and  com];lications  of  39a 

Dante  as  a  physician   755 

Dead,  disposal  of,  at  sea  601 

Deaver,  Dr.  John  B.,  dinner  to   390 

Diachylon   as  a  poison   341 

Diagnosis,  bacteriological  zcrsiis  clinical  651 

Disease,  nature  of   1205 

Diseases,  transmissible    49  5 

Disinfectants,  standardizing    12- 

Erythema  nodosum  and  tuberculous  in- 
fection  1 154 

Esmarch  band,  metallic  substitute  for..  11 04 

Esperanto  ',ersiis  Ilo   601 

E.xpert  testimony,   medical   288 

Fixation  abscesses  in  therapeutics   754 

Food   preservatives   127,  340 

Foot  and  mouth   disease  and  contami- 
nated vaccine   1057 

Fourth  of  July,  preparing  for  1276 

German   physicians,   remuneration   of...  390 

Glandular   fever  12-5 

Grocco's  sign  in  infantile  pleurisy   964 

Ilaeckel.    Ernst    34' 

H.-cmorrlioids.    Boas's   treatment  of....iio> 

operative   treatment   of  1012 

Harvey  Society  lecture,   Macallum's. . .  .  125 

Ifcalth   legislation,   national   804 

problems,   public   1203 

Heredity  in  man   547 

Hexamethylenamine   and    meningitis....  860 

Hospital   ship,   the   naval   339 

Hypnotism,    vaudeville   'S'.l 

Immunity,  some  problems  in....   445 

Immunization  with  living  bacteria   806 

Inebriety,    problem   of........   859 

Intestinal  initrefaction.  inhibition  of.... 232 
Jefferson    Medical    College,    portrait  of 

Dr.  Holland  to  be  presented  to....  704 


INDEX  TO  VOLUME  LXXXIX. 


1341 


Page. 

EDITORIALS: 

Journal  of  gynaecological  urolog)-   341 

Journal  of  Physical  and  Dietetic  Treat- 
ment   290 

Journalism,  official  medical    31 

Kentucky  State  Board  of  Health   77 

Kidney,  pathology  of,  and  chemical  cor- 
relation   390 

Lancet's   latest  bereavement   652 

Lead  poisoning    650 

Leprosy  in  Hawaii   179 

Leucocytes,  extracts  of,  in  therapeutics  2S7 

Life  insurance   -   75^ 

Light,  absorption  of,  by  the  skin   180 

Liver   and   fat   metabolism   178 

McDowell  centennial    9'i 

Massachusetts    General    Hospital   602 

Measles  and   disinfection   807 

Medical   education,   arbitrary  standards 

in   233 

men,  memorials  of    600 

officers,  actual  command  for   703 

profession,  overcrowding  of   127 

Schools  in   China   96+ 

Society  of  the  State  of  New  York..  180 

strike   ■   33 

titles,    changing   fashions   in   the  use 

of    600 

Medicine,  schools  of,  a  step  toward  the 

unity  of   1055 

Menstruation,  first,   and  pelvic  defects.  756 

Messina  disaster    77 

Military  medicine  as  a  career   910 

Milk,  pasteurization  of,  and  the  medical 

profession    806 

Mitchell,   Dr.   S.   Weir,   eightieth  birth- 
day of    446 

Mortality  statistics  of  1907  1012 

Nephritis  and  cutaneous  irritation  1012 

Nervous   system,    sympathetic,    in  path- 
clog)'    702 

News,  medical,   by  cable   "6 

Newspaper  medicine   75.  289 

treatment  of  medical  matters   494 

Nomenclature  and   classification  of  dis- 
eases  126,  1011 

system   in   1205 

Obstetrician,  the    547 

Oedema,  acute  pulmonary   34° 

Ophthalmia    neonatorum,  campaign 

against    32 

Osmosis    125 

Pancreas  in  diabetes  mellitus  1102 

Parasites,  intestinal?  in  the  Philippines..  860 

Parisianonianie    860 

Pathogenic   organisms,   invisible  II55 

Pelvis,    defects   in,   and   the   first  men- 
struation   756 

Pennsylvania's  home  coming  week   858 

Pharmacology-,   a  new  journal  of  1275 

Pharinacopceia,   criticisms  of  1314 

efforts  to  popularize  1314 

Ninth  Decennial  Convention  for  Revi- 
sion   of    962 

United  States,  in  Spanish  1204 

Pharmacoioeial  convention,  medical  rep- 
resentation at    599 

Plague  in  San  Francisco   859 

Prediction   in  medicine   650 

Proprietaries,  an  Australian  report  on,.  704 
Puncture,   lumbar,   for  nocturnal  incon- 
tinence of  urine   963 

Rectum,   congenital    absence   of  13 16 

Religion  and  medicine   233 

Resuscitation  after  apparent  death   30 

and  surgical  anxmia   30 

Rinderpest.  Ruediger's  antiserum  for...  860 
Rocky  Mountain  fever,  setiology  of....  599 

Sanitation  in   the  tropics  I3'5 

Saratoga  mineral   springs   446 

Sarcoma,  primary,  of  stomach  101 1 

Scarlet  fever,  necrotic  angina  of  1055 

School  teachers,  the  health  of   446 

Scottish  nurses  and  home  rule   601 

Secrecy,  professional,  and  duty   496 

S'ecialties.    correlation   of   911 

Stadium  for  Columbia  University   =48 

Straus    milk    scheme    and   the  medical 

profession    806 

Streptotrichiasis   1056 

Sunrarenal  bodies,  nephritis,  and  arterio- 
sclerosis   180 

Syndromes,  cholecystic  and  appendicular  540 
Tabes  dorsalis,  high  frequency  currents 

in   233 

thiosinamine  in   1274 

Telegraphy,  wireless,  dangers  of   963 

Tetanrs.  magnesjum  treatment  of   496 

Tetany  and  the  parathyreoid  bodies....  446 

T'-io=inamine  in  tabes  dorsalis  1274 

Thor-rad-x    495 

Thyreoiditis,   simple   acute  1056 

Tono-Rungay,  a  novel  on  a  proprietary 

medicine    807 

Tricbocephaliasis   11 53 

Trudeau.  Dr.  Edward  L..  a  tribute  to..  32 
Tuberculin,   diagnostic  injections  of .  .  .  .  288 


P.\GE. 

EDITORIALS: 

Tuberculosis  exhibition,  the  international  704 

in  New  York,  decrease  of  1057 

meat  as  a  source  of  infection  in  1273 

Tuberculous    families,    sanitary  homes 

for   1010 

Typhoid  carrier,  detection  of   339 

fever,  aetiology  of  1274 

L'ltramicroscope    912 

Uncinariasis,  anaemia  of  ii55 

L'niversity  of  Pennsylvania   289 

Urine,  lumbar  puncture  for  nocturnal  in- 
continence of    963 

\'accination    125 

\'omiting,   winter    704 

Water  supplies,  pollution  of   75 

Wightman,    Passed    Assistant  Surgeon 

William  M.,  the  death  of  11 04 

Effusions,  sterile  serous,  with  empyema  of 

pleura    921 

Egbert,  J.  Hobart.     Asthma  a  nasal  dis- 
ease   380 

Egyptians  and  Assyrians,  medicine  among, 

in  1500  B.  C   403 

Einhorn,   Max.       Idiopathic   dilatation  of 

the  CESophagus   1077 

Eisenberg,  A.  D.     Thoracic  aneurysm....  424 

Elbow,  injuries  to    295 

joint,  fractures  of    302 

Electric  sleep   1221 

Electricity  in  genitourinary  diseases  103S 

static,  in  treatment  of  neurasthenia....  114 

Electrization,  new  method  of    610 

Elephantiasis  of  male  genitals    406 

operation    for    249 

Elliott,  Arthur  R.      The  toxic  secondaries 

of  chronic  tonsillar  disease   883 

Elliott,  Edward  Everett.     Climates  for  con- 
sumptives   54J 

Embolism,    pulmonary,    after   injection  of 

mercury  salicylate  suspensions    353 

following  operations    133 

Embolus,   removal  of,  from  common  iliac 

artery   1113 

Emergencies,  abdominal    295 

Empyema  and  tuberculous  pleurisy,  relation 

between   1220 

of  antrum,   radical   operation   for  1285 

of  pleura,  sterile  serous  effusions  with..  921 

Encapsulation  of  spleen,  method  of   91 

Encephalitis,   purulent    557 

Endaneurysmorrhaphy    976 

Endocarditis,   chronic   infectious   12  lO 

infantile  bacillary    85 

malignant,   without   fever  ij68 

Endometritis    871 

Endometrium,  decidual  changes  in,  not  due 

to  pregnancy    715 

some  variations  of   121S 

Endurance  of  army  officers,  tests  of   231 

Enterostomy  in  intestinal  obstruction..,.  974 
Enucleation,  digital,  of  tonsils.. 42,  1087,  1089 

of  the  eye,  substitutes  for    438 

of  uterine  myomata   1215 

Enuresis,  nocturnal,  secretion  of  thyreoid 

gland  in  relation  to   1069 

Epididymitis,  puncture  treatment  of    869 

Epilepsy    240 

calcium  lactate  in  treatment  of..iioi,  1167 
cardiac,  clinical  history  of  cases  of....  1293 

problem  of    6o-^ 

surgical  treatment  of   406,  78S 

Epileptic  psychoses,   treatment  of   401 

Eiiiploitis  following  radical  cure  of  Jiernia  270 

Epithelioma,  adamantine    189 

pure  radium  salts  in  treatment  of   605 

Epityphlitis.  abscess  of  spleen  after    456 

Erdmann.  John  F.     L'reteral  calculi  1180 

Ergot,  determination  of  quality  of  1228 

o.xytocic  principle  of  1313 

Erui-tion.  bromide,  in  childhood    580 

bromoform   1145 

Erysipelas,    treatment    of,    by  inoculation 

with  specific  vaccine    553 

Erythema  nodosum  and  tuberculous  infec- 
tion  1 1  54 

Escalin  in  haemorrhage  of  the  stomach ..  1284 
Esmarch  band,  metallic  substitute  for  ....T104 

Esperanto  versus  Ilo   6f" 

Ether,  relation  of.  to  immunity  1231 

Ethics  of  the  medical  profession   201 

Ethmoiditis,  acute  suppurative    830 

Ethyl  chloride  in  general  anaesthesia   ....  500 

Eulaxans    177 

Eunhoria.  increased,  and  activity,  symptoms 

of  infections    355 

Euphyllin   230 

Eventration  treatment    6?i 

Exercise  and  baths  in  treatment  of  abnor- 
mal tone  of  heart  and  bloodvessels.  ...  242 
of  descending  in  treatment  of  disease..  211 

Expert  testimony,  medical    28S 

witnesses,  legislation  relating  to    24.; 

Exstrophy  of  the  bladder,  treatment  of..  615 

Extremities,  nermanent  hyperemia  of  1H7 

traumatic  injuries  of  . :   970 


P.\GE. 

Eye  and  annexa.  an.-csthetization  of   86 

and  heart,  relation  between  diseases  of.  24^ 

chronic  inflammatory  diseases  of  1237 

in  scarlet  fever  and  diphtheria   300 

removal  of  steel  from,  by  magnet   189 

scarlet  red  in  diseases  of    559 

substitutes  fpr  enucleation  of    43s 

Eyeball,    extraction    of    iron    from,  with 

magnet   13-20 

Eyelids,  oedema  of,  in  influenza   83 

Eyes,   significance  of,   in    disturbances  of 

the  nervous  system   224 

P  .\CE,  deformities  of,  aetiology  of   709 

hygiene  of,  in  acne   389 

Fxces.  blood  in,  clinical  demonstration  of.  714 

examination  of    811 

Fairchild,  D.  S.      Acute  postoperative  di- 
latation of  the  stomach    801 

Family  physician,  responsibility  of,  in  tu- 
berculosis   I 

Far  East,  opportunities  of  medical  profes- 
sion  in    192 

Fat  embolism  and  the  liver    178 

Fats,  metabolism  of,  function  of  liver  in 

relation   to    609 

Faught,   Francis  Ashley.     Blood  pressure 

observations  and  life  insurance   1040 

Faulkner,    Richard    B.      No    free  hydro- 
chloric acid  in  the  stomach  1308 

Feeding,  artificial,  of  infants    870 

infant,  Heubner's  system  of   1226 

science  and  art  of   1226 

percentage,  of  infants   1226 

Fees  and  fee  bills    407 

Feet,  weakened   1265 

Femur,   fracture  of  neck  of  22,  243 

injuries  to  neck  of    83 

Ferment,   demonstration   of.  by  injections 

of  alcohol    249 

solutions,  tryptic,  influence  of,  on  sur- 
gical  tuberculosis    190 

Ferments  of  digestive  canal    85 

use  of,  in  medicine   122.S 

Ferrier's   recalcifying  method   in  tubercu- 
losis  

Fetishisms.  iiharmacological   io65 

Fever,  glandular    239 

protracted,  common  types  of    191 

Fever   temperature  in  infectious  diseases, 

effects  of   1284 

Fevers,  deafness  following,  prevention  of.  1007 

tropical,  diagnosis  of    763 

Fibroid  tumors  and  pregnancy    404 

l-'ibroids.  intraligamentous    90 

utfrine.  complicating  pregnancy    90 

Fibrolysin  in  ophthalmic  practice    350 

in   pleuritic   deposits    299 

Fibromata,    uterine,    operative  indications 

in    610 

Fibromyomata  of  uterus   1219 

complicating  pregnancy    3S 

Fibula,  sarcoma  of  1071 

Files,   Charles  O.     Repair  of  fractures.  .  223 

Filicone    230 

Filix   mas,   ethereal    extract   of,    in  treat- 
ment of  echinococcus  and  cysticercus.  249 

Fingers.  Dunuytren's  contracture  of   457 

First  aid  dressing  for  wounds   458 

Fischer.  Hermann.     Diagnosis  and  differ- 
ential  diagnosis  of  appendicitis   886 

Fischer.    Louis.     Myocarditis   in  children 

caused  by  toxaemia  1295 

Von  Pirquet's  tuberculin  test  in  the  diag- 
nosis of   tuberculosis  in   infancy  and 

childhood    577 

Fish  contagion  in  leprosy    409 

Fiske.    James   Porter.      Care    of  crippled 

children  by  the  State  of  New  York..  282 
Fistula    between    stomach    and    bile  pas- 
pages   1068 

Fistulae.  treatment  of    250 

Fixation  of  tissues  and  staining  of  sections, 

an    improved   method   for    596 

Flagellation  of  leucocytes   '13J 

Flexner   serum   in   treatment   of  epidemic 

meningitis   1225 

Flint.   Dr.  Carlton   P..  resolutions  on  the 

death  of    306 

Fluid,  amount  of.  required  by  the  body.  1023 
cerebrospinal,  chemical  and  bacteriologi- 
cal examinations  of    404 

Folkes.  H.  M.     Neurasthenia   33 

Food,  adulteration  of    613 

containing  benzoates  injurious  to  health.  8.r 

extracts  made  from  yeast    83 

irtoxications  in  childhood   501,  1223 

preservatives   127,  34^1 

Foods  for  infants  and  tuberculosis,  rela- 
tion  between    i^^ 

proprietary   1229 

and  predigested.  from  the  standpoint  of 

the   podiatrist   1229 

I'se   and   abuse   of  •'1327 

Foot  and  mouth  disease  and  contaminated 

vaccine   1057 

nature   of    241 


1342 


INDEX  TO  VOLUME  LXXXIX. 


Pagb. 

Foot,    flat   734 

ulcer  of,  of  tuberculous  origin    298 

Football  injuries  at  Harvard   184. 

Forceps,  tonsil,  a  new   304 

Fordhain  Hospital,  surgical  service  of....  32_> 
Fordyce,  John  A.     Affections  of  oral  and 

nasal  cavities  related  to  skin  diseases.  465 
Formaldehyde  as  a  food  preservative....  127 
Formulary,  National,  and  U.   S.  Pharma- 
coi>uria,  drugs  and  preparations  of,  a 
sufficient  armamentarium   for  medical 

nomenclature  of   9f>9.  I330 

Fossa,  nasal,  search  for  meningococcus  in  .40 

supraspinous,  symptomatology  of    40 

Foster,  George  B.,  Jr.,  and  Gerhard,  C.  H. 
The  simultaneous  occurrence  of  hyper- 
nephroma and  carcinoma    IS4 

Foulkes,  Sara  E.     Treatment  of  asphyxia 

neonatorum    27 

Fourth  of  July,  preparing  for  1276 

Fracture,  CoUes's   1333 

of    bo.\ers    973 

of  neck  of  femur,  treatment  of    22 

of  patella;,   ununited    832 

of  skull    301 

prognosis  in  cases  of    612 

Fractures,  comminuted,  of  leg    505 

compound,  treatment  of    243 

diagnosis  and  treatment   of  243,  1221 

of  base  of  skull    186 

of  elbow  joint    302 

of  neck  of  femur    243 

of    olecranon    350 

of  pelvis    45" 

of  tibia    457 

Franklin,     Benjamin,    from    the  medical 

viewpoint    3 

Freezing  as  a  therapeutic  measure   86(i 

Fricks,  L.  D.  The  classification  of  con- 
sumptives   731 

Fridenberg,  Percy.     Opportunities  for  the 

Board  of  Health    563 

Fried,  G.  A.,  and  Bernstein,  E.  P.  Tu- 
berculosis without  tubercle  bacilli  in 

the  blood   1097 

Friedlaender  bacillus,  sepsis  from   1168 

Friedreich's  disease  with  diabetes  mellitus.  190 

Fulguration  treatment  of  cancer  765,  963 

» 

GALLBL\DDER,    removal    of  13JI 
Gallstones,    aetiology,    diagnosis,  and 

medical  treatment  of    771 

early  symptoms  of   i2'5 

operative  treatment  of   11 16 

Ganglion,  Gasserian,  danger  to  cornea  in 

removal  of    250 

Oangrene,  resection  of  small  intestines  for.  716 
Garlic,  ethereal  oil  of,  or  the  allyl  com- 
pounds  1043 

Gartner's  canal,  abscess  of    89 

■Gases,  intestinal,  surgical  importance  of..  1020 
<jasserian   ganglion,    danger  to  cornea  in 

removal  of    250 

Gastric  carcinoma,  early  diagnosis  of....  767 

digestion    in    infants  190,  11 19 

dilatation   as   a   postoperative  complica- 
tion  1 1 84 

disease,  indications  for  surgery  in   874 

irritation,   treatment   of    909 

mucus,  secretion   1324 

neuroses    872 

ulcer,  Ktiology  and  pathogenesis  of  ....  767 

diagnosis  of   11 19 

immediate  feeding  in  treatment  of....  866 

medical  treatment  of    767 

surgical   treatment  of    76S 

Gastritis,  phlegmonous    189 

Gastrodynia,   treatment  of    29 

Gastrointestinal    disorders,   indications  for 

drinking  of  mineral  waters  in   486 

disturbances  due  to  arteriosclerosis   657 

in  scarlet  fever'   661 

Gastrojejunostomy    in    acute    gastric  and 

duodenal  dilatation    70 

Gastroptosis.  pathology,  diagnosis,  and  sur- 
gical  treatment  of    615 

Generative  organs  in  women,  internal....  406 
repair  rather  than  removal  of  ...  .  92 

Genitals,  male,  elephantiasis  of    406 

Genitourinary     complications     of  typhoid 

fever    372 

diseases,  electricity  in   1038 

Gerhard,  C.  H.,  and  Foster,  George  I!.. 
Jr.     The  simultaneous  occurrence  of 

hypernephroma  and  carcinoma    154 

Gestation,  ectopic   45,  88,  560 

early  signs  of    616 

extrauterine,     pain      and  haemorrhage 

symi)toms   of    971 

with  delivery  of  a  viable  child   894 

Gilbridc,  John  J.  Indications  for  opera- 
tions on  the  stomach   io8;? 

Gland,  carotid,  pcritlielioma  of    555 

thyreoid,  diseased  conditions  of    562 

Glanders,  human   184,  454 

Glands,  cervical,  tuberculosis  of    456 

salivary,  tumors  of    562 

Glandular  fever   230,  127^ 

Glaucoma,  primary,  treatment  nf    401 


Pag  5. 

Globulin   1167 

Gloves,   rubber,  sterilization  and  use  of..  403 

Glycosuria  in  pregnant  women    191 

of    diabetics,    influence    of  temperature 

upon    400 

Goepp,  R.  Max.    Typhoid  fever  ushered  in 

by  an  attack  of  uraemia  1146 

Goffe,  J.  Riddle.  The  country  medical  so- 
ciety   725 

Goitre,  accidents  and  complications  in  op- 
erations  for   128S 

exophthalmic    67^ 

in  pregnancy   1286 

surgical   treatment  of    354 

X  rays  in  treatment  of    614 

malignant,   surgical  treatment  of   56J 

Iiarenchymatous    503 

simple  types  of,  surgery  of    562 

Gonococcic  urethritis  in  the  male,  treat- 
ment of    149 

Gonorrhoea,  anaphrodisiacs  in   iioi 

chronic,  pathology  and  treatment  of....  213 

clinical,  in  the  male  169,  217,  276 

curability   of    580 

gonococcic  vaccine  in    456 

Gonorrhteal  urethritis  in  the  female   584 

Gordon,  Alfred.     Amnesia  from  a  medical 

standpoint    260 

Gout,  asthenic,  tonic  ferruginous  pills  for.  701 

treatment   of    444 

by  thymic  acid    136 

Grace,  Ralph.  Significance  of  high  blood 
pressure  in  life  insurance  examina- 
tions   853 

Graham,  George  A.  Nonoperative  treat- 
ment of  disease  of  the  vermiform  ap- 
pendix  1097 

The  therapeutic  use  of  alcohol   854 

Treatment  of  asphy.xia  neonatorum  ....  175 
Graham,    St.   J.    B.     Treatment   of  acute 

dysentery    698 

Grant,  Sir  James  A.  The  clefts  of  the 
axis  cylinder,  the  cable  of  the  nervous 

system    98' 

Graves's  disease,  treatment  of    286 

Greek  for  physicians  527,  720 

language,  a  new  thesaurus  of   196 

Greene,  Robert  Holmes.  Diagnosis  of  dis- 
eases of  the  kidneys   695 

Grocco.  triangle  of   1069 

Grocco's  sign  in  pleurisy    964 

Growths,  malignant,  injections  of  mer- 
cury, arsenic,  and  iron  in  treatment 

of   425 

Gruening,  Emil.  Sinus  thrombosis  of  otitic 
origin    and    its    relation    to  strepto- 

cocchEmia   1141 

Guaiac  test  for  blood    451 

Gumma   of  auricular   septum  1325 

Gunshot  wounds,  suture  of  lung  in  11 17 

Gymnastics,  medical,  in  heart  disease....  191 
Gynaecological  and  obstetric  operations,  ir- 
rigation and  drainage  in  1219 

Gynaecology,  drugs  that  may  be  used  in..  308 

IJABITS,    drug,    preparations    used  in 

treatment  of   1329 

Haematemesis,   meaning  of   817 

Hsematoma,  rare  forms  of   354 

traumatic  pleural    815 

vulvae  a  hindrance  to  labor   869 

Haematoporphyrinuria    972 

Hematuria,  essential   1326 

Hasmoglobinuria,  paroxysmal,  and  hemo- 
lysis in  vitro    869 

Haemolysis  of  streptococci    402 

Haemoptysis,  adrenalin  in  treatment  of....  29 

chloroform  in   12S0 

Haemorrhage  and  pain  as  symptoms  of  ex- 
trauterine gestation    971 

at   time    of    delivery   a    factor    in  pre- 
vention of  full  secretion  of  milk   715 

from  cystic  artery,  checking  of    559 

internal    concealed    34^ 

invisible,  guaiac  and  benzidin  tests  for.  1279 
of  stomach,  escalin  in  treatment  of....  1284 

uterine,  curettage  for   12 19 

Haemorrhages,  gastric  and  intestinal,  treat- 
ment of    389 

post  partum.  of  placenta  praevia   661 

uterine    71s 

Hemorrhoids,  Boas's  treatment  of   1103 

operative  treatment  of   1012 

treatment  of    493 

Hemostatic,  atropine  as  a    564 

Hair  ball  or  hair  cast  of  stomach   12J4 

follicle,    unusual   disease   of   1125 

Hall,   Dr.    Marshall,    reforms  attributable 

to    7'5 

Halliday.  Charles  H.  Treatment  of  as- 
phyxia neonatorum   ,.   70 

Hand,   hot   air  treatment   of  purulent  in- 

f1-"Mmations  of  I28< 

sterilization    708 

Harbridge.  D.  Forest.    The  substitutes  for 

eniielration  of  the  eye    438 

ITare.  llobart  Amory.     The  unauthorized 

use  of  a  name  1288 


Page. 

Hare  lip  and  cleft  palate  operations,  tech- 
nique  of   I  1 69 

operative   technique   in    251 

Harris,   William   L.     Caesarean  operation.  686 
Treatment  of  malignant  growths  by  in- 
jections of  mercury,  arsenic,  and  iron.  425 
narrower,   Henry  R.     A  new  instrument 

for  the  estimation  of  urinary  acidity.  24 

routine    urinary   examinations    437 

Haskell,  Charles  Nahum.  The  early  diag- 
nosis of  pulmonary  tuberculous  dis- 
ease  I3ii 

Hay  fever  and  other  rhinological  causes  of 

asthma   1164 

Hays,  H.  M.  Treatment  of  chronic  eczema.  335 

Hays,  Harold  M.    A  pharyngoscope   822 

Hays,   Walter   E.     Treatment  of  chronic 

eczema    226 

Headache,  indurative    917 

of  neurasthenia,  remedy  for    230 

Headaches  of  ocular  and  nasal  origin....  82 
Health  associations,  national,  consolidation 
of,  with  the  Section  in  Hygiene  and 
Sanitary  Science  of  the  A.  M.  A....  1222 

problems,   public   1203 

Hearing,  conservation  of,  in  radical  mas- 
toid  operation    134 

Heart,  action  of    296 

arrhythmias   of   1067 

neurogenic  and  myogenic  theories  of.  11 14 

chronic  diseases  of   1238 

disease,  congenital   1302 

diseases,    treatment   of   1023 

early  inadequacy   of    4S5 

effect  of  cholecystitis  on  1280 

gunshot  wounds  of  1285 

in  hot  and  cold  baths    506 

in  pulmonary  tuberculosis    507 

in  scarlet  fever  and  diphtheria   300 

irregularities    of    130 

penetrating  wound  of  right  ventricle  of.  87 
point  of  commencement  of  activity  of..  1285 

prognosis  in  valvular  disease  of   923 

relation  of  venous  pressure  to  efficiency 

of   1232 

suture  of  wounds  of   345,  402 

thrombosis  of   1231 

valvular  disease  of,  and  rheumatic  fever 

1068,   1 1 15 

Heat  stroke,  new  theory  of    930 

Heath   operations    657 

Hebotomy    456 

Heels,  painful    020 

Heiser,  Victor  G.     Hook  worm  disease  in 

the  Philippines    329 

Hemiplegia   from  cerebral   apoplexy   502 

Henoch's  purpura  and  intussusception  . .  .  527 
Henson,   Graham   E.     The   anopheles  the 

sole  carrier  of  malaria  '333 

Hepatocholangioenterostomy    765 

Heredity,  cancer  as  a  problem  of,  673,  829,  1078 

fundamental   theories   of    49 

in  man    547 

theories  and  problems  of ...49,  309,  673, 

829,  1078 

Hernia,  abdominal,  correct  definition  for..  803 
indirect   inguinal,   new   method   for  the 

radical  cure  of    528 

inguinal,  followed  by  epiploitis    270 

intraabdominal  incarcerated    803 

oblique  inguinal   762,  1288 

vermiform  appendix    819 

operation,  injuries  to  bladder  during...  91 
strangulated  through  linea  semilunaris.  803 

through  pelvic  floor    870 

volvulus   associated   with    660 

Herzig,  Arthur  J.   Dacryocytitis  io»4 

sequehe  of  adenoids    267 

Heubner's  system  of  infant  feeding  1226 

He.xamethylenamine   and   meningitis   860 

Hip,  congenital  luxation  of,  results  of  op- 
eration  for    510 

joint,  knee  pains  in  diseases  of   11 18 

tuberculous,   resection   of   815 

Hippocrates,  the  modern    238 

Hirschsprung's   disease    87 

Hirst,  John  Cooke.  The  repair  of  lacera- 
tions of  the  cervix  during  puerperal 

convalescence    153 

Hofer,   Clarence  A.     Pharmacology  1307 

Hogan,    Austin.      Nonoperative  treatment 

of  appendicitis   ..,1200 

Homes,  sanitary,  for  tuberculous  families. loio 
Hook  worm  disease  in  the  Philippines....  329 

Hordenine  sulnhate  in  therapeutics    6to 

ITormons.  studies  in  the    492 

Hosiiital   shit>.   the  naval   331 

Hospitals,  influence  of.  on  doctor's  income.  408 

State,  voluntarv  patients  in  241 

Hiihner.  Max,     Clinical  gonorrhoea  in  the 

male   160.    217.  2/6 

Hydatid  disease,  precipitin  reaction  in  diag- 
nosis of   973 

Hydronephrosis,  congenital,  acute  infection 

of   ti68 

intermittent   068,  1020 

relation    of   anomalous    renal  bloodves- 
sels to    969 


INDEX  TO  VOLUME  LXXXIX. 


1343 


PAC.r;. 

Hygiene  of  face  in  acne    389 

of  torpedo  boat  destroyers    921 

oration  in   192 

Hyperaemia  in  surgical  tuberculosis   507 

permanent,   of  extremity   1117 

Hyperchlorhydria,  laxatives  in   1202 

tropical    298 

Hypernephroma   1323 

and  carcinoma,  simultaneous  occurrence 

of    "54 

Hyperplasia,  syphilitic,  of  bone    300 

Hypertrichosis,  treatment  of,  by  x  rays..  817 

Hypnotism,  vaudeville   1315 

Hypochlorites  in  cancer    399 

Hypodermic  solutions,  use  of  ampoules  for 

preservation   of   -.  651 

Hypoplasia  in  relation  to  health  and  dis- 
ease   355 

Hysterectomy  and  castration,  influence  of.  6ti 
Hysterectomy,  evolution  of  modern  opera- 
tion of   88 

vaginal,  for  carcinoma  of  cervix    405 

Hysteria,  clinicians"  concept  of    708 

present  status  of    53 

surgical  aspect  of    44 

traditional,   dismemberment  of    352 

Hysterosalpingostomy   ii93 

ICHTHYOSIS  and  the  thyreoid  gland...  610 

*       infantile,  treatment  of    229 

Icterus  gravis   714 

Idiocy,  amaurotic  family   953,  1115 

Iliac  artery,  common,  removal  of  embolus 

from   II 13 

Immune  bodies,  treatment  with    559 

Imm-unity  against  tuberculosis  in  general 

paresis      396 

new  theory  of,  based  on  ductless  glands, 

361.  43' 

relation  of  ether  to   123! 

some  problems  in    443 

Immunization  with  living  bacteria    806 

Immunizing  bodies  of  Carl  Spengler   1239 

Incontinence,  nocturnal,  and  adenoids,  re- 
lation between   io6g 

Indicanuria    76S 

Individual  as  a  surgical  factor    992 

Inebriety,  psychological  basis  of    833 

Infancy,  urine  in  diseases  of    524 

Infant  feeding,  calorimetric  method  of   404 

Heubner's  system  of   1226 

percentage   1226 

science  and  art  of   1226 

mortality   11 14.  1226 

prematurely   born,   protection   of   29S 

Infants,  artificial  feeding  of    870 

gastric  digestion  in   11 19 

Infection,  amoebic,  treatment  of    453 

of  kidney  by  bacillus  coli  communis....  716 

rheumatic   1328 

triple   venereal    661 

tropical  malarial,  leucocytes  in    926 

Infections,  acute,  sodium  nucleinate  in....  29 

human  milk  in  treatment  of    396 

increased   euphoria   and   activity,  symp- 
toms of   353 

septic,  use  of  bacterial  vaccines  in....  871 
Infectious  disease,  acute,  treatment  of....  818 
Inflammations,  purulent,  of  hand,  hot  air 

treatment  of   1285 

Influenza  and  oedema  of  eyelids    83 

pneumococcus    714 

subacute  stage  of    857 

Injections,    hypodermic,    ato.xyl  mercuric 

iodide    for    389 

intraabdominal,  of  oxygen    741 

intramuscular,  in  treatment  of  syphilis.  240 
of  alcohol,  demonstration  of  ferment  by.  249 

in  treatment  of  neuralgias  189,  1236 

of   arsenic    and   tuberculin    in  tubercu- 
losis   402 

of  bromides  for  puerperal  eclampsia.  .  . .  338 

of   mercurial   oil    229 

in  syphilis    177 

of  mercury,  arsenic,  and    iron    in  the 

treatment  of  malignant   growths...  425 

of  mercury  salicylate  suspensions   353 

of  osmic  acid  for  trifacial  neuraligia  . .  345 

of  salt  in  sciatica    347 

of  tuberculin,  diagnostic    288 

of  sea  water,  in  children   1225 

Inoculation  accident  in  Manila  in  1906.  .  .  .1066 
Inoculations,  prophylactic,  against  typhoid 

fever    265 

Insanity  and  pelvic  disease,  in  women,  re- 
lation between   1217 

as  a  defence   11 20 

Insomnia,   treatment   of    493 

Insufficiency,  aortic,  and  syphilis    190 

Insurance,   life,   blood    pressure    in  rela- 
tion to   1040 

examinations,     significance     of  high 

blood  pressure  in    853 

Intertrigo,  inguinal,  treatment  of    803 

Intestinal  gases,  surgical  importance  of..  1036 

localization    762 

obstruction   560,  614,  974 

parasites  in  the  Philippines    860 

perforation  in  typhoid  fever    501 


Page. 

Intestinal  gases,  putrefaction,  inhibition  of  232 

resection    662 

Intestine,  large,  chronic  dilatation  of  iiiS 

small,  surgery  and  surgical  anatomy  of.  762 
Intestines,  crises  of  pain  in,  in  tabes. ...  1070 

perforation  of,  in  typhoid  fever   11 19 

small  resection  of,  for  gangrene   716 

syphilis   of   1120 

Into.xication,  food,  in  childhood.  ... 501,  1223 
Intrathoracic    physiological    and  technical 

studies   1220 

Intravenous   therapy    249 

Intubation  in  laryngeal  stenosis    873 

Intussusception  and  Henoch's  purpura....  557 
Inunction  method  of  administering  drugs.  191 
Iodine  an  antidote  for  carbolic  acid  poi- 
soning   29 

in  major  surgery    186 

ointment  for  ringworm  1272 

potassium    iodide    the    most  serviceable 

preparation  of   1230 

lodipin  in  syphilis   1238 

Iritis,  aetiology  and  diagnosis  of  v  1234 

rheumatic,  treatment  of    597 

Iron  extracted  from  eyeball  with  a  magnet.  1320 

in   chlorosis    177 

pills,  tonic,  for  asthenic  gout   . .  701 

Irrigation  treatment  of  puerperal  sepsis..  1261 

JAW,   cancer   of,    results   of  operations 
for   1030 

deformities,  aetiology  of    709 

Jenkins,  Norburne  B.  Occlusion  of  the 
eyes  in  the  study  of  their  aetiological 
significance    in    disturbances    of  the 

nervous  system    224 

Jews,  immunity  of,  from  alcoholism   298 

tuberculosis  among    37 

Job's  tears,   pharmacology  of    649 

Johnston,  James  C,  and  Schwartz,  Hans 
J.  Studies  in  the  metabolism  of  cer- 
tain skin  disorders   535,   590,  636 

Joint    affections,    gonorrhceal,  gonoccocic 

vaccine    in    456 

Joints,  tuberculous,  operative  treatment  of.  969 

Journal  of  gynaecological  urology    3*1 

of  physical  and  dietetic  treatment   290 

Judd,  Aspinwall.  Treatment  of  enlarged 
thyreoid  by  x  rays  and  high  frequency 

currents    25 

Jungle  plant  in  morphine  addiction    115 

V  ARPAS,  MORRIS  J.  General  paralysis.  471 

Kawar  and  condurango    2.39 

Keen,   \V.   W.     Professional  secrecy  and 

professional   duty    563 

Keller,  Morris  J.     Treatment  of  asphyxia 

neonatorum    174 

Keller,  William  L.    A  new  operation  for 

ingrowing   toe   nail    387 

Kennedy,  J.  W.  Conservatism  in  abdom- 
inal surgery    484. 

Keown,  J.  A.  The  treatment  of  pneu- 
monia, with  special  reference  to  •  the 

use  of  quinine   11 86 

Kidney,   altered   function   of,    in  diabetes 

dermoid  oyst  of    302 

diagnosis  of  diseases  of    695 

disease,  diagnosis  of    553 

hypernephroma  of    898 

in  scarlet  fever  and  diphtheria    300 

infection    of    kidney    by    Bacillus  coli 

communis    716 

infectious  diseases  of   1240 

pathology  of,  and  chemical  correlation.  390 

stone   in    302 

tuberculosis  of   760,  1066 

Kidneys,  amyloid  degeneration  of   1239 

decapsulation  of,  for  Bright's  _ disease.  185 
Kirkpatrick,  M.  B.    The  therapeutic  use  of 

alcohol    960 

treatment  of  chronic  eczema    337 

Kivlin,  C.  F.    A  new  method  for  the  rad- 
ical cure  of  indirect  inguinal  hernia.  528 
Klotz,  J.  E.    The  therapeutic  use  of  al- 
cohol   906 

treatment  of  acute  dysentery    750 

Knee  joint,  diagnosis  and  treatment  of  de- 
rangements in    715 

pains  in  diseases  of  hip  joint   1118 

unusual  case  of  curs'ature  of    401 

Knopf.  S.  Adolphus.  The  responsibility  of 
the  family  physician  toward  tubercu- 
losis   I 

Knott.  John.    Spontaneous  combustion. 782,  843 
Knowles.    Frank   Crozer.     Bromide  erup- 
tion in  childhood    586 

Krauss,     Frederick.      Acute  suppurative 

ethmoiditis    839 

ophthalmia   neonatorum    991 

Kuhn's  lung  suction  mask,  treatment  with.  559 

LABOR,    best    methods   for   the  prompt 
termination  of  first  stage  of    560 

hiematoma  vulvx  a  hindrance  to    860 

Laboratories,  county  bacteriological    238 

Laboratory,  keeping  and  handling  of  rats 

for  use  in  the    275 


Page 

Lacerations   of  cervix,    repair   of,  during 

puerperal  convalescence    153 

Lachrymal  duct,   treatment  of  obstruction 

of    968 

Lactic  acid  bacilli,  living,  in  treatment  of 

summer  diarrhoea   1224 

therapy    307 

treatment    763 

Lampert,    il.   A.     Treatment   of  chronic 

lead  poisoning    491 

Landry,   Adrian  A.     Treatment  of  acute 

dysentery    643 

Lange,   Sidney.     Bilateral   ununited  frac- 
ture of  patellae    853 

the  Rontgen  examination  of  the  oesopha- 
gus   159 

Language,  the  international    719 

Languages,    universal   664 

Laparocolpohysterotomy    558 

Laparotomies,  abdomir.al  supporters  after.  92 

Laparotomy,  early  rising  after    869 

mobility   of   patient   after    45 

Laryngitis  of  measles,  antidiphtheritic  se- 
rum in  treatment  of   1167 

Laryngotomy   and  laryngectomy   for  can- 
cer   293 

Larynx,  tuberculosis  of    36 

Lavage   in   treatment   of   suppuration  of 

ureter  and  renal  pelvis    245 

Lawson,  George  B.     A  study  of  alcohol- 
ism   4S0 

Laxatives  in  hyperchlorhydria   1202 

Lay  press,    need   for   medical  censorship 

for    470 

Lead  poisoning    650 

chronic,   treatment  of   439,  491 

Leary,    Timothy.     Medical  investigation 

and  newspaper  methods    460 

Ledbetter.  Robert  E.    Treatment  of  acute 

dysentery    700 

Lederer,  William  J.    Relationship  between 

dental  and  systemic  disturbances   65 

Leeks,  therapeutics  of   1054 

Leg  ulcers.  Unna's  treatment  of    556 

Leishmannioses   1070 

L'Engle.  Edward  il.     The  flagellation  of 

leucocytes   1133 

Leprosy,  fish  contagion  in    dog 

in    Hawaii   1 79 

Le  Roy,  Bernard  R.     Epithelial  cells  of 

skin  and  kidneys    642 

Leshure,    John.      Physiological    action  of 

strong  cocaine-adrenalin  solutions....  271 
Lesions,   local,    relation    of  constitutional 

conditions  to    612 

LETTERS  TO  THE  EDITORS: 

.\shmead,  Albert  S.     Fish  contagion  in 

leprosy    409 

Bauer,  F.  M.    The  sting  of  bees  as  a 

cure  for  rheumatism    876 

Drum,  J.  H.     Tuberculous  disease  and 

diphtheria  antitoxine    251 

Fridenberg,   Percy.       Opportunities  for 

the   Board  of  Health    563 

Hare.  Hobart  Amory.    The  unauthorized 

use  of  a  name  1288 

Henson,  Graham  E.     The  anopheles  the 

sole  carrier  of  malaria  I333 

Keen.  W.  W.    Professional  secrecy  and 

professional   duty    563 

Leary.    Timothy.     Medical  investigation 

and  newspaper  methods  '   460 

Mayo.  Caswell  A.     "Ampoule"  or  "am- 
pul"   775 

Millican,  Kenneth  \V.  The  international 

language   idea    719 

Morris,  Robert  T.      Successful  medical 

treatment  of  appendicitis    773 

Prout.  J.  S.     Night  clinics  in  Brooklyn.i  122 

Robarts,    Heber.      Thor-rad-x   772 

Rose,  A.    Greek  for  physicians   720 

Introduction    of   brandy    into  Greece 

through  physicians    46 

A  new  thesaurus   of  the   Greek  lan- 
guage   196 

Rosenheck.  Charles.  Dementia  precox.  92 
Talmey,  McLX.  Universal  languages  ....  664 
Taylor,  Arthur  N.    Professional  secrecy 

and  professional  duty    719 

Todd.  John  B.     Rhus  poisoning   251 

Waugh,    William    F.     Atropine    as  a 

haemostatic    564 

Weber.  Leonard.    Lest  we  forget    563 

Leuchaemia  in   advanced  life    295 

X  ray  treatment  of    241 

Leucocyte    count    in    diagnosis    of  pre- 
eclamptic   toxemia    714 

Leucocytes   and    opsonins,    action    of  col- 

largol  on    661 

achroniasia   in    351 

carcinoma  in  relation  to    494 

excitants  of    330 

flagellation   of   ii33 

in  meningitis    764 

in    tropical   malarial   infection    926 

influence  of  streptococcus  infection  upon  1285 

Leucocytosis  in  appendicitis    296 

Life  insurance,  blood  pressure  in  relation 

to   1040 


1344 


INDEX  TO  VOLUME  LXXXIX. 


Page. 

Life    insurance    examinations,  significance 

of  high  blood  pressure  in   853 

Light,    absorption  of,   by   the   skin   180 

treatment   of   lupus    41 

Lightning,  injuries  to  eye  due  to    817 

Lime  in  pathology  of  rhachitis  13-24 

Lithium   in   the   treatment  of   disease.  ...  1 176 

Liver  and  fat  embolisiti   17X 

function   of,   in   relation   to  metabolism 

of  fats    609 

in    tuberculosis   1120 

nodular  hyperplasia  of    87 

primary   carcinoma    of   1163 

Log,  medical,  of  U.  S.  S.  Virginia  on  the 

cruise  to  Pacific    922 

Lomax,  Eugene  W.  Treatment  of  chronic 

lead  poisoning    491 

Longenecker,   Q.  W.     Therapeutic  use  of 

alcohol   907 

Longevity  and  rejuvenescence    795 

Lung  suction  mask,  Kuhn's    559 

suture  of   457,   11 17 

Lungs  and  heart,  behavior  of,  after  opera- 
tions on  abdomen    766 

examination  of,  by  x  rays   1022 

incipient   tuberculosis   of    166 

surgery   of    190 

Lupus,   light   treatment   of    41 

tuberculous,  of  the  face    713 

Luys  urine   separator    91  b 

Lydston,  Frank.    The  excision  of  chancre.  579 

Lying  in  women,  early  rising  of   611 

Lymph   follicles  in  bone  marrow  of  chil- 
dren   766 

McCORMICK,    WILLIAM    S.  Treat- 
ment of  asphyxia  neonatorum   120 

McCoy,  George  W.    The  keejiing  and  han- 
dling of  rats  for  laboratory  purposes.  275 

McDowell,  the  late  Dr.  Ephraim    933 

centennial  of    911 

McMurray,  T.  E.     Treatment  of  chronic 

lead  |)oisoning    49^ 

McMurtry,  Charles  Wood.     The  use  of  a 
printed  chart  in  the  serum  diagnosis 

of   syphilis    954 

McMurtry.  Lewis  S.  Ephraim  McDowell.  933 
McRae,  Floyd  W.    Penetrating  wounds  of 

the    abdomen    521 

McWilliams,    Clarence    A.  Exophthalmic 

goitre   ,   678 

Mackinney,  William  H.,  and  Uhie,  Alexan- 
der .\.     Pathology  and  treatment  of 

chronic  gonorrhoea    213 

MacWhinnie,  A.  Morgan.    Digital  enuclea- 
tion of  faucial  tonsils  1087 

Magnesium  in  the  treatment  of  disease. .  1 176 
sulphate,  analgesic  effect  of  local  appli- 
cations of  solutions   of   1230 

Magnet  extraction  of  iron  from  eyeball.  .  1320 

operations    189 

Makuen,  G.  Hudson.    Indications  for  the 

removal  of  the  faucial  tonsil  1253 

Malaria    carriers  of  '3,33 

quartan  and  sstivoauturanal   925 

with  special  reference  to  what  is  not  ma- 
larial fever    924 

Malarial   fever,  tropical   1143 

infection,   tropical,   leucocytes  in   926 

Malformations,  congenital,  of  oesophagus.  870 
Malignant  disease,  medical  treatment  of..  605 

postoperative   treatment   of    191 

X  rays  in    81 S 

Marchisio,  Alexander.    Therapeutic  use  of 

alcohol    856 

Markley,  P.  H.    Myocarditis    61 

Massachusetts  General  Hospital,  consump- 
tion of  alcohol  and   other  medicines 

in    864 

Mastoid  operation,  radical,  conservation  of 

hearing  in    134 

Mastoiditis    826 

acute,  indications  for  operation  in  1300 

preventive  and  abortive  treatment  of.  .  222 
reasons  for  the  frequent  misunderstand- 
ing of    866 

results  in  four  hundred  operative  cases 

.    314 

Maxillae,   upper,   separation  of    710 

May.  James  V.     An  improved  method  for 
the  fixation  of  tissues  and  staining  of 

sections    596 

Mayo.  Caswell  .A.  ".\mnoulc"  or  "ampul".  773 

Measles  and  disinfection    807 

artidi'htheritic  scrum  in  laryngitis  of.  1167 
Meat  .IS  a  source  of  infection  in  tubercu- 
losis  1273 

poisoning   1324 

Mechanism,  autoproteclive,  of  human  body 

36>.  431 

Mechanotherapy,  priciples  of    553 

Medical  censorship  (or  lay  press,  the  need 

for   470 

cdiir.Ttion.  arbitrary  standards  in    233 

investieation  and  newspaper  methods....  460 

journalism,   oficial    31 

journals,  f|ut>^tifinable  ethics  of   195 

laws    and    the    physician,    relation  be- 
tween   238 


Page. 

Medical  matters,   newspaper  treatment  of, 

460,  494 

men,  memorials  of    600 

mind    629 

news  by  cable    76 

profession,  ethics  of    201 

relief  from  overcrowding  of    127 

societies,   need    of   endowments   for....  40- 

society,  the  county    725 

students,  preliminary  education  of   812 

titles,  changing  fashions  in  the  use  of.  600 

words  commonly  mispronounced    409 

Medicine  and  religion    233 

in    1500   B.    C   403 

military,  as  a  career    9t.j 

newspaper   75,    254,  289 

practice  of,  as  a  career    91S 

preventive,   bearing  of  pathological  dis- 
covery upon    568 

relation  of  medical  profession  to.. ..1222 
Medicoliterary  notes,   978,  1171,  1242,  1289,  133  t 
Meeker,    Harold    Denman.     The  intraab- 
dominal injection  of  oxygen    741 

Meligrin    230 

Meller's    operation    for    removal    of  tear 

sac    239 

Meningitis  and  hexamhethylenamine   860 

carcinomatous,  diagnosis  of    299 

cerebrospinal,  sequelae  of    401 

serum  treatment  of    238 

chronic   spinal    608 

circumscribed  serous  spinal    822 

leucocytosis  of    764 

treatment  of,  with  the  Flexner  serum.  1225 

treatment  of   1324 

in  pneumonia   1284 

purulent,  operative  treatment  of    137 

serous,  acute    611 

tuberculous,   without  tubercles   11 66 

Meningococcus  in  nasal  fossa   40 

Menstruation,  first,   and  pelvic  defects...  756 

nature   of    659 

Mental    alienation    in  women    and  pelvic 

disease   1217 

Mercurial  oil  injections   177,  229 

Mercury,  high  percentage  mixtures  of,  in 

syphilis   87 

in   the   treatment   of   tuberculosis  11 80 

succinimide  in  syphilis    74 

Metabolism  of  certain  skin  disorders.  .  535, 

590,  636 

Microphotography  and  microscopy,  clinical.  611 

Midwifery,  our  forefathers  in   192 

Milk,  breast,  quantity  and  quality  of,  dur- 
ing first  two  weeks  of  puerperium  .  .  .  930 

for    infants    85 

mixtures,  middle   

pasteurization  of,  and  the  medical  pro- 
fession   806 

sickness,  cause  of   1067 

whey  obtained  by  colloidal  separation...  974 
Miller,    George    I.      A   correct  definition 
for    abdominal    hernia    illustrated  by 

two   cases    803 

Millican,  '  Kenneth   W.    The  international 

language    idea    719 

Mind,  the  medical    629 

Mineral   springs  of   Saratoga    446 

waters   in   gastrointestinal   disorders.  .  .  .  486 
Mitchell,  O.  W.  H.     Pancreatitis  from  ob- 
struction of  duct  by  a  calculus  at  the 

ampulla  of  Vater   1196 

Moore,  J.   Lytle.       Treatment  of  chronic 

lead  poisoning    439 

Moro  tuberculin  reaction   1031 

Morphine  addiction,  the  jungle  plant  in...  115 
Morris,    Robert    T.       Successful  medical 

treatment  of  appendicitis   773 

Morris's  point  of  tenderness  an  aid  in  di- 
agnosis   81 

Morrow,  Prince  A.  Blindness  of  the  new- 
born and  its  prophylaxis  through  edu- 
cation of  the  public    98S 

Morse,  John  Lovett,  and  Crothers,  Bron- 
son.  The  urine  in  diseases  of  in- 
fancy   524 

Moskowitz,  Samtiel.  .Spontaneous  absorp- 
tion  of  incipient  cataract    6<) 

Treatment  of  chronic  eczema   334 

Mosquito,  extermination  of    36 

Mouth    breathing,     orthopa:dic  treatment 

of    5ii 

cancer  of,  results  of  operations  for...  1020 

Mucus,  gastric,  secretion  of  1324 

Murray,  Dr.  Robert        resolutions  on  the 

death  of    826 

Mustard,  hedge,  therapeutics  of   1054 

in  treatment  of  bronchopneumonia.  .  .  .  389 
Myocarditis   in   chihlren   caused   by  toxne- 

mia   1 295 

pathological   symptoms  of   61 

Myogenic  and  neurogenic  theories  of  car- 
diac arrhythmias  11 14 

Myoma  and  myosarcoma  of  stomach   301 

and  pregnancy    349 

of   cervix    uteri    90 

Myomata,  uterine,  enucleation  of   12 19 

Myomectomy,  abdominal    352 

in  pregnancy   1219 


Page. 

Myopathy  and  syringomyelia   11 14 

atrophic    713 

Myosarcoma  and  myoma  of  stomach    301 

Myositis   ossificans,   traumatic  1284 

Myotonometer    456 

Myxoedema    613 

a  curable  condition   1221 


■^ARCOSIS   with   artificially  diminished 

■'^  circulation   

Nasal  permeability,  apparatus  to  determine. 

septum,  deflection  of   

submucous  resection  of   

Nascher,     J.     L.       Longevity    and  reju- 
venescence   

Neoplasms,   malignant,   of  upper   air  pas- 
sages, X  ray  treatment  of   

Nephralgia   

Nephritics,  mydriatic  action  of  serum  of.. 

Nephritis  and  cutaneous  irritation  

deficient   oxidation   in   relation  to, 

1000,  1046,  1091, 

traumatic   

Nephropexy,  indications  for   

Nephroureterectomy  in  women   _  . 

Nerve,  optic,  lesions  of,  in  oxycephalus.  . 
sheath    in    causation   and   treatment  of 

neuralgia   

Nervous  disease,  serum  diagnosis  of  syi  h- 

ilis  in  relation  to   "... 

simulating  pelvic  disease   

treatment  of   

Nervous  system,  syphilis   and  parasyphilis 

of  

cable  of   

disturbances,  aetiological  significance  of 

pulse  of   

significance  of  the  eyes  in  

sympathetic,  in  pathology  

Neuralgia,   injections   of  alcohol   in  treat- 
ment of   189, 

liniments  for   

nerve  sheath  in  causation  and  treatment 

of   

trigeminal,  intracranial  causes  of   

operative  treatment  of   

Neurasthenia   

battleship   

mental  aspect  of   

nature  and  treatment  of   

relation  of  surgery  to   

treatment  of   1 39, 

by   static  electricity  

Neuritis,  arsenical   

Neurogenic  and  myogenic  theories  of  car- 
diac arrhythmias   

Neuroretinitis  due  to  typhoid  fever  

Neuroses, -gastric   507. 

relation  of  surgery  to   

Newborn,  blindness  of   

its   prophylaxis  through   education  of 

the  public   

from  standpoint  of  obstetrician   

from  standpoint  of  the  ophthalmol- 
ogist   

haemorrhagic  diseases  of   


87 
558 
507 
427 

795 

921 
13^6 

400 
I  012 

I '34 
1239 
1068 
12 1 9 
558 

918 

821 
603 


1281 
981 

970 

2J4 

702 

1230 
74 

918 
623 
623 
331 
250 
193 
693 
356 
444 
114 
656 

1 1 14 
748 

872 
356 
991 


986 

982 
37 


NEW  INVENTIONS: 

Anderson,  A.  M.    A  new  frontal  sinus 

punch    460 

Hays.  Harold  M.    A  pharyngoscope   822- 

Panoff,  Charles  Edward.    A  new  sound...  1240 
Perkins,  Charles  E.     A  new  tonsil  for- 
ceps   304 

New  publications   358,  668,' 824,  1072,  1122 

New  remedies   230,  389,  598 

News,  medical,  by  cable    76 

Newspaper  medicine   7;,  254,  289 

methods  and  medical  investigation    460 

treatment  of  medical  matters   494 

Newton,  Richard  Cole.    Clinical  history  of 

cases  of  so  called  cardiac  epilcnsv .  .  .  .  1 293 
Nicoll,  .Alexander.    The  surgical  service  of 

Fordham  Hospital    322 

Nitroglycerin,  therapeutics  of   285 

Noble,   Charles    P.     The   doctor  and  the 

nurse    881 

Noguchi's  method  for  serum  diagnosis  of 

syphilis    973 

Noma    864 

Nomenclature    and    classification    of  dis- 
eases  126,  lOll 

of  diseases  and  conditions,  the  Bellevue 

Hospital   1016,  io6i,  1108,  1159 

of   National  Formulary    969 

Nomenclature  of  United  States  Pharmaco- 

Iioeia  and  National  Formulary  1330 

system  in   1205 

Nose  and  cars,  affections  of.  in  relation  to 

skin  diseases    465 

bismuth  paste  in  suppuration  of    132 

deformities  of,  aetiology  of   709 

diagnostic  reaction  of  tuberculin  on  mu- 
cous membranes  of   76- 

methods  of  examination  of   817 

obstruction  in    657 

Nose,  submucous  resection  of  cartilage  of  1260 
Notes,  medicoliterary.  978  1171.  I24-'.  1229.  1334 
Nurse   and   doctor,   relations   existing  be- 
tween   88 1 


INDEX  TO  VOLUME  LXXXIX. 


1345 


Pagf. 

Nurse  for  persons  of  moderate  income...  242 
of  Polyclinic  Hospital  Training  School, 
adO.ress  delivered  at  graduation  of....  15 


ATMEAL  in  diabetes  mellitus    916 


o 


OBITUARY: 

Bull.  William  Tillinghast,  M.  D.,  of  New 

York    448 

Chalmers,    Mattlievv,    Ji.    D.,    of  New.. 

York    128 

Conner,  Phineas  Sanborn,  M.  D.,  LL.D., 

of   Cincinnati    705 

Denison,  Charles,  M.  D.,  of  Denver....  128 
Hughes,  William,  M.  D.,  of  Lima,  Ind..ii5b 
Knight,    Frederick    Irving,    M.    D.,  of 

Boston    448 

ilcCollom,  William,  Jl,  D.,  of  Brooklyn.  497 
Murray,    Robert    A.,    M.    D.,    of  New 

York    497 

Penrose,  Richard  A.  F.,  M.  D.,  LL.  D., 

of  Philadelphia    33 

Reamy,  Thaddeus  Asbury,  M.  D.,  LL.D., 

of   Cincinnati,   Ohio   602 

Rindfleisch,    Ceorg   Eduard,   M.    D.,  of 

\\  urzbursr    128 

Robertson,  Douglas  Argyll,  M.  D.,  LL.D., 

of  tdinbuigh    234 

\\  ey,  Hamilton  Dox,  il.  D.,  of  Elmira, 

N.  V   653 

\\  ynkoop,   Cerardus   Hilles,   M.    D.,  of 

New  York   1058 

Obstetric  and  gynaecological  operations,  ir- 

r:gation  and  drainage  in   1219 

0.bsteirics,  clinical   and  private   401 

limitation  of  aseptic  precautions  in   136 

oration*  in   193 

the  problem  of    90 

Obstruction,  intestinal    614 

due  to  volvulus    560 

enterostomy  in    974 

following  operation  for  appendicitis...  560 

nasal    657 

of  bowels    353 

of  lachrymal  duct,  treatment  of   968 

CEdema,  acute  pulmonary    340 

of  eyelids  in  influenza    83 

CEsophagus,  congenital  malformations  of..  870 

idiopathic  dilatation  of   I077 

malformations  of    87') 

stricture  of    186 

X  ray  examination  of    159 

Ogilvy,  Charles.     Symptoms  arid  diagnosis  of 

so  called  clironic  rheumatism  1197 

Olecranon,  fractures  of    350 

Oliguria,  orthostatic,  and  albuminuria   973 

Omentum  a  factor  in  abdominal  surgery..  42 

versatile   I33- 

Operations,  pulmonary  embolism  following.  133 

undesired  results  after    559 

Ophthalmia  reonatorum   240,  991 

campaign  against    32 

Ophthalmodiaphanoscope    189 

Ophthalmoreaction    for    tuberculosis  dur- 
ing pregnancy    457 

Opium  smokers  in  the  Philippines  294 

Opsonic  index  as  a  clinical  aid   772 

Opsonins  and  leucocytes,  action  of  collar- 

gol  upon    661 

Optic   nerve,   disease  of,   following  injec- 
tions of  arsaretin   11 18 

Organs,  generative,  in  women,  repair  rath-  • 

er  than  removal  of    92 

Osmosis    125 

Osteitis,  acute  infective    923 

Otitis     media     complicated     by  cerebral 

lesions    792 

treatment  of   1009 

Otology,  oration  in    193 

Ovaries,  conservative  surgery  of  1219 

Ovariotomy  in  pregnancy   121 9 

Overfeeding  and  angina  pectoris   575 

Ovum,  human,  development  of,  during  first 

eight  weeks  of  pregnancy    90 

Oxidation,  deficient,  in  relation  to  nephri- 
tis  1000,  1046,  1091,  1134 

Oxycephalus,  lesions  of  optic  nerve  in...  558 
Oxygen,      intraabdominal  administration 

of   74i>  766 

PAIN  and  haemorrhage  as  symptoms  of 
extrauterine  gestation    971 

Palate,   cleft,    and  hare   lip,   technique  of 

operations  for   11 69 

operative  technique  in    251 

Palier,  E.    Successful  medical  treatment  of 

appendicitis    54° 

Palmer,  W.  H.     Concerning  the  need  for 

medical  censorship  of  the  lay  press..  470 

Pancreas,  atrophy  of    401 

Cammidge  reaction  in  diseases  of   812 

diseases  of    714 

in  diabetes  mellitus   1102 

test  of  function  of  1240 

Pancreatic  extract  in  treatment  of  diabetes.  609 

Pancreatitis   1222,  1235 

acute   89,  1235 

diagnosis  and  treatment  of  11 18 

obstructive   11 96 


Page. 

Panoff,  Charles  Edward.     A  new  sound..  1240 

Papilloedema,  operative  treatment  of   511 

Parabiosis  of  mammals  of  different  sexes..  137 

Paraguay  tea    352  ■ 

Paralyses  of  childhood    749 

Paralysis,  acute  ascending   608 

general    471 

infantile,  scoliosis  following    765 

of  serratus    352 

Volkmann's  ischsmic    243 

Paralytic  conditions  of  childhood    749 

Parasites,  intestinal,  in  the  Philippines   860 

Parasyphilis  of  nervous  system,  treatment 

of   1281 

Parathyreoid  bodies  and  tetany    446 

Paresis,  general,   immunity  against  tuber- 
culosis in    396 

Parisianomanie    860 

Parotiditis,    prevention    of,    during  rectal 

feeding   1282 

Parrish,  Henry.     The  "third  tonsil"   683 

Patella!,  ununited  fracture  of    852 

Pathogenic  organisms,  invisible  H55 

Pathological    discovery    and    its  bearing 

upon  preventive  medicine    568 

Peckham,  F.  E.     Flat  foot   734 

Pedersen,  .Tames.     Common  errors  in  the 

treatment  of  urethra  and  bladder   895 

The  treatment  of  acute  gonococcic  ure- 
thritis in  the  male    149 

Pellagra    936 

in  the  United  States    510 

treatment  of   1009 

with  atoxyl  and  arsenic    610 

Pelvic  disease,  nervous  disorders  simulat- 
ing  60s 

Pelvis,  defects  in,  and  the  first  menstrua- 
tion  '.   756 

fractures  of    457 

Pepsin  in  disorders  of  stomach  1321 

in  infant  stomach,  occurrence  of  1327 

Percussion    818 

Perforation,  intestinal,  in  typhoid  fever   501 

Pericolitis   1331 

Perineorrhaphy,  submucous   1066 

Periostitis,  multiple  acute   1240 

Peristalsis,  Rontgenographic  studies  of   822 

Perithelioma  of  carotid  gland   555 

Peritonitis,  caecostomy  and  continuous  colo- 

clysis   in   11 13 

in  children    41 

septic,  due  to  appendicular  inflammation.  42 

•tuberculous   615.  1286 

Perkins,  Charles  E.    A  new  tonsil  forceps.  304 
Peters,  W.  H.    The  sexual  factor  in  tuber- 
culosis   116 

Pfeiffer's   fever    239 

Pharmacodynamics,  growth  of    456 

Pharmacology   1307 

Pharmacomania    701 

Pharmacopceia,    additions  to   and  elimina- 
tions from   1328 

and  National  Formulary,  drugs  and 
preparations  recognized  by,  a  suffi- 
cient   armamentarium    for  medicinal 

treatment  of  disease   13^0 

criticisms  of   1314 

efforts  to  popularize   1314 

in    Spanish   1 204 

methods  of  revision  of    501 

Ninth  Decennial  Convention  for  the  Re- 
vision of    962 

nomenclature  of   1330 

problems  in  revision  of   1226 

preparations  from,  from  the  practitioner's 

standpoint   1328 

report   of   committee    on,    of  American 

Medical  Association   i3.''o 

work  of  physicians  in  improving  1329 

Pharmacopceial  convention,  medical  repre- 
sentation at    599 

Pharyngoscope    822 

Phenolphthalein  as  a  purgative   1230 

clinical  use  of   1230 

Philippines,  hook  worm  disease  in    329 

military  sanitary  problems  in   250 

sanitation  in    346 

Phosphatic  index    970 

Phosphergot    74 

Phosphorus  poisoning    766 

Phthisiophobia   1222 

Phthisis,  fibroid,  in  children    451 

Physician   and  medical   laws,  relation  be- 
tween  238 

familv,  responsibility  of,  in  tuberculosis.  i 

Physiologv,  lessons  from    242 

Piffard,   Henry   G.     Some   problems  con- 
nected with  tuberculosis   1245 

Pigment  cirrhosis  and  bronze  diabetes....  920 

Pitfield,  Robert  L.    The  medical  mind   629 

Pithiatism    352 

Placenta  pra-via   1234 

and  eclampsia,  treatment  of    457 

centralis    137 

post  partum  haemorrhages  of    66 1 

treatment  of    506 

Plague  in  San  Francisco    859 

Pleura,  diagnosis  and  treatment  of  morbid 

conditions  of   1166 


Pag-;. 

Pleura,     sterile     serous     effusions  with 

empyema  of    92! 

surgery  of    356 

Pleurisy,  dry  treatment  of    286 

Grocco's  sign  in    964 

a  mode  of  origin  of  tuberculosis    659 

tuberculous,  and  empyema,  relation  be- 
tween  ,220 

Pleuritic  deposits,  fibrolysin  in    299 

Pleuritis,  fibrinous  and  serofibrinous   864 

purulent    245 

serofibrinous,  autoserotherapy  in   456 

Pneumectomy  with  aid  of  differential  pres- 
sure  1220 

Pneumonia,  cardiac  and  vascular  complica- 
tions in   1215 

catarrhal,  treatment  of    389 

meningitis  in   1284 

cortical  motor  ajihasia  after   1285 

quinine  in  the  treatment  of   1186 

treatment  of    350 

Pneumothorax,  chronic    "41 

Poison,  diachylon  as  a    341 

Poisoning,  bismuth   1118 

by  potassium  permanganate    904 

from  bismuth  subnitrate    16 

ice  and  meat   13-24 

lead    650 

phosphorus   766 

rattlesnake   1022 

„  r'^us    251 

Poisons,  a  consideration  of   904 

Polak,  John  Osborne.     Acute  gastric  dila- 
tation as  a  postoperative  complication.  1 1 84 

Polioencephalitis,  syphilitic    85 

Poliomyelitis,  acute  anterior,  epidemic  of.  452 

anterior   1320 

epidemiology  of    769 

symptomatology  of    769 

treatment  of    770 

Polypus,  nasoantral    297 

Porche.-,  W.  Peyre.     Submucous  resection 

of  the  cartilage  of  the  nose  1260 

Porro  Caesarean  section    303 

Portio  pylorica— where  is  it?    920 

Potassium    iodide    the    most  serviceable 

preparation  of  iodine   1230 

permanganate,  poisoning  by    904 

Pott's  disease,  backache  in  1280 

Poultice  masses,  cooling  of    554 

Powders,  mobile,  use  of    649 

Pratt.  .7.  A.    Deafness  following  febrile  dis- 
eases and  its  prevention   1007 

Precipitin  reaction  in  diagnosis  of  hydatid 

disease    972 

Prediction  in  medicine    650 

Pregnancy  and  myoma    349 

cardiac  disease  a  complication  of   138 

complicated  by  appendicitis    890 

by   cancer   of  cervix  1163 

by  exophthalmic  goitre   128b 

by  fibromyomata  of  uterus    3S 

by  glycosuria    loi 

b.v  ovarian  cystoma    90 

by  uterine  fibroids    90 

development  of  ovum  during  first  eight 

weeks  of   90 

experimental  influencing  of    189 

extrauterine    45 

operation   for    40 

ophthalmoreaction  for  tuberculosis  dur- 
ing   457 

ovariotomy  and  myomectomy  early  in..i2i9 

pruritus  in    230 

streptococci  in  genital  secretions  during.  816 

toxaemia  and  eclampsia  of   138,  1218 

Press,  lay,  need  of  medical  censorship  for.  470 
Prince,   A.   E.     An   operation  for  frontal 
sinus  obliteration  avoiding  supraorbital 

deformity  and  nasal  scar    949 

Proescher,   Frederick.     Further  investiga- 
tion of  the  spirochaeta  lymphatica   848 

Propaesin    230 

Proprietaries,  an  Australian  report  on....  704 
Proprietary  medicine,  a  novel  founded  on.  807 

Prostate,  cancer  of,  early  diagnosis  of  1237 

physiological  signification  of    41 

study  of,  with  reference  to  curability  of 

gonorrhoea    580 

Prostatectomy    452 

problems  relating  to   ',   240 

suprapubic    302 

Prostatitis,  symptomatology  of   554 

Protein  ration  in  tuberculosis    397 

Protozoa,    action    of    drugs    on  diseases 

caused  by    613 

Prout,  .T.  S.    Night  clinics  in  Brooklyn  1122 

Pruritus  in  pregnancy,  application  for   230 

Pseudodysentery    714 

Pseudomyxoma  peritonei  ex  processu  ver- 

miformi    401 

Pseudoperitonaeum   1221 

Psoriasis   401 

Psychometer,  galvanic    661 

Psychoneuroses  and  digestive  disturbances.  816 

Psychoses,  epileptic,  treatment  of   401 

Psychosis,  zoophil    555 

Psychotherapy,  discussions  on  1099 


INDEX  TO  VOLUME  LXXXIX. 


Page. 

Psychotherapy,  some  aspects  of.   131 

Ptosis,    visceral,   as   a  constitutional  ano- 
maly   661 

mechanical  treatment  of    I94 

I'ubiications,  new   253,  358,  513,  668,  824, 

1072,  1122 

Puerperal  pyaemia,  treatment  of   1280 

sepsis   

irrigation  treatment  of   1201 

Pulse  ol  nervous  system    970 

Puncture   of   brain   Oi  1 

treatment  of  epididymitis   869 

Purgatives,  phenolphtiialein  and  its  deriva- 
tives used  as   .._  1230 

Purpura    haemorrhagica    caused   by  colon 

bacillus    658 

I'uruient  processes,  new  methods  of  treat- 
ment of    299 

Putrefaction,  intestinal,  inhibition  of   232 

I'yelitis  of  pregnancy    349 

Pyelocystitis   1117 

Pylorus,   congenital   hypertrophic  stenosis 

of    332 

diverticulum  of    121 7 

hypertrophic  stenosis  of   1222 

Pyucyanasis  in  treatment  of  diseases  of  the 

nose,  throat  and  ear   870 

QUIGLEY,  Dr.  John  J.,  resolutions  on 
death  of    255 

(juinine  in  treatment  of  pneumonia  1186 

proper  method  of  employing    546 

RABIES,  prevention  of    241 
in  relation  to  bacteria  1233 

in   surgery    454 

Rats  for  laboratory  purposes,  keeping  and 

handling  of    275 

Rattlesnake  poisoning   1022 

READERS'  DISCUSSIONS: 

Alcohol,  therapeutic  use  of  854,  905,  957 

Appendicitis,  nonoperative  treatment  of, 

1097,   1148.   1200,  1269 
Asphyxia  neonatorum,  treatment  of, 

26,  70,  120,  174 
Dysentery,  acute,  treatment  of.. 643,  698,  750 
Eczema,  chronic,  treatment  of.. 225,  283,  334 
Lead   poisoning,   chronic,   treatment  of 

439.  49: 

Tuberculosis,  pulmonary,  early  diagnosis 

of   1311 

Rectenwald,  J.  J.    Double  dilator  for  use 

in    obstetrics    and    gynaecology   627 

Rectum,  congenital  absence  of   

Rejuvenescence    and   longevity..'.   795 

Religion  and  medicine   233 

Remedies,  new  177,  230,  389,  598 

Resection,   intestinal    662 

of  caecum   1282 

submucous,  of  nasal  s^eptum   427 

Resolutions  on  the  death  of  Dr.  Carlton  P. 

Flint    306 

Dr.  John  J.  Quigley   255 

Dr.  Robert  A.  Murray   826 

Respiration,  artificial    973 

mechanism  underlying  methods  of....  815 
Rest,   graduated,    in  treatment   of  pulmo- 
nary tuberculosis    868 

Resuscitation  after  apparent  death   30 

Retrofle.xion  of  uterus,  treatment  of  1117 

Retroversion  of  uterus  after  childbirth   616 

Rhachitis,  lime  in  pathology  of   1324 

traces   of,   in   adults    29-^ 

Rheumatic  fever   1024 

and  valvular  disease  1068.  11 15 

Rheumatism,  acute,  allies  and  counterfeits 

of  1165 

symptoms  and  diagnosis  of   1197 

sting  of  bees  as  a  cure  for   876 

true  132S 

treatment  of  348,  898 

Rhinitis,  chronic,  insufflations  for   857 

Rhinoreaction  to  tuberculin....   765 

Rhinoscleroma,  treatment  of,  with  x  rays..  505 

Rhus  poisoning,   251 

Rib    cervical   299,  714 

Rickets,   blood   in  1024 

digestive   troubles   in   85 

Riesman,  David.    Address  to  nurses   15 

Rinderpest,  Ruediger's  antiserum  for  860 

Ringworm,  iodine  ointment  for   1272 

of  scalp,  X  ray  treatment  of   11S7 

Robarts,  Heber.    Thor-rad-x   772 

Robinson.   A.    R.     Some  cutaneous  cyst 
formations  and  unusual  disease  of  the 

hair  follicle   1125 

Robinson,  Beverley.    Treatment  of  appen- 
dicitis   88s 

Robinson,    Byron.     A    ureterorcnal  deca- 
Robinson,  W.  F.    Long  life  and  hot  cli- 
mates   800 

Rocky  Mountain  fever,  aitiology  of   399 

Rontgen  ray  and  aetiology  of  cancer   710 

treatment,    external,    of   internal  struc- 
tures (eventration  treatment)   621 

Rose,  A.    Greek  for  physicians   720 

Introduction    of    brandy    into  Greece 
through  physicians    46 


PAGf. 

Rose,  A.    A  new  thesaurus  of  the  Greek 

language    196 

Rosenberger,    Randle   C.     Tubercle  bacilli 

kin  the  circulating  blood  1250 
osenheck,  Charles.    Dementia  praecox   92 

The  paralytic  conditions  of  childhood..  749 
Rucker,  S.  T.     Nature  and  treatment  of 

neurasthenia    693 

Ruediger's   antiserum  for   rinderpest   860 

Ruminatio  humana    87 

Kunyon,  F.  J.  Treatment  of  acute  dysen- 
tery   644 

Rupture  of  aorta,  spontaneous   713 

Ryan,  \V'.  J.    Treatment  of  acute  dysentery  752 

C  .\CROILIAC  joint,  anatomy  and  clini- 

cal  importance  of  1218 

b«ptatome,  the  Avery  nasal  347 

Saeptum,  auricular,  gumma  of   1325 

nasal,   deflection  of    507 

deviations  of    656 

submucous  resection  of   427 

Sajous,  Charles  E.  de  M.  Is  the  human 
body  supplied  with  an  autoprotective 

mechanism?   361,  431 

Saliva,  role  of,  in  transmission  of  tuber- 
culosis   972 

Salivary  calculi    375 

Salt,  action  of,  in  impaired  gastric  diges- 
tion   456 

comrnon,  in  relation  to  uraemia   816 

toxic  action  of   249 

free  diet  in  treatment  of  disease   817 

injections  in  sciatica   347 

.Salts,  fluorescent,  in  surgery   1325 

Samuels,  A.     Gonorrhoeal  urethritis  in  the 

female    584 

Sanatorium  for  Tuberculosis,  U.  S.  Marine 

Hospital,  at  Fort   Stanton,   N.   M   417 

treatment  of  tuberculosis,  inadequacy  of  1251 

Sanitation  in  Philippine  Islands  250,  346 

in  the  tropics   13' 5 

Saratoga  mineral  springs   446 

Sarcoma,  Coley's  fluid  in  treatment  of  1239 

of  female  mammae   192 

of  fibula   1071 

of  gum,  action  of  x  rays  on   505 

primary,  of  stomach  loii 

Scalp,    X   rays    in  treatment   of  diseases 

of   1152,  1167 

Scapula,  excision  of   297 

Scarlatina    239 

Scarlet  fever  carriers   612 

complications  of    299 

gastrointestinal  troubles  in   661 

heart  in    300 

necrotic  angina  of  1055 

ocular  complications  in   300 

renal    complications   in   300 

serum  reaction  of  syphilis  in   299 

Wassermann's  reaction  in  11 18 

Scharaberg,  Jay  Frank.     Smallpox  before 

and  since  the  discovery  of  vaccination  98 
Schistosomiasis,    with   reference  to  obser- 
vations in  Hunan,  China   927 

.School  teachers,  health  of   446 

Schools,  boarding,  medical  supervision  of. .1215 

of  medicine,  a  step  toward  unity  of  1055 

Schwartz,  Hans  J.,  and  Johnston,  James 
C.  Studies  in  the  metabolism  of  cer- 
tain skin  disorders  535,  590,  636 

Sciatica,    liniment   for  29,  286 

salt  injections  in   347 

Science,  French  medical,  during  the  Mid- 
dle Ages    978 

Scleroderma,  report  of  a  case  of   242 

Scoliosis  following  infantile  paralysis   765 

Scopolamine  morphine,  action  of,  on  heart, 

liver,  and  kidneys   762 

Scottish  nurses  and  home  rule   601 

Seasickness,  calcium  chloride  in   299 

Sea  water,  subcutaneous  injections  of,  in 

children  1225 

Secrecy,  professional,  in  relation  to  pro- 
fessional duty  496,  563,  719 

Section,  abdominal,  factors  which  contrib- 
ute to  low  mortality  in  1219 

Caesarean    690 

elective    656 

Selfdecapitation,  intrauterine    401 

Sepsis  from  Friedlaender  bacillus  1168 

puerperal    58 

irrigation  treatment  of   1261 

tetragenous    190 

Serum  and  vaccine  therapy,  present  status 

of   1233 

antitryptic,  diagnostic  power  of   40 

Behring's  antidiphtheritic    921 

in  practical  surgery   816 

of  syphilis   190,  396,  816,  954 

clinical  value  of   207 

in  relation  to  nervous  disease   821 

of  nephritics,  mydriatic  action  of   400 

reaction  in  cancer   251 

cf  syphilis  in  scarlet  fever   299 

Wassermann's   402 

treatmcnl  of  cerebrospinal  meningitis..  238 
Sewage,  discharge  of,  into  tidal  waters   865 


Page. 

Sexual  characteristics  and  suprarenal  cap- 
sules, correlation  between   456 

continence   and   arteriosclerosis   298 

Sexual   factor   in  tuberculosis   116 

Shaffer,  Newton  M.  The  care  and  treat- 
ment of  crippled  and  deformed  chil- 
dren   264 

Sheddan,  L.  Therapeutic  use  of  alcohol..  905 
Shock,  condition  of  peripheral  bloodvessels 

in    82 

Shoemaker,  Harlan.  Prophylactic  inocula- 
tions against  typhoid  fever   265 

Shoemaker,  John  V.  Sodium,  lithium,  cal- 
cium, and  magnesium,  and  their  ac- 
tion in  the  treatment  of  disease  1176 

SichUr,    E.    H.     Treatment    of  asphyxia 

neonatorum    73 

Sigler,  C.  L.  Treatment  of  asphyxia  neo- 
natorum   71 

Sigmoid  colon,  adhesions  of,  intestinal  ob- 
struction due  to   560 

redundant    614 

Silkworth,  W.  Duncan.    The  jungle  plant 

in  morphine  addiction   115 

Sill,  E.  Mather.  The  Calmette  ophthalmic 
reaction  to  tuberculin  in  the  diagnosis 

of  tuberculosis    377 

Singer,   David  A.     Autointoxication  with 

acetonuria  and  extreme  bradycardia.  .  1 303 

Sinus,   frontal,  foreign   bodies  in   974 

a  new  punch  for   460 

infections,  nasal  and  accessory,  intra- 
cranial lesions  consecutive  to   132 

maxillary,  trepanation  and  curettage  of..  558 
thrombosis  of  otitic  origin,  relation  of 

streptococchaemia  to   1141 

Skeleton,   oldest  human   1285 

Skin,  absorption  of  light  by   180 

and  kidneys,  epithelial  cells  of   642 

blastomycosis  of    922 

diseases,    affections    of    oral    and  nasal 

cavities  related  to   465 

metabolism  of  535,  590,  636 

modern  methods  of  treatment  of  11 52 

infection  theory  of  bilharziosis   814 

irritation  of.  and  nephritis  1012 

superficial  carcinoma  of   506 

Skull,    fracture   of  186,  301 

surgery  of   1234 

traumatism  of   11 18 

Sleep,   electric   1221 

Smallpox  before  and  since  the  discovery 

of  vaccination    98 

Smith,  F.  H.    Nonoperative  treatment  of 

appendicitis   11 48 

Smith,  S.  ilacCuen.  The  importance  of 
cerebral  lesions  complicating  suppura- 
tive otitis  media   792 

Smith,  Thomas  A. ;  Dow,  Edmund  L. ; 
Carlisle,  Robert  J.;  and  Coleman, 
Warren.  The  Bellevue  Hospital  nom- 
enclature of  diseases  and  conditions.. 

1 016,  1 06 1 ,  II 08.  1 1  59 
Smoking,  excessive,  effects  of   39 

SOCIETIES,  PROCEEDINGS  OF: 

American    Association    of  Obstetricians 

and  Gynaecologists   43.  88 

American  Medical  Association ...  1 209.  i3-"8 
American  Society  of  Tropical  Medicine..  924 
College   of    Physicians   of  Philadelphia 

510.  S22 

Medical  Association  of  the  Greater  City 
of  New  York  138,  561,  665,  872 

Medicaf  Jurisprudence  Society  of  Phila- 
delphia  .-...1120 

Medical  Society  of  the  State  of  New 
York    238 

Medical  Society  of  the  State  of  Penn- 
sylvania  192,  407,  457,  562,  614.  767 

New  York  Academy  of  Medicine. .  .508, 

613,  716 

New  York  Neurological  Society   819 

Southern    Surgical    and  Gynaecological 

Association  300,  353.  404 

Western  Medical  and  Gynaecological  As- 
sociation  074.  luJ.i,  lo-o,  116S.  1287.  1330 

Sodium,  in  the  treatment  of  disease  11 76 

nusleinate  in  acute  infections   29 

Solutions,   cocaine-adrenalin,  physiological 

action  of    271 

Soule,    Robert    E.    Treatment  of  fracture 

of  neck  of  femur   22 

Soules,  S.  G.     Chimaphila  in  diabetes  1147 

Sound,  a  new  1240 

Specialties,  correlation  of   qii 

Spengler's  immunizing  bodies  1239 

Sphincters,   vesical  and   ureteral,   loss  of 

function    of    407 

Spinal  cord,  changes  in,  in  meningitis. ...  1324 

syphilitic  disease  of    507 

Spirochaeta  Ivmphatica,  further  investiga- 
tion of      848 

pallida,  examination  and  detection  of...  11 15 
Spirochaetae.  relation  of.  to  cancer  in  mice..  352 

Spleen,  abscess  of,  after  epityphlitis   456 

in  relation  to  resistance  against  infec- 
tion  1279 

method  of  encapsulation  of   91 

surgery  of    91 


INDEX  TO  VOLUME  LXXXIX. 


1347 


Page. 

Splenectomy,  study  of  blood  after   865 

Spienomegaly,  splenectomy  for   356 

Sputum,  diagnosis  of  tuberculosis  from...  246 

Stab  wounds,  suture  of  vessels  after  1285 

Stadium  for  Columbia  University   548 

Staining:  of  sections  and  fixation  of  tissues, 

an  improved  method  for   596 

Starch  in  urine   379 

State  care  of  crippled  children   2S2 

Statistics,  vital,  registration  of   37 

Steinhardt,  Irving  D.    Painful  heels   626 

Stenosis,  hypertrophic,  of  pylorus  1222 

laryngeal,   successfully  treated  by  intu- 
bation   872 

mitral    134 

of  pylorus,  congenital  hypertrophic   332 

Sterilization  of  the  hand   708 

Stokes-Adams   complex  and  bradycardia..  921 

Stomach,  acute  dilatation  of  70,  137 

postoperative    801 

cancer  of,  earlv  diagnosis  and  treatment 

of   '.   867 

chronic  dilatation  and  prolapse  of.. 745,  1025 

diagnosis  in  diseases  of   557 

escalin  in  haemorrhage  of   128.). 

indications  for  operation  in  diseases  of 

8-4,  1083 

infant,  occurrence  of  pepsin  in  1327 

myoma  and  myosarcoma  of   301 

no  free  hydrochloric  acid  in   1308 

pepsin  in  disorders  of   13-' 

perforating  ulcer  of    189 

postoperative  dilatation  of  1026 

primary  sarcoma  of  loii 

resistance  of,  to  autodigestion   297 

syphilis   of   8iJ,  I120 

ulcer  of    760 

Salomon  test  in  sarcoma  of  1273 

X  ray  examinations  of  surgical  diseases 

of   1284 

pathogeny  of   297 

unfolding  of    611 

X  ray  examination  of  surgical  diseases  o£  1168 

Stone  in  kidney   302 

Stones  in  lower  end  of  ureter   658 

Stools  of  infants,  composition  of  curds  in  131 

Stoppers,  stuck,  how  to  remove   95 

Strabismus,  operative  treatment  of   81 

Straus  milk  scheme  and  the  medical  pro- 
fession   806 

Streptococchaemia.    and   sinus  thrombosis, 

relation  between   1141 

Streptococci,  haemolysis  of   402 

in  genital  secretions  of  pregnant  and  ly- 
ing in  women    816 

Streptococcus  infection,  influence  of,  upon 

leucocytes   1286 

Streptotrichiasis   1056 

Stricture,    oesophageal,    earlv  recognition 

of    186 

Stricture,  urethral    505 

Strophanthus   and  strophanthin   81 

Stuart,  A.  F.    Treatment  of  chronic  lead 

poisoning    441 

Students,    medical,    preliminarv  education 

of    812 

Study,  postgraduate,  in  Europe   918 

Suction,  continuous,  in  surgery  1068 

Summers,  John  E.  The  cancer  question..  413 
Super,  Charles  W.  Greek  for  physicians..  527 
Suppuration    near    diaphragm,  diagnosis 

and  treatment  of   83 

Suppuration  of  ear,  nose,  and  throat,  bis- 
muth paste  in  treatment  of   132 

Suprarenal  bodies,  nephritis,  and  arterio- 
sclerosis   180 

Surgery,  abdominal,  conservatism  in  484 

conservative    303 

fluorescent  salts  in   1325 

individual    a    factor   in   992 

major,  iodine  in   186 

oration  in   1221 

practical,  serum  diagnosis  in   816 

ureterorenal    530 

Sutton.    R.    T.      Treatment    of  chronic 

eczema    223 

Sweeny,  Gilliford  B.     Human  and  bovine 
tubercle  bacilli:  their  relation  and  in- 

tertransmissibility   1237 

Syndrome,    brachioocular,    a  contraindica- 
tion to  surgical  intervention  in  cancer 

of  breast    765 

Syndromes,  cholecystic  and  aopendicular .  .  549 

Syphilis  and  aortic  insufficiency    190 

autoinoculation  and  reinfection  of  12S2 

effect  on  Wassermann's  reaction  of  spe- 
cific treatment  of   11 18 

infection  of  physicians  with   137 

injections  of  mercurial  oil  in   177 

internal  treatment  of   444 

intramuscular  injections  in   240 

iodopin  in   1238 

local  treatment  of  lesions  of   597 

mercury  in  treatment  of   87 

rnercury   succinimide   in  treatment   of..  74 
Xoguchi's  method  for  serum  diagnosis 
of    973 


Page 

Syphilis  of  nervous  system  556,  1281 

of  physicians   1285 

of  spinal  cord    507 

of  stomach    811 

and  intestines   1120 

serum  diagnosis  of   

190,  207,  396,  816,  821,  1283 

serum  reaction  of,  in  scarlet  fever   299 

surgery   of    452 

treatment  of    399 

use  of  a  printed  chart  in  serum  diag- 
nosis of    934 

Wassermann's  reaction  in.. 402,  662,  760,  974 
Syringomyelia  and  myopathy  1 1 14 

"T"  ABES,  crises  of  intestinal  pain  in....  1070 
■*■         dorsalis  and  aneurysm  of  aorta,  re- 
lation between   1022 

high  frequency  currents  in   233 

rational  treatment  of   813 

thiosinamine  in   1274 

high  frequency  currents  in  treatment  of  249 

nasal  crises  of   610 

Talmage,  John  B.    Treatment  of  chronic 

eczema    283 

Talmey,  Max.     Universal  languages   664 

Tatchell,   \V.  Arthur.     Surgical  treatment 

of  tuberculous  disease   956 

Taylor,   Arthur    N.     Professional  secrecy 

and  professional  duty   7:9 

Tea,   coffee,   and   chocolate   prohibited  in 

persons  with  uric  acid  in  urine   661 

Teah,   Theodore  Emil.     Treatment  of  as- 
phyxia neonatorum    26 

Tear  sac,  Meller's  operation  for  removal  of  239 
Teeth  and  faucial  tonsils,  relation  between  1320 

functional  relation  of  tonsil  to   11 12 

Telegraphy,  wireless,  dangers  of   963 

Test  for  blood,  aloin  or  guaiac   431 

hsemolytic.  for  malignant  tumors   42 

ocular  tuberculin    451 

Testimony,  medical  expert    288 

Tetanus  antito-xine,  preparations  of  IZ33 

magnesium  treatment  of   496 

of  uterine  origin   i8g 

treatment  of   11 68 

Tetany  and  the  parathyreoid  bodies   446 

gastric,  experimental  study  of  1216 

Tetragenous  sepsis    190 

Therapy,  intravenous    249 

Thesaurus,  a  new,  of  the  Greek  language  196 

Thiosinamine  in  tabes  dorsalis   1274 

Thompson,  Francis  A.    A  case  of  so  called 

birth  mark    334 

Thomson,  \V.  Hanna.    Asiatic  Cholera   12 

Thoracic  duct,  termination  of  1024 

lesions,  value  of  x  rays  in   941 

Thorax,  lesions  of.  value  of  x  rays  in   941 

transfixion,  a  report  of  a  case  of   243 

Thor-rad-x  493,  772 

Throat,  bismuth  paste  in  suppuration  of..  132 

methods  of  examination  of   817 

Thromboangitis    obliterans,  arteriovenous 

anastomosis  as  a  cure  for   917 

Thrombosis,  cardiac   1231 

of  inferior  vena  cava   663 

sinus,  of  otitic  origin,  and  its  relation  to 

streptococchaemia   1141 

Thymus,  death  caused  by   86 

enlargement  with   nervous  symptoms...  555 

gland,   histology   of  1231 

Thyreoid  disease,  signs  of   503 

enlarged,   treated   by   x  rays  and  high 

frequency  currents    25 

gland  and  ichthyosis   610 

secretion  of.  in  relation  to  nocturnal 

incontinence   and   adenoids  1069 

Thyreoiditis,  simple  acute  1056 

Tibia,  fractures  of   457 

Tic  douloureaux,  surgical  treatment  of   665 

Tics  and  their  treatment   404 

Tissue,  living,  experimental  transplantation 

of    713 

Toenail,  ingrowing    348 

new  operation  for   387 

Tongue,  cancer  of  247,  922 

results  of  operations   for  1020 

diseases  of    505 

Tonic  and  soothing  mixture   803 

pills  for  asthenic  gout   70! 

Tonsil  forceps,  a  new    304 

lingual    872 

relation  of.  to  teeth  11 12 

the  third    683 

toxic  secondaries  of  chronic  disease  of..  883 
Tonsillectomy,  otitic  significance  of,  with 

reference  to  digital  enucleation  1089 

faucial.  and  teeth,  relation  between  ....i.i2') 

Tonsils,  digital  enucleation  of  1089 

digital   enucleation   of  1087 

indications  for  removal  of   1253 

removal  of   397,  1253 

finger  enucleation  of   42 

removal  of   1116 

Toothache  pellets    701 

Torpedo  boat  destroyers,  hygiene  of   921 


Page. 

Torrance.  Gaston.  Acute  gastric  and  duo- 
denal dilatation  treated  by  gastrojeju- 
nostomy   70 

Tousey,  Sinclair.  Electricity  in  genitourin- 
ary diseases   1038 

Toxaemia  a  cause  of  myocarditis  1295 

and  eclampsia  of  pregnancy   1218 

preeclamptic,  blood  pressure,  leucocyte 
count,  and  ophthalmoscopic  examina- 
tion in  diagnosis  of   714 

Toxines.  tonsillar    883 

Tract,  bile,  new  incision  to  reach  1331 

digestive,   and  blood  diseases,  relations 

between    768 

upper  digestive,  ulcer  of   760 

Transfusion   of   blood,   therapeutic  value 

of    242 

Transplantation  of  vessels  and  organs..  86 
Trauma  and  disease,  excision  of  shoulder 

joint  for    243 

Trembles  and  milk  sickness,  cause  of  1067 

Trepanation    and    curettage    of  maxillary 

sinus    558 

Trichinae    662 

Trichocephaliasis   "SS 

Trimble.  William  B.  The  diagnostic  value 
of  the  inunction  tuberculin  reaction  in 

cutaneous  tuberculosis   1034 

Tropical  fevers,  diagnosis  of   763 

Tropics,  conquest  of.  for  the  white  race..  1320 

Trudeau,  Dr.  Edward  L..  a  tribute  to   32 

Tubercle  bacilli,  antiformin  in  demonstra- 
tion of   H.17 

human  and  bovine,  intertransmissibil- 

ity  of   708,  1257 

in  milk  in  Xew  York  City   709 

in  the  circulating  blood   1250 

Tuberculin  and  arsenic  in  tuberculosis....  402 

diagnostic  injections  of  288 

diagnostic  reaction  of,  on  nasal  mucous 

membrane    765 

diagnostic  use  of   398 

reaction  in  diagnosis  of  tuberculosis   82 

immction  in  cutaneous  tuberculosis. .  1034 
test,  ophthalmic,  in  the  diagnosis  of  tu- 
berculosis   377 

Von  Pirquet's.  in  the  diagnosis  of  tu- 
berculosis .   577 

tests,  conjunctival,  results  from   451 

therapy    920 

treatment,  antibacterial  or  antitoxic  im- 
munization in    244 

in    practice    136 

Tuberculosis,  abdominal,  acute  form  of   245 

abdominal  surgical  types  of   1287 

allyl   sulphide  in  1043 

Alpine  climates  in   348 

among  Jews    37 

and  diphtheria  antitoxine   231 

and  erythema  nodosum  1154 

antibodies  in   1226 

antigen   of    402 

body  weight  in  relation  to   348 

bovine,  transmission  of  1226 

climate  in  treatment  of   542 

complement  binding  antibodies  in   41 

conjunctival  tuberculin  reaction  in  diag- 
nosis of    82 

death  rate  from,  in  Scotland   26 

diagnosis  of,  from  sputum    246 

diet  in   397 

dispensary  system  of  Pennsylvania  State 

Department  of  Health  in  war  against  770 
duration  of  actively  infectious  stage  of. .  347 

Exhibition.   Dr.  Bryant's  address  at   257 

experimental  cavernous  pulmonary   1324 

Ferrier's  recalcifying  method  in   973 

financial  and  climatic  conditions  in  treat- 
ment of    811 

human  and  bovine,  relation  between... 

41,  86,  IZ37 

immunity  against,  in  general  paresis   396 

immunization  against    298 

in  children   352,  400,  402,  500 

in  Xew  York,  decrease  of  1057 

in  Panama    293 

in  rural  districts   770 

inadequacy  of  sanatorium  tre?tment  of..i2Si 

incipient  pulmonary,  diagnosis  of   166 

intestinal  obstruction  in  connection  with  615 
intravenous  injections  of  arsenic  and  tu- 
berculin  in    402 

joint.  X  ray  diagnosis  of   457 

the  liver  in   1120 

Jfarine    Hospital    Sanatorium    form  at 

Fort  Stanton,  X.  11   417 

meat  as  a  source  of  infection  in  I27'i 

mercury  in  treatment  of  863,  1180 

of  breast    502 

of  cervical  glands   456 

of  joints,  operative  treatment  of   969 

of  kidnev   1066 

of  larynx    36 

ophthalmic  tuberculin  test  in  the  diag- 
nosis of    377 

onhthalmoreaction  in.  during  pregnancy  457 
patients,  classification  of   731 


1348 


INDEX  TO  VOLUME  LXXXIX. 


Page. 

Tuberculosis  patients,  economic  Housing  of, 

especially  in  the  Southwest   727 

predisposition  ol  apices  of  lungs  to   457 

proicin  ration  in   397 

pulmonary,  creosote  treatment  of   177 

early  diagnosis  of   I3'' 

graduated  rest  in  treatment  of   868 

neari    in    507 

in  children    503 

inhalation  of  verdigris  dust   in  treat- 
ment of   1070 

operative   treatment   of   770 

second  recovery  from   770 

treatment  of,  in  the  West  '3^o 

x   ray   examinations   an   aid   to  diag- 
nosis of    663 

remedy    for    vomiting    associated  with 

cough  of   649,  127.! 

renal    760 

responsibility  of  family  physician  toward  i 

role  of  saliva  in  transmission  of    972 

serum  diagnosis  and  prognosis  in   84 

sexual  factor  in   116 

some  problems  connected  with   1245 

subphrenic   1219 

surgical,  influence  of  tryptic  ferment  so- 
lutions on    190 

open  air  and  hyperaemia   in   507 

treatment  of    956 

transmission  of,  through  family  associa- 
tion   870 

the  typical  chest  in   1280 

urinary  calcium  excretion  in  11 82 

without  tubercle  bacilli  in  the  blood  1097 

Tuberculous  families,  sanitary  homes  for..ioio 

parents,  children  of   709 

peritonitis   1286 

Tumor,  acusticus.  at  base  of  brain   189 

Coley's  fluid  in  treatment  of  1239 

Tumors,  borderline,  of  bieast   818 

fibroid,  and  pregnancy   404 

glandular,   of  neck,   treated   with  the  x 

ray  and  high  frequency  currents   138 

haemolytic  test  for   42 

of   breast,    improvements   in  operations 

for    458 

of  salivary  glands    562 

Turck,    Raymond    Custer.  Hysterosalpin- 

gostomy   .'  1 193 

Turgosphygmography  and    finger  plethys- 
mography   41 

Twitchell,  George  B.    The  therapeutic  use 

of  alcohol  in  internal  medicine  ...1052 

Typhlitis   91.  138 

Typhoid,  agglutination  of  paratyphus  ba- 
cilli in    352 

bacilli,  carriers  of  ,   817 

bacilluria   iiig 

carrier,  treatment  of   400 

detection  of    339 

Typhoid  fever,  aetiology  cf   1271 

carriers   184,  400 

diet   in   1217 

genitourinary  complications  of   372 

intestinal  perforation  in   501 

neuroretinitis  due  to    74S 

of  short  duration   241 

perforation  of  intestines  in  1119 

treatment  of   42,  qi 

prophylactic  inoculations  against   265 

treatment  of,  with  calcium  creosote...  648 

two  unusual  cases  of   698 

ushered   in  by  an  attack  of  uraemia. .  1 146 

vaccine  treatment  of   185 

infection    762 

foetal    611 

Typhus   bacilli  of  mice,  sickness  induced 

by    714 

T  THLE.  ALEXANDER  A.,  and  Mackin- 
ney,    William    H.      Pathology  and 

treatment  of  chronic  gonorrhoea   213 

Ulcer,  gastric,  a?tiology  and  pathogenesis..  767 

and  duodenal   711,  1332 

diagnosis  of   11 19 

immediate  feeding  in  treatment  of   866 

medical   treatment  of   767 

surgical  treatment  of   768 

of  duodenum    86 

of  foot  of  tuberculous  origin   298 

of  stomach,  pathogeny  of   297 

of  upper  digestive  tract   760 

perforating,  of  stomach   189 

I'ltramicroscope    912 

Uncinariasis    927 

anaemia  of   11 55 

mi'd    927 

United  States  Marine  Hospital  Sanatorium 

for  Tuberculosis  at  Fort  Stanton  N.  M.  4IT 

T^nna's  treatment  of  leg  ulcers   556 

l|ntr'iihs.  machine  for  detecting   661 

Tra-mia  and  common  salt   816 

preceding  typhoid  fever  1 146 


Pace. 

Uranium  wine  for  diabetics   649 

Ureter,  stones  in  lower  end  of   658 

suppuration  of,  treated  by  lavage   245 

Ureteral  isthmuses    813 

Ureterorenal  decalogue    530 

Urethra  and   bladder,   common   errors  in 

treatment   of    895 

plastic  surgery  of   505 

structures  of    505 

Urethritis,  acute  gonococcic,  in  the  male. 

treatment  of    149 

argyrol  in    610 

Urinary  findings,  transitory,  in  diseases  of 

childhood   1223 

Urine,  acidity  of  1236 

albumin  in,  quantative  estimation  of   768 

hsematoporphyrin  in    972 

in  diseases  of  infancy   524 

instrument  for  estimation  of  acidity  of..  24 
lumbar  puncture  for  incontinence  of....  963 

routine  examinations  of   437 

separator,  the  Luys   916 

starch  in    379 

test  for  bile  in  286,  443 

for  indican  in   230 

uric  acid  in   661 

Urobilin   1285 

Uterus,  adenomyoma  of   349 

arteriosclerosis  of    43 

atrophy   of    ...^   402 

cancer  of    500 

Wertheim's  operation  for  11 12 

present  means  of  lessening  the  mortal- 
ity from    606 

chronic  inversion  of   971 

dilatation  of  cervical  canal  of  1021 

fibromyomata  of   1219 

haemorrhages  of    715 

curettage  for   1219 

myomata  of,  enucleation  of  1219 

new  dilator  of   559 

retrodeviation  of    41 

retrodisplacements  of   1217 

retroflexion  of,  treatment  of  m? 

sacral  suspension  of   662 

temporary  ventrosuspension  of   405 

■WACCINATION    125 

'      legal   aspects  of   106 

smallpox  before  and  since  the  discovery 

of    98 

Vaccine  and  serum  therapy,  present  status 

of   1233 

antigonococcal    608 

contaminated,  accident  from   1066 

specific,  in  treatment  of  erysipelas   353 

treatment  of  typhoid  fever   185 

Vaccines,  bacterial    772 

in  septic  infections   871 

in  treatment  of  acne  vulgaris   919 

Vander  \'eer,   .'Mbert.     The  ethics  of  our 

profession   201 

Van  Sweringen,  B.     Caesarean  section   690 

Varix,  renal   1 326 

Veins,    treatment    of  1286 

Venereal    disease,   compulsory  projihylaxis 

against   1 327 

Venom  of  rattlesnakes,  haemolytic  action  of  i2?t 

therapeutic  action  of   961 

Veratrum  viride,  tincture  of,  therapeutics 

of   545 

Verdigris  dust,  inhalation  of,  in  pulmonary 

tuberculosis   1070 

Vertigo,  aural    919 

Vestibule  and  semicircular  canals,  func- 
tions of  end  organs  in   761 

X'iscera.  partial  inversion  of   12S4 

Vivisection,  legislation  relating  to   242 

Volkmann's  ischaemic  paralysis  and  con- 
tractures   243 

V^olvuKis   1281 

associated  with  hernia    660 

Von  Pirquet's  tuberculin  test  in  diagnosis 
of  tuberculosis  in  infancy  and  child- 
hood  577 

Voorhees,     Irving    Wilson.  case  of 

bromoform  eruption   i'45 

Submucous  resection  of  the  nasal  saep- 
tum    427 

WAIXWRIGHT,  John  W.  James  Rlake  iii 
"      Wandless,  H.  W.   Amaurotic  family 
idiocy    953 

Warren.   D.   E.     The  therapeutic  use  of 

alcohol   N  957 

Warren,  J.  N'.     Extrauterine  gestation   894 

Wassermann  reaction    402 

Rauer's  modification  of   505 

demonstration  of    821 

development  and  character  of    82- 

effect  of  specific  treatment  on  11 18 

in  congenital  syphilis   921 


A.  Page. 

Wassermann's    reaction    in    diagnosis  of 

syphilis    662 

in  scarlet  fever  11 18 

in  sypliilis   700,  974 

princip.es  and  technique  of   607 

lechnique    777 

Water  as  a  therapeutic  agent   502 

f.dal,  sanitary  protection  of   865 

Watson,  J.  J.     Pellagra   936 

Waugh,  William  Atropine  as  a  haemo- 
static   564 

Weight  in  relation  to  tuberculosis   348 

Weil,    Henry.      Irrigation     treatment  of 

puerperal  sepsis   1261 

Puerperal   sepsis    58 

Welch,  William  M.     So  called  dangers  of 

vaccination    102 

Welker,  William  H.,  and  Ditman,  Nor- 
man E.  Deficient  oxidation  in  its  rela- 
tion  to   the  aetiology,    pathology  and 

treatment  of  nephritis  

 1000,  1046,  1091,   1 134 

Wertheim's  operation  for  cancer  of  cervix 

uteri   1112 

White,  Francis  W.    Two  unusual  cases  of 

typhoid  fever    698 

Wightman,  Passed  Assistant  Surgeon  Wil- 
liam il.,  the  death  of   1104 

Wile,  Ira  S.     Amyluria   379 

Wiley,  H.  W.     Diet  as  a  prophylactic  and 

therapeutic   1173 

Williams,  Tom  A.     The  present  status  of 

hysteria    53 

The  psychological  basis  of  inebriety....  833 

W  ilson,  Gordon.    Incipient  tuberculosis  of 

the  lungs    166 

Wine,  uranium,  for  diabetics   649 

Wiseman,  Joseph  R.     Therapeutic  use  of 

alcohol    854 

Wolbarst,  A.  L.  A  study  of  the  prostate 
with  special  reference  to  the  curability 
of  gonorrha'a    580 

Women,  standard  weights  of   82 

Woodruff,  Charles  E.  The  medical  impor- 
tance of  the  study  of  anthropology ..  1030 

Wounds,  first  aid  dressings  in   458 

gunshot,  of  heart   1285 

suture  of  lung  in  n'/ 

of  the  heart,  suture  of  345 

treatment  of    135 

Wright,  Barton  Lisle.  Treatment  of  tuber- 
culosis by  the  administration  of  mer- 
cury  •.  ..ii8o 

Wright,  Jonathan.    Theories  and  problems 

of  heredity   49,  309,  673,  829,  107S 

Wrist  joint  deformity,  Madelung's   249 

Writer's  cramp,  aetiology  and  treatment  of  505 

XRAY  absorption,   nontoxic  substitute 
for   1 118 

and  aetiology  of  cancer   7x0 

diagnosis  of  joint  tuberculosis   457 

examination  of  oesophagus   159 

examination  of  surgical  diseases  of  stom- 
ach  iiu8.  12S4 

examinations  an  aid  to  diagnosis  of  pul- 
monary tuberculosis    663 

injuries    402 

interpretation  of  fractures   562 

treatment   of   internal   structures  (even- 
tration treatment)    621 

of  leuchaemia   241 

of  malignant  neoplasms  of   upper  air 

passages   :   921 

of  ringworm  of  scalp  1167 

X  rays,  action  of,  on  sarcoma  of  gum   505 

in  diagnosis    241 

in  diagnosis  of  carcinoma  of  stomach..  606 

of  ureteral  calculus   510 

in  examination  of  lungs   1022 

in  malignant  disease   818 

in  therapeusis    559 

in  thoracic  lesions,  value  of    941 

in  treatment  of  enlarged  thyreoid   25 

in  treatment  of  exophthalmic  goitre   614 

of  glandular  tumors   138 

of  hvpertrichosis    817 

of  rhinoscleroma    505 

of   skin   diseases  1 1  5^ 

injuries  produced  by   4°^ 

YE.XST  food  extracts   83 
Yellow  fever    85 

aetiology  of   i3-'4 

Young,  A.  A.  Treatment  of  acute  dysen- 
tery   75' 

Z.\\'.\TT.    Joscfa.      Nonoperative  treat- 
ment of  appendicitis   1270 

Zemp.  F..  R.    .\lcohol — •>hysiological  action 

and  therapeutic  indications    475 

Zoophil  psychosis    S5S 


I